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A   DICTIONARY 


PSYCHOLOGICAL    MEDICINE 


■/ 


A  DICTIONARY 


OF 


PSYCHOLOGICAL  MEDICINE 

GIVING  THE  DEFINITION,  ETYMOLOGY  AND  SYNONYMS 
OF  THE  TERMS  USED  IN  MEDICAL  PSYCHOLOGY 

WITH   THE 

SYMPTOMS,  TREATMENT,  AND   PATHOLOGY   OF   INSANITY 

AND   THE 

LAW  OF  LUNACY  IN  GREAT  BRITAIN  AND  IRELAND 

EDITED    BY 

D.    HACK   TUKE,  M.D.,  LL.D. 

EXAMINER    IN    MENTAL    PHYSIOLOGY    IN    THE    UNIVERSITY    OK    HINDON  ;    LEClUREk    ON 

I'SYCHOLOGICAL    MEDICINE   AT   THE   CHARING   CROSS    HOSPITAL   MEDICAL 

SCHOOL  J    CO-EDITOR   OF    THE    "JOURNAL   OF    MENTAL   SCIENCE" 


VOL.    II. 


PHILADELPHIA 
P.   BLAKISTON,    SON    &    CO. 

1012    WALNUT    STREET 
1892 


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fi 


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Jerks,  Jerkers 


[ 


] 


Juvenile  Insanity 


children's  affection  is  being  alienat  i  from 
the  mother. 

In  some  cases  strongly  infanticidal  im- 
pulses arise.  We  have  never  met  a  man 
insanely  jealous  of  his  offspring. 

The  last  form  of  insane  jealoi;sy  to 
which  we  refer  is  that  in  reference  to 
friends.  Here  again  the  disorder  is  mostly 
a  feminine  one. 

Women  believe  that  influences  are  at 
work  to  loosen  the  bands  of  established 
friendship ;  they  dwell  on  the  slightest 
signs  of  want  of  affection  and  magnify 
them.  These  cases  are  more  frequent 
in  middle-aged,  single  women  who  have 
poured  out  their  affection  upon  some 
female  friend.  These  women-friendships 
have  something  peculiar  in  them,  the 
relationships  being  often  emotional  and 
associated  with  unhealthy  mutual  self- 
analysis.  A  gradual  change  in  this 
relationship  may  lead  to  passionate 
jealousy,  with  fancies  that  the  once  loved 
one  has  become  influenced  against,  and  be- 
lieves all  sorts  of  moral  evils  of,  her  friend. 

Such  jealousy  may  lead  to  violent  hatred 
and  to  acts  of  passion.  We  have  known 
the  idol  attacked  and  seriously  damaged. 

To  sum  up.  Jealousy  as  a  symptom 
of  insanity  may  occur  in  men  and  women, 
and  may  be  the  chief  among  other  symp- 
toms of  mental  disorder  ;  or  it  may  be  the 
residuum  of  a  more  or  less  acute  attack  of 
insanity,  a  form  of  monomania. 

It  may  affect  the  marital,  the  parental, 
or  the  social  relationships. 

It  may  occur  in  the  single  or  married ; 
it  is  more  common  in  women  ;  it  may  be 
connected  with  age  and  loss  of  power,  or 
with  the  climacteric  period.  It  is  a  fre- 
quent accompaniment  of  alcoholic  in- 
temperance. It  has  no  special  import  as 
a  symptom,  but  it  often  leads  to  homicidal 
or  suicidal  acts. 

The  treatment  depends  on  general  con- 
ditions, but  must  generally  be  of  the 
so-called  moral  kind,  such  as  change  of 
surroundings  and  companionship,  rather 
than  medicinal.  Geo.  H.  Savage. 

JSXtKS,  JERKERS. — A  name  given 
to  the  hysterical  form  of  maniacal  ex- 
citement in  which  the  patients  went 
through  a  pantomimic  performance,  jerk- 
ing, twisting,  and  contorting  their  bodies 
into  all  manner  of  shapes.  It  was  due  to 
the  religious  enthusiasm  prevalent  in 
some  of  the  American  States  in  1798- 
1S05,  consequent  on  the  extravagances  of 
revival  preaching. 

TEVrS.       f,S'ee   ISKAELITES.) 


JOZXO'TS,  HYSTERZCAXi  AFFEC- 
TZOirs  OF. — A  mimicry  of  severe  disease 
of  a  joint,  described  by  Charcot,  generally 
the  knee  or  hip,  occurring  in  a  person  of 
hysterical  disposition.  The  main  symp- 
toms complained  of  are  pain  and  difficulty 
of  movement ;  the  former  is  always  de- 
scribed as  most  acute,  and  with  it  there  is 
associated  an  abnormal  degree  of  cuta- 
neous hypera3sthesia.  There  is  no  heat, 
redness  or  swelling  of  the  part,  and  the 
concurrent  deformity,  though  simulated, 
shows  a  mai-ked  difference  from  the  or- 
dinary abnormal  conformation  of  the 
joint  seen  in  hip  disease,  &c.  Occasionally 
there  is  some  cutaneous  hyperasmia  and 
some  crepitation  on  passive  movement  of 
the  joint,  but  there  is  never  any  rise  of 
temperature,  or  effusion  into  the  joint- 
cavity.     {See  Hysteria.) 

JVDGE  (INSANITY  OF). — A  /lO/t 
compos  ought  not  to  sit  as  a  judge  :  but 
it  is  laid  down  in  Brooke's  ''Abridge- 
ment" (fo.  258,  7)  that  should  such  a 
case  occur,  the  fines,  judgments  and  other 
records  taken  before  him  would  be  good ; 
but  it  is  otherwise  as  regards  matters  iii 
fait  {i.e.,  by  deed  or  writing),  which  might 
be  avoided  by  a  person  of  non-sane 
memory.  Since  the  Act  of  Settlement, 
the  judges  of  the  Superior  Courts  hold 
office  quatiidiu  se  henr.  gesserint  and  are 
not  removable  except  upon  an  address  to 
the  Crown  by  both  Houses  of  Parliament. 
A.  Wood  Rexton. 

TUDGIMCEITT  (Fr.  jugement,  from 
juger,  to  judge ;  from  \j^i.  judico,  I  decide). 
An  intellectual  operation,  by  which  the 
characteristics  of  ideas  or  facts  jDresented 
to  the  mind  are  valued  or  compared  so 
that  opinion  or  action  may  be  guided  by 
the  result.     (Ger.  Uriheilskraft). 

JirivxPERS. — A  name  given  to  those 
hysterical  fanatics  who  in  their  devotional 
exercises  worked  themselves  into  a  state 
of  frenzy,  and  began  to  jump  about  in  a 
strange,  uncontrollable  manner.  They 
appeared  in  Cornwall  in  1760.  The  name 
has  also  been  given  to  a  family  in  Maine, 
U.S.A.,  which  has  evinced  a  like  psycho- 
pathological  condition,  a  sudden  and 
peremptory  order  compelling  immediate 
response  on  their  part.  The  affection 
appears  to  have  spi-ead  among  the  members 
of  the  family  by  imitation,  and  thus 
evinced  a  spurious  hereditary  chai'acJjr. 

JURISPRUDENCE,  MEDIC AI..  {See 

Criminal  Lunatics,Eviden(e,  Plead.&c.) 
JUVENII.E    INSANITY.     (See  De- 
velopmental iNSAXn  I  K.s.) 


Kakosmia  Subjectiva        [    724 


Katatonia 


K 


XAKOSMXA  SUBJECTIVA  (kukos, 
bad  ;  ofr/x?},  a  smell ;  stihjicio.  I  cast  under). 
A  disturbance  of  the  olfactory  centre  in 
some  hysterical,  epileptic,  insane,  or  syphi- 
litic subjects,  which  causes  the  perception 
of  a  bad  odour.     (8ec  Smell,  Hallucixa- 

TIONS  Ol'). 

KAIiMUC  IBIOTS.  {See  Idiocy, 
Forms  or.) 

XATAIiEPSIA.  Catalepsy  (q-v.). 
KATATOHariA  (KaraTeivCL),  I  stretch 
tightly ;  Spannungs  Irresein,  Ger.)  is 
a  disorder  which  Kahlbauui  was  the  first 
to  describe  in  1874  as  a  special  form  of 
mental  disease  in  a  monograph,*  illus- 
trated by  numerous  examples. 

Typical  cases  of  this  kind  pursue  their 
course  according  to  the  following  scheme  : 
There  is  at  the  commencement  a  condition 
of  depression,  melancholia,  and  of  mental 
uneasiness  and  distress.  After  a  longer 
or  shorter  time  this  is  succeeded  by  a 
phase  of  excitement,  of  the  maniacal  kind, 
or  it  assumes  the  character  of  vielancholio. 
agitaia.  This  second  stage  is  followed — 
often  very  soon  —  by  a  condition  of 
rigidity  and  immobility,  to  which  the 
term  attonita  (Attonititat)  is  applied. 
After  this,  the  patient  may  recover,  or, 
in  an  unfavourable  case,  the  disease  termi- 
.  nates  in  general  confusion,  and  at  last  in 
actual  dementia. 

There  are,  however,  many  deviations 
from  this  general  scheme,  and  we  may 
distinguish  two  vai'ieties,  haiatonia  tnitis 
and  hatatonicv  pt'otructa.  In  the  former 
the  attonita  is  not  fully  descriptive,  for 
only  the  principal  symptoms  are  present ; 
in  the  latter  the  various  phases  frequently 
follow  each  other. 

The  prog-nosis  of  the  disorder  is  favour- 
able in  cases  of  hataAonia  tnitis ;  and  even 
in  protracted  cases,  after,  it  may  be,  a 
duration  of  several  years,  the  patient  may 
recover. 

The  various  stages  of  the  disease,  which 
we  have  described  above  in  general,  are 
distinguished  by  a  series  of  characteristic 
symptoms,  and  in  addition  to  the  actual 
mental  phenomena  we  have  specially  to 
mention  anomalies  of  the  psycho-motor 
sphere,  after  which  the  disorder  has  re- 
ceived its  name. 

The  most  conspicuous  symptoms  are 
those  of  the  stage  called  oAtonita.  We 
are  particularly  struck  by  the  absence  of 

*  Die  Kiitntonie,  August  Hirschwahl.  lierliu, 
1874. 


any  spontaneous  movements  and  by  more 
or  less  complete  immobility.  In  the  more 
advanced  phases  of  this  condition  the 
movements  of  inspiration  and  exjnration 
are  very  slight,  and  those  of  the  eyelids 
are  very  rare.  However,  as  soon  as  we 
attempt  to  produce  passive  movements  of 
any  part  of  the  patient's  body,  we  meet 
almost  always  with  a  powerful  resistance ; 
the  groups  of  muscles  antagonistic  to  the 
attempted  movement  commence  to  con- 
tract energetically — this  has  been  termed 
the  symptom  of  negativism.  The  negative 
muscular  contraction  is  not  equally  strong 
in  all  parts  of  the  body,  but  appears  to  be 
strongest  in  movements  of  the  shoulder- 
joint  and  in  attempts  to  extend  the  head 
or  to  raise  it  when  flexed  upon  the  chest. 
If  the  muscular  resistance  in  passive 
movements  is  but  slight,  and  if  we  succeed 
in  overcoming  it,  the  parts  often  remain 
for  some  time  in  the  position  given  them  : 
in  this  way  we  may  force  the  patient  into 
the  most  uncomfortable  positions :  this 
has  been  called  the  symptom  oi  flexibilitas 
cerea.  Even  the  ordinary  position  of  the 
patient  in  this  stage  is  not  a  comfortable 
one  ;  with  relaxed  muscles  he  seems  to 
have  become  rigid  in  the  most  hizoj-re 
attitudes ;  specially  frequent  is  the  posi- 
tion in  which  the  thighs  flexed  at  the  hijD- 
joint  are  drawn  up  close  to  the  abdomen 
(the  legs  being  flexed  on  the  thighs),  and 
the  head  is  flexed  on  the  chest,  so  that  the 
whole  body  appears  to  be  rolled  up  into 
one  mass.  As  a  partial  symptom  of  this 
tendency  to  muscular  contraction,  we 
have  to  mention  specially  the  condition  in 
which  the  lips  are  protruded  like  a  snout 
{SchnauzJcra'mpf). 

Not  unfrequently  this  rigid  immobilitj'' 
is  interrupted  by  monotonous  movements 
incessantly  repeated  in  an  automatic 
manner :  such  have  been  called  stereo- 
typed movements  {Beivegungsstereotypie). 
Another  most  important  symptom  is 
the  so-called  mutism  (mutacisnms),  a 
pathological  tendency  to  be  silent.  In  a 
slight  manner  this  symptom  is  present  in 
every  case,  and  in  many  cases  it  exists 
fully  developed  for  months  and  even  for 
years.  We  have,  however,  to  add  that 
in  some  cases  there  seems  to  be  a  desii'e 
to  speak,  so  that  in  such  instances  at 
least,  the  mutism  may  be  considered  as 
a  consequence  of  the  general  motor  inhi- 
bition. 
Just  as  the  immobility  is  frequently 


Eatatonia 


'25 


Kawa 


interrupted  by  stereotyped  movements, 
so  the  mutism  may  be  interrupted  by  the 
monotonous  utterance  of  incessantly  re- 
peated words — verbigeration  iq.v.). 

We  have  also  to  mention  that  patients 
of  this  kind  often  refuse  to  take  food;  on 
the  other  hand,  boulimia  is  not  unfre- 
quently  observed,  and  we  differ  decidedly 
in  our  opinion  from  some  authors,  who 
have  stated  that  the  latter  sym]itora  is  a 
sign  of  commencing  dementia,  and  there- 
fore unfavourable  with  regard  to  the 
prognosis  of  the  case. 

Among  the  vaso-motor  a.nd  trophic  de- 
rangements, we  have  specially  to  mention 
a  tendency  to  cyanosis  of  the  peripheral 
parts,  and  salivation  which  may  attain  a 
high  degree  and  last  a  long  time.  In  a 
case  described  by  Arudt  there  was  also 
polyuria  present. 

Among  the  other  stages  of  the  disorder, 
that  of  excitement  is  of  a  specially  peculiar 
form.  We  fi-equently  find  a  certain  pathos 
and  a  tendency  to  declamatory  and  sermon- 
like speaking ;  the  gestures  are  stiff  and 
theatrical ;  speech  shows  indications  of 
verbigeration,  or  it  may  be  fully  developed. 
The  monotony  of  the  whole  behaviour  is 
quite  distinct  fi'om  typical  mania. 

The  stage  of  commencement  is  the  least 
characteristic  one  ;  there  are  almost  with- 
out exception  hallucinations,  especially  of 
vision,  and  not  unfrequently  the  jDatient's 
ideas  run  on  religion.  In  well-developed 
cases  we  are  struck,  even  in  this  first  stage, 
by  the  motor  inhibition. 

Kahlbaum  states  that  sometimes  the 
commencement  of  the  disorder  is  marked 
by  a  convulsive  attack  of  a  varying  kind. 

Also  the  last  stage,  the  terminal  de- 
mentia, is  often  characterised  by  the  con- 
tinuation of  the  stereotyped  movements. 

In  order  to  fully  understand  katatonia 
it  is  necessary  to  know  the  points  of  view 
which  Kahlbaum  has  given  in  his  tho- 
roughly original  treatise  on  "  Die  Grup- 
pierung  der  psychischen  Ki-ankheiten " 
(Kafemann,  Danzig,  1863).  This  is  not 
the  place  to  go  deeply  into  this  question; 
however,  we  must  mention  that  Kahl- 
baum's  scheme  has  been  rejected  by  many 
renowned  authors.  There  are  undoubtedly 
cases  which  do  not  pursue  their  course 
according  to  the  scheme,  and  there  is 
also  such  a  number  of  mixed  and  ti'ansi- 
tional  forms  that  it  may  even  be  an  open 
question  whether  we  are  justified  in  con- 
sidering katatonia  a  special  disorder. 
However  this  may  be,  the  lasting  merit  of 
Kahlbaum's  treatise  is  that  he  has  given 
an  excellent  description  of  a  series  of 
morbid  conditions  which  up  to  his  time, 
and  unfortunately,  by  many  authors  even 
in  our  times,  were  considered  from  a  very 


superficial  and  merely  psychological 
standpoint.  The  parely  psychological 
interpretations,  upon  which  is  fouuded, 
e.g.,  the  name  of  "  onelancJiolici  attonitd." 
{Erstarrumi  im  Seeleusclimerz),  are,  when 
considered  from  the  standpoint  of  the 
motor  system,  nothing  but  empty  words 
and  a  yriuri  conclusions,  Kahlbaum 
was  the  first  to  give  us  an  objective  and 
clinical  symptomatology. 

Clemens  Neissek. 

{References. — De  la  Catalepsie,  Arch,  dc  Mod., 
Aout,   1857,  J.  Fali-et.     Allg.   Zeitsch.  f.    I'sych.. 

1877,  l?d.  xxxiii.  p.  602,  Hecker.  Kalilbaum's 
Katatoiiie,  A\\\i.  Zeitsch.   f.  Psych.,  13d.    xxxiv., 

1878,  s.  731,  Tlyges.  Alienist  and  Xcurolojiist. 
1882,  Kioniaii.  lieitrage  zur  Lehre  der  Katatonie, 
1882,  Kourad.  Uebor  Katatonische  Verriicktheit, 
Laufenauer,  1882.  ITcber  Normalc  uud  Katalep- 
tische  l'.ewe<4'uiig^eii,  Arch,  fiir  I'sych.  uud  Nerv.. 
Bd.  xiii.  Heft  2,  1882,  Kieger.  Auier.  Jouru.  of 
Xeur.  and  I'sych.,  1883,  p.  343,  Spitzka.  Ueber 
^Etiologie  and  lichandluuy  der  Katatonie,  Nied. 
XcT.  fiir  Psych.,  1883,  Uunkerlo.st.  Specialle 
Pathologic  imd  Therapie  des  Geisteskrankheiten. 
1886,  Schiilc.  Die  Katatonie,  AUg.  Zeitsch.  i. 
Psych.,  1887,  Bd.  xxxiii.,  Brosius.  Ueber  die 
Katatonie,  1887,  Clemens  Neisser.  In  addition  to 
Kahlbaum"s  Memoire,  La  Catatonie,  par  J.  S^glas 
et  Ph.  Chaslin,  Paris,  1888.  Katatonia,  Brain,  1891, 
Dr.  Mickle.  Ueber  Tetauie  und  Psychose,  AUi;. 
Zeitsch.  fiir  Psych.,  Bd.  xxx.  s.  28,  H.  Arudt. 

MM.  Seglas  and  Chaslin,  to  whom  ive  are  in- 
debted for  manj'  reference>i,  conclude  that  thi: 
attempt  which  Kahlbaum  has  made  to  diflferentiate 
katatonia,  is  not  justified  by  clinical  observation, 
and  repeats  J.  Falrefs  opinion  that  in  the  descrip- 
tion of  this  disorder  facts  more  or  less  dissimilar 
have  been  confounded  together,  and  that  Kahlbaum 
has  given  the  history  of  a  symptom  or  a  group  of 
symptoms  rather  than  a  genuine  and  distinct  form 
of  mental  disease.  Considering  that  on  the  physi- 
cal side  the  predominant  symptom  is  the  presence 
of  disorders  of  the  motor  system,  and  on  the  psychi- 
cal side  a  state  of  melancholia,  the  other  sj-mptoms 
not  being  in  any  way  special,  the  authors  tlnnk 
that  katatonia  ought  not  to  be  separated  from 
mental  stupor,  of  which  it  is  only  a  variety  related 
to  degeneration  and,  especially,  hysteria] 

KATZBNSUCHT.— The  German  term 
for  Galeanthropy  {q[.v.). 

KA'WA. — The  resin  of  Piper  viethy- 
diclium  which  has  been  macerated  and 
allowed  to  mix  in  a  vessel  with  saliva 
gives  a  kind  of  extract,  which,  mixed  with 
water  or  cocoa-nut  milk,  furnishes  an  in- 
toxicating drink,  which  is  used  habitually 
by  the  inhabitants  of  Tahiti,  but  which  is 
now  being  replaced  by  alcohol.  It  produces 
a  condition  of  intoxication,  a  blunting  of 
the  senses,  with  ecstasies  and  elation.  The 
controlling  centres  are  in  abeyance;  the  in- 
dividual is  absorbed  in  a  train  of  ideas,  on 
which  he  ruminates,  and  which  occupy  all 
his  attention.  Then  the  subject  falls  into 
a  state  of  torpor  from  which  he  cannot  be 
aroused  without  inducing  violent  excite- 
ment. He  enjoys  this  torpor,  which, accord- 
ing to  Bourra,  resembles  the  ecstasies  of  a 
prolonged  siesta  in  hot  countries,  althougli 


Xenophobia 


[    726    ] 


Kleptomania 


the  conceptions  are  of  a  more  melancholy 
and  painful  nature.  M.  Legraix. 

XEM'OPHOBXA  (Kfvos,  empty,  vacant  ; 
00/^oy,  fear).  A  synonym  of  Agora- 
phobia ((/.(•. ). 

KEN'OSPTTDIA  (Kepoa;Tov8eo),  I  am 
eager  for  ti'i  ties;  from  Kffoyjempty;  a-TTovSij, 
zeal).  A  term  formerly  used  to  express 
mental  absti-action,  or  what  is  commonly 
kno'vn  as  "  bi'own  study.''  It  is  also  used 
as  a  synonym  of  Somnambulism. 

KIDNEYS  (see  Bright's  Disease). — 
Dr.  Thomas  Ireland,  of  the  Berbice  Asy- 
lum, British  Guiana,  has  recently  stated 
that  Bright's  disease  is  very  common 
among  the  patients  there.  During  1890, 
there  were  thirty-five  deaths  from  this 
cause,  confirmed  by  post  mortem.  The  pa- 
tients were  mostly  dements,  and  when  ad- 
mitted were  obtuse,  without  any  clear  his- 
tory of  previous  acute  mental  disorder. 
Occasionally  delusions  or  hallucinations 
were  present. 

KI.EPTOIVIANXil.  (KXerrTOi,  I  steal). 

Synonyms.  —  Monomanie  du  vol,  or 
kleptomaniaque ;  Cleptomanie  (Fr.) ; 
Stehlsucht  (Ger.). 

Definition. — In  the  strict  sense  of  the 
term,  an  irresistible  impulse  to  steal. 

The  diseased  manifestations  of  such 
isolated  propensities  as  stealing,  fire-rais- 
ing, &c.,  were  viewed  by  some  of  the  older 
writers  on  psychology  as  distinct  varieties 
of  monomania,  and  elevated  by  them  into 
special  insanities  ;  thus  a  morbid  tendency 
to  acts  of  theft  received  the  name  of 
kleptomania. 

The  term  was  employed  by  Marc,  who 
observes,  that  this  condition — the  impul- 
sive form — is  doubtless  very  singular  and 
inexplicable,  as  are  so  many  of  the  in- 
tellectual and  phjrsical  phenomena  of  life  ; 
but  it  is  not  the  less  real  on  that  account, 
as  is  proved  by  numerous  examples. 
He  remarked  a  tendency  to  this  affection 
in  pregnant  women,  as  likewise  have  Jong 
and  Tardieu. 

Marce  states  that  many  observations  on 
the  subject  of  kleptomania  quoted  by  Es- 
quirol  are  evidently  cases  of  incipient 
general  paralysis;  but  independently  of 
.such  cases,  and  in  those  noticed  in  imbe- 
ciles and  dements,  others  are  recorded 
which  present  an  isolated  intellectual 
lesion,  and  an  ii-resistible  impulse  to  steal. 

Lasegue,  in  an  able  article  entitled  "  Le 
vol  aux  etalages  "  (Shop-lifting),  demon- 
strates the  existence  of  this  affection,  but 
regards  it  as  due,  not  so  much  to  irre- 
sistible impulse  as  to  cerebral  defect. 

A  desire  to  acquire  is  natural  to  every 
one.  This  feeling  in  persons  of  well- 
regulated  minds  and  honest  conceptions 
is  kept  under  control  of  the  will  ;  not  so. 


however,  in  the  case  of  the  professional 
thief,  who  regards  all  property  as  legiti- 
mate spoil,  and  with  whom  desire  is  soon 
followed,  if  possible,  by  possession.  There 
is  a  growing  disposition  amongst  the 
rising  school  of  criminal  anthropologists 
to  regard  the  majority  of  criminals  as 
persons  of  unsound  mind,  having  a  spe- 
cial neurosis,  to  look  upon  them  as  drawn 
to  crime  by  instinct.  Our  own  observa- 
tion leads  us  to  believe  that  the  pro- 
fessional thief,  setting  aside  those  of  weak 
mind,  is  not  a  ci'iminal  by  instinct,  but 
rather  from  the  force  of  bad  example  and 
a  criminal  education.  But  it  is  not  of 
him  we  would  speak,  the  opinion  of  the 
expert  is  not  called  for  in  his  case,  the  in- 
terest of  the  question  lies  with  those  indi- 
viduals whose  thefts,  as  Lasegue  state?, 
are  the  result  of  intellectual  disturbance. 

It  is  by  no  means  an  uncommon  occur- 
rence for  men,  but  especially  women,  of 
respectable  family,  who  move  about  in 
society,  and  who  are  able  to  satisfy  their 
wants  and  tastes,  to  be  arrested  on  a 
charge  of  stealing  articles  of  different 
value.  The  position  of  the  accused,  their 
correct  mode  of  living  in  the  past,  the 
nature  of  the  theft,  and  the  inconsiderable 
value  of  the  articles  stolen,  compared  with 
the  risk  of  detection  and  subsequent  ex- 
posure, all  tend  to  make  us  inquire,  how 
far  mental  disease  is  or  is  not  the  cause 
of  the  crime. 

These  cases  are  difficult,  the  plea  of 
irresistible  impulse  is  not  unfrequently 
adopted  in  extenuation  of  the  offence,  but 
unsupported  by  any  other  evidence  of 
mental  disturbance  it  is  indefensible. 
As  a  rule,  the  theory  of  irresistible  im- 
pulse is  incompatible  with  the  conduct  of 
the  accused;  generally  a  favourable 
moment  has  been  seized  to  execute  the 
theft,  art  and  precaution  have  been  em- 
ployed in  concealing  it,  and  either  a  denial 
of  the  act  when  detected  or  some  evasive 
excuse  has  been  made.  These  circum- 
stances do  not  remove  the  possibility  of 
insanity,  and  any  inquiry  into  the  mental 
state  ought  to  be  directed,  as  Lasegue  has 
pointed  out,  not  so  much  to  the  greater  or 
lesser  degree  of  the  impulse,  but  to  the  de- 
gree of  intellectual  confusion  or  weakness 
that  may  exist.  To  determine  this,  vari- 
ous points  requii'e  consideration  ;  as  I'e- 
gards  the  object,  the  inducement  to  steal, 
and  the  nature  and  value  of  the  articles 
stolen  ;  as  regards  the  subject,  whether 
there  was  a  perfect  consciousness  of  the 
act  and  its  illegality.  In  addition,  it  is  of 
considerable  moment  to  inquire  into  the 
family  history  and  antecedents,  to  estab- 
lish if  possible  the  existence  of  hereditary 
disease,  the  occurrence  of  tits  in  childhood 


Kleptomania 


[    727    ] 


Kleptomania 


or  any  evidence  of  mental  derangement 
prior  to  the  development  of  the  propensity. 
Symptoms  which  indicate  the  commence- 
ment of  general  paralysis  ought  to  be  par- 
ticularly noted.  The  com]>lications  of 
puberty  and  pregnancy,  the  presence  of 
physical  disorders,  a  history  of  head  injury, 
are  all  worthy  of  attention  ;  nor  must  the 
effect  of  alcohol  on  a  neurotic  tempera- 
ment be  overlooked  in  these  cases.  We 
are  cognisant  of  the  particulars  of  a 
case  where  a  lady  was  detected  stealing 
in  a  shop,  and  in  addition  to  various 
articles  of  wearing  apparel,  a  quantity  of 
brandy  was  found  in  her  possession. 
There  was  a  family  history  of  insanity, 
and  she  was  addicted  to  drink.  All  these 
circumstances  are  of  importance  in  at- 
tempting to  decide  the  existence  of  a  mor- 
bid mental  condition  which  might  have 
limited  the  intellectual  liberty  of  the  indi- 
vidual, and  which  alone  should  determine 
the  irresponsibility  of  the  accused. 

It  has  been  stated  that  pregnancy 
exerts  some  influence  in  the  development 
of  this  monomania.  Marc  alleges  that  a 
propensity  to  steal  shows  itself  in  women 
labouring  under  disordered  menstruation, 
and  in  those  far  advanced  in  pregnancy, 
the  motive  being  a  mere  wish  for  posses- 
sion. There  is  no  doubt  that  pregnant 
women  manifest  desires,  or,  as  they  are 
termed,  longings  for  various  things,  but  a 
distinction  ought  to  be  made  between 
those  longings,  which  have  for  their  object 
articles  of  food,  and  those  which  centre  on 
dress,  jewels,  &c.  On  the  one  hand  it  is 
known  that  utero-gestation  brings  about 
sympathetic  disturbances  in  the  whole  di- 
gestive system,  and  causes  not  only  such 
gastric  disturbances  as  sickness  and  vomit- 
ing, but  sometimes  also  an  excessive  or 
depraved  appetite.  The  cravings  result- 
ing from  this  morbid  state  of  the  appetite 
may,  according  to  Dr.  Playfair,  prove 
altogether  irresistible ;  to  appease  them 
theft  of  articles  of  food  may  be  resorted 
to.  Marc  details  the  case  of  a  wealthy 
lady  of  high  rank  in  society,  who,  being 
pregnant,  stole  a  roast  chicken  from  a 
pastry-cook's  shop,  in  order  to  satisfy  the 
keen  appetite  which  the  sight  and  smell 
of  this  dish  had  developed  within  her.  On 
the  other  hand,  when  the  longing  has  for 
its  object  articles  of  dress  or  jewels,  no 
such  physiological  explanation  is  forth- 
coming. Jong  states  that  pregnant  women 
do  not  steal  such  objects  as  the  result  of 
their  pregnant  condition,  but  from  bad 
instinct  or  gross  error.  He  further  re- 
marks that  women  of  the  lower  orders, 
who  willingly  indulge  in  longings  for  cer- 
tain aliments,  know  very  well  how  to 
abstain  from  stealing  from  fear  of  genera- 


ting in  their  children  a  like  predisposi- 
tion, thus  proving  that  i)regnant  women 
retain  possession  of  their  moral  liberty. 
Marco  endorses  Jong's  view  ;  Tardfeu  also 
agrees  with  him  on  the  whole,  but  makes 
the  reservation  that  pregnancy  may  in 
some  very  rare  instances  determine  in 
women  a  true  irresistible  impulse  to  theft. 
When  a  pregnant  woman  pleads  preg- 
nancy in  excuse  for  crime,  the  fact  of 
pregnancy  should  be  regarded  as  a  secon- 
dary consideration,  and  not  accepted  as 
direct  proof.  The  mental  condition  ought 
to  be  examined,  because  the  true  bearings 
of  the  case  are  much  more  likely  to  be 
elucidated  from  the  circumstances  accom- 
panying the  deed,  than  from  the  conside- 
ration that  she  is  pregnant. 

The  child  will  appropriate  what  does 
not  belong  to  it ;  the  fascination  of  a  new 
toy  or  the  appetite  aroused  by  a  favourite 
food  may  prove  too  strong.  There  is  in- 
ability to  resist  a  sudden  temptation.  In 
young  children  judicious  care  and  timely 
punishment  will  invariably  eradicate  the 
failiug.  There  are  certain  childi'en,  how- 
ever, of  a  morally  perverse  nature,  in 
whose  case  kindness  and  punishment  are 
alike  useless.  They  are  thieves  and  liars, 
and  are  cruelly  disposed,  because  it  is  in 
their  nature  to  be  so.  They  frequently 
possess  a  hereditary  neurosis  ;  they  are 
morally  insane.  Such  are  to  be  found  at 
a  later  age  in  schools :  they  pilfer  the 
property  of  their  companions.  Self- 
respect,  duty  towards  others,  reputation 
and  interest  are  forgotten,  and  it  is  a  bad 
omen  in  a  growing  lad  when  he  gives  way 
to  such  practices,  for  sometimes  the  evil, 
if  persisted  in,  becomes  incurable. 

There  are  certain  weak-minded  indi- 
viduals who  are  natural  criminals,  and 
amongst  them  petty  thieving  is  very 
common.  They  are  to  be  found  in  all 
classes  of  society.  They  are  intellectually, 
morally,  and  physically  degenerate,  and 
when  uncared  for  and  left  to  themselves, 
invariably  sink  into  the  dregs  of  the 
criminal  classes.  Such  are  more  or  less 
intellectually  weak,  yet  not  so  weak  that 
their  mental  state  excites  particular  atten- 
tion, unless,  perchance,  they  commit  some 
crime  involving  the  risk  of  life ;  their 
moral  nature  is  low,  and  their  physical 
state  below  par.  In  twenty-five  such  in- 
stinctive criminals  undergoing  sentence, 
mostly  for  repeated  acts  of  petty  larceny, 
we  found  a  low  receding  forehead,  a  weak 
lower  jaw,  a  contracted  high-arched  palate, 
weakly  developed  mammae  and  deficient 
sensibility,  the  most  general  marks  of 
physical  degeneracy.  Even  when  pro- 
tected from  want,  and  well  cared  for  by 
their   friends,    a    natural    propensity   to 


Kleptomania 


[    728    ] 


Kleptomania 


theft  will  betray  itself.  Take  the  case  of 
!M.  ;  he  had  been  at  school  but  never  ac- 
quired much  knowledge  ;  his  intellect  was 
limited.  He  possessed  three  different 
lodgings  in  Paris.  He  was  in  the  habit 
of  visiting  his  friend's  houses,  and  it  often 
happened  that  some  small  article  of  value 
was  missing  subsequent  to  his  visit.  Yet 
he  was  never  detected,  and  frequently 
servants  were  brought  into  trouble  and 
disgrace  owing  to  his  pilferings.  This 
system  continued  for  years.  After  his 
death,  which  hapi^ened  siiddenly,  in  each 
of  his  lodgings  a  miscellaneous  assortment 
of  articles  was  found,  which  he  had  pui'- 
loined  during  his  lifetime.  He  came  of  a 
neurotic  stock,  two  brothers  died  of  con- 
vulsions in  childhood,  and  an  uncle  was 
hypochondriacal. 

Amongst  the  insane  kleptomania  is  of 
most  frequent  occurrence  in  imbeciles, 
general  paralytics,  and  epileptics;  apart 
from  those  three  classes,  it  may  also  re- 
sult from  delusions. 

Theft  is  by  nomeans  infrequent  amongst 
idiots  and  imbeciles.  As  a  rule,  they 
steal  without  reflection,  and  merely  to 
satisfy  an  animal  instinct.  They  will 
purloin  whatever  takes  their  fancy.  Some- 
times they  display  a  considerable  amount 
of  ingenuity  and  low  cunning  in  their 
methods  of  procedure. 

It  is  an  important  point,  and  should 
always  be  borne  in  mind,  that  acts  of 
stealing  occur,  and  are  amongst  the  first 
noticeable  symptoms  in  the  initiatory 
stages  of  general  paralysis.  When  a  man 
in  apparent  health  attaches  undue  im- 
portance to  some  article  of  no  great  value, 
and  finally  carries  it  away  surreptitiously, 
it  is  more  than  probable  that  his  conduct 
is  the  result  of  cerebral  disease.  In  the 
Journal  of  Mental  Science,  January  1873, 
Dr.  Burman  has  related  six  interesting 
cases.  All  were  convicted  of  stealing  and 
sent  to  prison,  and  in  all  of  them  general 
paralysis  became  manifest  soon  after- 
wards. 

The  same  propensity  is  observed  in  the 
later  stages  of  the  same  disease.  The 
patients  steal  under  the  delusion  that 
everything  belongs  to  them.  They  appro- 
priate all  sorts  of  articles,  hoard  and  con- 
ceal them,  and  immediately  afterwards 
lose  all  recollection  of  them.  To  satisfy 
their  gluttonous  appetites  they  will  steal 
food,  and  in  their  hurry  and  eagerness  to 
devour  it,  disastrous  consequences  some- 
times ensue ;  suffocation  has  been  known 
to  take  place  in  such  circumstances.  We 
can  remember  one  patient,  in  Dundee 
Royal  Asylum,  who  snatched  a  piece  of 
meat  from  a  plate  which  an  attendant  was 
carrying,  bolted  it,  and  died  before  assist- 


ance could  be  rendered,  the  meat  having 
become  impacted  in  his  throat. 

Again,  theft  may  be  the  unconscious 
act  oi  an  epileptic.  Of  128  epileptics 
admitted  into  Broadmoor  Asylum  dur- 
ing the  twenty-three  years  (i  864-1 887), 
twenty-three  had  been  charged  with 
larceny.  Legrand  du  SauUe  has  recorded 
a  number  of  instances  where  acts  of  steal- 
ing were  committed  by  vertiginous  epi- 
leptics. One  case  in  particular  is  note- 
worthy. The  patient  was  a  young  man 
who  experienced  curious  sensations  in  the 
epigastric  region  about  three  or  four  times 
a  year.  This  aura  was  invariably  fol- 
lowed, for  a  period  varying  from  a  few 
hours  to  three  days,  by  confusion  of  the 
intellect.  During  this  time,  and  when  in 
his  confused  state,  he  displayed  a  strong 
l^ropensity  for  stealing,  although  at  other 
times  he  was  scrupulously  well  behaved. 
When  his  intellect  became  clearer  he  was 
questioned  with  reference  to  his  strange 
conduct,  but  declared  he  remembered 
nothing,  Legrand  du  SauUe,  in  summing 
up  the  case,  states  that,  taking  into  con- 
sideration the  aura,  the  supervening 
mental  disturbance,  the  amnesia,  and  the 
invariably  similar  character  of  the  acts 
committed,  it  was  clear  that  larvated  epi- 
lepsy was  the  sole  cause  of  this  unusual 
vesauia  and  abnormal  criminality. 

In  conclusion,  we  find  that  genuine 
kleptomania  does  not  proceed  from  irre- 
sistible impulse  so  much  as  from  a  morbid 
mental  condition.  This  latter  is  in  many 
instances  difficult  to  establish.  In  every 
case  it  is  impoi'tant  to  investigate  the 
antecedents  of  the  individual.  The  plea 
of  ii-resistible  impulse  alone  is  indefensible, 
and,  unless  sufficient  data  are  foi^thcoming 
to  establish  a  pathological  state  of  intel- 
lectual weakness,  the  accused  person 
ought  to  be  held  responsible. 

The  state  of  pregnancy  cannot  be  held 
as  an  exculpatory  plea  in  cases  of  stealing 
unless  sujojiorted  by  other  evidence  of 
mental  derangement. 

Acts  of  theft  may  be  due  to  the  pre- 
sence of  moral  insanity  in  certain  children. 

The  weak-minded  are  prone  to  commit 
petty  acts  of  larceny.  Their  mental  state 
ought  to  be  inquired  into  whatever  the 
nature  or  magnitude  of  the  offence.  They 
are  intellectually  and  physically  degene- 
rate. 

Imbeciles  and  idiots  steal  without  re- 
flection and  merely  to  satisfy  an  animal 
instinct. 

The  importance  of  the  occurrence  of 
acts  of  theft  as  one  of  the  symptoms  in 
the  early  stages  of  general  paralysis  can- 
not be  over-estimated.  It  has  happened 
that  men  have  been  convicted   and  im- 


Klikuschi 


[     729    ] 


Lathyrism 


prisoned  for  stealing,  who  soon  afterwards 
developed  most  marked  symptoms  of  this 
disease.  Were  the  evolution  of  the 
symptoms  of  mental  diseases  more  gene- 
rally recognised  aud  understood  an  im- 
provement might  be  looked  for  in  dealing 
with  such  cases. 

Theft  may  be  the  unconscious  crime  of 
an  epileptic,  or  the  unmeaning  act  of  a 
dement.  J.  Bakkr. 

[/i'fi  ri'iici'S. — Uuckuill  aiul  TuUc,  rsyi'liolo!4ical 
Mt'diciue.  Taylor,  Medical  Jiirisiiriulouce.  Marce, 
Trait(5  dc  la  Folic  des  Femuies  Knceiiitcs,  and 
Maladies  Mentalus.  Trelat,  La  Folic  Lucidc. 
Tardien,  Sur  la  Kolie.  Lei;raud  du  .Saullc, 
Gazette  des  Hopitaux,  Xov.  1876.  I>asei;ue 
■<abstract  liy  .Motet),  .Joiirual  of  ^Aleutal  Science, 
Jan.  1881.]" 

xiiZKUSCHZ.— A  hysterical  psycho- 
pathy of  an  epidemic  and  endemic  charac- 
ter, occurring  among  the  females  of  Kursk 
and  Orel.  The  attacks  have  been  de- 
scribed by  some  as  pure  hysteria,  others 
give  evidence  of  phenomena  of  a  hystero- 
epileptiform  type,  while  some  writers 
-describe  attacks  of  such  severity  as  to 
simulate  paroxysms  of  acute  mania.  The 
subjects  are  called  Klikuschi  (*'  screaming 
women  possessed")  and  the  attacks  are 


mainly  influenced  by  religious  emotion  ; 
they  last  usually  for  a  short  time  only, 
but  they  may  continue  for  a  whole  day  or 
more  in  a  succession  of  paroxysms.  It  re- 
sembles in  its  features  the  "  Ikota "  of 
the  Samojeds  (q-v.). 

KiiOPElvXAN-ZA  (also  Clopemania) 
((cXoTT?/,  theft  ;  jjMvia,  madness).  A  syno- 
nym of  kleptomania  (r/.u.). 

KOFZOPZ.A.  HYSTERICA  (kotto;, 
weariness  ;  wr//-,  the  eye;  hysteria,  ((.v.).  A 
term  applied  to  the  nervous  phenomena 
associated  with  weakness  of  vision  in  a 
hysterical  person.  The  symptoms  are 
described  as  hyperassthesia  of  the  fifth 
and  optic  nerves,  with  loss  of  power  of 
accommodation  and  inability  to  main- 
tain a  persistent  effort  of  fixation  on  any 
object. 

KREIDIiZNCS,      KRETZIfS.  {See 

Cretin.) 

KVTVBUTH  (Arab).  An  old  term  for 
a  form  of  melancholia  which  was  said  to 
affect  people  chiefly  in  the  month  of 
February.  It  was  characterised  by  great 
restlessness,  the  patients  wandering  to 
and  fro  continually,  quite  unconscious 
whither  they  were  going. 


I.ACTATZON'SZRRESEZN'.  The  Ger- 
man term  for  lactational  insanity. 

ZiAGirEZA  FUROR  {Xayveia,  lust  ; 
J'uror,  madness).  Insanity  with  unbridled 
appetency,  including  nymphomania  and 
satyriasis  (Mason  Good). 

ZiAGNESZS  ;  XiACSTEIA  (Kciyvos,  lust- 
ful, or  Xayveia).  A  term  for  an  excessive 
or  morbid  venereal  appetite. 

XiAGWOSZS  {Xdyvos,  lustful).  A  Syno- 
nym of  Satyriasis. 

XiAliOPATHY  (KaXos,  talkative  ;  Tcddos, 
a  disease).  A  synonym  of  Aphasia.  Also 
any  disorder  or  defect  of  speech. 

Ii  AIiOPZiEGZ  A  (XdXos, talkative ;  TrXrjyrj, 
a  stroke).  Paralysis  of  speech  from  what- 
ever cause. 

IiARVATES  EPZI.EPSY.  {See  Epi- 
LEPSIE  LAUVKK.) 

I.ARYM-GZSMVS  (Xapu-yyifw,  I  vocife- 
rate). Besides  the  ordinary  meaning  of  this 
word — spasm  of  the  laryngeal  muscles  only 
— Marshall  Hall  has  applied  the  term  to 
express  a  symptom  or  group  of  symptoms 
occurring  in  convulsive  diseases — e.g.,  in- 
fantile eclampsia,  epilepsy,  hysteria,  and 
hydrophobia — in  which  cases  the  larynx 
is  sometimes  partially-,  sometimes  com- 
pletely, closed. 


XARYNX,  HYSTERZCAIi  AFFEC- 
TZONS  OF. — The  laryngeal  developments 
of  hysteria  are  chiefly  aphonia  and  a 
short  dry  cough.     {See  Hysteria.) 

XiASCZVUS  (Zascifits,  unrestrained).  A 
Paracelsian  term  for  chorea,  in  allusion  to 
the  character  of  the  motor  symptoms. 

IiATA. — The  Malay  name  under  which 
a  form  of  religious  hysteria  is  known  in 
Java.  It  is  chiefly  found  among  the 
native  women,  both  of  the  higher  and 
lower  social  ranks,  and  is  marked  by 
paroxysmal  outbursts  which  take  the 
form  of  rapid  ejaculations  of  inarticulate 
sounds  and  of  a  succession  of  involuntary 
movements ;  there  is  temporary  loss  of 
consciousness,  but  the  mental  powers  re-' 
main  quite  intact  except  during  the  par- 
oxysm. The  disease  is  propagated  by 
imitation  (Hirsch). 

ZtATAH.      {See  MiRYACUIT.) 

IiATHYRZSIvx.  (Lathyrisme  medul- 
laire  spasmodique.  Lathyrismus.)  — 
Catani  proposes  this  name  icor  a  disease 
presenting  the  same  form  as  spastic  spinal 
paralysis,  caused  by  poisoning  with  several 
kinds  of  lathyrus,  which  is  the  name  of 
a  leguminous  plant  cultivated  in  the 
centre  and  the  South  of  France  ("gesses  "), 


Lathyrism 


[    730    ] 


Law  of  Lunacy 


in  Italy  and  Algeria  ("  djilbes "),  used 
partly  as  food  for  cattle,  and  partly,  under 
certain  conditions,  as  food  for  man. 

The  iirst  accounts  of  this  disease  were 
handed  down  from  antiquity.  "  At  times, 
those  wiio  contini;ousiy  lived  on  legu- 
minous plants  were  attacked  by  weak- 
ness in  the  loins,  which  remained ;  but 
also  those  who  lived  on  peas  (opo/Soy),  had 
pains  in  their  knees."     (Hippocrates.) 

In  more  recent  times  we  have  reports 
of  large  numbers  being  attacked  by 
lathyrism  from  some  districts  of  France 
(Departement  Loire  et  Cher),  from  Italj"^ 
(Abruzzo,  Latium),  from  India  (Allaha- 
bad), and  from  Algeria.  The  best  account 
of  it  we  have  is  that  by  Bouchard  and 
Proust,  whoobservedthedisease  in  Kabylia 
(Algeria,  province  of  Palestro). 

The  poisoning  was  always  produced  by 
mixing  the  corn-Hour  for  tbe  prepara- 
tion of  bread  with  flour  prepared  from 
lathyrus  (in  equal  parts  or  more),  in  cases 
where  corn  could  not  be  obtained  in  suffi- 
cient quantity  on  account  of  poverty, 
famine,  bad  soil,  climate,  or  unfavourable 
weather. 

It  seems  that  Lathyrus  cicera  and  L. 
clymenum  are  especially  poisonous ;  it 
has  been  maintained  that  only  the  crops 
of  certain  years  jiroduce  lathyrism.  The 
poison  is  contained  in  the  healthy  seed, 
unlike  to  ergotism  and  pellagra,  where 
the  poisoning  is  produced  by  diseased 
corn  or  maize  respectively. 

The  disease  attacks  people  of  any  age, 
who  for  some  time  (at  least  several  weeks) 
have  been  living  exclusively  or  mostly 
on  lathyrus,  generally  during  the  rainy 
season ;  a  cold  is  often  stated  as  the  ex- 
citing cause.  The  disease  mostly  breaks 
out  suddenly,  often  during  the  night  with 
pains  in  the  lumbar  region,  with  a  girdle 
sensation,  pains  in  the  legs,  and  para- 
lysis of  the  lower  extremities,  which  after 
a  while  develop  into  spastic  paraplegia. 
The  patients  on  awaking  feel  weakness  and 
tremor  in  their  legs,  so  that  they  can  rise 
and  walk  only  with  difficulty.  Afterwards 
stiffness  in  the  legs  comes  on  with  a  con- 
siderable resistance  to  active  and  passive 
flexion.  Walking  becomes  imjjossible,  or 
is  possible  only  with  the  help  of  a  long 
stick,  grasped  with  both  hands  and  put 
down  in  front  of  the  feet.  The  legs, 
which  are  in  a  state  of  rigid  extension  with 
the  thigh  adducted,  are  dragged  forwards 
with  flexion  of  the  knee,  with  the  toes 
flexed,  the  heel  raised  up,  and  the  foot 
slightly  rotated  inwards  ;  and  on  advanc- 
ing one  leg  the  whole  body  is  thrown  for- 
wards. Only  the  toes  touch  the  ground, 
and  they  collide  with  eveiy  obstacle,  so 
that  the  patient  easily  stumbles  and  the 


dorsal  surface  of  the  toes  becomes  sore 
through  constant  friction. 

The  tendon  reflexes  of  the  lower  ex- 
tremities are  greatly  increased,  including 
ankle  clonus. 

The  exaggeration  of  the  myotatic  ex- 
citability can  also  be  seen  in  spontaneous 
clonic  action  of  the  foot  in  standing,  walk- 
ing, or  sitting  with  the  heel  raised,  and 
this  is  imparted  to  the  whole  body  in  the 
form  of  vertical  oscillations. 

The  upper  extremities  are  perfectly  free 
from  motor  derangements.  The  sensi- 
bilit}^  and  reflex  excitability  of  the  skin 
do  not  show  any  constant  disturbances, 
not  even  in  the  lower  extremities.  Some 
reports,  however,  mention  insensibility  of 
the  lower  extremities  and  paraesthesia 
(formication). 

There  is  generally  no  atrophy  of  the 
muscles  nor  are  there  vaso-motor  de- 
rangements, but  retention  and  incon- 
tinence of  urine  as  well  as  sexual  impo- 
tence are  constantly  among  the  first  symp- 
toms. Cerebral  symptoms  and  general 
dei-angements  of  nutrition  are  absent. 

When  the  patients  abstain  fi'om  taking 
the  infected  food,  the  disease  terminates 
after  some  weeks  or  months  in  recovery.  In 
othercases,  spastic  phenomena  in  the  lower 
extremities  remain  permanently  and  some- 
times genuine  contractures  may  develop. 
We  do  not  know  of  any  case  in  which  the 
disease  has  terminated  fatally,  and  there- 
fore there  has  not  yet  been  any  post-mortem 
examination  of  lathyrism.  Although  we 
do  not  know  anything  yet  about  the  con- 
dition of  the  nervous  system,  all  the 
symptoms  seem  to  point  to  a  disease  of 
the  lateral  columns  of  the  spinal  cord,  so 
that  lathyrism  would  have  to  be  placed 
in  one  class  with  ergotism  which  affects 
the  posterior  column,  and  with  pellagra 
which  affects  the  lateral  and  posterior 
columns  combined. 

The  chemical  nature  of  the  poison  is 
also  quite  unknown  to  us  (alkaloid.'' 
Marie).  Paralysis  of  the  lower  extremities 
has  been  produced  in  animals  (rabbits)  by 
poisoning  with  lathyrus  and  by  an  injec- 
tion of  an  extract  of  the  seed  of  Lathyrus 
cicera.  Farmers  have  sometimes  lost  aU 
their  cattle  and  horses  through  lathyrus 
poisoning. 

The  treatment  follows  from  the  aetiology. 
F.  TrczEK. 

IiATV  OF  I.XTN-ACY,  1890  and  189U 
— An  abstract  of  the  law  relating  to  the 
reception  of  lunatics  into  asylums,  hos- 
pitals, or  licensed  houses,  and  into  private 
houses  as  patients  under  single  care, 
together  with  the  law  bearing  upon  theii- 
care  and  treatment,  and  their  removal 
and  discharge. 


Law  of  Lunacy 


L     731 


Law  of  Lunacy 


The  space  at  our  disposal  will  not  per- 
mit of  more  than  a  condensed  account  of 
the  law  as  it  stands  especially  with  regard 
to  the  duties  imposed  upon  medical  prac- 
titioners in  carrying  out  its  various  pro- 
visions. The  forms  which  ai'e  neces- 
sary for  the  reception,  discharge,  or  re- 
moval of  patients  are  given,  and  these 
are  deemed  sufficient  for  the  purposes  of 
this  abstract.  The  Lunacy  Act,  1890, 
which  came  into  operation  on  May  i,  1890, 
includes  the  Lunacy  Amendment  Act, 
1 889.  It  is  intended  to  consolidate  certain 
of  the  enactments  respecting  lunatics,  and 
will  now  be  the  standard  for  regulating  all 
matters  connected  with  the  care  and  treat- 
ment of  the  insane  in  England  and  Wales. 

Provisions  for  Placing:  Iiunatics 
under  Care  and  Treatment.  —  Under 
the  provisions  of  this  Act : 

(Sec.  9)  No  person  can  be  placed  under 
care  and  treatment  or  be  received  and 
detained  in  an  institution  for  lunatics, 
except  upon  "judicial  authority"  or  when 
found  lunatic  by  inquisition.  The  jiowers 
of  this  judicial  authority  shall  only  be 
exei'cised  by  a  justice  of  the  peace  specially 
appointed,  or  a  judge  of  County  Courts, 
or  a  magistrate.* 

(Sec.  10)  Justices  so  appointed  shall  be 
selected  with  regard  to  the  convenience 
of  the  inhabitants  of  each  petty  sessional 
division  of  the  county  and  the  appoint- 
ments shall  be  made  annually  l9y  the 
justices  of  a  county  at  the  Quarter 
Sessions  held  in  October,  and  all  such 
appointments  shall  be  published  in  each 
petty  sessional  division. 

Urgency. —  (Sec.  11)  In  cases  of  urgency, 
however,  any  person  (but  if  possible  a 
relative  of  the  alleged  lunatic)  who  is 
twenty-one  years  of  age,  and  who  has  seen 
the  alleged  lunatic  within  two  days  of  the 
date  of  the  order  under  which  a  person 
may  be  detained  as  a  lunatic,  may  sign 
an  "  urgency  order  "  {see  Form  4)  if  "  it 
is  expedient  either  for  the  welfare  of  the 
person  (not  a  pauper) alleged  to  bealunatic 
or  for  the  public  safety  that  the  alleged 
lunatic  should  be  forthwith  placed  under 
care  and  treatment;"  such  order  must 
be  accompanied  by  one  medical  certificate 
and  shall  remain  in  force  for  seven  days 
from  its  date.  It  may  be  made  before  or 
after  a  petition  is  presented  :  if  a  petition 
is  pending  it  remains  in  force  until  the 
petition  is  finally  disposed  of. 

The  medical  practitioner  signing  the 
certificate  shall  have  personally  examined 
the  patient  not  more  than  two  clear  days 

*  An  order  for  the  reception  of  a  patient  shall 
not  be  invalid  if  signed  by  a  .1.1*.  other  than  one 
specially  appointed,  if  tlic  order  is  subsef|uently 
sijjned  within  14  days  by  u  ''judicial  authority.'' 


before  his  reception  and  shall  state  the 
date  of  such  examination  in  the  certificate 
(see  Forms  8  and  9). 

Reception  Order. — (Sec.  4)  To  obtain 
an  order  (Form  3)  for  the  reception  of  a 
person  (not  a  pauper  or  criminal  lunatic) 
a  petition  (Form  i)  must  be  presented  to 
a  judicial  authority,  if  possible,  by  the 
husband,  wife,  or  relative  of  the  alleged 
lunatic,  or  if  not  so  presented  it  shall  con- 
tain a  statement  of  the  reasons  why  it  is 
not  so  presented,  and  of  the  connection 
of  the  petitioner  with  the  alleged  lunatic. 
The  petition  must  be  accompanied  by  two 
medical  certificates  on  separate  sheets  of 
paper  as  to  the  mental  condition  of  the 
alleged  lunatic  (Form  8). 

(Sec.  5)  The  petitioner  must  be  twenty- 
one  years  of  age,  he  must  have  seen  the 
alleged  lunatic  within  fourteen  days  before 
presenting  the  petition,  and  shall  himself 
undertake  to  visit  the  patient  twice  every 
six  months,  or  appoint  some  one  to  do  so. 
(Sec.  31)  Whenever  practicable,  one  of 
the  medical  certificates  accompanying  the 
petition  shall  be  signed  by  the  usual 
medical  attendant  of  the  alleged  lunatic  ; 
if  it  is  not  practicable  to  obtain  a  certifi- 
cate from  him  the  reason  must  be  stated 
in  writing  by  the  petitioner,  and  such  state- 
ment shall  be  part  of  the  petition.  Bach 
of  the  two  persons  signing  the  medical 
certificates  shall  separately  from  each 
other  personally  examine  the  patient  not 
more  than  seven  clear  days  before  the 
presentation  of  the  petition.  If  upon  the 
presentation  of  the  petition  the  judge  or 
justice  is  satisfied  with  the  evidence  of 
lunacy  he  may  make  an  order  forthwith, 
or  appoint  a  time  (sec.  6),  not  more  than 
seven  days  after  the  presentation  of  the 
petition,  for  the  consideration  thereof. 
The  judge  or  justice  if  bethink  necessary 
may  visit  the  alleged  lunatic.  The  petition 
shall  be  considered  in  private,  and  no 
persons  but  those  interested  shall  be  pre- 
sent without  the  permission  of  the  judge 
or  justice,  and  he  may  make  an  order, 
dismiss  the  petition  or  adjourn  the  con- 
sideration of  it  for  any  period  not  exceed- 
ing fourteen  days  ;  all  persons  admitted 
to  be  present  shall  be  bound  to  secrecy. 
(Sec.  7)  If  the  petition  is  dismissed  the 
judge  or  justice  shall  deliver  to  the 
petitioner  in  writing  his  reasons  for  dis- 
missing it,  and  send  a  copy  to  the  com- 
missioners, who  may  give  such  information 
as  they  think  proper  to  the  alleged  lunatic 
or  other  proper  person,  and  if  a  second 
petition  is  presented  the  person  present- 
ing it  shall  state  the  facts  concerning  the 
first  petition  and  its  dismissal. 

Authority  for  Reception.— (Sec.  35)  A 
reception  order  thus  obtained  shall  be  suffi- 


Law  of  Lunacy 


[    732    ] 


Law  of  Lunacy 


cient  authority  to  take  the  lunatic  to  the 
place  mentioned  in  the  order  for  his  recep- 
tion and  detain  him  there.  All  the  neces- 
sary documents  shall  be  delivered  to  the 
petitioner  and  shall  be  sent  by  him  to  the 
person  receiving  the  lunatic.  (Sec.  36) 
Where  a  lunatic  has  been  temporarily 
placed  in  a  workhouse  he  may  be  received 
in  the  institution  for  lunatics  named  in  the 
order  any  time  within  fourteen  days. 
And  if  his  removal  has  been  suspended  by 
a  medical  certificate  of  unfitness  for  re- 
moval he  may  be  received  in  the  institution 
for  lunatics  mentioned  in  the  order  within 
three  days  after  date  of  a  medical  certifi- 
cate that  he  is  fit  to  be  removed.  The 
reception  order  lapses  if  the  lunatic  is  not 
received  under  it  before  the  expiration  of 
seven  clear  days. 

Rig-bt  of  Iiunatic  to  be  seen  by  a 
Justice. — (Sec.  8)  If  a  lunatic  has  been 
received  as  a  private  patient  under  a 
judicial  order  without  seeing  a  judge  or 
justice  he  shall  have  the  right  to  be  taken 
before  or  visited  by  one  unless  the  medical 
superintendent  sign  a  certificate  within 
twenty-four  hours  of  the  patient's  recep- 
tion that  such  right  would  be  jDrejudicial 
to  the  patient  (see  Form  5).  Subject  to  such 
certificate,  the  person  receiving  the  patient 
shall  give  notice  of  his  right  in  writing 
to  the  patient  (see  Form  6)  within  twenty- 
four  hours  after  his  recei^tion,  and  if 
within  seven  days  he  wishes  to  exercise 
the  right  shall  get  him  to  sign  a  notice  to 
that  effect  {see  Form  7),  and  shall  post  it 
to  the  judge,  or  justice,  or  justices'  clerk 
of  the  petty  sessional  division  or  borough 
where  the  lunatic  is,  and  the  judge  or  jus- 
tice shall  arrange  as  soon  as  conveniently 
may  be  to  visit  the  patient  or  have  him 
brought  before  him.  The  judge  or  justice 
shall  be  entitled  to  see  all  documents,  and 
after  personally  seeing  the  patient  shall 
report  to  the  commissioners.  Any  person 
having  charge  of  a  lunatic  omitting  to  per- 
form any  duty  in  connection  with  such 
right  of  a  patient  to  see  a  judge  or  justice 
shall  be  guilty  of  a  misdemeanour. 

Reception  Order  after  Inquisition. — 
(Sec.  12)  A  lunatic  so  found  after  inquisi- 
tion may  be  received  in  an  institution  for 
lunatics,  or  as  a  single  jDatient  upon  an 
order  signed  by  the  committee  of  the 
person  of  the  lunatic  and  having  annexed 
thereto  an  office  copy  of  the  order  appoint- 
ing the  committee;  or,if  no  such  committee 
has  been  appointed,  upon  an  order  signed 
by  a  master. 

Xiunatics  not  under  Proper  Care  and 
Control,  or  cruelly  treated  or  neg:- 
lected. — (Sec.  13)  Every  constable,  re- 
lieving-officer,  and  overseer  of  a  pai'ish 
who  has  knowledge  that  any  person  within 


his  district  or  parish,  lolw  is  not  a  pauper 
and  not  v.-d/iiderlnr/  at  large,  is  deemed  to 
be  a  lunatic,  and  is  not  under  i)roper  care 
and  control,  or  is  cruelly  treated,  or 
neglected,  by  any  relative  or  other  person 
having  care  or  charge  of  him,  shall  within 
three  days  of  obtaining  such  knowledge 
give  information  thei'eof  upon  oath  to  a 
justice  specially  appointed  under  this  Act, 
who  receiving  such  information  upon  oath, 
from  any  person  whomsoever,  that  a 
person  within  the  limits  of  his  jurisdiction 
is  so  cruelly  treated  or  neglected,  or  not 
under  proper  care  and  control,  may  him- 
self visit  the  alleged  lunatic.  Or  without 
visiting  him,  authoi'ise  two  medical  prac- 
titioners to  examine  him  and  certify  as  to 
his  mental  state,  and  shall  proceed  in  the 
same  manner  as  if  a  petition  for  a  recep- 
tion order  had  been  presented  to  him  by 
the  person  giving  the  information  with 
regard  to  the  alleged  lunatic.  If  the 
justice  is  satisfied  after  such  inquiry  that 
the  alleged  lunatic  is  a  lunatic  and  is 
neglected,  or  cruelly  treated  by  any  re- 
lative or  person  having  charge  of  him,  and 
that  he  is  a  proper  person  to  be  detained 
under  care  and  treatment,  the  justice  may 
order  him  to  be  received  into  any  institu- 
tion for  lunatics,  to  which  if  a  pauper  he 
might  be  sent  under  this  Act,  and  the 
constable,  relieving-officer,  or  overseer 
upon  whose  information  the  order  has  been 
made,  or  any  constable  whom  the  justice 
may  require  to  do  so,  shall  forthwith  convey 
the  lunatic  to  the  institution  named  in 
their  order. 

(Sec.  14)  The  medical  officer  of  a  union, 
if  he  knows  that  a  pauper  in  his  district 
is  a  lunatic,  and  a  proper  person  to  be 
sent  to  an  asylum,  shall,  within  three 
days  of  such  knowledge,  give  notice 
thereof  to  the  relieving-officer  or  overseer, 
who  shall  give  notice  within  three  days  to 
a  justice,  who  shall  order  the  pauper  to 
be  brought  before  him  and  some  other 
justice  within  three  days. 

Iiunatic  VTandering:  at  Iiarge. — (Sec. 
15)  Evei'y  constable,  relieving-officer,  and 
overseer  of  a  parish  who  has  knowledge 
that  any  person  (whether  pauper  or  not) 
wandering  at  large  within  their  respective 
districts  is  deemed  to  be  a  lunatic,  shall 
immediately  take  the  alleged  lunatic  be- 
fore a  justice,  who,  upon  the  information 
of  any  'person,  may  cause  the  alleged 
lunatic  to  be  brought  before  him.  and 
shall  call  in  a  medical  practitioner,  and 
shall  examine  the  alleged  lunatic,  and 
make  such  inquiries  as  he  thinks  advis- 
able. And  if  the  justice  (sec.  16)  is  satis- 
fied that  the  alleged  lunatic  is  a  proper 
person  to  be  detained,  and  the  medical 
practitioner    signs   a   medical   certificate 


Law  of  Lunacy 


[     733     ] 


Law  of  Lunacy 


with  regard  to  the  lunatic,  the  justice 
may  by  order  direct  the  hinatic  to  be 
conveyed  to,  received,  and  detained,  in  an 
institution  for  lunatics  named  in  the 
order.  (Sec.  17)  Such  justice  may  ex- 
amine the  alleged  lunatic  at  his  own 
house  or  elsewhere. 

(Sec.  18)  Unless  a  justice  is  satisfied 
that  a  lunatic  is  a  pauper,  he  shall  not 
sign  an  order  for  his  reception  into  an 
institution  for  lunatics  or  workhouse.  A 
person  visited  by  the  medical  officer  at 
the  expense  of  the  union  shall  be  deemed 
a  pauper. 

(Sec.  19)  A  justice  making  an  order  for 
the  reception  of  a  lunatic  otherwise  than 
upon  petition,  in  this  Act  called  "  a  sum- 
mary reception  order,"  may  suspend  the 
execution  of  the  order  for  such  period,  not 
exceeding  fourteen  days,  as  he  thinks  fit, 
and  in  the  meantime  may  give  such 
directions  or  make  such  arrangements  for 
the  proper  care  and  comfort  of  the  lunatic 
as  he  considers  proper. 

If  a  medical  practitioner  who  examines 
a  lunatic  as  to  whom  a  summary  I'eception 
order  has  been  made,  and  certifies  in 
writing  that  the  lunatic  is  not  in  a  fit 
state  to  be  removed,  the  removal  shall  be 
suspended  until  the  same  or  some  other 
medical  practitioner  certifies  in  writing 
that  the  lunatic  is  fit  to  be  removed.  Any 
medical  practitioner  who  has  certified  that 
the  lunatic  is  not  in  a  fit  state  to  be  re- 
moved shall,  as  soon  as  in  his  judgment 
the  lunatic  is  in  a  fit  state  to  be  removed, 
be  bound  to  certify  accordingly. 

Removal  of  Iiunatic  to  Workhouse 
in  Urgent  Cases. —  (Sec.  20)  If  a  con- 
stable, relieving-olficer,  or  overseer  is 
satisfied  that  it  is  necessary  for  the  public 
safety  and  the  welfare  of  an  alleged  lunatic 
that  he  should  be  at  once  placed  under 
care  and  control,  such  constable,  officer, 
or  overseer  may  remove  the  alleged  lunatic 
to  the  workhouse,  and  the  master  of  the 
workhouse  shall  (unless  there  is  no  proper 
accommodation  in  the  workhouse  for  the 
alleged  lunatic)  receive,  relieve,  and  detain 
him  therein,  lor  not  more  than  three  days, 
and  before  the  expiration  of  that  time  the 
constable,  relieving-officer,or  overseer  shall 
take  such  proceedings  with  regard  to  the 
alleged  lunatic  as  are  required  by  this  Act. 

(Sec.  21)  Any  justice,  if  satisfied  that 
it  is  expedient  for  the  welfare  of  the 
lunatic  or  for  the  public  safety,  may  make 
an  order  for  the  receiDtioa  of  such  lunatic 
into  a  workhouse,  if  there  is  proper  accom- 
modation. In  any  case  where  a  summary 
reception  order  might  be  made,  such  order 
may  be  made  to  provide  for  the  detention 
of  the  lunatic  until  he  can  be  removed,  but 
not  for  a  period  Ijeyoud  fourteen  days. 


(Sec.  22)  In  the  case  of  a  lunatic  as  to 
whom  a  summary  reception  order  may  be 
made,  nothing  in  this  Act  shall  prevent  a 
relation  or  friend  from  taking  the  lunatic 
under  his  own  care,  if  a  justice  having 
jurisdiction  to  make  the  order,  or  the 
visitors  of  the  asylum  in  which  the  lunatic 
is  intended  to  be  placed,  shall  be  satisfied 
that  proper  care  will  be  taken  of  him. 

Reception  Order  by  two  Commis- 
sioners.—  (Sec.  23)  Any  two  or  more 
commissioners  may  visit  a  pauper  or 
alleged  lunatic  not  in  an  institution  for 
lunatics  or  workhouse,  and  may,  if  they 
think  fit,  call  in  a  medical  practitioner, 
and  if  he  signs  a  medical  certificate  with 
regard  to  the  lunatic,  and  the  commis- 
sioners are  satisfied  that  the  ])auper  is  a 
lunatic,  they  may  send  him  to  an  institu- 
tion for  lunatics. 

(Sec.  24)  If  the  medical  officer  of  a 
workhouse  certifies  that  a  person  therein 
is  a  lunatic  or  a  proper  person  to  be 
allowed  to  remain,  and  that  there  is 
accommodation  sufficient  for  his  care  and 
treatment,  such  certificate  shall  authorise 
his  detention  against  his  will  for  fourteen 
days  pending  a  justice's  order.  (Sec.  25) 
A  pauper  discharged  from  an  asylum  not 
recovered  may  also  be  detained  in  a  similar 
manner  in  a  workhouse. 

Requirements  of  Reception  Orders 
and  Medical  Certificates. — (Sec.  28)  A 
reception  order  shall  not  be  made  upon 
a  medical  certificate  founded  only  upon 
facts  communicated  by  others. 

(Sec.  29)  A  reception  order  shall  not  be 
made  unless  the  medical  practitioner  who 
signs  the  medical  certificate,  or  where  two 
certificates  are  required,  each  medical 
practitioner  who  signs  a  certificate,  has 
personally  examined  the  alleged  lunatic 
in  the  case  of  an  order  upon  petition  not 
more  than  seven  clear  days  before  the 
date  of  the  presentation  of  the  petition, 
and  in  all  other  cases  not  more  than  seven 
clear  days  before  the  date  of  order. 

Where  two  medical  certificates  are  re- 
quired, a  reception  order  shall  not  be 
made  unless  each  medical  practitioner 
signing  a  certificate  has  examined  the 
lunatic  separately  from  the  other  :  and  in 
the  case  of  an  urgency  order,  the  lunatic 
shall  not  be  received  unless  the  certifying 
medical  practitioner  has  seen  the  patient 
not  more  than  two  clear  days  before  his 
reception. 

Persons  disqualified  from  signing 
IMCedical  Certificates. — (Sec.  30)  A  medi- 
cal certificate  accompanying  a  petition  for 
a  reception  order,  or  accompanying  an 
urgency  order,  shall  not  be  signed  by  the 
petitioner  or  person  signing  the  urgency 
order,  or  by  the  husband  or  wife,  father  or 


Law  of  Lunacy 


[     734     j 


Law  of  Lunacy 


father-in-law,  mother  or  mother-ia-law, 
son  or  son-in  law,  daughter  or  daughter- 
in-law.  brother  or  brother-in-law,  sister  or 
sister-in-law,  partner  or  assistant  of  such 
petitioner  or  person. 

Patients  not  to  be  received  under  Cer- 
tificate by  Interested  Persons. — (Sec. 
32)  No  pei'son  shall  be  received  in  any 
institution  for  lunatics  or  as  a  single 
patient  where  any  certificate  accompany- 
ing the  reception  order  has  been  signed 
by  ((()  the  manager  of  the  institution  or 
person  who  is  to  have  charge  of  the  single 
patient ;  (b)  an3'  person  interested  in  the 
payments  on  account  of  the  patient ; 
(c)  any  regular  medical  attendant  of  the 
institution  ;  ((7)  the  husband  or  wife,father 
or  father-in-law,  mother  or  mother-in-law, 
son  or  son-in-law,  daughter  or  daughter- 
in-law,  brother  or  brother-in-law,  sister 
or  sister-in-law,  or  the  partner  or  assist- 
ant of  any  of  the  foregoing  persons,  Sec. 
Neither  of  the  j^ersons  signing  the  medi- 
cal certificates  shall  bear  a  similar  rela- 
tionship to  each  other  ;  no  person  shall  be 
received  as  a  lunatic  in  a  hospital  under 
an  oi'der  made  on  the  application  of  or 
under  a  certificate  signed  by  a  member 
of  the  managing  committee  of  the  hos- 
pital. 

Commissioners  and  Visitors  not  to 
sign  Certificates. — (Sec.  23)  -A-  medical 
practitioner  who  is  a  commissioner  or  a 
visitor  shall  not  sign  any  certificate  for 
the  reception  of  a  patient  into  a  hospital 
or  licensed  house  unless  he  is  directed  to 
visit  the  patient  by  a  judicial  authority 
under  this  Act  or  by  the  Lord  Chancellor, 
or  Secretary  of  State,  or  a  committee 
appointed  by  the  jndge  in  lunacy. 

Amendment  Orders  and  Certificates. 
— (Sec.  34)  Orders  and  certificates,  if  in 
any  respect  incorrect  or  defective,  may 
be  amended  within  fourteen  days  next 
after  the  reception  of  the  patient,  with 
the  sanction  of  one  of  the  commissioners 
and  (in  the  case  of  a  private  patient)  the 
consent  of  the  judicial  authority  by  whom 
the  order  for  the  reception  of  the  lunatic 
may  have  been  signed,  and  if  the  com- 
missioners deem  any  such  certificate  to  be 
incorrect  or  defective,  if  it  be  not  amended 
to  their  satisfaction  within  fourteen  days, 
any  two  of  them  may,  if  they  think  fit, 
make  an  order  for  the  patient's  discharge. 

Order  and  Certificate  to  remain  in 
Force  in  Certain  Cases. — (Sec.  27) 
Although  a  patient  may  be  admitted  as  a 
pauper,  and  afterwards  be  found  entitled 
to  be  classed  as  a  private  patient,  the 
same  order  shall  hold  good.  Also  an 
order  for  the  reception  of  a  private  patient 
shall  authorise  his  detention  if  he  after- 
wards   appear  to   be   a  pauper.     In  the 


case  of  a  patient  temporarily  removed, 
or  transferred  from  one  place  of  confine- 
ment to  another,  the  original  order  and 
certificate  or  certificates  shall  remain  in 
force. 

Duration  of  Reception  Orders. — (Sec. 
38,1  Every  reception  order  dated  after  or 
within  three  months  before  the  commence- 
ment of  this  Act,  shall  expire  at  the  end 
of  one  year  from  its  date,  and  any  such 
order  dated  three  months  or  more  before 
the  commencement  of  this  Act  shall  expire 
at  the  end  of  one  year  from  the  com- 
mencement of  this  Act  unless  continued 
as  provided  by  the  Act. 

In  the  case  of  any  institution  for  luna- 
tics the  commissioners  may  order  that 
the  reception  orders  of  patients  detained 
therein  shall  expire  on  any  quarterly  day 
next  after  the  days  on  which  the  orders 
would  expire  under  the  last  preceding 
subsection.  Transfers  are  not  to  be  con- 
sidered reception  orders  under  this  sec- 
tion. A  reception  order  shall  remain  in 
force  for  a  year  after  the  date  by  this 
Act  or  by  an  order  of  the  commissioners 
appointed  for  it  to  expire,  and  thereafter 
for  two  3'ears,  and  thereafter  for  three 
years,  and  then  for  successive  periods  of 
five  years,  if  not  more  than  one  month  nor 
less  than  seven  days  before  the  expiration  of 
the  period  of  one,  two,  three  and  five  years 
respectively,  a  special  report  of  the  medical 
ofiicer  of  the  institution  or  medical  atten- 
dant of  a  single  patient  as  to  the  mental 
and  bodil}'  condition  of  the  patient  with  a 
certificate  that  he  is  still  of  unsound  mind, 
and  a  proper  person  to  be  detained  under 
care  and  treatment,  is  sent  to  the  commis- 
sioners. If,  in  the  opinion  of  the  commis- 
sioners the  special  report  Joes  not  justify 
the  accompanying  certificate  in  the  case 
of  a  patient  in  a  hospital  or  licensed 
house,  they  shall  make  further  inquiry, 
and  if  dissatisfied,  they  may  order  his 
discharge.  If  the  patient  is  in  an  asylum 
the  commissioners  shall  send  a  copy  of 
the  report  to  the  clerk  to  the  visiting 
committee  of  the  asylum,  and  the  com- 
mittee, or  any  three  of  them,  shall  inves- 
tigate the  case,  and  may  discharge  the 
patient,  and  give  such  directions  respect- 
ing him  as  they  think  fit. 

The  manager  of  an  institution  for 
lunatics  or  person  having  charge  of  a 
single  patient  shall  be  guilty  of  a  mis- 
demeanour if  he  detains  a  patient  after 
he  knows  the  order  for  his  reception  has 
expired.  The  special  reports  and  certifi- 
cates under  this  section  may  include  and 
refer  to  more  than  one  patient.  A  certi- 
ficate of  the  secretaiy  to  the  commission- 
ers that  a  reception  order  has  been  con- 
tinued shall  be  sufficient  evidence  of  the 


Law  of  Lunacy 


[     735     ] 


Law  of  Lunacy 


fact.  This  section  does  not  apply  to 
lunatics  so  found  by  inquisition. 

Care  and  Treatment-  —  Report  of 
Mental  and  Bodily  Health  to  be  sent  to 
Commissioners. — (Sec.  39)  At  the  expi- 
ration of  one  month  from  the  reception  of 
a  private  patient,  the  medical  officer  of 
every  institution,  and  the  medical  attend- 
ant of  every  single  ])atient,  shall  send  a 
report  to  the  commissioners  as  to  the 
mental  and  bodily  condition  of  the  patient 
and  in  the  case  of  every  house  licensed  by 
the  justices  a  copy  of  such  report  shall 
be  sent  to  their  clerk.  In  the  case  of  a 
licensed  house  within  the  immediate  juris- 
diction of  the  commissioners,  one  of  them 
shall  visit  the  patient  as  soon  as  conve- 
nient, and  report  if  his  detention  is  proper. 
Where  the  house  is  licensed  by  justices, 
they  shall  arrange  for  the  medical  visitor 
to  visit  and  report  to  the  commissioners 
if  there  is  any  doubt  as  to  the  propriety 
of  detaining  the  patient.  The  commis- 
sioners shall  satisfy  themselves  whether 
the  patient  is  properly  detained,  whether 
he  should  be  discharged,  or  whether  an 
inquisition  should  be  held  upon  his  case. 
Similar  arrangements  for  visiting  a  single 
patient  shall  be  made  by  the  commis- 
sioners, and  the  commissioners  may,  with 
the  consent  of  the  Treasury,  pay  the 
medical  visitor  for  his  services.  Private 
patients  in  asylums  shall  also  be  visited 
in  the  same  manner  and  reported  upon. 
In  any  case  under  this  section  the  com- 
missioners may  order  a  patient's  dis- 
charge. This  section  shall  not  apjjly  to 
lunatics  received  under  a  removal  order 
or  to  lunatics  so  found  by  inquisition 
(sec.  8,  1891). 

IWecbanical  Restraint.  —  (Sec.  40) 
Mechanical  means  of  restraint,  which 
shall  be  such  appliances  as  the  commis- 
sioners may  bj'  regulation  determine,  shall 
not  be  applied  to  any  lunatic  except  for  the 
purposes  of  surgical  or  medical  treatment, 
or  to  prevent  him  from  injuring  himself  or 
others.  Where  restraint  is  applied  a  cer- 
tificate must  be  signed  by  the  medical 
officer  of  the  institution,  or  medical  at- 
tendant of  a  single  patient  giving  the 
reason  for  it.  A  full  record  is  to  be  kept 
from  day  to  day,  and  a  copy  sent  to  the 
commissioners  at  the  end  of  every  quar- 
ter. In  the  case  of  a  workhouse  the  copy 
to  be  sent  to  the  clerk  to  the  guardians 

Patient's  Xetters. — (Sec.  41)  All  letters 
written  by  any  patient  shall  be  forwarded 
unopened  by  the  manager  of  eveiy  insti- 
tutionfor  lunatics,  andever}-^  person  having 
charge  of  a  single  patient,  if  addressed  to 
the  Lord  Chancellor,  any  Judge  in  lunacy, 
Secretary  of  State,  Commissioners,  or  a 
commissioner,  or  to  the  person  who   signs 


the  order  for  his  recei>tion,  or  on  whose 
petition  such  order  was  made,  or  to  any 
Chancery  visitor,  or  any  other  visitor,  or 
to  the  visiting  committee,  or  any  member 
of  it.  Every  such  manager  or  person 
having  charge  of  a  single  patient  shall 
be  liable  to  a  penalty  of  ^20  who  makes 
default  in  carrying  out  the  obligations  of 
this  section. 

(Sec.  42)  In  every  institution  for  lunatics 
where  there  are  private  patients  the  com- 
missioners have  power  to  direct  that 
notices  shall  be  jjosted  up,  so  that  every 
private  patient  can  see  them,  setting  forth 
the  right  of  patients  to  have  such  letters 
forwarded  ;  and  the  right  to  request  a  per- 
sonal and  private  interview  with  a  visit- 
ing commissioner  or  visitor.  The  commis- 
sioners or  visitors  shall  direct  where  these 
notices  shall  be  posted,  and  any  manager 
of  such  institution  shall  be  liable  to  a 
penalty  not  exceeding  /^2o. 

The  nxedical Practitioners  certifying: 
shall  not  attend  the  Patient  profes- 
sionally.— (Sec. 33)  Amedical  practitioner 
upon  whose  certificate  a  reception  order 
for  a  private  patient  has  been  made  shall 
not  be  the  regular  professional  attendant 
of  the  patient  whilst  detained  under  the 
order,  nor  shall  a  medical  practitioner 
who  is  a  commissioner  or  visitor  profes- 
sionally attend  a  patient  in  a  hospital  or 
licensed  house,  unless  he  is  directed  to 
visit  the  patient  by  the  petitioner  upon 
whose  application  the  reception  order 
was  made,  or  the  Lord  Chancellor,  Secre- 
tary of  State,  or  committee  appointed  by 
the  judge  in  lunacy. 

(Sec.  44)  The  commissioners  shall  con- 
j  trol  the  visiting  of  a  single  patient  not 
j  found  lunatic  by  inquisition  by  a  medical 
!  practitioner  not  deriving  profit  from  the 
I  charge  of  the  patient ;  and  (sec.  45)  they 
i  may  require  him  to  report  upon  the  case 
and  give  any  information  they  may  direct. 

More  than  One  Patient  in  Vnlicensed 
House.  —  (Sec.  46)  The  commissioners 
have  power  to  give  permission  for  more 
than  one  patient  to  be  received  in  an  un- 
licensed house  Hs  "  single  patients." 

Order  to  Visit  Iiunatic.  —  (Sec.  47) 
One  commissioner  or  one  justice  may  give 
an  order  to  a  relative  or  friend  of  a  patient 
in  an  institution  for  lunatics  or  a  licensed 
house  to  be  admitted  to  see  him.  This 
oi'der  may  be  for  admission  generally,  or 
for  a  stated  number  of  times,  with  or 
without  restriction  as  to  the  presence  of 
an  attendant.  If  the  manager  or  princi- 
pal officer  refuses,  prevents,  or  obstructs 
such  admission,  he  shall  be  liable  to  a 
penalty  not  exceeding  ^20. 

Commissioners  may  appoint  Sub- 
stitute   for    Petitioner. — (Sec.    48)    The 


Law  of  Lunacy 


L     73(> 


Law  of  Lunacy 


commissioners  may  appoint  any  person 
as  a  substitute  for  the  person  upon  whose 
petition  a  reception  order  was  made  if 
such  person  is  willing  to  undertake  the 
duties  and  responsibilities  of  the  petitioner. 

Order  to  examine  detained  Iiunatic. — 
(See.  49)  Any  person  may  obtain  an  order 
from  the  commissioners  to  have  an}'  person 
who  is  detained  as  a  lunatic  examined  by 
two  medical  practitioners  who  satisfies 
the  commissioners  that  it  is  proper  for 
them  to  grant  such  an  order.  If  after  two 
examinations  with  seven  days  intervening 
between  them  the  medical  practitioners 
certify  the  patient  may  be  discharged 
without  risk  or  injury  to  himself  or  the 
public,  the  commissioner  may  order  his 
discharge  at  the  expiration  of  ten  days. 

Inquiry  as  to  Property  of  Xiunatic. 
— (Sec.  50)  The  Lord  Chancellor  and  the 
Commissioners  are  empowered  to  make  in- 
quiry as  to  the  property  of  any  person 
detained  as  a  lunatic. 

Order  to  Search  Records. — (Sec.  51) 
Any  person  applying  to  a  commissioner 
or  visitor  may,  if  the  commissioner  or 
visitor  think  fit,  have  an  order  to  search 
whether  a  particular  jierson  is,  or  has  been, 
detained  within  the  last  twelve  months  as 
a  lunatic,  together  with  date  of  his  admis- 
sion, removal  or  discharge.  The  applicant 
shall  pay  to  the  ])erson  appointed  to  search 
a  sum  not  exceeding  76-. 

Diet  of  Iiunatics. — (Sec.  52)  The  visit- 
ing commissioners  may  determine  and 
regulate  the  diet  of  the  jDauper  patients 
in  a  hospital  or  licensed  house,  and  the 
visitors  of  a  licensed  house  shall  have  the 
same  power  subject  to  the  direction  of  the 
visiting  commissioners. 

Males  not  to  have  custody  of  Female 
Iiunatics. — (Sec.  53)  Males  shall  not  be 
employed  in  the  personal  custody  of  female 
patients  except  in  cases  of  urgency  which 
must  be  reported  to  the  visitors  or  com- 
missioners at  their  next  visit. 

Diet  and  Accommodation  of  "Work- 
houses.— (Sec.  54)  The  visiting  guardians 
shall  enter  in  a  book  to  be  kept  by  the 
master  of  the  workhouse  a  quarterly  report 
upon  the  diet,  accommodation,  and  treat- 
ment of  any  lunatics  or  alleged  lunatics 
in  the  workhouse,  and  the  book  shall  be 
laid  before  the  commissioners  at  the  next 
visit. 

Iieave  of  Absence. — (Sec.  55)  Any 
two  visitors  of  an  asylum  or  licensed 
house,  or  a  commissioner,  or  in  the  case 
of  a  hospital,  two  members  of  the  manag- 
ing committee  may,  with  the  advice  of  the 
medical  officer,  permit  a  patient  to  be 
absent  on  trial  as  long  as  they  think  fit. 
In  the  case  of  a  pauper  they  may  make 
an  allowance  not  exceeding  the  cost  of  his 


maintenance  in  the  asylum.  The  manager 
of  any  hospital  or  licensed  house  may 
also,  with  such  permission,  take  or  send 
under  proper  control,  one,  two,  or  more 
patients  to  any  specified  place  or  to  travel 
in  England  (sec.  9,  1891)  for  the  benefit 
of  their  health  or  allow  a  private  patient 
to  be  absent  on  trial.  The  medical  officer 
of  a  hospital  or  licensed  house  may  on 
his  own  authority  permit  any  jiatient 
to  be  absent  for  forty-eight  hours.  Such 
patient  may  be  brought  back  to  the 
asylum  with  fourteen  days  of  the  expira- 
tion of  the  term  of  his  leave  of  absence, 
unless  his  detention  is  medically  certified 
to  be  no  longer  necessary. 

Removal  of  Single  Patients. — (Sec. 
56)  Any  person  having  charge  of  a  single 
patient  may  remove  him  to  any  new  resi- 
dence in  England  or  Wales,  seven  days' 
previous  notice  having  been  given  to  the 
commissioners  and  the  person  on  whose 
petition  the  reception  order  was  made  or 
who  made  the  last  payment  for  him. 
With  the  previous  consent  of  a  commis- 
sioner leave  of  absence  may  also  be  ob- 
tained (sec.  10.  1 891). 

Pauper  Iiunatic  may  be  delivered 
up  to  Friend. — (Sec.  57)  The  visiting  com- 
mittee of  an  asylum  may  order  a  pauper 
lunatic  to  be  delivered  up  to  a  relative  or 
friend,  and  the  authority  liable  for  his 
maintenance  shall  pay  to  the  person 
taking  charge  of  the  lunatic  an  allowance 
not  exceeding  his  rate  of  maintenance  in 
the  asylum. 

Removal  of  Iiunatics. — (Sec.  58)  A 
person  having  authority  to  dischai'ge  a 
private  or  a  single  patient  may,  with  the 
23revious  consent  of  a  commissioner,  I'e- 
move  the  jjatient  to  any  institution  for 
lunatics  or  to  the  charge  of  another  person 
named  by  the  commissioners  in  their  con- 
sent ;  (sec.  59)  two  commissioners  may 
order  the  removal  of  a  lunatic  from  one 
institution  to  another.  Upon  the  death 
of  a  person  having  charge  of  a  single 
patient  the  commissioners  may  direct  the 
patient  to  be  removed  to  the  charge  of 
another  person  or  may  also  at  any  time 
order  the  patient's  removal  to  the  care  of 
another  person  or  to  any  institution  for 
lunatics  :  (sec.  60)  two  commissioners 
may  in  a  like  manner  oi'der  the  removal 
of  a  lunatic  or  alleged  lunatic  from_  a 
workhouse  to  an  institution  for  lunatics 
if  they  think  the  case  unsuitable  for  the 
workhouse.  The  guai'dians  have  power 
of  appeal  against  the  commissioners' 
order  to  the  Secretary  of  State,  who  shall 
employ  another  commissioner  to  visit  the 
workhouse,  and  report  specially  to  him, 
and  his  decision  shall  be  final;  (sec.  61) 
the  authority  liable  for  the  maintenance 


Iiaw  of  Lunacy 


L     72,7     ] 


Law  of  Lunacy 


of  a   paui)er   lunatic    in    a    hospital   or 
licensed   house  may  order   his   removal  ; 
(sec.   62)    the    t,'uardians    may  order   the 
removal  of  any  lunatic  from  a  workhouse ; 
(sec.  63)  any  two  members  of  the  com- 
mittee of  an  asylum  may  order  a  pauper 
patient  who  has   been   delivered   to   the 
custody  of  a  relative  or  friend  to  be  I'e- 
nioved  to  the  asylum ;  (sec.  64)  any  two 
visitors  of  an  asylum  may  order  a  pauper 
lunatic  belonging  to   the   county  to   be 
removed  into  the  asylum  from  any  other 
institution,  or  they  may  order  him  to  be 
removed  from  the  asylum  to  some  other 
institution  for  lunatics ;  (sec.  67)  in  both 
cases  the  medical  officer  of  the  institution 
must  certify  that  the  lunatic  is  in  a  fit 
condition   to    be   removed ;    (sec.   70)    all 
removal   orders   signed    by  the   commis- 
sioners must  be  in  duplicate,  one  shall  be 
given  to  the  manager  of   the  institution 
from  which  the  lunatic  is  removed  and 
the   other   given    to    the    manager   who 
receives  him,  together  with  a  copy  of  the 
original  reception  order  and  other  docu- 
ments ;  (sec.  71)  an  alien  may  be  removed 
to  his  own  county  upon  the  (U'der  of  a 
Secretary  of   State,  after  inquiring  into 
the  case  and  report  by  the  commissioners. 
Siscbarg:e  of  liunatics. — (Sec.  72)  A 
l^rivate  patient  may  be  discharged  from 
an   institution  by  the  person   on  whose 
petition  the  reception  order  was  made,  or, 
if  tliere  is  no  person  qualified  to  direct 
his  discharge,  the  commissioners  may  do 
so :  (sec.  7;^  the  authority  liable  for  the 
maintenance   of  a   pauper  lunatic    may 
order  his  discharge,  but  in  the  case  of 
either  a  private  patient,  a  single  patient, 
or  a  paupei",  if  the  medical  officer  of  the 
institution   or  the  medical  attendant  of 
the  single  patient  certifies  that  the  pa- 
tient is  dangerous  and  unfit  to  be  at  large, 
he   shall   not   be  discharged   unless   two 
visitors  of  the  asylum,  or  the   commis- 
sioners  visiting    a    hospital    or   licensed 
house,  or  a  commissioner  in  the  case  of  a 
single  i^atient,  consent,  in  writing,  to  his 
discharge  ;  (sec.  75)  a  legal  and  a  medical 
commissioner    visiting    a    patient    may, 
within  seven  days  of  their  visit,  discharge 
liini  if  they  think  he  is  detained  without 
sufficient  cause ;  (sec.  "jj)  any  three  visitors 
of  an  asylum  may  order  the  discharge  of 
any  person  detained  therein,  whether  he 
is  recovered  or  not,  and  any  two  visitors 
may  do  so  with  the  advice  of  the  medical 
officer ;  (sec.  78)  two  visitors,  one  of  whom 
must  be  a  medical  practitioner,  after  two 
visits    with    not    less   than    seven    days' 
interval    between    them,    may    discharge 
any  patient  from  a  licensed  house  if  it 
aj^pears  to  them  that  he  is  detained  with- 
out sufficient  caiise. 


(Sec.  79)  On  the  application  of  a 
relative  or  friend  of  a  pauper  lunatic 
confined  in  an  asylum,  two  visitors  may 
discharge  the  lunatic  upon  the  under- 
taking of  the  relative  or  friend  that  he 
shall  no  longer  be  chargeable  to  any  union, 
and  shall  be  properly  taken  care  of,  and 
prevented  injuring  himself  or  others. 

(Sec.  80)  When  the  visitors  of  an  asy- 
lum intend  to  order  the  discharge  of  a 
pauper  patient,  e.\:cept  upon  the  applica- 
tion of  a  relative  or  friend,  they  may  send 
notice  of  their  intentions  to  a  relieving- 
officer  of  the  union  to  which  the  lunatic  is 
chargeable,  and  the  relieving-officer  may 
remove  the  lunatic  to  the  workhouse. 

Discharged  Patient  may  have  a 
Copy  of  the  Documents  upon  \7hich 
he  was  confined. — (Sec.  82)  The  secre- 
tary of  the  comniissioners  shall,  upon  the 
discharge  of  a  person  who  considers  him- 
self to  have  been  unjustly  confined  as  a 
lunatic,  furnish  to  him,  upon  his  request, 
free  of  expense,  a  copy  of  the  reception 
order  and  certificate  or  certificates  upon 
which  he  was  confined,  and  if  the  order 
was  made  upon  petition,  also  of  the  peti- 
tion, and  statement  of  particulars  upon 
which  the  reception  order  was  made. 

(Sec.  ^■^)  When  a  private  patient  in  a 
hospital  or  licensed  house  or  detained  as 
a  single  patient  recovers,  the  manager  or 
medical  attendant,  as  the  case  may  be, 
shall  notify  the  same  to  the  person  on 
whose  petition  the  reception  order  was 
made,  and  in  the  case  of  a  pauper,  to  the 
guardians  of  his  union,  and  if  the  patient 
is  not  removed  within  seven  days  he  shall 
be  forthwith  discharged. 

Inquests. — (Sec.  84)  The  coroner  shall 
summon  a  jury  to  inquire  into  the  cause 
of  death  of  a  lunatic  within  his  district  if 
he  considei's  it  necessary. 

Recapture  of  Escaped  Iiunatics.  — 
(Sec.  85)  If  any  person  detained  as  a  lunatic 
escapes,  he  may  be  retaken  within  fourteen 
days  without  a  fresh  order  or  certificate. 

(Sec.  86)  A  person  lawfully  detained 
as  a  lunatic  in  England  and  Wales  escap- 
ing into  Scotland  or  Ireland,  or  CTce  versa, 
may  be  brought  back. 

Voluntary  Boarders. — (Sec.  229)  Any 
person  who  is  desirous  of  voluntarily  sub- 
mitting to  treatment  may,  with  the  con- 
sent of  two  commissioners  or  justices,  be 
received  and  lodged  as  a  boarder  in  a 
licensed  house,  and  any  relative  or  friend 
may  also  be  received.  Consent  shall  only 
be  given  upon  the  application  of  the  in- 
tending boarder.  Notice  of  the  reception 
of  a  boarder  must  be  given  to  the  commis- 
sioners within  twenty-four  hours.  The 
commissioners  may  order  the  manager  to 
I'emove  a  boarder  or  take  steps  to  obtain 


Law  of  Lunacy 


r    7 


38    ] 


Law  of  Lunacy 


an  order  for  his  reception  as  a  patient  it' 
they  consider  his  mental  state  renders 
such  a  step  necessary  (sec.  20,  1891). 

(Sec.  338)  It  shall  be  lawful  for  the 
commissioners,  with  the  appi'oval  of  the 
Lord  Chancellox-,  by  rules,  to  prescribe 
the  books  to  be  kept  in  institutions  for 


lunatics  and  houses  for  single  patients, 
the  entries  to  be  made  therein,  and  the 
returns,  reports,  extracts,  copies,  state  ■ 
ments,  notices,  plans,  and  documents,  and 
information  to  be  sent  to  the  commis- 
sioners or  any  authority  or  person. 

T.    OlTTKRSOX  WOOU. 


Section  339. 


Sections  4,  5. 


THE  SECOND  SCHEDULE. 

Form  i. 

Petition  for  an  Order  for  reception  of  a  Private  Patient. 

In  the  matter  of  A.B.  a  person  alleged  to  be  of  unsound  mind. 
To  a  justice  of  the  peace  for 


To  His  Honour  the  judge  of  the  county  court  of  or  To 

stipendiary  magistrate  for  .] 

The  petition  of  CD.  of  ^  in  the  county  of 

1 .  I  am  -  years  of  age. 

2.  I  desire  to  obtain  an  order  for  the  reception  of  ^I.JB.  as  a  lunatic^  in 
the  asylum  [or  hospital  or  house  <is  the  case  ')naij  be]  of 
situate  at  * 

3.  I  last  saw  the  said  A.B.  at  on  the  *  day  of 

4.  I  am  the  •'of  the  said  A.B.  [or  if  the  petitioner  is  not  <-on- 
nevted  toith  or  related  to  the  patient  state  asfollovjS:] 

I  am  not  related  to  or  connected  with  the  said  A.B.  The  reasons  why 
this  petition  is  not  presented  by  a  relation  or  connection  are  as  follows  : 
[Stale  them.] 

The  circumstances  under  which  this  petition  is  presented  by  me  are  as 
follows  :  [State  them.] 

5.  I  am  not  related  to  or  connected  with  either  of  the  persons  signing 
house,  or  the  the  certificates  which  accompany  this  petition  as  [lohere  the  'petitioner  is  a 


1  Full  postal 
address  and 
rank,  pro- 
fession, or 
occupation. 
-  At  least 
twenty-one. 
s  or  an  idiot 
or  person  of 
unsound 
mind. 
♦  Insert  a 
full  descrip- 
tion of  the 
name  and 
locality  of 
the  asylum, 
hospital,  or 
licensed 


full  name, 
address,  and 
description 
of  the  per- 
so'i  who  is 
to  take 
charge  nf 
the  patient 
as  a  single 
patient. 

5  Some  day 
within  14 
days  before 
the  date  of 
the  presen- 
tation of  the 
petition. 

6  Here  state 
the  connec- 
tion or  rela- 
tionship with 
the  patient. 

(Section   23, 
1891). 


■tnau)  husband,  father,  father-in-law.  son,  son-in-law,  brother,  brother-in- 
law,  partner  or  assistant  (or  u-here  the  petitioner  isawoman),yfii'e,  mother, 
mother-in-law,  daughter,  daughter-in-law,  sister,  sister-in-law,  partner  or 
assistant. 

6.  I  undertake  to  visit  the  said  A.B.  personally  or  by  some  one  specially 
appointed  by  me  at  least  once  in  every  six  months  while  under  care  and 
treatment  under  the  order  to  be  made  on  this  petition. 

7.  A  statement  of  particulars  relating  to  the  said  A.B.  accompanies  this 
petition. 

If  it  is  the  fact  add: 

8.  The  said  A.B.  has  been  received  in  the  asylum  [or  hospital 
or  house  as  the  case  may  be]  under  an  urgency  order  dated  the 

The  petitioner  therefore  prays  that  an  order  may  be  made  in  accordance 
with  the  foregoing  statement. 

[Signed] 

full  Christian  and  surname. 
Date  of  presentation  of  the  petition 


Sections  4, 

5,  II- 

1  If  any  par- 
ticulars are 
not  known, 
the  fact  is  to 
be  so  stated. 
[Where  the 
patient  is  in 
the  petition 
or  order 
described  as 
an  idiot 
omit  the 
particulars 
marked  ■>  . 


Form  2. 

statement  of  Particulars. 

STATEiiENT  of  particulars  referred  to  in  the  annexed  petition  [or  in  the 
above  or  annexed  order]. 

The  following  is  a  statement  of  particulars  relating  to  the  said  A.B. '  : — 
Name  of  patient,  with  Christian  name  at  length. 
Sex  and  age. 
•^Married,  single,  or  widowed. 

■''"Rank,  profession,  or  previous  occupation  (if  any). 
"'"Religioits  persuasion. 
Residence  at  or  immediately  previous  to  the  date  hereof. 


Law  of  Lunacy 


[     739     ] 


Law  of  Lunacy 


t Whether  first  attack. 
Af^e  oil  first  attack. 
When  and  where  previously  under  care  and  treatment  as  a  lunatic, 

idiot,  or  jjcrson  of  unsound  raind. 
tDuration  of  existing  attack. 
Supposed  cause. 
Whether  subject  to  epilepsy. 
Whether  suicidal. 

Whether  dangerous  to  othera,  and  in  what  way. 
Whether  any  near  relative  has  been  atiiicted  with  insanity. 
Names,   Christian  names,   and  full  postal  addresses  of  one  or  more 

relatives  of  the  patient. 
Name  of  the  person  to  whom  notice  of  death  to  be  sent,  and  full  postal 

address  if  not  already  given. 
Name  and  full  jiostal  address  of  the  usual  medical  attendant  of  the 

patient. 


When  the  i)etitioner  or  person 
signing  an  urgency  order  is  not  the 
person  who  signs  the  statement, 
add  the  following  particulars  con- 
cerning the  person  who  signs  the 
statement. 


[Signed] 

Name,  with  Christian  name  at 
length. 

Rank,  profession,  or  occupation 
(if  any). 

How  related  to  or  otherwise  con- 
nected with  the  patient. 


Pou>i  3. 

Order  for  reception  of  a  p^'ivate  patient  to  be  made  by  a  Justice 

appointed  under  the  I/itnacy  Act,  1890,  Judge  of  County  Courts,  or 

Stipendiary  Magistrate. 

I,  the  undersigned  E.F.,  being  a  Justice  for  specially  appointed 

under  the  Lunacy  Act,  1890  [or  the  Judge  of  the  County  Court  of 

or  the  Stipendiary  Magistrate  for  ],  upon  the  petition 

of  CD.,  of  in  the  matter  of  A.B.  a  lunatic,"  accompanied  by 

the  medical  certificates  of  G.R.  and  I.J.  hereto  annexed,  and  upon  the 
undertaking  of  the  said  CD.  to  visit  the  said  A.B.  personally  or  by  some 
one  specially  appointed  by  the  said  CD.  once  at  least  in  every  six  months 
while  under  care  and  treatment  under  this  order,  hereby  authorise  you  to 
receive  the  said  A.B.  as  a  patient  into  your  asylum.-*  And  I  declare  that 
I  have  [or  have  not]  personally  seen  the  said  A.B.  before  making  this 
order. 
Dated 

[Signed]  E.F. 

A  Justice  for  appointed 

under  the  above-mentioned 
Act,  [or  The  Judge  of  the 
County  Court  of  or  a 

Stipendiary  Magistrate.] 
To* 


Section  6. 


i  Address 
and  descriji- 
tion. 

"  Or  an  idiot 
or  person  of 
unsound 
mind. 

3  ( )r  hospital 
or  house  or 
as  a  single 
patient. 
*  To  be  ad- 
dressed to 
the  medical 
superinten- 
dent of  the 
asylum  or 
hospital,  or 
to  the  resi- 
dent licensee 
of  the  house 
in  which  the 
patient  is  to 
be  placed. 


Section  II. 

1  Or  hospital 
•  PriRAr    /I  or  asylum  or 

^^^^  '^^  as  a  single 

Form  of  urgency  Order  for  the  reception  of  a  privoAe  patient.  a  or  an' idiot 

or  a  person 
I,  the   undersigned,   being  a  person  twenty-one  years  of  age,  hereby  of  unsound 
authorise  you  to  receive  as  a  patient  into  your  house*  A.B.,  as  a  lunatic,"  sgomcday 
whom  I  last  saw  at  on  the-'  day  of  within  two 

18     .     I  am  not  related  to  or  connected  with  the  person  signing  the  certifi-  the  da^^*o? 
tificate  which  accompanies  this  order  in  any  of  the  ways  mentioned  in  the  the  ordar 


Law  of  Lunacy 


[    740    ] 


Law  of  Lunacy 


*  Husband, 
wife,  father, 
father-in- 
law,  mother, 
mother-in- 
law,  soil, 
son-in-law, 
dausrhtor, 
daui:hter-in- 
law,  brother, 
brother-in- 
law,  sister, 
sister-in- 
law,  partner, 
or  assistant. 
5  See  Form  2. 
Desi'ribinir 
tlie  asylum, 
hospital,  or 
house  by 
situation 
and  name. 


margin.''     Subjoined  [or  annexed]  hereto*  is  a  statement  of  particulars 
relating  to  the  said  A.B. 

[Signed]         Name  and  Christian  name  at  length. 

Rank,  profession,  or  occupation  (if  any). 
Full  postal  address. 

How  related  to  or  connected  with  the  patient. 
[If  not  the  husband  or  wife  or  a  relative  of  the 
patient,  the  person  signing  to  state  as  briefly 
as  jjossible: — i.  Why  the  order  is  not  signed 
by  the  husband  or  wife  or  a  relative  of  the 
patient.  2.  His  or  her  connection  with  the 
patient,  and  the  circumstances  under  which  he 
or  she  signs.] 
Dated  this  day  of  i8     . 

superintendent  of  the 


To 

asylum  [ 
house]. 


hospital  or  resident  licensee  of  the 


sections.  FOKM    5. 

Certificate  as  to  Personal  Interview  after  Reception. 

I  certify  that  it  would  be  prejudicial  to  ^.i>.  to  be  taken  before  or  visited 
by  a  justice,  a  judge  of  county  courts,  or  a  magistrate. 

[Signed]'  CD., 

Medical  Superintendent  of 
the  Asylum  or 

Hospital  or  Resident  Medical 
Practitioner  or  Attendant  of 
the  .  or  Medical 

J^.ttendant  of  the  said  A.B. 


Sections.  FoRM   6. 

Notice  of  Right  to  Personal  Interview. 

Take  notice  that  you  have  the  right,  if  you  desire  it,  to  be  taken  before 
or  visited  by  a  justice,  judge  of  county  courts,  or  magistrate.  If  you  desire 
to  exercise  such  right,  you  must  give  me  notice  thereof  by  signing  the 
enclosed  form  on  or  before  the  day  of 


Dated 


[Signed]  CD. 

Superintendent  of  the 

Asylum  or  Hospi- 
tal  or  Resident   Licensee   of 
i  or  as  the  case 
may  he.] 


Sections.  FoRM   7. 

Notice  of  Desire  to  have  a  Personal  Interview. 

Dated 

[u4  ildress'] 
I  desire  to  be  taken  before  or  visited  by  a  justice,  judge,  or  magistrate 
having  jurisdiction  in  the  district  within  which  I  am  detained. 

[Signed] 


Law  of  Lunacy  [    74i     ]  Law  of  Lunacy 


Form  8.  seotions  4, 

Certificate  of  Medical  Practitioner.  "' '  '  '^'^'^' 

In  the  matter  of  A.B.  oV  in  the  county  -  of  , 

•',  an  alleged  lunatic.  '  insert 

residence  nf 

1,  the  undersigned  CD.,  do  hereby  certify  as  follows  :  '''0%"^ 

1.  I  am  a  person  registered  under  the  Medical  Act,  1858,  and  I  am  in  |',°j;7a8e' '''' 
the  actual  practice  of  the  medical  profession.  maybe. 

^  Insert  pro- 

2.  On  the  day  of  18      .af  in  the  county  •'' of  ofcupaHon, 

[separately  from  any  other  practitioner].''  I  personally  examined  ^f  any. 
the  said  A.B.,  and  came  to  the  conclusion  that  he  is  a  [lunatic,  an  idiot,  or  piJio  of   '* 
a  person  of  unsound  mind]  and  a  jiroper  person  to  be  taken  charge  of  and  examination, 
<letained  under  care  and  treatment.  nkmTofthe 

street,  with 

3.  I  formed  this  conclusion  on  the  following  grounds,  viz. : —  name  o'*f *"" 

house,  or 
(d)  Facts  indicating  insanity  observed  by  myself  at  the  time  of  should  there 
'  -J.-       7  „•„  be  no  num- 

exammation,'  VIZ. : —  ber  the 

Christian 
and  surname 
of  occupier. 
'  City  or 
boroup:h  as 
the  case 
may  be. 
e  Omit  this 

(h)  Facts  communicated  by  others,^  viz. :—  ^''lerc  only 

^   '  J  ^  Qjjg  certih- 

eate  is  re- 
quired. 
"  If  the  same 
or  other 
faots  were 
observed 
previous  to 
the  time  of 

[If  ail  urgency  certificate  is  reguired  it  must  he  added  here.    Hee  Form  g.]  ^^^io^The 

certifier  is 
at  liberty  to 

4.  The  said  A.B.  appeared  to  me  to  be  [or  not  to  be]  in  a  tit  condition  of  in  a  separate 

bodily  health  to  be  removed  to  an  asylum,  hospital,  or  licensed  house.*         paragraph. 
•'  J  I-        '  8  rpijg  names 

and  Chris- 
tian names 

s.   ]   give  this  certificate  having  first  read  the  section  of  the  Act  of  (if  known) 

•  1  01  iiitorm- 

Parliament  j^rmted  below.  ants  to  be 

Dated  n'wen,  with 

[Signed]         aD.,of^"  ^^^, 

descriptions. 

Extract  from  section  3170/  the  Lunacy  Act,  1890.  th1s"l^ause* 

Any  person  who  makes  a  wilful  misstatement  of  any  material  fact  in  in.fa^eof  f* 

any  medical  or  other  certificate  or  in  any  statement  or  report  of  bodily  patient 

or  mental  condition  under  this  Act,  shall  be  guilty  of  a  misdemeanor.  whose  re- 
moval is  not 
proposed. 
i«  Insert  full 
postal 
address. 


T-,  .  Sections  II, 

Form  9.  .g. 

Statement  accompanying  Urgency  Order. 

I  certify  that  it  is  expedient  for  the  welfare  of  the  said  A.B..,  \_or  for  the 
public  safety,  as  the  case  inay  be}  that  the  said  A.B.  should  be  forthwith 
placed  under  care  and  treatment. 

My  reasons  for  this  conclusion  are  as  follows :  [_state  them]. 


Law  of  Lunacy  [    742    ]  Law  of  Lunacy 

FORil   10. 
Section  •(.  Ccrlijicate  "-s  lo  ptatper  Lunatic  in  a  Workhouse. 

I,  tlic  undei'signed  medical  officer  of  workhouse  of  the 

Union  hereby  certify  that  1  have  carefully  examined  into 
the  state  of  health  and  mental  condition  of  A.B.,  a  pauper  in  the  said 
workhouse,  and  that  he  is  in  my  opinion  a  lunatic,  and  a  proper  person  to 
be  allowed  to  i-emain  in  the  woi'khouse  as  a  lunatic,  and  that  the  accom- 
modation in  the  workhouse  is  sufficient  for  his  proper  care  and  treatment 
separate  from  the  inmates  of  the  workhouse  not  lunatics  [or,  that  his  con- 
dition is  such  that  it  is  not  necessaiy  for  the  convenience  of  the  lunatic  or 
of  the  other  inmates  that  he  should  be  kept  separate]. 

The  grounds  for  my  opinion  that  the  said  A.B.  is  a  lunatic  are   as 
follows  : 
Dated 

[Signed] 

Medical  Officer  of  the  Workhouse. 


Section  34.  ^Oi^M    II- 

Order  for  detention  of  I/unatic  in  Workhouse. 

1,  the  undersigned  U.D.,  a  justice  of  the  peace  for  ,  being 

satisfied  that  ^LB.,  a  pauper  in  the  workhouse  of  the 

is  a  lunatic  [or  idiot  or  person  of  unsound  mind]  and  a  proper  person  to 
be  taken  charge  of  under  care  and  treatment  in  the  workhouse,  and  being 
satisfied  that  the  accommodation  in  the  workhouse  is  sufficient  for  his 
proper  care  and  treatment  separate  from  the  inmates  of  the  workhouse 
not  lunatics  [or.  that  his  condition  is  such  that  it  is  not  necessary  for  the 
convenience  of  the  lunatic  or  of  the  other  inmates  that  he  should  be  kept 
separate]  hereby  authorise  you  to  take  charge  of,  and,  if  the  workhouse 
medical  officer  shall  certify  it  to  be  necessary,  to  detain  the  said  A.B.  as 
a  patient  in  3^our  workhouse.  Subjoined  is  a  statement  of  particulars 
respecting  the  said  A.B. 

[Signed]  _      _  G.D., 

A  justice  of  the  peace 
for 
Dated 
To  the  Master  of  the 

Workhouse 
of  the 

Statement  of  PoA'ticulars. 

Name  of  patient  and  Christian  name  at  length. 

Sex  and  age. 

Married,  single,  or  widowed. 

Condition  of  life  and  previous  occupation  (if  any). 

Keligious  persuasion  as  far  as  known. 

Previous  place  of  abode. 

Whether  first  attack. 

Age  (if  known)  on  first  attack. 

When  and  where  previously  t^nder  care  and  treatment. 

Duration  of  existing  attack. 

Supposed  cause. 

Whether  subject  to  epilepsy. 

Whether  suicidal. 

Whether  dangerous  to  others. 

Whether  any  near  relative  has  been  afflicted  with  insanity. 

Name  and  Christian  name  and  address  of  nearest  known  relative  of  the 

patient  and  degree  of  relationship  if  known. 
I  certify  that  to  the  best  of  my  knowledge  the  above  particulars  are 

correct. 

[To  be  signed  by  the  relieving-officer.] 


Law  of  Lunacy  [    743    ]  Law  of  Lunacy 


Form   12.  section  ,6 

Onhrj'or  rvrcpiina  of  a  I\vu]_)er  Lunatic  or  Lunatic  icauderiufi  nl  lanje. 

I,  (.'.D.,  having  called  to  my  assistance  E.F.,  of  ,  a  iluly  qualified 

medical  practitioner,  and  being  satistied  that  A.B.  [ilcucrihiii;/  him]  is  a 
pauper  in  receipt  of  relief  [or  in  such  circumstances  as  to  require  relief  for 
nis  proper  care  and  maintenance],  and  that  the  said  .l.B.  is  a  lunatic  [or 
an  idiot,  or  a  person  of  unsound  mind]  and  a  proper  ]ierson  to  be  taken 
charge  of  and  detained  under  care  and  treatment,  or  that  A.B.  [dcucrilring 
hini]  is  a  lunatic,  and  was  wandering  at  large,  and  is  a  proper  person  to 
be  taken  charge  of  and  detained  under  care  and  treatment,  hereljy  direct 
you  to  receive  the  said  A.B.  as  a  patient  into  your  asylum  [ur  hospital,  or 
house].  Subioined  is  a  statement  of  2)articulars  respecting  the  said  A.B. 
[Signed]  _       CD., 

A  justice  of  the  peace  for 
Dated  the  day  of  one  thousand  eight  hundred  and 

To  the  superintendent  of  the  asylum  for  the  county  [or  borough]  of 
[(irthe  lunatic  hospital  of  ;  or  E.F. 

proprietor  of  the  licensed  house  of  ;  describing  the  asylum , 

lios])ital,  or  house]. 

Note. — Where  the  order  directs  the  lunatic  to  be  received  into  any 
asylum,  other  than  an  asylum  of  the  county  or  borough  in  which  the 
parish  or  place  from  which  the  lunatic  is  sent  is  situate,  or  into  a  registered 
hospital  or  licensed  house,  it  shall  state,  that  the  justice  making  the  order 
is  satistied  that  there  is  no  asylum  of  such  county  or  borough,  or  that 
there  is  a  deficiency  of  room  in  such  asylum ;  or  (as  the  case  may  be)  the 
special  circumstances,  by  reason  whereof  the  lunatic  cannot  conveniently 
be  taken  to  an  asylum  for  such  first-mentioned  county  or  borough. 

Siatetnent  of  Particulars. 

Statemknt  of  particulars  referred  to  in  the  above  or  annexed  order. 
The   following   is   a    statement   of  imrticulars    relating   to    the    said 

^•^■^  •~    .  .  ,    ^,     .     .  ,  'If  any 

Name  of  patient,  with  Christian  name  at  lengtli.  particulars 

Sex  and  age.  -  ?•"«  "°* ,, 

,^r        -1^1  •  T  1  known,  the 

tJlarried,  single,  or  widowed.  lact  is  to  be 

tEank,  profession,  or  previous  occupation  (if  any).  so  stated. 

;  r>    !••  •  r  ^  J  r  Where  the 

fReligious  persuasion.  patient  is  in 

Kesidence  at  or  immediately  previouslv  to  the  date  hereof.  the  order 

tWhether  first  attack.  '  t^-A^^f "' 

A  a:     A     Ai     1  an  idiot 

Age  on  first  attack.  omit  the 

When  and  where  previously  under  care  and  treatment  as   a  lunatic,  particulars 

idiot,  or  jierson  of  unsound  mind.  mare  tj- 

fDuration  of  existing  attack. 

Supposed  cause. 

Whether  subject  to  epilepsy. 

Whether  suicidal. 

Whether  dangerous  to  others,  and  in  what  way. 

Whether  any  near  relative  has  been  afflicted  with  insanity. 

Union  to  which  lunatic  is  chargeable. 

Names,  Christian  names,  and  full  postal  addresses  of  one  or  more  relatives 

of  the  patient. 
Name  of  the  person  to  whom  notice  of  death  to  be  sent,  and  full  postal 
address  if  not  already  given. 

[Signed]  G.H. 

To  he  signed  hy  the  lielirrimj-Officcr  or  Orprxeer. 


Law  of  Lunacy 


[     744     ] 


Law  of  Lunacy 


Section  3S.  FoRM    1 3. 

Certificate  that  'patient  continues  of  unsound  mind. 

I,  ,  certify  that  A.B.,  the  patient  [or  A.B.,  C.I).,  &c., 

the  patients]  to  whom  the  annexed  report  relates,  is  [or  are]  still  of  un- 
sound mind,  and  a  proper  person  [or  proper  persons]  to  be  detained  under 
care  and  treatment. 

[Signed] 

Medical  superintendent  or  resident 
medical  officer  of  the 
asylum,  or  superintendent  of  the 
hospital  or  resi- 
dent medical  practitioner  or 
medical  attendant  of  the 

house  situate  at  , 

or  medical  practitioner  visiting 
the  said  A.B. 
Dated 


Section  229.  FoRM    1 4. 

Consent  to  the  admission  of  a  hoarder. 

We  hereby  sanction  the  admission  of  A.B.  as  a  boarder  into 

for  the  term  of 
from  the  day  of  in  accordance  with  the  pro- 

visions of  the  statute  and  in  terms  of  A.B.^s  application. 
[Signed] 

Two  of  the  Commissioners  in  Lunacy. 
[or  Two  of  the  justices  for  .] 

Dated  the  day  of  18     . 


Section  13.  FOBlI  15. 

Order  fur  lieception  of  a,  Lunatic  not  under  proper  ca.re  and  control,  or 
cruelly  treated  or  neglected,  to  be  made  hy  a  Jiistice  appointed  tmder 
the  Lunacy  Act,  1890. 

I,  the  undersigned  CD.,  being  a  Justice  for  specially 

appointed  under  the  Lunacy  Act,  1890,  having  caused  A.B,  to  be  examined 
by  two  duly  qualified  medical  practitioners,  and  being  satisfied  that  the 
said  A.B.  is  a  lunatic  not  under  proper  care  and  control  {_or  is  cruelly 
treated  or  neglected  by  the  person  having  the  care  or  charge  of  him],  and 
that  he  is  a  proper  person  to  be  taken  charge  of  and  detained  under  care 
and  treatment,  hereby  direct  you  to  receive  the  said  A.B.  as  a  patient 
into  your  asylum  [or  hospital  or  house].  Subjoined  is  a  statement  of 
particulars  respecting  the  said  A.B. 
(Signed) 

A  justice  of  the  peace  for 

appointed  under  the  above-mentioned 
Act. 
Dated 

To  the  Superintendent  of  the  Asylum  for  _, 

or  of  the  lunatic  hospital  of  ,  or  the  resi- 

dent licensee  of  the  licensed  house  at 
Note. — Where  the  order  directs  the  lunatic  to  be  received  into  any 
asylum,  other  than  an  asylum  of  the  county  or  borough  in  which  the 
parish  or  place  from  which  the  lunatic  is  sent  is  situate,  or  into  a  regis- 
tered hospital  or  licensed  house,  it  shall  state,  that  the  justice  making  the 
order  is  satisfied  that  there  is  no  asylum  of  such  county  or  borough,  or 
that  there  is  a  deficiency  of  room  in  such  asylum  ;  or  (as  the  case  may  be) 
the  special  circumstances,  by  reason  whereof  the  lunatic  cannot  con- 
veniently be  taken  to  an  asylum  for  such  first-mentioned  county  or 
borough. 


Law  of  Lunacy 


[     745     ] 


Lead  Poisoning 


Statement  of  Particulars. 

State>u:nt  of  particulai's  referred  to  in  the  above  or  aunexed  order. 
The  followin,^  is  a  statement  of  particulars  relating  to  the  said  A.B.' : — 
Name  of  patient,  with  Christian  name  at  length. 
Sex  and  as;e. 
fMarried,  single,  or  widowed. 

tRank,  profession,  or  previous  occupation  (if  any). 
fReligioiis  persuasion. 

Residence  at  or  immediately  previous  to  the  date  hereof, 
f  Whether  lirst  attack. 
Age  on  first  attack. 
When   and  where  previously  under  care  and  treatment  as  a  lunatic, 

idiot,  or  person  of  unsound  mind. 
tDuration  of  existing  attack. 
Supposed  cause. 
Whether  subject  to  epilepsy. 
Whether  suicidal. 

Whether  dangerous  to  others,  and  in  what  way. 
Whether  any  near  relative  has  been  afflicted  with  insanity. 
Union  to  which  lunatic  is  chargeable. 

Names,  Christian  names,  and  full  postal  addresses  of  one  or  more  rela- 
tives of  the  patient. 
Name  of  the  person  to  whom  notice  of  death  to  be  sent,  and  full  postal 
address  if  not  already  given. 

[Signed] 

To  be  signed  by  the  relieving- 
officer,  overseer,  or  other 
person  on  whose  informa- 
tion the  order  is  made. 


1  If  any 
particulars 
are  not 
known,  the 
fact  is  to  be 
so  stated. 
[Where  the 
patient  is  in 
tlie  order 
described  as 
an  idiot 
omit  the 
particulars 
markedt]. 


IiEAD  POISON-IM'G,  MEITTAX.  DIS- 
ORDER FROM. — The  toxic  effects  of 
lead  on  the  nervous  system  have  been 
recognised  from  the  very  earliest  date  of 
medical  literature,  Paul  of  ^Egina  referring 
to  epilepsy  and  convulsions  caused  by  lead 
poisoning,  while  Dioscorides  mentions 
delirium  produced  by  lead. 

Areta3us  speaks  of  epilepsy  following 
colic,  and  several  wr-iters  in  the  Middle 
Ages  describe  colic  terminating  in  de- 
lirium, which  they  do  not  appear  to  have 
recognised  as  being  the  result  of  lead  in- 
toxication. 

In  the  nineteenth  century  the  effects 
of  lead  on  the  brain  have  been  fully  re- 
cognised ;  so  that  Tanquerel  des  Planches 
in  1836,  described  them  under  the  term 
"  lead  encephalopathy,"  as  being  divisible 
into  four  classes.  These  he  described  as 
(i)  delirious,  (2)  comatose,  (3)  convulsive, 
and  (4)  a  delirious,  comatose  and  con- 
vulsive form. 

The  conditions  described  by  Tanquerel 
were  those  produced  by  very  obvious, 
coarse  intoxication,  in  which  the  associa- 
tion of  the  lead  poisoning  and  the  cerebral 
results  was  obvious ;  but  in  a  paper 
printed  in  the  Journal  of  Mental  Science 
for  1880,  the  writer  drew  attention  to 
cases  in  which  mental  disorder,  of  a  more 
obscure  and  chronic  kind,  seemed  to  have 


resulted  from  a  minute  and  protracted 
toxic  action ;  the  mental  disorder  taking 
the  form  specially  of  chronic  hallucination. 
Drs.  Savage,  A.  Robertson,  and  Ringrose 
Atkins  {Journal  of  Mental  Science,  1880), 
published  cases  of  a  confirmatory  character. 

Dr.  Bartens  {Zeitschrift,  xxxvii.  Band. 
I  Heft)  has  recorded  cases  collected  from 
French  and  German  literature. 

The  physiological  action  of  lead  is  such 
as  to  warrant  the  conclusion  of  its  special 
action  on  the  nervous  system. 

In  small,  medicinal  quantities  (Lauder 
Brunton)  it  appears  to  "  cause  contraction 
of  the  muscular  walls  of  the  iarteries,  to 
raise  arterial  tension,  and  to  slow  the 
heart."  It  produces  mental  depression 
and  thirst. 

It  checks  the  elimination  of  uric  acid, 
and  so  probably  produces  gout.  It  is 
cumulative  in  the  system,  being  found 
largely  in  the  nervous  tissues. 

It  is  eliminated  to  a  slight  extent  by 
the  kidneys,  in  which  it  tends  to  produce 
cirrhotic  changes,  but  is  chiefly  elimi- 
nated in  the  mucus  of  the  intestinal 
canal. 

Single  poisonous  doses,  even  when  very 
large,  would  seem,  from  the  cases  re- 
corded by  Woodman  and  Tidy,  to  be 
rarely  fatal ;  convulsions  being  the  prin- 
cipal nervous  symptom  remarked. 


Ijead  Poisoning 


[    746    ] 


Lead  Poisoning 


In  experimental  cumulative  poisoning 
of  animals  by  Harnack  (Wynter  Blyth 
On  Poisons),  in  rabbits,  heart  paralysis 
occurred,  in  dogs,  chorea.  Henkel,  in 
dogs  observed  shivering,  paralysis  andcon- 
vulsions,  while  Dr.  Blyth,  in  accidental 
poisoning  of  cows,  noted  paralysis  and 
delirium.  Paralysis  has  also  been  noticed 
in  cats,  rats,  mice,  and  other  animals  in 
lead  factories. 

In  man  it  would  seem  to  have  special 
action  on  the  optic  nervous  apparatus  ; 
optic  neuritis,  amaurosis  and  blindness 
being  very  frequently  recorded  (four  of 
six  cases  recorded  by  Dr.  Robertson  were 
totally  or  partially  blind). 

The  tendency  of  lead  to  affect  the 
nervous  tissues  is  further  shown  by  the 
calculations  made  by  Blyth  on  Henkel's 
researches,  showing  the  proportion  of  lead 
to  the  dry  matter,  in 


Liver 

Kidney 

Brain 

Bone 

Muscles 


.03  to  .10  per  cent. 
.03  to  .07         ,, 
.02  to  .05 
.01  to  .04         ., 
.004  to  .008       „ 


Dr.  Blyth  obtained  [Lancet,  1887)  one 
grain  and  a  half  of  sulphate  from  the  cere- 
brum only,  in  a  fatal  case  of  cumulative 
poisoning. 

The  pathologic  results  on  the  nerve 
tissues,  have  been  studied  by  various 
observers.  Gombault  ("  Archiv  de  Phy- 
siologie,"  1873)  found  a  granular  condi- 
tion of  the  medullary  substance  of  some 
of  the  peripheral  nerves,  and  Westphal 
("Archiv  fiir  Psychiatrie,"  1874)  found  a 
similar  condition  in  the  radial  nerve. 
Kussmaul  and  Maier  ("  Deutscher  Archiv 
fiir  Klin.  Med.,"  Band.  ix.  Heft  2)  ioxmd 
sclerosis  of  the  cceliac  and  superior  cervi- 
cal ganglia,  in  a  case  in  which  there  had 
been  colic,  vomiting,  diarrhoja  and  col- 
lapse. Monakow  ("  Jievie'w,"Joitni.  Meni. 
Sci.  1 881)  found  wasting  of  the  frontal  and 
temporal  gyri,  effusion  in  the  membranes, 
but  no  adhesions,  the  brain  solid,  the 
scalp  thickened,  and  pigmentary  deposits 
in  the  nervous  tissue. 

In  a  case  in  which  delirium  was  followed 
by  coma  and  death  in  an  employ  of  a  lead 
factory  {Lancet,  1887),  the  appearances 
were  summarised  as  those  of  "  serous 
apoplexy  "  only. 

The  presence  and  toxic  action  of  lead  on 
the  body  generally,  are  evidenced  by  the 
blue  discoloration  of  the  gums  around 
the  teeth  (if  these  exist),  the  metallic  taste, 
offensive  breath  odour,  constipation,  yellow 
tint  of  skin,  emaciation,  look  of  premature 
senility  (a  marked  wrinkling  of  face  in 
very  chronic  cases),  as  well  as  by  the  well- 
known  colic,  palsies,  arthralgias,  anajs- 
thesise  and  gout. 


The  palsies  are  probably  due  to  affection 
of  the  nerves,  the  muscles  not  contract- 
ing with  the  faradic,  but  onlj-  with  the 
primary,  current. 

Vulpian  and  Raymond  have  also  de- 
scribed cases  of  ataxia  with  left  anaesthesia 
and  right  hypergesthesia. 

Absorption  of  the  poison  by  inhalation 
would  seem  to  lead  to  the  most  rapid  and 
violent  action  on  the  nervous  system ; 
the  most  acute  cases  occurring  in  those 
working  in  an  atmosphere  impregnated 
with  the  dust  of  lead  compounds ;  but 
severe  and  rapid  effects  result  from  it  in 
a  potable  form ;  the  slowest  and  most 
insidious  from  mere  contact. 

Predisposition  to  mental  defect  may 
probably  be  ascribed  to  this  toxic  agency, 
since  Dr.  Royer  (Woodman  and  Tidy)  has 
recorded  that  lead  poisoning  either  in  the 
father  or  mother  produces  miscarriages, 
and  causes  epilepsy,  eclampsia,  idiocy 
and  imbecility  in  the  offspring.  Further 
inquiry  into  the  results  of  such  nerve 
degeneration  in  the  families  of  workers  in 
lead  would  be  very  desirable. 

Mental  disorder  from  lead  intoxication, 
does  not  occur  without  an  antecedent 
period  of  premonitory  symptoms. 

These  consist  of  headache,  wakeful- 
ness, disturbed  sleep,  and  some  terrifying 
dreams;  with  sensory  derangements,  es- 
pecially tinnitus  aurium  and  flashes  of 
light,  together  with  slowness  of  ideation 
and  depression  of  spirits. 

These  may  endure  for  a  day  or  two  only, 
or  for  longer  periods,  varying  with  the 
intensity  of  the  toxic  action  or  the  neurotic 
predisposition. 

The  slighter  and  most  acute  forms  of 
lead  encephalopathy  assume  the  form  of 
delirium.  Three  cases  of  this  form  are 
described  as  having  occurred  under  the 
observation  of  Dr.  Langdon  Down  {Med. 
Times  and  Ga::ette,  Aug.  i860).  In  these 
the  delirium  occurred  only  at  night,  the 
patients  being  merely  dull  intellectually 
by  day.  Dread  was  the  striking  charac- 
teristic of  the  delirium,  with  visual  hallu- 
cinations of  black  animals,  &c.  The 
striking  likeness  of  this  delirium  to  that 
produced  by  alcohol  was  noted,  and 
Laurent  has  also  dwelt  on  this  similarity. 

Rapid  remission  and  recurrence  of  the 
delirium  is  a  marked  characteristic,  and 
it  yields  very  readily  to  treatment  on 
removal  of  the  cause. 

Beyond  these  conditions  in  which  the 
toxic  action  on  the  brain  is  more  or  less 
overcome  by  the  stimulus  of  the  daily 
life,  Tanquerel  describes  others  in  which 
there  is  a  state  of  melancholy,  tremor  or 
stupor,  with  tranquil  melanchoUc  delirium 
(especially    nocturnal),    these    conditions 


Lead  Poisoning 


[     747     ] 


Lead  Poisoning 


interchanging  rapidly  iu  a  few  hours.  ' 
These  more  severe  cases  usually  show  some  } 
muscular  diihculties,  especially  awkward-  ; 
ness  of  movement  of  the  limbs,  with  [ 
trembling  of  the  face  and  arms. 

Furious  delirium  of  a  maniacal  type, 
accompanied  by  marked  affection  of  speech 
with  hallucinations  in  which  those  of 
sight  predominate  and  associated  with 
amaurosis,  would  seem  to  be  next  in  the 
order  of  intensity  of  toxic  action. 

This  maniacal  delirium  may  be  com- 
plicated with  convulsions.  Dr.  A.  Robert- 
son (Journ.  3Irni.  Sci.,  1880)  reports  such 
a  case,  the  delirium  lasting  four  days  ;  on 
recovery  there  was  complete  amaurosis 
from  atrophy  of  the  optic  disc  and  other 
retinal  changes.  Hammond  ("  Dis.  of 
Nerv.  Sys.,"'  1876)  describes  a  case  in 
which,  after  a  few  days  of  maniacal  de- 
lirium, convulsions  occurred. 

Tanquerel  describes  cases  of  a  comatose 
form,  occurring  suddenly  without  ante- 
cedent mental  disturbance,  especially  in 
persons  who  already  have  some  lead  palsy. 
The  coma  is  incomplete,  as  the  patients 
can  be  roused  momentarily. 

He  also  describes  a  state  of  sub-delirious 
coma. 

These  states,  unless  they  rapidly  pass 
away,  become  complicated  by  convulsions, 
and  this  comatose  convulsive  form  is  the 
most  dangerous.  He  describes  limited 
convulsions,  like  those  produced  by  electric 
shocks  and  general  or  epileptiform  attacks. 

The  more  gradual  degeneration  of  the 
brain,  by  less  extensive  poisoning,  may 
produce  various  conditions. 

Dr.  MacCabe  {Journ.  Ment.  Sci.,  1872, 
p.  233)  records  a  case  of  "  monomania " 
with  *' depressing  visceral  symptoms  and 
a  fixed  idea  that  people  were  whispering 
about  her."' 

Dr.  IMonakow  {Journ.  Ment.  Sri.,  1881) 
describes  the  case  of  a  painter,  aged  fifty- 
six,  who  for  thirty-five  years  had  suffered 
from  attacks  of  lead  colic :  five  children, 
born  of  a  healthy  wife,  died  of  convul- 
sions. During  the  last  ten  years  there 
was  paralysis  of  extensors,  disorder  of 
articulation,  dulness  of  hearing.  Then 
ataxia,  left  aneesthesia  (incomplete)  and 
right  hyperesthesia.  The  train  of  mental 
symptoms  was  weakness  of  intellect,  loss 
of  memory,  sleeplessness,  maniacal  dis- 
turbance, confusion  of  thought,  delirium 
in  which  he  was  destructive,  dirty  and 
aggressive. 

Then  emaciation,  loss  of  strength  and 
of  articulation,  and  death  by  coma  in 
five  months. 

The  course  of  the  disease  had  in  this 
case  some  resemblance  to  general  para- 
lysis. 


In  the  cases  recorded  by  the  writer 
{Jaunt.  Ment.  Sci.,  1880)  of  the  gradual 
evolution  of  hallucinations  and  chronic 
insanity,  these  did  not  differ  from  similar 
disorder  produced  by  alcoholic  tippling, 
except  in  the  marked  wrinkling  of  the 
face  iu  two  of  the  cases  (a  symptom  dwelt 
on  by  Tanquerel)  and  by  the  greater  per- 
sistence and  predominance  of  visual  hallu- 
cinations and  motorial  troubles  (startings 
and  tremors). 

Lastly,  the  writer  recorded  {op.  cit.) 
two  cases  in  which  the  lead  first  caused 
gout,  and  in  conjunction  with  this  in  one 
man  produced  symptoms  closely  re- 
sembling general  paralysis  ;  in  the  other, 
complicated  by  alcohol,  there  were  epi- 
lepsy and  anajsthesia,  such  as  seen  in  pro- 
found alcoholic  poisoning.  Both  im- 
jn'oved  with  the  recurrence  of  gout. 

The  prog'nosis  in  lead  encephalopathy 
has  been  to  a  great  extent  indicated  in 
the  order  of  description.  The  cases  of 
nocturnal  delirium  may  I'ecover  at  once; 
the  continuous  delirium,  if  arrested  within 
three  or  four  days,  convalesces  in  a  week 
or  two :  but  if  more  protracted,  con- 
valescence may  occupy  two  or  thi'ee 
months,  as  in  Dr.  Savage's  case  {Journ. 
Ment.  Sci.,  1880). 

The  comatose  and  convulsive  forms  are 
very  unhopeful  of  mental  recovery, 
whilst  in  those  in  which  there  are  delirium, 
coma  and  convulsions,  there  is  great 
danger  of  a  fatal  termination. 

The  rapid  nerve  degeneration  produced 
by  this  poison,  as  illustrated  in  its  action 
on  the  optic  nerve,  makes  the  prognosis 
much  more  grave  than  in  similar  mental 
states  arising  from  other  causes. 

The  diairnosis  of  cerebral  disorder  due 
to  plumbism  primarily  rests  on  the  history 
of  exposure  and  of  the  special  symptoms 
already  enumei'ated. 

Lead  intoxication,  like  alcohol,  follows 
the  law  of  dissolution  of  the  nervous 
system,  from  the  least  organised  to  the 
most  organised  as  described  by  Dr.Mercier 
("  Coma,"  Brain,  1887),  and  formulated  by 
I3r.  Hughlings  Jackson  {Brit.  Med.  Journ., 
1889),  but  besides  this  general  degenera- 
tion there  are  localised  affections  and 
tendency  to  degeneration,  such  as  the 
affection  of  o])tic  and  motor  nerves  pro- 
bably determined  by  the  local  functional 
activity  in  the  individual,  which  markedly 
distinguish  the  special  action  of  lead  from 
alcohol,  in  acute  poisoning. 

In  chronic  poisoning  the  lead  cases  may 
pi'esent  the  extreme  wrinkling  of  the  face 
described  by  Tanquerel  and  present  in 
two  of  the  writer's  cases. 

The  rapidity  of  permanent  irrecover- 
able degeneration  is  a  notewoi'thy  charac- 


Lead  Poisoning 


[    748    1 


Life  Insurance 


teristic  of  lead  action,  and  the  sudden 
variation  in  intensity  of  symptoms  in  the 
acute  stages  is  also  striking. 

The  mental  sj'mptoms  do  not  offer  any 
pathognomonic  characteristic. 

The  action  of  lead  on  the  brain,  from 
the  symptoms  and  pathology  recorded,  is 
certainly  not  inflammatory,  but  degenera- 
tive, its  i^rimary  effect  probably  pro- 
ducing anjemia,  by  its  action  on  the 
vessels,  and  on  its  further  direct  action 
on  the  nervous  tissue  first  arresting 
nutrition  and  then  inducing  degenera- 
tion. 

The  blood,  although  on  analysis  it  con- 
tains so  little  poison,  is  doubtlessly  the 
vehicle  of  its  conveyance  to  the  tissues, 
and  these  are  found  to  contain  it,  very 
much  in  the  proportion  of  their  blood 
supply.  If  this  is  so,  the  localisation  of 
toxic  action  may  be  determined  by  local 
functional  activity  (increasing  local  blood 
supply),  and  it  would  be  desirable  to  bear 
this  in  mind  in  the  case  of  persons  exposed 
to  or  suffering  from  toxic  action. 

The  prevention  of  lead  poisoning  and 
its  treatment  are  fully  described  in  every 
work  on  medicine,  and  little  that  is  special 
to  the  cerebral  affection  can  be  advanced 
here. 

Elimination  of  the  poison  must  be  the 
primary  object  of  treatment.  For  this 
purpose  copious  diluents  with  increasing 
doses  of  the  iodide  of  potassium  are  most 
efficacioiTS,  aided  by  profuse  sweatings, 
from  hot  air  or  vapour  baths. 

Sulphur  baths  have  also  been  strongly 
recommended,  and  after  their  use  a 
blackish  discoloration  of  the  skin  and 
nails  has  been  observed,  ascribed  to  the 
"formation  of  a  sulphide"  (Fagge). 

The  slighter  forms  of  delirium,  if  special 
treatment  is  indicated,  demand  stimula- 
tion rather  than  sedatives ;  in  the  more 
violent  delirium,  ice  to  the  head  is  bene- 
ficial, while  in  coma  and  convulsions, 
active  counter-irritation  by  blisters,  and 
derivation  by  sinapisms  to  the  extremities 
appear  to  be  indicated. 

A  nutritious  diet,  with  an  excess  of  fat, 
is  advised,  as  a  preventive  and  as  aiding 
elimination.  H.  Rayner. 

ine/ereiiei's. — Taii<iuerel  dcs  riaiicht'?;,  Lcjul  En- 
cephalopathy, 1836.  Jouru.  Ment.  Sci.  1872,  -Mac- 
Cabe;  1880,  Urs.  Kayner,  Savage,  Kobertson,  and 
Atkins.  Martens,  Zeitschrift,  Band  xxxvii.  Heft  i. 
Winter  I'.lyth,  On  I'oisons,  Lancet,  1887.  Woodman 
and  Tidy,  Foiensic  Medicine,  (iouibault,  .Vrchiv. 
de  Psycholoiile,  1873.  Westphal,  Archlv  fiir  I'sy- 
chlatrie,  1874.  KussiuanI  and  Maier,  Dentsch. 
Arch.  f.  Kliu.  Med.  3[onako\v,  Ueview,  Joum. 
Ment.  Sci.,  1881.  Langdon  Down,  Med.  Times 
and  (jaz.,  i860.  I.anrcut,  ibid.  Hammond,  Dis. 
Nerv.  Sys.  Mercier,  lirain,  1887.  lluiihlinos 
Jackson,  Brit.  Med.  Jonrn.,  1889.  J^auder  ISruntim. 
IMiarmacoloyy.     Fagge'.s  Medicine,  1891.] 


X.EA.PX3a-G  AGUE.— A  variety  of  the 
dancing  mania  observed  some  time  .since 
in  Scotland.    (Nee  Chokomania;  Epidemic 

IXSANITY,  &C.) 

Ii  E     R  A.  G  Ii  E . — A   name   given   by 
d'Escayrac  de  Lauture  in  1885  to  hallu- 
cinations, mostly  visual,  more  rarely  au- 
I  ditory,    olfactory,    gustatory,  or    tactile, 
I  which  not  unfrequently  happen  to  travel- 
1  lers  in  the  desert,  especially  to  such  as  are 
j  in  a  debilitated  state  from  previous  illness, 
[  or  who  have  sufiered  from  great  fatigue, 
want  of  food,  anxiety,  terror,  &c.     Com- 
bined with  these  hallucinations  there  are 
illusions  of    sight   and    hearing.      They 
I  usually  occur  in  the  hours  between  mid- 
!  night  and  early  morning,  frequently  recur 
'  at  about  the  same  time  in  the  twentj'-four 
hours  for  each  individual,  and  are  of  sud- 
den onset  and  fleeting  duration.    (Hirsch). 
I.EREIVXA  mpTjjjia,  silly  talk).   The  silly 
childish    talk    of    senile   dementia.      (Fr. 
Jerrme ;   Ger.  Gesclnvatz.) 

IiERESIs  (^)7p^;o•^s■,  silly  talking).  Talk- 
ing nonsense  ;  the  garrulousness  of  an 
imbecile. 

itEROS  {\ripos,  silly  talk).  An  old  term 
for  a  slight  delirium. 

IiESCHE'N'OMA  (Xf(TXV>  gOSSip).  A 
term  for  garrulity  or  loquacity ;  the  idle 
or  useless  talkativeness  symptomatic  of 
certain  mental  affections  as  well  as 
hysteria. 

IiETHARGZC  STUPOR  {XfdapyiKos, 
drowsy;  .sf%po/',  insensibility).  A  synonym 
of  Trance  (q.r.). 

IiETHARGY  (X-qdr],  f Orgetf ulness :  dpyia, 
idleness).  A  condition  of  prolonged  semi- 
unconsciousness  partaking  of  the  character 
of  profound  sleep,  from  which  the  patient 
may  be  momentarily  aroused,  but  into 
which  he  immediately  lapses  again.  (See 
Trance.) 

ZiETKE  iXr]6ri).  Oblivion,  or  total  loss 
of  memory.  (Fr.  oubli;  Ger.  Ahsterben, 
Vergessen.) 

IiETHEOIVXAXriA  {Xfidrj ;  pavia,  mad- 
ness). The  morbid  or  insane  longing  for 
narcotics  or  aniesthetics. 

IiEUCOIVXORXA  (XevKos,  white,  wan; 
fiaipia.  folly).  A  term  for  restless  madness, 
restless  melancholia.  (Fr.  Jenco^norie ; 
GGx.unrv]n(jer\Vahnsinn,unruliige  Melan- 
cholic.) 

IiZEBES'WUTH  :  IiZEBESWAHIO'- 
SZN'N'.  The  German  equivalents  for  ero- 
tomania. 

XZFE  IKTSURANCE,  Suicide  in  rela- 
tion to. — The  question  how  far  suicide  is 
an  indication  of  insanity  in  the  contem- 
plation of  law  is  considered  in  the  article 
upon  Evidence.  It  is  here  proposed  to 
deal  with  the  suicide  'provisos  in  policies 
of  life  insurance,  whereby  the  insurers  are 


Life  Insurance 


[     749     ] 


Iiife  Insurance 


exempted  from  liability  in  case  the  assured 
should  "die  by  suicide,"'  "commit  suicide,"' 
or  "  die  by  his  own  hand."  The  construc- 
tion of  this  proviso  has  sharply  divided 
judicial  opinion  both  in  England  and  in 
America ;  but  it  is  thought  that  the 
English  law  upon  the  subject  may  be  ac- 
curately stated  as  follows  : — 

(1)  When  a  person  who  is  assured  com- 
mits suicide  in  a  sane  mind,  neither  his 
representatives  nor  his  assignees  have  any 
claim  under  the  policy,  even  although  the 
insurer  has,  by  an  express  condition, 
undertaken  the  hazai-d  of  the  suicide  of 
the  assured.  Such  contracts  are  void  on 
grounds  of  public  i^olicy.  ((//.  Amicable 
Societij  v.  Bolland,  4  Bligh,  N.S.  194,  re- 
versing BoUinul  v.  Disney,  3  Russ.  351  ; 
Cleaver  v.  Mutual  Reserve  Fund  Life, 
39  W.  R.  638,  and  see  LaiD  Qiiarterhj 
Jtevieiv,  vol.  vii.  -pp.  306-7.) 

(2)  When  the  assured  commits  suicide 
while  in  a  state  of  unsoimd  mind,  the 
policy  is  not,  in  the  absence  of  any  special 
condition,  rendered  void  thereby.  (Horn 
V.  Anglo-Australian  and  Universal  Family 
Life  Insurance  Co.  1861,  30  L.  J.  Ch.  511.) 

(3)  But,  when  there  is  a  condition  in  a 
life  policy  exempting  the  insurers  from 
liability  ia  case  the  assured  should  "  com- 
mit suicide,"  "  die  by  suicide,"'  or  "  die  by 
his  own  hand,"'  and  the  assured  does 
voluntarily  kill  himself,  the  policy  is  void 
whatever  may  have  been  the  mental  or 
moral  state  of  the  deceased  at  the  time, 
and  even  if  the  policy  has  been  assigned 
to  the  insurers  themselves.  (Cf.  White 
V.  British  Empire  &c.,  Co.,  1868,  L.  R.  7 
Eq.  394.  This  proposition  will  be  most 
easily  justified  by  a  rapid  survey  of  the 
cases  on  which  it  is  based.  In  Borrudaile 
V.  H'tnter  (1843.  5  M.  &  G.  639),  the  policy 
contained  a  proviso  terminating  the  risk 
in  case  the  assured  should  die  by  his  own 
hands,  or  by  the  hand  of  justice,  or  by 
duelling.  The  insured  had  been  observed 
for  some  time  to  be  labouring  under  dejec- 
tion of  spirits,  though  he  performed  his 
various  duties  as  usual.  Without  any 
apparently  direct  cause,  he  flung  himself 
from  Vauxhall  Bridge  into  the  Thames. 
The  defendants  refused  to  pay  the  policy 
money,  on  the  ground  that  the  case  came 
within  the  terms  of  the  suicide  proviso. 
The  jury  found  that  the  deceased  leaped 
from  the  bridge  voluntarily — i.e.,  knowing 
that  the  result  of  his  act  would  be  death, 
and  intending  to  bring  that  result  about 
— hut  that  at  the  time  he  did  so,  he  was 
not  in  a  state  of  mind  capable  of  judging 
between  right  and  wrong.  Erskine,  J., 
entered  judgment  for  the  defendants,  and 
this  ruling  was  supported,  on  appeal,  by 
a  majoi'ity  of  the  Court  of  Common  Pleas. 


Chief  Justice  Tindal,  however,  dissented 
on  the  ground  that  the  words  "  die  by  his 
own  hands,"  being  associated  in  the  pro- 
viso with  the  words  "  die  ....  by  the 
hands  of  justice  or  by  duelling,"  the  prin- 
ciple noscitur  a  sociis  applied,  and  the 
condition  must  be  construed  as  extending 
to  criminal  acts  of  self-destruction  alone. 

The  point  of  law  that  was  settled  in 
Borrodaile  v.  Hunter  cannot  be  better 
stated  than  in  the  language  of  Erskine,  J. 
"  It  seems  to  me  that  the  only  qualifica- 
tion that  a  liberal  interpretation  of  the 
words  with  reference  to  the  nature  of  the 
contract  requires  is,  that  the  act  of  self- 
destruction  should  be  the  voluntary  and 
wilful  act  of  the  man,  having  at  the  time 
sufficient  powers  of  mind  and  reason  to 
understand  the  physical  nature  and  con- 
sequences of  such  act,  and  having  at  the 
time  a  purpose  and  intention  to  cause  his 
own  death  by  the  act,  and  that  the  ques- 
tion whether  at  the  time  he  was  capable 
of  appreciating  and  understanding  the 
moral  nature  and  quality  of  his  purpose 
is  not  relevant  to  the  inquiry,  further  than 
as  it  might  help  to  illustrate  the  extent  of 
his  capacity  to  understand  the  physical 
character  of  the  act  itself." 

In  Cliff  Y.  Schwabe  (1846,  3  C.  B.  437) 
the  facts  were  as  follows  :  Louis  Schwabe 
effected  a  policy  with  the  Argus  Assur- 
ance Co.  on  his  own  life,  subject  inter 
alia  to  a  condition  that  "  every  policy 
effected  by  a  person  on  his  or  her  own  life 
should  be  void  if  such  person  should  c07n- 
mit  suicide  or  die  by  duelling  or  the  hand 
of  justice.""  Schwabe  died  in  consequence 
of  having  voluntarily — i.e.,  for  the  pur- 
pose of  killing  himself — -taken  sulphuric 
acid,  but  under  circumstances  tending  to 
show  that  he  was  at  the  time  of  unsound 
mind.  In  an  action  by  his  administratrix 
upon  the  policy,  the  defendants  pleaded 
that  Schwabe  did  co'mmit  suicide  whereby 
the  policy  became  void ;  and  at  the  trial 
Mr.  Justice  Cresswell  directed  the  jury 
"  that  in  order  to  find  the  issue  for  the  de- 
fendants it  was  necessary  that  they  should 
be  satisfied  that  Louis  Schwabe  died  by 
his  own  voluntary  act,  being  then  able  to 
distinrjuisli  between  right  and  wrong,  and 
to  appreciate  the  nature  and  c[ualiti/  of  the 
act  he  ivas  doing,  so  as  to  he  a  resijonsible 
■moral  agent,  that  the  burthen  of  proof  as 
to  his  dying  by  his  own  voluntary  act  was 
on  the  defendants  ;  but,  that  being  estab- 
lished, the  jury  must  assume  that  he  was 
of  sane  mind,  and  a  responsible  moral 
agent  unless  the  contrary  should  appear 
in  evidence."'  Upon  a  bill  of  exceptions  it 
was  held  by  the  Court  of  Common  Pleas 
— not,  however,  without  the  dissent  of  two 
strong  judges— Pollock,  C.B.,  and  Wight- 


Life,  Expectation  of 


r    7 


750    ] 


Locomotor  Ataxy 


man,  J. — that  that  part  of  the  directiou 
which  we  have  placed  in  italics  was  erro- 
neous, that  the  terms  of  the  conditiou 
included  all  voluntary  acts  of  self-destruc- 
tion, and  therefore  that  if  Schwabe  volun- 
tarily killed  himself,  it  was  immaterial 
whether  he  was  or  was  not  at  the  time  a 
responsible  moral  agent.  {Uf.  Diifaur  v. 
frorinrial  Life  Insurance  Co..  25  Beav. 
599).  In  Glif  V.  Schivahe  the  words  " com- 
mit suicide  "  were  held  to  be  equivalent  to 
the  words  "  die  by  his  own  hand."  The 
scope  of  Borrodaile  v.  Hunter  is  therefore 
accurately  defined  in  proposition  3. 

A  sketch  of  the  American  law  on  this 
subject  will  be  found  in  Porter's  "  Laws  of 
Insurance"  (1887,  p.  133).  (See  also  Nevj 
York  Medico-Legal  Societi/s  Papers,  ist 
series,  p.  i.) 

It  may  be  mentioned  that  life  policies 
now  very  frequently  contain  conditions  for 
the  compromise  of  claims  in  cases  of  suicide 
during  insanity.  A.  Wood  Rexton. 

I.IFZ:,     EXPECTATION^     OF.        (>SVe 

Statistics.) 

IiXGHT,  COIiOURES.     {,Sei  CoU)\j KKD 

Light.) 

XiZnilTATZOM-    OF  ACTION'S.      (See 

Prejsliiiptions.j 

XiZMOPKOITAS  ;  IiIMOPHOITOSIS 

(Xt/Ltoy,  hunger  ;  (fjoirds,  from  (J)oituco,  I  roam 
about  in  a  frenzy).  Insanity  caused  by 
hunger. 

IilIMCOSIS  (kifios,  hunger).  A  morbid 
appetite.  A  name  given  by  Good  to 
denote  those  diseases  characterised  by 
depraved,  excessive,  or  defective  appetites. 

liXPEMANlA.     {See  Lypemama.) 

XiOCAlilSATZOir.  {See  Bkaix,  Phy- 
siology OF.) 

XOCOMOTOR  ATAXY  AS  AI.- 
IiIED   TO  NEUROSES. 

By  origin : — 

There  may  be  maniacal  crises. 

There  may  be  insane  interpretations  of 
locomotor  ataxic  symptoms. 

Locomotor  ataxy  may  be  associated 
with  incontrollable  lust. 

Locomotor  ataxy  may  be  associated 
with  impotence  and  melancholia. 

Locomotor  ataxy  may  be  associated 
with  ideas  of  persecution. 

Locomotor  ataxy  may  be  a  symptom 
associated  with  general  paralysis. 

It  may  precede  general  paralysis. 

It  may  accompany  it. 

It  may  develop  after  its  onset. 

It  may  alternate  with  its  mental  symp- 
toms. 

Temporary  states  of  ataxy  may  occur 
as  the  result  of  alcohol,  &c.,  and  may  be 
associated  with  similar  mental  disorders. 

Xiocomotor  Ataxy,  Tabes  Dorsalis, 
Atazie  locomotrice  Progressive.- — This 


disease  is  chietly  characterised  by  the  in- 
stability of  the  patient  when  the  eyes  are 
closed,  the  slow  increase  of  the  symptoms 
of  paralysis,  and  the  frequent  recurrence 
of  peripheral  nerve  pains,  these  being 
associated  with  degenerative  changes  in  a 
special  region  of  the  spinal  cord  lying 
near  the  posterior  nerve  roots,  and  general 
reduction  of  nervous  I'etlexes.  Locomotor 
ataxy  may  be  associated  with  mental 
symptoms  in  several  ways. 

Though  not  an  ordinary  neurosis  loco- 
motor ataxy  is  very  common  in  members 
of  neurotic  families. 

Locomotor  ataxy  and  insanity  may 
occur  in  the  same  person  and  be  uncon- 
nected, or  locomotor  ataxj"^  may  precede 
the  development  of  associated  mental 
symptoms,  or  locomotor  ataxic  symptoms 
may  be  the  first  indications  of  general 
paralysis  of  the  insane.  Locomotor 
ataxy  and  insanity  may  to  some  extent 
alternate,  so  that  while  the  ataxic  symp- 
toms are  fully  developed,  the  mind  is  clear, 
and  while  the  mind  is  disordered  the  ataxy 
becomes  less  or  is  absent. 

Locomotor  ataxy  may  have  the  follow- 
ing special  mental  relations  : 

There  may  be  during  the  Course  of 
the  Disease  iwental  Crises. — A  patient 
who  is  recognised  as  suffering  from  loco- 
motor ataxy  suddenly  becomes  maniacal. 
In  these  cases  generally  there  is  more  or 
less  suspicion,  and  a  tendency  to  retaliate 
on  those  who  are  supposed  to  be  causing 
the  painful  sensations  in  various  parts  of 
the  body.  These  maniacal  attacks  are  of 
short  duration,  but  may  recur  at  irregular 
intervals. 

There  may  be  insane  interpretations 
ot  the  ordinary  crises,  so  that  one  pa- 
tient says  that  his  bowels  have  been 
twisted  by  his  persecutors,  while  another 
says  that  red  hot  irons  have  been  thrust 
into  his  feet  and  eyes,  and  another  com- 
plains that  unnatural  and  disgusting 
means  have  been  used  to  withdraw  his 
semen.  The  ordinary  symptoms  of  loco- 
motor ataxy  are  insanely  explained  in 
other  ways.  Thus  one  man  may  attribute 
the  pains  and  weakness  in  his  legs  to  poison- 
ing, or  to  "  influence  "' — electricity  or  mes- 
merism ;  while  another  will  say  the  pain 
and  thickening  about  his  ankles  are  due  to 
diabolical  possession,  and  that  the  bullae 
(which  occasionally  occur  as  well  as  cutis 
anserime)  are  marks  of  the  devil's 
grip.  Sexual  weakness  ma}'  also  be  ex- 
plained as  the  result  of  poisoning  or  evil 
influence. 

The  mental  symptoms  in  these  cases 
maybe  acute  or  cJironic  :  in  the  former 
case  they  may  occasionally  alternate,  so 
that  while  the  delusions  exist  the  ataxy 


Locomotor  Ataxy 


L 


7o' 


is  better,  and  vice  versa,  or  the  insanity 
may  be  transient  or  recurrent. 

In  some  cases  the  insanity  is  as  chronic 
as  the  locomotor  ataxy,  but  there  seems 
to  be  little  tendency  to  dementia  in  these 
patients. 

The  most  common  relationship  of 
insanity  and  locomotor  ataxy  is  met 
with  in  general  paral^'sis  of  the  insane, 
and  in  this  the  symptoms  of  both  may 
begin  at  the  same  time,  so  that  with  ex- 
travagance, boastt'ulness  and  lust,  ataxic 
weakness  may  develop.  In  other  cases 
locomotor  ataxy  is  the  tirst  symptom,  and 
after  a  period  varying  from  one  to  several 
years,  other  symptoms  point  to  the  exist- 
ence of  general  paralysis.  In  some  cases 
the  general  paralysis  has  tirst  been  recog- 
nised, and  it  is  only  later  that  locomotor 
ataxy  is  recognised.  A  fuller  description 
of  ataxic  general  paralysis  will  be  found 
under  General  Paralysis. 

Locomotor  ataxy  may  lead  to  insanity 
in  several  other  ways.  Thus  the  sexual 
desire  which  is  frequent  in  the  earlier 
stages  of  the  disease  may  lead  to  most 
insane  acts.  A  man  of  education  and 
position  may  lose  all  power  of  self-control, 
and  may  commit  indecent  assaults  on 
young  girls,  and  may  even  corrupt  his  own 
childx'en ;  or  a  man  may,  from  excess  of 
desire,  marry ;  soon  tind  himself  impo- 
tent, and  he  may  then  become  profoundly 
melancholy  and  suicidal.  Locomotor 
ataxy  may  lead  a  patient  through  a  feel- 
ing of  physical  weakness  into  a  belief  that 
he  is  an  unpardonable  sinner,  and  unfit 
to  live  :  again,  sensory  troubles  may  cause 
the  patient  to  believe  that  he  is  persecuted 
and  plotted  against. 

The  insanity  does  not  affect  ordinary 
locomotor  ataxy  as  apart  from  general 
jjaralysis  so  far  as  its  course  and  duration 
are  concerned.  If  the  case  be  one  of 
general  paralysis,  the  prognosis  will  be 
necessarily  bad  ;  if  on  the  other  hand  the 
symptoms  be  only  those  of  suspicion,  if 
in  fact  there  is  only  an  insane  explana- 
tion of  the  ataxic  symptoms,  the  prog- 
nosis will  depend  on  the  locomotor  ataxy, 
which  may  last  for  years. 

We  believe  that  syphilis  plays  an  im- 
portant part  in  the  production  of  loco- 
motor ataxy,  and  may  occasionally  lead 
to  hypochondriacal  depression  during  the 
course  of  the  disease. 

Syphilis  may  lead  to  locomotor  ataxy 
which  may  run  a  more  or  less  regular 
course,  the  locomotor  ataxy  may  be 
complicated  with  insane  crises,  or  may 
be  followed  by  or  associated  with  general 
paralysis  of  the  insane. 

The  tendency  of  the  cases  of  general 
paralysis  with  ataxy  is  to  dementia,  but 


Locomotor  Ataxy 

there  may  be  some  periods  of  temporary 

arrest   of   mental 

or  motor     symp-  ^ 

toms  or  of  both. 

With  syphilitic 
general  paralysis 
of  the  ataxic  type 
there  may  be 
other  brain  symp- 
toms depending 
on  local  specific 
nutritional  le- 
sions. 

There  is  a  form 
of  temporary  lo- 
comotor ataxy 
which  may  de- 
pend on  peripbe- 
I'al  neuritis.  In 
alcohol  certainly, 
and  probabh'  in 
lead,  and  in  other 
nerve  poisons 
there  may  be  loss 
of  co-ordination, 
loss  of  reflexes 
and  the  like  ;  in 
such  cases  delu- 
sions and  ideas 
of  suspicion  are 
likely  to  occur. 

We  have  met 
with  such  cases 
in  which  accusa- 
tions of  poison- 
ing, of  using  gal- 
vanism and  the 
like  were  made, 
and  in  which 
there  was  risk 
that  the  patients 
would  revenge  or, 
as  they  said,  de- 
fend themselves. 
In  these  cases 
both  the  mental 
and  motor  symp- 
toms pass  off 
if  the  irritant 
is  removed  soon 
enough,  and  if 
there  be  no  other 
cause  for  degene- 
ration. 

The  accom- 
panying is  a 
fac-simile  of  the 
handwriting  of  a 
patient  labouring  under  locomotor  ataxy, 
Geo.  H.  Savage. 

IiOCOSZARRHCEA  (Koyos,  a  word ; 
buippoia,  a  flowing  through).  An  excessive 
flow  of  words ;  the  prolixity  or  verbosity 
of  a  maniac. 


i 


Logomania 


[    752     ] 


Lycanthropy 


IiOCOMANZA  (ixcwUi,  madness).  A 
form  of  insanity  in  which  there  is  great 
talkativeness. 

I.OGOlviOM'OIMiAii'ZA  {jjiovos,  single ; 
navla,  madness).  A  term  for  a  form  of 
insanity  characterised  only  by  great  loqua- 
city (Guislain). 

XiOCOIfEUROSES       {Xoyos,      reason ; 
vivpov,  a  nerve j.    Another  term  for  mental 
affections.     In  the  singular,  used  to  de- 
note  a  derangement   or    impediment   of  I 
speech. 

IiOGOPATHY   {ttcWos,  a   disease).     A 
morbid  affection  of  speech  due  to  cerebral  j 
disease. 

liOCOPIiEGZA   inXrjyr],  a  stroke).      In-  I 
ability  to  pronounce  certain  words  as  a 
result     of     paralysis.      A     synonym     of 
Aphasia. 

IiOGORRHCEA  (poLo.,  a  flow).  The 
same  as  logodiai-rhoea  [q.v.). 

IiOXfGZirGS  (A.S.  longen,  to  desire 
earnestly).  The  name  given  to  the  mental 
symptom  observed  in  pregnant  women, 
and  in  those  suffering  from  suppression 
of  the  normal  uterine  discharges,  by  which 
peculiar  and  whimsical  desires  are  ex- 
pressed.    (Fr.  envie ;  Ger.  Gelilstung.) 

I.OQUACITY  {Fv.loquacite,h-om  loqua- 
citas,  talkativeness).  Excessive  talkative- 
ness, volubility  of  speech,  frequently  a 
symptom  of  mental  disease.  (Grer.  Gesch- 
wdtzigkeit.) 

IiOVE-IVIEIiANCHOIiY.  —  A  popular 
term  for  true  erotomania. 

IiVCIB  ITTTERVAIi  (Pr.  IntervaJU 
lucide).  An  interval  between  the  parox- 
ysms of  insanity,  during  which  the  mind 
appears  clear,  and  the  patient  is  appa- 
rently capable  of  conducting  himself 
sanely.     (Ger.  heller  Zivisclienramn.) 

IiUCXBITY  {lucidus,  clear).  A  state 
of  clearness  or  freedom  from  delusions  or 
mental  disorder. 

liUCOMAiriA.     (/SeeLYCOMANiA;  Ly- 

CANTIIKOPIA.) 

I.VES    DEZFICA  ;     I.UES     SIVISTA 

(lues,  a  spreading  or  contagious  disease ; 
deifica,  making  into  a  god ;  divina,  god- 
like).    Old  terms  for  epilepsy. 

I.UKE'S,  ST.,  HOSPZTAI.  OF.  (Sec 
Registered  Hospitals.) 

IiVNACY  (luna,  the  moon).  The  legal 
term  representing  those  deviations  from  a 
standard  of  mental  soundness,  in  which 
the  person,  property,  or  the  civil  rights 
may  be  interfered  with,  when  incapacity, 
violence,  or  irregularities  threaten  danger 
to  the  lunatic  himself  or  to  others.  (Fr. 
folie  ;  Ger.  IVali.nslnn,  Mondsnclit.) 

I.V3fACY     IiA-W,     EM-GI.ZSH.       {See 

Law  or  Lunacy.) 

XiViTACY  iiAW,  ZRZSH.  (See  Ire- 
land, The  Lunacy  Laws  oe.) 


I.UNACY    X.A-W,    SCOTTZSK.      (See 

ScoTLAxn.  The  Lunacy  Laws  of.) 

laina'ATZC  (Imia,  the  moon,  from  its 
supposed  influence  in  causing  mental  dis- 
ease), (i)  A  term  applied  to  those  dis- 
eases considered  to  be  under  the  influence 
of  the  moon's  phases,  as  ep^ilepsy  and 
insanity.  (2)  Also  those  affected  by  sach 
diseases.  (3)  Also  an  insane  person,  one 
affected  by  lunacy.  Act  16  &  17  A^ict. 
c.  97,  declares  that  the  term  lunatic  shall 
mean  and  include  every  p^erson  of  un- 
sound mind,  and  every  person  being  an 
idiot.  (Fr.  lunatique ;  Gev.Walinsinniger.] 
IiVITATZC  ASYI.T7iyiS.  (See  ASY- 
LUMS, England  and  Wales,  &c.) 

x.xru'ATzcs,  cRziviziTAii.  (See 
Criminal  Lunatics.) 

XiUNATZSMUS  (hona,  the  moon).  A 
name  given  to  those  somnambulists  who 
only  walk  about  at  the  time  the  moon 
shines. 

JiVNE  (lunu).  A  fit  of  insanity. 
XiYCAWTHROPXA  (\vkos,  a  wolf; 
nvdpcoTTos,  a  man).  A  species  of  insanity 
in  which  the  patient  is  under  the  delusion 
that  he  is  a  wolf  or  some  wild  beast, 
having  been  changed  into  such  by  the 
agency  of  the  devil. 

XYCAN-THROPY. — The  most  classic 
form  of  endemic  insanity  really  Greek, 
if  the  case  of  the  Proetides  cannot  be  so 
considered,  is  that  of  lycanthropy,  upon 
which  we  will  make  a  few  remarks,  be- 
cause it  is  a  subject  somewhat  obscure 
and  but  little  discussed  in  treatises  on 
mental  disorders.  "While  upon  this  theme 
we  shall  jDass  the  boundaries  of  the  country 
(Arcadia),  and  the  period  of  its  origin,  and 
follow  it  in  Europe  up  to  the  mediaeval 
epoch. 

We  note  especially  that  the  wolf  was  a 
constant  companion  of  Mars  in  Greek  and 
Roman  mythology. 

We  see  in  this  the  adoration  of  divine 
scourges,  such  as  still  exists  in  the  worship 
of  snakes  and  tigers  in  southern  India. 

Lycosura,  a  mountainous  city  of  Arcadia, 
specially  worshipped  wolves,  and  it  would 
appear  that  before  Lycaon,  Osiris  was 
transformed  into  a  wolf. 

A  bronze  she-wolf  was  sacred  to  the 
oracle  of  Delphos,  to  commemorate  the 
transformation  of  Latona  into  this  animal, 
in  order  that  she  might  more  securely  give 
birth  to  Apollo  and  Diana. 

The  fable  of  Romulus  and  Remus  is  well 
known. 

The  Greeks  worshipiDeJ  a  Zeus  Lj^cseus 
(from  XvKos,  a  wolf). 

In   its   primitive  meaning  lycanthropy 
probably  alluded  only  to  the  transforma- 
tion  into   wolves,   but   subsequently  the 
j  word  was  used  to  signify  transformation 


Lycanthropy 


[    753    ] 


Lycanthropy 


into  other  animals.  Thus,  in  the  period 
of  fully  developed  lycanthropy  when  men, 
transformed  into  wolves,  wandered  through 
the  forests,  Citeus,  son  of  Lycaon,  laments 
the  metamorphosis  of  his  daughter  into  a 
bear,  and  Iphigenia  at  the  moment  of 
sacrifice  was  changed  into  a  fawn. 

But  the  meaning  of  lycanthropy  con- 
tinued to  degenerate  until  more  recent 
times,  when  it  is  known  by  the  common 
people  as  a  most  mischievous,  bad  spirit 
that  roams  the  earth  at  night ;  this  is  the 
luup  garou  of  the  French,  called  in  Italy 
also  lupo  manaro,*  versiera. 

The  native  country  of  lycanthropy, 
therefore,  seems  to  have  been  Arcadia, 
but  in  some  sort  it  was  endemic  in  other 
mountainous  countries  where  there  were 
many  wolves. 

For  instance,  Virgil  (Eel.  viii.  95)  speak- 
ing of  another  region  says  : — 

Has  lierbas  atque  liaec  I'outo  milii  k'cta  veueiia 
Ipse  dedit  3Ia'ris  ;  uascuutur  pluriuia  i'onto  ; 
His  ego  sffipe  lupum  fieri  et  se  coudere  silvis 
Mccrim,  s;epe  alliums  imis  uxciix'  Sepulcris, 
Atqiie  satas  alio  \  idi  traduecLT  inessc's. 

This  is  the  fable  :  Lycaon,  King  of 
Arcadia,  son  of  Titan  and  the  earth, 
founder  of  Lycosura  on  Mount  Lyceo,  was 
one  of  the  founders  of  the  important 
Pelasgian  race.  He  was  the  first  to  sacri- 
fice human  victims  to  Jove  and  was,  there- 
fore, changed  into  a  wolf,  and  wandered  in 
the  woods  with  many  others  likewise 
transformed.     Ovid  says  of  him, 

Territus  ipse  lugit,  nactiisijue  silentia  laiiis 
Exululat,  Iriistraqiie  lo(iui  couatur. — 

Met.  i.  232. 

The  members  of  Lycaon's  and  Antheus's 
families,  who  passed  a  certain  river,  and 
gained  the  forest,  became  wolves,  and  when 
they  recrossed  this  river  regained  their 
human  forms.  Others  believe  that  Lycaon 
is  the  constellation  of  the  wolf,  and  this 
may  result  from  the  existence  of  the  con- 
stellation of  the  bear  into  which  Lycaon's 
niece  was  transformed. 

However  this  may  be,  in  Lycaon  we 
find  three  united  qualities,  those  of  wolf, 
king,  and  constellation. 

Perhaps  the  character  of  wolf  was  a 
divine  attribute,  where  the  wolf  repre- 
sented brute  force  as  seen  in  the  destruc- 
tion of  herds  in  a  mountainous  country, 
and  was  in  reality  given  to  him  who  appears 
to  have  consolidated  the  Pelasgians  and 
formed  their  first  laws,  inasmuch  as  we  see 
his  name  stamped  on  the  firmament. 

We  have  enlarged  on  the  mythology  of 
lycanthropy  because  it  affords  a  striking 

*  The  litpo  muiiaixi  of  tlie  Middle  Ages  was  a 
witch  dressed  as  a  wolf.  It  was  also  a  liubgoblin 
peculiar  to  the  City  of  lilois  that  frightened  chil- 
dren. The  IxjMj  miiriito  was  regarded  as  a  mos 
ravenous  iish. 


example  of  the  superstructure  of  'psycdo- 
IMithii  OH  fable. 

It  is  not  only  in  the  legend  of  Lycaon 
that  lycanthropy  is  mentioned.  Homer 
speaks  of  the  sorceress  Circe  who  changed 
Ulysses'  companions  into  swine. 

Sanctified  b}^  the  lupercalian  feasts  of 
the  Komans,  enriched  by  the  story  of 
Circe,  of  Nebuchadnezzar,  of  Jonah  in 
the  oriental  history,  lycanthropy,  how- 
ever modified,  found  much  nutriment  in 
Christianity  and  forms  an  interesting 
page  in  the  important  psychological 
phenomenon  of  witchcraft. 

A  'propos  of  this  we  refer  to  Bodin  ("  La 
Deraonomauie  on  traite  des  Sorciers," 
Paris,  1587),  who  connects  lycanthropy 
with  witchcraft  and  sorcery,  from  the  fact 
that  the  word  "ram"  is  used  for  demon,  be- 
cause the  ram  is  as  offensive  in  its  habits 
as  a  demon. 

Michael  Verdun  and  Pierre  Burgot, 
tried  at  Besaneou  in  1521,  were  changed 
after  dances  and  sacrifices  to  the  devil 
into  two  agile  wolves,  who  rejoined  others 
in  the  forest  and  coupled  with  them. 

Bodin  also  mentions  the  lycanthrope 
of  Padua,  the  famous  Zit^o  'manaro,  whose 
arms  and  legs  were  cut  off,  and  were  found 
to  be  covered  with  a  wolf's  skin. 

The  witches  of  Vernon  often  mettogether 
in  1566  under  the  form  of  cats  and  were 
dispersed  and  wounded.  Certain  women 
suspected  of  being  witches  were  examined 
and  found  to  bear  the  same  wounds  which 
were  inflicted  on  them  while  in  the  form 
of  cats. 

Pierri  Mamor  and  Henri  di  Colonia 
were  undoubtedly  transformed  into  wolves, 
according  to  the  same  Bodin. 

Greece  and  Asia  have  always  been  more 
infested  with  lycanthropy  than  the  West. 

In  1542  under  the  reign  of  the  Sultan 
Soliman  there  were  so  many  lupi  manari 
at  Constantinople  that  the  Sultan  with 
an  armed  force  drove  off  1 50  ! 

The  Germans  called  them  Werwolf 
(Wiihrvvolf).  Wer  was  derived  from  the 
Teutonic  word  signifying  man ;  in  Gothic 
iveir.  The  French  termed  them,  Joups 
garoua,  the  Picardiaus,  loups  varoihs.  The 
Latins  called  them  varies  et  rersipelles 
(Vir,  man). 

In  Livonia  at  the  end  of  December  the 
devil  called  together  the  witches,  beat 
them  and  transformed  them  into  wolves 
who  threw  themselves  on  men  ! 

For  Bodin  this  is  quite  possible.  Some 
contemporary  doctors  spoke  of  lycanthropy 
as  a  mental  malady,  but  he  shields  him- 
self behind  Theophrastus,  Paracelsus  and 
Pomponius,  and  deems  that  it  is  absurd 
to  attempt  to  compare  natural  with  super- 
natural phenomena,  and  bravely  coucludes 


Lycanthropy 


[    754 


Lycanthropy 


that  if  this  malady  existed  as  the  doctors 
said,  it  could  only  be  iu  the  individual 
affected  with  l)'canthropy.  and  how  could 
the  fact  be  explained  of  others  havintj 
assisted  cle  visn  at  the  transformation  ? 
"■  Now  that  silver  can  be  changed  to  gold 
and  the  philosopher's  stone  fabricated,  it 
ought  not  to  seem  strange  that  Satan 
transforms  persons."  St.  Thomas 
Aquinas  says,  "  Onine.-i  angel!  houi  ef 
mail  e.c  rirtiite  naturali  Iiaheni  poiestatrm 
transmutaucli  corpora  nu.<<tni." 

Gervais  of  Tilbury,  tevip.  Hen.  II.,  says, 
"  Videmus  enim  frequenter  in  Anglia  per 
lunationes  homines  in  lupos  mutari,  quod 
hominum  genus  geridfn>;  Galli  nominant. 
Angli  vero  ivereioolf  dicunt,  trcrc  enim 
Anglice  virum  sonat,  et  v:lf  lupum." 
"  Otia  imp.  ap.  Scriptt.  Brunsv.,"  p.  895. 

A  curious  work  translated  from  the 
French  in  1350  encouraged  the  spread  of 
this  delusion  :  this  was  the  romance  of 
"  William  and  the  Werewolf ;  or,  William 
of  Palermo."  As  to  this  history,  a  king 
of  Apulia  had  a  fair  son  named  William. 
The  king's  brother,  wishing  to  be  heir  to 
the  throne,  bribed  two  ladies  to  murder 
the  child.  What  follows  shows  a  mixture 
of  popular  belief  with  what  in  other  cases 
became  actual  mental  disease.  While  the 
child  was  at  play  a  wild  wolf  caught  him 
up,  ran  away  with,  him  to  a  forest  near 
Eome,  taking  great  cai-e  of  him.  But 
while  the  wolf  went  to  get  some  food,  the 
child  was  found  by  a  cowherd,  who  took 
him  home.  The  writer  then  says  :  "  Now 
you  must  know  that  the  wolf  was  not  a 
true  wolf,  but  a  werewolf  or  manwolf ;  he 
had  once  been  Alphonso,  eldest  son  of 
the  King  of  Spain,  and  heir  to  the  crown. 
His  step-mother,  Braunde,  wishing  her 
own  son  Braundinis  to  be  the  heir,  so  acted 
that  Alphonso  became  a  werewolf." 

In  the  sequel,  the  Emperor  of  Rome, 
while  hunting,  met  the  boy  William,  and, 
being  much  pleased  with  him,  took  him 
from  the  cowherd,  placing  him  behind 
him  on  his  horse.  At  Rome  he  was  com- 
mitted to  the  care  of  his  daughter  Melior 
to  be  her  page,  and,  of  course,  they  fell  in 
love  with  one  another. 

The  emperor,  however,  designed  her  for 
some  one  else.  A  friend  provides  for  their 
escape  by  sewing  them  up  in  the  skins  of 
two  white  bears,  and  they  concealed  them- 
selves in  a  den.  There  the  werewolf  finds 
them  and  supplies  them  with  food  :  they 
are  pursued,  but  escape  to  Palermo.  An 
opportunity  occurs  for  William  (a  were- 
wolf was  painted  on  his  shield)  to  fight 
againstthe  Spaniard, and  he  takes  the  king 
and  queen  prisoners,  and  refuses  to  release 
them  until  the  wicked  Queen  Braunde 
agrees  to  disenchant  the  werewolf.     This 


she  does,  and  Alphonso  is  restored  to  his 
right  shape,  and  is  warmly  thanked  for 
his  kindness  to  William,  who  is  happily 
married  to  Melior,  and  becomes  Emperor 
of  Rome.* 

A  typical  case  of  lycanthropy  wa.s 
admitted  into  the  asylum  of  Mareville 
under  the  care  of  M.  Morel,  and  reported 
by  him  in  his  "  Etudes  Cliniques." 

"  The  patient,  after  residing  for  a  time 
in  a  convent,  returned  home,  where  he 
became  the  victim  of  fearful  mental  agony 
and  terror.  He  was  not  only  absorbed  in 
dwelling  iipon  his  bodily  ailments,  but 
dreaded  everlasting  torture,  merited,  as 
he  believed,  for  crimes,  which,  however,  he 
had  not  committed.  He  trembled  in  all  his 
limbs,  imploring  the  help  of  Heaven  and 
his  friends.  Soon  after,  he  repelled  their 
sympathy,  and,  concentrating  all  his 
delusional  activity  on  his  own  sensations, 
became  aterrorto  himself,and  endeavoured 
to  inspire  every  one  else  with  the  same 
sentiment.  SS'ee  this  nioutli,'  he  exclaimed, 
separating  his  lips  with  his  fingers,  '  it 
is  tlie  'inouth  of  a  V'olf;  these  a.re  the 
teetli  of  a  wolf ;  I  Juive  cloven  feet ;  see  the 
long  hairs  ivhich  cover  tny  hocly ;  let  me 
run  into  the  tmods,  o.nd  you  shall  slwot 
me.'  All  that  human  means  could  adopt 
to  save  this  unfortunate  patient  was  done, 
but  unhappily  in  vain.  He  had  remissions 
which  gave  us  some  hope,  but  they  were 
of  short  duration.  In  one  of  these  he 
experienced  great  delight  in  embracing 
his  children,  but  he  had  scarcely  left 
them  when  he  exclaimed,  '  The  unfor- 
tunates, they  have  embraced  a  wolf." 
His  delusions  came  into  play  with  fresh 
force.  'Let  'nie  go  into  the  vsoods,'  said  he 
again,  'and  you  shall  shoot  ine  as  yoic 
ivonld  a  I'-olf  He  would  not  eat.  '  Give 
me  raiv  meat,'  he  said,  'J  ayui  a  loolf 
His  wish  was  complied  with,  and  he  eat 
some  food  like  an  animal,  but  he  com- 
plained that  it  was  not  sufficiently  rotten, 
and  rejected  it.  He  died  in  a  state  of 
marasmus  and  in  the  most  violent  despair  " 
(vol.  ii.  p.  58). 

Such  is  the  graphic  account  given  by 
M.  Morel.  It  wiU  suffice  to  illustrate  the 
terrible  suffering  which  the  delusion  of 
being  transformed  into  an  animal  occa- 
sions. A.  Tambcrin-i. 

S.  TONXIXI. 
[Hc/ennces.  —  Uotriger.  Beitr.  z>n-  Sprt-ngel's 
Geschichte  tier  >Ieiliziii,  Bd.  ii.  pp.  3-45.  Paul  us 
jEuineta  (S>yil.  Soc),  vol.  i.  p.  389.  Aetius,  vi.  2. 
Oi-ebasius.  Syuops:.  viii.  10.  Actuarius,  Meth. 
^led.  i.  i6.  I'sellus,  Carm.  de  re  meil.  Aviceuiia 
(who  calls  it  cm-iibiith),  iii.  1,5,22.  llaly  Abbas, 
Theor.    i-\.     7.        Tract,     v.    24.       Alsaharavius, 

*  See  translation  by  Sir  Huuipbrey  tie  Bohuu, 
A.D.  T350,  edited  by  the  Kev.  Walter  W.  Skeat, 
M.A.    1867. 


Lycomania 


[    755     ] 


Magnetism,  Animal 


I'ract.  i.  2,  28.  Kliases,  Divis.  10,  Cont.  i. 
Nicaiider,  Tlieriacs  (Schneider's  ed.)  lihau.Tns, 
Supploment  3,  Cur  uiul  Nutz  Anmork  von  Natur 
und  Kuiistiiescliiehteu,  1728.  Blajolus  Dicr  (aii- 
iiali,  t.  2,  colliHi.  iii.  \Vior,  Do  I'rjest.  l);i'iu., 
lib.  vi.  ch.  xi.  Fnicellus,  De  fllirabil.  lib.  xi.  1541. 
IJodin,  D<iuioiiomauie.  Collection  Droz,  sur  la 
Franche-t'omtc'  Jlelanges,  i,  4,  folio  267.  liiblio- 
thc(iue  royale :  also  vol.  xxii.  folio  257.  De  In 
Folio,  par  L.  F.  Calmeil,  torn.  i.  p.  279,  who 
states  that  the  I'arliament  of  Franche-Cointe 
ordained  iu  1573  that  the  lonpa-naron.r  should  bo 
hunted  down.  Art.  by  Dr.  X.  Parker,  on  Lyoan- 
thropy  or  Wolf-nxadness,  a  \'ariety  of  Insania 
Zoanthropica,  in  .lonrn.  .^lent.  Sci.,  1854,  p.  52. 
3Iorel,  Ktndos  Cliiii(iuos,  1852,  toni.  ii.  p.  58. 
lUirlon,  Anatomy  of  !!\Ielaneholy,  1651.  St.  Auuiis- 
tine,  De  Civitate  Dei,  cap.  v.  ^lizaldus,  cent.  v.  jj. 
Scheukius,  lib.  i.  Forest  us,  lib.  x.,  De  niorbis  cere- 
bri. ^■incontius  ISellavicensis,  Spec.  Met.,  lib.  xxxi. 
c.  122.     riiny,  lib.  viii.  c.  22.     Ovid,  Met.  I.  i.] 

IiYCOMAN'IA.     Lycanthropia. 

IiYCOREXXii  ;  I.VCORRHEXIS  (Xu- 
Kos,  a  wolf ;  ope^Ls,  a  longing  after).  A 
name  given  to  the  morbid  wolfish  appetite 
observed  in  some  forms  of  mental  disease. 
A  synonym  of  Bulimia  (q-v.). 


liYPE  (Xi'TT/;,  sadness).     Mournfulness. 
IiVPEIVXilTl'ZA. — A  synonym  of  Melan- 
cholia (Esquirol).     (Fr.  li/jti'uiaiu'e.) 

(Fr.).  Esquirol's  term  for  what  is  known 
as  reasoning  melancholia,  where  the 
patient  is  aware  of  the  absurdity  of 
liis  fears,  but  is  unable  to  escape  from 
them. 

XiVPEROPHR^NIE      (Fr.)      (KvTTiJpos, 

distressing  ;  (Pp'^v,  mind).     Melancholia. 

IiVPOTKYMlA  (KiiTTi] ;  Bvfios,  disposi- 
tion) A  synonym  of  Melancholia.  (Fr. 
lypothjjmie.) 

XiYSSA  (Kva-a-a,  rage).  A  synonym  of 
Madness,  mania;  also  used  for  Hydro- 
phobia. 

IiYSSAS  (Xvcra-as,  raging  inad).  A 
maniac. 

IiYSSETER  {\v(T(rr]rTjp,  one  who  is 
raging  mad).    A  madman.    (Fr.  lyssefere.) 

IiYSSOPHOBIA  (Kvcra-a,  rage  ;  <p6- 
l3os,  fear).  A  synonym  of  Hydrophobo- 
phobia. 


M 


BCACKIiOSYlVE  {paxkorrvvrj,  lust)  ; 
IVXACHIaOTES  {jiaxknuiiis,  lust).  Terms 
used  as  synonyms  of  Nymphomania. 
(Fr.  Tnachlosyne.) 

lM[ACROCEPHil.X.ZC  IDIOCY  {fiaKpos, 
large;  /cepaX?;,  head).     (/SVc  Idiocy.) 

IVIACROlVIAM'IACAIi  (iJ.aKp6s,  large  ; 
fxavia,  madness).  A  term  for  that  form  of 
insanity  in  which  the  insane  person  con- 
ceives things,  especially  parts  of  his  own 
body,  to  be  larger  than  they  in  reality 
are. 

MACROPSIA  HYSTERICA ;  MA- 
CROPSY,  HYSTERICAI.  {paKpos,  large  ; 
oy\n^,  sight ;  hysteria,  q.r.).  A  visional 
defect  found  in  hysterical  subjects,  and 
usually  associated  with  monocular  poly- 
opia. Objects  held  very  close  to  the 
affected  eye  appear  enormously  magnified, 
while  if  removed  a  few  feet  from  the  ob- 
server they  diminish  in  size  more  rapidly 
than  normal.  With  this  there  is  also  to 
be  found  concentric  lessening  of  the  field 
of  vision,  with  reduction  or  transposition 
of  the  colour-field  (Charcot).  {8ee  also 
MiCROpsY,  Hysterical.) 

MAB  (A.S.  getndd).  The  popular 
term  for  one  who  is  insane. 

MASCHEM-SCHM-EIBER  (Ger.)  A 
man  who  has  an  insane  desire  to  cut  or 
wound  girls.     A  "Jack  the  Ripper." 

MASirESS  (Sax.  gomaad).  Professor 
Wilson  in  his  lexicon  (p.  30),  states  that 


X 


this  word  may  be  recognised  in  several 
Indo-European  languages ;  that  Madah  is 
the  Sanskrit  for  madness,  and  Madayati 
for  "  he  drives  mad,  or  insane."  Prichard 
adopts  this  statement.  For  Hebrew  equi- 
valent see  page  3  of  this  Dictionary.  Gr. 
Mapyoa-vvT] ;  Mapyrj;  MapytWr^s.  Lat.Jii.sawtfi, 
Vesania,  Vecordia.  Lyssa  was  employed 
by  the  Greeks  not  only  for  rabies,  but  for 
madness  in  man.     {See  Mania.) 

ItXABN-ESS,  COITCEIiriTAI.  (coil- 
genihis,  born  with).  A  synonym  of 
Idiocy. 

M  ABN-ESS,  BEMEN-TI AI.  (dementia, 
madness).  A  term  used  as  a  synonym  of 
Dementia. 

IVIABNESS,  FURIOUS  (furiosus,  en- 
raged).    A  synonym  of  Acute  Mania. 

ni.3:EusioivxAN-iA.    (See  Maieusio- 

MANIA.) 

TXJENA.S  (patvcis,  one  frenzied  or  in- 
spired).    Mania,  fury.     (*SV('  Mainas.) 

MAGNETISM,  ANIIVIAI.  {pdyvr/s,  a 
magnet,  first  found  near  the  city  of 
Mayvrjaia).  Properties  attributed  to 
the  influence  of  a  particular  princijjle 
which  has  been  compared  to  that  which 
characterises  the  magnet.  It  is  supposed 
to  be  transmitted  from  one  person  to 
another,  and  to  impress  peculiar  modifica- 
tions on  organic  action,  especially  on  that 
of  the  nerves.  {See  Hypnotism  ;  Br aidism  ; 
&c.) 

3  (-' 


Magnus  Morbus 


[    756    ]         Malaria  and  Insanity 


MAGSrirs  MORBVS  {inagmis,  great; 
■iiwrbus,  a  disease).  An  old  name  foi* 
epilepsy. 

MAiEVSZOlviiiTJ-ZA  {fj.aUv(Tis,  delivery 
of  a  woman  in  cliildbirth  ;  fiavia,  madness). 
Insanity  attendant  upon  parturition  ;  a 
synonym  of  Puerperal  Mania.  (Fr. 
■m<'e)(sio'ma)iie.) 

MAIITAS  (fiaivcis,  from  fxaivofxaL,  I 
rage).  Derangement,  or  an  excited  state 
of  the  mind. 

MAXSOM-  D'Al.z^Dr^S  (Fr.).  A  lu- 
natic asylum. 

MAZSOSr  DZ:  S£LNt:±  (Fr.).  A  pri- 
vate lunatic  asylum. 

MAZSPSVCHOSEIO-.  —  The  German 
term  for  psychoses  connected  with  pellagra. 

IVKAIiACZA  {jiakaKia,  softness,  weakli- 
uess).  A  term  generally  used  to  denote 
morbid  softening  of  a  tissue  or  part,  but 
it  has  also  been  used  by  some  authors  to 
indicate  the  depraved  or  fanciful  appetite 
observed  in  hysteria,  pregnancy  and  in- 
sanity, such  as  dirt-eating,  &c. 

MAliADZE  3>tT  PAYS. —A  French 
synonym  of  Nostalgia. 

ItIAI.AI>ZS  SV  SOMMEZIi. — The 
French  term  for  what  is  popularly  known 
as  the  sleeping  sickness. 

IMCAXASZE  IiVITATZQUE. — A  term 
used  in  France  either  for  mania  or  epi- 
1  epsy. 

MAX.ABZES  MYSTZQITES. — A  gene- 
ral name  given  in  France  to  affections  of 
a  hysteric  type  such  as  ecstasy,  trance, 
catalepsy,  &c. 

iMCAXiABY,  EUTGlilSH.— A  term  used 
abroad  for  hypochondriasis. 

MAI.ARZA  and  ZN-SANZTY. — Mala- 
ria is  sometimes  assigned  as  the  cause  of 
mental  disorder.  An  attack  of  malaria 
may  be  attended  with,  or  followed  by, 
extreme  collapse,  coma  or  delirium,  epi- 
leptiform or  tetanoid  convulsions,  or 
mental  symptoms  of  various  degrees  and 
kinds.  In  many  cases  the  occurrence  of 
insanity  may  be  a  chance  coincidence,  and 
not  dependent  upon  an  attack  of  malaria 
as  a  cause.  Simple  uncomplicated  attacks 
of  malaria  are  rarely  followed  by  mental 
disturbance ;  but  when  the  nervous  sys- 
tem has  been  weakened  by  syphilis,  alco- 
hol, and  various  excesses,  not  only  is  some 
neurosis  likely  to  supervene,  but  it  is 
likely  to  be  of  a  serious  and  intractable 
nature.  Simple  cases,  whei'e  no  cause 
beyond  the  malaria  has  been  ascertained, 
generally  recover. 

Some  neuroses  appear  to  be  forms  of 
ague,  and  may  be  recognised  as  being 
malarious,  partly  by  their  periodic  nature, 
partly  by  their  supervention  on  a  more  or 
less  distinct  cold  stage,  partly  by  their 
occurrence  in   a   malarious   district,  and 


partly  by  the  fact  that  the  patient  has 
already  been  the  subject  of  ague.* 

In  the  Medical  Titnes  and  Gazette 
(vol.  i.  p.  217,  1865),  Dr.  Handheld  Jones 
reports  that  "in  a  situation  exposed  to 
malaria  and  never  free  from  its  diseases, 
while  the  other  members  of  a  family  had 
the  intermittent  fever  under  different  but 
ordinary  forms,  the  two  younger  ones 
were  attacked  with  paralytic  affections 
suddenly,  the  one  in  the  leg  and  thigh, 
the  other  in  the  arm.  The  palsy  dis- 
appeared almost  spontaneously  in  both, 
and  was  succeeded  by  the  regular  quo- 
tidian." He  further  states  that  "  perhaps 
nothing  is  more  proving  as  to  the  depres- 
sing effect  of  malaria  on  nervous  power 
than  the  diminution  of  the  intellect,  often 
proceeding  to  perfect  idiotism,  which 
sometimes  follows  severe  or  long-continued 
intermittents."  Sir  R.  Martin  says  :  "  I 
have  seen  a  complete  but  temporary  pros- 
tration of  the  mental  powers  result  from 
a  residence  in  our  terais  and  jungly  dis- 
tricts in  India,  as  in  the  Gondwana  and 
Aracan,  but  especially  after  the  fevers  of 
such  districts."  In  th.e Indian  Annals  of 
Medical  Science  (vol.  vii.  p.  76),  Dr.  Beat- 
son  states  that  "  after  repeated  attacks  of 
intermittent  fever,  in  addition  to  general 
muscular  weakness,  a  partial  paralysis  of 
one  or  more  limbs  is  not  an  uncommon 
occurrence,"  and  this  he  ascribes  to  con- 
gestion of  the  nervous  centres,  inducing 
a  chronic  degenerative  type. 

The  occurrence  of  paralysis  of  certain 
groups  of  muscles  after  malaria  is  not  un- 
common. Dr.  Manson,  in  his  medical  re- 
port on  the  health  of  Amoy,  quotes  a 
case  of  gradual  impairment  of  sight  follow- 
ing an  attack  of  dengue  fever.  Amongst 
the  Chinese  he  also  noted  many  instances 
of  dyspepsia,  debility,  rheumatism,  "para- 
lysis of  certain  groups  of  muscles,  and 
even  insanity,"  as  consequences  of  dengue. 

Pinel  has  recorded  a  case  of  recurring 
suicidal  tendencies  after  an  attack  of  ter- 
tian fever,  and  Baillarger  considers  that 
intermittent  fevers  predispose  to  insanity 
in  two  ways,  first  by  acting  like  all  ner- 
vous affections,  and  secondly  by  producing 
anaemia.  Sullivan,  writing  on  the  endemic 
diseases  of  tropical  climates,  states  that 
in  one  patient  the  effect  of  miasma  pro- 
duces prostration,  in  another  it  produces 
over-excitement,  or  increased  muscular 
sensibility ;  one  man  may  be  seized  with 
delirium,  another  falls  into  a  state  of 
stupor.  On  exposure  to  the  poison  of  ma- 
laria, some  are  seized  with  local  paralytic 
affection,  or  general  hyperassthesia,  while 
others  do  not  complain  of  pain. 

*  Bristowe,  "  I'rinciples  uud  I'ractice  of  Medi- 
cine," 7tli  edit.  p.  290. 


Malaria  and  Insanity 


[     757     ] 


Malaria  and  Insanity 


Neuralgic  affections  of  oue  or  other 
branches  of  the  fifth  pair,  as  in  that  in- 
volving the  supra-orbital,  and  constituting 
one  form  of  the  malady  known  as  "  brow- 
ague,"  is  adduced  as  an  example  of  a  neu- 
rosis being  a  distinct  form  of  ague. 
Several  authors  have  described  intermit- 
tent paroxysmal  mania  or  maniacal  deli- 
rium occurring  in  the  place  of  an  attack 
of  ague,  or  as  its  principal  symptom. 

Of  the  form  which  follows  ague,  Syden- 
ham, who  first  described  it,  states  that 
acute  mania  tending  to  pass  into  chronic, 
occurs  chiefly  after  protracted  quartans. 
Sebastian,  however,  states  that  insanity 
occurs  as  frequently  after  attacks  of  tertian 
or  double  quartan  type,  and  that,  in  these 
cases,  it  is  more  commonly  of  an  acute 
delirious  character,  whilst  after  quartan 
it  takes  on  a  more  chronic  form,  and 
tends  to  pass  into  stupidity  or  melan- 
cholia (Greenfield). 

During  an  attack  of  intermittent  fever 
there  may  be  delirium  in  persons  predis- 
posed thereto,  and  this  delirium  is  not 
always  in  proportion  to  the  intensity  of 
thefever(LemoineandChauminer,  J.ft«(«.Zes 
Med.  Psjjcli.  1887),  or  there  may  be  a  con- 
dition with  exhaustion  analogous  to  the 
typhoid  state  of  other  acute  disorders. 
In  severe  and  prolonged  cases  of  malarial 
disease  there  is  a  tendency  to  intermittent 
mental  affections,  or  chi'onic  insanity  with 
or  without  paralysis.  The  more  import- 
ant mental  conditions  are  met  with  as 
sequelse,  in  persons  who  have  {passed  into 
convalescence  after  a  very  acute  or  pro- 
longed attack  of  malaria.  These  symp- 
toms at  such  period  may  be  transitory 
and  curable,  in  the  form  of  quiet  delirium, 
melancholia  with  or  without  stupor,  or 
simple  mania  with  or  without  impulsive 
tendencies,  or  occasional  outbursts  of  ex- 
citement. These  conditions  are  generally 
considered  curable.  The  pseudo-general 
paralytic  type  has  been  frequently  ob- 
served. It  sometimes  presents  most  of 
the  features  of  general  paralysis,  with 
mental  and  physical  symptoms,  which,, 
although  difficult  to  distinguish  from 
those  of  general  paralysis,  are,  neverthe- 
less, somewhat  different  in  their  course 
and  duration.  Mentally  there  is  fi*e- 
quently  weak-mindedness  or  slight  exal- 
tation, with  or  without  marked  delusions. 
In  one  case  admitted  to  Bethlem  there 
was  partial  dementia  with  confusion,  and 
in  another  melancholia  with  confusion 
and  hallucinations  of  hearing.  The  phy- 
sical symptoms  may  be  those  of  nervous 
debility  with  tremors,  alteration  of  the 
reflexes,  or  even  definite  symptoms  of  a 
system  lesion  in  the  spinal  cord. 

Dr.  Osborne  has  described  a  peculiar 


appearance  of  the  margin  of  the  tongue 
after  attacks  of  malaria.  This  condition 
is  termed  the  "malarial  margin."  Its 
colour  is  faintly  blue,  and  there  is  marked 
transverse  indentation  or  crimping,  appa- 
rently confined  to  the  submucous  tissue, 
while  the  superficial  integument  continues 
smooth,  moist  and  transparent. 

The  prog:nosls  in  such  cases  is  unfavour- 
able. They  seldom  terminate  like  general 
paralysis,  but  go  on  for  years  and  die  of 
some  complication,  or  succumb  to  the 
advance  of  a  degenerative  lesion.  Some- 
times when  alcohol  has  formed  an  addi- 
tional factor  in  the  causation,  the  case 
may  do  well.  When  syphilis  forms  a 
complication,  recovery  is  rax-e.  In  one 
case,  under  observation  at  present  (with 
a  history  of  malaria  and  syphilis),  there  is 
partial  dementia,  with  hallucination  of 
hearing  and  lateral  sclerosis  of  the  cord. 
The  mental  symptoms  on  the  one  hand 
are  of  an  intermittent  type,  and  do  not 
appear  to  advance  in  severity,  although 
the  disease  is  of  four  years'  duration ; 
whilst,  on  the  other  hand,  the  lesion  in 
the  cord  is  progressing  unfavourably. 
The  mental  disorders  occurring  during  an 
attack  of  malaria  are  generally  transitory 
and  curable,  unless  the  malaria  is  of  un- 
due severity,  when  there  is  apt  to  be  per- 
manent instability,  or  a  chronic  form  of 
insanity. 

The  diagnosis  is  often  difficult.  The 
periodic  or  intermittent  nature  of  the 
mental  attacks  may  be  a  guide.  Some- 
times one  may  have  to  distinguish  between 
the  pseudo-general  paralysis  following 
malaria,  insanity  with  paralysis,  and 
general  paralysis. 

The  pathology  is  vague.  Suggestions 
have  been  made  as  to  the  presence  of 
micro-organisms  in  the  blood,  and  the 
existence  of  pigment  in  the  blood  and 
vessels,  but  their  relation  to  mental  dis- 
order is  quite  unknown. 

The  occurrence  of  a  large  amount  of 
pigment  granules  in  the  blood  has  long 
been  known.  Meckel,  Virchow,  and  Her- 
schel  have  described  them  as  frequently 
occurring  after  intermittent  fevers.  For 
accounts  as  to  the  mode  in  which  the  pig- 
ment is  formed,  the  reader  is  referred  to 
the  paper  by  Virchow,  "Die  Pathol.  Pig- 
mente,"  in  Archiv  fur  Pathol.  Anatomie 
and  Physioloyie,  vol.  i.  art.  9  ;  and  to  the 
work  of  Rokitansky,  "  Pathological  Ana- 
tomy," Sydenham  Soc.  Trans.,  vol.  i, 
p.  204  ;  also  to  the  works  of  I.  Vogel, 
Bruch,  Hensauger,  Lobstein,  Andral, 
Trousseau  and  Leblanc. 

Breschet  and  Cruveilhier  seem  to  have 
been  the  first  (in  1821)  to  detect  pigment 
in  the  blood-vessels  in  the  form  of  black, 


Malaria  and  Insanity 


^58 


Malum  Caducum 


sharply-cut  masses  ("  Considerations  sur 
une  alteration  oi-ganique  appelee  De- 
gencrescence  Noire '').  In  1823  Dr.  Halli- 
day  ptiblished  a  case  of  melanosis,  in  which 
he  found  black  pigment  in  the  vessels  at 
the  base  of  the  brain,  and  in  those  of  the 
choroid  plexus  (London  Med.  Bepos.).  In 
1825  Billard  and  Baily  observed  capilla- 
ries of  the  brain  to  be  obstructed  by  pig- 
ment. In  1852  Zervin,  in  a  contribution 
on  the  "  Treatment  of  Ague  by  Arsenic," 
throws  doubt  upon  the  researches  of 
Heschl  (Den t sell e  KUnilc,  Nos.  40,  41). 
Bright  described  and  figured  the  brain  of 
a  man  who  had  died  from  cerebral  para- 
lysis, which  appeared  to  have  resulted 
from  an  attack  of  fever.  The  cortical 
substance  was  of  a  dark  colour  like  black- 
lead.  In  1874  Hammond  had  a  patient 
suffering  from  deafness,  pains  in  the  head, 
and  epileptic  convulsions,  in  whom  an 
ophthalmoscopic  examination  showed  the 
existence  of  double  optic  neuritis,  with 
pigmentary  deposit.  There  was  a  history 
of  malarious  fever  in  the  case,  and  re- 
covery from  these  symptoms,  including 
the  deafness,  followed  the  use  of  arsenic. 
Planer  {Wien  Zeitschrift,  February  1854) 
found  that  in  cases  in  which  there  were 
cerebral  symjitoms,  the  pigment  in  the 
blood  was  found  in  the  state  of  black,  or 
more  commonly  of  brown-yellow,  brown, 
or  (very  rarely)  red  granules,  many  of 
which  were  united  together  by  a  clear 
hyaline  substance,  which  was  soluble  in 
acids  and  alkalies.  Meckel  observed  pig- 
ment cells  very  rarely  ;  Yirchow  more  fre- 
quently. Planer  never  saw  in  the  pigment 
masses  anything  like  a  nucleus.  The 
aggregation  of  the  pigment  grains  some- 
times formed  black  or  brown  flakes  of  the 
most  variable  form ;  these  flakes  were 
sometimes  considered  to  be  constituted 
by  a  hyaline  substance,  in  which  black 
pigment  was  imbedded.  Planer  found 
two  hajmatoidin  crystals  adhering  to  this 
clear  substance.  The  relative  number  of 
the  pigment  masses  as  compared  to  the 
blood  globules,  was  not  determined.  In 
some  cases  the  capillaries  seemed  almost 
choked  up  with  them.  He  did  not  find 
that  the  colourless  corpuscles  of  the  blood 
were  more  numerous. 

The  cerebral  substance  was  often  found 
affected  by  the  pigment  change,  and  it 
appeared  certain  that  the  pigment  was  in 
the  vessels.  Meckel  describes  a  case  in 
which  there  were  numerous  punctiform 
haemorrhages  in  the  grey  substance,  pro- 
duced by  blocking  of  vessels  through  pig- 
ment, and  since  then  several  cases  of  the 
same  kind  have  been  seen  by  Planer.  In 
some  cases  the  flakes,  already  referred  to 
as  seen  in  the  blood  in  the  heart  and  large 


vessels,  were  in  the  cerebral  capillaries, 
and  of  such  size  that  it  seemed  impossible 
they  could  pass.  In  fact,  Planer  conjec- 
tures that  the  extreme  abundance  of  jAg- 
ment  granules  in  the  cerebral  vessels  must 
have  been  caused  by  the  fact  that  they 
could  not  pass  through  the  cerebral  capil- 
laries,which  (especially  in  the  grey  matter) 
are  the  finest  in  the  body  (Kolliker). 

From  this  account  it  is  evident  that  the 
pathology  of  the  affection  is  very  indefi- 
nite, and  we  have  yet  to  learn  whether  in 
these  cases  excessive  pigmentation  occurs 
in  the  nerve-cells  of  the  brain  and  spinal 
cord,  and  if  so,  in  what  way  does  the  de- 
generation differ  from  the  pigmentary 
changes  found  in  ordinary  conditions  of 
functional  hyperplasia,  as  in  severe  attacks 
of  acute  mania,  epileptic  insanity  or  gene- 
ral paralysis  ':'  Theo.  B.  Hyslop. 

MAI.ARZAI.  z:pxi.epsy  (Italian, 
maVaria,  from  'tnalo,  bad ;  aria,  air ; 
eTnXrj-yl/la,  the  falling  sickness).  The  oc- 
currence of  ej^ileptic  seizures  in  persons 
resident  in  malarious  districts.  The  actual 
fit  is  preceded  by  a  great  rise  of  tempera- 
ture, followed  in  the  intervals  by  facial 
neuralgia,  and  the  attacks  are  said  to 
cease  when  the  subjects  are  removed  from 
malarial  influences, 

MAI.A.YiVN'  IDIOTS.  {See  Ibioct, 
Malayan*  ;  Idiocy,  Forms  of.) 

TflAlM  SE  IiAIRA  (Fr.).  The  barking 
disease,  a  form  of  hysterical  epidemic 
which  occurred  in  the  sevententh  century 
in  some  of  the  German  convents. 

MAI.  DE  TERRE,  MAI.  DE  SAIN-T- 
JEAN,  MAI.  BIVIN-,  MIAI.  CABUC, 
MAI.  INTEI.I.ECTUEI.,  MAI.  SACRE, 
IVXAI.  SAINT,  MAI.AI>IE  COMI- 
TIAI.E,  MAI.ABIE  HERCUI.EEM'M'E, 
MAI.ADIE  SACRisE.  French  syn- 
onyms of  Epilepsy. 

mai.forma'tzom'.  (.S'ee  Micro- 
cephaly; Idiocy;  &c.) 

MAI.  CRAM-D,  MAI.  HAITT  (Fr.). 
Terms  employed  both  in  England  and  on 
the  Continent  to  denote  the  typical  and 
fully  developed  epileptic  seizure. 

1VXAI.I.EATION  {malleus,  a  hammer). 
A  name  given  to  a  symptom  which  may 
occur  in  hysteria,  chorea  or  insanity, 
when  the  hands,  one  or  both,  act  convul- 
sively in  striking  as  if  with  a  hammer. 
(Fr.  malleaUon ;  Ger.  Hdmmem,  Schmie- 
den.) 

MAI.  PETIT  (Fr.)  A  form  of  epi- 
lepsy in  which  there  is  only  a  momen- 
tary loss  of  consciousness.  A  term  in 
general  use  in  England  and  on  the  Con- 
tinent. 

MAI.UM  CABVCUM  {malum,  an  evil ; 
caduciis,  falling).  A  synonym  of  Epilepsy. 
The  "  falling  sickness." 


Malum  Hypochondriacum    [    759    ] 


Mania 


MAIiUIVI         HYPOCHONDRZACUIMC 

{'■iiKdiim;  hypochondriasis)  (i/.r.).  A  syn- 
onym of  Hypochondriasis. 

MAIitTM  HYSTERXCUIVI  (malum  ; 
hysteria)  ((/.c).  A  synon}^!  of  Hysteria. 
'maIiUIVX  MZM'US  {maJiivi;  minor, 
less).  The  lesser  sickness  ;  the  form  of 
epilepsy  unaccompanied  by  convulsions  ; 
the  jici it  iiial  of  the  French. 

MANBRilGORil  and  VflANHItAOO- 
RZTES. — Mandragora  officinarum.  Linn. 
Common  Mandrake.    (Radix.) 

Mai'Spayopas  /ieXa?.  Dioscorides,  lib. 
iv.  cap.  76.  Mandragora,  Pliny,  Hist.  Nat. 
lib.  XXV,  cap.  94  ;  ed.  Valp.  Atropa  Man- 
dragora, Linn.  South  of  Europe.  Man- 
drake is  an  acro-narcotic  poison  ;  when 
swallowed  it  purges  violently.  The  roots 
from  their  fancied  resemblance  to  the 
human  form  were  called  anthroiwinorphon, 
and  were  supposed  to  pi'event  barrenness. 
Dr.  Sylvester  has  drawn  attention  to  the 
ancient  uses  of  this  plant  as  an  anaesthe- 
tic. 

Avicenua  employed  it  as  a  soporiiic. 

"  Mandragora,"'  says  Pliny,  "  may  be 
used  safely  enough  to  procure  sleep,  if 
there  be  proper  regard  to  the  dose,  that 
it  be  answerable  in  proportion  to  the 
strength  and  complexion  of  the  patient. 
Also  it  is  an  ordinary  thing  to  drink  it 
against  the  poison  of  serpents ;  likewise 
before  the  cutting,  cauterising,  pricking  or 
lancing  of  any  limb  to  take  away  the 
sense  or  feeling  of  such  extreme  cases. 
And  sufficient  it  is  in  some  to  cast  them 
into  a  sleep  with  the  smell  of  mandra- 
gora."   ("Natural  History,"  bk.  xxv.  ch. 

^^)- 

lago  soliloquises : — 

Not  ])oi)i>y,  nor  mandragora, 
Nor  all  the  ili-owsy  syrups  of  the  world, 
.Shall  ever  mfdiciue  thee  to  that  sweet  sleep 
Whieli  thou  ow'dst  yesterday. 

(Othelhi,  act  iii.  se.  3.) 

In  ancient  times  those  who  took  man- 
dragoi'a,  or  mandrake,  were  named  "man- 
dragorites."  It  is  a  very  interesting  fact, 
pointed  out  by  Dr.  B.  W.  Richardson, 
that  "  as  on  recovery  from  its  effects  there 
was  wildness  of  the  senses,  and  fear,  the 
saying  of  '  shrieking  like  mandrakes ' 
became  ajiplied,  by  a  strange  perversion, 
to  the  plant  instead  of  the  person  : 

And  shrieks  like  mandrakes  torn  out  of  th'  earth. 
That  living  mortals,  heuring  them,  run  mad." 

This  physician,  some  years  ago,  cut  up 
the  root  of  mandragora,  and  attempted  to 
make  a  tincture  from  itwith  alcohol.  He 
found  that  this  preparation  did  not  bring 
out  the  active  principle,  it  being  most 
soluble  in  water.  It  appears  that  the 
ancients  were  aware  of  this.  He  then 
made   a   weak   tincture,  using   one- sixth 


part  of  alcohol,  and  letting  the  root  (in 
fine  powder)  macerate  for  four  weeks. 
The  statements  of  ancient  writers  were 
now  fully  justified.  Narcotism,  dilated 
pupils,  motor  and  sensory  pai-alysis,  and 
then  mental  excitement  were  observed. 
He  concluded  that  its  action  was  purely 
upon  the  nervous  centres.  "  The  whole  of 
the  facts,  indeed,  lead  clearly  to  the  ac- 
ceptance of  the  belief  that  the  medicinal 
use  of  mandragora  in  ancient  times  has 
been  correctly  recorded  "  (•'  The  Ascle- 
piad,"  vol.  V.  No.  i8,  1888,  p.  182).  Its 
auffisthetic  properties  were  found  by  him 
to  be  of  the  most  potent  kind.  It  is  con- 
jectured that  Banquo  referred  to  mandra- 
gora in  the  question,  "  Or  have  we  eaten 
of  the  insane  root  that  takes  the  reason 
prisoner  .^  '" 

A  reference  to  the  plant  occurs  in 
"  Antony  and  Cleopatra  "  : — "  Give  me  to 
drink  Mandragora.'' 

It  was  regarded  as  possessing  aphrodi- 
siac properties.  It  is  employed,  accord- 
ing to  Littre  and  Robin,  in  the  form  of 
the  powdered  root,  the  average  dose  being 
8|  to  9  decigrammes.  The  Editor. 

\_Ri'/erences. — Pareira,  vol.  ii.  pt.  2,  p.  227.  The 
Mandr.ike,  sold  by  herbalists,  ^^'hite  Uryony  (Bry- 
onia dioica).] 

MANIA.  (Lat.  mania;  from  Gr. 
fjiavia,  madness  ;  from  fxaivoum,  I  rage  ;  from 
Aryan  root  ')nan,  to  think ;  derivation 
according  to  Esquirol,  from  fj-ijvr],  the 
moon).  Insanity  characterised  in  its 
full  development  by  mental  exaltation 
and  bodily  excitement.  The  term  is 
also  sometimes  used  for  acute  mania. 
Popularly  it  is  used  for  the  delusions 
of  the  insane.  (Pr.  tjuoiie;  Ger.  Wutlo, 
Baserei,  Tollheit,  Tollsucht.) — IWt.,  acute 
{acutus,  sharp).  An  intense  mental  exal- 
tation with  great  excitement,  complete  loss 
of  self-control,  with  at  times  absolute  inco- 
herence of  speech  and  loss  of  conscious- 
ness and  memory  (Clouston.) — m.,  acute 
delirious  [urutus ;  deliro,  I  am  insane). 
A  psychosis  of  sudden  onset,  attended 
with  increased  bodily  temperature,  and 
marked  by  delirium  with  sensory  hallu- 
cinations, marked  incoherence,  restless- 
ness, refusal  of  food,  loss  of  memory,  and 
rapid  bodily  wasting,  terminating  fre- 
quently in  death.  [See  Acute  Delirious 
Mania.) — ivi., alcoholic.  (/See Alcoholism.) 
— TH,,  amenorrhoeal  (o,neg;  ^i.r]v,  a  month; 
poia,  a  How).  A  term  employed  by  Skae  in 
his  causation  classification  of  mental  affec- 
tions. (See  Amenoriukeal  Insanity.) 
— Ht.  a  pathemate  ('(,  from  ;  TrdBt]p.a,  a 
calamity  or  catastrophe.)  (See  Empa- 
THEMA.) — M.  a  potu  {a,  from;  jjo^ms, 
drink).  Madness  following,  or  due  to 
alcoholic  abuse.     Also  a  synonym  of  De- 


Mania 


[    760    ] 


Mania 


lirium  Tremens  {q.r.), — 1«.,   asthenic  (a, 

neg. ;  aOfvos,  strength).  Mania  in  which 
there  is  a  general  aniiimic  state  with  ner- 
vous debility  and  consequent  irritative  ex- 
citement.)— IVl.  a  temulentla  {a,  from ; 
temuleniid,  drunkenness).  A  synonym  of 
Delirium  Tremens. — Wt.,  cardiac  (/capS/a, 
the  heart.)  A  form  of  insanity  occurring 
in  the  course  of  heart  disease  (Fr.  manie 
cardiaque.)  {See  Cardiac  Disease  nf 
THE  Insane.) — !«.,  chronic  (xpoviKos,  per- 
taining to  time).  A  condition  of  mental 
exaltation  in  which  the  acute  symptoms 
have  run  into  a  chronic  course,  and  in 
which  exacerbations  of  restlessness,  ex- 
citability, and  destructiveness  may  occur 
without  any  marked  physical  objective 
symptoms. — TfL.,  cong-estive  {congestus, 
heaped  up).  A  form  of  insanity  charac- 
terised by  marked  impairment  of  the 
intellect  from  the  beginning,  with  con- 
fusion of  ideas  and  incoherence  of  lan- 
guage ;  the  delusions  are  sometimes  of 
an  exalted,  and  at  other  times  of  a  de- 
pressed, nature ;  there  is  muscular  weak- 
ness and  perceptive  dulness.  (Pr.  inanie 
congestive.) — M.  contaminationis  {con- 
tfrniinatio,  defilement).  (See  Mysoi'IIOBia.) 
— TfL,  crapulosa  {crapula,  drunkenness). 
A  synonym  of  Dipsomania. — IW.,  dancing-. 
A  psychopathy  of  hysterical  origin  spread- 
ing like  an  epidemic,  being  induced  by 
imitation  and  sympathy,  in  which  dancing 
of  the  most  grotesque  and  extravagant 
character  formed  the  most  prominent 
symptom.  It  arose  in  Germany  in  the 
twelfth  century,  spreading  thence  to  Aix- 
la-Chapelle,  and  from  that  city  to  the 
Netherlands.  Occurring  generally  among 
women,  the  attack  usuall}'  commenced 
with  convulsions  of  an  epileptiform  cha- 
racter, on  recovery  from  which  the  pa- 
tients commenced  singing  and  leaping 
about,  contorting  their  bodies  most  vio- 
lently, until  they  fell  down  completely 
exhausted,  their  senses  all  the  while  being 
apparently  dead  to  surrounding  impres- 
sions. A  tympanitic  distension  of  the 
abdomen  accompanied  by  pain  followed 
the  attack,  which  in  mild  cases  then  ter- 
minated. In  the  more  severe  attacks  a 
species  of  temjjorary  furor  would  then 
seize  the  patients  who  dashed  themselves 
against  walls,  or  tiung  themselves  into 
rivers.  Similar  quasi-maniacal  attacks 
have  been  recorded  as  occurring  among 
the  ancients,  and  were  subsequently  com- 
mon in  Italy  (Hirsch).  (See  Epidemic 
Insanity  ;  Jumpers;  &c.) — to..,  delusional 
{deludo,  I  mock  at).  The  form  of  mental 
affection  in  which  maniacal  conduct  is 
associated  with  some  fixed  delusion. — 
M.  embriosa  (ehriosus,  given  to  drink- 
ing).    A  synonym  of  Dipsomania.) — IVI., 


ephemeral  (e(jjr}ij.epos,  living  only  a  day). 
A  rare  form  of  mental  exaltation  which 
is  sudden  in  its  onset,  acute  in  its  cha- 
racter, and  accompanied  by  incoherence^ 
partial  or  complete  unconsciousness  of 
familiar  surroundings,  sleeplessness,  and 
frequently  a  tendency  towards  homicide. 
An  attack  may  last  from  an  hour  up  to 
a  few  days.  It  occurs  mostly  in  the 
subjects  of  epilepsy,  or  in  such  as  are 
subject  to  the  Jacksonian  form  of  epilepsy; 
others  are  examples  of  the  epilepsie 
larvee  of  Morel,  the  mental  explosion 
taking  the  place  of  an  ordinary  epileptic 
fit ;  others  are  young  persons  with  a 
strong  neurotic  heredity,  and  it  is  there- 
fore found  among  hysterical  girls  and 
youths  (Clouston).  (See  Transitory  Ma.- 
NiA.) — IVl.,  epileptiform.  (See  Insanity^ 
Epileptic.) — za.,  erotic.  (See  Insanity, 
Erotic.)  —  aa.,  fei&ned.  (See  Feigned 
Insanity.)— m.,  furious  (furiosiis).  A 
synonym  of  Acute  Mania.  The  fully  de- 
veloped or  violent  stage  of  mania. — Tft. 
g:ravis  (^ravzs, heavy, serious).  Asynonym 
of  Acute  Delirious  Mania. — M.  hallucina- 
tOTia(q.i:)  (/io7/7!c/7i«ri,towanderinmind). 
A  form  of  mania  in  which  visual,  auditory, 
olfactory,  and  other  sense  hallucinations 
predomiTiate. — M.,  histrionic.  (See  His- 
trionic  Mania.) — WC.,  homicidal.      (See 

IXSANITY,H0MICIDAL;  InSAN ITY,Im;PULSIYE.) 

—  la.,  hysterical.  (See  Mania,  Hys- 
terical.)— M.,  incomplete.  A  synonym 
of  Manie  Eaisonnante. — T/£.,  incomplete 

primary.  An  abnormal  state  of  the  emo- 
tions and  sentiments  without  marked 
intellectual  affection. — T/t.  intermittens- 
(intennitto,  lit.,  I  send  between  :  I  leave  off 
for  a  while).  Mania  which  presents  a 
succession  of  attacks  during  the  inter- 
vals of  which  the  patient  appears  well. 
(>S'ee  Malaria  and  Insanity.) — ivx.,  joyous. 
Mental  exaltation  with  hilarious  light- 
heartedness.  (Fr.  manie  gaie;  Ger. 
Charovuinie).  (See  Ch^eromania.)  —  M. 
lactea  {Jacteiis,  milky).  A  name  given 
to  jjuerperal  insanity  in  allusion  to  the 
idea  that  it  was  caused  by  a  metastasis 
of  milk  to  the  head.  Also  used  as  a 
synonym  of  Lactational  Insanity.  (See 
Puerperal  Insanity.)  —  ivi.  melancho- 
lica  {melancholia).  A  synonym  of  Me- 
lancholia. —  m.  menstrualis.  {See 
Menstr.uation.)  — M.  metaphyslca  (to. 
fi€Tti  ra  (j)v(riKd).  A  term  for  a  form  of 
mental  disease  characterised  by  a  fidgety 
questioning  of  the  why  and  wherefore  of 
everything.  (Ger.  GriibeJsiiclii.) — M.  me- 
tastatica  (iJ.eTd(rTaais,  a  being  transformed 
or  changed).  Insanity  following  the  arrest 
of  an  accustomed  discharge,  or  the  sup- 
pression of  a  rash. — M.,  moral.  (See 
Moral   Insanity.) — M.,   partial   moral. 


Mania 


[    761     ] 


Mania 


The  intense  activity  of  some  one  passion 
or  propensity  and  its  predominance  or 
complete  mastery  over  every  other.  (See 
Kleptomania;  Insanity  (Erotic)  ;  Pvro- 
MANiA ;  Dipsomania  ;  &c.)—'BfL.  peilagrla. 
{See  Pellagra,) — nc.perlodlca  {Tr([}to8iK6s, 
coming  rovind  at  intervals).  A  form  of 
mania  which  returns  at  intervals.  The 
term  has  also  been  used  as  a  synonym 
of  Folic  circulaire.  (.s'eelNSANiTY,PERiODic.) 
— M.  postmenstrualis  {'post,  after  ;  vien- 
strualis,  the  monthly  How).  The  form  of 
insanity  which  occurs  just  after  the  men- 
strual 2^eriod.  (.See  Menstruation  and 
Insanity.)  —  iwc.  potatorum  (jjoto/or,  a 
toper).   A  synonym  of  Delirium  Tremens. 

—  M.  praemenstrualis  {prae,  before  ; 
menstrualis,  the  monthly  flow) .  The  form 
of  insanity  which  occurs  just  before  the 
menstrual  period.  {See  Menstruation 
and  Insanity.) — sx.,  puerperal.  {See 
Puerperal  Insanity.) — ivi.  puerperarum 
acuta  (_2J«erpera,a  lying-in  woman ;  acutus, 
sharp).  A  synonym  of  Insanity,  Puer- 
peral.)— IMC.,  reasoning-  (Fr.  raison).  A 
synonym  of  Insanity,  Moral.  (Fr.  folie 
raisonnante.) — IVI.,  recurrent  (re,  back 
again;  curro,  1  run).  The  form  of  mania 
indistinguishable  in  its  symptoms  from 
ordinary  mental  exaltation,  which  shows 
a  tendency  towards  relapse  without,  as 
in  folie  circulaire,  the  intervention  of 
some  other  mental  disturbance.  Also 
used  by  some  as  a  synonym  of  Folie  Cir- 
culaire.— IVI.,  senile  {senilis,  pertaining 
to  an  old  man).  Mania,  the  result  of 
senile  arterial  degeneration  and  brain 
changes,  or  the  mental  exaltation,  what- 
ever its  cause,  occurring  in  the  aged. — 
IMC.,  simple  {simplex).  A  state  of  mental 
exaltation  of  mild  character  marked  by 
restlessness,  loquacity,  i^artial  loss  of  self- 
control,  foolishness  of  conduct,  &c.,  per- 
sisting for  some  time,  and  unattended 
with  incoherence  or  marked  excitability. 

—  M.  sine  delirio  {sine,  without  ;  deli- 
riwin,  madness).  A  synonym  of  Moral  In- 
sanity. (Fr. 07ianie  sans  clelire ;  folie  raison- 
nante).— IW.,  sthenic  (cr^eVoy,  strength, 
vigour).  Mania  in  which  there  is  a  general 
hyperajmic  condition  with  an  excess  of 
nervous  energy.  —  !«.,  suicidal.  (iS'ee 
Suicidal  Insanity.) — Ttl.,  symptomatic 
{a-vfiTTTCJua,  an  occurrence).  The  form  of 
mania  caused  by  some  other  disease,  of 
which  it  is  as  it  were  a  symptom. — IVI., 
systematised  {a-vnTr^na,  an  organised 
whole).  A  synonym  of  Monomania.  (Fr. 
manie  sijstematisee.)  —  TUt.  transitoria 
{transitorius,  having  a  passage).  (See 
Transitory  Mania.) 

VZANIA  (Gr.  fxavia)  is  a  term  which 
appears  to  have  been  in  use  from  the 
earliest  period  in  the  history  of  medicine. 


It  has  borne  throughout  very  much  its 
modern  significance,  expressed  briefly  in 
the  old  English  synonym  of  furious  mad- 
ness. It  is  true  that  it  has  from  time  to 
time,  most  recently  by  ISkae,  been  used  in 
a  sense  covering  every  variety  of  insanity, 
but  this  usage  has  never  been  regarded 
as  quite  defensible,  and  the  modern  ten- 
dency certainly  is  to  restrict  the  meaning 
of  mania  to  a  form  of  acute  insanity 
having  more  or  less  definite  limitations, 
and  exhibiting  certain  groups  of  symp- 
toms more  or  less  distinctly  marked,  la 
this  sense  we  use  the  word. 

Mania  calls  for  detailed  study  as  one  of 
the  great  types  of  mental  disease.  Not 
only  is  mania  itself  a  common  condition, 
but  states  resembling  it  occur  as  inter- 
current (episodic)  phases  of  almost  every 
other  mental  affection. 

Definition. — Mania  may  be  defined  as 
being  an  affection  of  the  mind  character- 
ised by  an  acceleration  of  the  processes 
connected  with  the  faculty  of  imagination 
(perception,  association,  and  reproduc- 
tion), together  with  emotional  exalta- 
tion, psychomotor  restlessness,  and  an 
unstable  and  excitable  condition  of  the 
temper. 

The  typical  maniac  presents  a  rapid 
flow  of  ideas,  with  inability  to  fix  the 
attention,  producing  apparent  or  perhaps 
real  incoherence.  He  exhibits  unmeaning 
gaiety,  passing  into  uproarious  hilarity; 
he  is  constantly  in  motion  ;  his  temper, 
though  variable,  always  tends  towards 
excitement,  and  is  easily  roused  to  the 
extreme  of  fury. 

The  older  notion  that  mania  is  a,  so  to 
speak,  sthenic  disease,  and  that  its  pheno- 
mena correspond  to  a  genuine  increase  of 
functional  activity,  must  be  regarded  as 
incorrect.  The  restlessness,  mental  and 
motor,  of  mania  is  rather  the  analogue  of 
a  discharging  lesion,  and  is  no  more  to 
be  considered  a  sign  of  strength  than  are 
the  perhaps  forcible  movements  of  a  limb 
affected  with  spasm.  Dr.  Clouston  has 
pushed  this  analogy  to  the  length  of 
calling  mania  psychlampsia.  Without 
pursuing  the  comparison  too  far,  it  may 
suffice  to  point  out  that  the  highest  facul- 
ties of  the  mind  as  regards  intellectual 
matters  are  judgment  and  the  power  of 
fixing  the  attention.  As  regards  afl'ective 
matters,  the  highest  faculty  is  what  we 
may  briefly  call  balance.  These  mental 
powers  are  essentially  of  the  nature  of 
inhibition,  and  they  are  precisely  the 
powers  that  are  in  abeyance  in  mania. 
The  faculties  that  are  exalted  are  faculties 
of  the  lower  order.  The  result  is  the 
characteristic  loss  of  control,  together 
with  an  unstable  and  excitable  emotional 


Mania 


[    762    ] 


Mania 


state,  and  extreme  mobility  in  the  ima- 
ginative sphere. 

Analysis  of  Symptoms  of  Mania. 

A.  General  BodiJij  Sijuq^touis.  —  The 
general  nutrition  is  markedly  affected, 
especially  in  cases  of  a  severe  type  or  of 
any  considerable  duration.  In  cases  that 
never  pass  beyond  maniacal  exaltation 
{vide  infra),  and  sometimes  in  the  earlier 
stages  of'  mild  mania,  the  muscular  tone 
appears  to  be  really  increased,  and  the 
patients  assume  a  bright,  sharp  intelligent 
look  which  may  perhaps  not  be  natural 
to  them,  and  which  fades  out  on  recovery. 
But  this  condition  is  usually  very  tem- 
porary, and  in  severe  cases  never  appears. 
The  patient  in  the  early  stage  tends  to 
rapidly  lose  flesh  and  remains  meagre. 
The  skin  often  becomes  drj'  and  shrivelled, 
which  partly  accounts  for  the  aged  ap- 
pearance that  cases  of  mania  soon  put  on. 
Or  the  skin  is  more  rarely  greasy  and 
clammy.  It  is  observed  that  the  violent 
exertions  of  the  maniac  are  not  accom- 
panied by  an  abundant  flow  of  perspira- 
tion, and  that  it  is  difficult  to  get  the 
sweat  glands  to  act.  In  very  many  cases 
the  hair  becomes  rough  and  bristling.  In 
unfavourable  cases  there  is  a  tendency  of 
the  nails  to  become  brittle,  and  there  is  a 
great  liability  to  the;  occurrence  of  othse- 
matoma.  The  appetite  is  capricious.  In 
very  early  conditions  there  may  be  little 
care  for  food,  and  meals  may  be  neglected, 
but  the  general  tendency  is  towards  vora- 
city, increasing  if  the  case  become  chronic. 
In  spite,  however,  of  a  ravenous  appetite, 
the  patient  does  not  gain  flesh  as  long  as 
his  state  remains  purely  maniacal.  The 
tongue  is  rarely  healthy  ;  usually  coated 
with  white  fur  in  the  early  stages ;  it 
either  remains  foul  or  assumes  a  red  irri- 
table appearance,  and  often  presents  glazed 
patches.  It  is  generally  stated  that  the 
bowels  are  confined.  This  is  not  so  as  a 
rule.  In  some  early  cases,  especially  in 
women,  and  in  cases  of  a  distinctly  hys- 
terical type,  there  is  a  tendency  towards 
extreme  constipation,  and  frequent  purga- 
tion may  be  required  ;  but  in  a  very  large 
number  of  cases  of  mania  the  bowels  tend 
to  be  rather  more  active  than  in  health. 

In  women  the  menstrual  functions  are 
almost  always  disordered.  The  menses 
are  often  absent  during  the  continuance 
of  an  attack  of  acute  mania,  and  are 
usually  scanty  and  irregular.  In  very 
many  cases  the  menstrual  period  is  al- 
ways associated  with  an  exacerbation  of 
mental  trouble.  Violent,  dangerous,  de- 
structive, and  indecent  tendencies  are 
aggravated  at  that  time,  and  a  large 
number  of  women  then  show  a  liability 
towards  insane  impulse,  absent  at  other 


times.  iSelf-mutilation,  which  is  so  gene- 
rally associated  with  sexual  disturbance  in 
both  sexes,  is  most  apt  to  occur  in  women 
who  are  menstruating.  The  return  of  the 
menatraal  function,  after  its  suspension, 
may  be  either  a  good  or  bad  prognostic 
sign  according  as  it  is  or  is  not  accom- 
panied by  amelioration  of  mental  symp- 
toms. If  not  speedily  followed  by  mental 
improvement,  restoration  of  the  menses  re- 
moves one  element  of  hope,  and  often  pre- 
cedes the  passage  into  chronic  alienation. 

In  many  cases  salivation  is  a  well- 
marked  symptom,  passing  off  when  there 
is  a  temporary  improvement  in  the  mental 
state,  and  returning  with  an  exacerbation 
of  mental  excitement. 

The  pulse  in  ver}''  early  states  may  be 
full  and  bounding,  but  it  tends  to  become 
small,  and  often  remains  remarkably  slow 
even  though  the  patient  is  incessantly 
restless. 

Temperature  is  normal,  or  in  severe 
cases  subnormal.  Elevation  of  tempera- 
ture in  mania  means  either  the  setting  up 
of  gross  cerebral  mischief  with  passage 
into  acute  delirium,  or  the  approach  of  an 
intercurrent  inflammatory  affection. 

Early  maniacal  cases  exhibit  a  prone- 
ness  to  contract  acute  intercurrent  dis- 
eases. Whitlow  and  other  acute  sup- 
purations often  follow  trifling  injuries  or 
occur  without  apparent  exciting  cause. 
Anthrax  is  not  unfrequent.  Erysipelas, 
if  prevalent,  is  specially  apt  to  attack  such 
cases.  It  has  been  frequently  observed 
that  the  occurrence  of  an  illness  accom- 
panied by  much  pain  or  fever,  or  suppura- 
tion, will  sometimes  cut  short,  or  appear 
to  cut  short,  a  maniacal  attack.  Whether 
this  phenomenon  results  from  altered  con- 
ditions of  the  circulation  (and  perhaps  of 
the  blood  itself),  or  whether  it  is  a  mere 
eftect  of  "  shock,'"'  may  be  questioned. 

Insomnia  is  always  a  marked  feature  in 
mania.  In  many  cases  there  appears  to 
be  hardly  any  sleep  for  almost  incredible 
periods,  and  that  although  the  patient  is 
at  the  same  time  wearing  himself  out  by 
every  form  of  restlessness.  Without  a 
doubt,  absence  of  sleep  contributes  to 
bring  about  the  characteristic  wasting, 
and  is  an  element  of  danger  through  its 
liability  to  lead  to  exhaustion. 

B.  tSjiecial  Nervous  and  so-called  Psy- 
chical Syvipivins. —  Exaltation  shows  it- 
self in  the  sensory  sphere  by  an  apparent 
hypera3sthesia.  How  far  this  is  real  may 
be  questioned,  The  general  sensibility  in 
many  cases  no  doubt  seems  increased  in 
early  stages  of  mania,  but  later  on  there 
are  indications  that  a  degree  of  blunt- 
ness  of  this  sense,  and  also  of  smeU 
and  taste  supervenes.    Thus  the  patient, 


Mania 


[     763    ] 


Mania 


whose  skin  seemed  at  first  so  sensitive 
that  he  found  his  clothes  irksome,  will 
afterwards  endure  the  cold  of  a  winter's 
night  while  he  roams  his  room  naked, 
or  will  smear  himself  with  irritating  and 
loathsome  substances  in  a  manner  that  a 
person  with  normal  senses  hardly  could 
endure.  Occasionally  one  meets  with  in- 
stances in  which  the  acute  maniac  seems 
indifi'ei'ent  to  j^ain,  moving  a  broken  limb 
or  an  inflamed  joint  in  a  manner  that 
would  be  impossible  to  a  sane  person. 
Now  and  again  one  finds  traces  of  that 
singular  perversion  of  sense  which  a  re- 
cent German  teacher  calls  FrcmJensch.mer::, 
wherein  a  patient  seems  to  find  a  distinct 
pleasure  in  inflicting  severe  injuries  upon 
himself.  It  is  probable  that  this  condi- 
tion is  by  no  means  unknown  in  hysteria. 

With  regard  to  the  senses  of  hearing 
and  sight,  increased  acuity  in  the  joercep- 
tion  of  sense  impressions  certainly  exists. 
Attention  is  lively  and  sharp  though 
entirely  unstable.  The  acute  maniac 
appears  to  see  and  hear  better  than  a  sane 
person  because  every  impression  tells  upon 
him.  As  regards  capacity  for  perception, 
he  is  continually  in  a  state  similar  to 
that  of  the  sane  man  who  is  intently  look- 
ing or  listening  with  a  purpose.  Every- 
thing attracts  his  notice.  In  the  ordinary 
lives  of  all  of  us  thousands  of  impressions 
are  daily  made  upon  our  senses  which 
never  reach  the  higher  centres,  or,  if  they 
do,  make  so  little  impression  there  that 
they  can  only  be  recalled  by  an  effort  or 
imperfectly,  or  for  a  very  short  time  after 
the  perception  is  registered.  This,  of 
course,  is  in  some  degree  accounted  for  by 
pre-occupation,  but  not  altogether,  for  the 
idlest-minded  sane  ^jerson  does  not  exhibit 
the  apparent  increase  of  sensibility  shown 
by  the  maniac,  while,  on  the  other  hand, 
anger  sometimes,  and  mental  perturba- 
tion or  anxiety  frequently,  will  develop 
temporarily  in  the  sane,  a  similar  con- 
dition to  that  which  is  so  markedly  pro- 
duced in  the  earlier  conditions  of  alcoholic 
and  other  intoxications. 

The  filling  of  the  mind  with  an  enor- 
mous number  of  sense  impressions,  the 
blurring  as  it  were  of  the  mental  can- 
vas by  the  superposition  of  a  crowd  of 
details  without  the  due  and  normal  foi'e- 
shortening  and  proportional  distribution 
account  in  a  great  degree  for  the  con- 
fusion of  memory  which  is  one  of  the 
ordinary  phenomena  of  an  attack  of 
mania. 

This  sharpness  of  perception,  together 
with  abandonment  of  the  usual  restraints 
on  the  expression  of  whatever  thoughts 
or  feelings  are  called  up  by  surrounding 
objects,  produces  occasionally  an  appear- 


ance of  wit  and  smartness  which  is,  how- 
ever, very  superficial.  The  maniac  is  in- 
capable of  any  sustained  mental  effort, 
because  he  cannot  fix  his  attention.  He 
is  unable  to  add  anything  to  his  stock, 
and  his  mind  runs  in  a  very  narrow 
groove.  The  talk  of  such  a  man,  if  he 
have  been  clever  and  educated  may, 
in  case  it  remain  tolerably  coherent, 
seems  sparkling  at  first,  but  it  soon 
wearies.  There  is  no  real  production,  and 
no  genuine  mental  activity.  Together 
with  increased  perceptive  power  and  in- 
ability to  fix  the  attention,  there  is  a 
marked  increase  of  rapidity  in  the  asso- 
ciation of  ideas.  This,  in  mild  cases, 
heightens  the  notion  of  wit  which  the 
conversation  may  produce.  Sometimes 
the  ideas  tend  very  decidedly  to  arrange 
themselves  along  lines  of  mere  verbal 
assonance :  a  word  calls  up  another  of 
similar  sound,  the  latter,  again,  another 
more  or  less  alike,  and  so  on.  This  con- 
dition may  perhaps  be  related  to  a  state 
of  special  activity  of  the  centre  for  per- 
ception of  sound.  In  other  cases  objects 
seen  appear  to  serve  chiefly  as  the  start- 
ing-point of  trains  of  ideas  which  change 
rapidly  with  slight  changes  in  the  visual 
surroundings.  But  in  most  cases  no 
special  form  of  association  predominates. 

Incoherence  in  conversation  is  a  very 
striking  and  important  symptom  in  cases 
of  mania.  It  depends  chiefly  on  accele- 
rated association  of  ideas.  Thought  is 
always  so  much  more  rapid  than  speech 
that  in  communing  with  ourselves  we 
habitually  use  a  species  of  mental  short- 
hand. People  who  talk  to  themselves 
aloud  probably  always  seem  incoherent  to 
those  who  hear  them  and  who  are  unable 
as  one  usually  would  be  to  supply  many 
apparently  dropped  links  in  the  chain,  for 
we  can  seldom  know  what  lines  of  asso- 
ciation connect  diverse  ideas  in  the  mind 
of  another  person.  In  mania,  association 
is  much  accelerated,  the  attention  is  un- 
fixed, sensory  impressions  are  acutely  per- 
ceived, and  a  strong  tendency  exists  to 
give  immediate  utterance  to  every  passing 
thought;  therefore  apparent  incoherence 
naturally  results.  This  is  the  form  of  in- 
coherence common  in  acute  mental  disease. 
If  one  is  sufficiently  interested  to  listen 
carefully,  one  will  often  be  able  to  discover 
the  clue  to  much  which  at  first  seemed 
entirely  disconnected.  Absolute  incohe- 
rence of  ideas  is  certainly  very  much 
rarer.  It  is  a  phenomenon  not  easily  in- 
telligible, since  to  the  sane  a  succession  of 
ideas  without  any  connection  is  probably 
impossible,  but  it  does  seem  to  occur  in 
severe  cases  of  primary  mania,  as  well 
as  in  cases  of  secondary  mania  (i.e.,  acute 


Mania 


[    764    ] 


Mania 


mental  disease  that  lias  passed  into  a 
state  of  chronic  excitement  with  dementia). 

Combined  with  motor  restlessness  and 
accelerated  association  rate,  and  closely 
connected  wuth  increased  sensory  recep- 
tivit}^,  there  is  found  the  symptom  of 
garrulitj-.  Thereby  incoherence  is  em- 
phasised, and  the  hurrying  flow  of  ideas  is 
betrayed.  The  maniac  is  almost  always 
talkative,  nay,  almost  always  talking. 
Gaiety,  indignation,  anger,  tind  their  vent 
in  constant  speech.  The  tendency  to 
give  voice  to  every  emotion  and  every 
idea  is,  of  course,  in  strict  conformity  to 
the  general  mental  exaltation.  Garrulity 
is  often  the  earliest  indication  of  the 
oncome  of  an  attack,  whether  of  primary 
or  of  recurrent  mania.  That  vague  term 
"  excitement,"'  so  frequently  used  in 
describing  the  condition  of  the  maniac, 
generally  resolves  itself  into  garrulity 
with  motor  restlessness. 

Exaltation  in  the  emotional  sphere, 
though  a  symptom  of  varying  intensity, 
is  important  as  being  very  constant  and 
as  giving  its  special  tone  to  the  maniacal 
state.  Emotional  exaltation  shows  itself 
in  two  forms,  which  may  be,  and  generally 
are,  associated  together.  One  is  exhibited 
in  gaiety,  varying  from  mere  levity  to  the 
most  unbounded  hilariousness  ;  the  other 
in  irritability  of  temper,  which  similarly 
varies  from  the  mere  mood  in  which  a 
man  conceives  that  he  does  well  to  be 
angry  up  to  a  state  of  ungovernable  fury. 
How6ver  the  older  descriptions  of  mania 
may  have  been  tinctured  with  results  of 
mismanagement  and  inhumanity  rather 
than  with  the  true  colours  belonging  to 
the  disease,  there  can  be  no  doubt  that 
furious  madness  is  not  altogether  a  mis- 
nomer as  applied  to  acute  mania.  Yet  in 
this  state  we  do  not  see  the  outbursts  of 
utterly  blind  destructive  fury  with  pro- 
found engagement  of  consciovisness  which 
occur  in  epileptic  insanity.  In  average 
cases  the  temper  is  more  irritable  than 
constantly  exalted;  it  is,  as  it  were, 
vigilant.  The  patient  is  hypera3sthetic, 
trifling  excitation  produces  undue  dis- 
charge. To  use  Dr.  Savage's  apt  phrase, 
it  is  a  word  and  a  blow  with  him,  and 
the  blow  comes  tirst.  In  some  cases  bad 
temper  and  quarrelsomeness  so  far  pre- 
dominate as  to  be  a  special  feature  in  the 
ailment.  Usually  they  are  somewhat  less 
prominent  than  the  accompanying  hilarity. 
The  association  of  these  two  states  is  in 
itself  a  morbid  indication.  In  health, 
good  humour  and  high  sj^irits  are  asso- 
ciated. All  things  please  the  man  who  is 
pleased  with  himself,  and  irritability  of 
temper  subsides  when  the  mood  becomes 
gay. 


With  regard  to  the  emotional  exaltation 
of  the  maniac,  it  has  been  questioned 
whether  this  is  a  primary  condition  or 
whether,  according  to  Mendel,  it  is  merely 
the  result  of  increased  rapidity  of  thought 
and  lack  of  control,  producing  a  joyous 
feeling  of  freedom,  strength,  and  well- 
being. 

Though  the  emotional  exaltation  and 
the  acceleration  of  the  functions  of  mental 
reproduction  seem  in  many  cases  to  be 
merely  opposite  sides  of  the  medal,  yet  it 
is  to  be  noted  as  against  Mendel's  view 
that  the  former  is  often  out  of  all  proj)or- 
tion  to  the  latter,  and  that  in  the  worst 
cases,  when  excitement,  imaginative 
bustle,  and  the  rush  of  ideas  are  constant, 
there  is  often  little  trace  left  of  the  earlier 
emotional  exaltation.  The  feelings  are 
probably  comparable  in  such  a  case  to 
those  of  a  man  in  a  feverish  dream,  con- 
scious indeed  of  perpetual  movements 
and  incessant  thought,  but  finding  therein 
only  weariness  and  irritation,  not  by  any 
means  joy. 

A  case  of  mania  may  run  through  its 
course  without  the  appearance  of  hallu- 
cination. Usually  in  the  typical  form, 
however,  hallucinations  of  vision  or  of 
hearing  occur  at  one  time  or  other.  More 
rare  are  hallucinations  of  the  other  senses. 
Illusions  are  common.  Delusions  con- 
nected with  hallucination,  or  originating 
spontaneously,  occur.  The  general  cha- 
racteristic of  these  phenomena  is  that 
they  are  conformable  to  the  emotional 
state.  Hallucinations  are  in  the  main 
of  a  pleasurable  nature,  and  delusions 
are  usually  of  the  exalted  type.  In  fact, 
the  genesis  of  the  delusion  often  appears 
to  be  an  efJort  of  the  mind  to  account,  as 
it  were,  for  the  exalted  emotional  state, 
a  typifying  or  allegorisation  in  definite 
form  of  the  essential  maniacal  condition. 
Delusions  occurring  in  mania  are  to  be 
distinguished  from  those  of  paranoia  (de- 
lusional insanity)  by  the  absence  of  sys- 
tematisation,  and  of  that  peculiar  fixity 
and  limited  range  which  give  its  special 
character  to  the  latter  affection.  On  the 
other  hand,  the  exalted  ideas  of  the 
maniac  have  neither  the  exuberance,  the 
constant  variability,  nor  the  essential  in- 
coherence which  betray  the  entire  mental 
breakdown  of  general  paralysis  of  the 
insane. 

A  very  common  sj^raptom  in  maniacal 
conditions  is  erotic  excitement.  This 
varies  from  a  mere  coquetry,  a  some- 
what extended  application  of  the  command 
"  love  one  another,"  an  undue  attention  to 
the  opposite  sex,  and  so  forth,  up  to  the 
extreme  of  salacity,  when  the  mind  is 
wholly  occupied  by    the    urgent   sexual 


Mania 


[    765    ] 


Mania 


appetite,  and  all  restraint  is  abandoned 

(sec  Nymi'iiomanlv  ;  Satyktasis;  &c.). 
It  is  needless  here  to  dwell  upon  tbe  well- 
marked  signs  of  sexual  excitement,  but  it 
is  of  some  importance  to  recognise  the 
lesser  conditions  of  this  state.  In  milder 
cases  a  little  more  fondness  for  dress  and 
ornament  than  iisual,  a  tendency  to  talk 
on  questionable  subjects,  and  a  smirking, 
aflPected  manner  will  often  give  the  clue 
to  the  existence  of  these  feelings.  So 
will,  in  women,  a  tendency  to  excessive 
love  of  scandal,  a  liability  to  suspect  every 
one  about  them  of  misbehaviour,  com- 
plaints of  the  misconduct  of  other  women, 
and  so  forth.  A  tendency  to  protesta- 
tions of  the  patient's  personal  purity, 
together  with  an  over-energetic  and  ofteu 
dirtily  expressed  abhorrence  of  unclean- 
ness  points  in  the  same  direction.  In  more 
marked  conditions  nestling  in  the  hair, 
peeping  through  the  fingers,  and  peculiar 
restless  movements  form  the  transition  to 
downright  indecency  of  gesture  and  act. 

Closely  connected  with  salacity,  par- 
ticularly in  women,  is  religious  excite- 
ment. For  obvious  reasons  many  maniacs 
are  fond  of  talking  of  religious  matters, 
and  exalted  delusions  naturally  often  take 
a  religious  form.  But,  besides  this,  there 
is  a  large  class  of  cases  in  which  religious 
emotion  occupies  or  seems  to  occupy  the 
entire  imagination.  Ecstasy,  as  we  see 
it  in  cases  of  acute  mental  disease,  is 
probably  always  connected  with  sexual 
excitement  if  not  with  sexual  depravity. 
The  same  association  is  constantl}'  seen 
in  less  extreme  cases,  and  one  of  the 
commonest  features  in  the  conversation 
of  an  acutely  maniacal  woman  is  the 
intermingling  of  erotic  and  religious 
ideas. 

Many  cases  of  mania  exhibit  a  strong 
tendency  to  masturbation.  The  whole 
subject  of  this  vice  occurring  in  the  insane 
is  elsewhere  dealt  with  (see  Masturba- 
tion). It  suffices  here  to  say  that  the 
occurrence  of  self-abuse  in  acute  cases  is 
not  necessarily  of  bad  prognostic  import, 
nor  indication  of  any  special  astiological 
factor.  It  seems  in  such  cases  to  depend 
on  a  temporary  exaltation  of  the  sexual 
sensations  and  appetites  with  loss  of  con- 
trol, or  it  is  perhaps  to  be  regarded  as  a 
primary  perversion  of  instinct.  In  this 
light  we  may  also  probably  regard  certain 
other  dirty  acts  of  the  maniacal.  Most 
lunatics  are  untidy  in  personal  habits 
from  loss  of  the  liner  sense  of  propriety. 
Many  again  are  dirty  from  negligence, 
but  there  are  also  cases  of  pseudo  deli- 
berate filthiness,  which  are  not  easy  to 
account  for  unless  on  the  suj^position  that 
the  natural  instincts  are  perverted.    Such 


patients  will  eat  their  own  fajces,  or  smear 
their  bodies  and  their  rooms  with  excre- 
mentitious  substiiuces.  The  tendency  to 
these  disgusting  forms  of  filthiness  is 
often  combined  with  sexual  excitement 
and  masturbation.  This  combination  is 
l)articularly  likely  to  occur  in  young  hys- 
terical women. 

Many  patients  suffering  from  acute 
mania  are  apt  to  undress  themselves.  This 
habit  appears  to  be  in  some  cases  con- 
nected with  uneasy  sensations  in  the  skin 
(hyper-  and  parajsthesia)),  in  some  with 
more  or  less  definite  sexual  notions  (ex- 
posure, solicitation,  &c.),  in  others  it  is  a 
mere  form  of  general  restlessness.  It  is 
apt  to  be  accompanied  by  a  tendency  to 
destructiveness  (see  Destructive  Im- 
pulses). 

Course  of  the  Disease. — A  so-called 
prodromal  stage  of  melancholia  has  been 
described  by  many  authors  as  always  pre- 
ceding mania,  at  least  in  cases  of  first 
attack.  It  is  probable  that  the  import- 
ance of  this  symptom  has  been  exagger- 
ated. No  doubt  we  very  often  find  a  state 
of  mental  depression  with  or  without 
hyj)ochondriacal  dreads  occurring  as  a 
precursor  to  acute  mania.  But  this  is 
certainly  in  many  cases  the  mere  physio- 
logical expression  of  the  fact  that  the  pa- 
tient is  conscious  of  a  certain  illness  which 
he  may  or  may  not  recognise  as  chiefiy 
affecting  his  mind.  The  consciousness  of 
increasing  loss  of  mental  control  must 
necessarily  be  an  exceedingly  depressing 
feeling.  Excluding  such  a  condition,  the 
cases  are  comparatively  few  in  which  pro- 
dromal melancholia  is  a  well-marked  stage 
in  the  inception  of  mania. 

Digestive  troubles,  with  loss  of  sleep, 
are  usually  the  first  symptoms  that 
attract  notice.  In  the  early  stage  there 
is  very  often  headache.  The  temper  be- 
comes irritable,  the  patient  grows  rest- 
less, and  after  a  brief  period  true  mania- 
cal exaltation  appears.  Rarely,  this  re- 
mains the  condition  thi-oughout.  More 
often  excitement  rapidly  increases  into 
typical  mania,  which  may  then,  or  later, 
pass  into  grave  mania.  These  phases  re- 
quire brief  individual  consideration.  In 
maniacal  exaltation,  though  there  is  wast- 
ing, there  is  less  bodily  disturbance  than 
in  other  conditions  of  mania.  The  cha- 
racteristic acceleration  of  mental  processes 
is  present,  but  in  a  minor  degree.  The 
patient  sleeps  little,  is  restless,  change- 
able, full  of  2jlans  and  projects,  unable  to 
settle  down  to  anything,  bustling,  talka- 
tive, noisy,  but  only  slightly  if  at  all  in- 
coherent. All  his  acts  are  dictated  as  he 
imagines  by  distinct  motives,  and  he  is 
capable  of  giving  a  plausible  reason  for 


Mania 


[    766    ] 


Mania 


his  most  foolisli  actions.  Episodically, 
he  is  liiglily  passionate,  and  he  is  easily- 
moved  to  indignation  and  tears.  His 
restlessness  often  shows  itself  in  strange 
acts  of  vagabondage,  for  which  he  finds 
ingenious  reasons.  He  is  lavish  in  ex- 
pense, often  benevolent  in  an  extravagant 
way,  furious  if  he  is  thwarted,  but  full  of 
self-satisfaction  throughout.  He  inter- 
feres in  matters  in  which  he  has  no  con- 
cern, or  formerly  had  no  interest.  He 
expresses  with  exuberant  energy  the  most 
exaggerated  opinions  about  everything. 
Opposition  or  laughter  may  infuriate,  they 
never  suppress  him.  In  minor  matters 
he  disregards  the  ordinary  rules  of  society, 
or  believes  himself  to  be  superior  to  their 
consideration.  He  often  engages  in  wild 
matrimonial  projects,  or  exhibits  marked 
amatory  tendencies  with  little  restraint. 
He  frequently  also  indulges  in  intoxicants 
with  very  undue  or  unwonted  freedom, 
and  thereby  precipitates  the  course  and 
aggravates  the  symptoms  of  his  disease. 
Such  patients  in  modern  times  are  the 
eager  though  turbulent  followers  of  every 
"crank"  who  has  a  crazy  view  or  project 
to  promulgate ;  they  often  throw  them- 
selves into  politics,  and  many  of  them  ex- 
pend incredible  enei'gy  in  writing  to  the 
newspapers,  or  to  people  high  up  in  the 
political  and  social  world,  to  secure 
the  redress  of  grievances,  personal  or 
public,  and  to  generally  aid  in  reforming 
society. 

This,  or  a  similar  condition,  seems  to  be 
almost  permanent  in  some  cases,  forming 
one  of  the  phases  oifolie  raisomiante.  It 
is  also  common  in  recurrent  insanity.  In 
acute  primary  mania  it  is  rare  save  as  a 
stage  in  the  beginning,  or  towards  the  end 
of  the  affection. 

The  general  symptoms  of  typical  mania 
have  been  already  discussed.  It  is  only 
necessary  now  to  say  that  it  differs  from 
maniacal  exaltation  by  presenting  an  en- 
gagement of  consciousness.  The  typical 
maniac  is  not  merely  restless  and  talka- 
tive with  a  supposed  motive,  he  is  restless 
or  noisy  for  mere  noise'  and  motion's  sake. 
In  other  words,  excitation  passes  into 
movement  without  the  intervention  of  the 
reasoning  ego.  These  are  the  cases  also 
in  which  incoherence,  real  or  ajDparent,  is 
marked.  These  cases  exhibit  hallucina- 
tions and  delusions.  They  are  liable  to 
variations  of  temper  and  emotional  state 
partly  through  the  influence  of  delusions. 
They  sometimes  exhibit  an  almost  con- 
stantly furious  state  of  temper.  In  typi- 
cal mania  sleep  maybe  absent  for  length- 
ened periods,  and  it  is  always  jirofoundly 
disturbed.  After  an  attack  of  maniacal 
exaltation  it  usually  occurs  that  the  pa- 


tient's memory  for  the  events  of  his  illness 
is  perfect.  In  typical  mania,  on  the 
other  hand,  the  memory  is  commonly  lost 
from  an  early  period  of  the  attack,  and 
the  ]3atient  remembers  only  what  occurred 
from  a  date  corresponding  to  the  subsi- 
dence of  maniacal  symptoms.  Or  the 
recollection  may  exist  but  only  in  a  vague 
summary  way. 

In  grave  mania  consciousness  is  more 
profoundly  clouded,  movements  are  more 
entirely  objectless,  and  the  mental  state 
approaches  that  of  acute  delirious  mania 
iq-v),  to  which  mania  gravis  seems  to 
form  a  transition,  and  into  which  it 
sometimes  passes.  The  patient  has  lost 
the  distinctive  emotional  tone  of  ordinary 
mania.  He  is  indifferent  when  left  to 
himself,  but  may  be  passionate  and  in- 
tensely violent  if  disturbed.  He  lives 
seemingly  in  the  passing  moment.  His 
whole  mental  field  is  filled  with  hallu- 
cinations and  delusions.  He  does  not 
know  where  he  is,  nor  always  who  he  is. 
He  answers  without  seeming  to  attach 
any  significance  to  his  words,  and  jjroba- 
bly  when  asked  a  question  several  times 
answers  each  time  differently,  and  quite 
from  the  purpose.  He  babbles  to  himself 
sometimes  noisily,  sometimes  more  quietly 
with  little  or  no  traceable  coherence.  He 
is  dirty,  destructive,  and  regardless  of 
all  that  goes  on  around  him.  His  nu- 
trition is  profoundly  interfered  with  (vide 
sufra)  and  he  wastes  rapidly.  When  this 
state  gradually  develops  from  typical 
mania  it  usually  goes  on  to  death  by  ex- 
haustion. The  other  terminations  of 
mania  are  : — 

(i)  Recovery.  This  is  most  hopeful 
in  cases  of  typical  mania  :  less  so  in  ma- 
niacal exaltation,  and  in  the  latter  case 
specially  liable  to  be  followed  by  re- 
lapse. Mania  gravis  is  always  of  serious 
prognostic  import,  yet  perfect  recovery 
does  occasionally  occur.  It  is  usually  found 
that  recovery  from  any  form  of  mania 
is  preceded  by  a  state  of  dulness.  The 
patient  passes  from  excitement  into  a 
state  resembling  mild  dementia  before  he 
begjins  to  return  to  his  original  condition. 
This  appears  to  be  due  to  mere  exhaus- 
tion. Occasionally  one  sees  a  state  of 
mild  melancholic  depression  following  a 
favourable  case  of  mania,  but  this  is  not 
nearly  as  common  as  dulness.  Pi,ecovery 
may  take  place  with  a  certain  permanent 
mental  enfeeblement  (the  Heilung  mit 
Defeld  of  Neumann).  The  patient  is  fit 
to  rejoin  society,  and  is  sane,  but  he  is 
not  the  man  he  was.  He  is  on  a  lower 
level,  be  it  intellectually,  emotionally  or 
morally,  and  he  never  regains  the  status 
quo  ante. 


Mania  a  potu 


[    767    ] 


Mania,  Hysterical 


(2)  Passagre  Into  Chronic  'VtTeak- 
mindedness. — Patients  who  do  uot  re- 
cover, and  who  do  not  die  early  either 
of  exhaustion  or  of  some  intercurrent 
affection,  tend  to  fall  into  chronic  de- 
mentia iq.r.),  or  into  what  is  called 
chronic  mania.  With  the  latter  affection 
there  is  associated  a  considerable  degree 
of  permanent  loss  of  mental  power,  so 
that  it  is  really  a  state  closely  akin  to 
chronic  dementia.  However,  it  may  for 
descriptive  purposes  be  differentiated  by 
the  retention  of  delusion.  The  delusions 
of  this  state  are  unsystematised  and 
highly  incoherent.  The  emotional  state 
has  ceased  to  be  active.  Patients  of  this 
class,  though  often  noisy  and  sometimes 
passionate,  are  very  frequently  tractable, 
able  to  do  simple  work,  and  when  under 
proper  supervision  are  much  saner  in 
their  acts  than  in  their  words. 

CONOLLY   NOKJIAN. 
MAM-ZA    A    POTU.        {See     DELIRIUil 

Trkjiens.) 

MAM-ZA  HAZ.I.UCZN'ATORZA  (Men- 
del).— Under  the  name  "  mania  halluci- 
natoria  "  Mendel  describes  a  tolerably  well 
marked  variety  of  insanity,  the  clinical 
recognition  of  which  is  of  some  importance. 
It  is  usually  comparatively  sudden  in  its 
oncome.  It  is  the  most  frequent  form  in 
which  insanity  appears  after  acute  diseases, 
fevers,  child-birth,  etc.  It  is  common  in 
acute  alcoholism.  The  wi'iter  has  also 
found  this  type  of  disease  occurring  with 
phthisis,  and  other  wasting  affections,  and 
has  noted  its  association  with  nostalgia. 

Symptoms. — The  affection,  according 
to  Mendel,  is  ushered  in  by  a  brief  period  of 
insomnia,  or  disturbed  sleep.  Then  the 
patient  becomes  restless,  cries  and  laughs 
unmeaningly,  wanders  aimlessly  about, 
has  usually  a  sudden  outburst  of  violence 
or  destructiveness,  and  rapidly  passes  into 
incoherence  with  lively  and  varying  hallu- 
cinations of  one  or  more  senses,  accom- 
panied by  and  giving  rise  to  delusions  of 
grandeur  or  of  persecution,  or  more  com- 
monly of  both  mixed.  Hallucinations  of 
taste  and  smell  in  the  earlier  stage  very 
commonly  originate  the  ideas  that  there 
is  poison  or  dirt  in  the  food,  that  suffoca- 
ting vapours  are  being  applied,  &c.  Hal- 
lucinations of  sight  are  the  most  promi- 
nent in  the  fully  developed  stage,  and  are 
often  of  a  terrifying  nature.  The  emo- 
tional state  is  not  exalted,  it  is  variable, 
confused,  a  prey  to  hallucination  and  de- 
lusional impressions,  but  without  any 
persisting  tendency  to  elevation.  Super- 
ficially it  would  seem  as  if  the  hallucina- 
tion gave  colour  to  the  emotional  state, 
and  not  vice  versa,  as  in  other  forms  of 
mania.    Of  course,  both  phenomena  being 


subjective  have  essentially  the  same  origin, 
and  are  not  to  be  separated  any  more  than 
the  two  sides  of  a  coin.  The  real  point  is 
this,  that  in  the  condition  under  considera- 
tion the  mental  state  is  constantly  varying. 
There  is  a  continual  activity  of  a  sort,  but 
without  a  set  in  any  special  direction. 

Naturally,  the  concomitant  of  this  state, 
or  rather  it  would  be  more  correct  to  say 
a  portion  of  this  state,  is  confusion  in  the 
intellectual  sphere.  Incoherence  results 
in  this  affection,  not  so  much  from  mere 
want  of  attention  or  over-i-apidity  of 
association,  as  from  exuberant  halluci- 
nations perpetually  breaking  connection. 
German  authors  who  have  written  since 
the  appearance  of  Mendel's  memoir,  have 
generally  inclined  to  treat  confusion,  and 
not  hallucination,  as  the  characteristic 
phenomenon.  Under  the  name  "  verwirrt- 
heit"  (confusion)  Meynert  describes  an 
affection  which  includes  mania  halluci- 
natoria.  The  "'  confusional  stupor"  of  Dr. 
Hayes  Newington  is  closely  akin  to  the 
latter  affection,  and  no  doubt  must  be 
grouped  as  a  sub-division  of  the  former. 
KralFt-Ebing,  by  the  name  he  gives  to  a 
group  of  cases  {WoJinsinn).  emphasises 
the  prevalence  of  delirium,  but  in  his  de- 
scription of  the  state  he  attributes  more 
importance,  and  ascribes  more  generality, 
to  confusion  as  a  symptom.  No  doubt  the 
mania  hallucinatoria  of  Mendel  belonsrs  to 
a  large  class  of  cases  which  connect  typi- 
cal acute  mania  with  stupor  on  the  one 
hand  and  with  delusional  insanity  on  the 
other. 

Progrnosls  and  Course. — A  case  of  well 
marked  mania  hallucinatoria,  is.  on  the 
whole,  hopeful,  but  exception  must,  of 
course,  be  made  for  those  cases  in  which 
the  disease  is  associated  with  serious  or 
incurable  general  illness  (phthisis  and  so 
forth).  Attacks  are  sometimes  very  brief, 
menstrual  cases  occasionally  approaching 
to  mania  transitoria.  Rarely,  cases  pass 
into  a  state  resembUng  grave  mania  or 
acute  delirious  mania  and  terminate  in 
death. 

Mendel  draws  attention  to  the  fact  that 
patients  suffering  from  this  affection  are 
just  those  in  whom  most  frequently  there 
remains  after  recovery,  or  during  episodes 
of  partial  lucidity,  an  accurate  recollection 
of  their  numerous  hallucinations. 

COXOLLY  NORMAK. 
M  A  nr  Z  A,      HYSTERZCAZ..   —  The 

phrase  "  hysterical  mania"  has  been  used 
to  denote  insanity  associated  with  disturb- 
ance of  the  reproductive  organs  in  women, 
and  has  also  been  aj^jilied  to  the  forms  of  in- 
sanity that  follow  long-continued  hysteria; 
in  neither  case  very  correctly.  Insanity 
which   accompanies    sexual   affections    is 


Mania,  Hysterical 


[    768    ] 


Mania,  Hysterical 


often  not  maniacal,  and  alienation  follow- 
ing long-contiuued  hysteria  more  com- 
monly belongs  to  tlie  paranoiac  type.  But 
there  is  a  form  of  mania  characterised 
clinicall}'  b}-  certain  features  which  justify 
us  in  using  the  term  in  a  merely  descrip- 
tive sense. 

Symptoms.  —  Weakness,  with  irrita- 
bility, is  the  fundamental  note  of  the  hys- 
terical character.  Irritable  weakness,  long 
recognised  as  the  basis  of  many  functional 
nervous  affections,  has  become  more  com- 
prehensible by  the  aid  of  recent  theories 
of  brain  action.  The  higher  centre  is  weak : 
the  lower  unduly  active,  perhaps  from 
direct  irritation,  perhaps  merely  because 
the  controlling  (higher)  centre  is  enfeebled. 
Hence  the  tendency  to  convulsion,  the 
emotional  instability,  the  sensitiveness, 
the  desire  for  imitation,  and  the  other 
well-known  symptoms  of  hysteria.  All 
forms  of  mania  seem  to  have,  in  common 
with  hysteria,  the  element  of  irritable 
weakness.  It  is,  therefore,  not  to  be  won- 
dered at  that  some  cases  should  present 
features  common  to  both  conditions. 

The  sufferer  from  hysterical  mania,  in 
our  sense  of  the  word,  is  exceedingly  emo- 
tional. The  pain  of  melancholia  is  un- 
known, the  appearance  of  depression  is 
very  shallow.  A  trifling  and  passing  de- 
pressive emotion  is  responded  to  by  instant 
tears,  perhaps  with  loud  outcry,  and  by  a 
great  disj^lay  of  grief,  but  the  feeling  is 
quite  temporary.  There  is  a  certain  hyper- 
assthesia  showing  itself  by  a  too  quick 
response  to  every  emotional  irritation, 
without  any  permanent  substratum  of 
])ainful  feeling.  In  a  similar  way  there  is 
a  sharp  irritability  of  temper  without  the 
constant  state  of  anger  which  will  sometimes 
occur  in  other  forms  of  mania.  The  entire 
emotional  state  is  unstable  in  the  extreme, 
and  the  expression  of  emotion  bears  a 
peculiar  whimsical  and  uncertain  character, 
such  as  is  also  seen  in  the  entire  conduct  of 
the  patient.  Impulse  is  very  apt  to  be 
translated  into  action  with  alarming 
rapidity.  Impulse  and  whim  sometimes 
rise  almost  to  the  dignity  of  ruling  motives 
in  a  mind  incapable  of  forming  any  fixed 
resolution. 

Connected  with  impulse  is  the  so-called 
imperative  concept.  The  phenomenon  is 
very  common  in  hysterical  cases.  It  takes 
the  form  either  of  a  sudden  feeling  that 
such  and  such  an  act  must  be  performed, 
or  of  a  more  or  less  abstract  idea  invading 
the  mind  without  apparent  associative 
connection,  and  interrupting  the  ordinary 
train  of  thought.  In  many  of  these  im- 
perative ideas  there  is  evidently,  however, 
an  association  of  which  the  patient  is  un- 
conscious, which  we  might  call  the  asso- 


ciation of  opposition.  Thus,  a  j^atient  of 
Obersteiner's  could  not  behold  the  eleva- 
tion of  the  host  without  the  instant  intru- 
sion into  his  mind  of  a  certain  disgusting 
idea  ;  and  a  young  male  patient  of  mine, 
an  onanist  of  extremely  hysterical  cha- 
racter, complained  that  when  he  prayed  he 
was  tormented  by  imj^erative  thoughts  as 
to  whether  or  not  the  B.V.M.  obeyed 
natural  calls  like  other  people. 

The  association  of  opposites,  to  some 
degi'ee,  but  not  wholly,  explains  many  acts 
of  the  hysterical  maniac.  Such  cases,  if 
the  attack  is  not  of  a  very  mild  type,  are 
apt  to  be  extraordinarily  filthy.  The  dir- 
tiness does  not  arise  from  mere  careless- 
ness, nor  seemingly,  as  in  many  lunatics, 
from  mere  perversion  of  the  natural  in- 
stinct to  cleanliness,  but  the  hysterical 
patient  often  appears  to  be  possessed  of  a 
passion  for  the  dirty  both  in  the  moral  and 
physical  sense,  and  takes  a  special  delight 
in  nastiness  of  every  sort.  Here  we  find 
coprophagous  patients, patients  who  smear 
themselves  with  fgeces,  urine,  or  menstrual 
fluid ;  patients  who  masturbate  inces- 
santly, or  who  sometimes  adopt  fantastic 
methods  of  self-abuse. 

Intense  egotism  and  an  ever-wakeful 
self-consciousness  are  characteristic  fea- 
tures of  the  condition  under  consideration. 
In  everyday  life  the  selfish  egotism  of  the 
hysterical  woman  is  well  enough  known. 
The  morbid  introspection  and  self-con- 
sciousness which  lead  to  continual  watch- 
ing of  physical  and  mental  processes  no 
doubt  contribute  to  functional  disturbance 
in  both  spheres.  The  self-consciousness 
of  hysteria  not  only  gives  its  peculiar  note 
to  many  cases  of  mania,  but  has  a  very 
practical  bearing  on  their  treatment.  If 
we  can  rouse  the  patient  from  the  morbid 
state  of  introspection,  &c.,  we  have  ful- 
filled the  most  important  indication  for 
cure.  In  a  large  number  of  cases  thoughts 
and  feelings  connected  with  the  activity  of 
the  sexual  organs  chiefly  occupy  the  mind. 
In  women  the  function  of  menstruation  is 
very  frequently  interfered  with.  In  men, 
irritable  weakness  of  the  sexual  organs 
(or  centre)  is  very  common,  leading  to 
frequent  pollutions,  and  so  forth.  The 
influence  of  masturbation  in  producing 
these  conditions,  and  the  mental  disturb- 
ance accompanying  them,  has  been  pro- 
bably exaggerated.  No  doubt  self-abuse 
often  exists  in  such  cases,  but  it  may  be 
questioned  which  factor  stands  in  a  causal 
relation  to  the  other.  Certainl}^  the  brood- 
ing self-conscious  state  which  is  so  cha- 
racteristic of  the  hysterical  is  dangerously 
apt  to  lead  to  masturbation  in  persons 
who  are  not  strong-minded.  When  the 
thoughts,   especially  of  the  young,    are 


Mania,  Hysterical 


[    769    ] 


Mania,  Hysterical 


entirely  turned  inwards,  the  sexual  element 
is  certain  to  appear,  and  as  the  sexual 
function  is  eminently  an  altruistic  one,  the 
mere  secret  brooding  and  watching  over  it 
are  in  themselves  morbid  and  injurious. 
There  is  no  function  so  easily  disturbed  by 
attention  as  the  sexual.  Again,  tlie  activity 
of  the  sexual  organs  is  probably  in  both 
sexes  fundamentally  periodic.  The  con- 
centration of  the  attention  on  the  geni- 
talia, &c.,  by  keeping  up  a  constant,  even 
though  slight  excitement,  interferes  with 
the  rhythm  and  disturbs  tlie  action. 

Other  indications  of  morbid  egotism  are 
the  love  of  notoriety  and  of  histrionic  dis- 
play. Even  when  self-esteem  assumes  the 
guise  of  self-sacrifice  and  benevolence,  the 
truly  egotistical  feelings  which  lie  at  the 
basis  cannot  be  concealed.  Not  infre- 
quently the  hysterical  maniac  identifies 
himself  with  the  Saviour  of  the  world  or 
some  martyr  or  saint,  and  talks  of  sacri- 
ficing himself  for  the  sins  of  others,  of 
doing  some  great  penance,  or  the  like. 
Hysterical  patients  rarely  commit  suicide, 
and  then  more  often  from  whim  or  love  of 
attracting  attention  than  from  depression 
or  in  obedience  to  delusion.  Much  more 
frequent  is  the  tendency  to  mutilation, 
which,  indeed,  should  always  be  borne  in 
mind  in  cases  of  this  class.  Mutilation  is 
attempted  with  the  idea  of  expiation,  in 
the  glow  of  religious  excitement,  under 
the  notion  that  the  flesh  is  being  sacrificed, 
or  some  saintly  example  or  scriptural  pre- 
cept is  being  followed,  also  with  the  view 
of  attracting  notice  or  exciting  sympathy, 
and  finally,  from  mere  whim.  The  pu- 
denda, for  obvious  reasons,  are  a  frequent 
point  of  attack. 

In  milder  cases,  the  feigning  of  illnesses 
which  do  not  exist,  and  the  concealment  of 
existing  ones  are  common.  The  same 
subtlety  and  deceitfulness  which  occur  in 
the  hysterical  who  are  sane,  are  unfortu- 
nately not  unknown  among  the  class  of 
hysterical  maniacs. 

Religious  excitement  is  usually  a  promi- 
nent symi3tom,  and  is  not  uncommonly 
associated  with  a  disgusting  salacity.  This 
combination  is  probably  in  part  due  to  the 
mere  association  of  opposition. 

Religious  excitement,  with  or  without 
delusion,  more  commonly  the  former,  often 
passes  into  ecstatic  conditions  which  are 
sometimes  ushered  in  by  convulsions  ;  or 
more  rarely  the  period  of  ecstasy  termi- 
nates in  a  convulsion.  Ecstasy  may  pass 
into  stupor  (miscalled  "acute  dementia  "), 
which  may  again  pass  off,  giving  way  to 
maniacal  symptoms. 

Hysterical  cases,  though  liable  to  impul- 
sive outbursts  of  destructiveness  and  vio- 
lence, do  not  exhibit  the  same  degree  of 


motor  excitability  as  other  maniacal 
patients.  They  are  rather  distinctively 
noisy  and  talkative  than  restless.  The 
perpetual  motion  of  the  typical  maniac 
only  extends  to  the  tongues  of  the  hys- 
terical. Their  talk  is  particularly  in- 
coherent. It  is  apt  to  be  chopped  up 
into  short  sentences,  often  repeated  over 
and  over  again  with  unmeaning  per- 
sistence. It  very  often  takes  the  inter- 
rogative form.  A  peculiar  silliness  is 
very  common  ;  a  repeating  over  of  childish 
%vords  or  sentences  ;  a  deliberate  mal-posi- 
tion  of  the  words  of  a  sentence  ;  a  reckon- 
ing over  of  names,  numbers,  colours  in  a 
sort  of  catalogue,  and  so  forth.  Very 
often  the  semblance  to  the  feigning  of  in- 
coherence is  very  striking.  A  patient,  who 
from  her  acts  evidently  understands  what 
is  said,  will  reply  with  silly  sentences  or 
exclamations  entirely  from  the  purpose, 
laughing  and  grimacing,  then  perhaps 
replying  sensibly  for  a  moment  and  passing 
again  into  the  same  state  of  silly  incohe- 
rence or  verbigeration.  Some  patients 
feign  various  emotions,  fear,  delight,  &c. 
in  quick  succession.  Others  indulge  in 
unmeaning  attitudes  and  gestures,  which 
become  more  marked  when  the  patient 
perceives  that  they  are  observed.  This 
attitudinising  and  histrionic  display  adds 
much  to  the  odd  appearance  of  not  beino- 
in  earnest,  just  referred  to. 

With  regard  to  facial  expression,  traces 
of  sexual  excitement  are  generally  very 
evident,  especially  in  women. 

Hysterical  cases  are  particularly  liable 
to  suffer  from  constipation.  On  the  whole 
their  sleep  is  less  disturbed  than  in  pro- 
portionately severe  cases  of  other  forms  of 
mania. 

Hysterical  symptoms  may  give  their 
characteristic  tone  to  cases  of  very  varying 
degrees  of  severity,  from  maniacal  excite- 
ment up  to  grave  mania  :  but  speaking 
generally,  the  graver  cases  are  rare,  and 
cases  which  are  typically  hysterical  very 
seldom  pass  into  that  form  of  mania  which 
is  dangerous  to  life. 

With  regard  to  aetiologry,  the  influence 
of  sexual  affections  has  been  over-esti- 
mated. In  many  women  a  history  of  ute- 
rine disturbance  is  really  only  a  history  of 
hysteria.  Nevertheless,  sexual  affections 
in  both  sexes  sometimes  seem  to  lead  to 
this  condition.  Sexual  excess  is  no  doubt 
occasionally  a  cause,  and  incomplete  sexual 
intercourse  is  specially  liable  to  produce 
hysterical  mania.  Its  relations  to  mas- 
turbation have  been  already  dealt  with. 
The  writer  has  seen  some  exquisite  cases 
in  young  men  whose  minds  had  given  way 
under  the  terrors  held  over  their  heads  by 
advertising  quacks.     Sudden   fright  and 


Maniac 


[    770    ] 


Manias,  Fasting 


shock  not  uncommonly  appeal*  to  be  the 
immediate  exciting  cause  in  women.  Se- 
duction, and  more  particularly  indecent 
assault,  are  often  followed  by  insanity  of 
this  particular  form. 

In  view  of  progrnosis,  and  with  refer- 
ence to  the  course  of  the  disorder,  there  is 
nothing  specially  unfavourable  in  hys- 
terical mania  occurring  in  a  young  woman 
or  in  an  adolescent.  In  the  former  case, 
indeed,  it  is  perhaps  one  of  the  most 
favourable  as  it  is  one  of  the  commonest 
foi'ms  in  which  insanity  ap]3ears.  In  later 
life  hysterical  symptoms  form  an  element 
in  a  serious  prognosis  as  to  mental  re- 
covery. CoNOLLY  Norman. 

WLANXAC  (Mid.  E.  maniack,  from  Lat. 
inania ;  Gr.  jiavia,  madness).  One  suffering 
from  mental  exaltation.  Also  popularly 
one  who  is  insane.  (Fr.  maniaque  ;  Ger. 
Tobs'nchtig.) 

ItlAM'Z.A.CAIi  I>EI.IRIVIMC  {deliro,  I 
am  crazy);  TaA.NXA.CA.1.  TJTItY  (furiosus). 
Synonyms  of  Acute  Mania. 

MANIAS,  FASTIITG. — From  time  to 
time  a  fasting  mania  attracts  public  at- 
tention, and  the  medical  psychologist,  if 
he  is  wise,  will  profit  by  the  spectacle,  so 
far  as  he  can  eliminate  mere  imposture. 

Tliert'  is  some  soul  ot  tiiioducss  in  things  evil, 

AViiuld  men  observini;ly  distil  it  out. 

In  1890  and  1891,  such  manias  occurred 
and  were  witnessed  in  London.  We  have 
looked  back  on  our  medical  experience  to 
see  what  knowledge  it  might  afford  on  the 
ciuestion  of  tasters  and  fasting.  We  find 
from  this  review  of  the  past  that  we  have 
met  with  two  clear  examples  of  death  by 
voluntary  fasting.  The  latest  of  these  is 
too  near  the  present  to  allow  me  to  give 
the  details.  The  other,  having  occurred 
so  far  back  as  1848,  and  having  been  i-e- 
corded  already  in  part,  may  now  be  ren- 
dered in  the  following  report. 

A  Past  of  Fifty-five  Says. — A  gentle- 
man, about  thirty-three  years  old,  had 
often  been  subject  to  fits  of  depression  and 
melancholy.  He  was  a  man  of  good  social 
position,  had  somewhat  distinguished  him- 
self in  his  scholastic  life,  and  was  always 
considered  as  extremely  good-natured  and 
thoughtful,  though  from  his  earliest  age 
obstinate  and  self-willed.  He  was  one  of 
those  of  whom  it  is  said  that  if  "  he  took 
anything  into  his  head  nothing  would  turn 
him."  He  was  not  subjected  at  any  time 
to  much  restraint;  and,  as  he  was  com- 
fortably provided  for  by  a  business  which 
demanded  but  little  personal  attention,  he 
really  had  as  small  occasion  for  anxiety  as 
most  men  we  have  known.  He  read  a  great 
deal,  cared  nothing  for  out-door  or  athletic 
amusements,  and  was  somewhat  listless 
about  the  course  of  events,  though  he  could 


usually  be  interested  in  j^olitical  contro- 
versy, and  up  to  his  death  was  wont  to 
speak  on  the  state  of  political  parties.  He 
was  not  the  only  man  of  his  turn  of  mind, 
in  our  experience,  who,  whilst  brooding 
over  his  own  infirmities,  has  been  inclined 
to  political  discussion ;  but  he  perhaps 
showed  this  tendency  moi-e  than  others  of 
his  class.  He  was  always  nervous  about 
himself,  as  we  were  told,  and  yet,  at  the 
same  time,  was  ready-minded  and  even 
courageous  in  the  face  of  sudden  danger. 
In  religion  he  was  not  enthusiastic,  and  his 
melancholy  was  untouched  by  any  sadden- 
ing religious  sentiment ;  but  he  brooded 
over  imaginary  physical  evils,  which  he 
almost  invariably  referred  to  the  stomach, 
and  he  sought  advice  from  men  of  all 
kinds  who  professed  to  practise  medicine, 
having  just  as  much  faith  in  a  pretentious 
quack  or  in  the  veriest  old  woman,  as  in 
the  most  regular  professor,  so  long  as  his 
whim  for  liking  them  lasted.  In  a  word, 
he  became,  as  his  friends  said,  a  confirmed 
hypochondriac,  a  man  to  be  pitied,  and 
beyond  hope  of  amendment. 

In  stature  this  gentleman  was  tall,  we 
should  say  near  upon  six  feet.  In  figure 
he  was,  naturally,  very  slight,  and  he  was 
at  all  times  a  small  eater.  To  the  best  of 
our  recollection,  he  took  no  wine  nor  other 
alcoholic  drink  ;  if  he  took  any,  it  was  the 
smallest  quantity ;  so  that,  though  he 
would  be  under  no  pledge,  nor  connected 
with  the  total  abstinence  movement — 
which  at  the  time  was  little  considered — 
he  was,  practically,  a  total  abstainer. 

For  many  years  the  condition  of  this 
gentleman  had  continued  the  same.  He 
was  induced  to  try  the  effects  of  change 
of  air  and  scene ;  but  this  he  declared 
wearied  him  too  much,  and  finally  he 
settled  down  a  confirmed  invalid  of  the 
malade  vmaginaire  type,  pure  and  simple. 
In  seeking  one  day  advice  from  a  professor 
of  a  schismatic  school  of  physic,  he  gathered 
what  he  su^jposed  to  be  an  entirely  new 
light  as  to  the  cause  of  his  malady.  The 
professor,  very  learned  and  imposing,  de- 
tailed to  the  sufferer  the  ideas  then  prevail- 
ing as  to  the  cause  of  pi'imary  digestion, 
from  the  experiments  which  Dr.  Beaumont 
had  conducted  on  that  most  interesting 
of  physiological  instructors,  Alexis  St. 
Martin.  The  history  of  the  accidental  shot 
which  made  St.  Martin  such  a  figure  in 
history,  the  account  of  the  opening  into 
his  stomach,  and  the  notes  that  had  been 
made  from  visual  inspection  of  the  pro- 
cess of  digestion  ;  the  description  of  the 
gastric  juice  that  was  extracted  :  and  the 
further  explanation  as  to  the  solvent  action 
of  the  gastric  juice  on  food,  became  a  per- 
fect fascination  for  the  anxious  invalid  ; 


Manias,  Fasting 


[    in    ] 


Manias,  Fasting 


and  when  the  learned  expositor  improved 
the  occasion  by  telling  his  patient  that  all 
this  demonstrative  argument  was  but  a 
prelude  to  the  grand  inference  he  drew  as 
to  the  jiatient's  condition,  the  inference 
being  no  more  nor  no  less  than  that  the  un- 
fortunate patient  could  not  possibly  digest 
food  because  he  produced  no  gastric  juice, 
the  impression  produced  was  positive  and 
unanswerable. 

From  that  day,  by  a  tind  of  logical 
determination  which  was,  we  may  say  at 
once,  impossible  to  combat,  so  as  to  carry 
conviction  to  the  mind  of  the  sufferer,  he 
maintained  that,  as  he  had  no  gastric  juice, 
it  was  utterly  useless  for  him  to  take  nutri- 
ment of  any  kind  except  water,  which  re- 
quired no  digestion.  The  idea  implanted 
in  his  mind  held  its  place,  and  was  never 
uprooted.  Unfortunately,  it  was  confirmed 
by  the  effects  of  a  first  attempt  at  reduc- 
tion of  food.  The  stomach,  no  doubt  very 
feeble  and  irritable,  was  relieved  by  a  re- 
duction of  food,  and  therewith  the  depres- 
sion of  mind  was  signally  relieved,  an 
occurrence  by  no  means  unusual,  and 
perhaps  a  natural  consequence. 

Soon  after  his  first  attempt  to  reduce  food 
to  a  minimum,  thei'e  succeeded  another 
stage,  in  which  the  desire  for  food  appeared 
to  pass  away  altogether.  Then  when,  by 
a  great  effort  and  with  much  repugnance, 
food  was  taken,  it  caiased  pain,  disturbance, 
and  a  greater  depression  than  usual  of 
mental  power,  with  a  more  determined 
dislike  to  the  process  of  feeding,  and  a 
firmer  and  deeper  conviction  of  the  truth 
of  the  hypothesis  that  he  failed  to  produce 
digestive  fiuid. 

In  time  there  seemed  to  be  an  entire 
failure  of  desire  for  food  ;  a  loss  of  sense 
of  taste  ;  a  loathing  at  the  odour  of  food  ; 
an  irritable  objection  to  have  the  subject 
offeeding even  spoken  about;  and, finally, 
a  resolute  determination  not  to  take  any 
more  food  at  all  unless  appetite  or  desire 
for  some  particular  kind  or  quality  of  food 
revisited  him.  From  that  moment  the 
rigid  fasting  commenced.  Of  water  he  i 
would  partake  readily,  but  not  largely ; 
for  he  said  that  in  quantity  it  was  heavy 
and  cold,  and  caused  painful  distension.  He 
would  take  it  to  allay  thirst,  and  nothing 
more.  For  ten  days,  under  this  7-egiine, 
he  went  about  the  house,  and  walked 
occasionally  in  the  garden,  refusing  medi- 
cal advice.  After  this  he  took  to  his  bed, 
and  declined  to  rise  except  to  have  the 
bed  made.  He  now  wished  for  medical 
attention,  but  was  as  resolute  with  his 
medical  advisers  against  taking  food  as  he 
was  with  the  members  of  his  family.  Once 
an  effort  was  made  to  feed  him,  perforce, 
with  milk ;  but   he    resisted   so   determi- 


nately,  and  subjected  himself  to  such 
danger  by  his  resistance,  that  the  attempt 
was  not  made  a  second  time. 

A  great  reduction  of  bodily  weight  oc- 
curred during  the  earlier  stage  of  the 
process  of  fasting.  He  sank  into  the 
extremest  state  of  emaciation  during  the 
first  three  to  four  weeks  of  his  trial,  after 
which  he  did  not  seem  to  us  to  undergo 
rapid  change,  although  we  saw  him  almost 
daily.  He  slept  a  great  deal  and  at  times 
he  tried  to  read  ;  but  the  effort  of  reading 
soon  became  wearisome  and  painful,  and 
was  never  more  than  a  mere  listless  occu- 
pation. He  was  not  at  any  time  irritable, 
except  when  pressed  to  take  food,  and  he 
was  fond  of  hearing  the  current  topics  of 
the  day ;  but  he  soon  became  weary  with 
conversation,  and  would  drop  off  into  a 
semi-somnolent  state  while  conversing. 
We  never  heard  him  complain  of  any  pain 
or  discomfort ;  he  did  not  seem  to  express 
or  feel  desire  to  live,  and  he  certainly 
never  expressed  any  desire  to  die. 

As  the  last  days  of  his  life  drew  near  he 
became  much  feebler  rather  suddenly,  and 
his  mind,  we  thought,  was  inclined  to 
wander  for  brief  intervals.  But  he  quickly 
recovered  himself,  and  on  the  day  before 
his  death  he  was  unusually  clear  in  his 
mind.  He  was  painfully  shrunken  in  fea- 
ture ;  his  voice  was  low,  and  almost  bleat- 
ing ;  his  colour  was  leaden  dark ;  his  lips 
were  blue  and  cold ;  his  limbs  were  cold  ; 
and  his  breath  was  cold  and  offensive, 
having  the  odour  of  newly-opened  clayey 
soil.  On  the  morning  of  his  death  he, 
for  the  first  time  from  the  commence- 
ment of  his  fast,  said  that  he  would  eat, 
and  that  which  he  wished  for  was  fruit  or 
raw  vegetable,  with  cream.  An  attempt 
was  made  immediately  to  j^acify  his  de- 
sire, under  the  hope  that  if  he  once  re- 
commenced to  take  food  of  one  kind,  he 
might  be  tempted  to  take  more  promising 
sujjport ;  but  it  was  of  no  avail,  and  in 
fact  nothing  was  swallowed.  Soon  after 
this  he  sank  into  unconsciousness,  and  so 
succumbed.  He  died  on  the  fifty-fifth  day 
of  his  fast,  having  abstained  from  all  food 
and  partaken  of  no  other  drink  than 
water  for  seven  weeks  and  sis  days. 

We  had  the  opportunity  of  taking  part 
in  the  post-mortem  examination  of  this 
gentleman  on  the  day  immediately  follow- 
ing upon  his  death.  The  emaciation  was 
so  extreme  that  he  might  almost  be  said 
to  be  a  skeleton  clothed  in  semi-transparent 
fiesh.  The  outline  of  almost  every  bone 
could  be  traced.  On  opening  the  chest 
the  lungs  were  found  collapsed,  and  so 
shrunken  that  they  looked  like  small  and 
half-dried  sponges,  and  divided  by  the 
knife  rather  like   soft   leather  than  pul- 


Manias,  Pasting 


[   n^   ] 


Manias,  Fasting 


mouary  tissue.  The  heart  -was  reduced  to 
quite  half  its  natural  size,  was  empty  of 
blood  in  all  its  cavities,  and  had  its  ven- 
tricles so  attenuated  that  they  resembled 
auricles  rather  than  ventricles  ;  whilst  the 
auricles  were  mere  shrivelled  appendages 
that  could  not  easily  be  separated  from 
the  ventricles  as  distinctive  structures. 
The  abdominal  viscera  were  attenuated  to 
the  last  degree  ;  the  stomach  was  I'educed 
to  a  straight  tube,  and  was  with  difficulty 
distinguishable  from  the  duodenum.  The 
intestinal  canal  was  empty  through  its 
entire  length  ;  it  was  free  of  redness,  abra- 
sion, or  ulceration,  but  the  inner  sur- 
faces of  the  colon  and  the  peritoneal  sur- 
face presented  a  few  dark  spots,  melanotic 
in  type.  The  liver  was  reduced  to  half 
the  normal  size,  and  the  gall  bladder  was 
empty  and  collapsed.  The  pancreas  and 
spleen  were  so  reduced  in  size  they  could 
hardly  be  made  out,  and  the  kidneys,  al- 
though they  showed  no  obvious  sign  of 
organic  disease,  were  atrophied  quite  as 
much  as  the  liver,  and  were  separated,  by 
shrinkage,  from  their  capsules.  The  blad- 
der was  empty  and  shrunken. 

Not  a  trace  of  fatty  matter  was  found 
at  any  part,  not  even  in  the  orbits.  The 
muscles  were  flaccid,  wasted,  dry,  and 
leathery  to  the  touch. 

On  opening  the  skull  cavity,  the  dura 
mater  was  found  collapsed,  dry,  and  loose, 
wanting  entirely  in  tension  ;  the  arachnoid 
and  pia  mater  could  not  be  defined,  and 
the  sinuses  were  empty  of  blood.  The 
cerebrum  and  cerebellum,  like  the  other 
organs,  were  much  shrunken  ;  they  were 
white  and  firm,  resembling  the  same  struc- 
tures after  long  immersion  in  spirit.  Be- 
tween the  grey  and  white  matter  there 
was  no  difference  of  tint. 

The  brain,  which  was  dissected  very 
carefully,  yielded  no  obvious  trace  of  acute 
organic  mischief.  The  bulb  of  the  olfac- 
tor}"-  nerve  was  reduced  to  a  line  on  each 
side,  and  the  optic  nerves  wei'e  atrophied ; 
as  were  also  the  globes  of  the  eyes  them- 
selves. 

Altogether  there  was  universal  atrophy 
of  structure,  with  dryness  of  every  texture 
and  absence  of  blood. 

We  have  narrated  the  above  details  be- 
cause they  indicate  most  clearly  the  length 
of  time  during  which  fasting  may  be  car- 
ried on  in  man  under  favourable  circum^ 
stances,  and  the  condition  to  which  the 
body  is  reduced  by  fasting  before  it  ceases 
to  carry  vitality.* 

*  lu  the  Transactions  of  the  Albany  Institute 
for  1830  Dr.  MfXiiugbton  reported  a  ease  of  a  pre- 
ciselj'  similar  kind  in  a  man  named  Kelsey,  who 
died  from  self-starvation  on  the  tifty-third  day. 
Kelsey  took  more  e.xercisc^  than  the  patient  we  have 


Iiessons. — Bringing  these  facts  to  bear 
on  the  starvation  ordeals  which  were  com- 
menced publicly  in  America  by  Dr.  Tan- 
ner, and  which  have  been  continued  in  Lon- 
don, we  may  assume  (i)  ilicd  a  forty  or 
forty-tivo  days'  fast  ivith  continuance  of  life 
is  well  witldn  the  order  of  natural  phe- 
nomena, and  that  the  human  body  has  a 
possible  power  of  endurance  from  ten  to 
eleven  days  beyond  what  has  recently  been 
attempted,  the  extreme  limit  being  fifty- 
three  to  fifty-five  days.  It  is  right  to  dwell 
on  this  point,  because  the  technical  ojiinion 
on  fasting  that  will  have  to  be  given  in 
our  coronei-'s  courts,  and  in  courts  of  jus- 
tice, as  well  as  the  oj^inion  that  will  have 
to  be  written  in  our  technical  and  stan- 
dard works  of  medical  jurisprudence, 
must  in  future  be  considerably  modified 
in  many  particulars.  It  has  been  ac- 
cepted that,  after  a  certain  degree  of  star- 
vation— a  degree  comparatively  short  after 
what  is  now  known — any  act  requiring 
much  physical  exertion  is  impossible.  A 
once  famous  medical  jurist,  whose  lectures 
were  always  sound  and  practical.  Dr. 
Cummin,  related  that  a  girl  eighteen  years 
of  age  was  confined  in  the  depth  of  winter 
in  a  closed  room  for  twenty-eight  days. 
She  had  with  her  a  gallon  of  water,  some 
pifices  of  bread,  amounting  to  about  a 
quai'tern  loaf,  and  a  mince  pie  ;  and  she 
was  said  to  have  subsisted  on  this  small 
quantity  of  food  for  the  twenty-eight  days 
without  fire,  and  to  have  ultimately  es- 
caped from  her  prison  hj  breaking  down 
a  window-shutter  that  had  been  nailed  up, 
getting  out  of  a  window  on  to  a  roof  below, 
and  walking  several  miles,  from  Enfield 
Wash  to  Aldei'manbury.  In  commenting 
on  this  feat,  one  of  our  most  eminent  au- 
thorities, the  late  Dr.  Guy,  expressed  his 
disbelief  ;  and  he  was  confirmed  in  this 
opinion  by  Drs.  Woodman  and  Tidy,  who 
considered  that  while  it  is  possible  life 
might  be  prolonged,  "  in  all  the  recorded 
cases  the  muscles  have  become  so  weak 
before  half  the  time  mentioned,  that  the 
sufferers  could  not  even  help  themselves 
to  water,  much  less  walk  this  distance." 

This  opinion  bearing  on  starving  persons 
may  apply  to  persons  who  would  succumb 
easily  ;  and  it  might  possibly  apply  more 
distinctly  to  persons  who  have  been  sub- 
jected to  starvation  by  force  rather  than 
to  those  who  permit  themselves  voluntarily 
to  undergo  the  infliction ;  but  we  must 
henceforth  so  far  change  the  usually 
accepted  canon  as  to  admit  a  wide  range 
of  capacity  for  starvation  amongst  the 
various  specimens  of  human  kind.  It 
seems  clear  that,  where  the  disposition  to 

referred   to,  and  died,    therefore,  a  little  earlier, 
or  rather  existed  a  little  shorter  time. 


Manias,  Fasting 


[     m     ] 


Manias,  Fasting 


starve  ^'oes  with  the  starvintr,  the  powers 
of  endui-auce  are  immensely  prolonged. 
Nor  is  the  psychology  of  this  phenomenon 
peculiar.  When  the  disposition  for  the 
starvation  is  present,  when  the  will  goes 
with  the  experiment,  and  when  faith,  by 
whatever  it  may  be  fanned,  keeps  hope  and 
courage  alive,  the  chanoes  of  continuance 
of  life  must  be  greatly  increased.  There 
is  then  neither  wasting  worry  nor  feverish 
desire  for  life ;  there  is  then  none  of  that 
corroding  fear  and  dread  of  death  which  so 
materially — n^e  use  the  term  ia  its  phy- 
sical meaning — favour  dissolution. 

Thus  we  should  exjiect  that  men  or 
women  who  voluntarily  submit  to  starva- 
tion, and  that  men  and  women  who  in 
days  of  enforced  starvation  have  most 
courage  to  endure,  will  endure  the  longest, 
and  will  recover  with  the  greatest  facility, 
if  the  chances  of  recovery  be  offei-ed. 

Fasting  girls  of  the  hysterical  type, 
whether  they  succeed  in  secretly  obtaining 
a  small  supply  of  food  or  not,  are  exam- 
ples of  this. 

(2)  Sust(ii)iing  J'oivcr  of  Water.  —  A 
second  lesson  is  that  life  may  be  long 
sustained  by  water  alone,  and  that,  in  in- 
stances where  a  long  period  of  existence  is 
maintained  on  mere  aqueous  fluids,  it  is 
the  water  that  sustains.  In  short,  in  a 
sense,  water  becomes  a  food.  The  know- 
ledge of  this  truth  is  corrective  of  some  of 
the  most  grievous  and  mischievous  errors. 
Persons  undergoing  severe  privation  and 
fatigue,  persons  suffering  from  disease, 
persons  suffering  from  repugnant  dislike 
to  animal  and  vegetable  foods,  have  for 
long  seasons  been  supplied  with  drinks  of 
wine  or  of  spirits  and  water.  Forgetting 
the  water  altogether,  or  treating  it  as  a 
thing  of  no  consideration,  they  have  de- 
clared— and  others,  even  medical  men, have 
declared  for  them — that  they  were  sustained 
on  alcohol,  and  therefore  the  alcohol  was 
largely  diluted  with  water.  It  was  vain 
to  urge  that  the  Welsh  miners,  who,  some 
years  ago,  were  buried  alive  without  solid 
food,  were  able  to  live  ten  days  on  water 
alone.  It  wanted  such  proofs  as  these  we 
have  now  got  to  demonstrate  the  actual 
nature  of  the  sustaining  agent,  and  to 
exclude  the  agent  alcohol,  which,  often 
obtaining  all  the  credit,  does  more  evil 
than  good.  j 

(3)  Treatment. — A  third  lesson  relates 
to  the  practice  of  treating  patients  who 
have  long  abstained  from  food.  Hei'e  we 
may  be  guided  by  the  experience  gained  in 
districts  where  famines  most  commonly 
prevail.  Mr.  Cornish,  in  his  admii'able  j 
report  on  a  great  famine  in  India,  takes  the  I 
utmost  care  to  explain  that  the  danger  of 
the  deficient  food  supply  was  comparatively 


small  when  there  was  any  suificientquautity 
of  moisture.  So  long  as  fruits  and  lierbs 
and  plants  of  a  succulent  and  wholesome 
kind  could  be  obtained,  so  long  there  was 
strictly  no  famine.  But  when  the  juices 
of  fruits  and  other  succulent  vegetable 
supplies  of  water  were  cut  oti',  then  indeed 
the  people  were  famine-stricken  with  a 
vengeance.  Mr,  Cornish  also  refers  to 
another  fact — briefly,  it  is  true,  yet  still 
with  sufficient  effect  to  show  his  meaning 
— that  when  the  famine-stricken  had 
passed  a  certain  period  of  time  without 
food  or  drink,  when  they  had  to  a  large 
extent  lost  the  desire  for  food  and  drink, 
they  frequently  died  even  when  the  relief 
came  and  food  was  carefully  supplied  to 
them.  He  relates  that  in  one  instance  he 
took  a  sufferer  to  his  own  home,  and  there, 
with  the  most  scrupulous  care,  tried  to 
I'estore  life  and  health,  but  without  avail ; 
and  he  is  led  to  explain  that  there  is  a 
period  in  a  famine  when  all  the  foods  that 
may  come  in  are  practically  useless  to  the 
persons  who  are  in  hunger  and  athirst, 
and  yet  do  not  at  first  sight  appear  likely 
to  die.  This  is  the  secondary  effect  of 
famine  on  the  body ;  but,  be  it  observed, 
it  only  occurs  when,  in  addition  to  depri- 
vation of  solid  food,  there  is  also  depriva- 
tion of  fluid.  Let  the  fluid  be  supplied  in 
even  small  t^uantity,  and,  though  the 
emaciation  may  be  extreme,  death  may  be 
averted,  and  the  subjection  of  the  stomach 
to  new  and  proper  aliment  may  lead  to 
l^erfect  restoration  of  life.  For  insane 
patients  who  have  refused  food  it  is  most 
important  to  bear  this  in  mind. 

(4)  LessonsinEi:o)iO}ny.—¥o\i.xt\\\j,  a  les- 
son is  rendered  to  economic  science.  When 
we  know  how  little  food  is  really  required 
to  sustain  life,  we  may  the  more  readily 
surmise  how  very  much  more  food  is  taken 
by  most  persons  than  can  ever  be  applied 
usefully  towards  sustainraent.  We  have 
no  compunction  in  asserting  that,  while 
fasting  enthusiasts  are  subjecting  them- 
selves to  considerable  danger  from  abstin- 
ence, hundreds  of  thousands  of  jDersons 
are  subjecting  themselves  to  a  slower  but 
equal  danger  from  excesses  of  foods  and 
drinks.  These  keep  up  their  experiment, 
and,  with  every  vessel  in  their  bodies 
strained  to  rei)letion  and  seriously  over- 
taxed, continue  to  replete  and  to  strain 
the  more.  If  we  could  induce,  therefore, 
such  persons  to  contemplate  their  pro- 
ceedings, and  to  strike  a  fair  comparison 
between  their  own  foolhardiness  and  that 
of  the  faster,  the  moral  they  would  easily 
draw  would  not  be  witliout  its  worth. 
Unfortunately,  the  comparison  cannot  be 
made  with  ettect,  because  the  feat  of  excess 
is  in  the  swim  of  fashion,  while  the  feat 


Manias,  Fasting 


[     774     ] 


Manie  Calme 


of  fasting  is  very  much  out  of  it.  The 
iii'st  is  a  vice  which,  by  familiarity,  begets 
favour  and  competition :  the  second  is  a 
madness  which  must  be  treated  as  a  dis- 
ease, or  foil}',  which,  by  its  oddity,  begets 
only  curiosity,  compassion,  and  contempt. 

(5)  Physiological  Lessons. — From  a  phy- 
siological point  of  view,  a  good  many  les- 
sons are  to  be  learned  from  fasting  manias. 
That  during  a  fast  of  forty  days  the  tem- 
perature of  a  man  should  to  the  end 
remain  steady  is  of  itself  an  important 
bit  of  evidence.  We  have  been  led  to 
believe  that  in  a  very  few  days  the  process 
of  abstaining  from  a  sufHcient  supply  of 
food,  to  say  nothing  about  abstaining 
from  food  altogether,  is  a  certain  means 
of  reducing  the  animal  temperature.  It 
was  never  surmised  that  water  alone 
would  lead  to  conditions  in  which  the 
vital  warmth  would  for  many  weeks  re- 
main jiractically  sustained.  That  the 
respiration  should  remain  so  little  affected 
is  a  second  equally  remarkable  fact ;  and 
that  the  muscular  power  should  be  kept 
up  so  as  to  enable  a  starved  man  to  walk, 
talk,  and  compress  the  dynamometer  to 
82°  for  forty  days  is  beyond  what  any 
physiologist  living  would  have  admitted 
as  i^ossible  previously  to  the  events  that 
declare  the  possibility.  These  results, 
coupled  with  unquestionable  waste  of 
tissue,  and  with  the  jjainful  and  frequent 
disturbance  of  the  stomach,  are  quite 
sufficiently  remarkable  to  demand  the 
attention  of  the  thoughtful  physiological 
scholar. 

(6)  The  most  striking  lesson  of  all  re- 
mains, namely,  that  durinr/  the  wliole  of 
ilie  fasting  jperiod  the  mind  of  the  faster 
is  unclouded,  and,  taking  it  all  in  all,  his 
reasoning  powers  are  good.  Whoever  re- 
members what  depressions  of  mind,  what 
lapses  of  memory,  what  stages  of  inde- 
cision and  vacuity  come  on  when  for  a 
few  hours  only  the  body  is  deprived  of 
food,  will  wonder  not  a  little  that  any 
human  being  could  remain  self-possessed 
and  ready  for  argument  and  contention 
during  a  fast  of  over  six  weeks.  Yet, 
from  the  examples  supplied,  the  posses- 
sion of  mental  is  even  more  conspicuous 
than  that  of  physical  endurance.  Suppose 
it  be  urged  that  the  excellent  sleeping 
faculties  of  the  fasters  kept  their  minds 
in  good  balance,  we  do  but  move  the 
difficulty  one  step  farther  back,  since  to 
sleep  in  a  state  of  fast,  and  to  wake  again 
refreshed,  is  itself  a  strange  order  of 
phenomenon.  In  sleep  there  is  in  progress 
the  repair  of  the  body.  How  shall  there 
be  repair  when  the  food  material  out  of 
which  the  repair  is  secured  is  not  sup- 
plied ?     For  a  starving  man  to  sleep  and 


die  we  might  be  prepared ;  for  a  starving 
man  to  awake  in  the  shadow  of  semi- 
consciousness or  dementia,  or  for  a  starv- 
ing man  to  wake  in  the  teiTor  and  excite- 
ment of  delirium  and  rage,  we  might  be 
prepared;  but  tor  such  a  man  to  wake  up 
refreshed  and,  at  the  worst,  no  more  than 
irritable,  is  a  new  revelation  affording 
unsuspected  evidence  of  the  grand  part 
which  water  plays  in  the  economy  of  life. 
The  physiologist  himself  will  wonder 
how  water  sustains  life  for  such  long 
periods.  He  will  see  that  under  its  in- 
fluence a  kind  of  peripheral  digestion  is 
estabhshed  in  the  body  itself,  by  which, 
independently  of  the  stomach,  the  body 
can  subsist  for  a  long  time  on  itself ;  first 
on  its  stored-up  or  reserve  structures,  and 
afterwards  on  its  own  active  structures. 
He  will  infer  that,  by  the  influence  of  the 
water  imbibed,  the  digestive  juices  of  the 
stomach  are  kept  from  acting  on  the  walls 
of  the  stomach.  He  will  discern  that  by 
the  steady  introduction  of  water  into  the 
blood,  the  blood-corpuscles  are  retained 
in  a  state  of  vitality,  and  in  a  condition 
fitted  for  the  absorption  of  oxygen  from 
the  air.  He  will  note  that  the  minute 
vesicular  structures  of  the  lungs  and  of 
all  the  glandular  organs  are  kept  also 
vitalised  and  physically  capable  of  func- 
tion ;  and  he  will  understand  how  that 
water-engine,  the  brain,  is  sustained  in 
activity,  its  cement  fluid,  and  its  cell 
structures  free. 

The  act  of  the  professional  faster,  of 
taking  some  undescribed  powder  as  a 
sustainmeut,  is,  in  our  opinion,  either  a 
self-delusion  or  a  pretence,  but  it  may,  as  a 
fancy  or  placebo,  give  faith,  support  the 
mind,  and  sti'engthen  the  will ;  or  it  may 
be  a  mere  pretentious  discovery.  Which- 
ever it  be,  the  evidence  is  certain  that  the 
ordeal  can  be  borne  without  it  by  those 
who  can  undertake  the  ordeal,  a  class  of 
men  who  are  specially  constituted  to 
starve,  and  who,  b}'  the  speciality,  are  led 
to  undertake  what  to  the  ordinaiy  con- 
stitution would  be  impossible,  and  which 
under  compulsion  would  often  end  in 
death  in  the  second  quarter  of  a  trial  of 
forty  days.  B.  W.  Richardsox. 

MAnricocoMiviMC  {iiaviKos,  insane ; 
KOfiea,  I  care  for).  A  hospital  or  asylum 
for  the  insane.  (Fr.  manieocome ;  Ger. 
Irrenltaus  onanicomio.) 

MATTXE. — The  French  term  for  mania 
or  mental  exaltation. 

MAN-IE  AZCVE  (Fr.).    Acute  mania. 

IVIATriE  BZETJ-VEXI.X.AM-TE  (Fr.). 
Mental  exaltation  with  benevolence  of  dis- 
position. 

nXAxa-lE  CAI.ME  (Fr.).  A  mild  form 
of  mania.     Simple  mania. 


Manie  Continue 


[    775    ]        Marriage  and  Insanity 


VtANXH  CONTINUE.  The  French 
term  tor  mental  exaltation  of  long  stand- 
ing, as  opposed  to  manie  aigue. 

MANIE  CAIE  (Fr.).  (6'ee  CH.liRO- 
MAXI.V  ;    (' II  M  ROM  AN' I  A.) 

MANIE    HAI.I.UCINATOIRE   (Fr.). 

(^V('   II  \  1,1,1  tlNATKlNS.) 

MANIE  INCENSIAIRE  (Fr.).  {See 
P>  KUMAMA.) 

MANIE  INTERMITTENTE  (Fr.). 
Maniacal  attacks  with  short  intervals  of 
apparent  mental  health. 

MANIE  MIAIiFAISANTE  (Fr.). 
Mania  with  fi-eaks  of  mischievousness ; 
mental  exaltation  with  a  malevolent  dis- 
position. 

MANIE  RAISONNANTE  (Fr.). 
Pinel's  term  for  what  was  subsequently 
called  moral  or  emotional  insanity. 

MANIE  SANS  BEI.IRE  (Fr.).  {See 
MoKAL  Insanity.) 

MANIE  SYSTEMATISEE  (Fr.). 
(See  Monomania.) 

MANIE  TRISTE  (Fr.).  A  synonym 
of  Melancholia. 

MANICRAPH  ;  MANIGRAPHY  {fia- 
via;  7p«(/)co,  1  write).  One  who  specially 
studies  insanity.  Also  a  description  of 
or  work  on  insanity. 

MANIOBES  {fjLaviu>8j]i,  mad).  The 
same  as  maniacal. 

MANIOPCEOUS  {^avia  :  Troie'co,  I  make). 
Anything  causing  or  inducing  insanity. 
(Fr.  '-inaniope ;  Ger.  rasenchnachencl.) 

MANSTUPRATIO  {manus ;  stupro). 
Masturbation. 

MARRIAGE  AND  INSANITY,  As- 
sociation between ;  and  POST-CONNV- 
BlAla  INSANITY.  —  There  are  three 
distinct  heads  under  which  this  needs  to 
be  considered. 

(1)  Those  who  are  sligbtly  insane  be- 
fore marriag^e,  but  who  become  markedly 
so  after. 

(2)  Those  with  some  slig^ht  mental  dis- 
4>rder  like  h3'^steria  before  marriage, 
though  with  complete  recog^nition  of 
tbeir  surrounding:s.  who  marry  and  then 
develop)  insanity. 

(31  Those  in  whom  neurosis  iwas  in  no 
■way  suspected  before  marriag^e.  Of 
these  there  are  two  classes :  {a)  Those 
in  whom  the  .symptoms  come  on  very 
shortly  after  the  marriage,  and  (b)  those 
in  whom  the  insanity  develops  as  the 
result  of  nervous  exhaustion  from  sexual 
excess  at  a  later  period. 

In  all  the  above  cases  there  is  commonly 
a  history  of  neurosis  in  the  family  or  in 
the  individual.  The  disorder  may  occur  in 
men  or  in  women,  but  it  is  much  more 
common,  in  our  experience,  among  the 
latter.  It  may  occur  at  any  age.  We  have 
seen  it  in  very  yoiing  persons,  and  also  in 


women  who  have  married  after  forty-five. 
We  believe  it  is  predisposed  to  in  some 
cases  by  pi-olonged  and  intimate  court- 
ship, in  which  there  is  a  fre([uent  stimulus 
to  the  passion  with  no  gratification. 

As  will  be  seen,  the  symptoms  may 
vary,  there  being  nothing  which  is  spe- 
cially characteristic  of  the  cases  as  a 
whole ;  they  are  fairly  curable,  and  are  of 
great  medico-legal  interest. 

(i)  In  the  first  group  are  a  few  cases  of 
insanity  with  delusions,  but  with  quiet 
self-control,  which  enables  the  patient  to 
pass  muster  as  only  a  little  "  cold "  or 
odd.  Such  patients  will  in  some  instances 
follow  the  wishes  of  a  mother  and  allow 
the  marriage  ceremony  to  be  completed 
without  any  active  objection,  but  they 
rarely  allow  the  marriage  to  be  consum- 
mated, and  it  is  then  that  the  husband 
finds  out  the  terrible  accident  of  his  wife's 
insanity.  In  some  the  word  liysteria  has 
been  so  used  as  to  mislead  the  mother 
into  believing  that  marriage  will  cure  the 
disorder.  We  can  sjteak  from  experience 
when  we  say  that  the  prospect  of  relief 
being  thus  afforded  is  extremely  small, 
too  small  to  justify  the  risk  involved. 
This  form  of  disorder  is  more  common 
among  women,  but  we  have  met  one  man 
who  was  suffering  from  true  insanity 
when  he  married,  and  who  has  never  re- 
covered since.  He  showed  his  insanity 
on  the  day  of  his  marriage,  though  his 
friends  recognised  that  he  was  full  of 
extravagant  ideas  even  earlier.  We  have 
known  patients  contract  marriage,  both 
in  the  excited  stage  of  general  paralysis  of 
the  insane  and  also  m  early  locomotor 
ataxy,  who  later  developed  marked  in- 
sanity ;  in  these  latter  probably  there  was 
loss  of  sexual  self-control,  but  no  true 
insanity  before  the  marriage. 

In  speaking  of  the  cases  under  this 
head  it  is  necessary  to  remark  that  some 
weak-minded  women  have  been  made  to 
marry  men  for  pecuniary  reasons,  and 
in  some  such  cases  nullity  has  been 
decreed. 

(2)  The  second  group  is  nearly  allied 
to  the  one  just  considered,  but  in  it  the 
mental  disorder  preceding  marriage  is  of 
very  slight  degree  and  is  very  generally 
considered  to  be  hysteria,  and  nothing 
more.  There  is  a  certain  number  of  young 
persons  of  both  sexes  who,  at  the  onset  of 
the  engagement  or  during  its  progress, 
suffer  from  a  temporary  revulsion  of  feel- 
ings or  at  least  a  change  in  feeling.  Some 
say  they  have  an  antipathy,  while  others 
say  they  have  ceased  to  have  anj'  real 
human  feeling  at  all.  Some,  again,  will 
say  calmly  that  they  have  none  of  the  feel- 
ing or  sentiment  necessary  for  marriage, 


Marriage  and  Insanity       [    776    ] 


Marriage,  Law  of 


and  these  people  often  break  ofl"  their 
engagements.  In  one  case,  at  least,  such 
a  change  in  feeling  led  to  an  action  for 
breach  of  promise  of  marriage.  These 
cases  differ  somewhat  in  the  two  sexes. 
Thus,  3"onng  women  more  often  speak  of 
loss  of  affection,  while  young  men  think 
of  the  loss  of  power  and  fear  that  they  are 
impotent.  In  both  sexes  it  is  not  un- 
common to  hear  that  there  has  been  the 
habit  of  masturbation,  but  we  do  not  think 
this  is  the  general  cause  in  all  the  cases 
of  this  kind ;  absolute  chastity  is  in  some 
cases  quite  as  much  a  cause.  If  marriage 
is  completed  during  this  stage,  the  wife, 
as  a  rule,  refuses  marital  rights,  and  thus 
trouble  is  started.  The  wife  in  one  case  for 
which  niillity  was  declared  objecting  and 
resisting.  In  several  similar  instances 
we  have  had  the  same  history  of  refusal 
and  repugnance.  If  the  husband  is 
violent  and  forces  his  wife  to  yield,  the 
result  is  likely  to  be  even  worse,  and  per- 
manent estrangement  may  arise. 

On  the  man's  part  the  idea  of  impotence 
may  have  become  so  dominant  that  no 
congress  is  possible,  and  it  is  such  cases 
in  which  true  obsession  arises.  Instead 
of  the  fear  of  imjjotence,  some  idea  con- 
nected with  the  wife,  either  as  to  her 
purity,  or  as  to  her  local  physical  forma- 
tion, may  completely  prevent  congress, 
and  this  may  lead  to  suicidal  attempts. 
Probably  most  of  the  suicides  which  take 
place  soon  after  marriage  are  due  to 
ideas  of  impotence.  There  is  an  almost 
endless  chain  of  these  ideas  of  obsession 
which  may  prevent  for  a  time  or  for  ever 
virile  acts  in  relation  to  one  woman.  The 
best  treatment  is  to  recommend  abstinence 
from  marriage  as  long  as  morbid  feelings 
exist,  and  if  they  arise  after  marriage,  to 
suggest  general  measures,  and  command 
that  no  attempts  at  connection  be  made. 
Thus  the  benefit  of  the  desire  to  break  a 
commandment  may  come  to  your  aid. 

(3)  In  this  group  are  some  very  im- 
portant cases  from  a  medico-legal  iwmt 
of  view.  For,  if  in  the  former  groups  it 
can  be  shown  that  there  was  mental  dis- 
order of  a  kind  which  affected  the  mar- 
riage contract,  a  decree  of  nullity  may  be 
obtained ;  but  in  the  last  grou]),  if  the 
completion  of  marriage  is  the  cause  of  the 
mental  aberration,  no  such  relief  can  be  ob- 
tained. 

In  most  of  the  cases  which  have  come 
under  our  notice  there  has  been  marked 
instability  before  marriage,  and  in  some 
cases  there  have  been  previous  attacks  of 
insanity  or  of  grave  hysteria  which  may 
have  been  concealed  from  the  husband. 
It  is  possible  that  at  some  future  period 
the  concealment  of  such  imj^ortant  facts 


may  be  considered  sufficient  to  enable  the 
contract  to  be  adjudged  invalid.  In  some 
cases  the  day  after  marriage  the  bride  is 
found  to  be  in  a  kind  of  stupor  from  which 
it  is  impossible  to  rouse  her.  This  state 
of  partial  dementia  may  continue,  or  it 
may  pass  into  dementia  of  a  more  active 
type,  or  it  may  give  place  to  wildly  mania- 
cal excitement,  in  which  eroticism  is 
common,  so  that  the  coy  bride  assumes 
all  the  airs  of  the  courtesan.  There  often 
appears  to  be  some  terrible  dread  at  the 
bottom  of  the  mental  feeling,  and  this 
may  follow  though  there  has  been  no 
active  resistance  to  the  completion  of  the 
marriage.  Separation  from  home  and 
husband  for  a  time  will  generally  lead 
to  recovery,  and  ultimately  there  may 
be  return  to  home  and  domestic  life,  but 
this  must  be  tried  with  great  caution, 
as  the  memory  of  the  first  illness  wiU 
persist. 

The  shock  of  marriage  in  some  instances 
has  been  sufficient  to  start  acute  delirium 
which  has  ended  fatally,  but  we  have  so 
far  not  met  with  such  a  case  ourselves. 

The  second  set  of  cases  following  mar- 
riage result  from  exhaustion.  This  may 
arise  from  great  actual  excess  or  from 
what  we  would  call  relative  excess,  for, 
under  certain  conditions,  the  indulgence 
of  the  sexual  passion  is  more  exhausting 
than  under  others.  There  seem  too  to 
be  certain  women  who  j^roduce  much 
more  exhaustion  than  do  others.  The 
disorders  due  to  this  form  of  weakness 
occur  most  commonly  in  men,  women  not 
suffering  nearly  so  frequently  from  the 
results  of  sexual  excess.  These  men  begin 
by  losing  the  little  self-control  they  have, 
and  seek  a  continuance  of  their  gratifica- 
tion, and  often  take  alcoholic  or  other 
stimulants  to  assist  them. 

They  become  restless,  sleepless,  irritable, 
and  later  may  attack  their  wives.  Jealousy 
may  spring  up  with  fancies  that  the  wife 
has  carried  on  some  intrigue  or  that  she 
was  not  virtuous  before  marriage.  It  is 
common  for  acute  mania  to  develop.  The 
jDatient  when  jilaced  under  control  is  thin, 
with  a  worn  aspect  with  widely  dilated 
pupils  which  react  feebly.  There  is  general 
excitability,  appetite  is  bad,  the  tongue 
moist,  tremulous,  often  furred.  There  is 
often  aversion  to  friends,  and  both  homi- 
cidal and  suicidal  tendencies  are  common. 
Rest,  tonics,  and  liberal  diet  are  the  means 
to  be  used,  and  the  result  is  genei'ally 
favourable.  Geo.  H.  Savage. 

MARRIAGE     IN     REIiATZOM"     TO 

INSAN'ITV,  The  law  of. — This  difficult 
and  important  subject  may  be  considered 
most  conveniently  under  the  following 
heads : — 


Marriage,  Law  of 


[   m    ] 


Marriage,  Law  of 


{^(l)  Tbe  Effect  of  Insanity  upon  the 
Capacity  to  Marry  ;  and 

(2)  The  Effect  of  Supervening*  In- 
sanity upon  a  Valid  Contract  of 
IVIarriagre,  and  upon  the  Rig^hts, 
Duties,  and  Iicgral  Remedies  of  the 
Contracting^  Parties. 

(l)  The  Effect  of  Insanity  upon  the 
Capacity  to  Marry. — The  development  of 
the  present  law  of  England  as  to  the  com- 
petency of  the  insane  to  marry  is  a  study 
of  peculiar  interest.  It  seems  at  one  time 
to  have  been  held,  contrary  to  the  civil 
law,*  but  in  conformity  to  the  opinion  of 
some  of  the  civilians,!  that  the  marriage 
of  an  idiot  (and  a  fortiori  of  a  lunatic) 
was  valid,  and  that  his  children  were 
legitimate. J  By  the  middle  of  the  i8th 
century  a  more  rational  rule  had  been 
clearly  established.  It  was  settled  §  that 
idiots,  being  incapable  of  giving  the  con- 
sent which  is  the  basis  of  marriage,  were 
ipso  facto  incapable  of  marrying,  and  that 
the  marriage  of  a  lunatic  was  absolutely 
void,  unless  it  had  been  contracted  during 
a  lucid  interval.  The  statute  1 5  Geo.  II. 
c.  30 — extended  to  Ireland  by  5 1  Geo.  III. 
c.  57 — carried  the  reaction  against  the 
early  common  law  doctrine  to  a  somewhat 
extreme  length.  It  provided  that  the 
mari'iages  of  lunatics  and  persons  under 
frensies  (if  so  found  by  inquisition  or  com- 
mitted to  the  care  of  trustees  by  any  Act 
of  Parliament)  contracted  before  they  were 
declared  of  sound  mind  by  the  Lord  Chan- 
cellor or  the  majority  of  such  trustees, 
should  be  totally  void,||  by  the  operation 
of  the  statute  alone,  and  without  the  ne- 
cessity of  any  proceedings  for  declaration 
of  nullity  being  taken  in  the  Ecclesiastical 
Courts.^     The   practice  which    prevailed 

*  Furor  cotitraheiitis  matrimonhuii  noii  sinit, 
quia  consensu  opus  est  (I'aulus,  D.  23,  2,  16,  2). 

t  Sanchez,  lib.  i.  disp.  8,  num.  15  et  seq.  In 
Turner  v.  Meyers  (1808,  i  Hagg.  Consist.  Kep.  414), 
referrino-  to  this  point  Sir  "William  Scott  (after- 
wards Lord  Stowell)  said  :  "  It  is  true  that  there 
are  some  obscure  dietci  in  the  earlier  commentators 
on  the  law  that  a  iuarria£;c  of  an  insane  person 
could  not  be  invalidated  on  that  account,  founded, 
I  presume,  on  some  notion  that  prevailed  in  the 
Dark  Ages  of  the  mysterious  nature  of  the  contract 
of  marriage,  in  which  its  spiritual  nature  almost 
entirely  obliterated  its  civil  character." 

X  "  Un  Ideot  k  nativitate  poet  consenter  en 
marriage,  et  ses  issues  serout  legitimate.  Trin. 
3  Jac,  U.K.,  enter  Stile  and  "West  adjudge  sur 
un  special!  verdit,  pur  un  pettit  question."  KoUe's 
Abridg.,  357,  50  (7). 

§  Morison  v.  Stewart,  1745  ;  Cloudeslei/v.  Evans, 
1763;  Par  her  v.  Parker,  1757;  cited  i  Hagg. 
Consist.  Kcp.  417. 

II  This  Act  is  stated  to  have  been  passed  to  meet 
the  case  of  ^fr.  Newport,  the  natural  son  of  the 
Earl  of  I'.radford,  who  left  him  a  verj'  large  for- 
tune, with  remainder  to  another  person. 

^  Kv  parte  Turhuj,  1812,  i  ^'cs.  &  Beam,  140 
and  note. 


during  the  subsistence  of  this  statute  was 
thus  clearly  and  concisely  stated  by  Sir 
William  Scott  in  Turner  v.  Mei/ern. 
"  When  a  commission  of  lunacy  has  been 
taken  out,  the  conclusion  against  the 
marriage  will  be  founded  on  the  statute  ; 
where  there  has  been  no  such  commission, 
the  matter  is  to  be  established  on  evidence. 
The  statute  has  made  provisions  against 
such  marriages,  even  in  lucid  intervals, 
till  the  commission  has  been  superseded. 
In  other  cases,  the  Court  will  require  it  to 
be  shown  by  strong  evidence  that  the 
marriage  was  clearly  held  in  a  lucid  inter- 
val if  it  is  first  found  that  the  person  was 
generally  insane."  15  Geo.  II.  c.  30,  was 
however  repealed  by  the  Statute  Law  Ke- 
vision  Act,  1S73  (3^  &  37  Vict.  c.  91)  ;  the 
lunatic  so  found,  and  the  lunatic  not  so 
found,  by  inquisition  were  placed  as  re- 
gards their  capacity  to  marr}^  on  the  same 
footing  before  the  law,  and  no  further 
legislation  has  occurred  to  complicate  the 
subject. 

By  the  time  of  Lord  Stowell  it  was 
clearly  recognised,  and  indeed  insisted 
ujjon,  by  the  Ecclesiastical  Courts  that 
marriage  being  a  consensual  contract"^ 
could  be  entered  into  by  those  persons  only 
who  were  capable  of  consenting  ;f  but  till 
recent  years,  somewhat  hazy  and  even  con- 
tradictory notions  have  prevailed  as  to  the 
nature  and  degree  of  the  consent  which 
would  validate  this  particular  contract. 

It  may  be  interesting  to  consider  a  few 
of  these  dicta  in  chronological  order. J  In 
Turner  v.  Meyers  (1808,  uhi  supra  at 
p.  418)  Sir  William  Scott  said :"  We 
learn  from  experience  and  observation  all 
that  we  can  know ;  and  we  see  that  mad- 
ness may  subsist  in  various  degrees,  some- 
times slight,  as  partaking  rather  of  dis- 
position or  humour,  which  will  not  inca- 
pacitate a  man  from  managing  his  own 
affairs,  or  making  a  valid  contract.  It 
must  be  something  more  than  this,  some- 
thing tvhich,  if  there  be  any  tQst,  is  held  by 
the  00^17)1071  judgment  of  7)wnki7id  to  affect 
his  general  fitness  to  he  trusted  vjith  the 

*  Consensus  non  concuhitus  facit  matrimonium 
was  tlie  rule  of  the  civil  law.  It  is  laid  down  in 
some  of  the  old  books  {e.f/.  Collinson,  i,  555),  that 
a  marriage  by  a  non  cowpos,  when  of  unsound 
mind,  might  be  rendered  valid  by  consummation 
in  a  lucid  interval. 

t  Harford y.  Mor?-is,  1776,  2  Hagg.  Consist.  Kep., 
423,  427  ;   Turner  v.  Meyers,  nbi  supra. 

%  It  is  not  here  contended  that  our  law  on  the 
question  of  the  competency  of  the  insane  to  marry 
can  be  divided  into  precise  chronological  periods  ; 
still  less  is  it  suggested  that  the  cases  in  wliicli 
vague  or  erroneous  dicta  were  laid  down,  were 
wroniily  decided.  On  the  contrary  there  is,  ])er- 
hai)s,  no  case  upon  tlie  nvi/  capacity  of  the  insane 
under  the  old  law,  which  would  be  disposed  of  dif- 
ferently at  the  present  day. 


Marriage,  Law  of 


[   n^   ] 


Marriage,  Law  of 


fiianagement  of  himself  and  his  oiun  con- 
cerns." In  Browning  v.  Beane  (1812,  2 
Phill.  E.  R.  69,  70),  the  test  of  capacity  is 
stated  a  little  moi'e  precisely,  but  it  is 
mixed  up  with  the  test  of  competency  ap- 
plied in  inquisitions  de  livnatico  inqitirendo. 
"  If  the  incajpacity,"  said  Sir  John  Nicholl, 
"  be  such  ....  ihat  the  party  is  incapa- 
ble  of  understanding  the  nature  of  the  con- 
tract itself,  and  incapable  from  mentalim- 
becility  to  take  care  of  his  or  her  ovni:)erson 
and  property,  such  an  individual  cannot 
dispose  of  her  person  and  property  by  the 
matrimonial  contract  any  more  than  by 
any  other  contract." 

In  Harrod  v.  Harrod  (1854,  i  K.  &  J. 
at  pp.  14,  16),  the  modern  theory  was  fore- 
shadowed by  Page  Wood,  V.C.,  in  the  fol- 
lowing i^assages  :  "  The  contract  itself,  in 
its  essence,  independently  of  the  religious 
element,  is  a  consent  on  tlie  part  of  «  'inan 
and  wmnan  to  cohabit 'with  each  other,  and 

tuith    each   other   only When   the 

hands  of  the  parties  are  joined  together, 
and  the  clei'gyman  pronounces  them  to  be 
man  and  wife,  they  are  married  if  they 
understand  that  by  that  act  they  have 
agreed  to  cohabit  together,  and  with  no 
other  person." 

In  Hancock  v.  Peaty  (1867,  i  P.  &  D. 
335>  341).  Sir  J.  P.  Wilde  (afterwards 
Lord  Penzance)  made  use  of  the  following 
remarkable  expressions  :  —  "  The  Court 
here  has  not,  as  in  many  testamentary 
cases,  to  deal  with  varieties  or  degrees  in 
strength  of  mind  with  the  more  or  less 
failing  condition  of  intellectual  power  in 
the  prostration  of  illness  or  the  decay  of 
faculties  in  extended  age.  The  cpiestion 
here  is  one  of  health  or  disease  of  mind  : 
and  if  the  proof  shoivs  that  the  'mind  tvas 
diseased,  the  Court  has  no  means  of 
gauging  the  extent  of  the  derangement 
consequent  niwa  that  disease,  or  affirm- 
ing the  limits  within  which  the  disease 
might  ojjerate  to  obscure  or  divert  the 
mental  power."  * 

The  doctrine  of  Lord  Penzance  in  Han- 
cock v.  Peaty  has  now  been  impliedly  over- 
ruled. In  Durham  v.  Durham  (1885, 
10  P.  D.  at  p.  82),  Sir  James  Hannen 
said  :  "  It  apjjears  to  me  that  the  con- 
tract of  marriage  is  a  very  simple  one, 
which  (it)  does  not  require  a  high  degree 
of  intelligence  to  comprehend.  It  is  an 
engagement  between  a  man  and  woman 
to  live  together  and  love  one  another  as 
husband  and  wife  to  the  exclusion  of  all 
others.     This  is  expanded  in  the  j^romises 

*  These  observatious  should  be  compared  with 
the  remarks  of  the  same  learned  judye  in  Smith  v. 
Tehbitt  (1867,  I  P.  and  D.,  421),  and  with  those  of 
Lord  Brougham  in  Wariiir/  y.  Hariiic/,  1848,  6  Moo. 

r.  c,  pp.  348-353- 


of  the  marriage  ceremony  by  words  having 
reference  to  the  natural  relations  which 
spring  from  that  engagement,  such  as 
protection  on  the  part  of  the  man  and 
submission  on  the  part  of  the  woman. 
....  A  mere  comprehension  of  the  words 
of  the  promises  exchanged  is  not  suffi- 
cient. The  mind  of  one  of  the  parties 
may  be  capable  of  understanding  the 
language  used,  but  may  yet  be  affected 
by  such  delusions,  or  other  symptoms  of 
insanity  as  may  satisfy  the  tribunal  that 
there  was  not  a  real  appreciation  of  the 
nature  of  the  engagement  entered  into." 

It  may  now  be  possible  to  formulate, 
and  briefly  illustrate,  a  few  propositions 
which  will  give  an  accurate  idea  of  the 
law  as  to  the  competency  of  the  insane  to 
marry,  at  the  present  day. 

(1)  Marriage  is  the  voluntary  union  for 
life  of  one  man  and  one  woman  to  the 
exclusion  of  all  others.  (Of.  H>/de  v. 
Hyde,  i  P.  &  M.,  133  ;  in  Be  Bethell,  1888, 
L.  R.  38  Ch.  D.  294,  per  Stirling,  J.). 

(2)  The  contract  of  marriage  can  be 
entered  into  by  such  persons  only  as  are 
capable,  at  the  time,  of  understanding  its 
nature  and  comprehending  its  effects,  as 
above  described. 

An  analysis  of  this  proposition,  with  a 
few  illustrations  of  its  constituent  parts, 
may  be  useful. 

The  capacity  to  marry  means  in  law  a 
capacity  to  understand  the  nature  and 
effects  of  the  contract  of  marriage.  No 
other  evidence  of  capacity  is  necessary 
or  sufficient.  In  Harrod  v.  Harrod  (1854, 
I  K.  &  J.  4),  the  question  at  issue  was  the 
validity  of  the  marriage  of  a  woman  named 
Harrod.  She  was  deaf  and  dumb  and  ex- 
tremely dull  of  intellect,  had  never  been 
taught  to  read  or  write,  and  understood 
the  signs  and  gestures  of  those  persons 
only  who  were  constantly  living  with  her, 
and  was  unable  to  tell  the  value  of  money. 
Upon  the  other  hand,  the  evidence  showed 
that  she  did  understand  the  nature  of 
marriage.  "  She  had  been  residing  pre- 
viously," said  Page  Wood,  V.O.,  "  with  a 
married  couple  and  must  have  known 
that  they  lived  together  in  a  manner 
differently  from  unmarried  persons  like 
herself.  She  remained  up  to  the  time  of 
her  own  marriage  perfectly  respectable 
and  chaste :  she  went  through  the  solemnity 
in  which  the  hands  of  herself  and  her 
husband  were  joined.  A  child  was  born  of 
the  marriage  in  due  time  and  not  before. 
.  .  .  .  That  shows  she  was  aware  she  had 
performed  a  solemn  act,  imposing  new  du- 
ties, and  she  was  constant  to  her  husband 
during  the  rest  of  her  life — a  period  of 
nearly  thirty  years."  His  lordship,  held, 
therefore,  that  the  marriage  was  valid. 


Marriage,  Law  of 


[     779     ] 


Marriage,  Law  of 


Again,  the  capacity  required  by  law 
must  exist  at  the  time  of  marria<Te.  "  The 
law,"  said  Sir  John  Nicholl  in  Ports')iiunt]i, 
V.  Fortsmuutlt.  (1S29,  i  Hagg.  E.  R.  at 
p.  359)  ....  ''admits  of  no  controversy. 
....  When  a  fact  of  marriage  has  been 
regularly  solemnised,  the  presumption 
is  in  its  favour ;  but  then  it  must  be 
solemnised  between  parties  competent  to 
contract,  capable  of  entering  into  that 
most  important  engagement,  the  very 
essence  of  which  is  consent."  Two  recent 
cases  Hunter  v.  Ednen  (1881,  10  P.  D.  93) 
and  Gdiinoii  v.  Svialleij  (18S5,  10  P.  D. 
96)  must  be  referred  to  in  this  connection. 
In  Huiiier  v.  Edneij,  the  parties  were 
married  on  March  17,  1881.  There  was 
clear  evidence  that  the  wife,  whose  mental 
state  was  in  question  in  the  suit,  was  in  an 
abnormally  excited  and  troubled  condition 
on  the  morning  of  the  marriage.  She 
received  her  future  husband  coldly,  at 
first  refused  to  go  to  church,  and  was  con- 
tinually rubbing  her  hands.  After  the 
ceremony,  she  was  with  difficulty  per- 
suaded to  change  her  dress  to  go  away. 
When  the  newl}'  married  couple  reached 
their  apartments  in  London,  she  refused 
to  have  supper,  and  said  that  she  did  not 
want  to  get  married  and  that  she  was 
false.  She  lay  down  on  the  bed  in  her 
clothes,  and  for  three  hours  refused  to 
undress.  The  marriage  was  not  con- 
summated. In  the  morning,  she  asked 
her  husband  to  cut  her  throat.  A  medical 
man  was  called  in  who  pronounced  her 
to  be  insane,  and  this  view  was  sub- 
sequently confirmed  by  Dr.  Savage,  who 
reported,  and  gave  evidence  at  the  trial, 
that  in  his  opinion  the  patient  was  sufier- 
ing  from  melancholia,  owing  in  the  first 
instance  to  hereditary  insanity  excited  by 
the  idea  of  marriage.  Sir  James  Hannen, 
after  carefull}-  reviewing  the  facts,  gave 
judgment  as  follows  :  "  I  come  to  the  con- 
clusion that  the  evidence  which  has  been 
given  of  her  manner  preceding  the  mar- 
riage, establishes  that  that  excitement 
had  been  set  up  by  the  idea  of  her  ap- 
proaching marriage,  and  that  site  ivas  not 
able  to  hnovj  and  appreciate  the  act  she  was 
doing  at  that  time,  hut  that  she  took  an 
entirely  morbid  and  diseased  viev)  of  it.'^ 

In  Cannon  v.  Svialleij,  on  the  other 
hand,  the  respondent,  who  was  married 
to  the  petitioner  on  January  i,  1884,  and 
who  was  clearly  insane  ten  days  after- 
wards, was  shown  to  have  performed 
her  usual  duties  until  the  day  before  the 
marriage,  and  to  have  written  a  perfectly 
sensible  letter  to  the  petitioner  on  the  28th 
of  December  1883.  Sir  James  Hannen 
said  :  ■'  She  was  then  suffering  in  her 
physical  health,  and  it  might  be  in  this 


case  that  physical  had  something  to  do 
with  mental  health,  and  that  even  at  that 
date  the  balance  of  the  respondent's  mind 
was  unsettled  and  likely  to  be  upset ;  but 
the  question  to  be  decided  is  ixliether  it  is 
shoivn  to  have  been  ^ipset  on  ih,e  \sl  of 
■Jannary  1884,  the  date  of  the  marriage." 
His  lordship  was  of  opinion  that  the 
balance  of  the  evidence  was  in  favour  of 
the  respondent's  capacity. 

Darhani  v.  Durliam,  the  facts  of  which 
ai'e  too  well-known  to  need  recapitulation, 
was  decided  upon  the  same  principles. 
Sir  James  Hannen  held  that  the  circum- 
stances, which  threw  doubt  upon  the 
soundness  of  mind  of  the  respondent,  were 
capable  of  being  explained,  consistently 
with  the  assumjjtion  of  sanity,  by  her 
natural  shyness,  by  the  fact  that  her 
afi'ections  had  been  given  to  another  per- 
son, and  in  some  measure  by  the  conduct 
of  the  petitioner  himself.  His  lordship 
also  held  that  the  inference  of  incapacity 
to  which  the  subsequent  insanity  of  the 
respondent  gave  rise  was  rebutted  by  the 
methodical  and  rational  manner  in  which 
she  made  arrangements  for  her  approach- 
ing marriage. 

Without  discussing  the  merits  of  these 
pai'ticular  cases,  it  may  be  permissible  to 
point  out  that  the  principles  on  which 
they  were  determined  are  clear.  A  mar- 
riage is  presumed  to  be  valid.  Upon  the 
party  who  alleges  incapacity  rests  the 
burden  of  proving  his  assertion.  The 
proof  required  is  that  legal  capacity  to 
marry  did  not  exist  at  the  time  of  the 
marriage.  Supervening  insanity  ia  by  no 
means  conclusive  evidence  of  such  inca- 
pacity, even  in  the  absence,  and  <l  fortiori 
in  the  presence,  of  positive  proofs  of 
sanity  at  or  about  the  critical  period. 
But  where  marked  symptoms  of  mental 
unsoundness  appear  at  the  time  of  mar- 
riage, and  shortly  afterwards  develop  into 
undoubted  incapacity,  the  Court  both  may 
and  will  consider  whether  the  party  whose 
comi)etency  to  marry  is  in  dispute  was 
able  to  know  and  appreciate,  free  from  the 
influence  of  morbid  ideas  or  delusions,  the 
nature  of  the  contract  into  which  he  or  she 
was  entering.  It  is  thought  that  these  sen- 
tences contain  an  accurate  statementof  the 
present  law  of  England  upon  this  point.* 

(3)  Whenever  from  natural  weakness 
of  intellect  or  fear — v:li,ether  reasonablij 
entertained  or  not — either  party  is  actually 
in  a  state  of  mental  incompetence  to  resist 

*  'I'he  fiict  that,  after  an  euyaueineut  tu  iiian-y, 
a  ilel'endaut  discovers  that  he/ore  the  enj^imemeiit 
was  entered  into  the  plaiutilV  had  for  a  short  time 
been  insane,  is  no  answer  to  an  action  for  breacli 
of  iiromisc,  /kUcr  v.  Cartirrit/lit,  1861,  30  L.  ■). 
(N.  .S.J  C.  1'.  364. 


Marriage,  Law  of 


[    780    ] 


Marriage,  Law  of 


pressure  improperly  brought  to  bear,  such 
party  cannot  enter  into  a  valid  contract  of 
marriage — there  beingnomoreconsent  here 
than  in  the  case  of  a  person  of  stronger 
intellect  and  more  robust  courage  yielding 
to  greater  pressure  or  more  serious  danger. 

In  Scott  V.  Sebright  (1886,  12  P.  D.  21), 
from  which  this  proposition  is,  with  slight 
modifications,  taken,  the  petitioner,  a 
young  woman  of  twenty-two  years  of  age, 
entitled  to  the  sum  of  /^26,ooo  in  actual 
possession,  and  a  considerable  sum  in 
I'eversion,  had  become  engaged  to  the  re- 
spondent, and  shortly  after  coming  of 
age  was  induced  by  him  to  accept  bills  to 
the  amount  of  £332^-  The  persons  who 
had  discounted  these  bills  issued  writs 
against  her,  and  threatened  to  make  her 
a  bankrupt.  The  distress  caused  by  these 
threats  seriously  affected  her  health  and 
reduced  her  to  a  state  of  bodily  and  men- 
tal prostration  in  which  she  was  incapa- 
ble of  resisting  threats  and  coercion,  and 
being  assured  by  the  respondent  that  the 
only  method  of  evading  bankruptcy  pro- 
ceedings and  exposure  was  to  marry  him, 
she  reluctantly  went  through  a  ceremony 
of  mai-riage  with  him  at  a  registrar's 
office.  In  addition  to  other  threats  of 
ruining  her,  the  respondent  immediately 
before  the  ceremony  threatened  to  shoot 
her,  if  she  showed  that  she  was  not  acting 
of  her  free  will.  The  marriage  was  never 
consummated,  and  the  petitioner  and  the 
respondent  separated  immediately  after 
the  ceremony.  It  was  held  by  Butt,  J., 
that  there  was  not  such  a  consent  on  the 
part  of  the  petitioner  as  the  law  requires 
for  the  making  of  a  contract  of  marriage, 
and  that  the  ceremony  before  the  registrar 
must  be  declared  null  and  void.* 

A  suit  for  declaration  of  nullity  of  mar- 
riage on  the  ground  of  insanity  should  be 
brought  (i)  by  the  contracting  party  him- 
self on  the  recovery  of  his  reason  ;  (2)  by 
the  guardian,  where  the  contracting  party 
is  a  minor  ;  (3)  by  the  committee  of  the 
estate  of  a  lunatic  so  found  by  inquisition ; 

(4)  by  a  curator  or  guardian  ad  litem, 
where  the  contracting  party  is  sui  juris, 
but  still  insane,  though  not  found  lunatic  :f 

(5)  where  the  contracting  party  is  dead, 
by  one  of  the  next-of-kin,  or  any  one 
having  interest  :X  (6)  by  the  sane  contract- 
ing party.§ 

*  See  art.  Undue  Influence,  f/.also  Portsmouth 
V.  Portsmouth,  1828,  i  Hagg.  Eccles.  Kcp.  355. 

t  It  seems  that  a  giiiirdian  ad  litem  will  not  be 
appohiteil  where  there  is  a  substantial  dispute  as 
to  the  uusouniliiess  of  miiul  of  tht'  person  to  whom 
it  is  proposed  to  assign  the  guardian,  Fry  v.  Frii. 
W.K.  1890,  34. 

t  Cf.  I'ope  on  "Lunacy,"  pp.  249-251.  where 
this  subject  is  minutely  discussed. 

§  Mr.  rope's  statement  that  the  sane  eontraet- 


lu  Hancock  v.  Peottj  (1867,  I.  P.  &  D. 
at  p.  336)  the  Court  being  satisfied  by  the 
evidence  that  the  petitioner  was  not  of 
sound  mind  at  the  date  of  her  marriage 
with  the  resjiondent,  postponed  pronoun- 
cing its  decree  in  order  to  give  the  respon- 
dent an  opportunity,  if  so  advised,  of 
establishing  the  fact  of  the  petitioner's 
recovery,  and  intimated  that  if  satisfied 
of  her  recovery,  it  vjoulcl  not  i:)ronov.nce  « 
decree  of  mdlity  except  at  her  instance. 

(2)  The  Effect  of  Supervening  In- 
sanity upon  a  Valid  Contract  of 
IWarriagre,  and  upon  the  Rights, 
Duties,  and  Iicgal  Remedies  of  the 
Contracting  Parties. 

The  points  arising  under  this  head  are 
chiefly  points  of  practice. 

(ft)  Divorce  proceedings  are  not  criminal, 
and  may  therefore  be  instituted  by  a  hus- 
band or  wife  against  a  wife  or  husband  who 
is  insane  at  the  time  of  such  proceedings, 
and  continued,  in  spite  of  such  insanity, 
at  any  rate  when  it  is  incurable  (Mordaunt 
v.  Moncrieffe,  1874,  L.  E.  2  Sc.  &Div.  App. 

374). 

The  case  of  Mordaunt  v.  Moncrieffe  de- 
serves a  somewhat  careful  examination. 

On  April  28,  1869,  Sir  Charles  Mor- 
daunt presented  to  the  Divorce  Court  a 
petition  for  the  dissolution  of  his  marriage 
with  Lady  Mordaunt  on  the  ground  of 
her  adultery.  Two  days  afterwards,  the 
citation  was  duly  served  on  Lady  Mor- 
daunt, whose  solicitors  entered  an  appear- 
ance for  her,  but  on  a  representation,  sup- 
ported by  affidavit,  that  she  was  insane, 
the  Court,  on  July  27,  1869,  appointed 
her  father,  Sir  Thomas  Moncrieffe,  to  act 
as  guardian  ad  litem.  Upon  the  plea  of 
Lady  Mordaunt's  alleged  insanity,^  issue 
was  joined,  and  the  question  was  tried  by 
a  special  jury  who,  on  Feb.  25,  1870, 
found  that  Lady  Mordaunt  "  was,  on 
30th  April,  1869  (the  day  on  which  the 
petition  for  divorce  had  been  served  upon 
her),  in  such  a  state  of  mental  disorder 
as  to  be  unfit  and  unable  to  answer  the 
petition  ;  and  that  she  had  ever  since  re- 
mained and  still  remained  so  unfit  and 
unable."  On  March  8,  1870,  Lord  Pen- 
zance ordered  that  no  further  proceed- 
ings should  be  taken  in  the  suit  until 
Lady  Mordaunt  had  recovered  her  mental 
capacity,  and  the  order  was  confirmed,  on 
appeal,  by  the  full  Court  of  Divorce — 
Lord  Chief  Baron  Kelly  dissenting.  On 
March  12,  1872,  Dr.  Harrington  Tuke 
having  made  an  affidavit  that  the  recovery 
of  Lady  Mordaunt  had  become  hopeless, 

lug  party  had  in  no  case  successfully  petitioned  for 
declarator  of  nullity  is  no  longer  accurate.  Vf. 
Durham  v.  Durham,  Hunter  v.  Edneij,  Cannon  v, 
.Smalley,  ubi  supra. 


Marriage,  Law  of 


[    781    ] 


Marriage,  Law  of 


Sir  Charles  Mordaunt  applied  to  the 
Court  to  dismiss  his  petition  for  divorce 
so  that  he  might  appeal  to  the  House  of 
Lords  and  thereby  open  the  real  question 
requiring  adjudication.  The  petition  was 
accordingly  dismissed,  and  on  July  i, 
1873,  the  case  was  argued  at  the  Bar  of  the 
House,  the  following  Common  Law  judges 
attending  to  assist,  Kelly,  C.B.,  Martin, 
B.,  Keating,  J.,  Brett,  J.,  Denman,  J., 
and  Pollock,  B.  At  the  close  of  the  argu- 
ment, on  the  motion  of  Lord  Chelmsford, 
the  following  question  was  propounded 
for  the  opinions  of  the  Common  Law 
judges: — W'heilter  niider  tlie  statute  20  & 
21  Vict.  c.  %^,  proceedings  for  the  dissolu- 
tion ofamarriaf/e  can  beinstituted  or  pro- 
ceeded ivith,  either  on  heluilf  of  or  against 
ahusband  or  rvifetvho,  before  tlie  proceed- 
ings were  instituted  had  become  incurably 
insane  i 

The  majority  of  the  judges — Kelly,  C.B., 
Denman,  J.,  and  Pollock,  B.  (Martin,  B., 
had  retired  before  the  opinions  were  de- 
livered), concurred  in  holding  that  divorce 
may  be  asked  and  decreed  on  behalf  of,  or 
against,  a  lunatic,  the  Court  ajjpointing  a 
«f  uardian  ad  litem  for  his  protection.  But 
Keating,  J.,  and  Brett,  J.,  held  that  the 
insanity  of  either  husband  or  wife  is  an 
absolute  bar  to  divorce.  In  the  House  of 
Lords,  Lord  Chelmsford  and  Lord  Hather- 
ley  adopted  the  view  of  the  majority  of 
the  Common  Law  judges,  and  held  that 
the  wife's  insanity  ought  not  to  bar  or 
impede  the  investigation  of  the  charge  of 
adultery  brought  against  her.* 

A  summary  of  the  opposing  contentions 
in  Mordaunt  v.  Moncrieffe  may  be  of  in- 
terest and  value. 

Against  the  divorce  it  was  argued  (i) 
that  divorce  proceedings  are  quasi-penal, 
that  in  the  criminal  law  every  step 
against  a  prisoner  is  arrested  by  his  be- 
coming a  lunatic,  and  that  by  analogy  the 
same  rule  should  be  applied  to  suits  for 
the  dissolution  of  marriage ;  (2)  that  the 
Divorce  Act  clearly  intended  that  the 
new  Court  should  not  act  upon  a  petition 
until  it  had  .investigated  the  counter- 
charges (if  any)  of  condonation,  conniv- 
ance, or  recrimination,  and  that  for  the 
proper  determination  of  these  charges  the 
evidence  of  the  respondent  was  indispens- 
able ;  (3)  that  the  judgment  of  Sir  Cress- 
well  Cress  well  in  Baivdenv.  Bavden  {1 
Sw.  &  Tr.  417,  31  L.  J.  P.  M.  &  A.  94) 
was  a  distinct  authority  upon  the  point ; 
and  (4)  that  "  it  was  so  obviously  unrea- 

*  Sir  Charles  .Aloribiuiit  was  U'ft  at  liberty  to 
proceed  with  his  suit  for  a  divorce,  which  he  in  fact 
did.  Lord  Chelmsford  declined  to  determine  the 
question  whether  a  lunatic  can  be  a  jietitioner  for 
a  divorce.  See,  however,  Ba/c(  r  v.  BaLiT,  1880, 
S  1'.  D.,  142  ;  6  V.  D..  12. 


sonable  that  one  so  incapacitated  (as 
Lady  Mordaunt)  should  be  proceeded 
against  for  adultery  and  convicted,  and 
her  marriage  dissolved,  that  it  could  not 
have  been  intended  or  contemplated  by 
the  legislature." 

On  the  other  hand,  in  favour  of  Sir 
Charles  JihrdcunVs  petition,  it  was  con- 
tended (i)  that  adultery  was  not  by  the 
law  of  England  a  crime,  that  the  Act  con- 
ferred no  criminal  jurisdiction  on  the 
Divorce  Court,  and  that  therefore  the  as- 
sumed analogy,  above  mentioned,  failed ; 
(2)  that  under  the  Divorce  Act  the  Court 
ivas  bound  to  dissolve  a  petitioner's  mar- 
riage if  satisfied  that  his  case  was  proved 
unless  some  countercharge  was  estab- 
lished against  him ;  (3)  that  Bavxlen  v. 
Bavxlen  must  be  overruled  :  (4)  that  the 
evidence  of  the  respondent  was  not  neces- 
sarily indispensable  to  the  proof  of  a 
countercharge,  and  (5)  that  the  possi- 
bility of  hardship  to  individuals  was 
equally  unavoidable,  in  whichever  way 
the  case  might  be  decided.  The  language 
of  Kelly,  C.B.,  on  the  last  point  may  be 
referred  to,  L.  R.  2  Sc.  &  Div.  at  p.  381. 

Within  the  limits  of  the  present  article 
it  has  of  course  been  impossible  to  give  a 
complete  account  of  the  respective  argu- 
ments in  Mordaunt  v.  Moncrieffe,  but  it 
is  hoped  that  the  above  synopsis  may 
assist  students  of  this  very  complicated 
decision. 

It  cannot  be  too  clearly  pointed  out  and 
remembered  that  Mordaunt  v.  Moncrieffe 
is  merely  an  authority  for  the  proposition 
with  which  we  have  jDrefaced  our  analysis 
of  the  case. 

It  does  not  decide  that  the  insanity  of 
a  respondent  to  a  petition  for  divorce, 
existing  at  the  time  tvhen  an  alleged  act  of 
adultery  v-as  committed,  would  be  no  de- 
fence to  the  petition,*  and  the  question  of 
how  far  insanity  affords  an  answer  to  a 
charge  of  adultery,  would  in  all  proba- 
bility be  determined  by  "  the  rules  in  Mac- 
naghten's  case,"  applied  in  the  emascu- 
lated form  in  which  they  now  do  duty  in 
criminal  cases. 

(&)  The  lunacy  of  a  husband  or  wife  is 
not  a  bar  to  a  suit  by  the  committee  for 
the  dissolution  of  the  lunatic's  marriage 
(Baker  v.  Baker,  1880,  5  P.D.  142,  6  P.D. 
12).  But  if  the  lunatic  died  after  obtam- 
ing  a  decree  nisi  for  the  dissolution  of  the 
marriage,  the  legal  personal  representative 
could  not  revive  the  proceedings  for  the 
purpose  of  applying  to  make  the  decree 
absolute.  (S'tanhope  v.  Stanhope,  1886, 
per  Cotton,  L.  J.,  11  P.  D.,  at  p.  107.) 

The  supervening  insanity  of  a  husband 

*  Wc  are  not  able  to  refer  to  any  reported  case 
in  which  this  question  has  in  fact  arisen. 


Marriage,  Plea  of  Nullity  of    [    782    ]    Marriage,  Plea  of  Nullity  of 


or  wife  is  no  ground  for  a  dissolution  of 
their  marriage,*  and  is  no  answer  to  an 
action  for  the  restitutioa  of  conjugal 
rights.  In  Hayifard  v.  Haijii-ardf  Sir 
Cresswell  Cressvvell  said  :  "  A  husband  is 
not  entitled  to  turn  his  lunatic  wife  out 
of  doors.  He  may  be  rather  bound  to 
place  her  in  proper  custody,  under  proper 
care,  but  he  is  not  entitled  to  turn  her  out 
of  his  house.  He  is  less  than  ever  justified 
in  putting  her  away  if  she  has  the  mis- 
fortune to  be  insane."  Again,  a  judicial 
separation  will  not  be  granted  upon  the 
ground  of  cruelty  arising  from  positive 
mental  disease.  "An  insane  man,''  said 
the  Judge  Ordinary  in  Hall  v.  Hall  (1864, 
3  S.  &  T.,  at  p.  350),  "  is  likely  enough  to 
be  dangerous  to  his  wife's  personal  safety, 
but  the  remedy  lies  in  the  restraint  of  the 
husband,  not  the  release  of  the  wife." 
This  principle  is,  of  course,  inapplicable 
where  the  misconduct  complained  of  is 
unconnected  with,  or  is  shown  to  have 
been  itself  the  exciting  cause  of,  the  re- 
spondent's insanity  {White  v.  White,  i 
S.  &  T.  592).  A.  Wood  Eexton. 

MARRIAGE  ON  THE  GROVSTD 
OF  XirSAN-ITY,  The    Plea   of    Nullity 

of. — There  are  several  aspects  from  which 
this  subject  has  to  be  viewed ;  first,  there 
are  the  women  who  may  have  been  forced 
into  marriage,  they  being  either  at  the 
time  only,  or  permanently,  insane.  An 
idiot  or  imbecile  might  be  forcibly  married 
for  the  sake  of  her  property,  though  this 
is  only  likely  to  occur  when  the  imbecility  is 
of  a  mild  form,  or  only  partial,  so  that  with 
a  certain  amount  of  brilliancy  there  ma}' 
be  marked  intellectual  defect.  In  some 
of  these  cases  it  is  possible  that  the  con- 
tract might  be  held  to  be  good,  while  in 
others  it  would  clearly  be  seen  that  the 
marriage  was  null  and  void.  Several  such 
cases  have  been  tried  and  are  referred  to 
by  legal  authorities. 

In  the  following  remarks  we  shall  not 
enlarge  upon  the  possibilities  of  the  future 
but  only  speak  of  what  is  at  present  the 
law  and  its  practical  outcome.  This  will 
be  best  done  by  referring  to  certain  cases 
which  have  within  recent  years  been 
before  the  Courts.  Thei'e  seems  to  be  no 
chance  of  setting  aside  a  marriage  because 
one  or  other  of  the  contracting  parties 
has  had  former  attacks  of  insanity,  though 
it  can  be  shown  that  these  attacks  have 
afi"ected  the  mind,  and  are  likely  to  recur. 
The  onset  of  insanity  following  imme- 
diately on  marriage  will  not  be  admitted 
as    a  plea  for  nullity,  even   though   the 

*  The  usual  incidents  of  marriage  arise,  tlici-e- 
fore,  in  spite  of  superveniug  insanity.  This  sub- 
ject is  too  technical  to  be  pursued  here. 

t  1856,  I  S.  &  F.,  at  p.  84. 


marriage  have  not  been  consummated  at 
the  time ;  it  seems,  too,  that  though  the 
person  who  becomes  insane  have  all  sorts 
of  false  ideas  before  marriage,  yet,  unless 
these  affect  the  mind  in  direct  relationship 
to  the  marriage  itself,  it  is  doubtful  whe- 
ther they  would  be  accepted  as  a  ground 
for  declaring  nullity. 

It  is,  as  might  be  expected,  a  much 
more  common  thing  to  meet  with  cases  in 
which  the  question  is  raised  as  to  the 
sanity  of  the  wife  rather  than  as  to  the 
mental  capacity  of  the  husband.  The 
general  course  of  cases  in  which  the 
question  is  raised  is  as  follows  :  the  symp- 
toms may  be  maniacal  or  melancholic  ; 
a  woman  after  her  engagement  becomes, 
as  her  friends  think,  hysterical,  and  they 
honestly  believe  and  are  often  supported 
in  their  belief  by  medical  men,  that  this 
hysteria  will  pass  off  with  the  marriage 
and  with  the  usual  sexual  intercourse ;  the 
marriage  may  even  be  hastened  to  effect 
this,  but  instead  of  any  good  following 
the  woman  from  being  simply  fanciful 
and  depressed  becomes  markedly  melan- 
cholic, developing  strongly  suicidal  ideas 
and  strong  feelings  of  disgust  against 
her  husband.  In  such  cases,  there  is  little 
doubt,  but  that  the  woman  was  not  in  a 
fit  state  to  enter  into  a  contract  of  mar- 
riage, and  if  her  friends  admit  this  it  is 
possible  that  a  judge  may  allow  it  also  ; 
but  it  is  very  likely  that  the  judge  may 
require  more  proof  of  insanity  affecting 
the  contract  than  is  forthcoming,  and  so 
the  plea  may  be  set  aside. 

In  the  second  group  of  cases  a  woman 
instead  of  being  depressed  may  suffer 
from  erotic  insanity,  or  from  weakness  of 
mind  with  eroticism,  and  may  be  wilhng 
to  marry  any  one  who  may  offer  himself, 
and  here  again  it  will  be  found  to  be  very 
difficult  to  establish  the  fact  that  she 
was  too  insane  to  understand  the  nature 
of  her  act. 

To  return  to  the  first  class.  A  case 
was  tried  in  London  before  Mr.  Justice 
Hannen  ;  Hunter  v.  Hunter,  otherwise 
Edney,  and  in  this  nullity  was  decreed. 
The  young  woman  was  the  daughter  of 
an  insane  father,  she  herself  during  the 
courtship  wished  to  break  oif  the  engage- 
ment as  she  was  "  not  fit  for  man-iage," 
she  was  kept  away  from  her  lover  for  a 
time,  he  seeing  her  after  an  interval  only 
shortly  before  the  marriage.  Stimulants 
had  to  be  given  to  get  her  to  go  to 
church  ;  she  went  away  with  her  husband, 
but  would  not  undress,  and  did  not  get  into 
bed,  she  would  not  allow  marital  congress, 
and  the  next  day  her  husband  sent  her 
home  to  her  mother's,  where  we  found 
her   suffering   from   simple    melancholia. 


Marriage,  Plea  of  Nullity  of    [    7 S3    J 


Massage 


She  herself  was  wishful  for  the  divorce, 
and  gave  evidence  in  the  Court,  or  rather 
made  a  statement  which  satisfied  the 
judge,  and  nullity  was  decreed.  lu  ano- 
ther case  tried  later  lJan)io)i  v.  Gannon,, 
the  nullity  was  not  granted,  though  in 
nearly  every  particular  the  cases  were 
alike,  but  in  this  case  the  depression  was 
followed  by  a  period  of  exaltation,  during 
which  she  returned  to  her  husband,  and 
consummation  took  place  without  in  any 
way  relieving  her  symptoms,  and  though 
it  seems  to  us  that  this  should  not  make 
any  difference  in  law,  yet  it  appears  that  if 
the  woman  is  still  rirgo  infacta  thei'C 
would  be  a  better  chance  for  obtaining 
a  nullity  decision. 

In  a  third  case,  differing  in  many  par- 
ticulars, namely  the  "  cause  celebre "  of 
Lord  Durham,  there  were  shown  to  have 
been  peculiarities  in  the  lady  before  mar- 
riage, but  these  were  not  considered  suffi- 
cient to  cause  her  friends  to  take  any 
really  active  steps  for  her  protection.  She 
passed  placidly  through  her  engagement, 
and  seems  to  have  been  married  without 
causing  any  anxiety,  but  there  was  great 
objection  to  consummation,  and  very 
shortly  after,  though  the  husband  and 
wife  cohabited,  the  mental  symptoms  de- 
veloped rapidly,  passing  into  the  most 
violent  mania,  and  from  that  time  to  this 
there  has  been  no  restoration  to  health. 
It  was  decided  that  the  lady  was  suffi- 
ciently sane  at  the  time  of  marriage  to 
complete  the  contract,  and  so  the  marriage 
must  stand,  though  there  is  now  no  doubt 
that  the  insanity  was  developing  at  the 
time  of  marriage.  We  must  recognise 
that  certain  unstable  women  are  upset 
more  or  less  completely  in  mind  by  the 
mere  consummation  of  marriage,  and  we 
have  seen  several  well-marked  instances 
of  insanity  following  marriage  in  both 
men  and  women  within  a  few  days. 

This  is  one  of  the  accidents  which  must 
be  accepted  with  marriage  contracts. 

From  the  cases  already  tried  it  will  be 
seen  that  there  must  be  brought  very 
clearly  into  evidence  that  the  person  was 
insane  at  the  time  of  the  marriage,  neither 
only  before  nor  directly  after  :  the  facts  of 
its  being  both  before  or  after  are  import- 
ant, but  would  not  suffice  without  the 
proof  as  to  its  existence  on  the  actual  day 
of  marriage.  Though  such  insanity  is  most 
common  in  women,  we  have  seen  one  case 
in  which  a  doctor  was  undoubtedly  of  un- 
sound mind  when  he  married.  The  mar- 
riage being  in  Scotland,  and  taking  place 
in  a  private  house,  allowed  many  things 
to  be  passed  over  which  would  not  have 
been  tolerated  in  a  place  of  worshijj ; 
in    this  case   the  wife  elected  to  suffer, 


and  would  not  try  to  get  a  decree  of 
nullity. 

In  the  second  group  of  cases  in  which 
excitement  is  the  chief  symptom,  consider- 
able anxiety  may  be  caused  by  the  ero- 
ticism of  a  patient  who  was  formerly  staid 
and  proper.  In  several  such  cases  trouble 
has  arisen  in  this  way.  A  jDatient  in  this 
state  manages  to  escape  from  an  asylum, 
and  may  at  once  give  herself  up  to  i;)ros- 
titution,  and  cause  great  scandal  and 
distress  to  all  concerned.  In  several 
cases  we  have  known  such  patients  really 
try  to  get  married,  but  as  far  as  our 
experience  goes  these  attempts  have  failed, 
the  patient  either  being  taken  back  to  an 
asylum  or  being  otherwise  cared  for. 

Yet  there  is  a  very  real  danger  that  a 
person  in  the  earlier  stage  of  acute  mania 
may  be  still  able  to  control  his  actions 
sufficiently  to  mislead  those  who  do  not 
already  know  him  into  the  belief  that  he 
is  sane,  and  capable  of  entering  into  a 
contract,  though  within  a  very  short  time 
it  is  clear  that  he  is  maniacal.  We  have 
already  said  that  it  will  be  very  difficult 
to  prove  that  the  patient  was  not  capable 
of  entering  into  the  marriage,  but  we 
believe  it  is  quite  worth  a  trial,  rather 
than  to  allow  without  a  struggle  the  mad 
marriage  to  continue. 

In  the  earlier  stages  of  general  paraly- 
sis of  the  insane,  it  is  very  common  to 
find  patients  wishful  to  enter  into  mar- 
riage, and  we  have  met  with  several  in- 
stances in  which  during  the  earlier  periods 
of  nervous  degenerations,  strongly  marked 
eroticism  has  led  men  to  marry.  This 
has  occurred  in  early  mania,  in  early 
general  paralysis,  in  locomotor  ataxy,  and 
in  senile  dementia;  the  old  men's  mar- 
riages providing  a  number  of  such  cases. 
But  as  yet  we  do  not  know  of  any  case 
in  which  the  marriage  has  been  upset  on 
this  ground,  but  it  is  pretty  certain  that 
such  cases  will  occur. 

To  complete  the  subject,  it  should  be 
noted  that  certain  persons,  women  espe- 
cially, commit  acts  of  adultery  which  lead 
to  divorce  suits,  while  they  are  of  unsound 
mind  ;  so  far  the  plea  has  not,  we  be- 
lieve, been  successfully  raised,  but  we  have 
met  with  several  instances  in  which  pre- 
viously modest  and  virtuous  women  have, 
as  the  result  of  insanity,  generally  of  a 
maniacal  form,  formed  illicit  connections 
which  have  led  to  divorce.  It  seems  to 
us  that  in  these  cases  the  insanity  would 
be  a  defence  to  the  action,  but  the  point 
has  not  yet  been  raised  in  any  reported 
case.  Morclaunt  v.  Morclauid  relates 
solely  to  procedure.       Geo.  H.  Savage. 

MASSA.CE.  {See  Neuroses,  Treat- 
ment OF  Functional.) 


Masturbation 


[    784 


Masturbation 


IMCASTURBATIOM'  is  the  artiticial 
excitement  aud  gratification  of  sexual 
passion.  It  is  most  frequently  practised 
by  lads  about  or  after  the  period  of 
pubert)\  but  it  has  its  victims  in  both 
sexes,  aud  at  all  ages,  and  in  persons  of 
neurotic  temperament  it  produces  most 
baneful  results. 

(l)  Masturbation  may  be  a  mere  vice 
which  the  youth  has  been  taught  by  some 
prurient  companion  at  school  or  has  acci- 
dentally learned  in  the  awakening  of  his 
own  sexual  feelings,  and  which  he  dis- 
continues when  old  enough  and  wise 
enough  to  realise  its  natui'e.  It  leaves  a 
sense  of  shame  and  regret,  but,  unless  the 
jn-actice  has  been  long  and  greatly  in- 
dulged, no  permanent  evil  effects  may  be 
observed  to  follow.  It  is  needful  to  say 
this  plainl3%  not  in  order  to  minimise  the 
evils  of  the  vice,  but  because  the  after-lives 
of  such  youths  are  often  made  miserable 
through  their  falling  into  the  toils  of  the 
lying  "  specialists  "  and  "  nerve  doctors  " 
whose  advertisements  defile  our  walls  and 
newspapers.  These  impostors  trade  upon 
the  fears  of  their  victims  in  order  to 
empty  their  pockets.  They  paint  in  the 
strongest  colours  the  frightful  results  of 
masturbation,  asserting  the  loss  of  man- 
hood and  suggesting  the  approach  of 
permanent  insanity,butthey  "dare to  hope 
that  a  cure  may  yet  be  possible  "  if  the 
victim  will  only  pay  for  their  unparalleled 
skill  and  experience  and  for  the  priceless 
medicine  which  they  alone  can  supply. 
This  foul  trade  requires  to  be  exposed,  for 
its  extent  and  its  evil  results  are  little 
realised,  and  shame  shuts  the  mouths  of 
its  victims. 

{2)  Consequences.  —  If  years  do  not 
bring  wisdom,  and  if  the  vice  be  still 
secretly  indulged,  the  baneful  conse- 
quences cannot  be  escaped. 

This  habit,  when  long  and  often  in- 
dulged in  defiance  of  reason  and  con- 
science, seems  more  than  any  other  to 
acquire  a  mastery  over  its  victim,  and  the 
nervous  exhaustion  which  by  its  very 
nature  it  produces  makes  him  less  and 
less  able  to  resist  it.  Gradually  the 
appearance,  manner,  and  character  be- 
come altered,  and  the  typical  signs  of 
habitual  masturbation  are  developed. 

The  face  becomes  pale  and  j^asty,  and 
the  eye  lustreless.  The  man  loses  all 
spontaneity  and  cheerfulness,  all  manli- 
ness and  self-reliance.  He  cannot  look 
you  in  the  face  because  he  is  haunted  by 
the  consciousness  of  a  dirty  secret  which 
he  must  always  conceal  and  always 
dreads  that  you  may  discover.  He  shuns 
society,  has  no  intimate  friends,  does 
not  dare  to  marry,  and  becomes  a  timid, 


hypersensitive,  self-centred,  hypochron- 
driac. 

(3)  Moral  and  IMCental  Defeneration. 

— Too  often,  and  especially  in  neurotic 
subjects,  the  results  grow  darker  still,  and 
involve  moral  and  mental  shipwreck. 

The  whole  nature  is  deteriorated  and 
demoralised,  and  the  victim  of  confirmed 
masturbation  becomes  a  liar,  a  coward, 
and  a  sneak.  His  mental  faculties  become 
blunted,  his  energy  and  power  of  applica- 
tion fail,  and  his  only  shadow  of  enjoyment 
is  in  the  filthy  habit  which  has  so  debased 
and  degraded  him.  Even  that  palls,  and 
the  miserable  wretch  would  commit  suicide 
if  he  dared,  but  he  rarely  has  the  courage 
thus  to  close  the  life  he  has  wasted,  and 
sinks  into  melancholic  dementia,  relieved 
only  by  occasional  excitement  due  to  a 
temporary  revival  of  his  jaded  passions. 

This,  the  extremest  form  of  the  insanity 
of  masturbation,  may  be  greatly  modified 
in  different  cases.  Its  subjects  are  usually 
of  markedly  neurotic  temperament,  and 
the  nervous  exhaustion  and  weakened  will 
make  them  an  easy  prey  to  any  form  of 
neurotic  disturbance. 

Temporary  attacks  of  maniacal  excite- 
ment, or  of  obstinate  resistive  melancholia, 
or  of  di-eamy  stupor  may  occur,  and  the 
jDrevailing  mood  may  be  one  of  querulous 
discontent  or  of  vain  self-satisfaction. 

(4)  Masturbation  may  be  merely  a 
symptom  manifested  during^  an  insa- 
nity -which  has  been  quite  othervrise 
induced.  In  acute  mania  it  is  very  often 
observed,  and  is  merely  a  phase  of  the 
nervous  excitement  and  an  indication 
that  the  ordinary  and  normal  self-control 
is  lost  for  the  time.  In  general  paralysis, 
too,  it  is  frequent,  and  has  the  like  signi- 
ficance. 

In  epileptic  insanity  it  may  be  at  once 
a  cause  and  a  result.  Some  epileptics  are 
habitual  masturbators,  and  some  invari- 
ably have  a  fit  at  or  after  the  sexual  orgasm. 
The  religious  sentiment,  often  so  strong  in 
epileptics,  does  not  prevent  the  vice  ;  and, 
indeed,  masturbators  are  often  religiously 
disposed  persons  who  would  never  resort 
to  fornication,  and  compromise  with  con- 
science by  indulging  the  solitary  vice. 

(5)  Masturbation  may  be  purely  the 
result  of  perverted  innervation  in 
persons  who  never  previously  practised 
the  habit,  and  who  utterly  loathe  it  even 
while  yieldipg  to  it.  Such  cases  are  rare, 
but  they  certainly  do  occur,  aud  are  allied, 
as  instances  of  perverted  innervation,  to 
nymphomania  occurring  in  perfectly  chaste 
persons  or  to  the  storms  of  sexual  feeling 
sometimes  observed  during  lactation. 

(6)  Masturbation,  so-called,  is  some- 
times practised  by  very  young  children, 


Masturbation 


[     785 


Masturbation 


and  has  usually  been  taught  by  a  pru- 
rient nui-se,  or  provoked  by  phimosis,  or, 
iu  either  sex,  by  neglect  of  cleanliness. 
Some  kind  of  sexual  orgasm  seems  to  be 
thus  inducible  long  before  puberty,  and 
this  early  vice  powerfully  jn-edisposes  to 
habitual  masturbation  in  after  years. 
Mothers  cannot  be  too  vigilant  in  detect- 
ing and  correcting  such  practices. 

(7)  Masturbation  iu  women  is  more 
frequent  than  is  commonly  supposed.  It 
is  associated  not  rarely  with  the  nervous 
irritability,  wayward  fancies,  and  non- 
descript ailments  of  hysterical  girls,  and 
the  habits,  amusements,  and  literature  of 
certain  classes  of  society  are  too  apt  to 
encourage  the  vice.  About  the  age  of 
thirty-three,  when  the  chauce  of  mai-riage 
is  getting  faint,  and  again  about  the 
climacteric  period,  some  women  experience 
great  sexual  instability,  of  which  this 
practice  is  too  often  the  result. 

While  possibly  less  exhausting  and 
injurious  than  iu  the  other  sex,  it  may  be 
more  frequently  and  easily  indulged,  mere 
friction  of  the  thighs  often  sufEcing  to 
produce  the  erotic  spasm ;  and  it  is  im- 
possible to  prevent  the  practice  by  any 
mechanical  or  surgical  interference.  To 
tie  the  hands  or  enclose  them  in  a  muff 
sometimes  answers  well,  but  in  bad  cases 
it  is  futile,  as  friction  is  made  against  the 
bed,  or  the  furniture,  or  even  by  the 
patient's  own  heel. 

(8)  The  treatment  of  masturbation 
must  be  at  once  moral  and  medical. 

First  and  chiefly  the  moral  sense  must 
be  awakened  to  the  evil  and  the  danger 
of  the  practice,  and  the  will  must  be 
strengthened  to  resist  the  temptation 
which  habit  has  intensified,  and  which 
inclination  and  opportunity  make  so 
strong.  Tonic  treatment,  local  and 
general,  is  required  to  correct  relaxation 
and  restore  normal  energy,  and  lastly 
other  interests  and  occupations  must 
banish  the  prurient  fancies  and  im- 
pulses by  which  the  patient  has  been  en- 
thralled. 

It  is  easy  to  lay  down  these  clear  general 
principles,  but  few  tasks  are  more  difficult 
than  their  effectual  application  in  actual 
practice. 

The  co-operation  of  the  patient  is,  of 
course,  essential  to  recovery,  but  to  secure 
and  maintain  it  is  the  great  difficulty.  If 
he  really  desires  to  conquer  himself  and 
honestly  tries  to  aid  his  cure,  the  old 
habit  is  apt  to  prove  stronger  than  his 
good  resolutions,  his  weakened  will  is 
overcome,  and  he  falls  just  when  victory 
seemed  near.  This  pitiful  experience  is 
so  often  repeated  that  the  struggle  seems 
vain,  and   it  is   difficult  to  inspire  new 


hope  and  new  eftbrt  iu  one  who  has  so 
often  failed. 

If  he  does  not  really  wish  to  conquer 
and  forsake  his  vice,  help  and  encourage- 
ment are  alike  in  vain.  He  chooses  and 
seals  his  own  fate,  and  makes  mental 
and  moral  shipwreck. 

When  honest  efforts  fail,  and  the  pa- 
tient declares  iu  pitiful  despair  that  he 
cannot  forsake  tlie  vice  which  he  deplores, 
or  argues  that  his  nature  absolutely 
demands  and  requires  the  relief  it  aftbrds, 
some  direct  operative  interference,  which 
shall  prevent  masturbation  and  show  him 
that  he  cau  live  without  it,  may  be  of 
much  service.  The  best  form  of  such 
interference  is  so  to  fix  the  prepuce  that 
erection  becomes  painful  and  erotic  im- 
pulses very  unwelcome.  To  accomplish 
this,  the  prepuce  is  drawn  well  forward, 
the  left  forefinger  inserted  within  it  down 
to  the  root  of  the  glans,  and  a  nickel- 
plated  safety-pin,  introduced  from  the 
outside  through  skiu  and  mucous  mem- 
brane, is  jiassed  horizontally  for  half  an 
inch  or  so  past  the  tij)  of  the  left  finger, 
and  then  brought  out  through  mucous 
membrane  and  skin  so  as  to  fasten  out- 
side. Another  ])iu  is  similarly  fixed  on 
the  opposite  side  of  the  prepuce.  With 
the  foreskin  thus  looped  up  any  attempt 
at  erection  causes  a  painful  di'agging  on 
the  pins,  and  masturbation  is  effectually 
prevented.  In  about  a  week  some  ulcera- 
of  the  mucous  membrane  will  allow  greater 
movement  and  with  less  pain,  when  the 
pins  can,  if  needful,  be  introduced  into  a 
fresh  place,  but  the  patient  is  already 
convinced  that  masturbation  is  not  neces- 
sary to  his  existence,  and  a  moral  as  well 
as  a  material  victory  has  been  gained. 

For  cases  so  extreme  that  there  is  no 
wish  to  discontinue  the  practice,  or  so 
long  continued  that  the  power  of  erection 
is  almost  lost,  this  mode  of  ti'eatment  is 
unsuitable  and  of  little  service.  ■ 

Blistering  and  cauterising  are  some- 
times used  to  prevent  masturbation,  but 
they  are  only  effectual  for  the  time,  and 
the  itching  which  follows  them  tends  to 
aggravate  the  evil.  An  irritable  condition 
of  the  valve  at  the  junction  of  the  seminal 
and  urinary  tracts  is  believed  by  some  to 
be  a  great  cause  of  secret  vice,  and  the 
local  application  of  nitrate  of  silver  is 
said  to  be  followed  by  excellent  results. 

Castration  and  ovariotomy  have  been 
urged  as  radical  cures,  but  it  is  doubtful 
if  they  deserve  the  title.  Sexual  desires 
are  not  destroyed,  and  their  prurient  in- 
dulgence would  not  be  jirevented,  although 
impregnation  were  made  impossible.  Cli- 
toridectomy  still  has  its  advocates,  but 
the  whole  of  the  sensitive  sui'face  cannot 


Masturbation 


[    786 


Medico-Psychological 


be  removed,  and  in  this  country  at  least 
the  operation  is  generally  deemed  in- 
effectual and  unsatisfactory. 

To  allay  local  irritation  and  excitement, 
a  prolonged  sitz  bath  as  hot  as  can  pos- 
sibly be  borne  is  probably  the  most 
effectual  remedy,  while  the  cold  sitz  bath 
night  and  moriiing  is  very  helpful  as  a 
tonic.  Of  the  medicines  which  are  said 
to  be  calmatives  of  sexual  excitability,  not 
one  can  be  really  depended  on,  and  even 
the  bromides  seem  to  act  by  virtue  of 
their  calmative  power  over  all  forms  of 
nervous  excitement  rather  than,  by  any 
special  action  as  sexnal  sedatives.  Many 
deem  salix  nigra  a  specific,  and  it  well  de- 
serves trial.  Seminal  emission  is  cer- 
tainly controlled  by  goteroo,  but  it  has 
failed  to  correct  masturbation.  Of  gene- 
ral tonics,  strychnine  and  quinine  are  the 
most  serviceable. 

All  treatment  is  likely  to  fail  unless  the 
solitary  habits  which  so  favour  the  vice 
are  broken  and  unless  the  prurient  ima- 
ginings be  disjaelled  by  new  interests  and 
healthful  occupation.  The  patient  should 
take  to  cricket,  or  golf,  or  volunteering,  or 
cycling,  or  any  other  pursuit  which  im- 
plies healthy  exercise  and  free  intercourse 
with  others. 

He  must  avoid  everything  that  suggests 
debasing  thoughts,  he  must  shun  the 
society,  amusements,  and  novels  which 
favour  them,  and  he  must  by  patient 
effect  conquer  his  inclinations  and  regain 
the  self-control  he  had  thrown  away.  We 
may  give  the  most  earnest  counsel  and 
the  wisest  prescriptions,  but  the  patient's 
recovery  depends  after  all  mainly  on  him- 
self. 

To  prescribe  sexual  intercourse  as  a 
certain  cure  for  masturbation,  which  is 
too  often  done,  is  wrong  both  morally  and 
medically.  Marriage  is,  of  course,  the 
natural  remedy  for  strong  sexual  feeling, 
but  some  of  the  worst  masturbators  are 
married  persons,  of  both  sexes,  who  con- 
tinue to  practise  their  vice  notwithstand- 
ing full  opportunities  for  normal  inter- 
course. Entire  continence  is  quite  com- 
patible, in  both  sexes,  with  perfect  health, 
and  sexual  excess  does  not  cease  to  be 
baneful  although  indulged  naturally  and 
under  the  shelter  of  marriage.  Such 
excess  entails  its  own  penalty,  not  sel- 
dom in  the  form  of  general  paralysis, 
just  as  certainly  as  confirmed  masturba- 
tion. 

The  duty  of  parents  as  to  warning  their 
children  against  secret  vice  is  delicate  and 
difiicult.  There  is  the  risk  of  suggesting 
what  had  never  been  thought  of,  but  this 
risk  seems  small  compared  with  the 
danger  of  allowing  a  child  to  contract,  for 


want  of  warning,  a  habit  so  baneful  and 
degrading.  D.  Yellowlees. 

MATTOID  (Ital.  mcitouU,  mad-like). 
On  the  border  line  of  insanity.  A  crank. 
(Lombroso  and  Havelock  Ellis.) 

IVIATURXTV,  IN-SANZTT  OP.  The 
various  forms  of  mental  disturbance  pecu- 
liar to,  and  occurring  at  the  age  of,  full 
vitality — e.g.,  general  paralysis  of  the 
insane,  &c. 

ItlECHANZCAI.  RESTRAZN-T.  {See 
Treatment.) 

IMCEDZCAI.  CSRTZFZCATES.  {See 
CERTiriCATES,  MeDICAL.) 

MESZCO  -  I.EGAI..  {See  Index  — 
E.ENTON,  A.  Wood.) 

IVIEDZCO-PSYCHOI.OCZCAI.  ASSO- 
CZATZON-  OF  GREAT  BRZTAZN  ANS 
ZREIiATTD. — This  Association  originated 
in  a  circular  dated  Gloucester.  June  19, 
1 84 1,  addressed  to  medical  men  ofiicially 
connected  with  the  Public  Lunatic  Asy- 
lums of  Great  Britain  and  Ireland.  It 
was  signed  by  Dr.  Samuel  Hitch,  at  that 
time  medical  officer  of  the  Gloucester 
Lunatic  Asylum. 

It  proposed  the  foundation  of  an  "  As- 
sociation of  Medical  Officers  of  Hospitals 
for  the  Insane  " — the  original  title.  On 
July  27  of  the  same  year  the  Association 
was  instituted,  having  for  its  object  the 
inter-communication  of  all  matters  calcu- 
lated to  improve  the  treatment,  care,  and 
recovery  of  the  insane,  the  management 
of  institutions  for  this  class,  and  the 
acquirement  of  a  more  extensive  and  cor- 
rect knowledge  of  insanity. 

It  was  decided  to  hold  annual  meetings 
at  which  papers  should  be  read  and  dis- 
cussed bearing  on  the  subject. 

Among  the  original  members  of  the 
Association  were  Sir  A.  Morison,  Dr. 
Prichard  (Bristol).  Dr.  Conolly,  Mr. 
Gaskell,Dr.  Monro, Dr.  Stewart  (Belfast), 
Dr.  W.  A.  F.  Browne,  Dr.  Hitch,  Dr. 
Hutcheson,  Dr.  Shute,  Dr.  Davey,  Dr.  de 
Vitre,  Dr.  Charlesworth,  Dr.  Begle}',  Dr. 
Sutherland,  Dr.  Poole,  Dr.  Kirkman,  Dr. 
Corsellis,  Dr.  Thurnam,  Dr.  (afterwards 
Sir  Charles)  Hastings,  Dr.  Mackintosh, 
and  Dr.  McKinnon. 

The  first  annual  meeting  was  held  at 
the  Nottingham  Asylum,  November  1841. 

In  1844,  the  Association  held  its  annual 
meeting  at  the  York  Retreat,  Dr.  Thur- 
nam being  president.  It  was  on  this 
occasion  that  the  idea  was  suggested  of 
a  Journal,  as  the  organ  of  the  association, 
in  consequence  of  a  letter  received  from 
Dr.Damerow  (Halle),  who  was  the  editor  of 
the  Allgemeine  Zeitschrift  firr  Psychiatrie. 
He  expressed  the  hope,  writing  on  behalf 
of  the  corresponding  Society  in  that  land, 
that  their  English  brethren  would  follow 


Medico- Psychological        [    787    ] 


Melancholia 


their  example  "  by  publishing  a  periodical 
devoted  to  the  same  important  object,  by 
which  means  a  mutual  exchange  of  publi- 
cations might  take  place,  highly  beneficial 
to  both  nations."  A  resolution  was  cor- 
dially adopted  declaring  the  proposal  to 
be  "deserving  ot"  the  best  consideration 
of  this  Association."  At  subsequent 
meetings  the  subject  was  discussed,  and 
in  1852  (July  20),  at  the  Annual  Meet- 
ing held  at  Oxford,  it  was  resolved  on 
the  motion  of  Mr.  Ley  (the  Treasurer), 
seconded  by  Dr.  Thiirnam,  that  the  Jour- 
nal shoiild  be  undertaken.  Dr.  Bucknill 
was  elected  editor.  Mr.  Ley's  proposition 
was  coi'dially  sui^ported  by  Dr.  (>onolly. 
The  first  number  of  'rhe  Asijlwm  Journal 
was  issued  on  November  15,  1853.  This 
name  was  changed  to  The  Asyltmi  Jour- 
nal of  Menial  Science  in  1855,  and  to  The 
Journal  of  Mental  Science  at  the  Annual 
Meeting  in  1S58. 

The  title  of  the  Association  itself  was 
changed  in  1853  to  "The  Association  of 
Medical  Officers  of  Asylums  and  Hospi- 
tals for  the  Insane  "  ;  and  in  1865  to  ''The 
Medico- Psychological  Association." 

In  1887  the  words  were  added  "of 
Great  Britain  and  Ireland." 

The  Jubilee  of  the  Association  was  held 
at  Birmingham  on  July  23,  1891,  only 
one  original  member  having  survived. 
Dr.  Davey,  formerly  one  of  the  Medical 
Superintendents  at  the  Hanwell  Asylum. 
Mr.  E.  B.  Whitcombe,  M.R.O.S.,  Medical 
Superintendent  of  the  Borough  Asylum 
(Winsoii  Green),  Birmingham,  occupied 
the  presidential  chair. 

It  may  be  stated  that  whereas  the 
Association  numbered  44  members  at  its 
foundation,  there  are  now  (October  1891) 
on  the  roll  474. 

The  Association  has  carried  out  and 
amplified  the  original  purpose  of  its 
founders. 

It  has  introduced  a  pass  examination, 
successful  candidates  in  which  receive  a 
Certificate  of  Efficiency  in  Psychological 
Medicine.  Combined  with  this,  the  Gas- 
kell  Prize  is  offered  annually  to  those 
who,  having  passed  the  above,  and  com- 
plied with  certain  conditions,  present 
themselves  for  the  Honours  Examina- 
tion. 

The  Association  has,  moreover,  insti- 
tuted examinations  of  attendants,  male 
and  female,  and  grants  certificates  to  those 
who  satisfy  the  examiners. 

A  medal  and  ten  guineas  are  offered 
annually  for  the  best  essay  on  a  clinical 
subject  contributed  by  an  Assistant  Medi- 
cal Officer  of  an  Asylum.    Thk  Editor. 

{References.— \)r.  Ulaiulfonrs  Index  to  the  Hrst 
twenty-four   volumes   of    the   .louniiil  of   Mental 


Seicncc.  with  Historical  Sketch  of  the  Assocmtion, 
by  Hack  Tuke,  M.D.     Also  Jouni.   Ment.  Sci.  Oct' 

1881.  I 

MEDICO  -  PSYCHOI.OGY  (niedicUH  ; 
•^vx*h  the  mind  ;  \6yos,  a  discourse).  That 
branch  of  medicine  dealing  with  the  symp- 
toms, pathology,  and  treatment  of  mental 
affections. 

IVXEGAIiOMASTIA  (/x6yaAos,from  fieyas, 
great;  fiuvlii,  madness).  This  word  has 
been,  and  still  is,  employed  in  reference  to 
two  distinct  mental  disorders,  or  rather  to 
the  same  symptom  occurring  under  very 
different  psychological  conditions.  For- 
nierly,  the  term  was  applied  to  the  exalta- 
tion or  delirium  of  grandeur  which 
usually  accompanies  general  paralysis  of 
the  insane.  French  alienists  have  re- 
stricted its  use  to  cases  in  which  this 
symptom  is  present  without  paralysis, 
and  this  is  the  practice  generally  adopted 
at  the  present  day.  From  this  point  of 
view  it  is  a  systematised  delusion — a  mo- 
nomania—and by  those  who  adopt  the 
terra  "  paranoia,''  it  is  regarded  as  a  fre- 
quent characteristic  of  this  form.  (See 
Exaltation.)  An  article  by  the  late 
Dr.  Foville  on  "  Megalomania "  will  be 
found  in  the  Transactions  of  the  Inter- 
national Medical  Congress,  1881.  (Fr. 
Megalonianie,  Monomanie  des  grandeurs, 
and  Monomanie  ambitieuse ;  Ger.  Gros- 
senvnilinsinn.) 

niZ:GAI.OPIA  HYSTERICA  ;  JMCE- 
CAI.OPSIA  HYSTERICA  (yityas,  great ; 
w\//',  the  eye  or  vision  ;  hysteria).  A  visual 
defect  occurring  in  hysterical  subjects  in 
which  some  objects  appear  larger  than 
they  in  reality  are.     {See  Mac  hops  y,  Hys- 

TEKICAL.) 

mCECRXnxs  {migraine,  from  hemi- 
crania).  Besides  its  ordinary  meaning,  a 
term  sometimes  applied  to  epilepsy  and 
epileptic  seizures. 

MEIiAirCHOI.IA.  —  Definition.  —  A 
disorder  characterised  by  a  feeling  of 
misery  which  is  in  excess  of  what  is  justi- 
fied by  the  circumstances  in  which  the 
individual  is  placed. 

Symptoms — (i)  The  cardinal  symp- 
tom of  melancholia  is  indicated  by  the 
definition  ;  it  is  the  expression  of  a  feeling 
of  misery  for  which  no  sufficient  justifica- 
tion exists  in  the  circumstances  of  the  in- 
dividual. Associated  with  this  cardinal 
symptom  are  two  other  groups  of  symp- 
toms ;  (2)  defects  of  nutrition  and  of  other 
bodily  processes;  and  (3)  defect  of  con- 
duct. Commonly  there  is  present,  (4)  the 
expression  of  a  delusion. 

(i)  The  feeling  of  misery  is  expressed 
(a)  by  the  face,  (/S)  by  attitude,  (y)  by  ges- 
ture,   (8)    by  verbal   expression. 

(a)  The  expression  of  the  face  in  melau- 

3  E 


Melancholia 


[    788 


Melancholia 


cholia  is  vei-y  characteristic.  The  jaws  are 
not  firmly  closed,  the  lower  jaw  falls  away 
from  the  upper,  with  or  without  parting 
of  the  lips,  and  thus  gives  the  face  an 
elongated  appearance.  The  forehead  is 
puckered  by  several  parallel  transverse 
wrinkles,  which  extend  high  up  on  the 
forehead,  and,  beneath  these,  at  the  middle 
of  the  forehead,  are  several  vertical 
wrinkles.  The  eyebrows  are  drawn  up- 
ward at  their  inner  ends,  and  are  approxi- 
mated to  one  another,  so  that  the  direction 
of  each  is  downward  and  outward.  The 
fold  of  skin  between  the  brow  and  lid  par- 
ticipates in  this  movement,  and  gives  to 
the  opening  of  the  eyelids  a  triangular 
outline,  the  base  of  the  triangle  being 
horizontal,  and  the  inner  and  shortest 
side  perpendicular.  The  corners  of  the 
mouth  are  drawn  downwards,  the  under 
lip  is  sometimes  thi-ust  forward  and  up- 
ward, at  others  hangs  away  from  the  teeth. 

(/3)  The  attitude  in  melancholia  is  one 
of  general  flexion.  An  erect  figure  is 
never  seen  in  this  malady.  The  head  is 
bowed,  the  back  is  bent,  in  severe  cases  the 
legs  are  bent  at  the  knees.  The  tendency 
of  the  thumb  is  to  lie.  not  opposed  to  the 
fingers,  but  parallel  with  and  alongside 
them. 

(7)  Among  the  gestures  expressing 
misery,  the  most  prominent  and  character- 
istic is  that  of  weeping,  which  is  common 
in  its  full  expression.  But  when  not  fully 
expressed,  the  eyes  in  melancholy  patients 
are  commonly  full  of  tears.  Very  loud 
obtrusive  uproarious  weeping  does  not 
appear  to  be  associated  with  deep  melan- 
choly. Wringing  of  the  hands  may  be 
either  constant,  frequent  or  occasional. 
A  succession  of  slow  nods  of  the  head, 
the  first  of  which  is  the  most  emphatic, 
and  the  remaining  three  or  four  of  much 
less  and  of  decreasing  emphasis,  is  a 
striking  and  characteristic  gesture  expres- 
sive of  melancholy.  Sighing  and  groan- 
ing, striking  the  head  with  the  fists,  sitting 
with  the  face  buried  in  the  hands,  tearing 
the  hair,  standing  for  a  considerable  time 
in  one  attitude,  sitting  and  rocking  the 
body  backwards  and  forwards,  are  all 
gestures  expressive  of  misery. 

(S)  The  verbal  expressions  of  misery  in 
melancholia  are,  apart  from  the  expres- 
sion of  delusion,  not  numerous,  and,  be- 
longing chiefly  to  the  emotional  division 
of  language,  may  be  looked  upon  in  the 
light  of  verbal  gestures.  Such  an  utter- 
ance as  "  Oh  dear  !  "  is  scarcely  more  arti- 
culate, and  no  more  expressive,  than  a 
groan.  The  peculiarity  of  the  verbal  ex- 
pressions of  misery  is  mainly  the  fre- 
quency of  their  repetition.  A  man  will 
repeat  such  a  phrase  as  "  Oh  dear !  "  or 


"Oh    God!"  hundreds   of  times   in    the 
course  of  an  hour. 

It  should  here  be  stated  that  the  expres- 
sion of  misery  is  not  always  proportionate 
to,  nor  a  measure  of,  the  degree  of  misery 
that  is  felt.  The  training  of  civilised  man, 
especially  in  this  country,  is  so  much 
directed  towards  the  suppression  of  the 
display  of  emotion,  that  in  the  early 
stages  of  melancholia,  when  control  is  but 
little  impaired,  the  expression  exhibited 
before  other  people,  and  especially  before 
strangers,  may  fall  far  short  of  indicating 
the  degree  of  feeling  experienced.  On  the 
other  hand,  when  misery  has  been  severely 
felt  and  freely  expressed  for  long  periods, 
a  habit  of  complaining  by  face,  gesture 
and  utterance  has  grown  up,  which  con- 
tinues after  all  real  intensity  of  feeling 
has  passed  away  ;  and  thus,  in  the  later 
stages  of  the  malady,  the  expression  is  fre- 
quently in  excess  of  the  feeling. 

(2)  In  true  melancholia — that  is  to  say, 
in  cases  in  which  there  is  not  merely  an 
expression,  but  an  actual  experience  of 
misery  —  there  is  defect  of  nutrition 
throughout  the  whole  body,  and  this  de- 
fect is  always  of  the  nature  of  a  slacken- 
ing, weakening,  diminution  of  activity  in 
the  process  of  nutrition.  In  all  the  parts 
of  the  body  that  are  open  to  observation, 
the  nutritive  defect  shows  itself  con- 
spicuously. The  skin  is  dry,  and  is  often 
of  an  earthy,  muddy,  unwholesome  tint : 
the  hair  is  dry,  harsh  and  staring  ;  the 
nails  grow  unusually  slowly,  and  rarely 
want  cutting.  The  mouth  is  dry,  the 
tongue  is  furred,  the  bowels  are  consti- 
pated, the  urine  is  loaded,  the  pulse  is  slow, 
the  body-temperature  is  lowered,  the  whole 
consensus  of  symptoms  goes  to  show  that 
every  bodily  process  is  slackened,  lowered, 
wanting  in  vigour. 

(3)  The  conduct  in  melancholia  exhibits 
a  defect  which  is  strictly  comparable  with 
the  defect  in  the  nutritive  processes.  It 
is  wanting  in  energy  and  vigour.  When 
the  feeling  of  misery  is  not  very  great, 
the  defect  in  activity  of  conduct  may  be 
but  small.  The  patient  takes  less  exer- 
cise, is  prone  to  sit  indoors  rather  than 
to  exert  himself  by  walking  abroad  or  by 
games  of  activity ;  but  when  the  misery^ 
is  great,  the  inactivity  become^.^'^ry 
marked.  The  patient  does  not  ^  out  at 
all,  but  shuffles  up  and  down  his  room,  or 
sits  in  his  chair  all  day,  and  cannot  be  in- 
duced by  any  amount  of  urging  to  take 
even  the  exertion  necessary  to  keep  his 
person  neat  and  tidy,  nor  even  clean. 
His  hair  becomes  unkempt  and  matted, 
his  linen  dirty,  his  skin  filthy. 

(4)  Delusion  is  a  very  frequent,  though 
not    an    invariable     accompaniment     of 


Melancholia 


[    789    ] 


Melancholia 


melancholia.  Many  cases  begin  with  a 
simple  feeling  of  misery  without  delusion, 
and,  in  trifling  and  mild  cases,  delusion 
may  not  occur,  or  may  not  become  con- 
spicuous in  the  whole  course  of  the 
malady.  But,  as  a  rule,  the  disorder  of 
feeling  is  accompanied  with  more  or  less 
evidence  of  disorder  of  thought,  and 
actual  delusion  accompanies  the  melan- 
cholia. Not  only  does  delusion  usually 
accompany  the  melancholia,  but  as  a  rule 
the  gravity  of  the  delusion  has  some  rela- 
tion to  the  depth  of  the  feeling  of  misery, 
so  that  if  the  circumstances  were  as  the 
patient  deludedly  believes  them  to  be, 
they  would  go  far  to  justify  the  feeling 
that  he  experiences.  It  would  serve  no 
useful  purpose  to  enter  at  large  here  upon 
the  character  of  the  delusions  entertained 
by  melancholiacs.  They  are  extremely 
numerous  and  diverse,  and  belong  to  all 
the  varieties  of  delusion  enumerated  else- 
where (see  Delusion),  except  of  course 
those  of  increased  consequence  and  wel- 
fare. A  Ust  of  those  already  observed,  to 
be  exhaustive,  would  well-nigh  occupy 
the  whole  of  this  volume,  and  it  is  itn- 
probable  that  the  next  case  that  occurs 
would  repeat  any  one  of  those  so  enume- 
rated. 

Course  and  Terminations. — Melan- 
cholia differs  from  other  varieties  of  in- 
sanity in  that  it  commonly  arises  de  novo 
in  a  healthy  person.  It  is  very  far  less 
common  for  a  person  who  already  exhibits 
some  other  form  of  insanity  to  become 
melancholic  than  to  become  maniacal,  de- 
mented or  epileptic.  Usually  the  onset 
of  melancholia  is  gradual.  A  patient 
does  not  suddenly  sink  into  deep  melan- 
cholia, as  he  suddenly  becomes  maniacal 
or  epileptic.  He  is  noticed  to  be  some- 
what dull,  somewhat  lethargic,  somewhat 
uneasy,  and  in  less  than  his  usual  spirits, 
but  usually  these  slight  beginnings  of  the 
malady  attract  no  notice,  and  it  is  not 
until  the  disorder  has  become  fully  estab- 
lished that  it  is  remembered  for  how  long 
the  symptoms  have  been  gradually  in- 
creasing. At  length  the  degree  of  misery 
and  the  other  symptoms  reach  a  grade  at 
which  the  limits  of  the  normal  are  un- 
mistakably exceeded,  and  it  becomes  mani- 
fest that  the  patient  is  suffering  from  a 
moi'bid  depression. 

The  subsequent  course  of  the  case  may 
vary  within  wide  limits.  A  large  propor- 
tion of  patients  who  are  young,  and  who 
are  taken  in  hand  at  an  early  stage  of  the 
malady,  recover  rapidly  and  completely  ; 
and  there  is  scarcely  any  class  of  patients 
that  comes  under  the  care  of  the  alienist 
that  shows  results  so  satisfactory  as  this 
one.     The   recovery   is  often  rapid,   and 


may  sometimes  be  even  sudden,  a  person 
who  was  last  night  plunged  in  misery, 
being  this  morning  cheerful  and  con- 
tented. More  commonly  the  first  step 
in  the  improvement  is  a  long  stride,  and 
occurs  upon  a  definite  date,  and  there- 
after follows  a  period  of  slower  and  more 
gradual  improvement,  attaining  at  length 
to  recovery.  Not  uncommonly  it  happens 
that  improvement  may  he  gradually 
gained  until  a  certain  degree  of  nearness 
to  recovery  is  reached,  and  at  that  point 
the  ameliorative  pi'ocess  comes  to  a  stand- 
still, and  the  final  stages  of  recovery  are 
extremely  difficult  to  bring  about. 

Melancholia  is  a  malady  which  is  very 
liable  to  relapse,  and  the  relapse  may  take 
place  at  almost  any  period  in  the  life  his- 
toi'y  of  the  patient.  Thus  it  may  take 
place  during  the  period  of  recovei-y,  and 
the  course  of  recovery  may  be  interrupted 
and  delayed  by  the  occurrence  of  one  or 
two  or  several  relapses.  Or  the  relapse 
may  occur  at  a  longer  or  shorter  period 
after  recovery — at  the  end  of  a  few  months, 
or  a  few  years,  or  of  half  a  lifetime. 

On  the  other  hand,  melancholia  may 
terminate  rapidly  in  death.  The  patient 
may  become  thinner,  weaker,  more  de- 
jected, more  incapable  of  assimilating 
food,  more  incapable  of  exhibiting  energy, 
until  he  dies  of  exhaustion  :  and  death  m 
this  way  may  occur  very  rapidly,  in  a  few 
weeks,  or  may  be  the  termination  of  many 
months  of  illness. 

Instead  of  terminating  either  in  re- 
covery or  death,  melancholia  may  merge 
into  mania  of  more  or  less  acuteness,  of 
which  it  then  appears  to  have  been  the 
initial  stage.  Indeed,  the  frequency  with 
which  this  occurs  has  led  a  very  thought- 
ful alienist — Dr.  Sankey — to  the  conclu- 
sion that  all  cases  of  insanity,  save  of 
course  general  paralysis,  begin  in  melan- 
cholia ;  or  at  least  that  the  ordinary  and 
normal  succession  of  events  is  melan- 
cholia, mania,  dementia,  a  succession  which 
may  be  interrupted  at  any  stage  by  re- 
covery or  death.  Be  this  as  it  may,  it  is 
certain  that  melancholia  is  often  a  step  to 
mania,  and  still  more  often  a  stage  on  the 
road  to  dementia.  These  observations 
lead  us  directly  to  the  consideration  of 
the 

Varieties  of  melancholia,  which  the 
industry  of  clinical  alienists  has  rendered 
perhaps  unnecessarily  numerous,  no 
fewer  than  thirty  varieties  having  been 
described  by  various  authors.  It  will 
not  be  necessary  to  consider  all  these  in 
detail  here,  especially  as  st)me  of  the  varie- 
ties are  dealt  with  at  length  in  other 
articles  in  this  volume  (xep  Folie  Circu- 
LAIRE  ;  Melancholia  Attonita),  but  cer- 


Melancholia 


790    ] 


Melancholia 


tain  well-marked   varieties  may  well    be 
described. 

SinijjJe  Melancholia  is  that  variety  of 
the  malady  in  which  the  depression  of 
feeling  is  unattended  by  delusion.  Most 
cases  of  melancholia  exhibit  this  phase  at 
the  outset,  when  the  depression  is  not 
severe ;  and  a  few  cases,  which  never  at- 
tain a  great  degree  of  severity,  remain 
throughout  free  from  manifestation  of 
delusion.  But  the  great  majority  of  cases 
show,  at  one  time  or  another  of  their 
course,  evidence  of  the  existence  of  de- 
lusion, and  probably  in  no  case  does  the 
feeling  of  depression  attain  great  intensity 
without  the  appearance  of  delusion. 

Melancholia  wlfl>-  delusion  is  the  com- 
plement of  simple  melancholia,  and  in- 
cludes all  cases  which  are  not  included  in 
the  previous  class. 

Cases  of  melancholia  are  again  divided 
into  acute  or  chronic  according  to  their- 
duration.  Any  case  which  culminated  in 
a  few  weeks  would  come  under  the  former 
category.  Cases  of  really  chronic  melan- 
cholia, that  is  to  say,  cases  in  which  an 
unjustifiable  feeling  of  misery  is  experi- 
enced, for  many  months  or  for  years  to- 
gether, are  far  from  common.  Doubtless 
there  are  many  cases  in  which  the  expres- 
sion of  misery  has  become  habitual,  and 
is  maintained  long  after  the  actual  feeling 
has  passed  away,  but  it  is  very  doubtful 
whether  there  is  any  real  feeling  of  misery 
in  many  of  the  cases  classed  as  chronic 
melancholies. 

Melancholia  has  again  been  divided 
into  active  and  passive,  according  as 
the  manifestations  of  the  feeling  of 
wretchedness  consist  of  exaggerated 
gestures,  loud  cryings  and  moanings,  &c., 
or  as  the  patients  are  listless,  lethargic 
and  languid.  An  extreme  degree  of  pas- 
sivity with  depression  of  spirits  constitutes 
the  variety  known  as  tnelancholia  cum 
stupore  or  melancholia  attanita  {q.c). 

Intervals  of  melancholy  occur  in  the 
course  of  other  forms  of  insanity,  as  in 
mania,  dementia,  epilepsy,  and  general 
paralysis,  and  when  so  occurring  it  has 
been  designated  by  a  special  title ;  but 
there  is  nothing  in  the  symptoms  or  mani- 
festations of  melancholy  occurring  under 
these  circumstances  which  is  different 
from  those  of  ordinary  melancholy,  and 
although  its  manifestations  may  be 
mingled  with  those  of  the  other  mala- 
dies or  their  results,  there  is  no  need  to 
consider  such  cases  separately. 

Suicida,l  Melancholia.  —  A  separate 
variety  of  melancholia  has  been  ei'ected 
under  this  title,  and  iu  it  would  be  in- 
cluded any  case  in  which  there  is  a  ten- 
dency to  suicide.     The  tendency  to  self- 


destruction   is   by   no   means   always   in 
proportion  to  the  depth  of  the  depression, 
some  cases,  in  which  the  manifestations  do 
not  indicate  severe  depression,  being  most 
determined    and   persistent   in   their    at- 
tempts to  commit  suicide,  while  to  others, 
in  whom  the  feeling  of  misery  is  evidently 
profound,  the  idea  of  suicide  never  seems 
to  present  itself.     Often,  it  may  be  said 
usually,  the  attempt  at  suicide  is  made  in 
the  same  way  in  the  same  case,  and  a 
man  who  is  bent  upon  destroying  himself 
by  shooting,  will  neglect  opportunities  of 
compassing  his  end  by  drowning  or  hang- 
ing, and  will  use  only  the  one  particular 
method  which  commends   itself  to   him. 
The  tendency  to  suicide  having  once  ex- 
hibited  itself  in   any  case,  renders  that 
patient  for  ever  after  a  source  of  anxiety 
to  those  who  have  the  cai-e  of  him  ;  for  in 
consequence  of  the    want   of   proportion 
between  the  tendency  to  suicide  and  the 
manifestations  of  depression,  it  becomes 
impossible  to  infer,  with  any  safety,  from 
the  disappearance  of  the  latter,  that  the 
former  also  has  disappeared.     Many  cases 
are  on  record  in  which  patients,  who  have 
apparently  recovered   from    melancholia, 
have   committed    suicide   on   being  freed 
from  restraint.     When  once  a  person  has 
fully  determined  to  commit  suicide,  it  is 
well-nigh  impossible  to  prevent  him  from 
carrying  out  his  intention.     The  ingenuity 
with    which     he     will    construct    lethal 
weapons  out  of  the  most  harmless  imple- 
ments, out  of  the  materials  of  clothing, 
the    secrecy    with    which    he   will  carry 
out  his  preparations,  and  the  suddenness 
and  determination  with    which    he    will 
carry  them  into  effect,  are  such  as,  if  per- 
sisted in  over  a  long  period,  to   render 
futile  the  most  stringent  watchfulness  and 
precaution.      The  sharpening  of  bits   of 
barrel  hoop,  of  nails  and  bits  of  wire,  into 
deadly  instruments,  is  a  matter  of  daily 
occurrence   in    large     asylums.      Female 
patients  will   pull   threads   out   of  their 
sheets  until  they  have  got  enough  to  twist 
into  a  cord  wherewith  to  strangle  them- 
selves.    One  man  will  hang  himself  from 
a  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. 

Patbolog-y. — The  nature  of  the  change 
in  nerve-tissue  that  underlies  melancholia 
is  obscure.  Whatever  change  may  be  as- 
signed as  the  efficient  cause  of  the  symp- 
toms must  be  one  which  will  account  for 
the  whole  of  them.  When  we  find  the 
alteration  of  feeling,  the  alteration  of  con- 
duct, and  the  alteration  of  nutrition  in- 
variably concomitant,  and  invariably 
exhibiting   certain  common   features,  we 


Melancholia 


[     79'     ] 


Melancholia 


cannot  reasonably  ascribe  them  to  sepa- 
rate lesions  of  nerve-tissue,  bnt  must 
admit  that  any  valid  explanation  must 
account  for  all  by  the  occurrence  of  a 
single  change.  The  nature  of  this  change 
is  indicated  by  the  nature  of  the  modifi- 
cation that  effects  all  these  processes. 
The  characteristic  alteration  of  conduct 
is  its  diminished  activity.  The  charac- 
teristic alteration  of  the  nutritive  pro- 
cesses is  their  diminished  activity.  The 
characteristic  alteration  of  consciousness 
is  the  diminution  of  the  feeling  of  well- 
being  ;  and  we  now  know  enough  of  the 
nervous  accompaniment  of  con'5ciousness 
to  know  that  the  feeling  of  well-being  is 
dependent  for  its  existence  on  a  high  state 
of  activity  of  the  nerve-tissue,  on  a  high 
degree  of  tension  of  the  nerve  energy  exist- 
ing therein.  But  a  high  degree  of  activity 
of  the  nerve  elements  produces  great 
activity  of  conduct;  and  a  high  tension 
of  nervous  energy  produces  great  activity 
of  all  the  nuti'itive  processes.  Hence, 
when  feeling  is  depressed,  conduct  di- 
minished, and  nutritive  processes  inactive, 
we  must  infer  that  the  opposite  con- 
dition exists — that  the  nervous  elements 
are  unduly  inactive,  and  the  tension  of  the 
nervous  energy  is  reduced  below  the 
normal.  Any  lowering  of  the  vigour  of 
the  motor  currents  going  to  the  muscles 
will  have  the  effect  of  reducing  the  energy 
of  the  muscular  contractions  ;  and  when 
the  vigour  of  the  nerve-currents  is  lowered 
throughoutthe  whole  ofthe  hierarchy  of  the 
nerve-centres,  not  only  will  muscular  con- 
tractions be  weakened,  by  affection  of  the 
lowest  rank  of  centres;  not  only  will  move- 
ments be  rendered  less  frequent  and  less 
vigorous,  by  affection  of  the  middle  rank 
of  centres  ;  bnt,  by  affection  of  the  highest 
ranks,  the  whole  phenomena  of  conduct 
will  be  diminished,  weakened,  attenuated 
and  impaired.  The  muscular  system  is 
not  the  only  recipient  of  motor  nerve- 
currents.  .Similar  currents  have  been 
demonstrated  to  regulate  the  activity  of 
glands,  and  the  disturbances  of  nutrition 
that  invariably  follow  section  of  nerves, 
indicate  with  equal  certainty  that  the 
nutrition  of  every  tissue  in  the  body  is 
dependent  on  and  is  regulated  by  ''  motor," 
that  is  to  say.  outgoing,  currents  from  the 
central  nerve  regions.  When  the  vigour 
of  these  motor  currents  is  great,  the 
nutritive  processes  in  the  tissues  are 
active,  the  various  bodily  processes  ex- 
hibit an  abounding  vitality,  secretions 
are  copious,  visceral  movements  vigoi'ous, 
the  skm  is  clear  and  tense,  the  eyes  are 
bright,  the  hair  and  nails  grow  rapidly 
and  evenly,  the  whole  body  exhibits  evi- 
dence of  activity  and  vigour.     When  the 


motor  currents  are  feeble  and  attenuated, 
the  opposite  state  of  affairs  obtains ; 
secretions  are  scanty,  excretion  is  in- 
efficient, visceral  movements  are  languid, 
the  skin  is  lax,  and  is  oi:)aque  and  earthy 
looking,  the  eye  is  dull,  the  muscles  are 
lax,  the  hair  and  nails  grow  slowly  and 
irregularly,  and  the  whole  of  the  bodily 
processes  exhibit  evidence  of  languor, 
leebleness  and  inactivity.  Thus,  the  defect 
of  conduct,  the  passivity,  the  indolence, 
the  lethargy  of  melancholia  are  dependent 
upon  precisely  the  same  alteration  of 
nerve  action  as  the  constipation,  the  loaded 
urine,  the  foul  tongue  and  the  other 
physical  symptoms  ;  and  hence  it  appears 
no  longer  extraordinary  that  the  one  set 
of  symptoms  should  invariably  accom- 
pany the  other.  That  precisely  the  same 
nervous  defect  underlies  the  feeling  of 
melancholy  does  not  appear  to  need  very 
urgent  insistence,  for  it  is  found  generally 
that  the  feeling  of  well-being  bears  a 
regular  proportion  to  the  manifestations 
of  activity  of  nerve  elements.  Generally, 
when  there  is  a  high  degree  of  spon- 
taneity of  movement,  and  a  high  degree  of 
activity  of  bodily  processes,  the  conscious- 
ness of  self  is  highly  pleasurable ;  and 
when  movements  are  languid,  and  bodily 
processes  slackened,  the  consciousness  of 
self  loses  its  buoyancy  and  becomes  de- 
pressed. This  concomitance  of  the  varia- 
tions of  the  feeling  of  well-being  with 
the  variations  in  the  other  signs  of  ner- 
vous activity  is  shown  in  many  ways. 
It  is  shown  in  the  diurnal  fluctuations, 
the  general  feeling  of  well-being  attain- 
ing its  height  at  mid-day  when  activity  is 
greatest :  and  being  at  its  ebb  in  the 
small  hours  of  the  morning  v/hen  activity, 
both  of  movement  and  of  nutrition,  is  at 
its  minimum.  It  is  shown  in  the  pheno- 
mena of  illness,  and  the  fluctuations  that 
occur  from  time  to  time  in  the  course  of 
all  lives ;  and  it  is  shown  conspicuously 
in  the  contrast  between  youth  and  age, 
one  full  of  abounding  vigour  and  with 
exalted  feeling  of  well-being,  always  in 
high  spirits  and  happy  ;  the  other  placid 
alike  in  body  and  in  mind,  physically 
inactive,  and  mentally  no  more  than  con- 
tent. 

.Stiolo^y. — If  such  be  the  pathology 
of  melancholia,  the  search  for  its  astiology 
is  considerably  simplified,  for  whatever 
will  produce  a  lowering  in  the  tension  of 
the  nerve  energy,  and  an  inefficiency  or 
slackening  in  the  mode  of  working  of  the 
nerve-elements,  may  produce  melancholia. 
Of  all  the  conditions  upon  which  this 
modification  of  nervous  action  may  depend 
the  most  important  is  undoubtedly  that 
of  hereditary  disposition  {see  Herkdity). 


Melancholia 


[    792    ] 


Melancholia 


While  some  individuals  are  born  with 
iiervons  sj^stems  of  great  vigour,  contain- 
ing so  great  a  store  of  energy,  so  easily 
and  rapidly  renewed,  that  they  are  capable 
of  powerful  and  sustained  exertion,  are 
with  difficulty  fatigued,  require  little 
sleep,  rapidly  recuperate  the  energy  that 
they  expend,  exhibit  a  high  degree  of 
vigour  in  all  their  bodily  processes,  and 
maintain  throughout  all  vicissitudes  of 
circumstances  a  buoyant,  hopeful,  eager 
and  confident  mind  :  others  are  so  con- 
stituted from  birth  that  their  nervous 
systems  contain  but  a  poor  accumulation 
of  force,  an  accumulation  which  is  easily 
depleted,  is  slow  to  recuperate,  so  that 
they  are  capable  of  but  little  and  brief 
exertion,  are  easily  fatigued,  require  much 
sleep,  but  obtain  perhaps  little,  exhibit 
the  signs  of  feebleness  and  languor  in  all 
their  bodily  processes,  are  easily  and  pro- 
foundly depressed  in  mind  by  slight  re- 
verses of  fortune,  and  even  in  their  best 
moments  are  rather  content  than  happy, 
rather  placid  than  in  good  spirits.  Persons 
of  the  first  class  of  constitution  are  proof 
against  the  attacks  of  melancholia,  while 
persons  of  the  second  class  require  but 
little  solicitation  or  provocation  from 
circumstances  to  sink  into  a  slough  of 
despond. 

An  hereditarily  acquired  tendency  to 
undue  feebleness  of  nerve  action  may  be 
aggravated  into  activity  by  several  difi"e- 
rent  pi'ovocative  agents.  Any  unusual 
demand  upon  the  powers  of  the  organism, 
any  occasion  requiring  the  expenditure  of 
large  draughts  of  energy,  may  so  deplete 
the  activity  of  the  nervous  system  as  to 
bring  about  melancholia.  Occasions  of 
this  nature  may  arise  from  circumstances 
either  within  or  without  the  organism. 
Thus,  at  the  period  of  puberty,  when 
large  re-arrangements  in  the  distribution 
of  nerve  energy  are  being  made,  and  when 
copious  draughts  of  energy  are  being  called 
for  in  order  to  satisfy  the  new  functions 
and  new  activities  that  are  then  arising, 
melancholia  frequently  appears,  mingled 
usually  in  more  or  less  intricate  com- 
bination with  hysteria,  the  special  product 
of  that  time.  At  the  time  of  the  other 
momentous  changes,  of  pregnancy,  child- 
birth, suckling,  and  the  climacteric,  all  of 
which  dej^lete  the  activities  of  the  nervous 
system  by  making  large  draughts  upon 
its  energies,  melancholia  may  appear. 
After  exhausting  attacks  of  bodily  disease, 
after  exhausting  exertion,  either  physical 
or  mental,  after  the  prolonged  exertion  of 
climbing  a  mountain,  or  after  the  pro- 
longed exertion  of  preparing  for  an  ex- 
amination, melancholia  may  supervene. 
Similarly,   uutowai'd   circumstances,    the 


loss  of  friends,  or  of  fortune,  or  of  cha- 
racter ;  any  circumstance  which  is  calcu- 
lated to  produce  sorrow,  grief,  uneasiness, 
anxiety,  in  an  ordinarily  constituted  per- 
son, may,  if  it  act  upon  a  person  of  less 
than  ordinary  stamina,  produce  melan- 
cholia ;  and  the  more  severe  the  stress, 
the  greater,  naturally,  is  the  chance  of 
melancholia  occurring. 

Diagnosis. — The  nearest  allies  to  me- 
lancholia, and  the  maladies  for  which  it 
is  most  likely  to  be  mistaken,  are  de- 
mentia, hypochondriasis,  and  hysteria. 
To  dementia  it  is  allied,  not  merely  in 
a2:>pearance,  but  in  nature,  for  the  melan- 
choly feeling  never  reaches  a  morbid 
degree  without  some  general  weakening 
of  the  mental  powers,  which  constitutes  a 
slight  degree  of  dementia,  and,  in  well 
marked  cases  of  melancholia,  in  which  the 
amount  of  depression  is  great,  the  weaken- 
ing of  the  mental  power  becomes  very 
marked,  and  constitutes  of  itself  a  veri- 
table dementia.  If  in  such  cases  we  have 
regard  to  the  conduct  alone,  and  neglect 
the  manifestations  of  misery,  we  shall 
have  no  hesitation  in  recognising  the  con- 
siderable degree  of  dementia,  or  impair- 
ment of  mind,  that  exists.  Melancholia 
differs,  then,  from  dementia  in  the  super- 
addition  to  the  symptoms  of  the  latter  of 
evidence  of  depression  of  mind;  this 
evidence  being,  in  many  cases,  so  much 
the  more  prominent  symptom  as  to  throw 
into  the  shade  the  co-existing  dementia, 
which  then  remains  unrecognised.  On 
the  other  hand,  there  are  cases  in  which 
the  dementia  is  by  far  the  more  prominent 
of  the  mental  peculiarities,  and  the  de- 
pression of  mind  is  not  conspicuous  ;  in 
such  cases  the  melancholic  element  may 
be  overlooked,  and  the  case  be  considered 
one  of  simple  dementia.  Such  errors  of 
diagnosis  are  not  of  great  importance,  the 
two  conditions  being  sufficiently  alike  in 
nature  to  need  the  same  treatment  and  to 
warrant  the  same  prognosis. 

HyiMchondriusis  is  distinguished  from 
melancholia,  to  which  it  is  very  nearly 
allied,  by  the  persistence  with  which 
the  patient  assigns  his  malaise  to  bodily 
disease,  and  by  the  degree  to  which  his 
thoughts  are  enthralled  and  engrossed 
by  his  bodily  condition.  Between  hypo- 
chondriasis and  melancholia  there  is  every 
possible  gradation,  from  the  patient  whose 
only  peculiarity  is  his  persistent  and  too 
much  absorbed  attention  to  some  real  or 
half  imaginary  local  disorder,  to  him  who 
is  sank  in  misery  which  he  ascribes  to  the 
judgment  of  God  upon  his  sins.  In  the 
former  case  the  patient  is  distinguished 
by  his  enthusiastic  acceptance  of  remedy 
after  remedy,  and   his  eager  pursuit  of 


Melancholia 


[     793     ] 


Melancholia 


one  medical  practitioner  after  another. 
Throughout  all  the  dread  and  wretched- 
ness of  his  career  he  clinajs  fast  to  the 
taith  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  enter- 
taining hopes  of  recovery  or  confidence  in 
treatment,  he  rejects  with  something  like 
contempt  the  advice  that  is  tendered  for 
his  welfare. 

The  distinction  of  liysteria  from  melan- 
cholia is  in  the  different  degrees  to  which 
the  attention  of  others  is  sought  and 
claimed  in  the  two  cases.  In  hysteria  the 
whole  aim  and  end  of  the  display  of  symp- 
toms by  the  patient  will  be  found  to  have 
regard  to  the  attraction  of  notice,  of 
interest,  and  of  sympathy  from  others. 
In  melancholia,  on  the  other  hand,  the 
patient  is  quite  indifferent  to  the  way  in 
which  her  actions  and  symptoms  may 
impress  other  people.  She  is  too  much 
absorbed  in  the  misery  that  she  suffers  to 
bestow  a  thought  upon  the  way  in  which 
her  conduct  is  regarded. 

One  other  condition  is  necessary  to  bear 
in  mind  in  the  diagnosis  of  melancholia. 
The  malady  has  been  defined  as  "  a  feeling 
of  misery  in  excess  of  what  is  justified  by 
the  circumstances  in  which  the  individual 
is  placed  :  "  and,  in  order  to  say  with  any 
confidence  that  the  malady  exists,  it  is 
necessary  to  know  the  circumstances  of 
the  individual  in  order  to  judge  whether 
the  misery  experienced  is  justified  by 
them  or  no.  It  may  be  that  the  misery 
is  so  profound  that  scarcely  any  circum- 
stances, however  adverse,  would  be  a  justi- 
fication for  it,  and  in  such  cases  the 
diagnosis  is  not  difficult ;  or  it  may  be 
that  the  feeling  of  misery  may  be  ac- 
counted for  by  a  reason  which  is  palpably 
and  manifestly  the  outcome  of  a  delusion, 
as  that  the  patient  has  been  deprived  of 
his  wings,  or  has  had  another  person's 
brains  substituted  for  his  own.  But  there 
is  a  large  class  of  cases  in  which  the 
reason  alleged  may  possibly  be  true,  and, 
if  true,  would  justify  the  feeling  of  un- 
happiness.  If  a  patient  appears  afflicted 
with  melancholy,  and  declares  that  he  is 
on  the  brink  of  ruin;  that  his  wife  is 
unfaithful :  that  he  is  a  wicked  and  dis- 
honest man  ;  that  he  is  liable  to  arrest ;  it 
is  necessary  to  be  very  cautious  in  regard- 
ing his  statements  as  unfounded.  It  may 
be  that  they  are  true,  and  that  his  feeling 
of  misery  is  only  the  normal  and  natural 
feeling  that  such  circumstances  ought  to 
inspire. 

Treatment. — The  treatment  of  melan- 
cholia is  indicated  very  obviously  by  the 


account  of  the  pathology  that  has  been 
given.  If  the  defect  which  underlies  the 
whole  malady  is  a  weakening  and  slacken- 
ing of  the  nerve-action,  and  a  diminution 
of  the  tension  of  the  nerve-currents,  then 
the  treatment  must  be  directed  to  arous- 
ing a  more  intense  activity,  and  restoring 
the  tension  to  its  normal  height.  There 
is  no  reason  to  doubt  that  the  process  of 
storing  energy  in  the  nerve-elements  is 
a  part  of  the  general  process  of  nutrition, 
nor  that  if  we  can  by  any  means  increase 
the  activity  and  vigour  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.  The  whole  of  the  treatment  of 
melancholia  is  therefore  directed  to  stimu- 
lating and  increasing  the  activity  of  the 
processes  of  nutrition.  First  among  the 
restorative  measures  is  the  administration 
of  food.  It  is  usually  found,  when  a 
melancholic  patient  comes  under  care, 
that  for  a  considerable  time  he  has  not 
taken  a  sufficiency  of  food.  Owing  to  the 
slackening  of  the  nutritive  processes, 
sufficient  pabulum  has  not  been  assimi- 
lated by  the  tissues,  and  owing  to  the 
same  reason  the  representation  in  con- 
sciousness of  the  needs  of  the  body  has 
been  obscure  and  insufficient.  Hunger 
has  not  been  felt,  and  hence  food  has  not 
been  taken  in  sufficient  quantity.  The 
subjects  of  melancholia  are  often  ema- 
ciated, usually  thin,  and  always  are  less 
well  nourished  than  they  are  wont  to  be 
in  their  normal  condition  of  cheerfulness. 
Always  there  is  want  of  inclination  for 
food,  often  there  is  positive  distaste  for  it, 
and  not  unfrequently  there  is  complete 
and  obstinate  refusal  to  take  it.  Hence 
the  first  necessity  in  the  treatment  of  a 
melancholy  patient  is  to  insist  on  the 
ingestion  of  abundance  of  aliment,  and  if 
necessary  to  employ  force  for  the  pur- 
pose. 

Dr.  Blandford  has  pointed  out  that  in 
some  cases  food  is  withheld  in  consequence 
of  the  dyspepsia  which  so  frequently  co- 
exists with  the  mental  depression ;  but 
this  is  a  mistake,  and  may  easily  become  a 
fatal  mistake.  Food,  abundance  of  food, 
must  always  be  administered,  no  matter 
what  the  state  of  the  patient's  digestion 
may  appear  to  be,  no  matter  how  directly 
contrary  it  may  be  to  his  inclination.     It 

'  is  not  enough  to  give  slo]:)S  and  concen- 
trated essences  of  meat  and  peptic  fluids. 
Solid  food  of  varied  nature  and  consider- 

j  able  bulk  must  be  given  if  the  greatest 
benefit  is  to  be  obtained. 

In  order  that  the  food  thus  given  may 
be   digested    and    assimilated,   the   next 


Melancholia 


[     794    ] 


Melancholia 


point  ot  iiuportauce  is  to  see  that  plenty 
of  exercise  be  taken.  Some  care  will  be 
necessary  here  to  graduate  the  exercise 
to  the  patient's  strength,  for  it  is  probable 
that  before  he  has  come  under  care  he 
has  for  long  taken  but  little  exercise,  and 
the  siidden  undertaking  of  strenuous  exer- 
tions may  have  a  very  deleterious  effect; 
but  some  exercise  should  be  insisted  on, 
and,  as  strength  returns,  it  should  be  gra- 
dually and  somewhat  rapidly  increased. 
In  prescribing  exercise  two  points  are  to 
be  attended  to.  The  exercise  should  bring 
into  play  as  far  as  possible  the  large  mus- 
cular masses.  The  patient  should  not 
stand  at  a  bench  manipulating  with  his 
hands.  If  nothing  better  offers  he  should 
be  made  to  walk,  but  better  than  walking 
is  some  exercise  which  employs  in  strenu- 
ous exertion  a  larger  number  of  muscles, 
including  the  bulky  muscles  of  the  back. 
Rowing,  riding,  and  cycling  are  indicated 
if  there  be  no  suicidal  tendency,  while,  if 
such  a  tendency  exist,  excellent  exercise 
may  be  got  from  such  work  as  using 
a  cross-cut  saw,  woi-king  a  chaff-cutter, 
or  turning  the  homely  mangle.  In  very 
severe  cases,  in  which  emaciation  is  great, 
weakness  extreme,  and  disinclination  to 
exertion  profound,  the  employment  of 
massage  may  be  of  great  benefit  to  start 
the  processes  of  nutrition,  and  make  them 
recommence  their  forgotten  task,  but  such 
methods  do  not  commonly  need  to  be 
employed  for  long. 

It  will  always  be  difficult  to  carry  out 
the  measures  indicated  so  long  as  the 
patient  is  in  his  own  home,  and  sur- 
rounded by  his  familiar  environment ;  and 
for  this  reason  an  important  part  of  the 
treatment  is  the  removal  of  the  patient  to 
new  surroundings.  But  this  is  not  the 
only  reason  why  such  a  change  is  bene- 
ficial. The  mere  fact  of  change,  of  living 
in  different  rooms,  in  a  different  locality, 
among  different  people,  in  a  different 
physical,  menfal  and  moi-al  atmosphere 
to  that  which  is  customary,  is  itself  a 
powerful  provocative  of  increased  tissue 
metamorphosis.  In  customary  surround- 
ings, the  organism  becomes  habituated 
to  certain  sets  of  impressions  arriving  at 
more  or  less  regular  and  expected  times  ; 
and  the  more  thorough  the  habituation  the 
less  the  change  produced  by  the  impres- 
sions. All  are  familiar  with  the  fact  that 
a  slight  noise  which  is  new  and  unaccus- 
tomed will  awake  them  from  the  profound- 
est  sleep,  while  sleep  may  continue 
throughout  a  deafening  uproar  if  only  the 
organism  has  become  accustomed  to  the 
noise  by  long  habituation.  The  value  of 
removal  to  new  surroundings  is  in  the 
much  more  vigorous  tissue-changes  that 


are  brought  about  by  impressions  of  ordi- 
nary intensity.  A  third  reason  tor  the 
beneficial  action  that  is  always  found  to 
result  from  change  of  surroundings,  when 
the  change  is  to  the  interior  of  an  asylum, 
is  in  the  habits  of  order,  discipline,  an<l 
obedience  that  are  there  found  to  prevail. 
In  the  patient's  own  home  he  has  been 
accustomed  to  freedom  of  action,  and  the 
influence  of  others  by  persuasion  or  other- 
wise has  been  discontinuous  and  feeble. 
But  in  an  asylum  he  lives  in  an  atmo- 
sphere of  oi'der  and  discipline ;  and  finding 
that  all  around  him  submit  with  cheerful- 
ness to  rule  and  governance,  he  is  insen- 
sibly influenced  by  the  contagious  example 
of  the  I'est  to  subordinate  his  own  inclina- 
tions to  the  desires  of  those  with  whom 
he  is  placed.  Of  course  the  surroundings 
should  be  made  as  cheerful  as  possible. 
Every  effort  should  be  made  to  engage 
the  patient's  attention,  to  cause  him  to 
interest  himself  in  some  occupation,  to 
get  his  mind  as  well  as  his  body  to  work; 
but  efforts  in  this  direction  will  be  for  the 
most  part  futile  until  the  nerve-elements 
have  been  compelled  by  ph)'sical  means 
to  resume  their  function  of  storing  and 
expending  energy. 

With  regard  to  drugs,  it  was  for  many 
years  customary  to  treat  melancholic  pa- 
tients by  routine  with  ojnum  ;  but  this 
treatment  has  of  late  years  dropped  al- 
most entirely  out  of  practice.  Every  now 
and  then  we  meet  with  a  patient  who 
appears  to  be  benefited  by  opium,  but 
the  cases  are  not  frequent,  and  the  druff 
is  now  seldom  used.  Of  much  more  avail 
are  drugs,  such  as  iron,  quinine,  arsenic, 
and  strychnine,  which  tend  to  simulate  the 
processes  of  digestion  and  of  nutrition 
generally  ;  and  in  the  writer's  experience 
the  most  valuable  drug  in  the  treatment 
of  melancholia  has  been  the  syrup  of  the 
phosphates  of  quinine,  iron,  andstrychnine, 
known  as  Easton's  syrup. 

Of  the  symptoms  that  have  to  be  dealt 
with,  the  most  frequent  and  troublesome 
are  dysjiepsia,  with  its  attendant  constipa- 
tion, and  sleeplessness.  The  constipation 
appears  to  be  often  largely  due  to  the  fact 
that  the  bowels  are  empty  or  nearly  so,  and 
that  nothing  passes />t'rtuiH?K,  because  there 
is  nothing  to  pass,  or  at  any  rate  the  intes- 
tines do  not  contain  enough  solid  matter 
to  arouse  them  to  the  performance  of 
their  normal  movements.  It  is  found 
that  in  many  cases  the  bowels  are  freely 
relieved  without  the  use  of  aperients,  when 
a  systematic  course  of  copious  feeding  is 
entered  on  and  maintained.  When  it  be- 
comes necessary  to  give  aperients,  the  best 
form  is  one  of  the  many  aperient  mineral 
waters  given  fasting  in  the  morning. 


Melancholia 


[     795     J 


Melancholia 


What   has   been    said   of  couHtipation 
applies  also  in  great  measure  to  sleepless- 
ness.    It  is  a  frequent  experience  of  the 
most  healthy  people  that  sleep  and  hun- 
ger are  incompatible,  and  that  it  is  a  hope- 
less task  to  endeavour  to  sleep  with  an 
empty    stomach.      In    melancholia     the 
amount  of  food  taken  is  habitually  less 
than  normal,  and  less  than  the  body  needs, 
and  it  is  for  this  reason,  as  much  as  for 
any  other,  that  sleep  is  so  rare  and  so 
difficult  to  obtain.     In  the  great  majority 
of  cases  it  will  be  found  that  the  best  so- 
porific is  a  bellyful  of  food,  and  it  not 
unfrequently  happens  that  patients  who 
have  not  slept,  or  have  scarcely  slept,  for 
weeks  in  spite  of  the  administration   of 
enormous  does  of  opium,  of  bromides,  of 
chloral   and    other    hypnotics,    will    fall 
asleep  immediately,  and  sleep  long  and 
soundly,  after  being  compelled  to  eat  a 
hearty   and  copious  meal.     Whei'e    food 
alone  will  not  produce  sleep,  it  will  usually 
be  found  that  the  addition  to  the  food  of 
some  stimulant  will  produce  the  desired 
effect.     A  bottle  of  stout,  or  a  glass  of 
stiff  hot  grog,  on  the  top  of  a  good  supper 
will  produce  a  drowsiness  which  is  very 
hard  to  resist.      More  especially  is  this 
the  case  when  the  meal  comes   at  the  end 
of  a  day  of  tiring  exercise  in  the  open  air. 
When  the  patient  is  not  strong  enough  to 
take   much   exercise,   and,    indeed,  often 
when  he  is,  it  will  be  found  that  a  long 
drive  in  an  open  carriage  produces  a  re- 
markably soporific  effect.     All  these  mea- 
sures should  be  well  tried  before  recourse 
is  had  to  drugs,  and  the  cases  will  be  rare 
indeed  in  which  their  combined  action  will 
be  ineffectual.     Of  course,  in  very  severe 
and  very  acute  cases,  several  of  the  mea- 
sures cannot  be  taken,  and  it  may  then 
happen   that   recourse   must   be   had    to 
drugs.     In  that  case  it  is  best  to  give  the 


place  in  society.  Of  course  all  weapons 
and  appliances  that  could  be  used  for  a 
suicidal  purpose  should  be  removed  from 
his  reach.  He  should  not  be  allowed 
razors,  knives,  scissors,  glass,  crockery,  <n- 
anything  that  can  be  made  into  a  weajjon. 
But  no  amount  of  pi-ecautiou  of  this  cha- 
racter is  of  the  slightest  avail  if  tht;  patient 
is  allowed  to  be  alone.  He  must  be 
watched  incessantly  ;  an  attendant  must 
be  always  with  him.  He  must  be  watched 
while  dressing  and  undressing,  taken  to 
the  closet,  watched  while  on  the  seat,  and 
brought  away.  Even  with  all  this  pre- 
caution, it  is  not  always  possible  to  pre- 
vent a  patient  from  destroying  himself. 
He  may  run  head  forwards  against  a  wall, 
and  fracture  his  skull ;  or  he  may  throw 
himself  headlong  downstairs.  But  unless 
such  precautions  as  have  been  mentioned 
are  taken,  the  patient  may  as  well  be  left 
to  himself. 

When  the  measures  of  treatment  here 
described  have  been  followed,  when  abun- 
dance of  food  has  been  administered,  and  a 
sufficiency  of  exercise  taken,  the  waste  of 
the  tissues  that  exercise  involves,  the  ac- 
tivity of  tissue  that  it  necessitates,  predis- 
poses the  tissues  to  absorb  nourishment, 
and  stimulates  them  to  resume  their  ne- 
glected function  of  assimilation.  The  pro- 
cess of  assimilation,  once  begun,  is  a  stimu- 
lus to  the  innumerable  nerve-endings  that 
are  distributed  among  the  tissues,  and 
initiates  a  constant  tide  of  nerve-currents 
that  flow  upward  to  the  brain.  Stimu- 
lated by  these  currents,  the  elements  of 
the  nerve-tissue  in  their  turn  begin  to  re- 
sume their  activity  both  of  function  and 
of  nutrition.  They  begin  once  more  to 
absorb  energy,  and  to  expend  it  through 
the  channels  of  nerve-fibre.  The  energy 
thus  distributed  enters  the  tissues  of  the 
body  at  large,  and,  acting  as  "  motor "' 


drug    hypodermieally,    after   the  patient  i  currents,    reinforces    their    molecular   ac- 


has  had  a  meal,  and  it  is  important  that 
the  patient  should  be  already  undressed, 
in  bed,  and  quiescent  before  the  drug  is 
given.  After  its  administration,  absolute 
stillness  should  be  enjoined,  and  in  this 
way  the  effect  is  most  likely  to  be  obtained, 
when  it  is  necessary  to  give  a  drug  the 
dose  should  be  a  full  one.  If  morphia, 
not  less  than  |  gr. ;  if  chloral,  not  less  than 
30  grs. 

Under  the  head  of  treatment  should  be 
mentioned  the  precautions  that  it  is  neces- 
sary to  take  in  suicidal  cases.  These  pre- 
cautions may  be  summed  up  in  two  words 
— incessant  watchfulness.  When  a  pa- 
tient has  once  manifested  a  suicidal  ten- 
dency, he  should  never  be  left  alone, 
waking  or  sleeping,  day  or  night,  until 
he  is  quite  cured  and  fit  again  to  take  his 


tivity,  re-invigorates  their  nutrition,  and 
is  a  cause  of  still  more  energetic  currents 
returning  to  the  brain,  there  to  act  as 
stimuli  to  nutrition  and  activity.  Once 
the  process  is  started,  it  continually  re- 
inforces itself,  and  hence  we  find  that  in 
the  cure  of  melancholia  it  is  the  first 
step  only  which  gives  trouble.  Once  we 
can  bring  about  a  slight  amelioration  we 
need  as  a  rule  have  little  anxiety  for  the 
result. 

Not  unfrequently  it  happens,  however, 
that  the  process  is  started  in  the  way  indi- 
cated, and  is  successfully  pursued  up  to  a 
certain  point,  but  that  when  the  patient 
is  nearly  well  he  comes  to  a  standstill,  and 
the  final  stage,  the  finishing  ott'of  the  cure, 
is  very  difficult  of  attainment.  In  such 
cases  an  entire  change  of  scene  and  sur- 


Melancholia 


[    796    ] 


Melancholia 


roundinga  will  sometimes  complete  the 
recovery. 

Prog^nosis. — In  the  majority  of  cases 
of  melancholia  the  prognosis  is  favour- 
able. The  majority  of  cases  recover.  The 
character  of  the  prognosis  is  influenced 
by  the  following  considerations:  (i)  llie 
acutenefts  of  the  case.  Moderately  acute 
cases  are  the  most  favourable.  Exti'emely 
acute  cases,  in  which  the  patient  almost 
suddenly  falls  into  extreme  depression, 
rapidly  wastes,  early  becomes  wet  and 
dirty,  and  neglectful  of  decency,  are  less 
hopeful.  It  is  not  always  possible  to 
arrest  a  process  so  headlong  in  character. 
But  cases  of  moderate  acuteness,  in  which 
the  progress  of  the  case  has  been  rapid 
without  being  sudden,  are  favourable  ; 
chronic  cases,  in  which  there  is  merely  an 
exaggeration  of  a  state  of  depression  which 
is  usual,  are  much  less  hopeful.  (2)  The 
period  at  t'-liicli.  ireahnent  is  begun  is  an 
important  factor  in  the  formation  of  pro- 
gnosis. Every  day  that  is  lost  in  begin- 
ning vigorous  treatment  retards  recovery, 
and  renders  it  less  probable ;  and  pro- 
longed neglect  to  enforce  the  measures 
already  described,  prolonged  dependence 
on  moral  suasion,  is  disastrous.  (3)  Tlte 
degree  to  ivliich  the  bodily  health  and 
condition  are  affected.  The  more  com- 
pletely the  affections  of  bodily  health  and 
condition  correspond  with  the  mental 
depression,  the  more  hopeful  the  case. 
When  the  mental  depression  is  severe, 
but  the  patient  eats  pretty  well  and 
sleeps  pretty  well,  the  prognosis  is  less 
favourable.  In  youth,  the  prognosis  is 
almost  always  favourable,  and  the  more 
advanced  the  age  the  less  favourable  the 
prospect.  A  strong  hereditary  tendency 
is  not  as  a  rule  an  unfavourable  element 
in  a  case.  It  is  not  unfavourable  to  re- 
covery, although  it  increases  the  chances 
of  subsequent  recurrence  of  the  malady. 
Termination  in  death  does  not  as  a  rnle 
take  place  except  in  the  very  acute  cases  : 
and  on  the  other  hand  the  more  chronic 
the  case  the  more  is  it  likely  to  terminate 
in  dementia.  Charles  Mercikr. 

nXEI.AN'CHOXIA,  active  {fieXayxo- 
Xi'a;  ago,  I  do  or  perform).  A  condition 
of  mental  depression  occurring  most  fre- 
quently in  women  and  men  of  middle  age, 
characterised  by  a  restless  agitated  state  of 
misery,  with  occasional  outbn  rsts  of  aggres- 
siveness, the  result  of  some  prominent  de- 
lusion. —  Ttl.,  affective  (affectio,  feeling). 
The  form  of  melancholia  in  which  the 
affections  or  emotions  only  are  concerned. 
— M.  ag-itata  or  ag-itans  {agitaius,  from 
agito,  I  disturb,  excite,  &c.).  Those  in- 
stances of  acute  melancholia  in  which 
there  is  an  active  expression  of  the  in- 


ternal anguish  by  voice,  behaviour,  and 
gesture. — M.,  alcoholic  (alcohol).  The 
form  which  occasionally  results  after 
long-continued  alcoholic  abuse  from 
the  sudden  stoppage  of  the  stimulant 
when  combined  with  insufficient  food. — 
TH.  angrlica  {anglicus,  EngUsh).  A  syno- 
nym of  Suicidal  Insanity. — ivi.  a  potu 
(",  from  ;  potus,  a  drinking,  or  tippling.) 
Mental  depression  due  to  alcohol. — M. 
attonita  (attonita,  thiinderstruck).  A 
term  used  by  Bellini,  Sauvages,  &c.,  for 
melancholy  with  stupor. — M.  autocbirica 
(avTos,  self  ;  x^'P'  ^^^  hand).  A  synonym 
of  Melancholia,  Suicidal. —  IMt.  canina 
{caniiius,  pertaining  to  a  dog).  A  synonym 
of  Lycanthropia  {q.v.).  —  IVI.,  cataleptic 
(KaraXafil^dpo),  I  seize).  A  condition  of 
mental  depression  chiefly  occurring  among 
the  young,  in  which  the  mental  stupor  is 
associated  with  a  plastic  rigidity  of  the 
muscles. — IVI.,  cbronic  (xpoviKos,  pertain- 
ing to  time).  Melancholia  in  which  the 
acute  symptoms,  somewhat  modified,  have 
persisted  for  any  great  length  of  time. — 
IWC.  complacens  (eo'inplaceo,  I  am  well 
liked).  The  form  in  which  there  is 
self-complacency  and  satisfaction.  —  IVX., 
convulsive  (conrello,  I  tear).  Clouston's 
term  for  a  state  of  mental  depression  of 
an  extreme  type  accompanied  by  muscular 
agitation  and  excitement  and  usually  by 
great  obstinacy,  complicated  by  convul- 
sive seizures  of  an  epileptiform  character, 
which  occur  seldom,  are  prolonged  in 
character,  and  ai*e  succeeded  by  a  rise 
of  temperature  (Clouston). — M.,  deliri- 
ous {deliro,  I  rave).  A  psychosis  the 
analogue  of  acute  delirious  mania,  iu 
which  the  mental  symptoms  are  of  a 
melancholic  type,  coloured  at  times  with 
those  of  hysteria.  A  condition  of  typho- 
melancholia  as  opposed  to  typhomania  or 
acute  delirious  mania. — TIL.,  delusional 
{deludo,  I  deceive).  A  term  for  that 
variety  of  mental  depression  in  which 
delusions,  many  being  what  are  known  as 
fixed  delusions,  remain  thi'oughout  the 
disease  of  the  same  character  and  are 
from  the  beginning  the  most  prominent 
mental  symptom. — M.,  epileptiform  (epi- 
lepsy). A  synonym  of  Melanchoha,  Con- 
vulsive (q.v.). — M.  erotica  (epcoriKos,  per- 
taining to  love).  {See  Insanity,  Erotic.) 
— IVI.  errabunda  {erro,  I  roam  about). 
A  synonym  of  Kutubuth  {q.v).  —  M., 
excited  {e.i'cito).  A  condition  of  melan- 
cholia in  which  the  muscular  expression 
of  the  prevailing  emotion  is  strong  and 
uncontrollable  by  volition  (Clouston). — 
MC  flatuosa  {fl^atuosus,  from  flatus,  wind). 
A  synonym  of  Hypochondriasis.  —  M., 
general.  The  form  of  melancholia  iu 
which  the  depression  extends  to  all  the 


Melancholia 


[     797     ] 


Melancholia 


i  acuities  and  intellectual  mauit'estations. 
(Fr.mrhotrolic  (ji'ut'rch'). — V/t.,  homicidal 
[homicida,  a  nianslayer).  The  condition 
of  melancholia  usually  associated  with 
suicidal  tendencies,  in  which,  under  the 
influence  of  some  delusion,  a  patient 
harbours  homicidal  intentions. — IW.,  hy- 
pocbondrlacal  (hypochondriasis,  'y.r.). 
A  condition  of  mental  depression  in  which 
hypochondriacal  symptoms  colour  the 
melancholic  state. — ai.,  hysterical  (hys- 
teria, q.r.).  A  condition  of  mental  de- 
pression occurring  principally  in  young 
girls,  in  which  symptoms  of  a  hysterical 
type  predominate.  —  1*1.  malevolens 
(vialevolenn,  evilly  disposed).  The  form  in 
which  mischievous  acts  and  propensities 
prevail.  —  AX.  metamorphosis  ( /xern/xop- 
(f)(o(Tis,  a  transtormation).  A  form  of 
melancholia  in  which  the  patient  imagines 
he  has  been  tranformed  into  some  annnal, 
or  that  he  is  some  inanimate  object 
— e.g.,  a  building,  a  glass  utensil,  &c. — 
mx.  misanthropica  (fji.ia-di'dpwTros,  hating 
men).  The  form  of  mental  depression  in 
which  the  patient  hates  and  shuns  the 
society  of  his  fellowmen. — V/l.,  misanthro- 
pical {fj.i(Tnv6pcoTria,  hatred  of  mankind). 
Melancholia  with  aversion  to  human 
society,  a  desire  for  solitude,  and  a  repug- 
nance to  the  pleasures  of  life.  —  m. 
moralls  (mo7V(Zis,  pertaining  to  morals). 
Mental  depression  with  moral  perversion 
or  with  moral  delusions.  —  K/L.  nervea 
(nervus,  a  nerve).  A  synonym  of  Hypo- 
chondriasis.— ivi.  of  lactation.  [See  Puer- 
peral IxsAXiTY.) — M.  of  pregrnancy.  (See 
Puerperal  Insanity.)  —  la.  of  puberty 
(pubertas,  marriageable  age).  A  form  of 
mental  alienation  occurring  at  puberty  in 
which  the  patient  often  evinces  a  listless 
and  moody  apathy  and  perverseness  of  con- 
duct. {See  Developmental  Insanities.) 
—  IW.,  orgranic  (opyavop,  arrangement). 
The  mental  depression,  usually  of  a  simple 
type,  accompanying  gross  organic  brain 
disease,  such  as  tumours,  ramollissements, 
&c.  —  IVl.,  passive  (pntior.  I  suffer).  A 
form  of  melancholia  allied  to  melancholia 
cum  stupore,  in  which  the  delusions  and 
hallucinations  of  ordinary  melancholia  are 
combined  with  passivity  and  apparent 
listlessness  to  surrounding  sense  impres- 
sions. (.S'ee  Melancholia  cum  Stupore.) 
— T/t.  periodica  (TrepioStKoy,  coming  round 
at  intervals).  A  name  given  to  the 
melancholic  stage  of  folie  circulaire. — »I. 
persecutlonls  {persecutio,  a  following 
after).  The  form  of  mental  depression  in 
which  the  patient  has  the  delusion  that  he 
is  followed  or  persecuted  by  enemies  ;  it  is 
generally  associated  with  auditory  hallu- 
cinations and  suicidal  tendencies.  —  IVX. 
pleonectlca  (TrXeoi/e/cre'oj,  I   strive  to   gain 


more).  Insanity  with  desire  for  gain ; 
morbid  covetousuess.  —  Ml.,  puerperal. 
{See  Puerperal  Insanity.) — M.,  reason- 
ing-, (^ee  Lyi'EManie  Kaisonnantk.) — 
1*1.,  recurrent  (re,  back  again ;  ciirro, 
I  run).  The  form  of  mental  depres- 
sion in  which  there  is  an  irregular  al- 
ternation of  melancholic  symptoms  and 
recovery,  extending  over  a  great  many 
years,  and  resulting  in  most  cases  in  per- 
manent dementia. — 1*1.  relig-iosa  (re- 
lifjio,  piety).  The  form  of  melancholia  in 
which  the  patient  has  great  despondency 
as  to  his  future  salvation,  or  in  which  a 
morbid  religious  emotionalism  tinges  the 
mental  aberration. — ja.,  resistive.  Me- 
lancholia accompanied  by  obstinate  resist- 
ance to  any  form  of  interference,  generally 
purposeless  and  independent  of  delusion, 
but  also  frequently  the  direct  result  of 
some  present  delusion.  —  TfL.  saltans 
(saltii,  1  dance).  A  synonym  of  Chorea. — 
M.,  senile  (seibilis,  old).  The  mental  de- 
pression occurring  in  the  aged,  and  usually 
associated  with  arterial  degenerative 
change.  —  la.,  sexual  (sexualis,  from 
se.i-us,  the  male  or  female  gender).  The 
mental  affection  in  which  delusions  as  to 
the  sexual  organs  or  powers  predominate. 
(See  Masturbation,  and  Insanity.) — la., 
simple  (swvple.v).  The  form  of  mental 
depression  in  which  the  melancholia  is 
mild  and  uncomplicated,  and  where  the 
affective  depression  and  pain  are  more 
marked  than  the  intellectual  or  volitional 
aberrations  (Clouston).  —  la.  simplex 
(simplex,  simple).  Heinroth's  term  for 
melancholia  without  delusions  or  halluci- 
nations.— 1*1.  sine  delirio  (sine,  without; 
delirium,  raging  madness).  Etmiiller's 
term  for  an  abortive  form  of  melancholia 
in  which  there  is  only  mental  depression 
without  delusion. — 1*1.,  stuporous,  M. 
cum  stupore  {stiqior,  unconsciousness). 
A  state  of  mental  depression  accompanied 
by  a  morbid  condition  of  mental  lethargy 
or  torpor.  (Fr.  tntlancolie  avec  stupeur.) 
— M.,  suicidal  (sui,  himself :  caedere,  to 
kill).  The  form  of  mental  depression  in 
which  ideas  of,  or  a  longing  after,  self- 
destruction,  dependent  on  or  independent 
of  delusion,  are  present. — 1*1.,  sympathe- 
tic ((rvp.7radr]TiKns,  affected  by  like  feel- 
ings), A  mental  depression  primarily 
produced  by  an  affection  of  some  other 
organ  than  the  brain. — 1*I.  transitoria 
{traasitoriiis,  having  a  passage  through). 
A  condition  similar  to  mania  transitoria 
or  mania  ephemeral,  in  which  a  mental 
depression  takes  the  place  of  a  meutal 
exaltation. — T/L.  uterina  (uterinus,  per- 
taining to  the  womb).  A  synonym  of 
Nymphomania. — 1*1.  zoanthropia  (C(^ov, 
an  animal ;  uvOpconoi,  a  man).     A  species 


Melancholia  cum  Stupore     [    798    ]       Memory,  Disorders  of 


of  monomania  in  which  the  patient  be- 
lieves himself  transformed  into  an  animal. 
{See  Cynanthroim.v  ;  Lvcanthropta.) 
MX:X.i\.9rCHOXiZA    CUM    STUPORE. 

{See  Sti  roK,  :Mk\t\l.) 

MEIiAN'CHOI.XC     DIATHESIS. — A 

hereditary  brain  constitution,  consisting 
of  a  melancholic  temperament  with  a 
nei-vous  diathesis.  The  snbjects  are  per- 
sons wanting  in  emotional  balance  and 
resistive  power,  have  strong  unreasoning 
likes  and  dislikes,  are  morbidly  introspec- 
tive and  gloomily  imaginative,  and  very 
often  irritable  (Clouston). 
MEi.AnrcHoi.ic,    iviex.am-cho:li- 

CUS.  MEI.ASrCKOI.ODES,  MEI.AN- 
CHOX.VS.  {S'ee  Melancholia.)  A  la- 
bouring under  mental  depression  or  me- 
lancholy. One  of  a  gloomy,  morose  dis- 
position. Also  that  which  belongs  to  or 
relates  to  melancholy. 

MEX.AII-CHOI.Y  {fieXayxoXia).  {See 
]\1elanciiolia.)  a  state  of  mental  de- 
pri^ssion  in  which  the  subject  experiences 
a  feeling  of  mental  pain  with  listlessness, 
weariness,  and  a  sense  of  ill-being,  but 
which  differs  from  melancholia  in  that 
there  are  no  morbid  sense  perversions,  no 
irrationality  of  conduct,  no  morbid  loss  of 
self-control,  no  sudden  or  determined  im- 
pulse towards  suicide  or  homicide,  and 
where  surrounding  events  and  occurrences 
still  afford  a  certain  amount  of  interest, 
though  lessened  in  degree,  and  where  the 
power  of  application  to  ordinary  duties 
is  still  present. 

MEI.ANCOI.IE  AVEC  DEI.I3tE, 
MEXiAM-COI.IE  DEI.IRAM-TE  (Fr.). 
Melancholia  with  disturbance  of  the  in- 
tellectual faculties.  Delusional  insanity 
of  a  melancholic  character. 

M±I.AM'COI.IE  SAITS  DEI.ZRE. — 
Btmiiller  and  Guislain's  term  for  simple 
melancholia. 

MEMORIA  {memoria,  memory).  The 
cerebral  faculty  by  which  past  impressions 
are  recalled  to  the  mind. 

IMCEMORT.  (See  Philosophy  of 
Mixi),  p.  27.) 

MEMORY,  Disorders  of. — Disorders 
and  alterations  of  the  memory  are  so 
frequent,  so  various  and  so  conspicuous, 
that  it  is  not  surprising  to  find  them  men- 
tioned from  early  times.  Greek  physicians 
were  occupied  with  them  from  a  practical, 
other  authors,  among  whom  was  St. 
Augustine,  from  a  speculative  point  of 
view.  The  subject,  however,  has  only 
recently  been  studied  scientifically  and  in 
detail.  Several  conditions  were  neces- 
sary to  achieve  this,  among  which  the 
most  important  was  the  predominance  of 
the  physiological  method  in  psychology. 
As  long  as  the  memory  was  considered  a 


"  faculty,"  a  sort  of  independent  entity  of 
the  organism,  it  was  impossible  to  look 
for  or  even  to  conceive  the  immediate 
cause  of  its  derangement.  In  addition  to 
this,  the  study  of  the  cerebral  functions, 
although  still  imperfect,  has  opened  quite 
a  new  field  of  research.  Anatomy,  phy- 
siology and  pathology  have  led  us  to  con- 
sider the  brain  not  so  much  a  single  organ 
as  a  congeries  of  organs,  each  of  which 
has  its  function  and  is  comj^aratively 
independent  of  the  others.  Nothing  but 
this  doctrine,  known  under  the  name  of 
"  cerebral  localisation,"  renders  intelligible 
that  most  frequent  disorder,  partial  loss 
of  memory,  which  for  a  long  time  was  an 
inexplicable  mystery. 

With  so  rich  a  material,  the  investiga- 
tion of  which  is  but  of  recent  date,  we 
are  able  to  undertake  only  a  provisional 
classification,  founded  on  the  principal 
symptoms  and  intended  only  to  put  in 
some  order  the  pathological  phenomena 
of  the  memory.  From  this  standpoint 
the  classification  may  be  made  into  three 
fundamental  groups,  comprising  (i)  loss 
{amnesia),  (2)  exaltation  {]i,y2Jermnesia),a,ndi 
(3)  illusions  of  the  memory  {jjaramnesia). 

(i)  Amnesia  represents  by  far  the 
most  important  group  of  diseases  of  the 
memory.  A  subdivision  may  be  made 
into  classes,  according  as  amnesia  is  total 
or  partial. 

Total  amnesia  affects  the  whole  memory 
in  all  its  forms.  It  divides  our  mental 
life  into  two  or  more  pieces,  thus  leaving 
gaps  which  cannot  be  bridged  over. 
These  gaps  made  by  the  absence  of  the 
memory,  may  be  of  very  variable  duration 
and  may  extend  over  from  two  seconds  to 
several  weeks  and  months.  Such  tem- 
porary amnesia  appears  and  disappears, 
as  a  rule,  very  suddenly. 

The  shortest,  most  distinct  and  most 
common  cases  of  this  form  are  met  with 
in  epileptic  vertigo.  The  suicidal  and 
homicidal  attempts,  robbery,  unreasonable 
or  ridiculous  actions,  accomplished  during 
this  period,  which  Hughlings  Jackson 
styles  "  mental  automatism  "'  are  so  well 
known  and  so  numerous,  that  it  suffices 
to  recall  them  here.  It  is  probable  that 
in  certain  short  cases  of  epileptic  vertigo 
there  is  momentary  loss  of  consciousness, 
so  that  in  order  to  be  quite  exact,  we 
ought  to  say,  that  there  is  loss  of  con- 
sciousness  and  not  loss  of  memory,  but  in 
cases  of  longer  duration,  in  which  the  pa- 
tient conceives  and  performs  actions,  which 
are  complicated  and  nevertheless  well 
adapted  to  their  purpose,  it  is  difficult  to 
assume  loss  of  consciousness  ;  some  of 
the  patients  even  say  "  that  they  seem 
to  awake  out  of  a  dream,"  so  that  it  is 


Memory,  Disorders  of 


799    ]        Memory,  Disorders  of 


really  the  impression  upon  the  memory 
which  fails. 

Tomporary  amuesia  is  also  frequent  in 
cases  of  cerebral  excitement,  and  then 
represents  a  rclro-nrfire  character,  that  is 
to  say,  the  patient,  when  recovering  from 
unconsciousness,  has  lost  not  only  the  re- 
collection of  the  accident  he  met  with 
(fall  from  a  horse  or  a  carriage,  blow  on 
the  head,  &c.),  but  also  the  recollection  of 
a  more  or  less  long  period  of  his  life 
before  the  accident.  Dr.  Frank  Hamilton 
has  reported  twenty-six  cases  of  this  kind, 
which  he  communicated  to  the  Medico- 
legal Society  of  New  York  (1875)  ^^^ 
upon  the  forensic  importance  of  which  he 
lays  stress.  According  to  his  opinion 
amnesia  of  events  Jiefore  the  cerebral 
shock  may  extend  over  a  period  varying 
from  five  minutes  or  more  to  two  or 
three  seconds.  It  seems,  therefore,  that 
in  order  that  a  recollection  maj'^  organise 
and  fix  itself,  a  certain  time  is  necessary, 
which  in  consequence  of  the  cerebral  ex- 
citement does  not  suffice. 

The  forms  of  amnesia  which  we  intend 
to  mention,  represent  suppression  of  only 
a  short  period  in  the  mental  life  of  the 
patient ;  there  are  also  many  cases  of  long 
duration,  as,  e.g.,  that  of  a  woman  who  in 
consequence  of  her  delivery  forgot  the 
period  of  her  life  between  her  marriage 
and  the  birth  of  the  child,  and  never  re- 
covered the  recollection  of  it.  She  did 
not  believe  she  v;as  married  and  the  mother 
of  a  child  until  those  around  her  had 
borne  witness  of  the  fact.  She  remem- 
bered accurately  the  rest  of  her  life 
{Letfre  de  Villiers  a  G.  Curier).  More 
recently  Sharpey  has  published  in  Brain 
(October  1879)  curious  observations  of 
total  amnesia,  which  necessitated  complete 
re-education  of  the  patient,  which  was 
very  soon  eft'ected. 

Lastly,  we  have  in  the  group  of  total 
amnesiato  mention  theaZfej-jw/imiy  memory, 
which  is  met  with  in  the  changes  of  per- 
sonality (cases  of  Macnish,  Azam,  &c.). 
This  pathological  condition  may  be  arti- 
fically  produced  in  individuals  who  have 
often  been  hypnotised,  in  which  case  there 
are  two  memories,  one  comprising  the 
facts  of  normal  life,  the  facts  of  hypnotic 
life  being  excluded  ;  the  second  comprising 
the  facts  of  the  whole  life,  normal  as  well 
as  hypnotic.  The  individual  thus  passes 
through  two  conditions  :  in  the  former  he 
possesses  a  partial  memory  only,  composed 
of  all  the  fragments  of  his  normal  life, 
which  he  links  together  ;  in  the  latter  he 
retains  the  memory  of  his  whole  life. 

As  an  hypothesis  about  the  causes  of  this 
alternating  memory,  we  should  say,  that 
there  are  two  different  physiological  con- 


ditions, which,  by  their  alternation,  produce 
two  cenjssthesia^  which  on  their  part 
produce  two  different  forms  of  association 
of  ideas,  and  consequently  two  memories. 

Portidl  amnesia  is  represented  by  the 
most  frequent  and  best  known  forms  of 
the  pathology  of  memory.  The  isolated 
loss  of  one  distinctly  limited  group  of 
recollections  appears  at  first  sight  bizarre 
and  inexplicable,  but  if  we  consider  the 
exact  meaning  of  the  word  "  memory," 
partial  amnesia,  far  from  being  surprising, 
seems  but  the  natural  and  logical  conse- 
quence of  a  morbid  induenoe.  The  word 
"  memory ''  is  actually  a  general  term, 
meaning  a  property  common  to  all  feeling 
and  thinking  beings,  but  this  general 
term  is  reducible  to  particular,  concrete 
cases ;  in  one  word,  the  memory  is  broken 
up  into  memories,  memory  of  sight,  hear- 
ing, muscular  sensations,  taste,  smell, 
&c.),  and  therefore  it  is  natural  that  there 
should  be  partial  amnesia. 

The  study  of  aphasia,  pursued  with  such 
ardour  and  success  for  the  last  twenty 
years,  affords  us  an  excellent  example  of 
partial  amnesia.  Taking  the  word  apha- 
sia as  a  generic  term  to  denote  disorders 
of  the  faculfas  signatri,c,  it  is  necessary 
to  distinguish  different  species  :  word- 
blindness,  word-deafness,  aphemia  (verbal 
aphasia)  and  agraphy.  These  morbid 
conditions  are  so  well  known  that  it  will 
be  sufficient  to  recall  their  general  features 
and  to  show  that  they  depend  on  partial 
amnesia. 

Word-blindness  is  the  loss  of  the  memory 
of  the  graphic  images  of  words.  The 
patient  is  able  to  see  and  distinguish 
figures,  colours  and  objects,  but  letters 
and  syllables  are  incomprehensible  to  him, 
and  he  is  reduced  to  the  condition  of  a 
man  unable  to  read ;  he  has  lost  one 
group  of  recollections.  Moreover,  this 
disorder  has  again  varieties,  thus  it  may 
be  confined  to  the  loss  of  memory  of  only 
musical  signs  (notes,  fiats,  sharps,  &c.). 

Word-deafness  is  amnesia  of  auditory 
images.  The  patient  is  not  deaf :  he  is 
able  to  hear  noises,  the  striking  of  clocks, 
or  the  ticking  of  a  watch,  but  words  sound 
to  his  ear  as  a  noise  without  meaning. 
He  resembles  a  man  who  has  gone  into  a 
country  where  speech  is  not  known. 

Aphemioj  (the  most  frequent  case),  that 

is  to  say  ordinary  aphasia  (Broca's  type), 

consists  in  the  loss  of  the  motor  memory 

of  articulation.     There  is  neither  paralysis 

of  the  tongue  nor  of  the  lips,  nor  of  the 

organs  of  articulation  in  general,  but  the 

I  patient  does  not  know  how  to  articulate, 

I  and  is  reduced  to  the  condition  in  which 

.  we  all  were  before  we  were  able  to  speak ; 

,  the  motor   memory  of  speech  has    been 


Memory,  Disorders  of 


800    ]        Memory,  Disorders  of 


lost  or  severely  injured.  This  condition 
comi^rises  a  larger  number  of  varieties 
than  the  others,  from  the  loss  of  all  words 
to  the  loss  of  a  small  number  only. 

Agriiplnj  has  been  ingeniously  defined 
as  ■*  aphasia  of  the  hand  "  (Charcot)  ;  it 
consists  in  the  loss  of  motor  graphic  re- 
presentation. Many  agraphic  patients 
move  their  hands  and  arms  easily,  and 
hold  the  pen  or  pencil  correctly,  but  it  is 
impossible  for  them  to  recall  any  co-ordi- 
nate movements,  which  allow  of  writing 
letters  and  words.  These  patients  also 
resemble  those  who  have  never  learned 
wi-iting.  There  are  numerous  varieties  of 
this  form  of  disorder  ;  some  patients  are 
able  to  draw,  to  copy,  &c. 

Ifwekeepin  mind  that  each  of  these  forms 
corresponds  to  a  definite  cerebral  lesion 
(the  third  left  frontal  convolution  in  aphe- 
mia;  the  inferior  parietal  lobule  in  word- 
blindness,  the  first  temporal  convolution 
in  word-deafness,  and  probably  the  lower 
part  of  the  second  frontal  in  agraphy)  we 
come  to  the  conclusion,  that  the  images 
— our  recollections — are  localised  in  cei*- 
tain  parts  of  the  cerebrum,  and  that  par- 
tial amnesia  depends  on  organic  causes. 

It  remains  to  mention  amnesia  of  pro- 
gress ire /orm,  which  consists  in  a  slow  but 
continuous  dissolution  leading  to  complete 
abolition  of  the  memory,  as  in  paralytic 
and  senile  dementia.  The  dissolution  of 
memory  seems  to  follow  a  lair,  not  in  the 
rigorous  sense  of  the  word.  We  can  only 
say  what  takes  place  in  the  majority  of 
cases.  The  progressive  destruction  of  the 
memory  descends  from  the  unstable  to  the 
stable  recollections.  Recent  imj^ressions 
not  sufficiently  fixed,  and  rarely  repeated, 
represent  the  weakest  degree  of  recollec- 
tion and  disajjpear  first  of  all ;  old  impres- 
sions, well  fixed — automatic  habits — in 
short  all  impressions  which  represent  the 
stable  form  of  recollections,  disappear 
last.  In  the  same  way  the  recollection  of 
proper  names  (individual  termsj  disap- 
pears before  that  of  the  common  nouns  and 
of  the  adjectives  (general  terms).  This  is 
however  nothing  but  a  particular  instance 
of  the  biological  law,  that  the  structures 
formed  last  are  the  first  to  disappear. 

(2)  Hypermnesia,  or  exaltation  of  the 
memory,  about  which  we  have  little  to 
say.  General  exaltation  of  the  memory 
is  difficult  to  determine,  because  the 
degree  of  exaltation  is  quite  a  relative 
matter ;  we  should  have  to  compare  the 
memory  of  one  and  the  same  individual 
with  itself;  it  seems  to  depend  exclusively 
on  physiological  causes,  especially  on  the 
rapidity  of  the  circulation.  Hypermne- 
sia may  also  be  divided  into  yeneral  and 
2Jartial. 


Gciwral  over-activity  of  the  memoiy  is 
produced  in  many  individuals  in  danger 
of  being  drowned,  who  after  having  been 
saved  from  an  imminent  death,  say  that 
"  at  the  moment  when  the  asphyxia  com- 
menced, they  seemed  to  see  in  one  instant 
the  whole  of  their  life  with  even  the 
smallest  incidents  spread  out  before  them." 
It  may  also  be  due  to  the  ingestion  of 
toxic  substances  (haschisch  and  opium) : 
Ue  Quincey,  Moreau  (of  Tours),  and 
many  others  have  given  detailed  descrip- 
tions of  this  general  hypermnesia. 

Partial  hypermnesia  is  by  its  nature 
strictly  limited  ;  the  most  frequent  cases, 
and  the  easiest  to  prove,  consist  in  the 
recollection  of  languages,  long  completely 
forgotten,  which  returns  in  fever,  in  chlo- 
roform-narcosis, &c.  Coleridge,  Aber- 
crombie,  Hamilton,  and  Carpenter,  have 
reported  a  great  number  of  cases.  Still 
more  curious  is  the  regressive  recollection 
of  several  languages,  or  the  recollection 
of  the  native  language  long  forgotten,  in 
the  hour  of  death.  Dr.  Rush  observed  that 
an  Italian,  who  had  lived  for  a  long  time 
in  America,  and  been  attacked  by  yellow 
fever,  spoke  English  at  the  commencement 
of  his  malady,  French  in  the  middle,  and 
Italian  the  day  of  his  death.  A  great 
number  of  similar  cases  have  been  reported 
by  careful  observers ;  the  last  sentences 
spoken  in  the  hour  of  death  were  in  the 
native  language,  which  the  patients  had 
neglected  for  a  great  many  years. 

(3)  Paramnesia,  the  term  applied  to 
certain  illusions  of  the  memory,  which 
consist  in  the  fact,  that  an  individual 
believes  that  he  has  before  experienced 
circumstances  which  are  actually  new  to 
him.  This  illusion  may  be  produced 
while  a  person  is  awake,  but  more  fre- 
quently in  dreams.  Wigan,in  his  "Duality 
of  the  Mind,"'  seems  to  have  been  the  first 
who  reported  a  case.  Being  present  at 
the  funeral  service  of  a  princess  at  Wind- 
sor, he  all  at  once  had  the  feeling  as  if  he 
had  been  present  at  a  similar  occasion 
before.  Sander  (Archiv  f.  Psychiatrie, 
1883,  iv.)  and  A.  Pick  (ibid.  1876,  vi.)  have 
since  published  similar  observations. 
This  phenomenon,  however,  has  been 
studied  more  recently,  and  more  in  detail 
by  Kraepelin  (ibid.  xvii.  and  xviii.),  who 
has  grouped  these  false  recollections  in 
three  classes  : — 

(ft)  Simple  paramnesia,  a  simple  image 
which  appears  as  a  recollection.  Thus 
Kraepelin,  who  had  never  smoked,  dreamed 
that  he  was  having  his  fourth  or  fifth 
cigar.  These  illusions  are  very  frequent 
in  general  paralytics,  who  fatigue  those 
around  them  with  accounts  of  voyages  or 
adventures,  which  are  not  true. 


Meningitophobia 


[     Soi 


Menstruation  and  Insanity 


(b)  Paramnesia  by  identification  ;  a  new 
experience  appears  as  the  photography  of 
a  former  one.  Some  lunatics  brought  for 
the  first  time  into  an  asylum  have  the 
feeling  as  if  they  had  been  there  before 
and  had  seen  the  same  persons,  itc. 

((•)  Associated  or  suggested  paramnesia: 
an  actual  impression  suggests  an  illusion 
of  the  memory — a  pseudo-recollection  of 
something  similar  in  the  past.  Among 
others  Kraepelin  cites  the  case  of  a  young 
man,  with  whom  everything  that  he 
imagines  seems  to  have  occurred  in  the 
past. 

Several  theories  have  been  proposed  for 
the  explanation  of  these  illusions,  but  none 
have  succeeded  in  accounting  for  them  in  a 
satisfactory  manner.  Tu.  Rihot. 

[lit'/t'niia-f. — Sir  Hiiuy  Holland,  Mental  I'hysio- 
loiiy,  i8s2.  Heriug-,  Uobev  dus  (iedfichtiiiss  uls 
aljoeuieirie  Function  der  ( ^ganisirtc-n  Materic, 
1876.  ( 'iU-peiiter,  >Iont:il  Physiology.  Wundt, 
(irundziig:e  dcr  I'liilosoidiischen  Psychologic.  Ki- 
l)ot,  Lcs  !A[;iladies  de  la  Memoirc,  1881.  Sully, 
(lutlincs  of  Psychology,  1884.  Dr.  Savage,  Case 
of  Acute  Loss  of  Memoiy,  Journ.  Blent.  Sci.  April 
1883.  Dr.  Creighton,  Unconscious  Jleniory  in  Dis- 
ease, 1886.  Forel,  Das  Gedfichtniss  und  seine  abnor- 
niitiiten,  1885.  Fouillde,  La  Survivanco  ot  la  Se- 
lection des  Idees  dans  la  M^nioire,  Kev.  des  Deux 
Jlondes,  1885.  A.  Pick,  Loss  and  Recovery  of  Mem- 
ory, Archiv  f.  Psychiatric.  Bd.  xvii.  lleft  i.  Krae- 
jK^lin,  Ueber  Erinuernngsfalsehungen,  Archiv  f. 
Psychiatrie.  1887,  Bd.  xviii.  199,  395.  H.  Verneuil, 
Memory  from  the  Physiological,  Psychological, 
and  Anatomical  Point  of  Vie\v,  1888.  Burnham, 
Memory  Historically  and  Experimentally  Consid- 
ered, Amer.  Journ.  1888-9,  'i-  43i"4640 

MENznrczTOPHOBIA  (meni)igitis ; 
(fio^eo),  I  fear).  Symptoms  of  cerebro- 
spinal meningitis,  produced  from  fear  of 
the  disease.     {See  Hysteria.) 

MCENOPiiUSS.       (See  ClIMACTEKIC  IN- 
SANITY.) 
AXESrSTRViiTZOir  and  ZM'SAN'ITY. 

— Esquirol  has  said  that  the  derange- 
ments of  menstruation  form  one-sixth  of 
the  physical  causes  of  insanity,  and  Morel 
exactly  agrees  with  him. 

The  following  general  conclusions  have 
been  arrived  at  by  the  writer  after  careful 
inquiry  into  the  condition  of  the  men- 
strual function  in  500  lunatics. 

(i)  That  in  idiocy  and  cretinism  puberty 
is  usually  delayed  or  absent. 

(2)  That  in  epilejitic  insanity  the  tits 
are  generally  increased  in  number,  and 
that  the  patients  frequently  become  ex- 
cited at  the  catamenial  period. 

(3)  That  in  mania  exacerbations  of  ex- 
citement usually  occur  at  the  menstrual 
2>eriod,  and  that  a  state  of  intense  excite- 
ment is  almost  continuous  in  patients 
suffering  from  menorrhagia. 

(4)  That  in  melancholia  a  large  propor- 
tion of  patients  suffer  from  amenorrhoea. 

(5)  That    in    dementia    the    patients 


usually  menstruate  in  a  normal,  healthy 
manner. 

(6)  That  in  general  paralysis  the  change 
of  life  frequently  occurs  early. 

(7)  That,  very  rarely,  the  catamenia 
reappear  in  aged  insane  women  after  a 
prolonged  cessation. 

Amongst  thirteen  idiots  and  imbeciles 
menstruation  was  delayed  beyond  the 
normal  time  in  half  the  number  of  cases. 
''  In  extreme  degrees  of  cretinism  the  re- 
productive powers  ai'e  never  develo))ed  at 
all ;  and  in  less  degrees  menstruation 
appears  late  and  continues  scanty  and 
irregular  through  life ;  whilst  even  in 
cases  of  the  slightest  description  the 
average  date  of  the  first  menstruation  is 
as  late  as  the  eighteenth  year."  * 

Amongst  fourteen  idiots,  imbeciles,  and 
cretins,  seven,  aged  respectively  14,  16, 
16,  18,  19,  22.  and  22,  had  not  begun  to 
menstruate. 

In  mania,  it  is  agreed  by  Esquirol, 
Greissinger,  and  Morel  that  increased  ex- 
citement is  observable  at  the  catamenial 
period.  On  the  other  hand,  we  occasion- 
ally find  instances  in  which  mania  is  asso- 
ciated with  more  or  less  suppression  of 
the  menses.  The  mischief  in  these  cases 
may  be  due  either  to  congestion  of  the 
brain  in  consequence  of  the  blood  usually 
discharged  by  the  normal  channel  being 
retained,  or  the  amenorrhoea  may  be  due 
to  the  general  condition  of  anaemia  which 
often  accompanies  an  attack  of  asthenic 
insanity. 

It  cannot  fairly  be  stated  that  in  cases 
of  recovery  from  mania  the  return  of  the 
catamenia  always  precedes  the  cure  of 
insanity  in  cases  where  the  discharge  has 
been  suppressed.  Frequently  the  order  is 
reversed,  the  patient  becomes  sane  and  is 
discharged  from  the  asylum,  but  the 
monthly  Hux  does  not  occur  regularly  for 
some  weeks  or  months  afterwards.  A  re- 
appearance, however,  of  the-  catamenia 
cannot  but  be  regarded  as  a  favourable 
sign  during  an  attack  of  insanity,  and  in 
many  cases  is  followed  by  recovery.  In 
puerperal  insanity  also  the  outlook  be- 
comes brighter  on  the  return  of  the  men- 
strual flux. 

In  insanity  with  menorrhagia,  erotic 
actions  and  obscene  language  are  frequent 
accompaniments. 

Out  of  one  hundred  and  sixty-two  cases 
of  mania,  no  less  than  ninety-nine,  or 
about  two-thirds  of  the  total  number  had 
attacks  of  excitement  which  could  be  dis- 
tinctly referred  to  the  catamenial  period. 

Of  these  ninety-nine,  in  eleven  instances 
the  maniacal  excitement  was  observed  to 

*  IJeport  on  "  Cretinism,"  presented  to  the  Sar- 
dinian Government,  1848. 


Menstruation  and  Insanity 


802 


Menstruation  and  Insanity 


occur  at  periods  varying  from  one  day  to 
a  week  before  the  accession  of  the  cata- 
menia.  In  the  remaining  eighty-eight, 
the  mania  appeared  to  occur,  and  to  be  at 
its  worst,  during  the  period  of  the  cata- 
menial  discharge. 

An  increase  in  the  number  of  fits  and 
maniacal  excitement  occurred  in  many 
epileptics  at  the  monthly  periods. 

Eighty-nine  cases  were  made  the  subject 
of  inquiry.  The  mental  condition  was  in 
most  cases  that  of  dementia  with  excite- 
ment, but  in  a  few  instances  dementia  and 
melancholia  were  represented.  In  twenty- 
seven  cases  out  of  these  eighty-nine  the 
epileptic  fits  were  either  more  numerous 
or  occurred  only  at  that  time  ;  in  eleven 
cases  maniacal  excitement  alone  occurred  ; 
and  in  twenty-eight  cases  there  was  an 
exacerbation  both  of  the  epileptic  seiz- 
ures and  of  the  maniacal  condition  at 
the  menstrual  periods.  Four  epileptics 
had  amenorrhcBa  ;  and  of  these  four,  three 
had  ceased  to  menstruate  from  old  age. 
This  last  fact  is  remarkable  as  showing 
the  effect  of  epilepsy  in  shortening  life, 
since  only  three  in  eighty-nine  epileptics 
had  reached  the  menopause. 

In  melancholia  "  the  uterine  functions 
are  more  or  less  disordered,  and  are  sus- 
pended in  the  large  majority  of  cases."  * 
In  such  patients  the  general  condition  of 
anaemia  may  produce  amenorrha^a,  and 
hence  asthenic  melancholia,  but  amenor- 
rhoea  and  melancholia  are  also  sometimes 
the  result  of  a  plethoric  condition  of  the 
system,  "  Many  patients,  in  consequence 
of  plethora  uteri,  imagine  themselves 
pi'egnant,  and  lament  the  disgrace  which 
they  thereby  incur,  but  this  delusion 
vanishes  with  the  return  of  the  period."  t 

The  recurrence  of  menstruation  in  me- 
lancholia, if  coincident  with  an  improve- 
ment in  the  mental  symptoms,  justifies 
our  giving  a  favourable  prognosis. 

In  dementia,  if  the  bodily  health  im- 
proves or  remains  good  and  there  is  no 
amelioration  of  the  mental  condition,  the 
prognosis  as  to  the  recovery  of  mental 
health  is  most  unfavourable,  but  such 
patients  live  to  a  great  age.  The  cata- 
menial  function,  as  well  as  those  of  other 
organs,  is  discharged  with  great  regu- 
larity. 

Amongst  forty-two  cases  of  dementia, 
exclusive  of  epileptics,  no  less  than  thirty- 
two  were  regular  in  every  respect,  and 
eight  had  amenorrhoea. 

Sixteen  cases  of  delusional  insanity 
were  investigated.     Thirteen  were  regular, 

*  Bucknill  and  Tuke's  "  l'sj"ehological  Medi- 
cine." i>ee  also  Falret's  work,  p.  300,  and  Hlorel, 
p.  194, 

t  Van  der  Kolk,  on  "  Jlental  Diseases,"  p,  144. 


one  had  menorrhagia,  and  two  amenor- 
rhoea. This  form  of  insanity  is  compatible 
with  healthy  function  in  most  of  theorgans 
of  the  body. 

In  two  cases  of  moral  insanity  both 
were  regular. 

One  case  of  monomania  was  regular. 

Of  four  convalescents,  three  were  regu- 
lar, one  had  amenorrhoea. 

Five  cases  had  been  in  the  asylum  less 
than  a  month.  Condition  of  function  un- 
known. 

Suppression  of  the  catamenia  in  general 
paralysis  at  an  early  age  was  found  in  a 
larsre  proportion  of  instances. 

We  venture  to  offer  two  suggestions  in 
explanation  of  this  abnormality. 

In  the  first  place,  one  of  the  theories  of 
the  pathology  of  general  paralysis  assumes 
that  this  disease  is  due  to  diminution  of 
the  calibre  of  the  vessels  of  the  brain.  If 
this  diminution  exists  in  the  vessels  of 
that  organ,  why  should  it  not  also  be  pre- 
sent in  the  vessels  of  the  uterus  ? 

Hence  a  smaller  quantity  of  blood 
would  proceed  to  the  ovaries,  and  these 
bodies  being  already  j^redisposed  to  a 
sluggish  performance  of  their  function  by 
the  general  state  of  depression  of  the 
whole  system,  amenorrhoea  would  natur- 
ally be  the  consequence. 

In  the  second  place,  it  has  been  found 
by  the  writer  and  others  that  in  general 
paralysis  of  the  insane  there  is  a  large 
increase  in  the  white  corpuscles  of  the 
blood  at  the  expense  of  the  red  globules, 
which  iindoubtedly  shows  that  a  condition 
of  ana3mia  exists.  Amongst  the  sane 
ana3mia  is  frequently  the  cause  of  amen- 
orrhoea, and  there  is  no  reason  why  the 
same  cause  should  not  operate  just  as 
forcibly  in  constitutions  already  lowered 
and  depressed  by  a  disease  which  is 
almost  universally  acknowledged  to  be 
slowly  but  surely  fatal. 

Thirteen  cases  of  general  paralysis  were 
inquired  into.  Of  these  thirteen,  three, 
aged  respectively,  46,  53,  and  55,  were 
considered  too  old  to  menstruate. 

Excluding  these  three,  ten  remain,  of 
whom  four  only  menstruated  regularly, 
being  aged  respectively,  31,  29,  34,  and  32. 

The  remaining  six,  or  three-fifths  of 
the  number  who  had  not  arrived  at  the 
change  of  life,  never  menstruated.  Their 
ages,  resjjectively,  were,  34,  40,  30,  ^^t  4°' 
and  35. 

Three  of  these  six  cases  were  aphasic. 

Amongst  158  old  women*  whose  cases 
wei'e  inquired  into,  four  were  found  in 
whom  the  catamenia  had  reappeared  late 

*  llcnstruatiou  returning  in  old  women  is  not 
tnie  meustrnation.  The  ovaries  and  uterus  are  in 
senile  atrophy.     Haemorrhage  simulating-  menstraa- 


Menstruation  and  Insanity    [    803    ] 


Mental  Epidemics 


in  life.  Two  of  these  were  more  than  60 
years  old,  and  two  were  over  70. 

A  cui'ious  case  was  also  under  the  care 
of  the  writer  in  which  an  insane  patient, 
who  had  long  passed  the  change  of  life, 
was  under  the  delusion  that  she  was  preg- 
aant.  Her  efforts  to  expel  the  supposed 
foetus  had  the  effect  of  bringing  on  the 
catamenia,  which  continued  for  several 
months,  and  then  ceased  suddenly. 

The  above  remarks  apply  only  to 
healthy  or  disordered  uterine  functions 
and  their  connection  with  the  various  forms 
of  insanity.  The  reader  is  referred  to  an 
able  and  exhaustive  work  (''La  Femmo 
pendant  la  Periode  meustruelle,"  Dr, 
Icard,  1S90)  for  a  record  of  cases  of  or- 
ganic disease  of  the  womb,  and  their 
effects  upon  the  intellectual  faculties  of 
the  female.  In  this  work  it  is  affirmed 
that  Rossignol  (1856)  has  stated  that  out 
of  1 236  prostitutes  980  wei'e  troubled  with 
some  uterine  affection,  which  in  many 
cases  produced  more  or  less  mental  aber- 
ration. 

The  idea  that  menstruation  is  a  dis- 
grace to  a  woman  has  long  since  dis- 
appeared with  the  advance  of  civilisation. 
We  no  longer  say  "  Mulier  sjjeciosa,  tem- 
plum  oedificatum  super  cloacam."  "We 
try  rather  to  alleviate  the  symptoms  of 
painful  but  healthy  function  by  modern 
therapeutical  appliances. 

The  importance  of  avoiding  all  emo- 
tional disturbance  at  the  menstrual  period 
has  been  insisted  on  by  the  authors  of  all 
ages. 

The  Levitical  law  prohibited  connection 
with  a  woman  at  this  crisis.  Ezekiel  con- 
sidered such  an  act  equivalent  to  adultery. 
A  council  of  Nice  ordered  that  Christian 
women  should  not  enter  a  church  during 
the  catamenial  period. 

The  Talmud  affirmed  that  a  child  con- 
ceived during  the  flux  was  subject  to  every 
vice  and  disease.  He  would  become  a 
drunkard,  insane,  epilejitic,  or  homicidal. 

The  Koran  declared  that  a  woman  was 
impure  eight  days  before  and  eight  days 
after  her  courses. 

Michelet  believes  that  out  of  28  days 
a  woman  is  suffering  from  the  effects  of 
the  monthly  period  for  not  less  than  20. 

Moreau  states  that  the  negroes  shut  up 
their  women  in  huts  during  the  time  of 
the  menstrual  discharge.* 

The  medico-legal  aspect  of  the  effects 
of  menstruation  upon  the  emotional  cen- 
tres cannot  be  over-estimated.  Krugel- 
stein  says :  "  Amongst  all  the  female 
suicides  it  has  been  my  lot  to  see,  the  act 

tiou  may  be  due  to  disease  uf  uterus  or  of  distant 
ort^ans. 

*  "  La  Femiiie,''  It-ard. 


was  committed  during  the  catamenial 
period."* 

Dr.  Icard  truly  says  :  "  The  menstrual 
function  can  by  symi)athy,  especially  in 
those  predisposed,  create  a  mental  con- 
dition varying  from  a  simple  psychalgia, 
that  is  to  say,  a  simple  moral  malaise,  a 
simple  troubling  of  the  soul,  to  actual  in- 
sanity, to  a  complete  loss  of  reason,  and 
modifying  the  acts  of  a  woman  from  simple 
weakness  to  absolute  irresponsibility. 
The  tribunal  cannot  appraise  with  any 
certainty  the  disposition  of  a  woman 
who  is  the  subject  of  menstrual  disturb- 
ance."t 

The  following  moi-bid  mental  pheno- 
mena have  been  observed  by  Icard  to 
occur  at  the  menstrual  periods  :  Klep- 
tomania, pyromania,  dipsomania,  homi- 
cidal mania,  suicidal  mania,  erotomania, 
nymphomania,  religious  dehisions,  acute 
mania,  deliriotis  insanity,  impulsive  in- 
sanity, morbid  jealousy,  lying,  calumny, 
illusions,  hallucinations,  melancholia;  of 
which  he  reports  cases  at  great  length  in 
his  admirable  work. 

In  the  writer's  experience,  kleptomania 
is  met  with  more  frequently  at  the  climac- 
teric, pyromania  being  associated  with 
puberty ;  dipsomania  is  also  chiefly  a 
disorder  of  the  change  of  life.  Eroto- 
mania is  found  at  all  ages,  morbid 
jealousy  at  the  menopause,  lying  in  young 
women,  calumny  in  moral  insanity  ;  and 
the  other  forms  of  mental  aberration  men- 
tioned by  Icard,  which  are  not  symptoms 
but  diseases,  are  met  with  at  all  ages. 

H.    SUTHERLAXD. 

llieffrence.H. — Sutherlaud,  H.,  The  C'huugc  of 
Life  and  lusaiiity,  West  Riding  Asyl.  Mud.  Re- 
ports, vol.  ill,  p.  299.  Sutherland,  H.,  Menstrual 
Irregularities  and  Insiiulty,  West  Ridin<;- Asyl.  Med. 
Reports,  vol.  ii.  p.  54.  3Icrson,  J.,  The  Climacteric 
Period  in  Relation  to  Insanity,  West  Riding  Asyl. 
Med.  Reports,  vol.  Yi.i).85.  Bucknill and Tnke,  Cata- 
menia in  Prognosis,  3r(l  edit.  pp.  148,  150.  Mayer, 
Die  Beziehungen  der  krankhaften  Zustfinde  in  deu 
Sexualorgauem  des  Weibes  zur  (ieistessturuugen. 
Marie,  Etudes  sur  les  Causes  de  laFolie  puer])erale, 
Ann.  Med.-psych.  1857,  t.  iii.  p.  577.  Bruant, 
De  la  Melancolie  survenant  ;i  la  Menopause.  Brou- 
ardel,  Etat  mental  des  Femmes  enceintes.  I'etit, 
Des  Rapports  de  la  Paralysie  geuerale  avec  certains 
Troubles  de  la  Menstruation.  Marce,  Traite  de  la 
Folie  des  Femmes  enceintes.  Brierre  de  Boismont, 
De  la  Folie  j)uerperale,  Aim.  Med.-psych.  1851,  p. 
587.  Ricard,  l']tude  sur  les  Troubles  de  la  Seusi- 
bilite  genesiijue  ix  I'Epoque  dela  Menopause.  Ber- 
thier,  Des  Nevroses  meustruelles.  Sdiroter,  Die 
Menstruation  in  ihren  Beziehungen  zur  den  Psy- 
choseii.     Reikel,  De  la  Folie  imerperale.] 

MEN^TAI.  ABERRa-TIOSr,  IMCEIT- 
TAIi  A.ImIENA.'XION  {mens,  alieno,  1 
alter  in  nature  from).  Synonyms  of  In- 
sanity. 

I»IENT.a.X.  EPZBEMZCS.  {8e('  EPI- 
DEMIC Insanity.) 

*  Op.  cit.  p.  179.  t  1*.  266. 

3  F 


Mental  Experts 


[    804    ] 


Metromania 


MEN-TAI.   EXPERTS.    (^SV  EXPERTS, 

Medical.) 

mENTAI.   PHYSIOI.OGV.— Mental 

physiology  is  one  division  of  the  great  de- 
partment of  physiology.  It  seeks  to  dis- 
cover the  bodily  organisation  with  which 
mental  operations  are  connected.  Seeing 
that  the  brain  is  admitted  to  be  the  organ 
of  mind,  it  endeavours  to  trace  their  cor- 
relation in  detail.  Unconscious  no  less 
than  conscious  mind  falls  within  its 
range.  The  student  of  mental  physiology 
makes  the  functions  of  the  nervous  sys- 
tem his  special  object  of  study,  employing 
for  this  end  all  the  means  within  his 
reach.  He  endeavours  to  discover  the 
laws  by  which  mental  operations  are 
governed,  and  to  classify  their  pheno- 
mena, but  he  is  not  concei'ned  with  specu- 
lative metaphysics  in  the  usual  sense  of 
the  term.  Mental  physiology  embraces 
the  modern  j^sychological  methods  of  re- 
search which  are  instituted  to  determine 
the  relation  between  the  action  of  external 
stimuli  on  the  sensory  end-organs,  and 
the  resulting  sensation  or  motion,  as  well 
as  the  reaction  time  of  mental  phenomena 
generally. 

Sir  Henry  Holland,  the  first  to  write  a 
work  entitled  "Mental  Physiology"  (1852), 
defined  it  as  "that  particular  part  of  human 
physiology  which  comprises  the  reciprocal 
actions  and  relations  of  mental  and  bodily 
phenomena  as  they  make  up  the  totality 
of  life."  His  book  comprised  chapters  on 
the  effects  of  mental  attention  on  bodily 
organs,  on  mental  consciousness  in  its 
relation  to  time  and  succession,  on  time  as 
an  element  of  the  mental  functions,  on 
sleeiD,  on  the  relations  of  dreaming,  &c., 
on  the  memory  as  affected  by  age  and  dis- 
ease, on  the  brain  as  a  double  organ,  on 
phrenology,  on  instincts  and  habits. 
Hypnotic  phenomena  and  doctrines  were 
also  included  in  his  survey. 

Dr,  Carpenter  adopted  the  same  title 
for  his  work  which  appeared  in  1874.  He 
included  in  his  range  of  subjects  the 
general  relations  between  mind  and  body, 
the  functions  of  the  nervous  system,  atten- 
tion, sensation,  pei'ception  and  instinct, 
ideation,  ideo-motor  action,  the  emotions, 
the  will,  habit,  memory,  common  sense, 
imagination,  unconscious  cerebration,  re- 
verie and  abstraction,  sleep,  dreaming,  and 
somnambulism  (si^ontaneous  and  induced), 
and  the  influence  of  mental  states  on  the 
organic  functions. 

Both  Sir  Henry  Holland  and  Dr.  Carpen- 
ter travelled  beyond  the  strict  boundary  of 
mental  physiology,  and  entered  ujoon  the 
consideration  of  mental  pithology,  because 
the  latter  throws  light  upon  the  former. 
Following  these  lines,  the  University  of 


London  introduced  in  1886  the  subject  of 
"  Mental  Physiology,  especially  in  its  re- 
lations to  Mental  Disorder." 

Professor  Ladd's  text-book  adopts  the 
expression  "  physiological  pyschology  "  as 
the  equivalent  of  mental  physiology,  and 
he  defines  it  as  "  the  science  of  the  pheno- 
mena of  human  consciousness  in  their  re- 
lations to  the  structure  and  the  functions 
of  a  nervous  system."  In  other  words, 
he  regards  the  mind  as  standing  in  pe- 
culiar relations  to  the  bodily  mechanism. 
Its  object  is  to  bring  mental  phenomena 
and  those  of  the  nervous  system  "  face  to 
face."  The  Editor. 

niEN-TAii  sciEircE.  {See  Philo- 
sophy OF  Mind,  p.  27.) 

MEN'TA.IiISil.TZON'  [mens,  the  mind). 
The  physiological  act  of  exercisingthe  func- 
tions of  the  brain  for  thought,  reasoning, 
perception,  judgment,  or  other  mental  acts. 

MENTE  CAPTI  {'mens,  the  mind ; 
ca/pio,  I  seize  or  lay  hold  of).  The  term 
applied  in  Roman  law  to  those  deficient 
in  intellect. 

3»CERAXsr.a:sTHESZA  (/xfptV,  a  part 
or  portion  :  dvaiadrjaia,  want  of  feeling). 
The  condition  of  partial  anaesthesia.  {See 
Hysteria.) 

MESMERism  (Mesmer,  Anthony,  the 
promulgator  of  the  doctrine  of  animal 
magnetism).  The  process  whereby  the 
mesmeric  sleep  or  trance  was  induced. 
This  condition  is  identical  with  what  is 
now  known  as  hypnotism,  induced  hyp- 
notism, induced  somnambulism,  the  hyp- 
notic state.  &c.     (See  HYPxoTisii.) 

MESIVIERO-PHREN'OIiOGT(mesmer- 
ism  :  c})pr]i'.  the  mind  ;  Xoyos,  a  discourse). 
The  name  formerly  given  to  that  condition 
of  a  mesmerised  person  in  which  when 
any  phrenological  organ,  so  called,  is 
touched,  its  functions  are  manifested. 
{See  Hypnotism  :  Suggestion.) 

nxETAliliOPKAGZil  {fiiraXXov,  a  min- 
eral ;  (paye'tv,  to  eat).  A  name  given  to 
a  kind  of  insanity  in  which  the  patient 
exhibits  a  desire  to  swallow  pieces  of 
metal.  (Fr.  meialJoiihagie ;  Ger.  Metall- 
schlucke)t.) 

IWETAPHVSXCAI.  MAxriA.  {See 
Doubt,     Insanity     of  :      Mania     Meta- 

PHYSICA.) 

METASTATIC  IWrSAWITY.  {See 
Insanity,  Metastatic  ;  jNIania  Metasta- 

TICA.) 

METHZIiEPSXA  {uedrj  ;  Xt^v/^jv,  a  seiz- 
ing) ;  or  ivxETHOlVXAiriA  {fie6t],  intoxica- 
tion: fxavia.  madness).  An  irresistible  de- 
sire for  intoxicating  substances  or  alco- 
holic stimulants.     {See  Dipsomania.) 

METHYliAli.     {See  Sedatives.) 

METROIVXAWXA  {fti'jTpa,  the  WOmb ; 
lj,avia,  madness).     A  synonym  of  Nyrapho- 


Microcephaly 


[    805 


Microcephaly- 


mania.     (Fr.  metromanie ;    Ger.  Mutter- 

XK'Utll.) 

»llCROCi:PHi\.Ii  Y. — Microcephaly 
means  abnoi-inal  smallness  of  the  head. 
What  makes  this  condition  intei-estiug  is 
that  the  diminished  size  is  principally  in 
the  brain.  We  should  call  any  head 
microcephalic  which  measures  less  than 
17  inches — 431  millimetres — in  circumfer- 
ence. 

As  a  general  rule,  the  heads  of  idiots 
are  somewhat  smaller  than  those  of  ordi- 
nary people.  But  this  observation  is  of 
little  use  in  dealing  with  individuals  ;  for, 
save  in  the  case  of  hydrocephalic  and  of 
microcephalic  idiots,  the  difference  in  the 
size  of  the  head  from  normal  people  is 
never  considerable,  and  it  is  not  uncommon 
to  meet  with  imbeciles  who,  without  any 
hydrocephalus,  have  heads  larger  than 
those  of  people  of  ordinary  intelligence. 

Charles  Vogt  wrote  a  book  ("  Memoire 
surlesMicrocephalesouHommes-Singes") 
to  show  that  these  diminutive  heads  indi- 
cated a  stage  of  development  of  the  original 
simian  ancestors  of  man.  This  thesis, 
though  supported  by  descriptions  of  a 
painstaking  collection  of  cases  with  com- 
parative studies  of  the  brains  of  a  few 
monkeys,  was  not  confirmed  by  more  care- 
ful inquiries.  There  ai'e  brains  of  human 
microcephales  which  weigh  even  less  than 
the  full-grown  brain  of  the  ourang  or 
chimpanzee  ;  but  when  one  leaves  cubic 
capacities  and  weights  to  examine  the 
anatomical  structure,  it  soon  appears  that 
the  brain  of  the  microcephale  is  human  in 
its  characteristics.  All  the  typical  fissures 
and  convolutions  are  there,  though  dimi- 
nutive in  size  and  simple  in  form.  It  is 
a  small  rudimentary  human  brain  which 
does  not  resemble  that  of  any  monkey 
that  exists,  or  indeed  could  have  existed. 
The  variations  in  the  convolutions  of  the 
microcephale  sometimes  indicatethe  period 
when  the  arrest  of  development  began. 
Though  microcephalic  brains  cannot  be 
reduced  to  one  type,  they  are  often  asym- 
metrical in  their  convolutions,  much  more 
so  than  those  of  the  highest  ape.  The 
corpus  callosum  is  often  shortened  in  pro- 
portion to  the  hemispheres,  and  the  occi- 
pital lobes  arrested  in  growth  so  that  they 
do  not  completely  cover  the  cerebellum. 
Gratiolet  has  observed  that  in  the  brain 
of  the  ape  the  temporo-sphenoidal  convo- 
lutions appear  first,  and  the  frontal  lobe 
last ;  whereas  in  man  the  frontal  convo- 
lutions appear  first  and  the  temporo- 
sphenoidal  last.  From  this  it  follows 
that  no  arrest  of  development  can  make 
the  human  brain  to  resemble  more  nearly 
that  of  the  ape  than  the  human  adult 
brain  does.     Evolutionists  also  sought  to 


find  in  other  parts  of  the  organism  of  the 
microcephale  vestiges  of  arrested  develop- 
ment of  the  simian  type,  but  here  they 
were  even  less  successful.  The  peculiari- 
ties which  they  noted,  such  as  elongation 
of  the  forearm,  or  the  body  being  covered 
with  shining  hairs,  were  inconstant  in 
their  occurrence.  There  were  also  other 
peculiarities  found  in  various  micro- 
cephales, such  as  want  of  the  testicles,  or 
the  non-appeai'ance  of  the  incisors,  which 
could  in  no  way  be  explained  by  the  theory 
of  atavism. 

On  the  other  hand,  Bischoff,  Aeby,  and 
Giacomini,  who,  in  the  most  painstaking 
manner,  examined  and  measured  every 
part  of  the  bodies  of  microcephales,  have 
declared  that  their  inquiries  afford  no 
ai'gumeuts  for  the  simian  origin  of  man, 
and  that  the  deficiency  in  microcephales 
is  generally  localised  in  the  cranium  and 
its  contents. 

Though  not  the  reappearance  of  an 
atavistic  type,  microcephaly  seems  to  be 
a  very  ancient  malformation.  Microce- 
phalic heads  are  portrayed  in  the  Egyptian 
monuments,  both  in  sculpture  and  paint- 
ing. One  such  figure  is  evidently  intended 
to  represent  a  lunatic  or  a  man  of  small 
intellect.  A  mummified  skull  has  been 
engraved  by  Dr.  Morton,  in  which  the 
head  is  abnormally  small  and  low  in  the 
forehead  with  prognathous  jaw.  Two 
microcephalic  statues  have  been  found  at 
Rome. 

In  microcephalic  brains  the  deficiency  is 
proportionally  most  marked  in  the  hemi- 
spheres, especially  in  the  upper  gyri.  The 
basal  ganglia  and  the  cerebellum  are  not 
diminished  in  the  same  proportion.  The 
forehead  generally  slants  rapidly ;  the 
head  is  cone-shaped  or  oxycephalic,  giving 
the  creature  a  bird-like  appearance.  The 
base  of  the  skull,  as  well  as  the  cerebrum, 
is  sometimes  asymmetrical  in  microce- 
phales. The  palate  is  gene-rally  flat, 
though  in  some  cases  it  is  arched  or 
vaulted.  The  face  is  large  in  proportion 
to  the  cranium.  Microcephales  are  gene- 
rally short  of  stature,  sometimes  mere 
dwarfs. 

The  causes  of  this  deficiency  are  obscure. 
Though  in  a  considerable  number  of  micro- 
cephalic skulls  the  sutures  have  been 
found  closed,  the  cases  in  which  the 
sutures  still  remain  open  are  so  numerous 
that  it  is  now  impossible  to  hold  that 
closure  of  the  sutures  can  be  anything 
more  than  an  occasional  cause  of  micro- 
cephaly. Possibly  the  closure  of  the 
sutures  is  simply  a  process  accompanying 
the  cessation  of  the  growth  of  the  brain. 
The  theory  of  Klebs  that  microcephaly  is 
owing  to   hour-glass   contraction   of  the 


Microcephaly 


[     806    ] 


Microcephaly 


utenis  on  the  foetal  head  does  not  seem  to 
have  received  confirmation  of  late.  There 
is,  however,  no  doubt  that  early  morbid 
processes,  such  as  inflammation  or  the 
pressui'e  of  fluid  within  the  cranium,  are 
sometimes  the  cause  of  the  premature 
arrest  of  the  growth  of  the  brain.  It  has 
been  recently  shown  that  microcephaly  is 
sometimes  accompanied  by  micromyelia. 
The  spinal  cord  shares  in  the  abnormally 
small  development  of  the  brain :  it  is 
shortened  and  smaller.  The  diminution 
in  size  has  been  found  to  be  most  marked 
in  the  pyramids,  the  columns  of  Groll,  the 
ganglia  of  the  anterior  horns,  and  to  a 
lesser  degree  in  the  direct  lateral  cerebellar 
tract.  As  this  deficiency  in  development 
is  unaccompanied  by  any  traces  of  local 
disease,  it  would  appear  that  the  diminu- 
tion of  bulk  in  the  cord  comes  in  corre- 
spondence with  the  diminished  brain. 

No  doubt  the  cerebral  tissues  are  some- 
timesmoreor  less  diseased.  Fletcher  Beach 
in  one  case  found  in  microscopic  sections 
from  the  frontal  lobe  that  few  of  the  nerve 
cells  had  processes,  and  these  were  small 
and  stunted.  Alexandra  Steinlecher 
found  the  nerve-cells  in  the  microcephalic 
brain  less  in  quantity.  The  same  scarcity 
of  large  cells  was  found  in  the  shortened 
spinal  cord.  Further  studies  of  these 
brains  are  much  to  be  desired. 

Though  this  is  a  rare  form  of  idiocy,  it 
has  been  noted  that  microcephales  have 
frequently  brothers  and  sisters  with  the 
same  deformity.  A  villager  in  Holland 
had  fourteen  children,  of  whom  four  were 
microcephalic ;  and  in  the  Becker  family 
there  were  four  microcephalic  children, 
one  of  whom  was  described  at  length  in 
the  monograph  of  Professor  Bischoff  on 
Helene  Becker.  Fig.  i  is  a  side  view  (left) 
of  her  brain. 

All  persons  with  heads  less  than  17 
inches  in  circumference  are  of  feeble  in- 
telligence. With  heads  of  12  inches  in 
circumference  and  less  the  mental  mani- 
festations are  very  faint.  The  smallest 
human  brain  which  we  ever  saw  was  shown 
to  us  by  Dr.  Fletcher  Beach.  It  belonged 
to  a  girl  of  twelve  years  of  age  who  died 
at  the  Clapton  Asylum.  It  weighed  only 
seven  ounces.  There  is  an  engraving  of 
this  brain  in  the  Transactions  of  the 
International  Congress,  vol.  iii.  p.  618, 
London,  1881.* 

This  child  never  could  stand  or  walk. 
She  had  to  be  fed  with  a  spoon,  she  never 
spoke  a  word  ;  and  her  highest  accom- 
plishment was  shaking  hands.  We  have 
many  other  brain  weights  on  record,  from 
300  grammes,  the  weight  of  a  new-born 
child's  brain,  up  to  610  grammes  with  a 
*  See  also  Iuiocy  (liy  Dr.  Beacb,  p.  651). 


circumference    of    i6|    inch  =  426    milli- 
metres. 

The  mental  power  and  energy  of  micro- 
cephales are  not  always  commensurate 
with  the  volume  or  weight  of  the  brain, 
some  have  more  intelligence  than  others 
who  have  larger  heads.  This  disparity  is 
often  owing  to  the  brain  tissues  in  the 
microcephales  being  more  or  less  diseased. 
Nevertheless,  dealing  with  larger  weights, 
the  rule  becomes  apparent  that  the  men- 
tal powers  mount  with  the  size  of  the 
brain. 

Fig.  I. 


P- 


The  central  fissure  (of  Eolando)  runs  between 

<l  and  f/i. 
The  unfinished  fissura  occipitalis  peri>eudicu- 

laris  externa. 
Tosterior  brant-li  of  Sylvian  fissure. 
.  The  parallel  fissure. 
The  superior  frontal  gyrus. 
The  inferior  frontal  gyrus. 
Anterior  central  gyrus. 
Posterior  central  gynis. 
Precuneus. 

Lobulus  supra  marginalis. 
(iyrus  angidaris. 
Undetermined. 
Cuueus. 

Gyrus  temporalis  superior. 
Gyrus  temporalis  medius. 


From  Dr.  Berkhan's  statistics*  it  ap- 
pears that  in  Germany  microcephales 
stand  to  other  idiots  as  one  to  a  hundred. 
We  are  sure  that  for  Scotland  this  pro- 
portion would  be  much  too  high. 

*  Dr.  Berkban,  of  Brunswick,  has  made  valuable 
contributions  to  the  study  of  idiocy  and  imljecility. 
Herr  Kielhorn,  of  the  same  place,  is  the  excellent 
master  of  an  "  AuxUiary  School"  for  the  border- 
land cases  which  we  have  visited.  We  have  de- 
scribed his  work,  and  suggested  the  establishment 
of  similar  institutions  in  England,  in  the  Journol 
of  McntuJ  Science,  Jan.  1888.  This  course  has  been 
also  urged  by  Dr.  Shuttleworth  (Journal  of  Mental 
Science,  April  1888).  3Iuch  has  been  done  since 
then, mainly  through  the  indefatigable  exertions  of 
Dr.  F.  ■SVaruer,  tt)  render  the  adoption  of  this 
scheme,  or  a  modification  of  it,  probable. — Ed. 


Microcephaly 


[    807    ] 


Microcephaly 


There  are  always  about  a  dozen  micro- 
cephales  iu  the  large  asylum  of  Darenth 
for  the  pauper  idiots  of  London.  Many 
of  them  are  wretched  little  creatures  who 
cannot  even  execute  any  voluntary  motions, 
save  perhaps  to  follow  with  their  eyes  the 
spoon  which  feeds  them.  On  the  other 
hand,  some  microcephales  are  active  and 
energetic.  The  impressions  of  the  senses 
are  lively,  but  they  have  little  power  of 
continuous  attention.  They  are  generally 
restless,  imitative,  and  inclined  to  Hy  into 
a  passion.  Few  of  them  can'  speak. 
Their  mental  capacities  difter  little  from 
idiots  of  other  types,  though  in  general 
they  have  more  use  of  their  limbs  and 
better  health.  Their  command  of  the 
muscles  is  perhaps  due  to  the  better  de- 
velopment of  the  cerebellum. 

Under  a  special  system  of  education, 
microcephales  improve  like  other  idiots, 
though  perhaps  not  so  much  as  might  be 
expected.  The  spontaneous  mental  ac- 
tivity, in  their  case,  is  more  vivacious 
than  the  power  of  receiving  knowledge 
through  systematic  lessons.  Some  writers 
have  stated  that  there  is  found  in  the 
mental  characteristics  of  microcephales  a 
strong  resemblance  to  those  of  monkeys. 
Microcephales  are  a  deal  stupider  than 
normal  human  beings,  and  so  are  monkeys; 
but  here  the  resemblance  ends.  The 
microcephale  has  less  energy  than  an 
ordinary  child,  hence  he  is  less  fond  of 
climbing,  he  has  human  affections  and 
human  sympathies ;  he  laughs  at  what 
amuses  him,  and  weeps  when  in  pain.  A 
microcephalic  boy,  a  pauper  boarder  from 
the  north,  whom  we  had  at  Larbert,  was 
a  cunning  and  calculating  thief.  He  was 
very  imitative  and  observing,  but  never 
uttered  a  word.  In  general  when  micro- 
cephales remain  mute,  we  believe  it  is 
owing  to  the  low  sum  of  their  mental 
faculties,  not  to  deficiency  in  any  parti- 
cular convolution  of  the  brain. 

In  the  lower  grades  of  microcephaly  the 
sexual  instinct  is  either  very  faint  or 
wanting.  In  the  higher  grades  the 
testicles  become  developed,  though  later 
than  with  normal  males,  and  the  female 
microcephales  menstruate  later  than  or- 
dinary women.  One  microcephale  aged 
twenty-five  years  conceived,  but  the  em- 
bryo was  born  dead.  This  is  the  only 
instance  on  record  of  the  reproductive 
function  coming  into  exercise  in  one  of 
these  creatures. 

As  generalisations  drawn  from  beings 
so  abnormal  are  a})t  to  be  misleading,  let 
us  consider  some  particular  cases  of 
microcephales  which  have  been  carefully 
studied.  The  two  Aztecs  who  have  been 
exhibited  for  many  years  in  America  and 


Europe  are  fair  examples  of  microcephales. 
They  have  been  often  examined  and  de- 
scribed. Originally  brought  from  Mexico, 
they  are  obviously  of  Indian  origin. 
They  have  curious  heads  of  black  crisp- 
looking  hair  which  stands  outlike  a  broom, 
starting  up  after  being  depressed.  Profes- 
sor Dalton  who  saw  them  when  they  were 
seven  and  five  years  01  age,  says  that  the 
boy  was  2  feet  9!  inches  high,  and  weighed 
a  little  over  twenty  pounds.  The  girl  was 
2  feet  ^l  inches  high,  and  weighed  seven- 
teen pounds.  Their  bodies  were  tolerably 
well  proportioned,  but  the  heads  were  ex- 
tremely small.  The  antero-posterior  dia- 
meter of  the  boy's  head  was  only  4I  inches 
=  1 1 4  millimetres ;  the  transverse  diameter 
less  than  4  inches  =  100  millimetres.  The 
antero-posterior  diameter  of  the  girl's 
head  was  45  inches  =111  millimetres  ;  the 
transverse  diameter  only  3f  inch  =  94 
millimetres. 

They  were  described  as  very  vivacious, 
restless,  and  excitable,  but  unable  to  speak 
anything  save  a  few  isolated  words.  In 
manners  they  were  soft  and  gentle.  We 
saw  these  creatures  twice,  the  last  time  in 
Glasgow  in  1880  where  they  were  being 
exhibited  for  a  penny.  They  were  publicly 
married  in  London  in  1867,  and  cohabited, 
but  had  no  offspring.  The  female  showed 
jealousy  of  the  male  by  shaking  her  finger 
at  him  "  when  he  paid  attention  to  other 
ladies."  She  was  playing  with  a  toy. 
They  said  that  she  was  not  fond  of  chil- 
dren. They  seemed  gentle  and  good- 
natured,  and  spoke  a  few  isolated  words, 
such  as,  when  we  asked  the  male  what  he 
would  do  with  some  money  ?  he  answered, 
"cigar,"  being  fond  of  smoking.  The 
female  said  "  cold,"  when  the  showman 
exposed  her  neck  to  let  me  see  how  well 
nourished  she  was.  They  were  both  of 
low  stature.  The  male  had,  for  an  Indian, 
a  tolerable  beard.  He  was  said  to  be 
forty-six, the  female  several  years  younger. 
We  could  see  no  grey  hairs.  The  male  had 
ff  teeth,  some  of  which  were  decayed. 
They  had  both  vaulted  palates.  The  male 
wanted  a  metacarpal  bone  in  each  little 
finger,  and  the  big  toe  overlapped  the 
others  on  each  foot.  Deformities  of  the 
toes  ai'e  common  with  idiots.  We  measured 
the  head  of  the  male  microcephale  as  well 
as  we  could  for  his  bushy  hair. 

The  following  were  noted : 

Mill.      Inch. 
Antero-posterior  (from  glabella 

to  occipital  protuberance)      .       2x6  =     8^ 
Circumference.         .         .         .       381   =  15 
Transverse  (from  tragus  to  tra- 

g-us) 240  =     95 

A  boy  named  Freddy,  with  a  very  small 
head,   has   been   carefully    observed    and 


Microcephaly 


[    808    ] 


Microcephaly 


described  by  Dr.  Shuttleworth,  under 
whose  care  he  has  been  for  eighteen  years. 
He  is  short  of  stature,  but  well  built, 
vigorous,  and  active.  The  following  are 
some  of  the  head-measurements  : 


Inch. 

Mill 

Antcro-posterior 

in  1875 

81  = 

215 

Cireiimfcreuce . 

in  I 87 I 

14A  = 

3S» 

in  1875 

i4i  = 

368 

>> 

in  I 88 I 

15     = 

3»i 

Transverse 

in  1875 

10     = 

280 

Other  comparative  measurements 
showed  a  slow  growth  of  the  head  be- 
tween 1871  and  1875. 

When  seventeen  years  of  age  he  was 
four  feet  six  inches  in  height.  In  the  first 
years  of  his  residence  in  the  asylum 
Freddy  was  difficult  to  manage,  biting 
and  kicking  when  angry.  As  a  result  of 
his  discipline  he  became  better  behaved, 
and  fairly  sociable.  He  is  still  quick  and 
irritable.  He  has  good  use  of  his  limbs, 
joins  in  the  drill,  and  is  observant  of  exter- 
nal changes  and  new  objects.  He  uses  a 
few  words  such  as  "look,"  come,"  and 
"  see,"  which  he  does  with  a  meaning. 
His  mental  processes  are  very  simple,  and 
he  learns  little  with  the  passing  years. 
His  portrait  is  given  below,  from  a  wood- 
cut used  in  the  writer's  book  on  "  Idiocy," 
at  p.  93. 

Fig.  2. 


The  case  of  Antonia  Grandoni  has  been 
described  by  Professor  Cardona  and  Dr. 
Adriani,  of  Perugia.  Antonia  died  in 
1872,  aged  41  years.  She  was  52  inches 
in  height,  and  weighed  66  pounds.  Two 
of  her  portraits  (Figs.  3  and  4)  are  given 
from  other  woodcuts  in  the  writer's  work, 
at  pp.  104-5. 


Fig.  3. 


Fig.  4. 


Amongst  the  head  measurements  were : 
Mill.     Inch. 


Autero-posterior 
Circumference . 
Transverse 


135  =    5-4 
380  =  15 
105  -    4.2 


The  encephalon  weighed  289  grammes ; 
the  cerebrum,  238  grammes ;  the  cere- 
bellum, pons,  and  medulla,  51.  The  cere- 
brum was  not  only  absolutely  small,  but 
small  out  of  due  proportion  to  the  other 
parts. 

On  comparing  these  ascertained  facts 
with  the  brains  of  other  microcephales, 
it  appears  that,  while  with  brain  weights 
nearly  corresponding,  the  mental  manifes- 
tations in  all  other  cases  were  those  of 
the  lowest  grades  of  idiocy,  in  Antonia 
they  did  not  sink  below  weakmindedness. 
She  could  dance,  play  well  on  the  cymbals, 


Micromania 


[    809    ] 


Mind-blindness 


was  fond  of  being  noticed,  especially  by 
the  other  sex,  had  a  good  memory  for  the 
names  of  places  aud  persons,  but  no 
memory  of  time.  She  learned  to  do  easy 
work  in  the  house,  and  to  go  out  to  buy 
pi-ovisions.  Indeed  Cardona  goes  so  far 
as  to  say  that  the  poverty  of  the  brain 
of  Graiidoni  in  the  small  size  accorded  to 
it  by  Nature  could  admit  of  a  sensibility, 
an  intelligence,  and  an  education,  which 
has  not  fallen  much  short  of  the  average 
of  her  connti-ywomen. 

A  longer  description  of  Autonia  and  of 
Freddy  will  be  found  in  the  writer's  book 
above  mentioned.  In  Antonia's  case  one 
might  expect  the  bram  tissues  to  be 
healthy,  and  this  was  fairly  borne  out  by 
a  careful  microscopical  examination. 

Dr.  Lannelongue  has  tried  an  operation 
for  the  relief  of  microcephaly,  which  con- 
sists in  the  renioval  of  strips  of  the  frontal 
and  parietal  bones  along  the  lines  of  the 
sutures.  Though  he  does  not  hold  that 
the  closure  of  the  sutures  is  the  cause 
of  microcephaly,  he  believes  that  there 
is  often  compression  or  arrest  of  the 
growth  of  the  brain.  Professor  Horsley, 
and  Dr.  Keen  of  Philadelphia,  have  per- 
for-med  similar  operations  on  microcephalic 
children.  So  far  as  we  can  gather,  in  twelve 
such  operations  there  were  four  deaths, 
and  decided  improvement  is  specified  in 
only  two  cases.  These  surgeons  consider 
that  the  hopelessness  of  any  considerable 
improvement  in  the  mental  power  of  the 
microcephale  justifies  the  risk  of  the  ope- 
ration. We  should  be  inclined  to  restrict 
the  operation  to  children  under  five  years 
in  whom  there  were  some  proofs  of  com- 
pression. W.   W.  lilELAND. 

[References. — Uratiolet,  Memoire  sur  la  ilicro- 
cephalie  consid^ree  dans  ses  rapports  avec  la 
■question  dcs  Caracteres  du  Genre  humain,  .Four- 
nal  de  la  l'hysioloi;ic  de  rHomuie  et  dusAnimaux, 
Taris,  i860.  Voij;t,  Memoires  sur  les  Microce- 
phales,  ( icuLva,  1867.  Bischoff  (Th.  L.  AV.),  Anato- 
uiiscbe  Beschrelljung-  eint's  Mlcroeuphalen  8  Jahr- 
i^en  Mfidchens,  Aluuicli,  1873.  Aeby,  lieitragc 
zur  Kenntniss  dur  Mlkrocephalie,  Arcbiv  liir  An- 
thropologic, sot/hster  uud  siebenter  Band,  Bruns- 
wick, 1874-5.  Ii'eland,  On  Idiocy  aud  Imbe- 
cility, London,  1877.  Bucknill  aud  Tuke's 
Manual,  4tb  edit.  1879.  Beach,  Morphological 
aud  Histological  Aspects  of  Mieroccpbalic  and 
Cretinoid  Idiocy,  Transactions  of  International 
Medical  Congress,  vol.  iii.,  London,  1881.  (iiaco- 
luini's  Cervelli  del  Microcefali,  Turin,  1890  :  at 
the  end  of  this  complete  monograph  there  is  a  list 
of  the  literature  of  microcephaly  lilling  fourteen 
pages.  Horsley,  V.,  On  Craniectomy  in  Micro- 
cephaly, Brit.  3Ied.  Journ.,  September  12,  1891.] 

ItCZCROMAII'ZA  (fxiKpos,  small ;  fxavia, 
madness).  The  form  of  insanity  in  which 
the  patient  imagines  that  his  body  or 
some  part  of  it  has  become  small.  De- 
lusion of  belittlement.  (i'r.  ddire  dea 
petiiesses.) 


AXZCROPSY,  HYSTERZCAIi  {^iiKpos  ; 
o\lns,  signs ;  hysteria,  q.p.)-  The  visual 
defect  found  in  hysterical  subjects,  in 
which  objects  at  a  certain  distance  appear 
smaller  than  they  really  are,  associated 
as  a  rule  with  functional  monocular  poly- 
opia and  hysterical  macropsy  {(/.v.). 

lyilNS.      (Sec  PlFlLOSOIMlY    (H''    MiND,  p. 

27.) 

iviiia-D-BliZN'sia'iiSS. — Mind-blmdness 
represents  a  form  of  visual  disturbance  in 
which  the  capability  of  seeing  and  per- 
ceiving objects  is  preserved,  but  in  which 
the  capability  of  rerognisimj  them,  save 
through  the  other  senses,  is  lost. 

The  term  "  mind-blindness  "'  has  been 
chosen  by  Munk  for  a  certain  condition  in 
the  dog,  which  he  was  able  to  produce  by 
an  operation  on  the  occipital  lobe.  The 
dogs  are  able  to  see,  but  they  are  not 
able  to  recognise  by  means  of  the  visual 
sense  persons,  localities,  and  objects  fami- 
liar to  them.  The  operation — extirpation 
of  the  cortex  at  a  certain  part  of  the  occi- 
pital lobe  —  is  said  to  extinguish  the 
memory  of  all  visual  images.  The  science 
of  mind-blindness  in  man  has  not  yet 
been  brought  to  a  definite  conclusion. 
The  results  of  the  experiments  on  animals 
cannot  without  reserve  be  transferred  to 
human  pathology.  In  a  series  of  cases 
the  condition  which  has  been  described  as 
mind-blindness  has  also  been  observed  in 
man. 

In  these  cases  perception  of  the  impres- 
sions of  light,  simple  optical  perception  as 
such,  continues  to  exist  ;  the  patient  sees, 
but  he  is  not  able  to  interpret  the  impres- 
sions which  he  receives  through  the 
retina,  he  is  not  able  to  make  any  use  of 
them  mentally,  he  does  not  connect  any 
ideas  with  them.  The  memor}^  of  visual 
images  is  entirely  lost.  In  several  in- 
stances colour-blindness  was  found  asso- 
ciated with  mind-blindness,  but  we  cannot 
decide  whether  this  is  constant.  It  is  im- 
portant to  note  that  in  one  and  the  same 
case  hemianopsia  can  be  present  with 
mind-blindness,  as  has  been  observed 
several  times.  Remarkable  is  the  occur- 
rence of  mind-blindness  in  connection 
with  aphasic  derangements  of  speech.  It 
has  been  already  attempted  to  make  a 
distinction  between  certain  forms  of  mind- 
blindness.  We  may  he  allowed  to  separate 
from  pure  mind-blindness  in  the  sense  as 
stated  above,  the  word-blindneas — i.e.,  the 
inability  to  recognise  writing  or  print, 
because  there  have  been  cases  in  which 
word-blindness  existed  without  mind- 
blindness.  Whether  we  are  also  allowed 
to  separate  from  mind-blindness  other 
cases  in  which  there  is  ajjhasia — the  so- 
called  optical  aphasia — is  not  certain. 


Mind-blindness 


[     8io 


1 


Mneme 


We  must  take  care  not  to  compare 
mind-blinduess  with  a  similar  visual  de- 
rangement, as  represented  by  diminution 
of  the  acuteness  of  vision  and  by  mono- 
chromasia.  This  condition  can  be  pro- 
duced in  man  experimentally,  by  means 
of  coloured  lic^ht  and  the  use  of  limned 
spectacles.  For  the  decision  of  the  ques- 
tion whether  there  is  in  a  given  case 
genuine  mind-blindness,  the  consideration 
of  these  factors  is  of  great  importance,  be- 
cause, in  order  to  produce  an  optical  image 
in  our  perception,  a  certain  degree  of 
acuteness  of  vision  and  the  capability  of 
distinguishing  colours  are  necessary.  The 
anatomical  cause  of  mind-blindness,  which 
is  a  disturbance  of  vision,  originating  in 
the  cortex,  lies  in  a  disease  of  the  occipi- 
tal lobe.  Supposing  that  the  optical  field 
of  perception  lies  in  the  cuneus,  and  has 
its  centre  in  the  first  occipital  convolution, 
we  have  to  place  the  field  of  the  memory 
of  visual  images  in  the  remaining  part  of 
the  cortex  of  the  occipital  lobe,  without 
being  able  to  say  whether  it  covers  only  a 
part,  and  in  that  case  which  part,  of  the 
remainder  of  the  cortex  of  this  lobe. 

E.  81EMEKLING. 

[Rejennci's. — H.  Muuk,  I'eber  die  Funktionen 
der  Grosshiriiriude,  Berlin,  1881.  H.  Wilbnind, 
Die  Seelenblindlieit  als  Heiderscheinuug'  uiid  ihre 
Bezieliungen  v.wr  homonymeii  Hemianopsie,  ziir 
Alexie  und  Agraphie,  Wiesbaden.  1881.  Nothnagel 
und  Xaunyn,  Ueber  die  Localisation  der  Gebirn- 
krankbeiten,  AViesbadeu.  1887.  Wernike,  Lebr- 
bueli  der  (iebirnkrankbeiten,  IJd.  ii.  p.  544. 
Fuerstner,  Sebstoruugboi  J'aralytikern.  Arch,  fixer 
Psych,  und  Xervenkr.  Bd.  viii.  p.  162,  und  Bd.  ix. 
p.  90.  Stenger,  Die  Cerebralen  JSebstilrungen  der 
Faralytiker,  Arch,  fuer  I'sycb.  und  Nervenkr., 
Bd.  xiil.  Zacher,  Heitraege  /ur  I'athologie  und 
Pathologischen  Anatoniie  iler  progressiven  Para- 
lyse, Arcli.  luer  Psycli.  Bd.  xiv.  Reinliard,  Bei- 
traege  zur  Localisation  im  (irosshirn.,  Arch,  fuer 
Psych.  Bd.xvii.andxviii.  Luciani  und  Sepilli,  Die 
Functionslocalisation  auf  der  (Trosshirnrinde,  1886. 
Bernheim,  Contribution  :i  I'etude  de  Taphasie,  de 
la  cecite  psychique  des  cho.ses,  Kev.  de  Med.  viii. 
p.  185.  Jastrowitz,  ('entra)blatt  luer  pi-actiscbe 
Augenheilkunde,  1887,  p.  254.  Hoss,  On  Aphasia, 
London,  1887.  Thiniisen,  Charlte-Annalen,  x. 
Jabrgang,  p.  573.  A.  Pick.  Zur  Pathologie  des 
Gedaechtnisses,Arch.  1".  Psycli..  Bd.  xvii.  Charcot, 
Un  cas  de  8U])i)ression  brusque  et  isolee  de  la 
vision  meiitale  des  sigues  et  des  objets  (formes  et 
couleurs).  Mauthuer,  <  entralblatt  tiier  Augeuheil- 
kunde,  1880.  p.  288.  Schoeler-Uhthotr.  Beitraege 
zur  I'athologie  der  Selmerven  und  der  Netzhaut 
bei  Allgemeinerkrankungen.  Uerlin.1884.  Freund, 
Ueber  optische  Apliasie  uud  Seelenblindlieit, 
Arch.  f.  I'sych.  Bd.  xx.  ISrandenburg,  Arch.  f. 
Ophthalmologie,  xxx.  3.  liatterliaiu,  I'.rain,  1888. 
Bruns  und  Stoelting,  Aeuml.  Centralbl  1888,  No.  7. 
Lissauer.  Ein  Fall  \on  Seelenblindheit  nebst 
einem  Beitrage  der  Theorie  derselben.  Wernicke. 
Die  neueren  Arbciten  ueber  Aphasie,  Fortscliritte 
der  Medicin,  1886,  p.  371. .  Siemerliiig,  Ein  Fall 
von  sogenannter  Seelenblindheit  nebst  ander- 
weitiyen  cerebnilen  Symiitonien,  Arch.  1.  I'sych. 
Bd.  xxi.  ]).  284.  liughliiios  Jacksou,  Is'eiu-ol. 
Centralbl.  1884,  47. 


TCZTrs-DEAFTrESS.  —  A  term  em- 
ployed by  Munk  to  denote  the  condition 
in  which  the  power  of  recognising  familiar 
words  and  terms  is  lost,  the  auditory 
apparatus  being  unimpaired.  In  animals 
it  is  caused  by  destruction  of  the  first 
temporal  convolution. 

ivnirs,  DEPRAVED.     {See  Cacothy- 

MIA.) 

AXZM'D,  FACtTXiTZES  OF  THE.     {See 

Philo.sophy  of  Mind,  p.  27.) 

MZM'D,      PHZI.OSOPHY      OF.        {See 

Philosophy  of  Mind,  p.  27.) 

MZITD,  SCZENCE  OF.  {See  PHILO- 
SOPHY OF  Mind,  p.  27.) 

IVXZN'DpVM'SOUM'DZrESS  OF. — A  term 
first  used  by  Lord  Eldon  to  denote  a  con- 
dition of  intellect,  not  marked  by  delusions 
or  idiocy,  but  which  unfits  the  j^erson  for 
the  management  of  himself  and  his  affairs. 

XVIZSANTHROPZA  {fJLKTem,  I  detest; 
avdpwTTos,  a  man).  A  term  for  hatred  of 
men  or  their  society,  or  dislike  of  human 
companionship  or  conversation ;  it  was 
ranked  by  old  writers  as  the  second  stage  of 
melancholia  andhypochondriasis.  in  which 
men  show  an  aversion  towards  friends  and 
acquaintances,  shun  their  presence  and 
seek  seclusion. 

AXZSOGAMOS,  MZSOGAMUS  {ydfJLOS, 
marriage).  An  abnoruial  mental  condition 
in  which  a  person  shows  an  unreasoning 
and  morbid  hatred  of  wedlock.  (Fr. 
niisogame  ;  Ger.  Heimatlisclieu.) 

MZSOCYNOVS  iyvvi],  a  woman).  An 
uni'easoning  and  morbid  dislike  of  the 
female  sex.  (Fr.  misogyne ;  Ger.  Weiher- 
feind.) 

MZSOIiOGZA  {ra  \6yia,  literary  mat- 
ters). An  unreasoning  hatred  of  intel- 
lectual or  literary  matters. 

MZSOMAirzA  (fuaos,  hatred,  detesta- 
tion, persecution ;  navia,  madness).  A 
synonym  of  Delirium,  or  Delusion  of  Per- 
secution. 

MZSOF.s:dza  (TraZ?,  a  child).  An  in- 
sane hatred  of  one's  own  children. 

ivizsopsvcazA  {-^vxr],  life,  the  soul). 
A  term  for  hatred  or  weariness  of  life ; 
melancholia  with  disgust  of  life.  (Fr, 
misopsychie ;  Ger.  Triihsinn  mit  Leben- 
silherdriiss). 

MZSOZOETZCUS,  MZSOZOZA  {Ccori, 
life).  Hatred  or  disgust  of  life.  Melan- 
cholia with  suicidal  inclinations. 

IVIZSSAIVTK  (Ger.).  Melancholy, 
sadness. 

MZSTAKEN*   IDENTZTY.  —  A  term 

used  in  mental  disease  for  the  delusion 
exhibited  by  some  insane  persons,  who 
deny  their  identity,  claiming  to  be  kings, 
potentates,  deities,  &.c. 

IVXNEIVEE  {fivrmi],  recollection).  A  syn- 
onym of  Memory. 


Mnemonica 


[     8ii     ] 


Monomania 


MsrEMonrzcA  (fivrjixoviKos,  pertaining 
to  memory).  The  art  of  memory  or  of 
remembering. 

IMCOCXIiAZiZA  (fxoyiXnXtn,  from  jJioyLS, 
XaXeu),  1  speak  with  difficult}-) ;  MCOZiZ- 
Ii.A.liZA  (fioXii,  for  iJioyis,  v.s.)  Old  terms 
for  any  difficulty  of  speech  either  from 
physical  or  mental  defect.  Also  a  synonym 
of  Stammering  ('/.'■.). 

»IOI.YBX>EM-EPZI.EPSIA  (fio\v(-i8os, 
lead;  epilepsy).  A  synonym  of  Saturnine 
Epilepsy,  or  Epilepsy  induced  by  Lead 
Poisoning.  (Fr.  moli/hdepilepsie ;  Ger. 
BleifaJhnrhl.) 

MOirATSREZTEREZ. — The  German 
equivalent  for  Nymphomaniaor  Satyriasis. 

IVTOM-BXRANXHEZT.  —  A  German 
term  for  madness;  insanity. 

MOM'DSUCHT. — A  German  term  for 
lunac}' ;  also  a  synonym  of  Somnam- 
bulism. 

vlo'nooJmXa.js  xbzots.  {See  Idiocy, 
Forms  of.) 

mon'ocvx.ar  foxivopza  hvs- 
TERZCA  {yiovos,  one  ;  oculi(s,  eye  ;  ttoXvs 
a>\l^,  many-eyed  ;  hysteria,  q.v.).  A  term 
employed  lor  the  monocular  diplopia  or 
triplopia  occurring  in  hysterical  subjects. 
It  may  also  occur  as  a  natural  defect 
corrected  in  the  healthy  condition  of  the 
normal  action  of  accommodation,  and  due 
to  the  segmentary  structure  of  the  crys- 
talline lens,  occurring  in  the  aged,  com- 
mencing cataract,  astigmatism,  &c. 
Parinaud  ascribes  its  occurrence  in  hys- 
teria to  the  contraction  of  the  muscle  of 
Briicke  {m.  ciliaris  oculi).  It  embraces 
the  conditions  known  as  hysterical 
macropsy  and  micropsy  (^.r.)  (Charcot). 

1VION-ODZPI.OPZA  HYSTERZCA 
(SiTrXo'os-,  co\|/-,  hysteria).  A  synonym  of 
Monocular  Polyopia  Hysterica. 

MOnrOMAKrzA.  —  The  essential  ele- 
ment of  the  definition  of  monomania  is 
partial  insanity.  Those  who  have  logi- 
cally maintained  its  existence  hold  that 
the  morbid  mental  state  is  restricted  to 
one  subject,  the  patient  being  of  sound 
judgment  and  healthy  feeling  on  all 
others.  Employed  in  this  sense  it  must 
be  discarded  as  untrue  to  clinical  experi- 
ence, and  as  the  term  is  sure  to  be  mis- 
understood when  employed  in  a  broader 
sense,  its  use  is  to  be  regretted.  At  the 
same  time  there  is  truth  in  the  doctrine 
that  the  range  of  mental  aberration  in 
some  instances  is  by  no  means  co-exten- 
sive with  the  mental  faculties,  and  the 
subjects  upon  which  they  may  be  engaged. 
No  one  wiho  has  anything  to  do  v/ith  the 
insane,  doubts  that  a  man  who  labours 
under  a  terrible  delusion  or  hallucination 
or  an  uncontrollable  impulse,  may  be  able 
to  prepare  an  elaborate  balance-sheet,  or 


if  a  lawyer,  might  give  trustworthy  advice 
to  his  client.  Partial  insanity  in  this 
sense  must  therefore  be  admitted. 

The  term  monomania  has  a  history 
which  cannot  be  passed  over  without  a 
brief  notice.  No  less  than  one  hundred 
and  thirty  pages  of  Esquii-ol's  "  Maladies 
Mentales "  are  devoted  to  this  form  of 
mental  disease.  He  invented  the  word. 
He  described  it  as  a  chronic  cerebral 
affection  without  fever,  characterised  by  a 
partial  lesion  of  the  intelligence,  the  affec- 
tions, or  the  will. 

Intellectual  inonomania  was  defined  as 
based  on  illusions,  hallucinations,  morbid 
associations  of  ideas,  or  delusions,  con- 
centrated ujjon  a  single  object  or  a  cir- 
cumscribed series  of  objects,  outside  of 
which  the  patient  feels,  reasons,  and  acts 
like  sane  people. 

Affective  nio)iO'inania  (corresponding  to 
the  vnanie  raisonnante  of  previous  authors) 
was  defined  as  a  state  in  which  without 
defect  of  reason  the  affections  are  per- 
verted, and  the  character  changed. 

Instinctive  monomania  (or  monomanie 
sans  delire)  was  regarded  by  Esquirol  as 
a  lesion  of  the  will,  the  patient  being 
driven  to  perform  acts  of  which  his  reason 
and  conscience  disapprove. 

These  varieties  of  partial  insanity  may 
be  associated  with  exaltation  or  depres- 
sion, but  if  the  latter,  Esquirol  applied  to 
them  the  term  lypemania,  while  he  re- 
solved to  restrict  that  of  monomania  to 
partial  insanity  of  a  joyous  character. 
He  observes,  "  writers  have  confounded  " 
monomania  with  melancholia  because  in 
both  the  delusion  is  fixed  and  partial. 

Under  monomania  Esquirol  placed  : — ■ 
(i)  M.  erotiqiie  {see  Insanity,  Erotic),  (2) 
M.  raisonnante.  Under  this  head  he  dis- 
cusses the  moral  insanity  of  Prichard, 
and  expresses  a  doubt  whether  he  has 
quite  sufficiently  distinguished  it  from 
another  variety  of  insanity  free  from  in- 
tellectual disorder,  the  manie  sans  delire. 
"  The  moral  insanity  of  Prichard,  or  the 
■manie  raisonnante  of  Pinel,  is  a  true 
monomania.  Patients  labouring  under 
this  variety  of  insanity  certainly  have  a 
partial  mental  disorder."  {Op.  cit.  ii.  70.) 
(3)  M.  d'irresse,  (4)  M.  incendiare,  (5)  M. 
homicide*     It  must  be  remembered  that 

*  "A  la  liu(lu(|uiiizit;ine  siecle,  Marescot,  Riolau 
et  Duret,  eharyes  d'exaniiuer  31arthc  Brossier, 
accusec  du  sorcillorie,  termliiercnt  leur  rapport  par 
ci's  mots  memorablcs  :  Xiliil  11  (Icmone  ;  iiuilta.n'rta, 
(I  iiKirho  paiica.  Cette  decision  servit  de])iiis  le 
ref^le  aux  juges  qui  eurent  i^.  i)roiionc-i'r  sur  le  sort 
des  sorcitTs  et  des  magiciens.  Nous  nous  disous, 
en  caracterisant  le  meutre  des  monomauiaques- 
liomicidcs :  Nihil  a  rrimiiw,  nulla  .ricta,  <i  timrbo 
tola."  (Op.  cit.  ii.  843.)  Ks(|nir(il's  defence  of 
homicidal  monomania  is  one  of  the  ablest  chapters 


Monoraania,  Affective        [    812    J 


Monopathophobia 


this  form  is  also  an  example  of  reasoning 
mania.  Esqnirol  observes  that  nearly  all 
the  facts  of  'manie  savx  delire  belong  to 
monomania  or  to  lypemania,  being  cha- 
racterised by  a  fixed  and  exclusive  insa- 
nity. There  are  irresistible  impulses.  (6) 
M.  suicide,  (7)  M.  hypocliondriaque. 

Athoughtfulcontribution*  to  the  subject 
now  treated  of  has  been  made  by  Dr. 
Bannister  (of  the  Kankakee  Asylum, 
Illinois),  who  is  disposed  to  defend  the 
continued  employment  of  the  term. 
"  That  there  may  be  and  are  cases  in 
which  a  single  delusion  or  imperative 
conception  forms  the  whole  of  insanity, 
either  at  one  of  its  stages,  or  during  its 
whole  course,  I  have  very  little  doubt." 
He  argues  that  we  admit  that  there  may 
be  a  single  hallucination,  and  if  this  be 
true,  it  may  be  a  starting-point  for  an 
equally  limited  delusion.  The  case  is 
given  of  a  female  patient,  who  had  a  cer- 
tain delusion  in  regard  to  a  family  living 
next  door  to  her,  who  were  constantly 
tormenting  and  injuring  her  and  her 
friends.  She  talked  reasonably  upon 
every  subject  but  this.  She  had  auditory 
hallucinations  which  she  referred  to  the 
evil  influence  of  this  family.  She  also 
charged  them  with  injuring  her  lungs, 
and  appeared  from  her  grimaces  and 
semi-convulsive  movements  to  be  in  acute 
pain.  Her  disposition  was  excellent,  and 
she  never  expressed  a  wish  to  do  her 
imaginary  enemies  harm.  We,  however, 
can  hardly  agree  with  Dr.  Bannister,  that 
"  the  defect  of  judgment  that  permitted  a 
patient  to  accept  the  hallucniations  as 
realities,  and  to  build  up  upon  them  the 
delusions,  does  not  necessarily  imply  any 
general  defect  of  intelligence."  Other 
cases  are  recorded  in  support  of  the 
writer's  opinion,  but  we  scarcely  think 
that  they  justify  the  scientific  use  of  the 
term,  although  they  justify  its  employ- 
ment in  a  general  sense,  and  it  is  probable 
that  it  will  pass  current  as  a  practically 
reasonable  word.  Although  it  would  be 
unsafe  to  employ  it  in  a  Court  of  Law, 
there  are  occasions  on  which  a  medical 
witness  may  truthfully  contend  for  a  par- 
tial insanity,  which  allows  of  a  patient 
exercising  his  judgment  in  some  matters, 
while  admitting  that  there  are  others  on 
which  his  opinion  would  be  warped  by  his 
delusions.  Tjie  Editok. 

IMCONOMANZil,  AFFECTIVE  {mono- 
>manie  affective).  Esquirol's  term  for 
emotional  insanity  in  which  the  subject 
is  not  deprived  of  reason,  but  in  which 

of  bis  reuiuvkiible  work,  Avliic]i  it  is  iuipossibk'  to 
read  without  surprise  and  admii'iitioii. 

*  The  American  Journal  of  2\<:iirut(i(/ij  and 
Psychiatrii,  vol.  iii.  Xo.  i,  1884. 


affections  and  dispositions  are  perverted. 
{See  Moral  Insanity.) 

IMCOirOMANIA,  ZN'STIN'CTZVE 

{monotnanie  iastinctivc),  Esquirol's  term 
for  emotional  insanity  marked  by  per- 
verted moral  sense  or  by  destructive  im- 
pulses. In  this  form  the  actions  are 
involuntary,  instinctive  and  irresistible. 

MOXromXAie'IA,  ZirTEIiIiECTUAZi 
{monvmanie  intelleduelle).  Esquirol's 
term  for  monomania  with  delusions  of  an 
exalted  nature. 

WtONOV/lA.NXA.  OF  CRANDEX7R, 
MONOIVIAN'IA  OF  PRZBE  (/xwoj,  alone, 
single;  ^lavia,  madness).  That  form  of 
monomania  in  which  the  i:)atient  believes 
himself  to  be  some  great  or  noble  person 
or  deity,  or  one  endowed  with  extraordi- 
nary talents,  beauty,  grace,  attributes,  &c. 

IMCOMOMAN-IA  OF  SUSPICIOZir. — 
That  form  of  monomania  in  which  the 
patient  believes  himself  to  be  the  victim  of 
some  enemy  who  has  evil  designs  against 
him. 

MoxronxAirzA  of  uxrsEEir 
AGEirCY. — That  form  of  monomania  in 
which  patients  believe  that  they  are  in- 
fluenced by  some  agency,  unnatural, 
unseen  or  impossible. 

MONOMAnrZACUS,  MOirOlfO- 
IWAirzAC.  —  Terms  for  one  labouring 
under  monomania. 

ivKoxroiviAirzE  aitthropopha- 
CIQVE  (Fr.).  The  species  of  insanity  in 
which  the  patient  shows  a  longing  for 
human  flesh  or  food. 

IVKON-OMAig-IE  BOUI.ZMIQUE  (Fr.). 
A  term  synonymous  with  Bulimia  {([.c.). 

MONOMAnrZE  DES  RZCHES  (Fr.). 
A  term  for  monomania  of  great  riches  or 
possession. 

iKCOifOMAiirzE  i>u  vol.  (Fr.).  A 
synonym  of  Klejitomania  ((/.r.) 

MOirOIVIAirZE  isROTXQVE  (Fr.).  A 
synonym  of  Erotomania  {(j-v.). 

MONOMAN^ZE     EXPANSZVE,     MO- 

NOIVIANZE  GAZE.  French  terms  used 
in  the  same  sense  as  amenomania  {q.r.). 

IVIONOIVXAM^ZE  Zlf  CEITSZAZRE  (Fr.) 
A  term  for  pyromania  {(j.v.). 

MOiroiviAirzE  meurtrzere. — A 
French  term  for  homicidal  insanity. 

IVIOSrOMANZE  ORCVEZI.X.EUSE 

(Fr.).     A  synonym  of  Megalomania  (q.v.). 

MON'OI^ORZA  (fjLovos,  alone,  single  ; 
ficopia,  folly;.    A  synonym  of  Melancholia. 

XVXON'OIi'CEA  (voos,  the  mind).  Thought 
or  concentration  of  mind  on  one  subject 
as  in  monomania. 

IMCOiroPACZA  (Trdytof,  flxed,  estab- 
lished).   A  synonym  of  Clavus  Hystericus. 

MONOPATHOPHOBZA  (Trddos,  an 
affection ;  cf)6(ios,  fear).  A  term  synony- 
mous with  HyjjochonJriasis.     A  morbid 


Monoplegia,  Hysterical 


tii3     ] 


Moral  Insanity 


fear  or  dread  that  one  is  about  to  sufFer 
from  some  detiuite  disease. 

IVfONOPIiECZA,   HYSTERXCAX. 

{n\r]yrj,  a  stroke,  hysteria,  i/.r.);  IVIOWO- 
PXiEGZA,  HYSTERICAIi  TRAV- 
ItlATlC  (hysteria ;  rpavfia,  a  wound). 
The  occurrence  in  a  hysterical  subject  of 
paralysis  or  paresis  of  one  limb,  either 
following  or  independent  of  traumatic 
injury.  With  it  may  be  associated  anajs- 
thesia,  either  total,  partial,  or  irregular 
in  distribution,  while  other  phenomena 
of  hysterical  type  may  accompany  the 
affection,  such  as  retraction  of  the  visual 
field,  monocularpolyopia,  diminution  of  the 
sense  of  hearing  or  smell  on  the  affected 
side.    Charcot  has  noticed  rapidly  ensu- 


studied  by  those  who  reside  there,  the  in- 
fluence of  the  moon  is  not  believed  in.  I 
may  say  the  same  of  the  Bicctre  and  cer- 
tain private  asylums  in  Paris."  He,  how- 
ever, adds,  with  an  open  miud,  that  an 
opinion  which  has  been  held  for  centuries 
and  is  consecrated  by  popular  language, 
merits  careful  observation  ("  Des  Maladies 
Mentales,"  t.  i.  p.  29). 

No  observations  which  have  been  made 
since  the  time  of  Esquirol  have  shown, 
conclusively,  any  relationship  between  the 
moon  and  lunacy.  Medical  men  have  en- 
deavoured to  erase  the  words  descriptive 
of  insauity  in  the  insane  which  orginated 
in  the  popular  belief,  but  custom  has 
proved  too  strong,  and  the  last  Lunacy  Act 


ing   and   persistent  amyotropliy    of    the  1  iias  continued  to  employ  the  terms  in  ques 


affected  limb, 

MONOPSYCHOSIS  i^vxr],  the  mind 
or  soul).  Clouston's  term  for  monomania 
or  delusional  insanity. 

MOON. — The  belief  in  the  influence  of 
the  moon  in  causing  insanity  is  of  great 
antiquity.  Hence  the  Greeks  employed  the 
word  SeXTyi/mfo)  to  denote  the  production 
of  madness  and  epilepsy. 

Reference  is  made  by  Giraldus  Cam- 
brensis  in  his  "TopographiaHibernica"to 
the  influence  of  the  moon  :  "  Hinc  est  quod 
hinatici  dicuntur,  qui  singulis  mensibus 
pro  lunse  augmento  cerebro  excrescente 
languescunt."  He  reports  the  observation 
of  an  "  expositor  "  on  Matt,  chap,  iv.  24, 
that  the  sick  are  here  called  lunatics,  not 
because  their  insanity  comes  from  the  moon, 
but  because  the  devil,  who  causes  insanity, 
avails  himself  of  "  lunaria  tempora  "  in 
order  that  he  may  disgrace  the  creature 


tion,  both  in  the  title  of  the  Act  and  in  the 
medical  certificate,  where  "  an  alleged 
lunatic  "  appears  in  the  printed  form. 

The  employment  of  words  derived  from 
the  "  moon,"  as  applied  to  the  insane,  is 
sufficiently  frequent  in  English  literature, 
whether  prose  or  jDoetry,  to  indicate  the 
general  belief  in  the  old  doctrine. 

The  Editor. 

ll'cfi  ri-nci'S. — Kiish,  Sled.  Juiiuirics,  1815,  i>. 
170.  Mead,  Dc  iiui)t'rii)  solis  ct  luiiae  in  corpoi'f 
liuuiaiia  ct  luorbis.  Dr.  Alk'ii,  Cast's  of  lusaiiity, 
1821,  pp.  76-104  :  Maiuuil  of  Psycliologica]  Medi- 
cine, 1879,  4tli  cd.,  p.  79.  MM.  Leurel  and 
Mitivie,  De  la  Ireqiiencc  du  pouls  eliez  les  alieiies, 
Paris,  1832.  Dr.  8.  15.  AV^oodward,  Report  of  the 
Worcester  Asylum  (U.S.),  1841.  Dr.  Laycock,  On 
Lniiai-  Influeiife,  Lancet,  1842-3.  Dr.  Tlmrnam, 
Tlic  Statistics  of  the  Ketreat,  1845,  PP-  HS^H?!- 

MOOSTES;  MOOTTSTRUCK.  — 
Popular  terms  for  one  of  unsound  mind. 
A  lunatic. 

MORAI.  CON-TACZOVr. — The  engen- 


into  blaspheming  the  Creator,  and  sensibly    dering  or  engrafting  of  some  moral  per 
iirlrlo .  "  Potuisset  autcm,  ut  arbitror,  salva    version  on  a  subject  of  weak  moral  charac 


adds 

ejusdem  venia,  non  minus  vere  dixisse. 
propter  varios  humores  in  plenilunio  ni- 
mis  enormiter  excresceutes,  valetudinariis 
L^ec  accidere "  (Dymock's  Op.  Girald. 
Camb.  V.  p.  79). 

Esquirol,  in  his  day,  stated  that  the  Ger- 
mans and  the  Italians  believed  in  lunar 
influence  as  a  cause  of  mental  disorder,  and 
he  refers  to  the  use  of  the  word  "  lunatic  " 
by  the  Euglish  as  an  evidence  of  their 
holding  the  same  behef.     He  cites  Daquin, 


ter  by  some  abnormality  in  the  moral  con- 
duct of  another.  (See  CoMJirNiCATivE 
In.'iANiTY;  CoNTAGiox,  Mental;  Epidemic 
Insanity  ;  Hystekia  ;  and  Imitation.) 

MORAIi  ZWSAWZTY.  —  Syn.  Emo- 
tional or  Affective  Insanity.  Fr.  FoUe 
raisonnante  or  folie  lucide  rdisonnanfe, 
monomanie  affective;  Ger.  Moralisches 
Irreseiii;  Lat.  Mania  sine  (lelirio. 

Definition. — A  disorder  which  affects 
the  feelings    and  affections,  or  what  are 


of  Chambery,  among  his  own  countrymen,  i  termed   the    moral     powers,     in     contra- 


as  holding  this  opinion,  and  supporting  it 
in  his  "  La  Philosophie  de  la  Folie,"  pub- 
lished in  1804.  Esquirol  himself  writes 
thus  cautiously  and  wisely  :  "  Certain  iso- 
lated facts — the  phenomena  observed  in 


distinction  to   those  of   the  understand- 
ing or  intellect  (Prichard). 

A  form  of  mental  disease,  in  regard  to 
which  so  much  difference  of  opinion  exists 
among  mental  j)hysicians — a  difference  of 


some  nervous  affections — would  seem  to  opinion  doubtless  "held  with  equal  honesty 
justify  this  opinion.  I  have  not  been  able  by  each  party— calls  for  dispassionate  con- 
to  satisfy  myself  that  this  influence  is  real,  ;  sideratiou,  and  a  mode  of  treatment  alto- 
notwithstanding  all  the  care  I  have  taken    gether   free    from   heated    assertion  and 

to    a^scertain    the    truth At    the  ^  dogmatism.     We  have  no  doubt  that,  to  a 

Salpetriere,    where   practical   truths   are  !  very   considerable  extent,  the  divergence 


Moral  Insanity 


[    814    ] 


Moral  Insanity 


of  sentiment  among  medical  men  equally 
competent  to  arrive  at  a  conclusion,  is 
due  to  the  want  of  definition  of  the  terms 
employed  in  discussing  the  question. 
Probably  those  who  entertain  different 
views  on  moral  insanity  would  agree  in 
their  recognition  of  certain  cases,  as  clini- 
cal facts,  but  would  label  them  differ- 
ently. 

To  come  then  to  the  root  of  the  diffi- 
culty which  has  arisen — we  meet  with  a 
certain  ninnber  of  persons  who  grow  up 
presenting  a  marked  contrast  in  their 
moral  nature  to  the  other  members  of 
the  family,  although  they  have  all  been 
subjected  to  the  same  influences,  social, 
educational,  and  religious.  The  theolo- 
gian may  be  satisfied  to  explain  the  phe- 
nomenon, by  attributing  to  such  member 
of  the  family  a  double  dose  of  original 
sin,  but  those  j^hysicians  who  are  opj^osed 
to  the  doctrine  of  moral  insanity  would 
not  adopt  this  explanation.  Severity  and 
tindness  may  alike  fail  to  elicit  the  moral 
feelings  or  to  check  immoral  tendencies. 
The  child  in  spite  of  parental  and  scho- 
lastic training  may  remain  an  incorrigible 
liar  or  thief ;  may  exhibit  premature 
depravity  :  may  be  cruel  to  other  children 
and  to  animals  ;  and,  having  grown  to 
man's  estate,  may  break  the  laws  of  the 
land,  and  be  convicted  of  a  criminal  act. 
The  examination  of  the  mental  condition 
of  the  person  may  show  no  defect  of  the 
intellectual  faculties,  and  yet  the  mental 
expert  may  feel  confident  that  the  alleged 
criminal  is  not  responsible  for  his  actions. 
Or  again,  an  individual  who  has  betrayed 
no  strangeness  in  his  youth  may  receive 
a  shock  which  is  followed  by  a  change  of 
character  including  moral  perversion, 
terminating  it  may  be  in  a  homicidal  out- 
burst. Now  in  these  examples  it  may 
occur  that  a  careful  investigation  into 
the  past  history  fails  to  reveal  any  lack 
of  mental  power,  in  the  direction  of 
memory  and  facility  in  acquiring  ordinary 
knowledge.  What  then  is  the  position 
taken  by  those  who  have  studied  the  sub- 
ject and  refuse  to  admit  the  presence  of 
moral  imbecility  or  insanity,  although 
granting  that  such  persons  are  not  morally 
guilty  of  the  crime  ?  It  is  this :  In  the 
vast  majority  of  the  cases  of  alleged 
moral  insanity,  very  careful  inquiry  proves 
that  there  is  congenital  or  acquired  intel- 
lectual weakness.  Hence  it  is  safe  to 
infer  that  such  mental  disorder  would  be 
found  in  all  cases  whatever,  provided  a 
thorough  investigation  were  carried  out 
by  competent  experts.  This,  however,  is 
an  inconclusive  argument  —  something 
very  like  &  jjetitio  j^rhx-ipil.  At  any  rate 
one  thing  is  perfectly  certain,  that  it  may 


be  practically  impossible  to  detect  the  in- 
tellectual flaw,  and  yet  a  physician  may 
be  driven  to  decide  that  a  person  is  in- 
sane. The  really  important  clinical  fact 
remains  that  cases  arise  in  which  the 
stress  of  the  disease  falls  on  the  moral 
nature  while  those  faculties  which  are 
generally  regarded  as  reasoning  and  per- 
ceptive, are  so  little,  if  at  all,  deranged, 
as  not  to  attract  attention.  It  has  na- 
turally hapi^ened  that  moral  insanity  has 
become  associated  with  questions  of  crime, 
but  it  would  be  a  very  great  mistake  thus 
to  limit  the  range  of  this  term.  Cases 
occur  in  which  there  is  a  simple  feeling 
of  intense  mental  depression  for  which 
the  sufferer  can  give  no  explanation,  and 
which  is  in  no  degree  associated  with  a 
delusion.  Here  there  can  be  no  doubt  that 
the  clinical  fact  would  be  admitted  by  aU 
experienced  alienists,  but  those  who  are 
unable  to  regard  it  as  a  disorder  of  the 
emotions  only  would  hold  that  the  in- 
ability to  recognise  the  groundlessness  of 
the  depression  is  in  itself  an  intellectual 
defect. 

It  would  seem,  as  we  began  by  saying, 
to  resolve  itself  into  a  question  of  words. 
At  the  same  time  it  apj^ears  unscientific 
to  confound  together  a  state  of  simple 
emotional  depression  with  that  of  delu- 
sional melancholia. 

There  can  be  no  doubt  that  in  a  num- 
ber of  cases  of  seeming  moral  insanity, 
there  develop,  in  course  of  time,  definite 
delusions,  especially  of  suspicion.  But 
what  if  a  man  commits  a  crime  in  the 
preliminary  stage  of  the  disorder  of  the 
emotions,  prior  to  the  development  of  in- 
telligential  disorder  ?  It  is  not  sufficient 
to  predict  what  will  eventually  be  deve- 
loped— the  fact  remains  that  the  disorder 
has  not  advanced  beyond  moral  insanity. 
If  it  be  preferred  to  call  moral  insanity 
the  incipient  stage  of  a  form  of  mental  dis- 
ease which  involves  the  intellectual  as  well 
as  the  moral  faculties,  enough  is  conceded 
to  permit  both  parties  in  the  debate  to 
agree.  Just  as  mental  frequently  precede 
motor  symptoms  in  coarse  brain  disease 
(tumours,  syphilitic  disease,  arterial  de- 
generation, atrophy,  &c.),  so  may  mental 
symptoms  firtt  marked  by  moral  per- 
versity be  followed  by  delusional  insanity. 
In  a  young  man  under  Dr.  Clouston's 
care,  this  was  the  sequence  of  events, 
while  a  third  stage  was  marked  by  motor 
disturbance — convulsions  with  partial 
paralysis  of  one  side.  Likewise  there  are 
instances  of  senile  insanity  in  which 
moral  lapses  first  attract  attention,  then 
distinct  mental  weakness,  and  lastly 
apoplexy  and  paralysis.  There  may  be 
even  in  these  cases  occurring  in  advanced 


Moral  Insanity 


[    815    J 


Moral  Insanity 


life,  a  predisposition  to  insanity  which 
is  brought  to  the  surface  by  a  moral  or 
physical  shock  ;  this  so  far  affects  the 
question  of  moral  insanity  now  under 
consideration  that  there  may  be  under- 
lying the  apparently  coarse  causation  of 
the  attack  an  instability  of  nerve-tissue 
which  is  the  factor  in  immediate  relation 
to  the  moral  disorder. 

It  is  highly  important  to  bear  in  mind 
that  many  cases  of  moral  insanity  are 
complicated  with  epilepsy. 

This  fact  does  not  appear  to  us  to  re- 
move the  case  from  the  category  of  moral 
disorders.  Epilepsy  may  surely  affect 
one  part  of  the  mental  constitution  in 
preference  to  another.  It  may,  and  gen- 
erally does,  seriously  injure  the  memory, 
but  it  may  pervert  the  moral  nature  so 
as  to  induce  homicidal  attacks,  and  leave 
the  memory  intact. 

On  the  whole,  it  appears  to  us,  while 
fully  granting  that  a  searching  inquiry 
into  the  mental  condition  present  in  such 
<5ases  of  alleged  moral  insanity,  would  very 
frequently  reveal  intellectual  disorder — 
that  clinical  observation  cannot  be  satis- 
fied without  distinguishing  between  the 
cases  which  are,  and  those  which  are  not, 
markedly  complicated  with  intellectual 
defect  or  disorder.  To  obliterate  distinc- 
tions, however  fine,  between  these  condi- 
tions, does  not  seem  the  way  to  advance 
the  scientific  study  of  insanity. 

We  would  now  refer  to  the  bearing  of 
mental  science  on  the  form  of  insanity 
under  consideration.  We  have  elsewhere 
recorded  how  Herbert  Spencer  would  meet 
a  legal  opponent  of  the  doctrine  of  moral 
insanity  who  should  base  his  argument 
on  the  statement  that  as  intellect  is 
held  to  be  evolved  out  of  feeling,  and 
as  cognitions  and  feelings  are  declared 
by  him  to  be  inseparable,  there  cannot  be 
organic  or  acquired  moral  defect  without 
the  intellect  being  involved.  Spencer's 
answer  does  not  militate  against  anything 
maintained  in  the  present  article.  In- 
deed,* he  finds  an  indication  of  such  struc- 
tural deficiency  as  may  lead  to  results 
alleged  to  be  present  in  moral  imbecilit}' 
and  insanity,  in  the  fact  that  every  com- 
plex aggregation  of  mental  states  is  the 
outcome  of  the  consolidation  of  simpler 
aggregations  already  established.  This 
higher  feeling  is  merely  the  centre  of  co- 
ordination, through  which  the  less  com- 
plex aggregations  are  brought  into  j^roper 
relation.  The  brain  evolves  under  the  co- 
ordinating plexus  which  is  in  the  ascend- 
ency, an  aggregate  of  feelings  which 
necessarily  vary  with  the  relative  propor- 

*  These  views  are  also  expressed  in  the  '•  I'riii- 
•tiples  of  Psychology,"  vol.  i.  p.  575. 


tions  of  its  component  parts.  But  in 
this  evolution  it  is  obviously  possible  that 
this  centre  of  co-ordination  may  never  be 
developed  ;  what  Spencer  calls  the  higher 
feeling,  or  most  complex  aggregation  of 
all,  may  never  be  reached  in  the  progress 
of  evolution,  and  moral  imbecility  may 
result,  or  such  waywardness  of  moral  con- 
duct from  youth  upwards  as  we  main- 
tain occurs  v/ithout  marked  disorder  of 
the  intellect.  When  in  the  absence  of 
congenital  defect,  the  moral  character 
changes  for  the  worse  under  conditions 
which  imply  disease  rather  than  mere 
vice,  Spencer  finds  a  clue  to  a  probable 
cause  in  so  simple  an  occurrence  as  fret- 
fulness,  which  arises,  as  we  all  know, 
under  physical  conditions,  such  as  inac- 
tion of  the  alimentary  canal.  Fretfulness 
is,  as  he  justly  says,  "  a  display  of  the 
lower  impulses  uncontrolled  "by  the 
higher."  This  is  essentially  a  moral  in- 
sanity. So  is  the  irascibility  of  persons 
in  whom  the  blood  is  poor,  and  the  heart 
fails  to  send  it  with  sufficient  force  to  the 
brain.  Spencer  puts  it  in  terms  which 
bear  directly  upon  the  question  we  are 
discussing,  when  he  says,  "  irascibility 
implies  a  relative  inactivity  of  the  superior 
feelings The  plexuses  which  co- 
ordinate the  defensive  and  destructive  ac- 
tivities, and  in  which  are  seated  the  ac- 
companying feelings  of  antagonism  and 
anger,  are  inherited  from  all  antecedent 
races  of  creatures,  and  are  therefore  well 
organised — so  well  organised  that  the 
child  in  arms  shows  them  in  action.  But 
the  plexuses  which,  by  connecting  and  co- 
ordinating a  variety  of  inferior  plexuses, 
adapt  the  behaviour  to  a  variety  of  exter- 
nal requirements,  have  been  but  recently 
evolved,  so  that,  besides  being  extensive 
and  intricate,  they  are  formed  of  much 
less  permeable  channels.  Hence,  when 
the  nervous  system  is  not  fully  charged, 
these  latest  and  highest  structures  are  the 
first  to  fail :  instead  of  being  instant  to 
act,  their  actions,  if  ajjioreciable  at  all, 
come  too  late  to  check  the  actions  of  the 
subordinate  structures."    {Op.  cit.  p.  605.) 

Hence,  although  "no  emotion  can  be 
absolutely  free  from  cognition  "  (jx  475), 
it  is  allowed  by  Spencer  that  there  may 
be  "a  relative  inactivity  of  the  superior 
feelings,"  and  therefore  moral  insanity,  by 
whatever  name  it  may  be  called,  is  in  full 
accord  with  the  princijiles  of  mental  evo- 
lution and  dissolution,  as  laid  down  by 
this  great  psychologist. 

The  following  propositions  appear  to 
be  warranted  by  a  careful  consideration 
of  the  psychological,  as  well  as  the  clini- 
cal, facts  : 

(i)  The    higher  levels  of   cerebral  de- 


Moral  Insanity 


8i6    J 


Morbi  Sancti  Valentini 


velopraent  which  are  concerned  in  the 
exercise  of  moi'al  control — i.e.,  "the  most 
voluntarj'"  of  Hughlings  Jackson,  and 
also  "  the  altruistic  sentiments  "  of  Spen- 
cer^are  either  imperfectly  evolved  from 
birth,  or  having  been  evolved  have  become 
diseased  and  more  or  less  functionless, 
although  the  intellectual  functions  (some 
of  which  may  be  supposed  to  lie  much  on 
the  same  level)  are  not  seriously  affected  ; 
the  result  being  that  the  patient's  mind 
presents  the  lower  level  of  evolution  in 
which  the  emotional  and  automatic  have 
fuller  play  than  is  normal. 

(2)  No  doubt  it  is  difficult  to  lay  down 
rules  by  which  to  differentiate  moral  in- 
sanity from  moral  depravity.  Each  case 
must  be  decided  in  relation  to  the  indi- 
vidual himself,  his  antecedents,  educa- 
tion, surroundings,  and  social  status,  the 
nature  of  certain  acts,  and  the  mode  in 
which  they  are  performed,  along  with 
other  circumstances  fairly  raising  the 
suspicion  that  they  are  not  under  his 
control.*  The  Edjtgk. 

[Keferences. — For  a  series  of  cases  supporting  the 
position  talceu  in  this  article,  see  the  writer's  paper 
on  Moral  Insanity  in  the  .Journal  of  Mental 
Science,  July  and  October,  1885  ;  also,  I'richard  and 
Symonds,  with  chapters  on  Moral  Insanity,  by  Dr. 
Hack  Tnke,  1891.  Consult  the  works  of  Maudsley 
and  Clouston.  Jules  Falret,  L»e  la  Folic  morale, 
1866.  C.  H.  Hughes,  A  Case  of  Moral  Insanity, 
Alienist  and  Neurologist,  1882,  :So.  4.  Wright,  The 
Physical  Basis  of  Moral  Insanity,  Alienist  and 
Neurologist,  1882,  No.  4.  A.  Hollander,  Zur  Lelire 
von  der  "Moral  Insanity,"  1882.  lUancaleone  Ri- 
bando,  Contributo  suU'  esistenza  della  f cilia  morale, 
Palermo,  1882.  Salenii-Pacc,  Un  caso  di  follia 
morale,  Palermo,  1881.  Tamburini  and  Seppilli, 
Studio  di  psico-patologia  criminale  >opra  un  caso 
di  imbecillita  morale  con  idee  fisse  imi)ulsive, 
Keggio,  1883,  2nd  edit.  1887.  G.  B.  Verga,  Caso 
tipico  di  follia  morale,  Milano,  1881.  Virgilio, 
Delle  malattie  mentali,  1882.  Legrand  dn  SauUe, 
Les  SiL;ues])hysi(|nes  des  Foliesraisounautes,  Paris, 
1878.  3Iendel,  Die  moralischcWahnsiini,  1876,  No. 
52.  M.  (iauster,  Ueber  moralisches  Irrsinn,  1877. 
3Iotet,Cas  de  Folic  morale,  Ann.  Med. -psych.  1883. 
Reimer,  Moralisches  Irrsinn,  Deutsche  Wochen- 
schrift,  1878, 18, 19.  H.  Emmingliaus,  AUgemeiii. 
Psycho-patht)logie,  &c.,  Leipzig,  1868.  Todi,  I 
pazzi  ragionanti,  Novara,  1879.  Grohmann, 
Nasse's  Zeitschrift,  1819,  162.  Heinrich,  All- 
gem.  Zcitschrift  f.  Psychiatric,  i.  338.  Morel, 
Traite des Degenerescences,  1857.  B.  de  Boismont, 
Les  Fous  criniinels  de  TAngleterre,  1869.  Solbrig, 
Verbrechen  und  \^'ahnsinn,  1867.  Griesinger, 
Vierteljahrsehrift  t.  ger.  u.  offentl.  Med.,  N.F.  iv. 
No.  2.  Krafft-Ebing,  Die  Lehre  von  moral  Wahu- 
sinn,  1871.  Stolt/.,  Zeitschr.  f.  Psychiatric,  33,  H. 
5  und  6.  I>ivi,  Kevista  sperimentale,  1876,  fasc.  5 
et  6.  Ganster,  Wien.  med.  Klinik,  iii.  Jalirg. 
No.  4.  Mendel,  Deutsche  Zeitschr.  f.  prakt.  Med. 
i876,No.  52.  Wahlberg,  Der  Fall  Hackler,  Gesam- 
melte  kleinere  Sclirifteu,  Wien,  1877.  Bannister, 
Chicago  Journal,  Oct.  1877.  I'almerini,  lionfigli, 
Revista  si)erimentale,  1877,  fasc.  3  et  4,  &c. 
Bonvecchiato,   II  senso  morale  e  la  follia  morale, 

*  Dr.  Goldsmith, "  ( 'ase  of  Moral  Insanity,"  Ann-r. 
Joiirii.  of  insfinity,  Oct.  1883. 


A'enice,  1883.  Dagonet,  Folie  morale,  1878.  Lom- 
broso,  L"  uomo  delinquente,  4th  edit.  1889.  Lau- 
rent, Les  Habitues  des  Prisons,  1890,  ch.  vi. 
Tamburini  and  Guicciardini,  Ulteriori  studi  8U  un 
caso  d'  imbecillita  morale,  Archivio  di  Psichiatria, 
1888,  fasc.  i.  Sii^hicelli  and  Tambroni,  Pozzia 
morale  ed  epilessia,  Revista  sperimentale,  1888, 
fasc.  iv.  D'  Abundo,  Un  caso  di  pozzia  morale, 
Archivio  di  Psichiatria,  1889,  fasc.  i.  Marro.  I 
caratteri  dei  delinquenti,  Turin,  1887,  part  ii. 
cli.  18. 

IVXORAI.  TREATMEN-T  OF  ZIT- 
SA.N'E.     {Sie  Treatmkxt.) 

IVIORBUS  A  CEXiSZ  (Celsus).  A  syn- 
onym of  Catalepsy. 

nxoRBVS  ASTRAZiIS  (morbus,  a  dis- 
ease :  (isfralis,  pertaining  to  the  stars). 
A  synonym  of  Epilepsy. 

IMIORBUS  CABTTCUS  (cado,  I  fall)  ; 
IVIORBUS  COMITIAIiZS  (romitia,  the 
assemblies  for  the  election  of  magistrates); 
MORBirs  HJETi/lONXACVS  idaemon; 
Gr.  dalfxcov,  an  evil  spirit);  IMCORBVS 
D.a:iVIOiriUS  [daemon);  MORBUS 
BIVZM'US  (divinns,  holy,  belonging  to 
the  gods).     Synonyms  of  Epilepsy. 

MORBUS  ERUDZTORUM  {eri'ditus, 
learned) :  MORBUS  fZiATUIiEITTUS 
(flatus,  wind).  Synonyms  of  Hypochon- 
driasis. 

IVIORBUS  FSDUS  {foedus,  horrible). 
A  synonym  of  Epilej^sy. 

MORBUS  GESTZCUI.ATORZUS 

(gesticulatio,  expression  by  signs).  A 
synonym  of  Chorea. 

MORBUS  HERACZiEUS  {'HpaKX^s, 
Hercules)  :  MORBUS  HERCUI.EUS 
{Hercules)  ;  MORBUS  ZM'FATl'TZI.ZS  ; 
MORBUS  ZTTTERZiUNZS  {inter;  h'.na, 
between  the  moon's  phases)  ;  MORBUS 
IiUlfATZCUS  {Innaticv.s.  belonging  to  an 
insane  person)  ;  IVIORBUS  MAGNUS  ; 
MORBUS  MAJOR;  MORBUS  MEN"- 
TAIiZS  {nientalis,  pertaining  to  or  affect- 
ing the  mind).     Synonyms  of  Epilepsy. 

IVIORBUS  MZRACHZAZiZS  (miro.- 
chialis,  adjectival  form  of  tnirachulum, 
corruption  of  iniraculiom,  a  miracle).  A 
synonym  of  Hypochondriasis. 

MORBUS  POPUZiARZS  (populus,  the 
people) ;  IVIORBUS  PUBZ.ZCUS  (p^'.bli- 
cus,  the  people) ;  MORBUS  PUERZ1.ZS 
(p'lier,  a  youth).     Synonyms  of  Epilepsy. 

MORBUS  RESZCCATORZUS  {re ; 
sicco,  I  exhaust);  MORBUS  RUCTU- 
OSUS  (rucfo,  I  eructate).  Synonyms  of 
Hypochondriasis. 

IVIORBUS  SACER  (sneer,  holy).  A 
synonym  of  Epilepsy. 

IVIORBUS  SAZ.TATORZUS  (salto,  I 
dance).     A  synonym  of  Chorea  Major. 

MORBUS  SAM^CTZ  JOAM-M-ZS. — A 
synonym  of  Epileps}'. 

MORBUS  SANCTZ  VAZ.EM'TZM^Z. 
— A  synonym  of  Chorea  Major,  also  of 
Ejiilepsy. 


Morbus  Scelestus 


817     J 


Morphiomania 


MORBUS  SCEliESTTTS  (scelesius,  in- 
famous) ;        IVXORBUS        SEIiENIACUS 

{a-eXijvr],  the  moon )  ;  MORBUS  SZDBRil- 

TIIS  (sicZera,  the  stars);  MORBUS  SOTT- 
TZCUS  {sonticU'S,  dangerous)  ;  MIORBUS 
VIRZDEXiIiUS  {riridellHi^,  from  viriditi, 
young,    youthful);    AXORBUS    VXTRZO- 

IiATUS  {intnim,  anything  clear  or  trans- 
parent).    Synonyms  of  Epilepsy. 

MORDTRXEB. — The  German  term  for 
homicidal  mania. 

MORXi\.  (fioipia,  folly).  A  synonym  of 
Idiotism,  also  Dementia. 

IVIOROSXS  (ixapoxTis,  duluess  of  the 
senses).     Fatuitas,  idiotism. 

IVIOROSITATES  (jLtcuptufrt?,  dulness  of 
the  senses,  silliness).  A  term  apj^lied  by 
Linnajus  to  certain  forms  of  mental  aberra- 
tion under  which  he  includes  pica,  buli- 
mia, polydipsia,  antipathia,  nostalgia, 
panophobia,  satyriasis,  nymphomania, 
tarentismus,  hydrophobia,  etc.  iq.v.). 

MOROTROPHXUM  (/xcopos,  foolish ; 
Tpocjir],  that  which  nourishes  or  sustains). 
An  insane  establishment,  lunatic  asylum 
or  madhouse. 

MORPHIA.     (See  Sedatives.) 

MORPHIM-OMAirXA,  MORPHXO- 
MANIA,  MORPHOMAirXA  (morphia, 
morphine  ;  pavia,  madness) .  The  morbid 
uncontrollable  desire  for  morphia.  The 
morphia  habit.  {Yv.  niorplbeomanie  ;  Ger. 
Morphiomanie.)     (See  Art.) 

MORPHXOMAM-XA,  or  MORPHXM'O- 
T/LAJtlA  (morphia  habit,  opium  habit, 
morphinism,  Morphiuinsuclit,  morphinis- 
'mus  cJironicus,  'niorphinisnie). 

Definition.  —  By  morphiomania  we 
understand  the  diseased  craving  for  mor- 
phia as  a  stimulant,  together  with  the  cli- 
nical aspect  ot  the  disease,  which  is  pro- 
duced by  morphia-intoxication.  Morphio- 
mania is  similar  to  alcoholism,  in  which 
also  the  diseased  craving  for  drink  is  con- 
nected with  somatic  and  mental  derange- 
ments, produced  by  the  continuous  taking 
of  alcohol. 

The  history  of  morphiomania  begins 
with  the  year  1864.  C^reat  Britain  has 
contributed  very  little  indeed  to  the  litera- 
ture of  this  subject,  which  is  very  exten- 
sive. 

As  causes  of  morphiomania,  all  those 
conditions  have  to  be  mentioned  for  which 
morphia  is  used  on  account  of  its  narcotic 
effects :  conditions  of  bodily  pain  and  mental 
distress.  To  the  former  belong  all  kinds 
of  neuralgia,  migraine,  and  headache ;  pains 
at  the  commencement  of  tabes  dorsalis 
and  in  cerebral  diseases,  gout  and  rheu- 
matism, hepatic  colic  and  dysmenorrhoea, 
asthma,  nausea  of  pregnant  women,  and 
nocturnal  emissions,  &c.  To  the  latter 
belong   the   mental  depression  of   hypo- 


chondriasis and  melancholia,  grief  over 
the  loss  of  a  dear  relative  or  friend, 
mental  excitement  caused  by  over-work, 
anxiety  in  agoraphobia,  neurasthenia, 
hysteria,  &c.  Among  other  causes  we 
may  mention  imitation  and  falling  a 
victim  to  temptation.  Mental  causes 
alone  induce  morphiomania  much  more 
rarely  than  somatic  ones.  Between  men- 
tal and  somatic  causes  stands- — often  be- 
longing to  both — sleeplessness,  which  is  of 
great  importance  because  of  its  frequency.. 
Not  every  one  who  gets  morphia  injected 
becomes  a  raorphiomaniac ;  a  certain  dis- 
position, a  neuropathic  constitution,  is  re- 
quired, which  is  characterised  by  weak- 
ness of  will,  inability  to  resist  mental  im- 
pressions, and  an  abnormal  excitability. 
If  morphiomania  is  produced  by  these,  it 
is  a  disease ;  if  this  disposition  is  not  pre- 
sent, it  is  a  vice. 

There  is  no  pathological  anatomy  of 
morphiomania  because  the  changes  which 
have  been  found  to  have  taken  place  in 
the  bodies  of  morphio maniacs  cannot  be 
brought  into  distinct  connection  with  mor- 
phia, and  have  therefore  to  be  taken  as 
accidental  changes. 

The  symptoms  of  morphiomania  have, 
for  the  sake  of  a  better  view,  to  be  con- 
sidered under  several  groups.  We  ought 
to  take  into  this  chapter  the  symptoms  of 
intoxication  only,  but  it  is  practical  to 
treat  here  also  of  those  symptoms  which 
are  produced  by  leaving  off  morjjhia,  and 
which  are  called  symptoms  of  abstinence 
or  deprivation. 

A.  Intoxication. — First  we  shall  enu- 
merate   THE    SYMPTOMS    OF    INTOXICATION, 

and  we  distinguish  these  as  {a)  somatic 
and  (6)  mental  symptoms.  In  every  mor- 
phiomaniac  symptoms  of  abstinence  can  be 
observed  during  the  period  of  intoxication, 
because  the  effect  of  one  dose  of  morphia 
ceases,  and  therefore  produces  symptoms 
of  abstinence  before  another  dose  is  in- 
jected. 

Among  the  («)  somatic  symptoms  of  in- 
toxication have  to  be  mentioned — 

(i)  Motor  Bisturhances. — -These  are 
paresis,  ataxy,  and  tremor,  represented  by 
the  decrease  of  peristaltic  motion  of  the 
intestines,  incontinence  of  the  bladder, 
ataxic  gait,  and  tremor  on  writing.  The 
knee-jerks  are  not  at  all  influenced  by 
morphia  ;  if  they  are  absent,  we  have  to 
suspect  tabes  dorsalis ;  if  they  are  in- 
creased, we  have  to  think  of  neuritis  or  of 
spastic  spinal  paralysis. 

(2)  Derangements  of  the  Organs  of 
Secretion:  Partial  or  complete  impo- 
tency  in  men.  There  is  not  only  no 
libido,  but  also  no  erections,  and  the 
seminal    secretion    ceases,   although  ex- 


Morphiomania 


[     8i8     3 


Morphiomania 


ceptions  are  not  rare.  In  women,  amen- 
orrhoea  and  sterility  develop,  but  here 
also  we  have  exceptions.  The  children  of 
mothers  who  suffer  from  chronic  morphia 
poisoning  have  in  the  first  days  of  their 
life  to  pass  through  a  stage  of  abstinence 
similar  to  that  of  adults,  during  which 
often  dangerous  collapses  occur,  and  in 
which  the  life  of  the  children  can  only  be 
saved  by  an  injection  of  morphia  or  by 
opium.  In  women  the  secretion  of  milk, 
and  fiuor  albus  cease.  The  seci'etion  of 
saliva  decreases,  and  that  of  sweat  in- 
creases. Often  also  the  quantity  of  urine 
is  increased.  The  functions  of  the  seba- 
ceous glands  of  the  skin  are  lessened,  and 
the  skin  becomes  dry  and  brittle. 

(3)  Derangements  of  Nutrition. — Loss 
of  appetite,  foul  tongue,  no  sense  of 
satiety,  slow  digestion,  sluggishness  of 
the  bowels.  General  loss  of  nutrition ; 
anaemia  begins  to  develop  itself. 

(4)  Various  Derangements.  —  Trophic 
derangements  of  the  nails  of  the  fingers 
and  toes  (dry  and  brittle),  of  the  hair 
(becomes  grey,  white,  and  comes  off),  and 
of  the  teeth,  the  enamel  of  which  becomes 
soft  and  falls  off.  Healthy  teeth  become 
loose  and  are  very  often  observed  to  fall  out. 
Contraction  of  the  pupils  produced  by 
morphia-taking  is  sometimes  unilateral — 
consequently  unequal  pupils  and  decrease 
of  the  range  of  accommodation  (hyperme- 
tropia).  Cutaneous  eruptions  occur  in  con- 
sequenceof  the  increased  diaphoresis.  Fever 
is  mostly  a  consequence  of  abscesses  caused 
by  the  injections.  The  occurrence  oifebris 
intermittens  ex  'ynor2Jhinism,o  is  doubtful. 
If  morphia  is  injected  into  a  vein,  the 
vaso-motor  system  is  greatly  irritated,  the 
temperature  rises,  congestions  are  pro- 
duced in  the  head  and  lungs  (dj'spuoea), 
and  the  frequency  of  the  pulse  is  greatly 
increased.  That  albumen  and  sugar 
appear  in  the  urine  of  persons  who  suffer 
from  chronic  morphia  poisoning,  as  a  sole 
consequence  of  intoxication  by  morphia, 
has  not  been  proved  with  sufficient  cer- 
tainty. Neuralgia  is  rarely  a  consequence 
of  the  morphia  habit. 

(b)  The  mental  symptoms  of  intoxica- 
tion have  to  be  divided  into  temporary  and 
pertnanent.  To  the  (1)  teinporarg  symp- 
toms belong  attacks  of  anxiety,  hallucina- 
tions of  vision,  and  drowsiness.  The  (2) 
permanent eS^ect  on  the  mind  is  repi'esented 
in  a  decrease  of  its  general  functions, 
which,  however,  developsin  most  cases  only 
after  large  doses  have  been  taken  for 
years.  It  includes  weakening  of  the 
intellect,  loss  of  memory,  deadening  of 
all  sensation,  and  an  extraordinary 
injury  to  the  morale.  This  last  point  is 
of  the  greatest  impoi'tance,  and  we  have 


to  keep  it  well  in  mind  in  treating  a 
jjatient.  The  whole  nature  of  the  man 
undergoes  a  moral  revolution.  Truth, 
right,  and  honour  lose  for  him  their 
meaning,  and  the  mental  state  of  such 
patients  can,  without  straining  the  in- 
terpretation, be  called  a  kind  of  moral 
insanity.  Morphiomaniacs  forge  prescrip- 
tions, deceive  their  relations  and  the 
doctor,  become  negligent,  hardened  in 
conscience,  and  dissolute,  and  show 
morbid  impulses  of  various  kinds ;  they 
acquire  an  extraordinary  artfulness  in 
trying  to  hide  and  to  excuse  things  which 
relate  to  their  abuse  of  morphia.  Chronic 
morphia-poisoning  produces  mental  weak- 
ness, and  therefore  belongs  to  the  causes 
of  insanit}'.  We  are  not  allowed  to  speak 
of  "  morphia-insanity "  in  general,  be- 
cause intoxication,  as  well  as  abstinence — 
two  conditions  contrary  to  each  other — 
can  produce  forms  of  insanity  which  differ 
as  regards  symptoms  and  prognosis.  The 
most  frequent  form  of  insanity  produced 
by  intoxication  is  monomania  (mania 
marked  by  delusions  as  to  persecution, 
and  mania  with  exalted  views,  together 
with  mental  weakness).  This  form  is 
mostly  incurable.  Very  frequent  also  in 
morphiomaniacs  are  abnormal  mental  con- 
ditions which  do  not  present  a  fully  deve- 
loped form  of  insanity.  We  may  well  say 
that  such  persons  are  not  in  a  normal  men- 
tal state,  but  it  is  often  very  difficult  to 
refer  the  symptoms  to  any  special  form  of 
insanity. 

B.  Symptoms  of  Abstinence.  —  It  is 
practicable  to  distinguish  between  the  (a) 
sytnptoiins  of  sudden  and  of  sloio  depriva- 
tion. The  most  important,  because  the 
most  dangerous,  symptom  is  collapse, 
which,  however,  only  occurs  after  sudden 
deprivation,  and  which  may  cause  death  by 
paralysis  of  the  heart.  Another  symptom 
of  sudden  deprivation  is  the  excitement 
which  bears  the  character  of  delirium 
maniaeale ;  in  women  it  often  assumes  a 
somewhat  hysterical  form.  It  is  well 
known  that  every  delirium  may  be  fol- 
lowed by  albuminuria,  a  fact  which  we 
do  well  to  bear  in  mind. 

(6)  8I0VJ  deprivation. — -We  shall  first 
treat  of  the  somatic  and  then  the  'mental 
symptotns.  To  the  (i)  sotiiatic  symptoms 
belong :  Contractions  of  single  muscles, 
local  and  general  tremor,  sense  of  weak- 
ness and  debility,  ataxic  gait,  paresis  of 
the  muscles  of  the  eye,  inequality  of  the 
pupils,  disturbance  of  accommodation, 
neuralgia  and  neuralgic  jjains,  especially 
in  the  calves  of  the  legs,  hemicrania,  all 
kinds  of  partesthesia,  sense  of  heat  and 
cold,  pains  in  the  stomach,  the  intestines, 
anus,  and  bladder,  dysmenorrhoea,  hyper- 


Morphiomania 


[    819    ] 


Morphiomania 


ajsthesia  of  all  the  senses,  derangements  of 
the  vaso-motor  and  respiratory  system, 
paralysis  of  the  vessels,  -which  can  be 
proved  by  the  sphygmograph,  and  which 
can  be  changed  by  a  full  dose  of  morphia 
into  normal  tension ;  besides  tliis,  reflex 
disturbances,  as  paroxysmal  sneezing, 
yawning,  singultus,  choking,  vomiting, 
and  general  convulsions.  Of  anomalies  of 
the  secretory  system  we  must  mention : 
coryza,  lacrymation,  diarrhoea,  sweating, 
nocturnal  emissions,  and  menorrhagia. 
General  nutrition  fails,  and  the  body  loses 
weight.  We  have  .to  mention  among  ilie 
(2)  inental  sijmiUoms  of  abstinence  :  gene- 
ral restlessness,  sleeplessness,  depression 
of  mind,  loss  of  memory,  slight  mental 
disturbance  (a  quiet  and  an  excited  form), 
great  craving  for  morphia,  wine  and  other 
nai-cotic  and  alcoholic  stimulants.  Among 
other  symptoms  of  abstinence,  forms  of 
insanity  (one  lasting  a  short  time  and 
another  chronic)  and  attacks  of  hysteria 
have  been  observed.  After  the  patients 
have  become  weaned  from  morphia,  some 
of  the  before-named  symptoms  still  con- 
tinue, and  we  have  to  watch  very  carefully 
over  the  'morale  of  the  patient. 

(c)  Under  secondary  sympto'nis  of  absti- 
nence, or,  better,  under  secondary  condi- 
tions of  debility,  we  include  symptoms  of 
general  weakness  which  appear  some 
weeks  or  months  after  the  period  of  de- 
privation, if  the  patient  is  not  very  careful ; 
it  is  a  breaking  down  resulting  from  too 
early  and  too  great  exertion. 

(c?)  We  have  no  sufficient  e.eplanation  of 
the  symptoms  of  abstinence  ;  we  have  still 
to  accept  the  explanation  that  the  nervous 
system  is  deprived  of  a  customary  stimu- 
lant. It  is  impossible  to  explain  the  symp- 
toms chemically,  as  has  been  tried  by  sup- 
posing that  oxide  of  morphia,  which  is  said 
to  be  formed  in  the  organism,  causes  the 
symptoms  of  abstinence  as  soon  as  no 
more  morphia,  which  is  an  antidote  to 
oxide  of  morphia,  is  introduced  into  the 
system. 

The  diag^nosis  of  morphiomania  is  gene- 
rally easy,  because  the  patient  himself 
confesses  his  abuse,  and  because  the 
marks  of  the  injections  confirm  his  state- 
ments. It  is  more  difficult  if  the  patient 
is  suspected  to  be  in  the  habit  of  taking 
morphia  but  he  himself  denies  it.  This 
may  happen  if  morphia  is  during  or  after 
the  period  of  deprival  secretly  introduced 
into  the  system.  It  is  impossible  to 
prove  it  as  certain,  and  we  have  therefore 
to  try  to  find  it  out  in  any  possible  way. 
To  analyse  the  urine,  saliva,  faeces,  and 
the  contents  of  the  stomach  in  search  of 
morphia  is,  apart  from  the  complexity  of 
this  process,  far  from  being  reliable.     It 


is  best  to  inspissate  the  urine  of  the  pa- 
tient suspected  to  take  morphia  secretly, 
and  to  inject  the  residue  subcutaneously 
into  an  animal.  If  the  urine  contains 
morphia,  the  animal  will  show  symptoms 
of  acute  morphia  poisoning.  But  this 
experiment  is  only  successful  if  large 
doses  have  been  taken  secretly.  We  also 
can  examine  the  ])ulse  with  a  sphygmo- 
graph. For  a  short  time  after  the  period 
of  deprival  there  is  paralysis  of  the  vessels. 
If  we  find  during  this  time  signs  of  tension 
of  the  arteries,  we  must  be  suspicious. 
However,  this  is  not  a  certain  proof. 

Treatment. — A.  Methods  of  Depriva- 
tion.— (n)  Slotv  Deprivation.  Laelir-Burh- 
ardt  Method. — This  is  the  oldest  method, 
but  also  the  worst  of  all.  It  reduces  slowly 
the  daily  doses,  but,  as  even  in  the  slowest 
process  the  symptoms  of  abstinence  can- 
not be  avoided,  the  sufferings  of  the 
patients  are  very  much  prolonged,  and, 
as  the  patient  is  not  kept  under  control, 
he  mostly  succumbs  to  the  temptation  to 
take  morphia  secretly.  This  method  does 
not  require  any  special  arrangements  as 
regards  a  locality  for  the  patient  to  stay 
in,  but  can  be  applied  at  any  place. 

(6)  Sudden  Deprivation,  Levinstein  Me- 
thod.— The  patient  is  at  once  deprived  of 
all  morphia,  but,  as  it  always  causes  a 
maniacal  delirium,  special  arrangements 
have  to  be  made.  This  method  can 
only  be  applied  in  an  asylum,  where  the 
patient  can  be  isolated.  It  is  apt  to  cause 
collapse  and  paralysis  of  the  heart,  and 
therefore  it  must  be  rejected,  although 
apart  from  this  danger  it  helps  the  pa- 
tient in  the  quickest  way  over  the  suffer- 
ings of  deprivation. 

(c)  Quick  Deprivation,  Erlenmeyer 
Method. — It  is  the  best  and  most  rational 
method,  and  is  highly  esteemed.  Il 
avoids  all  the  dangers  of  sudden  absti- 
nence, and  deprives  the  patient  of  the 
customary  dose  in  from  three  to  eight  days 
with  the  greatest  care  and  under  proper 
supervision.  The  patient  is  kept  in  bed, 
and  is  surrounded  by  experienced  atten- 
dants; female  attendants  are  to  be  pre- 
ferred, even  in  the  case  of  male  patients. 
B.    The     Place    most    Suitable    for 

UNDERGOING    TREATMENT  BY  DEPRIVATION. 

— It  must  not  be  at  the  patient's  own  house 
or  in  his  family,  neither  at  a  bathing-place, 
because  these  do  not  give  the  slightest 
chance  of  sixccess.  Better  is  a  hydro- 
pathic institution,  an  institution  for 
nervous  diseases,  or  even  an  asylum,  but 
the  most  suitable  place  is  a  house  specially 
established  for  and  restricted  to  this  one 
purpose  of  cure  of  morphiomania  by 
deprivation.  Of  the  greatest  importance, 
however,  in  all  such  institutions  is  the 

36 


Morphiomania 


[    820    ] 


Movements 


personality  of  the  physician  himself.  A 
patient  who  snfi'ers  from  morj^hia  poiBon- 
ing  should  never  be  placed  under  the  care 
of  a  doctor  who  has  been  or  is  a  morphio- 
maniac  himself,  because  this  does  not 
give  the  slightest  guai'antee  for  the  success 
of  the  treatment. 

C.  The  Treatment  oe  Individual 
Symptoms  during  the  period  of  depriva- 
tion can  not  be  gone  into  here,  because 
there  are  too  many  of  them,  and  a  de- 
scription of  their  treatment  would  ex- 
ceed the  space  of  this  article.  We  will 
only  draw  attention  to  two  important 
points  :  First,  that  collapse  has  always 
to  be  considered  as  a  symptom  dangei'ous 
to  life,  even  in  its  commencing  stage,  and 
that  a  full  dose  of  morphia  is  the  only 
means  to  save  the  life  of  the  patient; 
secondly,  that  it  is  entirely  wrong  to  try 
to  lessen  the  suffering  of  the  period  of 
deprivation  by  substituting  for  morphia 
another  drug  or  another  medicine.  The 
lamentable  consequences  of  the  treatment 
of  morphiomaniacs  with  cocaine  are  an 
instructive  example  hereof.  Codeine, 
which  lately  has  been  very  much  recom- 
mended, must  be  absolutely  rejected,  and 
it  is  contrary  to  experience  to  maintain 
that  people  cannot  become  accustomed  to 
codeine,  and  that  the  dej^rivation  of 
codeine  does  not  cause  any  symptoms  of 
abstinence.  In  fact,  there  exists  a  codeine 
mania,  and  its  withdrawal  causes  severe 
symptoms  of  abstinence. 

D.  Prevention  OF  Kelapses. — We  have 
to  keep  in  mind  that  morphiomania  is  a 
secondary  disease  which  has  been  pro- 
duced by  another  disease  preceding  it 
(aetiology).  Under  the  intoxication  by 
morphia  the  symptoms  of  the  first  disease 
disappear,  but  return  after  the  patient 
has  left  off  taking  morphia.  Therefore, 
to  prevent  the  patient  returning  to  mor- 
phia, the  first  disease  has  to  be  treated, 
and  everything  depends  on  the  success  of 
this  treatment.  The  chronic  intoxication 
by  morphia,  as  well  as  the  deprivation  of 
it,  have  very  much  weakened  the  patient. 
We  have  to  be  careful  not  to  be  deceived 
by  an  increase  of  weight,  which  is  often 
astonishing,  and  which  takes  place  in 
consequence  of  the  patient's  large  appe- 
tite after  the  period  of  deprivation  is  over. 
This  is  only  the  laying  on  of  fat,  which  is 
of  no  importance  whatever  as  regards  the 
general  strength.  For  months  after,  the 
patient  must  remain  without  mental  or  bo- 
dily work  which  requires  effort;  he  must 
be  placed  in  pleasant  surroundings,  and 
must  be  kept  away  from  every  temptation. 

E.  General  prophylaxis  would  be  pos- 
sible by  making  laws  by  which  the  sale  of 
morphia  to  the  public  would  be  regulated  ; 


also,  by  public  instruction  and  warning, 
and  lastly  by  the  exercise  of  great 
caution  on  the  part  of  medical  men.  Such 
laws  are  in  force  in  many  countries,  but 
the  avarice  and  the  passions  of  men 
succeed  in  making  them  void. 

The  prog-nosis  of  morphiomania  as  a 
disease  is  most  unfavourable ;  it  termi- 
nates sooner  or  later  fatally  by  general 
marasmus.  A  certain  number  of  patients 
become  insane,  while  others  commit 
suicide.  The  prognosis  of  deprivation  is 
good.  If  done  cleverly,  the  treatment 
by  deprivation  will  prove  successful.  The 
prognosis  of  relapses  is  very  doubtful. 
There  are  some  morphiomaniacs  who 
cannot  be  induced  to  leave  off  taking 
morphia  because  they  suffer  from  painful 
incurable  diseases,  or  because  morphia 
would  have  only  to  be  replaced  by 
other  still  more  dangerous  stimulants 
(alcohol,  tobacco,  &c.).  The  prognosis  is 
always  better  in  proportion  to  the  length  of 
time  which  can  be  given  to  treatment  and 
for  the  patient's  restoration  to  strength. 

Forensic  .a,spect  of  the  Subject. — In 
all  judicial  proceedings  by  morphiomaniacs 
(will,  sale,  purchase,  &c.)  it  is  a  question 
of  the  responsibility  of  the  person  con- 
cerned, because  intoxication  lay  morphia 
can  produce  mental  derangement.  It  is 
not  sufficient  to  have  proved  morphio- 
mania, but  in  every  single  case  it  must 
be  proved  that  a  mental  derangement  is 
present,  and  that  therefore  the  jserson  is 
not  responsible  for  his  actions.  It  is  well 
known  that  morphiomaniacs  forge  pre- 
scriptions. Prescriptions  are,  from  a  legal 
point  of  view,  deeds,  and  the  forgery  of 
deeds  is  punishable.  Great  caution  is 
necessary  as  regards  life  insurance. 
Healthy  people  who  have  insured  their 
lives  and  who  afterwards  become  morphio- 
maniacs lose,  like  drunkards,  their  claims 
on  the  insurance  company.  Chemists  and 
druggists  who  act  contrary  to  the  laws  of 
those  countries  which  forbid  the  sale  of 
morphia  to  the  public,  are  justly  liable  to 
punishment.      Albrecht  Eklexmeyer. 

[Ii</<-rt'))C)>s. — Die  Morphiumsuclit,  vcu  Albrecht 
Erlenmeyer,  1887.  Morithiuisiiie,  par  51.  BaU. 
Les  Morphinomanes,  par  Dr.  H  Guimbai!,  1892.] 

MORTAXITV,    RATE    OT.       {See 
Statistics.) 
ivxovssz:  ECUMEUSE. — The  French 

term  for  frothing  at  the  mouth  in  epilepsy 
and  hydrophobia. 

MOVEMEN'TS  AS  SIGN'S  OF  IVIEM-- 
TAIi  ACTIOM*. — All  mental  action  is 
known  to  us  only  by  its  expression  in 
movements.  The  movement  of  a  part  of 
the  body  is  a  physical  fact ;  we  may  de- 
scribe the  part  moving,  and  the  time  and 
quantity  of  the  visible  action,  which  are 


Movements 


[ 


Movements 


here  called  the  attributes  of  the  move- 
ment ;  the  results  of  the  movement,  and 
its  necessary  antecedents,  though  not 
parts  of  the  act  itself,  often  help  to  deter- 
mine the  mental  character  of  the  act. 

A  single  movement  of  an  individual  part 
of  the  body  is  less  often  considered  as  a 
sign  of  mental  action  than  a  series  of 
movements  of  many  parts.  Hence  we 
have  to  consider  the  modes  of  studying 
a  single  movement  and  series  of  move- 
ments, and  their  relations  to  their  ante- 
cedents and  sequents,  as  well  as  to  sur- 
rounding objects. 

We  are  here  dealing  with  purely  phy- 
siological action,  no  metaphysical  con- 
siderations or  concern  with  the  facts  of 
consciousness  will  disturb  the  line  of  ob- 
servation and  argument  or  enter  into  any 
definition  or  explanation  given.  From 
this  point  of  view  the  study  of  mental 
action  is  simply  a  study  of  visible  move- 
ments and  the  corresponding  brain  action  ; 
we  are  concerned  with  their  accurate 
description,  their  causation  and  outcome. 
It  is  convenient  to  describe  modes  of 
movement  as  observed,  then  to  infer  the 
modes  of  brain  action  corresponding  there- 
to ;  various  mental  states  may  be  de- 
scribed in  terms  indicating  movement  and 
the  brain  action  corresponding. 

The  greatest  number  of  signs  that  we 
have  to  observe  are  movements  of  small 
parts  of  the  body,  parts  of  small  mass 
and  weight,  such  as  the  eyes,  the  mobile 
features  of  the  face,  the  hands  and  fingers. 
We  shall  proceed  to  study  a  visible  move- 
ment, then  some  series  of  movements  and 
the  corresponding  action  in  nerve-centres. 

A  visible  movement  may  follow  some 
impression  received  through  the  eye  or 
ear,  something  seen  or  some  word  heard  ; 
the  action,  if  it  follows  immediately  upon 
the  stimulus,  may  be  clearly  produced  by 
it.  When  there  is  the  least  amount  of 
present  brain  stimulation  the  brain  cen- 
tres are  the  most  free  and  ready  for  con- 
trol through  the  senses.  The  boy  who 
has  been  impressed  before  school  by  talk- 
ing of  a  bird-nesting  expedition  is  in- 
attentive to  his  master's  explanation  of 
Euclid.  When  the  movements  seen  have 
apparently  no  known  circumstances  im- 
mediately stimulating  them  they  are 
sometimes  said  to  be  "  spontaneous,"  and 
the  occurrence  of  many  such  acts  is  said 
to  indicate  spontaneity  in  the  subject. 
Examples  of  these  uncontrolled  move- 
inents  are  seen  in  the  wandering  eyes 
and  fidgeting  fingers  which  indicate  some 
emotional  states.  The  movements  of  the 
new-born  infant  which  we  have  described 
under  the  term  microkinesis  are  similarly 
"■'  spontaneous." 


The  sequents  of  movements  seen  may 
also  be  observed,  the  results  following  the 
action  are  not  parts  of  the  physiological 
phenomenon  but  serve  to  give  it  a  certain 
character  ;  a  muscular  contraction,  stimu- 
lated by  a  nerve-centre  is  always  itself 
a  physiological  fact,  the  first  outcome  of 
the  visible  movement  may  be  a  mechanical 
act  such  as  lifting  a  weight,  or  writing, 
&c.  The  sequents  of  movements  may  be 
very  complex  although  the  movement 
itself  be  a  simple  fact.  We  may  observe 
the  antecedents  and  the  sequents  of  an 
action  ;  noting  the  time  and  the  quantity 
of  each.  If  light  be  allowed  suddenly  to 
fall  upon  the  eye  the  iris  immediately 
contracts  the  pupil ;  if  we  speak  to  a 
child  there  may  be  a  period  of  delay  before 
he  moves. 

It  seems  impossible  to  give  any  detini- 
tion  distinguishing  action  of  a  purely 
mental  kind  from  such  as  effects  other 
purposes,  but  the  general  characters  of 
some  acts  distinguishing  them  as  in- 
telligent will  be  given. 

Certain  characters  of  brain  are  essential 
to  the  manifestation  of  mental  action, 
they  are  inferred  from  the  attributes  of 
visible  movements  and  may  be  described 
as  Spontaneity,  Retentiveness,  Delayed 
expression  of  impressions,  Double  action 
in  nerve-centres.  Controllability  of  nerve- 
centres  by  physical  forces. 

Spontaneity  as  a  character  of  brain 
is  specially  characteristic  of  infancy  and 
childhood.  It  is  indicated  in  visible  action 
by  a  large  number  of  movements  of  dif- 
ferent parts  of  the  body  apparently  oc- 
curring without  any  present  circumstances 
stimulating  them;  the  child  and  the  young 
animal  are  full  of  such  movements,  they 
are  specially  seen  in  small  parts.  Pro- 
bably in  all  cases  such  movements,  if  not 
really  stimu.lated  by  surrounding  forces, 
are  due  to  previous  impressions  received 
by  the  individual  or  inherited. 

Separate  brain  centres  appear  to  be 
capable  of  acting  without  any  external 
stimulus ;  such  mode  of  action  is  seen  in 
many  conditions  of  adult  life,  and  it 
seems  likely  that  in  mental  function  this 
is  the  foundation  of  mental  spontaneity 
and  spontaneous  thought. 

Retentiveness  as  a  property  of  brain 
is  somewhat  analogous  to  inertia  as  a 
physical  property  of  inanimate  objects. 
Ketentiveness  may  be  indicated  by  the 
recurrence  of  a  movement,  or  a  certain 
series  of  acts,  following  a  certain  im- 
pression by  sight  or  sound;  a  similar 
sight  being  followed  by  similar  action,  or 
movements  of  the  same  parts  in  similar 
order  upon  different  occasions.  Retentive- 
ness in  nerve-centres  tends  to  rei)etitioii 


Movements 


[    822    ] 


Movements 


of  similar  action  under  similar  stimula- 
tion; as  in  the  case  of  some  common  re- 
flex-action, e.g.,  knee-jerk.  The  common 
"  automatic  movements  "  of  some  low  class 
idiots  show  the  retentiveness  of  their  un- 
impressionable brains.  Frequent  repeti- 
tion of  the  same  words  and  j^hrases  shows 
great  retentiveness  and  little  aptitude  for 
fresh  mental  action.  The  increasing 
vocabulary  of  the  develoj^ing  child  is  a 
sign  of  advancing  power.  A  parrot  is 
very  retentive  of  the  few  words  he  has 
become  capable  of  speaking. 

Delayed  expression  of  impressions 
is  indicated  by  a  relation  between  the 
time  at  which  the  impression  is  produced 
in  the  nerve-centre,  and  that  of  the  visible 
action  by  which  it  is  subsequently  ex- 
pressed. Ketentiveness  preserves  the  im- 
pression which  may  not  be  known  to  us 
till  it  is  subsequently  expressed.  This 
delay  in  observing  the  visible  effects  of 
the  impression  may  be  prolonged,  there 
may  be  no  outward  manifestation  till 
some  further  impression  is  made,  or  the 
expression  may  come  out,  as  it  is  said, 
spontaneously. 

A  child  four  years  old  quietly  looks  at 
some  one  piitting  a  letter  into  a  pillar-post; 
we  cannot  at  the  time  see  the  impression 
produced  upon  the  child's  brain,  but  we 
guess  that  an  impression  has  been  pro- 
duced because  the  child's  head  and  eyes 
turned  towards  the  pillar-post.  We  know 
that  an  impression  has  been  made  when 
next  day,  on  the  child  finding  a  letter  on 
the  table,  "  he  takes  it  and  posts  it  behind 
the  door." 

Double  Action  in  ITerve-Centres.— It 
seems  that  a  nerve-centre,  when  affected 
by  an  impression,  may  undergo  some 
local  molecular  change,  and  also  send 
efferent  currents  to  muscles,  producing 
visible  movements  at  the  same  time. 
When  speaking  to  another  man  he  re- 
plies —  immediate  outcome  —  his  subse- 
quent actions  show  that  some  impression 
was  produced. 

Double  action  as  thus  explained  pro- 
bably does  not  always  occur,  as  in  the 
case  of  simple  reflex  actions,  and  other 
unintelligent  movements.  When  an  im- 
pression has  been  produced  in  a  nerve- 
centre,  the  time  of  observation  must  be 
prolonged  to  see  if  you  may  find  any  de- 
layed exj^ression.  Delayed  expression  of 
impressions  is  very  common  in  mental 
phenomena,  the  expression  is  always  by 
movement.  Memory  is  due  to  impression 
on  nerve-centres  ;  the  expression  of  an  im- 
pression may  be  often  repeated. 

When  we  study  movements  we  study 
the  outcome  of  efl:'erent  currents;  in  study- 
ing brain  action  expressing  mind  (psycho- 


sis) we  mainly  consider  the  local  or  mole- 
cular changes  in  the  nerve-centres.  The 
evidence  of  a  permanent  local  impression 
is  its  expression  when  the  subject  is  stimu- 
lated. Evidence  of  local  impressions  in 
the  centres,  as  produced  by  the  sound  of 
a  word,  is  seen  when  immediate  action 
follows  in  the  hearer,  and  later  signs  of 
memory  of  that  word  are  found.  The 
stimulus  of  the  sound  of  the  word  may 
produce  efferent  currents  from  the  centre 
leading  to  movements,  and  also  a  perma- 
nent impression  in  the  centre  itself,  such 
expression  of  the  impression  must  be  by 
movements,  as  by  speech. 

Controllability  of  Movements  by  Pby- 
sieal  Forces. — Observations  on  the  ante- 
cedents of  acts  show  that  many  may  be 
controlled  by  physical  forces  acting  upon 
the  senses,  such  as  light,  sound  and  touch, 
or  mechanical  impact.  When  such  forces 
immediately  determine  the  action,  it  is 
clear  that  they  must  decide  the  combina- 
tions and  series  of  movements  in  the  parts 
of  the  body. 

Compound  Series  of  Acts. — In  noting 
the  relations  of  an  observed  series  of  move- 
ments involving,  as  to  their  antecedents, 
many  parts  of  the  body,  it  is  very  usual  to 
see  a  long  series  of  acts  follow  some  slight 
stimulus,  such  as  the  sound  of  a  word  of 
command,  or  even  a  gesture  in  another  per- 
son. This  may  be  termed  a  compoinid  se- 
ries of  acts ;  it  does  not  necessarily  termi- 
nate in  a  strong  movement,  but  in  an  action 
which — as  it  is  said — is  well  adapted  to  the 
circumstances  ;  this  is  probably  due  to  the 
nerve  arrangements  for  such  action  having 
been  previously  adapted  by  similar  circum- 
stances. In  all  such  cases  of  movement 
adapted  to  the  surroundings  it  will  be 
found  that  impressions  had  been  received 
previous  to  the  slight  stimulus  which 
started  the  compound  action  observed. 
The  kind  of  action  now  referred  to  is  then 
in  part  an  example  of  delayed  expression 
of  previous  impressions  upon  the  brain, 
and  is  a  mode  of  action  absent  in  the 
infant  at  birth,  and  in  the  early  stages 
of  infancy,  the  necessary  arrangements 
among  nerve-centres  must  be  built  up. 
As  to  the  theory  of  adapted  action,  it 
appears  that  a  stimulus  acting  upon  one 
of  the  senses  may  be  followed  by  nerve- 
currents  i^assing  from  certain  cells  to 
other  groups  of  cells,  to  be  finally  suc- 
ceeded by  movements  well  adapted  to  the 
circumstances  which  produced  the  primary 
stimulus.  Spontaneous  movements  must 
commonly  be  controlled,  or  temporarily 
inhibited,  in  any  attempt  to  produce  a  new 
line  of  action  by  any  educational  method. 

The  most  obvious  signs  of  mental  action 
are   special   series  of  movements  in  the 


Movements 


[ 


] 


Movements 


body  which  must  be  observed  in  their  re- 
lations to  surrounding  objects,  and  actions 
in  other  persons. 

The  principal  intrinsic  character  of  a 
series  of  acts  is  the  relation  in  time  of  the 
movement  of  the  visible  parts  of  the  body. 
There  are  four  great  classes  of  movements: 
(i)  Uniform  series,  (2)  Augmenting 
series,  (3)  Diminishing  series,  (4)  Action 
adapted  by  circumstances.  A  uniform 
series  of  movonents  is  the  repetition  of 
the  movement  of  the  same  parts  in  uni- 
form degree,  or  quantity  of  displacement, 
and  in  uniform  time  ;  this  is  seen  when 
the  individual  does  the  same  things  over 
and  over  again.  Walking  is  a  uniform 
series  of  acts,  and  is  not  considered  as 
necessarily  a  sign  of  intelligence,  for  it  is 
not  necessarily  much  controlled  by  the 
senses.  Some  manipulative  processes 
consist  of  purely  repetitive  action.  Some 
of  the  "awkward  habits  "  of  children  are 
the  repetition  of  uniform  series  of  move- 
ments, such  as  lateral  movements  of  the 
head  in  rotation,  grinning,  shrugging  the 
shoulders,  movement  of  the  head  to  one 
side  with  slight  inclination  and  rotation 
to  the  same  side,  putting  fingers  in  the 
mouth,  such  movements  frequently  occur- 
ring spontaneously,  or  on  any  and  every 
stimulus.  In  commencing  an  educational 
system  with  a  young  child,  the  sponta- 
neity may  at  first  be  more  easily  controlled 
to  become  a  uniform  action  than  one 
adapted  to  any  useful  purpose. 

Augmenting  Series  of  Movements,  or 
Reinforcement  of  Action.  —  A  series  of 
movements  may  occur,  sequential  to  some 
stimulus,  in  which  the  final  movement  is 
much  stronger  than  would  be  expected 
from  the  force  of  the  primary  stimulus, 
each  group  of  movements,  as  the  series 
progresses,  increasing  in  number  and  in 
force.  It  is  the  spreading  of  the  area  of 
movement,  or  number  of  parts  moving  as 
the  action  proceeds,  that  is  here  specially 
indicated,  such  augmenting  series  of  move- 
ments being  started  by  a  very  slight 
stimulus,  the  force  expanded  in  such  series 
being  out  of  all  proportion  to  the  strength 
of  the  original  stimulus.  The  sound  of  a 
sharp  word  to  a  child  may  be  followed  by 
depression  of  the  angles  of  the  mouth  ; 
alternate  tonic  contraction  and  relaxation 
of  the  orbicularis  oculi,  altered  respiratory 
movements,  causing  screaming,  flushing 
of  the  face,  and  finally  clonic  contractions 
of  many  parts  from  action  spreading  to 
all  the  motor  areas  of  the  brain. 

It  appears  that  a  nerve-centre  may  be 
tstimulated  by  an  afi'erent  impulse,  and 
may  then  discharge  its  efferent  impulse  to 
more  than  one  centre,  so  that  the  nerve- 
currents   become  reinforced  or  strength- 


ened, as  they  proceed  finally  to  the  muscles 
which  produce  visible  movement. 

Such  reinforcements  occur  at  the  earliest 
stages  of  existence,  whereas  "  compound 
cerebral  action"  occurs  only  as  a  later 
development. 

An  augmenting  area  of  action  is  often 
considered  a  sign  of  emotion  or  mental 
excitement.  Visible  action  in  the  body 
may  rapidly  spread  as  the  return  of  the 
natural  spontaneous  action  of  the  nerve- 
centres;  in  this  case  respiration  is  less 
interfered  with  than  in  the  morbid  dis- 
plays of  augmenting  action  :  this  is  well 
exemplified  in  the  march  of  spasm  in  an 
epileptic  fit.  In  the  child  let  out  from 
school  the  crowd  of  movements  seen  re- 
sults from  the  resumption  of  natural 
brain  action  uncontrolled ;  when  fatigue 
leads  to  an  increasing  area  of  fidgetiness 
the  state  may  be  a  return  to  the  more 
childish  condition  where  spontaneity  of 
movement  is  usual. 

In  observing  augmenting  action  (cere- 
bral reinforcement)  it  is  necessary  to  note  if 
the  movement  spreads  from  large  parts  to 
small  parts,  e.g.,  shrugging  of  the  shoul- 
ders, then  lordosis  with  lateral  bend- 
ing of  the  spine,  and  later  drooping  of  the 
head,  then  movements  of  the  facial  mus- 
cles, eyes,  and  fingers ;  in  other  cases 
movement  spreads  from  small  parts  to 
larger  ones.  To  set  the  teeth,  double  the 
fist  and  hit  out  from  the  shoulder  is  to 
use  larger  muscles  than  when  the  mouth 
quivers,  and  the  eyes  are  turned  away, 
with  many  words  and  crying.  With  an 
augmenting  area  of  movement,  the  time 
of  action  is  often  quickened,  as  in  condi- 
tions of  mental  excitement. 

Diminishing  Series  of  Moceynents. — 
Conversely,  we  may  observe  a  dimin- 
ishing series  of  movements,  fewer  and 
fewer  parts  being  in  visible  action,  indi- 
cating a  corresponding  limitation  of 
cerebral  activity.  This  may  be  a  quelling 
of  the  storm  of  nerve-action,  it  may  indi- 
cate a  return  to  aptitude  for  mental  ac- 
tivity or  approaching  somnolence,  i.e., 
subsidence  of  all  action,  or  it  may  signify 
cerebral  exhaustion.  The  order  of  sub- 
sidence should  be  observed. 

It  may  be  well  to  touch  briefly  upon 
some  points  which  illustrate  the  advan- 
tages of  studying  mental  phenomena  by 
the  methods  here  described. 

(i)  We  may  find  certain  new  signs  by 
which  to  define  the  intellectual  condition 
of  a  subject,  its  evolution  or  its  devia- 
tions from  the  normal. 

*(2)  We  are  enabled  to  note  precisely 
certain  signs  indicating  the  evolution  of 

*  8ec  Author's  I'aper,  Jourii.  Men/.  ,SV/.,  April 
1889;  aiKl  Prill) idings  o/BfUj.  Soru'f!/,.iunv  21,1888. 


Movements 


[    824    ] 


Movements 


mental  function  from  infancy  upwards, 
and — as  we  think — the  organisation  of  the 
spontaneous  movements  of  the  new-born 
infant  (microkinesis)  to  become  the  signs 
ol"  intelligence. 

(3)  Movements  observed  at  different 
ages  may  be  classified  and  grouped,  so  as 
to  show  the  ratio  of  action  due  to  spon- 
taneity in  relation  to  that  due  to  sur- 
rounding conditions  and  the  impressions 
which  they  produce. 

(4)  It  may  be  shown  that  thought,  as 
a  physiological  action,  is  probably  some 
kind  of  molecular  change  among  nerve- 
cells,  while  its  outwai'd  manifestation  is 
always  by  visible  movement — as  a  directly 
reflex-movement,  or  as  a  delayed  expres- 
sion of  some  previous  impression. 

Voluntary  and  Mental  IMovements. 
— Movements  studied  as  signs  of  mental 
action  are  often  said  to  be  voluntary, 
more  or  less  voluntary  in  contrast  to 
others  described  as  automatic  or  spon- 
taneous. Probably  we  cannot  define  a 
voluntary  movement,  but  we  may  explain 
what  conditions  observed  make  us  call  it 
more  or  less  voluntary.  A  movement 
following  quickly  upon  a  word  of  com- 
mand may  be  considered  vohmtary. 

Resj^iratory  movements  when  occurring 
in  a  uniform  series  are  not  considered 
voluntary ;  when  the  action  is  specially 
modified,  as  in  speaking  or  smging ; 
when  the  action  is  controlled  by  the  sound 
of  music  they  are  more  voluntary. 
Respiratory  movements  in  the  infant  are 
unitorm,  except  when  the  child  cries  as 
an  expression  of  pain  or  other  mental 
pihenomena  ;  in  the  adult  many  forms  of 
emotion  are  expressed  by  variation  in  re- 
spiratory action,  as  in  fear  or  anger.  The 
modified  respiratory  actions  termed  sigh- 
ing, laughing,  singing,  &c.,  may  be  signs 
of  mental  states,  because  they  indicate 
nerve  states,  modified  by  special  circum- 
stances or  antecedents.  We  consider  such 
signs  as  mental  phenomena,  not  so  much 
on  account  of  these  (attributes  or)  intrin- 
sic characters  as  because  of  their  relation 
to  antecedents — the  previous  sight  or 
sound.  When  no  sjiecial  antecedent  of 
the  act  of  sighing  is  known  it  is  often  said 
to  be  spontaneous,  automatic,  or  involun- 
tary. The  voluntary  character  of  a  move- 
ment appears  to  be  indicated  partly  by  its 
relation  to  some  antecedent  impression, 
and  in  part  by  its  sequence  :  useful  acts  ai*e 
often  considered  to  be  voluntary,  and 
these  are  such  as  produce  some  result. 
The  voluntary  character  is  also  in  part 
due  to  its  control  by  some  fresh  impres- 
sion in  place  of  spontaneous  action  ;  it 
may  also  be  a  change  from  one  series  of 
acts  to  another.  In  other  cases  the  volun- 


tary character  is  admitted  because  the 
act  is  obviously  an  example  of  delayed 
expression  of  some  previous  impression. 
As  examples  of  voluntaiy  and  intelligent 
action  see  the  ready  reply,  the  exact  copy, 
the  act  appropriate  to  the  circumstance. 

A  complex  series  of  movements  of  many 
parts  in  succession  —  i.e.,  a  compound 
series  of  movements  following  some  slight 
stimulus  through  eye  or  ear  without  re- 
inforcement of  action,  and  producing 
some  result  or  impression,  is  usually  in- 
telligent and  voluntary ;  the  more  dis- 
tinctly we  see  the  action  controlled  by 
circumstances  without  reinforcement,  the 
more  is  it  like  an  intelligent  and  voluntary 
action.  We  see  a  cat  sitting  on  the  door- 
step of  a  house,  a  dog  comes  by,  the  cat 
simply  moves  behind  the  railings  without 
any  excess  of  movement  or  display  of 
emotion ;  that  is  a  voluntary  and  intelli- 
gent act,  the  outcome  of  experience  or  pre- 
vious impressions. 

Action  adapted  by  circumstances  is 
a  high-class  manifestation ;  such  action 
usually  ends  in  something  being  done,  or 
something  said,  which  produces  an  im- 
pression so  that  the  outcome  of  action  is 
not  lost.  Adapted  action  appears  in  the 
child  late  in  its  evolution,  it  is  increased 
by  training,  and  is  more  easily  acquired 
when  the  ancestors  have  been  similarly 
trained.  A  large  amount  of  spontaneity 
and  reinforcement  is  antithetical  to 
action  adapted  to  circumstances. 


A  meehanical  diagram,  represciitiniir  :i  cer- 
tain area  of  the  brain.  The  circles  represent 
Ijrain  centres.  When  a  centre  is  represented 
as  black,  it  is  sending  out  force  to  iiitiscles  and 
produciny  visible  movement  in  the  body  as 
expressed  by  ele^  ation  of  signals  at  the  side. 
The  full  action  of  .v  causes  elevation  of  sii,aial 
a,  &c. ;  centres  c  <;  are  supposed  to  be  active, 
but  not  to  be  sendini;  nerve-current  touuiscles; 
centres  b  d  e  are  not  actinu. 

Adapted  action  may  begin  with  a  slight 
stimulus,  and  may  consist  of  many  acts, 
the  final  act  being  such  as  is  not  usually 
produced  directly  by  the  primary  stimulus. 


Movements 


[    S25    ] 


Movements 


The  corresponding  neural  action  we  have 
termed  compound  cerebration.  The  prim- 
ary stimuhis  forms  one  diatactic  union, 
the  currents  from  this  form  a  secondary 
union,  and  so  on — during  the  period  of 
quelled  spontaneity — and  at  last  a  fourth 
or  fifth  union,  as  the  case  may  be,  sends 
efferent  currents  to  muscles  producing  a 
visible  expression  indicated  by  move- 
ment. The  hypothesis  of  compound  cere- 
bration may  be  illustrated  by  a  mechani- 
diagram  represented  on  i)age  S24. 

An  advantage  of  such  modes  of  study 
as  are  here  presented  may  be  to  enable 
us  to  apply  to  psychology  the  principles 
known  as  evolution,  reversion,  and  anti- 
thesis. 

If  we  describe  certain  mental  states  in 
terms  of  series  of  movements  which  indi- 
cate them,  then  when  we  see  similar 
acts  recur,  we  may  say  that  reversion  has 
taken  place.  In  infancy  we  see  series  of 
movements  of  very  small  parts,  not  under 
control  by  the  circumstance ;  in  adult  life 
{e.g.,  in  chorea  and  conditions  of  mental 
irritability)  we  may  see  series  of  sponta- 
neous movements  of  many  small  parts, 
not  under  control  by  the  circumstance. 
This  is  a  reason  for  speaking  of  such  con- 
ditions as  reversions  to  a  lower — an  ante- 
cedent, or  more  infantile — state.  Such 
statements  have  at  least  the  advantage  of 
being  intelligible,  and  are  capable  of 
criticism  founded  upon  the  observations 
of  other  men. 

Again,  if  the  attributes  of  action  in  the 
cellular  elements  of  the  brain  be  taken  as 
the  means  of  desci'ij^tion,  the  processes  of 
action  in  brain-cells  maybe  compared  with 
processes  and  conditions  (of  growth)  in 
other  living  cellular  organisms.  Further, 
the  physical  forces  controlling  the  attri- 
butes of  cellular  action  in  general  may  be 
studied  as  to  their  power  to  control  action 
among  the  brain-cells. 

Antithetical  (or  opposed)  mental 
states  are  such  as  do  not  commonly  co- 
exist, but  are  capable  of  replacing  one 
another.  The  mental  states  termed  kind 
and  unkind,  defiance  and  shame,  joy  and 
pain,  may  be  called  antithetical,  as  they 
do  not  commonly  co-exist,  the  presence  of 
the  one  mental  state  for  the  time  pre- 
cludes the  other.  The  antithesis  of  the 
states  joy  and  pain  is  expressed  by  the 
opposition  of  the  signs  which  indicate 
these  states.  The  antithesis  of  the  men- 
tal states  joy  and  pain,  might  be  antici- 
pated by  the  student  of  the  physical  ex- 
pression of  these  states,  for  the  two  modes 
of  facial  action  cannot  co-exist.  This 
illustrates  one  reason  why  the  student  of 
mental  science  should  observe  the  expres- 
sion of  mental  states  as  seen  in  visible 


action  of  the  parts  of  the  body.  Hands 
cannot  at  the  same  time  be  both  motionless 
and  full  of  movement ;  now  in  the  mental 
state  called  attention  the  hands  are  mostly 
still,  in  the  fidgety  child  the  fingers  present 
numerous  spontaneous  movements ;  the 
physical  signs  are  opposed  to  one  another 
as  are  the  mental  states  corresponding. 
Those  emotions  whose  physical  expres- 
sions are  antithetical  are  the  most  un- 
likely to  occur  together,  or  if  they  do  coin- 
cide momentarily  there  is  a  conflict  seen 
in  the  body  between  the  two  physical 
states,  as  in  an  individual  who,  while 
suffering  pain,  still  tries  to  look  happy, 
and  soon  one  or  other  condition  gains  the 
ascendency.  Huppose  a  child  has  hurt 
his  finger,  but  is  trying  hard  not  to  cry, 
we  shall  see  the  muscles  about  the  mouth 
quiver,  until  finally,  the  eff'ect  of  the 
injury  to  the  finger  acting  upon  the  nerve- 
centres  becomes  so  strong  that  the  angles 
of  the  mouth  are  depressed  and  the  out- 
break of  sobbing  follows.  The  opposite 
emotions,  j^ain  and  self-restraint,  or  the 
conflicting  nerve-currents  acting  upon  the 
nerve-centres,  result  in  one  action  pre- 
dominating. This  principle  of  antithesis 
is  very  useful  in  trying  to  gain  knowledge 
as  to  the  causation  of  mental  states,  and 
may  serve  to  guide  practice  in  education. 
Spontaneous  Movements  and  Spon- 
taneous Tboug-hts. — The  mass  of  spon- 
taneous movements  in  the  infant  (micro- 
kinesis)  has  already  been  referred  to,  the 
corresponding  brain  action  seems  to  be 
the  spontaneous  activity  of  many  small 
nerve-centres,  as  a  result  of  nutrition, 
with  discharge  of  weak  nerve-currents  to 
the  muscles  of  small  parts  of  the  body, 
i.e.,  to  those  parts  which  in  adult  life  are 
most  concerned  in  expressing  mental 
action.  Later  we  see  definite  series  of 
movements,  and  the  expression  of  mental 
states.  In  our  theory  of  the  physical 
changes  corresponding  to  mental  action, 
it  is  supposed  that  intelligent  acts  depend 
upon  the  arrangement  or  "  getting  ready  " 
(diatactic  action)  of  certain  groups  of 
nerve-cells  before  the  movement.  It  is 
this  arrangement  among  the  nerve-ceUs 
that  seems  to  correspond  to  the  mental 
act.  Observation  of  movement  in  the 
infant  seems  to  show  that  such  unions 
for  action  occur  very  early,  there  may  be 
arrangement  among  the  cells  not  expressed 
by  movement  corresponding  to  initial 
mental  acts.  When  the  child  is  three 
years  old,  we  still  see  much  spontaneous 
movement,  there  is  continuous  chatter 
with  the  disconnected  use  of  a  few  words 
and  gesticulations.  It  seems  probable 
that  there  may  be  many  spontaneous 
arrangements   occurring  among  the  cea- 


Movements 


[    826    ] 


Movements 


tres,  corresponding  to  the  visible  move- 
ments. The  microkinesis  is  in  adult  life 
replaced  by  co-ordinated  or  intelligent 
acts,  but  mici'opsychosis  seems  to  con- 
tinue. Spontaneous  movements  in  the 
adult  appear  to  be  due  to  a  reversion  to 
the  microkinesis  of  the  infant,  and  often 
correspond  to  spontaneous,  irregular 
uncontrolled  "  little  thoughts. '^  As  rough 
analogy : — A  child  is  fidgety  (full  of 
uncontrolled  movements),  and  is  inatten- 
tive (uncontrolled  thoughts)  ;  nervous 
children  have  many  spontaneous  move- 
ments, and  often  have  many  strange, 
disconnected,  imaginative,  precocious 
thoughts  ;  during  sleep  impressionability 
is  lessened,  and  dreams  are  spontaneous. 
In  adult  life  this  spoataneous  occurrence 
of  many  thoughts  may  or  may  not  be 
accompanied  by  much  spontaneous  move- 
ment, there  are  wandering,  unbidden, 
wild,  ungoverned  thoughts,  a  mass  of 
thoughts,  a  cloud  or  rush  of  thoughts 
through  the  brain  ;  such  may  occur  in  a 
man  who  is  motionless,  or  in  one  who 
presents  many  movements. 

This  spontaneous  thinking  may  result 
from  fatigue,  and  unchecked  it  may  lead 
to  exhaustion ;  it  is  best  controlled  by 
things  heard  and  seen. 

Illustrations  of  Move:\ient  and 
Expression  in  the  Face,* 

Fic.  I. 


Fig.  2. 


Thomas  P.,  aged  52.  Kiybt  heuiiplegiii,  with 
cerebral  facial  palsy,  right  side.  The  face  is 
asymmetrical,  and  the  muscles  in  the  right 
lower  zone  aljout  the  mouth  act  very  iuditter- 
ently.  The  naso-labial  groove  on  this  side  is 
almost  lost ;  this  is  well  seen  on  comijaring 
the  two  sides.  No  asymmetry  is  seen  in  the 
upper  and  middle  facial  zones. 


*  The  engravings  have  Ijeeu  executed  from  photo- 
graphs taken  from  life. 


.John  H. ,  aged  52.  Left  hemiplegia,with  cere- 
bral facial  palsy,  left  side.  The  facial  asymme- 
try is  less  marked  than  in  Fig.  i.  From  the 
median  line  to  the  angle  of  the  mouth  is  a  longer 
distance  on  the  right  than  on  the  left  side.  The 
hemiplegia  is  of  long  standing ;  there  was  much 
rigidity  of  the  paralysed  arm.  There  was  well- 
marked  valvular  disease  of  the  heart. 

Fic.   :;. 


Bell's  paralysis  of  the  face,  right  side. 
Thomas  C,  aged  50.  Seen  Xovember  1880. 
Four  days  previously  he  had  suddenly  found 
bis  face  drawn  to  the  left  side  ;  no  other  para- 
lysis. The  paralysis  appeared  due  to  the  effect 
of  cold  ;  recovery  was  complete  in  tliree  weeks. 
The  sjnnmetry  in  each  zone  of  the  face  is  strik- 
ing. The  orbicular  muscle  of  the  right  eye  is 
much  weakened,  as  seen  in  the  lower  eyelid  : 
the  right  eyeljrow  has  fallen  a  little  lower  than 
on  the  left  ;  the  line  of  the  eyebrow  is  nearer 
to  the  level  of  the  pupil  on  tiie  right  thau  on 
the  left,  owing  to  the  paralysis  of  the  occipito- 
frontalis.  The  right  cheek  is  flattened,  the 
mouth  and  nose  are  drawn  to  the  left. 


Movements 


Vu:.  4. 


[       827       ] 


Mutism 


JoUn  Wiilkor,  iii:e(l  67.  t^ccn  April  1882. 
Paralysis  ag-itans,  in  advanced  stat;e.  Face 
jilmost  expressionless,  with  loss  of  all  tlie  fine 
:idjustmeiits  of  expression.  He  presents  one 
dull  monotony  of  facial  expression.  At  the 
same  time  he  can  occasionally  be  made  to 
<^iu,  can  show  his  teeth,  elevate  the  eyebrows, 
or  close  the  eyes,  <fcc.  The  face  is  symmetri- 
cal in  its  passive  condition  and  in  its  move- 
ments, and  the  condition  is  similar  in  all  its 
zones.  His  voice  is  as  monotonous  as  his 
face — one  uniform  low  monotone.  The  riiilit 
hand  was  the  earliest  limb  affected  ;  there  is 
little  tremor  now,  hut,  when  held  out,  it  pre- 
sents the  posture  of  the  '■  writing-  hand  "  de- 
scribed by  ( 'harcot. 


John  B.,  a^ed  7  years.  A  hi;;h-class  imbe- 
cile. Head  well-shaped  and  of  lair  size  :  no 
paralysis.  He  has  illusions,  and  has  had 
maniacal  attacks.  His  hands  jiresent  much 
linf^^er  twitchin^%  and  they  often  assume  the 
'•nervous  jiosture."  Any  excitation  causes 
smilin-^-  ;  pain,  pleasure, stroni;  lif^ht,  all  cause 
the  same  expression. 


John  B.,  smiling'.  The  greatest  change  is 
in  the  lowest  zone — i.e.,  the  zone  that  is  most 
paralysed  by  brain-disease.  This  is  the  only 
active  expression  possible  in  the  boy  ;  it  is 
symmetrical,  and  affects  the  upper  zone  the 
least,  the  lower  zone  the  most.  Exagge- 
rated muscular  action  is  common  with  brain 
defects. 

Francis  Warner. 

MUSIC  IM-  THE  TREATMESTT  OF 
THE  INSILNTi.      {See  TREATMENT.) 

MUSZCOIVIAiriA,  nXUSOlMCATrZA 

{iimsica ;  navla,  madness).  A  variety  of 
insanity  in  which  the  passion  for  music 
has  been  fostered  to  such  an  extent  as  to 
derange  the  mental  faculties. 

IVIVSSITATIO  {muniiitare,to  murmur). 
A  condition  in  which  the  tongue  and  lips 
move  as  in  the  act  of  speaking,  but  with- 
out sounds  being  produced.  An  un- 
favourable sign  in  disease,  indicating  great 
mental  debility. 

IMCVTII.ATZOM-,  SEI.F.  (^'e  SelF- 
MUTIL.\TION.) 

IWUTZSIVI. — Dumbness  from  mental 
defect  or  disorder.  In  addition  to  the 
cases  of  Deaf-Dumbness  (q.r.),  mutism 
occurs  in  the  course  of  various  mental 
disorders,  as  Mental  Stupor,  Delusional 
Insanity,  &c.  As  an  instance  of  the  latter, 
the  following  may  be  mentioned.  The 
writer  asked  a  patient  in  Bethlem  Hospi- 
tal, who  had  been  mute  for  a  long  period, 
why  he  did  not  speak.  He  wrote  down, 
*'  Because  I  have  not  been  ordained." 
Subseqixently,  Dr.  Rhys  Williams  took 
him  to  Archbishop  Tait  at  the  Palace. 
He  had  previously  told  the  doctor  that  he 
could  not  go  through  any  mimic  form  of 
ordination,  but  he  spoke  kindly  to  him. 
The  patient  was  much  gratified,  spoke 
from  that  time,  and  was  discharged  not 
long  after  as  recovered.     A  year  or  two 


Mutitas  Surdorum, 


L 


828    J     Myxoedema  and  Insanity 


afterwards    he     relapsed,    and    was    re- 
admitted.    (See  Diagnosis.) 

Thk  Editok. 

MUTZTAS  STJRSORTrM  {mutitas, 
mutism  ;  xurdonDii,  of  the  deaf).  Deaf- 
mutism,  si^eechlessness  from  deafness,  con- 
genital or  acquired.     (Fr.  sourdsviuets.) 

MVTTi:RPI.iiCE,  MUTTERSUCHT, 
BlXjTTERZXrrAliIi. — German  terms  for 
hysteria. 

MYODYNIA,  HYSTERXCAI.  (iivs,  a 
muscle  ;  oSvi/r;,  pain  ;  h3'steria).  Hysteri- 
cal muscle-pain.  A  term  for  what  is  re- 
garded by  some  as  ovarian  tenderness, 
but  which  Briqiiet  maintains  is  simply 
muscular. 

iviYSOPKOBZiV  (fxva-os,  an  action  of 
disgust ;  also  tilth  ;  (pofSos,  fear  of).  Mor- 
bid dread  or  fear  of  filth,  or  of  personal 
impurity  or  uncleanness. 

IMCYXffiSEMA  AIO-S  IN-SAITITY. 
— Attention  was  first  directed  to  what  he 
called  cretinoid  degeneration  in  adults,  by 
Sir  William  Gull,  in  a  paper  published  in 
the  6'Zi»..  (S'or.  ^Vciis,  vol.  vii.  1873.  This 
he  showed  to  be  marked  by  a  change  in  the 
features,  which  become  broad  and  flat- 
tened, the  eyes  appear  unduly  separated, 
the  lips  large  and  thick,  and  the  folds  of 
connective  tissue  about  the  eyes  become 
loose  and  baggy,  while  under  the  jaws 
and  about  the  neck  the  skin  becomes 
thickened  and  lies  in  folds.  The  hair 
comes  out,  the  hands  become  broad,  the 
skin  dry  and  harsh,  not  sweating ;  the 
temperature  becomes  sub-normal,  the 
comjjlexion  generally  is  sallow,  bearing,  in 
some  cases,  a  jaundiced  aspect.  But  with 
the  alteration  in  complexion  there  is  al- 
most always  a  bright  patch  of  red,  due 
to  capillary  congestion,  over  the  malar 
bones.  The  disease  occurs  most  frequently 
in  women  about  forty  to  fifty  years  of  age. 
The  above  description  applies  fully  to 
myxoedema,  which  occurs  more  rarely  in 
young  jjatients,  though  we  have  met  with 
it  in  both  young  men  and  women.  There 
is  some  distinct  relationship  between  this 
condition  and  the  stateof  the  thyroid  gland 
iq.v.),  A  special  name  has  been  given 
by  continental  physicians  to  an  allied 
state  called  by  them  cachexia  strumai^riva. 
Sir  William  Gull  recognised  the  mental 
deterioration  occurring  in  these  cases.  In 
hisfirst  report  on  the  disease  he  says:  "The 
mind  which  had  previously  been  active 
and  inquisitive  assumed  a  gentle,  placid 
indifierence,  corresponding  to  the  muscu- 
lar languor,  yet  the  intellect  was  unim- 
paired." In  a  second  case  he  describes 
the  mind  as  generally  placid  and  lazy, 
liable  to  being  suddenly  ruffled.  There  is 
certainly  a  degree  of  habitual  and  mental 
indifference,  though  this  may  under  occa- 


sional circumstances  be  absent,  since  the 
intellect  is  unimpaired. 

In  1880  we  published  notes  on  myx- 
oedema with  nervous  symptoms  in  the 
Journa  I  ofMento  I  Science,  and  we  shall  refer 
later  to  these  observations.  In  1888  the 
committee  of  the  Clinical  Society  of  Lon- 
don appointed  to  investigatethewholesnb- 
jectof  myxoedema  published  an  exhaustive 
repoi-t  on  the  disease,  and  this  committee 
recognised  the  mental  degeneration  which 
is  common  in  myxoedema.  It  reports 
that  convulsions  occur,  though  rarely, 
that  of  the  intellectual  changes,  slowness 
in  apprehension,  thought  and  action,  is 
the  most  constant,  its  absence  being  noted 
in  only  three  cases.  Abnormal  persist- 
ence in  thought  and  action  is  recorded  in 
about  one  case  in  four.  In  a  rather  larger 
proportion  there  is  more  or  less  imperfec- 
tion of  mental  processes,  the  defect  being, 
as  noted  before,  one  of  retardation  or 
sluggishness.  Writing  is  sometimes  slow, 
sometimes  imperfect ;  in  the  case  of  edu- 
cated persons  the  handwriting  is  usually 
good,  and  the  length  of  letters,  in  all  re- 
spects well  indited,  is  remarkable.  Irrit- 
ability is  a  marked  feature,  though  in  ex- 
ceptional instances  there  is  the  reverse. 
In  some  cases  placidity  alternates  with 
occasional  outbursts  of  fretfulness  and 
irritability.  In  a  large  proportion  sleep 
is  noted  as  good,  but  in  many  of  these 
there  is  excessive  somnolence,  especially 
in  the  daytime.  In  about  one-third  of  the 
cases  wakefulness  is  recorded,  and  sleep 
is  often  disturbed  by  horrible  dreams  and 
sensations.  It  may  be  noted  that  drowsi- 
ness during  the  day  is  very  common  in 
myxoedema  in  both  good  and  bad  sleepers. 
Delusions  and  hallucinations  occur  in 
nearly  half  the  cases,  mainly  where  the 
disease  is  advanced.  Insanity  as  a  com- 
plication is  noted  in  about  the  same  pro- 
portion as  delusion  and  hallucination.  It 
takes  the  form  of  acute  or  chronic  mania, 
dementia,  or  melancholia,  with  a  marked 
predominance  of  suspicion  and  self-accu- 
sation ;  exalted  ideas  may  occur.  Memory 
is  xisually  impaired  from  an  early  period, 
especially  in  respect  of  recent  events.  It 
is  recorded  as  deficient  in  forty-six  out  of 
seventy-one  cases.  It  may  be  mentioned 
that  exophthalmos  has  been  observed 
once  or  twice  in  the  early  periods  of  myx- 
oedema ;  the  special  senses  may  be  more  or 
less  affected  especially  in  the  later  stages 
of  the  disease. 

Myxoedema,  though  not  common,  is  by 
no  means  exceptionally  rare  among  the 
insane,  and  every  large  asylum  has  exam- 
ples of  the  disease.  It  occurs  chiefly  in 
middle-aged  women,  and  the  disease,  as 
a  rule,   has   made  considerable   j^rogress 


Myxcedema  and  Insanity     [    829    ]     Myxoedema  and  Insanity 


before  any  symptoms  of  insanity  have 
become  well  marked.  The  symptoms 
divide  themselves  into  two  well-marked 
groups,  those  of  disorder,  and  those  of 
decay  or  weakness.  A  certain  number  of 
patients  suffering  from  myxedema  become 
slowly  self-conscious  and  distressed  by 
the  alteration  in  their  appearance,  so 
that,  from  simple  exaggeration  of  self- 
consciousness  they  become  suspicious  and 
pass  through  a  stage  of  watchfulness  and 
expectancy  into  one  of  doubt,  dread, 
timidity,  and  suspicion,  till  in  fact  they 
become  fully  developed  examples  of  the 
delirium  of  suspicion  or  chronic  mania. 
And  as  such  they  may  have  ideas  of  ex- 
altation ;  thus,  in  one  elderly  patient  in 
Bethlem,  the  idea  that  all  sorts  of  things 
were  being  done  which  she  did  not  under- 
stand led  her  to  believe  that  these  things 
were  being  done  against  her;  with  the 
increase  of  the  disease,  loss  of  hearing 
came  on,  and  this  caused  still  greater 
mental  confusion  and  doubt.  Instead 
of  being  actively  dangerous  or  violent 
she  slowly  passed  into  a  state  of  satis- 
faction with  all  the  many  attentions 
which  she  imagined  were  being  paid  to 
her,  so  that  she  became  one  of  the  queens 
of  Bedlam. 

In  these  cases  it  is  pretty  certain  that 
all  the  mental  symptoms  have  their  origin 
in  the  impaired  conduction  of  sensory 
impressions,  so  that  as  there  are  altera- 
tions in  the  structure  of  the  skin  and  pro- 
bably also  in  the  structure  of  the  con- 
ducting and  receiving  nervous  organs, 
the  ideas  derived  from  these  impressions 
differ  materially  from  the  ideas  which 
were  previously  originated  by  similar 
healthy  impressions.  This  leads  to  con- 
fusion, doubt,  and  either  suspicion  or 
dread j  the  loss  proceeds  further  so  that 
there  is  definite  intellectual  change  as  evi- 
denced by  defects  of  memory,  will-power, 
and  the  like.  In  one  group  of  cases,  the 
chief  cause  of  mental  disorder  is  the  idea 
that  persons  are  noticing  their  j^hysical 
peculiarities.  Most  of  these  in  the  end 
exhibit  the  same  symptoms  as  those 
already  described ;  the  chief  cause  of 
trouble  is  the  idea  that  being  peculiar  in 
aspect  they  are  particularly  noticed  by 
people  in  the  streets. 

It  is  from  this  set  of  ideas  that  dread 
of  going  out  arises.  We  have  met  with 
two  such  cases,  and  Dr.  Wilks  has  re- 
corded another;  in  the  one  the  patient 
slowly,  from  being  a  good-looking  young 
lady,  became  conspicuously  broad-faced 
and  ugly.  Living  as  she  did  in  a  small 
countiy-town,  the  change  in  her  face  was 
remarked,  and  rude  village  boys  used  to 
jeer  at  her.     Later,  as  the  disfigurement 


became  still  more  pronounced  they  fol- 
lowed her,  calling  out  that  she  was  "  the 
pig-faced  woman."  Naturally  this  caused 
her  a  great  deal  of  distress  and  worry,  so 
that  she  avoided  going  out  of  doors  as 
much  as  i:)Ossible,  and  then  took  active 
steps  to  defend  herself  against  real  or 
assumed  insults.  Under  these  circum- 
stances being  violent  and  threatening  she 
had  to  be  sent  to  an  asylum.  In  this 
case  it  is  noteworthy  that  there  was  com- 
plete sexual  pei'version.  In  the  asylum 
she  steadily  lost  power  and  died  of  bron- 
chitis with  the  onset  of  cold  weather. 
And  it  is  noteworthy  that  in  all  such 
cases  the  change  of  temperature  is  likely 
to  produce  serious  and  often  fatal  com- 
plications in  the  disease.  It  will  be  seen 
then  that  with  myxoedema  there  may  be  a 
delirium  of  suspicion,  developing  out  of 
the  personal  disfigurement  and  there  may 
be,  primarily  or  secondarily  to  the  above, 
progressive  mental  weakness  showing  it- 
self in  chronic  mania  with  suspicion,  doubt, 
irritability  and  occasionally  violence.  The 
natural  termination  of  these  cases  is  in 
dementia  which  may  become  very  pro- 
nounced and  may  be  associated  with  loss 
of  physical  power,  so  that  the  ijatient  is 
confined  to  bed ;  death  generally  depends 
upon  some  secondary  cause.  The  patho- 
logy of  the  disease  does  not  require 
special  consideration  here,  but  it  is  note- 
worthy that  the  mental  symptoms  may 
depend  directly  upon  some  alteration  in 
the  nervous  tissues  themselves.  In  some 
cases  in  which  we  have  examined  both 
brain  and  spinal  cord  we  have  been  con- 
vinced that  there  were  distinctly  visible 
changes  which  would  account,  at  all  events, 
for  progressive  weakmindedness. 

It  is  possible  that  in  some  cases  the 
mental  disorder  really  originates  from  the 
slowness  and  imperfection  of  the  nervous 
conduction  due  to  the  changes  in  the 
2)eripheral  nervous  structures,  while  in 
some  the  defect  lies  in  the  changes  which 
have  taken  place  in  the  higher  nervous 
structures. 

Imperfect  reception  of  messages  leads 
to  doubt  and  suspicion,  while  the  i^ro- 
gressive  degeneration  of  the  highest  ner- 
vous elements  leads  to  loss  of  control  and 
later  to  loss  of  memory. 

Myxcedema  is  not  specially  a  nervous 
disease  either  by  origin  or  alliance. 

Mental  symptoms  may  arise  from  changes 
in  the  j^eripheral  or  central  nervous  tissues, 
so  that  altered  impressions,  conductions, 
or  ideations  may  arise,  leading  to  various 
forms  of  mental  loss  or  confusion. 

The  dulness  produced  and  the  altera- 
tions of  aspect  may  be  associated  with 
suspicion  of  an  insane  type. 


Najab  ud  din  Unhammad    [    830    ]    Najab  ud  din  Unhammad 


The  general  tendency  of  myxa3dema  is 
to  produce  mental  weakness  sooner  or 
later.  Gko.  H.  Savage. 

[Re/ereiios. — Gull,  On  ;i  CrttiDoid  State  super- 
venint;'  in  Adult  LilV  in  Women,  Clin.  Sue.  'J'rans., 
viil.    vii.    1873.      Dr.  Ord,    <  in    Myx<L'denia,  .Med. 


Chii-.  Traus.,  vol.  Ixi.  1878.  Kocher  (BerneX  Lan- 
fiunljt'ck's  Arcliiv  f.  Chlrurt^ie,  vol.  xix.  1883. 
Dr.  Savage,  .Journ.  Ment.  Sci.,  1880.  Dr.  Felix 
Semon,  Clin.  Soc.  Trans.  1883.  Report  of  a  Com- 
mittee of  tbe  Clinical  Society  of  London  on  Myx- 
(I'dema,  Clin.  Soe.  Trans,,  Supplement  to  vol.  xxi. 
1888.] 


N 


TTAJ-AB    UD    HJN    TTiarHAIVIMIA]}. — 

To  this   Arab  physician,   who   flourished 
about  the  middle  of  the  eij^hth  century, 
we  owe  our  knowledge  of  the  symptoms 
and  also  the  treatment  of  insanity  as  re- 
cognised  by  the  Arab  physicians.      The 
title  of  his  treatise  was  Asbab  wa  Ulla- 
mut.     On  this  work  a  commentary  was  , 
written  in  Arabic  by  Nafis  bin  Awaz  in  I 
1450,  entitled   Sharh  ul  Asbab  wa  Ulla-  j 
mut.  It  was  translated  in  the  seventeenth 
century  into  Persian  by  Muhammad  Akbar 
under  the  name  of  Tibb  i  Akbari. 

The  various  forms  of  mental  disease  are 
as  follows : — 

I. — Souda  a  Tabee. 
(i)  Souda. 
(2)  Janoon. 
II. — Murrae  Souda. 
III. — nxalikholia  a  Maraki. 
IV. — Diivang^i. 

(i)  Kutrib. 

(2)  Mania. 

(3)  BaulKulb. 

(4)  Sadar. 
V. — Haziyan. 

( 1 )  Mibda  a  illut  dimagh. 

(2)  Mibda  a  illut  Marak. 

(3)  Bukharat  Had. 
VI. — Raoonut. 

VII. — Himak. 
VIII.— Ishk. 

(t)  Haram. 
(2)  Fak. 
IX. — Nisyan. 
(i)  Zikr. 

(2)  Fikr. 

(3)  Takhil. 

Insanity  is  defined  as  "  a  state  of  agita- 
tion and  distraction,  with  alteration  and 
loss  of  reason,  caused  by  weakness  or 
disease  affecting  the  brain." 

It  is  not  very  clear  to  what  types  of 
insanity  the  preceding  terms  correspond. 

I.  Souda  a  Tabee  appears  to  re- 
semble dementia  in  most  respects.  The 
patient  disregards  clothing,  cleanliness, 
and  the  calls  of  nature  ;  the  memory  may 
be  impaired,  and  there  may  be  childish 
laughter.  In  some  cases — and  here  the 
symptoms  resemble  melancholia — intense 
anxiety  is  manifested,   and    the   patient 


suffers  from  the  constant  dread  of  ap- 
proaching evil.  With  these  symptoms 
ax-e  associated  extraordinary  movements 
of  the  hands  and  feet,  leaping  and  beat- 
ing the  ground.  When  Souda  becomes 
chronic  it  terminates  in  Janoon,  in 
which  the  patient  is  restless,  sleepless, 
taciturn,  but  at  times  roars  like  a  wild 
beast.  The  prognosis  was  considered  very 
unfavourable. 

As  to  the  treatment  of  Souda  a  Tabee 
the  patient  was  bled  and  purged  in  the 
early  stage,  but  nutritious  food  was  given 
to  him,  baths  were  ordered,  and  milk  was 
rubbed  on  the  skin  of  the  head  and  body. 
In  fact,  notwithstanding  venesection  and 
purgation,  thepatient  was  far  bettertreated 
than  in  the  good  old  days  of  the  lancet  in 
England.  He  had  not  only  nutritious 
food,  but  his  taste  was  consulted ;  he  was 
allowed  to  have  sweets,  dry  fruits,  grapes, 
apples  and  water  melons.  Further,  change 
of  climate  was  recommended,  and  every- 
thing likely  to  cause  irritation  was  to  be 
avoided  in  order  that  the  mind  might  en- 
joy complete  rest.  Nay,  pleasure  was  to 
be  afforded  him  by  soft  music,  gardens 
planted  by  trees  and  fragrant  shrubs — 
shady  places  to  allow  of  protection  from 
the  heat.  By  this  means  it  was  intended 
to  induce  sound  sleep,  which  was  acknow- 
ledged to  be  a  better  remedy  for  mental 
disorder  than  medicines.  Very  remark- 
able is  the  following  j^assage  from  an 
Arabian  writer,  Shaik  la  Ajab,  unsur- 
passed by  anything  in  the  writings  of 
Pinel,  or  in  the  principles  of  treatment 
enunciated  at  the  York  Retreat  at  the 
latter  end  of  the  eighteenth  century  : — 
'•  Be  it  known  that  of  all  remedies,  to 
strengthen  the  heart  and  brain  is  the 
safest  and  most  sure,  by  which  means  the 
mind  and  action  are  guided  aright.  Do 
nothing  to  frighten  a  patient,  and  let  him 
select  his  own  employment.  Make  the 
senses  a  special  subject  of  treatment,  and 
occasionally  give  stimulants.  Eest  and 
fresh  air  are  required  for  the  miserable 
men  afflicted  with  insanity.  They  should 
be  shown  every  possible  kindness  ;  in  fact, 
they  are  to  be  treated  by  those  under 
whose   care   they   are  placed  as   if   they 


Najab  ud  din  Unharamad    [831     j 


Narce 


were  iheirown  offspring,  so  as  to  encourage 
them  to  place  confidence  in  their  care- 
takers, and  communicate  their  feelings 
and  sufferings  to  them.  This  will  be  at 
least  a  relief  to  those  unfortunates,  and 
a  charity  in  the  eyes  of  God." 

Should  the  patient  continue  to  be  un- 
duly excited  or  distracted,  drugs  were  to 
be  administered,  some  of  a  soothing  na- 
ture, and  others  calculated  to  drive  melan- 
choly away.  Actual  prescriptions  are 
given. 

II.  IVIurrae  Souda. — In  this  form  of 
mental  disorder  the  patient  is  morbidly 
anxious  and  "  constantly  full  of  doubts." 
Here  we  are  confronted  with  the  Griibel- 
sucht  of  German  alienists.  In  walking, 
his  eyes  rest  on  the  ground,  his  head  and 
face  are  thin,  his  pulse  weak,  sometimes 
fast  and  other  times  slow,  his  urine  thin 
and  clear.  Among  the  earliest  symptoms 
of  ill-health  is  insomnia.  As  to  treat- 
ment, blood-letting  if  necessary  must  not 
be  large,  or  it  would  add  to  the  debility. 
Before  resorting  to  it  the  effect  of  certain 
prescriptions  was  to  be  tried.  "  Do  no- 
thing to  agitate  the  brain,  avoid  violent 
purgatives,  give  nourishing  drinks,  also 
llesh  and  fish.  The  patient  should  live 
in  a  i^lace  where  the  temperature  is  mild, 
and  be  surrounded  by  many  trees  and 
roses." 

III.  Maliktaolia  a  IVIaraki. — The  hu- 
moral pathology  comes  in  here.  From 
the  limbs,  the  humours  and  the  heat  of 
the  body  pass  to  the  brain.  This  heat 
(Marak)  ascends,  it  destroys  the  soul  and 
darkens  intellect.  The  patient,  if  not  re- 
lieved, loses  all  power  of  reasoning  and 
action,  and  the  disorder  terminates  in  de- 
mentia. He  is  quarrelsome  and  danger- 
ous, if  the  humour  affected  be  bile  ;  but  if 
it  be  the  saliva  he  will  be  quiet,  and  as  if 
under  the  influence  of  liquor.  The  treat- 
ment must  depend  upon  whether  there 
are  signs  of  inflammation  or  not;  if  the 
former,  bleed  and  pat  the  patient  on  a 
milk  diet ;  if  the  latter,  feed  him  up. 

IV.  Diwangi. — The  sub-division  (K^tirift) 
of  this  type  derives  its  name  from  a  small 
animal  which  is  for  ever  on  the  move,  and 
therefore  serves  to  represent  the  ex- 
treme restlessness  which  is  present  in 
this  disorder.  As  the  same  word  signifies 
a  jackal,  it  also  indicates  the  howling  which 
such  patients  sometimes  indulge  in.  They 
are  represented  as  suspicions,  and  hiding 
themselves  during  the  day  in  woods  and 
among  tombs,  only  coming  out  during 
the  night.  Their  expression  is  sad,  they 
are  acutely  melancholy,  sometimes  they 
lacerate  their  bodies  with  thorns  and 
stones.  The  treatment  consisted  in  com- 
pelling the  patient  "  to  be  constantly  em- 


ployed, it  being  of  the  utmost  importance 
to  get  the  patient  to  work."  The  patient 
might  be  bled  at  the  outset.  If  the  above 
treatment  failed,  water  was  to  be  con- 
stantly dashed  on  his  head,  and  he  was 
to  be  prevented  from  sitting  in  the  dark. 
The  prognosis  was  good.  We  next  come 
in  the  second  sub-division  of  Diwangi,  to 
the  familiar  title  of  "  Mania,"  the  Arabic 
equivalent  being  "  Janooib  Tabcc,"  termed 
by  one  Arab  writer  Razuo,  "  Janoon 
Haeeg."  Those  labouring  under  this 
malady  smash  and  tear  whatever  they 
come  across.  In  short,  they  are  maniacs. 
Another  sub-division  (Du.uh-Kulh)  re- 
sembles hydi'ophobia.  The  patient  fawns 
like  a  dog.  If  he  bites  another  person, 
the  latter  speedily  dies  with  symptoms 
similar  to  those  observed  in  men  bitten 
by  a  mad  dog.  The  fourth  sub-division 
{Sudor)  is  described  as  mania  associated 
with  "  swelling  of  the  brain."  We  notice 
here  the  first  reference  to  restraint.  The 
hands  and  feet  were  to  be  tied,  and  this 
for  three  reasons  : — That  the  patient's 
restlessness  may  be  controlled  ;  that  his 
brain  may  have  rest,  and  lastly  that  he 
may  be  prevented  from  killing  himself 
and  others. 

V.  Haziyan  is  a  disorder  of  judgment 
involving  the  loss  of  the  power  of  thought. 
It  is  unnecessary  to  detail  its  sub-divi- 
sions. 

VI.  Raoonut,  and  VII.  Kimak. — The 
symptoms  under  these  forms  appear  to 
be  very  similar  to  the  foregoing. 

VIII.  Zslik.  —  This  word  signifies  a 
creeper  which  twines  around  a  tree  and 
gradually  causes  its  death.  Grief  and 
weeping,  love  of  solitude,  concentration  of 
the  mind  on  a  loved  object,  anxiety  and 
silence  characterise  this  form.  The  pa- 
tients labouring  under  it  must  be  amused 
and  kept  merry.  Marriage  is  prescribed 
as  the  best  remedy  of  all.  The  cause 
given  is  excessive  venery. 

IX.  TTisyan  is  the  loss  of  memory, 
the  ti'eament  of  whicb  was  unknown  to 
Najab  ud  din  Unhammad.  Neither  Mr. 
Stokes  nor  M.  Loisette  appears  to  have 
had  his  analogue  in  Arabia. 

The  Editor. 

\  llrjVri'iice. — Di-.  .1.  <i.  Balfonr,  "An  Arab  pliy- 
siciaii  on  Insiinity,"  .lourn.  of  Ment.  .Si-i.  .Inly  1876, 
from  whicli  Paper  this  article  is  derived.] 

XTATrOCEPHAXiVS  vavoi,  a  dwarf; 
KecpaXr],  head).  A  term  meaning  the  pos- 
session of  a  diminutive  head,  the  size  of 
the  rest  of  the  body  being  normal.  (Fr. 
nauoceplude ;  Ger.  Zwergkopf.) 

UTA-RCi:  (vapKT],  stupor).  An  old  term 
meaning  diminished  activity  of  the  nervous 
system.  Applied  byHippocrates  to  mental 
torpor.     (Fr.  stitpewr;  Ger.  FiihllosigkeU.) 


Narcema,  Narcesis         [    832    ]      Negations,  Insanity  of 


la*  ARC  EM  A,    NARCESIS     {vdpKi]). 

Narcosis  iq.r.). 

KTARCOSES  (vdpKT] ;  codes,  tei'minal). 
An  adjective  meauing  '*  having  stupor  "  ; 
narcous.     (Fr.  nan-ei(.'' ;  Ger.  betihiht.) 

NARCOIiEPSY  {vdpKr];  Xap^dpco,  I 
take).  Irresistible  attacks  of  sleep,  short 
in  duration,  but  occurring  at  frequent  in- 
tervals. 

ITARCOSIS  (vapKoo),  I  become  torpid). 
A  condition  of  insensibility  produced  by 
the  action  of  certain  drugs,  poisons,  and 
retained  excretory  products  on  the  ner- 
vous system.  (Fr.  ^uircose ;  Ger.  Betixu- 
huiig.) 

NARCOTICS  (papKoco).  Certain  drugs 
and  poisons  which  act  on  the  nervous  sys- 
tem, and  in  small  doses  promote  sleep,  but 
in  lai'ge  doses  bring  on  complete  insensi- 
bility and  death.  (Fr.  narcotiques.)  (See 
Sedatives.) 

WARRENHAUS  (Ger.).  A  mad- 
house. 

NARRHEZT  (Ger.).   Lunacy,  madness. 

NASAIa  TUBE. — A  soft  india-rubber 
tube  which  is  passed  through  the  nose 
into  the  tesophagus,  for  the  forcible  feed- 
ing of  those  either  unable  or  unwilling  to 
take  food  naturally  ;  it  is  also  used  for 
washing  out  the  stomach  in  cases  of 
poisoning  and  in  certain  gastric  diseases. 
(See  Feeding.) 

NATIVISTIC  THEORY,— The  theory 
that  asserts  that  visual  and  other  sensa- 
tions give  rise  to  perceptions  of  space, 
form,  distance,  &c.,  not  through  a  mental 
interpretation  as  the  result  of  experience, 
but  through  the  agency  of  some  innate 
power. 

M'ATTTRAXi. — A  commou  term  for  an 
idiot. 

IffATJTOlVIANIA  {vavrrjs,  a  seaman ; 
pavia,  madness).  Morbid  fear  of  a  shiij. 
By  some  authors  it  has  been  applied  to  a 
form  of  insanity,  said  to  be  occasionally 
observed  among  seamen,  characterised  by 
a  morbid  dread  of  water,  and  a  furious, 
destructive,  and  homicidal  mania.  (Fr. 
tmiU  omanie.) 

urECROiVTZMESis  (vfKpos,  a  corpse  ; 
pipr]ais,  imitation).  The  delusion  in  which 
a  patient  believes  himself  to  be  dead, 
(Mickle.) 

NECROPHZIilSIVI  {v(Kp6s ;  ^iXe'co,  I 
love).  A  term  used  in  two  senses,  either  a 
morbid  desire  for  eating  dead  bodies,  or  an 
insane  impulse  to  violate  a  corpse.  Those 
so  affected  are  called  necrophiles. 

NECROPKOBXA  {v(Kp6s;  4>ofifU),  I 
fear).  Either  morbid  fear  at  the  sight  of 
a  dead  body,  or  morbid  fear  of  death.  (Fr, 
necrophohie ;  Ger.  Lvirlienseheu.) 

Xa-ECATZONS,  INSAWITY  OT{DeJire 
rles  Negations). — The   French  term    was 


introduced  by  Dr.  Jules  Cotard  in  1882, 
to  designate  a  state  to  which  Griesinger 
made  special  reference  in  describing 
melancholia : — "  A  state  of  mental  pain, 
becoming  always  more  dominant  and  per- 
sistent, and  increased  by  every  impression, 
is  the  essential  mental  disorder  in  melan- 
cholia ;  and,  so  far  as  the  patient  himself 
is  concerned,  this  mental  pain  consists  in  a 
profound  feeling  (Unwohlsein)  of  ill-being, 
of  inability  to  do  anything,  of  suppression 
of  the  physical  powers,  of  depression  and 
sadness,  and  of  total  abasement  of  self- 
consciousness The  disposition  as- 
sumes an  entirely  negative  character  (that 
of  aversion).'"'  * 

The  employment  of  the  woi'd  in  question 
by  the  Germans,  as  also  by  the  French, 
includes  the  antithesis  of  that  healthy  con- 
dition of  the  mind  which  may  be  termed 
positive.  It  involves  a  repulsion,  and 
may  therefore  be  said  to  be  a  negation 
of  mental  health.  It  is  not  necessarily 
accompanied  by  vei'bal  denials.  The  idea 
which  those  intend  to  convey  who  employ 
the  term  is  expressed  in  Griesinger's 
words,  "Die  Stimmung  nimmt  einen 
durchaus  negativen  Charakter  (des  Verab- 
scheuens)  an."  Without  this  explanation 
the  reader  would  naturally  expect  a 
morbid  mental  condition  similar  to  that 
of  "  insanity  of  doubt,*'  and  in  truth  one 
variety  of  the  insanity  of  negations 
appears  to  the  writer  to  be  almost  if  not 
quite  identical.  From  the  above,  how- 
ever, it  will  be  seen  that  Griesinger  had 
in  view  one  phase  of  melancholia.  He 
would  have  included  mania  of  persecution. 
It  has  been  the  object  of  M.  Cotard  to 
extricate  it  from  this  category,  and  he 
gives  with  great  perspicuity  the  differen- 
tial diagrnoses  between  the  two. 

In  the  insanity  of  negrations  there  is 
anxiety,  groaning,  prtscordial  distress ; 
the  patients  are  typical  examples  of 
anxious  melancholia ;  others  fall  into 
mental  stupor  ;  some  exhibit  alterna- 
tions of  mental  stupor  and  acute  melan- 
cholia. 

Hypochondriasis,  especially  moral,  is 
observed  at  the  onset.  The  patient 
accuses  himself;  he  is  incapable,un worthy, 
guilty,  lost :  should  the  police  come  to 
arrest  him  and  conduct  him  to  the  scaffold, 
he  only  too  richly  deserves  death  for  his 
crimes.  Suicide  and  self-mutilation  are 
frequent,  homicide  is  rare.  There  are 
disordei's  of  sensation,  including  anes- 
thesia. Hallucinations  are  often  absent. 
When  present  they  are  simply  confirma- 
tory   of   delusions ;     hence   there    is   no 

*  '•  Die  I'atholouie  xind  Therapie  tier  psychis- 
chen  Kratikbeiteu."  1861,  pp.  227-8.  See  also 
Syd.  Soc.  tniusl.,  1867.  p.  223. 


Negations,  Insanity  of      [    833    ]       Negations,  Insanity  of 


antagonism  between  the  patient  and  voices 
that  speak  to  him — no  dialogue ;  when  such 
patients  speak  to  themselves  it  is  in  order 
to  repeat  in  the  form  of  litanies  the  same 
words  or  the  same  phrases  addi-essed  to 
real  persous  around  them.  Visual  hallu- 
cinations are  tolerably  frequent.  ['lii/si(((l 
hypochondriasis  follows.  Patients  think 
they  have  no  brain  or  stomach,  &c.  Tliey 
may  either  deny  that  they  are  alive  or 
that  they  will  ever  die.  The  personality 
is  transformed  ;  some  speak  of  themselves 
in  the  third  person.  Patients  deny  every- 
thing, they  have  no  parents,  no  family ; 
everything  is  destroyed,  there  is  no  longer 
anything ;  they  have  no  mind  ;  God  him- 
self does  not  exist.  There  is  a  morbid 
desire  to  oppose  everything.  Food  is 
■e-iitircly  refused ;  such  patients  refuse 
because  they  are  unworthy,  because  they 
cannot  pay,  because  they  have  no  stomach, 
&c.  The  course  of  this  form  is  at  first 
intermittent,  then  continuous. 

On  the  other  hand,  the  symptoms  of 
persecution  mania  are  as  follow  : — The 
patient  does  not  as  a  rule  present  the 
usual  fades  inijlanculique.  Hypochon- 
driasis, especially  jj/;-^siroi,  is  observed  at 
the  onset.  The  patient  holds  aloof  from  the 
external  world  and  the  harmful  influences 
coming  from  various  sources — especially 
from  the  midst  of  social  life.  He  does  not 
accuse  himself  :  he  rather  boasts  of  his 
physical  and  moral  force,  and  the  excellent 
constitution  which  allows  him  to  bear  so 
many  evils.  Suicide  is  comparatively  rare. 
Homicide  is  more  frequent.  Disorders  of 
common  sensation  are  very  rare.  Auditory 
hallucinations  are  constantly  developing 
themselves  as  is  well  known.  Visual  hal- 
lucinations are  very  rare.  Moral  hypochon- 
driasis is  secondary.  Patients  declare  that 
their  persecutors  attack  the  moral  faculties, 
and  that  they  are  made  idiotic.  There  is 
(lelire  cles  grandeurs.  The  refusal  to  take 
food  is  partial.  lu  consequence  of  the 
fear  of  being  poisoned,  patients  eat 
voraciously  such  food  as  they  believe 
not  to  be  poisoned.  The  course  of  the 
disorder  is  remittent  or  continuous,  with 
paroxysms. 

The  above  presents  in  a  lucid  form  the 
points  of  differential  diagnosis  between 
insanity  of  negation  and  that  of  delusions 
of  persecution  as  sketched  by  M.  Cotard. 
Examples  are  given.  One  is  that  of  a 
lady  who  when  asked,  "  How  do  you  do, 
madame  P"  rep)lied, "  The  person  belonging 
to  myself  is  not  a  dame,  call  me  Made- 
moiselle, if  you  please." 

"  I  do  not  know  your  name.  Will  you 
tell  it  me  ?" 

"  The  person  belonging  to  myself  has  no 
name  ;  I  desire  that  you  do  not  write  it." 


"  I  still  desii'e  to  know  your  name,  or 
rather  what  you  were  formerly  called  ?  " 

"I    understand  you.     I  was  Catherine 

X .     It  is   needless    to  speak  of  what 

took  place.  The  person  belonging  to  my- 
self has  lost  her  name,  She  gave  it  away 
when  she  entered  the  Salpetricre." 

"  How  old  are  you  ?" 

"  The  person  belonging  to  myself  has 
not  an  age." 

"  Are  your  parents  still  living  ? '' 

"  The  person  belonging  to  myself  is 
alone,  has  no  parents  and  never  had  any."' 

"  What  have  you  done  ?  and  what  has 
happened  to  you  since  you  became  the 
person  of  yourself.'"' 

"  The  person  belonging  to  me  has  re- 
mained in  the  Asylum  of  .  Experi- 
ments, physical,  metaphysical,  have  been 
and  are  still  made  upon  it." 

In  attempting  to  trace  the  pathological 
evolution  of  those  melancholiacs  who  ac- 
cuse themselves,  and  of  those  patients  who 
labour  under  the  insanity  of  negation,  M. 
Cotard  sketches  in  the  first  instance  the 
principal  characters  of  the  mental  condi- 
tion of  the  former.  In  the  simplest  form 
they  ai-e  those  which  belong  to  the  variety 
of  melancholia  known  as  ''  simple"  or 
"  without  delusion,"  oi-,  as  some  term  it, 
moral  hypochondriasis  (J.  Ealret).  Al- 
ready such  patients  present  a  negative 
condition  of  mind.  They  mourn  over 
their  lost  energy  and  feeling  ;  they  assert 
that  the}^  no  longer  feel  affection  for  their 
friends  or  even  their  own  children.  Ideas 
of  ruin  arise  and  appear  to  be  a  delire 
negatif  of  the  same  nature.  There  is 
a  veil  interposed  between  the  patient  and 
his  surroundings,  which,  as  in  cases  of 
mental  stupor,  may  become  so  opaque  as 
to  entirely  mask  the  world  of  reality. 
There  is,  M.  Cotard  holds,  only  a  difference 
of  degree  between  the  foregoing  conditions 
of  moral  hypochondriasis,  self-accusation, 
and  the  systematised  delusion  of  negation. 
It  is  easy  to  understand  the  transition 
from  a  sense  of  the  external  world  being 
changed  and  the  denial  of  its  existence. 
Even  the  state  of  mind  which  leads  the 
patient  to  deny  the  possibility  of  his  re- 
covery, logically  ends  in  an  absolute  dis- 
belief in  his  environment  and  his  own 
existence.  While  some  patients  believe 
in  their  immortality,  asserting  to  the  last 
moment  that  they  shall  not  die,  patients 
who  pass  into  a  state  of  delusional  stupor, 
imagine  that  the}'  are  dead. 
_  In  classifying  cases  of  insanity  of  nega- 
tion, M.  Cotard  gives  three  categ-orles, 
the  first  of  which  comprises  what  he  calls 
the  simple  condition  {ctat  de  simjjUciie), 
the  second,  those  cases  in  which  it  is  a 
symptom    of  general  paralysis,  and  the 


Negations,  Insanity  of 


«34     ] 


Nerve  Storms 


third,  those  in  which,  associated  with 
persecution  mania,  it  constitutes  those 
complex  forms  of  insanity  which  account 
for  the  confusion  between  melancholia 
and  delusions  of  poverty,  culpability,  dis- 
trust, and  of  persecution. 

As  an  example  of  the  first  category,  the 
case  of  a  lady  is  given,  suicidal,  hypo- 
chondriacal, and  with  delusions  of  guilt. 
During  paroxysms  of  distress  she  asserted 
that  all  her  organs  were  displaced,  and 
that  she  was  lost,  that  she  had  no  longer 
a  head,  and  that  in  short  she  was  dead. 
After  a  time  she  denied  having  arms  or 
legs,  and  in  short  believed  that  all  parts 
of  her  body  were  metamorphosed.  The 
disorder  terminated  in  dementia. 

Under  the  second  division  a  case  is 
given  in  which  the  patient  expressed 
negative  ideas  of  a  very  absurd  character ; 
he  denied  that  there  was  any  night,  and 
refused  to  go  to  bed ;  he  passed  whole 
nights  in  his  office,  asserting  that  he  could 
not  retire  to  bed  because  it  was  still  day. 
He  refused  to  eat  any  more,  and  however 
abundant  the  food,  he  became  infuriated 
and  denied  that  there  was  anything  on 
the  table.  He  asserted  that  he  was  in  a 
desert  where  no  one  lived,  and  from  which 
he  could  not  escape,  because  there  were 
no  more  carriages  or  horses.  Shown  a 
horse,  he  said,  "  This  is  not  a  horse,  it  is 
nothing,''  He  refused  to  have  his  clothes 
put  on  because  the  whole  of  his  body  was 
not  greater  than  a  hazel-nut.  He  would 
not  eat  because  he  had  no  mouth,  or  walk 
because  he  had  no  legs.  He  died  from 
general  paralysis. 

The  third  class  is  illustrated  by  a  patient 
who  had  severe  attacks  of  hysteria,followed 
by  melancholia,  with  ideas  of  guilt ; 
mystical  ideas,  and  paroxysms  of  wild  ex- 
citement, and  believed  herself  to  be 
possessed.  One  delusion  was  that  she 
had  become  a  scorpion,  and  she  displayed 
remarkable  contortions  in  imitation  of  its 
movements.  She  imagined  herself  to  be 
persecuted  by  people  who  could  read  her 
thoughts.  She  denied  at  last  being  any 
longer  human. 

We  have  thought  it  well  to  put   the 
reader  in  possession  of  the  views  enter- 
tained by  certain  French  alienists  in  regard 
to  the  dclire  des  negations,  but  an  English 
alienist  finds  it  difficult  to  see  the  force  of 
the  various  forms  or  divisions  which  are 
laid  down  by  M.  Cotard.     That  there  is  a 
mental    condition  to     which    the    terms 
"  negation"  and  "  negative"'  as  ordinarily 
understood  might  very  properly  be  applied, 
cannot  be  doubted.    An  instance  in  which  ! 
the  term  may  be  very  properly  used  has  j 
been  already  given  in  this  article  (p.  833),  j 
for  no  statement,  however  elementary  as 


regards  its  truth,  could  be  made  without 
the  patient  instantly  denying  it.  If  a  man 
is  asked  his  name,  and  he  says  he  has  none ; 
or  his  age,  and  he  denies  being  of  any  age  : 
where  he  was  born,  and  he  replies  that  he 
never  was  born  ;  who  was  his  father,  and 
he  denies  ever  having  parents  :  if  he  has 
headache  or  stomach-ache,  and  he  responds 
that  he  has  not  either  of  these  organs ;  or 
lastly,  if  a  patient  is  shown  the  commonest 
flower  there  is,  and  he  denies  that  it  is  that 
flower — well  then,  we  admit  that  no  better 
term  can  be  found  for  such  a  mental  condi- 
tion than  the  one  under  consideration,  but 
this  is  only  a  small  part  of  the  area 
covered  by  the  cases  which  French  alien- 
ists have  in  view.  Moreover,  we  should 
be  falling  far  short  of  Griesinger's  "  revul- 
sion " — the  negation  of  mental  health.  In 
truth,  his  description  apjjears  to  us  to  be 
so  comprehensive  that  it  ceases  to  be  dis- 
tinctive. The  Editor. 

[He/i-ri'nceti.  — Louret,  Fragments  psycliolog-iques. 
I'aris,  i83i,pp.  i2i,  40J  et  .siiir.  :  Traitemeiit  moral 
de  lii  Folic.  Taris,  1840,  pp.  274,  281.  Esquirol, 
Dcs  maladies  meiitales,  chap.  Demoiiomanie,  Paris, 
1838.  Fodere,  Traite  dii  Delire.  t.  i.  p.  345. 
Morel,  Ktndes  eliiiiqnes  sur  les  maladies  mentales. 
t.  ii.  pp.  37,  448.  Macario,  Aiinales  medico-psy- 
chologiiines.  t.  i.  Haillarger,  De  Tetat  deslgiie 
sous  le  Tiom  de  stui)idite,  1843;  I^"  theorie  de 
I'automatisuie  (Ann.  Jled.-l'sycli.  1855);  Note  sur 
Ic  Delire  hypochoiidriaque  (Aeademie  des  Sciences, 
i860).  Archamhanlt,  Aimales  medico-psycholo- 
Siques.  1852,  t.  iv.  p.  146.  I'etit.  Archives  clini- 
(|U(^s,  p  59.  Michea.  Du  Delire  hypochondi-iaqne, 
Ann.  iNIed.-I'sych.  1864.  JIatenie,  Th.  de  Paris, 
1869.  Knilft-Ebing,  Lehrlmch  der  Psychiatrie, 
obs.  ii.  et  vii.  M.  Cotard,  to  whom  we  are  in- 
del)ted  for  the  above  references,  has  written  an 
article  in  the  Ann.  5re<l.-l'sych.,  1880.  entitled  Dn 
Delire  hy]>ochondriai|Uc  dans  nne  forme  grave  de  la 
melancolie  an.xieiise.  See  also  Archives  de 
Keurologie.  1882  :  and  his  Etudes  snr  les  ;Maladies 
Cercl)ral(s  ct  Jlcntalcs.  1891.    I'refaee  by  Falret.l 

irsGRO-CACHEXY.  A  form  of  pica 
or  depraved  appetite  not  uncommonly 
found  in  negroes  when  afflicted  with  some 
diseases  ;  akin  to  the  pica  of  chlorosis  and 
pregnancy.     Syn.,  Cachexia  Africana. 

M-EGRO-IiETHARGV.  (.SVe  NeLAVAX.) 

NEJsA.yrA.N. — The  "  African  sleep  dis- 
ease." An  endemic  disease  of  negroes  on 
the  West  Coast  of  Africa  characterised 
by  morbid  somnolence,  headache,  and 
emaciation.     It  is  usually  fatal. 

srERVE  STORMS. — A  name  loosely 
given  to  paroxysmal  attacks  of  emotional 
disturbance  functional  in  character.  It 
is  also  applied  to  certain  diseases,  such 
as  epilepsy,  migraine,  paroxysmal  vertigo, 
&c.,  some  of  whose  characteristics  are  a 
regular  succession  of  phenomena  in  each 
attack,  an  inverse  relation  between  the 
severity  and  frequency  of  the  attacks,  and 
a  culmination  to  a  certain  pitch  of  inten- 
sity followed  by  subsidence.     It  has  been 


Nervosism 


[ 


] 


Neuralgia 


thought  by  some  that  the  pathology  of 
these  diseases  is  best  summed  u])  by  the 
term  "nerve-storm"  on  the  supposition 
that  there  is  a  gradual  accumulation  of 
nervous  force  which  is  suddenly  dis- 
charged, with  the  result  of  producing  the 
peculiar  symptoms. 

M-ERVOSZSIVI.  —  The  doctrine  which 
maintains  that  all  morbid  phenomena  are 
due  to  variation  in  nerve  force. 

NERVOUS  DIATHESIS.  {See  DIA- 
THESIS, IXSAXE.) 

WEURJEMZA  {vevpov,  a  nerve ;  alfj.a, 
blood).  A  term  used  for  functional  dis- 
ease of  ihe  nervous  system  (Laycock). 

ITEURAIiGZA  in  its  Relation  to  MCen- 
tal  Derangrement.  —  It  would  be  more 
correct  to  substitute  for  "  neuralgia  "  the 
term  "  derangement  of  sensibility,"  for 
we  are  going  to  treat  here  not  only  of 
circumscribed  affections  of  one  or  another 
nerve  with  the  characteristic  painful 
points  of  Valleix  {Valleix'sclie  Sclmierz- 
punhte),  but  likewise  of  hypersesthesise, 
ana3sthesia3  and  parsesthesia3,  of  central 
or  peripheral  origin,  and  of  a  circum- 
scribed or  diffuse  nature,  and  of  their 
connection  with  mental  processes. 

Symptoms.  —  Considered  from  this 
wider  standpoint,  the  tiJioma?tes  of  sensory 
nerves  form  a  frequent  element  in  the 
clinical  aspect  of  mental  disorders,  and 
also — as  we  are  about  to  prove — an  im- 
jsortant  factor  in  their  production.  Such 
anomalies  are  part  of  the  acute  as  well 
as  chronic  forms  ;  they  sometimes  precede 
the  mental  derangement  and  sometimes 
accompany  it  throughout  its  course  ;  they 
sometimes  are  mere  accidental,  and  some- 
times, on  the  contrary,  exciting  causes,  by 
constituting  a  basis  for  the  mental  dis- 
order, or  by  causing  the  outbreak  of  an 
actual  attack.  Thus  we  may  speak  of 
(l)  a  psycho-pbysical,  and  (2)  of  a 
pathog:enic  function  of  neuralgia  in  its 
relation  to  mental  derangement. 

(i)  Under  psycho-physical  function  we 
understand  the  psychical  interpretation  of 
neuralgia — i.e.,  the  explanation  of  abnor- 
mal sensations  by  a  deranged  mind.  From 
the  pathology  of  the  nervous  system  we 
know  those  abnormal  perceptions  through 
which  anaesthetic  limbs  are  often  con- 
sidered to  be  foreign  bodies,  or  the  fre- 
quent delusions  following  the  amputation 
of  limbs  in  consequence  of  irradiation 
from  the  nerves  of  the  stump.  Such 
illusory  interpretations  take  place  in  a 
still  higher  degree  in  mental  derange- 
ment when  all  critical  power  is  absent,  or 
all  perceptions  are  determined  by  one 
predominant  fixed  idea.  Thus  every 
"pressure"  on  any  part  of  the  body  is 
explained  by  the  melancholiac  as  a  "warn- 


ing of  his  guilty  conscience,"  and  by  the 
paranoiac  as  a  "  point  of  attack  on  the 
part  of  his  persecutors."     In  the  so-called 
"  maniacal  rage"  (Zom-manie),  a  frequent 
form  of  mania  in   anaemic  patieats,  the 
prsecordial  pain  causes  the  patient  to  make 
violent  attacks.     In  consequence  of  such 
interpretations  of  derangements  of  sensi- 
bility, neuralgia  becomes  the  direct  foun- 
dation, i.e.,  the  cause,  of  delusions  or  fixed 
ideas.     The  qualify  of  the  abnormal  sen- 
sation most  frequently  decides  the  subject- 
matter  of  the  delusions ;    painful  sensa- 
tions and  those  of  pressure  produce  ideas 
of  persecution  and  danger  in  melancholic 
and  paranoiac  patients;  abnormal  sensa- 
tions in  the  viscera  produce  the  idea  of 
"  strange  animals  in  the  stomach"  or  of 
"displaced  viscera"  in  the  hypochondrium ; 
the  ideas  of  "  pregnancy  "  and  of  "  rape  " 
are  caused  by  uterine  disorder.    Abnormal 
sensations  in  the  male  genital  organs  are 
explained  as  "  attempts  to  castrate."    On 
the   other  hand,  abnormal   sensations   of 
the  skin  produce  changes  in  the  sense  of 
bodily  limitation  :  the  patient  feels  smaller 
or  larger,  he  even  becomes  the  "universal 
spirit "  or  feels  "  wings    growing,  which 
carry  him   as  if  he   were   as   light  as  a 
feather."     Sometimes  local  hypergesthesia 
and  anesthesia  occur  combined ;  a  melan- 
choliac feels  a  *'  hole  "  (anaesthesic  portion 
of  the  skin)  in  his  chest,  thi-ough  which 
the  devil  has  fetched  his  evil  soul  (deep 
intercostal  pains)."     The  "  ogres  "  {Wehr- 
wolf)  in  the  epidemics  of  the  Middle  Ages 
must  probably  to  a  great  extent  be  con- 
sidered as  abnormalities  of  cutaneous  sen- 
sation in   melancholiacs.      In    the   same 
way  the  sensations  of  motor-inhibition  in 
the    persecution-mania   of    certain  tabic 
patients    become   man-traps    and  snares 
which  the  supposed  enemies  of  the  patient 
have  laid  for  him. 

We  find  an  analogy  to  these  psycho- 
physical relations  in  dreams.  Here  also 
certain  sensations  (in  the  viscera,  and 
muscles)  produce  a  "  dream  of  flying,"  or 
a  "dream  of  falling ;"  and  iu  certain  in- 
dividuals approaching  internal  disorder 
(indigestion,  &c. )  announces  itself  in  certaia 
ever-returning  dreams.  "  Nightmares," 
also,  with  the  sense  of  sufibcation  and 
of  danger  to  life,  belong  to  this  category. 
The  connection  of  certain  delusions 
with  certain  abnormalities  of  sensation  is 
a  clinical  fact,  not  only  of  psychological 
but  practical  interest.  For  if  the  psy- 
chical quality  of  a  delusion  corresponds 
to  the  physiological  timbre  of  a  neuralgic 
sensation,  we  seem  justified  in  concluding 
from  the  subject-matter  of  the  former,  the 
quality  and  seat  of  the  latter.  Experience 
confirms  this  in  a  great  number  of  cases. 

3  H 


Neuralgia 


[    836    ] 


Neuralgia 


Thus  the  complaints  of  "  depression  and 
possession ''  of  some  melancholiacs  or  the 
localised  "  persecutions  and  attacks "  of 
a  certain  group  of  paranoiacs  are  pro- 
duced by  local  disorders  of  sensation  or 
painful  nerve-tracts.  To  this  class  we 
have  to  refer,  especially,  the  frequent  jwx- 
cordial  sense  of  weight  in  conditions  of 
depression,  which  in  a  great  number  of 
cases  corresponds  to  a  neuralgic  tract  of 
intercostal  nerves  {vide  infra).  Thus  cer- 
tain qualities  of  the  delusions  become  for 
the  physician  important  psychical  indica- 
tions for  the  bodily  loci  dolentes,  the  sub- 
ject-matter of  the  delusion  becomes  an 
important  tnental  auscultation,  so  to  say, 
a  semeiotic  indicator  of  the  corresponding 
diseased  nerve-tract.  For  both — the  neu- 
ralgia and  the  delusion — form  a  whole  : 
the  physical  irritation  and  its  psychical 
equivalent. 

Derangement    of  sensibility,    clinically 
most  different,  may  assume  this  psycho- 
physical character  and  become  the  cause 
of  delusions,  examples  of  which  have  al- 
ready been    given.      In  addition   to    the 
latter,   we   have  to  mention   diffuse  and 
local   hyperffisthesiae  and   anassthesiae   of 
central    and  spinal   origin    (in    paralysis 
and  other  organic  diseases  of  the  brain) 
and  local  neuralgise  of  spinal  or  constitu- 
tional anfemic    origin    (paranoia,   melan- 
cholia) as  vaso-motor  neuroses  (especially 
in  their  jirimary  stages).     Clinically,  the 
most  frequent  are  intercostal  neuralgise, 
especially   in  neuropathic   women ;  after 
these,  neuralgic  affections  of  the  nerves  of 
the  head,  especially  of  the  forehead  and 
occiput.     Both  conditions  frequently  ac- 
company melancholia,  the   former  being 
the  objective  sign  of  the  patients'  guilty 
conscience  or  "  heartache,"  which — a  most 
significant  fact — is  localised  in  the  pos- 
terior boundary  of  the  axilla  (sometimes 
even  on   the  rigid    side)    and  the  latter 
causing     the     mental    confusion     which 
the  patients  complain  of  ("  so  that  they 
are  even  unable  to  think  of  their  rela- 
tives").     For,  in  a  normal  condition  of 
mind   our  thoughts  are   accompanied  by 
certain  sensations  on  and  in  the  head,  and 
of  slightly  oscillating  visual  pictures.     In 
addition  to  the  tract    of  the   intercostal 
nerves  irritation  of  the  vagus  plays  fre- 
quently a  great  part  in  melancholia  which 
is  indicated  by  alterations  in  the  beats  of 
the  heart  and  by  a  sense  of  weight  in  the 
chest,  by  dryness  of  the  throat  and  hoarse- 
ness.       These   sensations    also    indicate 
to  the  patient  "  the  seat  of  the  evil  one 
in  his  breast,"  or  point  out  to  him  that 
*'  part  of  the  throat  by  cutting  which  he 
must   commit   suicide."    The   prsecordial 
pressure   or  so-called  ^rsecordial  anxiety 


consists    of  affections  of   the    intercostal 
nerves,  of  the  vagus  and    of  the   corre- 
sponding  vaso-motor   tracts  —  united  or 
separately — and   is    felt   by    the   patient 
according  to  its  nervous  origin  as  situated 
externally  in  the  pit  of  the  stomach,  above 
the  heart  in  the  axillary  line  on  the  lower 
part  of  the  sternum,  or   as  an  internal 
weight.     Next  in  frequency  to  this  group 
of  derangements  of  sensibility  follow  the 
numerous  visceral  neuralgiie,  which  occur 
especially  in  hypochondriac  melancholia, 
and  there  produce  the  illusory  sensation 
of  an   abnormal  situs   viscerum   or  delu- 
sions of  all  sorts  of  incurable  disease,  of 
the  presence  of  foreign  substances  and  of 
animals,  of  the  absence  of  certain  organs 
or  their  transformation  into  glass,  metal, 
&c.  Then  follow  the  hypergesthesiae,  anaes- 
thesise   and   partBsthesiaj   of  the   genital 
organs,    which    especially    in   paranoiac 
ivomen   produce   delusions  of  pregnancy 
and  of  rape,  in  men  the  delusion  of  noc- 
turnal castration,  and  of  sexual  assaults, 
and  in  both  sexes  under  certain  conditions 
the  delusion  of  perverse  sexual  sensation 
and  transformation.     In  many  conditions 
doubtless  cutaneous  hyperaesthesiae  play 
a  great  part  and  cause   the  delusion  of 
"  burning "   followed   by   constant   reflex 
attempts   to   undress.     In  paralysis   and 
hysterical  insanity  the  abnormal  cutaneous 
sensations    in  connection  with  abnormal 
muscular  sensations  produce  the  delusion 
of  the  change  of  cutaneous  limitation,  of 
becoming  greater  or  smaller  (macromania 
and  micromania),  of  bodily  deformity,  of 
levitation  and  of  the  flying  away  of  single 
limbs.     The  whole  spinal  cord  even  may 
be   attacked  by   neuralgia  as  in  the  so- 
called  spinal  paranoia   (of  masturbatory 
or  hereditary  neuropathic  origin) ;  in  this 
case  all  forms  of  perverse  sensations  occur, 
partly  localised,  partly  diffuse,  and  pro- 
duce   "  physical     persecution-mania,"    a 
disease,  in  which  every  spot  of  the  body 
in  consequence  of  the  altered  sensibility 
seems  to  the  morbid  ego  to  be  the  points 
of  attack  of  the  persecutor. 

The  principal  condition  for  such  an  in- 
terpi'etation  of  abnormal  sensations  is  a 
morbid  consciousness,  because  the  delusion 
we  have  spoken  of  is  only  possible  under 
the  influence  of  a  deranged  state  of  the 
mind,  and  only  so  far  as  the  critical 
faculty — i.e.,  the  normal  association  of 
ideas — has  been  injured.  Thus,  the  sub- 
ject matter  of  the  delusion  depends  on  the 
quality  of  the  sensation  and  on  the  pre- 
dominant condition  of  the  mind  ;  conse- 
quently, a  central  (psychical)  and  a  peri- 
pheral (neuralgic)  factor  act  together. 
From  this  it  follows  that,  in  the  coui-se  of 
the   mental    derangement,  the  psychical 


Neuralgia 


[    837     J 


Netiralgia 


result — i.e.,  the  subject-matter  of  the 
delusion — of  those  two  factors  undergoes 
changes  ;  during  convalescence  from  me- 
lancholia, when  the  consciousness  becomes 
clearer,  the  former  "guilty  conscience" 
in  the  pit  of  the  stomach  becomes  a 
natural  "  painful  home-sickness,"  and 
gradually  the  painful  nervous  sensation  is 
correctly  interpreted. 

(2)  The  pathogrenic  function  of  neural- 
gia is  connected  with  the  psycho-physical 
factor,  and  still  more  closely  with  the 
physiological  origin  of  the  genuine  affec- 
tion. The  connection  of  both  has  al- 
ready been  mentioned  in  the  co-operation 
of  the  central  and  peripheral  factors — the 
morbid  consciousness  and  derangement  of 
sensibility — spoken  of  above  ;  but  here  it 
is  essentially  of  a  psychical  natui'e  and  is 
the  cause  of  the  delusion  as  an  elementary 
psychosis,  and  the  latter  is  the  psychical 
equivalent  of  the  physical  cause.  From 
this  differs  the  importance  of  neuralgia  as 
a  physio-pathological  factor  of  the  psy- 
chosis, in  which  case  it  is  an  essential 
factor  in  the  production  of  the  latter  ;  not 
a  single  element  of  psychical  importance 
only,  but  a  conditio  sine  qua  non  of  phy- 
siological importance,  and  as  such  it 
forms  necessarily  part  of  the  cerebx'al 
affection,  because  without  its  co-operation 
we  should  not  find  an  entity  of  mental 
derangement. 

In  the  latter  interpretation  it  finds,  as 
mentioned  above,  its  analogue  in  the 
normal  pi'ocess  of  emotion,  which  also  has 
physiologically  a  centro-peripheral  origin. 
For  in  emotion  (and  especially  in  depres- 
sive emotion,  which  corresponds  to  the 
condition  of  depression)  there  is  a  central 
and,  of  necessity,  a  peripheral  process 
(vaso-raotor  and  sensory). 

We  daily  experience,  at  the  very  moment 
of  perception,  that  something  refers  to 
ourselves ;  we  feel  certain  physical  sensa- 
tions, which,  though  changeable  and 
different  according  to  the  individual, 
generally  return  with  typical  regularity. 
We  remind  the  reader  of  the  vaso-motor 
rash  in  the  emotion  of  shame,  the  sensa- 
tion of  weight  at  the  pit  of  the  stomach, 
difficulty  of  breathing,  dryness  of  the 
throat,  palpitations  and  the  feeling  of  in- 
tense coldness,  &c.,  in  the  emotions  of 
/ear,  yrief,  Sind  fright.  Anger  even  influ- 
ences the  vaso-motor  action  and  inhibits 
breathing,  whilst  the  rolling  of  the  eye- 
balls, the  mimicry,  and  lastly,  the  move- 
ments of  defence  or  attack  of  the  arms, 
indicate  the  spreading  of  the  irritation 
from  the  oculo-motor  nerve  downwards 
over  the  spinal  cord.  And  as  the  latter 
movements  liberate  the  inhibition  felt  at 
first  in  the  emotion  of  anger  (the  anger 


expending  itself),  so  in  grief  and  sorrow 
the  flow  of  tears  acts  as  a  reflex,  relieving 
the  painful  (irradiated)  sensation  of 
weight  at  the  pit  of  the  stomach.  It  is 
understood  that,  in  the  process  just  de- 
scribed, the  cerebral  conditions  of  the 
emotion — i.e.,  the  mental  inhibition  in  the 
process  of  ideas  and  the  altered  relations 
— precede  the  fresh  idea,  which  causes  the 
emotion,  but  that  the  ego  feels  this  dis- 
turbance and  is  affected  by  it,  is  produced 
by  the  accompanying  physical  sensations, 
which  give  the  emotion  its  typical  timbre. 
In  this  way  it  becomes  clear  how  certain 
peripheral  sensations  resembling  that 
timbre  are  able  to  suggest  to  the  ego  cer- 
tain morbid  emotions.  Thus,  a  choreic 
patient  is,  in  consequence  of  the  emotions 
caused  by  his  abnormal  muscular  move- 
ments, constantly  in  an  angry  temper ; 
and  in  a  patient  suffering  from  depression, 
new  attacks  of  anguish  are  continually 
caused  by  the  preecordial  weight.  Those 
attacks  are  at  first  without  any  motive, 
but  before  long  the  ego  interprets  them 
in  the  manner  indicated. 

What  is  the  physio-pathological  ex- 
planation of  the  accompanying  sensa- 
tions ?  They  consist  of  affections  of  the 
cranial  nerves,  so  far  as  we  are  able  to 
analyse — especially  of  the  vagus  and 
glosso-pharyngeal — of  the  spinal  nerves 
of  the  thorax  and  abdomen,  and  of  the 
vaso-motor  nwves  according  to  the  j^arti- 
cular  affection.  Certain  affections,  espe- 
cially of  the  vagus  and  of  the  intercostal 
nerves,  accompany  the  normal  conditions 
of  depression  as  well  as  decided  melan- 
cholia, in  which  they  produce  distinct 
points  of  localised  pain,  generally  over 
the  lower  part  of  the  sternum,  and  in  the 
epigastric  region  (precordial  anxiety,  pra3- 
cordialpaiu).  Through  their  connection 
and  their  action  simultaneously  .with  the 
cerebral  disorder,  which  produces  the  con- 
dition of  melancholia,  the  sensory  tracts 
just  mentioned  become  psychical  nerves 
in  the  strictest  sense.  It  is  possible,  and 
seems  to  be  confirmed  by  experience,  that 
especially  in  grief  and  in  analogous  men- 
tal conditions  first  the  vagus  is  affected 
(sensations  in  the  pharynx,  alteration  in 
the  voice,  respiration,  and  the  heart's 
beat),  and  that  gradually,  and  in  propor- 
tion to  the  strength  of  the  emotion,  the 
excitement  spreads  downward  over  the 
medulla  oblongata  and  the  spinal  cord, 
and  affects  the  intercostal  nerves,  thus 
causing  the  sense  of  weight  on  the  chest, 
and  especially  the  "  heartache  "  (Herz- 
weh)  ot  which  the  patients  complain,  with 
the  reciprocal  influence  on  the  patient's 
interpretations,  mentioned  above.  Ac- 
cording to  the  individual  disposition,  the 


Neuralgia 


L 


] 


Neuralgia 


vaso-motor  system  is  also  affected,  pro- 
bably in  the  brain  (contraction  of  tbe  cor- 
tical arteries  with  inhibition  of  mental 
function),  and  spreading  downward  over 
the  thorax  and  abdomen  {cf.  "  Die  neu- 
esten  sphygmographischen  Untersuch- 
ungen,"  von  Gr.  Burckhardt). 

In  normal  depression  the  depressor 
nerve  (according  to  CI.  Bernard)  counter- 
acts this  increase  of  blood-pressure  and 
cardiac  pressui'e  in  consequence  of  the 
arterial  tension,  by  causing  relaxation  of 
the  capillaries  and  afterwards  also  dilata- 
tion of  the  contracted  arteries.  This  self- 
regulation  of  the  normal  emotion  is  pro- 
bably annihilated  in  conditions  of  morbid 
depression  by  the  circumstance,  that  the 
sympathetic  (vaso-contractor)  is  by  some 
peripheral  stimulation  (intercostal  neu- 
ralgia) kept  in  a  condition  of  reflex  irri- 
tation, which  cannot  be  counteracted 
(Goltz). 

To  return  to  clinical  observations. 
In  the  group  of  conditions  of  melancholia 
tlie  co-operation  of  the  cerebral  affection 
{inliibition  of  psycldcal  function)  with  the 
'peripheral  irritation  of  a  sensory  nerve- 
tract  is  an  undoubted  fact.  There  are 
two  reasons  for  this:  (i)  We  always  find 
associated  with  the  cerebral  excitement — 
i.e.,  the  psychical  paroxysms — the  vaso- 
motor symptoms  ;  (2)  the  exacerbation  of 
the  latter  is  invariably  followed  by  a 
psychical  crisis — i.e.,  an  exacerbation  of 
the  mental  condition.  As  soon  as  the 
patient  feels  his  melancholia  increasing, 
the  loci  dolentes  on  the  chest,  &c.,  become 
more  distinct  tvith  or  vAthout  the  vaso- 
motor conditions  mentioned,  and,  vice 
versd,  as  soon  as  the  neuralgia  is  excited 
(by  some  physical  condition,  as  menstrua- 
tion, &c.),  the  anxiety  returns  or  the  pain 
and  delusion  increase.  Tlie  patient  lives 
in  a  vicious  circle  of  circumstances.  The 
occurrence  of  the  so-called  raptus  melan- 
cholicus,  especially,  is  frequently  caused 
by  "  epileptoid  "  irradiation  from  a  neu- 
ralgic zone.  This  pathogenesis  belongs 
to  the  "neuralgic  reflex-psychoses,"  of 
which  we  shall  treat  separately  below. 
A  group  also  of  maniacal  conditions 
belongs  to  this  neuralgic  circle,  especially 
mania  furiosa,  which  has  nothing  in 
common  with  amenomania  (with  couleur 
de  rose  esprit  and  graceful  manner),  but 
consists,  on  the  contrary,  of  a  sulky  mood, 
acts  of  violent  resistance,  and  assaults. 
Here  also  the  angry  temper  and  the  pain- 
ful inhibition  of  consciousness,  with  con- 
stant return  of  one  and  the  same  furious 
idea  in  the  midst  of  an  otherwise  rapid 
flow  of  ideas,  are  accompanied  physically 
by  a  peripheral  neuralgia,  the  motor  reflex 
discharges  of  which  are  represented  by 


the  acts  of  destruction,  and  the  move- 
ments of  defence  and  motiveless  attack. 
The  patient,  when  asked  in  a  quiet  con- 
dition where  his  anger  is  situated  and 
what  causes  his  rage,  points  to  his  chest 
or  the  pit  of  his  stomach. 

Oi paranoiac  conditions,  the  wide-spread 
so-called  spinal  persecution-mania  is 
caused  by  various  derangements  of  peri- 
pheral sensibility,  and  its  course  is,  among 
other  circumstances,  essentially  connected 
with  the  course  of  this  diffuse  spinal 
neurosis.  We  have  spoken  above  about 
the  relations  of  the  latter  to  the  formation 
of  delusions,  and  have  especially  pointed 
out  the  importance  of  the  tiynhre  of  the 
peripheral  sensations,  which  is  reflected 
in  the  subject-matter  of  the  delusion 
(sexual  neuralgiaB  with  obscene  delusions, 
&c.).  Here  we  must  say  more  about  the 
pathogenic  element,  which  consists  in  the 
connection  of  the  cerebral  process  with  a 
sensory  spinal  neurosis,  and  especially 
about  the  further  development  of  these 
cases  of  paranoia.  In  one  group  of  cases 
we  find  the  co-operation  of  the  mental 
derangement  (ideas  of  persecution)  with 
physical  pareesthesia,  in  such  a  manner 
that  the  ideas  of  persecution  are  com- 
pletely made  up  of  the  interpretation  of 
the  paraesthesia :  wherever  the  patient 
perceives  a  sensation,  to  that  point  the 
attack  of  the  persecutor  is  directed ; 
every  pain  is  explained  by  the  patient  as 
a  new  sign  of  the  action  of  his  enemies  or 
of  the  demons.  This  circle  of  ideas  be- 
comes gradually  narrower,  so  that  the 
change  of  the  sensation  into  the  delusion 
becomes  more  and  more  direct,  without 
any  intervention  of  reasoning  or  of 
critique.  Thus,  colicky  pains  in  the 
stomach  are  at  once  interpreted  as  "  ope- 
rations on  the  abdomen,"  itching  of  the 
skin  is  bond  fide  explained  as  "  bites  of 
snakes  which  the  persecutor  has  secretly 
placed  in  the  bed  of  the  patient."  On  the 
other  hand,  every  thought  of  the  perse- 
cutor is  reflected  in  a  peripheral  paraes- 
thesia or  paralgia.  In  another  group  of 
cases  we  find  a  transference  of  the  sensory 
irritation  to  the  motor  system :  in  the 
parts  affected  by  neuralgia,  temporary 
or  permanent  spasms  and  contractures 
(especially  in  the  extremities)  occur,  a 
sort  of  status  attonitus.  In  this  form  of 
development  of  the  neuralgic  i3S3xhosis 
consciousness  generally  sinks  to  a  more 
or  less  profound  stupor,  though  with  a 
dream-like  internal  life,  in  which  the 
altered  muscular  sensations  are  also 
interpreted  as  "  persecution  "  (especially 
demoniacal).  The  patients  Lie  down  still 
and  motionless,  often  spasmodically  cry- 
ing; they  have  to  be  fed,  and  object  to 


Neuralgia 


[    839    ] 


Neuralgia 


being  approached.  The  contractures  of 
the  limbs  frequently  cause  swelling  of  the 
joints  and  local  abscesses.  During  con- 
valescence the  patients  state  the  exact 
localisation  of  the  painful  sensations 
which  compelled  them  to  hold  their  limbs 
contracted,  and  also  their  delusional  per- 
ceptions— e.g.,  that  the  evil  one  had  been 
sitting  on  their  chest  and  taken  their 
breath  (intercostal  neuralgia  with  con- 
sequent tension  of  the  muscles  of  the 
thorax) ;  that  he  had  made  their  limbs 
crooked  so  that  they  were  bewitched  and 
unable  to  move  (interpretation  of  neu- 
ralgia of  the  fifth  nerve  with  consequent 
contractures  of  the  muscles). 

It  does  not  escape  our  notice  that  the 
cases  of  paranoia  which  we  have  men- 
tioned represent  in  their  full  development 
a  sort  of  cerehro-spinal  reflex-meclianistn, 
in  which  ideas  and  emotions  on  the  one 
hand,  and  the  manifold  physical  abnor- 
malities of  sensation  on  the  other,  enter 
into  direct  relation  and  reaction,  and  in 
which,  after  the  disappearance  of  the 
inhibitory  function  of  the  brain,  the  eyo 
gradually  becomes  dissolved — dissociated 
— into  individual  mental  acts  without 
any  connection.  This  is  actually  the 
psycho-physiological  character  of  the 
secondary  stages  and  of  the  termination 
of  this  group  of  spinal  paranoia. 

As  an  addition  to  the  pathogenic 
actions  of  neuralgia  we  have  to  mention 
the  sensory •tro2Jlilc  reflex-action  of  certain 
cases  of  irautnatic  neuralgia  on  the  brain. 
We  find  peripheral  lesions  of  the  nerves 
of  the  head  (fifth  nerve  or  occipitalis 
major)  giving  rise  sometimes  to  conditions 
of  chronic  depression  or  excitement  with 
severe  headache  radiating  from  the  cica- 
trised part,  with  congestions,  numbness, 
vertigo,  loss  of  memory,  sometimes  also 
with  hallucinations  and  attacks  of  mania 
furibunda.  The  trophic  derangements 
appearing  with  the  psycho-neuralgic  cere- 
bral disorder  on  the  affected  side  of  the 
head  are :  falling  off  of  the  hair,  local 
secretion  of  sweat,  and  sometimes  itching 
exanthems.  Thickening  of  the  membrana 
tympani  has  also  been  observed.  As  a 
rule,  pressure  on  the  cicatrix  is  followed 
by  an  increase  of  the  radiating  headache 
and  usually  also  by  an  outbreak  of  mania. 
The  latter  therefore  seems  to  be  a  sort  of 
epileptoid  equivalent  (in  some  cases  actual 
convulsions  are  present  during  the  attack), 
and  the  mental  disorder  an  actual  reflex- 
psyclwsis.  By  excision  of  the  painful 
scar,  and  production  of  a  new  and  pain- 
less one,  a  complete  cure  of  the  severe 
mental  disorder  has  been  sometimes 
effected  {vide  infra). 

In   the   same   neuralgic-reflex  manner 


the  attacks  of  mental  derangement  in  pro- 
lapse of  the  uterus  ai'e  probably  brought 
about,  which  soon  subside  after  the  intro- 
duction of  a  pessary,  but  return  after  its 
removal.  The  relapses  of  mania  often 
observed  as  a  consequence  of  a  painful 
whitlow  cannot  be  explained  otherwise 
than  by  the  same  pathogenesis.  Vaso- 
motor influences  undoubtedly  form  here, 
as  in  all  neuralgic  psychoses,  an  impor- 
tant connecting  link. 

The  therapeutics  of  these  derange- 
ments of  sensibility,  especially  of  the 
neuralgiee,  must  be  founded  on  the  con- 
sideration that  the  sensation  of  local  pain 
or  the  paresthesia  proceed  from  some 
central  or  peripheral  source  (by  irradia- 
tion), but  it  must  be  kept  in  mind  that  in 
the  former  case  also  the  central  irritation 
of  the  nerves  does  not  persist  as  such, 
but  spreads  over  a  certain  sensory  tract, 
settles  down  in  it,  and  thus  causes,  sooner 
or  later,  an  independent  neuralgia.  The 
mental  pain  and  the  ideas  of  persecution 
in  paranoia  are,  so  to  say,  formed  in  the 
sensory  nerves  of  the  body.  Thus,  in  the 
course  of  states  of  depression  different 
intercostal  neuralgiae,  with  the  character- 
istic points  of  pressure  and  the  altered 
cutaneous  sensibility,  are  differentiated 
from  the  (what  is  at  first  a  vague)  prae- 
cordial  weight. 

This  relation  must  be  kept  in  mind  in 
treatment.  As  long  as  the  cerebral  affec- 
tion predominates,  and  irradiation  over  a 
certain  peripheral  tract  has  not  taken 
place  (i.e.,  as  long  as  no  definite  neuralgia 
has  been  caused),  ordinary  therapeutics 
are  sufficient,  as  applied  in  the  commence- 
ment of  conditions  of  depression.  A 
methodical  treatment  with  opium,  to- 
gether with  the  corresponding  general 
treatment,  will  have  a  soothing  eflect  on 
the  brain,  as  well  as  on  the  peripheral 
tracts  of  irradiation.  But  as  soon  as  the 
latter  become  marked  out  and  prominent, 
local  treatment  has  an  excellent  curative 
effect.  In  these  cases,  especially  of  melan- 
cholia with  definite  intercostal  affections, 
the  internal  exhibition  of  opium  may  be 
changed  for  subcutaneous  injections  of 
morphia  with  methodically  increasing 
doses  at  the  neuralgic  points,  or  in  their 
neighbourhood.  If  the  attacks  are  parox- 
ysmal, especially  in  cases  of  periodical 
anxiety,  it  is  important  to  prevent  them 
by  making  the  injection  before  the  attack. 
In  many  cases  this  method  of  treatment 
has  excellent  results,  assuming  that,  in 
addition  to  this,  general  treatment,  soma- 
tic and  mental,  is  applied.  In  slighter 
cases,  in  which  the  paroxysms  are  not  so 
violent,  and  the  anxiety  or  pain  less 
severe,  the  local  application  of  chloroform 


Neuramie 


[    840    ] 


Neiirasthenia 


on  cotton-wool,  or  the  internal  applica- 
tion of  anodynes,  especially  of  antipyrin, 
render  valuable  service,  especially  as  this 
process  ma}-  be  repeated  several  times  a 
day  at  the  commencement — i.e.,  before 
the  increase  of  the  pain.  In  more  severe 
cases,  daily  galvanic  treatment  of  the 
painful  intercostal  tract,  according  to  cir- 
cumstances, with  simultaneous  galvanisa- 
tion of  the  spinal  cord  (descending  current) 
has  very  good  results.  Massage  has  also 
been  successful. 

It  must  be  understood  that  if  the  neu- 
ralgia is  very  distinct  and  persistent,  we 
have  to  attempt  to  find  the  peripheral 
reflex  origin.  Disorders  of  the  abdominal 
functions,  and  especially  affections  of  the 
sexual  organs,  are  often  the  first  cause,  in 
which  case  the  treatment  should  be 
directed  accordingly.  Other  indications 
belong  to  gynascology,  and  the  general 
treatment  of  angemic  conditions  (iron, 
hydro-therapeutics)  so  frequently  neces- 
sary, belongs  to  internal  medicine.  We 
must  make  it  our  principle  to  apply  one 
sort  of  treatment  after  the  other  (often 
also  combined)  when  one  of  them  has 
f  ailed,and  alway  s  to  proceed  with  methodical 
])ersistence.  Medicinal  treatment  has  as 
yet  had  most  unsatisfactory  results  in  the 
neuralgige  and  par£esthesia3  of  spinal  para- 
noia (the  so-called  physical  persecution- 
mania)  ;  electric  treatment  can  frequently 
not  be  applied  on  account  of  the  specific 
delusion  of  the  patient  that  he  is  under 
thf.  influence  of  hostile  electrical  machines, 
but  if  apjjlied  is,  according  to  our  expe- 
rience, of  little  use,  and  th(3  good  achieved 
is  but  temporary.  But,  if  the  spinal 
hypersesthesia  is  caused  by  a  peripheral 
irritation  accessible  to  treatment,  as  affec- 
tions of  the  genital  organs  (especially  in 
women),  a  good  influence  may  be  exercised 
over  the  spinal  reflex  neuralgias  by  the 
treatment  of  the  peripheral  irritation. 

The  treatment  of  reflex  i^syclwses  in 
consequence  of  traumatic  neuralgiie  has 
been  much  more  successful,  as  in  a  certain 
number  of  cases  a  complete  and  lasting 
cure  of  the  irradiated  mental  affection  was 
effected  by  operative  removal  of  the  pain- 
ful cicatrix  (on  the  head). 

HeiNRICH    SCHIJLE. 

XTEVRAiviZE  {vevpov,  nerve).  Neur- 
asthenia (q.v.). 

M-EURiLlMCaiBZMETER.— An  instru- 
ment for  the  measurement  of  Reaction- 
time.     {See  PsYcaio-PHYsiCAL  Methods.) 

NEVHASTHJlNiA.  (vevpop,  the  nerve  ; 
ao-^eVeia,  weakness). — Definition. — By  this 
term  we  denote  a  peculiar  condition  of  the 
nervous  system,  deviating  more  or  less 
from  the  normal  state,  and  characterised  by 
a  loss  of  resistance,  the  latter  in  its  turn 


producing  an  increased  irritability  and 
debility,  so  that  the  nervous  system  is  in 
a  condition  which  may  vary  from  that  of 
apparent  health  to  severe  and  distinct  ner- 
vous disease.  Thus  neurasthenia  extends 
over  the  whole  sphere  lying  between 
health  and  the  more  severe  forms  of  ner- 
vous disorder,  without  however  separat- 
ing them  distinctly ;  on  the  contrary,  in 
the  neurasthenic  condition  of  the  nervous 
system  lie  the  roots  of  the  symptoms  of 
the  nervous  disease,  and  out  of  it,  if  not 
checked,  the  roots  grow  and  form  the  dis- 
ease. Neurasthenia  therefore  rej^resents  to 
a  certain  degree  the  starting-point  of  all 
the  more  severe  nervous  disorders,  and  the 
soil  from  which  they  grow.  The  pheno- 
mena, however,  are  in  neurasthenia  much 
less  marked  than  in  actual  disorder,  and 
are  often  but  slightly  indicated ;  at  the 
same  time  they  are  invariably  present. 

If  the  conditions  mentioned  continue 
to  develop,  hysteria,  epilepsy,  locomotor 
ataxy,  or  general  progressive  paralysis 
appears ;  if  they  do  not  continue  to 
develop,  the  individual  in  question  re- 
mains neurasthenic,  or,  after  a  shorter  or 
longer  time,  is  restored  to  health,  having 
had  only  a  severe  attack  of  neurasthenia. 
Compared  with  the  other  nervous  dis- 
orders, neurasthenia  has  many  peculiari- 
ties, or  else  it  would  not  have  been 
possible  to  separate  the  two  groups. 
These  peculiarities  consist  more  in  nega- 
tive than  in  positive  qualities,  inasmuch 
as  neurasthenia  is  distinguished  from 
other  more  marked  nervous  disorders,  less 
by  the  qualities  it  possesses  than  by  those 
which  it  does  not  possess.  There  will  be 
scarcely  one  neurasthenic  patient  in  whom 
there  are  not  a  number  of  hypocbondriacal 
symptoms  ;  in  a  great  number  of  neur- 
asthenic patients  we  also  find  hysteroid 
and  epileptoid,  in  others  again  tabiform  and 
paralytiform  symptoms  ;  these  symptoms, 
however,  are  not  so  well  marked  as  to  en- 
able us  to  speak  of  hypochondriasis,  hys- 
teria, epilepsy,  locomotor  ataxy  or  general 
progressive  paralysis.  Although  they  may 
develop  into  these  diseases,  they  do  not 
yet  re^jresent  them.  It  is  the  same  with, 
gastro-intestinal  derangements,  at  a  time 
when  dysentery,  cholera  or  typhoid  fever 
is  prevalent,  or  with  slight  catarrhal  and 
rheumatic  afl'ections  at  the  present  day 
when  influenza  prevails  over  the  globe. 
The  slight  afl'ections  mentioned  are  un- 
doubtedly connected  with  the  epidemics, 
but  are  the  simulation  only  of  the  more 
severe  forms.  They  are  not  as  yet  the 
cholera,  dysentery  or  typhoid  fever  itself: 
the  characteristic  element  is  absent. 

Nomenclature.  —  Neurasthenia  has 
also  been  called  nervotisiiess  or  irritable 


Neurasthenia 


[    841     ] 


Neurasthenia 


tveahness.  About  1850,  Hasse  termed  it 
morbid  irritability  and  also  exagr/crated 
sensibilifij,  but  before  him  some  English 
and  French  authors  had  at  least  partly 
described  it :  in  the  sixteenth  century, 
Jean  Fernet ;  in  the  seventeenth,  Lepois, 
Thomas  Willis  and  Sydenham  ;  in  the 
eighteenth  century — especially  towards 
the  end— Robert  Whytt,  Raulin,  Pomme, 
Tissot  and  Erasmus  Darwin,  and  at  the 
commencement  of  this  century,  V.  W. 
Jaeger,  Louyer-Villermain,  and  others. 
The  terms  cadiexie,  diatJuse  nerreuse, 
viarasme,  t'tdt  nervenx,  affection  raiJor- 
euse,  nt'vropatliie  and  raiJeurs,  which  after- 
wards became  inarasvnis  nervosus,  status 
nervosus,  neuropathic  diathesis,  neuro- 
pathic disposition  or  constitution,  were 
formed  at  those  periods.  About  1840 
Brachet  described  it  as  nevrosjxismie,  and 
Valleix  as  nevralgie  generate  qui  si')nule 
des  maladies  graves  des  centres  nerveux ; 
and  not  much  later — about  1850 — San- 
dras.  Cerise  and  Gillebert  d'Hercourt 
described  it  as  nevroixtthie  proteifornie, 
siirexcitation  nerveuse,  etat  nerveux,  &c. 
From  i860,  when  Bouchut  published  his 
monograph:  "Du  nervosisme  etdes  maladies 
nerveuses''  it  was  often  called  by  the  awful 
name  of  nervosismus,  and  after  1868, 
when  George  M.  Beard  published  his  first 
treatise  on  the  disease  in  question,  it  was 
termed  neurasthenia,  a  name  which  un- 
doubtedly is  the  best,  because  the  most 
significant.  Weakness  in  all  its  conditions 
and  with  all  its  consequences  is  the  cha- 
racteristic of  neurasthenia,  which  no  other 
international  term  has  expressed  so  well. 

From  the  time  when  Bouchut  and  Beard 
wrote,  we  may  date  a  new  era  in  the 
history  of  the  disease  in  question.  Each 
of  them  claims  more  than  once  that  lie 
was  the  first  to  shed  light  on  this  affec- 
tion, and  that  up  to  his  time  there  had 
been  only  confusion  and  want  of  clearness 
on  the  subject !  They  say  that  nervosismus 
or  neurasthenia  has  mostly  been  con- 
founded with  hysterical  and  hypochon- 
driacal conditions.  They — and  they  only — 
had  introduced  a  separation  of  these  con- 
ditions. But  if  we  are  completely  unpre- 
judiced, we  must  confess  that  an  absolute 
separation  is  impossible,  and  we  actually 
find  Bouchut  and  Beard  describing  symp- 
toms as  belonging  to  neurasthenia,  which 
undoubtedly  belong  to  hysteria  and  hy- 
pochondriasis, or  even  to  mental  disorders. 
Beard,  indeed,  maintains  that  neurasthenia 
is  a  modern  and  especially  an  American 
disease,  scarcely  known  in  Europe,  and  not 
at  all  in  some  European  countries,  as 
Germany,  Russia,  Italy  and  Spain. 

Neurasthenia,  however,  is  neither  a 
modern  nor  an  American   disease   only. 


It  existed  thousands  of  years  ago  in  the 
old  world,  and  already  in  Hippocrates  we 
find  descriptions  of  morbid  conditions 
which  must  be  referred  to  it.  In  addition 
to  this  we  remind  the  reader  of  the  de- 
scriptions in  former  times,  mentioned 
above,  in  order  to  prove  that  these  state- 
ments are  quite  erroneous. 

In  many  other  places  we  find  also  some 
very  characteristic  descriptions  of  the 
subject  in  question,  which  however  ap- 
peared under  a  different  name  or  as  pass- 
ing statements  in  other  treatises,  and 
therefore  escaped  the  notice  of  many.  We 
mention  among  others  the  article  on 
"  Spinal  Irritation,"  by  Brown  {Glasgoio 
Medical  Journal,  May  1828)  ;  a  treatise 
on  Neuralgic  Diseases  by  Thomas  Pridgln 
Teale,  sen.  (1829) ;  remarks  on  Spinallrri- 
tation  by  Parrish  (1831) ;  "Practical  Ob- 
servations on  Diseases  of  the  Heart,  Lungs, 
&c.,  occasioned  by  Spinal  Irritation,"  by 
John  Marshall  (1835)  '■>  ^^^  remarks  of 
Henle  on  the  Erethism  of  the  Nervous 
System  in  his  Pathologische  Untersuchun,- 
gen  {1840),  and  in  his  Bationelle  Pathologie 
(1846-51);  also  on  Spasmophilic  or  Con- 
vulsibilitaet  as  a  special  morbid  condition, 
by  Hirsch,in  his  Beitraege  zur  Erkenntniss 
unci  Heilung  der  Spinalneurosen  (1843); 
the  description  of  Cerebral  Irritation  by 
Griesinger  in  the  Neue  Beitraege  zur  Phij- 
siologie  unci  Bathologie,  in  the  Archiv 
fuer  pliysiolog.  Heilkunde  (1844);  the 
treatises  on  Spinal  Irritation  and  Habitual 
Spinal  Debility,  by  Wunderlich,  in  his 
Handbucli  der  Pathologie  und  Therapie 
(1854);  and  lastly,  the  remarks  of  Hasse, 
when  speaking  of  Nervous  Weakness  in 
his  Kranhheiten  des  Nervensystems  (1855). 

The  claims  of  Bouchut  and  Beard  are 
therefore  gi-oundless,  and  the  circum- 
stance that  the  works  of  these  two  men 
were  received  with  an  enthusiasm  which 
they  did  not  deserve,  is  due  to  the  fact, 
that  the  study  of  nervous  diseases  had 
been  neglected  for  a  long  time.  It  is  how- 
ever a  merit  of  Beard's,  whose  work  is 
entirely  in  accordance  with  Bouchut's,  to 
have  invented  the  suitable  term  "neur- 
asthenia," a  fact  which,  considering  the 
international  importance  of  science,  is  of 
great  value. 

Symptoms.  —  The  character  of  neur- 
asthenia is  weakness,  loss  of  power  of  resist- 
ance, decrepitude.  The  nervous  system  is 
weak,  partly  in  consequence  of  faulty  de- 
velopment, in  which  it  remained  more  or 
less  behind,  and  partly  in  consequence  of 
insufficient  or  inappropriate  nutrition, 
which  has  produced  a  condition  of  more 
or  less  advanced  atrophy  or  paratrophy ; 
it  may  be  compared  to  a  not  yet  fully 
developed,  or  worn  out,  or  diseased  single 


Neurasthenia 


[    S42    ] 


Weurasthenia 


nerve,  because  its  functions  have  under- 
gone the  same  changes.  It  reacts  accoi'd- 
ing  to  the  law  of  stimulation  of  the 
fatigued  nerve,  just  as  in  hypochon- 
driasis, hysteria,  epilepsy,  and  in  mental 
derangement.  It  is  not  surprising,  there- 
fore, that  neurasthenia  has,  according  to 
the  views  of  Bouchut  and  Beard,  often 
been  confounded  with  hysteria  and  hypo- 
chondriasis, and  that  in  spite  of  this,  Bou- 
chut and  Beard  do  the  same,  describing 
distinctly  hysterical,  hypochondriacal, 
epileptic,  and  epileptoid  conditions  as  be- 
longing to  neurasthenia. 

Whilst  in  the  conditions  mentioned  the 
reaction  may  be  that  of  profoundly 
fatigued  or  even  degenerating  nerve,  in 
neurasthenia  it  is  always  that  of  slightly 
fatigued  nerve.  Neurasthenia  is,  from 
this  point  of  view,  we  repeat,  the  com- 
mencement of  all  these  more  fully 
developed  conditions;  it  is  the  soil  in 
•which  they  take  root  and  from  which  they 
grow.  Neurasthenia,  occurs  as  mentioned 
above,  in  all  possible  degrees  of  intensity, 
and  varies  from  the  condition  of  joerfect 
health  to  that  of  fully  developed  disease. 
It  is  therefore  to  a  certain  degree  nothing 
more  than  a  greater  or  less  disposition  to 
assume  the  symptoms  of  the  diseases  men- 
tioned ;  it  is  what  in  neuropathology  is 
called  the  neuropathic  diathesis,  as  long 
as  it  keeps  itself  within  certain  limits  ; 
as  soon  as  it  steps  over  these  limits  it  be- 
comes actual  disease  or  a  symptom  of  dis- 
ease with  well-marked  characters — hypo- 
chondriasis, hysteria,  epilepsy  or  psycho- 
sis. On  the  other  hand,  it  is  clear  that 
the  commencement  of  the  latter  diseases 
necessarily  coincides  with  the  symptoms 
of  neurasthenia,  and  that  it  is  impossible 
to  separate  them  clearly.  It  will  always 
be  at  the  discretion  of  the  physician  to 
consider  symptoms  as  neurasthenic  or  as 
belonging  to  hypochondriasis,  hysteria, 
epilepsy,  or  to  mental  derangement ;  this 
was  the  case  with  Bouchut  and  Beard 
in  classing  under  neurasthenia,  as  new 
discoveries,  symptoms  which  by  others 
were  regarded  as  belonging  to  more  seri- 
ous conditions. 

The  same  holds  good  with  regard  to  the 
relation  of  neurasthenia  to  the  so-called 
organic  diseases  of  the  nervous  system. 
Both  Bouchut  and  Beard  maintain  that 
neurasthenia  is  distinguished  from  the 
latter  in  not  being  caused  by  organic 
changes.  But  is  it  possible  to  imagine  an 
alteration  in  function  without  organic 
change?  If  we  consider  as  organic 
changes  those  only  which  are  obvious  to 
the  blindest  observers,  we  shall  frequently 
not  find  them  even  in  cases  in  which  dur- 
ing a  whole  lifetime  abnormal  phenomena 


presented  themselves  in  a  most  striking 
manner.  If,  however,  we  keep  in  mind 
that  there  is  no  function  without  an  organ, 
and  that  every  function  is  but  the  product 
of  the  action  of  the  latter,  and  must  vary 
according  to  the  nature  of  the  organ,  we 
cannot  possibly  doubt  that  there  are  or- 
ganic changes  in  cases  in  which  the  func- 
tions are  altered,  however  slightly,  the 
more  so  if  we  have  learned  in  our  own  re- 
searches to  recognise  those  changes 
chemically  and  physically.  From  a  large 
experience  we  shall  derive  the  conviction 
that  there  can  be  no  difference  between 
the  so-called  functional  and  organic  dis- 
eases, but  that  when  the  former  develop 
and  when  disorders  of  function  have  ex- 
isted for  a  longer  or  shorter  time,  they  can 
have  sprung  only  from  organic  changes. 

The  so-called  functional  diseases  must 
therefore  be  always  regarded  as  possibly 
serious ;  and  this  in  proportion  to  the 
degree  in  which  they  are  developed  and 
the  sufferings  they  cause.  The  history 
of  many  a  case  of  encephalitis,  myelitis, 
neuritis  (neuralgia),  locomotor  ataxy,  and 
of  general  progressive  paralysis  has  un- 
fortunately but  too  often  proved  this. 
Beard,  who  lays  special  stress  on  the 
difference  between  functional  and  organic 
disease  and  calls  neurasthenia  a  purely 
functional  disorder  which  causes  much 
pain,  is  quite  wrong  in  maintaining  this 
distinction.  All  the  affections  mentioned 
are  caused  by  profound  organic  changes, 
and  their  character  does  not  develop 
except  after  a  prodromic  stage  of  many 
years  ;  yet  the  symptoms  were  considered 
merely  functional  disorders,  and  under 
the  circumstances  naturally  so.  Their 
relation  to  the  prodromic  stage  is  the 
same  as  that  of  hypochondriasis,  hys- 
teria, epilepsy,  and  mental  disorders  to 
pure  neurasthenia ;  they  spring  from  it. 
Such  is  the  case,  also,  with  multiple  scle- 
rosis, with  progressive  bulbar  paralysis, 
and  with  sclerotic  plaques  in  the  spinal 
cord,  a  sufficient  reason  for  taking  every 
case  of  neurasthenia  very  seriously,  be- 
cause we  never  know  whether  more  seri- 
ous disorders  may  not  at  last  develop, 
or  whether  the  neurasthenia  is  not  already 
an  indication  of  more  severe  troubles.  Of 
course  the  longer  neurasthenia  has  been 
present,  and  the  graver  the  symptoms, 
the  less  favourable  is  the  prognosis. 

According  to  the  law  of  stimulation  of 
a  fatigued  or  degenerating  nerve,  the 
nervous  excitability  as  such  is  decreased, 
but  nevertheless  appears  at  tirst  increased 
on  account  of  the  greater  capacity  of  con- 
duction in  consequence  of  the  decreased 
resistance  ;  this  exaggerated  excitability 
still  increases,  at  first  rapidly,  thereby  pro- 


Neurasthenia 


[    843    ] 


Neurasthenia 


ducing  painful  and  spasmodic  symptoms, 
which  are  far  from  being  proportionate  to 
the  stimulation,  but  afterwards  the  in- 
creased excitability  decreases  rapidly,  so 
that  strong  stimulation  only  is  able  to 
produce  any  effect,  until  at  last  no  effect 
at  all  can  be  produced.  The  increased  ex- 
citability being  produced  by  a  decrease  of 
the  normal  resistance,  which  naturally  is 
followed  by  a  decrease  of  nutrition  and 
consequently  by  a  condition  of  weakness, 
it  is  clear  that  the  increased  excitability 
which  a  degenerating  nerve  at  first  pre- 
sents, cannot  last  long,  and  that  soon  de- 
creased excitability,  bluntness,  paresis,  or 
whatever  we  call  fatigue  and  exhaustion, 
must  take  its  place.  Excitability,  with 
a  tendency  to  rapid  fatigue  or  exhaus- 
tion, is  therefore  a  characteristic  of  neur- 
asthenia. Sensory  nerves  being  normally 
more  excitable  than  motor  ones,  it  follows 
that,  with  a  few  exceptions,  neurasthenia 
will  present  itself  first  in  the  sensory 
sjahere  in  the  form  of  hyperaBsthesia,  and 
afterwards  also  in  the  motor  sphere  of  the 
nervous  system,  in  the  form  of  hypei'- 
kinetic,  hypereccritic,  and  hypertrophic 
symptoms,  which,  however,  often  soon 
change  into  the  opposite  condition.  As 
among  the  latter  states  the  kinetic  symp- 
toms and  the  fatigue  are  the  most  con- 
spicuous phenomena,  hypenesthesia  and 
muscular  tveakness  are  considered  the 
principal  symptoms  of  neurasthenia. 

Hyperassthesia,  with  the  corresponding 
hyperkinesis,  spasmophilia  or  convulsi- 
bility,  is  the  principal  symptom  of  spincd 
irritation  which  we  have  mentioned  above, 
and  which  was  for  some  time  thought  to 
be  caused  by  a  greater  or  less  excitability 
of  the  spinal  cord  due  to  hypera3mia  or 
inflammation.  This  was,  however,  a  mere 
hypothesis,  to  which,  on  the  whole,  little 
value  was  attached.  It  was  an  attempt 
at  an  explanation,  but  more  stress  was 
laid  on  the  phenomena  themselves.  There 
was  naturally  a  great  difference  of  opinion 
about  these  phenomena  and  their  import- 
ance, but  many  authors  were  of  the  same 
opinion,  especially  in  this,  that  sjjinal  irri- 
tation and  its  symptoms  were  closely 
related  and  formed  the  transition  to  hypo- 
chondriasis, melancholia,  mania  and  de- 
mentia, and  that — as  Romberg  especially 
points  out — it  would  not  be  well,  to  attri- 
bute too  much  to  spinal  irritation,  thereby 
taking  away  from  hysteria  and  neuralgia, 
in  order  to  gain  material  for  a  new  in- 
terpretation, or  rather  misinterpreta- 
tion. The  enthusiastic  advocates  of  neur- 
asthenia as  a  condition  of  its  own,  widen, 
nowadays,  its  sphere  at  the  cost  of  hys- 
teria and  of  the  more  severe  neurotic  con- 
ditions— e.g.,  locomotor  ataxy  and  general 


paralysis ;  in  this  way  many  a  patient 
has  met  an  early  fate,  who  by  timely  and 
appropriate  treatment  might  have  been 
saved.  We  therefore  cannot  too  strongly 
emphasise  that  neurasthenia,  although 
not  yet  a  disease  properly  speaking,  is 
often  the  co'ni'mence'inent  of  a  disease,  and 
that  all  the  more  serious  neurotic  condi- 
tions, not  the  result  of  some  sudden 
special  accident,  have  their  origin  in  neur- 
asthenia. Neurasthenia,  after  having 
reached  a  certain  degree,  does  not  neces- 
sarily continue  to  develop  ;  it  may  exist 
unchanged  for  years,  thus  representing 
the  neurasthenia  of  most  authors  of  our 
times  ;  it  may  be  relieved  and  its  symp- 
toms may  be  suppressed,  but  they  may 
also  at  any  time  become  aggravated  and 
glide  into  one  or  the  other  nervous  dis- 
ease ;  it  is  impossible  to  say  with  certainty 
that  the  latter  will  not  occur.  If  any- 
body believes  that  he  has  been  able  to  as- 
sert this  in  a  number  of  cases,  we  must 
say,  to  put  it  mildly,  he  deceives  himself. 
Many  reasons  and  arguments  have  been 
pressed  upon  us,  but  we  have  not  found 
them  sufficiently  forcible  to  make  us  alter 
our  opinion. 

The  characteristics  of  neurasthenia  are, 
therefore,  hyperaesthesia  and  muscular 
weakness,  or,  in  other  words,  increased 
excitability  with  a  tendency  to  rapid 
fatigue,  especially  of  the  muscular  system. 
If,  instead  of  the  mere  fatigue,  spasms 
occur,  and  if  in  the  muscular  and  vas- 
cular, and  the  corresponding  processes 
in  the  glandular  system,  neurasthenia 
passes  over  into  hysteria  or  epilepsy, 
the  symptoms  have  now  attained  a 
certain  height  and  periodicity,  and  have 
developed  into  paroxysms  which  by  most 
authors  are  considered  the  proper  and  only 
criterion  of  either  pronounced  hysteria  or 
epilepsy.  In  the  same  way,  if  more 
severe  mental  excitement  follows  on  a 
sense  of  uneasiness,  with  or  without 
oppression  and  anxiety,  then  we  shall  see 
hypochondriasis  or  melancholia  develop 
according  to  the  subjects  with  which  the 
mind  of  the  patient  is  occuiDied,  or  even 
the  imperative  ideas  or  false  sensations 
which  usher  in  some  forms  of  insanity. 

However  this  may  be,  hyperaasthesia, 
as  the  most  widely  spread  phenomenon, 
especially  attracts  our  attention,  because 
it  is  completely  of  a  subjective  nature, 
and  even  in  the  most  painstaking  exami- 
nation no  objective  foundation  can  be 
found,  so  that  it  is  generally  regarded  as 
imagination,  exaggeration,  or  a  product 
of  the  craving  to  appear  interesting,  &c. 
It  causes  the  patient,  however,  enough 
trouble  and  discomfort  to  make  him  lose 
his  happiness  for  a  considerable  period  of 


Neurasthenia 


[    844    ] 


Neurasthenia 


his  life.  This  hypera3sthesia  occurs  most 
frequently  in  the  muscular  system  and  its 
belongings,  especially  the  bones.  This 
sphere  is  the  most  excitable,  because 
offering  the  least  resistance,  and  hence  it 
is  intelligible  that  it  is  so  easily  exhausted 
and  so  soon  fails  to  perform  its  functions. 
All  kinds  of  unpleasant  sensations  and 
even  vivid  pains  in  the  muscles  or  limbs 
are  therefore  of  usual  occurrence  in  neur- 
asthenic individuals.  These  pains  appear 
mostly  in  the  muscles  of  the  back  and  in 
the  spinal  column,  and  are  therefore  re- 
garded as  jjathognomonic  of  neurasthenia ; 
as  in  former  times  they  were  attributed 
to  spinal  ii*ritation.  Beard,  who  objects 
to  considering  neurasthenia  as  the  *'  spi- 
nal irritation  ''  of  former  times,  maintains 
therefore  that  it  is  only  a  symptom  of 
neurasthenia,  which,  however,  may  ob- 
scure all  other  symptoms,  and  then  actually 
represent  the  spinal  irritation  of  our  fore- 
fathers. 

Next  to  pains  in  the  back,  which 
have  been  wrongly  referred  to  the  spinal 
cord,  because  pain  cannot  be  anything 
else  but  a  cerebral  function,  many  other 
cerebral  symptoms — symptoms  of  Grie- 
singer's  cerebral  irritation — are  regarded 
as  characteristic  of  neurasthenia,  and 
are  therefore  next  to  spinal  irritation 
of  pathognomonic  imjiortance  in  neur- 
asthenia. 

The  symptoms  of  cerebral  irritation  are 
manifold.  Strictly  speaking,  all  subjective 
symptoms  and  conditions  of  altered,  espe- 
cially increased,  excitability  belong  to 
them,  and  this  includes  pains  in  the  back 
and  in  the  joints,  in  short,  spinal  irrita- 
tion. We  comprise,  however,  among  the 
symptoms  those  phenomena  and  condi- 
tions only  which  ])resent  themselves  in 
the  cranial  nerves,  especially  in  those  of 
the  higher  senses,  and  particularly  in  the 
mind  (in  the  strict  sense) — the  sphere  of 
abstract  imagination  and  its  relations. 
The  frequent  occurrence  of  headache, 
especially  of  migraine,  of  a  sensation  of 
numbness  and  heaviness  of  the  head,  of 
pains  in  the  eye,  of  photopsia  and  chroma- 
topsia,  of  scotoma,  of  indistinctness  of 
vision,  of  noises  in  the  ear,  of  humming 
and  buzzing,  of  bell-ringing,  of  sensitive- 
ness to  smell,  and  of  subjective  sensations 
of  smell  as  well  as  of  taste,  and  of  idio- 
syncrasies {e.g.,  pica),  are  important  lyneno- 
mena  of  cerebral  irritation.  In  addition 
to  all  these,  we  have  to  mention,  as  equally 
important,  instability  of  mental  equili- 
brium, easy  and  rapid  changes  of  temper, 
a  sudden  and  apparently  unaccountable 
sense  of  discomfort,  dissatisfaction,  de- 
pression and  sadness,  of  oppression, 
anxiety,   fear,  and   anger,  a  tendency  to 


vertigo  and  absent-mindedness,  more  or 
less  numerous  antipathies  and  sympathies, 
certain  tics  and  whims,  the  more  or  less 
frequent  occurrence  of  imperative  ideas, 
and,  lastly,  most  troublesome  insomnia 
or  somnolence. 

Of  the  conditions  of  mental  oppression 
and  anxiety  some  that  are  produced  by 
certain  external  causes  are  remarkable. 
Of  these,  liypsopliobia  is  a  type.  Under 
just  the  reverse  conditions  oppression 
may  occur  in  some  individuals  as  hato- 
jihohia  when  they  pass  by  a  high  wall 
and  look  up,  or  when  they  are  in  a  deep 
and  narrow  valley.  In  others,  again,  the 
sense  of  anxiety  is  produced  when  they 
are  about  to  cross  a  large  open  space  as 
agorajjhohia,  or  when  they  are  compelled 
to  stay  in  small  closed  rooms  as  claustro- 
-pliohia,  or,  better,  cleistrojphobia  or  doma- 
toijliobia. 

According  to  the  cause  of  this  fear, 
many  special  conditions  have  been  de- 
scribed, and  Beard  especially  has  taken 
great  pains  in  particularising  them.  Thus, 
we  find  '))ionoplLohia,  fear  as  such  ;  anthro- 
IMiohohia,  the  fear  of  being  with  others; 
pathophobia,  the  fear  of  becoming  ill 
(otherwise  comprised  under  hypochon- 
driasis) ;  pantophobia,  fear  of  everything ; 
asirophobia,  fear  of  lightning ;  rupo- 
phobia  (Verga),  the  fear  of  being  dirty  ; 
siderodromophobia,  the  fear  of  going  by 
train ;  nyctopjhobia,  the  fear  of  night  ; 
phobophobia,  the  fear  of  becoming  afraid. 
Were  we  to  carry  this  absurdity  further,  we 
might  distinguish  a  much  greater  number 
of  conditions  of  fear  :  sTcopophobia  and 
Mopsopjhobia,  the  fear  of  spies  and  thieves ; 
thanatophobia,  the  fear  of  death  ;  necro- 
phobia, the  fear  of  the  dead  and  of 
phantasms;  triakaidel-aphobia,  the  fear 
of  the  number  thirteen,  &c.,  but  what 
should  we  gain  ?  The  conditions  in  ques- 
tion are  nothing  but  a  kind  of  idiosyncrasy 
or  antii^athy,  which  in  its  turn  is  a  kind 
of  imperative  idea.  If  very  slight  and 
temporary,  it  is  a  symptom  of  neur- 
asthenia ;  but  if  more  severe  and  perma- 
nent, it  passes  over  into  the  gravest 
condition  of  mental  disorder.  This  proves 
the  connection  between  neurasthenia  and 
mental  disorder,  and  also  that  neur- 
asthenia is  frequently  onl}^  the  earliest  and 
slightest  indication  of  a  psychosis. 

Of  pains  in  themuscles,which  are  said  to 
be  symptoms  of  neurasthenia,  we  have  to 
mention  peculiar  and  vague  sensations  of 
great  fatigue,  stiffness,  heat  and  uneasi- 
ness, which  occur  j^rincipally  in  the  legs 
and  feet,  and  sometimes  also  in  the  upper 
extremities  ;  they  induce  constant  chang- 
ing of  the  position  of  the  limbs,  so  fre- 
quently met  with  in  nervous  and  restless 


Neurasthenia 


[    845    ] 


Neiirasthenia 


people,  as  the  layman  calls  them.  This 
uneasiness,  mostly  due  to  hyperaisthesia 
of  the  muscles,  is  considered  a  patho- 
gnomonic symptom  of  neurasthenic  con- 
ditions. 

Among  the  other  conditions  of  hyper- 
aesthesia,  those  of  the  skin  must  be  men- 
tioned as  the  most  frequent ;  as  dragging 
and  tearing  jiains  in  the  course  of  the  vari- 
ous nerves,  hyperalgia  and  hyperalgesia 
as  well  as  hyperj^selaphesia.  Among 
the  latter  conditions  we  have  specially 
to  mention  the  feeble  resistance  to  either 
a  liigli  or  low  temperature.  Neurasthenic 
individuals  will  rarely  bear  a  high  tem- 
perature, and  on  the  other  hand  they  are 
very  liable  to  catch  cold  ;  even  a  slight 
draught  is  troublesome  and  hurtful  to 
them  ;  such  individuals  are  also  very 
ticklish  and  complain  of  subjective  sensa- 
tions of  heat,  of  parsesthesia,  pruritus, 
formication,  &c. 

In  the  visceral  sphere  we  find  as  symp- 
tams  of  hyperassthesia,  conditions  of  cyn- 
orexia  and  polydipsia  as  wellas  of  anorexia 
and  adipjsia.  Special  stress  is  laid  by 
Beard  on  adipsia  as  a  neurasthenic  symp- 
tom. He  considers  the  adipsia  or  hypo- 
dipsia  of  the  Americans  to  be  partly  a 
cause  of  frequent  and  well  developed 
neurasthenia,  especially  as  compared  with 
the  Germans,  for  whom  the  copious  use 
of  beer  serves  as  a  jiireventive.  Another 
marked  consequence  of  this  hyperassthesia 
is  a  certain  liking  for  stimulants,  as  coffee, 
tea,  alcoholic  beverages  and  tobacco.  Most 
nervous  individuals  like  sweets  and  fat, 
and  frequently  also  gelatinous  substances, 
l^referring  gelatinous  to  ordinary  meat ; 
they  possess  little  power  to  resist  alcohol, 
and  are  affected  and  even  intoxicated  by 
small  doses  in  a  striking  manner,  especially 
if  in  a  warm  place.  Some  of  them,  how- 
ever, are  able,  under  special  circumstances, 
as,  e.g.,  after  cold,  fatigue,  &c.,  to  take 
a  great  amount  not  only  for  the  moment, 
but  also  without  any  evil  effects  after- 
wards. For  these,  alcohol  may  be  the 
best  medicine  in  all  their  slight  complaints, 
among  which  we  have  mentioned  frequent 
colds. 

Neurasthenic  individuals  are  in  their 
youth,  as  a  general  rule,  very  susceptible 
to  sexual  feeling,  and  have  atendency  to  all 
kinds  of  improper  practices.  Like  all 
sensations  caused  by  hypera3sthesia,  these 
are  not  permanent,  and  the  sexual  capacity 
is  not  proportionate  to  the  susceptibility 
— the  best  gift  which  nature  could  pro- 
vide for  such  individuals  in  order  to  keep 
them  from  excess  and  its  evil  conse- 
quences. 

As  oxyajsthesia  or  acroaesthesia  is  not  dis- 
tincti'rom  hypera^sthesia  or  aniesthesia,but 


represents  merely  the  commencement  of  the 
alteration  of  sensibility  which  terminates 
in  these  conditions,  it  is  quite  natural 
that  hypiosthesic  or  ana3sthesic  conditions 
should  be  sometimes  developed  where  hy- 
pera3sthesia  is  present.  Only  so  long  as 
this  hypaisthesia  or  ansesthesia  is  slight 
and  temporary,  is  it  allowable  to  attribute 
it  to  neurasthenia,  whilst  if  not  so,  it  is 
due  to  hysteria  or  to  other  grave  dis- 
orders of  the  nervous  system.  The  slight 
and  temporary  hypa^sthesia  and  anaesthe- 
sia in  the  region  of  the  spinal  cord  are  com- 
jirised  in  the  term  ')ieurasth,enia  spjinnlis 
which  is  almost  the  same  as  the  spinal 
irritation  of  old  authors.  The  same  symp- 
toms arising  from  disease  in  the  region 
of  the  brain,  and  especially  of  the  part 
connected  with  psychical  functions,  are 
produced  by  neurasthenia  cerehralis,  which 
is  on  the  whole  the  same  as  Griesinger's 
cerebral  irritation.  Similar  conditions 
affecting  the  visual  organ  are  called  neur- 
astlienia  retimv,  asilienojjia  or  Tcopiopia; 
affecting  the  digestive  organs  neurastlien  iu, 
gastrica;  affecting  the  sexual  apparatus 
■neurasthenia^  sexualis,  nervous  impwtencij, 
&c.  Here  we  might  create  quite  as  many 
forms  of  neurasthenia  as  we  have  seen 
terms  ending  in  phohia,  without  however 
doing  anything  more  than  creating  new 
names  for  forms  long  known,  without 
making  matters  any  clearer.     Gui  bono  / 

Seeing  that  hypera^sthesia  is,  so  to  say, 
nothing  but  the  commencement  of  an- 
aesthesia, in  the  same  way  hyperkinesia 
is  the  commencement  of  hypokinesia  or 
akinesia.  We  have  already  mentioned 
that  a  certain  uneasiness  and  increased 
restlessness  may  be  considered  as  patho- 
gnomonic of  neurasthenic  conditions. 
The  rapid  exhaustion  of  the  muscle  is 
due  to  the  readiness  to  contract  more 
or  less  violently,  however  slight  the  stim- 
ulation may  be.  Besides  this  hyper- 
kinesia, there  occur  in  neurasthenic  indi- 
viduals spasmodic  movements,  and  even 
actual  convulsions,  which,  if  exceeding  a 
certain  degree  and  not  being  merely  slight 
and  temporary,  belong,  we  maintain,  to 
hysteria,  chorea  and  other  related  con- 
ditions. 

These  spasms  occur  most  frequently  in 
the  muscles  of  the  face  and  eyes,  as 
malleatio,  nictitatio,  twitching  of  the 
angles  of  the  mouth  and  of  the  lii^s,  as 
nystagmus,  dilatation,  contraction  or  in- 
equality of  the  pupils,  and  extremely  slow 
or  rapid  reaction  of  the  pupils  so  as  to  be 
scarcely  perceptible.  In  addition  to  this, 
all  sorts  of  cramps  present  themselves, 
esi:>ecially  in  the  calves,  the  leratores  sra- 
'pulm  and  in  the  muscles  which  pro'luce 
erection    and    ejaculation.      The    tendon 


Neurasthenia 


[    846    ] 


Neurasthenia 


reflexes  are  often  very  much  exaggerated. 
Further,  the  Hke  spasmodic  conditions 
occur  also  in  the  intestinal  tract,  and  in 
the  circulatory  and  respiratory  appa- 
ratus, and  produce — in  a  less  marked 
degree  however — all  the  symptoms,  which 
we  find  more  especially  in  hysterical 
patients — globus,  flatulency,  constipation, 
and  diarrhoea,  palpitation  and  a  sense  of 
oppression  and  anxiety,  which  latter  es- 
pecially are  due  to  abnormal  processes  in 
the  circulatory  apparatus,  particularly  in 
the  heart.  To  these  abnormal  conditions 
of  the  circulatory  system  is  due  the  ten- 
dency to  blush  which  is  so  often  observed 
in  neurasthenic  individuals,  and  which 
Beard  rightly  counts  among  the  most 
characteristic  symptoms  of  neurasthenia. 
In  addition  to  this  there  is  a  tendency  to 
cedema,  which  appears  especially  in  the 
face,  and  on  the  hands  and  feet,  and  can- 
not be  ascribed  to  renal  disease  or  more 
grave  disorders  of  circulation ;  telan- 
giectasis, hgemorrhoids  and  capillary 
aneurism  also  develoi),  which  afterwards 
may  become  ver}'^  troublesome  and  even 
fatal.  To  the  abnormal  conditions  in  the 
respiratory  apparatus  are  due  the  almost 
irrepressible  fits  of  yawning,  so  frequent 
in  neurasthenic  individuals,  a  troublesome 
singultus  and  cough  for  which  the  most 
careful  examination  is  unable  to  findcause, 
and  lastly,  some  forms  of  asthma,  among 
which  Beard  reckons  liay  fever,  some 
kinds  of  pollen  producing  the  asthmatic 
paroxysms  on  a  soil  prepared  by  the 
neurasthenia. 

The  hypokinesia  presents  itself  in  the 
first  instance  in  a  certain  languor  and 
immobility.  Neuropathic  individuals,  if 
they  do  not  happen  to  be  excited,  are 
very  easy  in  their  manners,  they  like  to 
have  much  rest,  stay  long  in  bed  in  the 
morning,  and  lounge  in  the  daytime  on  a 
sofa  or  in  a  comfortable  arm-chair.  Ac- 
tual paresis  is  rare,  and  if  paralysis  is 
present,  it  may  almost  always  be  attributed 
to  other  more  serious  disorders.  Among 
the  paretic  conditions  must  be  reckoned 
a  certain  relaxation  of  the  muscles  of  the 
larynx,  in  consequence  of  which  the  voice 
sounds  very  hollow,  some  forms  of  stra- 
bismus— especially  strabisvius  iutenuis — 
slow  reaction  of  the  pupil,  which  some- 
times is  scarcely  perceptible,  and,  lastly, 
decrease  or  even  absence  of  the  tendon 
reflexes. 

In  the  secretory  and  trophic  sphere  the 
reaction  is  similar  to  that  in  the  motor 
sphere.  To  the  hyperkinesia  correspond 
hypereccrisia  and  hypertrophy,  which  are 
indicated  by  increased  diuresis  and  dia- 
phoresis, salivation  and  steatosis,  as  well 
as  by  an  increased  nutrition  and  an  in- 


creased production  of  heat.  To  the  hyper- 
kinesia correspond  hypuresis,  hyphidrosis, 
hyposialosis,  hyposteatosis,  a  faulty  nutri- 
tion, although  perhaps  tending  to  produce 
obesity,  and  a  decreased  production  of  heat. 
Neurasthenic  patients,  therefore,  readily 
complain  of  a  troublesome  sense  of  heat 
or  cold,  and,  in  fact,  they  often  have  their 
heads  very  hot,  or  hot  hands  and  feet, 
and  vice  versa ;  they  also  frequently  suffer 
from  shivering  and  horripilatio,  not  only 
at  a  low  temperature,  but  sometimes  when 
the  sun  of  July  or  August  shines  upon 
them,  and  have  often  a  feverish  attack ; 
which  occasionally,  when  accompanied  by 
more  severe  nervous  symptoms,  may  de- 
velop to  such  a  height,  that  it  seems  to 
be  the  commencement  of  typhus,  pneu- 
monia or  meningitis,  but  it  mostly  dis- 
appears again  aa  suddenly  as  it  came. 

The  secretion  of  iirine  is  very  change- 
able ;  in  one  and  the  same  individual  there 
may  exist,  other  circumstances  being  equal, 
sometimes  hyperuresis,  and  at  other  times 
hyjDuresis;  sometimes  more  phosphates 
and  carbonates,  sometimes  more  urates 
are  secreted.  Generally  the  urine  is  rich 
with  substances  reducing  salts  of  copper 
{kreatiniii,  Schwanert)  and  may  be  mis- 
taken for  diabetes  mellitus,  especially  as  a 
number  of  symptoms,  such  as  a  sense  of 
weakness  and  actual  debility,  comparative 
impotency  and  an  increased  sense  of  thirst, 
seem  to  assist  the  latter  diagnosis.  Un- 
doubtedly secretion  of  sugar  occurs,  which 
is  sometimes  more  and  sometimes  less 
marked,  and  may  cease  for  some  time, 
thus  repi'esenting  a  kind  of  intermittent 
melituria,  sometimes  observed  to  be  pre- 
cursory to  an  attack  of  actual  diabetes 
mellitus,  which  often  breaks  out  suddenly 
and  unexpectedly  after  catching  cold  or 
after  getting  wet.  According  to  Beard, 
oxalates  are  also  abundant  in  the  urine  of 
neurasthenic  patients ;  it  often  emits, 
when  fresh,  a  most  disagreeable  odour 
caused  by  some  very  volatile  substances, 
with  a  goat-like  smell  when  concentrated 
and  rich  with  urates,  and  not  quite  so 
strong,  but  nauseous  when  more  dilute, 
and  containing  phosphates  and  carbonates. 
The  smell,  especially  in  the  latter  case 
soon  disappears,  and  this  may  be  the 
cause  that  it  has  not  yet  been  sufliciently 
observed.  Bouchut  says  that  the  urine 
of  neurasthenic  patients  represents  dia- 
betes insipidus  and  is  without  smell.  On 
the  contrary,  the  smell  is  sometimes  so 
strong  as  to  cause  vomiting. 

The  secretion  of  svseat  is  very  much  in- 
creased in  neurasthenic  individuals,  es- 
pecially on  the  extremities,  so  that  per- 
spiring, and  in  consequence,  damp,  cold 
hands  and  feet  are  of  common  occurrence. 


Neurasthenia 


[     S47    ] 


Neurasthenia 


But  the  reverse  also,  as  we  mentioned 
above,  may  be  the  case,  and  dryness  of 
hands  and  feet  as  well  as  over  the  whole 
of  the  body  may  be  observed.  There  are 
neurasthenic  patients  who  have  never  per- 
spired in  their  lives.  Not  rarely  the  sweat 
carries  with  it  foreign  substances — smell- 
ing, coloured  or  stickj^ — thus  representing 
the  products  of  parhidrosis,  osmidrosis, 
and  bromhidrosis. 

Neurasthenia  is  said  to  occur  frequentlj' 
in  well-fed  or  even  robust  individuals. 
Beard,  however,  when  giving  the  differen- 
tial diagnosis  between  neurasthenia  and 
hysteria  says  :  "  Neurasthenia  is  always 
associated  with  physical  debility.  Hys- 
teria, in  the  mental  or  physical  form,  oc- 
curs in  those  who  are  in  perfect  physical 
health,"  but  in  another  jilace  he  says  of  a 
neurasthenic  jiatient :  "  The  man  was  tall, 
vigorous,  full-faced,  and  physically  and 
mentally  capable  of  endurance  "  (pp.  104 
and  30).  In  fact,  therefore,  he  admits  the 
statement  made  above,  but  his  other  view 
is  the  correct  one.  Nothing  but  a  total 
misunderstanding  of  what  good  nutri- 
tion and  a  robust  constitution  are,  could 
lead  any  one  to  assume  that  neurasthenia 
occurs  in  strong  robust  individuals. 

The  good  nutrition,  which  has  its  source 
in  the  moderately  increased  excitement  of 
the  nervous  system,  is  but  apparent  ;  it 
corresponds  to  the  plethoric  condition  of 
former  physicians,  which  for  a  long  time 
is  taken  for  health  and  strength,  but 
when  affected  by  some  attack  or  other, 
proves  to  have  not  the  slightest  power  of 
resistance.  When  the  latter  circumstance 
is  the  case,  the  good  nutrition  is  the  result 
of  an  increased  or  even  decreased  excita- 
bility of  the  nervous  system  and  there- 
fore undoubtedly  indicates  weakness  or  a 
kind  of  paralytic  condition,  which  is  the 
consequence  of  an  exaggerated  excitability. 
As  hyperkinesia  or  hyperajsthesia  is 
nothing  but  the  commencement  of  akine- 
sia and  anaesthesia,  in  the  same  way  hy- 
pereccrisia  and  hypertrophy  are  the  com- 
mencement of  hypeccrisia  and  aneccrisia, 
and  of  hypotrophy  and  atrophy.  The  pre- 
mature involution  which  takes  place  in  so 
many  fresh  and  healthy  individuals,  and 
which  has  its  symptoms  in  becoming 
grey  or  in  loss  of  the  hair,  the  loss  of 
teeth,  and  of  the  sexual  appetite,  &c.,  is 
mainly  due  to  this,  while  as  the  last  cause 
must  be  regarded  a  chlorotic  constitution, 
and  hypoplasia  of  the  blood  corpuscles 
together  with  hypoplasia  of  the  nervous 
system. 

The  symptoms  of  neurasthenia  appear 
sometimes  on  only  one  side,  and  then  in 
preference  on  the  left.  Beard  calls  this 
hemi-neurasthenia,  but  in  reality  it  only 


appears  because  the  usual  condition  is  so 
much  more  strongly  developed,  that  the 
left  side  is  more  excitable  on  account  of 
its  smaller  power  of  resistance  than  the 
right.  This  is  also  the  reason  why 
ana3sthesia,  as  well  as  hemianajsthesia 
is  mostly  left-sided,  and  why  we  also 
tind  hypei-kinesia  and  hypokinesia  as  well 
as  dyseccrisia  and  dystrophy  on  the  left 
side.  If  the  secretion  of  sweat  is  ab- 
normal, it  occurs  usually  on  the  left  side 
only.  Hcmititrophia  fiu-iei  progressiva  is 
also  usually  left-sided.  The  hair  fre- 
quently becomes  sooner  grey  on  the  left 
than  on  the  right  side,  and  rarely  vice. 
versa. 

According  to  the  different  symptoms, 
which  in  different  individuals  come  into 
the  foreground,  and  of  which  we  have 
treated  above  as  useful  for  distinguish- 
ing different  groups  of  neurasthenia, 
several  forms  have  been  described  with 
reference  to  the  nervosismus.  Bouchut 
already  mentions  nervosisme  aigu  and 
chroniqzie,  meaning  by  the  former  the 
conditions  of  fever  with  all  their  accom- 
panying and  consequent  symptoms,  which 
so  easily  occur  in  nervous  individuals, 
and  by  the  latter  the  habitual  condition 
of  irritable  weakness,  which  we  have 
attempted  to  describe.  According  to  the 
different  symptoms  of  these  conditions,  he 
speaks  of  nervosisme  cerebral,  spinal, 
cardiaque,  larynge,  gastrique,  uterin, 
seminal,  cutane,  spasmodique,  paralytique, 
and  douloureux;  of  nervosisme  simple, 
hysterique,  and  hypochondrique ;  corre- 
sponding to  which  modern  authors  have 
described  quite  as  many  forms  of  neur- 
asthenia, like  neurasthenia  cerehralis  or 
cerebrasthenia,  neurasthenia  spinalis  or 
myelasthenia,  neurasthenia  sexualis,  gas- 
trica,  &c.,  all  of  which  are  merely  like  the 
endless  varieties  of  roses,  carnations 
and  hyacinths  which  we  find  in  the  price- 
list  of  nurserymen  when  compared  with 
the  original  stock  ! 

Neurasthenia  being,  partly  at  least,  due 
to  a  faulty  development  of  the  nervous 
system,  its  form  depends  very  much  on 
the  individual.  It  is  essentially  a  con- 
genital and  mostly  hereditary  condition, 
and  in  cases  where  it  appears  to  have 
been  acquired  its  development  was 
furthered  by  certain  injurious  influences. 

Neurasthenia  might  be  compared  to 
chlorosis,  the  character  of  which  is  small- 
ness,  delicacy,  and  faulty  develojiment  of 
the  vascular  system.  The  character  of 
neurasthenia  is  smallness,  delicacy,  and 
faulty  development  of  the  nervous  system. 
All  chlorotic  individuals  are  neurasthenic, 
and  all  neurasthenic  individuals  are  chlo- 
rotic, although  the  chlorosis  may  be  rubra 


Neurasthenia 


[    S48    J 


Neiirasthenia 


and  may  be  disguised  by  a  healthy  and 
robust  appearance,  as  mentioned  above. 

Causes.  —  The  development  of  neur- 
asthenia is  specially  favoured  by  overwork, 
more  particularly  of  a  mental  kind,  by 
late  hours,  disappointment,  grief  and 
care,  by  unsatisfied  ambition,  exhaustion, 
long  or  severe  illness,  sexual  excesses, 
frequent  or  profuse  seminal  losses,  loss  of 
blood  during  menstruation,  confinement, 
lactation,  &c. — that  is  to  say,  by  circum- 
stances which,  on  the  one  hand,  bring 
about  a  direct  wearing  out  of  the  nervous 
system  and,  on  the  other,  injure  the 
general  nutrition  by  loss  of  blood  and 
strength,  thus  also  weakening  the  nerves. 
The  latter  influences  often  cause  poverty 
of  blood,  olichaemia  or  hydrtemia — Bouchut 
■well  calls  it  liypoglohuUe  {i.e.,  chlorosis) 
— and  this  is  the  easier  because  the 
individuals  in  question  are  chlorsemic, 
and  therefore  also  comparatively  olichae- 
mic,  to  begin  with.  This  olichgemia  or 
hydreemia  necessarily  influences  the 
nervous  system.  It  explains  also  why 
the  influences  mentioned  above  are  not 
dangerous  when  the  special  disposition — 
i.e.,  neurasthenia,  however  slight — is  ab- 
sent, because  then  the  nervous  system 
and  the  blood-corpuscles  are  more  highly 
developed,  and  are  able  to  supply  easily 
from  their  own  strength  and  from  the 
nourishment  ingested  the  force  which  is 
used  up  in  the  wear  and  tear  of  life. 

Inasmuch  as  neurasthenia  is  mainly 
congenital,  and  always  associated  with 
chlorosis,  or  at  least  with  a  chlorotic 
diathesis,  it  is  natural  that  the  female 
sex,  being  more  sensitive,  should  be  more 
subject  to  it.  It  occurs  most  frequently 
in  middle  life,  from  puberty  down  to  the 
climacteric.  It  is  rare  in  early  age  and 
in  old  age,  perhaps  because  in  the  former 
the  strength  of  the  individual  is  not  yet 
taxed,  and  in  the  latter  it  has  ceased  to 
be  so,  whilst  in  a  full-grown  individual 
non-fulfilment  of  the  duties  of  life  makes 
the  insuflBcienoy  and  weakness  of  the 
nervous  system  conspicuous. 

Neurasthenia,  being  caused  by  or  re- 
presenting a  constitutional  anomaly,  is 
chronic  in  its  course,  which,  however,  is 
not  always  uniform,  but  subject  to  many 
variations,  the  cause  of  which  is  not 
always  clear.  There  is  frequently  a 
striking  periodicity  in  its  symjDtoms,  as  is 
mostly  the  case  in  nervous  disorders 
caused  by  weakness,  and  is  especially 
characteristic  of  those  disorders  which 
are  congenital  or  transmitted  by  heredity. 

Course. — It  has  been  repeatedly  men- 
tioned before  that  under  unfavourable 
circumstances  graver  nervous  disorders 
may  develop  out  of  neurasthenia.    It  may 


also  give  rise  to  a  number  of  other  dis- 
eases representing  their  first  symptom, 
when  the  disease  itself  cannot  yet  be 
recognised.  Neurasthenia  may  for  years 
precede  cancer  or  cancerous  formations 
and  sarcoma.  Gout  also  is  often  pre- 
ceded by  it,  or  rather  people  with  a  gouty 
diathesis  are  mostly  neurasthenic.  As 
such  individvals  have  a  great  tendency  to 
apoplexy  (it  is  an  open  question  whether 
or  not  the  greater  number  of  cases  of 
apoplexy  may  not  be  associated  with 
gouty  conditions),  neurasthenia  also  pre- 
cedes or  accompanies  those  morbid  cere- 
bral conditions  which  at  last  terminate  in 
apoplexy.  Thus,  neurasthenia  frequently 
appears  to  be  only  a  symptom  of  other 
disorders,  especially  those  of  a  constitu- 
tional character,  out  of  which,  in  the  seat 
of  least  resistance,  certain  local  disorders 
develop.  This  is  proved  by  the  fact  that 
neurasthenia  is  the  consequence  of  faulty 
development  of  the  vascular  and  nervous 
systems,  thus  representing  a  chloraemic 
and  nervous  constitution  with  faulty 
metabolism  and  a  tendency  to  all  kinds  of 
disorders.  The  products  of  an  abnormal 
metabolism,  as  an  excess  of  urates,  phos- 
phates, and  oxalates,  and  the  strong 
aromatic  substances  found  in  the  urine, 
sweat,  and  breath,  and  sometimes  also 
ptomaines  and  leukomaines,  serve  to 
increase  neurasthenia  and  to  develop  out 
of  it  still  more  serious  disorders.  The 
urates — e.g.,  may  produce  gout,  and  in 
connection  with  it  hysteria  and  mental 
disorder.  The  aromatic  substances  also 
may  produce  hysteria,  hystero-epilepsy, 
and  ps3'-choses.  If,  in  addition,  the  inter- 
stitial connective  tissue  is  influenced  in 
its  growth,  as — e.g.,  by  some  dyscrasia  like 
syphilis,  alcoholism,  or  saturnism,  so  that 
it  commences  to  proliferate  and  to  become 
inflamed  or  even  neoplastic,  then  we  find 
the  so-called  organic  changes  of  the 
nervous  system,  like  m3"eliti3,  encephalitis, 
peri-encephalitis,  and  grey  degeneration. 
The  last-mentioned  circumstances,  how- 
ever, being  less  frequently  met  with  in 
women  than  in  men,  it  follows  that  the 
latter  serious  disorders  are  much  less 
frequently  met  with  in  women  than  in 
men. 

On  the  other  hand,  even  highly  de- 
veloped nervousness  may  be  cured  or  so 
far  improved  that  the  individual  is  able 
to  bear  his  condition  or  even  that  he  feels 
quite  well.  Relapses,  however,  frequently 
occur  as  soon  as  the  duties  of  life  make 
themselves  felt  again  or  nutrition  becomes 
deranged.  It  always  takes  a  long  time 
before  the  patient  feels  permanenth^  well, 
and  a  strict  regime  is  necessary  in  order 
to  obtain  this  result. 


Neurasthenia 


[    849 


Neurasthenia 


Treatment. — It  is  easily  seen  that  in 
neurasthenic  conditions  medicines  do  not 
do  much  good ;  they  may  be  used  as 
palliatives,  but  they  will  never  cure  the 
disorder.  This  holds  good  especially  of 
the  narcotics  and  ana3sthetics,  which  often 
are  used  against  insomnia  a,nd  trouble- 
some sensations.  In  addition  to  this 
there  is  always  a  danger  lest  the  patient 
falls  a  victim  to  morphinism,  cannabism, 
alcoholism,  cocaiuism,  coft'einism,  &c. 

Here  we  might  mention  that  a  perfectly 
healthy  man  rarely  becomes  a  morphinist, 
cannabist,  Sec,  but  that  such  individuals 
are  without  exception  neurojjathic.  In 
these  cases  cause  and  effect  have  often 
been  confounded,  and  to  the  substances 
mentioned  has  been  attributed  what  in 
reality  was  due  to  the  constitution.  How- 
ever, we  do  not  mean  to  say  that  those 
substances  do  not  exercise  any  harmful 
influence,  but  the  matter  lies  thus :  in  a 
neurasthenic  individual  a  stimulant  gives 
temporary  relief,  but  leaves  the  neur- 
asthenia as  it  is  or  even  increases  it,  and 
afterwards  the  neurasthenia  causes  an 
irresistible  desire  for  the  stimulant  which, 
while  it  gave  relief,  aggravated  the  dis- 
order. Therefore  the  substances  in  ques- 
tion cannot  be  considered  as  the  only 
causes  of  the  disorders  mentioned,  but 
they  form  a  secondary  link  in  the  vicious 
circle,  which  alwaj's  in  pathology  plays 
such  an  important  role,  the  primary  link 
being  the  morbid  constitution. 

We  might  almost  entirely  dispense  with 
the  use  of  narcotics  in  the  treatment  of 
neurasthenia,  especially  if  we  want  to 
effect  something  more  than  merely  tem- 
jDorary  improvement.  We  most  highly 
recommend  iron  with  small  doses  of 
quinine  ;  the  iron  improves  the  condition 
of  the  blood,  whilst  quinine  decreases  the 
excitability  of  the  nervous  system,  and  it 
may  be  given  in  small  doses  of  i  to  2  gr. 
per  diem  for  weeks  without  any  injurious 
effects.  It  has  been  maintained  that 
quinine  weakens  the  stomach  and  impairs 
digestion,  but  this  is  probably  only  the 
case  when  the  gastric  secretion  is  not 
sufficiently  acid. 

After  this,  we  recommend  the  nervine 
stimulants  ;  as  Valerian,  assafoetida,  and 
castoreum,  remedies  which  have  almost 
entirely  gone  out  of  use,  but  which,  never- 
theless are  invaluable.  Valerian,  if  con- 
stantly used,  is  an  excellent  remedy  for 
the  troublesome  sensations,  for  some 
spasmodic  conditions,  and  especially  for 
insomnia.  We  consider  tinctura  assafa3- 
tidse  et  castorei  ufi  20  to  25  min.  in  infusum 
Valerianae  the  most  reliable  remedy,  giving 
relief  in  conditions  of  oppression  and 
distress,  and  having  no  bad  after-effects. 


We  also  recommend  electricity  in  all  its 
forms,  as  the  condition  of  the  patient 
requires  it.  General  galvanisation,  fara- 
disation, and  franklinisation  often  give 
results  we  scarcely  expect. 

Above  all,  however,  we  have  to  regulate 
nutrition  and  everything  connected  with 
it.  Living  in  healthy  surroundings  is 
necessarily  required.  In  vain  the  physi- 
cian applies  all  his  remedies  if  the  patient 
lives  in  a  place  which  is  damp  in  winter 
and  hot  in  summer,  and  which  at  all 
times  is  close  and  stuffy. 

AVith  regard  to  food,  we  recommend 
mixed  food  in  moderate  quantities ;  in 
some  cases  Mitchell-Playfair's  treatment 
gives  good  results,  in  others  vegetarianism. 
The  latter  seems  to  be  useful  when  neur- 
asthenia is  a  symptom  of  a  gouty  con- 
dition, the  former  when  a  symptom  of 
hypoplasia.  In  cases  in  which  neur- 
asthenia is  produced  by  gouty  disorders — 
cases  more  frequent  than  usually  sup- 
posed—  alkaline  waters  must  be  freely 
used,  whilst  beer  and  wine,  with  the  ex- 
ception of  light  hock  taken  in  moderate 
quantities,  must  be  forbidden.  The  same 
holds  good  for  corpulent  neurasthenic 
patients,  who,  however,  must  never  un- 
dergo an  anti-fat  treatment. 

The  patient  must  stay  out  as  much  as 
possible  in  the  fresh  air,  in  the  woods,  on 
the  mountains,  or  at  the  seaside.  For 
some  jiatients,  exercise,  as  walking,  riding 
on  horseback,  and  gymnastics,  is  bene- 
ficial, whilst  others  require  rest  in  bed. 
The  former  seems  to  be  required  when 
there  is  a  certain  sluggish  nutrition,  the 
latter  when  there  is  an  excess.  In  the 
same  manner  baths  may  be  recommended ; 
moderately  cold  if  nutrition  is  to  be 
increased,  warm  if  it  is  to  be  decreased. 
Actually  cold  or  hot  baths  ought  not  to 
be  ordered.  It  is,  however,  evident  that 
we  may  sometimes  also  recommend  hot 
baths  and  vapour  baths  if  the  neur- 
asthenia seems  to  require  them.  Massage 
has  also  been  highly  recommended,  and 
with  good  reason.  Carefully  practised, 
we  consider  it  suitable  for  cases  of  slow 
nutrition,  whilst  it  may  be  harmful  in 
cases  of  an  opposite  character. 

Although  medicines  are  unable  to  do 
much  for  neurasthenia,  we  cannot  get  on 
without  them.  In  patients  in  whom 
nutrition  is  low,  small  doses  of  arsenic, 
taken  for  some  weeks,  are  useful.  The 
bromides  have  been  recommended  for 
conditions  of  troublesome  excitement  and 
insomnia.  They  are  good,  but  if  used  for 
some  length  of  time  they  produce  de- 
rangement of  nutrition,  and  make  the 
patient  drowsy.  The  same  holds  good  of 
sulphonal,paraldehyde,chloral,and  chloral- 


Neurhypnology 


[    850    J        Neuroses,  Functional 


amide,  which  mast  be  given  only  for  a 
short  time,  and,  if  they  are  indispensable, 
must  frequently  be  changed.  We  must 
keep  in  mind  that  in  neurasthenics  small 
doses  have  a  greater  effect  than  they 
have  in  non-neurasthenics,  and  that, 
therefore,  intoxication  is  much  more  easily 
produced. 

For  the  same  reason,  neurasthenic  per- 
sons do  not  bear  tobacco,  coffee,  tea,  &c., 
so  well  as  healthy  individuals  ;  sometimes 
they  cannot  bear  it  at  all.  According  to 
the  case,  some  foods  and  stimulants  must 
be  forbidden  or  given  with  extreme  care. 

Neurasthenic  patients  mostly  suffer 
also  from  irregular  digestion  and  costive- 
ness.  Both  must  be  regulated,  but  if 
possible  by  mild  means,  as  sour  milk  or 
butter-milk,  whey,  ketir,  vegetables,  fruit, 
and  saline  draughts ;  rarely,  if  ever,  by 
drastic  pui'gatives. 

Lastly,  we  may  mention  the  application 
of  hypnotism  and  suggestion  in  the  treat- 
ment of  neurasthenia.  Both  have  exer- 
cised, according  to  our  experience,  an 
undoubtedly  beneficial  influence  on  this 
disorder,  but  only  for  a  short  time.  After- 
wards the  neurasthenic  condition  easily 
returns.  Therefore  we  cannot,  at  least  for 
the  present,  recommend  the  application 
of  hypnotism  and  suggestion,  with  hope  of 
permanent  success.        Rudolf  Arndt. 

ivBURHYPiU'OiiOGY.      {See    Neuro- 

HYPNOLOGY.) 

WEUROBIi  ACZ  A  (i/f  {)poj/,nerv6 ;  ^XaKeia, 

stupidity).  A  dulled  state  of  nervine 
sensibility.     (Fr.  nevroblacie.) 

NEUROGAMXA  {vevpov,a  nerve;  ya/xof, 
marriage).  A  term  given  to  "animal 
magnetism  "  because  of  the  alleged  nervous 
community  of  feeling  between  the  magne- 
tiserandthe  magnetised.  (Fr.nevrogamie; 
Ger.  Neurogamie.) 

NEUROHYPWOliOCY(i^eOpoj^,  a  nerve; 
vnuos,  sleep ;  Xdyoy,  speech).  The  name 
given  by  Braid  to  his  theory  of  magnetic 
sleep.     (See  Hypnotism.) 

ZO'EVROHYPM'OTXSIMC  (i/evpov,  a  nerve ; 
vTTvos,  sleep).  A  term  for  the  state  induced 
by  hypnotic  manipulations.  (Fr.  neuro- 
hypnotisDie.) 

ITEUROIMCETABRASIS  (vevpov,  a 
nerve ;  fifrci,  with ;  Spacrts,  efiicacy).  A 
term  for  animal  magnetism,  signifying  the 
influence  of  one  body  upon  another. 

ITETTROIMCZIVIESIS  (p(/x60/xa(, I  imitate). 
Mimicry  of  disease  in  nervous  or  hysterical 
persons.     (Fr.  nevro'Dmnosie.) 

UTEVROPYRA  (veiipov,  a  nerve ;  nvp, 
flre  or  fever).  Nervous  fever.  (Fr.  fievre 
nerveuse ;  Ger.  Kervenfieher.) 

NTEVROSES  {vevpov,  a  nerve).  Nervous 
diseases.  A  neurosis  is  usually  described 
as  a  functional  disorder  of  the  nervous 


system — that  is  to  say,  a  disorder  such  as 
migraine,  which,  so  far  as  we  know  at 
present,  is  unattended  with  any  constant 
organic  lesion.  (Fr.  nevroses ;  Ger.  Neu- 
rose.) 

N^EVROSES,     FV»rCTZO»rAI.,      Tbe 
Systematic      Treatment     of     (so-called 
Weir  Mitchell  Treatment). — The  treat- 
ment of  functional  neurosis  has,  until   of 
late  years,  been  the  despair  of  physcians 
and  a  real  "opprobium  medicinae."     No 
one  can  contest  this  statement  who  will 
honestly  reflect  on  his  experience  of  such 
cases.       Take    a    confirmed    neurotic    of 
many  years  standing,  whose  social  position 
and  means  enable  her  to  follow  any  advice 
she  may  have  received,  and  consider  what 
her  probable  history  has  been.     Ever  since 
her  illness  began  she  has  been  going  from 
one  health  resort  to  another.  She  has  tried 
Schwalbach,    St.  Moritz,  and  the  Riviera; 
she   has  swallowed  pints  of  drugs,  iron, 
quinine,  bromides,  chloral,  and  anti-spas- 
modics ;  she  has  exhausted  the  virtues  of 
hydropathic   establishments  ;  she  is  lucky 
if  she   has   not  also    run  the  gauntlet  of 
innumerable  pessaries,  and  much  uterine 
treatment ;  of  late  years  almost  certainly 
she  has  "  tried  a  little  massage,"  and  most 
certainly  it  has  failed  to  do   good ;  and 
lastly   she  has  had  hosts  of  sympathetic 
friends,  many  nurses,  and  a  whole  phalanx 
of  doctors.  This  is  no  exaggerated  picture. 
It  is  a  simple  statement  of  what  almost  all 
well-to-do  patients  of  this  kind  have  gone 
through,  and  their    last  state   is  always 
worse  than  their  first.     To  have  systema- 
tised  a   scientific  and  rational   means  of 
dealing  with  such  illnesses,  which  rarely, 
if   ever,    fails    to  effect    a    cure   in    well 
selected  cases,  or  if  not  a  cure,  at  least  a 
great  amelioration,is  no  slight  achievement 
and,  to  my  mind,  constitutes  one  of  the 
greatest    gains   to  practical   medicine  of 
which  the  present  generation  can  boast. 
This  we  owe  to  the  sagacity  and  intimate 
knowledge  of  this  form  of  disease  possessed 
by  Dr.  Weir  Mitchell,  of  Philadelphia,  by 
whose  name   the    method    of  systematic 
treatment,  a  brief  description  of  which  it 
is  the  object  of  this  article  to  give,  is  now 
veiy    generally    known.      His    claim    to 
originality  with  regard  to  it  has  been  con- 
tested.    AH  that  need  be  said,  in  passing, 
on  this  point  is,  that  while  many   have 
suggested  and  adojited  individual  portions 
of  this  treatment,  such    as    the    removal 
of   unhealthy  influences  and  the  like,  no 
one  else  has  laid  down  a  complete  scheme 
by  which  a  serious  attack  on  the  disease, 
on  rational  principles,  is  carried  out,  and 
to  him  alone  this  merit  is  due. 

Before  describing  in  detail  the  method 
to  be  adopted,  it  would  be  very  desirable 


Neuroses,  Functional        [851     ]        Neuroses,  Functional 


to  study  the  forms  of  functional  neurosis 
for  which  it  is  adapted;  for  success  depends 
quite  as  much  on  the  proper  selection  of 
cases,  as  on  the  intelligent  and  sufficient 
carrying  out  of  the  treatment  itself.  Nor 
is  a  word  of  warning  on  this  point  un- 
necessary. The  remarkable  results  which 
have  often  followed  the  application  of  this 
method  in  proper  cases  has  not  unnatu- 
rally attracted  a  good  deal  of  attention, 
and  many  have  been  tempted  to  try  it 
without  sufficient  stud}'  of  the  subject,  and 
they  have  used  it  in  altogether  unsuitable 
cases,  with  the  natural  result  of  failure 
and  disappointment,  which  have  cast  dis- 
credit, and  very  unfairly,  on  the  treatment 
itself.  It  will  be  advisable,  therefore,  to 
state  briefly  the  kind  of  case  in  which 
alone  it  should  be  used,  but  this  the  limits 
of  si^ace  will  oblige  us  to  do  in  the  baldest 
and  briefest  way.  To  describe  the  course 
and  symptoms  of  the  functional  neuroses 
concerned  would  require  a  volume  in  itself, 
a  volume  much  needed,  since  we  are 
satisfied  that  there  is  no  department  of 
medicine  so  little  understood,  and  so  much 
requiring  study.  We  shall  content  our- 
selves with  enumerating  some  of  the 
more  prominent  classes  of  neuroses  for 
which  this  treatment  is  adapted,  without 
any  attempt  at  classification,  adding  a  few 
observations  as  to  the  cases  in  which  it 
should  not  be  tried,  but  in  which,  we  are 
sorry  to  say,  from  want  of  sufficient  caution, 
we  have  often  seen  it  used. 

(l)  Nervous  Exbaustion  or  IVeur- 
astbenia. — The  form  of  disease  in  which 
it  answers  best  is,  in  our  experience,  that 
species  of  general  nervous  breakdown  which 
constitutes  a  very  real  and  very  impor- 
tant malady,  the  existence  of  which,  how- 
ever, has  only  been  recognised  of  late 
years,  and  which  we  have  not  seen  suffi- 
ciently recognised  in  any  of  our  medical 
text-books.  We  are  sadly  in  want  of  a 
name  for  it.  By  some  it  is  called  "  ner- 
vous exhaustion,"  by  others,  "  neurasthe- 
nia," and  both  these  names  have  been  ob- 
jected to  because  of  their  associations, 
and  not  unreasonably.  Yet  no  better 
ones  have  been  proposed,  and  they  seem 
to  us  to  describe  what  we  believe  to  be  the 
real,  essential  nature  of  the  illness  better 
than  any  other  designation  we  have  seen 
suggested.  It  is  often  called  "  hysteria," 
a  word  associated  with  fanciful  and  imagi- 
native illness,  no  doubt  often  complicating 
this  condition,  but,  on  the  other  hand, 
often  entirely  distinct  from  it.  In  our 
experience  many  of  these  cases  occur  in 
clever,  emotional  and  excitable,  but  not 
fanciful,  women,  who  would  give  all  they 
possess  to  be  well,  and  heartily  long  for 
good  health  if  they  only  knew  how  to  ob- 


tain it.  A  condition  such  as  this,  in  such 
women,  is  as  far  removed  as  possible  from 
the  state  that  is  known  to  us  as  "  hysteri- 
cal." In  a  large  proportion  of  these  cases 
the  origin  of  the  illness  can  be  directly 
traced  to  some  shock  or  over-strain  af- 
fecting the  nervous  system.  Amongst  the 
most  common  of  the  former  are  the  death 
of  some  near  relative,  money  losses,  dis- 
appointments in  love  affairs,  and  the  like ; 
of  the  latter,  overwork  in  the  modern  sys- 
tem of  high-class  education  in  girls,  whose 
physical  health  is  unfltted  for  the  efforts 
they  are  unwisely  encouraged  to  make. 
The  disease  is  not,  as  a  rule,  suddenly  es- 
tablished, but  is  the  gradual  outcome  of 
deteriorated  health.  No  one  symptom  can 
be  mentioned  as  distinctive,  but  the  result 
is  a  state  of  continuous  inability  for  any 
exertion,  and  a  constant  feeling  of  weari- 
ness and  fatigue  on  the  slightest  effort, 
until  at  last  all  effort  is  given  up,  and  the 
patient's  life  is  practically  passed  on  the 
sofa  or  invalid  chair.  The  appetite  gra- 
dually fails  and  little  or  no  food  is  taken, 
and  dyspepsia,  with  its  train  of  evils,  such 
as  flatulence,  constipation,  and  so  on,  is 
constant ;  emaciation,  more  or  less  marked, 
is  very  general,  and  sometimes  it  is  exces- 
sive. On  the  other  hand,  there  is  a  com- 
]3aratively  rare  but  well-marked  type  of 
this  class  of  disease  in  which,  while  the 
muscles  are  wasted  and  flabby,  there  is  an 
abnormal  development  of  unwholesome 
subcutaneous  fat,  the  whole  appearance 
being  of  great  obesity.  We  have  observed 
in  cases  of  this  kind  that  the  fat  is  de- 
posited in  masses  in  particular  parts,  such 
as  near  the  joints  or  on  the  outside  of  the 
thighs,  and  that  its  distribution  is  irre- 
gular. 

Marked  evidence  of  mal-nutrition  is  to 
be  found  in  the  urine,  which  is  generally 
pale  in  colour,  containing  abundance  of 
phosphates,  sometimes  a  trace  of  albumen, 
with  an  amount  of  urea  always  markedly 
below  the  average.  Other  indications 
of  nervous  disturbance  besides  those  men- 
tioned are  frequently  met  with,  but  are 
too  variable  to  be  desci*ibed ;  amongst  the 
most  common  are  severe  headaches,  sleep- 
lessness, vaso-motor  disturbance  of  many 
kinds,  such  as  palpitations,  irregularities 
of  the  pulse,  flushings,  cutaneous  erythe- 
matous patches  of  a  transient  character 
Emotional  and  mental  phenomena  are 
pretty  sure  to  become  developed  in  long- 
standing cases  of  this  type,  and  although, 
as  we  have  said,  many  cases  are  not  "  hys- 
terical "  in  the  ordinary  acceptation  of  the 
word,  unquestionably  few  protracted  cases 
can  escape  some  moral  conditions  which 
may  fairly  be  so  classed.  There  is  gene- 
rally some  devoted  and  over-sympathetic 

31 


Neuroses,  Functional       [    852    ]        Neuroses,  Functional 


mother  or  sister,  husband  or  uurse,  in  the 
background,  and  eventually  the  constant 
watching  of  symptoms,  the  incessant  trial 
of  all  sorts  of  cures  and  drugs,  have  pro- 
duced a  mental  condition  that  is  most  un- 
wholesome. The  fact,  however,  must  be 
insisted  on  that  at  the  bottom  of  all  this 
is  a  condition  of  real  disease,  and  so  far 
as  our  present  knowledge  goes,  the  author 
believes  that  this  disease  is  in  reality  one 
of  defective  nerve-power,  on  which  the 
other  phenomena  mentioned  have  become 
engrafted. 

(2)  Hysteria. — The  second  class  of  case 
may  more  properly  be  termed  "  hysteri- 
cal," and  it  includes  a  vast  number  of 
neurotic  conditions  impossible  to  classify. 

One  of  the  most  common,  and  one  which 
most  readily  and  certainly  answers  to 
treatment,  is  that  form  of  neurosis  which 
has  been  called  "  hysterical  apepsia." 
Generally  it  begins  with  ordinary  dyspep- 
tic symptoms,  leading  to  pain  and  discom- 
fort after  eating.  To  avoid  this,  one 
article  of  food  after  another  is  dropped, 
until  at  last  scarcely  any  food  at  all  is 
taken.  It  is  quite  astonishing  to  see  how 
patients  of  this  kind  can  exist  on  the 
almost  starvation  diet  to  which  they  have 
accustomed  themselves.  The  emaciation 
in  old-standing  cases  is  so  excessive  that 
all  the  sub-cutaneous  fat  is  absorbed,  and 
the  patient  assumes  a  wizened  and  strange 
appearance,  which  is  highly  distinctive 
and  most  remarkable.  One  jjeculiar 
feature  of  these  cases  is  very  charac- 
teristic of  the  nervous  origin  of  the  dis- 
ease, and  that  is  a  strange  unrest,  if  it 
may  be  so  described.  The  patient  will 
not  keep  still.  She  takes  long  prostrat- 
ing walks,  and  other  forms  of  muscular 
exercise,  for  which  her  wasted  body  is 
quite  unfit.  It  is  only  in  the  worst  cases, 
when  the  strength  has  absolutely  broken 
down,  that  patients  of  this  class  get  bed- 
ridden and  completely  laid  by. 

Other  types  of  neuroses  are  more  or  less 
distinctly  mimetic,  and  are  apt  to  be  con- 
founded with  organic  disease.  These 
assume  such  protean  and  varied  forms 
that  any  enumeration  of  them  is  impos- 
sible, and  yet  they  are  probably  the  most 
important  of  all,  since  in  them  the  diffi- 
culties of  diagnosis  are  often  immense ; 
and  yet  it  is  in  these  forms  of  nervous 
disease  that  accurate  diagnosis  is  most  im- 
portant, for  if  the  mistake  is  made  of 
treating  organic  disease  as  functional,  not 
only  is  failure  certain,  but  real  injury  to 
the  patient  may  follow.  It  is  in  cases 
more  or  less  simulating  disease  of  the 
central  nervous  system  that  such  difficul- 
ties are  most  apt  to  occur.  Such  are,  among 
others,  various  forms   of   paresis,    often 


closely  simulating  sclerosis ;  hysterical 
paralysis ;  hysterical  locomotor  ataxy ; 
various  spasmodic  and  convulsive  condi- 
tions, chorea,  and  the  like.  In  some  cases 
of  this  type  accurate  diagnosis  may  be  said 
to  be  impossible  ;  in  all  a  most  careful 
examination,  and  a  full  knowledge  of  the 
most  advanced  neurology  is  necessary. 
Moreover,  in  certain  old-standing  cases, 
originally  purely  functional,  eventually 
certain  obscure  and  little  understood 
changes  in  the  nerve  centres  may  become 
established,  which  render  complete  cure 
impossible,  although  judicious  treatment 
may  effect  great  amelioration.  Still  it  is 
in  bad  cases  of  this  type  that  the  most 
successful  and  brilliant  cures  are  often 
effected.  This  class,  moreover,  includes 
simulated  diseases  of  many  other  organs 
besides  those  of  the  central  nervous  sys- 
tem :  thus  we  may  have  the  most  intense 
neurotic  vomiting  ;  or  again  cardiac  affec- 
tions, such  as  pseudo-angina,  or  palpita- 
tions ;  or  some  simulated  chest  disease, 
such  as  asthma,  or  spasmodic  cough.  Xone 
of  these,  however,  present  the  same  diffi- 
culties in  diagnosis  as  those  already 
alluded  to,  and  all  of  them  are  amenable 
to  treatment  when  properly  conducted. 

(3)  ITarcosis. — Another  class  of  case, 
which  may  fairly  be  called  neurotic,  is 
according  to  the  writer's  experience,  better 
treated  in  this  than  in  any  other  way,  and 
that  is  the  acquired  habit  of  taking  nar- 
cotic drugs,  such  as  chloral  or  morphia, 
or  alcohol  in  excess.  In  a  large  propor- 
tion of  the  functional  neuroses  already 
alluded  to  the  patients  had  insensibly 
fallen  into  the  practice  of  consuming  large 
quantities  of  narcotics,  which  had  origi- 
nally been  prescribed  for  the  relief  of 
symptoms,  but  which  had  gradually  been 
taken  in  increasing  doses  until  the  habit 
had  been  fully  established.  The  compa- 
rative facility  with  which  this  pernicious 
custom  was  abandoned,  when  the  patient 
was  under  treatment,  as  the  nutrition  im- 
proved, and  health  and  strength  were 
gained,  was  very  striking.  The  author 
has  since  treated  many  cases  in  which  the 
habit  was  not  merely  incidental  to  a 
functional  neurosis,  but  in  which  it  alone 
was  the  cause  of  ill  health,  and  for  the 
express  purpose  of  breaking  it  off.  The 
result  has  been  nearly  uniformly  success- 
ful, and  it  has  been  obtained  at  the  cost 
of  far  less  physical  and  mental  suffering 
than  is  possible  under  any  other  way  of 
dealing  with  these  unfortunate  cases.  This 
is  doubtless  due  in  part  to  the  complete 
control  which  the  isolation  of  such  cases 
under  a  thoroughly  competent  nurse  gives 
the  practitioner,  but  largely  also  to  the 
regular  habits,  the  full  occupation  of  the 


Neuroses,  Functional        [    S53    ]        Neuroses,  Functional 


patient's  time,  and  above  all  to  the  rapid 
improvement  of  the  nutrition  under  treat- 
ment, which  enable  the  patient  to  resist 
the  craving  for  narcotics  or  stimulants  in 
a  way  which  is  quite  impossible  under  any- 
other  conditions.  In  some  of  the  author's 
cases  the  amount  of  narcotics  taken  for  a 
lengthy  period  has  been  quite  enormous, 
and  yet  the  habit  has  been  completel}'' 
abandoned  in  a  few  weeks,  with  compara- 
tively little  suffering,  and  has  not,  as  a 
rule,  been  again  resumed. 

(4)  IVXental  Disease. — It  is  important 
to  lay  stress  on  the  fact  that  there  are  cer- 
tain forms  of  neurotic  disease  in  which 
this  systematic  treatment  should  not  be 
attempted.  This  is  a  point  of  real  im- 
portance, for  the  striking  success  which 
has  followed  treatment  in  suitable  cases  has 
led,  far  too  frequently  of  late,  to  its  being 
heedlessly  tried  in  cases  in  which  it  is  prac- 
tically certain  to  fail,  and  thus  a  really 
good  thing  comes  to  be  discredited. 

One  form  of  nervous  case  in  which 
this,  like  everything  else,  is  sure  to  be 
unsuccessful,  is  that  of  the  comfort- 
able, well-feeding,  well-nourished,  and 
thoroughly  seltish,  nervous  patient,  to 
whom  her  illnesses  are  sources  of  enjoy- 
ment, and  who  has  neither  the  wish  nor 
the  intention  of  being  bettered.  Cases  of 
this  kind  are  not  rare,  and  the  wise 
physician  will  leave  them  alone. 

This  treatment  is  often  unfortunately 
tried  in  cases  of  real  mental  disease,  espe- 
cially in  chronic  melancholia.  The  relatives 
and  friends  of  such  patients  are  often,  and 
very  naturally,  exceedingly  desirous  of 
shirking  the  real  facts,  and  will  do  any- 
thing rather  than  admit  that  the  patient 
is  insane.  The  term  "hysterical"  is  a 
very  convenient  cloak  in  cases  of  this 
kind  for  masking  the  truth,  and  strong 
pressure  is  often  brought  to  bear  on  the 
medical  man  to  treat  cases  on  this  as- 
sumption. No  doubt  there  are  some 
few  cases  in  which  the  diagnosis  is  un- 
certain, and  in  which  the  treatment  may 
do  good.  There  are  patients  who,  being 
predisposed  to  insanity,  are,  from  defec- 
tive nutrition,  some  temporary  shock, 
and  the  like,  walking  along  the  edge  of  a 
precipice,  as  it  were.  On  the  one  side  is 
mental  disease,  on  the  other  health.  It  is 
conceivable  that,  under  the  improved  nu- 
trition resulting  from  systematic  treat- 
ment, the  patient  may  be  drawn  away 
from  the  precipice  along  which  she  is 
walking,  in  the  direction  of  health ;  on 
the  other  hand,  however,  it  is  quite  as 
likely  that  the  isolation,  &c.,  may  precipi- 
tate her  over  it,  sooner  than  would  other- 
wise have  been  the  case.  We  have  seen 
both  results  occur,  and  we  know  no  class 


of  case  requiring  more  care  in  selection. 
If  there  is  any  decided  symptom  of  in- 
sanity, such  as  marked  religious  delu- 
sions, suicidal  impulses,  and  the  like,  then 
we  hold  the  rule  to  be  absolute  that  this 
treatment  is  positively  contra-indicated. 
We  have  cases  constantly  brought  to  us 
for  treatment  under  such  conditions. 
More  than  once  we  have  been  persuaded 
to  try  treatment  against  our  own  better 
judgment,  and  we  have  never  done  so 
without  regretting  it.  In  one  sense,  most 
well-marked  neurotic  cases  are  closely 
allied  to  cases  of  mental  disease.  For 
example,  it  is  quite  common  to  meet  with 
cases  admirably  adapted  for  systematic 
treatment, where  the  family  history  clearly 
shows  an  hereditary  disposition  to  in- 
sanity. We  have  even  seen  cases  quite 
cured  by  treatment,  who  subsequently  be- 
came insane ;  and  the  moi'e  we  see  of  such 
cases,  the  more  convinced  we  are  that  the 
rule  we  have  laid  down  should  be  strictly 
adhered  to. 

The  rationale  of  systematic  treatment 
is  abundantly  simple,  and  it  is  well  that 
this  should  be  thoroughly  understood. 
There  is  nothing  mysterious  or  complex 
about  it ;  it  is  nothinp-  more  or  less  than 
a  rapid  means  of  putting  the  patient  into 
good  physical  condition,  of  raising  her 
health  from  the  low  level  into  which  it 
has  fallen  to  the  highest  level  which  is 
possible  in  the  individual  case.  And, 
coincident  with  good  physical  health,  we 
hope  for  the  disappearance  of  the  func- 
tional neurosis  which  in  most  cases  is 
incompatible  with  perfect  health.  The 
rank  weeds  of  neurotic  disease  will  only 
grow  and  flourish  in  suitable  soil — that  is, 
in  a  state  of  depressed  vitality ;  improve 
the  soil,  and  the  unhealthy  growth  will 
disappear.  That  this  can  be  done  through 
the  chemist's  shop,  the  health  resort,  or 
the  injudicious  tending  of  unwise  friends, 
all  exiDcrience  shows  is  an  impossibility ; 
these,  as  a  rule,  only  make  the  patient  go 
from  bad  to  worse.  Get  rid  of  all  these, 
put  the  patient  under  thorough  physical 
and  moral  training,  such  as  systematic 
treatment  enables  us  to  do,  and  it  is  sur- 
prising how  rapidly  her  whole  being  seems 
to  alter,  how  the  confirmed  invalid  may 
be  changed  into  the  strong  and  healthy 
woman,  and  how  all  her  acquired  neuroses 
vanish. 

The  chief  elements  of  systematic  treat- 
ment are : 

(i)  Removal  of  the  patient  from  her 
usual  surroundings,  and  putting  her  com- 
pletely at  rest,  under  the  care  of  a  suit- 
able nurse. 

(2)  nxassagre,  combined  generally  with 
the  use  of  electricity,  as  a  means  of  pro- 


Neuroses,  Functional        [    S54 


Neuroses,  Functional 


clucing  tissue  waste,  and  enabling  the 
patient  to  consume  large  quantities  of 
food. 

(3)  Over-feeding-,  as  a  means  of  rapidly 
increasing  nutrition. 

Each  of  these  will  require  separate  con- 
sideration. 

(i)  Removal.  —  Isolation  is  generally 
found  to  be  the  great  obstacle  on  the 
part  of  the  friends  to  the  adoption  of  this 
treatment,  and  strong  pressure  is  invari- 
ably brought  to  bear  on  the  medical 
attendant  to  secure  some  modification  of 
this  most  unpleasant  necessity,  a  pressure 
to  which  unfortunately  he  too  often 
yields,  and  thus  ruins  the  success  of  his 
treatment.  It  is  impossible  to  speak  too 
emphatically  on  this  point.  Increasing 
experience  convinces  the  author  that  any 
compromise  in  this  respect  will  assuredly 
prove  disastrous.  No  doubt  the  difficulty 
of  securing  it  is  often  great.  In  London 
and  other  large  cities  there  are  an  abun- 
dance of  medical  homes  where  it  is  easy 
enough  to  place  patients,  but  in  the 
country  and  in  small  towns  these  are  not 
to  be  had.  On  this  account  the  attempt 
is  often  made  to  isolate  the  patient  in  her 
own  house,  under  the  belief  that  she  can 
thus  be  separated  from  her  friends  and 
relatives,  a  belief  that  will  certainly  mis- 
lead. Even  if  they  can  be  persuaded 
really  to  remain  away,  which  is  almost 
impossible,  their  vicinity  is  known,  there 
is  an  incessant  passing  of  messages  and 
notes,  and  a  fret,  which  is  entirely  avoided 
if  the  absolute  removal  of  the  patient  is 
secured.  Still  more  fatal  is  the  concession 
often  made  of  the  occasional  visit  of  a 
relative  or  friend.  The  medical  man  will 
almost  certainly  be  told  that  this  plan  of 
complete  removal  from  the  usual  domestic 
surroundings  is  admirable  for  Mrs.  Brown, 
Jones,  or  Robinson,  but  that  this  par- 
ticular patient  is  so  sensitive,  so  deeply 
attached  to  her  mother  or  sisters,  that  it 
is  an  absolute  impossibility  in  her  case, 
and  that  they  will  readily  submit  to  every- 
thing proposed  but  this,  and  that,  there- 
fore, they  must  be  allowed  to  visit  her  as 
before.  All  that  need  be  said  on  this 
point  is,  that  if  the  medical  man  who  pro- 
poses to  carry  out  systematic  ti'eatment 
cannot  resist  pressure  such  as  this,  he  is 
quite  unfit  to  treat  the  case  at  all,  and 
had  much  better  not  make  the  attempt. 

When  the  writer  first  began  to  treat 
these  cases  he  placed  them  in  lodgings 
with  a  nurse.  This  he  never  does  now, 
much  preferring  that  they  should  be  in  a 
medical  home.  In  the  first  place,  they 
are  there  spared  the  trouble  and  worry  of 
housekeeping,  which  is  incompatible  with 
perfect  rest  of  body  and  mind,  and,  what 


is  of  more  importance  still,  they  are  not 
placed  absolutely  at  the  mercy  of  the 
nurse,  but  are,  in  some  degree,  also  under 
the  supervision  of  the  manager  of  the 
home,  who  can  report  on  their  general 
progress.  This  is  a  matter  of  great  im- 
portance, since  it  places  a  check  on  the 
nurse,  and  enables  the  medical  attendant 
to  judge  if  she  and  the  patient  get  on 
well  together. 

The  selection  of  a  suitable  nurse  is  of 
primary  consequence,  and  a  good  nurse 
for  neurotic  patients  is  a  rara  chvis 
indeed.  As  a  matter  of  fact,  nine 
nurses  out  of  ten,  however  large  their 
experience  and  thorough  their  training, 
are  quite  unable  to  manage  these  cases 
properly.  The  majority  err  by  supposing 
that  they  must  rule  the  patients,  and 
endeavour  to  do  so  by  a  harsh  assumption 
of  authority  which  is  sure  to  fail  in  its 
object;  or  if  they  do  not  do  this,  they 
fall  into  the  opposite  error  of  being  over- 
sympathetic  and  yielding.  What  is  wanted 
is  tact,  kindness,  common-sense,  and  firm- 
ness, a  combination  of  qualities  which,  it 
is  needless  to  say,  is  not  easily  found. 
One  practical  rule  should  be  borne  in 
mind,  and  that  is,  that  when  a  case  is  not 
doing  well,  when  the  patient  is  fretting 
and  dislikes  her  attendant,  an  immediate 
change  should  be  made.  The  nurse  is 
there  for  the  good  of  the  patient,  not  for 
her  own  advantage,  and  the  fear  of  hurting 
her  feelings  should  never  stand  in  the 
way  of  the  patient's  welfare.  It  is  always 
advisable  that  the  nurse  should  be,  if 
possible,  a  person  of  some  culture  and 
education.  She  is  shut  up  for  many 
weeks  with  the  patient,  whom  she 
must  be  able  to  read  to  and  otherwise 
amuse.  To  condemn  a  cultivated  lady  to 
a  lengthy  and  intimate  intercourse  with 
a  coarse,  vulgar,  and  illiterate  woman 
would  not  only  be  a  positive  cruelty,  but 
would  certainly  defeat  the  object  desired. 

Combined  with  isolation,  the  patient  is 
placed  absolutely  at  rest  in  bed,  and  is 
practically  kept  there  dui-ing  the  whole 
treatment.  In  some  severe  cases  it  is 
advisable  that  the  rest  should  be  so  abso- 
lute that  no  physical  exertion  of  any 
kind  should  be  allowed,  and  the  patient  is 
not  permitted  to  leave  her  bed  to  pass  her 
evacuations,  nor  should  she  wash  herself, 
nor  use  any  other  form  of  physical  exex*- 
tion.  It  will  presently  be  seen  how  com- 
plete repose  is  associated  with  extreme 
tissue-waste  produced  by  massage,  a 
process  so  fatiguing  that  it  could  not  pos- 
sibly be  borne,  unless  all  voluntary  effort 
both  of  body  and  mind  is  avoided.  It  is 
not  until  the  fifth  or  sixth  week  of  treat- 
ment, when  the  physical  powers  are  re- 


Neuroses,  Functional        [    855 


Neuroses,  Functional 


stored,  that  the  patient  is  allowed  to  sit 
up  for  an  hour  or  two,  and  shortly  after- 
wards she  may  go  out  for  a  short  walk  or 
drive,  until  gradually  healthy  habits  of 
life  are  i-eaumed. 

(2)  IVXassag:e. — Combined  with  rest  and 
isolation,  a  jjrocess  of  massage  is  com- 
menced on  the  second  or  third  day.  Now, 
with  regard  to  this  it  is  necessary  to  make 
some  observations.  This  is  in  itself  a  new 
therapeutic  agent ;  it  strikes  the  imagina- 
tion, and,  in  s^ute  of  all  that  the  writer  and 
others  have  said  about  it,  both  the  public 
and  the  profession  have  insisted  on  look- 
ing upon  it  as  the  main  factor  in  this 
method  of  treatment,  which  is  called  by 
many  "  massage  treatment,"  or  some  other 
term  indicating  that  this  is  the  essence  of 
the  cure.  Accordingly,  many  who  have 
not  taken  the  trouble  to  study  the  matter 
have  thought  that  if  they  only  order  their 
patients  to  undergo  some  amount  of  mas- 
sage, all  is  done  that  is  essentially  neces- 
sary, and  they  believe  that  they  are  carry- 
ing out  this  treatment.  The  result  is 
necessarily  failure  and  disappointment, 
and  a  really  good  therapeutic  agent  is  dis- 
credited and  looked  upon  with  suspicion. 
When  the  writer  first  began  to  treat  cases 
in  this  way,  there  was  no  such  thing  as  a 
masseuse  to  be  had  ;  now  they  exist  by 
hundreds.  Schools  for  massage  have  been 
established,  whence  numbers  of  perfectly 
useless  operators  are  turned  out  after  a 
short  perfunctory  training  ;  every  nursing 
institute  professes  to  supply  them  ;  works 
on  massage  have  been  j^ublished,  which 
render  a  perfectly  simple  matter  obscure  ; 
and,  in  fact,  the  author  believes  he  was 
quite  justified  in  stating,  as  he  has  done 
elsewhere,  that  massage  has  become  the 
prevailing  medical  folly  of  the  day.  Against 
such  a  state  of  things  it  is  necessary  to 
protest.  In  the  view  of  the  writer,  mas- 
sage, properly  applied  in  suitable  cases,  is 
an  invaluable  remedy,  which  may  per- 
haps best  be  called  a  mechanical  tonic. 
It  works  all  the  muscles  passively,  without 
effort  on  the  part  of  the  patient,  and  thus 
enables  her  to  consume  the  large  amount 
of  food  which  it  is  necessary  to  assimilate. 
In  this  there  is  nothing  mysterious.  It  is 
simply  a  remedy,  just  as  cod-liver  oil  or 
quinine  are  remedies,  and  a  remedy  of  a 
strictly  scientific  and  common-sense  char- 
acter. As  to  the  details  and  method  of 
applying  it,  the  writer  deems  it  ([uite  un- 
necessary to  say  anything.  A  very  short 
experience  is  necessary  to  enable  the  prac- 
titioner to  judge  whether  it  is  being  pro- 
perly done  or  not.  It  is  quite  needless  for 
him  to  be  acquainted  with  the  technique 
of  the  process.  The  simple  rule  is,  that  if 
in  a  week  or  ten  days  the  patient  is  unable 


to  assimilate  with  ease  all  the  food  that  is 
given  to  her,  then  assuredly  the  massage 
is  ineffective,  and  the  operator  should  at 
once  be  changed.  In  the  author's  ex- 
l^erience  not  one  woman  in  a  dozen  who 
professes  to  be  a  "  masseuse"  is  of  any  use 
at  all.  At  first  not  more  than  a  quarter 
of  an  hour  to  twenty  minutes'  massage  is 
given  twice  daily ;  then  the  time  is  gradu- 
ally increased,  until  an  hour  to  an  hour  and 
a  half  is  given,  also  twice  in  the  day,  and  by 
the  time  this  amount  is  reached  the  patient 
should  be  taking  the  full  amount  of  food 
prescribed.  During  the  process  she  is 
freely  lubricated  with  oil,  and  when  each 
rubbing  is  over  she  is  left  to  lie  in  the 
blanket  for  an  hour's  absolute  rest,  the 
room  being  darkened,  and  complete  repose 
enjoined.  In  very  feeble  and  delicate  pa- 
tients it  may  be  necessary  to  proceed  more 
slowly,  and  then  the  full  rubbing  will  not  be 
reached  for  perhaps  a  week  or  ten  days 
longer.  At  the  end  of  the  treatment,  when 
the  patient  leaves  her  bed,  the  afternoon 
rubbing  is  omitted,  and  then  by  degrees 
the  massage  is  stopj^ed  altogether. 

Combined  with  the  massage  in  most  cases 
electricity  is  used  as  a  subsidiary  means 
of  exercising  the  muscles.  It  is  generally 
given  by  the  masseuse  for  about  twenty 
minutes  to  half  an  hour,  twice  daily.  The 
interrupted  current  is  used,  and  the  reo- 
phores,  well  wetted,  are  placed  on  the 
principal  muscles  of  the  upper  and  lower 
extremities,  the  back,  thorax,  and  abdo- 
men, at  a  distance  of  about  four  inches 
from  each  other,  until  the  muscles  are 
thoroughly  contracted.  It  requires  a  good 
deal  of  skill  and  practice  to  use  this  so  as 
not  to  pain  the  patient  needlessly.  The 
electricity  is  not  commenced,  as  a  rule, 
until  the  patient  has  been  about  a  fort- 
night under  treatment,  and  should  she 
object  to  it  strongly,  or  appear  to  suffer 
much  pain,  it  should  certainly  be  discon- 
tinued. It  appears  to  be  of  very  secondary 
importance  to  the  massage,  and  the  author 
very  frequently  treats  cases  without  using 
it  at  all. 

(3)  Feeding. — The  very  essence  of  this 
method  of  cure  is  the  dietai'y,  the  object 
of  which  is  to  improve  the  nutrition  of  the 
patient,  and  place  her  in  a  condition  of 
perfect  physical  health.  The  other  modes 
of  treatment  adopted  are  all  subsidiary  to 
this.  It  is  quite  surprising  to  witness  the 
facility  with  which  a  patient  who  for  years 
has  been  subsisting  on  an  almost  starva- 
tion diet,  who  has  suffered  from  every  pos- 
sible form  of  dyspeptic  derangement,  and 
who  has  loathed  the  very  name  of  food, 
can,  in  nine  cases  out  of  ten,  be  got,  under 
rest  and  effective  massage,  to  take,  in  a 
week  or  ten  days,  an  amount  of  food  which 


Neuroses,  Functional       [    S56    ]        Neuroses,  Functional 


is  quite  incredible  to  those  who  have  not 
seen  it,  and  not  only  to  take  it  without 
repugnance,  but  perfectly  to  digest  and 
assimilate  it.  It  is  well  from  the  first  for 
the  nurse  to  feed  the  patient,  and  she  com- 
mences by  administering  about  three 
ounces  of  fi-esh  milk  every  third  hour.  In 
a  day  or  so  this  is  increased  to  five,  and 
then  to  ten  ounces,  at  the  same  interval. 
By  this  time  the  patient  is  getting  from  a 
quarter  to  half  an  hour's  massage  twice 
daily,  and  then  the  administration  of  solid 
food  is  commenced.  At  first  some  break- 
fast is  given,  then  a  fish  dinner,  afterwards 
a  finely  divided  chop  ;  and  so,  by  degrees, 
the  full  diet  is  arrived  at.  When  a  case 
is  doing  well,  in  about  ten  days  the  full 
amount  of  three  hours'  massage  is  given, 
and  with  it  the  full  diet.  A  careful  record 
should  be  kept  by  the  nurse,  in  a  book 
provided  for  the  purpose,  of  all  that  the 
patient  takes,  and  with  it  a  journal  of  her 
general  progress,  such  as  her  sleep,  the 
action  of  the  bowels,  and  the  like.  The 
following  maj'  be  taken  as  a  fair  sample  of 
the  dietary  consumed.  Breakfast :  a  plate 
of  porridge  and  a  gill  of  cream,  fish  or 
bacon,  toast,  with  cocoa,  or  cafe  au  lait ; 
1 1  A.M.,  a  cujD  of  beef-tea,  with  two  teaspoon- 
fuls  of  beef  peptonoids;  luncheon,  1.30 
P.M.,  fish,  cutlets,  or  joint,  with  a  sweet, 
such  as  stewed  fruit,  or  a  milky  pudding ; 
5  P.M.,  beef -tea  and  peptonoids,  as  at  1 1 ; 
dinner  at  7,  soup  or  fish,  joint  or  poultry, 
and  sweet.  In  addition,  not  less  than 
80  ounces  of  milk  is  given  in  twenty-four 
hours ;  10  ounces — that  is,  a  full  tumbler 
— every  third  hour.  It  is  not  uncommon 
for  this  amount  to  be  exceeded,  and  patients 
often  take  as  much  as  100  or  no  ounces. 
It  is  very  rare  to  find  any  inconvenience 
follow  this  apparently  enormous  dietary. 
Every  now  and  again  a  patient  may 
become  bilious,  or  may  even  vomit,  when 
sohd  food  should  be  stopped  for  twenty- 
four  hours,  after  which  it  is  resumed.  As 
a  rule,  however,  all  this  is  taken  easily ; 
and  it  coincides  with  a  rapid  gain  in 
flesh  and  strength.  In  an  emaciated  case 
a  patient  may  at  first  gain  5  or  61bs.  in 
weight  per  week,  afterwards  2ilbs.  is  a  fair 
average  gain.  It  is  quite  common  to  see 
cases  which  gain  15  to  3olbs.  in  the  course 
of  six  weeks,  and  it  is  to  be  observed  that 
this  is  not  a  gain  of  fat,  but  of  good  sub- 
stantial flesh,  the  muscles  previously 
wasted  becoming  firm  and  resistant,  while 
the  pallor  of  the  skin  disappears,  and  a 
good  ruddy  glow  of  health  takes  the  place 
of  the  anaemic,  sallow  look  of  the  patient. 
The  change  in  the  appearance  of  many  of 
these  cases  at  the  end  of  a  course  of  treat- 
ment must  be  seen  to  be  believed.  It  is 
no  exaggeration  to  say  that  they  are  often 


hardly  recognisable  as  the  same  persons. 
Coincident  with  the  gain  in  flesh  and 
strength  is  often  to  be  noticed  a  change 
for  the  better  in  all  ways  ;  the  bowels, 
before  so  obstinately  confined,  act  regu- 
larly and  without  drugs ;  sleep  becomes 
good,  sedatives  being  no  longer  required  f 
and  gradually  the  invalid  habits  of  years 
are  drojjped.  These  results  of  course  are 
not  invariable.  It  is  needless  to  say  that 
pi'actical  difficulties  are  often  met  with, 
which  can  only  be  dealt  with  by  experience 
and  tact,  but  it  is  very  rarely  that  they 
cannot  be  overcome  ;  one  may  almost  say 
never,  provided  only  that  the  case  has 
been  well  selected. 

The  best  test  of  progress  is  the  gain  in 
weight,  and  therefore  the  patient  should 
be  weighed  every  fortnight.  Unless  at 
least  2lbs.  per  week  is  being  gained  the 
case  cannot  be  considered  to  be  doing  well, 
and  this  is  often  largely  exceeded. 

In  that  type  of  neurotic  disease,  pre- 
viously alluded  to,  in  which  the  patient  is 
abnormally  fat,  another  form  of  manage- 
ment is  required.  It  is  no  use  com- 
mencing to  massage  and  feed  cases  of  this 
kind  at  once.  Some  means  must  first  be 
adopted  to  clear  the  tissues  of  the  un- 
wholesome fats  with  which  they  are  loaded. 
This  is  a  tedious  and  a  trying  process,  but 
the  results  are  generally  eminently  satis- 
factory. For  this  purpose  the  patient  is 
put  to  bed  and  completely  at  rest ;  and  at 
first  she  is  placed  on  a  diet  consisting  of 
two  quarts  of  skimmed  milk  daily,  given 
in  small  quantities  every  two  hours.  After 
this  amount  has  been  taken  for  a  day  or 
two,  it  is  gradually  lessened  until  not  more 
than  a  pint  a  day  is  consumed.  Under 
absolute  rest,  and  the  absence  of  any  mus- 
cular exertion,  this  apparently  starvation- 
diet  does  not  cause  any  discomfort  or  in- 
convenience- Of  course  it  is  necessary  to 
watch  the  patient  closely  to  see  that  no  ill 
efi"ects  follow.  If  there  should  be  any 
appearance  of  undue  weakness,  some  beef- 
tea  or  good  soup  should  be  temporarily 
substituted  for  the  milk.  After  the  amount 
of  milk  has  been  reduced  to  a  minimum, 
the  weight  will  gradually  lessen  at  the 
rate  of  half  a  pound  a  day,  and  the  fat  with 
which  the  tissues  are  loaded  will  rapidly  dis- 
appear. The  length  of  time  the  patient 
may  safely  be  treated  in  this  way  wiU,  of 
course,  vary  according  to  circumstances ; 
and  it  is  essential  that  she  should  be 
weighed  daily. 

Probably  from  three  to  four  weeks  will 
be  about  the  outside  time  that  this  process 
should  be  employed,  and  from  fourteen  to 
twenty  pounds  taken  off  the  weight.  "When 
this  has  been  done,  pure  milk  may  be  sub- 
stituted for  skim  milk,  and  the  treatment 


Nexiroses,  Functional        [    857    ] 


Nocturnal  Crises 


conducted  from  this  point  precisely  as  in 
the  case  of  an  originally  emaciated  patient. 
The  writer  has  now  treated  many  fat, 
ana)mic,  neurotic  patients  in  this  way,  and 
the  results  have  been  extremely  satisfac- 
tory. He  has  never  met  with  any  serious 
trouble  from  it,  nor  has  he  found  the 
patients  rebel  against  what  would  seem  to 
be  a  very  trying  rvgivie.  As  a  matter  of 
fact,  they  are  all  without  appetite  to  start 
with,  and  little  complaint  is  made,  nor 
does  much  discomfort  appear  to  be  ex- 
perienced. 

Nothing  has  been  said  as  to  the  use 
of  drugs.  The  writer  generally  pre- 
scribes some  ferruginous  tonic,  such  as 
Blaud's  pills,  or  a  mixture  containing  dia- 
lysed  iron  and  arsenic ;  and  some  form  of 
aperient  is  usually  required  at  first, 
although  the  bowels  almost  invariably 
soon  take  on  a  healthy  action,  however 
constipated  they  may  have  previously 
been.  As  a  matter  of  fact  medicines 
are  so  entirely  secondary  in  import- 
ance to  improved  nutrition,  that  they 
may  very  generally  be  dispensed  with 
altogether. 

Something  must  be  said  as  to  the 
moral  management  of  these  cases.  It  is 
obvious  that  a  good  deal  must  depend 
on  the  medical  man's  aptitude  in  deal- 
ing with  the  multiform  peculiarities  of 
patients  of  this  class.  Just  as  a  nurse 
of  great  experience  may  be  found  quite 
nnfit  for  managing  patients  of  this  type, 
so  it  is  with  doctors.  The  necessary 
combination  of  tact,  knowledge  of  human 
nature,  patience,  and  temper,  are  quali- 
ties not  possessed  by  all,  and  not  easily 
acquired.  Difficulties  are  to  be  met, 
not  by  bullying,  nor  by  weak  yielding  to 
the  fancies  of  a  sick  person,  but  by  firm 
kindness,  and  by  showing  that  the  prac- 
titioner has  the  superior  will  which  intends 
to  have  its  own  way.  If  he  cannot  suc- 
ceed in  impressing  this  fact  on  his  patient, 
and  at  the  same  time  in  securing  her 
regard  and  esteem,  it  is  to  be  feared  that 
she  may  gain  the  upper  hand,  and  the  case 
may  be  a  failure.  How  this  is  to  be  done 
it  is  not  easy  to  teach  in  a  short  article. 
Perhaps  it  may  be  said  of  the  doctor  who 
is  suited  to  cure  such  cases — that,  like 
the  jwet,  "  nascitur  non  fit." 

Finally,  whenever  it  is  practicable, 
after  the  treatment  is  concluded,  the  j^a- 
tient  should  be  sent  away  with  her  nurse 
for  an  after-cure,  in  the  way  of  travel  by 
sea  or  land.  It  is  of  the  utmost  import- 
ance that  the  gain  should  be  perpetuated, 
and  if  she  returns  at  once  to  all  her  old 
habits  and  ways  of  life,  the  danger  of 
relapse  is  naturally  much  increased. 

W.  S.  Playfair. 


M'EVROSTHEM'Xii.  (vfipov,  a  nerve ; 
a-dfvos,  strength).  Great  nervous  power 
or  excitement.     (Fr.  m'vrostltenie.) 

NEVROTZC  (vfvpov,  a  nerve  ;  ikos,  ter- 
minal). Of  or  belonging  to  nerves.  Used 
also  as  an  adjective  to  describe  a  tempera- 
ment characterised  by  hypersensibility  to 
subjective  and  objective  impressions.  (Fr. 
iiei^rotiquc.) 

NEUROTIC  XN-HERXTANCE. — An 
inherited  tendency  to  nervous  diseases  and 
to  exalted  nervous  sensibility. 

M-E-W    SOUTH    -W-AZ.es,    THE    IXQ-- 

SATTE  IN-.     (See  Australia.) 

vrxGHTiMCARE.— A  troubled  dream 
with  sense  of  oppression  and  great 
anxiety.  (Fr.  caucJie'inar ;  Ger.  Alp- 
driicken,  imp-pressure.) 

NXGHT  TERRORS.— An  affection  of 
children  akin  to  nightmare.  An  hour  or 
two  after  onset  of  sleep,  the  child  affected 
suddenly  screams  out  and  wakes  in  a 
great  fright,  not  at  first  recognising  its 
surroundings  or  nurse.  The  child  often 
has  difficulty  in  getting  to  sleep  again,  the 
fright  passing  off  gradually.  As  a  rule 
there  is  no  recurrence  the  same  night,  but 
there  usually  is  on  succeeding  nights. 
(iSee  Developmental  Insanities.) 

M'OASTHEM'XA  (voos,  mind  ;  dcrdeufia, 
debility).  Mental  debility.  (Fr.  noas- 
thenie.) 

NOCAR  (i/wKop, drowsiness.)  Heaviness, 
lethargy. 

WOCARODES  (i/wKC/j,  drowsiness;  (o8t}s, 
terminal).     Lethargic. 

XrOCTAMBUIiATION-  [nox,  night ; 
avibulo,  I  walk).  Literally  night-walking, 
but  from  the  association  of  night  with 
sleep,  sleep-walking.  (Fr.  7ioctambula- 
tion;  Ger.  NaclUivandehi.) 

N-ocTAnxBUiiXSivius.  Noctambula- 
tion  iq.v.) 

woCTAHIBUliUS  (nox,  night;  ambulo, 
I  walk).     One  who  walks  during  sleep. 

NOCTISURGIunc  (;nox,  night ;  surgo, 
I  arise).     Sleep-walking. 

UOCTURWAI.  CRISES.— The  name 
given  to  the  nightly  exacerbation  of  symp- 
toms sometimes  observed  in  the  insane. 
There  seems  to  be  an  exaggeration  of,  or 
alteration  in,  the  nightly  cyclic  changes 
common  to  every  individual,  which  in 
health  produce  sleep,  but  in  the  insane 
produce  sometimes,  increased  violence  and 
other  symptoms.  No  doubt  the  altered 
surroundings  of  the  patient  at  night,  the 
seclusion  and  the  quietude,  account  for 
much  of  the  change  in  the  patient's  con- 
dition, but  probably  it  is  partly  due,  as 
already  mentioned,  to  a  perversion  of  a 
natural  phenomenon  common  to  every 
one.  (See  Bevan  Lewis's  "Mental  Dis- 
eases.") 


Nocturnal  Vertigo 


[    858    ] 


Nostalgia 


NOCTURWAI.  VERTIGO. — The  Sud- 
den sensation  of  falling  from  a  height 
sometimes  experienced  just  after  going  to 
sleep.     Akin  to  nightmare. 

DTOEUCA  (vof<o,  I  think).  A  thought. 
(Fr.  pensee ;  Ger.  Gedanke.) 

iroESZS  (vorjais,  thought).  Reflection, 
thought. 

NoiviEM-ci.ATURE.  (See  Classifi- 
cation.) 

NON  COMPOS  MEirTzs. — A  medico- 
legal term,  meaning  unsoundness  of  mind. 
Under  this  term, Coke  included  :  (i)  Idiots. 
(2)  Acquired  weakness.  (3)  A  lunatic  who 
has  lucid  intervals  is  non  compos  mentis 
so  long  as  he  has  not  his  understanding. 
(4)  One  who  deprives  himself  of  his  under- 
standing, as  the  drunkard.  Plural — Non 
compotes. 

wow  -  RESTRAINT.  {See  TREAT- 
MENT.) 

WobliOGIA  (voos,  mind;  Xoyos,  a  dis- 
course). Noology,  the  doctrine  of  mind. 
(Fr.  noologie;  Ger.  Verstandeslelire.) 

WObSFHAIiES  {voos,  mind;  (T(pa\\o^ai, 
I  am  deceived).  An  adjective  applied  to 
one  disordered  mentally.     (Ger.  verrilcht.) 

WObSTERESIS  {voos,  mind;  ar^prjais, 
deprivation).  Loss  of  intellect.  De- 
mentia. (Fr.  noosterese ;  Ger.  Verstandes- 
herauhung.) 

WOR'WAV,  iwsATirE  iw.  {See  Scan- 
dinavia.) 

WOSOIVXAWIA  {voaos,  malady  ;  fiavla, 
madness).  A  form  of  monomania,  in 
which  the  patient  suffers  mentally  from 
an  imaginary  bodily  disease.  Allied  to  hy- 
pochondriasis.    (Fr.  noso'manie.) 

WOSOPHOBZA  {voaos,  malady;  0d/3o?, 
fear).  A  form  of  monomania  in  which, 
through  fear  of  a  malady  from  which  the 
patient  is  not  really  suffering,  he  adopts 
most  stringent  precautions,  and  undergoes 
dieting  and  medical  treatment  quite  un- 
necessarily. For  example,  some  indivi- 
duals diminish  their  food  and  become 
anaemic  and  dyspeptic  through  fear  of 
apoplexy.     (Fr.  nosoplwhie.) 

WOSTAI.GIA.— There  is  a  kind  of 
melancholia  which  setiologically  has  been 
called  nostalgic  melancholia,  or  nostalgia. 
We  do  not  intend  to  sjDcak  of  this  form  of 
disease  only  ;  we  shall  consider  nostalgia 
from  a  more  general  standpoint. 

Definition. — Under  nostalgia  we  must 
understand  the  abnormally  exaggerated 
longing  for  his  home  of  a  man  who  lives 
away  from  it,  whether  it  be  that  relatives  or 
friends  who  were  left  behind,  or  the  pecu- 
liarity of  the  home  as  regards  landscape 
or  climate,  are  the  object  of  his  longing. 
This  longing  often  does  not  come  into  the 
circle  of  full  consciousness.  Nostalgia 
always  represents  a  combination  of  psy- 


chical and  bodily  disturbances,  and  for 
this  reason  it  must  always  be  defined  as 
disease,  and  may  become  the  object  of 
medical  treatment. 

We  must  be  careful  to  find  out 
whether  the  alteration  in  the  patient's 
feelings  is  in  a  strict  sense  the  pjrimary 
cause.  In  that  case  we  can  effect  the 
cure  only  by  sending  the  patient  back  to 
his  own  home.  But  if  in  becoming  accus- 
tomed to  other  surroundings,  another 
sphere  of  activity,  and  a  different  climate 
and  food,  a  fever  with  gastric  disturbances 
comes  on,  which  may  be  observed  in  most 
men  who  become  acclimatised,  and  which 
is  followed  by  a  melancholy  depression  of 
nostalgic  character,  then  a  cure  is  possible 
without  sending  the  patient  home.  We 
have  to  take  care  not  to  confound  nostal- 
gia with  disappointment,  and  moroseness, 
produced  by  bad  temper  and  discontent 
with  the  temporary  position  abroad. 
This  point  in  the  differential  diagnosis  is 
of  great  importance. 

Conditions  and  Symptoms. — It  is 
not  every  one  who  resides  abroad  that  is 
attacked  by  nostalgia ;  there  are  no 
general  rules  for  its  occurrence  in  the 
different  sexes,  ages,  and  temperaments. 
Most  people  will  probably  never  suffer 
from  nostalgia,  whilst  many  are  attacked 
by  it  each  time  they  leave  home.  Some 
nations  who  inhabit  mountainous  coun- 
tries, as  the  Swiss,  the  inhabitants  of  the 
Tyrol  and  others,  are  said  to  have  a  great 
tendency  to  nostalgia,  and  this  especially 
out  of  love  for  the  landscape  of  their  native 
country.  The  nostalgia  of  the  rural  popu- 
lation is  peculiar,  and  their  want  of  educa- 
tion is  of  great  importance  in  considering 
it,  as  it  is  a  predisjDOsing  cause.  Nos- 
talgia also  occurs  more  frequently  in 
young  persons  than  in  old.  Epidemic 
nostalgia  has  been  observed  in  soldiers, 
and  prisoners  of  war,  and  in  troops  sent  to 
distant  colonies.  Homer  has  sung  about 
the  nostalgia  of  Ulysses,  and  Goethe  has 
created  in  his  Mignon  an  immortal  rei^re- 
sentation  of  home-sickness.  In  animals, 
also,  phenomena  are  said  to  occur  which 
are  similar  to  nostalgia.  Dogs,  for  ex- 
ample, refuse  to  take  food  in  the  house  of 
a  new  master,  begin  to  sicken,  become 
weak  and  languid,  and  pine  away. 

Compulsory  absence  from  home  has 
great  influence  in  causing  nostalgia,  as  in 
the  case  of  prisoners,  or  of  servants  who 
have  undertaken  to  stay  a  certain  time 
abroad,  and  are  prohibited  by  their  con- 
tract from  returning  when  they  wish ;  such 
persons  are  more  liable  to  nostalgia  than 
those  who  are  at  liberty  to  do  what  they  like. 
The  most  important  bodily  symptoms 
of  nostalgia  are  loss  of  appetite   (which 


Nostomania 


[    859    ] 


Nursing 


may  increase  to  the  refusal  of  food)  dis- 
turbances of  digestion,  and  emaciation. 
In  this  condition  phthisis  sometimes  de- 
velops itself.  Besides  this,  sleeplessness, 
congestion  of  the  brain,  and  acceleration 
of  pulse  have  been  observed.  Among  the 
psychical  disturbances,  that  alteration  of 
the  feelings  which  appears  in  the  form  of 
pure  melancholia  is  of  greatest  import- 
ance, indicating  mental  distress  with  a  de- 
sire to  commit  suicide.  Fre(|uently,  and  in 
cases  of  longer  duration,  we  find  also  hal- 
lucinations and  illusions. 

It  is  an  exceedingly  important  point,  not 
yet  sufficiently  appreciated,  to  consider 
nostalgia  from  aj'orenslc  point  of  view,  be- 
cause it  is  an  abnormal  state  of  mind 
which  suspends  the  free  determination  of 
will  in  an  individual,  and  because  it  is  apt 
to  cause  certain  acts  and  crimes  which  bear 
the  character  of  impulsive  actions.  Very 
frequently,  nostalgia,  especially  if  it  ori- 
ginates from  the  pressure  of  unalterable 
and  involuntary  conditions,  is  the  motive 
to  incendiarism,  infanticide,  and  suicide. 
Nostalgia  may  easily  end  in  impulsive  ac- 
tions, if  it  assume  a  form  of  mental  affec- 
tion involving  anger  or  rage  against  those 
persons  who  are  thought  to  be  the  cause 
of  suffering.  The  impulsive  action  then 
bears  the  character  of  an  act  of  ven- 
geance. We  ourselves  have  observed  a 
case  where  a  servant  attacked  by  home 
sickness,  and  repeatedly  hindered  by  her 
mistress  from  leaving  the  service  and  re- 
turning home,  threw  a  child  of  her  mis- 
tress into  the  water  and  drowned  it.  It  was 
an  act  of  vengeance  committed  in  an  emo- 
tional condition,  but  under  the  influence 
of  a  deranged  mind.  Cases  like  this  have 
to  be  very  cautiously  judged  in  foro,  and 
the  limit  between  genuine  nostalgia  and 
mere  ill-will  has  especially  to  be  strictly 
defined.  Albreciit  Erlenmeyer. 

iroSTOMANXA  (voaTico,  I  return  ; 
ixavla,  madness).  The  longing  for  home 
so  morbidly  intense  that  it  has  become  a 
monomania.  (Fr.  and  Ger.  nostomanie.} 
(See  Nostalgia.) 

irOSTRASZil.,  NOSTRASSIA  {nos- 
tras, of  our  country).  Similar  to  nostal- 
gia. 

M-OTEM-CZ:PHiiI.US  (varos,  back  ; 
(yKe(l)d\os,  brain).  A  deformity  of  the 
skull  in  which  the  brain  protrudes  behind 
and  lies  over  the  upper  part  of  the  neck. 
(Fr.  notenrciiliale.) 

irVI.Z.ZTY     OF    MARRZACE.      (See 

Marriage,  tue  Plea   of  Nillity  of,  on 
THE  Grounds  of  Insanity.) 

irURSZM-G;  or,  TRAINZNG 
SCHOOIiS  FOR  NURSES. — The  history 
of  nursing  in  hospitals  holds  a  large  place 
in  that  of  modern  hospital  reform.     The 


jiresent  era  of  scientific  hospital  con- 
struction had  its  forerunners  in  the  little 
pavilion  hospital  at  Plymouth,  and  in  the 
advanced  views  advocated  by  M.  Tenon 
in  France,  and  Dr.  Jones  in  America,  more 
than  a  century  ago. 

One  of  the  marvels  of  our  time  is  the 
great  reform  in  the  nursing  of  the  sick. 
It  is  marvellous  also  that  so  good  a  thing, 
and  one  so  eagerly  accepted,  should  have 
waited  so  long  for  the  world  to  be  shown 
its  need.  But  it  is  a  woman's  work,  and 
it  waited  for  the  woman  and  for  the  time 
when  her  inspiration  and  faith  could  have 
their  way.  The  reform  of  Miss  Florence 
Nightingale  has  placed  in  the  hands  of  the 
physician  a  new  order  of  instruments,intel- 
ligent  and  thinking,  that  teach  their  users, 
and  that  give  a  new  embodiment  to  the 
spirit  of  humanity. 

But  the  work  of  Miss  Nightingale  also 
had  its  forerunners,  and  they  are  found  to 
have  been  at  Kaiserswerth,  where  she  went 
in  1849,  to  strengthen  her  inspiration  by 
a  year's  training  in  nursing.  Pastor 
Fliedner  had  there  founded  the  first  of  the 
modern  orders  of  nursing  "  sisterhoods  " 
in  the  Protestant  Church,  and  the  ante- 
cedents of  these  organisations  were  those  in 
the  Roman  Catholic  Church.  While  the 
humane  labours  of  Fliedner  were  going  on, 
in  the  same  Rhenish  province,  but  a  few 
miles  distant,  Dr.  Maximilian  Jacobi  had 
already,  in  1836,  been  eleven  years  at  the 
head  of  the  hospital  at  Siegburg  for  the 
insane  of  those  provinces.  He  had  de- 
veloped there  the  ideas  that  we  accept  to- 
day, which  no  one  could  put  in  clearer 
terms,  or  with  a  more  humane  spirit,  than 
he  did — the  needs  of  the  unhappy  sufferers 
from  mental  disease.  When  Samuel  Tuke 
republished  in  England,  in  1841,  Jacobi' s 
work  on  "  Hospitals  for  the  Insane,"  he 
presented  in  his  own  views  a  like  humane 
conception  of  the  need  of  intelligent  and 
sympathetic  personal  attendance.  We 
have  only  to  examine  the  writings  of 
Jacobi  and  Tuke  to  find  that  while  these 
writers  knew  what  they  wanted,  they 
missed  the  way  of  going  to  work  to  get  it. 
Pinel's  reform  in  France  included  the 
claim  for  humane  attendance,  but  he  sim- 
plified the  question,  which  has  been  diffi- 
cult from  the  beginning,  by  employing 
jilles  de  service,  the  patients  who  were 
completely  cured  of  their  former  insanity 
or  subject  to  the  lucid  interval  of  peri- 
odical mania.  Esquirol  adopted  this  plan 
and  advocated  a  system  of  pensions  for 
superannuation,  but  the  French  alienists 
in  later  years  found  no  practical  escape 
from  the  defects  of  the  ordinary  at- 
tendants. The  religious  orders  did  not 
prove  satisfactory.     They  were  approved 


Nursing 


[    860    ] 


Nursing 


by  some  and  objected  to  by  others.  Lay 
societies  of  persons  devoted  to  the  care  of 
the  sick  were  advocated,  and  the  formation 
of  an  institution  which  should  furnish 
attendants  for  all  the  asylums  of  the 
country,  but  with  no  practical  results.  Pi- 
nel's  teachings  were  early  taken  to  Ger- 
many by  his  pupils,  notably  by  Heinroth, 
and  inspired  the  humane  conception  of  the 
proper  provisions  for  the  insane  in  the 
dozen  new  asylums  opened  there  in  the 
first  thirty  yeai-s  of  the  century. 

Dr.  Jacobi  then  evolved  his  noble  views 
of  the  right  of  the  insane  to  have  kind  and 
intelligent  attendants.  But  Jacobi  was 
not  prompted  alone  by  the  French  influ- 
ence. The  work  of  William  Tuke,  begun 
independently  of  and  contemporaneously 
with  Pinel's,  had  gradually  developed  a 
truer  idea  of  humane  attendance  upon  the 
insane,  and  attendants  were  trained  at  the 
York  Retreat  for  other  asylums.  Such 
were  the  operative  influences  in  Germany, 
when  in  1825  Jacobi  at  Siegburg,  and 
Fliedner  at  Kaiserswerth,  commenced 
their  work.  The  latter  devoted  his  first 
years  to  prison  reform,  but  not  beginning 
till  1836,  as  before  stated,  the  first  dea- 
coness's house  and  small  hospital. 

Tuke's  reform  progressed  slowly  in 
England,  but  being  sustained  at  York,  it 
found  its  expression  at  Lincoln  and  Han- 
well  by  Charlesworth,  Hill,  and  Conolly, 
who  published  his  "  Teachings  for  At- 
tendants."' The  few  American  asylums 
of  the  first  three  decades  were  founded 
upon  the  humane  teachings  of  Pinel  and 
Tuke.  In  the  notable  fourth  decade,  and 
contemporary  with  Jacobi  and  Fliedner, 
equally  advanced  work  was  being  done  in 
America.  Dr.  Bell's  "Directions  for  At- 
tendants "  was  published,  and  a  similar 
treatise  by  Dr.  Woodward,  before  the  pub- 
lication of  Conolly's  book.  Within  the 
next  ten  years  similar  works  were  produced 
by  Drs.  Kirkbride,  Cnrwen,  and  E.ay. 

Dr.  Browne,  at  the  Crichton  Institution, 
Dumfries,  in  1854,  made  the  first  attempt 
"  to  educate  the  attendants  upon  the  in- 
sane "  by  a  course  of  thirty  lectures  to  his 
staff.  He  strove  to  get  for  his  patients 
the  ideal  nurse,  and  in  this,  as  in  other 
matters,  he  anticij^ated  many  of  the  best 
ideas  of  the  present  day  ;  but  the  leader- 
ship went  over  to  the  general  hospitals 
when  Florence  Nightingale  took  into  them 
the  good  things  which  she  found  in  the 
sisterhood  system,  by  which  Fliedner  put 
into  practice  the  main  ideas  then  adopted 
by  all  the  leading  alienists. 

The  important  question  of  nursing  and 
attendance  for  the  insane  continued  to  re- 
ceive serious  consideration.  The  Commis- 
sioners in  Lunacy  for  England  made  it  a 


si^ecial  subject  of  comment  and  inquiry  in 
their  report  for  1859.  They  declared  "  that 
the  engaging  of  competent  attendants  of 
good  character,  and  in  some  instances  of 
superior  ediacation,  cannot  be  too  strongly 
insisted  upon  ;"  and  they  endeavoured  "  to 
impress  upon  all  who  are  responsible  for 
the  care  and  treatment  of  the  insane,  the 
paramount  duty  of  adopting  means  for 
securing  the  zealous  service  of  competent 
attendants."  But  the  Commissioners, 
twenty  years  later,  referring  to  their  former 
report,  said  — "  Although  the  care  and 
treatment  of  the  insane  have  in  most 
respects  altered  greatly  for  the  better,  im- 
l^rovement  in  the  character  and  position  of 
attendants  has  not  been  nearly  so  marked," 
and  they  were  still  convinced  that  "  much 
of  the  evil  arises  from  the  insufficiency  of 
wages." 

A  notable  article  on  "  Sisterhoods  in 
Asylums,"  appeared  in  the  Journal  of 
Mental  Science  for  April  1866.  It  advo- 
catedthe  employment  of  women  for  thecare 
of  the  insane  of  both  sexes,  by  having  re- 
course to  the  religious  orders,  or  something 
like  them,  in  which  there  would  be  a  sur- 
vival of  the  better  features  of  the  old 
monastic  system. 

Dr.  Clouston,  in  a  paper  read  before  the 
Medico-Psychological  Association  in  1876, 
lamented  the  unattainableness  of  the  ideal 
asylum  and  asylum  attendants.  (See  In- 
sane, Attendants  on,  p.  694.) 

During  the  ten  years  previous  to  1880, 
the  system  of  infirmary  wards  became 
more  common.  In  those  for  men,  married 
attendants  and  their  wives  were  sometimes 
employed,  and  in  a  few  instances  there 
were  single  women  ;  but  there  did  not  exist 
in  any  asylum  in  the  world  as  recently  as 
that  date,  an  organised  school  for  the 
training  of  nurses  for  the  insane.  Dr. 
Clouston's  stirring  words  stated  the  posi- 
tion to  which  the  alienists  had  come.  It 
was  still,  as  for  many  years,  an  attitude 
of  knowing  what  was  wanted,  and  asking 
how  to  get  it.  The  asylum  physicians 
were  the  first  to  recognise  what  was  re- 
quired, but  they  did  not  get  at  the  prin- 
ciple which  Florence  Nightingale  had  dis- 
covered from  the  general  hospital  point  of 
view.  The  jarinciple  was  that  the  way  to 
get  good  nurses  was  to  give  them  know- 
ledge and  thus  quicken  their  sympathy, 
and  to  attract  intelligence  to  the  service, 
by  giving  it  a  worthy  field  for  its  exer- 
cise. The  alienists,  from  the  asylum  point 
of  view,  only  made  attempts  that  were  not 
sufficiently  organised — the  scope  of  every 
plan  of  teaching  was  too  limited  and  gave 
nothing  that  the  attendant  could  use  else- 
where ;  they  never  got  beyond  the  idea  of 
improving  the  attendants  upon  the  patients 


Nursing 


[     «6i     ] 


Nursing 


immediately  concerned.  In  the  hospitals 
the  nurses  were  fitted  for  a  new  profession. 
The  hospital  was  made  a  school,  and  in 
the  process  of  giving  the  training  it  re- 
ceived its  reward  in  trained  service.  The 
motive  influence  of  a  wholesome  self-inter- 
est was  brought  into  play,  and  the  nurse, 
like  the  physician,  was  asked  for  no  more 
philanthropy  than  she  could  afford  to  give 
while  gaining  self-support  in  the  woi'ld's 
work.  The  career  of  the  asylum  attend- 
ant was  made  to  end  only  in  the  asylum ; 
that  of  the  hosj^ital  nurse  only  began  in 
the  hospital  where  she  was  anxious  to 
learn  her  profession.  The  question  of  the 
inducement  of  better  wages  which  troubled 
the  asylums  and  the  Lunacy  Boards  for 
so  many  years,  was  quickly  disposed  of  in 
the  new  hospital  schools,  and  became  of 
minor  importance.  The  inducement  of  the 
education  offered  was  the  jjotent  factor  in 
the  reform  because  it  opened  the  way  to 
higher  rewards.  Wages  became  nominal 
for  the  major  part  of  the  work,  which  was 
done  by  j^upils,  and  even  an  income  has 
been  derived  from  the  giving  of  instruc- 
tion. The  compensation  to  the  few  quali- 
fied nurses  retained  in  the  hospitals  could 
be  made  satisfactory,  because  they  became 
practically  part  of  the  teaching  staff. 
These  are  principles  which  underlie  all 
practical  nursing  reform. 

The  next  decade  after  1880  witnessed 
the  beginning  of  a  change  in  the  asylums 
that  is  destined  to  become  as  radical  and 
beneficent  as  that  which  has  taken  place 
in  the  general  hospital.  In  January 
1884,  Dr.  Camjibell  Clark  published  in 
the  Journal  of  Mental  Science  the  fii'st 
results  of  his  practical  experiments  in 
training  attendants  in  the  Glasgow  Dis- 
trict Asylum.  Upon  its  being  opened  in 
1 88 1,  having  many  female  patients  with 
serious  bodily  diseases,  he  employed  a 
matron  especially  trained  to  hospital  work, 
and  an  attendant  who  had  been  trained 
in  a  London  hospital.  He  advocated  the 
hospital  idea,  and  taking  ujj  the  subject 
where  Dr.  Olouston  left  off,  he  urged  the 
expediency  and  necessity  of  so  training 
the  attendants,  that  they  would  have 
something  reliable  and  desirable  as  a  per- 
manent occupation,  and  he  argued  that 
*' by  raising  the  value  of  the  trainingtothem 
better  maAerial  tvill  be  attracted  to  the 
work."  Here  is  touched  the  foundation 
principle;  Dr.  Clouston  almost  stated  it 
in  his  proposition — and  better  than  those 
who  preceded  him.  In  Dr.  Clark's  report 
for  1889,  he  speaks  with  rightful  satisfac- 
tion of  his  new  departure  as  having  "  be- 
come an  organised  system  of  our  asylum 
work,'"  and  is  able  to  say  that  many 
asylums  in  this  country  have  given  prac- 


tical effect  to  the  principle  of  s]>ecially 
training  attendants  and  nurses  with  very 
good  results.  Dr.  Clouston's  plan,  de- 
veloped upon  the  reorganisation  of  the 
female  hospital  at  Morningside  in  1883, 
required  that  all  new  attendants  should 
pass  thi'ough  it,  and  be  taught  the  nurs- 
ing of  the  sick  with  bodily  ailments  and 
acute  mental  diseases.  It  is  significant 
that  those  so  instructed  were  reluctant  to 
leave  the  hospital  because  the  duties  were 
more  interesting  than  in  the  ordinary 
wards. 

In  1885  there  was  published  the  excel- 
lent "  Handbook  for  the  Instruction  of 
Attendants  on  the  Insane,"  prepared  by  a 
Committee  of  the  Medico-Psychological 
Association. 

The  ultimate  development  of  this  im- 
portant reform  is  stated  at  length  in  the 
Journal  of  Mental  Science  for  October 
1890.  It  consists  of  a  report  by  the  com- 
mittee appointed  by  the  Medico-Psycholo- 
gical Association  of  Great  Britain  and 
Ireland,  to  inquire  into  the  question  of 
systematic  training  of  attendants  in 
asylums  for  the  insane.  {See  Insane, 
Attendants  on,  p.  692.) 

In  New  South  Wales  effective  work  is 
reported  hy  Dr.  Norton  Manning,  the 
Inspector  General.  It  was  begun  in  1885 
by  the  ofl&cial  publication  of  a  manual  on 
the  care  and  treatment  of  the  insane  for 
instruction  of  attendants  and  nurses. 

The  contemporary  movement  in 
Amei'ica  is  equally  interesting  and  in- 
structive. The  writer  of  this  article  being 
familiar  with  the  work  there,  can  best 
illustrate  by  reference  to  it,  the  variety  of 
method  in  the  organisation  and  conduct 
of  training  schools.  The  first  effective 
American  work  in  the  general  hospitals 
began  in  1873.  Under  the  stimulation  of 
this  the  McLean  Asylum  employed  a 
trained  nurse,  an  unmarried  woman,  in 
the  common  wards  for  men  as  early  as 
1877.  It  was  determined  in  1879  ^o  '^^' 
tablish  there  a  fully  organised  system  of 
training  nurses  on  the  plan  of  the  schools 
of  the  general  hospitals,  in  one  of  which 
the  superintendent  of  the  asylum  had  just 
previously  established  such  a  school.  The 
problem  having  thus  been  studied  prac- 
tically from  the  hospital  point  of  view,  the 
motive  forces  were  recognised.  The  pre- 
parations wei'e  begun  in  1880  and  a  num- 
ber of  hospital-trained  nurses  were  em- 
ployed, but  with  indifferent  success,  they 
having  acquired  a  preference  for  "bodily" 
nursing.  The  practice  of  placing  unmarried 
women  as  nurses  in  the  common  wards  for 
men  was  made  successful.  General  hos- 
pital methods  were  introduced  with  some 
practical  class  work,  such  as  massage,  &c.. 


Nursing 


[    862    ] 


Nursing 


and  special  difficulties  were  overcome  that 
seemed  to  stand  in  the  way  of  accom- 
plishing the  purpose  of  giving  instruction 
in  general  nursing.  The  asylum  school 
was  formally  established  in  1 882  upon  the 
appointmeut  of  a  nurse  with  both  asylum 
and  hospital  training  as  the  head  of  it. 
Subsequently  a  more  successful  arrange- 
ment was  gained  by  sending  the  super- 
visor, who  had  been  long  in  the  service,  to 
a  general  hospital  to  learn  the  technique 
of  school  work.  She  was  then  promoted 
and  became  an  excellent  superintendent  of 
nurses  and  alsomati'on.  Eegular  instruc- 
tion was  given  in  cooking  for  the  sick,  and 
later  in  physical  exercise  and  medical 
gymnastics. 

In  a  little  over  three  years  six  nurses, 
who  had  been  under  training  three  or  four 
years,  were  graduated  as  qualified  in 
general  bodily  nursing  as  well  as  special 
nursing  of  the  insane.  The  training  of 
male  nui-ses  was  begun  in  1886  and  the 
first  five  were  graduated  in  1888.  In  1890 
the  i^roduct  of  the  school  reached  an  aggre- 
gate of  92  nurses,  70  women  and  22  men. 
In  July  1890  there  remained  in  the  service 
22  graduate  nurses,  12  women  and  10  men. 
About  32  were  engaged  in  private  nursing, 
all  but  4  being  women,  and  others  had 
married,  gone  to  their  homes  or  into  other 
work.  Three  had  taken  responsible  posi- 
tions in  other  institutions  as  teachers  and 
matrons.  The  plan  of  development  of  the 
McLean  Asylum  may  be  briefly  stated  as 
(first)  the  establishment  of  a  complete 
organisation  for  teaching  in  the  practical 
work  and  classes,  exercises  in  text-books. 
Sec,  and  (secondly)  the  final  addition  of  per- 
sonal instruction  by  the  medical  stafi"  by 
means  of  didactic  lectures  and  demon- 
strations. The  first  step  required  only 
some  extra  work  from  the  superintendent 
of  nurses  and  the  supervisor,  but  they 
were  carefully  prepared  for  it  long  before 
the  formal  work  began.  The  second  step 
was  easier  and  was  complementary  to  the 
main  organisation  of  the  school  system. 

The  McLean  Asylum  has  not  been  alone 
in  this  labour  in  America.  At  the  Buffalo 
Hospital,  at  the  Willard  Asylum,  at  the 
Kankakee  Asylum,  at  Essex  Asylum,  at 
the  Hampshire  Asylum,  at  the  Danvers 
Hospital,  similar  work  has  been  under- 
taken. 

But  the  results  obtained  at  the  McLean 
Asylum  are  typical  of  those  gained  in  all 
the  asylums  under  the  new  system.  The 
trained  nurses  preferring  to  remain  in 
asylum  work  may  eventually  constitute 
about  one-third  of  the  whole  service  as  the 
substantial  part  of  the  nursing  staff  be- 
comes more  and  more  permanent.  The 
other  two-thirds  include  pupils  of  the  first 


and  second  years.  This  system  of  classi- 
fication leads  the  head  nurses  to  regard 
the  pupils  as  subjects  for  instruction  and 
correction  and  to  feel  they  have  a  share  of 
responsibility  in  this  respect  and  as  to  their 
own  example.  The  puinh  learn  the  rigid 
ivay  from  the  outset.  Minor  faults  are 
quickly  brought  to  light.  The  current 
courses  of  instruction,  besides  the  techni- 
cal teachings,  continually  stimulate  the 
acquirement  of  the  qualifications  most 
desirable  in  a  nurse.  In  fact,  the  service 
largely  disciplines  itself.  The  employment 
of  ward-maids  to  do  the  drudgery  leaves 
the  nurses  more  free  for  their  legitimate 
duties  and  for  companionship,  which 
should  be  the  rule. 

There  is  now  proof  to  demonstration 
that  these  asylum  schools  can  efi"ectively 
teach  general  nursing,  both  medical  and 
surgical,  particularly  the  former.  This 
implies  the  hospitalisation  of  asylums, 
and  is  of  immense  importance  in  pro- 
moting the  coming  asylum  reform.  The 
plan  of  organisation  most  likely  to  give 
assured  results  is  undoubtedly  that  of 
providing  at  the  outset  an  adequate  teach- 
ing staff  of  trained  women  and  adopting  a 
definite  curriculum  of  study,  the  work  of 
the  medical  officers  being  complimentary. 
This  is  the  plan  of  the  general  hospitals. 
Another  way  is  to  begin  with  lectures. 
This  plan  may  be  pushed  to  success,  but 
history  shows  how  many  failures  there 
have  been. 

The  greater  part  of  the  service  should 
always  be  done  by  pupils.  The  life  of  the 
school  depends  on  keeping  its  work  of  teach- 
ing active,  not  letting  the  service  become 
clogged  by  too  many  lingering  graduates. 
Eagerness  to  go  into  private  nursing 
should  be  fostered  in  every  way.  The 
graduate  should  have  the  feeling  of  being 
possessed  of  the  ability  to  undertake  any 
general  nursing.  There  is  then  the  cour- 
age to  seek  it. 

It  is  important  that  the  asylum  schools 
should  press  their  products  upon  the  pub- 
lic. They  may  take  advantage  of  the 
demand  created  by  the  hospital  schools. 
When  their  value  is  known  the  demand  for 
the  asylum-trained  nurses  will  stimulate 
and  benefit  the  schools  that  trained  them. 
It  should  never  be  forgotten,  moreover, 
that  all  this  is  but  the  means  to  a  greater 
end.  The  duty  of  the  asylums  to  promote 
the  public  good  demands  their  best  efforts 
to  diffuse  a  general  knowledge  of  the 
mental  aspects  of  illness,  of  mental  hy- 
giene and  the  proper  early  care  of  the 
insane. 

It  will  be  long  before  the  movement  of 
nursing  reform  will  pass  the  first  stage  in 
which  the  supply  is  creating  the  demand. 


Nursing 


[     863     ] 


Nymphomania 


It  is  conclusive  that  every  hospital  and 
asylum  must,  for  mere  economy's  sake, 
train  its  own  nurses.  No  asylum  can 
much  longer  hold  aloof  from  this  move- 
ment. Such  is  the  breadth  of  the  field 
in  which  the  asylums  are  beginning  to 
do  this  new  work  and  thus  better  repay 
their  cost,  that  while  they  are  simply  per- 
fecting their  own  internal  service,  they 
are  promoting  most  effectively  preventive 
psychiatry.  These  ideas  are  not  simply 
Utopian.  They  result  from  the  observa- 
tion of  what  has  happened  during  the  last 
eighteen  years,  while  the  writer  was  di- 
rectly engaged  in  establishing  training 
schools  in  the  general  hospital  and  in  the 
asylum.  He  draws  the  following  conclu- 
sions :  First,  The  teaching  should  be 
systematic,  definite  in  its  aim,  and  com- 
prehensive enough  to  give  the  nurse  htio-w- 
Icdge  of  her  pi-oper  work.  Then  an  en- 
lightened interest  is  enlisted,  repugnance 
is  overcome,  sympathy  is  quickened  by 
knowing  how  to  relieve  suffering,  and  her 
motherliness  does  the  rest.  She  knows 
the  tcrong  of  withholding  sympathy  and 
faithful  care.  Secondhj,  The  plan  of  train- 
ing should  include  the  intention  of  making 
the  pupil  successful  in  private  nursing. 
While  the  hospital  and  asylum  exist 
primarily  for  the  benefit  of  the  patients, 
the  school  within  them  for  its  own  sake 
should  do  thoroughly  the  work  of  a 
school.  The  interests  of  the  asylum  and 
the  school  are  one.  The  better  the  nurse 
is  qualified  for  all  the  manipulations  of 
nursing,  the  better  she  is  for  the  asylum 
in  which  she  is  taught.  The  value  of  the 
professional  training  is  made  so  great  to 
the  nurse  as  to  stimulate  a  cheerful  doing 
in  the  best  way  of  what  is  expected  of  her. 
These  are  the  lessons  to  be  learnt  from 
the  history  of  nearly  a  century  of  gradual 
amelioration  in  the  condition  of  the  insane 
since  Pinel  and  Tuke  recognised  the  im- 
portance of  humane  i^ersonal  attendance. 
It  is  to  be  hoped  that  a  liberal  interpreta- 
tion will  be  put  upon  the  maximum  of 
requirements  of  the  Medico-Psychological 
Association  of  Great  Britain  in  regard  to 
the  training  of  attendants.  The  principle 
that  history  teaches  is  that  general  train- 
ing in  nursing  for  the  nurse,  and  in  gen- 
eral medicine  for  the  physician,  are  alike 
essential  as  a  proper  basis  for  special 
practice  in  either  case.  The  danger  of 
keeping  up  the  old  barriers  to  the  progress 
of  reform  lies  in  a  Umitation  in  the  train- 
ing of  medical  nursing  when  "  all  the  mani- 
pulations "  may  be  taught  so  easily.  The 
characteristic  of  the  American  plan  is  that 
the  attendant  should  be  made  a  nurse, 
and  that  the  nurse  should  be  assured  of 
such  a  recognition  as  will  command  em- 


ployment in  her  calling.  The  main  re- 
liance is  not  to  be  upon  "  sufficiency  of 
wages,"  or  "  religious  vows  to  do  good 
works,"  upon  the  taking  of  hoiiest- 
hearted  human  nature  as  we  find  it,  re- 
specting its  right  to  a  wholesome  self- 
interest,  keeping  to  the  conservation  of 
values  in  the  giving  and  taking  of  philan- 
thropic personal  service,  imparting  know- 
ledge to  the  woman,  and  thereby  revealing 
the  way  to  the  exercise  of  a  natural  mother- 
liness, and  having  due  regai-d  for  the  duty 
of  hospital  and  asylum  to  the  public  that 
supports  them.  These  are  the  common 
sociological  principles  that  underlie  the 
whole  matter.  E.  Cowles. 

lli'cferoiccs. — Haiulliook  for  the  Instnu-tion  of 
Attendants  on  the  Insane^  prepared  by  the  sulj- 
Coiiiniittei'  of  the  IMcdico-rsychoIogical  Association 
of  (ircat  liritaiu  and  Ireland,  aiiiioiiitcd  at  a  branch 
uiei'tin^;'  liehl  in  (iias^^ow  nn  the  21st  of  Fel).  1884  ; 
autliors,  A.  C.  Chirk,  C.  M.  Campbell,  A.  K.  Turn- 
Ijull,  A.  K.  Urquhart,  octa\-o,  64  pp.  ;  London  : 
liailliere  and  Co.,  1885.  Nnrsins;-  Keform  for  tlie 
Insane,  American  Journal  of  Insanitj',  October 
1887.  Training-  Schools  of  the  Future ;  .Seven- 
teenth Annual  Report  of  the  National  Conference 
of  Charities  and  Correction  at  Baltimore,  i8go,  by 
the  writer  of  this  article] 

TIYCTEGERSIA  {vv^,  night ;  eyepcrty, 
a  waking  or  rousing).  Nocturnal  excite- 
ment. A  rousing  in  the  night.  (Fr. 
nyctecjersie.) 

WYCTEPIiATXCTOS,  WYCTI- 

PIiASTCTUS,  M^YCTIPOXOS,  NYCTl- 
POI.US,  NYCTIPORUS  {vi^,  night ; 
Trkavdonai,  TToXevco,  and  nopevofiai,  I  wan- 
der or  march).  Terms  for  one  who  walks 
during  sleep.  (Fr.  somnamhule ;  Ger. 
Nachtwandler.) 

M-YCTOBADZA,  N-YCTOBASZ5  {vv^, 
night ;  ^aivco,  I  step).  An  old  term  for 
sleep-walking.     (Fr.  nyctohase.) 

ITYCTOBATESZS,  ITYCTOBATZA 
[vv^,  night;  (iareoi,  I  move).  Sleep- 
walking. 

NYCTOPHON-ZA  {vv^,  night  ;  (poivrj, 
the  voice).  Term  for  the  loss  of  voice 
during  the  day ;  an  occasional  symptom 
in  hysteria.  (Fr.  nyctophonie ;  Ger. 
Tagstimmlosiglceit.) 

TrYMPHOIMCAirZA.  —  Definition.  — 
Under  this  term  we  understand  a  morbid 
condition  peculiar  to  the  female  sex,  the 
most  prominent  character  of  which  con- 
sists in  an  irresistible  impulse  to  satisfy 
the  sexual  appetite  — the  same  patho- 
logical condition  which  in  the  male  has 
received  the  name  .of  satyriasis  (q.v.). 
Some  alienists  have  with  Esquirol  at- 
tempted to  distinguish  erotic  insanity  of 
purely  cerebral  origin  from  an  irresistible 
impulse  caused  by  morbid  irritation  of  the 
reproductive  organs.  This  thesis  may  be 
maintained  as  a  theory,  and  cases  may  be 
quoted  to  support  it.     It  would,  however, 


Nymphomania 


[    864    ] 


Nymphomania 


be  rasli  to  affii'm  that  it  is  always  so,  and 
the  proof  is  ditScultto  establish.  Nobody 
disputes  that  morbid  love  may  be  entirely 
intellectual  or  platonic,  and  may  have  as 
its  object  a  living  or  dead  person,  a.souvenir, 
a  statue,  or  a  picture,  but  in  addition  to 
this,  there  exists  a  violent,  irresistible 
sexual  appetite  which  must  be  satisfied, 
regardless  of  age  or  any  other  considera- 
tion. Of  these  two  kinds  of  phenomena, 
the  former  is  the  consequence  of  a  disorder 
in  which  the  brain  predominates  over  the 
sexual  organs  ;  the  latter  is  the  result  of 
a  reverse  action  of  the  sexual  organs  upon 
the  brain,  but  with  reciprocal  re-action, 
without  our  being  always  able  to  deter- 
mine, however,  the  starting-point  with  suf- 
ficient precision.  ISTymphomania  must 
not  be  considered  as  a  morbid  entity,  but 
rather  as  a  form  or  variety  of  mental  de- 
rangement connected  with  affections  which 
may  differ  as  regards  their  seat,  nature, 
and  development.  We  describe  it  as  an 
impulse,  even  if  the  doctrine  of  pure  im- 
pulsive monomania  has  disappeared  from 
mental  pathology.  Its  aetiology  is  the 
most  interesting  part  of  its  history.  The 
appetite  in  question  is  not  the  same  in  all 
women.  There  is  also  a  difference  betwen 
the  sexes,  and  there  are  racial  differences 
also.  In  some  women  it  appears  early, 
and  remains  to  a  very  advanced  age  ;  in 
others  it  develops  slowly,  is  dormant,  and 
becomes  prematurely  extinct,  so  that  such 
women  never  reach  their  full  sexual  de- 
velopment. Longitude  and  latitude  have 
but  a  limited  effect  on  this  function,  but 
a  high  temperature,  together  with  stimu- 
lating food,  intensifies  it.  Thus,  the  negro 
in  his  tent  under  the  burning  rays  of  the 
sun,  and  the  Esquimaux,  during  the  long 
winter  nights  in  his  over-heated  hut, 
equally  give  themselves  up  to  repulsive 
excesses  in  the  midst  of  orgies  which  con- 
stitute their  festivals ;  the  civilised  man 
obeys  the  same  instincts  when  his  imagi- 
nation,excitedby  sensuous  representations, 
and  his  stomach  filled  with  exciting  ali- 
ment, have  aroused  his  animal  passions. 
Temperature,  food,  surroundings,  and 
example  increase,  therefore,  the  activity  of 
this  sense,  and  moderate  excitement  is  too 
often  followed  by  an  irresistible  morbid 
impulse.  Education  may  diminish  or  aug- 
ment the  appetite,  and  hence  impressions 
received  in  childhood,  and  especially  at 
puberty,  have  a  great  influence  on  its 
development ;  the  innate  morbid  germs  or 
proclivities  do  not  necessarily  thrive,  but 
may  be  easily  fostered.  On  the  one  hand, 
a  pathological  predisposition,  wisely  re- 
stricted, may  be  even  turned  to  the  benefit 
and  preservation  of  the  species,  whilst  on 
the  other  hand,  if  not  moderated,  it  ter- 


minates in  the  premature  extinction  of  the 
individual,  or  in  the  degeneration  of  the 
race.  The  final  result  often  depends  upon 
accidental  causes  :  the  woman,  as  a  child 
or  an  adult,  very  easily  receives  impres- 
sions from  her  environment ;  she  uncon- 
sciously receives  the  motive  of  her  actions 
from  her  reading,  from  pictures,  statuary, 
plays,  or  daily  scenes.  When  the  neuro- 
pathic condition  affects  and  dominates  her, 
all  the  impressions  appeal  to  her  morbidly 
impressionable  state,  and  she  of  ten  becomes 
the  slave  of  her  instincts. 

Nymphomania  frequently  appears  in 
the  course  of  various  mental  disorders, 
differing  in  seat  and  lesion :  idiocy  and 
its  varieties,  mania,  circular  insanity,  hy- 
pochondriasis, hysteria,  epilepsy,  general 
paralysis,  hypochondriacal  insanity,  and 
brain  degeneration.  Exceptionally,  it  per- 
sists during  the  whole  duration  of  the 
princij^al  disorder,  but  generally  it  is  only 
a  transitory  phenomenon.  Nymphomania 
is  frequent  at  the  commencement  of  dif- 
ferent forms  of  insanity,  but  its  duration 
is  short ;  it  is  frequently  observed  during 
the  first  two  stages  of  general  paralysis, 
and  seems  to  be  directly  connected  with 
lesions  of  the  brain  and  spinal  cord.  After 
the  nerve- cells  and  fibres  have  become 
atrophied,  sexual  impotency  ensues,  and 
we  no  longer  observe  erotic  insanity  or 
sexual  excitement.  Nymphomania  is  ob- 
served as  a  temporary  phenomenon  in  old 
women  whose  intellect  has  become  deranged . 
and  who  later  on  are  affected  with  cerebral 
softening  and  encephalitis  around  a  local- 
ised lesion.  In  religious  insanity  of  mystic 
form,  erotic  insanity  amounting  to  an 
irresistible  impulse  is  by  no  means  rai'e  ; 
later  it  is  succeeded  by  remorse  which 
causes  the  patient  most  painful  suffer- 
ing. 

The  affections  of  the  spinal  cord,  my- 
elitis, incipient  softening,  and  locomotor 
ataxia,  cause  the  same  sexual  disorders 
(reflexly),  which  we  have  described  as  re- 
sulting from  cerebral  disease. 

Causes. — Nymphomania  may  have  as 
a  cause  disease  of  the  genital  apparatus  : 
eruptions  on  the  labia  majora  and  minora, 
inflammation  of  the  vagina,  uterus,  Fallo- 
pian tubes,  and  organic  affections  of  the 
uterus  and  the  commencement  of  the 
vagina.  Women  given  to  the  use  of  opium, 
morphia,  and  haschisch  may,  in  the  same 
way  as  men,  exhibit  sexual  excitement  bor- 
dering on  nymphomania — a  condition  in 
which  their  imagination  dwells  in  conse- 
quence upon  erotic  ideas  and  images. 
Later  on,  when  the  intoxication  has  become 
chronic,  the  sexual  appetite  slowly  dimin- 
ishes and  becomes  extinct ;  the  annihila- 
tion of  the  intellectual  faculties,  combined 


Nymphomania 


[    865    ] 


Nymphom^ania 


with  general  exhaustion,  becomes  com- 
jilete. 

Nymphomania  presents  various  degrees 
of  symptoms.  At  first  it  shows  itself  by 
simple  excitement  of  the  reproductive 
organs,  which  is  brief,  and  upon  which  the 
will  still  exercises  control ;  subsequently 
there  is  irresistible  erotic  impulse.  The 
patient's  expression  is  bright,  the  face 
turgid,  the  respiration  quickened,  the 
sexual  organs  are  congested,  and  the  ges- 
tures amatory.  The  appetite  demands 
satisfaction  without  regard  to  age  or 
person;  the  desire  may  even  lead  to 
murder  if  resistance  is  offered  to  the 
patient's  desires.  The  duration  and  ter- 
mination of  such  a  disorder  depends  upon 
the  primary  cause  ;  most  frequently  tem- 
porary, it  becomes  a  permanent  and  pre- 
dominant phenomenon  in  certain  idiots 
and  chronic  lunatics,  and  causes  general 
weakening  with  disorders  of  the  bodily 
functions  ;  diseases  and  traumatisms  of 
the  genital  organs  are  the  consequence ; 
very  exceptionally  death  is  the  direct  re- 
sult ;  if  it  occurs,  it  is  in  consequence  of 
some  accidental  affection,  for  the  enfeebled 
organism  is  more  disposed  to  contract  any 
malady. 

Various  intoxicants  are  apt  to  produce 
nymphomania  :  i^oisoning  by  cantharides 
was  formerly  supposed  to  have  this  effect, 
but  subsequently  it  was  denied  ;  irritation 
of  the  genito-urinary  apparatus  is  noticed 
after  the  absorjition  of  cantharides,  but  it 
does  not  cause  eroticism.  This  subject 
requires  fresh  investigation,  as  the  obser- 
vations reported  by  former  observers  can 
be  interpreted  in  various  ways.  It  is 
well  known  that  fatal  poisoning  by  can- 
tharides causes  painful  turgescence  of  the 
generative  organs  without  any  sexual  im- 
pulse. From  the  moment  we  are  able  to 
prove  that  nymj^homania  is  accompanied 
by  a  mental  disorder  or  is  its  immediate 
consequence,  a  nymphomaniac  must  be 
declared  to  be  irresponsible  from  a  legal 
point  of  view,  if  under  such  circumstances 
she  obeys  an  irresistible  morbid  impulse. 
As  a  general  rule,  the  man  solicits  and  the 
woman  complies,  but  it  may  be  that  she 
is  the  one  to  solicit.  It  would  be  unjust 
to  attribute  all  the  actions  of  libertinism 
in  women  to  morbid  proclivities ;  i:>er- 
verted  immorality  often  accomjolishes 
actions  which  the  most  vivid  imagination 
would  scarcely  be  able  to  conceive,  and 
such  actions  fall  within  the  reach  of  the 
law,  if  not  caused  by  mental  derangement. 
But  insanity  must  be  suspected  and  looked 
for,  if  a  woman  after  a  long  life  of  pro- 
priety and  modesty  gives  herself  suddenly 
to  debauchery,  thus  bringing  scandal  and 
contempt   upon  her  family  and   herself. 


This  sudden  change  of  conduct  frequently 
finds  its  explanation  in  commencing  or- 
ganic lesions  or  in  an  insanity  as  yet 
doubtful,  but  which  will  soon  become  ob- 
vious. General  i)aralysis  in  its  com- 
mencement often  produces  in  women  a 
condition  of  sexual  excitement  liable  to 
become  nymphomania ;  such  excitement 
strikes  the  observer  from  its  exaggeration, 
whilst  the  insanity  remains  obscure  or 
passes  by  altogether  unrecognised.  Nurses 
and  servants,  to  whom  the  care  of  chil- 
dren is  confided,  should  be  kept  under 
strict  surveillance  by  the  parents,  because 
it  is  not  uncommon  that  under  the  influ- 
ence of  hysteria  or  of  a  morbid  disposi- 
tion they  subject  the  children  to  manipu- 
lations which  affect  their  health  and  com- 
promise their  existence.  Many  cases 
have  been  divulged,  but  how  many  hapj^en 
of  which  we  hear  nothing !  A  habit  of  our 
times,  which  is  far  spread  and  most  dan- 
gerous for  our  children,  is,  not  to  keep  the 
dogs,  which  are  now  in  almost  every  house, 
in  the  yard  or  in  the  stables,  but  to  allow 
them  to  come  into  the  house  and  even 
into  the  bed  ;  their  habit  of  introducing 
their  tongues  everywhere  causes  the  child 
to  contract  habits  against  which  it  is 
unable  to  strive,  whilst  the  parents  are  too 
much  absorbed  in  their  pursuits  to  notice 
what  passes  around  them.  For  many 
years  a  whole  literature  of  romance  and 
j^lays  has  been  occupied  in  the  description 
of  Lesbic  love,  to  the  great  damage  of  young 
girls  and  neuropathic  women  ;  curiosity  at 
first  attracts  and  soon  misleads  them ;  the 
sensation  experienced  enslaves  them,  and 
then,  aided  by  the  use  of  morphia,  ether, 
and  cocaine,  nymj^homania  establishes 
itself.  The  word  has  spread  from  the 
unfortunates  to  the  women  of  the  theatres, 
and  from  thence  has  taken  possession  of 
unoccupied  women  of  all  classes  of  society 
with  unsatisfied  desires. 

Hypnotism  is  stated  to  have  been  used 
for  the  purpose  of  committing  crimes  on 
women,  and  this  may  be  done  under  hyp- 
notism as  well  as  any  other  anaasthetic.  it 
is  useful  to  keep  here  in  mind  that  simu- 
lation may  always  be  expected  in  hysteri- 
cal women,  and  that  it  is  well  to  remem- 
ber the  possibility  of  its  existence.  We 
cannot,  however,  discuss  these  questions 
here,  and  it  must  therefore  suffice  merely 
to  indicate  them.  A  hypnotiser,  who, 
by  rejieated  manoeuvres,  has  tried  the  dis- 
position of  his  subject  (a  woman  easy  to 
hypnotise),  might  experience  little  resist- 
ance if  he  wished  to  excite  her  amativeness. 
His  responsibility  is  exactly  the  same  as 
that  of  an  individual  who  abuses  a  weak 
imbecile  or  idiotic  person. 

Intercourse  calms  the  natural  want  but 


Nystagmus 


[    866    ]     Obsession  and  Impulse 


does  not  cure  the  morbid  excitement. 
Marriage  only  results  in  introducing  un- 
happiness  into  two  families,  and  in  addi- 
tion to  this  a  child  resulting  from  the 
union  will  probably  be  a  source  of  new 
pathological  conditions.  Hence  absten- 
tion from  marriage  is  the  best  advice  to 
give  both  for  the  individual  and  for 
society. 

The  treatment  must  be  directed  to  the 
principal  disease  which  causes  nympho- 
mania. Anaphrodisiacs  are  useful,  with- 
out, however,  being  very  effective  ;  bro- 
mide of  camphor  and  of  potassium,  Sitz 
baths  and  sedative  lavements,  moderate 
exercise,  regular  work,  life  in  the  open  air, 
and  a  good  physical,  moral  and  intellec- 
tual hygiene  should  be  prescribed. 

As  regards  surgical  operations,  clitori- 
deetomy,  nymphotomy,  circumcision,  and 
oophorectomy,  are  useless,  and  some  of 
them  are  even  to  be  condemned.     It  is 


evident  that  the  cause  of  nymphomania  is 
a  lesion  or  a  disease  of  the  cerebro-spinal 
axis.  To  revive  here  an  old  subject  of 
debate  would  serve  no  useful  purpose.  It 
has  been  demonstrated  in  important  dis- 
cussions in  medical  societies,  the  authority 
of  which  is  indisputable.  Observations 
made  on  different  sides,  seem  to  confirm 
their  conclusions. 

GUSTAVE  BOUCHEREA.TJ. 

[References. — Esquirol,  Maladies  mentale.s,  torn, 
ii.  Foville,  Nouveau  Dictioiiuaire  de  Sledecine  et 
deCliiruryie pratique,  Jaccoud,tom.  xiv.  Guislain, 
Logons  Orales,  toui.  i.  Morel,  Etudes  cliniques, 
toni.  ii.     Trelat,  La  Folie  lucidc.] 

nrvSTAGMUS  (vvcTTaynos,  nodding  of 
the  head  when  sleepy).  A  constant  in- 
voluntary movement  of  the  eyeballs, 
generally  horizontal,  observed  in  some 
forms  of  disease  of  the  nervous  system. 
May  occur  in  the  insane,  but  is  not 
pathognomonic.     (Fr.  nystagme.) 


o 


OAF  (A.S.  otigh,  an  elf).  A  fool,  or 
idiot,  so  called  from  the  notion  that  all 
idiots  are  changelings  left  by  the  fairies 
in  the  place  of  the  stolen  ones  (Brewer, 
"Phrase  and  Fable"). 

OBJECT  COM'SCZOVSN'ESS.  —  The 
consciousness  of  the  presence  of  an  object 
which  is  really  at  the  time  affecting  the 
sensation  of  the  observer.  In  this  mental 
state,  that  which  occupies  consciousness 
is  an  object  contemplated  as  something 
belonging  to  the  non-ego.  Objective 
science  is  the  theory  of  the  known. 

OBIilvzo  {obliriscor,  1  forget).  A 
word  used  occasionally  in  psychological 
medicine  for  forgetfulness  or  lethargy. 
(Fr.  oublier ;  Ger.  Vergessen.) 

OBSruBZI. ATZOM- '  (ob,  towSLYds  ;  vu- 
bilo,  I  am  cloudy).  A  cloudiness.  The 
word  is  used  to  express  such  a  state  of 
mind  as  that  immediately  preceding  syn- 
cope or  death.  The  term  is  also  applied 
to  giddiness.  (Fr.  obnubilation;  Ger. 
Umtvolkung.) 

OBSESSioir. — In  the  occult  sciences, 
"  obsession  "  is  the  state  of  a  person  tor- 
mented by  a  demon,  while  "  possession  " 
indicates  the  permanent  sojourn  of  the 
devil  in  the  body.  It  is  also  used  in  the 
present  day  to  mean  the  haunting  of  a 
person's  mind  by  a  dead  person's  spirit  (Soc. 
for  Psych.  Research.)  In  psychological 
medicine  it  is  synonymous  with  Impeka- 
TiYE  Ideas  {q.r.). 

OBSESSZOir,     AM-D    IMPUI.SE     Zia* 

GENERA Zi.  —  Obsession    and    impulse 


are  two  phenomena  observed  in  normal 
conditions  and  forming  a  part  of  cerebral 
biology. 

Every  cerebral  manifestation,  either  of 
the  intellect  or  of  the  affections,  which  in 
spite  of  the  efforts  of  the  will,  forces  itself 
uiiontiie  mind,  tlms  interru]jting  for  a.  time, 
or  in  an  intermittent  'tnanner,  the  regular 
course  of  association  of  ideas,  is  an  ob- 
session. Every  action  consciously  a^cconi- 
plished,  %ohich  cannot  be  inhibited  by  an 
effort  of  vjill,  is  due  to  an  impulse. 

Impulse  bears  the  same  relation  to  acts 
which  obsession  does  to  ideas.  Obsession 
may  exist  alone  ;  impulse  is  mostly  the 
consequence  of  a  series  of  obsessions.  The 
two  phenomena  are  connected  with  each 
other  by  means  of  the  psychological  pro- 
cess, which  always  connects  actions  with 
cerebral  life  ;  thought  is  transformed  into 
act ;  the  idea  shows  itself  externally  by  a 
series  of  muscular  actions.  And  like  the 
idea  or  group  of  ideas  oi-iginating  them, 
this  series  of  actions  could  not  be  in- 
hibited by  the  will.  In  reality,  these  two 
physiological  conditions  are  rare  :  we  may 
even  say,  that  without  having  a  distinctly 
pathological  character,  they  indicate  gene- 
rally a  temporary  derangement  of  the  mind. 
One  centre  cannot  work  for  a  long  time 
isolatedly  in  an  individual  who  is  other- 
wise sane,  but  suffers  from  impotency  of 
will,  without  causing  profound  derange- 
ment in  the  regular  operations  of  the 
intellect,  the  result  of  which  will  be  a  state 
of  suffering,  and  consequently  a  patho- 


Obsession  and  Impulse         [    867    ]         Obsession  and  Impulse 


logical  condition.  In  a  normal  individual, 
obsession  and  impulse  are  the  consequence 
of  a  violent  irritation  of  certain  centres, 
transferred  by  molecular  vibrations,  which 
continue  for  a  vai-iable  length  of  time, 
gradually  decreasing  until  the  primordial 
irritation  is  exhausted.  We  remind  the 
reader  of  the  impulses  of  passion,  of  those 
which  follow  violent  excitement  of  the 
mind,  and  strong  or  exaggerated  affection, 
ttc.  ;  the  violence  of  the  emotional  phe- 
nomenon is  so  great  that  the  reaction 
comes  on  suddenly  before  the  will  has  time 
to  exercise  its  inhibitory  influence ;  such 
are  the  impulses  following  a  sudden  out- 
burst of  anger  and  the  impulsive  actions 
caused  by  excessive  love,  &c. 

What  are  the  physiological  conditions 
accompanying  these  phenomena?  The 
regular  succession  of  operations  of  the  in- 
tellect is  normally  this:  an  idea  arises 
which  is  logically  connected  with  a  series  of 
associations  of  ideas,  or  with  a  sensation, 
or  with  an  affection;  the  mind  then  comes 
into  play,  controls  the  idea,  and  the  latter  is 
transformed  into  an  action,  with  interven- 
tion of  the  will.  Let  us  suppose  an  idea  to 
rise  suddenly  within  the  field  of  conscious- 
ness, without  being  apparently  connected 
with  the  usual  generating  factors,  and  let  us 
further  suppose  this  idea  to  be  the  expres- 
sion of  an  exaggerated  irritation  of  the 
centres  which  originate  it,  and  that  its 
incessant  repetition  hinders  the  normal 
course  of  all  former  associations  of  ideas  ; 
volition  will  be  paralysed  and  obsession  is 
constituted. 

Two  elements  are  indispensable  to 
obsession : 

(i)  A  centre  which  suddenly  and  iso- 
latedly  enters  into  function,  its  action  not 
being  required  by  the  mental  needs  of  the 
moment. 

(2)  Temporary  impotence  of  the  will 
to  remove  this  obsession. 

Such  is  obsession  in  the  first  analysis, 
if  now  this  obsession  is  transformed  into 
an  action,  which  by  its  suddenness  inter-, 
rupts  the  regular  succession  of  the  actions 
of  life,  or  if  an  action  or  series  of  actions 
is  suddenly  accomplished,  being  caused 
only  by  exaggerated  affection  or  sensation, 
and  in  consequence  of  its  suddenness  alto- 
gether escaping  the  control  of  the  reason 
— the  will  being  paralysed — an  impulse  is 
constituted. 

To  resume :  loss  of  the  equilibrium  of 
mental  operations,  caused  by  the  exagger- 
ated function  of  a  certain  numberof  centres, 
and  causing  temporarily  impotence  of  will 
— such  are  the  causes  of  obsession  and  im- 
pulse. 

It  is  true,  will  is  neither  annihilated  nor 
inhibited,  because  it  is  not  a  simj^le  faculty 


connected  with  a  definite  gi'oup  of  cells. 
Imagine  a  centi-e,  irritation  would  cause  it 
to  enter  into  action,  but  its  activity  has 
degrees  i)roportionate  to  the  intensity  of 
the  irritation.  In  the  normal  condition  of 
cerebral  equilibrium,  this  irritation  never 
exceeds  a  certain  degree,  which  allows  the 
faculty  of  will  to  exercise  its  inhibitory 
influence.  If  the  primary  irritation  ia 
exaggerated,  the  activity  of  the  centre 
excited  will  also  be  exaggerated,  and  sur- 
passing the  normal  limit,  will  continue  for 
some  time  and  escape  the  controlling 
action  of  the  will ;  the  normal  equilibrium 
will  be  suspended  for  the  time  being.  We 
see  that  in  this  case  the  will  appears 
neither  weakened  nor  paralysed,  but,  its 
energy  being  in  the  normal  state,  it  is  un- 
able to  strive  efficiently.  Let  us  now  sup- 
pose this  primary  irritation  to  be  still  more 
exaggerated,  and  to  be  specially  favoured 
by  the  susceptibility  of  the  individual, 
then  the  activity  of  the  centre  will  assume 
a  still  more  lasting  intensity,  the  pheno- 
menon will  be  followed  by  other  conditions 
which  we  are  about  to  study,  and  the 
pathological  condition  in  question  is  con- 
stituted. We  then  recognise  between  the 
physiological  and  pathological  phenomena 
only  a  difference  in  degree,  the  cause  of 
which  lies  in  an  innate  cerebral  defect. 

Physiological  obsession  and  impulse  are 
incidents  without  importance  in  intellec- 
tual life.  They  appear  as  a  temporary 
difficulty.  The  jDcriodical  return  of  the 
obsession  is  troublesome,  but  the  will  is 
not  absolutely  disarmed.  On  the  other 
hand  the  patient  easily  directs  his  atten- 
tion to  another  point.  With  regard  to 
impulse,  the  will  is  comi^letely  annihilated, 
for  it  appears  with  such  suddenness  that 
the  mind  becomes  aware  of  it  only  at  the 
moment  it  is  accomplished,  and  the  will 
has  not  had  time  to  intervene ;  but,  like 
obsession,  it  is  followed  by  only  slight 
moral  suffering.  After  the  deed  has  been 
accomplished  the  mental  condition  is  again 
quite  normal. 

What  is  psychologically  necessary  in 
order  that  ^physiological  obsession  and  im- 
pulse should  become  morbid  syndromes  ? 
Let  us  suppose  that  these  two  phenomena, 
instead  of  remaining  isolated  facts  in  the 
mental  pi'ocesses,  assume  considerable  im- 
portance, and  that  their  incessant  per- 
sistency  and  repetition  during  a  long  time 
make  the  constant  fatigue  a  condition  of 
actual  suffering.  Let  us  also  suppose  that 
obsession  and  impulse  instead  of  originat- 
ing in  an  idea,  sentim^,nt,  or  a  trifling  sen- 
sation, spring  from  eccentricity,  perverted 
affections  and  abnormal  sensations,  suici- 
dal impulse,  sexual  perversion,  &c.,  which 
represent  so  many  pathological  conditions 


Obsession  and  Impulse        [    868    ] 


(Eciomania 


of  the  cei'ebruni,  what  will  happen  ?  The 
consequence  will  be  moral  sufEering  and 
inexpressible  anguish,  increased  tenfold 
by  the  absolute  impotence  in  which  the 
individuals  know  themselves  to  be  to 
expel  the  obsession  or  to  arrest  the  im- 
pulse by  a  free  effort  of  will.  The  mind 
is  wide  awake  and  the  patient  is  at  first 
quite  astonished  with  this  kind  of  auto- 
matism of  one  part  of  himself.  He  tries 
to  get  rid  of  it,  but  the  obsession  becomes 
dominant,  and  from  that  time  he  is  engaged 
in  a  continuous  struggle  in  which  he  knows 
he  will  be  defeated.  Henceforth  the  nor- 
mal course  of  operations  of  the  intellect  is 
interrupted,  the  obsession  usurps  the 
whole  attention  of  the  patient  and  makes 
him  its  powerless  slave.  The  anguish  is 
now  complete  and  shows  itself  by  physical 
symptoms  (prascordial  anxiety,  tremor,  &c.) 
which  invariably  are  the"  consequence  of 
every  pathological  obsession  or  impulse. 
When  the  impulse  has  followed  the  obses- 
sion the  contest  is  suspended  for  a  while, 
leaving  the  patient  still  deeply  afflicted 
with  his  impotence,  but  in  reality  relieved 
from  a  great  burden.  The  idea  of  having 
satisfied  a  temporary  and  dominant  need 
gives  the  patient  a  sort  of  undefinable 
sense  of  well-being,  whatever  the  nature 
of  the  impulse  may  be.  But  this  remission 
is  of  short  duration  ;  the  obsession  comes 
back  and  must  be  again  satisfied.  The 
anxiety  returns  and  the  struggle  recom- 
mences, leaving  the  patient  once  more  in 
a  state  of  helplessness ;  the  will  also  suc- 
cumbs. And  so  it  goes  on,  subsides,  and 
again  returns,  until  the  first  cause  of 
automatism  disappears. 

Such  are  pathological  obsession  and 
impulse.  We  see  that  they  may  be  re- 
duced to  the  same  character  as  the 
physiological  phenomena  ;  we  only  have 
to  add  the  accompanying  moral  suffering 
and  anxiety.  The  impotency  of  the  will 
as  regards  inhibition  is  always  a  prin- 
cipal, but  not  the  most  important  symp- 
tom. Are  obsession  and  impulse  caused 
by  a  sort  of  temporary  and  moi'bid  loss  of 
energy  of  the  will,  or  in  other  words,  does 
there  in  reality  exist  a  disease  of  the  will  ? 
This  does  not  seem  probable.  The  truth 
is  that  the  normal  amount  of  voluntary 
energy  is  often  increased  in  the  struggle 
against  the  obsession.  And  that  the  will 
succumbs  is  not  the  consequence  of  tem- 
porary weakness,  but  because  it  strives 
against  a  power  stronger  than  itself.  It 
will  be  well,  however,  to  add  that  in  this 
loss  of  mental  equilibrium  which  precedes 
the  appearance  of  obsessions  and  impulses, 
diminution  of  power  of  resistance  may 
actually  exist  and  favour  the  defeat  of  the 
patient  in  his  struggle,  but  this  diminu- 


tion of  power  is  never  the  most  important 
fact. 

In  short,  inressant  recurrence  of  obses- 
sion and  impulse,  to  which  the  patient 
offers  only  useless  resistance ;  consciousness 
of  the  phenomenon  ;  energetic  struggle  to 
get  rid  of  it;  moral  anguish  in  consequence 
of  the  sense  of  impotency ;  relief  after  the 
impulse  has  been  satisfied  ;  are,  briefly, 
the  psychological  characters  of  patholo- 
gical obsession  and  impulse. 

We  see,  therefore,  that  these  patients 
are  completely  conscious,  even  in  the  midst 
of  the  most  fearful  anguish,  and  when 
the  impulse  is  on  the  point  of  being  carried 
into  effect.  {See  Imperative  Ibeas.) 
M.  Legrain. 

OBSTUPESCBKTTIA  (obstupesco,  I 
grow  or  become  stupefied).  An  old  term 
for  that  state  of  stupefaction  in  which  the 
patient  remains  perfectly  quiescent  with 
his  eyes  open  as  if  astonished,  and  not 
moving  or  speaking.  (Fr.  ohstupescence  ; 
Ger.  Bestiirzung.) 

occvPATZosr.    ((S'ee  Treatment.) 

OD  FORCE. — Od  is  a  suffix  proposed 
by  von  Reichenbach  for  the  peculiar  force 
alleged  to  be  produced  on  the  nervous 
system  by  all  magnetic  agents.  According 
as  it  is  found  in  magnets,  heat,  light,  &c., 
he  called  it  magnetod,  thermod,  photod, 
&c.  The  influence  of  magnets  on  the 
body  is  not  proved. 

ODAXESMUS  (oSa^ao),  I  bite).  Term 
applied  by  Marshall  Hall  to  the  bitten 
tongue,  cheek,  or  lip  which  is  an  import- 
ant sign  of  an  epileptic  fit.  (Fr.  oda.c- 
esme). 

ODOUR  OF  THE  ZXTSANE. — In  com- 
mon with  other  functions  in  the  insane, 
the  function  of  the  skin  is  often  dis- 
ordered and  its  abnormal  secretion  leads 
to  a  smell  of  a  disagreeable  character. 
The  skin  is  often  dry  and  harsh  at  the 
same  time.  If  perspiration  be  induced 
and  baths  afterwards  given  the  smell  can 
be  greatly  lessened.  Much  diversity  of 
opinion  exists  as  to  whether  there  is  an 
odour  peculiar  to  the  insane  or  not. 

ODVli. — A  so-called  new  "  influence  " 
said  to  be  developed  by  magnets,  heat, 
electricity,  &c.  The  odylic  foi'ce  is  alleged 
to  give  rise  to  luminous  phenomena  visible 
to  certain  sensitive  persons,  and  to  them 
only. 

ODYNEFHOBZA  {6?ivvrj,  pain  ;  (/)o/3ea), 
I  fear).  A  morbid  dread  of  pain.  (Fr. 
odynephobie ;  Ger.  iSclimerzselieu.) 

CECZOIVXAHTZA  (oIkos.  a  house  ;  fiavia, 
madness).  A  variety  of  moral  insanity 
characterised  by  domestic  perversity.  l\o 
doubt  many  unstable  natures  are  able  to 
get  on  fairly  well  when  away  from  home, 
but  "  oeciomania ''  is    one  of  the   many 


CEnomania 


[    869 


1 


Old  Age  and  its  Psychoses 


examples  of  the  needless  multiplication  of 
psycholotjical  terms. 

aUrOT/lANlA.      (Ser  OiNDMAMA.) 

CESOPHAGEAZi  TUBE.  (iS'ee  FEED- 
ING (Foiuiiu,!-;)  oi'  riiK  Insaxk.) 

CESTROIVIAN'ZA  (oi<TTfms,  a  gadHy,  also 
amorous  desire  ;  ^avia,  madness.)  Au  old 
term  for  nj'mphomauia  (q.r-)-  {Vr.  and 
Ger.  .7v',s7 )•(!((; ('///('.) 

OHRBI.VTGESCH-WUI.ST  (Grer.). 
Hannatonia  auris  (q.r.). 

OIKEIOMAN'XA.  {oiKftos,  belonging  to 
a  family  :  fxavia.  madness),      Q^ciomania 

OZKOPHOBZA  {oiKos,  home ;  <l)6^os, 
fear").  A  morbid  and  unreasoning  dread 
of  home. 

ozuroiWAsriA  {olvos,  wine  ;  fxavia,  mad- 
ness.) A  term  meaning  amorljid  ci'aving 
for  wine,  and  also  madness  produced  by- 
drink.  It  is  used  especially  for  that  form 
of  drunkenness  in  which  there  are  long 
intervals  of  sobriety  between  isolated 
drinking  bouts.  (Fr.  oinotiKunr ;  Ger. 
Sanfenrahnsi)iii.) 

OXiD  AGE  AN-B  ITS  PSYCHOSES. 
Senile  Involution. — lu  many  cases  man 
preserves  in  old  age  a  fair  amount  of 
mental  and  bodily  power.  Not  unfre- 
qnently,  indeed,  old  age  seems  to  be  the 
time  of  actual  ripeness  and  perfection,  on 
which  a  man  like  Jakob  Grimm  is  in  the 
happy  position  of  being  able  to  pronounce 
an  enthusiastic  eulogy.  TJsaally,  however, 
old  age  is  that  period  of  life  in  which 
mental  and  bodily  power  suffer  loss  in  the 
form  of  increasing  weakness.  It  would  not 
be  in  accordance  with  facts  to  fix  a  certain 
year,  or  even  3'ears,  at  which  old  age  com- 
mences. The  transition  is  generally  gra- 
dual, and  the  limit  differs  according  to  the 
individual.  In  one  man  we  see  the  symp- 
toms of  old  age  appear  between  sixty  and 
seventy,  whilst  in  others  they  may  appear 
ten  years  before  that  time,  or  still  earlier. 
This  however  we  may  say,  that  in  the 
female  sex  the  period  of  general  involution, 
which  may  be  considered  as  the  commence- 
ment of  old  age,  begins  at  the  end  of  the 
menopause,  which,  although  there  is  no 
certain  rule  for  all,  nevertheless  is  finished 
in  most  cases  about  the  fifty-fifth  year. 

As  in  the  male,  evolution  mostly  begins 
a  little  later  than  in  the  female,  we  may 
fix  the  time  of  the  commencement  of  senile 
involution  about  the  sixtieth  year.  Inas- 
much as  the  transition  is  gradual,  and  the 
symptoms  of  old  age  onl}'  become  pro- 
nounced later  on,  we  assume,  in  accord- 
ance with  most  other  authors,  that  senile 
involution  definitely  begins  from  sixty  to 
sixty-five. 

Patbolo^y. —  Senile  involution  com- 
mences mostly  with  slowly  developing  con- 


stitutional changes, as  atheromatousdegen- 
eration  of  the  walls  of  the  vessels,  changes 
in  the  blood  (hydnomia),  and  increasing 
atrophy  of  all  organs.  The  only  exception 
is  the  heart,  which  in  old  age  becomes  greatly 
hypertrophied  ;  in  more  advanced  age, 
however,  atrophy  also  takes  place.  These 
changes  become  externally  manifested  by 
symptoms  of  senile  weakness,  which  de- 
velop gradually  in  mind  and  body,  and 
which  are  termed  "  Ii(ihituss<iiiilis.'' 

Symptoms. — This  pathological  involu- 
tion commences  with  headache,  sense  of 
pressure  on  the  head,  dizziness,  sense  of 
weakness  and  fatigue,  subjective  pheno- 
mena of  vision  and  hearing,  partesthesise 
(which  are  manifold  and  vary  much  in  the 
beginning),  decrease  of  the  functions  of  the 
senses,  temporary  vaso-motor  and  cardiac 
derangement  accompanied  by  dyspnoea 
and  asthmatic  troubles,  which  appear  often 
and  severely,  especially  by  night,  disturb- 
ance of  sleep,  intercurrent  states  of 
somnolency  during  the  day,  and  disturb- 
ance of  digestion.  There  is  often  great 
sexual  appetite,  frequently  in  the  form  of 
perverted  sensations  and  impulses  ;  there 
is  often  also  a  craving  for  alcoholic  stimu- 
lants. 

The  objective  examination  shows  the 
symptoms  of  the  *'  habitus  senilis,"'  slight 
emaciation  or  a  tendency  to  corpulence 
in  many  cases,  atheromatous  arteries, 
irregular  vaso-motor  and  cardiac  action, 
tendency  to  venous  stasis,  emphysema  of 
the  lungs,  and  chronic  bronchitis.  Fre- 
quently the  knee-jerk  islessenedor  entirely 
absent,  and  there  is  also  lessened  sensi- 
bility of  the  lower  extremities. 

In  regard  to  the  mind  there  is  greater 
or  less  weakness,  especially  forgetfulness 
of  recent  events,  apathy  and  indifierence 
with  weakness  of  will,  a  tendency  to  tem- 
porary hallucinatory  states,  absence  of 
mind  and  sensory  derangements.  More- 
over, there  are  other  symptoms  of  mental 
excitement,  as  increased  recollection  of 
things  long  past,  hypochondriacal  depres- 
sion with  an  inclination  to  cry,  excitability 
often  to  the  extent  of  fury,  motor  restless- 
ness, especially  by  night,  in  connection 
with  phantasms,  illusions  of  visions  and 
hallucinations,  disturbance  of  conscious- 
ness and  mental  confusion.  The  patient 
sees  tire,  animals,  and  pictures,  and  hears 
noises;  he  believes  that  somebody  is 
going  to  rob  him  ;  lastly,  he  has  immoral 
ideas  with  sexual  hallucinations  and  an 
intense  apprehension. 

All  these  bodily  and  mental  symptoms 
of  pathological  involution  may  be  tem- 
porary and  come  on  in  paroxysms,  but 
they  also  may  become  permanently  estab- 
lished.    They   must  be   regarded   as  so- 


Old  Age  and  its  Psychoses      [    870    ]     Old  Age  and  its  Psychoses 


called  functional  derangements,  and  they 
are  probably  closely  connected  with  the 
derangements  of  circulation  and  nutri- 
tion of  the  central  nerve-substance,  caused 
by  the  morbid  condition  of  the  organs 
of  circulation. 

Idiopathic  anfemia  and  hydrasmiaofthe 
nerve-centres  cause  and  accompany  these 
derangements.  In  other  cases  cardiac 
disorders,  derangements  of  the  organs  of 
digestion  or  of  the  bladder  may  be  the 
cause  of  the  derangements  of  circulation 
and  nutrition  of  the  central  nervous 
system,  which  then  are  secondary  symp- 
toms. This,  at  least,  is  certain,  that  all 
these  abnormal  states  may  entirely  dis- 
ajipear  or  appear  as  paroxysms,  or  as 
attacks  which  last  rather  longer,  or  even 
if  chronic,  they  remain  stationary.  Also 
with  regard  to  intensity  and  variety  of  the 
symptoms,  they  may  range  from  slight 
disturbances  to  fully  developed  disease. 
We  consider  them  identical  with  those 
conditions  of  transition  between  mental 
and  nervous  health  and  disease,  which 
have  been  frequently  observed  in  recent 
times  as  inherited  or  acquired  neuropathic 
and  psychopathic  diathesis. 

We  draw  attention  to  the  gre9.t  import- 
ance of  these  conditions  in  forensic 
medicine,  because  they  frequently  lead  to 
crimes,or  by  weakening  the  patient's  power 
of  control  cause  damage  to  his  own 
interests  as  well  as  to  those  of  his  family, 
and  thereby  entail  prosecution  by  civil 
law.  Sexual  crimes  of  all  kinds  play  a 
prominent  part ;  theft,  incendiarism  and 
assaults  have  been  observed.  The  ex- 
amination of  the  mental  condition  fre- 
quently offers  very  great  difficulties  to 
the  physician,  especially  as  lucid  intervals 
are  frequent  and  often  of  long  duration. 

Actual  mental  derangement  occurs  in 
old  age,  but  nothing  certain  is  known 
about  its  frequency.  It  is  highly  probable 
that  it  is  more  frequent  in  the  male  sex 
than  in  the  female.  We  have  found  8  per 
cent,  of  all  mental  disorders  to  belong  to 
old  age  (and  of  this  number  10  per  cent, 
were  males  and  6  per  cent,  females),  whilst 
Schuele  found  for  the  whole  6.5  per  cent. 

In  former  times  the  mental  disorders  of 
old  age  were  divided  into  functional  and 
organic  derangements.  We  think  Fuerst- 
ner  is  right  in  adding  to  these  two  groups 
a  third,  which,  of  more  uncertain  cha- 
racter, lies  midway  between  the  functional 
and  organic  psychoses,  and  does  not  be- 
long to  either  the  one  or  the  other  group 
entirely.  Our  observations  completely 
confirm  this.  We  therefore  have  in  old 
age: 

(1)  Functional  psychoses; 

(2)  Psychoses  vrhich   are    no    longer 


functional,  but  do  not  'wholly  bear  the 
stamp  of  organic  psychoses ; 

(3)   Organic  psychoses. 

(l)  The  functional  psychoses  of   old 

age  are  not  rare,  but  certainly  much  rarer 
than  the  organic.  If  we  were  to  reckon 
under  this  heading  all  mental  derange- 
ments which  occur  in  women  after  the 
cessation  of  the  menses,  their  number 
would  be  still  greater,  but  we  are  not 
allowed  to  do  so,  because  all  these  psy- 
choses do  not  belong  to  old  age.  We  may 
speak  of  senile  j^sychoses  only  when  those 
constitutional  changes  occur  in  the  organ- 
ism which  we  call  senile,  and  when  the 
psychoses  can  with  certainty  be  regarded 
as  caused  by  them.  According  to  this 
view,  many  cases  during  and  after  the 
cessation  of  the  menses  cannot  be  reckoned 
in  this  group,  while,  on  the  other  hand, 
cases  have  to  be  included  which,  as  regards 
the  age  of  the  patient,  would  not  have 
been  considered  as  psychoses  of  old  age 
(cases  of  premature  old  age).  Old  age 
causes  the  senile  psychoses;  it  creates 
those  conditions  of  body  and  mind  which 
lead  to  mental  derangement ;  it  acts  pre- 
disposingly  as  heredity  does  for  the  earlier 
periods  of  life.  But  the  mental  disorders 
of  this  group  have,  with  regard  to  astiology 
and  symptomatology,  nothing  character- 
istic; they  are,  on  the  whole,  like  the 
mental  derangements  of  earlier  life.  There 
is,  however,  sometimes  less  intensity  in 
the  onset  of  the  disorder  ;  less  force  in  the 
delusions,  which  are  of  a  more  limited 
number ;  and  the  psychopathic  process  is 
often  less  marked.  This,  however,  is, 
according  to  our  experience,  not  the  rale, 
but  the  exception. 

Taken  in  the  order  of  frequency,  the 
following  forms  are  observed  : 

(a)  Hypocltondnasis. 

(b)  Melancholia,  or  still  more  frequently 
a  mixture  of  both  forms  as  hypochon- 
di'iacal  melancholia.  We  must  here  men- 
tion that  hypochondriacal  elements  often 
accompany  other  forms  of  senile  psy- 
choses. 

After  hypochondriacal  melancholia,  the 
most  frequent  is  the  passive  form,  melan- 
cholia passira  or  siuiplex.  Pure  dysthy- 
mia — constant  depression,  without  delu- 
sions— frequently  occurs.  The  excited 
form  is,  according  to  our  experience,  more 
frequent  than  the  stuporous  form. 

Sometimes  we  have  observed  melan- 
cholia complicated  with  elements  of  para- 
noia. 

(c)  Mania,  almost  exclusivel}'  in  the 
mild  form  of  simple  maniacal  exaltation 
{viania  levis).  Acute  mania  with  frenzy 
was  observed  by  us  in  only  a  few  cases. 

(d)  More  rare  than  the  forms  mentioned 


Old  Age  and  its  Psychoses     [    871     ]      Old  Age  and  its  Psychoses 


above  is  paranoia,  but  we  have  several 
times  observed  tyjiical  paranoia  even  at 
the  age  of  eighty.  They  were  mostly  cases 
in  which  at  iirst  hallucinations  came  on 
and  remained  for  some  time  with  general 
clearness  until  at  length  dolusionary  ideas 
appealed.  Subjective  phenomena  played 
therein  a  great  part,  and  almost  always 
introduced  and  accompanied  the  halluci- 
nations. Hallucinations  of  vision  were 
the  most  frequent,  and  organic  and  func- 
tional derangements  of  the  peripheral 
Sensory  organs  coiild  always  be  found. 
Paranoia  occurred  in  the  acute  and  chronic 
form,  the  latter  more  frequently  because 
many  cases  of  originally  acute  paranoia 
become  chronic.  In  the  subject-matter 
of  paranoia,  the  hypochondriacal  element 
was  predominant. 

■  Sexiud  illusions  are  generally,  and  klep- 
tomania is  often,  found.  'J'he  latter  may 
be  considered  as  the  affection  most  marked 
in  old  age,  although  it  may  be  absent  in 
some  cases. 

The  sym])toms  of  these  forms  have, 
however,  nothing  absolutely  characteristic, 
neither  has  their  course,  which  is  in  no 
■\*ay  different  from  that  of  the  other  func- 
tional mental  derangements.  We  lay 
stress  upon  this,  the  more  because  Fuerst- 
fier  arrived  at  different  conclusions,  and 
found  striking  remissions  and  even  inter- 
missions. 

In  respect  to  the  progrnosis,  the  func- 
tional psychoses  of  old  age  terminate 
as  frequently  in  recovery  as  those  of  an 
earlier  age.  We  have  repeatedly  observed 
this  termination  in  patients  who  were  be- 
tween seventy-five  and  eighty.  However, 
this  course  is  very  rare  in  paranoia. 

As  regards  treatment,  we  are  not  in  a 
position  to  give  other  indications  besides 
those  which  are  accepted  in  the  treatment 
of  mental  disorders  in  general ;  only  they 
will  have  to  be  modified  according  to  the 
conditions  of  more  advanced  age.  We 
some  time  ago  pointed  out  in  an  article 
on  this  subject  that  in  the  mental  de- 
rangements of  the  old  great  caution  must 
be  exercised,  and  that  exact  observation 
must  be  employed.  Characteristics  of  old 
age  are  a  great  reticence  and  desire  for 
seclusion  ;  the  former,  however,  is  some- 
times followed  by  loquacity.  On  the  other 
hand,  there  is  a  certain  mistrust  and  great 
irritability,  qualities  which  lead  the  pa- 
tients often  to  simulation  and  to  sudden 
and  unexpected  actions  of  a  violent 
character.  Assaults  on  others  and  on 
themselves  are  not  rare. 

(2)  With  regard  to  cases  of  the  second 
group,  we  find  in  them  not  only  intellec- 
tual defects,  as  Fuerstner  states,  but  also 
other  central  derangements,  as  they  are 


found  in  organic  diseases  of  the  brain. 
The  difference  between  the  second  and 
third  group  is  that  in  the  former  the  cases 
terminate  favourably  or,  if  not,  they  re- 
main stationary.  They  give  the  impres- 
sion of  commencing  senile  dementia,  but 
their  further  i^rogress  shows  that  this  is 
not  so.  They  frequently  commence  in  an 
acute  manner  in  so  far  as  attacks  of  apo- 
plexy and  vertigo  pi'ecede  the  actual  out- 
break, although  already  long  before  this, 
premonitory  phenomena  appear,  similar 
to  the  symptoms  described  above. 

The  disease  itself  appears  in  the  form 
of  acute  mania,  melancholia,  stupor,  or 
mania.  Its  symptoms  are  much  more 
variable  than  Fuerstner  supposed.  It  is 
characteristic  that  all  these  forms  are  not 
pure  but  are  accompanied  by  regular 
sensory  disorders,  which  are  at  the  begin- 
ning very  severe,  but  later  on  are  milder. 

These  patients  are  in  a  state  of  confusion 
and  absent-mindedness  ;  perception  and 
apperception  are  faulty ;  there  exists  am- 
nesia, and  occasionally  also  aphasia.  There 
are  disturbances  of  the  optic  nerves,  the 
facial  and  hypoglossal ;  sometimes  there 
are  actual  paralytic  attacks.  After  some 
weeks,  or  it  may  be  months,  the  patients 
become  mentally  clearer,  and  the  psy- 
choses disappear,  together  with  other  cere- 
bral derangements.  Recovery  may  take 
place  without  any  relapse  ;  on  the  other 
hand,  recovery  is  often  very  incomplete, 
and  there  remain  conditions  of  weakness 
of  the  central  nervous  system,  which 
sometimes  influence  the  body  most,  some- 
times the  mind.  It  is  clear  that  cases 
of  this  group  are  more  severe  than 
those  of  the  former.  We  suppose  with 
Fuerstner  that  there  are  disturbances  of 
the  circulation  and  nutrition  of  the  cen- 
tral nervous  organs  in  consequence  of 
atheroma  which  make  the  disease  more 
severe.  We  have  here  to  point  out  the 
essential  importance  of  the  influence 
which  the  heart  exercises  when  fatty, 
mostly  in  conjunction  with  dilatation,  but 
also  with  valvular  disease. 

The  treatment  of  these  patients  is 
extremely  difficult.  The  severe  stujDor, 
the  inability  to  localise  his  symptoms,  the 
obstinate  sitophobia,  the  frequently  dan- 
gerous bodily  weakness,  the  often  exag- 
gerated motor  impulsesj  and  persistent 
insomnia,  interfere  with  the  usual  indica- 
tions. One  must  be  most  cautious  in  the 
employment  of  remedies,  on  account  of 
the  great  change  in  the  heart  and  ves- 
sels, and  the  often  critical  bodily  weak- 
ness. Everything  has  to  be  administered 
to  the  patients  by  force.  We  think  the 
main  jDoint  of  the  treatment  to  be  suffi- 
cient nutrition,  to  carry  out  which  we  have 


Old  Age  and  its  Psychoses     [    872    ]     Old  Age  and  its  Psychoses 


to  resort  early  to  artificial  feeding.  This 
indicates  the  kind  of 'food  which  ought  to 
be  given ;  it  must  be  easily  digestible, 
readily  assimilated,  nourishing,  strength- 
ening and  stimulating — e.g.,  broth,  milk, 
eggs,  peptones,  extract  of  beef  and  similar 
food.  In  addition  to  this,  give  alcohol  in 
a  concentrated  form  as  egg-flip  or  punch, 
sherry,  old  Bordeaux,  &c. 

Of  hypnotics  the  least  dangerous  and 
most  eflicient  seems  to  us  to  be  sulphonal ; 
we  have  learned  to  prefer  this  to  any 
other.  According  to  cii'cum stances  we 
may  make  use  of  opium  or  digitalis,  as 
Fuerstner  recommends. 

(3)  To  the  third  group  belong  the  dis- 
tinctly org:anic  psychoses  of  old  age, 
the  characteristic  of  which  is  the  pi'ogres- 
sive  nature  of  the  disease.  There  is  an 
increasing  stujoor  and  bodily  weakening 
which  have  their  anatomical  foundation 
in  increasing  atrophy  of  the  central  nerve 
substance  in  the  form  of  retrogressive 
metamorphosis.  The  process  originates 
in  the  disease  of  the  arterial  system, 
especially  of  the  cranial  cavity  and  of 
the  heart.  We  mention  this,  because 
often  the  arterial  system  in  general  is 
found  relatively  well  preserved,  whilst  the 
carotids  and  the  vertebral  arteries  are 
found  to  be  much  diseased.  There  are 
even  cases,  in  which  the  great  arteries  of 
the  brain  appear  to  be  healthy,  whilst  the 
small  arteries  and  capillary  vessels  are 
diseased.  The  disorders  caused  thereby 
lead  on  the  one  hand  directly  to  a  chronic 
change,  on  the  other  hand,  indirectly  in 
a  more  acute  manner  (through  softening 
which  is  partly  multiple,  partly  metasta- 
tic) to  disintegration  and  primary  atro- 
phy of  the  nerve  substance.  That  ha3- 
morrhage  into  the  latter  plays  a  great 
part  is  equally  a  consequence  of  arterial 
disease.  The  membranes  of  the  brain 
also  often  partake  of  the  disease.  Inter- 
nal, external  and  bilateral  pachymenin- 
gitis, sirnple  and  haemorrhagic,  chronic 
leptomeningitis,  and  above  all  ependymi- 
tis  are  frequently  found  at  the  post-mor- 
tem examination.  The  whole  is  accom- 
panied by  an  excess  of  fluid  in  the  ven- 
tricles, corresponding  to  the  wasting  of  the 
brain,  &c.  Senile  dementia  is  mostly  for 
some  time  preceded  by  senile  marasmus 
of  mind  and  body.  These  manifold  symp- 
toms are  found  as  we  have  described  them 
above,  as  the  stage  of  transition  between 
physiological  and  pathological  old  age. 
We  have  to  add  that  sometimes  this  dis- 
ease is  observed  without  being  preceded  by 
any  conspicuous  premonitory  symptoms. 

The  transition  to  the  state  of  actual 
disease  is  mostly  gradual,  the  sensory  de- 
rangements  becoming   more   permanent. 


and  the  symptoms  of  bodily  and  mental 
weakness  more  and  more  distinct.  In 
rare  cases  only  the  transition  is  an  acute 
one  introduced  by  symptoms  which  may 
be  violent  in  character.  This  takes  place 
in  the  form  of  an  acute  mental  derange- 
ment with  the  character  of  hallucinatory 
confusion,  of  mania,  of  stupor,  or  with 
apoplectiform  symptoms,  and  also  after 
epilei)tiform  attacks.  It  is  quite  excep- 
tional for  the  disease  to  commence  in  the 
form  of  general  disorder  with  fever.  Cases 
of  the  latter  kind  which  begin  acutely,  pur- 
sue frequently  an  acute  course.  After  some 
weeks  or  months  they  terminate  fatally 
with  symptoms  of  central  irritation,  and 
especially  of  increasing  cerebral  weakness 
and  paralysis.  These  are  cases  which,  in 
their  symptoms,  bear  great  similarity  to 
those  of  galloping  paralysis,  which,  how- 
ever, distinguishes  itself  by  more  con- 
spicuous central  disorders.  We  find  pro- 
cesses like  that  of  pachymeningitis,  with 
or  without  hasmorrhagic  exudation,  foci 
of  softening  —  especially  multiple  —  and 
haemorrhage  into  the  central  nervous  sub- 
stance. In  a  few  cases  only  there  is  acute 
atrophy  with  strongly  developed  effu- 
sion of  fluid  with  severe  ependymitis. 
These  forms  have  been  long  known  and 
have  been  described  by  Lobstein  as  "  mor- 
bus climacterius,'"  and  by  Yirchow  as 
"febrile  atrophy  in  old  men." 

This  transition  is  mostly  gradual. 
The  symptoms  of  senile  dementia  de- 
l^end  upon  whether  the  disease  is  difi'use 
or  localised ;  they  are  also  influenced  by 
complications.  Processes  like  pachymen- 
ingitis often,  although  not  necessarily, 
modify  the  symptoms,  which  then  are 
characterised  by  sleepiness,  complete 
lethargy,  flushing  of  the  face,  weakness  of 
the  lower  extremities,  staggering  gait,  and 
almost  absolute  sito phobia;  in  semi-lateral 
sclerosis  by  symptoms  of  conjugate  devia- 
tion of  the  eyes,  and  temporary  spasmodic 
motor  disorders. 

Another  complication  is  a  spinal  one 
with  symptoms  like  those  of  tabes.  Al- 
though typical  locomotor  ataxy  rarely 
occurs  in  old  age,  symptoms  like  tabes 
often  occur  (absence  of  the  knee-jerk,  hy- 
pera3sthesia,  anaesthesia  and  weakness 
of  the  lower  extremities,  paresis  of  the 
sphincters,  &c.). 

According  to  our  expei'ience,  general 
paralysis  occurs  in  a  few  cases.  But  alto- 
gether, these  symptoms  ai-e  much  rarer 
than  those  which  arise  from  localised 
lesions.  AVe  must  here  add  that  we 
have  to  take  great  care  not  to  connect  all 
the  symptoms  of  the  latter  with  changes 
of  a  definite  anatomical  nature.  We  have 
often    experienced   this    with    regard    to 


Old  Age  and  its  Psychoses     [    873    ] 


Old  Maid's  Insanity 


symptoms  of  aphasia,  and  also  with  re- 
gard to  permanent  symptoms  of  mono- 
plegia and  hemiplegia. 

Senile  dementia  assumes  the  form  of 
progressive  central  degenerations.  Most 
characteristic  of  this  are  the  profound 
sensory  disorders,  the  continuous  and  com- 
mon conditions  of  obliviousness  and  the 
prominent  amnesic  derangements,  which 
often  render  old  men  completely  incapable 
of  setting  themselves  right. 

The  well-known  pathological  weakness 
of  mind,  tendency  to  sentimentality  and 
emotion,  are  symptoms  of  senile  degene- 
ration, but  not  of  complete  senile  de- 
mentia ;  they  belong  to  the  prodromic 
stage  of  the  disease.  Frequently,  however, 
but  not  always,  a  chronic  mental  change 
may  be  observed,  in  which  the  patient 
believesthat  he  lives  again  through  periods 
long  gone  by,  or  thinks  he  is  in  surround- 
ings and  in  situations  of  the  past.  "We  have 
often  thought  that  the  elements  of  this  de- 
rangement bear  the  character  of  plasticity 
(Flasticiiaei)  and  a  certain  degree  of  sen- 
suality, and  sometimes  even  take  an  hal- 
lucinatory character.  They  are  more  fre- 
quent and  vivid  by  night  than  in  the  day- 
time. Aphasic  disorders  are  frequently 
only  temporary,  but  not  always  so.  Vague 
illusionary  ideas  of  hypochondriacal  cha- 
racter and  of  sexual  intercourse,  theft, 
poisoning,  persecution,  &c.,  and  sometimes 
also  macromania  occur,  but  are  not  stabile, 
and  assume  more  of  the  character  of  in- 
sanity. ]\Iorbid  excitability  of  temper 
may  often  be  observed. 

The  most  characteristic  bodily  symptoms 
are  motor  weakness,  tremor,  often  to  the 
extent  of  paralysis  agitans,  failure  of  the 
senses,  caused  by  various  anatomical 
changes  in  the  external  sense-organs,  low- 
ered temperature  of  the  body,  the  chang- 
ing states  of  somnolency  and  insomnia,  the 
former  of  which  appears  in  the  day,  the 
latter  by  night,  and,  in  connection  with  all 
these,  great  weakness  of  the  heart. 

Duration. — There  are  forms  which  ter- 
minate fatally  after  a  few  weeks  or  months. 
The  greater  number  of  cases  last  some 
years  ;  but  cases  of  still  longer  duration 
are  of  not  infrequent  occurrence.  We  do 
not  know  any  other  termination  of  the 
disease  but  death,  which  comes  on  slowly, 
through  gradual,  general  weakening,  and 
marasmus,  but  more  quickly  in  conse- 
quence of  disease  of  the  brain  (as  pachy- 
meningitis, softening,  or  hajmorrhage),  or 
frequently  also  in  consequence  of  affections 
of  the  pulmonary  organs.  In  the  case  of 
general  marasmus,  bed-sores  often  occur, 
and  in  connection  with  them  general  dis- 
orders, or  affections  of  the  bladder,  with 
their  consequences. 


We  have  already  pointed  out  the  naked- 
eye  pathological  changes.  They  are  dif- 
ferent from  those  of  general  paralysis. 
The  brain  is  generally  lighter,  softer,  more 
atrophied,  but  sclerotic  foci  are  not  ex- 
cluded, leptomeningitis  is  less  marked  and 
less  diffuse ;  the  dura  mater  is  nearly 
always  adherent  to  the  cranium  ;  ependy- 
mitis  is  very  distinct ;  the  spinal  changes 
consist  more  in  general  atrophy  than  local 
disease  ;  but  we  sometimes  find  grey  de- 
generation of  the  posterior  and  lateral 
columns. 

The  microscopical  results  confirm  this 
statement.  The  disease  of  the  vessels  of 
the  brain  is  mostly  general  and  much  more 
intense,  and  therefore  the  disease  of  the 
nerve-tissue  is  much  more  extensive.  Not 
only  the  convolutions  of  the  cerebrum,  and 
especially  the  ascending  frontal  and 
parietal,  are  affected,  but  all  other  parts 
of  the  brain,  and  the  degeneration  ex- 
tends especially  into  the  white  substance. 
The  degeneration  and  atrophy  of  the 
nerve-tissue  are  the  same  in  all  parts 
of  the  central  nerve-substance.  As  in 
general  paralysis,  we  find  also  here  absence 
of  tangential  fibres  (Exner)  and  atrophy 
of  the  nerve-cells  of  the  third  layer,  but 
we  also  find  the  cells  and  fibres  absent 
wherever  we  look  for  them.  There  are 
also  more  strongly  developed  peri-vascular 
and  peri-cellular  cavities,  an  enormous 
number  of  spider-cells,  and  in  all  parts  of 
the  tissue  emigi'ated  lymph-corpuscles  and 
leucocytes,  the  latter  often  in  foci  in  con- 
sequence of  hfBmorrhage.  In  other  places 
the  elements  of  decay  are  more  prominent, 
as  granular  cells,  stratified  and  pigmented 
cells,  but  also  often  elements  without  form, 
as  characteristic  of  capillary  foci  of 
softening. 

As  we  sometimes  find  in  old  men  from 
sixty  to  seventy,  symptoms  of  mental 
disease  which  we  cannot  distinguish  from 
those  of  general  paralysis,  so  with  regard 
to  anatomical  examination,  we  sometimes 
find  central  changes  which  bear  the  cha- 
racteristics of  senile  involution  as  well  as 
of  paralysis.  This  circumstance  favours 
the  belief  in  the  occurrence  of  general 
paralysis  in  old  age,  or  rather,  as  seems 
more  probable,  of  a  complication  of  both 
diseases.  Ludwig  Wille. 

OI.l>  MAID'S   ZTrSANITY A  form 

of  insanity  so  called  by  Dr.  Clouston,  and 
"  Ovai'ian  Insanity,"  by  Dr.  Skae.  It 
is  characterised  by  a  morbid  alteration  in 
the  normal  state  of  affection  of  woman 
towards  the  other  sex.  The  patients  are 
as  a  rule  unattractive  old  maids  about  from 
forty  to  forty-five,  who  have  led  very  strict 
and  virtuous  lives.  Theladybecomes  seized 
with  an  absurd  and    reasonless  passion 


Oligomania 


[    874    ] 


Othsematoma 


for  some  particular  individual  of  the  op- 
posite sex,  very  often  lier  clergyman. 
She  believes  him  to  be  deeply  in  love  with 
her  or  accuses  him  of  seduction  or  other 
misdeed  in  connection  with  herself,  and 
uses  the  merest  trifles  as  proofs  of  her 
beliefs.  Recovery  is  rare,  the  insanity 
often  passing  into  some  other  form. 
There  is  no  proof  that  the  ovaries  are 
affected  (Clouston). 

OIiIGOIXiiN'ZA  (oXi'yof ,  few  ;  /lavla, 
madness).  A  needless  •ivord  used  by  some 
authors  instead  of  the  term  monomania, 
on  the  ground  that  the  latter  is  an  in- 
sufficient term  for  any  form  of  insanity, 
there  always  being  more  than  one  morbid 
phenomenon  in  an  insane  person.  (Fr., 
oligo'iiianie.) 

OIiIGOPSVCHIA  (aXlyos,  little  ;  irvxri, 
the  soul,  mind).  Imbecility  or  fatuity. 
The  term  is  quite  unnecessary.  (Fr.  oli- 
gopsycliic  ;  Ger.  Geistesarnmth.) 

ONrEZRODViriii  {oveipos,  a  dream  ; 
ohvvrj,  pain).  A  painful  dream.  The  term 
includes  both  incubus  and  somnambulism. 

OM'EiROIiOG'V  (opeipos,  a  dream;  Xoyos, 
a  discourse).  The  doctrine  or  theory  of 
dreams.  (Fr.  oneirologie ;  Ger.  Trau'm- 
iheorie.)     {See  Dkeamixg.) 

OTTEZROM-OSOS,  OSTEZROXrOSUS 
{oveipos,  a  dream  ;  voaos,  disease).  Morbid 
dreaming,  uneasiness  while  dreaming. 
(Fr.  oneironose.) 

ON'OAIATOIVIAM'ZA  (ovofia,  a  name). 
The  irresistible  impulse  to  repeat  a 
particular  word,  or  the  morbid  dread  of 
a  particular  word.  [See  Imperative 
Ideas.) 

OOARZE.     Hysteria  (Fr.)  (q.v.). 

OOPHORECTOMY.  {See  OVARI- 
OTOMY.) 

OOPKORZil  {oo2)horiivi,  ovary).  A 
name  given  to  hysteria  from  its  supposed 
connection  with  affection  of  the  ovaries. 

06PHORO-EPZI.EPSY. — Epilepsy  de- 
pending on  ovarian  disease. 

OOVROROWLANlA.. — Insanity  result- 
ing from  ovarian  disease. 

OPEN"  DOOR  SYSTEM.  —  Allowing 
the  doors  in  an  asylum  to  be  unlocked. 

OPZOPHZIi  [oiiium;  andt^tXew,  I  love). 
A  lover  of  opium.  There  is  an  opiophil 
club  in  Paris.  Akin  to  morphinomauia 
(q.v.). 

OFZSTHOTOIfUS,       HYSTERZCAZi. 

(See  Hysteria.) 

OPZUM.     {See  Sedatives.) 

OPZVM  CRAVE. — The  intense  crav- 
ing for  opium  and  morphia  leading  to 
moral  and  other  insanity.  (Ger.  Opkmi- 
sucht.)     {See  Morpiiiomania.) 

OPSOIVIANZA  {oylrov,  aliment  ;  fxavia, 
madness).  Either  a  craving  for  some 
particular   aliment  to  the  extent   of  in- 


sanity, or  a  morbid  craving  for  dainties- 
(Fr.  ojjsomanie.) 

OPSOPHAGZE. — Morbid  daintiness  as 
to  food. 

OPTZCAli  3>EIiirszON'. — The  popular 
term  for  a  visual  hallucination  or  illusion. 

OPTZivizsivx.     {See  Exaltation.) 

ORCHESTROIVIAn'ZA  {opxW^W,  ^ 
dancer ;  p-avia,  madness).  Chorea,  St. 
Vitus's  dance. 

ORGATric  SEIVIEM-TZA. — Dementia 
accompanying  and  resulting  from  gross 
brain  lesions  such  as  hasmorrhage,  tu- 
mours, &c.  Distinct  from  general  para- 
lysis.    {See  Demextia.) 

ORGANZC     IVXEI.ANCHOX1ZA. — 

Melancholia  accompanied  by  gross  brain 
lesion  and  causally  connected  with  the 
lesion  (Clouston). 

ORTHOPHRENZA,  ORTKOPHRE- 
iriSlVKirs  {up6i)i,  right ;  (ppriv,  the  mind). 
Right-mindedness.  A  term  also  used  for 
the  cui-e  of  a  disordered  mind.  (Fr, 
Orthophrtnie.) 

ORTHOPHRBNZCUS.— Of  or  belong- 
ing to  orthophrenia,  the  cure  of  a  diseased 
mind. 

OSTEOIVIAI.ACZA.  {See  BoxE  De- 
generation  IX  THE  InS.\NE.) 

osTEOPOROSzs.  {See  Bone  Degene- 
ration  IX   TUE   IXSAXE.) 

OTHJCnSATOMA.  —  A  synonym  of 
Heematoma  Auris  {ij.r.).  The  appearance 
of   the  commoner  forms   of   sanguineous 

Fig.  I. 


1.  Otha?itiatoma  iu  the  acute  or  prima  ry  stage. 
Tumour  of  extraonlinary  size  occupying'  tlie 


Othsematoma 


^75     ] 


Ovariotomy 


entire  cavity  of  tlie  auricle,  and  obliterating- 
its  ridges  and  liollows.  Surface  uneven,  and 
in  parts  of  a  idum  colour.  licsii/t,  slow  absorp- 
tion, with  extreme  contraction,  and  finally  the 
almost  complete  distortion  of  the  auricle,  and 
obliteration  of  its  scvt-ral  component  parts. 
Case  of  E.H.,  afflected  with  active  melancholia 
(taken  from  life). 

Vu\.  2. 


2.  Othaematoma  in  the  acute  or  priiiKiry  stage. 
Tumour  of  moderate  size  hlliug  up  tlie  cavity 
of  the  concha;  full  and  rounded  above  where 
it  is  bounded  by  the  ridge  of  the  antihelix, 
being  lost  below  in  the  lobule.  Result,  disap- 
pearance with  but  little  subsequent  deformity. 
Case  of  C.H.,  affected  with  recurrent  paroxys- 
mal mania  (taken  from  life). 
Fic.  3. 


3.  Otluematoma  in  advanced  sacondaru  stage. 
Helix  folded  over  antihelix,  fossa  of  latter  com- 


pletely obliterated,  the  upper  portion  of  the 
auricU^  was  transformed  into  an  irregularly 
tuberculated  missliiipeu  mass  ;  on  section  a 
triangular  jiortion  (»f  bone  had  become  deve- 
loped in  the  centre,  surrounded  with  cartilage 
and  connective  tissue.  Affection  of  very  long 
standing,  ('ase  of  J.  ]>!.,  att'ected  with  chronic 
dementia  (.taken  after  death). 

sub-perichoiidrial  effusion  of  tte  auricle  iu 
the  recent  state,  or  of  the  puckering  or 
shrunken  condition  of  the  ear  in  the 
secondary  stage  of  this  affection,  is  so 
familiar  as  to  need  no  special  illustration, 
but  the  rarer  varieties,  stich  as  (i)  involve- 
ment of  the  whole  of  the  anterior  auricular 
stirface,  and  (2)  implication  of  only  the 
concha  and  external  auditory  meatus  are 
here  figured.  The  first  illustration  shows 
the  limitation  of  the  effusion  to  the  carti- 
laginous portions  of  the  auricle,  and  the 
freedom  from  implication  of  the  lobtile 
and  the  outermost  portion  of  the  helix. 
The  third  shows  the  secondary  stage  after 
effusion  and  absorption.  The  wood-cuts 
are  inserted  by  kind  permission  of  Dr. 
Macnaughten  Jones  from  his  work  on  the 
ear.  Dr.  Ringrose  Atkins  (Waterford) 
drew  them  from  cases  under  his  care. 

J.  F.  G.  PlETEltSEN. 

OVARIAN  ZirSAXI-XTV. — A  name  for 

old  maid's  insanity  (q-v.)- 

OVARIOTOIVIV  and  OOPHOREC- 
TOmV  in  relation  to  ZMTSANZTV  and 
EFlIiEPSV. — The  subjective  and  objec- 
tive signs  revealed  by  the  ordinary  methods 
of  clinical  observation  teach  us  much,  but 
how  infinitely  more  precise  our  knowledge 
becomes  when  the  opportunity  is  afforded 
of  studying  the  condition  of  the  economy 
when  these  organs  are  taken  away.  Of 
course  we  know  that  removing  the  organs 
of  reproduction  entails  sterility ;  but  this 
is  not  all.  What  is  the  effect  upon  the 
organism  as  a  whole,  or  upon  the  nervous 
system  iu  j^articular?  One  factor  in  the 
question  is  the  immediate  influence  of  the 
operation  itself.  Severe  injuries,  starva- 
tion, shock  of  great  catastrophes,  sun- 
stroke, have  been  followed  by  insanity ; 
surgical  operations  other  than  those  with 
which  we  are  now  concerned  are  occa- 
sionally followed  by  insanity.  The  shock 
of  labour  may  be  enough  to  overturn  the 
nervous  equilibrium.  Temporary  de- 
lirium, hallucinations,  violence  to  self  or 
child,  in  some  cases  passing  into  mania, 
are  evidence  of  this.  No  doubt  there  are 
other  factors  ;  simple  shock  can  hardly 
be.^ 

Knowing  this,  we  have  inquired  whether 
abdominal  surgery,  involving  the  removal 
of  the  ovaries  and  uterus,  is  especially 
causative  of  insanity.  If  it  be  shown 
that  insanity  follows  these  operations  in 
a  sensibly  larger  proportion  than  it  does 


Ovariotomy 


[    876    ] 


Ovariotomy 


other  operations,  then  a  reasonable  pre- 
sumption arises  that  it  is  the  deprivation 
of  the  uterus  and  ovaries  and  not  the 
mere  surgical  operation  which  leads  to 
the  insanity.  The  facts  actually  ac- 
quired strongly  support  this  j^roposi- 
tion.  A  point  to  bear  in  mind  is,  that 
the  effect  of  shock  is  likely  to  be  imme- 
diate, whilst  privation  of  the  uterus  and 
ovaries  may  not  be  felt  until  after  a  con- 
siderable lapse  of  time. 

This  proposition  established,  do  we  not 
see  in  it  a  proof  that  these  organs  exer- 
cise a  motor  and  governing  power  over 
the  nervous  centres  ?  We  have  long  been 
familiar  with  the  effect  of  castration  upon 
the  male  ecouomy.  The  eunuch  retains 
the  voice  of  the  boy ;  the  essentially  virile 
attributes  are  not  developed.  Does  his- 
tory record  an  undoubted  example  of  a 
great  discovery  or  a  great  invention  made 
by  a  eunuch  ?  It  would  be  interesting  to 
learn  the  relative  prevalence  of  insanity 
amongst  entire  and  castrated  Orientals. 
The  application  of  this  to  our  argument  is 
obvious.  To  unsex  a  woman  is  surely  to 
maim  or  affect  injuriously  the  integi'ity  of 
her  nervous  system.  Observations  of  the 
effect  of  castrating  and  spaying  animals 
might  throw  some  light  upon  this  ques- 
tion. Appeal  may  be  made  to  the  experi- 
ence of  veterinary  surgeons  to  help.  M. 
Barthelomy  {Journ.  de  Med  Vcterinaire) 
says  that  oestrum  or  rut  can  occur  in  pigs 
after  complete  removal  of  the  ovaries.  We 
have  no  opportunity  of  making  anything 
approaching  to  an  exhaustive  summary 
of  cases,  but  the  following  facts  are  in- 
structive : —  Sir  Spencer  Wells  writes 
(June  1890)  to  the  writer  :  "Twice  dur- 
ing convalescence  after  ovariotomy  I 
have  seen  maniacal  attacks,  but  both  pa- 
tients were  of  lunatic  families In 

some  cases  where  double  oophorectomy 
has  been  performed  without,  as  I  think, 
sufficient  reason,  I  have  seen  patients 
almost  melancholic  at  their  mutilated  con- 
dition and  sterility."  Dr.  Savage,  of  Bir- 
mingham, informs  us  (July  1890)  that 
he  has  removed  the  appendages  on  both 
sides  in  483  cases.  Of  these,  twenty-six 
died  after  the  operation ;  three  aged  respec- 
tively 25,  25,  and  30,  became  insane  and 
recovered ;  one,  aged  38,  committed  suicide 
six  months  after  the  operation.  Dr. 
Thomas  Keith  writes  (May  1890)  : — "  So 
far  as  my  limited  experience  goes,  I  would 
say  that  the  removal  of  the  ovaries  for 
disease  has  not  been  in  any  case  followed 
by  any  disturbance  in  the  mental  condi- 
tions, nor  have  I  seen  any  change  after 
the  removal  of  the  ovaries  for  checking 
the  growth  of  bleeding  fibroids  ;  but  after 
hysterectomy  and  removal  of  both  ovaries, 


the  effect  has  been  decided,  and  I  cannot 
consider  the  results  accidental.  Of  sixty- 
four  hysterectomies  (supra-vaginal  or 
complete  removal  of  entire  uterus),  there 
have  been  six  cases  of  insanity — three 
acute,  and  three  chronic  cases.  In  one  of 
the  acute  cases,  the  patient,  a  hospital 
nurse,  had  been  in  Morningside  Asylum 
with  an  attack  of  acute  mania.  Two  of 
the  acute  cases  died  after  operation,  the 
other  four  are  alive,  but  none  of  them 
well.'' 

Lawson  Tait,  referring  to  Keith's  state- 
ment cited  above,  says  : — "I  have  operated 
upon  a  very  much  larger  number  of  cases 
of  hysterectomy,  and  I  know  of  no  case 
of  insanity  in  my  practice.  Instances  of 
insanity  occur  after  all  surgical  proceed- 
ings, even  the  most  trivial,  and  even  after 
the  administration  of  an  anaesthetic."  On 
the  other  hand,  Tait  states  that  "  there 
are  three  cases  of  insanity  of  the  most  pro- 
nounced type  completely  cured  by  the  re- 
lief of  the  sufferings  incurred  by  the 
haemorrhagic  myoma.  Besides  this,  there 
are  a  number  of  cases  of  striking  eccen- 
tricities and  ill  temper,  clearly  due  to  the 
sufferings  which  have  been  equally  re- 
lieved." 

One  lesson  to  be  deduced  from  this 
api^arent  conflict  of  experience  is,  that 
the  question  demands  earnest  and  ex- 
tended inquiry.  One  difficulty  in  the 
way  is  that  the  subsequent  history  of  the 
subjects  of  operation  can  hardly  be  com- 
plete. 

We  will  offer  this  one  reflection.  It 
seems  more  rational  to  look  for  freedom 
from  mental  disease  in  those  women  who 
have  undergone  a  successful  operation  for 
the  cure  of  an  ovarian  or  uterine  disease. 
Such  diseases  we  know  are  apt  to  entail 
nervous  disorders,  and  we  have  seen  that 
the  nervous  disorders,  when  complicating 
disease  of  the  sexual  organs,  are  fre- 
quently cured  when  the  diseased  organs 
are  removed.  But  another  inquiry  should 
also  be  instituted  as  to  the  influence  of 
removal  of  the  healthy  organs  on  the 
nervous  system. 

As  to  the  question,  are  we  justified  in 
operating  on  a  lunatic  who  cannot  give  a 
responsible  assent  ?  In  a  case  which 
came  under  our  notice,  the  indication  to 
remove  the  ovaries  was  to  our  judgment 
decisive.  We  were  supported  by  the  as- 
sent of  her  guardian,  of  an  eminent  hos- 
pital physician,  and  of  a  distinguished 
alienist,  but  we  declined  to  undertake  the 
responsibility  without  the  sanction  of  the 
Commissioners  in  Lunacy.  The  patient 
continued  insane.  Sir  Spencer  Wells,  in 
a  case  somewhat  different,  being  con- 
sulted as  to  the  legality  of  ovariotomy 


Oxaluria  and  Insanity 


[    877    ] 


Pachymeningitis 


upon  a  lunatic,  asked  Sir  William  Har- 
court,  tben  Home  Secretary,  who  said, 
"  If  she  is  incapable  of  judging  for  herself, 
treat  her  as  if  she  was  an  infant!  "  So  the 
operation  was  done  ;  the  patient  recovered 
and  married.  Surely  this  dictum  is  good 
sense  as  well  as  good  law. 

Does  epilepsy,  often  so  intimately  asso- 
ciated with  menstruation,  justify  removal 
of  the  ovaries  ?  Lawson  Tait  ("  Diseases 
of  the  Ovaries,"  p.  328)  has  removed  the 
ovaries — Battey's  operation — in  five  cases 
under  this  indication.  All  recovered  from 
the  operation,  but  the  results  as  regards 
cure  were  not  so  satisfactory  as  to  en- 
courage him  to  pursue  the  practice.  "VVe 
believe  that  the  cases  are  quite  excep- 
tional in  which  it  can  be  advantageous  m 
epilepsy.*  Robert  Barnes. 

OXAIiURIA    ANTS    INSANITY. — It 

has  been  noticed  that  the  continued  pre- 


sence in  the  ui-ine  of  oxalates  has  often 
been  associated  with  symptoms  of  nervous 
depression,  dyspepsia,  hypochondriasis 
and  even  melancholia.  These  affections 
have  been  said  to  be  dependent  on  as  well 
as  associated  with  the  presence  of  oxalates. 
It  must  however  be  owned  that  oxalates 
are  frequently  found  in  the  urine  of  per- 
sons in  excellent  health,  and  it  seems  as 
likely  that  the  oxaluria  is  dependent  on 
the  deranged  digestion,  want  of  assimila- 
tion and  nervous  depression,  as  that  the 
latter  are  dependent  on  the  former.  (See 
Urixe.) 

oxv.a:sTHx:szA  (o^vs,  sharp,  acute ; 
aia-drfcns,  sensation).  Abnormally  acute 
power  of  sensation,  such  as  occurs  in  cer- 
tain forms  of  hysteria. 

OXVGEUSZA  ((5£vs,  sharp,  acute; 
yevais,  taste).  Excessive  acuteness  of 
taste. 


PACHYMENINCXTZS  INTERNA 

H.S:iVIORR,HACICA.  —  Arachnoid 
Cysts.  Arachnoid  Haematoma.  Hse- 
matoma  of  the  Dura  Mater  (7ra;(us,  thick; 
/i^fty^,  membrane). 

1.  Cerebral. — The  conditions  variouslj'- 
described  under  one  or  other  of  the  above 
names,  although  not  unknown  under  other 
circumstances,  are  nevertheless  met  with 
in  overwhelming  pi'eponderance  in  asso- 
ciation with  the  various  forms  of  mental 
disease.  Hence  it  follows  that  it  is  chiefly 
in  asylum  practice  that  the}'  come  under 
notice.  Among  the  insane  inmates  of 
asylums,  indeed,  the  condition  is  far  from 
uncommon  ;  nevertheless,  in  spite  of  the 
opportunities  thus  atForded  for  the  study 
of  the  affection,  much  difference  of  opinion 
has  existed  as  to  its  pathology,  which 
perhaps  even  now  can  hardly  be  said  to  be 
thoroughly  elucidated. 

Since  the  morbid  appearances  met  with 
vary  greatly  in  different  cases,  it  will  be 
convenient  to  single  out  two  or  three  of  the 
leading  types  of  the  affection  for  brief 
description. 

In  what  may  perha])s  be  styled  the 
simplest  form,  the  inner  surface  of  the 
dura  mater  is  found  to  be  covered  to  a 
greater  or  less  extent  with  a  thin,  delicate, 

*  See  I'aptT  read  hcforc  tlie  Hrit.  Gynscolos, 
Soc.  by  Dr.  Barnes,  "  On  the  Correlations  of  the 
Sexual  Functions  anil  ,'Mental  Disorders  of 
Women,"  Oet.  8,  1890,  and  tlie  disenssion  \vlii(di 
followed,  in  which  Drs.  Savage,  Wilks,  Hack  Tuke, 
Mcrcier,  ISantock,  1!.  T.  Smith,  Heywood  Snuth, 
Hush  Fenton,  I'erey  Smith,  JIacnauuhteu  .Jones, 
Lankford  (U.S.A.).  took  pan. 


gelatinous  film  or  pellicle,  which  is  almost 
always  more  or  less  coherent,  so  that  what- 
ever be  its  degree  of  tenuity,  it  can  gene- 
rally be  detached,  to  a  certain  extent  at 
any  rate,  as  a  distinct  membrane  ;  the 
film  may  be  colourless  and  translucent,  or 
have  a  slightly  yellowish  tint,  or  may 
present  a  reddish  hue  over  a  large  portion 
of  its  area,  and  it  is,  in  any  case,  very 
generally  spotted  or  blotched  with  black, 
rust-coloured  or  ochreous  dots  or  patches. 
On  raising  the  film  with  forcej^s  from  the 
inner  surface  of  the  dura  mater,  to  which 
it  is  loosely  adherent,  the  epithelial  sur- 
face of  this  latter  membrane  is  seen  to 
present  its  usual  smooth,  shining  cha- 
racter, and  to  be,  to  all  appearance,  un- 
altered. 

The  most  common  situation  for  such 
a  membranous  film  is  the  convexity  of  the 
hemispheres,  and  if  occurring  to  but  a 
small  extent  it  may  be  confined  to  the 
parietal  region  of  one  or  both  sides  ;  fre- 
quently, however,  it  extends  down  towards 
the  base,  and  occupies  a  portion  of  the 
middle  and  occipital  fossas,  one  or  both  ;  or 
it  may  reach  into  the  middle  fossa  on  one 
side  and  the  occipital  on  the  other.  When 
spread  over  a  more  extended  area  the 
membrane  is  usually  thicker  than  that 
above  noted,  as  will  be  shortly  described. 
It  tapers  oft"  gradually,  so  that  its  boun- 
daries are  not  clearly  defined.  At  other 
times  the  membrane,  although  still  pre- 
serving a  soft,  filmy  character,  has  a  more 
decided  ba^morrhagic  appearance  than  is 
indicated  in  the  above  description;  indeed, 


Pachymeningitis 


[    878    ] 


Pachymeningitis 


one  of  the  most  common  forms  under 
which  this  condition  occurs,  is  that  of  a 
thin,  reddish,  or  reddish-black  peUicle, 
spread  over  the  inner  surface  of  the  dura 
mater  and  loosely  attached  thereto,  which 
both  to  the  naked  eye  and  to  the  micro- 
scope has  much  the  appearance  of  recent 
blood  clot.  Frequently,  however,  the 
morbid  phenomena  met  with  are  much 
more  pronounced  than  those  above  de- 
scribed. It  is  not  uncommonly  the  case 
that  large,  soft,  reddish,  reddish-black, 
chocolate-brown,  or  buff-coloured  mem- 
branes are  found  lining  the  whole,  or  a 
large  portion,  of  the  inner  surface  of  the 
dura  mater,  occupying  not  only  the  con- 
vexity, but  spreading  also  over  the  fossae, 
and  varying  in  thickness  from  i  to  3  mm. 
or  more ;  they  are  still  but  loosely  attached 
to  the  inner  surface  of  the  dura  mater, 
from  which  they  can  be  I'eadily  peeled  off. 
It  is  usually  the  case,  under  such  circum- 
stances, that  a  considerable  quantity  of 
reddish  serum  is  found  in  the  sub-dui"al 
space,  and  the  surface  of  the  cerebral 
convolutions  may  present  in  places  a  flat- 
tened ajjpearance  as  if  they  had  been 
subjected  to  pressure,  and  here  and  there 
they  may  be  tinged  with  a  rusty  red  or 
ochre  hue,  as  if  from  imbibition  of  blood- 
colouring  matter.  The  surfaces  of  these 
soft  membranes  are  frequently  paler  and 
more  fibrinous-looking  than  the  central 
parts,  so  that  on  section  the  membrane 
shows  a  dark  centre  bounded  by  paler  lines, 
and  sometimes  they  consist  of  two  distinct 
laminae,  the  space  between  which  is  occu- 
pied with  broken-down  or  variously  altered 
blood,  or  serum.  When  this  is  the  case, 
thewhole  presents  something  of  theappear- 
ance  of  a  cyst,  hence  one  of  the  names 
under  which  this  condition  has  been  de- 
scribed. Like  the  thin  filmy  pellicles,  these 
larger  membranes  taper  oft'  gradually  at 
their  extremities. 

Under  other  circumstances  the  mem- 
brane is  found  to  have  acquired  a  firmer 
consistence  and  a  paler  tint,  and  to  present 
much  more  the  appearance  of  a  la3'er  of 
fibrin  ;  these  characters  may  prevail 
throughout  its  whole  extent,  but  more 
commonly,  perhaj^s,  portions  of  the  lamina 
are  pale  and  fibrinous-looking,  whilst  in 
other  portions  the  signs  of  recent  luumor- 
rhage  predominate.  The  union  with  the 
dura  mater  is  somewhat  more  intimate 
than  in  tlie  cases  hitherto  noted,  but  the 
membrane  can  still  be  readily  stripped 
from  the  surface  to  which  it  is  attached. 

But  at  times,  although  somewhat  rarely, 
the  whole  of  the  inner  surface  of  the  dura 
mater  is  found  to  be  lined  with  a  firm 
fibrinous  membrane  varying  from  2  to  4 
mm.,  or   more,   in  thickness  ;  this  mem- 


brane is  not  homogeneous,  but  consists  of 
several  distinct  layers  of  fibrin,  which  are 
more  or  less  separable  from  each  other ; 
the  adhesion  to  thedura  mater  ismuch  more 
intimate  than  in  any  of  the  cases  hitherto 
described,  the  whole,  in  fact,  appearing  to 
form  one  laminated  membrane  ;  the  adhe- 
sions, which  are,  for  the  most  part,  vas- 
cular in  nature,  can  however  always  be 
broken  down  without  difficulty.  The 
entire  surface  of  the  dura  mater  may  be 
thus  coated,  including  all  the  fossae  at  the 
base  of  the  skull,  with  the  exception  of 
that  beneath  the  tentorium  cerebelli,  in 
which  position  it  is  rarely  met  with ;  the 
membrane  is,  however,  seldom  or  never 
equally  thick  throughout;  almost  in- 
variably it  is  thickest  over  the  convexity, 
and  gradually  tails  off  in  the  fossae, 
Ijeing  generally  thinnest  over  the  orbital 
plates. 

Although  the  leading  types  of  the  affec- 
tion have  been  described  separately,  it 
must  not  be  supposed  that  any  hard-and- 
fast  line  can  be  drawn  between  them. 
Contrasted  as  they  are  in  their  extremes, 
as  instanced  in  the  delicate  gelatinous 
films,  and  the  thick  laminated  fibrinous 
membranes,  they  nevertheless  graduate 
into  one  another  by  an  almost  perfect 
gradation  of  transitional  forms  ;  not  only 
so,  but  it  is  common  to  find  the  different 
forms  mixed  up  in  the  same  case  ;  thus,  a 
portion  of  the  dura  mater  may  be  lined 
with  a  fibrinous  lamina  of  greater  or 
less  thickness,  and  on  the  surface  of  this 
latter  lamina  may  be  found  a  distinctly 
liaemorrliagic  membrane  of  obviously  much 
more  recent  origin. 

A  word  or  two  as  to  the  microscopical 
appearances.  In  the  case  of  the  thin 
hfBmorrhagic  membranes  first  described, 
we  find  a  meshwork  of  hbrin  in  which  are 
entangled  red  and  white  corpuscles,  the 
whole  having  much  the  character  pre- 
sented by  a  layer  of  blood-clot.  But  as 
the  membrane  becomes  thicker  and  more 
fibrinous  we  find  the  appearances  change. 
Bands  of  imperfectly  formed  fibrous  tissue 
now  make  their  appearance,  running 
parallel  to  one  another,  and  to  the  surface 
of  the  membrane,  and  containing  long 
oval  nuclei;  between  , the  bands  may  be 
seen  in  places  collections  of  red  blood- 
globules  without  definite  boundary  wall, 
whilst  delicate  newly  formed  capillary 
vessels  are  numerous.  Whilst  in  the 
case  of  the  firm  fibrinous  membranes  the 
fibrous  bands  have  become  closer,  the 
nuclei  more  distinct  and  the  capillary 
vessels  less  numerous,  collections  of  red 
blood-globules  a,re  no  longer  met  with, 
but  little  heaps  of  ha3matoidiu  granules 
are  frequent. 


Pachymeningitis 


[    879    ] 


Pac  hy  me  ningitis 


But  although  the  above  are  the  chief 
types  of  what  has  been  described  as 
pctchymeningiiis,  an  incorrect  idea  would 
be  obtained  of  the  affection  did  we  not 
include  other  cases  which,  though  not 
usually  grouped  under  this  term,  never- 
theless appear  to  the  writer  to  have  a 
most  important  bearing  on  the  question 
of  pathology. 

Allusion  is  made  to  the  presence  of 
fluid  blood  in  the  sub-dural  space,  or  of 
this  combined  with  recent  blood-clot  lying 
upon  the  surface  of  the  arachnoid  or  dura 
mater,  but  not  forming  a  continuous  mem- 
brane. Such  cases  occur  more  frequently 
than  is  supposed.  Thus,  out  of  54  cases 
observed  by  the  writer  in  which  blood  or 
membrane  or  both  combined  were  found 
in  the  sub-dural  space,  no  less  than  8 — 
about  one- seventh  of  the  whole — pre- 
sented fluid  blood  or  recent  clot  without 
the  presence  of  any  trace  of  membrane  on 
the  inner  surface  of  the  dura  mater. 

Before,  however,  discussing  the  patho- 
logy of  the  aff'ection,  it  will  be  convenient 
to  consider  certain  facts  bearing  on  its 
etiology. 

The  writer  has  elsewhere  given*  an 
analysis  of  42  cases  of  this  disease,  which 
had  come  under  personal  observation  in 
Eainhill  Asylum,  and  to  these,  12  others 
can  now  be  added,  raising  the  total  to  54. 

These  54  cases  occurred  in  a  series  of 
637  unselected  post-mortem  examinations 
of  insane  patients,  which  gives  a  percent- 
age of  8.47  cases  of  hcematoma,  on  the 
whole  series  of  autopsies. 

In  the  54  cases,  the  age  of  the  youngest 
patient  was  thirty,  that  of  the  oldest 
eighty-flve,  the  average  age  of  the  whole 
being  51.61,  the  average  age  of  the  asylum 
population  from  which  the  cases  were 
drawn  being  about  43.33.  Taking  the 
cases  according  to  the  decades  at  which 
they  occurred,  we  get  the  following 
result  :— 

Cases. 
From  30  to  40  years  .  .  .  n 
„  40  „  50  „  .  .  .  13 
,,  50  ,,  60  „  .  .  .  18 
,  60  „  70  „  .  .  .6 
„  70  „  80  „  .  .  .3 
„      80  „  90      „       .         .         .3 


Total 


54 


Hence  it  appears  clear  that  haamatoma  or 
pacbymenmgitis  is  an  affection  of  ad- 
vancing years,  the  decade  between  fifty 
and  sixty  seeming  to  be  the  one  most 
obnoxious  to  the  disease.  Of  the  637 
autopsies,  in  330  the  patients  were  males, 
and  in  307   females ;  whereas  of  the   54 

*  "  On  liicmorrhaucs  and  False  Membranes 
within  the  Cerebral  Sub-dural  Space  occurring-  in 
the  Insane,"  ./oiiriial  0/  Men  fat  Sciiiicc,  .Ian.  1888. 


cases  of  hfematoma  3 1  were  males,  and  23 
females.  This  gives  a  percentage  of  9.39 
on  the  total  number  of  male  cases  ex- 
amined, and  of  7.49  on  the  total  number 
of  females.  These  figures  indicate,  there- 
fore, that  ha^matoma  is  more  common  in 
males  than  in  females,  a  result  which  is 
in  accordance  with  the  usual  opinion. 

The  greater  preponderance  of  male  cases 
becomes  more  pronounced  if  we  take  ex- 
amples of  general  paralysis  only.  Thus, 
out  of  126  cases  of  this  disease  in  males, 
hrematoma  was  met  with  in  23 — a  per- 
centage of  18.25;  whereas  out  of  49  female 
cases,  6  occurred — a  percentage  of  12.24. 

Coming  now  to  the  form  of  mental  dis- 
order, we  find  that  the  54  cases  of  htema- 
toma  can  be  classified  as  follows  : — 

Cases. 


(ieneral  paralysis  . 

.     29 

^Melancholia,  acute 

3 

,,             chronic 

2 

Jrental  stupor 

I 

^Mania  with  epilepsy- 

I 

Chronic  mania 

4 

„           ,,        with  dementia 

2 

Senile  mani-i 

I 

Dementia,  secondary 

5 

senile    . 

.       6 

Total 


54 


Hence  it  appears  that  hematoma  is 
somewhat  more  common  in  general  para- 
lysis than  in  all  other  forms  of  insanity 
put  together.  This  great  preponderance 
of  cases  of  general  paralysis  is  also  shown 
by  the  statistics  of  Sir  James  Crichton 
Browne,  who  found  *  that,  out  of  a  series 
of  59  cases  of  all  forms  of  insanity  in 
which  hrematoma  was  met  with,  29  were 
examples  of  general  paralysis. 

It  is  further  apparent  from  the  above 
statement  that  it  is  chiefly  in  cases  of 
chronic  insanity  that  this  affection  comes 
under  notice,  for  in  only  3  out  of  the 
54  cases  had  the  mental  disease  been  of 
less  than  three  months'  duration,  and  in 
the  vast  majority  it  had  been  reckoned 
rather  by  years  than  by  months. 

Although  it  is  not  unusual  for  the  affec- 
tion to  be  unilateral,  it  is  more  common 
to  find  both  sides  of  the  brain  involved. 
Of  the  54  cases,  20  were  entirely  unilateral, 
and  34  bilateral.  In  many  of  these  latter 
cases,  however,  the  disease  was  more 
marked  on  one  side  than  the  other,  and  in 
7  of  them  the  difference  was  pronounced. 
When  one  side  only  is  involved,  the  dis- 
ease does  not  appear  to  have  a  marked 
preference  for  either ;  thus,  of  the  above 
20  unilateral  cases,  in  10  the  right  side 
was  affected,  and  in  10  the  left.  Sir 
James  Crichton  Browne,  however,  thinks 

*  Joitrnal  of  Psychological  Medicine,  Oct.  1875. 


Pachymeningitis 


[    880    ] 


Pachymeningitis 


that  tlie  left  side  is  the  one  most  prone  to 
be  attacked. 

Although  it  is  chietly  among  those  re- 
cognised as  insane  that  the  affection  is 
met  with,  it  also  occurs  in.  the  subjects  of 
chronic  alcoholism,  a  neurosis  which  is  in- 
deed closely  allied  to  insanity,  and  which 
connotes  a  similar  brain  degeneration. 
Apart  from  these  conditions,  and  exclud- 
ing traumatic  cases,  the  affection  appears 
to  be  extremely  rare. 

"What  is  the  pathology  of  the  conditions 
above  described  under  the  name  pachy- 
meninijUis  or  luvmatoma  of  dura  mater '^ 

Two  opposing  theories  have  been  formu- 
lated with  reference  to  it.     The  one  de- 
scribes the  phenomena  met  with  in  terms 
of  inflammation,  and,  whilst  recognising 
the  hsemorrhagic  element,  regards  this  as 
secondary   to    a    primary    inflammatory 
change  ;  the  other  ignores  the  agency  of 
inflammation,  looking   upon  this   at  the 
most  as  secondary  and  trivial,  and  attri- 
butes the  appearances   presented  to  the 
organisation  more  or  less  partial  or  com- 
plete of  a  primary  hiemorrhagic  effusion. 
According  to  the  inflammatory  theory, 
the  thin   gelatinous    film   which   is   met 
with  on   the   inner  surface  of  the  dura 
mater  is  the  result  of  an  inflammatory 
exudation  from  the  vessels  of  the  dura 
mater    itself.      This    film   becomes    per- 
meated with  delicate  thin  walled  capil- 
laries, and  gradually  becomes  organised. 
Other  similar   films   are  developed  upon 
this  in  slow  succession,  until  at  length  a 
laminated  membrane  is  formed.     To  ac- 
count for  the  haamorrhagic  element  it  is 
supposed  that  the  delicate  newly  formed 
vessels  which  ramify  through  the  mem- 
brane frequently  become   ruptured,   and 
pour  out  their  contents  in  greater  or  less 
amount ;  and  that  the  presence  of  recent 
clot,  or  of   pigment   granules   and  other 
forms  of  altered  blood,  may  thus  be  ex- 
plained.    This  interpretation  of  the  phe- 
nomena   was     especially    advocated     by 
Virchow,  and  it  is  to  the  authority  of  that 
great  name  that  we  are  indebted  for  the 
predominance  of  the  inflammatory  theory. 
The  opposite  view,  according  to  which  the 
primary  mischief  is  a  hemorrhagic  effu- 
sion, was  insisted  on  by  Prescott  Hewett  * 
and  others   before  Virchow's   researches 
on  the    subject;    Hugueninf   has    since 
then  revived  this  view,  and  more  recently 
the  present  writer,+  as  the  result  of  an 
entirely   independent    investigation,   has 
come  to  the  same  conclusion. 

It  is  reasonable  to  suppose  that,  if  the 
affection  were  a  primary  inflammation  of 

-    '•iledico-Chirur^ical  Trausactions,"  1845. 
t  Ziemssen's  '■  Cyclopadiii." 
J  Loc  <:it. 


the  dura  mater,  evidence  of  this  would  be 
afforded   by  the   condition   of   the   dura 
mater  itself.     This,  however,  is  far  from 
being  the    case.      As   previously   stated, 
when  the  membrane  is  stripped  from  the 
dura  mater  to  which  it  is  loosely  attached, 
the  epithelial  surface  of  this  latter  mem- 
brane is  seen  to  be  smooth  and  shining. 
There  is  no  capillary  injection  or  other 
evidence  of  inflammatory  mischief;  nor, 
indeed,  in  the  earlier  stages  at  least,  is 
there   any   increase   of  thickness.     It   is 
true  that,  in   association  with  the  thick 
laminated  fibrinous  membranes,  it  is  not 
uncommon  to  find  the  dura  mater  slightly 
thicker  than  normal,  and,   on   stripping 
the   false   membrane   from   it,  a   certaia 
roughness  may  be  left,  due  to  the  separa- 
tion  of   the  vascular  adhesions.      These 
changes    are,  however,  very  slight,   and, 
occurring  as  they  do  late  in  the  progress 
of  the  case,  are  much  more  readily  explic- 
able on  the  idea  that  they  are  occasioned 
by  the  irritation  set  up  by  the  clot,  than 
that  they  are  marks  of  a  primary  inflam- 
matory process.     It  is  reasonable  to  sup- 
pose that,  if  the  latter  supposition  were 
correct,  the  signs  of  inflammation  would 
be  abundantly  manifest,  and  not  either 
altogether  absent,  or  trivial  and  equivocal. 
As  is  well  known,  a  thrombus  in  a  vein 
sets   up   irritation   in   the   walls   of    the 
vessel  with  effusion  of  leucocytes,  and  it 
is  through  the  agency  of  these  migratory 
cells  that  the  clot  becomes  adherent  to 
the  vessel,    and   subsequently  undergoes 
organisation.     ISTow,  the  inner  surface  of 
the  dura  mater  may  be  compared  to  the 
inner  wall  of  a  vein  within  which  coagu- 
lation  has   occurred,    and    the   fibrinous 
membranes  found  beneath  the  dura  mater 
may  be  looked  upon  as  clots,  which  have 
undergone  partial  organisation  through 
the  agency  of  the  leucocytes  which  have 
migrated   from   the  vessels  of   the  dura 
mater,  in  response  to  the  irritation  set  up 
by  these  clots. 

The  structure  of  the  membrane  itself 
supports  this  view.  The  reddish  or 
reddish-black  membranes  have  much  the 
appearance  both  to  the  naked  eye  and  to 
the  microscope  of  recent  clot,  whilst  the 
pale  laminated  membranes  closely  resem- 
ble the  fibrinous  thrombi  met  with  in 
veins  when  the  coagulation  has  been  of 
some  standing,  or  the  layers  of  fibrin 
occurring  in  the  sac  of  an  aneurism. 

The  laminated  membranes  are  doubt- 
less at  times  caused  by  successive  haemor- 
rhages ;  but  a  single  large  haemorrhage 
appears  quite  capable  of  producing  a 
laminated  appearance  owing  to  the 
changes  which  take  place  in  the  clot. 
In  an  organising  membrane  also  rupture 


Pachymeningitis 


[     88i     ] 


Pachymeningitis 


of  newly  formed  vessels  undoubtedly  at 
times  occurs,  producing  fresh  haemor- 
rhages, but  these  appear  to  be  always 
small  in  amount. 

On  the  theory  that  the  membrane  is 
formed  from  the  blood,  and  not  the  blood 
from  the  membrane,  it  is  reasonable  to 
suppose  that  the  hoBmorrhagic  effusion 
would  occasionally  occur  to  a  sufficient 
•extent  to  prove  fatal  before  there  was 
time  for  a  membrane  to  become  deve- 
loped. As  a  matter  of  fact,  as  indicated 
above,  such  cases  are  by  no  means  rare. 

If  it  be  argued  that  these  cases  are  not 
to  be  included  in  the  same  category  as 
those  in  which  a  sub-dural  membrane  is 
present,  it  may  be  replied  that  the  two 
•classes  of  cases  occur  under  just  the  same 
sets  of  conditions,  and  there  is  a  very 
gradual  transition  from  one  to  the  other. 

The  rarity  with  which  the  affection 
occurs  in  the  cerebellar  fossa3  is  also 
worth  noting.  Whilst  it  is  quite  common 
to  meet  with  a  hemorrhagic  membrane 
on  the  upper  surface  of  the  tentorium 
cerebelli,  it  is  very  rare  to  meet  with  one 
beneath  it.  On  the  inflammatory  theory 
such  a  condition  of  things  is  quite  inex- 
plicable, but  the  mechanical  obstacle 
which  the  tentorium  must  jjresent  to  the 
gravitation  of  blood  into  the  cerebellar 
fossas,  supplies  us  at  once  with  the  inter- 
pretation of  the  exemption  of  this  region. 
The  period  of  life  at  which  this  aflfec- 
tion  occurs  is  also  significant.  As  shown 
in  the  statistics  previously  quoted,  sub- 
dural hiBmatoma  is  distinctly  a  disease 
of  advancing  years,  and  the  connection 
between  age  and  arterial  degeneration  and 
tendency  to  heemorrhage  scarcely  requires  [ 
emphasising. 

The  affection  is  indeed  relatively  com- 
mon in  very  aged  dements  where  the  con- 
ditions are  as  little  favourable  to  intiam-  ; 
matory  action  as  can  well  be  imagined. 

The  inflammatory  theory  is  rejected 
then  in  favour  of  that  which  ascribes 
all  the  phenomena  met  with  to  the  simple 
effusion  of  blood  into  the  arachnoid 
■  cavity,  in  greater  or  less  quantit}-,  and 
it  may  be  more  or  less  frequently  re- 
peated. But  we  have  yet  to  inquire  into 
the  source  of  these  hasmorrhagic  effu- 
sions, and  into  the  reasons  for  their  occur- 
rence. With  reference  to  the  origin  of 
the  haemorrhage,  there  can  be  but  little 
doubt  that  it  comes  in  the  majority  of 
cases  from  the  vessels  of  the  pia  mater, 
which  occupy  the  summits  of  the  gyri ;  in 
these  regions  the  pia  mater  and  arachnoid 
have  in  many  cases  of  insanity  an  inti- 
mate union,  whilst  in  most  cases  of  general 
paralysis  they  are  so  glued  together  as 
practically  to  constitute  one  membrane,  so 


that  if  a  vessel  were  to  rupture,  it  would 
tend  to  pour  its  contents  direct  into  the 
arachnoid  cavity,  and  not  diffuse  them 
into  the  sub-arachnoid  space. 

Sometimes,  however,  as  the  writer  has 
observed,  the  blood  first  diffuses  itself  to 
a  small  extent  beneath  the  arachnoid, 
and  afterwards  bursts  into  the  sub-dural 
space. 

As  regards  the  reasons  for  such  rup- 
ture, the  writer  has  previously  expressed 
his  opinion  that  a  solution  of  the  problem 
is  to  be  found  in  two  of  the  conditions, 
which  singly  or  combined  occur  in  most 
cases   of  insanity — viz.,    wasting   of   the 
hemispheres,    and    general    or    localised 
congestion  of   the   meninges,  assisted  as 
these  conditions  undoubtedly  are  in  many 
cases  by   actual   degeneration   of    vessel 
walls.     Since   the   writer  published   this 
view,  he  has  found  that  Sir  James  Crich- 
!  ton     Browne    had    expressed    a     similar 
j  opinion,  and   that   Huguenin,  in   laying 
j  stress  on  the  brain-wasting  which  occurs 
j  in  the  class  of  cases  in  which  haimatoma 
I  is  met  with,  appears  to  have  had  the  same 
;  idea  in   mind.     It  is  clear,  indeed,  that 
the  atrophy  of  the  convolutions  must  tend 
to  remove  a  good  deal  of  support  from  the 
vessels  of  the  pia  mater  occupying    the 
summits  of  the  gyri,  and  thus  create  a 
tendency  to  congestion  and  rupture,  and 
if  we  analyse  the  conditions  under  which 
the  so-called  pachymeningitis  occurs,  we 
find  that  brain- wasting  is  the  one  feature 
that  is  common  to  all  cases  alike.     It  is 
not  asserted  that  hasmatoma  never  occurs 
without   cerebral    atrophy,  although   the 
writer  has  not  met  with  such  cases,  but 
the  two  conditions  are  at  any  rate  asso- 
ciated in  such  an  overwhelming  majority 
of  cases  that  the  connection  can  hardly  be 
accidental.     This  it  is  which  explains  the 
comparative    frequency    of    the    disease 
among  the  insane,  especially  where  the 
mental  affection  has  been  of  some  stand- 
ing, and  the  rarity  with  which  it  occurs 
outside  asylums. 

If  along  with  loss  of  support  from 
atrophy  of  convolutions,  there  is  attendant 
congestion  of  meninges,  either  local  or 
general  (which  again  may  itself  be  partly 
occasioned  by  loss  of  support),  it  is  clear 
that  the  conditions  favourable  to  rupture 
are  enhanced.  As  a  matter  of  fact,  the 
vessels  of  the  pia  mater  which  occupy  the 
summits  of  the  gyri  are  subject  in  many 
cases  of  insanity  to  repeated  and  violent 
attacks  of  congestion,  such  attacks  being 
especially  frequent  and  intense  in  general 
paralysis.  Thus,  it  is  not  uncommon  in 
cases  of  this  disease  to  find  patches  of 
extreme  congestion  of  the  pia  mater  so 
extreme  as  almost  to  resemble  an  ecchy- 


Pachymeningitis 


[    882     ] 


Pachymeningitis 


mosis.  ^Such  a  condition  is  of  course 
highly  favourable  to  actual  rupture,  and 
if  combined  with  this  there  is  weakness  of 
vessel  walls  from  degeneration,  we  have 
another  powerful  factor  in  favour  of 
hsemorrliage. 

Hitherto  no  mention  has  been  made  of 
the  symptoms  which  the  affection  occa- 
sions, and,  as  a  matter  of  fact,  in  the 
majority  of  cases,  any  symptoms  that 
may  be  pi'oduced  pass  unrecognised. 

This  circumstance  of  itself  points  to  the 
compensatory  nature  of  the  affection  ;  for 
making  every  allowance  for  the  fact  that 
the  disease  is  usually  met  with  in  de- 
mented persons  in  whom  symptoms  of  all 
kinds  are  masked,  there  can  be  little  doubt 
that  even  in  such  cases  an  inflammatory 
process  would  make  itself  known  more  fre- 
quently than  is  found  to  be  the  case  in 
the  affection  before  us. 

On  the  supposition,  however,  that  the 
blood  as  a  rule  does  little  or  nothing  more 
than  fill  up  the  space  left  by  the  wasting 
brain,  we  find  a  ready  explanation  of  the 
comparative  rarity  of  symptoms.  As  a 
matter  of  fact,  indeed,  the  affection  is 
usually  discovered  after  death  in  cases  in 
which  during  life  there  had  been  no  sus- 
picion of  its  presence. 

But  this  absence  of  symptoms  does  not 
always  occur.  Occasionally,  as  indeed 
one  might  expect  would  happen  at  times, 
the  effused  blood  does  not  stop  short  with 
filling  up  the  vacuum  left  by  the  wasting 
brain,  but  spreading  further  compresses 
the  surface  of  the  brain,  acts  as  an  irri- 
tant, and  declares  itself  by  such  signs  as 
convulsions,  paralysis,  &c.  Thus,  in  one 
case,  a  female  general  paralytic,  aged 
forty-four,  fell  down  one  morning  in  a  fit, 
and  for  some  twelve  hours  after  this  she 
lay  completely  comatose  with  all  her  limbs 
perfectly  paralysed,  and  fiaccid,  stertorous 
breathing,  abolition  of  reflexes, and  lowered 
temperature.  Death  occurred  nine  months 
after  this  attack,  and  a  thick  fibrinous 
membrane  was  found  coating  the  whole  of 
the  inner  aspect  of  the  dura  mater. 

In  another  case,  that  of  a  female  aged 
fifty-eight,  who  had  melancholia  with  delu- 
sions of  persecution,  the  patient  one  evening 
was  found  comatose,  with  complete  para- 
lysis of  left  side.  After  death,  which  oc- 
curred in  34  hours,  a  recent  clot,  mostly 
black  in  colour,  was  found  in  the  sub-dural 
space,  covering  the  frontal,  parietal  and 
temporo-sphenoidal  lobes  on  the  right 
side  only,  and  weighing  altogether  92 
grammes. 

In  a  third  case,  a  female  senile  dement, 
aged  seventy-one,  was  seized  with  convul- 
sions, bilateral,  but  more  marked  on  right 
side  than  onlett,  with  conjugate  deviation 


of  head  and  eyes  to  right.  Death  occurred 
in  the  course  of  twelve  hours,  and  at  the 
autopsy  recent  clot  was  found,  loosely  at- 
tached to  the  dura  mater,  spread  over  both 
hemispheres,  but  being  distinctly  more 
pronounced  on  the  left  side  than  the 
right. 

In  a  fourth  case  in  which  a  female  gene- 
ral paralytic, aged  twenty-eight,  died  seven 
days  after  being  seized  with  severe  left- 
sided  convulsions  succeeded  by  paralysis, 
followed  three  days  later  with  signs  of 
irritative  contracture  of  right  arm,  there 
were  found  at  the  autopsy  two  haemor- 
rhagic  membranes,  already  commencing 
to  organise,  a  small  one  on  the  left  and  a 
larger  one  on  the  right ;  the  latter  occu- 
pied the  whole  of  the  convexity  and  dipped 
down  into  the  fossas ;  it  was  about  3  mm. 
in  thickness,  attached  loosely  to  the  dura 
mater,  and  its  surfaces  were  already  be- 
coming fibrinous. 

If  these  last  cases,  instead  of  proving 
rapidly  fatal,  had  been  prolonged  for  a  few 
weeks  or  months,  the  inference  is  that  a 
fibrinous  membrane  would  have  been 
found,  as  in  the  first  case. 

In  two  or  three  other  cases  observed  by 
the  writer  when  the  haemorrhage  was  less 
in  amount,  and  death  did  not  occur  for  a 
fewdays,anirregulai\elevation  of  temjjera- 
ture  was  noted,  also  occasional  vomiting, 
and  a  tendency  to  frequent  restless  move- 
ments of  the  upper  extremities.  Drowsi- 
ness, or  a  deepening  of  the  usual  hebetude, 
and  headache,  were  likewise  at  times  ob- 
served. Even,  however,  when  the  ha3mor- 
rhage  has  been  sufficient  to  produce 
localised  paralysis,  it  is  often  a  matter  of 
extreme  difficulty  to  determine  whether 
the  effusion  has  taken  place  within  the 
substance,  or  upon  the  surface,  of  the 
brain. 

Huguenin  mentions  as  very  important 
gradually  appearing  symptoms  of  super- 
ficial lesions  of  both  hemispheres,  facial 
paralysis,  hemiparesis  on  the  same  side, 
and  then  symptoms  of  irritation  or  para- 
lysis on  the  opposite  side. 

The  writer  thinks  also  that  ceteris 
paribus,  the  coma  is  not  so  profound  when 
the  effusion  takes  place  upon  the  surface 
of  the  brain,  as  when  it  occurs  within  its 
substance. 

It  will  be  observed  that  the  diagnosis, 
unsatisfactory  as  it  is,  rests  upon  the 
recognition  of  the  initial  haemorrhage, 
and  the  symptoms  of  irritation  set  up  the 
clots,  and  that  the  formation  of  membrane 
does  not  declare  itself  by  symptoms. 

The  question  of  treatment  may  be  dis- 
missed in  a  few  words.  Having  regard  to 
the  secondary  nature  of  the  affection,  and 
to  the  fact  that  it  is  comparatively  seldom 


Pachymeningitis 


[     883     ] 


Paracope 


recognised  durin!?  life,  treatment  is  for 
the  most  part  alike  uncalled  for,  and  of  no 
avail.  Where,  however,  a  copious  haemor- 
rhage pi'oduces  recognisable  symptoms, 
the  indications  for  medical  treatment  are 
the  same  as  those  for  cerebral  haemor- 
rhage generally,  with  the  exception,  per- 
haps, that  local  measures,  such  as  ice  to 
the  head,  are  likely  here  to  be  more  effica- 
cious. When  the  symptoms  are  obviously 
those  of  brain  compression,  surgical  inter- 
ference may  at  times  be  resorted  to  with 
a  successful  result.  The  rnle  of  the  tre- 
phine in  this  affection  is,  however,  a  very 
limited  one,  and  its  frequent  use  would  be 
likely  to  have  a  deleterious,  rather  than  a 
beneficial  effect. 

2.  Spinal. — Under  this  head  it  is  not 
2)roposed  to  deal  svith  the  affection  com- 
monly known  as  pachymeningitis  of  the 
cord,  descriptions  of  which  may  be  found 
in  all  works  on  neurology.  Allusion  is 
rather  made  to  the  jji'esence  of  hsemor- 
rhagic  and  fibrinous  membranes  within  the 
spinal  canal,  which  appear  to  be  analogous 
to  those  already  described  within  the 
cranium.  This  affection  is  far  less  fre- 
quent in  the  spinal  canal  than  in  the 
cranium.  Mickle*  alludes  to  the  occa- 
sional occurrence  of  old  durhBematomata 
within  the  spinal  canal,  and  also  traces  of 
spinal  hEemorrhagic  pachymeningitis,  as 
well  as  softish  dark  clot  from  recent  spinal 
meningeal  hismorrhage  in  general  para- 
lysis ;  and  Savage  has  also  seen  pachy- 
meningitic  membranes,  and  recent  spinal 
haemorrhage  under  similar  circumstances. 
In  all  these  cases  the  membrane  or  blood 
was  found  within  the  sac  of  the  dura 
mater  between  it  and  the  surface  of  the 
cord. 

In  all  cases  observed  by  the  writer,  how- 
ever, the  membrane  was  situated  on  the 
outer  aspect  of  the  dura  mater,  between  it 
and  the  walls  of  the  spinal  canal.    In  three  j 
such  cases  t  there  was  a  fibrinous-looking  : 
membrane  from  2  to  4  mm.  thick,  occupy-  | 
ing   the  cervical  or  dorsal  region  of  the 
cord  lying  upon  the  outer  surface  of  the  ; 
dura  mater  on  its  posterior  aspect,  and 
being  loosely  attached  to  this,  and  to  the 
posterior  aspect  of  the  spinal  canal ;  the 
membranes  were  for  the  most  part  pale 
in  colour  and  soft  in  consistence;  in  one 
case  the  membrane  extended  along  some 
of  the  nerves  proceeding  from  the  cord. 

Dr.  Percy  Smith  has  described  an  exactly 
similar  case,  and  Dr.  Clouston  alludes  to 
two  others.  All  these  cases  occurred  in 
genei-al  paralytics. 

It  may  be  taken  for  granted,  there- 
fore, that  although  haemorrhagic  effusions 

*  ''General  Paralysis  of  the  Insane,''  and  ed. 
t  liritish  Mfitical  Journal,  Sept.  21,  i88q. 


may  be  found  within  the  spinal  arachnoid 
cavity  in  general  paralysis,  there  are  also, 
though  somewhat  rarely,  met  with  in  this 
disease,  fibrinous  membranes  lying  upon 
the  external  aspect  of  the  dura  mater 
between  it  and  the  spinal  canal,  and  oc- 
cupying usually  the  cervical  and  dorsal 
regions  of  the  cord.  The  balance  of  evi- 
dence seems  to  be  in  favour  of  these  mem- 
branes being  of  haemorrhagic  origin,  and 
comparable  to  the  somewhat  similar  mem- 
branes so  commonly  met  with  beneath  the 
cranial  dura  mater  in  this  disease.  It  is 
doubtful  how  far  they  produce  symptoms. 
In  one  of  the  writer's  cases  a  diagnosis 
was  made  during  life  by  the  presence  of 
symjitoms  of  irritation  of  spinal  nerves — 
viz.,  retraction  of  the  head  and  rigidity  of 
the  extremities ;  but  here  the  effusion  had 
extended  along  some  of  the  spinal  nerves, 
to  the  irritation  of  which  the  symptoms 
were  doubtless  attributable.  {See  Patho- 
logy.) Joseph  Wiglesworth. 

PACK,  THE  "WET.— A  form  of  treat- 
ment in  some  varieties  of  insanity.  {See 
Baths.) 

PAZiATE  IN  ZSZOTS. — In  genetous 
idiocy  the  shape  of  the  hard  palate  is 
often  very  characteristic.  It  is  high, 
very  arched  and  narrowed  from  side  to 
side,  so  that  the  molar  teeth  are  closely 
approximated.  This  kind  of  palate  is 
sometimes  met  with  in  healthy  individuals, 
but  if  it  is  present  in  a  young  subject  who 
is  showing  signs  of  mental  incompetency, 
it  is  useful  in  indicating  that  the  mental 
affection  is  probably  congenital.  {See 
Idiocy.) 

PAAIOISON-  (Fr.).  Hystei-ical  swoon- 
ing. 

PAMPHOBZA.     {See  Panophobia.) 

PAMPliEGZA.     General  paralysis. 

PAM-OPHOBZA,  PAN-PHOBZA  (deri- 
vation disputed  ;  either,  Tray,  all ;  0d(3os, 
fear;  or  from  the  legend  in  Herodotus, 
which  relates  that  Pan  assisted  the  Athe- 
nians at  Marathon  by  striking  causeless 
terror  among  the  enemy,  who  therefore 
fled  panic  stricken ;  a,nd  (f)6^os,  fear).  A 
variety  of  hypochondriasis  characterised 
by  groundless  alarm.  Indefinable  fear. 
Morbid  apprehension.  (Fr.  and  Ger. 
poitopliohie.) 

PANTAPHOBIA  (Trds:,  all  ;  a,  priv.  ; 
(f)6j3os,  fear).     Absolute  fearlessness. 

PANTOPHOBZA.     {See  Panophobia.) 

PARABUIiZA  {napd,  beside ;  (BovXij, 
will  or  purpose).  Disordered  mind  or 
purpose ;  perverted  will.  (Fr.  para- 
bulie.) 

PARACHOIiZA.      {See  PoLYCHOLIA.) 

PARACOPE  (TrapaKo-n-TO),  I  strike 
falsely).  Literally,  coining,  but  used  by 
Hippocrates  for   delirium,    especially  for 

3^ 


Paracoptic 


[ 


1 


Paralysis  Agitans 


the  slight  delirium  accompanying  fevers. 
Used  also  for  insanity.     (Fr.  paracope.) 

PiiRACOPTIC.  Insane ;  pertaining 
to  insanity. 

PARACOUSZA  (TvapaKovu),  I  hear  im- 
perfectly). False  sensations  of  hearing. 
Auditory  illusions.  (Fr.  paracousie ;  Ger. 
Falsclilwren.) 

PARACROVSZS,  PARACRUSIS  (tto- 
pnKpovco,  I  strike  aside).  Literally,  strik- 
ing a  false  note.  A  term  used  similarly  to 
paracope ;  applied  to  madness  by  Hippo- 
crates.    (Fr.  paracruse.) 

PARACUSIS  ZIVIAGIM-ARIA.  The 
hearing  of  imaginary  sounds,  not  existing 
outside  the  body.  (Fr.  paracuse  itnagi- 
naire.) 

PAR.a:STHESIA  {TTapd,  beyond;  aiadrf- 
a-is,  sensation).  Perverted  sensation  oc- 
curring in  the  form  of  "  tingling "  or 
"  pricking"  sensations,  when  a  part  of  the 
body  is  touched  or  injured.  A  symptom  in 
various  forms  of  mental  disease.  Also 
applied  to  perverted  emotional  states  (emo- 
tional parajsthesia).     (Fr.  paraistMsie.) 

PARACEUSIS  {irapd,  beyond ;  yevais, 
taste).  A  term  for  morbid  taste.  (Fr. 
parageiisie.) 

PARAGRAPHIA  {irapaypac^ci),  I  write 
improperly).  Thej  making  of  mistakes 
in  writing,  such  as  using  one  word  for 
another,  or  omitting  the  end  of  a  word ;  a 
manifestation  of  cerebral  disorder. — P. 
llteralis,  form  in  which  the  patient  cannot 
write  even  letters,  but  only  signs. — P. 
verbatis,  form  in  which  the  patient  is 
able  to  write  letters  or  syllables,  but  not 
complete  words. 

PARARVPirOSIS  {TTapa;  vnvos,  sleep). 
Abnormal  sleep  as  in  hypnotism  or  som- 
nambulism. 

PARAIiAIiIA  {napaXaXeo),  I  talk  at 
random).  A  permanent  or  temporary 
alteration  in  oral  expression  characterised 
by  the  retention  of  the  power  of  thought, 
and  of  formation  and  combination  of  ideas, 
and  yet  at  the  same  time  by  the  impossi- 
bility of  finding  the  right  words  to  express 
those  ideas,  or  of  co-ordinating  those  words 
which  can  still  be  articulated.  (Fr.  para- 
lalie.) 

PARAI.SEHYDE.      {See  SEDATIVES.) 

PARAIiEREMA  (7rapa,beyond ;  XTjpr]p.a, 
foolish  talk).     Delirium. 

PARAIiERESIS(7rapa,beyond ;  Xrjprjcris, 
dotage).  A  term  for  shght  delirium,  as 
from  fever.  (Fr.  paraUreme  ;  Ger.  Irre- 
reden.) 

PARAIiEROS,  PARAXiERVS  {napd- 
Xrjpos,  talking  foolishly).  Delirious.  (Fr. 
delirant;  Ger.  Irreredend.) 

PARAIiEXIA  (irapd ;  \e$is,  a  word). 
Difficulty  in  reading,  though  the  person 
may  be  able  to   write  readily  from   dic- 


tation; a  form  of  aphasia  with  word  blind- 
ness. 

PARAIiCESIS  (napd,  beyond ;  oKyos, 
pain).   The  abolition  of  pain.    Anaesthesis. 

PARAIiZiAGE,  PARAXIiAGMA, 
PARAIiIiAXIS  {-rrapaWda-cro},  I  pervert 
or  change).  The  terms  really  apply  to 
the  ovei'lapping  of  bones,  but  have  been 
applied  to  mental  aberration. 

PARAIiOGIA  (TTapd,  beyond;  Xoyos, 
speech).  A  slight  degree  of  madness  or 
delirium.     (Fr.  paralogie.) 

PARAI.YSIE  CER±BRAI.E,  PARA- 
I.VSIE  G±N'±RAI.E  (Fr.).  Terms  for 
general  paralysis  of  the  insane. 

PARAI.VSIE  DES  AX.lilN'ES  (Fr.). 
PARALYSE  I>£R  IRREM*  (Ger.) 
General  paralysis  (q.v.). 

PARAI.YSIS  AGITAirs,  Insanity 
associated  witb. — The  mental  disorders 
to  which  jDaralysis  agitans  may  give  rise 
have  not  as  yet  attracted  much  attention. 
This  is  not  surprising,  when  we  consider 
that  the  history  of  this  affection  is  but  of 
recent  date,  and  that  all  its  peculiarities 
have  not  yet  been  fully  recognised.  In 
1817  Parkinson  first  described  this  disease, 
which  has  sometimes  been  named  after 
him,  Parkinson's  disease,  but  in  spite  of 
most  careful  investigations,  the  anatomical 
lesions  connected  with  the  affection  have 
not  yet  been  elucidated. 

In  order  to  study  the  psychical  conse- 
quences of  paralysis  agitans,  we  must 
discriminate  between  tbree  groups  of 
mental  abnormalit3^ 

(1)  Those  patients  belong  to  the  first 
who  present  nothing  but  a  change  of 
temper  and  character ;  they  become  im- 
pressionable and  excessively  irritable,  are 
troubled  and  excited  about  trivial  matters, 
are  unable  to  bear  contradiction,  and  fly 
into  a  rage  at  the  slightest  provocation. 
They  insist  on  having  incessant  and  un- 
divided attention  shown  them,  while  they 
are  restless,  distrustful,  and  suspicious  ; 
they  will  not  allow  any  one  to  speak  near 
them  in  a  subdued  voice,  and  imagine  that 
people  try  to  hide  themselves  from  them  ; 
some  of  them  are  ashamed  of  themselves 
by  reason  of  their  atliiction  and  the  incon- 
venience that  results  therefrom ;  they 
become  taciturn,  and  indulge  in  emotional 
weeping  on  the  slightest  occasion;  this 
disposition  is  reflected  in  their  features, 
which,  in  many  cases,  partake  of  an  ex- 
pression of  intense  grief.  Lastly,  they 
become  indifferent  and  apathetic,  lose 
their  inclination  for  work,  and  no  longer 
derive  any  pleasure  from  matters  formerly 
interesting  to  them.  None  of  the  symp- 
toms mentioned,  i^roperly  speaking,  apper- 
tain to  insanity,  but  the  transformation 
brought  about  by  them  may  well  be  con- 


Paralysis  Agitans 


[    885    ] 


Paralysis  Agitans 


sidered  as  a  first  stage  of  mental  aberra- 
tion. Although  we  may  meet  with  similar 
modifications  in  many  other  nervous 
diseases,  we  have  to  recognise  that  grief 
and  irritability  are  two  tendencies  common 
to  paralysis  agitans. 

(2)  Patients  of  the  second  group  are 
those  who  present  weakening  of  the  intel- 
lectual faculties,  which  may  vary  from 
simple  blunting  of  the  mind  to  complete 
dementia.  Authors  have  paid  special 
attention  to  this  form  of  insanity  in 
paralysis  agitans,  and  most  of  them  de- 
scribe it.  The  disoi'der  manifests  itself  in 
a  weakened  intellect,  memory  becomes 
unreliable,  thought  is  slow  and  difficult, 
and  those  who  come  into  contact  with  the 
patient  note  that  he  no  longer  possesses 
his  ordinary  mental  lucidity.  The  symp- 
toms become  aggravated,  and  mental  de- 
crepitude ensues  long  before  the  advent  of 
old  age.  These  mental  conditions  are 
nearly  always  reflected  in  the  features  of 
the  patient  and  give  him  a  peculiar  aspect, 
which  may  be  considered  as  pathogno- 
monic of  the  affection  ;  the  face  is  immo- 
bile and  mask-like  in  its  changelessness 
of  expression,  the  eyes  at  the  same  time  are 
fixed,  and,  as  Ball  aptly  remarks,  the  ex- 
pression simulates  certain  cases  of  stuj^or 
with  melancholia  ;  in  the  latter,  however, 
the  intellect,  although  much  disordered, 
persists,  whilst  here,  on  the  contrary,  it 
fails,  and  the  patients  are  in  a  condition  of 
actual  dementia  which,  as  the  malady  pro- 
ceeds, becomes  aggravated  and  is  at  last 
quite  incurable. 

(3)  The  third  group  comprises  those  who 
present  symptoms  of  insanity  properly 
speaking.  The  knowledge  of  this  third 
group  is  of  recent  date,  and  is  to  be 
reckoned  only  from  the  time  when  Ball 
drew  attention  to  it  by  his  paper  read 
before  the  Section  of  Mental  Medicine  at 
the  International  Congress  in  London  in 
1881.  Before  that  time  only  two  or  three 
isolated  observations,  of  which,  however, 
little  notice  had  been  taken,  had  been  pub- 
lished. Since  then.  Ball  has  resumed  his 
inquiries  into  the  subject,  while  opportu- 
nities have  likewise  been  afforded  us  of 
investigating  this  psychosis. 

Positive  observations  leave  no  doubt 
that  paralysis  agitans  may  bring  about 
mental  disorder ;  in  fact,  none  of  the  usual 
causes  of  insanity  can  be  found  in  these 
cases,  and  notably  one  prominent  factor 
is  wanting  —  viz.,  hereditary  influence. 
There  is  no  reason  to  dispute  the  assump- 
tion that  paralysis  agitans  may  effect 
this  mental  disturbance,  because  we  have 
parallel  instances  in  chorea,  epilepsy,  and 
other  neuroses,  in  which  lesions  of  the 
nerve-centres  have  not   been  discovered, 


but  which  may  equally  be  the  causes  of 
mental  disorder. 

The  symptoms  of  insanity  in  paralysis 
agitans  are  variable.  The  most  common 
is  a  morbid  exaggeration  of  the  senti- 
ments or  the  grief  in  which  the  patients 
have  been  steeped  since  the  commence- 
ment of  the  malady,  into  a  melancholia 
proper,  which  may  either  be  simple,  or  con- 
sist of  a  more  or  less  profound  depression 
complicated  and  accompanied  by  hallu- 
cinations and  insane  ideas.  The  hal- 
lucinations may  afi'ect  either  hearing  or 
sight.  The  patient  believes  he  hears 
threatening,  insulting  or  mocking  voices. 
The  hallucinations  of  sight  are  very 
prominent  ;  he  may  see  himself  sur- 
rounded by  enemies,  and  he  may  hear  them 
at  the  same  time  ;  another  patient  sees 
his  bed  surrounded  by  individuals  who 
threaten  him  ;  while  another  imagines  his 
room  to  be  full  of  robbers,  and  sees  them 
groping  and  feeling  about  the  walls  ;  or  he 
sees  his  wife  surrounded  by  suspicious- 
looking  persons  who  wish  to  annoy  her. 
These  hallucinations  may  occur  by  day  as 
well  as  by  night.  There  are,  however, 
some  to  whom  they  occur  only  at  night, 
and  who,  with  the  approach  of  day,  cease 
to  be  troubled  by  such  sensory  disorders. 

The  insane  conceptions,  if  hallucina- 
tions are  present,  are  in  conformity  with 
the  latter,  and  partake  of  the  character  of 
ideas  of  persecution.  The  patients  believe 
themselves  besieged  by  enemies,  of  whom 
they  see  traces  everywhere  ;  they  imagine 
that  they  are  about  to  be  robbed,  or  that 
people  are  endeavouring  to  injure  them 
in  some  other  way.  Under  the  influence 
of  these  ideas  they  become  still  more  irri- 
table and  distrustful ;  they  carry  weapons 
in  order  to  defend  themselves,  and,  as  may 
readily  be  understood,  may  become  dan- 
gei'ous  to  those  about  them.  It  is,  how- 
ever, necessary  to  bear  in  naind  that  the 
ideas  of  persecution  obsei'ved  in  such  cases 
are  not  those  of  true  persecution  mania, 
especially  because  they  do  not  develop  in 
the  same  manner;  and,  in  addition  to  this, 
the  frequency  of  visual  hallucinations 
proves  that  we  have  here  a  m.orbid  con- 
dition quite  different  from  persecution- 
mania,  in  which  hallucinations  of  sight 
are  very  rare. 

Besides  hallucinations  and  insane  con- 
ceptions we  have  to  mention  disorders  of 
sensibility,  which  may  be  connected  with 
either  of  these  two  forms  of  mental  aber- 
ration. One  patient  believes  himself  con- 
sumed by  an  internal  fire  ;  another  feels 
pricks  and  cuts  on  his  skin ;  a  third  believes 
that  he  has  more  than  two  legs,  and  has 
the  sensation  of  having  one  in  front  and 
one  behind.     Some  patients  have  an  im- 


Paralysis  Agitans 


[    886    ] 


Paralysis  Agitans 


pression  that  their  legs  gradually  grow 
longer  until  they  reach  an  obstriictioji  at 
some  distance  from  them.  These  disorders 
are  undoubtedly  connected  with  the  cuta- 
neous hypera3sthesia  sometimes  met  with 
in  the  course  of  paralysis  agitans. 

One  of  the  most  serious  and  common 
symptoms  of  melancholic  depression  in 
paralysis  agitans  is  the  tendency  to  suicide 
which  is  found  in  the  majority  of  those 
labouring  under  this  affection,  and  is  due 
either  to  hallucinations,  insane  concep- 
tions, or  to  the  restlessness  and  weakness 
induced  by  the  disease  itself. 

The  symptoms  of  insanity  which  we 
have  here  enumerated  are  those  most  com- 
monly met  with  in  paralysis  agitans  ;  they 
are  always,  therefore,  of  a  depressive  type, 
bordering  in  some  cases  on  simple  melan- 
cholia, but  most  frequently  constituting  a 
melancholia  accompanied  by  multiple  hal- 
lucinations, or  suicidal  impulses.  There 
are  few  exceptions  to  this  rule.  Patients 
are  sometimes  to  be  met  with  who  are  con- 
tinually or  intermittently  the  subjects  of 
excitement.  There  are  also  some  who, 
without  being  actually  excited,  present  ani- 
mated accessions  of  a  gay,  self-satisfied 
character,  which,  by  their  alternation  with 
depression,  recall  the  symptoms  of  circular 
insanity. 

A  remarkable  jjeculiarity  of  the  insanity 
connected  with  paralysis  agitans  is  that 
sometimes  its  paroxysms  and  intermissions 
coincide  with  the  exaggeration  and  dimi- 
nution of  the  tremor.  According  to  Ball, 
this  coincidence  is  almost  the  rule.  He 
says :  "  The  disorders  of  the  intellect  in 
paralysis  agitans  are  not  permanent,  but 
appear  to  become  exaggerated  with  the 
aggravation  of  the  sensory  sj'^mptoms,  and 
they  seem  to  disappear  when  the  tremor 
decreases  or  ceases  entirely."'  Our  obser- 
vations, however,  point  to  the  fact  that  in 
some  well-determined  cases  intellectual 
disorder  is  developed  in  a  manner  abso- 
lutely independent  of  the  motor  and 
sensory  disorders. 

The  usual  tendency  of  the  insanity — 
whatever  its  form  may  be — is  to  lead 
rapidly  to  dementia,  and  therefore  the 
patients  of  the  third  group  are  easily  con- 
founded with  those  of  the  second. 

Is  insamty  frequent  in  the  course  nf  para- 
lysis agitans  ?  If  we  are  to  judge  merely 
from  the  small  number  of  observations 
recorded  it  would  appear  that  it  is  not. 
Ball,  however,  thinks  this  to  be  a  mistake, 
and  he  maintains  that  paralysis  agitans  is 
more  frequently  accompanied  by  mental 
disorders  than  is  generally  supposed.  The 
reason  why  we  do  not  see  it  is  because  the 
patients  in  some  way  hide  their  mental 
symptoms,  because  their  physical  disorder 


overshadows  their  mental  obliquity,  or 
because  they  advance  towards  dementia 
rapidly,  and  the  weakening  of  their  mental 
faculties  prevents  the  symptoms  of  in- 
sanity from  becoming  obvious.  With 
regard  to  insanity,  properly  speaking,  we 
have,  according  to  the  opinion  expressed 
by  Bucknil.l  and  Rayner  at  the  Congress 
in  London  in  i88i,  to  limit  ourselves, 
until  further  investigations  have  been 
made,  to  the  assertion  that  it  is  sometimes 
met  with  in  the  course  of  this  neurosis. 
We  have,  however,  at  the  same  time  to 
admit  thatthei'e  are  but  few  such  patients 
who  could  not  in  various  degrees  be  classi- 
fied under  one  of  the  first  two  groups 
which  we  have  enumerated. 

It  remains  for  us  to  study  the  patho- 
grenic  relation  between  paralysis  agitans 
and  insanity  ;  of  the  relation  itself  there 
can  be  no  doubt  as  we  have  already  indi- 
cated, but  the  fact  remains  that  in  the 
observations  published,  insanity  did  not 
develop  for  some  time  after  the  commence- 
ment of:  the  tremor ;  there  is  an  interval 
ranging  up  to  eight  years  between  the  two; 
beyond  this  statement,  however,  every- 
thing is  hypothetical.  If  it  were  proved, 
as  Ball  avers,  that  the  fluctuations  of  in- 
sanity are  intimately  connected  with  the 
variations  in  intensity  of  the  tremor,  it 
would  undoubtedly  be  necessary  for  these 
two  phenomena  to  be  attributable  to  one 
and  the  same  case.  On  the  other  hand, 
we  know  almost  nothing  about  the  patho- 
logical anatomy  of  paralysis  agitans,  so 
that  we  are  unable  to  refer  the  symptoms 
of  insanity  to  gross  cerebral  lesions.  As, 
however,  science  in  its  progress  has  estab- 
lished the  fact  that  every  form  of  insanity 
is  due  to  an  organic  or  functional  change 
of  the  nervous  centres,  we  maj''  be  per- 
mitted to  assume  that  insanity  in  paralysis 
agitans  obeys  the  same  law,  and  that  if 
mental  disorders  occur  in  this  neurosis  it 
is  because  some  modifications  have  been 
brought  about  in  the  brain  which  are  apt 
to  alter  and  jjervert  the  normal  mental 
operations. 

The  prognosis  and  the  treatment  of 
insanity  in  paralysis  agitans  are  the  same 
as  those  indicated  for  the  disease  which 
causes  it.  V.  Paraxt. 

[liifenmci", — 15.  Ball,  De  riiisanite  dans  la 
paralysie  anitantu.  Eucepliale.  1882.  V.  I'araut, 
La  paralysie  anitauto  exumiuee  comme  cause  de  hi 
Folio.  Aiiiiales  medieo-psychologiiiues.  1883.  Kiui;- 
rose  Atkins,  A  Case  of  Paralysis  Agitans  in  whicb 
Insanity  occnrred,  .Tourn.  Ment.  Sci.,  Jan.  1882. 
I'roceedings  of  the  International  ( 'on;;  ress  of  Lou- 
don, Journ.  Ment.  Sci..  Oct.  iSSi.] 

PARiiliYSXS,  ASCEWDING.— Term 
applied  to  cases  of  general  paralysis  which 
commence  with  tabetic  symptoms.  (See 
Locomotor  Ataxy.) 


Paralysis,  Galoppirende 


[    887    ] 


Paranoia 


PARAIiYSZS,  CAIiOPPXRENDi: 

(Ger.)  Term  applied  to  the  form  of  genei-al 
paralysis  ■whicli  runs  a  ra])id  fatal  coui-se, 
and  is  characterised  by  extreme  mental 
and  nervous  excitement  with  sudden  col- 
lapse. It  is  a  subdivision  of  the  mjifirle 
Fanii  of  general  i)aralysis  (Kraepelm). 

Pil.RAI.YTIC  IDIOCY,  OR  IMBE- 
CIlilTY.     (,SVe  Idiocy  and  Imhkcilitv.) 

PARiiX.YTIC  INSANITY.  Term 
applied  to  general  i)aralysis,  but  it  should 
be  restricted  to  insanity  following  ordinary 
paralysis. 

PARAMIIWCIA  (Tvapu  ;  fxifxio^ai,  I  imi- 
tate). Disordered  expression  ;  use  of  tone 
or  gesture  not  in  accord  with  the  words 
employed. 

PARAIVXNESIA  [napa,  beyond  ;  ^uijais, 
memory).  An  afiection  of  the  faculty  of 
expression  caused  by  a  loss  of  memory  of 
tlie  signification  of  words  heard  and  seen. 
(Fr.  paramncsie.)  (See  Mejiorv,  Dis- 
ORDEKS  or.) 

PARANEURISIVXUS  {napci,  beyond  ; 
vevpov,  a  nerve).  A  term  for  a  nervous 
affection.     (Pr.  panmeurisme.) 

PARANOIA.     {Si'e  Paranoia.) 

PARANOIA (TTopn,  beyond, the  opposite 
of;  voea>,  1  understand). — The  use  of  this 
word  has  become  very  frequent  in  Germany 
and  in  the  United  States,  but  it  has  not 
obtained  favour  in  Great  Britain.  It  was 
the  term  employed  by  Dr.  von  Gudden  in 
regard  to  the  mental  malady  under  which 
Leopold  II.  of  Bavaria  laboured.  The 
Greek  etymology  does  not  render  us  any 
assistance  in  the  endeavour  to  comprehend 
the  particular  class  of  case  to  which  it  is 
applied.  It  is  regarded  as  synonymous 
with  that  very  favourite  word  of  the  Ger- 
man alienists,  VerriicMlteit,  in  respect  of 
whicli  there  bas  been  so  much  difference 
of  opinion,  and  so  much  change  since  the 
time  of  Griesinger  to  the  present  day,  that 
a  lamentable  amount  of  confusion  and  j 
obscurity  bas  been  introduced  into  the 
nomenclature  of  this  form  of  mental  alien- 
ation, j 

Definition.  —  A  condition  of  which  \ 
chronic  and  systematised  delusion  is  the 
essential  sign.  English  alienists  have  con-  i 
sidered  "delusional  insanity"  a  suflBciently 
distinctive  term.  As  Koch  says,  "  without 
delusion,  no  Verriiclctlieit "' ;  and  he  adds 
"it  is  always  primary.'"  He  adopts  the 
view  that  there  is  no  secondary  form,  and 
that  therefore  it  is  needless  to  speak  of 
"primary"'  and  "secondary"  in  relation 
to  this  mental  affection.  On  the  con- 
trary, Griesinger  held  that  emotional  dis- 
turbance was  the  first  link  in  the  chain, 
that,  in  short,  it  was  the  basis  of  Verrilck- 
tlieit.  AVe  are  not  prepared  to  admit  that 
this  alienist  was  wrong,  and  to  say  with  | 


Koch  and  the  majority  of  German  alien- 
ists that  delusions  do  not  develop  out  of 
the  moral  soil.  Heredity  is  so  common 
in  this  form  of  insanity  that  it  is  usually 
assumed  that  it  springs  out  of  a  mental 
constitution  which  is  by  nature  aljnormal 
and  unstable.  At  the  same  time,  there  is 
not  originally  a  state  of  weakmindedness. 
Mental  instability  is  usually  present  from 
the  earliest  period  of  life ;  the  develop- 
ment of  insanity  may  not  occur  until  the 
patient  has  attained  his  majority,  or  later 
in  life.  The  prevalent  use  of  the  word 
no  doubt  implies  a  constitutional  tendency 
to  mental  disorder  of  a  delusional  type. 
Long  before  he  is  recognised  as  an  actual 
lunatic  he  is  styled  "  a  crank."  Hallucina- 
tions may  be  and  frequently  are  mixed  up 
with  delusions,  but  they  are  not  essential 
to  i3aranoia.  Delusions  of  persecution 
are  extremely  common,  and  lead  to  the 
commission  of  homicidal  acts. 

Drs.  Amadei  and  Tonnini  have  made  an 
elaborate  classification  of  systematised 
insanity  or  paranoia.* 

It  consists  of  two  great  classes — de- 
generative and  psycho-neurotic  paranoia. 
In  the  former  it  is  congenital,  being  due 
to  insane  inheritance.  Subdivisions  of 
this  class  are  (i)  cases  in  which  there  is  a 
very  early  and  sudden  outburst  of  abnor- 
mal symptoms,  (2)  cases  in  which  there  is 
a  gradual  development  of  mental  disorder. 
From  both  conditions  ma}'  arise  ideas  of 
persecution,  ambition,  morbid  religious 
views,  and  eroticism,  these  states  being 
accompanied  by  hallucinations,  or  not. 
And  the  same  holds  good  of  that  form  in 
which  the  symptoms  appear  gradually. 

Psycho-neurotic  paranoia  comprises 
cases  in  which  there  is  no  hereditary  de- 
generation. It  develops  slowly,  as  in 
ordinary  mania  and  melancholia.  It  ter- 
minates in  either  recovery,  or  more  fre- 
quently in  dementia.  Its  course  is  more 
rapid,  and  it  is  more  intense  in  character 
than  degenerative  paranoia.  This  group, 
like  the  first,  is  subdivided,  the  genera  being 
I^rimary  and  secondary. 

The  primary  division  is  the  most  fre- 
quent, and  may  be  acute  or  chronic.  The 
secondary  cases  follow  an  attack  of  melan- 
cholia or  succeed  to  one  of  mania.  Fur- 
ther, there  may  be  the  persecution  and 
other  manias  above  mentioned,  and  these 
may  run  their  course  with  or  without 
hallucinations. 

Course. — It  is  essentially  chronic.  The 
tendency  is  to  an  increase  of  the  congenital 
mental  degeneration,  but  it  may  last 
for  years  without  passing  into  profound 
dementia.  Time  tends  to  weaken  the  inten- 

*  "Arcliivio  Italiiriio  per  le  Malatie  Xervose," 
&c'.  (Anno  xxi. ). 


Paranoia 


[     888     ] 


Paranoia 


sity  of  the  delusions,  and  therefore  renders 
the  patient  less  and  less  dangerous  to 
society.  As  Krafft-Ebiiig  forcibly  ex- 
presses it,  •'  the  delusion  of  the  Ven-iiclirn 
I'emains  a  dead  mass  of  ideas  which  can- 
not undergo  any  moditication.  It  becomes 
more  and  more  a  mere  phrase."  This 
alienist  is  one  who  holds  that  the  dis- 
order is  the  outcome  of  melancholia  or 
mania,  much  jnore  commonly  of  the 
former. 

Paranoia  occurring  in  two  sisters  has 
been  reported  by  Dr.  Peterson.*  They 
differed  but  slightly  from  other  persons 
when  they  were  young.  Only  trifling 
eccentricities  and  some  excess  of  self- 
consciousness  were  obsei'ved.  Ideas  of 
persecution  and  suspicion  developed  so 
gradually  that  their  friends  did  not  re- 
cognise them  until  actual  insanity  de- 
clared itself.  When  Dr.  Peterson  first 
saw  them  they  wore  veils,  the  removal  of 
which  revealed  the  fact  that  their  faces 
were  patched  all  over  with  small  square 
pieces  of  cloth  covering  sores.  An  erup- 
tion of  acne  had  been  made  much  worse 
by  picking  and  by  their  wearing  wet  cloths 
all  night  in  oi'der  to  prevent  poisonous 
vapours  entering  their  lungs,  as  also  by 
the  cloths  being  torn  from  the  bleeding  sur- 
face. These  patients  had  hallucinations 
of  hearing,  taste,  and  markedly  of  smell. 
Moreover,  they  had  illusions  of  sight  and 
cutaneous  sensibility.  Their  mother 
laboured  also  under  paranoia  with  delu- 
sions of  a  religious  character,  and  one  of 
the  sisters  was  conceived  when  her  mother 
was  insane. 

The  same  physician  has  published  an 
autobiographical  sketch  of  a  religious 
paranoiac  who  was  a  patient  for  more 
than  seven  years  in  the  Hudson  Eiver 
State  Hospital  for  the  Insane,  having 
been  thirty  years  of  age  when  he  was  ad- 
mitted. As  regards  heredity,  his  great- 
uncle  was  a  paranoiac,  living  on  a  farm 
in  intimate  companionship  with  the  pa- 
tient until  the  latter  was  twent3--three ; 
his  father  was  exceedingly  eccentric,  and 
Dr.  Peterson  suspects  was  himself  some- 
thing of  a  paranoiac ;  his  wife  was  his  tirst 
cousin.  She  said  that  her  son  had  always 
been  despondent,  and  since  the  age  of 
twenty  had  done  very  little  on  account  of 
his  bad  health.  A  year  before  his  ad- 
mission he  shot  himself  in  the  head,  and 
subsequently  fancied  that  people  in- 
fluenced him  by  magnetism.  He  laboured 
under  auditory  hallucinations  all  the  time 
he  was  in  the  asylum  ;  and  in  the  early 
period  of  his  residence  he  manifested  sus- 
picions of  persecution.  After  seven  yeaiV 
confinement  delusions  of  grandeur  de- 
*  Alienist  and  Xturologlst,  Jan.  1890,  St.  I.ouis. 


veloped.  He  rarely  lost  his  self-control, 
and  was  allowed  a  great  deal  of  freedom. 
His  autobiography  covered  400  manu- 
script pages.  "  He  had  unusual  talents 
and  aptitudes,  and  we  find  him  studying, 
in  the  original,  many  of  the  classic  Latin 
authors ;  while  among  his  favourite  com- 
panions were  the  works  of  Boethius,  Lucre- 
tius, Josephus,  and  the  Bible.  His  literary 
style  and  modes  of  thought  are  in  them- 
selves an  evidence  of  more  than  ordinary 
attainments  in  rhetoric,  jDhilosophy,  and 
logic." 

A  very  elaborate  history  of  a  male  para- 
noiac in  the  Bloomingdale  Asylum,  in  New 
York,  has  been  given  by  Dr.  ISoyes.*  It 
is,  in  fact,  a  study  of  the  evolution  of 
systematised  delusions  of  grandeur.  He 
possessed  much  artistic  skill.  As  a  child 
marked  peculiarities  of  manner  and  di'ess 
were  observed.  It  was  difficult  to  him  to 
concentrate  his  attention  on  books, 
although  he  learnt  readily.  Among  his 
peculiarities  of  conduct  it  may  be  men- 
tioned that  on  his  return  from  a  half- 
hour's  smoke  out  of  doors  after  each 
meal,  he  had  one  method  of  procedure 
from  which  he  never  varied.  "  He  first 
washed  his  hands  in  the  bath ;  then  going 
to  the  dining-room,  he  tilled  a  glass  with 
water  from  the  cooler,  and  holding  this 
extended  in  his  right  hand,  he  would 
balance  himself  on  one  heel,  and  suddenly 
whirl  about,  always  to  the  right,  and  then 
drink  the  water."  At  one  time  he  was  an 
art  student  in  Paris,  where  he  was  re- 
garded as  exceedingly  bright,  but  so 
wanting  in  application  that  he  was  styled 
the  "  unfinished  artist."  Naturally,  re- 
peated attempts  were  made  when  he  was 
in  the  asylum  to  induce  him  to  execute 
works  of  art  continuously,  but  his  con- 
stant excuse  was,  "  the  Spirit  does  not 
move  me."  In  view  of  the  remarkable 
sketches  which  are  reproduced  by  Dr. 
Noyes,  we  must  acknowledge  with  him, 
that  "  the  grace,  beauty,  and  poetic  con- 
ception shown  in  these  sketches  and  draw- 
ings, and  also  in  the  quotations,  are  such 
that  it  must  cause  the  most  profound  re- 
gi"et  that  such  talent  and  originality 
should  have  been  hampered  in  their 
growth  by  a  faulty  physical  development, 
and  that  an  incurable  mental  disease 
should  have  clouded  such  a  brilliant  in- 
tellect"  {op.cit.  p.  375). 

Prog-nosis.  —  Very  unfavourable.  If 
decided  improvement  takes  place  it  is 
very  likely  to  be  followed  by  relapse. 
Delusional  insanity,  the  outcome  of  an 
attack  of  mania  or  melancholia,  may  run 
a   more  favourable  course,  inasmuch   as 

*   The  American  Journal  of  Paycholof/y,  vol.  ii. 

1889. 


Parapathia 


[    889    ] 


Parliament 


the  original  mental  constitution  may- 
have  been  sound.  From  the  point  of 
view  taken  by  those  who  deny  secondary 
paranoia,  the  prognosis  must  always  be 
distinctly  unfavourable,  if  not  hopeless. 
(Sec  Veuiutcktheit.)  Tue  Euitok. 

Pii.RAPil.THIA  (TTapd  ;  rrdBos,  an  aifec- 
tion).     Moral  insanity. 

PARAPHASIA  {napd;  (/)Ho-t?,a  speech). 
A  term  for  using  one  Avord  when  another 
is  intended,  or  for  mispronunciation  of 
words,  due  to  cerebral  disorder. 

PARAPHIA  {napd,  beyond ;  dcfirj,  a 
touching).  A  morbid  sense  of  touch.  (Fr. 
parajiliic.) 

PARAPH ORA  {TTapafjjepo,  I  move  in  a 
wrong  direction).  A  going  aside,  generally 
applied  to  the  mind,  and  to  mental  de- 
rangement or  distraction.  It  has  been 
applied  to  the  unsteadiness  of  intoxica- 
tion.    (Fr.  2^arapliare.) 

PARAPHRASIA  {napd;  (fipdcris, 
sjDeech,  expression).     Incoherent  speech. 

PARAPHRENESIS      (Trapd,     beyond  ; 
cf)pijv,   the   raind).     A  term   for   amentia,  [ 
delirium,    or    any    mental    derangement, 
(Fr.  paraphrcnesie.) 

PARAPHRENIA  (Trapd,  beyond  ;  0pi?J/, 
the  miiia).  Paraphrenitis.  (Fr.  para- 
l^hreyiie.) 

PARAPHREiriTIS  [irapd,  beyond ; 
(jipeviTis,  inflammation  of  the  brain).  A 
term  for  mental  derangement,  but  also 
used  for  inflammation  of  the  diaphragm. 

PARAPHROSYN-E,  PARAPHRONE- 
SIS  {rrapdcppav,  out  of  one's  mind).  De- 
rangement or  wandering  of  mind.  Used 
by  Hippocrates  in  the  same  sense  as  he 
used  'paracope  and  paracrousis.  (Fr. 
paraphrosyne.) 

PARAPHROSYTTE  CAIiETrTURA 
{napd,  beyond  ;  0pr}i',  the  mind  ;  caleo,  I 
am  hot).  The  name  given  by  Sauvage 
to  a  mental  disease  formerly  observed  in 
sailors  in  the  tropics.  The  characteristic 
symptom  said  to  exist  was  a  delusion  that 
the  sea  was  green  fields,  the  result  being 
that  the  men  attempted  to  throw  them- 
selves into  it.  Le  Roy,  of  Mericourt,  has 
demonstrated  that  the  descriptions  of  this 
malady  show  it  to  be  a  delirium  produced 
by  insolatio  or  residence  in  a  hot  climate, 
aggravated  by  excessive  fatigue.  (Fr. 
piaraphrosyne  calenture.) 

PARAPIiECTICXrS,  PARAPIiECTUS 
(7rapd7rX;;KTos, struck  on  the  side).  Stricken 
on  one  side;  paralysed;  frenzy-stricken. 
Also  used  by  the  Greek  poets  for  one  who  is 
brain-struck  or  crazy;  cf.  Soph.  "Ajax," 
229.     (Fr.  parapjlectiqxe.) 

PARAPX.EGI A,  HYSTERICA!!.  {See 
Hy.sti:i{1.\.) 

PARAPSIS  {Trapd,  beyond  ;  utttco,  1 
touch).     A  morbid  sense  of  touch. 


PARARTHRIA  (TTapd;  np5p,ico,  I 
articulate).  Any  disorder  of  difficulty  in 
articulation  of  speech. 

PARATERESIOMANIA  {TrapaTi'jpTja-is, 
an  observing ;  pnpia,  madness).  A  rage 
for  observing.     {Fv.  2MratcrcfiiomaHie.) 

PARATHYIVIIA  (Trapd,  beyond  ;  ^vpos, 
the  mind).  An  overstraining  of  the  mind. 
(Fr.  and  Ger.  paratliymie.) 

PARENTS. — Where  a  parent  or  other 
guardian,  whose  consent  is  necessary  to  a 
marriage,  is  insane,  application  may  be 
made  to  any  division  of  the  High  Court 
of  Justice,  and  the  marriage  may  be  de- 
clared to  be  proper.  This  declaration  is 
equivalent  for  all  purposes  to  a  consent 
(4  Geo.  IV.  c.  76,  s.  17;  Ux  parte  lieibetj, 
7  Jur.  589).  A.  Wood  Renton. 

PAREPITHYMIA  (Trapd,  beyond  ; 
nidvpla,  a  longing).  Morbidly  depraved 
longings  and  desires.     (Fr.  parepithymie.) 

PARERETHISIS,  PARERETHIS- 
ivxus  {ivapd ;  epiOi^a,  I  raise  to  anger). 
Abnormal  excitement.  An  irritated  con- 
dition of  a  part.     (Fr.  parerethhse.) 

PARESIS  {ndpeais,  weakness,  want  of 
strength).     Partial  paralysis. 

PiiRESTHESIS,  PARS:STHESIA 
(7rap<j,  beyond ;  aiadrja-is,  sensibility).  Per- 
verted sensibility. 

PARETIC.  Pertaining  to  or  affected 
with  paralysis.  P.  DEMEM-TIA.  General 
paralysis  {q.v.). 

PARIiIAMENT  (Xaw  of)  in  Relation 
to  Insanity. — Idiots  and  lunatics  (except 
during  lucid  intervals)  are  disqualified  for 
being  chosen  members  of  Parliament  (i 
Whitlock's  "  Notes  on  the  King's  Writ," 
461) ;  and  the 2}eri)ianent  mental  incapacity 
in  a  member,  returned  while  of  sound  mind, 
has  from  a  very  early  period  in  our  law 
been  regarded  as  a  ground  on  which  his 
seat  might  be  vacated.  In  the  28th  year 
of  his  reign,  Edward  I.  issued  writs  direct- 
ing the  sheriffs  to  summon  those  members 
who  had  been  elected  for  the  Parliament 
holden  in  the  preceding  Easter,  and  in  all 
cases  where  the  person  so  elected  should 
be  prevented  by  death  or  infirmity  from 
attending  to  elect  others  in  their  room. 
It  is  stated  in  Brooke's  Abridgment  (tit. 
Pari.  s.  7)  that  similar  writs  were  issued 
in  the  38th  year  of  the  reign  of  Henry 
VIII.  without  making  any  distinction  be- 
tween illness  curable  and  incurable.  But 
it  must  be  recollected  that  at  those  periods 
the  session  of  Parliament  was  usually  of 
so  limited  a  duration  that  it  might  rea- 
sonably be  presumed  that  any  severe  ill- 
ness, however  short,  would  incapacitate  a 
member  from  attending.  In  subsequent 
cases*  the  House  appears   uniformly  to 

*  In  the  "Journal  of  the  House  of  Commons," 
vol.  i.  Feb.  14,  1609,  there  is  the  following^  entry  : 


Parliament 


[    890    ] 


Partnership 


liave  inquired  into  the  nature  of  the 
alleged  malady  and  to  have  granted  or 
refused  a  new  writ  according  as  there 
seemed  to  be  a  permanent  or  temporary 
incapacity  in  the  member  previously  re- 
turned.* 

The  present  practice  is  regulated  by  the 
Lunacy  (Vacation  of  Seats)  Act,  1886.+ 
The  provisions  of  this  statute  may  be 
summarised  as  follows :  If  a  member 
of  the  House  of  Commons  is  henceforth 
committed  into  or  detained  in  any  asylum 
as  a  lunatic,  the  fact  must  be  certified 
forthwith  to  the  Speaker,  by  the  Court, 
judge,  or  magistrate,  upon  whose  order, 
and  by  every  medical  practitioner,  upon 
whose  certificate,  such  committal  or  deten- 
tion has  taken  jilace,  and  by  every  super- 
intendent or  other  person  having  the  prin- 
cipal charge  of  the  asylum  aforesaid.^ 
Any  two  members  of  the  House  of  Com- 
mons may  certify  to  the  Speaker  that 
they  are  credibly  informed  of  such  com- 
mittal and  detention.  The  Sj^eaker  is  re- 
quired to  transmit  the  certificate  or  certi- 
ficates aforesaid,  to  the  Commissioners  in 
Lunacy  in  England  or  Scotland,  or  to  the 
Inspectors  of  Lunatic  Asylums  in  Ireland 
according  as  the  place  in  which  the  mem- 
ber is  detained  is  situated  in  England, 
Scotland  or  Ireland.  It  is  the  duty  of  the 
department,  to  which  such  certificates  are 
transmitted,  to  examine  the  alleged  lunatic 
and  report  to  the  Speaker  whether  he  is 
of  unsound  mind.  If  the  report  is  to  the 
effect  that  the  member  is  of  unsound 
mind,  a  second  examination  and  report  by 
the  same  department  are  required  by  the 
Speaker  at  the  expiration  of  six  mouths 
from  the  date  of  the  first,  if  the  House  of 
Commons  be  then  sitting,  and  if  not,  then 
as  soon  as  may  be  after  the  nest  sitting 
thereof.  If  the  Lunacy  Department  re- 
ports that  the  member  is  still  of  unsound 
mind,  the  Speaker  lays  both  reports  on  the 
table  of  the  House  of  Commons  ;  the  seat 
is  thereupon  vacant  and  a  new  writ  is 
issued  by  the  clerk  of  the  Crown. 

An  idiot  cannot  vote  at  a  parliamentary 
election.  A  lunatic  during  a  lucid  inter- 
val can  do  so.  The  returning  officer  must 
satisfy  himself  that  a  lucid  interval  exists 
at  the  time  of  voting.  It  seem.s  that  the  i 
test  of  comi)etency  in  such  a  case  is  the 

"Hassard,  69,  incurable — bed-rid — a  new  writ." 
See  also  in  162  Hansard,  3rd  ser.  1941 — a  com- 
plaint that  Mr.  A.  Steuart,  a  certified  lunatic 
patient,  had  voted  in  a  division,  May  13,  1861. 

*  66  "  Commons  Jour.,"  226,  265,  appendix  687 
(1811),  Mr.  Alcock's  case;  Shelford's  "Lunacy," 
490-1. 

t  49  Vict.  c.  16. 

t  A  medical  practitioner  or  superintendent  fail- 
ing- to  comply  with  this  reiiuirement  is  liable  to  a 
penalty  not  exceeding;^  100. 


capacity  of  the  voter  to  distinguish  be- 
tween the  candidates,  and  generally  to 
understand  the  nature  and  consequences 
of  his  act.  A.  Wood  Eextox. 

VAJUENZA.  {TTcipd,  from  ;  olvns,  wine). 
In  medical  jurisprudence,  an  act  com- 
mitted while  under  the  influence  of  wine. 
PilRONIRZA  (napd,  near;  ovfipos,  a 
dream).  Disturbance  of  sleep  by  disagree- 
able dreams.  (Fr.  'paronirie ;  Ger.  die 
lirnnkhaften  Trilume.) 

PARON-ZRIA.  AMBVX.AM'S  (ambido, 
I  walk  about).  A  synonym  of  somnam- 
bulism. 

PARONtEA.     Paranoia. 
PAROPHOBIA  {irdpos,  intens.  ;  (^o/3os, 
fear).     A  synonym  of  hydrophobia. 

PAROPSIS  (napd,  beyond ;  o\j/is,  vision). 
False  seeing,  illusion,  or  hallucination  of 
vision.  {Fr.  par ojjsis  ;  Ger.  Falschselien.) 
PARORASIS  {Trapd,  beyond ;  opda,  I 
see).  An  old  term  for  weak  or  disordered 
vision.  It  has  been  also  used  for  hallu- 
cination of  sight.  (Fr.  paroru.se  ;  Ger. 
Falschselien.) 

PAROSIVIIA,  PAROSPHRESZS (TTapa, 
beyond ;  oapi^,  a  smell).  Morbid  sense  of 
smell.     (Fr.  parosphrl'se.) 

PAROXVSMAI.  IIO-SAM'ZTY. — Sud- 
den mental  attacks  characterised  by  strong 
emotional  distress  or  excitement  passing 
off  in  a  short  time.  {See  Epilepsy  and 
Insanity;  Insanity,  Paroxysmal.) 

PARTIAI.    MORAI.    MANIA.      {See 

Kleptomania,  Pyromania,  &c.). 

PARTNERSHIP  (I.aw  of)  in  Rela- 
tion to  Insanity. — The  lunacy  of  a  part- 
ner does  not  ipso  facto  dissolve  the  firm  ; 
but  the  permanent  lunacy  of  an  active 
partner  is  a  ground  for  the /^(cZi'cmZ  dis- 
solution of  a  partnership  at  the  instance 
either  of  the  sane  partner  or  partners,  or 
of  the  proper  representative  of  the  lunatic 
partner  himself. 

Dissolution  at  the  Instance  of  a  sane 
Partner. — In  the  leading  case  of  Jones  v. 
Xoy,  1833  (2  M.  &  K.  125),  the  principle 
and  the  conditions  upon  which  such  a  dis- 
solution will  be  allowed  were  very  clearly 
explained.  Two  persons  had  agreed  to 
become  j^artners  as  solicitors  for  a  period 
of  twelve  years.  One  of  them  became 
lunatic  before  the  expiry  of  the  stipulated 
period,  and  subsequently  died  in  a  lunatic 
asylum.  The  other  carried  on  the  busi- 
ness for  some  time  and  then  sold  it.  The 
representative  of  the  deceased  litnatic  was 
held  to  be  entitled  to  a  share  of  the  profits 
up  to  the  time  of  sale.  The  judgment  of 
Sir  John  Leach,  M.R.  in  this  case  is  at 
once  so  short  and  so  instructive  that  it 
deserves  quotation  in  extenso. 

"  It  is  clear  upon  principle  that  the 
complete  incapacity  of  a  party  to  an  agree- 


Partnership 


S91 


Patentees  (Insane) 


ment  to  perform  that  which  was  a  condi- 
tion of  the  agreement  is  a  ground  for 
determining  the  contract.  The  insanity 
of  a  partner  is  a  ground  for  the  dissohi- 
tion  of  the  2>artnership  because  it  is  imme- 
diate incapacity  ;  but  it  may  not  in  the 
result  prove  to  be  aground  of  dissolution, 
for  the  partner  may  recover  from  his 
malady.  When  a  partner,  therefore,  is 
affected  with  insanity,  the  continuing 
partner  may,  if  he  think  tit,  make  it  a 
ground  of  dissolution,  but  in  that  case  we 
consider  with  Lord  Kenyon  that  in  order 
to  make  it  a  ground  of  dissolution,  he 
must  obtain  a  decree  of  the  Court.  If  he 
does  not  apply  to  the  Court  for  a  decree 
of  dissolution,  it  is  to  be  considered  that 
he  is  willing  to  wait  to  see  whether  the 
incapacity  of  his  partner  may  not  prove 
merely  temporary.  If  he  carry  on  the 
partnership  business  in  the  expectation 
that  his  partner  may  recover  from  his 
insanity,  so  long  as  he  continues  the  busi- 
ness with  that  expectation  or  hope,  there 
can  be  no  dissolution." 

All  the  distinctive  doctrines  of  English 
law  upon  the  subject  are  logically  implied 
in  these  sentences:  (i)  Lunacy  is  merely 
a  ground  of  dissolution  (cf.  Anon.,  1855, 
2  K.  &  J.  441  ;  Hehnore  v.  Smith,  1887, 
35  Ch.  D.  at  p.  442  ;  (2)  the  lunacy  which 
will  justify  a  dissolution  must  be  perma- 
nent {Jones  V.  Lloyd,  1874,  L.  R,  18  Eq. 
265)  ;  (3)  it  must  also  be  existing  when 
appUcation  for  the  interference  of  the 
Court  is  made  {Anon.,  ubi  sup.) ;  *  and 
(4)  it  must  be  of  such  a  nature  as  to 
render  the  partner  incompetent  to  conduct 
the  business  of  tlie  partnership  according  to 
the  articles.  In  Anon,  {ubi  sup.)  a  mo- 
tion for  an  interim  injunction  to  restrain 
a  partner  who  six  months  j^reviously,  being 
temporarily  of  unsound  mind,  had  at- 
tempted to  commit  suicide,  from  interfer- 
ing in  the  jDartnershiji  affairs,  was  refused, 
the  evidence  not  showing  that,  at  the  time 
of  the  motion,  he  was  incomi:)eteut  to  con- 
duct the  partnership  business. 

All  causes  or  matters  for  the  dissolution 
of  partnerships  or  the  taking  of  partner- 
ship accounts  are  assigned  to  the  Chancery 
Division  (Jud.  Act,  1873,  s-  34  (3))-+ 

*  If  the  lunatic  is  not  so  found  by  inquisition, 
the  Court  will,  if  necessary,  direct  an  inquiry  into 
the  nature  and  extent  of  his  malady. 

t  The  Lunacy  Act,  1890,  provides  (s.  119)  that, 
"  where  a  person  beiiiu'  a  member  of  a  partuersliip 
becomes  lunatic,  the  judge  ma.v  by  order  dissolve 
the  partnership  ; "  and  the  I'artnership  Act,  1890, 
enables  (s.  35  (a) )  the  Court  to  decree  a  dissolu- 
tion "  when  a  partner  is  found  lunatic  by  inquisi- 
tion, or  in  Scotland  by  coicnition,  or  is  shown,  to 
the  satisfaction  of  Wn:  Court,  to  be  of  penuancTitly 
unsound  mind,  in  either  of  which  cases  the  applica- 
tion may  be  msule  as  well  on  behalf  of  that  partner 


Dissolution  at  the  Instance  of  the 
Representative  of  aliunatic  Partner. — 

"  A  dissolution,"  says  Sir  F.  Pollock 
("Partnership,"  p.  91),  "may  be  sought 
andobtained  on  behalf  of  the  lunaticpartner 
himself,  and  this  may  be  done  either  by 
his  committee  in  lunacy  under  the  Lunacy 
Regulation  Act,  or  where  he  has  not  been 
found  lunatic  by  inquisition  by  an  action 
brought  in  his  name  in  the  Chancery  Divi- 
sion by  another  person  as  his  next  friend. 
In  the  latter  case  the  Court  may,  if  it 
thinks  fit,  direct  an  application  to  be  made 
in  lunacy  before  finally  disposing  of  the 
cause.'' 

Date  from  which  a  Judicial  Dissolu- 
tion takes  Effect. — (i)  The  articles  may 
authorise  a  dissolution,  and  the  partner- 
ship be  dissolved  under  the  articles.  Here 
the  judicial  dissolution  takes  effect  from 
the  date  of  the  actual  dissolution,  and  not 
from  the  date  of  the  decree.  (2)  The  part- 
nership may  be  at  will.  Here  the  date  of 
dissolution  is  the  time  fixed  in  the  notice 
to  dissolve.  (3)  In  all  other  cases  the  dis- 
solution will  be  from  the  date  of  the  judi- 
cial decree. 

When  the  Court  dissolves  a  partnership 
on  the  ground  of  insanity  it  directs  the 
costs  to  be  paid  out  of  the  partnership 
assets.  A  power  under  the  articles  to  dis- 
solve a  partnership  ujDon  any  ground  may 
be  exercised  by  one  partner  notwithstand- 
ing the  lunacy  of  the  other.  Thus  in 
Ixobertson  v.  Locke,  1846  (15  Sim.  235),  by 
articles  of  partnership  between  A.  and  B., 
the  partnership  was  to  be  dissolved  upon 
either  party  giving  the  other  a  six  months' 
notice.  A.  gave  the  required  notice.  It 
was  held  effectual  notwithstanding  the 
insanity  of  B.  at  the  time. 

A.  "Wood  Renton. 
PASSIO    CADIVIA.     A  synonym  of 
epilepsy. 

PASSZO  HYSTERICA.  A  term  for 
hysteria  {g.r.). 

PATEM-TEES  (INSANE).  —  Insanity 
creates  no  disability  which  will  prevent 
any  person  from  applying  for  and  obtain- 
ing letters  patent  for  an  invention.  The 
Patents  Act  1883,  sec.  99,  expressly  pro- 
vides for  such  cases  in  the  following  terms  : 
"  If  any  person  is  by  reason  of  ...  . 
lunacy  ....  incapable  of  making  any 
declaration  or  doing  any  thing  required 
or  permitted  by  this  Act,  or  by  any  rules 
made  under  the  authority  of  this  Act, 
then  the  ....  committee  if  any  of  such 
incapable  person,  or  if  there  be  none,  any 
person  appointed  by  any  Court  or  Judge 
possessing  jurisdiction  in  respect  of  the 
property  of  incapable  jjersons,  upon  the 

by  his  committee  or  next  friend,  or  person  having 
title  to  intervene,  as  by  any  other  partner.'" 


Pathema 


[    892     ] 


Pathology 


petition  of  any  person  on  behalf  of  such 
incajDable  person,  or  of  any  other  person 
interested  in  the  making  such  declaration 
or  doing  such  thing,  may  make  such 
declaration  or  a  declaration  as  nearly 
corresponding  thereto  as  circumstances 
permit,  and  do  such  thing  in  the  name 
and  on  behalf  of  such  incapable  person, 
and  all  acts  done  by  such  substitute  shall 
for  the  purposes  of  the  Act  be  as  effectual 
as  if  done  by  the  person  for  whom  he  is 
substituted." 

This  section  applies  not  only  to  patents 
but  to  trade-marks  and  designs. 

A.  Wood  Eenton. 
PATHEMil.    (nddos,    a     suffering    or 
passion).     A  term  for  suffering.     Disease 
of  body   or   mind.      (Fr.  jpatlteme ;  Ger. 
Ein  Leiden.) 

PiiTHEMiLTOIiOGV  (Trd^os,  passion ; 
\6yos,  a  discourse).  The  doctrine  of  pas- 
sion or  affection  of  the  mind ;  or  merely 
pathology.     (Fr.  iKitlieynatologie.) 

FATHETIsm  {iraOos,  feeling).  A  term 
for  animal  magnetism,  hypnotism,  or  any 
doctrine  of  mental  influences. 

PATHOCRATZA,  PATHOCRATO- 
RZ  A  (Traces',  passion  ;  Kpareu),  I  am  strong). 
Self-restraint.  The  holding  of  the  pas- 
sions under  control.     (Fr.  patliocratie.) 

PATHOCTONXTS  [ttcSos,  passion  ; 
KTeiva,  I  kill).  The  killing  of  the  passions  ; 
that  is,  self-restraint.     (Fr.  ijatliocione.) 

PATHOIiOGY. — Insanity  is  not  a  dis- 
ease :  it  is  a  symptom  of  many  diseased 
conditions  of  the  brain,  the  term  disease 
being  for  the  moment  employed  in  its 
widest  sense,  and  being  held  to  comprise 
not  only  well-marked  morbid  changes,  but 
also  imperfect  development  and  malforma- 
tion of  the  organ  and  its  envelopes.  In- 
sanity may  therefore  be  defined  as  a 
syiuijto'm  of  variotis  ')iiorhid  conditions  of 
the  brain,  the  results  of  defective  formation 
or  altered  nutrition  of  its  substance ;  in- 
duced by  local  or  general  tnorbid  ])rocesses, 
and  cliaracierised  especially  by  non-de- 
velopment, obliteration,  or  perversion  of  one 
or  more  of  its  psychical  functions.  This 
definition  obviously  covers  a  large  number 
of  abnormal  mental  conditions  which  con- 
ventionality does  not  include  under  the 
term  "  insanity."  Coma,  delirium,  and 
intoxication  (amongst  others)  are  not  re- 
garded as  insanities ;  an  arbitrary  line  is 
drawn  between  them  and  so-called  mental 
disease.  But  it  is  a  line  which  cannot  be 
acknowledged  by  the  scientific  observer  ; 
it  is  one  drawn  solely  for  social  and  legal 
purposes,  and  demanding  no  attention  in 
an  article  which  deals  with  the  causes  of 
morbid  mentalmanifestations,irrespective 
of  the  duration,  degree,  or  social  conse- 
quences of  the  abnormal  conditions.     To 


the  pathologist  and  physiologist  the 
patient  under  coma  and  delirium,  and  the 
drunkard  under  alcoholism,  are  as  much 
insane  as  the  maniac  or  melancholiac. 
The  two  sets  of  conditions  are,  or  may  be, 
linked  together  by  causation,  anatomical 
relations,  symptomatology,  natural  his- 
tory and  results,  and  to  exclude  their  re- 
lative consideration  would  only  tend  to 
narrow  the  field  of  inquiry,  and  would 
divest  the  observer  of  the  power  of  em- 
ploying argument  based  on  analogy. 
Griesinger  asserted  the  position  correctly 
when  he  said,  "  diseases  of  the  nervous 
system  form  one  inseparable  whole,  of 
which  the  so-called  mental  diseases  form 
only  a  certain  moderate  proportion." 

The  results  of  experiments  and  observa- 
tion bearing  on  the  region  of  the  brain 
specially  affected  by  insanity,  are  best  ex- 
pressed in  the  words  of  Ferrier:  ""We 
have  many  grounds  for  believing  that  the 
frontal  lobes,  the  cortical  centres  for  the 
head  and  ocular  movements,  with  their 
associated  sensory  centres,  form  the  sub- 
strata of  those  psychical  processes  which 
lie  at  the  foundation  of  the  higher  intel- 
lectual operations.  It  would,  however,  be 
absard  to  speak  of  a  special  seat  of  intel- 
ligence or  intellect  in  the  brain.  Intelli- 
gence or  will  has  no  local  habitation  dis- 
tinct from  the  sensory  and  motor  sub- 
strata of  the  cortex  generally.  There  are 
centres  for  special  forms  of  sensation  and 
ideation,  and  centres  for  special  motor  ac- 
tivities and  acquisitions,  in  response  to, 
and  in  association  with,  the  activity  of 
sensory  centres ;  and  these,  in  their  re- 
spective cohesions,  actions,  and  inter- 
actions, form  the  substrata  of  mental 
ojDerations  in  all  their  aspects  and  all  their 
range.*'  * 

The  ganglionic  cells  of  the  cortex  are 
the  organs  through  whose  instrumen- 
tality all  cerebral  action  is  manifested, 
and  on  the  implication  of  their  healthy 
condition  morbid  phenomena  depend. 
The  object  of  this  article  is  to  indicate  the 
various  morbid  influences  which  may  act 
on  these  organs,  their  methods  of  action, 
the  causes  of  solutions  of  the  continuity  of 
their  connections,  and  to  seek  for  expla- 
nation of  the  resultant  mental  conditions 
by  deductions  drawn  from  direct  and  com- 
parative pathological  and  physiological 
argument. 

The  remote  causes  of  nervous  disease 
accompanied  by  insanity  are  dealt  with 
iinder  Heredity,  Statistics,  &c. 

The  influence   of   nationality,  civilisa- 
tion, education,  and  occupation,  can  rarely 
be  brought  to  bear  on  the  circumstances 
of  a  particular  case,  whilst  that  of  sex  and 
*  "  The  Functions  of  the  Bniin,"  1886. 


Pathology 


[    893    ] 


Pathology 


age  fall  to  be  considei'ed  in  the  body  of  this 
article.  lu  regard  to  heredity,  it  may  be 
remarked  that  through  whatever  channel 
a  tendency  to  nervous  degeneration  may 
have  been  introduced  into  the  constitu- 
tion of  a  family,  or  of  an  individual,  it 
may  make  itself  felt  in  two  directions  : 
either  in  arrest  of  development  of  the 
bones  of  the  skull,  or  of  the  brain  itself, 
and  consequent  idiocy  or  imbecility  ;  or 
by  the  development  of  the  nervous  dia- 
thesis. The  former  are  conditions  fixed 
by  the  pathological  circumstances  under 
which  their  subjects  are  born  (constitut- 
ing a  true  congenital  insanity),  and  are 
effectually  marked  off  from  the  results  of 
the  nervous  diathesis.  They  present  them- 
selves in  two  forms  :  first,  a  liability  to 
break  down  under  circumstances  which 
would  not  afiect  persons  of  originally 
stable  constitution  ;  and  second,  in  irre- 
gular and  abnormally  defective  nervous 
action.  Thus,  hereditary  predisposition 
may  act  as  a  factor  common  to  all  classes 
of  insanity,  whatever  their  immediate 
causes  may  be  ;  or  it  may  be  an  indepen- 
dent factor  in  itself.  The  nervous  dia- 
thesis aflfects  actually  or  potentially  the 
whole  nervous  system,  and  it  is  by  no 
means  certain  that  it  will  appear  in  the 
same  form  in  the  descendant  as  it  did  in 
the  parent ;  hence,  if  we  take  a  family 
stock  in  which  the  nervous  diathesis  is 
strongly  developed,  we  may  find  in  the 
first  instance  individuals  in  no  way 
affected  by  it;  in  some  it  may  result  in 
outbreaks  of  insanity,  in  others  of  un- 
controllable drinking,  in  others  of  epi- 
lepsy, in  others  of  violent  neuralgias, 
while  in  some  we  may  have  varieties  of 
unstable,  passionate,  and  eccentric  tem- 
pers which  never  break  down  into  actual 
disease  at  all.  Once  established  there  is 
no  possibility  of  predicting  in  what  direc- 
tion it  will  act. 

An  important  preliminary  question  to 
determine  in  pathology  is,  do  morbid  pro- 
cesses going  on  in  the  brain  or  its  mem- 
branes act  under  conditions  materially 
different  from  those  occurring  in  other 
regions  ?  It  has  been  generally  asserted 
that  they  do  act  under  a  special  condi- 
tion in  consequence  of  the  assumption 
that  the  cranium  is  a  •'  practically  closed 
sac,"  which  assumption  has  actuallj' 
taken  the  position  of  an  axiom.  The 
cranium  is  not  by  any  means  a  closed 
sac.  The  dura  mater,  which  is  practi- 
cally its  periosteum,  and  the  pia  mater, 
have  numerous  and  extensive  conduits,  the 
sectional  area  of  which  is  considerable, 
to  the  extra-skeletal  lymphatic  system, 
passing  through  each  foramen  at  the  base 
of  the  skull  and  in  the  vertebral  column. 


The  immense  activity  of  the  contained 
organ,  and  its  constant  changes  of  size, 
demand  free  exit  of  the  pi-oducts  of  waste 
and  unused  material,  and  for  the  fiuctua- 
tion  of  the  normal  cerebro-spinal  fluid. 
The  patency  of  these  conduits  may  under 
certain  conditions  of  disease,  mainly  in- 
crease of  blood-pressure,  be  compromised 
to  a  considerable  extent ;  still  they  are 
never  completely  closed,  and  an  inter- 
change of  fluid  constantly  goes  on  between 
the  interior  and  exterior  of  the  cranium. 

Were  the  cranium  a  "  practically  closed 
sac"  pressure  would  be  diffused  equally 
all  through,  its  contents,  which  we  know 
is  not  the  case  in  brain  abscess  or  apo- 
plectic clots ;  and  local  tension  can  even 
exist,  limited  by  the  resistance  of  con- 
nective and  other  tissue,  as  in  other  re- 
gions of  the  body.  Were  the  axiom  alluded 
to  correct,  the  rigid  skull  would  be  as 
mucli  a  cause  of  death  under  diseased 
conditions,  as  it  is  a  protector  of  tlie  deli- 
cate organ  it  contains  against  the  or- 
dinary accidents  of  life.  But  the  brain  is 
liable  to  suffer  under  pathological  condi- 
tions from  a  circumstance  which  does  not 
affect  many  other  important  organs ;  it 
can  obtain  no  vicarious  aid,  it  cannot 
delegate  any  of  its  functions  to  other 
systems,  it  must  do  its  own  work,  and  rid 
itself  of  its  own  products  of  waste  and 
disease. 

When  we  analyse  the  list  of  immedlafe 
causes  assigned  as  the  producers  of  in- 
sanity in  cases,  as  they  present  themselves, 
we  find  them  to  be  divisible  into  nine 
great  classes.  It  may  be  admitted  that 
in  a  certain  proportion  accuracy  of  state- 
ment cannot  be  guaranteed  ;  but,  allowing 
for  error,  there  is  adequate  warrant  for 
ranging  immediate  causes  under  the  fol- 
lowing heads  : — 

(i)  Over-excitation  of  the  higher  brain 
function. 

(2)  Idiopathic  morbid  processes. 

(3)  Adventitious  products. 

(4)  Traumatism. 

(5)  Secondary  effects  of  other  neuroses. 

(6)  Concurrent  effects  of  disease  of  the 

general  system. 

(7)  Toxic  agents. 

(8)  Concurrent    effects    of    evolutional 

and  involutional  conditions. 

(9)  Heredity. 

Over-excitatioil,  of  the  Brain  is  univer- 
sally acknowledged  as  an  inducer  of  in- 
sanity without  the  intervention  of  any 
other  morbid  factor.  Over  excitations, 
whether  produced  by  such  emotions  as 
joy,  sorrow,  fright,  anxiety,  or  by  unduly 
prolonged  intellectual  action,  are  gene- 
rally spoken  of  as  "moral"  causes,  and 
in  many  works  on  insanity  are  placed  in 


Pathology 


[    894    ] 


Pathology 


strong  contradistinction  to  "  physical '" 
causes,  the  psychical  influence  of  the  foi*- 
mer  being  apparently  held  to  be  sufficient 
to  account  for  the  subsequent  phenomena 
irrespective  of  their  action  on  the  tissues 
of  the  brain.  Very  generally  a  psychical 
continuit}^  is  suggested,  and  we  very  rarely 
find  any  attempt  made  to  connect  the 
action  of  the  cause  with  its  effects  in  dis- 
ease on  the  cortical  constituents.  But  due 
consideration  of  the  facts  of  anatomy  and 
physiology  ought  to  demonstrate  that  no 
distinction  exists  between  ''moral"  and 
"  physical "  causes ;  that,  in  effect,  the 
former  are  as  much  physical  as  trauma- 
tism and  alcoholic  poisoning. 

There  is  sufficient  evidence  founded  on 
direct  observation  to  prove  that  when  the 
psychical  functions  of  the  cortex  are  exer- 
cised hypereemia  of  the  active  region  is  an 
immediate  consequence.  The  observations  ', 
of  Mosso  (Ueber  den  Kreislauf  des  Blutes 
itn  Menscliliclien  Gehirn)  cannot  be  called 
in  question.  We  have  observed,  in  two 
cases,  distinct  hyperasmic  bulging  of  the 
cortex  through  openings  in  the  skull  during 
mental  action,  and  amongst  others,  Dr.  Gr. 
Gibson,  of  Edinburgh,  has  recorded  the  tra- 
cings taken  in  a  similar  case.  In  the  latter 
case,  and  in  those  that  came  under  our  own 
observation,  the  bulging  was  steadily  main- 
tained whilst  mental  action  continued.  In 
degree  it  depended  on  the  intensity  of  the 
action,  and  steadily  increased  according  to 
the  length  of  time  the  action  persisted, 
until  a  certain  maximum  point  was  gained. 
With  the  withdrawal  of  stimulus  the 
bulging  gradually  disappeared.  The  de- 
duction to  be  drawn  from  this  phenome- 
non is  aptly  put  by  Crichton  Browne : — 
"The  blood-vessels  were  clearly  made  for 
the  brain,  and  not  the  brain  for  the  blood- 
vessels ;  and  the  amount  of  blood  supply 
to  the  brain  and  its  several  parts  is  deter- 
mined, not  by  vascular  domination,  but  by 
the  functional  activity  of  the  nervous  tis- 
sues.'' It  is  of  importance  to  consider  by 
what  circulatory  and  nervous  apparatus 
this  functional  hyjierfemia  is  induced. 

The  vessels  directly  involved  are  those 
which  su2;)ply  the  cortex  of  the  superior, 
frontal,  and  superior-lateral  aspects  of  the 
brain  ;  whilst  the  central  or  ganglionic 
vessels  influence  the  nutrition  of  the  organ 
through  the  nutrition  they  afford  the  vaso- 
motor centres.  The  relative  supply  of 
blood  to  the  cortex  and  to  the  white  mat- 
ter is  as  five  to  one,  the  ssupply  to  the 
central  ganglia  being  intermediate.  Refer- 
ence to  Brain  anji  Membkaxes  will  show 
that  the  regions  above  mentioned  are  sup- 
plied with  blood  by  the  three  cerebral 
arteries,  which  are  the  terminal  branches 
of  the  internal  carotid.    These  vessels  are 


at  the  extreme  limit  of  the  circulatory 
apparatus ;  they  are  furthest  away  from 
the  heart,  and  the  effect  of  gravity  tells 
more  upon  them  than  on  the  vessels  of 
any  other  part  of  the  body.  Further, 
those  running  directly  perpendicularly 
(the  main  branches  of  the  middle  cerebral) 
must  feel  the  effects  of  variation  of  pres- 
sure more  than  any  other  of  the  cerebral 
arteries.  The  effects  of  gravity  come  into 
play  even  more  definitely  and  effectively 
in  connection  with  the  venous  system 
after  the  blood  has  reached  the  sinuses, 
when  its  weight  determines  its  course  into 
the  large  veins  passing  through  the  base, 
and  almost  directly  to  the  heart.  Under 
ordinary  circumstances,  notwithstanding 
certain  mechanical  obstruction  to  the 
venous  flow  in  the  pia  mater,  the  current 
of  blood  through  the  brain  is  very  free  ; 
it  is  evident  that  this  is  necessary,  and 
that  anything  that  interferes  with  this 
free  circulation  must  exert  a  most  in- 
jurious effect  on  the  nutrition  of  the 
cerebral  tissues. 

The  vaso-motor  influences  are  of  two 
kinds,  vaso-consti'ictor  and  vaso-dilator. 
The  centres  of  vaso-motor  action  con- 
sist of  numerous  ganglionic  cells  in  the 
floor  of  the  medulla  oblongata,  lying  in 
groups  on  each  side  in  the  upward  con- 
tinuation of  the  lateral  columns  after 
they  have  given  off  their  fibres  to  the 
decussating  pyramids  (Ludwig.  Dittmar). 
The  results  of  stimulation  and  paralysis 
of  this  centre  are  mentioned  in  Brain, 
Physiology  of  ;  but  for  the  sake  of  con- 
venience it  may  be  stated  here  that  re- 
flex stimulation  {e.g.,  from  the  cortex)  is 
followed  by  contraction  of  the  arteries, 
increase  of  arterial  blood  pressure,  dis- 
tension of  the  systemic  veins  and  of  the 
right  heart :  whilst,  on  the  other  hand, 
paralysis  causes  relaxation  of  the  arteries, 
with  resultant  lowered  blood  j^ressure. 
This  centre  is,  under  ordinary  circum- 
stances, in  a  state  of  moderate  tonic 
excitement ;  but  there  is  experimental 
evidence  that,  although  there  is  no  reason 
to  believe  in  the  existence  of  a  cerebral 
vaso-constrictor  centre,  alterations  in 
blood  pressure  may  be  produced  reflexly, 
by  stimulation  of  the  cerebral  cortex 
acting  on  the  medullary  centre.  The 
course  of  the  fibres  connected  with  this 
centre  is  circuitous.  According  to  Gaskell 
and  Foster,  those  going  to  the  head,  after 
passing  down  the  cord,  leave  b}''  the 
anterior  roots  of  the  dorsal  nerves  below 
the  second  pair,  run  along  the  mixed 
nerve  trunk,  pass  along  the  visceral 
branch,  the  white  ramus  communicans  to 
the  chain  of  sympathetic  ganglia,  through 
the   annulus   of  Vieussens  to  the   lower 


Pathology 


[    895    ] 


Pathology 


cervical  ganglia,  and  thence  to  the  cer- 
vical sympathetic.  After  passing  through 
the  sympathetic  ganglia  they  are  fine 
uon-meduUated  fibrils. 

Gaskell  says  {Journal  of  Pliyt^iology, 
vol.  vii.) : — "  The  presence  of  special  vaso- 
dilator nerves  for  the  blood-vessels  of 
every  part  of  the  body  is  an  article  of 
faith  accepted  by  almost  all  physiologists 
of  the  present  day.  Owing,  however,  to 
the  fact  that  in  most  instances  such 
nerves  are  found  mixed  up  with  the  vaso- 
motor nerves,  the  evidence  upon  which 
their  existence  is  based  is  in  the  majority 
of  instances  indirect  rather  than  direct. 
Fortunately,  we  possess  among  the  vaso- 
inhibitory  nerves  a  few  examples,  the 
separate  existence  of  which  is  beyond 
dispute.  In  these  cases  these  nerves  run 
separately  from  the  vaso-motor,  so  that 
an  examination  of  their  structure  and 
distribution  may  fairly  be  expected  to 
give  indications  of  general  laws,  if  such 
exist,  which  may  afterwards  be  tested  in 
the  case  of  the  other  vaso-inhibitory 
nerves.  The  nerves  in  question  are  j^tr 
e<ix'ellence  the  inhibitory  nerves  of  the 
heart,  the  vaso-dilators  contained  in  the 
chorda  tympani  and  small  petrosal  nerves, 
and  the  nervi  erigentes." 

The  distribution  of  these  dilator  nerves 
difJers  materially  from  that  of  the  vaso- 
constrictors, as  they  pursue  a  more  or 
less  direct  course  to  their  destination. 
Thus,  the  vaso-dilator  fibres  for  the  sub- 
maxillary gland  run  in  the  chorda  tym- 
pani, and  may  be  traced  back  to  the 
facial ;  the  ramus  tympanicus  of  the  glos- 
so-pharyngeal  nerve  contains  similar  fibres 
for  the  parotid  gland,  and  it  appears  pro- 
bable that  the  trigeminal  nerve  contains 
vaso-dilator  fibres  for  the  eye  and  nose, 
and  possibly  for  other  parts  (Foster). 
The  ceutre  in  each  case  appears  to  be  in 
the  central  nervous  system  not  far  from  the 
centre  of  the  ordinary  motor  fibres  which 
they  accompany  (Foster).  Considering 
the  close  analogy  between  the  active 
functional  congestion  of  the  cortex  and  of 
various  glands,  it  may  fairly  be  assumed 
that  these  and  other  nerves  as  they  pass 
to  their  ultimate  areas  of  distribution 
send  off  vaso-dilator  fibres  to  the  mem- 
branes and  the  convolutions.  There  are, 
moreover,  certain  characteristics  of  the 
vaso-dilator  system,  which  afford  support 
to  the  assumption  of  their  extensive  dis- 
tribution to  the  brain.  As  stated  by 
Foster,  their  action  is  less  complicated 
than  that  of  the  vaso-constrictors,  as 
they  appear  to  have  no  tonic  influence ; 
stimulation,  as  in  the  salivary  gland,  here 
producing  reflex  dilatation  of  the  glandu- 
lar  vessels    by   active   extension   of    the 


muscular  fibre  ;  and  "  the  effects  of  the 
activity  of  vaso-dilator  fibres  appear  to 
be  essentially  local  in  character.  When 
any  set  of  them  comes  into  action,  the 
vascular  area  which  they  govern  is  dilated, 
and  the  vascular  areas  so  governed  are 
relatively  so  small  that  changes  in  them 
produce  little  or  no  effect  on  the  vascular 
system  in  general."  Further,  under  ordi- 
nary circumstances  their  influence  is  of 
shorter  duration  than  that  of  the  con- 
strictor fibres.  But  there  may  be  cited 
here  an  interesting  experimental  result 
as  possibly  bearing  on  future  remarks. 
Foster  states :  "  When  a  nerve  [he  in- 
stances the  sciatic]  after  section  com- 
mences to  degenerate,  the  constrictor 
fibres  lose  their  irritability  earlier  than 
the  dilator  fibres,  so  that  at  a  certain 
stage  a  stimulus,  such  as  the  interrupted 
current,  while  it  fails  to  affect  the  con- 
strictor fibres,  readily  throws  into  action 
the  dilator  fibres.  The  latter,  indeed,  in 
contrast  to  ordinary  motor  nerves,  retain 
their  irritability  after  section  of  the  nerve 
for  very  many  days." 

That  the  products  of  metabolism  have 
considerable  effect  on  the  capillaries  of  a 
region  called  into  activity  may  be  almost 
accepted  as  a  postulate,  and  Roy  and 
Sherrington  have  advanced  a  theory  that 
such  products  alone  cause  variations  of 
the  calibre  of  the  cerebral  vessels.*  Their 
opinion  is  based  on  the  absence  of  ana- 
tomical proof  of  the  existence  of  cerebral 
vaso-motor  or  vaso-dilator  nerves  ;  and  in 
the  effects  of  the  injection  of  filtrates  pre- 
pared from  brains  showing  acid  reaction. 
The  injection  of  such  filtrates  is  followed 
rapidly  by  hyperaemia.  They  conclude 
that  "  the  chemical  products  of  cerebral 
metabolism  contained  in  the  lymph  which 
bathes  the  walls  of  the  arterioles  of  the 
brain  can  cause  variations  of  the  calibre  of 
the  cerebral  vessels  :  that  in  this  reaction 
the  brain  possesses  an  intrinsic  mechanism 
by  which  its  vascular  supply  can  be  varied 
locally  in  correspondence  with  local  varia- 
tions of  functional  activity."  The  ob- 
servations of  Langendorf  andGescheidlenf 
are  conclusive  as  to  the  alkaline  reaction 
of  normal  brain  tissue,  and  the  rapid  pro- 
duction of  acidity  under  abnormal  con- 
ditions ;  but  the  additional  deduction  we 
feel  inclined  to  draw  from  these  observa- 
tions and  the  ingenious  experiments  of 
Roy  and  Sherrington  is,  that  acid  lymph 
may  so  increase  the  irritability  of  the  mus- 
cular wall  of  the  vessels  as  to  render  it  all 
the  more  susceptible  to  nervous  vaso- 
dilator or  vaso-constrictor  influence.  As 
will  be  shown  latei',  we  also  believe  that 

*  ./oiirnal  of  I'hytiiology,  vol.  xi. 
t  liiolon.  Ccvtralblatt,  1886. 


Pathology 


[ 


] 


Pathology 


the  products  o£  disease  exercise  a  very 
marked  influence  in  the  maintenance  of 
congestion. 

In  the  present  state  of  knowledge  of  the 
subject  it  is  impossible  to  come  to  a  definite 
conclusion  as  to  the  mechanism  of  cortical 
functional  hypei'ajmia.  The  views  of  most 
physiologists  seem  to  be  in  favour  of  the 
inhibitory  theory.  But  a  priori  the  theory 
of  stimulation  for  a  deflnite  hyperasmia 
necessary  for  a  sijecial  functional  activity 
is  supported  by  the  analogy  of  the  vaso- 
dilator nervous  influence  on  the  blood 
supply  of  muscles  and  of  certain  glands, 
when,  as  we  have  seen,  the  cortex  of  a  man's 
brain  bulges  through  a  hole  in  his  skull  on 
the  application  of  mental  stimulus,  the 
resemblance  to  the  turgescence  of  the 
salivary  glands  on  stimulation  of  the 
chorda  tympani  and  small  petrosal  nerves 
is  highly  suggestive.  We  have  also  the 
results  of  stimulation  of  the  nervi  eri- 
gentes,  and  the  phenomena  of  angio- 
neuroses  of  the  head  and  face  afford  a 
degree  of  support.  Our  belief  is  that  both 
sets  of  nerves  may  exercise  influence — 
that  stimulation  of  the  vaso-dilator  system 
is  the  immediate  producer  of  functional 
hypergeraia,  that  subsequently  inhibition 
of  the  vaso-motor  system  of  nerves  assists 
its  maintenance  :  and  that  the  products 
of  metabolism,  especially  under  diseased 
conditions  also  exercise  a  powerful  influ- 
ence. However  impossible  it  may  be  at 
the  present  moment  to  demonstrate  the 
actual  mechanism,  or  unravel  its  mode  of 
action,  there  can  be  little  doubt  that  we 
have  a  vaso-constrictor  centre  in  the 
medulla,  and  vaso-dilator  centres  (pro- 
bably in  the  cerebrum),  which  under 
ordinary  circumstances  control  the  supply 
to  the  cortex,  and  which  are  controlled  by 
the  cortex  itself  through  the  action  of 
intercurrent  nerves.  No  organ  of  the 
body  has  such  sudden  and  frequent  calls 
for  raj)id  change  of  blood  supply  to  deflnite 
areas,  and,  even  were  we  in  total  ignorance 
of  the  existence  of  vessel-controlling  nerves 
acting  upon  it,  there  is  such  an  array  of 
accessory  facts  as  to  warrant  the  assump- 
tion of  their  presence. 

Functional  hyperEemia  is  in  every  re- 
spect a  condition  of  health  ;  one  necessary 
for  the  provision  of  temporary  nutriment 
during  temporary  activity,  ceasing  with 
the  withdrawal  of  stimulus,  when  the 
calibre  of  the  vessels  is  reduced  to  its  ori- 
ginal dimensions  through  the  constricting 
nervous  influence.  The  vascular  supply 
of  the  brain  is  so  arranged  as  to  favour 
the  rapid  production  of  hyperasmia. 
Moxon  pointed  out  that  the  greater  veins 
of  the  pia  enter  the  superior  longitudinal 
sinus  at  such  an  angle  that  as  the  blood 


enters  the  sinus  it  is  directed  against  the 
general  backward  running  current,  so  that 
unless  the  blood  in  the  sinus  is  much  di- 
minished in  quantity  there  is  always  re- 
tardation of  the  venous  flow  from  the  piai 
vessels,  and  maintenance  of  a  mild  me- 
chanical congestion.  As  B.  Lewis  ob- 
serves, this  maintains  the  patency  of  the 
vessels  both  of  pia  and  cortex  so  long  as 
the  heart  works  with  ordinary  vigour ;  and 
marked  phenomena  result  from  either  di- 
minution or  increase  of  arterial  or  venous 
pressure.  At  the  base  (as  the  same  author 
points  out)  "  a  sustained  pressure  of  no 
inconsiderable  degree  "  is  maintained  on 
the  vessels  of  the  pons  by  the  combined 
streams  of  the  two  vertebrals  being  poured 
into  the  basilar  artery,  the  sectional  area 
of  the  former  being  but  slightly  greater 
tlian  that  of  the  latter  single  artery  ;  this 
sustained  pressure  may  not  be  entirely  ex- 
pended on  the  vessels  of  the  pons,  but  may 
extend  to  the  arteries  given  off  from  the 
circle  of  Willis,  thus  supplementing  the 
suppl}'  of  the  internal  carotids.  Un- 
doubtedly under  such  conditions  arterial 
vaso-constrictor  action  must  be  in  force, 
and  any  interference  with  it  by  morbid 
processes  must  produce  specially  deflnite 
results.  The  combined  action  of  these  in- 
fluences favours  a  full  and  constant — it 
might  be  said  an  over-fall — blood  supply, 
as  is  shown  by  the  slight  bulging  of  the 
dura  mater  into  a  trephine  hole,  and  by 
the  hernia  cerebi'i  in  fracture  of  the  skull : 
although  in  the  latter  condition  the  pro- 
trusion may  be  extreme  in  consequence  of 
paralysis  of  the  vaso-motor  system  pro- 
duced by  traumatic  shock.  The  increase 
of  bulk  of  the  convolutions  due  to  func- 
tional hyperaemia  is,  under  conditions  of 
health,  provided  for  by  the  displacement 
of  cerebro-spinal  fluid  into  the  elaborate 
system  of  lymph  spaces  existing  in  the  pia, 
the  sub-dural  space  and  the  dura  mater — 
into  which  two  latter  spaces,  and  into  the 
longitudinal  sinus,  it  is  conducted  by  the 
Pacchionian  villi — and  into  the  cisterns  at 
the  base,  between  the  dorsal  surface  of  the 
medulla  and  the  posterior  part  of  the  cere- 
bellum, in  the  inter-peduncular  space,  in 
front  of  the  optic  chiasma,  between  the 
under  surface  of  the  cerebellar  hemispheres 
and  the  lateral  portions  of  the  medulla,  on 
both  sides  of  the  transverse  Assure,  and  at 
the  lower  ends  of  the  Sylvian  fissures.  All 
these  spaces  and  cisterns  are  in  direct 
communication  with  the  ventricles,  and 
with  the  great  spaces  in  the  spinal  column. 
The  fluid  reaches  the  extra-skeletal  lym- 
phatics by  peri-vascular  and  peri-neural 
conduits  passing  out  through  every  fora- 
men of  the  skull  and  vertebral  column. 
The  amount  of  this  fluid  produced  daily 


Pathology 


[    897     ] 


Pathology 


has  not  been  estimated,  but  surgical  re- 
cords show  that  it  must  be  considerable. 

We  have  said  that  so  lout^  as  functional 
hyperasmia  is  merely  sufficient  to  supply 
the  temporary  extra  demand  for  the  nu- 
trition of  the  cells  during  functional 
activity,  and  for  the  making  up  of  the 
loss  of  energy,  there  is  a  return  of  the 
normal  circulation  as  soon  as  the  extra 
demand  ceases,  and  the  cell  has  got  rid 
of  its  exti-a  excretory  products.  But  the 
demands  on  the  local  circulation  niay  be 
so  great  and  may  be  so  long  continued 
that,  as  in  other  organs  and  other  parts 
of  the  body,  the  physiological  line  may 
be  passed,  and  pathological  conditions 
may  be  induced,  not  confined  to  the  vessels 
themselves,  but  extending  to  the  tissues 
they  supply.  On  account  of  the  basal 
position  of  the  openings  of  the  skull  it  is 
evident  that  even  slight  pathological  al- 
terations (either  at  the  vertex  or  the  base, 
but  especially  at  the  vertex),  if  they  inter- 
fere with  the  removal  of  lymph  fluid,  must 
implicate  the  maintenance  of  the  perfect 
vascular  unity  of  the  cerebrum  ;  and  that 
any  long-continued  angio-neurotic  changes 
extending  beyond  the  limits  of  normality, 
must  have  considerable  effect  on  the  tissues 
of  the  brain. 

If  the  nutrition  of  the  cells  is  unduly 
interfered  with  for  any  long  continued 
period,  there  ensues  a  series  of  changes 
not  only  in  the  cerebral  cells,  but  also  in 
the  vaso-motor  and  vaso-dilator  control 
systems,  which  may  be  temporary,  or  per- 
manent according  to  circumstances.  The 
circulatory  apparatus  has  been  adjusted 
to  meet  the  increased  demand,  but  the 
cells,  being  stimulated  beyond  the  health 
limit,  a  condition  of  unstable  equilibrium 
between  nutrition  and  function  is  reached 
— they  receive  the  increased  blood  supply 
and  a  certain  amount  of  nutrition,  and 
consequently,  instead  of  the  normal  dis- 
charge of  energy,  irregularity  of  discharge 
is  produced  by  the  prolonged  mainten- 
ance of  over-vascularity.  The  continuous 
excitation  demands  a  greater  supply  of 
nutriment,  and  in  consequence  a  gradually 
increasing  strain  is  laid  on  the  vaso-con- 
trol  system,  till  at  length  one  of  two 
events  occurs ;  either  a  diseased  balance 
between  nutrition  and  function  is  reached, 
or  the  balance  is  completely  destroyed. 

In  the  first  case  discharges  take  place 
at  a  lower  level  of  cell  nutrition  and 
function  ;  in  the  second,  vascular  changes 
become  so  advanced  that  what  must  be 
regarded  as  a  series  of  sub-inflammatory 
processes  ensues.  To  take  a  parallel 
example  from  the  field  of  general  patho- 
logy ;  the  over-exercise  of  function  of  the 
special   cells  of  the  kidney,    whether  in- 


duced by  excess  of  blood,  by  effete  sub- 
stances, or   by  the   presence  of   poisonous 
agents,  is  the  immediate  cause  of  paren- 
chymatous nephritis ;    and  we    have  the 
first  symptoms  of  the  disease  associated 
with  cell  changes,  followed  by  vaso-motor 
disturbances,  which,  in  their  turn,  re-act 
on  the  cells  and  the  tissues  of  the    organ 
through  histological  alteration  of  the  vas- 
cular and  lymphatic  apparatus.     It  may 
be   objected   that  the   parallel    does   not 
exist  in  the  case  of  excess  of  blood  acting 
on  the  cells  ;  but  it  must  be  remembered 
that  the  excess  of  blood,  especially  of  blood 
loaded  with  effete  matter,  is  only  an  irri- 
tant, and  the  producer  of  the  permanent 
hyperasmia  which  is  the  first  efficient  factor 
in  the  production  of  histological  changes. 
The  implication  or  alteration  of  the  rela- 
tion   of  nutrition  to  function  constitutes 
the  preliminary  or  primary  factor  in  the 
production  of  the  prodromal  symptoms  of 
idiopathic   insanity ;  the   arteries   of   the 
cortex  are  dilated,  and  send  an  abnormal 
amount  of  blood  inwards,  and  as  a  result 
thei'e  is  increased  and  sustained  pressure 
in  the  veins.   This  condition  may  persist  for 
considerable  periods  of  time  before  definite 
mania  or   melancholia  is  developed,  un- 
noticed by  any  but  those  immediately  sur- 
rounding the  patient,  and  its  symptoms  of 
restlessness,  irritability  and  bodily  deca- 
dence, are  even  by  them  often  disregarded 
or    misconstrued.      If   early    recognised, 
appropriate  treatment  very  generally  pre- 
vents degradation  of  tissue,  and  procures 
recovery  ;  but  if  the  condition  is  neglected 
the    sequence  of    events,    common  to  all 
tissues  under  similar  circumstances  of  irri- 
tation, ensues.     A  sub-inflammatory  stage 
is  reached,  evidenced  by  deposits  of  leu- 
cocytes much  greater  than  normal  between 
the  adventitia  and  the  muscular  coat,  and 
by  various  degrees  of  proliferation  of  the 
fixed  connective-tissue  cells  af  the  vessel. 
Both  leucocytes  and  fixed  cells  break  down, 
and  a  debris  is  formed,  which,  along  with 
masses   of   blood   pigment,    occupies   the 
peri- vascular  space  in  large  quantities,  and 
can  be  found  distributed  along  the  whole 
course  of  a  cortical  vessel  to  its  ultimate 
i-amifications,    although    it   can    be   most 
readily  demonstrated  at  the  bifurcations. 
This  material  has  been  found  in  quantities 
so  large  as  to  interfere  with  the  patency  of 
the  lymphatic  sheath,  and  to  procure  its 
distension  by  the  obstruction  of  exudation 
fluid.     Implication  of  the  lymphatic  cir- 
culation is  one  of  the  most  important,  if 
not  the  most  important,  of  the  pathological 
factors  in  the  production  of  insanity.     It 
may  act  in  two  ways  ;  first,  by  submitting, 
through  diminished  drainage,  the  cells  to 
the  action  of  waste  products,  and  secondly, 


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by  affecting  the  conductivity  of  vaso- 
motor fibres.  It  must  be  remembered  that 
each  cell  is  surrounded  by  a  capsule  con- 
nected by  the  the  "  spur-like "  process  of 
Obersteiner  with  the  hyaline  sheath,  form- 
ing the  main  lymphatic  apparatus  of  the 
individual  cell.  This  process  is  a  very  tine 
tubule,  and  necessarily  is  easily  occluded. 
Not  only  does  the  occurrence  of  exudates 
in  the  hyaline  sheath  dam  back  the  flow 
from  the  capsule,  but  the  deposits  of  leu- 
cocytes, epithelial  cells  and  masses  of  pig- 
ment, may  actually  occlude  the  openings 
of  Obersteiner's  processes.  Under  these 
circumstances  the  cell  lies  bathed  in  a. 
poisonous  fluid,  the  reaction  of  which  is 
acid,  and  therefore  opposed  to  its_  healthy 
alkaline  constitution.  Degradation  is  a 
necessary  consequence,  shown  flrst  by 
granularity  of  the  ]Kotoplasmic  body,  and 
subsequently  by  changes  of  the  cell  pre- 
sently to  be  described.  This  granularity 
does  not  at  first  exceed  the  "  cloudy  swell- 
ing" of  all  active  cells;  it  only  becomes 
morbid  when  persistent  and  exaggerated. 
But  exudation  fluid  may  also  affect  the 
exercise  of  the  function  of  the  vaso-con- 
strictor  fibres.  Possibly  a  certain  amount 
of  pressure  may  be  caused,  and  it  is  well 
known  that  pressure  at  firsttends  to  stirnu- 
late,and,if  continued, to  paralyse  the  action 
of  these  nerves.  In  their  case  also  the  acid 
exudate  acts  in  a  similar  manner,  procuring 
intensification  of  function ,  followed  by  ex- 
haustion from  extreme  stimulation.  In 
whatever  manner  exudates  act  on  the  vaso- 
constrictors it  is  certain  to  be  finally  in 
the  direction  of  reduction  of  inhibitory 
function  and  consequent  dilatation.  When 
the  pia  mater  becomes  infiltrated,  as  it 
often  does  in  severe  cases,  there  can  be 
little  doubt  that  pressure  acts  strongly 
on  the  branches  of  this  system  running 
between  its  layers.  Wherever  a  vaso- 
constrictor nerve  is  involved  in  an  in- 
flammatory mass  we  have  the  same  con- 
dition as  where  it  is  actually  cut,  and  this 
alone  would  be  sufficient  to  account  for 
the  obstinate  congestion  of  the  brain  caus- 
ing delirium  or  death,  not  only  in  cases 
of  idiopathic  insanity,  but  also  in  many 
other  head  affections. 

We  can  only  speak  from  the  experience 
•derived  from  the  examination  of  four 
cases  of  idiopathic  insanity,  which  proved 
fatal  within  two  months  of  the  develop- 
ment of  mania  and  melancholia,  as  to  the 
period  at  which  the  products  of  inflam- 
mation show  themselves  and  exercise  any 
marked  influence.  In  two  cases,  one 
symptomatised  by  mania,  the  other  by 
melancholia,  deposits  of  leucocytes,  pig- 
ment, and  nuclei  of  endothelium  were 
found  in  considerable  quantities,  here  and 


there  in  aggregated  masses,  in  vessels 
taken  from  the  superior  convolutions ; 
the  proliferation  of  fixed  cell  nuclei  was 
marked.  In  two  others,  one  of  mania 
(death  having  resulted  from  exhaustion) 
and  one  of  excited  melancholia  (the  sub- 
ject of  which  committed  suicide),  stasis  of 
a  very  well-marked  character  was  found  ; 
the  lumen  of  many  cortical  vessels  of  all 
sizes  was  occupied  by  blood  corpuscles, 
the  peri-vascular  lymphatics  were  much 
distended  and  blocked  by  debris,  and  wide 
spaces  between  the  sheath  and  tbe  brain 
substance  were  seen  in  the  maniacal  case. 
There  can  be  little  doubt  that  these  morbid 
products  are  deposited  much  earlier  in  the 
history  of  a  case  than  two  months,  but  in 
the  absence  of  data  it  is  impossible  to 
assign  any  definite  period  for  their  ap- 
pearance. It  is  highly  improbable  that 
such  intensity  of  diseased  action  occurs, 
save  in  extreme  cases,  but  in  the  first  two 
instances  adduced,  the  pathological  pro- 
ducts were  not  much  more  stronglymarked 
than  those  presented  in  subjects  of  older 
standing  insanity  of  a  milder  type.  In 
such  we  have  constantly  found  the  pro- 
ducts described,  and  have  noted  the  evi- 
dence of  extensive  exudation.  It  is  not 
often  that  the  observer  is  fortunate  enough 
to  get  the  cellular  capsule  and  its  process 
in  absolute  relation  to  the  lymphatic 
sheath ;  but  in  three  instances  we  have 
procured  evidence  of  their  continuity,  and 
noted  the  distension  of  the  whole  appa- 
ratus, the  cell  lying  in  a  clear  open 
space  in  connection  with  a  wide  canal. 
This  can  be  easily  demonstrated,  as  re- 
gards the  capsule  alone,  in  chronic  cases. 
If,  as  B.  Lewis  asserts  (and  we  entirely 
agree  with  him),  each  cell  is  surrounded 
by  a  looped  capillary,  and  if  the  vessel 
becomes  implicated  to  the  extent  of  stasis, 
or  even  short  of  it,  it  is  not  difficult  to 
understand  how  degeneration  of  cell  pro- 
toplasm is  hastened  by  two  sets  of  action  ; 
toxic  from  within,  and  deprivation  of 
nutriment  from  without. 

But  further  morbid  instrumentality  is 
at  work.  We  have  direct  evidence  that 
during  sleep  the  cortex  of  the  superior 
convolutions  is  antemic ;  according  to 
Mosso's  experiments  {loc.  cif.)  and  observa- 
tions, the  supply  to  the  cortex  is  much 
diminished,  the  vessels — both  arteries  and 
veins — being  contracted,  and  the  brain  is 
smaller.  Insomnia  is  one  of  the  earliest 
symptoms  of  incipient  insanity,  and  con- 
tinues during  its  acute  period  ;  sleep  is  not 
obtained  in  its  natural  degree  till  con- 
valescence, or  terminative  dementia,  is 
reached.  It  cannot  be  doubted  that  this 
insomnia  is  due  to  hypertemia.  In  those 
rare  cases  of  insanity,  in  which  there  is  no 


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Pathology 


interf  eren  ce  with  the  periodicity  or  intensity 
of  sleep,  the  fact  of  its  presence  ought  to 
influence  diagnosis.  Sleep  is  the  condition 
necessary  for  the  recuperation  of  cell- 
tissue  ;  in  its  absence  the  downward  ten- 
dency to  degeneration  must  necessarily 
be  assisted. 

The  question  which  now  naturally  pre- 
sents itself  is,  how  can  we  reconcile  the 
dependence  of  three  such  apparently  widely 
divergent  morbid  mental  symptoms  as 
mania,  melancholia,  and  dementia,  on  one 
common  pathological  condition.  The  fol- 
lowing clinical  observations  support  the 
position  as  to  the  unity  of  pathological 
causal  conditions : — 

(a)  During  the  prodromal  period  the 
symptoms  of  excitement  and  melancholia 
frequently  alternate. 

(6)  In  many  acute  cases  mania  and 
melancholia  co-exist — i.e.,  it  is  impossible 
to  say  whether  they  are  cases  of  maniacal 
melancholia  or  of  melancholic  mania. 

(c)  As  many  cases  run  their  course 
towards  recovery  the  symptoms  are  con- 
secutively melancholia,  mania  and  de- 
mentia. 

(d)  In  folic  circulaire  the  same  sequence 
of  symptoms  occurs  time  after  time. 

{e)  In  general  paralj'sis  of  the  insane, 
the  inflammatory  nature  of  which  is  be- 
yond doubt,  a  certain  proportion  of  cases 
is  characterised  by  exaltation  of  feeling, 
another  by  depression,  and  a  third  by 
obfuscation,  from  beginning  to  end;  whilst 
in  certain  others  we  may  have  all  varieties 
and  degrees  of  symptoms  presenting  them- 
selves. 

(/)  The  effect  of  the  administration  of 
certain  poisons,  especially  alcohol,  is  a 
sequence  of  psychical  phenomena  of  much 
the  same  character. 

These  observations  point,  not  to  a  dif- 
ference in  kind  of  primary  causation,  but 
to  variation  of  symptoms  in  accordance 
with  the  progress  and  nature  of  patho- 
logical processes,  which  vary  principally 
in  accordance  with  the  constitution  of  the 
tissues  of  the  individual.  It  must  be 
borne  in  mind  that  the  deposits  of  in- 
flammatory products  and  congestion  are 
Dot  identical  or  constant  in  the  individuals 
of  a  series  of  subjects,  because  the  indi- 
viduals and  their  tissues  are  not  constant 
quantities.  We  have  thus  a  constant 
condition  of  irritation  acting  on  incon- 
stant subjects.  We  know  that  the  patho- 
logical results  of  over-taxation  of  brain 
function  are  accompanied  b}'  morbid  ex- 
citement of  action  of  the  organ ;  but  we 
are  apt  to  forget  that  although  mania  is 
accompanied  by  exaltation,  and  melan- 
cholia by  depression  of  feeling  (speaking 
of  each  in  the  mass),  they  are  both  mani- 


festations of  excitement  of  feeling.  Given 
this  common  psychological  condition  of 
excitement  of  feeling  we  must  seek  for  an 
explanation  of  the  varieties  of  its  pheno- 
mena either  in  some  quality  or  quantity 
of  its  exciting  cause,  in  some  peculiarity 
of  its  pathological  products,  or  in  some 
idiosyncrasy  of  the  affected  individual. 
We  derive  no  material  assistance  from 
psychological  considerations,  for  there  is 
no  necessary  connection  between  dej^ress- 
ing  emotions  and  melancholia  on  the  one 
hand,  or  between  stimulating  emotions 
and  mania  on  the  other.  Intense  grief 
produces  mania  as  often  as  melancholia, 
and  the  insanity  of  the  man  of  saturnine 
disposition  is  as  often  as  not  characterised 
by  mania.  The  peculiarity  of  the  exciting 
cause  appears  to  be,  not  its  psychological 
characteristics,  but  its  intensity  and 
rapidity  of  incidence  ;  the  latter  depend- 
ing not  only  on  the  former,  but  also  en 
the  stability  or  instability  of  tissue.  Ac- 
coi'ding  as  excitement  of  feeling  is  rapidly 
jDroduced  so  the  more  likely  is  mania  to  be 
the  symptom,  especially  when  it  acts  on 
an  extremely  irritable  but  unstable  proto- 
plasm. It  is  not  only  to  the  constitution 
of  the  cortical  cells  and  their  network  to 
which  we  may  look  for  evidence  of  in- 
stability and  irritability,  but  also  to  the 
ganglia  which  govern  the  vaso-motor 
systems  of  nerves.  Inherent  weakness  of 
these  centres  may  play  an  even  more  im^ior- 
tant  role  in  the  production  of  insanity  than 
instability  of  the  peripheral  ganglia,  more 
esi^ecially  in  the  rapidity  of  its  production. 
That  melancholia  often  su2:)ervenes  on  de- 
pressing emotions,  gradual  in  their  inci- 
dence and  action,  does  not  imply  a  j^sycho- 
logical  nexus  ;  but,  that  as  their  irritating 
influence  is  slowly  applied  to  cells  of  di- 
minished vitality  and  nutritive  power,  so 
the  results  of  the  irritation  are  slowly  pro- 
duced ;  and,  as  in  the  case  of  every  organ 
of  the  body,  we  have  variety  of  degree  of 
symptoms  in  conformity  with  the  rajjidity 
of  the  progi-ess  of  pathological  events. 
In  extreme  cases  of  recent  excitement, 
maniacal  or  melancholic,  we  have  found 
stasis  and  the  products  of  inflammation  : 
in  chronic  cases  the  same  appearances  are 
l^resented,  although  in  a  less  degree,  what- 
ever the  symptom  may  liave  been  :  and  if 
we  have  any  right  to  connect  post-mortem 
demonstration  with  the  indications  of  dis- 
ease during  life  the  iuferenceis unavoidable 
that  considerable  variety  of  clinical  phe- 
nomena may  be  dependent  on  a  common 
cause  acting  on  differently  constituted 
tissues. 

Evidence  of  inflammator}- action  is  con- 
stantly met  with  in  the  encephale  of  the 
insane,  and  is  frequently  alluded  to   by 


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Pathology 


writers  on  the  changes  observed,  with- 
out, however,  any  definite  reference  to  it 
in  connection  with  the  natural  history  of 
the  various  diseases  causing  insanity,  with 
the  occasional  exception  of  general  para- 
lysis and  traumatism.  But  setting  aside 
all  cases  of  these  two  conditions  and 
chronic  alcoholism,  estimating  them  as 
together  forming  one-third  of  the  insani- 
ties, in  the  remaining  70  per  cent,  we  find 
evidences  of  inflammatory  action  having 
been  at  work  at  some  period  or  other  in 
about  one-half.  In  the  other  half,  where 
such  evidence  is  not  seen,  the  insanity  has 
been  dependent  on  anasmia  or  other  causes 
presently  to  be  spoken  of. 

The  marks  of  inflammatory  action  are 
met  with  in  the  («)  Skull,  (h)  IVIem- 
tiranes,  (c)  Blood-vessels,  (d)  Weurog- 
lia,  (e)  Cells. 

(a)  There  can  be  little  doubt  that  in- 
flammation plays  an  important  part  in  pro- 
ducing thickening  of  the  skull,  and  in- 
creased density  and  rarefaction  of  its 
diploe  ;  and  that  these  changes  are  the  re- 
sult of  irritations  common  to  the  bone,  the 
membranes,  and,  in  many  instances,  the 
cortex  itself.  Tnedura  mater  is  the  perios- 
teum of  the  calvaria,  and  is  supplied  by  the 
same  vessels  and  lymphatics,  and  the  two 
must  always  inevitably  suffer  from  common 
causes  of  irritation.  The  thickenings  of 
the  inner  table,  causing  a  nodose  appeai*- 
ance,  often  correspond  to  adhesions  with 
the  membrane.  The  frequency  of  the  co- 
incidence of  a  thickened  vitreous  lamina 
and  a  rarefied  diploe  are  strongly  sugges- 
tive of  the  change  being  a  compensatory 
one,  a  view  held  by  Rokitansky  and  others; 
but  the  strong  jirobability  is  that  such 
thickening  is,  to  say  the  least,  marked  by 
23revious  or  contemporaneous  inflammatory 
action. 

(b)  IVXembranes. — B.  Lewis  states  that 
his  records  show  that  in  20  per  cent, 
of  those  dying  insane  the  dura  mater  was 
found  adherent  to  the  skull.  In  our  own 
■experience  the  proiwrtion  is  much  greater, 
for  in  300  autopsies  we  noted  109  cases  in 
which  this  condition  existed.  This  is  all 
the  more  curious  as  in  Scottish  asylums 
the  proportion  of  general  paralytics  and 
epileptics  is  less  than  in  England.  Adhe- 
sion may  be  complete  over  the  whole  dome, 
so  complete  indeed  as  to  necessitate  section 
of  the  dura  before  the  calvaria  can  be 
removed.  This  is  rare  ;  the  adhesions  are 
generally  local  and  are  most  frequently 
over  the  frontal  lobes,  at  the  sagittal 
suture  and  under  the  parietal  eminences. 
They  are  evidences  of  "  bygone  inflamma- 
tory change  "  (Lewis),  which,  judging  from 
the  frequency  of  frontal  or  vertical  head- 
ache in  the  prodromal  period  of  idiopathic 


insanity,  must  be  of  early  incidence.  It 
IS  of  importance  to  emphasise  the  early 
occurrence  of  this  pain  as  bearing  on  the 
inflammatory  theory.  As  Duret  points  out, 
inflammatory  conditions  of  the  bone  or  of 
the  dura  mater  are  accompanied  by  pain 
set  up  by  the  compression  of  the  branches 
of  the  fifth,  twelfth,  and  sympathetic 
nerves,  produced  by  exudates.  Given  such 
testimony  as  to  the  conditions  of  the  enve- 
lopes it  is  the  natural  inference  that 
the  brain  elements  which  are  primarily 
affected  must  be  under  the  agency  of 
similar  conditions.  Marked  thickening  of 
the  dura  is  not  common,  but  wherever  the 
membrane  is  adherent  to  the  bone  a  cer- 
tain increase  of  its  thickness  can  be  found. 
The  microscopic  characters  are  irregular 
dilatation,  tortuosity,  and  thickening  of 
the  vessels.  Adhesions  between  the  dura 
and  arachno-pia  are  rare.  When  found, 
there  is  invariably  accumulation  of  sub- 
dural fluid  producing  flattening  of  the 
subjacent  convolutions.  Granularity  of 
the  epithelium  of  the  external  surface  of 
the  arachno-pia  is  occasionally  but  rarely 
met  with. 

Pachymeningitis  has  been  discussed  in 
a  separate  article  (g. v.).  Whilst  agreeing 
that  in  certain  cases  the  tnodus  operandi 
is  as  there  stated,  it  is  necessary  to  men- 
tion that  German  authorities  lay  great 
stress  on  the  production  of  this  condition 
by  inflammatory  j^rocesses.  In  Ziegler's 
"  Pathologische  Anatomie,"  Band  ii. 
1890,  par.  129,  p.  2)73,  his  views  are  thus 
stated  : — 

"Pathological  Anatonirj  of  the  Dura 
Mater. — The  dura  mater  is  a  membrane 
closely  adherent  to  the  bone  within  the 
cranial  cavit}^  and  forms  its  inner  perios- 
teum. It  is  accordingly  subject  to  all 
those  changes  that  affect  the  periosteum 
of  other  bones :  but  as  the  sheath  of  the 
central  nervous  system  certain  special 
changes  occur  in  it  which  require  con- 
sideration. 

"  This  membrane  is  very  frequently  the 
seat  of  an  inflammator}^  process  known  as 
chronic  internal  pachymeningitis,  which 
evidently  appears  in  consequence  of  various 
injuries  whose  precise  nature  is  not  exactly 
understood.  The  inflammation  is  most 
frequently  "  hematogenous  "  and  appears 
either  independently  or  associated  with 
inflammation  of  the  pia  mater  and  sub- 
arachnoid tissue  ;  it  may  also  accompany 
inflammation  of  the  adjoining  bones.  It 
appears  either  unilaterally  and  in  cir- 
cumscribed areas,  bilaterally  and  in  scat- 
tered areas,  or  generally  diffused  over  the 
entire  cranial  cavity. 

"  So  far  as  is  known,  the  outset  of  the 
inflammation  is    characterised   anatomi- 


Pathology 


[    901     ] 


Pathology 


cally  by  the  formation  of  exceedingly  thin 
deposits  on  the  inner  surface  of  the  dura, 
which  consist  essentially  of  thin,  granular, 
thready,  or,  at  times  even  more  homo- 
geneous, fibrin  with  scanty  round  cells. 

"After  some  time  the  membranes  be- 
come pervaded  by  active  (lehensfi'irhige) 
cells,  and  interpenetrated  by  vessels  grow- 
ing as  offshoots  from  the  dura.  From 
this  germ  tissue  is  afterwards  formed  a 
delicate  fibrous  tissue  which  lines  the 
interior  surface  of  the  dura  in  the  form 
of  a  membranous,  transparent  deposit, 
abounding  in  wide,  thin-walled  vessels 
filled  with  blood. 

"  The  newly  formed  vessels  of  the  mem- 
brane are  particularly  prone  to  bleed,  the 
ver}'  slightest  circulatory  disturbances 
appai'cntly  sufficing  to  cause  hasmor- 
rhages  through  diapedesis  and  rupture. 
Consequently  pachymeningitic  mem- 
branes neax'ly  always  contain  recent  ha3- 
morrhagic  areas  or  pigmented  deposits 
proceeding  from  older  hasmorrhages,  a 
peculiarity  which  has  led  to  the  process 
being  described  as  hasmorrhagic  pachy- 
meningitis. The  hemorrhages  ai'e  usually 
small,  but  may,  however,  attain  such  very 
considerable  dimensions  as  partly  to  sepa- 
rate the  already  formed  membranes  from 
the  dura  and  thus  to  form  hasmatomata 
enclosed  in  a  membranous  sac  which 
compress  the  brain  more  or  less.  If  the 
new  membranes  (the  blood-cysts  or  hasma- 
tomata)  give  way,  blood  finds  its  way  into 
the  sub-dural  space. 

"  When  once  the  inflammation  has  set 
in  it  seems  very  rarely  to  be  recovered 
from.  The  extravasated  matters  are  in- 
deed re-absorbed,  but,  where  discharges 
are  great,  the  process  is  both  slow  and 
imperfect,  while,  at  the  same  time,  the 
presence  of  the  extravasated  and  disinte- 
grated blood  keeps  up  an  irritation  tend- 
ing to  fresh  inflammation.  Hence  the 
inflammation  continues,  fresh  exudations 
and  fresh  membranes  are  formed,  which 
assume  more  and  more  a  tough  scar-like 
or  callous  character  and  contain  more  or 
less  pigment,  fibrinous  residue,  disinte- 
grated blood  and  lime.  Sometimes  after 
absorption  of  a  larger  extravasation  a 
local  collection  of  liquid  appears  between 
the  dura  and  the  neo-membrane ;  this  is 
known  as  hygroma  of  the  dura  mater  or 
partial  pachymeningitic  hydrocephalus. 

"  In  older,  tougher  membranes  less  rich 
in  cells  and  more  fibrous,  a  portion  of  the 
vessels  i;sual]y  atrophies,  but  a  cure  is 
not  attained  through  this  obliteration. 
Other  parts  remain  highly  vascular  and 
fresh  ha3morrhages  maintain  the  inflam- 
matory condition. 

"  Pachymeningitic   membranes  do   not 


usually  form  any  adhesions  in  their  im- 
mediate neighbourhood  ;  it  may,  however, 
happen  that  more  or  less  firm  connections 
are  formed  between  them  and  tlie  arach- 
noid, in  consequence  of  which  blood- 
vessels from  the  false  membranes  pass 
into  the  soft  meninges. 

"  In  addition  to  pachymeningitis  in- 
terna chronica,  there  is  also  an  external 
form,  in  which  the  inflammatory  processes 
are  confined  essentially  to  the  outer  sur- 
faces of  the  dura,  and  are  associated  with 
thickening  of  the  latter  membrane  and 
with  resorption  and  new  formation  of  the 
bone  substance.  Moreovei',  the  dura  is 
very  frequently  inflamed  through  injuries 
and  through  inflammatory  processes  in 
the  contiguous  parts.  When  for  example 
the  skull  is  injured  by  a  stab  or  blow, 
in  consequence  of  which  various  inflam- 
matory processes  have  been  set  up,  the 
dura  may  also  be  involved  sympathetically. 
In  the  same  way  inflammation  of  the 
middle  ear,  of  the  petrous  bone  or  even 
of  the  orbital  cavity  may  extend  to  the 
dura.  When  once  suppuration  sets  in, 
the  dura  appears  of  a  yellowish  white  or 
grayish-yellow  colour.  If  previous  hre- 
mori'hages  have  occurred,  the  shade  of 
colour  may  be  dirty  gray  or  grayish-green 
and  brown." 

In  the  pia  mater  in  which  the  arteries 
ramify  before  their  passage  into  the  brain, 
and  in  which  the  veins  are  contained  on 
their  exit,  the  results  of  frequent  and 
pathological  congestions  are  extremely 
well  marked  to  the  naked  eye ;  and,  as 
might  be  expected  from  the  intimate  rela- 
tion of  the  cortical  pia  to  the  exterior  and 
interior  of  the  brain  substance,  patholo- 
gical processes  in  the  one  are  usually 
associated  with  similar  or  allied  morbid 
conditions  in  the  other.  Milky  opacity  is 
the  most  prominent  departure  from  the 
normal  condition;  it  is  by  no- means  con- 
fined to  the  brains  of  the  insane,  and  may 
be  often  noted  in  the  post-mortem  rooms 
of  general  hospitals.  It  appears  fir-^t  as 
an  opalescent  streak  on  either  side  of  the 
larger  veins,  and  is  doubtless  due  to  occa- 
sional pathological  congestion,  superadded 
to  the  normal  mechanical  obstruction 
induced  by  the  j^eculiar  anatomical  rela- 
tions of  the  vessels  to  the  longitudinal 
sinus.  But  the  condition  is  never  so  well 
marked  as  in  the  insane,  in  whom  the 
cloudy  opacity  is  found  involving  the 
whole  of  the  superior  surface  of  the  brain, 
and  sometimes,  although  rarely,  impli- 
cating its  inferior  aspect.  In  such  cases 
the  arachno-pia  is  often  much  thickened 
and  separated  from  the  visceral  pia  by  the 
fluid,  the  trabeculte  being  stretched,  and 
its  lymphatic  sjiaces  immensely  dilated. 


Pathology 


[    902    ] 


Pathology 


This  condition,  according  to  oui*  own 
records,  has  been  noted  in  58  per  cent,  of 
those  dj'ing  insane.  Occasionally  we  find 
great  tortuosity  of  the  vessels,  especially 
of  the  veins  ;  lately  we  examined  a  case  in 
which  certain  vessels  were  twisted  three 
times  on  themselves  like  a  coil  of  ro7)e. 
The  patient  died  from  haemorrhage  into 
the  sac  of  the  j^ia  mater,  thin  clots  and  fluid 
blood  occupying  the  greater  part  of  the 
cavity.  Adhesion  of  the  visceral  pia  to 
the  brain  substance  has  been  noted  by  us 
as  occurring  in  '^']  per  cent,  of  our  dis- 
sections. The  morbid  connection  between 
the  membrane  and  the  cortex  is  of  two 
kinds,  ((()  the  thickened  sheath  of  the 
vessels,  and  (&)  a  fine  reticulum  produced 
by  increase  of  the  connective-tissue  cor- 
puscles of  the  external  layer  of  grey 
matter.  These  are  undoubtedly  indica- 
tions of  intiammatory  action,  but  not  the 
only  ones.  We  have  said  that  such  adhe- 
sions are  found  in  yj  per  cent,  of  insane 
persons,  but  they  probably  would  be 
found  in  a  larger  proportion  were  it  not 
that  in  many  instances  they  have  been 
obliterated  (at  least  in  the  case  of  the 
reticulum)  by  the  floating  up  of  the  mem- 
brane by  fluid  finding  its  way  to  the  sur- 
face from  below.  In  many  cases  we  find 
the  visceral  pia  separated  from  the  sur- 
face of  the  cortex  by  a  considerable  open 
space,  the  membrane  being  attached  by  the 
hyaline  sheaths  only.  A  space  in  this 
position  has  been  described  by  His  as  the 
"  epicerebral  lymph  space,"  and  the  under 
surface  of  the  visceral  pia  has  been  stated 
to  be  lined  by  endothelium.  This  lining 
we  have  failed  to  demonstrate,  and  the 
existence  of  such  a  lymphatic  space  is 
difiicult  to  realise,  as  no  provision  has 
been  suggested  by  which  the  fluid  could 
reach  the  main  currents.  The  only  means 
of  communication  would  be  by  stomata, 
and  their  existence  has  never  been  demon- 
strated. In  connection  with  these  adhe- 
sions B.  Lewis  says,  when  speaking  of 
the  subject  generally,  without  definite 
reference  to  general  paralysis  or  other  in- 
flammatory conditions,  'In  earlier  stages 
[the  italics  are  our  own]  the  appearance 
is  suggestive  of  inflammatory  implication 
in  the  distinctly  pinkish  appearance  of 
the  cortex,  sometimes  diffused,  sometimes 
limited  to  the  areas  of  recent  adhesions  ; 
the  pia  is  thickened,  tumid,  and  the  seat 
of  nuclear  proliferation,  its  vessels  deeply 
engorged,  and  the  superjacent  arachnoid 
also  thickened,  opaque,  and  oedematous. 
The  distended  vessels  are  coarse  and 
tortuous,  their  sheaths  thickened  by  mul- 
tiplication of  their  cells  and  the  traversing 
of  their  structure  by  wandering  leucocytes" 
— a  very  picture  of  inflammatory  action. 


(c)  Exactly  the  same  state  of  matters 
exists  around  the  vessels.  We  have  al- 
ready indicated  the  appearance  presented 
by  vessels  during  the  earlier  and  later 
stages  of  congestion.  If  a  vessel  is  care- 
fully removed  from  the  brain  matter,  laid 
on  a  slide,  and  gently  washed  with  a 
camel's  hair  brush  and  water,  it  will  often 
be  found  full  of  blood,  sometimes  so  firmly 
packed  as  to  defy  all  attempts  to  remove  it. 
In  such,  and  in  bloodless  vessels,  especially 
at  bifurcations,  deposits  of  blood  pigment 
and  the  other  debris  above  alluded  to, 
are  found  in  large  quantities,  and  the 
nuclei  of  the  sheath  are  seen  increased 
in  number  and  size.  In  hardened  sections 
the  lumen,  both  of  the  vessel  and  lympha- 
tic sheath,  are  seen  fully  occupied,  the 
former  by  blood,  the  latter  by  leucocytes 
and  fatty-looking  debris.  We  repeat  :  the 
whole  position  points  to  the  action  of  sub- 
inflammatory  processes,  the  effects  of 
which  present  themselves  to  the  naked 
eye  more  prominently  over  the  vertex  and 
immediately  surrounding  parts,  leaving 
the  base  and  inferior  lateral  regions  of  the 
brain  unafi"ected.  The  condition  of  the 
arachno-pia  affords  a  very  fair  index  of 
that  of  the  subjacent  convolutions  ;  it  is 
in  fact  (in  addition  to  the  lymphatic  func- 
tion) the  connective-tissue  capsule  of  the 
brain,  and  its  intimate  relations  with  the 
neuroglia  that  involve,  almost  necessarily, 
a  liability  of  the  two  kinds  of  connective 
tissues  to  be  affected  by  similar  patholo- 
gical processes. 

{d  and  e)  ITeurogrlia  and  Connective- 
tissue  Cells. — The  clinical  fact  that  a  very 
large  proportion  of  idiopathic  cases  (70 
per  cent.)  recover  indicates  that  resolution 
can  be  procured  by  appropriate  treatment, 
and  that  the  channels  becoming  again 
nearly  normal,  the  various  functions  of  the 
organ  can  be  again  healthily  exercised. 
The  theory  has  been  advanced  by  B.  Lewis 
that  the  connective-tissue  corpuscles  exer- 
cise an  important  influence  in  the  removal 
of  effete  products.  In  Bkaix,  Anatomy 
OF,  it  will  be  found  stated  that  these 
bodies  are  of  two  kinds,  one  considerably 
larger  than  the  other.  The  larger,  called 
after  their  discoverer,  Deitei-'s  cells,  are 
branched,  and  it  is  held  that  they  are  con- 
nected with  the  hyaline  sheath  by  a  pro- 
cess which  may  be  canalicular,  but  which 
has  not  as  yet  been  proved  to  be  so.  It  is 
difficult  to  demonstrate  these  Deitei-'s,  or 
spider,  cells  in  healthy  subjects;  but  in 
morbid  conditions  they  are  frequently  met 
with,  and  can  easily  be  made  evident, 
especially  in  frozen  sections  stained  with 
aniline  black.  In  health  neither  the  larger 
nor  the  smaller  cells  take  up  staining 
agents  readily,  and  it  is  therefore  inferred 


Pathology 


[    903    ] 


Pathology 


that  their  ready  colouring  in  sections 
taken  from  diseased  subjects  indicates 
some  molecular  change  in  their  proto- 
plasm. It  is  undoubtedly  true  that  it  is 
impossible  to  obtain  a  demonstration  so 
perfect  in  health  as  in  disease.  B.  Lewis 
holds  that  these  Dciter's  cells  are  the 
"  lymph  connective  "  elements  of  the  brain, 
that  they  are  "  scavenger  "'  cells,  and  that 
they  take  a  very  active  share  in  the  pro- 
cesses of  disease  att'ecting  the  nervous 
centres.     In  his  own  words  : — - 

"Thedelicate  system  of  lymph  connective 
elements  permeating  in  the  normal  state 
the  whole  of  the  cerebral  mass  of  white  and 
gre}''  substance  takes  a  more  active  share 
in  the  pathogenesis  of  mental  decadence 
than  any  other,  and  the  more  the  question 
is  investigated  the  greater  importance,  we 
feel  convinced,  will  be  attached  to  these 
elements  in  the  processes  of  disease  as 
affecting  the  nervous  centres.  Their  j^hy- 
siological  indications  are  clear ;  they  are 
sravengers  of  the  brain,  and  the  evidence 
obtainable  renders  it  now  incontrovertible 
that  they  are  liable  to  excessive  and  rapid 
development  under  certain  morbid  con- 
ditions ali'ecting  cerebral  nutrition  and 
repair  in  the  normal  condition  of  healthy 
cerebration Whatever  leads  to  in- 
creased waste  of  cerebral  neurine  ;  when- 
ever structure  disintegration  is  slowly 
proceeding  either  in  nerve  cell  or  fibre; 
whenever  accumulation  of  debris  occurs 
from  disease  of  the  vascular  tracts  ;  then 
we  invariably  note  an  augmented  activity 
registered  in  these  scavenger  elements  of 
the  brain.  That  their  activity  is  in  direct 
ratio  to  the  functional  activity  of  the 
essential  neurine  tissue  we  think  there  can 
be  no  doubt,  nor  that  with  each  accession 
of  the  nerve-tide  they  are  stimulated  to 
increased  activity  in  the  removal  of  the 
products  of  waste  and  the  jjlasma  effused 
from  the  vessels.  In  healthy  states,  how- 
ever, they  assume  the  hypertrophiedform, 
the  deep  staining,  the  coarse  fibrillation, 
the  rapid  multiplication,  and  the  evidence 
of  obvious  intra-cellular  digestion,  which 
are  readily  observed  in  pathological 
states."* 

The  hypertrophied  processes  being  dis- 
tributed between  the  nerve  elements  and 
surrounding  the  vascular  walls  replace  the 
delicate  neuroglia,  and  as  the  cells  under- 
go further  alteration  they  produce  a  fully 
formed  felt-like  material.  Hamilton, 
Zeigier,  and  B.  Lewis  agree  that  this 
material  is  liable  to  contract  and  seriously 
interfere  with  the  permeability  of  the  ves- 
sels. The  last  insists  that  these  changes 
belong  to  the  latter  stages  of  disease,  so 
that  they  are  always  associated  with  very 
*   '•  A  Text-Book  of  ^lentiil  Diseases." 


rapid  and  advanced  pathological  pro- 
cesses or  with  chronic  conditions.  He 
believes  that  this  condition  is  due  to  the 
irritation  of  certain  specific  poisons,  but 
that  it  is  also,  in  part  at  any  rate,  brought 
about  wherever  '"  a  large  accudiulation  of 
degenerated  material  has  to  be  carried  ott' 
from  the  cortex,  or  where  effete  material 
as  the  result  of  some  obstruction  to  the 
normal  transit  of  lymph  from  the  brain 
has  accumulated  ;  in  such  positions  we 
are  likely  to  meet  with  this  development 
of  fibre  cells." 

Although  we  agree  in  the  main  with 
the  above,  we  cannot  help  thinking  that 
too  much  importance  is  attached  to  the 
function  of  these  so-called  scavenger  cells 
on  the  one  hand,  and  too  little  on  the 
other;  and  that  we  must  guard  ourselves 
against  the  theory  that  there  is  associated 
with  them  in  the  brain,  a  jjathological  j^ro- 
cess  different  from  that  which  occurs  in 
other  organs.  There  can  be  no  doubt  that 
the  connective-tissue  cells  play  an  impor- 
tant phagocyte  role  in  all  parts  of  the  body 
both  in  health  and  disease.  It  is  equally 
certain  that  where  there  is  material  to  be 
removed  we  find  an  increased  development 
of  connective-tissue  cells.  The  greater 
the  amount  of  effete  material  to  be  re- 
moved the  more  rapid  is  the  development 
of  these  cells,  and  the  moi'e  embryonic  is 
the  character  they  assume.  It  is  during 
the  embryonic  stage  that  they  appear  to 
be  specially  active  as  scavengers,  and  it 
is  only  in  the  later  stages  when  the  proto- 
plasm is  losing  its  jjhagocyte  activity  that 
the  reticular  material  is  most  fuU}^  de- 
veloped, and  we  feel  inclined  to  regard  the 
large  "  scavenger  cells"  of  B.  Lewis  as  cells 
that  have  passed  through  a  more  active 
phagocyte  stage  than  that  in  which  they 
are  when  they  assume  the  forms  and 
appearances  he  so  vividly  describes.  Still 
in  this  condition  their  i)hagocyte  function 
is  not,  in  all  i^robability,  entirely  lost,  and 
the  substitution  of  the  reticulum  of  pro- 
cesses serves  to  implicate  the  association 
system  of  ganglionic  cell  poles.  The  re- 
lation of  these  cells  to  the  lymph  spaces 
of  the  brain  is  indicative  of  the  jaart  they 
have  to  play  in  the  absorjition  of  neurine 
material  and  in  the  digestion  or  trans- 
formation of  foreign  matter  and  waste  pro- 
ducts. A  parallel  example  of  phagocyte 
function  is  afforded  by  the  connective 
tissues  of  the  lung,  where  the  cells  lining 
the  lym2)hatic  spaces  and  those  free  cells 
that  are  budded  off  from  the  fixed  cells, 
have  been  shown  to  take  up  foreign  par- 
ticles of  carbon  or  blood  pigment,  pass 
them  on  from  2)oint  to  point,  and  even- 
tually get  rid  of  them  into  the  general 
stream  ;  or,  if  the   mass   be  large,  they 


Pathology 


[    904    ] 


Pathology 


atteuqit  to  surrouud  it,  so  that  it  may  be 
temporarily,  or  even  permanently,  cut  off 
from  the  general  lymphatic  system. 
Wherever  this  takes  place  there  is  i)ro- 
liferation  of  the  cells,  and  au  alteration  of 
the  whole  connective  tissue  arrangement. 
This  proliferation  may  be  the  most  per- 
manent feature  in  the  disease-processes, 
whilst  in  other  cases  it  appears  to  play 
oul}^  a  secondary  part.  To  instance  the 
lung  again :  during  the  early  stages  of  a 
catarrhal  pneumonia  there  may  be  a 
marked  increase  in  the  number  of  epi- 
thelial cells  lining  the  air  vesicles  of  cer- 
tain lobules,  but  this  is  accompanied  by 
comparatively  slight  connective  tissue 
change  or  proliferation.  After  a  time, 
however,  if  the  process  becomes  chronic, 
we  find  that  there  is  an  absorption  of 
irritant  material  formed  from  the  mass  of 
degenerating  epithelial  cells  in  the  lym- 
phatics, and  as  a  result  there  is  a  marked 
proliferation  of  the  connective-tissue  cells. 
Here  the  proliferation  is  evidently  quite 
secondary  to  the  processes  that  have  been 
going  on  in  the  air  vesicles.  But  in  cer- 
tain other  cases  of  pneumonia  (as  also  in 
specific  disease  affecting  the  brain  and  in 
chronic  alcoholism),  there  is  apparently 
an  almost  primary  increase  in  the  amount 
of  connective  tissue,  the  irritant  appear- 
ing to  pass  directly  from  the  blood-vessels 
into  the  lymphatics,  there  setting  up  con- 
nective tissue  proliferation.  Whenever 
this  is  the  case  there  is  of  course  inter- 
ference with  the  nutrition  of  the  epithelial 
cells,  in  consequence  of  which  there  may 
be  either  proliferation  and  degeneration 
or  degeneration  only.  We  are  inclined  to 
apj)!}'  this  analogy  to  the  connective  tissue 
changes  in  the  brain,  and  to  assign  very 
difterent  degrees  of  importance  in  various 
forms  of  insanity  to  them,  and  to  the 
action  of  the  scavenger  cells.  In  the  forms 
of  insanity  in  which  a  new  formation  of 
connective  tissue  takes  place  there  will 
necessarily  be  a  greater  tendency  to  the 
removal  of  partially  devitalised  nerve 
tissue  which,  once  removed,  can  so  far  as 
we  know  at  present  never  be  completely 
replaced  ;  and  nerve  cells  and  processes 
which,  if  left  to  themselves,  might  have 
regained  under  proper  nutrition  a  portion, 
if  not  the  whole,  of  their  former  activity, 
will  be  removed  by  the  over-active  con- 
nective-tissue cells,  by  which  they  are  as 
a  matter  of  fact  replaced.  Although  we 
make  this  general  statement  it  must  be 
borne  in  mind  that  without  the  removal 
of  degenerated  cells  and  effete  products 
there  can  be  no  ijossibility  of  a  return  to 
health,  so  that  the  scavenger  cells  doubt- 
less play  a  double  I'ule — reparative  and 
destructive.     Except  in  the   most   acute 


cases  of  idiopathic,  and  probably  other 
forms  of,  insanity,  their  proliferation  is  not 
a  marked  feature  in  the  early  stage.  In 
that  stage  we  have  increase  of  endothelium 
and  debris  occupying  the  lymphatic 
sheaths.  With  reduction  of  congestion 
this  morbid  material  is  removed  ;  but  if 
it  is  not  got  rid  of  b}'  flushing  we  find,  as 
in  the  case  of  chronic  catarrhal  pneu- 
monia, well  marked  increase  of  these  con- 
nective-tissue cells  in  the  neighbourhood  of 
vessels.  This  must  be  regarded  as  an 
etfort  of  nature  to  remove  the  effete 
material  collected  in  the  ganglionic  cell 
capsule.  In  cases  of  rapid  recovery  re- 
duction of  inflammation  may  be  assumed  ; 
when  recovery  is  protracted  the  slower 
process  of  elimination  by  phagocytes  is  at 
work  ;  in  the  case  of  chronic  terminative 
dementia  the  scavenger  cells  have  failed, 
and  in  the  abortive  effort  have  so  pro- 
liferated that  they  cause  destruction  of 
nerve  fibre,  of  the  latei'al  processes  of  the 
nerve  cells,  and  finally  of  a  considerable 
number  of  the  cells  themselves.  We  can 
only  deduce  from  clinical  observations  the 
length  of  time  taken  by  this  destructive 
process.  In  the  case  of  acute  idiopathic 
mania,  symptoms  of  recovery  show  them- 
selves in  from  one  to  six  months ;  if  no 
improvement  shows  itself  during  the  next 
six  months,  and  a  tendency  to  dementia 
is  manifested,  the  case  is  all  but  hopeless, 
and  we  may  infer  that  cell  degradation 
has  taken  jjlace  to  such  an  extent  as  to 
preclude  the  possibility  of  repair,  and  that 
certain  other  morbid  products  have  been 
thrown  out  as  a  result  of  degeneration  of 
fibre. 

Lately  we  have  obtained  evidence  of 
leucocytes  taking  on  phagocyte  action. 
In  a  case,  the  subject  of  which  died  of 
intercurrent  disease,  within  nine  months 
of  the  appearance  of  insanity,  accompanied 
by  obscure  motor  symptoms,  the  large 
cells  of  the  motor  area  were  found  under- 
going degeneration,  and  had  evidentl}^ 
been  attacked  by  leucocytes.  They  were 
clearly  distinguishable  from  the  scavenger 
cells  of  Lewis ;  when  observed  under  high 
powers  ( X  2000)  the  character  of  the 
nucleus  was  obnervable,  and,  moreover, 
no  appearance  of  processes  existed.  The 
substance  of  the  cells  was  in  many  in- 
stances invaded  b^^  one,  two,  or  three  such 
bodies,  and  were  also  surrounded  by  large 
numbers  of  the  small  nuclei  of  neuroglia. 
Throughout  the  whole  specimen  connec- 
tive-tissue proliferation  was  extreme,  es- 
pecially on  the  vessels  :  but  Deiters  cells 
were  not  to  be  found. 

The  first  and  most  frequent  evidence  of 
over-action  in  idiopathic  insanity  is  an 
excessive  deposit  of  pigment  in  the  large 


Pathology 


[     905     ] 


Pathology 


cells  of  the  fifth  layer.  Pigment  is  found 
in  these  cells  even  in  healthy  subjects.  We 
lately  examined  the  brains  of  twelve  adult 
subjects  taken  casually  from  the  patho- 
logical department  of  the  Edinburgh  In- 
firmary, and  in  every  instance  an  amount 
of  pigment  (variable  indeed)  was  found, 
which,  however,  was  specially  well  marked 
in  three  cases  in  which  delirium  had  been 
a  feature  ;  in  no  instance  were  the  cells 
changed  in  shape  or  size.  We  have  ex- 
amined the  brains  of  six  cases,  terminating 
fatally  in  from  two  to  ten  months  from  the 
incidence  of  insanity  from  exhaustion,  or 
some  intercurrent  disease,  with  the  special 
object  of  observing  the  condition  of  these 
cells.  In  all  there  was  great  pigmentation, 
beginning  at  the  base  and  extending  to  the 
apex.  It  was  impossible  to  say  wliether 
this  was  preceded  or  accompanied  by  in- 
crease of  size,  an  appeai-ance  produced  as 
if  by  distension,  the  angles  being  oblite- 
rated and  the  sharp  outlines  destroyed. 
The  pigment  seemed  to  creep  round  the 
nucleus,  occasionally  displacing  it.  In  all 
cases  the  nucleus  itself  was  the  last  part 
to  be  affected  by  any  degenerative  change, 
and  the  first  evidence  of  its  implication 
seemed  to  be  a  white  translucent  spot,  as 
if  the  nucleolus  had  disappeared  and  a 
transparent  material  had  been  substituted. 
The  basal  poles  in  the  earlier  cases  pi'e- 
sented  a  broader  appearance,  and,  like  the 
whole  cell,  readily  took  on  pigment ;  but 
in  no  case  did  the  staining  agent  affect 
these  processes  for  more  than  three  milli- 
metres from  the  body,  at  which  distance 
the  pole  first  became  less  colourable,  and 
then  refused  to  receive  any  stain.  In  the 
later  cases  neither  cells  nor  poles  took  on 
the  staining  reagent  to  such  an  extent  as 
in  the  earlier  ones;  the  lateral  or  proto- 
plasmic processes  could  not  be  traced,  and 
the  cells  presented  the  ajipearance  of 
possessing  a  distinct  cell  wall.  In  the 
ten  months  case  many  cells  had  broken 
down,  leaving  nothing  but  the  nuclei, 
and  in  certain  instances  these  had  been 
destroyed,  the  original  body  being  repre- 
sented by  a  mass  of  coloured  granules, 
rounded,  or  diffused  over  a  space  three  or 
four  times  that  which  had  been  originally 
occupied.  As  was  pointed  out  by  Howden, 
pigmentation  is  always  associated  with 
hgematoidin  deposits  round  the  vessels. 
The  cells  of  the  outer  layers  do  not  seem 
to  sufi'er  so  severely  from  this  process, 
only  faint  tingeing  of  a  much  finer  yellow 
material  being  observable  at  their  bases, 
and  this  but  rarely.  In  the  two  cases  of 
longest  standing  many  cells  were  noticed 
undergoing  a  granular  degeneration  unas- 
sociated  with  pigmentation.  These  also 
had  changed  shape,  the  nuclei  were  dis- 


placed, and  the  lateral  poles  lost,  although 
the  apical  processes  could  be  traced  for 
considerable  distances.  In  cases  of  chronic 
terminative  dementia,  this  is  invariably  to 
be  noticed.  In  some  instances  we  have 
found  immensely  "  inflated "  or  swollen 
non-granulated  cells  in  the  motor  area, 
almost  uncolourable  by  carinineor  logwood. 
Meynert  speaks  of  this  condition  as 
"  (edematous."  Here  it  is  often  very  difla- 
cult  to  demonstrate  any  cellular  ele- 
ments ;  those  in  the  three  outer  layers  are 
withered  and  collapsed-looking,  showing 
as  mere  streaks  slightly  more  coloured 
than  the  surrounding  tissue.  Often  they 
will  not  take  on  carmine  at  all,  but  hsema- 
toxylin  usually  is  absorbed  slightly.  The 
larger  cells,  again,  in  such  cases  are  often 
highly  granular,  and  present  little  or  no 
pigmentation  :  they  may  be  reduced  to 
fatty-looking  masses,  irregular  in  outline, 
the  nuclei  having  even  disappeai-ed.  Both 
in  connection  with  pigmentary  and  granu- 
lar degeneration  i-esulting  from  idiopathic 
mania,  vacuolation  is  occasionally  met 
with,  but  not  nearly  to  the  extent  to  which 
it  is  observable  in  other  forms  of  insanity. 
We  have  said  that  the  condition  of  the 
pia  mater  affords  a  fair  index  of  the  con- 
dition of  the  immediately  subjacent  tissues. 
Membranes  covering  the  convolutions 
which  are  believed  to  contain  identical 
centres — those  of  the  frontal  lobes,  are  as 
a  rule  much  less  deeply  affected  by  dis- 
eased action  than  those  of  the  superior, 
and  superior  lateral  aspects.  This  is 
mainly  due  to  anatomical  arrangements 
already  described,  and  the  presence  of 
mental  symptoms  must  be  largely  refer- 
able to  imperfect  drainage  of  the  region  of 
intellectual  action.  It  is  impossible  to 
say  how  far  the  almost  invariable  impli- 
cation of  the  large  cells  of  the  motor  area 
is  productive  of  hebetude  and  other  motor 
symptoms  so  constant  in  the  insane. 

The  loss  of  the  protoplasmic  lateral  or 
associative  processes  of  the  cells  must  be 
regarded  as  a  most  important  feature, 
probably  even  more  important  than  the 
destruction  of  individual  cells.  If  w& 
accept  the  theory  of  ideational  centres, 
the  cutting  off  of  one  from  another  must 
form  the  basis  on  which  to  found  a  sys- 
tem of  morbid  psychology.  In  this  con- 
nection we  cannot  do  better  than  quote 
the  words  of  B.  Lewis  : — 

"  The  interdependence  of  the  structural 
elements  of  the  cortex,  due  to  its  terminal 
system  of  arteries,  is  of  primary  import- 
ance to  us  in  correctly  appreciating  the 
morbid  appearances  presented  in  insanity. 
Another  factor,  however,  must  be  invari- 
ably considered  with  respect  to  all  morbid 
lesions  of  the  cortex,  and  that  is  the  sym- 


Pathology 


[    906    ] 


Pathology 


pathy  betwixt  distant  territories  which 
are  functionally  associated  in  their  activi- 
ties, and  structurally  linked  together  by 
'association'  fibres.  The  former  condi- 
tion— the  interdependence  of  parts  in 
terminal  systems — was  the  direct  outcome 
of  elaborate  difEerentiation  ;  the  latter 
condition  of  sympathy  betwixt  distant 
territories  is  established  by  an  equally 
elaborate  structural  integration." 

Aiw^jhij  of  the  brain,  general  or  local, 
is  a  sequence  of  inflammatory  action. 
General  atrophy  is  rare  ;  it  is  usually  con- 
fined to  the  superior  or  lateral  convolu- 
tions, and  may  be  induced  by  pressure 
from  exuded  fluid,  or  by  phagocyte  action. 
In  the  former  case  inflammatory  exudates 
are  poured  into  the  cavity  of  the  pia  (sub- 
.  arachnoid  space)  more  rapidly  than  they 
can  be  carried  off' by  the  natural  channels, 
they  flood  the  sub-dural  space,  and  pro- 
duce pressure  of  no  inconsiderable  degree. 
In  dealing  with  intra-cranial  fluid  in  con- 
nection with  insanity  it  seems  to  have 
been  assumed  by  most  authors  that  all 
such  accumulations  are  "compensatory;" 
by  which  is  meant,  passive  accumulations 
of  fluid.  We  find  inflammation  credited 
with  the  production  of  many  lesions,  but 
its  influence  in  the  production  of  exudate 
fluid  is  studiously  ignored.  Still  in  fatal 
cases  of  recent  acute  insanity  we  find 
large  accumulations,  which  had  they  oc- 
curred in  the  subject,  say,  of  basal  menin- 
gitis, would  be  regarded  as  a  direct  result 
of  the  condition.  We  have  no  direct  evi- 
dence of  this  during  life  so  far  as  idio- 
pathic insanity  is  concerned,  but  we  have 
most  undoubtedly  observed  a  marked 
bulging  of  the  dura  mater  in  two  early 
cases  of  general  paralysis,  a  condition  dis- 
tinctly due  to  inflammatory  action.  As 
we  shall  have  to  consider  the  subject  of 
fluid  pressure  in  the  production  of  atrophy 
in  extenso  when  speaking  of  general  para- 
lysis, it  is,  to  save  repetition,  relegated  to 
that  section. 

Shrinking  of  the  brain  may  be  caused 
by  contraction  of  sclerosed  regions  and 
pathological  phagocyte  action.  In  this 
case,  of  course,  compensatory  fluid  is 
called  for  and  provided  ;  as  also  in  the 
case  of  local  atrophy.  Local  ati'ophy 
isgenerallyproducedbypluggingor  serious 
congestive  interference  with  the  patency 
of  the  terminal  arteries  of  the  convolutions. 
One  of  the  most  important  of  Buret's  ob- 
servations is  that  these  vessels  are  strictly 
terminal  and  do  not  anastomose  with 
those  of  immediately  adjacent  regions. 
If  this  assertion  be  correct,  when  such  an 
artery  is  plugged  atrophy,  confined  to  the 
area  which  it  supplied,  is  a  necessary  con- 
sequence.      The    frequency    of    atrophy, 


general  and  local,  in  the  insane  is  re- 
markable. The  statistics  of  B.  Lewis,  re- 
ferring to  insanity  in  the  mass  show  that 
out  of  1565  fatal' cases,  it  was  present  in 
1055  (or  67.4  per  cent.)  "that  the  wasting 
was  general  throughout  the  hemisphere  in 
574  cases,  although  261  also  showed  a 
special  implication  of  certain  areas,  and 
that  in  48 1  other  cases  partial  or  localised 
atrophy  was  observed."  The  occurrence 
of  local  atrophies  occurred  in  the  following 
sequence  of  frequency — the  fronto-parietal 
segment,  postero-parietai  lobule,  the  cen- 
tral gyri,  the  separate  frontal  gyri  and 
Sylvian  boundary,the  temporo-sphenoidal, 
the  occipital  and  angular  gyri. 

The  most  important  of  the  degenerative 
changes  shown  by  the  microscope  are 
viiliary  sclerosis  and  colloid  bodies.  The 
former  was  first  described  by  Drs.  Batty 
Tuke  and  Eutherford,*  and  their  observa- 
tions were  confirmed  by  Dr.  Kesteven.t 
Many  attempts  have  been  made  to  prove 
that  these  appearances  are  produced  by 
hardening  agents  and  spirit;  but  this 
theory  is  shown  to  be  utterly  unsubstan- 
tial by  the  fact  that  miliary  sclerosis  is 
easily  demonstrable  in  fresh  frozen  sec- 
tions. Were  it  artificial  it  would  be  found 
in  all  brains  hardened  in  spirit,  which  is 
not  asserted  by  Savage  and  others  who 
have  tried  to  discredit  it ;  that  it  is  found 
in  the  spinal  cords  of  animals  is  what 
might  be  expected,  when  we  consider  how 
liable  they  are  to  spinal  injuries  and  to 
inflammation  of  the  cord  in  early  life. 
Spirit  was  never  used  by  us  in  our  har- 
dening methods  ;  we  have  since  tried 
various  methods  of  hardening,  and  also 
of  cutting  in  a  fresh  condition  and  always 
with  the  same  i-esult.  But  the  question 
has  been  set  at  rest  by  B.  Lewis,  who 
shows  that  miliary  sclerosis  can  be  traced 
in  sections  prepared  both  by  hardening 
and  in  the  fresh  state.  This  we  had  ob- 
served ourselves  previous  to  the  publica- 
tion of  Lewis's  important  work.  The 
original  description  of  miliary  sclerosis 
still  holds  good:  "as  a  rule  the  spots 
are  unilocular,  occasionally  bilocular,  and 
in  rare  instances  multil ocular  ;  but  what- 
ever their  condition  in  this  respect  is,  they 
possess  the  same  internal  characteristics. 
A  thin  section  prepared  in  chromic  acid, 
viewed  by  the  naked  eye,  shows  a  number 
of  opaque  spots  irregularly  distributed 
over  the  surface  of  the  white  matter;  they 
are  best  seen  in  a  tinted  section,  as  they 
are  not  colourable  b}"-  carmine.  When 
magnified  under  a  low  power,  they  have 
a  somewhat  luminous  pearly  lustre,  and 
when   magnified  250   and  800  diameters 

*  Ji:<liii.  Mtd.  Journ.,  1868. 

t  Brit,  and  For.  Medico-fhir.  Jieview,  1868. 


Pathology 


[    907     ] 


Pathology 


linear,  they  are  seen  to  consist  of  mole- 
cular material,  with  a  stroma  of  exceed- 
ingly delicate,  coloui-less  fibrils.  They 
possess  a  well-defined  outline,  and  the 
neighbouring  nerve  fibres  and  blood- 
vessels are  pushed  aside  and  curve  round 
them.  In  well-advanced  cases  the  plasm 
■seems  denser  at  the  circumference  of  the 
spots  than  at  their  centres,  and  a  degree 
ot  absorption  of  the  contiguous  nerve 
iibres  is  evident;  this  solution  of  con- 
tinuity is  only  noticeable  at  the  jjoint 
■where  the  lateral  expansion  is  greatest. 
The  spots  are  generally  colourless,  but  in 
■Bome  instances  they  are  of  a  yellowish- 
green  tint,  which  may  be  attributable  to 
chromic  acid.  They  vary  much  in  size ; 
multilocular  spots  are  g^,,  of  an  inch  to 
•j-5q  of  an  inch  in  diametei*,  the  unilo- 
cular fi-om  over  ^w  ^0  y^o  of  an  inch. 
As  many  as  eleven  locules  have  been  ob- 
served in  one  patch,  separated  one  from 
the  other  by  fine  trabeculaj  of  nervous 
tissue." 

These  spots  are  very  rarely  found  in  the 
grey  matter,  and  then  only  at  its  edge ; 
in  the  white  matter  they  may  be  seen  with 
the  naked  eye,  studding  the  white  matter 
in  considerable  numbers.     B.  Lewis  states 
that  the  condition  is,  at  a  certain  stage, 
invariably  associated  with  an  increase  of 
Deiter's   cells,    and    that  the  peri-vascu- 
lar nuclei  frequently  exhibit  proliferation 
and  granular  hgematoidin,  in  the  vascular 
sheaths,  in  sections  in  which  miliary  scle- 
rosis exists.     We  have   found   it   in    the 
superior  convolutions,  the  pons,  medulla, 
cerebellum,    and    cord.      B.    Lewis    has 
figured  with  great  accuracy  its  appear- 
ance in  longitudinal  sections  of  the  spinal 
cord  :  "  The  morbid  product  is  then  seen 
to   be   aggregated   in   oval   or   elongated 
elliptic  i^atches  measuring  139/x  to  i86yxin 
length,  by  40/x  to  yojj.  in  breadth  .... 
and  its  appearance  at  once  suggests  to  the 
mind  the  forcible  extravasation  at  numer- 
ous points  of  a  coagulable  material  which 
has  driven  the  textural  elements  asunder 
before  it."     We  are  entirely  at  one  with 
this  author  as  to  the  nature  of  this  jiro- 
duct,  having  changed  our  opinion  on  the 
subject   after   having  examined  his   pre- 
parations.    These    patches    undoubtedly 
consist  of  altered  myelin  exuded  in  drop- 
lets from  the    medullated  tubes  and  co- 
alescing more  or  less  completely,  the  axis- 
cylinder  being  forced  aside  along  with  the 
neighbouring  tissues,  or  undergoing  solu- 
tion of   continuity.     Miliary   sclerosis   is 
"  not  a  primary  sclerotic  change,"  but  is 
an    accident   occurring   in  the  course  of 
sub-acute    inflammatory   action    (Lewis). 
The  term  miliary  sclerosis  does  not  ex- 
press the  nature  of  the  condition  except 


so  far  as  certain  of  its  results  or  accom- 
paniments are  concerned ;  but  it  has 
been  so  long  in  use  as  to  make  it  difficult 
to  suggest  a  change  in  nomenclature. 

Colloid  degeneration  is  a  condition  allied 
to  miliary   sclerosis.      Hamilton   from  a 
series  of  experiments  on  the  spinal  cord  of 
animals    came    to    the    conclusion    that 
colloid   bodies   were   developed   from  the 
axis  cylinder  as  the  result  of  infiamniation. 
He  describes  them  as  occasionally  showing 
concentric   rings,    undergoing  fissiparous 
division,    and     pi'oducing     "  depots"     of 
similar  round  translucent  bodies  of  smaller 
size  :  in  a  later  stage  developing  nuclei, 
becoming  transparent  and  granular,  pre- 
senting the  appearance  of  "  mother  cells," 
with  small  cells  in  their  interior,  which 
are  set  free  as  pus-corpuscles.     This  de- 
scription can  only  apply  to   these  bodies 
under  the  condition  of  acute  inflammation. 
Woodhead  described  a  similar  condition 
as  due  to  a  more  chronic  infiamniation  of 
the  cord  in  a  case  of  locomotor  ataxia.* 
We  have  never  seen  this  form  of  degenera- 
tion in  the  human  brain  except  as  roimd 
or  oval  translucent  bodies,  a  little  larger 
or  smaller  than  a  blood  corpuscle.     In  the 
pons,  medulla,  and  cord  certainly  they  are 
found  somewhat  larger  ;  and  we  have  met 
with  them  much  smaller  in  the  brains  of 
birds  undergoing  irritation — e.g.  in  jDigeons 
we   have     seen    them    3ju.    in     diameter. 
They  stain  with  hfematoxylin  ;  osmic  acid 
renders   them    black  ;    but    they   do  not 
readily   take   up    carmine,  and    are   un- 
aff'ected  by  aniline  blue-black.     They  are, 
without    doubt,    produced    like     miliary 
sclerotic  spots,  by  change  occurring  in  the 
hyaline  sheath.     It  is  possible  the   axis- 
cylinder  may  assist,  but  the  changes  in 
that  organ   noticed   in    connection   with 
colloid  degeneration  are  usually  the  result 
of  affections  of  the  sheath.     In  fact  the 
axis-cylinder  may  often  be  traced  through 
a    tumour   or    ampullation   consisting  of 
swollen  hyaline.     Colloid  bodies  are  found 
in    groups    in  the   white    matter,   some- 
times near  vessels,  or  in  lines  following 
the  course  of  fibres  of  the  part.     In  old- 
standing  cases  of  senile  dementia  we  have 
found  them  (small  in  size)  immediately 
below   the   visceral   pia,    and    below  the 
epithelium    of    the   ventricles.       Dr.    A. 
Miles,  of  Edinburgh,  has  lately  found  them 
in  great  numbers  and  of  large  size  in  the 
brains  of  persons  dying  after  traumatic  in- 
jury to  the  head.     He  examined  specimens 
by  both  the  fresh  freezing  and  hardening 
methods  ;  and  found  them  in  a  boy  who 
died  fourteen  hours  after  an  accident,  and 
in  another  case  which  died  in  two  hundred 
and  fifty-six  hours.  They  were  distributed 
*  Jimrn.  Aiiai.  and  I'lii/s.,  vol.  xvi.  p.  364. 


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all  through  the  white  matter  of  the  cod- 
volutions  near  the  seat  of  injury,  in  the 
most  superficial  layer  of  the  grey  matter, 
and  in  the  lymphatic  system.  In  the 
white  matter  they  appeared  as  small 
round  droplets,  7^  in  size,  gradually  in- 
creasing in  size  as  they  approached  the 
cortex,  and  most  numerous  in  the  vicinity 
of  punctiform  hasmorrhages.  They  were 
largest  (30jLi  to  50/x)  on  the  free  surface 
of  the  brain  below  the  visceral  pia,  sug- 
gesting that  several  drojilets  had  coalesced 
after  finding  their  way  outwards  by  the 
space  between  the  hyaline  sheaths  and 
the  brain  substance.  When  seen  in  the 
meshes  of  the  pia  mater  they  were  always 
near  lacerations  of  the  visceral  pia : 
"when  in  relation  to  the  inti-a-cortical 
vessels,  they  were  found  in  the  pei'i-vas- 
cular  lymph  space  of  His."*  It  is  evident 
that  colloid  bodies  can  be  produced  by 
inflammatory  processes,  and  by  direct  in- 
jury to  the  head,  causing,  so  to  speak,  a 
bruised  condition  of  the  nerve  fibre.  But  it 
is  probable  that  in  those  suffering  from 
chronic  insanity  they  are  secondary  lesions, 
the  result  of  impaired  nutrition  of  fibre 
consequent  on  cell  degenei-ation.  It  is  also 
more  than  probable  that  their  composition 
is  identical  with  miliary  sclerosis,  and  that 
the  more  highly  organised  appearance  of 
the  latter  is  due  to  a  slower  process  of  pro- 
duction, and  a  greater  accumulation  of 
material. 

The  examination  of  nerve  fibre  requii-es 
to  be  conducted  with  special  precautions 
on  account  of  the  rapidity  with  which  post- 
mortem changes  occur  in  it.  Even  in 
winter,  and  when  subjects  have  been 
removed  to  a  mortuary,  the  temperature 
of  which  is  not  greater  than  that  of  the 
atmosphere,  the  examination  should  not 
be  delayed  for  a  longer  period  than  twenty- 
four  hours ;  under  any  circumstances  it  is 
better  to  keep  the  head  surrounded  by  ice 
till  the  autopsy  can  be  conducted.  The 
myelin  sheath  is  the  structure  first  impli- 
cated, although  it  appears  to  resist  the 
action  of  inflammatory  processes  for  a  long 
period.  The  degeneration  is  first  marked 
by  a  tendency  to  ampullatiou  under  very 
moderate  pressure  on  the  cover-glass ; 
later  on  the  myelin  breaks  down  and 
forms  masses  of  a  fatty  nature,  colloid 
bodies  and  points  of  "  miliary  sclerosis.'' 
The  axis  cylinder  may  be  traced  for  a  con- 
siderable distance  denuded  of  its  medulla. 
Although  we  have  sought  very  carefully 
for  changes  in  the  axial  cylinder,  such  as 
those  described  by  Ranvier,  we  have  failed 
to  detect  them  in  the  brains  of  the  insane; 
this  is  probably  due  to  the  rapid  obliter- 
ation of  the  axial  cylinder  after  destruc- 
*  Brain,  July  1890. 


tion  of  the  sheath  has  taken  place.  The 
small  slightly  refractile  bodies  often  seen 
in  recent  specimens  are  apparently  the 
detritus  of  degenerated  myelin. 

The  pathological  appearances  presented 
in  general  paralysis  have  occupied  the 
attention  of  many  observers  ;  and  lesions 
of  the  various  constituents  of  the  eoce- 
phale  have  been  described  with  consider- 
able accuracy.  But  it  remained  for  Bevan 
Lewis  to  collate  these  observations  with 
his  own,  eliminate  error,  and  put  the 
whole  together  in  consecutive  form  :  add- 
ing to  existing  knowledge  the  most  accu- 
rate and  minute  descriptions  of  diseased 
tissues ;  advancing  and  demonstrating 
their  modus  operandi  in  producing  the 
naked  eye  appearances,  and  co-reiating, 
as  far  as  possible,  the  clinical  phenomena 
with  the  results  of  pathological  research. 
His  account  of  the  morbid  anatomy  of  the 
disease  must  be  accepted  as  the  most  per- 
fect which  has  as  yet  been  produced,  and 
we  therefore  give  a  summary  of  it,  inter- 
polating remarks  where  his  conclusions 
seem  opeii  to  doubt. 

Three  well  marked  stages  in  the  morbid 
implication  of  the  cortex  are  to  be  ob- 
served:  (i)  A  stage  of  inflammatory 
change  in  the  tunica  adventitia  with 
excessive  nuclear  proliferation,  profound 
changes  in  the  vascular  channels,  and  tro- 
phic changes  induced  in  the  tissues  around; 
(2)  a  stage  of  extraordmary  development 
of  the  lymph  connective  tissue  of  the  brain, 
with  a  pai'allel  degeneration  and  disap- 
pearance of  nerve  elements,  the  axis  cylin- 
ders of  which  are  denuded  ;  (3)  a  stage  of 
general  fibrillation  with  shrinking  and 
extreme  atrophy  of  the  parts  involved. 

(i)  Stage  of  inflammatory  engorgement. 
Lesions  are  first  noticed  in  the  vessels  of 
the  pia,  and  the  lymphatic  sheath  is  where 
inflammatory  change  originates.  Although 
in  early  cases  slight  cloudiness  of  the 
arachno-pia  may  be  noted,  and  there  may 
be  greater  difficulty  than  in  health  in 
removing  the  visceral  pia,  there  is  no 
general  adhesion  to  the  brain  substance. 
In  our  own  experience  we  have,  in  two  very 
early  cases,  both  dying  from  lung  affec- 
tions within  six  months  of  the  definite 
symptoms  of  general  paralysis,  and  in  two 
others  who  died  within  nine  months, 
observed  a  much  greater  degree  of  adhesion 
than  B.  Lewis  mentions,  and  feel  inclined 
to  the  opinion  that  the  disease  may  either 
first  affect  the  visceral  pia  and  extend  to 
the  hyaline  sheath,  or  that  the  two  por- 
tions may  be  synchronously  affected.  But 
it  ma)^  be  admitted  that  in  most  cases  the 
proliferation  of  the  cells  of  the  adventitia 
IS  better  marked  than  in  those  of  the  outer 
layer  of  grey  matter.     Still,  in  the  four 


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cases  alluded  to  the  difference  iu  amount 
was  slight.  The  amount  of  proliferation 
may  be  enormous,  so  niucli  so  as  to  con- 
ceal the  vessel ;  it  is  a  genuine  inflamma- 
tory process,  accompanied  l)y  the  usual 
signs  of  inflammation,  transudation  of 
fluid,  diapedesis,  and  collection  of  ha;ma- 
toidin  crystals,  es])ecially  at  the  bifurca- 
tions of  vessels.  From  the  cells  of  the 
pia  processes  are  sent  downwards  even  to 
the  deepest  layers  of  the  cortex.  As  tlie 
disease  advances  the  soft  membranes  be- 
come more  and  more  gravely  implicated. 

"  The  nuclear  proliferation  around  the 
vessels  of  the  pia,  their  distension  and 
engorgement  (from  paralysis  of  the  vital 
contractility  of  the  muscular  coat)  lead  to 
a  very  free  exudation  into  the  meshes  of 
the  pia.  The  connective  trabecule  lying 
between  the  intima  pia  and  arachnoid 
(arachno-pia)  ....  become  saturated 
with  a  fluid  exudate,  present  a  swollen  and 
gelatiuiform  aspect  to  the  naked  eye, 
streaked  with  opaque  lines,  or  assume  a 
patchy,  or  a  general  and  uniformly  dif- 
fused opalescence Into  this  space 

exude  the  cellular  and  fluid  pi'oducts  of 
the  inflammatory  sheath.  This  tendency 
to  the  accumulation  of  exudate  in  the  sub- 
ai'acbnoid  (pial)  lymph-tissues  receives  a 
marked  increment  at  a  later  stage  of  the 
disease  ;  for  when  atrophic  changes  occur 
in  the  cortex  as  the  result  of  impaired  nu- 
trition and  degeneration  of  nerve  elements, 
a  great  compensatory  serosity  of  this 
lesion  is  established,  and  the  membranes 
become  fairly  water-logged.  The  atrophy, 
which  IS  the  result  of  a  genuine  sclerotic 
change  in  the  cortex,  is  necessarily  more 
marked  in  the  sulci  than  over  the  summits 
of  the  gyri,  the  area  of  cortical  surface 
involved  in  the  one  case  being  far  greater 
than  in  the  other,  and,  in  consequence 
thereof,  the  gyri  become  narrower  and 
attenuated,  the  thinning  of  the  cortical 
layers  being  the  most  marked  feature."* 

Whilst  fully  agreeing  with  this  author 
as  to  the  compensatory  nature  of  the  fluid 
at  a  later  stage  of  the  disease,  when 
shrinking  has  taken  place  consequent  on 
the  contraction  by  the  sclerosed  condition 
of  the  glia  cells,  we  have  pretty  defluite 
data  for  holding  that  iu  the  early  inflamma- 
tory stage  the  fluid  is,  as  he  states,  a  true 
exudate,  and  is  being  poured  out  in  such 
quantities  that  it  cannot  be  removed  by 
the  normal  channels,!  and  so  acts  by  pres- 
sure on  the  convolutions  in  the  production 
of  general  atrophy  of  the  superior  gyri. 
The  question  is  one  of  great  import- 
ance in  its  bearings  on  treatment.  Dr.  B. 
Tuke,    in   three,    and    Dr.    Claye    Shaw  [J; 

''    Beviin  Lewis,  loc.  clt.,  pj).  497-8. 

t  Brit.  Med.  Journ.,  4  Jan.  1890.   %  lb.  6  Xov.  1889. 


in  two,  cases  caused  the  parietal  bones 
to  be  trephined,  on  the  presumption  that 
exudates  cause  pressure  on  the  convolu- 
tions. If  such  is  not  the  case,  and  if  the 
fluid  is  purely  compensatory,  of  course 
such  an  ojieivation  is  not  justifiable.  But 
iu  the  case  so  treated  deflnite  evidence 
was  afforded  that  positive  pressure  did 
exist,  as  on  removal  of  the  disc  of  bone  the 
dura  mater  bulged  freely  into  the  hole, 
and  after  the  operation  in  each  case, 
marked  i-emission  of  symptoms  took  place, 
and  in  thi-ee  instances  the  progress  of  the 
disease  was  distinctly  stayed.  In  two  of 
Dr.  Tuke's  cases  where  the  arachno-pia 
was  laid  bare  the  naked-eye  evidence  of 
inflammation  was  most  evident  and  de- 
finite ;  no  doubt  could  exist  for  a  moment, 
but  that  the  pia  as  a  whole  was  in  a  state 
of  actual  inflammation,  more  evident 
however  on  one  side  than  the  other. 
Negative  pressure  could  not  have  pro- 
duced bulging,  and  the  demonstration  of 
positive  pressure  is  complete.  One  of  our 
first  cases  died  of  pneumonia  eight  months 
after  the  operation.  The  dura  mater  had 
not  been  opened.  On  post-mortem  ex- 
amination a  large  accumulation  of  fluid  in 
the  sub-dural  and  pia-matral  spaces  was 
found  in  the  left  side  on  which  the  bulging 
took  place ;  on  the  other  side,  where  no 
protrusion  had  occurred,  the  amount  of 
fluid  was  slight.  On  the  left  side  corre- 
sponding to  the  accumulation  of  fluid, 
the  whole  subjacent  area  of  the  convolu- 
tions was  atrophied ;  on  the  right  side 
no  marked  change  in  the  bulk  of  the 
gyri  presented  itself.  The  localisation 
of  the  efi"usion  was  probably  due  to  in- 
flammatory thickening  and  adhesion  of 
the  two  layers  of  pia,  forming  a  closed  sac, 
and  occluding  the  lymphatic  channels. 
Into  this  sac  the  fluid  was  being  con- 
stantly poured,  and  the  only  means  of 
escape  was  by  the  Pacchionian  villi  into 
the  sub-dural  space  and  the  longitudinal 
sinus.  The  pressure  caused  by  rapid  infil- 
tration and  slow  absorption  gradually 
caused  atrophy  of  the  subjacent  convo- 
lutions. From  these  definite  observations 
we  iire  of  opinion  that  Bevan  Lewis  has 
overlooked  the  important  fact  that  intra- 
cranial fluid,  especially  at  the  earlier  stages 
of  this  and  other  diseases,  is  a  producer 
of  pressure,  and  is  often  not  compensatory. 
He  proves  to  demonstration  the  presence 
of  inflammatory  action,  but  excludes  from 
the  process  one  of  its  tirst  and  most  im- 
portant jiroducts. 

Epilej-tiic  Insmiity. — The  whole  subject 
of  epilepsy  having  been  fully  considered 
in  a  special  article,  it  is  only  necessary  to 
refer  to  the  morbid  appearances  j^resented 
in  the  brains  of  the  ej)ileiitic  insane.     An 


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amount  of  interest  connected  with  the 
subject  generally  surrounds  the  observa- 
tions of  B.  Lewis.  Founding  certain  phy- 
siological deductions  on  the  fact  that  he 
has  noticed  a  diseased  condition  of  the 
cells  of  the  second  layer,  and  of  the  large 
ganglionic  cells  of  the  motor  tract,  he 
infers  that  the  former  possess  inhibitory 
powers  over  the  latter.  The  change  in  the 
cells  of  the  second  layer  is  peculiar,  inas- 
much as  the  nucleus  is  the  first  part  af- 
fected :  "  the  centre  of  the  nucleus  is  occu- 
pied by  an  extremely  bright,  highly  refrac- 
tile,  spherical  body — obviously  of  a  fatty 
nature."  In  stained  specimens  this  spot 
shows  as  a  "  bright  spherical  bead,"  stand- 
ing out  all  the  more  strongly  on  account 
of  the  deep  tint  taken  on  by  the  body  of 
the  cell. 

Vacuolation  takes  place  as  the  disease 
advances,  caused  by  the  "bursting  out 
from  the  cell  of  the  globular  bead  of  fatty 

substance This  exti'eme  degree  of 

change  may  occupy  thewhole  of  the  second 
layer  of  the  cortex,  but  in  certain  cases  it 
has  been  found  to  affect  every  layer  down 
to  the  spindle-seriesof  the  cells."  Although 
the  cell  protoplasm  becomes  eventually 
affected,  it  resists  for  a  long  time  the  action 
of  the  nuclear  disease  ;  in  the  long  run, 
however,  the  whole  cell  disappears,  or  is 
reduced  to  debris.  The  large  ganglionic 
cells  suffer  in  the  earlier  stages  in  the 
manner  we  described  in  the  fourth  edition 
of  Bucknill  and  Tuke's  "  Manual "  ;  they 
are  abnormally  large  and  distinct,  stain 
much  more  deeply  than  in  healthy  subjects, 
become  distended  in  appearance,  and  lose 
their  natural  contour.  According  to  Lewis, 
they  lose  their  special  processes. 

Still  following  B.  Lewis's  statements, 
there  is  no  associated  vascular  change, 
and  spidei'-cells  are  not  present.  On  the 
assumption  that  the  cells  of  the  second 
layer  possess  inhibitory  power  over  the 
motor  cells  he  finds  in  their  affection,  and 
in  the  destruction  of  all  means  of  commu- 
nication with  the  ganglionic  cells,  an  expla- 
nation of  the  convulsive  phenomena  of 
epilepsy.  Were  these  statements  appli- 
cable to  all  cases, the  pathology  of  epilepsy 
would  have  had  considerable  light  thrown 
upon  it.  It  may  be  admitted  that  in  a 
certain  class  of  epileptics  Lewis's  observa- 
tions may  hold  good  :  but  it  is  certainly 
not  applicable  to  all,  inasmuch  as  the 
appearances  described  do  not  present 
themselves  in  every  case  of  brain  disease 
symptomatosed  by  epilepsy.  We  have 
seen  the  appearances  spoken  of,  although 
never  to  such  a  marked  degree  as  Lewis 
describes;  but  we  have  also  examined  many 
cases  by  the  same  methods,  in  which  the 
lesions  differed  entirely  or  in  part.    Besides 


the    condition    of    the    ganglionic     cells 
already  spoken  of,  we  have  noted  in  them 
the  brightly  refracting  nucleus,  which  has 
been  absent  in  the  superior  layers,  and  the 
apical,  along  with  the  other  poles  have,  in 
common  with  the  cell, presented  an  appear- 
ance suggestive  of  the  term  hypertrophy, 
the  apical  poles  being  traceable  for  long 
distances.     At   the   same   time    vascular 
changes  have  been  well  marked;  the  vessels 
have  been  thickened,  and  the  lumen  of  the 
channel  in  the  cerebral  matter  has  been 
distinctly  dilated.     It  may  be  suggested 
that    this   was    the    result  of  hardening 
agents  causing  retraction  of  the  tissues, 
but  all  our  siDecimens,  morbid  and  healthy 
alike,  were   treated    in  exactly  the    same 
manner  ;  the  wide  open  spaces  around  the 
vessels  were  particularly  well-marked  in 
the   case   of   epileptics.     And,  again,  we 
have  never  procured  more  typical  speci- 
mens of  spider-cells  than  around  the  ves- 
sels   in    epileptic    brains,   in    which    the 
connective  tissue  generally  was  markedly 
affected.     There   can    be   no   doubt  that 
during  attacks   of   the  grand  mal  great 
cerebral  congestion  exists.     This  has  been 
duly  considered  elsewhere.    But  the  effects 
of  constantly  recurring   extreme  conges- 
tion  tell   on   the  whole   economy  of  the 
cells,  and  in  the  case  of  a  cei-tain  propor- 
tion  of    epileptics,    insanity  of   a  pretty 
definite  character  results  from  the  impli- 
cation of  these  cells.     It  is  frequently  of 
an  impulsive,  "  explosive  "  type,  and  sug- 
gests an  interesting  correlation  with  the 
muscular  phenomena  of  the  affection. 

Another  change  met  with,  and  fre- 
quently described  as  associated  with  the 
epileptic  condition,  is  the  formation  of 
granulations  on  the  floor  of  the  ventricles. 
This  is  iisually  associated  with  prolifera- 
tive or  other  changes  of  the  cells  of  the 
ependyma,  or  with  proliferation  or  in- 
creased new  formation  of  the  subjacent 
connective  tissue.  Along  with  this  there 
is  usually  evidence  of  congestion  of  the 
blood-vessels  in  this  region.  The  simplest 
form,  and  the  one  most  frequently  met 
with,  is  a  simple  throwing  into  folds  of 
the  ependymal  covering — really  a  further 
extension  of  the  choroid  fringe.  A  second 
form  consists  of  a  kind  of  granulation 
tissue,  in  which  the  young  connective 
tissue  first  projects  the  ependymal  cells 
before  it  into  the  cavity  of  the  ventricle, 
and  then  breaks  through,  leaving  a  solu- 
tion of  continuity  of  the  cellular  layer. 

In  the  third  form,  in  which  the  granu- 
lations are  not  nearly  so  large,  there 
appears  to  be  simple  swelling,  accom- 
panied by  vacuolation,  of  the  ependymal 
cells.  There  is  some  diversity  of  opinion 
as    to   whether    these    granulations    are 


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really  the  cause  of  any  clinical  symptoms ; 
but  the  strong  probability  is  that  they 
interfere  with  the  tree  movement  of  the 
upper  part  of  the  brain  over  the  base,  and 
that  the  friction  generated  by  the  rubbing 
together  of  the  two  surfaces,  or  even  by 
the  passage  of  fluid  through  the  ventri- 
cular cavity  in  cases  of  sudden  movement, 
may  cause  considei'able  irritation  and 
excitation  of  the  areas  covered  by  these 
granulations.  They  will  certainly  impede 
the  free  movements  of  fluid,  and  also  of 
the  brain,  so  necessary  to  keep  up  con- 
pensatory  changes  in  connection  with 
alterations  in  the  blood  supply  of  the 
various  parts  of  the  cerebral  cortex  ;  they 
will  thus  interfere,  not  only  with  the 
nutrition,  but  also  with  the  actual  function 
of  the  nervous  tissues. 

In  the  acute  vianiaccd  delirium  which 
occasionally  presents  itself  during  the 
course  of  acute  infective  fevers  two  factors 
have  to  be  taken  into  consideration  :  first, 
the  specific  poison  which  appears  to  act 
directly  on  the  nerve  cells,  giving  rise  to 
stimulation  and  impaired  nutrition,  and 
consequent  granular  degeneration ;  and, 
secondly,  the  high  temperature,  during 
the  persistence  of  which  metabolic,  or, 
to  speak  more  accurately,  catabolic,  pro- 
cesses go  on  more  rapidly.  In  such  cases 
we  have  always  clinical  evidence  of  a 
more  or  less  well-marked  affection  of 
both  sensory  and  motor  cells.  In  very 
acute  cases  there  is,  accompanying  the 
changes  in  nerve  elements,  extraordinary 
proliferation  of  connective  tissue  cells 
around  the  vessels,  and  migration  of  leu- 
cocytes, a  condition  commonly  associated 
with  the  presence  of  micro-organisms,  and 
well  marked  in  cases  of  acute  exudative 
meningitis.  The  insanity  following  fever 
is  more  frequently  of  an  ana3mic  type. 

The  insanity  of  sunstroke  is  a  toxic 
condition  allied  to  that  just  spoken  of. 
It  is  the  result  of  catabolic  changes  pro- 
duced by  high  temperature.  In  certain 
instances  it  may  be  caused  by  carbonic 
acid  poisoning. 

There  is  strong  reason  for  believing  that 
in  ijuerperal  insanity  a  considerable  pro- 
portion of  cases  is  due  to  toxic  influences. 
It  must  be  remembered  that,  although  a 
woman  may  become  insane  during  the 
puerperal  period,  her  case  need  not  be 
referable  primarily  to  childbirth.  Mental 
symptoms  may  be,  in  point  of  fact,  idio- 
pathic—i.e.,  the  result  of  so-called  moral 
causes — the  effect  of  which  culminating 
at  the  birth  of  her  child  show  themselves 
some  three  weeks  or  a  month  later  by  an 
attack  of  simple  mania  or  melancholia. 
But  the  violent  delirous  mania  which  is 
apt  to  develop  within  fifteen  days   after 


delivery  has  all  the  aspect  of  being  due 
to  toxic  influence.  Its  sudden  incep- 
tion, delirious  character,  rapid  develop- 
ment, inflammatory  complications,  and 
tendency  to  death  are  eminently  sugges- 
tive of  septic  origin.  Such  cases  rarely 
present  themselves  later  than  a  fortnight 
after  childbirth  (the  period  during  which 
septic  changes  go  on  in  the  uterus),  and 
more  frequently  within  ten  days.  Absorp- 
tion from  the  uterine  surface  of  dis- 
organised material  and  blood,  acting  on  a 
system  which  has  been  already  subjected 
to  considerable  drain,  exercises  its  in- 
fluence on  the  most  highly  organised  cells, 
and  acute  violent  mania,  temporary  in 
character  but  followed  by  prolonged  brain 
weakness,  is  the  result. 

It  is  of  importance  to  note,  from  an 
ajtiological  point  of  view,  the  absence  o£ 
insanity  as  an  accompaniment  or  sequela 
of  certain  complaints  which  d priori  might 
be  supposed  to  be  prolific  causes,  but,  to 
which  morbid  mental  symptoms  can  in 
fact,  be  rarely  referred.  Insanity  is  never 
the  pathological  consequence  of  diseases 
of  individual  organs,  but  is  occasionally 
more  or  less  closely  associated  or  con- 
nected with  those  forms  of  disease  which 
result  from  diathesis  or  cachexia,  such 
as  tuberculosis,  rheumatism,  gout,  and 
syphilis.  There  are  many  diseases  painful 
in  character  and  very  depressing  to  the 
nervous  system,  such  as  calculus,  fistula, 
cancer  of  the  rectum  and  uterus,  stricture, 
with  its  often  miserable  complications, 
and  many  others  which  suggest  them- 
selves, which  might  be  presupposed  to  be 
probable  fertile  causes  of  insanity,  but 
which,  in  point  of  fact,  are  not  inimical  to 
brain  health.  They  may  be  so  indirectly, 
inasmuch  as  they  prevent  sleep  ;  but  even 
in  this  wise  their  effect  is  very  slight. 
Nor  does  there  appear  sufficient  evidence 
to  warrant  the  connection-  of  diseases  of 
the  heart,  liver,  or  kidneys  with  insanity. 
It  has  been  sought  to  show  that  certain 
forms  of  heart  disease  are  associated  occa- 
sionally with  simple  or  hypochondriacal 
melancholia,  and  others  with  mania. 
These  observations,  however,  are  not  sup- 
ported by  extended  clinical  observation. 
Nor  do  we  think  that  diseases  of  the  liver 
or  kidneys  have  any  real  connection  with 
the  induction  of  insanity ;  except,  per- 
haps, that  in  Bright's  disease  a  temporary 
mania  is  rarely  met  with,  probably  the 
first  indication  of  urajmic  i)oisoniug.  The 
direct  production  of  insanity  or  delirium 
of  short  duration  has  been  observed,  but  it 
is  very  doubtful  whether  prolonged  mania 
or  melancholia  can  be  clearly  shown  to 
be  associated  with  such  diseases  except  as 
producers  of  over-excitation  of  the  brain. 


Pathology 


[    912    ] 


Pathology 


Much  stress  has  been  hiid  on  diseases 
of  the  uieriis  and  ovaries,  and  move  espe- 
cially on  tumours  of  those  organs,  as  the 
primary  factors  in  the  production  of  in- 
sanity. Skae  hiid  down  as  special  forms, 
utero-  and  ovario-mania,  and  Hergt  has 
described  the  various  morbid  conditions  of 
the  female  organs  found  on  post-mortem 
examination,  and  has  connected  them  with 
mental  symptoms.  But  authors  on  gynae- 
cology make  no  mention  of  insanity  as  a 
sequela  of  uterine  disease,  except  in  so  far 
the  mental  depression  which  in  many 
women  follows  on  the  knowledge  that  they 
are  affected  by  serious,  perhaps  fatal, 
disease,  and  the  pain  and  anxiety  insepar- 
able therefrom,  may  xjroduce  sleeplessness 
and  consequent  melancholy  ;  and  there  is 
no  proof  of  such  tumours  exercising  an 
extensive  influence  on  causation  by  peri- 
jjheral  irritation.  The  fallacy  that  such 
connection  exists  has,  in  the  great  majority 
of  instances,  probably  arisen  from  the 
observation  often  made  in  asylums  that 
insanity  arising  from  whatever  cause  is 
conditioned  by  the  presence  of  uterine 
growths,  and  that  delusions  of  a  sexual 
character  may  arise  from  the  sensations 
thereby  produced.  For  all  practical  piir- 
poses  peripheral  irritation  may  be  dis- 
missed from  the  list  of  producers  of  in- 
sanity. Did  it  so  act  the  records  of  surgical 
hospitals  would  surely  produce  endless  ex- 
amples of  its  morbid  action  on  brain  health. 
We  are  aware  that  there  are  reported 
cases  of  mania  being  produced  by  such 
slight  causes  as  a  splinter  of  wood  in  the 
hand  or  foot :  in  all  such  we  are  convinced 
more  important  underlying  factors  have 
been  overlooked.  It  is  an  interesting  but 
unexplainedfact  that  insanity  occasionally 
follows  on  extirpation  of  the  ovaries  ;  and 
that  in  all  the  insanities  resulting  from 
morbid  conditions  of  the  female  genera- 
tive organs,  delusions  of  mistaken  identity 
are  commonly  met  with. 

It  cannot  be  said  that  any  strong  patho- 
logical evidence  has  been  advanced  to 
connect  such  diailietic  conditions  as  tuber- 
culosis, gout,  andrheumatism  with  the  pro- 
duction of  insanity.  The  strongest  case 
has  been  made  out  in  favour  of  tubercu- 
losis ;  there  is  a  probability  that  its  ac- 
companiment, ana3mia,  may  exercise  a 
certain  influence.  There  is  apparently  no 
toxic  agent  at  work  in  such  cases.  But 
on  the  whole  we  are  inclined  to  think 
that  insanity  is  more  conditioned  than 
induced  by  the  tubercular  state.  In  the 
same  way  gout  and  rheumatism  undoubt- 
edly exercise  an  influence  on  the  pro- 
gress of  a  case.  The  connective  tissues, 
predisposed  by  the  diatheses  to  morbid 
changes  no  doubt  now  and  then  increase. 


probably  in  the  immediate  neighbour- 
hood of  blood-vessels,  and,  by  the  con- 
sequent affection  of  motor  areas,  choreic 
movements  are  induced.  These  may  also 
be  induced  by  similar  affection  of  the 
cord.  But  a  true  gouty  or  rheumatic  in- 
sanity— i.e.,  an  insanity  arising  out  of 
structural  changes  produced  primarily  in 
the  nervous  centres  by  the  action  of  the 
several  poisons  is  extremely  doubtful. 
Did  such  cases  exist  it  might  be  expected 
that  motor  symptoms  would  be  the  first 
to  occur,  whereas  in  all  the  reported  cases 
the  choreic  movements  presented  them- 
selves after  the  mental  symptoms  were 
more  or  less  confirmed.  The  rheiimatic, 
and  especially  the  gouty,  poison  attacks 
regions  undergoing  degeneration  or  weak- 
ened by  disease,  and,  given  vessels  in  a 
sub-inflammatory  condition,  the  strong 
probability  is  that  these  toxic  agents  will 
fasten  on  their  connective  tissue,  and  com- 
plicate the  condition  and  its  symptoms. 

Excluding  the  consideration  of  depres- 
sion, contre  coiij),  and  laceration,  as  results 
of  traumatic  injury  of  the  skull,  the  lesions 
produced  are  the  diffused  clots  in  the  pia- 
mater  (sub-arachnoid  space),  and  under 
the  visceral  pia,  and  bruise  of  the  sub- 
stance of  the  convolutions.  This  bruise 
affects  the  small  vessels  and  the  myelin 
sheath  of  the  nerve  fibre.  In  the  case  of 
the  former,  small  rounded  clots  are  seen 
in  section  in  the  grey,  and  extending  for 
some  distance  into  the  white  matter.  "We 
have  already  drawn  attention  to  the  re- 
sults of  injury  in  the  myelin  sheath.  In 
the  attempt  of  the  tissues  to  remove  the 
morbid  materials  produced  b}'  traumatism, 
the  connective  tissue  becomes  increased  in 
quantity,  and  the  consequence  is  a  local 
sclerosis,  extending  probably  for  some 
distance  from  the  area  of  injury.  Cases 
of  ''  general  paral^-sis  "  as  a  consequence 
of  local  injury  are  not  uncommon,  and  are 
induced  by  this  pathological  process. 

Toxic  Insanity. — In  considering  the 
various  insanities  associated  with  toxic 
conditions,  there  may  be  taken  as  types 
three  difterent  forms  of  poisoning,  and 
under  one  of  these  three  headings  may  be 
approximately  arranged  the  various  forms 
of  insanity  which  are  looked  upon  as  toxic, 
(i)  In  the  first  place,  the  toxic  group 
associated  with  alcolwlic  poisoning,  may 
be  divided  into  (a)  those  acute  conditions 
in  which  alcohol  appears  to  act  directly  on 
the  nerve  cells,  along  with  which  may  be 
associated  such  forms  as  chloroform  and 
ether  poisoning  ;  (6)  the  condition  brought 
about  by  chronic  alcoholism,  whei*ein  con- 
sequence of  frequent  acute  poisiinings  the 
cells  gradually  undergo  a  process  of  de- 
generation,   associated    with    which   are 


Pathology 


913    J 


Pathology 


marked  lesions  in  tlie  blood  vascular  and 
connective  tissue  systems.  (2)  In  the 
second  group  may  be  placed  those  acute 
maniacal  conditions  in  which  poisons  de- 
veloped ivifliiii  the  body  ai^pcar  to  act  first 
in  stimulating  and  tVien  in  depressing  the 
nerve  cells;  such  conditions  as  are  found 
in  the  delirium  of  fevers  and  septic  poison- 
ings. And  (3)  we  may  arrange  in  a  third 
group  those  forms  of  insanity,  compara- 
tively chronic  in  character,  which  result 
from  poisons  which  continue  to  be  de- 
veloped in  the  system  after  their  first  in- 
troduction ;  of  this  group  sijj^lulis  is  pro- 
bably the  most  typical.  A  more  minute 
subdivision  might  undoubtedly  be  made, 
but  most  of  the  characteristic  forms  of 
toxic  insanity  may  be  brought  under  one 
or  other  of  these  headings. 

The  alcoholic  or  etherial  poisoning,  of 
which  acute  alcoholism  may  be  taken  as 
the  type,  induces  acute  symptoms  through 
two  channels  :  first,  by  acting  directly  on 
vaso-motor  cells,  the    motor  cells  of  the 
fifth  layer,  and  the  presumably  iuhibitory 
cells  of  the  second  layer ;  and  secondly,  by  , 
acting  through  altered  vascular  supply, 
through  the  vaso-motor  cells.     It  has  been  j 
experimentally  shown  by  Binz,  that  after  , 
the    exhibition    of    chloroform,    ether  or 
alcohol,  there  is  distinct  alteration  in  the 
appearance  of  the  larger  cells  in  the  brain, 
characterised    by    a   parenchymatous  or 
cloudy,  granular  swelling  of  their  proto- 
plasm.    There  is  in  fact  mai-ked  evidence 
of  inci'eased  activity  of  their  protoplasm, 
but,  so  far  as  has  been  noted,  there  is  little 
or  no  change  in   the   a[)pearance  of  the 
nucleus.     There   is   thus  evidence  of  in- 
creased activity  and   of  increased  func- 
tional  discharge  of  and  from  the  brain 
cells.     If,  however,  this  condition  is  main- 
tained for  any  length  of  time,  it  is  found 
that  not  only  is  the  protoplasm  affected, 
but  slight  alterations  take  place,  even  in 
the  nucleus.     Along  with  this  change  in 
the  cells  of  the  cortex  there  appears  to  be 
sometimes,  in  the  earliest  stages,  increased 
vascularity  of  the  cerebral  tissues,  a  con- 
dition which  must  be  associated  with  the 
increased  functional  activity  of  the  cells  ; 
this  is  invariably  accompanied  by  a  greater 
functional  activity  of  the  lymph-vascular 
system — in  which  we  find  an  increase  of 
nuclei — and  a  greater  prominence  of  the 
endothelial  plates  lining  the  lymph  spaces, 
changes  that  must  be  associated  with  the 
increased  quantity  of  the  effete  matter  that 
has  to  be   carried  away    from   the    more 
active  cells.    This  condition  of  stimulation 
and  exaltation  appears  to  be  so  intense  that 
the    cells   are   rapidly    exhausted,    and  a 
condition   of   stupor   supervenes,   a  con- 
dition which  allows  of  the  ready  excretion 


of  the  poison,  of  a  rebuilding  up  of  the 
cell   substances,  and  of  a  comparatively 
rapid  return  to  the  normal   condition  of 
the  vaso-motor   system.     In  acute    alco- 
holism   we    have    in    fact    a    temporary 
mania,  with  increased   motor  discharge, 
diminished  inhibition,  rapid  running  down, 
and  a  temporary  degeneration  of  the  nerve 
cells,   accompanied    by    abnormal    blood 
supply  and  production  of  waste  materials, 
for  the  removal  of  which  there  is  increased 
activity  of  the  blood  and  lymph- vascular 
systems.     By  an  easy  transition  we  pass 
from  acute  to  chronic  alcoholic  insanity, 
in  which  essentially  the  same  structures 
are  affected,  but  in  different  degrees,  and 
giving  rise   to    different  symptoms.      In 
chronic  alcoholic  insanity  the  convulsive 
element  very  frequently  predominates,  and 
in  many  respects  the  pathology  is  similar 
to   that   of  epilepsy.      The   blood-vessels 
are  found  to  have  invariablj'  undergone 
very   marked   changes.     In    the    smaller 
vessels  these  conditions  are  evidenced  in 
the  one  case  by  marked  proliferation  of  the 
nuclei,  leading  to  great  increase  in  their 
number,  by  which  the  lines  of  the  vessels 
are  very  distinctly  marked  out  in  the  cor- 
,  tical  substance   (Lewis).     In  other  cases 
the  cells  are  distinctly  fatty,  they  do  not 
take  on  the  staining  reagents,  and  have 
a  peculiar  granular  appearance.     Bevan 
Lewis  points  out  that  in  addition  to  these 
changes  there  is  a  very  great  increase  in 
the  number  of  "  scavenger  "  cells  in  the 
Outer  layer  of  the  cortex,  where  the  con- 
nective tissue  is  intimately  associated  with 
the  vessels  of  the  pia  mater,  and  a  similar 
increase  along    the   line  of  blood-vessels 
running  towai'ds  the  deeper  layers ;  this 
being  accompanied  by  other  evidences  of 
inflammatory  change,  such  as  the  charac- 
teristic amyloid  bodies  in  the  lymph  spaces 
and  proliferation  of  the  connective  tissue 
nuclei. 

The  pathological  changes  enumerated  by 
Bevan  Lewis  are  as  follows: — (i)  Vessels 
in  cortex  large  and  tortuous  ;  coats  in  ad- 
vanced stages  of  atheromatous  and  fatty 
degeneration.  (2)  Nuclei  in  adventitia  pro- 
liferating, or  protoplasm  of  cells  fatty. 
(3)  In  superficial  layer  of  cortex  and  along 
line  to  blood-vessels  scavenger  cells  nu- 
merous. (4)  Amyloid  bodies  in  epicerebral 
spaces.  (5)  Numerous  lymphoid  elements 
in  peri-vascular  and  peri-cellular  paces. 
(6)  Lesions  in  second  and  third  layers  are 
only  seen  after  implication  of  the  motor 
cells  of  fifth  layer.  These  and  the  layer 
of  spindle  cells  immediately  beneath  the 
deepest  cortical  layers  then  become  de- 
generated and  fatty.  Invasion  here 
appears  to  be  from  the  medulla  and  the 
central  gyri. 


Pathology 


[    914    ] 


Pathology 


The  changes  in  the  vessels  are  nuclear 
proliferation,  atheroma,  and  aneurysmal 
dilatation,  the  latter  of  which  eventually 
gives  rise  to  the  cribriform  condition. 
The  motor  cells  are  swollen  and  rounded, 
stain  deeply,  become  granularly  pig- 
mented, and  the  apical  process  degene- 
rates. This,  according  to  Lewis,  accounts 
for  the  interference  with  the  inhibitory 
action  of  the  cells  of  the  second  layer 
in  chronic  alcoholism.  The  cell  wall  is 
thickened,  which  shows  that  it  is  losing 
its  functional  activity.  Thei'e  is  a  con- 
siderable quantity  of  pigment  deposited 
between  the  shrinking  protoplasm  and 
this  cell  wall.  The  processes  of  the  cells 
are  stunted  and  are  covered  with  nuclei, 
and  the  protoplasm  is  granular  or  vacuo- 
lated. In  the  lowest  layer  "  scavenger  " 
cells  and  nuclei  cover  the  spindle  cells, 
which  are  very  much  altered  and  degene- 
rated, and  are  practically  being  devoured 
by  these  proliferating  cells.  The  me- 
dullary sheath  of  the  nerve  processes 
gradually  disappears,  or  is  so  altered  by 
the  invading  connective  tissue  that  the 
axis  cylinder,  which  is  frequently  fusiform 
as  in  other  cases  of  inflammation  of  the 
nerve  fibres,  can  be  perfectl)^  well  stained 
with  the  aniline  colour  when  it  becomes  a 
prominent  feature  in  the  cortex.  These  are 
to  be  demonstrated  with  great  difficulty  in 
a  normal  brain,  but  in  senile  decay  of  the 
cortex  they  are  even  more  evident  than 
in  alcoholics.  In  the  white  matter  the 
blood-vessels  are  found  much  dilated  and 
aneurysmal ;  they  are  atheromatous,  and 
are  undergoing  fatty  degeneration  of  the 
intima  ;  and  proliferation  of  the  cells  of 
the  adventitia,  small  collections  of  extra- 
vasated  blood,  hsematoidin  crystals,  and 
sometimes  fat  embolisms,  are  observable. 
Along  with  these  changes  in  the  brain 
somewhat  similar  changes  go  on  concur- 
rently in  the  cord.  There  is  apparent 
thickening  of  the  muscular  coat  of  the 
vessels,  but  this  is  due  to  an  increase  of 
fibrous  tissue  and  not  to  any  true  increase 
of  muscular  fibre.  Along  the  lines  of  the 
larger  vessels  are  patches  of  sclerosis  which 
are  not  in  any  way  due  to  ascending  or 
descending  degenerative  changes  ;  but  are 
rather  the  result  of  a  process  which  is 
usually  met  with  in  other  organs  in  which 
there  is  chronic  endarteritis,  and  one 
almost  invariably  found  in  chronic  alco- 
holics. 

It  is  a  noteworthy  fact  that  in  the  cord, 
as  in  the  brain,  the  membranes,  with  their 
free  vascular  reticula,are  epecially  affected ; 
and  at  those  points  where  the  pia  mater 
is  most  closely  associated  with  the  cord 
and  with  the  cortex — i.e.,  along  the  lines 
of  the  columns  of  Goll,  and  in  the  motor 


area  of  the  brain — the  connective  tissue 
and  vascular  changes  are  always  most 
marked.  It  will  be  observed  that  we  have 
here  two  processes,  both  of  which  must 
be  associated  with  the  presence  of  irrita- 
tive material,  which,  first  causing  stimu- 
lation of  the  protoplasm,  eventually  leads 
to  marked  interference  with  nutrition, 
inducing  development  of  the  more  stable, 
but  less  highly  developed,  tissues,  which  is 
followed  by  further  degeneration  of  the 
more  highly  endowed  cells.  Thus  we  find 
that  in  this  condition  we  have  both  fatty 
degeneration  and  sclerosis  going  on 
simultaneously ;  the  one  resulting  from 
imjiaired  nutrition  of  the  jDre-existing 
cells,  the  other  being  due  to  increase  of 
the  cells  of  the  lymph  connective  tissue 
system,  which  cells  are  called  upon  to  per- 
form a  gradually  increasing  amount  of 
work  in  the  removal  of  effete  products. 

In  difEerent  individuals  these  processes 
go  on  at  different  rates,  and  consequently 
different  pathological  appearances  are 
presented  and  different  clinical  symptoms 
may  be  the  result ;  but  in  all  cases  the 
difference  is  one  of  degree  rather  than 
of  kind.  Lewis  contends  then  that  cer- 
tain cases  of  chi-onic  alcoholism  are  very 
similar  to  cases  of  general  paralysis,  not 
only  in  their  clinical  history  but  in  the 
fact  that  the  membranes  of  the  brain  often 
present,  in  the  two  sets  of  cases,  similar 
appearances,  "  both  as  regards  naked-eye 
aspects  and  distribution  of  lesion."  He 
then  goes  on  to  say,  however,  that  in  alco- 
holism "  the  morbid  change  is  centred  in 
the  (atheromatous)  change  of  the  inner 
coat,"'  whilst  "  in  general  j^aralysis  the 
morbid  change  is  concentrated  in  the 
adventitial  sheath,  and  is  a  far  more 
acute  irritative  process  in  the  loose  ex- 
ternal tunic  of  the  vessel,  which  explains 
the  more  rapid  implication  of  the  nervous 
structures  lying  immediately  around  by 
direct  extension,"  and  he  explains  on  the 
gi'ound  of  this  difference  in  the  site  of  the 
original  change  "  the  slow  yet  progressive 
impairment  of  nutrition  of  the  nerve  cen- 
tres," and  the  "  steady  enfeeblement  of 
the  mental  faculties  akin  to  the  advancing 
imbecility  of  senile  atrojihy,  in  which 
similar  changes  of  the  vessels  "  are  found. 
In  general  paralysis,  on  the  other  hand, 
"  the  early  implication  and  rapid  spread 
of  morbid  activity  along  the  adventitial 
tunic  of  the  vessels "  induce  the  more 
acute  changes  "  in  the  nerve  cells  of  the 
cortex."  When  in  chronic  alcoholism  the 
adventitia  is  also  affected,  especially  in 
the  peripheral  zone  of  the  cortex,  not  only 
the  nerve  fibres  of  this  region  but  the 
deeper  ganglionic  cells  are  affected  and 
symptoms    similar   to    those   of    general 


Pathology 


[    915    ] 


Pathology- 


paralysis  are  the  result  of  similar  patho- 
logical changes.  Lewis  states  that  "  ex- 
tensive atrophy  of  these  large  elements  of 
the  cortex  is  coincident  only  with  the 
most  advanced  forms  of  alcoholic  de- 
mentia ;  the  earlier  stage  of  vascular  im- 
paii'ment  and  the  growth  of  young  sca- 
venger cells  in  the  peripheral  xone,  ere 
the  cells  themselves  are  involved,  being 
apparently  associated  with  the  maniacal 
excitement  and  early  delusional  perver- 
sions of   alcoholism Whilst    the 

cortical  lesions  of  general  paralysis  indi- 
cate an  invasion  from  without  inwards, 
affecting  the  sensory  elements  and  apical 
(?  sensory)  poles  of  the  motor-cells ;  alco- 
holism induces  in  addition  thereto,  ex- 
tensive vascular  changes  from  within  out- 
wards, implicating  the  medulla  of  the 
gyri  and  affecting  a  destructive  degenera- 
tion of  the  meduUated  fibres." 

These  points,  insisted  on  by  Lewis,  are 
of  very  considerable  interest  in  connection 
with  Eetiology  of  the  alcoholic  condition 
and  of  general  paralysis.  We  have  in 
alcoholism  the  condition  of  an  etherial 
poisoning  rapidly  making  its  way  to  the 
blood,  giving  rise  to  irritation  of  the 
intima.  The  effect  of  this  poison  on  the 
extremely  active  connective-tissue  cells, 
with  which  it  comes  into  contact,  is  not 
marked,  and  such  of  the  alcohol  as  is  not 
directly  and  rapidly  excreted  is  rapidly 
broken  down,  so  that  the  effects  on  the 
lymphatics,  except  in  the  later  stages  of 
the  poisoning  when  nutrition  and  activity 
of  the  cells  is  very  greatly  impaired,  is  not 
a  very  marked  factor  in  the  process  :  but 
when  that  impairment  of  activity  and 
nutrition  does  come  on  the  changes  in  the 
lymph  connective  tissue  go  on  rapidly, 
and  we  have  the  conditions  associated 
with  general  paralysis. 

In  Lewis's  statement,  although  he  does 
not  use  it,  we  have  a  strong  argument  in 
favour  of  the  occasional  syphilitic  origin 
of  general  paralysis.  It  is  a  well-known 
fact  that  the  poison  of  syphilis  circulat- 
ing through  the  body,  attacks,  not  only  the 
intima  of  the  vessels,  but  also  the  adven- 
titia,  and  the  lymph  connective  system; 
in  point  of  fact  the  poison,  comparatively 
stable,  passes  from  the  vessels  into  the 
lymph  spaces,  disturbs  the  functional 
action  of  the  various  cells,  interfering 
with  their  nutrition,  giving  rise  to  abnor- 
mal stimulation,  and  bringing  about  the 
conditions  met  with  in  general  paralysis. 
Stating  the  matter  briefly  alcohol  acts 
on  the  blood-vessels  and  on  the  nerve 
cells  in  the  first  instance,  and  only  later 
affects  the  lymph  connective  tissue ;  whilst 
the  syphilitic  poison  acts  almost  from  the 
first  on  the  whole  three,  and  so  gives  rise 


to  marked  tissue  changes,  and  clinical 
consequences  ;  the  congeries  of  symptoms 
of  which  are  summed  up  under  the  term 
general  paralysis. 

Lewis  here  makes  an  exceedingly  laud- 
able attempt  to  associate  symptoms  with 
Eetiology  and  pathology,  and  he  sums  up 
thus : — 

"  The  constitutional  state  engendered 
in  chronic  alcoholic  insanity  is  identical 
with  what  forms  the  basis  of  chronic 
Bright's  disease  ;  and  as  in  this  affection 
we  have  a  multiplicity  of  local  expressions 
of  the  morbid  lesions,  so,  here,  we  find  the 
tendency  is  towards  a  concentration  in 
the  nervous  centres  ;  atro2)hic  states  of 
brain,  or  of  sjiinal  cord,  or  of  both  com- 
bined, are  thus  induced  by  predominance 
of  [a)  simple  fatty  degeneration  of  their 
nutritive  vessels  and  tissues  ;  (h)  from 
fatty  degeneration  associated  with  inter- 
stitial sclerosis  ;  (e)  from  diffuse  sclerous, 
interstitial  change  ;  (d)  from  peri-arter- 
itis  and  hypertrophy  of  the  tunica  mus- 
cularis. 

"  In  the  pei'i-arteritis,  occasionally  engen- 
dered in  chronic  alcoholics  of  a  certain 
age,  we  probably  see  the  boundary  Hue 
overstepped  betwixt  simple  alcoholic  in- 
sanity and  general  paralysis  of  the  insane  ; 
and  we  have  resulting  therefrom,  in  a 
more  acute  spread  of  the  cortical  lesion, 
what  might  be  regarded  as  general 
paralysis  accidentally  evolved  out  of 
chronic  alcoholism,  or,  as  some  would  less 
correctly  state  the  case,  general  paralysis 
caused  by  alcohol.  Alcohol  has  its  own 
rule  to  play,  and  a  most  extensive  one  it 
is ;  but,  the  tissue  changes  engendered 
thereby  are  always  as  highly  characteris- 
tic as  are  the  morbid  sequences  of  general 
paralysis,  and  we  must  seek  to  dissever 
from  the  latter  disease  our  notions  of 
alcohol  playing  the  part  of  a  direct  aetio- 
logical  factor,  in  the  sense  of  originating 
the  primal  tissue  changes  by  which  the 
disease  is  characterised." 

b'oUowing  out  the  analogy  of  the  kidney 
it  may  be  pointed  out  that  even  the 
changes  in  the  brain  in  acute  alcoholic 
mania  may  be  likened  to  acute  changes  in 
the  kidney  also  due  to  alcoholic  poisoning. 
We  have  cloudy  swelling  of  the  function- 
ally active  or  secreting  cells  of  that  organ  ;. 
they  become  swollen,  their  protoplasm  is 
even  more  granular  than  normal  ;  the 
vessels  are  dilated.  One  of  three  things 
may  happen  in  either  case  ;  first,  excretion 
of  the  alcohol,  and  the  cells,  if  allowed  to 
rest,  return  to  the  normal  condition  ; 
secondly,  in  consequence  of  chill,  or  the 
results  of  any  extra  exertion  being  thrown 
on  the  kidney  during  this  stage  of  exhaus- 
tion, acute  inflammatory  changes  are  set 


Pathology  [    916    ]  Pathology 


We  append  a  scheme  for  practical  use  in  post-mortem  examinations  as  employed 
by  Dr.  Barrett,  Pathologist,  Royal  Infirmary,  Edinburgh  ; 

Xame 

."^cx  Age 

Case  Book  :  vol.  pa^e  Pathological  Record  :  vol,  page 

Died 

Autopsy  date  time  Weather 


EXTERNAL  EXAMIXATIOX. 

Height  Circumference  at  Shoulder 

Pupils  „  of  Head 

I'.  M.  Rigiditv 

r.  31.  Lividity 

State  of  Nutrition 

External  Jlarkiugs 

External  Injuries  and  Evidences  of  Disease 


INSPECTION  OF  CAVITIES. 

Cavity  of  Abdomen 

Fluid 
Cavity  of  Right  Pleura 
Left  Pleura 

Fluid  Right  Fluid  Left 

Cavity  of  Pericardium 

Fluid 
Cavity  of  Skull — Dura  mater  reflected 

Fluid 

WEIGHTS  OF  ORGANS. 

Encephalon  (including  Cerebrum, ~|  Fluid  (measure) 

Cerebellum,    Pons,    Medulla,  l  „      (weight) 


and  ^in.  of  Cord,  and  Fluid) 

Cerebellum 

Pons  and  Medulla  and  iin.  of  Cord 
Liver  Spleen  Right"  Kidney         Left  Kidney  Right  Lung  Left  Lung  Heart 

Other  Organs 

Spinal  Cord 

Membranes  Vessels 

{(i)  Cervical 

{h)  Dorsal — Upper 
Do.        Lower 

(c)  Lumbar 
Section  above  Lateral  Ventricles  at  level  of  Lateral  Ventricles  Basal 

1.  Grey  Matter  (it)  Co/our 

lb)  Consistence 
{(■)  Atrophied 
{(I)  Lrn/ers  visible 

2.  White  Matter  (ri)  Colour 

(b)  Consistence 

3.  Vessels  and  Peri-vascular  Spaces  J  1 
Lateral  Ventricles  rf/faf('(/                             contain          oz.  clear  turbid  fluid 

Membrane         thickened 
Granulations     absent 
Vessels  and  Choroid  Plexuses 
Third  ^'entricle 
Fifth  Ventricle 
Basal  Ganr/lia — (a)  Colour 

{b)  Consistence 

((■)  Vessels  and  Peri-vascular  Spaces 
■Cerebellum — AiTangement  of  Lobes,  &c. 
Pia  and  Arachnoid 
Section — i.  Grey  matter,  with  Corpus  Dentatum 

2.  White  matter 
Vessels  and  Peri-vascular  Spaces 


Pathology 


[    917    ] 


Pathology 


J'liiis  (111(1  M('ilii//(i.      Exteniiil  Alterations  in  shape 
Sjectiou — I.  Consistence 

2.  Colonr  of  grey  matter 

3.  Ditto  of  wliite  matter 

4.  Softenings 

5.  Ha'niovrliaLies 
l''oiirtli  \i'nlricle  :   i.  Jlenihrane 

2.  (irannlatidus  (ihsiiil 

3.  Clioroid  I'lexns 
I'ititUitrji  Bodji  find  iiij'iiiKliliidiiiii 
Pineal  (lldud 

Microscopical  Exam  inn  f  ion,  Results  of — 


aiciill-Ciqi :  Capacity 

Outer  table 
Diploe 
Inner  table 


3I0KBID  ANATOMY  OF  ORGAXS, 
Head. 

weight 

EXCEPIIALON. 


sp.  gr. 


Dnni  Mtitcr :  i.  Adhesions  {a)  to  Bone 

(I))  to  ria  Mater 
2.  Thickenings 
Sinuses 

Veins  from  I'ia 
ArncIino.Pid  :■'   1.  Milky 

1'    i.  Anterior 

2.  ('0  Adherent  to  Dura  '  ii.  Vertex 
(1^)  Separated  from  Brain  by  Fluid  "  iil.  l*osterior 

(iv.  Basal 

3.  Fibrous  Bands  to  Dura 

4.  I'achjaueningitis         Extent         Position  of 

5.  Htemorrhages 
Pifi  (a)  Adherent  to  Brain  matter 
Blood-rcsse/s 

External  Conjii/urdlion  of  Brain  as  a  whole  as  regards  coinph'.citij  0/ convolutions,  sliape,  cfr. 


Cerebru:m. 


Convolutions,  superficial  atrophij,  cfc. 

1.  Frontal— Right 

Left 

2.  rarietal  — llight 

Left 

3.  Temporo-sphenoidal — Right 

Left 

4.  Occipital — Right 

Left 
Sulci  wide  compressed 


Sympathetic 

(iANGLIA    AND    XeHVES 

Thorax. 

Left  Lunri 

III  art.     Cavities 

Valves- 
Muscle 

Size  and  shape 
Contents 

Pulmonary         coinpetent 
Aortic                  competent 
Tricuspid 
^Fitral 

liii/ht  LuiHi 

Blood 

Mediastinum 

Abdomen. 

Liver 

Gall-Bladdtr 

Spleen 

Biijht  Kidneij 
Left  Kidni'ii 
Stomach  and  Inte 

Cone  Diameter. 


«  The  terminology  here  difl'ers  fmni  tliat  of  Dr.  Barrett. 


Pathology 


[    918    ] 


Pellagra 


ixp,  there  is  breaking  down  and  desquama- 
tionof  the  epithelium,dilationof  the  blood- 
vessels, proliferation  of  the  connective 
tissue,  and  partial  or  complete  stoppage 
of  the  functional  activity  of  the  organ, 
corresponding  to  similar  conditions  in  the 
brain ;  thirdly,  there  may  be  a  continua- 
tion of  the  irritation,  impairment  of  the 
nutritional  and  functional  activity  of  the 
epithelial  cells — here  also  corresponding 
to  the  similar  conditions  already  described 
in  the  brain — increase  in  the  amount  of 
connective  tissue,  preceded,  however,  by 
proliferation  of  the  endothelium  of  the 
intima  of  the  vessel,  fatty  degeneration  of 
the  endothelial  cells,  atheroma  of  the 
larger  branches,  and  a  thickening  of  the 
muscular  coat  by  an  increase  of  fibrous 
tissue  ;  a  condition  similar  to  that  met 
with  in  the  vessels  of  the  cord  in  chronic 
alcoholic  insanity.  Exactly  similar  stages 
may  be  observed  in  the  brain. 

From  what  has  already  been  said  the 
effect  of  syphilitic  poisoning  in  the  jDro- 
duction  of  cerebral  disease  and  mental 
symptoms  must  be  very  marked,  and  it  is 
a  remarkable  fact  that  nowhere  in  his  ad- 
mirable work  on  mental  diseases  does  Bevan 
Lewis  refer  to  syphilis  as  an  astiological 
factor,  though  in  his  chapter  on  general 
paralysis  he  gives  a  most  excellent  descrip- 
tion of  the  pathological  processes  set  up  by 
this  disease  without  association  of  cause 
and  effect.  In  the  brain  and  cord,  as  iu 
other  organs,  the  manifestations  of  the 
action  of  syphilitic  poison  are  exceedingly 
varied.  The  congenital  idiocy  associated 
with  this  disease  must  be  looked  upon  as 
the  result  of  an  increase  in  the  amount  of 
connective  tissue,  similar  to  that  met  with 
in  congenital  syphilitic  cirrhosis  of  the 
liver  and  lung  of  children,  in  which  we  find 
a  mai'ked  increase  in  the  connective  tissue 
around  the  liver  cells,  or  lung  alveoli,  in 
connection  with  the  lymph  channels  and 
with  the  vessels  themselves.  In  the  liver 
this  may  be  so  extensive  as  to  cause  atrophy 
of  the  parenchymatous  cells.  They  are  cut 
off'  into  small  groups  and  their  connection 
with  bile-ducts  is  interfered  with.  Simi- 
larly, in  the  brain,  we  have  a  diffuse  scle- 
rosis ;  the  communicating  network  of  the 
nerve  cells  is  interfered  with,  and  the 
cells  themselves  are  atrojjhied  or  degene- 
rated in  structure  and  function.  The  pre- 
sence of  the  syphilitic  condition  may  be 
manifested  in  acquired  syphilis  by  slightly 
impaired  nutrition  of  the  cells,  by  increased 
irritability  of  the  motor  cells  and  by  im- 
paired activity  of  inhibitory  cells.  More 
gross  lesions  are  the  gummata,  which  are 
sometimes  met  with  as  the  result  of  local- 
ised inflammation  set  up  by  the  syphilitic 
poison,  in  which  case  we  have  the  symp- 


toms of  cei'ebral  tumour  associated  with 
those  of  the  more  marked  or  modified 
forms  of  the  general  syphilitic  condition. 
Gummata  may  also  be  met  with  in  cases 
of  acquired  syphilis,  where  the  symptoms 
are  much  the  same  as  those  already  de- 
scribed ;  except  that  instead  of  a  condition 
of  imbecility  or  idiocy,  or  congenital  irri- 
tability and  want  of  inhibition,  there  is  a 
gradual  retrocession  from  the  normal  men- 
tal activity  through  the  vai'ious  stages  of 
degeneration  to  a  more  or  less  marked 
condition  of  dementia. 

J.  Battv  Tuke. 
German  Sims  Woodhead. 

PATHOMANZA  (TTc'idos,  passion  ;  y.avia, 
madness).  Mania  without  delirium.  Ano- 
ther name  for  moi'al  insanity.  (Fr.  %)atlio- 
tnanie.) 

PATKOPATRZSiV.I.GZA  {irados,  pas- 
sion ;  warpis,  fatherland ;  (iXyos,  pain). 
Nostalgia.  (Fr.  puthopatridalgie ;  Ger. 
Heimv-eh.) 

PATHOPHOBZA  (nddos,  suffering ; 
(po^os,  fear).  Another  term  for  hypochon- 
driasis.    Morbid  fear  of  disease. 

PAVZTATZODT  (jjavor,  fear).  A  term 
for  fright  or  fear,  with  trembling.  (Fr. 
pavitaiion.) 

PAVOR  mroCTURNVS  ipavor,  fear  ; 
nocturnus,  at  night).  A  term  for  the  night 
terrors  of  children.  (/S'ee  Developmextal 
Insanities.) 

PEDZCUI.OPHOBZA  {pediculus,  a 
louse :  (pofdos,  fear).  Morbid  dread  of 
phthiriasis. 

PEZ.I.ACZA.  Pica  (q.v.).  (Fr.  alio- 
iriophagie ;  Ger.  die  krankhafte Begierde.) 

PEZiIiACRA  {pellis,  the  skin;  liypa,  a 
seizure — an  affection  of  the  skin  ;  but 
more  likely  derived  from  the  Italian, 
jje/  agra,  "  sore  skin.")  Syn.  Maidismus, 
Psycho-neurosis  ma'idica,  Mai  della  Rosa, 
Mai  rosso,  Mai  del  Sole,  Mai  del  Padrone, 
Cattivo  male,  Mai  della  Vipera. — Bef.  A 
disease  of  comparatively  recent  origin,  in- 
duced by  the  toxic  action  of  diseased  or 
damaged  maize,  the  chief  characteristics 
of  which  are  morbid  conditions  of  the  skin 
and  of  the  mucous  membrane  of  the  diges- 
tive tract,  with  symptoms  referable  to  the 
cei'ebro-spinal  system. 

History  and  Distribution. — The  ear- 
liest account  of  this  malad^^as  an  endemic 
affection  came  from  Spain  in  the  beginning 
of  the  eighteenth  century  (in  the  Asturian 
district  of  Oviedo  in  1735),  while  it  ap- 
peared in  Italy  in  the  vicinity  of  Sesto 
Calende  (on  Lago  Maggiore)  just  prior  to 
1750,  where  it  was  first  scientifically  in- 
vestigated in  1 77 1.  It  invaded  Lombardy 
and  Venetia,  spread  over  Emilia,  and  in 
the  last  decade  of  the  eighteenth  century 
extended  over  Piedmont  and  Liguria  and 


Pellagra 


[    919    1 


Pellagra 


later  on  over  Ceutral  Ital3^  In  the  be- 
ginning of  the  present  century  it  first 
appeared  in  the  south-west  of  France  (in 
1829),  in  Rouniania  (in  1846),  and  in  Corfu 
(in  1S56)  ;  it  has  never  disappeared  from 
the  regions  in  which  it  has  implanted 
itself,  and  a  noteworthy  fact  remains  that 
the  number  of  cases  has  increased  in  the 
eai'liest  seats  of  the  disease.  Its  present 
distribution  embraces  the  districts  of 
Eui'ope  situated  within  a  zone  extending 
from  42°  to  46°  N.,  and  comprising  the 
north  of  Spain,  its  esjiecial  haunt  (the  pro- 
vinces of  Asturia,  Aragonia,  Burgos, 
Guadalagara,  Navarra,  Galicia,  Zaragoza, 
Cuenca,  Granada,  Frabeios  and  Zamora 
being  those  in  which  the  disease  mainly 
occurs),  the  south-west  of  France  (in  the 
departments  Girondes,  Landes,  Hautes 
Pyrenees,  Basses  Pyrenees,  Haute  Gar- 
onne and  Aude),  Italy  (the  provinces  of 
Yenetia,  Lombardy,  Emilia,  more  recently 
in  Piedmont  and  Liguria),  Roumania  and 
Corfu.  In  Italy  about  ten  per  cent,  of  all 
cases  are  insane,  and  the  deaths  vary  from 
2.5  jjer  cent,  of  all  the  inmates  in  the  dis- 
trict asylums,  to  5  per  cent,  in  the  city 
ones.  The  disease  attacks  males  and 
females  indiscriminately,  and  no  age  is 
exempt,  while  those  who  most  readily 
succumb  are  the  aged  and  infirm  ;  the 
extent  and  ravages  of  the  disease  vary  in 
persons  living  under  the  same  nutritive 
and  hygienic  conditions. 

.Sltiologry. — The  evidence  that  the  ap- 
pearance of  pellagra  was  coincident  with 
the  first  general  cultivation  of  maize  in 
large  quantities,  that  its  area  of  distribu- 
tion is  and  has  been  confined  to  rural  dis- 
tricts inside  which  maize  forms  the  ex- 
clusive or  i^rincijial  food,  and  where  the 
grain  does  not  grow  to  perfection,  coupled 
with  the  fact  that  such  imperfect  and  dis- 
eased maize  is  at  certain  seasons  the  staj^le 
food-stuff  of  the  populace,  help  us  to  con- 
clude what  the  source  and  character  of 
the  actual  material  disease  agent  are.  In 
those  districts,  moreover,  where  mixed 
food  is  taken — e.g.,  along  the  sea-coast  of 
aflected  areas  where  fish  is  eaten,  or  where 
rice  or  potatoes  are  substituted  for  maize, 
the  people  remain  exempt.  With  the  re- 
currence of  bad  seasons  and  the  con- 
sumption of  damaged  maize,  the  disease 
increases  in  extent  and  severity,  and  the 
deduction  to  be  made  from  these  facts  is 
that  pellagra  is  due  to  certain  toxic  sub- 
stances developed  in  the  course  of  the 
decomposition  of  Indian  corn,  and  possi- 
bly, under  the  infiuence  of  epiphytes  on 
the  corn.  The  consumption  of  good  well- 
cultivated  maize  never  causes  jiellagra,  a 
fact  that  militates  against  the  opinion 
adopted  by  some  observers,  that  the  dis- 


ease is  due  to  the  low  nutritive  value  of  a 
maize  diet.  The  maize  cut  before  it  is 
ripe,  gathered  in  rainy  seasons,  stored 
away  damp,  sown  from  affected  seed  or 
what  is  known  as  quarantine  seed  {::cxb 
■inais  privcoie),  all  contribute  to  the  en- 
gendering of  some  toxic  development  in 
the  grain  which  forms  the  true  pellagra- 
poison.  In  Corfu  the  maize  consumed  is 
chiefly  imported  from  Roumania,  an  in- 
fected district,  and  in  all  the  areas  in 
which  pellagra  prevails  it  is  usually  the 
poorest  classes,  the  small  tenant-farmers 
and  labourers,  who  suffer.  The  nature  of 
the  pellagra-poison  is  still  an  open  ques- 
tion. Balardini  attributed  the  symptoms 
to  the  development  of  a  parasitic  mould 
on  musty  maize  (named  by  him  "  ver- 
derame  "),  while  Lombroso  conjectures  it 
to  be  due  to  the  occurrence  of  a  fatty  oil 
and  an  extractive  substance,  the  products 
of  decomposition  or  of  bacterial  action, 
which  are  never  found  in  sound  maize. 
An  indirect  heredity,  the  transmission  of 
a  congenital  feebleness  to  the  offspring 
thus  increasing  its  susceptibility,  has  been 
noticed.     The  afi'ection  is  not  contagious. 

Symptoms. — The  phenomena,  as  well 
as  the  periodical  recurrence  of  this  affec- 
tion, occur  in  most  cases  in  the  beginning 
of  spring,  and  the  earlier  symptoms  ]:>oint 
to  lesions  of  the  gastro-intestinal  tract 
and  the  cutaneous  structures,  while  the 
more  advanced  symptoms  evince  the  im- 
plication of  the  cerebral  and  cerebro- 
spinal system. 

From  observations  personally  made, 
the  disease  presents  the  following  charac- 
teristic signs  : — a  premonitory  feeling  of 
lassitude  and  disinclination  foi"  exertion, 
with  occipital  headache,  vertigo,  tinnitus 
aurium,  and  a  sense  of  pain  in  the  gastric 
region  with  burning  pain  in  the  back  and 
extremities,  usher  in  the  attack  ;  these  are 
succeeded  by  furring  of  the  tongue, marked 
anorexia,  and  occasional  diarrhoea;  coin- 
cident with  these  symptoms  an  exanthem 
appears,  at  first  limited  to  those  parts  of 
the  body  exposed  to  the  sun's  I'ays,  the 
skin  becomes  red  and  swollen,  desquamat- 
ing after  some  weeks  in  large  flakes,  there 
being  a  sense  of  burning  tension  about 
the  affected  parts.  At  the  height  of  the 
attack  the  tendon  reflexes  are  much  ex- 
aggerated, there  is  great  mental  depres- 
sion, thinking  is  an  efibrt,  and  the  jiatient 
is  irritable,  excitable  and  obtuse.  After 
lasting  three  or  four  months  the  symp- 
toms decline,  the  skin  where  affected  re- 
mains dark-coloured,  rough  and  dry,  and 
all  the  objective  and  subjective  pheno- 
mena disappear.  The  next  spring  it  recurs 
with  increased  severity,  and  at  perhaps 
the   third   attack  the  symptoms  become 


Pellasra 


[    920    ] 


Pellagra 


serious.  An  increase  in  the  general  feeble- 
ness, so  great  that  the  patient  cannot 
walk,  paresthesia  of  the  trunk  and  ex- 
tremities, acute  headache,  ptosis,  my- 
driasis, diplopia,  hemeralopia,  amblyopia 
and  other  visual  defects  occur  ;  the  exan- 
them  now  implicates  larger  areas,  the  skin 
thickens  and  cracks,  diarrhoea  becomes 
frequent,  the  tongue  is  thickened  and  red, 
the  gums  bleed  readily.  The  muscular 
weakness  attacks  preferably  the  lower  ex- 
tremities, and  occasionally  a  paretic  affec- 
tion of  the  extensors  ensues,  by  reason  of  j 
which  the  flexors  come  into  excessive 
action,  and  phenomena  of  motor  excita- 
tion, such  as  increased  resistance  against 
passive  movement,  spasms,  cramps,  tonic 
and  clonic  convulsions  ("pellagrous  at- 
tacks ")  and,  rarely,  well-marked  epileptic 
seizures,  are  to  he  observed.  Atrophy 
of  certain  muscle  groups  with  paralysis,  a 
paretic,  at  times  spastic,  gait,  and  idio- 
muscular  and  fibrillar  contractions  on 
mechanical  stimulation  are  additional 
phenomena.  In  the  tense  or  paretic 
muscles  faradisation  shows  decreased  ex- 
citability, sensory  abnormalities  are  not 
constant,  but  hypersesthesia  to  cold  and 
hypalgesia  are  occasionally  found.  The 
muscular  sense  is  not  affected.  Vision 
is  impaired  as  stated  above,  and  Lom- 
broso  describes  retinal  implication  in  80 
per  cent,  of  the  cases  he  investigated — 
cloudiness  of  the  retina,  atrophy  of  the 
arteries,  dilatation  of  the  veins,  and  marked 
atrophy  of  the  papilla.  In  66  per  cent, 
of  the  cases  examined  the  patellar  tendon 
reflexes  were  highly  exaggerated,  and  all 
the  tendon  reflexes  were  in  a  state  of 
hyper-excitability,  but  variations  in  the 
intensity  of  the  knee-jerk  phenomenon  up 
to  total  absence  of  response  were  in  a  few 
cases  noted  (without,  however,  any  con- 
current tabetic  signs).  The  vaso-motor 
derangements  are  a  general  contraction 
of  the  cutaneous  vessels  with  pallor,  cold- 
ness of  the  skin  and  in  the  later  stages 
oedema  due  to  vaso-paralytic  dilatation  of 
the  veins  and  capillaries.  The  trophic 
affections  are  the  above-mentioned  erythe- 
matous eruption  ;  the  skin  after  the  exan- 
them  fades,  becoming  dark  brown,  smooth, 
dry,  thin,  and  non-elastic  ;  the  subcutane- 
ous cellular  tissue  disajipears  and  white 
cicatricial  stria)  develop,  or  it  becomes  in- 
filtrated, bluish,  and  ichthyotic.  The 
nails  too  crack  and  peel  off.  Emaciation, 
aneemia,  and  general  cachexia  ensue,  para- 
lysis of  the  bladder  su]3ervenes,  the  pa- 
tient is  bedridden,  diarrhoea  becomes  in- 
cessant, and  death  occurs  owing  to  cardiac 
failure  and  general  weakness.  Occasionally 
phthisis  or  septicasmia  from  bedsores  puts 
an  end  to  the  patient's  sufferings,  while 


the  not  infrequent  superve  ntion  of  "  ty- 
phus pellagrosus  "  (an  acute  and  intense 
exaggeration  of  all  and  especially  the 
mental  symptoms  to  a  delirious  stage, 
with  more  or  less  hyper-pyrexia  which 
otherwise  is  absent  in  pellagra)  termi- 
nates the  malady. 

Mental  Symptoms. — These  which  are 
rarely  absent  in  the  more  advanced  cases 
bear  chiefly  the  character  of  melancholia. 
The  milder  signs  of  mental  implication — 
the  mere  retardation  of  ideas,  the  dis- 
inclination for  thought  or  activity,  and 
simple  mental  depression,  occur  in  the 
earlier  stages  of  the  affection  and  in 
slight  cases.  The  later  developments  of 
the  disease  are  associated  with  a  profound 
melancholia  with  a  sense  of  painful  ap- 
prehension, panphobia,  micro-maniacal 
symptoms,  self-accusation,  delusions  of 
persecution,  demonomania,  hypochon- 
driacal delusionary  ideas,  refusal  of  food, 
and  a  tendency  to  suicidal  impulses.  The 
retardation  of  the  flow  of  ideas  becomes 
more  marked  until  a  likeness  to  stuporous 
melancholia  ensues,  the  patient  being 
apathetic,  resistful  and  susi^icious.  Con- 
sciousness is  rarely  impaired.  Occasional 
instances  of  homicidal,  more  frequently 
suicidal,  impulse  occur.  The  mental,  like 
the  physical,  symptoms,  run  through  a 
steady  course ;  if  showing  improvement, 
recurring  at  rejDeated  intervals,  until  a 
jjermanent  insanity  is  induced.  Second- 
ary dementia,  owing  no  doubt  to  the 
periodicity  of  the  disease,  is  a  rare  sequela 
of  the  mental  affection.  Maniacal  symp- 
toms are  still  rarer,  and  when  such 
occur,  gay  excitement,  an  acceleration  in 
the  flow  of  ideas,  with  general  mental  ex- 
altation and  increased  motor  impulses, 
mark  the  disease.  Folie  circulaire  has 
also  in  a  few  instances  been  observed, 
but  actual  paranoia,  in  its  typical  form, 
is  rare,  and  sensory  hallucinations  are 
seldom  met  with.  Imperative  ideas, 
movements,  positions,  &c.,  are  frequent, 
and  the  combination  of  the  spinal  symp- 
toms with  euphoria  often  renders  the 
diagnosis  between  pellagrous  insanity  and 
general  paralysis  difiicult. 

Prog^nosis.  —  Pellagra  may  run  its 
course  with  intermissions  through  a 
period  extending  over  ten,  fifteen  or  more 
years,  without  reaching  even  then  its 
highest  degree  of  development.  Eecovery 
can  only  be  expected  if  the  patient  has 
gone  through  no  more  than  one  or  two 
slight  attacks,  and  is  immediately  placed 
in  more  favourable  hygienic  conditions. 
If  the  disease  is  already  far  advanced  the 
prognosis  is  unfavourable,  the  most  hope- 
ful of  these  cases  exhibiting  permanent 
nervous  lesions — e.g.,  chronic  insanity  and 


Pellagra 


[    921     J 


Pellagra 


motoi"  paresis;  suicide  occurs  among  a 
fairly  large  percentage,  the  inclination 
being  towards  death  by  drowning;  death 
ensues  in  other  cases  from  marasmus  or 
from  the  complications  of  this  ait'ection, 
especially  tuberculosis.  Or  the  advent  of 
typhus  pellagrosus  or  sevei'e  intestinal 
atiection  may  bring  the  patient  to  his 
end. 

Siag^nosis. — In  cases  where  the  sub- 
jective symptoms  are  especially  prominent, 
the  diagnosis  has  to  be  made  from  neur- 
asthenia and  hysteria  ;  here  the  aetiology 
and  history  of  the  case,  the  periodicity  of 
the  affection,  its  exacerbations  in  the 
spring,  with  the  tendon  retlex  abnormali- 
ties, will  help  to  distinguish  between  the 
affections.  The  exanthem  may  be  absent 
("■  pellagra  sine  pellagra  "),  but  when  pre- 
sent, and  with  the  other  symptoms  in 
abeyance,  the  distinction  must  be  drawn 
between  it  and  pure  solar  erythema.  The 
condition  of  the  tongue  and  intestinal 
tract  will  in  such  instances  frequently 
assist  in  the  diagnosis.  In  all  cases 
where  the  spinal  symptoms  primarily 
attract  our  attention,  the  coincident  men- 
tal disorder,  the  erythematous  eruption, 
and  the  gastro-intestinal  lesions  will  be  of 
great  value  in  determining  between  pella- 
gra and  a  pure  neurosis.  The  spinal 
symptoms  are  not,  moreover,  progressive, 
but  with  frequent  changes  of  intensity 
remain  stable  for  years,  so  that  even  in 
long-standing  cases  complete  paralysis  or 
contractions  are  not  developed.  Where 
the  mental  symptoms  stand  out  promi- 
nently, the  other  associated  affections  will 
help  us  in  the  differential  diagnosis.  A 
special  diificulty  may  arise  when  the  men- 
tal condition  corresponds  to  that  of  gene- 
ral paralysis  of  the  insane,  if  at  the  same 
time  the  tendon  retlexes  are  increased,  or 
lessened,  or  entirely  absent  (pseudo-para- 
lysis pellagrosa) ;  in  such  cases,  the 
absence  of  motor  speech  derangements  is 
an  important  distinctive  sign — i.e.,  if  the 
speech  derangements  are  not  a  symptom 
of  the  transition  of  the  disease  into  general 
paralysis,  an  event  which  undoubtedly 
sometimes  occurs.  The  predominance  of 
the  gastro-intestinal  symptoms,  with 
abeyance  of  other  pellagrous  signs,  some- 
times occurs.  Here  a  careful  inquiry  into 
the  history  of  the  case  will  frequently 
clear  up  any  doubts  which  might  be  felt 
as  to  their  origin.  The  diagnosis  between 
typhus  pellagrosus  and  other  febrile 
affections,  notably  typhus,  enteric  fever, 
pneumonia,  &c.,  may  be  made  by  noting 
the  irregular  course  of  the  fever,  the  nega- 
tive results  of  examination  of  the  sus- 
pected organs  and  urine,  the  absence  of 
any  specific  exanthem  unlike  that  of  pel- 


lagra, and  the  positive  gastro-intestinal 
symptoms. 

Patbology. — Putting  on  one  side  ap- 
pearances incidental  to  the  general  con- 
stitutional disturbance,  and  those  due  to 
intercurrent  disease,  &c.,  found  in  pella- 
gra— e.g.,  general  nutritional  derange- 
ments which  are  not  constantly  present, 
such  as  wasting  of  the  adipose  and  mus- 
cular tissues,  fragilitas  ossium,  degenera- 
tion of  the  cardiac  muscular  tissue,  fatty 
degeneration  and  atrophy  with  a  slight 
degree  of  sclerosis  of  the  liver,  spleen,  and 
kidneys,  we  have  to  consider  the  more 
constant  post-mortem  results  obtained  in 
pellagrous  patients.  These  are  :  (i) 
Changes  in  the  intestinal  tract — attenua- 
tion of  the  intestinal  wall  in  consequence 
of  atrophy  of  the  muscular  coat,  with 
occasional  hyperaemia  and  ulceration  of 
the  lower  parts  of  the  canal ;  (2)  Abnor- 
mal pigmentary  deposit,  such  as  is  usually 
met  with  only  in  senility,  is  commonly 
found,  especially  in  the  ganglionic  cells, 
the  muscles  of  the  heart,  the  hepatic  cells 
and  in  the  spleen  ;  (3)  Changes  in  the 
nervous  system ;  these  are  by  far  the 
most  important  and  constant  post-mortem 
signs.  The  hyperfemic  and  anaemic  con- 
ditions, or  the  oedema  of  the  central  ner- 
vous system,  though  frequently  present, 
are  by  no  means  the  characteristic  changes, 
neither  are  those  inflammatory  conditions 
such  as  pachymeningitis  and  cerebral  and 
spinal  lepto-meningitis,  or  the  obliteration 
of  the  spinal  canal  by  granulations,  or 
ossific  arachnitis,  at  all  peculiar  to  this 
malady,  they  being  common  to  many 
chronic  nervous  aff"ections  ;  the  most  note- 
worthy and  constant  lesion,  and  one  that 
may  be  taken  as  peculiar  to  this  disorder, 
is  an  affection  of  the  spinal  cord  and 
especially  of  its  lateral  columns.  The 
brain  when  examined  furnishes  generally 
negative  results,  apart  froin  the  occasion- 
ally found  pigmentary  deposits  in  the 
cortical  cells,  and  in  the  adventitia  of  the 
smaller  vessels,  with  fatty  degeneration 
or  calcification  of  the  intima  ;  atrophy  of 
the  cerebrum  and  its  cortex  has  been 
found  in  cases  of  long-standing  mental 
derangement.  The  cord  lesion,  though 
mainly  one  of  the  lateral  columns,  fre- 
quently implicates  also  the  posterior 
columns  ;  in  the  former  the  pyramidal 
tracts  are  generally  affected  with  partial 
involvement  of  the  anterior  columns  ;  in 
the  latter  the  postero-lateral  columns  are 
generally  left  free.  The  lesion  of  the 
lateral  columns  is  shown  most  promi- 
nently in  the  dorsal  region  of  the  cord, 
while  that  of  the  posterior  columns  is 
limited  to,  or  rather  most  distinctly 
marked  in,  the  cervical  and  dorsal  regions. 


Pellagra 


[    922    ] 


Pellagra 


Microscopically,  the  affection  seems  to  be 
a  primary  degeneration  of  the  nerve- 
fibres,  with  secondary  joroliferation  of  the 
neuroglia,  the  walls  of  the  vessels  not 
being  necessarily  implicated ;  sometimes 
granular  cells,  and  more  frequently  amy- 
laceous corpuscles,  are  met  with  in  the  de- 
generated areas.  Degeneration  of  the 
anterior  root-fibres  along  the  anterior 
cornua  has  also  been  demonstrated,  while 
there  is  to  be  found  in  addition  a  more  or 
less  considerable  degree  of  pigment-atro- 
phy of  the  ganglion  cells  in  the  anterior 
cornua,  with  sclerosis  of  the  matrix  and 
atrophy  of  the  nerve-roots.  Besides  the 
excessive  j^igmentary  deposit  found  in  the 
peripheral  ganglia,  both  spinal  and  sym- 
pathetic, there  are  no  characteristic  micro- 
scopical evidences  in  other  parts  of  the 
nervous  system.  "  T3'phus  pellagrosus  " 
furnishes  us  with  definite  post-mortem 
results — chronic  gastro-enteritis  with  for- 
mation of  ulcers  and  swelling  of  the 
mesenteric  glands,  and  well-marked 
changes  in  the  central  nervous  system, 
associated  with  secondary  affection  of  the 
kidneys,  lungs,  pleura,  &c.,  being  the  main 
features  on  examination.  It  is  to  be  noted 
that  the  spleen  is  usually  involved  in  the 
general  visceral  atrophy,  and  is  never  en- 
larged. Majochi  has  found  micrococci  in 
cases  of  typhus  pellagrosus  both  in  the 
blood  during  life  and  post-mortem  in  the 
intestines,  liver,  spleen,  and  other  viscera 
which  he  regards  as  characteristic  ;  but 
successful  cultivation  of  these  has  not  yet 
been  carried  out. 

Pellagra  may  therefore  be  regarded  as 
a  disease  occasioned  by  the  action  of  some 
toxic  substance,  bearing  in  its  clinical 
aspect  a  close  resemblance  to  another 
affection  of  similar  origin — ergotism.  A 
like  mental  derangement  is  found  in  each, 
and  the  lesions  which  occur  in  both  are 
certain  degenerative  changes  in  definite 
portions  of  the  spinal  cord,  the  posterior 
column,  being  especially  implicated  in 
ergotism,  while  the  lateral,  or  both  lateral 
and  posterior  columns,  are  affected  in 
pellagra.  It  may  be  regarded  as  taking, 
so  far  as  its  spinal  symptoms  go,  a  posi- 
tion midway  between  ergotism  and  another 
disease,  similarly  induced  by  toxic  influ- 
ence, lathyrism  (a  condition  produced  by 
the  use  of  the  seeds  of  lathyrus  cicera,  a 
species  of  vetch,  as  food,  the  symptoms 
being  hyperassthesias,  convulsive  move- 
ments and  paraplegia),  in  which  the 
actual  cord  lesions  have  not,  however,  been 
demonstrated.  The  exanthera,  though 
undoubtedly  in  part  the  result  of  solar  in- 
fluence, owes  its  origin  in  the  flrst  place 
to  the  poison,  as  it  is  only  to  be  observed 
during    the    spring    months    when     the 


disease  is  at  its  height,  and  in  the  later 
stages  imj^licates  cutaneous  areas  to 
which  the  sun  has  had  no  access.  The 
intermissions  and  exacerbations  at  defi- 
nite i^eriods  have  been  explained  by  the 
fact  that  maize  forms  in  the  afi'ected  dis- 
tricts the  only  food  during  the  winter,  and 
it  is  at  its  close  that  the  symptoms  first 
begin  to  assert  themselves  ;  while  it  is 
during  the  winter  too  that  the  specific 
poison,  whether  bacterial  or  chemical,  has 
the  best  chance  of  developing  in  the  grain. 
Other  causes,  however,  of  which  we  as  yet 
know  nothing,  also  come  into  play  in 
determining  this  periodicity,  as  during 
the  treatment  of  patients  so  affected,  and 
when  maize  in  any  form  has  been  with- 
held for  years,  the  vernal  recurrence  is 
never  entirely  absent.  Belmondo's  view 
that  typhus  pellagrosus  is  due  to  the 
sudden  impregnation  of  the  blood  by  the 
toxic  influence,  which  has  either  been 
taken  in  large  quantities  or  acts  cumula- 
tively, is  certainly  tenable. 

Treatment. — The  flrst  and  most  natu- 
ral step  in  treatment  is  the  prohibition  of 
maize  in  any  shape  or  form  as  food,  or  if 
this  be  impossible,  the  use  of  only  such 
grain  as  is  rijje  to  perfection,  is  well 
dried  and  stored,  and  which  is  the  result 
of  the  sowing  of  a  good  quality.  The 
encouragement  of  cultivation  of  unaffected 
maize,  of  other  cereals,  potatoes,  &c.,  as 
well  as  the  improvement  in  the  hygienic 
and  social  condition  of  the  rural  popula- 
tion which  has  of  late  been  the  especial 
care  of  the  State  in  Italy,  have  furnished 
extremely  good  results.  When  once  the 
disease  has  broken  out  in  a  district,  it  is 
curable  if  taken  in  hand  early,  but  a 
vigorous  crusade  against  the  affection  has 
hitherto  been  frustrated  by  the  action  of 
the  i^easantry  themselves,  who  conceal 
the  fact  of  an  outbreak,  regarding  it  as 
a  "  mal  de  miseria,"  but  the  erection  of 
special  institutions  where  sufferers  can 
be  received,  and  in  which  for  a  trifling 
cost  they  can  be  provided  with  good  food 
and  find  healthful  occupation,  has  lately 
served  in  some  measure  to  remedy  this 
condition  of  things.  With  regard  to 
medical  treatment  there  is  little  to  add ; 
the  various  affections  must  be  treated 
symptomaticall}''  as  they  arise,  there 
being  no  known  drug  which  can  act  as  a 
specific.  F.  TuczEK. 

[References. — Art.  Pellagra  in  tbe  Encyclopedia 
Medica  Italiana.  Salveraglio,  Bibliografia  della 
I'ellagra,  1887.  Belmondo,  Le  alterazioui  anato- 
miche  del  midolla  spinale  nella  Pellagra  e  loro 
rapporto  coi  fatti  clinici,  1890.  Tuezck,  Ueber  die 
uervoesen  8toenmgen  bei  der  I'ellagi-a,  1888. 
Touriui,  DLsturbi  spiuali  nei  pazzi  pellagTosi.  For 
other  and  less  recent  works  see  Hirseh,  Handbuch 
dor  liistorisch-geographiscbcn  I'atbologie,  18S3.] 


Perception 


[    923    ]        Peripheral  Neuritis 


PSRCEPTION*  (percipio,  I  take  up 
•wholly).  Perception  is  a  mental  i)rocess  ; 
it  is  the-  result  of  a  very  comjilex  activity 
of  the  mind,  involving  the  synthesis  of  a 
number  of  sense-data.  The  sensations 
are  merely  modes  of  our  being  affected  by 
external  stimuli,  but  perception  is  purely 
psychical.  Perception  has  been  divided 
by  Wundt  into  simple  perception  and  ap- 
perception, the  former  being  the  simple 
knowledge  that  we  are  somehow  mentally 
affected,  the  latter  being  the  mental  state 
after  discerning  attention  has  been  given 
by  the  observer  to  the  sense  data.  {See 
PjiiLosoriiY  OF  Mind,  p.  27.) 

PERCEPTZVZ:       FACUIiTIES.  —  In 

]3hrenology — term  for  the  faculties  recog- 
nising the  existence  and  j^hysical  j^roper- 
ties  of  external  objects ;  form,  size,  order, 
eventuality,  language,  &c.     (Spurzheim.) 

PSRZiiliGES  (Trepi,  very ;  (iXyos,  pain). 
Very  painful,  sad,  or  melancholy.  (Fr. 
P'riaJfje.) 

PERIBXiEPSIS  (nepi,  around  ;  /SXeVco, 
I  stare).  The  wild  look  in  those  who  are 
delirious.  (Fr.  periblepsie ;  Ger.  Umher- 
selien.) 

PERZCHAREIil  {nepixaprjs,  glad  in 
excess).  Sudden  or  vehement  joy.  The 
opposite  of  ecplexia,  or  stupor. 

PERICHONDRITIS  A.URICUI.JE. 
(See  HEMATOMA  AuEis.) 

PERIMEM-INGITIS.  (See  Pachy- 
MENIXGITIS.) 

PERIODICITY  XN  IVIEM-TAI.  DIS- 
EASES.— Periodicity  is  more  marked  in 
mental  depression  than  in  exaltation,  and 
rarely  occurs  in  hallucinations  and  in 
delusional  insanity.  In  depression,  the 
duration  of  the  disorder  is  frequently 
about  a  year.  In  exaltation  the  disorder 
may  continue  from  four  to  six  months  or 
more  (Kraepelin).  Periodicity  and  cir- 
cular insanity  must  not  be  confounded, 
although  the  latter  may  be  periodical. 
The  reader  will  find  a  valuable  chapter  on 
the  subject  in  Clouston's  "  Clinical  Lec- 
tures on  Mental  Diseases." 

PERIPHERAI.  NEURITIS. —  Para- 
lysis, usually  more  or  less  generalised  over 
the  upper  and  lower  extremities,  and  de- 
pendent upon  peripheral  neuritis,  is  a  fre- 
quent result  of  chronic  alcoholism. 

Symptoms. — (i)  Motor.  It  commonly 
hajajDens  thatthe  patient,  when  first  seen,  is 
unable  to  stand  ;  it  may  be  that  the  power 
of  flexing  the  thighs  upon  the  pelvis  is 
fairly  preserved,  and  sometimes  the  knees 
can  be  flexed,  although  with  greater  diffi- 
culty. But  the  feet  will  usually  be  found 
"dropi^ed,"  that  is,  they  lie  flaccidly  in  a 
position  of  over-extension,  and  the  patient 
is  unable,  when  requested,  to  dorsal-flex 
them.     The  knee-jerks  are  absent.     The 


muscles  of  the  legs,  especially  those  on 
the  anterior  surface  below  the  knee,  are 
probably  atrophied,  and  are  found  to  yield 
no  response  to  induced  currents  of  elec- 
tricity, but  to  contract  slowly  to  galvanic 
currents  ofmoderate  strength.  The  arms 
are  thin,  and  the  thenar  and  hypothenar 
eminences  may  be  atrophied.  There  is 
more  or  less  "  wrist-drop,"  so  that  the  pa- 
tient presents  the  appearance  of  one  suf- 
fering from  lead  palsy.  The  extensor 
muscles  in  the  forearm  as  well  as  the  in- 
trinsic muscles  of  the  liand  may  exhibit, 
like  those  of  the  lower  extremities,  signs 
of  degenerative  i-eaction  to  electrical  cur- 
rents. 

On  the  (2)  sensory  side  we  may  ex^ject 
to  hear  of  pains,  which  are  often  of  light- 
ning character,  coming  and  going  in 
sudden  darts,  like  stabs  of  a  knife  or  the 
boring  of  a  gimlet,  and  quite  recalling 
those  characteristic  of  tabes  dorsalis. 
These  are  usually  most  pi'onounced  in  the 
lower  extremities.  It  is  commonly  ob- 
served that  much  tenderness  of  the  mus- 
cles is  complained  of  when  these  are 
grasped  by  the  hand.  The  patient  wiU 
sometimes  describe  a  sensation  of  aching 
in  the  muscles,  and  very  commonly  a  feel- 
ing of  "numbness,"  "  deadness,''  or  "pins 
and  needles,''  which  is  referred  especially 
to  the  hands  and  feet.  More  or  less  cu- 
taneous anesthesia  is  found  in  the  extre- 
mities,. esiDecially  in  the  feet  and  hands. 
As  a  general  rule  the  functions  of  the 
bladder  are  not  disordered,  and  there  is  no 
tendency  to  bed  sores. 

In  females  affected  with  alcoholic  para- 
lysis the  writer  has  observed  that  the 
catamenia  are  almost  always  suppressed, 
and  often  for  many  months  during  the 
illness. 

Although  in  the  majority  of  instances 
it  is  the  extremities  which  are  most  se- 
riously affected,  yet  in  some  cases  the 
facial  muscles,  the  external  muscles  of  the 
eyeballs,  the  respiratory  muscles,  and 
those  subserving  deglutition  may  be  more 
or  less  involved.  Exceptionally  there  may 
be  no  pains,  and  but  little  or  no  disturb- 
ance of  cutaneous  sensibility,  indicating 
the  probability  that  in  some  rare  cases 
the  efferent  fibres  only  are  involved. 
TJiere  is  often  a  considerable  amount  of 
oedema  of  the  feet  and  legs,  and  the  hands 
may  look  puffy  and  sodden.  In  some 
cases  it  is  chiefly  a  tottering  gait  which 
is  noticeable.  This  often  precedes  the 
paralytic  state,  which  may  sometimes 
arrive  quite  suddenly. 

(3)  Mental. — There  is  considerable  di- 
versity in  the  amount  and  kind  of  mental 
disturbance  in  cases  of  alcoholic  neuritis, 
and  it  does  not  necessarily  happen  that 


Peripheral  Neuritis        [    924    ] 


Pernoctation 


the  most  marked  paralysis  goes  with  the 
most  serious  mental  disorder.  There  is 
usually  in  sevei'e  cases,  a  remarkable 
loss  of  memory.  Patients  who  may 
perhaps  have  been  confined  to  bed  for 
many  weeks  will  describe  the  long  walk 
that  they  have  taken,  and  the  various 
things  they  have  done  that  very  day,  and 
this  with  an  air  of  such  fraiseinblance 
that  it  is  difiicnlt  to  disbelieve  their  story. 
There  is  very  often  a  condition  of  com- 
l^lacent  indifference  to  their  state,  and  ap- 
parent incapability  of  grasping  the  fact 
that  they  are  helpless.  There  is  usually 
no  anxiety  for  the  future,  though  the  cir- 
cumstances may  signify  utter  ruin.  This 
is  the  more  frequent  condition,  but  now 
and  then  the  symj^toms  are  those  of  de- 
lirium tremens  with  hallucinations  of  sight 
and  hearing,  with  sleeplessness  and  de- 
pression. 

Course  of  the  Disease. — Patients  who 
are  cut  oti'  from  further  suj^ plies  of  alcohol, 
who  have  not  advanced  too  far,  and  who 
are  well  nursed  and  cared  for  generally 
recover.  There  is  gradual  remission  in 
the  pains  and  sensory  disturbances  with 
a  slow  return  of  power  in  the  affected  ex- 
tremities. In  severe  cases,  months,  and 
sometimes  years,  are  required  for  recovery. 
The  paralysis,  at  first  flaccid,  becomes 
marked  by  troublesome  contractures  as 
the  muscles  which  are  least  affected  over- 
pull  those  most  seriously  involved.  In 
fatal  cases  the  termination  may  be  by  in- 
creasing exhaustion,  pneumonia,  or  more 
suddenly  by  cardiac  failure. 

Morbid  Anatomy. — The  spinal  cord 
is  usually  found  free  from  change.  The 
peripheral  nerves,  unaltered  in  appearance 
to  the  eye,  are  found  on  microscopic  ex- 
amination to  be  the  seat  of  marked 
changes  which  are  most  pronounced 
towardsthe distal  extremities.  Thechanges 
in  the  nerve-fibres  consist  in  segmentation 
of  the  myelin,  with  multiplication  of 
nerve-corpuscles,  and  disappearance  of 
many  axis  cylinders.  With  these  there  is 
often  proliferation  of  the  nuclei  of  the 
endoneurium,  and  the  walls  of  the  minute 
vessels  are  stuffed  with  cells,  affording 
evidence  of  interstitial  neuritis.  The 
changes  are  usually  most  marked  in  the 
lower  portions  of  the  sciatic  nerve  and 
distal  ends  of  the  median,  ulnar  and 
radial  nerves ;  they  are  also  often  appa- 
rent in  the  intercostal  nerves,  the  vagus, 
phrenic,  and  it  may  be  in  the  oculo- 
motors. 

Imperfect  striation  and  a  tendency  to 
fatty  change  may  be  noted  in  the  affected 
muscles. 

Siag-nosis. — The  absence  of  knee-jerk, 
ataxic  gait,    and  lightning  pains  cause  a 


strong  lyrivid  facie  resemblance  to  tabes 
dorsalis,  in  the  course  of  which  disease,  too, 
mental  disorder  may  sometimes  supervene. 
In  cases  of  peripheral  neuritis,  however, 
the  pupils  retain  their  power  of  contract- 
ing to  light.  Examination  of  the  affected 
extremities  by  electrical  currents  reveals  a 
wide-spread  loss  of  faradic  excitability 
which  is  no  part  of  the  symptoms  of  tabes 
dorsalis.  In  this  latter  disease  there  may 
occasionally  be  a  narrowly  localised  change 
of  this  kind  from  peripheral  neuritis,  but 
this  is  rare.  The  kind  of  mental  disturb- 
ance, too,  differs  much  from  that  which 
may  occasionally  occur  in  the  course  of 
tabes  dorsalis,  where  it  is  apt  to  be  charac- 
terised by  the  features  of  general  para- 
lysis. There  is  also  the  history  of  chronic 
alcoholism,  which  cannot  fail  to  be  evoked 
by  inquiry. 

From  anterior  jDolio-myelitis  the  disease 
is  differentiated  by  the  presence  of  marked 
sensory  disturbance,  and  from  this  as 
well  as  from  other  acute  affections  of  the 
spinal  cord  by  the  presence  of  mental 
disorder. 

Treatment. — Rest  in  bed,  abstinence 
from  alcohol,  nutritious  food,  are  the  chief 
requisites.  Salicylate  of  soda  in  doses  of 
twenty  grains,  or  antipyrin  in  doses  of 
from  ten  to  twenty  grains,  three  times  a 
day,  if  not  contra-indicated,  may  be  given 
to  relieve  the  pains.  When  the  acute 
symptoms  have  subsided  the  galvanic 
current  should  be  applied  in  order  to  keep 
up  the  nutrition  of  the  muscles,  as  well  as 
massage  with  active  and  passive  move- 
ments, especial  care  being  taken  to  over- 
come the  tendency  of  the  feet  to  become 
rigidly  contractured  in  a  position  of  over- 
extension. This  treatment  will  require  a 
long  time  and  patience,  which  will  usually 
bring  about  a  satis  tactory  recovery  without 
the  necessity  of  dividing  tendons. 

T.  BrzzARD. 

PERKINZSIVI,  PERKXirS'  TRAC- 
TORS.— Dr.  E.  Perkins  of  Norwich,  Con- 
necticut, U.S.A.,  introduced  a  novelty 
into  therapeutics,  which  has  been  called 
Perkinism,  after  him.  He  treated  some 
diseases  by  drawing  two  metallic  rods 
(of  different  metal)  which  he  called  "  trac- 
tors," over  the  surface  of  the  affected 
part.  He  obtained  a  fair  amount  of  suc- 
cess, due  no  doubt  to  the  influence  of  the 
mind  uj)on  the  body,  and  possibly  to  the 
determination  of  afflux  of  blood  to  the 
part  by  mechanical  action.  The  same 
effects  were  produced  by  wooden  trac- 
tors.* 

PERiroCTATZOX  {per,  through;  /io.v, 
night).     A  term    for  insomnia  or  night- 

*  t'f.  "  Illustrations  of  the  lufluenceof  the  Mind 
upon  the  Body  LuHealth  aud  Disease,"  vol.  ii.  p.  250. 


Persecution,  Ideas  of      [    925     ]      Persecution,  Mania  of 


wakefulness.  (Fr.  pernoctation :  Ger. 
jS^ar1ittracke)i.) 

PERSECUTION-,   IDEAS    OF.        {See 

Persecution,  Mama  of.) 

PERSECUTION-,  IVI ANIA  OP. — Syn. 

Delusion  of  suspicion  ;  Monomania  of 
susincion :  JMonomania  of  persecution  ; 
Delire  des  pei'secutious ;  Folie  des  perse- 
cutions. 

Sefinition. — Monomania  of  suspicion 
is  a  mental  disorder  of  chronic  form, 
which  is  essentially  characterised  by  hal- 
lucinations, by  general  sensory  derange- 
ment and  by  insane  ideas,  in  consequence 
of  which  the  patient  considers  all  his 
morbid  sensations  as  the  result  of  persecu- 
tions, of  which  he  believes  himself  to  be 
the  victiin. 

History. — The  first  treatise  on  the  de- 
lusion of  suspicion  was  published  in  1852 
by  Lasegue,  who  proposed  to  group  under 
this  terra  a  number  of  symptoms,  all  of 
which  possessed  a  striking  resemblance. 
According  to  him  they  were  all  peculiar  to 
a  morbid  type  which  in  itself  was  so  dis- 
tinct as  to  allow  of  its  being  detached 
from  other  conditions  of  mental  aliena- 
tion. In  this  he  was  not  mistaken ; 
numerous  works  which  followed  his  dis- 
covery, and  the  almost  unanimous  assent 
with  which  the  name  he  gave  to  it  was 
adopted,  show  the  imjjortance  of  the  step 
taken. 

We  do  not  mean  to  say  that  before 
Lasegue  persecution  mania  had  never 
been  observed.  At  all  times  there  have 
been  persons  labouring  under  this  dis- 
order, and  in  reading  the  observations  of 
ancient  authors,  we  shall  soon  find  that 
persecution-mania  of  former  times,  al- 
though different  in  form,  was  the  same  in 
principle.  In  the  works  of  Pinel,  Esquirol 
and  others,  many  symptoms  are  described, 
which,  when  examined,  will  not  be  found 
less  significant  than  those  mentioned 
above. 

The  classifications,  however,  established 
by  these  masters  of  psychical  medicine, 
placed  those  symptoms  under  the  cate- 
gory of  lyjDemania,  and  the  influence  of 
these  men  was  so  great,  that  even  at  a 
time  when  the  type  indicated  by  Lasegue 
was  almost  universally  admitted  as  a 
special  morbid  condition,  alienists  con- 
tinued to  describe  it  as  one  of  the  varie- 
ties of  lypemauia,  a  fact  of  which  we 
may  easily  convince  ourselves  by  referring 
to  the  works  of  Bucknill  and  Tuke,  of 
Marce,  Foville,  Dagonet,  and  others. 

In  his  first  essay  on  persecution-mania, 
Lasegue  treats  principally  of  the  course 
of  the  disorder  when  it  has  assumed  its 
characteristic  form.  He  has  himself  con- 
tributed to  the  study  of  other  peculiarities 


of  the  derangement  in  question,  and  was 
also  assisted  in  his  work  by  other  ob- 
servers, and  it  seems  as  il:  there  is  not 
much  left  to  be  done  in  the  study  of  this 
subject. 

One  of  the  most  important  complemen- 
tary works  is  certainly  that  of  Foville,  in 
which  he  shows  that  persecution-mania 
is  intimately  related  to  insanity  of  ambi- 
tion, and  that  the  latter  frequently  follows 
the  former. 

The  last  and  most  complete  work  has 
been  recently  published  by  Ritti  in  the 
Dictionnaire  encijcloprdiijue  des  Sciences 
niedicales.  Every  one  who  intends  to 
thoroughly  study  this  subject  must  cer- 
tainly refer  to  the  article  mentioned. 

General  Description  of  the  Disorder. 
— In  giving  a  clinical  description  of  per- 
secution-mania, we  shall  treat  separately 
of  the  period  of  incubation,  and  then  pass 
on  to  the  development  of  the  disorder  as 
such. 

According  to  Falret  and  Ritti,  the  de- 
velopment comprises  the  following  four 
periods : — 

(i)  Period  of  insane  interpretation. 

(2)  Period   of   visual  hallucinations, 

the  disorder  being  established. 

(3)  Period  of  general  sensory  derange- 

ment. 

(4)  Stereotyped  state;    or,  mania  of 

ambition. 

This  classification  has  undoubtedly  the 
great  advantage  of  dividing  all  the  various 
phenomena  observed  in  the  course  of  the 
disorder.  There  are,  however,  two  objec- 
tions to  it.  First,  it  may  happen  that 
the  hallucinations  of  vision  develop  al- 
most at  the  same  time  as  the  hallucina- 
tions of  the  other  senses,  and  with  various 
disorders  of  general  sensibility.  And 
secondly,  at  the  period  when  it  becomes 
stereotyped,  the  ambition  may  be  absent ; 
as  a  matter  of  fact,  it  is  ■  frequently  so, 
and  therefore  we  are  not  jiistified  in  count- 
ing the  insanity  of  ambition  among  the 
characteristic  symptoms. 

Under  these  circumstances  it  appears 
to  us  to  be  more  rational,  in  spite  of  the 
high  authority  of  Falret  and  Kitti,  to  de- 
scribe in  persecution-mania  three  prin- 
cipal periods : 

(i)  Period  of  insane  interpretation. 

(2)  Period  of  sensory  disorders. 

(3)  Period  of  stereotyped  or  systema- 

tised  insanity. 
Period  of  Incubation. — The  period  of 
incubation  of  persecution-mania  is  almost 
always  long;  it  takes  place  slowly  and 
gradually,  and  mostly  without  the  know- 
ledge of  the  patient  and  his  friends.  There 
are  individuals  who,  from  their  childhood 
seem  to  be  predisposed  to  become  victims 


Persecution,  Mania  of      [    926    ]      Persecution,  Mania  of 


of  this  form  of  mental  disease.  From  the 
earliest  times  they  have  had  a  tendency 
to  seek  solitude  ;  they  are  taciturn  and 
distrustful,  and  always  believe  that  people 
mock  at  or  ridicule  them. 

Others  begin  by  being  hypochondriacs. 
Morel  was  one  of  the  first  to  describe 
hypochondriasis  as  a  phenomenon  pre- 
cursory to  persecution-mania ;  he  says 
that  a  tendency  to  melancholia  contains 
the  germ  of  this  disorder.  And  it  is  easy 
to  understand  this  if  we  consider  the 
facility  with  which  hypochondriacs  retire 
into  themselves,  analyse  the  slightest  im- 
pressions, and  believe  that  being  ill  they 
ought  to  be  constantly  an  object  of  the 
care  of  others.  When  this  care,  however, 
is  not  practised  according  to  their  wish, 
they  become  uneasy,  angry,  and  distrust- 
ful. They  begin  to  imagine  that  nobody 
cares  for  their  more  or  less  imaginary 
sufferings,  and  that  they  are  neglected  by 
every  one.  Thus  disposed  they  are  only 
too  ready  to  plunge  into  persecution- 
mania. 

Morel  was  wrong  in  giving  hypochon- 
driasis as  the  necessary  prelude  to  persecu- 
tion-mania. There  are  certainly  j^atients 
who  suffer  from  this  disorder,  but  who 
have  never  been,  strictly  speaking,  hypo- 
chondriacs. It  would  be  more  exact  to 
say  that  almost  all  patients  labouring 
under  monomania  of  suspicion,  have 
during  the  period  of  incubation,  passed 
through  a  period  of  moral  depression, 
which  made  them  receptive  of  their  mor- 
bid impressions.  In  addition  to  this, 
hypochondriasis  and  a  tendency  to  melan- 
cholia may  be  observed  at  the  commence- 
ment of  almost  all  forms  of  mental  dis- 
orders, even  of  simj^le  acute  mania,  and 
under  these  circumstances  there  is  no 
reason  why  we  should  represent  hypo- 
chondriasis as  a  premonitory  symptom 
peculiar  to  persecution-mania. 

We  have  to  add  that,  as  Lasegue  has 
stated,  the  disease  commences  sometimes 
at  the  first  onset  in  a  sort  of  cerebral 
attack,  which  consists  in  a  kind  of  vertigo 
or  giddiness,  which  may  be  more  or  less 
prolonged,  and  of  which  the  patient  is 
able  to  state  not  only  the  time,  but 
sometimes  even  the  exact  date  of  com- 
mencement, and  after  that  date  the  insane 
ideas  begin  to  appear  quite  suddenly. 

Period  of  Insane  Interpretation. — 
This  period  consists  essentially  in  the 
fact  that  the  patient  interprets  everything 
that  hajjpens  in  a  bad  sense  and  as  in- 
tended to  do  himself  harm.  Although  in 
reality  the  disorder  is  already  in  full 
activity,  nevertheless  his  insane  ideas  are 
but  rudimentary  and  vague,  and  do  not 
attach   themselves   to   anything   special. 


He  suspects  everything  and  is  constantly 
on  his  guard,  and  the  slightest  incidents 
acquire  in  his  eyes  an  extraordinary  im- 
portance. He  imagines  that  everybody 
looks  at  him  and  talks  about  him.  If  he 
sees  several  persons  speaking  to  each 
other,  he  believes  that  he  is  the  object  of 
their  conversation,  and  that  they  are  cer- 
tainly speaking  ill  of  him.  The  slightest 
movement  made  in  front  of  him  by  any 
unknown  passer-by  appears  to  him  as  an 
insult.  If  somebody  spits  on  the  floor,  it 
is  in  detestation  of  himself.  He  believes 
all  the  words  he  hears  to  refer  to  himself, 
and  they  acquire  in  his  eyes  a  significance 
in  connection  with  his  predominant  ideas. 
If  one  speaks  to  him,  every  word  seems  to 
have  a  double  meaning.  He  suspects 
everybody  and  everything,  even  tokens  of 
affection  or  esteem.  He  mistrusts  his 
parents  and  friends  as  well  as  strangers. 
He  believes  that  everybody  deceives  and 
abuses  him,  and  this  idea  gains  ground  in 
him  because  he  fancies  that  people  ex- 
change among  each  other  mysterious 
signs  referring  to  himself.  Even  when  he 
is  alone  in  his  house,  he  is  not  safe  from 
the  universal  ill-will ;  he  imagines  that 
peoj^le  listen  and  spy  at  his  door  and  that 
he  IS  kept  under  a  secret  surveillance. 
When  he  happens  to  go  out,  he  has  a 
feeling  that  he  is  followed  by  persons 
whom  somebody  has  paid  to  watch  his 
footste]js.  Even  the  way  in  which  the 
things  around  him  have  been  arranged 
gains  in  his  eyes  a  special  significance. 
A  casement  or  a  door  which  is  half  open, 
linen  clothes  hanging  out  of  a  window,  or 
a  curtain  newly  hung,  means  for  him 
something  important,  and  only  adds  to 
the  signs  of  hostility  shown  him  from 
all  sides. 

At  this  stage,  however,  the  patient  does 
not  give  himself  entirely  up  to  his  insane 
ideas  ;  he  reflects  and  says  to  himself  that 
he  imagines  all  the  things  and  that  they 
are  absurd;  he  is  ashamed  of  it.  He  also 
tries  to  conceal  his  suspicions ;  he  often 
succeeds  in  it  so  well  that  nobody  around 
him  knows  about  his  infatuation.  There 
are  a  great  number  of  cases  who  pass 
through  this  period,  and  even  through  the 
greater  part  of  the  following  one,  without 
having  shown  the  slightest  external  sign 
of  mental  disorder.  The  mistrust,  how- 
ever, which  is  one  of  the  elements  of  their 
malady,  prevents  them  from  showing  con- 
fidence to  any  one,  fearing  lest  this  trust 
itself  might  turn  against  them  ;  conse- 
quently they  are  extremely  reserved. 

But  whatever  the  patient  may  do,  and 
in  spite  of  the  unconscious  resistance  he 
offers,  the  disease,  stronger  than  he  is, 
follows    its  course.     At  first,  the  insane 


Persecution,  Mania  of      [    927    ]      Persecution,  Mania  of 


inlerpretatious  have  been  vague,  iudefinite 
and  confused.  The  patient  imagines  that 
somebody  is  about  to  do  him  harm,  but 
he  does  not  know  who,  nor  why,  nor  how. 
Soiiiehodij  is  the  expression  he  uses,  and 
somebody  he  complains  of.  Soon  he  goes 
one  step  further  and  commences  to  attri- 
bute to  a  body  of  men  the  animosity  of 
which  he  is  the  object,  to  secret  societies, 
to  the  freemasons,  to  the  Government,  or 
to  the  police.  The  number  of  his  enemies 
is  legion,  but  an  organised  legion  which 
marches  in  a  body  against  him.  One 
more  step,  and  his  suspicion  turns  against 
this  or  that  individual,  who  becomes  his 
persecutor.  In  many  cases  he  shows 
great  ill-will  towards  this  pretended  perse- 
cutor, on  whom  he  wishes  to  take  ven- 
geance. It  is,  however,  necessary  to  add 
that  the  last  step  mentioned  takes  place 
in  the  following  period. 

At  this  point,  the  patient  who  labours 
under  persecution-mania  has  not  any 
hallucinations  strictly  speaking,  his  senses, 
however,  begin  already  to  be  disordered. 
Occasionally  he  believes  that  he  hears  a 
vague  noise,  a  murmur  or  a  whisper. 
Natural  noises,  as  the  rattling  of  a  cart, 
steps  on  the  staircase,  or  the  opening  or 
shutting  of  a  door,  become  sounds  for  him 
which  are  connected  with  his  prepossession. 
One  of  our  patients  was  unable  to  go  to 
the  railway  station  because  the  whistling 
of  the  engines  appeai-ed  to  him  to  be 
signals  given  to  his  enemies  ;  he  imagined 
that  the  whistling  said,  "  There  he  is ; 
there  he  is  ;"  and  he  ran  back  to  his  house. 
From  this  point  it  is  one  step  only  to 
the  period  of  actual  hallucinations,  which 
soon  appear  at  the  same  time  with  a 
variety  of  troubles  of  general  or  special 
sensibility. 

Period  of  Sensory  Disorders. — This  is 
the  period  when  persecution-mania  is  at 
its  height,  and  when  that  factor  appears 
which  is  essential  to,  and  characteristic  of, 
this  form  of  mental  disorder,  viz.,  hallu- 
cinations. 

Of  all  hallucinations  the  principal  one 
is  that  of  hearing;  it  is  of  such  import- 
ance that  most  authors  following  Lasegue, 
consider  it  as  the  only  one  essential  to 
persecution-mania.  There  are,  however, 
a  few  cases  in  which  other  forms  of  hallu- 
cination are  met  with.  In  any  case,  the 
auditory  hallucinations  are  almost  always 
the  first  to  appear. 

We  have  mentioned  above  that  at  first 
hallucinations  consist  of  simple  noises, 
and,  to  use  a  term  which  Ball  applied  to 
them,  are  elementary ;  afterwards  they 
become  more  defined,  and  the  patient 
begins  to  hear  voices,  which,  however,  are 
still  at  some  distance  and  confused  so  that 


the  ])atient  does  not  easily  understand  the 
words  ;  in  addition  to  being  distant,  they 
are  also  uttered  in  a  deep  voice.  Rapidly 
they  seem  to  be  nearer,  and  become  more 
distinct.  At  first  the  patient  hears  only 
isolated  words  which  are  abusive,  insult- 
ing and  obscene  ;  the  patient  hears  him- 
self called  murderer,  assassin,  drunkard, 
or  similar  epithets.  Then  the  isolated 
words  become  framed  into  more  or  less 
lengthy  sentences,  which  are  all  of  the 
same  character,  and  in  which  accusation, 
insults  and  threats  always  predominate. 

These  auditory  hallucinations  are  heard 
by  day  and  night,  but  they  are  generally 
most  intense  at  the  beginning  of  the  night. 
Most  patients  hear  them  with  both  ears, 
but  some  also,  as  Eegis  has  proved,  hear 
them  on  only  one  side.  They  may  come 
fi-om  all  directions,  through  the  ceiling 
or  the  walls,  and  through  the  chimney,  or 
out  of  cupboards  and  wardi'obes  ;  some- 
times they  come  from  underneath  the 
ground,  and  are  then  heard  not  only  with 
the  ears  but  by  means  of  a  transmission 
of  the  vibrations  by  the  whole  system. 
This  is  analogous  to  the  fact  observed  in 
deaf-mute  individuals,  who  perceive  the 
sounds  of  music  with  their  stomach. 

At  the  moment,  the  patient  believes 
that  he  hears  clearly  and  well-articulated 
words ;  he  also  believes  he  recognises  the 
voice  of  a  certain  person  whom  he  con- 
siders as  the  originator  of  all  the  persecu- 
tions of  which  he  himself  is  the  victim  ; 
the  voice  of  this  individual,  who  is  the 
cause  of  all  misfortune,  harasses  the 
patient  incessantly.  Thus  he  recognises 
a  physician,  a  priest,  or  even  his  father  or 
mother,  and  consequently  directs  against 
these  his  hatred  and  desire  for  vengeance. 
Hallucinations  of  sight  are  very  rare  in 
persecution-mania.  Lasegue  was  ofojiinion 
that  patients  presenting  them  do  not  be- 
long to  the  classical  type,  and  most  authors 
agree  with  this  view.  According  to  him, 
the  patients  are  incapable  of  generating 
visual  hallucinations.  They  are  indignant 
if  considered  capable  of  having  visions. 
Some  declare  that  they  have  often  tried 
to  get  their  persecutor  face  to  face,  but 
that  they  have  not  succeeded,  because  he 
has  run  away  or  has  hidden  himself  with- 
out any  possibility  of  tracing  him. 

Hallucinations  of  smell  and  taste  are 
frequent,  although  much  less  so  than 
those  of  hearing,  and  they  soon  impress 
their  mark  upon  the  character  of  persecu- 
tion-mania. The  patient  smells  foul, 
nauseating,  and  intolerable  smells,  which 
he  attributes  to  vapours  or  chemical 
agents  placed  in  his  neighbourhood.  Some 
believe  that  they  are  surrounded  by  an 
atmosphere   of    sulphur.       One    of     our 


Persecution,  Mania  of     [    928    ]      Persecution,  Mania  of 


patients  who  had  studied  chemistry  dis- 
tinctly smelt  the  whole  series  of  odours 
which  he  had  studied  in  the  laboratory,  car- 
bon ate  of  sulphur,  the  vapours  of  arsenic 
and  chlorine,  and  many  other  smells. 

If  under  the  influence  of  hallucinations 
of  taste,  the  patient  finds  an  unpleasant 
smell  in  everything  which  he  takes  into 
his  mouth  ;  all  food  ajjpears  to  him  bitter 
or  bad.  It  is  only  one  step  to  the  idea 
that  people  tiy  to  poison  him,  and  most 
patients  arrive  at  this  conclusion. 

Hallucinations  of  general  sensibility  in 
persecution-mania  are  extremely  numer- 
ous and  of  remarkable  variety  ;  they  may 
affect  all  parts  of  the  body  and  cause  the 
patient  great  physical  suffering.  The 
skin  is  tormented  by  all  kinds  of  pain ; 
the  patient  feels  itching,  he  has  a  sense  of 
heat  or  of  burning,  and  he  has  bizarre 
impressions,  which  he  attributes  at  once 
to  mysterious  agencies,  to  electricity, 
chemistry,  magnetism,  or  to  hypnotism  ; 
he  feels  that  somebody  strikes  or  pinches 
or  pricks  him  with  needles.  The  same 
sensations  are  perceived  in  the  internal 
organs,  and  many  patients  believe  that 
somebody  is  twisting  their  intestines 
about.  The  most  painful  impressions, 
however,  are  experienced  in  the  genital 
organs.  Female  patients  imagine  that 
they  are  being  outraged,  and  some  arrive 
at  the  conclusion  that  they  are  pregnant. 
Male  patients  imagine  that  they  are  being 
emasculated,  and  that  they  are  being  sub- 
jected to  masturbation  ;  some  also  believe 
that  their  genital  organs  are  penetrated 
by  the  mysterious  agencies  we  have  spoken 
of  above. 

Before  finishing  the  subject  of  hallu- 
cinations, we  should  like  to  mention  a 
peculiar  transformation  due  to  auditory 
hallucinations  ;  some  patients  greatly 
troubled  by  the  voices  which  they  believe 
that  they  hear,  identify  these  voices  so 
completely  with  their  own  thoughts  that 
they  finally  believe  that  they  are  no 
longer  masters  even  of  their  own  ideas. 
They  are  actually  possessed  by  what 
Baillarger  describes  as  psychical  hallu- 
cinations. The  patient  believes  that  people 
read  his  own  mind,  that  somebody  steals 
his  ideas,  and  that  the  voices  which  he 
hears  immediately  transform  his  ideas 
into  words. 

Ball  reports  a  case  where  the  patient, 
an  old  sufferer  from  persecution-mania, 
said  one  day  :  "  Somebody  steals  my  ideas 
before  I  have  had  time  to  conceive  them." 
Under  the  influence  of  this  idea,  some 
patients  when  questioned  as  to  what  they 
ieel,  do  not  answer  at  all,  but  look  at  their 
questioner  in  such  a  manner  as  to  indicate 
that  they  do  not  want  to  be  made  dupes 


by  his  pretended  ignorance,  or  they  will 
even  say,  "  What  is  the  good  of  telling  you, 
you  know  it  quite  as  well  as  I  do."  Siach 
a  condition  is  most  serious,  as  indicating 
an  advanced  stage  of  the  disorder,  and  not 
leaving  any  doubt  that  the  derangement 
has  become  chronic.  After  this  it  may 
also  happen  that  the  patient  feeling  that 
his  ideas  escape  him,  and  are  known  to 
every  one  when  he  would  rather  conceal 
them,  imagines  that  he  has  in  himself  two 
separate  individuals.  He  experiences  an 
actual  doubling  of  his  personality,  and  in 
addition  to  this  he  is  quite  prepared  for 
other  modifications  which  may  occur  at  a 
later  period. 

Period  of  Stereotyped  Znsanity. — 
Foville  has  used  a  very  expressive  term 
to  describe  the  condition  of  the  patient 
at  this  stage  ;  he  says  that  it  is  a  kind 
of  crystallisation.  And,  as  a  matter 
of  fact,  when  this  point  is  reached,  perse- 
cution-mania is  definitely  established ; 
if  it  undergoes  any  more  modifications,  it 
is  only  to  eliminate  elements  of  secondary 
importance,  and  not  to  acquire  fresh  ones ; 
the  ideas  of  persecution  peculiar  to  the 
various  individuals,  the  hallucinations  and 
the  sensory  disorders  have  reached  the 
stage  of  complete  development.  The 
patients  do  not  add  anything  more  ;  they 
are,  so  to  say,  crystallised  in  their  insanity. 
Such  patients  we  may  see  living  for  a 
great  number  of  years,  and  find  them  at 
the  end  of  this  time  in  the  very  same  con- 
dition as  at  the  commencement ;  they  have 
exactly  the  same  hallucinations,  and  they 
are  persecuted  by  exactly  the  same  per- 
sons. They  repeat  constantly  the  same 
words  and  phrases,  and  their  actions  are 
also  the  same  as  before. 

It  may,  however,  happen  that  at  this 
point  rather  insane  ideas  are  formed,  thus 
giving  the  disease  a  new  appearance. 
Although  there  is  an  intimate  connection 
between  the  former  and  the  latter,  these 
ideas  do  not  change  the  nature  of  persecu- 
tion-mania and  do  not  alter  its  proper 
character.  As  Lasegue  and  Falret  aptly 
remark,  there  is  simply  juxtaposition  of 
the  ideas,  and  no  transformation  of  the 
disease.  To  a  certain  extent,  the  position 
of  this  class  of  patients  is  analogousto  that 
of  melancholiacs,  whose  mental  troubles 
Cotard  has  described  under  the  name  of 
insanity  of  negation.  {See  Negations, 
Insanity  or.) 

These  fresh  insane  ideas  are  ideas  of 
ambition,  of  haughtiness,  and  of  supe- 
riority. The  patient  who  presents  this 
symptom,  attributes  to  himself  every  high 
quality,  grand  titles,  great  riches,  and 
power  and  superiority  over  all  who  are 
around  him.     He  believes  himself  to  be  a 


Persecution,  Mania  of      [    929    ]      Persecution,  Mania  of 


dtike.  prince,  mai-quess,  king  oi*  enipei'or  ; 
some  go  still  further  and  regard  them- 
selves as  saints  or  as  God.  They  are 
millionaires,  and  are  possessed  of  bound- 
less wealth.  They  make  the  most  mar- 
vellous discoveries,  and  imagine  they  have 
the  jDower  to  perform  miracles  ;  nothing  is 
impossible  for  them. 

Insanity  of  grandeur,  so  far  as  it  is  con- 
nected with  persecution-mania,  has  been 
admirabl}^  described  by  Foville,  whose 
works  on  this  subject  are  of  the  greatest 
importance. 

It  is  an  interesting  question  to  eluci- 
date how  persecution-mania  develops  out 
of  insanity  of  ambition. 

One  element  of  this  transformation  is 
undoubtedly  the  doubling  of  the  person- 
ality spoken  of  at  the  end  of  the  preceding 
period.  The  patient  says  to  himself — 
consciously  or  not :  "  There  are  in  myself 
ideas  in  which  I  recognise  myself,  and 
others  in  which  I  do  not  recognise  my- 
self; there  are  therefore  in  me  two  indi- 
viduals, one  who  is  myself,  and  the  other 
who  is  not  myself."  And  pursuing  this 
train  of  ideas  the  patient  forgets  more  or 
less  completely  his  real  personality,  and 
attributes  to  himself  an  imaginary  one. 

Let  us  now  consider  how  the  ideas  of 
ambition  are  formed.  The  jsatient  re- 
turns into  his  own  personality,  and  con- 
sidering on  the  one  hand  his  social  posi- 
tion, artisan,  labourer,  or  whatever  he 
may  be,  and  on  the  other  hand  the  per- 
secutions, of  which  he  believes  himself 
to  be  a  victim,  and  the  power  which  he 
attributes  to  his  persecutors,  he  questions 
himself  whether  he  is  really  a  person  of 
so  little  importance  as  he  appears  to 
himself.  He  says  to  himself  that  he  must 
be  a  person  of  distinction,  because  people 
take  so  much  trouble  to  torment  him 
and  to  persecute  him  in  so  many  ways. 
He  imagines  that  he  has  been  changed 
in  the  nursery,  that  he  is  evidently  the 
descenda.nt  of  princes,  kings,  or  emperors, 
and  that  those  whom  he  has  hitherto  re- 
garded as  his  parents,  are  not  his  parents 
at  all.  Then  he  begins  to  say,  and  to 
believe,  as  we  have  indicated  just  now, 
that  he  is  a  grand  personage,  and  some- 
times he  raises  himself  even  to  the  ranks 
of  divinity. 

This  mode  of  production  of  ambitious 
ideas  has  been  called  by  Foville  "  trans- 
formation by  logical  deduction  ;"  the  logic 
in  these  ideas  is  evident  in  spite  of  their 
absurdity.  We  have  however  to  add, 
that  in  other  cases  insanity  of  grandeur 
appears  spontaneously  and  almost  sud- 
denly :  the  patient  may  present  himself 
quite  unexpectedly  with  all  the  attributes 
of  the  new  position  which  he  gives  him- 


self. This  may  be  induced  by  one  word 
which  the  patient  happens  to  hear,  and 
which  appears  to  him  to  be  revelation,  or 
it  may  be  caused  by  auditory  hallucina- 
tions, and  in  the  latter  case  the  reasons 
for  this  transformation  cannot  be  under- 
stood, because  these  new  ideas  are  self- 
suggested. 

Arrived  at  this  stage,  the  patient  has 
gone  through  all  the  phases  of  persecution- 
mania.  We  have  described  the  symptoms 
peculiar  to  each  period,  but  this  will  not 
yet  be  sufficient  to  give  a  perfect  idea  of 
the  malady.  Therefore,  we  proceed  to 
occupy  ourselves  with  peculiarities  which, 
although  varying  in  different  individuals, 
are  nevertheless  identical,  and  are  valu- 
able additional  characteristics  of  this 
form  of  insanity  ;  these  peculiarities  refer 
to  the  actions  of  patients  labouring  under 
this  disorder. 

Actions  of  Patients  in  Persecution- 
mania. — It  is  evident  that  in  consequence 
of  his  malady,  the  patient  never  passively 
yields  to  the  attacks  of  which  he  believes 
himself  to  be  the  victim.  All  either  try 
to  escape  the  persecutor,  or  to  take  ven- 
geance upon  him.  We  must  keep  in  mind 
that  although  the  patient's  intellect  has 
undergone  changes,  the  wheel-work  is 
nevertheless  intact,  and  that  he  reacts  to 
certain  impressions  in  almost  the  same 
manner  as  healthy  individuals. 

As  Regis  aptly  remarks,  the  first  thing 
they  do  is  to  complain;  they  immediately 
apply  to  the  authorities  asking  them  to 
put  a  stop  to  the  persecutions,  the  origin 
and  cause  of  which  they  are  unable  to 
discover.  In  this  manner  police-officers, 
magistrates,  ministers,  and  even  sove- 
reigns are  constantly  assailed  with  their 
applications. 

Just  as  their  insanity  is  still  vague  and 
consists  in  insane  interpretations  only,  in 
the  same  manner  their  suspicions  and 
accusations  are  also  vague.  The  patient 
will  say  :  "  I  have  enemies,  but  I  do  not 
know  them,  I  try  to  discover  them,  but  I 
fail  to  do  so ;  I  most  certainly  have  ene- 
mies who  want  to  do  me  harm,  but  I  am 
ignorant  who  they  are.'' 

The  more  the  insanity  becomes  definite 
the  more  precise  also  become  the  accusa- 
tions ;  then  the  i^atient  begins  to  direct 
his  accusations  against  his  doctor,  against 
a  certain  friend,  or  even  against  his  father 
or  mother.  Foville  remarks  that  such 
individuals  are  sometimes  actually  hapjsy, 
if  they  can  address  themselves  to  men  who, 
understanding  their  mental  condition, 
take  the  necessary  steps  to  have  them 
admitted  and  cared  for  in  an  asylum. 

On  the  other  hand,  people  often  do  not 
recognise  that  they  are  insane,  and  listen- 


Persecution,  Mania  of     [    930    ]      Persecution,  Mania  of 


ingto  their  complaints  try  to  quiet  them 
and  afterwards  leave  them  to  themselves, 
thus  exposing  them  to  the  dreadful  conse- 
quences of  their  insanity.  And,  as  a 
matter  of  fact,  they  then  abandon  their 
complaint,  and,  taking  to  more  effective 
measures,  they  become  aggressive.  Their 
attacks  are  mostly  absolutely  spontaneous 
and  unexpected.  The  patient  will  rush 
up  to  any  one  who  happens  to  pass  by  in 
the  street,  and  who  he  believes  has  spoken 
of  him,  or  has  looked  at  him  with  con- 
tempt, and  attack  him  with  his  fist  or 
stick.  In  many  other  cases,  however,  the 
attacks  are  premeditated,  and  are  directed 
against  the  person  by  whom  the  patient 
imagines  himself  to  be  constantly  tor- 
mented. 

Lastly  come  the  more  serious  attacks, 
namely,  murderous  assaults.  The  patient 
generally  does  not  reach  this  stage  all  at 
once,  but  passes  through  a  long  period  of 
hesitation.  His  ideas  however  drive  him 
on,  and  seeing  no  other  way  out  of  such 
a  deplorable  situation,  he  commits  some 
frightful  deed.  Some  become  homicides 
in  the  hope  that  they  will  have  peacL 
after  their  persecutors  are  dead ;  others, 
because  they  hope  to  be  given  over  into 
the  hands  of  justice,  and  that  on  the  day 
of  the  trial  they  will  be  able  to  denounce 
their  persecutors,  to  cleanse  themselves 
from  all  imputations  they  believe  to  be 
made  against  them,  and  to  have  their 
innocence  pviblicly  proclaimed.  In  the 
same  manner,  patients  with  ideas  of  gran- 
deur wish  to  obtain  acknowledgment  of 
the  rights  to  vphich  they  believe  them- 
selves entitled. 

The  number  of  assaults  committed  by 
individuals  labouring  under  persecution- 
mania  is  extremely  great ;  if  we  were  to 
count  those  which  have  been  published 
under  different  titles  since  the  days  of 
Pinel  and  Esquirol,  we  might  fill  volumes. 
It  follows  from  what  we  have  said,  that 
in  most  cases  the  patients  who  commit 
homicidal  attacks,  have  definite  motives 
and  act  with  refiectiou  and  determination, 
but  we  must  also  keep  in  mind  that  in 
certain  cases  the  patient  executes  his 
plans  in  the  paroxysms  of  the  disease,  so 
that  it  seems  as  if  such  patients  could  only 
be  impelled  by  a  morbid  infiuence  or  im- 
pulse. We  have  to  mention  a  fact  to  which 
Blanche  has  properly  drawn  attention. 
He  has  shown  that  patients  before  they 
act,  pass  from  time  to  time  through  a 
condition  of  exaltation.  Habitually  calm 
they  become  at  times  excited  without  any 
other  cause  than  a  cerebral  modification, 
of  which  they  are  not  conscious,  and  in 
one  of  these  moments  of  excitement  they 
commit  the   deed.     Generally   speaking, 


we  may  say  that  the  motives  which  drive 
the  patient  to  murder,  are  as  numerous 
as  the  ideas  which,  according  to  the  mind 
of  the  patient,  form  the  foundation  of 
persecution-mania. 

Frequently  it  is  not  characterised  by 
violence,  but  the  patient  addresses  writ- 
ings of  all  kinds — letters  and  petitions — 
to  those  whom  he  believes  to  have  power 
to  protect  him.  The  patient  generally 
writes  at  great  length,  and  we  must  re- 
mark, that  frequently  his  writings  give  a 
better  account  of  his  condition  than  his 
words  and  conversation.  There  are  few 
alienists  who  have  not  met  with  patients 
whose  letters  alone  revealed  the  mental 
disorder.  Such  patients  have  sufficient 
power  over  themselves  to  control  their 
conversation,  and  knowing  that  their 
words  would  be  considered  unreasonable, 
take  good  care  not  to  say  anything  that 
might  compromise  them  ;  they  are  not  so 
suspicious  when  writing,  and  thus  soon 
expose  their  insane  ideas.  Usually  the 
letters  of  the  patient,  especially  when  he  is 
in  an  asylum,  are  denunciations,  couched 
in  precise  and  categorical  terms,  against 
the  physician  and  the  management.  These 
denunciations  are  sometimes  so  plausible, 
that  we  must  carefully  investigate  the 
character  of  the  individual  who  wrote 
them,  and  not  receive  them  in  earnest. 

Having  regard  to  the  actions  which  we 
have  mentioned  above,  the  patient  may 
often  become  himself  an  actual  persecu- 
tor to  others. 

Individuals  labouring  under  persecution- 
mania  are  not  always  aggressive,  and 
there  are  man}'  cases  in  which  the  patient, 
instead  of  trying  to  avenge  himself,  en- 
deavoursto  avoid  the  evils  planned  against 
him  ;  this  is  done  in  various  ways,  accord- 
ing to  the  insane  ideas  which  predominate 
in  the  patient,  and  according  to  his  cha- 
racter. 

The  most  troublesome  insane  concep- 
tion from  which  a  j^atient  can  possibly 
sufier,  is  certainly  the  fear  of  being  poi- 
soned ;  this  fear  causes  him  first  of  all 
to  examine  all  his  food  minutely,  then 
instead  of  taking  his  meals  with  his 
family,  or  continuing  to  go  to  his  usual 
restaurant,  he  constantly  changes  without 
however  trusting  the  food  placed  before 
him.  Then  he  begins  to  buy  his  provi- 
sions himself,  and  does  so  by  enveloi^ing 
himself  in  mystery ;  every  daj'  he  goes 
to  a  different  shop,  and  preferably  to  one 
where  he  thinks  he  is  unknown,  but  at 
last  he  finds  everywhere  signs  of  poison, 
and  distrusting  even  himself  ceases  to 
eat  altogether.  If  this  happens  with  a 
patient  in  an  asylum,  the  only  remedy  is 
to  resort  to  artificial  feeding. 


Persecution,  Mania  of       [    931     ]        Persecution,  Mania  of 


Again,  the  patient  may  try  to  escape 
persecution  by  fii^lit.  Foville  has  de- 
scribed this  condition  under  the  name  of 
migratory  insanity  (he  calls  these  patients 
alienis  viigrate2irs).  The  patient  com- 
mences by  changing  his  lodgings  or  his 
house  ;  then  he  changes  from  onequai'ter 
to  another,  and  later  to  another  town.  At 
last,  when  this  migratory  insanity  is  fully 
developed,  he  changes  to  another  country, 
soon,  however,  removing  again,  in  order  to 
seek  in  the  most  distant  countries  the  rest 
which  he  cannot  find  anywhere. 

It  would  seem  natural  that  suicide 
should  be  common  in  cases  of  persecu- 
tion-mania, but  that  is  not  the  case. 
Suicides  are  rare.  Some  authors,  espe- 
cially Regis,  go  so  far  as  to  deny  that  there 
are  any,  and  attributes  this  tendency  to 
melancholiacs  alone. 

Course  of  Persecution-mania. — Al- 
though the  progress  of  insanity  in  perse- 
cution-mania is  very  regular,  there  is 
nevertheless  a  great  irregularity  in  the 
duration  of  each  period.  Generally,  as 
we  have  pointed  out  before,  the  period  of 
incubation  is  very  long.  There  are  indi- 
viduals, who,  from  early  childhood,  have 
shown  themselves  predisposed  to  this 
mania,  but  who  arrive  at  middle  life 
before  succumbing  to  the  disease.  It  is 
generally  impossible  to  assign  a  definite 
period  to  the  actual  commencement  of 
the  malady.  The  period  of  insane  inter- 
pretation is  also  sometimes  very  long, 
but  in  the  greater  number  of  cases,  it 
is  comparatively  the  shortest  period.  We 
must  not,  however,  think  that  there  is 
always  a  well-marked  division  between 
each  of  these  two  periods  ;  the  character- 
istic symptoms  of  one  period  always  ex- 
tend into  the  succeeding  one.  The  sepa- 
ration is  most  distinct  between  the  period 
of  insane  interpretation  and  that  in  which 
the  sensory  disorders  appear.  A  great 
number  of  patients  present  almost  un- 
expectedly hallucinations,  and  acquire  in 
a  short  time  all  their  sensory  disturbances 
to  which  they  become  victims.  There 
are  numerous  cases  in  which  persecution 
mania  does  not  develojD  beyond  the  period 
of  sensory  disorders,  but  the  greater  num- 
ber arrive  at  least  at  the  stage  of  system- 
atisation.  After  this  time,  some  plunge 
into  dementia ;  their  ideation  becomes 
weak,  the  impressions  become  confused, 
and  the  insane  phenomena  lose  their 
acuteness.  Others  remain  for  an  indefi- 
nite time  in  the  same  condition ;  their 
disorder  does  not  undergo  any  more  modi- 
fication, and  in  spite  of  the  disease  they 
may  retain  a  pretty  normal  mental  ac- 
tivity, which  under  certain  conditions  may 
deceive  us. 


Many  patients  have  intermittent 
attacks  of  agitation  which  border  on  ma- 
niacal excitement ;  they  then  become  very 
aggressive,  and  abusive,  talk  with  great 
animation,  and  are  very  angry,  so  that 
at  such  times  it  would  not  be  prudent 
to  approach  them.  This  agitation  may 
last  for  several  hours  or  even  days,  and 
may  return  with  almost  regular  periodi- 
city. One  of  our  patients  becomes  thus 
excited  every  day  for  two  hours  after 
dinner.  In  female  patients  an  exacerba- 
tion takes  place  at  the  time  of  menstrua- 
tion. 

Some  patients  have  actual  remissions, 
during  which  they  cease  tu  suffer  from 
hallucinations  of  persecution,  being,  how- 
ever, thoroughly  convinced  that  their 
previous  experience  was  quite  real.  These 
remissions  are  rare,  and  we  must  be  care- 
ful not  to  be  deceived  by  appearances  and 
regard  as  remission  what  frequently  is 
nothing  but  simulation. 

This  is  the  place  to  consider  a  very 
interesting  question  lately  raised  at  the 
medico-psychological  society  of  Paris. 
Magnan  and  his  pupils  maintain  that 
persecution-mania  ought  no  longer  to  be 
considered  as  a  morbid  entity,  but  rather 
as  a  symptom  of  a  more  complex  condi- 
tion, to  which  at  first  they  gave  the 
name  of  chronic  insanity,  but  which  on 
account  of  the  many  objections  made  to 
this  term,  they  now  call  by  the  name 
jjroposed  by  CuUerre,  of  "  progressive 
systematised  insanity."  The  new  morbid 
condition  thus  called,  is  said  to  be  charac- 
terised by  a  progressive  and  systematic 
evolution,  and  by  the  succession  of  four 
distinct  periods  which  invariably  appear 
in  the  same  order. 

In  the  first  period,  called  that  of  incu- 
bation, the  patient  is  uneasy  and  absorbed 
in  himself ;  in  short,  he  is  in  a  kind  of 
hypochondriacal  condition,  .and  after  a 
shorter  or  longer  period  of  hesitation, 
arrives  at  the  stage  of  insane  interpreta- 
tion. 

The  second  period  is  marked  by  or- 
ganised persecution-mania,  when  the 
morbid  ideas  incessantly  nourished  by 
sensory  disorders,  establish  themselves, 
and  become  coordinateii  and  systematised. 

The  third  period  is  characterised  by  the 
occurrence  of  ideas  of  grandeur,  which 
indicate  the  ultimate  systematisation  of 
the  disorder. 

The  fourth  and  terminal  period  con- 
sists in  an  incurable  decay  of  the  mental 
faculties. 

It  cannot  be  disputed  that  this  classifi- 
cation corresponds  to  a  great  number  of 
cases  accurately  observed,  and  that  it  has 
a  right  to  be  quoted  in  science  ;  the  mis- 

3  " 


Persecution,  Mania  of       [    932    ]        Persecution,  Mania  of 


take,  howevei",  made  by  those  who  intro- 
duced it,  is,  that  they  generalised  its  appli- 
cation too  much.  They  maintain,  in  the 
first  place,  that  the  progressive  systema- 
tised  insanity  is  invariable  in  its  evolu- 
tion ;  bxit  how  will  their  classification  in- 
clude patients  whose  disorder  comes  to  a 
standstill  after  the  period  of  sensory  dis- 
orders ?  They  also  assert  that  persecu- 
tion-mania always  terminates  in  insanity 
of  grandeur.  There  are,  however,  plenty 
of  patients  who  suffer  from  persecution- 
mania  only,  and  live  in  this  condition 
for  an  indefinite  number  of  years,  and 
who  may  fall  victims  to  dementia, 
without  having  ever  had  any  ambitious 
ideas. 

Lastly,  with  regard  to  the  dementia 
which  characterises  the  last  period,  it  is 
quite  as  often  absent  as  insanity  of 
gi-andeur.  The  authors  in  question  have 
generalised  all  these  latter  facts  because 
it  suited  their  scheme,  and  in  order  to 
justify  their  manner  of  observation,  they 
were  comj^elled  to  create  a  new  variety 
of  dementia.  In  the  present  case,  de- 
mentia is,  according  to  their  opinion,  less 
the  annihilation  of  the  intellectual  facul- 
ties than  the  disintegration  of  an  insane 
structure  which  up  to  that  point  had  been 
of  remarkable  fixity  and  solidity ;  but 
even  this  granted,  one  must  admit  that  it 
often  appears  long  before  the  period  as- 
signed to  it  in  progressive  systematised 
insanity.  As  a  matter  of  fact,  we  see 
patients  who,  as  soon  as  their  insanity  is 
organised,  begin  to  separate  its  elements 
and  abandon  some  of  their  insane  concei^- 
tions.  From  this  it  follows  that  if  we 
consider  all  the  facts  with  impartiality, 
we  must  admit  that  we  may  under  the 
name  of  progressive  systematised  de- 
lirium class  all  the  symptoms  which  in 
former  times  were  considered  as  cases 
of  persecution-mania  with  megalomania, 
but  also  that  there  are  other  symptoms 
almost  as  numerous,  in  which  persecution- 
mania  preserves  its  individuality  and 
autonomy,  and  that  it  certainly  is  in  itself 
characteristic  enough  to  preserve,  as  the 
type  discovered  by  Lasegue,  the  special 
place  occupied  by  it  hitherto. 

Prog°nosis. — The  prognosis  is  almost 
always  unfavourable.  If  there  are  cases 
cured,  they  are  certainly  not  numerous, 
and  we  for  our  part  have  not  yet  met 
with  one.  In  this  respect  we  must  not 
allow  ourselves  to  be  deceived  by  apj^ear- 
ances  and  attribute  cures  to  persecution- 
mania,  which  concern  other  morbid  con- 
ditions in  which  ideas  of  persecution  may 
be  met  with. 

The  duration  of  the  disease  is  always 
long,  and  the  patient  may  live  to  an  ad- 


vanced age,  provided  that  other  complica- 
tions do  not  shorten  his  days. 

Diagrnosis . — When  persecution-mania 
is  fully  established,  it  is  generally  easy  to 
recognise.  The  great  number  of  halluci- 
nations, especially  of  those  of  hearing, 
and  their  influence  on  the  life  and  actions 
of  the  patient,  are  excellent  diagnostic 
means.  The  greatest  difficulty  with  re- 
gard to  persecution-mania  is  simulation, 
to  which  a  certain  number  of  patients 
have  a  great  tendency.  This  simulation 
may  in  some  cases  embarrass  even  the 
most  experienced  alienist;  still  more  so 
those  who  have  no  practice  in  the  treat- 
ment of  mental  disorders.  Magistrates 
are  frequently  deceived  when  they  have 
to  deal  with  lunatics  of  this  class.  There 
are,  indeed,  patients  who  are  remarkably 
clever  in  concealing  their  insanity,  wholly 
or  partially.  They  know  that  their  ideas 
are  considered  to  be  devoid  of  reason  and 
take  every  care  not  to  allow  them  to  be 
noticed.  Some  succeed  marvellously,  and 
defy  the  most  minute  examinations. 
Clouston  rejjorts  the  case  of  a  patient 
who  believed  himself  in  constant  danger 
of  being  poisoned,  and  who  was  possessed 
by  a  hundred  morbid  suspicions,  but  who 
for  a  great  number  of  years  did  not  con- 
fess his  troubles  except  to  one  person. 
To  all  others  he  pretended  to  be  free  from 
any  anxiety  ;  he  was  pleasant  and  behaved 
as  if  he  was  not  at  all  troubled.  Marandon 
de  Montyel  has  recently  published  an  as- 
tonishing account  of  a  patient  who  for 
almost  two  years  was  of  irreproachable 
behaviour ;  he  was  considered  cured,  and 
by  a  decision  of  the  Court,  he  was  allowed 
to  leave  the  asylum  in  which  he  had  been 
confined.  The  very  same  night  he  killed 
his  mother  whom  he  accused  of  all  the 
persecutions  of  which  he  believed  himself 
to  be  the  victim.  The  ntxt  morning  he 
gave  himself  up  to  the  police  after  having 
posted  a  letter  to  the  magistrate  thank- 
ing him  for  having  facilitated  the  accom- 
plishment of  an  act,  which  jjut  a  stop  to 
all  the  misery  with  which  he  had  been 
afilicted  for  so  many  years.  In  this  same 
letter  he  confessed  to  have  simulated. 

If  one  has  time  to  observe  the  patient, 
it  is  not  difficult  with  a  little  experience 
to  make  a  correct  diagnosis.  Certain 
words  which  alwa3's  return  in  the  same 
form,  the  gesticulations  —  sometimes 
rather  bizarre — and  the  way  of  acting  in 
connection  with  his  fixed  ideas  are  signi- 
ficant indications,  and  in  addition  to  this, 
l^atients  who  seem  to  be  healthy  in  mind, 
so  far  as  their  words  and  conversation  are 
concerned,  are  not  afraid  to  confide  their 
insane  ideas  to  papei\  Once  on  the  track 
of  the  disorder,  it  only  remains  to  ask  the 


Persecution,  Mania  of       [    933    ]        Persecution,  Mania  of 


patient  a  tew  questions,  or  to  throw  into 
the  conversation  a  few  leading  insinua- 
tions. 

The  insanity  of  grandeur,  which  appears 
in  the  third  period,  cannot  be  confounded 
with  general  paralysis  it'  we  remember 
that  paralytics  are  generally  incoherent 
and  confused,  and  they  exhibit  a  satisfac- 
tion with  themselves  which  is  in  inverse 
ratio  to  the  mistrust  and  the  reserve 
shown  by  patients  sufi'eriug  from  persecu- 
tion-mania. 

We  often  meet  with  ideas  of  persecution 
and  hallucinations  in  alcoholism.  The 
specific  symptoms,  however,  of  the  latter 
disorder,  enable  us  to  avoid  mistakes,  and, 
in  addition  to  this,  there  is  another  funda- 
mental difference,  in  so  far  as  that  in  j^er- 
secution-mania  the  hallucinations  are 
mostly  auditoiy,  whilst  in  alcoholism  they 
are  mostly  visual.  Lastly,  alcoholism  is  of 
short  duration,  whilst  persecution-mania 
may  last  for  an  indefinite  period.  One 
individual  may  suffer  at  one  and  the  same 
time  from  delusion  of  suspicion  and  alco- 
holic insanity — that  is  to  say,  a  patient 
suffering  from  the  former  disorder  may 
also  fall  a  victim  to  alcoholic  intoxication. 
Patients  suffering  from  delusion  of  sus- 
picion cannot  be  confounded  with  melan- 
choliacs,  if  we  keej)  in  mind  the  condition 
of  depression  of  the  latter,  and  also  their 
anxiety  and  distress. 

Speaking  generally,  we  must  not  con- 
found persecution-mania  with  ideasof  per- 
secution met  with  in  a  great  number  of 
morbid  conditions.  These  latter  ideas 
taken  isolatedly  are  incoordinate,  and  are 
not  necessai-ily  founded  on  hallucinations. 
Among  the  conditions  in  which  they  are 
present,  we  mention  specially  organic  af- 
fections, locomotor  ataxy,  sclerosis  en 
l^laques  and  paralysis  agitans.  There  is 
often  in  hysteria  a  marked  tendency  to 
make  accusations  and  complaints,  but  it 
is  rarely  accompanied  by  auditory  hallu- 
cinations, and  the  patients  are  not  subject 
to  general  sensory  disorders.  In  folie 
raisonnante,  or  in  moral  insanity,  the 
patients  often  complain  of  being  perse- 
cuted, and  more  frequently  still  they  be- 
come in  their  turn  terrible  persecutors, 
but  their  disorder  has  no  analogy  at  all 
with  true  persecution-mania. 

We  have  specially  to  mention  the  ideas 
of  persecution  which  mark  the  commence- 
ment of  senile  dementia.  Old  people, 
timorous  and  distrustful  under  the  infiu- 
ence  of  old  age,  begin  to  exaggerate  this 
tendency  when  senile  dementia  super- 
venes ;  they  believe  that  some  one  wants 
to  do  them  injury,  to  rob  and  ruin,  or 
even  to  kill  them  ;  they  accuse  their  dearest 
and  most  devoted  friends  and  relatives  of 


ill-will.  They  also  believe  that  they  are 
neglected  and  looked  upon  with  contempt. 
Under  these  circumstances  they  have  an 
aversion  to  everyone,  and  intercourse  with 
them  becomes  most  ditiicult.  Although 
this  condition  is  extremely  similar  to  per- 
secution-mania, it  differs  from  it  because 
it  is  not  based  on  hallucinations  ;  it  is 
nothing  but  the  pi-oduct  of  a  cerebral 
alteration,  and  the  progressive  and  rapid 
intellectual  weakening  will  soon  reveal  the 
true  nature  of  the  disorder. 

.Stiolog-y. — The  conditions  under  which 
persecution-mania  develops,  and  the  causes 
which  produce  it,  ax'e  of  a  very  compli- 
cated nature.  Ritti  has  in  his  excellent 
description  of  persecution-mania  made 
some  statistical  researches,  which  it  will 
suffice  for  us  to  review. 

Persecution-mania  is  a  mental  disorder 
of  frequent  occurrence,  and  cases  seem  to 
become  more  and  more  numerous.  In 
this  respect  it  bears  some  analogy  to 
general  paralysis. 

The  statistical  returns  of  several  asylums 
show  that  there  are  a  greater  number  of 
female  than  male  patients,  namely,  in  the 
proportion  of  five  to  three. 

Speaking  generally,  ideas  of  persecu- 
tion-mania make  their  appearance  in 
individuals  before  they  reach  an  advanced 
age.  The  greater  number  of  patients  in 
asylums,  whose  disorder  is  at  the  stage  of 
full  develojmient,  are  from  thirty  to  fifty 
years  old. 

Persecution-mania  attacks  individuals 
of  every  profession  and  of  every  class  of 
society.  It  seems,  however,  that  the 
greater  number  of  cases  belong  to  the 
wealthy  class. 

With  regard  to  the  influence  of  heredity, 
we  may  state  that  some  authors,  especially 
Krafft-Ebing,  consider  it  an  important 
factor.  According  to  these  authors,  we 
find  among  the  ancestors  of  most  of  the 
patients  in  question  various  .morbid  con- 
ditions, either  well-developed  insanity,  or 
more  frequently  an  eccentric  character 
and  behaviour,  or  symptoms  of  hysteria, 
hypochondriasis  or  alcoholism. 

The  investigations  of  Christian  and 
E/itti  at  Charenton  do  not  attribute  to 
hereditary  degeneration  such  a  marked 
influence  as  the  authors  just  meutioaed. 
There  were  among  134  patients  admitted 
at  Charenton  in  seven  years  suffering  from 
persecution-mania  not  more  than  36^ 
about  26  per  cent,  among  whose  ancestors 
traces  of  mental  disorders  could  be  found. 
Contrary  to  the  general  opinion,  moral 
causes  play  only  an  unimportant  part  in 
the  production  of  this  form  of  insanity.  It 
is  so,  however,  with  all  other  forms  of 
insanity.     Moral   causes,  to    which   some 


Persecution,  Mania  of       [    934    ]       Persecution,  Mania  of 


importance  has  been  attributed  in  the  cases 
which  concern  us  here,  are,  principally : 
prolonged  grief,  loss  of  fortune,  jealousy, 
excessive  religious  exercises,  every  kind  of 
anxiety,  vicious  education,  &c. 

It  is  necessary  to  add  that  these  various 
moral  influences  have  a  powerful  eft'ect  on 
the  physical  constitution  of  the  individual ; 
they  weaken  nutrition,  debilitate  the 
organism,  and  prepare  the  soil  for  all 
kinds  of  morbid  conditions  ;  moreover,  the 
more  we  study  mental  disease,  the  more 
we  become  convinced  that  physical  causes 
are  among  the  most  important  factors  m 
producing  insanity,  and  applying  this  to 
the  disorder  with  which  we  are  now  occupied , 
we  have  good  reason  to  say  that  moral 
causes  are  connected  with  the  production 
of  mental  disorder,  but  only  indirectly. 

Eitti  divides  the  physical  causes  of 
persecution-mania  into  three  classes  :  (i) 
causes  which  act  on  the  brain  and  nervous 
system  (meningitis  in  childhood,  infantile 
convulsions,  cranial  traumatism,  apoplec- 
tic attacks,  complications  of  various  dis- 
eases, &c.) ;  (2)  causes  which  have  their 
origin  in  the  reproductive  organs  or  in 
sexual  life  (faulty  formation  of  the  organs 
in  question,  seminal  losses,  onanism,  and 
the  various  forms  of  venereal  disease,  &c.) ; 
(3)  general  causes  of  physical  debility  (pri- 
vation, misery,  and  insufficient  nutrition, 
amemia,  chlorosis  and  related  conditions). 

Treatment. — The  indications  for  treat- 
ment are  to  arrest  the  development  of  the 
disorder  or  to  mitigate  its  effects. 

Those  which  refer  to  the  former  are 
almost  all  of  doubtful  efficacy.  Distrac- 
tions do  no  good  because  the  patient  does 
not  feel  interested  in  them.  Travelling 
has  sometimes  done  good,  but  frequently 
it  is  more  harmful  than  iiseful.  As  a 
matter  of  fact,  the  patient  cai-rying  with 
him  all  his  insane  ideas  and  hallucinations, 
is  the  more  irritated,  because  he  finds 
them  everywhere,  and  instead  of  becoming 
better,  his  condition  becomes  still  worse. 
Hydrotherapeutics  have  yielded  many 
good  results,  but  a  tonic  regime  according 
to  the  wants  of  the  organism  is  the  best 
of  all. 

■  In  most  cases  it  is  necessary  to  place 
the  patient  in  an  asylum  ;  first,  because 
he  is  dangerous  to  public  order  and 
security  ;  and  secondly,  because  methodical 
and  effective  treatment  can  only  be  pro- 
perly applied  there. 

We  must  add  that  the  symptomatic 
indications  are  numerous,  and  that  accord- 
ing to  the  case  we  have  to  allay  insomnia, 
excitement,  and  various  disorders  of  the 
alimentary  canal.  Lastlj^  in  cases  where 
the  patient  is  afraid  of  being  poisoned  we 
have  to  resort  to  artificial  feeding. 


Forensic  Medicine. — From  a  medico- 
legal point  of  view,  cases  of  persecution- 
mania  afford  matter  for  consideration  of 
the  greatest  importance.  We  cannot  go 
deeply  into  it  here,  and  must  limit  our- 
selves to  stating  the  elementary  principles. 
In  almost  all  patients  there  is  at  certain 
times  a  perfect  contradiction  between  their 
reasonable  manner  and  the  gravity  of 
their  condition.  Their  attitude  is  habitu- 
ally that  of  healthy  people,  although  an 
experienced  eye  is  not  easily  deceived  and 
soon  discovers  the  anomalies.  For  inex- 
perienced peojjle,  however,  the  anomalies 
pass  unnoticed.  The  same  holds  good  of 
the  conversation,  which  may  be  neither 
incoherent  nor  improbable,  because  the 
account  of  the  persecutions  is  so  plausible 
that  it  may  ajipear  as  by  no  means  impos- 
sible. Then,  putting  aside  the  external 
symptoms,  there  are  many  internal  mani- 
festations, which  might  pass  as  signs  of  a 
healthy  mind.  The  patient  is  fully  con- 
scious of  his  doings  and  sayings  ;  most  ot 
his  actions  are  fully  considered  and  pre- 
meditated, and  even  if  reprehensible  they 
ai-e  accomplished  with  real  discernment 
of  good  and  evil.  Nevertheless,  in  spite 
of  all  this  apparent  reasonableness,  an 
individual  suffering  from  persecution - 
mania  is  a  lunatic  in  the  strictest  sense  of 
the  word.  Constantly  beset  by  hallucina- 
tions, and  governed  by  the  disorder,  he 
acts  only  under  the  influence  of  morbid 
ideas  which  do  not  allow  him  one  moment's 
personal  liberty.  To  maintain  that  under 
these  circumstances  he  can  be  declared 
responsible  would  be  to  misunderstand 
the  essentials  of  psychiatry,  to  pretend 
that  one  individual  can  be  insane  and 
sane  at  the  same  time,  and  that  although 
he  has  no  longer  his  Uheruin  orhitriiim, 
he  is  in  the  same  position  as  if  he  had  got 
it.  Therefore,  if  an  individual  labouring 
under  delusion  of  suspicion  commits  a 
criminal  act,  he  must  be  exonerated  from 
responsibility,  and  ought  not  to  be  sent  to 
prison,  but  an  asylum. 

The  criminal  actions  committed  by  this 
class  of  patients  are  numerous,  and  vary 
according  to  the  predominating  tendency 
in  every  individual :  calumnies,  libels, 
assaults  ou  any  class  of  society,  and  lastly 
attempts  at  homicide.  We  might  inde- 
finitely extend  the  nomenclature,  but  what- 
ever the  actions  are,  we  are  able  to  find  in 
all  of  them,  contrary  to  appearance,  the 
influence  of  insanity. 

Therefore,  generally  speaking,  indivi- 
duals attacked  by  persecution- mania  are 
from  the  commencement  of  their  malady 
not  res])onsible  for  their  actions. 

From  the  same  standpoint,  they  must 
be   considered    incapable  of   having    the 


Persecution,  Mania  of 


935     J 


Phantasm 


free  disposal  of  their  person  and  property. 
It  sometimes  happens  that  a  patient  makes 
a  will  dejjriving  his  whole  family  and 
relatives  of  their  due,  and  giving  all  he 
possesses  to  strangers,  and  sometimes 
even  to  persons  of  whom  he  has  no  know- 
ledge. He  does  this  to  be  revenged  for 
the  persecutions  of  which  he  believes  him- 
self the  victim  ;  and  full  of  spite  against 
his  natural  heirs  he  will  disinherit  them, 
rejoicing  beforehand  in  the  idea  of  having 
returned  evil  for  evil. 

With  patients  suffering  from  this  mental 
affection,  attempts  made  by  designing 
persons  to  inveigle  them  into  leaving  their 
property  to  them  are  likely  to  be  success- 
ful ;  but,  in  law,  such  bequests  would  be 
annulled. 

We  have  already  mentioned  that,  as  a 
rule,  it  is  necessary  to  confine  this  class  of 
patients  in  an  asylum,  on  account  of  the 
treatment  as  well  as  the  danger  to  public 
order  and  personal  safety.  Once  confined 
in  an  asylum,  the  patient  commences  to 
make  accusations  ;  not  believing  that  he 
is  insane  he  complains  of  being  made  a 
victim  of  arbitrary  sequestration ;  he 
writes  letter  after  letter  to  the  administra- 
tion and  the  authorities,  demanding  his 
release,  and  claiming  damages  against 
those 'who  have  caused  his  confinement. 
It  is  necessary  that  the  authorities  should 
be  instructed  about  the  dangers  which 
may  arise  if  release  is  granted  under  such 
cii'cumstances.  Cases  are  very  numerous 
in  which  patients  have  been  set  at  liberty 
because  the  magistrates  did  not  appreciate 
their  condition,  and  soon  after  they  com- 
mitted the  most  frightful  crimes. 

In  conclusion,  we  may  say  that  by  their 
apparently  reasonable  accusations  and 
complaints,  patients  have  frequently  been 
the  cause  of  making  the  public  believe 
that  the  sequestrations  have  been  arbitrary, 
whilst  impartial  investigation  by  compe- 
tent authorities  has  not  hitherto  been  able 
to  find  one  single  case  of  the  kind. 

ViCTOK  Paraxt. 

{Eeferences.  —  Baillarger,  Des  halluciuatious, 
Paris,  1846.  Ball,  Le9ous  sur  les  maladies 
mentales,  Paris,  1880.  Blanche,  Des  homicides 
commis  par  les  alienes,  Paris,  1878.  Bucknill 
and  Hack  Tnke,  Psychological  Medicine,  Lon- 
don, 1879.  Christian,  Etude  sur  la  melaucolie, 
Paris,  1876.  Clouston,  Mental  Diseases,  London, 
1883.  (.'uOerre,  Traite  pratlciue  des  maladies  men- 
tales,  I'aris,  1889.  Ksquirol,  Des  maladies  men- 
tales,  Paris,  1838.  Falret,  De  revolution  du  delire 
dea  persecutions  ;  Annales  medico-psycliologiques, 
1881.  Foville,  Ach.,  Lypemauie,  dans  le  nouveau 
diet,  de  med.  et  chirurj;'.  vol.  xxi.  ;  Etude  cliuiiiue 
de  la  folic  avec  predominance  du  delire  des  L;rau- 
deurs,  Paris,  1871  ;  Les  alienes  voyageurs  ou 
migrateurs,  Annales  medlco-psychologiques,  1875. 
Laseg-ue,  Du  delire  des  persecutions,  Archives 
g-enerales  de  medecine,  1852.  Legrand  du  SauUe, 
Le  delire  des  persecutions,  Paris,  1871.     ilaynan, 


Formes  et  marche  du  delire  chroniciue,  Lemons 
faites  :i  Ste.  Anne,  1883.  Marandou  de  Montyel, 
De  la  dissimulation  en  alienation  mentale,  Annales 
d'hyKiene  publi(iuc  et  de  medecine  leuale,  1889. 
^lorel,  Traite  des  maladies  mentales.  I'aris,  1859. 
Parant,  Kapiiort  inedico-le;;al  sur  I'etat  mental 
du  sieur  A.,  meurtricr  du  Dr.  JIarcliant,  delire  des 
persecutions,  Annales  medico-iisycli()lo;;i(|ues,  1881: 
La  paralysie  agitantc  examinee  comme  cause  de  la 
folic,  Annales  medico-psycholosi<iues,  1883 ;  La 
Paison  dans  la  I'olie,  Paris,  1888.  I'inel,  Traits 
medico-philosophi(iue  de  I'alienalion  mentale,  Paris, 
1809.  Kenis,  JIanuel  de  medecine  mentale,  Paris, 
1885.  Kitti,  Ddlire  de  persecution,  Dictionnaire 
encyclopediiiue  des  sciences  medicales,  Paris. 
Kouper,  Essai  sur  la  lypenianie  et  le  dt'Iire  des 
persecutions  chez  les  tabetiques,  Lyon,  1881.] 

PERSON-AI.  EQUATZOU.  The  spe- 
cial reaction  time  of  each  individual.  {See 
Reaction'  Time.) 

PERSON-il.I.ZTV,    DISORDERS    OF. 

(See  Doi'BLE  CoxsciovsNEss.) 

PERTURBiLTZOll'  {perturho,  1  dis- 
turb). Excessive  restlessness,  especially 
of  the  mind. 

PERTURB ATZ ONES  ATTZMZ.  Dis- 
turbances of  mind. 

PERVERSZOM-.  —  Alteration  for  the 
worse  in  instincts,  feelings,  habits,  appe- 
tite, or  any  other  previous  characteristic 
of  the  i^atient,  is  a  constant  accompani- 
ment of  insanity.  Perversion  of  some  of 
these  attributes  is,  however,  an  essential 
sign  of  moral  insanity. 

PERVZGIIiZVIVI  {imrv'ujilo,  I  watch 
through).  Disinclination  or  inability  to 
sleep.  Night  watching.  (Fr.  vicjilance ; 
Ger.  die  krankhafte  Schlaflosigkeit.) 

PESSZMZSIVI. — The  making  the  worst 
of  everything,  a  common  mental  condition 
in  hypochondriasis  and  melancholia. 

PETZT  IVIAI..     {See  Epilepsy.) 

PEUR  DES  ESP  ACES.  Agoraphobia. 
{See  Impekative  Ideas.) 

PKAGOIVXAM'ZA  {(paydv,  to  eat ;  fj.avia, 
madness).  A  term  for  a  paroxysmal  and 
uncontrollable  craving  for  food  leading  to 
thefts. 

PHAITTASZA  {(jjavracria,  a  making 
visible).  An  imaginary  representation ; 
phantasy.     (Fr.  phaiiictsie.) 

PHANTASIVI,  PHATfTASlMCA  {(f)av- 
rd^o),  I  make  appear).  A  hallucination  or 
illusion  {q.v.).  The  term  has  been  largely 
applied  to  so-called  apparitions.  The 
authors  of  "  Phantasms  of  the  Living " 
have  excluded  the  alleged  apparitions  of 
the  dead,  and  restricted  their  inquiries  to 
the  apparitions  of  persons  still  living, 
although  on  the  brink  of  physical  dis- 
solution. Auditory,  tactile  or  even  purely 
ideational  and  emotional  impressions  in 
addition  to  visual  phenomena,  are  "in- 
cluded under  the  term  pluDitas'in ;  a  word 
which,  though  etymologically  a  mere  vaid- 
ant  oi  ijhantu)ii,  has  been  less  often  used, 
and  has  not  become  so  closely  identified 


Phantasmagoria 


[    936    ] 


Phrenicula 


with  visual  impressions  alone "  {op.  cU. 
vol.  i.  p.  xxxv).  (Fr.  liliantasme ;  Ger. 
Lvftgebild.) 

PHAKTTASIVXiiGORIA  ((pavraafxa,  a 
phantom  ;  ayw,  1  lead  along).  Term  for 
the  raising  or  recalling  of  spirits  of  the 
dead  as  formerly  supposed  to  be  practised. 
Patients  sometimes  say  they  see  "  phan- 
tasmagoria/' meaning  ghosts  or  spirits  of 
the  dead.    (Fr.  and  Ger. ^ilianiKsmagorie.) 

PHANTi^SMATOIVIORIii  {(f)dvTaafJ.a, 
au  image ;  jjnopla,  folly).  Silliness  or 
childishness,  with  absurd  fancies.  (Fr. 
phantasmaiomoric.) 

PHANTASMOPHREIfOSXS  {(ficw- 

raa-fxa,  an  image  ;  (f)pivcocns,  instruction). 
Schultz  used  this  term  for  dreamy  fancies 
while  in  a  waking  state.  (Fr.  phantas- 
mapliTtniosc.) 

PHANTASIVIOSCOPIA  {(fjiii'Tacrfia,  an 
image ;  a-Koiria),  1  see).  A  seeing  of 
spectres,  ghosts,  or  spirits.  (Fr.  plian- 
ii'.smoscopie  ;  Ger.  Gespejisierselien.) 

PHAM-TASTOir,  PHAUTASTUBl 
{cjiavTacTTos,  conceiving  visions).  Term  for 
a  mental  conception  or  idea. 

PKAITTOIVI  TUMOURS.— In  hysteri- 
cal women  there  occasionally  occurs  a 
rounded  prominence  of  the  abdomen 
which  is  thought  by  them  to  be  due  to 
the  presence  of  a  tumour  or  to  pregnancy. 
It  is  uniformly  smooth,  resonant,  soft, 
and  movable  from  side  to  side.  No  pain, 
tenderness,  or  pressure  symptoms  are  pre- 
sent, and  the  tumour  disappears  entirely 
lender  the  influence  of  au  anaesthetic,  re- 
turning gradually  as  the  patient  regains 
consciousness.  The  cause  is  unknown, 
but  the  condition  has  been  said  (Roberts) 
to  be  probably  due  to  paralysis  of  the  in- 
testines, a  consequence  of  disordered  ner- 
vous influence.  The  treatment  is  that  for 
hj'steria  (q.v.) ;  galvanism  may  be  tried, 
and  the  bowels  should  be  kept  well  open. 

PHANTOIVIA  {(pavTd(cLi.  1  make  visible). 
A  ghostly  appearance.     A  phantom. 

PHARMACOniASTZA  ((pcippaKou,  a 
drug  ;  pavia,  madness).  A  mania  for  tak- 
ing medicines.  Applicable  to  morbid 
craving  for  drugs.  (Fr.  pharniacomanie ; 
Ger.  ArzneiivHth.) 

PHARYNGEAI.  Air.S:STHi:SIA. — 
A  symptom  in  hysteria.  Anaesthesia  of  the 
pharynx  is  so  uncommon,  except  in  hys- 
steria,  that  it  is  a  useful  aid  lu  the  dia- 
gnosis of  that  disease.     (Nee  Hystekia.) 

PHIIi(EM'IA  (0iAeco,  I  love ;  olvos, 
wine).  Addiction  to  wine  or  drink.  (Fr. 
pliHivnie  ;   Ger.  Wtinliehe.) 

PHXIiOAIZniESIA  ((pikew,  I  love; 
fxipTjais,  imitation).  A  love  of  mimicry, 
not  uncommonly  seen  among  the  insane. 
(Fr.  pliilomimesie ;  Ger.  Xachahmungs- 
suclit.) 


PHZliOMZiviETZC. — Of  or  belonging 
to  philomimesia  (q.r.). 

PHZI.OPATRZDAI.CIA  ((/>iXe'co,I  love: 
Trarpi's,  fatherland  ;  aXyos,  pain).  Morbid 
home-sickness.     (See  Nostalgia.) 

PHZI.OPATRZI>OIVXAIirZA  ((f)iXi(o,  I 
love  ;  TTarpis,  one's  country  ;  pLavla,  mad- 
ness). A  craving  for  home  so  intensified 
that  it  has  become  insanity.  It  occurs  in 
young  soldiers  and  sailors  on  foreign  ser- 
vice.    (•S'ee  Nostalgia.) 

PHI.EBOTOMATrZA  (0Xe\/^,  a  vein  : 
Tefivd),  I  cut ;  pavia,  madness).  An  exces- 
sive belief  in  and  rage  for  phlebotomy.  (Fr. 
2)hJehotomanie ;  Ger.  Aderlassiruth) 

PHI.ZIBOTI'ZA  {(pXedoveia,  idle  talk). 
Delirium.     (Fr.  deJire;  Ger.  'WaJinsinn.) 

PHI.ECIMCATZC      TEIVIPERAMEM-T. 

(*S'ee  Temperament.) 

PHOBZA  ((po^os,  fear).  A  termination 
literally  meaning  "  fear  of."  The  com- 
pound word  so  formed  often  has  its 
meaning  much  extended,  as  for  example, 
hydrophobia:  in  other  cases, such  as  agora- 
phobia or  photophobia,  the  literal  mean- 
ing is  the  one  usually  understood. 

PKOBOSZFSZA  (06/3o<r,  fear;  8i\f/a, 
thirst).     A  syuonj'm  of  hydrophobia. 

PHOSPHATURZA  ANH  ZTTSAITZTT. 
■ — It  has  been  observed,  that  in  connection 
with  excess  of  phosphates  in  the  urine, 
hyjiochondriasis,  irritability,  depi'ession  of 
spirits,  and  even  melancholia,  have  oc- 
curred. It  is,  however,  doubtful  what  re- 
lation these  symptoms  bear  to  the  phos- 
phaturia  ;  it  seems  possible  that  the  latter 
is  as  likely  to  be  the  eflect  as  the  cause  of 
the  symptoms.  {See  Urine  of  the  In- 
sane.) 

PHOTOMANZA  {(ficos,  light;  ^lapia, 
madness).  The  inability  in  some  of  the 
insane  to  bear  the  pi'esence  of  light  with- 
out increase  of  symptom.  (Fr.  pliotO' 
Diaiiie.) 

PHOTOPSZA  {(f>o)s,  light ;  o\l/is,  sight). 
A  subjective  sensation  or  appearance  of 
light.     (Fr.  2^^>oiopsie.) 

PHREN'AI.CZA  {<^pi]v,  mind :  «Xyos, 
pain\     A  term  for  melancholia. 

PHRETfES  {(t)pi]v,  the  mind).  Ancient 
term  for  the  priecordium  and  also  for  the 
diaphragm,  each  of  which  has  at  some  time 
been  considered  to  be  the  seat  of  the  mind. 

PHREITESZS  (0/J'';i',  the  mind).  {See 
Phrexitis.) 

PHRENETZC.  Frenzied,  wildly  de- 
lirious. (Fr.  phrenetique;  Ger.  phrene- 
tiscli.) 

PHREN'ZCA.     Mental  diseases. 

PHREM-ZCUX.A,        PHRENXTZCUX.A 

{(j>pi]v,  the  mind).  These  terms  have  been 
used  for  "  brain  fever,"  and  for  acute  hy- 
drocephalus. (Fr. plirenicide;  Ger.  Hirn- 
fieher.) 


Phrenitis 


[    937     ] 


Phthisical  Insanity 


PHRENITIS  (0pr?i',  the  mind).  Liter- 
ally intlammation  of  the  mind ;  it  has 
been  used  tbi-  intlammation  of  the  brain 
and  its  membranes,  and  for  inflammation 
of  the  diaphrai,nn. 

PHRZ:iI-OBX.ABZ:s  {4>pr]v,  the  mind  ; 
/SXaTTTw,  1  damage).  Damaged  or  impaired 
understanding.  (Fr.  'phrenohlabe ;  Ger. 
am  Versiamle  hcschiulitjt.) 

PHRz:n-obi.abia. — A  lesion  of  the 
intellect.     {See  Purexoblabes.) 

phreii-oi.z:psia  erotematica 

{(f)p7]i',  the  mind ;  Xij\/riy,  a  seizing ;  iparrj- 
fiariKQs,  pertaining  to  interrogation). 
Doubting  insanity  {q-v.). 

PHREiroiiOCY  {(^prjv,i\\e  mind  ;  Xdyos, 
a  discourse).  The  study  of  the  faculties 
of  the  human  mind  in  connection  with 
the  so-called  "  organs  "  in  the  brain  asso- 
ciated with  those  faculties.  These  "  or- 
gans "  are  studied  through  the  impres- 
sions they  are  supposed  to  make  on  the 
shape  of  the  cranium.  Gall's  hypothesis. 
(Fr.  phrenologie.) 

PHREiro-i^iAGTirETiSM.— Same  as 
phreno-mesmerism. 

PHRETTO  -  iviesmerisim:. — A  com- 
pound term  applied  to  the  supposed  dis- 
covery that  the  manipulations  practised  in 
mesmerism,  being  directed  to  any  pai'ticular 
phrenological  development  of  the  brain 
could  call  into  action  the  corresponding 
faculty,  sentiment  or  propensity. 

PHRENOM-ARCOSIS  (^p^r,  mind ; 
vcipKoxris,  a  benumbing).  A  benumbing  of 
the  intellect  ;  a  dulling  of  the  senses. 
(Fr.  phrenonarcose ;  Ger.  Plirenonarkose.) 

PHRESrOPATHIA  {(j)pr]v,  the  mind  ; 
Trddos,  disease).  Disease  of  the  mind.  (Fr. 
phrenopathie  ;  Ger.  Gemilthskrankheit.) 

PHREN'OPZ.EGIA  {(Ppr]v,  the  mmd ; 
TrXrjyTj,  a  blow).  A  sudden  failing  or  up- 
setting of  the  mind  ;  fatuity.  (Fr.  phreno- 
plegie ;  Ger.  SeelenUUimnng.) 

PHRENORTHOSIS  {(l)pr]v,  the  mind; 
6p66s,  right).     Kightmindedness. 

PHREM-SV  {'^pi]v,  the  mind).  The 
same  as  phrenitis.  Inflammation  of  the 
brain  and  its  membranes,  and  the  accom- 
panying delirium. 

PHRICASIVXUS  {(f)piKaa-p6s,  a  shudder- 
ing).    Shivering  from  mental  emotion. 

PHROWEIVIOPHOBIA  {<i)p6vrjyia, 
thought  ;  (poliea,  I  fear).  A  dread  or 
hatred  of  thought.  (Fr.  phronemophohie ; 
Ger.  Denksclieu.) 

PHRONTIS  (0poi/eco,lthink).  Thought, 
reflection,  anxiety.  (Fr.  ademonie ;  Ger. 
Sorgc.) 

PHTBISICA  SPES.— The  phthisical 
hope.  It  is  a  characteristic  of  patients 
suffering  from  tuberculous  diseases  (to 
which  the  term  "  phthisis "  is  usually 
applied)  that  they  are  to  the  last  hopeful 


of  cure  and  convinced  they  are  getting  on 
well.     {See  Putuisical  Insanity.) 

PHTHISICAI.     inrSAXiriTY.  —  It  is 

now  commonly  admitted,  as  the  result  of 
the  observations  of  many  keen  observers 
of  the  psychological  condition  of  patients 
suffering  from  certain  bodily  diseases, 
that  the  emotional  and  even  the  intel- 
lectual state  of  such  patients  seems  to  be 
affected  dift'erently  according  to  the  seat 
and  nature  of  the  disease  present.  There 
is,  in  fact,  a  psychology  of  many  diseases 
and  of  the  great  organs  of  the  body. 
Many  of  the  symptoms  are  apt  to  be  ob- 
scure till  looked  for.  A  certain  subtilty 
of  mind  as  well  as  a  trained  observation 
are  required  to  see  them.  Not  every 
physician  of  great  general  diagnostic 
skill  in  cardiac  disease  will  observe  that 
the  patient  is  morbidly  fearful  in  mind, 
or  will  ascertain  that  this  mental  con- 
dition appeared  coincidentally  with  the 
first  symptoms  of  the  heart  troubles, 
or  even  preceded  their  detectable  signs. 
No  doubt  the  glaring  anomaly  of  a  calm 
hopefulness  of  recovery  in  the  minds  of 
multitudes  of  patients  on  the  point  of 
death  from  consumption  could  not  fail  to 
attract  attention.  The  spes  phthisica  was 
an  early  generalisation  in  medical  psycho- 
logy. To  estimate  the  jirecise  mental 
and  emotional  condition  of  their  patients 
would  imply  a  double  series  of  mental  acts 
on  the  part  of  the  physicians  in  attend- 
ance for  bodily  diseases,  that  cannot  fairly 
be  expected  of  many  of  them.  And  we 
must  keep  in  mind  that  the  observation 
of  mental  symptoms  is  not  yet  generally 
taught  or  insisted  on  in  our  medical  curri- 
culum. Yet  the  importance  of  the  pa- 
tient's subjective  condition  is  very  great 
in  regard  to  the  eft'ect  of  treatment  on 
the  objective  symptoms  of  many  diseases. 
Why  do  change  of  scene,  pleasant  society, 
travel,  and  suitable  occupation  often 
"cure"  certain  diseases?  Unquestion- 
ably, in  many  cases,  they  do  so  through 
the  change  they  produce  on  the  patient's 
mental  condition,  and  the  subsequent 
nutritional  improvements.  When  medi- 
cal psychology  is  taught  as  a  part  of  the 
course  of  study  of  every  medical  student, 
we  believe  the  science  will  advance  far 
more  rapidly  than  it  has  hitherto  done  in 
some  directions,  for  we  shall  have  a  hun- 
dred observers  of  mental  symptoms  where 
now  we  have  only  one.  Not  only  are  we 
deficient  in  an  exact  knowledge  of  the 
psychology  of  bodily  disease,  but  we  have 
too  few  facts  as  to  the  precise  mental 
symptoms  present  in  the  deliriums  of  the 
different  febrile  disorders,  and  as  to  the 
exact  differences  between  the  febrile  de- 
lirium of  childhood,  of  adult  life,  and  of 


Phthisical  Insanity  [    938    ]         Phthisical  Insanity- 


old  age.  Such  additions  to  our  psycho- 
logical knowledge  can  only  be  made  by 
the  general  practitioners  of  medicine, 
alter  being  trained  to  observe  mental 
symptoms,  as  a  part  of  the  examination  of 
their  patients. 

Eecent  physiological  and  clinical  inves- 
tigation more  and  more  tends  to  set  up 
the  brain  as  the  great  inhibitor  and 
stimulator  of  all  nutrition,  the  master  of 
the  functions  of  all  other  organs  and 
tissues.  It  influences  strongly  both  the 
blood  formation  and  the  blood  supply. 
AVe  lately  had  a  case  in  which,  when  the 
excessive  brain  energising  of  a  five  years' 
elevated  stage  oifolie  circulaire  suddenly 
ceased,  and  the  low  stage  of  the  disease 
began,  one  effect  was  that  the  blood  lost 
half  its  red  corpuscles,  and  otherwise 
altered  greatly  in  quality  in  a  fortnight. 
This  seemed  to  us  to  be  a  direct  trophic 
effect  of  an  alteration  in  the  brain  state. 
On  the  other  hand,  we  are  coming  more 
practically  to  recognise  that  the  condition 
of  the  nutrition  of  all  the  tissues  and 
organs  affects  the  brain  directly  through 
the  changes  they  produce  in  the  blood, 
and  reliexly  through  their  afferent  nerves. 
We  are  not  surprised  when  an  attack  of 
indigestion  causes  irritability  and  depres- 
sion of  mind,  or  when  impaired  meta- 
bolism results  in  lassitude,  or  when  badly 
working  kidneys  j^roduce  sleeplessness 
with  hallucinations  of  the  senses.  The 
recognition  of  the  action  and  reaction  of 
l^eripheral  organs  and  brain  are  now  parts 
of  our  ordinary  medical  state  of  mind. 
This  clearly  implies  an  intense  reactive- 
ness  of  the  highest  of  the  brain  functions, 
that  of  mind,  to  all  abnormalities  of  func- 
tion and  nutrition  throughout  the  body, 
for  the  mental  centre  is  necessarily  the 
highest  and  the  most  universally  related 
of  all  the  nerve  centres.  We  know  these 
physiological  and  pathological  facts,  but 
we  do  not  always  apply  them  and  endea- 
vour to  extend  them  in  our  daily  work  as 
physicians. 

From  the  time  of  Hippocrates  a  special 
connection  has  been  assumed  to  exist  be- 
tween sluggish  action  of  the  liver  and 
melancholia,  and  modern  physiology  has 
enabled  us  partially  to  realise  the  reason 
of  this.  But  to  the  lungs  and  their  dis- 
eases was  attached  no  special  mental 
symptom.  Two  facts  only  had  attracted 
attention  half  a  century  ago.  One  was 
the  great  frequency  of  phthisis  pulmon- 
alis  among  the  insane  in  asylums.  This 
had  been  noted  by  various  observers  in 
this  country,  France,  and  Germany.  The 
second  fact  was  later  in  being  noticed.  It 
was,  as  expressed  by  MuKinnon  in  1845  : 
"  The  scrofulous  and  insane  constitutions 


are  nearly  allied,"  and  by  Van  der  Kolk  : 
"  Lung  phthisis  especially  appears  to  me 
to  stand  very  frequently  in  close  connec- 
tion with  insanity." 

In  1862-63*  we  made  a  careful  exami- 
nation into  the  connection  of  phthisis  pul- 
monalis  and  tuberculosis  generally  with 
mental  diseases,  both  statistically  and 
clinically,  with  the  result  that  ever  since  it 
has  been  generally  admitted  that  there  are 
important  relationships  between  the  two 
diseases.  The  first  of  these  relationships 
is  the  much  greater  frequency  of  phthisis 
l^ulmonalis  as  a  cause  of  death  among  the 
insane  than  among  the  sane  of  the  same 
age.  Whether  the  assigned  causes  of 
death  among  the  insane  are  taken,  or  the 
frequency  of  tubercular  deposit  in  their 
lungs,  as  found  post  mortem,  the  fact  is 
equally  proved  that  the  insane  are  more 
prone  to  consumption  than  the  sane.  In 
the  older  institutions,  where  the  hygienic 
conditions  were  bad,  the  number  of  deaths 
from  phthisis  was  often  from  25  to 
30  per  cent,  of  the  whole  number  who 
died.  And  when  the  post-mortem  records 
of  those  institutions  were  examined,  from 
30  to  60  per  cent,  showed  signs  of  tuber- 
cular deposit  to  a  greater  or  less  extent. 
The  sanitary  conditions  of  the  modern 
hospitals  for  the  insane  are,  however,  much 
better  than  they  were  fifty  years  ago ;  the 
diet  of  the  patients  is  far  better,  and  the 
clothing  and  warmth  needed  by  those 
suffering  from  insanity  are  also  far 
better  attended  to,  so  that  the  recent 
statistics  of  the  i:)revalence  of  phthisis  are 
far  more  favourable  than  they  used  to  be. 
In  the  Royal  Edinburgh  Asylum  for  the 
Insane,  from  1842  to  1863,  the  percentage 
of  deaths  from  phthisis  on  the  whole 
number  of  deaths  was  29,  while  for  the 
ten  years  from  1879  to  1888  it  was  only 
13.6  per  cent. 

The  true  test  of  the  i^revalence  of 
phthisis  among  the  insane  is  got  by  com- 
paring the  proportion  of  those  who  die 
from  this  cause  in  asylums  with  the  same 
proportion  in  the  general  population  at 
the  same  ages,  that  is,  in  those  over  twenty 
years  of  age.  Accoi-ding  to  Dr.  James,t 
the  very  highest  rate  of  mortality  from 
phthisis  at  any  age  occurs  in  women  from 
twenty-five  to  thirty — viz. ,0.40  per  cent,  of 
those  living  at  that  age.  Now,  in  the 
Royal  Edinburgh  Asylum  in  the  ten  years 
1 879- 1 888,  when  the  phthisis  mortality 
had  been  reduced  to  a  rate  below  the  aver- 
age of  similar  institutions,  it  amounted 
to  1. 19  per  cent,  of  the  average  popula- 
tion of  the  asylum,  the  average  numbers 
being  9.7    deaths  a  year   from   phthisis, 

*  Journal  of  Mental  Science,  April  1863. 

t  "Pulmonary  Phthisis,"  by  Alex.  James,  M.D. 


Phthisical  Insanity 


[     939     ] 


Phthisical  Insanity 


and  the  average  population  8 1 8.1 8.  A 
low  tubercular  mortality  in  an  asylum  is 
tlieret'ore  three  times  the  highest  rate  to 
be  found  at  any  age  in  the  general  popu- 
lation. This  mode  of  ascertaining  the 
prevalence  of  any  disease  is  now  admitted 
by  all  statisticians  to  be  the  true  one,  and 
not  the  percentage  of  deaths  from  any 
disease  out  of  the  whole  number  of  deaths. 
Much  misconception  as  to  the  prevalence 
of  phthisis  among  the  insane  has  arisen 
from  an  ignorance  of  the  proper  mode  of 
estimating  it.  It  is  to  this  ignorance 
alone  that  statements  about  phthisis  not 
being  more  2)revalent  in  good  asylums 
than  in  the  general  population  are  due. 

In  man}'  respects  the  insane  in  well- 
conducted  asylums  are  now  far  better  ofi 
than  many  great  classes  of  our  working 
population.  Their  diet,  their  amuse- 
ments, their  clothing,  are  all  regulated  on 
medical  principles,  and  they  are  not  ex- 
posed to  cold  unduly  in  winter  and 
spring. 

The  fact  that, under  the  most  favourable 
conditions  of  life  and  treatment  that  we 
can  at  present  devise  for  the  insane  in 
the  best  asylums,  three  of  them  die  of 
pulmonary  phthisis  to  one  person  in  the 
general  population  at  the  same  age,  is  one 
full  of  interest  and  significance  to  the 
student  of  brain  function.  When  it  was 
discovered  that  vascular  disease  was  found 
in  an  enormous  proportion  of  all  the  cases 
of  a  certain  kind  of  kidney  disease,  an  im- 
portant light  was  considered  to  have  been 
thrown  on  both  classes  of  disease,  leading 
to  very  practical  results  in  regard  to  our 
conceptions  of  blood  supply,  vascular  ten- 
sion, and  processes  of  excretion.  So  this 
fact  of  the  combination  of  two  such  apjoa- 
rently  dissimilar  diseases  as  insanity  and 
consumption  should  have  attracted  more 
attention  than  it  has  done  to  the  patho- 
logical character  of  both  diseases.  It  is 
certain  that  writers  on  phthisis  have  not 
referred  to  it  as  its  importance  demands. 
If  the  bacillar  theory  of  phthisis  is  true, 
the  general  conditions  within  the  body  and 
outside  it  that  produce  a  suitable  nidus  for 
the  development  of  the  tubercle  bacillus 
must  always  be  of  the  highest  consequence. 
And  here  we  have  something  that  in- 
creases the  fertility  of  the  soil  threefold  for 
the  bacilli.  We  know  that  almost  every- 
thing that  depresses  the  nutrition  tends 
towards  phthisis  if  long  continued.  We 
know  also  that  insanity  has  in  most  cases 
trophic  symptoms.  The  nutrition  of  the 
tissues  is  commonly  depressed,  this  going 
along  with  the  mental  phenomena  as  an 
essential  part  of  the  morbid  process.  ISTo 
such  trophic  symptom  could  be  of  more  im- 
portance than  this  general  reduction  of  the 


bodies  of  the  insane  to  that  state  in  which 
they  form  fertile  seed-beds  for  the  tubercle 
bacillus.  The  resistiveness  of  the  healthy 
body  against  this  the  most  destructive  of 
all  the  enemies  of  longevity  is  evidently 
reduced  enormously  by  the  mental  disease. 
We  have  for  many  years  preached  the 
"gospel  of  fatness  "  in  the  treatment  of 
insanity.  No  better  proof  exists  of  the 
grounds  on  which  this  "gospel "  is  based 
than  the  fact  that  thereby  we  also  fight 
against  consumption,  the  twin  sister  and 
the  common  sequel  of  insanity.  The  fre- 
quency of  phthisis  in  chronic  insanity  is 
the  strongest  proof  that  mental  disease 
has  marked  trophic  symptoms.  The  fre- 
quent association  of  the  depraved  nutri- 
tion known  as  scrofula  with  idiocy  and 
congenital  imbecility  has  long  been  known. 
Ireland  says  :  *  "  perhaps  two-thirds  or 
even  more  are  of  the  scrofulous  constitu- 
tion." Idiots  and  congenital  imbeciles 
are  very  often  of  the  strumous  diathesis, 
having  weak  circulation,  a  low  tempera- 
ture, a  pale  complexion,  bad  and  badly 
set  teeth,  the  glandular  and  mucous 
structures  being  especially  liable  to  dis- 
ease. The  likeness  of  idiocy  and  secondary 
dementia  to  each  other  trophically  is  in 
many  ways  marked,  and  therefore  it  is 
not  matter  of  surprise  that  so  many  pa- 
tients suffering  from  both  states  fall  into 
consumption  and  die.  Ireland  says  that 
"  fully  two-thirds  of  all  idiots  die  of 
phthisis.  It  may  be  asked,  is  idiocy  it- 
self not  another  though  a  rarer  manifes- 
tation of  this  diathesis  ?  " 

The  hereditary  relationship  of  insanity 
and  phthisis  was  observed  by  Van  der 
Kolk,t  who  says :  "  It  is  remarkable 
when  in  the  very  same  family  some  of  the 
children  suffer  from  mania  or  melancholia, 
and  the  brothers  and  sisters  who  have  re- 
mained free  from  these  diseases  die  of 
phthisis."  This  we  have  observed  so 
many  times  that  we  cannot  regard  it  as  a 
mere  accident.  Our  experience  and  con- 
clusions on  this  point  are  precisely  those 
of  Van  der  Kolk,  and  GuislainJ  says: 
"  Pulmonary  tuberculosis  ajDpears  to  me 
to  be  in  direct  relationship  with  insanity  ; 
it  is  frequently  seen  in  the  descendants  of 
the  insane  and  in  their  progenitors." 
Dr.  James  quotes  Thompson  as  showing 
that  as  to  heredity  the  two  diseases  are 
similar  in  the  following  respects — viz. ; 
(i)  Transmission  is  from  either  parent; 
(2)  The  disease  may  appear  in  the  child 

*  "  Idiocy  and  Imbecility,"  by  W.  W.  Ireland, 
M.D. 

t  "Mental  Diseases,"  by  J.  L.  C.  Seliroedor  Van 
der  Kolk.     Translated  by  Rudall. 

t  "Le9onsorales8urles  Phrenopathies,"  Guislain, 
2nd  ed.  by  Ingels. 


Phthisical  Insanity 


[    940    ] 


Phthisical  Insanity 


before    it    is    developed    in   the  parent; 
(3)  The   disease  may  be  transmitted  by 
the    parent    without    development ;     (4) 
Atavism  is  a  frequent  and  important  cha- 
racteristic.     He  might  have  added  that 
the   age   at  which   the  two   diseases  are 
most   commonly  developed  is  somewhat 
the  same.     They  both  appear  first  to  any 
marked  extent  at  adolescence,  they  attack 
full  maturity  and  middle  life  freely,  and 
they  both  tend  to  decline  in  old  age.    The 
tendency  to  insanity  is  strongest  in  the 
male  sex  from  thirty  to  thirty-five,  while 
consumption  attacks  its  victims  in  that  sex 
in  greatest  numbers  from  twenty-five  to 
thirty-five.     In  the  female  sex  insanity  is 
later  in  reaching  its  acme,  being  at  the  age 
of  from  fifty  to  fifty-five,  while  consump- 
tion plays  greatest  havoc  in  that  sex  from 
twenty-five  to  forty.*  In  our  investigations 
we  found  that  a  hereditary  predisposition 
to  insanity  was  yi  jier  cent,  more  common 
in  those  patients  who  had  died  of  con- 
sumption than  among  the  inmates  of  the 
asylum  generally.     This  seems  to  indicate 
that  a  strong  neurotic  heredity  not  only 
produces  insanity,  but  that,  after  having 
thus  tended  to  mental  death,  such  a  here- 
dity leads  also  to  bodily  death  by  con- 
sumption.    We  have  not  been  able  to  get 
statistics  showing  the  hereditary  relation- 
ships of  the  two  diseases,  but  we  constantly 
meet   with   families  where  both  diseases 
exist.     We  lately  had  two  insane  patients, 
brother  and  .sister,  whose  mother  had  been 
insane,  and  in  whose  father's  family  con- 
sumption  had   been  prevalent,  and  who 
had  had  two  sane  sisters   die  of  phthisis. 
Few  practitioners  but  have  met  with  many 
similar  cases.     It  is  our  impression  that 
a  simple   phthisical    heredity    is    not  so 
dangerous  in  leading  to  insanity,  as  an 
heredity   to    insanity    is    in    leading    to 
phthisis.     Where  both  diseases  have  ap- 
peared in  the  ancestry,  we  believe  that 
the  risk  to  the  descendants  from  both  dis- 
eases is  greater  than  the  same  amount  of 
hereditary  taint   of  phthisis   or  insanity 
singly   would    have    produced.      For  ex- 
ample, if  we  have  a  couple  marrying,  the 
husband's  mother  having  been  insane,  and 
the   wife's   father  phthisical,    we   believe 
that  the  children  would  run  a  greater  risk 
of  both  phthisis  and  insanity  than  if  those 
grandparents  had  been  both  consumptive 
or  both  insane. 

The  most  important  questions  to  the 
psychiatric  physician  in  regard  to  the  re- 
lationship of  insanit}^  and  phthisis  are : 
Which  is  first  commonly  seen  as  an 
actuality  in  the  cases  where  both  are  ulti- 

*  James  on  "Phthisis,"  and  the  30th  Report 
(for  1888;  of  the  Commissioners  in  Lunacy  for 
Scotland. 


mately  combined  ?  Is  the  relationship  of 
the  primary  disease  to  the  secondary 
causal  .P  Does  the  one  influence  the 
symptoms  and  course  of  the  other  ?  And, 
if  so,  how  ?  Is  there  any  form  of  phthisis 
that  can  be  called  that  of  insanity  ?  Is 
there  any  form  of  insanity  that  can  be 
called  phthisical?  If  so,  what  are  the 
special  symptoms  of  the  insanity  ?  and  of 
the  phthisis  so  tinctured  ? 

It  is  certain  we  cannot  as  yet  answer  all 
these  queries  satisfactorily.  But  the  sta- 
tistical and  clinical  observations  we  made 
in  1863,  as  well  as  our  subsequent  experi- 
ence, do  enable  us  to  answer  some  of  them. 
There  can  be  no  doubt  that  taking  all  the 
cases  of  insanity  that  fall  into  phthisis, 
in  the  majority  of  them  the  mental  dis- 
ease appeared  first.  We  found  that  of  282 
insane  patients,  who  died  tubercular, 
about  one-third  only  died  within  two 
years  after  the  insanity  had  first  appeared. 
As  the  average  duration  of  pulmonary 
consumption  in  the  cases  in  whom  it  was 
the  cause  of  death  was  found  by  Ancell  to 
be  about  eighteen  months,  it  is  clear  that 
in  two-thirds  of  the  cases  at  least,  the 
mental  symptoms  preceded  the  pulmon- 
ary. But  then  in  some  of  the  cases  the 
phthisis  preceded  the  insanity,  and  we 
found  that  66  out  of  the  282,  or  23^  per 
cent.,  died  within  a  year  after  becoming 
insane.  This  proportion  of  cases  in  which 
the  two  diseases  had  arisen  so  very  nearly 
together  is  far  too  large  to  be  accidental. 
The  predisposing  cause  of  both  we  ascer- 
tained in  many  of  the  individual  cases,  to 
be  a  heredity  to  both  insanity  and 
phthisis. 

All  recent  investigation  points  to  the 
fact  that  every  severe  disturbance  of  brain 
function  of  whatever  kind  is  accompanied 
by  lowering  or  disturbance  of  its  trophic 
energising,  and  that  such  troj^hic  lowering 
means  sooner  or  later  functional  or  struc- 
tural change  in  the  peripheral  organs  and 
tissues  of  the  body.  The  fact  that,  out  of 
the  three-fourths  of  the  cases  in  which  the 
insanity  pi-eceded  the  phthisis  by  more 
than  a  year,  7.5  per  cent,  were  cases  of 
secondary  dementia,  shows  clearly  that  it 
is  the  ti'ophically  lowest  and  terminal 
variety  of  insanity,  the  true  "  mental 
death,"  that  leads  most  to  consumption. 

The  next  question  as  to  whether  the 
one  disease  infiuences  the  other,  apart 
from  causation,  and  how  this  influence 
takes  effect,  can  chiefly  be  determined  by 
clinical  observation.  First,  as  to  how  the 
insanity  influences  the  jihthisis.  The 
most  common  effect  is  this,  that  the  sub- 
jective and  many  of  the  objective  symp- 
toms of  the  disease  are  abolished.  The 
disease   is  frequently  rendered  latent,  in 


Phthisical  Insanity 


[    941     ] 


Phthisical  Insanity 


fact,  as  regards  cough,  pain,  conscious 
weakness,  and  discomfort.  It  is  this 
eftect,  being  a  very  striking  one,  that  has 
given  rise,  even  among  careful  observers, 
to  the  idea  that  an  acute  attack  of  in- 
sanity benefits  the  phthisis.  Guislain  even 
thought  that  there  was  an  "  antagonism  " 
sometimes  between  the  two,  and  Grie- 
singer  says  that  "  even  the  nutrition 
slightly  improves  in  certain  cases  on  the 
outbreak  of  the  mental  disease."  Our  ex- 
perience is  that  the  facts  that  seem  to 
point  in  this  direction  are  fallacies.  If 
we  take  the  three  tests  of  careful  physical 
examination  of  the  patient's  lungs,  his 
evening  temperature,  and  his  body  weight, 
we  have  never  known  any  phthisical  case 
really  improve  on  the  outbreak  of  insanity. 
No  doubt,  if  the  mental  attack  is  one 
of  maniacal  exaltation,  the  patient  will 
entirely  cease  to  complain  of  any  symptom 
of  his  chest  disease ;  he  will  say  he  is  cured, 
he  will  take  exercise,  and  run  and  leap,  he 
will  no  doubt  eat  more  food,  but  he  will  lose 
in  weight,  and  his  lungs  will  not  heal.  That 
there  may  be  a  tendency  to  a  temporary 
arrest  of  the  morbid  process  in  the  lungs, 
we  are  not  prepared  absolutely  to  deny. 
Nature  often  seems  unable  to  carry  on 
two  active  pathological  processes  in  differ- 
ent organs  simultaneously  in  their  full 
activity. 

It  is  certain  that  the  tubercular  deposi- 
tion is  often  very  localised  at  first  in  the 
lungs  of  the  insane,  that  it  is  lobular,  and 
that  it  is  at  first  often  very  difficult  of  de- 
tection by  auscultation.  The  absence  of 
wearing  cough,  of  pain,  of  any  subjective 
sense  of  illness  must  save  the  patient 
from  the  exhaustion  which  those  symp- 
toms cause.  In  addition  to  the  signs  that 
can  be  got  by  examination  of  the  chest, 
we  trust  for  the  early  detection  of  the 
disease  in  many  cases  also  to  the  facial 
expression  of  the  patients,  to  their  losing 
weight,  to  their  diminished  appetite,  to 
observing  little  clearings  of  the  throat  as 
a  baby  does,  and  to  small  rises  of  the 
evening  temperature. 

We  do  not  think  there  is  any  special 
variety  of  phthisis  that  prevails  among 
the  insane.  The  "fibroid"  variety  is 
certainly  rare.  Though  many  insane 
patients  live  for  many  years  after  they 
have  become  phthisical,  yet  we  believe  the 
dui-ation  of  the  disease  from  its  com- 
mencement till  the  death  of  the  patient 
is  much  less  on  the  average  among  the 
demented  class  when  it  is  distinctly 
secondary  to  the  insanity  than  among  the 
sane.  Such  patients  go  down  very  fast 
at  the  last.  We  have  seen  many  of  them 
walking  out  and  uncomplainingly  at  work 
in.  the  garden  one  week  and  die  the  next 


without  any  acute  inflammatory  attack 
at  the  end. 

The  low  innervation  of  the  lungs  in 
such  cases  is  seen  in  an  extreme  degree 
when  gangrene  of  the  lungs  takes  place 
at  the  last,  though  this  is  more  common 
in  the  cases  of  melancholia  with  refusal  of 
food,  where  the  phthisis  is  not  a  sequel  to 
the  insanity,  but  almost  contemporaneous 
with  it  in  first  appearance. 

As  to  the  effect  of  phthisis  on  the 
mental  disease  we  have  more  evidence. 
Griesinger  said  in  1845  :*  "  It  has  not  been 
proved  that  the  insanity  which  is  accom- 
panied by  or  developed  from  tuberculosis 
presents  any  peculiar  character."  In  this 
ojsinion  he  was,  we  are  convinced,  quite 
wrong,  acute  clinical  observer  though  he 
was. 

The  observations  of  some  of  the  older 
authors  were  more  correct.  They  had 
distinct  inklings  of  the  true  facts  of  the 
case.  When  Laycock  ascribed  to  this  in- 
sanity "  a  certain  capriciousness,  a  whim- 
sical fluctuation  between  extremes,"  and 
when  Neumann  noted  "  self-absorption, 
great  irritability  and  morosity,  and  ten- 
dency to  swear,"  when  Morelf  directed 
the  attention  of  physicians  in  charge  of 
phthisical  patients  to  the  "  nervous  states 
complicated  with  depression,  morosity, 
and  eccentricities  of  character  "  they  were 
likely  to  meet  with,  it  is  clear  that  many 
of  the  clinical  facts  of  "  j^hthisical  in- 
sanity "  had  been  observed  before  it  was 
segregated  as  a  distinct  form  of  mental 
disease,  or  got  a  name. 

Many  years'  careful  study  of  this  sub- 
ject, from  a  clinical  point  of  view,  have 
led  us  to  the  conclusion  that  there  are  two 
entirely  distinct  ways  in  which  the  mental 
disturbances  stand  related  to  phthisis. 
The  one  is  where  the  insanity  has  arisen  at 
first  quite  independently  of  any  phthisical 
cause  or  relationship,  and  run  an  ordinary 
course  usually  into  dementia  or  chronic 
melancholia,  and  then  after  many  years  the 
patients  fall  into  phthisis  and  die  of  it. 

In  such  cases  physiological  and  patho- 
logical considerations  relating  to  the 
general  solidarity  of  brain  function,  and 
the  way  in  which  the  trophic  energising 
tends  to  become  lowered  with  the  lower- 
ing of  the  rest  of  the  brain  functions, 
especially  with  the  mental — all  point  to 
the  insanity  as  a  direct  causative  influ- 
ence. One  fact  is  very  suggestive — in 
dementia  we  found  the  average  tempera- 
ture to  be  lower  than  in  an}'  other  form 
of  insanity — -viz.,  96.98,  J  and  most  of  the 

*  Op.  cit.  p.  193. 

t  "  Traitd  des  Mahalies  Meutales,"  Morel. 
X  Journal  of  Mental  Sckncr,  1868, "  Observations 
on  the  Temperature  of  the  Body  in  the  Insane." 


Phthisical  Insanity         [    942    ]  Phthisical  Insanity- 


chronic  cases  of  insanity  who  die  of 
phthisis  are,  as  we  have  seen,  dements. 
In  this  class  of  cases  the  phthisis,  when 
it  comes  on,  has  commonly  the  following 
effect.  In  the  early  stage  the  patients 
are  more  demented,  more  sluggish,  have 
less  inclination  for  food,  and  tend  to 
become  more  dirty  in  habits,  and  less 
inclined  or  able  to  employ  themselves.  In 
fact  the  mental  symptoms  of  their  de- 
mentia become  aggravated.  Then  when 
the  temperature  begins  to  rise,  such  pa- 
tients will  often  waken  up  somewhat.  They 
will  become  more  talkative,  even  more 
reasonable,  much  more  irritable,  more 
suspicious,  and  in  a  few  cases  just  before 
death,  will  seem  to  become  intelligent  and 
sane.  All  this  more  active  mental  energis- 
ing seems  to  be  due  to  the  higher  tempera- 
ture of  the  brain,  and  to  the  effects  of 
more  blood  circulating  through  it.  We 
have  no  doubt  that  it  was  these  mental 
symptoms — simulating  improvement  as 
they  do  —  that  led  some  of  the  older 
authors  to  attribute  a  really  curative 
effect  on  the  insanity  to  the  lung  disease 
in  some  cases.  The  amount  of  intelli- 
gence that  some  patients,  apparently  for 
years  "  demented,"  will  thus  exhibit 
under  the  influence  of  the  elevated  tem- 
perature of  phthisis,  would  suggest  that 
there  had  been  no  great  cell  atrophy  and 
no  extensive  degenerative  changes  in  the 
cells  of  the  cortex,  but  rather  a  trophic 
lowering  and  an  asthenic  energising, 
which  had  caused  the  mental  symj^toms 
of  the  dementia.  It  may  be  the  dementia 
in  such  cases  is  more  allied  to  stupor  than 
true  secondary  dementia. 

Another  suggestive  fact  is  that  in  asy- 
lums cases  of  epilepsy  with  insanity  die  of 
phthisis  in  a  proportion  greater  than 
most  other  forms  of  insanity.  Van  der 
Kolk  attributed  this  to  the  direct  influ- 
ence of  the  pneumogastric  nerve  whose 
centres  are  in  the  medulla,  and  which  he 
believed  to  be  specially  affected  in  epi- 
lepsy, the  pathological  seat  of  which  he 
placed  there.  We  think  a  far  more  reason- 
able hypothesis  as  to  the  cause  of  the  fre- 
quency of  phthisis  in  old  epileptics  and 
congenital  epileptics  is  that  the  disease 
causes  a  deep  form  of  dementia,  in  which 
the  general  trophic  condition  is  lowered, 
and  that  after  each  fit  we  have  conges- 
tion of  the  lungs  from  impeded  respira- 
tion, one  effect  of  this  being  that  the 
lungs  become  a  more  ready  seat  of  the 
tubercle  bacillus.  The  most  complete 
forms  of  secondary  dementia  that  exist 
are  those  occurring  in  the  cases  of  adoles- 
cent insanity  that  do  not  recover,  and  in 
epileptic  insanity.  Both  yield  phthisis  in 
the  highest  degree. 


The  other  way  in  which  the  two  diseases 
are  related  is  much  the  more  interesting, 
and  by  far  the  most  important.  It  is 
where  they  arise  either  simultaneously, 
or  within  a  year  or  two  or  three  of  each 
other,  when  there  is  usually  a  heredity 
to  phthisis  or  to  innutrition  as  well  as  to 
insanity,  or  to  some  of  the  graver 
neuroses,  and  when,  above  all,  there  is 
a  series  of  mental  symptoms  present  that 
constitutes,  in  our  opinion,  a  distinct 
clinical  form  of  insanity,  to  which  we 
gave  the  name  of  "  Phthisical  Insanity  " 
in  1863.  In  such  cases  the  astiology  of 
the  mental  disease,  and  its  clinical  cha- 
racters, its  duration,  and  its  termination, 
are  all  connected  with  the  accompanying 
phthisis  or  the  tubercular  diathesis  of 
the  patient.  The  best  of  the  most  re- 
cent authors  on  mental  diseases,  Spitzka 
in  America,  Ball  in  France,  Krafft-Ebing 
in  Germany,  and  Maudsley,  Blandford, 
Bucknill  and  Tuke,  and  Savage  in  this 
country,  all  recognise  phthisical  insanity 
as  a  true  clinical  vai'iety  of  the  disease. 
Ball,  after  quoting  our  general  descrip- 
tion of  the  disease,  says  "  that  descrip- 
tion is  without  doubt  exact  in  a  great 
number  of  cases."*  Savage  sums  up  his 
chapter  on  the  subject  in  these  words : 
"  Phthisis  in  the  insane  is  associated  with 
certain  groups  of  symptoms  characterised 
by  suspicion  and  refusal  of  food  on  the 
one  hand,  and  with  masking  of  the 
phthisical  symptoms  on  the  other."t 

Before  describing  the  special  features 
of  this  form  of  insanity,  it  is  necessary  to 
say  that  there  is  a  certain  general  like- 
ness of  some  of  the  symptoms  in  every 
kind  of  insanity  that  is  accompanied  or 
caused  by  an  anasmic  brain.  We  all 
know  that  where  we  have,  for  instance, 
an  attack  of  simple  melancholia  result- 
ing from  slow  starvation,  the  first  symp- 
tom is  usually  morbid  susjDicion.  So 
with  another  essentially  antemic  insanity, 
that  of  over-lactation.  Now,  as  we  shall 
see,  morbid  suspicions  form  one  of  the 
marked  symptoms  of  phthisical  insanity. 
But  in  that  disease  we  have  something 
far  more  than  that  one  symptom.  We 
have  a  group  of  symptoms,  mental  and 
bodily,  in  a  certain  sequence,  and  the 
whole  case  standing  out  clinically  as 
following  a  certain  course.  No  descriptive 
picture  of  any  disease  can,  however,  apply 
to  all  the  cases.  Nature  does  not  so  uni- 
form herself.  We  therefore  cannot  differ 
from  Ball  when  he  says  that  our  clinical 
picture  of  a  typical  case  does  not  abso- 
lutely cover  the  whole  ground.     Our  sub- 


Ball. 


"  Le9ons  sur  les  Maladies  Meutales,"  par  B. 


t  "  Insauity,"  by  George  H.  Savage,  M.D. 


Phthisical  Insanity 


[     943     ] 


Phthisical  Insanity 


sequent  clinical  experience  of  twenty-six 
yeai's,  tends  stroni^ly  to  confirm  our 
original  couclusion  in  1863  that  phthisical 
insanity  differs  from  the  oi'dinary  amumic 
or  diathetic  insanity.  It  does  not  arise 
in  asylums  from  their  hygienic  defects.  It 
arises  commonly  from  a  combined  here- 
dity towards  insanity  and  phthisis,  or 
when  heredity  insanity  arises  in  a  subject 
whose  trophic  energy  is  low.  It  is  met 
with,  not  in  the  cases  where  long-con- 
tinued insanity  or  the  bad  conditions  of 
life  in  asylums  could  have  produced  it, 
but  in  the  newly  occurring  cases.  It  is 
capable  of  diagnosis  at  once,  or  within 
the  first  year  commonly. 

The  general  characters  of  phthisical  in- 
sanity are  such  as  might  be  expected  to  be 
found  in  j^ersons  of  weak  vitality.  If 
classitiedfrom  the  mental  symptoms  alone, 
some  of  the  cases  would  be  called  mania, 
of  the  asthenic  mildly  delusional  type, 
more  of  them  monomania  of  suspicion  or 
unseen  agency,  and  some  of  them  melan- 
cholia, also  of  the  mildly  delusional  kind. 
A  few  of  them  have  an  element  of  mental 
stupor,  and  the  wrongly  named  acute 
dementia.  It  is  a  remarkable  fact  that 
most  cases  of  monomania  of  susjiicion 
sooner  or  later  die  of  phthisis.  The 
symptoms  of  a  morbid  mental  suspicion 
run  through  nearly  all  the  cases  of 
phthisical  insanity.  Sometimes,  but  not 
commonly,  they  have  an  acute  stage  at 
first,  but  this  is  short  and  not  very  intense. 
Most  frequently  the  disease  begins  by  a 
gradual  alteration  of  disposition,  conduct, 
and  feeling  in  the  direction  of  morbid 
suspicion,  of  irritability,  of  moroseness, 
and  of  unsociability.  The  social  instincts 
and  the  keen  enjoyments  that  arise  there- 
from are  lessened  in  intensity  or  gone. 
There  is  often  a  morbid  fickleness  of  pur- 
pose, a  want  of  buoyancy  and  enjoyment 
of  life,  a  depi-ession  of  spirits,  and  some- 
times senseless,  and  to  the  patient  himself 
causeless,  and  unaccountable  dislikes. 
Sometimes  there  is  a  lassitude  and.  utter 
incapacity  for  exertion.  There  is  in  young 
women  a  waywardness  and  perversion  of 
feeling  that  simulates  hysterics.  Often  in 
bad  cases  there  are  delusions  as  to  the 
food  being  poisoned.  With  these  symp- 
toms of  lowered  brain  vitality  and  force, 
there  are  in  some  of  the  cases  fitful  gleams 
of  high  spirits,  of  happiness,  and  spurts 
of  unsustained  energy.  Both  the  low  un- 
social and  the  high  energetic  phases  are 
apt  to  be  accompanied  by  an  intellectual 
condition,  characterised  by  want  of  sus- 
tained reasoning,  by  a  changeable  voli- 
tional state,  and  by  a  lack  of  common 
sense  in  the  conduct  of  life. 

The  early  bodily  symptoms   are  com- 


monly a  loss  of  weight,  a  diminished 
appetite,  a  pigmented  dirty-looking  skin, 
indigestion,  often  perverted  taste  in  regard 
to  food,  which  no  doubt  suggests  the  de- 
lusions of  poisoning.  There  is  sleepless- 
ness, incapacity  for  continued  muscular 
exertion  of  all  sorts.  The  temperature  is 
low,  the  extremities  especially  cold.  Com- 
monly there  are  no  pulmonary  symptoms 
detectable  at  this  early  stage. 

The  next  stage  is  one  of  actual  maniacal 
excitement  or  melancholic  depression,  or 
openly  expressed  insane  suspicion,  or  some 
act  of  mild  violence.  If  the  patient  is 
melancholic, the  symptom  speciallynoticed 
by  Savage — viz.,  refusal  of  food — is  very 
common.  Sometimes,  on  the  contrary,  if 
maniacal,  the  extra  muscular  exertion  im- 
j^roves  the  appetite,  and  makes  the  patient 
look  better.  In  this  stage  asylum  treat- 
ment becomes  necessary,  and  the  phthisi- 
cal insane  are  especially  apt  to  resent  this 
and  to  denounce  their  friends  for  having 
placed  them  in  asylums.  But  up  to  this 
time  many  of  the  cases  are  curable,  and 
proper  treatment,  of  the  hygienic,  dietetic 
and  open-air  kind,  is  frequently  followed 
by  at  least  temporary  recovery.  If  our 
studies  and  conclusions  in  regard  to 
phthisical  insanity  have  done  nothing 
else,  they  have  made  us  give  patients  in 
the  state  we  have  described  the  benefit  of 
much  milk,  many  eggs,  cod-liver  oil  and 
maltine,  the  hypophosphites,  quinine, 
extra  warm  clothing,  an  extra  amount  of 
fresh  air,  the  airiest  bedrooms,  hospital 
treatment  generally,  and  all  the  mental 
and  moral  influences  that  can  be  brought 
to  bear  on  him  for  the  diversion  of  his 
mind  from  his  suspicions  into  healthy 
channels,  our  own  mind  being  hopeful 
of  cure  from  our  experience  of  other 
cases.  If  chest  symptoms  have  actually 
appeared,  the  usual  local  treatment  is 
required  in  addition.  The  result  of  such 
treatment  at  this  early  stage  is  that 
over  30  per  cent,  of  the  cases  may  re- 
cover at  least  for  a  time  :  and  this  per- 
centage is  an  increasing  one,  as  such  cases 
are  diagnosed  early.  Both  the  morbid 
mental  condition  and  the  phthisis  are  in 
some  cases  recovered  from,  the  patient 
gains  weight,  becomes  cheerful  and  soci- 
able again,  and  gets  rid  of  his  suspicions. 
But  in  the  cases  who  do  not  recover,  all 
the  symptoms  we  have  described  persist, 
except  that  the  initial  maniacal  excitement 
or  melancholic  refusal  of  food  passes  off, 
and  the  patient  has  a  period  of  months  or 
years  during  which  he  is  a  typical  phthisi- 
cal mental  case.  He  makes  no  friends  in 
the  asylum,  he  is  moody,  discontented, 
suspicious,  commonly,  though  not  always, 
idle,  with  a  capricious  apj^etite.     He  has 


Phthisical  Insanity 


[     944     ] 


Phthisical  Insanity- 


slight  spurts  of  maniacal  excitement,  or 
sometimes  periods  of  stupor.  His  brain 
behaves  like  a  lamp  ill-supplied  with  oil, 
giving  a  fitful  light.  If  you  examine  the 
chest  during  this  time,  you  find  either  no 
active  lung  symptoms  at  all,  or  only  evi- 
dence of  slight  and  non-progressive  lesions. 

In  the  cases  where  this  state  lasts  for 
several  years,  the  patient,  when  the  disease 
has  not  assumed  the  form  of  monomania 
of  suspicion,  gets  partially  demented,  but 
is  not  so  enfeebled  in  mind  as  he  looks. 
The  state  of  utter  mindlessness  seen  in 
typical  secondary  dementia  following 
adolescent  insanity  does  not  commonly 
supervene.  The  patients  can  be  roused 
into  wonderful  exhibitions  of  intelligence 
for  short  periods.  The  adolescent  cases 
are  most  apt  to  exhibit  the  deepest  de- 
mentia :  the  cases  over  thirty  commonly 
tend  to  monomania  of  suspicion. 

In  the  majority  of  the  cases  of  phthi- 
sical insanity  we  have  distinct  physical 
signs  of  phthisis  within  two  years  after 
the  mental  symptoms  have  appeared. 
There  can  be  no  doubt  that  in  by  far  the 
majority  of  the  cases  the  insanity  pre- 
cedes the  detectaole  signs  of  lung  disease. 
But  that  the  "  pre-tubercular  stage  of 
phthisis "  is  as  real  a  part  of  the  dis- 
ease in  some  cases  as  the  tubercular,  few 
physicians  of  experience  can  doubt.  The 
tro^Dhic  failure  that  leads  to  the  formation 
of  the  right  nidus,  without  which  the 
tubercle  bacillus  would  be  perfectly  harm- 
less, must  be  held  to  be  as  important  a 
stage  in  the  disease  as  the  local  lung  de- 
struction. In  a  few  cases  five  years  elapsed 
between  our  diagnosis  of  "  phthisical  in- 
sanity "  and  the  appearance  of  the  symp- 
toms of  tuberculisation.  In  about  5  per 
cent,  of  those  who  died  of  consumption  in 
the  Royal  Edinburgh  Asylum,  the  lung 
affection  distinctly  preceded  the  mental 
symptoms,  for  it  was  diagnosed  on  admis- 
sion. In  a  few  of  those  cases  the  insanity 
consisted  of  a  transitory  delirium  that 
soon  passed  off. 

We  know  no  better  proof  that  the  men- 
tal symptoms  in  insanity  may  be  influ- 
enced by  lung  tuberculosis  than  the  fact 
which  we  ascertained  statistically,  that 
general  paralysis,  so  commonly  charac- 
terised by  morbid  exaltation,  delusions  of 
grandeur,  ambitious  delirium,  happy 
facility,  and  an  exaggerated  sense  of  bien 
etre,  is  apt  to  be  attended  by  melancholic 
symptoms,  morbid  fears,  and  refusal  of 
food,  when  its  subjects  also  suffer  from 
pulmonary  consumption.  We  found  that 
in  most  of  the  27  general  paralytics, 
whose  lungs  were  found  tubercular  out 
of  92  in  all,  the  mental  symptoms  had 
begun  by  depression,  or  had  been  those 


of  depression  throughout.  The  few 
suicidal  general  paralytics  were  nearly  all 
tubei'cular.  We  have  repeatedly  been  led 
to  suspect  lung  disease  in  our  general 
paralytic  patients,  when  we  found  them 
beginning  to  be  melancholic,  or  stuporous, 
and  to  refuse  food,  and  we  have  often  had 
our  suspicions  confirmed  by  an  examina- 
tion of  their  lungs,  and  by  finding  phthi- 
sis, bronchitis,  or  pneumonia. 

In  order  to  rest  this  connection  of  in- 
sanity and  phthisis  on  a  statistical  basis, 
so  far  as  this  is  possible,  we  have  gone 
carefully  through  the  case-books  of  the 
Eoyal  Edinburgh  Asylum  for  the  past 
fourteen  years — -1874  to  1888  inclnsive. 
There  have  been  1031  deaths  in  that  time, 
of  which  140  were  from  phthisis.  This  is  a 
percentage  of  13.6,  or  one  in  seven  deaths. 
During  these  fourteen  years,  out  of  the 
4891  admissions,  134  were  diagnosed 
within  the  first  twelve  months  of  resi- 
dence as  being  cases  of  "  phthisical  in- 
sanity "  in  the  case-books.  This  is  a  pro- 
portion of  2.7  per  cent.,  or  one  in  every 
thirty-seven  patients.  It  was  by  no 
means  those  134  phthisically  insane  pa- 
tients, however,  who  furnished  the  ma- 
jority of  the  140  who  died  of  phthisis. 
They  only  furnished  30  of  the  140,  or 
about  21.5  per  cent,  of  the  mortality  for 
that  disease.  Of  the  134  phthisically  in- 
sane, there  have,  up  to  this  time,  died 
22.4  per  cent,  of  phthisis.  But  49  of 
the  134  have  been  removed  from  the 
asylum,  some  of  them  in  the  last  stages 
of  jDhthisis  to  die  at  home,  or  by  transfer 
to  other  asylums,  so  that  it  would  be  a 
more  correct  statement  to  say  that  of  those 
diagnosed  as  phthisicall}^  insane,  and 
whose  cases  could  be  followed  up  to  this 
time,  35.3  Y>eY  cent,  have  died  of  phthisis. 

One  of  the  most  interesting  facts  re- 
vealed by  these  statistics  is  this,  that 
out  of  the  134  there  have  been  44  re- 
coveries from  their  mental  disease,  and 
some  of  them  also  from  these  lung  symp- 
toms, or  a  percentage  of  ;};^.  We  cer- 
tainly did  not  anticipate  in  1862  that  such 
a  proportion  of  recoveries  was  possible  in 
this  clinical  variety  of  insanity.  In  fact, 
one  of  our  conclusions  fi-om  our  then  data 
was  that  it  was  very  incurable.  But  we 
had  not  then  had  a  very  long  clinical  ex- 
jaerience,  and  our  conclusions  on  the 
whole  subject  had  largely  to  be  formed 
from  the  descriptions  of  the  mental  con- 
dition of  those  patients  who  had  died  of 
lahthisis,  as  we  found  them  in  the  as3dum 
case-books,  for  phthisical  insanity  had  not 
been  known  or  thought  of  till  then.  The 
hygienic  state  of  the  older  asylums,  too, 
was  not  so  good  as  it  is  now.  Nor  was 
the  dietary,  or  clothing,  or  exercise  in  the 


Phthisical  Insanity  [    945    ]  Phthisical  Insanity- 


fresh  air  at  all  as  they  are  at  present. 
The  fact  that  we  now  think  we  can  dia- 
gnose phthisical  insanity  in  its  early  stage 
before  the  actual  lung  disease  has  ap- 
peared, or  while  it  is  incipient,  makes  us 
take  energetic  therapeutic  means  to  com- 
bat the  disease  by  special  treatment, 
medical,  dietetic,  and  general.  We  find 
the  percentage  of  recoveries  is  rising  under 
such  means  of  treatment,  though  the 
numbers  we  diagnose  as  labouring  under 
the  disease  are  about  the  same  from  year 
to  year.  A  percentage  of  ;i^  of  recoveries 
is  a  very  low  one  for  recent  uncomplicated 
cases  of  insanity.  Excluding  all  cases  of 
organic  brain  disease,  senile  insanity,  and 
cases  over  twelve  months  insane,  the  re- 
covery rate  has  been  at  least  70  per  cent. 
The  cases  diagnosed  as  phthisical  insanity 
recover,  therefore,  in  less  than  half  the  pro- 
jiortion  of  recent  insanity  uncomplicated 
with  brain  disease. 

But  we  do  not  for  a  moment  say  that 
in  some  of  the  44  who  recovered,  or  of 
the  49  who  were  removed  from  the  asy- 
lum unrecovered,  or  of  the  11  yet  in 
the  asylum,  or  of  those  who  died  of 
other  diseases,  we  did  not  make  a  mistake 
in  diagnosis,  calling  cases  "  phthisical  in- 
sanity "  which  were  really  not  so.  It 
cannot  yet  be  claimed  that  it  is  so  entirely 
distinct  that  it  is  not  liable  to  be  con- 
founded with  insanity  (non-phthisical) 
accompanied  by  anajmia  or  caused  by 
syphilis  or  alcohol,  or  with  ordinary  idio- 
pathic hereditary  delusional  insanity. 

We  found  that,  statistically,  morbid 
suspicion  was  the  most  frequent  mental 
symptom  in  all  those  who  died  tubercular. 
It  existed  in  43  per  cent,  of  282  who  died 
of  phthisis.  A  suicidal  tendency  we  find 
to  be  more  common  among  the  tubercular 
than  among  the  ordinary  inmates  of  the 
asylum,  having  been  present  in  21  per 
cent,  of  them.  Melancholia  and  mono- 
mania of  susi^icion  existed  in  undue  pro- 
portion among  those  who  afterwards  be- 
came phthisical.  The  very  deeply  melan- 
cholic cases  that  had  refused  food  and  had 
to  be  fed,  died  of  phthisis  more  frequently 
than  almost  any  other  class,  some  of  them 
having  been  phthisical  before  the  onset  of 
the  insanity,  and  in  some  the  lung  disease 
was  secondary.  It  was  in  such  cases  that 
gangrene  of  the  lung  was  sometimes  asso- 
ciated with  ijhthisis.  Hallucinations  of 
the  senses  existed  in  20  per  cent,  of  the 
cases,  the  order  of  frequency  being  of 
hearing,  of  sight,  and  of  smell.  In  our 
1063  cases  the  ordinary  sym^itoms  of  lung 
disease  were  latent  in  about  30  per  cent, 
of  those  whose  lungs  were  found  tuber- 
cular after  death,  but  this  proportion  is 
not  so  great  now  since  we  make  a  more 


careful  physical  examination  of  our  pa- 
tients on  admission,  weigh  them  at  I'egu- 
lar  intervals,  and  use  the  thermometer  in 
every  case  night  and  morning  after  ad- 
mission. It  is  one  of  the  many  important 
uses  of  the  thermometer  among  the  in- 
sane, that  its  valuable  indications  do  not 
depend  in  any  way  on  dulled  reflexes  or 
sensibility,  or  want  of  attention,  or  lack  of 
power  on  the  patient's  part  to  tell  of  sub- 
jective symptoms.  Latency  is  most  seen 
in  general  paralysis.  It  is  surprising  how 
slight  is  the  apparent  eff"ect  of  even  ad- 
vanced phthisis  on  some  of  the  insane. 
They  go  about,  do  work,  take  food,  make 
no  complaint,  and  even  look  fairly  well 
with  advanced  tubercular  deposition — 
large  cavities  and  enormous  disorganisa- 
tion in  their  lungs.  Sudden  terminations 
are  not  uncommon.  A  man  who  had 
only  been  failing  in  strength  and  appetite 
for  a  few  weeks  and  in  whom  the  physical 
signs  of  phthisis  had  been  discovered,  sat 
down  to  dinner  as  usual,  took  his  food, 
and  died  suddenly  of  syncope  immediately 
afterwards.  His  lungs  were  found  riddled 
with  tubercular  cavities.  Though  tuber- 
cular ulceration  of  the  intestines  is  very 
common  in  the  phthisical  insane,  yet  diar- 
rhoea is  not  so  common  or  so  troublesome 
as  in  ordinary  phthisical  patients. 

We  shall  only  cite  two  typical  examples 
of  the  disease,  showing  its  clinical  fea- 
tures. The  first  is  one  occurring  at  ado- 
lescence, and  was  more  acute  and  rapid  in 
its  course  than  the  average  case. 

H.  S.,  aged  20,  a  map-colourer,  of  ordi- 
nary education,  cheerfuldisposition,  steady 
and  industrious  habits.  She  had  been 
subject  to  "fainting  fits,"  but  otherwise 
had  been  in  good  health.  She  had  been 
engaged  to  be  married  to  a  respectable 
young  man,  but  shortly  before  the  com- 
mencement of  her  illness — or  rather,  per- 
haps, at  the  commencement  of  her  illness 
— she  began  to  entertain  fears  that  he  was 
not  a  Christian,  and  she  came  to  the  con- 
clusion that  in  those  circumstances  it  was 
her  duty  to  postpone  her  marriage.  She 
then  became  melancholy,  took  a  gloomy 
view  of  everything,  and  proposed  going  as 
a  missionary  to  the  Indians.  She  then 
began  to  fancy  her  food  was  poisoned,  be- 
came irritable  and  dangerous  to  her  rela- 
tions when  in  a  passion.  She  was  sleep- 
less, and  her  ajipetite  was  diminished,  and 
she  was  sent  to  the  asylum. 

On  admission,  she  was  excited,  her  eyes 
were  very  bright,  her  countenance  ani- 
mated and  expressive  ;  she  talked  freely ; 
she  did  not  express  much  surprise  or  as- 
tonishment at  finding  herself  in  an  asy- 
lum. She  evidently,  though  apparently 
pretty   rational,    did   not  appreciate  her 


Phthisical  Insanity 


[    946    ] 


Phthisical  Insanity 


position.  She  had  dark  hair,  beautiful 
dark  eyes,  and  delicate,  refined  featiires. 
Phthisical  symptoms  and  physical  signs 
were  well  marked. 

At  first  she  became  very  melancholy  at 
her  catamenial  periods,  but  under  the  in- 
fluences of  fresh  air,  good  food,  and  quiet, 
she  became  apparently  well,  and  was  re- 
moved from  the  asylum.  Her  phthisical 
symptoms  abated  also.  But  in  a  very 
short  time  she  was  brought  back  to  the 
asylum  with  all  her  symptoms  aggravated. 
She  was  more  suspicious,  and  more  inco- 
herent when  excited.  She  was  very  list- 
less and  weak,  suffered  from  cough,  night 
sweats,  expectoration,  and  pain,  when  free 
from  excitement.  But  when  she  became 
excited  she  got  out  of  bed,  dressed  herself, 
walked  about  the  ward,  never  coughed, 
never  spat,  talked  almost  constantly,  ima- 
gined herself  a  person  of  importance,  or 
hinted  her  suspicions  in  a  vague  way  to 
those  about  her.  Her  pulse  was  quicker 
when  excited,  however,  than  when  free 
from  excitement.  Those  attacks  came  on 
irregularly  till,  in  six  months,  she  died. 
Her  appetite  was  better  during  her  ex- 
citement, but  she  did  not  sleep  then. 
When  free  from  excitement  she  sometimes 
was  quite  rational  but  listless,  and  was  so 
before  she  died.  Both  lungs  were  com- 
pletely disorganised. 

The  following  is  a  good  example  of  the 
disease  developing  in  a  man  of  middle 
life.  E.M.,aged37.  Admitted  to  asylum 
March  1886,  and  died  December  1888  of 
phthisis  pulmonalis.  He  was  of  a  quiet, 
reserved,  and  somewhat  suspicious  dis- 
position. His  habits  were  steady  and 
hard-working.  He  was  a  "  rubber 
worker,"  a  healthy  trade,  at  all  events  as 
regards  tubercular  complaints. 

Heredity — a  half  sister  (same  mother) 
who  was  insane  and  recovered,  and  more 
insanity  than  this  is  supjoosed  to  be  in 
his  mother's  family.  For  two  years  be- 
fore admission  to  asylum  he  had  exhi- 
bited morbid  suspicions  and  jealousy  of 
his  wife,  and  was  generally  suspicious 
about  trifles.  His  general  suspicions 
became  gradually  organised  into  delusions 
that  his  food  was  poisoned,  and  that  his 
wife  introduced  men  into  the  house  at 
night.  He  would  put  his  food  into  the 
fire,  and  would  go  out  and  dine  off  a 
crust.  He  fancied  bloodhounds  were  sent 
after  him.  He  would  not  take  of?  his 
clothes  at  night,  and  behaved  altogether 
strangely.  Next  he  began  to  have  hallu- 
cinations of  hearing,  and  imagined  his 
life  was  in  danger.  He  fancied  his 
child,  ten  months  old,  was  "  reading  his 
thoughts,"  and  in  consequence  sharpened 
a  razor  to  murder  it.     He  got  more  and 


more  unsocial  too.     For  ten  months  before 
admission  he  had  been  quite  insane. 

About  the  time  his  morbid  suspi- 
cions first  arose  two  years  ago  his  chest 
"  got  weak,"  and  he  was  advised  to  take 
cod-liver  oil,  which  he  did  at  times,  always 
carrying  the  bottle  in  his  pocket  in  case 
any  poison  should  be  put  into  it. 

On  admission  he  was  suppressedly 
excited  and  somewhat  exalted  instead  of 
being  depressed  as  formerly.  He  had 
some  difficulty  in  restraining  his  desire 
to  smash  things.  He  was  quite  coherent, 
and  his  memory  good.  He  complained 
of  parjesthesia  such  as  a  peculiar  "  creepy" 
sensation  up  one  side  of  head,  with  an 
oppression  at  the  top.  His  right  apex 
was  consolidated,  and  in  the  left  apex 
there  were  moist  sounds.  T.  98.4,  weight 
8  stone,  pulse  117,  weak. 

He  was  placed  in  our  hospital  ward,  put 
on  extra  milk  and  eggs,  malt  liquors, hypo- 
phosphates  and  cod-liver  oil. 

His  being  placed  here  seemed  to  have 
the  effect  at  first  of  strengthening  his 
inhibitory  power,  so  that  his  conduct  and 
speech  for  two  months  were  almost  those 
of  a  sane  man.  He  was  unsocial,  and 
admitted  he  heard  voices,  but  seemed  to 
agree  with  one  when  he  was  told  they 
were  "  in  his  head  "  and  not  real.  His 
bodily  health  imj^roved  a  little,  and  he  put 
on  a  few  pounds  more  of  flesh.  But  he 
had  cough, expectoration, and  hjemoptysis. 
He  got  apparently  so  well  that  we  let  him 
go  home  on  pass.  But  it  turned  out  that 
we  were  wrong  in  doing  so,  for  he  said 
afterwards,  that  when  out  he  was  tempted 
to  throw  himself  into  the  canal. 

Then  his  old  suspicions  returned.  He 
would  trust  no  one.  He  would  ask  day 
by  day  to  get  home,  and  could  not  see 
that  he  could  not  work  to  support  his 
family.  He  would  not  read  or  talk  with 
any  one.  Kindnesses  to  himself  and  to 
his  wife  were  not  appreciated.  He  became 
gradually  more  irritable  and  more  delu- 
sional, fancying  his  wife  and  family  were 
here.  He  was  very  suspicious  of  the 
medical  officers,  fancying  they  kept  him 
here  for  some  occult  purpose  which  he 
could  not  state.  He  wanted  to  be  sent 
from  one  ward  to  another  on  account  of 
his  suspicions  of  the  attendants,  but  was 
never  contented  in  any  place.  After  a 
year  and  a  half  he  was  more  insane,  and 
showed  some  signs  of  mental  enfeeblement 
tinctured  with  susjaicions.  His  lungs 
gradually  got  worse.  He  had  several 
severe  attacks  of  hgemoptysis,  and  he 
died  very  ana3mic  and  exhausted.  His 
mental  state  did  not  improve  before  death. 
He  had  no  hectic,  and  his  temperature 
did  not  rise  very  much. 


Phthisical  Insanity 


947    ]    Physiognomy  of  the  Insane 


Hia  brain  after  death  was  found  to 
have  a  small  spot  of  limited  softening  on 
the  tip  of  the  left  occipital  lobe,  there 
were  four  bony  spicules  projecting  into 
the  dura  mater  from  inner  table  of  skull- 
caps; over  first  frontal  convolution.  The 
brain  substance  was  otherwise  normal  in 
appearance.  There  were  cavities,  purulent 
infiltrations,  and  tubercular  depositions 
in  both  lungs.  The  liver,  kidneys,  and 
pancreas  were  waxy. 

Patbology. — Strictly  speaking,  phthi- 
sical insanity  cannot  as  yet  be  definitely 
connected  with  any  pathological  change 
demonstrable  after  death  in  the  brain. 
Deposition  of  tubercle  in  the  organ  is 
very  rare  indeed  in  the  insane.  We  found 
it  in  only  eight  cases  out  of  282  who  were 
tubercular.  But  there  was  one  morbid 
appearance  in  so  many  of  the  cases,  that 
one  cannot  but  connect  it  in  some  way 
with  the  mental  symptoms  during  life. 
This  was  a  general  and  great  ansemia  of 
the  grey  matter  of  the  convolutions  with 
more  or  less  of  atrophy,  with  a  great 
pallor  of  the  white  substance,  and  a  dis- 
tinct tendency  to  loss  of  consistence  in 
most  parts,  and  limited  areas  of  conges- 
tion. The  loss  of  consistence  was  espe- 
cially marked  in  the  fornix  and  its  neigh- 
bourhood, being  sometimes  difiluent  at 
that  part.  Louis  noticed  this  softening 
of  the  fornix  in  many  of  his  cases  of 
phthisis  who  tvere  not  insane,  and  he 
associates  the  lesion  with  the  tuberculosis. 
The  specific  gravity  of  the  grey  matter 
Skae  found  to  be  considerably  below  the 
mean  in  those  who  had  died  of  phthisis. 

The  whole  condition  of  the  brain  gives 
the  impression  of  an  ill-nourished  organ. 
As  yet  we  know  nothing  for  certain  of  the 
direct  influence  on  the  mental  functions  of 
the  brain  of  the  myi'iads  of  specific  bacilli 
that  must  circulate  in  the  blood  in  the 
various  infective  diseases,  or  of  the  poisons 
which  thebacteriaeither  ci'eate,  or  in  which 
they  find  a  nidus,  but  we  do  know  that 
the  delirium  is  diiferent  as  in  different 
fevers,  being  low  and  "muttering"  in 
one,  fierce  and  noisy  in  another,  gently 
chattering  in  another  ;  this  difference  in 
character  not  being  accounted  for  by  dif- 
ferences of  temperature.  We  know,  too, 
that  most  men  may  take  a  catarrh,  and 
have  a  temperature  of  104°,  without  much 
risk  of  "  wandering"  at  night,  while  few 
patients  go  through  an  attack  of  typhoid 
without  more  or  less  delirium,  or  mental 
confusion,  though  the  temperature  may 
never  rise  much  above  100°.  So  in  phthi- 
sis pulmonalis  we  have  the  unknown 
effect  of  the  tubercle  bacillus  and  its 
ptomaines  circulating  in  the  brain  to 
account  for  the   spes    phthisica,   or  the 


suspiciousness,  or  the  moroseness  ex- 
hibited by  various  phthisical  patients. 

Many  acute  observers.  Dr.  Maudsley 
amongst  them,  think  that  there  is  not 
only  a  phthisical  insanity,  but  a  morbid 
psychology  of  phthisis  in  many  cases 
apart  from  technical  insanity,  and  apart 
from  the  spes  phthisica.  Persons  of  a 
strongly  tubercular  diathesis  and  with  a 
consumption  heredity,  have  been  observed 
in  too  many  cases  to  be  a  mere  coinci- 
dence to  exhibit  an  irregular  mental  bril- 
liancy without  balance,  a  fancifulness,  a 
causeless  changing  from  hope  to  despond- 
ency, an  incapacity  for  continued  mental 
exertion,  a  causeless  suspiciousness  at 
times,  that  we  cannot  but  connect  with 
the  influence  of  weak  respiratory  organs 
on  the  brain.  And  if  careful  inquiry  is 
made  of  those  who  have  been  their  con- 
stant attendants  during  their  last  illness, 
and  have  observed  the  mental  condition 
of  two  or  three  consumptive  relatives, 
they  will  often  tell  you  of  the  whimsical 
notions,  the  mental  unrest,  the  vivid 
fancies,  almost  amounting  to  delusions, 
that  they  have  noticed.  It  stands  to 
physiological  reason,  that,  as  consump- 
tion is  often  essentially  a  disease  of  innu- 
trition, the  brain  cortex  should  suffer 
like  the  rest  of  the  body,  at  all  events  in 
some  cases.  T.  S.  Cloustox. 

PHTHZSZOPKOBXE  (Fr.).  A  morbid 
dread  of  phthisis. 

PHYCAirTKROPZil  {(t>vyr),  flight ; 
avdpcoTTos,  a  man).     Misanthropia. 

PHYSZOGirOMY  OF  THE  ISTSAITE. 
— The  article  on  the  Expression  of  tho 
Face  (p.  482),  by  Dr.  Warner,  and  the 
description  of  the  facial  expression  and 
gestui-es  in  melancholia,  &c.,  under  the 
head  of  various  forms  of  idiocy  and  in- 
sanity will  afford  the  reader  a  large 
amount  of  information.  In  this  connec- 
tion should  be  also  read  the, article  by  Dr. 
Crochley  Clapham,  on  the  size  and  shape 
of  the  head  (p.  574). 

The  reader  of  Lavater's  "Physiognomy" 
finds  him  advising  those  who  would  study 
this  art  to  begin  with  the  insane.  It  has 
been  pointed  out,  however,  by  Dr.  Buck- 
nill,*  that  "  to  comni'-nce  the  study  of 
physiognomy  in  a  lunatic  asylum,  would 
be  not  less  impracticable  than  to  study 
jihysiology  in  the  first  instance  by  means 
of  pathology.  It  would  have  been  as 
irrational  to  expect  that  the  functions  of 
the  lungs  could  be  discovered  by  the  in- 
spection of  a  piece  of  hepatised  ^pul- 
monary tissue,  as  that  the  signs  of  natural 
expression  could  be  determined  solely  by 
the  observation  of  that  which  is  strange 

*  "  Manual  of  rs3-cliologicalMediciue,"4th  edit. 
p.  420. 


Physiognomy  of  the  Insane    [    948    ]    Physiognomy  of  the  Insane 


aud  unnatural.  It  would  seem,  that  in 
all  the  departments  of  investigation,  it  is 
right  to  commence  with  the  study  of  that 
which  is  most  normal,  simple,  and  re- 
gular ;  and  from  thence  to  proceed  with 
inquiries  respecting  that  which  is  un- 
usual and  irregular."  Hence  it  is  justly 
affirmed  "  that  no  one  can  become  profi- 
cient in  the  recognition  of  the  facial  ex- 
pression of  the  various  forms  of  insanity, 
who  has  not  acquired  a  considerable 
amount  of  physiognomical  tact  by  his  in- 
tercourse with  the  sane  portion  of  man- 
kind." In  this  study,  the  reader  will  find 
in  addition  to  the  great  work  of  the 
founder  of  the  science,  two  treatises  of 
the  utmost  value  —  Pierre  Gratiolet's 
remarkable  publication  "  De  la  Physio- 
nomie  at  des  Mouvements  d'Expression," 
and  Chai'les  Darwin's  "  Expression  of  the 
Emotions."  The  much  earlier  work  of  Sir 
Charles  Bell,  "  The  Anatomy  and  Philo- 
sophy of  Expression  as  connected  with 
the  Fine  Arts,"  must  be  studied.  Sir 
Alexander  Morison  published  in  the  year 
1826  a  workwhich  contained  several  strik- 
ing illustrations  of  the  insane.  Recently, 
Dr.  Byron  Bramwell  has  in  his  "  Atlas  of 
Clinical  Medicine,"  reproduced  some  of 
these,  and  given  others  which  are  beauti- 
fully executed. 

Portraits  of  patients  labouring  under 
various  forms  of  mental  defect  and  dis- 
order will  be  found  in  the  Frontispiece 
{Plate  I.)  viz.  :-- 

Fig.  I. — Acute  mania  ;  female  patient 
in  the  St.  Hans  Hospital  near  Copen- 
hagen, photographed  by  Dr.  Pontoppidan. 

Fig.  2. — Chronic  mania,  with  exalted 
ideas ;  believes  herself  to  be  Princess 
Beatrice.  Photograph  of  a  female  pa- 
tient taken  by  Dr.  Walter  P.  Turner,  at 
that  time  Assistant  Medical  Officer,  Kent 
County  Asylum  (Chartham). 

Fig.  3. — Acute  melancholia;  male  pa- 
tient, Bethlem  Hospital.     Never  speaks. 

Fig.  4. — Mental  stupor.  (Melancholia 
cum  stupore.)     Bethlem  Hospital. 

Fig.  5. — General  paralysis.  Dementia. 
Bethlem  Hospital.  Figs.  3,  4,  and  5  were 
under  Dr.  Savage's  care. 

Fig.  6. — Idiocy.  Photographed  by  Dr. 
Walter  P.  Turner. 

Fig.  7. — Sporadic  cretinism.  Case  re- 
ported to  the  International  Medical  Con- 
gress, 1 88 1,  by  the  writer.  The  patient, 
a  male,  had  a  girlish  appearance,  and, 
it  will  hardly  be  credited,  was  39  years  of 
age  when  photographed. 

In  the  plate  which  accompanies  this 
article  (PI.  II.)  the  physiognomical  ex- 
pressions are  of  the  most  marked  charac- 
ter, and  illustrate  cases  of  erotomania ; 
delusional  insanity  (megalomania) ;  apa- 


thetic dementia  with  asymmetry  of  the 
forehead,  under  certain  emotional  condi- 
tions; melancholia  with  similar  asymmetry 
of  the  forehead  ;  acute  melancholia,  with 
facial  asymmetry  under  emotion ;  and 
secondary  dementia  with  asymmetry  of 
the  forehead. 

Fig.  I,  PI.  II.— The  patient  whose 
physiognomy  is  here  represented,  laboured 
tor  many  years  uuder  the  fixed  delusion 
that  she  was  a  queen.  Her  expression 
and  bearing  were  to  the  last  degree 
characteristic  of  exaltation  and  a  sense  of 
her  royal  dignity.  Her  dress  was  studded 
in  front  with  silver  coin  to  mark  her 
exalted  rank.  When  photographed  by  the 
writer,  she  was  delighted  with  this  mark 
of  attention,  and  exclaimed,  "  Now  photo- 
graph my  back!" 

Fig.  2,  PI.  II. — Represents  the  face  of 
a  patient  formerly  in  the  Norfolk  County 
Asylum  under  the  care  of  Dr.  Hills.  She 
developed  a  large  head  and  moustache. 
Her  case  was  one  of  sexual  perversion. 
It  is  referred  to  at  page  129  of  this  work. 
Dr.  John  Turner  (Essex  County  Asy- 
lum) has  photographed  the  faces  of  a 
number  of  patients  in  the  asylum  in  which 
asymmetry  of  the  facial  muscles  is  strik- 
ingly shown.  He  observes, "  It  is  a  signi- 
ficant fact  that  the  muscles  of  the  upper 
part  of  the  face  display  asymmetrical 
action  much  more  frequently  than  do  the 
muscles  of  the  lower  part — viz.,  in  the  pro- 
portion of  -^.7  to  I."  He  adds  that  he  has 
been  impressed,  while  observing  the  faces 
of  the  female  insane,  by  "  the  frequency 
with  which  the  muscles  of  expression  of 
the  lower  part  of  the  face  are  called  into 
play  under  emotional  states  which  would 
in  the  sane  result  in  expression  more 
confined  to  the  muscles  of  the  upper 
parts,  or  to  paraphrase  Warner's  re- 
marks, their  expressions  are  more  animal- 
like,  less   mental To   take  the 

occipito-frontalis,  it  is  the  largest  and 
most  powerful  muscle  of  the  upper  part 
of  the  face,  and  although  described  in 
the  books  of  anatomy  as  one  muscle,  or 
at  most  of  a  right  and  left  half,  yet  we 
must  further  subdivide  it  into  at  least 
an  inner  and  outer  division  for  each  side, 
each  of  these  divisions  being  capable  of 
contracting  by  themselves,  and  frequently 
doing  so.  It  is  important  also  to  note 
that  the  inner  or  median  division  of  the 
muscle  is  more  concerned  in  the  produc- 
tion of  the  physical  signs  of  the  higher 
(more  idealised)  forms  of  expression, 
whilst  the  outer  halves  when  they  con- 
tract alone,  produce  no  definite  form 
of  expression,  but  give  to  the  face  an 
inane  aspect  frequently  seen  in  dements. 
Asymmetry  of  action  is  more  frequently 


PHYSIOGNOMY"    OF  THE    INSANE 


PKH. 


Physiognomy  of  the  Insane    [    949    ]    Physiognomy  of  the  Insane 


seen  in  this  muscle  (alone  or  in  combina- 
tion with  the  corrugator  supercilii)  than 
in  any  other  of  the  muscles  of  expi'ession." 
And  Dr.Turuor  thinks  that  "  by  carefully 
studying  the  symptoms  of  paralysis  of 
movements,  together  with  the  patholo- 
gical appearances  of  the  brain  in  suitable 
cases,  we  shall  ultimately  be  enabled  to 
identify  the  site  or  sites  in  the  cortex, 
whose  integrity  is  necessary  for  the  pro- 
per accomplishment  of  those  physical 
changes  whicli  accompany  these  emo- 
tions, and  which  are  eventually  expressed 
at  the  periphery  in  the  form  of  muscle 
contraction." 

Cb.  Fchv  in  "Les  signes  physiques  des 
Hallucinations  "  endeavours  to  show  that 
*'  with  the  various  hallucinations  there 
may  be  special  expressions  which  may 
become  organically  fixed  and  may  thus 
serve  as  aids  to  diagnosis,"  and  that  in 
some  cases  there  are  special  wrinkles 
formed  about  the  eyes,  the  mouth,  and 
nose,  in  direct  relation  with  the  habit  of 
mind  induced  by  chi'onic  hallucination. 
In  at  least  one  case  he  found  that  when 
the  hallucinations  were  on  only  one  side, 
the  wrinkles  were  also  one-sided.  Re- 
ferring to  these  statements  Dr.  Turner 
observes  :  "  It  seems  to  me  highly  likely 
that  these  one-sided  wrinkles  to  which 
Fere  refers  have  no  other  relation  to  the 
one-sided  hallucinations  than  exists  in  the 
fact  that  whilst  disorder  of  some  of  the 
higher  centres  in  one  half  the  brain  may 
produce  hallucinations  of  the  senses,  italso 
produces  paralysis  of  certain  movements 
accompanying  certain  emotional  states."* 

We  are  indebted  to  Dr.  Turner  for 
photographs  representing  the  facial 
characteristics  of  four  patients  in  the 
Essex  County  Asylnm,  asymmeti-y  being 
common  to  all. 

Fig.  3,  PI.  IT.-F.M.L.,  aged  21,  her  in- 
sanity on  admission  two  years  ago  was 
of  two  years'  duration.  She  was  then 
maniacal  for  a  week  or   so,  but  quieted 

*  It  will  no  doubt  be  objected  to  the  Importiince 
attached  to  facial  asymmetry,  that  a  yveat  many 
sane  people  present  tlie  same  physioiinoraical  si^ns. 
On  this  point  Dr.  Turner  observes  :  ■•  We  must  not 
fxpeet  asyunnetry  of  exjiression  to  be  peculiar  to 
insanity,  inequality  in  the  size  of  the  pupils  occurs 
comparatively  frequently  iu  others  than  the  inmates 
of  asylums,  and  I  have  met  with  many  and  marked 
instances  of  asymmetry  in  the  lines  ])roduced  by 
the  contraction  of  the  muscles  of  expression  :  but 
iilthou;;h  I  have  no  tabulated  results  as  to  these 
cases,  I  am  certain  that  tliey  are  more  frecpiently 
to  \>c  met  with  in  nervous,  excitable  peoiile,  in 
whom  an  unstable  condition  of  the  hiuher  nervous 
centres  exists,  I  luivc  seen  t^ood  instances  in  those 
who  come  to  visit  their  insane  relations  licre 
[Itrentwood]  :  In  hysterical  twirls,  reli-ious  fanatics, 
and  rarely,  if  ever,  in  robust,  healthy  individuals" 
(Jonrn.  Meat.  Sci.,  Jan.  1892). 


down,  and  ever  since  has  been  in  an  apa- 
thetic condition,  gradually  drifting  into 
dementia,  sitting  huddled  u]i  with  her 
head  bent  down,  speaking  in  a  whisper  and 
never  spontaneously ;  only  moving  when 
urged — fond  of  chewing  bits  of  paper. 
With  the  increase  of  degenerative  brain- 
changes,  asymmetrical  conditions  ap- 
peared first  in  the  face  and  then  in  the 
trunk.  These  began  by  slight  elevation  of 
the  left  eyebrow,  which  was  more  arched 
than  the  right.  The  elevation  became  more 
and  more  marked,  when  present,  but  at  no 
time  was  it  a  fi.xed  condition,  being  only 
assumed  with  certain  emotional  states. 

The  pupils,  which  on  admission  were 
equal,  became  unequal,  the  right  being 
slightly  the  larger,  and  now  when  stand- 
ing up  she  droops  over  on  the  right  side. 
The  asymmetery  is  described  in  a  note 
made  recently  as  follows : — She  keeps 
elevating  her  left  eyebrow,  which  is  angu- 
lar, causing  well-marked  furrows  on  the 
left  side  of  the  brow.  When  she  frowns 
and  brings  into  play  the  internal  portions 
of  the  occipito-frontalis  and  the  corru- 
gators,  although  there  is  very  considerable 
furrowing  of  the  outer  half  of  the  leftside 
of  the  brow,  the  right  outer  half  is  quite 
smooth. 

Since  the  foregoing  was  written  she  has 
died  of  phthisis.  There  was  adhesion  of 
the  meninges  to  the  incus  on  both  sides, 
but  very  much  more  on  the  left,  which  was 
decidedly  softer  than  the  right,  being 
almost  diffluent.  Over  the  pre-frontal 
lobes,  the  meninges  were  thickened  in 
patches,  the  ventricles  were  dilated  and 
full  of  fluid.  Lungs  extensively  infil- 
trated with  tubercle,  the  left  being  more 
disorganised  than  the  right. 

Fig.  4. — Annie  T.,  aged  32,  admitted  in 
good  health  and  suffering  from  acutely  me- 
lancholic symptoms  which  had  appeared 
within  a  few  weeks  of  admission.  She 
was  restless,  resistive,  and  troublesome  ; 
her  face  wore  a  mingled  expression  of  per- 
plexity, misery,  and  fear.  She  exhibited 
a  most  extreme  condition  of  asymmetry, 
called  forth  when  she  was  startled,  or  by 
a  reference  to  some  topic  displeasing  to 
her.  Sometimes  the  occipito-frontalis  on 
the  right  half  of  her  forehead  contracts, 
but  when  it  does  so  it  is  as  part  of  a 
symmetrical  associated  action  in  the 
voluntary  elevation  of  both  brows.  The 
asymmetry  appears  to  be  due  to  the  non- 
action of  the  right  half  of  the  occipito- 
frontalis,  whilst  at  the  same  time  the  left 
half  and  both  corrugators  are  acting.  The 
paralysis  of  the  occipito-frontalis  on  the 
right  side  allows  the  unantagonised  cor- 
rugator  of  the  same  side  to  pull  down  the 
skin  on  this  side  more  forcibly,  it  being  in 


Physiognomy  of  the  Insane    [    950    ]  Physiological  Time 


a  more  or  less  flaccid  state  ;  the  result  of 
this  is  to  produce  the  furrows  running  up- 
wards from  the  inner  end  from  the  right 
eyebrow,  and  across  the  middle  line  where 
they  coalesce  with  the  transverse  furrows 
formed  by  the  action  of  the  left  occipito- 
frontalis.  This  woman,  after  a  little  while, 
lost  most  of  her  active  symptoms,  became 
silent  and  mulish,  her  face  grew  fat  and 
expi-essiouless ;  she  developed  two  forms 
of  asymmetry,  one  caused  by  contraction 
of  the  outer  half  of  the  right  occijiito- 
frontalis,  and  both  corrugators ;  this  ex- 
pression was  easily  evoked  if  her  attention 
■was  drawn  to  unexi^ected  sounds  on  her 
right  side  ;  but  when  so  startled  from  the 
left,  her  forehead  sometimes  assumed  the 
expression  here  figured.  This  latter  con- 
dition was  now  more  difficult  to  evoke,  and 
much  more  rarely  seen  than  the  former. 

Fig.  5. — Female  patient  who  had  delu- 
sion that  her  child  was  dead.  Whenever 
reference  was  made  to  the  subject  her 
face  assumed  the  expression  seen  in  the 
figure.  At  times  she  complained  of  great 
pain  on  pressure  of  the  abdomen.  Her  left 
leg  was  swollen,  oedematous  and  painful, 
and  if  the  abdomen  was  pressed  or  her 
leg  touched,  her  face  assumed  exactly  the 
same  expression  as  that  caused  by  allusion 
to  her  child.  It  began  by  elevation  and 
retraction  of  the  left  nostril  and  left  half 
of  the  upper  lip,  causing  a  deep  naso- 
labial fold  to  ai3pear  on  this  side  ;  it  then 
gradually  spread  to  the  other  muscles. 

Fig.  6. — Face  of  female  patient  showing 
strong  contraction  mainly  of  the  outer 
half  of  the  right  occipito-frontalis  ;  neither 
corrugator  is  acting.  She  is  in  a  state  of 
secondary  dementia,  her  insanity  being  of 
very  manyyears  standing.  She  is  intensely 
silly,  gives  and  makes  foolish  and  irrel- 
evant answers  when  si^oken  to  ;  she  can 
only  be  usefully  employed  in  carrying 
articles,  and  for  this  simple  duty  requires 
considerable  personal  supervision.  If  left 
to  herself  she  will  sit  unoccupied  all  day 
with  her  right  eyebrow  elevated  more 
than  an  inch.  This  condition  gives  a 
stupid  look  to  her  face,  it  assimilates  to 
no  recognised  form  of  expression,  is  not 
intensified  with  any  emotional  states ;  in- 
deed, if  her  attention  is  attracted  in  any 
way  it  generally  disa23])ears. 

Dr.  Turner  observes :  "  That  the  highest 
nerve-centres  represent  movements  and 
not  muscles  is  brought  forcibly  to  our 
minds  in  observing  these  asymmetrical 
appearances.  In  any  of  these  cases  when 
the  muscles  on  one  side  show  evidence  of 
weakness  when  contracting  under  the 
influence  of  certain  emotions,  or  jjerhaps 
are  incapable  of  contracting  at  all,  it  is 
only  necessary  to  ask  the  patient  to  volun- 


tarily frown  or  elevate  the  brows  as  the 
case  may  be,  to  see  that  all  evidence  of 
one-sided  weakness  disa2:)pears  altogether  ; 
both  sides  will  now  contract  with  equal 
force."  * 

To  complete  this  brief  sketch  of  the 
more  notable  physiognomical  indications 
of  mental  disease  we  must  mention  the 
marked  changes  which  occur  in  the  face 
of  a  patient  suffering  from  myxoederaa. 
Fig.  7  is  from  a  photograph  of  the  Case 
referred  to  in  the  article  on  this  form  of 
insanity  (p.  829, 1.  17).  The  illustration  is, 
we  can  testify,  an  excellent  representation 
of  the  features  of  the  original — a  patient 
under  Dr.  Savage  at  Bethlem  Hospital,  to 
whom  we  are  indebted  for  the  engraving. 
Fig.  7.       The  Editor. 


[Eefi'rences. — Duclicniu'  iilo  lioulogae),  Mecan- 
isuie  do  la  phj-siououiie  huraaine  on  analyse  electro- 
physiolouliiue  de  rcxpression  des  passions,  avec 
Atlas  compose  de  soixaute-rjuatorze  pi.  photo- 
grapbiees  represeutant  cent  cjuaraute-quatre  figures. 
Dagouet,  3Ialadics  uieutales,  avcc  liuit  plauches 
eu  photogiyptie,  representaut  tivnte-trois  types 
d'alienes,  1876.  S.  Seback,  La  pbysiouomie  cbez 
rhomme  ct  ehez  les  animaux,  1887.  ilantcuazza. 
Pbysiognomy  and  Expression,  Havelook  Ellis's 
Coutetuporary  Science  Series  (N.n.i.] 

PHVSXOI.OGICAIa      PSVCHOIiOGV. 

[See  ]\[extal  Physiology.) 

FHVsioiiOCZCAii  TiiviE. — A  name 
for  reaction-time  {(j-v-)-     The  astronomers 

*  Tbe  reader  is  referred  to  Dr.  Turner's  able 
articles  in  tbe  Journal  of  Mental  .Scieita',  Jan.  and 
April,  1892,  entitled  "  Asymmetrical  conditions 
met  witbinthe  Faces  of  tbe  Insane,  with  some  Re- 
marks on  tbe  Dissolntion  of  Exjiression,""  in  which 
Dr.  Turner  explains  tbe  ineebanism  of  asymmetry. 


Physostigma 


[951     ]    Plead,  Capacity  of  Insane  to 


long  ago  discovered  that  impressions 
on  the  sense  of  sight  were  much  moi'e 
quickly  apperceivcd  when  they  were  ex- 
pected; tlie  interval  elapsing  between  the 
external  stimulus  and  its  apperception  was 
by  them  called  Physiological  Time. 

PHYSOSTZCIVIA.      (*Seo  SEDATIVES.) 

PICA  (the  magpie,  either  from  its 
varied  colour  or  because  it  was  supposed 
to  subsist  on  mud  and  earth).  A  term 
for  depraved  appetite  with  regard  to  the 
quality  of  the  food.  It  is  seen  commonly 
in  insanity,  pregnancy  and  hysteria,  and 
less  commonly  in  chlorosis.  (Fr.jJi'ca;  Ger. 
Elshr.) 

PZQUEUR.  —  Term  corresponding  to 
the  English  "  Jack  the  Kipper."' 

PX.ii6ZOCZ:PHAI.ZC  IDIOCY.  {Sec 
lDK)CV,Foi;.MS{n';ll)l()CV,PLAGIOCEPUALIC.) 

PIiANroivIAK'lii  (TrXaw'o/Lint,  I  wander; 
fxavia,  madness).  A  morbid  tendency  to 
wander  away  from  home  and  to  throw 
off  the  restraints  of  societ}'. 

PXATZATfCST.     Agoraphobia  (q.v.). 

Plifiil  or  INSANITY.  {See  Chi- 
MiXAL  Cases,  Plea  or  Insanity  in.) 

PXtEAD  (Capacity  of  Insane  to). — 
Before  a  person  is  actually  placed  upon 
his  trial,  there  are  some  preliminary  steps 
which  have  to  be  taken.  In  the  first 
place,  the  indictment  goes  before  the  grand 
jury,  which,  however,  has  no  power  to  take 
into  consideration  the  question  of  the 
mental  condition  of  the  accused,  but  which 
is  required  to  say  whether  it  finds  a 
true  bill  or  not,  irrespectively  of  any 
question  of  sanity  or  insanity.  In  the 
event  of  a  true  bill  being  found  by  the 
grand  jurj',  the  accused  is  then  arraigned, 
and  is  called  upon  to  jjlead :  and  then 
may  arise  the  question  whether  he  is  in 
a  fit  state  of  mmd  to  be  placed  upon  his 
trial ;  for  as  Blackstone*  says,  "If  a  man 
in  his  sound  memory  commits  a  capital 
offence,  and,  before  arraignment  for  it  he 
becomes  mad,  he  ought  not  to  be  ar- 
raigned for  it ;  because  he  is  not  able  to 
plead  to  it  with  that  advice  and  caution 
that  he  ought." 

So,  too,  the  Act  of  iSoo,t  enacts  in  the 
second  section,  that  "  if  any  person  in- 
dicted for  any  offence  shall  be  insane,  and 
shall,  upon  arraignment,  be  found  so  to 
he  by  a  jury  lawfully  impannellecl  for  that 
purpose,  so  that  such  person  cannot  be 
tried  upon  such  indictment,  or  if  upon  the 
trial  of  any  person  so  indicted  such  per- 
son shall  appear  to  the  jury  charged  with 
such  indictment  to  be  insane,  it  shall  be 
lawful  for  the  Court  ....  to  direct  such 
finding  to  be  recorded,  &c." 

"  Commentaries  of  the  Laws  of  Euglaiul,''  Ijy 
Sir  William  lilackstoiiu,  Kiit.,  book  iv.  l-Ii.  ii. 
t  39  &  40  Geo.  III.,  C-.  94. 


But  here  the  question  at  once  arises  as 
to  the  degree  of  unsoundness  of  mind 
which  has  to  be  proved  before  it  can  be 
said  that  a  person  cannot  be  tried  ;  and 
in  order  to  endeavour  to  arrive  at  an 
answer  to  that  question  it  may  be  well 
to  consider  a  few  recent  cases,  which,  for 
the  sake  of  convenience  may  be  grouped 
as  follows : — 

(1)  Simple  unopposed  cases. 

(2)  Cases  in  which  counsel  for  the  de- 
fence submits  that  the  accused  is  unfit  to 
plead ;  whilst  counsel  for  the  prosecution 
maintains  the  contrary. 

(3)  Cases  in  which  counsel  for  the  pro- 
secution submits  that  the  accused  is  in- 
sane, whilst  the  accused  himself  objects 
to  this,  and  insists  on  pleading. 

(4)  Cases  in  which  the  accused  is  mute 
on  arraignment. 

(i)  As  an  instance  of  a  simple  unop- 
posed case  the  following  may  be  taken. 
At  the  Spring  Assizes  for  the  County  of 
Cambridge,  held  in  February  1890,  before 
Mr.  Justice  Denman,  Walter  Lawrence,*  a 
labourer,  aged  36,  was  charged  with  the 
m.urder  of  his  son,  on  the  i8th  of  Febru- 
ary, 1890.  The  prisoner,  on  being  ar- 
raigned, made  no  plea,  and  the  learned 
judge  asked  whether  any  one  suggested 
anything  as  to  the  man's  state  of  mind, 
and  said  that  before  any  evidence  could 
be  taken,  there  must  be  some  suggestion, 
however  informal,  to  the  effect  that  the 
prisoner  was  not  capable  of  taking  his 
trial.  The  foreman  of  the  grand  jury 
then  intimated  to  his  lordshijj  that  one 
of  the  witnesses  (Mr.  Kidd)  who  had 
given  evidence  before  the  grand  jury,  had 
stated  that  he  had  attended  the  prisoner 
for  an  affection  of  the  brain.  The  jury 
was  then  sworn  to  try  the  question 
whether  the  accused  was  capable  of  taking 
his  trial.  The  report  then  goes  on  to  say 
that  his  lordship  explained  to  the  jury 
that  a  man  was  supposed  to  be  sane  until 
the  contrary  had  been  proved.  But  when 
it  was  suggested  that  his  state  of  mind 
was  such  that  he  was  incapable  of  an- 
swering such  a  c^uestion,  for  instance,  as 
whether  he  wished  to  employ  counsel,  or 
to  object  to  any  juryman,  then  it  was 
not  a  case  which  would  be  put  on  trial. 
It  was  suggested  that  there  was  a  doubt 
about  this  man's  state  of  mind,  and  it 
would  be  the  duty  of  the  jury,  after  hear- 
ing evidence,  to  say  whether  they  found 
him  capable  of  being  tried  or  not.  Evi- 
dence was  then  given  by  Mr.  Kidd  that 
he  had  had  the  prisoner  under  his  care 
for  epilepsy  and  general  cerebral  disturb- 
ance. Hethoughtthemanwas  incapable  of 
knowing  what  was  taking  j^lace,  and  that 
*  Tlie  C(nnbri(l(je  Chronicle,  Feb.  28,  1890. 


Plead,  Capacity  of  Insane  to    [    952    ]    Plead,  Capacity  of  Insane  to 


his  mental  condition  put  it  out  of  his 
power  to  plead  ;  and  for  this  opinion  the 
witness  stated  his  reasons  in  detail.  Wit- 
ness, being  further  questioned  by  his 
lordship,  said,  from  what  he  knew  of  the 
prisoner,  and  what  he  saw  of  his  beha- 
viour that  day,  he  did  not  think  he  was 
capable  of  distinguishing  between  a  plea 
of  guilty  and  one  of  not  guilty.  Dr. 
Rogers,  the  medical  superintendent  of  the 
Cambridge  County  Asylum,  said  that  he 
had  had  the  accused  under  his  charge  at 
the  asylum,  and  had  formed  a  judgment 
as  to  his  state  of  mind,  and  thought  it 
was  such  that  he  could  not  do  any  of  the 
things  his  lordship  had  suggested.  Wit- 
ness thought  it  would  not  be  fair  to  try 
the  accused,  inasmuch  as  he  would  not  be 
able  to  protect  himself  in  such  simple 
matters  as  had  been  mentioned.  His 
lordship  remarked  that  that  evidence  was 
conclusive,  and  bethought  the  jury  would 
find  the  accused  insane.  The  jury  agreed 
upon  this  decision,  and  his  lordship  or- 
dered Lawrence  to  be  detained  during  Her 
Majesty's  pleasure. 

In  another  unopposed  case,  Nathaniel 
Curragh,  aged  53,  was  ai-raigned  at  the 
Central  Criminal  Court,  before  Mr.  Justice 
Wills,  in  July  1 889,  charged  with  the  wilful 
murder  of  Charles  Thomas  Goran,  the 
chief  of  a  troupe  of  bicyclists,  known  as 
the  Letine  troupe,  by  stabbing  him,  at  the 
door  of  the  Canterbury  Music  Hall. 

Mr.  Mead,  who  prosecuted  for  the 
Treasury,  said  that  he  was  informed  that 
the  prisoner  was  undoubtedly  insane,  and 
on  account  of  his  mental  condition  quite 
incompetent  to  plead  to,  or  understand 
the  nature  of,  the  offence  with  which  he 
was  charged.  Dr.  Charlton  Bastian,  who 
had  examined  the  prisoner  upon  instruc- 
tions from  the  Treasury,  was  then  called, 
and  was  examined  at  length,  and  gave  the 
opinion  that  the  prisoner  was  undoubtedly 
insane,  and  that  he  was  quite  incapable  of 
appreciating  the  jDOsition  in  which  he  stood 
or  of  pleading  to  the  charge.  The  jury, 
upon  this,  at  once  returned  a  verdict  that 
the  prisoner  was  insane  and  unable  to 
plead,  and  he  was  ordered  to  be  detained 
during  Her  Majesty's  pleasure.  In  this 
case  the  initiative  was  taken  by  the  counsel 
for  the  prosecution  ;  but  sometimes,  as  in 
the  following  instance,  the  initiative  is 
taken  by  counsel  for  the  defence,  no  objec- 
tion being  made  by  the  prosecution. 

At  the  Kent  Assizes,*  held  in  February 
1888,  before  Mr.  Justice  Mathew,  A.  W. 
E-ichardson,  aged  34,  was  charged  with 
the  wilful  murder  of  Charles  Pillow,  at 
Kamsgate,  on  January  r.  Mr  .  Dering 
appeared  to  prosecute  ;  Mr.  Murphy,  Q.C., 
«  The  Kait  Messenuer,  Feb.  i8,  i88S. 


and  Mr.  Poland  being  for  the  defence,  Mr. 
Murphy  contended  that  the  prisoner  was 
not  in  a  fit  state  of  mind  to  plead,  and  a 
jury  was  sworn  to  decide  that  point.  Dr. 
C.  E.  Hoar,  the  medical  officer  of  the 
Maidstone  prison,  and  Dr.  G.  H.  Savage 
gave  evidence  to  the  efi'ect  that  the  pri- 
soner was  insane,  and  not  in  a  fit  state  to 
plead.  The  jury  thereupon  decided  in 
accordance  with  the  medical  evidence;  and 
the  usual  order  was  made  for  the  deten- 
tion of  the  prisoner  during  Her  Majesty's 
pleasure. 

With  respect  to  the  foregoing  cases,  it 
will  be  seen  that  Lawrence  was  stated  to  be 
incapable  of  "  knowing  what  was  taking 
place,"  orof  "distinguishing  between  a  plea 
of  guilty  and  one  of  not  guilty,"  or  of  '"an- 
swering such  a  question,  for  instance,  as 
whether  he  wished  to  employ  counsel,  or 
to  object  to  any  juryman " ;  and,  there- 
fore, in  his  case,  no  doubt  could  be  felt,  by 
any  one,  that  he  was  not  capable  of  taking 
a  rational  part  in  the  trial. 

In  the  case  of  Curragh,  the  report  states 
that  counsel  for  the  prosecution  opened 
the  case  by  telling  the  jury  that  he  was 
informed  that  the  prisoner  was  "  undoubt- 
edly insane,"  and  that,  on  account  of  his 
mental  condition,  he  was  "  quite  incom- 
petent to  understand  the  nature  of  the 
offence  with  which  he  was  charged  "  ;  and 
this  statement  was  confirmed  by  the 
medical  witness  called  by  the  prosecution, 
who  expressed  the  opinion  "  that  the  pri- 
soner was  undoubtedly  insane,  and  that 
he  was  quite  incapable  of  appreciating  the 
position  in  which  he  stood,  or  of  pleading 
to  the  charge.'' 

In  the  case  of  Richardson,  the  medical 
witnesses  gave  evidence  to  the  effect  that 
"  the  j^risoner  was  insane,  and  not  in  a  fit 
state  to  i^lead  " ;  and  it  does  not  appear 
that  any  objection  was  made  to  receiving 
the  evidence  in  that  form. 

It  is  unnecessary  to  multiply  examples 
of  unopposed  cases ;  but  the  following 
ma)^  be  given  for  the  purpose  of  illustrat- 
ing the  effect  of  delusions  as  bearing  upon 
the  question  of  capacity  to  plead.  The 
report  is  taken  from  the  Carlisle  Exjpress 
of  January  14,  1882. 

William  Jones,  aged  43,  a  doctor  of 
medicine,  was  arraigned  at  the  Carlisle 
Assizes,  before  Mr.  Baron  Pollock,  on  a 
charge  of  having  committed  criminal 
assaults  on  four  girls  under  the  age  of 
twelve  years, whom  he  haddecoj^ed  into  his 
house  by  promising  to  give  them  Christmas 
cards.  He  was  labouring  under  the  delu- 
sion that  he  had  invented  some  wonderful 
medicines,  which  he  called  his  Alpha  and 
Omega  medicines  ;  and  Dr.  Clouston  gave 
evidence  to  the  effect  that  the   accused 


Plead,  Capacity  of  Insane  to    [    953    ]    Plead,  Capacity  of  Insane  to 


believed  that  it  had  been  revealed  to  him 
that  the  offsi:)ring  of  a  virgin  was  to  trans- 
mit his  theories,  as  to  his  medicines,  to 
posterity ;  and  that,  underlying  these  delu- 
sions, there  was  a  condition  of  morbid 
exaltation  and  mental  enfeeble ment.  Mr. 
Baron  Pollock,  in  charging  the  jury,  said 
"If  the  balance  of  a  man's  mind  was  dis- 
turbed by  some  hallucinatiou,  or  if  he 
believed  there  was  a  special  and  Divine 
interposition  in  his  favour,  for  the  benefit 
of  the  world,  by  which  a  male  child 
should  be  born  to  him,  and  that  the  office 
of  that  child  in  the  woi'ld  should  be  some- 
thing special,  one  could  hardly  imagine 
anything  that  could  be  more  dangerous." 
His  lordshi})  laid  stress  on  the  evidence  of 
Dr.  Cloustou,  who  said  that  in  spite  of  the 
prisoner's  position  the  dominant  idea  in 
his  mind  was  the  delusion  as  to  his  medi- 
cines and  the  benefit  they  were  destined 
to  do  to  the  world. 

The  jury  returned  a  verdict  that  the 
accused  was  "  not  capable  of  defending 
the  case  against  him,"  and  his  lordship 
made  his  customary  order  for  detention 
during  Her  Majesty's  pleasure. 

Although  this  man  was  unquestionably 
insane,  and  was  incapable  on  that  account 
of  pleading  to  the  charge  "with  that 
advice  and  caution  that  he  ought,"  or  of 
"■  taking  a  rational  part  in  the  trial,"  yet 
it  could  scarcely  be  said  that  his  mental 
derangement  was  such  as  to  render  him 
incapable  of  knowing  when  he  was  in 
prison,  or  when  he  was  going  to  take  his 
trial,  or  what  was  taking  j^lace  in  Court. 

One  more  case  may  be  cited  for  the  sake 
of  the  terms  in  which  the  same  learned 
judge  directed  the  jury. 

Thomas  Mills,  aged  57,  was  charged  at 
the  Ipswich  Assizes  in  May  1884,  before 
Mr.  Baron  Pollock,  with  the  murder  of 
his  wife.  He  had  beaten  her  to  death, 
with  a  stake,  and  then  he  gave  himself 
up  to  the  police,  and  said  he  did  not 
know  why  he  had  done  it.  When  about 
to  be  arraigned,  evidence  was  given  by 
Dr.  Eager,  the  medical  superintendent 
of  the  Suffolk  County  Asylum,  to  the 
effect  that  the  prisoner  was  insane  and 
unfit  to  plead.  Upon  this,  the  learned 
judge  directed  the  jury  that  "  there  was  a 
law  that  no  man  could  be  tried  except  he 
was  present  at  his  trial ;  and  present,  not 
only  in  body,  but  also  in  mind,  in  such 
wise  that  he  could  take  a  rational  part  in 
the  trial,  understand  the  evidence  against 
him,  and  do  his  best  to  defend  himself 
against  such  a  charge." 

The  jury  returned  a  verdict  to  the 
efiect  that  the  prisoner  was  insane  and 
unfit  to  plead  . 

In  this  case,  again,  it  will  be  seen  that  a 


prisoner  may  be  quite  aware  of  the  natui-e 
of  the  act  that  he  has  committed,  may 
give  himself  up  to  the  police  foi"  it,  and 
may  know  quite  well  when  he  is  in  prison 
and  when  he  is  being  tried,  and  yet  may 
be  held  to  be  unable,  by  reason  of  his 
mental  condition,  to  "  take  a  rational 
part  in  his  trial,  understand  the  evidence 
against  him,  and  do  his  best  to  defend 
himself  against  such  a  charge." 

(2)  Leaving  for  thepi-esentthe  unopposed 
cases,  and  coming  to  those  in  which  the 
point,  whether  the  accused  is  in  a  fit 
mental  condition  to  take  his  trial,  is 
closely  contested,  the  following  may  be 
taken  as  useful  examples : — 

The  first  of  these  is  reported  in  the 
Leeds  Mercury  of  the  17th  of  February 
1888. 

William  Taylor  was  indicted  at  the 
Yorkshire  Winter  Assizes,  held  at  Leeds, 
in  February  1 888,  before  Mr.  Justice  Day, 
for  the  wilful  murder  of  his  daughter,  and 
also  of  a  police  superintendent,  at  Otley, 
on  the  24th  of  November,  1887. 

The  prosecution  was  conducted  by  Mr. 
Hardy  and  Mr.  C.  M.  Atkinson;  and  the 
prisoner  was  defended  by  Mr.  Waddy,Q.C., 
and  Mr.  Kershaw. 

Mr.  Waddy  said  that,  acting  on  the  ad- 
vice of  several  eminent  medical  witnesses, 
he  would  ask  his  lordship  to  enable  him 
to  put  an  issue,  in  the  first  instance,  as  to 
the  power  of  the  prisoner  to  plead.  He 
was  prepared  with  evidence  to  show  that 
at  the  present  moment  the  man  was  in- 
sane. The  jury  having  been  sworn  to 
decide  this  issue,  Dr.  Clifford  Allbutt  was 
called,  and  stated  that  he  had  examined 
the  prisoner  on  the  previous  Saturday,  and 
also  on  that  (Thursday)  morning  before 
the  sitting  of  the  Court. 

Mr.  Waddy  then  put  this  question : 
"And  on  Saturday  was  he  sane  or  in- 
sane ?  "  But  Mr.  Hardy,  for  the  prose- 
cution, objected  to  that  question,  and  his 
lordship  sustained  the  objection,  observ- 
ing that  the  condition  of  the  man's  mind 
was  a  matter  for  the  decision  of  the  jury. 
Upon  Mr.  Waddy  urging  that  he  was 
entitled  to  ask  the  witness,  as  an  expert, 
what  his  opinion  was,  his  lordship  said. 
Certainly  not.  That  was  a  matter  on 
which  he  was  perfectly  clear.  Experts 
were  not  to  be  asked  their  opinion  on  sub- 
jects which  it  was  the  function  of  the  jury 
to  decide.  He  was  not  laying  this  ruling 
down  with  reference  to  that  particular 
case,  or  with  reference  especially  to 
questions  of  sanity.  He  laid  it  down  in 
all  cases  in  which  scientific  or  exjiert 
witnesses  could  be  called  to  give  evidence 
as  to  their  opinion.  Mr.  Waddy  then  said 
that  he  proposed  to  put  witnesses  into  the 


Plead,  Capacity  of  Insane  to    [    954    ]    Plead,  Capacity  of  Insane  to 


box  for  the  purpose  of  showing,  from  the 
prisoner's  past  history,  his  present  state 
of  mind;  but  his  lordship  dej^recated  that 
course,  and  said  that  it  might  be  possible 
that  the   prisoner    had   spent  his    whole 
existence  in  a  lunatic  asylum,  and  pro- 
perly ;  but  the  question  before  them  now 
was  whether  he  was  at  present   a   sane 
man   and  able  to  distinguish  between  a 
plea  of  guilty  aud  one  of  not  guilty.     He 
was  not  going  to  shut  out  the  evidence, 
but  if  proceeded    with  he   considered    it 
■would   represent   so   much  wasted  time. 
Mr.  Waddy  then  suggested  that  he  might 
ask  Dr.  AUbutt  whether,  from  the  inves- 
tigation   he   had  made,  he   thought  the 
jDrisoner  was,  or  was  not,  capable  of  under- 
standing his  position ;    but   his  lordship 
ruled  that  that  was  not  a  proper  question 
at  all ;  and  went  on  to  say  that  it  was  not 
for  doctors  to  give  verdicts.     The  witness 
could  describe  the  prisoner's  conversation 
and  his  manner,  and  the  jury  would  de- 
cide as  to  his  sanity.     He  could  not  allow 
their  functions  to  be  delegated  to  profes- 
sional witnesses.     Mr.  Waddy  then  asked 
Dr.  Allbutt  to  simply  describe  the  course 
of  his  interviews  with  the  prisoner.     In 
reply,   Dr.   Allbutt   said  that   when  the 
prisoner  was  brought  to  the  room,  on  the 
Saturday  morning,  he    had  the   manner 
and    aspect   suggestive    of  an   epileptic, 
looking  confused   and   puzzled.     He  was 
vacantly  smiling.     Witness  put  a  number 
of  questions   to  him,   and   among   other 
answers   the  prisoner  gave  was  that  he 
was  born  into  this  world  with  four  endow- 
ments, which  were  health,  strength,  pros- 
perity,  and    knowledge,   and  that  these 
were  given  him   by   God.     He  also  said 
there  were  two  Gods,  and  that  one  of  them 
had  forced  those  qualities  against  him  in 
a  manner  which  he  could  not  adequately 
explain.       He     appeared     to    be    weak- 
minded,  confused,  and  incoherent.  Witness 
thought  that,  shortly,  these  were  the  facts 
observed  at   the  interview.     Counsel   for 
the   defence   then   asked :  Had  you   any 
conversation  with  the  accused  with  regard 
to  the  facts  of  the  crime  alleged  against 
him  ?     To   which  Dr.  Allbutt   replied,  I 
had.     I  asked  him,  in  the  first  instance, 
concerning  the   alleged   shooting   of    his 
child.     He  told  me  that  he  remembered 
nothing,  and  was  not  prepared  to  admit 
that  the  event  had  ever  happened.     Con- 
cerning the  evidence  of  the  police  superin- 
tendent, he  said  that  he  had  no  remem- 
brance until  one  day,  while  in  gaol,  he  saw 
an  account  of  the  affair  in  a  newspaper. 
He  then  thought  it  must  be  true,  and  at 
that  moment  he  was  convinced  he  had 
done  it.     He  added  that  he  had  a  more 
or  less  distinct  recollection  of  some  one 


breaking  into  his  house,  and  of  his  shoot- 
ing at  the  intruder.  In  answer  to  further 
questions,  witness  went  on  to  say  that 
there  was  no  sign  of  hypocrisy  about  the 
prisoner ;  that  one  might,  at  first,  have  a 
suspicion  of  malingering,  but  such  sus- 
picion was  removed  by  the  freedom  with 
which  the  prisoner  spoke.  As  a  result 
of  his  interview  he  came  to  a  certain  con- 
viction in  his  own  mind.  During  the 
interview  he  had  had  with  the  prisoner 
that  morning  he  seemed  more  excited,  and 
his  faculties,  no  doubt,  were  brisker.  In 
reply  to  a  further  question  whether,  as 
a  matter  of  medical  science,  where  there 
is  long-continued  epilepsy,  it  affects  the 
mind,  witness  said,  it  may,  and  often  does, 
have  that  effect. 

In  cross-examination  the  witness  said 
it  was  quite  possible  that  the  prisoner 
might  have  assumed  his  peculiar  manner, 
but  he  did  not  believe  that,  in  this  case, 
there  was  any  pretence.  At  that  moment 
the  prisoner  certainly  knew  that  he  was 
on  his  trial,  and  probably-  he  knew  that 
he  was  being  tried  for  murder.  His  in- 
sanity was  more  pronounced  at  one  time 
than  at  another,  and  witness's  impression 
was  that  he  had  gradually  been  becoming 
more  lucid,  up  to  the  present  time.  In  re- 
examination, witness  said  he  thought  the 
prisoner  was  then  unfit  to  give  adequate 
instructions  to  his  solicitor,  and  that  he 
did  not  fully  appreciate  his  position  and 
danger.  His  moods  were  ver}''  variable, 
sometimes  indifferent  and  sometimes  dis- 
tressed. 

Mr.  Gladstone,  solicitor,  then  deposed 
that  he  had  had  several  interviews  with 
the  prisoner,  but  had  been  unable  to  ex- 
tract any  information  with  respect  to  his 
trial.  Dr.  Ritchie  then  deposed  that  he 
had  known  the  prisoner  for  more  than 
twenty  years,  and  had  attended  him  for 
epileptic  fits.  On  the  day  of  the  crime  he 
had  been  called  to  the  prisoner.  He  would 
not  believe  that  he  had  murdered  his  child 
and  the  police  superintendent.  He  said 
a  black  cloud  came  over  him,  and  in  that 
cloud  was  the  Lord  Almighty,  and  what- 
ever he  commanded  him  to  do  he  was 
bound  to  do  it.  He  added  that  his  wife 
had  put  some  stuff  in  his  tea  for  the  pur- 
pose of  poisoning  him,  and  that  she  was 
also  trying  to  poison  the  infant.  Witness 
had  seen  the  prisoner  again  that  morning, 
and  concurred  with  the  evidence  of  Dr. 
Allbutt.  In  cross-examination,  witness 
said  that  when  he  examined  the  prisoner 
on  the  day  of  the  crime  he  was  not  then 
in  a  fit  either  of  epilepsy  or  of  petit  mal. 
From  what  he  had  known  of  him  for  the 
last  twenty  years  he  thought  his  mind  had 
now  entirely  given  way.     In  reply  to  his 


Plead,  Capacity  of  Insane  to    [    955    ]    Plead,  Capacity  of  Insane  to 


lordship,  witness  said  he  hud  not  tried  to 
engage  the  prisoner  in  general  conversa- 
tion, but,  with  the  exception  of  a  reference 
to  his  wife,  he  had  confined  the  conversa- 
tion to  the  subject  of  his  delusions. 
The  Kev.  Mr.  Brooks  gave  evidence  that 
he  had  visited  the  prisoner  in  prison 
about  a  dozen  times  and  that  he  had 
found  him  subject  to  dehisions  the  whole 
time.  Prisoner  said  God  had  told  him  he 
■could  not  kill,  and,  therefore,  it  was  im- 
possible. Dr.  Wright,  consulting  phy- 
sician to  the  West  Riding  Asylum  at 
Wakefield,  agreed  with  the  account  given 
by  Dr.  Ritchie  and  Dr.  AUbutt  as  to  the 
prisoner's  manner ;  and  he  believed  there 
•was  no  feigning  or  exaggeration  on  the 
part  of  the  prisoner.  This  concluded  the 
■evidence  in  support  of  the  contention 
that  the  prisoner  was  unfit  to  plead ;  and 
then  Dr.  Clark,  the  medical  officer  of 
Wakefield  Prison,  Dr.  Be  van  Lewis  the 
medical  superintendent  of  the  West  Rid- 
ing Asylum,  and  Mr.  Edwards,  the  medi- 
cal officer  of  Arm  ley  Gaol,  were  called  by 
the  prosecution  for  the  purpose  of  proving 
the  contrary,  namely,  that  the  prisoner 
was  in  a  fit  state  of  mind  to  be  called  upon 
to  plead.  Dr.  Clark  said  that  whilst 
prisoner  was  in  the  gaol  at  Wakefield  he 
had  enjoyed  good  health,  had  slept  well, 
and  had  exhibited  no  symptoms  that 
•would  lead  to  the  supposition  that  he  was 
insane ;  and  that  he  answered  all  ques- 
tions rationally  and  intelligently. 

By  his  lordship :  "  Prisoner  knew  he 
was  in  gaol  and  that  he  was  about  to 
take  his  trial." 

Dr.  Bevan  Lewis,  in  his  evidence, 
stated  that  he  had  examined  the  prisoner 
on  two  occasions  at  Wakefield,  and  had 
not  observed  in  him  any  appearance  of 
insanity.  He  had  conversed  with  the 
prisoner  on  general  subjects,  and  the  man 
talked  rationally. 

Mr.  Edwards  agreed,  generally,  with 
the  two  previous  witnesses,  but  he  ad- 
mitted, in  cross-examination,  that  the 
prisoner  had  spoken  to  him  of  the  four 
endowments,  health,  strength,  knowledge, 
and  prosperity,  mentioned  by  Dr.;Allbutt, 
and  that  he  had  lately  been  incoherent  in 
his  manner.  The  prisoner  had  asked 
witness  several  times  if  he  thought  a  man 
in  his  sane  mind  could  commit  such  a 
crime  as  that  with  which  he  was  charged. 
In  reply  to  his  lordship,  Mr.  Edwards  said 
that  at  Armley  Gaol  the  prisoner  had 
been  associated  with  two  other  prisoners  ; 
and,  by  the  direction  of  the  learned  judge, 
these  men  were  sent  for,  and  one  of  them 
deposed  that  the  prisoner  did  not  seem  to 
remember  anything  about  the  crime  with 
■which  he  was  charged,  but  that  he  had 


said  that  he  thought  lie  should  be  confined 
in  an  asylum,  as  the  result  of  the  trial. 
Counsel  having  addressed  the  jury,  for 
the  prosecution,  and  for  the  defence,  his 
lordship  pointed  out  what  he  considered  a 
very  singular  remark  of  the  prisoner's, 
with  respect  to  the  asylum,  which  he  did 
not  think  would  be  made  by  an  insane  man. 
And  then,  after  a  few  minutes'  consulta- 
tion, the  foreman  announced  that  the 
jury  were  unanimously  of  opinion  that  the 
prisoner  was  sane. 

The  prisoner  was  then  indicted  for  the 
wilful  murder  of  the  superintendent  of 
police,  and  when  called  to  plead,  said,  "  I 
know  nothing  about  it."  The  trial  then 
proceeded,  and  occupied  the  remainder  of 
that  day,  as  well  as  the  greater  portion  of 
the  following  day ;  with  the  ultimate 
result  that  the  jury  found  a  verdict  to  the 
effect  that  the  prisoner  was  guilty  of  the 
murder,  but  that  he  was  of  unsound  mind 
when  he  committed  the  act;  upon  which 
the  usual  order  was  made  for  his  deten- 
tion as  a  criminal  lunatic. 

The  fact  that  the  medical  witnesses 
were  divided  in  opinion  in  the  foregoing 
case  may  possibly  have  formed  one  of  the 
reasons  which  led  the  jury  to  say,  by  their 
verdict,  on  the  first  day,  that,  in  their 
opinion,  the  prisoner  was  sane,  so  as  to 
be  fit  to  take  his  trial ;  but  it  would  be 
by  no  means  right  to  conclude  that  this 
was  the  only  reason  ;  as  will  appear  from 
a  consideration  of  the  following  case,  in 
which,  although  the  medical  ofiicer  of  the 
gaol,  in  which  the  prisoner  had  been  con- 
fined whilst  awaiting  trial,  regarded  him 
as  being  unfit  to  plead  by  reason  of  his 
mental  condition,  and  although  he  was 
supported  in  this  opinion  by  the  medical 
superintendent  of  the  Coi^nty  Asylum, 
who  had  examined  the  prisoner  upon  in- 
tructions  from  the  Home  Secretary,  never- 
theless, it  was  decided  otherwise,  and  the 
case  was  tried  out ;  with,  however,  the 
ultimate  result,  in  this  case  also,  that  the 
prisoner  was  declared  by  the  verdict  of  the 
jury  to  have  been  *'  insane  at  the  time  he 
committed  the  act.''  The  case  is  fully  re- 
ported in  the  Norfolk  Neivs  of  November 
19,  1887  :  Arthur  Edward  Gilbert  Cooper, 
aged  34,  clerk  in  holy  orders,  was  indicted 
for  feloniously,  wilfully,  and  of  his  malice 
aforethought,  killing  and  murdering  the 
Rev.  William  Farley,  at  Cretingham,  on 
October  2,  1887.  The  case  was  ti-ied  be- 
fore Mr.  Justice  Field,  now  Lord  Field, 
on  November  15,  1887,  at  Norwich.  In 
his  charge  to  the  grand  jury,  on  a  previous 
day,  his  lordship  had  referred  to  the  case 
in  the  following  terms  :  "  It  is  a  very  sad 
case.  It  is  one  in  which  a  clergyman,  the 
rector  of  the  parish  of  Cretingham,  came 


Plead,  Capacity  of  Insane  to    [    956    ]    Plead,  Capacity  of  Insane  to 


by  his  death  undoubtedly,  upon  the  evi- 
dence, by  the  acts  of  the  prisoner,  who 
was  his  curate.  There  is  no  doubt  what- 
ever upon  the  facts.  The  only  question 
which  will  arise,  when  it  comes  here,  will 
be  as  to  the  prisoner's  state  of  mind  when 
he  did  what  it  is  clear  he  did.  That  is  a 
matter  with  which  you  need  not  have  to 
■do.  It  will,  of  course,  be  carefully  inquired 
into  in  the  Court  below." 

On  the  day  when  the  prisoner  was  ar- 
raigned, he  was  about  being  called  upon 
to  plead  to  the  indictment,  when  Mr. 
Murphy,  Q.C.,  counsel  for  the  prisoner, 
said  that,  before  the  prisoner  was  called 
upon  to  plead,  he  had  certain  information 
before  him  to  which  he  deemed  it  impera- 
tive ujDon  him  to  direct  the  attention  of 
the  Court,  in  order  that  an  inquiry  might 
first  be  made  as  to  whether  or  not  the 
prisoner  was  in  a  fit  state  to  plead  or  to 
conduct  his  defence. 

Hislordship:  "You deny prisoner'scom- 
petence  to  plead  ?  " 

Mr.  Murphy  :  "  I  do," 

The  jury  was  then  sworn  to  try 
whether  "  the  prisoner  is  of  sound  mind 
and  understanding,  so  as  to  be  capable  of 
taking  his  trial  on  the  charge  whereof  he 
stands  indicted." 

Mr.  Murphy  then  said  that  it  had 
come  to  his  knowledge  that  Dr.  Eager,  a 
medical  man  of  eminence,  instructed  by 
the  Home  Office,  had  inquired  into  the 
condition  of  the  prisoner  during  the  past 
month,  and  that  the  surgeon  of  the  gaol, 
under  whose  charge  the  prisoner  had  been, 
had  also  formed  an  opinion  on  the  sub- 
ject, to  which,  in  justice  to  the  prisoner, 
an  appeal  ought  to  be  made  before  he  was 
put  on  his  trial.  The  law  j^resumed  that 
all  men  were  responsible  for  their  actions 
until  the  contrary  had  been  proved.  Still, 
the  law  was  merciful,  for  it  neither  made 
a  man  responsible  for  an  act  committed 
when  insane,  nor  did  it  call  upon  him  to 
take  his  trial  when,  through  his  state  of 
mind,  he  would  be  unable  to  instruct  his 
advisers  to  take  the  necessary  steps  to 
present  his  defence  in  a  proj^er  way.  He, 
therefore,  intended  to  call  medical  gentle- 
men who  had  that  morning  seen  the 
prisoner,  to  give  their  opinion  as  to  the 
prisoner's  condition. 

His  lordshij)  intimated  that  the  sole 
question  upon  which  evidence  would  have 
to  be  given  was  the  prese7it  state  of  mind 
of  the  prisoner. 

Mr.  George  Hetherington,  the  medical 
officer  of  the  Ipswich  Gaol,  was  called,  and 
said,  "I  have  had  the  prisoner  under  my 
charge  from  October  6  until  within  the 
last  week,  when  he  was  removed  to  Nor- 
wich for  trial." 


His  lordship  :  "  Under  charge  is  a  gene- 
ral expression.     What  did  he  do  ?  " 

Mr.  Dering  (coixnsel  for  prisoner) : 
"  Was  he  especially  put  under  your 
charge  ?  " 

Witness  :  "Yes." 

His  lordship :  "  What  did  you  do  with 
him  ?  " 

Witness  :  "  My  attention  was  called  to 
him,  particularly,  because  of  the  nature  of 
his  offence.  I  attended  him  daily  during 
the  time  he  was  in  Ipswich  prison." 

Mr.  Dering :  "  What  opinion  did  you 
form  as  to  his  state  of  mind  ?  " 

His  lordship :  "  We  must  get  at  the 
facts.  We  can  only  now  inquire  as  to  his 
present  state  of  mind." 

Witness  :  "  I  examined  him  this  morn- 
ing.    I  asked  him  several  questions." 

His  lordship  :  "  What  did  you  say  ?  " 

Witness  :  "  I  said,  '  Can  you  recollect 
what  happened  that  Saturday  night  ? '  My 
conversation  was  part  of  that  carried  on 
by  Dr.  Eager,  who  commenced  it.'"' 

Dr.  Eager  was  then  called  into  the 
witness-box.  He  said  :  "  I  am  the  resi- 
dent physician  and  superintendent  of  the 
Suffolk  County  Asylum.  I  first  saw  the 
prisoner  on  November  i  at  Ipswich  Gaol, 
in  the  Governor's  room." 

Mr.  Murphy  :  "  By  whose  instruction  did 
you  see  him  ?  " 

Witness  :  "  By  the  Home  Secretary's. 
I  conversed  with  him  about  an  hour.  I 
next  saw  him-' this  morning,  in  the  cell  at 
the  back  of  the  Court.  I  spoke  to  him 
this  morning  for  two  or  three  minutes." 

Mr.  Murphy  :  "  What  occurred  between 
you  and  him  this  morning  ?  I  may  have  to 
ask  you  what  took  place  on  November  i." 

His  lordship,  interposing  :  "  I  think 
the  first  course  you  mention  is  the  proper 
one.  We  are  trying  whether  the  prisoner 
is  noiv  in  such  a  state  of  mind  that  he  is 
fit  to  plead." 

Mr.  Murphy:  "What  occurred  this 
morning.''  " 

Witness :  "  I  said,  '  Good  morning. 
Cooper.'  He  said,  '  Good  morning.'  I 
said,  'How  are  you  this  morning.^  '  He 
hesitated  a  good  deal,  and  said,  '  Pretty 
well.'  I  said,  '  Have  you  felt  any  of  the 
sensations  of  which  you  spoke  to  me  when 
I  was  at  Ipswich  ?  '  He  said,  '  I  do  not 
know  that  I  have.'  " 

His  lordship  :  "  Did  you  say  anything 
more  to  him  ?  " 

Witness :  "  I  don't  know  that  I  said 
anything  more.  Oh  yes,  I  said,  '  Do  you 
know  the  day  of  the  month  ? '  He  replied, 
'I  do;  it  is  November  15.'  I  said.  'Do 
you  know  the  day  of  the  week .'' '  He 
said,  '  It  is  Tuesday.'  I  cannot  recollect 
that  I  said  anything  else  to  him." 


Plead,  Capacity  of  Insane  to    [    957    ]    Plead,  Capacity  of  Insane  to 


Mr.  Murphy  :  "  Now  tell  me  what  oc- 
cun-ed  on  November  i.  Have  you  any 
notes  you  made  at  the  time  ?  " 

Witness  :  "  No,  not  here." 

His  lordship :  "  After  this,  do  you 
think  it  necessary  to  go  on  ?  " 

Mr.  Murphy  :  "  Oh  yes  ;  the  impression 
formed  at  the  previous  examination,  made 
on  November  i,  may  be  confirmed,  in  a 
few  minutes,  later  on,  by  a  look  as  well  as 
by  a  question." 

Witness  :  "  I  was  with  him  for  an  hour 
on  November  i." 

His  lordship  intimated  that  he  should 
leave  the  question  to  the  jury  upon  facts, 
not  i;pon  opinions,  so  that  it  was  import- 
ant to  have  facts. 

Witness  :  "  I  sent  a  report  to  the  Home 
Office." 

Mr.  Mayd  (counsel  for  the  prosecution)  : 
"  That  report  gives  no  details  of  any  con- 
versation." 

His  lordship :  "  In  the  second  para- 
graph of  your  report,  dated  November  2, 
you  say,  '  He  is  now  hopelessly  insane, 
and  irresponsible  for  the  action.'  Will 
you  tell  us  what  are  the  facts  upon  which 
you  founded  that  opinion — that  he  was 
hopelessly  insane  ?  " 

Witness  :  "  From  his  appearance,  which 
was  very  vacant.  His  manner  was  hesi- 
tating and  doubtful." 

Mr.  Murphy :  "  Was  he  serious,  or 
otherwise,  in  his  conversation  ?  " 

Witness  :  "  He  was  mostly  serious." 

Mr.  Murphy  :  "  Was  he  laughing  ?  " 

Witness  :  "  At  one  time  he  stood  up, 
his  expression  became  fixed,  his  eyes  half 
closed,  and  he  seemed  to  be  looking  into 
space.  He  was  perfectly  unaware,  appa- 
rently, that  I  was  in  the  room  until  I 
called  his  attention  to  myself." 

Mr.  Murphy  :  "  How  did  you  call  his 
attention  ?  " 

Witness  :  "I  said,' What  are  you  doing?' 
He  suddenly  came  to  himself,jerked  his  head 
up,  and  laughed  in  a  very  foolish  way.'' 

Mr.  Murphy :  "  Can  you  tell  us  any 
other  facts  upon  which  you  founded  this 
judgment?  " 

Witness  :  "  He  said,  '  I  feel  that  I  am 
influenced  by  people  I  cannot  see.'  I 
think  he  volunteered  that.  I  said, '  When 
do  you  feel  that  sensation  ?  '  He  replied, 
'  More  especially  at  night.  I  do  not  feel 
alone  at  night  when  I  awake,  but  feel  that 
I  am  surrounded  by  things  in  the  air.  I 
felt  dazed  when  I  got  out  of  bed ;  I  did 
not  know  what  1  was  going  to  do." 
During  the  conversation  he  said,  '  I  did 
not  distinctly  understand  what  happened 
until  a  few  days  ago.'  " 

His  lordship :  "  All  this  is  what  we 
may  have  to  hear  by-and-by." 


Ml*.  Murphy  :  "  The  issue  we  are  to  try 
is  one  upon  which  the  prisoner  can  only 
have  assistance  from  the  people  about 
him  in  gaol.  Fi'oni  his  manner  and  ap- 
pearance did  you  form  any  judgment  as 
to  prisoner's  condition  to-day  ?  " 

Witness :  "  Yes." 

His  lordship  :  "  What  was  his  appear- 
ance this  morning  ?  " 

Witness  :  "  He  was  in  the  same  condi- 
tion." 

His  lordship :  "  Did  you  form  any 
opinion  that  he  is  not  in  a  condition  fit  to 
understand  why  he  is  here  to-day,  and  to 
follow  the  evidence,  and  able  from  his 
state  of  mind  to  instruct  learned  coun- 
sel?" 

Witness  :  "  I  think  he  is  able'to  form  a 
judgment  as  to  why  he  is  here  ;  but  I  do 
not  think  he  is  able  to  form  any  judgment 
as  to  instructing  his  counsel." 

"  From  mental  disease,  do  you  mean  ?  " 

"Yes." 

"  From  what  did  you  di-aw  that  infer- 
ence ?  " 

"  From  my  own  experience  and  know- 
ledge." 

"What  are  the  facts  which  enabled  you 
to  form  the  opinion  that  he  is  not  able  to 
do  so  ?  " 

"  I  think  his  mind  naturally " 

"  I  know  you  think.  What  are  the 
facts  upon  which  you  arrived  at  that 
opinion  ?  " 

"  His  hesitating  manner  ;  his  api^arent 
inability  to  answer  simple  questions." 

His  lordship:  "  The  only  question  you 
asked  this  morning  was,  how  he  was." 

Mr.  Murphy  :  "  Is  it  consistent  with 
your  experience  that  a  man  suffering  from 
unsoundness  of  mind  should  be  able  to 
answer  ordinary  questions,  and  conduct 
himself  like  a  reasonable  man  ?  " 

Witness  :  "  Quite  so." 

Mr.  Mayd :  "  Is  the  prisoner  able  to 
understand  the  difference  between  a  plea 
of  guilty  and  one  of  not  guilty  ?  " 

Witness  :  "  I  believe  he  is." 

The  foregoing  evidence  has  been  given 
in  extenso  for  the  purpose  of  showing 
more  vividly  the  kind  of  questions  that 
are  likely  to  be  put  to  a  witness  in  a  case 
of  this  sort ;  but  considerations  of  space 
render  it  necessary  to  condense  what  fol- 
lows. 

Mr.  Hetherington  was  recalled,  and,  in 
reply  to  questions,  said  :  "  I  believe  that, 
from  the  condition  of  his  mind,  the  pri- 
soner is  unable  to  23lead.  I  foi'm  that 
opinion  from  what  I  have  seen  of  him  in 
the  gaol,  and  from  what  I  saw  of  him  this 
morning." 

This  witness  was  then  examined  and 
cross-examined  at  length  as  to  his  reasons 


Plead,  Capacity  of  Insane  to    [    958    ]    Plead,  Capacity  of  Insane  to 


for  that  opinion  ;  and,  ultimately,  coansel 
for  the  prosecution  put  these  questions  : 

''  In  3"our  opinion,  is  the  prisoner  able 
to  understand  the  difference  between  a 
plea  of  guilty  and  one  of  not  guilty  ?  " 
To  which  witness  replied,  "  Yes."  And 
then.  "  From  what  you  ha.ve  seen,  do  you 
think  he  is  able  to  give  instructions,  for 
his  defence,  to  his  counsel  ?  "  to  which 
witness  replied,  "  No." 

His  lordship  then,  after  counsel  had 
addressed  the  jury,  pointed  out  that  the 
question  at  issue  was  whether  the  pri- 
soner was  in  a  fit  state  of  mind  to  take 
his  trial.  "  The  law  of  England,"  said 
his  lordship,  "  had  not  come  to  the  posi- 
tion that  a  man  was  not  to  take  his  trial 
merely  upon  the  opinion  of  some  other 
person,  however  eminent  he  might  be. 
The  jury  had  to  say  whether  or  not  they 
were  of  opinion  that  the  prisoner  was  at 
that  moment  of  such  a  sound  mind  as  to 
plead  and  take  his  trial.'' 

The  jury,  after  very  brief  deliberation, 
found  a  verdict  "  that  prisoner  was  able 
to  understand,  to  plead,  and  to  take  his 
trial." 

The  clerk  of  assize  then  read  over  the 
indictment  to  the  prisoner,  and  asked 
him  if  he  were  guilty  or  not  guilty  ;  to 
•which  the  prisoner  replied,  "  Not  guilty, 
wilfully." 

A  fresh  jury  was  then  sworn  to  try  the 
case,  and  ultimately,  after  a  lengthened 
trial,  the  report  goes  on  to  say  that  "  the 
jury  consulted  for  about  two  minutes, 
and  then  returned  a  verdict  that  prisoner 
was  insane  at  the  time  he  committed  the 
act." 

His  lordship  :  "  You  find  that  he  was 
guilty  of  killing,  but  that  he  was  insane 
so  as  not  to  be  responsible,  according  to 
law,  for  his  actions  at  the  time  the  act 
was  committed." 

The  foreman  :  "  We  do,  my  lord." 

His  lordship:  "The  prisoner  will  be 
detained  during  Her  Majesty's  pleasure." 

The  whole  of  the  evidence  which  led  the 
jury  to  this  verdict  is  instructive,  but  a 
brief  summary  will  suffice. 

Counsel  for  the  prosecution  opened  the 
case  by  stating  that  in  1878  the  prisoner 
had  been  under  the  care  of  Dr.  Harrington 
Tuke ;  that  he  was  subsequently  sent  to 
Northumberland  House  Asylum,  and 
afterwards  to  St.  Luke's,  where  he  was 
treated  as  a  lunatic  until  September  1882, 
when  he  obtained  leave  of  absence,  and 
was  ultimately  discharged  as  relieved,  but 
not  cured.  Since  then  he  had  assisted 
friends  in  clerical  duty. 

The  evidence  showed  that  he  had  offi- 
ciated as  Mr.  Farley's  curate  for  about  a 
year,    when,    shortly   after   midnight   on 


October  2,  he  rapped  at  Mr.  Farley's  bed- 
room door,  and,  upon  obtaining  admis- 
sion, he  walked  up  to  the  bed  in  which 
Mr.  Farley  was  lying,  and  cut  his  throat 
with  a  razor,  and  then  left  the  room. 

Mrs.  Farley,  in  giving  evidence,  stated 
that  neither  she  nor  her  husband  knew 
that  the  prisoner  had  been  in  an  asylum, 
but  they  had  noticed  that  he  was  very 
strange. 

The  parish  clerk  stated,  in  his  evidence, 
that  in  a  conversation  which  he  had  had 
with  the  prisoner  directly  after  the  occur- 
rence, he  had  asked  him,  "Did  you  think 
about  it  betoi'e.P"  to  which  prisoner  re- 
plied, "Yesterday." 

Evidence  as  to  the  insanity  of  the  pri- 
soner was  given  by  Mr.  G.  Jones,  who  was 
called  to  the  deceased,  and  who  afterwards 
saw  the  prisoner  ;  by  Dr.  Wright,  of 
Northumberland  House  ;  by  Dr.  Mickley, 
medical  superintendent  of  St.  Luke's ; 
by  Dr.  Wood,  physician  to  St.  Luke's  ; 
by  Dr.  Harrington  Tuke ;  and  by  an  uncle 
of  the  prisoner,  who  stated  that  insanity 
was  hereditary  in  the  family. 

In  this  case,  the  accused  had  been  an 
inmate  of  different  asylums  for  some 
years,  and  had  then  been  discharged,  not 
recovered,  but  only  relieved  ;  and,  after 
being  apparently  at  large  for  some  four  or 
five  years,  he  killed  his  vicar  in  the  man- 
ner that  has  been  described.  For  this 
offence  he  was,  six  weeks  afterwards, 
placed  upon  his  trial ;  with  the  result  that 
the  jury  found,  without  any  hesitation, 
and  without  leaving  the  box,  that,  at 
the  time  he  committed  the  act,  he  was 
insane  so  as  not  to  be  responsible.  But, 
on  the  other  hand,  when  he  was  ar- 
raigned, he  was  declared  by  the  jury  to 
be  competent  to  plead  and  to  take  his 
trial.  The  jury  had  been  sworn  to  try 
"whether  the  prisoner  is  of  sound  mind 
and  understanding  so  as  to  be  capable  of 
taking  his  trial,"  but,  according  to  the 
report  given  by  the  Korfolk  J^eics,  they 
would  appear  to  have  avoided  saying  in 
so  many  words  that  he  was  "  of  sound 
mind  and  understanding,"  and  to  have 
limited  themselves  to  saying  "that  pri- 
soner was  able  to  understand,  to  plead, 
and  to  take  his  trial."  Both  the  medical 
witnesses  who  were  examined  at  the  pi*e- 
liminary  inquiry  said  that,  in  their  opinion, 
the  prisoner  was  able  to  understand  the 
difference  between  a  plea  of  guilty  and 
one  of  not  guilty,  and  also,  that  he  was 
capable  of  knowing  that  he  was  on  his 
trial ;  but  they  both  concurred  in  saying 
that,  in  their  opinion,  he  was  not  com- 
petent to  give  adequate  instructions  for 
his  defence  to  his  counsel.  If,  then,  the 
jury,   in    saying    that   the    prisoner   was 


Plead,  Capacity  of  Insane  to    [    959    ]    Plead,  Capacity  of  Insane  to 


able  to  understand,  intended  only  to  say 
that  he  was  able  to  understand  the  dif- 
ference between  a  plea  of  guilty  and  one 
of  not  guilty,  they  said,  on  this  point,  no 
more  than  was  said  by  the  medical  wit- 
Tiesses,  and  indeed,  with  reference  to  this 
point,  the  fact  that  the  prisoner,  when 
called  ui)on  to  plead,  replied,  "  Not  guilty 
wilfully,"  showed  that  the  opinion  as  to 
his  ability  to  understand  this  difference 
was  well  grounded,  whilst  that  he  knew 
the  nature  of  the  charge  preferred  against 
him  may  be  inferred  from  the  observa- 
tion made  by  him  to  one  of  the  medical 
witnesses  to  the  effect  that  he  "did  not 
distinctly  understand  what  had  happened 
until  a  few  days  ago,"  implying  thereby, 
that,  at  the  time  when  he  said  this,  he 
did  understand  what  had  happened.  To 
say,  however,  that  a  person  is  able  to 
understand  the  difference  between  a  plea 
of  guilty  and  one  of  not  guilty  is,  of  course, 
by  no  means  equivalent  to  saying  that 
such  person  is  of  sound  mind  generally, 
and  j-et,  supposing  for  the  sake  merely  of 
illustration,  that  the  cajiacity  to  under- 
stand this  difference  were  held  to  con- 
stitute the  test  of  fitness  to  plead,  a  per- 
son who  possessed  this  capacity  might,  no 
doubt,  in  the  purely  technical  as]>ect  of  the 
case,  be  looked  upon  as  being  of  "  sound 
mind  and  understanding  "  so  far  as,  but 
no  farther  than,  that  particular  matter  is 
concerned. 

This  use  of  the  formula.  "  sound  niiud 
and  understanding  "  is,  however,  some- 
v/hat  puzzling  to  those  who  are  not  ac- 
customed to  it,  and  indeed,  the  necessity 
for  its  retention  is  not  very  manifest,  for 
if  it  is  the  case  that  the  law  says  that 
a  pei'son  is  to  be  called  upon  to  take  his 
trial,  although  not  of  sound  mind,  pro- 
vided that  he  is  able  to  understand  the 
difference  between  a  plea  of  guilty  and 
one  of  not  guilty,  or  provided  that  he 
comes  up  to  a  certain  standard  of  coher- 
ence, then  it  would  appear  that  the  only 
question  for  the  jury,  at  that  stage  of  the 
inquiry,  would  be  whether  the  accused 
did  or  did  not  come  up  to  such  standard, 
and  it  would  not  appear  to  be  necessary 
to  require  the  jury,  at  that  stage,  to  pre- 
judge the  wider  question  of  whether  the 
prisoner  was  or  was  not  of  sound  mind. 

Possibly  an  argument,  in  support  of 
the  view  that  persons  may  be  called  upon 
to  plead  although  insane,  might  be  de- 
duced from  the  wording  of  the  Act  of  1883, 
the  46  &  47  Vict.  ch.  38,  the  first  sec- 
tion of  which  is  to  the  etfect  that  the  Act 
may  be  cited  as  the  "  Trial  of  Lunatics 
Act."  This  might  be  held  to  indicate 
that  the  Act  contemijlated  that  lunatics 
might  be  placed  upon  their  trial ;  but  here 


again  a  question  might  arise  as  to  whether 
this  could  only  be  done  during  a  luciil 
interval,  and  a  further  question  would  be 
as  to  what  constituted  a  lucid  interval. 

The  question  that  was  raised  in  this  case, 
as  to  whether  the  prisoner  was  able  to 
give  adequate  instructions  to  his  counsel, 
does  not  appear  to  have  been  definitely 
answered,  unless  we  may  assume  that  it 
was  answered  by  the  jury  saying  that  he 
was  "  able  to  take  his  trial."  There  was 
no  dispute  in  this  case  as  to  the  facts ; 
and,  indeed,  the  learned  judge  had,  as 
we  have  seen,  stated,  on  a  previous  day 
in  his  charge  to  the  grand  jury,  that  the 
only  question  was  as  to  the  state  of  the 
prisoner's  mind ;  and,  in  a  case  of  this 
kind,  where  it  is  the  object  of  counsel  to 
prove  the  insanity  of  his  client,  it  is 
evident  that  counsel  must  rely  far  more  on 
the  instructions  which  he  receives  from 
others  than  on  those  which  he  receives 
from  the  client  himself 

It  must  not,  however,  be  overlooked  that 
one  risk  which  is  incurred  by  calling  upon 
a  prisoner,  whose  sanity  is  in  doubt,  to 
plead,  even  when  there  is  no  dispute  as  to 
the  facts  of  the  offence  with  which  he  is 
charged,  is,  that  he  may  plead  guilty  ;  and 
if  he  does  that,  and  if  he  persists  in  that 
plea,  after  having  been  declared  fit  to 
plead,  the  further  inquiry  into  his  mental 
condition  by  the  Court  would  appear  to  be 
barred. 

In  that  case  it  apparently  becomes 
necessary  to  pass  sentence,  and  then  to 
leave  the  matter  in  the  hands  of  the  Home 
Secretary.* 

The  problem,  therefore,  in  those  cases 
where  the  facts  are  admitted,  and  where 
the  only  question  is  as  to  the  mental  con- 
dition of  the  accused,  appears  to  be  how 
to  obtain  a  full  and  complete  investiga- 
tion into  all  the  circumstances,  without 
incurring  such  risk  as  may  be  involved  in 
calling  upon  an  insane  person  to  plead. 

(3)  Cases  occasionally  arise  in  which, 
whilst  the  jDrosecution  submits  that  the 
accused  is  insane,  the  accused  himself 
objects.  A  case  of  this  description  was 
tried  at  the  Central  Criminal  Court  in 
February  1887,  before  Mr.  Baron  Pollock. 
Isaac  Jacob  Mauerberger,  aged  36,  a 
journalist,  was  charged  with  sending  a 
threatening  letter  to  Lord  Rothschild. 
Mr.  Poland,  who  appeared  for  the  prose- 
cution, stated  that  he  had  received  a  re- 
port from  the  medical  officer  of  HoUoway 
Gaol  to  the  effect  that  the  prisoner  was 
not  in  a  fit  state  of  mind  to  plead,  and  a 
jury  was  thereupon  impanneiled  to  try 
that  issue. 

Mr.  Gilbert,  the  medical  officer  oE  Hol- 
*  See  the  case  of  Swatmau,  p.  961. 


Plead,  Capacity  of  Insane  to    [    960    ]    Plead,  Capacity  of  Insane  to 


loway  Gaol,  said  that  in  his  judgment 
the  prisoner  was  insane,  and  not  possessed 
of  sufficient  undprstanding  to  enable  him 
to  comprehend  the  charge  or  to  defend 
himself.  His  lordship  inquired  what  form 
this  insanity  took,  and  witness  replied  that 
the  prisoner  was  subject  to  many  delu- 
sions. Dr.  Blandford  having  given  similar 
evidence,  the  prisoner  said  he  should  cross- 
examine  the  medical  men  minutely  as  to 
the  grounds  upon  which  they  based  their 
opinions.  He  should  prove  that  he  had 
never  been  insane,  but,  on  the  contrary, 
was  of  perfectly  sound  mind.  The  jury, 
however,  intimated  that  they  were  per- 
fectly satisfied.  Mr.  Baron  Pollock  then, 
after  referring  to  the  medical  evidence, 
said  he  need  not  tell  the  jury  that  accord- 
ing to  the  law  of  every  civilised  country 
a  man  could  not  be  tried  unless  he  could 
understand  and  appreciate  the  forms  of 
trial.  According  to  the  statute  law  of 
this  country  a  man  could  not  be  called  on 
to  plead  unless  he  was  of  sound  mind.  If 
his  intellect  was  such  that  he  could  not 
understand  what  was  going  on  in  a  court 
of  justice,  it  was  the  duty  of  the  jury  to 
say  whether  or  not  he  was  of  sufficiently 
sound  mind  to  take  his  trial.  The  jury 
then  returned  their  verdict  that  the 
prisoner  was  not  of  sufficiently  sound  mind 
to  take  his  trial ;  and  the  usual  order  was 
thereupon  made  for  his  detention  during 
Her  Majesty's  pleasure. 

It  sometimes  happens,  however,  that  in 
cases  where  the  accused  himself  objects  to 
being  thought  unfit  to  plead  by  reason  of 
unsoundness  of  mind,  he  is  successful  in 
maintaining  this  objection.  John  Ambrose 
Douglas  was  indicted  at  Maidstone*  in 
July  1 88 5, before  Mr.  Justice  Hawkins,  on  a 
charge  of  shooting,  with  intent  to  murder. 
The  accused  was  defended  by  Mr.  War- 
burton,  who  said  he  apprehended  the  ques- 
tion would  be  whether  the  prisoner  was  in 
a  fit  state  of  mind  to  plead ;  whereupon 
prisoner  exclaimed,  "  That  is  all  nonsense, 
there  is  no  better  man  in  the  country,  and 
I  shall  not  allow  that  there  is  anything 
wrong  with  my  mind,  it  is  as  right  as 
ever  it  was,  and  I  will  not  be  defended  by 
a  liar.  I  knew  perfectly  well  what  I  was 
about."  His  lordship  then  asked:  "Do 
you  perfectly  understand  what  the  nature 
of  the  case  against  you  is  ?  "  To  which 
the  prisoner  replied,  "  Yes,  what  T  am 
accused  of  is,  I  believe,  firing,  with  intent 
to  murder,  and  I  say  I  did  not  intend  to 
murder.  I  fired  at  him  because  the  man 
is  a  thief,  and  stole  my  wife's  horse" — and 
much  more  to  the  same  effect.  After 
further  discussion,  the  case  was  adjourned 

*  Tlie  Maidstone  and  Kent  Omntij  Standard, 
July  17,  1885. 


to  the  following  day,  when  it  was  tried  out, 
with  the  result  that  the  jury  found  that 
the  prisoner  was  guilty  of  the  act,  but 
that  he  was  not,  at  the  time,  responsible 
for  his  actions — the  prisoner  exclaiming 
upon  hearing  the  verdict  :  "  I  can't  agree 
with  you."  The  usual  order  for  his  de- 
tention during  Her  Majesty's  pleasure  was 
then  made. 

In  this  case  it  was  at  the  prisoner's  own 
request  and  insistence  that  he  was  placed 
upon  his  trial,  although  it  is  very  doubt- 
ful whether  it  could  be  said  that  he  was 
capable  of  taking  a  rational  part  in  the 
trial,  and  certainly  he  was  not  of  sound 
mind. 

The  following  is  a  case  in  which  the 
accused  at  first  pleaded  guilty,  notwith- 
standing that  there  was  ground  for  be- 
lieving him  to  be  insane.  At  the  Car- 
marthen Assizes,*  held  in  February  1888, 
before  Mr.  Justice  Stephen,  Henry  Jones 
was  arraigned  and  charged  with  the 
murder  of  his  daughter. 

The  clerk  of  arraigns  then  said,  "What 
say  you  Henry  Jones,  are  you  guilty  or 
not  guilty?" 

Prisoner  (weeping):  "  Guilty,  my  lord." 
The  judge:  "Prisoner,  if  yoti  take  ray 
advice  you  will  say  you  are  not  guilty.   You 
must  recollect  what  you  are  charged  with. 
Do  you  mean  to  say  that  you  knew  all 
about  what  you  were    going  to  do,  and 
that  yoa  meant  to  kill  your  child?" 
Prisoner:  "  Oh  no,  my  lord, but  I  did  it. 
His  lordship  :  "  Then  you  are  not  guilty 
you  say.     He  says  he  did  not  mean  it." 

The  trial  then  proceeded,  and  resulted 
in  a  verdict  to  the  effect  that  the  prisoner 
was  insane  at  the  time  he  committed  the 
act. 

Here  again  is  a  case,  reported  in  the 
Hertfordshire  Standard  of  the  4th  of 
August,  1888,  in  which  a  different  course 
was  pursued.  Henry  Cullum,  aged  24, 
was  indicted  before  Mr.  Bai'on  Pollock  for 
the  murder  of  Emily  Bignall  at  Shenley 
in  the  month  of  March.  Mr.  Forrest 
Fulton  appeared  for  the  defence.  The 
prisoner,  on  arraignment,  pleaded  guilty. 
Mr.  Fulton  then  said  that  he  was  instruc- 
ted to  pi-oduce  certain  evidence  as  to  the 
state  of  the  prisoner's  mind,  but  he  had 
intimated  to  the  solicitor  by  whom  he  was 
instructed  that  he  did  not  think  it  right 
to  interfere  with  the  plea  that  the  prisoner 
had  thought  fit  to  make.  Mr.  Wedder- 
bur n , coun sel  for  th e  prosecution ,  said  th ere 
were  some  medical  reports  which  the  judge 
might  like  to  see.  His  lordship  having 
had  the  reports  handed  up,  said :  "  I  think 
it  will  be  best  for  me  to  take  the  usual 
course;  yet,  certainly,  any  documents 
■'  Tbc  Welshman,  Carmarthen,  March  2,  1888. 


Plead,  Capacity  of  Insane  to    [961     ]    Plead,  Capacity  of  Insane  to 


sent  in  will  be  forwarded  by  me  to  the 
Home  Office.  It  would  be  better  to  leave 
it  unfettered,  for  tlie  Home  Office  to  deal 
with  the  matter  of  the  state  of  the  pri- 
soner's mind."  Mr.  Forrest  Fulton  ex- 
plained that  the  reason  he  had  taken  the 
course  he  had,  with  regard  to  the  defence, 
was  because  it  was  extremely  difficult  to 
ask  a  jury  to  come  to  the  conclusion  that 
at  the  time  of  the  commission  of  the  crime 
the  prisoner  did  not  know  the  difference 
between  right  and  wrong.  Having  regard 
to  the  family  history  of  the  man  it  would 
be  for  the  authorities  to  consider  his  state 
of  mind.  His  lordship  then  said  :  "I  think 
the  course  you  have  adopted  Mr.  Fulton 
is  the  right  one,  I  think  it  is  better  to 
leave  it  unfettered  in  the  hands  of  the 
Home  Office." 

Sentence  of  death  was  then  passed  in 
the  usual  form.  This  sentence,  however, 
was  not  carried  out,  but  the  prisoner  was 
subsequently  removed  to  the  asylum  for 
criminal  lunatics  at  Broadmoor. 

The  reason  assigned  by  prisoner's 
counsel  in  this  case  for  not  interfering 
with  the  plea  of  guilty  has  been  already 
referred  to  in  considering  the  answers  of 
the  judges  to  the  questions  put  to  them 
by  the  House  of  Lords  after  the  trial  of 
Macnaghten,  in  1843.* 

It  does  not  apjjear  that  any  one  ques- 
tioned the  fitness  of  the  prisoner  to  plead 
to  the  indictment,  although  it  was  evi- 
dently regarded  as  probable  that  the 
criminal  lunatic  asylum  would  be  his 
ultimate  destination.  The  case  was, 
doubtless,  a  difficult  one  ;  but  if  difficult 
cases  are  thus  deliberately  left  in  the  hands 
of  the  Home  Office,  this  appears  to  almost 
amount  to  an  admission  that  in  dealing 
with  questions  involving  the  relation  of 
madness  to  crime  the  ordinary  rules  of 
procedure  of  a  criminal  court  are  not  pre- 
cisely ajDplicable. 

Supposing  that  a  Court  of  Criminal  Ap- 
peal had  been  in  existence,  it  may  be 
asked,  what  would  the  result  have  been  in 
this  case  ?  Supposing  that  the  prisoner 
had  again  pleaded  guilty,  would  the  sen- 
tence of  death  have  then  been  confirmed, 
without  any  possibility  of  intervention  on 
the  part  of  the  Home  Office  .'' 

Many  questions  of  this  description  will 
present  themselves  for  consideration 
whenever  the  proposal  for  the  establish- 
ment of  a  Court  of  Criminal  Appeal  begins 
to  take  definite  shape. 

The  following  is  a  somewhat  different 
case.  Elizabeth  Swatman  was  tried  for 
wilful  murder  at  the  Ipswich  Assizes  on 
April  I,  1876.  She  had  killed  another 
woman,  who  lived  in  an  adjoining  cottage, 

*  See  Criminal  Kkspoxsiiiilitv,  p.  310  i-t  ■■a-q. 


by  striking  her  on  the  head  with  a  shovel. 
No  one  was  near  at  the  time,  and  there 
was  no  evidence  either  that  there  had,  or 
had  not,  been  a  quarrel.  At  first,  the 
perpetrator  of  the  act  was  not  discovered, 
but  the  next  day  the  pi'isoner  accused 
herself.  She  said  she  had  often  thought 
of  killing  the  old  woman,  her  neighbour, 
and  at  last  she  did  it.  At  her  trial  she 
persisted  in  saying  that  she  "  hit  the  old 
woman,"  and  this  statement  was  taken  as 
a  plea  of  guilty,  and  she  was  sentenced  to 
death.  The  learned  judge  then  reported 
the  case  to  the  Home  Office,  with  an  ex- 
pression of  opinion  that  a  further  medical 
examination  was  desirable.  This  exami- 
nation resulted  in  her  being  sent  to  Broad- 
moor. She  was,  if  one  may  be  allowed 
the  phrase,  very  mad  indeed — demented 
and  incoherent — and  she  died  in  the  month 
of  September  following,  from  disease  of 
the  brain.  She  was  undefended,  until 
counsel  was  assigned  to  her  at  the  time  of 
the  trial ;  and  it  does  not  appear  to  have 
occurred  to  any  one  to  suggest,  before  she 
was  arraigned,  that  she  was  unfit  to  plead ; 
and  then,  after  she  had  been  called  on  to 
plead,  and  had  persisted  in  saying  that 
she  had  "  hit,''  and  that  she  "  had  killed 
the  old  woman,''  it  was  decided  that  it 
would  not  have  been  right  to  go  back  to 
the  consideration  of  the  question  of 
whether  or  not  the  prisoner  ought  to 
have  been  called  upon  to  plead.  The 
learned  judge  immediately  made  the 
necessary  representation  to  the  Home 
Office,  with  the  result  that  we  have  seen ; 
but  here,  again,  it  may  be  asked,  what 
course  would  have  been  taken  to  set  the 
matter  right  if  there  had  been  no  Home 
Office  to  which  to  appeal  ? 

(4)  With  respect  to  those  cases  in  which 
the  accused  is  mute  on  arraignment,  it  is 
not  intended,  in  this  place,  to  treat  of  deaf 
mutes  generally,  but  only  of  cases  in 
which  the  accused  is  mute  by  reason  of 
mental  disease  or  defect,  either  alleged  or 
suspected. 

Taylor,  in  his  work  on  the  principles 
and  practice  of  medical  jurisprudence, 
mentions  (page  589,  vol.  ii.,  third  edition) 
the  case  of  Taquierdo,  who  was  tried  at 
the  Herts  Summer  Assizes  in  1854,  and 
gives  the  following  account  :  — "  The  pri- 
soner, who  was  charged  with  wilful  murder, 
was  found  by  the  jui*y  to  be  wilfully  mute. 
The  man  refused  to  plead,  although  it 
was  obvious  that  he  was  well  aware  of 
the  nature  of  the  proceedings.  No  counsel 
could  be  assigned  to  him,  as  this  could 
not  be  done  without  the  prisoner's  con- 
sent. He  was  convicted.''  But  to  render 
the  account  of  this  case  complete,  it  must 
be  added  that  the  prisoner,  after  conviction 


Plead,  Capacity  of  Insane  to    [    962    ]    Plead,  Capacity  of  Insane  to 


and  sentence,  was  found  to  be  unquestion- 
ably insane,  and  was  removed  to  the  cri- 
minal wing  of  Bethlem  Hospital,  from 
■whence  he  was  transferred,  ten  years  later, 
to  Bi'oadnioor. 

A  case  in  which  the  prisoner  was  mute 
on  arraignment  recently  came  before  Mr. 
Justice  Charles  at  the  Stafford  Summer 
Assizes,  in  18SS.  Ernest  Harper,  23  years 
of  age,  was  charged  with  the  murder  of 
his  brother.  The  prisoner  when  called 
upon  to  plead  made  no  reply,  and  the 
learned  judge  then  said  that  he  should 
follow  the  course  pursued  by  Baron 
Aldersou  in  Eeg.  v.  Goode,  and  should 
ask  the  jury  to  say,  1st,  whether  the 
prisoner  is  mute  of  malice  ;  2nd,  whether 
he  is  able  to  plead;  and  3rd,  whether  he  is 
sane  or  not. 

The  jury  having  found  that  the  prisoner 
was  incapable  of  pleading,  the  learned 
judge  said  :  "  You  find  he  is  mute,  not  of 
malice,  not  on  purpose,  but  of  the  visita- 
tion of  God  ?  "  To  which  the  foreman 
replied  :  "  Quite  so." 

It  may  be  noted,  with  reference  to  this 
case,  that  during  the  course  of  the  inquiry 
as  to  the  capacity  of  the  prisoner  to  plead. 
Dr.  Spence  gave  evidence  to  the  effect  that 
in  May  the  prisoner  had  said  that  he 
was  guilty,  and  that  a  voice  inside  him 
told  him  to  do  what  he  had  done  ;  from 
which  it  appears  that,  although  the 
prisoner  was  mute  when  he  was  arraigned, 
he  was  not  always  mute,  but  had  con- 
versed on  the  subject  of  his  offence  whilst 
awaiting  trial. 

As  a  complement  to  the  foregoing  case, 
we  may  take  another,  which  was  tried 
at  the  Yorkshire  Summer  Assizes,  and 
which  is  fully  reported  in  the  Leech 
Mercury  of  August  5,  1890.  Samuel 
Harrison,  aged  30,  a  slipper-maker,  was 
indicted,  before  Mr.  Justice  Charles,  for 
the  wilful  murder  of  his  wife,  at  Leeds,  on 
the  9th  of  May.  The  report  states  that 
the  prisoner,  when  placed  in  the  dock,  was 
unkempt  and  slovenly,  and  made  no 
answer  to  the  charge,  but  remained  silent 
when  addressed  by  his  lordship,  keeping 
his  eyes  downcast,  and  apparently  being 
unconscious  of  what  was  going  on.  A 
jury  was  then  impannelled  to  inquire 
"  whether  the  prisoner  stood  mute  by  the 
act  of  God  or  out  of  malice."  Addressing 
the  jury,  his  lordship  said  the  question 
upon  which  he  wanted  the  help  of  the 
jury  was,  "  Why  did  the  prisoner  stand 
mute  ?  was  he  doing  it  on  purpose,  in 
which  case  he  was  standing  mute  out  of 
malice ;  or  was  he  doing  it  because  his 
state  was  such  that  he  did  not  know  what 
was  going  forward,  in  which  case  he  was 
mute  by  the  visitation  of  God  ?     Was  he 


doing  it  on  purpose,    or,   to  use  an  ordi- 
nary expression,  was  he  shamming?'' 

Mr.  John  Edwards,  the  medical  officer 
at  Armley  Gaol,  stated  that  he  had  had 
the  prisoner  under  his  observation  since 
May  10;  that,  at  that  time,  he  was  quite 
capable  of  understanding  what  was  said  to 
him  ;  but  that,  about  May  20,  he  began  to 
change,  and,  when  asked  a  question,  re- 
plied that  he  '"'  could  not  think  on,"  and, 
at  other  times,  that  he  "  could  not  re- 
member ;  "  that  the  prisoner  altered  so 
suddenly,  without  there  being  anything 
to  account  for  it,  that  he  put  it  down  that 
his  manner  was  assumed.  About  a  fort- 
night ago  there  was  another  change :  he 
became  quite  dumb.  His  opinion  was 
that  the  prisoner's  attitude  was  assumed. 
In  cross-examination,  witness  said  that  he 
believed  it  was  after  the  prisoner  had 
been  visited  by  the  Rabbi  that  he  changed 
his  demeanour.  He  was  of  opinion  that 
the  prisoner  was  quite  conscious  of  what 
was  going  on  in  court.  Dr.  Bevan  Lewis, 
the  medical  director  of  the  Wakefield 
Asylum,  stated  that  on  July  19  he  ex- 
amined the  prisoner,  and  came  to  the  con- 
clusion that  he  was  assuming  insanity. 
On  that  occasion  he  answered  questions 
intelligibly  as  to  an  occurrence  with  his 
fellow-prisoners  on  June  30.  He  had 
examined  him  again  and  found  his  condi- 
tion changed  ;  but  he  was  still  of  opinion 
that  his  state  was  assumed. 

A  temporary  attendant  at  the  gaol  said 
he  had  had  charge  of  the  prisoner  at 
night  since  June  16.  At  first  he  was 
communicative,  but  after  the  Rabbi  had 
visited  him  he  changed  and  ceased  to  talk. 
His  lordship),  in  putting  the  matter  to 
the  jury,  said  he  saw  nothing  in  the 
evidence  to  lead  to  the  belief  that  the 
prisoner  was  mute  by  the  visitation  of  God. 
The  jury  immediately  found  that  the 
prisoner  was  "  mute  out  of  malice." 

His  lordship  then  directed  a  plea  of 
not  guilty  to  be  entered  on  behalf  of  the 
prisoner  ;  and  the  trial  then  proceeded, 
and  ultimately  the  jury  found  the  prisoner 
guilty,  and  he  was  sentenced  to  death  in 
the  usual  form : — the  report  stating  that 
when  the  prisoner  was  asked  if  had  any- 
thing to  say  why  sentence  of  death  should 
not  be  passed  upon  him,  he  made  no 
answer,  and  gave  no  indication  of  con- 
sciousness of  what  was  taking  place. 

A  paragraph,  however,  appeared  in  the 
Times  of  August  19,  to  the  effect  that 
the  Home  Secretary  had  recommended 
Her  Majesty  to  respite  the  sentence  ;  the 
paragraph  going  on  to  say,  "  Harrison 
has  been  found  to  be  insane,  and  he  will, 
this  week,  be  removed  to  the  criminal 
lunatic  asylum  at  Broadmoor." 


Plead,  Capacity  of  Insane  to    [    9(^2,    ]   Plead,  Capacity  of  Insane  to 


Betore  leaving  this  branch  of  the  subject 
it  must  not  be  overlooked  that  cases 
occasionally  arise  in  which,  whatever  may 
be  the  mental  condition  of  the  accused, 
his  counsel  may  desire  to  obtain  a  verdict 
on  the  facts  ;  and,  with  that  view,  no  ques- 
tion of  ability  to  plead  is  raised  when  the 
accused  is  arraigned.  A  case  of  this  de- 
scription, in  which  Samuel  George  Milner 
was  charged  with  manslaughter  before 
Mr.  Justice  Mathew,  is  reported  in  the 
Times  for  July  30,  1890. 

If  we  now  turn  to  the  statistical  side  of 
this  matter,  we  find  that  the  total  number 
of  persons  admitted  into  the  criminal 
lunatic  asylum  at  Broadmoor,  who  had 
been  arraigned  in  court,  from  the  time 
at  which  the  asylum  was  opened  down  to 
the  end  of  1888,  was  1737,  and  that  this 
total  was  made  up  as  follows  :— 

Fduiul  iiisiiiio  on  arrais'nmeut  .  .  265 
Acquitted  011  the  <i:rouiul  of  insanity,  or 

found   insane   in   the   terms   of    the 

Trial  of  Lunatics  Act,  1883  .  .  579 
Reprieved  on  the  ground  of  insanity  .  29 
Found  to  be  insane  whilst  undergoing 

sentences  of  penal  servitude  .  .  817 
Found  to  be  insane  whilst  undergoing- 

shorter  terms  of  imprisonment  .  .         47 


Total 


1737 


That  is  to  say,  there  were  1737  persons 
who  were  arraigned  in  court  and  were 
charged  with  criminal  oflFences,  and  who 
ultimately  were  sent  to  the  asylum  for  cri- 
minal lunatics,  but,  of  these  1737  persons, 
only  265,  or  rather  less  than  16  per  cent., 
were  found  insane  on  arraignment ;  leaving 
more  than  84  per  cent,  who  were  found 
insane  at  later  stages,  whilst  in  custody. 

This  represents  the  general  result  for 
the  whole  period ;  but  there  are  two  useful 
subdivisions  that  may  be  made.  First, 
the  records  show  that  the  question  as  to 
the  fitness  of  a  prisoner  to  plead  is  much 
more  closely  examined  into  in  grave  than 
in  slighter  offences ;  and,  secondly,  they 
show  also  that,  in  cases  of  all  kinds,  the 
proportion  of  prisoners  found  insane  on 
arraignment  has  been  greater  in  recent 
than  it  was  in  former  years. 

To  illustrate  the  latter  point  we  may 
compare  the  period  down  to  the  end  of 
1882  with  the  six  years  from  1882  to  1888  ; 
whilst  to  illustrate  the  former  point  we 
may  take  the  cases  of  murder  and  com- 
pare them  with  all  the  others. 

We  find  then  that,  of  the  total  of  1737 
persons  above  referred  to,  1395  were  ad- 
mitted up  to  the  end  of  1882,  and  342 
during  the  following  six  years.  We  find, 
further,  that  of  the  1395,  there  were  193 
who  had  been  found  insane  on  arraign- 
ment ;  whilst  of  the  342,  there  were  72 
who  had  been  so  found.     It  will  be  seen 


from  these  figures  that  the  proportion, 
found  insane  on  arraignment,  before  1882 
was  a  little  less  than  14  per  cent.  ;  whilst 
for  the  six  years  from  1882  to  1888  the 
proportion  rose  to  2 1  per  cent. 

Next,  with  respect  to  those  cases  in 
which  the  offence  was  murder,  we  find 
that,  during  the  whole  period,  the  number 
of  persons  who  had  been  arraigned  and 
charged  in  court  with  that  crime  and  who 
ultimately  were  sent  to  the  asylum  for 
criminal  lunatics  was  444,  and  that  this 
total  was  made  up  as  follows : — 


Found  insane  on  arraignment 

Aciiuitted  on  the  ground  of  insanity,  or 
found  insane  in  terms  of  the  Trial  of 
Lunatics  Act,  1883    .... 

Keprievcd  on  the  ground  of  insanity     . 

.Sentence  commuted  to  penal  servitude 
and  afterwards  found  to  be  insane     , 


109 


286 
29 


444 


And  from  these  figures  it  appears  that,  of 
the  total  number  of  persons  arraigned  for 
murder  who  ultimately  became  inmates 
of  the  asylum  for  criminal  lunatics,  some- 
what less  than  25  per  cent,  were  found 
insane  on  arraignment,  leaving  75  per 
cent,  who  were  considered  sufficiently  sane 
to  be  tried. 

If  we  now  go  on  to  subdivide  these  cases 

with  reference  to  the  periods  during  which 

they  occurred,  the  figures  are  as  follows: — 

Up  to  the    From  1882 

Cases  of  Murder  only.  end  of       to  the  end 

1882.  of  1888. 


Found  insane  on  arraignment 

Acquitted  on  the  ground  of 
insanity,  or  found  insane 
in  the  terms  of  the  Trial  of 
Lunatics  Act,  1883     . 

Reprieved  on  the  ground  of 
insanity     .... 

Commuted  to  penal  servitude 
and  afterwards  found  to  be 


Totals 


79 


228 


18 


16 


341 


30 


103 


These  figures  show  a  proportion  of 
about  23  per  cent,  for  the  former  period, 
and  a  proportion  of  about  29  per  cent,  for 
the  six  years  from  1882  to  1888  ;  and  this 
increase  in  the  proportion  found  insane 
on  arraignment,  of  persons  accused  of 
murder,  although  not  so  great  as  the  in- 
crease (from  14  to  21  per  cent.)  in  the 
general  total  above  mentioned,  is  yet 
sufficiently  great  to  afford  ground  for 
surmising  that  the  question  of  the  precise 
degree  of  mental  unsoundness  that  is 
sufficient  to  render  a  person,  in  the  words 
of  the  statute,  "  insane  so  that  he  cannot 
be  tried,"  has,  probably,  not  yet  reached 
a  final  settlement.  On  close  examination, 
it  might,  indeed,  be  found  to  be  as  diffi- 
cult to  lay  down  hard-and-fast  rules,  which 


Plead,  Capacity  of  Insane  to   [    964    1  Plethysmograph  and  Balance 


would  satisfactorily  meet  every  case  in 
which  the  ability  of  an  accused  person  to 
plead  is  in  question,  as  it  would  be  to 
frame  an  entirely  satisfactory  definition 
of  the  precise  degree  of  insanity  that 
renders  a  person  not  responsible  accord- 
ing to  law  for  his  acts  ;  and  we  know  what 
the  mature  opinion  of  Lord  Blackburn  is 
upon  this  latter  point.* 

In  Kussell  "  On  Crimes"  (vol.  i.  p.  114), 
the  test  of  capacity  and  fitness  to  plead 
to  an  indictment  is  stated  in  the  following 
terms : — "  Whether  he  (the  accused)  is  of 
sufficient  intellect  to  comprehend  the 
course  of  the  proceedings  on  the  trial,  so 
as  to  be  able  to  make  a  proper  defence." 
But  here,  again,  it  is  evident  that  the 
term  "  proper"  is  by  no  means  an  exact 
or  precise  one. 

The  general  rule  of  law  may  be  said  to 
be  that  every  one  is  presumed  to  be  sane 
until  the  contrary  has  been  proved  ;  and, 
in  the  apjjlication  of  this  rule,  it  would 
ajDjDear  that  every  one  is  presumed,  in  law, 
to  be  sane,  with  resjDect  to  any  particular 
matter,  until  the  contrary  has  been  proved 
with  respect  to  that  very  matter  ;  and 
with  regard  to  the  manner  in  which,  from 
the  legal  point  of  view,  a  person  may  be 
both  sane  and  insane  at  the  same  time, 
Sir  John  ISTichol  has  observed  :  "  If  it  be 
meant  by  this  that  the  law  of  England 
never  deems  a  person  both  sane  and  in- 
sane at  one  and  the  same  time  upon  one 
and  the  same  subject,  the  assertion  is  a 
mere  truism.  But  ....  if  it  be  meant 
that  the  law  of  England  never  deems  a 
party  both  sane  and  insane  at  different 
times  upon  the  same  subject,  and  both 
sane  and  insane  at  the  same  time  upon 
different  subjects,  there  can  scarcely  be  a 
position  more  adverse  to  the  current  of 
legal  authority." 

Looking  at  the  matter  in  this  light,  it 
is  quite  clear  that  an  accused  person  may 
be  insane,  and  may  be  well  known  to  be 
insane,  and  yet  may  declared  to  be  sane 
so  far  as  liis  ability  and  fitness  to  plead 
are  concerned  ;  and,  this  being  so,  it  is  not 
a  matter  for  surprise  that  the  proportion 
of  insane  persons  who  are  found  insane  on 
arraignment  is  not  large. 

But  there  is  another  mode  in  which  the 
subject  might  be  approached.  We  have 
seen  that  out  of  a  total  of  1737  persons 
who,  after  having  been  arraigned  in  court, 
ultimatelyreached  the  asylum  for  criminal 
lunatics,  only  265  (equivalent  to  less  than 
16  per  cent.),  were  found  insane  on  arraign- 
ment ;  leaving  1472  persons  (equivalent  to 
more  than  84  per  cent.)  who  passed  through 
various  further  stages  of  trial,  of  sentence, 
or  of  imprisonment,  before  they  reached 
*  See  Crimlnal  Responsibility. 


their  ultimate  destination ;  and  it  is  quite 
conceivable  that,  in  the  course  of  time,  it 
may  come  to  be  thought  that,  with  respect 
to  a  considerable  proportion  of  such  per- 
sons, if  a  decision  were  arrived  at  as  to 
their  mental  condition  at  an  earlier  stage, 
and  if  action  were  taken  upon  such  de- 
cision, it  might  be  much  to  the  advantage, 
not  only  of  the  accused  themselves,  but 
also  that  of  the  public  at  large. 

W.  Orange. 

PIiEOIO'ECTICA  ii-THYMIA  (TrXeo- 
veKTTjs,  greedy;  d,  priv.;  dvfios,  mind).  A 
form  of  insanity  characterised  by  greedi- 
ness and  desire  for  gain.  Over-bearing 
arrogance.  (Fr.  pleonexie ;  Ger.  Mehrha- 
bemfollen.) 

pu:oM'£Xiii.  (TrXeove^ia,  greediness). 
Greediness,  selfishness  or  arrogance  re- 
garded as  mental  disease.     (Fr. 2yleonexie.) 

PIiETHYSIVXOGRAPH  and  BAXi- 
AirCE. — The  plethysmogrraph  was  de- 
vised by  Prof.  Angelo  Mosso,  of  Turin,  for 
the  purpose  of  studying  the  circulation  by 
measuring  the  varying  volume  of  the  arm 
or  foot,  or  even  a  single  finger  (Fig.  i). 


It  consists  of  a  glass  cylinder  (G),  freely 
suspended,  oj^en  at  one  end,  and  terminat- 
ing at  the  other  in  a  small  tube.  There 
are  two  openings  on  the  side  of  the  cylin- 
der, serving  to  fill  it  with  water,  and  to 


Plethysmograph  and  Balance  [    965    ]  Plethysmograph  and  Balance 


allow  of  the  passage  of  electrodes  when 
it  is  desired  to  study  the  iiiHuence  of 
electrical  irritation.  These  openings  are 
hermetically  closed,  and  into  one  is  in- 
serted a  thermometer  to  measure  the  tem- 
])erature  of  the  water  in  the 
cylinder.  The  hand,  fore- 
arm, and  elbow  are  intro- 
duced into  the  cylinder,  and 
a  caoutchouc  ring  closes  the 
cavity  of  the  cylinder, 
slightly  compressing  the 
arm  near  the  elbow.  The 
ring  must  be  si^fficiently 
thick  to  prevent  oscillations 
under  the  influences  of  slight 
increases  of  pressure.  The 
tube  at  the  farther  extre- 
mity of  the  cylinder  commu- 
nicates with  an  open  vessel 
(F),  which  is  graduated,  or 
contains  a  float,  which  may 
be  put  in  connection  with  a 
lever  to  record  the  variations 
in  level  on  a  smoked  cylin- 
der. As  the  blood  in  the  arm 
(and,  therefoi'e,  the  volume 
of  the  arm)  increases,  water 
is  driven  into  the  graduated 
vessel,  or  raises  the  float ;  as 
the  blood  in  the  arm  de- 
ci'eases,  water  is  drawn  from 
the  graduated  vessel.  Mosso 
found  that  mental  exertion, 
or  emotion,  produced  a 
diminution  in  the  volume  of 
the  arm.  This  result  is  not, 
however.uniformly  obtained, 
nor  must  it  be  supposed  that 
the  change  of  volume,  when 
obtained,  enables  us  to  cal- 
culate the  vascular  changes 
in  the  brain ;  we  have  also 
to  consider  the  probable 
changes  in  the  lungs,  con- 
nected with  the  concomitant 
variations  in  respiratory 
rhythm  pointed  out  by 
]\Iosso. 

Another  very  ingenious  in- 
strument, devised  by  Mosso, 
like  the  plethysmograph,  to 
demonstrate  changes  in  the 
vascular  system,  is  the 
Balance.  This  is  a  kind  of 
delicately  adjusted  see-saw, 
on  which  the  subject  lies  at 
full  length  (Fig.  2).  It  consists  of  a  wooden 
case  {D  C)  placed,  as  a  balance,  on  a 
transverse  bar  of  steel  (E).  This  rests 
on  a  table  {B  A),  pierced  by  three  open- 
ings, one,  in  the  middle,  giving  passage 
to  an  iron  bar  {G  H),  a  metre  in  length, 
ending  in  an  iron  cylinder  (I),  weighing 


kilos. 


The  other  two  openings  give 
passage  to  similar  iron  bars  {LHM)  fixed 
obliquely  to  the  first.  The  centre  of 
gravity  being  thus  placed  very  low,  the 
balance  does  not  oscillate  with  too  great 


facility.  It  is  necessary  that  the  subject 
should  lie  on  the  balance  for  at  least  an 
hour  before  the  experiments  begin,  in 
order  that  the  circulation  may  be  ad- 
justed to  the  horizontal  position,  and  the 
excess  of  blood  removed  from  the  lower 
extremities.     Mosso  also  applies  two  in- 


Plumbism  and  Insanity     [    966    ]         Poisons  of  the  Mind 


struments,  constructed  on  principles  simi- 
lar to  the  pletliy sinograph,  to  the  hand 
and  thumb,  to  aid  in  controlling  the  ex- 
periments. It  is  found  that  with  every 
inspiration  the  balance  sinks  at  the  feet, 
and  at  the  same  time  the  lower  extremi- 
ties increase  in  volume  ;  this  movement  is 
apparently  due,  not  to  visceral  movement, 
but  to  increase  of  abdominal  pressure  in- 
terfering with  the  return  of  blood  from  the 
lower  extremities.  Mosso  finds  that  dur- 
ing severe  intellectual  efforts  the  balance 
sinks  at  the  head.  During  sleep  it  sinks 
at  the  feet,  but  if  the  subject  is  disturbed 
without  being  awakened,  it  sinks  slightly 
at  the  head. 

The  jDlethysmograph  is  described  or  re- 
ferred to  in  ail  works  on  general  phy- 
siology, and  it  has  led  to  the  construction 
of  various  instruments  on  the  same  j^rin- 
ciple,  such  as  Roy's  oncometer.  The 
balance  has  not  come  into  general  use, 
although,  as  Mosso  points  out,  for  the  de- 
monstration of  psychic  influences  on  the 
circulation  it  is  much  superior  to  the 
plethysmograph.  A  full  descrii^tion  of  it 
by  Mosso  will  be  found  in  the  Archives 
Italiennes  cle  Biologie,  tome  v.  fasc,  i. 
(1884) 

[The  figure  of  the  balance  is  inserted  by 
the  kindness  of  Prof.  Mosso,  and  that  of 
the  jrilethysmograph  by  the  courtesy  of 
Prof.  Stirling  and  Messrs.  Griffin.] 

Havelock  Ellis. 

PI.UIVIBISIVI        AN-S        IN-SANXTY. 

()S'ee  Lead  Polsoning.) 

PXVTOIVIAN'IA  {ttXovtos,  wealth ; 
fiapia,  madness).  Insane  belief  in  the 
possession  of  large  proj^erty  —  a  kind  of 
megalomania. 

PM'ZGAI.IOII',  PIO-IGAIiIUIM:  {jTviyco, 
I  suffocate).  An  old  term  for  incubus  or 
nightmare,  because  of  the  sense  of  suffo- 
cation in  that  affection.     (Fr.  epliialte.) 

POSACROUS       INSAN-ZTV.  {See 

Gout  and  Insanity.) 

POXSOSrs  OF  THE  IMEZM-D. — Defi- 
nition.    Iiimits  of    the    Subject. — The 

study  of  the  whole  of  the  mental  poisons 
embraces  all  substances,  whatever  may 
be  their  origin  and  nature,  which  are 
capable  of  exercising  a  morbid  action  on 
the  intellectual  processes,  either  by  dis- 
ordering them  or  by  suspending  them 
completely  for  a  moment  or  longer. 
Speaking  of  poisons  which  act  specially 
upon  the  brain,  and  of  theinfiuence  which 
shows  itself  mainly  or  almost  exclusively 
by  cerebral  disorders,  we  shall  mention 
all  the  intoxications  the  symptomatology 
of  which  includes  intellectual  disturb- 
ances, whether  the  latter  be  prominent  or 
latent.  Strictly  speaking,  the  former 
alone  ought  to  be  called  psycJiical  poisons; 


but  on  the  one  hand  there  is  scarcely  any 
poison  —  even  among  those  which  are 
commonly  called  by  this  name  —  which 
limits  its  action  absolutely  to  the  brain, 
and  on  the  other  hand,  there  ai'e  many 
injurious  substances  which,  although  in- 
juring this  organ  in  an  indirect  manner 
only,  nevertheless  disturb  its  functions 
occasionally.  It  is  for  this  reason,  and 
in  order  to  be  more  complete,  that  we 
have  extended  our  studies  to  all  intoxi- 
cants which  affect  primarily  the  intellec- 
tual sphere,  reserving,  howevei",  special 
attention  for  all  toxic  substances  the 
action  of  which  on  the  brain  is  predomi- 
nant. It  is  necessary  to  understand  the 
term  "primarily";  as  a  matter  of  fact, 
there  is  no  substance  which  inti'oduced 
accidentally  into  the  circulation,  does  not 
affect  in  some  way  the  cerebral  functions; 
all  functions  are  connected  one  with  the 
other,  and  in  certain  intoxications,  which 
are  not  altogether  psychical,  we  observe 
secondary  {cleiiteropathic)  intellectual  dis- 
turbances, which  may  be  the  consequence 
of  circulatory  or  thermic  disorders,  or  of 
the  disturbance  of  some  other  mechanism 
connected  with  the  initial  action  of  the 
poison.  These,  however,  are  not  poisons 
of  the  mind,  a  term  which  must  be  defi- 
nitely reserved  for  substances  which  act 
primarily,  to  a  greater  or  less  extent,  on 
the  cerebral  cells. 

As  we  have  said,  almost  all  substances 
introduced  into  the  organism  modify 
the  cerebral  processes,  and  the  reason  of 
this  lies  evidently  in  the  delicacy  of  the 
organisation  of  the  nervous  system,  which, 
like  every  complicated  mechanism,  is  ex- 
tremely vulnerable  ;  the  brain,  as  the 
terminus  of  all  sensations,  and  as  the 
regulator  of  even  the  most  minute  cellular 
functions,  has  to  bear  the  brunt  of  all 
attacks,  even  the  slightest,  directed 
against  the  vital  equilibrium,  and  has 
also  to  react  in  order  to  re-establish  this 
equilibrium.  In  every  intoxication,  in 
addition  to  the  cerebral  reaction  due  to 
the  effect  of  the  poison  itself,  there  are 
other  reactions  requii'ing  as  many  reflexes 
for  the  defence  of  the  body,  and  closely 
connected  with  the  impressions,  which 
the  sensorium  receives,  of  modifications 
of  nutrition,  or  of  changes  which  take 
place  in  other  organs  under  the  influence 
of  the  poison.  These  reactions  are  the 
symptoms  common  to  every  intoxication 
and  are  not  specially  important. 

The  cerebral  reactions  which  take  place 
under  the  more  direct  influence  of  the 
toxic  substance  are  of  two  kinds :  they 
are  either  diffuse,  general  and  undefined, 
and  are  exjDressed  by  vague  symptoms 
which  indicate  a  lesion  of  the  organ  as  a 


Poisons  of  the  Mind        [    967    ]        Poisons  of  the  Mind 


whole  ;  or  they  are  clear,  well  defined  and 
localised,  and  are  expressed  by  symptoms 
which  indicate  that  the  poison  aii'ects  one 
special  centre  to  the  exclusion  of  all  others 
(visual  hallucinations,  psychomotor  de- 
rangement, disorders  of  ideation,  &c.). 

In  addition  to  the  disorders  of  the 
brain,  we  meet  at  almost  every  step  with 
spinal  derangement.  The  cerebrum  and 
cord  are  the  two  great  organs  formed 
by  a  conglomeration  of  the  same  delicate 
elements ;  they  react  in  the  same  manner, 
and  it  is  therefore  not  surprising  to  see 
that  in  a  great  number  of  cases  a  spinal 
poison  also  affects  the  brain,  and  vice 
rersd.  Chloroform,  carbon  monoxide, 
alcohol,  &c.,  are  principally  psychical 
poisons,  but  at  the  same  time  entail 
cord  disturbances.  On  the  other  hand, 
nux  vomica  and  arnica,  which  are  princi- 
pally poisons  of  the  latter  class,  never- 
theless occasionally  produce  intellectual 
troubles. 

Under  wbich  Class  of  Poisons  ougrht 
•we  to  include  tbose  of  the  IVIind  7 — 
The  two  classifications  generallj'  accepted 
in  France,  are  those  of  Rabuteau  and  of 
Tardieu,  and  even  in  these,  it  is  clear  that 
the  poisons  in  question  cannot  form  a 
separate  class :  the  classifications  are 
merely  symptomatological,  based  on  the 
preponderance  of  a  special  group  of 
symptoms  in  the  intoxication.  Rabuteau 
has  taken  into  his  class  of  neurotics  a 
group  of  cerebro-spinal  poisons,  under 
which  he  comprises  the  psychical  poisons 
proper  (chloroform,  ether,  opium,  &c.). 
In  Tardieu's  classification,  the  latter  have 
been  subdivided  into  three  classes :  (a) 
stupefying  poisons  (tobacco)  ;  (b)  narcotic 
poisons  (opium),  and  (c)  neurasthenic 
poisons  (quinine).  These  classifications, 
although  without  solid  basis,  are  the  two 
most  satisfactory.  It  is,  however,  clear  that 
intellectual  disorders  may  form  part  of  the 
syndromes  met  with  in  all  classes  of  toxic 
substances.  Among  the  hasmatic  poisons 
Rabuteau  counts  alcohol;  among  the  neHro- 
onuscular  poisons,  he  gives  the  poisonous 
classes  of  nightshades  ;  among  the  ')nus- 
cular  poisons  he  includes  lead ;  and,  lastly, 
among  the  irritant  or  corrosive  poisons, 
he  enumerates  ammonia  and  bromine. 
Each  one  of  these  poisons  may  have  an 
influence  on  the  mind,  and  as  a  matter  of 
fact,  some  of  them,  like  alcohol  and  the 
poisonous  nightshade,  produce  such  dis- 
tinct and  special  disorders  of  the  intellect, 
that  it  would  be  logical  to  class  them 
under  the  "poisons  of  the  mind."  The 
same  remark  holds  good  with  regard  to 
the  classification  of  Tardieu. 

Psychical   poisons,    therefore,    do    not 
allowof  being  classified,  and  it  could  not  be 


otherwise,  because  the  symptoms  of  mental 
intoxication  are  sometimes  predominant, 
but  quite  as  often  accessory,  and  these  do 
not  ofter  any  safe  basis  for  classification. 
With  regard  to  the  question  of  classifying 
psychical  poisons  among  themselves,  we 
shall  see  that  the  nosography  is  extremely 
deficient  in  documents  about  an  extremely 
great  number  of  poisons  which  aftect  the 
mind.  Although  many  of  them  have  been 
thoroughly  investigated,  many  others  are 
scarcely  known. 

General  Symptomatologry. — In  spite 
of  the  dissimilarity  of  the  substances 
which  are  capable  of  producing  cerebral 
intoxication,  there  are,  nevertheless,  cer- 
tain clinical  characteristics  common  to 
all.  We  might  even  say,  that  there  are 
no  intellectual  disorders  more  pathogno- 
monic of  one  poison  than  of  another. 
The  artificial  insanity  produced  by  toxic 
substances  is  nothing  but  the  reaction 
of  the  cerebrum,  which  is  arrested  in  its 
full  and  regular  function,  and  the  coming 
into  play  of  cellular  elements,  under  the 
influence  of  an  external  and  abnormal  ex- 
citation, which  is  different  from  the  usual 
stimulation.  This  excitation,  naturally, 
may  affect  one  part  of  the  brain  more 
than  another  ;  hence  the  apparent  differ- 
ence in  the  symptoms,  which  also  may 
vary  in  different  individuals  although  they 
are  under  the  influence  of  the  same 
poison.  The  toxic  substance  certainly 
does  not  add  any  new  element  to  those 
which  the  normal  brain  possesses,  and 
herein  lies  the  great  diff'erence  between 
the  superadded  insanity  and  the  insanity 
which  the  brain  produces  itself — i.e.,  be- 
tween toxic  derangement  and  psychosis. 
All,  or  nearly  all,  slight  intoxications,  be 
the  poison  animal,  vegetable,  or  mineral, 
may  be  briefly  characterised  thus  :  excita- 
tion of  the  organ  of  thought,  intoxication, 
and  incoherence  in  ideas  and  actions  ;  in 
toxic  derangement  there  is  only  a  func- 
tional disturbance  and  a  quantitative 
modification  of  psychical  expression  while, 
in  organic  derangement  (psychosis  or 
encephalopathy),  there  is  a  qualitative 
ideational  alteration. 

The  special  symptoms  are  of  infinite 
variety,  although  at  bottom  they  are 
nothing  but  the  expression  of  one  and  the 
same  disorder,  and  this  variation  of  the 
special  jjhenomena  depends  on  two  factors 
— viz.,  on  the  localisation  of  the  toxic 
effects  in  a  special  cell-group,  and  on  the 
individual  reaction.  Nervous  and  pre- 
disposed individuals  are  evidently  more 
easfly  affected  than  normal  subjects.  Al- 
cohol, morphia  and  cocaine  do  not  produce 
the  same  effects  on  all  individuals,  male 
or  female,  under   all    latitudes.     Among 


Poisons  of  the  Mind 


c 


] 


Poisons  of  the  Mind 


all  the  poisons  which  we  shall  enumerate 
later  on,  a  great  number  produce  cere- 
bral effects  but  rarely,  in  consequence  of 
certain  dispositions  of  the  individual. 
Among  the  labourers  who  have  to  handle 
carbon  disulphide  or  aniline,  some  only 
l^resent  mental  disorders.  The  individual 
factor,  thei'efore,  with  its  idiosyncrasies 
plays  here,  as  everywhere  else,  a  very  im- 
portant part.  In  addition  to  this,  there 
are  other  factors,  the  degree  of  education, 
habits  and  social  condition,  the  course  of 
ideas,  fulness  or  emptiness  of  the  stomach, 
the  season,  locality,  &c.,  which  serve  to 
modify  the  symptoms  of  cerebral  intoxi- 
cation. The  hallucinations  of  the  western 
people  under  the  influence  of  haschisch  are 
not  identical  with  the  voluptuous  dreams 
of  the  orientals.  Lastly,  we  must  take 
into  consideration  the  dose  absorbed,  and 
the  mode  of  preparation  of  the  poison. 

Generally  speaking,  the  symptoms  of 
cerebral  intoxication  may  be  divided  into 
tbree  types : 

(i)  Certain  poisons  produce  a  general 
disturbance  of  the  intellect,  a  disorder  of 
all  the  faculties,  so  that  there  is  no  longer 
any  elective  localisation  of  the  intoxication 
in  one  faculty  over  another.  If  there  is 
insanity,  it  is  an  incoherent  insanity, 
absurd  and  without  consistency,  as  in 
drunkenness  or  mania ;  there  are  neither 
fixed  ideas  nor  any  organised  or  hallu- 
cinatory derangement.  If  there  are  hallu- 
cinations (and  this  is  frequentl)'  the  case, 
because  the  cortical  cells  are  uniformly 
over-excited)  they  do  not  influence  the 
course  of  the  ideas ;  they  modify  ideation 
at  the  moment  they  appear,  but  the 
phenomenon  is  transitory  (derangement 
in  pyrexia,  &c.). 

(2)  Other  poisons,  without  causing  such 
intense  disorder,  nevertheless  disturb  the 
enseinhle  of  the  faculties,  but  to  a  less  de- 
gree. To  use  a  comparison,  we  might  say 
that  the  former  group  is  to  the  latter 
what  alcoholic  insanity  is  to  simple 
drunkenness.  General  disturbance — al- 
though slight  —  of  the  intellect,  in  one 
word,  intoxication,  is  the  characteristic  of 
this  group.  Save  the  intensity  of  the 
processes,  the  only  difference  separating 
the  two  groups  is  the  partial  or  even 
complete  persistency  of  consciousness 
(camphor,  musk,  betel,  &c.). 

(3)  Other  poisons,  although  producing 
temporary  intoxication,  seem  to  limit 
their  action  to  one  of  the  intellectual 
spheres,  or  to  one  cerebral  department — 
either  to  ideation — or  to  voluntary  move- 
ments or  loss  of  sense  of  space  (haschisch) 
— or  to  sentiments  (instinctive  impulse, 
erotic  passions,  Ac),  or  to  sensory  centres 
(hallucinations  of    various    senses,  bella- 


donna, &c.).  The  conceptions  also  vary 
according  to  the  predominance  of  the  ex- 
citement in  one  psychical  department, 
eroticism  in  some,  and  incessant  restless- 
ness, hyper-ideation,  ambitious  or  mystic 
ideas,  &c.,  in  others. 

We  shall  now  group  the  various  symp- 
toms observed  in  cerebral  intoxication, 
analyse  them,  and  then  extract  from  them 
some  general  truths. 

Intoxication. — Intoxication  is  a  symp- 
tom common  to  all  forms  of  cerebral 
poisoning,  and  it  is  the  flrst  phenomenon 
observed  after  the  absorption  of  the  toxic 
substance,  whether  the  latter  be  of  an 
exciting  or  depressing  nature.  On  account 
of  the  characteristic  differences,  authors 
have  described  intoxication  by  alcohol, 
quinine,  chloral,  ergot,  atropine,  iodine, 
&c.  The  study  of  these  intoxications  shows 
that  they  are  all  accompanied  by  the  same 
cerebral  disturbances  and  therefore  may 
be  embraced  in  the  same  description. 

Intoxication  has  various  degrees:  some- 
times very  slight  (Physalis  alkekengi)  or 
very  profound,  even  making  an  individual 
semi-comatose  (aniline)  ;  under  other  cir- 
cumstances the  patients  deserve  theepithet 
dead-drunk  (alcohol,  opium).  The  most 
typical  intoxication  which  might  serve  as 
a  standard  for  others  to  be  compared  with 
is  alcoholic  drunkenness.  Certain  poisons, 
like  camphor,  produce  an  intoxication  very 
similar  to  it. 

The  intellectual  troubles  are  :  great  ex- 
citement with  exaltation  (the  ideas  follow 
each  other  rapidly  and  are  not  logically 
connected,  and  imagination  is  more  pro- 
ductive), volubility  and  incoherency,  em- 
barrassment of  speech,  difficulty  of  articu- 
lation (atropine),  and  sometimes  actual 
aphasia  (iodoform).  In  a  case  of  poison- 
ing with  the  honey  of  lecheguana  (A.  de 
St.  Hilaire)  total  amnesia  was  observed 
with  regard  to  the  French  language ; 
when  wishing  to  speak  French  the  pa- 
tient could  express  himself  in  Portuguese 
only.  In  addition  to  these  iDhenomena, 
there  is  considerable  neuro-muscular  ex- 
citement ;  gesticulation  is  frequent  and 
disordered,  and  the  patient  commits  all 
kinds  of  eccentric  actions.  In  certain 
cases  (haschisch)  we  observe  an  exuberant 
sentimentality  which  is  much  more  marked 
than  in  any  other  case.  This  last  poison, 
as  well  as  ether,  produces  also  a  singular 
stimulation  of  the  memory  :  events  long 
past  recur  with  a  clearness  which  they  had 
lost.  In  certain  cases  (eigne)  the  intoxi- 
cation produces  an  actual  darkening  of 
the  intellect. 

In  the  majority  of  cases,  unless  there  is 
a  special  predisposition  to  the  contrary, 
the  intoxication  induced  causes  a  certain 


Poisons  of  the  Mind        [    969    ]        Poisons  of  the  Mind 


enjoj^ment.  It  is  gay,  pleasant  and  play- 
ful to  the  extreme  under  the  intlnence  of 
guarana,  haschisch  and  mate,  or  it  may 
manifest  itself  in  hilarity,  or  even  in  in- 
suppressible  ontbreal<s  of  laughter  (has- 
chisch, codeine,  laughing  gas,  opium, 
lecheguana).  It  may  also  produce  a  feel- 
ing of  profound  voluptuousness(haschisch), 
a  kind  of  ecstasy,  and  an  indescribable 
sense  of  well-being  (datura,  laughing  gas, 
opium). 

Lastly,  we  may  observe  at  the  same 
time  a  kind  of  'sub-delirious  condition 
(datura,  Indian  hemp).  In  haschisch 
intoxication  we  frequently  meet  with  an 
exaggeration  of  the  personality  with  ideas 
of  self-satisfaction  and  ambition.  Some- 
times most  singular  illusions  are  observed. 
Individuals  under  the  influence  of  has- 
chisch make  gross  mistakes  with  regard 
to  time,  and  completely  lose  their  know- 
ledge of  locality.  Opium-eaters  have  no 
longer  an  exact  knowledge  of  place  or 
time. 

The  attitude  of  the  patients  reflects  the 
course  of  their  ideas,  and  varies  according 
to  whether  the  poison  acts  upon  the  gene- 
ral sensibility  or  on  the  vaso-motor  system. 
They  are  pale  and  depressed,  and  their 
eyes  are  sad  and  dull  (kawa) ;  or  the  face 
is  animated,  and  the  expression  bright 
and  lively ;  again,  the  patient  may  have 
a  wandering  look  (lecheguana) ;  or,  lastly, 
he  may  lie  down  and  be  prostrated  (iodo- 
form). 

The  general  phenomena  are :  cephalalgia, 
vertigo,  giddiness,  heaviness  of  the  head, 
sense  of  compression  in  the  region  of  the 
temples, tinnitus  aurium, vomiting, tremor, 
reeling  and  uncertain  gait,  sense  of  weak- 
ness in  the  lower  extremities  (pelletierine) 
and  numbness  of  the  limbs  (kawa).  In 
poisoning  with  aniline  we  observe  actual 
automatic  movements,  and  in  that  with 
datura  or  laughing  gas  the  patient  has  an 
irresistible  desire  to  move. 

Consciousness  is  generally  soon  obscured 
although  there  are  cases  in  which  it  may 
persist  (benzene,  chloroform,  lecheguana) ; 
we  then  have  conscious  intoxication  with 
exact  perception  and  comprehension  of  the 
outer  world.  In  some  cases  (laughing  gas) 
the  patient  loses  all  relation  to  the  external 
world,  although  his  knowledge  of  it  is 
pi'eserved.  In  poisoning  with  carbon 
monoxide  the  intellect  remains  intact  till 
nearly  the  approach  of  death. 

Intoxication  ajjpears  rapidly  after  the 
absorption  of  the  poison.  It  may  last  a 
very  short  time,  and  terminate  in  a  condi- 
tion of  more  or  less  profound  sleep.  Ex- 
ceptionally, the  intoxication  by  chloral 
may  apjiear  after  the  narcosis  ;  there  is  at 
first  slight  excitement  of  short  duration, 


then  deep  sleep,  and  the  intoxication 
appears  on  the  patient  waking  up. 

Intoxication  is  followed  by  recovery, 
although  it  may  leave  behind  various 
cerebral  troubles,  which  we  shall  describe 
later  on. 

other  Elementary  Troubles  of  the 
Intellect. — The  clinical  picture  is  not 
always  so  simi:)le,  and  the  intoxication  is 
not  the  only  symi)tom  to  be  observed.  We 
have  isolated  it  because  it  is  so  typical, 
but,  on  the  other  hand,  it  may  have  com- 
plications, and  it  may  also  be  absent.  The 
individual  reactions  to  one  and  the  same 
poison  are  of  an  infinite  variety,  and  the 
dose  absorbed,  as  well  as  all  the  accom- 
panying symptoms,  must  be  taken  into 
account.  Absorbed  in  great  quantity  the 
poison  produces  intoxication,  or  it  may 
prostrate  the  patient  and  even  kill  him  ; 
it  also  may  be  taken  in  a  dose  insuflicient 
to  produce  intoxication,  but  repeatedly, 
and  in  this  case  the  intoxication^  is  from 
the  commencement  chronic  (certain  forms 
of  alcoholism,  poisoning  in  certain  pro- 
fessions, aniline,  carbon  disulphide,  &c.). 
It  is  easy,  therefore,  to  see  that  intoxica- 
tion which  is  jj»«r  excellence  an  acute 
phenomenon,  may  be  absent,  and  we  shall 
now  analyse  the  intellectual  disorders 
which  may  take  its  place,  may  complicate 
it,  or  may  follow  after  the  intoxication  has 
disappeared.  We  shall  first  study  the 
g^eneral  intellectual  phenomena  and 
then  the  insane  conditions. 

The  simple  intellectual  troubles  pro- 
duced by  the  various  poisons  are  of  two 
kinds:  (i)  condition  oi  excitement,  and  (2) 
condition  of  depression.  We  have  seen 
that  both  conditions  may  belong  to  the 
history  of  one  and  the  same  toxic  sub- 
stance, the  latter  following  the  former; 
there  are,  however,  substances  which  may 
cause  principally  excitement,  and  others 
which  more  specially  cause' depression. 

{\)Gonditionof  Excitement. — The  poisons 
which  produce  general  excitement  of  the 
brain  are  very  numerous,  among  them, 
betel,  coffee,  aromatic  stimulants,  mint, 
snake-root,  benzene,  &c.  Some  even  pro- 
duce actual  erethism  of  the  nervous  system, 
as  coffee,  mate,  and  tea.  Others  stimu- 
late particularly  the  intellect  and  produce 
exaltation,  e.g.,  Indian  hemp,  hydrocyanic 
acid, datura, hyoscyamin,  iodoform,  ginger, 
turpentine,  lecheguana  and  opium  ;  at  the 
same  time  the  poison  may  possess  great 
power  of  motor  excitation  (anamirte). 

It  is  easy  to  conceive  the  consequences 
of  these  various  conditions  of  excitement. 
The  most  common  one  is  insomnia, 
(atropine,  cocaine,  copaiba,  002*66,  and 
guarana).  This  insomnia  is  connected 
with   a   sense   of    very    great    resistance 


Poisons  of  the  Mind        [    970 


Poisons  of  the  Mind 


to  fatigue  in  lai-ger  doses  ;  mate  soothes 
and  stimulates  to  work  ;  tea  keeps  awake, 
coffee  takes  away  fatigue,  mint  gives  new 
strength  and  tone  to  the  nervous  system. 

The  character  undergoes  a  profound 
change,  and  becomes  irritable  and  bizarre 
(kawa,  turpentine,  carbon  disulphide).  In 
nervous  subjects,  especially  in  women,  this 
irritability  borders  on  insanity  (turpen- 
tine). Some  patients  are  very  impression- 
able (nux  vomica) ;  others  are  restless,  ex- 
cited, and  feel  uneasy  (iodine). 

As  regards  ideation,  the  stimulus  may 
make  the  course  of  ideas  more  rapid,  but 
they  are  superficial  (coifee) ;  sometimes 
they  may  be  incoherent  or  they  may  even 
be  boisterous  ;  the  incoherence  is  due  to  a 
want  of  uniformity  in  the  stimulation  of 
the  various  faculties ;  the  patient  also  may 
become  unable  to  generalise  and  to  reason 
(chloroform). 

The  imagination  presents  an  almost 
delirious  vivacity  (haschisch  and  opium), 
and  the  passions  become  stronger  (chloro- 
form). The  jiersonality  may  become  trans- 
formed, and  the  patient  may  have  actual 
illusions  ;  sometimes  a  sense  of  well-being 
and  of  quiet  happiness  is  experienced 
(mate),  and  sometimes  the  patient  believes 
himself  to  be  much  lighter  than  usual, 
and  he  seems  to  fly  from  the  ground 
(camphor). 

As  to  movements,  there  is  generally  an 
excessive  impulse  to  be  in  motion. 

(2)  Condition  of  Depression. — There  are 
various  degrees  of  general  depression, 
from  simple  tranquillity  (maratia-moogho), 
with  affection  of  the  mental  jsowers  (bro- 
mides), to  complete  torpor  (aniline,  lauro- 
cerasus,  iodine,  quinine).  Some  patients 
sufier  from  extreme  languor  (lauro-rosa- 
tus).  The  most  conspicuous  effect  of  the 
depressing  poisons  is  narcosis,  which  has 
various  degrees,  from  a  tendency  to  sleep 
(datura,  hyoscyamin,  turpentine),  drow- 
siness (mushrooms),  somnolency  (urea), 
and  slight  narcosis  (duboisia,  thebane),  to 
actual  sleep,  with  apparent  annihilation 
of  all  cerebral  life  (chloroform,  haschisch, 
opium,  lecheguana,  mandragora).  The 
characters  of  sleep  are  of  an  infinite 
variety.  It  may  be  absolutely  irresistible, 
or  only  an  actual  craving  for  sleep  (chloro- 
form, bromides).  It  may  be  profound  and 
quiet  (chloroform),  and  heavy  and  fatiguing 
(haschisch, opium), agitated  (benzene),  and 
full  of  dreams  (chloral),  or  of  nightmare 
(kawa,  haschisch).  In  former  times,  some 
country-peoiDle,  imbued  with  ideas  of 
witchcraft,  would  rub  into  the  skin  lini- 
ments of  belladonna  or  stramonium, 
thus  securing  a  sleep  full  of  all  the 
illusions  of  the  witches'  sabbath,  or  lycan- 
thropy.     The  sleep  may  last  many  hours. 


and  may  be  followed  by  either  absolute 
amnesia,  or  by  a  fairly  clear  recollection 
of  the  dream. 

Should  no  narcosis  be  produced,  the  de- 
pression may  be  diminished,  or  reduction 
of  mental  acumen  and  moral  energy  (car- 
bon disulphide),  enfeeblement  of  volition, 
to  the  point  of  suppression  (duboisia) 
great  fatigue  after  slight  exertion  (santo- 
nin), moroseness,  sense  of  discourage- 
ment and  annihilation  (hydrocotyle),  of 
atonishment  and  indifference,  with  dul- 
ness  and  immobility  (haschisch). 

The  depression  may  be  accompanied  by 
a  certain  degree  of  well-being  (coca),  and 
by  a  sensation  reminding  us  of  the  lassi- 
tude of  the  siesta  in  hot  countries  (kawa), 
of  ecstasies  and  of  enjoyment.  In  other 
cases,  there  is  a  happy  satisfaction,  similar 
to  that  of  an  idiot,  with  incoherency  of 
speech  (bromides). 

The  two  conditions  we  have  just  men- 
tioned do  not  exclude  each  other :  we  have 
already  seen  that  the  condition  of  nar- 
cosis or  depression  in  many  cases  follows 
the  initial  excitement  (Indian  hemp, 
opium,  tobacco,  and  kawa).  Occasionally, 
we  may  observe  alternations  of  torpor, 
somnolency  and  agitation  (carbon  disul- 
phide). In  other  cases,  agitation  follows 
the  depression,  as  in  the  case  of  datura, 
which,  after  having  produced  sleep,  causes 
agitation,  with  obstinate  insomnia. 

After  the  various  intoxications,  the 
memory  often  undergoes  singular  altera- 
tions ;  sometimes  comparatively  intact 
with  regard  to  events  before  or  during 
the  disorder,  it  may  completely  disappear 
(iodine,  chloroform,  oenanthe).  Cases 
have  even  been  observed  of  retrograde 
amnesia  (carbon  monoxide,  datura,  ben- 
zene). 

Insane  Conditions. — In  addition  to 
the  intoxication  and  general  disturbance 
of  the  mind  just  described,  the  mental 
poisons  produce  also  mental  disorder, 
which  we  term  insane  conditions  (etats  dt- 
lirants).  These  conditions  are  so  inti- 
mately connected  with  the  former,  that  it 
is  difficult  to  separate  them,  except  for  the 
purpose  of  description.  The  individual 
variations  are  here  very  numerous,  the 
same  poison  j^roducing  different  effects  in 
two  individuals,  thus  proving  again  that 
the  individual  reaction  is  everything. 
The  other  symptomatic  differences  depend 
on  the  more  special  action  of  a  poison  on 
one  special  function,  as  is  the  case  with 
the  poisonous  kinds  of  nightshade,  which 
create,  as  Lasegue  says,  such  a  desire  to 
wander,  that  the  patient  can  never  be 
kept  quiet. 

We  shall  describe  several  types  of  dis- 
order, and  at  the  same  time,  we  shall  class 


Poisons  of  the  Mind        [    971     J        Poisons  of  the  Mind 


into   groups   those   poisons   which    have 
similar  efPects. 

(i)  MiOiiucal,  or  incoherent  type,  which 
is  the  most  frequent.  The  derangement 
is  absolutely  general.  To  this  class  be- 
long— e.g.,  all  febrile  disorders  and  those 
caused  by  auto-intoxication. 

(2)  Alcoholic  tiipe  (maniacal  condition  of 
a  depressive,  painful  and  frightful  form). 
The  poisons  of  this  class  are  numerous — 
alcohol,  carbon  disulphide,  datura,  ab- 
sinthe, tea,  mandragora,  atropine,  &c. 
{See  Alcoholism.) 

(3)  Maniacal  ti/pe  of  expansive  form — 
ambitious,  mystic  and  erotic  ideas,  ideas 
of  self-satisfaction  and  of  exaggeration 
of  personality  (benzene,  laughing  gas, 
haschisch,  cantharides). 

(4)  Melancholic  type  (kawa,  lecheguana, 
and  iodoform).  Not  well  defined  and 
always  temporary. 

(5)  Mixed  forms.  Depression  may  alter- 
nate with  excitement. 

(6)  Vesanic  conditions — i.e.,  attacks  of 
insanity,  which  although  excited  by  poi- 
sons, do  not  derive  their  special  colour  or 
chai-acter  from  the  drug,  but  arise  in  per- 
sons strongly  predisposed  to  insanity. 

The  elements  which  constitute  the  de- 
rangement are : 

(i)  Disorders  of  ideation:  false  and 
strange  conceptions  ;  g.ay,  sad,  ambitious 
and  erotic  ideas,  and  those  of  persecution. 
They  are  generally  isolated  and  inco- 
herent, and  are  very  frequently  caused  by 
sensory  disorders.  It  is  noteworthy  that 
the  derangement  is  most  intense  during 
the  night.  Lastly,  the  individual  reac- 
tions ai'e  in  close  relation  to  the  course  of 
these  ideas  (anger,  stupor,  hilarity,  &c.). 

(2)  Sensory  illusions. 

(3)  Hallucinations  of  all  the  senses, 
especially  of  vision. 

(4)  Consciousness  is  obscured  or  anni- 
hilated. 

Other  PathoIog^icalPhenomenaivhich 
accompany  the  Intoxication. — In  order 
to  complete  the  general  history  of  mental 
intoxications,  we  have  to  mention  the 
disorders  other  than  psychical,  produced 
by  the  poisons  which  affect  the  mind. 
These  are  of  great  importance  as  aiding 
the  diagnosis,  if  the  latter  is  left  doubtful 
when  the  mental  symptoms  alone  are  taken 
into  consideration. 

There  are,  first,  some  general,  more  or 
less  severe,  symptoms,  caused  by  the 
impression  which  the  nervous  system  ex- 
periences—/am^uigr,  tendency  to  syncope 
(camphor  {?)),  hjpothymia,  pjrofound  syn- 
cope (muscarine,  cantharides,  camphor, 
cigue,  oenanthe,  quinine,  and  turpentine) ; 
prostration  (cherry-laurel  and  iodides), 
sittjjor  (mushrooms,  atropine,  Indian  hemp 


(haschisch),  hydrocyanic  acid,  datura,  du- 
boisia),  and,  lastly,  coma,  which  is  very  fre- 
quent, and  may  terminate  fatally  ;  it  is  very 
distinct  in  alcoholic  and  lead  intoxications, 
and  as  a  terminal  symptom  of  epilepti- 
form attacks  (V.  Bertin,  art.  "  Coma,"  in 
"  Dictionnaire  Encyclopedique  ").  The 
hypasthenic,  stupefying,  narcotic  and 
neurasthenic  poisons  are  characteristic  in 
producing  coma.  In  the  hypasthenic 
class,  coma  is  somewhat  rare  ;  "  the  func- 
tional depression  here  affects  more  the 
ensemble  of  the  vital  powers  than  the 
brain-centres "  (arsenic,  corrosive  subli- 
mate, tartrate  of  antimony,  bromide  of 
potassium,  and  phosphorus — in  the  last 
case  the  coma  may  follow  the  mental  de- 
rangement —  somnolency,  derangement, 
coma,  and  death).  In  the  class  of  stupe- 
fying poisons  the  coma  is  more  profound 
(alcohol,  lead,  belladonna,  hyoscyamus, 
datura,  tobacco,  and  chloroform).  The 
narcotics  produce  narcosis,  which  may  pass 
over  into  coma.  Lastly,  in  the  class  of 
neurasthenic  poisons,  the  coma  is  the  con- 
sequence of  a  loss  of  nervous  energy  (nux 
vomica,  cantharides,  and  hydrocyanic 
acid).  In  febrile  and  septic  diseases  coma 
is  frequent  (intermittent  fever,  Planer  and 
Frerichs),  as  also  in  the  auto-intoxications 
(uraemia). 

ZWotor  Disorders. — Motility  may  be 
exaggerated,  diminished,  abolished,  or 
perverted,  and  the  disorders  may  be  local- 
ised in  various  manners.  Exaggeration 
of  motility  may  present  itself  in  simple 
stimulation  of  muscular  contractility 
(coffee),  increasing  to  the  production  of 
involuntary  movements  (carbon  disul- 
phide), in  co7itractures  (creasote  and  iodo- 
form), in  cramps  (carbon  disulphide  and 
alcohol),  and  in  convulsions,  which  are  of 
great  importance  and  very  frequent.  They 
may  be  general  (argas,  atrojjine,  creasote, 
digitalis,  duboisia,  ei'got,  jusquiame,  lauro- 
cerasus,  lead,  quinine,  &c.)  (due  to  a  spe- 
cial action  of  the  poisons  or  to  individual 
reaction  ;  they  may  be  a  precursory  symp- 
tom of  death,  or  are  characteristic  of  the 
acute  phase  of  the  intoxication),  or  they 
may  be  localised — face,  limbs,  jaw  (oenan- 
the) ;  diaphragm  (hiccough  in  digitalism) ; 
posterior  cervical  region  (aniline  and  co- 
paiba) ;  neck,  abdomen,  j^harynx  (copaiba); 
or  opisthotonos  and  trismus  (oenanthe, 
santonin,  and  turpentine) ;  they  remind 
the  observer  of  convulsions  in  hydro- 
phobia (cantharidism). 

The  diminution  of  'inuscular  energy 
presents  various  degrees,  from  simple  mus- 
cular weakening  (creasote,  jusquiame, 
lauro-cerasus  and  all  narcotic  and  stupe- 
fying poisons)  to  diminution  of  mobility 
(bromides),  and  even  to  its  complete  abo- 


Poisons  of  the  Mind        [ 


97: 


Poisons  of  the  Mind 


lition.  Paralysis  is  extremely  frequent 
in  the  course  of  intoxications  ;  either  gene- 
ral in  acute  cases  (chloroform,  laughing 
gas,  cantharides,  chloral,  atropine,  jus- 
quiame,  belladonna  and  turpentine),  or 
Joccil  (temporary  or  permanent)  in  chronic 
cases  (alcoholism,  lead-poisoning);  hemi- 
plegia and  alternating  paralysis  (iodine) ; 
and  paralysis  of  the  extremities  (lead) ; 
the  most  common  form  is  paraplegia  of 
the  lower  limbs  (alcohol,  carbon  disul- 
phide  and  chloral).  In  the  presence  of 
paraplegia  we  have  always, to  consider 
the  possibility  of  intoxication.  In  chronic 
cases  we  may  observe  generalised  para- 
lysis due  to  muscular  changes  (degenera- 
tion, sclerosis  and  trophic  disorders). 

Sensory  Disorders. — These  form,  to- 
gether with  mental  and  motor  disorders, 
the  three  great  parts  of  the  symptoma- 
tology of  intoxications. 

As  regards  general  sensibility  we  find 
pseiidxsthesia,  a  general  and  local  anies- 
tJiesia;  hemiansestliesia  and  analgesioj ; 
and  lastly,  general  and  local  hyperses- 
thesia,. 

On  the  part  of  special  sensibility  we 
observe  augonentatiou  and  diminution  of 
sensory  acuteness.  "With  regard  to  vision 
we  meet  with  hyperaasthesia  of  the  optic 
nerve,  photopsia,  dyschi-omatopsia,  dip- 
lopia, diminution  of  visual  acuteness,  dis- 
ordered vision,  amblyopia,  amaurosis, 
temporary  or  permanent,  blindness,  and 
contraction  or  dilatation  of  the  pupils. 
With  regard  to  hearing  we  observe  tinni- 
tus aurium,  paracousia,  augmentation  or 
diminution  of  auditory  acuteness,  and 
deafness.  On  the  part  of  taste  and  smell 
there  may  be  exaggeration  or  abolition  of 
both.  On  the  part  of  genital  sensibility 
poisons  may  have  an  aiahrodisiac  effect, 
or  they  may  be  anaphrodisiac. 

The  disorders  of  sensibility,  howevei-, 
are  not  truly  pathognomonic.  Generally 
speaking,  sensibility  may  be  exaggerated 
or  diminished,  and  it  is  easy  to  see  that 
many  poisons  may  produce  both  effects, 
according  to  the  idiosyncrasies  and  doses, 
and  according  to  whether  the  intoxication 
is  acute  or  chronic. 

Course,  Duration,  and  Termination  of 
Mental  Intoxication. — We  shall  consider 
the  development  of  the  symptoms  separ- 
ately in  acute  poisoning  (therapeutic, 
suicidal,  criminal,  &c.)  and  in  chronic  in- 
toxications (voluntary,  professional,  &c.). 
In  the  former  case  we  obsei've  nothing 
but  a  pathological  storm  accidental  in 
the  life  of  the  patient,  and  to  this  category 
belong  the  greater  number  of  cases  of 
poisoning  (chloroform,  cjuinine,  cantha- 
rides, digitalis,  mushrooms,  &c.). 

Many  poisons  produce  nothing  but  in- 


significant and  temporary  troubles  which 
disappear  without  leaving  any  trace  be- 
hind ;  their  effect  is  limited  to  a  slight 
excitement  or  depression  of  the  faculties, 
to  a  short  intoxication,  or  to  a  more  or 
less  profound  narcosis.  Afterwards,  per- 
fect order  is  re-established.  Other  poisons 
cause  more  serious  symptoms  :  confusion, 
stupor,  convulsions,  coma  and  even  death. 
The  duration  varies  according  to  the  in- 
dividual disposition  and  the  dose  absorbed, 
but  generally  speaking,  the  acute  stage — 
if  recovery  should  follow — does  not  last 
more  than  a  few  days  or  weeks.  If  death 
should  slowly  supervene  it  is  due  to  ex- 
haustion of  the  nervous  system  or  to 
organic  disorder.  Recovery  may  be  slow 
and  may  be  accompanied  by  fatigue,  ma- 
laise, intellectual  inability,  and  by  symp- 
toms of  neurasthenia,  and  in  some  cases 
the  brain  may  be  incurably  affected,  as — 
e.g.,  poisoning  by  carbon  monoxide  is 
sometimes  followed  by  persistent  retro- 
grade amnesia  (Rouillard,  Briand)  and 
occasionally  by  so-called  acute  dementia 
(Bouchereau,  Raffegeau).  Lastly,  we  in- 
dicate as  a  possible  consequence  insanity 
itself  in  predisposed  individuals. 

In  chronic  intoxications,  which  comprise 
the  great  social  intoxications,  the  course 
of  the  symptoms  depends  necessarily  on 
the  habits  of  the  patient,  including  of 
course  the  influence  of  individual  reaction. 
It  is  useful  to  distinguish  between  volun- 
tary and  involuntary  intoxication,  as  the 
course  of  each  is  rather  different. 

In  the  former  case,  the  chronic  period 
does  not  generally  establish  itself  from 
the  first.  At  the  commencement  we  ob- 
serve acute  symptoms  which  here  more 
than  anywhere  else  deserve  the  name  of 
intoxication  (morphia,  cocaine,  alcohol, 
haschisch,  opium,  kawa).  These  acute 
phenomena  may  rejjroduce  themselves  a 
number  of  times,  without  however  prevent- 
ing chronicity  from  establishing  itself : 
they  are  nothing  but  epiphenomena  which 
appear  again  and  again  in  the  course  of 
this  period  ;  the  two  essential  kinds  of 
symptoms,  however,  are  the  irresistible 
appetite  for  the  poison,  with  periodical 
return  of  the  acute  and  subacute  symp- 
toms, and  the  progressive  decay  of  the 
mental  faculties.  The  acute  symptoms 
correspond  to  the  temporary  saturation 
of  the  body  with  the  poison,  while  the 
chronic  symptoms  are  the  expression  of 
organic  lesions,  gradually  developed  under 
the  toxic  influence.  Thus  regarded  it  is 
easy  to  see  that  while  both  kinds  of 
symptoms  may  coincide,  the  former  are 
necessarily  transitory. 

The  character  common  to  all  these 
varieties   of    poisoning   at    the    chronic 


Poisons  of  the  Mind 


[     973     ] 


Poisons  of  the  Mind 


period,  and  which  is  at  the  same  time 
the  cause  and  effect  of  this  chronicity,  is 
the  impulsive  craving  ot'  the  brain  for  the 
return  of  the  sensations  experienced. 
Once  intoxicated,  the  patient  glides  down 
a  dangerous  slope,  because  deprivation  of 
the  stimulant  produces  cerebral  symptoms 
of  all  kinds,  which  temporarily  disappear 
again  on  a  new  dose  being  taken.  At  the 
same  time  the  dose  has  to  be  increased 
progressively  on  account  of  the  singular 
adjustment  of  the  cerebral  cells  to  these 
substances.  If  not  by  force  withdrawn 
from  the  morbid  influence,  the  patient 
falls  a  victim  after  a  variable  length  of 
time,  which  counts  by  years,  under  parti- 
cular cerebral  symptoms,  which  are  the 
same  in  all  cases,  and  indicate  definite 
organic  lesions  of  the  brain. 

The  professional  intoxications  (aniline, 
carbon  disulphide,  lead,  mercury,  and  tur- 
pentine) have,  strictly  speaking,  no  acute 
phase.  The  disease  is  chronic  from  its 
commencement ;  the  saturation  takes 
place  slowly  and  may  for  a  long  time 
produce  only  insignificant  symjjtoms,  but 
it  also  may  terminate  in  the  same  lesions 
as  the  former  class,  a  fact  which  depends 
on  the  individual  resistance.  The  course 
is  slow  and  insidious,  although  some- 
times interrupted  by  the  appearance  of 
subacute  phenomena  as  an  expression  of 
temporary  ovei'-saturation  ;  but  generally 
the  cei'ebral  symptoms  are  the  work  of 
time,  brought  about  more  by  organic 
lesions  which  have  slowly  been  formed 
under  the  poisonous  influence  than  by  a 
direct  action  of  the  intoxicant. 

This  terminal  period  of  all  chronic 
cerebral  poisoning  deserves  special  men- 
tion. It  is  essentially  and  uniformly 
characterised  by  a  progressive  weakening 
of  the  mental  faculties,  which  may  pass 
over  into  complete  dementia  (alcohol  and 
lead).  This  weakening  manifests  itself 
by  a  condition  of  stupidity  and  moral 
degradation,  and  by  disoi'ders  of  ideation 
and  of  memory  (opium,  haschisch,  alcohol, 
lead  and  betel) ;  the  patients  are  quiet 
and  inactive,  and  nothing  but  automata, 
leading-  a  material  life.  It  is  a  singular 
fact,  that  the  appetite  for  the  poison  out- 
lives the  intellectual  decay.  Le  Roy  de 
Mericourt  says  with  regard  to  mate- 
drinkers,  they  know  three  things  only  : 
to  take  mate,  to  sleep,  and  to  eat — and 
we  might  say  the  same  of  all  inveterate 
inebriates.  Physical  decay  soon  produces 
marasmus  and  cachexia,  and  the  patient 
dies  from  exhaustion  or  in  consequence  of 
some  organic  complication,  which  easily 
establishes  itself  on  such  a  soil. 

Many  victims  of  mental  poisons  die 
before  having  reached  the  stage  of  com- 


plete dementia,  if  the  poison  is  energetic 
enough  to  disorganise  rapidly  not  onlj'- 
the  mind  but  also  the  other  functions. 
This  is  the  case  in  morphinism  and  cocain- 
ism.  If  dementia  supervenes,  it  shows 
all  the  symptoms  of  organic  dementia, 
and  may  be  complicated  by  motor  and 
sensory  disorders,  especially  by  paralysis, 
as  we  have  pointed  out  above. 

To  sum  up,  the  life  of  chronic  cases  may 
be  divided  into  two  periods :  a  period  of 
cerebral  over-exertion — cerebral  usury — 
and  a  period  of  cerebral  annihilation,  if 
the  patient  has  not  exceptional  power  of 
resistance  or  if  death  does  not  intervene ; 
but  however  great  the  resistance  is,  the 
patient  will  always  become  an  inferior 
creature  in  consequence  of  the  poison;  he 
may  be  brilliant  in  consequence  of  the 
stimulation  of  his  brain,  but  the  reaction 
afterwards  brings  him  below  the  cerebral 
average.  In  addition  to  this,  the  cerebral 
energy  wants  reviving  by  a  fresh  toxic 
dose,  and  this  is  followed  by  another  fall ; 
thus  the  vicious  circle  is  formed  in  which 
the  patient  finds  his  end. 

General  Characters  of  Mental  Xntoxi- 
cation. — The  following  is  the  ensemble  of 
the  characters  deduced  from  the  study  of 
poisons  of  the  mind  : 

(i)  Toxic  insanity  is  artificial  and  not 
organic ;  heredity  and  mental  conditions 
modify  the  symptomatic  aspect  of  the  in- 
toxication. 

(2)  Most  mental  poisons  produce  a  special 
acute  phenomenon,  a  simple  pathological 
manifestation,  which  has  received  the 
name  of  intoxication. 

(3)  The  intellectual  disorders  produced 
by  this  class  of  poisons  are  general.,  and 
affect  the  whole  of  the  cerebral  manifes- 
tations, although  there  is  a  special  locali- 
sation for  certain  poisons,  which,  how- 
ever, does  not  diminish  the  clinical  value 
of  the  general  disorder ;  these  disorders 
are  of  two  kinds — excitement  and  depres- 
sion ;  the  former  is  the  more  common  and 
is  generally  followed  by  the  latter. 

(4)  In  addition  to  intoxication,  these 
poisons  cause  two  kinds  of  mental  disorder, 
some  consist  in  simple  disturbance  of  the 
normal  mental  processes,  consciousness 
however  being  intact ;  others  ai'e  con- 
stituted by  deviation  and  perversion  of 
the  same  processes  and  by  loss  of  con- 
sciousness ;  the  latter  constitute  toxic 
insanity. 

(5)  Toxicinsanity  is  secondary  insanity. 
It  is  general,  all  the  departments  of  the 
mind  taking  equal  part  in  it ;  sometimes 
the  derangement  is  predominant  in  certain 
centres.  It  is  incoherent  and  idroteus-lihe; 
there  is  no  clearly  systematic  insanity 
and  no  logical  intellectual  disorder ;  the 


Polycholia 


[    974    ]      Post-apoplectic  Insanity 


conceptions  are  rapid,  diffuse,  ill  con- 
nected and  without  consistency  ;  there  is 
no  tendency  to  systematisation,  and  it 
reminds  the  observer  more  of  mania  than 
of  vesania.  It  is  pohjmorjjJwns  :  all  forms 
of  insanity  may  be  observed  not  only  in 
two  different  intoxications  but  even  in  the 
course  of  one  and  the  same  intoxication — 
sadness,  ambition,  mysticism,  eroticism, 
and  ideas  of  persecution.  It  is  Uallu- 
ciufitonj :  the  hallucinations  play  a  pre- 
dominant part,  affecting  all  the  senses, 
with  preference,  however,  for  vision ;  they 
are  very  mobile  and  fugitive,  and  impress 
upon  the  insane  ideas  the  character  of 
incoherency  and  instability.  Lastly  it  is 
temporary:  nothing  but  a  momentary, 
acute  effervescence,  terminating  with  the 
elimination  of  the  poison. 

(6)  Although  the  insane  ideas  may 
assume  almost  any  form,  they  are  in  the 
majority  of  cases  jjcito/hZ  ;  the  hallucina- 
tions,   especially    the    visual    ones,    are 

frighiful.  The  clinical  picture  fre- 
quently shows  the  character  of  alcoholic 
insanity,  which  is  a  perfect  type  of  all 
toxic  derangement.  When  the  ideas 
are  gay,  and  the  conceptions  happy,  the 
condition  will  be  more  a  sub-delirious 
state — a  dream — than  actual  insane  dis- 
order. 

(7)  Prolonged  abuse  of  mental  poisons 
produces  definite  anatomical  lesions,  which 
manifest  themselves  in  a  progressive 
weakening  of  all  the  faculties,  passing 
over  into  deineniia. 

(8)  Toxic  insanity  is  almost  always  com- 
plicated with  extra-cerebral  pathological 
disorders,  indicating  that  the  whole  organ- 
ism takes  part  in  the  morbid  process. 
These  disorders  are  spinal  (sensory  and 
motor),  but  all  the  other  functions  are 
liable  to  be  disturbed,  frequently  in  even 
a  predominant  manner,  showing  that  the 
mental  disorders  are  not  essential,  and 
that  toxic  insanity  is,  strictly  speaking, 
only  a  symptom — a  syndrome — of  a  gene- 
ral malady. 

(9)  Lastly,  we  mention  the  capital  im- 
portance of  inclividual  reaction,  which 
modifies  profoundly  the  clinical  picture  of 
one  and  the  same  intoxication,  and  dimin- 
ishes the  clinical  value  of  toxic  insanity  as 
a  morbid  entity,  making  it  only  a  modifi- 
cation varying  according  to  personal 
idiosyncrasies. 

M.  Legkain. 
POIiVCHOIiZil  (ttoXvs,  much ;  x"^"?* 
bile.)  Excess  of  bile  in  connection  with 
mental  disorder.  Paracholia  signifies  any 
abnormality  in  the  secretion  of  bile,  and 
in  accordance  with  the  doctrine  of  the 
ancients  is  closely  connected  with  in- 
sanity. 


FOI.VBIPSZil  (tvoKvs,  much;  8t\//^, 
thirst).  Excessive  thirst.  (Fr.  polydip- 
sie.) 

POI.YOPIii,  POI.VOPSZS  (ttoXvs, 
many;  aJx//-,  the  eye).  Multiplication  of 
images.  Sometimes  a  symptom  in  hys- 
teria (Charcot).  (Fr.  polyopic  ;  Ger.  Viel- 
selien.) 

POI.YPAR±Slz:.  (Fr.).  A  term  for 
general  paralysis. 

POIiVPATHZA  {nokvs,  many  :  Tvcidos, 
disease).  The  existence  of  a  multiplicity 
of  diseases,  mental  and  bodily.  (Fr.  and 
Ger.  piolypatliie.) 

POIiYPHAGIA  {iTokvs  ;  (f)ayfiv,  to  eat). 
A  synonym  of  Bulimia  (qA\). 

POIiYPHRASIA  {noXvs;  cj)paais,  a 
saying).     A  synonym  of  Logorrhoea  (([.v.). 

POIiYPOSIA  {iroXvs,  much  ;  ttoo-is,  a 
drinking).  A  term  for  a  passion  for 
drinking.  (Fr.  pjolyposie ;  Ger.  Trink- 
sucht.) 

POREN-CEPHAI.VS,  POREIT- 

CEPHAZiY  (TTopos,  a  pore  ;  €yKecf)aXos, 
brain).  A  form  of  brain  found  in  some 
congenital  idiots  and  foetus.  A  large  por- 
tion of  the  convolutions  and  centrum  is 
wanting,  so  that  the  ventricle  can  be  seen 
through  the  aperture.  The  commissural 
fibres  being  destroyed,  idiocy  is  the  result. 
POSSESSION'. — In  olden  times  anyone 
suffering  from  epilepsy  or  other  strange 
neurotic  affection  was  supposed  to  be 
possessed  with  a  devil.  The  idea  is  still 
extant  in  such  phrases  as  "  he  behaves 
like  a  man  possessed."     (Sec  Obsessiox.) 

POST-APOPXiECTXC  ZN-SATTZTY. — 
Definition. — As  the  term  apoplexy  has 
been  applied  to  morbid  conditions  differ- 
ing considerably  from  each  other,  it  is 
necessary  to  explain  the  sense  in  which  it 
will  be  here  used.  Some  authorities  re- 
strict its  application  to  cases  in  which 
there  is  sudden,  nearly  or  quite  complete, 
and  prolonged  deprivation  of  conscious- 
ness, with  entire,  or  very  considerable,  loss 
of  sensation  and  power  of  motion,  but 
only  when  due  to  sanguineous  effusion  in 
or  upon  the  brain.  Others,  who  apjorove 
of  this  definition  of  symptoms,  do  not 
limit  the  causation  to  rupture  of  blood- 
vessels. But  there  are  many  more  who 
employ  it  with  a  wider  signification, 
though  one  which  is  fully  consistent  with 
the  origin  of  the  word  (otto,  from,  and 
ttXjjo-o-o),  I  strike).  They  describe  as  apo- 
plectic not  only  cases  presenting  the  pro- 
found symptoms  mentioned,  but  also 
others  in  which  the  chief  result  of  the 
seizure  is  a  mono-  or  hemiplegia  of  sudden 
development  and  intra-cranial  origin, 
even  though  the  impairment  of  conscious- 
ness may  have  been  only  slight  and  of 
short    duration.     The   degree    in    which 


Post-apoplectic  Insanity      [    975    ]       Post-apoplectic  Insanity 


consciousness  is  involved  varies  greatly, 
both  in  depth  and  duration  in  different 
cases;  it  is,  thei-efore,  not  a  sufficient 
ground  of  distinction.  In  describing  the 
mental  disorders  following  apoplexy,  the 
word  will  be  used  in  the  most  comprehen- 
sive of  these  senses.  It  will  not,  however, 
include  cases  of  injury,  which  occasionally 
give  rise  to  conditions  and  symptoms  al- 
most identical  with  those  of  disease  ;  nor 
toxic  states  from  self-genei-ated  poisons, 
as  in  Bright's  disease,  in  which  apoplecti- 
form attacks,  followed  by  mental  disorder, 
occasionally  occur. 

JEtiologry.  —  Effusions  of  blood  from 
rupture  of  a  blood-vessel,  and  damage  to 
the  brain  from  embolism  or  thrombosis  are 
the  leading  causes  of  apoplexy  and  the 
after  disorders  of  the  mind.  Obviously, 
the  results,  both  psychical  and  somatic, 
will  largely  depend  on  the  position  and 
severity  of  the  lesion.  A  small  effusion  of 
blood  in  the  white  matter  of  the  occipital 
or  pr;v-frontal  lobe  may  prodvice  slight  and, 
for  the  most  part,  transitory  symptoms  ; 
a  similar  effusion  in  the  substance  of  the 
pons  Varolii  will  probably  cause  death  in 
a  few  minutes.  The  mental  functions 
may  be  in  complete  abeyance,  either  from 
the  pressure  of  a  clot  of  blood  or  from  the 
deprivation  of  a  large  area  of  the  brain  of 
its  blood  supply  by  the  obstruction  of  a 
considerable  vessel.  But  unless  the 
plugged  vessel  is  large,  consciousness 
is  usually  little  if  at  all  impaired;  or  if 
lost  directly  after  the  attack,  as  hap- 
pens in  exceptional  cases,  it  is  quickly 
restored. 

It  is  especially  the  artery  of  the  Sylvian 
fissure,  or  one  or  other  of  its  branches, 
which  is  most  liable  to  rupture  or  plug- 
ging :  though  either  lesion  may  occur  in 
any  of  the  other  vessels  of  the  brain. 
Should  the  patient  recover  from  the 
primary  effects  of  the  seizure,  he  is  ex- 
posed to  fresh  danger  during  the  period  of 
reaction.  Then  there  may  be  congestion 
or  even  inflammation  of  the  cerebral  tis- 
sue, which  may  implicate  the  membranes 
in  varying  degree.  If  this  happen  there 
may  probably  be  more  definite  mental 
symptoms,  as  will  be  explained. 

The  state  of  previous  nutrition  of  the 
brain  will  exert  an  important  modifying 
effect  on  the  result.  Should  the  blood- 
vessels have  long  been  atheromatous,  as 
is  common  in  advancing  life,  the  cerebral 
tissue  may  have  become  defective  in  con- 
stitution, even  though  no  very  definite 
impairment  of  function,  mental,  sensory, 
or  motor,  may  have  been  obvious.  Its  re- 
sistive power  will  be  weak,  so  that  an 
effusion  of  blood  or  obstruction  in  a  vessel 
may  lead  to  disturbance  in  a  much  wider 


area  than  in  a  brain  whose  structure  was 
previously  healthy. 

The  influence  of  heredity  is  probably  in 
some  respects  similar  to  that  of  senility. 
Where  there  is  a  disposition  to  mental 
disease,  the  substance  of  the  brain,  in  its 
intimate  composition  and  arrangement, 
does  not  attain  the  normal  standard  of 
development :  it  more  readily  gives  way 
to  strain  or  shock  ;  in  many  cases  it  does 
not  seem  fitted  to  wear  for  an  average 
number  of  years ;  and,  it  may  be,  at  a 
period  of  life  corresponding  to  that  at 
which  the  morbid  tendency  showed  itself 
in  the  ^larent,  or  other  ancestor  from 
whom  it  is  derived,  that  its  nutrition  be- 
comes more  distinctly  impaired.  Should 
an  apoplectic  seizure  occur  in  one  so  con- 
stituted, even  though  it  does  not  cause  im- 
portant local  changes,  the  disturbing  in- 
fluence which  it  exercises  on  the  brain,  as 
a  whole,  may  be  sufficient  to  overthrow 
the  weak  cerebro-mental  stability,  and  in- 
sanity arises. 

An  abnormal  state  of  the  circulation 
sometimes  distinctly  influences  the  mental 
condition ;  in  some  very  markedly.  The 
heart's  action  may  have  become  weak  and 
irregular  through  the  position  or  extent 
of  the  cerebral  lesion,  or  both,  especially 
if  it  be  so  situated  as  to  act  on  the  me- 
dulla oblongata;  or  its  feebleness  and 
irregularity  may  be  dependent  on  disease 
of  the  heart  itself.  In  such  states  mere 
position  of  the  patient  will  occasionally 
modify  the  mental  functions.  One  so 
affected  may  be  confused  and  talk  inco- 
herently when  erect  or  trying  to  walk, 
but  comparatively  clear  and  collected  in 
the  recumbent  posture.  The  physician 
now  and  again  sees  similar  psychical 
changes  in  the  use  of  cardiac  tonics. 
Thus,  mental  confusion  and  hallucinations 
will  disappear  at  least  for  a  time  under 
the  action  of  digitalis  in  s-teadying  and 
strengthening  the  circulation  through  the 
brain,  thereby  removing  states  of  conges- 
tion due  to  permanent  lesions.  This  the 
writer  has  noticed  in  sub-acute  softening 
of  the  brain  consequent  on  a  slight  apo- 
plectic seizure.  It  need  scarcely  be  said 
that  the  tendency  to  disorder  of  the  mind 
will  also  be  increased  should  the  blood 
itself  be  in  an  unhealthy  state,  charged, 
for  example,  with  excrementitious  matter 
which  the  kidneys  have  failed  to  remove. 

Mere  constipation  has  a  bearing  on  the 
question.  In  ordinary  cases  of  insanity, 
maniacal  excitement  or  melancholic  de- 
pression is  usually  intensified  by  confine- 
ment of  the  bowels,  and  marked  relief  to 
the  symptoms  often  follows  the  action  of 
a  purgative.  So  in  the  psychical  disturb- 
ance of  apoplexy — particularly  that  which 


Post- apoplectic  Insanity      [    976    ]      Post-apoplectic  Insanity- 


is  due  to  occasional  general  congestive 
attacks  of  the  brain  in  some  cases  of  sub- 
acute softening — excitement  and  hallu- 
cinations may  for  a  time  pass  away  par- 
tially, or  entirely  when  the  bowels  are 
freely  moved.  There  is  a  derivant  and 
depletory  eflect  on  the  cerebral  vessels  by 
the  discharge  from  the  intestinal  mucous 
membrane. 

The  influence  of  age  is  shown  by  its 
determining  some  forms  of  apoplectic 
seizure  rather  than  others.  Thus  embolism 
from  valvvilar  disease  of  the  heart,  and 
thrombosis  during  and  after  severe  attacks 
of  the  exanthemata,  in  post-partum  states, 
and  in  syphilitic  changes  in  the  walls  of 
theblood-vesaels.are  incident  to  the  earlier 
decades,  and  are  rare  after  middle  life. 
The  character  of  the  psychical  disorder, 
as  will  be  afterwards  explained,  is  fre- 
quently modified  by  the  particular  cause 
in  operation. 

How  far  the  position  of  the  lesion  may 
determine  the  form  and  degree  of  the 
mental  defects  is  a  subject  of  great  in- 
terest and  importance.  The  opinion  has 
been  expressed  by  Bastian  and  others  that 
tumours  and  disease,  implicating  the 
cortex  of  the  occipital  lobes  generally, 
are  more  apt  to  be  associated  with  marked 
disorders  of  the  mind  than  when  they  in- 
volve any  other  part  of  the  surface  of  the 
brain  ;  and  Hughlings  Jackson,  while  con- 
curring in  this  view,  further  holds  that 
the  derangement  is  more  marked  when 
the  morbid  condition  is  of  the  right  rather 
than  of  the  left  side.  It  is  also  main- 
tained by  Ferrier  and  other  observers 
that  the  power  of  intelligent  attention 
suffers  most  in  damage  from  any  cause  to 
the  jor^-frontal  lobes.  However,  Bastian 
himself  admits  that  the  cases  are  not  rare 
in  which  disease  of  the  occipital  lobe  gives 
rise  to  only  slight  mental  change,  and 
that  others  occur  where  bilateral  lesions 
confined  to  the  prse-fi'ontal  lobes  are  at- 
tended with  considerable  weakness  of 
intellect.  Upon  the  whole,  it  does  not 
appear  that  our  present  knowledge  war- 
rants any  definite  conclusions  on  this 
point,  unless  so  far  as  the  psychical  defect 
partakes  of  one  or  other  of  the  forms  of 
aphasia.  These  aphasic  complications  are 
very  important,  and  will  afterwards  re- 
ceive special  consideration. 

Forms  of  mental  Disorder. — The  men- 
tal defects  that  follow  an  apoplectic  seizure 
range  from  a  degree  scarcely,  if  at  ail, 
appreciable,  which  may  be  very  brief,  to 
profound  and  lasting  impairment  of  the 
faculties  of  the  mind.  Some  of  them 
occur  within  a  short  time  after  the  attack ; 
others,  though  directly  related  to  it,  do 
not  assume  their  distinct  and  definite  form 


till  a  later  period.  They  will  be  described 
as  primary  and  secondary. 

(1)  Primary  Disorder  of  tbe  Mind. — 

In  most  cases  where  a  patient  does  not 
succumb  immediately  or  within  a  few  days 
to  an  apoplectic  seizure,  he  gradually 
emerges  first  from  the  coma  and  then 
from  the  remaining  stupor,  which  are 
usually  present  when  the  cause  has  been 
cerebral  haemorrhage,  and  may  or  may 
not  be  present  when  it  has  been  plugging 
of  one  of  the  main  arteries  of  the  brain. 
The  improvement  is  often  slow,  and  some 
weeks  may  elapse  before  an  estimate  can 
be  made  of  the  amount  of  probable  per- 
manent damage  to  the  mind ;  but  though 
slow,  the  improvement  as  a  rule  is  steady 
and  uninterrupted,  at  least  up  to  a  certain 
point.  Cases,  however,  occasionally  occur 
in  which  after  the  patient  has  pai'tially 
recovered  consciousness  and  the  power  of 
speech,  if  it  has  been  lost,  in  which  he 
passes  into  a  state  of  delirious  excitement, 
talking  incohei'ently,  and  tossing  about  in 
bed,  so  far  as  the  paralysis  permits,  should 
any  be  present.  The  mental  disorder  is 
due  to  the  inflammatory  action  around 
the  lesion,  and  to  the  wider  vascular  and 
nervous  disturbance  to  which  it  gives  rise. 
It  is  accompanied  by  a  quick  pulse  and  an 
elevated  temperature,  which  may  reach 
105°  to  108°  F.,  when  a  fatal  termination 
may  be  expected.  In  other  patients  the 
acute  mental  and  physical  symptoms 
gradually  subside  after  two  or  three  days, 
and  they  pass  into  a  chronic  state  of  more 
or  less  mental  enfeeblement. 

(2)  Secondary  IVIental  Disorders. — 
They  may  be  broadly  divided  into  two 
classes — namely,  the  various  states  of 
mental  weakness  which  do  not  amount 
in  degree  and  kind  to  a  condition  which  in 
a  legal  sense  might  be  jiroperly  designated 
insanity;  and  the  disorders  which  may  be 
so  regarded.  These  will  be  considered  in 
the  above  order. 

(a)  IVIental  Defects. — This  group  in- 
cludes the  psychical  weaknesses  which 
follow  apoplectic  attacks.  They  differ 
from  the  class  already  noticed  in  not 
being  dependent  on  acate  action  at  the 
seat  of  lesion,  or  in  the  brain  generally. 
They  represent  the  stable,  and  to  a  large 
extent  permanent  injury  to  the  nervous 
structures  connected  with  mental  action. 
In  some  cases  the  mind  as  a  whole  suffers 
pretty  uniformly;  in  others,  certain  powers 
are  markedly  affected,  while  the  remainder 
are  less,  if  at  all,  involved.  A  general  idea 
may  be  formed  of  the  proportion  in  which 
the  leading  faculties  are  weakened  by  the 
following  study  of  fifty  cases.  They  were 
inmates  of  the  infirm  wards  of  a  work- 
house,   and    were    all   hemiplegic.      The 


Post- apoplectic  Insanity      [    977    ]      Post-apoplectic  Insanity- 


primary  seizure  had  occurred  at  least  a 
month  before  examination,  and  in  several 
there  had  been  an  interval  of  some  years. 
Twenty-six  were  men  and  twenty-four  were 
women.  The  ages  ranged  from  twenty-five 
to  seventy-two.  Care  was  taken  to  exclude 
cases  complicated  with  senile  mental 
changes.  No  attempt  was  made  to  differ- 
entiate between  those  apparently  due  to 
effusion  of  blood  and  others  more  probably 
the  result  of  thrombosis  or  embolism.  In- 
deed, though  there  is  in  a  lai-ge  proportion 
of  patients  usually  slight  but  distinct 
alterations  in  the  mental  condition,  which 
suggest  thennture  of  theimpendingattack, 
before  an  apoplectic  seizure  due  to  thi'om- 
bosis,  after  its  occurrence  the  psychical 
defects  do  not  appreciably  differ  from  those 
consequent  on  the  rupture  of  a  blood- 
vessel. 

Beginning  with  apprchetision,  it  was 
found  to  be  fairly  quick  and  clear  in  38 
oases  and  dull  in  12.  This,  however,  is 
only  applicable  to  simjsle  remarks  and 
questions  which  do  not  require  sustained 
attention.  Memory  was  regarded  as  cor- 
rect in  19  and  impaired  in  31.  In  the 
latter  section  impressions  produced  since 
the  seizure,  more  particularly,  were  faint 
and  evanescent.  In  a  few  it  was  slowly 
improving,  ajiparently  jjari  passu  with 
the  other  symptoms,  physical  and  mental. 
Judgment  was  obviously  affected  in  28 
cases,  and  was  apparently  sound  in  22. 
The  tests  applied  did  not  go  beyond  simple 
subjects,  and  it  is  probable  that  in  many 
of  those  in  whom  it  had  apparently  escaped 
injury  it  was  really  somewhat  weakened. 
The  emotional  poii-ers  were  normal  in  only 
8  cases ;  they  were  more  or  less  implicated 
in  42.  The  impairment  was  slight  in  5 
cases,  moderate  in  22,  and  very  marked  in 
15.  There  was  an  undue  disposition  to 
weep  from  trifling  causes  in  20,  to  laugh 
in  6,  both  to  laugh  and  weep  in  1 5.  Where 
the  tendency  was  to  weep,  <iven  a  sympa- 
thetic tone  of  voice  accompanying  a  remark 
which  was  not  in  itself  calculated  to  excite 
feeling,  would  in  some  patients  induce  a 
paroxysm  of  sobbing.  One  woman  would 
go  off  into  a  fit  of  laughter  on  a  slight 
smile  or  shake  of  the  head.  Several  who 
suffered  from  emotional  weakness  were 
also  very  irritable. 

It  is  to  be  observed  that  the  analysis  of 
these  cases  probably  conveys  too  unfavour- 
able an  idea  of  the  degree  in  which  the 
mind  suffers  in  apoplexy.  They  were  all 
of  a  severe  kind  and,  as  mentioned,  were 
accompanied  by  one-sided  palsy.  In 
slighter  attacks  there  are  occasionally  no 
apparent  after  mental  effects ;  but  when 
carefully  examined  it  will  be  found  that 
the  cases  which  are  absolutely  free  from 


permanent  eufeeblement  of  mental  power 
are  by  no  means  common. 

With  the  lapse  of  months,  or  more 
generally  years,  a  considerable  proportion 
of  weak-minded  and  paralytic  patients 
become  slowly  feebler  in  mind  and  body; 
they  cease  to  be  able  to  move  about  and 
are  bedridden ;  they  lose  control  of  the 
bladder  and  bowels,  and  if  care  be  not 
taken  bed-sores  form,  when  death  soon 
closes  the  scene,  A  still  larger  number 
have  a  second  or  third  shock,  in  which 
they  may  die,  or,  if  they  survive,  their  con- 
dition becomes  worse  and  the  end  is 
hastened.  The  old,  it  need  scarcely  be 
said,  are  most  disposed  to  rapid  degenera- 
tion and  repeated  seizures.  The  younger 
patients  may  recover  to  a  large  extent  the 
power  both  of  mind  and  body ;  and  the 
recovery  will  or  will  not  be  enduring 
according  to  the  nature  of  the  cause  or 
causes  in  operation, 

(6)  Forms  of  Insanity. — It  is  not  un- 
common for  an  apoplectic  seizure  to  be 
followed  by  such  imsoundness  of  mind 
as  would  warrant  confinement  in  a  luna- 
tic asylum.  Any  of  the  leading  forms  of 
insanity,  classified  according  to  the  symp- 
toms, may  occur.  The  maniacal  dis- 
orders are  the  most  common,  but  they 
are  usually  associated  with  more  or  less 
of  dementia.  Noisy  excitement  and  in- 
coherence, hallucinations  and  illusions, 
destructiveness  and  filthy  habits,  may  all 
be  features  of  the  mania.  Generally  the 
paroxysm  does  not  last  longer  than  two 
or  three  weeks,  but  in  some  cases  it  is 
much  more  protracted.  Sometimes  it 
assumes  the  recurrent  form ;  there  mav 
be  an  interval  of  a  fortnight  or  so  during 
which  the  patient  is  calm  and  nearly 
rational,  but  afterwards  the  mania  returns 
as  before.  Melancholic  depression  may 
occupy  the  interval,  and  the  condition 
approximates  to  that  of  circular  insanity. 
Some  patients  are  fairly  reasonable  in 
their  conduct  and  what  they  say  during 
the  day,  but  talk  nonsense  and  are  noisy 
at  night.  Occasionally  melancholia  is 
the  form,  and  is  maintained  throughout 
the  entire  attack,  with  or  without  a  dis- 
tinct suicidal  disposition.  The  mental  dis- 
order, whether  mania  or  melancholia,  may 
follow  quite  a  slight  apoplectic  seizure 
within  a  few  days  of  its  occurrence  ;  or 
the  patient  may  have  emerged  from  the 
coma  and  stupor,  and  have  been  apparently 
rational  for  a  time  before  the  symptoms  of 
derangement  make  their  appearance. 

In  some  cases  there  is  a  more  gradual 
development  of  mental  unsoundness  cor- 
responding to  a  comparatively  slow  in- 
crease of  softening  due  to  thrombosis  and 
the    amount  of    the   associated   cerebral 


Post-apopleetic  Insanity      [    978    ]      Post-apoplectic  Insanity 


disturbance.  The  following  case  illus- 
trates this  variety.  An  acute  man  of 
business  had  a  slight  apoplectic  attack, 
inducing  spasms  and  ultimately  paralysis 
of  the  left  side.  His  mind  was  not  ap- 
preciably affected  till  about  three  weeks 
after  the  onset.  Within  another  month 
psychical  disturbance,  beginning  with 
mistakes  in  the  days  of  the  week  and  in 
identifying  people,  had  developed  into  a 
mild  mania.  He  saw  imaginary  forms  and 
even  threw  articles  at  them.  He  talked 
confusedly  and  occasionally  displayed  con- 
siderable irritability  with  emotional  weak- 
ness. This  condition  subsided  to  a  large 
extent  after  about  a  fortnight,  though  it 
occasionally  recurred  in  less  degree  till  his 
death  about  two  months  afterwards. 

Persistent  delusional  insanity  may  be 
the  form  of  derangement.  Thus,  a  woman 
about  forty  years  of  age,  who  had  been 
long  insane  and  paralytic  on  the  left  side 
of  the  body,  was  in  the  habit  of  bitterly 
denouncing  the  officials  of  the  asylum  for 
being  privy  to  tortures  by  electricity  which 
she  declared  were  inflicted  on  her. 

A  progressive  dementia  with  emotional 
weakness,  and  in  some  cases,  occasional 
periods  of  excitement,  is  a  common  condi- 
tion after  apoplectic  seizures  of  consider- 
able severity.  The  majority  of  such  cases 
among  the  poor  gravitate  into  the  infirm 
wards  of  the  workhouse;  some  are  certi- 
fied as  insane  and  spend  their  remaining 
days  in  asylums.  There  is  little  or  no 
difference  between  the  two  classes,  except 
that  the  latter  are  occasionally  more  noisy 
and  troublesome   than  the  former.     The 


wreck  of  mind  is  much  the  same  in  them 
both. 

Apoplexy  in  the  Insane. — There  is 
often  considerable  mental  change  in  an 
insane  person  after  an  attack  of  apoplexy. 
Troublesome  and  demonstrative  mono- 
maniacs not  unfrequently  become  quieter 
and  more  manageable.  There  is  no  im- 
provement, however,  but  rather  the  con- 
trary ;  they  have  sunk  to  a  lower  mental 
level.  But  there  are  instances  where  a 
mild  dement  changes  into  a  noisy,  de- 
structive lunatic.  Here,  too,  the  psychical 
state  has  altered  for  the  worse. 

The  Relations  of  Aphasia  to  In- 
sanity.— One  of  the  most  serious  conse- 
quences of  an  apoplectic  attack  is  the  oc- 
currence of  the  condition  which  bears  the 
name  of  aphasia  (rt,  neg.;  (^acrty,  speech). 
In  describing  its  relations  to  mental  disease, 
a  brief  account  of  its  various  forms  will 
be  given  at  the  outset,  so  that  the  manner 
and  degree  in  which  the  mind  is  involved 
may  be  more  clearly  shown.  The  term 
will  be  used  in  its  most  general  accepta- 
tion to  include  all  varieties  of  partial  or 
complete  loss  of  language  or  power  of 
expression,  when  these  are  of  cortical 
origin  or  at  least  due  to  lesions  situated 
on  a  higher  plane  than  the  centres  imme- 
diately related  to  the  muscles  by  whose 
action  thought  is  communicated  to  others, 
whether  by  vocal  sounds  or  otherwise. 
Many  of  these  defects  differ  materially 
from  each  other,  but  they  may  be  all 
grouped  in  three  divisions,  namely — 

(l)  IMotor  aphasia;  (2)  Sensory 
aphasia ;  (3)  Mixed  forms. 


R  R.  Fissure  of  Rolando.  S  S.  Fissure  of  Sylvius,  i,  2,  3.  First,  second  and  third  fronal 
convolutions.  F  F.  Transverse  frontal  convolutions.  P  P.  Transverse  parietal  convo  ut  ons. 
O  O  Orbital  convolutions.  T  i,  T  2.  First  and  second  temporo-sphenoidal  convolutioii». 
I.  Island  of  Reil  (the  superior  and  inferior  marsinal  convolutions  are  representeit  as  oem, 
drawn  asunder  so  as  to  expose  it).  .,•*„„*  „ftn,^i,ps 

We  arc  indebted  to  Dr.  P.ateman  for  the  use  of  this  block,  to  which  a  special  interest  attache*, 
as  it  was  sent  to  him  by  his  friend,  the  late  Prof.  Broca,  to  illustrate  the  work  on  Aphasia,  to 
Which  the  Academy  of  Medicine  has  awarded  the  Alvarenza  Prize  for  the  year  1891. 


Postapoplectic  Insanity      [    979    ]      Post-apoplectic  Insanity 


(l)  Motor  Apbasla. — Iniincomiilicated 
cases  of  this  kiud  the  patients  can  under- 
stand what  is  said  to  them,  they  can  read 
and  comi>rehend  written  or  printed  woi'ds 
and  also  the  language  of  signs.  They 
are,  however,  unable  to  communicate  their 
thoughts  to  others  by  speech,  and  in 
most  cases  also  by  writing.  But  the 
majority  make  use  of  a  most  expressive 
pantomime  to  convey  their  meaning.  It 
is  probable  that  in  these  cases  the  highest 
centres  for  the  co-ordination  of  the  nerv- 
ous incitations  for  words  spoken  or 
written,  or  the  channels  for  the  trans- 
mission of  these  incitations  to  the  lower 
centres  directly  connected  with  the  nerves 
for  the  muscles  involved,  are  specially  if 
not  alone  implicated.  The  lesion  is  there- 
fore motor  in  its  nature  ;  and  there  seems 
at  first  sight  no  sufficient  reason  why  the 
mental  powers  should  be  distinctly  im- 
paired. The  patient's  organs  for  the  re- 
ception of  the  impressions  which  give  rise 
to  language  are  not  damaged,  and  those 
parts  of  the  cortex  on  which  previous 
inijiressions  coming  through  the  sensory 
nerves,  particularly  those  of  hearing  and 
sight,  were  registered,  are  probably  ueai'ly 
in  their  normal  condition. 

The  writer  is  of  opinion  that  in  think- 
ing, words  in  most  cases  are  revived  in 
the  sensory  area  of  the  convolutions. 
But  he  also  holds  that  in  their  repi'oduc- 
tion  they  are  ordinarily  accompanied  by 
faint  motor  intuitions,  which,  in  rare 
cases,  especially  in  jieople  who  sjjeaA;  their 
thoughts,  apart  from  conversation,  may 
be  so  distinct  as  to  be  sufficient  instru- 
ments for  reasoning,  independent  of  au- 
ditory revivals.  In  accordance  with  this 
view  words  in  the  motor  aphasic  may 
revive  in  consciousness  much  as  before, 
though  probably  bereft  of  their  non- 
essential motor  accompaniment,  and  so 
far  as  verbal  reproductions  are  concerned, 
there  is  no  apparent  impediment  to  the 
exercise  of  thought.  That  such  patients 
really  have  the  use  of  words  will  appear 
from  a  consideration  of  such  acts  as  evince 
a  process  of  reasoning  in  their  execution. 
For  thought  hi  the  sense  of  reasoning  can- 
not be  carried  out  without  words,  or,  as 
in  the  case  of  trained  deaf-mutes,  without 
conscious  motor  intuitions  of  finger-lan- 
guage. This  is  the  opinion  of  most  meta- 
physicians, so  far  as  words  are  concerned 
(Hegel,  Mill,  Schelling,  Dugald  Stewart, 
Condillac,  Warburton,  Ac).  So  eminent 
a  philologist  as  Max  Miilleris  very  decided 
on  the  point;  he  says,  "thought  in  one 
sense  of  the  word — i.e.,  in  the  sense  of 
reasoning,  is  impossible  without  language." 
Assuming  the  soundness  of  this  conclu- 
sion, it  is  only  necessary  to  consider  care- 


fully the  acts  of  i)atients  suffering  from 
this  form  of  aphasia  to  enable  us  to  deter- 
mine if  they  have  the  use  of  words.  It 
requires  very  little  observation  to  satisfy 
the  observer  that  their  ordinary  conduct 
is  reasonable  and  in  all  respects  correct. 
Indeed,  cases  are  on  record  where  the 
patients  have  succeeded  in  conveying 
instructions  to  others  by  gestures  for  the 
conduction  of  important  business.  This 
almost  certainly  indicates  i-easoning.  But 
caution  is  here  necessary.  Accustomed 
acts  even  of  a  complicated  kind  cannot  be 
taken  as  absolutely  sure  evidence  of  dis- 
tinct reasoning  on  the  part  of  the  actor. 
The  skilled  musician  plays  intricate  miasic 
while  his  mind  is  otherwise  occupied. 
The  chronic  lunatic  does  excellent  work 
at  tailoring  or  shoemaking,  or  takes  part 
in  games,  which  he  had  learned  and  prac- 
tised when  of  sound  mind,  even  though 
his  speech  is  now  incoherent,  and  his 
replies  to  simple  questions  are  irrelevant. 
So,  many  occupations,  perhaps  difficult  to 
learn,  when  once  their  details  have  become 
thoroughly  familiar  require  but  little 
exercise  of  thought.  The  accustomed 
circumstances  or  combination  of  circum- 
stances at  once  suggest  wonted  conclu- 
sions, and  action,  semi-automatic,  follows 
in  due  course.  The  slight  thinking  neces- 
sary may  perhaps  not  be  more  in  many 
cases  than  can  be  carried  out  without  the 
use  of  words. 

A  better  way  to  ascertain  the  presence 
or  absence  of  words  in  the  minds  of  motor 
aphasics,  and  at  the  same  time  the  condi- 
tion of  their  reasoning  powers,  is  to  ask 
them  to  show  by  act  or  gesture  what 
would  be  their  course  of  procedure  in  cer- 
tain circumstances,  infrequent  in  their  ex- 
perience, and,  as  far  as  possible,  out  of 
the  ordinary  beaten  path.  Tlius,  the 
writer  has  asked  a  female  patient  to  show 
what  she  would  do  if  the  nurse's  arm  were 
bleeding.  She  thought  for  a  little,  then 
went  Vi-p  to  the  nurse  and  began  to  wrap 
a  piece  of  cloth  round  the  arm,  mean- 
while, making  signs  that  the  bleeding 
would  be  stopped  by  that  means.  To 
another  patient  he  said,  "  Show  me  what 
you  would  do  if  that  bed  were  on  fire." 
She  went  to  the  end  of  the  ward,  lifted  a 
basin  of  water  off  the  table,  brought  it  to 
the  bedside  and  indicated  very  clearly  that 
she  would  pour  the  contents  on  the  burn- 
ing clothing.  By  questions  and  requests 
of  this  kind,  varying,  however,  in  different 
cases  according  to  the  social  position, 
education,  and  other  points,  a  very  fair 
idea  may  be  formed  of  the  condition  of 
the  reasoning  faculty  and  moral  powers. 
The  general  faculty  of  memory  has  been 
proved    to   be  good  by  asking  patients, 


Post-apoplectic  Insanity      [    980    ]      Post-apoplectic  Insanity 


after  the  lapse  of  a  number  ot'  weeks,  to 
repeat  what  they  did  at  the  previous  ex- 
amination, no  reference  having  been  made 
to  the  subject  in  the  interval :  they  have 
done  the  same  things,  after  a  little  reflec- 
tion, without  the  questions  being  put  to 
them  anew. 

The  conclusion  which  careful  considera- 
tion, based  on  an  inquiry  conducted  in 
this  way,  warrants,  is  that  attention,  per- 
ception, and  memory  are  frequently  not 
appreciably  impaired,  and  moreover  that 
the  moral  faculty  and  reasoning  power 
ai'e  retained  in  some  cases  veiy  fully.  As 
a  corollary  to  the  preservation  of  the 
power  of  sustained  thinking,  words  are 
not  lost  to  the  mind  ;  the  patients,  though 
speechless,  are  not  wordless. 

It  is  improbable,  however,  that  in  any 
case  the  capacity  for  continuous  thought 
is  in  no  respect  impaired.  No  doubt,  as 
stated,  the  disability  is  motor,  but  motor 
intuitions,  though  quite  unexpressed, 
arise  in  consciousness  while  thought  is 
l^roceeding,  and  it  is  difficult  to  conceive 
that  the  mechanism  for  their  production 
should  be  destroyed  without  the  power  of 
thinking  also  suffering  to  some  extent. 
The  defect  will  be  greatest  in  those  who 
have  been  in  the  habit  of  faintly  or  more 
distinctly  articulating  while  reading  or 
thinking,  in  order  to  make  the  subject- 
matter  of  their  thoughts  easier  for  their 
comprehension. 

Cases  of  uncomplicated  motor  aphasia, 
though  not  rare,  are  far  from  being  com- 
mon. It  is  much  more  usual  to  find  it 
associated  with  the  sensory  form  ;  and  in 
this  combination  it  will  again  come  before 
us.  There  still  remain  for  consideration, 
from  a  mental  point  of  view,  two  impor- 
tant varieties  belonging  to  the  first  group, 
to  which  attention  will  now  be  directed. 

(a)  Aijlietnia  (d,  neg. ;  (j}ri}xi,  I  speak). 
— As  already  mentioned,  most  motor 
aphasics  are  unable  to  express  their  ideas 
either  by  speaking  or  writing.  There  are 
some,  however,  but  not  many,  who,  though 
unable  to  speak,  except  perhaps  a  few 
words  or  phrases,  which  they  often  do  not 
use  intelligently,  have  no  difficulty  in 
communicating  with  others  by  writing. 
A  patient  of  the  writer's,  a  man  about 
twenty-three  years  of  age,  was  in  the 
habit  of  carrying  a  small  slate  with  him 
on  which  he  wrote  his  remai-ks  in  conver- 
sation. It  was  clear  that  he  had  a  free  if 
not  a  full  use  of  words,  though  he  had 
almost  entirely  lost  the  power  of  articulate 
speech.  His  general  conduct  was  correct, 
and  produced  the  impression  that  he  was 
of  fair  intelligence  and  unimpaired  moral 
sense.  There  are  all  degrees  of  this  de- 
fect, ranging  from  a  slight  inability  to  ex- 


l^ress  the  last  part  of  a  long  sentence,  to 
absolute  incapacity  to  utter  a  single  word. 
The  remarks  already  made  on  the  state  of 
the  mental  faculties  in  ordinary  motor 
aphasia  and  the  method  of  determining  it 
are  equally  applicable  to  this  variety  of 
the  disease. 

(6)  Agraphia  {a,  neg. ;  -ypd^co,  to  write). 
—  The  existence  of  complete,  uncompli- 
cated agraphia  without  some  other  defect 
in  the  expression  of  language  is  doubtful, 
though  one  or  two  cases  are  on  record 
where  there  was  a  near  approach  to  it. 
But  it  is  not  by  any  means  uncommon  to 
meet  with  patients  whose  power  of  ex- 
pression by  writing  has  suffered  to  a  much 
greater  extent  than  by  vocal  speech,  inde- 
pendent altogether  of  the  paralysis  of  the 
arm.  As  patients  in  this  condition  retain 
to  a  large  extent  the  power  of  speech, 
there  is  no  difficulty  in  ascertaining  the 
state  of  their  minds.  Any  psychical  de- 
fect which  may  be  present  is  related  to 
the  accompanying:  loss  of  language,  even 
though  that  may  be  slight,  rather  than  to 
the  inability  to  communicate  by  writing. 

(2)  Sensory  Aphasia.  —  In  a  well- 
marked  case  of  this  form  of  aphasia,  the 
patient  can  comprehend  only  very  imper- 
fectly, if  at  all,  any  remark  that  may  be 
made  to  him.  If  asked  to  do  some  simple 
act,  such  as  to  hold  uj)  his  hand,  he  fails 
to  do  so,  unless  the  request  be  accom- 
panied by  a  suggestive  gesture,  when  he 
may  perhaps  comply,  but  without  intelli- 
gence. He  can  in  general  mechanically 
repeat  words  emphatically  spoken  in  his 
hearing,  and  there  may  be  no  hesitation 
in  their  expression  ;  but  a  minute  after- 
wards he  cannot  tell  what  he  was  asked 
to  say.  This  is  the  condition  to  which 
the  term  "  amnesia  "  has  been  applied. 

It  is  clear  that  in  this  state  the  mind  is 
much  more  deeply  involved  than  in  un- 
complicated motor  aphasia.  The  two 
great  channels,  hearing  and  sight,  for  the 
transmission  of  impressions  from  without 
that  add  to  knowledge  and  give  rise  to 
thought,  are  still  open,  but  the  receiving 
mechanism — the  part  of  the  cortex  of  the 
brain  in  connection  with  these  senses — is 
no  longer  perfect,  and  has  perhaps  been 
seriousl}'^  damaged.  New  impressions  can. 
therefore,  be  only  imperfectly  received, 
and  perhaps  not  at  all. 

It  may  be  here  remarked,  parentheti- 
cally, that  the  fact  of  an  association  be- 
tween the  auditory  and  optic  nerves,  and 
definite  areas  of  the  cortex,  at  least  in 
their  most  distinctly  psychical  relations, 
if  not  established,  is  rendered  highly  pro- 
bable by  the  results  of  post-mortem  ex- 
aminations. These  have  shown  that  where 
words  are  not  apprehended,  the  lesion  in- 


Post-apoplectic  Insanity      [981     ]      Post-apoplectic  Insanity 


volves  the  upper  temporo-sphenoidal  con- 
volution, and  that  a  corresponding  failure 
to  recognise  visual  impressions  points  to 
a  morbid  change  in  the  occipito-angular 
region.  In  a  case  under  the  writer's  ob- 
servation, where  the  symptoms  corre- 
si^onded  closely  to  the  description  above 
given,  more  especially  in  the  absence  of 
intelligent  apprehension  of  what  the  pa- 
tient either  saw  or  heard,  complete  de- 
struction of  the  greater  part  of  the  parietal 
lobe,  most  of  the  upper  temporo-sphenoidal 
convolution,  and  the  back  part  of  the  fron- 
tal lobe,  was  found  after  death. 

But  it  might  be  expected  that  the  regis- 
tration of  previous  impressions  would  be 
in  the  same  district  of  the  brain,  and  that 
damage  to  it  would  prevent  or  interfere 
with  their  revival  in  consciousness,  as 
well  as  with  the  perception  of  those  that 
are  new.  This  seems  really  to  happen  in 
a  large  proportion  of  the  sufferers.  Sen- 
sory ajihasics,  though  they  may  probably 
perform  simple  habitual  acts  as  of  old, 
give  no  indications  by  signs  or  in  any 
other  way  of  silent  thought,  at  least,  such 
thought  as  implies  reasoning.  No  other 
result  could  be  anticipated.  The  area  of 
the  surface  of  the  brain,  where,  as  stated, 
there  is  good  reason  to  believe,  that  im- 
pressions from  the  two  chief  senses  are 
received  and  recorded,  has  suffered  damage 
or,  as  in  the  case  referred  to,  been  de- 
stroyed. We  have  seen  that  the  revival  of 
these  impressions,  more  particularly  those 
of  spoken  language,  is  necessary  for  sus- 
tained thought ;  consequently,  a  lesion  of 
that  part  of  the  cortex  must  interfere  with 
or  prevent  a  reproduction  of  auditory  or 
visual  S3'mbols  in  consciousness.  Con- 
tinuous thought  or  reasoning  is  therefore 
not  possible  to  one  in  this  condition. 

The  severe  form  of  sensory  aphasia,  to 
which  the  foregoing  remarks  are  applic- 
able, is  by  no  means  uncommon,  though 
it  is  not  often  seen  in  an  extreme  degree. 
The  patient  has  generally  the  use  of  a 
number  of  words  which,  however,  are 
uttered  in  a  haphazard  or  recurring  way, 
with,  as  a  rule,  little  or  no  bearing  on  the 
observation  that  may  have  been  made  to 
him.  If  the  lesion  has  been  less  severe, 
some  meaning  may  be  picked  out  of  the 
disjointed  expressions.  The  function  of 
the  more  jjurely  motor  mechanism  not 
being  appreciably  injured,  words,  as 
mentioned,  may  be  rejieated  correctly,  or 
neai-ly  so,  immediately  after  they  are 
spoken  to  the  patient ;  but  there  is  no 
reason  to  think  they  are  more  than  auto- 
matic utterances  that  do  not  enter  into 
consciousness. 

The  degree  to  which  the  mind  suffers 
apjiears   to   correspond   very  much  with 


the  extent  of  the  actual  loss  of  language, 
especially  words.  Should  that  be  small, 
the  patient's  intelligence  may  be  little  im- 
paired, but,  if  great,  thought  may  be  in 
abeyance.  The  patient  may  still  respond 
to  and  be  conscious  of  impressions  that 
come  to  him  from  any  of  the  other  senses, 
such  as  touch  or  the  muscular  sense,  but 
these,  though  they  may  give  rise  to  coii- 
cepts,  are  not  by  themselves  sufficient  to 
maintain  continuous  thought. 

Just  as  in  motor  aphasia,  there  are 
partial  defects,  one  channel  of  expression 
being  fi'ee  while  the  other  is  blocked,  so 
in  the  sensory  form  either  of  the  two 
main  areas  in  the  cortex  for  the  reception 
of  impressions  may  alone  be  affected. 
Thus  there  is  a  word-deafness  and  a  word- 
blindness. 

{a)  Word-deafTiess. — In  the  complete 
and  isolated  development  of  this  condi- 
tion the  patient  hears  the  sound  of  any 
one's  voice,  and  may  even  recognise  the 
words,  but  fails  to  understand  the  mean- 
ing of  what  is  said,  however  simple  the 
remark.  At  the  same  time  his  perception 
of  what  he  sees  or  feels,  or  of  other  sense- 
impressions,  is  normal.  He  can  also  con- 
verse, and  his  command  of  language  may 
not  be  greatly  impaired.  He  has  no  diffi- 
culty in  the  expression  of  words. 

It  is  not  a  common  condition,  apart 
from  other  defects.  There  are  all  degrees 
of  the  affection.  In  illustration  of  a 
minor  one,  the  case  of  a  gentleman  may 
be  mentioned,  who  spoke  to  the  writer 
about  an  inability  he  had  in  understand- 
ing the  meaning  of  words.  He  was  a 
highly  intelligent,  energetic  man  of  busi- 
ness, about  fifty-five  years  of  age.  "  I 
hear  quite  well,"  he  remarked,  "  all  that 
is  said,  but  the  words  sound  strange ;  I 
cannot  understand  them  as  formerly." 
He  spoke  with  fluency  and  gave  a  clear 
account  of  his  condition,  besides  convers- 
ing on  other  subjects  without  hesitation. 
His  disorder  was  almost  entirely  subjec- 
tive, for  there  was  scarcely  any  flaw  to 
be  detected  in  his  jDower  of  apprehension 
during  the  interview. 

This  case  may  be  regarded  as  the 
slightest  of  its  kind.  Many  patients,  be- 
sides being  unable  to  understand  clearly 
what  is  said,  as  in  that  instance,  are  un- 
able to  recall  words,  esj^ecially  names  and 
nouns  generally.  In  them  the  power  of 
reviving  old  impressions  of  articulate 
sounds  as  well  as  that  of  receiving  those 
that  are  new  is  impaired. 

The  state  of  the  mind  in  word-deafness 
has  already  been  referred  to  when  con- 
sidering sensory  aphasia  generally.  It  is 
only  necessary  to  add  that  the  degree  of 
mental  defect  will  be  modified  by  the  ex- 


Post-apoplectic  Insanity      [    982    ]      Post-apoplectic  Insanity 


tent  to  which  the  individual  when  in 
health  was  dependent  for  his  knowledge 
on  visual  rather  than  on  auditory  impres- 
sions, and  also  on  the  amount  of  help  he 
derived  from  silent  articulations  in  think- 
ing. There  are  persons  whose  perceptions 
of  objects  they  see  are  exceptionally  vivid, 
some  of  whom  have  the  remarkable  power 
of  being  able  to  project  their  visual  per- 
cej^ts  into  space,  and  avow  to  have  scenes 
and  objects  before  them  as  clearly  as 
when  they  saw  them  in  reality,  though 
that  may  have  been  many  years  before. 
The  writer  had  an  experience  under  the 
influence  of  medicine,  which  he  may  men- 
tion in  illustration.  He  had  taken  a  good 
deal  of  opium  to  relieve  pain,  and  while 
under  the  action  of  the  drug,  which  lasted 
for  about  three  days  after  its  administra- 
tion was  stopped,  he  was  annoyed  by  the 
almost  constant  ijresence  on  the  wall  of 
the  room  of  varying  figures  and  land- 
scapes, most  of  the  latter  being  very  beau- 
tiful. Some  were  American  scenes,  and 
were  reproduced  nearly  in  the  form  he 
had  seen  them  thirteen  years  previously  ; 
others  he  failed  to  recognise.  It  is  evident 
that  if  any  one  whose  optical  impressions 
in  health  are  unusually  clear  and  definite 
should  suflfer  from  word-deafness,  in- 
volving the  power  of  recollection,  his 
visual  mental  revivals  may  furnish  him 
with  subjects  of  thought  in  greater  degree 
than  the  average  of  people.  His  mind 
will  be  so  much  the  richer  for  their  pos- 
session, and  from  their  distinctness  they 
may  be  more  readily  called  into  conscious- 
ness in  the  absence  of  auditory  percejDts  : 
they  will  thus  help  to  compensate  for  the 
lack  of  the  latter. 

So,  too,  those  who,  in  reading,  either 
faintly  articulate  or  distinctly  pronounce 
what  they  read,  and  also  such  individuals 
as  are  much  given  to  "  thinking  aloud," 
will  probably  suffer  less  mentally  than 
others,  for  they  may  have  the  use  of 
motor  intuitions  representing  words,  re- 
vived in  motor  areas,  by  means  of  which 
sustained  thought  may  be  possible  to 
them.  Their  condition  in  fact  approxi- 
mates to  that  of  the  trained  deaf-mute 
who,  as  previously  stated,  thinks  by  means 
of  motor  symbols  derived  from  the  move- 
ments of  the  fingers,  internally  reproduced. 

(b)  Word-hlindness. — In  a  typical  case 
of  this  variety  the  patient  understands 
what  is  said  to  to  him  and  can  express 
his  ideas  correctly  by  speech.  He  may 
even  be  able  to  communicate  his  thoughts 
by  writing.  But  though  vision  is  perfect 
he  cannot  understand  the  meaning  of 
words  that  he  sees,  whether  they  be  written 
or  printed.  He  may  even  fail  to  recognise 
individual  letters.     It  is  often  part  of  a 


more  general  disorder,  which  has  been 
named  mind-blindness  ;  but  it  occurs  occa- 
sionally, though  not  often,  in  an  isolated 
form.  There  is  no  diflB.culty  in  determining 
the  condition  of  the  patient's  mind,  as  he 
has  considerable,  if  not  the  full,  use  of 
language,  and  can  converse  much  as  before 
his  illness.  There  may  be  clear  mental  loss 
should  the  lesion  interfere  with  the  power 
of  reviving  in  the  mind  general  visual 
images,  as  the  ability  to  think  on  subjects 
into  which  they  enter  must  necessarily 
suffer  materially.  But  more  particularly, 
the  injury  to  the  mind  will  be  much  greater 
if  the  patient  have  acquired  the  habit  of 
thinking  to  a  large  extent  by  the  revived 
visual  impressions  of  words  either  printed 
or  written,  rather  than  by  revived  auditory 
impressions.  This  will  happen  to  recluses 
or,  generally,  those  who  converse  little  or 
do  not  hear  much  spoken  speech,  and  store 
their  minds  with  knowledge  derived  from 
books.  Their  loss  will  be  much  more 
serious  than  that  of  the  unlettered  pa- 
tient whose  knowledge  has  been  acquired 
through  the  sense  of  hearing.  (See  MiXD 
Blindness.) 

(3)  IVXixed  Forms. — Motor  and  sensory 
aphasia  may  be  variously  combined.  In 
a  large  proportion,  probably  the  majoi'ity 
of  aphasics,  there  is,  during  the  early 
period  of  their  illness,  almost  complete  loss 
of  language,  and  also  of  the  power  of  ex- 
pressing what  little  remains.  This  holds 
true  of  cases  which  ultimately  resolve 
themselves  into  simple  motor  aphasia ; 
for  a  time  the  function  of  the  sensory 
areas  is  also  in  abeyance,  even  though 
they  may  be  free  from  organic  lesion. 
This,  however,  is  only  a  part  of  the  shock 
which  the  brain  generally,  and  especially 
its  most  complex  part,  has  received, 
through  the  damage  to  an  important  sec- 
tion of  it. 

There  are  other  cases  in  which  the 
sufferer  has  the  command  of  a  vei'v  con- 
siderable amount  of  language  and  can 
freely  express  it,  but  the  words  are  so 
utterly  disconnected  that  the  name  gib- 
herisli.  aphasia  has  been  applied  to  the 
condition.  In  one  recorded  case  of  this 
kind,  the  patient  is  stated  to  have  under- 
stood spoken  and  written  remarks  and  to 
have  been  able  to  write  his  thoughts  cor- 
rectly, seldom  making  a  mistake.  His 
mental  powers,  as  a  whole,  were  considered 
to  have  escaped  injury,  notwithstanding 
the  jargon  of  his  speech.  It  may  be  sup- 
posed that  the  association-fibres  between 
the  sensory  and  motor  regions,  rather 
than  these  parts  themselves,  are  the 
special  seat  of  lesion  in  this  state. 

Summary  of  the  Mental  Condition. 
— In  sim2)le  uncomplicated  motor  aphasia, 


Post-apoplectic  Insanity      [    983    ]      Post-apoplectic  Insanity 


affecting  both  speech  and  writing,  there 
is  evidence  of  tair  intelligence  and  no 
indication  of  marked  defect  in  judgment. 
Care,  however,  requires  to  be  exercised  in 
judging  these  cases,  lest  too  favourable 
an  estimate  be  formed  of  the  mental 
powers  by  the  performance  of  familiar 
acts,  which,  having  become  largely  auto- 
matic, do  not  evince  the  exercise  of  fresh 
thought.  Indeed,  in  the  great  majority  of 
these  cases,  cai-eful  examination  and  in- 
quiry will  show  that  the  patient  does  not 
possess  as  much  mental  vigour  and  deci- 
sion of  character  as  he  had  previous  to 
his  illness.  It  is  also  to  be  noted  that 
in  proportion  to  the  degree  that  motor 
intuitions  enter  into  thought,  varying 
much  as  they  do  in  different  persons,  so 
will  the  lesion  in  this  form  of  the  disoi'der 
exert  a  corresponding  disturbing  influence 
on  the  reasoning  faculty. 

The  interference  with  mental  action  in 
pure  cases  of  aphemia  or  agraphia  (if  it 
occur)  ought  to  be  even  less  than  is  usual 
in  complete  motor  aphasia,  as  only  one  of 
the  channels  for  the  expression  of  lan- 
guage is  blocked,  instead  of  both.  This, 
as  shown  in  the  account  of  the  former  of 
these  conditions,  appears  to  be  so,  as 
aphemics  manifest  both  intelligence  and 
force  of  character. 

In  complete  sensory  aphasia  there  is 
profound  affection  of  the  mind.  In  almost 
all  cases  reasoning  is  not  practicable 
owing  to  the  obliteration  of  auditory  and 
visual  percepts,  though  a  degree  of  thought 
may  be  possible  to  some  patients  by  the 
exercise  of  the  motor  intuitions  of  speech 
or  of  writing.  In  the  majority,  however, 
the  lesion  is  incomplete,  and  one  sense  is 
usually  involved  more  than  the  other. 
Should  it  be  that  of  hearing  which  is  spe- 
cially implicated,  the  mind  generally  suffers 
much  more  than  where  the  visual  sense  is 
chiefly  affected. 

In  word-blindness  and  word-deafness, 
if  the  defect  be  limited  to  the  reception  of 
new  impressions,  and  the  faculty  of  recol- 
lection be  retained  in  full  or  little  dimi- 
nished vigour,  the  reasoning  power  and 
judgment  may  not  be  appreciably  affected. 
This  will  be  evident  from  the  patient's 
conversation,  the  capacity  for  which  is  re- 
tained. However,  cases  in  which  the  de- 
fect is  so  restiicted  are  exceedingly  rare. 
There  is  generally  also  some  impairment 
of  the  memory  of  words,  and  then  the 
mental  power  is  more  or  less  enfeebled. 

These  are  briefly  the  mental  conditions 
in  the  leading  forms  of  aphasia.  It  will 
be  observed  that  the  most  important  de- 
fects, consist  in  partial  or  complete  loss  of 
the  reasoning  faculty,  and  that  this  corre- 
sponds closely  with  the  extent  of  the  loss 


of  words,  whether  associated  with  the 
sense  of  hearing  or  of  sight,  but  particu- 
larly the  former.  Judgment  is  weakened, 
not  disordered,  Thei'e  are  no  illusions, 
hallucinations,  or  delusions.  Should  any 
of  these  be  present,  the  case  is  not  one  of 
simple  aphasia.  There  may  be  aphasia 
with  insanity  ;  but  this  is  not  common, 
unless  as  an  incident  in  the  course  of  men- 
tal disease.  Reference  will  afterwards  be 
made  to  this  combination.  The  moral 
powers  are  not  disordered  or  weakened, 
except  in  so  far  as  they  may  be  affected 
by  the  enfeeblement  of  the  intellect.  As 
a  rule,  there  is  no  excitement  of  feeling, 
nor  is  there  depression,  at  least  not  more 
than  might  be  expected  in  one  who  appi'e- 
ciates  the  serious  character  of  the  disease 
from  which  he  suffers.  In  some  cases 
there  is  emotional  weakness,  but  it  is  not 
so  marked  as  in  cases  of  hemiplegia,  either 
left  or  right,  especially  the  former,  which 
are  not  associated  with  aphasia. 

Civil  Responsibility  in  Aphasia. — 
From  the  foregoing  account  of  the  diverse 
mental  states  in  the  various  forms  of 
aphasia,  it  will  be  inferred  that  the  re- 
sponsibility of  patients  for  their  acts  must 
vary  greatly.  The  motor  aphasic,  retain- 
ing reasoning  power  almost  entirely,  is  an 
accountable  agent,  whereas  the  sensory 
aphasic,  if  the  disorder  be  complete,  and. 
involve  both  auditory  and  visual  cortical 
areas,  cannot  reason,  and  is  therefore  irre- 
sponsible. It  is  very  different  with  the 
minor  defects,  word-deafness  and  word- 
blindness.  In  some  cases  of  the  former, 
such  as  in  that  of  the  writer's  already 
referred  to,  it  would  be  difficult  to  show 
ground  for  the  reduction  of  the  person's 
responsibility  for  a  criminal  act.  And 
yet  one  might  well  hesitate  to  maintain 
that  a  derangement  involving  a  part  of 
the  brain  intimately  connected  with  the 
revival  of  word-symbols,  the  very  instru- 
ments of  thought,  even  though  the  ab- 
normality were  scarcely  noticeable  by  the 
observer,  would  have  no  disturbing  in- 
fluence on  the  reasoning  faculty. 

The  uncertainty  respecting  the  mental 
condition  in  slight  forms  of  the  disorder  is 
greater  in  recent  cases  than  in  those  of 
long  standing.  In  the  latter,  active  phy- 
sical disease  may  have  ceased  for  years,  a 
small  healed  lesion  exists,  but  exerts  no 
disturbing  influence  on  the  neighbouring 
healthy  tissues,  which  have  accommodated 
themselves  to  the  loss.  There  is  some  but 
no  great  defect  in  language,  and  apart 
from  it  normal  psychical  processes  are  not 
interrupted.  On  the  other  hand,  should 
the  disorder  be  of  recent  origin,  its  per- 
turbing effect  will  probably  extend  much 
more  widely  than  the  area  of  definite  mor- 


Post-apoplectic  Insanity      [    984    ]    Post-epileptic  Automatism 


bid  change  of  structure,  and  consequently 
the  general  mental  equilibrium  may  be 
markedlj'-  upset  for  a  time. 

How  the  degree  of  mental  deficiency 
may  be  best  ascertained  is  obviously  a 
matter  of  great  importance.  The  appa- 
rentl}'  intelligent  aspect  of  countenance 
and  gestures  are  apt  to  mislead  in  many 
cases.  The  patient  may  seem  to  under- 
stand what  is  said,  when  a  little  observa- 
tion will  probably  show  that  his  compre- 
hension has  been  very  imperfect.  Some 
idea  of  the  i^erson's  mental  condition  will 
of  course  be  formed  by  a  study  of  his  con- 
duct. But,  as  exjilained,  a  better  estimate 
may  be  made  of  the  state  of  the  reasoning 
powers  and  moral  faculties  by  subjecting 
him  to  the  test  of  a  carefully  considered 
series  of  orders  and  requests.  In  further 
illustration  of  the  method  of  determining 
the  condition  of  the  sense  of  right  and 
wrong,  it  may  be  stated  that  one  of  the 
patients  referred  to  was  asked  what  she 
would  do  if  the  nurse  were  to  steal  her 
shawl.  She  smiled,  seized  the  nurse  by 
the  arm,  and  shook  her  fist  very  signifi- 
cantly. After  this  manner  it  may  be 
practicable  to  find  out  the  patient's  views 
of  dishonesty  generally,  and  also  his 
opinion  of  attacks  on  the  person  of  others 
— subjects  in  connection  with  which  the 
question  of  responsibility  is  most  likely  to 
arise. 

The  doctrine  of  modified  responsibility 
with  mitigated  punishment  is  very  applic- 
able to  aphasics.  In  regard  to  it  they 
stand  on  similar  ground  to  some  of  the 
insane.  Fortunately  several  medico-legal 
trials  of  late  years  have  shown  that  its 
soundness  is  becoming  gradually  recog- 
nised both  by  judges  and  the  general 
public  in  certain  cases  of  mental  defect 
due  to  insanity,  either  congenital  or 
acquired.  Probably  the  risk  in  motor- 
aphasia  may  more  generally  be  to  hold 
the  accused,  when  guilty  of  criminal  acts 
less  responsible  than  they  actually  are.  A 
prisoner  at  the  bar,  speechless  or  only  able 
to  ejaculate  yes  or  no,  or  an  oath  or  two 
under  emotion,  would  be  very  apt  to  im- 
press the  jury  and  court  with  the  idea 
that  his  reasoning  power  was  much  weaker 
than  a  careful  study  of  his  condition 
would  show.  At  the  same  time  it  is 
doubtful  if  in  any  case  of  that  kind,  how- 
ever slight,  the  sufferer  should  be  con- 
sidered fully  responsible  for  his  acts; 
though  on  the  other  hand  thei-e  are  very 
many  who  should  not  be  allowed  to  escape 
without  punishment  for  their  crimes. 

Apbasia  in  the  Insane. — A  consider- 
able number  of  the  insane  are  more  or  less 
aphasic.  The  defect  in  language  or  speech 
or  both,  occurs  in  the  congenital  as  well 


as  the  acquired  forms  of  mental  disease. 
There  are  profoundly  demented  patients 
who  seem  absolutely  to  have  lost  all 
language,  except  perhaps  a  few  word* 
which  they  repeat  in  a  parrot-like  way, 
and.  with  scarcely  so  much  intelligence  as 
that  animal  sometimes  shows.  In  low 
types  of  idiocy  a  very  similar  condition 
exists.  The  unfortunate  youths,  though 
neither  deaf  nor  dumb  in  the  ordinary 
sense,  notwithstanding  all  efforts  at 
tuition,  attain  maturity  without  having 
acquired  language  of  any  kind,  their  only 
vocal  expression  being  inarticulate  cries ; 
or  in  less  severe  cases  they  may  have 
learned  a  few  simple  words. 

The  sensory  defect  is  probably  much  in 
excess  of  the  motor  in  most  of  these  cases. 
Both  the  innate  and  post-natal  forms  are, 
however,  only  part  of  a  wider  and  pro- 
bably deeper  morbid  condition  of  the  cortex 
of  both  hemispheres,  in  connection  with 
which  the  general  mental  deficiency  dwarfs 
and  overshadows  the  ajohasic  element  of 
its  constitution.  Alex.  Robektsox. 

POST-CONM-UBIAI.  xirsAjrzTTr. — 
The  mental  excitement  of  marriage  culmi- 
nating in  sexual  excitation,  often  exces- 
sive, is  liable  to  act  as  an  exciting  cause 
of  insanity  in  an  individual  predisposed  to 
mental  affection.  Sometimes  an  epileptic 
fit  occurs.  {See  Maheiage  axd  Ixsanity, 
Association  between.) 

POST-EPIXEPTXC     AUTOMATISM 

(post,  after;  epilejjsy  (q.c.)  ;  airofj.aTos, 
acting  spontaneously). — This  is  a  name 
given  to  a  series  of  phenomena  occurring 
in  certain  individuals  immediately  after 
an  epileptic  seizui'e,  and  more  commonly 
after  those  forms  known  and  described  as 
jjetit  tnal.  It  consists  of  involuntary 
motor  performances  which  may  range 
from  extremely  simple  and  objectless 
movements  to  advanced  complex  and 
apparently  purposive  acts ;  from  interjec- 
tional  sjjeech  utterances  to  connected  sen- 
tences ;  from  mild  emotional  displays  to 
outbursts  of  ungovernal)le  fury  and  pas- 
sion. The  degree  of  the  epileptic  seizure 
appears  to  bear  some  relationship  to  the 
range  and  complexity  of  the  actions,  as 
they  are  moi"e  intense  after  slight  fits  and 
vice  versa,  but  this  rule  is  by  no  means 
constant.  The  wild  and  aimless  clutch- 
ing at  persons  and  objects,  sometimes  ob- 
served in  the  immediate  post-epileptic 
state,  the  frequent  involuntary  change  of 
position  from  the  supine  to  the  prone,  a 
serious  automatic  movement  in  which  the 
patient  may  become  suffocated,  the  pur- 
poseless gesticulations,  the  uncalled-for 
laughter  or  weeping,  the  efforts,  in  some 
cases  violent,  made  by  the  patient  to  un- 
clothe himself,  to  bite  and  scratch,  to  get 


Post-epileptic  Automatism      [    985    ]  Post-febrile  Insanity 


up,  to  walk  to  and  fro,  to  repeat  some  set 
word  or  phrase,  these  and  kindred  pheno- 
mena are  easily  to  be  recoijuised  as  indi- 
cations of  the  milder  less  complex  condi- 
tion of  post-epileptic  automatism.  The 
motor  automatism  may,  as  it  were,  assume 
an  explosive  character,  taking  the  form  of 
convulsive  hysterical  attacks  immediately 
after  a  true  epileptic  seizure,  either  of  the 
ijndid  or  peiif  mal  type  ;  this  is  commonly 
found  in  young  women  or  men  afflicted 
with  epilepsy,  whose  mental  instability  is 
of  a  hysteric  type,  but  by  whom  hysteri- 
cal manifestations  are  ordinarily  not  ob- 
truded, the  tit  being  succeeded  by  a  violent 
spasmodic  convulsion  accompanied  or  fol- 
lowed by  unconscious  acts,  such  as  stamp- 
ing, clapping  the  hands,  acts  of  indecency, 
aggi'essiveness,  &c.  The  more  deliberate 
complex  post-epileptic  involuntary  acts 
are  of  an  extremely  interesting  nature, 
both  from  a  clinical  as  well  as  from  a 
medico-legal  point  of  view.  A  patient 
will,  after  a  petit  mal  attack,  sometimes  so 
extremely  slight  in  degree  as  hardly  to  be 
perceptible,  proceed  either  to  acts  foreign 
to  his  usual  habit  {e.g.,  he  will  pilfer  or 
secrete  articles  of  little  value  to  himself, 
will  attack  a  bystander,  destroy  pu'operty, 
shout,  sing,  gesticulate,  commit  indecen- 
cies, &c.),  or  to  quiet  rational  systematic 
actions  which  to  an  ordinary  observer  ap- 
pear premeditated,  voluntary,  and  re- 
sponsible {e.g.,  he  will  engage  himself  in 
his  ordinary  occupations,  will  indulge  in 
a  long  walk,  or  even  unclothe  himself  and 
jump  into  the  water,  &c.).  Crimes  of  a 
serious  nature,  such  as  murder,  arson,  &c., 
have  undoubtedly  been  committed  by  pa- 
tients while  in  this  condition.  The  ^ieriod 
of  duration  of  these  motor  phenomena  is 
very  variable,  extending  from  a  few 
seconds  to,  in  rare  cases,  some  hours  ;  in 
the  less  complex  forms  the  automatic  acts 
are  constantly  repeated  after  each  fit,  but 
the  more  highly  developed  actions  do  not 
ap23ear  to  recur  so  consistently.  It  is  not 
easy  to  distinguish  these  motor  phe- 
nomena from  the  motor  automatism  of 
larvated  epilepsy,  but  in  the  former,  the 
seizure,  however  slight,  can,  as  a  rule, 
be  recognised  to  be  an  antecedent  jsheno- 
menon,  though  the  patient  himself  may 
subsequently  be  unconscious  of  having 
had  a  fit.  Undoubtedly,  the  condition 
may  be  feigned  by  educated  persons,  but 
in  such  the  complex  acts  will  usually  be 
found  to  be  too  purjiosive  in  character,  a 
motive  can  usually  be  discovered  to  under- 
lie the  deed,  and  they  will,  on  close  ques- 
tioning, betray  their  consciousness  of  the 
act  itself.  The  automatism  has  been  at- 
tributed by  Hughlings  Jackson  and  others 
to  a  temjiorary  loss  of  controlling  power 


of  the  highest  over  the  next  grade  of  nerve 
centres,  so  that  the  loss  of  inhibitory  con- 
trol over  the  motor  centres  results  in  the 
independent  action  of  the  latter.  The 
condition  being  correlated  to  epilepsy  and 
due  thereto  shares  in  its  general  treat- 
ment. (6'ee  Ei'iLKi'siEs  and  Insanities, 
Ei'iLEi'SY  AND  Insanity.) 

J.     h\    (J.    PlETERSKX. 
POST  -  EPXIiEPTXC  INSiiTI'ITY. 

{See  Ei'iLEi'sv  AND  Insanity.) 

POST-FEBRIIiE    ZIVSAirZTY. — The 

name  given  by  Dr.  Skae  to  the  insanity 
which  sometimes  occurs  during  exhaustion 
following  fevers. 

The  occurrence  of  insanity  as  a  sequel  or 
complication  of  acute  disease  has  been 
observed  by  many  writers,  among  whom 
may  be  mentioned  VVestphal,  Foville, 
Delasiauve,  Christian,  Webber,  See,  Cor- 
mack,  Jaccoud,  Sydenham,  Graves,  Bur- 
rows, Hermann,  Baillarger,  Thore,  Gries- 
inger,  Greenfield,  Tuke,  Savage,  Clouston, 
Mickle  and  others.  Mental  disorder  may 
occur  during  any  jjart  of  an  acute  febrile 
disease.     It  may  apjjear  : 

(1)  ils  the  earliest  symptoms; 

(2)  During:  a  later  stagpe  ;  or, 

(3)  IVIore  commonly  to'nrard  the  ter- 
mination  or  period  of  convalescence- 

Dr.  Bristowe  has  recorded  a  case  of 
acute  mania  occurring  as  the  earliest 
symptom  of  typhoid  fever,  and  Dr.  Mur- 
chison  has  noted  three  similar  cases 
(Greenfield).  Thore  has  given  an  account 
of  an  outbreak  of  acute  mania  preceding 
pneumonia,  and  Dr,  Greenfield  the  occur- 
rence of  melancholia  followed  by  general 
excitement,  with  hallucinations  of  sight 
and  hearing,  appearing  and  subsiding 
pari  passu  with  an  attack  of  pneumonia. 
'J^he  symptomatic  delirium  or  febrile  de- 
lirium is  often  difficult  to  distinguish 
from  true  insanity,  and  almost  any  of 
the  affective  states  of  mental  disorder  may 
be  completely  simulated  in  febrile  delirium. 
According  to  Greenfield,  "the  intensity  of 
the  fever  alone  forms  no  criterion,  from 
the  more  frequent  association  of  delirium 
with  prostration,  and  certain  other  condi- 
tions of  the  system  ;"  this  difficulty  how- 
ever, is  somewhat  lessened  as  the  period 
of  commencing  recovery  or  convalescence 
is  reached. 

Nasse*  has  classified  the  mental  affec- 
tions originating  in  fever  according  as 
they  are  (i)  the  immediate  result  of  the 
fever  itself ;  or  (2)  as  they  constitute  a 
prolongation  of  the  delirium  when  the 
fever  has  subsided ;  or  (3)  as  they  arise 
during  convalescence.  With  regai'd  to 
the  first  two  conditions  we  are  in  want  of 

*  Huckuill  and  Tiikc,  "  MiinuiU  of  I'sychulogiciil 
Medicine,"  p.  371. 


Post-febrile  Insanity 


[    986 


Post -febrile  Insanity 


data ;  the  relation  of  high  temperature 
to  delirium  is  unknown.*  Here  we  have 
chieriy  to  do  with  the  consideration  of 
the  third  group,  which  includes  by  far  the 
greater  number  of  cases  of  true  vesania. 
The  forms  of  acute  disease  commonly 
followed  by  insanity  are  the  specific  in- 
fectious fevers  (Greenfield),  intermittent 
fevers  and  long  agues,  especially  if  they  be 
quartan,  and  this  forms  siii  generis  a 
peculiar  form  of  mania  (Sydenham), t 
erysipelas  (Baillarger,  Boyle),  acute  py- 
rexia of  phlogoses  (Voisin),  articular 
rheumatism  (Jaccoud,  Contesse),  acute 
angina,  diphtheria,  erythema  nodosum, 
miliary  roseola,  purpura,  febrile  urticaria, 
guttural  herpes,  and  others  (Gubler).J 
Of  the  forms  of  acute  disease  enteric 
fevers,  pneumonia,  and  rheumatism  are 
nearly  on  an  equality  as  causes. 

At  present  we  are  not  in  a  position  to 
sa3^  whether  the  forms  of  insanitj'  bear 
any  definite  relation  to  the  nature  of  the 
febrile  disease ;  nor  do  we  know  the  re- 
lative frequency  of  the  forms  of  mental  dis- 
order after  any  particular  class  of  diseases. 
According  to  Thore,§  the  commonest 
form  of  insanity  consists  in  the  sud- 
den onset  of  acute  maniacal  delirium, 
characterised  by  great  agitation  with 
hallucinations  of  sight  and  hearing,  its 
duration  varying  from  fifteen  hours  to 
three  or  four  days,  and  the  termination 
often  occurring  as  abruptly  as  the  onset. 
This  form  occurs  chiefiy  after  rapid  acute 
diseases,  such  as  2:)neunionia  and  tonsil- 
litis, and  much  more  rarely  after  typhoid 
fever  (Greenfield).  A  table  of  the  relative 
frequency  of  the  various  forms  of  insanity 
has  been  compiled  by  Christian,  and 
quoted  by  Greenfield.  Christian  found, 
that  out  of  1 14  cases,  4  had  isolated  insane 
ideas,  15  hallucinations,  34  mania  or 
maniacal  agitation,  8  ambitious  delusions 
{cUlire  ambit ieux),  16  sadness  or  melan- 
cholia, 27  stupidity,  and  10  intellectual 
weakness  or  dementia. 

Considered  seriatim,  after  typhoid 
the  cerebral  condition  may  be  one  of 
torpor  mingled  with  agitation  and  hallu- 

"■  McDowall  lias  reported  a  case  of  typhoid  fever 
with  physical  and  mental  symptoms  of  "typical" 
general  paralysis  whilst  tlie  fever  lasted,  Journal 
of  Mental  Science,  July  1881,  p.  279.  Dr.  Savage 
has  also  seeu  a  case  of  liiL;h  temperature  in  a 
youth  aged  twenty-one,  alfected  with  ulcerated 
.sore  throat  and  a  diffuse  syphilitic  rash,  in  which 
there  were,  in  addition,  mental  symptoms  such  as 
restlessness,  excitability,  change  of  disposition  and 
refusal  (jf  food.  This  case  was  of  interest  on  ac- 
count of  the  concomitance  of  the  mental  symptoms 
and  the  hi;^h  temperature. 

t  See  Malaria. 

t  Airhiceti  (ii-n.  clc  Med.,  i860,  t.  i.  pp.  257,402, 
534-  693;  t.  ii.  pp.  137,  718;  t86i,  t.  i.  p.  301. 
Mickle,  "General  Paralysis,"  2nd  ed.  p.  240. 

§  Annaks  Med.-Psych,,  April  and  Oct.  1856. 


cinations.*  This  condition  may  be  tran- 
sitory, or  may  pass  from  melancholia 
into  mania  and  chronic  dementia.f  In 
many  of  the  more  chronic  cases,  especially 
those  which  arise  early,  there  is  often 
great  moral  perversion  witb  extreme  irri- 
tability of. 'temper,  J  sometimes  there  is 
weakened  memory  or  general  apathy  and 
failure  to  form  clear  conceptions  as  to  the 
objective  significance  of  things.  In  one 
case  at  present  in  Bethlem  there  is  com- 
plete failure  to  grasp  the  environment, 
together  with  some  confusion  andanergia. 
Delasiauve  §  has  described  ambitious 
monomania  as  occurring  temporarily  dur- 
ing the  period  of  decline  of  mild  typhoid 
fever  in  a  female  aged  twenty-three. 
Similar  cases  have  been  related  by  Chris- 
tian||  and  Simon.  A  case  of  delire  avi- 
bitieiix  in  a  male  aged  twenty-one  during 
convalescence  has  also  been  described  by 
Liouville.^  A  form  of  insanity  has  been 
described  by  many  writers,  in  which  there 
are  many  physical  symptoms  closely  re- 
sembling those  of  general  paralysis. 
These  symptoms  may  be  aff"ections  of  the 
speech,  or  ataxy  of  movement.  The 
speech  is  slow  with  deliberate  drawling ; 
the  syllables  are  articulated  in  a  monoto- 
nous tone,  and  with  a  nasal  twang.** 
The  affections  of  the  motor  system  may 
further  be  evidenced  by  muscular  weak- 
ness, with  or  without  tremors  or  trem- 
blings of  lips,  facial  muscles,  or  even 
limbs. ft  Westphal  has  described  also  a 
peculiar  trembling  of  the  head  when  un- 
supported, in  a  case  in  which  there  were 
no  lip  tremors,  and  in  which  sensation 
was  unaffected.  The  pathology  of  this 
condition  is  little  known.  In  chronic 
cases  which  have  died  in  asylums,  ana3mia 
of  the  brain,  or  atrophy  of  the  cortical 
substance,  opacity  of  the  pia  mater,  and 
excess  of  the  sub-arachnoid  fluid,  have  been 
found.  Jaccoud  ascribes  the  paraplegia 
following  typhoid  to  congestion  of  the  cord. 

After  typhus  the  character  of  the  men- 
tal disturbance  is  not  unlike  that  follow- 
ing typhoid.  Greenfield  is  of  opinion  that 
there  is  more  frequently  some  moral  per- 
version than  mania  with  distinct  delusions 
or  hallucinations.  This  observation  is  not 
confirmed  by  others.  Thore  says  the 
most  frequent  sequents  are,  dementia, 
general    maniacal    delirium,    continuous 

*  Delasiauve,  AmiuleK  Med.-Psi/ch.,  July  1849. 

t  Griesinuer,  "  3Iental  rathology "  (Syd.  Soe. 
trans.);  also  Arch.  d.  HciU:.,  i860. 

X  Greenlield,  St.  Thos.'s  Hasp.  Jiepoi-fs. 

§  Ann.  Med.  Psych.,  1850,  p.  148. 

II  Ai-chives  Gen.  de  Med.,  1873,  t.  ii.  pp.  257,  421. 

•[  Ann.  Med.  Psych.,  1879,  t.  i.  p.  428. 

*'  A\'estphal,  Arch.  f.  Psych.  11.  XervenkranL: 
1872,  iii.  2. 

tt  Christian.  Arch.  Gen.  de  Med.,  Sept.  and  Oct. 

1873- 


Post-febrile  Insanity 


[    987    ] 


Post-febrile  Insanity 


or  intermittent,  and  ot  varying  dnration, 
with  or  withont  hallucinations  of  the 
senses,  or  partial  insanity,  monomania, 
or  ambitious  monomania.  The  onset  of 
acute  transitory  mania  may  occur  during 
the  early  stages  of  convalescence,  and  this 
is  believed  by  some  to  be  due  to  some 
sudden  change  in  the  cerebral  circulation. 
"Weber  calls  this  the  "  delirium  of  col- 
lapse," and  states  that  with  the  symptoms 
of  prostration  the  pulse  is  feeble,  rapid, 
and  irregular;  further,  that  this  condi- 
tion is  common  at  the  period  of  crisis  and 
may  be  di;e  to  sudden  anremia  of  the  brain 
from  heart  failure.  Westphal  {Arch, 
fii.r  PsycJi.  v..  New.,  Band  iii.)  and  Foville 
{Ann.  Mcd.-Psijch.,  January  1873)  ob- 
served intellectual  weakness  in  relation 
to  variola  and  typhus,  and  such  symptoms 
as  change  in  jjhysiognoniy,  slow  clumsy 
movements,  movements  by  fits  and  starts, 
trembling  of  the  limbs,  partial  or  general 
ataxy  of  limbs,  stiff  gait,  disorders  of 
speech,  impaired  deglutition,  and  in  one 
case  loss  of  the  power  of  sneezing,  whilst 
mentally  there  was  some  alteration  with 
excitability.  Westphal  noted  the  scanned, 
nasal  and  monotonous  speech  in  which  the 
letters  and  syllables  were  not  displaced,  but 
separated  by  intervals  and  uttered  jerkily, 
or  with  visible  efforts,  yet,  as  after  typhoid, 
without  co-existing  tremblings  of  the  lips 
and  face 

Foville,  on  the  other  hand,  noted  the 
occurrence  not  only  of  marked  twitchings 
of  the  muscles  of  the  face,  but  also  a  ten- 
dency to  convulsive  pi-ojection  of  saliva  or 
the  return  of  fluids  by  the  nose  during 
the  act  of  deglutition.  The  pathology  of 
these  conditions  is  vague.  The  frequent 
substitution  of  convulsions  for  rigors  in 
children  is  said  to  indicate  the  early  im- 
plication of  the  nervous  centres,  and, 
according  to  Greenfield,  the  acute  transi- 
tory mania  may  be  the  analogue  of  these 
convulsions  affecting  the  psychical, instead 
of  the  motor,  centres.  In  the  early  stage 
of  typhus  there  is  said  to  be  an  increase  of 
the  watery  constituents  of  the  white 
matter  in  the  brain  (Buhl).  There  may 
be  no  appreciable  organic  lesions,  the 
symptoms  depending  chiefly  upon  cerebral 
aneemia,  resulting  from  debility  (Trous- 
seau).* The  atony,  exhaustion,  and 
anaemia  of  the  brain  may  be  farthered  by 
moral  shock  or  debility  of  the  blood 
(Sydenham),  the  nutritive  defect  produc- 
ing atrophy,  serous  exudations,  &c.  The 
hebetude  dite  to  wasting  of  the  nervous 
matter  and  nerve  tubules  (Behier)  may  also 
occur  after  typhus  or  any  of  the  more 
severe  fevers. 

*  Cliiiicil  Leciures  (!?yd.  Soc.  iraiis.),  vcl.  ii.  p. 
429. 


After  the  delirium  of  smallpox  melan- 
cholia with  refusal  of  food  and  insomnia 
has  been  noted  by  Berti*",  and  is  tjuoted  in 
the  London  Medical  L'ecord,  vol.  i.  j).  135. 

Baillargert  has  recorded  a  case  of  del  ire 
anibiiieux  of  fifteen  days'  duration  follow- 
ing scarlatina. 

The  most  frequent  form  of  insanity 
after  eruptive  fevers  is  said  to  be  maniacal 
delirium,  often  with  hallucinations.  In 
children  the  exanthematous  diseases  play 
an  important  part  in  the  a3tiology  of  deaf- 
ness, and  secondarily  in  the  causation  of 
idiocy  and  imbecility. 

Cbolera  may  be  followed  by  transient 
delirium,  paroxysms  of  mania,  or  melan- 
cholia ;  but  the  foi'm  does  not  appear  at 
all  definite  (Greenfield).  In  all  febrile 
conditions,  insanity  arising  early  and  due 
to  toxic  conditions  of  the  blood,  conges- 
tion of  the  internal  organs  (including  the 
brain)  may  occur.  These  altered  vascular 
conditions  may  be  active  or  passive, 
general  or  partial,  chronic  or  acute. 
TrousseauJ  would  explain  the  cases  of 
paralysis  at  the  onset  of  acute  disease  as 
arising  in  one  of  these  ways.  Greenfield 
attributes  the  mental  symptoms  in  some 
cases  to  direct  excitation  from  peripheral 
irritation,  as  the  influence  of  pain,  organic 
disease,  &c.,  producing  central  exhaustion 
or  irritability  ;  or  due  to  reflex  irritation, 
or  peripheral  irritation  acting  in  a  reflex 
manner,  either  on  the  vessels  or  the 
nervous  tissue  itself.  Other  conditions, 
such  as  sub-acute  inflammation  of  the 
cortical  substance  or  membrane  of  the 
brain,  capillary  embolism,  or  thrombosis 
(as  in  the  melana3mia  following  ague), 
(Griesinger)  have  been  cited  as  probable 
causes.  Undoubtedly  many  of  the  forms 
of  insanity  may  be  regarded  as  instances 
of  metastasis.  Griesinger  has  noted  in- 
stances of  insanity  alternating  with  arti- 
cular rheumatism  ;  Sebastian,  with  ague ; 
the  author,  with  thrombosis  of  the  cerebral 
sinuses§  and  many  others. 

Acute  Rheumatic  Affections  are  not 
uncommonly  followed  by  mental  disturb- 
ance. The  development  of  the  insanity 
mostly  coincides  with  the  fall  of  the  tem- 
perature, cessation  of  joint  affections,  and 
subsidence  of  the  symptoms.  Trousseau, 
Clouston  and  Griesinger  have  recorded 
instances  of  mania  with  chorea  following 
rheumatism.  The  form  of  the  insanity 
following  rheumatic  fever  is,  as  a  rule,  one 
of  depression.  In  some  cases  there  may 
be  agitation  with  sensory  distui'bance, 
refusal  of  food,  and  a  tendency  to  delirium, 

*   Giorn  Veneto  delle  Sc.  Med.,  Jan.  1873. 
t  Ann.  Med.-PsycJi.,  Jan.  1879,  p.  79. 
t  Clinical  Lectures  (Syd.  Soc.  trans.). 
§  JSrain,  1886. 


Post-febrile  Insanity 


[    988    ] 


Postures 


but  the  majority  suffer  from  melancholia 
with  or  without  hypochondriasis,  or  there 
may  be  some  delusions  present  which 
gradually  pass  off  or  take  the  character  of 
ideas  of  persecution.  The  more  severe 
forms  of  insanity,  such  as  dementia, 
paralytic  insanity,  and  general  paralysis 
have  been  observed  but  rarely.  Affections 
of  the  special  senses  are  not  uncommon. 
Jaccoud,  Contesse,  and  Voisin  have  re- 
corded instances  of  articular  rheumatism 
leading  to  general  paralysis. 

Pneumonia  is  sometimes  followed  by 
insanity,  and  the  tendency  to  mental  dis- 
turbance is  not  ^proportionate  to  the 
severity  of  the  disease.  Dr.  Webber  states 
that  the  onset  of  acute  maniacal  delirium 
usually  occurs  suddenly  towai'dsthe  period 
of  crisis,  or  early  in  convalescence,  and 
manifests  itself  first  eai'Iy  in  the  morning 
or  after  waking  from  sleep.  Many  of  the 
more  chronic  forms  have  no  premonitory 
symptoms,  or  there  may  be  loss  of  sleep 
and  want  of  mental  rest. 

Any  form  of  insanity  may  occur  at  any 
age  associated  with  rbeumatic  affections. 
Transitory  mania  in  a  child  does  not 
generally  appear  so  serious  as  in  an  adult 
(Greenfield).  The  male  sex  appears  to  be 
mostly  affected,  and  the  liabilit}^  to  affec- 
tion is  increased  by  heredity,  previous 
mental  strain,  or  intemperance. 

In  addition  to  the  ordinary  symptoms 
of  exhaustion  following  an  attack  of 
pneumonia  there  may  be  local  or  general 
hyperassthesia,  loss  of  electro-contracti- 
lity of  muscles,  and  of  reflex  excitability, 
paralysis  of  special  nerves  or  of  systems 
of  nerves,  various  forms  of  spasm  and  con- 
vulsions, ataxy  of  movement,  hemiplegia 
or  paraplegia.  Griesinger  has  also  de- 
scribed a  transient  form  of  hemiplegia,  and 
Mickle  quotes  general  paralysis  as  occur- 
ring, but  does  not  give  examples. 

Other  febrile  conditions,  such  as  erysi- 
pelas and  diphtheria  are  apt  to  be 
followed  by  various  paralyses  or  insanity. 
Erysipelas  of  the  face  and  scalp  was 
assigned  by  Baillarger  as  the  cause  of 
general  paralysis  in  two  cases.  Boyle  and 
Voisin  have  also  each  observed  a  similar 
case. 

It  is  impossible  to  enter  here  upon  the 
consideration  of  the  various  paralyses 
which  follow  febrile  affections.  General 
paralysis  is  said  to  follow  typhus,  cholera, 
typhoid,  dysentery,  diphtheria,  pneumonia, 
articular  rheumatism,  erysipelas,  &c. 
Localised  and  diffused  paralysis  may  also 
follow  pmeumonia,  erysipelas,  cholera, 
dysentery,  typhoid,  typhus,  and  the  ex- 
anthematous  fevers,  acute  angina,  diph- 
theria, erythema  nodosum,  miliary  roseola, 
purpura,  febrile  urticaria,  guttural  herpes, 


and  other  disorders.  According  to  Mickle  * 
the  diff'nse  form  may  be  distinguished  from 
general  paralysis  by  the  more  frequent  and 
obvious  preceding  anaesthe.sia,  analgesia, 
numbness,  pricking  and  arthritic  pains, 
andby  the  circumstance  that  it  often  begins 
in  the  velum  palati,  almost  always  under- 
goes recovery  in  the  space  of  a  few  weeks, 
and  is  rarely  accompanied  by  intellectual 
trouble,  and  he  further  states  that  "should 
the  paralysis  be  diphtheritic  (and  even  in 
some  other  cases)  it  is  apt  to  extend  from 
the  velum  palaii  to  the  pharynx,  thence 
to  the  lower  limbs,  then  sight  and  hearing 
become  affected,  then  the  upper  limbs, 
and  finally  the  trunk  and  respiratory 
muscles,  while  the  premonitory  signs  men- 
tioned above  are  often  present." t 

The  diagnosis  of  these  conditions  is 
often  attended  with  extreme  difficulty,  and 
it  is  only  late  in  the  course  of  the  disease 
that  its  true  nature  can  be  ascertained. 

The  treatment  must  depend  upon  the 
nature  of  the  case.  Lowering  treatment 
is  seldom  efficacious,  and  not  unfrequently 
the  administration  of  drugs,  such  as  opium, 
may  possibly  have  had  much  to  do  with 
the  excitement.  Tiieo.  B.  Hyslop. 

POST-MORTEIVI     APPSARANCES. 

(See  Pathology.) 

POST  -  PUERPERAI.      INSA-NITTT. 

(See  Puerperal  Insanity.) 

POSTURES  AND         IVIVSCUI.AR 

BAIiAirCE  OF  THE  BODV  AS  IN- 
DICATZOKTS   OF   IVXEHrTAI.    STATES. 

— All  writers  on  expression  of  the  emo- 
tions and  other  mental  states  agree  in 
ascribing  some  importance  to  the  postures 
or  attitudes  of  the  body.  The  artist,  in 
expressing  emotion  and  character,  has  for 
centuries  depicted  on  canvas  the  balance 
of  the  body,  as  well  as  indications  of  its 
movements,  its  form  and  proportions. 
The  records  of  antique  art,  in  the  form  of 
ancient  statuary,  engravings  on  gems,  and 
the  drawings  on  vases,  are  valuable  indi- 
cations that  human  expression  centuries 
ago  was  much  the  same  as  in  our  day. 

A  posture  of  the  parts  of  the  body  con- 
cerns us  as  a  sigrn  of  the  brain  state, 
it  is  a  result  of  the  last  movement,  and 
its  change  is  a  movement.  The  posture 
indicates  a  balance  of  muscular  action, 
and  is  usually  temporary  in  character. 
This  balance  of  visible  parts  corresponds 

*  "General  I'aralysis,"'  2ud  edit.  p.  241. 

t  See  also  Webber,  Trans.Anier.Xeur.  Assoc., yo\. 
ii.  For  fuller  information  relating  to  these  various 
paralyses  the  reader  is  referred  to  the  works  of 
.See,  L' Union  Mcdicale,  'Sov.  8,1886.  p.  257  :  West- 
phal.  Archil- fiir  Psych,  itnil  Acre.  lid.  iii.  p.  376: 
Foville,  Ann.  Med.  Psych.,  Jan.  1873,  pp.  12,  40  : 
Cormaek,  Brit.  Med.  Joiirn.,  vol.  ii.  1S74 :  Jao- 
coiul,  Lcroiis  de  Clin.  Med.,  1886 ;  Whipham  and 
Myers,  Clin.  Soc,  March  12,  1886. 


Postures 


[    9S9    ] 


Postures 


to  a  condition  of  nerve-centres  in  equili- 
brio,  or  a  given  ratio  in  the  amount  of 
force  they  respectively  dischai'ge.  In 
studying  postures  we  observe  the  out- 
come of  certain  ratios  of  nerve  action. 

Postures,  like  movements,  may  be  either 
"spontaneous,"  or  due  to  some  present 
stimulation  of  nerve-centres  through  the 
senses ;  it  is  the  former  class  that  most 
directly  indicates  the  average  balance  or 
condition  of  the  brain.  Spontaneous 
postures,  in  parts  of  the  body  that  are  free, 
may  be  described  as  indications  of  emo- 
tional and  mental  states ;  visible  parts 
must  be  mechanically  free  in  order  that 
they  may  be  balanced  by  the  governance 
of  the  brain,  the  hand  must  not  be  in  the 
pocket,  or  the  back  resting  against  a  sup- 
port ;  the  nerve-centres  should  also  be 
free,  not  strongly  controlled  by  impres- 
sions from  the  surroundings  at  the  time 
of  observation. 

When  about  to  observe  the  spontaneous 
postures  assumed  in  the  arms,  or  upper 
extremities  of  a  patient,  we  ask  him  to 
stand  up  and  say,  "  Put  out  your  hands 
with  the  palms  down,  spreading  the 
fingers,"  speaking  in  a  quiet  tone,  and 
not  showing  our  own  hands  ;  it  is  then 
possible  to  notice  the  balance  of  the  body, 
the  head  and  the  spine,  the  arms  and  the 
hands,  as  well  as  the  movements  of  these 
parts.  This  action  in  the  patient  is  con- 
venient, leaving  the  arms  and  hands  free, 
and  ready  for  observation  and  descrip- 
tion. 

There  are  four  principal  postures  of 
the  head — (l)  flexion,  (2)  extension,  (3) 
rotation  to  one  or  other  side  in  a  hori- 
zontal plane,  the  head  remaining  erect, 
but  the  face  being  turned  to  the  right  or 
left,  (4)  inclination  to  one  or  other  side, 
lowering  that  ear  so  that  the  two  do  not 
remain  on  the  same  level — inclination  is 
said  to  be  towards  that  side  on  which  the 
ear  is  lowest.  The  posture  may  be  com- 
pound, the  head  may  be  flexed,  inclined 
and  rotated  to  the  right,  or  it  may  bei  ex- 
tended and  inclined  to  the  left,  &c.  The 
head  when  held  erect  is  in  a  symmetrical 
posture,  so  also  when  it  is  flexed  or  ex- 
tended ;  to  produce  such  balance  both 
sides  of  the  brain  must  act  equally  and 
at  the  same  time.  If  the  head  be  rotated 
to  the  right,  this  indicates  more  force  sent 
from  the  left  half  of  the  brain  than  from 
the  right  ;  asymmetry  of  posture  means 
unequal  action  of  parts  of  the  brain. 

The  typical  hand  posture  (Fig.  i)  seen  in 
health  and  strength,  is  the  straight  ex- 
tended hand.  The  fingers  are  straight 
with  the  palm  of  the  hand,  and  on  a  level 
with  the  forearm  and  shoulder,  the  palm  of 
the  hand  or  metacarpus  is  straight  and 


not  arched  transversely,  or  contracted  as  in 
the  feeble  hand.  All  parts  are  in  the  same 
horizontal  plane. 

The  second  typical  posture  (Fig.  2)  is 
but  a  slight  deviation  from  the  first,  the 
thumb  with  its  metacarpal  bone  being 
drooped,  all  other  parts  being  in  the  same 
plane  as  befoi-e. 

The  hand  in  rest  (Fig.  3)  is  the  natural 
posture  when  it  is  not  being  energised  by 
the  brain.  There  is  slight  flexion  of  the 
wrist  and  fingers,  and  slight  arching  of  the 
palm  of  the  hand. 

The  energretic  hand  (Fig.  4)  is  a  pos- 
ture produced  under  moderately  strong 
brain  stimulation.  The  wrist  is  extended, 
the  fingers  and  thumb  being  moderately 
flexed.  The  four  typical  postures  that 
have  been  given  are  normal,  as  signs  of 
certain  healthy  brain  states. 

The  nervous  hand  (Fig.  5)  is  due  to  an 
abnormal  brain  state,  an  ill-balanced  con- 
dition of  the  brain  centres.  The  wrist  is 
flexed,  the  metacarpus  slightly  contracted, 
the  thumb  somewhat  separated  from  the 
other  digits,  the  fingers  and  the  thumb 
are  bent  backwards  at  the  knuckle-joints. 
This  posture  is  in  direct  antithesis  to  the 
energetic  hand,  the  wrist  and  knuckle- 
joints  being  in  exactly  opposite  positions 
in  the  two  attitudes. 

The  feeble  hand  (Fig.  6)  presents  gene- 
ral flexion,  this  is  seen  in  the  wrist,  thumb 
and  fingers,  the  palm  of  the  hand  being 
considerably  contracted,  thus  approxi- 
mating the  thumb  and  little  finger.  It 
probably  represents  the  least  possible 
amount  of  force  coming  from  the  nerve- 
centres  to  the  muscles  of  the  limb  ;  mus- 
cular tone  is  here  lower  than  in  the  hand 
at  rest. 

The  Convulsive  Hand  (Pig.  7). — The 
closed  fist,  or  the  clenched  hand  has  the 
fingers  strongly  drawn  over  the  thumb 
which  is  pressed  upon  the  palm  of  the 
hand.  The  palm  is  contracted  or  drawn 
together. 

To  complete  the  types,  the  hand  in 
fright  (Fig.  8)  will  be  described,  but  we  do 
not  think  it  is  often  seen  in  real  life.  The 
wi'ist  is  extended  as  well  as  all  the  fingers, 
this  posture  thus  diff'ers  from  the  energetic 
hand  only  in  the  character  of  extension  of 
the  fingers. 

While  observing  the  hand  posture  look 
also  for  any  finger  movement.  If  the  two 
arms  be  held  out  we  may  see  a  posture  of 
weakness  on  one  side  only,  more  usually 
on  the  left  side,  or  the  characteristic  pos- 
ture may  be  more  strongly  marked  on  one 
side.  Thus  we  frequently  see  the  nervous- 
hand  posture  strongly  marked  on  the  left 
side,  and  less  distinct  on  the  right,  thus 
indicating  a  different  balance  of  the  action 


Postures 


[    990    ]  Postures 


Fig.  I. 


Fig.  6. 


The  linml  in  fright. 


The  nervous  hand. 


Postures 


[    991    ] 


Postures 


in  the  corresponding  nerve-centres  on  the 
two  sides. 

The  sjiine  may  be  too  mxich  rounded,  or 
it  may  be  asymmetrical  with  slight  tem- 
2")0rary  lateral  curvature  ;  this,  as  well  as 
lordosis,  is  frequently  found  when  the 
other  balances  are  of  the  feeble  type,  and 
the  hands  asymmetrical. 

Certain  spontaneous  postures  and  mus- 
cular balances  are  antithetical,  and  it 
may  be  shown  that  the  mental  states  cor- 
responding are  likewise  opposed  to  one 
another.  The  "  nervous  hand  posture  " 
and  the  "  energetic  hand  "  are  anatomical 
opposites ;  in  the  former  the  wrist  is 
Hexed,  the  knuckles  being  over-extended ; 
in  the  latter  the  wrist  is  extended,  the 
knuckle-joints  being  flexed.  The  first 
jiosture  is  seen  in  weak  and  excitable 
children  with  other  signs  of  feebleness, 
the  energetic  hand  is  commonly  seen  in 
strong  and  eager  children.  The  anti- 
thesis of  the  mental  states,  joy  and  pain, 
is  expressed  by  the  opposition  of  the  signs 
which  indicate  these  conditions ;  this  will 
be  obvious  to  the  student  of  physical  ex- 
pression, for  the  two  modes  of  facial  action 
cannot  co-exist. 

In  speaking  thus  briefly  of  certain 
physical  signs  observable  in  man,  it  is 
found  impossible  to  dissociate  those  that 
indicate  general  brain  states  from  those 
indicative  of  mental  conditions. 

ToUowing  the  method  of  describing  only 
the  physical  signs  seen,  we  shall  never  say 
that  a  feeling  or  emotion  produces  a  cer- 
tain balance  or  posture  of  the  body,  but 
that  a  certain  brain  state  produces  the 
postures,  and  these  are  the  signs  of  its 
condition  —  certain  subjective  mental 
states  may  be  constant  accompaniments. 
Postures  are  more  easy  of  description  than 
movements,  but  their  significance  is  far 
less  indicative  than  the  mobile  signs. 

Abnormal  Postures.  —  A  few  words 
must  be  said  about  abnormal  postures  due 
to  conditions  of  the  nerve-system.  We 
refer  to  such  as  are  sometimes  seen,  often 
as  a  temporary  matter,  and  difi"er  from 
those  previously  described. 

In  the  hand,  sqiiaring  of  tlie  fingers 
with  extension  at  the  knuckle-joints,  the 
internodes  being  flexed  at  a  right  angle, 
has  been  seen  in  cases  of  athetosis,  hys- 
teria, and  a  few  cases  of  chorea,  which 
proved  to  be  very  intractable.  In  other 
cases,  flexion  of  the  index  and  ring  fingers, 
the  other  digits  being  extended  is  an 
unusual  posture  sometimes  seen. 

Among  other  indications  of  abnormal 
neural  balance,  we  may  mention  as  signs 
of  feebleness,  contraction  of  the  meta- 
carpus, lordosis,  and  a  head  flexed  and 
slightly  inclined  and  rotated  to  one  side. 


Over-extension  of  the  head  with  arching 
of  the  spine  is  well  known  as  an  accom- 
paniment of  cerebral  irritation  ;  the  same 
balance  in  less  degree  may  be  seen  in 
mental  excitement. 

The  coincidence  of  certain  postures  is  a 
fair  indication  of  the  neural  balance.  In 
143  cases  pi'esenting  "  nervous  hand,"  we 
found  coincident  lordosis  in  46  cases.  In 
54  cases  presenting  "  weak  hand  posture," 
lordosis  was  seen  in  13  cases.  Other 
examples  might  be  given.  The  balance 
on  the  two  sides  should  be  compared ;  it 
is  usually  to  the  disadvantage  of  the  left 
if  nerve  force  is  weakened.  In  making 
observations,  conditions  of  movements 
should  always  be  noted  together  with  the 
postures  seen. 

Conditions  of  muscular  balance  in  the 
face  and  eyes  are  given  in  the  article 
Expression. 

A  few  examples  of  the  artistic  use  of 
postures  as  indicating  expression  of  nerve- 
states  may  be  given  from  the  antique. 


Sir  Charles  Bell  draws  attention  to  this 
statue  (Fig.  9)  as  representing  postures  of 
the  body  resulting  from  the  urgent 
dyspnoea  of  a  man  iu  mortal  agony. 
Here  the  limbs  are  not  free  to  express  the 
finer  nerve-states. 


Postures 


[    992    ] 


Postures 


Fu:.    10. 


Venus  de  Medici. 

It  was  this  statue  (Fig.  10)  in  the  Pitti 
Gallery  of  Florence  that  taught  me  how  to 
describe  the  balance  termed  "  the  nervous 
hand ;  "  each  hand  is  here  thus  balanced. 
The  same  may  be  seen  in  antique  bronze 
statuettes. 

Fig.  12 


Fig.  II. 


Diana.     (British  iluseum.) 

This  is  a  strong  tigure  (Fig.  11):  the 
right  hand  held  a  spear,  the  left  is  free  and 
balanced  in  •'  the  energetic  posture." 


A  feast  of  the  gods.    (From  an  antique  vase. ) 


Potassium  Bromide 


[    993    ]   Prescription  and  Limitation 


All  hands  among  those  at  the  feast  (Fig. 
12)  present  some  feature  of  "  the  nervous 
hand  "  in  over-extension  of  the  knuckle- 
joints.  The  Genius,  who  is  not  a  partaker 
of  the  feast,  presents  the  energetic  hand. 

Fig.  13. 


Cain.     (I'itti  Gallery,  Florence.) 

The  whole  figure  (Fig.  13)  expresses 
horror,  or  mental  fear.  Each  hand  is 
free  and  balanced  in  the  posture  of  "  the 
hand  in  fright."  Fraxcis  Warxer. 

POTASSZUIVI  BROMIDE.  {See 
Sedatives.) 

POTHOPATRIDAI.CIA  {-rrodos,  a 
longing ;  -n-arpls,  one's  country ;  ciXyos, 
pain).  A  morbid  home-sickness,  seen 
sometimes  in  young  soldiers  and  others  in 
foreign  countries.  (Fr.  pothopatriclalgie  : 
Ger.  Heivu'-eli.) 

TOTOT/tATTZA.  (ttotos,  drink  ;  fiavia, 
madness).  Drink-madness.  Delirium  tre- 
mens.    (Fr.  pAomanie  ;  Gev.  Trialcsuclit.) 

POTOPARAMffiA,  POTOTROMA- 
irZA.       ^See  POTOTROMOPARAXOIA.) 

POTOTROMOPARANOIA  [ttiWos, 

drink  ;  Tfjofios,  trembling ;  irapdvoia,  mad- 
ness or  folly).     Delirium  tremens,  or  mad- 


ness from  drink.     (Fr.  23otntromoparanee; 
Ger.  ZUferi'-ii.hnsinn  der  Trinker.) 

PO-WER        or        ATTORN-EY        (See 

Agexcv  and  Partxeksiui'). — (1)  A  power 
of  attorney  not  given  for  valuable  con- 
sideration, and  not  expressed  in  the  power 
to  be  irrevocable,  is,  as  between  the  donor 
and  donee,  ii^so/acfo,  revoked  by  the  lunacy 
of  the  donor.  Third  persons  dealing  with 
the  donee,  without  notice  of  the  lunacy  of 
the  donor,  are  (probably)  protected  (Con- 
veyancing Act,  1 88 1,  s.  47  (i),  Drew  v. 
Nunn,  1879,  4.Q-  B.  D.  661).  (2)  A  power 
of  attorney  given  for  valuable  considera- 
tion aiul  expressed  in  the  power  to  be 
irrevocable  is  irrevocable  in  farour  of  a 
purchaser,  notwithstanding  the  superven- 
ing lunacy  or  unsoundness  of  mind  of  the 
donor  (Conveyancing  Act,  1882,  s.  8). 
(3)  A  power  of  attorney,  vjhetlier  given  for 
valuable  consideration  or  not,  if  expressed 
in  the  instrument  creating  it  to  be  irre- 
vocable for  a  fixed  time  not  exceeding  one 
year  from  the  date  of  the  instrument  is,  in 
favour  of  a,  ptirchaser,  irrevocable  for  that 
time,  notwithstanding  the  supervening 
lunacy  or  unsoundness  of  mind  of  the 
donor  (Conveyancing  Act,  1882,  s.  9). 
The  last  two  provisions  apjily  o)ilij  to 
powers  of  attorney  executed  after  De- 
cember 31,  1882.  (4)  The  capacity  to 
grant  a  jDOwer  of  attoi-ney  would  probably 
be  determined  in  the  same  way  as  the 
capacity  to  appoint  an  agent  in  any  other 
way.  A.  Wood  EeiNtox. 

PRECOCITY. — It  has  been  noticed  that 
l^recocious  children  are  as  a  rule  connected 
with  families  some  of  whose  members  are 
insane.  The  mental  defects  of  some  mem- 
bers of  a  family  seem  to  be  made  up  for  by 
the  exti'aordinary  mental  acquirements  of 
others  of  the  family.  Precocious  children 
are  more  liable  to  insanity  than  others. 

PREDISPOSITION.    {See  Heredity.) 

PRE-EPIIiEPTIC    IM'SAM'ITY. — 

Morbid  mental  states  frequently  occur 
befoi'e  as  well  as  after  an  epileptic  fit. 
Delusions  may  be  j^resent,  hallucinations 
manifest  themselves,  or  there  may  be  a 
dreamy  confused  state  of  mind. 

PREOCCUPATION*. — A  common 
symptom  in  some  forms  of  insanity,  espe- 
cially in  melancholia.  The  patients  do 
not  answer  when  spoken  to,  nor  do  they 
seem  to  hear  anything,  being  so  much 
wrapped  up  in  their  own  thoughts. 

PRESCRIPTION,  and  ZiIIMCITA- 
TION  or  ACTIONS. — These  subjects 
may  conveniently  be  considered  together. 
The  terms  2:)rescription  and  limitation 
may  with  sufficient  accuracy  for  the  pre- 
sent purpose  be  defined  as  follows : — 
"  Prescription  "  is  the  undisturbed  and 
continuous  enjoyment  of  a  legal  right  for 


Prescription  and  Limitation   [    994    ]    Prescription  and  Limitation 


a  period  fixed  by  law,  on  the  expiry  of 
which  all  attempts  to  overthrow  it  are 
baiTcd.*  The  time  within  which  such 
attempts  ranst  be  made  is  the  period  of 
"limitation."  The  docti'ines  of  prescrip- 
tion and  limitation  rest  upon  the  pre- 
sumption of  law,  that  a  person  who  know- 
ingly fails  to  enforce  a  legal  right,  which 
he  alleges  to  be  infringed,  acquiesces  in 
the  infringement.t  Now,  if  a  person  is 
prevented  by  mental  disease  from  know- 
ing that  his  rights  are  being  invaded,  clearly 
he  cannot  be   said  to   acquiesce  in  such 


invasion.  It  would  seem,  therefore,  a 
priori,  that  lunacy  should  suspend  the 
operation  of  the  law  of  limitation.  Such, 
however,  is  the  importance  which  the  law 
assigns  to  the  doctrines  of  prescription 
and  limitation  that  lunacy  has  only  re- 
ceived a  very  partial  and  half-hearted 
recognition  as  a  ground  of  disability. 

The  present  state  of  the  law  will  be 
apprehended  from  the  following  table.J 
in  which  the  leading  forms  of  action  are 
noticed : — 


Account  (action  of)      ....         . 

Admiralty  (suits  for  seamen's  wages)  . 
Aclvowsous  (recovery  of)     . 

Assault,  battery,  wounding,  or  false  impri- 
sonment       ...... 

Awards  (actions  npon)  .... 

Bills  of  Excliange  (including  chsques  and 
promissory  notes)  .... 

Bonds  ....... 

Common  (rights  of)  and  other  profits  a 
prendre,  claims  to         ...         . 


Constables  (actions  against) 
Copyhold  fine  (action  for)     . 

Copyright  (action  for  infringement  of). 
Covenants  (actions  upon) 

Djbt  (actions  of) 

Deed  (action  npon)       .         .         .         . 
Detinue  (action  of)      .         .  .         . 

Distress  for  rent  charge 


Disti-ess  for  other  rents 


Divorce       ...... 

Dower  (arrears  of)  action  fur 

Ejectment  ...... 

.Justices  of  the  Peace  (actions  against) . 

Land  (action  for  recovery  of) 
Legacies  (suits  for)      .... 


Period  of  limitation  runs  against  a  Innatic  from  time  of 

his  recovery.     (21  .Jac.  I.,  c.  16,  s.  7.) 
.Same  rule.     (4  &  5  Anne,  c.  16,  s.  18.) 
Lunacy  no  bar  to  limitation.     {Cf.  3  &  4  AVill.  IV.,  c.  27, 

ss.  30-33) 

Same  rule  as  in  action  of  account.     (21  Jac.  I.,  c.  16,  s.  7.) 
Time  runs  from  recovery  of  lunatic.     (3  &  4  Will.   IV., 
c.  42,  s.  4.) 

Ditto.     (21  .lac.  I.,  c   16,  s.  7.) 
Ditto.     (3  &  4  Will.  IV.,  c.  42,  s.  4.) 

Same  rule  ;  except  in  cases  where  the  right  or  claim  is 
declared  by  the  Prescription  Act  to  bs  absolute  and 
indefeasible.§     (2  &  3  Will.  IV.,  c.  71,  s.  7.) 

Lunacy  no  bar  to  limitation.     {Cf.  24  Geo.  II.,  c.  44,  s.  8.) 

Time  runs  from  recovery  of  lunatic.  (3  &  4  Will.  IV., 
c.  42,  s.  4.) 

Lnnacy  no  bir  to.     (Cf.  5  &  6  Vict.,  c.  45,  s.  26.) 

Time  runs  from  recovery  of  lunatic.  (3  &  4  Will.  IV.. 
c.  42,  s.  4.) 

Ditto.     (21  Jac.  L,  c.  16,  s.  7  ;  3*4  Will.  IV.,  c.  42,  s.  4. ) 

Ditto.     (3  &  4  Will.  IV.,  c.  42,  s.  4. ) 

Ditto.     (21  Jac.  I.,  c.  t6,  s.  7.) 

3Iay  be  made  at  any  time  within  6  years  from  recovery 
or  death  of  lunatic,  whichever  happens  first,  bnt 
utmost  allowance  for  such  disability  is  30  years 
from  accrual  of  the  right  of  action.  (Real  Property 
Limitation  Act,  1874,  ss.  3  and  5.) 

Lunacy  no  bar  to  limitation.  (Cf.  3  &  4  Will.  IV.,  c.  27, 
s.  42.) 

See  article  on  Marriage. 

Lunacy  no  bar  to  limitation.  (Cf.  3  &  4  Will.  IV.,  c.  27, 
S.41.) 

Same  rule  as  Distress  for  rent-charge  {q.r.). 

Lunacy  no  bar  to  limitation.  (Cy.  11  &  12  Vict.,  c.  44, 
s.  8.) 

Same  ride  as  Distress  for  rent-charge  {q.v.'). 

Lunacy  not  a  statutory  bar  to  limitation.  (Cf.  3  &  4 
Will.  IV.,  c.  27,  s.  40  ;  and  Keal  Property  Limita- 
tion Act,  1874,  s.  8.) 


*  Prescription  has  no  place  in  English  law  ex- 
cept in  respect  to  easements  and  rights  of  common. 

t  "  Vigilantibus  non  dormientibus  jura  subvcni- 
unt."  But  the  doctrines  of  prescription  and  limi- 
tatiou  are  based  upon  public  policy  as  well  as  upon 
equity.  "  Interest  reipublicae  ut  sit  finis  litium.'' 
"  If  time,"  said  Lord  Plnnket,  "  destroys  the  evi- 
dence of  title,  the  laws  have  wisely  and  humanely 
made  length  of  possession  a  substitute  for  that 
which  has  been  destroyed.  He  comes  with  his 
scythe  in  one  liand  to  mow  down  the  muniments 
of  our  rights  ;  but  in  his  other  hand  the  law-giver 
has  placed  an  hour-glass,  by  which  he  metes  out 
incessantly  those  i>ortions  of  duration  which  render 
needless  the  evidence  that  he  has  swept  away." 
Cited  by  Best,  "  Evidence,"  p.  31,  note  (A). 


t  Only  lunacy  existing  M'/te»  tJie  right  of  aHion 
accrued  will  suspend  the  operation  of  the  law  of 
limitation. 

§  The  cases  here  referred  to  are — i.  'Where  the 
right,  profit,  or  benefit  has  been  actually  taken  and 
enjoyed  for  the  full  period  of  60  years.  2.  Where 
any  way,  easement,  or  water-course,  or  the  use  of 
any  water  has  been  enjoyed  for  the  full  period  of 
40  years.  3.  Where  the  use  of  light  has  been  en- 
joyed for  the  full  period  of  20  years  :  unless  in  any 
of  those  cases  it  shall  appear  that  the  same  wa.s 
enjoyed  by  some  consent  or  agreement  expressly 
given  or  made  for  that  purpose  by  deed  or  writing. 
The  statutory  periods  of  limitation  are  given  in  a 
convenient  tabular  form  in  Wharton's  •'  Law  Lexi- 
con." 


Presentations  of  Sense 


[     995     ] 


Presumptions  (Legal) 


Libel  (action  of) 

'•  ^[orcliiiiit's  ;ici'Oiiiits" 

Mortii-.ine  (redcmiUiou  of )    . 

Mortii'auv  (I'oveclosure  of)    . 

Mortg-iis'c  (money  seL-ured  by),  recovory  of 

Kent  (l)y  leasi'  or  deed),  action  for 
lU'nt  (not  secured  liy  lease  or  deed) 
Seduction  (action  for) .... 
Slander  (action  of)       .... 


Time  rnns  from  recovery  of  liniatic.     (21  Jac.  I.,  c.  16, 

s.  7.) 
Lnnacy  no  bar  to  limitation.     (I'f.  19  &  20  A'ict.,  c.  97, 

s.  9.) 
Lnnacy  no  bar  to  limitation.     {Cf.  i  Vict.  c.  28,  s.  i  ; 

and  Kinxmaii  v.   /Iouhc,  tSot,  17  Cli.  1).,  at  p.  107.) 
Same  rule  as  Distress  for  rent-charH:o  iq.v.). 
Period  of  limitation  runs  from  accrual  of  risht  of  action 

to  some  person  capable  at  the  time  of  giving  a  valid 

discbarge.      (Real   Property  Limitation   Act,   1874, 

s.  8.) 
Time  runs  from  recovery  of  lunatic.     (3  &  4  Will.  IV., 

c.  42,  s.  4.) 
Lunacy  no  statutory  bar  to  limitation,     {('f.  3  &  4  Will. 

IV.,  c.  27,  s.  4-2.) 
Time  runs  from  recovery  of  lunatic.     (21  Jac.  I.,  c.  16. 

s.  7.) 
Ditto. 


The  right  of  a  person  to  recover  land 
of  which  he  has  been  deprived  by  fraud 
accrues  at  the  time  when  such  fraud 
might  with  reasonable  diligence  have  been 
discovered  (3  and  4  Will.  IV.  c.  27,  s.  26). 
Nothing  short  of  absolute  liinacy  will  be 
recognised  by  the  Court  as  disqualifying 
a  person  for  the  detection  of  "  fraud " 
within  the  meaning  of  the  section  {Manhij 
V.  Beimcke,  1857,  3  K.  &  J.  342). 

A.  Wood  Renton. 

PRESEM-TATZOSrS      OF     SENSE. — 

Presentations  of  sense  are  those  complex 
objects  of  consciousness  which  result  from 
an  act  of  mental  synthesis  of  several 
simultaneous  sensations.  The  elements 
of  presentations  of  sense  are  therefore 
sensations,  which  are  merely  modes  of  our 
being  atfected,  mere  psychical  states.  The 
transference  of  these  ijsychical  states  to 
definite  presentations  of  sense  is  a  mental 
achievement  resulting  from  a  long  process 
of  development.  The  characteristic  of  a 
presentation  of  sense  is  that  it  has  space- 
forms,  which  the  sensations  composing  it 
have  not.  For  the  formation  of  sense 
presentations  the  following  are  neces- 
sary :  (a)  A  synthetic  activity  of  mind ; 
{h)  A  difference  in  the  quality  of  the  sen- 
sations, so  that  a  graded  series  can  be 
formed  (spatial  series)  ;  (c)  Local  signs  ; 
((?)  Localisation  and  eccentric  pi'ojection  ; 
and  (e)  As  a  rule,  more  than  one  organ  of 
sensation  (Ladd). 

PRESUMPTIOZfS  (I.ECAI.)  REI.AT- 
ING  TO  Ill's ANZTY; — Legal  presump- 
tions are  inferences  or  positions  estab- 
lished by  law  for  the  regulation  of  judi- 
cial procedure,*  and  are  of  two  kinds  (i) 
conclusive  or  irrebuttable,  called  by  the 
civilians  prsesumptlones  juris  et  de  jure, 
and  (2)  rebuttable,  or  praesumptiones 
juris  tantum. 

(i)  In  the  law  of  insanity  there  are  only 
two   rules  that    seem  to  have  belonged 

*  The  rai.wii  d'rtre  of  such  presumptions  is  ad- 
mirably explained  by  Best :  "  Evidence,"  ss.  42,  43, 
304  (t  ser/. 


to  the  former  class — viz.,  that  idiocy  is 
incurable,  and  that  a  lunatic  upon  the 
other  hand  is  always  capable  of  recover- 
ing his  understanding.*  With  regard  to 
these  rules  it  must  however  be  pointed 
out  that  the  old  legal  incidents  of  idiocy 
are  now  of  little  importance,  and  that  the 
presumption  in  favour  of  the  recovery  of 
a  lunatic  may  now  be  rebutted.f 

(2)  The  praesumptiones  juris  tantum. 
relating  to  insanity  are  very  numerous. 
The  following  are  the  most  important : 

(a)  A  person  deaf  and  dumb  from  his 
birth  is  presumed  to  be  an  idiot.J  But 
this  presumption  may  be  rebutted.  Thus, 
in  Dickinson  v.  Blisset  (i  Dick.  268)  a 
lady  born  deaf  and  dumb,  having  attained 
the  age  of  twenty-one  years,  applied  to  the 
Court  of  Chancery  for  possession  of  her 
real  estate,  and  to  have  an  assignment  of 
her  chattel  estate,  and  Lord  Hardwicke 
having  put  questions  to  her  in  writing,  to 
which  she  gave  sensible  answers  in  writ- 
ing, granted  the  application. 

(b)  Every  person  who  has  attained  the 
usual  age  of  discretion  is  presumed  to  be 
of  sound  mind  until  the  contrary  is  proved, 
and  this  holds  as  well  in  civil  as  in  crimi- 
nal cases. 

This  presumption  of  law  rests  upon  the 
fact  that  sanity  is  the  normal  condition 

*  Cf.  the  Statute  de  Praerogativa  Regis,  17 
Edw.  II.,  c.  10,  as  to  lunatics  ;  17  Edw.  II.,  c.  9, 
as  to  idiots.  See  also  article  on  Idiocy,  and 
FitzoeraWs  case,  1805,  2  Sch.  &  Lef.  438,  per  Lord 
Redesdale,  and  Ex  parte  Wliitbread,  3  Mod.  44, 
2  Mer.  99. 

t  Cf.  Ex  parte  Whitbnail,  2  Mer.  99.  lie  Blair, 
I  Myi.  &  Cr.  300,  and  lie  Frost,  39  L.  J.  Ch.  808. 

t  See  article  Deaf-Dumbne.ss.  The  opinion  of 
Lord  Coke  was  that  a  person  born  deaf,  dumb,  and 
blind,  is  included  within  the  legal  definition  of  any 
idiot  as  wanting  those  senses  which  furnish  the 
human  mind  with  ideas.  But  it  was  decided  in 
Eli/ot's  ca.^e  (Carter  53),  that  a  person  deprived  of 
only  one  or  two  senses,  and  who  can  convey  his 
meaning  by  writing  or  signs,  is  not  incapacitated. 
The  ratio  decidendi  in  this  case — vi/.,  the  capacity 
to  understand  communications — clearly  covers  the 
case  of  a  deaf  and  blind  nmte  wlu)  i.s  now  capable 
of  being  instructed. 

3s 


Presumptions  (Legal)      [    996    ]      Prevention  of  Insanity 


of  human  beings  and  upon  the  jealousy 
with  which  our  law  protects  personal  be- 
lief* 

{c^  Mental  derangement,  once  proved, 
or  admitted,  to  have  existed  at  any  par- 
ticular period,  is  presumed  to  have  con- 
tinued ;  and  consequently  the  party  who 
alleges  a  lucid  interval  or  recovery  must 
establish  his  allegation.f 

The  omis  2Jrohandi  may  shift  more  than 
once  during  the  progress  of  a  trial. 
Thus,  suppose  the  validity  of  a  marriage 
to  be  in  dispute.  Here  we  start  with  the 
general  presumption  in  favour  of  sanity, 
which  the  party  impeaching  the  marriage 
must  displace,  if  he  can.  Evidence  that 
the  ]3erson,  whose  competency  to  marry 
is  in  question,  had,  at  or  about  the  critical 
period,  been  found  lunatic  by  inquisition, 
would  throw  the  burden  of  proof  upon 
the  person  supporting  the  marriage,  who 
might  again,  jiartially  at  least,  rebut  the 
presumption  of  insanity  arising  from  the 
inquisition  by  showing  that  the  alleged 
lunatic  had  obtained  liberty  to  traverse. 
(Of.  Elliot  v.  Ince,  1857,  26  L.  J.  N.  S.  Ch. 
at  p.  824.)! 

{(l)  Unexplained  delay  in  impeaching 
deeds,  instruments  or  contracts  on  the 
ground  of  incapacity,  will  raise  a  pre- 
sumption in  favour  of  their  validity. 

This  rule  rests  upon  a  clear  principle 
of  public  policy.  "  If  property,"  said 
Lord  Chancellor  Eldon  in  Towart  v. 
Sellars  (18 19,  5  Dow.  Pari.  Cas.  at  p. 
236),  "  has  been  disposed  oftiventy  or  tliirty 
years  before,  formally  and  with  the  con- 
currence and  assistance  of  individuals  of 
good  character,  and  if  that  disposition  is 
not  quarrelled  tvitli  as  speedily  as  vnay 
he,  and  only  challenged  when  the  parties 
best  acquainted  ivith  the  ivhole  circum- 
stances of  the  transaction  are  dead  and 
gone,  it  is  dangerous  to  set  aside  that 
disposition  at  the  distance  of  twenty  or 
thirty  years  upon  a  ground  so  fallible  as 
human  memory  and  testimony  as  to  the 
state  of  the  person  making  that  disposi- 
tion at  other  moments  without  at  all 
applying  to  the  moment  when  he  executes 
the  deed."  The  latter  part  of  this  judg- 
ment refers  to  the  special  circumstances 
of  the  case,  but  the  clauses  in  italics  ex- 
plain and  clearly  justify  the  presumption 
above  stated. 

*  Testamentary  capacity,  however,  must,  in  the 
interest  of  the  persons  entitled  under  the  Statutes 
of  Descent  and  Distribution,  be  proved  aflarmatively 
by  the  executor  who  propounds  a  will.  See  article 
Testamentary  Capacity  in  Mental  Disease. 

t  See  A.  G.  v.  Par/ifhei;  per  Lord  Thurlow, 
3  Bro.  C.  C.  433. 

t  As  to  the  meaning  of  "lucid  interval,"  see 
article  Testamentary  Capacity.  See  also 
article  on  Evidence. 


Thus,  in  support  of  an  action  (ToKoyrt 
v.  Sellars,  uhi  sup.)  brought  in  1808  to 
reduce  certain  deeds  executed  between 
1782  and  1799,  upon  the  ground  of  the 
insanity  of  the  grantor,  parol  evidence 
was  given  that  he  was  quite  deranged 
from  1 78 1  till  his  death  in  1804  ;  but  this 
evidence  applied  to  his  insanity  generally, 
and  not  at  the  jjarticular  moments  when 
the  deeds  were  executed,  and  it  was  en- 
countered by  positive  evidence  relating  to 
those  periods.  The  House  of  Lords,  re- 
versing the  decision  of  the  Court  of  Ses- 
sion in  Scotland,  held  that  the  deeds  were 
valid. 

Still  more  emphatic  effect  was  given  to 
the  same  presumption  in  Price  v.  JBerring- 
ton  (1850,  3  Mac.  &  G.  pp.  4S6.  495).  In 
that  case  Lord  Chancellor  Truro  dis- 
missed a  bill,  filed  to  set  aside  a  deed  of 
conveyance  twenty-seven  years  after  its 
execution,  although  it  appeared  that  the 
grantor  had  been  found  lunatic  not  only 
by  inquisition,  but  upon  an  issue  directed 
in  the  particular  matter. 

(e)  "  Where  the  persons  who  have  pre- 
l^ared  deeds  and  are  the  attesting  wit- 
nesses to  their  execution  are  dead,  when 
process  is  commenced  for  setting  such 
deeds  aside,  it  will  be  assumed  in  the 
absence  of  evidence  to  the  contrary  that 
they  would  have  sworn  that  the  party 
was  of  sane  mind  when  the  deeds  were 
executed,  although  it  be  attempted  to 
disprove  the  sanity  of  the  grantor  by 
general  parol  evidence  of  incomjietency 
at  other  times  "  (per  Lord  Eldon,  C,  in 
Towart  v.  Sellars,  ubi  sup.  at  p.  245,  and 
Shelford's  Lunacy,  p.  54). 

A.  Wood  Rextox. 

PREVZSTM'TZOM-  OF  INSANITT 
(PROPHYI.AXIS).— To  prevent  insanity 
in  persons  predisjaosed,  and  to  ward  off 
subsequent  attacks  from  those  whose 
minds  have  already  been  disordered,  are 
amongst  the  most  important  duties  of 
medical  practitioners.  The  first  form  the 
large  class  who  have  inherited  a  tendency 
to  the  malady  from  parents  or  forefathers, 
and  are  liable  to  transmit  it  in  turn  to 
their  offspring.  Those  who  are  able  to 
observe  such  individuals  from  their  birth, 
and  advise  concerning  their  bringing  up, 
their  schooling,  and  entry  into  the  world, 
may  do  much  to  save  them  from  the  here- 
ditary scourge,  whereas  specialists  will 
not  come  into  contact  with  them  till  the 
evil  has  revealed  itself.  But  the  task  is  a 
difficult  one.  Every  effort  will  be  made 
to  conceal  or  explain  away  the  family 
taint.  Any  occurrence  of  the  kind  will 
be  minimised,  will  be  ascribed  to  natural 
causes,  as  bodily  illness,  old  age,  or  brain 
disease,  or,  failing  these,  will  be  denied 


Prevention  of  Insanity      [    997    ]      Prevention  of  Insanity 


altogether  without  the  slightest  hesita- 
tion. The  family  medical  attendant,  how- 
ever, if  he  is  acquainted  with  the  life-his- 
tory of  more  than  one  generation,  will  for 
himself  gain  sufficient  insight  into  the 
constitution  and  temperament  of  the 
members  to  guide  him  in  his  advice  con- 
cerning the  rearing  and  training  of  the 
younger  branches,  and  denial  of  the  family 
peculiarities  and  weaknesses  will  not  be 
practised  towards  him,  because  he  is  too 
conversant  with  the  facts. 

It  has  often  been  urged,  and  cannot  be 
too  strongly  insisted  on,  that  a  nervous 
inheritance  may  be  derived,  not  only  from 
parents  or  grandparents  in  whom  actual 
insanity  has  developed,  but  from  those 
who  have  suffered  froni  epilepsy,  dipso- 
mania, hysteria,  hyiiochondriasis,  or  neu- 
ralgia. A  combination  of  two  of  these  in 
the  parents,  or  of  one  of  them  with  phthi- 
sis or  gout  may  lead  to  insanity  in  various 
members  of  a  family,  and  to  j^hthisis  or 
neuralgia  in  others.  It  is  evident,  how- 
ever, that  children  will  be  born  under 
various  conditions,  and  some  will  be  far 
more  liable  to  nervous  disorder  than 
others  born  of  the  same  parents.  For 
some  may  be  born  before  the  mother  has 
shown  any  symptoms  of  the  disease,  others 
may  be  children  of  one  who  has  been  in- 
sane during  her  pregnancy,  or  has  had 
repeated  attacks  of  mania.  In  the  case 
of  others  conception  may  have  taken  place 
after  the  father  has  shown  undoubted 
symptoms  of  general  paralysis.  This  is 
not  an  infrequent  occurrence.  Some  may 
be  born  of  a  mother  who  becomes  insane 
after  every  childbirth,  and  only  recovers 
to  a  very  partial  extent  by  the  time 
another  is  born.  Such  childi-en  stand  in 
a  diflferent  class  from  those  whose  parents 
have  never  been  insane,  but  inherit  a  taint 
from  their  own  progenitors,  which  shows 
itself,  it  may  be,  in  brothers,  sisters,  or 
other  collateral  branches.  Children  born 
before  insanity  has  shown  itself  in  a 
parent  are  in  a  better  position  than  those 
born  after,  and  those  born  of  parents  in 
whom  the  disease  has  appeared  at  a  very 
early  age,  are  more  likely  to  inherit  it 
than  the  children  of  parents  in  whom  it 
appeared  later  in  life,  especially  if,  in  the 
case  of  the  latter,  there  was  an  adequate 
and  assignable  cause.  Those  whose 
pai'ents  are  cousins  are  liable  to  heredit- 
ary disease.  If  any,  as  insanity,  exists  in 
the  family,  it  will  most  likely  be  intensi- 
fied by  the  relationship,  and  the  offspring 
are  likely  to  be  not  only  insane,  but 
stunted  and  weakly  in  other  respects,  and 
very  possibly  idiots.  In  this  they  but 
follow  the  laws  of  in-breeding,  which  apply 
equally  to  man  and  animals. 


If  a  medical  man  has  under  his  obser- 
vation and  care  a  child  born  of  a  father 
or  mother  who  has  already  shown  signs 
of  insanity,  or  is  "  nervous,"  epileptic,  hys- 
terical, hypochondriacal,  or  unstable  in 
any  way,  what  is  he  to  observe  and  what 
precautions  are  to  be  taken  ?  From  the 
earliest  age  he  may  note  symptoms 
enough  to  put  him  on  his  guard.  The 
infant  may  sleep  badly,  may  be  cross,  or 
over-excitable,  or  have  infantile  convul- 
sions. If  the  mother  is  the  affected  per- 
son, it  will  be  better  for  her  not  to  suckle 
it,  as  a  nervous,  excitable  woman,  prone, 
it  may  be,  to  varying  mental  moods,  is  not 
likely  to  be  a  good  nurse,  and  it  is  of  the 
first  importance  that  a  nervous  child 
should  be  thoroughly  well  nourished 
either  by  a  good  wet-nurse  or  hand-feed- 
ing. Bad  sleeping  is  a  point  not  to  be 
overlooked,  and  judicious  management 
and  regular  hours  and  habits  may  do 
much  to  remedy  the  evil.  The  child 
should  be  taught  to  sleep  by  day  as  well 
as  by  night  till  a  veiy  considerable  age  is 
attained. 

When  a  few  years  have  passed,  other 
signs  may  show  the  nervous  inheritance 
The  child  may  suffer  from  "night-horrors," 
may  be  afraid  of  being  alone  or  in  the 
dark,  or  its  temper  may  be  fractious  and 
capricious,  or  violent  and  passionate. 
Everything  here  will  depend  on  the  judg- 
ment and  prudence  of  those  who  have 
charge  of  it.  Many  a  child  is  frightened 
and  rendered  nervous  and  timid  for  life 
by  tales  told  by  foolish,  servants  and 
nurses,  of  ghosts,  spectres,  and  robbers, 
or  is  terrified  into  obedience  by  threats 
based  on  such  fictions.  The  sensitive  and 
imao'inative  brain  carrios  such  romances 
to  bed  with  it,  and  wakes  from  its  too 
vivid  dreams  in  an  agony  of  panic. 
Another  evil,  it  is  to  be  fea,red,  comes 
occasionally  from  nurses,  who,  in  order  to 
make  such  children  sleep,  teach  them 
habits  of  self-abuse.  And  while  they  are 
thus  exposed  to  risks  from  servants,  they 
may  receive  no  less  harm  from  parents, 
who  will  spoil  them  at  one  moment  and 
indulge  them  with  improper  food  and 
drink,  while  at  another  they  behave 
towards  them  with  intemperate  fury  and 
frighten  them  by  noise  and  passion.  It 
is  above  all  important  that  the  bodily 
health  of  these  children  should  be  regu- 
lated with  discretion,  that  they  should 
have  abundance  of  plain  wholesome  food 
and  no  alcohol,  live  and  play  much  in  the 
open  air,  and  be  encouraged  at  an  early 
age  in  such  pastimes  as  riding,  swimming, 
and  other  suitable  pursuits.  A  love  of 
and  consideration  for  animals  should  be 
promoted,  and  the  fellowship  of  other  boys 


Prevention  of  Insanity      [    99S    ]      Prevention  of  Insanity 


and  girls  should  be  cultivated,  so  that  self- 
ishness and  egoism  may  be  as  far  as  pos- 
sible repressed.  The  time  soon  arrives 
when  education  has  to  be  considered.  A 
certain  proportion  of  these  children  are 
sharp  and  precocious,  and  learn  their  les- 
sons with  ease  ;  others  are  backward  and 
dull  and  hate  their  books.  The  choice 
of  a  school,  especially  a  preparatory 
school,  is  of  the  greatest  importance, 
When  a  precociously  clever  boy  enters  a 
preparatory  school  he  will  be  hailed  as  a 
promising  candidate  for  one  of  the  scholar- 
ships for  which  boys  of  twelve  or  thirteen 
compete  at  most  of  our  public  schools. 
The  competition  for  these  scholarships  is 
very  severe,  great  numbers  of  boys  enter- 
ing for  a  few  vacancies.  Consequently,  a 
large  proportion  are  doomed  at  this  early 
age  to  all  the  evil  consequences  of  mental 
disappointment  and  sense  of  failure  after 
years  of  brain  work  with  all  its  dangers. 
Truly,  modern  education,  with  all  its 
boasted  advance,  has  here  invented  an  ill 
for  its  children  of  which  our  grandfathers 
knew  nothing.  ISTo  less  care  must  be 
bestowed  upon  the  backward  children. 
Where  the  brain  development  is  slow  and 
learning  acquired  with  difficulty,  great 
patience  must  be  exercised  by  teachers. 
Such  children  may  learn  some  subjects 
easily,  but  have  no  aptitude  for  mastering 
others.  They  must  not  be  put  in  a  class 
with  a  dozen  or  twenty  others,  and  made 
to  conform  to  a  common  standai'd,  and 
punished  according  to  rule  if  all  their 
lessons  are  not  learned  uniformly  well. 
Masters  and  mistresses  are  apt  to  mistake 
inability  for  idleness,  and  to  unduly  press 
and  punish  the  backward,  assuming  that 
because  one  subject  is  well  learned,  it  is 
mere  idleness  that  prevents  all  being 
eo[ually  well  done.  They  have  not  suffi- 
cient discrimination  to  see  who  are  idle 
and  who  backward,  and,  no  doubt,  it  is 
often  a  difficult  matter  to  decide,  and  re- 
quires great  judgment  and  patience. 

The  choice  of  a  school  for  children 
calls  for  no  less  care.  Are  girls  to  go  to 
school  at  all  ?  Much  will  depend  on  the 
character  of  their  home  life,  and  the 
judicious  or  injudicious  management  of 
their  parents.  School  may  be  the  salva- 
tion of  some  girls  by  taking  them  away 
from  uncomfortable  homes,  or  foolish 
siDoiling  and  petting,  subjecting  them  to 
the  rules  and  discipline  and  public  opinion 
of  a  number,  instead  of  the  self-indulgence 
of  home  life  and  the  caprices  of  an  hysteri- 
cal, violent,  and  indiscreet  mother.  The 
marvellous  effects  produced  in  some  boys 
by  the  broad  views  and  higher  tone  of  a 
large  public  school  cannot  but  be  paralleled 
to  some  extent  in  the  case  of  girls,  and  as 


a  rule  the  larger  the  school  the  better  will 
be  the  result.  Where  a  boy  or  girl  goes 
to  school,  it  is  above  all  things  necessary 
that  the  bodily  health  should  be  carefully 
watched.  Clothing  should  be  adequate 
and  dormitories  properly  ventilated.  The 
food  should  be  good  and  sufficiently  tempt- 
ing to  be  eaten,  and  outdoor  play  and  ex- 
ercise should  be  enforced. 

Much  controversy  has  lately  arisen  as 
to  the  propriety  of  making  boys  join  in 
games  in  the  playground,  and  not  allowing 
them  to  "  loaf"  in  their  studies,  or  get 
into  mischief  in  a  town.  Whatever  may 
be  said  as  to  the  propriety  or  impropriety 
of  this  compulsory  play  as  a  general  rule, 
there  are,  beyond  question,  many  of  these 
peculiar  and  nervous  children  who  would 
never  play  unless  compelled,  but  would 
spend  their  time  in  solitary  amusements, 
or  get  to  the  public  house  if  opportunity 
offered.  The  writer  has  met  within  asylum 
walls  in  after-life  more  than  one  whom  he 
recollects  at  school  as  loafing  and  idling 
in  this  manner,  not  stupid  or  neglecting 
his  school  work,  but  avoiding  the  play- 
ground and  school  games,  taking  no  exer- 
cise, often  dirty  in  dress,  and  remarkable  for 
some  peculiarity  of  habit  or  appearance. 

There  is  a  matter  of  great  importance 
in  a  boy's  school-life  which  cannot  be 
passed  over  without  notice.  It  is  the 
subject  of  masturbation.  It  is  a  habit 
learned  in  a  very  large  number  of  cases  at 
an  early  age,  and  taught  by  one  school- 
fellow to  another  at  a  time  when  neither 
is  old  enough  to  know  that  it  is  likely  to 
grow  into  a  habit,  or  to  be  productive  of 
evil ;  though  they  may  be  conscious  that 
it  is  a  practice  which  must  be  concealed 
as  indecent  and  unclean.  It  is  not  wise 
to  allow  a  boy  to  take  the  chance  of  con- 
tracting such  a  habit,  often  one  most  in- 
eradicable, without  his  having  the  slightest 
idea  that  it  is  hurtful  to  health.  It  is 
almost  certain  that  he  will  hear  of  it  in 
school,  and  it  is  far  better  that  he  should 
be  warned  by  a  father,  guardian,  elder 
brother,  or  the  family  doctor,  that  he  must 
on  no  account  indulge  in  this  vice  than 
that  he  should  take  his  chance  of  refrain- 
ing therefrom.  AVith  girls  it  is  different. 
Their  chance  of  being  taught  the  practice 
is  far  less,  especially  if  they  are  educated 
at  home,  and  this  is  a  very  strong  argu- 
ment in  favour  of  home  education.  If 
they  are  to  go  to  school,  the  greatest  care 
must  be  taken  in  the  selection  of  one 
where  such  things  do  not  exist.  It  has 
been  said  that  girls  may  find  out  the 
habit  for  themselves,  and  this  is  true, 
though  probably  not  common.  But  no 
one  would  bring  it  to  the  knowledge  of 
girls  in  general,  because  here  and  there 


Prevention  of  Insanity      [    999    ]      Prevention  of  Insanity- 


one  has  niaJe  the  discovery.  Such  know- 
ledge would  in  truth  be  a  dangerous 
thing.  The  time  of  puberty  and  of  the 
tirst  appearance  of  the  catamenia  is  one 
fraught  with  considerable  peril  to  these 
nervous  and  sensitive  girls,  and  they  should 
be  carefully  watched  throughout  it.  It  is 
a  time  when  all  extremes  must  be  avoided. 
They  should  not  be  allowed  to  over-fatigue 
themselves  with  tennis,  long  walks,  or 
rides.  They  should  not  be  exposed  to 
great  heat  or  cold,  or  anything  which  will 
check  the  menstrual  tiow  or  render  it  too 
profuse.  They  should  not  overtax  the 
brain  with  lessons  or  competitive  examina- 
tions, and  a  strict  watch  must  be  kept 
upon  their  sleeping,  as  an  inability  to  sleep 
in  young  people  of  such  an  age  is  often  a 
warning  and  forerunner  of  coming  mis- 
chief, and  if  a  girl  sleeps  alone  it  may 
easily  be  overlooked.  This  period  of  life 
is  one  of  greater  peril  to  girls  than  to  boys, 
to  whom  it  makes  comparatively  little 
diflference,  and  who  break  down  at  the 
time  of  adolescence  rather  than  that  of 
puberty.  A  boy  of  twelve  develops  slov^ly 
and  gradually,  and  he  is  not  a  fully  per- 
fected man  till  he  is  twenty- five.  But  a 
girl  of  seventeen  or  eighteen  is  far  nearer 
to  a  fully  developed  woman  if  we  compare 
her  with  one  of  twelve,  and  as  her  time  of 
development  is  crowded,  so  to  speak,  into 
a  narrower  space,  so  is  it  fraught  with 
greater  peril  to  her. 

Dangerous  as  is  the  period  of  puberty 
to  boys  and  girls,  especially  the  latter, 
that  of  adolescence,  between  the  ages  of 
eighteen  and  twenty-five  is  far  more  so, 
and  more  bi-eak  down  and  become  insane 
at  the  latter  than  at  the  former  epoch. 
In  this  time  the  lives  of  a  great  number 
of  both  sexes  are  virtually  chosen  and 
entered  upon.  Young  men  go  from  school 
to  college,  make  choice  of  a  profession  and 
commence  life.  Many  of  the  women  do 
the  same,  they  choose  an  occupation  or 
calling  ;  they  also  fall  in  love  and  marry. 
Some  men  do  this  too,  but  not  so  many. 
Few  at  any  rate  of  those  who  have  to  earn 
a  livelihood  are  able  to  marry  at  so  early 
an  age.  It  is  a  time,  moreover,  when 
a  girl's  religious  feelings  are  apt  to  be 
highly  excited,  and  she  is  especially  liable 
to  hysteria  and  hysterical  emotion  in  con- 
nection with  such  subjects.  From  all 
this  it  will  be  seen  that  when  we  have  to 
deal  with  a  neurotic  girl  or  young  man 
inheriting  insanity,  it  will  be  of  the  utmost 
imjjortance  that  the  career  chosen  should 
be  one  fitted  to  the  mental  constitution, 
and  that  everything  about  them  should 
be  equally  studied  and  regulated  with 
the  view  of  constantly  warding  off  the 
threatened  evil. 


Looking  at  the  history  of  so  many  of 
these  predisposed  persons,  and  at  the  part 
which  drink  plays  in  filling  our  asylums, 
it  surely  is  not  too  much  to  advise  that 
all  such  should  totally  abstain  from  alco- 
holic liquors.  The  young  are  not  likely 
to  indulge  to  excess  in  other  stimulants, 
as  opium,  haschish  or  snuif,  but  a  liking 
for  wine  or  spirits  may  be  cultivated  at 
an  early  age,  and  the  liking  may  grow 
into  a  craving,  and  how  hard  this  is  to 
resist  and  overcome  every  medical  man 
knows  full  well.  To  abstain  in  the  first 
instance  is  not  nearly  so  difficult.  Girls 
at  the  present  time  are  in  great  numbers 
accustomed  to  avoid  beer  and  wine. 
They  in  no  way  suffer  from  the  depriva- 
tion ;  on  the  contrary,  with  exercise  and 
plenty  of  food  they  have  grown  and  at- 
tained a  stature  and  muscular  develop- 
ment which  is  very  striking.  With  young 
men  it  is  not  so  common,  yet  a  consider- 
able number  abstain,  and,  if  the  habit  is 
commenced  at  an  early  age,  the  difficulty 
vanishes.  In  fact  it  is  certain  that  apart 
from  the  question  of  drinking  to  excess, 
many  of  these  neurotic  persons  suffer  from 
various  kinds  of  nervous  dyspepsia  which 
are  aggravated  by  alcohol,  and  cannot  be 
cured  unless  it  is  abandoned.  If  left  to 
themselves,  they  will  probably  fiy  to 
brandy  to  relieve  dyspeptic  pain  and 
spasm,  and  instead  of  curing  will  increase 
their  sufferings,  and  so  drift  into  the 
practice  of  constant  stimulation.  It  is 
also  impoi'tant  in  the  choice  of  a  calling 
that  none  should  be  chosen  which  entails 
a  constant  tasting  of  wine  or  spirits,  or 
the  entertaining  or  drinking  with  others 
as  is  the  practice  in  some  walks  of  life. 
It  is  equally  important  that  the  feeding 
as  well  as  the  drinking  of  the  predisposed 
should  be  carefully  watched.  Stimulants 
in  the  shape  of  alcohol  they  need  not,  but 
abundance  of  plain  wholesorne  food  they 
require,  and  many  break  down  from  want 
of  it.  It  constantly  happens  that  from 
hypochondriacal  notions  about  dysjaepsia, 
from  fancies  of  various  kinds  as  to  what 
is  or  is  not  wholesome,  or  what  agrees  or 
disagrees  with  them,  or  a  fear  on  the  j^ai't 
of  girls  of  getting  fat,  a  small  and  in- 
adequate amount  of  food  is  taken,  and 
certain  important  items  are  frequently 
omitted.  One  cannot  take  bread,  another 
milk,  another  potatoes  or  vegetables.  So 
the  diet  list  is  reduced  till  little  remains, 
and  that  innutritions  or  indigestible.  If 
this  occurs  in  men  who  are  at  the  same 
time  hard  worked  in  brain,  a  break  down 
is  most  likely  to  follow  sooner  or  later, 
and  it  is  often  most  difficult  to  induce  them 
to  take  the  food  which  is  necessary  for 
recovery.     Another  class  think  it  carnal 


Prevention  of  Insanity      [     looo 


Prevention  of  Insanity 


and  sensual  to  indulge  the  appetite  and 
eat  their  till,  and  endless  evil  conies  to 
many  who  fast  during  Lent  and  other 
such  seasons,  and  mortify  the  flesh  ac- 
cording to  the  doctrines  of  the  ultz-a- 
ritualistic  party.  The  whole  of  the  re- 
ligious ti'aiuing  of  the  predisposed  re- 
quires the  most  careful  handling,  a  difficult 
matter,  as  they  are  for  the  most  part 
averse  to  consult  those  best  able  to  advise 
them,  and  seek  the  excitement  of  the  fol- 
lowers of  extreme  views  from  revivalists 
and  the  Salvation  Army  to  the  Roman 
Catholic  Church.  Young  people  of  both 
sexes  should  not  spend  an  undue  time  in 
reading  religious  books  or  writing  long 
accounts  of  their  spiritual  state.  Their 
religion  should  be  practical  and  not  in- 
trospective, and  they  should  not  be  allowed 
to  remain  an  abnormally  long  time  on 
their  knees  and  thus  expose  themselves 
to  cold.  On  the  other  hand,  there  are 
not  a  few  who  fancy  themselves  philoso- 
phers, and  read  Herbert  Spencer's  works, 
or  worry  their  bi'ains  by  reasonings  which 
they  cannot  follow,  parading  their  studies 
for  the  sake  of  effect  or  for  the  annoy- 
ance of  those  about  them. 

The  time  has  now  arrived  when  the 
young  man  has  to  choose  the  profession 
or  occupation  in  which  life  is  to  be  passed, 
and  this  choice  has  to  be  made  by  many 
young  women  as  well.  It  is  a  momentous 
question,  and  one  often  decided,  not  by  the 
individuals  themselves,  but  by  parents  or 
guardians,  or  force  of  circumstances. 
Where  a  free  choice  can  be  made,  what 
should  influence  the  selection  of  a  call- 
ing ?  Of  the  learned  professions  the  Church 
is  the  least  eligible  ;  it  appeals  stronglj^ 
to  the  emotional  part  of  the  mental  con- 
stitution, the  jDart  which  in  neurotic  people 
is  apt  to  be  easily  and  strongly  aroused 
and  least  under  control.  Religious  doubts 
and  difficulties  concerning  creeds  will  pro- 
bably arise  in  these  excitable  minds, 
questions  as  to  whether  a  clergyman 
having  doubts  should  retain  his  benefice 
or  resign  it,  and  in  so  doing  reduce  him- 
self and  his  family  to  poverty.  Fear  may 
arise  in  a  vacillating  and  doubting  mind 
as  to  whether  the  duties  of  the  parish  are 
properly  discharged,  and  on  the  slightest 
depression  overwhelming  religious  remorse 
may  ensue.  And  this  profession  once 
adopted  cannot  be  thrown  up  or  changed 
for  another,  so  that  it  is  by  no  means  a 
desirable  vocation  for  those  whom  we  are 
considering.  For  the  last  reason  law  and 
medicine  are  preferable.  The  study  of 
them,  especially  the  latter,  has  great  and 
j)ractical  interest  for  one  who  likes  it,  an 
interest  which  cannot  flag,  as  new  dis- 
coveries in  science  and  new  methods    of 


alleviating  disease  are  made  and  pub- 
lished. There  may  be  a  certain  amount 
of  anxiety  in  both  professions,  business 
may  be  slack  and  fees  scarce,  but  in  the 
calling  of  a  solicitor  or  general  medical 
practitioner  there  is  usually  a  livelihood 
to  be  earned,  and  a  certain  amount  of 
routine  and  unexciting  work  to  be  done 
without  much  worry.  A  clerkship  in  a 
Government  office,  where  hours  are  short, 
responsibility  small,  and  holidays  long, 
is  the  place  of  all  others  for  the  "  ner- 
vous "  man.  In  the  old  time  such  posts 
were  obtained  without  much  difficulty, 
but  now  that  a  competitive  examination 
is  a  necessary  preliminary,  the  case  is 
altered,  and  the  work  and  disappointment 
which  may  follow  failure  make  such  less 
desirable.  Still  our  neurotic  people  are 
not  devoid  of  brains,  and  steady  work  for 
a  time  may  gain  this  prize,  to  be  held 
without  detriment  for  many  years  with 
the  consolation  of  a  pension  at  the  end. 
The  army  is  unfavourable,  as  it  may  ne- 
cessitate a  long  residence  in  an  unwhole- 
some tropical  climate  ;  the  emolument  is 
small,  there  is  no  great  interest  in  the 
work  during  a  lai'ge  portion  of  the  time, 
and  desultory  and  idle  habits  often  lead 
to  drinking.  Life  in  our  colonies  or  in 
North  or  South  America,  tempts  many 
young  men,  and  it  is  a  good  calling  for 
those  who  wish  to  work  under  others,  and 
are  fond  of  a  hard  out-door  life ;  but  it 
may  entail  much  solitude  and  privation, 
and  the  vicissitudes  of  seasons  and  prices 
may  cause  great  care  and  anxiety,  if  a 
man  is  farming  land  of  his  own.  There 
is  one  piece  of  advice  valuable  to  all.  Be- 
sides his  work  or  profession  let  every  one 
have  a  pursuit,  taste,  or  hobby,  call  it 
what  we  will,  to  which  he  may  turn,  and 
with  which  he  may  distract  his  thoughts 
and  recreate  his  mind,  tired  and  sick  of 
work  and  worry.  The  want  of  this  has 
caused  many  a  one  to  break  down,  and 
many  by  it  have  been  saved  from  mental 
rum. 

Besides  choosing  a  profession,  young 
I^eople  have  another  serious  question  to 
ask  themselves  :  Shall  they  marry,  and  if 
so,  whom.''  Avast  number  will  answer 
for  themselves  without  asking  advice  from 
others,  even  their  own  parents,  but  here 
and  there  the  medical  adviser  of  the 
family  may  be  consulted.  Unfortunately 
this  is  generally  done  when  the  engage- 
ment is  made  and  marriage  impending, 
and  adverse  advice,  if  given,  is  rarely 
heeded.  But  if  we  note  the  number  of 
young  men  and  women  who  break  down 
during  the  time  the}"  are  engaged,  imme- 
diately after  marriage,  or  in  the  honey- 
moon, it  is  certain  that  it  is  all  fraught 


Prevention  of  Insanity      [     looi     ]      Prevention  of  Insanity 


with  danger  to  those  predisposed  to  in- 
sanity by  constitution  and  inheritance. 
That  all  persons  who  have  insanity  in 
their  family  should  abstain  from  matri- 
mony is  more  than  can  be  expected.  Not 
only  do  these  marry,  but  they  are  spe- 
cially prone  to  make  ill-judged  selections. 
There  seems  a  tendency  among  these 
neurotic  folk  to  choose  for  their  partners 
people  of  a  like  nervous  temperament,  and 
irom  a  shyness  which  is  characteristic 
and  constitutional,  they  often  choose 
cousins  whom  they  have  long  known  in 
preference  to  strangers,  whom  they  know 
not  and  are  too  shy  to  approach.  It 
need  not  be  said  that  the  danger  is  in- 
creased if  cousins  from  two  families  where 
insanity  exists  intermarry  and  have  chil- 
dren. This,  however,  happens  but  too 
fi'equently,  and  parents  do  not  oppose 
such  unions,  because  they  prefer  to  ignore 
the  whole  risk  ;  they  hope  for  the  best, 
and  invent  excuses  for  the  cases  that  have 
occurred,  as  drink,  sunstroke,  falls  on  the 
head,  and  the  like,  or  deny  that  the 
maladj-  has  ever  existed  at  all.  If  a 
member  of  such  a  family  is  to  marry,  it 
is  important  that  he  or  she  should  be  in 
good  health  and  marry  a  person  who  is 
also  in  good  health,  and  has  a  good  family 
history.  If  a  girl  is  delicate  and  neurotic 
she  should  not  marry  a  very  poor  man, 
and  have  the  additional  anxiety  of  poverty 
and  the  constant  and  daily  obligation  to 
pinch  and  save  for  the  sake  of  husband 
and  children.  The  continual  anxiety  of 
small  economies  and  the  necessity  of 
meeting  small  debts,  may  break  down  one 
who  in  more  affluent  circumstances  might 
have  gone  unscathed.  Another  fertile 
source  of  insanity  is  a  numerous  family, 
one  child  following  another  in  rapid  suc- 
cession. Many  delicate  women  having  no 
break  or  respite,  succumb  to  this  strain, 
even  those  in  whom  insanity  may  not  be 
markedly  hereditary.  The  nervous  sys- 
tem has  no  rest  or  chance  of  recuperation, 
and  mental  or  lung  disease,  or  both,  is 
the  result.  There  is  an  idea  prevalent 
amongst  many  that  nervous  or  hysterical 
young  men  and  women  should  marry  as 
soon  as  possible,  and  that  marriage  is  a 
sovereign  cure  for  this  state.  Now  it  is 
probable  that  many  men  predisposed  to 
insanity  may  benefit  greatly  by  marriage 
if  they  are  so  fortunate  as  to  meet  with 
a  suitable  wife.  Henceforth  they  lead  a 
regular  life,  keep  earlier  hours,  have  a 
confidante  to  share  their  troubles,  who 
also  cares  for  their  meals  and  domestic 
comforts,  and  nurses  and  guards  them. 
On  the  other  hand,  if  marriage  does  not 
benefit  them,  and  they  prove  unfitted  for 
it,  it  is  a  condition  which  the  unfortunate 


wife  cannot  free  herself  from.  An  irri- 
table man  will  quarrel  more  with  his 
wife  and  behave  worse  to  her  than  to  any 
other  being,  and  there  is  besides  the  risk 
that  the  offspring  may  be  an  idiot,  epi- 
leptic or  neurotic  in  some  shape  or  way. 
The  benefit  to  be  derived  from  marriage 
by  a  predisposed  woman  is  far  less,  and 
the  danger  far  greater.  There  is  marriage 
with  all  its  trying  surroundings  in  which 
so  many  break  down.  Then  follow  preg- 
nancy and  parturition,  to  recur,  it  may  be, 
frequently.  If  there  is  immunity  on  the 
first  or  second  occasions,  later  on  insanity 
maj'  be  developed.  One  thing  is  certain, 
that  women  who  have  already  had  attacks 
of  insanity  should  abstain  from  marriage, 
and  the  concealment  of  such  a  history  from 
an  intended  husband  and  his  friends  is  a 
most  serious  and  rei^rehensible  step. 

The  next  question  for  consideration  is 
this  :  What  should  be  done  when  a  man 
or  woman  who  has  not  been  previously 
insane,  is  threatened  with  symptoms  of 
a  mental  disorder  ?  In  many  cases  the 
treatment  is  obvious.  An  exciting  cause, 
if  we  are  sure  it  is  the  cause,  must  at 
once,  if  possible,  be  removed.  Overwork 
must  cease,  overworry  may  not  be  so  easy 
to  deal  with,  but  the  attempt  must  be 
made,  and  a  long  journey  to  a  foreign  land 
may  by  the  mere  effect  of  distance  reduce 
it  to  a  trifling  amount.  The  effect  of  a 
fright  or  shock  may  subside,  and  the 
shock  be  unlikely  to  recur  ere  time 
comes  to  our  aid.  Over-excitement  about 
religious  matters  must  be  stopped,  and 
undue  devotion  and  early  services  strictly 
forbidden.  Drinking  must  be  checked, 
and  sexual  excess,  and  excesses  of  all 
kinds.  Betrothals  must  be  broken  off  or 
suspended  if  it  is  plain  that  they  are  pro- 
ducing a  state  of  mind  which  renders 
marriage  an  impossibility.  In  short, 
when  we  see  that  there  is  an  exciting 
cause  it  must  be  removed,  but  it  may 
happen  that  no  definite  or  tangible  cause 
can  be  ascertained.  The  individual  is 
leading  his  or  her  ordinary  life,  yet  there 
is  a  deviation  from  the  normal  state,  there 
is  depression  or  excitement,  unfounded 
fear,  suspicion  or  irritation  \yith  disturb- 
ance of  health,  and  in  the  majoi-ity  of 
cases  want  of  sleep.  The  failure  of  sleep 
is  a  symptom  of  the  highest  importance, 
and  one  constantly  disregarded  both  by 
the  patient  and  his  relatives.  Yet  by 
remedying  this,  more  jsrobably  can  be 
done  towards  warding  off  insanity  than 
by  any  other  treatment.  Again  and  again 
it  happens  that  a  week's  good  sleep  pro- 
cured by  sulphonal,  paraldehyde,  chloral 
or  the  like,  will  dissijjate  the  fears  and, 
suspicions,  allay  the  excitement  and  irri- 


Prevention  of  Insanity      [    1002    ] 


Private  Asylums 


lability,  and  bring  the  sufferer  back  to 
his  sane  mind.  The  most  foolish  prejudice 
exists  against  the  production  of  sleep  by- 
such  medicines,  and  there  is  often  a  diffi- 
culty in  getting  the  patient  to  take  them. 
It  is  objected  that  a  habit  of  using  such 
drugs  will  be  set  up,  as  if  such  a  habit 
could  be  contracted  in  a  week  or  two. 
Certain  it  is  that  if  the  sleeplessness  goes 
on  unchecked,  the  threatened  insanity  will 
rapidly  develop,  and  will  have  to  be  dealt 
with  in  a  more  serious  way.  The  next 
most  potent  weapon  with  which  to  avert 
the  disorder  is  change  of  scene.  It  is 
wonderful  how  removal  from  the  environ- 
ment in  which  the  symptoms  have  arisen, 
and  the  people  amongst  whom  the  patient 
has  been  living,  working  and  complaining, 
will  change  the  ideas  and  substitute 
others  in  place  of  the  morbid.  The  re- 
moval will  have  to  be  of  longer  or  shorter 
duration  according  to  the  time  the  mental 
disturbance  has  existed  and  its  depth, 
but  it  is  unwise  to  bring  a  man  back  to 
his  old  surroundings  immediately  on  his 
showing  signs  of  convalescence.  The 
companion  or  companions  must  be  care- 
fully chosen.  Friends  are  better  than 
relatives,  strangers  than  friends,  for 
strangers  bring  fresh  views  and  ideas, 
and  are  less  able  to  talk  about  the  troubles 
of  the  past.  Anything  like  a  delusion 
should  be  discussed  as  little  as  jjossible, 
for  delusions  grow  and  are  consolidated, 
not  dispersed,  by  discussion. 

To  i^revent  a  recurrence  in  those  who 
have  already  had  an  attack  of  insanity, 
the  same  precautions  to  a  great  extent 
must  be  observed.  The  previous  illness 
will  furnish  valuable  information,  and  a 
question  may  arise  as  to  what  was  the 
real  cause,  and  how  it  can  be  prevented 
from  being  the  source  of  a  second.  The 
exciting  cause,  for  instance,  may  be  par- 
turition. The  patient  may  have  made  a 
perfect  recovery,  but  there  will  be  a  risk 
of  recurrence  when  the  next  child  is  born. 
Is  she  then  to  abstain  from  any  risk  of 
pregnancy  ?  Much  here  must  necessarily 
be  left  to  the  discretion  of  husband  and 
wife,  but  beyond  a  doubt  the  risk  must  bo 
pointed  out,  especially  if  insanity  or  symp- 
toms approaching  it  have  followed  more 
than  one  confinement.  With  regard  to 
other  causes,  it  may  be  necessary  that  a 
man  should  even  give  up  his  profession  or 
vocation,  if  his  mental  health  does  not 
admit  of  his  continuing  it.  A  soldier  may 
have  to  give  up  the  army  ;  a  civilian  may 
be  compelled  to  leave  India,  if  it  is  plain 
that  his  brain  cannot  stand  a  tropical 
climate.  In  all  this  the  physician  can 
only  advise.  He  may  be  able  to  avert  the 
early  symptoms   by  procuring   sleep,  or 


ordering  rest  or  change  of  scene,  but  he 
may  have  great  difficulty  in  persuading 
the  patient  or  friends  to  forego  that  which 
is  the  chief  danger,  for  the  predisposed 
are  self-opinionated  and  obstinate  in  no 
small  degree.  Great  will  be  the  difficulty 
in  persuading  those  whose  insanity  depends 
upon  drink  to  abstain  altogether  from 
alcohol.  Yet  there  is  no  safety  in  any 
half  measures,  especially  for  women. 
Their  only  hope  is  in  total  abstinence  ;  if 
they  take  a  little,  they  will  certainly  want 
more,  till  excess  is  reached.  And  only  by 
the  closest  vigilance  and  supervision  can 
total  abstinence  be  enforced.  Insanity  in 
spite  of  every  care  will  return  in  those 
who  by  constitution  are  prone  to  break 
down  periodically.  The  best  that  a  phy- 
sician can  do  is  to  bring  the  patient  under 
treatment  as  soon  as  symptoms  indicate 
the  approach,  and  to  try  and  shorten  the 
attack  by  prompt  and  early  measures. 

Can  anything  be  done  to  prevent  the 
alternation  of  mania  and  melancholia,  to 
which  has  been  given  the  name  of  folic 
circulaire ;  or  the  periodical  recurrence  of 
the  same  form,  mania  or  melancholia  ? 
Where  the  alternation  or  recurrence  is 
once  firmly  established,  the  prognosis  is 
most  unfavourable,  do  what  we  will. 
Change  of  scene  and  constant  moving 
from  place  to  place  may  be  of  some  use, 
if  the  case  admits  of  it.  Medicines  avail 
little.  As  the  attacks  come  round,  each 
must  be  treated  according  to  the  symp- 
toms, but  they  pass  away  to  return  with 
greater  or  less  regularity  perhaps  through 
a  long  life.         C  Fielding  Blaxdfokd. 

PRIIVliiRE  VERXtTJCKTHEIT.    {See 

Paranoia,  and  A^errucktheit.) 

PRiivxoGEM-ZTURE.  —  It  has  been 
stated  that  the  first-born,  especially  if  a 
boy,  runs  a  greater  risk  of  being  an  idiot 
than  a  later  child.  According  to  some, 
the  right  of  primogeniture  rests  on  the 
danger  the  eldest  son  runs  at  birth. 

PRIVATE  ASYiiVMS  (See  Great 
Britain,  Insanity  is). — It  would  be  im- 
possible in  the  space  at  our  command  to 
give  a  history  of  the  legislation  affecting 
the  licensed  houses  of  Great  Britain  and 
Ireland.  They  have  formed  the  object  of 
attack  from  the  public,  and  the  occasion 
of  a  vast  number  of  legislative  enactments 
during  the  greater  part  of  this  century. 
All  that  we  propose  to  do  in  the  present 
article  is,  to  give  some  of  the  most  im- 
portant regulations  now  in  force  (53  Vict, 
c.  5,  s.  207,  1890)  in  regard  to  them. 

If  the  commissioners,  in  the  case  of  a 
house  within  their  immediate  jurisdiction, 
or  in  the  case  of  a  house  licensed  by  jus- 
tices, are  of  opinion  that  a  house  has 
been  well  conducted  by  the  licensees,  the 


Procedure 


[    1003    ] 


Procedure 


commissioners  or  justices  may,  lapon  the 
expii-ation  of  the  licence,  renew  it  for  that 
house  to  the  former  licensees,  or  any  one 
or  more  of  them,  or  to  their  successors  in 
business. 

If  at  any  time  it  is  shown  to  the  satis- 
faction of  the  commissioners  or  justices, 
as  the  case  may  be,  that  it  would  be  to 
the  advantage  of  the  patients  that  another 
house  should  be  substituted,  they  may 
grant  a  licence  subject  to  the  same  condi- 
tions as  may  have  existed  in  respect  of  the 
first-mentioned  house. 

In  the  case  of  joint  licensees  or  pro- 
prietors desiring  to  carry  on  business 
apart,  the  commissioners  or  justices  may 
grant  to  each  licensee  renewed  licences 
for  such  number  of  patients  (not  exceed- 
ing in  the  aggregate  the  number  allowed 
by  the  joint  licence)  as  such  joint  licensees 
agree  upon,  or  as  the  commissioners  or 
justices  determine. 

Where  the  licensee  of  a  house  is  a 
medical  man  in  the  employment  of  the 
proprietor  of  such  house  as  his  manager, 
the  licence  shall  be  transferable  or  renew- 
able to  him  so  long  as  he  continues 
manager  of  the  house  or  to  his  successor. 

The  most  important  section  of  all  the 
sections  of  the  recent  Lunacy  Act  (respect- 
ing private  asylums)  is  that  which  enacts  : 

"  Save  as  in  this  section  provided,  no 
new  licence  shall  be  granted  to  any  per- 
son for  a  house  for  the  reception  of  luna- 
tics, and  no  house  in  respect  of  which 
there  is,  at  passing  of  this  act,  an  existing 
licence,  shall  be  licensed  for  a  gi'eater 
number  of  lunatics  than  the  number 
authorised  by  the  existing  licence." 

It  may  be  added,  that  a  medical  visitor 
to  a  private  asylum  shall  be  entitled  to 
such  remuneration  as  the  justices  may 
approve  (Lunacy  Act,  1890,  53  Vict.  c.  15, 
s.  177,  sub-s.  12).  Medical  visitors  are  not 
appointed  to  visit  licensed  houses  within 
the  Metropolitan  area,  but  only  those 
licensed  by  county  justices  (s.  177, 
sub-s.  i).  The  Editor. 

PROCEDURE,  in  layingr  Evidence 
before  Jury,  when  the  ACCUSED  is 
ilIiI.EGED  to  be  INSANH. — The  mode 
of  procedure  at  the  present  time,  with 
i-egard  to  the  manner  in  which  evidence 
as  to  the  sanity  or  insanity  of  an  accused 
person  is  laid  before  the  jury,  may  be 
gathered  from  the  following  extract  from 
Hansard's  Parliamentary  Reports,  3rd 
series,  vol.  286,  p.  40,  giving  a  repoi't  of 
the  proceedings  in  the  House  of  Commons 
on  March  17,  1884.  In  reply  to  a  ques- 
tion asked  by  Mr.  Mellor,  the  Attorney- 
General  (Sir  Henry  James)  said:  "Per- 
haps it  will  be  the  better  course  for  me,  in 
answer  to  the  question  of  my  honourable 


friend,  to  state  what  directions  I  have 
given  to  the  Director  of  Public  Prosecu- 
tions. I  lately  received  a  communication 
from  the  Homo  Office  to  the  effect  that, 
in  some  recent  cases,  great  inconvenience, 
if  not  injustice,  had  resulted  from  no  re- 
sponsible person  being  in  charge  of  cases 
when  the  life  of  the  accused  was  at  stake. 
I  was  also  informed  that  the  Home  Office 
had  found  great  difficulty  in  dealing  with 
cases  of  alleged  insanity,  in  consequence 
of  the  facts  not  being  brought  before  the 
jury,  and  being  only  suggested  after  the 
trial.  It  seemed  to  me,  therefore,  advisa- 
ble to  take  steps  to  insure  that  all  evidence 
bearing  on  the  case,  whether  tending  to 
prove  the  guilt  or  innocence  of  the  pri- 
soner, should  be  placed  before  the  jury; 
and,  with  that  object,  I  have  requested 
that  whenever  an  accused  person  is 
brought  before  justices  on  a  capital 
charge,  the  magistrate's  clerk  shall  com- 
municate with  the  Solicitor  of  the 
Treasury,  and  that  that  officer  shall  take 
charge  of  the  prosecution,  unless  he  finds 
that  some  competent  private  person  or 
local  body  has  the  conduct  of  it ;  but,  in 
the  absence  of  such  proper  conduct,  it 
will  be  the  duty  of  the  Treasury  Solicitor, 
acting  as  Director  of  Public  Prosecutions, 
to  see  that  the  evidence  in  everjr  capital 
case  be  fully  brought  before  the  jury.  I 
have  also  requested  that,  in  those  cases 
where  insanity  in  the  accused  is  alleged, 
full  inquiry  shall  be  made,  and,  in  the 
absence  of  his,  or  his  friends',  ability  to 
produce  witnesses,  the  Treasury  Solicitor 
shall  secure  their  attendance." 

With  reference  to  the  foregoing  state- 
ment of  the  Attorney- General,  a  few 
words  of  explanation  as  to  the  terms 
Public  Prosecutor,  and  Treasury  Solicitor, 
may  be  not  altogether  superfluous.  A 
Public  Prosecutor,  in  England,  is  a  com- 
paratively recent  institution,  dating  only 
from  the  year  1879.  In  that  year  an  Act, 
entitled  the  "  Prosecution  of  Offences 
Act,"  was  passed  (42  &  43  Vict.  c.  22), 
by  which  Act  provision  was  made  for  the 
appointment  of  an  officer  to  be  called  the 
Director  of  Public  Prosecutions,  whose 
duty  it  should  be,  "  under  the  superin- 
tendence of  the  Attorney-General,  to  in- 
stitute, undertake,  or  carry  on  such 
criminal  proceedings,  whether  in  the 
Court  for  Crown  Cases  Reserved,  before 
sessions  of  Oyer  and  Terminer  or  of  the 
peace,  before  magistrates  or  otherwise, 
and  to  give  such  advice  and  assistance  to 
chief  officers  of  police,  clerks  to  justices, 
and  other  persons,  whether  officers  _  or 
not,  concerned  in  any  criminal  proceedmg 
respecting  the  conduct  of  that  proceeding, 
as  may  be  for  the  time  being  prescribed 


Procedure 


[     1004 


Procedure 


by  regulations  under  this  Act,  or  may  be 
directed  in  a  special  case  by  the  Attorney- 
General." 

In  1 884, however,  it  was  found  expedient 
to  amend  the  Act  of  1879  ;  and  on  August 
14,  1884,  an  amending  Act  was  passed 
(47  A;  48  Vict.  c.  58),  by  which  all  ap- 
pointments made  in  pursuance  of  the  Act 
of  1S79  were  revoked,  and  it  was  pro- 
vided, amongst  other  things,  that  "  the 
person  for  the  time  holding  the  office  of 
Solicitor  for  the  affairs  of  Her  Majesty]s 
Treasury,  shall  be  Director  of  Public 
Prosecutions,  and  perform  the  duties  and 
have  the  powers  of  such  Director." 

It  will  be   observed   that   the  date,  at 
which  Sir  Henry  James  made  the  state- 
ment above  quoted,  was  March  1884,  and 
at  that  date  the  Solicitor  of  the  Treasury 
was    acting   for    the   Director   of    PubUc 
Prosecutions,  whilst,  by  the  Act  which  was 
passed  in   the  month  of  August  of  that 
year,   he   became   actually  the  Director, 
and    has    so   continued  to   be  from  that 
time.     To  say,  therefore,  that  a  prosecu- 
tion is  being  conducted  by  the  Director  of 
Public  Prosecutions  is  now  the  same  as 
to  say  that  it  is  being  conducted  by  the 
Treasury  Solicitor,  and  the  latter  term  is 
the  one  which  is  the  more  commonly  used. 
Sir  Henry  James  referred  more  particu- 
larly in  his  statement  to  capital    cases, 
but,  as  has   been  seen  from  the  extract 
setting  forth  the  duties  of  the  Director  of 
Public     Prosecutions,     the     prosecutions 
undertaken    by   that   officer    are    by   no 
means  limited  to  capital  cases ;  and  the 
instructions  with  respect  to  "  those  cases 
where  insanity  in  the  accused  is  alleged  " 
would  appear  to  be  interpreted  as  apply-  I 
ing    to  any  prosecutions  imdertaken  by 
him.     And  thus,  in  the  case  of  Richard 
Coolidge  Duncan,  who  was  tried  at  Car- 
narvon, in    July   1 89 1,    on    a   charge    of 
feloniously  wounding  his  wife,  the  prose- 
cution was    undertaken  by  the  Treasury 
Solicitor,   and,   in    conformity   with    the 
usual  practice,  the  medical  superintendent 
of  the  neighbouring  county  lunatic  asylum 
•was  applied  to,  and  was  asked  to  examine 
the  accused  and  to  give  evidence  at  the 
trial.     This  was  accordingly  done,  and  a 
report  of  the  trial  may  be  found   in  the 
papers  for  July  14,  189 1. 

The  general  results  of  the  working  of 
the  Prosecution  of  Offences  Acts  may  be 
seen  by  reference  to  the  annual  reports 
laid  before  Parliament,  the  latest  of  which 
was  ordered  by  the  House  of  Commons  to 
be  printed  on  March  12,  1891  (No.  139). 

In  carrying  out  the  instructions  of  the 
Attorney -General  to  the  effect  that,  in 
those  cases  where  insanity  in  the  accused 
is  alleged,  "  full  inquiry  shall  be  made," 


the    general     practice    of    the    Treasury 
Solicitor  is  to  apply  to  medical    men  of 
experience   and   repute,  one  of  whom  is 
usually  the  medical  superintendent  of  the 
lunatic  asylum  for  the  county  in  which 
the  accused  is  in  custody,  and  to  request 
them  to  examine  the  accused  with  a  view 
to  giving  evidence  at  the  trial,  and  in  the 
meantime  to  draw  up  a  report  as  to  the 
mental  condition  of  the  accused,  for  the  in- 
formation of  counsel ;   and  then,  if   the 
gentlemen  applied  to  are  willing  to  comply 
with  this  request,  they  are  afforded  every 
facility  for  obtaining  the  fullest   possible 
information  as  to  the  antecedents  of  the 
accused.     It  is  the  usual  practice  of  the 
Treasury  Solicitor  to  appoint  a  local  soli- 
citor as  his  agent  in  the  assize  town  where 
the  case  is  to  be  tried,  and  that  solicitor 
will  always  take  whatever  trouble  may  be 
necessary  to  obtain  full  information  as  to 
the  antecedents  of  the  accused.     The  de- 
positions taken  before  the  magistrate  or 
before   the   coroner  afford  the  necessary 
information  as  to  the  offence  with  which 
the  accused  is  charged,  and  every  reason- 
able  facility   is    given    for   the    purpose 
of   securing   a    satisfactory    personal  ex- 
amination  of  the   accused.     Everything, 
indeed,  is  done  to  endeavour  to  give  full 
effect  to  the  instructions  of  the  Attorney- 
General  that  "  full  inquiry  shall  be  made," 
and   that  the    evidence    shall   be   "fully 
brought   before   the   jury."     One  of  the 
gravest  objections    that   may  be  urged 
against   a   plan    of  this    kind  was   very 
clearly  jjointed  out  by  Dr.  Bucknill,  in  a 
lecture*  delivered  by  him  at  the  London 
Institution,  in  February  1884.    Dr.  Buck- 
nill observed  :  "  The  greatest  objection  to 
an  examination  forerunning  the  trial  is 
that   it  would    be    almost    impossible    to 
prevent  it  from  eliciting  confession  of  the 
deed,  which  would  often  be  embarrassing 
and  contrary  to  the  spirit  of  our  law,  al- 
though in  France,  as  you  may  know,  con- 
fession   is    encouraged    or   provoked.     A 
solicitor    for    the    defence   would   decide 
whether  this  danger  existed  or  not,  and 
would  have   a  mental  examination  insti- 
tuted or  not,  as  he  thought  best  for  his 
client.     An  official  examination,  forerun- 
ning the  trial,  which  had  the  misfortune 
to  elicit  a  confession  fatal  to  the  prisoner 
would,  I  think,  be  condemned  by  English 
opinion.     I  do  not  know  what  legal  right 
the  prosecution  or  the   executive  has  to 
order  the  examination  of  a  prisoner  com- 
mitted for  trial." 

The  difference  between  the  English  and 

the  French  modes  of  criminal  procedure, 

to  which  Dr.  Bucknill  very  rightly  draws 

"■  See  Jiiitish  Medical  Journal,  Marcli  15  and  22, 


Procedure 


[     1005    ] 


Procedure 


attention  in  the  foregoing  extract,  forms 
the  subject  of  a  very  instructive  chapter 
in  Sir  James  Fitzjames  Stephen's  '"  His- 
tory of  the  Criminal  Law  of  England," 
and  that  chapter  will  well  repay  perusal 
on  the  part  of  those  who  are  interested  in 
this  matter. 

Mr.  Wood  Renton,  in  an  article  con- 
tributed to  the  Medico-Legal  Journal,  of 
New  York,  for  June  1891,  puts  the  point 
very  tersely  iu  the  following  extract : 
"  Criminal  jurisprudence  on  the  Continent 
is  inquisitorial.  Criminal  jurisprudence 
in  England  and  most  English-speaking 
countries  (Scotland  excepted)  is  litigious." 

Although,  however,  these  two  terms 
"  inquisitorial  "  and  "  litigious  "  serve 
admirably  to  accentuate  the  essential  dis- 
tinction between  the  criminal  jurispru- 
dence of  the  Continent  and  that  of  Eng- 
land, it  would  be  scarcel}'  right  to  assume 
that,  at  the  present  time,  the  criminal 
jurisprudence  of  England  is  litigious  and 
litigious  only. 

As  the  institution  of  a  Public  Prosecutor, 
whose  business  it  is,  not  so  much  to  ob- 
tain a  conviction  as  to  see  that  justice  is 
done,  is  only,  as  already  stated,  of  com- 
paratively recent  date,  there  has  been 
scarcely  yet  time  for  the  realisation  of  the 
full  eii'ect  of  the  appointment  of  this 
officer.  Then,  again,  the  statement  of  the 
Attorney-General,  that  it  appeai'ed  to  him 
"advisable  to  take  steps  to  insure  that  all 
evidence  bearing  on  the  case,  whether 
tending  to  prove  the  guilt  or  innocence  of 
the  prisoner  should  be  brought  before  the 
jury,"  is  a  strong  indication  that  the  atti- 
tude of  the  prosecution  is  by  no  means  a 
purely  litigious  attitude;  whilst  the  in- 
struction, that  in  the  absence  of  the  ability 
of  the  accused  to  produce  witnesses,  ''  the 
Treasury  Solicitor  shall  secure  their  at- 
tendance," aifords  further  strong  evidence 
in  the  same  direction. 

But,  if  it  is,  happily,  no  longer  possible 
to  say  that,  in  England,  criminal  proceed- 
ings are  purely  litigious  in  their  charac- 
ter, neither  is  there  any  desire  that  the 
"  full  inquiry,"  directed  by  the  Attorney- 
General,  should  run  the  risk  of  defeating 
its  object  by  becoming  inquisitorial;  nor 
is  there  any  wish  or  intention  to  interfere 
with  the  perfect  liberty  of  the  accused  to 
present  his  defence  in  whatever  way  may 
seem  best  to  him  and  to  his  advisers. 

And  when  the  accused,  or  Avhen  his 
friends,  on  his  behalf,  are  taking  their 
own  steps  for  the  defence,  and  are  employ- 
ing legal  aid,  the  risk,  referred  to  by  Dr. 
Bucknill,  of  eliciting  "  a  confession  fatal 
to  tbe  prisoner  "  would  be  guarded  against 
by  the  medical  examiner  placing  himself 
in  communication  with  the  solicitor  for 


the  accused.  In  other  cases,  where  the 
accused  is  undefended,  the  medical  ex- 
aminer will  be  able  to  judge,  from  the 
documents  in  the  case,  as  to  the  degree  of 
risk  on  this  point,  and  will  proceed  with 
due  caution.  If  he  iinds  ground  for  seri- 
ous doubt  as  to  the  extent  to  which  he 
would  be  legally  justified  in  pushing  his 
examination  of  the  accused,  his  prudent 
course  will  be  to  lay  a  statement  of  his 
doubts  before  the  Treasury  Solicitor,  who 
will  advise  him  in  the  matter. 

If  more  than  one  medical  man  is  en- 
gaged in  the  examination,  it  is  well  that 
their  report  should,  if  possible,  be  a  joint 
report.  Sir  James  Fitzjames  Stephen 
observes  upon  this  point  :*  "  If  medical 
men  laid  down  for  themselves  a  positive 
rule  that  they  would  not  give  evidence 
unless,  before  doing  so,  they  met  in  con- 
sultation the  medical  men  to  be  called  on 
the  other  side,  and  exchanged  their  views 
fully,  so  that  the  medical  witnesses  on  the 
one  side  might  know  what  was  to  be  said 
by  the  medical  witnesses  on  the  other, 
they  would  be  able  to  give  a  full  and  im- 
partial account  of  the  case  which  would 
not  provoke  cross-examination." 

In  any  case,  what  is  wished  for,  from  the 
medical  examiners,  is  a  full  and  impartial 
report,  for  the  information  and  guidance 
of  the  Court.  It  is  very  desirable  there- 
fore, in  the  first  place,  to  ascertain  accu- 
rately all  the  facts,  and  then  to  point  out 
what  are  the  medical  inferences  which 
may  legitimately  be  drawn  from  those 
facts;  carefully  distinguishing  between 
fact  and  inference.  It  is,  perhaps,  un- 
necessary to  hint  that  a  report  loses  much 
of  its  weight  if  there  is  any  evident  want 
of  care  in  the  manner  of  stating  facts.  A 
statement  like  the  following  naturally 
provokes  suspicion  :  "  The  accused  has  no 
recollection  of  the  occurrence."  The  ques- 
tion at  once  arises  in  the  mind  of  any  one 
reading  a  statement  of  this  sort  whether 
what  is  meant  is  that  the  accused  is  so 
fatuous  as  not  to  remember,  from  one  mo- 
ment to  another,  anything  that  he  does, 
or  that  occurs  around  him,  or  whether  it 
only  means  that  the  accused  says  that 
he  has  no  recollection  of  the  occurrence. 
And  then,  in  the  latter  case,  the  further 
question  naturally  arises  whether  the  ac- 
cused says  this  spontaneously,  or  whether 
he  says  it  in  answer  to  a  leading  ques- 
tion. 

It  is,  however,  by  no  means  right  to 
suggest  to  an  insane  man  that  he  has 
no  recollection  of  acts  committed  by  him. 
Excepting  in  those  cases  where  either 
violent  delirium  or  absolute  dementia 
-  "History  of  the  Criminal  Law  of  Eu«4land." 
By  Sir  James  Fitzjames  Stephen.     Vol.  i.  p.  576. 


Processifs 


[    1006    ] 


Prognosis 


is  present,  there  is  ordinarily  very  fair 
recollection  ;  and  to  suggest  the  contrary 
is  only  to  place  the  accused  in  a  false 
position.  There  is  perhaps  only  one  more 
hint  of  importance  to  add.  It  is,  that 
there  need  be  no  undue  haste  in  coming  to 
a  conclusion,  in  cases  of  doubt  or  genuine 
difficulty.  If,  in  spite  of  every  endeavour 
to  clear  up  doubtful  points,  the  medical 
examiner  still  feels  unable  to  arrive  at  a 
decision,  his  right  course  is  to  inform 
the  Treasury  Solicitor,  and  at  the  same 
time  to  state  whether,  in  his  opinion,  a 
longer  period  of  observation  would  serve 
to  elucidate  the  matter.  A  trial  can  be 
postjjoned  when  there  is  good  and  suffi- 
cient reason  for  so  doing. 

When  the  case  ultimately  comes  into 
Court,  the  medical  examiner  must  not  for- 
get that  he  appears  there  as  a  witness  :  an 
independent  witness  whose  sole  object  is  to 
assist  the  Court  to  the  best  of  his  ability  : 
but  still,  a  witness,  who  is  expected  to 
answer  the  questions  put  to  him  in  a 
plain  and  straightforward  manner.  The 
conduct  of  the  case  rests  with  counsel, 
subject  to  the  direction  of  the  presiding 
judge  :  but  it  may  be  remembered  that 
the  two  points  that  will  arise  with  refer- 
ence to  the  mental  condition  of  the  accused 
are,  first,*  as  to  his  capacity  to  jjlead 
to  the  indictment ;  or,  secondly  ,t  as  to  his 
criminal  responsibility,  or,  in  other  words 
his  liability  to  legal  punishment. 

W.  Okange. 

PROCESSIFS  (Fr.).  Persons  labour- 
ing under  what  the  French  call  delire  de 
la  chicane  (Cullerre).  {See  Persecution, 
Mania  of.) 

PR.OGM'OSZS. — Insanity  is  a  disease 
requiring  for  its  cure,  even  under  the  most 
favourable  conditions,  a  period  not  of  days 
but  of  weeks  or  months.  Its  natui-e  in 
the  majority  of  cases  necessitates  removal 
from  home — from  home  surroundings  and 
relatives.  The  treatment  therefore  be- 
comes a  costly  matter,  and  the  friends  of 
a  patient  will  anxiously  inquire  for  the 
physician's  prognosis,  and  ask  first  whe- 
ther the  sufferer  is  likely  to  die,  then, 
whether  he  will  recover ;  thirdly,  at  what 
time  recovery  is  likely  to  take  place  ;  and 
fourthly,  what  is  the  danger  of  a  recur- 
3-ence  of  the  disorder. 

Before  examining  the  varieties  of  in- 
sanity it  may  be  well  to  consider  generally 
the  principles  on  which  our  prognosis  is 
to  be  formed. 

The  first  question  will  be  as  to  the  time 

during  which  the  mental  symptoms  have 

been  noticed,  and    the   manner  of  their 

oncoming.     If  they  have  commenced  re- 

*  See  Pjlead. 

t  See  Criminal  Eespoxsibility. 


cently,  have  developed  rapidly,  and  are 
acute  in  character,  the  prognosis  will  be 
favourable.  But  if,  on  the  other  hand,  the 
commencement  is  uncertain,  and  they  have 
gradually  and  insidiously  shown  them- 
selves so  that  the  friends  cannot  fix  the 
beginning,  but  think  the  patient  has  been 
changed  during  the  last  year  or  two, 
then  will  the  prognosis  be  gloomy,  espe- 
cially if  the  bodily  health  be  but  little 
disturbed. 

In  the  second  place,  the  age  of  the 
patient  must  be  taken  into  consideration. 
The  young  recover  in  larger  proportion 
than  the  old,  especially  females.  At 
Bethlem  Hospital  there  were  admitted  in 
sixteen  years  933  patients  of  both  sexes 
below  the  age  of  twenty-five.  Of  these  595 
recovered,  being  a  percentage  of  63.7.  In 
the  same  number  of  years  there  were  ad- 
mitted 1872  patients  between  the  age  of 
twenty-five  and  forty,  of  whom  968  re- 
covered, a  percentage  of  51.7,  while  of  the 
whole  number  admitted  the  percentage  of 
recoveries  was  only  50.4.  Those  under  the 
age  of  twenty-five  have  a  comparative 
immunity  from  the  dire  disease,  general 
paralysis,  which  destroys  so  many  between 
the  age  of  twenty-five  and  fifty :  and  this 
may  account  for  some  of  the  difference, 
though  not  all,  because  at  Bethlem  gene- 
ral paralytic  patients  are  not,  or  were  not, 
admitted  as  at  other  asylums.  From  an 
acute  attack  of  insanity,  if  it  be  the  first, 
the  young  generally  recover,  unless  it  be 
complicated  by  some  other  disease,  as  epi- 
lepsy or  phthisis.  If  it  is  a  second  attack, 
recovery  is  more  doubtful,  and  so  in  each 
recurrence  the  prognosis  becomes  less  and 
less  favourable,  especially  if  the  intervals 
are  shorter  and  recovery  less  complete. 

lu  the  third  place,  the  insanity  of  the 
young  is  largely  due  to  hereditary  trans- 
mission. How  is  the  prognosis  affected 
by  this  ?  It  is  a  popular  idea  that  a  pa- 
tient will  not  recover  if  the  malady  is 
inherited.  It  is  clear  that  boys  or  girls 
under  twenty  cannot  have  brought  about 
their  insanity  by  the  cares  and  worry  of 
life,  by  anxieties  about  money,  or  excess 
in  drinking.  They  have  become  insane 
because  they  have  derived  from  their 
fathers  and  mothers  an  unstable  neurotic 
constitution  prone  to  disturbance  even 
from  a  very  slight  cause.  But  the  figures 
given  above  show  that  recoveries  take 
place  in  large  projjortion,  so  that  the 
prognosis  amongst  the  young  is  favour- 
able. It  may  be  that  being  so  unstable  by 
nature,  they  are  often  thrown  off  their 
balance  by  something  which  is  but  a  slight 
and  passing  cause,  and  the  equilibrium 
so  easily  disturbed  is  easOy  regained,  and 
they  recover,  probably  to  be  again  upset 


Prognosis 


[     J007     ] 


Prognosis 


by  something  equally  trivial.  Much 
may  be  gaiued  by  a  knowledge  of  the 
family  history,  for  families  in  which  in- 
sanity exists  vary  greatly  in  their  average 
standard  of  health,  and  a  member  of  one 
may  be  more  likely  to  recover  than  a 
member  of  another  more  degenerate  race. 
We  see  families  in  which,  it  is  true,  in- 
sanity has  attacked  certain  members,  yet 
the  others  are  healthy  and  sti'ong,  men- 
tally and  bodily,  and  able  to  hold  their 
own  in  the  struggle  for  existence.  In 
another,  though  there  may  have  been  less 
actual  insanity,  yet  the  general  average 
is  of  a  low  character,  and  neurotic  dis- 
orders of  ever}'-  kind  abound — fits  in  child- 
hood or  at  puberty,  partial  imbecility, 
early  habits  of  drinking,  the  moral  in- 
sanity of  the  young,  excessive  masturba- 
tion, sleep-walking  and  the  like.  If  one  of 
these  has  an  attack  of  mania  under  the  age 
of  twenty-five,  he  either  does  not  recover, 
but  drifts  at  once  into  dementia,  or  he  re- 
covers partially,  so  as  to  be  able  to  leave 
the  asj'lum,  whither  he  returns  iu  the 
course  of  a  year  or  two,  and  remains  a 
chronic  patient  to  the  end  of  his  life, 
swelling  the  ranks  of  the  young  demented 
people  of  whom  we  see  so  large  a  number 
in  all  our  asylums. 

In  the  fourth  place,  something  may  be 
learned  by  examining  the  cause  of  the  in- 
sanity. In  many  cases  the  friends  of  a 
patient  will  plead  ignorance  of  the  cause, 
especially  when  it  is  family  taint,  but  in 
some  there  may  be  an  undoubted,  exciting 
cause,  without  which  the  disorder  would 
probably  not  have  occurred.  This  may  be 
the  loss  of  a  near  relative  or  friend,  a 
serious  reverse  of  fortune,  or  a  sudden 
shock,  fright  or  accident ;  or  it  may  be 
physical  illness,  a  bout  of  drinking,  or 
great  fatigue,  overwork  or  exhaustion,  as 
that  produced  by  over-lactation.  Wher- 
ever there  is  a  well-defined  and  appre- 
ciable cause,  and  the  insanity  follows  at 
no  great  distance  of  time,  the  prognosis 
is  good ;  so,  too,  the  prognosis  is  better 
if  the  condition  of  the  patient  is  markedly 
feeble,  and  his  strength  diminished,  than 
if  his  health  is  excellent,  his  weight  nor- 
mal, and  his  sleep  but  little  broken.  By 
judicious  medical  treatment  health  may 
return,  both  bodily  and  mental,  but  the 
prognosis  will  be  most  unfavourable  if 
we  detect  any  symptom  that  points  to  or- 
ganic brain  change.  In examiningpatients 
between  the  ages  of  twenty-five  and  fifty- 
five,  particularly  if  they  be  males,  the  doubt 
will  always  arise  as  to  whether  we  have 
before  us  a  case  of  general  paralysis  of 
the  insane.  The  onset  of  this  fatal  dis- 
ease is  so  variable  that  the  ordinary  symp- 
toms of  exaltation  may  be  wanting,  nay. 


the  disorder  may  present  all  the  appear- 
ance of  melancholia,  or  there  may  be 
excitement  and  exaltation  without  the 
physical  symj^toms  of  general  paralysis. 
In  many  cases  the  prognosis  must  be 
very  guarded,  but  where  any  physical 
symptoms  are  present,  and  where  there  is 
any  history  of  fits,  however  slight,  even 
faintings,  or  any  ataxy  or  optic  neuritis, 
the  chance  of  recovery  is  small,  though 
improvement  may  take  place.  The  pro- 
gnosis also  is  bad  if  we  detect  evidence  of 
syphilitic  brain  disease,  of  tumour  or 
sclerosis,  or  if  the  insanity  is  complicated 
by  epilepsy. 

The  prognosis  is  bad  in  all  cases  marked 
by  periodicity.  This  may  vary  from, 
alternate  days,  on  one  of  which  the  patient 
is  very  insane,  melancholic,  or  maniacal, 
while  on  the  next  he  is  comparatively 
sane,  up  to  periodical  attacks  recurring 
with  tolerable  regularity  every  two  or 
or  three  months,  or  two  or  three  years. 
In  some  cases  the  recurring  attack  is  al- 
ways of  the  same  character  and  runs  the 
same  course,  pi'esenting  the  same  delu- 
sions and  lasting  the  same  time.  In 
others  an  attack  of  mania  is  followed  after 
a  longer  or  shorter  interval  by  an  attack 
of  melancholia,  and  this  again  by  mania, 
the  regular  recurrence  constituting  what 
the  French  have  termed /oZie  circulaire. 

From  this  general  view  of  the  prognosis 
of  insanity  we  may  pass  to  the  various 
forms  of  the  disorder,  and  first  to  mania, 
or  mental  excitement,  which  I'anges  from 
slight  but  abnormal  hilarity  or  irascibility 
to  the  most  furious  delirium.  The  latter 
is  often  called  acute  mania,  but  a  better 
name  is  acute  delirious  mania,  a  grave 
form  often  fatal  to  life,  to  be  distinguished 
from  acute  mania  without  delirium,  which 
may  exist  for  a  considerable  length  of 
time  without  any  danger  to  life. 

If  we  are  called  to  a  case  of  acute  de- 
lirious mania  with  sleeplessness,  incessant 
singing  or  shouting,  restless  violence  and 
incoherent  raving,  what  must  be  observed 
in  order  to  arrive  at  an  accurate  prog- 
nosis ?  The  history  is  of  importance  :  a 
patient  is  more  likely  to  recover  in  the 
first  than  in  subsequent  attacks,  his 
chance  diminishing  with  each  successive 
invasion.  Young  people,  especially 
women,  almost  invariably  recover  from 
the  first  attack — recover  both  in  mind  and 
body.  Later,  they  may  die  in  the  acute 
stage,  or,  recovering  to  a  certain  extent, 
drift  into  a  state  of  chronic  insanity. 
When  repeated  attacks  occur,  with  no 
long  interval  of  time,  this  result  is  greatly 
to  be  feared,  especially  when  there  is  a 
history  of  marked  hereditary  taint.  Be- 
sides the  age  of  the  suiTerer  and  the  ques- 


Prognosis 


[    1008    ] 


Prognosis 


tion  of  previous  attacks,  the  cause  of  the 
acute  delirium  must  be  investigated.  It 
may  be  the  delirium  of  drink  to  which  the 
foregoing  observations  equally  apply.  In 
young  and  strong  individuals,  and  in  first 
or  second  attacks,  the  prognosis  is  favour- 
able, while  it  is  most  gloomy  in  the  old, 
or  in  men  broken  in  health,  who  have  had 
many  such  attacks  already.  The  compli- 
cations of  serious  bodily  organic  disease, 
tuberculosis,  heart  or  kidney  disease,  may 
lead  us  to  a  grave  prognosis,  while,  on  the 
other  hand,  the  delirium  which  supervenes 
not  unfrequently  in  the  course  or  during 
the  decline  of  febrile  disorders,  as  pleu- 
risy, measles,  scarlatina,  or  small-jDox, 
usuallj'  passes  away  in  a  brief  time  and 
recovery  follows. 

Turning  to  the  patient,  the  prognosis 
will  be  regulated  by  several  important 
observations.  It  is  more  favourable  in 
women  than  in  men,  and  in  persons  whose 
previous  health  has  been  strong  and 
sound.  The  mode  and  means  of  treat- 
ment will  have  much  weight  in  pronounc- 
ing a  prognosis.  There  must  be  suitable 
rooms,  airy  yet  safe,  with  the  windows 
carefully  guarded,  so  as  to  obviate  the 
necessity  of  perpetual  holding  or  me- 
chanical restraint.  Many  a  patient,  con- 
cerning whom  a  most  favourable  prog- 
nosis might  have  been  pronounced,  has 
been  sacrificed  to  the  prejudices  of  rela- 
tions, who  have  refused  the  advantages 
of  a  good  asylum,  or  grudged  the  expense 
of  proper  apartments  and  attendants. 
During  the  acute  stage  the  prognosis  will 
be  affected  (i)  by  the  amount  of  sleep  pro- 
cured. Formerly,  many  patients  died 
from  the  exhaustion  caused  by  want  of 
sleep,  but  in  these  daj'-s  there  are  so  many 
drugs  available  that  by  one  or  other  sleep 
to  some  extent  can  generally  be  produced. 
(2)  The  quantity  of  food  taken  is  an  im- 
portant consideration.  The  prognosis  is 
favourable  if  it  can  be  administered  in 
sufficient  quantity,  and  without  a  violent 
and  exhausting  struggle.  For  this  an 
adequate  staff'  of  attendants  will  be  re- 
quired. (3)  A  vei-y  high  temperature  is 
not  usually  met  with  in  acute  delirium  ; 
where  it  occurs  it  is  of  very  unfavourable 
import.  (4)  So  also  is  a  very  rapid  jiulse. 
In  times  of  great  muscular  movement  and 
excitement,  the  pulse  may  become  very 
quick,  but  in  the  intervals  of  comyjarative 
quiet  fall  again  considerably.  If  it  re- 
mains rapid  throughout,  the  symptom  is 
a  grave  one.  (5)  The  tongue  may  afford 
us  valuable  information.  Under  very 
great  excitement  and  sleeplessness  it  fre- 
quently keeps  clean  and  moist,  and  this  is 
a  good  sign.  If,  on  the  contrary,  it  be- 
comes dry  and  furred,  and  this  state  gets 


worse,  and  the  lips  and  teeth  are  covered 
with  sordes,  and  assume  a  typhoid  appear- 
ance, the  pi'ognosis  is  most  unfavourable. 
Here  inquiiy  should  be  made  as  to 
whether  opium  or  its  preparations  have 
been  administered,  as  the  dryness  may 
be  due  to  a  large  extent  to  such  medicine. 
If  all  things  are  favourable  for  treatment, 
if  the  j^atient's  health  has  previously  been 
good  and  attacks  few,  we  may  give  a 
favourable  i^rognosis,  both  as  regards  the 
danger  to  life  and  the  recovery  from  the 
mental  disorder.  But  if  attacks  recur 
with  short  intervals  and  with  increasing 
violence,  death  will  probably  ensue,  or  at 
any  rate  there  will  be  no  mental  recovery, 
and  permanent  insanity  or  dementia  will 
supervene. 

There  are  patients  whose  disorder  is 
more  fitly  termed  acute  mania — mania 
without  delirium.  There  is  here  no  im- 
mediate danger  to  life,  so  in  our  prognosis 
this  question  need  not  detain  us.  The 
sufferers  are  violent,  noisy,  often  dirty  in 
habits ;  they  sleep  but  little,  but  are 
quite  conscious,  and  know  perfectly  what 
they  are  doing.  They  may  have  many 
delusions,  or,  on  the  other  hand,  the 
mania  will  vent  itself  in  outrageous 
conduct  without  delusions ;  they  are  con- 
stantly destructive,  mischievous  and  abu- 
sive. On  what  can  we  found  a  prognosis 
in  these  cases .f'  (i)  The  first  question  is, 
how  long  has  the  attack  lasted  ?  If  it  is 
recent  and  proceeds  from  a  definite  cause, 
there  is  hope,  and  recovery  takes  place 
even  after  a  year  or  two  of  such  violence, 
(2)  The  character  of  the  mania  may  assist 
us.  If  it  is  mere  noisy  turbulent  violence, 
without  delusions,  or  with  perpetually 
changing  delusions,  the  prognosis  is  better 
than  if  there  are  strongly  fixed  delusions 
or  hallucinations.  Hallucinations  of  sight 
and  hearing,  especially  the  latter,  are 
always  grave  symptoms,  and  though  they 
do  frequently  pass  away  as  the  acute 
stage  subsides,  yet  they  are  always  to  be 
regarded  as  formidable,  and  the  pi-ognosis 
mustbeguardedin  such  cases.  (3)  We  must 
examine  the  physique  andage  ofthe  patient. 
The  young  and  strong  ma}'  have  rej^eated 
attacks  of  mania,  and  recover  on  each 
occasion.  It  is  the  form  of  insanity  which 
chiefiy  affects  the  young.  If  the  patient 
is  elderly,  the  prognosis  is  bad,  especially 
if  at  the  outset  he  is  debilitated  by  some 
bodily  disease,  or  the  effects  of  some 
former  wound  or  accident.  He  has  not  the 
strength  necessary  to  combat  the  mental 
excitement,  and  being  further  reduced  by 
the  latter  and  by  want  of  sleep,  he  will 
gradually  sink  and  die. 

Under  the  general  term  of  mania  are 
comprised    various     cases     of      insanity 


Prognosis 


[    1009    ] 


Prognosis 


marked  not  by  depression  but  by  excite- 
ment, tbough.  this  excitement  differs 
much,  ranging  from  suspicion  and  fear, 
almost  amounting  to  melancholia,  up  to 
delusions  of  grandeur  and  exaltation  of 
ideas  with  squandering  of  money,  which 
may  raise  the  suspicion  of  general  para- 
lysis. The  prognosis  in  these  cases 
appears  to  vary  according  as  they  are 
removed  from  the  melancholic  pole  and 
approach  the  paralytic.  The  patholo- 
gical condition  of  the  former  is  more 
lavourable  to  recovery  than  that  of  the 
latter.  When  we  find  a  patient  present- 
ing most  of  the  mental  symptoms  of 
general  paralysis  with  exaltation  of  ideas 
and  maniacal  conduct  in  accordance  there- 
with, we  may  be  sure  that  his  patholo- 
gical condition  is  not  far  removed  from 
that  of  the  graver  malady,  and  if  speedy 
amendment  does  not  take  place  under 
treatment,  this  condition  may  become 
chronic,  and  the  brain  will  remain  per- 
manently damaged.  Such  ai'e  to  be  found 
in  every  asylum.  They  fancy  themselves 
dukes  or  kings,  millionaires,  inventors. 
They  are  the  class  who  invent  fantastic 
dresses,  and  decorate  themselves  with 
trumpery  and  tinsel,  or  fill  their  pockets 
with  stones  and  call  them  diamonds. 
They  never  recover. 

Passing  to  the  varieties  of  melancholia 
or  mental  depression,  we  meet  with  one 
which,  like  acute  delirious  mania,  is 
dangerous  to  life,  and  may  indeed  be 
fitly  termed  acute  delirious  melan- 
cholia. We  see  not  the  dull  gloom  or 
stupor  of  oi'dinary  melancholia,  but 
frenzied  and  panic-stricken  violence,  the 
patient  resisting  everything  and  every- 
body, trying  to  escape  from  imaginary 
enemies  by  door  or  window,  thinking  he  is 
going  to  be  burned  by  fire  in  the  house  or 
the  fires  of  hell,  intensely  suicidal,  refus- 
ing all  food,  trying  to  stx'ij)  of  all  clothing, 
resisting,  in  fact,  everything  that  those 
about  him  wish  him  to  do.  Here,  so  far 
as  prognosis  is  concerned,  almost  the  con- 
verse of  all  that  was  said  with  regard  to 
acute  delirious  mania  holds  true,  and  the 
prognosis  is  most  unfavourable.  The 
sufferers  are  not  the  young  and  strong, 
but  the  old  and  debilitated  in  health.  As 
they  will  take  no  food,  and  much  is  required, 
there  is  a  constant  and  exhausting 
struggle  to  administer  it.  There  is  a 
struggle,  too,  to  dress  them,  and  they  will 
not  lie  down  or  remain  in  bed  unless 
fastened,  so  that  their  failing  strength 
becomes  more  and  more  exhausted,  and 
the  feeble  power  of  life  does  not  derive 
adequate  nutriment  and  new  nerve-force 
from  the  food  that  is  given.  Sleep,  more- 
over, is  entirely  absent.     The  melancholia 


of  such  patients  is  often  the  outcome  of 
bodily  disease,  of  phthisis,  pleurisy,  or 
heart  or  kidney  disease,  the  latter  being 
frequently  masked  by  the  acute  mental 
symptoms.  A  very  short  period  of  treat- 
ment will  materially  assist  our  prognosis. 
If  it  be  properly  carried  out,  we  ought,  in 
a  few  days  to  notice  an  improvement,  the 
frenzy  will  be  less,  the  patient  more  in- 
clined to  sit  or  lie  down,  food  will  be  taken 
with  less  resistance  and  the  aspect  will 
improve.  If  there  is  no  improvement  in 
a  short  time,  death  from  exhaustion 
quickly  follows,  and  in  fact  the  mental  con- 
dition often  appears  to  be  one  stage  in  the 
process  of  dying.  If  the  patient  does  not 
die  but  the  acute  state  passes  away,  then 
we  have  to  deal  with  a  case  of  ordinary 
melancholia,  and  there  is  no  reason  why 
recovery  should  not  take  place.  For  this 
nervous  depression  is  a  pathological  con- 
dition, yet  one  which  does  not  greatly 
affect  the  organic  life  and  structure  of  the 
brain.  It  is  the  expression  of  a  defect  of 
nerve  force,  an  insufficient  genesis,  where- 
by the  individual's  whole  nervous  enei'gy 
is  lessened,  and  so  there  are  produced  dull 
and  gloomy  feelings  which  in  turn  give 
rise  to  dull  and  gloomy  ideas.  Something 
of  the  same  kind  constantly  occurs  in  per- 
sons who  are  not  insane,  but  are  over- 
worked or  overworried  and  get  no  sleep  or 
rest.  Melancholia  then  is  the  smallest 
departure  from  the  normal  state,  and  the 
one  most  likely  to  pass  away.  Many,  in- 
deed, suff"er  periodically  from  low  spirits 
often  for  a  considerable  time,  months  or 
even  years,  yet  when  the  fit  passes  away, 
they  are  as  they  were  before  it.  The 
brain  does  not  appear  to  sufiier  any  per- 
manent damage  from  the  insufficient 
supply  of  nerve  energy,  and  so  it  is  that 
melancholia  may  last  even  for  many 
years,  and  then  the  patient  recovers  and 
returns  to  perfect  health,  good  spirits  and 
sanity.  It  follows  that  the  prognosis  in 
melancholia  is  good ;  especially  so  is  it 
in  cases  of  so-called  simple  melancholia 
marked  by  depression  only,  and  inability 
to  follow  an  occupation  or  take  pleasure 
in  anything,  yet  without  delusions  of  any 
kind.  Hundreds  of  these  patients  recover 
without  coming  to  an  asylum  or  even  to 
a  doctor.  Such  attacks  return  again 
and  again,  often  with  regular  jieriodicity, 
passing  away  with  but  little  treatment. 
As  the  depression  deepens,  delusions  of 
many  kinds  appear,  or  a  strong  suicidal 
tendency,  but  even  here  the  prognosis, 
though  graver,  is  not  necessarily  hope- 
less, and  most  of  the  lamentable  suicides 
recorded  in  the  newspapers  are  committed 
by  persons  who  might  have  been  cured  if 
placed  under  proper  treatment. 


Prognosis 


[       lOIO      ] 


Prognosis 


The  conditions  unfavourable  to  recovery 
from  melancbolia  ai-e  chiefly  those  which 
indicate  an  enfeebled  state  of  the  bodily 
health.  For  this  reason  hypochondriacal 
melancholia  is  unfavourable ;  and  those 
persons  are  less  likely  to  recover  whose 
symptoms  are  of  a  hypochondriacal  nature, 
having  delusions  that  the  bowels  never 
act,  that  their  inside  is  gone,  and  delusions 
about  various  parts  of  the  body,  impotence 
and  the  like :  moreover,  the  class  of  melan- 
choliacs  who,  having  been  hypochondriacal 
for  years,  have  drifted  from  ordinary  hypo- 
chondriasis to  insane  melancholia,  rarely 
recover  from  the  latter  development. 

All  hallucinations  of  the  senses  are  un- 
favourable in  melancholia  as  in  all  non- 
acute  insanity;  so  is  a  long-continued 
suicidal  tendency,  a  symptom  very  likely 
to  recur  even  when  apparent  convalescence 
has  taken  place.  Long  and  persistent 
refusal  of  food  with  delusions  that  it  is 
poisoned  is  a  bad  sign,  and  so  is  picking 
of  the  face  and  hands,  though  the  writer 
has  known  one  lady,  in  whose  case  this 
was  a  marked  symptom,  recover  after 
seven  years.  It  is  a  popular  idea  that 
religious  melancholia  is  unfavourable. 
This  is  not  correct.  The  particular  cha- 
racter of  the  delusion  depends  on  the 
bent  of  the  patient's  mind.  The  clergy- 
man thinks  he  is  to  be  eternally  lost ;  the 
city  man  thinks  that  his  business  is 
ruined,  that  his  family  are  going  to  the 
workhouse  and  he  to  prison.  But  both 
recover,  things  being  equal,  the  one  as 
quickly  as  the  other. 

In  pronouncing  a  prognosis  concerning 
male  patients  between  the  age  of  twenty- 
five  and  fifty-five,  whether  the  insanity 
presents  the  symptoms  of  mania  or  me- 
lancholia, we  must  always  bear  in  mind, 
if  we  see  them  in  an  early  stage,  that  the 
disorder  may  turn  out  to  be  general  para- 
lysis. It  is  often  preceded  by  melancholic 
ideas,  and  these  may  last  for  a  consider- 
able time,  and  be  looked  upon  as  an 
attack  of  melancholia.  They  may  pass 
away  in  due  course,  and  perfect  recovery 
apparently  ensue,  to  be  followed  at  a  later 
date  by  maniacal  excitement  and  all  the 
usual  train  of  exalted  delusions.  It  is 
most  difficult  to  diagnose  some  cases 
of  general  paralysis  in  the  initial  stage, 
and  it  is  as  well  to  guard  one's  prognosis 
in  this  direction. 

We  may  also  be  deceived  by  recurring 
attacks.  A  patient  is  suffering  from  me- 
lancholia which  progresses  satisfactorily 
and  recovery  ensues  after  a  hopeful  and 
gradual  amendment ;  but  in  no  long  time 
it  is  followed  by  symptoms  of  excitement 
and  a  violent  attack  of  mania  has  to  be 
treated,  to  be  followed  again  by  recovery. 


Then,  after  a  longer  or  shorter  time,  the 
melancholia  again  makes  its  appearance, 
and  this  cycle  goes  on  frequently  through 
life  in  ever  recurring  sequence.  When 
this  sequence  is  once  established  the 
prognosis  is  most  unfavourable. 

Passing  from  states  of  mental  excite- 
ment or  depression,  we  come  to  those  of 
mental  weakness  or  dementia.  This  may 
be  either  primary  or  secondary,  the  latter 
being  the  sequel  of  other  forms  of  insanity 
or  of  organic  disease  of  the  brain,  or  epi- 
leptic or  apoplectic  seizures. 

Primary  dementia  may  be  divided  into 
the  acute  and  the  chronic,  the  former 
being  curable,  the  latter  not.  Acute  'pri- 
mary dementia,  is  a  variety  of  insanity 
which  occurs  in  young  persons,  and, 
although  it  is  very  acute  and  requires 
much  care  and  skilled  treatment,  it  gene- 
rally terminates  in  recovery.  Such  pa- 
tients appear  utterly  lost  and  demented : 
they  will  not  converse,  but  sit  in  motion- 
less stupor,  or  wag  their  heads,  or  snap 
their  jaws  in  some  silly  automatic  fashion, 
stopping  perhaps  if  sharply  spoken  to 
and  then  commencing  again.  They  re- 
quire to  be  fed,  washed,  and  dressed, 
like  young  children  ;  they  can  do  nothing 
for  themselves.  The  circulation  is  very 
feeble,  and  the  hands  are  blue  with  cold, 
even  in  the  hottest  weather.  Nothing 
can  look  more  utterly  unpromising  and 
hopeless  than  the  condition  of  these  pa- 
tients, yet  the  prognosis  is  good,  and  as  a 
rule  they  recover.  We  may  entertain 
good  hope  if  they  are  young,  for  the 
curable  form  of  dementia  generally  attacks 
those  at  the  ages  of  puberty  or  adolescence 
between  thirteen  and  twenty-five  years. 
In  the  writer's  experience,  this  form  only 
occurs  in  patients  between  these  ages. 
The  prognosis  is  good  if  the  onset  is 
recent,  and  the  sufferer  is  at  once  sub- 
jected to  appropriate  treatment.  When 
recovery  takes  place,  if  we  question  the 
patient,  and  he  remembers  anything  of 
the  early  part  of  the  attack,  we  generally 
find  that  there  have  been  no  strictly 
melancholic  ideas  or  feelings  at  any  stage 
of  the  disorder.  This  form  generally  has 
its  origin  in  some  fright  or  shock,  and  the 
prognosis  is  favourable  if  we  can  trace  it 
to  some  known  and  adequate  cause. 

Primary  dementia  in  people  moi*e  ad- 
vanced in  life  is  of  very  different  omen, 
and  most  unfavourable  is  the  pi'ognosis. 
It  may  come  on  very  suddenly,  the  chief 
symptom  being  a  marked  and  rapidly 
increasing  loss  of  memory.  This  may 
show  itself  without  any  other  mental 
symptoms,  but,  if  severe  and  growing 
quickly,  it  renders  a  patient  at  once  unfit 
for  the  ordinary  affairs  of  life.     The  cause 


Prognosis 


[     ion     ] 


Prognosis 


in  a  great  numbei-  of  instances,  especially 
in   women,    is   alcohol.     Women   do   not 
exhibit  delirium  tremens  as  men  do,  and 
the    secret    tipplers — and   these    are   the 
majority — do  not  drink  enough  at  a  time 
to  produce  it,  but  the  common  result  of 
their  drinking  is  this  loss  of  memory,  and 
with  it,  frequently,  a  certain  amount  of 
paralysis  of  arms  and  legs.     Total  absti- 
nence   sometimes,   though    rarely,   cures 
these  patients  in  a  marvellous  and  un- 
expected manner;    both  the  mental  and 
bodily   symptoms    disappear,    to   return, 
unfortunately,  in   the    majority  of  cases 
when  the  woman  returns  to  her  evil  habit. 
Our  prognosis  that  she  will  do  this,  if  she 
has  the  chance,  is  about  the  most  certain 
that  we  can  jDronounce.     The  prognosis 
as  to  recovery  at  all  is,  as  a  rule,  very 
unfavourable.      The    memory    once    lost 
rarely  returns,  whatever  may  be  the  cause 
of    its    impairment.      Primary   dementia 
comes  on  very  frequently  after  epileptic 
attacks  when  the  latter  are  numerous  and 
frequent.     Everything   here  will   depend 
on  the  frequency.     If  they  are  infrequent, 
and  only  occur  one  at  a  time,  the  mental 
disturbance  may  be  very  slight  and  com- 
pletely jjass  away  before  the  next  seizure. 
If  frequent,  the  mind  will  become  more 
and  more  obscured    and  demented,  and 
here,  too,  the  loss  of  memory  will  be  very 
noticeable.    Inasmuch  as  chronic  epilepsy 
in  adults  is  a  most  intractable  disorder,  it 
follows  that  the  prognosis  is  necessarily 
bad.     Primary  dementia  is  also  found  in 
connection  with  syphilis,  and  here  also  the 
jsrognosis  is  bad,  for  with  the  most  anti- 
syphilitic  treatment  the  result  is  seldom 
favourable  when  the  disease  has  advanced 
to   the   extent    of    destroying   the  mind. 
Apoplectic  effusions,  tumours,  and  soften- 
ing  may  all   equally  produce   dementia, 
and  are  all  of  evil  omen.     Besides  this, 
we  find  senile  dementia,  the  childishness 
and  loss  of  memory  of  old  age,  a  natural 
decay  of  brain  power,  of  which  there  is  no 
cure.     Sometimes,  too,  we  meet  with   a 
similar  dementia  coming  on,  apparently 
without  cause,  in  persons  who  are  not  in 
advanced  age,  but  of  sixty  years  or  so. 
This  is  a  premature  old  age,  occun-ing  in 
minds  which  have  never  been  strong,  and 
without  work    or  worry  are  nevertheless 
worn    out   before   their   time.      It    need 
hardly  be  said  that  hope  of  cure  there  is 
none. 

Secondary  dementia  may  follow  at- 
tacks of  acute  delirium  where  the  latter 
has  lasted  long ;  if  convalescence  is  re- 
tarded, and  great  exhaustion  has  super- 
vened, a  demented  condition  may  be  the 
result,  and  may  continue  for  some  time, 
gradually   passing   away  with   returning 


health,    and    requiring    probably  change 
of  air  and  scene.     The   prognosis  is  not 
unfavourable  if  the  individual  is  young, 
and  has   not  had   any  or   many  previous 
attacks.     The  converse  is   unfavourable, 
especially   where   there   is    a   history   of 
strong  hereditary  taint.     We  may  hope 
for   recovei'y  if  there   is  progressive  im- 
provement, however  slow,  but  if  months 
go  on,  and  the  patient  does  not  wake  up, 
or  improves  up    to  a  certain  point   and 
then  stops,  remaining  weak-minded  and 
vacuous,  content  to  remain  in  an  asylum 
without  wishing  to  leave,  and  indifferent 
as  to  his  future,  the  worst  is  to  be  feared. 
There  is  a  form  of  dementia  not  uncom- 
mon amongst  young  people,  the  course  of 
which  is  after  this  fashion.     In  the  be- 
ginning there  occurs  a  somewhat  sudden 
attack   of   mania.     It   runs  an   ordinary 
course,    being     possibly    somewhat    pro- 
tracted ;  recovery  then  takes  place,  though 
it  may  not  be  quite  so  perfect  as  one  could 
wish.     After  a  year  or  two  of  convales- 
cence, more  or  less  satisfactory,  another 
attack  of  acute   insanity   comes   on,  and 
when  the  patient  emerges  from  it,  he  does 
not   go   forward   to  recovery,  but    slides 
gradually  into   a    chi-onic  and  incurable 
condition  of  dementia.     This  is  the  his- 
tory of  a  number  of  the  young  demented 
patients,  especially  males,  to  be  found  in 
every  asylum.     They  all  have  a  bad  here- 
ditary history  and    all  masturbate,  men 
and  women.     The  friends  try  to  lay  the 
insanity  to  this  cause  and  urge  its  preven- 
tion.    But  prevention   of  the  habit  does 
not  cure  such  persons ;  the  prognosis  in 
every  such  case  is  of  the  most  gloomy 
character.        This     secondary     dementia 
rarely  follows  melancholia  for  the  reasons 
already   stated.     Melancholia  may   exist 
for    a    long   time,    nay,   indeed,   become 
chronic,  but  the  mental  faculties  are  re- 
tained, and  if  the  sufferer  can  be  diverted 
from  his  gloom   and  self-absorption,  and 
induced   to  turn    his   thoughts   to   some 
other  subject  and  converse  thereon,  it  will 
be  found  that  his  memory  is  as  good  as 
ever,  that  nothing  has  escaped  his  obser- 
vation, and  that  his  criticism  of  what  goes 
on  around  him  is  wonderfully  keen. 

If  we  apply  to  the  various  clinical  in- 
sanities the  principles  laid  down  at  the 
commencement,  we  see  why  the  prognosis 
in  each  is  good  or  bad.  For  example,  in 
puerperal  insanity  the  prognosis  is 
highly  favourable.  Clouston  states  that 
out  of  60  cases  45  recovered,  a  proportion 
of  75  per  cent.  Bevan  Lewis'  record  of 
recoveries  reaches  80  per  cent.  Here  we 
have  an  acute  disorder  occurring  for  the 
most  pai"t  in  young  women,  due  to  a  defi- 
nite cause  and  coming  on  rapidly.     Even 

3  T 


Progressive  Paralysis        [    1012    ] 


Pseudosmia 


here  the  prognosis  will  be  affected  by  the 
age  of  the  patient,  and  will  be  less  favour- 
able when  it  is  over  thirty,  and  there  have 
been  former  attacks.  Heredity  bears  a 
large  part  in  the  causation,  yet  even  with 
this  inherited  predisposition  75  to  80 
jjer  cent,  recover.  So,  too,  the  prognosis 
in  the  insanity  of  pregrnancy  is  good 
though  not  so  good  as  in  the  last.  We 
find  here  a  well-defined  cause  producing 
melancholia,  which,  like  most  melancholia, 
passes  away  with  time  and  treatment.  In 
the  insanity  of  lactation  the  strength  is 
exhausted,  and  the  weakened  brain  upset, 
the  attack  ranging  from  simple  melan- 
cholia to  acute  delirium.  The  prognosis 
will  depend  somewhat  on  the  rapidity  of 
the  onset,  cases  which  come  on  slowly  and 
gradually  after  a  long  period  of  suckling 
being  less  Ukely  to  recover.  The  recovery 
rate  according  to  Clouston  is  even  higher 
than  in  puerperal  insanity,  being  77.5  per 
cent.  Bevan  Lewis,  however,  gives  it  as 
only  65.6  per  cent.  In  alcoholic  insanity 
the  prognosis  is  good  or  bad  according  as 
the  drinking  has  been  prolonged  and 
chronic  or  not.  The  young  man  who  has 
had  few  or  no  previous  attacks  recovers 
from  his  delirium.  For  the  old  tippler, 
male  or  female,  there  is  but  little  hope. 
In  phthisical  insanity  the  prognosis  is 
bad,  the  brain  disturbance  being  compli- 
cated by  severe  bodily  disease.  So,  too,  is 
the  insanity  of  epilepsy.  The  melan- 
cholia of  the  climacteric  is  for  the  most 
part  a  curable  complaint,  unless  the  bodily 
strength  is  too  far  reduced.  It  is  a  ques- 
tion whether  any  insanity  merits  to  be 
classed  as  uterine  or  ovarian.  But  the 
prognosis  in  what  is  so  called  must  be 
based  on  the  principles  already  laid  down. 
It  should  never  be  forgotten  that  in  a 
vast  majority  of  recent  cases  of  insanity 
a  favourable  prognosis  must  depend  upon 
treatment  being  early.  Statistics  from 
every  source  prove  that  on  early  treat- 
ment depends  recovery,  and  perfect  re- 
covery. The  poor  are  far  better  off  in  this 
respect  than  the  rich.  The  latter  will 
avoid  proper  treatment  as  long  as  possible : 
hence  the  records  of  private  asylums  can- 
not show  the  percentage  of  recoveries  to 
which  the  physicians  of  our  public  asylums 
can  point.  This  is  a  fact  strongly  to  be 
impressed  upon  the  friends  of  every  insane 
patient.  G.  Fielding  Blandford. 

PROCRESSXVZ:  PARAI.YSIS.      {See 

General  Paralysis.) 

PSEIiAFHESXS,  PSEX.ii.PHXA  {yj/rjXa- 
(jxioi,  I  grope  or  feel).  A  feeling  or  search- 
ing about  with  the  fingers,  as  in  delirium. 
(Fr.  pselaphese ;  Ger.  Toucliiren.) 

PSEUSA.CUSXS    (^//•euS)7S•,    false ;    aKorj, 

SL  sound  or  noise).    False  or  deceptive  hear- 


ing. Hallucination  or  illusion  of  hearing. 
(Ger.  Gehurstauscluing .) 

PSEUD2:STHESXS  (\j/(v8^s,  false ; 
a.'^(T^r|a■ls,  feeling).  False  or  deceptive 
feeling.  Imaginary  sense  of  touch  in 
organs  long  removed,  as  after  amputa- 
tion. (Fr.  pseudaesthesie  ;  Ger.  Gefiihls- 
tduschung.) 

PSEui>APHXA  {\l/-ev8r]s,  false;  d(l)T], 
touch).     The  same  as  pseudaesthesis. 

PSEVX>OBI.EPSXS  {-^ev^s,  false  ;  /3Xe- 
•^is,  a  beholding).  Hallucination  or  illu- 
sion of  vision.  (Fr.  i:)seudQhlei^sie  ;  Ger. 
Falschselien.) 

PSEVDOCHROIVX2:STHESXA(A//^6vd>7f, 
false;  ;(pa)/xa,  colour ;  ato-^j^o-if,  sensation). 
Anomaly  in  the  perception  of  visual  sen- 
sations, in  which  the  vowels  in  words 
appear  coloured,  each  having  a  different 
tint.  Their  combination  gives  to  each 
word  a  particular  colour  depending  on  the 
arrangement  of  the  vowels  in  the  word. 
Sometimes  the  word  is  seen  black  as  usual, 
but  soon  this  perception  revives  the  idea 
of  a  colour  such  as  red  for  a,  rose  for  e, 
white  for  ?",  &e.  The  memory  of,  or  the 
hearing,  the  word  revives  the  idea  of  its 
colour,  independent  of  any  visual  sensa- 
tion cause  by  the  objective  presentation. 
(Littre). 

PSEUDOCHROivilA —  False  percep- 
tion of  colour. 

PSEUSOGEUSXA,      PSEXTBO- 

GEUSTXA  {rp-€v8r]s,  false ;  yfV(TLs,  taste). 
A  false  perception  of  taste.  Taste  hallu- 
cination. 

PSEUDO-KYPERTROPHXC     PARA- 

liYSXS.  —  This  disease  is  occasionally 
associated  with  imbecility,  according  to 
Duchenne. 

PSEUX>OMAN'XA  (•v//'euS?7y,  false;  fiavia, 
madness).  A  state  of  mind  in  which  a 
person  accuses  himself  of  crimes  of  which 
he  is  innocent.  It  is  often  connected  with 
habitual  lying  or  inordinate  vanity. 

PSEUBOMlf ESXA  {yj/'evd^s,  false ; 
jjLvrjo-is,  memory).  An  affection  of  memory 
observed  in  some  mental  conditions  in 
which  a  person  believes  he  remembers  facts 
that  never  existed. 

PSEVDONARCOTXSM  (\//evS)7f,  false  ; 
vapKooi,  I  stupefy).  A  nervous  condition, 
having  somewhat  the  appearance  of 
narcotism,  sometimes  met  with  at  the 
menstrual  periods  and  at  the  menopaase. 
Hysterical  narcotism. 

PSEVBOXrOMANXA  i\l/-ev8r]s  ;  fxav'ia). 
A  morbid  propensity  for  lying.  A  form 
of  moral  insanity. 

PSEUBOPSXA  (i/revSijs ;  af^,  the  eye, 
sight).  False  vision.  Visual  haUuciua- 
tion  or  illusion. 

PSEUBOSIVIXA  {y\revbrjs,  false;  ocr/iij, 
odour).     A  false  or  exaggerated  sense  of 


Psychagogia 


[     IOJ3     ] 


Psyehogenesis 


smell.  (Fr.  pseuclosmie ;  Ger.  Geruchstau- 
schding.) 

PSYCHAGOGIA  {^vxr],  the  mind  ; 
<'iy<o,  I  lead).  Mental  excitement  pro- 
duced by  certain  impi-essions.  (Fr,  and 
Ger.  j),s//(7/  ri r/(  k/  ic . ) 

PSYCHAGOGICA  ('^vx'j,  the  mind ; 
/lyo),  I  lead).  Medicines  which  restore  con- 
sciousness or  restore  the  mind,  as  in  syn- 
cope. (Fr.  ])S!/cluujogiqiie ;  Ger.  psijclut- 
gogii^rli.) 

PSYCHAIiGZA  (\|/'uxj;,  the  mind;  ctXyos, 
pain).  A  name  devised  for  melancholia 
owing  to  its  supposed  analogy  to  neural- 
gia.    Literally  mental  pain. 

PSYCHE  i'^vxi],  the  breath ;  the  mind 
or  soul  as  usually  understood ;  a  but- 
terfly, on  account  of  its  transformation 
from  the  caterpillar,  becomes  an  image 
of  the  soul.).  At  a  later  period  of 
antiquity  it  was  used  to  personify  the 
soul  of  man.  See  the  beautiful  myth 
related  by  Apuleius.  Her  beauty  ex- 
cited the  envy  of  Venus,  who  ordered 
Amor  to  inspire  Psyche  with  love  for  a 
contemptible  man.  The  sequel  is  well 
known.  Eventually  she  overcame  the 
jealousy  of  the  goddess,  and  having  be- 
come immortal,  was  united  with  Amor  for 
ever. 

PSYCHEZSIVX  i^l^vxri,  the  mind).  An- 
other term  for  the  somnolent  condition 
induced  by  manipulation,  &c.,  called 
animal  magnetism  or  mesmerism. 

PSYCHEN-TOM-XA  {^vxv,  the  mind; 
4vTov'ia,  tension).  Mental  over-exertion. 
(Fr.  psgchentonie.) 

PSYCHIATER  i^^xi],  the  mind ; 
larpos,  a  physician).  A  mental  physician. 
The  Medico-psychological  Association  of 
Great  Britain  and  Ireland  adopts  for  its 
motto,  yl^vx^is  tarpos-. 

PSYCHIATREIA,  PSYCHIATRIA 
{^vxr],  the  soul ;  larpeia,  healing).  The 
treatment  of  mental  diseases,  (Fr,  psy- 
chiatrie ;  Ger.  Seelenheilkimde.) 

PSYCHIATRZE  (Ger.).  Psychological 
Medicine. 

PSYCHIC  FORCE. — A  supposed 
"force"  to  which  the  phenomena  of 
spiritualism  were  assigned  by  Mr.  Crookes, 
F.R.S.,  in  1871. 

PSYCHIC  PARAXYSZS.  —  A  para- 
lysis such  as  hysterical  hemiplegia,  where 
no  organic  central  lesion  is  known  to  be 
the  cause  of  the  paresis. 

PSYCHICAI..  Of  or  belonging  to 
the  mind ;  P.  blindness,  mind  or  soul- 
blindness  ;  P.  deafness,  word-deafness. 

PSYCHICAI.  EXAI.TATIOTI-.  {See 
Exaltation',  Mkntal). 

PSYCHICAI.  REMEBIES.— The  em- 
ployment of  the  mind  and  its  faculties  in 
the  treatment  of  bodily  disease.     Psycho- 


therapeutics,    (*S'ee  Hypnotism  and  Sug- 
gestion.) 

PSYCHICAI.  RESEARCH, 
SOCIETY  FOR.— The  object  of  this 
Society  is  to  investigate  in  a  systematic 
manner  that  large  group  of  debatable 
phenomena  designated  by  such  terms  as 
mesmeric,  psychical,  and  spiritualistic. 
It  is  thought  that  amidst  much  illusion 
and  deception,  an  important  body  of  re- 
markable phenomena,  which  are  primd 
facie  inexplicable  on  any  generally  recog- 
nised hypothesis,  would  be,  if  incontesta- 
bly  established,  of  the  highest  possible 
value.  It  includes  an  examination  of 
the  nature  and  extent  of  any  influence 
which  may  be  exerted  by  one  mind  upon 
another,  apart  from  any  generally  recog- 
nised mode  or  perception.  It  is  the  aim 
of  the  Society  to  approach  these  various 
problems  without  prejudice  or  preposses- 
sion of  any  kind,  and  in  the  same  spirit 
of  exact  and  unimpassioned  inquiry  which 
has  enabled  science  to  solve  so  many  pro- 
blems, once  not  less  obscure,  nor  less  hotly 
debated  (Proceedings  of  the  Society,  vol,  i. 
p.  3).  Among  the  prominent  members 
(past  or  present)  of  the  Society  are.  Prof. 
Sidgwick,  the  late  Prof.  Balfour  Stewart, 
the  late  Prof.  Adams,  Lord  Rayleigh, 
Mr,  Arthur,  J.  Balfour,  Prof.  Alex. 
Macalister,  Mr,  Alfred  Russel  Wallace, 
Prof.  Barrett,  Prof.  Oliver  Lodge,  Dr. 
Lockhart  Robertson,  Prof,  Oh.  Richet, 
the  late  Mr.  Edmund  Gurney,  and  Dr. 
A.  T.  Myers.  Hon.  Secretaries,  Mr,  F.  W. 
H,  Myers,  and  Mr,  Frank  Podmore,  As- 
sistant Secretary,  E,  T,  Bennett,  19 
Buckingham  Street,  Adelphi,  W.C, 

PSYCHI.AIVIPSIA  or  PSYCX.AIVIP- 
SIA  (yf/^vx^i,  the  mind  ;  eKX(ip,Trw,  1  shine), 
A  name  for  mania,  proposed  by  Olouston 
to  show  the  analogy  between  it  and  chorea 
or  eclampsia.  He  calls  it  a  mental  chorea 
or  eclampsia. 

PSYCHOCOMA  (V'vx'?.  the  mind; 
Kcbfia,  deep  sleep).  Mental  stupor.  (See 
Stupor,  Mental.) 

PSYCHODOIWETER  (xp-vxij,  mind ; 
686s,  a  way;  pirpov,  a  measure).  An  in- 
strument for  measuring  the  rapidity  of 
psychic  events. 

PSYCHOGEM-ESis.— The  law  of  psy- 
ehogenesis is  the  elimination  of  the  incon- 
gruous in  mental  development  and  pro- 
gress. It  is  the  assimilation  or  incorpora- 
tion of  life  with  life.  It  is  a  common 
principle  which  sweeps  through  the  whole 
range  of  mental  evolution,  alike  in  the 
individual  and  the  race.  It  applies  to 
the  simpler  inferences  of  perceptual  ex- 
perience, and  to  the  more  complex  judg- 
ment in  matters  intellectual,  gesthetic  and 
moral  (Prof.  Lloyd  Morgan). 


Psychokinesia 


[    1014    ]    Psyeho-phiysical  Methods 


PSYCHOKIM'ESXA  {-^vxv,  mind; 
Kivea,  I  move).  Defective  inhibition  ;  im- 
pulsive insanity. 

PSYCHOI.OCY  ii^vxTJ,  the  soul;  Xoyoy, 
a  description).  Science  of  mind.  (Fr. 
psifchoJogie  ;  Ger.  Psychologie.) 

PSYCHOMETRY  (irvx^,  the  mind; 
fierpov,  measure).  The  measurement  of 
sense-relations  of  mental  phenomena. 

PSYCHOMOTOR  (yf^vxn,  the  mind  ; 
moveo,  I  move).  Term  applied  to  cortical 
centres, supposed  to  cause  voluntary  move- 
ments, but  now  rarely  employed. 

PSYCHOM-EUROSES  Hrvxr],  the  mind; 
vevpov,  a  nerve).     Mental  diseases. 

PSYCHOITEVROSIS,  VASOMOTOR. 
— A  special  form  of  insanity  described  by 
Reich  as  occurring  in  a  child  whose 
mother  had  been  frightened  during  preg- 
nancy. 

PSYCHOiroSEIVIA  (irvxrj,  the  mind  ; 
voarjfia,  a  disease).  Mental  disease.  (Fr. 
psychonoshne ;  Ger.  SeelenJcranl-heit.) 

PSYCHOM-OSOI.OGY  (\//ux'?',  the  mind; 
voaos,  disease  ;  Xdyos,  a  description).  The 
doctrine  of  mental  diseases.  (Fr.  ^3S//- 
chonosologie ;  Ger.  die  Lehre  von  den  See- 
lenhranJcheiten.) 

PSYCHOPAM-N-YCHZA  (^/'l'X'/.  the 
mind;  Travvvxi-os,  all  night  long).  The 
repose  or  sleep  of  the  soul  after  the  death 
of  the  body.  {¥y.  lisycJiopannycliie;  Ger. 
Seelenschlaf.) 

PSYCHOPARESIS  (^vxn,  the  mind; 
Trdpeais,  weakness).     Mental  enfeeblement. 

PSYCHOPATHZST. — A  mental  phy- 
sician ;  an  alienist. 

PSYCHO  -  PATHOIiOGY.— (Forensic) 
Science  which  treats  of  the  legal  aspect  of 
insanity,  i.e.,  the  rights  and  responsibili- 
ties of  lunatics. 

PSYCHOPATHY  {-^vxt],  the  mind; 
TTcidos,  a  disease),  l^lental  disease.  (L. 
Tsycliopathia  ;  Fr.  psycJiopathie ;  Ger. 
GeinilthskranJiheit.) 

PSYCHOPHYSZC  I.A'W'. — The  law  ex- 
pressing the  relation  between  a  change  of 
intensity  in  the  stimulus,  and  the  result- 
ing change  in  the  sensation. 

PSYCHOPHYSZCAXi  ACTZVZTY. — 
The  activity  of  a  hypothetical  substratum 
which  fills  up  the  time  between  stimulus 
and  apperception.  It  is  a  variety  of 
j: sycho-physical  movement  {q-v.). 

PSYCHO-PHYSZCAIi  METHODS.— 
Z.  The  following  suggestions  are  made 
with  a  view  of  getting  data  beyond  those 
which  are  strictly  necessary  for  diagnosis, 
since  such  data  would  be  extremely  valu- 
able, both  from  the  psychological  stand- 
point and  as  a  basis  for  determining  the 
function  of  diseased  parts,  should  the  case 
come  to  autopsy. 

The  above  title  is  emj^loyed  in  a,  general 


as  well  as  a  special  sense.  In  the  latter, 
it  is  intended  to  supplement  the  article  on 
Reaction-Time  by  Professor  Jastrow,  by 
detailing  the  particular  methods  employed 
at  the  present  time  in  the  investigation  of 
time  relations  of  mental  phenomena,  &c. 

How  to  Observe. — Patients  should  be 
away  from  all  distractions,  in  a  room 
apart  and  at  ease — as  a  rule,  either  sitting 
or  lying  down,  and  with  the  mind  placid, 
a  condition  which  of  course  is  difl&cult  to 
secure  in  a  large  number  of  mental  cases. 
Experiments  should  rarely  last  an  hour,  as 
the  attention  is  easily  fatigued.  Suc- 
cessive observations  should  be  made  at 
the  same  time  of  day.  For  experiments 
not  involving  the  eyes,  it  is  best  to  have 
the  patient  thoroughly  blindfolded. 

Records. — May  be  written,  or  (in  some 
cases,  e.g.,  areas  of  anaesthesia)  delineated 
on  an  outline  of  the  body,  such  as  may  be 
copied  from  any  work  on  anatomy. 

In  progressive  disease,  a  careful  study 
of  one  patient  has  more  value  than  a  casual 
study  of  several. 

Beginning  with  tbe  Skin  Sensations. 
— Is  the  sense  of  contact  anywhere  ab- 
sent? Where  .'^  If  present,  test  "dis- 
criminative sensibility"  with  compasses. 
(For  a  table  of  normal  discriminations  in 
various  regions  see  Foster's  "  Text-book  of 
Physiology"  under  "  Tactile  Sensations.") 
Compasses  should  be  made  of  a  substance 
non-conductive  of  heat,  and  slightly 
blunted  at  the  points,  like  the  rounded 
end  of  a  small  needle.  The  best  form  is 
that  whei'e  one  point  is  fixed  and  the  other 
slides  along  an  arm  (at  right  angles  to 
the  first  point)  on  which  a  scale  is  marked 
so  that  the  distance  between  the  points  is 
easily  read  off.  (See  "^sthesiometer,"'  by 
J.  Jastrow,  Ai)ierican  Journal  of  PsycliO' 
logy,  vol.  i.  p.  552.) 

Sense  of  Xiocality. — The  patient  to 
touch  a  spot  on  his  body  which  the  ob- 
server is  touching  or  has  touched. 

Temperature-sense.  —  Discrimination 
of  differences.  Two  objects — preferably 
thermometers  with  large  bulbs — the  tem- 
jjerature  of  which  is  known,  are  applied 
successively  to  the  same  spot  on  the  body, 
and  the  patient  required  to  distinguish 
between  them. 

Sensibility  to  Heat  and  Cold. — Test 
by  applying  metal  points  suitably  warmed 
or  cooled.  If  these  sensations  are  dull, 
the  area  stimulated  must  often  be  large, 
a  square  inch  or  more,  to  get  any  reaction 
at  all.  (Refer  to  "  Eine  neue  Methode  der 
Temperatursinnprilfung,"  Dr.  A.  Gold- 
scheider,  Arcliiv  fio-  Psycliiafrie  und 
Kerrenkranklieitcn,  Bd.xxm.Jieit  3,  1S87. 
"  Research  on  the  Temperature-sense," 
H.  H.  Donaldson,  Blind,  No.  xxxix.  1SS5.) 


Psycho-physical  Methods    [     1015     ]    Psycho-physical  Methods 


Those  cases  in  which  the  sensation  for 
one  sort  of  tomperature-stimnhis  remains 
while  that  for  the  other  is  absent,  are 
sjiecially  important. 

Motion  on  the  Skin. — By  drawing  a 
point  up  or  down  the  skin  of  a  limb,  to 
determine  whether  the  direction  can  be 
recognised.  (Refer  to  "  Motor  Sensations 
of  the  Skin,"  by  G.  Stanley  Hall  and  H.  H. 
Donaldson,  Mind,  ^o.  xl.,  1886.) 

Pressure.  —  By  placing  weights  suc- 
cessively on  the  same  spot,  the  patient  to 
detect  the  diffei'ence  between  any  pair  of 
weights.  Such  weights  can  easily  be  made 
by  loading  paper  cartridge-shells  with 
various  charges  of  shot. 

Tickling-. — It  is  specially  important  to 
determine  the  conditions  under  which  this 
disapjjears. 

Muscle -sense.  —  Discrimination  of 
weights.  Weights  to  be  lifted  and  thus 
distinguished.  Mr.  Francis  Galton  has  a 
set  of  weights  for  this  purpose.  {See  "  On 
Apparatus  for  Testing  the  Delicacy  of 
Muscular  and  other  Senses  in  Different 
Persons,"  by  Francis  Galton,  F.R.S.,  Jour, 
of  the  Anthropol.  Inst.,  May  1 883.  A  brief 
account  of  this  is  given  in  ''  A  Descrip- 
tive List  of  Anthropometric  Apparatus, 
Ac,"  published  by  the  Cambridge  Scien- 
tific Instrument  Co.,  Cambridge,  England. 
Refer  to  Weber's  Tastsinn  unci  Gemein- 
gefiild.  Miiller  und  Schermann,  "  Ueber 
die  ijsychologischen  Grundlagen  der  Ver- 
gleichung  gehobener  Gewichte,"  Pfliiger's 
Archiv,  Bd.  xlv.  1889.) 

With  paper  cartridge-shells  filled  with 
shot,  the  more  elegant  apparatus  of  Galton 
can  be  fairly  imitated. 

Position  of  loinibs. — To  imitate  with 
a  sound  limb  the  position  in  which  the 
affected  limb  is  placed,  or  the  reverse — 
eyes  closed. 

Clonus,  Knee-jerk. — {See  "The  Varia- 
tions of  the  Normal  Knee-jerk  and  their 
Kiclations  to  the  Activity  of  the  Central 
Nervous  System,''  Dr. Warren  P.Lombard, 
American  Journal  of  Fsychology,  vol.  i. 
1887.) 

Vision. — Ophthalmoscopic  data.  Pu- 
pillary reactions.  In  case  of  paral3-sis  of 
the  external  ocular  muscles,  test  the  sub- 
jective sensations  of  motion  on  attempted 
movement  of  the  paralysed  muscles. 

Field  of  vision. 

Field  for  various  colours.  For  this  some 
sort  of  perimeter  is  needed. 

Colour-blindness.  Some  system  of 
coloured  wools  is  the  simplest  device  for 
this  purpose. 

Visualisation  {ipv.),  number-forms,  &c. 
{See  "  Inquiries  into  the  Human  Faculty 
and  its  Development,"  Francis  Galton, 
F.R.S.,  3Iacmillan  &  Co.,  1883.) 


Hearing. — Limits  of  audition, by  means 
of  a  small  whistle.  (See  "  Descriptive 
List.") 

Coloured  sounds.  Associations  of  cer- 
tain colours  with  given  tones.  (Refer  to 
Zivaiigmissige  Liclitempfindungen ;  Leh- 
mann  &  Bleuler.  "  Inquiries  into  Human 
Faculty,  &c.,"  Francis  Gallon.) 

Time-sense.  —  Repetition  and  main- 
tenance of  a  given  tempo.  This  involves 
the  use  by  some  device  of  which  a  gi'aphic 
record  can  be  obtained  —  a  revolving 
drum,  for  example.  (Refer  to  a  series  of 
articles  in  Wundt's  Philos.  StiuUen,  under 
the  title  "  Zeitsinn.") 

Smell. — Its  delicacy,  by  means  of  stan- 
dai'd  solutions  of  graded  strength. 

Taste. — Test  different  portions  of  the 
tongue  for  bitter,  sweet,  acid,  and  salt. 
For  bitter  and  sweet  the  test  can  now  be 
made  with  accuracy.  {See  "  Note  on  the 
Specific  Energy  of  the  Nerves  of  Taste," 
by  W.  H.  Howell  and  J.  H.  Kastle,  Studies 
from  tlie  Biological  Laboratory  of  the  Johns 
Hophins  University,  Baltimore,  vol.  iv. 
1887.) 

Equilibrium-sense.  —  Special  suscep- 
tibility to  dizziness  on  whirling,  &c.  These 
facts  bear  on  the  functions  of  the  semi- 
circular canals.  {See  "  The  Sense  of  Dizzi- 
ness in  Deaf  Mutes,"  American  Journal  of 
Otology,  Boston,  1882,  by  W.  James.) 

Reaction-time.  —  To  get  valuable  re- 
sults, some  apparatus  is  needed.  The 
simplest  is  that  described  by  Joseph  W. 
Warren,  M.D.,  in  a  paper  "  On  the  Effect 
of  Pure  Alcohol  on  the  Reaction  Time, 
with  a  Description  of  a  New  Chronoscope," 
Journal  of  Physiology,  vol.  viii.  1887.* 

Dr.  Warren  employs  a  chronoscope 
which  he  names  the  Bowditch  Neura- 
moebinieter,  or  "  nerve-reply  measurer,"  a 
term  which  scarcely  does  it  justice,  as  its 
range  is  very  wide  (Pig.  i). 

The  apparatus  consists  of  certain  appli- 
ances, including  (i)  the  standard  tuning- 
fork  {F)  ;  (2)  the  recording  magnet  of 
Deprez  (M)  ;  (3)  the  adjustable  holder 
{H,  H').  The  following  description  is 
taken  from  Dr.  Warren's  article :  "  The 
tuning-fork  carries  on  one  arm  alittle brass 
plate  whose  edges  are  turned  up  to  hold 
a  stripof  smokedcardboard(ii5  x  28mm.), 
the  other  arm  being  balanced  by  another 
brass  plate,  which  is  held  in  place  by  a 
screw  clamp.  The  fork  is  attached  in  the 
usual  manner  to  a  wooden  carriage,  which 
slides  in  grooves  on  the  larger  base  board. 
This  board  has  an  upright  block  at  the 
end,  held  in  place  by  a  large  screw  which 
permits  some  movement  for  adjustment. 
In  the  centre  of  the  block  is  an  elliptical 

*  We  are  iudcbtecl  to  Prof.  M.  Foster  for  per- 
mission to  reproduce  Figs,  i  and  2. 


Psycho-physical  Methods    [    1016    ]    Psycho-physical  Methods 


Fui.  I. 


plug  (P)  or  spreadei",  which  can  be  set  by 
a  rod  at  the  back.  This  plug  is  so  placed 
as  to  allow  the  fork  to  be  pushed  up  to 
the  head  board  when  the  long  axis  is  per- 
pendicular. If  the  fork  be  pulled  with 
the  spreader  in  this  position,  the  record 
is  a  straight  line.  Turning  the  spreader 
through  an  angle  of  90°  forces  the  prongs 
apart,  and  the  fork  begins  to  vibrate 
when  the  pull  removes  it  from  the  plug, 
the  record  changing  from  a  straight  line 
to  an  undulating  one.  At  the  left  a  brass 
rod  runs  up  to  cany  the  adjustable  holder, 
which  in  turn  carries  the  writing  magnet. 
On  the  base  board  (7v )  is  seen  a  key  to 
which  wires  go  from  the  binding  posts, 
and  which  may  be  opened  by  the  brass 
strip  or  tongue  (T),  whose  position  on  the 
slide  can  be  varied  by  the  set-screw.  To 
ensure  a  good  electrical  contact,  the  key 
is  faced  with  platinum,  and  has  a  small 
spring  (S)  to  keep  it  open  or  shut  as  the 
case  may  be.  Evidently,  the  entire  ar- 
rangement for  mounting  and  using  the 
fork  and  magnet  is  so  simple,  that  a  very 
moderate  ability  to  use  tools  will  suffice 
for  its  construction."  Dr.  Warren  adds 
that  "the  working  of  the  instrument  is 
equally  simple.  A  card  suitably  smoked 
is  placed  upon  the  plate  as  it  stands  drawn 
away  from  the  magnet.  The  key  (K)  is 
opened,  and  the  plug  (P)  turned  so  as  to 
have  its  long  axis  perpendicular.  Then 
the  magnet  is  lifted  by  pressing  on  the 
spring  {H'),  and  held  while  the  fork  is 
pushed  home.  The  magnet  now  drops  on 
to  the  card  and  is  adjusted,  the  plug  is 
turned  to  spread  the  tuning-fork,  and  the 
key  is  closed.  While  the  left  hand  holds 
the  head  board,  the  right  pulls  the  fork 


which  records  its  vibrations  by  the- 
scratcher  of  the  writing  magnet,  and  also 
in  passing  opens  the  key  (K)  when  the 
tongue  (T)  reaches  it.  We  shall  have 
then  a  record  of  the  vibrations  of  the 
tuning-fork  whose  legibility  will  depend 
on  the  speed  with  which  the  fork  is 
pulled.  If  we  connect  the  wires  from  a 
battery  with  the  writing  magnet  and  the 
binding  posts  in  such  a  way  that  the  key 
will  break  its  circuit,  we  shall  be  able  ta 
indicate  the  instant  of  opening  the  key  in 
the  record ;  for  the  magnet  will  lose  its 
magnetism,  and  the  pen  will  change  its 
position,  and  this  will  caiise  a  change  of 
level  in  the  vibrations  recorded  by  the 
tuning-fork.  If,  after  a  brief  interval,  a 
current  of  electricity  should  pass  again 
through  the  magnet,  the  pen  would  re- 
tarn  to  its  former  position,  and  another 
change  of  level  in  the  recoi'd  of  vibrations 
would  occur ;  the  number  of  vibrations 
fi'om  the  beginning  of  the  first  change 
of  level  to  the  beginning  of  the  return, 
gives  us  the  tneasure  of  the  time  which 
elapsed  from  breaking  the  circuit  until 
it  was  closed  again.  In  the  apparatus 
described  a  standard  tuning-fork  (100  vi- 
brations to  the  second)  is  used.  The  load 
changes  the  rate  of  vibration  somewhat, 
and  for  exact  time-measurements,  a  com- 
parison must  be  made  with  some  other 
standard  (pendulum).  Obviously,  the 
opening  of  the  key  {K)  may  be  adapted  to 
giving  a  variety  of  signals  dependent  upon 
breaking  an  electric  curi-ent,  and  we  may 
thus  signal  to  anij  of  the  senses  of  the 
percipient,  or  stimulate  nerve  or  muscle 
directl)"-,  and  a  reply  may  be  given  by  any 
object  which  undergoes  such  changes  ou 


Psycho-physical  Methods    [     1017    ]    Psycho-physical  Methods 


account  ol"  the  stimulation  as  to  cause  an 
electric  current  to  pass  anew  through  the 
writing  magnet.  The  application  of  the 
Bowditch  Neuramoebimeter  is  thus  seen 
to  be  very  extended.  Although  this  in- 
strument is  not  quite  so  simple  as  that  of 
Exner  and  Obersteiuer,*  it  has  certain 
very  important  advantages  besides  a 
greater  variety  in  its  applications." 

Many  details  in  regard  to  the  practical 
working  of  the  apparatus  employed  by 
Dr.  Warren  in  connection  with  the  gal- 
vanic battery  t  are  not  necessary  for  our 
present  purpose,  but  the  diagram  below 
(Fig.  2)  shows  the  arrangement  of  the 
apparatus. 


The  primary  factors  of  all  chronoscopes 
are  signal  and  reaction.  The  particular 
mode  of  registering  the  period  of  time 
which  has  elapsed  between  these  two  re- 
corded factors  has  been  variously  carried 
out  by  different  observers.  Hence  chrono- 
graphs have  been   adopted  according  to 

*  "  Ueber  eine  neue  einfache  Methode  zur  Bes- 
tinunung  der  psj'chischen  LeistuiiusfUhii^kcit  des 
(iehimcs  Gcisteskranken,"  Arcliiv fin- patliol.  Aitat. 
1874,  lix.  427.  S.  Exner  has  coutiiljuted  '■  Experi- 
mentelle  Untersuchuii!^-  der  einfachstenpsycliiscben 
J'rocessc,"  V&ugiir'i  Arcliiv  /.  d.  ges.  I'hysiol.,  vii. 
601.  E.  Kraepelin  has  contributed  "  Ueber  die 
Eiiiwirkuny  einiger  uiedicamenttiser  StolTe  auf  die 
DaiuT  eiufacher  psychischen  Vorj;auge";  Zweite 
Abtheilunif,  "  Ueber  die  Einwirkuny  von  iEthyl- 
alkohol,"  Wundt's  Philos.  Stiidien,  Bd.  i.  573. 

t  The  time  which  elapses  between  the  stimula- 
tion of  one  or  two  Jin^ers  of  the  left  hand  by  an 
induction  shock, and  the  closing  of  a  simple  key  by 
the  right  hand  which  rests  upon  it,  is  recorded  on  a 
card. 


preference.     By    some   Marey's    Chrono- 
graph* is  preferred. 

The  nature  of  the  mental  process  in- 
volved in  experiments  in  reaction-time 
has  given  rise  to  much  difference  of 
opinion.  Professor  James  has  always 
maintained  that  the  opinion  originally 
held  by  Wundt  is  not  tenable.  Wundt 
distinguished  "  between  two  stages  in  the 
conscious  reception  of  an  impression, 
calling  one  i^ercejjtion,  and  the  other  ajj- 
percejjtion,  and  likening  the  one  to  the 
mere  entrance  of  an  object  into  the  peri- 
phery of  the  field  of  vision,  and  the  other 
to  its  coming  to  occupy  the  focus  or  point 
of  view.  Professor  James,f  on  the  con- 
trary, holds  that  inattentive  aivareness 
of  an  object  and  attention  to  it  are  equiva- 
lents for  perception  and  apperception. 
Then  there  is,  according  to  Wundt,  the 
conscious  volition  to  react,  thus  making 
three  successive  elements  in  the  psycho- 
physical process.  The  succession  of  con- 
scious feelings  during  the  stage  in  ques- 
tion, James  denies.  According  to  him, 
it  is  a  process  of  central  excitement  and 
discharge,  with  which  doubtless  some 
feeling  co-exists,  but  what  feeling  we 
cannot  tell,  because  it  is  so  fugitive.  .  .  . 
The  feeling  can  be  nothing  but  the  mere 
sense  of  a  reflex  discharge-  Tlie  rea,ction 
ivhose  titne  is  measured  is,  in  short,  a 
reflex  action  inire  and  sini^de,  and  not  a 
psycliic  act.  A  foregoing  psychic  condi- 
tion is,  it  is  true,  a  pre-requisite  for  this 

reflex   action The  tract  from  the 

sense-organ  which  receives  the  stimulus 
into  the  motor-centre  which  discharges 
the  reaction,  already  tingling  with  pre- 
monitory innervation,  is  raised  to  such  a 
pitch  of  heightened  irritability  by  the  ex- 
pectant attention,  that  the  signal  is  in- 
stantaneously sufficient  to  cause  the  over- 
flow  "  Expectant  attention  "  is  but 

the  subjective  name  for  what  objectively 
is  a  partial  stimulation  of  a  certain  path- 
way, the  pathway  from  the  centre  for  the 
signal  to  that  for  the  discharge.  J  Wundt 
has  more  recently  adopted  the  same  view 
of  the  nature  of  the  psychic  process, 
namely,  that  there  is  neither  appercep- 
tion nor  will,  but  that  they  are  merely 
brain  reflexes  due  to  prrtch'ce.§  Cattell's 
conclusions  are  in  accord  with  those  of 
Professor  James. 

The  "Hipp  Chronoscope"  is  a  some- 
what costly  instrument,  to  be  used  only 

*  i'f.  ''  La  Methode  Graphique,"  part  ii.  chap.  ii. 

t  "  The  Principles  of  Psychology."  By  William 
James,  Professor  of  Psychology  in  Harvard  Univer- 
sity.    2  vols.     London  :  Macmillan.     i8go. 

t   O])-  cif.,  vol.  i.  p.  91. 

§  "Physiol.  P.sych.,"  3rd  edition  (1887),  vol.  ii. 
p.  266.  See  also  Lange's  experiments,  I'hiloso- 
pliisclie  StuiUen,  vol.  iv.  p.  479  (1888). 


Psycho-physical  Methods    [     1018    ]    Psycho-physical  Methods 


with  great  caution.  The  conditions  at- 
tending its  use  have  been  given  by  Prof. 
J.  McK.  Cattell,  of  New  York,  in  his  ar- 
ticle "  Psychometrische  Untersuchungen," 
which  appeared  in  Wundt's  Journal, 
Philosophische  Studien,  vols.  iii.  and  iv., 
1886-87. 

Quite  recently  Prof.  Jastrow  has  stated 
that  a  large  amount  of  work  in  regard  to 
time-measurements  of  mental  processes 
has  been  done  with  the  Hipp  Chrono- 
scope.  The  objections  to  its  use  are  the 
difficulty  of  regulating  it  and  "  the  possi- 
ble sacrifice  of  accuracy  to  convenience." 
He  succeeded,  however,  after  many  trials 
in  accurately  determining  the  error  of  the 


tus  for  measuring  reaction-time  which  has 
the  merit  of  great  simplicity.  He  calls  it 
the  A-form  Chronoscope.  The  description 
which  follows  (Fig.  3)  *  is  given  by  the 
inventor  himself : — 

It  measures  the  interval  between  a 
signal  and  the  response  to  it,  by  the  space 
traversed  by  an  oscillating  pendulum 
when  measured  along  a  chord.  The  pen- 
dulum is  always  released  at  the  same 
angle  of  18°  from  the  vertical,  and  the 
graduations  are  made  on  a  chord  of  the 
arc  through  which  it  swings,  situated  at 
a  vertical  distance  of  Soo  millimetres 
from  the  point  of  suspension.  In  this 
case,  the  length  of  the  half-chord  or  of 


Fig.  3. 


instrument,  by  means  of  apparatus  con- 
structed for  the  purpose.  The  maximum 
error  during  six  months  was  .005  seconds, 
and  the  average  error  about  .002  seconds. 
He  concludes  with  stating  that  the  appa- 
ratus thus  modified  "  has  proved  itself  so 
easy  of  manipulation,  and  so  time-saving, 
that  its  use  is  confidently  recommended 
to  experimental  psychologists."* 

Mr.  Galton  has  introduced  an  appara- 
*  American  Jtnirnal  of  Pai/chokigi/,   Dec.  i8gi, 
p.  211,  art.  "Studies  from  the  Laboratory  of  Ex- 
perimental Psychology  of  the  University  of  Wis- 
consin." 


800  X  tan  1&-,  is  equal  to  259.9  milli- 
metres. The  graduations  show  the  space 
travelled  across  from  the  starting-point, 
at  the  close  of  each  hundredth  of  the  time 
required  to  perform  a  single  oscillation. 
The  places  for  the  alternate  graduations 
are  given  in  the  subjoined  table,  which  has 
been  calculated  for  the  purpose,  and  may 
be  useful  in  other  wa3's,  but  the  times  to 
which  the  entries  there  refer,  are  counted 

*  See  the  Journal  of  the  AnthropoJogical  Insti- 
tute, Aug.  1889.  Mr.  Groves,  89  Bolsovcr  Street, 
^V.,  is  the  maker,  aud  lias  supiilied  a  number  of 
instruments  to  hospital  laboratories. 


Psycho-physical  Methods    [     1019    ]    Psycho-physical  Methods 


from  the  vertical  position  of  the  pendu- 
lum, and  are  reckoned  up  to  —  50  on  the 
one  side,  and  to  +  50  on  the  other.  The 
value  of  the  decimal  is  only  apin-oximate; 
it  had,  in  many  cases,  to  be  obtained  by 
graphical  interpolation.  If  the  pendulum 
is  of  such  a  length  as  to  beat  seconds,  the 
graduations,  as  below,  will  be  for  hun- 
dredths of  a  second  ;  if  made  to  beat  Lilf- 
seconds  (which  is  the  case  in  the  instru- 
ments now  made),  the  interval  between 
each  alternate  graduation  will  stand  for  a 
hundredth  of  a  second.  The  graduations 
arenumbered  on  the  bar  of  the  instrument, 
starting  from  the  point  whence  the  pen- 
dulum is  released,  which  counts  a.s  zero. 

T=the  time  of  a  single  osdllatiou.  Angle  of 
oscillation  18^  on  cither  side  of  the  vertical. 
The  distances  are  measnred  upon  a  chord  that 
lies  800  millimetres  vertically  below  the  point 
of  suspension.  The  decimals  are  only  ap- 
proximately correct. 


T 

Distances 

T 

Distances 

from 

from 

100 

vertical. 

100 

vertical. 

0 

0 

26 

185.9 

2 

^5-7 

28 

197.0 

4 

31-3 

30 

207.4 

6 

46.8 

32 

216.2 

8 

62.2 

34 

224.8 

10 

77.6 

36 

232.7 

12 

92-3 

38 

239.8 

14 

107.0 

40 

246.4 

16 

121. 5 

I       42 

251.2 

18 

135-2 

44 

255-1 

20 

148.5 

46 

257-9 

22 

161.5 

48 

259-5 

24 

174.0 

50 

259-9 

A  pendulum  must  have  considerable 
inertia  in  order  to  keep  good  time ;  on  the 
other  hand,  it  is  impossible  to  give  a  sud- 
den check  to  the  motion  of  a  body  that 
has  considerable  inertia  without  a  serious 
jar.  Therefore  it  is  not  the  pendulum 
that  has  to  be  sudddenly  checked  in  this 
apparatus,  but  a  thread  that  is  stretched 
parallel  to  it,  by  an  elastic  band  both 
above  and  below.  As  the  pendulum 
oscillates  the  thread  swings  with  it,  and 
the  thread  passes  between  a  pair  of  light 
bars  that  lie  just  below  the  graduated 
chord,  and  are  parallel  to  it.  On  press- 
ing a  key,  these  bars  revolve  round  an 
axis  common  to  both,  through  a  little 
more  than  a  quarter  of  a  circle.  They 
thus  nip  the  thread  and  hold  it  tight, 
while  no  jar  is  communicated  to  the  pen- 
dulum. The  signal  either  for  sight  or 
for  sound  is  mechanically  effected  by  the 
detent  at  the  moment  when  it  is  pushed 
down  to  release  the  pendulum.  The  pen- 
dulum may  also  be  released,  without  giv- 


ing any  signal.  A  sound-signal  is  made 
by  releasing  the  hammer  which  strikes  the 
detent.  This  produces  the  sound-signal 
and  at  the  same  time  releases  the  pen- 
dulum. The  sight-signal  is  produced  by 
pressing  a  key  at  the  back  which  changes 
the  colour  of  the  disc  and  at  the  same 
time,  releases  the  pendulum. 

Mr.  Galton  prefers  this  instrument  to 
one  he  formerly  used,  the  action  of  which 
depends  upon  a  falling  rod. 

It  may  be  serviceable  to  state  some 
details  respecting  the  laboratory  of  psy- 
chology in  the  University  of  Pennsylvania 
where  Professor  Cattell  has  hitherto 
worked.*  Similar  apparatus  may  be  seen 
at  most  of  the  Universities  in  the  United 
States,  including  Harvard  University, 
where  Professor  James  fills  the  chair  of 
psycholog}^  and  Clark  University  where 
Dr.  Sanford  is  instructor  in  psychology. 

The  laboratory  possesses  apparatus 
which  measures  mental  times  conveniently 
and  accurately.  The  chronoscope  in  use 
is  an  improvement  on  one  described  in 
Mind  (No.  42).  The  mean  variation  of 
the  apparattts  is  now  under  one-thou- 
sandth of  a  second.  New  pieces  have 
been  made  for  the  production  of  sound, 
light,  and  electric  stimuli.  Apparatus  for 
measuring  the  rate  of  movement  and  other 
purposes  has  been  added.  The  observer 
is  placed  in  a  compartment  separated 
from  the  experimenter  and  measuring  ap- 
paratus. With  this  apparatus  researches 
are  being  carried  out  in  several  directions. 
Professor  Dolley  is  measuring  the  rate  at 
which  the  nervous  impulse  travels,  using 
two  different  methods.  In  one  series  of 
experiments  an  electrical  stimulus  is  ap- 
plied to  different  parts  of  the  body,  and 
a  reaction  is  made  either  with  the  hand 
or  foot.  The  rate  of  transmission  in  the 
motor  and  sensory  tracts  of  the  spinal 
cord  has  thus  been  determined.  In  a 
second  series  of  experiments  two  stimuli 
are  given  at  different  parts  of  the  body, 
and  the  interval  between  them  adjusted 
until  the  observer  seems  to  perceive  them 
simultaneously.  Professor  Fullerton  is 
carrying  on  a  research  to  determine  the  rate 
at  which  a  simple  sensation  fades  from 
memory.  A  stimulus  is  allowed  to  work  on 
the  sense  organ  for  one  second,  and  after  an 
interval  of  one  second,  a  stimitlus,  slightly 
diff'erentin  intensity  is  given  for  one  second, 
and  the  least  noticeable  difference  in  inten- 
sity is  determined  by  the  method  of  right 
and  wrong  cases.  The  interval  between  the 
stimuli  is  then  altered,  and  it  is  deter- ' 
mined  how  much  greater  the  difference 
between  the  stimuli  must  be  in  order  that 
*  I'rof.  Cattell  has  now  removed  to  Columbia 
College,  New  York. 


Psycho-physical  Methods 


J 


Psycho-physical  Methods 


it  may  he  noticeable.  The  rate  of  for- 
getting is  thus  measured  in  terms  of  the 
stimulus.  InteiTals  varying  from  one 
second  to  three  minutes  have  been  used. 
For  these  experiments  a  new  apparatus 
was  constructed,  and  it  was  discovered 
thatwhen  sensationsof  light  are  successive 
and  last  for  one  second, the  least  noticeable 
difference  in  intensity  is  not  about  one- 
hundreth  as  is  supposed,  but  much  the 
same  as  for  the  other  senses  under  hke 
conditions.  The  rate,  extent  and  force  of 
movement  are  the  subject  of  a  somewhat 
extended  investigation.  The  least  notice- 
able difference  in  motion  has  never  been 
studied  in  the  same  way  as  the  like 
difference  in  passive  sensation.  Yet  it 
would  seem  to  merit  such  study  even  more, 
owing  to  the  importance  and  obscurity  of 
the  *'  sense  of  effort."'  The  laboratory 
possesses  apparatus  for  studying  the  time, 
intensity  and  area  of  stimulation  needed 
to  produce  the  just  noticeable  sensation 
and  a  given  amount  of  sensation.  These 
mental  magnitudes  are  correlated  so  that 
one  may  be  treated  as  the  function  of  the 
other.  The  results  of  studying  the  rela- 
tion of  time  to  intensity  have  been  pub- 
lished in  Brain  (pt.  31 ),  it  being  found  that 
the  time  which  coloured  light  must  work 
on  the  retina  in  order  that  it  may  be  seen, 
increases  in  arithmetical  progression  as  the 
intensity  of  the  light  decreases  in  geome- 
trical progression.  The  laboratory  has  a 
valuable  collection  of  Ka^nig's  apparatus 
for  the  study  of  hearing  and  the  ele- 
ments of  music,  and  a  spectrophotometer, 
a  perimeter  and  other  pieces  for  the  study 
of  vision.* 

In  conclusion  the  writer  may  observe 
that  it  would  yield  the  best  results  if  any 
one  interested  in  work  of  this  nature 
would  settle  on  some  single  topic  and 
pursue  that  specially. 

Hexky  H.  Donaldson. 

\_References. — In'addition  to  references  given,  see 
especially  A  Laboratory  Course  in  I'hysiologicul 
I'sychology,  by  Edmund  C.  Sanford,  Ph.D.,  The 
American  Journal  of  I'sychology,  edited  by  G. 
Stanley  Hall,  April  1891,  et  avq.,  and  the  follow- 
ing literature  cited: — Dermal  sensations:  Weber, 
Tastsinn  und  GemeiniicfUhl ;  Wai;iier,  Handwor- 
terbuch  der  Physiologic,  vol.  iii.  pt.  2  ;  Funke, 
Hermann's  Haiidbuch  der  Physiologic,  vol.  iii.  pt.  2. 
Sensations  of  temperature ;  Blix,  Zeitsclirift  fiir 
Biologie,  Bd.  xx.  h.  2,  1884  ;  Goldscheider,  Neue 
Thatsachen  liber  die  Hautsinnesnerven  ;  Du  Bois- 
Keymond's  Archiv,  Supplement,  Bd.  1885,  pp.  i- 
iio  :  Fechner,  Elemente  der  Psychophysik,  vol.  ii. 
pp.  201-211.  Sensations  of  pressure :  Beaunis, 
Elements  de  phy.siologie  bumainc,  ii.  379  ;  Eulen- 

*  The  foregoing  account  is  condensed  from  a 
description  given  in  Ike  American  Journal  0/  Psij- 
chology,  April  1890.  p.  281,  under  the  beading  of 
"  Psychology  at  the  University  of  Pennsylvania." — 
LED.]. 


berg,  Berliner  klin.  'VVochen.sch.,  1869,  Xo.  44; 
Pefereiice  Handbook  of  tlie  Medical  Sciences,  vol.  i. 
p.  85  :  Aubert  and  Kammler,  Molescbott's  Unter- 
suchuugen,  v.  145  ;  Blascbko,  Zur  Lebre  von  deu 
Druckenipfindungen,  Verhandl.  d.  Berliner  Phy- 
."^iol.  Gesell.  Sitz.,  27  Miirz  1885.  Static  and 
linfiesthesic  senses :  Aubert,  PbysiologLsche,  Studien 
iiber  die  ,Orientierung  (trans,  with  comments  of 
Delage's  Etudes  Experimeutales  sur  les  illusions 
Btatitjues  et  dynamiques  de  direction,  &c.,  Tiibin- 
gen,  1888,  p.  41.  Sensation  of  rotation  and  pro- 
(/ressire  motion  :  Aubert,  trans,  above  cited  ;  Mach, 
Bewe^;ungs-Empfindungen,  Leipsic,  1875  ;  Brown, 
On  Sensations  of  Motion,  Isature,  vol.  xl.  1889, 
p.  449.  Innervation  sense:  'Wundt,  Physiologische 
Psychologic,  i.  397  ;  Sternberg,  Zur  Lebre  von  den 
Vorstellungen  iiber  .  die  Lage  unserer  Glieder  ; 
I'fliiger's  Archiv,  xxxvii.  1885,  i  :  Loeb,  ibid., 
xlvi.  1-46 ;  James,  Psychology,  ii.  516 ;  C.  L. 
Franklin,  Amer.  Jour.  Psychol.,  ii.  653  ;  Ferrier, 
Functions  of  the  Brain,  p.  382  ;  Funke,  op.  cit. 
Sensations  of  motion:  Goldscheider,  L'ntersuchun- 
gen  iiber  den  Muskclsinn  ;  Du  Bois-Eeymond's 
Archiv,  1889,  pp.  369,  540.  Sensations  of  resist- 
ance :  Goldscheider,  op.  cit.  Bilateral  asymme- 
tries of  position  and  motion:  Hall  and  Hartwell, 
Mind,  vol.  ix.  ;  Loeb,  Pfliigers  Archiv,  xli.  1887; 
ibid.  xlvi.  1890,  1-46.  Taste :  Kitfmeyer,  Gesch- 
macks])i-iifungen,  Gottingen  Diss.  1885  ;  Oehrwall, 
Untcrsuchungen  iiber  den  Gcschmackssinn,  Scan- 
diuav.  Archiv  f.  Physiol.,  Bd.  ii.  1890,  pp.  1-69,  and 
Dr.  Sanford"s  abstract  in  Zeitschrift  f.  Psych.,  Bd.  i. 
1890,  p.  141  :  Bailey  and  Kichols,  The  Delicacy  of 
the  Sense  of  Taste,  Nature,  xxxvii.  1887-8,  557  ; 
Lombroso  und  Ottolenghi,  Die  Sinne  der  Yerbre- 
cher,  Zeitsch.  f  Psych.,  Bd.  ii.  1891,  pp.  346-48  ; 
Camerer,  Die  Metbode  der  richtigen  u.  falscben 
Ffille  angcwendet  auf  den  Gcschmackssinn,  Zeitsch. 
f.  Biol.,  xxi.  570 ;  Keppler,  Das  Unterscheidungs- 
vermiiiien  des  Gescbniackssinnes  f.  Concentration.s 
differenzeu  der  schmeckbaren  Kijrper,  Pfliiger's 
Archiv  ii.  1869.  449.  Snu  It :  The  olfactometer  of 
Zwaardemakercan  be  obtained  at  Utrecht  (Mecban- 
icker  Hurting  Bank)  at  1.50  mk. :  see  his  paper. 
Die  Bestimniung  der  Geruchscharfe,  Berlin,  klin. 
"Wochensch.,  xxv.  1888,  47,  p.  950,  abst.  in  Brit. 
Med.  Journ.,  1888,  ii.  1295  :  Bailey  and  Nichols, 
The  Sense  of  Smell,  Nature,  xxxv.  1886-87,  74  ; 
Lombroso  and  Ottolenghi,  op.  cit.  ;  Du  Bois-Key- 
mond"s  Archiv,  1886,  pp.  321-57 ;  Hermann's 
Haudbuch,  iii.  i(pt.  21,  pp.  225-86.  Hearing:  For 
special  instruments  see  Hciisen,  Pbysiologie  des 
(iehiirs  ;  Hermann's  Handbuch,  iii.  (pt.  2),  pp.  119- 
120  :  Jacobson,  Du  Bois-Keymond,  ^Vrchiv,  1888, 
189;  Sturke,  AVundt's  I'hilos. -Studien,  iii.  1886, 
266:  ibid.  V.  1B89,  157:  Helmholtz,  Sensations 
of  Tone,  Eng.  trans,  by  Ellis ;  Wundt,  Phys.  Psych, 
(under  this  head  the  references  are  too  niuuerous  to 
cite)  :  see  Sauford's  second  article,  The  Amer.  Jour, 
of  Psychology,  Dec.  1891,  pp.  307-322.] 

iz.  In  the  absence  of  complicated  and 
expensive  apparatus  designed  ad  hoc,  the 
observer  may  advantageously  employ  the 
ordinary  apparatus  current  in  the  physio- 
logical laboratory — viz.,  clockwork  and 
cylinder  covered  with  smoked  paper, 
chronograph,  and  Marey's  tympana. 

(i)  The  clockirork  and  cylinder  in  ordin- 
ary physiological  use  is  the  most  expen- 
sive item  i£io  to  ^20) ;  but  it  is  the  most 
universally  useful  as  regards  all  kinds 
of  records  and  time-measurements,  and 
should  therefore  appear  as  a  matter  of 


Psycho-physical  Methods    [     103 1     ]    Psycho-physical  Methods 


course  in  the  furniture  of  a  neurological 
laboratory.  A  very  convenient  form  is 
that  in  which  the  clockwork  bears  three 
axes,  upon  any  one  of  which  the  smoked 
cylinder  is  placed,  giving  speeds  of  approxi- 
mately 270,  45,  and  7o  mm.  per  second 
(for  still  slower  records  it  is  convenient 
to  have  a  separate  clockwork  carrying  a 
cylinder  on  the  one  hour  axis  {£1  to  ^2)). 
(2)  The  cltronoijruijh.  (£2,  to  ^4)  is  re- 
quired to  control  the  rate  of  movement 
of  the  smoked  surface.  In  its  simplest 
form  it  is  a  tuning-fork  or  reed  (10  to  100 
vibrations  per  second),  marking  the  un- 
dulations against  the  smoked  surface  by 
means  of  a  light  style,  or  as  a  more  handy 
arrangement,  it  consists  of  {(i)  a  reed  with 
a  platinum  wire  dipping  in  and  out  of 
mercury,  kept  in  vibration  by  an  electro- 
magnet ;  (6)  second  electro-magnet  mark- 
ing vibrations  against  the  smoked  surface ; 
(c)  a  battery  ;  and  {d)  wires  joining  the 


The  reaction-times  given  in  the  figure 
below  are  taken  in  this  way. 

A  still  simpler  device  is  formed  by  a 
straight  slip  of  wood  or  metal  working  in 
a  vertical  plane  on  a  horizontal  axis,  and 
marking  against  the  cylinder  as  usual, 
with  stops  to  prevent  excessive  move- 
ment. This  is  easily  adapted  to  give  the 
ordinary  reaction-times  to  touch,  to  hear- 
ing, and  to  sight,  and  by  using  two  snch 
slips  side  by  side,  the  time  of  discrimina- 
tion or  that  of  volitional  choice  can  be 
determined.  Practically  it  is  most  con- 
venient to  rest  the  two  slips  across  a 
closed  india-rubber  tube  in  connection 
with  a  recording  tambour. 

Toucli. — The  observer,  blindfolded,  rests 
his  finger  on  the  lever,  and  has  to  remove 
it  in  response  to  a  tap  ;  the  interval  on 
the  smoked  surface  between  the  marks  of 
taj)  and  removal  gives  the  reaction-time. 

Hearing. — The    observer  has  to  move 


To  touch 
.14  see. 


Time  in 

J  J^ths  set- 


two  electro-magnets,  mercury  pool  and 
battery  into  one  circuit.  For  reaction 
timing  we  may  employ  the  cylinder  on 
the  quick  axis  (270  mm.  per  second),  and 
mark  time  in  hundredths  of  a  second  by 
tuning-fork  or  reed  ;  or  when  very  numer- 
ous records  are  desired  on  the  same  paper, 
it  is  sufficient  to  take  the  medium  speed 
(45  mm.  per  second)  and  mai'k  time  with 
a  reed  of  20  per  second. 

(3)  Tympana  in  the  form  of  miniature 
kettle-drums,  with  drum-heads  of  elastic 
membrane,  and  joined  by  india-rubber 
tubing,  are  useful  for  time-signalling  as 
well  as  for  other  purposes.  The  recording 
tympanum  carries  a  lever  which  marks 
against  the  smoked  surface.  Or,  if  de- 
sired, the  chronographic  signal  may  be 
employed  with  two  keys  in  its  circuit,  one 
the  question  key,  to  make  the  circuit  with 
application  of  tactile,  auditory,  or  visual 
stimulus,  the  other,  the  answer  key,  to 
indicate  sensation  by  breaking  the  circuit. 


the  lever  in  response  to  a  tap  upon  it ;  the 
interval  gives  the  time  as  before. 

Sighi. — -A  signal  fixed  to  the  lever  is 
raised  and  made  visible  by  its  movement 
(which  must  be  made  soundless) ;  the 
subject  taps  the  lever  as  soon  as  he  sees 
it;  reaction-time  marked  as  usual. 

The  following  "  directions  to  students  " 
in  use  in  the  physiological  laboratory  of 
St.  Mary's  Hospital,  will  sufficiently  ex- 
plain the  principle  upon  which  reaction- 
times  are  taken,  and  in  accordance  with 
which  the  conditions  of  response  may  be 
adjusted  to  measure  the  shortest  time  re- 
quired to  discriminate  between  two  sen- 
sations (discrimination-time  or  dilemma), 
or  the  shortest  time  required  to  choose 
between  two  volitional  acts  (volition- 
time).  In  the  first  case  the  hand  of  a 
blindfolded  person,  on  whom  the  simple 
reaction-time  to  touch  has  been  deter- 
mined to  be,  say  0.1 5  second,  is  stimulated 
on  the  little  finger  or  on  the  thumb,  with 


Psycho-physical  Methods    [     1022    ~     Psycho-physical  Methods 


tlie  undei-staiuiirg  that  only  one  of  these 
stimuli  is  to  be  signalled  ;  the  reactiou- 
time  is  now  found  to  be,  say  0.17  second, 
from  wliicli  the  conclusion  is  drawn  that 
0.02  second  was  the  discrimination-time 
— i.e.,  that  required  to  distinguish  between 
the  two  sensations.  In  the  second  case 
the  experiment  is  condncted  with  two  sig- 
nals (in  this  case  the  tympanum  method 
will  be  found  most  convenient),  on  the 
understanding  that  one  signal  is  to  be 
used  when  the  little  linger  is  touched  and 
the  other  when  the  thumb  is  touched  ;  the 
total  time,  say  0.20  second,  under  these 
conditions,  is  considered  to  be  the  sum  of 
0.15,  the  simple  reaction-time,  ^J^^ts  0.02, 
the  discrimination-time,  jjIhs  0.03,  the 
volition -time.  The  experiments  may  be 
still  further  complicated  in  a  variety  of 
ways,  to  measure  the  time  of  recognition 
of  letters,  numbers,  words,  simple  ideas, 
&c.  The  following  are  taken  from  the 
"directions  to  students"  alluded  to 
above,  and  are  carried  out  with  the  re- 
action-timer already  described,  i.e.,  a  slip 
of  wood  (or  for  discrimination  two  slips  of 
wood)  across  a  tube  attached  to  a  record- 
ing tympanum,  and  with  the  cylinder  on 
the  middle  rate  axis.  Two  persons  co- 
operate in  the  observations,  one  as  opera- 
tor and  one  as  subject. 

Measure  tlie  simple  reaction-time  tvith 
tactile,  auditory,  and  visual  sensations. 

Tactile.  —  The  subject,  blindfolded, 
places  a  finger  on  the  lever.  The  opera- 
tor taps  the  finger.  The  subject  responds 
by  pressing  the  lever  as  soon  as  he  feels 
the  tap.  The  interval  between  the  two 
marks  on  the  smoked  cylinder  gives  the 
measure  of  the  reaction-time  to  a  tactile 
stimulus. 

Auditory.  —  The  subject,  blindfolded, 
places  his  hand  ready  to  press  the  lever. 
The  operator  strikes  the  lever  so  as  to 
make  a  sharp  sound.  The  subject  re- 
sponds by  pressing  the  lever  as  soon  as  he 
hears  the  sound.    Eeaction-time  as  before. 

Visual. — (The  butt  end  of  the  lever  is 
painted  white ;  the  rest  of  the  apparatus 
and  the  movements  of  the  operator  are 
hidden  by  a  screen).  The  lever  is  de- 
pressed quickly  and  quietly.  The  subject 
responds  as  soon  as  he  sees  the  white  end 
move  down.     Reaction-time  as  before. 

Take  an  average  of  ten  observations  in 
each  case. 

Measure  the  discrimination-time.  A 
double  lever  is  now  used. 

Tactile.  —  The  subject,  blindfolded, 
places  an  index  finger  of  each  liand  on 
each  lever,  it  being  agreed  tl.at  he  is  to 
react  only  to  a  touch  on  one  side  ;  some- 
times one,  sometimes  the  other,  finger  is 
taj^ped  by  the  operator.     Take  the  average 


of  ten  responses  made  in  succession  with- 
out mistake. 

Auditory. — A  single  lever  is  struck, 
now  with  a  small  bell,  now  with  a  bit  of 
wood.  The  subject,  blindfolded,  has  to 
answer  only  to  one  or  other  of  these  two 
sounds.     Take  average  as  before. 

Visual. — (The  butt  ends  of  the  two 
levers  are  painted  of  different  colours.) 
The  subject  has  to  signal  the  movement  of 
one  or  other  of  them  as  agreed  upon. 
Average  as  before. 

The  result  =  simple  reaction-time 
-i-  discrimination-time. 

Measure  tlie  volition-ti'ine. 

Repeat  the  previous  series  of  observa- 
tions, but  with  the  understanding  that 
the  left  hand  is  to  be  used  to  signal  touch, 
sound  or  sight  in  connection  with  the  left 
hand  lever,  and  the  right  hand  for  differ- 
ing stimuli  of  these  three  kinds  in  con- 
nection with  the  right-hand  lever.  Aver- 
ages to  be  taken  as  before. 

The  result  =  simple  reaction-time 
+  discrimination-time 
+  choice  or  volition-time. 

In  connection  with  these  observations 
of  reaction-times  (which  presumably  are 
cerebral)  measure  the  lost  time  of  a  true 
refiex  act  (which  is  presumably  bulbar)  as 
follows : — 

Fix  a  fine  thread  to  one  of  your  eyelids 
and  to  the  lever  of  a  bell  crank  myograph. 

From  the  secondary  coil  take  a  wire  to 
a  large  electrode  fixed  to  any  convenient 
part  of  the  body,  and  for  the  second  elec- 
trode take  a  silver  chloride  silver  wire 
covered  with  chamois  leather  and  mois- 
tened with  salt  solution. 

Use  the  cylinder  on  the  quickest  axis, 
or  else  use  a  shooting  myograph,  placing 
the  trigger  key  in  the  primary  circuit. 

Press  the  silver  electrode  against  the 
conjunctiva  of  the  lower  lid  ;  select  by  trial 
a  suitable  strength  of  shock  ;  see  that  the 
thread  from  the  upper  eyelid  is  kept  tight, 
and  that  the  trigger  key  is  shut ;  let  off 
the  apparatus,  and  measure  the  interval 
between  the  moment  when  the  conjunc- 
tiva is  stimulated  and  the  moment  when 
the  upper  eyelid  moves.  You  will  find  it 
to  be  about  five-hundredths  of  a  second. 
A.  D.  Waller. 

zzz.  The  instrument  chosen  for  the  in- 
quiries carried  on  at  the  Wakefield  Asylum 
was  one  of  a  series  of  anthropometric  appa- 
ratus made  by  the  Cambridge  Scientific  In- 
strument Co.,  and  designed  by  Mr.  Francis 
Galton,  with  certain  modifications  intro- 
duced by  the  writer.  "We  have  found  it 
to  be  a  most  valuable,  simple,  and  exact 
instrument,  well  adapted  for  the  purpose 
in  view. 

The  instrument  consists  of  a  solid,  up- 


Psycho -physical  Methods          1023    ]    Psycho-physical  Methods 


right,  square  standard  of  pitch  pine  about 
5ft.  loin.  iu  height,  supported  on  a  firm  tri- 
pod of  the  same  material,  fitted  with  level- 
ling screws.  Tothesummit  of  this  standard 
is  adapted  a  simjile  arrangement  for  the 
suspension  and  release  of  a  graduated  rod 
which  should  hang  from  this  support  iu  a 
perfectl}'^  vertical  jiosition,  and  uotiu  con- 
tact with  any  of  the  other  fittings  of  the 
instrument.  This  position  of  the  rod  is 
readily  secured  by  the  levelling  screws  of 
the  tripod.  Astride  the  rod  at  its  upper 
end  is  a  brass  weight,  which  descends  a 
certain  distance  with  the  falling  rod.  A 
little  more  than  half  way  down  the 
standard,  a  rectangular  piece  of  teak*  is 
screwed  verticall}-.  and  at  right  angles  to 
its  long  axis,  supporting  a  small  electro- 
magnet, to  which  is  adapted  (as  an  arma- 
ture) a  spring  stirrup  which  clamps  the 
falling  rod  on  the  breaking  of  an  electric 
circuit.  The  further  end  of  this  cross 
piece  supports  a  horizontal  slab  or  table 
on  which  rests  the  hand  of  the  person  to 
be  tested. 

For  a  sound  sig;nal  the  metal  weight 
astride  the  rod  is  caught  by  a  teak  dia- 
phragm projecting  from  the  standard  after 
a  definite  descent  of  the  rod ;  or,  if  an 
electric  signal  lie  required,  an  arrangement 
is  adapted  to  this  diaphragm,  whereby  an 
electric  circuit  is  broken  by  the  impact  of 
the  weight. 

The  rod  itself  is  concealed  from  the  sub- 
ject to  be  tested  by  a  projecting  ledge  of 
pine  wood,  which  lies  parallel  with  it  and 
betwixt  it  and  the  subject  ;  and  to  this 
ledge  is  fitted,  at  a  convenient  height  for 
the  eye,  a  brass  plate  with  a  small  slit  or 
window.  A  lengthened  slit  in  the  rod 
corresponds  to  this  window  in  its  position 
of  x"est;  but,  as  the  rod  falls,  the  window 
is  shut  olF,  and  a  sight  signal  thus  given. 
The  window  in  the  brass  plate  can  be  ad- 
justed vertically. 

The  rod  hangs  free  within  the  stirrup 
clamp,  which,  being  attached  by  a  hori- 
zontal spiral  spring,  effects  on  the  release 
of  the  stirrup  the  clamping  of  the  rod. 
The  base  of  the  stirrup  is  kept  fixed  as  an 
armature  to  the  electro-magnet,  either  by 
the  induced  magnetism  of  an  electric  cur- 
rent, or  by  the  simple  arrangement  of  a 
cord  attaching  it  to  a  bell-crank  lever, 
whose  vertical  arm  is  fixed  by  a  steel 
spring  placed  below  it.  If  this  latter 
arrangement  be  adopted,  pressure  on  the 
hori^iontal  arm  of  the  lever  releases  it 
from  the  spring,  and  the  stirrup  clamp 
closes  upon  the  rod.  It  need  scarcely  be 
added  that  this  mechanical  arrangement 
should  be  discarded  whenever  an  electric 
circuit  is  available.  It  will  be  useful  to 
-  Jliihouauy  or  teak. 


describe  more  particularly  the  rod  and  its 

release,  the  s^ignalUng,  the  chunp. 

The  Rod. — This  consists  of  a  strip  of 
box-wood*  about  three  feet  in  length, 
graduated  along  its  edge  in  hundredths 
of  a  second  up  to  thirty  divisions ;  hence, 
it  fails  to  register  a  longer  interval  than 
three-tenths  of  a  second.  This  limitation 
in  the  measurable  period  was  a  serious 
defect,  which  has  been  completely  reme- 
died by  a  modified  arrangement  whereby 
the  period  may  be  extended  indefinitely. 
It  is  unnecessary  to  detail  here  the  author's 
new  arrangement,  since  the  results  given 
{see  Reactiox-time)  were  chiefly  obtained 
by  the  shorter  registiy  of  the  older  in- 
strument. In  the  original  instrument  the 
rod  was  suspended  by  a  horizontal  bar, 
which,  on  the  turning  of  a  milled  head  by 
an  assistant,  swung  round  and  released 
the  rod.  An  appreciable  click  was  often 
thus  induced  lyreccdiwi  the  true  sound 
signal.  To  obviate  this  the  writer  has 
substituted  a  straight  bar  electro-magnet, 
and  the  rod  susjjended  therefrom  was  re- 
leased, on  breaking  the  electric  cii'cuit, 
with  absolute  silence.  The  button  for 
breaking  the  circuit  was  placed  on  the 
top  edge  of  the  teak  cross-piece,  so  that 
the  operator  could,  whilst  seated  in  front 
of  the  instrument,  start  the  rod  and  read 
off  the  register  without  the  assistant's 
aid. 

The  Signal. — For  a  sound  signal  we 
have  attached  to  the  upper  end  of  the 
standard  an  electric  bell  which  rings  when 
the  weight  falls  on  the  diaphragm. 

For  a  siglit  signal  we  have  added  a 
small  brass  table  supporting  a  candle 
shaded  from  draught,  which  slides  into  a 
slot  in  the  standard,  and  can  be  drawn 
out  immediately  opposite  the  small  window 
already  indicated.  The  light  can  be  ad- 
justed vertically  by  a  screw.  We  have 
found  this  arrangement  essential  for 
securing  a  fairly  uniform  intensity  of 
stimulus. 

The  Clamp. — The  stirrup,  as  before 
stated,  is  held  in  position  by  an  electro- 
magnet, which  in  our  instrument  will, 
with  a  single  Bunsen  cell,  support  a 
weight  of  over  3I  lbs.  The  circuit  for 
clamjiing  the  rod  passes  to  a  small  con- 
tact-breaker on  the  teak  table.  So  that 
the  dejiression  of  a  button  here  effects 
the  clamping  of  the  falling  rod,  whilst 
the  mechanical  arrangement  of  bell-crank 
lever  may  be  utilised  with  advantage  for 
drawing  the  armature  back  into  contact. 

The  steel  base  of  the  stirrup  is  fitted 
with  rubber  where  it  comes  sharply  into 
contact  with  the  rod.     This  rubber  is  apt 

*  Either  box-  or  liiucuwoLitl  luiiy  bu  utilised  for 
this  purpose. 


Psycho-physical  Movement    [    1024    ] 


Psycho-physics 


to  loosen,  and  is  best  secured  by  two  stout 
ligatures.  The  hempen  cord  securing 
the  base  of  the  stirrup  to  the  bell-crank 
lever  should  also  be  replaced  by  strong 
catgut.  The  most  essential  features  to 
be  secured  in  the  use  of  this  instrument 
are  its  solidity,  steadiness,  simplicity  of 
arrangement,  good  levelling  adjustments, 
the  silent  release  of  the  rod,  uniformity  in 
the  intensity  of  the  stimulus,  secure 
clamping  of  rod,  arrangement  for  check- 
ing momentum  and  rebound  of  rod. 

The  Test.  —  The  individual  to  be  ex- 
amined sits  with  his  hand  comfortably 
resting  on  the  small  tea-k  slab,  the  fore- 
linger  gently  applied  to  the  button,  the 
depression  of  which  breaks  the  circuit  to 
the  electro-magnet.  The  operator  sits  in 
front  of  the  instrument,  and  reads  off 
from  time  to  time  the  extent  of  fall  of  the 
rod.  An  assistant,  if  jjreferred,  stands 
behind  the  instrument,  and,  pressing  upon 
the  button  fixed  betwixt  the  two  binding 
screws  (on  the  top  edge  of  the  teak  cross- 
piece),  breaks  contact,  and  releases  the 
rod  attached  to  the  upper  electro-magnet ; 
and,  after  the  fall  of  the  rod,  he  releases  it 
again  by  drawing  back  the  stirrup  arma- 
ture, and  suspends  the  rod  in  its  former 
position  on  the  magnet.  Oi-,  if  the  old 
arrangement  be  preferred,  the  assistant 
stands  behind  and  suspends  or  releases 
the  rod  from  the  horizontal  bar  by  turn- 
ing the  milled-head  screw  to  the  right  or 
left  respectively. 

In  the  test  for  an  acou>itic  stimulus  the 
individual  with  his  forefinger  resting  on 
the  button  is  told  to  listen  for  the  signal 
and  depress  the  key  as  quickJij  as  jjossihie 
when  he  hears  it.  In  the  test  for  optical 
stimuli  the  candle-flame  is  brought  on  a 
level  with  the  small  slit  in  the  brass  plate. 
With  his  finger  still  on  the  button,  he  is 
directed  to  keep  his  eye  fixed  upon  the 
light,  and  instantly  depress  the  button 
when  the  light  disappears.  The  upper 
edge  of  the  stirrup  armature  is  exactly 
opposite  the  zero  line  of  the  rod,  at  the 
moment  when  the  sound  and  sight  signals 
are  given,  so  that  the  further  fall  of  the 
rod  is  read  off  in  hundredths  of  a  second 
at  the  time  when  it  is  clamped  by  the 
stirrup.*  {See  Reaction-time  in  Cer- 
tain Forms  of  Insanity.) 

W.  Bevan  Lewis. 

PSYCHO-PHYSXCAI.  MOVEMEM-T. 

— The  movement  of  either  an  impondei'- 
able  or  ponderable  agent,  upon  which  all 
psychical  processes  are  supposed  to  depend. 

*  The  Cambridge  Instrument  Company  inform 
tlie  Editor  tbat  since  tliey  supplied  Dr.  Ucvan 
Lewis  witli  the  instrument  he  has  described,  tliey 
have  made  some  imi)rovements,  but  their  new  ap- 
paratus is  the  same  in  principle. 


Fechner  postulates  a  ponderable  substance 
as  the  medium  of  psychical  phenomen.a. 

PSYCHO-PHYSZCAIi  TIME.  —  This 
expression  is  used  in  psychometry  for 
the  time  occupied  during  the  fourth  of 
Exner's  seven  processes,  which  occupy 
Reaction-time  (q.v.).  Reaction-time  is  the 
interval  between  the  instant  when  the 
external  stimulus  begins  to  acton  the  end- 
organ  of  sense  and  the  resulting  move- 
ment of  some  member  of  the  body ;  the 
fourth  process,  or  psycho- physical  time,  is 
the  time  occupied  in  transmission  of  the 
sensory  excitation  into  the  motor  impulse 
in  the  brain.  This  time  is  further  sub- 
divided into  three  parts,  occupied  by  three 
processes,  as  follows :  (a)  Perception 
simple.  This  is  the  mere  perception  that 
the  subject  is  in  some  way  affected ; 
(b)  Apperception  or  discernment-time, 
which,  as  the  name  implies,  is  the  time 
occupied  in  clearly  discerning  the  nature 
of  the  affection  ;  (r)  Will-time — the  time 
occupied  in  deciding  on  the  motor  impulse. 
Either  of  these  times  can  be  reduced  by 
experiment.  The  measurement  of  psycho- 
physical time  is  obtained  by  directly  find- 
ing the  whole  reaction-time,  then  measur- 
ing the  time  exclusive  of  psycho-physical 
time  and  finding  the  difference.  {See  Re- 
action-time.) 

PSYCHO  -PHYSICS. — Experimental 
psychology.  Fechner  divides  it  into  outer 
and  inner  psychophysics ;  the  former 
{aussere  Psychophysilc)  comprising  sti- 
mulus and  apperception ;  and  the  latter 
{innere  Psychophysik)  including  the  pro- 
cess which  intervenes  between  stimulus 
and  apperception ;  it  connotes  mental 
function. 

Psycho  -  physical  Laivs. — Under  the 
heading  of  "  Psycho-Physical  Methods  " 
a  jjractical  account  of  these  methods  is 
given,  and  to  this  article  the  reader  is 
referred  for  a  description  of  the  instru- 
ments employed.  Theory  and  practice 
go  hand  in  hand  together,  and  the  results 
must  be  ultilised  in  the  direction  of  for- 
mulating general  laa^s  with  regard  to 
sensibility.  Researches  are  directed  to, 
(i)  absolute,  and  (3)  comparative  sensi- 
bility. Of  the  former,  the  sense  of  touch 
has  been  the  most  thoroughly  investigated, 
little  having  been  done  with  regard  to  the 
other  senses.  The  latter  (2),  however, 
has  been  much  more  the  object  of  psycho- 
physical research,  and  observers  have  been 
able  to  arrive  at  general  conclusions  and 
to  formulate  certain  laws.  The  first 
general  law  with  regard  to  comparative 
sensibility  was  pronounced  by  Weber,  and, 
although  it  has  been  expressed  in  differ- 
ent manners  and  has  often  been  modified, 
and  although  it  has  been  contradicted,  it 


Psycho-physics 


L 


] 


Psychosis 


■has  nevertheless  proved  to  hold  good  in 
all  cases. 

Weber's  law  is  this :  The  sense-impres- 
sions produced  by  two  pairs  of  stimuli 
remain  the  same,  provided  that  the  dif- 
ference in  each  of  the  two  sets  increases 
ov  decreases  iu  the  same  proportion.  For 
example,  the  difference  between  a  stimulus 
which  may  be  expressed  by  loo  and  iu- 
■creases  by  i ,  and  between  another  stimulus 
which  may  be  expressed  by  200  and  in- 
<;reases  by  2,  or  is  expressed  by  400  and 
increases  by  4,  would  be  perceived  as  oue 
and  the  same  sense-impi-ession. 

On  this  law  has  been  based  the  science 
of  psycho-physics,  on  which  we  have  the 
greatest  authority  in  Fechner,  who  by  his 
methods  of  arranging  psycho-physical 
experiments  and  of  utilising  their  results, 
has  proved  Weber's  law  to  hold  good 
for  all  kinds  of  sensibility.  Fechner's 
methods*  are:  (i)  Methode  der  eben 
merklichen  Unterschiede ;  (2)  Methode 
der  richtigen  und  falschen  Fiille ;  (3)  Me- 
thode der  mittleren  Fehler. 

(i)  The  method  of  ascertaining  dif- 
ferences of  sensation  which  are  just  dis- 
tinguishable.—  This  may  be  done — e.g., 
by  comparing  the  difference  between  two 
weights ;  if  the  difference  is  great,  it  is 
easily  distinguished ;  but  if  it  is  not  great 
enough,  it  will  barely  be  distinguished,  or 
even  not  at  all.  The  method  consists  in 
finding  that  difference  which  just  becomes 
appreciable,  and  this  difference  is  recipro- 
cal to  the  sensibility — i.e.,  if  the  appreci- 
able difference  is  great,  the  sensibility  is 
small,  and  vice  versa, 

(2)  Method  of  right  and  wrong  cases, — 
It  consists  in  testing  the  sensibility — e.g., 
by  weights  or  light,  constantly  varying 
the  amount  of  the  former  and  the  inten- 
sity of  the  latter.  Cases  in  which  the 
difference  is  correctly  appreciated  are 
called  "  right "'  cases  ;  those  in  which  it  is 
not  recognised  or  appreciated  are  called 
"wrong  cases."  From  these  results  is 
ascertained  the  mean  difference,  which,  as 
before,  is  reciprocal  to  the  sensibility. 
This  method  yields  very  good  results,  but 
a  very  great  number  of  observations  must 
be  made. 

(3)  Method  of  ascertaining  the  mean 
error. — It  consists — e.g.,  in  trying  to  find 
from  a  number  of  weights  one  which  is 
equal  to  a  given  weight  previously  deter- 
mined, or  to  draw  a  line  equal  to  a  given 
line.  The  difference  between  the  actual 
weight   or    line,   and    those    erroneously 

*  The  term  "  methods  "  is  iiseil  in  two  senses ; 
first,  in  re^^iird  to  the  practical  means  adopted  as 
regards  apparatns,  &c.  ;  secondly,  the  princijjles 
accordin'4  to  which  certain  experiments  shouhl  hi; 
conducted,  and  the  rcsnlts  utilised. 


chosen  or  di-awn  by  the  person  making 
the  experiment,  as  being  equal  to  the 
former,  serves  to  determine  the  mean 
error,  which  again  is  reciprocal  to  the 
sensibility. 

Each  one  of  these  three  methods  may 
be  applied  to  all  spheres  of  sensibility,  but 
it  must  be  understood  that  one  method 
is  more  suitable  for  one  kind,  another  for 
another  kind  of  sense-organ. 

We  refer  the  i-eader  to  Fechner's  "  Eie- 
mente  der  Psychophysik,"  1889,  and 
Wundt's  "  Grundzilge  der  Physiologischen 
Psychologie"  (trans,  into  French,  1 886),  and 
to  a  treatise  by  Dr.  Georg  Elias  Miiller, 
of  Gottingen,  in  the  "  Bibliothek  fiir  Wis- 
senschaftundLitteratur  "  (vol.  xxiii.),  en- 
titled "  Kritische  Beitriige  zur  Gruudle- 
guug  der  Psychophysik.'' 

PSVCKORHYTHM  (^//•ux7(  the  mind  ; 
pvdjios,  a  measured  movement).  Alter- 
nating  mental    conditions.      {See   Folie 

CiRCULAIllE.) 

PSVCHOSES  ifvxrj,  the  soul).  The 
name  for  mental  affections  as  a  class. 
Used  very  loosely  for  mental  phenomena, 
states  of  consciousness,  thoughts,  ideas, 
&c.  German  alienists  restrict  the  mean- 
ing of  psychose  (sing.)  to  healthy  states 
of  mind,  whilst  they  employ  psychosen 
(plur.)  in  the  sense  of  abnormal  mental 
conditions. 

PSYCHOSES,  TVI.VaXNA.TZNa 

{■^vxrj;  fidmen,  lightning).     Mental  affec- 
tions characterised  by  explosive  outbreaks. 

PSYCKOSlir.  —  The  cerebroside  of 
sphingosin.  {See  Bkain,  Chemistry  of, 
p.  149.) 

PSYCHOSIS. — Amental  affection.  (Fr. 
psychose;  Ger.  GemiitslcranJcheit.) 

PSYCHOSIS;  OR,  THE  M^EURAI. 
ACT  CORRESPOM-BIITC  TO  MEN*- 
TAI.  PHEM-OMENA.— In  studying 
mental  action  the  physiologist  must 
necessarily  confine  his  descriptions  to 
physical  facts,  and  observe  the  physical 
signs  accompanying  mental  action.  All 
expression  of  mental  states  is  by  move- 
ment ;  we  begin  by  studying  these  signs. 
The  general  means  of  studying  movements 
and  classifying  them,  is  described  under 
"Movements  "  {q.r.),  and  the  early  signs 
of  mental  action  in  the  child  are  given 
under  "  Evolution  ;"  the  general  mental 
capacity  of  an  individual  may  be  studied 
by  observation  of  these  signs.  In  the 
following  table  the  properties  of  neural 
action  necessary  to  certain  mental  states 
are  indicated. 

The  table  (p.  1026)  illustrates  the  advan- 
tage of  the  scientific  method  of  studying* 
mental  action,  as  well  as  the  convenience 
of  the  metaphysician's  methods.  The  meta- 
physician names,  or  labels,  an  almost  in- 


Psychosis 


[    1026    ] 


Psychosis 


niinierable  list  of  "  mental  activities,"  but 
does  not  necessarily  give  us  exact  means 
by  which  we  can  observe  and  determine 
them.  These  are  said  by  the  physiologist 
to  correspond  roughly  to  various  aggrega- 
tions of  a  few  observable  physical  phe- 
nomena— i.e.,  certain  modes  of  action 
among  nerve-centres  similar  to  those 
found  among  the  modes  of  action  and 
growth  in  the  cellular  elements  of  other 
living  things. 

Intellectual  Faculties  or  Modes 
OF  Action. 


Physical 
Conditions.^' 

0 

.1 

"3 

1 

P. 

P. 
P. 

P. 
P. 

0 

S 

0 

p. 

p. 

p. 
p. 

0 

g 


p. 

p. 
p. 
p. 

p. 
1'. 

p. 
p. 

p. 
p. 

0 

1 

p. 

A. 
A. 

A. 
P. 

A. 

1.  Spontaneous    ac- 

tion 

2.  Impressionability 

3.  Controllability  of 

spontaneity    . 

4.  Reteutiveness     , 

5.  Diatactic  action  . 

6.  Delayed    expres- 

sion 

7.  Reinforcement    . 

8.  Double  action     . 

9.  Compound    cere- 

bration . 
10.   Unif  oi-m  series  of 
acts 

r. 
1'. 

p. 

A. 

p. 

P. — present.         A. — absent. 

Spontaneity. — An  essential  character 
of  brain  action  giving  aptness  for  mental 
function  is  spontaneit}^  That  is  spon- 
taneous action  of  many  small  centres,  or 
centres  governing  small  movemeuts  ;  this 
is  shown  to  be  a  marked  character  of  the 
infant  brain,  it  is  nearly  lost  in  the  adult 
fur  movements,  bi;t  reverts  in  some  con- 
ditions— e.g.,  fatigue  and  emotion,  chorea, 
delirium.  It  seems  that  as  evolution  ad- 
vances spontaneous  action  of  the  centres 
for  movements  decreases,  but  that  it  re- 
mains for  mental  action,  and  leads  to  new 
thoughts,  spontaneous  and  vague  uncon- 
trolled thinking. 

Controllability  of  Spontaneous  .A.C- 
tion  is  seen  in  evolution  of  the  infant 
and  when  action  is  temporarily  inhibited 
by  sight  of  an  object,  this  is  commonly 
followed  by  acts  not  previously  performed; 
it  is  probable  that  some  (diatactic  action) 
neural  arrangement  for  action  among  the 
cells  is  formed  during  the  quiet  time  by 
the  sight  of  the  object. 

Delayed   Expression. — Here  we  have 

*  These  i)hysical  conditions  arc  referred  to  in 
the  text  by  quoting-  the  numbers  as  given  in  the 
table. 


reteutiveness,  the  physical  impression  re- 
ceived by  the  centres  through  the  senses 
is  left  as  a  diatactic  union  among  them  ; 
the  impress  is  strong  enough  just  to  form 
such  union  ready  for  subsequent  action. 
The  remaining  physiological  properties 
of  the  brain  necessary  to  mental  function 
are  sufficiently  described  for  present  pur- 
poses under  Movements  (q.v.). 

We  now  commence  the  study  of  brain 
action  in  disj^laying  mental  function  with 
certain  facts  and  observations  before  us, 
and  have  mainly  to  consider  the  theory 
put  forward,  and  its  fitness  for  describing 
various  well-known  mental  phenomena. 
Further  evidence  as  to  theusef  ulness  of  the 
hypothesis  may  be  found  in  the  suitability 
of  the  same  modes  of  observing,  describing 
andarguingas  applied  to  general  conditions 
of  the  nerve-system  and  to  mental  action. 
Lastly  it  will  be  seen  that  the  theory  and 
methods  used  are  in  harmony  with  the 
laws  of  evolution  which  have  so  greatly 
aided  biological  research.  To  study  sub- 
jective conditions,  is  to  study  our  own 
mind,  not  those  observed. 

Hypothesis. — The  hypothesis  is  that 
every  mental  act  depends  upon  the  for- 
mation and  action  of  a  certain  combina- 
tion among  the  nerve-cells. 

The  neural  state  corresponding  to  men- 
tal action  depends  on  the  special  centres 
called  successively  into  co-action,  and  the 
ratios  of  their  action.  When  we  see  a 
series  of  movements  we  infer  activity  and 
discharge  of  force  from  a  number  of  nerve- 
centres  corresponding.  In  obeying  a 
word  of  command,  in  catching  a  ball, 
sound  and  sight  are  respectively  the 
stimuli  preparing  particular  groups  of 
nerve-centres  for  action.  We  assume 
as  our  hypothesis  that  such  actions  are 
due  to  some  kind  of  functional  union  of 
the  centres  produced  by  the  stimulus 
received  through  the  senses  antecedent  to 
the  movement.  The  act  of  getting  the 
nerve-centres  ready  for  action  is  here  sup- 
posed to  be  the  formation  of  some  kind  of 
union  among  them  forthepassage  of  nerve- 
currents  through  the  cells  which  govern  the 
particular  combinations  of  the  resultant 
movements.  Examples  of  unions  among 
nerve-centres  are  seen  in  the  symmetrical 
movements  of  the  eyelids  and  mobile  fea- 
tures of  the  face — we  infer  that  the  cen- 
tres for  the  two  sides  of  the  face  usually 
form  a  functional  union  because  the  sight 
or  sound  which  precedes  a  change  of 
facial  expression  is  usually  followed  by 
equal  and  synchronous  movement  on  either 
side.  This  hypothesis  of  functional  unions 
for  action  w^e  have  illustrated  by  examples 
of  facts  seen  in  cellular  growth.  The 
term    "  functional    union   for   action,"'  or 


Psychosis 


[     1027    ] 


Psychosis 


"  a  union,"  simply  applies  to  the  co-action, 
or  synchronous  action  for  a  certain  period 
of  time,  on  a  single  occasion,  or  many 
occasions,  or  uniformly  within  our  expe- 
rience— of  a  certain  number  of  like-living 
elements. 

The  evidence  as  to  the  functional  union 
occurring  is  the  combination  of  action,  or 
the  series  of  combinations.  We  observe 
the  combination  of  movements,  and  infer 
combination  of  action  in  the  centres.  The 
term  "  functional  union  "  is  convenient ; 
it  involves  a  theory — we  must  explain 
rather  than  define  the  meaning  of  the 
term  ;  it  is  an  inference  from  the  time  of 
the  acts  ;  it  is  probably  the  outcome  of  the 
common  impressionability  of  the  subjects. 

As  evidence  that  some  kind  of  physical 
union  among  the  centres  is  formed  we 
refer  to  the  following  facts : — Repetition 
makes  all  actions  quicker  and  more  pre- 
cise ;  they  follow  more  readily  and  cer- 
tainly upon  the  same  stimulus.  Practice 
makes  the  actions  precise  and  perfect. 

It  is  assumed  here  that  a  mental  act  is 
not  due  to  the  function  of  one  mass  of 
brain  which  does  nothing  but  produce 
that  one  act,  but  the  outcome  of  the 
particular  set  or  combination  of  cells 
which  happen  at  the  moment  to  act 
together,  the  union  of  cells  for  such  act 
being  temporary,  though  capable  of  re- 
curring. It  has  been  shown  that  one 
group  of  cells  acting  together  produces 
one  particular  movement,  and  it  is  believed 
that  similarly  one  group  of  cells  can 
produce  one  particular  act  of  mind — the 
particular  thought  thus  depends  upon  the 
particular  group  of  cells  acting.  It  is 
also  believed  that  groups  of  cells  can  be 
caused  to  act  together  in  mental  acts,  as 
for  certain  movements,  by  a  very  slight 
stimulus  of  sound  or  sight. 

The  expression  of  a  thought  consists  in 
the  motor  action  of  a  group  of  cells ; 
the  thought  (act  of  psychosis)  consists  in 
the  formation  of  the  union  of  cells  whose 
motor,  or  efferent  action,  produces  ex- 
pression of  the  thought.  Thought  pre- 
cedes and  is  known  by  subsequent  move- 
ment; thought  is  a  part  of  the  cause  of 
the  movement,  and  must  correspond  to 
some  physical  (it  may  be  temporary) 
arrangement  among  the  cells.  We  do  not 
know  what  the  "  arrangement "  may  be, 
but,  as  it  leads  to  associated  movements, 
we  suppose  that  it  consists  of  associations 
among  cells.  Thus,  '"thinking"  is  the 
getting  ready  for  action  ;  it  is  the  mole- 
cular or  functional  formation  or  arrange- 
ment of  unions  among  nerve  cells.  A 
special  combination  or  series  of  move- 
ments may  occur,  and  these  may  not  be 
called  up  again  till  some  special  stimulus  . 


recurs — i.e.,  a  special  associated  actiou  of 
cells  or  union  among  them  does  not 
recur  till  that  special  stimulus  recurs. 
These  associations,  ties,  or  unions  among 
cells  may  be  dissolved. 

The  mental  function  of  nerve-centres 
appears  to  be  merely  the  faculty  for  the 
formation  of  combinations  for  action ;  it 
is  a  form  of  impressionability,  such  that 
forces  acting  through  the  senses  can  pro- 
duce unions  among  the  centres,  controlling 
the  special  centres  in  the  union,  and 
deciding  how  long  the  union  shall  last, 
whether  it  be  quickly  dissolved  or  ren- 
dered permanent. 

Diatactic  Action  and  Compound 
Cerebration. — This  formation  of  unions 
among  nerve-centres  previous  to  sending 
efferent  currents  to  muscles,  and  thus 
producing  movements  and  visible  expres- 
sion, we  have  termed  "  diatactic  action  " 
{SiaTaaao},  to  get  ready  for  action). 

This  diatactic  action  is  infen-ed  to  exist 
as  the  neural  change  or  activity  corre- 
sponding to  a  "  thought ;  "  it  is  exactly  the 
same,  so  far  as  we  know,  as  the  getting 
ready  for  a  co-ordinated  motor  action. 

The  analogy  between  the  motor  (or 
efferent)  action  of  nerve-centres,  as  ex- 
pressed by  movements  and  the  hypothe- 
tical diatactic  unions  supposed  to  be  the 
neural  representation  of  thoughts,  is 
shown  in  the  following  table.  The  facts 
placed  in  parallel  columns  are  usually 
found  to  co-exist,  or  to  follow  one  another 
rapidly: — 

__  ^      _  Conditions   of 

IMCotor  Expression.      __ 

Mental  Faculty. 

1.  Much     spontaneous     Capacity  for  intelligent 

action  controllable         thought, 
through  senses. 

2.  Visible   impressions 

cause  many   com- 
bined actions  auil  many  thoughts. 

3.  Identical       impres- 

sions followed    by 

similar  actions  and  similar  thoughts. 

4.  Inherited    tendency 

to  certain  actions      and  to  recurreucc  of  cer- 
tain thoughts. 

5.  I'niform  work  causes     A  change  of  subject  of 

more  fatigue  than         thought  is  recreative, 
variety. 

6.  Variations  of  work     Variations    of    thought 

do  not  necessarily  not     necessarily    fol- 

cause  more  bodily  lowed     by     signs     of 

waste.  brain  fatigue. 

7.  Permanent    reflex  Permanent       fixed 

actions.  thoughts,  easily  called 

up. 

8.  ['■'ixod  lines  of  motor     Uniform     lines    of 

action.  thought. 

9.  Habits  of  movement.     Habits  of  thought. 

10.  I'ntrained        mov(!-     Untrained  thoughts  are 

meiits  are  irrcgu-        irregular, 
lar. 

11.  In  somnolence,  gra- 

dual subsidence  of 

movement  and  of  thought. 

3  u 


Psychosis 


[     1028    ] 


Psychosis 


12.  In  passion,  a  spread-  A  rapid  flow  of  uncoil- 

ing- area  of  move-         trolled  thoug-hts. 
ment  not  control- 
led from  without. 

13.  Certain    movements  Certain  thouglits  cannot 

cannot  co-exist.  co-exist. 

Fsycbosls. — Writers  on  mental  science 
define  and  illustrate  the  law  of  adhesive- 
ness. Those  scientific  thinkers  who  ac- 
cept the  generalisation  of  evolution  will 
find  in  the  writer's  "  Law  of  Syntrophy  " 
some  evidence  of  a  widely  spread,  if  not 
nniversal,  mode  of  action,  both  in  growth 
and  modes  of  action  of  nerve-centres,  em- 
bracing the  modes  of  neural  action  which 
lead  to  adhesiveness. 

The  law  of  Syntrophy. — When  the 
attributes  of  action  in  a  living  thing  have 
for  a  time  been  controlled  by  a  force 
acting  upon  it,  and  that  force  causes  its 
action,  then  the  impressions  made  may 
be  followed  by  action  similar  to  that 
which  occurred  during  the  period  of 
stimulation.  Any  force  producing  syn- 
chronous action  among  like  living  ele- 
ments is  usually  followed  by  subsequent 
synchronous  action  among  them.  The 
law  of  syntrophy  states  that,  when  such 
a  union  has  been  brought  about  by  some 
force,  as  an  impression  made  upon  them, 
then  the  same  force  acting  again  is  usually 
followed  by  action  in  the  same  group  or 
union  of  elements. 

This  law  of  syntrophy  is  of  course  only 
a  generalisation  from  observed  facts,  many 
of  which  occur  among  conditions  of  vege- 
table and  animal  growth,  and  their  enu- 
meration here  would  be  out  of  place ; 
suffice  it  to  say  we  have  arranged  and 
classified  a  catalogue  of  such  facts  in 
support  of  this  theory.* 

This  law  of  syntrophy,  like  other  laws 
of  nature,  is  only  a  generalisation  of 
experience;  it  is  based  on  observation, 
and  shows  that  synchronous  action  may 
result  from  the  like  stimulation  of  similar 
living  subjects.  Now,  the  nerve-centres 
are  similar  subjects  of  nutrition,  and  their 
special  co-action,  or,  as  we  commonly 
call  it,  union,  may  be  similarly  brought 
about.  It  is  suggested  that  a  "  diatactic 
union  of  nerve-centres  "  may  be  formed  by 
coincident  stimulation,  and  is  not  neces- 
sarily due  to  organic  union  of  the  nerve- 
centres  by  nerve-fibres.  Why  a  certain 
diatactic  union  is  formed  by  one  sight 
impression,  a  second  union  by  another 
sight  impression,  we  do  not  know,  but 
this  is  the  inference  drawn  from  observed 
facts. 

See  a  boy  looking  earnestly  at  an  object 
that  interests  him,  he  gazes  at  it  and  is 
*  See  author's  work  on  "  Mental  Faculty,"  Cam- 
bridge University  Tress. 


motionless  ;  when  spoken  to  he  begins  to 
talk  of  it  and  to  describe  it,  saying  what 
he  thinks  about  it.  The  boy  while  looking 
at  the  object  is  supposed  to  be  thinking 
about  it,  acts  of  psychosis  are  supposed 
to  be  taking  place  in  his  brain,  his  brain 
is  being  got  ready  for  the  subsequent 
speech.  We  cannot  see  what  is  going  on 
in  his  brain,  but  when  he  tells  us  what 
he  thinks  about  the  object  we  have  an 
expression  by  movement  of  that  which 
occiirred  in  his  brain  during  his  quiet 
time.  The  words  he  now  says  are  the 
outcome  of  certain  movements  of  his  body 
produced  by  currents  from  those  groups 
of  nerve-cells  which  were  being  prepared 
by  the  impression  following  the  sight  of 
the  object.  The  words  that  come  out  de- 
pend upon  the  special  cells  previously 
arranged  into  unions.  The  inference  is 
that  during  that  wonderful  "  quiet  time," 
while  he  gazed  motionless  at  the  object, 
the  light  reflected  from  the  object  gets  the 
brain  ready,  preparing  diatactic  unions 
among  his  centres.  In  such  a  case  the 
expression  of  what  took  place  in  the  brain 
might  be  delayed ;  he  does  not  speak  de- 
scribing his  thoughts  till  he  is  questioned 
— the  acts  of  psychosis  and  their  expres- 
sion may  be  separated  by  an  interval  of 
time,  the  impression  produced  upon  the 
brain  is  not  expressed  till  it  is  again 
stimulated  by  our  interrogations. 

A  boy  learns  his  lessons  from  a  book  at 
night  and  says  it  in  school  next  morning ; 
while  looking  at  his  book  his  sight  of  the 
book  results  in  certain  arrangements 
among  his  nerve-cells  (A  B  C),  such  that 
next  day  when  told  to  say  his  lesson  we 
have  expression  by  movement  in  the  words 
produced  by  movements  of  a  h  c.  If  that 
has  happened  in  the  boy's  brain  which 
the  teacher  wished  for  during  evening 
preparation,  impressions  were  produced 
making  functional  arrangements  among 
the  centres ;  the  expression  of  such  im- 
pressions is  delayed  till  the  time  for 
saying  the  lesson ;  then,  the  word  of  com- 
mand is  followed  by  expression  of  the 
brain  action,  and  if  the  lesson  be  suc- 
cessful, the  brain  impressions  are  rendered 
firmer  and  stronger. 

We  observe  our  travelling  companion, 
his  eyes  are  directed  towards  a  particular 
advertisement  at  several  stations ;  subse- 
quently he  speaks  to  us  of  the  subject 
matter  of  that  advertisment.  Such  action 
in  our  companion  indicates  intelligence. 
During  the  time  of  our  journey  an  im- 
pression must  have  been  made  upon  his 
centres  by  the  sight  of  the  advertisement, 
this  was  a  functional  union  of  centres 
(theory)  formed  by  light,  "  a  getting 
ready,"  a  change  molecular  in  kind,  seated 


Psychosis 


[    1029    ] 


Psychosis 


in  certain  nerve-centres,  occurring  at  the 
time  of  the  impression  by  light,  not  at 
that  time  followed  by  elt'ei'ent  nerve- 
currents  from  centres  to  muscles.  Such 
may  be  called  an  act  of  psychosis  without 
expression  at  the  time. 

Instinct. — (i)  Spontaneity.  (2)  Im- 
pressionability. (4)  Retentiveness.  (10) 
Uniform  series  of  actions. 

Instinct  as  a  mental  character  is  indi- 
cated by  certain  actions  which  result  in 
an  impression  upon  the  animal,  and  such 
action  is  looked  upon  by  some  as  an  indi- 
cation of  intelligence.  The  nerve  arrange- 
ments for  instinct  are  congenital,  or  con- 
structed previous  to  an  individual  exist- 
ence, or  as  the  result  of  impressions  upon 
the  ancestry.  It  seems  that  certain 
groups  of  nerve-cells  tend  to  co-act  in  a 
diatactic  union  either  spontaneously  or 
i;pon  the  occurrence  of  certain  stimuli. 
An  infant  breathes  on  coming  into  con- 
tact with  the  air,  the  act  is  due  to  the 
construction  of  the  nerve  system,  making 
the  centres  for  certain  movements  tend  to 
co-act;  the  action  may  even  begin  spon- 
taneously (i).  The  chick  pecks  (10)  his 
way  out  of  the  shell  without  any  apparent 
stimulus  to  action,  but  picks  up  food 
better  off  the  dark  ground  (2).  The  in- 
fant's lips  begin  to  move  when  in  want  of 
food,  even  before  they  touch  the  breast. 
The  continuance  of  these  special  neural 
arrangements  shows  the  high  degree  of 
retentiveness  (4)  in  the  brain  ;  they  are 
very  fixed  and  permanent.  The  actions 
of  instinct  are  usually  a  uniform  series  of 
movements  (10).  The  congenital  faculty 
of  instinct  does  not  involve  aptitude  for 
intelligence  and  compound  cerebration. 
A  capacity  for  imitation  is  a  special  and 
high  class  form  of  instinct,  but  this  latter 
does  not  necessarily  imply  special  capacity 
of  impressionability.  There  may  be  no 
known  differences  in  the  neural  arrange- 
ments for  instinct  and  intelligence,  but 
there  are  great  differences  in  the  relations 
of  their  action  to  their  necessary  ante- 
cedents. 

Zntellig-ence. — Brain  characters:  (i) 
Spontaneity.  (2)  Impressionability  to 
external  forces.  (3)  Controllability  of 
spontaneity.  (4)  Retentiveness.  (5)  Dia- 
tactic action.  (6)  Delayed  expression. 
(S)  Double  action.  (9)  Compound  cere- 
bration. 

Intelligence  as  a  term  may  be  incapable 
of  formal  definition,  but  we  may  indicate 
the  modes  of  brain  action  necessary  to  the 
display  of  this  faculty.  Aptitude  for  in- 
telligence necessitates  spontaneity,  this 
being  capable  of  control  through  the 
senses  {see  Evolution)  (i,  2,  3,  5).  Later, 
adapted  action  following  a  period  of  inhi- 


bition (6),  or  control  of  spontaneity,  shows 
the  occurrence  of  compound  cerebra- 
tion (9).  We  think  it  will  be  found  that 
the  physiologist's  studies  of  intelligence 
are  observations  and  inferences  on  com- 
pound cerebration,  its  history  and  causa- 
tion ;  this  is  the  great  character  of  brain 
action,  giving  capacity  for  thought ;  illus- 
trations are  given  under  explanation  of 
the  processes  of  logic.  Adapted  action 
indicating  compound  cerebration  is  very 
suggestive  of  the  higher  character  of  in- 
telligence as  compared  with  instinct, 
memory,  imitation.  Of  course  an  act  of 
memory  or  imitation  may  lead  to  com- 
pound cerebration  and  intelligent  and 
adapted  action. 

These  signs  of  intelligence  are  not  found 
at  birth,  we  do  not  find  that  impressions 
received  are  retained  (4)  ;  memory  and 
retentiveness  are  later  acquisitions  ; 
further,  in  the  earliest  stages,  there  seems 
no  evidence  of  double  action  in  the 
brain  (8)  ;  we  do  not  see  a  stimulus  to 
action  leave  any  definite  impression  on  the 
brain  which  produced  it. 

Want  of  spontaneity,  or  absence  of 
controllability  of  the  spontaneity  may 
lead  to  defective  intelligence  ;  it  is  well  to 
try  and  define  the  physical  defect  of  a 
brain  leading  to  defective  psychosis. 

"Will  or  Volition. — (2)  Impression- 
ability. (3)  Controllability  of  spontaneity. 
(4)  Retentiveness.  (6)  Delayed  expres- 
sion.    (9)  Compound  cerebration. 

Volition  is  absent  in  the  infant,  it  is 
present  in  a  variable  degree  in  man.  Will 
is  indicated  by  voluntary  action  {see 
Voluntary  Movements).  This  kind  of 
mental  action  is  often  independent  of  any 
strong  present  impression,  and  is  due 
rather  to  past  or  antecedent  impressions 
(4),  or  to  inherited  impression  and  train- 
ing. Volition  or  will,  as  a  neural  act, 
niajr  be  delayed  in  its  expression  (6),  the 
mind  is  made  up,  its  visible  action  may 
be  deferred.  To  the  physiologist,  will 
does  not  appear  to  be  some  essential 
unknown  force  acting  upon  nerve-centres 
stimulating  them  to  action.  Physical 
health  promotes  strength  of  will ;  to  exer- 
cise will  strongly  against  present  impres- 
sions from  wibhoub  leads  to  the  signs  of 
fatigue,  as  is  readily  seen  in  children.  It 
is  due  to  the  intrinsic  force  or  diatactic 
unions  formed  by  past  im23ression,  and  as 
in  all  such  cases  may  be  very  persistent, 
but  easily  exhausted  for  a  time  though  apt 
to  recur.  S^jontaneity  (micro-psychosis) 
is  antithetical  to  the  display  of  will ; 
capacity  of  compound  cerebration  favours 
it. 

Emotion. — (7)  Reinforcement.  (6)  No 
delayed    expression.       (i)     Spontaneity. 


Psychosis 


[     1030    ] 


Psychosis 


Here  we  may  gronp  tlie  moi*e  prominent 
signs  of  emotion  of  various  kinds,  so  as  to 
consider  the  cliaracters  iu  which  they  are 
distinguished  from  more  direct  indications 
of  intellectual  activity.  Let  tis  look  at 
the  expressions  of  mental  excitement — 
speech  becomes  more  and  more  rapid  (7), 
words  are  frequently  repeated,  so  that 
though  utterance  is  constant,  the  vocabu- 
lary becomes  very  limited.  There  is  much 
movement  in  the  parts  of  the  face,  the 
area  of  movement  increasing  (7) ;  but  un- 
less the  condition  pass  on  to  what  is  called 
an  explosion  of  passion,  expression  in  the 
face  remains  symmetrical.  The  individual 
is  not  easily  controlled  in  action  through 
the  senses ;  these  signs  are  well  marked 
in  mania,  the  action  shows  much  spon- 
taneity both  for  movement  and  psychosis 

The  signs  of  exhaustion  follow. 

"  Mental  excitement "  is  a  condition 
known  to  every  one  by  numerous  and 
rapid  actions  involving  many  small  parts, 
the  area  of  action  tending  to  increase 
from  cerebral  reinforcement.  There  is  di- 
minished impressionability  to  control. 
The  action  following  upon  stimulation  is 
different  from  the  normal  in  many  cases. 
The  signs  of  strong  emotional  conditions 
may  be  illustrated  by  reference  to  passion, 
excess  of  laughter,  emotional  crying,  hys- 
terical attacks. 

T/temory.  —  (2)  Impressionability.  (4) 
Eetentiveness.  (6)  Delayed  expression. 
(8)  Double  action. 

Memory  as  a  mental  faculty  is  known 
to  us  by  the  relations  of  the  antecedent 
force  which  impressed  the  brain  to  the 
outcome  of  action  (4).  It  appears  that 
when  an  impression  is  produced  upon  the 
brain  (2)  the  subsequent  expression  in 
memory  is  due  to  a  union  among  cells 
having  been  produced  by  that  imj^ression 
which  may  long  remain  inactive  (6)  ;  the 
expression  may  be  by  word  or  gesture. 
The  antecedent  force  which  produced  the 
neural  impression  may  have  had  a  double 
action  (8),  an  immediate  efferent  current 
producing  movement  and  a  later  or  de- 
layed outcome.  Thus  a  special  facial 
gesture  may  recur  upon  sight  of  a  well- 
known  object ;  recurrence  of  the  impres- 
sion strengthens  the  certainty  with  which 
the  act  recurs  or  is  remembered,  the  effect 
of  the  impress  is  "  cumulative."  Too 
large  a  number  of  acts  of  memory  may 
lessen  the  faculty  of  spontaneous  think- 

Imitation.  —  (2)  Impressionability. 
(3)  Controllability,  (4)  Retentiveness. 
(5)  Diatactic  action. 

The  objects  of  imitation  are  jDOstures 
and  movements  in  other  men  ;  sight  of 


action  in  another  man  is  followed  by  action 
of  the  parts  seen  moving.  The  impression 
received  stimulates  the  nerve-centres  cor- 
responding to  those  acting  in  the  party 
imitated ;  it  appears  that  common  im- 
pressions in  the  past  upon  the  ancestors 
of  both  subjects  leads  to  this  impression- 
ability. Imitation  is  analogous  to  in- 
stinct in  depending  upon  congenital 
nenral  arrangements,  and  not  necessitat- 
ing compound  cerebration  ;  it  differs  from 
instinct  in  being  stimulated  by  an  object 
similar  to  itself,  in  which  character  it 
appears  to  be  a  higher  form  of  impres- 
sionability. 

We  have  explained  our  hypothesis  as 
to  the  neural  processes  corresponding  to 
the  expression  of  mental  states  and  men- 
tal activities,  we  must  now  consider  tVie 
diatactic  neural  action  corresponding  to  a 
train  of  iliought  under  the  name  com- 
pound cerebration.  This  is  the  hypo- 
thesis :  "  In  the  mode  of  brain  action 
termed  compound  cerebration  one  diatac- 
tic union  may  by  its  activity  stimulate 
another  to  action,  and  thus  a  series  or 
train  of  activities,  in  part  the  result  of 
past  impressions,  may  occur,  ending  in 
some  visible  expression."  A  careful  study 
of  the  motor  signs  of  mental  acts  has  led 
us  to  frame  this  hypothesis.  It  apj^ears 
that  a  primary  stimulus  may  produce  a 
diatactic  union  ABC,  the  stimulus  from 
this  a  union  BDE,  followed  by  EFG,  and 
finally  GHK,  which,  sending  efferent  cur- 
rents to  muscles,  produces  action  in  glik 
as  a  visible  expression  of  the  outcome  of 
the  train  (series  of  acts)  of  thought. 

Compound  Cerebration. — Intellectual 
effort,  trains  of  thought,  and  the  higher 
modes  of  thinking,  must  correspond  to 
neural  acts  highly  adapted  and  controlled. 
It  is  this  association  of  past  neui'al  im- 
pressions and  present  stimulation  that  we 
have  now  to  study,  under  the  term  com- 
pound cerebration.  This  kind  of  neural 
action  is  believed  to  occur  when  we  see 
specially  adapted  action  slightly  delayed 
after  its  stimulation,  but  well  adapted  to 
the  circumstances.  Compound  cerebra- 
tion is  in  part  due  to  previous  impressions, 
in  part  to  pi'esent  forces;  it  is  to  some 
extent  expressed  in  the  selection  and  use 
of  woi'ds.  Among  persons  whose  ante- 
cedents and  inheritance  are  similar,  there 
is  an  average  or  normal  for  the  outcome 
of  compound  cerebration,  which  we  should 
expect  to  see  follow  a  certain  impression. 

In  evolution  the  capacity  for  diatactic 
action  precedes  the  appearance  of  adapted 
action  and  compound  cerebration.  Dia- 
tactic unions  when  formed  may  cohere 
and  produce  larger  unions,  or  may  be  con- 
nected in  serial  order,  so  that  a  fixed  series 


Psychosis 


[     1031     ] 


Psychosis 


of  neural  diatactic  unions  act  in  fixed  order 
of  succession  on  a  certain  stimulus. 

Brief  evidence  of  some  neural  process, 
such  as  compound  cerebration,  is  given  in 
the  foUowiucr  table: 


Methods  of  Thoiir/ht. 

A  period  of  time  is  re- 
quired for  thinking 
out  a  subject  previous 
to  11  new  line  of  ac- 
tion. 

I'eraistent  thinking  is 
followed  by  fatigue. 


Mental  development  con- 
sists in  the  formation 
of  trains  of  thought 
leading  to  certain  re- 
sults. 


Observed  Facts. 
Spontaneity      being 
quelled,   a    period    of 
quiescence       precedes 
adapted  action. 

The  acquisition  of  new 

modes   of    expression 

is  followed  by  signs  of 

fatigue. 
Visible  developmentcon- 

sists  of  series  of  acts 

of  growth  and  move- 
ment resulting  in  tiiial 

action  well  adapted  to 

circumstances. 

The  mental  jihilosopher  says,  "  Human 
knowledge  consists  of  mind  and  matter — 
i.e.,  the  subjective  world  and  the  objective 
world."  We  would  rather  say  that  we 
study  diatactic  neural  action  in  relation 
to  objects,  and  objects  in  action  and  to 
physical  forces.  We  are  not  here  con- 
cerned with  consciousness  or  any  form  of 
subjective  feeling,  but  it  may  be  remarked 
in  passing  that  the  subjective  impressions 
probably  corresiiond  to  the  formation  of  a 
neural  diatactic  union  occurring  in  every 
mental  act.  Prof.  Bain  says :  "  The 
primary  attributes  of  intellect  are  reten- 
tiveness  and  consciousness  of  difference 
and  agreement."'  Romanes  indicates 
"  choice  "  as  a  criterion  or  character  ana- 
logous to  those  of  mind,  and  instances 
examples  of  choice  in  the  amoeba  which 
retains  certain  particles  of  food  and  rejects 
others. 

It  is  tints  desirable  that  we  should  de- 
scribe the  neural  processes  which,  accord- 
ing to  our  hypothesis,  correspond  to  the 
increase  of  judgment  or  making  compari- 
sons. This  will  be  dealt  with  in  speaking 
of  the  physiological  process  corresijonding 
to  the  processes  of  logic. 

Tbinkingr,  or  the  exercise  of  intellect, 
may  be  said  to  be  present  in  any  man 
capable  of  conducting  a  train  of  thought, 
and  expressing  inferences  or  results  of 
thought  by  words  or  other  mode  of  ex- 
pression. The  mental  processes  in  a  cor- 
rect mode  of  thinking  have  been  defined 
by  the  logician ;  we  may  begin  by  study- 
ing the  neural  processes  corresponding  to 
the  logician's  use  of  the  terms,  "  proposi- 
tion," "  syllogism." 

The  consideration  of  a  proposition  may 
be  represented  by  two  diatactic  unions  in 
coincident  activity  ;  should  they  remain 
co-active  the  unions  corresponding  to  sub- 
ject and  predicate  become  coherent  and 


the  proposition  is  granted  as  true.  The 
possibility  of  cohesion  of  these  diatactic 
unions  depends  upon  their  previous  coin- 
cident activity  —  i.e.,  past  experience. 
Speaking  of  the  terms  predicable  in  psy- 
chology, we  use  those  which  connote  facts 
in  the  body  of  the  living  man  ;  abstract 
terms  connote  expression  by  his  nerve- 
muscular  action — e.g.,  kindness,  joy,  &c. 
Such  diatactic  unions  result  from  impres- 
sions produced  by  sight  of  movements 
and  postures  in  others.  Examples  may 
be  drawn  from  motor  action  showing  that 
certain  nerve-centres  cannot  be  in  coin- 
cident action.  It  is  difficult  to  perform 
the  acts  of  stroking  with  one  hand  and 
patting  with  the  other,  or  to  move  the 
feet  and  hands  at  different  ratio.  The 
"  energetic  hand  posture  "  on  one  side, 
and  the  nervous  posture  on  the  other,  do 
not  usually  coexist. 

Logician's  Definitions. 


Term — the  simplest  re- 
sult of  thought. 

Proposition — implies  co- 
existence of  two  terms. 

Sj'llogism — two  premises 
or  propositions  with 
one  term  common  to 
both. 

The  proposition  is  ac- 
cepted or  denied. 


Abstract    terms   predic- 
able of  man. 


Mental  comparison. 


Physioloffist's  Equi- 
valent. 

A  diatactic  neural  union 
— the  simplest  repre- 
sentation of  a  thought. 

Two  diatactic  unions 
must  be  brought  into 
co-activity. 

Three  diatactic  unions 
are  rendered  active  In 
pairs  in  succession. 

Unions  representing 
"  terms  "  cohere  per- 
manently ;  or,  they 
will  not  cohere  perma- 
nently. 

Unions  the  results  of 
impressions  by  sight 
of  nervo- muscular  ac- 
tion. 

Two  unions  rendered 
temporarily  co-active, 
they  either  cohere  or 
not,  according  to  past 
impressions  received. 


A  Xtine  of  Thought  or  Argrument. — 

(i)  Spontaneity.  (2)  Impressionability. 
(4)  Eetentiveness.  (5)  Diatactic  action. 
(6)  Delayed  expression.  (9)  Compound 
cerebration. 

Thinking  is  represented  in  neural 
action  by  a  series  of  diatactic  unions 
due  to  compound  cerebration,  partly  se- 
quential to  past  impressions,  and  it  may 
be  in  part  due  to  present  stimulus.  A 
child  sees  an  object,  and  thinks  about  it ; 
he  sees  a  knife,  and  leaves  it  alone,  taking 
scissors  instead,  so  as  not  to  cut  himself 
The  stages  of  thought  are  a  compound 
series  of  neural  acts  ending  in  visible 
movement.  Any  great  amount  of  re- 
inforcement may  lead  to  mental  confu- 
sion, hence  emotion  is  antithetical  to 
quiet  and  correct  thought.  Spontaneous 
thought  is  apt  to  be  vague,  as  contrasted 


Psychosis 


[     1032    ] 


Psychosis 


Psychosis 


[     1033    ] 


Psychosis 


Fiu.  2. 


Frame  supporting  the  recording-  tambours  for  taking  tracings. 


Fig.  3. 


I,ulia-rnbl.er  motor  gauntlet  ;  each  finger-tube  is  connected  with  a  recording  tambour  by  a 
flexible  tube,  and  its  movements  arc  recorded  in  the  tracing  (see  Journal  oj  J  lujsioh'au,  i»»3 
and  1887).     The  apparatus  used  is  now  in  the  South  Kensington  Museum. 


Psychosis 


[     1034    ]         Puerperal  Insanity 


with  thinking  due  to  knowledge  the 
result  of  experience  or  impressions  from 
without. 

XTormal  and  Abnormal  Mental  Ac- 
tion.— Normal  mental  action  may  be 
briefly  defined  as  that  which  in  a  large 
average  of  cases  is  usual  under  the  special 
circumstances ;  this  necessarily  varies 
with  the  age,  and  social  and  educational 
position  of  the  man.  Normal  mental 
action  may  be  said  to  be  such  as  is  in 
"harmony  with  the  environment."  To 
be  in  "  harmony  "  is  to  be  in  concord  or 
agreement,  and  the  use  of  the  term  con- 
notes at  least  two  similar  things  com- 
pared as  to  action.  In  the  mental  action 
which  is  said  to  be  harmonious  with  the 
environment,  it  is  the  intrinsic  forces  (or 
results  of  former  impression)  which  are 
compared  in  action  with  the  forces  at 
present  acting  upon  the  brain.  They 
tend  to  similar  action  or  otherwise.  The 
present  environment  of  the  brain  is 
mainly  the  sum  of  the  forces  or  stimuli 
incident  to  it,  calling  into  action  the  dia- 
tactic  neural  unions  which  have  previously 
been  formed  in  it  as  intrinsic  conditions. 
Harmony  or  discord  in  action  depends 
upon  whether  the  forces  now  stimulating 
its  action  are  similar  to  those  which  built 
up  its  present  tendencies  to  action  ;  if  the 
tendencies  thus  formed  are  similar  to  the 
action  at  present  stimulated,  this  is 
harmony. 

Harmony  with  the  environment  is  due 
to  the  fact  that  the  outcome  or  sequence  of 
past  impressions  is  similar  to  that  stimu- 
lated at  the  present  by  forces  around. 
Spontaneous  action  being  solely  produced 
by  past  or  inherited  impressions,  is  less 
likely  to  be  in  harmony  with  the  environ- 
ment, than  action  controlled  by  present 
conditions.  Thus  microkinesis  may  be 
compared  with  adapted  action.  The 
value  we  put  upon  a  particular  mental 
act  depends  in  part  upon  the  value  we 
put  upon  its  relation  to  surrounding 
things  and  forces  ;  if  it  have  no  relation 
to  the  environment,  it  will  probably  pro- 
duce no  internal  impression,  and  will 
probably  not  be  preserved.  It  is  the 
expression  of  mental  acts  adapted  by  the 
environment,  and  impressing  it,  that  are 
most  tiseful,  and  are  preserved. 

A  marked  feature  of  normal  mental 
action  is  its  variation.  In  an  imbecile 
there  are  few  variations  of  action,  and 
but  few  brain  centres  acting  separately. 
A  farm  labourer  has  a  vocabulary  of 
about  300  words,  Shakespeare  employed 
about  15,000;  the  variability  of  mental 
acts  is  a  fair  criterion  of  mental  activity. 

Conclusion.  —  This  brief  account  of 
the   working    of   our   hypothesis   of  the 


neural  action  corresponding  to  mental 
acts,  may  serve  to  show  that  it  is  possi- 
ble to  study  psychology  as  a  department 
of  pure  physiology,  and  to  describe  men- 
tal facts  in  terms  connoting  brain  proper- 
ties, such  as  may  be  observed  and  com- 
pared with  other  modes  of  vital  action. 
Clinical  descriptions  thus  given  appear 
useful  for  the  advancement  of  medical 
knowledge,  and  enable  us  to  avoid  speak- 
ing of  physical  conditions  as  if  they  were 
ever  produced  by  immaterial  causes.  The 
value  of  mental  action  is  not  to  be  es- 
timated in  foot-pounds,  because  it  does 
not  depend  upon  the  quantity  of  force, 
but  upon  the  control  of  its  distribution 
by  past  and  present  impressions  upon  the 
nerve-centres.  Francis  Warner. 

PSYCHOSIS  TRAVMATZCA. — Men- 
tal affection  following  injury.  (»See Trau- 
matism AND  Insanity.) 

PSYCHOSOMATZATRZA  {■^vxVj  the 

mind ;  awua,  body ;  larpeia,  a  healing). 
A  medicine  for  mind  and  body.  (Fr.  psy- 
clwsomiatrie.) 

PSYCHOTHERAPEZA,  PSYCKO- 

THERAPEUTZCS  (^/^vx'7,  the  mind  ; 
depanevo),  I  attend  the  sick).  Treatment 
of  disease  by  the  influence  of  the  mind  on 
the  body. 

PSYCHROPHOBIA  (^//•vxpc)y,  cold  ; 
(f)o(3€0),  I  fear).  Excessive  dread  of  cold, 
especially  cold  water.  (Fr.  jisycliro- 
phobie.) 

PTYAliZSM  (TTTuaXoi',  spittle).  Exces- 
sive secretion  and  escape  of  saliva ;  some- 
times observed  in  mental  disorders.  {See 
Salivatiox.) 

PUBESCEITT        IM'SAN'ZTY.  {See 

Developmental  Insanities.) 

PUERPERAIi  ZirSANZTY. — Under 
this  head  we  propose  considering  the 
insanity  of  pregnancy,  of  parturition, 
and  of  the  post-parturient  period.  There 
is  no  special  form  of  insanity  which  is  to 
be  distinguished  as  puerperal  insanity, 
for  though  the  various  symptoms  of 
mental  disorder  may  appear  in  certain 
relationships  more  commonly  with  puer- 
peral conditions  than  with  others,  yet 
there  is  nothing  really  sj^ecial  as  to  the 
form  of  the  disorder,  and  we  meet  with 
mania,  melancholia,  dementia,  or  delu- 
sional insanity  at  this  period. 

First  we  shall  consider  the  whole  sub- 
ject, and  later  enter  into  the  more  special 
questions,  for  it  will  be  found  that  to  a 
great  extent  causes  which  may  at  one 
time  lead  to  one  form  of  the  d.sorder  may 
at  another  start  one  of  the  other  forms  : 
puerperal  insanity  resulting  in  one  case, 
and  insanity  of  pregnancy  in  another. 

JEtiolog^y. — Neurotic  heredity  is  a  very 
common  cause,  and  in  some  cases  there  is 


Puerperal  Insanity         [     1035    ]         Puerperal  Insanity 


a  direct  transmission  of  a  tendency  to 
break  down  at  the  reproductive  times.  In 
these  cases  a  direct  inheritance  of  the 
neurosis  and  the  powerful  agency  ofdread 
or  expectancy  combine  to  precipitate  the 
attack.  Bodily  conditions,  more  than 
moral  or  intellectual  distress,  act  as  excit- 
ing causes.  General  causes  of  exhaustiou, 
such  as  frequent  pregnancies,  are  potent. 
Frequent  child-bearing,  especially  if  the 
mother  is  in  poor  circumstances,  is  danger- 
ous. The  age  of  the  woman  is  important ; 
child-bearing  is  more  dangerous  if  not 
within  ordinary  physiological  limits.  Thus 
first  pregnancies  after  thirty  are  specially 
so,  and  again  pregnancies  taking  place 
about  the  menopause  after  years  of  absence 
of  pregnancy  are  dangerous.  Alcoholic 
intemperance  is  a  factor  in  some  cases, 
though  less  common  than  might  have 
been  expected. 

We  do  not  find  that  albuminuria  or  con- 
vulsive attacks  are  peculiarly  dangerous, 
and  but  little  if  any  special  danger  arises 
from  severe  sickness  or  other  allied  troubles 
during  the  pregnancy.  We  shall  consider 
septic  conditions  and  their  influence  later. 

There  is  no  special  relationship  between 
the  time  of  the  year  and  the  attacks,  and 
there  is  but  little  difference  as  to  the  social 
state  of  the  patients  ;  the  general  opinion 
is  that  it  is  more  common  among  the  rich 
than  among  the  poor,  and  that  luxurious 
living  and  indolence  are  really  dangerous 
conditions  in  neurotic  persons. 

Among  the  most  powerfiil  psychical 
causes  must  be  mentioned  previous  attacks ; 
a  woman  who  has  had  one  attack  is 
specially  liable  to  other  attacks  if  the 
pregnancy  follow  quickly  on  recovery  from 
the  former  attack,  and  also  if  the  symp- 
toms and  surroundings  of  the  patient  are 
similar  in  the  two  pregnancies. 

Thus,  some  women  suffer  more  when 
pregnant  with  boys  than  with  girls,  and 
vice  versa,  and  it  may  happen  that  insanity 
accompanies  only  the  one  or  the  other 
sex.  Epilepsy  also  may  occur  during  the 
pregnancy  with  children  of  one  sex  but 
not  with  that  of  the  other. 

Worry  and  anxiety  rnay  play  some  part 
in  the  production  of  puerperal  insanity, 
but  it  is  not  the  worry  of  poverty,  as  the 
disorder  is  less  common  in  the  poor  than 
the  rich.  Illegitimate  pregnancy  seems 
to  be  more  dangerous,  as  might  be  ex- 
l^ected,  in  some  classes  and  in  some  cases 
than  in  others  ;  it  is  more  dangerous,  we 
believe,  directly  as  it  affects  the  social 
status  of  the  individual  and  as  it  inter- 
feres with  rest  and  general  nutrition 
during  the  pregnancy.  Grief,  such  as 
caused  by  the  death  of  husband,  or  of 
other  children,  is  occasionally  a  cause  ;  the 


birth  of  twins  is  among  the  poor  a  grave 
cause  of  depression,  and  may  act  as  a  con- 
tributing cause.  Fright  or  shock,  and 
causes  which  lead  the  mother  to  suspect 
some  injury  to  the  child,  have  also  been 
rarely  given  as  predisposing  conditions. 
We  believe  that  the  administration  of  an- 
aesthetics has  been  a  direct  exciting  cause 
of  puerperal  insanity  in  some  cases.  We 
have  met  with  several  such  in  which  in- 
sanity has  only  occurred  when  these  have 
been  given,  normal  recovery  taking  place 
in  the  same  woman  delivered  without  their 
use. 

Insanity  of  Pregnancy. — This  is  less 
common  than  any  of  the  other  disorders 
which  occur  at  this  pei'iod.  It  is  most 
commonly  associated  with  some  very  dis- 
tinct neurosis  in  the  individual  herself,  as 
well  as  in  her  family.  Thus,  a  daughter  of 
an  insane  mother  who  herself  has  had 
insanity  of  adolescence  or  has  been  an 
hysterical  girl,  is  very  likely  to  develop  in 
a  more  or  less  marked  degree  the  disorder 
to  which  we  now  refer.  Illegitimate  preg- 
nancy may  be  a  contributing  cause,  but  is 
less  common  than  might  be  expected.  As 
a  rule,  the  s3-mptoms  are  of  a  more  or 
less  melancholic  type,  with  loss  of  mental 
power,  of  will  and  energy,  and  with  a  feel- 
ing that  there  is  some  bodily  ailment  pre- 
sent from  which  she  will  not  recover,  or 
that  she  will  not  get  over  the  pregnancy. 
There  may  be  a  special  dislike  and  dis- 
trust of  the  husband  and  aversion  to  the 
other  children  ;  there  may  be  infanticidal 
tendencies.  It  is  common  to  meet  with  a 
history  of  previous  pregnancies  and  of 
previous  attacks  of  insanity  associated 
with  them.  We  have  frequently  met  with 
such  histories  as  the  following  : — A  woman 
has  an  attack  of  post-partum  insanity 
from  which  she  recovers  ;  she  has  another 
attack  of  the  same  nature  followed  by 
another  pregnancy  during  which  she 
develops  insanity,  which  may  pass  off 
during  the  pregnancy,  or  which  may  pass 
from  the  first  into  the  second  group  of 
cases,  being  first  an  attack  of  insanity  of 
pregnancy,  but  later  one  of  ordinary  puer- 
peral insanity. 

The  insanity  of  pregnancy  may  be  only 
an  accentuation  of  the  longingt-  of  that 
period  ;  thus,  while  one  woman  takes  only 
a  diet  of  apples,  another  prefers  pickles, 
and  there  may  yet  be  more  strange  tastes, 
such  as  for  coal  or  slate  pencil.  These 
may  be  of  little  importance  in  themselves, 
but  if  the  longing  be  for  alcohol  there  is 
no  knowing  to  what  this  may  lead.  We 
are  sure  that  these  longings  may  represent 
neuroses,  as  we  have  seen  them  most  pro- 
nounced in  the  members  of  nervous 
families ;    we   have  seen  the  offspring  of 


Puerperal  Insanity 


[    1036    ] 


Puerperal  Insanity 


such  pregnancies  develop  insanity,  while 
other  children  of  the  same  parents  have 
escaped. 

The  insanity  of  pregnancy  occurs 
specially  at  two  periods,  (a)  before  the 
fourth  month,  and  (b)  after  that  time. 

The  cases  occurring  before  the  fourth 
month  are  the  more  hopeful.  They  fre- 
quently pass  off  with  the  sickness  or  at 
the  coming  on  of  the  so-called  "  quicken- 
ing." The  symptoms  vary  from  the 
simple  hysterical  to  the  profoundly  melan- 
cholic, there  being  generally  a  good  deal 
of  moral  disorder  and  tendency  to  cause 
disturbance  in  the  home  relationships.  If 
these  cases  are  placed  under  favourable 
conditions,  for  a  time  being  separated 
from  husband  and  old  surroundings,  the 
symptoms  will  probably  pass  off  about 
the  fourth  month.  There  is  no  indication 
for  the  production  of  abortion  as  this  will 
l^robably  do  no  good. 

Acertain  number  of  patients  get  through 
the  earlier  period  of  pregnancy  without 
trouble,  but  during  the  later  months  be- 
come sleepless,  restless,  timid  and  im- 
pressed by  the  fear  that  some  evil  is  going 
to  happen ;  they  suspect  their  husbands 
of  infidelity,  fancy  that  they  are  going  to 
be  abandoned,  or  that  their  children  are 
to  be  taken  from  them.  Gradually  more 
pronounced  melancholia  may  appear  so 
that  the  patient  has  to  be  put  under  con- 
trol, and  this  is  better  done  early,  for  it  is 
not  like  the  last  group  of  cases  which  will 
be  pretty  certain  to  get  well  at  a  fixed 
time.  These  cases  pass  into  the  ordinary 
forms  of  puerperal  insanity  (after  delivery). 
It  is  not  at  all  common  for  such  patients 
to  be  relieved  by  the  birth  of  the  child, 
though  during  labour  there  may  be  a 
temporary  relief  to  the  symptoms. 

During-  delivery  the  ordinary  emo- 
tional disturbance  may  pass  beyond  all 
bounds,  so  that  a  patient  may  become 
quite  uncontrollable.  We  have  known 
several  women  in  this  state  get  out  of 
bed,  and  rush  about  the  house  threaten- 
ing to  injure  themselves  if  the  child  were 
not  born  soon.  We  have  also  met  with 
cases  of  marked  hysteria  during  labour. 
These  symptoms  may  pass  off  with  de- 
livery, and  this  is  the  rule  ;  but  in  others 
the  symptoms  pass  into  a  more  organised 
form  of  maniacal  excitement.  It  is  note- 
worthy, too,  that  in  some  cases  in  which 
there  has  been  mental  depression  during 
the  later  months  of  pregnancy,  delivery 
may  take  place  without  any  apparent 
pain,  and  thus  the  child  may  die  untended 
without  there  being  any  iufanticidal  in- 
tention. 

During  delivery,  as  already  stated,  some 
patients  who  have  been  depressed  become 


temporarily  bright  and  sane,  only  to  re- 
lapse in  the  course  of  a  few  hours.  It 
will  appear,  then,  that  with  natural 
labour  in  specially  emotional  subjects, 
there  may  be  maniacal  excitement  as  an 
exaggeration  of  the  ordinary  disturbance, 
and  that  this  may  pass  off  or  may  develop 
into  true  insanity, 

Ephemeral  Insanity  (Mania  Transi- 
toria)  after  Child-birth. — This  state  is 
not  much  recognised,  but  is  important 
from  a  medico-legal  point  of  view,  as  well 
as  from  the  physician's  stand-point. 
Some  women,  especially  those  who  are  in 
weak  health,  and  who  belong  to  a  ner- 
vously unstable  stock,  within  the  first 
week,  generally  within  the  first  three  days 
of  delivery,  become  suddenly  delirious 
with  rapid  small  pulse,  tremulous  tongue, 
and  great  restlessness.  There  may  have 
been  a  period  during  which  there  was  a 
dread  of  impending  evil.  This  deUrious 
state  may  have  been  preceded  by  a  rigor, 
but  this  is  not  very  common.  The  breasts 
are  tense  or  tender,  and  the  bowels  are 
confined.  This  state  may  pass  off  as 
rapidly  as  it  came  on,  being  relieved  by 
the  onset  of  the  milk,  or  by  a  free  action 
of  the  bowels.  It  must  be  remembered 
that  in  this  state  the  mother  may  injure 
herself  or  her  child,  and  in  the  latter  case 
she  may  be  quite  unconscious  of  the  act 
which  she  has  done.  It  is  well  to  remem- 
ber that  there  may  be  a  temporary  relief 
from  the  mental  disorder  which  may 
recur,  to  run  the  ordinary  course  of  puer- 
peral insanity.  Or  this  may  start  a  form 
of  delirious  mania  hardly  to  be  distin- 
guished from  septic  puerperal  insanity. 

Ordinary  Puerperal  Insanity. — The 
causes  already  considered  require  to  be 
referred  to  rather  more  in  detail  before 
proceeding  to  the  consideration  of  the 
forms  of  the  disorder  and  its  course. 
Hereditary  neuroses  are  very  commonly 
met  with  in  these  cases,  and  play  a  very 
important  part.  Insanity  follows  the 
birth  o£  first  children  more  than  other  de- 
liveries, but  it  must  not  be  forgotten  that 
one  quarter  of  such  cases  do  not  recover, 
and  so  do  not  run  the  same  risk  again, 
and  a  certain  jDroportion  of  first  cases  die, 
yet  these  facts  being  taken  into  conside- 
ration the  first  deliveries  are  the  most 
dangerous.  Child-bearing  begun  after 
thirty  is  in  our  experience  specially  dan- 
gerous. As  far  as  the  nature  of  the  de- 
livery is  concerned,  we  do  not  think  that 
instrumental  labour  affects  the  risk  to 
any  appreciable  degree  ;  the  majority  of 
our  cases  have  been  delivered  naturally 
and  rapidly.  There  is  some  increase  in 
the  danger  if  the  labour  has  been  very 
prolonged,  and  if  there  has  been  excess  of 


Puerperal  Insanity         [     1037    ]         Puerperal  Insanity 


haemorrhage.  The  occurrence  of  twins 
has  been  a  not  nncommou  condition,  but 
we  are  not  in  a  position  to  state  whether 
this  was  in  greater  proportion  than  might 
be  naturally  expected  in  the  proper  pro- 
portion of  such  cases. 

Drink  adds  a  slightly  increased  danger 
to  these  cases,  but  here  again  intempe- 
rance is  so  commonly  associated  with 
neurotic  heredity  that  we  feel  it  hard  to 
decide  what  part  it  really  plays  in  the 
production  of  the  insanity.  The  next 
causes  to  be  specially  referred  to  are  sep- 
tic. It  was  originally  thought  by  Sir  J. 
Simpson  that  albuminuria  was  common 
in  puerperal  insanity.  This  has  not  been 
our  experience,  but  Dr.  Campbell  Clark 
has  recently  reported  his  experience,  which 
showed  a  rather  large  proportion  of  cases 
in  which  some  albumen  was  found  in  the 
urine.  Therefore  the  relationship  of  the 
insanity  to  renal  complications  remains 
undecided.  We  believe  that  convulsions 
may  be  a  cause  of  mental  disorder,  and 
these  generally  are  associated  with  albu- 
minuria. 

It  is  necessary  for  us  to  point  out  that 
there  are  different  modes  of  blood-poison- 
ing which  may  be  in  action.  Thus  the 
source  maj'  be  purely  external,  such  as 
alcohol  or  scarlet  fever  poison  ;  or  it  may 
arise  from  within,  as  in  the  sepsis  due  to 
retention  of  the  uterine  discharges ;  or 
the  source  of  poisoning  may  be  double, 
as  seen  in  some  cases  in  which  alcoholism 
or  uraemia  is  associated  with  suppres- 
sion of  lochia  or  of  milk.  Suffice  it  to 
say,  that  from  whatever  source  derived, 
blood-poisoning  may  be  directly  related 
to  puerperal  insanity.  We  believe  that 
neurotic  patients  are  specially  liable  to 
some  septic  influences,  and  we  know  that 
depressing  nervous  conditions  will  con- 
duce to  the  development  of  blood-poison- 
ing in  suitable  conditions,  such  as  the 
puerperal  period.  We  shall  later  refer  to 
the  special  symptoms  met  with  in  septic 
puerperal  insanity  which  support  our 
views.  We  fear  that  at  present  the  sta- 
tistics of  puerj^eral  insanity  are  defective, 
as  to  complete  them  we  need  the  experi- 
ence of  the  general  practitioner,  the  gene- 
ral physician,  as  well  as  the  specialist,  for 
a  very  large  number  of  cases  occurring  in 
private  practice  are  never  seen  by  the  last 
named. 

If  blood-poisoning  be  the  cause,  the 
symptoms  develop  within  a  few  days  of 
the  delivery,  and  there  is  generally  marked 
increase  of  temperature,  which  is  variable 
in  its  elevation.  There  may  or  may  not 
be  rigors.  The  general  aspect  is  similar 
to  that  met  with  in  delirium  tremens  or 
in  acute  delirious  mania.     The  milk  and 


lochia  are  generally  arrested,  though  this 
is  not  universally  the  case.  'Lhere  may 
be  the  development  of  secondary  trouble, 
such  as  2>neumonia,  local  abscesses  and 
the  like. 

We  have  done  no  more  here  than  state 
the  symptoms  as  they  occur,  leaving  it 
till  later  to  discuss  them  in  more  detail. 
The  use  of  chloroform  has  in  some  in- 
stances been  followed  by  nervous  troubles 
in  such  peculiar  circumstances  as  to  make 
us  believe  that  it  may,  in  some  cases,  be 
at  least  a  partial  cause  of  the  insanity. 

IMCoral  Causes.  —  As  already  stated, 
these  are  not  so  common  in  puerperal 
insanity  as  might  be  expected,  yet  they 
do  in  some  cases  act  as  partial  causes  of 
the  disorder.  Dread  of  the  delivery, 
especially  when  a  former  delivery  has  been 
followed  by  physical  or  mental  disorder,  is 
very  powerful  for  evil,  and  in  the  same 
way  a  previous  attack  of  insanity  in  the 
patient  or  a  near  relation  may  have  the 
same  effect ;  desertion  by  the  father  of 
the  child,  or  his  death,  the  death  of  a  child, 
or  other  cause  of  grief  may  do  much  to 
prepare  the  way  for  an  attack.  The  shock 
of  labour  itself,  or  the  shock  or  fright 
produced  by  foolish  or  brutal  acts  perpe- 
trated at  the  time  of  delivery  are  of 
serious  importance.  Thus  we  have  seen  a 
woman  so  frightened  by  the  sight  of  the 
placenta  that  she  could  not  sleep,  and 
passed  into  a  maniacal  state.  A  drunken 
nurse,  or  a  violent  or  drunken  husband  has 
been  seen  to  cause  the  same,  and  we  think 
it  worth  recording  that  in  a  fair  number 
of  patients  who  have  recovered,  there  has 
been  a  history  that  their  mental  disorder 
was  started  by  a  terrifying  dream.  In 
some,  no  doubt,  the  dream  was  part  of 
the  unhealthy  nervous  process  already 
begun.  The  causes  may  be  predisposing 
or  exciting  ;  simple  or  mixed;  single  or 
combined ;  and  in  the  great  majority  of 
cases  there  are  predisposing  influences, 
which  are  stimulated  into  action  by  more 
than  one  exciting  cause. 

To  sum  up :  the  causes  most  com- 
monly met  with  are,  hereditary  tendencies 
to  neurosis,  advanced  age  at  first  preg- 
nancy, frequent  pregnancy,  especially  in 
those  who  are  nervously  degenerate,  pre- 
vious nervous  illnesses ;  the  sex  of  the 
child  may  exert  an  influence;  so  may  the 
nature  of  the  labour,  the  occurrence  of 
eclampsia,  blood-poisoning,  or  the  weak- 
ness of  flooding  ;  and  besides,  there  are 
certain  depressing  moral  influences,  such 
as  shock,  which  may  directly  tend  to  pro- 
duce the  disorder. 

The  forms  which  puerperal  insanity 
may  assume  are  almost  as  manifold  as  the 
names  given  to  mental  diseases.  Wo  have 


Puerperal  Insanity         [     1038    ]         Puerperal  Insanity- 


seen  every  variety,  from  exaggerated  hys^ 
teria  to  general  paral^^sis  of  the  insane, 
but  there  are  certain  pretty  well  recog- 
nised forms  which  it  may  be  well  espe- 
cially to  refer  to,  as  they  are  the  more 
common.  We  have  already  spoken  of  the 
ephemeral  mania,  Avhich  may  be  associ- 
ated with  the  influx  of  milk  ;  but  there  is 
also  a  t3"pe  of  hysterical  mania  which  is 
not  very  uncommon.  This  is  generally  met 
with  in  primiparce  of  nervous  or  weakly 
stock.  The  labour  being  perfectly  natural, 
all  going  well  for  several  days,  querulous- 
ness  is  noticed  and  intolerance  of  husband 
or  child :  then  there  are  emotional 
displays  of  a  markedly  hysterical  type, 
sleeplessness,  constipation  and  capricious- 
ness  about  food  follow.  The  symptoms 
may  not  go  beyond  this,  but  for  some 
days  they  may  cause  the  utmost  anxiety  ; 
for  there  is  no  rule  by  which  to  tell 
whether  the  case  will  remain  in  this  state 
or  develo])  into  one  of  the  moi-e  advanced 
forms.  The  best  treatment  is  absolute 
quiet,  the  friends  not  being  allowed 
access,  the  baby  is  to  be  weaned,  the 
bowels  are  to  be  freely  relieved,  and  all 
the  general  antiseptic  and  other  measures 
usual  are  to  be  followed  carefully,  seeing 
particularly  that  the  breasts  are  tended 
and  the  lochial  discharge  removed ;  we 
believe  it  is  often  good  at  this  period  to 
give  some  diffusible  stimulant,  such  as 
champagne  or  brandy  and  soda  water. 
A  week,  as  a  rule,  suffices  to  clear  up 
these  cases.  We  have  known  one  woman 
have  several  similar  short  attacks  in  re- 
curring pregnancies. 

The  next  form  to  be  noticed  is  the 
ordinary  puerperal  mania.  This  may 
depend  on  the  development  of  the  last 
class,  or  may  be  in  some  way  connected 
with  blood-poisoning.  In  these  cases  the 
symptoms  generally  come  on  with  the 
same  sort  of  moral  disorder  and  emotional 
disturbance  as  the  last,  although  it  is 
more  common  to  meet  with  a  history  of 
slight  depression.  The  patient  may  have 
been  found  crying,  and  when  pressed  as 
to  the  cause  has  said  that  she  felt  she  was 
going  to  die,  or  was  going  to  be  taken  from 
her  home  and  her  baby.  This  depression 
may  slowly  pass  into  a  state  of  discontent 
with  those  about  her,  and  at  this  period 
the  nurse  is  almost  sure  to  be  blamed  both 
by  patient  and  friends. 

The  maniacal  onset  generally  occurs 
within  the  first  fourteen  days  after  deliv- 
ei-y,  but  it  may  occur  later,  and  be  due  to 
exhaustion.  Thei'e  is  little  or  no  increase 
of  temperature.  The  appetite  is  generally 
bad  or  variable  ;  the  skin  is  j^ale,  not  dis- 
coloured or  flushed  ;  the  tongue  is  tremu- 
lous, the  bowels  confined ;  the  milk  may 


be  present  or  absent ;  the  lochial  discharge 
may  be  present  or  absent ;  the  general 
strength  fails  rapidly  ;  the  sleep  is  wanting 
or  broken,  often  disturbed  by  dreams ; 
there  is  jealousy  and  irritability,  loss  of 
power  of  attention,  and  feeling  of  restless- 
ness ;  there  may  be  eroticism  and  mistakes 
as  to  personal  identity,  and  as  to  that  of 
friends.  These  symptoms  may  be  followed 
by  or  associated  with  hallucinations  or 
delusions.  There  are  often  spectral  hallu- 
cinatioTis,  and  hallucinations  of  smell  are 
frequent,  the  (skin)  feeling  may  also  be 
morbidly  affected ;  hearing  is  at  times 
disturbed,  but  not  quite  so  commonly  as 
the  other  senses  already  referred  to.  Sugar 
may  be  present  in  the  urine  for  a  time. 

In  such  a  case  as  that  already  described, 
the  symptoms  will  vary,  there  being  many 
lulls  which  mislead  the  friends  into  the 
belief  that  recovery  has  taken  place,  but 
as  a  rule  the  cases  pass  from  the  more 
acute  stage  through  a  more  or  less  chronic 
stage  of  excitement,  before  any  real  im- 
provement takes  place.  Thus  after,  say 
six  or  eight  weeks,  of  acute  mania,  the 
patient  begins  to  eat  and  drink  well,  to 
sleep  better,  to  get  stouter,  but  at  the 
same  time  there  is  a  marked  dissatisfac- 
tion with  her  past  treatment  by  her 
friends.  She  accuses  nurses,  doctors  and 
others  of  unkindness,  and  expresses  a 
general  discontent.  This  stage  often  lasts 
a  few  weeks,  and  may  become  permanent, 
or  it  may  pass  off  altogether,  or  may 
further  pass  into  one  of  placid  fatness  and 
weakness  of  mind,  which  may  be  recovered 
from,  or  may  become  lasting.  In  many 
cases  there  is  apathy  associated  with 
amenorrhoea,  and  in  this  state  it  is  well, 
if  possible,  to  try  the  eff"ect  of  return  to 
home  surroundings  and  duties,  even  in- 
cluding cohabitation,  precautions  against 
pregnancy  being  taken. 

The  general  course  of  these  attacks  is 
first,  slight  depression,  followed  by  excite- 
ment, which  may  vary  greatly  in  degree 
from  time  to  time.  This  maj^  be  followed 
by  a  return  to  general  health  without  any 
mental  gain  for  a  time.  Although  about 
75  per  cent,  of  these  cases  recover,  some 
die  from  secondary  affections,  or  from 
sudden  exhaustion,  and  some  remain 
permanently  weak-minded,  deluded,  or 
unstable.  It  is  to  be  noted  that  though 
most  of  the  cases  which  recover  do  so 
within  the  first  nine  months,  yet  a  few  ulti- 
mately get  well  after  from  one  to  three 
years  of  apparently  hopeless  dementia. 

The  next  group  to  be  referred  to  con- 
tains those  cases  which  depend  on  septic 
causes,  and  we  repeat  that  there  are  some 
neurotic  people  who  seem  to  be  predis- 
posed to  blood-poisoning  by  their  neurosis: 


Puerperal  Insanity         [     1039    ]         Puerperal  Insanity 


conditions  of  vital  depression  and  expec- 
tancy will  lead  to  serious  danger.  It  is 
rare  to  meet  with  a  case  of  puerperal 
insanity  which  depends  solely  on  septic 
causes.  In  septic  cases  the  symptoms 
come  on,  as  a  rule,  within  a  short  time  of 
delivery,  with  or  without  rigors,  with  vari- 
able increase  in  temperature,  cessation  of 
the  lochia  and  the  milk ;  but  one  or  aU  of 
these  symptoms  may  be  modified.  The 
tendency  of  the  symptoms  is  to  start 
without  any  initial  depression.  There  is 
a  near  ai^proach  to  delirium  in  the  excite- 
ment, and  the  confusion  of  the  senses  also 
resembles  this  more  than  mania.  The 
ordinary  symptoms  of  puerperal  septi- 
caemia may  be  masked.  There  may  be 
no  complaint  of  lung  trouble,  though 
pneumonia  may  be  present.  It  seems  to 
us  that  a  very  considerable  number  of 
patients  with  some  septic  troubles  follow- 
ing delivery  and  associated  with  mental 
disorder,  recover ;  more,  in  fact,  than  we 
should  have  expected,  looking  at  the 
gravity  of  the  complication;  there  may  be 
in  such  cases  a  tendency  to  secondary 
deposits  of  pus,  and  there  may  be  active 
delirium,  delirious  mania,  with  refusal  to 
take  food,  great  restlessness,  sleepless- 
nes,  and  violence.  The  refusal  of  food  is 
one  of  the  most  dangerous  symptoms,  and 
one  for  which  steps  have  to  be  taken  at 
once  if  life  is  to  be  saved.  The  progress 
of  these  cases  is  generally  rapid,  so  that 
little  is  to  be  done  beyond  the  utmost  care 
as  to  general  measures  and  feeding.  We 
have  known  the  mental  symptoms  relieved 
by  the  occurrence  of  some  localised  septic 
complication.  It  may  be  necessary  to  use 
hypnotics,  but  in  all  cases  these  must  be 
given  with  great  caution,  and  we  prefer  to 
give  stimulants  as  well,  if  not  instead  of 
these.  Chloral  or  sulphonal  is  of  use, 
but  we  do  not  think  that  hyoscyamine 
should  be  tried,  as  the  depressing  effects 
are  serious,  and  a  further  distaste  for  food 
may  arise  from  the  dryness  of  the  throat. 
If  the  patient  get  over  the  blood-poisoning 
there  may  follow  a  period  of  mental  dis- 
order of  a  maniacal  type,  or,  what  is  more 
common,  a  period  of  partial  mental  weak- 
ness with  or  without  stupor  may  follow. 
In  the  state  of  mania  the  ordinary 
measures  will  have  to  be  tried,  but  it 
is  noteworthy  that  most  of  these  patients 
are  very  hard  to  be  managed,  and  are 
erotic,  obscene,  and  filthy,  and  so  are  unfit 
for  home  treatment.  In  the  stage  of 
stupor  or  dementia,  time  and  suitably 
adapted  changes  are  to  be  tried,  the  visits 
of  friends  often  being  useful,  and  as  soon 
as  all  signs  of  suicidal  or  destructive 
tendencies  have  passed  the  patient  ought 
to  be  tried  at  home,  under  precautions. 


The  greatest  difficulty  in  cases  of  this 
kind  is  to  distinguish  between  true  septic 
mania  and  acute  delirious  mania,  and  it 
is  only  after  very  careful  study  of  all  the 
points  in  the  case  that  this  can  be  made 
certain.  It  is  not  of  very  great  impor- 
tance, from  the  physician's  point  of  view, 
as  the  ti-eatment  will  be  similar  in  both 
conditions,  but  the  friends  greatly  prefer 
"  blood-poisoning  "  to  "  insanity." 

In  the  first  place  the  septic  cases  fre- 
quently arise  in  association  with  other 
bodily  symptoms,  such  as  rigors,  suppres- 
sion of  discharges,  sallowness  of  com- 
plexion, sweating  and  the  like.  The 
tongue  is  often  covered  with  a  white  fur 
and  is  tremulous.  The  onset  has  not,  as 
a  rule,  followed  any  special  moral  trouble, 
but  may  have  been  quite  sudden  or  con- 
nected only  with  symptoms  of  sepsis,  the 
mental  disorder  coming  on  later.  In 
acute  delirious  mania,  it  is  more  common 
to  get  a  history  of  a  fright  or  sudden 
cause  of  mental  disorder  followed  by 
mental  depression,  which  may  have  lasted 
only  a  few  hours,  but  was  well  marked. 
There  may  be  neither  rigors  nor  suppres- 
sion of  the  discharges,  or  this  suppression 
may  follow  the  first  symptoms  of  the 
insanity.  The  skin  is  i^ale  rather  than 
sallow,  with  a  tendency  to  a  flush  of  the 
cheeks  ;  the  tongue  very  rapidly  gets  dry 
and  brown  out  of  proportion  to  the  amount 
of  recorded  temperature.  This  latter 
symptom  can  only  give  indefinite  help,  for 
in  both  the  temperatm-e  is  raised  and  un- 
certain, but  in  septic  cases  the  tempera- 
ture is  likely  to  be  higher  and  more  irre- 
gular, rising  at  night,  while  in  acute 
delirious  mania  the  temperature  is  little 
above  101°,  yet  the  patient  has  the  aspect 
of  extreme  febrile  disorder.  In  both,  we 
believe  that  large  doses  of  quinine  and  a 
free  supply  of  alcoholic  stimulants  are  the 
proper  treatment,  yet  with  all  care  the 
majority  die. 

Instead  of  maniacal  excitement  there 
may  be  excitement  of  the  melancholic 
type.  Thus,  a  patient  with  or  without  any 
real  cause  for  anxiety  becomes  emotional 
or  depressed,  full  of  foreboding,  sleepless, 
and  with  distaste  for  food ;  then  passes 
into  a  state  of  terror  that  something  is 
going  to  be  done  to  her  child,  her  hus- 
band or  herself.  Thei'e  is  a  tendency, 
which  rapidly  develops,  to  resist  every 
attempt  to  do  anything  for  her,  and  it  is 
common  to  meet  with  patients  who  repeat 
over  and  over  again  the  same  piteously 
monotonous  sentence,  such  as  that  she 
does  "  not  know  what  to  do,"  or  that  it 
was  "  not  her  fault."  With  this  there 
may  or  may  not  be  active  attempts  at 
escape   or   self-injury ;  nothing  that  can 


Puerperal  Insanity         [    1040    ]         Puerperal  Insanity 


be  done  seems  to  give  any  rest,  and  the 
case  is  for  a  time  an  example  of  resistive 
melancholia.  These  cases  are  tedious,  and 
require  constant  feeding  and  care  as  to 
their  bodily  functions,  and  little  in  the 
way  of  change  of  surroundings  or  stimu- 
lation effects  any  good.  Waiting  and 
painstaking  care  are  often  rewarded  by  a 
return  to  health,  and  hope  need  not  be 
given  up  for  two  years  at  least.  This  is 
generally  i^receded  by  return  of  the 
menses,  which  are  almost  always  absent 
during  the  disordered  stage,  and  return  of 
sleep  and  appetite  and  improved  general 
circulation,  as  seen  in  better  nutrition  and 
healthier  complexion.  In  these  cases 
from  time  to  time  the  husband  and 
children  should  be  allowed  to  see  the 
patient.  At  the  end  of  a  few  months 
change  should  be  tried,  from  one  asylum 
or  home  to  another.  In  some  of  these 
cases  the  bodily  wasting  is  such  that 
massage  may  be  tried. 

In  other  cases  the  melancholia  is  less 
active,  but  there  may  be  more  marked 
delusions,  and  these  cases  are,  as  a  rule, 
untrustworthy  and  suicidal.  They  often 
have  hallucinations  of  their  senses,  and 
may  be  led  to  desperate  acts.  In  some 
there  are  ideas  of  ruin  or  unworthiness, 
sleeplessness  of  a  passive  kind  is  also 
common,  and  food  may  be  refused.  Here 
again,  time  and  steady  care  with  endeavour 
to  excite  interest  in  the  outside  and  family 
world  are  useful,  but  from  six  to  twelve 
months  is  usually  required  before  the 
mental  health  is  restored.  Menstruation 
is  generally  absent  for  some  time.  In 
some  of  these  cases,  as  in  those  of  mania, 
there  may  be  a  period  of  careless  indiffer- 
ence to  home  and  its  surroundings,  which 
may  render  it  well  that  the  patient  should 
be  sent  there  on  trial. 

In  nearly  all  ordinary  cases  of  puerperal 
insanity  there  is  a  period  of  apathy  ;  this 
may  be  the  initial  or  terminal  symptom 
of  the  attack.  A  mother  may  be  careless 
about  her  child  and  her  husband  without 
having  any  really  melancholic  feeling. 
This  state  varies  from  simple  indifference 
to  the  most  profound  stupor,  and  the 
different  cases  must  be  treated  on  different 
plans.  Thus,  in  the  simpler  cases  removal 
from  home  for  a  few  weeks  will  suffice, 
while  in  others  the  removal  to  asylum  care 
is  necessary. 

These  cases  are  as  curable  as  the  others, 
but  take  from  four  to  twelve  months  as  a 
rule.  All  varieties  of  stupor  may  be  re- 
presented during  this  period. 

There  remain  still  to  be  considered 
cases  in  which  the  disorder  is  more 
generalised,  in  which  something  allied  to 
primary   delusional   insanity    arises.     In 


our  experience  patients,  who,  as  it  were, 
are  saturated  with  neurosis,  and  in  whom 
puerperal  conditions  only  act  as  the  excit- 
ing causes  of  disorder,  may,  after  delivery, 
develop,  rapidly  or  slowly,  symptoms  of 
suspicion  and  doubt ;  they  may  then 
become  solitary,  dissatisfied,  and  later, 
after  separating  from  home  ties,  they  may 
be  discovered  to  have  all  sorts  of  sensory 
perversions  and  delusions.  In  some  cases 
the  patient  has  ideas  of  persecution,  ideas 
that  conspiracies  are  being  formed  against 
her,  fancies  that  the  husband  is  unfaith- 
ful— this  is  a  very  common  idea — ideas 
that  the  children  are  not  hers,  or  that 
they  are  being  affected  or  infected  in  some 
way.  It  is  almost  endless  to  attempt 
to  describe  the  forms  which  this  disorder 
may  assume.  We  believe  that  if  seen 
early  and  sent  away  from  home,  under 
proper  conditions  and  with  a  suitable 
companion,  recovery  may  often  follow  in 
such  cases,  but  there  is  a  proportion  of 
these  cases  in  which  nothing  makes  any 
difference,  and  who  once  having  broken 
down  never  recover. 

The  duration  of  the  symptoms  and 
their  complete  organisation  make  the 
prognosis  unfavourable.  In  these  cases 
the  bodily  health  is  good,  and  the  patients 
may  live  at  least  as  long  as  ordinarj'' 
persons. 

In  the  last  place,  we  must  record  the 
fact,  which  we  believe  has  not  been  gene- 
rally recognised,  that  general  paralysis  of 
the  insane  may  arise  after  pregnancy  and 
childbirth  without  any  other  apparent 
cause.  In  these  cases  we  have  known  at 
least  four  women  who,  after  leading 
healthy  lives,  and  without  special  or 
general  predisposing  causes,  have  slowly 
developed  mental  weakness,  fits  of  an 
epileptiform  nature,  tremulousness,  loss 
of  exjiression,  and  the  rest  of  the  ordinary' 
symptoms  of  general  paralysis  of  the  in- 
sane. In  one  such  case  the  patient  had  a 
remission,  during  which  she  again  became 
pregnant.  It  is  noteworthy  that  in  some 
female  general  paralytics  the  menses  will 
continue  uj)  to  the  end.  We  believe  the 
tendency  in  these  cases  is  rapidly  to  de- 
mentia, and  that  there  is  little  risk  of  ex- 
travagance, though  eroticism  is  not  iin- 
common.  The  prognosis  in  these  cases  is 
bad. 

As  alread}^  said,  ever}'  form  of  mental 
disoi'der  may  be  met  with  in  puerperal 
insanity  ;  in  asylums  every  form  of  chro- 
nic insanity  may  be  met  with  which  has 
had  this  for  its  cause,  and  it  is  not  neces- 
sary to  give  in  any  detail  notes  of  such 
cases,  but  it  is  well  to  state  that  in 
patients  who  have  become  insane  at  such 
periods  and  recovered,  there  may  be  a  ten- 


Puerperal  Insanity         [     1041     ]  Puerperal  Insanity 


dency  to  finally  break  down  at  the  climac- 
teric, instead  of,  as  might  be  expected, 
gaining  increased  stability.  And  again, 
cases  of  chronic  puerperal  insanity  do  not 
often  get  well  at  the  climacteric,  yet  a  few 
of  the  cases  of  melancholia  will  thus 
almost  suddenly  recover.  Some  patients 
who  have  had  attacks  of  puerperal  in- 
sanity never  have  recurrences,  but  others 
have  attacks  with  each  returning  preg- 
nancy. Patients  who  have  had  attacks 
of  puerperal  insanity  are  often  rendered 
more  liable  to  break  down  from  other 
causes,  and  others  are  never  the  same  in 
habits  and  mode  of  action  as  before  the 
illness.  There  are  a  certain  number  of 
patients  who  are  morally  perverse  after 
one  or  more  such  attacks. 

Puerperal  insanity,  then,  is  variable  in 
its  symptoms,  is  liable  to  recur,  is  fairly 
curable,  but  is  not  uncommonly  associated 
with  grave  dangers  to  life. 

Insanity  of  I>actation. — This  is  arbi- 
trarily fixed  as  mental  disorder  following 
six  weeks  or  later  after  delivery.  This  is 
like  the  other  forms  ah'eady  considered, 
there  being  no  special  causes  needing  to 
be  named.  It  is  not  infrequently  asso- 
ciated with  weaning,  so  that  we  prefer  to 
divide  the  cases  into  those  in  which  the 
disorder  follows  immediately  on  weaning, 
and  those  in  which  the  insanity  seems  to 
develop  out  of  the  physical  exhaustion  of 
suckling,  commonly  associated  with  other 
causes  of  vital  depression.  The  former 
class  presents  cases  in  which  there  is 
commonly  mental  depression  with  one  or 
other  of  the  forms  of  delusions  of  dread, 
fear,  jealous}-  and  suspicion.  There  will 
be  often  ideas  related  to  the  reproductive 
organs,  fancies  that  people  are  trying  to 
infiuence  or  mesmerise  them  and  the  like. 
There  may  be  very  suicidal  tendencies, 
and  it  is  in  such  cases  that  infanticidal 
ideas  as  well  as  acts  are  commonly  met 
with.  There  is  generally  amenorrhoea 
with  complaints  that  "  feeling  is  dead  ;  " 
complaints  of  weight  or  pains  in  vertex  or 
occiput,  and  an  utter  inability  to  care  for 
children  or  husband.  There  is  often  an 
extension  of  this,  so  that  the  patient 
believes  herself  forsaken  of  God.  These 
cases  need  very  careful  watching,  and  are 
rarely  fit  for  home  treatment,  asylums 
being  the  only  safe  place  for  them. 
Tonics,  baths  and  change  of  scene  and 
absence  from  home  are  generally  followed 
by  recovery  in  from  three  to  six  months. 

In  the  other  cases  in  which  there  is 
physical  exhaustion  as  the  chief  cause  of 
breakdown,  the  patient  may  often  be 
treated  at  the  seaside  with  nurses,  the 
great  thing  being  change  from  home  and 
abundant  food  and  rest.     In  these  latter 


cases  death  from  phthisis  or  some  secon- 
dary cause  is  to  be  guarded  against. 

There  is  no  special  form  of  insanity 
following  lactation  ;  the  symptoms  may 
be  those  of  mania,  melancholia,  dementia, 
stupor,  or  may  from  the  outset  be  delu- 
sional. In  nearly  all  cases  there  is  marked 
physical  exhaustion.  The  symptoms  may 
come  on  at  any  time  after  delivery  from 
six  weeks  up  to  one  year  or  more.  It 
is  much  more  common  among  the  poor 
than  the  well-to-do.  It  is  frequent  in 
those  predisposed  by  hereditary  weak- 
ness;  it  is  common,  too,  in  those  who 
have  had  other  attacks  of  insanity,  such 
as  puerperal  insanity  or  the  insanity  of 
pregnancy  ;  it  is  not  uncommonly  met 
with  in  i^atients,  who  from  one  cause  or 
another  approached  or  passed  through 
their  puerperal  period  in  an  exhausted 
state  ;  it  appears  in  some  cases  to  depend 
on  prolonged  or  repeated  suckling,  or  on 
over-nursing,  as  with  twins ;  while  in 
some  cases  weaning  seems  to  be  the  real 
active  excitant.  The  state  of  the  uterus 
may  also  have  an  influence.  Thus,  sub- 
involution is  not  uncommon,  and  with 
this  there  may  be  metrorrhagia  or  leucor- 
rhoea.  It  has  been  supposed  that  there 
is  more  danger  at  the  time  representing 
the  first  return  of  the  menstrual  period 
after  delivery,  but  we  have  no  experience 
to  confirm  this  opinion.  In  a  few  cases 
mammary  abscesses  have  acted  as  exciting 
causes. 

The  onset  of  the  disease  may  be  quite 
sudden,  but  as  a  rule  sleeplessness  and 
dread  are  among  the  earliest  symptoms, 
and  the  mothers  may  continue,  greatly  to 
the  danger  of  their  children,  to  suckle 
while  still  suffering  from  the  earlier  symp- 
toms of  mental  disorder.  The  duration 
of  the  disease  varies  from  three  months  to 
eighteen  months  or  more.  The  symptoms 
may  pass  from  initial  melancholia  through 
maniacal  excitement,  to  partial  dementia, 
to  be  slowly  replaced  by  health.  There  is 
almost  always  a  pei'iod  of  dull  apathy,  in 
which  the  patient  may  become  fat,  sleepy, 
and  indolent,  while  there  is  also  absence 
of  menstruation.  These  symptoms  may 
pass  off  rapidly  with  a  return  to  home 
cares  and  surroundings.  In  our  experi- 
ence nearly  80  per  cent,  of  these  cases 
recover,  5  to  8  per  cent,  die,  the  rest 
remaining  more  or  less  j^ermanently  de- 
ranged. The  ordinary  course  of  the  dis- 
order is  as  follows  : — 

A  woman  rendered  physically  weak 
from  some  cause  when  still  suckling 
becomes  emotional,  sleeisless,  irritable, 
and  hard  to  deal  with.  She  may  make 
accusations  against  those  near  her,  may 
be  generally  comj^laining.    This  state  may 


Pulse  in  Insanity 


[     1042    ] 


Pulse  in  Insanity 


pass  slowlj'  or  almost  suddenly  into  one  of 
])rofound  disturbance  of  feeling,  in  which 
she  ma}'  kill  herself  or  her  children,  or 
may  impulsively  attack  husband  or  nurse. 
She  may  develop  hallucinations  of  any  of 
her  senses,  but  we  believe  that  hallucina- 
tions of  sight  and  of  smell  are  specially 
common  :  she  may  refuse  food  and  rapidly 
lose  strength,  till  her  case  is  rendered 
serious  from  simple  exhaustion.  The 
melancholia  may  last  for  a  longer  or 
shorter  time,  and  may  vary  greatly  in 
degi'ee  from  time  to  time,  there  often 
appearing  breaks  in  the  clouds  before  its 
final  dissipation.  In  some  cases,  instead 
of  melancholia  there  is  an  outbreak  of 
maniacal  excitement  with  impulsive  vio- 
lence, and  often  there  is  great  eroticism. 
With  either  of  the  forms  of  disorder  it  is 
common  to  meet  with  special  aversion  to 
or  delusions  about  the  husband.  The 
form  in  which  stupor  is  present  is  hardly 
to  be  distinguished  from  profound  melan- 
cholia. In  all  cases  the  prognosis  is  de- 
cidedly good  unless  there  be  some  second- 
ary bodily  disease.  The  treatment  is  one 
of  feeding  and  tonics,  with  change  of  scene 
and  surroundings  for  some  time,  tonics 
such  as  the  more  simple  forms  of  iron  in 
effervescent  form,  cod-liver  oil,  peptonised 
milk,  cocoa,  soups,  with  a  fair  amount  of 
stimulant.  We  prefer  malt  liquor  as  a 
rule  to  wine.  Attention  to  the  bowels  is 
necessary,  and  a  return  to  home  as  soon 
as  delusions  have  passed  away. 

George  H.  Savage. 
PVliSx:  IM"  INSANITY. — There  are 
few  diseases,  either  mental  or  bodily,  into 
which  a  consideration  of  the  pulse  does 
not  enter  as  an  element  of  greater  or  less 
importance,  either  in  connection  with  the 
diagnosis,  prognosis,  or  treatment,  and  so 
it  occurs  in  the  insane  that  from  each  of 
these  points  of  view  some  information  is 
to  be  derived  by  close  examination.  The 
cardio-vascular  system  is  doubtless  af- 
fected in  some  way  by  evei'y  transient 
thought,  by  every  voluntary  effort,  a  point 
demonstrated  by  the  experiments  of 
jVIosso,  who  was  able  to  show  by  means 
of  the  plethysmograph,  that  during  active 
mentalisation  the  amount  of  blood  pass- 
ing to  the  arm  was  appreciably  diminished, 
and  at  the  same  time  it  was  observed  that 
the  radial  pulse  became  considerably 
smaller  and  more  frequent.  The  relative 
condition  of  the  pulse  in  the  carotid  and 
radial  arteries  during  intellectual  effort 
has  been  studied  by  Gley,  who  observed 
that  at  this  period  the  carotid  pulse  be- 
came more  frequent  and  exhibited  the 
condition  of  dicrotism,  which  was  not  pre- 
sent in  the  radial  artery  at  the  same  time, 
an   observation   which  would  indicate  a 


dilatation  of  the  encephalic  vessels,  caus- 
ing a  more  rapid  circulation  of  the  intra- 
cranial blood  to  supply  the  increased  de- 
mand for  nutritive  material  made  by  the 
hemispherical  ganglia  during  the  period 
of  active  cellular  metabolism.  These 
physiological  experiments  have  their 
parallel  in  the  realms  of  pathology,  since 
it  has  been  shown  by  Mendel  that  in  cer- 
tain maniacal  conditions  occurring  in  the 
course  of  general  paralysis,  a  correspond- 
ing change  to  that  described  by  Gley 
occurs,  and  it  has  been  maintained  by 
Milner  Fothergill  that  this  comparative 
increase  in  the  vascular  areas  of  the  cere- 
bro-spinal  system  leads  to  a  distinct  ac- 
centuation of  the  aortic  second  sound.  It 
is  thus  rational  to  assume  that  the  condi- 
tion of  the  pulse,  indicating  as  it  does  the 
volume  and  rapidity  of  the  blood  current, 
and  the  pressure  under  which  the  circula- 
tion is  proceeding,  should  in  a  measure  be 
a  guide  to  some  at  least  of  the  various 
forms  of  altered  mental  condition  which 
occur  in  the  insane,  inasmuch  as,  on  the 
one  hand,  transient  changes  in  the  cen- 
tral nervous  system  produce  demonstrable 
changes  in  the  pulse  form,  and  on  the 
otiaer  hand,  changes  in  the  blood  supply 
of  nervous  matter  can  be  clinically  and 
experimentally  shown  to  intluence  its  sus- 
ceptibility to  stimuli. 

Hypnotism. — In  order  perhaps  the 
more  fully  to  demonstrate  the  close  rela- 
tionship which  exists  between  the  psychi- 
cal condition  and  the  circulatory  appa- 
ratus, attention  may  be  di-awn  to  their 
relative  states  in  the  various  stages  of 
hypnotism.  Dr.  Brugia  has  shown  that 
during  the  lethai'gic  condition,  the  sphyg- 
mographic  line  rises,  while  during  cata- 
lepsy and  somnambulism  it  falls,  and 
during  the  latter  stage  it  is  possible  to 
diminish  the  pulse  rate  considerably.  A 
similar  variation  has  been  shown  by  Tam- 
burini  and  Sepilli  to  exist  by  making  use 
of  the  i^lethysmograph,  the  conclusion 
being  that  during  the  lethargic  state  of 
hypnotism  vascular  dilatation  is  present, 
while  during  the  cataleptic  stage  vascular 
contraction  is  the  rule,  facts  of  very  con- 
siderable significance  when  considered 
along  with  the  allied  conditions  which 
occur  in  insanity. 

Neurastbenia  and  Hypochondriasis. 
—  In  the  condition  of  so-called  neura- 
sthenia or  nervous  weakness,  which  may 
practically  be  regarded  as  a  functional 
disease  of  the  nervous  system,  on  the 
borderland  of  insanity,  the  typical  pulse- 
tracing  to  be  obtained  is  one  showing  a 
varying  degree  of  low  tension,  and  the 
sphygmograph  is  claimed  to  be  of  service, 
not  only  in  determining   the   degree   of 


Pulse  in  Insanity 


[     1043    ] 


Pulse  in  Insanity 


nervous  exLaustiou  present  in  any  indivi- 
dual case  by  estimation  of  the  tension,  but 
also  to  discriminate  between  fictitious  and 
real  improvement.  Dr.  Webber,*  from  the 
examination  of  a  large  number  of  cases, 
has  suggested  theuse  of  thesphygmograph 
as  a  means  of  arriving  at  a  prognosis  in 
neurasthenia,  havin™  observed  that  if, 
when  a  case  comes  under  observation,  the 
pulse  tension  be  not  much  diminished,  the 
]irobability  is  that  the  patient  is  merely 
temporarily  "  run  down,"'  and  will  readily 
respond  to  appropriate  treatment,  the 
pulse  again  resuming  its  normal  degree 
of  tension  ;  if,  however,  the  pulse  be  of 
markedly  low  tension,  the  prognosis  is 
not  so  good,  and  if  the  tension  be  not  per- 
manently raised,  then  no  reliable  improve- 
ment takes  place.  It  is  difficult  in  these 
cases  exactly  to  determine  whether  the 
pulse  tension  be  raised  secondarily  to  the 
improvement  in  the  nervous  system,  or 
vice  versa,  but  it  is  interesting  to  observe 
how  closely  comparable  this  low  tension 
pulse  with  its  associated  symptoms  in  the 
condition  of  nervous  exhaustion,  is  to 
that  which  obtains  in  the  muscular  ex- 
haustion of  fatigue,  resulting  from  pro- 
longed convulsions. 

Schiile  considers  neurasthenia  to  he  a 
form  of  hypochondriasis,  and  apparently, 
as  regards  their  pulse  form,  a  relationship 
seems  borne  out.  In  the  pure  form  of 
hypochondriasis  the  pulse  tension  is  al- 
most invariably  low,  and  it  would  appear 
that  this  low  tension  may  stand  in  some 
part  as  a  cause  of  the  mental  condition, 
since  where  the  blood-pressure  is  habit- 
ually low,  it  can  scarcely  be  that  the 
tissue  nutrition  is  maintained  at  a  high 
level,  and  in  this  imperfect  nutrition  the 
cerebro-spinal  system  must  necessarily 
suffer.  Dr.  Broadbent  has  described  a 
well-marked  case  of  this  disease  in  which 
pulse  tension  was  continually  low,  and  in 
which,  in  addition,  the  condition  called 
agoraphobia  was  developed  at  a  later 
period. 

Hysteria  and  Hysterical  Insanity. — 
The  vascular  disturbance  in  hysteria 
varies  within  the  widest  limits,  and  with 
it  the  pulse  and  sphygmographic  tra- 
cings. In  many  cases  the  pulse  is  charac- 
terised chiefly  by  its  extreme  mobility  in 
response  to  the  various  emotions,  and  in 
these  a  low  tension  pulse  may  not  unfre- 
quently  be  observed,  but  probably  the 
more  characteristic  form  of  pulse  in  hys- 
teria is  that  showing  increased  tension, 
the  result  of  arterial  spasm,  probably  the 
cause  of  the  excessive  flow  of  urine  of  low 
specific  gravity  so  frequently  observed  m 
this  disease,  and  possibly  also  associated 
*  Ik'Stvn  M'd.  and  Surg   Journal,  1888. 


in  some  way  with  the  condition  of  hemi- 
ancesthesia.  Dr.  Weir  Mitchell  has  re- 
corded the  case  of  a  female  in  whom 
arterial  spasm  was  so  marked  as  to  render 
the  radial  pulse  exceedingly  small,  hard, 
thin,  and  wiry. 

Insanity  associated  -with  Cardiac 
Disease. — Without  here  entering  into 
any  detail  as  to  the  various  forms  of  in- 
sanity connected  in  some  way  with  or- 
ganic disease  of  the  heart,  it  is  important 
to  observe  that  a  consideration  of  the 
pulse  may  suggest  in  some  cases,  the  pos- 
sible oi'igin  of  the  mental  symptoms,  and 
in  others  may  materially  modify  the  pro- 
gnosis. In  cases  of  maniacal  delirium  of 
cardiac  origin  an  examination  of  the  pulse 
not  unfrequently  reveals  the  failure  of 
cardiac  compensation  for  some  mitral 
lesion  by  its  irregularity  in  rhythm  and 
force,  its  tendency  to  intermittence,  its 
weak  percussion  stroke,  and  its  easy  com- 
pressibility, points  which  not  only  tend  to 
establish  the  character  of  the  case,  but 
which  at  the  same  time  suggest  the  treat- 
ment and  means  of  arriving  at  a  pro- 
gnosis. 

Again,  amongst  the  numerous  cases  of 
simple  melancholia,  or  those  on  the  bor- 
derland between  this  condition  and  hypo- 
chondriacal melancholia,  there  is  a  dis- 
tinct class  of  cases  to  be  recognised  whose 
mental  condition  is  in  all  probability 
based  on  a  pre-existing  cardiac  mitral 
lesion,  most  frequently  a  stenosis,  in 
which  mental  exacerbations  are  coincident 
with  the  failure  of  compensation  which 
occurs  from  time  to  time ;  in  these  cases 
the  ijulse  i^resents  the  usual  characters 
indicative  of  this  condition,  and  it  is  to 
be  observed  that,  as  in  many  cases  of  un- 
complicated melancholia,  here  also  asso- 
ciated with  the  cardiac  phenomena,  the 
pnlse  is  mostly  well  sustained  between 
the  beats.  Again,  in  the  expansive  form 
of  insanity,  which  sometimes  occurs  as  a 
concomitant  or  sequence  of  aortic  disease, 
and  simulates  in  these  points  general 
paralysis  in  its  grandiose  form,  assistance 
in  the  differential  diagnosis  is  sometimes 
to  be  derived  from  a  consideration  of  the 
pulse,  since  a  sphygmographic  tracing 
typical  of  the  second  stage  in  general 
paralysis  differs  markedly  from  that  cha- 
racteristic of  aortic  regurgitation,  the 
forms  of  aortic  disease  said  to  be  most 
frequently  associated  with  this  kind  of 
insanity. 

The  alteration  of  the  pulse  which  occurs 
in  the  forms  of  mental  disease  occasionally 
associated  with  acute  endo-  and  peri- 
carditic  lesions,  varies  within  wide  limits  ; 
it  is,  however,  usually  of  low  tension,  and 
although  in  many  acute  cases  of  insanity 


Pulse  in  Insanity 


[    1044    ] 


Pulse  in  Insanity 


and  delirium  of  this  kind,  the  pulse  must 
enter  largely  into  the  diagnosis  and  im- 
mediate prognosis,  it  can  scarcely  be  said 
to  have  any  features  peculiarly  its  own  to 
be  considered  here. 

Insanity  associated  'witb  Pulmonary 
Xesions.  —  Of  the  cases  of  acute  deli- 
rious mania  in  which  acute  bodily  disease 
has  been  an  eminently  prominent  factor 
in  causation,  pulmonary  inflammation,  in 
the  form  of  acute  pneumonia,  seems  to 
occupy  a  leading  place.  In  this  form  of 
insanity  the  pulse  is  of  the  typical  febrile 
character,  of  fairly  good  percussive  stroke, 
and  fully  or  even  hyper-dicrotic,  rapid  and 
mobile,  the  respiratory  line  being  usually 
uneven,  its  alterations  in  the  course  of  the 
case  are  necessarily  the  main  guide  to 
treatment,  and  while  diminution  in 
rapidity  accompanied  by  increased  tension 
is  associated  with  a  favourable  termina- 
tion, it  is  observed  that  a  very  rapid  pulse 
of  low  percussion  stroke  is  to  be  regai'ded 
as  an  unfavourable  element  in  prognosis, 
and  an  indication  for  cardiac  tonics  and 
stimulants,  as  many  of  the  patients  are 
apt  to  die  from  simple  cardiac  failure. 

Another  form  of  pulmonary  lesion  fre- 
quently associated  with  mental  disease,  of 
which  in  many  cases  it  may  be  regarded 
as  a  distinct  element  in  causation,  result- 
ing in  a  definite  series  of  symptoms,  is 
phthisis,  and  it  might  be  readily  imagined, 
in  a  wasting  disease  such  as  this,  asso- 
ciated with  ansemia,  and  frequently  eleva- 
tion of  temperature,  that  the  pulse  would 
rather  tend  to  be  feeble  and  dicrotic. 
This,  however,  would  appear  to  be  rarely 
the  case,  unless  excavation  is  proceeding 
rapidly,  with  considerable  variations  in 
temperature.  When,  however,  the  phy- 
sical disease  is  advancing  rapidly,  the 
mental  symptoms  are  usually  much  im- 
proved, they  being  most  prominent  as  a 
rule  in  the  earlier  stages,  and  at  this 
period  the  pulse  very  frequently  presents 
the  signs  of  considerable  tension,  the 
exact  significance  of  which  is  not  at  pre- 
sent known,  but  it  is  noteworthy,  that 
classed  according  to  mental  symptoms,  a 
large  number  of  these  cases  come  under 
the  clinical  heading  of  melancholia,  a 
form  of  mental  disease  frequently  asso- 
ciated with  increased  tension.  The  condi- 
tion of  increased  tension  in  the  systemic 
arteries  in  phthisis,  however,  occurs  in 
cases  other  than  those  requiring  asylum 
treatment.  Emphysema  is  a  form  of  pul- 
monary disease  which  has  been  recognised 
by  some  authorities  as  a  causative  factor 
in  mental  disease,  chiefly  melancholic, 
though,  as  suggested  by  Griesinger,  it 
may  be  that  the  mental  and  bodily  condi- 
tions are  merely  associated  senile  changes. 


In  these  cases  there  is  probably  a  general 
fibrotic  change  which  involves  both  lungs 
and  systemic  vessels,  with  the  result  that 
the  pulse  exhibits  characters  closely  allied 
to  the  "senile pulse"  of  Marey,a  sphygmo- 
graphic  tracing  showing  a  fairly  high  per- 
cussion stroke,  according  to  the  condition 
of  the  heart,  a  well  marked  pre-dicrotic 
wave,  and  a  somewhat  gradual  line  of  de- 
scent, indicating  considerable  pressure  in 
the  vessels  with  some  impeded  outflowinto 
the  veins. 

IVCelanctaolia  (Fig.  i). — Melancholia  is 
an  example  of  a  form  of  mental  disease  in 
which  a  very  varied  form  of  pulse  may  be 
found,  more  particularly  is  this  so  as 
regards  tension.  MM.  Ball  and  Jennings 
have  .shown  that  in  chronic  morphinism, 
when  the  mental  condition  is  one  of  the 
intensest  misery,  the  pulse  tension  is  in- 
variably high,  and  this  tension  is  reduced 
coincidently  with  the  recurrence  of  mental 
comfort,  when  an  additional  dose  of  mor- 
phia is  administered.  Dr.  Haig  has  re- 
marked on  the  resemblance  of  this  melan- 
cholic condition  in  chronic  morphinism  to 
certain  cases  of  melancholia  associated 
with  the  so-called  uric-acid  headache,  in 
which  there  is  a  markedly  high  tension 
pulse,  and  he  suggests  that  opium  in  all 
these  cases  produces  the  increased  sense 
of  well-being  by  its  action  on  uric  acid, 
and  by  this  means  on  pulse  tension  and 
cerebral  circulation.  However  this  may 
be,  it  is  established  that  a  fair  proportion 
of  melancholiacs  present  a  slow  pulse  of 
high  physiological  or  pathological  degree 
of  tension,  a  point  upon  which  stress  has 
been  laid  by  Dr.  Broadbent,  who  has  re- 
garded it  as  possibly  the  cause  of  the 
mental  condition,  or  at  least  the  index  of 
the  state  of  system  on  which  the  mental 
condition  depends.  It  is  noteworthy  that 
the  aneemia,  which  is  so  frequently  pre- 
sent in  young  melancholiacs,  does  not  at 
all  prevent  the  recurrence  of  a  high  ten- 
sion pulse,  since  anaemia  by  itself  is  not 
unfrequently  associated  with  increased 
tension. 

On  the  other  hand,  however,  a  certain 
but  smaller  percentage  of  cases  of  melan- 
cholia is  associated  with  a  pulse  tending 
towards  the  opposite  extreme  of  tension, 
that  is  a  pulse  of  low  tension  and  com- 
pressible, and  somewhat  more  rapid  than 
in  the  former  condition,  mobile  and  readily 
affected  by  transient  emotions.  Melan- 
cholia associated  with  a  very  low  tension 
pulse  is  stated  by  Dr.  Broadbent  to  be  of 
worse  prognosis  than  the  reverse  condi- 
tion. 

Cbronic  Melancholia.  —  In  cases  of 
melancholia,  of  which  clironicity  is  a 
marked  feature,  the  high  tension  pulse  is 


Pulse  in  Insanity 


[    1045    ] 


Pulse  in  Insanity 


almost  invariable,  though  it  has,  as  a  rule, 
but  little  resemblance  to  the  form  of  high 
tension  pulse  associated  with  cirrhotic 
Bright's  disease,  unless  this  condition  be 
also  present,  because  the  cardiac  percussion 
stroke  is  weak,  and  results  in  a  low  line 
of  ascent,  while  the  line  of  descent,  form- 
ing a  wide  angle  with  it,  gradually  reaches 
its  lowest  point ;  the  presence  or  absence 
of  the  pre-dicrotic  wave  in  this  form  of 
pulse  depending  chiefly  on  the  degree  of 
force  of  the  cardiac  contractions.  The 
whole  pulse  is  iisually  small,  and  indicates 
a  sluggishness  of  the  circulation,  resulting 
from,  on  the  one  hand,  enfeebled  vis  a 
tergo,  and  on  the  other,  some  obstruction 
to  the  peripheral  outflow. 

Melancbolia  Attonita. — In  this  form  of 
melancholia  the  vessels  also  show  signs  of 
contraction,  and  the  pulse  in  the  stage  of 
apathy  or  immobility  presents  many  of 
the  features  of  the  pulsus  tardus,  pointing 
to  a  difficulty  in  the  outflow  of  blood  into 
the  veins,  and  in  addition,  a  feebly  acting 
heart :  the  pulse  to  the  finger  is  weak, 
owing  to  the  fact  that  its  variations  in 
magnitude  are  slight  and  slow.  Any 
mental  improvement  in  these  cases  is  asso- 
ciated with  a  corresponding  change  in  the 
pulse,  the  line  of  ascent  becomes  higher, 
and  the  tension  is  diminished,  while  the 
volume  is  increased,  and  the  pulse  becomes 
more  rapid,  indicating  that  with  the 
changed  mental  condition  the  heart  is 
acting  more  strongly  and  the  peripheral 
resistance  is  diminished. 

Senile  Melancbolla.  —  The  changes 
which  occur  in  the  vessels  and  other  tissues 
associated  with  the  incidence  of  senility 
are  necessarily  the  chief  factors  in  the 
production  of  the  familiar,  tense  '*  senile 
pulse,"  which  regularly  occurs  in  the  forms 
of  mental  disease  which  are  apt  to  arise 
at  this  epoch.  Not  unfrequently,  however, 
in  addition  to  the  ordinary  pulse  change, 
which  is  the  inevitable  concomitant  of  old 
age,  increased  tension  over  and  above  this 
may  be  brought  about  by  gouty  or  renal 
disease,  in  which  the  impairment  of  cere- 
bral blood-supply  is  presumably  increased 
temporarily  or  permanently. 

Ecstasy. — In  the  condition  of  ecstasy, 
or  phreno-plex'.a  of  Guislain,  where  the 
patient  is  almost  perfectly  immovable, 
and  the  expression  is  fixed,  and  graphically 
represents  one  of  the  forms  of  emotion, 
and  the  muscles  are  in  a  state  of  excessive 
tension,  the  pulse  does  not  usually  show 
any  marked  degree  of  tension,  but  is  fre- 
quently somewhat  accelerated,  and  tends 
to  be  more  or  less  dicrotic,  the  heart  factor 
producing  a  fairly  good  line  of  ascent.  It 
is  possible  that  the  tendency  to  dicrotism 
in  these  case.s  is  to  be  associated  with  the 


strong   and    prolonged    muscular   strain, 
which  is  such  a  marked  feature. 

Stuporose  conditions. — In  some  forms 
of  insanity  the  whole  disease  is  charac- 
terised by  the  condition  of  stupor,  while 
in  others  this  merely  occurs  as  a  passing 
phase  of  longer  or  shorter  duration.     In 
the  former  class,  many  authorities  agree 
in  characterising  the  pulse  as  essentially 
feeble,  a  point  which  is  certainly  true  as 
regards  the  alteration  of  the  volume  of 
the  pulse.     But  on  examination  with  the 
sphygmograph,    as    has   been   shown  by 
Greenlees  and  the  writer,  it  is  to  be  ob- 
served that  the  vessel  is  full  between  the 
beats,  and  the  line  of  descent  is  therefore 
well  sustained,  a  condition  which  inevi- 
tably points  to  the  fact  that  there  must  be 
a  considerable  degree   of  tension  within 
the  vessel ;  a  pre-dicrotic   wave   may  in 
addition  be  present,  provided  the  cardiac 
factor  be  sufficiently  active,  and  thus  a 
tendency  to  the  formation  of  a  plateau 
may  be  evident.     That  increased  tension 
should  be  observed  in  a  mental  disease 
such  as  this  is  somewhat  surprising,  until 
considered  together  with  the  observations 
of  Aldridge  with  the  ophthalmoscope,  who 
has  shown  that  in  this  form  of  insanity 
the  retinal  vessels  are  straight  and  atten- 
uated and  the  choroids  pale,  and  of  the 
writer  who  has  been  able  to  demonstrate 
that  at  least  in  a  certain  percentage  of 
these  cases  an  actual  diminution  in  the 
calibre  of  the  vessels  at  the  base  of  the 
brain  is  present.  It  is  evident  that  arterial 
stenosis,  such  as  these  observations  sug- 
gest, may  account   for   the   condition  of 
increased  tension  so  frequently  observed 
in  stuporose  conditions,  and  also  for  the 
cardiac  complication  referred  to  by  Mabille 
and  other  authors.     That  this  increased 
pulse  tension  is  of  considerable  import- 
ance, as  indicative  of  a  physical  condition 
definitely    associated   with-  this   peculiar 
form  of  mental  disease,  is  evidenced  by 
the  fact  that  a  change  inevitably  occurs 
in  the  pulse,  with  that  in  the  mental  con- 
dition, either  as  a  causative,  concomitant 
or   sequential    alteration,    so  that   when 
mental  health  is  established,  the  signs  of 
tension  previously   present  are  removed, 
the  cardiac  factor  becoming  more  active, 
the  aortic  notch  and  dicrotic  wave  more 
obvious,  and  the  outflow  into   the  veins 
more  rapid. 

In  the  stuporose  stage  of  the  mental 
state  or  states  which  Kahlbaum  would 
call  "Katatonia"  (Pigs.  5  and  6),  the 
sphygmographic  tracings  give  evidence  of 
difficulty  of  peripheral  outflow,  as  shown 
in  the  mental  disease  exhibiting  this  phase, 
and  the  condition  of  tension  rapidly  sub- 
sides when  the  stage  of  lucidity  occurs. 


Pulse  in  Insanity 


[    1046    ] 


Pulse  in  Insanity 


Intermittent  Stupor.  —  The  change 
which  occurs  in  the  pulse  becomes  most 
marked  in  cases  of  intermittent  stupor, 
sphygraographic  tracings  taken  during 
the  stupor  stage  showing  a  striking  con- 
trast to  those  taken  during  the  stage  of 
lucidity,  as  regards  tension.  It  is  note- 
worthy that  the  arterial  tension  observed 
in  the  stupor  stage  can  be  considerably 
reduced  by  amyl  nitrite,  and  that  in 
certain  cases  a  corresponding  degree  of 
mental  improvement  occurs  during  the 
action  of  the  drug.  Correlative  conditions 
suggestive  of  the  return  to  mental  health 
and  of  arterial  spasm  are  a  possible  ex- 
planation of  the  condition. 

Aprosexia. — This  is  a  name  introduced 
by  Dr.  Guye  to  indicate  the  inability  to 
fix  attention  on  any  definite,  more  or  less 
abstract  subject,  not  unfrequentlj^  asso- 
ciated with  chronic  disease  of  the  nose  and 
naso-pharynx,  and  inasmuch  as  the  lead- 
ing symptoms  are  dulness  and  incapacity 
for  work  or  movement,  resulting  in  ad- 
vanced cases  in  a  semi-stupid  condition, 
there  would  appear  some  reason  for  classi- 
fying it  with  the  stuporose  conditions  under 
consideration,  and  the  more  so  since  it  is 
observed  that  it  is  associated  in  most 
cases  with  a  pulse  of  excessive  tension. 
Guye  has  suggested  that  the  mental  con- 
dition is  due  to  the  incomplete  removal  of 
the  products  of  tissue  changes,  and  it  is 
possible  that  it  may  be  a  condition  allied 
to  that  described  by  Dr.  Haig  as  connected 
with  the  uric-acid  excretion. 

I^ania.  —  It  is  by  some  authorities 
admitted,  or  even  demanded,  that  a  con- 
dition of  vascular  turgescence  and  hyper- 
Eemia  is  essential  to  functional  nervous 
hyper-activity,  whether  that  activity  be 
manifested  in  the  normal  direction  of 
health  or  on  the  abnormal  lines  of  disease, 
and  therefore  it  has  been  premised  that, 
in  states  of  mental  exaltation  and  excite- 
ment generally,  cerebral  hypera^mia  is 
invariably  present,  a  postulate  which  it 
would  appear  imjjossible  to  admit  when 
it  is  considered  that  a  degree  of  malnu- 
trition of  nerve-cells,  in  the  first  instance, 
usually  leads  to  their  increased  activity, 
whence  results  a  period  of  excitement. 
This  change  is  strictly  comparable  to 
what  has  been  shown  to  occur  in  the 
case  of  the  muscular  system  by  Sterson 
and  Schmoulewitch,  who  demonstrated 
that  when  experimental  anasmia  is  in- 
duced in  muscles,  their  irritability  is  in- 
creased, in  fact,  a  state  of  "  irritable 
weakness "  and  adynamic  activity  is 
brought  about,  just  as  in  the  case  of  the 
nervous  system.  That  a  hypera3mic  con- 
dition of  the  nervous  centre  in  this  form 
of  mental  disease  is  not  at  any  rate  uni- 


versal, is  suggested  by  the  fact  that 
medicinal  agents  increasing  the  blood 
pressure  and  pulse  tension  not  unfre- 
quently  result  in  diminution  or  abolition 
of  maniacal  excitement. 

Acute  2>elirious  Mania  [Delire  aigu} 
(Figs.  3  and  4). — It  is  in  this  form  of  mania, 
probably,  that  the  pulse  condition  is  most 
markedly  altered,  doubtless  to  a  large  ex- 
tent on  account  of  the  increase  of  body 
temperature,  which  may  be  considerable. 
It  is  the  form  of  insanity  in  which  there  is 
the  nearest  approach  to  the  typical  febrile 
pulse.  The  pulse  is  invariably  rapid,  and 
this  acceleration  may  reach  to  as  much  as 
1 50  per  minute  ;  it  is  usually  perfectly 
regular  in  rhythm,  but  not  always  so  in 
force,  and  invariably  of  low  tension;  a 
sphygmographic  tracing  exhibits  the 
following  points  :  the  line  of  ascent  is 
practically  vertical,  and  about  the  average 
height,  the  apex  is  acute,  and  the  line  of 
descent  falls  rapidly  to  the  aortic  notch, 
which  may  or  may  not  sink  below  the 
base  line,  the  pulse  being  usually  fully 
and  sometimes  hyper-dicrotic.  In  the 
later  stages  of  the  disease,  if  it  be  not 
arrested,  the  pulse  becomes  altered  by 
enfeeblement  of  the  cardiac  factor,  and 
the  condition  of  so-called  typhomania  is 
brought  about.  If,  however,  on  the  other 
hand,  im2:>rovement  commence,  the  change 
which  occurs  in  the  pulse  is  even  more 
marked  than  that  of  the  mental  condition, 
the  line  of  ascent  indicates  a  good  cardiac 
impulse,  the  line  of  descent  becomes  more 
gradual  in  its  slope,  and  shows  the 
development  of  a  small  pre-dicrotic  wave. 
The  aortic  notch  and  dicrotic  wave,  on 
the  other  hand,  become  slight  in  develop- 
ment, the  rapidity  of  the  pulse  is  reduced, 
and  the  tension  raised  considerably.  There 
are  few  mental  diseases  in  which  the  pulse 
is  of  greater  value  in  immediate  prognosis 
and  treatment,  and  it  is  observed  that  the 
artificial  raising  of  the  tension,  in  addition 
to  cardiac  stimulation,  in  some  cases  will 
produce  a  degree  of  mental  improvement, 
and  even  though  this  do  not  occur  it 
undoubtedly  tends  to  avert  the  tendency 
to  heart  failure,  so  great  a  danger  in  this 
form  of  mental  disease. 

/Lcute  Mania. — In  the  more  or  less 
intense  excitement  which  occurs  in 
this  form  of  mental  disorder,  many 
observations  have  been  made  on  the 
pulse  and  circulator)^  system  in  attempt 
to  localise  in  time  a  causative  or  con- 
comitant alteration  which  may  be  of 
service  in  throwing  light  on  this  abstruse 
condition.  That  some  change  occurs  in 
the  blood  vascular  system  is  evidenced  by 
the  striking  pallor  of  the  face,  and  other 
alterations  of  a  similar  nature.     Clifford 


Pulse  in  Insanity 


[    1047    ] 


Pulse  in  Insanity 


Allbutt  has    suggested,  from  ophthalmo- 
scopic observation  of  51    cases,  that  the 
condition    of    mania    is  accompanied  by 
anaimia  of  the  fundus,  and  Griesinger  has 
■observed    that  the    cardiac    soiands    are 
muffled  during  the  maniacal  attack,  and 
clear  in  the  intervals  of  lucidity,  an  obser- 
vation difficult  of  absolute  decision  in  many 
cases  on  account  of  the  mental  condition 
of  the  patient.     As   regards    the    actual 
condition  of  the   pulse  in    acute   mania, 
various  observers  have  differed  consider- 
ably,  Dr.   Howard  stating  that  there  is 
rarely  any  marked  disturbance  other  than 
that  which  would  be  caused  by  any  one  in- 
dulging in  the  violent  and  incessant  move- 
ments peculiar  to  mania  :  and  doubtless, 
as   Dr.   Hack   Tuke   has   observed,  it   is 
difficult   to   know   how  much   the    pulse 
alterations  are  due  to  muscular  exercise, 
and   how    much    to    the    disease    itself. 
However  this  may  be,  it  is  a  matter  of 
clinical  observation  that  the  condition  of 
mania  is  very  frequently  associated  with 
a  pulse  of  abnormally  low  tension,  just 
as  probably  the   more   frequent  form  of 
pulse  in  melancholia  is  one  of  increased 
tension ;    and  moreover,    mania  of   even 
short  duration  is  able  to  reduce  a  pulse  of 
previously  high  tension,  as  is  seen  in  the 
maniacal  attacks  of  general  paralysis,  to 
one  of  complete  dicrotism,  a  point  of  the 
greatest    importance,   as  suggesting   the 
most  frequent    cause    of    sudden    death 
which  is  apt  to  occur  in  this  disease ;  a 
view  which  would   appear  more  tenable 
than  that  of  Griesinger,  who  lays  stress  on 
the  occurrence  of  apoplectiform  collapse. 
The   sphygmographic  tracing  to    be  ob- 
tained in  these  cases  varies  with  the  degree 
and  duration  of  the  excitement,  but  usu- 
ally  shows  a  line  of  ascent   about  the 
average  height  and  vertical,  the  apex  is 
generally  acute,  and  the  line  of  descent 
falls  directly  and    suddenly  down  to  the 
aortic  notch,  which  along  with  the  dicrotic 
wave,  is  well  marked  ;  this  former  may 
reach  the  respiratory  line,  but  rarely  goes 
beyond  it  to  any  extent.    There  are,  never- 
theless, cases   in  which  a  fairly  distinct 
pre-dicrotic  wave  occurs,  and  persists  for 
a  considerable  time,  the  line  of  descent 
however    falling   rapidly   afterwards.     If 
the   maniacal  condition  be  of  prolonged 
duration,  the  line  of  ascent  becomes  con- 
siderably  shortened,   and    the   condition 
of    full  dicrotism  obtains,  while   to   the 
finger    the    pulse   is   small,    feeble,    and 
almost  flickering  in  character.     Raising 
the  tension  and  increasing  the  vigour  of 
the  cardiac  factor  in  these  cases  by  medi- 
cinal agents,  certainly  sometimes  dimin- 
ishes, or  completely  quiets  the  maniacal 
excitement,   as   has  been  shown   by   Dr. 


Mickle,  while  in  cases  in  which  this  most 
desirable  result  is  not  brought  about,  the 
tendency  to  sudden  death  during  or 
as  a  result  of  excitement,  is  considerably 
diminished,  and  in  addition,  with  the  ele- 
vation of  the  blood  pressure,  nutrition  is 
considerably  improved,  a  point  scarcely 
less  important  than  the  immediate  return 
to  mental  health. 

That  there  is  some  value  in  this  arti- 
ficial elevation  of  the  pulse  tension  is 
suggested  by  the  fact  that  mental  improve- 
ment in  cases  of  acute  mania  is  invariably 
accompanied  by  increased  pulse  tension, 
resulting  in  a  sphygmographic  tracing 
in  which  the  line  of  descent  is  well  sus- 
tained. 

The  rapidity  of  the  pulse  in  mania 
varies  within  wide  limits,  inasmuch,  as  it 
may  be  only  slightly  increased,  or  may 
reach  120,  or  even  more.  It  would  appear 
that  this  rapidity  of  pulse  is  not  neces- 
sarily proportionate  to  the  degree  of  excite- 
ment of  the  patient,  as  suggested  by 
Guislain,  but  has  closer  relationship  to 
the  duration  of  the  illness,  degree  of 
tension,  and  other  factors.  Any  great  fre- 
quency would  naturally  suggest  the  possi- 
bility of  the  form  of  acute  mania  known 
to  be  associated  with  exophthalmic  goitre. 

Cbronic  Mania. — Although  in  a  chronic 
disease,  which  presents  features  of  such 
great  variety  as  this,  it  could  scarcely  be 
expected  that  a  uniform  character  of  pulse 
would  be  found,  it  is  remarkable  with  what 
great  frequency  the  tension  is  of  abnormal 
height,  and  this,  as  far  as  can  be  ascer- 
tained, independently  of  history  or  physi- 
cal manifestations  of  such  poisons  as 
alcohol  or  syphilis.  The  occurrence  of 
this  form  of  pulse  in  chronic  mania  is  of 
interest  in  connection  with  the  obser- 
vations of  Dr.  Burman,  who  found  that 
the  average  weight  of  the  heart  was 
somewhat  increased  in  the  older  cases  of 
mania.  In  chronic  and  recurrent  alcoholic 
mania,  this  condition  of  increased  tension 
is  an  almost  constant  feature,  resulting  in 
a  deliberate,  forcible,  and  well  sustained 
pulse. 

General  Paralysis. — The  pulse  and 
circulatory  system  in  this  form  of  mental 
disease  have  received  considerable  attention 
from  time  to  time,  chiefly  owing  no  doubt 
to  the  fact  that  it  is  one  of  the  most 
definite  forms  of  mental  disease  with 
which  the  physician  is  brought  into  con- 
tact. In  the  earlier  stage  Spitzka  states 
that  the  pulse  frequently  shows  very  higli 
tension  in  the  active  forms  of  the  disease, 
but,  however,  modifies  this  statement  con- 
siderably by  adding  that  in  a  large  number 
of  patients  it  is  normal.  Some  truth 
appears   to    exist    in  both    these    state- 


Pulse  in  Insanity 


[ 


] 


Pulse  in  Insanity 


meuts,  inasmuch  as  the  pulse  in  the  first 
stage  varies  within  the  same  limits  as  the 
normal  pulse  as  regards  tension,  but  as 
the  disease  ]irogresses  with  its  mental  and 
bodily  symptoms  the  tension  almost  in- 
variably increases.  In  the  early  stage 
then  the  sphygmographic  tracing  may 
show  features  indicating  a  low  state  of 
arterial  tension,  with  ready  outflow  from 
the  arterial  system,  and  it  may  possibly 
be  that  this  condition  occurs  most  fre- 
quently in  that  class  of  cases  in  whom, 
coincident  with  the  mental  breakdown  at 
the  commencement  of  the  attack,  there  is 
also  considerable  physical  debility  (Fig.  7). 
In  another  class  of  cases,  however,  the  pulse 
shows  distinctly  a  much  higher  arterial 
tension,  and  it  is  the  form  of  tracing 
obtained  from  these  cases  that  has  been 
regarded  as  the  typical  pulse  of  the  early 
stage  of  general  paralysis,  and  represented 
as  such  by  Dr.  Thompson  (  Fig.  8).  The 
line  of  ascent  is  slightly  oblique  and  short, 
the  primary  ventricular  wave  never  forms 
an  acute  augle,but  usually  one  more  nearly 
approaching  to  the  right  angle.  The  line 
of  descent  is  of  considerable  length  and 
has  a  gradual  slope,  and  presents  no 
traces  (Thompson),  or  slight  traces,  of  the 
aortic  notch  and  dicrotic  wave,  and  the 
only  point  calling  for  sjjecial  notice  is  the 
occurrence  in  this  line  of  a  "  number  of 
wavelets"  such  as  almost  invariably  occur 
in  a  pulse  of  fairly  high  tension,  in  which 
the  pre-dicrotic  wave  does  not  reach  a 
pathological  degree  of  prominence,  and  the 
dicrotic  wave  is  as  such  scarcely  definable. 
In  comparing  these  two  sphygmograms, 
both  of  which  represent  the  condition  of 
the  pulse  which  may  occur  in  the  early 
stage  of  general  paralysis,  it  is  readily 
seen  what  very  opposite  conditions  are  at 
work  in  their  production  ;  in  the  former  a 
fairly  active  heart  with  diminished  arterial 
tension,  and  in  the  latter  a  less  active 
heart  with  increased  arterial  tension,  the 
latter  being  shown  by  the  increase  oE  the 
apical  angle  and  the  marked  want  of  pro- 
minence of  the  dicrotic  wave  ;  but  even 
this  evidence  of  tension  rapidly  disappears, 
and  a  fully  dicrotic  condition  may  be 
brought  about,  if  during  this  stage  the 
patient  become  temporarily  acutely  mania- 
cal, a  i^oint  which  would  tend  to  indicate 
that  the  degree  of  tension  previously  pre- 
sent was  due  to  a  persistent  spasm  of  the 
vessels,  a  view  which  is  generally  assented 
to.  It  is  thus  seen  that  during  the  early 
stage  of  uncomplicated  general  paralysis, 
the  pulse  may  present  almost  any  feature 
from  complete  dicrotism  to  a  considerable 
degree  of  tension,  the  latter  not  usually 
exceeding  what  must  be  termed  the 
physiological  limits,  though  the  cardiac 


factor  is  almost  invariably  somewhat  at 
fault,  producing  a  feebler  line  of  ascent 
than  normal.  It  has  been  suggested  that 
the  sphygmographic  tracings  in  this  eai'ly 
stage  of  general  paralysis  may  be  of  some 
service  in  thedifEerential diagnosis  between 
the  syphilitic  and  non-syphilitic  forms  of 
general  paralysis,  the  force  of  the  dis- 
ease in  the  former  being  spent  presum- 
ably on  the  blood-vessels,  some  propor- 
tionate increase  in  pulse  tension  may  be 
expected  to  occur.  There  is,  however, 
scarcely  evidence  to  indicate  that  this 
takes  place,  and  in  many  cases  it  would 
almost  appear  that  rather  the  reverse 
obtains,  i^ossibly  explicable  by  the  condi- 
tion of  debility  of  not  unfrequent  occur- 
rence in  patients  sufi"ering  from  syphilis. 

The  typical  line  of  progress  in  the 
march  of  the  disease  is  now  towards  in- 
creased tension,  as  is  shown  by  sphygmo- 
grams taken  during  the  second  and  more 
typical  stage  of  general  paralysis  (Figs.  9 
and  10).  The  line  of  ascent  becomes  some- 
what less  slanting  than  formerly,  and  is 
also  longer,  the  apex  varies  a  little  but  tends 
to  form  a  plateau,  owing  to  the  verymarked 
prominence  of  the  pre-dicrotic  wave.  From 
this  point  the  line  of  descent  falls  rapidly 
to  the  aortic  notch,  which  varies  a  little  as 
regards  its  prominence,  cases  sometimes  oc- 
curring in  which  the  aortic  notch  reaches 
quite  down  to  the  respiratory  line,  and  is 
followed  by  a  well-marked  dicrotic  wave. 
In  these  latter,  the  condition  of  actual 
tension  present  in  the  first  and  early 
second  stage  has  been  replaced  by  what 
has  been  called  by  Dr.  Broadbent  virtual 
tension,  and  it  is  more  particularly  in 
these  cases  that,  though  the  pressure 
required  for  tracing  is  generally  consider- 
able, the  average  occlusion  pressure  as 
pointed  out  by  Dr.  Bevan  Lewis  is  low, 
and  it  is  in  this  point  that  the  pulse  in 
the  second  stage  of  general  paral3"sis 
chiefly  differs  from  that  which  occurs 
typically  in  chronic  Bright's  disease,  to 
which  it  is  apparently  so  nearly  allied. 
The  typical  pulse  of  the  second  stage  of 
general  paralysis  would  indicate  that  the 
heart  at  first  is  fairly  active,  but  not  hy- 
pertrophied  to  any  great  extent,  a  point 
which  has  been  suggested  by  the  clinical 
observation  of  Dr.  Milner  Fothergill,  but 
which  Dr.  Burman,  on  jiost-mortem 
grounds,  did  not  uphold,  though  the  actual 
figures  given  by  the  latter  rather  indicate 
that  what  hypertrophy  may  exist  in  these 
cases  when  uncomplicated  is  comparatively 
slight.  The  tension,  however,  on  the 
vessel  wall  is  shown  by  the  sphygmo- 
graphic tracings  to  be  considerable,  owing 
probably  to  some  interference  with  the 
outflow  of  blood  from  the  arterioles  and 


Pulse  in  Insanity 


[     1049    ] 


Pulse  in  Insanity 


capillaries,  this  being  brouj?ht  about  by  a 
pathological  alteration  in  the  coats  of  the 
vessels  interfering  with  their  elasticity. 
That  this  change  is  to  some  extent 
muscular  rather  than  fibrous  is  suggested 
by  the  fact  that  in  many  cases  the  signs  of 
tension  may  be  completely  removed  by 
amyl  nitrite.  The  condition  of  virtual 
tension  which  is  apt  to  appear  in  sphygmo- 
graphic  tracings  during  the  second  stage 
apparently  points  to  a  secondary  degenera- 
tion of  the  vessel  wails,  and  the  subsequent 
dilatation  of  their  lumen,  a  condition 
which  has  been  shown  by  the  writer  to 
occur  in  the  cerebi'al  basal  vessels  in  some 
cases  of  general  paralysis,  and  combined 
with  this  it  is  probable  some  relative 
cardiac  failure  is  necessary  to  produce  this 
form  of  pulse.  Although  the  form  of 
pulse  varies  considerably,  as  do  the  details 
of  the  line  of  mental  and  bodily  progress 
of  the  disease  towards  its  termination,  it 
would  appear  that  as  a  rule  the  cardiac 
factor  diminishes  in  force  and  vigour,  and 
in  the  most  advanced  condition  the  line  of 
ascent  is  slightly  oblique  and  short,  and 
the  line  of  descent  has  only  a  low  elevation, 
and  is  of  gradual  slope.  Evidence  of  in- 
creased tension  may  be  present  even  at  a 
late  period  in  the  disease,  and  the  effect 
of  continued  convtdsions  is  to  reduce  the 
tension  considerably,  and  slightly  increase 
the  rapidity.  In  connection  with  the  sub- 
ject of  general  paralysis,  it  is  of  interest 
to  note  how  frequently  the  high  tension 
pulse  as  it  occurs  in  the  second  stage  is  to 
be  observed  in  cases  ofsimple  coarse  spinal 
disease  such  as  locomotor  ataxy. 

Epileptic  Insanity. — In  connection 
with  epilepsy  it  is  a  noticeable  fact  of  fre- 
quent observation  that  in  a  certain  pro- 
portion of  cases  there  is  a  co-existing 
cardiac  disturbance,  and  it  is  believed  by 
many  authorities  that  in  some  cases  the 
relationship  is  causal,  owing  to  a  disturb- 
ance of  the  cerebral  circulation,  while  in 
others  that  it  is  a  secondary  lesion  as  a 
result  of  the  strain  put  upon  the  heart 
during  each  epileptic  paroxysm,  in  other 
cases,  again,  it  may  be  merely  a  concurrent 
condition,  possibly  in  congenital  cases, 
both  diseases  being  related  in  some  way 
to  a  common  cause,  and  in  addition  it 
seems  probable  that  there  are  cases  of 
epilepsy  in  which  the  seat  of  the  discharg- 
ing lesion  is  intimately  associated  with  the 
nucleus  of  the  vagus  nerve.  Each  of  these 
conditions  requires  consideration  in  a  study 
of  the  pulse  in  epileptics.  Dr.  Brown- 
Sequard  has  reckoned  a  weak  and  slow 
acting  heart  among  the  causes  of  epilepsy, 
but  also  admits  the  reverse  condition  as  a 
causal  condition.  He  in  addition  makes 
use  of  the  pulse  as  an  important  element 


in  diflPerential  diagnosis  of  cases  of  petit 
mal  from  those  of  simple  syncope,  in  that 
in  the  former  the  pulse  does  not  lose  so 
much  in  frequency  and  force  as  it  does  in 
the  latter.  Ur.  George  Thompson  suggests 
the  lax  condition  of  the  arterial  wall  as  of 
most  frequent  occurrence  in  epilepsy,  this 
condition  being  more  exaggerated  in  the 
epileptic  status.  Dr.  Haig  has  drawn 
attention  to  a  relationship  which  he  believes 
to  exist  between  epilepsy  and  a  form  of 
migrainous  headache,  which  he  considers 
is  due  to  uric  acid  in  the  blood,  and  has 
shown  that  some  epileptic  fits  are  pre- 
ceded by  a  diminished  and  accompanied 
by  an  excessive  excretion  of  this  acid.  It 
would  appear  that  for  convenience  of  de- 
scription the  varying  conditions  of  the 
pulse  in  epileptics  may  be  arranged  into 
five  groups. 

(i)  A,  Class  of  epileptics  in  whom 
there  is  present  a  cardiac  lesion  of  con- 
g-enital  origrin  of  the  nature  of  a  mal- 
formation, and  in  whom  as  a  concomitant 
or  resultant  condition  epilepsy  exists. 
Owing  to  the  not  unfrequent  occurrence 
of  epilepsy  in  congenital  heart  disease, 
many  authorities  hold  that  the  epilepsy  is 
a  secondary  condition,  owing  to  a  disturb- 
ance in  the  cerebral  circulation,  resulting 
from  the  cardiac  lesion.  In  these  cases 
the  pulse  varies  somewhat  in  accordance 
with  the  heart  condition  which  is  present, 
and  the  state  of  the  heart  as  regards  com- 
pensation ;  not  unfrequently,  however,  the 
sphygmographic  tracings  show  a  con- 
siderable degree  of  tension,  owing  pro- 
bably to  some  difficulty  in  the  peripheral 
outflow  into  the  veins.  It  is  evident, 
howevei*,  that  no  single  tracing  could  be 
looked  upon  as  typical  of  the  series. 

(2)  A  class  of  epileptics,  fairly  ac- 
tive, and  otherwise  healthy,  in  whom 
dementia  has  not  proceeded  to  any  great 
extent,  and  in  whom  the  heart  hypertro- 
phies slightly  in  accommodation  for  the 
intense  strain  thrown  on  it  from"  time  to 
time  in  the  occurrence  of  epileptic  attacks. 
In  these  the  arteries  are  lax,  and  the 
heart  is  irritable  and  mobile,  and  the 
sphygmographic  tracings  present  the 
following  characters  :  The  line  of  ascent 
is  of  average  height  and  vertical,  the  apex: 
is  sharply  acute,  and  the  line  of  descent 
is  not  very  long,  the  outflow  into  the  veins 
being  rapid ;  the  tidal  wave  is  slight  if 
present,  and  the  aortic  notch  and  the 
dicrotic  wave  are  well  marked,  and  the 
pulse  tends  to  be  somewhat  more  rapid 
than  normal.  If  the  fits  in  epileptics  of 
this  class  be  preceded  by  a  pre-convulsive 
stage  of  stupor,  the  pulse  tension  is 
usually  raised  at  this  period,  but  the 
highest  pulse  tension  which    can   be  re- 


Pulse  in  Insanity 


[    1050    ] 


Pulse  in  Insanity 


corded  in  epileptics  in  whom  the  normal 
condition  is  low  tension,  is  almost  invari- 
ably immediately  after  the  paroxysm, 
when  some  irregularity  in  rhythm  also 
tends  to  occur. 

(3)  A.  class  of  less  active  and  more 
demented  epileptics  in  whom  the  bodily 
nutrition  tends  to  be  rather  below  normal, 
and  who  also  show  some  enfeeblement  of 
bodily  function,  and  torpidity  of  the  cir- 
culation manifested  by  the  coldness  and 
lividity  of  the  extremities.  In  these  the 
form  of  pulse  associated  with  dementia 
tends  to  occur,  indicating  a  condition  of 
organic  decline,  the  result  of  advanced 
cerebral  disease.  In  these  the  line  of 
ascent  is  usually  slightly  oblique  and 
short,  the  apex  is  an  obtuse  angle,  and  the 
line  of  descent  is  long  and  well  sustained, 
the  pre-dicrotic  and  dicrotic  waves  vary  as 
regards  their  prominence,  but  the  pulse  is 
one  of  higher  tension  than  in  the  former 
group,  and  tends  to  be  slower.  Between 
these  two  perfectly  natural  groups  of  epi- 
leptics, there  is  no  sharp  line  of  demarca- 
tion, inasmuch  as  the  transition  from 
mental  health  to  the  most  profound  de- 
mentia is  a  decline  of  no  great  obliquity. 

(4)  A  class  of  epileptics,  the  com- 
mencement of  whose  fits  dates  from  an 
agre  considerably  later  than  any  of  tbe 
preceding  (usually  later  than  thirty  years 
old),  in  whom  a  cause  is  frequently  found 
or  whose  condition  may  be  ascribed  to 
alcoholism,  plumbism,  syphilis,  or  other 
poison,  the  force  of  which  is  largely  spent 
on  the  arteries,  leading  to  impairment  of 
the  elasticity  of  the  vessel  wall.  In  these 
cases  the  tracing  and  occlusion  pressure  is 
considerably  higher  than  normal,  the  vessel 
walls  being  frequently  somewhat  thickened, 
and  the  heart  hypertrophied.  The  pulse 
is  of  good  volume,  and  a  sphygmographic 
tracing  shows  that  the  line  of  ascent  is  of 
considerable  height,  and  usually  quite 
vertical ;  the  apex  is  an  acute  angle,  but 
not  unfrequently  has  the  pre-dicrotic  wave 
almost  merged  into  it  to  form  a  plateau, 
owing  to  its  extreme  prominence.  The 
aortic  notch  and  dicrotic  wave  are  almost 
invariably  present,  but  are  not  necessarily 
marked  features  in  the  tracing,  the  pulse 
being  one  of  considerable  tension. 

(5)  Another  form  of  pulse  mrhich  may 
occur  in  epileptics  is  that  to  which 
attention  has  been  chiefly  drawn  by 
Tripier,  and  stated  by  him  to  be  essen- 
tially associated  with  epilepsy.  It  mainly 
occurs  in  persons  beyond  middle  age,  and 
with  the  form  of  epilepsy  called  ]jetit 
mal.  Here  the  pulse  is  infrequent, 
varying  from  18  to  40  or  more,  the  car- 
diac pulsation,  however,  being  much  more 
frequent.     Cases  in  which  this  association 


has  been  observed  have  been  recorded  by 
various  authors,  but  Dr.  Broadbent  has 
combated  the  view  that  it  is  of  necessity 
associated  with  epilepsy. 

Sementia. — It  is  stated  by  Wolff  that 
there  is  a  form  of  pulse  which  may  be  re- 
garded as  characteristic  of  incurable  in- 
sanity— namely,  the  pulsus  tardus,  in 
which  the  artery  does  not  at  once  attain 
its  maximum  expansion,  expands  but 
little,  and  subsides  slowly  during  the  in- 
tervals of  percussion.  Although  this  kind 
of  pulse  to  the  finger  is  apparently  weak, 
and  is  frequently  regarded  as  such,  it  is  in 
reality  a  form  of  high-tension  pulse,  which 
is  "  full  between  the  beats  "  to  a  greater  or 
less  extent, its  apparent  weakness  being  due 
to  the  fact  that  the  variations  in  capacity 
of  the  vessel  are  slow,  gradual,  and  ill- 
defined.  It  has  been  suggested  that  the 
pulse  is  to  be  regarded  as  indicative  of 
the  neuropathic  constitution  upon  which 
the  actual  mental  disease  is  developed, 
and  fatal  as  a  point  in  prognosis  in  cases 
of  insanity.  Although  it  may  be  accepted 
that  a  high-tension  pulse  is  frequently  to 
be  considered  as  an  element  of  bad  pro- 
gnosis in  many  forms  of  insanity,  there  is 
scarcely  evidence  to  show  that  any  par- 
ticular form  of  pulse  must  be  regarded  as 
absolutely  damnatory,  more  especially 
when  it  is  remembered  that  pulses  of  the 
type  under  consideration  are  perfectly 
compatible  with  mental  health,  and  also 
occur  in  certain  phases  of  the  curable 
forms  of  mental  disease.  Inasmuch,  how- 
ever, as  not  unfrequently  it  is  said  to  in- 
dicate a  loss  of  arterial  elasticity,  as  from 
sclerosis,  from  this  point  of  view  it  carries 
with  it  the  prognostic  importance  usually 
attached  to  this  condition,  but  in  this  way 
would  rather  represent  the  physical  diffi- 
culty in  the  way  of  recovery,  than  the 
fundamental  neuropathic  constitution.  It 
is  obvious  that  a  degree  of  imperfect  cir- 
culation, associated  with  mechanical  diffi- 
culty at  the  periphery,  and  frequently 
also  the  centre  of  the  vascular  system,  is 
present  in  all  cases  of  most  advanced  de- 
mentia, whether  this  occur  as  the  terminal 
condition  of  general  paralysis  or  epilepsy, 
or  as  secondary  to  an  acute  psychosis, 
and  it  would  appear  that  the  condition  of 
the  pulse  can  give  no  reliable  indication 
of  the  previous  pathological  condition  to 
which  the  dementia  has  succeeded,  nor 
does  it  seem  to  be  of  any  value  in  diffe- 
rential diagnosis  between  such  conditions 
as  post-maniacal  dementia,  and  the  secon- 
dary stupor  which  in  some  cases  resembles 
it.  In  cases  of  chronic  cerebral  atrophy, 
the  pulse,  as  shown  by  Dr.  Bevan  Lewis, 
is  small,  very  hard,  and  incompressible, 
and  indicates    a   considerable    degree   of 


Pulse  in  Insanity 


[     105'     ] 


Pulse  in  Insanity 


arterial  tension,  its  tidal  wave  being  well 
sustained,  and  the  occlusion  pressure  high. 
In  senile  dementia  also  a  high  tension 
pulse  occurs,  the  more  so  as  it  is  not  lu- 
irequently  associated  with  renal  cirrhosis. 
Idiocy  and  Imbecility. — In  a  large 
number  of  cases  of  congenital  mental  de- 
tect, signs  of  imperfect  circulation  are 
uot  wanting  in  the  cold  extremities  and 
other  obvious  signs  of  vascular  difficulties  ; 
and  it  is  interesting  that  iu  many  con- 
genital imbeciles,  as  pointed  out  by  Dr. 


Greenlees,  high  arterial  tension  exists, 
quite  irrespective  of  age,  and  he  has  sug- 
gested in  explanation  of  this,  that  the 
introduction  into  the  course  of  the  sys- 
temic circulation  of  a  brain  of  arrested 
development,  is  comparable  to  the  condi- 
tion of  things  which  obtains  in  cirrhotic 
renal  disease.  {See  Sfhygmograpji,  and 
Stui'OK,  Mental.) 

We  append  a  series. of  pulse  tracings, 
reference  to  which  will  be  found  in  this 
article.* 


Fig.  I. — Melancholia  (A), 


Fig.  2.— Melancholia  (B).     Same  pulse  on  recovery. 


Fig.  3. — Acute  delirious  mania  (A). 


Fk;.  4. — Acute  delirious  mania  (B).     Same  pulse  on  recovery. 


Fig.  5. — Mental  stupor  (A). 


*  Figs.  T,  2,  3,  4,  5  and  6  arc  sphyi^-mographic 
tracings  of  our  own  ;  Figs.  7  and  10  are  from  an 
article  in  the  Journal  of  Mental  Science,  1881,  p.  8, 
hy  Dr.  Bevan  Lewis  ;  Fiy.  8  is  from  an  article  by 


Dr.  George  Thompson,  in  the  "West  Hiding  Medi- 
cal Reports,"  vol.  i. ;  Fig.  9  i«  »  sphygmograni 
taken  by  Dr.  Duncan  Greenlees  (see  Journal  of 
Menial  Science,  1886,  p.  483). 


Punning  in  Mania  [    1052    ]     Pupils,  Reactions  of  the 


Tig.  6.— Mental  stupor  (B).     Same  pulse  during  period  of  lucidity. 


Fig.  7.— General  paralysis  (A).    First  stage. 


Fig.  8.— General  paralysis  (B).     First  stage. 


Fig.  9. — General  paralysis  (C).     Second  staye. 


Fig.  10. — General  paralysis  (D).     Second  stage. 


J.  E.  Whitwell. 


TVSmiNG  lia-  MATHA.— In  the  ex- 
citement and  exaltation  of  mania,  rapid 
verbal  association  is  often  a  marked  fea- 
ture, and  clever  puns  are  sometimes  made 
— but  oftener  the  reverse. 

PUPIIiS,THZ:  REACTION'S  OF  THE, 
in  HEAIiTH  and  DISEASE. — The  size 
of  the  pupils  in  a  healthy  subject  is  depen- 
dent chiefly  on  the  intensity  of  the  light 
to  which  the  eyes  are  exposed.  They  are 
large  in  dull  light,  small  in  bright  light. 
They  become  contracted  during  accom- 
modation  and  convergence    and  dilated 


again  when  the  muscular  efforts  are  re- 
laxed. 

The  normal  pupil  has  three  distinct  re- 
actions, the  first  and  second  of  which  are 
reflexes,  the  third  is  an  associated  action. 

( I )  Reflex  Contraction  on  Exposure  to 
Xiig-bt. — This  may  be  brought  about  by 
light  falling  upon  the  eye  under  examina- 
tion, or  upon  its  fellow,  and  to  differen- 
tiate between  these  two  reactions,  the 
terms  direct  and  consensiuiJ  are  used  ;  the 
former  signifies  the  alteration  in  the 
pupil  of  the  lighted  eye,  the  latter  the 


Pupils,  Reactions  of  the     [     1053    ]     Pupils,  Reactions  of  the 


movement  excited  simultaneously  in  tlie 
opposite  pupil.  In  this  retlex  act  the 
optic  is  the  ati'erent,  and  the  third  (motor 
ocnli)  the  efferent  nerve,  and  the  centre, 
situated  in  the  grey  matter  beneath  the 
aquednct  of  Sylvius,  is  that  part  of  the 
third  nerve  nucleus,  near  its  anterior 
limit,  which  specially  controls  the  sphinc- 
ter iridis.  The  impulse  travels  centri- 
petally  by  the  optic  nerve,  and,  at  the 
chiasma,  in  consequence  of  the  decussa- 
tion of  the  fibres,  exhends  along  each  optic 
tract  to  the  corpora  quadrigeraina. 
Thence,  by  way  of  Meynert's  fibres,  it 
reaches  the  oculo-motor  nuclei,  and  be- 
coming an  efferent  impulse,  passes  down 
the  trunk  of  the  third  nerve,  to  the  cili- 
ary ganglion,  and  thence  along  the  ciliary 
nerves  to  the  iris.  The  centre  of  each 
third  nerve  receiving  an  equal  stimulus, 
an  equal  contraction  occurs  in  the  two 
pupils — i.e.,  the  consensual  and  direct  re- 
actions are  equal.  Clinical  observations 
and  anatomical  researches  indicate  that 
the  consensual  reaction  of  the  pupil  via;/ 
be  brought  about  in  a  way  other  than  that 
just  mentioned.  In  the  rabbit's  brain  it 
has  been  shown  that  the  oculo-motor 
nerve  has  a  double  origin,  part  crossed, 
part  uncrossed  (Gudden),  and  although 
the  crossed  origin  has  not  been  actually 
proved  in  man,  it  is  very  probable  that  it 
exists.  Transverse  fibres  crossing  the 
middle  line  between  the  two  third  nerve 
nuclei  are  figured  by  several  writers. 
Thus  it  is  readily  conceivable  that  an 
impulse  reaching  the  nucleus  of  one  side 
should  cross  directly  to  that  of  the  other 
side.  It  has  been  asserted  recently  by 
good  authorities  that  the  optic  nerve  con- 
tains special  fibres  whose  function  is  to 
convey  the  impressions  which  give  rise  to 
these  pupil  refiexes  and  that  these  fibres 
are  not  directly  concerned  in  vision.  By 
some  it  is  stated  that  these  pupillary  fibres 
can  be  distinguished  microscopically.  In 
the  nerve  trunk  they  run  with  the  fibres 
supplying  the  macular  part  of  the  retina 
and  appear  to  be  less  readily  damaged  by 
disease  than  are  the  visual  fibres.  Bech- 
terew  holds  that  these  pupillary  fibres  do 
not  cross  at  the  optic  commissure  but  pass 
to  the  oculo-motor  nucleus  of  the  same 
side  by  entering  the  grey  matter  sur- 
rounding the  third  ventricle :  however, 
there  is  not  as  yet  sufficient  anatomical 
evidence  to  establish  this  view. 

(2)  Reflex  Dilatation. — The  centre  for 
this,  often  described  as  the  skin-reflex,  is 
stated  to  be  in  the  medulla  oblongata 
(Salkowski)  or  beneath  the  corpora  quad- 
rigemina  to  the  outer  side  of  the  centre 
for  the  light-reflex  (Gowers.)  The  path 
of  the   afferent  impulses  varies  greatly, 


and  may  be  along  almost  any  cutaneous 
nerves,  spinal  or  ci'anial,  or  some  of  the 
nerves  of  special  sense.  Pinching  or 
pricking  the  skin  of  the  face,  neck,  arm 
or  leg,  will  excite  the  reflex,  and  loud 
noises  have  been  known  to  induce  it 
(Westphal)  in  persons  under  chloroform. 
It  also  occurs  in  emotional  states  as  anger 
or  fright.  The  efferent  (motor)  impulses 
reach  the  eye  generally  by  way  of  the 
cervical  and  upper  dorsal  spinal  cord 
(where  the  cilio-spinal  centre  of  Budge  is 
situated),  the  two  first  dorsal  nerves,  the 
cervical  sympathetic,  the  cavernous  plexus, 
the  branches  of  the  fifth  nerve,  and  the 
ciliary  ganglion.  It  seems  unlikely,  how- 
ever, that  this  constitutes  the  only  path 
along  which  efferent  impulses  may  pass, 
for  the  reaction  is  retained  after  complete 
division  of  the  cervical  sympathetic. 

(3)  Contraction  in  Association  xrith 
Accommodation,  and  Convergence  of 
the  Visual  Axes. — This  narrowing  of 
the  pupil,  the  object  of  which  is  to  cut  off 
the  light  rays  which  would  traverse  the 
peripheral  parts  of  the  lens,  is  more 
intimately  connected  with  convergence  of 
the  optic  axes  than  with  accommodation. 
A  good  deal  of  evidence  has  been  adduced 
in  favour  of  the  existence  of  a  special 
centre  for  the  three  associated  movements, 
accommodation,  convergence,  and  pupil- 
lary contraction,  and  at  least  one  clinical 
case  has  been  recorded  (Eales)  which 
almost  proves  that  in  man  such  a  centre 
is  present,  although  it  has  not  yet  been 
accurately  localised.  In  dogs,  as  shown 
by  the  experiments  of  Hensen  and 
Volckers,  the  centres  controlling  the 
ciliary  muscle,  the  sphincter  iridis,  and 
the  internal  rectus  muscle,  are  situated 
close  together  in  the  posterior  part  of  the 
floor  of  the  third  ventricle  ;  and  these 
observers  regard  this  region  as  the 
probable  centre  for  the  associated  action 
of  the  three  muscles,  internal  rectus, 
ciliary  muscle,  and  sphincter  of  the  iris. 

There  are  in  addition,  some  pupillary 
movements,  which  should  probably  be 
regarded  as  associated  with  other  cerebral 
centres,  as,  for  example,  the  respiratory 
centre,  and  others  again  in  which  no  such 
association  is  likely.  Dilatation  of  the 
pupil,  sometimes  considerable  in  degree, 
occurs  with  each  deep  expiration  or  inspi- 
ration. The  pupil  is  also  subject  to 
minute  and  ever-recurring  alterations  in 
size.  This  unceasing  movement  is  called 
hippus,  or  the  unrest  of  the  pupil 
(Laqueur),  and  is  ascribed  to  the  influence 
of  the  multitudinous  sensory  and  other 
impressions  to  which  the  reflex  centres 
are  constantly  exposed.  It  has  been 
stated  that  in  very  excitable  people  the 


Pupils,  Reactions  of  the      [    1054    ]     Pupils,  Reactions  of  the 


effect  of  psychical  and  sensory  stimuli  is  | 
manifest   in   the   unduly  wide  pupils  so  ! 
often  seen  in  such  individuals.     During 
sleep,  when  reaction  to  outside  stimuli  is 
almost  nil,  the  jjupils  are  contracted. 

Alterations  in  Size  of  Pupils. — The 
two  i^ujiils  are  of  equal  size  in  the  great 
majority  of  healthy  people  ;  exceptionally 
however,  marked  inequality  is  present, 
without  any  local  conditions,  such  as  pos- 
terior synechise,  to  explain  it,  and  in  eyes 
with  perfect  vision.  If  inequality  of  pupils 
(anisocoria),  due  to  disease,  be  present,  the 
most  sluggish  is  usually  the  pathological 
pupil.  There  is  no  standard  size  for  the 
pupil,  but  an  average  can  be  obtained 
by  the  measurement  under  similar  con- 
ditions as  regards  light,  &c.,  of  the  pupils 
of  a  large  number  of  healthy  individuals. 
Even  on  this  point,  however,  the  figures 
published  by  different  observers  do  not 
entirely  agree.  In  adults  an  average  size 
of  4  mm.  in  good  daylight  is  probably 
nearly  correct.  The  measurement  should 
be  made  with  the  accommodation  at  rest — 
i.e.,  with  the  eye  gazing  into  the  distance. 
Speaking  generally,  the  pupils  are  larger 
in  children  than  in  adults,  and  in  young 
than  in  old  persons.  It  was  formerly 
held,  and  by  good  authorities,  that  the 
j)upils  of  myopic  eyes  were,  as  a  general 
rule,  wider  than  those  of  emmetropic  or 
hypermetropic  eyes,  and  the  explanation 
given  was  that  in  myopic  eyes  accommo- 
dative efforts  are  seldom  required.  It 
seems  doubtful,  however,  if  such  is  really 
the  case.  Hutchinson  thinks  that  there 
"is  a  relationship  between  the  size  of  the 
l^upils  and  the  state  of  the  patient's 
nerve  tone,  due  allowance  being  made  for 
age  and  other  circumstances.  If  the  tone 
be  low  the  pupils  are  large.  The  size  of 
the  pupils  is  almost  in  inverse  ratio  with 
that  of  the  arteries." 

Mydriasis  is  the  term  used  to  denote 
abnormal  dilation  of  the  pupil ;  three 
varieties  are  recognised,  (i)  Artificial, 
produced  by  drugs,  such  as  atropine, 
which     are      hence     called     mydriatics ; 

(2)  Paralytic,  generally  due   to  disease 
of  the  pupil-contracting  centre  or  fibres ; 

(3)  Spasmodic,  caused  by  irritation  of  the 
j^upil-dilating  centre  or  fibres  by  disease. 

Paralytic  IMydriasis  (Zridoplegria.)  — 
This  condition  of  pupil  may  result  from  a 
lesion  situated  in  the  nucleus  of  the  third 
nerve  or  in  any  part  of  the  nerve  between 
its  nucleus  and  the  iris.  Disease  of  the 
ciliary  ganglion  through  which  the  nerve 
fibres  pass  on  their  way  to  the  sphincter 
iridis,  gives  rise  to  this  symptom,  although 
in  such  a  case  the  dilating  fibres  to  the 
iris,  or  at  least  some  of  them,  might  also 
be  affected.     Damage  to  the  extreme  peri- 


pheral filaments  supplying  the  iris,  as  in 
some  cases  of  intra-ocular  disease,  also 
leads  to  this  form  of  mydriasis.  Any 
interruption  in  the  transmission  of  stim- 
uli from  the  retina  to  the  third  nerve 
centre  gives  rise  to  the  condition,  and  this 
may  occur  even  though  the  pupil-con- 
tracting centres  and  fibres  be  nearly  or 
quite  healthy.  The  pupil  in  paralytic 
mydriasis  is  moderately  dilated  ;  this  di- 
latation can  be  increased  to  the  maximum 
by  mydriatics,  but  only  a  medium  con- 
traction can  be  effected  by  myotics ;  the 
reflex  dilatation  to  sensory  stimuli  is 
retained,  but  the  other  reactions  may 
vary ;  if  the  lesion  be  situated  in  the 
oculo-motor  nucleus  or  in  the  course  of 
the  third  nerve,  reflex  action  to  light, 
direct  and  consensual,  and  associated 
action  with  convergence  are  lost ;  if  the 
lesion  be  in  the  afferent  path — i.e.,  between 
the  retina  and  the  centre,  the  efferent 
tracts  being  healthy,  the  direct  contrac- 
tion of  the  pupil  to  light  is  lost,  but  the 
consensual  reaction  and  the  associated 
reaction  are  unaffected- 
Paralytic  mydriasis  is  met  with  in 
tumour  or  other  forms  of  disease  at  the 
base  of  the  brain,  which  destroy  the  third 
nerve  in  any  part  of  its  course  between 
the  inter-peduncular  space  and  the  sphe- 
noidal fissure  through  which  it  leaves  the 
iutra-cranial  cavity.  New  growths  in  the 
meninges  or  bones  of  the  basis  cranii, 
disease  (thrombosis)  of  the  cavernous 
sinus,  or  tubercle  at  the  base  are  among 
such  causes.  Destruction  of  the  third 
nerve-nucleus  will  of  course  give  rise  to 
this  condition.  In  instances  like  the 
above,  in  which  the  whole  nerve  is  affected, 
the  pupil  symptom  will  be  accompanied 
by  paralysis  of  the  other  ocular  muscles 
supplied  by  this  nerve  ;  there  will  be 
ptosis,  divergent  strabismus  with  loss  or 
impairment  of  upward,  downward,  and 
inward  rotation  of  the  globe,  and  cyclo- 
plegia. 

In  general  paralysis  of  the  insane 
{see  Eye),  in  epilepsy,  in  cerebral  haemor- 
rhage, in  orbital  disease  (tumour  or  ab- 
scess), damaging  the  ciliary  nerves,  in  in- 
creased intra-ocular  pressure,  as  in  glau- 
coma of  any  variety,  this  pupillary  con- 
dition may  be  present.  In  hgemorrhage 
from  the  middle  meningeal  artery  uni- 
lateral mydriasis  on  the  same  side  as  the 
hgemorrhage,  occurs  iu  about  50  per  cent, 
of  the  cases,  and  is  thus  a  valuable  symp- 
tom in  regard  to  trephining.  Paralytic  my- 
driasis due  to  interruption  in  the  afferent 
fibres  is  met  with  in  optic  atrophy  and 
other  lesions,  such  as  injury  to  the  nerve 
by  perforating  wounds,  or  by  fracture  of 
the  boues  at  the  apex  of  the  orbit. 


Pupils,  Keactions  of  the      [ 


]     Pupils,  Reactions  of  the 


Spasmodic  Mydriasis,  or  Irritation 
Mydriasis,  is  a  condition  concerning  which 
our  knowledge  is  more  limited.  Belief  in 
the  presence  of  radial  or  dilator  nruscle- 
fibi'es  in  the  iris  renders  discussion  of  the 
pupillary  condition,  which  would  result 
from  spasm  of  them,  comparatively  easy. 
There  seems,  however,  scarcely  a  doubt 
that  in  man  such  tibres  do  not  exist,  and 
hence  it  is  no  longer  accurate  to  speak  of 
spasmodic  mydriasis.  The  alternative 
term  is  a  better  one,  and  should  be  held 
to  signify  mydriasis  induced  by  irritation 
of  the  nerves  which  inhibit  the  action  of 
the  sphincter  of  the  pupil.  This  condi- 
tion is  recognised  (Leeser),  and  is  to  be 
distinguished  from  paralytic  mydriasis 
by  a  moderately  dilated  pupil,  which  does 
not  become  larger  in  response  to  sensory 
stimuli  (reflex  dilatation  lost) ;  its  reaction 
to  light  and  with  convergence  are  retained 
although  diminished  in  degree.  Mydriatics 
dilate  this  jiupil  to  the  maximum,  but  its 
contraction  under  the  influence  of  myotics 
is  less  than  normal. 

Irritation  mydriasis  may  be  present  in 
the  early  stages  of  disease  of  the  cervical 
spinal  cord,  as  tumours  or  meningitis,  or 
of  disease  in  the  course  of  the  cervical 
sympathetic,  by  which  irritation  but  not 
paralysis  of  the  pupil-dilating  fibres  is 
caused.  It  also  occurs  in  some  conditions 
of  mental  disturbance,  acute  mania, 
melancholia  with  excitement,  &c.  It  has 
been  stated  to  accompany  severe  intes- 
tinal irritation. 

ivxyosls  is  the  name  applied  to  any  ab- 
normally small  pupil.  Here  also  three 
forms  are  recognised: — • 

(i)  Artificial,  due  to  the  action  of 
drugs,  such  as  Calabar  bean,  which  are 
hence  termed  myotics;  (2)  Paralytic,  due 
to  paralysis  of  the  pupil-dilating  centre  or 
fibres  ;  (3)  Spasmodic,  due  to  irritation 
of  the  pupil-contracting  centre  or  nerve- 
fibres,  giving  rise  to  spasm  of  the  circular 
muscle  of  the  iris. 

Paralytic  IMyosis. — This  condition  is 
induced  by  any  pathological  process  pre- 
ventingthe  ti-ansmission  of  impulses  which 
in  health  are  inhibitory  to  the  action  of 
the  sphincter  pupillas — i.e.,impulses  travel- 
ling along  the  pupil-dilating  fibres  {see 
page  1053).  In  oi'der  that  the  term  shall 
be  correct  (just  as  in  using  the  term  spas- 
modic mydriasis)  the  paralysis  must  be 
understood  to  refer  to  loss  of  nerve  power 
only,  and  in  no  wise  to  a  dilator  muscle  in 
the  iris.  The  pupil  in  this  condition  is 
moderately  contracted,  it  does  not  react  to 
sensory  stimuli  (reflex  dilatation  lost),  but 
retains  its  reactions  to  light  and  with  con- 
vergence. It  is  further  contracted  by  myo- 
tics and  dilates  but  partially  to  mydriatics. 


Paralytic  myosis  is  met  with  in  tabes 
dorsalis  and  in  general  paralysis  of  the 
insane  (see  Eve).  It  is  sometimes  spoken 
of  as  the  "  spinal  pupil,"  and  has  to  be  dis- 
tinguished clinically  from  the  Argyll- 
Robertson  pupil.  In  the  former  the  pupil 
is  contracted  but  not  very  small,  and  re- 
tains its  reactions,  both  i-eflex  and  asso- 
ciated ;  the  lesion  is  then  in  the  medulla 
oblongata  or  the  spinal  cord  (cilio-spinal 
centre).  In  the  latter  the  reaction  of  the 
pupil  to  light  is  lost,  the  associated  action 
with  convergence  is  retained,  and  the  lesion 
is  probably  in  Meynert's  fibres. 

In  spinal  cord  disease,  above  the  first 
dorsal  vertebra,  disease  in  the  neck,  such 
as  goitre  and  other  tumours,  aneurism, 
enlarged  glands,  &c.,  this  form  of  myosis 
may  be  present  and  results  from  interfer- 
ence in  the  efferent  path  of  the  pupil 
dilating  impulses  in  the  cord  or  cervical 
sympathetic.  In  injuries  to  the  spinal 
cord  or  sympathetic  in  the  neck  the  condi- 
tion found  is  stated  by  Hutchinson,  jun., 
to  be  not  so  much  an  active  contraction  of 
the  pupil,  as  loss  of  dilatation  in  full  light. 
Spasmodic  Myosis,  or  Irritation 
iviyosis.— Disease  which  gives  rise  to  this 
condition  acts  as  an  irritant  to  the  centres 
from  which  impulses  travel  to  the 
sphincter  of  the  pupil,  or  to  the  nerve 
fibres  in  their  course.  It  is  doubtful  if 
myosis  due  to  spasm  is  ever  more  than  a 
temporary  condition,  and  one  about  which 
we  have  not  as  yet  much  accurate  know- 
ledge. Spasm  of  the  ciliary  muscle  is  not 
uncommonly  met  with  and  easily  recog- 
nised. In  some  of  these  cases  the  pupils 
are  unduly  small,  and  there  is  doubtless 
spasm  of  the  sphincter  iridis  as  well,  but 
the  association  is  not  constant.  In  this 
condition  the  pupil  does  not  generally 
contract  to  light,  neither  does  it  dilate 
when  shaded.  The  associated  action  with 
convergence  is  lost.  It  dilates  widely  to 
mydriatics,  and  becomes  still  further  con- 
tracted under  the  influence  of  myotics. 

The  contraction  of  pupil  which  is  spoken 
of  as  congestion  inyosis,  and  which  is  seen 
in  the  early  stages  of  inflammatory  con- 
ditions of  the  anterior  jDarts  of  the  eye 
(generally  slight  injuries  to  the  cornea), 
may  be  here  referred  to.  The  explanation 
generally  given  that  it  is  due  to  an 
increased  vascularity  of  the  iris  is  probably 
in  the  main  correct,  though  it  may  be 
said  with  equal  probability  to  be  partly  a 
reflex  contraction. 

Spasmodic  myosis  is  met  with  more 
frequently  than  the  paralytic  form.  It  is 
a  nearly  constant  symptom  of  the  early 
stage  of  inflammatory  intra-cranial  afi'ec- 
tions,  as,  for  example,  meningitis  of  all 
kinds,  and  marks  the  onset  of  inflamma- 


Pursuit,  Ideas  of 


[    1056    ] 


Pyromania 


tory  reaction  after  injuries  to  the  cortex 
and  deeper  parts  of  the  brain.  In  cei'ebral 
hfemorrhage,  myosis  is  at  first  present 
(Berthold.)  It  may  be  caused  by  intra- 
cranial tumours  in  the  neighbourhood  of 
the  origin  of  the  third  nerves,  or  in  the 
coui'se  of  the  nerves,  and  would  then  pro- 
bably be  followed  by  paralytic  mydriasis. 
It  has  been  noted  at  the  beginning  of 
hysterical  and  epileptic  seizures  and  is  a 
sign  of  poisoning  by  certain  drugs — e.g., 
opium,  Calabar  bean,  tobacco. 

J.  B.  Lawford. 

PURSVXT,  ZBEAS  OT.  {See  PERSE- 
CUTION Mania.) 

PYROMAWIA  {rrvp,  fire).  Synonyms. 
— Monomanie  incendiaire  (Fr.) ;  Feuerlust, 
Brandstiftungsmonomanie,  or  lust,  or 
iriel  (Ger.). 

Definition. — A  morbid  impulse  to  burn. 

Historical. — The  mental  condition  to 
which  has  been  attached  the  term  pyro- 
mania is  more  frequently  alluded  to,  and 
more  fully  treated  in  foreign  than  in 
English  psychological  literature.  This  is 
doubtless  owing  to  the  fact  that  it  is  a  con- 
dition not  specially  recognised  by  English 
jurists  or  in  English  courts  of  law.  In 
offences  like  arson  the  question  of  respon- 
sibility is  rarely  raised,  the  cases  seldom 
attract  attention,  no  interest  is  felt  in  the 
accused,  and  conviction  and  imprisonment 
follow  as  a  matter  of  course.  In  the  past 
no  inconsiderable  number  of  incendiaries 
have  been  found  insane  whilst  undergoing 
sentence,  and  transferred  from  penal  re- 
straint to  asylum  custody.  The  method 
of  inquiring  into  the  mental  condition  of 
such  cases  before  trial  might  be  improved 
upon.  As  has  been  said,  it  is  to  foreign 
psychologists  that  we  owe  most  of  our 
knowledge  on  the  subject  of  pyromania. 
Some  have  maintained  that  it  is  an  in- 
stinctive insanity  characterised  by  inter- 
mittent irresistible  impulse,  some  that  it 
is  a  reasoning  insanity,  whilst  others  have 
contended  that  it  is  the  accidental  result 
of  some  recognised  form  of  mental  disorder. 

Platner  did  not  describe  pyromania  as 
such,  although  he  mentions  most  of  the 
facts  upon  which  it  was  afterwards 
founded — viz.,  the  Feuerlust  or  delight  in 
seeing  a  fire,  characteristic  of  imbeciles, 
the  disturbances  of  sexual  development, 
more  especially  in  the  case  of  young 
females,  and  also  the  apparent  want  of 
motive  in  many  of  the  incendiary  acts. 
According  to  Platner  one  of  the  causes  of 
incendiarism  is  "  amentia  occulta,"  by 
which  he  designates  a  condition  of  mind 
where  the  intellect  remains  unaffected, 
whilst  the  feelings  and  conduct  are  dis- 
ordered. Henke  regarded  the  frequent 
disposition  to  incendiarism  amongst  young 


people  as  often  consequent  upon  irregular 
bodily  conditions,  especially  irregular  or- 
ganic development  at  the  time  of  puberty 
or  just  before.  Meckel  was  the  first  to  use 
the  term  impulsive  incendiarism  {Brand- 
stiftnngstrieb)  and  to  describe  it  as  a  new 
disorder.  Vogel  did  not  look  on  impulsive 
incendiarism  as  a  mental  disease  if  cri- 
minal motives  were  present ;  he  allowed, 
however,  that  when  irresistible  impulse 
existed  with  absence  of  motive,  it  arose 
from  a  morbid  mental  disorder.  Masius 
was  far  from  accepting  the  doctrine  of  an 
instinctive  incendiary  monomania,  and 
declared  that  impulses  to  fire-raising  fre- 
quently occur  in  connection  with  some  of 
the  well-known  forms  of  insanity  —  e.g., 
idiocy  and  melancholia,  but  that  a  greater 
number  are  duetocriminalmotives.  Flem- 
ing also  rejected  the  instinctive  theory, 
and  considered  that  the  propensity  to  in- 
cendiarism originated  almost  always  from 
normal  motives — e.g.,  revenge,  hatred,  &c. 
He  found  in  some  cases  a  morbid  mental 
condition  which,  however,  possessed  no 
special  features.  He  disallows  the  influ- 
ence of  puberty,  and  regards  the  incen- 
diary act  as  merely  the  accidental  outcome 
of  a  morbid  mental  state.  Meyer  held 
somewhat  similar  views  on  the  subject. 
Casper  too  denies  the  existence  of  a  special 
incendiary  insanity.  He  believes  that  fire- 
raising  perpetrated  either  with  or  without 
motive  is  always  a  criminal  act ;  and  un- 
less there  is  clear  evidence  of  a  disordered 
mind,  it  should  always  be  punished  as  a 
crime.  Jessen,  who  wrote  largely  on  the 
subject,  admits  its  existence  as  a  reasoning 
monomania,  but  demurs  to  its  occurrence 
in  an  instinctive  form.  Griesinger  adopts 
the  same  conclusion.  He  states  that  it 
is  due  to  a  diseased  mental  condition, 
especially  melancholia,  or  to  a  spasmodic 
neurosis,  such  as  epilepsy,  or  associated 
with  derangements  of  the  sexual  organs. 
In  France  the  docti'ine  of  instinctive  mono- 
mania was  founded  by  Esquirol,  and 
applied  to  incendiarism  by  Georget.  Marc 
was  the  first  to  use  the  term  pyromania. 
He  states  that  genuine  pyromania  is 
chiefly  manifested  in  young  persons 
between  the  ages  of  twelve  and  twenty, 
and  is  generally  the  result  of  abnormal 
development  of  the  sexual  organs.  Morel 
regarded  it  as  an  instinctive  form  of  in- 
sanity in  some  children  with  hereditary 
predisposition.  Motet  says  that  impul- 
sive incendiarism  is  found  in  all  forms  of 
insanity,  yet  not  as  a  blind  instinct  in  such 
cases.  He  affirms  that  in  genuine  pyro- 
maniacs,  in  whom  there  is  a  real  appetite, 
the  real  satisfaction  of  which  is  eagerly 
sought  after,  there  is  the  irresistibleness 
of  a  morbid  impulse.     Moussel  concludes 


Pyromania 


[    1057    ] 


Pyromania 


that  there  exists  a  mental  disease  which  is 

•  essentially  characterised  by  an  impulse  to 
burn.  This  impulse,  it'  not  irresistible,  is 
unique,  and  seems  to  spring  of  its  own 
accord  from  the  unconscious  victim.  He 
also  excludes  cases  of  real  insanity,  stating 
that  by  real  pyromaniacs  he  means  per- 
sons who  set  tire  to  things,  not  on  account 
of  sensorial  perversions  or  delirious  con- 
ceptions, but  impelled  to  do  so  by  an  over- 
powering impulse.  Lasrgne  and  Tardieu 
have  dealt  with  the  subject  in  connection 
with  imbecility,  and  Giraud  and  Rousseau 
have  added  to  the  literature  of  the  question 
by  contributing  a  number  of  interesting 

•cases   bearing   more   particularly  on   the 

•  association  of  incendiarism  with  disorders 
of  the  sexual  functions.  Marro  found  that 
in  incendiaries  lesions  of  sensibility  are 
frequent,  and  religious  sentiment  remark- 
ably prevalent.  He  was  struck  with  the 
large  proportion  of  cases  mentally  alien- 
ated. Such  is  a  brief  rrsnmc  of  the 
views  entei'tained  by  various  observers  on 
the  subject  of  pyromania.  No  doubt  is 
cast  upon  its  existence,  but  a  decided 
difference  of  opinion  is  ex])ressed  as  to 
whether  it  exists  alone  without  other 
symptoms  of  insanity.  As  a  rule  English 
observers  appear  to  agree  with  the  views 
held  by  many  of  the  German  writers— viz., 
that  it  is  not  a  disease  jjer  se,  but  the 
result  of  some  of  the  well-known  forms  of 
insanity,  and  this  view  we  are  inclined  to 
support. 

Criminal  Class. — Amongst  a  consider- 
able number  of  incendiaries  who  have 
come  under  our  own  observation,  a  large 
proportion  belonged  to  the  epileptic  and 
weak-minded  class,  others  were  truly  in- 
sane, whilst  a  few  possessed  characteristics 
of  an  essentially  criminal  nature — viz.,  an 
inferior  cranial  development,  a  low  state 
of  moral  feeling,  a  capacity  for  alcoholic 
indulgence,  and  an  unscrupulous  perse- 
verance towards  the  gratification  of  their 
animal  instincts.  One  man  who  answers 
to  this  description  set  fire  to  a  stackyard, 
for  which  he  underwent  a  term  of  penal 
servitude ;  shortly  after  his  release  he 
returned  to  the  same  place,  and  again  fired 
the  stackyard,  because  the  owner  had 
given  evidence  against  him  at  his  first 
trial.  He  affirmed  that  the  long  term  of 
imprisonment,  to  which  he  was  sentenced 
for  his  crime,  was  more  than  counter- 
balanced by  the  great  loss  the  farmer  sus- 
tained by  the  burning  of  his  stacks. 
Allusion  has  been  made  to  Morel's 
opinion,  that  pyromania  occurs  as  an  in- 
stinctive form  of  insanity  in  some  children, 
with  hereditary  predisposition.  There 
are  certain  children,  more  or  less  weak- 
-minded although  not  imbecile,  who  suffer 


from  moral  defect,  the  result  of  an  in- 
herited neurosis.  They  are  prone  to  Ijing, 
to  stealing,  and  to  acts  of  cruelty,  in 
which  they  seem  to  take  a  special  delight ; 
occasionally  they  develop  a  propensity 
for  incendiai'ism.  Of  a  morallj'  pervei'se 
nature,  they  exhibit  a  passion  for  playing 
with  fire,  simply  because  it  is  forbidden 
them  to  go  near  it.  Dr.  Savage  instances 
the  case  of  a  boy  who  set  fire  to  eveiy 
house  he  was  sent  to,  after  being  there  a 
short  time.  Sometimes  the  act  is  com- 
mitted out  of  spite  or  malice,  at  other 
times  from  wantonness  or  for  the  mere 
pleasure  of  seeing  a  blaze.  This  propen- 
sity may  be  instinctive  in  the  sense  that 
such  children  display  a  powerful  instinct 
to  destroy,  but  it  can  hardly  be  regarded  as 
characteristic,  for  they  are  as  likelyto  prove 
destructive  in  other  ways  as  opportunity 
offers.  Pyromania,  therefore,  in  this  class 
does  not  appear  to  be  a  form  of  mental 
disorder  jjer  se,  but  rather  the  outcome  of 
a  primary  moral  insanity. 

Puberty. — In  many  cases,  if  the  de- 
velopment of  the  mental  symptoms  be 
traced,  it  will  be  found  that  they  tend  to 
become  intensified  at  the  age  of,  or  after, 
puberty,  the  result  being  that  some  be- 
come truly  insane,  others  criminal,  few  do 
well.  From  them  the  ranks  of  the  older 
incendiaries  are  largely  recruited,  and 
amongst  them  the  advocates  of  the  inde- 
pendent existence  of  pyromania  find  many 
of  their  clients. 

Genuine  pyromaniacs  are  usually  de- 
scribed as  young  persons,  for  the  most 
part  dwellers  in  the  country ;  badly  de- 
veloped, of  defective  intelligence,  heredi- 
tarily tainted  with  insanity  or  epilepsy, 
and  presenting  anomalies  in  character, 
habits,  and  feelings ;  having,  as  a  rule,  no 
delusions,  no  motive  for  their  crimes,  but 
imbued  with  an  irresistible  imjjulse to  burn. 
We  have  met  with  incendiaries  to  whom 
the  above  description  generally  applies. 
In  some  cases  repeated  questioning  has 
elicited  a  reason  for  their  criminal  doings, 
— e.g.,  a  feeling  of  revenge,  or  desire  to  get 
into  prison,  to  avoid  want  and  exposure. 
An  outstanding  feature  in  these  cases  is 
their  remarkable  forgetfulness,  and  it  is 
almost  always  a  difficult  matter  to  arrive 
at  a  satisfactory  explanation  with  them, 
for,  as  a  rule,  they  jiossess  unlimited 
capacity  for  lying  and  deceit,  and  their 
invariable  answer  to  all  queries  is,  "  I 
don't  know."  Owing  to  this  pretended 
want  of  memory,  it  is  sometimes  by  no 
means  an  easy  task  to  deduce  the  measure 
of  their  responsibility.  The  cunning  dis- 
played by  them,  the  precautions  taken  to 
avoid  discovery,  and  the  presence  of 
motive  without  clear  evidence  of  insanity, 


Pyromania 


[     1058    ] 


Pyromania 


will  stamp  the  act  as  criminal.  In  the 
absence  of  motive,  an  examination  into 
their  antecedents  may  reveal  a  history  of 
hereditary  neurosis,  or  of  infantile  convul- 
sions, of  previous  indulgence  in  drink,  and 
also  of  a  period  of  unrest  and  mental  in- 
quietude before  the  commission  of  the 
crime.  The  establishment  of  such  and 
similar  symptoms  will  afford  a  more  solid 
basis  for  the  plea  of  Irresponsibility  being 
raised  than  the  advancement  of  the  mere 
dictum  of  intermittent  irresistible  impulse. 

In  the  case  of  females,  especially  young 
girls,  attention  should  be  directed  to 
derangements  of  the  reproductive  organs. 
Pyromania  often  appears  at  the  be- 
ginning of  the  sexual  life,  and  just  as 
sly  stealing  seems  to  be  characteristic  of 
the  mental  disturbances  arising  from 
pregnancy,  so  fire-raising  aj^pears  to  be  a 
feature  of  the  nervous  disorders  attendant 
on  the  establishment  of  menstruation. 
Puberty  is  a  critical  period  when  weak 
systems  succumb,  as  at  each  recurring 
epoch  there  are  nervous  changes  which 
exercise  a  disturbing  influence  on  the 
system  generally.  The  occurrence  of 
incendiarism  dependent  on  the  altered 
mental  conditions  coincident  with  the 
evolution  of  puberty  has  been  frequently 
observed  and  described,  amongst  others 
by  Rousseau  who  relates  (Ann.  Med. 
Psych.  1 881)  the  case  of  a  young  girl  who 
suffered  from  headache,  general  malaise, 
great  anxiety,  and  abdominal  pain.  Her 
nights  were  disturbed  by  voices  whisper- 
ing, "  Set  on  fire,  set  on  fire."  She  resisted 
for  some  time,  but  yielded  to  the  delusional 
promptings  on  the  day  of  her  first  men- 
strual flow,  and  again  at  her  third  men- 
struation ;  both  dates  coincided  exactly. 

In  this  class  of  cases  the  presumption 
that  the  incendiarism  has  been  the  result 
of  disease,  will  be  strengthened  by  the 
presence  of  such  symptoms  as  vertigo, 
epistaxis,  and  derangement  or  suppression 
of  the  menses,  by  the  complication  of  epi- 
lepsy or  chorea,  and  by  the  occurrence  of 
such  physical  signs  as  glandular  swell- 
ings and  cutaneous  eruptions.  Anaes- 
thesia also  may  be  present. 

Such  physical  signs  as  glandular  swell- 
ings and  cutaneous  eruptions  are  worthy 
of  note.  The  mental  symptoms  may  vary 
from  hysterical  excitability  and  irritability 
to  depression  and  stupor,  but  in  the  gen- 
erality of  cases  a  tendency  to  sadness  and 
melancholia  will  be  found.  When  a 
motive  exists  with  absence  of  mental  de- 
rangement the  act  should  be  regarded  as 
criminal  ;  on  the  other  hand,  the  presence 
of  mental  aberration  with  or  without 
motive  will  indicate  that  the  patient  is 
suffering  from  the  insanity  of  pubescence 


or  adolescent  insanity,  and  is  therefore 
irresponsible. 

Such  cases  —  i.e.,  of  pyromania 
amongst  young  females — seem  to  be  of 
much  rarer  occurrence  in  this  country 
than  on  the  Continent,  where  they  are  not 
infrequently  observed.  This  probably 
arises  partly  from  the  fact  that  they  are 
rarely  suspected  and  partly  that  they  are 
treated  with  leniency  if  arrested.  What- 
ever may  be  the  reason,  an  examination 
of  the  English  prison  blue-books  afi'ords 
evidence  that  females  are  rarely  connected 
with  arson  in  this  country.  Daring 
twenty-two  years  only  six  females  were 
received  into  Broadmoor  asylum  charged 
with  incendiarism,  the  youngest  of  whom 
was  twenty-one  years  of  age  at  the  date  of 
her  trial. 

iviotives. — The  most  common  motives 
for  arson  may  be  enumerated  as  revenge,, 
fear,  anger,  hati'ed,  and  nostalgia.  These 
states  of  feeling  may  be  aggravated  by 
drink,  which,  in  this  as  in  other  forms  of 
crime,  plays  a  conspicuous  part,  and  by 
exercising  its  pernicious  influence  on  the 
brain  tends  to  weaken  the  powers  of  self- 
control  in  many  individuals  who  might 
otherwise  hold  in  check  their  revengeful 
passions.  In  the  case  of  one  prisoner,  a 
young  man  who  came  under  our  observa- 
tion, the  combined  effects  of  drink  and 
passion  led  to  his  attempting  to  set  on 
fire  his  father's  dwelling-house  whilst  the 
family  were  asleep.  He  had  been  refused 
some  slight  request,  and  whilst  under  the 
influence  of  alcohol,  adopted  this  means  of 
revenging  himself.  In  this  instance  the 
prisoner  was  sane. 

The  element  of  revenge  is  also  a  power- 
ful incentive  to  arson  amongst  weak- 
minded  individuals,  who,  by  reason  of  real 
or  fancied  wrongs,  seek  to  wreak  their 
vengeance  on  those  who  they  fancy  have 
injured  them  ;  or  who,  driven  by  distress 
and  want,  whilst  wandering  aimlessly 
about  the  country,  set  fire  to  isolated 
stacks  and  outhouses,  in  order  that,  by  so 
doing,  they  may  find  shelter  in  prison. 
Men  of  this  type  sometimes  enlist  as 
soldiers  ;  as  a  rule  they  turn  out  worth- 
less characters,  who  find  the  salutary 
restraints  imjjosed  by  discipline  more 
than  they  care  to  submit  to,  and  who,  in 
order  to  obtain  their  discharge,  occasion- 
ally, amongst  other  offences,  commit 
arson,  preferring  penal  to  military  disci- 
pline. Of  S3  men  tried  in  1863  by  court- 
martial,  S  or  nearly  10  per  cent,  were 
incendiaries.  Acts  of  fire-raising  com- 
mitted by  men  such  as  these  may  be 
regarded  as  essentially  criminal,  for 
although  a  certain  amount  of  weak- 
mindedness  may  be  proved  to  exist,  it  is 


Pyromania 


[     1059    ] 


Pyromania 


not  of  sufEcient  importance  as,  taking  the 
nature  oi:  the  act  and  the  existent  motive 
into  consideration,  to  warrant  the  question 
of  responsibility  being  raised. 

Associated  Forms  of  Insanity. — The 
association  of  pyromania  with  the  various 
recognised  forms  of  insanity  has  now  to 
be  considered.  In  the  course  of  22  years 
(1864-86)  103  persons,  who  had  committed 
incendiarism,  were  admitted  into  Broad- 
moor asylum  ;  95  were  males,  and  only 
8  females.  The  percentages  to  the  total 
number  of  persons  admitted  for  all  offences 
are — males,  7.5  per  cent;  females,  2  per 
cent;  total,  6.2  per  cent.  The  annexed 
figures  show  approximately  the  nature  of 
the  psychical  condition  observed  in  con- 
nection with  these  cases. 


Males. 

Fe- 
males. 

Total. 

Imbecility  (cougenital)    . 
Epilepsy              „ 
General  paralysis     . 
Mauia,   acute   (iLsually  <i 
potti)  .... 
Mania,  recurrent     . 
Mania,  chronic 
Melancholia    . 
Monomania     . 
Dementia 

35 
4 
6 

5 
4 
6 

17 

8 

10 

I 
0 
0 

T 

° 

T 

4 
I 
0 

36 
4 
6 

6 

4 

7 

21 

9 
10    . 

95 

8 

103 

This  table  indicates  that  incendiarism 
occurs  most  frequently  among  congenital 
imbeciles  and  melanclioliacs.  The  ages  of 
the  male  congenital  imbeciles  averaged 
20-25  years  ;  that  of  the  female  congenital 
imbecile  was  21  years  ;  all  the  rest  of  the 
women  exceeded  30  years  of  age  at  the  date 
of  the  commission  of  the  crime  which  led 
to  their  incarceration. 

There  are  not  a  few  imbeciles  who  are 
dangerous  to  society,  and  who  are  prone 
to  commit  offences,  some  of  which  are  of 
an  incendiary  character.  This  obtains 
also  in  the  case  of  true  idiots.  Some  are 
quiet,  others  peevish  and  irritable,  given 
to  acts  of  violence,  and  addicted  to  mas- 
turbation. In  some  instances  the  fire- 
raising  is  perpetrated  for  the  mere  plea- 
sure of  seeing  a  blaze,  in  others  from 
childish  mischief  or  imbecile  spite.  One 
imbecile  on  being  questioned  as  to  his 
motives  will  stoutly  deny  any  knowledge 
of  the  crime,  and  endeavour  to  cast  the 
blame  on  some  other  person  ;  another  will 
take  keen  pleasure  in  detailing  the  num- 
ber and  describing  the  effects  of  the  fires 
he  has  caused.  Sometimes  these  poor 
creatures  become  the  too  facile  tools  of 


other  individuals  more  designing  than 
themselves,  and  by  whom  they  are  incited 
to  crime.  Simplicity  and  asymmetry  of 
the  cerebral  convolutions  are  pathological 
appearances  which  have  been  noticed  in 
those  incendiaries. 

Epileptics  are  more  given  to  crimes  of 
violence  than  to  such  offences  as  arson, 
yet  instances  of  incendiarism  do  occur 
amongst  this  class.  For  the  most  part 
the  culprits  are  of  the  congenital  type, 
and  revenge  is  almost  always  the  exciting 
cause.  The  presence  of  epilepsy  in  cases 
of  incendiarism  is  an  important  factor  in 
determining  the  mental  condition  of  the 
accused. 

This  crime  is  rarely  committed  by 
general  paralytics.  The  Broadmoor  re- 
cords show  six  cases — one  patient  who 
set  fire  to  several  ricks  gave  as  his  reason 
for  so  doing,  that  he  wished  "  to  clean 
the  stackyard." 

In  the  various  phases  of  mania,  more 
particularly  mania  <t  potu,  pyromania 
may  be  developed.  In  such  cases  it  is 
frequently  associated  with  delusions  of 
persecution. 

Next  to  congenital  imbeciles,  persons 
suffering  from  melancliolia  supply  the 
greatest  number  of  insane  incendiaries. 
Under  this  heading  will  be  found  many 
of  the  class  described  in  connection  with 
the  disorders  of  puberty.  In  some  cases, 
the  fire-raising  seems  to  be  resorted  to 
for  the  purpose  of  relieving  the  intense 
feeling  of  anxiety  and  general  uneasiness 
which  pervades  the  mind,  and  compara- 
tive mental  ease  has  been  known  to  follow 
the  morbid  depression  of  acute  melan- 
cholia after  the  commission  of  the  crime. 
This  feeling  was  experienced  by  one  of 
the  Broadmoor  inmates,  who  set  fire  to 
several  stacks  of  straw  whilst  labouring 
under  acute  mental  distress,  brought  on 
by  domestic  troubles.  He  afterwards 
declared  that  he  felt  relieved  in  mind 
after  the  act  was  committed.  In  other 
cases,  a  prominent  feature  is  the  presence 
of  religious  delusions,  which  frequently 
have  a  direct  bearing  on  the  incendiary 
act.  This  was  curiously  illustrated  in 
another  of  the  Broadmoor  cases.  The 
patient's  father  had  died ;  this  event  was 
the  exciting  cause  of  his  mental  malady. 
He  conceived  the  idea  that  it  was  possible 
to  communicate  with  his  father's  spirit  by 
writing.  With  this  view  he  posted  the 
letter,  and  inserted  with  it,  in  the  letter 
box,  some  matches  and  several  pieces  ot 
straw,  believing,  that  if  the  letter  were 
then  and  there  consumed,  the  smoke 
would  waft  the  message  to  its  destina- 
tion. 

Closely   allied  with  the  subject  of  in- 

3  Y 


Pyrophobia 


[     1060    ] 


Quer-alantenwahn 


cendiarism  in  melancholia,  is  the  consider- 
ation of  those  cases  where  the  act  is  an 
accompaniment  of 'Dionomania ;  here,  too, 
it  is  frequeutly  associated  with  religious 
delusions  and  characteristic  sensory  hal- 
lucinations. In  one  case  the  crime  was 
due  to  the  patient  being  constantly  tor- 
mented by  an  intolerable  smell  of  burn- 
ing and  the  noise  of  the  crackling  of  fire  ; 
his  sense  of  taste  was  also  affected.  Other 
cases  have  been  observed  where  hallucina- 
tions of  sight  were  present,  and  one  pa- 
tient declared  he  was  burned  with  hot 
irons  during  the  night. 

In  dements  the  arson  is  invariably  of 
an  aimless  character. 

In  conclusion,  we  find  that  pyromania 
occurs  amongst  certain  children.  In  such 
cases  it  does  not  appear  to  be  the  result 
of  a  specific  instinctive  monomania,  but 
to  be  due  to  a  primary  moral  defect  of 
hereditary  origin.  It  is  a  condition  fre- 
quently observed  at  the  onset  of,  or  after 
the  development  of  puberty,  when  it  is 
associated  with  the  nervous  disorders 
arising  from  the  changes  in  the  repro- 
ductive system  at  that  period.  Incen- 
diarism is  a  crime  frequently  perpetrated 
by  weak-minded  individuals  from  various 
motives,  and  for  which  they  ought  to  be 
held  responsible. 

It  is  associated  with  various  recognised 
forms  of  insanity,  especially  imbecility 
and  melancholia. 

Responsibility. — There  are  not  suffi- 
cient grounds  for  supposing  that  pyro- 
mania is  a  disease  per  se,  an  instinctive 
monomania  characterised  by  intermittent 
irresistible  impulse.  It  is  requisite  that 
some  other  evidence  of  insanity  be  forth- 
coming,   in    order    that    the    incendiary 


may  be   held  irresponsible  for  his  mis- 
deeds. 

"When  a  motive  is  present  without  defi- 
nite symptoms  of  a  disordered  mind,  the 
incendiary  act  should  be  regarded  as 
criminal. 

With  or  without  motive,  if  evidence  of 
insanity  exists,  the  accused  should  be  held 
irresponsible. 

Each  case  ought  to  be  judged  accord- 
ing to  its  individual  psychological  pecu- 
liarities. 

The  following  extract  from  Griesinger 
thus  appropriately  sums  up  the  subject: 
"The  grand  question  inforo  in  all  such 
cases  must  ever  be  to  ascertain  whether 
there  existed  a  state  of  disease  which 
limited,  or  could  have  limited,  the  liberty 
of  the  individual ;  sometimes  the  symp- 
toms of  undoubted  mental  disease  can  be 
clearly  distinguished — a  dominant  feeling 
of  anxiety,  hallucinations,  states  of  hys- 
terical exaltation  ;  in  other  cases,  the  actual 
existence  of  a  nervous  disease,  epilepsy, 
or  chorea,  renders  probable  the  assumjjtion 
that  the  accused  has  been  subject  to  some 
passing  mental  aberration"  (p.  271). 

John  Baker. 

YUcfercnces. — Bucknill  and  Tuke,  Psychological 
Medicine.  Taylor,  Medical  Jtirisprudence.  Jessen, 
Die  Brandstiftungen  in  Aflecton  u.  Geistestorungeu. 
(iriesinger  on  Mental  Diseases.  Motet,  Jaccond's 
Dictionnaire  de  Medecine  et  de  Chirurgie.  Mout- 
jel,  Areliives  de  Neiirologie,  vol.  xiii.,  1887.  Tar- 
dieu,  Medecine  Legale.  Marro.  I  Caratteri  del 
Delinquent!.  Kousseau,  Ann.  Med.-Psych.,  1881. 
Journal  of  Mental  Science — viz.,  Savage,  Moral 
Insanity,  .Tuly  1881  ;  Xorth,  Insanity  and  Crime, 
July  1886  ;  Campbell  Chirk,  The  Sexual  and  Ke- 
productive  Functions,  October  1888 ;  English  Prison 
Blue-books. 

PYROPHOBIA  {iTvp,  fire  ;  (j}6^os,  fear). 
Morbid  dread  of  fire. 


QVEEN  ii.X>EI.AII>E'S  FVSTD. — This 
fund  was  established  in  1839  for  the  bene- 
fit of  such  patients  as  might  be  discharged 
cured  from  the  Pauper  Lunatic  Asylum 
at  Hanwell,  then  the  only  county  asylum 
for  Middlesex.  It  was  formed  by  private 
donations  and  legacies,  and  accumulations 
were  invested  and  a  portion  thereof 
applied  towards  the  foundation  "  of  a 
separate  fund  called  Queen  Victoria 
Fund,"  for  the  benefit  of  patients  at 
Colney  Hatch  Asylum,  then  the  second 
Middlesex  asylum.  In  view  of  the  Local 
Government  Act,  1888,  a  scheme  was 
approved  by  the  Charity  Commissioners 
dated  December  10,  1889,  consolidating 
the  charities  and  endowments,  and  direct- 


ing that  the  income  should  be  applied  for 
the  benefit  "  of  lunatics  maintained  at 
any  time  during  their  period  of  detention 
in  any  asylum  for  the  reception  o£  pauper 
lunatics  at  the  cost  of  any  parish,  extra- 
parochial  place  or  liberty,  mentioned  in 
the  second  schedule  hereto,  being  situate 
either  wholly  or  partially  within  the  limits 
of  the  county  of  Middlesex,  as  defined  at 
the  date  of  the  creation  of  the  charity." 

[For  these  particulars  we  are  indebted 
to  Mr.  J.  W.  Palmer,  Clerk  to  the  London 
County  Asylum,  Hanwell.] 

QUERUXiANTEM-WAHia-  (Ger.). — A 
form  of  so-called  paranoia  in  which  there 
exists  in  a  patient  an  iusuppressible  and 
fanatic  craving  for  going  to  law  in  order 


Quinine 


[     1061     ] 


Quinine 


to  get  redress  for  some  wrong  which  he 
believes  done  to  him. 

Individuals  who  fall  victims  to  this  dis- 
order are  always  strongly  predisposed  ;  in 
their  youth  they  are  extremely  egotistical, 
and  are  the  kind  of  people  who  "  know 
everything  better."  QueniJantemvahu 
differs  from  other  forms  of  paranoia  in  so 
far  as  the  wrong  which  the  patient  is 
suffering  or  has  suffered  may  not  be  quite 
imaginary — e.g.,  some  law-suit  has  been 
decided  against  him.  This  event  is  the 
exciting  cause  of  Querulanienicalui  in  a 
predisposed  individual ;  not  being  capable 
of  appreciating  the  real  state  of  affairs 
and  acknowledging  that  he  himself  is  to 
blame  for  what  he  suffers,  he  appeals  from 
the  higher  to  the  highest  courts.  The 
more  he  fails,  the  more  he  becomes  con- 
vinced that  enormous  wrong  is  being  done 
to  him,  and  with  growing  passion  he 
plunges  into  other  law-suits  to  enforce  his 
rights.  Feeling  that  not  only  the  judges 
but  even  his  own  lawyers  are  conspiring 
against  him,  he  takes  his  legal  affairs  into 
his  own  hand,  often  acquiring  a  consider- 
able knowledge  of  the  law.  Thus  he 
becomes  a  plague  to  the  com'ts  of  justice, 
and  a  terror  to  judges  and  lawyers,  as 
well  as  to  his  friends  and  neighbours, 
because,  egotist  as  he  is,  he  is  most  sensi- 
tive to  even  harmless  words  and  actions 
referring  to  himself,  while  he,  in  his 
morbid  passion,  is  not  ashamed  of  using 
any,  even  illegal,  means  to  injure  his  sup- 
posed enemies.  Beyond  all  this,  he  neglects 
his  family,  his  business,  and  his  money 
matters,  spending  everything  on  his  insane 
hobby,  and  gradually  going  down  the  road 
to  ruin.  Unfortunately,  it  is  only  when 
he  has  lost  everything  he  possesses  that 
the  true  condition  of  things  is  recognised, 
and  steps  are  taken  to  prevent  further  legal 
proceedings  and  to  render  him  harmless. 

An  individual  labouring  under  this  dis- 
order is  mostly  quite  logical  in  his  reason- 
ings and  conclusions,  only  he  starts  from 
a  wrong  premiss,  and,  as  the  most  impor- 
tant morbid  element,  there  is  a  complete 
absence  of  capability  of  recognising  that 
other  people  have  equal  rights  with  the 
patient.  This  form  of  "  paranoia"  (Ver- 
riicktheit)  has  occasionally  been  observed 
in  connection  with  phthisis  and  mitral 
stenosis  (Griesinger,  Kraepelin).  (See 
Paranoia.) 

QVINXNH, — Pbysiolog:ical  aud  The- 
rapeutical effect.  Quinine  lessens  proto- 
plasmicandamffiboid  movement,  makes  the 
enlarged  spleen  shrink,  lessens  outwander- 
ings  of  leucocytes,  augments  the  red 
haemacytes  in  size,  but  lessens  their  power 
of  giving  up  oxygen,  and  the  conversion 
of  oxygen  into  ozone  by  hsemoglobin,  thus 


lessening  the  ozonising  action  of  the  blood; 
it  also  lessens  excretion  or  formation  of 
uric  acid ;  but  in  fever  increases  the  appe- 
tite, blood  circulation  and  pressure, 
quickens  respiration,  lessens  tissue  change. 
Contrary  effects  follow  large  doses. 

iLctlon  In  Disease. — As  to  the  theory 
of  its  action  i7i  disease  ;  it  may  control 
inflammation  by  restraining  diapedesis  of 
leucocytes.  It  may  control  high  tempera- 
ture by  lessening  the  ozonising  action  of 
the  blood  and  thus  checking  oxidation, 
and  also  abate  febrile  temperature  by 
dilating  the  contracted  cutaneous  vessels, 
thus  increasing  the  discharge  of  heat; 
while  by  its  influence,  just  referred  to, 
in  lessening  the  formation  of  heat  it 
also  reinforces  the  cooling  effect,  as  is 
shown  by  the  lessened  expiration  of  car- 
bonic acid  under  the  influence  of  quinine, 
which  also  checks  over-fermentation,  as  in 
the  digestive  canal,  and  checks  sepsis  and 
microbic  life. 

Zn  the  insane,  as  in  the  sane,  quinine 
may  be  used  beneficially  for  its  corroborant 
or  tonic,  or  indirect  sedative  effects.  It 
may  rightly  be  employed  as  a  specific  in 
malarial  fever  ;  for  various  other  maladies 
making  periodic  rhythmic  attacks,  such 
as  periodical  or  malarial  neuralgia, 
epilepsy,  diarrhoea,  dysentery,  ha3maturia, 
intermittent  headache  ;  or  to  relieve  neur- 
algia, and  especially  of  the  supra-orbital 
type,  even  when  not  of  periodic  or  of 
malarial  nature ;  or  as  antipyretic  in 
fevers,  inflammations,  and  phthisis.  Also 
in  rheumatism,  lumbago,  excessive  sweat 
of  chronic  phthisis,  cutaneous  diseases  of 
malnutrition,  the  pallor  of  townsfolk  ; 
and  to  counteract  losses  of  blood,  profuse 
secretions,  or  pathological  discharges. 

For  those  who  are  pyrexial,  feeble,  ex- 
hausted, cachectic,  or  in  advanced  organic 
cerebro-spinal  disease  or  phthisis ;  in 
moderate  doses,  and  with  the  adjunct  of 
tepid  sponging  of  the  whole  frame,  it  is 
the  most  valuable  and  safest  antipyretic 
we  have  used. 

It  is  one  of  the  best  tonic  and  corrobor- 
ant agents  for  thin,  or  weak,  or  pallid 
exhausted  insane  persons.  In  small  doses 
it  improves  their  appetite,  digestion,  and 
circulation,  gives  tone  and  force  to  the 
nervous  system,  stimulating  sluggish  or 
feeble  brain  function,  inci'easing  the  reflex 
action  of  the  spinal  cord,  and  adding  fire 
to  the  sinking  vital  flame.  Hence,  in  all 
forms  of  melancholia,  or  stuporous  in- 
sanity and  its  congeners,  it  acts  well,  even 
at  early  stages.  But  great  doses  act  the 
contrary  way,  and  are  hurtful. 

In  mental  diseases,  larger  doses  have 
also  been  employed  to  act  on  the  co- 
existent states  of  the  cerebral  and  spinal 


Rabies 


[    1062    ] 


Bationalism 


system.  Thus  the  congestive  condition 
and  tendencies  of  general  paralysis  have 
been  treated  by  full  doses  of  quinine,  al- 
though theoretically  benefit  is  hardly  to  be 
expected.  In  stuporous  insanity,  also,  full 
doses  have  been  given  ;  sometimes  appa- 
rent good  effect  follows  the  employment  of 
moderate  quantities. 

Where  the  insanity  is  based  on  malarial 
intoxication  of  blood  and  tissues,  and 
hence  deranged  action  of  brain,  quinine 
may  have  conspicuous  success,  as  we  have 
observed  in  several  patients  who  had  been 
saturated  with  malaria  in  India,  or  who 
had  been  brought  thence  with  mental 
disease  and  latent  malarial  conditions  of 
the  system.  One  such  case  we  published  in 
the  Practitioner  in  November  1881.  It  is 
that  of  a  young  soldier  who  had  several  at- 
tacks of  ague,  and  some  time  after  the  last 
attack  became  strange  in  manner,  wan- 
dered away  without  object,  and  was  irri- 
table, sullen,  talked  incoherently,  and  was 
disposed  to  be  violent.  During  more  than 
half  a  year  the  mental  perversion  persisted 
and  became  worse,  the  patient  also  mutter- 


ing and  talking  to  himself,  being  at  times 
noisy,  mischievous,  and  even  passing 
motions  in  bed.  Still  later,  he  was  noisy 
and  restless  at  night,  filthy  and  obscene 
in  language,  or  threatening,  destructive, 
and  inclined  to  violence ;  still  later, 
morose,  impudent  even  to  effrontery, 
irrelevant  and  incoherent  in  statement, 
sometimes  excited,  defiant — he  was  the 
subject  of  delusions  of  being  followed  and 
annoyed.  At  last  he  was  mentally  dull, 
confused,  amnesic,  slept  badly,  had  but 
little  appreciative  perception  of  time,  place, 
or  surroundings.  The  face  had  become 
sallow,  muddy,  lenion-hued, oedema  swelled 
the  feet  and  legs,  the  urine  was  albumen- 
free,  heart  and  pulse  failed,  lungs  evinced 
disease,  the  spleen  enlarged,  the  body- 
weight  sank,  the  heemacytes  showed  mala- 
rial changes  microscopically  ;  and,  after 
failure  of  other  treatment,  the  whole  com- 
plex of  symptoms,  psychic  and  somatic, 
steadily  and  rapidly  disappeared  in  a  few 
weeks  under  quinine,  at  first  in  full  and 
then  in  moderate  or  small  doses. 

W.   J.   MiCKLE. 


RABIES  (Lat.  rabies,  rage  or  mad- 
ness). Madness  occurring  after  the  bite 
of  a  rabid  animal.  In  an  animal  inocu- 
lated with  the  poison  of  rabies  three  stages 
are  generally  noticed  ;  those  of  restless- 
ness, outbursts  of  excitement  and  fury, 
and  finally  depression,  exhaustion,  and 
paralysis,  ending  in  death.  (Fr.  la  rage  ; 
Ger.  Hundstvuth.)     {See  Hydrophobia.) 

RABIES  CAM'IM'A. — Rabies  produced 
by  the  bite  of  a  dog,  wolf,  or  fox ;  also 
rabies  in  the  dog,  &c. 

RABIES  FEXiIITA. — Rabies  from  cat 
bite  ;  also  rabies  in  the  cat,  &c. 

RABIES  MEPHITICA.— The  result 
of  a  skunk  bite,  which  is  nearly  always 
fatal. 

RACE  (Fr.).  Hydi'ophobia  of  animals. 

RAIIiVT-AV  BRAIM-.  —  Under  this 
term  cases  of  obscure  nervous  disease 
following  railway  accidents  have  been  de- 
scribed. Many  such  cases  are  probably 
hysterical.  Their  chief  importance  is  in 
connection  with  medico-legal  practice. 
{See  Hysteria  and  Shock.) 

RAIIiVTAY  SPIITE. — A  peculiar  class 
of  symptoms  attributed  to  affection  of 
the  sjiinal  cord  following  railway  acci- 
dents, &c.  It  includes  spinal  rigidity  and 
irritation,  sensory  disturbances,  and  vari- 
ous manifestations  of  neurasthenia.  {See 
Shock,  and  Hystero-Epilepsy.) 


RAMOI.I.ISSEIVIEN-T  (Fr.  ramoUir, 
to  soften  again).  This  term  is  applied  to 
softening  of  any  tissue,  but  by  English 
pathologists  is  usually  confined  to  soften- 
ing of  the  bi*ain  and  spinal  cord. 

RAPHAnriA;  or,  RHAPHAITIA. — 
An  affection  jjroduced  by  eating  the  seeds 
of  the  wild  charlock  or  Baphanus  rapha- 
nistrum.  Also  a  synonym  for  Ergotism 
{q.r.). 

RAPTUS  MEIiAN'CHOI.ICUS  (rapio, 
1  seize  ;  melancholia,  q.v.).  A  term  for 
the  sudden  and  impulsive  acts  of  suicide 
or  homicide  sometimes  observed  in  melan- 
choliacs.  Also  used  as  a  synonym  of 
Ecstasy. 

RASERIE  (Ger.).  Furious  insanity, 
delirium. 

RATiOTfAlilsill  {ratio,  reason).  An 
ambiguous  word  meaning  the  doctrine  of 
following  the  dictates  of  reason.  Ration- 
alism is,  according  to  Descartes,  belief  in 
those  things  only  which  can  be  presented 
to  the  mind  so  clearly  and  distinctly  that 
they  admit  of  no  doubt.  This  definition 
is  essentially  anti-theological,  and  it  is 
in  this  sense  that  the  word  is  used  to- 
day. In  psychological  medicine  the  term 
may  be  applied  to  the  treatment  of  pa- 
tients, especially  those  labouring  under 
delusions,  by  an  appeal  to  reason,  and  by 
advancing   actual   proof  that  the   beUef 


Ravery 


[     1063    ] 


Reaction-time 


held  by  the  patient  is  absurd  and  illogi- 
cal. 

RAVERY. — Delirium. 

REiVCTZOM-TIME      IN*    CERTAIST 

FORMS  or  ZM-SAM-ITY. — The  simple 
reaction-time,  which  is  the  basis  of  all 
other  measurements  of  psycho-physical 
operations,  has  been  the  subject  of  inquiry 
at  the  hands  of  numerous  observers  ;  and 
we  have  the  conclusions  arrived  at  by 
such  authorities  as  Helmholtz,  Donders, 
Wundt,  Exner,  Hirsch,  and  others,  with 
respect  to  the  normal  reaction-time  to 
acoustic,  visual,  tactual,  or  gustatory 
stimuli,  as  well  as  the  variations  observed 
under  diverse  physiological  conditions,  or 
alterations  in  the  intensity  or  nature  of 
stimulus  applied.  It  is  the  object  of  the 
present  article  to  summarise  results  ob- 
tained in  certain  forms  of  mental  disease, 
explaining  the  instrument  and  method 
adopted,  and  giving  the  bai-e  facts  without 
any  attempt  at  their  further  elucidation. 
The  method  adopted  was  similar  in  every 
respect  to  that  employed  for  results 
already  given  by  us,  and  the  tabulated 
records  embrace  amongst  fresh  cases 
many  of  those  published  in  a  previous 
work. 

Simple  as  the  mechanism  is,  which  we 
have  described  under  "  Psycho-physical 
Methods  "  iq.v.),  we  find  it  absolutely  ne- 
cessary when  dealing  with  the  insane  to 
observe  several  precautions  which  it  may 
be  of  interest  to  note  here. 

First,  as  regards  the  patient,  he  should 
be  told  precisely,  beforehand,  what  he  is 
to  expect,  and  what  he  is  expected  to  do. 
Let  him  listen  to  the  electric  signal,  and, 
by  a  few  preliminary  trials,  accustom  him 
to  respond  quickly  thereto.  Instruct  him 
to  keep  his  finger  on  the  contact  breaker 
at  slight  tension  so  that  no  time  be  lost  in 
breaking  circuit.  In  certain  subjects  it 
is  needful  to  insist  frequently  upon  keeping 
the  attention  on  the  bell  and  responding 
as  quickly  as  possible. 

The  room  where  such  observations  are 
carried  on  should  be  as  absolutely  quiet 
as  practicable ;  voices  in  conversation,  the 
chiming  of  a  clock,  the  bark  of  a  dog, 
movements  of  others  m  the  same  room, 
objects  passing  to  and  fro  within  the  field 
of  vision,  such  as  birds  in  a  cage,  will 
utterly  vitiate  the  results  obtained  in 
many  of  this  class  of  patients.  If  such 
accidental  circumstances  intervene,  the 
register  should  be  regarded  as  doubtful  or 
discarded. 

So  vagrant  becomes  the  attention  of 
many  from  visual  impressions,  that  it  is 
occasionally  necessary,  when  testing  the 
reaction  to  acoustic  stimuli,  to  blindfold 
the  eyes,  and  it  is  equally  essential,  when 


testing  the  reaction  to  visual  stimuli,  to 
maintain  the  most  absolute  silence. 

Each  case  must  be  treated  on  its  own 
merits,  but  it  is  often  fatal  to  our  results 
to  arouse  by  any  stray  remark  the 
slightest  emotional  disturbance  in  our 
patients  ;  in  fact,  the  attention  should  be 
directed  solely  to  the  experiments  in  hand. 
The  operator  and  assistant  should  remain 
quite  immobile  whilst  the  signal  is  being 
awaited.  A  little  acquaintance  with  these 
tests,  personally  applied,  readily  suffices 
to  show  how  distracting  these  slight  move- 
ments and  sounds  are,  and  this  applies 
with  far  greater  force  to  the  insane,  and 
particularly  to  certain  forms  of  mental 
ailment.  The  slightest  preliminary  click 
in  the  release  of  the  I'od  is  distinctly  mis- 
leading, and  should  at  once  be  rectified. 
This,  however,  never  occurs  with  the 
armature  suspension. 

After  a  series  of  preliminary  trials, 
when  it  is  obvious  our  subject  has  accus- 
tomed himself  to  respond  properly,  a  series 
of  test  trials  should  be  taken.  We  never 
exceed  twenty  trials  with  these  subjects, 
since,  beyond  this  number,  a  large  pro- 
portion of  cases  betray  some  exhaustion 
from  the  sustained  attention  requisite ; 
an  average  is  struck  from  their  total,  and 
the  maximum  and  minimum  delay  also 
recorded. 

Table  I.  (p.  1064)  is  a  list  of  the  re- 
action-time to  visual  and  acoustic  stimuli 
in  some  typical  cases  of  general  para- 
lysis. 

In  the  earlier  stage  of  this  disease,  when 
maniacal  excitement  predominates  with 
the  obtrusive  egoism  engendered  by  the 
extravagant  nature  of  their  delusive  con- 
cepts, there  is  often  some  difficulty  in 
keeping  our  patient's  attention  on  the 
signal.  It  is  often  necessary  to  take  ad- 
vantage of  this  feature  to  induce  him  to 
regard  the  trial  as  a  "  test  of  skill,"  when 
even  acutely  maniacal  subjects  can  be 
satisfactorily  dealt  with.  In  this  early 
stage  of  general  paralysis,remarkably  little 
if  any  delay  characterises  the  response 
to  an  acoustic  stimulus.  A  glance  at  the 
table  referred  to  will  at  once  indicate 
that  the  reaction  to  acoustic  stimuli 
averaged  eighteen-hundredths  of  a  second 
for  the  early  stage  attended  with  excite- 
ment, and  this  is  the  average  for  healthy 
subjects,  according  to  Donders  and  Von 
Wittich.  An  exception  occurs  in  the  case 
of  W.  R.,  where  the  response  occupied 
twenty-two-hundredths.  The  remaining 
cases  were  all  instances  of  more  advanced 
disease,  dementia  and  negative  emotional 
states  being  the  more  prevalent  feature. 
These  patients  were  carefully  selected  to 
exclude  sources  of  fallacy,  and  whenever  a 


Reaction-time 


[     1064    ] 


Reaction-time 


Table  I. — Reaction-Time  in   General  Paralysis. 

Acoustic 

Stimulus. 

Sec. 


T.  C.  Heavy,  demoutcd,  but  attentive 

C.  A.  Calm,  sluggish,  unobtrusive        .... 

JE.  D.  Advanced  dementia,  with  excitement  and  egoism 

S.  M.  Calm,  dull,  heavy,  demented       .... 

J.  N.  Heavy  and  demented,  depressed,  much  paresis  . 

J.  M.  Calm,  subdued,  demented  ..... 

F.  L.  Heavy,  demented       ...... 

C.  P.  Depressed,  obscure  egoism,  sluggish  . 

T.  E.  Cheerful,  calm,  slight  dementia,  no  optimism     . 

J.  S.  Early  excitement,  gamUous,  optimistic 

T.  15.  Early  stage,  slight  mental  enleeblement     . 

"W.  W.  Sub-acute  mania,  grandiose,  noisy,  and  obtrusive 

C.  E.  Noisy,  boisterous,  maniacal,  egoistic  . 

W.  T.  Garrulous,  maniacal,  incoherent,  optimistic 

W.  R.  Mania,  garrulous,  obtrusively  egoistic 

J.  R.  .Sub-acute  mania,  grandiose,  egoistic  . 

T.  S.  Tremulous  with  excitement,  optimistic,  notable  paresis 

W.  L.  AVild,  maniacal,  incoherent,  extravagant  optimism 

T.  P.  Maniacal,  garrulous,  egoistic    .... 

E.  C.  Calm,  notable  bulbar  paralysis,  much  optimism 


.249 


.246 
.194 
.203 
.178 

•259 
.211 
.248 

•195 
.172 
.174 


.164 
.221 


.183 
.165 
•195 


Optic 
Stimulus. 
Sec. 
.247 
.260 

•255 
.242 
.272 
.246 

■277 
.270 
.300 

.267 

•257 
.204 
.270 

o 

•230 

.212 
.271 
.188 
.250 
.232 


fugitive  attention  was  betrayed,  or  such 
enfeeblement  as  rendered  the  test  doubt- 
ful, the  case  was  excluded  from  the  cate- 
gory. The  average  reaction-time  of  this 
latter  class  to  acoustic  stimuli  rose  to 
twenty  -  one  -  hundredths  of  a  second, 
several  ranging  to  twenty-four  andtwenty- 
six-hundredths. 

Tested  for  their  reaction  to  a  sight 
signal,  these  subjects,  with  few  exceptions, 
betrayed  a  decided  delay  beyond  the 
normal  standard.  The  greater  number  of 
observers*  give  nineteen-hundredths  of  a 
second,  or  even  less,  as  the  normal  reac- 
tion-time to  visual  stimuli.  Hankel  has 
certainly  overstated  it  at  twenty- two- 
hundredths.  Taking  nineteen-hundredths 
as  the  standard  in  health  civt.  jxir.,  we 
find  notable  delay  in  these  cases  of 
general  paralysis  where  the  average  reac- 
tion-time for  the  whole  series  of  cases 
was  twenty-five-hundredth  s.  However, 
several  cases  ranged  as  high  as  twenty- 
seven-hundredths  and  upwards.  Upon 
the  whole  it  may  be  stated  that  in  earlier 
stages  of  general  paralysis  the  reaction- 
time  to  visual  stimuli  is  more  uniformly 
delayed,  and  that  later  on  both  visual  and 
acoustic  stimuli  show  a  retardation  in  the 
response. 

The  Reaction-time  in  Chronic  Alco- 
holic Insanity. — Table  II.  (p.  1065)  exhi- 
bits the  more  important  cases  examined. 

In  all  these  cases  of  chronic  alcoholic 
insanity,  with  (in  the  majority  of  instan- 
ces) systematised  delusions  of  perse- 
cution, delay  in  the  reaction-time  is  noted 
for  both  acoustic  and  optic  stimuli,  but 
especially  so   with  the   latter.     On  ana- 

*  £.</.,  Auerbach,  Von  Kries,  Vt)n  AVittieb, 
Bonders,  Wundt,  and  Exner. 


lysing  the  results  given  above  it  will  be 
found  that  for  acoustic  stimuli  the  average 
reaction-time  was  twenty-one-hundredths, 
and  for  optic  stimuli  twenty-six-hun- 
dredths.  A  proportion  of  one-fifth  of  the 
series  registered  above  twenty-four-hun- 
dredths  for  a  sound  signal,  and  one-third 
of  these  cases  gave  over  twenty-seven- 
hundredths  as  the  time  of  their  response 
to  an  optic  stimulus.  A  few  cases  exceeded 
these  limits,  and  being  estimated  by  a 
special  method  (the  rod  being  graduated 
up  to  thirty-hundredths  only),  were  found 
to  exceed thirty-two-huudredthsfor  sound, 
and  forty-eight-hundredths  for  sight,  the 
maximum  attained. 

The  Reaction-time  in  Epileptic  In- 
sanity.— Tlie  individuals  selected  for  the 
test  comprised  those  cases  only  of  chronic 
epilepsy  of  many  years'  duration,  where 
mental  enfeeblement  was  not  so  far 
advanced  as  to  introduce  any  notable 
fallacy  into  the  results  obtained  ;  and  for 
the  same  reason,  the  trial  was  made 
during  an  inter-paroxysmal  period,  some 
days  subsequent  to  the  last  epileptic 
seizure.  Table  III.  (p.  1065),  although 
short,  will  sufiice  to  establish  the  more 
important  facts  observed. 

The  average  reaction-time  for  sound  in 
the  above  series  is  twenty-three-hun- 
dredth s,  and  for  an  optic  stimulus  twenty- 
six-hundredths.  One  case  tested  by  an- 
other method  gave  as  high  a  register  as 
forty-hundredth s.  Those  who  are  familiar 
with  the  special  features  of  epileptic 
insanity  need  scarcely  be  reminded  that 
such  subjects,  beyond  all  other  instances 
of  mental  derangement,  lend  themselves 
most  readily  to  inquiries  which  have  as 
their  object  the  ]jhysiological  condition  of 


Reaction-time 


[     1065    ] 


Reaction-time 


Table  IZ. — Reaction-Time  in  Cbronle  Alcoholic  Insanity. 


W.  J.  Calm,  atteutivo,  ^ivossly  ileludod        .... 

J.  M.'  t'hroiiic  aU'oliolisin,  delusions  of  persecution 

H.  W.  Chronic  alcoholisni,  delusions,  violent         .         .         . 

J.  C.  Slight  mania,  liallucinatious,  suspicious,  tremulous     . 

W.  W,  Chronic  alcoholism,  demented,  morbus  lirisi'htii 

H.  (i.  Dangerous,  homicidal,  delusions  ol'  iiersecution  . 

J.  C.  Slight  dementia,  with  consideral)le  excitement   . 

K.  B.  Chronic  alcoholism,  hy])()chondriasis,  susi)icious 

E.  L.  Chronic  alcoholism,  liallucinatious,  suspicious    . 

B.C.  Delusions  of  persecution,  vindictive,  violent 

W.  F.  Calm,  amnesic,  demented,  and  grossly  deluded    . 

W.  N.  Sliiiht  mania,  deluded,  suspicious,  irrational 

.J.  .J.^  Hallucinations,  delusions  of  persecution     . 

D.  F.  Tremulous  from  excitement,  timid,  suspicious,  deluded 

J.  F.  Noisy,  obtrusive,  maniacal,  egoistic    .... 

G.  A.  Suspicious,  deluded,  reticent,  and  grim 

J.  M.-  Extreme  depression,  suicidal,  suspicious    . 

W.  .S.  Tabetic,  deluded,  treacherous,  homicidal    . 

G.  M.  Ulania  a  potn,  excited,  voluble  ..... 

W.  H.  Demented,  maniacal,  grandiose,  and  egoistic 

S.  31.  Alcoholic  jiaraplegia,  amnesia,  deluded 

J.  N.  Sub-acute  mania,  amnesia,  suspicious,  hostile 

J.  J.3  Maniacal,  wild,  boisterous,  recurrent  excitement 

J.  J.2  Delusions  of  persecution^  grim,  treacherous,  homicidal 

J.  G.  Delusions  of  persecution,  querulous,  suspicious  . 

J.  R.  Advanced  dementia,  delusions,  depression 

J.  W.  Dementia,  much  eufeeblenient  of  memory,  apathetic  . 

A.  K.  Calm,  iuobtrusive,  demented      ..... 

J.  T.  Suspicious,  deluded,  hostile,  treacherous     . 

J.  B.  Degraded,  maniacal,  vicious,  and  repulsive 

J.  K.  Calm,  demented,  amnesic,  deluded      .... 

W.  M.  Dementia  with  much  excitement,  deluded  . 

T.  C.  Demented,  degraded,  much  paresis     .... 


Acoustic 

Stimulus. 

Sec. 

•155 
•153 
.176 
.181 
.180 
.    .i8q 


.197 

•195 
.199 
.198 
.206 
.206 

•215 
.218 
.211 
.211 
.216 
.219 
.228 
.228 
.225 
.222 
.228 
.220 
.230 
.230 
.241 

•243 
.244 
.270 
.300 
.300 


Optic 
Stimulus. 
Sec. 
.217 
.212 
.265 

•253 
.2t;o 

.2X8 

•253 
.266 
.256 
.287 
.264 
.242 
.262 
.286 
.265 
•254 
•245 
.251 
.250 
.296 

•254 
.276 

•297 
.236 
.277 
.241 

•  275 

.270 

•259 
.300 
.300 


Table  IZZ. — Reaction-Time  in  Epileptic  Insanity. 


F.  P.       Calm,  apathetic,  slight  imbecility,  sluggish 
J.  AV.  S.  Dementia,  sluggish  and  apathetic       .... 

G.  A.       Mild  imbecility,  querulous,  suspicious,  hypochondriacal 
J.  D.        Mental  enfeeblement  with  excitement        .         . 
J.  .T.  M.  Depression  with  dementia,  sluggish    .... 
B.  L.        Dementia,  deluded,  suspicious,  hostile,  violent   . 
.1.  V.        Notable  suspicion,  gToss  delusion,  maniacal,  violent   . 
J.  I.         Dementia  with  excitement  and  delusions  . 
M.  C.       Hemiplegia  with  contractures,  querulous,  often  suspicious 

violent         ........ 

W.  H.      Dementia,  apathy,  negative  states      .... 

R.  H.       Advanced  dementia,  torpor         ..... 

T.  O.  M.  Dementia  witli  excitement     ...... 

W.  W.     jNianiacal  at  times  and  violent,  mental  enfeeblement  . 
L.  D.       Dementia  with  much  depression  .... 

A.  D.        I'rofoimd  dementia,  great  torpor,  ajid  apathy 

S.  F.        Bright  aspect,  lively,  excitable,  but  childish  and  most  un 

stable ......... 

R.  T.  R.  Bright  and  lively  in  aspect,  but  of  sluggish  intelligence 


Acoustic 

Stimulus. 

Sec. 


.192 
.200 
.219 
.211 
.220 


.223 
.223 
.240 
.252 
.260 
.270 
.28? 


.297 


Optic 

Stimulus. 

Sec. 

•235 
.251 

.235 
.211 
.232 
•295 
•257 
.258 

•251 
.262 
.265 
.269 
.294 

•275 
.297 

.300 
.294 


the  patient.  The  eagerness  with  which 
they  one  and  all  submit  to  the  test  was 
sufficient  evidence  that  their  whole  atten- 
tion, so  far  as  possible,  would  be  con- 
centred upon  a  quick  response  to  the 
signal.  It  will  be  evident,  however,  on 
examining  Table  III.  (given  above),  that 
all  except  three  cases  exceed  the  normal 
reaction-time  for  a   sound   signal,  some 


registering  as  high  as  twenty-eight-hun- 
dredths  or  twenty-nine-hundredths.  One 
case  only  can  be  assigned  to  the  normal 
reaction  limits  for  an  optic  stimulus. 
Most  of  the  others  range  high  ;  and,  in 
the  case  of  A.  D.,  B.  L.,  W.  W.,  R.  T.  R., 
S.  F.,  we  find  nearly  three-tenths  of  a 
second  registered  in  all  alike.  We  have 
therefore  in  these  cases  a  retardation  of 


Reaction-time 


[    1066    ] 


Reaction-time 


the  normal  reaction-time  beyond  that 
noted  in  general  paralysis  or  in  alcoholic 
insanity,  the  comparative  results  being  as 
follows : 

Average  Reaction-Time  for  a  Series 
of  Cases. 

Acoustic.    Optic. 
General  Paralysis  .         .         .         .  ig  .23 

Alcoholic  lusanity .         .         .         .21  .25* 

Epileptic  Insauity .         .         ,         .23  .26t 

So  far,  therefore,  as  the  above  results 
are  concerned  they  confirm  the  view  al- 
ready expressed  by  the  writer,  and  which 


may  be  repeated  here  : — "  It  will  be  appa- 
rent, from  the  observations  on  healthy 
subjects,  that,  whereas  from  twelve-hun- 
dredths  to  eighteen-hundredths  of  a 
second  formed  the  limit  of  variability  for 
acoustic  stimuli,  and  fifteen-hundredths 
to  twenty-two-hundredths  *  for  visiud 
stimuli  ;  in  the  insane,  the  former  is  only 
exceptionally  below  twenty-hundredths, 
and  the  latter  rises  from  twenty-four- 
hundredths  to  thirty-hundredths  of  a 
second."  t 


Table  ZV. — Insanity  of  tbe  Adolescent  Period. 

Acoustic  Optic 

Stimulus.  Stimulus. 

Sec.  Sec. . 

M.  D.       Maniacal,  vicious,  impulsive,  degraded       ....         .277  .295 

J.  T.        Egoistic,  obtrusive,  impulsive    ......         .243  .259 

F.  N.       Maniacal,  obtrusively  egoistic   ......         .239  .264 

F.  W.       Egoistic,  exalted  notions,  impulsive  .....         .242  .300 

J.  B.  S.   Exalted  notions,  gradually  advancing  mental  enfeeblement        .246  .282 

W.  S.       Convalescing- from  recent  maniacal  seizure         .         .         .         .159  .260 

E.  M.       Chronic  mental  enfeeblement  following  upon  adolescent 

insanity      .........         .261  .287 


In  all  these  cases  it  is  to  be  noted  that 
sexual  perversion  existed,  the  vice  of  mas- 
turbation having  been  for  years  jjractised. 
The  same  remark  applies  to  the  following 


typical  instances  of  hypochondriacal  me- 
lancholia occurring  in  individuals  at  the 
fourth  and  fifth  decades  of  life : 


A. 

H. 

J. 

D.  H. 

G 

K. 

K 

K. 

G. 

A. 

J. 

H. 

J. 

M. 

J. 

W. 

T. 

E. 

R.  W. 


Table  V. — Hypochondriacal  IMCelancboIia. 

Acoustic 
Stimulus. 
Sec. 
Depressed,  suicidal,  craving  for  sjTnpathy,  visceral  hypo- 
chondriasis        ........         .202 

Acute  melancholic  distress,  numerous  subjective  ailments, 

loss  of  self-confidence,  timidity,  and  distrust        .         .         .180 
Fanciful,  importunate,  "  visceral  "  hallucinations       ,         .         -233 
Self-distrust,  importunate,  introspective    ....         .245 

Hypochondriasis       .         .         .         .         .         .         .         .         .211 

Morbid  depression,  fretful,  querulous,  numerous   fanciful 

visceral  ailments  .         .         .         .         .         .         .  .212 

Fitful,   explosive,   melancholic    states,  visceral    ailments 

(imaginary),  numerous  subjective  perversions      .         .         .204 
Greatly  depressed,  fretful,  deluded     .....         .239 

Reticent,   gloomy,   morose,   introspective,  and  hypochon- 
driacal       .........         .267 

Much  depressed,  fanciful,  and  obtrusively  querulous  .         .         .290 


Optic 

Stimulus. 

Sec. 


.270 

.267 
.290 
.266 
•254 

.274 


.249 


.274 
.300 


An  instance  of  hypochondriacal  melan- 
cholia in  an  aged  subject,  J.  W.,  aged 
seventy,  gave  as  the  reaction-time  for 
sound  1.360  (or  136-hundredths  of  a 
second)  as  estiuiated  by  another  method  ; 
whilst  his  reaction-time  for  a  sight  signal 
was  twenty-seven-hundredths  of  a  second. 
This  was  a  reversal  of  the  order  hitherto 

*  One  -third  of  the  cases  range  above  .27. 

t  One-third  of  the  cases  range  above  .29. 


obtained,  and  was  quite  exceptional  in  our 
experience.  The  greatest  care  was  ob- 
served to  detect  any  possible  fallacy,  but 
in  almost  every  trial  this  subject  responded 
to  the  sound  signal  after  a  delay  of  from 
one  to  one  and  a  half  seconds. 

*  This,  as  previously  stated,  is  too  wide  a  mar- 
gin, nineteen-huudrcdths  being  more  correct. 

t  "  Text-book  of  Mental  Diseases,  1889,"  p. 
136-  i 


Reaction-time 


[     1067    ] 


Reaction-time 


Table  VI. — Results  in  Other  Porms  of  Insanity. 

Acoustic 

Stimulus. 

Sec. 


t'hronic  niuiiia,  deluded,  very  incoherent   . 
„  ,,      much  mental  enfccbleuient 


delusions,  incoherence 


Chronic  melancholia,  suicidal 
,,  „  ilelusional 


„  hypochondriac: 

impulsive,  suicidal     . 
apathetic,  reticent 


T.  11. 

W.  K. 

J.  L. 

J.  AV.i 

T.  G. 

1?.  T. 

G.  1". 

J.  G. 

K.  W. 

J.  M.  B. 

T.  H. 

J.  W.2    Recurrent  mania 

W.  W. 

J.  W.3 

J.  G.        Jraniacal  excitement,  simple,  garrulous,  and  incoherent 

W.  H.  McI..  Acute  mania        ..... 

K.  K.       Slania  superadded  to  congenital  defect 

J.  D.        Chronic  liraiu  atrophy,  dementia,  depression 

I?.  -T. 

M.  H.  L.  Amnesia  after  iiuerperal  eclampsia    . 

J.  F.         Amnesia,  demeutia,  de])ression  . 

G.  McI.   Slight  dementia,  i)osterior  spinal  sclerosis. 

Mania,  optimism,  egoism,  tabetic 

Profound  melancholic  depression,  timid,  deluded 

Dementia  with  excitement 

Chronic  melancholia,  delusions  of  persecution 

Simple  melancholia  of  mild  type 
,,  „  convalescing- 


J.  E. 
S.  W. 
W.  W. 
C.  P. 
C.  W. 

s.  s. 
w.  p. 

J.  H.  B 
E.  H. 
C.  K. 
W.H. 
M.  R. 
J.  H. 


Monomania  of  pride  .         .         ,         .         . 
Simple  maniacal  excitement 
Chronic  melancholia — mild  type 
Mania  of  suspicion     ..... 
"W.  H.  S.  Excitement  superadded  to  congenital  defect 
M.  E.  B.  Delusional  insanity    ..... 


.215 
.271 
.252 
■  2  SI 
.268 

•257 
.224 
.271 
.290 

.2IO 
.204 
.268 
.176 
.284 
.300 
.226 
.223 

•235 
.186 
.228 
.199 
.172 
.136 
.292 
.221 
.181 

.188 

.180 
.178 
•  139 


.146 

.187 

•  195 
.171 
.232 

•195 


Optic 
Stimulus 
Sec. 
.258 
.284 
.256 
.288 
.294 
.288 

•273 
.282 

•  300 

.250 
.258 
.289 
.260 
.300 
.300 
.226 
.262 
.262 

•  236 
.252 

■239 

•  251 
.215 
.298 
.247 
.213 
.221 
.180 
,199 
.205 
.188 
.241 
.236 
.252 
.223 
.280 
.232 


REACTION-TIIVIZ:  (in    the  Sane.) — 

The  study  of  the  time-relations  of 
mental  phenomena  has  in  recent  years 
acquired  considerable  importance.  Im- 
provements in  specialised  methods  and 
apparatus,  the  introduction  of  rigid  analy- 
ses of  mental  processes  along  the  lines 
suggested  by  physiological  science  and 
the  comparative  study  of  mind,  have 
resulted  in  a  body  of  facts  and  general- 
isations which,  though  destined  to  much 
revision  and  modification,  may  be  sub- 
jected to  an  orderly  and  critical  expo- 
sition. 

.Analysis  of  a  Simple  Reaction. — 
The  simple  reaction  may  be  defined  as 
the  signalling  by  a  predesignated  move- 
ment that  an  expected  stimulus  has  been 
jierceived.  We  are  informed  that  a  bell  is 
about  to  strike,  and  that  as  soon  as  the 
sound  is  heard  we  are  to  press  a  key  ;  the 
time  intervening  between  the  striking  of 
the  bell  and  the  pressure  of  the  key  is  "  a 
simple  reaction-time."  In  this  process  we 
distinguish  as  physiological  factors,  {a) 
the  impression  of  the  sense-organ,  (6)  the 


W.  Bevan  Lewis. 
passage  of  the  impulse  along  afferent 
nerves  (and,  it  may  be,  spinal  cord, 
together  with  delays  whenever  the  impulse 
enters  cells)  to  the  brain,  (c)  the  passage 
of  the  return  efferent  impulse  from  the 
brain  to  spinal  cord,  and  nerve  and  muscle, 
and  (d)  the  contraction  of  the  muscle. 
The  factor  thus  unaccounted  for,  the 
transformation  of  the  sensory  into  the 
motor  impulse,  is  the  central  or  psycholo- 
gical factor,  of  which  we  have  regrettably 
little  knowledge.  It  is,  however,  the 
variations  of  this  factor  and  the  influences 
by  which  its  time  relations  are  favourably 
or  unfavourably  affected  that  will,  to  a 
great  extent,  occupy  us  in  the  jsresent 
article,  (a)  The  inertia  of  sense-organs 
has  been  determined  by  measuring  how 
rapidly  sense-impressions  may  follow  one 
another  without  fusing — e.g.,  in  the  rate 
of  rotation  of  a  disc  with  coloured  sectors, 
or  of  a  toothed  wheel  held  against  the 
finger.  This  determination  would  include 
the  time  of  stimulation  and  of  recovery  of 
the  sense-organ,  and  thus  measure  a 
longer  interval  than  the  one  sought.     On 


Beaction-time 


[    1068    ] 


Reaction-time 


the  other  hand,  if  we  expose  an  impression 
for  the  minimum  time  during  which  it 
can  be  recognised,  the  recognition  will 
take  place  upon  the  basis  of  the  after- 
image, and  the  determination  be  shorter 
than  the  one  sought.  For  clear  optical 
impressions  well  illuminated,  the  former 
process  varies  between  25  and  400-;*  the 
latter  may  be  as  brief  as  50-.  For  other 
senses  and  under  other  conditions  very 
different  results  would  be  found,  (b)  The 
rate  of  a  nervous  impulse  may  be  pre- 
liminarily accepted  from  experiments  upon 
the  lower  animals  as  well  as  upon  man, 
as  1 10  feet  per  second,  under  normal  con- 
ditions, for  both  sensory  and  motor  nerves, 
(c)  The  latent  time  of  the  muscle  and 
{d)  the  time  of  its  contraction  have  been 
determined  upon  the  lower  animals,  and 
would  form  a  slight  and  constant  factor 
in  the  reaction.  With  these  facts  in  view, 
it  has  been  estimated  that  in  a  reaction 
from  eye  to  hand,  requiring  1500-,  the 
central  process  and  the  remaining  pro- 
cesses occupy  about  equal  times.  The 
rate  of  this  simplest  voluntary  act  is  thus 
relatively  slow ;  for  if  men  were  to  form 
a  line  by  grasping  one  another's  out- 
stretched hands,  it  would  take  about  three 
minutes  to  pass  a  hand  pressure  along  a 
mile  of  such  a  human  telegraph. 

Conditions  affecting;  Simple  Re- 
action-Times.— The  influences  affecting 
reaction-times  may  be  considered  as — 

{A)  Objective,  or  afftctiqg  the  condi- 
tion of  the  experiment,  and 

(B)  Subjective,  or  affecting  the  atti- 
tude of  the  reactor. 

Under  (A)  we  may  consider  (i)  the 
nature  of  the  impression.  The  reaction- 
time  will  vary  according  to  the  sense- 
organ  stimulated  ;  averages  of  large 
numbers  of  determination  s  give  forbearing 
1380-,  touch  1480-,  sight  1850-.  This  order 
is  quite  constant,  and  the  long  time  of 
visual  reactions  is  to  be  referred  to  the 
long  inertia  period  of  that  sense  as  well 
as  to  the  fact  that  it  requires  a  more 
precise  accommodation  to  the  stimulus 
than  the  others.  If  the  eye  be  electri- 
cally stimulated  the  reaction-time  is  some 
300-  shorter.  The  reaction  to  a  contact 
upon  the  skin  is  a  quicker  process  than 
to  a  temperature  impression,  and  cold  is 
reacted  to  in  a  considerably  shorter  time 
than  heat.  The  senses  of  taste  and  smell 
have  a  much  longer  period  of  reaction,  and 
the  time  seems  different  for  different  types 
of  taste  and  smell ;  for  smell,  oil  of  roses 
2730-,  camphor  3210-,  musk  3190-,  ether 
2550-  ;  it  takes  most  time  to  taste  quinine, 
least  to  taste  sugar,  and  an  intermediate 

*  The  sijjTi  cr  stands  for  the  one-thousandth  of  a 
second  (.001  see.). 


time  for  salt  and  acid.  The  chief  factor 
in  the  differences  above  noted  would  seem 
to  be  the  mode  of  action  of  the  sense 
stimulation  ;  the  slow  chemical  processes 
acting  upon  the  relatively  inaccessible 
sense-organs  of  the  tongue  and  nose 
require  most  time;  the  probably  chemical 
stimulation  of  the  retina  being  next  in 
order,  and  the  mechanical  processes  of 
contact  and  sound  consuming  least  time. 
Within  the  same  sense  the  more  sensitive 
portions  and  those  most  accustomed  to 
be  stimulated  lead  to  the  quickest  reac- 
tions ;  stimulation  on  the  front  of  the 
hand  is  reacted  to  more  quickly  than  on 
the  back ;  on  the  fovea  more  quickly  than 
on  the  outlying  portions  of  the  retina. 

An  important  factor  is  (2)  the  inten- 
sity of  the  stimulus,  the  law  being  that 
withia  limits  the  time  decreases  as  the 
intensity  increases.  Berger  and  Cattell 
varied  a  light  from  7  to  23,  to  123,  to  315, 
to  1000  units,  and  to  two  greater  degrees 
of  intensity,  and  found  a  decrease  in  time 
from  2100-to  1840- to  1740-,  to  1700-  to  1690- 
to  1560-  to  1480-.  For  sound,  as  a  ball  fell 
from  the  heights  of  60,  160,  300,  and  560 
millimetres,  the  reaction-times  were  1510-, 
1460-,  1270-,  and  1230-.  For  four  degrees 
of  electrical  touch-excitations  1730-,  1590-, 
1540-,  and  1450-.  Wundt  and  Exner  find 
corroborative  results. 

(3)  The  mode  of  reaction  may  affect 
the  reaction-time  ;  simple  movements  and 
those  made  familiar  by  practice  will  be 
more  quickly  executed  than  complex  and 
unfamiliar  ones.  Reacting  by  uttering 
a  sound  was  found  longer  (by  160-  and 
by  300-)  than  reacting  by  moving  the 
finger ;  and  a  movement  of  the  thumb 
or  little  finger  is  at  the  outset  less 
prompt  than  a  movement  of  the  fore- 
finger. In  the  experiment  of  Ewald,  in 
which  the  stimulus  was  given  in  the  very 
key  by  which  the  reaction  (consisting  in 
the  very  natural  movement  of  drawing 
the  finger  away)  was  to  be  made  a  very 
brief  time,  900-,  was  found,  and  the  pro- 
cess seemed  to  lose  something  of  its 
voluntary  character. 

(B)  The  more  important  subjective 
factors  refer  in  the  main  to  the  expecta- 
tion and  the  attention.     We  begin  with : 

(l)  The  subject's  forekno-wledgpe  of 
the  experiment,  formulating  the  law  that 
the  more  definite  this  foreknowledge  the 
quicker  the  reaction.  If  we  experiment 
once  with  a  preparatory  signal  preceding 
the  stimulus  by  a  regular  interval,  and 
again  without  such  a  means  of  fixing  the 
precise  ti'))ie  of  the  impression,  we  shall 
find  the  second  time  longer  than  the  first ; 
Wundt  1750- and  2660-;  Martins  1270-  and 
1780-,  Dwelshavers   1930-  and  2660-.    The 


Reaction-time 


[    1069    ] 


Reaction-time 


most  favourable  interval  between  signal 
and  stimulus  seems  to  be  from  one  to 
two  seconds.  If  we  inform  tiie  subject  of 
the  nature,  but  not  of  the  iniensit)/  of  the 
stimulus,  and  vary  that  irregularly,  the 
time  is  lengthened — with  the  intensity 
of  the  sound  foreknown,  l2lo-;  with  it 
irregularly  varied,  2030-. 

(2)  The  effect  of  distraction  has  been 
studied  by  having  a  disturbing  noise  in 
the  room  or  by  imposing  a  mental  task 
while  reacting.  Wundt's  reaction-time 
lengthened  from  iSgcrtoSi  30- (weak  sound) 
and  from  1580-  to  2030-  (strong  sound)  by 
the  former  means ;  while  Cattell's  reac- 
tion was  lengthened  by  300-  when  attempt- 
ing mental  addition  during  reactions. 
Some  persons  are  very  sensitive  to  dis- 
turbances, others  (and  especially  those 
•with  whom  the  reacting  jirocess  is  almost 
automatic)  not  at  all  so. 

(3)  An  important  distinction  is  the 
direction  of  the  attention  first  brought 
forward  by  N.  Lange — if  the  attention 
be  focussed  upon  the  expected  stimulus, 
the  reaction  is  sensory;  if  the  attention  be 
focussed  upon  the  intended  movement 
the  reaction  is  tnotor.  The  latter  is  found 
to  be  the  shorter — to  sound,  Lange,  2270- 
and  1330-  ;  Miinsterberg,  1620-  and  I20cr  ; 
Martins,  161  o-  and  1410- ;  to  sight,  Lange, 
2900-  and  1130- ;  to  touch,  2130-  and  loStr. 
This  change  in  the  attitude  of  the  subject 
seems  to  modify  the  central  process  in- 
volved ;  it  is  also  important  in  the  expla- 
nation of  divergent  results  obtained  before 
this  distinction  was  taken  into  account. 

(4)  Practice  and  Fatigue. — These  in- 
fluences are  quite  generally  observed,  but 
their  extent  is  very  various.  They  are 
most  marked  in  processes  that  are  com- 
plicated and  not  thoroughly  learned.  The 
effect  of  practice  is  most  marked  at  first; 
later  the  stage  of  constant  times  no  longer 
affected  by  practice  or  by  a  period  of  dis- 
use sets  in. 

(5)  Individual  Variations. — The  gen- 
eral fact  here  to  be  noticed  is  that  different 
individuals  require  different  times  for  the 
performance  of  the  same  operations.  It 
■was  this  fact  brought  to  notice  by  the 
astronomers  that  called  attention  to 
mental  differences,  and  the  term  "  personal 
equation  "  used  by  them  to  denote  such 
differences  has  been  given  a  wider  mean- 
ing. Such  differences  seem  to  be  greater 
in  complicated  than  in  simple  tasks. 
Though  correlation  of  personal  character- 
istics with  a  quick  or  slow  reaction-time 
would  be  ])remature,  it  may  be  noted  that 
the  time  in  children  is  longer  than  in 
adults,  that  in  extreme  age  the  time  is 
also  long,  and  that  the  educated  react 
more  quickly  than  the  uneducated. 


(6)  Variations  under  ilbnornial  Con- 
ditions.— While  lengthening  of  the  re- 
action-time has  been  observed  as  the  result 
of  headache  or  indisposition,  the  more 
systematic  observations  relate  to  the  action 
of  drugs.  We  may  here  cite  the  researches 
of  Kraepelin  showing  that  the  effect  of 
amyl,  ether,  and  chloroform  is  sudden 
lengthening  of  the  reaction-times  (from 
1850-  to  2980-),  reaching  a  maximum  in  a 
very  few  minutes,  and  followed  by  a 
rather  long  period  of  slightly  shorter  than 
the  normal  times  ( 1 700-) ;  the  effect  o£ 
alcohol  was  a  brief  period  of  shortened 
times  followed  by  a  long  period  of  length- 
ened times.  A  strong  dose  increases  the 
extent  of  both  phases  of  the  effect,  but  the 
manner  of  taking  the  drug  seems  also  of 
importance.  Along  reaction-time  amongst 
the  insane  has  been  frequently  observed 
(especially  in  melancholia),  but  the  field 
for  individual  variation  is  here  very  large. 
Obersteiner  cites  a  case  of  general  para- 
lysis, in  the  incipient  stages  of  which  the 
time  was  1660-,  in  a  more  advanced  stage 
2810-,  in  a  most  advanced  stage  45  lo"- 
Abnoi-mal  variations  of  reaction-times 
have  also  been  observed  in  hypnotised 
subjects. 

Analysis  of  Complex  Reactions. — 
When,  instead  of  reacting  in  a  prescribed 
way  to  a  single  expected  stimulus,  the 
reaction  depends  upon  and  varies  with 
the  stimulus,  the  process  is  an  adaptive 
reaction  ;  for  example,  let  there  be  two 
stimuli,  say  a  red  or  a  blue  colour,  and  if 
red  appears  let  the  right  hand  press  the 
key,  and  if  blue  appears  let  the  left  hand 
do  so.  The  additional  processes  here  in- 
volved above  those  of  the  simple  reaction 
are  thus  a  more  specific  recognition  of  the 
stimulus  and  a  choice  between  movements. 
Thus  Bonders  and  his  pupils  (1865-68), 
who  first  performed  experiments  of  this 
kind,  with  a  simple  reaction-time  of  201  o-, 
react  with  the  right  hand  to  a  red  light, 
with  the  left  to  a  white  light  in  3550-. 
Cattell  performs  a  similar  reaction  in 
3400-,  his  simple  reaction-time  being 
1460-.  The  next  step  would  naturally 
be  to  determine  how  much  of  the  ad- 
ditional time  is  needed  for  the  distinc- 
tion, how  much  for  the  choice ;  but  it  is 
doubtful  whether  we  can  signal  the  ap- 
preciation of  a  distinction  except  by  show- 
ing it  in  the  resulting  movement,  and  we 
cannot  execute  a  choice  except  on  the 
basis  of  some  distinction.  A  favourite 
mode  of  attempting  such  an  analysis  is 
by  reacting  to  only  one  of  a  group  of 
impressions  passing  all  others  without 
reaction  ;  this  "  incomplete  "  form  ot  re- 
action is  interesting  and  useful  for  com- 
parative purposes,  but  while  it  is  admitted 


Reaction-time 


[    1070    ] 


Reaction-time 


that  the  recognition  of  the  stimulus  as 
the  one  to  be  reacted  to  is  in  itself  a  dis- 
tinction, though  an  easy  one,  it  seems 
quite  as  plausible  to  regard  the  choice 
between  action  and  non-action  as  an  easy 
form  of  choice. 

Cattell  and  Berger  with  simple  reac- 
tion-times of  ]  460-  and  1 500-,  perform  the 
"  incomplete  "  reaction  (i.e.,  react  if  the 
one  colour  appears,  but  do  nothing  if  the 
other  colour  apjjears)  in  3060-  and  2770-, 
the  adaptive  m  3400-  and  2950- ;  Douders' 
times  for  the  three  processes  are  2010-, 
2370-,  and  2840-. 

Another  mode  of  measuring  the  "dis- 
tinction-time "  is  to  ask  the  subject  not  to 
react  as  soon  as  he  appreciates  the  pre- 
sence of  the  stimulus,  but  only  after  he 
has  appreciated  some  detail — e.g.,  not  to 
react  when  a  colour  appears,  but  only 
when  he  knows  what  the  colour  is.  This 
leaves  everything  to  the  subject  himself, 
and  the  difference  between  this  and  the 
simple  reaction  may  be  large  or  small 
according  as  the  tendency  of  the  subject 
leads  him  to  make  the  distinction  some- 
what before  or  somewhat  after  pressing 
the  key.  Friederich  makes  this  "  subject- 
ive "  distinction  between  colours  in  2670- 
(simple  reaction-time  I75<r),  but  both 
Tigerstedt  and  Tischer  find  only  about 
half  this  difference  in  a  closely  similar 
experiment.  While  utilising  all  these 
methods  for  studying  the  influences  to 
which  these  times  are  subject,  it  seems 
best,  in  view  of  the  fact  that  the  varia- 
tions in  the  "  incomplete"  and  "  subject- 
ive "  times  found  by  different  observers 
are  so  great  as  compared  to  the  variation 
in  adaptive  times,  not  to  decide  what 
portion  of  the  time  is  needed  for  distinc- 
tion, what  for  choice. 

Conditions  affecting:  Complex  Reac- 
tions.— Amongst  the  variety  ot  condi- 
tions affecting  complex  reactions  we  will 
begin  with— 

(l)  The  Number  of  Distinctions  and 
of  Choices. — A  variation  in  the  range  of 
distinction  while  leaving  the  choice  the 
same  is  effected  in  the  incomplete  and 
subjective  reactions.  Cattell  reacts  to  a 
colour  when  either  that  or  one  other 
colour  may  appear,  in  3060-,  when  either 
that  or  one  of  nine  others,  in  3130-.  Fried- 
erich makes  a  subjective  distinction  be- 
tween two  colours  in  2670-,  between  four 
colours  in  2960-.  Six  of  Tischer's  subjects 
recognise  one  of  two  sounds  in  1460- 
(simple  reaction  1140-),  one  of  three  in 
1640-,  one  of  four  in  1780-,  one  of  five  in 
1940-.  For  adaptive  reactions  involving 
increase  in  the  number  of  distinctions  and 
of  choices,  Merkel's  ten  subjects  react  with 
the  several  fingers  to  one  of  two  visual 


impressions  in  2760- (simple  reaction,  1 88a-), 
to  one  of  three  in  3300-,  to  one  of  four  in 
3940",  to  one  of  five  in  4450-,  to  one  of  six 
in  4890-,  to  one  of  seven  in  5260-,  to  one  of 
eight  in  5620-,  to  one  of  nine  in  5810-,  to 
one  of  ten  in  5880-.  When  the  movements 
are  naturally  associated  with  the  impres- 
sions the  increase  in  time  with  the  in- 
crease in  number  of  modes  of  reaction  is 
less  marked  ;  thus,  in  reacting  by  naming 
words,  a  process  that  habit  has  rendered 
familiar,  there  is  but  an  increase  of  lOo- 
in  naming  one  of  twenty  above  naming  one 
of  two  words ;  but  an  increase  of  600-  for 
naming  pictures,  and  of  1630-  for  naming 
colours  under  like  conditions.  A  further 
important  result  is  that  the  increase 
affects  the  choice  more  than  it  does  the 
distinction,  and  in  general  the  faculty  of 
making  complex  distinctions  is  easier  and 
earlier  of  acquisition  than  the  faculty  of 
utilising  and  indicating  these  in  one's 
reactions. 

(2)  A  condition  allowing  of  almost 
endless  variation  is  the  specific  nature 
of  the  impression  and  reaction.  All 
the  types  of  reaction  above  cited  may  be 
regarded  as  illustrating  this  point,  but 
including  other  variations  as  well.  A  few 
typical  results  are  the  following :  (a) 
Theniore  closely  alike  the  impressions, 
the  longer  the  distinction.  As  two 
sounds  originate  from  positions  nearer  the 
median  plane,  it  takes  longer  to  decide 
whether  the  sound  comes  from  the  right  or 
the  left ;  at  three  points  the  additional 
time  above  the  simple  reaction-time  was 
170-,  ySa,  1370-.  (&)  When  the  reaction  is 
to  take  place  to  one  of  two  impressions 
different  in  intensity  and  not  to  the  other, 
the  time  is  shorter  \irhen  that  one  is 
the  more  intense  of  the  fnro.  (c)  The 
complexity  of  the  impression  is  an  im- 
portant factor.  Pictures  are  recognised 
more  quickly  than  letters ;  letters  more 
quickly  than  words  ;  English  words  (by 
an  English-speaking  person)  more  quickly 
than  German  words.  As  numbers  in- 
crease from  one  to  six  places,  the  time  of 
recognising  them  increases,  (d)  Again, 
different  qualities  of  sensation  vary  in  the 
ease  of  their  perception.  Salt  is  recog- 
nised more  quickly  than  acid ;  acid  more 
quickly  than  sugar ;  sugar  more  quickly 
than  bitter  (adaptive  reactions  3840-,  3940-, 
4090-,  4560-). 

(3)  The  fore-knowledg-e  of  the  sub- 
ject may  be  varied  by  having  the  impres- 
sion any  one  of  a  more  or  less  extended 
group.  Thus  if  either  a  light  or  a  fore- 
known letter  was  to  appear,  the  light  was 
reacted  in  1900-,  but  if  either  a  light  or 
a  one  to  three-place  number,  the  reaction 
was  2970-.     Miinsterberg  reacts  with  the 


Reaction-time 


[     1071     ] 


Re  action- time 


five  fingers  to  five  Latin  declensional  end- 
ings in  4650- ;  to  five  German  declensional 
forms,  each  finger  reacting  to  one  of 
three  woi-ds,  in  6880- ;  and  to  five  general 
categories,  each  finger  reacting  to  one  of 
an  indefinite  gi'oup  of  words,  in  8930-.  The 
less  definite  the  range  of  possible  impres- 
sions the  longer  the  reaction-time.  The 
mode  of  reaction  has  a  like  infiuence  as  in 
simple  reactions,  except  that^ 

(4)  The  association  of  stimulus  with 
movement  plays  a  more  important  part. 
When  that  association  is  natural,  as  in 
naming,  the  time  is  relatively  short. 
Again,  when  the  thing  named  is  one  that 
we  are  accustomed  to  name,  as  a  letter 
(4240-)  or  a  word  (4090-),  the  time  is  shorter 
than  when  not,  as  a  picture  (5450-),  or  a 
colour  (601  (t),  though  the  relation  of  the 
recognition-times  is  quite  the  reverse. 
Again,  when  the  name  is  one  that  we  are 
accustomed  to  speak  (('.e.,  in  the  vernacular), 
it  takes  less  time  than  when  the  association 
is  less  famihar,  as  in  a  foreign  tongue. 
Cattell  has  measured  one's  familiarity 
with  foreign  languages  very  successfully 
by  this  method. 

An  important  difference  between  the 
laboratory  experiment  and  equivalent 
mental  processes  in  daily  life,  is  that  in 
the  latter  case — 

(5)  An  overlapplngr  of  mental  pro- 
cesses takes  place.  The  processes  take 
place  not  serially,  but  in  part  overlap. 
The  infiuence  of  this  distinction  may  be 
tested  by  comparing  the  time  per  word 
of  reading  100  words,  2550-,  or  letters  2240-, 
with  the  time  of  reading  one  word  4300-, 
or  one  letter  4240-.  Cattell  has  experi- 
mented by  reading  letters  through  a  slit 
in  a  screen  as  they  moved  across  the 
field  ;  and  found  that  as  the  width  of  the 
slit  increased,  and  so  the  number  of  letters 
visible  at  one  time  increased,  the  time  of 
reading  a  letter  decreased.  The  fact  that 
we  can  thus  to  some  extent  do  several 
things  at  once  appears  as  the  result  of 
observation  as  well  as  of  experiment,  and 
emphasises  the  difference  between  isolated 
and  continuous  mental  operations. 

We  may  finally  considei*,  under — 

(6)  Miscellaneous  variations,  a  few 
points  already  noticed  in  simple  reactions. 
The  generalisations  respecting  practice 
and  fatigue  are  equally  true  of  complex 
reactions.  Berger  has  measured  the  time 
of  reading  Latin  words  in  the  several 
classes  of  a  German  Gymnasium,  and 
shown  a  decrease  in  time  as  the  pupils 
advance  in  class  ;  that  this  is  the  result 
of  practice  rather  than  of  general  develop- 
ment appears  from  the  fact  that  the  time 
of  naming  colours  shows  no  such  regular 
difference.       The    individual    variations 


occur  as  in  simple  reactions,  and  are  prob- 
ably greater  in  extent.  Complex  re- 
actions are  similarly  subject  to  the  action 
of  drugs,  the  distinction  being  especially 
different  under  such  circumstances.  These 
times  have  been  measured  in  a  few  cases 
of  insanity,  and  shown  to  be  very  con- 
siderably longer  than  in  normal  persons. 

Association  Times. — A  great  variety 
of  reactions  may  be  viewed  as  responses 
to  questions ;  the  appearance  of  the 
stimulus  being  equivalent  to  the  ques- 
tion "What  in  certain  respects  is  this  im- 
pression ?  "  and  the  answer,  whether  indi- 
cated by  a  name  or  a  movement,  is  the 
reaction.  From  this  point  of  view  the 
association  between  question  and  answer 
is  deserving  of  special  study. 

We  will  consider  first  those  cases  in 
which — 

(i)  The  answer  is  limited  to  a  sing-le 
one,  and  (a)  the  arriving  at  the  answer 
involves  nothing  more  than  an  act  of 
memorij.  Thus  the  naming  of  objects  in 
a  foreign  tongue,  translation  of  words,  - 
simple  addition  and  multiplication, 
answers  to  geographical  and  miscellaneous 
questions,  would  be  here  pertinent,  and  a 
few  such  results  may  be  cited.  Cattell 
names  a  picture  in  German  in  644,  in 
English  in  5450- ;  translates  words  from 
Engbsh  to  German  in  3230-,  from  German 
to  EngUsh  in  2810-.  Vintschgau  multi- 
plies numbers  from  i  x  i  to  9  x  9  in 
2330-.  Given  a  city  to  name  the  country 
in  which  it  is  situated  requires  4620-; 
given  a  month  to  name  its  season,  3100-; 
to  name  the  following  month,  3890-,  the 
preceding  month,  8320- ;  given  an  author 
to  tell  in  what  language  he  wrote,  3500- ; 
given  an  eminent  man  to  tell  his  sphere 
of  activity,  3680-.  In  the  next  type  of 
association  the  attainment  of  the  answer 
involves  (b)  an  act  oi  judgment  or  com- 
parison;  such  a  judgment  being,  not  a 
deliberate  decision,  but  the  selection  under 
the  stress  of  an  immediate  response  of 
some  one  factor  as  the  deciding  one.  Thus, 
Cattell  decides  which  is  the  greater  of  two 
eminent  men  in  5580-.  Miinsterberg 
answers  a  miscellaneous  group  of  such 
comparisons  in  9470-,  or  990-  longer  than 
the  same  process  without  comparison. 
The  comparison  may  be  extended  to  more 
than  two  terms,  as  in  asking  which  is 
greatest,  best,  and  so  on  of  a  group  of 
objects. 

(2)  We  pass  next  to  questions  admitting 
of  more  than  a  singrle  answer,  the 
answer  being  determined  by  the  mental 
peculiarities  of  the  individual.  The  ques- 
tion becomes  more  general,  and  the  answer 
chosen  from  a  moi-e  or  less  extended  class. 
Thus,  Cattell,  when  given  a  country,  names 


Reaction-time 


[    1072    ] 


Reaction-time 


a  city  in  it  in  3460- ;  given  a  season,  names 
a  month  in  it  in  4350- ;  given  a  language, 
names  an  author  writing  in  that  language 
in  5190";  given  an  author,  names  one  of 
his  works  in  7630-.  Answers  involving  a 
more  extended  selection  are  the  following  : 
Given  a  general  term,  to  name  a  parti- 
cular instance  under  it,  5370- ;  given  a 
picture,  to  name  some  detail  of  it,  4470" ; 
given  a  quality,  to  name  an  object  possess- 
ing that  quality,  3510-;  given  an  intran- 
sitive verb,  to  find  an  appropriate  subject, 
5270- ;  given  a  transitive  verb,  to  find  an 
object,  3790-. 

Before  passing  on  we  may  conveniently 
consider    a    few   typical    generalisations 
suggested  by  the  above  results.     In  the 
first    place,   the   reactions   here   studied 
vary   considerably   in   character.      Thus, 
easy  and  quick  reactions  under  various 
headings  are  the  following  : — To  name  the 
country  in  which  a  given  city  is  situated, 
"Paris,"  2780-;  to  give  the  language  in 
•which  an  author  wrote,  "  Shakespeare," 
.2580-;    "Which   has    the  more  agreeable 
odour,  cloves  or  violets  ?"  "  Who  is  greater, 
Virgil  or  Ovid .'^"6oo-8oocr;  to  name  a"Ger- 
man  wine,"  "  a  number  between  ten  and 
four"  (450-6000-).     Correspondingly  diffi- 
cult and  long  reactions  are  "  Geneva,"  48  50- ; 
"Plautus,"   4780-;    "Which   is  healthier, 
swimming  or  dancing?"  "Which  is  more 
difficult,   physics   or  chemistry?"    1200- 
1 5000- ;  to  name  "  a  beast  of  the  desert,"  "a 
French  writer,"  1200-15000-.     Secondly, 
the  effect   of  the   foreknowledge   of  the 
subject   again   appears.     In   multiplying 
numbers   from   i  X  i  to  9x9,  where  the 
smaller  number   always   stood   first,  the 
multiplication  by  9,  8,  and  7  took  least 
time   because  then  the  first  number  gave 
the  subject  a  more  definite  foreknowledge 
of  the  number  to  follow.    Again,  Miinster- 
berg  precedes  the  asking  of  a  question  by 
a  series  of  words,  from  amongst  which  a 
pair  is  to  be  selected  for   comparison — 
thus  :  "  Apples,  pears,  cherries,  peaches, 
plums,  grapes,  dates,  figs,  raisins ;  which 
do  you  like  bettei',  grapes  or  cherries  ?  " 
— and  finds  that  this  hint  of  the  nature 
of  the  question  shortens  the  time  from 
9470-  to  6760-.  Furthermore,  Cattell  asked 
the  question  once  for  a  series  of  terms, 
varying  only  the  term  in  each  case,  while 
Miinsterberg  varies   the   entire  question 
each  time ;  accordingly,  the  foreknowledge 
of  the   general    nature   of   the   question 
makes    the    former's    time    considerably 
shorter  than  the  latter's.     Thirdly,  the 
overlapping  of  mental  processes  may  also 
be  illustrated  in  associations.     Miinster- 
berg   finds    that    it   takes   less   time   to 
answer  a  question  consisting  of  two  others 
than  to  answer  those  two  separately — e.g., 


10490-  to  name  the  most  important  Ger- 
man river,  9920-  to  decide  which  is  more 
westerly,  Berlin  or  the  Rhine :  but  only 
18550-  (or  1760-  less  than  the  sum  of  the 
two)  to  answer  by  the  word  "  Rhine"  the 
question,  "  Which  is  more  westerly  Berlin 
or  the  most  important  German  river." 
Finally,  it  is  here  shown  that  the  bond 
of  association  is  often  stronger  in  one 
direction  than  in  the  reverse.  Thus,  not 
only  is  it  easier  to  pass  from  the  special 
to  the  general  than  from  the  general  to 
the  special  (Cattell,  3740-  and  4330- ; 
Trautscholdt,  7570-  and  9470-),  but  it  takes 
longer  to  recall  that  May  precedes  June 
than  that  June  follows  May  ;  longer  to  go 
back  and  find  a  subject  for  a  verb  than  to 
go  forward  and  find  an  object  for  it ; 
longer,  when  given  a  quality,  to  find  an 
object  having  that  quality  than  to  recall 
a  quality  for  a  given  object. 

(3)  Unlimited  Associations. — Here 
the  task  is  simply  to  name  any  word  sug- 
gested by  a  given  word,  and  the  result 
depends  very  greatly  upon  the  associative 
habits  of  the  individual.  For  a  variety 
of  such  associations  Miinsterberg  finds  a 
time  of  8960-,  Trautscholdt  of  10240-.  (We 
may  calculate  the  time  needed  for  asso- 
ciating the  word  by  subtracting  from  the 
total  time  the  time  needed  to  repeat  a 
word ;  in  the  latter  case  the  "  pure  asso- 
ciation-time "thus  found  was  7270-.)  These 
times  vary  greatly  with  the  particular 
association,  and  it  may  be  stated  that  the 
variation  increases  as  the  task  becomes 
more  complex  and  more  dependent  upon 
individual  diff"erences.  Short  associations 
were  "  gold-silver,"  3900- ;  "  storm-wind," 
3680-.  Long  ones,  "God-fearing,"  1132; 
"throne-king,"  14370-.  Trautscholdt  clas- 
sifies the  associations  into  those  sug- 
gested by  the  sound  of  the  word,  by  the 
sense-qualities  of  the  object  denoted  by 
the  word,  and  by  logical  I'elations,  and 
finds  10330-,  10280-,  and  9890-  as  average 
times  for  the  three  classes.  Cattell  and 
Berger  find  the  association-times  to  con- 
crete nouns  3740-,  to  less  concrete  nouns 
4620-,  to  abstract  nouns  570a-,  to  verbs 
5010-,  all  being  "pure  association-times." 
Many  of  the  mfluences  to  which  less 
complex  reactions  are  subject  are  also 
true  of  association-times ;  practice,  fatigue, 
the  taking  of  drugs,  individual  variations, 
have  all  been  more  or  less  successfully 
investigated,  but  the  great  variability  of 
the  reactions  makes  a  concise  and  conclu- 
sive statement  of  the  results  impracti- 
cable. 

The  facts  thus  briefly  reviewed  by  no 
means  exhaust  the  field  of  investigation ; 
but  with  an  increase  in  our  power  of 
analysis,  and  of  subjecting  mental  states 


Reason,  Disorders  of       [     1073    ]         Recurrent  Insanity 


to  experimental  methods,  the  stiady  of  the 
time-relations  of  mental  phenomena,  al- 
ready fertile  in  suggestions  and  results, 
will  increase  in  interest  and  importance. 
JosKi'U  Jastkow. 
l_/!(>fer('>ir(>s. — 111  JuMilion  to  those  i^ivi'ii  in  other 
iirticlcs,  espi'i-iiilly  \\'un(lt,  Fi'cliiiiT,  Kxiilt,  uiid 
(Jattell,  sec  :  The  Tiuu'-rehU ions  of  Jlentiil  I'hono- 
Hieua,  by  rrofessor.Iastrow,  1890.  (ioneral. — Sergi, 
La  Psycholoijie  rhysiolo^iciue,  1888.  Buccola,  I.a 
Icgge  del  tempo  uei  I'enoiiieni  del  peiisiero,  1883. 
I.add,  Elements  of  I'hysiological  I'sycholo^y,  1887 
jind  1890.  Kraeiielin,  Die  ^'eueste  JJteratnr  auf 
dem  Gebiete  der  iisyehischen  Zeitmessnug,  JJiolo- 
<jiselies  ('eutrall)hitt,  vol.  iii.  pp.  53-63.  Fricke, 
Ueber  psychischc  Zeitmessniii;',  Idem,  vol.  viii. 
pp.  673-690 ;  ix.  pp.  234-256,  437-448,  467-469. 
Kibot,  (iermau  Psychology  of  To-day  (translation), 
1886,  pp.  250-287.  Bonders,  Die  Sclmellegkeit 
rsychiseher  Processe,  Du  Bois-Peymond's  Archiv, 
1868,  pp.  657-681.  Jastrow,  An  Easy  Method  of 
Jleasnrini^-  the  Time  of  Mental  Processes,  Science, 
September  10,  1886.  Simple  Peactions.  Preyer, 
(irenzen  des  Emi>findniigsvermii^ens,  &c.,  1868. 
V.  Wittich,  Bemerkungen  zu  Preyer's  Abhand- 
luiit;-,  Ptliiger's  Archiv,  vol.  ii.  pp.  329-350.  Baxt, 
Ueberdie  Zeit.  welche  nothii^istdamit  ein ( Jesichts- 
eiudruck  znm  Bewusstsein  Kommt,  &c.,  idem,  iv. 
pp.  325-336.  Adaptive  Peactions.  Miinsterberg, 
Beitriige  zur  Exiierimentellen  Psychologie,  pp.  64- 
188.  Kries,  Ueber  Unterschcidungszeiteii,  Vier- 
teljahrsschrift  flir  wissenscliaftlichc  Philosophic, 
xi.  pp.  1-23.  Tigerstedt  and  Bergqvist,  Ziir 
Kenntniss  der  Apperccptionsdauer  zusammenge- 
setzter  (iesichtsvorstellungeu,  Zeitschrift  fur  Bio- 
logic, xix.  pp.  5-44.  Merkel,  Die  zeitlichen  Yer- 
haltnisse  der  Willeusthatigkeit,  Wuudt's  Studicn, 
vol.  ii.  pp.  73-127.  Association  Times.  Vintsch- 
gun.  Die  physiologische  Zeiteiner  Kopfmultiplica- 
tionvon  zwei  eiuziffrigenZahlen,  Pfliiger's  Archiv, 
xxxvii.  pp.  127-202,  45-53.  Trautscholdt,  Ex- 
perimentelle  Untcrsuchungen  liber  die  Association 
der  Voi'stelhmgen,  AVundt's  Stndien,  i.  pj).  213. 
250  ;  i.  14,  45.  Galton,  Imiuiries  into  Human 
Faculty,  pp.  182-203.] 

REASGM'.SXSORDEItS  OF. — Popular 

term  for  mental  disorders. 

HHA-SONINO  IMTSAM'ITY. — Insanity 
where  the  reasoning  power  is  still  present. 
Moral  insanity,  &c.  (Fr.  folie  raison- 
nante.) 

REASOIO-XirG  MANIA,  REASOIT- 
ING  IVIEI.AM-CHOX.IA,  REASON-IM-C 
TCON'OIVIAN'XA. — These  terms  are  given 
to  each  particular  form  of  insanity,  mania, 
melanchoUa,  monomania,  respectively, 
when  still  accompanied  by  reasoning 
power,  though  the  ordinaiy  mental  symp- 
toms are  evident. 

RECOVERIES.      {See  STATISTICS.) 

RECTAIi  FEEDING.  —  There  are, 
among  the  insane,  many  cases  iu  which 
the  administration  of  food  by  means  of 
enemata  is  essential  to  the  preservation  of 
life.  Setting  aside  those  in  which  it  is 
necessary  for  surgical,  or  special  medical, 
reasons,  persistent  refusal  of  food  fre- 
quently co-exists  with  so  much  irritability 
of  stomach  that  a  sufl&cient  quantity  of 
food    cannot     be    administered    by    the 


stomach-pump  or  nose-tube  to  maintain 
life,  and  we  have  to  rely  upon  the  power 
which  the  intestines  possess  of  absorbing 
and  applying  such  liquid  food  in  digestible 
form  as  may  be  introduced  into  them. 

In  this  way  patients  may  be  kept  alive, 
and  in  tolerable  health,  for  weeks,  or  even 
months,  without  a  particle  of  nutriment 
being  taken  by  the  mouth ;  and,  even  in 
minor  cases,  it  is  frequently  a  distinct  ad- 
vantage to  give  rest  to  the  stomach  when 
that  organ  is  unduly  irritable. 

The  food  should  consist  of  beef-tea  or 
milk,  with  peptones,  and  the  addition  or 
not,  of  a  small  quantity  of  whisky.  The 
beef-tea  should  be  made  fresh  by  placing 
in  one  quart  of  cold  water  one  pound  of 
shredded  lean  beef,  and  macerating  on  the 
hob  for  two  hours,  or  until  the  quantity 
has  been  reduced  one-half. 

To  this  should  be  added  ten  grains  of 
pepsine,  and  thirty  minims  of  diluted 
hydrochloric  acid. 

Four  ounces  of  this  mixture  should  be 
given  every  three  or  four  hours,  or  a 
smaller  q^uantity  more  frequently.  It 
may  be  varied  by  the  substitution  of  milk, 
to  a  pint  of  which  has  been  added  two 
drachms  of  Benger's  Liquor  Pancreaticus, 
and  twenty  grains  of  bicarbonate  of  soda. 

These  enemata  must,  of  course,  be  given 
warm. 

In  most  cases  the  addition  of  half  an 
ounce  of  whisky  to  each  enema  is  dis- 
tinctly beneficial. 

There  are  various  forms  of  peptonised 
meat  which  may  be  used  as  enemata  or 
suppositories,  but  it  is  obviously  better  to 
rely  upon  home-made  productions,  the 
composition  of  which  is  accurately  known. 

The  mode  of  using  the  enemata  should 
be  as  follows  : — 

After  the  bowels  have  been  cleared  by 
an  aperient  or  an  enema,  the  patient 
should  be  placed  upon  the  left  side  or  the 
back  on  a  bed,  and  the  oiled  nozzle  of  a 
four-ounce  brass  syringe,  charged  with 
the  nutritive  fluid,  inserted  into  the  rec- 
tum, and  there  kept  for  some  moments 
after  its  contents  have  been  discharged. 

The  enema  will  then  be  usually  retained 
without  difficulty,  but  there  are  cases  in 
which  it  may  be  necessary  to  plug  the 
anus. 

A  much  larger  quantity  than  four 
ounces  may  be  retained  by  using  a  flexible 
tube,  which  should  be  passed  for  eight  or 
ten  inches  up  the  intestine,  and  the  nutri- 
tive enema  slowly  and  gently  introduced 
either  by  means  of  a  syringe  or  by  pour- 
ing into  the  tube  by  a  funnel- 

Feedemck  Needham. 

RECURRENT      INSANITY.   —  The 

term  recurrent  is  more  especially  applied 


Recurring  Utterances        [    1074 


Reflex  Action 


to  mania,  in  those  cases  in  which  there 
are  repeated  returns  of  the  attack.  It 
may  be  applied  to  melancholia  also.  The 
recurrence  is  referred  to  in  the  description 
of  forms  of  insanity,  and  does  not  call  for 
a  special  article. 

RECURRZM-G  XTTTERAM-CES.  —  A 
term  applied  to  the  verbal  repetitions 
made  at  every  attempt  to  speak  by  one 
who  is  the  subject  of  motor  aphasia. 
{See  Aphasia,  Post  Apoplectic  Insanity.) 
They  are  either  the  last  words  uttered,  or 
the  words  a  patient  was  about  to  express 
when  taken  ill  (Hughlings  Jackson).  As 
the  lesion  involves  the  motor  speech  area 
of  the  left  side,  the  opposite  correspond- 
ing centre  must  be  the  one  to  originate 
these,  and,  as  Gowers  points  out,  the  right 
hemisphere  must  ordinarily  therefore  take 
part  in  normal  speech.  In  the  early  stages 
of  the  illness  new  word-processes  cannot 
be  voluntarily  originated,  but  the  residual 
disposition  of  those  last  energised  by  the 
will  leads  to  the  stimulation  of  the  right 
motor  speech  centre  at  every  attempt  to 
speak.  The  loss  of  speech  from  disease 
of  the  left  motor  region  is  not  a  complete 
loss  of  speech,  but  a  loss  of  voluntary 
speech  (H.  Jackson).  When  speech  is 
being  slowly  regained  by  the  right  hemi- 
spliere,  many  of  the  recurrences  of  utter- 
ance will  be  found  to  have  been  due  to 
the  defective  voluntary  influence,  and  to 
a  tendency  to  the  re-energising  of  nerve 
processes  recently  in  activity — consonants 
will  be  repeated  instead  of  the  proper  con- 
sonants being  uttered,  and  those  which 
occurred  in  the  recurring  utterances  will 
be  cropping  up  in  wrong  places.  Ulti- 
mately, almost  complete  recovery  may 
occur,  and  there  may  remain  only  slight 
and  occasional  errors  in  the  form  of  words 
with  a  difficulty  in  finding  the  word 
desired  and  a  tendency  to  use  wrong  words. 
(Gowers.) 

JtETJt'ECTXO'N  {reflecto,  I  turn  again). 
Meditation  or  the  turning  over  in  the 
mind  a  series  of  thoughts  that  follow  each 
other.     (Ger.  Nachdenhen.) 

REFIiEX  ACTIOM-  (Physiologrical). 
— Although  what  are  generally  known 
as  reflexes  are  to  a  great  extent  inde- 
pendent of  mental  influence,  and  there- 
fore hardly  come  under  the  classification 
of  psychological  phenomena,  yet  there  are 
some  which  do  not  differ  essentially  from 
the  general  class,  which  must  be  taken 
into  consideration  in  the  study  of  func- 
tional irregularities  of  the  machinery  of 
thought.  It  is  impossible  to  draw  a  sharp 
line  between  the  simple  reflex  action,  in 
which  the  centre  of  transference  between 
the  afferent  and  efferent  impulses  is  in  the 
spinal  cord  or  medulla,  as,  for  instance,  the 


spasmodic  twitching  of  the  leg  or  foot 
when  the  sole  is  tickled,  and  the  infinitely 
more  complex  processes  which  we  term 
mental,  but  which  owe  their  initiation  to 
as  distinct  a  provoking  impression  through, 
the  nerves  of  sense  as  in  the  other  case, 
and  which  usually  eventuate  in  some  form 
of  purposive  muscular  activity.  As  a  rule 
the  term  "  reflex  action "  is  confined  to 
those  motor  or  other  results  which  are 
immediate,  and  which  impress  us  as  being 
comjDaratively  mechanical ;  for  where 
there  is  a  time-interval  beyond  that  re- 
quired for  mere  conduction  between  the 
peripheral  stimulus  and  the  muscular 
contraction,  there  is  obviously  oppor- 
tunity for  the  exercise  of  judgment,  and  a 
distinctly  psychological  process  inter- 
venes and  supplants  or  vai-ies  the  more 
automatic  method  of  transference.  The 
intervention  may  be  of  the  simplest  de- 
scription, and  may  not  occupy  more  than 
a  moment  of  time,  and  bring  about  no 
appreciable  variation  of  reflex  result ;  or 
it  may  be  prolonged  and  of  infinite  com- 
plexity, so  that  the  primary  sensory  im- 
pulse may  be  varied  to  such  a  degree  by 
the  higher  nerve  centres  as  to  take  the 
form  of  an  efferent  impulse  of  a  very 
different  character  from  that  which  would 
have  been  brought  about  in  the  more 
direct  manner,  or,  again,  the  primary 
stimulus  may  be  inhibited  and  no  conse- 
quent movement  may  follow. 

In  considering  the  bearing  of  the  phe- 
nomena of  reflex  action  upon  psychology 
it  is  well  to  bear  in  mind  that  as  the 
nervous  mechanism  becomes  more  com- 
plex, actions  which  originally  were  per- 
formed independently  of  cerebral  influence 
become  subject  to  the  action  of  the  higher 
mental  centres,  and  as  we  go  up  the  scale 
of  animal  life  we  find  a  constant  emer- 
gence of  non-intelligent  reflex  actions, 
which  apparently  differ  scarcely  at  all 
from  the  movements  among  plants,  into 
the  region  of  intelligent  choice  of  alterna- 
tion which  we  call  mental.  Thus,  the 
newly  hatched  snapping  turtle  will  snap 
indiscriminately  at  everything  which 
comes  between  its  eyes  and  the  light, 
whereas  a  dog,  when  provoked,  even 
though  its  inclination  may  be  to  bite,  will 
weigh  the  circumstances,  and  will  refrain 
if  it  perceives  that  its  welfare  may  be 
affected  adversely  by  such  action. 

Seeing  that  the  first  effects,  in  aU 
cases,  of  the  intervention  of  the  cerebral 
centres  between  the  afferent  and  efferent 
currents  is  one  of  temporary  arrest  of 
action,  and  that  the  functions  of  what  we 
regard  as  the  higher  parts  of  the  nervous 
organism  are  in  a  large  measure  inhibi- 
tory, it  becomes  well  worth  while  to  con- 


Reflex  Action 


[     1075     ] 


Reflex  Action 


sider  what  becomes  of  the  energy  repre- 
sented by  the  attereut  current  when  its 
immediate  return  is  arrested  or  deflected 
by  the  exercise  of  the  higher  nervous 
faculties. 

Quite  low  down  iu  the  animal  scale 
intervention  of  cerebral  phenomena  iu  the 
reflexes  which  have  to  do  with  self-pre- 
servation and  reproductiou,  take  the  form 
of  desire  or  api^etence,  and  the  whole 
organism  is  thereby  stimulated  towards 
the  accomplishment  of  acts  which  are 
required  for  the  sustenance  of  the  indi- 
vidual or  the  continuance  of  the  race. 

The  strength  of  appetite  as  an  induce- 
ment to  action  is  too  well  known  to  require 
comment,  but  it  is  worth  while  to  observe 
that  the  acts  consequent  on  such  ajipetites 
as  those  mentioned  are  often  still,  even 
among  the  higher  animals  and  mankind, 
dependent,  for  their  successful  achieve- 
ment, upon  the  primary  reHexes  of  which 
they  are  a  development.  Thus,  the  in- 
gestion of  food  and  the  accomplishing  of 
the  sexual  act  are  neither  of  them  com- 
pleted without  becoming  subject  to  auto- 
matic nervous  processes  beyond  the  control 
of  the  will. 

In  these  and  other  reflexes  where  desire 
is  a  prominent  factor,  it  is,  of  course,  ini- 
tiated and  intensified  by  influences  oh 
ej'tra  acting  in  certain  special  ways 
through  the  organs  of  sense. 

Recognising  the  enormous  influence  of 
appetite  in  calling  forth  and  swaying 
the  bodily  and  mental  activities  in  all 
animals,  and  bearing  iu  mind  the  con- 
tinuity of  the  chain  of  physiological  rela- 
tionship which  connects  together  all  living 
beings,  it  becomes  obvious  that  it  would 
be  very  unsafe  to  ignore,  in  dealing  with 
normal  or  perverted  mental  processes,  any 
important  facts  in  the  natural  history  of 
appetence.  And  especially  must  we  con- 
sider the  nature  of  those  influences  which, 
at  one  time  unconsciously,  but  now  more 
or  less  with  the  mental  cognizance,  kindle 
into  life  these  imperious  and  powerful 
motive  forces,  which,  even  when  the  mind 
retains  its  balance,  will  impel  to  action, 
setting  at  nought  the  inhibitory  action  of 
conscience  and  the  will,  and  which,  when 
higher  inhibitory  centres  are  weakened 
or  paralysed,  may  dominate  the  whole 
economy  with  disastrous  results. 

There  can  be  no  doubt  that  in  man  and 
the  higher  animals,  in  spite  of  changed 
environment  and  consequent  alteration 
of  habit  and  structure,  certain  of  the 
reflexes  which  were  appropriate  to  former 
conditions  of  life  remain  as  vestiges,  just 
as  do  the  traces  of  organs  which  at  one 
time  had  important  duties  to  perform. 
.  The  seats  of  specialised  sensation  which 


were  a  necessary  part  of  the  chain  of 
causation  in  the  performance  of  life  duties 
of  our  remote  progenitors  still  respond  in 
some  degree  to  appropriate  stimuli,  even 
although  their  functions  have  long  been 
out  of  date.  Thus,  the  writer's  experi- 
ments have  shown  that  the  titillation  of 
the  palms  of  the  hands  and  soles  of  the 
feet  of  young  infants  at  once  sets  to  work 
the  grasping  muscles  of  the  fingers  and 
toes,  which  in  the  new-born  ape  are  so 
vitally  necessary  in  enabling  it  to  cling  to 
its  dam. 

It  is  noteworthy  that  not  only  does  this 
response  of  the  reflex  apparatus  to  appro- 
priate stimuli  in  this  instance  persist  long 
after  the  need  of  the  instinct  has  ceased, 
but  also  that  there  is  found  remaining  a 
very  considerable  degree  of  the  muscular 
power  which  among  arboreal  beings  is 
necessary  to  render  it  efficient.  Thus  ex- 
periments have  shown  that  some  infants 
of  a  few  days  old  can  sustain  their  whole 
weight  by  the  grasping  power  of  the  fingers 
for  two  minutes  and  upwards  (see  figure, 
p.  1076).  This  is  important  as  proving 
that  we  may  have  accompanying  a  ves- 
tigial reflex  of  any  kind  a  persistence  of 
other  attributes  which,  were  once  appro- 
priate and  necessary,  but  which  now  may 
be  useless,  and  in  some  cases  even  a  source 
of  danger. 

Reflexes  which  do  not  work  in  the  same 
simple  manner  as  the  above,  but  which 
l^roceed  to  action  via  the  appetites  and 
emotions,  are  also  continued  in  part,  even 
when  the  animal  has  so  changed  in  accord- 
ance with  evolutionary  law  that  their 
appropriateness  is  a  thing  of  the  past. 
Indeed,  it  seems  probable  that  the  deeper 
reflex  jorocesses,  such  as  the  pleasure  or 
desire  intervening  between  an  external 
stimulus  and  the  movements  towards 
which  it  tends,  are,  from  the  fact  that 
they  are  more  central,  and  therefore 
sheltered  from  the  stress  of  changed  en- 
vironment, of  a  more  persistent  nature 
than  those  on  the  peripheral  receptive 
surface,  where  the  wear  and  tear  is 
greater,  and  where  the  jjlasticity  neces- 
sary to  ensure  a  ready  adaptation  to  new 
surroundings  must  be  always  a  prominent 
feature.  It  is  evident  that  these  deeper 
vestigial  impressions  partake  of  the  nature 
of  ideas,  and  ideas  which  at  one  time  were 
the  habitual  precursors  of  acts  which  may 
from  altered  habits  of  life  have  become 
inappropriate,  and  therefore  vicious. 

It  is  obvious  that  in  the  study  of  mental 
(and  moi'al)  pathology  such  2:)0ssible  ves- 
tigial reflexes  deserve  serious  considera- 
tion, for  it  is  more  than  probable  that 
they  may  have  an  immense  influence  in 
causing  certain  morbid  lines  of  thought 

3Z 


Reflexes 


[    1076    ] 


Regicides 


Infants  suspended  from  branch  of  tree. 


and  action  in  the  insane  and  those  whose 
powers  of  mental  and  moral  restraint  are 
weak  or  perverted.        Louis  Kobinson. 

REFliEXES.  (See  General  Para- 
lysis.) 

ItEFTTSil.Ii  OF  FOOD.  A  common 
symptom  in  insanity,  especially  in  melan- 
cholia.    (See  Feeding,  Forcible.) 

REGICIDES. — We  describe  by  this 
name,  for  want  of  a  more  exact  term,  the 
fanatics  who,  without  belonging  to  any 
sect  or  any  conspiracy,  have  assassinated, 
or  tried  to  assassinate,  a  monarch  or  one 
of  the  great  men  of  the  day. 

It  is  expedient  at  the  outset  to  distin- 
guish between  true  and  false  regicides. 

The  true  regicides  are  those  who, 
prompted  by  some  special  idea,  make  an 
actual  attempt  on  the  life  of  some  politi- 
cal or  religious  leader. 

The  false  regicides  are  those  who  make 
a  sham  attempt  in  order  to  attract  atten- 


tion, and  so  arrive  at  obtaining  redress  for 
more  or  less  imaginary  grievances.  These 
latter  are  in  reality  only  calculating  per- 
sons with  ideas  of  persecution  {persecutes 
raisonnants) .  We  are  not  concerned  witb 
them  here  (Mariotti,  Perin,  &c.). 

The  true  regicides  in  their  turn  fall  into 
two  categories : 

(i)  The  mad  regricides,  whom  some 
sudden  frenzy  prompts  to  strike  at  a  king. 
These  are  simply  regicides  who  have  be- 
come so  accidentally — madmen  in  reality 
rather  than  regicides,  and  among  whom 
are  met  all  the  types  of  madmen,  from  the 
simple  visionary  (vesanique)  to  the  epilep- 
tics acting  under  the  influence  of  their 
hallucinations  or  their  unconscious  im- 
pulses. Apart  from  the  fact  of  their 
crime,  which  renders  them  suddenly  cele- 
brated, these  individuals  do  not,  as  so 
many  sick  j^ersons,  afibrd  special  interest 
(Margaret    Nicholson,    Charlotte    Carle- 


Regicides 


[     1077    ] 


Regicides 


migellix,    Anne    Neil,    Eobert    Maclean, 
<tc.). 

(2)  The  typical  regicides,  the  most 
important,  those  whom  in  this  study  we 
have  especially  in  our  mind,  and  of  whose 
nature  we  are  s?oing  brielly  to  speak. 

Typical  Reg-icides. — The  typical  I'egi- 
cides  are  essentially,  from  a  clinical  point 
of  view,  persons  of  ill-balanced  or  degene- 
rate brain.  That  is  to  say,  they  almost 
always  have  inherited  morbid  tendencies, 
and  are  the  bearers  of  intellectual  and 
physical  stigmata  of  degeneration.  Some 
even  have  for  the  moving  spring  of  their 
actions  strongly  marked  psychopathic  an- 
tecedents. 

One  tiling  especially  distingviishesthem 
as  regards  the  temperament  of  the  mind  ; 
that  is,  mysticism.  We  mean  by  that  a 
half  instinctive  tendency  to  become  over- 
excited on  matters  of  politics  or  religion. 
It  is  particularly  to  be  noted  that  this 
mysticism  is  commonly  hereditary  with 
them  (Charlotte  Corday,  Staaps,  Karl 
Sand,  John  Wilkes  Booth,  Orsini,  Nobil- 
ing,  Passanante,  Guiteau,  &c.  &c.). 

Such  is  the  true  nature  of  regicides. 
They  are  persons  of  ill-balanced  mind,  in- 
telligent for  the  most  part,  but  of  weak 
will  and  morbid  instability,  who  lead  the 
most  aimless  and  unsettled  existence  till 
the  day  when  their  temperament  makes 
them  espouse  with  ardour  the  political  or 
religious  quarrel  that  the  occasion  hap- 
pens to  bring  into  notice.  Then  their 
imagination  becomes  over-heated,  and  by 
a  more  or  less  long  initiation,  they  end  by 
transforming  party  questions  into  truly 
frenzied  ideas. 

The  frenzy  of  regicides  is  an  essentially 
'mystic  delirium,  either  religious,  or  reli- 
gious and  jjolitical,  or,  in  certain  instances, 
political  only.  In  its  habitual  form,  this 
mysticism  finds  expression  in  the  belief  in 
a  mission  to  be  fulfilled,  a  tnission  that 
onost  covimonly  h.as  been  inspired  by  God, 
and  which  is  to  be  crowned  by  martyrdom. 
In  the  ideas  that  constitute  it  there  is 
nothing  absurd  or  incoherent ;  on  the  con- 
trary, they  are  generally  based  on  a  logical 
and  likely  principle  (Balthazar  Gerard, 
Pierre  Barriere,  Jean  Chatel,  Charles 
Ridicoux,  Ravaillac,  Aimee  Cecile  Re- 
nault, Charlotte  Corday,  Staaps,  La  Sahla, 
Karl  Sand,  Guiteau,  Hillairaud,  &c.  &c.). 
Hallucinations  may  accompany  this 
frenzy,  but  when  they  are  present,  they 
are  of  a  peculiar  nature.  They  are 
genuine  visions,  analogous  to  those  of 
hysteric  frenzy  and  of  ecstasy.  They  are 
intermittent,  occurring  especially  at  nicjht 
during  sleep,  and  sometimes  seeming  to 
mingle  with  dreams.  The  type  of  this 
kind  is  that  of  Jaques  Clement :   "  One 


night,  when  Jaques  Clement  was  in  bed, 
God  sent  him  his  angel  in  a  vision,  who, 
in  a  bright  light,  appeared  to  him  and 
showed  him  a  naked  sword,  with  these 
words,  '  Brother  Jaques,  1  am  a  messenger 
from  Almighty  God,  and  come  to  an- 
nounce to  you  that  by  your  hand  the 
tyrant  of  France  is  to  be  put  to  death; 
reflect  then,  and  know  that  the  martyr's 
crown,  too,  is  prepared  for  you ! '  Having 
said  this,  the  angel  disappeared  "  (Palma 
Cayet). 

The  crime  of  the  regicide  is  not  a  sud- 
den or  blind  act ;  it  is,  on  the  contrary,  a 
well-considered  and,  for  a  longer  or  shorter 
time,  premeditated  act.  Often,  even,  it 
has  been  j^receded  by  a  period  of  con- 
scious obsession  that  has  ended  in  anni- 
hilation of  the  will,  and  during  which  the 
regicide,  a  mystic  always,  sometimes  in- 
vokes Heaven  in  order  to  seek  there  an 
inspiration. 

Be  that  as  it  may,  when  the  act  has 
been  decided  upon,  the  regicide  hesitates 
no  more,  he  goes  straight  to  the  end 
thenceforth  with  the  boldness  of  a  con- 
vinced person.  Proud  of  his  mission  and 
his  part,  he  strikes  at  his  victim  in  broad 
daylight,  in  public,  in  an  ostensible  and 
almost  theatrical  manner.  Hence,  he 
rarely  makes  use  of  poison;  frequently  he 
has  resort  to  the  dagger  or  to  firearms, 
and,  far  from  fieeing  after  the  crime  is  ac- 
complished, he  seems  to  put  himself  in 
evidence  as  if  he  had  performed  some  great 
deed. 

Laschi  maintained  that  suicide  is  of 
frequent  occurrence  with  regicides  imme- 
diately after  the  crime.  Such  is  not  the 
case,  and  it  may  be  said  that  it  is  the  ex- 
ception (de  Paris  I'Aine,  Sand,  Nobiling). 
What  is  true  is  that  a  tendency  to  suicide 
is  frequently  met  with  in  such  persons, 
but  at  any  moment  whatever  of  their  ex- 
istence as  one  of  the  consequences  of  their 
morbid  organisation.  As  regards  the  in- 
direct suicide,  alleged  by  certain  regicides, 
and  jsarticularly  by  Passanante,  as  the 
determining  cause  of  their  crime,  it  has 
nothing  to  do  with  facts  of  this  kind.  In 
indirect  suicide  the  madman  kills  a  person 
in  order  to  obtain  death,  his  only  end;  with 
regicides,  the  ci'iminal  accepts  death  in 
order  to  kill  another,  his  only  object.  It 
is  not  to  suicide  that  he  aspires,  but 
to  tnartyrdotn.  The  distinction  here  is 
essential. 

This  idea  that  they  are  suffering 
martyrdom  for  an  heroic  act  and  with  a 
view  of  obtaining  happiness  in  heaven  and 
celebrity  on  earth  explains  the  behaviour 
of  regicides  after  the  crime.  It  accounts 
for  their  proud,  haughty,  and  declamatory 
bearing    in    the    courts    of    j  ustice ;    it 


Regicides 


[    1078    ] 


Regicides 


explains  especially  their  courage  and 
stoicism  in  the  face  of  death.  All  indeed, 
men  and  women,  political  or  religious 
fanatics,  from  Mucins  Scaevola,  burning 
his  right  hand  coolly  in  the  fire  in  order 
to  punish  it  for  having  struck  at  another 
than  Porsenna,  from  William  Parry  and 
Balthazar  Gerard  in  1584,  to  Charlotte 
Corday,  Staaps,  Sand,  and  Guiteau,  with- 
out speaking  of  Damiens,  of  whom 
Michelet  could  say  that  he  was  the  most 
striking  example  in  phj'siology  of  what  a 
man  may  suffer  without  dying,  all  have 
endured  without  complaint,  and  almost 
with  indifference,  the  most  horrible  tor- 
tures, like  the  martyrs  whom  in  this  point 
they  resemble. 

Among  the  causes  that  induced  the 
crime  of  regicides  there  must  be  named 
first  in  order  a  predisposition,  most  com- 
monly hereditary,  that  makes  them  from 
their  birth  of  ill-balanced  m.inds  and  thus 
subject  to  all  accidental  influences — as 
regards  these  they  may  to  a  great  extent 
be  summed  up  in  the  operation  of  the 
surrounding  mental  atmosphere :  Spirit 
of  the  time,  monastic  life,  important 
events,  exciting  preaching  and  reading, 
former  or  recent  examples,  &c.  &c.  The 
surrounding  mental  atmosphere  gives  be- 
sides a  special  colouring  to  the  frenzied 
ideas  in  accordance  with  the  spirit  and  the 
tendencies  of  the  epoch.  That  is  why  in 
the  present  day,  instead  of  invoking  the 
interests  of  heaven  or  the  realm  as  for- 
merly, most  of  the  regicides  put  forward 
socialism  or  anarchy  (Max  Hoedel, 
Nobiling,  Passanante,  Olivia  Moncusi, 
Otero  Gonzales,  BafSer,  Gallot,  &c.). 

What  we  know  of  the  nature  of  regi- 
cides and  the  motive  power  of  their 
actions,  enables  us  to  cormprehend  a  priori 
that  they  cannot  have  accomplices.  At 
all  times,  however,  people  have  tried  to 
see  in  them,  not  madmen  of  any  degree 
whatevei",  but  the  instruments  of  a  sect  or 
a  party.  From  this  there  have  resulted 
grave  historical  errors,  notably  in  the 
cases  of  Jaques  Clement  and  Ravaillac. 
In  reality,  with  the  typical  regicides,  save 
with  rare  exceptions,  as  in  the  cases  of 
Fieschi  and  Orsini,  the  crime  is  the  act  of 
one  person  only.  It  has  been  conceived, 
meditated,  and  executed  as  the  act  of  a 
madman  is  conceived,  meditated,  and 
executed. 

To  sum  up,  we  see  that  regicides  are 
hereditarily  ill-halanced  or  degenerate 
persons  of  mystic  temperament,  who,  led 
astray  by  some  political  or  religious  frenrnj , 
tvhich  is  cotnplicated  som,etimes  hy  hallu- 
cinations, imagine  themselves  called  to  the 
double  part  of  justiciary  and  martyr,  and 
under  the  tnjhience  of  an  obsession  ivhicli 


they  are  not  able  to  resist,  they  strike  oA 
one  of  the  greed  persons  of  the  day  in  tlie 
name  of  Heaven,  their  country,  or 
htimanity. 

The  practical  question  to  be  asked  from 
this  study  is  the  following  :  "What  is  to 
be  done -with  regicides  ?  Formerly,  and 
in  spite  of  the  vague  idea  one  had  of  their 
insanity,  they  were  condemned  to  the  most 
terrible  punishment,  that  for  parricides, 
not  only  for  the  purpose  of  punishing 
them,  but  also  to  constitute  an  example. 
In  our  own  time  physicians  have  almost 
always  been  in  disagreement  regarding 
them,  and  in  consequence  of  this  disagree- 
ment they  have  suffered  the  full  penalty 
of  the  law.  Yery  few  have  escaped  with 
their  lives,  but  the  number  of  them 
sufficient  to  show  that  regicides,  when 
they  survive,  fall  into  madness  and  de- 
mentia. This  is  what  happened  especially 
in  the  cases  of  La  Sahla,  Passanante,  and 
Galeote.  After  that,  can  their  morbid 
predisposition  be  denied  ? 

We  repeat,  therefore.  What  is  to  be  done 
with  regicides  ? 

It  is  not  allowable  that,  in  a  question  of 
this  kind,  one  should  be  chiefly  concerned 
with  the  idea  of  constituting  an  example. 
Besides,  the  means  would  be  badly  chosen, 
for  nothing  helps  so  much  to  make  regi- 
cides as  the  martyrdom  of  a  regicide.  On 
the  other  hand,  to  pardon  them  is  hardly 
more  practicable  :  the  case  of  La  Sahla 
is  sufficient  to  establish  that. 

There  can  be  no  doubt  that  one  must 
place  oneself  on  scientific  ground,  judging 
always,  not  the  crime,  but  the  criminal. 
In  that  manner  it  is  easy  to  draw  a  con- 
clusion in  each  case. 

Where  the  regicide  is  mauifestlj'  the 
victim  of  frenzy  and  of  hallucinations,  as 
Jaques  Clement,  Eavaillac,  Staaps,  Gui- 
teau, &c.,  there  is  no  room  for  hesitation, 
and  confinement  in  a  lunatic  asylum  be- 
comes imperative.  It  is,  moreover,  the 
thing  the  regicide  dreads  most;  such 
treatment  breaks  his  pride,  because  he 
considers  it  a  disgrace  to  be  treated  as  an 
insane  person,  lie  a  hero  and  a  martyr! 
If  one  wanted  to  constitute  an  example, 
this  would  assuredly  be  a  better  one. 

As  regards  the  other  regicides,  those 
whom  Laschi  calls  regicides  from  inclina- 
tion, and  who  are  in  reality  insane,  al- 
though to  a  less  degree,  one  must  be 
guided  by  the  special  case.  As  a  general 
principle,  these  individuals  being  un- 
balanced and  their  act  an  abnormal  one, 
it  shows  how  dangerous  they  may  become 
to  societ}'.  The  solution  that  is  most 
conformable  to  the  principles  of  science 
and  the  joublic  interest  would  be  to  place 
them  for  the  necessary  period  and  with 


Registered  Hospitals       [    1079    ]       Registered  Hospitals 


medico-legal  safeguards  in  one  of  those 
asylums  for  the  criminal  insane  which 
in  England  and  Ireland  have  long  been 
established,  and  which  the  groat  majority 
of  specialists  in  France  and  Italy  demand 
as  intermediate  between  the  prison  and 
the  asylum  properly  speaking. 

'l'].  Ekgts. 

RECXSTERED  HOSFZTiVI.S.— Le- 
gally, a  hospital  means  in  England  and 
Wales  any  hospital  or  part  of  a  hospital 
or  other  house  or  institution  (not  being 
an  asylum)  wherein  lunatics  are  received 
and  supported  wholly  or  partially  by 
voluntary  contributions,  or  by  any  charit- 
able bequest  or  gift,  or  by  applying  the 
-excess  of  payment  of  some  patients  for  or 
towards  the  support,  provision,  or  benefit 
of  other  patients.  If  registered,  as  these 
institutions  are  and  have  been  since  the 
passing  of  the  Act  {1845)  8  &  9  Vic.  c.  100, 
s.  43,  they  are  called  registered  hospitals. 

"  After  the  passing  of  this  Act  (or  im- 
mediately after  the  establishment  of  such 
hospital,  as  the  case  maj'  be)  the  superin- 
tendent shall  ajjply  to  the  Commissioners 
to  have  such  hospital  registered,  and 
thereupon  such  hospital  shall  be  regis- 
tered in  a  book  to  be  kept  for  that  pur- 
pose by  the  Commissioners." 

Under  the  recent  Act  (1890),  53  Vic. 
c.  5,  s.  230,  it  is  enacted  that  every  hos- 
pital for  the  reception  of  lunatics  shall 
have  a  medical  practitioner  resident 
therein  as  the  superintendent  and  medical 
officer  thereof.  When  application  is  made 
for  registration,  the  Commissioners  inspect 
the  hospital,  or  employ  persons  to  report 
to  them  thereon.  If  they  are  of  opinion 
that  the  application  should  be  acceded 
to,  they  are  to  make  a  report  to  a  Secre- 
tary of  State,  who  shall  finally  determine 
upon  the  application  ;  if  this  be  granted, 
the  Commissioners  issue  a  provisional 
certificate  of  registration.  Within  three 
months  the  managing  committee  are 
obliged  to  frame  regulations  for  the  hos- 
pital and  submit  them  to  the  Secretary 
of  State  for  approval ;  if  this  is  obtained, 
the  Commissioners  issue  a  complete  certi- 
ficate, specifying  therein  the  number  of 
patients  of  each  sex  who  may  be  received 
in  the  hospital.  A  superintendent  who 
receives  or  detains  a  patient  in  the  hos- 
pital contrary  to  the  provisions  of  the 
Lunacy  Act  or  the  terms  of  the  certificate 
of  registration  shall  be  guilty  of  a  misde- 
meanour (s.  231). 

Other  sections  enact  that  the  regula- 
tions for  the  time  being  in  force  shall  be 
hung  up  in  the  visitors'  room  in  the  hos- 
pital, and  a  copy  of  them  sent  to  the 
Commissioners.  ISfo  building  which  is 
not  shown  on  the  plans  sent  to  the  Com- 


missioners shall  be  deemed  pai-t  of  the 
hosjiital  for  the  reception  of  patients ; 
infraction  of  this  rule  subjecting  the 
superintendent  to  a  penalty  as  guilty  of 
a  misdemeanour.  Tne  accounts  of  the 
hospital  must  be  audited  once  a  year  by 
an  accountant  approved  by  the  Commis- 
sioners, and  printed  ;  further,  the  form  in 
which  the  accounts  are  to  be  reported  may 
be  prescribed  by  the  Commissioners. 

With  regard  to  pensions,  it  is  enacted 
that  the  managing  committee  may  grant 
to  any  officer  or  servant  who  is  incapa- 
citated by  confii'med  illness,  age,  or  in- 
firmity, or  has  been  an  officer  or  servant 
in  the  hospital  for  not  less  than  fifteen 
years,  and  is  not  less  than  fifty  years  old, 
such  superannuation  allowance,  not  ex- 
ceeding two-thirds  of  the  salary  of  the 
superannuated  person,  with  the  value  of 
the  lodgings,  rations,  or  other  allowances 
enjoyed  by  him,  as  the  committee  think 
fit. 

Certain  disqualifications  in  regard  to 
the  members  of  the  managing  committee 
are  insisted  upon  :  (a)  Any  medical  or 
other  officer  of  the  hospital,  (6)  any  person 
who  is  interested  in  or  participates  in  the 
profits  of  any  contract  with  or  work  done 
for  the  managing  committee  of  the  hos- 
pital, but  so  that  this  disqualification 
shall  not  extend  to  a  person  who  is  a 
member  of  a  corporate  company  which 
has  entered  into  a  contract  with  or  done 
work  for  the  managing  committee. 

Lastly,  if  the  Commissioners  are  of 
opinion  that  the  regulations  of  the  hos- 
pital are  not  properly  carried  out,  they, 
after  giving  due  notice,  and  after  the  ex- 
piration of  six  months,  are  empowered, 
with  the  consent  of  the  Secretary  of  State, 
to  close  the  hospital. 

Betblem  Royal  Hospital. — We  have 
already  given  a  brief  account,  of  this  hos- 
pital.    (See  Bethleji  Royal  Hospital.) 

Bethel  Hospital,  STorwicIi.  —  This 
institution  was  founded  in  17 13  by  Mrs. 
Mary  Chapman,  widow  of  the  Rev.  S.  Chap- 
man, rector  of  Thorpe,  near  Norwich. 
Its  care  and  government  were  committed 
by  her  to  a  master,  under  the  direction  of 
seven  trustees.  By  her  will  she  endowed 
ib  with  the  rents  of  all  her  real  estates  in 
Norfolk  or  elsewhere,  and  her  residuary 
personal  property,  amounting  to  about 
^3500,  to  which  bequests  and  donations 
have  been  since  added  from  time  to  time, 
to  the  amount  of  upwards  of  ^11,000. 
The  money  is  invested  in  the  names  of 
the  trustees,  either  in  the  funds  or  on 
mortgage.  Unfortunately,  abuses  of  vari- 
ous kinds  were  committed  in  the  hospital 
through  the  default  of  the  master.  The 
foundress,  in  consequence,  resided  for  some 


Registered  Hospitals       [    1080    ]        Begistered  Hospitals 


years  in  the  house,  and  practically  directed 
it  herself. 

The  primary  objects  of  the  charity  are 
declared  in  her  will  to  be  "  Such  persons 
as  are  afflicted  with  lunacy  or  madness 
(not  such  as  are  fools  or  idiots  from  their 
birth),  and  are  poor  inhabitants  of  the 
city  of  Norwich,  or  elsewhere,  to  be  from 
time  to  time  put  into  the  house  by 
appointment  under  writing  of  her  said 
trustees,  or  major  part  of  them,  always 
preferring  such  persons  as  are  inhabi- 
tants of  the  city  of  Norwich."  It  is 
provided  that  should  there  not  be  a  suffi- 
cient number  of  distempered  persons  in 
the  city  of  Norwich  whom  the  trustees 
shall  judge  fit  and  proper  objects  to 
partake  of  the  charity,  they  are  em- 
powered to  put  into  the  house  any  jjersons 
in  the  county  of  Norfolk,  or  elsewhere, 
afflicted  with  lunacy,  whose  relations  or 
friends  may  desire  to  place  them  in  the 
hospital.  Very  low  sums  are  paid  by  the 
friends  of  patients  for  their  maintenance. 

A  Eoyal  Charter  was  granted  to  the 
hospital  in  the  fifth  year  of  the  reign  of 
George  III.,  under  which  the  board  of 
governors  now  act. 

There  are  about  two  acres  of  ground, 
including  the  site  for  the  hospital.  The 
chief  officers  of  the  institution  are  a  visit- 
ing physician,  medical  superintendent,  a 
master  and  matron. 

The  general  style  of  architecture  is  that 
of  a  plain  brick  building  with  no  preten- 
sions to  ornament ;  there  have  been  addi- 
tions and  alterations  from  time  to  time  in 
the  original  building. 

Lunatics  above  the  pauper  class,  and 
belonging  to  the  city  of  Norwich,  are 
provided  for  on  such  terms  as  their  friends 
can  afibrd,  some  free,  and  others  from  the 
nominal  rate  of  is.  up  to  20s.  per  week. 
Cases  are  admitted  from  beyond  the  city 
at  20s.  and  up  to  30s.  per  week.  The 
weekly  cost  per  head  is  16s.  3f7.  as  re- 
turned to  the  Commissioners ;  the  total 
cost,  exclusive  of  structural  additions  and 
alterations,  being  i8s.  6(7. 

St.  Iiuke's  Hospital. — This  hospital 
originated  in  the  good  intentions  of  a  few 
persons  who  desired  to  make  further  provi- 
sion for  indigent  lunatics.  We  are  not 
aware  that  among  the  motives  which  led  to 
this  step  there  was  any  intention  to  reform 
the  treatment  then  in  vogue.  Buildings 
were  found  in  Upper  Moorfiekls,  in  a 
locality  called  Windmill  Hill,  and  formed 
part  of  a  leasehold  estate  held  under  the 
Corporation  of  the  City  of  London.  The 
hospital  was  opened  July  30,  1751.  The 
accommodation  proved  to  be  insufficient, 
and  in  consequence  land  formerly  known 
by  the  name  of  The  Bowling  Green,  in 


Old  Street  Eoad,  was  obtained.  Upon 
this  spot  St.  Luke's  now  stands,  the  first 
stone  being  laid  July  30,  1782.  The 
expense  of  the  building  was  about 
;/^5o,ooo.  In  1787  thei'e  were  1 10  patients^ 
now  there  are  200. 

The  institution  is  under  the  direction 
and  control  of  governors,  and  the  qualifi^ 
cation  for  the  office  is  the  payment  of 
thirty  guineas  to  the  treasurer.  The 
general  management  is  placed  in  the  com- 
mittee, annually  appointed  by  the  court  of 
governors,  which  committee  appoints  a 
house  committee,  the  members  of  which, 
attend  weekly  at  the  hospital. 

The  funds  of  the  hospital  are  derived 
from  patients,  charitable  subscriptions,, 
donations,  and  bequests,  the  property  of 
the  hospital  being  vested  in  the  public 
funds. 

The  cost  per  head  per  week  is  at  the 
present  time  £1  4s.  exclusive  of  building^ 
repairs,  rates  and  taxes. 

The  terms  of  admission  are  as  follows  t 
Cases  in  which  the  patient  has  been  insane 
twelve  months,  or  has  been  discharged 
uncured  from  a  similar  institution,  are 
ineligible,  except  on  payment  of  21s.  per 
week.  Idiots,  persons  suffering  from  epi- 
lepsy, or  under  the  age  of  twelve  or  above 
seventy,  or  being  pregnant,  are  not  eligible 
under  any  circumstances.  Patients  other 
than  free  cases  are  admitted  at  14s.,  21s., 
or  20s.  per  week,  according  to  the  nature 
of  the  case  and  the  circumstances  of  the 
friends.  The  medical  staff  consists  of  a 
consulting  physician,  a  resident  medical 
superintendent,  an  assistant  medical  offi- 
cer, and  a  qualified  clinical  assistant.* 

Manchester  Royal  Iiunatic  Hospital.. 
— This  hospital,  which  is  connected  with 
the  Manchester  Royal  Infirmary,  and  was 
originally  contiguous  to  it,  was  oj^ened  in 
1766,  the  building  having  cost  ^15,000, 
which  was  raised  by  voluntary  contribu- 
tions. The  object  of  its  foundation  was 
to  make  provision  for  poor  lunatics,  to 
lessen  the  exj^ense  of  their  maintenance, 
to  assist  persons  of  middling  fortune,  and 
sui:>ply  a  hospital  for  lunatics  on  moderate 
terms,  the  lowest  weekly^  charge  being- 
fixed  at  ys.  In  1845  it  was  removed  to 
Cheadle,  nine  miles  from  Manchester,  in 
the  county  of  Chester.  An  entirely  new 
building  was  erected.  The  two  institu- 
tions remained  under  the  control  of  the 
same  body  of  trustees  or  governors.  The 
land  and  building  cost  ^30,208,  and 
with  villas  built  and  general  extension 
of  the  main  building,  the  cost  was  about 
^60,000,  raised   by   private  benevolence. 

*  Some  of  the  above  information  has  been  ob- 
tained from  Dr.  ]Miekley,  the  Medieal  Superiuten- 
(lent  of  St.  Lulie's. 


Registered  Hospitals        [     loSi     ]        Registered.  Hospitals 


It  was  opened  August  25,  1S49.  After 
the  expiration  of  three  years  the  pay- 
ments of  patients  enabled  the  governors 
to  dispense  with  contributions  from  the 
public. 

The  Manchester  Royal  Lunatic  Hospital 
is  designed  for  patients  of  the  middle  and 
higher  classes.  It  is  the  desire  of  the 
governors  to  relieve  those  persons  whose 
position  in  life  disqualifies  them  from 
coming  on  the  rates  and  being  admitted 
into  county  asylums,  but  who  are  unable 
to  pay  at  private  asylum  rates.  When 
the  income  exceeds  the  expenditure  the 
surplus  is  to  be  applied  to  the  diminution 
of  the  rates  of  payment  made  by  poor 
patients  or  in  otherwise  increa,sing  the 
usefulness  of  the  institution. 

Mr.  Mould,  the  medical  superintendent, 
has  introduced  the  treatment  of  patients 
in  separate  villas  to  a  very  large  extent 
and  with  very  beneficial  results.  A  very 
interesting  account  of  this  important  work 
was  given  by  Mr.  Mould  himself  in  his 
presidential  address  in  1880.* 

In  this  address  he  observed  : — "  Some 
eighteen  years  since,  with  the  liberal  aid 
and  cordial  co-operation  of  the  committee 
of  visitors,  I  established  in  connection  with 
the  Royal  Hospital  at  Cheadle,  three  villa 
or  cottage  residences,  built  in  the  asylum 
grounds;  and  subsequently,  in  addition, 
rented  ordinary  dwelling-houses,  with 
suitable  surroundings,  for  the  purpose  of 
placing  in  them  patients  who,  I  believe, 
from  their  chronic  or  convalescing  con- 
dition, would  derive  benefit  from  the 
change  from  the  ordinary  routine  of 
asylum  ward-life.  All  asylum  physicians 
constantly  experience  the  injurious  effect 
a  large  number  of  chronic  cases  collected 
together  have  upon  the  comfort  and  con- 
venience in  the  treatment  of  the  more 
acute  cases,  and  the  serious  interference 
with  the  means  of  classification  ;  and  it 
is  generally  accepted  that  the  greater  free- 
dom you  can  accord  a  patient,  consistent 
with  safety,  the  less  irritation  and  excite- 
ment there  is ;  and  it  constantly  occurs 
that  a  patient  who  is  noisy  and  trouble- 
some in  a  hospital  ward  amongst  numbers 
of  others  settles  down  into  comparative 
quiescence  in  a  cottage  house  with  its 
more  home-like  freedom.  I  do  not  of 
course  claim  originality  in  the  placing  of 
cottages  in  the  grounds  of  an  asylum  for 
the  treatment  of  patients,  as  it  was 
adopted  years  ago  by  Dr.  Bucknill,  at  the 
Devon  Asylum  ;  but  I  venture  to  urge  the 
adaptation  of  it  outside  the  grounds  of 
the  asylum  as  a  practical  solution  of  the 

*  Delivireil  at  tin-  auiiual  meeting  of  the Medieo- 
rsycholonical  Association,  .July  30,  1880  {Jour. 
Aleut.  Sci.,  Oct.  1880,  p.  327). 


increasing  difficulty  now  existent  in  pro- 
viding sufficient  accommodation  for 
patients  of  both  the  private  and  pauper 
class.  Ordinary  dwelling-houses  are  taken 
either  on  lease  or  at  an  annual  rent  as 
may  be  the  most  convenient,  and  would, 
of  course,  revert  to  their  original  use 
without  any  deterioration  in  value,  if  not 
required  for  patients.  They  vary  in 
annual  value  from  ^8  to  ^350.  They  are 
readily  and  efficiently  worked  by  the 
asylum's  staff,  and,  in  my  opinion,  if  such 
houses  were  attached  to  the  county 
asylums  as  well  as  the  existing  hospitals 
for  the  insane,  to  be  rented  when  con- 
venient, and  to  be  built  when  not,  they 
would  relieve  the  State  from  the  cost  of  a 
very  large  number  of  patients,  whose 
friends  could  and  would  very  gladly  pay 
moderate  and  remunerative  rates  for  such 
separate  accommodation.  The  extra 
trouble  and  responsibility  thrown  upon 
the  medical  superintendent  would  be  met 
by  a  small  quarterly  charge  made  upon 
each  patient,  which  though  little  in  it- 
self, would  amount  in  the  aggregate  to  a 
fair  sum.  County  asylums  would  of 
course  obtain  money  from  the  rates  for 
the  i:)urpose  of  providing  and  furnishing 
such  buildings  as  we  have  described  for 
the  treatment  of  private  patients  ;  but  in 
the  case  of  hospitals  the  State  should  be 
empowered  to  advance  money  at  a  low 
rate  of  interest,  as  is  now  done  to  other 
public  bodies,  and  in  this  way  providB 
accommodation  for  a  class  of  patients 
whose  urgent  need  has  hitherto  been 
supplied  by  public  benevolence  or  private 
enterprise." 

Mr.  Mould  concludes  his  account  of 
the  treatment  of  patients  by  means  of 
villas  or  cottages  by  the  following  state- 
ment: 

"  In  this  way  more  than  one  half  of  the 
patients  at  least  reside  outside  the  main 
building,  and  many  more  might  be  so 
placed  with  advantage,  if  the  necessary 
accommodation  could  be  readily  obtained. 
This  system  requires  constant  and  vigi- 
lant supervision,  and  the  immediate  tem- 
porary removal  to  the  hospital  of  any 
patient  requiring  more  active  treatment" 
{Jour.  Ment.  Sci,  October  1880,  p.  340). 

Since  the  period  above  referred  to,  the 
system  has  been  still  further  extended, 
and  when  Cheadle  was  visited  by  mem- 
bers of  the  association  in  March  1890,  a 
very  favourable  impression  was  produced 
upon  the  visitors. 

The  general  management  of  the  insti- 
tution is  vested  in  a  committee  elected 
annually  by  the  trustees  of  the  Manches- 
ter Royal  Infirmary,  and  out  of  their  own 
body.     The  medical  superintendent  is  the 


Registered  Hospitals       [    1082    ]        Registered  Hospitals 


sole  responsible  master  and  manager  of 
the  whole  establishment. 

The  terms  vary  according  to  the  accom- 
modation, that  is,  rooms  and  attendance 
required,  and  the  pecuniary  means  of  the 
patients. 

The  usual  terms  are  twenty-five  shil- 
lings, one  guinea  and  a  half,  two  guineas, 
three  guineas,  four  guineas,  six  guineas 
a  week,  and  some  pay  even  higher ; 
but  these  latter  are  wealthy,  and  require 
large  separate  accommodation  and  ser- 
vice. 

Some  patients  are  received  without 
any  charge,  others  at  from  ten  to  twenty 
shillings  per  week,  and  fully  three-fifths  of 
the  whole  number  of  patients  pay  one 
guinea  and  a  half  per  week  and  uncle)'. 
As  the  institution  in  all  its  departments 
is  self-supporting,  the  number  of  patients 
paying  the  lower  rates  of  board  is  of  ne- 
cessity regulated  by  the  surplus  arising 
from  the  payments  made  by  the  wealthier 
patients.  Those  paying  the  highest  rates 
have  of  course  the  separate  rooms  and 
attendance  they  specially  pay  for;  but 
all  who  pay  the  lower  rates,  and  whose 
social  position  and  mental  condition 
allow  of  it  have  the  full  advantage  of 
association  with  and  of  the  comforts  and 
conveniences  of  those  who  pay  the  higher, 
both  in  the  main  hospital  building  and 
in  the  various  houses  in  the  immediate 
neighbourhood  and  at  the  seaside,  without 
extra  charge  being  made. 

Tbe  Vork  lunatic  Hospital,  or  York 
Asylum. — This  institution  was  opened  in 
the  year  1777,  and  is  situated  in  that  part 
of  the  city  of  York  called  Bootham.  A 
public  meeting  was  held  at  York  in  1772, 
summoned  by  Archbishop  Drummond  and 
24  gentlemen  of  the  county,  at  which  a 
liberal  sum  of  money  was  subscribed.  The 
class  of  patients  in  view  were  those  of 
limited  incomes,  and  it  was  not  till  1784 
that  accommodation  was  provided  for  per- 
sons in  more  affluent  circumstances.  A 
charitable  fund  was  founded  in  1789  by 
Mr.  Thomas  Lupton,  and  another  in  1843 
by  Dr.  Wake,  for  many  years  visiting 
physician  to  the  institution. 

The  York  Asylum  is  under  the  manage- 
ment of  a  body  of  governors  consisting  of 
the  Lord  Mayor  of  York,  the  governor  of 
the  Merchants'  Company,  York,  the 
Mayor  of  Doncaster,  and  all  benefactors 
of  ^20  and  upwards. 

At  the  Annual  General  Court  of  Gov- 
ernors, four  of  their  number  are  appointed 
auditors,  quarterly  courts  appoint  seven 
governors  to  form  the  managing  com- 
mittee for  the  ensuing  quarter,  and 
visitors  are  appointed  for  the  male  and 
female  wards. 


The  number  of  acres  is  22,  exclusive  of 
pasture  and  farm. 

Sources  of  income  are  payments  of 
patients'  donations  and  legacies,  the  pro- 
duce of  the  land  and  rent  of  a  farm,  and 
the  interest  assigns  from  the  Lupton  and 
Wake  funds. 

The  rates  of  payment  and  number  of 
patients  on  December  31,  1891,  were  as 
follows : — 

39  patients  from  £  1  to  ^4  4s.  per  week 
each  inclusive;  16  from  los.  to  19s., 
partially  maintained  from  Lupton's  Fund; 
4  from  5s.  to  9s. ;  13  from  ^20  i6s.  to  ;^i5o 
each  per  annum;  i  wholly  maintained  from 
Lupton's  Fund;  55  city  paupers  at  14s. 
per  week.     Total,  128. 

The  contrast  between  the  condition  in 
which  this  excellent  asylum  has  long  been, 
and  its  unsatisfactory  state  at  an  early 
period  of  its  history,  is  so  gratifying,  and 
redounds  so  greatly  to  the  credit  of  the 
modern  management  of  the  institution, 
that  it  is  only  right  to  quote  the  descrip- 
tion given  by  Dr.  Conolly  of  its  former 
condition  :  —  "  Among  the  ill-conducted 
asylums  of  this  country  at  the  time  when 
Pinel's  great  work  of  reformation  was 
effected  in  France,  the  worst  seems  to 
have  been  that  of  the  city  of  York,  which 
had  been  founded  in  1777,  and  had  soon 
become  a  scene  of  mercenary  intrigue  and 
mismanagement.  At  a  much  later  period 
it  had  arrived  at  the  perfection  of  whatever 
was  wrong  and  detestable." 

The  Retreat,  Vork. — In  1791,  a  female 
patient  confined  in  the  old  York  Asylum, 
and  a  member  of  the  Society  of  Friends, 
was  treated  in  such  a  way  as  to  attract 
grave  suspicions  of  ill-treatment,  but  her 
relations  were  refused  admission.  It  was 
thought  by  William  Tuke  desirable  under 
these  circumstances  to  project  a  new 
asylum  at  York,  one  which  should  be  con- 
ducted in  a  humane  manner,  and  mth  pro- 
per regard  to  the  feelings  of  the  patients' 
friends.  The  proposal  took  a  definite  form 
at  a  meeting  of  this  community  in  the 
spring  of  1792,  and  at  midsummer  a  "  re- 
tired habitation  "  was  "instituted,"  bear- 
ing the  name  of  "  The  Retreat,"  the  first 
instance  in  which  the  term  was  applied 
to  an  asylum  for  the  insane.  Ground 
was  purchased  in  the  neighbourhood  of 
the  city,  amounting  to  eleven  acres,  and 
a  building  of  modest  pretensions  was 
erected.  It  still  remains,  and  forms  the 
centre  of  a  very  much  larger  establish- 
ment. It  was  surrounded  by  airing  courts, 
gardens,  and  fields.  A  few  years  after- 
wards, a  small  separate  institution,  de- 
sired for  a  limited  number  of  convalescent 
patients,  was  established,  within  an  easy 
distance   of  the  original  building.     The 


Registered  Hospitals        [     10S3    ]        Registered  Hospitals 


^'Appendage,"  as  it  was  called,  was  occu- 
pied for  about  thirteen  years. 

Prom  the  earliest  period  occupation  on 
the  farm  was  introduced,  and  regarded  as 
highly  important  to  the  health  and  re- 
<;overy  of  the  jjatients. 

The  methods  of  restraint,  when  regarded 
as  absolutely  necessary,  were  of  a  simple 
character.  The  idea  of  employing  chains 
was  abhorrent  to  those  who  conducted 
the  Retreat,  although  they  were  to  be 
found  in  use  many  years  afterwards  at 
St.  Luke's  and  at  Bethlem  Hospital. 

The  result  of  the  humane  treatment 
here  pursued  was  so  satisfactory  that  it 
became  the  cradle  of  the  reform  of  the 
general  and  medical  treatment  of  mental 
disorders. 

Constitution,  Government,  and  Manage- 
1/nent. — The  government  of  the  Retreat 
is  vested  by  the  trust  deed  in  a  general 
meeting  of  subscribers  and  directors  held 
annually  at  Yoi'k.  Forty  subscribers  were 
originally  nominated  as  directors.  They 
and  their  successors,  duly  appointed,  to- 
gether with  any  other  donors,  subscribers, 
and  agents  api^ointed  by  any  qualified 
meeting,  constitute  the  general  meeting 
and  continue  the  directors  of  the  institu- 
tion, in  whom  the  government  of  it  is 
perpetually  to  vest  and  remain. 

The  committee,  of  which  the  treasurer 
is  ex  officio  a  member,  meet  at  the  Retreat 
every  month,  and  oftener  if  required,  for 
the  transaction  of  business;  amongst  other 
things,  they  admit  and  discharge  patients, 
and  sanction  the  necessary  current  expen- 
diture of  the  establishment. 

The  main  soui'ces  of  income  consist  of 
the  payments  of  the  patients,  the  great 
deficiency  which  would  arise  from  the  low 
payment  of  some  being  counterbalanced 
by  the  higher  scale  of  payment  by  others ; 
when,  however,  the  income  falls  below  the 
expenditure,  or  when  there  is  a  special 
outlay  upon  the  building,  donations 
and  annual  subscriptions  must  be  relied 
upon. 

The  rates  of  payment  vary  from  four- 
teen shillings  to  seven  guineas  per  week. 

Officers.  Attendants,  &c. — The  officers 
attached  to  the  Retreat  are :  a  medical 
superintendent,  one  visiting  medical  offi- 
cer, and  two  assistant  medical  officers,  a 
steward,  and  a  matron.  The  number  of 
attendants  necessarily  varies  with  the  pro- 
portion of  the  higher  class  patients  in  the 
asylum.* 

*  It  is  to  the  Editor  of  this  work  an  interesting- 
circumstance  tliat  the  centenary  of  this  institution 
is  celebrated  tliis  year  at  York,  and  that  tlie  super- 
intendent of  the  lietreat,  Dr.  llnhert  Maker,  is 
elected  to  preside  over  the  annual  meeting  of  the 
Medico-Psychological  Association,  which, in  honour 
of  tlie  event,  meets  at  the  York  Retreat. 


The  average  weekly  cost  per  head  is 
£i  15s.  6d. 

The  number  of  acres  is  34. 

During  the  past  eighteen  years  no  addi- 
tion has  been  made  to  "The  Retreat" 
main  building,  but  many  decided  improve- 
ments have  been  made.  But  although 
the  main  building  has  not  been  added  to, 
the  following  villas  have  been  erected,  and 
one  (Belle  Vue)  has  been  purchased  :  The 
East  Villa,  at  a  cost  of  ^1900;  Gentle- 
men's Lodge,  accommodating  30  patients, 
^12,000;  West  Villa,  ]>roviding  for  15 
ladies,  ^{^4000  (including  electric  lighting, 
^400).  Belle  Vue  House  was  bought  for 
the  sum  of  ^4000.  Gainsborough  House, 
Scarboro',  is  leased  at  ^^90  a  year  as  a 
seaside  residence.* 

■V«/"onford  House,  Exeter.  —  Wonford 
House  dates  back,  under  the  name  of  St. 
Thomas's  Hospital,  to  an  earlier  period. 
The  first  proposal  for  founding  a  hospital 
for  the  insane  was  laid  before  the  Grand 
Jury  of  the  County  of  Devon  at  their 
meeting  at  the  Castle  of  Exeter,  March 
16,  1795.  as  follows  : 

"  (Jittline  of  a  Plan  for  a  LunatiG 
Asylum. — This  institution  is  intended  to 
relieve  the  most  helpless  and  pitiable  class 
of  mortals  who  cannot,  consistently  with 
the  care  of  the  patients,  be  received  into 
the  county  hospital.  This  relief  may  be 
afforded  without  aftecting  the  present 
hospital  as  to  its  regulatious  and  expenses, 
it  being  proposed  that  the  lunatic  asylum 
should  be  a  distinct  and  independent  in- 
stitution, standing  on  its  own  foundation, 
and  supported  by  separate  and  distinct 
means. 

"  The  patients  of  the  lunatic  asylum,  by 
a  weekly  payment  suited  to  their  circum- 
stances, will  render  annual  subscriptions 
unnecessary.  The  experiment  has  been 
tried  in  several  parts  of  the  kingdom,  and 
has  answered  the  most  sanguine  expecta- 
tions." 

The  grand  jury  having  passed  a  re- 
solution approving  of  the  above  proposal, 
a  subscription  was  opened,  and  at  a  meet- 
ing of  subscribers  held  at  Exeter,  July  29, 
1795,  a  series  of  resolutions  were  adopted 
in  accordance  with  the  foregoing  pro- 
posal. 

It  was  not,  however,  until  1799  ^^'^^ 
sufficient  funds  were  in  hand,  and  a 
suitable  house  and  estate  purchased.  The 
hospital  was  opened  for  the  reception  of 
patients  July  i,  1801,  and  on  July  18 
the  first  patient  was  received.  The  insti- 
tution was  subsequently  registered  as  St. 
Thomas's  Hospital. 

Government. — It    was   governed    by   a 

*  Dr.  Jlakcr  has  kindly  supplied  as  with  these 
particulars. 


Registered  Hospitals        [    1084    ]        Registered  Hospitals 


committee  of  management,  consisting  of 
Jonors  of  twenty  guineas  and  upwards, 
and  of  ten  members  elected  annually  by 
the  governors.  For  many  years  the  medi- 
cal staff  consisted  of  two  visiting  phy- 
sicians and  a  resident  medical  officer,  but 
about  ten  years  ago  the  visiting  ph}'- 
sicians  were  abolished,  and  the  medical 
superintendent  became  the  sole  responsible 
head  under  the  committee. 

The  hospital  remained  on  its  original 
site  of  Bowhill  House,  in  the  district  of 
St.  Thomas,  until  1869,  when  it  was  trans- 
ferred to  its  ])resent  site,  a  mile  and  a  half 
from  Exeter,  on  the  rising  ground  to  the 
east  of  the  city,  a  beautiful  and  healthy 
situation.  The  estate  purchased  then 
consisted  of  about  twenty  acres  ;  and  on 
this  was  erected  the  present  hospital, 
afterwards  called  Wonford  House,  a  name 
taken  from  a  neighbouring  village.  It  is 
also  the  name  of  the  hundred  in  which 
Exeter  itself  is  situated. 

During  the  last  few  years  forty  addi- 
tional acres  of  land  have  been  purchased. 
A  comfortable  house,  with  garden,  accom- 
modating fifteen  to  twenty  patients  has 
also  been  secured  at  Dawlish  as  a  sea-side 
residence  and  sanatorium. 

The  hospital  has  accommodation  for 
between  130  and  140  patients.  They  be- 
long to  the  upper  and  middle  classes,  and 
consist  of  (i)  those  who  can  pay  re- 
munerative rates  of  board  ;  (2)  those  of 
the  same  social  position,  but  unable  to 
pay  the  full  charges,  and  admitted  by  the 
committee  after  careful  consideration,  at 
various  reduced  rates,  according  to  cir- 
cumstances. The  lull  rate  is  ^2  js.  per 
week.  About  three-fifths  of  the  patients 
pay  less  than  this.  At  present  five  are 
received  free  of  charge ;  twenty-two  pay 
from  ten  shillings  to  ^i  a  v/eek,  and  forty- 
eight  more  at  varioiTs  rates,  between 
twenty-seven  and  forty-seven  shillings ; 
the  remaining  fifty  patients  pay  the  full 
rate  or  more.* 

The  average  cost  of  maintenance,  ex- 
clusive of  additions  or  repairs  to  building, 
rates  and  taxes,  is  about  £1  15s.  weekly. 

St.  Andrew's  Hospital  for  IVIental 
Diseases,  Northampton.  —  It  appears 
that  this  institution  originated  in  two 
benefactions  of  £100  each  by  an  anony- 
mous donor  in  1804  and  1807,  who  pre- 
sented these  sums  to  the  Governors  of 
the  General  Infirmary  at  Northampton, 
in  trust,  to  api^ly  the  same  towards  the 
building  of  a  lunatic  asylum.  It  was  de- 
cided to  establish  a  hospital  separate  from 
the  infirmary  for  the  reception  of  120 
private  and  pauper  patients,  to  be  under 

"  We  are  iudebted  tci  Dr.  Miiiiry  Dcus  for  the 
particulars  here  yiven. 


the  management  of  a  committee,  and 
maintained  independently  of  the  county 
rate.  Earl  Spencer,  the  Marquis  of 
Northampton,  Earl  Fitzwilliam,  Mr. 
Bouverie,  and  others  assisted  in  the 
undertaking.  The  institution  is  sup- 
ported by  donations,  legacies,  and  the 
payments  of  the  more  opulent  patients. 

The  management  of  the  institution  is 
vested  in  the  governors,  who  consist  of 
benefactors  of  £20;  the  Lord-Lieutenant 
of  the  county  for  the  time  being  is  pre- 
sident. At  the  annual  meeting  the  direc- 
tors choose  a  committee  of  management, 
which  meets  at  least  once  a  month. 

The  number  of  acres  is  105. 

The  rates  of  payment  are  as  follows : 
1st  class,  £2  2s.  and  upwards  ;  2nd  class, 
^i  5s.  a  week  and  upwards,  according  to 
the  requirements  of  each  case.  Patients 
are  assisted  in  their  payments  at  the  dis- 
cretion of  the  committee,  the  number  so 
helped  in  1891  being  2>j^  a  large  propor- 
tion of  whom  were  free. 

The  reception  of  jjauper  patients  was 
discontinued  in  the  year  1876,  and  the 
hospital  is  now  entirely  devoted  to  the 
care  and  treatment  of  patients  of  the 
upper  and  middle  classes.  There  is  no 
endowment,  the  hospital  being  supported 
by  the  payments  of  patients. 

There  is  accommodation  for  350,  includ- 
ing detached  villas  on  the  hospital  estate, 
and  houses  at  Moulton  Park.  Moultou 
Park  is  an  estate  of  450  acres,  two  and  a 
half  miles  distant  from  and  belonging  to 
the  hospital,  and  is  used  for  the  occupa- 
tion in  farm,  garden,  and  dairy  work  for 
the  patients  who  reside  there. 

There  is  also  a  seaside  mansion  and 
estate  leased  by  the  hospital  near  Conway, 
called  Benarth  Hall,  to  which  patients 
are  regularly  sent  for  the  benefit  of  their 
health  and  change  of  scene.  The  estate 
is  situated  on  the  estuary  of  the  River 
Conway,  and  the  patients  have  the  sport- 
ing rights  over  more  than  500  acres. 

Coton  Hill  Institution,  near  Stafford^ 
—  A  Ithough  the  present  building  was 
oj^ened  in  1854,  there  was  an  institution 
intended  for  paupers  as  well  as  j)atients 
of  the  higher  and  middle  classes,  which 
was  opened  in  1818,  under  the  Act  48 
Geo.  III.  c.  96. 

The  foundation  of  this  original  charity 
arose  out  of  a  legacy  left  to  the  Stafford 
General  Infirmary  for  the  purpose  of 
adding  wards  for  insane  patients  to  that 
institution.  But  it  was  agreed  to  erect  a 
separate  asylum.  Patients  were  admitted 
at  rates  of  payment  varying  fi'om  2s.  6d. 
to  los.  or  I2S.  per  week,  according  to  their 
means.  The  surplus  payments  derived 
from    the   patients    of    the    independent 


Registered  Hospitals        [     10S5    ]        Registered  Hospitals 


classes  were  an  important  source  of  in- 
come, and  considerably  diminished  the 
charge  for  pauper  patients.  This  appro- 
priation of  the  funds  was  taken  into  con- 
sideration in  1846,  and  it  was  directed 
that  in  futui-e  the  savings  of  the  hospital 
should  be  placed  to  the  credit  of  the 
charitable  fund  in  accordance  with  the 
original  agreement.  Lord  Ashley's  Act 
(1845)  rendered  it  necessary  to  extend  and 
remodel  the  institution.  After  many 
plans  were  considered  and  discarded,  it 
was  decided  to  dissever  the  connection 
between  the  county  and  the  voluntary 
part  of  the  institution,  and  to  erect  upon 
an  extended  scale  a  suitable  building  for 
the  various  classes  of  private  patients. 
Great  difficulty  had  been  experienced  in 
the  working  of  a  large  mixed  establish- 
ment. It  was  decided,  therefore,  that  cer- 
tain additions  should  be  made  to  the  county 
asylum,  to  adapt  it  for  the  reception  of  an 
increased  number  of  pauper  patients.  The 
committee  decided  upon  the  present  site 
for  the  building,  land  being  placed  at  their 
disposal  by  the  late  Earl  Talbot. 

In  spite  of  the  liberal  help  afforded, 
assisted  by  a  public  meeting  held  in  No- 
vember 185 1,  and  the  funds  at  the  disposal 
of  the  committee,  it  was  found  impossible 
to  finish  the  building.  The  arrangements 
were,  however,  completed,  and  it  was  de- 
cided to  open  the  institution  as  soon  as 
practicable,  the  sum  required  being  raised 
upon  mortgage.  This  has  unfortunately 
crippled  the  action  of  the  governors,  a 
considerable  debt  having  been  incurred. 
The  institution  stands  in  the  centre  of  an 
elevated  plot  of  land  of  38  acres  in  extent, 
and  can  accommodate  140  patients  (both 
sexes).  The  private  patients  were  re- 
moved from  the  county  asylum  to  the 
new  building  in  May  1854. 

The  government  of  the  institiition  is 
vested  in  president,  vice-president,  and  a 
general  committee  qualified  and  elected 
from  the  body  of  subscribers. 

The  sources  of  income  are  derived  from 
the  annual  subscrijDtions  and  the  pay- 
ments of  patients. 

The  original  main  building,  with  the 
chapel  in  the  grounds,  cost  ^30,374.  Since 
1854,  when  the  place  was  opened,  the 
following  additions  have  been  made, 
namely,  two  galleries,  one  each  side  of  the 
maihbuilding,  two  semi-detached  villas  and 
three  lodges  in  the  ground,  and  a  large  re- 
creation hall  and  theatre  were  added  to 
the  main  building  in  1889,  and  opened  in 
1890.  These  additions  have  cost  £7791, 
making  the  total  cost  of  the  hospital 
;/^38,i65.  There  are  surrounding  it  31 
acres  of  land,  garden,  &c.,  for  which 
;^6ooo   was  paid.     In  addition    to  this, 


about  81  acres  generally  are  i-ented  for 
farming  purposes. 

The  average  weekly  cost  per  head  was, 
in  1891,  ^i  13s.  7d. 

The  object  of  this  hospital  has  from  the 
first  been  to  a  great  extent  charitable. 
Some  92  of  the  patients  at  the  present 
time  pay  for  their  board  less  than  the 
average  cost,  and  26  of  these  pay  less  than 
^i  per  week.  It  may  be  added  that  there 
are  still  some  few  cases  that  have  been  in 
the  asylum  since  1854,  paying  the  nominal 
sums  of  4s.  6d.  and  7s.  6d.  per  week. 

The  number  of  patients  that  can  be 
accommodated  is  140.  There  are  two 
classes  of  insane  patients  for  whom  this 
hospital  is  designed — (i)  patients  in  more 
or  less  affluent  circumstances  who  shall 
contribute  according  to  the  accommoda- 
tion required,  such  weekly  sum  as  may 
be  agreed  upon  ;  (2)  patients  in  such  cir- 
cumstances, although  not  paupers,  who 
shall  be  received  at  such  reduced  rates 
of  payment  as  the  committee  upon  con- 
sideration of  their  circumstances  may  de- 
termine, the  deficiency  being  made  up  out 
of  the  surplus  moneys  received  from  the 
patients  of  the  first  class  beyond  their 
actual  cost,  assisted  by  annual  subscrip- 
tions, donations,  and  legacies. 

Government. — The  real  estate  and  funds 
of  the  institution  are  vested  in  five  trus- 
tees. 

The  general  direction  and  management 
of  the  institution  are  vested  in  the  presi- 
dent, vice-presidents,  and  a  general  com- 
mittee, qualified  and  elected. 

The  immediate  conti'ol  of  the  institu- 
tion is  under  the  direction  of  the  resident 
medical  superintendent,  who  is  respon- 
sible to  the  committee. 

A  president  and  six  vice-presidents  are 
elected  for  life. 

Annual  subscribers  of  two  guineas  and 
upwards,  and  all  donors  of  twenty  guineas 
and  upwards  at  one  payment,  aregovernors 
of  the  institution,  and  privileged  to  vote 
in  the  election  of  the  general  committee. 

The  president  and  vice-presidents  are 
members  of  the  general  and  house  com- 
mittees. 

The  court  of  quarter  sessions  of  the 
county  of  Stafford  may  appoint  any  num- 
ber not  exceeding  24  of  the  Justices  of  the 
county  to  be  visitors  of  the  institution.* 

Iiincoln  Iiunatic  Hospital  (Tbe 
Iiawn). — This  institution  was  opened  for 
the  reception  of  patients,  April  26,  1820, 
the  funds  having  been  furnished  by  dona- 
tions from  the  nobility  and  gentry  con- 
nected with  the  county  of  Lincoln,  who 

*  We  are  indebted  to  Dr.  Jlewsoii,  tlie  Mi  dical 
.Superinleiidciit  of  Cotou  Hill,  for  luiiiiy  ol'  the 
foregoing-  particuhirs. 


Registered  Hospitals        [     1086    ]        Registered  Hospitals 


in  consequence  became  "  governors  of  the 
lunatic  asylum  for  the  county."  The 
object  was  to  enable  patients  to  be  ad- 
mitted at  lower  rates  than  elsewhere. 

We  believe  that  the  origin  of  this  hos- 
pital was  really  due  to  a  donation  of  /^  100 
from  Paul  Parnell,  Esq.,  a  surgeon  in 
Lincoln. 

The  government  of  the  hospital  was 
vested  in  a  board  of  governors,  the  quali- 
fication being  a  donation  of  twenty  guineas 
or  an  annual  subscription  of  not  less  than 
two. 

Unfortunately,  the  building  was  very 
faulty  in  construction,  and  the  airing 
courts  consisted  of  damp,  small,  and 
cheerless  enclosures  situate  on  the  north 
side  of  the  building.  The  grounds  to  the 
south,  commanding  a  beautiful  prospect, 
were,  strange  to  say,  scarcely  used  by  the 
patients.  Since  1847  all  this  has  been 
altered,  and  the  south  side  of  the  build- 
ing, formerly  used  by  patients  under 
restraint,  consists  of  cheerful  and  well- 
furnished  day-rooms.  There  are  about 
nine  acres  of  land  belonging  to  the  in- 
stitution. 

Previous  to  January  i,  1854,  the  rates 
of  jDayment  were  for  first  class  patients, 
21S.  per  week  ;  for  second  class  patients, 
15s.  per  week  ;  for  third  class  ijatieuts, 
IDS.  per  week.  These  terms  were  raised 
to  20s.,  20s.,  and  128,  per  week,  partly  in 
consequence  of  the  removal  of  the  pauper 
lunatics.  The  terms  are  now  30s.  weekly 
and  upwards,  but  they  may  be  lowered  by 
the  committee  to  a  smaller  sum  when  they 
think  proper.* 

It  was  in  this  institution  that  absolute 
non-restraint  was  first  introduced  as  a  sys- 
tem. This  was  done  gradually  through 
the  exertions  of  Mr.  Gardiner  Hill  and 
Dr.  Charlesworth,  the  last  use  of  restraint 
being  in  the  year  1837. 

The  following  table  is  of  interest  as 
showing  the  gradual  change  in  regard  to 
restraint  at  the  Lincoln  Asylum  : 


Total 

bi 

Total 

Total  Num- 

Year. 

Number 

"3  ,§  .5 

Number  of 

ber  of  Hours 

in  the 

0  a  s 

instances  of 

under 

House. 

Restraint. 

Restraint. 

1829 

72 

39 

1,727 

20,424 

1830 

92 

54 

2,364 

27.113 

1831 

70 

40 

1,004 

10,839 

1832 

81 

55 

1,401 

15,671 

1833 

87 

44 

1,109 

12,003 

1834 

109 

45 

647 

6,597 

1835 

108 

28 

323 

2,874 

1836 

"5 

12 

39 

334 

1837 

130 

2 

3 

28 

*  Dr.  Russell,  the  medical  superintendent,  has 
supplied  us  with  these  particulars. 


"Warneford  Hospital  or  Asylum, 
Headington  Hill,  Oxford. — It  is  stated 
that  some  of  the  governors  of  the  Ead- 
clifFe  Infirmary,  especially  Dr.  Cooke, 
President  of  Corpus  Christi  College, 
originated  this  hospital  by  their  praise- 
worthy exertions. 

A  number  of  propositions  were  adopted 
at  a  meeting  of  the  governors  of  the 
infirmary  held  April  28,  181 3.  The 
necessary  funds  were  obtained  as  follows  : 
The  trustees  of  the  Radcliffe  Infirmary 
granted  at  different  periods  the  sum  of 
£2700 ;  corporate,  testamentary,  and  indi- 
vidual contribtttions  raised  the  amount 
to  about  ;^2o,ooo.  The  site  fixed  upon 
was  Headington  Hill. 

The  asylum  was  opened  on  July 
10,  1826,  as  "The  Oxford  Lunatic  Asy- 
lum." The  institution  has  twenty-two 
acres  of  ground,  ten  of  which  are  laid  out 
as  a  garden  and  cricket-field,  the  other 
twelve  being  kitchen  garden  and  grass 
land. 

It  is  intended  for  the  care  and  treat- 
ment of  patients  of  both  sexes  belonging 
to  the  middle  and  upper  classes  of  society. 
The  situation  on  Headington  Hill,  about 
a  mile  and  a  half  from  Oxford,  is  very 
healthy.  The  buildings,  to  which  large 
additions  have  been  recently  made,  are 
substantial  and  are  comfortably  furnished, 
and  are  well  adapted  for  the  successful 
treatment  of  the  inmates. 

The  management  is  under  the  control 
of  a  committee.  The  staff  consists  of  a 
medical  superintendent,  assistant  medical 
officer,  chaplain,  and  matron,  all  of  whom, 
with  the  exception  of  the  chaplain,  are 
resident.  There  is  a  private  chapel  within 
the  grounds. 

The  ordinary  terms  are  two  guineas  a 
week,  but  many  of  the  patients  pay  less. 
The  average  cost  of  each  patient  (exclusive 
of  building  repairs,  rates  and  taxes,  and 
extraordinary  expenses)  is  £1  7s.  lod. 
per  week. 

There  is  accommodation  for  100 patients, 
50  of  each  sex.  There  are  at  present  80 
patients,  vacancies  being  in  the  new  wing 
for  male  patients,  which  was  opened  a 
short  time  ago. 

No  person  in  a  state  of  idiocy  or  suffer- 
ing: from  epilepsy  or  paralysis  is  admis- 
sible. 

The  annual  income  is  aided  by  the  rents 
and  interest  of  the  real  estates,  and  of  a 
mortgage  given  by  the  late  Dr.  "Warne- 
ford, in  honour  of  whom,  on  the  grant  of 
a  new  charter  some  years  ago,  its  name 
was  changed  from  the  "  Radcliffe  Asy- 
lum "  to  that  of  the  "  Warneford  Lunatic 
Asylum."  He  lived  long,  and  was  awarm 
friend   and  munificent  benefactor  of  the 


Kegistered  Hospitals  [     10S7    ]        Registered  Hospitals 


institution,*  his  donations  exceeding  the 
value  of  /^yo.ooo. 

ITottin^Iiani   Iiunatic  Hospital   (The 
Coppice). — ''  The  Coppice"  is  a  registered 
hospital  for  the  insane,  situate  about  two 
miles   from    Nottingham    ]\Iarket    Place 
and   the  Midland    and   Great   Northern 
Railway  Stations.     It  was  originally  pro- 
moted   and    brought   into    operation    by 
gentlemen  connected  with  the  Nottingham 
General  Hospital.      Donations  and   sub- 
scriptions for  the  purchase  of  land   and 
building  an  asylum  were  commenced  in 
1789,  and  had  accumulated,  in   1809,  to 
about    /^6ooo.      It  was  then  decided  by 
the  subscribers,  in  conjunction   with   the 
county   and  borough  of  Nottingham,   to 
build  an  asylum  at  Sneinton,  near  Not- 
tingham, to  be  called  the  General  Lunatic 
Asylum  for  the  County  and  Town  of  Not- 
tingham, for  the  reception  of  private  and 
pauper    patients.      It     was    opened    on 
February  13,    181 2,  and  afterwards  was 
from  time  to  time  enlarged  to  meet  the 
increasing    number  of    apjilications    for 
admission.      The    accommodation    being 
still  found  inadequate,  it  was  decided,  on 
the  recommendation  of  the  Commissioners 
in  Lunacy,  to  separate  the  private  from 
the  paujjer  patients,  and  to  build  a  new 
asylum   for   the  former.     Terms   having 
been  equitably  arranged,  and  a  suitable 
site  found  at  a  convenient  distance  from 
Nottingham,    the    present    hospital    for 
sixty  patients  was  built  and  furnished  at 
a  cost  of  about  ^{^20,000,  leaving  a  balance 
of  about   ^10,000    in    the   hands  of   the 
trustees,  as  an  endowment  fund  for  chari- 
table purposes.     The   first  stone  of   the 
new    building  was  laid    on   October   30, 
1857,  by  the  Duke  of  Newcastle,  the  then 
president,  and  it  was  opened  for  the  recep- 
tion of  patients  by  Dr.  W.  B.  Tate,t  the 
present      medical      superintendent,      on 
August    I,    1859,  on    which  day    thirty 
private  patients  were  transferred  to   the 
hospital   from    the    asylum  at  Sneinton. 
Since  its  opening  the  hospital  has  been 
enlarged  by  the    addition    of  wings,   the 
cost  of  which  and  furnishing  was  about 
^10,000.     It  will  now  accommodate  about 
100  patients,  all  of  whom  pay,  for  their 
medical  treatment  and  maintenance,  sums 
varying  from  los.  to   ^2   a  week.     It  is 
exclusively  for  the    reception   of  private 
patients  of  the  middle  class.     The  pro- 
perty of  the  hospital  is  vested  in  trustees, 
and   it   is  managed   by   a   committee   of 
gentlemen  of  the  county  and  town  of  Not- 

*  Wu  arc  indebted  for  these  particulars  to  the 
SIcdieal  Siiperintendeut  of  the  AVanieford  Asylum, 
Dr.  .1.  By  water  Ward. 

t  To  whom  we  are  indebted  for  these  particui 
lars. 


tingha  ni  who  are  subscribers  to  it,  and  are 
chosen  yearly.  The  endowment  fund  and 
annual  subscriptions  amount  to  about 
;^Soo  a  year,  whereby  the  committee  are 
enabled  to  admit  a  certain  number  of  de- 
serving cases  belonging  to  the  county  and 
town  of  Nottingham  at  reduced  rates  of 
payment.  The  site  is  an  elevation  facing 
the  south,  and  commanding  an  exten- 
sive viev?  of  the  surrounding  country. 
Mr.  T.  C.  Hine,  of  Nottingham,  was  the 
architect. 

The  weekly  rate  of  cost  per  head  is 
£1  I  IS., exclusive  of  any  charge  for  lodging. 
Dr.  Tate  informs  us  that,  although  there 
are  patients  paying  only  los.  a  week,  the 
hospital  will  not  in  future  take  any  at  so 
low  a  rate. 

Barnvrood  House,  Gloucester.^ — In 
January  1857  a  general  meeting  of  the 
surviving  subscribers  to  the  Gloucester 
Lunatic  Asylum  was  held  at  Gloucester, 
and  appointed  a  committee  to  acton  their 
behalf  in  all  matters  affecting  the  interest 
of  the  trust.  In  the  report  of  this  com- 
mittee it  is  stated  that  the  sale  of  the 
subscribers'  interest  in  the  county  asylum 
had  been  completed  for  £i2,,ooo.  With 
that  sum  at  their  disposal  and  other  sums 
amounting  to  ^{^6500  they  entered  into  an 
agreement  in  the  month  of  May  to  pur- 
chase, from  the  County  of  Gloucester  Bank, 
Barnivood  House,  with  its  gardens,  plea- 
sure ground,  and  lands,  amoiinting  to 
forty-eight  acres,  which  purchase  was 
completed  on  February  8, 1858.  Plans  were 
submitted  to  the  committee  for  the  adap- 
tation of  the  house  to  the  purjDOses  of  an 
asylum,  involving  extensive  additions. 
These  plans  were  adopted. 

The  establishment  was  registered  as 
a  hospital  for  the  insane  January  i, 
i860.  The  Commissioners  in  Lunacy 
made  their  first  visit  on  the  17th,  and 
stated  in  their  report  that  the  building 
afforded  excellent  accommodation  for 
the  upper  as  well  as  the  middle  class 
patients. 

The  first  general  meeting  of  the  sup- 
porters of  the  institution  was  held  Janu- 
ary 30,  i860,  Earl  Ducie,  lord-lieutenant 
of  the  county,  presiding. 

A  general  committee  of  management 
was  appointed.  This  asylum  has  well 
fulfilled  the  object  for  which  it  was  estab- 
lished. Additions  have  constantly  been 
made  to  its  size  in  improving  the  charac- 
ter of  the  accommodation.  The  average 
weekly  cost  of  maintenance  is  just  under 

£2. 

HolIo\iray  Sanatorium,  St.  Ann's 
Heath,  Virg-inia  -Water. — This  hospital, 

*  This  account  is  derived  from  information  sup- 
plied by  the  late  superinteudent.  Dr.  Needham, 


Registered  Hospitals         [     1088    ] 


Religion 


foimLled  by  tbe  late  Mr.  Thomas  Hollo- 
way,  was  opened  Jnne  12,  1885.  It  is  a 
registered  hospital  for  the  care  and  cure 
of  the  insane  and  nervous  invalids  of  the 
upper  and  upper-middle  classes  at  mode- 
rate rates  of  payment. 

The  charge  for  board,  &c.,  varies  from 
£2  2s.  to  £2)  o^-  ^  week  and  uj) wards, 
according  to  tlie  requirements  of  the  case, 
at  the  discretion  of  the  committee.  One- 
fourtb  at  least  of  the  total  number  of 
jiatients  are  maintained  at  weekly  i-ates 
of  25s.  or  under.  Payment  for  one  quarter 
must  be  made  at  the  time  of  admission; 
subsequent  payments  must  be  made 
quarterly  and  in  advance.  For  each  pa- 
tient or  boarder  there  must  be  furnished 
an  obligation  for  payment  of  board,  &c., 
to  be  signed  by  two  responsible  persons; 
fourteen  days  are  allowed  for  signatures 
to  be  obtained  for  this  document  after  a 
patient  has  been  admitted. 

Lady  companions  live  with  the  lady  pa- 
tients. Gentlemen  companions  live  with 
the  gentlemen  patients.  The  assistant 
medical  officers,  four  in  number,  also 
lunch  and  dine  and  spend  much  of  their 
time  with  the  patients.  One  of  the  assist- 
ant medical  officers  is  a  fully  qualified 
medical  woman.  Lectures  and  practical 
tuition  on  special  and  general  nursing  are 
given  to  the  staff,  and  trained  nurses  and 
attendants  are  sent  out  to  nurse  cases  at 
their  own  homes. 

A  seaside  branch  at  Brighton  has  been 
established.  It  is  fitted  with  all  modern 
sanitary  improvements. 

St.  Ann's  Heath  is  situated  on  the  Bag- 
shot  sands  formation.  The  building  is 
surrounded  by  its  own  pleasure  grounds. 
It  is  close  to  the  Virginia  Water  Station, 
twenty  miles  from  London. 

We  observe  from  the  auditor's  report, 
dated  January  1892,  that  the  income  from 
maintenance  accounts  during  the  previous 
twelvemonths  amounted  10^42,9015  4s.  8fZ. 
and  that  the  expenditure  (less  repayments 
by  patients,  &c.)  was  ^33,088  i6s.  2f?., 
leaving  a  surplus  revenue  of  ^{^98 16  8s.  6(1 
The  average  number  of  patients  and 
boarders  during  the  year  was  347  ;  aver- 
age weekly  income  per  patient,  ^2  8s.  i  id.; 
average  weekly  expenditure  jjer  patient, 
£2  OS.  yd.,  leaving  an  average  weeklj' 
surplus  per  patient  of  8s.  4cZ.  The  num- 
ber of  patients  and  boarders  at  the  end 
of  the  year  (1891)  was  340.* 

The  Averagre  "Weekly  Cost  per  Head 
in  Reg-istered  Hospitals  (including 
everything  except  the   charges  for  build- 

*  The  particuliirs  of  the  uccount  of  the  Hollo- 
ways  Saiiiitorium  are  derived  from  Information 
received  from  Dr.  Rees  Pl>ilipps,tlie  medical  super- 
intendent. 


16 

3 

4 

0 

i=i 

0 

15 

6 

0 

II 

II 

0 

7 

10 

-8 

2 

eturn) 

^9 

II 

17 

10 

13 

7 

0 

7 

ing,  repairs,  rates  and  taxes)  is  as  fol- 
lows : 

£  «•   'I- 

Bethlem  Royal  Hospital .         .  .1120 

Kethel  Hospital,  Norwich         .  .     o 

St.  Luke's  Hosi)ital  .         .  .1 

AVonford  House,  l'2xeter  .  .  .1 

The  Retreat,  York  .  .         .  .1 

York  Lunatic  Hospital    .         .  .1 

Nottiui;ham  Lunatic  Hospital  .      i 

AVarneford  Asylum,  Oxford    .  .     i 

Lincoln  Lunatic  Hospital         .  .1 
Alanchcster  Royal  Lunatic  Hospital  {no  1 

IJarnwood  House     ...  .1 
.St.  Andrew's  Hospital,  Northampton     i 

Coton  Hill,  Stafford         .         .  .      i 

Holloway  Sanatorium      .         .  .2 

The  foregoing  institutions  for  the  insane 
form  a  complete  list  of  Registered  Hospitals. 
There  are  also  registered  under  "  The 
Idiots  Act,  1886,"'  the  Eastern  Counties 
Idiot  Asylum,  Essex  Hall,  Colchester, 
Essex;  the  Royal  Albert  Asylum  for 
Idiots,  Lancaster;  and  the  Asylum  for 
Idiots,  Earlswood,  Redhill,  Surrey. 
These  are  referred  to  at  pp.  551-552. 

There  are,  further,  the  military  and 
naval  hospitals,  not  included  under 
"  Registered "  hospitals,  namely,  the 
Royal  Military  Hospital,  Netley,  Hants, 
and  the  Royal  Naval  Hospital,  Yar- 
mouth, Norfolk. 

Lastly,  there  is  the  State  Criminal 
Asylum,  Broadmoor,  Crowthorne,  Berks, 
which,  like  the  military  and  naval  hos- 
pitals, stands  apart  from  the  hospitals 
which  are  called  "  Registered."  It  was 
erected  in  1863  in  conformity  with  the 
Act  23  &  24  Vic.  c.  75,  entitled  "to  make 
better  provision  for  the  Custody  and  Care 
of  Criminal  Lunatics,"  passed  in  i860. 
This  is  a  most  important  and  successful 
institution,  and  has  been  and  is  under 
excellent  management.  For  a  somewhat 
detailed  account  of  this  asylum,  the 
editor  may  refer  to  "  Chapters  in  the  His- 
tory of  the  Insane  in  the  British  Isles," 
1882,  pp.  265-284.  The  Editor. 

REXAPSSS.     {See  Statistics.) 

REIiZGIOM',  Relations  of,  to  Zir- 
SAirXTY. — Religion  may  be  defined  for 
present  purposes  as  the  relations  of  man 
to  a  supernatural  being  or  beings,  rightly 
or  wrongly  believed  to  exist.  The  connec- 
tions of  such  a  belief  with  insanity  are 
far-reaching  and  complicated  ;  they  will 
be  best  dealt  with  under  the  following 
heads.  Religion  may,  on  the  one  hand, 
produce  unsoundness  of  mind,  or,  on 
the  contrary,  hinder  its  development; 
secondly,  it  may  cause  certain  symptoms 
of  insanity,  or  modify  them  ;  finally,  it 
may  be  employed  as  a  means  of  moral 
prevention  and  treatment. 

(i)  Like  all  the  so-called  moral  causes 
of  insanity,  the  influence  of  religion  can 


Religion 


[     1089    ] 


Religion 


hardly  be  stated  with  accuracy.  Statistics 
are  of  little  use,  for  countries  which  differ 
as  to  religion,  differ  also  in  those  other 
conditions  of  civilisation  which  are  potent 
factors  in  the  causation  of  imsoundness 
of  mind.  This  would  obviously  be  the 
case,  if  figures  were  equally  available  for 
study  in  Mahomniedan  and  heathen 
nations  as  in  Europe.  Even  such  scanty 
means  of  comparison  as  asylum  statistics 
in  Turkey  and  Egypt  afford  are  rendered 
of  no  avail,  by  the  much  smaller  number  of 
the  insane  placed  under  confinement  in 
those  lands  than  in  Christendom.  Any 
comparison  between  Christian  countries 
of  different  faith  is  liable  to  similar  falla- 
cies. Schiile,  for  instance,  points  out  that 
the  relative  preponderance  of  Protestant 
over  Catholic  admissions  into  lUenau  is 
probably  due  to  the  fact  that  the  former 
are  proportionately  more  numerous  in  the 
towns,  the  rural  population  being  mainly 
Catholic.  One  inference  only  seems  to  us 
deducible  from  statistical  tables  of  the 
relative  proportion  of  insanity  among 
Catholics,  Protestants,  and  Jews,  in  some 
of  the  German  provinces,  Switzerland, 
and  Denmark.  The  religion  of  the  ma- 
jority of  each  nation  or  district  will  be 
found  to  contribute  relatively  more  persons 
to  the  ranks  of  the  insane  than  the  religion 
of  the  minority ;  a  resiilt  which  may  be 
naturally  accounted  for  by  observing  that 
the  minority  usually  belong  to  a  higher 
social  stratum  than  the  majority  of  the 
population.  But  in  the  case  of  very  small 
religious  bodies,  such  as  the  Mennonites 
and  Jews  in  Germany,  this  rule  is  reversed, 
and  insanity  is  more  frequent  propor- 
tionately among  their  members,  owing 
apparently  to  the  influence  of  consan- 
guineous marriages. 

If  we  leave  statistics,  and  consider  the 
matter  a  priori,  it  would  at  first  sight 
seem  as  if  the  effect  of  religion  must  be 
■exclusively  beneficial,  and  have  consider- 
able influence  in  preventing  insanity.  The 
precept,  "  Walk  before  me,  and  be  per- 
fect," which  stands  at  the  origin  of  all  the 
monotheistic  religions  of  the  world,  con- 
tains explicitly  or  implicitly  every  moral 
■element  which  could  be  appealed  to  for 
such  a  purpose.  The  consciousness  of 
responsibility  in  the  presence  of  an  all- 
seeing  judge  will  restrain  the  passions, 
and  urge  to  wholesome  industry,  with 
a  sanction  that  no  less  far-reaching  belief 
can  equal ;  the  sense  that  he  can  always 
turn  to  an  ever-present  father  and  friend 
should  give  to  one  who  leans  upon  his  God 
aconstant  support  in  the  loneliest  and  most 
sorely  tried  life  ;  lastly,  to  the  Christian 
the  example  of  his  Master,  who  chose  a 
life  of  poverty,  ending  in  ignominy  and 


apparent  failure,  is  the  surest  comfort  in 
the  troubles  and  disappointments  which 
must  be  the  lot  of  all. 

We  believe  this  estimate  of  the  influence 
of  religion  is  the  true  one,  and  that  every 
religion,  however  widely  it  may  differ 
from  our  standard  of  the  truth,  if  it  en- 
forces the  precepts  of  morality,  is  a  source 
of  strength  to  the  sound  mind  that  sin- 
cerely accepts  it.  An  agent  which  can 
effect  so  much  good  must,  however,  be 
equally  potent  for  harm.  The  mind  on 
which  religion  acts  may  be  abnormal,  in 
which  case  it  is  not  wonderful,  as  an  old 
author  puts  it,  "  that  the  light  should  be 
painful  to  sick  eyes,  which  to  healthy  ones 
is  delightful."  Or  the  fault  may  lie  in 
the  application  of  religion,  like  a  drug 
which  can  save  lif(;,  but  is  equally  able  to 
destroy  it,  if  given  inopportunely  or  ex- 
cessively. For  the  characters  of  religion 
which  we  have  just  enumerated  may  all 
be  exaggerated  into  potent  causes  of  in- 
sanity. The  sense  of  responsibility  to 
omniscient  justice  may  pass  into  a  belief 
in  condemnation  irrevocable  and  inevit- 
able ;  the  habit  of  communing  with  God 
may  easily  grow  into  self-contemplation 
and  ecstasy ;  the  repression  of  the  lower 
part  of  human  nature  may  be  strained 
into  practices  ruinous  to  health  of  mind 
and  body.  The  common  factor  in  all  these 
exaggerations  is  fdnaticisni,  which  looks 
only  at  one  side  of  religion,  and  commits 
the  fallacy  of  supposing  that  the  depend- 
ence of  man  upon  a  higher  being  must 
supersede  all  those  other  duties  which, 
on  the  contrai'y,  derive  therefrom  their 
greatest  sanction.  As  one  of  the  natural 
growths  of  an  ill-balanced  mind, fanaticism 
is  closely  akin  to  the  other  manifestations 
of  the  insane  temperament ;  and  this  ac- 
counts for  the  fanatical  habit  of  mind 
that  is  so  often  associated  with  the  here- 
ditary neuroses,  above  all  with  epilepsy. 
Overstrained  and  one-sided  religious  views 
are,  however,  not  so  often  the  primary 
cause  of  an  attack  of  insanity,  as  its  first 
symptoms,  though  symptoms  which  in 
turn  act  as  causes  of  further  evil  and 
intensify  the  disease.  For  instance,  an 
endeavour  to  study  the  mystery  of  exist- 
ence and  solve  the  problem  of  evil  has 
been  rightly  denounced  as  highly  danger- 
ous to  mental  health ;  yet  it  is  recognised 
as  an  early  symptom  ("  Griibelsucht ")  of 
an  otherwise  deranged  mind.  Or  again, 
a  case  of  melancholia  in  which  religious 
delusions  seem  at  first  sight  to  have  been 
the  cause  of  all  the  troubles,  will  be  found, 
if  traced  from  the  beginning,  to  have 
originated  in  disordered  bodily  health. 

But   the   influence   of    religion   as    an 
exciting  cause   of  insanity  is   far   more 


Religion 


[    1090    ] 


Religion 


important  in  its  action  on  masses  of  men 
than  on  individuals.  Religious  excite- 
ment, culmiuating  in  insanity,  prevailed 
endemicall}'  about  the  chief  shrines  of 
heathen  antiquit}-,  and  among  the  wor- 
shippers of  C3-bele  and  Bacchus,  and  still 
continues  among  the  dervishes  and  fakirs 
of  Eastern  countries.  In  all  Christian 
communities  epidemics  of  the  same  kind, 
of  varying  gravitj'  and  extent,  have  from 
time  to  time  occurred,  such  as  the  Flagel- 
lants of  the  middle  ages,  the  Camisards 
and  Convulsionnaires  of  France  in  the 
last  century,  and  the  Revivalists  of  Ireland 
and  America  almost  in  our  own  days.  The 
last  is  particularly  interesting,  because  its 
characters  can  be  studied  in  the  excellent 
description  given  by  Archdeacon  Stopford 
("The  Work  and  the  Counter-Work," 
Dublin,  1859).  He  considered  all  the 
cases  of  morbid  religious  excitement  in 
Belfast  as  "  clearlj^  and  unmistakably 
hysterical  " ;  but  he  tells  us  that  physi- 
cians recognised  characters  difiering  from 
the  ordinary  type  of  hysteria.  The  pro- 
portion of  what  we  should  now  term 
hystero-epilepsy  and  of  catalepsy  seems 
to  have  been  considerable,  and  on  a  very 
brief  and  limited  inquiry  he  met  with 
more  than  twenty  cases  of  positive  insa- 
nity of  an  hysterical  kind,  and  usually 
with  erotic  symptoms.  The  main  point  of 
medical  interest  appears  to  be  that  these 
cases  of  insanity  are  developed  out  of,  and 
among,  a  much  larger  number  of  neuroses 
of  vaguer  character.  We  are  able  to  con- 
firm this  by  our  own  observation,  happily 
on  a  very  small  scale,  of  the  fanatical 
excitement  of  an  obscure  sect — "  the  Army 
of  the  Lord  " — where,  we  believe,  only  two 
cases  of  insanity  occurred  out  of  many 
hysterical  ones.  It  is  remarkable  that 
Stopford  was  informed  by  an  American 
ahenist,  that  one  revival  in  the  United 
States  had  been  free  from  any  instances 
of  these  evil  results,  which  were  so  common 
on  other  occasions  ;  and  it  is  even  more 
striking  that  we  have  so  very  little  evidence 
of  insanity  amongthevast  audiences  which 
followed  the  great  preachers  of  the  middle 
ages,  or  Wesley  in  later  times.  Even 
Whitefield's  preaching  seems  to  have  been 
usually  free  from  any  such  manifestation, 
though  on  at  least  one  occasion  (at  Cam- 
buslang),  among  many  instances  of  bodily 
manifestations,  like  those  of  an  Irish 
revival,  some  cases  of  positive  insanity 
occurred.  It  is  clear  that  some  other 
factor  is  at  work  in  the  epidemics  we  have 
described,  besides  appeals,  however  im- 
passioned, to  the  conscience,  and  even  to 
the  emotions.  This  injurious  element 
appears  to  consist  in  encouraging  cries 
and    groans,    dancing,     contortions ;     in 


short,  bodily  manifestations  of  any  kind 
which  are  propagated  by  imitation.  Some 
further  light  is  thrown  on  these  religious 
epidemics  by  the  analogous  results  of  in- 
discriminate hypnotism,  as  practised  by 
non-i)rofessional  exhibitors,  which  have 
been  recorded  of  late  years,  insanity 
having  been  occasionally  evolved  among 
many  instances  of  somnambulism,  cata- 
lepsy, and  other  neurotic  states. 

(2)  We  need  not  dwell  at  any  length 
upon  the  influence  of  religion  in  produc- 
ing special  symptoms  of  insanity,  or  in 
modifying  those  caused  in  some  other 
manner.  It  will  be  obvious  that  a  delu- 
sion which  is  to  account  for  the  morbid 
feelings  of  a  lunatic,  must  be  constructed 
by  him  out  of  his  previous  beliefs  ;  and 
that  many  religious  delusions  must  there- 
fore be  confined  to  the  members  of  par- 
ticular religious  bodies.  It  may  not  be 
uninteresting  for  us  to  mention  as  an  ex- 
ample of  this,  that  we  have  only  met  with 
one  Catholic  "  unpardonable  sinner,"  a 
type  relatively  far  more  numerous  among 
other  melancholiacs  in  this  country.  For 
this  reason  it  is  often  difficult  to  fathom 
the  delusions  of  persons  whose  religion  is 
unfamiliar  to  us ;  and  care  is  needed  lest 
we  set  down  to  insanity  what  may  be  due 
to  religious  convictions  or  practices  we  do 
not  understand.  The  religious  delusions 
of  the  insane  have  of  course  the  general 
characters  of  their  unsoundness  of  mind ; 
being  exalted  in  the  maniacal,  depressed 
in  melancholiacs,  inconsistent  and  wild  in 
general  paralytics,  and  systematised  in 
chronic  lunac)^  But  there  are  some 
varieties  of  religious  insanity  which  are 
uniform  and  chai-acteristic  enough  to  be 
typical.  Such  are  the  mixture  of  erotic 
and  religious  excitement  in  many  epilep- 
tics ;  the  simple  belief  in  perdition  common 
in  amenorrhoeal  melancholia ;  and  the 
manner  in  which  insane  masturbators 
will  assert  that  they  are  heroes  and 
martyrs,  under  some  special  dispensation 
of  Providence. 

(3)  The  way  in  which  religion  is  to  be 
employed  in  the  prevention  and  treatment 
of  insanity  may  be  deduced  from  what 
we  have  said  of  their  etiological  relations. 
If  we  can  control  the  education  of  children 
of  insane  temperament  and  unsound 
family  history,  the  religious  training 
should  not  be  neglected.  Such  chUdren 
are  naturally  attracted  by  the  emotional 
side  of  religion  ;  let  its  moral  aspect  be 
the  more  earnestly  pressed.  Above  all, 
we  should  constantly  urge  upon  them 
that  belief  in  a  higher  power  does  not  ex- 
clude duties  to  self  and  to  others,  but 
rather  invests  such  offices  with  a  higher 
motive  and  sanction.     Singularity  should 


Religious  Diseases 


C    1091    ] 


Religious  Insanity 


be  repressed  most  effectually  by  gentle 
ridicule  and  humour ;  and  wholesome 
activity  should  be  used  to  prevent  reverie 
and  self-conteni]il:ition. 

In  the  treiitmout  of  insanity,  religious 
influence  plays  an  important  part.  Like 
all  other  moral  treatment,  it  will  be 
generally  injurious  when  the  disease  is 
advancing  or  at  its  lieight ;  but  it  is  often 
raost  useful  when  improvement  has  once 
begun,  and  the  mind  is  seeking  for  sup- 
port. Much  may  oven  be  done  by  religion 
to  humanise  chronic  and  incurable  luna- 
tics, to  give  them  rational  interests  in 
life,  and  make  them  more  resigned  to 
fancied  grievances,  and  to  the  calamity 
which  has  overtaken  them.  The  main 
lines  of  management  will  here  be  the  same 
as  in  the  prevention  of  insanity  ;  but  they 
can  only  be  applied  successfully  by  one  of 
training  and  experience.  We  cannot  too 
earnestly  add  our  protest  to  those  of 
Griesinger  and  Maudsley  against  any  at- 
tempt to  wield  religious  influence  by  those 
who  have  not  been  completely  trained  to 
use  a  weapon  so  potent  for  good  or  ill. 
J.  II.  Gasijuet. 

REiiZCZous  DISEASES. — Diseases 
of  the  nervous  system  arising  from  excess 
of  religious  emotion.     (See  Convulsion- 

NAIRE.) 

REiiXGZOirs  ZN-SAM-XTV. — A  female 
patient  above  sixty  years  of  age,  at 
present  in  Bethlem  Hospital,  under  the 
care  of  Dr.  Percy  Smith,  is  an  excel- 
lent example  of  the  exalted  variety  of  re- 
ligious insanity — theomania.  She  asserts 
that  when  she  speaks  it  is  not  herself, 
but  God's  voice  which  is  heard.  She  says 
she  has  visions  from  God,  and  that  she 
is  in  the  hospital  simj^ly  for  the  purpose 
of  converting  the  inmates.  The  power  of 
the  devil  has  recently  ceased.  She  says 
she  could  not  be  happier,  and  is,  in  fact, 
in  a  state  of  ecstasy.  She  believes  that 
God  will  avenge  her  cause,  and  bring 
vengeance  upon  those  who  force  her  to  do 
anything  against  her  will.  This  patient 
labours  under  chronic  diabetes. 

Under  the  heads  of  Delusion  and  Me- 
lancholia, the  subject  of  Religious  Melan- 
choly, with  or  without  marked  delusions, 
has  already  been  treated.  Under  Demono- 
MANIA,  we  have  referred  to  theomania  and 
caco-demonomania.  It  is  necessary,  how- 
ever, to  describe  in  more  detail  the  extra- 
ordinary religious  aberrations  under  which 
a  number  of  insanepersons  labour,whether 
of  an  exalted  or  depressed  character.  Es- 
quirol  stated  (writing  in  1824)  that  indif- 
ference in  religion  had  become  so  great  in 
France  that  forms  of  insanity  caused  by 
religious  fanaticism  or  mysticism  were  no 
longer  observed,  or  at  least  had  almost 


entirely  disappeared.  Such  cannot  be 
said  to  be  the  case  at  the  present  day 
even  in  France  ;  much  less  does  it  apply 
to  Great  Britain  and  the  United  States. 
From  the  latter  country  we  have  a  very 
lucid  description  of  the  religious  delusions 
of  the  insane,  contributed  by  Prof".  Henry 
M.  Hurd,  M.D.,  who  read  a  paper  under 
this  title  at  the  International  Medical  Con- 
gress, held  at  Washington  in  1887.  We 
proceed  to  give  a  resimic  of  his  article. 

The  patient  may  either  have  the 
delusion  that  he  is  uuder  the  especial 
patronage  of  the  deity,  nay,  possibly, 
deity  itself  ;  or  the  very  reverse,  an  out- 
cast, the  object  of  the  wrath  of  God,  and 
altogether  too  wicked  to  obtain  His  mercy. 
Hence  there  are  to  be  found  in  asylums 
"  Gods,"  "  Messiahs,''  "  Kings  of  Kings," 
and  "  Loi'ds  of  Lords,"  while  at  the  other 
end  of  the  pole,  figure  "devils"  and  the  like. 

Religious  delusions  may  be  classified 
according  as  they  : — 

(1)  Accompany  the  IVIental  Develop- 
ment of  Over-stimulated  and  Injudi- 
ciously Educated  Children. — The  usual 
form  of  the  delusion  is  morbid  fear,  and 
when  the  youth  fails  to  derive  from  reli- 
gion the  emotional  satisfaction  which  he 
expects,  he  fancies  that  he  has  neglected 
some  religious  duty,  and  he  is  before  long 
overwhelmed  by  remorse  for  imaginary 
sins. 

(2)  Characterise  the  Insanity  of  Pu- 
bescence.— Here  the  mental  depression 
and  hebetude  which  so  frequently  occur 
at  this  age  occasion  the  fear  of  death  and 
future  punishment,  leading  to  the  desire 
to  perform  some  religious  act  either  as  a 
penance  or  as  the  means  of  procuring 
peace  of  mind  and  solace. 

(3)  Are  Caused  by  Self-abuse. — The 
patient  is  self-conscious  and  introspective; 
is  scrupulous  in  religious  observances; 
and  frequently  falls  into  the  delusion  that 
he  has  committed  the  unpardonable  sin. 
Mental  weakness  follows  in  a  considerable 
number  of  cases  ;  auditory  hallucinations, 
visions,  trances,  and  ecstasies  are  com- 
mon. Suicide  is  likely  to  take  the  form 
of  self-immolation,  immediately  connected 
with  religious  delusions.  Fearful  mutila- 
tion of  the  person  may  occur. 

(4)  Are  associated  with  (so-called) 
Paranoia. — Sexual  excitability  is  often 
associated  with  misapprehended  religious 
duty.  This  combination  in  a  neurotic 
subject  has  repeatedly  led  to  extravagant 
ideas  and  the  foundation  of  fanatical  sects. 
Johanna  Southcote  is  a  type  of  one 
variety.  Texts  of  Scrijjture  are  applied 
personally,  and  nothing  is  too  absurd  for 
adoption  under  the  guise  of  superior 
spirituality. 

4  A 


Religious  Insanity 


[    1092    ] 


Remittent  Insanity 


(5)  Are  associated  \(rith  Epilepsy, 
Dementia,    and     General    Paralysis. — 

Dr.  Hurd  denies  that  the  delusions  which 
accompany  epilepsy  are  generally  of  a 
religious  character,  and  holds  that  the 
religious  acts  to  which  they  are  certainly 
remarkably  prone  are  generally  the  result 
of  a  previous  religious  education,  and  are 
continued  from  force  of  habit  after  the 
development  of  mental  disease.  "  There  is 
never  or  rarely  any  sense  of  religious  fear 
or  unworthiuess,  but  rather  a  sense  of 
satisfaction  in  the  performance  of  religious 
duties Occasionally,  in  the  de- 
mentia which  follows  religious  melan- 
cholia, there  is  an  abiding,  habitual  sense 
of  religious  unworthiuess  and  sjiiritual 
deadness.  In  general  paralysis,  on  the 
other  hand,  there  may  be  extravagant  de- 
lusions of  religious  imi^ortance,  which 
closely  resemble  those  developed  in  acute 
or  chronic  mania,  and  are  due  to  the 
rapid  flow  of  ideas  through  the  brain, 
and  are  a  part  of  the  general  cerebral  ex- 
citement." 

(6)  Are  observed  in  I^elancholia 
and  Climacteric  Insanity. — The  enor- 
mous influence  of  certain  forms  of  religious 
training  must  be  taken  into  account. 
Delusions  of  unworthiness  are  frequently 
only  the  crystallised  form  of  the  tenets 
which  have  been  inculcated  from  child- 
hood. It  is  but  too  true  that  the  mental 
sufferings  of  the  religious  melancholiac 
exceed  in  intensity,  by  a  long  way,  those 
of  the  other  forms  of  mental  disease.  He 
is  in  the  peculiar  condition  of  believing 
that  he  merits  all  the  tortures  he  endures, 
and  that  it  will  be  redoubled,  and  justly 
so,  in  the  world  to  come.  In  unison  with 
the  amazing  inconsistency  which  charac- 
terises the  lunatic,  he  frequently  antici- 
pates the  awful  suff'erings  of  limitless 
duration  by  terminating  his  life. 

(7)  Arise  in  Chronic  Mania,  or  Toxic 
Insanity. — These  delusions  are  usually  of 
an  exalted  character.  They  are  not  al- 
ways developed  in  persons  of  religious 
antecedents,  even  when  assuming  a  devo- 
tional form.  Assumptions  of  religious 
superiority  are  not  felt  by  such  patients 
to  be  incongruous.  Again,  a  patient  be- 
lieves that  he  must  expiate  his  sins  on  the 
Cross.  Another  hears  the  Almighty's 
voice  commanding  him  to  do  this  or  that, 
and  he  may  succeed  in  deluding  many 
others  as  well  as  himself. 

Course  and  Determination  of  Re- 
ligrious  Delusions. — As  they  are  fre- 
quently associated  with  the  insanity  of 
pubescence,  the  study  of  developmental 
insanities  (q.v.)  bears  esj^ecially  upon  the 
subject  of  this  article.  "  The  religious  de- 
lusions    which     accompany    masturbatic 


insanity  are  not  necessarily  incurable. 
They  are,  however,  liable  to  become  per- 
sistent, and  are  not  readily  amenable  to 
treatment.  They  may  be  considered  in- 
curable whenever  the  patient  has  reached 
the  stage  of  religious  extravagance,  which 
is  surely  indicative  of  mental  deteriora- 
tion. The  religious  delusions  of  paranoia 
are  essentially  incurable,  being  the  legiti- 
mate development  of  a  mental  '  twist,' 
and  the  outgrowth  of  an  abnormal  per- 
sonality. They  eventually  become 
thoroughly  assimilated  by  the  mind  and 
integral  part  of  its  constitution.  During 
the  stage  of  persecution  they  may  at  times 
pass  from  the  mind,  btit  after  the  stage  of 
transformation  they  cannot.  The  reli- 
gious delusions  of  epilepsy,  general  para- 
lysis, chronic  mania,  alcoholic  and  toxic 
insanity  require  little  special  mention. 
They  are  the  debris  of  decay,  and  the 
broken  fragments  of  a  hopeless  wreck. 
The  religious  delusions  of  melancholia  are 
more  curable.  They  mark  deep-seated 
disease,  but  the  prognosis  is  not  hopeless." 
{Joe.  cit.)  The  Editor. 

REIVKITTEM'T  ISrSANITV  OCCurs 
when  there  is  a  distinct  remission  of  the 
symptoms  followed  by  a  i^eriod  of  exacer- 
bation. Such  alternate  jjeriods  of  abey- 
ance or  cessation  of  the  malady  and  re- 
lapse are  frequently  observed  in  general 
paralysis.  Esquirol  says,  "I  have  often 
seen  during  the  first  month  after  the 
commencement  of  the  attack,  a  very 
marked  remission  take  place,  after  wliich 
the  disorder  returns  with  increased  inten- 
sity "  ("  Maladies  mentales,"  vol.  i.  p.  42). 
"  Melancholia  is  much  more  frequently 
remittent  than  continuous  or  intermittent, 
and  there  are  very  few  labouring  under 
this  form  of  insanity  who  are  not  worse 
every  other  day ;  some  enjoy  a  marked 
remission  every  evening  and  after  dinner, 
while  some  are  worse  on  waking  from 
sleep  in  the  morning''  (p.  439).  Again 
he  says  :  '"  Kemittent  insanity  offers  some 
very  remarkable  anomalies,  either  in  its 
character  or  in  the  duration  of  the  remis- 
sion. In  some  cases  it  is  only  the  tran- 
sition or  transformation  from  one  form  of 
mental  disorder  to  another  ;  thus  a  patient 
passes  three  months  as  a  melancholiac, 
the  three  following  months  as  a  maniac, 
and  lastl}^,  about  four  mouths  as  a  de- 
ment, and  this  successively,  sometimes  in 
a  regular  manner ;  but  others  with  great 
variation.  A  lady,  aged  fifty-two,  is 
melancholy  for  one  year,  and  mania- 
cal and  hysterical  for  another  year.  In 
other  instances  the  remission  only  pre- 
sents a  sensible  diminution  of  the  symp- 
toms of  the  same  form  of  insanity  "  (p. 
78). 


Renal  Affections 


[     1093 


Rheumatic  Fever 


ilFFECTIOirS    Ain>     ZKT- 

(^e   Bkigut's    Disease   and 


REXrAIi 
SATTZTY. 

DiAHETKS.) 

RESISTIVE       MEIii\.KrCHOI.IA.  — 

The  marked  feature  of  many  cases  of 
melancholia  is  the  extreme  resistance  to 
an3'thing  the  patient  is  wished  to  do.  Its 
chief  importance  is  in  connection  with 
feeding  ((/.r.). 

RESPON'SIBII.ITY.  {See  Ceiminal 
Respoxsibilitv.) 

RE  STR  AIN'T.  {See  Historical 
Sketch  of  the  Ixsaxe,  and  Tkeatjient.) 
RETISriTZS  PARAIiYTICA.  —  An 
abnormality  of  the  retina  described  by 
Klein,  and  chietly  found  in  general 
paralytics.  {See  Eye  Symi'tojis  in  In- 
sanity.) 

REVERIE. — When  the  controlling 
power  of  the  will  over  the  thoughts  and 
feelings  is  removed,  the  sequence  of  ideas 
depends  either  on  new  sensorial  impres- 
sions or  on  subjective  suggestions,  the 
result  of  previous  states  of  ideation.  In 
the  latter  case,  which  is  the  condition  of 
reverie,  the  attention  is  so  engrossed  that 
objective  stimuli  make  no  impression  on 
the  mind  unless  strong  enough  to  enforce 
attention.     (Pr.  reverie.) 

RHABSOMAirTIA  (pdjihos,  a  rod  ; 
fiavTela,  a  prophesying).  Term  for  the 
supposed  manifestations  derived  from  the 
use  of  the  divining  rod.  The  art  is  allied 
to  that  of  clairvoyance,  &c.  (Fr.  rhabdo- 
mantie.) 

RHACHIASIMCUS  (pa'xis-,  the  spine). 
Dr.  M.  Hall  gave  this  name  to  the  spas- 
modic action  of  the  muscles  at  the  back  of 
the  neck,  which  occurs  early  in  epilepsy. 
(Fr.  rliacliias)ne.) 

RHE1VIBASI«1US  (/3«>/3co,  I  wander 
about,  or  am  distracted).  Has  been  used 
for  a  wandering  state  of  mind,  and  for 
somnimbulism.     (Fr.  rliemhasme.) 

RHEUMATIC  FEVER  AND  IM-SAN- 
ITY. — Though  there  are  some  grounds 
for  believing  that  rheumatic  fever  may 
depend  on  or  be  associated  with  changes 
in  the  nervous  system,  it  cannot  be  con- 
sidered to  be  a  neurosis  ;  yet  there  are 
some  very  distinct  relationships  between 
acute  rheumatism  and  mental  disorder.  On 
several  occasions  we  have  met  with  marked 
moral  changes  in  patients  after  recovery 
from  rheiamatic  fever.  This  may  occur  in 
patients  who  have  had  high  fever  and  de- 
lirium ;  in  those  who  have  had  heart  com- 
plications, or  in  those  in  whom  the  disease 
appeared  to  have  run  a  simple  and  un- 
complicated course. 

We  believe  it  is  most  common  in  those 
who  have  suffered  with  delirium,  and  that 
it  is  in  fact  the  direct  result  of  some 
brain  affection.  Symptoms  may  vary  from 


slight  moral  change  to  well-markedj  men- 
tal disorder. 

We  have  met  with  several  patients, 
mostly  women,  who  have  ceased  to  per- 
form their  domestic  duties,  and  have  caused 
family  discord  in  consequence  of  their 
changed  habits,  the  industrious  mother 
becoming  indolent  and  negligent  of  her 
duties.  It  is  certain,  too,  that  soraepersous 
who  before  rheumatic  fever  were  sober  and 
truthful,  after  it  became  intemperate  and 
untruthful.  In  some  the  chief  symptom  is 
either  forgetfulness  or  neglect  of  simple 
and  necessary  work,  so  that  the  patients 
lose  their  situations  and  lie  in  bed. 

There  may  be  loss  of  interest,  loss  of 
will  power,  loss  of  affection  on  the  one 
hand,  and  loss  of  control  with  moral  de- 
fect on  the  other.  This  partial  mental 
weakness  may  be  temporary  or  may  be 
permanent,  not  leading  to  any  progressive 
degradation,  but  leaving  the  patient  men- 
tally crij^pled  for  life. 

In  some  cases  mental  disorder  has  fol- 
lowed the  heart  disease  so  common  in 
rheumatic  fever,  and  though  in  our  expe- 
rience melancholic  conditions  have  been 
the  most  common,  yet  we  have  met  with 
several  cases  of  acute  mania  in  which 
great  restlessness  and  excitement  have 
followed  close  on  endocarditis  or  peri- 
carditis. Dr.  Julius  Mickle  has  fully 
studied  the  relationship  of  insanity  to 
heart  disease  in  his  Gulstoniau  Lectures. 
In  the  next  place,  we  will  refer  to  the 
so-called  cases  of  metastasis  to  the  brain, 
during  the  course  of  rheumatic  fever;  seri- 
ous delirium  may  appear,  and  at  the  same 
time  the  joint  affection  may  disappear  ;  in 
these  cases  there  generally  is  great  increase 
of  temperature;  the  delirium  and  the  rapid 
exhaustion  resemble  in  many  particulars 
acute  delirious  mania,  and  both  diseases 
often  end  fatally ;  but  the  rheumatic  dis- 
ease is  generally  associated  with  a  much 
higher  temperature  than  that  met  with  in 
acute  delirious  mania,  in  which  the  tem- 
perature rarely  rises  above  103°. 

The  alternation  between  the  brain  affec- 
tion and  the  joint  affection  is  noteworthy, 
as  in  the  cases  to  be  considered  later  this 
alternation  is  the  essential  symptom.  After 
the  acute  delirious  stage  of  rheumatic  fever 
true  delirious  mania  may  arise,  or  more 
or  less  well-marked  attacks  of  insanity 
may  follow,  or  a  period  of  partial  weak- 
mindedness  very  similar  to  that  met  with 
after  continued  fevers  may  be  present, 
the  rheumatic  fever  starting  mental 
disorder  which  does  not  pass  off  with  the 
rheumatic  symptom. 

In  some  cases  a  true  alternation  be- 
tween rheumatic  fever  and  mental  disor- 
der occurs;  for  example,  a  patient  suSering 


B-hinolerema 


[     1094    ]    Royal  Asylums  in  Scotland 


from  an  ordinary  attack  of  rheumatic 
fever  suddenly  loses  all  joint  affection 
and  becomes  maniacal.  Such  alternations 
have  in  our  experience  been  more  com- 
mon among  women  than  among  men,  and 
do  not  seem  to  be  specially  related  to 
neurotic  heredity. 

The  alternations  may  follow  any  of  the 
forms  of  treatment,  and  do  not  depend  on 
the  medication.  A  patient  may  suddenly 
become  maniacal,  and  the  mania  may  run 
a  course  of  several  months,  and  may  pass 
off  without  any  special  complication,  but 
as  a  rule  there  is  almost  always  a  return 
of  the  rheumatic  fever  before  the  recovery. 
In  one  case  we  have  seen  two  well  marked 
recurrences  of  the  rheumatic  fever  alter- 
nating with  two  attacks  of  mania,  in  the 
end  subacute  rheumatism  coming  on  before 
mental  convalescence.  Melancholia,  or 
any  other  form  of  mental  disorder  may 
alternate  with  rheumatic  fever,  but  we  be- 
lieve mania  to  be  much  the  more  common. 

Nearly  all  such  cases  recover. 

No  special  form  of  treatment  directed 
to  the  rheumatic  state  seems  in  any  way 
to  afPect  the  mental  disorder.  In  some  cases 
of  insanity  with  the  on  set  of  rheumatic  fever 
the  mental  symptoms  may  pass  off  either 
for  a  time  or  permanently.  Only  for  a 
time  if  the  insanity  belong  to  the  chronic  or 
degenerative  types,  and  more  permanently 
if  it  occur  in  patients  already  improving 
from  acute  mental  disorders. 

GrEo.  H.  Savage. 

RHZNTOIiEREMA,   RHIN-OI.ERESIS 

{pis  (pivus),  the  nose;  Xrjprjpa,  Xijpricns,  a 
silly  action  or  saying).  Terms  tor  "  de- 
lirium nasi "  or  depraved  sense  of  smell. 
(Fr.  rhinolereme ;  Ger.  Deliriuin  cier 
Nase.) 

RIBS,  FRACTURES  OP. — In  former 
days  when  there  was  much  scandal  in 
connection  with  the  management  of 
lunatic  asylums,  fractures  of  the  ribs  were 
often  heard  of ;  in  the  present  day  such 
occurrences  are  infrequent.  It  is  stated 
by  some  authorities  that  owing  to  nutri- 
tive changes  the  bones  are  more  brittle  in 
the  insane  than  in  healthy  individuals ; 
the  ribs  are  also  so  exposed  to  violence 
when  force  has  to  be  used,  that  fractures 
of  those  bones  ai'e  more  common  among 
the  insane  than  among  healthy  indi- 
viduals.    (See  Bone  Degeneration.) 

RIGIBITY.— In  psychological  medi- 
cine rigidity  of  limbs  is  met  with  most 
often  in  cataleps}'  and  hysteria  {g.r.). 
There  is  also  a  general  rigidity  in  melan- 
cholia with  stupor.  Rigidity  is  also  ob- 
served in  paralytic  idiocy  and  insanity, 
and  sometimes  the  early  and  late  rigidity 
in  hemiplegia  is  complicated  with  mental 
disorder. 


RISVS  SARDOiricus  (risus,  a  laugh; 
sardonicus,  connected  with  the  herb  sardo- 
nia,  which  was  said  to  draw  up  the  fea- 
tures of  the  eater).  A  distortion  of  the 
features,  said  to  resemble  a  grin,  caused 
by  spasm  of  the  muscles  of  the  face.  It  is 
observed  in  tetanus.  The  unilateral  form 
has  been  observed  in  hysteria  (q.v.). 

ROYAI.  ASYI.VIVIS  ZM"  SCOT- 
ItAKm. — These  institutions  were  founded 
by  the  exertions  and  benevolence  of  pri- 
vate individuals,  before  legislative  enact- 
ments compelled  the  erection  of  asylums 
for  pauper  lunatics.  They  are  also  called 
"  Chartered  Asylums,"  because  each  has 
a  Royal  Charter  of  Incorporation.  Prior 
to  the  Lunacy  Act  (Scotland,  1857),  all 
these  establishments  i-eceived  pauper  as 
well  as  private  patients  ;  but,  owing  to 
the  erection  of  District  (County)  Asylums, 
there  now  is  a  tendency  to  reserve  them, 
in  whole  or  in  jjart,  for  the  insane  of  the 
middle  classes.  It  has  been  felt  that  the 
charity  of  the  founders  should  not  form  a 
grant  in  aid  of  the  ratepayers,  to  relieve 
them  of  the  obligations  imposed  by  the  law. 

The  Royal  Asylums  are  seven  in  num- 
ber, and  were  all  opened  about  the  be- 
ginning of  the  century.  The  oldest  is  at 
Montrose,  where  action  was  first  taken  in 
1779.  I^  '"'^s  built  on  the  Links  near  the 
town  in  1781.  The  death  of  the  poet 
Ferguson  (1774),  in  deplorable  circum- 
stances in  the  "  City  Bedlam,"  of  Edin- 
bui'gb,  moved  Dr.  Andrew  Duncan  to 
persist  for  more  than  a  quarter  of  a 
century  in  advocating  the  erection  of  an 
asylum  for  the  insane,  specially  for  such 
as  belonged  to  the  cultured  classes,  and 
those  who  were  in  straitened  circum- 
stances. 

After  years  of  unsuccessful  effort,  the 
Edinburgh  Royal  Asylum  was  at  length 
opened  in  18 13,  for  patients  who  were  able 
to  pay  for  the  accommodation  afforded. 
In  1806  only  ^223  had  been  subscribed, 
but  a  grant  of  ^^2000  was  obtained  from 
Government;  and  it  is  noteworthy  that 
this  was  the  only  aid  given  by  the  Govern- 
ment to  these  asylums.  However,  the 
money  so  obtained  was  spent  in  purchas- 
ing ground  at  Morningside,  and  voluntary 
contributions  enabled  the  managers  to 
build  the  East  House  as  above  stated.  In 
1842,  the  West  House  was  opened  for  the 
reception  of  pauper  patients  belonging  to 
Edinburgh  ;  and  the  history  of  the  insti- 
tution, designed  as  a  }iafio)ial  churity, 
and  conducted  successfull}^  to  its  present 
eminence,  can  best  be  followed  by  pernsal 
of  an  interesting  memorandum  bj'  Sir 
Arthur  Mitchell,  K.C.B.,  published  in 
the  Twenty-fifth  Report  of  the  Commis- 
sioners in  Lunacy  for  Scotland. 


Royal  Asylums  in  Scotland    [     1095     ]    Royal  Asylums  in  Scotland 


Of  the  seven  Royal  Asylums,  five  wei'e 
built  by  public  subscription,  and  two  were 
endowed  out  of  funds  left  for  charitable 
purposes.  There  is  reason  to  believe  that 
no  country,  proportionately  to  its  popu- 
lation, has  voluntarily  done  so  much  for 
the  care  of  the  insane,  durint:^  the  period 
in  which  laws  were  chaotic  on  the  subject. 
It  is  to  be  regretted  that  the  benevolence 
towards  this  class  of  sufferers  which 
marked  the  early  years  of  the  present 
century  should  have  diminished  with  its 
progress;  and  it  is  to  be  hoped  that  the 
institutions  inherited  from  that  time  will 
yet  provide  for  the  accommodation  of  all 
the  private  patients  for  whom  only  low 
rates  of  board  can  be  paid.  There  is  at 
present  a  marked  effort  being  made  to 
compass  this  end.  Thirty  years  ago  the 
directors  of  Murray's  Eoyal  Asylum  at 
Perth,  decided  that  it  would  be  contrary 
to  the  constitution  of  the  institution  to 
receive  paupers  ;  while,  at  the  same  time, 
they  were  empowered  to  receive  local 
patients  not  belonging  to  that  class  at 
such  unremunerative  rates  as  they  thought 
fit.  Lately,  the  Glasgow  Royal  Asylum 
has  been  similarly  set  apart  for  the  admis- 
sion of  private  patients  only ;  and  the 
Royal  Edinburgh  Asylum,  after  a  full  and 
impartial  legal  inquiry,  has  been  freed 
from  the  incubus  of  maintaining  pauper 
patients  for  less  than  they  cost. 

In  1855  it  was  found  that  the  total 
capital  expenditure  made  by  the  several 
chartered  asylums  for  laud,  buildings,  and 
furniture  amounted  to  ^SS^fij'^-  That 
figure  has  been  steadily  increased  year 
by  year,  mainly  out  of  surplus  revenue, 
derived  from  the  profits  on  keeping  the 
richer  class  of  patients,  until  the  total 
sum  now  stands  at  ^929,473.  This  is 
exclusive  of  the  new  houses  at  Morning- 
side  and  the  extension  at  Abei'deen,  which 
are  expected  to  cost  £80,000  and  ^50,000 
respectively. 

The  Elgin  District  Asylum  was  also 
built  in  a  remarkably  public-spirited 
manner.  Although  it  does  not  rank  as  a 
Royal  Asylum,  it  was  built  before  the 
passing  of  the  Lunacy  Act  of  1857,  on 
ground  given  by  the  Trustees  of  (J  ray's 
Hospital,  the  county  agreeing  to  a  volun- 
tary assessment  to  defray  the  expense  of 
the  building.     It  was  opened  in  the  year 

1835- 

It  should  also  be  noted  that  prior  to 
1855  great  exertions  were  made  to  erect 
an  asylum  at  Inverness,  and  subscriptions 
were  obtained  to  the  amount  of  ^5000. 
In  consequence  of  the  prospect  of  the 
provision  of  district  asylums,  however,  the 
money  was  ultimately  returned  to  the 
subscribers. 


On  reviewing  the  present  position  of  the 
Royal  Asylums  it  may  be  stated  that  they 
generally  fulfil  their  important  functions 
with  success.  "  They  are  distributed  over 
the  counti'y  so  as  to  make  them  fairly 
convenient,  as  regards  locality,  for  supply- 
ing the  accommodation  required."  That 
they  command  the  coutidence  of  the  public 
is  evident  by  these  figures  : — In  1857  there 
were  652  private  patients  in  Royal  Asy- 
lums and  231  in  licensed  houses  (called 
in  Scotla.nd  private  asylums).  In  1890 
there  were  1402  in  Royal  Asyhims  and 
152  in  licensed  houses.  The  private 
asylums  of  Scotland  ai-e  now  retained  for 
the  higher  classes ;  and  those  which  for- 
merly received  patients  at  low  rates  are 
practically  extinct.  It  yet  remains  for 
the  Royal  Asylums  to  provide  for  the 
accommodation  of  all  the  indigent  private 
insane,  and  to  obviate  the  necessity  of  sub- 
mitting those  who  can  only  pay  such  rates 
as  ^30  a  year  to  pauper  conditions.  This 
is  a  matter  for  public  consideration, 
which  should  be  placed  in  the  forefront  of 
lunacy  administration.  The  directors  or 
managers  of  the  Royal  Asylums  have  not 
only  a  trust  to  conserve,  but  are  also 
bound  to  enlarge  the  limitations  of  that 
trust  by  fostering  the  spirit  of  Scottish 
independence  in  avoiding  in  so  far  as  is 
possible  the  stigma  of  pauperism. 

From  what  has  been  said  above,  it  will 
be  evident  that  the  writer  entertains  an 
invincible  objection  to  0)11x6(1  asylums,  if 
by  that  term  it  be  understood  that  middle 
class  private  and  pauper  patients  live 
under  one  roof  and  use  recreation  grounds 
common  to  both.  There  are  indeed  valid 
arguments  in  favour  of  the  managers  of 
Royal  Asylums  undertaking  the  charge 
of  private  and  pauper  patients  in  sepa- 
rate buildings  and  separate  grounds  ;  and 
experience  has  pi'oved  that,  in  the  latest 
developments  of  asylum  administration, 
this  system  is  capable  of  the  best  results. 

Aberdeen. — Founded  in  connection  with 
the  infirmary,  under  the  same  managers  ; 
built  by  voluntary  contributions  ;  opened 
in  1800;  now  rebuilt,  and  disjoined  from 
the  infirmary,  which  had  been  unduly 
benefiting  by  the  joint  management ;  con- 
sists of  three  main  buildings: — (i)  The 
pauper  house,  containing  both  pauper  and 
private  patients  at  low  rates ;  (2)  The 
detached  establishment  for  private  pa- 
tients paying  over  ^60  per  annum ;  (3) 
An  estate  and  mansion  in  the  county, 
some  miles  away,  principally  occupied  by 
working  patients.  Extent  of  grounds, 
330  acres.  Accommodation  provided  for 
230  private  and  450  pauper  patients. 
The  charitable  area  of  the  institution  in- 
cludes Aberdeenshire.     Lowest  rates  for 


Royal  Asylums  in  Scotland    [     1096    ]    Royal  Asylums  in  Scotland 


paupers,  ;/^26 ;  for  private  patients,  ;^28 
per  annum.  Income  from  board  paid  by 
patients  assisted  by  a  small  charitable 
fund — total  _;/"20,5oo  in  1890.  Lectures 
on  mental  diseases  during  the  summer 
session  of  the  university. 

Dumfries. — The  Crichton  Eoyal  Insti- 
tution was  founded   by  the   widow    and 
other    trustees    of    the   late   Mr.   James 
Crichton,  of  Friars  Carse,  whose  name  it 
bears,  and   the   residue   of   whose  estate 
was  devoted  to  its  endowment.     Its  affairs 
are    administered   by   a  board   regulated 
by  their  Act    of  Incorporation,    4   Vict. 
3rd  July  1S40,  and  consisting  of  the  suc- 
cessors  of  the  original   trustees    of   Mr. 
Crichton,  and  of  noblemen  and  gentlemen 
holding  oiEcial  positions  in  the  county  of 
Dumfries,  whose  trusteeship  is  e.c  officio, 
and  five  elected  directors  holding  office  for 
a  term  of  three  years  each.     The  institu- 
tion was  opened  in   1839,  when  its  first 
house,  now  reserved   for  patients  of  the 
higher  class,  was  completed.     A  second 
house,  principally  devoted  to  jjatients  of 
an  intermediate  class,  was  opened  in  1849. 
This   house   also  accommodates  patients 
sent  by  the  parochial  boards  of  the  three 
southern  counties.     The  rates  of  board  for 
patients  in  the  first  house  range  from  an 
ordinary  minimum  of  ^70  upwards.     For 
patients    of    the    intermediate     class    in 
the    second    house    the    rates     are    from 
£2^    to  ^52   per    annum.      There    is    a 
charitable  fund  in  connection  with  both 
houses    of    the    institution    from    which 
grants   are   made    to   persons   in    strait- 
ened   circumstances     belonging     to     the 
three   southern    counties   to  assist   them 
in  maintaining  their  relatives,  inmates  of 
the  institution.  These  grants  vary  accord- 
ing to  circumstances  from  ^10  to  ^50  in 
each  case.     There  are  usually  about  fifty 
patients  on  this  fund  whose  rate  of  board 
is  thus  reduced  to  a  mei'ely  nominal  sum. 
Besides  the  first  and  second  houses  men- 
tioned above,  there  are  several  detached 
villas,  formerly  mansions,  on  neighbouring 
residential   properties   which    have    been 
purchased  by  the  institution.  The  grounds 
have   thus   been   extended  to  665    acres. 
The  accommodation   is    now   about   1000 
beds,  of  which  about  300  are  required  for 
the  pauper  lunatics  of  the  district,  leaving 
about  700  available  for  private  patients. 
Besides  the  purchase  of  land,  there  has 
been  expended  in  buildings  to  date  a  sum 
of    ;^ 1 30,000.      The    annual    revenue    is 
;^45,ooo. 

Dundee. — Founded  in  connection  with 
the  infirmary,  and  under  the  same 
managers,  in  1805.  Built  by  voluntary 
subscriptions  and  opened  in  1820.  Now 
disjoined  from  the  infirmary  and  rebuilt 


in  1882.  The  old  asylum  had  become  too 
small,  and  was  surrounded  by  the  town. 
Consists  of  one  modern  building  in  the 
country.  Extent  of  grounds  250  acres. 
Accommodation  provided  for  80  private, 
and  320  pauper  patients.  The  charitable 
area  of  the  institution  includes  the  coun- 
ties of  Forfar  and  Fife.  Lowest  rates  for 
paupers  ^28  I2.s.,  for  private  patients  £2^ 
per  annum.  Income  from  board  paid  by 
patients  ^11,700  per  annum. 

Edinburg-b. — Built  by  voluntary  con- 
tributions, aided  by  a  small  Government 
grant.  Opened  in  1813.  Managed  by  eaj 
officio  directors  and  a  medical  boai'd.  Con- 
sists of  three  main  buildings  : — 

(i)  The  East  House  for  private  patients 
at  an  ordinary  minimum  rate  of  ^{^84  per 
annum.  This  is  the  original  establish- 
ment, repeatedly  enlai'ged  and  altered. 
It  is  soon  to  be  replaced  by  a  new  building, 
now  in  process  of  construction,  on  a  newly 
purchased  estate  of  62  acres  lying  to  the 
west  of  the  old  asylum  property.  Great 
pains  have  been  taken  by  Mr.  Sydney 
Mitchell,  the  architect,  to  make  it  attrac- 
tive, cheerful,  and  devoid  of  any  prison- 
like characteristics ;  to  make  the  plan 
meet  all  modern  ideas  and  requirements. 
The  idea  underlying  tlie  design  of  this 
building  is  to  adapt  its  various  wards 
and  villas  to  the  varying  mental  condi- 
tion of  the  patients  who  are  to  inhabit 
it ;  from  the  padded  room  suitable  for  the 
deliriously  maniacal  patient,  to  the  attrac- 
tive separate  villa  suitable  to  the  quiet 
and  convalescent.  Every  eifort  has  been 
made  to  remove  the  hurtful  prejudice  of 
the  public  against  asylums,  by  making  this 
one  a  true  hospital  for  the  treatment 
of  this  special  disease  with  none  of  the 
repulsive  features  of  the  older  buildings. 

The  site  is  richly  wooded  with  old  tim- 
ber ;  part  of  it  is  on  Easter  Craiglockhart 
hill ;  the  views  include  some  of  the  finest 
near  Edinburgh.  The  design  provides  for 
central  building  with  four  wards  for  each 
sex,  with  private  parlours,  dining-rooms, 
drawing-rooms,  billiard-rooms,  library  and 
great  central  hall.  This  part  of  the 
asylum  will  accommodate  about  100 
patients,  who  will  consist  of  the  more 
recent,  dangerous,  troublesome  and  dirty 
class,  along  with  some  quietly  demented 
cases.  The  wards  occupy  the  ground  and 
first  floor,  while  the  second  floor  is  en- 
tirely occupied  by  bedrooms.  The  dif- 
ferent wards  are  differently  constructed  to 
suit  different  classes  of  patients.  On  the 
estate  at  various  distances  from  the  main 
building  there  are  six  villas,  two  of  which 
are  hospitals.  The  general  character  of 
these  villas  is  that  of  private  houses  for 
the   well-to-do   classes   of   society.      The 


Royal  Asylums  in  Scotland    [     1097    ] 


Running  Amuck 


head  of  each  is  to  be  an  educated  and 
responsible  official. 

(2)  The  West  House,  opened  in  1842, 
for  paupers  and  patients  at  low  rates  of 
board. 

(3)  Craig  House,  for  patients  of  the 
higher  classes,  purchased  in  1879.  Be- 
sides these,  several  smaller  villas  and 
cottages. 

Extent  of  grounds,  120  acres.  Accom- 
modation provided  for  344  private  and 
500  pauper  patients.  The  charitable  area 
of  the  asylum  includes  all  Scotland.  It 
is  a  national  institution.  Lowest  rates 
for  paupers,  ^31  ;  for  private  patients, 
^28  I  OS.  per  annum.  Income  from  board 
paid  by  patients  aided  by  charitable  funds 
(now  amounting  to  ^'15,600),  /,46,ooo 
per  annum.  Lectures  on  mental  diseases 
during  the  summer  session  of  the  univer- 
sity. 

Glasg-ow. — Founded  in  1 810.  Built  by 
voluntary  contributions  and  opened  in 
1 8 14.  Rebuilt  on  a  better  site  and  on  a 
more  extended  scale  in  1S42.  Under  the 
management  of  directors  representing  the 
subscribers  and  various  public  bodies  in 
the  city.  The  physician  superintendent 
is  also  a  director.  It  consists  of  two  main 
buildings.  The  building  called  the  East 
House  was  designed  for  pauper  patients, 
while  the  West  House  has  always  been 
reserved  for  the  higher  class  of  private 
patients.  For  nearly  two  years  no  paupers 
have  been  admitted,  and  those  now  re- 
sident are  only  retained  until  their  respec- 
tive parishes  can  remove  them  to  the 
rate-provided  asylums  at  jjreseut  being 
erected.  The  accommodation  thus  gained 
will  be  devoted  to  private  patients  at  the 
lowest  possible  rates  of  board.  Of  333 
private  patients,  resident  at  the  beginning 
of  1892,  III  pay  ^40  a  year,  and  34  pay 
/[30  a  year  or  less.  Extent  of  grounds 
66  acres.  Accommodation  will  be  pro- 
vided for  about  460  private  patients  by 
this  recent  arrangement.  The  charitable 
area  of  the  institution  has  no  limit,  but  is 
chiefly  exercised  in  the  West  of  Scotland. 
Lowest  rates  for  private  patients  ^30  per 
annum,  and  less  in  exceptional  cases. 
Income  from  board  paid  by  patients, 
^28,000  per  annum.  No  endowment. 
Lectures  on  mental  diseases  during  the 
summer  session  of  the  university. 

Montrose.  —  Founded  in  connection 
with  the  infirmary  ;  but  with  the  infirmary 
and  dispensary  subsidiary  to  the  asylwni. 
The  infirmary  continues  to  benefit  by  this 
long-continued  connection.  Built  by  vo- 
luntary subscription.  Opened  in  1782. 
Rebuilt  in  the  counti-y  in  1857.  The  mana- 
gers, fifty  in  number,  are  self-elected,  with 
a  few  ex  officio.    The  asylum  consists  of 


three  main  buildings,  (i)  The  main  asy- 
lum containing  patients  at  moderate  rates 
of  board.  (2)  The  hospital,  opened  in  1891, 
for  sick  and  infirm  cases.  (3)  A  separate 
villa  for  ladies  at  the  higher  rates.  Extent 
of  grounds,  270  acres.  Accommodation 
provided  for  80  private,  and  480  pauper 
patients.  The  charitable  area  of  the  asy- 
lum extends  to  the  counties  of  Forfar  and 
Kincardine.  Lowest  rates  for  paupers, 
^28  lis.,  for  private  patients  ^25  per 
annum.  Income  from  the  board  paid  by 
patients,  ^16,903  per  annum. 

Perth. — Founded  by  the  trustees  of  the 
late  James  Murray,  Esq.,  whose  name  it 
bears.  Managed  by  directors  self-elected 
and  ex  officio  in  terms  of  the  charter. 
Opened  in  1827.  Consists  of  two  main 
buildings.  (i)  The  original  institution, 
enlarged  in  1839,  and  further  enlarged  and 
modernised  in  1889.  (2)  A  neighbouring 
mansion  house  for  quiet  and  convalescent 
patients  of  the  higher  class.  Several 
houses  in  the  vicinity,  the  Highlands  and 
St.  Andrews,  are  also  occupied  by  pa- 
tients. Extent  of  grounds,  63  acres. 
Accommodation  for  136  private  patients. 
The  charitable  area  of  the  institution  is 
limited  to  Perthshire.  Lowest  rate  for 
local  patients,  ^52  per  annum.  This  is 
modified  by  the  directors  in  special  cases 
with  the  result  that  out  of  104  patients 
resident  at  present,  17  pay  less  than 
that  rate,  the  actual  minimum  being  £^0 
per  annum.  The  income  is  derived  from 
board-rates  paid  by  patients — the  total 
for  1 89 1  being  ;/^io,ioo. 

A.  R.  Ub-QUHakt. 

"RTJ-NTUXNG  AMUCIC. — A  term  origi- 
nally used  by  Anglo-Indians  and  others 
to  denote  the  exhilarated  state  of  intoxi- 
cation accompanied  by  frenzy  induced  by 
the  abuse  of  certain  forms  of  cannabis 
(notably  the  cannabis  satiiri  or  inclica, 
Indian  hemp)  by  the  natives- of  India,  the 
Malayan  Archipelago,  Arabia,  and  West- 
ern Africa.  Under  the  influence  of  lai-ge 
quantities  of  this  drug  they  become  so 
excited  that  they  rush  blindly  and  furi- 
ously about  the  streets  with  knives  or 
other  weapons,  shouting  "  amuck ! 
amuck  !  "  ("  kill !  kill !  "),  indiscriminately 
attacking  passers  by,  and  even  committing 
murdei-.  European  soldiers  have,  under 
the  influence  of  this  intoxicant,  presented 
the  same  symptoms  of  impulsive  destruc- 
tiveness,  and  in  one  recently  recorded  in- 
stance a  private  succeeded  in  killing  a 
number  of  his  comrades  and  others  befoi'e 
being  shot  down.  In  India  the  plant  is 
known  as  bhang,  subjee,  or  sidhee,  and 
that  prepared  for  sale,  dried,  and  from 
which  the  resin  has  been  extracted  is 
popularly  called  gunjah.     In  Arabia  the 


Bussia,  Insane  in 


[    1098    ] 


Russia,  Insane  in 


leaves  and  capsules,  without  the  stalks, 
are  known  as  haschish,  and  it  was  with 
this  that  Hassan,  the  subah  of  Nishapour, 
used  to  stupefy  his  victims  before  murder- 
ing them,  whence  the  name  assassin.  In 
Western  Africa  it  is  known  as  dakka  or 
diamba.  The  former  word  has  travelled 
south,  and  is  used  by  the  Hottentots  of 
the  northern  parts  of  the  Cape  Colony  for 
the  leaves  of  a  native  species  of  hemp 
which  they  smoke,  and  which  induces  first 
an  excitable  frenzy  and  later  a  stuporous 
narcotism  like  that  of  opium. 

The  term  "  to  run  amuck "  has  been 
popularised  into  a  colloquialism  for  the 
action  of  one  who  talks  or  writes  on  a 
subject  of  which  he  is  totally  ignorant, 
or  who  runs  foul  of  sense  or  popular 
opinion. 

"Froutless  auil  satire-proof  he  scorns  the  streets, 
And  runs  an  Indian  muck  at  all  he  meets." 

Dryden. 

"  Satire's  my  weapon,  but  I'm  too  discreet 
To  run  amuck  and  tilt  at  all  I  meet." 

Pope. 

It  is  also  fancifully  used  to  denote  the 
blind  impttlsive  aggressiveness  of  epileptic 
furor. 

RUSSIA,  PROVISION  FOR  THE 
IKTSAWE  IN". — The  facts  which  serve  to 
illustrate  the  condition  of  the  insane  in 
Russia  during  various  periods  of  histoi-y,  to 
illustrate  the  gradual  amelioration  of  their 
condition  of  life,  provision  made  for  them 
by  the  organisation  of  institutions  adapted 
to  the  management  and  treatment  of 
mentally  aiSected  individuals,  as  also 
various  statistical  information  concerning 
the  insane,  &c. — such  facts  have  only 
quite  recently  been  subjected  to  scien- 
tific investigation.  Facts  serving  to 
illustrate  various  data  pertaining  to  the 
above-mentioned  questions  were  princi- 
pally worked  out  in  1887  by  the  initiation 
of  the  first  Congress  of  Psychiatry  in 
Russia.  It  is  precisely  these  facts  and 
data  which  have  been  utilised  for  tbe 
present  sketch. 

Owing  to  the  state  of  ignorance  which 
prevailedduringtheMiddleAgesinRussia, 
as  also  to  a  great  extent  in  other  European 
countries,  it  could  hardly  be  expected  that 
any  correct  idea  concerning  the  insane  as 
invalids  that  ought  to  undergo  proper 
treatment,  could  be  at  all  conceived.  In 
Russia  one  group — the  so-called  "  youro- 
divie,"  which  wei-e  according  to  all  proba- 
bility no  other  than  imbeciles  or  idiots — 
were  regarded  with  special  honour  by  the 
lower  classes,  and  were  accoi'dingly  sur- 
rounded with  a  kind  of  halo  of  sanctity, 
and  therefore  set  apart  from  the  mass. 
Others,  principally  hysterical  women  (so- 
called  "  klikoushy  "),    were  looked  upon 


as  being  possessed  by  the  devil,  and 
were  therefore  jDursued  by  the  people  and 
tortured. 

In  the  Middle  Ages,  when  religion  exer- 
cised a  paramount  influence  on  social 
life,  philanthropy  being  centred  in  the 
clergy,  the  solicitude  for  the  insane,  as 
also  for  the  poor,  for  pilgrims,  &c.,  was 
left  to  the  charge  of  the  monks  and  priests. 
Such  solicitude  was  even  regarded  as 
their  direct  duty,  as  we  learn  from  an 
authentic  statute  of  the  Grand  Duke 
Wladimir,  the  Saint  (eleventh  century), 
which  was  later  corroborated  in  the  six- 
teenth and  seventeenth  centuries. 

The  radical  reform  which  was  intro- 
duced in  the  government  administration, 
as  also  in  the  whole  social  condition  of 
Russia,  by  Peter  the  Great,  affected  the 
insane,  inasmuch  as  the  Emperor  caused 
cases  of  insanity  occurring  amongst  the 
nobility  to  be  brought  before  the  Senate. 
This  ukase  (1722)  or  ordinance,  specially 
introduced  with  the  intention  of  organ- 
ising a  criterion  of  the  capacity  of  the 
nobility  to  serve  in  the  army,  to  govern 
their  estates,  and  to  enter  into  matrimony, 
has  in  great  measure  influenced  the  legis- 
lation of  the  present  day  in  Russia  as 
concerns  the  acknowledgment  of  the  legal 
rights  of  the  insane.  The  maintenance 
of  the  insane  in  monasteries,  under  the 
charge  of  the  monks  and  the  clergy,  was 
corroborated  by  an  ukase  of  Peter  the 
Great  (1725). 

The  primary  ordinances  concerning  the 
establishment  of  special  institutions  for 
providing  for  the  insane  appeared  in  the 
reign  of  Catherine  II.,  in  1762  :  the 
preceding  year  a  similar  ukase  had 
been  already  issued  by  her  predecessor, 
Peter  III.,  but  had  not  been  put  in 
practice.  However,  the  new  ordinance 
of  Catherine  II.  could  not  be  immediately 
brought  into  action,  it  being  of  great 
importance  beforehand  to  obtain  infor- 
mation concerning  similar  institutions  in 
other  countries  of  Europe.  It  was  only 
in  1776  that  the  first  "mad  house"  in 
Russia  was  erected  in  Novgorod.  During 
the  reign  of  the  same  empress  (Catherine 
II.),  only  three  years  later  in  1799,  ^ 
"mad  house"  was  erected  also  in  St. 
Petersburg,  on  the  very  spot  on  which 
later  (1784)  was  established  theObouchow 
Hospital,  which  exists  to  the  present  day. 
Dating  from  that  time  the  organisation  of 
various  institutions  for  the  insane  in 
many  towns  of  the  extensive  Russian 
Empire  can  be  easily  traced,  such  insti- 
tutions being  erected  principally  in  the 
capital  either  by  direct  order  of  the  Go- 
vernment, or  of  various  administrative 
departments. 


Russia,  Insane  in 


L    1099    J 


Russia,  Insane  in 


The  beneficial  endeavours  on  behalf  of 
the  pi"ovision  for  the  insane,  made  greater 
progress  in  St.  Petersburg  than  in  other 
towns,  the  capital  being  the  great  centre 
of  the  administration,  and  theretbre  under 
specially  favourable  conditions.  Thus, 
during  the  reign  of  the  Em]ieror  Nicholas 
L,  in  1832,  the  inauguration  of  the  hospital 
of  Misericorde  took  place  ;  it  being  origin- 
ally destined  for  the  accommodation  of 
120  patients,  and  organised  according  to 
the  model  of  the  best  asylums  for  the  in- 
sane existing  at  that  time  in  England ; 
later  the  hospital  of  Miscricorde  was  very 
much  enlarged  and  reformed.  In  its  time 
that  hospital,  owing  to  its  admirable  or- 
ganisation and  regulations,  was  accounted 
one  of  the  best  for  the  insane,  and  stood 
on  a  level  with  the  best  of  the  kind  in 
Europe. 

Endeavours  towards  providing  for  the 
insane  in  St.  Petersburg  were  unaui- 
mousl}'  approved  of  during  the  first  half 
of  the  present  century.  At  that  period 
was  founded  the  hospital  of  St. 
Nicholas  (1856).  In  the  year  1859,  a 
section  for  insane  military  officers  and 
soldiers  with  their  families  was  organised, 
according  to  the  highest  then  known 
standard  for  providing  for  the  insane ; 
this  section  was  confided  to  the  charge  of 
the  ImperialMedico-Chirurgical  Academy. 
It  was  in  this  section  that  Professor 
Balinsky  undertook,  for  the  first  time  in 
Kussia,  a  course  of  lectures  on  psychiatry. 
A  clinic  for  the  insane  was  established 
several  years  later  (1S66)  at  the  Medico- 
Chirurgical  Academy.  This  clinic,  en- 
dowed with  profuse  materials  for  scien- 
tific investigations,  has  proved  itself  to 
have  been  a  nursery  for  rearing  a  num- 
ber of  competent  specialists  in  the  domain 
of  medical  psychology,  who  in  course  of 
time  have  successfully  occupied  posts  as 
directors  in  various  asylums  for  the  in- 
sane in  Russia.  During  the  same  period 
several  private  asylums  for  the  insane 
were  also  established,  amongst  v?hich 
the  first  was  organised  in  1847,  by  Dr. 
Leidesdorf,  who  latterly  occupied  the 
post  of  professor  at  Vienna.  In  1870,  a 
new  exemplary  asylum  was  inaugurated 
out  of  the  private  funds  of  the  Czarevitch, 
the  present  Emperor,  Alexander  III. ; 
this  hospital  was  originally  intended  for 
as  many  as  120  patients.  During  the 
following  years  the  town  administration 
undertook  the  task  of  placing  the  incura- 
ble insane  in  various  asylums  and  sections 
of  almshouses.  In  1885,  a  special  asylum 
was  established  fur  the  incurables — the 
hospital  of  St.  Panteleimon  containing 
from  500  to  600  patients. 

At  the  present  time  (January  i,  1889), 


St  Petersburg  possesses   accommodation 
for  the  insane  as  follows  :  — 

Beds. 
In  lidspitals  ami  asyliiuis  pertiiiuiiig:  to 

the  iduii  administi-iition 1370 

III  I  lie  hospital  of  Misericonle.  .  .  .  250 
In  the  hospital  of  the  Emperor  Alexau- 

dei-  III 280 

lu  the  clinics  of  tho  military  hospitals  .  200 

In  private  asylums 145 


Total 


224s 


The  number  of  inhabitants  of  St. 
Petersburg,  according  to  the  census  (made 
during  one  day,  December  15,  1888), 
amounted  to  a  total  of  975,368;  therefore 
one  bed  for  the  insane  is  provided  for  every 
434  inhabitants. 

The  duty  of  providing  for  the  insane  in 
the  extensive  Russian  Empire,  was,  at  the 
latter  end  of  the  last  century,  centred 
in  the  "  Board  of  Public  Assistance." 
Measures  were  then  taken  by  this  Board 
for  gradually  establishing  asylums  for  the 
insane  in  various  government  towns.  The 
most  ancient  of  these  is  the  Rogdest- 
wensky  Hospital  in  Moscow,  established 
towards  the  end  of  the  last  century,  and 
rebuilt  in  1812,  after  the  conflagration 
of  Moscow.  By  the  middle  of  our  cen- 
tury, nearly  fifty  of  our  government 
towns,  including  Siberia,  possessed  asy- 
lums of  public  assistance.  According  to 
official  data  in  1852,  these  asylums  con- 
tained 2554  insane,  the  yearly  mainten- 
ance of  each  of  these  patients  amounting 
to  the  sum  of  89  roubles  82  copecks  (^12). 
Tinder  such  conditions  the  maintenance 
of  each  patient  could  hardly  be  satisfac- 
tory, and  as  early  as  1840,  the  Minister  of 
the  Interior  endeavoured  to  procure  means 
for  the  better  provision  of  the  insane,  both 
as  to  quantity,  as  also  to  quality ;  however, 
the  difficulty  of  the  question  to  be  solved 
was  such  that  no  radical  reform  could  be 
possibly  undertaken  at  the  time. 

In  1869  the  Minister  of  the  Interior  es- 
tablished an  asylum  for  the  insane  in 
Kazan.  Owing  to  the  insufficiency 
of  medical  specialists,  and  to  the  lack 
of  scientific  knowledge  of  psychiatry, 
it  is  not  until  quite  recently  that  a 
system  of  providing  for  the  insane  in 
Russia  has  been  thoroughly  undertaken  ; 
previously  the  insane  were  looked  upon 
as  uulbrtunate  beings  who  should  be 
taken  care  of,  but  at  the  same  time  who 
should  be  kept  under  strict  control  as 
dangerous  to  the  public  safety.  Owing 
to  this  fact,  in  the  majority  of  asylums 
established  by  the  Board  of  Public  Assist- 
ance the  sections  for  the  insane  bore  the 
character  rather  of  prisons  than  of  asy- 
lums for  curing  the  mentally  affected.  In 
these  wards  the  patients  were  all  huddled 


Russia,  Insane  in 


[     iioo    ] 


Russia,  Insane  in 


together,  no  diiference  whatever  being 
made  for  the  acute  or  chronic  forms,  for 
curable  or  incurable  patients,  or  even  im- 
beciles. The  care  of  these  sections  was 
nearly  always  entrusted  to  such  medical 
men  as  were  considered  deficient  in  ability 
for  practising  their  profession,  or  who 
had  in  some  way  or  other  proved  them- 
selves guilty  of  breaking  the  law  of  the 
land. 

It  was  only  during  the  beneficial  re- 
forms of  the  reign  of  Alexander  II.,  owing 
to  which  the  local  administration  in  the 
provinces  of  Russia  underwent  a  radical 
reform,  that  rapid  progress  was  made  in 
the  mode  of  providing  for  the  insane. 
Thus,  beginning  from  i860  in  a  whole 
range  of  governments  of  the  provinces  of 
Russia  were  organised  rural  municipali- 
ties {zemstroo) — an  institution  based  on 
a  system  of  election,  in  which  case  the 
deputies  are  chosen  amongst  the  local 
inhabitants — mostly  landowners  thor- 
oughly acquainted  with  the  wants  of  the 
province  in  which  they  live,  and  per- 
sonally interested  in  its  welfare.  It  was 
to  the  solicitude  of  these  rural  munici- 
palities that  the  government  entrusted 
the  task  of  providing  for  the  sick  and 
the  insane  amongst  the  local  inhabit- 
ants. These  municipalities  having  under- 
taken to  carry  out  the  instructions  to 
place  in  the  asylums  all  persons  suffering 
from  insanity,  and  requiring  proper  treat- 
ment and  care,  the  old  buildings  of  the 
Board  of  Public  Assistance  proved  very 
shortly  to  be  overcrowded  with  patients, 
and  it  became  expedient  to  build  new 
asylums. 

Taking  into  consideration  the  enormous 
expense  which  such  buildings  incur,  the 
government  decided  to  come  to  the  aid 
of  the  rural  municipalities.  Thus,  in  1879 
the  Minister  of  the  Interior  issued  an 
order  by  which  the  government  endowed 
the  municipalities  with  a  fund  of  fifty  per 
cent,  of  the  total  expenses  laid  out  by  them 
for  the  amelioration  of  the  asylums  for 
the  insane. 

Dating  from  that  time  great  efforts 
were  directed  towards  the  improvement 
of  the  system  of  providing  for  the  insane; 
willing  and  able  supporters  of  such  im- 
provements manifested  themselves  at  the 
beginning  of  1S80,  amongst  a  consider- 
able contingent  of  young  Russian  medical 
psychologists,  endowed  with  thorough 
scientific  knowledge  of  their  task  ;  a  fact 
most  certainly  to  be  attributed  to  the 
successful  teaching  of  ps5'chiatry  in  the 
Medical  Academy  of  St.  Petersburg  and 
at  the  Universities  of  Moscow,  Kazan, 
Charkoff,  Kiew,  "Warsaw,  and  Dorpat. 
Some  of  the  rural  municipalities  endea- 


vouring to  forward  the  improvement  in 
the  system  of  provision  for  the  insane  in 
their  districts,  undertook  to  send  doctors 
of  their  staff  to  the  universities  of  the 
empire,  with  the  intention  of  affording 
them  the  opportunity  of  acquiring  a 
thorough  knowledge  of  the  best  systems 
of  the  treatment  of  the  insane.  At  the 
same  time  plans  of  projected  asylums 
for  the  insane  were  subjected  to  the  ex- 
amination of  specialists  belonging  to  the 
Association  of  Medical  Psychologists  at 
St.  Petersburg. 

Measures  were  also  taken  to  entirely 
separate  the  insane  from  other  groups  of 
patients  by  the  inauguration  of  establish- 
ments specially  adapted  to  the  regulation  of 
professional  workshops,  of  agricultural 
labour  and  to  the  transfer  of  the  chronic 
jDatients  to  the  colonies.  These  beneficial 
reforms  rendered  it  possible  to  adopt  in 
such  asylums  to  a  wide  extent  the  sys- 
tem of  "non-restraint,"  to  obtain  a  great 
percentage  of  convalescence  amongst  the 
palients,  to  introduce  a  regular  system  of 
statistical  information,  &c.  However,  the 
realisation  of  such  beneficial  reforms  even 
in  the  present  day  is  to  be  found  only  in 
a  small  number  of  rural  municipalities ; 
more  than  in  any  other  governments  we 
find  that  these  beneficial  reforms  have 
been  partially  realised  in  the  improve- 
ment in  various  ways  of  the  condition  of 
the  insane  in  the  governments  of  Twer, 
Saratow,  Tauride,  Poltawa,  also  partially 
in  the  governments  of  Riazan  and  Nov- 
gorod. In  many  other  governments  un- 
fortunately, asylums  for  the  insane,  even 
in  the  present  day,  form  only  a  certain 
section  of  the  municipal  general  hospitals 
for  the  various  groups  of  patients.  Lastly, 
in  an  immense  portion  of  the  Russian 
Empire,  for  instance  in  Siberia,  in  the 
Western  Provinces  of  European  Russia, 
such  asylums  have  not  yet  been  intro- 
duced and  mentally  affected  patients  are 
all  confined  together  in  the  badly  organised 
asylums  of  the  old  Board  of  Public  As- 
sistance system  introduced  before  the 
above-mentioned  reform  took  place.  In 
general  we  are  bound  to  state  the  fact 
that  the  above-mentioned  reform  of  the 
provision  for  the  insane  is  very  slowly 
advancing  in  the  rural  districts  of  the 
Russian  Empire ;  in  fact  it  may  be  said 
to  be  still  at  an  early  period  of  the  carry- 
ing out  of  such  desirable  reforms. 

Undoubtedly  the  general  number  of 
asylums  and  wards  for  the  insane  in  the 
empire  is  yearly  increasing,  and,  accord- 
ing to  the  latest  official  data  (the  sta- 
tistical returns  of  the  Medical  Depart- 
ment of  the  Ministry  of  the  Interior, 
1887),  there  exist  already  85  asylums  for 


Russia,  Insane  in 


[ 


] 


Russia,  Insane  in 


the  insane  with  accommodation  for  9125 
patients  to  the  general  number  of  no 
millions  of  inhabitants  of  the  Russian 
Empire. 

For  the  purpose  of  being  better  able  to 
estimate  such  data,  it  is,  of  coiirse,  indis- 
pensable to  be  acquainted  with  the  total 
number  of  the  insane  in  Russia.  Unfor- 
tunately, however,  taking  into  considera- 
tion the  natural  difficulties  which  hinder 
any  attempt  to  conduct  satisfactory  sta- 
tistical tables  in  so  vast  an  empire  as 
Russia,  we  must  own  to  the  fact  that  at 
the  present  time  correct  data  do  not 
and  cannot  possibly  exist.  This  most 
important  question  has  been  partially 
solved  by  statistical  information  ob- 
tained by  the  former  director  of  the 
medical  department,  the  late  Dr.  Mamo- 
noff.  According  to  the  reports  of  the 
conscription  committee,  the  number  of 
the  insane  and  epileptic  could  be  ascer- 
tained through  the  examination  of  recruits 
in  1876.  1877,  and  1878.  The  percentage 
of  insane  and  epileptics  existing  amongst 
a  given  number  of  young  men  of  twenty 
years  old  become  clearly  exhibited  by  these 
reports.  Thus  it  has  become  obvious  that 
out  of  a  number  of  754,362  recruits  claimed 
by  the  conscription  committee  to  be 
examined  by  the  medical  inspectors,  3072 
young  men  were  rejected  by  the  Commis- 
sioners owing  to  their  being  affected  with 
various  forms  of  insanity.  It  follows  that 
the  number  of  cases  of  insanity  is,  ap- 
proximately, 4  to  a  ratio  of  1000  recruits  ; 
•while  the  number  of  epileptics  was  1.7  to 
1000  recruits.  In  these  cases  there  was 
great  disjjarity  in  the  returns  as  regards 
various  districts  of  Russia.  The  greatest 
percentage  of  cases  of  mental  afiections 
was  to  be  found  in  the  Baltic  provinces — 
namely,  in  the  government  of  Esthonia, 
12.8  to  1000  :  of  Livonia,  7.9  ;  of  Courland, 
6.2 ;  also  in  the  northern  governments  of 
Novgorod,  6.9,  and  Olonetz,  5.6;  in  the 
western  governments  of  Vilna,  5.8;  and 
the  governments  of  the  Vistula,  from  5.4 
to  4.4.  The  average  percentage  of  cases 
of  mental  affections  is  to  be  found  in  the 
government  of  Pskow,  Moskow,  Toula, 
Kief,  and  Bessarabia.  The  minimum  per- 
centage (less  than  4  to  1000)  fell  to  the 
lot  of  the  governments  of  Central  and 
Southern  Russia. 

Undoubtedly  it  is  impossible  to  judge 


of  the  extent  of  cases  of  insanity  amongst 
the  whole  population  of  Russia  by  the 
percentage  of  insanity  obtained  from  the 
examination  of  recruits  of  a  known  age. 
It  is  probable  that  the  actual  proportion 
of  the  mentally  affected  in  Russia  is  con- 
siderably less  than  the  above-mentioned 
average.  This  is  clearly  proved,  indepen- 
dently of  general  conclusions,  by  various 
private  data  collected  in  separate  govern- 
ments of  Russia.  For  instance,  in  the 
government  of  Courland,  according  to  the 
returns  obtained  by  the  Medical  Inspector- 
General,  the  number  of  the  insane  (in  the 
year  1 884)  was  estimated  at  i  in  400 ;  in  the 
government  of  Livonia  (1881),  i  in  884; 
in  the  government  of  Perm  (1881),  i  in 
1 1 20;  of  Oufa,  I  in  788;  in  the  govern- 
ment of  Esthonia  (1878),  i  in  530.  In  the 
government  of  Moscow  (1886)  the  total 
num.ber  of  the  insane  (not  counting 
the  town  of  Moscow)  was  estimated  at 
1662. 

According  to  the  census  of  1882,  in  the 
government  of  Moscow  (without  counting 
the  town  of  Moscow  itself)  the  number  of 
inhabitants  was  reckoned  at  1,287,509; 
therefore  there   appears  a  ratio  of  i   in 

774- 

It  is  needless  to  add  that  such  data 
cannot  be  looked  upon  as  infallible ;  and, 
besides,  owing  to  their  bearing  only  a 
partial  signification,  therefore,  the  above- 
mentioned  statistical  returns  cannot  on 
any  account  be  used  as  a  basis  for  any 
statistical  information  as  regards  the 
whole  population  of  Russia.  However,  in 
the  absence  of  other  more  accurate  statis- 
tics, even  such  scant  returns  can  be  taken 
into  serious  consideration. 

Recently  the  members  of  the  Medico- 
Psychological  Association  of  St.  Peters- 
burg, as  also  those  of  the  First  Congress 
of  Russian  Medical  Psychologists,  tirmly 
insisted  on  and  pointed  out  the  extreme 
necessity  of  obtaining  a  definite  knowledge 
of  the  general  percentage  of  the  insane  in 
our  fatherland.  For,  to  facilitate  the 
furtherance  of  such  information,  there 
exists  already  a  series  of  statistical  tables, 
with  questions  demanding  exact  answers 
to  the  same.  We  may  therefore  cherish 
the  hope  that  in  some  not  far  off  future 
we  shall  fully  possess  the  means  of  resolv- 
ing in  a  satisfactory  manner  this  most 
difficult  problem.  J.  Mierzejewski. 


Sacer  Morbus 


[     iio-     ] 


Salicylic  Acid 


SACER  l^ORBUS  {sacer,  sacred; 
onorhits,  a  disease).  An  old  name  for  epi- 
lepsy. 

SAITTT  AVERTZN-. — The  patron  saint 
of  lunatics ;  so-called  from  the  French 
oreWnR'Hi'c  (lunatics).  St.  Avertin's  disease 
is  a  name  given  to  epilepsy. 

SAINT  DYIVZPHN-A.  —  The  tutelar 
saint  of  those  afflicted  with  insanity.  She 
was  said  to  be  a  native  of  Britain  and  a 
woman  of  high  rank,  and  is  supposed  to 
have  been  murdered  at  Gheel,  in  Belgium, 
by  her  own  father,  who  was  insane.  St. 
Dymphna's  disease  is  a  term  used  for  in- 
sanity.    (.S'ee  Gheel.) 

SAZTrT     HUBERT'S    DISEASE. — A 

synonym  of  Hydrophobia.  St.  Hubert 
was  the  patron  saint  of  huntsmen,  and 
those  descended  from  his  race  were  sup- 
posed to  possess  the  power  of  curing  the 
bite  of  mad  dogs. 

SAINT  JOHN'S  EVIIi. — A  synonym 
of  Epilepsy. 

SAINT  MATHURIN'S  DISEASE. 
— A  name  given  either  to  epilejjsy  or  in- 
sanity. St.  Mathurin  was  the  patron  saint 
of  idiots  and  fools. 

SAINT  VITUS'S  DANCE.  {See  ClIO- 
KEA.)  A  psychopathy  of  hysterical  origin, 
spreading  by  imitation,  at  one  time  widely 
prevalent  in  Germany  and  the  Low  Coun- 
tries. For  its  cui'e  an  annual  procession  of 
jumping  and  dancing  performers  was  made 
on  Whit  Tuesday  to  a  chapel  in  Ulm  dedi- 
cated to  St.  Vitus,  who  was  supposed  to 
have  the  power  of  healing  all  nervous  and 
hysterical  affections. 

"  At  Strasbourg  hundreds  of  folk  began 
To  dance  and  leap,  both  maid  and  man  ; 
In  open  market,  laue,  or  street, 
They  skipped  along,  nor  cared  to  eat 
Until  their  plague  had  ceased  to  fright  us, 
'Twas  called  the  dance  of  holy  Vitus." 

Translation  from  an  old  German  chronicle 
(Jan  von  Kouigshaven). 

SAINT  VITUS'S  DANCE  AND  IN- 
SANITY.    {See  Chokea.) 

SAXAAM  CONVUI.SIONS.  (AS'ee 
ECLAMl'HIA  NrTAj;,s.) 

SAIiICVI.IC  ACID — The  actions  of 
salicylic  acid  and  salicylate  of  soda  upon 
the  nervous  system  are  very  nearly  the 
same,  and  any  slight  diiference  that  may 
be  observed  is  probably  due  to  the  greater 
solubility  and  consequently  more  rapid 
absorption  of  the  sodium  salt.  When 
combined  with  powerful  bases,  such  as 
quinine,  the  effect  of  the  compound  may 


be  due  to  the  base  rather  than  the  acid, 
and  we  need  not  consider  such  compounds 
here. 

The  toxic  effect  of  salicylic  acid  or  of 
sodium  salicylate,  for  in  this  article  we 
shall  use  the  names  indiscriminately,  is 
exerted  both  on  the  functions  of  sen- 
sation and  motion,  and  its  effects  appear 
to  be  due  partly  to  a  peripheral  and  partly 
to  a  central  action.  The  most  marked 
symjjtoms  of  its  action  are  very  much 
like  those  produced  by  quinine,  namely, 
ringing  in  the  ears  and  a  certain  amount 
of  deafness.  These  are  sometimes  accom- 
panied by  fulness  in  the  head,  actual 
headache,  giddiness,  and  sometimes  by 
sickness  and  vomiting,  which  may  be 
due  to  a  local  irritant  action  of  the  drug 
on  the  stomach,  but  which  may  possibly 
also  have  to  a  certain  extent  a  central 
origin.  When  the  administration  of  the 
drug  ceases,  these  symptoms  quickly  pass 
off,  but  with  large  doses  numbness  and 
loss  of  sensation,  v/ith  or  without  itching 
in  the  extremities,  hallucinations  of  sight, 
nervous  excitability,  drowsiness,  delirium, 
and  unconsciousness  have  been  observed. 
Indications  of  paralysis  sometimes  appear 
in  the  form  of  strabismus,  ptosis,  and 
difficulty  in  moving  the  legs,  while  sudden 
starts  or  twitchings  of  the  muscles  or  tre- 
mor occur.  Although  ringing  in  the  ears 
is  usually  the  first  symptom  to  attract 
attention,  yet  the  optic  nerve  frequently 
shows  signs  of  affection  before  the  audi- 
tory. The  first  indication  of  such  an 
affection  in  our  experience  has  been  the 
appearance  of  spectra  whenever  the  eyes 
were  shut.  These  frequently  take  the 
form  of  disagreeable  faces,  but  they 
disappear  whene%'er  the  eyes  are  opened. 
In  other  people  the  ocular  spectra  persist 
while  the  eyes  are  open.  In  one  of  our 
patients  the  administration  of  sodium 
salicylate  caused  large  patches  of  red  and 
green  colour,  but  without  any  distinct 
form,  to  appear  before  the  eyes  while  open. 
In  another  patient  actual  hallucinations 
taking  definite  form  occurred,  and  he  saw 
processions  of  people  going  round  his 
bed.  At  first  we  mistook  these  halluci- 
nations for  the  delirium  of  fever,  but  there 
was  no  high  fever  to  account  for  delirium. 
The  visions  ceased  when  the  salicylate  was 
discontinued.  The  delirium  varies  in 
character — may  sometimes  be  gay  and 
sometimes  melancholy  or  frightened,  and 
may  alternate  with  unconciousness,  either 


Salicylic  Acid 


[    1 103    ] 


Salivation 


partial  or  complete.     As  a  rule  the  deli- 
rium is  not  violent.*     The  exact   itiodus 
operandi  of   salicylic    acid    in    producing 
these  symptoms  has  not   been   precisely 
made  out.      We  observe,  however,   that 
they  may  be  classed  as  (i)  irritation  with 
(2)  diminished  activity  ol  the  normal  func- 
tions, both  of  the  central  and  peripheral 
nervous  system.     Thus,  in  the  case  of  the 
optic  nerve,  we   have  diminution  of  the 
visual   power  with    subjective  sensations 
of  colour   or   form   amounting  to   actual 
hallucinations.     lu  the  case  of  the  audi- 
tory nerve  we  have  deafness  more  or  less 
complete,  with  buzzing  or  ringing  in  the 
ears.     In  the  case   of   nerves  of  general 
sensation  we  have  itching,  and  more  or 
less  complete  aniBsthesia.     In  the  case  of 
the  motor  functions   we  have  twitching, 
starting,  tremor,  and  occasional  paralyses. 
The  delirium  is  probably,  to  some  extent, 
dependent  upon  the  false  impressions  con- 
veyed to  the  cerebrum  by  the  nerves  of 
sense,  but  in  all  probability  the  cerebrum 
itself  is  also  affected   by  the  drug.     On 
post-mortem    examination,    in    cases     of 
poisoning  by  salicylic  acid,  both  in  animals 
and  man,  considerable  congestion  of  the 
membranes  of  the  brain  has  been  found 
with    ecchymoses.     A    similar    condition 
has  been  found  in  the  internal  ear,  and  in 
.addition  to  great  congestion  and  ecchy- 
moses, exudation  of   yellowish  red  fluid 
has   been    found.      In    animals    and    in 
patients  the  tympanum  has   shown  indi- 
cations   of   inflammation,    and    fluid    has 
been  found  in  the  tympanic  cavity.     The 
labyrinth  appears  also  to  be  affected,  as 
high  tones  are  not  so  readily  heard,  and 
the  hearing  of  a  tuning-fork  through  the 
bones  of  the  head  is  also  impaired.     The 
retinal    vessels    appear     usually    to     be 
contracted.       On   the   skin   eruptions   of 
various  kinds  have   been  observed,  some 
of  them  having  a  character  like  urticaria. 
Although  in  these  cases  no   microscopic 
examination  has  been  made  of  the  skin,  yet 
we  may  probably  be  correct  in  assuming 
that   the  pathological    anatomy  of   urti- 
caria, due  to  salicylic  acid,  is  like  that  of 
urticaria  due  to   other  causes,  and  in  it 
distension  of  the  vessels  of  the  skin  has 
been  found   with  great   numbers  of  leu- 
cocytes in  the  meshes  of  connective  tissue 

*  In  one  case  salicylate  of  soda  has  appeared  to 
produce  double  consciousuess.  The  patient,  a  man 
of  <;reat  ability  and  mental  power,  was  sutVeriny 
from  orchitis  following  influenza.  <)a  awaking 
durin;^'  the  night,  drenched  with  perspiration,  he 
had  the  feeling  that  the  one  jjcrson,  wet  and  cold, 
was  in  duty  bound  to  attend  to  the  swollen  and 
painful  testicles  of  the  other  i)erson.  As  he  sat  \\\> 
to  do  this  he  got  warmer,  and  the  exertion  seemed 
to  make  the  two  personalities  come  nearer  and 
nearer  together  until  they  uulteiL 


and  surrounding  the  blood  and  lymphatic 

vessels.     The  disorders  of  sight,  hearing, 
and  general  sensation,  usually  disappear 
very  quickly  after  the  drug  has  been  dis- 
continued, and  this  fact  seems  to  indicate 
that    they    are    probably    due   in    great 
measure  to  disturbances  of  tlie  circidation, 
although   we    must    not   forget  that   the 
salicylic  acid  probably  has  an  action  upon 
the    nerve  structures  themselves.     Occa- 
sionally the  deafness  due  to  salicylic  acid 
is  more  j^ermanent,  and  this  would  point 
to  changes  in  the  ear  from  inflammation 
or  extravasation  caused  by  the  drug,  and 
remaining  after  its  complete  elimination 
from  the  body.     The  treatment  of  these 
effects  of  salicylic  acid  or  salicylate  of  soda 
is  based  on  the  idea  that  they  are  due  to 
congestion,  and  therefore  ergot  has  been 
administered  with  the  idea  of  contracting 
the  vessels.     This  has  been  administered 
either  in  the  form  of  infusion  or  Bonjean's 
extract,  one  part  of  this  being  given  to  ten 
parts  of  salicylate  of  soda.     In  deafness 
remaining  after  the  medicine  has  been  dis- 
continued the  cold  compresses,  ice-bags, 
the  local  application  of  tincture  of  iodine 
round  the  ear,  or  abstraction  of  blood  by 
leeches,  has  been    recommended,   and   if 
necessary  the  tympanum  should  be  j^unc- 
tured.     In  more  chronic  cases  the  regular 
use  of  air  douches,  the  introduction  of  the 
chloride   of   ammonium   vapour  into  the 
middle   ear,    and  the   injection  of   a  few 
drops  of  3  per  cent,  solution   of   chloral 
hydrate  has  been  found  useful.     The  dose 
required  to  produce  toxic  effects  appears 
to  vary  very  greatly  indeed  in  different 
individuals.      Persistent   singing    in    the 
ears   has  been   produced   by  as  little  as 
fifteen   grains   of    salicylate    of    soda    in 
divided  doses.     Severe  symptoms  of  deli- 
rium have  usually  been  consequent  on  the 
administration    of  large    doses,    such   as 
twenty  grains  of  salicylic  acid  every  three 
hours.      Yet  doses  of  twenty   grains  of 
salicylate   of  soda  have  frequently  been 
given    every   two  hours   in   acute   rheu- 
matism   without  injurious    effects.     The 
unpleasant    effects    of    salicylic   acid   or 
salicylate  of  soda  on  the  nervous  system 
are  supposed  by  some  to  be  due  in  great 
measure,  if  not  entirely,  to  impurities,  and 
it  has  been  stated  that  similar  symptoms 
are  either  not  produced  at  all  or  only  to  a 
much  slighter  extent  by  salicylic  acid  or 
salicylate  of  soda  of  vegetable  origin. 

T.  Lauder  Brunton. 
SilIiIVATI09r  {saliva,  spittle).  — 
Definition. — A  symptomatic  disorder, 
either  central  or  peripheral  in  its  origin, 
characterised  by  hyper-activity  in  the 
functions  of  the  salivary  glands.  The  term 
salivation  is  used  to  denote  an  excessive 


Salivation 


[     H04    ] 


Salivation 


secretion  of  saliva  from  whatever  cause, 
and  is  emploj'^ed  indiscriminately  as  a 
sj'nonym  of  ptyalism  {TTTvaXoi/,  spittle), 
sialorrhosa  (a-laXov,  saliva ;  pica,  I  flow),  and 
flow  of  saliva.  The  amount  of  saliva 
normally  secreted  by  an  adult  in  the 
twenty-four  hours  is  about  1 500  grammes, 
but  this  quantity  is  rarely  constant,  a 
large  number  of  external  factors  being 
able  to  induce  sialorrhoea  temporarily, 
such  as  cold,  cutaneous  irritation,  &c., 
while  vai-ious  articles  of  food,  such  as 
mustard,  ginger,  pepper,  &c.,  may  bring 
about  the  same  eft'ect.  Excessive  masti- 
catory movements,  too,  can  cause  a  copious 
flow  of  saliva,  as  we  have  on  several  occa- 
sions been  able  to  prove  by  making 
patients  masticate  substances  other  than 
food  stuff's,  such  as  india-rubber  ;  here  the 
salivation  is  purely  mechanical  in  origin. 
All  these  cases  of  sialorrhoea  are  acci- 
dental and  not  pathological. 

Before  treating  of  salivation  as  a 
symptom  in  nervous  disease  it  is  neces- 
sary to  mention  that  there  may  exist  at 
times  an  apparent  ptyalism,  a  false  sia- 
lorrhcBa,  the  recognition  of  which  is  ini- 
l^ortant.  Thus,  during  sleep  in  weak 
patients  or  in  individuals  who  breathe  with 
their  mouths  open  (especially  children 
with  adenoid  vegetations  of  the  naso- 
pharynx), and  in  whom  the  head  is  in- 
clined forwards,  the  saliva  often  dribbles 
out  of  the  corners  of  the  mouth,  though 
the  salivary  secretion  is  not  increased,  but 
is  on  the  contrary  less  abundant  during 
the  night.  In  the  same  way  we  may  see 
in  absent-minded  individuals,  and  espe- 
cially in  old  people,  the  saliva  escaping 
from  an  imperfectly  closed  mouth.  As 
for  ptyalism  in  cretins  and  idiots  we 
shall  deal  with  it  in  a  special  paragraph. 
After  having  thus  eliminated  the  sources 
of  error  by  which  we  may  be  misled,  chiefly 
when  measuring  the  quantity  of  saliva 
secreted  per  diem,  we  may  consider  the 
phenomena  of  actual  salivation,  and  we 
shall  here  treat  of  it  as  coincident  with 
certain  nervous  conditions.  The  relations 
between  the  flow  of  saliva  and  the  modifi- 
cations of  the  nervous  system  with  which 
they  appear  to  be  connected  are  not  always 
perfectly  clear,  and  this  form  of  sialorrhoea 
has  been  called  syniiKithetic  ptyalism. 

Symptoms.  —  It  will  perha]3S  be  of 
advantage  primarily  to  describe  the 
general  symptomatology  of  salivation  as 
found  uniformly  in  all  cases,  and  to  men- 
tion the  pathogenic  results  arrived  at  from 
observation  and  experimental  research. 
During  salivation  the  quantity  of  fluid 
secreted  is  increased  in  variable  propor- 
tions according  to  circumstances  ;  we  have 
frequently    obtained   quantities    of    two, 


three,  and  even  five  litres,  but  as  in  most 
cases  a  certain  amount  of  the  saliva  is 
swallowed  by  the  patient,  the  numbers 
given  are  less  than  the  actual  amount. 
The  saliva  in  cases  now  under  considera- 
tion is  generally  transparent  and  not 
opalescent  as  in  ptyalism  due  to  causes 
other  than  nervous  disorder.  The  con- 
sistence of  the  secretion  is  less  tenacious 
than  in  the  normal  condition,  and  it  is  the 
less  viscous  the  greater  the  quantity 
secreted.  The  density  of  the  liquid  pro- 
duced has  not  attracted  the  attention  of 
observers  :  according  to  the  investigations 
of  Tubini  it  is  diminished  in  sialorrhoea. 
The  saliva  is  usually  without  any  smell,  a 
fact  which  distinguishes  this  type  again 
from  the  salivation  present  in  other  forms 
of  disease.  Although  the  chemical 
charactei's  of  the  saliva  in  pathological 
cases  have  been  well  studied,  a  good  many 
particulars  still  remain  to  be  cleared  up. 
The  reaction  of  the  saliva  in  nervous 
or  sympathetic  sialorrhoea  is  generally 
slightly  alkaline ;  moreover,  it  is  now 
admitted  that  the  substance  which  gives 
to  the  mixed  saliva  its  acidity  is  furnished 
by  the  buccal  mucus.  The  chemical  com- 
position of  the  saliva  when  secreted  in 
excess  shows  first  of  all  that  the  quantity 
of  water  is  considerably  increased ;  more- 
over, we  generally  find  an  abundance  of 
fats,  and  lastly  albumen .  This  last-named 
substance  we  know  is  not  found  in  normal 
human  saliva,  it  is  only  present  in  lesions 
of  the  medulla  oblongata,  as  we  shall  show 
later  on ;  it  is  absent,  too,  in  functional 
affections  and  organic  disease  of  the  brain. 
Microscopical  examination  does  not  show 
any  anomaly  worth  mentioning,  save  per- 
haps that  there  may  be  a  lai'ge  or  small 
number  of  micro-organisms.  The  loss  of 
saliva  is  accompanied  by  various  func- 
tional disturbances.  Some  patients  get 
rid  of  the  saliva  by  continuous  spitting, 
others  allow  it  constantly  to  dribble  from 
the  corners  of  their  half-open  mouths. 
During  the  night,  according  to  whether 
the  salivation  takes  place  consciously 
(spitting),  or  unconsciously  (dribbling),  the 
patient  wakes  up  to  spit  and  suffers  from 
insomnia,  or  he  is  not  inconvenienced,  and 
the  dribbling  continues  incessantly.  This 
persistent  and  abundant  loss  of  saliva 
always  entails  suffering  on  the  whole 
organism,  and  for  two  reasons:  it  is,  first, 
the  loss  of  a  fluid  containing  valuable  in- 
organic substances,  which  exhausts  the 
patient,  and  secondly  the  non-utilisation 
of  a  necessary  digestive  medium  which 
causes  dyspepsia. 

The  course  and  duration  of  salivation 
are  variable  according  to  the  causes  which 
produce  it,  a  fact  which  we  shall  consider 


Salivation 


[     1105    ] 


Salivation 


later,  when  reviewing  the  principal  ner- 
vous disorders  which  originate  tliis  morbid 
disposition.  It  may  be  temporary,  chronic, 
and  also  intermittent. 

A  brief  consideration  of  the  mechanism 
of  salinirij  ticcrction  will  help  ns  to  under- 
stand the  iuHuence  of  nervous  disorders 
on  the  production  of  salivation,  aud  in  the 
short  description  we  are  about  to  give  we 
shall  specially  avail  ourselves  of  the  results 
arrived  at  by  Francois  Franck,  who  has 
experimentally  investigated  the  influence 
of  the   brain   on   the  salivary   secretion. 
Above    all   we  would  briefly  remind  the 
reader  of  the  fact  that  the  researches  of 
Ludwig,    Claude     Bernard,    Schitf    and 
Vulpiau  have  unmistakably  marked  out 
the  efferent  channels  and  actions  of  the 
nervous   influence.     We   know    that    the 
■  centripetal  (sensory)  nerves  are  principally 
represented  by  the  lingual   and    glosso- 
pharyngeal.     The    vascular    centrifugal 
nerves  come  from  the   sympathetic,  and 
the  glandular  centripetal  nerves  from  the 
chorda    tympani.      The    nervous    system 
acts  at  one  and  the  same   time  on  the 
vascular  apparatus  and  on  the  secretory 
apparatus,  and  experiment  has  shown  the 
independent  action  of  the  nervous  system 
on  each  of  these  two  factors  of  secretion. 
The  same  organs,  however,  may  be    in- 
fluenced positively  (excito-secretoire),    or 
negatively  (freno-secretoire),  but  we  have 
not  been   able  as   yet   to   determine  the 
special   nerve    tracts    for  each  of    these 
modifications.     Less  is  known   as  to  the 
nerve  centres  for  salivary  secretion.  Some 
physiologists    place    it    in    the    medulla, 
Claude  Bernard  has  shown  that  puncture 
of  the  pons  produces  an  abundant  secre- 
tion in  the  submaxillary  gland,  aud  that 
puncture  of  the  floor  of  the  fourth  ven- 
tricle in  front  of  the  diabetic  point  also 
causes  salivation.     Beaunis  has  observed 
in    the    rabbit    abundant    salivation    on 
electric  cauterisation  in  the  region  of  the 
third  ventricle.     Eckart  has  siiown  that 
stimulation  in  the  region  of  the  origin  of 
the  facial  nerve  produces  salivation.     On 
the  other  hand,  having  regard  to  the  com- 
mon observation  that  pure  cerebral  rejire- 
sentations    (ideas,    emotions)    act  on  the 
salivary  secretion,  the  question  is  raised 
how  far  direct  experiments   are  able   to 
reproduce  these  secretory  functions  of  the 
cerebrum.     Bochefontaine  in  1876  investi- 
gated the  amount  of  salivary  flow  under 
the   influence  of   stimulation  of   various 
points  of  the  cerebral  surface,  and  repeated 
his  experiments  in  18S3.     He  found  that 
salivation  was  produced  in  consequence  of 
stimulation  of  the  angular  gyrus  as  well 
as  of  other  points,  and  he  draws  the  con- 
clusion that  the  brain  itself  as  a  whole 


influences  the  secretion  of  saliva.  Is  there 
not,  however,  a  direct  cerebral  influence 
which  brings  into  play  actual  centres  of 
salivation,  or  are  the  effects  due  to  some 
kind  of  reflex  action,  that  is  to  say,  has 
the  stimulation  no  other  eflect,  such  as  the 
I^roduction  of  subjective  phenomena  of 
gustation  which  on  their  part  cause  sali- 
vation ?  Fran9ois  Franck,  to  whose  ex- 
perience we  shall  have  to  return  when 
treating  of  epilepsy,  thinks  that  cortical 
localisation  of  salivation  is  out  of  the 
question,  but  he  believes  that  ptyalism 
following  stimulation  of  the  brain  is  due 
to  "  a  central  epileptic  influence." 

It  will  now  be  well  to  consider  the  saliva- 
tion of  different  neuroi^athic  conditions, 
and  we  shall  study  it  (d)  in  the  nervous 
diseases  strictly  so-called,  and  (b)  in 
mental  disorders. 

(a)  Salivation  may  be  observed  in 
central  nervous  diseases  (of  the  cerebrum, 
medulla,  &c.)  and  in  peripheral  nervous 
affections  (lesions  of  the  trifacial  and 
facial).  It  may  occur  in  neurasthenia, 
a  fact  to  which,  to  our  knowledge,  due 
importance  has  not  been  given.  We  have 
had  an  opportunity  of  observing  some 
cases  in  which  this  symptom  showed  itself 
with  peculiar  character.  In  one  patient 
who  presented  most  of  the  symptoms  of 
neurasthenia,  and  especially  the  character- 
istic headache,  salivation  appeared  in 
crises  coincident  with  the  exacerbations  of 
the  cephalalgia,  and  we  have  met  with  this 
same  intermittent  form  in  several  other 
laatients.  It  is  necessary  to  add  that 
among  this  class  of  patients  the  salivation 
is  often  attributed  to  the  gastric  disorders 
from  which  they  so  frequently  suffer.  In 
hysteria  salivation  is  somewhat  rai-e,  and 
we  have  not  had  many  instances  among 
the  large  number  of  hysterical  patients 
who  frequent  Professor  Charcot's  clinique. 
If  it  occurs  in  these  it  presents  itself  with 
extraordinary  intensity.  Tanquerel  des 
Planches,  who  has  collected  a  great 
number  of  cases  of  sialorrhoea,  maintains 
that  this  affection  appears  in  hysterical 
women  in  consequence  of  moral  emotions, 
or  after  the  ingestion  of  cold  or  acid 
beverages,  or  after  the  inhalation  of  strong 
scents.  We  have  probably  also  to  deal 
with  hysteria  in  a  case  reported  by  Rayer, 
that  of  a  young  lady  who  suffered  from 
IDtyalism  which  returned  for  several  years 
at  x'egular  intervals  ;  and  a  case  observed 
by  Gilles  de  la  Tourette  appears  to  belong 
to  the  category  in  which  the  intense  cha- 
racter of  salivation  peculiar  to  hysterical 
patients  showed  itself.  We  may  add 
that  we  have  tried  the  influence  of  sugges- 
tion on  some  of  Professor  Charcot's 
hystero-epileptic  patients  who  had   been 


Salivation 


C    1106   ] 


Salivation 


thrown  into  tlie  condition  of  grand  ]i)jpno- 
tismc,  but  we  obtained  si^ittine;  rather  than 
an  actual  excess  of  saliva  (hypercrinia). 
In  epilcps}/,  Albertoni,  in  1876  and  1879, 
satisfactorily  proved  that  salivation  is  in- 
deed a  secretion,  and  he  has  completed  his 
investigations  ex]ierimentally  by  counting 
the  drops  of  saliva  flowing  out  from  a 
tube  which  he  introduced  into  Wharton's 
duct.  Francois  Franck  has  studied  the 
mechanism  of  salivation  in  its  relation  to 
the  phases  of  an  epileptic  attack.  For 
this  purpose  he  made  a  tracing  of  the 
salivary  flow,  together  with  that  of  the 
convulsions,  and  demonstrated  that  actual 
salivation  does  not  take  place  during  the 
tonic  ]ihase  of  the  attack,  the  slight  flow 
of  saliva  observed  in  that  stage  being  due 
to  mechanical  expulsion.  In  the  clonic 
phase  alone  actual  hyper-secretion  occurs, 
which  increases  as  the  convulsions  become 
more  violent.  If  we  examine  the  course 
of  the  salivation  in  a  series  of  attacks  we 
find  that  it  becomes  less  mai'ked,  and  may 
even  cease  after  a  certain  number  of 
seizures,  reajapearing  however  after  an 
interval  of  rest.  Fere  (1890)  has  also 
studied  salivation  in  epileptics,  and  has 
made  various  exj^eriments  on  his  patients. 
He  found  that  the  salivary  secretion  was 
increased  during  the  period  of  the  attack, 
but  decreased  as  the  attacks  became  more 
frequent,  disappearing  altogether  after  a 
certain  number  of  seizures  ;  he  tried  the 
effect  of  the  injection  of  pilocarpine  and 
found  that  the  salivary  function  became 
exhausted  after  a  period  of  hyper-activity. 
Local  affections  of  the  brain  may  produce 
salivation.  A  certain  number  of  cases  of 
cerebral  hemiplegia,  produced  either  by 
hsemorrhage  or  by  focal  softening,  have 
been  recorded,  in  which  sialorrhoea  formed 
an  important  symptom.  Here  we  may 
remind  the  reader  of  the  case  of  hemi- 
plegia with  sialorrhoea,  in  which  Ebstein 
first  tried  the  subcutaneous  injection  of 
atropine  for  the  purpose  of  arresting  the 
excessive  salivary  flow.  Salivation  may 
present  itself  also  in  lesions  of  the 
medulla.  It  has  always  been  found  in 
labio-glosso-laryngeal  paralysis,  in  which 
however  it  may  have  been  only  apparent, 
due  to  the  non-closure  of  the  lips  as  well 
as  to  the  difficulty  of  deglutition.  In  the 
same  wa}'  salivation  is  met  with  as 
a  frequent  symptom  in  cases  of  bulbar 
tumour,  and  in  pseudo-bulbar  paralysis. 
Neuralgia  and  neuritis  of  the  trifacial  ai-e 
said  by  most  authors  to  produce  salivation, 
a  fact  which  is  indisputable,  so  far  as 
neuralgia,  especially  of  the  superior  and 
inferior  maxillary  divisions  is  concerned, 
but  which  is  far  less  certain  with  regard 
to    neuritis ;    in   fact  Adamkiewicz    has 


recently  (1890)  published  a  ver}'  complete 
record  of  paralysis  of  the  trifacial,  in  which 
he  does  not  mention  any  disorders  of  sali- 
vation, a  circumstance  which  it  is  easy  to 
understand  from  a  physiological  stand- 
point. In  facial  paralysis  salivation  de- 
serves mention  on  account  of  its  diagnostic 
value.  If  in  these  cases  ptyalism  appears 
it  indicates  that  the  nervous  lesion,  which 
is  the  cause  of  the  paralysis,  is  seated 
above  the  medulla.  If  the  paralysis  is 
caused  by  a  lesion  of  the  facial  nerve  the 
secretion  of  saliva  may,  on  the  contrary, 
be  arrested  on  the  paralysed  side  in  con- 
sequence of  the  pathological  condition  of 
the  salivary  secretory  fibres  which  are 
contained  in  certain  branches  of  the  facial 
(chorda  tympani,  lesser  superficial  petro- 
sal). If  salivation  exists  in  a  case  of 
facial  paralysis  in  which  the  orbicularis 
palpebrarum  is  also  affected,  we  may  make 
the  diagnosis  of  focal  cerebral  lesion. 

(h)  Alienists  have  for  a  long  period 
noticed  and  described  the  frequency  of 
disorders  of  the  salivary  secretion  in  the 
insane  and  idiots.  These  modifications 
are  due  to  different  causes  according  to 
the  form  of  mental  affection  in  which  they 
occur. 

Diminution  in  the  quantity  of  saliva  is 
very  difficult  to  observe  and  estimate.  It 
is  only  found  in  certain  forms  of  melan- 
cholia, and  even  then  not  frequently.  The 
increase  of  salivary  secretion  is  very  fre- 
quently to  be  found,  but  in  order  to  be 
appreciated  it  must  be  very  considerable. 
There  is,  moreover,  especially  in  these 
cases,  the  liability  to  error  already  men- 
tioned. The  flow  of  saliva  from  the 
mouth  may  indeed  occur  either  because 
the  jjatients  do  not  pay  any  attention  to 
deglutition,  as  in  dements,  idiots,  &c.,  or 
because  the  patient  is  prevented  swallow- 
ing by  an  exc  ss  of  sahva.  iSTevertheless 
authorities  agree  as  to  the  existence  of 
ptyalism  in  certain  cases  of  mental  dis- 
order, a  subject  we  shall  consider  concur- 
rently with  the  prognostic  value  of  this 
symptom. 

The  practical  researches  mentioned 
above  have  demonstrated  to  a  certain 
point  that  stimulation  of  the  cerebral 
cortex  in  general,  and  stimulation  of  cer- 
tain parts  of  the  brain  in  particulai*,  pro- 
duce an  increased  salivary  secretion  ;  they 
explain  why  such  an  increase  of  saliva  is 
observed  (Krafft-Ebing)  in  affections  con- 
nected with  lesions  of  the  "  fore-brain." 
We  may  here  mention  that  salivation  is 
easily  produced  by  moral  excitement,  so 
that  it  is  not  surprising  to  find  the  salivary 
function  influenced  by  a  permanent  mental 
disorder.  As  Francois  Franck  remarks, 
the   general   expression   "to   make   one's 


Salivation 


1 107    ] 


Salivation 


mouth  water  "  corresponds  perfectly  to  a 
phenomenon  in  which  an  emotion  produces 
an  actual  increase  of  secretion.  In  ana- 
lysing this  fact  we  are  able  to  construct  a 
logical  series  at  the  commencement  of 
which  stands  an  impression  of  taste  which, 
connected  with  a  former  sensation,  pro- 
duces by  a  reflex  act. the  secretory  reaction; 
the  latter  may  present  itself  later,  inde- 
pendently of  the  special  cause  which 
originally  produced  it.  The  more  or  less 
conscious  recollection  of  the  former  sen- 
sation registered  in  the  cerebral  cells  may 
be  called  up  again  by  various  associations 
of  ideas,  having  their  starting-point  in 
visual,  auditory,  or  olfactoi'y  impressions, 
which  again  recall  the  gustatory  impres- 
sions formerly  perceived.  Up  to  this  point 
we  remain  in  the  region  of  fact,  material 
in  so  far  as  the  secretory  reaction  is  the 
result  of  the  recollection  of  a  sensation 
previously  produced  by  an  external  im- 
pression. By  a  species  of  cerebral 
education,  however,  it  may  happen  that 
sensations  completely  independent  of  the 
gustatory  sensation — a  general  desire  to 
possess  something — may  be  accompanied 
by  a  similar  salivary  reaction.  If  we 
neglect  the  phases  through  which  the 
phenomenon  has  passed,  in  order  to  con- 
sider the  fact  alone  of  a  cerebral  influence 
without  any  connection  with  an  actual 
gustatory  influence,  we  come  to  the  con- 
clusion that  there  is  a  direct  action  of  the 
brain  on  the  salivary  secretion.  By  con- 
structing the  logical  series,  however,  we 
are  always  able  to  go  back  to  a  gustatory 
impression,  stored  up  as  a  recollection  in 
certain  cerebral  cells,  which  are  in  a  con- 
dition to  react  to  impressions  other  than 
gustatory,  and  produce  an  increase  of  se- 
cretion. 

After  this  psychological  explanation  let 
us  look  at  the  opinions  of  investigators 
into  the  occurrence  of  salivation  in  the 
insane.  Esquirol  attributed  ptyalism  to 
spasm;  Fodereto  over-excitation;  and  both 
say  that  it  is  especially  met  with  in  mani- 
acal conditions.  Morel,  Krafft-Ebing,  and 
Dagonet  hold  the  same  views.  Berthier 
attributes  spitting  in  the  insane  to  three 
causes — (i)  agitation,  (2)  hallucinatory 
disorders,  and  (3)  gastric  disorders ;  but 
he  confounds  spitting  and  ptyalism,  two 
undoubtedly  distinctly  difi'erent  pheno- 
mena, one  of  which  may  exist  without  the 
other.  It  is  very  difficult  to  appreciate 
whether  we  have  to  deal  with  true  sali- 
vation when  we  encounter  a  case  of 
excessive  spitting,  but  generally  when 
ptyalism  is  present  the  voluntary  ejection 
of  saliva  is  absent.  The  latter  condition 
is  of  great  clinical  importance,  because  it 
almost   always   indicates  a   chronic   con- 


dition. We  find  it  not  only  in  agitated 
mental  states,  as  Berthier  believes,  but 
frequently  also  in  melancholia,  in  which 
it  is  a  symptom  that  the  mental  affection 
is  passing  over  into  a  chronic  form.  In 
perseciUio)i  nnaniih  we  find  it  most  fre- 
quently associated  with  hallucinations  of 
taste,  the  jjatient  endeavouring  to  get  rid 
of  the  poisons  introduced  into  his  mouth 
by  his  enemies.  We  must  also  take  into 
account  the  gastric  disorders  so  frequent 
in  insanity,  and  especially  in  conditions  of 
melancholia. 

The  value  of  ptyalism  as  a  means  of 
progrnosis  is  great,  a  fact  of  which  we 
may  easily  convince  ourselves  by  the 
observation  of  certain  mental  conditions, 
such  as  mania  or  melancholia,  with  or 
without  periodical  exacerbations.  In  cases 
of  this  kind  when  ptyalism  appears  a  re- 
turn of  the  attack  may  at  the  same  time 
be  observed,  the  end  of  which  was,  on  the 
other  hand,  indicated  by  a  diminution  in 
the  amount  of  salivary  secretion.  Like 
spitting,  but  in  a  much  less  degree,  saliva- 
tion indicates  generally  the  transition  into 
a  chronic  state,  and  in  all  cases  is  a  sign 
of  the  gravity  of  the  affection  and  an  indi- 
cation of  its  long  duration. 

Ptyalism  has  in  certain  cases  been  de- 
scribed as  a  crisis  of  insanity,  and  Perfect, 
Roflinck,  Pinel,  Esquirol,  and  Baillou 
have  furnished  examples  of  this.  Foville 
reports  the  case  of  a  female  patient  who 
suffered  from  intermittent  dementia,  and 
recovered  several  times  through  s2:»onta- 
neous  ptyalism.  Thore  reports  a  case  of 
a  high  degree  of  mental  stupor,  in  which 
a  very  abundant  sialorrhcBa  appeared, 
which  was  followed  by  rapid  recovei-y. 

Starck,  lastly,  believes  ptyalism  to  be 
of  use  as  a  means  of  dlag'nosis,  founding 
his  view  on  the  difference  between  the 
saliva  secreted  under  the  influence  of  the 
tri-facial  and  facial  nerves,  in  case  it  is  thin 
and  aqueous,  and  that  secreted  under  the 
influence  of  the  sympathetic,  when  it  is 
viscid  and  stringy.  He  believes  that  when 
salivation  is  present,  we  may  deduce  from 
the  nature  of  the  saliva  which  point  of  the 
nervous  system  is  affected.  As  yet,  how- 
ever, no  definite  conclusion  can  be  drawn 
from  this  tempting  hypothesis. 

Ptyalism  in  dementia  is  of  little  interest. 
Most  frequently  it  is  associated  with  pa- 
ralysis of  the  tongue  and  lips,  the  latter 
being  continually  kept  half  open.  The 
flow  of  saliva  may  in  all  respects  be  com- 
pared with  incontinence  of  urine  and 
faeces,  which  occurs  in  the  same  patients 
in  consequence  of  atonia  of  the  sphincters 
through  the  failure  of  will  power.  At  the 
commencement  of  secondary  dementia  we 
very  frequently  observe  as  one  of  the  first 

4B 


Saltatio 


[    1108    ] 


Satyriasis 


symptoms  of  decline  a  slight  increase  in 
the  salivary  secretion.  It  may  easily  be 
imagined  that  the  buccal  sphincter  being 
weak,  and  acting  nnlike  the  vesical  and 
anal  sphincters  nnder  the  influence  of 
reflex  action,  is  the  first  to  give  way;  we 
therefore  have  to  deal  with  simple  incon- 
tinence of  saliva,  so  to  speak,  and  not 
with  actnal  hypersecretion.  Various  au- 
thors interested  in  idiocy,  jjai'ticulai-ly 
Seguin,  have  observed  in  this  affection  an 
increase  of  the  salivary  secretion.  Seguin 
even  attributes  the  insensibility  of  the 
mouth  and  tongue  partly  to  a  kind  of 
maceration  of  these  parts  in  the  liquid 
saliva,  comparing  the  process  to  that 
which  happens  when  we  keep  one  part 
of  the  body  for  a  long  time  in  a  bath. 
Whether  in  idiocy  we  have  to  deal  with 
simple  incontinence  of  saliva  or  actual 
hypersecretion  is  at  present  undetermined. 
According  to  our  own  investigations  and 
personal  observations,  there  exists  in  many 
cases  a  decided  hypersecretion.  Certain 
incurable  idiots  slobber  to  an  extraoi-di- 
nary  degree,  actually  soaking  themselves 
with  fluid,  while  others  not  less  incurable 
slobber  but  little,  and  then  only  when  the 
mouth  is  constantly  kept  open.  On  the 
other  hand,  we  have  seen  in  some  of  these 
patients  the  salivary  incontinence  ceasing 
at  the  time  when  the  intellect  and  tbe  will 
first  showed  signs  of  development  under 
the  influence  of  treatment,  whilst  in  other 
patients  we  have  found  salivation  to  re- 
main absolutely  incurable  in  spite  of  local 
and  general  treatment.  Lastly,  we  are 
frequently  unable  to  attribute  the  saliva- 
tion to  a  feeble  tonicity  of  the  labial 
sphincter,  because  idiots  are  to  be  met  with 
who  cease  to  slobber  while  incontinence  of 
urine  and  faeces  persists.  There  must 
therefore  be  some  other  reason  than  want 
of  tone  of  the  lips  or  weakening  of  the 
will  of  the  patient,  and  we  then  have  to 
take  into  consideration  some  lesion  of  the 
centres  on  which  salivation  dejoends. 

Paul  Blocq. 

SAI.TATZO,  SAIiTATIO  SANCTX 
VITI  {salto,  I  dance).  Synonyms  of 
Chorea  Magna. 

SAI.Til.TORZC  SPASM  (saUator,  a 
dancer).  A  name  given  to  a  rare  form  of 
clonic  spasm  in  the  legs  which  comes  on 
when  the  patient  attempts  to  stand,  causing 
springing  or  jumping  movements.  It  is 
more  frequent  in  males,  and  in  some 
there  has  been  an  antecedent  history  of 
functional  nerve  disturbance,  epilepsy, 
&c.,  while  in  others  depressing  physical 
or  mental  influences  have  preceded  its 
occurrence.  The  onset  of  the  affection  is 
sudden,  and  the  spasms  affect  the  flexors 
and  extensors  of  the  legs  alternately,  and 


with  great  rapidity  in  severe  cases  ;  there 
is  no  loss  of  power  in  the  limbs,  sensation 
is  apparently  unaffected,  and  there  are 
no  concurrent  nerve  disturbances,  though 
Bamberger  relates  a  case  in  which  palpi- 
tation, dyspnoea,  pupillary  inequality,  and 
unilateral  facial  spasm  coexisted.  The 
affection,  after  lasting  some  months, 
gradually  disappears.  Its  pathology  is 
obscure,  and  its  treatment  unsatisfactory 
(Gowers).  (For  further  information  on 
this  subject  see  Bamberger,  Wien.  Med. 
Wochenschr.,  i859;Erlenmeyer,  Centrlblt. 
f.  Nervenkr.,  1887;  Frey.  Arch.  f.  Psych., 
Bd.  vi.,  1875;  Guttman,  Berl.  Med. 
Wochenschr.,  1867,  and  Arch.  f.  Psych., 
Bd.  v.,  1 876 ;  KoUman,  Deut.  Med.Wochen- 
schr.,  1883,  No.  40,  and  1884,  No.  4;  and 
Gowers,  Lancet,  ii.  1877  j  especially  the 
last-named,  who  discusses  the  probable 
pathology  of  the  malady  at  length.) 

SAI.VATZ:i.I.A  (sahis,  health).  The 
name  of  the  vein  of  the  little  finger.  It 
I'eceives  its  name  because  it  was  believed 
in  olden  times  that  blood-letting  from  it 
was  efficacious  in  the  treatment  of  melan- 
cholia.    (Fr.  salvatelle  ;  Ger,  Salvatella.) 

SAM'GVZM'B  TEIVIPERAIVIEN'T.  {See 

Temperaments.) 

SARDOZTZC  I.AUGH.  {See  Risus  Sar- 
DONICUS.) 

SATURNXNE    XN'SAM-ITY.      {See 

Lead.) 

SATVRZASZS. — This  word  denotes  a 
condition  of  morbid  excitement  of  the 
sexual  functions  in  the  male,  with  an 
irresistible  tendency  to  repeat  the  act 
frequently.  To  this  irresistible  impulse 
we  find  sometimes  superadded  insane 
ideas,  hallucinations,  and  disorders  of 
general  sensibility.  The  same  morbid 
condition,  when  occurring  in  the  female, 
has  received  the  name  of  nymphomania. 
In  order  not  to  repeat  ourselves,  we  refer 
the  reader  to  the  article  treating  of 
nymphomania,  which  comprises  the  whole 
question. 

Satyriasis  must  be  regarded  more  as  a 
symptom  than  a  special  and  distinct  affec- 
tion. It  appears,  in  fact,  as  a  symptom 
in  the  course  of  various  maladies,  but  in 
a  transitory  form,  and  its  duration  is  very 
short.  In  other  cases,  but  only  as  an  ex- 
ception, its  duration  is  long,  and  its  course 
chronic. 

Its  patIiolog;ical  causes  are  manifold. 
Lesions  of  brain  or  spinal  cord,  encephal- 
itis, myelitis,  htemorrhage,  softening, 
tumour,  traumatism,  and  compression; 
diseases  dating  from  intra-uterine  life  or 
from  early  childhood,  and  followed  by 
intellectual  and  physical  disorders  ;  de- 
formity of  the  vertebral  column  seems 
to   be   frequently  connected  with  a  dis- 


Satyriasis 


[     1 109    ] 


Satyriasis 


position  to  sexual  excitement.  Satyriasis 
also  may  occur  at  the  commencement  of 
various  forms  of  mental  disorder,  as  mania, 
congestive  mania,  generiil  paralysis,  epi- 
lepsy, moral  insanity,  and  all  varieties  of 
mental  degeneration  ;  in  alfections  of  the 
akin  of  the  genital  organs,  in  cases  of 
parasites  and  tumours  of  the  rectum,  and 
also  as  a  consequence  of  toxic  action  of 
various  medicines,  e.g.,  cantharides. 

Among  the  predisposing-  causes  it  is 
sufficient  to  mention  a  vicious  life  and 
immoral  books  and  pictures,  especially  if 
the  intellectual  life  is  limited.  In  de- 
generated individuals,  whose  imagination 
is  much  more  developed  than  tlieir  power 
of  judgment,  the  sexual  appetite  pre- 
dominates over  all  other  desires  and  wants, 
and  for  such  the  distance  between  desire 
and  act  is  very  short ;  thus  certain  crimes 
arise  which  have  become  much  more  fre- 
quent of  late  years.  They  are  all  the  work 
of  individuals  with  a  limited  intellect,  and 
all  bear  the  distinct  character  of  imitation. 
The  individual  has  read  about  or  seen  the 
scene  whicli  he  reproduces.  His  brain, 
apparently  gifted  with  fairly  normal  facul- 
ties, is  unable  to  resist  the  sexual  impulse ; 
and  there  is  at  the  time  no  thought  of  the 
responsibility  which  justice  afterwards 
will  claim  from  him.  In  some  patients  the 
insane  ideas  and  the  morbid  impulse  have 
their  common  cause  in  the  brain  as  well 
as  in  the  genital  organs.  This,  however, 
does  not  hold  good  for  all  cases,  for  there 
are  differences.  Extreme  abstinence,  as 
well  as  the  abuse  of  sexual  intercourse, 
may  produce  satyriasis.  The  authors  on 
this  subject  have  described  at  great  length 
the  disorders  and  murders  of  Gilles  deRetz, 
of  the  Marquess  de  Sade,  and  other  well- 
known  lunatics.  The  disorder  is  quite  as 
evident  in  the  case  of  the  curate  of  Cours 
as  in  the  tormented  existence  of  the  monks 
in  Egypt,  and  in  the  monasteries  every- 
where, the  history  of  which  tells  of  the 
passionate  struggles  with  the  evil  one. 
In  the  former  case  insanity  and  vice 
co-operate  ;  in  the  latter,  prolonged  ab- 
stinence and  mysticism  produce  aliena- 
tion, liegime  influences  the  want  of  in- 
tercourse more  than  climate.  The  sexual 
appetite  differs  according  to  race,  mode  of 
living,  and  education.  Toxic  agents,  like 
alcohol,  opium,  and  haschisch,  increase  at 
first,  but  diminish  and  extinguish  it  after- 
wards. 

Symptoms. — Satyriasis  shows  itself  by 
libidinous  ideas,  obscene  language,  and 
lascivious  gestures  and  attitudes,  showing 
the  morbid  proclivity  to  sexual  acts,  which 
nothing  except  a  material  obstacle  can 
restrain.  The  intensity  and  the  course 
of  the  phenomena,  as  well  as  the  termina- 


tion, depend  on  the  principal  disease. 
The  frequent  repetition  of  the  act  may  in 
the  long  run  pi-oduce  exhaustion,  and 
death  may  occur  in  coma ;  a  case,  however, 
which  is  rare.  The  symptoms  mentioned 
occur  frequently  at  the  commencement  of 
various  mental  disorders,  and  of  paralysis 
agitans,  and  are  of  short  duration  ;  but  it 
may  also  happen  that  in  degenerated  in- 
dividuals they  reappear  like  attacks  of 
mental  disorder  of  intermittent  form. 

iviedlco  -  Iiegal. —  Satyriasis  deserves 
attention  from  a  medico-legal  point  of 
view  with  regard  to  the  responsibility  of 
the  patient.  Generally,  it  is  not  found  in 
confirmed  insanity,  in  dementia,  or  in 
epilepsy,  and  it  varies  at  the  commence- 
ment of  general  paralysis,  of  moral  in- 
sanity, and  in  the  less  advanced  states  of 
mental  degeneration.  In  studying  these 
various  categories  of  patients  it  is  often 
difficult  to  say  whether  we  have  before  us 
a  lunatic  or  a  perverted  individual.  The 
act  committed  by  the  patient  is  at  first 
sight  in  no  way  different  from  the  action 
of  a  vicious  person.  When  we  are  obliged 
to  make  a  distinction  between  the  two,  we 
have  to  examine  their  whole  existences 
in  their  daily  manifestations,  and  then, 
although  certain  lunatics  and  certain 
criminals  present,  on  our  first  examina- 
tion, numerous  points  of  similarity  from  a 
social  and  criminal  point  of  view,  it  is 
found  possible  to  separate  them. 

Sexual  excitement  connected  with  sa- 
tyriasis may  develop  a  tendency  to  paeder- 
asty. All  paederasts  are  not  lunatics,  and 
with  many  it  is  an  acquired  vice,  deserving 
to  be  punished  at  the  hands  of  justice. 

Treatment. — A  patient  suffering  from 
satyriasis  must  in  any  case  be  seques- 
trated, in  his  own  interests  and  in  those 
of  society,  and  this  measure  must  be  taken 
as  soon  as  possible  in  order  to  avoid  acci- 
dents. In  the  first  period  of  general 
paralysis  there  exists  occasionally  sexual 
excitement,  which  may  bring  trouble  and 
scandal  into  conjugal  life. 

The  treatment  of  the  first  symptoms  of 
satyriasis  may  be  successful.  Bromide 
of  potassium,  bromide  of  camphor,  pro- 
longed baths,  and  saline  purgatives  are  the 
best  remedies.  The  principal  indication 
is  to  cure  the  disease  of  which  satyriasis 
is  a  symptom.  In  every  individual,  espe- 
cially in  the  young,  physical  strength  must 
be  developed,  and  the  mind  must  be  di- 
rected to  healthy  studies.  Satyriasis  is 
often  the  result  of  the  want  of  employment 
so  frequent  among  the  wealthy  classes,  es- 
pecially when  art  and  literature  exercise  a 
pernicious  infiuence  by  indelicate  repre- 
sentations and  descriptions. 

GUSTAVE  BoUCUEilEAU. 


Sauteuse 


[     mo    ] 


Scandinavia 


[References. — Sauvagc,  Nosologie  rndthodique 
Loude,  Dictioiinaire,  vol.  iii.  Slarc,  Ue  la  folic. 
Morel,  Traits  des  maladii's  meiitales.  Moti't,  Dic- 
tioniiairi',  Jaccoud.  Dechambru,  Diftionnaire  en- 
cyi'lopcdique.] 

SATTTEUSB    (Fr.).    Literally    dancer. 

{See    CONVULSIONNAIKES.I 

SCABXOPHOBZA.  {scabies  ;  0O(3ea),  I 
fear).  Morbid  fear  of,  or  erroneous  belief 
that  one  is  affected  with,  scabies. 

SCAN-DZNAVIA,  PROVISION 
FOR   THE  IN-SAN-E  IN. 

Sweden.* — The  tirst  traces  of  any  kind 
of  care  for  the  insane  in  Sweden  is  to  be 
found  in  the  Middle  Ages,  "  Houses  of 
the  Holy  Ghost,"  religious  establish- 
ments under  the  management  of  the 
Roman  Catholic  priests,  originally  des- 
tined for  the  lodging  and  nursing  of  the 
sick  poor,  but  receiving  some  insane 
patients  also. 

During  the  Reformation  (1527)  all 
monasteries  were  confiscated,  except  those 
which  acted  in  accordance  with  the 
"Houses  of  the  Holy  Ghost."  These 
were  by-and-by  transformed  into  asy- 
lums and  hospitals  which  were  partly 
occupied  by  the  insane.  The  largest  of 
these  asylums  was  founded  in  1531,  by 
Gustavus  I.,  on  the  "  Riddarholm "  at 
Stockholm;  it  was  in  1551  removed  to 
Danviken,  in  the  vicinity  of  the  capital, 
and  more  recently,  in  1861,  to  Koni'ads- 
berg,  and  has  been  erected  for  109  patients 
according  to  the  latest  views  of  asylum 
construction. 

As  the  general  care  for  the  sick  poor 
was  by  degrees  improved,  one  or  more 
establishments  for  this  purpose  were 
founded  within  every  county.  Con- 
nected with  these  were  arranged  small 
wards  for  the  insane.  These,  however, 
were  soon  found  to  be  insufficient  and 
defective,  and  at  the  beginning  of  the 
century  the  treatment  of  the  insane 
began  to  make  greater  strides  in  conse- 
quence of  the  increased  knowledge  of 
psychological  medicine. 

Small  county  hospitals  were  therefore 
abolished,  and  larger  special  asylums  for 
the  insane  were  erected  in  several  coun- 
ties. (Central  Hospitals,  1832.)  More 
recently  this  division  has  also  been  aban- 
doned, and  the  asylums  ai'e  now  opened 
to  patients  from  any  jjart  of  the  whole 
country.  The  supreme  government  of 
the  asylums,  from  the  year  1837  to 
1876,  was  vested  in  delegates  from  the 
"  Serafimer  Order,"  the  duties  of  which 
were  subsequently  taken  over  by  the 
Royal  Medical  College.  In  the  year  1858 
a  common  law  for  all  asylums  came  into 
operation. 

*  Coutribiited  by  Dr.  Tbure  lijiirek,  Lund. 


The     asylums   in    Sweden   which    are 
altogether  public  are  as  follows  : 


Stockholm  ( KouradsberL;- ) 

Patien 

.     265 

I'psala       .... 

.     400 

Nykoepini; 

•       70 

Vadstena  .... 

■     360 

Vexioe      .... 

220 

AVisby        .... 

•       30 

Maluioe     .... 

■     175 

Lund          .         .         . 

•     354 

Goeteborg-  (Flisingen) 

.     170 

Kristinehamii    . 

.     290 

Hernoesand 

.     221 

In  the  course  of  1890  were  opened: 
(i)  A  new  building  for  incurables 
(700)  in  connection  with  the  asylums 
at  Lund ;  (2)  A  new  asylum  in  the 
vicinity  of  Piteaa  for  300  patients.  Most 
of  these  asylums  are  up  to  the  modem 
requirements  of  psychological  medicine, 
and  aft'ord  the  opportunity  of  occupying 
the  patients  in  large  gardens,  and  with 
suitable  agricultural  labour. 

The  statistics  for  1887  give  the  num- 
ber of  insane  as  6885,  and  of  idiots  as 
4984  in  a  population  of  4,700,000.  Idiots 
with  dangei'ous  tendencies  are  confined  in 
public  asylums,  but  for  the  most  part 
idiots  are  placed  by  the  municipal  autho- 
rities under  their  charge  in  special 
schools.  There  exist  fourteen  schools 
of  this  description,  in  all  for  343  idiots, 
with  subvention  from  the  State.  More- 
over, five  workhouses  for  adult  idiots 
have  been  founded  (1857).  These  estab- 
lishments are  for  the  most  part  due  to 
the  energy  of  Professor  Kjellberg,  in  1856 
medical  superintendent  of  the  asylum  at 
ITpsala,  who  has  done  much  to  forward 
the  claims  of  psychological  medicine  in 
Sweden. 

Clinical  lectures  on  psychiatry  are 
given  at  the  Universities  of  Upsala, 
Stockholm,  and  Lund,  and  every  medical 
student  is  obliged  to  be  on  duty  in  an 
asylum  for  two  months  before  he  can  be 
admitted  for  the  final  medical  examina- 
tion. 

TTorway.* — Even  in  the  early  ages  of 
N'orwegian  history  mention  is  made  of 
mental  diseases.  The  notorious  Eang 
Sigurrd  Jorsalfar  (1130)  suffered  from 
melancholia  with  hallucinations ;  while 
the  state  of  unbridled  fury  mentioned  by 
the  sagas,  or  mythological  traditions  of 
the  North,  and  known  as  "  Berserkgang,'" 
in  the  opinion  of  the  historian  Munch, 
was  a  periodical  insanity,  the  subjects  of 
which  were  under  the  influence  of  an  un- 
controllable homicidal  and  destructive 
impulse ;  those  thus  afflicted  sought  by 
vows  to  the  deities  to  be  freed  from  their 

*  Contributed  by  Dr.  M.  Holmboe,  Kotvold,  Nor- 
waj'. 


Scandinavia 


[     nil     ] 


Scandinavia 


malady.  At  a  later  period  the  persecution 
of  sorceresses  showed  the  extent  to  which 
the  demonopathy  of  witchcraft  had  taken 
root  in  the  northern  as  in  the  southern 
countries  of  Europe.  Besides  this  we 
know  little  or  nothing  about  the  condition 
of  the  insane  in  j^ast  ages.  No  public 
provident  care  for  them  existed ;  they 
were,  it  seems,  under  the  care  of  their 
relatives,  or  allowed  to  roam  about  at 
their  own  free  will.  Later  the  prisons 
became  the  receptacles  of  the  more  dan- 
gerous section  when  relatives  and  friends 
were  incai)able  of  properly  taking  care  of 
them. 

The  first  sign  that  the  welfare  of  the 
insane  was  regarded  as  a  State  concern 
was  given  by  the  royal  rescript  issued  in 
1736,  enjoining  that  in  all  the  chief  hos- 
pitals of  the  kingdom  one  or  two  rooms 
should  be  set  apart  for  the  reception  and 
safe  custody  of  the  insane  poor,  "  that 
they  should  not  easily  break  out  there- 
from." In  accordance  with  this  rescript, 
reception  rooms  were  by  degrees  ar- 
ranged in  the  hospitals  of  Oslo,  Bergen, 
Throndhjem,  Christianssand,  Stavanger, 
Arendal,  and  in  the  district  of  Hede- 
marken.  These  rooms  were  called  "  Doll- 
huse,"  or  "  Daare-kister ; "  they  were 
destined  only  for  the  detention  of  the 
most  dangerous  of  the  insane,  and  their 
arrangement  and  accommodation  were 
dismal  and  defective. 

The  agitation  on  behalf  of  an  improve- 
ment in  the  condition  of  the  insane  which 
arose  about  the  beginning  of  the  century 
in  most  civilised  nations,  in  a  short  time 
also  reached  Norway.  In  1824  the  atten- 
tion of  the  Storthing  (Parliament)  was 
called  to  the  wretched  state  of  some  of  the 
above-mentioned  madhouses, and  itwasde- 
mandedof  the  Government  that  they  should 
appoint  a  committee  for  the  investigation 
of  this  matter,  and  in  the  next  year  a 
commission  was  constituted,  the  result  of 
whose  investigations  was  made  public  in 
1828,  by  an  account  written  by  one  of  its 
members,  Fr.  Bolst,  jirofessor  of  medicine. 
He  clearly  demonstrated  the  defective  and 
unsuitable  state  of  the  above-mentioned 
houses,  and  proposed  the  founding  of  a 
number  of  new  establishments  for  the 
treatment  of  the  insane  at  the  public  ex- 
pense. A  long  period,  however,  elapsed 
before  any  public  benefit  resulted  from 
these  proposals,  financial  difficulties  in  all 
probability  causing  the  delay. 

It  was  not  before  the  year  1843  that 
the  matter  was  taken  in  hand  again  by 
the  physician,  H.  Major.  In  eloquent 
terms  he  described  the  wretched  condition 
in  which  the  insane  lived,  and  the  un- 
justifiable, and  very  often  cruel,  treatment 


to  which  they  were  subjected.  His  warm 
and  energetic  appeal  succeeded  in  raising 
a  strong  opinion  in  favour  of  an  improve- 
ment in  the  treatment  of  the  insane ;  and 
the  result  was  the  first  step  towards  the 
amelioration  of  their  condition — the  found- 
ing of  the  first  State  asylum  for  the  in- 
sane, atGaustad,  near  Christiania  (opened 
in  1855),  and  the  passing  of  the  Norwe- 
gian Lunacy  Law  by  the  Storthing  in 
1848.  By  this  law,  which  is  still  in  force, 
every  asylum  and  other  establishment  for 
the  custody  of  the  insane  must  obtain 
ro5"al  authority,  and  the  conditions  under 
which  such  is  granted  are  merely  that  a 
modernised  and  humane  method  of  treat- 
ment shall  be  carried  out.  Patients  are 
to  be  employed  in  becoming  labour,  are 
to  live  together  socially,  are  to  have  exer- 
cise in  the  open  air  ;  isolated  confinement 
and  mechanical  restraint  are  only  to  be 
resorted  to  for  a  short  time  and  when  the 
state  of  the  patient  makes  it  absohttely 
necessary ;  the  association  of  the  insane 
withcriminals  is  interdicted.  Every  lunatic 
asylum  has  to  be  directed  by  an  autho- 
rised physician,  and  his  management  is 
controlled  by  a  committee  appointed  by 
the  Crovernment,  among  the  members  of 
which  one  at  least  must  be  a  physician. 
The  insane  placed  with  private  families 
are  also  to  be  under  the  supervision  of 
physicians ;  and  no  patient  is  to  be 
secluded  without  notice  of  the  matter 
being  given  to  a  physician,  who  has  to 
investigate  the  necessity  and  advisability 
thereof.  The  expenses  for  the  care  of  the 
insane  poor  are  charged  upon  the  towns 
and  counties. 

The  successful  working  of  the  asylum 
at  Gaustad,  and  the  important  literary 
productions  as  to  the  cause  and  spread 
of  mental  disease  in  Norway  published 
by  its  physicians,  Sandberg  and  L.  Dahl, 
effectively  maintained  and  promoted  the 
public  interest  in  the  improvement  of  the 
condition  of  the  insane.  By  degrees  the 
Storthing  voted  sums  of  money  for  the 
building  of  two  new  State  asylums, 
ada]3ted  to  the  demands  of  our  time — 
Rotvold,  near  Throndhjem  (opened  in 
1872),  and  Eg,  near  Ohi-istianssand 
(opened  in  1881).  Besides  these,  several 
of  the  older  establishments  above  named 
have  undergone  considerable  improve- 
ment, and  still  exist  as  municipal  asylums. 
At  Bergen  a  new  municipal  asylum  is  in 
course  of  construction. 

The  census  of  1865  shows  that  there 
were  in  Norway  2039  idiots,  3156  cases  of 
acquired  mental  disease,  or  a  total  of 
5195  insane.  This  gives  a  proportionate 
ratio  to  the  population  of  idiots  1.835,  of 
acquired  mental  diseases  1.529,  and  of  the 


Scandinavia 


[      "12      ] 


Scandinavia 


total  number  of  insane  1.327  per  1000. 
A  comparison  with  past  enumerations 
shows  that  there  is  a  relative  increase  in 
the  number  of  those  suffering  from  ac- 
quired mental  disease,  while  there  is  a 
decrease  in  the  number  of  idiots.  The 
last  census  of  1875  made  the  number  of 
insane  to  be  4568,  or  a  proportion  of 
1.398  per  1000;  but,  no  distinction  being 
made  between  idiocy  and  acquired  mental 
disease,  these  numbers  are  unfavourable 
for  comparison  with  past  enumerations. 
From  all  the  computations  made,  it  ap- 
pears that  mental  disease  is  more  preva- 
lent in  the  southern  parts  of  the  country, 
less  widely  distributed  in  the  north. 

At  the  present  time  Norway  has  eleven 
lunatic  asylums  in  use,  with  the  following 
average  number  of  insane  (in  1887)  : — 
(a)  asylums  founded  and  managed  by 
the  State — Gaustad  324,  Eg  242,  Rotvold 
224,  or  a  total  of  790 ;  (6)  municipal 
asylums  and  those  founded  by  charitable 
associations — Christiania  108,  Oslo  40, 
Christianssand  24,  Stavanger  8,  Bergen 
65,  Throndhjem  80,  or  a  total  of  325  ; 
(c)  private  asylums — Rosenbei'gs  160, 
Mollemdal  63  (both  at  Bergen),  a  total 
of  223.  Thus,  taken  as  a  whole,  the 
asylums  of  Norway  accommodate  1338 
insane,  the  accommodation,  however, 
being  frequently  inadequate,  and  in  view 
of  providing  for  this,  some  asylums 
(Christianssand,  Gaustad,  and  Rotvold) 
have  endeavoured  to  place  dements  with- 
out dangerous  tendencies  in  private  fami- 
lies residing  in  their  vicinity,  under  the 
constant  supervision  of  their  several 
physicians.  This  system  is  mainly  in 
vogue  at  Rotvold,  where  at  present  70 
insane  are  placed  out  in  this  manner. 
For  idiots  three  private  educational  estab- 
lishments, with  subventions  from  the 
State,  have  l)een  founded,  two  at  Chris- 
tiania,  one  near  Bergen. 

At  the  Norwegian  University  psycholo- 
gical medicine  is  not  yet  recognised  as  a 
distinct  branch  of  medical  education. 
Courses  of  clinical  lectures  on  mental  dis- 
eases are  given  every  year  by  the  super- 
intendent physician  of  Ganstad  Asylum 
to  a  limited  number  of  medical  students. 

[licferences. — 1*.  A.  Munch,  Det  norske  Folks 
Historie,  1852-53.  Fr.  Hoist,  IJeretuing  fia  en  etc-. 
i  Aaret  1825,  ua:uligst  uedsat  kongelig  Kunimis- 
sion.  H.  Major,  ludbfretning-  oui  >Siudssygel'or- 
holdene  i  Norge  i  1846.  L.  Dahl,  IJidragtil  Kund- 
skab  om  de  Sindssyge  i  Noj-ge  den  31.  December 
1865.     iSandberg,  Gaustad,  1855-70.] 

[Note. — Since  the  foregoing  article  was  written 
Dr.  Ilabgood,  senior  assistant  medical  officer,  Kent 
County  Asylum,  Maidstone,  has  contributed  an 
article  to  the  Journal  of  Mental  Science,  Jimna,ry 
1892,  the  I'esult  of  a  visit  to  the  Norway  asylums. 
Referring  to  the  preponderance  of  melancholia 
over  mania  in  that  country,  he  observes  that  "  the 


distribution  of  a  small  population  over  a  large 
tract  of  country,  the  mountainous  character  of  that 
country,  the  monotony  of  life,  the  lack  of  amuse- 
ment, the  phlegmatic  character  of  the  race,  in  con- 
trast to  the  crowded  condition  of  the  people,  the 
high  tension  of  living,  and  the  excitement  of  city 
life  which  prevail  in  England,  probably  explain 
the  difference  between  the  two  countries.  The 
small  number — 1.9  per  cent,  of  the  admissions 
(being  6.4  less  than  in  England) — of  those  suffer- 
ing from  general  paralysis  might  be  explained  in 
the  same  manner."  He  states  that  the  eleven 
asylums  (three  (Government,  six  municipal,  and  two 
private)  are  under  the  control  of  the  Medical  De- 
partment of  the  Ministry  of  Justice.  The  King 
appoints  the  superintendent  of  the  Government 
asylums.  While  speaking  favourably  of  the  Xew 
Jlunicipal  Asylum  at  Bergen,  Dr.  Habgood  ob- 
serves that  the  rooms  used  for  the  seclusion  of 
maniacal  cases  with  destructive  propensities  con- 
tained nothing  but  a  heap  of  straw,  the  patient 
himself  being  naked.  Observation  is  carried  on 
through  lantern-lights  in  the  roof  by  an  attendant 
who  walks  np  and  down  on  a  place  provided  on 
the  roof.  "  The  medical  officers  defend  the  method 
by  arguing  that  it  is  useless  to  give  clothes  and 
bedding  to  those  who  will  not  only  not  use  them, 
but  destroy  them  as  fast  as  they  are  supplied." — 
Ei>.] 

Denmark. — In  former  times  the  care 
of  the  insane  was  considered  to  be  a 
private  matter,  and  the  first  disposition 
on  the  part  of  the  State  to  interest  itself 
in  their  condition  was  manifested  by  the 
fact  that  Christian  IV.  ordered  in  the 
year  1632  the  construction  of  daareJciste 
in  connection  with  the  "  pest-house  *'  at 
Copenhagen.  Originally  this  pest-house 
was  a  domus  leprosorum;  later  it  was 
used  for  the  common  epidemic  diseases 
under  the  name  of  St.  Hans  Hospital. 
In  the  course  of  the  following  century 
similar  rooms  of  confinement  were  ar- 
ranged in  connection  with  the  common 
hospitals  of  nearly  the  whole  kingdom. 
The  purpose  of  these  establishments, 
however,  was  the  protection  of  the  com- 
munity from  the  insane,  not  the  ameliora- 
tion of  the  condition  of  the  insane  them- 
selves. The  veritable  reform  of  Danish 
psychiatry  is  to  be  dated  from  the  year 
1808,  when  the  city  of  Coi^enhagen 
bought  "  Bidstrupgaard,"  in  the  vicinity 
of  Roskilde,  about  sixteen  (English)  miles 
from  the  capital,  and  built  on  the  spot  an 
asylum,  which  was  ready  for  occupation 
in  1 8 16,  and  was  therefore  one  of  the 
earliest  established  asylums  of  the  Con- 
tinent. Its  official  name  was  converted 
into  St.  Hans  Hospital,  with  the  addi- 
tion of  "  Claude  Rosset's  Stittelse,"  in 
memory  of  a  French  emigrant  who  en- 
riched the  asylum  with  an  endowment. 

In  1820  the  asylum  of  Schleswig  was 
founded,  at  that  time  belonging  to  the 
Danish  monarchy.  Originally  built  after 
designs  by  Esquirol,  it  has  lately  been 
considerably  enlarged,  and  is  now  under 
the  German  Government. 


Scandinavia 


[     1113    ] 


Scandinavia 


The  next  period  of  iniiiortance  in  the 
history  of  Danish  jisychiatry  is  the  be- 
ginning of  the  fourth  decade  of  this 
century,  when  a  philanthropic  and 
scientific  reformation  was  started  by  the 
late  Dr.  Hiibertz  and  Dr.  Selmer,  lead- 
ing to  a  total  re-organisation  of  the  lunatic 
establishments  of  the  country  in  accord- 
ance with  modern  principles.  These 
efforts  resulted  in  the  foundation  of  the 
first  provincial  asylum  near  Aarhus  on 
Jylland,  in  1852,  of  which  Selmer  be- 
came the  medical  superintendent;  and 
next,  in  1858,  Oringe,  in  the  vicinity  of 
Vordingborg  (Sjaslland),  and  the  rebuild- 
ing of  St.  Hans  Hospital  (i860).  The 
latter,  which  iireviously  had  given  room, 
in  addition  to  the  insane,  to  some  old  and 
infirm  sick  poor,  was  arranged  only  for 
the  purpose  of  cure.  More  recently  it 
has  become  necessary  to  build  several 
houses  for  incurables.  The  St.  Hans 
Hospital  admits  only  the  insane  of  Copen- 
hagen ;  it  is  now  unfortunately  too  small, 
and  will  be  further  enlarged.  It  has 
been  sui^erintended  since  1863  by  Pro- 
fessor Steenberg,  renowned  for  his  re- 
searches in  syphilitic  cerebral  disorders, 
ixntil  the  present  month  (March  1892), 
when  he  died.  In  addition  to  the  en- 
largement of  the  asylum  for  the  capital, 
it  has  been  necessary,  during  the  past 
ten  years,  to  erect  new  asylums  for  the 
rest  of  the  country  (Viborg,  1877,  for  in- 
curables;  Middelfort,  1888).  The  ward 
for  insane  patients  at  the  "  Communal 
Hospital "  in  Copenhagen,  which  is  con- 
nected with  a  ward  for  diseases  of  the 
nervous  system,  is  intended  for  the  pro- 
visional admission  of  the  insane  of  the 
capital,  and  for  the  observation  of  crimi- 
nals. It  has  of  late  been  enlarged  to  the 
extent  of  fifty-five  beds.  In  the  above- 
mentioned  asylums  the  number  of  patients 
is  as  follows : 

Patients. 
St.  Hans  Hospital    .         ,         .     990* 
Aarhus    .....     ^40 

Oringe 450 

A'iborg 340 

Middelfort        ....     400 

Besides  these  asylums,  some  of  the  old 
establishments  were  chiefly  erected  as 
workhouses,  and  they  are  still  in  use 
for  the  reception  of  insane  patients — 
namely : 

Patients. 
Koskilde  .         .     with  about  50 

Holbaik   .         .         .         „         „      12 
Soro  .  .  .  „         ,,35 

'"'t'-'gf        •  •  ■  »         „      74 

.Saxkoebinj      .         .         „         „     88 
JIariager  .         .         „        „      30 

*  There  will  be  an  additional  separate  building,'-, 
providing  for  250  patients. 


Spread  over  the  country  there  are  to 
be  found  single  patients  or  a  small 
number  of  insane  under  private  care, 
but  no  true  private  asylums.  This  is  in 
all  probability  because  the  public  asylums 
are  open  to  patients  of  the  higher  classes, 
who  pay  an  extra  fee. 

The  census  of  1880  gave  the  number  of 
3,263  insane,  a  proportion  to  the  popula- 
tion of  1.6  per  1000.  Besides  these  there 
were  recorded  2602  idiots  (1.3  per  1000). 
Only  about  one-tenth  of  the  idiots  are  con- 
fined in  special  "  schools,"  partly  public, 
partly  private,  with  assistance  from  the 
State. 

Clinical  lectures  on  mental  diseases  are 
given  in  the  ward  for  the  insane  in  the 
Communal  Hospital.  Moreover,  an  op- 
portunity is  granted  for  junior  assistant- 
physicians  to  be  on  duty  for  some  months 
in  the  asylums. 

From  the  statistical  report  on  mental 
diseases  in  asylums  in  Scandinavia  pre- 
sented to  the  International  Medical  Con- 
gress at  Copenhagen  in  1884  by  Prof. 
Steenberg,  we  find  that  the  number  of 
insane  in  Finland  was  at  that  time  4400, 
or  21.2  per  10,000,  a  higher  proportion 
than  in  Norway,  Sweden,  or  Denmark.  In 
1 77 1,  forty  beds  for  the  insane  were  pro- 
vided in  the  old  leper  hospital  Sjahlo ; 
but  it  was  not  until  the  foundation  of 
an  asylum  at  Lappvik  in  1841  that  an 
attempt  was  made  to  treat  the  insane. 
At  the  same  date  some  cells  were  set  apart 
for  this  class  in  all  the  hospitals  in  the 
country,  where  the  authorities  were  obliged 
to  place  lunatics  in  the  neighbourhood  for 
treatment.  In  1884  there  were  two  old 
asylums  (Sjahlo  and  Lappvik),  five  recep- 
tion houses,  and  an  entirely  new  hospital 
at  Kuopio ;  subsequently,  also,  at  Kex- 
holm  and  at  Tammarfors. 

In  the  most  recent  publication  having 
reference  to  the  insane  in  Denmark  *  it  is 
stated  that  there  were  at  the  beginning  of 
1890  a  little  more  than  1000  patients  in 
the  asylums  of  Coj^enhagen,  which  would  be 
about  the  whole  number  in  this  town.  As 
the  population  is  somewhat  over  300,000, 
the  rate  would  be  about  one  insane  to 
every  300  inhabitants.  If  this  scale  were 
applied  to  the  rest  of  the  country,  whose 
population  is  exactly  six  times  as  large, 
the  total  number  of  the  insane  would  be 
6000,  but  this  figure  is  certainly  too  high. 
A  metropolitan  population  produces  more 
lunatics  than  a  rural  population  ;  instances 
need  only  be  given  of  the  greater  number 
of  cases  of  general  paralysis  among  the 

*  "  Denmark  ;  its  Medical  Organisation,  Hj-- 
gieue,  iind  Demography ''  (presented  to  the  Seventh 
International  ('oni;Tess  of  Hygiene  and  Uemo- 
graphy,  London,  1891). 


Scandinavia 


[    1114    ] 


Sclerencephalia 


former  than  the  latter.  In  1889  these 
represented  one-seventh  of  the  patients 
sent  to  the  asyhims  from  Copenhagen, 
which,  in  proportion  to  the  population,  is 
nearly  nine  times  as  many  as  from  the 
rest  of  the  counti'y,  but  how  great  the 
difference  is  altogether  can  scarcely  be 
determined.*  From  the  returns  made 
in  i860,  1870,  1880,  and  appi'oximately 
in  1890,  of  the  number  of  insane  in 
Denmark,  it  appears  that  in  the  first 
twenty  years  "  the  number  has  been 
steadily  and  gradually  increasing ;  in  the 
first  decade  with  578,  and  in  the  second 
with  809.  Presuming  (what  everything 
tends  to  prove)  that  this  increase  has  also 
continued  at  the  same  rate  in  the  third 
decade,  the  number  given  by  the  recent 
census  of  1890  will  be  about  4300.  This 
number  would  be  too  low,  just  as  the 
figures,  6000,  obtained  by  judging  from  the 
number  of  insane  in  Copenhagen,  were  too 
high.  The  correct  number  must  be  be- 
tween these — namely,  5150,  or  about  one 
to  each  390  inhabitants.  Of  these  it  is 
known  that  a  little  above  1000  are  found  in 
Copenhagen.  The  rest,  about  4 1 50,  would 
therefore  reside  in  the  country." 

It  is  stated  in  the  same  document,  with 
regard  to  inebriety  as  the  cause  of  insanity, 
that  it  stands  at  10.2  per  cent,  of  the 
admissions  taking  the  whole  of  Denmark. 
In  Copenhagen  it  is  11.5  per  cent. — in 
other  words,  one-tenth  of  the  individuals 
admitted  into  asylums  have  themselves 
caused  their  disease  through  drink.f 

With  regard  to  restraint,  it  is  observed  : 
"  Conolly's  endeavoui's  to  do  away  with 
the  mechanical  restraint  reached  this 
countiy  a  little  more  than  twenty  years 
ago,  and  for  several  years  this  system  was 
consistently  carried  out,  but  by-and-by 
less  doctrinaire  opinions  became  prevalent. 
It  is  not  only  by  doing  away  with  the 
abuse  of  mechanical  restraint  that  the 
striving  for  liberty  manifests  itself,  but 
also  by  making  the  wards  more  open,  and 
the  life  in  them  less  restrained."  J 

"With  regard  to  the  number  of  imbeciles 
(including  idiots),  statistics  were  obtained 
in  1845,  but,  as  in  all  other  countries,  they 
must  have  been  very  imperfect,  and  the 
same  remark  applies  to  census  returns  in 
subsequent  years.  In  1888-89  more  ac- 
curate information  was  obtained,  with  the 
result  that  3907  of  the  population  were 
found  to  be  idiotic  or  feeble-minded.  It 
is  stated  that  the  actual  number  of  imbe- 
ciles may  be  estimated  at  about  5000,  and 
that  while  the  imbecile  rate  for  the  whole 
country  is,  according  to  the  figures,  18  per 
10,000  inhabitants,  it  is  in  fact  nearer  25 

*  Op.  cit.  p.  399.  t  Oj).  cit.  ]).  405. 

;J:  Oj).  cit.  p.  410. 


per  10,000.  It  is  observed  that  the  social 
condition  appears  to  have  no  influence 
upon  the  distribution  of  imbecility  in  the 
agricultural  classes.  Of  all  the  cases  there 
were  about  85  per  cent,  congenital.  With 
regard  to  their  care  it  appears  that  Dr. 
Hiibertz  took  up  the  idea  of  improving 
their  education  at  the  time  that  Guggen- 
biihl  was  prominently  before  the  world. 
Only  a  small  proportion  of  imbeciles  in 
Denmark  are  cared  for  in  asylums ;  the 
rest  are  at  home  or  in  workhouses,  and 
are  not  subject  to  official  inspection.  In 
order  to  advance  from  the  existing  inade- 
quate provision  for  imbeciles  in  this 
country,  it  will  be  necessary  to  be  content 
to  wait  for  many  years.  Such  is  a  state- 
ment by  Di\  Chr.  Keller,  who  has  an  insti- 
tution for  500  imbeciles.  The  first  Danish 
imbecile  institution  was  opened  in  1855  ^^ 
Gamle  Bakkehus,  in  the  vicinity  of  Copen- 
hagen. The  institution  was  removed  in 
i860  to  a  more  suitable  building,  and  ac- 
commodates 60  imbeciles.  It  is  called 
"  The  Institution  for  the  Care  of  Feeble- 
minded Children."  A  large  building  is 
about  to  be  opened,  which  will  accommo- 
date 460.  It  is  situate  at  Ebberodgward. 
The  sujierintendent  is  Dr.  Friis.* 

KXUD   PONTOPPIDAN. 

SCiiPHOCSPHAI.XC  ZDIOCT,  {See 
Idiocy,  Forms  oi\) 

SCAPH0CZ:PHAI.VS  {aKd(})r],  a  boat ; 
Ke(j)aXrj,  the  head).  A  form  of  head  some- 
times noticed  in  congenital  idiocy,  in 
which  the  shape  is  like  the  keel  of  a  boat 
upside  down.  The  head  is  out  of  all  pro- 
portion larger  in  the  antero-posterior 
diameter  than  in  the  transverse. 

sCARiiA.TZN'A.  (See  Post-febrile 
Insanity.) 

SCATOPHACZA  {(TKaTos,  excrement ; 
cf)ayeh,  to  eat).  Synonym  of  Coprophagia 
iq.v.).     (Ger.  Skatopliagie,  q.v.) 

SCHZ:ZN-BII.D  (Ger.).     An  illusion. 

SCHi.AFGAN'Cz:R(Ger.).  A  somnam- 
bulist. 

SCHI.AFSUCHT,  SCHIiAFKRASriC- 
HZiIT  (Ger.).  Abnormal  somnolency,  nar- 
colepsy. 

SCHOOX.S,  ASYI.VM.  {See  Treat- 
ment.) 

SC  KWAIT  GSRS  C  HAFT  S'WAHM- 

(Ger.).     Puerperal  insanity. 

SCH-WERMVTK  (Ger.).  A  term  for 
melancholia. 

SCZI.I.OCEPHAI.VS  (sciUa,  the  squill; 
KecpaXr],  the  head).  Term  for  a  small 
peaked  head,  seen  sometimes  in  idiots. 
(Fr.  scillocephale.) 

SCIiEREN'CEPHAI.IA  {aKXrjpos,  hard ; 
(■yKefpaXos,  the  brain).     Induration  of  the 
brain.     Cerebral  sclerosis. 
*  Op.  cit.  p.  413. 


Scotland,  Asylums  in         [ 


]        Scottish  Lunacy  Law 


SCOTIiASTD,  ASYX.VIMCS  iw.  (See 
Grkat  Britain,  Insanity  in  ;  and  Royal 
Scottish  Asylums.) 

SCOTTISH   IiiriVACY   I.A"W.* 

From  the  earliest  records  it  would  appear 
that  the  Sovereign,  aspt/('/-j)a/riae,  was  the 
natural  and  legal  guardian  of  the  insane.f 
The  ward  and  custody  of  the  property  of 
lunatics  were  deputed  to  tutors,  ap- 
pointed after  cognition  by  inquest.  These 
were  selected  as  being  kinsmen  of  lawful 
age,  men  of  judgment,  discretion,  and 
rule.  By  a  statute  of  Robert  I.,  in  the 
beginning  of  the  fourteenth  century,  the 
custody  of  persons  of  furious  mind  was 
devolved  upon  their  relations,  and,  failing 
them,  ujion  the  sheriff  of  the  county. 
According  to  Sir  Thomas  Craig,  there  was 
a  distinction  between  the  "fatuous"  and 
the  "  furious."  The  custody  of  the  former 
was  committed  to  the  nearest  agnate  J 
(nearest  male  relative  on  the  father's 
side),  while  that  of  the  latter  belonged  to 
the  Crown,  as  having  the  sole  power  of 
coercing  with  fetters.  Legal  procedure 
was  more  definitely  settled  by  the  statute 
of  1474,  cap.  67,  which  was  amended  by 
the  Act  of  1585,  cap.  18;  and  these 
statutes  continued  to  regulate  the  ap- 
pointment of  tutors-at-laiv  until  1868, 
when  the  Court  of  Session  Act  (31  &  32 
Vict.  cap.  100)  was  passed,  and  provided 
for  cognition  of  the  insane  as  described 
under  that  heading. 

Another  class  of  guardians  to  lunatics 
are  termed  tutors-dative.  This  process 
has  fallen  into  disuse  for  many  years,  and 
has  now  merely  an  antiquarian  interest. 

Judicial  factors,  or  curators  bonis, 
are  at  the  present  time  by  far  the  most 
important  functionaries  in  this  depart- 
ment. They  are  appointed  by  the  Court 
of  Session  or  by  the  sheriffs  under  the 
regulations  described  under  curatory  of 
tlie  insane.  The  practice  seems  to  have 
originated  in  the  nohile  officium  inherent 
in  the  Court  of  Session  as  the  supreme 
court  of  equity  in  Scotland.  The  nomina- 
tion of  judicial  factors  has  now  practically 
superseded  the  more  ancient  procedure, 
so  that  the  cumbrous  and  costly  process 
of  cognition  has  become  almost  extinct. 

There  is  another  remedy  provided   by 
the  law  of  Scotland  for  the  protection  of 
silly,  imbecile,  or  facile  persons  who  are 
lavish,   improvident,    or   careless    in   the 
management  of  their  property.    This  pro- 
cedure is   called  interdiction,  which  has 
been  defined  as  "  a   legal   restraint   laid 
upon  those  who,  either  through  their  pro- 
fuseness  or  the  e.xtreme  facility  of  their 
*  See  also  Ci  ratokv  iuid  ('ocmtion. 
t  Craig-,  .Jus.  l-'ciuliile,  lib.  ii.  cap.  20. 
t  Adopted  from  the  Komau  Law. 


tempers,  are  too  easily  induced  to  make 
hurtful  conveyances,  by  which  they  are 
disabled  from  signing  any  deed  to  their 
prejudice  without  the  consent  of  curators, 
who  are  called  interdictors."  Interdic- 
tion may  be  either  {a)  voluntary  or  {b) 
judicial. 

(a)  Voluntary  Interdiction.  —  This 
was  of  frequent  occurrence  in  ancient 
times.  An  Act  j^assed  in  1581  regulated 
it  in  some  measure,  and  it  was  formally 
sanctioned  in  the  seventeenth  century. 
Voluntary  interdiction  proceeds  upon  exe- 
cution of  a  deed,  or  bond  of  interdiction, 
narrating  the  weakness  of  the  grantor  as 
the  cause,  declaring  confidence  in  persons 
to  be  named  (the  interdictors),  which 
binds  the  party  not  to  alienate  "  his  lands, 
teinds,  heritages,  annual  rents,  life  rents, 
reversions,  tacks,  or  others  ;  nor  to  grant 
dispositions  or  assignations,  nor  bonds, 
obligations,  or  contracts ;  nor  to  become 
cautioner  for  sums  of  money,  or  to  per- 
form acts  and  deeds,"  without  the  concur- 
rence of  his  interdictors.  There  must  be 
a  valid  cause,  or  the  deed  may  be  set  aside 
by  the  courts.  Prodigality  and  injury  to 
the  family  must  be  conjoined  with  mental 
weakness  and  facility.  But  the  cause  may 
be  scarcely  referred  to  in  the  bond.  It  is 
imperative  that  the  bond  be  recorded  in 
the  register  known  as  the  "  Books  of 
Council  and  Session,"  *  whereby  it  is  held 
to  be  published  to  the  lieges  and  made 
patent  to  all. 

(5)  Judicial  interdiction  is  obtained 
by  decree  of  the  Supreme  Court,  after 
proof  being  led  as  to  the  facility  and 
weakness.  In  modern  practice,  the  rela- 
tions may  institute  proceedings  for  inter- 
diction when  the  defects  of  the  proclirjiis 
are  not  sufficiently  marked  for  cognition 
or  curatory.  Or  it  may  proceed  from  the 
nohile  ojjicium  of  the  Court  themselves, 
when  they  perceive  that  a  party  to  any 
suit  before  them  is  liable  to  imposition, 
from  an  extreme  profuseness  and  facility 
of  temper.f  This  not  being  an  actio 
2]opuIaris,  neither  the  Lord  Advocate  nor 
the  public  can  interfere.  The  summons 
states  that  the  jjerson  is  "  of  weak  and 
facile  disposition,  easily  imposed  on  and 
liable  to  do  deeds  to  his  own  lesion  and 
prejudice."  The  Court  will  name  inter- 
dictors without  whose  consent  there 
would  be  no  power  of  alienating  heritage 
or  of  contracting  debts,  if  the  action  be 
unopposed.  If  the  Court  proceeds  to 
proof,  the  defender  must  appear  ;  and,  if 
the  interdiction  is  granted,  it  is  published 

*  General  Register  of  Inbibitious  (31  &  32 
Vict.  c.  64,  8.  16). 

t  Keport  of  i)roceu(liiiL;8  under  a  brieve  of  Idio- 
try :  Duncan  r.  Voolow,  by  L.  Colquhoun,  1837. 


Scottish  Lunacy  Law        [    1116    ]        Scottish  Lunacy  Law 


and  registered.  The  interdictors  must 
be  of  perfect  age  and  sane  mind.  They 
have  no  trust,  no  management.  Their 
duties  are  rather  negative  than  positive, 
as  they  do  not  originate  deeds,  but  merely 
adhibit  their  consent.  The  interdiction 
terminates  by  sentence  of  Court ;  by 
death  ;  if  statements  in  the  original  deed 
are  false ;  if  re-convalescence  can  be  de- 
clared. Voluntary  interdiction  cannot  be 
recalled  by  the  person  interdicted  without 
the  consent  of  his  interdictors,  and  if 
there  be  a  failure  of  a  quorum  of  these  he 
must  aj^ply  for  others.  But  there  are  so 
many  exceptions  and  limitations  to  the 
bond  of  interdiction  that  it  is  not  often 
in  use.  For  instance,  it  only  affects  heri- 
tage and  no  other  property.  Rational 
and  onerous  deeds,  moderate  and  reason- 
able tradesmen's  accounts,  are  also  ex- 
cepted. Moreover,  the  whole  system  of 
interdiction  may  be  rendered  futile  by 
imprisonment  for  non-payment  of  debt* 
— for  the  Courts  will  not  grant  relief, 
although  the  party  interdicted  may  have 
to  bui'den  his  lands. 

Besides  these  remedies,  which  have  re- 
ference, chiefly,  though  not  exclusively,  to 
the  future  protection  of  persons  of  deficient 
capacity,  a  retrospective  remedy  is  pro- 
vided by  the  action  of  Reduction  on  the 
ground  of  insanity,  or  idiocy,  or  facility, 
fraud,  and  lesion  as  the  case  may  be. 
And  this  last  remedy  seems  to  reach  all 
those  causes  by  which  an  individual  may 
be  injured  by  the  weakness  of  his  intellect, 
even  where  the  defect  is  not  so  grave  as 
to  render  him  a  proper  subject  for  curatory 
or  interdiction.  Of  course,  it  has  been 
decided  by  the  highest  authority  that 
even  insane  persons  can  execute  valid 
deeds,  but  the  circumstances  under  which 
this  subject  is  considered  will  be  found 
detailed  under  the  head  of  Civil  In- 
capacity. 

We  have  seen  that  it  was  the  policy  of 
the  law  of  Scotland,  from  a  vei'y  early 
period,  to  entrust  the  persons  of  lunatics 
to  the  care  of  their  relatives.  This  policy 
in  a  modified  form  is  continued  to  the  pre- 
sent day.  As  a  general  rule,  the  law 
takes  no  special  cognizance  of  insane  per- 
sons, unless  their  seclusion  or  protection 
is  necessitated,  or  their  property  is  en- 
dangered. It  was  only  towards  the  close 
of  the  reign  of  George  lll.f  that  the  Legis- 
lature directed  its  attention  to  the  devising 
of  securities  for  the  due  regulation  of  the 
custody  and  treatment  of  the  person  of 

*  But  see  Debtors  Ac-t,  1880  (43  &  44  Yict.  c. 
34)  ;  and  Civil  Imprisonmunt  Act,  1882  (45  &  46 
Vict.  c.  42). 

t  55  Geo.  III.  c.  69  ;  9  Geo.  1\.  cap.  34  ;  4  &  5 
Vict.  cap.  60  i  all  of  which  are  repealed. 


unsound  mind.  It  is  unnecessary  to  go 
into  detail  as  to  the  history  of  the  circum- 
stances which  brought  about  the  report 
of  the  Commissioners  appointed  to  inquire 
into  the  lunatic  asylums  of  Scotland, 
bearing  date  1857.  A  resume  of  the  laws 
enacted  consequent  on  that  report  will 
sufficiently  describe  the  machinery  by 
which  the  personal  care  and  control  of 
the  insane  are  governed. 

[Explanatory  Note. — Throughout  the  follow- 
ing resnmi':  of  the  Lunacy  Acts  it  will  be  understood 
that  there  is  a  uniformity  of  procedure  as  regards 
pauper  and  non-pauper  lunatics,  except  where 
specially  noted.  The  terms  used  are  Ijriefly  defined 
(also  ill  20  &  21  Vict.  c.  71,  s.  3)  as  follows  : — The 
"  Board  "  means  the  General  Board  of  Commis- 
sioners in  Lunacy,  Scotland  ;  "  Secretary,"  means 
the  secretary  of  the  Board  :  "  District  Board " 
means  the  Board  chosen  by  the  County  Council 
to  manage  the  lunacy  affairs  of  the  district  ; 
"Public  Asylums'"  means  all  asylums  erected 
without  view  to  pecuniary  gain ;  '•  District  Asy- 
lum "  means  the  asylum  erected  and  maintained 
uuder  the  provisions  of  the  Acts  bj'  the  district 
board  ;  "  Private  Asylum  "  means  an  asylum  for 
the  reception  of  more  tlian  one  lunatic  kept  for 
pecuniary  gain  ;  "  Lunatic "  means  any  person 
who,  in  the  opinion  of  two  properly  qualified  medi- 
cal persons,  is  a  lunatic,  an  insane  person,  an  idiot, 
or  a  person  of  unsound  mind  ;  •'  Pauper  Lunatic  " 
includes  any  lunatic  towards  the  expense  of  whose 
maintenance  any  allowance  is  made  by  a  parochial 
board  :  "Medical  Person"  means  any  person  regis- 
tered as  a  practitioner  in  medicine  or  surgery  pur- 
suant to  the  Act  21  &  22  Vict.  c.  90:  "Judicial 
Factor"  means /acfor /wo  tutvris,  factor  loco  ab- 
sentis,  curator  bonis,  tutor  dative,  or  tutor  at  law 
by  reason  of  service,  having  charge  of  a  lunatic  ; 
"  Sheriff  "  includes  sheriff-substitutes  :  "  Superin- 
tendent "  means  the  person  having  the  charge  of 
any  asylum,  includiiig  proprietors  of  private  asy- 
lums, or  licensed  houses,  and  those  having  pecuniarj- 
interest  therein,  also  the  governor  of  a  poorhouse 
where  lunatics  are  kept  ;  the  word  "  Month '" 
means  a  calendar  month  ;  "  Private  "  patient  means 
non-pauper.] 

Board  of  Iiunacy. — The  General  Board 
of  Lunacy  for  Scotland  is  composed  of 
five  commissioners.  The  chairman  and 
two  legal  commissioners  are  unpaid ;  the 
two  medical  commissioners  are  paid.* 
The  Board  is  aided  by  a  secretary,  clerks, 
and  two  depiity  commissioners,  who  are 
all  paid  under  statutory  regulations.  The 
meetings  of  the  Board,  their  powers  and 
their  duties,  are  regulated  by  the  various 
Acts  of  Parliament,  the  titles  of  which  are 
appended  to  this  article.  The  commis- 
sioners serve  under  an  oath,  may  derive 
no  profit  for  discharging  their  duties,  and 
are  specially  exempted  from  personal  re- 
sjDonsibility.t  The  paid  commissioners  are 
required  to  devote  their  whole  time  to  the 
duties  of  their  office.  Generally  speaking, 
theBoard  have  the  regulation  of  all  matters 
in  relation  to  lunatics  and  asylums,  the 

*  There  is  no  statutory  reason  for  this  arrange- 
ment of  legal  and  medical  commissionei's. 
t  29  &  30  Vict.  c.  52,  s.  23. 


Scottish  Lunacy  Law        [    1117    ]        Scottish  Lunacy  Law 


superintendence  of  all  affairs  arising  out 
of  the  Lunacy  Acts.  They  are  also 
authorised,  with  the  concurrence  of  the 
Lord  Advocate  or  Solicitor-General,  to 
institute  inquiries,  summon  witnesses  and 
examine  them  on  oath  relative  to  any 
case  falling  under  the  provisions  of  the 
Lunacy  Acts.*  It  is  also  competent 
for  them  to  authorise  search  of  records 
as  to  whether  any  particular  person  has 
been  confined  as  a  lunatic  within  twelve 
months.t  The  Board  is,  moreover, 
endoAved  with  powers  to  require  asy- 
lum accommodation  to  be  provided  J  to 
their  satisfaction,  and  to  alter  or  vai-y 
the  lunacy  districts,  subject  to  the  sanction 
of  the  Secretary  of  State  for  Scotland, § 
and  to  take  steps  for  the  adequate  accom- 
modation of  pauper  lunatics  in  any  dis- 
trict. ||  They  are  em powered^[  to  inspect 
lunatics  in  private  houses, '  *  where  the  per- 
son is  not  kept  for  gain,  but  whose  case 
may  require  confinement,  or  coercion,  and 
who  may  have  been  detained  for  more 
than  a  3^ear,  or  who  has  been  subjected  to 
harsh  treatment;  but  only  with  the  consent 
of  a  Secretary  of  State  or  the  Lord  Advo- 
cate. If  removal  should  appear  necessary, 
however,  the  Board  must  apply  to  the 
sheriff  for  an  order.  It  is  also  specially 
enactedftthat  the  commissioners  may  take 
the  assistance  of  such  medical  persons  as 
may  be  required  for  the  purposes  of  the 
Lunacy  Acts.  As  the  Board  is  empowered 
to  enforce  such  rules  and  regulations  as 
they  may  make,  a  statutory  penalty  is 
fixed  for  any  infringement  or  violation. JJ 
The  secretary  is  required  by  the  Act  to 
keep  the  books,  minutes,  and  accounts  of 
the  Board,  and  to  make  annual  returns  as 
to  lunatics  and  asylums. §§  He  is  aided 
by  a  staff  of  clerks.  Finally,  on  the  ist 
day  of  February  of  each  year  a  report  is 
presented  to  the  Secretary  of  State,  re- 
garding the  lunacy  affairs  of  Scotland. 

Inspection  of  Asylums  and  Singrle 
Patients. — A  most  important  duty  of  the 
paid  commissioners  is  the  inspection,  at 
least  twice  a  year,  of  all  asylums  (char- 
tered, ||  II  district,  parochial  and  private),  all 
lunatic  wards  of  poorhouses,  the  Lunatic 
Department  of  H.M.  Prison  at  Perth, 
and    the    training    schools    for   imbecile 

*  20  &  21  Vict.  c.  71,  s.  II. 
t  20  <&  21  Vict.  c.  71,  s.  40. 
t  20  «!c  21  Vict.  f.  71,  ss.  51,  52. 
§   50  &  51  Vict.  c.  39,  8.  I. 
II  25  &  26  Vict.  c.  54,  8.  9. 
"J   29  &  30  \ict.  c.  51,  8.  14. 
**  I.e.,  detained  without  the  sanction  of  the  lioanl. 
ft  20  &  21  Vict.  c.  71,  s.  20. 
}t    29  &  30  Vict.  c.  51,  8.  20. 
§§    29  &  30  Vict.  c.  51,  s.  15. 
III!  Included  under  the  head  of  Public  Asylums, 
and  usually  termed  "l{oyal  Asylums"  (q.v.). 


children.  They  are  specially  enjoined*  to 
inquire  into  the  condition  of  the  lunatics, 
to  record  in  the  "  Patients'  Book "  the 
general  state  of  health  of  the  patients, 
what  coercion  has  been  imposed,  remarks 
on  any  special  cases,  and  the  particulars 
of  the  management  of  the  asylum.  They 
are  empowered  to  visit  by  night  or  by  day, 
and  to  record  all  inspections,  stated  and 
occasional,  in  a  book  to  be  kept  by  them. 

In  addition  to  these  inspections  by  the 
commissioners,  the  Secretary  of  State 
ma}'  order  a  special  visitation,  and  asylums 
are  subject  to  the  scrutiny  of  the  Sherifl't 
and  three  of  the  justices  of  the  peace  spe- 
cially appointed.  J  A  section  of  the  Act  § 
seldom  put  in  force  provides  for  the  ap- 
pointment of  district  inspectors  by  the 
district  boards.  The  entries  made  in  the 
patients'  book  on  the  occasions  of  these  in- 
spections must  be  copied  and  transmitted 
to  the  Board  within  eight  days  under  a 
penalty  for  neglect.  || 

The  Deputy  Commissioners,  of  whom 
there  are  two,  are  chiefly  occupied  in  visit- 
ing lunatics  in  private  dwellings.^  They 
are  deputed  with  such  powers  of  the  com- 
missioners as  the  Board  directs,  and  are 
by  statute  medical  persons.** 

Access. — Access  of  friends  and  others 
to  lunatics  is  provided  for  by  the  statutes 
ordaining  ft  that  the  minister  (clergyman) 
of  any  parish  in  which  an  asylum  is 
situated,  or  the  minister  of  any  church  to 
which  a  patient  belongs,  or  any  relative  of 
a  patient,  or  any  member  of  the  parochial 
board  liable  for  the  maintenance  of  a 
pauper  patient  has  liberty  to  visit  any 
such  patient  in  an  asylum,  subject  to  the 
general  regulations  imposed  by  the  super- 
intendent. These  regulations  must  have 
the  sanction  of  the  Board  of  Lunacy. 
Under  a  special  instruction  from  the 
Board,  the  superintendent  of  the  asylum 
must  intimate  to  them  any  refusal  of 
access  within  two  days,  whether  it  be 
complained  of  or  not  ;  and  by  statute  an 
entry  of  the  refusal  must  be  made  in  the 
register  of  the  asylum.  The  decision  of 
the  Board  is  made  final ;  and  an  order  can 
be  obtained  from  the  Board  for  access  to 
a  patient  by  a  relative  or  friend  for  them- 
selves, or  for  any  medical  or  other  person 
whom  they  may  desire  to  have  admitted. 
There  is  also  provision  J  J  for  the  access  of 

'■  20  &  21  Vict.  c.  71,  s.  17. 
t  20  &  21  ^'ict.  c.  71,  s.  25. 
t  20  &  21  A'ict.  c.  71,  s.  26. 
§  20  A:  21  A'ict.  c.  71,  s.  70. 
II  20  &  21  Vict.  c.  71,  s.  17. 
if  See  BoARDiNC-oi  ■!■. 

**  20  &  21  Vict.  c.  71,  s.  21 ;  also  29  &  30  Aict. 
c.  51,  s.  3. 

tt  20  &  21  Vict.  c.  71,  ss.  47,  48. 
tt  20  &  21  Vict.  c.  71,  s.  79. 


Scottish  Lunacy  Law        [    iiiS    ]        Scottish  Lunacy  Law 


parties  haviug  an  interest  in  the  main- 
tenance of  a  pauper  lunatic,  b}"-  warrant 
of  the  sheriff",  in  any  investigation  re- 
garding his  settlement.* 

Xietters. — Patients  can  only  communi- 
cate by  letter  with  the  sanction  of  the 
superintendent  ;  butf  any  letters  ad- 
dressed to  the  Board,  or  their  secretary', 
or  one  of  the  commissioners,  must  be  for- 
warded unopened.  And  any  letter  from 
the  Board,  or  their  secretary,  or  one  of 
the  commissioners,  addressed  to  a  patient, 
must  be  delivered  unopened  if  marked 
"private."  But  if  it  appears  to  the  Board 
that  the  contents  of  the  letter  are  of  such 
a  nature  that  the  sujjerintendent  should 
be  made  acquainted  therewith,  a  copy  will 
be  transmitted  to  him. 

Asylums. — There  are  various  classes  of 
asjdums  for  the  reception  of  lunatics  re- 
cognised by  the  law. 

(i)  Eoyal,  chartered,  or   public  asy- 
lums. 

(2)  District  asylums. 

(3)  Parochial  asylums. 

(4)  Lunatic  wards  of  poorhouses. 

(5)  Criminal  asylums. 

(6)  Private  asylums. 

(7)  Training  institutions  for  idiots, 
(i)  Tlie  chartered  asylums  are  charitable 

institutions  built  from  legacies,  or  funds 
derived  from  donations,  and  from  any 
profits  that  may  accrue.  They  are  man- 
aged by  directors  elected  and  ex.  officio, 
and  nearly  all  receive  both  private  and 
pauper  patients.  Where  they  have  been 
established  (all  before  the  passing  of  the 
Lunacy  Act)  they  have  usually  under- 
taken the  work  of  district  asylums.  It 
was  found  to  be  unnecessary  to  build  dis- 
trict asylums  for  certain  counties  where 
chartered  asylums  existed.  They  are 
supi:)orted  by  the  payments  made  by  the 
patients,  either  as  private  patients  or  as 
paupers  under  contract  with  district 
boards.  The  district  boards  are  em- 
powered X  to  contract  with  asylums  exist- 
ing prior  to  1858,  for  the  reception  and 
maintenance  of  paupers  belonging  to  the 
district,  subject  to  the  decision  of  the 
General  Board.  There  are  at  present 
seven  chartered  asylums  in  Scotland,  and 
at  five  of  them  paupers  are  received  on 
these  terms.  Statutory  powers  have  been 
conferred  on  the  royal  asylums  to  bor- 
row money,  and  to  grant  pensions  to 
officials.  § 

*  The  legul  resklence  or  estalilislimcut  of  a  plt- 
6on,  in  a  particular  parisli,  town,  or  locality,  which 
eutitks  him  to  luaintenaucc  of  a  pauper,  aiul  sub- 
jects the  parish  or  towu  to  his  support. 

t  29  &  30  Vict.  c.  51,  s.  16. 

X  20  &  21  ^■ict  c.  71,  s.  59. 

§  29  &  30  Vict.  c.    51,  ss.  25,  26.      See   KoYAL 

ASVLL.MS. 


(2  &  3)  District  and  Parochial  Asylums. 
— These  were  called  into  existence  by  the 
Acts  now  under  consideration,  and  are 
built  by  assessment.*  The  inmates  are 
paupers,  with  a  comparatively  small  num- 
ber of  private  patients,  who  have  the  same 
accommodation  as  pauper  lunatics,  and 
are  a  little  above  the  pauper  class.  But 
these  are  only  admitted  t  if  the  whole  space 
be  not  occupied  by  paupers. 

Parochial  asylums  are  institutions  which 
existed  prior  to  1857.  No  parochial  asy- 
lum was  called  into  existence  by  these 
Acts.  Parochial  asylums  were  permitted 
to  be  continued  by  21  &  22  Vict.  c.  89. 
They  are  not  built  by  assessment,  but  out 
of  the  poor  rate. 

The  whole  of  Scotland  is  divided  into 
districts,J  which  may  be  varied  or  altered, 
subject  to  the  approval  of  the  Board.  For 
each  district  a  district  board  is  chosen 
from  and  by  the  county  council, § — and 
the  included  town  councils — which  has 
succeeded  to  the  powers  and  duties  of  the 
commissioners  ot  supply.  ||  The  Board 
may  require  a  district  board  to  provide 
an  asylum  after  having  inquired  into  the 
necessities  of  the  district,  •[  and  the  asylum 
so  erected  is  vested  in  the  district  board, 
which  acquires,  holds,  and  administers  it. 
Full  powers  are  given  to  sell  old  or  to 
l)rovide  new  asylums,**  or  even  to  dissolve 
the  district  board  ft  where  no  district  asy- 
lum is  required. 

The  expense  of  providing,  altering,  and 
repairing  district  asylums  is  reported  by 
the  district  board  to  the  General  Board, 
and  the  assessment  is  levied  on  counties 
and  burghs  according  to  the  real  rents. JJ 
District  boards  have  power,  subject  to 
the  approval  of  the  Board,  to  make  con- 
tracts for  the  maintenance  of  the  lunatics 
of  the  district  with  any  pixblic,  private, 
district,  or  parochial  asylum,§§  to  buy  up 
the  right  of  accommodation  iu  asylums,||i| 
to  acquire  additional  grounds.'y^  to  borrow 
money  on  the  security  of  the  assess- 
ments,*** under  statutory  regulations.ftt 

"   20  &  21  Vict.  c.  71,  ss.  54,  55. 

t  20  &  21  Vict.  c.  71,  s.  80. 

t  20  &  21, Viet.  c.  71,  s.  49. 

§  52  &  53  Vict.  c.  50,  s.  II  ;  40  &  41  Vict.  c.  53, 
s.  61,  &c. 

II  Commissioners  appointed  to  assess  the  laud 
tax,  <kc. 

^  20  &  21  Vict.  c.  71,  ss.  51,  52  ;  25  &  26  Vict, 
c.  54,  s.  9. 

-■*  20  &  21  Vict.  c.  71,  s.  53. 

tt  25  «t  26  Vict.  c.  54,  s.  12. 

tt  20  &  21  Vict.  c.  71,  ss.  54,  55. 

§§   25  &  26  Aict.  c.  54,  s.  8. 

nil  20  &  21  Vict.  c.  71,  s.  58. 

fir  25  &  26  Vict.  c.  54,  s.  11.  Also  Lauds 
Clauses  Consolidation  (Scotland)  Act,  1S45. 

***  20  &  21  Vict.  c.  71,  ss.  61,  62. 

ttt  20  &  21  Vict.  e.  71,  ss.  63,  64,  65,  66 ;  and  25 
&  26  Vict.  c.  54,  s.  13. 


Scottish  Lunacy  Law        [     1119    ]        Scottish  Lunacy  Law 


In  brief,  the  State  lays  on  them  the  duty 
of  i^roviding  asyhim  accommodation  for 
the  pauper  hinatics  of  their  district,  and  of 
furuiahing  annual  and  special  statements* 
to  the  General  Board  regarding  their  pro- 
ceedings. The  charge  for  jmuper  lunatics 
detained  in  asylums  under  agreement  with 
the  district  board  is  tixed  at  a  weekly 
sum,  with  the  approbation  of  the  General 
Board,  and  the  district  board  is  bound 
to  keep  books  and  accounts  in  such  man- 
ner as  the  General  Board  directs  from 
time  to  time.f  It  is  enacted  that  every 
pauper  lunatic  shall  be  sent  to  a  district 
asylum, ;J;  unless  other  arrangements  have 
been  made  with  the  consent  of  the  General 
Board.  There  are  now  ten  district  and 
six  parochial  as3dums,  and,  owing  to  the 
policy  of  the  Board,  no  pauper  lunatic  has 
been  admitted  into  a  private  asylum  for 
many  years.  By  a  recent  Act§  the 
General  Board  have  the  jjower,  on  the 
application  of  the  county  council,  burgh 
magistrates,  or  the  parochial  board  of  any 
parish  or  combination  interested,  to  alter 
or  vary  the  districts,  and  to  regulate  the 
whole  matters  arising  out  of  such  altera- 
tion, with  the  sanction  of  the  Secretary  of 
State  for  Scotland  {vide  sujpra). 

(4)  Lunatic  Wards  ofPoorhouses. — This 
isanimportantfeature  in  the  lunacy  laws — 
viz.,  that  special  wa^rds  in  poorhouses  may 
be  licensed  by  the  Board  ||  for  the  recep- 
tion of  lunatics,  for  the  maintenance  of 
whom  the  Government  subvention  is  pay- 
able. Moreover,  no  patient  is  admitted 
without  the  sanction  of  the  Board ;  and, 
by  statute,  only  those  who  are  not  danger- 
ous, and  do  not  require  curative  treat- 
ment, are  admissible  to  these  wards.  The 
result  of  this  is  that  they  are  a  relief  to 
the  over-crowding  of  the  lunatic  asylums 
by  the  removal  of  incurable  and  inoffen- 
sive patients.  Sometimes  these  are  ad- 
mitted from  their  homes  direct,  under  the 
order  of  the  sheriff,  and  with  the  sanction 
of  the  Board ;  but  the  great  majority  are 
transferred  from  the  asylums.^ 

(5)  Criminal  Asylum  at  Perth. — This 
is  established  in  connection  with  her  Ma- 
jesty's General  Prison,  and  is  regulated 
by  sj^ecial  Acts.**  It  is  a  separate  build- 
ing, and  contains  all  the  criminal  lunatics 
in  Scotland  except  those  who  may  have 
been  removed  to  the  ordinary  asylums,tt 

*  20  &  21  Vict.  c.  41,  s.  67. 

t  20  &  21  Vict.  c.  71,  ss.  73,  74. 

X  20  &  21  Vict.  c.  71,  s.  95. 

§  50  &  51  Vict.  c.  39. 

II  21  &  22  Vict.  c.  89,  s.  I  ;  and  25  &  26  Vict.  c. 
54,  8s.  3,  4. 

f  25  &  26  Vict.  c.  54,  ss.  4,  14. 

'«  23  &  24  Vict.  c.  105  :  and  40  &  41  Vict.  c.  53. 

tt  25  &  26  A'ict.  c.  54,  8.  23  ;  34  &  35  Vict,  c.  55, 
s.  4, 


or  have  been  discharged.  Provision  has 
been  made*  for  criminals  found  insane  as 
bar  to  trial,  or  acquitted  on  the  ground  of 
insanity,  or  becoming  insane  in  confine- 
ment. An  important  sectionf  deals  with 
the  liberation  of  criminal  lunatics  under 
proper  precautions  and  regulations.  In 
case  these  are  infringed,  warrant  is  issued 
by  any  principal  Secretary  of  State  for  the 
custody  and  removal  of  the  person  as  if 
no  liberation  had  been  granted. 

(6)  Private  Asylums. — In  former  days 
there  were  many  private  asylums,  espe- 
cially in  the  neighbourhood  of  Musselburgh, 
but  the  policy  pursued  has  limited  these  to 
a  few  houses  for  the  better  class  of  patients. 
They  are  five  in  number,  exclusive  of  the 
specially  licensed  houses  to  be  mentioned 
hereafter.  All  private  asylums  are 
licensed  by  the  Board  J  to  the  superin- 
tendent of  the  asylum,  after  consideration 
of  his  qualifications  and  of  the  plan  of 
the  proposed  asylum.  Any  alteration 
must  be  described,  even  if  the  total 
number  of  patients  is  not  to  be  increased. 
The  licence  costs  not  less  than  fifteen 
pounds,  and  lasts  for  no  longer  than 
thirteen  months.  §  If  the  renewal  of  a 
licence  be  refused  it  may  be  continued 
for  three  months,  II  and  if  application  for 
transfer  is  made,  provision  exists  for  that 
purpose.  There  is  a  penalty,  not  exceed- 
^^K  i^ioo  or  a  year's  imprisonment, 
attached  to  the  offence  of  receiving  a 
lunatic  in  an  unlicensed  house,  or  of  send- 
ing him  thither.^ 

(7)  Training  Institutions  for  Lnbecile 
Ghildren. — These  may  be  licensed  by 
the  Board  without  any  fee,  in  the  name 
of  the  superintendent  for  the  time  being. 
They  must  be  supported  in  whole  or  in 
part  by  private  subscription.  There  are 
at  present  two  institutions  of  this 
nature ;  in  addition  to  Dr.  Ireland's  train- 
ing school  for  imbeciles,  which  is  also  in- 
sjjected  by  the  Board. 

Private  Dwelling's. — These  are  of  two 
kinds,  (n)  where  not  more  than  four  pa- 
tients are  received  ;  (6)  and  where  not  more 
than  one  patient  is  received. 

(a)  The  Board  grant  special  licences 
for  the  reception  of  not  more  than  four 
lunatics  to  occupiers  of  houses  without 
the  payment  of  any  fee.**  The  holders  of 
these  licences  are  subject  to  the  same  pro- 
visions as  proprietors  of  private  asylums.tt 

*  20  &  21  Vict.  e.  71,  ss.  87,  88,  89 ;  25  &  26  Vict, 
c.  54,  ss.  19,20,  21;  and  34  &  35  Vict.  c.  55,  ss.  2,  3. 
t  34  &  35  V'ft.  (-■.  55,  s.  2. 
t  20  &  21  \'ict.  c.  71,  s.  27. 

§    20  &  21   ^■ict.  C.   71,  8.  28. 

II  2c  &  21  Vict.  0.  71,  8s.  29,  30. 

^  20  &  21  Vict.  c.  71,  s.  39. 

**  25  &  26  Vict.  e.  54,  8.  5. 

ft  Except  in  so  far  as  cxeuipted  by  the  Hoard. 


Scottish  Lunacy  Law       [     1120    ]        Scottish  Lunacy  Law 


Sanction  for  reception  and  detention  of  a 
lunatic  is  given  by  the  Board  under  a 
special  form,  and  any  one  concerned  in 
the  disposal  of  a  lunatic  in  one  of  these 
houses  without  the  sanction  of  the  Board 
is  liable  to  a  penalty  not  exceeding  ^^{^lo. 
The  patients  in  these  houses  ai'e  visited  by 
the  commissioners  or  deputy  commission- 
ers, and  a  continuous  record  of  their  con- 
dition is  kept.  They  are  repoi'ted  to  the 
Board  on  arrival  and  departure,  just  as  if 
they  were  in  an  asylum.  Notice  of  recep- 
tion and  departure  of  every  boarder,  not 
being  a  lunatic,  is  to  be  given  to  the  Board 
within  three  days.  This  by  regulation  of 
the  Board. 

(b)  The  reception  of  lunatics  as  single 
patients  is  governed  by  statute,  so  that 
any  one  detaining  or  aiding  in  detain- 
ing any  person  who  on  inquiry  is  found 
to  be  a  lunatic,  without  the  order  of  the 
sheriff  or  the  sanction  of  the  Board,  is 
liable  in  a  penalty  not  exceeding  ^20.'' 
But  fourteen  days  are  allowed  in  which  to 
make  application  for  an  order  or  a  sanc- 
tion. In  case  of  a  pauper  the  ins^Dector 
must  make  application,  and  the  sheriff 
may  grant  his  order  on  the  production  of 
one  medical  certificate.  Visitation  is  made 
by  the  commissioners  or  deputy  com- 
missioners, the  medical  attendant,  and 
(if  a  pauper)  by  the  inspector  of  poor 
(relieving  officer).  The  medical  attendant 
visits  at  least  once  a  quarter,  and  the  in- 
spector of  ]DOor  at  least  twice  a  year.  The 
deputy  commissioners  visit  as  nearly  as 
can  be  once  a  year.  A  recoi'd  of  visits  is 
kept  in  a  book  designed  for  the  purpose, 
and  false  entries  are  subject  to  a  penalty 
ofi;io. 

There  is  an  important  reservation  which 
legalises  the  position  of  insane  persons 
who  may  have  been  received  into  tem- 
porary residence,  not  exceeding  six  months, 
and  under  a  medical  certificate  stating 
that  the  malady  is  not  confirmed. 

This  is  an  important  part  of  the  lunacy 
system  of  Scotland,  fully  referi'ed  to  under 
Boarding-out  (q.v.).  Briefly,  all  lunatics 
in  private  dwellings  who  are  paupers  are 
under  the  control  of  the  Board,  and  also 
all  those  under  curators  honis,  or  who  are 
kept  for  gain,  or  whose  malady  is  of 
more  than  a  year's  duration  and  who 
are  confined  to  the  house  or  otherwise 
under  any  form  of  coercion.  The  dealing 
of  the  Board  with  these  cases  is  intimate 
and  constant.  The  statutes  require  a 
report  in  the  circumstances  detailed  above, 
whether  the  patient  be  j^auper  or  not,  or 
dangerous  or  not,  and  occasionally  the 
attention  of  the  public  is  directed  to  this 
by  public  advertisement.  It  is  important 
*  29  &  30  Vict.  c.  51,  s.  13. 


to  note  that  claims  on  the  contribution 
(^90,500)  from  imjoerial  funds  in  aid  of 
the  cost  of  maintenance  of  pauper  lunatics 
is  admitted  only  if  the  Board  are  satisfied 
that  the  patients  are  properly  provided 
for. 

Having  now  referred  to  the  different 
circumstances  in  which  lunatics  may  be 
placed  for  care  and  treatment,  it  becomes 
necessary  to  refer  in  detail  to  the  proce- 
dure for  their  admission,  detention,  trans- 
fer, or  liberation. 

The  detention  of  a  lunatic  in  an  asylum 
can  only  be  secured  by  the  order  of  a 
sheriff.  The  schedule  in  use  *  sets  forth 
a  petition  to  the  sheriff  supj^orted  by  a 
statement  and  two  medical  certificates. 
This  procedure  f  rests  on  the  idea  that  the 
step  is  one  which  involves  a  loss  of  per- 
sonal liberty,  and  accordingly  the  officials 
who  are  entrusted  with  the  power  of  taking 
away  personal  liberty  for  other  causes 
than  lunacy  are  authorised  to  admit 
patients  into  an  asylum.  The  sheriff  is 
the  judge ;  that  is  to  say,  he  may  refuse 
his  order  or  call  for  further  evidence,  &c., 
and,  whether  the  person  in  question 
be  rich  or  poor,  the  procedure  is  the 
same.  First,  then,  some  person,  who 
has  to  state  the  relationship  in  which  he 
stands  to  the  patient,  must  petition  the 
sheriff  to  gi'ant  his  order,  and  must  make 
a  statement  of  particulars.  This  is  accom- 
panied by  two  medical  certificates  granted 
by  properly  qualified  medical  persons,  and 
bearing  that  they  have  separately  ex- 
amined the  patient  and  found  him  to  be  a 
lunatic,  and  a  fit  and  proper  person  to  be 
placed  in  an  asylum.  Facts  supporting 
these  opinions,  observed  by  the  certifiers, 
must  be  given.  A  certificate  must  not  be 
founded  only  on  facts  communicated  by 
others.  The  petition  should  be  signed 
after  the  statement  and  certificates.  On 
these  documents  being  presented  to  the 
sheriff,  he  considers  them  as  he  would  any 
other  petition  which  craves  him  to  inter- 
pose his  authority  ;  and  he  may  refuse  to 
grant  an  order.  If  granted,  the  order  must 
be  acted  on  within  fourteen  days  or  it  falls 
to  the  ground,  and  the  date  of  the  petition 
must  not  be  more  than  fourteen  days  after 
the  dates  of  the  medical  certificates. J 

But  if,  as  is  very  probable,  the  cir- 
cumstances do  not  permit  of  the  delay 
which  is  implied  in  getting  the  sheriff"'s 
order,  a  certificate  of  emergency  §  granted 
by  a  qualified  medical  person  authorises 
the   detention    of   the    lunatic   for    three 

*  Schcduk'  C,  20  &  21  Viet.  c.  74. 
t  25  &  26  Vict.  c.  54.  s.  14. 
}  See  Discliarge  or  Keiuoval,  iii/ra. 
§  25  &  26  Vict.  c.  54,  s.  14  ;   ami  29  &  30  Vict, 
c.  51,  s.  4. 


Scottish  Lunacy  Law        [    1121     ]        Scottish  Lunacy  Law 


days,  thus  permitting  of  ready  access  to 
asylum  treatment.  By  si^ecial  instruc- 
tion of  the  Board,  a  written  request 
from  the  person  desiring  to  place  the 
lunatic  in  the  asylum  should  accompany 
the  certificate  oi"  emergency  and  be  ad- 
dressed to  the  superintendent.  But  i£ 
the  order  of  the  sheriff  be  not  obtained 
before  the  expiry  of  the  three  days,  the 
lunatic  must  be  discharged,  as  his  de- 
tention becomes  illegal.  There  is  no 
limitation  as  to  who  shall  sign  the  peti- 
tion, except  in  the  case  of  paupers,  when 
it  must  be  done  by*  the  inspector  of 
poor.  The  primary  duty  of  the  inspector 
of  poor,  however,  on  learning  of  the  pres- 
ence of  an  unintiniated  pauper  lunatic  in 
his  parish,  is  to  report  the  fact  to  the 
Board  and  to  the  parochial  board,  under 
a  statutory  penalty  of  ^10  in  case  of 
failure.  He  must  also  observe  the  same 
rule  when  made  aware  of  a  lunatic  in  an 
asylum  becoming  chargeable  to  his  parish, 
and  must  similarly  intimate  when  the 
chargeability  of  the  pauper  is  transferred 
to  another  parish. 

The  settlement  of  pauper  lunatics  is 
often  much  disputed.  The  statutes  dis- 
tinctly state  that  a  pauper  lunatic  is  to  be 
held  to  belong  to  the  i^arish  of  his  legal 
settlementf  at  the  time  of  the  sheriif' s 
order  granted  in  his  case.  By  the  next 
section  it  is  provided  that  the  parish  of 
settlement  is  to  be  liable  in  payment  of 
expenses  subject  to  the  decision  of  the 
sheriff  in  assessing  them.  But  if  the 
lunatic  has  adequate  estate,  it  must  bear 
the  expense  of  maintenance,  &c.  If  the 
lunatic  is  a  pauper,  the  expense  will  be 
defrayed  by  the  parish  in  which  he  was 
found,  and  from  which  he  was  sent.  The 
sheriflf  is  empowered  J  to  certify  the 
amount  of  expenses,  and  his  finding  is 
not  subject  to  review.  Notice  must  be 
given  to  the  parish  of  settlement  by  the 
parish  disbursing  these  expenses. 

The  oi'der  for  admission  into  an  asylum 
costs  §  five  shillings  for  a  non-pauper, 
and  half  a  crown  for  a  pauper  lunatic. 
These  fees  are  remitted  by  the  sheriff 
clerk  II  to  the  Board,  and  are  at  present 
applied  in  reduction  of  the  estimate  of 
the  Board's  expenses.  And  whatever^ 
balance  of  moneys  over  receipts  for 
such  fees,  licences,  &c,,  may  be  necessary, 
is  voted  by  Parliament.  The  sheriff 
clerk  is  also  bound  to  send  notice  to  the 

*  20  A:^  21  Vict.  c.  71,  s.  112;  and  25  &  26  Vict, 
e.  54,  s.  18. 

t  20  &  21  Vict.  c.  71,  s.  75,  et  seq. 
J  20  &  21  Vict.  c.  71,  (5.  78. 

§  20  &  21  Vict.  c.  71,  8.  31  ;  ami  29  &  30  Vict. 
•  c.  51,  s.  22. 

I|  20  it  21  Vict.  c.  71,  8.  32. 
^  20  (k  21  Vict.  c.  71,  s.  33. 


Board  as  to  each  order  within  seven 
days  from  the  granting  of  the  order, 
under  a  ])enalty  not  exceeding  ^10.* 
The  sheriff's  order  is  granted  by  the 
sheriff  of  the  county  in  which  the  luna- 
tic is  found,  or  in  which  the  asylum  is 
situated,  and  the  procedure  is  governed 
by  the  uudernoted  sections.!  The  order 
and  medical  certificates  may  be  amended,  if 
incorrect  or  defective,  within  twenty-one 
days  after  admission,  but  these  amend- 
ments must  obtain  the  sanction  of  the 
Board,  or  they  may  refer  the  matter  to 
the  sheriff  for  recall  should  he  decide  on 
that  course. J 

The  medical  certificates  §  must  not 
be  granted  by  persons  having  immediate 
or  pecuniary  interest  in  the  asylum  in 
which  the  lunatic  is  i^laced  ;  nor  can  a 
medical  officer  of  any  asylum  grant  a  cer- 
tificate of  insanity  for  the  reception  of 
any  lunatic,  not  a  pauper,  into  such  asy- 
lum, except  the  certificate  of  emergency. 
Heavy  penalties  are  attached  to  the 
otf"ences  of  granting  a  certificate  without 
examination  or  of  granting  it  falsely.  Un- 
qualified medical  persons  are  specially 
debarred  from  practising  under  the  Lunacy 
Acts ;  and  precautions  are  taken  to  pre- 
vent any  qualified  medical  person  grant- 
ing lunacy  certificates  with  reference  to 
an  asylum  in  which  he  has  pecuniary 
interest  or  concern. |1 

If  any  action  at  law  be  raised  against  a 
medical  person  in  respect  of  a  lunacy 
certificate  under  these  Acts,  it  must  be 
initiated  within  a  year  of  the  date  of 
liberation  of  the  person  who  alleges  in- 
jury, and  the  Lord  Ordinary  tries  the  case 
without  a  jury. ^ 

On  the  admission  of  a  patient  to  an 
asylum  it  becomes  the  duty  of  the  superin- 
tendent to  report  upon  the  physical  con- 
dition of  the  person  so  admitted  within 
three  days,  by  regulation  of  the  Board. 
And  by  statute  it  is  enacted**  that 
copies  of  the  orders,  medical  certificates^ 
petition,  and  statement  shall  be  trans- 
mitted to  the  Board  by  the  sujjerinten- 
dent  within  fourteen  clear  days  but  after 
two  clear  days  from  the  day  of  admis- 
sion. With  these  copies  must  be  sent  a 
notice  of  admission  and  a  report  as  to 
the  mental  and  bodily  condition  of  the 
lunatic  by  the  medical  attendant  of  the 
asylum.     This  must  be  in  the  prescribed 

*  20  &  21  Vict.  c.  71,  s.  37. 

t  25  &26  Vict.  c.  54,  8.  14 ;  29  &  30  Vict.  c.  51, 
ss.  4,  5,  6,  7. 

t  29  &  30  Vict.  c.  39,  s.  5. 

§  25  &  26  Vict.  c.  54,  s.  14  ;  and  schedule  1), 
20  &  21  Vict.  e.  71. 

U  20  &  21  Vict.  c.  71,  s.  71. 

IT  29  &  30  Vict.  c.  52,  s.  24. 

**  20  &  21  Vict.  c.  71,  s.  37. 


Scottish  Lunacy  Law       [    1122    ]        Scottish  Lunacy  Law 


form,*  and  failure  to  transmit  is  punish- 
able by  tine  of  /'20. 

In  every  asylum  licensed  for  100  pa- 
tients a  medical  jierson  must  beresident,t 
and  in  every  asylum  licensed  for  more 
than  50  a  medical  person  must  visit  daily. 
Rules  are  also  laid  down  as  to  the  visit- 
ing of  smaller  asjdums  by  medical  per- 
sons. It  is  a  statutory  duty  of  the 
superintendent  to  keep  a  register  of  luna- 
tics in  which  particulars  are  entered 
according  to  schedule.^  The  formalities 
of  admission  may  be  delayed  by  the  dis- 
tance at  which  the  lunatic  is  found  from 
the  asylum,  and  the  law  has  provided  a 
remedy  §  for  that  in  the  case  of  Ork- 
ney and  Shetland.  Another  part  of 
the  statutes  deals  |1  with  the  difficulty  of 
conveying  dangerous  lunatics  from  remote 
localities.  It  provides  for  a  justice  of  the 
peace,  on  sworn  credible  information, 
granting  a  warrant  for  safe  custody  and 
transmission  to  the  nearest  town  in  which 
a  sheriff"  or  sheriff  substitute  resides. 

There  is  a  small  class  of  lunatics,  not 
criminal,  but  dangerous  or  offensive  to 
decency,  who  are  dealt  with  after  appre- 
hension under  a  special  clause.^  The 
sheriff  may,  in  such  a  case,  on  the  appli- 
cation of  the  procurator  fiscal  (public  pro- 
secutor) or  the  inspector  of  poor  or  any  per- 
son, accompanied  by  a  medical  certificate 
so  describing  the  lunatic,  commit  him  to 
safe  custody.  The  sheriff  thereupon 
causes  notice  to  be  given  in  the  local 
newspapers  of  such  a  commitment,  and 
that  it  is  intended  to  inquire  into  the 
condition  of  the  lunatic  on  a  day  named. 
If  lunacy  is  shown  to  exist,  the  sheriff** 
issues  an  order  for  removal  to  an  asylum, 
and  detention  there  until  recovery  takes 
place,  or  until  two  medical  men  approved 
by  him  certify  that  the  lunatic  may  be 
discharged  without  risk  of  injury  to  him- 
self or  the  public. 

Voluntary  patients  are  also  admitted 
under  a  special  section.ft  These  patients 
are  desirous  of  submitting  themselves  to 
treatment,  but  their  mental  state  is  not 
such  as  renders  it  legal  to  grant  certifi- 
cates of  insanity.  They  can  only  be  re- 
ceived on  the  previous  assent  of  one  of 
the  commissioners,  which  is  given  in  the 
form  of  a  sanction  to  the  superintendent 

*  Schedule  F,  20  &  21  Vict.  c.  71. 

t  20  &  21  Vict.  c.  71,  ss.  45,  46. 

}  Schedule  I,  20  &  21  Vict.  c.  71. 

§  25  &  26  Vict.  c.  54,  s.  14. 

'I  20  &  21  Vict.  c.  71,  s.  qo. 

f  25  &  26  Vict.  c.  54,  8.  15. 

**  Tliiit  is,  if  the  inspector  of  the  parish  docs  not 
within  tweuty-l'our  hours  undertake  to  the  satis- 
faction of  tlie  sheriff  to  provide  for  the  safe  cus- 
tody of  the  lunatic. 

tt  29  &  30  Vict.  f.  51,  s.  15. 


to  keep  and  entertain  the  patient  as  a 
boarder.  It  is  necessary  that  the  com- 
missioner should  have  the  patient's 
written  application  before  he  grants  the 
sanction.  It  is  also  enacted  that  all 
voluntary  patients  miTst  be  produced  to 
the  commissioners  at  their  visits,  and  none 
can  be  detained  for  more  than  three  days 
after  having  given  notice  of  intention  to 
leave  the  asylum,  unless  in  the  interval 
the  sheriff's  order  be  obtained  subject  to 
all  the  regulations  aforesaid.* 

The  penalties  for  maltreatment  are  set 
forth  by  statute  ;f  and,  by  the  rule  of  the 
Board,  the  superintendent  is  obliged  to 
give  immediate  notice  to  the  procurator 
fiscal  if  a  patient  has  been  seriously  hurt. 
The  fiscal  then  investigates  the  case,  and 
takes  action  if  so  advised. 

Moreover,  all  attendants  must  be  noti- 
fied to  the  Board  on  arrival  and  departure, 
and  the  reasons  for  their  departure  must 
be  specified.  The  Board  keeps  a  register 
of  attendants,  and  when  an  attendant, 
against  whose  name  an  evil  report  stands,  j 
is  engaged,  the  superintendent  engaging 
him  is  notified  by  the  secretary  as  to  the 
facts,  and  must  say  if  he  intends  to  re- 
tain the  services  of  the  person  referred  to. 
This  is  governed  by  special  instructions 
from  the  Board,  and  gives  some  security 
against  maltreatment ;  which  is  further 
regulated  by  an  instruction  to  the  effect 
that  the  procurator  fiscal  must  be  made 
aware  of  any  maltreatment  of  a  serious 
nature  within  twelve  hours,  and  precau- 
tions must  be  taken  to  prevent  any 
incriminated  party  from  leaving  the 
asylum. 

Improper  detention  is  provided  for 
under  the  statutory  regulations  above  de- 
tailed, and  any  patient,  on  liberation  from 
asylum  control,  who  considers  himself  to 
have  been  unjustly  confined,  may  get 
without  charge  a  copy  of  the  order,  peti- 
tion, and  certificates  on  which  he  was  con- 
fined. §  Since  the  passing  of  these  Acts 
there  has  been  but  one  action  in  Scot- 
land on  account  of  illegal  detention,  and 

*  The  Board  lia'se  recently  referred  at  length  to 
the  position  of  voluntary  patients  in  asylums.  They 
state  that  no  person  should  be  received  or  kept  in 
an  asylum  as  a  voluntary  patient  unless  he  fully 
understands  and  ajipreciates  the  voluntary  nature 
of  his  residence.  Should  it  be  necessary,  for  the 
safety  of  the  patient,  that  he  should  be  certified, 
the  lioard  recommend  that  he  should  be  removed 
on  that  step  to  another  asylum,  if  there  has  been  no 
marked  change  in  the  mental  state  since  admis- 
sion. And  the  I'.oard  also  indicate  that  the  super- 
intendent should  regard  voluntary  and  certified 
patients  with  an  equal  feeling  of  resi)onsibility. 

t  20  &  21  Met.  c.  71,  s.  99. 

t  That  is.  notice  of  dismissal  from  an  asylum 
for  serious  misconduct  has  been  received. 

§  20  &  21  Vict.  c.  71,  s.  94. 


Scottish  Lunacy  Law 


1 1 23    ]        Scottish  Lunacy  Law 


it  was  not  instigated  by  the  i:)atient  him- 
self. 

Blscbargre  or  Removal. — The  sheriff's 
order  is  not  f,n-antod  without  limit  as  to 
time.  It  remains  in  force  altboutfh  the 
patient  may  be  absent  from  the  asylum  * 
temporarily.  The  lunatic  may  have  been 
absent  on  pass  or  by  having  escaped  for 
twenty-eight  days,  or  may  liave  been  ab- 
sent for  three  months  under  the  personal 
care  of  the  asylum  officials,  or  may  have 
been  absent  for  a  specified  time  on  pro- 
bation with  the  consent  of  the  Board.f  But 
if  these  periods  have  been  exceeded,  or  if 
the  superintendent  or  medical  attendant 
fail  to  grant  a  statutory  certificate  X  after 
the  expiry  of  three  years  from  the  date  of 
the  order,§  or  if  the  superintendent  give 
notice  of  the  discharge  of  the  lunatic, 
then  the  sheriff's  order  remains  no  longer 
in  force — the  authority  for  the  detention 
of  the  person  as  lunatic  lapses. 

Pauper  lunatics  may  be  discharged  by 
authority  of  the  parochial  board,  at  a 
duly  constituted  meeting,  if  a  certified 
copy  of  the  minute  be  left  with  the  super- 
intendent of  the  asylum,  and  if  the 
patient  be  not  a  dangerous  lunatic,  either 
detained  as  such  or  certified  by  the  super- 
intendent as  such. II  Strict  regulations 
are  laid  down  for  the  protection  of  lunatics 
so  removed.lj 

Iiiberatlon  on  probation  **  is  granted 
on  the  application  of  the  person  at  whose 
instance  a  lunatic  is  detained,  the  nearest 
known  relative,  or  the  inspector  of  poor  of 
the  ijarish,  or  by  the  Board,  without  an 
order  by  the  sheriff.  The  Board  fixes  the 
time  and  regulations  under  which  the  pro- 
bation is  authorised,  but  the  period  is 
limited  to  twelve  months,  and  it  is  spe- 
cially enacted  that  the  conditions  on  which 
probationary  discharge  is  granted  shall 
not  be  altered.ft 

*  29  &  30  \'iet.  c.  51,  s.  6. 

t  25  &  26  Vict.  c.  54,  s.  16. 

t  /■€.,  that  the  detention  of  tlie  hiiuitic  ia  neces- 
sary iiud  proper,  either  for  his  own  welfare  or  the 
safety  of  the  i)ublic,  in  tlie  lawt  fortiiii;ht  of  l>e- 
ceml)cr  of  each  year,  or  on  the  isl  day  of  January. 

5  29  &  30  Vict.  e.  51,  .s.  7.  "  III  no  case  shall 
the  sheriff's  order  remain  in  force  lonr/er  than  the 
Jirst  (lay  of  January  jirst  occurrinff  after  the  ex- 
j)iry  if  three  years  from  the  date  on  which  it  was 
(/ranted;  or  than  the  jirst  day  <f  .lannary  in  each 
sacceediny  year,  unless  the  superintendent  or  medi- 
cal attendant  of  the  asylum,  on  each  of  the  frst 
days  of  January,  or  within  fourteen  clear  days 
immediately  preceding',  f/rant  <ind  transmit  to  the 
Board  a  rertijicate,  on  soul  and  conscience,  that  the 
detention  of  the  lunatic  is  necessary  and  j)rojier, 
either  for  his  own  welfare  or  the  safety  of  the 
public." 

II  29  &  30  Viet.  c.  51,  s.  9. 

^  29  &  30  Vict.  c.  51,  ss.  lo,  II. 

»»  25  &  26  Vict.  c.  54,  s.  16. 

tt  25  &  26  N'iet.  c.  54,  s.  16 ;  29  &  30  A'ict.  v.  5r, 


Recovery  *  of  a  lunatic,  in  so  far  that 
he  may  be  safely  liberated  without  risk  of 
injury  to  himself  or  others,  must  be  inti- 
mated to  the  Board  by  the  superintendent 
of  the  asylum,  and  also  to  the  person  at 
whose  instance  the  lunatic  was  detained, 
or  to  the  nearest  known  relative,  or  to  the 
inspector  of  poor.  If  these  do  not  remove 
the  person,  the  Board  may  order  his  dis- 
charge forthwith,  and  the  expenses  will 
be  borne  by  the  parish  liable.f 

The  liberation  of  a  lunatic  is  pro- 
vided for  by  statute  in  the  following 
manner  :| — Any  person  who  may  have 
procured  two  certificates  from  medical 
persons  approved  by  the  sheriff,  and  who 
in  consequence  may  have  obtained  an 
order  of  liberation  from  the  sheriff,  may 
procure  the  liberation  of  the  lunatic.  The 
Board  may  similarly  grant  an  order  for 
liberation,  but  with  this  difference — the 
certificate  laid  before  the  sheriff  may  be 
to  the  effect  that  the  lunatic  has  recovered 
or  may  be  liberated  without  risk  of  injury 
to  himself  or  others,  while  the  certificates 
on  which  the  Board  can  act  must  be  of 
absolute  recovery.  The  facts  of  these 
removals  must  be  entered  in  the  register 
and  transmitted  to  the  Board.  Lunatics 
detained  by  courts  of  law§  cannot  be 
released  under  this  section  without  the 
authority  of  the  Court  or  the  warrant  of 
a  principal  Secretary  of  State.  Should  an 
attempt  be  made  to  remove  a  dangerous 
lunatic  the  case  must  be  reported  by  the 
superintendent  to  the  procurator  fiscal. || 

Lunatics  may  be  transferred  from  one 
asylum  to  another  under  various  circum- 
stances.^ Should  certificates  be  granted 
by  two  medical  persons  that  an  asylum 
is  unsuitable  for  the  confinement  of  any 
lunatic,  the  procurator  fiscal  or  one  of 
the  commissioners  may  make  application 
to  the  sheriff  for  an  order  for  removal  to 
another  asylum,  and,  when  such  is  granted,, 
intimation  to  the  responsible  parties  must 
be  made.**  If  the  sujjerintendent  of  any 
asylum  shall  show  good  cause  to  the 
Board,  they  may  grant  authority  for  the 
transfer  of  patients  from  one  building  to 
another  without  any  additional   sheriff's 

*  25  &  26  Vict.  c.  54,  s.  17. 

t  25  &  26  N'ict.  c.  54,  8s.  17,  18.  The  snperin- 
tendent  of  au  asylum  has  no  lonf^er  any  statutory 
autliority  to  detain  a  patient  after  he  ceases  to  be 
a  hinatic. 

%  20&  21  Vict.  c.  71,  s.  92. 

§  20  &  21  Viet.  c.  71,  s.  93. 

I  29  &  30  Vict.  c.  51,  s.  12. 

IT  20  &  21  Vict.  c.  71,  s.  91. 

*•■■  20  &  21  Vict.  c.  71,  8.  44.  This  section  re- 
fers only  to  the  transfer  of  the  patients  from  one 
bnildiny  to  anotlier,  as  when  tlie  liceuee  of  a  pri- 
vate asylum  is  transferred  (see  25  &  26  Vict.  e.  54, 
8.  16),  whieli  ^iives  authority  for  transfer  of  a  patieut 
and  for  proluition. 

4C 


Scottish  Lunacy  Law        [     1124    ]        Scottish  Lunacy  Law 


order.  But  due  intimation  must  be  given 
to  the  parties  interested,  and  notice  must 
be  made  to  the  Board  regarding  the 
patients  so  transferred.*  The  usual  form 
of  transfer  is  an  authorisation  from  the 
Board  granted  on  the  application  of  the 
nearest  known  relative  or  inspector  of 
poor,  or  the  person  at  whose  instance  the 
lunatic  was  confined.  This  application 
is  accompanied  by  a  statement  and  a 
medical  certificate,  and  the  effect  of  the 
authority  for  transfer  is  to  continue  the 
original  sheriff's  order  in  the  asylum  to 
which  the  lunatic  is  conveyed  as  if  no 
such  change  had  taken  place. 

Escape. — By  a  regulation  of  the  Board 
all  escapes  must  be  reported  to  the  Board 
within  fourteen  days  from  the  date  of 
escape.  By  a  recent  Actf  the  commis- 
sioners have  the  power  to  authorise  an 
application  to  be  made  to  the  sheriff  for 
a  warrant  to  retake  a  lunatic  who  may 
have  escaped  from  Scotland  to  England 
or  Ireland.  This  warrant  is  sufficient 
authority  for  any  justice  of  the  peace  in 
England  or  Ireland  to  countersign  the 
same,  and  such  warrant  may  then  be 
legally  executed  in  the  countries  named. 
The  question  as  to  whether  the  police  have 
power  to  arrest  a  lunatic  under  a  sheriff's 
order  has  not  been  decided  in  the  law 
courts. 

The  deatb  of  a  lunatic  must  be  entered 
in  a  register  kept  for  that  purpose,^  and 
notified  to  the  responsible  parties  and  to 
the  Board.  By  special  instruction  of  the 
Board  every  case  of  sudden  or  unexpected 
death,  or  death  under  suspicious  circum- 
stances, is  to  be  at  once  intimated  to  the 
procurator  fiscal  and  to  the  Board. 

Restraint  and  seclusion,  as  well  as  the 
compulsory  use  of  the  shower  bath,  must 
be  entered  in  a  register  kept  for  the 
purpose.  By  a  special  instruction  of  the 
Board  restraint  is  defined  as  follows : 
Whenever  a  patient  is  iiiade  to  wear  an 
article  of  dress,  or  is  placed  in  any  appa- 
ratus which  is  fastened  so  as  to  prevent 
the  patient  from  putting  it  off  without 
assistance,  and  which  restricts  the  move- 
ments of  the  patient  and  the  use  of  his 
hands  and  feet,  it  is  restraint.  And  when- 
ever a  patient  is  placed  by  day  in  any 
room  or  locality  alone,  and  with  the  door 
of  exit  locked  or  fastened,  or  held  in  such 
a  way  as  to  prevent  the  egress  of  the 
patient,  it  is  seclusion. 

The  statistics  of  insanity  in  Scotland, 
as  officially  reported  by  the  General  Board 
of  Lunacy  for  1890,  may  be  briefly  summed 
up  as  follows : 

*  25  &  26  Vict.  c.  54,  s.  16, 
t  52  &  53  Vict.  c.  41,  s.  79, 
t  20  &  21  Vict.  c.  71,  .s.  97, 


The  number  of  lunatics  coming  under 
the  official  cognizance  of  the  Board  was 
12,595  ;  I o» 5 39  of  these  were  maintained 
by  parochial  rates,  1945  from  private 
sources,  and  57  at  the  expense  of  the 
State.  The  royal  and  district  asylums 
contained  5589  pauper  and  1527  private 
patients.  The  poorhouse  wards  contained 
882  paupers,  besides  15 17  in  parochial 
asylums.  There  were  152  private  patients 
in  private  asylums,  but  no  paupers.  Pri- 
vate dwellings  accommodated  124  private 
and  2489  pauper  lunatics.  The  lunatic 
department  of  H.M.  prison  at  Perth  con- 
tained 57  lunatics,  the  training  institu- 
tions 142  private  and  116  pauper  idiots 
and  imbeciles. 

During  the  year  522  private  and  2213 
pauper  patients  were  received  into  estab- 
lishments by  direct  admission  (sheriffs' 
orders),  while  there  were  30  private  and 
321  pauper  transfers;  98  voluntary 
patients  were  admitted,  the  total  number 
of  such  cases  resident  on  January  i,  1891, 
being  61.  199  private  patients  and  975 
paupers  were  discharged  recovered.  Those 
unrecovered  were  removed  as  follows : 
By  friends  114,  by  minute  of  parochial 
boards  328,  by  escape  17,  after  probation 
46,  on  expiry  of  emergency  certificate  i, 
by  warrant  of  sheriff  35,  by  being  placed 
in  Perth  prison  as  a  Queen's  pleasure  luna- 
tic I,  total  542.  The  deaths  numbered  140 
and  638  for  private  and  pauper  patients 
respectively.  105  cases  were  discharged 
on  statutory  probation,  exclusive  of  those 
sent  out  on  trial  for  twenty-eight  days. 

These  figures  show  a  great  increase 
since  the  Board  was  first  constituted.  The 
number  of  those  under  cognizance  has,  in 
fact,  doubled.  The  development  of  the 
lunacy  administration  of  Scotland  has 
proceeded  upon  the  lines  indicated  by  the 
undermentioned  Acts  of  Parliament,  and 
is  set  forth  in  detail  in  the  annual  reports 
of  the  General  Board  of  Lunacy. 

LuxACY  Acts,  Scotlajjd. 
Iiunacy  : 

20  &  21  Vict.  c.  71.  An  Act  for  the 
regulation  of  the  care  and  treatment  of 
lunatics,  and  for  the  provision,  mainten- 
ance, and  regulation  of  lunatic  asylums  in 
Scotland.     1857. 

21  &  22  Vict.  c.  89.  An  Act  to  amend 
the  act  of  last  session.     1858. 

25  &  26  Vict,  c  54.  An  Act  to  make 
further  provision  respecting  lunacy.     1862. 

27  &  28  Vict.  c.  59.  An  Act  as  to  de- 
puty commissioners  and  others.     1864. 

29  &  30  Vict.  c.  51.  An  Act  to  amend 
the  Acts  relating  to  lunacy.     1866. 

30  &  31  Vict.  c.  55.  An  Act  to  enlarge 
for  the  present  year  the  time  within  which 


Scythian  Disease 


[     1125     ]        Secondary  Sensations 


certain  certificates  regarding  lunatics  may 
be  granted.     1867. 

34  &  35  Vict.  c.  55.  An  Act  to  amend 
the  law  relating  to  dangerous  and  criminal 
lunatics.     1871. 

50  &  5 1  Vict.  c.  39.  An  Act  relative  to 
lunacy  districts.     1887. 

52  &  S3  Vict.  c.  41.  An  Act  to  amend 
the  Acts  relating  to  lunatics  (certain  sec- 
tions applicable  to  Scotland).     1889. 

52  &  53  Vict.  c.  50.  An  Act  to  amend  the 
laws  relating  to  Local  Government.  1889. 
Also  references  in  these  : 

Assessments : 

14  &  15  Vict.  c.  23.  An  Act  to  author- 
ise the  advance  of  money.     1 85 1. 

17  &  18  Vict.  c.  91.  An  Act  for  the 
valuation  of  lands  and  heritages.     1854. 

20  &  21  Vict,  c  58.  Valuation  of  Lands 
Amendment  Act.     1857. 

31  &  32  Vict.  c.  82.  County  General 
Assessment  Act.     r868. 

Prisons : 

23  it  24  Vict,  c,  105.  The  Prisons  Ad- 
ministration Act.    i860. 

40  &  41  Vict.  c.  53.     The  Prisons  Act. 

1877. 

Court  of  Session  : 

13  &  14  Vict.  c.  36.  An  Act  to  facilitate 
procediu'e  in  the  Court  of  Session.     1850. 

20  &  21  Vict.  c.  56.  An  Act  to  regulate 
the  distribution  of  business  in  the  Court 
of  Session.     1857. 

31  &  32  Vict.  c.  100.  (Cognition,  s. 
loi.)  To  amend  the  procedure  in  the 
Court  of  Session.     186S. 

Factors : 

12  &  13  Vict.  c.  51.  The  Pupils  Protec- 
tion Act.     1849. 

43  &  44  Vict.  c.  4.  Judicial  Factors 
Act.     1880. 

52  &  53  Vict.  c.  39.  Judicial  Factors 
Act.    1889. 

Aim  the  various  Ads  of  Sederunt  of  the 
Court  of  Session  hearing  on  these  Court  of 
Session  and  Factors  Acts,  published  yearly 
in  the  Parliament  House  Book. 

Drunkards  : 

42  &  43  Vict.  c.  19.  The  Habitual 
Drunkards  Act.     1879. 

51  &  =12  Vict.  c.  19.  The  Inebriates  Act. 
1888.     '  A.  R.  Ukquhart. 

SCYTHIAKr  DISEASE. — Disease  said 
to  be  not  infrequent  in  the  Caucasus,  and 
occasionally  seen  elsewhere,  characterised 
by  atrophy  of  the  male  reproductive 
organs  in  adults,  followed  by  mental 
abnormity,  leading  to  the  assumption  of 
the  dress  and  habits  of  women.  (Billings.) 

SEASON'S,  EFFECTS  OF.  {See  STA- 
TISTICS.) 

SEBASTOIVXANZA  {aefiuaTos,  wor- 
shipped ;  fxavia,  madness).  A  term  for 
religious  insanity.  , 


SECiiVSZOir.     {See  Treatment.) 

SECON-DARY  SENSATION'S  (Ger. 
ScciuKliirGiiipJiiuliuujcii  ;  Fr.  audition 
colored). — There  are  people  with  whom 
every  sensation  of  sound  is  accom- 
panied by  a  sensation  of  light.  If,  for  in- 
stance, a  bell  is  rung  in  the  vicinity  of  such 
a  person  (colour-hearer),  he  not  only  hears 
the  sound  as  such,  but  at  the  same  time 
observes  a  red  colour;  if  he  hears  the 
letter  a  (German  a)  pronounced,  he  has 
the  impression  of  a  blue  colom*. 

Such  sensations  for  which  the  physical 
cause  seems  inadequate  (a  sensation  of 
light  produced  by  sound)  are  called 
secondary  sensations ;  primary  and 
secondary  sensations  together  are  desig- 
nated as  dual  sensations. 

In  addition  to  (i)  sensations  of  colour 
accompanying  sensations  of  sound  (sound 
photisms),  other  secondary  sensations 
have  been  observed,  namely:  (2)  Sensations 
of  sound  from  perception  through  light 
(ligrht  phonlsms) ;  (3)  Sensationsof  colour 
from  perception  through  taste  (taste 
photisms) ;  (4)  Sensations  of  colour  from 
perception  thi'ough  smell  (odour  phot- 
isms) ;  (5)  Sensations  of  colour  from  per- 
ception of  pain,  temperature,  and  touch 
(pain  photisms,  &c.). 

In  sensations  of  colour  caused  by 
musical  sounds  the  shade  is  determined 
by  the  pitch,  the  lighter  shades  corre- 
sponding usually  to  a  high  pitch,  the 
darker  to  a  low  pitch.  The  colours  repre- 
senting different  tones  vary  with  different 
persons.  The  scale  of  colours  correspond- 
ing to  the  scale  of  musical  sounds  passes 
most  frequently  from  dark  brown  or  dark 
red,  through  red  and  yellow  to  white.  In 
isolated  cases,  however,  the  lower  notes 
give  colours  quite  different  from  the 
higher ;  thus,  D  produces  a  brownish 
violet.  A,  a  Prussian  blue,  Aj,  an  ochre,  C^, 
a  whitish  yellow. 

The  overtones  (partial  tones)  of  a  sound 
often  cause,  in  addition  to  the  photism  of 
the  fundamental  tone,  special  photisms 
which  can  be  separated  from  each  other 
even  when  the  acoustic  impression  appears 
as  a  single  sound.  By  representing  the 
partial  tones  of  a  sound  on  a  coloured  top, 
Nussbaumer,  a  colour-hearer,  was  able  to 
imitate  the  photism  of  the  entire  sound. 

Entire  musical  selections  usually  make 
the  impression  only  of  the  single  sounds 
with  which  the  photisms  come  and  go. 
Often,  however,  an  entire  combination  of 
sounds,  a  melody,  and  especially  a  parti- 
cular key,  appears  in  a  fixed  colour,  so 
that,  for  instance,  a  whole  piece  of  music 
seems  dark  blue  because  it  is  written  in  E 
flat.  With  many  persons  sounds  from 
different    instruments    produce  different 


Secondary  Sensations       [    1126    ]        Secondary  Sensations 


colours,  so  that  all  notes  of  a  cornet  are 
yellow  (light  or  dark  according  to  the 
pitch),  while  those  from  a  flute  seem  blue, 
^^ozst's  also  have  corresponding  photisms. 
These  are  generally  brown  or  gray ;  other 
colours,  red  especially,  are  less  frequent. 

Most  sound  ijliotisnis  are  projected  on 
exteiiiality,  not,  however,  on  the  field  of 
vision  as  ordinary  sensations  of  light,  but 
on  the  field  of  hearing  ;  they  are  localised 
just  as  the  sound  itself  is.  Thus  the  sound 
and  its  accompanying  photism  produced 
by  a  guitar  seem,  in  the  opinion  of  the 
colour-hearer,  to  come  from  the  string 
struck  ;  the  bright  photism  of  a  note  from 
a  fife  appears  to  come  out  of  the  fife,  &c. 
If  the  sound  itself  is  falsely  localised 
(i-inging  in  the  ears  referred  to  externality) 
the  same  occurs  with  the  photism.  In  a 
few  rare  cases  sound  photisms  are  always 
localised  in  the  head. 

The  limitation  in  space  of  sound 
photisms  is  even  more  uncertain  than 
their  localisation,  but  the  photisms  of 
higher  and  less  sonorous  sounds  have, 
other  things  being  equal,  more  definite 
boundaries  than  those  from  lower  and 
more  sonorous  ones ;  their  expansion,  too, 
is  much  less.  In  a  few  cases  the  colour 
phenomena  assume  definite  forms  and 
appear  as  flames,  as  brilliant  drops,  and 
the  like.  The  photisms  of  simultaneously 
occurring  sounds  often  unite  to  form  a 
single  colour;  under  other  circumstances 
the  different  single  colours  are  sharply 
differentiated  from  each  other.  The  latter 
often  occurs  with  discords,while  the  colours 
from  sounds  which  accord  easily  unite. 

The  duration  of  photisms  is  exactly 
the  same  as  that  of  the  sounds  which  pro- 
duce them.  The  sensation  of  colour  and 
form  referred  to  a  definite  locality  lasts 
just  as  long  as  the  sound  is  heard.  If  the 
first  sound  is  replaced  by  a  second,  the 
photism  is,  in  the  same  moment,  corre- 
spondingly changed. 

The  photisms  of  the  sounds  of  speech 
occupy  apeculiar  position.  Of  all  photisms 
those  for  vowels  are  most  frequent.  It 
may  be  stated  as  a  rule  that  e  and  a 
(German  i  and  e)  give  light  colours,  0  and 


Photisms  for  entire  vjords  are  frequent ; 
they  are  usually  of  several  colours,  which 
correspond  to  the  colours  of  the  sounds 
composing  the  word.  Although  the  pro- 
nunciation of  a  word  progresses  in  time, 
in  the  mind  of  the  colour-hearer  the 
photisms  of  the  entire  word  are  blended  to 
form  a  simple  image,  that  is,  from  the 
succession  in  time  of  the  sound  impres- 
sions results  a  juxtaposition  in  space  of 
their  photisms  ;  thus,  for  the  author,  the 
word  "  country"  consists  of  a  brownish 
part  (oil),  and  a  smaller  white  part  (y), 
which  are  connected  with  each  other  from 
left  to  right.  Word  photisms  are  often  of 
a  single  colour,  which,  generally,  corre- 
sponds to  the  principal  vowel  or  the  prin- 
cipal syllable — "  Eudolph,"  for  example, 
may  be  green  with  a  person  whose  phot- 
ism for  u  is  green. 

Names  of  persons,  months,  days  of  the 
tve'eh,  and  numbers  often  produce  ideas  of 
a  single  colour.  These  do  not  always 
correspond  to  the  colours  of  the  component 
parts,  and,  therefore,  differ  in  principle 
from  sound  photisms  proper.  Perhaps 
they  are  due  simply  to  the  influence  of  the 
constant  involuntary  association  of  ideas. 
In  isolated  instances  the  colour  image  for 
the  sound  of  a  name  can  be  easily 
separated  from  the  colour  impression  for 
the  corresponding  conception  (conceptions, 
too,  produce  sensations  of  colour)  ;  thus, 
with  the  author,  the  photism  for  the  word 
"Friday"  is  white, the  day  itself  is  thought 
of  as  blue.  These  single-colour  ideas  for 
numbers,  names,  &c.,  seem  to  follow  no 
well-defined  rule. 

The  photism  of  an  entire  speech  depends, 
first,  on  the  voice  of  the  sjieaker,  then  on 
the  language,  that  is,  on  the  predominance 
of  particular  sounds  (vowels  or  conson- 
ants). The  photisms  of  the  words  follow 
each  other  so  quickly  that  it  is  generally 
impossible  to  fix  the  attention  on  these, 
while  the  voice  remains  about  the  same 
throughout   and   so   determines   the    im- 


pression. 

Not  sound  alone,  but  all  sense  percep- 
tions produce  sensations  of  colour.  There 
are  people  who  have  a  photism  with  every 


■u  (long)  darker,  while  «.,  as  in  "are,"  some- j  taste,  with  every  smell.  On  account  of 
times  gives  darker  colours,  sometimes 
lighter,  e  (long)  gives  a  great  preponder- 
ance of  white.  The  higher  vowels  have, 
therefore,  like  the  higher  musical  tones, 
lighter  shades,  the  lower  darker.  Other 
than  these  no  rules  can  be  given  for  the 
photisms  of  the  vowel  sounds. 

For  the   consonants   colour   sensations 
are  much  rarer.     They  are,  if  joresent  at 


all,  usually  very  weak,  of  a  greyish  colour, 
and  are  only  exceptionally  strongly 
coloured. 


the  iufrequency  of  taste  and  smell  phot- 
isms it  is  at  present  impossible  to  give 
with  certainty  any  general  rules  concern- 
ing them.  Agreeable,  delicate  tastes  and 
smells,  however,  seem  to  produce  the  more 
agreeable  and  delicate  shades  of  colour ; 
disagreeable  sensations  cause  correspond- 
ingly disagreeable  colours.  Green,  a 
colour  rare  in  other  forms  of  photisms, 
occurs  comparatively  often  in  taste  phot- 
isms. With  these  taste  and  smell  phot- 
isms, moi'e  important,  probably,  than  the 


Secondary  Sensations        [    1127 


Secondary  Sensations 


colour  itself  is  its  transferency,  its  dis- 
tinctness, and  its  saturation. 

Taste  photisms  are  nearly  always  re- 
ferred to  that  part  of  the  oral  cavity  which 
receives  the  sensation.  With  odours  the 
colour  is  referred  not  only  to  tlie  nose 
itself,  but  the  space  surruuuding  the  per- 
son and  the  fragrant  body — that  is,  the 
immediate  neighbourhood  of  the  body 
seems  filled  with  the  colour. 

In  jihotisms  of  cutaneous  sensibility 
the  general  law  seems  to  prevail  that  the 
sensation  produced  depends  upon  the  ex- 
tent of  cutaneous  surface  receiving  the 
impression  ;  thus,  if  but  a  point  is  touched, 
the  photism  is  brighter  than  when  a  sur- 
face is  aifected.  Pain  generally  gives 
strong,  even  brilliant  colours.  Eed  and 
yellow  predominate  also  in  these  phot- 
isms. 

With  some  persons  sensations  of  sound 
are  produced  by  the  sigrbt  of  certain 
forms  and  colours  {2Jhonis')ns).  Phouisms 
are  usually  very  slight  noises,  rarely  loud 
sounds.  Since  these  are  very  uncommon, 
not  much  can  be  said  concerning  them. 

The  disagreeable  sensations  which  many 
people  experience  from  a  screeching  sound 
have  been  described  as  secondary  sen- 
sations of  general  feelingr. 

With  most  colour-hearers  these  second- 
ary sensations  invariably  accompany  the 
primary  sensations.  The  former  may  be 
blended  with  associated  ideas  of  the  pri- 
mary perceptions  ;  thus,  a  colour-hearer 
may  conceive  Adam  as  blue  because  the 
photism  of  the  word  "Adam"  is  blue,  &c. 
In  an  article  in  the  Musical  World,  en- 
titled "  Scales  and  Colours,"  Grant  Allen 
examines  Haydn's  "  Creation,"  and  finds 
that,  according  to  the  key,  chaos  is  com- 
posed in  dark  and  gloomy  colours,  light 
in  white,  &c.  In  the  autumn  of  1883  a 
long  discussion  over  this  subject  was 
carried  on  in  the  Standard. 

From  the  examination  of  a  few  ex- 
quisite colour-hearers,  Bleuler  and  Leh- 
mann  conclude  that  photisnis  have  no 
influence  upon  the  function  of  the  eyes, 
phonisms  no  influence  ujion  the  func- 
tion of  the  ears.  Urbantschitsch,  on 
the  contrary,  found,  by  examining  a  great 
number  of  persons  (not  colour-hearers), 
that  looking  at  certain  colours  increases 
the  capacity  for  hearing  certain  sounds ; 
that  a  high  note  of  a  tuning-fork  seems 
higher  when  one  looks  at  red,  blue,  green, 
or  yellow,  but  lower  if  at  violet.  The 
apparent  contradiction  in  the  observa- 
tions of  Urbantschitsch  and  Bleuler  and 
Lehmann  seems  to  indicate  that  these  ob- 
servers investigated  ditt'erent  phenomena. 
Itaws. — The  individual  testimony  of 
different    persons   concerning    secondary 


sensations  presents  no  general  conformity. 
A  few  laws,  however,  seem  well  estab- 
lished :  (i)  Photisms  light  in  colour  are 
produced  by  sounds  of  high  ([uality,  in- 
tense pain,  sharply  defined  sensation  of 
touch,  small  forms,  pointed  forms;  dark 
])hotisms  from  opposite  conditions ;  (2) 
High  phonisms  are  produced  by  bright 
light,  well-defined  outlines,  small  forms, 
pointed  forms  ;  low  phonisms  from  oppo- 
site conditions ;  (3)  Photisms  with  well- 
defined  forms,  small  photisms,  pointed 
photisms  are  produced  by  sounds  of  high 
pitch  ;  (4)  Red,  yellow,  and  brown  are  fre- 
quent photism  colours,  violet  and  green 
are  rare,  while  blue  stands  between  these 
extremes. 

rrequency.  —  Secondary  sensations 
occur  more  frequently  than  is  generally 
supposed.  Bleuler  and  Lehmann  found 
such  sensations  in  76  persons  out  of  596 
(i2i  per  cent.).  A  disposition  to  secondary 
sensations  seems  to  be  present  with  most 
persons,  for  such  expressions  as  "  clear 
tones,"  "  pointed  tones  "  (*'  spitze  Torxe  "), 
"  dull  sounds,''  &c.,  are  found  in  all  lan- 
guages, are  understood  by  everybody,  and 
are  in  harmony  with  rules  given  for  se- 
condary sensations.  Wundt  ("  Physio- 
logische  Psychologie  ")  ascribes  to  these  a 
chief  part  in  the  formation  of  language. 

Secondary  sensations  are  transmissible 
by  heredity.  Entire  families  of  colour- 
hearers  are  known.  A  connection  with 
nervous  and  mental  disease  is  unproved. 

Many  theories  have  been  suggested  to 
explain  colour-hearing.  Some  of  these 
will  not  bear  even  the  most  superficial 
criticism,  and  all  are  incapable  of  positive 
proof.  The  explanation  commonly  offered, 
that  colour-hearing  is  due  to  a  simple  as- 
sociation of  ideas  which  constantly  occur 
together,  is  certainly  lalse.  The  regularity 
with  which  light  colours  predominate  for 
high  notes,  &c.,  is  on  this  theory  unex- 
plainable. 

The  colours  appearing  in  photisms 
diff"er  but  slightly  from  the  ordinary 
colours  perceived  by  the  eye.  It  must  be 
noticed,  however,  that  these  photism- 
colours  usually  appear  as  pure  colour 
sensations,  separated  from  all  ideas  of 
matter  which  are  associated  with  every 
coloui'ed  surface.  They  can  best  be  com- 
pared with  coloured  flames,  or  with  even- 
ing red  in  a  cloudless  sky.  Photism 
colours  have  been  observed,  although  very 
rarely,  which  optically  have  never  been 
perceived,  which  indeed  are,  optically,  in- 
conceivable; for  examjile,  the  author's 
photism  for  the  German  modified  u  (ii)  is 
a  mixture  of  light  red  and  yellow  and  a 
little  blue  without  producing  a  trace  of 
green. 


Secondary  Sensations       [    1128    ] 


Sedatives 


The  surroundings  of  photisms — that  is, 
the  field  on  which  they  appear — are  not 
black,  but  a  neutral  ground  tree  from  every 
colour. 

The  transitions  from  one  photism  to 
another  frequently  correspond  to  similar 
changes  in  common  colours  ;  thus  for  a 
colour-hearer (X  (in  "father")  may  be  blue, 
0  (in  "  bone "')  yellow,  and  the  sound  be- 
tween these  two  oa  (a  in  "  water"),  green. 
Mixtures  of  colours  frequently  occur  and 
follow  the  ordinary  laws  which  govern 
the  mixing  of  pigments ;  for  example,  the 
simple  photism  of  a  word  of  two  syllables 
may  be  orange,  because  the  vowel  of  the 
first  syllable  appears  red,  and  that  of  the 
second,  yellow. 

The  colour  sensations  caused  by 
optic  impressions  differ  somewhat  from 
ordinary  secondary  sensations.  These 
occur  very  infrequently,  are  usually  less 
exactly  defined  than  other  photisms,  yet 
always  clear  enough  to  admit  of  descrip- 
tion. One  rule  only  can  be  stated  for 
these :  pointed  and  small  bodies  j^roduce 
lighter  colours  than  blunt  and  larger 
bodies.  Perhaps  the  colour  phenomena 
are  photisms  of  form-phonisms — that  is, 
tertiary  sensations. 

Bearing  a  certain  relation  to  secondary 
sensations, but  perhaps  differing  in  nature 
from  them,  are  impressions  of  form  for 
general  ideas  (as  for  piety),  especially  for 
a  series,  for  a  succession  of  numbers,  mu- 
sical scales,  days  of  the  week,  &c.  Such 
"form  ideas"  are  more  frequent  than 
photisms,  but  appear  with  colour-hearers 
to  be  very  pronounced.  Francis  Galton 
in  his  work,  "  Enquiries  into  Human 
Faculty  and  its  Development"  (1883),  de- 
voted considerable  attention  to  these 
"numberj  forms"  and  similar  i^heno- 
mena.  With  these  ideas  a  certain, 
though  unconscious  i^rocess  of  reflec- 
tion cannot  be  excluded. 

E.  Bleulek. 

[Iteferences. — The  first  observations  of  secondary 
sensations  were  pnblished  by  Pick  in  Menders; 
Neurolouisches  Centralblatt,  1887,  p.  536,  and  by 
Lussana,  tjur  Taudition  coloree,  Arch.  Italiennes  de 
Biologie,  1883.  Fnrther,  the  following-  puldica- 
tions  are  of  importance  :  Nussbauiuer,  AViener 
med.  Wocheiischrift,  1873,  ^o*-  i"3-  l>leuler  and 
Lehmann,  Zwang-smilssige  Lichtemptindung-en 
durcb  Sehall  und  vervvandte  Erseheinuugen,  Leip- 
zig, 1881  (report  of  seventy-seven  cases).  Francis 
Galton,  Enquiries  into  Hnman  Facnlty  and  its  De- 
velopment, ]\Iacmillan  &  Co.,  1883.  Kochas,  in  La 
Nature,  1885,  April,  :May,  September,  (iirandeau, 
De  I'audition  coloree,  in  I'Encepliale,  1885,  p.  589. 
Baratoux,  Audition  coloree,  in  Progres  medic,  1887. 
Steinbriigge,  Ueber  secundiire  Sinnesempfindiingen, 
Wiesbaden,  1887  (preliminary  report  of  442  cases). 
Urbantschitscb,  Sitznngsliericht  der  Gesellscliaft 
der  Aerzte  in  Wien,  Oct.  i,  1887.  iMiinchnermed. 
Wochenschrift,  Oct.  25,  1887,  p.  845.  Suarez  de 
Mendoza,  1/audition  coloree,  Paris,  1890.] 


SECUNDARZ:   VERRitCICTHEZT. — 

A  synonym  for  Secondary  Delusional  In- 
sanity. 

SEDATIVES. — Under  this  heading  we 
shall  include  sedatives  proper,  hypnotics 
or  soporifics,  narcotics.  Before  considering 
these  in  detail  we  must  first  say  a  few 
words  on  sleep,  and  the  general  means  at 
our  disposal  for  inducing  it. 

The  activities  of  the  body  during  sleep 
are,  as  a  whole,  lowered,  the  pulse-rate  is 
diminished,  the  breathing  less  frequent, 
the  movements  of  the  stomach  and  intes- 
tines less.  There  is  less  heat  produced, 
secretion  is  not  so  free.  Most  striking  of 
all,  however,  is  the  quiescence  of  the 
central  nervous  system,  which  shows  itself 
in  the  cord  and  lower  centres  generally  by 
an  impaired  reflex  excitability  *  (of  which, 
indeed,  the  above  phenomena  are,  to  a  great 
extent,  the  expression),  and  in  the  brain  by 
abolition,  at  times  perhaps  complete,  of  the 
more  complex  workings  of  the  cortex.  A 
sleejiing  man  has  been  likened  to  a  being 
which  has  suffered  extirpation  of  its  cere- 
bral hemispheres,  and  at  any  rate  these 
organs  are  not  functionally  in  evidence. 
It  is  generally  accepted  that  the  brain 
during  sleep  contains  less  blood  than  in 
the  waking  state. 

The  object  of  sleep  is  repair,  and  for 
this  the  vital  activities  which  still  persist 
are,  in  health,  wholly  sufiicient. 

Sleep  varies  much  in  health — i.e.,  in 
degree  ;  and  this  not  only  among  difi'erent 
individuals,  but  also  for  the  sam.e  indi- 
vidual at  different  times.  Each  spell  of 
sleep,  moreover,  has  its  own  curve  of  in- 
tensity. At  the  beginning,  the  dip  into 
sleep  is  greatest,  and  is  to  be  measured 
by  fathoms,  then  the  curve  rises  rapidly 
again,  and  thence  on,  till  the  awakening, 
sleep  is  comparatively  light,  the  organism 
is  in  shallow  waters.  The  ultimate  causes 
of  sleep  it  is  unnecessary  to  consider. 
They  are  still  obscure.  It  is  sufiicient  for 
us  that  we  have  in  sleep  aaother  instance 
of  periodicity  belonging  essentially  to  all 
organisms,  and  that  the  capacity  for  sleep, 
though  it  may  suffer  great  modification 
by  disease,  is  never  abolished  completely. 
We  must  always  bear  this  in  mind  in  our 
treatment  of  sleeplessness,  viz.,  that  the 
organism  before  us  is  still  capable  of  sleep 
if  we  can  only  find  out  and  remove  the 
disturbing  elements.  It  is  necessary  that 
we  should  remember  further  that  sleep  is 
one  thing  and  unconsciousness  another, 
*  This  is  true  generally  in  spite  of  the  fact  that 
certain  local  mechanisms  appear  to  be  in  a  state  of 
excitation — cy'.  the  closure  of  the  eyelids  and  the 
contracted  state  of  the  pupils  (Landois,  "  Physio- 
logy '■) :  and  that  certain  reflexes  appear  to  be  more 
easily  started  during  sleep — e.g.,  glottis  spasm  in 
larjiigismus  stridulus  and  catarrhal  croup. 


Sedatives 


[    1 129    ] 


Sedatives 


and  that  we  seek  sleep,  not  for  the  sake  of 
unconsciousness,  but  tor  the  sake  of  rest 
and  repair.  But  repair  demands  the  ac- 
tivities of  the  vital  processes.  Hence  we 
must  always  aim  at  procuring  sleep  at 
least  cost  ;  i.e.,  with  least  interference  of 
these  processes. 

For  all  functions,  periodic  in  their  nature, 
there  is,  if  interference  be  called  for,  a 
right  and  a  wrong  time  to  interfere. 

This  holds  pre-eminentlj'  for  sleep,  and 
more  particularly  for  those  cases  in  which 
we  aim  at  obtaining  sleep  of  the  most 
natural  kind  possible.  It  may  be  stated 
as  an  axiom  that  the  more  gentle  the 
means  employed  to  induce  sleep,  the  more 
natural  will  be  the  sleep  induced  ;  and 
further,  that  the  more  gentle  the  means 
employed,  the  more  careful  must  we  be  to 
select  the  right  time  for  their  use.  This 
is  the  meaning  of  the  formula  "  hora  somni 
sumendus";  viz.,  that  the  adjuvant  must 
come  in  at  that  moment  when  the  organ- 
ism is  itself  moving  sleep  wards. 

In  studying  the  problem  of  sleep  pro- 
curing we  shall  do  best  to  examine  the 
natural  phenomena  of  sleep  in  health,  and 
to  imitate  these  as  far  as  possible.  The 
physiology  of  the  bedi-oom  is  the  with- 
drawal of  the  organism  from  disturbing 
influences,  light,  sound,  and  the  main- 
tenance of  the  temperature  of  the  body  by 
means  of  a  minimum  of  heat  production. 
The  therapeutics  of  the  sick  chamber  will 
require  the  more  careful  exclusion  of  ex- 
ternal stimuli,  and  the  question  of  an 
extra  blanket,  or  a  hot  bottle  to  the  feet, 
may  have  to  be  considered.  Soi^orifics  of 
this  class  will  include  all  and  every  means 
at  our  disposal  for  removing  the  irritant, 
external  or  internal,  which  is  preventing 
sleep.  It  is  not  necessary  to  specify 
further. 

Next  it  is  recognised  in  physiology  that 
the  prolonged  and  uniform  aj^plication  of 
certain  stimuli  of  small  degree  of  intensity 
promotes  sleep.  Thus  the  monotone  of  a 
voice,  the  stroking  of  the  hand,  or  playing 
with  the  hair,  have  frequently  the  required 
soothing  effect.  These  means  have  their 
value  in  sickness  also,  and  accordingly  we 
recognise  that  the  addition  of  certain 
stimuli,  defined  as  above,  gives  us  a  new 
class  of  soporifics.  It  is  certain  that  the 
phenomena  of  hypnotism  depend  to  some 
extent  upon  this  engaging  of  the  con- 
sciousness by  gentle  and  continuous  stimu- 
lation. The  phenomena  of  Braidism,  for 
instance,  are  of  this  kind.  Heidenhain 
considers  that  in  such  we  have  to  deal 
with  the  inhibition  of  the  activity  of  the 
cells  of  the  cortex  cerebri. 

For  further  information  on  this  subject 
see  Hypnotism. 


Before  leaving  this  class  it  may,  perhaps, 
be  well  to  mention  the  value  in  some  cases 
of  a  small  quantity  of  light  food  shortly 
before  sleeping  time.  This  is  sometimes 
of  undoubted  value,  and  it  may  be  that 
the  explanation  of  its  action  falls  in  here, 
for  in  it  we  have  the  addition  of  a  slight 
stimulus  to  the  organs  of  digestion  ;  pos- 
sibly also  the  slight  afflux  ot'  blood  to  the 
site  of  stimulation  is  a  further  element  in 
causing  sleep,  since  it  must  to  some  extent 
withdraw  from  the  brain. 

Should  the  organism  not  respond  to 
these  simpler  means  we  must  examine  the 
nervous  system  peripherally  and  centrally, 
for  it  maybe  that  an  abnormal  state  is  at 
fault,  and  not  abnormal  stimulation.  If 
peripheral,  e.g.,  pruritus  (without  external 
cause),  a  neuralgia,  with  inflamed  nerve- 
trunk  or  nerve-ending,  then  we  shall  look 
among  local  analgesics  (e.f/.,  heat  or  warmth, 
cocaine,  &c.)  for  the  required  soporific.  If 
central,  or  if  we  are  unable  to  combat  the 
local  trouble  by  local  means,  then  our 
remedies  must  be  such  as  influence  the 
central  nervous  system.  To  this  class 
more  properly  belong  the  remedies  known 
as  somnifacients,  soporifics,  hypnotics, 
and  narcotics. 

At  the  outset  we  must  put  the  question, 
Is  there  a  distinction  between  hypnotics 
and  narcotics.''  Dujardin-Beaumetz  an- 
swers in  the  affirmative.  He  holds  that 
for  the  drug  to  be  hypnotic  it  must  imitate 
the  natural  condition  of  sleep  by  effecting 
a  lowered  intra-cranial  pressure,  and  that 
drugs  which,  though  bringing  about  un- 
consciousness, do  not  lower  cerebral  pres- 
sure, or  which  increase  it,  cannot  claim  to 
be  hypnotics.  On  this  line  he  sejjarates 
chloral  as  a  hypnotic  from  opium  as  a 
narcotic.  Whether  this  position  can  be 
maintained  is  doubtful.  In  disease  we 
are  certainly  familiar  with  loss  of  con- 
sciousness in  association  with  raised  in- 
tra-cranial pressure ;  e.g.,  the  coma  of 
apoplexy.  But  we  are  also  familiar  with 
unconsciousness  as  the  result  of  a  toxaemia; 
e.g.,  the  coma  of  urjemia.  And  though 
such  unconscious  states  differ  strikingly 
from  natural  sleep,  yet  in  the  different 
forms  of  artificial  or  drugged  sleep  it  is 
probable  that  these  two  factors — quantity 
ot  blood,  including  blood  pressure,  and 
quality  of  blood — do  each  play  a  part.  To 
dissociate  these  factors,  however,  in  any 
given  case  is  very  difficult,  and  it  will 
therefore  be  safest  not  to  attempt  any  such 
absolute  separation. 

It  will  be  convenient  to  arrange  in 
groups  the  drugs  employed  as  sleep  pro- 
ducers. In  this  we  shall  follow  Schmiede- 
berg  {"  Grundriss  der  Arzneimittellehre," 
If 


Sedatives 


[    1 130 


Sedatives 


The  first  group  includes  the  bromides 
of  potassium,  sodium,  ammonium,  and 
lithium.  It  is  included  in  the  larger  class 
of  salts,  of  which  chloride  of  sodium  may 
be  taken  as  the  structural  type. 

Potassium  bromide  is  the  best  known 
member  of  the  group,  and  the  following 
statements  will  refer  to  it.* 

It  is  a  general  depressant  to  the  tissues ; 
the  frequency  and  force  of  the  heart's 
actiou  are  lowered;  the  temperature  (in 
toxic  doses)  is  decidedly  lowered;  the 
nervo-muscular  system  is  generally  af- 
fected— thus  the  muscles  are  relaxed,  sen- 
sation is  impaired  both  general  and  special 
(skin,  sight,  hearing),  in  particular  the 
mucous  membrane  of  the  soft  palate  and 
fauces  is  benumbed  ;  reflex  irritability  of 
the  spinal  cord  as  a  whole  is  lessened ; 
sexual  vigour  may  be  impaired  or  abolished 
■  (it  is  to  be  noted  that  the  sexual  act  is  in 
part  a  skin  reflex  :  Gowers) ;  the  recep- 
tivity of  the  brain  is  diminished — cf.  lower- 
ing of  sensation  ;  the  motor  area  is  less 
easily  roused  into  action  (this  has  been 
shown  by  direct  irritation  of  the  motor 
area  in  dogs) ;  the  finer  workings  of  the 
cortical  cells  are  interfered  with  ;  there  is 
mental  apathy  even  to  hebetude ;  the 
memory  is  impaired.  The  stress  of  the 
action  of  the  drug  falls,  indeed,  upon  the 
nervous  system,  and  though  all  parts  of 
this  system  suffer  from  the  drug,  yet  it 
appears  to  be  the  sensory  nerves,  the  sen- 
sory portions  of  the  spinal  cord,  and  the 
cortex  cerebri  which  suffer  most.  The 
action  on  the  cortex  cerebri  is  much  less 
marked  for  animals  than  for  man,  but 
then  our  means  of  testing  the  cortex  cere- 
bri in  animals  is  very  defective.  From 
the  above  list  of  symptoms  we  would 
single  out  the  following:  first,  diminished 
reflex  exeitabiJity  of  the  fauces,  because  it 
is  an  early  symptom  and  marks  the  point 
when  the  patient  is  coming  under  the  influ- 
ence of  the  drug;  secondly,  the  influence 
on  the  sexual  function,  because  this  also 
appears  early,  and  because  undue  sexual 
excitement  plays  so  important  a  part  in 
the  genesis  of  mental  affections  ;  thirdly, 
the  lowering  of  cerebral  {cortical)  activity, 
motor  and  sensory,  because  it  is  the  direct 
application  of  this  action  which  makes 
the  value  of  the  drug  in  the  controlling  of 
the  cortical  explosions  of  epilepsy,  and  in 
the  treatment  of  cerebral  excitement  of  all 
kinds,  esi->ecially  epileptic.  In  these  latter 
states  broLiides  promote  sleep  by  render- 
ing the  brain  less  sensitive  to  disturbing 
influences.  It  is  probable  that  the  patient 
is  permitteil  to  go  to  sleep  rather  than 
actually  put  to  sleep.     It  is  difficult  to 

*  Some  of  the  symptoms  here  jiiveu  do  not  ap- 
pear except  for  very  large  and  continuous  dosing. 


ascertain  to  what  extent  the  potassium 
element  is  active  in  obtaining  these  re- 
sults, to  what  extent  the  bromine,  but  it 
is  certain  on  the  one  hand  that  the  drug 
undergoes  but  little  decomposition  within 
the  tissues,  therefore  acts  as  such,  and  on 
the  other  hand  that,  on  man,  potassium 
bromide  acts  quite  differently  from  an 
equivalent  dose  of  potassium  carbonate 
or  jDotassium  sulphate.  It  may  indeed  be 
true  that  potassium  salts  in  general  are 
dej)ressant,  but  it  is  certain  that  the 
sedative  action  of  the  special  salt,  potas- 
sium bromide,  is  largely,  if  not  chiefly, 
attributable  to  the  bromine.  Experiments 
on  animals  with  potassium  salts  give 
results  which  closely  resemble  each  other  ; 
so  much  so  that  it  is  clear  that  the 
potassium  rules  the  effect ;  but,  after  all, 
these  tests  are  very  coarse  as  compared 
with  the  delicate  tests  which  we  can  apply 
clinically,  and  it  is  clinical  evidence  which 
establishes  the  special  sedative  action  of 
potassium  bromide. 

Sodium  Bromide. — On  man  therapeu- 
tic and  toxic  doses  of  this  salt  yield 
effects  like  those  of  potassium  bromide  ; 
thus,  in  epilepsy,  the  psycho-motor  centres 
are  controlled,  and  in  the  insomnia  of 
excitement  the  patient  is  calmed  and  sleep 
promoted.  Reflex  excitability  is  dimin- 
ished. This  is  most  evident  in  the  condi- 
tion of  the  soft  palate  and  fauces.  These 
effects  must  be  due  to  the  bromine  ele- 
ment, since  neither  on  man  nor  on  animals 
are  we  able  to  determine  any  positive 
action  as  belonging  to  sodium  salts  as 
such. 

In  the  molecule  of  bromide  of  sodium 
the  percentage  of  bromine  is  greater  than 
in  that  of  bromide  of  potassium  in  the 
proportion  of  20  to  17. 

Bromide  of  Ammonium  acts  thera- 
peutically like  the  potassium  and  sodium 
salts,  but  we  have  reason  to  believe  that 
it  is  less  depressant  than  the  potassium 
salt.  Experiments  on  animals  show  that 
ammonium  salts  as  a  class  exert  a  stimu- 
lant action  on  the  organism.  This  appears 
as  an  early  eflFect,  but  it  does  not  last, 
and  in  the  later  stages  these  salts  are  de- 
pressant like  potassium  salts.  Clinically 
there  is  not  much  evidence  in  favour  of 
even  a  transient  stimulant  action  of  bro- 
mide of  ammonium,  but  the  probability 
is  great  that  the  salt,  if  not  noticeably 
stimulant,  is  yet  less  depressant  than  the 
2)otassium  salt. 

The  percentage  of  bromine  in  the  mole- 
cule is  practically  the  same  as  that  in 
bromide  of  sodium. 

Bromide  of  Iiitbium  has  also  been 
introduced  into  practice :  it  is  said  b}' 
Weir  Mitchell  to  act  in  smaller  doses,  and 


Sedatives 


[     "31     ] 


Sedatives 


to  be  etRcient  in  some  cases  of  epilepsy 
which  have  not  yielded  to  potassium  bro- 
mide, also  to  be  a  more  powerful  agent  in 
insomnia.  Weight  tor  weight  there  is 
much  more  bromine  in  the  lithium  salt 
than  in  any  other  salt  of  bromine,  the  pcir- 
centage  of  bromine  in  the  molecule  being 
92  per  cent. 

Bromide  of  Calcium  has  a  similar 
action  to  potassium  bromide  ;  it  has  been 
given  in  doses  of  15  to  30  grains  ;  it  is  said 
not  to  depress. 

Bromide  of  Strontium  has  been  re- 
commended by  Laborde,  G.  See,  Dujardin- 
Beaumetz.  It  is  said  to  be  well  borne  by 
the  stomach.  In  epilepsy  as  much  as 
150  grains  have  been  given  'pro  die. 

Bromide  of  Rubidium  has  been  em- 
ployed, and  also,  for  cheapness,  a  com- 
pound of  this  salt  with  bi'omide  of  am- 
monium— a  double  salt  (Laufeuauer). 
These  preparations  are  said  to  have  been 
used  with  good  results  as  substitutes  for 
bromide  of  potassium. 

Bromide  of  Caesium  is  said  to  possess 
similar  properties  to  the  rubidium  com- 
pound. 

Bromide  of  Gold. — Goubert  has  re- 
ported most  enthusiastically  on  the  use  of 
this  salt  in  the  treatment  of  epilepsy.  He 
speaks  from  a  ten  years'  experience.  The 
salt  used  by  him  is  probably  the  tribro- 
mide,  AuBr^,  since  it  is  given  in  solution 
in  water.  The  doses  are  per  diem  ^V^rV 
grain  for  children,  ^-V  grain  for  adults. 
Symptoms  of  bromism  are  said  not  to 
occur.     (Note  the  very  small  dosage.) 

Ferric  Bromide  (Fe^Br,,)  has  been  re- 
commended by  Dr.  Hecquet,  formerly 
physician  to  the  Abbeville  Hospital,  as  of 
value  in  all  those  cases  in  which  it  is 
desired  to  soothe  without  depressing  or 
to  strengthen  without  exciting.  The 
compound  is  said  to  be  well  borne  even 
by  irritable  stomachs.  It  is  given  either 
in  solution  or  in  lozenge  form,  dose  3  to  5 
grains.  Dr.  Hecquet  gives  preference  to 
the  ferric  over  the  ferrous  salt  (FeBro). 
It  will  be  of  interest  to  observe  to  what 
extent  this  salt  will  be  available  as  a  se- 
dative in  the  treatment,  e.g.,  of  epilepsy 
and  cerebral  excitement  among  anasmics. 
Ethylene  or  Ethene  Bromide(CoH4Br.,). 
— This  compound  has  recently  been 
brought  before  us  as  a  sedative  in  epilepsy 
by  Dr.  Julius  Donath,  of  Budapesth.  The 
theory  of  the  action  is  that  the  radicle 
C2H4  is  burnt  up  in  the  body  and 
liberates  bromine,  which,  acting  in  statu 
no.scendi,  exerts  its  sedative  action 
under  the  most  favourable  conditions. 
Dr.  Donath  holds  that  the  bromine  is  t]t,e 
sedative  factor  in  the  action  of  bromides. 
Ethylene  bromide,  a  liquid,  is  given  in 


oily  emulsion  or  in  solution  in  rectified 
spirits.  Dose  1.5  to  3  grains  twice  or  thrice 
daily.  The  results  obtained  are  encourag- 
ing, {'literal}.  ]\[(inafs.,  June  1891.) 
IVXonobromideofCamphor,C,gH,r^(Br)0, 
is  obtained  by  replacing  one  atom  of 
hydrogen  in  the  molecule  of  camphor 
by  an  atom  of  bromine ;  its  action  is  de- 
pressant like  that  of  bromides  generally, 
but  it  is  liable  to  irritate  the  stomach,  and 
cannot  claim  any  special  advantages. 
The  dose  is  gr.  ij-x  in  pill  with,  curd  soap 
or  Canada  balsam. 

Hydrobromic  Acid  has  been  employed 
as  a  substitute  for  potassium  bromide,  but 
though  it  appears  to  possess  similar  pro- 
perties, and  to  have  the  advantage  of  a 
less  tendency  to  produce  bromism,  yet  it 
is  rarely  used,  and  its  position  is  not  defi- 
nitely determined.  It  is  very  acid  and 
very  irritant  to  the  stomach,  and  requires 
free  dilution.  As  a  soporific  one  drachm, 
divided  into  two  or  three  separate  doses, 
each  well  diluted,  may  be  given  at  bed- 
time. 

It  cannot  be  said  that  the  relative  value 
of  the  bromides  has  yet  been  established. 
Theoretically,  on  the  viewthat  the  bromine 
is  the  active  element,  the  order  of  etiiciency 
should  be  as  follows  :  Lithium  bromide, 
and  then  the  ammonium,  sodium,  potas- 
sium, and  rubidium  salts  in  descending 
scale.  Clinical  experience,  according  to 
some  observers,  favours  this  view,  but, 
according  to  others,  it  does  not;  thus  the 
potassium  salt  is  held  on  good  authority 
to  be  a  more  eiScient  cerebral  sedative 
than  sodium  bromide,  the  difference  being 
attributed  to  the  depressant  action  of  the 
potassium.  Others,  whilst  admitting  the 
superiority  of  the  potassium  salt  in  the 
treatment  of  epile^Dsy,  regard  the  sodium 
salt  as  the  more  efficient  hypnotic.  More 
recently,  M.  Fere  {Annuaire  de  Thcra- 
peutique,  February  1892)  has  endeavoured 
to  establisli  the  relative  poisonous  action 
of  a  long  list  of  bromides,  but  his  list  has 
reference  to  lethal  doses,  and  the  results 
obtained  we  can  hardly  accept  as  final, 
even  from  a  toxicological  point  of  view. 

Dosage. — Bromide  of  potassium  is  a 
safe  drug,  and  may  be  given  without  fear 
up  to  one-drachm  doses,  and  these  re- 
peated four  times  a  day  if  necessary.  As 
a  hypnotic  and  sedative  in  cases  of  great 
excitement  it  may  be  given  even  more 
frequently  (Clouston).  Of  course,  smaller 
doses,  gr.  xv-xxx,  should  be  first  tried. 

Sodium  and  ammonium  bromides  may 
be  given  in  similar  doses.  The  sodium 
salt  is  being  extensively  administered,  and 
is  frequently  given  up  to  drachm  doses. 

Lithium  bromide  is  efficient  in  half  the 
dose  of  the  potassium  salt  (Weir  Mitchell). 


Sedatives 


[    1132    J 


Sedatives 


The  combination  of  two  or  more  bro- 
mides in  the  dose  was  advocated  by  Brown- 
Sequard  in  the  treatment  of  epilepsy  ;  he 
considered  it  more  efficient  than  the  same 
total  dose  of  any  one  bromide.  Erlen- 
meyer  recommends  a  combination  in  the 
following  proportions :  Potassium  and 
sodium  bromides  of  each  one  j^art,  ammo- 
nium bromide  one-half  part.  Combina- 
tions such  as  these  will  undoubtedly 
succeed  sometimes  when  the  single  bro- 
mide fails. 

Bromides  are  frequently  combined  with 
cannabisindica,orconium,orhyoscyamus ; 
this  is  especially  recommended  by  Clouston 
and  Eccheverria.  The  former  speaks  most 
highly  of  tincture  of  cannabis  indica  thus 
administered. 

The  efficacy  of  the  combination  of 
chloral  with  bromides  is  universally  re- 
cognised. Ten  to  twenty-five  grains  of 
chloral  with  half  a  drachm  to  a  drachm  of 
bromide  of  j^otassium  are  very  useful  in 
cerebral  excitement  (Clouston).  Ecche- 
verria advises  the  use  of  ergot  of  rye  with 
bromide,  and  Macfarlane  the  use  of  ergot 
of  rye  and  digitalis  with  the  bromide. 
These  latter  adjuvants  affect  powerfully 
the  circulation,  ergot  contracting  the 
arterioles,  and  digitalis  effecting  the  same 
and  in  addition  controlling  the  heart.  In 
the  acute  mania  which  may  follow  epi- 
leptic attacks  bromides  in  half-drachm  or 
drachm  doses  with  half  a  drachm  of 
tincture  of  digitalis  will  be  found  very 
useful.  [M.  Poulet  has  further  recom- 
mended the  combination  of  calabar  bean, 
picrotoxine,  and  belladonna  with  bromides 
— e.g.,  gi'-Y^ti  of  sulphate  of  eserine  or 
T^o^eV  gi*-  of  atroi^ine  sulphate.  See 
Bulletin  General  de  Therapeutique.'] 

It  should  be  added  that  the  smallest 
dose  of  bromide  which  is  adequate  must 
be  given,  and  that  if  the  sodium  salt  will 
answer  the  purpose  it  should  have  pre- 
ference. In  the  treatment  of  children  the 
sodium  salt  is  to  be  preferred  (Nothuagel 
and  Eossbach). 

It  is  well  known  that  bromides  fre- 
quently cause  the  appearance  of  acne-form 
eruptions.  This  troublesome  complaint 
may  in  many  cases  be  prevented  by  the 
simultaneous  administration  of  arsenic 
{e.g.,  yiXy  of  the  liquor  arsenicalis,  Ecche- 
verria). 

One  toxic  symptom,  happily  very  rare, 
calls  for  mention  because  of  its  gravity : 
it  is  oedema  of  the  glottis.  Death  has 
been  thus  caused,  and  in  other  cases  it 
has  only  been  avoided  by  the  performance 
of  tracheotomy.  This  symptom  manifests 
itself  rarely,  and  hence  special  heed  should 
be  taken  during  the  early  administration 
of  the  drug,  and  on  the  appearance  of  any 


roughness  of  the  throat,  hoarseness,  or 
difficulty  in  swallowing  we  should  be 
ready  to  lessen  or  suspend  the  adminis- 
tration. Oedema  of  the  larynx  has  arisen 
even  with  small  doses ;  it  is  impossible  to 
foretell  it.  We  need  not  dwell  on  the 
other  symptoms  of  bromism,  which  in- 
clude mental  torpor,  tremor,  ataxia, 
anasmia,  wasting,  intestinal  and  bronchial 
catarrh. 

Bromides  are  held  to  be  somewhat  con- 
tra-indicated by  anaemia  [ride  Ferric  Bro- 
mide). 

Chloroform  and  Alcohol  Groups. — 
Schmiedeberg  thus  names  the  large  group 
of  bodies  derived  from  the  fatty  series 
and  possessed  of  hypnotic  or  anaesthetic 
powers.  The  following  list  includes  the 
more  important  members  of  the  group  : — 
Alcohol  (and  the  alcohols),  ether  (and  the 
ethers),  aldehyde  and  esi^ecially  ixiralde- 
liyde,  chloroform,  chloral  hydrate,  chloral- 
amide,  urethane,  cldoral  urethane,  acetal, 
methylal,  sulphonal,  tetronal,  amylene 
hydrate,  hypnone  (Leech,  Brit.  Med.  Jcnim. 
November  1889).  The  list  will  certainly 
become  much  more  extensive. 

These  bodies  act  upon  the  nervous 
system  as  follows  [the  sequence  of  events 
in  detail  is  not  always  the  same  for  the  dif- 
ferent members  of  the  group  (Schmiede- 
berg)] :        _   _ 

(i)  Sensibility  for  impressions,  external 
and  internal,  is  dulled. 

(2)  Voluntary  motor  control  is  impaired ; 
the  psychical  activities  become  confused. 

(3)  The  impairment  of  sensibility  pro- 
ceeds to  complete  extinction  ;  the  volitional 
movement  is  likewise  abolished  ;  the  psy- 
chical activities  are  reduced  to  mere  dream- 
like rei^resentations,  or  even  these  are  lost. 
In  this  stage  the  reflexes  generally  of  the 
cord  and  base  of  the  brain  are  impaired  or 
practically  abolished,  all  excejDt  those  very 
stable  reflexes,  circulatory  and  respiratory, 
which  still  permit  of  organic  life. 

(4)  The  centres  respiratory  and  circula- 
tory become  paralysed,  and  death  ensues. 

Stage  (3)  is  the  stage  of  complete  nar- 
cosis. 

The  implication  of  the  nervous  centres 
is,  as  Dr.  Leech  puts  it,  in  the  inverse 
order  of  their  development :  first  the  cortex 
cerebri,  then  the  centres  of  base  of  brain 
and  cord,  then  the  respiratory  and  circu- 
latory centimes  of  the  medulla. 

Imj^ortant  is  the  influence  ou  the  vas- 
cular system,  which  varies  greatly  with 
the  particular  hypnotic  employed.  Though 
it  is  only  in  the  latest  stage  that  the  heart 
gives  out,  yet  vascular  tone  and  blood- 
pressure  always  suff'er  more  or  less.  With 
some  the  impairment  is  scarcely  notice- 
able even  for  deep  narcosis — e.g.,  urethane 


Sedatives 


[    1 133    ] 


Sedatives 


(Schmiedeberg) ;  with  otliers  it  is  very- 
marked — e.g.,  chlorofbrui,  chloral  hydrate. 

Practically  for  this  gi'oup  we  may  dis- 
regard the  intluence  exerted  upon  the 
peripheral  structures,  nerve  trunk  and 
nerve  ending. 

We  may  now  consider  individually  the 
action  of  the  different  members  of  the 
group. 

illcohol. — The  use  of  alcohol  as  a  night- 
cap is  well  known,  though,  as  a  rule,  it  is 
only  in  the  milder  forms  of  insomnia  that 
it  is  efi'ectual.  In  some  cases,  however,  of 
the  acute  delirium  of  fever  it  acts  very 
beneficially  as  a  sedative  and  sleep-giver, 
and  in  acute  mania  it  is  a  recognised  mode 
of  treatment.  It  is  an  excellent  sleep- 
giver  for  children,  whose  nervous  systems 
are  readily  affected  by  the  unaccustomed 
influence.  It  may  be  given  as  brandy  or 
whisky  or  in  the  form  of  wines  and  malt 
liquors :  in  acute  mania  these  latter  are 
frequently  to  be  preferred.  In  connection 
with  this  it  is  of  much  interest  to  recall 
the  fact  that  porter  was  employed  as  a 
soporific  in  acute  mania  at  the  York 
Retreat  early  in  the  present  century 
(Samuel  Tuke,"  The  York  Retreat,"  181 3), 
and  that  this  treatment  gave  rise  to  much 
comment  at  the  time.  In  cases  where 
the  heart  flags  and  the  nervous  system  is 
much  weakened  Anstie  prefers  wines  con- 
taining plenty  of  compound  ethers  to 
brandy.  In  general,  whisky  is  superior  to 
brandy  or  wines.  Strong  ale,  stout,  and 
porter  are  highly  hypnotic. 

Alcohol  in  its  various  forms  may  serve 
as  a  vehicle  for  and  adjuvant  to  the 
administration  of  other  hypnotics,  but  the 
importance  of  keeping  its  use  well  in  hand 
cannot  be  too  much  insisted  on ;  it  is  a 
drug,  and  to  be  used  as  such.  To  obtain 
the  best  effect  from  alcohol  it  should  be 
given  in  full  dose — e.g.,  oij-oiij  of  whisky 
taken  as  a  draught,  warm,  not  slipping — 
hot,  just  as  the  patient  is  getting  into  bed 
(Whitla). 

The  higher  alcohols  of  the  ethylic  series 
—e.g.,  propylic,  butylic,  amylic — are  not 
employed  as  medicines ;  they  contaminate, 
however,  wines  and  beers,  in  particular 
the  cheaper  and  less  carefully  prei:)ared 
sorts,  being  present  as  the  fusel  oils. 
These  contaminants  act  like  alcohol,  but 
they  are  much  more  powerful  than  it,  and 
hence  the  deleteriousness  of  crude  speci- 
mens of  beers  and  wines.  Derivatives  of 
these  alcohols  may  be  used  for  anassthetic 
or  sedative  j^urposes — e.g.,  amylene,  amy- 
lene  hydrate  {vide  infra). 

If  alcohol  be  given  at  all  continuously 
and  in  large  dose — e.g.,  six  to  eight  ounces 
— as  in  the  treatment  of  the  delirium  of 
fever  or  acute  delirious  mania,  we  would 


urge  special  attention  to  the  tongue,  skin, 
])ulse,  respiration,  and  the  delirium  itself. 
Should  the  tongue  become  moist  and  the 
skin  lose  its  dry, harsh  character,  the  pulse 
and  respiration  become  slower  and  the 
delirium  lessen  or  give  way  to  quiet  sleep, 
then  alcohol  is  doing  good ;  but  should 
there  be  no  improvement  in  these  respects, 
it  will  not  be  wise  to  push  the  alcohol 
beyond  the  above  doses. 

Ether  finds  its  chief  employment  as  an 
anoBsthetic  and  anti-spasmodic  stimulant. 
We  need  not  discuss  these  actions  here, 
but  in  full  doses  by  the  mouth  it  often 
acts  as  a  soporific — e.g.,  in  doses  of  one 
drachm.  It  may  be  given  in  the  form  of 
a  julep  with  syrup  of  orange  and  orange- 
flower  water,  or  with  the  further  addition 
of  rectified  spirits  of  wine. 

Acetic  Ether,  acetate  of  ethyl,  was  long 
since  described  as  possessed  of  soporific 
powers.  M.  Sedillot  gave  thirty  drops  for 
this  purpose,  but  MM.  Trousseau  and 
Pidoux  could  not  confirm  this  action. 

It  will  be  rarely  necessary  to  fall  back 
on  ether  for  soporific  purposes. 

Chloroform,  like  ether,  ranks  as  an 
anassthetic.  It  is  rarely  used  as  a  hyp- 
notic, but  in  some  cases  in  which  violent 
movements  make  sleep  impossible — e.g., 
severe  cases  of  chorea — it  has  been  inhaled 
more  or  less  continuously  to  keep  the  pa- 
tient at  rest.  It  has  also  been  employed 
in  the  same  way  in  the  treatment  of  re- 
peated convulsive  attacks,  but  in  such  cases 
chloral  is  far  more  valuable.  Chloroform 
insensibility  sometimes  passes  into  natural 
sleep  after  withdrawal  of  the  drug ;  this 
is  true  of  ether  also.  A  hypodermic 
injection  of  morphia  previous  to  the  ad- 
ministration of  chloroform  ensures  a  more 
persistent  effect;  this  combination  is  in 
some  cases  desirable,  as  advocated  by 
Victor  Horsley  in  opei'ationg  on  the  brain. 
Chloroform  may  be  used  as  a  means  of 
diagnosis  in  some  cases  of  insanity  com- 
plicated with  hysteria;  practically  it  is 
not  used  either  as  a  simple  sedative  or  as 
a  hypnotic. 

Paraldehyde  (CoH^O);;. — This  sub- 
stance is  a  polymer  of  aldehyde  ;  che- 
mically it  is  therefore  closely  allied  to 
alcohol.  It  has  been  much  used  of  late 
as  a  hypnotic,  in  particular  by  alienists. 
It  shows  the  generic  action  of  the  alcohol 
group,  affecting  first  the  brain,  then  the 
cord,  then  the  medulla  oblongata.  If 
death  take  place,  it  is  at  the  lungs  ;  the 
action  on  the  circulation  is  comjiaratively 
slight.  Quinquaud  and  Henocque  have 
maintained  that  the  blood-colouring  mat- 
ter undergoes  change  by  reduction  into 
methasmoglobin,  but  this  is  disputed  by 
Hayem,  who  states  that  the  blood  is  not 


Sedatives 


[     "34     ] 


Sedatives 


affected  (Dujardin-Beaumetz,  "  Nouvelles 
Medications  ").  The  advantages  of  paral- 
dehyde are :  its  relatively  slight  depress- 
ant action  on  the  heart  and  vascular 
system,  and  on  the  respiratory  apparatus  ; 
also  its  slight  poisonous  action  on  the  tis- 
sues, which  allows  of  its  administration  for 
long  periods  without  obvious  detriment. 

The  disadvantages  are :  its  unpleasant 
taste  and  the  unpleasant  odour  imparted 
to  the  breath ;  the  fact  that  a  stage  of 
excitement  frequently  precedes  the  hyp- 
nosis, this  being  more  marked  than  for 
chloral;  further,  its  slighter  povrer  over 
pain  as  compared  with  opium,  and  even 
with  chloral  (Loebisch,  "  Dieneueren  Arz- 
neimittel "). 

The  sleep  of  paraldehyde  is  quiet,  and 
closely  resembles  physiological  sleep. 

The  drug  has  been  very  largely  used 
by  alienists,  and  their  verdict  is  that  it 
is  a  very  valuable  hypnotic.  Morselli, 
Kraift-Ebing,  Koravai  and  Nerkam, 
S.  A.  K.  Strahan,  Clouston,  and  many 
others  speak  in  the  highest  terms  of  it. 
It  is  said  to  be  contra-indicated  in  ad- 
vanced cases  of  phthisis  with  laryngeal 
complications,  since  in  these  cases  it  is 
liable  to  cause  cough,  vomiting,  and 
much  excitement  (v.  Noorden,  c/. 
Loebisch) ;  also  in  cases  of  ulceration 
of  the  stomach.  Krafft-Ebing  insists 
that  the  drug  is  well  borne  by  the 
tissues ;  he  admits,  however,  that  with 
prolonged  and  high  dosage  it  does  harm. 
He  himself  reports  a  case  in  which  the 
symptoms  resembled  chronic  alcoholism, 
and  another  case  in  which  delirium  and 
epileptiform  attacks  occurred  during  the 
withdrawal  of  the  drug.  These  cases 
do  not  invalidate  the  general  statement 
that  paraldehyde  is  well  borne. 

Dose. — Fort3'--tive  minims  to  i,  i|,  or 
2  drachms  are  given  for  hypnotic  pur- 
poses, beginning  of  course  with  the 
smaller  dose.  Clouston  sometimes  ad- 
vances the  dose  to  3  or  4  drachms.  At 
one  asylum  a  patient,  a  woman,  received 
with  benefit  10  drachms  every  night. 
Sleep  generally  obtains  in  from  five  to 
twenty  minutes  (Dujardin-Beaumetz).  In 
ordinary  asylum  practice  Strahan  advises 
that  a  first  dose  of  from  45  minims  to 
I  drachm  should  be  followed  by  the  same 
dose  if  sleep  do  not  set  in  in  five  minutes. 
As  a  rectal  injection  i  to  2.5  drachms  may 
be  given. 

As  vehicles  for  the  drug  have  been 
recommended:  Olive  oil,  flavoured  with 
some  volatile  oil — e.g.,  of  peppermint; 
mucilage,  flavoured  with  orange  peel  or 
cinnamon ;  spirit  in  the  form  of  grog 
or  as  a  spirituous  mixture,  with  vanilla 
flavouring  (Loebisch). 


Chloral  Hydrate. — The  theory  that 
this  body  becomes  broken  up  in  the 
system  with  evolution  of  chloroform,  and 
that  its  action  is  of  this  nature,  is  not 
tenable ;  chloral  acts  as  such.  In  respect 
of  its  administration  the  most  important 
points  to  be  remembered  are — (a)  That 
the  respiratory  and  circulatory  mechan- 
isms (cardiac  and  vaso-motor)  are 
markedly  affected ;  in  over-dose  death 
threatening  at  the  lungs  and  heart; 
(h)  that  the  temperature  is  greatly  de- 
pressed by  toxic  dose ;  (c)  that  in  ordinary 
hypnotic  dose  the  drug  has  not  much 
power  over  painful  impressions  nor  over 
reflex  excitability ;  hence,  e.g.,  the  reflex 
cough  still  continues.  In  lung  cases  this 
is  a  point  of  practical  importance,  and  in 
respect  of  this  chloral  hydrate,  and  indeed 
the  whole  chloral  group,  contrasts  with 
opium  ;  (d)  that  idiosyncrasy  towards  the 
drug  is  not  infrequently  manifested. 

The  chloral  sleep  of  small  dose  is  gene- 
rally regarded  as  a  refreshing  sleep, 
closely  resembling  natural  sleep ;  it  is 
considered  to  be  in  part  the  result  of 
antemia  of  the  brain ;  in  full  dose  it  is 
possible  that  the  lowering  of  blood-pres- 
sure, which  will  include  a  lowering  of 
intra-cranial  pressure,  may  also  be  a 
factor. 

In  giving  chloi-al  we  must  use  the  drug 
with  caution  in  low  states  of  vitality 
generally,  but  especially  if  the  heart  be 
weak  ;  in  this  case,  indeed,  though  small 
doses  may  still  be  given — e.g.,  15  to  20 
grains — large  doses  are  dangerous.  In 
the  insomnia  of  cardiac  disease,  of  me- 
diastinal tumour,  of  aneurism,  in  which 
diseases  dyspnoea  is  prominent,  great 
benefit  results  from  combining  chloral 
hydrate  with  opium.  In  cases  of  ob- 
structed lung  circulation — e.g.,  bronchitis 
and  emphysema — we  must  watch  carefully 
the  effects  of  the  drug.  In  cases  of  over- 
dose the  usual  stimulant  and  rousing 
treatment  of  narcotic  poisoning  is  to  be 
adojjted.  Artificial  respiration  may  be 
called  for,  and  as  an  antidote  strychnia 
may  be  injected — 4  minims  of  the  liq. 
strychnina3,  B.P.,  rej^eated  every  ten  to 
twenty  minutes,  if  necessary  (Brunton); 
but,  in  addition,  it  is  most  essential  that 
the  patient  should  he  kept  very  icarm. 
When  pain  is  the  cause  of  sleeplessness 
chloral,  in  safe  dose,  is  uncertain;  it  is 
greatly  surpassed  by  opium ;  it  may,  how- 
ever, be  tried. 

When  convulsions  are  present,  and  by 
their  violence  and  frequent  recurrence  are 
exhausting  the  patient,  chloral  is  often  of 
the  greatest  value  as  a  rest  giver.  In  the 
status  convuJsicus  vet  epilepticiis  it  is  the 
most  valuable  drug  at  our  command. 


Sedatives 


[    1135    ] 


Sedatives 


Chloral  may  be  given  for  long  periods 
without  causiug  much  gastric  or  intestinal 
derangement ;  it  contrasts  in  this  respect 
with  opium.     But,  on  the  other  hand,  a 
chloral  luihit  or  craving/  is  rather  easily 
established,  and  this  manifests  itself  in 
great  depression  of  the  vital  powers,  the 
geaei'al  nutrition   suffering,  and  the  tone 
of  the  nervous  system  in  particular  being 
much  lowered.     Among  the  list  of  symp- 
toms we  note  feeble-mindedness,  tremor, 
and  sensory  impairment;  gastro-intestinal 
disturbance  ;  vaso-raotor  troubles,  includ- 
ing erythematous  rashes.    Dyspnoea,  with 
praacordial  anxiety,  and  even  asphyxia,  are 
recorded.   Joint  pains  are  sometimes  com- 
plained  of  (Rosenthal,    Wie)i.  vied.  Pr., 
Sept.  1889).     It  is  to  be  noted  for  this  as 
well  as  for  other   drugs   that   prolonged 
administration  does  not  necessarily  estab- 
lish a  Jiahit  or  craving. 
Children  bear  chloral  well. 
Dose. — On  account  of  the  susceptibility 
of  some  people  chloral  ought  never  to  be 
given,  as  a  first  dose,  in  larger  quantity 
than    15    to    20  grains ;    this   for   adults. 
Wood  states  that  this  dose  should  not 
be  repeated   oftener  than  once  an  hour 
till  the  total  quantity  taken  has  reached 
I  drachm ;  some  hours  should  then  elapse 
before  any  more  is  given,  except  the  case 
be  very  urgent.     Once  the  powers  of  the 
patient  have  been  gauged  the  dosing  may 
be  less   restrained.      In    cases    of    great 
mental     excitement,     and      in     delirium 
tremens,  Nothnagel  and  Rossbach  have 
recommended     doses     varying     between 
45    grains    and    2    drachms.     Constantin 
Paul  in  similar  states  has  given  90  grains 
of  chloral  in  an  enema  with  good  results. 
These  higher  doses,  however,  are  danger- 
ous, and  they  ought  never  to  be  given  as  a 
first  dose  to  any  one  unaccustomed  to  the 
drug.     Clouston,  after  a  very  extensive 
experience  of  the  drug,  always    gives  it 
in    small   dose — e.g.,    10   to   25    grains — 
along    with    bromides    ("  Treatment    of 
Mania,"   "Mental   Diseases").     On    the 
whole,  much   larger  doses   are   given   in 
asylums     than     in      ordinary     practice. 
Chloral  IwMtues  sometimes  mount  up  to 
very  big  doses — 5  drachms  (Rosenthal). 

Given  by  the  mouth,  chloral  should  be 
freely  diluted  because  of  its  pungency ; 
weak  syrup  forms  a  good  vehicle.  By 
the  bowel  the  same  dose  may  be  given  as 
by  the  mouth,  and  either  as  an  injection 
or  as  a  suppository.  If  given  for  convul- 
sions the  suppository  form  is  best,  be- 
cause there  is  less  likelihood  of  extrusion 
during  a  convulsion  ;  the  suppository 
should  be  jjushed  up  as  high  as  possible 
with  the  finger. 

Chloral  maybe  injectedhypodermically, 


but  this  method  has  the  disadvantage  of 
requiring  several  syringefuls  (the  Pravaz 
syringe),  and  of  causing  abscess  not 
infi'equently. 

Vox  children,  from  three  upwards, 
suffering  from  convulsions,  the  dose  may 
be  5  grains  by  the  mouth  or  anus ;  this 
is  to  be  repeated  according  to  the  require- 
ments of  the  case.  The  new-born  infant 
may  receive  i  to  2  grains  by  the  mouth 
(Wood). 

Chloral  hydrate  may  be  very  advan- 
tageously combined  with  bromides  ;  also, 
in  certain  cases  already  referred  to,  with 
opium. 

Bromal  Hydrate. — In  this  compound 
bromine  takes  the  place  of  the  chlorine  of 
chloral  hydrate.  The  poisonous  action  of 
bromal  is  much  greater  than  of  chloral  ; 
great  excitement  precedes  (in  animals)  the 
production  of  angesthesia — the  soporific 
action  is  not  marked.  Clinical  experience 
of  the  drug  is  still  lacking.  It  has  been 
given  in  doses  of  from  3  to  5  grains ;  it 
should  be  freely  diluted,  because  very  irri- 
tant locally. 

Butyl  Chloral  Hydrate,  also  called 
croton  chloral  liydrate,  G ^K-Ju\.Jd f^Jd , 
represents  a  chlorine  derivative  from 
butylic  alcohol,  analogous  to  chloral 
hydrate,  the  derivative  from  ethylic  alco- 
hol. Within  the  tissues  the  chemical 
behaviour  of  butyl  chloral  hydrate  is 
exactly  similar  to  that  of  chloral  hydrate. 
As  a  hypnotic  the  action  of  this  drug  is 
less  marked  than  for  chloral,  but  given  in 
large  doses  it  is  soporific,  and  the  sleep  is 
accompanied  by  ansBsthesia  of  the  head 
(Liebreich).  Its  chief  use  is  in  the  treat- 
ment of  neuralgic  states,  esj^ecially  of  the 
trigeminus  nerve,  and  of  insomnia  de- 
pendent thereon.  It  is  given  in  5  to  10 
grain  doses,  frequently  repeated  if  need 
be.  These  doses  have  no  direct  hypnotic 
action.  V.  Mering  calls  in  question  the 
auEesthesia  of  the  fifth  nerve,  described  by 
Liebreich,  but  there  can  be  no  question  as 
to  the  value  of  butyl  chloral  hydrate  in 
neuralgia  of  the  fifth. 

Chloral- Amide. — By  the  interaction  of 
chloraldehyde  and  the  amide  of  formic 
acid  this  body  is  obtained.  The  molecule 
C3CI3H4NO2  contains  the  grouping  NH^. 
It  is  2>ossible  that  the  introduction  of  this 
will  explain  the  absence  of  depressant 
action  said  to  be  characteristic  of  chloral- 
amide  as  contrasted  with  chloral  hydrate 
(seo  Leech,  Brit.  Med.  Jour.,  Nov.  2,  18S9). 
This  new  drug  has  been  favourably 
reported  on  by  Drs.  Reichmann,  Hagen, 
and  Hilfler,  in  Germany,  also  by  observers 
in  this  country.  Hale  White,  Strahan, 
and  others.  The  last  observer  speaks 
from  an  experience  of  over  two  hundred 


Sedatives 


[    1136    ] 


Sedatives 


administrations.  It  is  claimed  for  chloral 
amide:  (i)  that  it  does  not  depress  the 
respiration  or  the  circulation;  (2)  that  the 
temperature  is  not  lowered  ;  (3)  that  it 
is  serviceable  in  many  cases  of  sleepless- 
ness from  pain  ;  (4)  that  after-effects  and 
by-effects  are  rarely  witnessed  (a  little 
drowsiness  the  next  day  has  been  com- 
plained of,  and  in  a  few  cases  there  has 
been  slight  headache ;  there  has  been  no 
o-astro-intestinal  disturbance).  Collapse 
symptoms  have,  however,  been  observed 
after  the  administration  of  chloral-amide, 
and  attributed  to  the  drug  (Robinson, 
Deutsch.  mecl.  Wochenschr.,  No.  49,  1889) ; 
also  some  erythematous  eruptions  recall- 
ing the  eruptions  of  chloral  hydrate 
(Umpfenbach,  Ther.  Monats.,¥eh.  iSgo). 
Pye-Smith  records  a  case  of  universal 
dermatitis  after  two  doses  of  40  grains, 
at  intervals  of  eight  hours  {Lancet,  1890, 
p.  546).  The  sleep  of  chloral-amide  is 
said  to  be  calm  and  refreshing.  Dr. 
Strahan  says  that  at  any  time  the  patient 
can  be  roused  and  made  to  answer  a 
question,  protrude  the  tongue,  or  the  like. 
Sleep  was  obtained  by  him  in  nearly  every 
case,  "even  in  patients  suffering  from 
extreme  maniacal  excitement,  and  in  no 
case  where  it  failed  to  induce  sleep  did  it 
excite."  He  observes  that  "it  may  be 
given  to  paralytics,  whatever  their  stage." 
In  his  opinion  it  is  equal  to  paraldehyde, 
"  but  in  no  way  superior,"  except  in  that 
it  is  pleasanter  to  take,  and  that  it  does 
not  give  any  disagreeable  odour  to  the 
breath. 

It  is  not  quite  so  prompt  in  its  action 
as  chloral,  but  takes  effect  in  from  half  an 
hour  to  one,  two,  or  even  three  hours. 
The  average  is  about  an  hour.  The  dose 
is  30  to  45  grains  ;  55  grains  are  quite  a 
safe  dose  (Strahan).  Weak  alcoholic  solu- 
tions are  the  best  to  administer,  as  the 
drug  dissolves  readily  in  spirit.  It  must 
not  be  given  with  alkalies,  nor  must  the 
solution  be  hot,  as  under  these  conditions 
it  is  decomposed.  Chloral-amide  has  a 
faintly  bitter  taste. 

Chloralimide,  with  formula  C0CI3NH.,, 
must  not  be  confounded  with  chloral- 
amide.  In  the  former  there  are  reasons 
to  believe  that  there  is  present  the  group 
NH  (imidogen),  not  NHo  (amidogen). 
The  substance,  a  crystalline  solid,  insol- 
uble in  water,  but  soluble  in  alcohol,  ether, 
and  chloroform  and  oils,  is  very  stable. 
Broken  up  it  yields,  weight  for  weight, 
more  chloroform  than  either  chloral-amide 
or  chloral  ammonium,  and  for  this  reason 
Choay  claims  that  it  is  more  hypnotic 
than  either  of  these.  Inasmuch,  however, 
as  it  is  improbable  that  chloral  compounds 
act    by    yielding    chloroform  within    the 


organism,  this  theoretical  ground  cannot 
be  admitted  as  of  much  value,  and  more 
testimony  is  required  to  establish  its  real 
value.  Chloralimide  is  given  in  the  same 
doses  as  chloral  hydrate,  and  either  as 
pills  or  wafers,  or  in  alcoholic  solution  or 
oily  emulsion  (Merck). 

Chloral  Ammonium,  C0CI3OXH4,  is 
closely  allied  to  chloral  hydrate  in  its 
structure  ;  in  the  molecule,  however,  there 
is  the  group  NHo.  The  salt  has  been 
given  in  doses  of  15  to  30  grains  with 
good  effect,  and  it  takes  rank  as  a  non- 
depressant  hypnotic.  It  appears,  however, 
to  be  unstable,  slowly  breaking  up  even  in 
the  solid  state ;  in  this  it  contrasts  with 
chloralimide. 

Urethane,  or  ethyl  carbamate,  CgH^KOo, 
belongs  to  a  group  of  bodies,  the  ure- 
thanes,  in  which  radicles  of  the  ethyl 
series  replace  one  atom  of  hydrogen  of 
carbamicacid.  In  the  molecule  is  present 
amidogen,  NHg,  and  to  this  is  ascribed,  as 
in  the  case  of  chloral-amide,  the  absence 
of  depressant  action  upon  the  circulatory 
system.  The  compound  occurs  in  the 
form  of  colourless  columnar  or  tabular 
crystals,  of  nitre-like  taste.  It  is  freely 
soluble  in  water  and  most  media. 

Urethane,  as  a  hypnotic,  has  the  advan- 
tage of  being  very  safe,  and  for  the  reason 
chiefly,  that  it  does  not  depress  the  heart. 
Even  in  the  deeper  grades  of  narcosis  in 
rabbits  there  was  no  appreciable  lowering 
of  the  blood-pressure  (Schmiedeberg).  It  is 
sjaecially  indicated  for  children,  who  bear 
it  well,  and  it  has  been  employed  among 
these  by  Otto  and  Konig  in  the  treatment 
of  the  excitement  of  the  feeble-minded.  It 
is  of  value  in  sleeplessness  without  defi- 
nite cause,  and  especially  if  this  occur  in 
very  debilitated  states  of  body,  particularly 
in  heart  weakness.  On  the  other  hand  it 
is  not  a  very  certain  hypnotic ;  it  fails 
where  pain  is  the  cause  of  insomnia,  or 
where  there  exists  a  disturbing  reflex — 
e.g.,  cough.  KraeiDclin  obtained  good 
results  in  melancholia  and  general  paraly- 
sis, but  in  the  stage  of  excitement  of  the 
latter  disease,  also  in  mania  and  delirium 
tremens,  he  was  obliged  to  turn  to  paralde- 
hyde. Otto  and  Konig  confirm  his  results 
(Loebisch,  "  Die  neueren  Arzneimittel," 
1888).  On  the  whole  urethane  stands  as  a 
safe  but  rather  feeble  and  unreliable  hyp- 
notic (Gordon,  Needham,  Brit.  Med.  Jour., 
Nov.  2,  1889).  Urethane  sleep  is,  for  tlie 
smaller  doses,  natural,  and  the  reflexes 
are  but  little  modified.  In  dose  of  30  to 
60  grains  there  is  marked  slowing  of  the 
pulse,  and  the  breathing  is  deepened.  In 
general  there  are  neither  by-  nor  after- 
effects, but  with  the  lai'ger  doses  thei-e  has 
been   complaint  of  a  sense  of   weight  of 


Sedatives 


[     1137    ] 


Sedatives 


head  and  somnolence,  also  vomiting.  There 
may  be  some  little  excitement  on  first 
giving  the  drug. 

Dosage. — For  children,  grains  4  to  8  to 
16;  for  adults,  30  to  60  grains  (given  in 
half  the  total  dose  at  an  interval  of 
fifteen  to  thirty  minutes).  In  excep- 
tional cases,  90  to  120  grains  may  be 
given,  but  the  dose  must  not  be  carried 
further.  Urethane  should  be  given  in 
10  per  cent,  solution,  with  a  little  syrup 
of  orange  peel,  to  cover  the  saline  taste. 
Subcutaneously  a  30  per  cent,  solution 
may  be  injected  ;  one  to  three  injections, 
each  containing  4  grains,  were  effective 
(Rottenbiller).  {Gf.hoehisQ^up.cit.)  Tole- 
rance of  the  drug  is  rapidly  established. 

Cbloral-urethane,  also  called  ural 
(CjHgCl.-jOjN),  is  a  compound  of  urethane 
with  chloral  {cf.  chloral-amide).  The 
urethane  is  held  to  counteract  the  depress- 
ant influence  of  the  chloral.  The  drug 
acts  very  similarly  to  urethane ;  it  is 
given  in  doses  of  30  to  45  grains.  At 
present  the  reports  concerning  chloral- 
urethane  are  discrepant.  Poppi  speaks 
very  highly  of  it,  but  Hilbner  and  Sticker, 
and  Mairet  and  Combemale,  do  not  give 
it  unmodified  praise. 

A  preparation  known  as  somnal  is, 
according  to  Merck,  only  an  alcoholic 
solution  of  chloral  and  urethane — it  is  a 
mixture  and  not  a  compound ;  it  is  given 
in  half-drachm  doses. 

Acetal,  CoH^(CoH50)._,,  has  practically 
ceased  to  exist  as  a  hypnotic.  According 
to  Leech,  it  has  the  disadvantage  of  an 
unpleasant  taste  and  smell,  and  no  advan- 
tages. (For  references  see  Brit.  Med. 
Jour.,  Nov.  2,  1890.) 

Hypnone,  (CH3)(C„H5)0O,  or  methyl- 
phenyl-ketone,  is  a  substance  crystalline 
at  14°  C,  liquid  and  oily  at  20°  C.  ;  it  has 
a  peculiar  fragrant  odour  and  a  pungent 
creasote-like  taste,  is  but  little  soluble  in 
water,  readily  soluble  in  alcohol,  ether, 
chloroform,  and  fixed  oils  ;  its  reaction  is 
neutral.  It  was  introduced  as  a  hypnotic 
by  Dujardin  -  Bea.umetz  in  1885.  The 
drug  has  not  made  much  way,  and  is  not 
likely  to,  for  the  following  reasons  :  It  is 
very  uncertain  (Dujardin-Beaumetz  and 
Bardet,  von  Hirt,  Rey,  Mairet  and  Com- 
bemale, and  others) ;  it  inHuences  pain 
very  little ;  is  unable  to  act  in  cases 
where  cough  ijrevents  sleep  ;  the  j^atieut 
soon  grows  accustomed  to  it,  and  the  dose 
needs  to  be  increased  ;  it  is  very  irritating 
to  the  stomach,  and  the  blood  is  said  to 
suffer  from  its  prolonged  administration  ; 
the  blood-pressure  and  the  breathing 
suffer  depression  in  toxic  dose,  but  in 
ordinary  therapeutic  dose  this  effect  is 
very  slight. 


Dujardin-Beaumetz  and  Bardet  con- 
sider hypnone  of  special  value  for  the 
insomnia  of  alcoholics,  and  for  nervous 
insomnia.  They  state  that  it  leaves  no 
after-effect.  For  the  insomnia  of  mor- 
phinism it  is  useless. 

Dose. — Three  to  six  drops,  best  given 
diluted  with  glycerine  or  almond  oil  in 
capsules,  or  as  an  emulsion  with  tincture 
of  orange.  Much  larger  doses  have  been 
given  in  mental  affections— viz.,  up  to 
17  to  25  minims.  Krafft-Ebing  gets  no 
result  under  10  drops.  He  speaks  well  of 
15-drop  doses,  and  says  that  30  droj^s 
may  be  given.*  Hypnone  is  not  adapted 
for  hypodermic  injection,  according  to 
Kraff't-Ebing — i.e.,  there  is  no  advantage 
in  so  using  it ;  but  ConoUy  Norman 
records  good  results  from  the  undiluted 
injections  of  l^^v-xij.t 

Hypnal  (mono-chloral  antipyrine). — If 
chloral  and  antipyrine  be  brought  together 
in  solution,  a  body  separates  which,  if  the 
mother  solutions  be  dilute,  is  oily  in  the 
first  instance,  then  crystalline,  but  crystal- 
line at  once  if  the  solutions  be  concen- 
trated. The  body  is  a  compound  of 
chloral  and  antipyrine  with  definite 
chemical  formula.  M,  Bonnet,  of  Dreux, 
first  described  it  as  possessing  hypnotic 
and  analgesic  properties.  M,  Bardet,  by 
further  experiment,  estabhshed  these 
statements. 

The  hypnotic  dose  is  about  15  grains  ; 
rarely  are  30  grains  required.  Pain  is 
decidedly  infiuenced  according  to  M.  Bar- 
det. The  quantity  of  chloral  is  45  per 
cent.,  of  antipyrine  55  per  cent,  of  the 
compounded  drug,  hence  the  quantities 
which  are  efficient  of  the  two  components 
are  remarkably  small,  the  action  of  each 
being  apparently  heightened  by  the  other. 
Hypnal  has  a  saline  taste,  and  is  without 
the  irritant  action  of  either  comj^ound 
on  the  stomach. 

M.  Bardet  has  not  tried  the  drug  in 
mental  affections  ;  he  regards  it  less  as  a 
new  drug  than  as  an  efficient  way  of 
administering  chloral  and  antijDyrine  (see 
"Nouveaux  Remedes,"  March  24,  1890). 

Hypnal  is  soluble  in  about  five  to  six 
times  its  weight  of  water,  and  is  best  given 
in  such  solution  along  with  an  equal  volume 
of  simple  syrup,  to  which  may  be  added 
sjjirits  of  wine  and  tincture  of  orange 
peel  (see  Bonnet's  formula,  "  Nouveaux 
Remedes,"  1890,  p.  361). 

Methylal,  C;jHgOo,  is  a  limjiid,  volatile 
liquid,  which  in  odour  resembles  acetic 
acid  and,  to  some  extent,  chloroform  also. 

*   Wiener  klinische  Wochensclirift,J?in.  16,  1890. 

t  Consult  Loebisch,  "  Dio  ueuereii  Arznei- 
mittel,"  1888;  Diijanlin-Bcaumetz,  "  Dictionnaire 
de  Tlierapeutiqut'.'' 


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[    1138    ] 


Sedatives 


It  is  an  anajsthetic,  local  and  general. 
It  may  be  inhaled  or  given  by  the  mouth, 
in  doses  of  i  to  4  drachms,  freely  diluted 
with  water  and  syrup ;  it  acts  as  a 
hypnotic  (Leech,  Brit.  Med.  Jour.,  Nov. 
1889).  The  sleep  obtained  is  tranquil 
and  deep,  and  supervenes  quickly  ;  it  is, 
however,  of  short  duration  only,  a  result 
of  the  speedy  elimination  of  the  drug. 
The  heart  is  slightly  accelerated  and  the 
blood-pressure  lowered,  but  in  therapeutic 
dose  it  does  not  rank  as  a  cardiac  depress- 
ant ;  the  respiration  is  rendered  slower. 
Keflex  excitability  generally  is  lessened  : 
also  the  excitability  of  the  psycho-motor 
centres.  Injected  under  the  skin  it  may 
irritate  so  violently  as  to  produce  slough- 
ing, but  diluted  (i  in  9)  it  has  been  used 
successfully  by  KrafFt-Ebing  in  the 
treatment  of  delirium  tremens.  He  finds 
that  in  a  few  hours  a  prolonged  and  quiet 
sleep  is  produced.  Two  injections,  each 
containing  about  1.5  grain  of  pure  methy- 
lal  in  solution  (1  in  9),  would  in  many 
cases  suffice  to  give  sleep,  but  often  four 
to  five  injections  during  the  day  are 
needed.*  His  results  confirm  the  previous 
results  obtained  by  Eichardson,  Personal!, 
Mairet  and  Combemale ;  the  latter  ob- 
servers made  observations  on  36  cases  of 
insanity  ;  the  doses  ranged  between  75 
and  120  grains.  Tolerance  of  methylal  is 
easily  established  {cf.  Dujardin-Beau- 
metz,  "  Dictionnaire  de  Therapeutique," 
vohiv. ;  H.C.Wood;  Leech,  Brit.  Med. 
Jour.,  November  1889). 

On  account  of  the  high  price  of  the 
drug,  the  hypodermic  method  is  to  be  pre- 
ferred. 

Methylal  is  very  little  used  now. 

Sulphonal,  C;Hi,;S._;04,  is  a  white  crys- 
talline powder  very  insoluble  in  cold  water, 
sparingly  in  boiling  water,  fairly  soluble 
in  alcohol  and  ether.  It  is  without  taste 
or  odour.  Sulphonal  has  been  extensively 
used  as  a  hypnotic,  and  with,  on  the  whole, 
excellent  results.  It  does  not  depress  the 
heart  or  give  rise  to  serious  effects  (Kraift- 
Ebing).  Leech  places  sulphonal  thus  in 
relation  to  some  other  hypnotics — (i)  sul- 
phonal, (2)  amylene  hydrate,  (3)  paralde- 
hyde, (4)  urethane,  (5)  methylal ;  but  not 
one  of  these,  he  says,  equals  chloral 
hydrate  in  the  certainty  of  its  eftects. 
Kabbas  and  Gamier  speak  very  highly  of 
sulphonal;  Clouston,  on  the  other  hand, 
places  it  far  behind  paraldehyde.  Urap- 
fenbach  holds  that,  for  certainty  of  action 
combined  with  safety,  sulphonal  does  not 
present  any  advantages  over  chloral_  in 
the  treatment  of  the  insane.  One  objec- 
tion to  sulphonal  is  the,  so-called,  delayed 
or  deferred  action,  the  patient  not  sleeping 

*   Wiener  Idinische  Wochemchrift,  Jan.  16,  i8qo. 


during  the  night  after  the  administration 
of  the  drug,  but  sleeping  much  or  being 
very  drowsy  the  next  day.  In  exceptional 
cases  after-effects  are  witnessed — viz., 
fulness  in  the  head,  giddiness,  slight 
ataxia  of  the  limbs,  difficulty  of  speech  ;  in 
some  rare  cases  vomiting  has  occurred 
(Knoblauch,  J.  M.  Stewart,  Umpfenbach). 
In  most  of  these  cases  these  effects  have 
resulted  from  large  doses,  but  Knoblauch 
lays  more  stress  on  the  prolonged  use  of 
sulphonal  as  causal,  and  Umpfenbach  also 
refers  to  this  cumulative  action.  A  few 
cases  of  rash,  scarlatiniform  or  measly, 
have  been  observed  during  sulphonal  ad- 
ministration (Schotten). 

Tolerance  is  not  easily  established;  some, 
indeed,  have  stated  that  patients  do  not 
grow  accustomed  to  the  drug.  If  toler- 
ance do  occur,  a  break  in  the  administra- 
tion will  re-establish  its  efficacy.  Of  late 
two  cases  of  sulphonal  habit — i.e.,  craving 
— "  amounting  to  a  perfect  mania,"  have 
been  recorded  by  Dr.  Gilbert,  of  Baden- 
Baden,  and  cases  of  toxic  symptoms  have 
been  more  frequently  described. 

Dose. — 15  to  30  grains  in  soup  or  warm 
milk,  one  or  two  hours  before  bed-time  ; 
the  gritty  crystalline  powder  should  be 
rubbed  up  finely  in  a  mortar,  else  it  hangs 
about  the  gums  and  teeth.  Sulphonal 
thus  powdered  may  also  be  given  in  beer, 
or  mixed  up  with  the  food  (Krafft-Ebing). 
More  recently  the  method  has  been 
adopted  of  pouring  boiling  water  on  to  the 
dose,  say  half  or  two-thirds  of  a  tumbler- 
ful of  water,  and  allowing  this  to  cool  just 
sufficiently  to  make  it  drinkable.  The 
sulphonal  dissolves  in  the  boiling  water, 
and  has  not  time  to  separate  out  before  it 
is  taken.  Sleep  follows  this  mode  of  ad- 
ministration in  from  fifteen  to  twenty 
minutes.  Sulphonal  may  also  be  given  in 
cachet  or  tabloid  form  ;  it  then  acts  more 
slowly,  viz.,  in  from  one  to  f.wo  hours. 

Very  large  doses  of  sulphonal  have  been 
taken  without  bad  effects,  and  Krafft- 
Ebing  recoi-ds  the  administration  by  mis- 
take of  150  grains,  with  no  other  effect 
than  a  prolonged  sleep  of  twenty  hours, 
and  some  giddiness  on  awakening.  Given 
in  small  doses,  7  to  8  grains  several  times 
a  day,  it  quiets  the  patient  and  favours 
sleep.  Erlenmeyer  considers  that  the 
dose  should  never  exceed  30  grains. 

Tetronal  is  a  body  having  the  same 
structure  as  sulphonal,  but  differing  in 
the  replacement  of  two  methyl  groupings 
by  two  of  ethyl.  It  is  said  to  be  a  more 
powerful  hypnotic  than  sulphonal,  and 
that  this  increase  of  power  is  due  to  the 
excess  of  ethyl  groupings,  of  which  there 
are  four  in  all,  whence  the  name.  It  oc- 
curs in  tabular  crystals  and  plates,  which 


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[     1 139    ] 


Sedatives 


are  but  sparingly  soluble  in  water,  but 
freely  soluble  in  alcohol  and  fairly  so  in 
ether.  They  possess  a  camjihoraceous 
taste. 

Halfway  between  tetronal  and  sulphonal 
is  a  body  containing  three  molecules  of 
ethyl  in  all  and  one  of  methyl :  it  is  called 
trlonal,  and  it  is  said  to  be  intermediate 
between  sulphonal  and  tetronal  in  its 
activity  (Brit.  Med.  Jonni.,  vol.  i.  1890, 
p.  87).  Trional  forms  tabular  crystals 
rather  more  soluble  in  water  than  tetronal, 
I  in  320  parts,  freely  soluble  in  alcohol 
and  ether.  The  dose  of  tetronal  is  gr.  x-xx, 
but  Schultze  recommends  gr.  xv-lx  of 
either  tetronal  or  trional.  Either  may  be 
given  in  suspension  like  sulphonal,  or  in 
cachet,  or  in  a  large  quantity  of  warm 
water,  or  in  soup.  If  the  terms  tetronal 
and  trional  are  to  stand,  it  would  be  well 
to  call  sulphonal  dional,  and  so  place  the 
three  in  relation.  Tetronal  and  trional  are 
still  insufficiently  examined  clinically,  but 
there  is  no  doubt  that  they  come  near  to 
suljihonal  in  therapeutic  value.  Schultze 
considers  that  trional  has  the  advantage 
over  tetronal,  and  that  the  former  is  equal, 
if  not  in  some  respects,  superior  to  sul- 
phonal {Therap.  Monais.,  Oct.  1891). 

.Ajnylene  Hydrate  (C5H10O).  —  This 
substance  is  tertiary  amyl  alcohol,  the 
molecular  groiiping  being  different  from 
that  of  the  primary  amyl  alcohol  of  fer- 
mentation, the  chief  constituent  of  fusel 
oil.  It  is  a  colourless  mobile  liquid  with 
high  boiling-point.  The  odour  is  pungent, 
the  taste  unpleasant ;  it  is  ethereal  and 
camphor-like;  it  dissolves  in  18  parts  of 
water,  in  alcohol  in  all  proportions.  In 
toxic  dose  amylene  hydrate  kills  by  arrest 
of  respiration  and  then  of  the  heart,  but 
these  centres  are  the  last  to  give  way. 
The  cortex  cerebri  first  suffers,  then  the 
centres  of  the  base  of  the  brain  and  cord 
with  abolition  of  the  reflexes.  The  drug 
therefore  resembles  essentially  alcohol  in 
its  mode  of  action.  Hypnosis  occurs  at  a 
stage  when  the  respiration  and  heart  are 
practically  unaffected.  Mering  has  studied 
exhaustively  the  effects  on  man  :  he  finds 
thatdosesof  45  to  75  grains  cause  a  refresh- 
ing sleep  of  five  to  twelve  hours,  without  any 
preliminary  stage  of  excitement.  Cases 
of  the  insomnia  of  over-strung  nerves,  the 
sleeplessness  of  old  age,  of  convalescence 
from  acute  disease,  of  delirium  tremens, 
&c.,  are  well  treated  by  it.  For  the 
insomnia  of  pain  it  is  less  reliable. 
Mering  advises  in  such  cases  that  it 
should  be  combined  with  opium.  Nausea, 
vomiting,  headache  do  not  follow  the  use 
of  amylene  hydrate.  Mering  places  the 
drug  between  chloral  hydrate  and  paralde- 
dyde.     He  says  that  1 5  grains  of  chloral 


are  equivalent  to  30  grains  of  amylene 
hydrate  and  to  45  grains  of  paraldehyde. 
It  has  the  advantage  over  paraldehyde 
in  taste,  and  over  chloral  in  that  it  does 
not  depress  the  heart.  It  should  be 
diluted  some  10  times  if  given  by  the 
mouth.  The  extract  of  liquorice  is  a  useful 
corrigens.  Beer  is  an  excellent  vehicle. 
As  a  rectal  injection  it  should  be  adminis- 
tered with  water  and  mucilage,  diluted 
some  12  to  15  times.  The  appetite  is 
liable  to  suffer,  and  the  stomach  is  some- 
times upset  by  the  drug.  The  peculiarity 
of  the  durability  of  the  effects  of  amylene 
hydrate,  as  compared  with  ordinary  al- 
cohol, is  probably  to  be  explained  in  part 
by  its  higher  boiling-point.  {Cf.  Loebisch, 
op.  cit.) 

The  results  of  more  recent  experience 
confirm  in  general  Mering's  statements. 
Jastrowitz,  among  others,  speaks  strongly 
in  favour  of  the  drug ;  he  finds  it  very 
useful  in  the  treatment  of  the  sleepless- 
ness of  morphinists.  Dietz  speaks  highly 
of  it  in  nervous  affections.* 

Piscidia  Erythrina  (Jamaica  Dog- 
wood).— The  rind  of  the  root  of  this  tree 
is  employed  either  as  such,  dose  60  grains, 
or  as  tincture,  or  liquid  extract,  dose  of 
either  one-half  to  two  drachms.  Water 
with  some  flavouring  is  the  vehicle.  Krafft- 
Ebing  considers  that  2  to  3  teaspoonfuls 
of  the  fluid  extract  are  required  for  hyp- 
notic effects. 

Piscidia  is  generally  regarded  as  a  sub- 
stitute for  opium  ;  it  raises  blood-pressure 
and  retards  the  pulse,  but  dilates  the 
pupil  (Bruuton).  Krafft-Ebing,  however, 
regards  it  as  more  allied  to  simple  seda- 
tives— e.g.,  the  bromides.  He  thinks  it 
deserves  the  name  "vegetable  broniine."i' 
Sleep  is  brought  about,  according  to  him, 
indirectly  as  the  result  of  a  benumbing 
influence  on  the  cortex  cerebri.  Neither 
headache  nor  constipation  is  produced. 

Drs.  Scott  and  McGrath  have  found  it 
useful  in  nervous  excitement.  Senator 
has  used  it  with  advantage  in  cases  of 
neuralgia  of  the  head.  Piscidia  has  of 
late  fallen  into  comparative  disuse.  A 
few  years  ago  it  was  much  prescribed  in 
London. 

Opium  and  its  Alkaloids. — The  prin- 
cipal alkaloid  of  opium  is  morphia;  the 
similarity  of  action  between  the  mother 
drug  and  morphia  depends  on  the  pre- 
ponderance of  morphia.  The  action  of 
morphia  is  a  twofold  one :  it  paralyses 
the  functions  of  the  cortex  cerebri  on  the 
one  hand ;  it  causes  an  increased  reflex 
excitability  of  the  central  nervous  system 
on  the  other  hand.  The  first  effect  is 
*  Hoa.s,  Deutsch.  Med.  IVoclitnschi:,  Jan.  9,  1890. 
t   Wiener  Ktin.  Wochenschr.,  Jan.  1890. 

4D 


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[    1140    ] 


Sedatives 


narcotic,  the  other  is  convulsant.  Of  the 
other  alkaloids  of  opium,  some  show  the 
double  action  of  morphia,  but  in  these  the 
nai'cotic  influence  is  less  and  the  tetanic 
influence  relatively  greater  ;  this  differen- 
tiation culminates  in  thebain,  which  is 
a  pure  convulsant,  and  belongs  to  the 
strychnine  group.  (It  must  be  understood 
that  the  tetanic  stage  ultimately  gives 
waj^  to  a  paralytic  stage.)  This  twofold 
effect,  nai'cotic  and  convulsant,  is  wit- 
nessed alike  in  man  and  the  lower  animals, 
but,  whereas  in  man  the  cerebral  effects 
are  most  pronounced,  in  the  vertebrates 
farthest  from  man — e.g.,  frogs — it  is  the 
phenomena  of  an  increased  reflex  excita- 
bility which  are  most  striking. 

In  detail,  the  effects  of  opium  and 
morphia  on  man* and  the  higher  animals 
include,  first,  a  diminished  perception  of 
pain  (whilst  the  sense  of  touch  remains 
unaffected)  and  a  lowered  reflex  excita- 
bility, as  is  evidenced,  e.g.,  in  respect  of 
cough.  Schmiedeberg,  whose  description 
we  closely  follow,  points  out  that,  whilst 
these  effects  occur  without  there  being,  at 
first  sight,  any  apparent  affection  of  the 
cortex  cerebri,  yet  the  heaviness  and 
sleepiness  which  soon  set  in  suggest  that 
from  the  very  outset  the  receptive  centres 
of  the  brain  are  depressed  in  their  func- 
tions. The  occurrence  in  certain  cases  of 
vivid  imagining  and  mental  excitement 
during  the  waking  state  as  well  as  imme- 
diately preceding  sleep  has  been  inter- 
preted by  some  as  due  to  actual  stimula- 
tion of  certain  parts  of  the  brain,  but  it  is 
possible  that  these  flights  of  fancy,  which 
may  amount  to  hallucinations,  are  the  re- 
sult of  a  withdrawal  of  control,  a  loss  of 
balance  by  subtraction  rather  than  by  ad- 
dition {cf.  Schmiedeberg),  though  against 
this  view  is  the  fact  of  the  smallness  of  the 
dose,  which  in  some  cases  will  suffice  to 
excite.  The  next  effect  is  sleep,  at  first 
slight,  and  from  which  the  patient  can  be 
easily  roused  ;  then  more  deep,  and  not  to 
be  interrupted  except  by  powerful  stimu- 
lation ;  then  the  unconsciousness  deepens, 
and  a  state  of  coma  supervenes,  in  which 
the  excitability  of  the  cortex  cerebri  is 
practically  annulled.  The  benumbing 
influence  of  opium  ultimately  spreads  to 
the  medulla  oblongata  and  specially  influ- 
ences respiration ;  death  takes  place  by 
asphyxia. 

In  animals  the  vascular  system  suffers 
no  diminution  of  tone  except  in  the  deepest 
stages  of  narcosis  ;  but  in  man  local  vas- 
cular dilatation,  as  of  the  face  and  surface 
of  the  body,  may  show  itself  even  with 

*  Man  is  without  exception  far  more  sensitive  to 
opium  than  all  other  animals (Nothnagel  and  Ross- 
bach). 


therapeutic  doses,  and  probably  dependent 
on  the  vascular  dilatation  are  the  occur- 
rence of  a  sense  of  warmth,  the  outbreak  of 
perspiration,  sudaminal  eruptions,  itching 
of  the  surface.  The  fall  of  temperature 
noted  in  animals  poisoned  by  morphia  is 
probably  due  to  the  excessive  loss  of  heat 
by  the  surface  (Brunton  and  Cash). 
When,  at  a  later  stage,  the  vessels  gene- 
rally are  relaxed,  the  flushed  face  becomes 
pale  ;  and,  still  later,  when  the  breathing 
has  become  much  impaired,  a  livid  tint  su- 
pervenes. Schmiedeberg  suggests  whether 
the  capillaries  of  the  brain  are  not  also 
congested  at  the  same  time  as  those  of 
the  face ;  but  the  teaching  of  Horsley  and 
S chafer  is  that  the  brain  under  the  in- 
fluence of  a  moderate  dose  of  morphia 
bleeds  much  less  than  in  the  natural 
state.*  The  heart  is  one  of  the  mechanisms 
most  resisting  to  the  influence  of  opium 
(Nothnagel  and  Rossbach).  The  pulse  is 
in  the  early  stage  increased  in  frequency  ; 
later  it  becomes  slower  and  increased  both 
in  fulness  and  in  force ;  in  the  end  it  may 
again  become  more  frequent,  and  it  then 
becomes  weak  also.  Blood-pressure  is 
lowered  to  a  variable  extent  by  large  doses 
of  opium,  but  we  may  remember  that,  prac- 
tically, opium  and  morphia  do  not,  in 
therapeutic  dose,  depress  the  heart  and 
vascular  system. 

The  condition  of  the  pupil  is  not  con- 
stant even  for  man ;  it  is  very  variable 
indeed  for  animals.  All  that  can  be  said 
with  certainty  is  that  the  contraction  is 
not  due  to  peripheral  action.  Peripheral 
action  on  muscle  and  nerve  may  be  dis- 
regarded. The  activities  of  the  stomach 
are  diminished  and  appetite  is  checked. 
The  action  upon  the  intestinal  tract  is  not 
sufficiently  explained,  but  what  we  do 
know  is  that  peristaltic  action  is  lessened, 
that  the  secretion  of  the  bowel  and  its 
appendages  is  diminished,  and  that  con- 
stipation results.  The  amount  of  urine  is 
generally  diminished. 

Of  these  effects  of  opium,  it  is  important 
to  note :  (rt)  the  influence  over  pain ;  (b) 
the  quieting  of  cough;  (c)  the  non-depress- 
ant action  on  the  heart  and  vessels 
(indeed,  opium  in  therapeutic  dose  may 
rank  as  a  cardiac  stimulant) ;  {d)  the  pro- 
duction of  anorexia  and  constipation, 
with  their  disturbing  action  or  assimila- 
tion in  general. 

The  sleep  obtained  by  opium  is  not  very 
refreshing ;  it  is  in  many  instances  light 
and  disturbed  by  exciting  dreams.  It  is 
frequently  followed  by  fulness  in  the  head 
and  a  dull  listless  feeling. 

Opium  is  eminently  a  drug  for  tempo- 
rary use ;  if  given  for  any  length  of  time, 

*  "Brain  Surgery,"  Brit.  Med.  Assoc,  18S6. 


Sedatives 


[     1141     ] 


Sedatives 


it  invariably  does  harm  by  its  effects  on 
assimilation.  Its  influence  over  pain 
makes  it  of  the  t^reatest  service  when  this 
is  the  cause  of  insomnia.  The  like  holds 
in  eases  of  sleeplessness  from  irritative 
cough;  but  where  there  is  much  secretion 
within  the  bronchial  tubes,  opium  is 
contra-indicaled,  in  relation  to  pain  and 
cough,  o|)ium  contrasts  with  the  chloro- 
form, chloral  hydrate,  and  alcohol  groups 
generally.  The  intluonce  on  the  urine  is 
a  somewhat  uncertain  one,  but  there  is  no 
doubt  that  the  dangers  of  opium  adminis- 
tration in  kidney  disease — e.g.,  the  con- 
tracted kidney — have  been  overstated. 
The  presence  of  albumen  sliould,  however, 
in  all  cases  make  us  more  watchful  in  the 
use  of  opium  and  morphia.  On  account 
of  its  non-depressant,  even  stimulant, 
action  on  the  heart,  opium  is  never  contra- 
indicated  by  cai'diac  disease;  indeed,  it 
forms  one  of  the  most  valuable  drugs  we 
possess  in  the  treatment  of  heart  pain,  and 
of  heart  distress  generally — e.(/.,  dyspnoea. 
In  the  startings  from  sleep  of  heart 
disease  morphia  gives  great  relief.  Balfour 
points  out  that  "  mental  aberration  of  a 
more  or  less  violent  character  "  may  occur 
in  the  course  of  aortic  disease.  He  thinks 
it  is  mostly  occasioned  by  anasmia,  and  he 
finds  that  full  hypnotic  doses  of  morphia, 
given  subcutaueously,  are  of  great  benetit. 

Opium  is  found  of  great  use  in  mental 
states  of  worry,  fret,  apprehension ;  it  is 
in  such  cases  that  some  practitioners 
insist  on  the  value  of  opium  as  against 
morphia.  Sir  Andrew  Clark  speaks  of 
the  advantage  of  whole  opium  in  such 
cases  for  the  purpose  of  "  taking  the 
grizzle  off  the  nerves." 

For  simple  insomnia,  independent  of 
pain  or  cough  or  heart  disease,  it  is  not 
usual  to  have  recourse  to  opium,  and  more 
especially  if  the  insomnia  be  habitual — for 
such  it  is,  however,  always  available  as  an 
occasional  dose — though  other  drugs  are 
to  be  preferred. 

For  the  insomnia  which  frequently  pre- 
cedes the  establishment  of  mental  disease 
opium  may  be  employed,  and  here  it  may, 
according  to  Clouston,  act  as  prophylactic 
by  a  timely  interruption  of  a  sleeplessness 
which  threatens  to  become  a  habit.  In 
these  cases,  however,  there  appears  to  be 
no  special  indication  for  opium  rather 
than  for  bromides  or  chloral. 

In  established  mental  disease  the  value 
of  opium  is  much  debated.  In  melan- 
cholia Clouston  holds  it  to  be  harmful  ; 
he  speaks  most  emphatically  on  this  point, 
asserting  that  "in  a  series  of  elaborate 
experiments  which  he  made  it  always 
caused  loss  of  appetite  and  loss  of  weight." 
In  acute  mania  he  says  that  opium  should 


be  used  only  as  a  temporary  placebo,  and 
not  continuously.  Schiile  states  broadly 
that  opium  is  "  the  plaster  splint  of  the 
sick  mind,"  and  that  the  general  indica- 
tion for  its  employment  is  the  presence  of 
a  hypenusthesia  with  heightened  reflex 
excitability  (c/.  Nothnagel  and  lloasbach). 
In  melancholias  associated  with  unrest 
and  excitement  Nothnagel  and  Kossbach 
state  that  there  is  a  general  agreement  as 
to  the  good  effects  of  opium.  They  speak 
more  vaguely  of  its  use  in  other  forms  of 
mental  disease,  but  according  to  them  the 
tendency  of  late  years  in  the  treatment  of 
the  insane  has  been  the  use  of  morphia 
more  and  chloral  less.  Krafft-Ebing 
writes  that  even  now  the  indications  for 
the  use  of  opium  are  by  no  means  clear; 
he  finds  opium  of  the  greatest  value  in 
delirium  tremens,  in  dysthymias,  and  in 
commencing  melancholias.  In  ana3mic 
conditions  opium,  he  says,  acts  dispropor- 
tionately strongly,  and  is  of  doubtful 
utility.  Blandford  says  that  each  case 
of  mental  disease  must  be  treated  on  its 
own  merits,  and  that  it  is  necessary  "  to 
experimentalise,  so  to  speak,  on  each 
individual,"  and  so  determine  the  use 
or  uselessness  of  opium.  The  form  of 
insanity  in  which,  in  his  experience,  opium 
"  does  least  good  and  most  harm,  is  acute 
delirious  mania  in  stlienic  patients,  where 
there  is  great  excitement  with  heat  of 
the  head,"  and  that  it  does  most  good  in 
cases  of  quiet  melancholia.  In  delirium 
tremens  both  opium  and  morphia  (as 
hypodermic  injections)  have  been  much 
employed,  and  very  large  doses  have  been 
given.  Some  give  preference  to  the  mor- 
phia hypodermic,  others  to  opium  in 
substance  and  by  the  mouth.  Of  late  it 
has  been  maintained  that  this  disease  is 
best  treated  by  a  simple  expectant  dietetic 
treatment  (r/.  Nothnagel  and  Rossbach). 
If  employed  it  is  probable  that  the  hypo- 
dermic method  is  the  best,  because  the 
surest,  since  we  know  so  little  about  the 
absorptive  powers  of  the  alimentary  tract 
of  an  alcoholic.  The  delirium  of  alcohol 
and  also  that  of  fever  have  been  treated 
beneficially  by  combining  tartar  emetic  or 
tincture  of  aconite  with  opium.  It  is 
obvious  that  this  treatment  is  indicated 
chiefly  in  sthenic  cases. 

The  action  of  morphia  is  similar  to,  but 
not  the  exact  equivalent  of,  opium.  The 
difference  in  this  action  is  difficult  to 
express.  Practical  men  state  somewhat 
vaguely  that  opium,  in  its  calming  efl'ects 
on  the  nervous  system,  acts  more  smoothly 
than  morphia  ;  by  this  they  imply  that 
the  other  alkaloids  of  opium  modify  or 
round  the  action  of  the  morphia.  The 
difference  is  a  clinical  experience  and  not 


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[     1 142    ] 


Sedatives 


a  scientific  finding.  Besides  this  pri- 
mary difference,  opium  differs  from  mor- 
phia, it  is  said,  in  being  more  constipat- 
ing, and  more  liable  to  cause  headache  and 
nausea,  but  more  stimulant  and  more  dia- 
phoretic. 

Nothnagel  and  Rossbach  consider  that 
the  controversy  as  to  the  choice  between 
opium  and  morphia  must  be  regarded  as 
decided  in  favour  of  the  morphia.  They 
refer  to  the  subcutaneous  administration 
of  morjihia,  and  certainly  this  method  has 
the  advantage  of  greater  precision. 

Administration.  —  Opium,  as  a  hyp- 
notic, may  be  given  as  powder  or  extract, 
or  in  the  form  of  one  of  its  numerous 
preparations.  These  are  really  special 
formulas  adapted  to  meet  special  morbid 
conditions — e.g.,  of  the  intestinal  tract,  of 
the  respii-atory  organs,  &c.  Opium  by  the 
mouth  generally  requires  one  to  two  hours 
to  develop  its  effects.  Morphia  in  the  form 
of  one  of  its  salts  may  be  given  by  the 
mouth  in  the  place  of  opium.  Some 
choose  the  bi-meconate  of  morphia  in 
preference  to  the  other  salts,  but  it  is 
doubtful  whether  this  has  more  than  a 
theoretic  advantage. 

Opium  or  morphia  may  be  given  per 
rectum  if  need  be,  and  either  as  an 
injection  or  as  a  suppository. 

Or  morphia  maybe  administei'ed  hypo- 
dermically,  and  this  plan  has  been  largely 
adopted  in  the  treatment  of  the  insane. 
Thus  employed  the  narcotic  action  is  more 
rapid  and  more  lasting,  and  the  alimentary 
tract  is  less  affected  in  the  way  of 
anorexia  and  constipation.  A  small  piece 
of  ice  with  smooth  surface  dipped  in  salt 
and  applied  firmly  for  about  thirty  se- 
conds is  the  best  means  of  producing 
anaesthesia  in  cases  where  the  slight  pain 
of  the  puncture  is  dreaded. 

Whether  the  subcutaneous  or  oral 
method  be  adopted,  opium  or  morphia 
may  be  given  either  in  occasional  big 
doses  to  meet  occasional  urgent  symptoms, 
or  systematically  and  in  ascending  doses. 
Schiile,  Wolff,  Voisin,  have  urged  the 
systematic  use  of  morphia  injections  in 
rising  dose  till  the  patient  is  calmed.  In 
elderly  people,  in  general,  the  dose  should 
be  smaller,  and  this  holds  in  2:>articular  for 
cases  of  general  paralysis  of  the  insane 
(Nothnagel  and  Rossbach). 

Dose. — Tolerance  of  opium  and  morphia 
soon  becomes  established,  and  for  this 
reason,  and  the  disastrous  nature  of  the 
opium  habit,  the  drugs  must  always  be 
kept  well  in  hand.  Idiosyncrasy  is  some- 
times manifested  with  regard  to  opium,  the 
smallest  doses  exciting  and  not  soothing. 
Age  is  a  very  important  element.  The  hypo- 
dermic method  is  not  suitable  for  children. 


Of  opium  it  is  unnecessary  to  consider 
the  doses  of  all  the  preparations  ;  it  will 
suffice  to  give  those  of  the  pure  prepara- 
tions which  may  safely  be  commenced 
with,  viz. : 

Of  the  crude  opium  and  of  the  extract, 
\  gr.-i  gr. ;  of  the  tincture,  liquid  extract 
anil  wine,  11\^xv-xx. 

Morphia  may  safely  be  given,  by  the 
mouth,  to  the  extent  of  {— i  gr.  as  first 
dose,  though,  according  to  H.  C.  Wood, 
the  largest  quantity  of  morphia  which 
should  be  injected,  as  a  first  dose,  should 
not  exceed  one-eighth  grain  for  a  woman 
and  one-sixth  grain  for  a  man. 

The  above  are  safe  doses,  though  they 
may  in  cases  of  idiosyncrasy  give  rise  to 
unrest   or   excitement   instead   of  sooth- 

Of  the  other  alkaloids  of  opium  it  may 
be  said  in  general  that  the  statements  by 
observers  are  very  conflicting,  and  that 
this  variance  is  probably  the  result  of  the 
difficulty  there  is  in  securing  reliable  pre- 
])arations.  So  far  as  observation  up  till 
the  present  goes,  there  is  no  reason  to 
believe  that  in  papaverine,  or  narceine 
or  codeine,  we  have  drugs  possessing  any 
advantages  over  morphia,  excepting,  as 
Krafft-Ebing  puts  it,  those  of  "higher 
price  and  weaker  action." 

Convulsant  action  is  more  pronounced 
for  these  alkaloids  than  for  morphia. 

Codeine  is  obtainable  in  a  pure  form, 
and,  in  combination  with  phosphoric  acid, 
it  is  adapted  for  hypodermic  injection 
because  it  is  so  little  irritant.  PronmiiUer 
claims  that  it  produces  less  headache, 
giddiness,  and  vomiting  than  morphia 
{Wiener  Klin.  Wochenschr.,  1890,  No.  3, 
p.  45).  It  must  be  given  in  about  twice 
the  dose  of  morphia. 

Hyoscyamine  and  Hyoseine. — From 
the  Hyoscyamus  niger,  an  alkaloid  hyos- 
cyamine is  obtained ;  it  is  crystallisable, 
and  is  isomeric  with  atropine.  In  addi- 
tion there  is  present  an  amorphous  alka- 
loid which  is  likewise  isomeric  with  atro- 
pine ;  it  has  been  named  hyoseine.  Com- 
mercial hyoscyamine  is  said  to  consist 
largely  of  hyoseine. 

The  whole  plant  hyoscyamus  certainly 
resembles  in  its  action  the  whole  plant 
belladonna,  and  this  resemblance  holds  to 
a  considerable  extent  for  the  active  prin- 
ciples of  the  plants,  atropine  on  the  one 
hand,  hyoscyamine  and  hyoseine  on  the 
other.  In  a  case  of  acute  mania  the 
action  of  the  two  alkaloids,  hyoscyamine 
and  atropine,  appeared  to  be  identical 
(Ringer,  Fractitioner,'i\l?i\-c\i  1877).  This 
question  of  the  precise  relative  value  of 
these  plants,  and  of  their  active  prin- 
ciples needs  further  investigation,  but  as 


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[     "43     ] 


Sedatives 


it  now  stands  it  may  be  said  that  hyoscya- 
nius  aud  its  active  principles  are  credited 
with  less  deliriaut  action  and  more  sopori- 
fic action  than  belladonna  and  its  deriva- 
tives. 

From  experiments  with  crystallised 
hyoscyamine  Dr.  J.  C.  Shaw  concludes 
that  the  drus;  acts  exactly  like  atropine 
upon  the  heart  and  vessels,  increating 
the  frequency  of  the  pulse  with,  in  the 
first  instance,  rise,  but  subsequent  fall, 
of  blood-j)ressur'e.  Dr.  Laurent,  from  a 
careful  study,  comes  to  the  same  conclu- 
sions (Dupuy,  "LesAlcaloides,"  1890).  In 
fact,  the  only'dili'erences  admitted  are  tliat 
the  delirium  produced  is  more  subdued 
than  for  atroj)ine,  and  that  there  is  a 
greater  tendency  to  sleep.  The  mydriatic 
action  of  hyoscyamine  is  less  than  that  of 
atropine,  according  to  Shaw. 

Hyoscine,  according  to  Wood,  differs 
from  atropine,  and  therefore  from  hyos- 
cyamine also,  in  its  effect  upon  the  heart — 
i.e.,  it  does  not  depress  the  heart  to  any 
degree,  nor  does  it  paralyse  the  vagi ;  the 
pulse  rate  is  somewhat  diminished.  Other 
observers  maintain  that  it  acts  upon  the 
heart  like  atrojjiue — e.g.,  Kobert  (see  alsu 
Dupuy,  "  Les  Alcaloides  ").  The  proba- 
bility IS  that  the  substances  used  have  not 
alwaj's  been  identical.  Hyoscine  is  gen- 
erally admitted  to  be  a  much  more  decided 
soporific  than  hyoscyamine. 

The  advantage  of  hyoscine  as  a  soporific 
is  its  freedom  from  after-effects.  Some 
dryness  of  the  throat  may  occur,  and 
sometimes  there  is  headache,  but  the 
alimentary  tract  is  not  upset,  and  in  par- 
ticular there  is  no  constipation.  It  is  in 
this  that  the  drug  has  such  an  advan- 
tage over  opium.  (Atropine,  it  will  be  re- 
membered, is  held  to  act  in  small  doses 
as  a  laxative,  and  Laurent  states  that 
hyoscyamine  acts  .similarly.) 

Hyoscyamine,  or  by  preference  hyoscine, 
is  used  in  the  treatment  of  acute  mania 
and  of  insomnia  accomj^anied  by  de- 
lirious excitement,  whether  in  the  insane 
or  not  (Wood).  Mitchell,  Bruce,  and 
Tirard  say  that  kidney  disease  does  not 
contra-indicate  hyoscine  ;  and  Bruce,  that 
he  has  used  it  with  benefit  in  exceed- 
ingly feeble  states  of  the  heart.  Both 
alkaloids  have  been  largely  tried  by 
alienists:  hyoscyamine  by  liobert  Lawson, 
Clouston,  Savage,  Gnauck,  Fronmiiller, 
hyoscine  by  Gnauck,  Claussen,  Kraft't- 
Ebing,  Magnan,and  others.  Hyoscine  is 
generally  given  as  hydrochlorate  or  as 
hydrobromate. 

Hyoscyamine  may  be  given  in  doses  by 
the  mouth  of  ^  to  '.  and  up  to  ^  grain. 
Gnauck  allows  the  administration  of 
crystalline    hyoscyamine    suhcidaneously 


lip  to  \  grain  as  the  maximum  dose,  but 
the  doses  .,',,  to  ,'.,  grain,  advocated  by 
Browne,  should  be  exceeded  with  caution, 
and  as  initial  dose  it  would  be  well  to 
begin  with  j^',,,  grain. 

Hyoscine  by  the  mouth  may  be  given 
in  doses  of  fi,,  to  ,,',„  grain,  mounting  up 
if  need  be  to  „\,  or  -\,  grain,  or  even  to 
7,\|  grain  of  the  hydrochlorate  of  hyoscine. 
Hypodermically  the  dose  should  vary  from 
j^^  to  „'„  grain.  Very  marked  idio- 
syncrasy is,  according  to  Wood,  not  infre- 
quent. Drs.  Bamadier  and  Scrieux  {Bid' 
letiu  Gmcral  de  Tlicraj).,  Jan.  1892),  after 
two  years'  expei'ieuce  with  hyoscine  hydro- 
chlorate at  the  Yaucluse  Asylum,  speak 
highly  of  its  value  in  the  treatment  of 
mania,  in  all  its  varieties,  alcoholic,  epi- 
leptic, &c.  They  consider  the  subcutane- 
ous administration  the  best,  but  counsel 
that  the  dose  should  begin  with  t^ott  grain 
or  even  ^^l,^,  if  the  patient  be  weakly. 

Merck's  prepai-ations  of  hyoscyamine 
and  hyoscine  are  to  be  advised. 

Caustic  alkalies  should  not  be  given 
with  either,  since  they  decompose  the 
alkaloids.  This  fact  we  owe  more  espe- 
cially to  Garrod,  who  showed  the  ineffi- 
ciency of  hyoscine  as  a  mydriatic  after 
admixture  with  caustic  alkalies. 

Sulphate  of  Duboisine,  obtained  from 
the  Duboisia  myoporoides,  has  of  late  been 
employed  in  cases  of  mental  excitement. 
The  alkaloid  duboisine  is  regarded  as 
identical  with  hyoscine  and  isomeric  with 
hyoscyamine  and  atropine.  Max  Lewald 
and  Vladimir  Preininger  speak  to  the 
value  of  duboisine,  but  there  seems  no 
reason  to  prefer  it  to  hyoscine  or  to  an 
equivalent  dose  of  hyoscyamine.  The 
actual  quantities  used  by  the  above  ob- 
servers are  0.002  gramme,  or  about  ^V 
grain  ;  they  counsel  that  this  dose  should 
not  be  exceeded.  We  would  advise  that 
for  the  present  at  least  the  same  caution 
should  be  observed  as  for  hyoscine,  and  a 
very  much  smaller  dose,  viz.,  ^  /^^j  grain  be 
commenced  with  {vide  Therap.  Monats., 
December  1891). 

Cannabis  Indlca,  or  Indian  Hemp 
(Gunjah,  Bang,  are  Indian  names  for  the 
dried  plant ;  Haschish  is  the  Arab  name 
given  either  to  the  plant  itself  or  a  pre- 
paration of  which  Indian  hemp  is  the 
chief  constituent).  Indian  hemp  contains 
avolatile  alkaloid,  can nabinin,  the  qualities 
of  which  have  not  been  thoroughly  deter- 
mined ;  also  a  base,  strychnine-like  in  its 
action,  tetano-cannabin  (it  is  not  known 
whether  all  varieties  of  Indian  hemp  con- 
tain this),  and  further  an  amorphous, 
resinoid,  bitter  substance,  cannabiuou, 
which  is  the  special,  active  substance  of 
the  hemp.  Cannabinou,  or  the  crude  hemp, 


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[    1 144    ] 


Sedatives 


acts  chiefly  upon  the  cerebrum,  causing 
exaltation  of  the  psychic  functions  ;  the 
excitement  is  mostly  pleasing,  the  ideas 
flow  easily,  hallucinations  of  sight  or  hear- 
ing may  be  present,  and  forced  movements 
of  various  kinds  (motor  hallucinations) 
ai-e  often  executed.  At  times  the  merri- 
ment is  very  boisterous  ;  at  times  there  is 
delirium.  Mental  depression  may  follow, 
and  the  distress  be  very  great.  Sleep  is 
the  next  event,  but  before  it  sets  in  there 
may  be  much  impairment  of  sensation, 
preceded  or  accompanied  by  sensations  of 
pins  and  needles  ;  the  anassthesia  may  be 
almost  complete  and  hold  for  both  tactile 
and  painful  imjsressions  ;  muscular  sense 
may  be  lost.  The  efi:ect  on  the  breathing 
and  circulation  is  but  slight.  The  pupils 
are  dilated,  but  they  contract  to  light. 

Cannabis  indica  has  been  much  em- 
ployed as  a  hypnotic  and  as  a  sedative. 
Dr.  Russell  Reynolds,  speaking  from  an 
experience  of  thirty  years,  states  that  it  is 
of  much  value  in  the  treatment  of  senile 
insomnia,  in  which  there  may  be  wander- 
ing and  great  restlessness  (fidgetiness)  at 
night,  whilst  during  the  day  the  patient 
may  be  quite  rational.  "  In  this  class  of 
cases  there  is  nothing  comparable  in 
utility  to  a  moderate  dose  of  Indian 
hemp — viz.,  i  to  |  grain  of  the  extract  at 
bedtime."  In  alcoholic  delirium  it  is  very 
uncertain  ;  in  melancholia  it  is  sometimes 
of  service  b}'  converting  the  depression 
into  exaltation.  In  the  treatment  of  night 
restlessness  of  patients  with  "  general 
paralysis  "  it  is  very  useful ;  also  in  the 
insomnia  of  "  temper  disease,"  whether  in 
children  or  adults,  it  is  eminently  use- 
ful. Dr.  Reynolds  has  found  it  of  no  use 
in  acute  mania,  but  on  the  other  hand 
Dr.  Ciouston  has  found  it  of  the  greatest 
service  when  combined  with  bromide  of 
potassium. 

In  the  ti-eatment  of  neuralgia,  especially 
of  the  fifth,  and  of  sleeplessness  the  result 
of  such,  cannabis  indica  is  most  valuable. 
It  is  very  valuable  in  migraine. 

Dose.  —  Rosenthal  advocates  cannabis 
indica,  the  extract  prepared  according  to 
the  recent  method,  m  doses  of  from  i  to  3 
grains  in  the  treatment  of  the  opium 
habit.  The  more  recent  extract  is,  accord- 
ing to  him,  less  liable  to  fungus  than  the 
older  preparation  ( Wien.  Med.  Presse, 
September  15,  1889).  A  preparation,  the 
tannate  of  cannabin,  has  been  recently 
introduced  and  much  praised  as  a  hypno- 
tic by  Fronmiiller.  Kraflt-Ebing  finds  it 
very  uncertain.  Wood  speaks  to  the  same 
effect. 

The  simple  oflicinal  extract  appears  to 
be  very  variable  in  composition,  and  from 
this  result  the  discrepancies  in   the   ob- 


served effects.  Dr.  Reynolds  lays  great 
stress  on  the  importance  of  securing  a  pure 
drug.  According  to  him,  the  dose  of  such 
in  the  form  of  extract  should  not  exceed 
gr.  I;  in  the  first  instance  for  an  adult, 
gr.  Y^y  for  a  child  ;  it  may  be  increased  sub- 
sequently. The  doses  of  the  extract  given 
by  Fronmiiller,  viz.,  gr.  3  to  8,  must 
represent  a  much  weaker  preparation  than 
that  of  the  B.P.  The  tincture  is  on  the 
whole  the  best  preparation  according  to 
Dr.  Reynolds  (20  minims  =  i  gr.  of  the 
extract) ;  he  advises  for  convenience  that 
it  should  be  made  of  double  strength,  and 
that  it  should  be  administered  on  sugar  or 
bread-crumbs  as  drops,  beginning  with  a 
minimum  dose  which  must  not  be  repeated 
in  less  than  four  to  six  hours,  and  which 
may  be  inci'cased  by  one  drop  every  third 
or  fourth  day  until  relief  is  obtained  or 
the  drug  pi'oved  useless.  It  should  be 
noted  that  according  to  his  scale  of  dosage 
the  quantity  of  the  B.P.  tincture  to  be 
begun  with  would  be  4  minims.  Given  in 
a  mixture  the  resin  is  liable  to  separate 
out  unequally. 

Cannabinon  is  given  in  the  same  dose 
as  the  officinal  extract.  The  tannate  of 
cannabin,  introduced  by  Merck,  is  re- 
commended by  Fronmiiller  in  doses  of  5 
to  10  grains.  The  substance  is  a  yellowish 
brown  powder  insoluble  in  water  and  in 
ether,  soluble  in  alcohol ;  it  is  inodorous, 
rather  bitter,  and  tastes  somewhat  like 
tannin.  The  drug  is  said  not  to  intoxicate 
and  not  to  constipate.  It  may  be  given 
in  powder  simply  or  with  the  addition  of 
a  little  sugar.     {Bullet,  de  Therap.,  1883, 

P-  334-) 

Conlum  (Hemlock).  —  The  officinal 
species  of  this  genus  is  the  Conium  macu- 
latum.  Two  alkaloids  are  present  in  the 
plant,  coni'ine  and  methyl-coniine.  The 
former  alkaloid,  CgHi-JST,  is  in  the  pure 
state  quite  colourless  (Merck),  liquid, 
volatile,  and  possessed  of  a  peculiar  pene- 
trating odour  :  it  is  unstable.  It  forms  a 
number  of  salts,  of  which  the  hydrobro- 
mate  is  well  adapted  for  therapeutic  use, 
since  it  is  fairly  stable  and  forms  well- 
defined  crystals  which  are  sufficiently 
soluble  in  water.  The  action  of  coniine 
closely  resembles  that  of  curare,  poison- 
ing, as  it  does,  the  motor  nerve-endings 
throiighout  the  body.  The  sympathetic 
motor  fibres  ai-e  paralysed  more  slowly 
than  the  cerebro-sijinal.  The  terminations 
of  the  efferent  fibres  of  the  vagus  are  also 
paralysed,  and  in  this  respect  the  drug  con- 
trasts with  curare,  which  is  without  influence 
upon  them.  (Pelissard,  Jolyet,  Cahours  ; 
see  Dujardin-Beaumetz,  "  Dictionnaire  de 
Therap.'')  Sensory  nerves  are  affected 
to  some  extent  ;  thus,  numbness,  formica- 


Sedatives 


[     1145    ] 


Sedatives 


tion  are  comjilaincd  of,  but  the  action  is 
slight,  and  is  slow  in  appearing,  and 
with  a  massive  dose  motor  paralysis 
may  exist  without  any  apparent  sensory 
failure.  The  tojiical  application  of  either 
coniine  or  conium  (the  whole  drug)  causes 
some  local  amesthesia. 

The  iutiuence  on  the  cerebral  nervous 
system,  in  particular  the  brain,  is  much 
less  definite  than  that  on  the  peripheral 
system  ;  still,  there  does  appear  to  be  some 
benumbing  action  on  the  brain  when  large 
doses  are  taken — e.g.,  thinking  becomes 
very  laborious,  and  a  state  of  cerebral 
vacuity  is  present  (Dujardin-Beaumetz). 
Schmiedeberg  speaks  of  a  slight  cerebral 
narcosis,  and,  among  the  older  records, 
Pereira  states  that  an  actual  condition  of 
coma  has  been  occasioned.  Special  sensi- 
bility may  sutler — e.g.,  vision.  Along 
with  the  impairment  of  sight  there  is  dila- 
tation of  the  pupils  and  some  ptosis.  The 
affection  of  sight  will  in  part  be  the  result 
of  the  internal  ocular  paralysis. 

According  to  ^ome  observers,  the  spinal 
cord  is  also  slightly  affected,  its  functions 
depressed;  occasionally,  convulsions  are 
witnessed  which  are  not  the  result  of 
asphyxia.  On  the  whole,  it  is  certain  that 
the  central  nervous  system  is  relatively 
unaffected. 

Conium  kills  by  respiratory  paralysis. 
The  influence  on  the  circulation  is  still 
uncertain.  In  toxic  doses  the  temperature 
is  lowered.  'Jhe  urine  frequently  shows 
the  presence  of  much  mucus  (catarrhal 
state  of  the  urinary  passages).  Sweating 
of  the  skin,  and  sometimes  skin  eruptions, 
are  produced. 

Use. — In  mental  diseases  conium  has 
been  extensively  employed — e.g..,  mania 
and  hysterical  excitement ;  some  alienists 
speak  well  of  it  when  given  in  full  doses. 
The  indications  for  its  use,  however,  are 
by  no  means  clear,  and  we  are  disposed  to 
regard  it  as  a  sedative  of  secondary  value, 
the  more  so  on  account  of  the  uncertainty 
of  its  preparations. 

In  motor  excitement,  chorea,  tetanus, 
it  has  been  employed,  and  in  the  former 
affection  it  is  easy  to  demonstrate  its 
power  to  control  the  movements,  though 
this  action  appears  to  be  palliative  and 
not  curative.  It  might  be  found  useful  in 
the  motor  restlessness  of  the  insane.  The 
employment  of  conium  in  spasmodiclung 
affections,  asthma,  whooping-cough,  does 
not  belong  here. 

In  neuralgias,  tic  douloureux,  sciatica, 
conium  has  its  advocates.  Dujardin- 
Beaumetz  insists  on  the  much  greater 
efficacy  of  conium  when  introduced  sub- 
cutaneously,  and  that  in  this  respect  the 
parallelism  to  curare  is  maintained,  though 


less  strikingly.  The  dose  for  injection 
should  be  ,\  to  -',-  grain  of  the  liydro- 
bromate  of  coniine.  He  i-ecommends  the 
following  solution : 

Grins. 
Crystallised  coiiiint'  li.\  (Irobvoniate.       0.5 

Alcohol 1.5 

Cliorry  laurel  waier         .  .  .     23.0 

Of  this  solution  a  Pravaz  syringeful  would 
contain  h  grain  of  the  salt.  By  the  mouth 
25  grains  (0.15  gramme)  of  the  hydro- 
bromate  of  coniine  may  be  given  in  the 
twenty-four  hours. 

Of  the  whole  drug,  conium,  the  succus 
is  generally  regarded  as  the  most  efficient 
preparation,  though  H.  C.  Wood  has  fre- 
quently found  it  inoperative.  Large 
doses  must  be  given — e.g.,  two  drachms  to 
half  an  ounce— but  even  these  doses  rapidly 
become  tolerated  ;  thus,  in  one  case,  a  child 
suffering  from  chorea  I'eceived  hourly, 
except  when  asleep,  seven  drachms  of 
the  succus  conii  (Ringer,  "Therapeutics"). 
Dujardin-Beaumetz  finds  the  alcoholic 
extract  of  the  seeds  the  best  preparation 
of  the  whole  drug.  The  alkaloid  confine 
being  volatile  and  unstable,  we  should  be 
prepared  to  find  that  specimens  which 
have  been  kept  may  be  almost  wholly 
inert  or  exceedingly  variable  in  their  acti- 
vity. We  must  remember,  moreover,  that 
the  proportions  of  confine  and  of  methyl 
coniine  in  the  plant  are  variable,  and  that 
the  alkaloid  methyl  coniine  differs  from 
coniine  by  acting  more  powerfully  on  the 
spinal  cord;  hence,  that  different  specimens 
would  act  differently.  At  Bethlem  Hos- 
pital the  succus  conii  has  been  given  by 
Dr.  Savage  continuously,  in  doses  ranging 
from  two  drachms  to  two  ounces,  without 
causing  any  bad  symptoms ;  the  cases 
were  of  recurrent  mania.  These  doses, 
even  the  larger  ones,  were  given  thrice 
daily. 

Calabar  Bean,  the  dried  seed  of 
Physostigma  venenosum,  is  a  sjoinal  seda- 
tive, but  it  influences  the  brain  also.  The 
active  principle  is  an  alkaloid,  physo- 
stigmine,  also  called  eserine :  but  there  is 
present  in  the  brain  another  alkaloid, 
calabarine,  whose  action,  strychnine-like, 
opposes  that  of  physostigmine.  The 
influence  of  the  latter  predominates,  how- 
ever. Physostigmine  occurs  in  colourless 
crystals  slightly  soluble  in  water,  freely 
soluble  in  ether  ;  it  forms  various  salts — 
e.g.,  the  sulphate,  hydrobromate,  salicy- 
late, borate. 

The  action  of  physostigmine  is  upon 
muscular  tissue,  striped  and  plain,  as 
shown  by  twitchings  of  the  skeletal 
muscles,  contractions  of  the  stomach, 
spleen,  uterus,  bladder,  and  pupil;  the  latter 
action    finds  practical  application.     The 


Sedatives 


[    1146    ] 


Sedatives 


blood-pressure  rises  (action,  on  heart  and 
vaso-motor  fibres).  Tliere  may  be 
dyspnoea.  The  respirations  are  first 
accelerated,  then  retai-ded.  Further,  it 
causes  increase  of  glandular  secretions — 
e.g.,  mucous,  salivary,  lachrymal,  cutane- 
ous, &c.  It  acts  also  on  the  central  nervous 
system,  in  particular  the  cord,  causing 
paralysis,  general  and,  if  the  dose  be  suffi- 
cient, complete  ;  death  results  from  arrest 
of  respiration.  Physostigmine  paralysis 
is  of  spinal  origin,  and  the  brain  does  not 
share  in  the  production  of  this  symptom  ; 
the  posterior  limits  suffer  before  the  an- 
terior. Death  results  from  the  invasion  of 
the  medulla  by  the  paralysis.  Sensation 
if  affected  is  so  secondarily.  The  peri- 
pheral nerves,  motor  and  sensory,  prac- 
tically escape.  Preceding  the  paralysis  a 
period  of  great  excitement  may  occur ; 
this  has  been  especially  witnessed  in  ex- 
periments on  cats,  the  animals  running 
wildly  about ;  guinea-pigs  may  exhibit  the 
same.  The  excitement  has  been  attributed 
to  the  dyspnoea  caused  by  the  drug,  but, 
as  Dr.  Bruntou  states,  this  can  hardly  be 
the  whole  explanation,  and  we  must  infer 
tliat  tliere  is  direct  cerebral  stimulation. 
In  confirmation  of  this  we  find,  from  ex- 
periments on  animals,  predisposed  to 
epileptiform  attacks,  by  Brown-Sequard's 
method,  that  physostigmine  increases  the 
liability  to  convulsive  seizures,  and  the 
same  has  been  observed  in  respect  of 
epileptic  patients,  the  attacks  becoming 
more  frequent. 

When  Calabar  bean,  not  its  active  prin- 
ciple physostigmine,  is  administered,  dis- 
cordant results  are  frequent ;  thus,  convul- 
sions probably  of  spinal  origin,  and  like 
those  produced  by  strychnine,  may  occur  ; 
it  is  held  that  these  are  caused  by  the 
calabarine  present. 

Therapeutic  Use. — In  tetanus  physo- 
stigmine would  seem  to  be  directly  indi- 
cated, and  by  several  observers  successful 
cases  are  recorded.  To  be  serviceable  here 
it  must  be  given  freely  in  quantity  suffi- 
cient to  produce  paralysis,  and  must  be 
jjushed  indeed  to  such  an  extent  that  but 
a  little  more  would  permanently  arrest 
breathing  (Ringer,  "  Therapeutics").  Dr. 
Eben  Watson  gave  72  grains  of  a  spiritu- 
ous extract  in  twenty-four  hours  ;  and 
one  of  the  writers  of  this  article  gave  2  J 
grains  of  the  watery  extract  every  hour 
for  thirty-six  hours  (for  a  short  time  four 
grains  were  given  hourly :  Ringer's  "Thera- 
peutics"). In  chorea  the  value  of  physo- 
stigmine is  not  established.  In  paraplegia 
and  locomotor  ataxy  the  drug  has  been 
employed. 

In  general  paralysis  of  the  insane  Cala- 
bar bean  has  been  repeatedly  tried.     Sir 


James  Crichton  Browne  speaks  highly  of 
it,  and  he  is  even  quoted  as  having  cured 
two  cases  by  means  of  it.  This  statement 
is,  however,  an  entire  misrepresentation, 
for  in  a  letter  to  the  Journal  of  Mental 
Science,  April  1875,  P-  ^S->  ^^  says: — 
"  While  claiming  for  the  Calabar  bean 
a  valuable  power  of  modifying  and  arrest- 
ing the  progress  of  that  most  persist- 
ent malady,  I  have  never  suggested  that 
it  should  be  regarded  as  a  cure."  Other 
observers  confirm  Sir  Crichton  Browne 
as  to  the  modifying  influence  of  physo- 
stigma  on  general  paralysis.  But  more 
recent  and  extended  trials  with  the  drug 
at  the  Wakefield  Asylum  have  yielded  in- 
different results. 

Dose. — The  large  doses  which  may  be 
given  in  the  treatment  of  a  critical  disease 
like  tetanus  have  been  mentioned  above ; 
it  must  be  added  that  the  plan  of  admin- 
istration in  this  disease  should  be,  moderate 
doses  at  short  intervals — e.g.,  hourly — so 
that  the  drug  may  be  withheld  should 
symptoms  of  collapse  or  of  paralysis 
appear. 

In  the  treatment  of  chronic  spinal  affec- 
tions or  of  general  paralysis  small  doses 
should  be  employed,  but  they  should  be 
continued  for  long  periods ;  thus,  in  Sir 
Crichton  Browne's  cases,  doses  of  J-^ 
grain  of  the  extract  were  given  continu- 
ously for  from  nine  to  twelve  months. 
Doses  of  -io-jo  grain  every  two  or  three 
hours  may  also  be  tried  in  these  com- 
plaints (Ringer,  "  Therapeutics  ").  Phy- 
sostigraa,  as  the  officinal  extract,  may  be 
given  in  the  above  doses,  either  by  the 
mouth,  or  by  rectum ;  or,  diluted  with 
water  (e.g.,  3  grain  in  10  minims),  it  may 
be  injected  subcutaneously. 

If  the  salts  of  physostigmine  be  admin- 
istered— e.g.,  sulphate  or  salicylate — the 
dose,  by  the  mouth,  is  ^V^V  grain  ;  this 
may  be  increased  to  -^^ ;  hypodermically, 
grain.     If  we  use  these  salts  of  the 


1  2  O      30   0\ 

alkaloid  in  the  treatment  of  tetanus  we 
must  push  the  drug  by  rej^etition  of  the 
dose  till  an  effect  is  produced. 

Boldine  is  an  alkaloid  obtained  from 
the  leaves  of  the  Peumus  boldus,  of  Chili 
(nat.  order,  Mominiaceas).  It  is  only 
slightly  soluble  in  water  ;  freely  soluble  in 
alcohol,  ether,  and  chloroform  ;  it  is  said  to 
possess  feeble  narcotic  powers.  In  the 
plant,  however,  another  active  principle,  a 
glucoside,  has  been  found  ;  it  has  been 
named  boldo-glucine. 

Boldo-g-lucine  possesses  decided  hyp- 
notic powers,  and  it  is  held  that  the  whole 
plant  acts  as  a  hypnotic  by  means  of  boldo- 
glucine  chieriy.  A  certain  amount  of  motor- 
incoordination  precedes  sleep.  In  toxic 
dose  death  takes  place  by  asphyxia ;  the 


Seleniasis 


1147    ] 


Self- mutilation 


heart  also  is  weakened  ;  the  temperature  is 
shghtly  lowered  (Laborde  :  Dupiiy,  "Les 
Alcaloides"). 

Of  the  glucoside,  doses  of  2  to  8  grammes 
(30  grains  to  2  drachms)  have  been  given 
in  draughts,  capsules,  or  rectal  injections. 
M.  Magnan  treated  successfully,  at  St. 
Anne's  Asylum,  a  case  of  insomnia  with 
horrific  hallucinations;  he  gave  30  grains 
of  the  plant.  Dr.  Juranville  mentions  ten 
similar  cases.  The  sleep  is  said  to  be 
natural  and  not  to  be  accomj)anied  by 
anajsthesia  {Brit.  Med.Journ.,  1888,  vol.  i. 
p.  918).  Ur.  Laborde  states  that  there  is 
some  amysthesia  (loc.  cit.).  It  cannot  be 
said  that  the  drug  has  been  thoroughly 
investigated  (Leech). 

Sydney  Ringkr. 
h.vk  kington  sainsbukv. 
SEXiENZASis,      sz:i>Eirxii.sivius 
{a-fXrjvT],  the  moon).     Literally,  the  moon- 
disease;  lunacy.       (Pr.    selaiiase ;     Ger. 
Mondsuclit.) 

SEIiEM'OBI.ETUS  (o-eXZ/rr;  ;  I3Xt]t6s, 
stricken).  Moonstruck.  Supposed  disease 
from  exposure  to  the  moon's  influence. 
Lunatic.     (Fr.  srlenuhlcfe.) 

SEIiSN'OGA.IWZA  {aeXt'jvrj  ;  ydnos, 
marriage).  A  synonym  of  Somnambulism. 
Literally,  wedded  to  the  moon. 

SEI.ETI-0PX.X:G£,  SEIiEM-OPXiEXZil. 
(aeXrjVT] ;  irXiiyrj,  a  stroke).  "Apoplexia" 
from  exposure  to  the  moon's  influence. 
(Fr.  selenoplexie.) 

SEZiF-MUTlIiATZOM'.  —  The  interest 
which  naturally  attaches  to  those  strangely 
mysterious  cases  of  self-mutilation,  self- 
torture,  and  self-dismemberment  of  various 
parts  of  the  body  which  are  sometimes 
met  with  in  medical  practice,  and  not 
unfrequently  by  the  alienist  phj'^sician, 
both  within  and  out  of  asylums,  will 
probably  be  intensified,  and  possibly  some 
additional  light  may  be  thrown  upon  the 
obscurity  which  surrounds  the  whole 
subject,  by  an  endeavour  to  trace  some  of 
the  motives  which  have  prompted  to 
the  commission  of  the  acts  at  various 
periods  of  history,  and  under  various  re- 
ligious conditions. 

Cases  of  the  kind  are  on  record  from  the 
earliest  ages  ;  by  the  Levitical  law  priests 
were  forbidden  to  make  any  cuttings  in 
their  flesh,  showing  that  the  custom  then 
prevailed.  Many,  perhaps  most,  of  those 
self-inflicted  tortures  have  at  all  times 
had  their  origin  in  unduly  exaggerated 
religious  fervour,  enthusiasm,  or  fanati- 
cism, and  the  custom  of  inflicting  self- 
injury  jjrobably  had  its  birth  in  the 
peculiar  religious  beliefs  of  Orientals  in  the 
remoter  East. 

Believing,  as  they  did,  the  material 
body  to  be  essentially  corrupt,  the  handi- 


work of  an  evil  spirit,  they  sought  com- 
munion with  Deity,  by  extirpating  its 
passions  and  desires. 

Dean  Milman  says  regarding  this 
common  Oriental  belief,  "  The  principle 
of  the  ]:)urity  of  mind  and  malignity  of 
matter  is  the  parent  of  all  that  asceticism 
which  from  earliest  ages  pervaded  the  old 
religions  of  the  East." 

In  Thibet,  in  India,  in  China,  in  Siara, 
and  in  Mahomedan  Asia,  the  Lama,  the 
Faquir,  the  Bonze,  the  Dervish,  are  all 
examjiles. 

These  fanatics  have  withdrawn  from 
the  society  of  man  in  order  to  abstract 
the  pure  mind  from  the  dominion  of 
corrupting  matter. 

Under  each  of  these  systems  the  per- 
fection of  human  nature  was  estrange- 
ment from  the  influence  of  the  senses 
which  were  enslaved  to  the  material 
elements  of  the  world. 

An  approximation  to  the  essence  of  the 
Deity  was  sought  to  be  attained  by  a 
total  secession  from  the  interests,  the 
thoughts,  the  passions,  the  common  being 
and  nature  of  man. 

The  practical  operation  of  this  elemen- 
tary pi'inciple  of  Eastern  religion  has 
deeply  influenced  the  whole  history  of 
man,  but  it  had  made  no  progress  in 
Europe  till  after  the  introduction  of  Chris- 
tianity. 

The  manner  in.  which  it  allied  itself 
with  a  system  to  the  original  nature  and 
design  of  which  it  appears  altogether 
foreign,  forms  an  important  chapter  in  the 
history  of  Christianity. 

The  worship  of  Cybele  was  orgiastic  ; 
there  was  an  inward  frenzy  helped  on 
by  wild  music  and  dancing,  the  sup- 
posed working  of  a  divine  influence 
upon  the  soul.  The  priests  of  Cybele 
were  seen  in  devotees  and  females  of 
excitable  temperament.  ■  The  vulgar 
beheld  them  with  awe,  as  manifestly 
possessed  with  divinity.  The  philosophers 
despised  them  as  impostors. 

Atys,  in  a  paroxysm  of  false  devotion, 
mutilated  himself  to  qualify  for  the  priest- 
hood of  Cybele. 

"  He  pluii<;;ed  into  the  Phryf^ian  forest  dark 
Wherein  the  mijihty  goddess  [Cybele]  dwells, 
And  by  a  zealot  fi'enzy  stung, 
Shore  with  a  Hint  his  sex  away, 
^Vhi(•h  madly  on  the  ground  he  flung." 

His  feelings  when  he  comes  to  the  con- 
sciousness of  his  condition  are  the  subject 
of  the  famous  poem  of  Catullus. 

Origen,  a  father  of  the  Church,  whose 
Christianity  had  a  strong  Oriental  tinge, 
made  himself  an  eunuch  on  the  strength 
of  a  liberal  understanding  of  St.  Matthew 
xix.    12.     Probably,  also,  his  bitter  grief 


Self-mutilation 


[    1148    ] 


Self-mutilation 


and  remorse,  as  recorded  in  his  "  sad  and 
doleful  lamentations  after  his  fall,  in  the 
days  of  Severn?,"  may  have  helped  to 
conduce  to  the  act,  being  betrayed  into 
making  sacrifice  as  the  only  alternative 
left  to  him  of  having  his  hitherto  unde- 
filed  body  polluted  by  miscreants. 

We  have  in  the  monastic  flagellations 
of  the  Christian  Church  instances  of  self- 
torture  as  an  expiation  for  sin. 

Sometimes  self-torture  arose  from  a 
desire  to  conciliate  malignant  powers 
supposed  to  delight  in  the  pain  of  their 
votaries  ;  thus,  the  priests  of  Baal,  who, 
failing  to  bring  fire  from  heaven  by  their 
enchantments,  cut  themselves  with  knives 
and  lancets  until  the  blood  gushed  out 
upon  them  (i  Kings  xviii.  28). 

The  woi'shijjpers  of  Moloch  ("horrid 
king  besmeared  with  blood  ")  made  their 
children  pass  through  the  fire  in  his 
honour.  The  Hindoo  prostrates  himself 
before  the  car  of  Juggernaut. 

Sometimes  the  motive  for  self-torture 
has  been  remorse,  self-hatred;  the  offend- 
ing senses  or  members  must  be  chastened 
for  their  sins. 

The  Gadarene  demoniac  expresses  the 
sense  of  his  misery,  and  the  terrible  bond- 
age under  which  he  had  come,  by  a  blind 
rage  against  himself  as  the  true  author  of 
his  evil,  wounding  and  cutting  himself 
with  stones.  Such  persons  are  described 
in  the  Gospels  as  grievously  possessed  by 
devils  or  evil  spirits. 

Sometimes  the  motive  for  which  self- 
torture  is  undergone  is  simply  to  show 
endurance  of  pain  and  strength  of  will,  as 
by  the  American  Indians,  and  by  Mucins 
Scevola,  in  the  Roman  legend,  Avho  burnt 
his  hand  in  a  brazier  of  live  coals  to  con- 
vince Porsena  that  no  amount  of  pain 
could  subdue  his  spirit. 

Other  motives  conduce  to  self-muti- 
lation. Thus,  the  convict,  if  opportunity 
serves  him,  will  mutilate,  or  even  dis- 
member, himself  to  avoid  the  performance 
of  his  allotted  task,  or  to  excite  sympathy. 
Individual  cases  are  to  be  found  in  our 
criminal  reports. 

In  a  quamt  treatise  on  mutilation  and 
demembration  by  Sir  Alexander  Seton,  a 
Scotch  lawyer  of  the  seventeenth  century, 
he  defines  mutilation  to  be  the  cessation 
and  prevention  of  the  office  and  distinct 
operation  of  a  member,  albeit  no  particle 
of  it  be  cut  off';  and  by  demembration 
he  understands  the  cutting  off'  of  a  mem- 
ber. 

In  speaking  of  castratio  viridimn,  he 
says  it  is  one  of  the  most  atrocious  de- 
membrations,  and  when  a  man  does  it 
himself  he  is  siii  licmiicicla,  and  so  punish- 
able with  death  and  confiscation  of  goods, 


and  its  equivalent  if  one  suffered  himself 
willingly  to  be  castrated  by  another. 

All  the  states  of  mind  leading  to  self- 
mutilation,  self-torture,  &.G.,  hitherto  con- 
sidered, are  compatible  with  reputed  sanity, 
although  they  are  to  insanity  near  akin, 
and  generally  indicate  more  or  less  mental 
derangement. 

Of  actual  insanity  leading  to  self- 
mutilation  Herodotus  records  a  notable 
example  in  the  Spartan  king,  Cleomenes. 
The  Lacedaemonians  had  invited  Cleo- 
menes back  to  Sparta,  offering  him  his 
former  dignity.  After  indulging  in  wild 
and  extravagant  enterprises,  immediately 
on  his  return  he  was  seized  with  madness ; 
he  struck  every  citizen  he  met  in  the  face 
with  his  sceptre.  This  extravagant  be- 
haviour induced  his  friends  to  confine  him 
in  a  pair  of  stocks.  Seeing  himself  on 
some  occasions  left  with  only  one  person 
to  guard  him,  he  demanded  a  sword.  The 
man  at  first  refused  to  obey  him,  but, 
finding  him  persist  in  his  request,  the 
man,  being  a  helot,  gave  him  one.  Cleo- 
menes, as  soon  as  he  received  the  sword, 
began  to  cut  the  flesh  off  his  legs.  He 
ascended  to  his  thighs,  from  his  thighs 
to  his  loins,  till  at  length,  making  gashes 
in  his  belly,  he  died. 

Of  St.  Francis  of  Assisi  it  was  said  that 
he  had  divinely  received  the  stigmata, 
or  marks  of  the  Saviour's  passion,  on 
hands  and  feet.  The  question  has  been 
much  debated  whether  these  marks  were 
self-inflicted  from  fanatical  motives. 

A  similar  imitation  of  the  crucifixion  is 
told  of  certain  French  devotees  of  the  last 
century. 

Orgiastic  paroxysms  of  intense  devotion 
have  at  different  times  found  their  way 
into  Christianity,  and  perverted  its  pure 
and  peaceful  spirit  into  a  visionary  frantic 
enthusiasm,  where  the  mild  and  rational 
faith  has  been  too  calm  for  persons  brood- 
ing over  their  internal  emotions. 

In  the  present  day  it  is  found  that, 
although  instances  of  self-injury  are  not 
unfrequent,  probably  the  intention  of  those 
inflicting  them  is  more  commonly  suicidal 
in  character,  whereas  instances  of  wilful 
self-mutilation  for  its  own  sake  are  much 
more  rare.  -An  investigation  into  the 
various  causes  leading  to  the  act  is  at- 
tended with  so  much  the  greater  interest 
on  that  account. 

The  usual  diiEculty  presents  itself  in 
investigating  the  origin  of  cases  of  this 
kind  that  occurs  in  the  investigation  of 
many  other  forms  of  mental  disease,  or 
perhaps  it  exists  in  even  a  greater  degree, 
owing  to  the  condition  of  mind  to  which 
the  patient  is  frequently  reduced  before 
being   brought  to  an  asylum   after  the 


Self-mutilation 


[    1 149    ] 


Self- mutilation 


injury,  oi*  to  the  difficulty  of  obtaining 
reliable  evidence  as  to  the  mental  condi- 
tion of  the  patient  before,  at  the  time  of, 
and  immediately  subsequent  to  the  intlic- 
tiou  ;  and  we  are  often  battled  by  obstinate 
and  persistent  taciturnity  or  by  stupor, 
the  associate  of  the  melancholic  condition. 

The  task  of  investigation  becomes  easier, 
however,  when  we  find  the  mutilative  act 
the  direct  result  of  hallucination  affect- 
ing the  special  senses,  or  delusion  evi- 
dently conducing  to  it. 

Patients  labouring  under  those  forms 
of  mental  disorder,  being  sometimes  talka- 
tive and  communicative,  will  readily 
admit  that  the  act  has  been  committed 
owing  to  hearing  a  voice  from  heaven 
commanding  them  to  do  it,  or  by  terror  at 
seeing  a  vision,  and  in  the  frenzy  produced 
thereby,  being  impelled  to  self-mutilation 
or  injury.  The  act  may  be  induced  by  fear 
of  loathsome  disease,  produced  by  a  per- 
verted sense  of  smell,  or  of  poison  by  dis- 
eased sense  of  taste. 

The  number  of  j^ublicly  recorded  cases 
of  self-mutilation  is  not  great;  it  there- 
fore becomes  of  the  more  importance  when 
well-authenticated  facts  are  ascertained 
with  regard  to  causation  in  cases  of  the 
kind  that  they  should  be  brought  under 
the  notice  of  the  profession  through  the 
usual  channels. 

Before  proceeding  with  the  narrative  of 
several  cases  which  have  during  recent 
years  come  under  the  notice  of  the  writer, 
reference  may  be  made  to  the  importance 
of  the  subject  iu  its  general  as  well  as  in 
its  medico-legal  aspect,  and  with  this 
object  in  view  also  attention  is  called  to 
two  cases  which  were  published  in  the 
Journal  of  Mental  Science  for  April  1&82. 

In  the  first  of  these,  reported  by  Dr. 
Howden,  of  Montrose,  a  tendency  to  self- 
mutilation  was  shown  to  exist  in  several 
members  of  the  same  family,  and  the 
injury  inflicted  was  similar  in  character 
in  each  member,  although  it  does  not 
appear  that  one  was  even  aware  of  the 
act  which  had  been  perpetrated  by  the 
other  many  years  before.  One  member 
imagined  that  God  had  ordered  her  to 
mutilate  herself,  and  she  accordingly  at- 
tempted to  pull  out  her  tongue,  and,  on 
being  restrained,  she  succeeded  in  biting  a 
large  piece  off.  A  brother  of  the  fore- 
gomg  patient  had  succeeded  in  gouging 
out  one  of  his  eyes.  In  a  subsequent 
attack  the  first-named  patient  believed 
that  God  had  ordered  her  to  burn  herself, 
in  order  to  purify  her  soul,  which  would 
then  appear  in  heaven  of  pure  gold.  She 
subsequently  succeeded  in  injuring  her 
body  internally  and  in  gouging  her  eyes 
oat. 


The  second  case,  that  of  a  farmer  named 
Brooks,  is  of  peculiar  interest  medico- 
legally,  for  this  man,  in  whom  insanity 
does  not  seem  even  to  have  been  sus- 
pected, not  only  inflicted  an  injury  upon 
his  own  person,  but  he  succeeded  in  getting 
a  jury  to  believe  the  false  story  he  told 
with  regard  to  the  manner  of  its  infliction, 
and  was  thus  the  means  of  causing  two 
neighbouring  farmers,  who  were  perfectly 
innocent  of  the  crime  with  which  they 
were  charged  by  Brooks,  to  be  sentenced 
each  to  ten  years'  jDcnal  servitude.  What 
mental  state  he  was  in,  or  what  moral  or 
other  obliquity  existed  in  Brooks  to  ac- 
count for  his  conduct,  is  not  shown  by 
this  account. 

In  connection  with  the  medico-legal 
aspect  of  this  subject,  the  writer  would 
also  briefly  remark  upon  those  curioua 
cases,  sometimes  causing  much  anxiety, 
which  are  occasionally  met  with,  especially 
among  the  more  educated  classes,  where 
circumstantial  statements  are  made  with 
regard  to  supposed  injuries  said  to  be 
self-inflicted,  of  which  there  is  no  evidence. 
A  remarkable,  although  extreme,  instance 
of  this  kind  occurred  many  years  ago  in 
the  case  of  an  eminent  scientific  man  who 
had  been  educated  as  a  surgeon.  This 
gentleman  laboured  under  occasional 
maniacal  attacks,  alternating  with  extreme 
depression.  He  informed  the  writer,  when 
visiting  him  one  morning  in  his  bedroom, 
that,  in  the  course  of  the  preceding  night, 
he  had  dislocated  his  ankle-  and  hip-joint 
on  one  side,  and  broken  both  bones  of  the 
leg  on  the  other.  As  if  this  were  not 
enough,  he  spoke  also  of  a  wound  in  the 
temporal  artery.  He  gave  evidence  of  his 
own  firm  belief  in  the  existence  of  those 
injuries  by  having  carefully  and  accu- 
rately bandaged  all  the  parts  named  for 
them  respectively,  and  for  this  purpose  he 
had  torn  his  sheets  into  bandages,  and  he 
resisted,  with  evident  anxiety,  the  removal 
of  those  bandages,  whereupon  not  the 
smallest  sign  of  any  injury  was  found  to 
exist. 

Cases  in  which  the  mutilative  act  was 
occasioned  by  hallucination. — The  first 
of  these  to  be  narrated  was  that  of 
a  lady,  concerning  whom  the  accounts 
heard  were  of  a  very  alarming  and  un- 
usual character.  They  were  somewhat 
as  follows  :  That  if  she  were  left  alone,  or 
free  from  restraint  for  even  a  single  in- 
stant, some  dire  tragedy  would  certainly 
ensue  ;  that  if  her  hands  were  allowed  to 
be  free  for  one  moment,  she  would  gouge 
out  her  eyes  with  her  fingers,  pull  out  her 
tongue,  or  do  something  else  equally 
dreadful.  She  was  reported  to  have 
occupied  a  "  locked  bed  "  every  night  for 


Self- mutilation 


[     1150    ] 


Self- mutilation 


a  very  lengthened  period,  and  to  have 
seldom  been  without  some  form  of  re- 
straint for  many  days  together.  It  was 
further  reported  concerning  her  that  self- 
injury  was  attempted  in  every  possible 
way  ;  that  she  necessarily  had  an  attend- 
ant to  w^atch  her  at  all  times,  whilst  fre- 
quently and  for  long  periods  she  had 
required  more  than  one. 

She  was  admitted  into  the  Crichton 
Eoyal  Institution  in  October  1875,  and  the 
entries  in  the  case-book  on  December  2, 
1875,  regarding  her  proved  the  correct- 
ness of  the  foregoing  history.  There 
occurs  the  following  entry  in  the  case- 
book : 

This  is  a  very  bad  case,  in  which  little  or 
no  improvement  has  taken  place.  The 
patient  an  hour  and  a  half  after  admis- 
sion gouged  out  her  right  eye,  which  now 
presents  a  horrible  wreck.  She  refuses 
her  food,  and  has  to  be  fed  artificially 
three  times  a  day.  Restraint  is  employed 
to  prevent  her  gouging  out  the  other  eye, 
as  she  is  on  the  qui  rive  to  get  an  oppor- 
tunity of  doing  herself  injury. 

In  1880  this  patient  was  examined  by 
the  writer,  and  the  following  was  her  men- 
tal and  bodily  condition : 

A  greatly  reduced,  exhausted,  and  ema- 
ciated frame,  cachectic  and  hollow  features 
and  worn  facial  appearance  ;  the  right  e3'e 
is  wanting,  the  hair  is  grizzled  and  grey, 
and  there  are  marked  facial  lines  ;  the 
cause  of  the  repeated  mutilative  attempts 
of  which  she  has  been  guilty,  and  to  which 
she  has  still  a  determined  tendency,  is 
hallucination  of  the  senses  both  of  hear- 
ing and  vision,  whilst  the  other  special 
senses  are  markedly  disordered  as  well. 
She  hears  voices  commanding  her  to  do 
the  acts  referred  to  ;  she  sees  her  children 
burning  in  the  tire,  shrieks  willi  terroi-, 
and  tries  to  push  in  her  head  beside  them. 
She  says  she  feels  she  is  not  worthy  to 
live,  because  she  is  so  diseased  and 
wicked  that  she  is  a  burden  to  herself, 
and  she  refuses  her  food  because  it  is 
poisoned. 

Under  careful  nursing  and  nourishing 
with  generous  diet  and  a  moderate  amount 
of  stimulant  she  gradually  improved,  and 
it  became  possible  to  entirely  discontinue 
the  nse  of  restraint,  and  the  last  report  in 
the  case-book  referring  to  the  year  1883 
was  as  follows  : 

From  the  time  of  the  last  entry  to  the 
present  the  improvement  then  reported 
has  been  well  maintained,  and  restraint 
of  any  kind  has  never  again  been  found 
necessary.  Although  still  subject  to  the 
same  hallucinations  and  delusions  they 
are  well  under  control,  and  do  not  influ- 
ence her  conduct  in  the  same  manner  as 


previously.  She  is  never  without  super- 
vision, but  she  is  allowed  a  considerable 
amount  of  liberty  to  admit  of  her  taking 
healthful  exercise.  She  attends  and  enjoys 
the  various  amusements,  and  she  enters 
with  spirit  and  animation  at  times  into 
the  dances,  she  plays  the  piano,  and  alto- 
gether leads  a  life  of  as  much  composure 
and  comfort  as  can  be  expected  in  a  case 
of  the  kind,  in  which  recovery  cannot  be 
hoped  for. 

A  vei'y  marked  case  of  self-injury,  the 
direct  result  of  aural  hallucination,  oc- 
curred in  A.  B.,  a  patient  in  a  metro- 
politan asylum.  This  patient  not  only 
heard  voices  in  the  manner  peculiar  to 
such  cases,  but  he  was  in  the  habit  of 
shouting  at  the  top  of  his  voice  up  to  the 
skies,  and  asking  questions  to  which  he 
professed  to  receive  direct  replies ;  on  one 
occasion,  in  reply  to  a  question  put  in  this 
manner,  he  received  an  order  to  mutilate 
his  throat,  whereupon,  having  obtained 
surreptitious  access  to  the  shoemaker's 
shop,  he  secured  a  knife,  and  carried  out 
the  order  ;  fortunately,  surgical  aid  was  at 
hand,  and  his  life  was  saved. 

Prichard,  in  his  work  on  insanity  (p. 
113),  describes  a  case  in  which  the  patient 
habitually  wounded  his  hands,  wrists,  and 
arms  with  needles  and  pins ;  the  blood 
poured  copiously,  dropi^ing  from  his  elbows 
when  his  arms  were  bare. 

The  following  are  cases  of  sexual  self- 
mutilation  ;  similar  ones  are  given  in 
Kraift-Ebing's  "Psychopathia  Sexualis," 
by  Moll,  and  by  some  of  the  French 
authors,  more  particularly  in  their  syste- 
matic works  on  mental  diseases. 

An  officer  in  the  Indian  service,  who 
had  been  many  years  resident  in  the  East, 
and  had  come  to  acquire  many  Eastern 
languages  and  ways,  m  a  fit  of  religious 
enthusiasm  and  excitement  removed  the 
testes  and  part  of  the  sci'otum.  The  deter- 
mination with  which  he  carried  his  muti- 
lation into  effect  is  shown  by  the  fact 
that,  the  knife  which  he  used  being  a  very 
blunt  one,  the  patient  was  occupied  two 
hours  in  doing  it.  It  subsequently  trans- 
pired that  he  removed  the  testes  under 
the  impression  that  he  must  become  an 
eunuch  to  enable  him  to  preach  to  and 
convert  tribes  in  Northern  India.  He  said 
that  he  would  do  the  same  again  ;  that  he 
wasquite  justified  in  doing  it.  He  evidently 
gloried  in  the  idea  and  spoke  openly  on 
the  subject.     He  died  insane  recently. 

The  following  case  of  sexual  self-muti- 
lation was  admitted  into  the  Southern 
Counties  Asylum  in  1S83  :  W.  B., 
eighteen  years  of  age,  a  tall  and  hand- 
some farm  servant,  single,  by  religious 
persuasion  a  Presbyterian.     He  has, had 


Self-mutilation 


[     "51     ] 


Self-mutilation 


no  previous  attacks  of  mental  disease ;  he 
has  been  foui-  days  insane ;  the  cause  of 
his  insanity  is  not  known  ;  he  is  stated  to 
be  neither  epileptic  nor  suicidal,  but 
dangerous  to  others.  No  member  of  the 
family  is  known  to  have  been  insane.  The 
facts  indicating  insanity  as  given  in  the 
medical  certiticate  for  admission  are : 
Violent  in  his  conduct  at  times,  has  fixed 
delusions,  prays  that  he  may  be  delivered 
from  his  enemies,  states  that  his  medical 
attendant  is  in  league  with  others  in 
plotting  against  him.  His  mother  states 
that  he  believes  himself  to  be  the  "  Apostle 
Paul,"  and  that  he  is  being  persecuted  ; 
he  i-efases  food  from  her,  saying  that  she 
wants  to  drug  him,  and  deliver  him  to  his 
enemies. 

The  following  particulars  were  ascer- 
tained with  regard  to  the  seriously  muti- 
lated condition  in  which  he  was  found  on 
admission  : 

On  March  6,  1883,  whilst  employed  as 
a  farm  servant,  he  told  his  fellow-ser- 
vants, who  were  then  at  dinner,  that  he 
was  going  home  to  his  father's  house 
about  two  miles  oiF,  but  it  appeal's  that 
instead  of  doing  so,  when  alone  in  a  field 
a  short  distance  off,  he,  with  a  sharp  pen- 
knife, completely  and  cleanly  removed  the 
whole  of  the  penis.  The  haemorrhage 
ensuing  from  the  wound  was  very  great, 
and  feeling  alarmed  about  it,  he  went  to 
some  running  water  near  at  hand,  and 
bathed  the  wound  ;  the  water  being  very 
cold  at  the  time,  it  seems  to  have  assisted 
in  arresting  the  haemorrhage. 

The  lad's  master  soon  after  found  him 
lying  in  a  field  ivith  marks  of  blood  about 
him,  and  had  him  conveyed  home.  On 
his  medical  attendant  visiting  him  he 
found  him  quite  rational  at  the  time,  but 
he  seemed  much  dejected,  and  expressed 
his  regret  several  times  to  his  mother  and 
medical  attendant  for  what  he  had  done. 
The  haemorrhage  had  ceased,  there  had 
been  oozing  from  the  cut  surface,  but  the 
lad's  mother  had  applied  cobwebs,  which 
caused  a  clot  to  form  and  this  had  arrested 
the  oozing. 

When  questioned,  he  admitted  that  he 
had  masturbated,  and  when  asked  why  he 
had  so  mutilated  himself  he  said  that  he 
considered  he  was  only  doing  his  duty, 
and  following  out  the  spirit  of  Scriptural 
injunction  :  "If  thy  right  hand  offend 
thee  cut  it  off.''  He  had  been  reading 
some  quack  publications  on  nervous  de- 
bility, and  also  Salvation  Army  publica- 
tions, which  roused  within  him  strong 
convictions  of  his  wickedness,  and  an 
impulse  came  upon  him  that  he  ought  to 
do  something.  So  he  got  his  Bible,  and 
happening  to  open  it  at  Leviticus  he  be- 


lieved it  to  be  his  duty  to  do  what  he  did, 
but  he  remarked  if  he  had  opened  his 
Bible  at  any  other  place  he  would  not  have 
done  so. 

For  some  time  after  admission  there 
was  much  taciturnity,  depression,  and 
stupor,  with  absolute  refusal  of  food,  and 
he  had  to  be  fed  with  the  stomach  pump. 
He  also  tore  the  surgical  dressing  from 
his  wound,  and  had  to  be  constantly 
watched  to  prevent  this.  This  condition 
was  followed  by  excitement,  an  exalted, 
and  religiously  exhilarated  frame  of  mind, 
during  which  he  sang  and  repeated  psalms 
and  hymns  by  night  and  day.  This  was 
succeeded  by  a  gradual  return  to  his 
normal  mental  condition,  in  which  he  now 
i-emains,  the  wound  having  healed  by 
granulation  over  its  entire  surface, 

The  following  is  a  case  possessing 
interest  from  the  fact  that  self-mutilation 
and  attempted  self-mutilation  were  always 
sought  to  be  effected  by  the  same  agent, 
namely,  "  fire,"  although,  unfortunately, 
from  the  extreme  taciturnity  which  charac- 
terised the  case,  the  reason,  first,  why 
self-mutilation  was  so  persistently  at- 
tempted at  all,  and,  secondly,  why  the  par- 
ticular agent  employed  was  "  fire,"  could 
not  be  ascertained. 

The  lady  in  question  was  a  patient  in 
West  Mailing  Place,  Kent.  Two  and  a 
half  years  previously  to  her  admission 
there, and  whilst  in  an  acutely  melancholic 
state,  she  thrust  her  right  hand  into  the 
fire,  and  it  became  necessary  to  amputate 
some  portion  of  it,  the  hand  remaining 
permanently  contracted  and  disfigured. 

Throughout  the  year  1882  she  made  re- 
peated attempts  to  do  the  same,  un- 
deterred by  her  previous  experience  of 
pain  and  sufiering.  She  also  tried  to  set 
tire  to  herself  with  a  candle  and  to  get 
possession  of  matches. 

The  patient  died  in  the  year  1887  of 
well-marked  organic  brain  disease.  She 
had  pin  point  pupils  followed  by  con- 
tinuous convulsions  and  paralysis. 

In  going  round  the  wards  of  almost  any 
asylum  for  the  insane  cases  are  continu- 
ally encountered  of  what  may  be  described 
as  minor  self-mutilations.  A  patient  is 
met  with  here  and  there  who  inflicts  severe 
punishment  upon  his  own  head  or  body 
with  his  clenched  fists,  causing  extensive 
ecchymosis  or  even  wounding.  Anothei*, 
again,  in  a  maniacal  or  excited  state,  will 
cause  self-injury  or  laceration  by  dashing 
himself  against  walls,  or  by  throwing  him- 
self upon  the  ground.  Some  of  these 
injuries  are  undoubtedly  self-inflicted  for 
supposed  sin  or  other  cause,  but  a  large 
proportion  of  the  minor  mutilations,  such 
as  biting  the  nails  into  the  quick,  picking 


Senile  Dementia 


[     1 152    ]  Sex,  Influence  of,  in  Insanity 


the  skin  of  the  face,  or  head,  or  hands, 
arms  or  body,  with  finger-nails,  needles, 
pins,  glass,  etc.,  into  sores  more  or  less 
extensive,  are  self-intlicted  by  patients  in 
a  state  of  dementia  who  do  not  reflect  or 
reason  upon  what  they  are  doing,  and  the 
mischievous  propensities  probably  arise 
simply  from  nervous,  fidgety,  restless 
habits,  generating  a  desire  to  be  doing 
something,  or  possibly  in  some  cases 
originating  in  an  irritable  state  of  the 
skin.  James  Adam. 

SEIO^XIfZ:  SEiyiENTXA,  SEM^IIiE  ZW- 
S.a.N'XTV.SHIfXI.ZTV. — Mental  maladies 
of,  and  the  mental  weakness  from,  old  age, 
commencing  at  various  ages  in  different 
persons.     {See  Dementia  ;  Old  Age.) 

SEIfSATXOM'.  —  Psychologically  con- 
sidered, sensations  are  merely  modes  of  our 
being  affected  mentally  through  our  sense 
organs;  these  sensations  are  built  up  by 
synthetic  and  other  processes  into  pre- 
sentations of  sense,  and  we  then  perceive 
"  things"  as  having  qualities  revealed  by 
our  mental  states.     {See  Philosophy    of 

Ml>'D.) 

SEN'S  ATI  ONS,   SUBJECTIVE.    {See 

Hallucinations.) 

SENSE. — The  faculty  by  which  im- 
pressions are  received  so  as  to  affect  the 
mind.  The  senses  usually  enumerated 
are  sight,  hearing,  touch,  smell,  and  taste, 
but  to  these  a  sixth  must  be  added, 
namely,  muscular  sense. 

SENSES,     DISORDERS      OF.       {See 

Hallucinations;  Illusions;  Smell,  Hal- 
lucinations OE.) 

SENSIBIIiITY.  —  The  power  living 
parts  possess  of  receiving  conscious  im- 
pressions from  external  objects.  It  is 
termed  "  organic  "  when  impressions  are 
unconsciously  received. 

SENSITIVE, — Capable  of  receiving 
conscious  impressions.  It  is  also  used  to 
express  the  state  of  mind  of  any  one 
easily  or  deeply  affected,  by  impressions  so 
slight  as  to  be  out  of  proportion  to  the 
effect  produced. 

SENSXTORIVm,  SENSORIVM 
CommuNE.  —  The  seat  of  sensation 
in  the  brain.  {See  Brain,  Physiology 
of.) 

SENS  US  COMIVIUNIS,  —  Literally, 
"  common  feeling."  It  is  the  tone  of  con- 
sciousness at  any  moment,  and  is  made 
up  of  the  general  result  of  mingling  of 
nervous  impulses  of  indefinite  origin  and. 
great  variety  from  all  parts  of  the  body 
pouring  into  the  central  nervous  system. 
Among  the  stimuli  are  the  changes  in  the 
blood  and  blood-vessels,  the  presence  of 
extractives,  &c.,  in  the  blood,  the  move- 
ments of  the  various  bodily  organs,  &c. 
The  characteristic  of  the  sensus  communis 


is  the  entire  absence  of  localisation  of  the 
feelings  composing  it. 

SENTIMENTAIi  TEMPERAMENT, 

— Lotze's  alternative  name  for  the  melan- 
cholic temperament.  {See  Temperaments.) 
SENTIMENTS.  {See  Feelings.) 
SERICUIVIi — The  Arabian  physicians 
prescribed  sericum  for  a  bad  memory,  and 
as  a  general  nervine  tonic  and  cordial. 
Avicenna  in  this  agreed  with  Serapion, 
and  gave  it  with  musk.  It  formed  an 
ingredient  in  the  electuary  of  Mesne 
(Syrian),  which  was  administered  as  a 
remedy  in  insanity.  A  London  physician, 
the  author  of  "  A  Discourse  on  the  Nature, 
Cause,  and  Cure  of  Melancholy  and 
Vapours,''  published  in  the  early  part  of 
the  eighteenth  century,  recommended  it, 
among  other  restoratives,  in  melancholia, 
"  toasted."  Passing  from  its  internal 
administration,  Moses  Charras  ("  Royal 
Pharmacopoeia")  lauds  its  fragrance  and 
its  beautiful  texture  as  affecting  the  senses. 
A  special  influence  has  been  attributed  to 
it  in  this  connection,  and  is  by  Grant 
Allen  accounted  for,  psychologically,  by 
the  soft  and  voluminous  character  of  the 
material.  An  old  French  author  (anony- 
mous) writes  of  "  ce  tissu  charmant  qui 
inspiroit  aux  dieux  un  amour  eperdu,  et  aax 
hommes  la  furenr  et  la  rage  des  plaisirs 
effrenes,"  and  which  in  the  form  of  "  la 
ceinture  de  la  merede  I'amour,"  possessed 
"  la  vertu  des  philtres."  AEoll  has  recently 
referred  toits  aphrodisiac  properties;  meta- 
phorically, Shakespeare  ("  2  Hen.  V.") 
does  the  same. 

Recognising  a  subtle  sensuousness 
in  the  material,  the  Roman  Senate,  in 
the  i-eign  of  Tiberius,  enacted,  "  Ne  vestis 
serica  vii-os  foedaret"  (Tacit.  "Ann."  ii.  23  ; 
Dion.  Cass.  Ivii.  1 5  ;  Suidas  v.  TitepMs). 
Stringent  measures  were  taken  in  subse- 
quent reigns  against  its  use.  Christian 
writers  denounced  it  —  e.g.,  Clemens 
Alexand.  (''P£edag."ii.  10),  Tertullian  ("  De 
Pallio  ").  The  virtuous  wife,  according  to 
Plutarch,  ought  not  to  wear  it  ("  Conj. 
PrjBC."  vol.  vi.  550,  ed.  Reiske).  See  refer- 
ences to  sericum,  including  the  Goa 
Vestis,  in  TibuUus,  Horace,  Ovid,  &c. 
The  psychology  of  clothes  receives  curious 
illustrations  from  this  study,  and  is  a 
deeper  subject  than  appears  at  first  sight. 
The  psychical  relations  between  sensory 
impressions  and  particular  textures  are 
not  unimportant  in  mental  affections, 
and  deserve  more  study  than  they  have 
received. 

SEX,  INFIiUENCE  OF,  IN  IN- 
SANITY.— Areta3us,  the  Greek  physician 
of  the  first  century,  and  Coelius  Aurelianus, 
a  writer  of  uncertain  age  and  country, 
taught   that   men   are    moi-e    subject    to 


Sex,  Influence  of,  in  Insanity  [     1 153    ]  Sex,  Influence  of,  in  Insanity 


insanity  than  women.  Esquirol,  who 
appears  to  have  been  the  first  who  aii- 
plieii  statistics  to  the  matter,  showed 
elaborately  that  more  women  arc  insane 
than  men,  the  proportion  beiutr  thirty- 
eight  women  to  thirty-seven  men.*  Geor- 
get,  Haslani,  and  others  confirmed  this 
conclnsiou.  Burrows,  even  before  Esqairol, 
had  said  that  more  women  were  insane 
than  men  in  large  towns,  but  that  it  was 
not  so  in  the  country.  Parchappe  made 
an  important  steji  in  advance  by  pointing 
out  that  in  order  to  form  an  accurate 
estimate  of  the  sexual  incidence  of  insanity 
we  must  consider  the  admissions  to  asy- 
lums,and  not  theactual  number  of  inmates, 
the  latter  being  aftected  by  the  varying  rates 
of  mortality  and  recovery  in  the  two  sexes. 
He  considered  the  admissions  to  various 
large  asylums  (Bethlem,  Bicotre,  Sal- 
petriere,  Charenton,  Turin,  &c.),  and  found 
that,  with  the  very  marked  exception  of 
Bicetre  and  Salpetriere,  the  admissions  of 
men  exceeded  those  of  women.  He  con- 
cluded that  the  solution  of  the  question 
was  still  doubtful.f  A  few  years  later 
Thurnam  made  a  more  accurate  and  deci- 
sive investigation  than  any  that  had  gone 
before.^  He  showed  that  the  probability 
of  recovery  is  greater  in  women  than  in 
men,  the  recoveries  of  women  exceeding 
those  of  men  by  from  4  to  28  per  cent. 
He  showed  also  that  there  is  a  still  greater 
difference  in  the  rate  of  mortality,  the 
mortality  of  men  being  50  and  sometimes 
nearly  90  per  cent,  greater  than  that  of 
women — i.e.,  nearly  double.  In  1844,  in 
England  and  Wales,  there  were  9053  male 
inmates  of  asylums  to  9701  females,  the 
admissions  of  women  in  London  greatly 
predominatmg  over  those  of  men,  in  com- 
parison with  the  country.  In  24  asylums 
out  of  32  (including  a  total  of  71,800  ad- 
missions), Thurnam  found  a  decided  ex- 
cess of  men  among  admissions,  the  aver- 
age excess  being  13.7  per  cent.  In  a  very 
large  number  of  British  asylums  (includ- 
ing 67,876  admissions)  there  were  about 
36  men  to  32  women.  In  France  more 
women  become  insane  relatively  to  men 
than  in  England.  Thurnam  also  observed 
that  a  larger  proportion  of  women  become 
insane  relatively  to  men  among  the  lower 
classes  than  among  the  higher.  He  con- 
cluded that  "in  nearly  all  points  of  view 
women  have  an  advantage  over  men  in 
reference  to  insanity ;  for  not  only  do  they 
appear  to  be  less  liable  than  men  to  men- 
tal derangement,  but,  when  the  subjects 

»  "  Maladies  mentales,"  1838. 

t  "  Keclierches  statistiques  sur  les  Causes  de 
I'Alidnation  mentale."    Kouen,  1839. 

t  "  Observations  and  Essays  on  the  Statistics  of 
Insanity."   London,  1845. 


of  it,  the  probability  of  their  recovery  is 
on  the  whole  greater,  and  that  of  death 
considerably  less.  On  the  other  hand,  the 
probability  of  a  relapse,  or  of  a  recurrence 
of  the  disorder,  is  somewhat  greater  in 
women  than  in  men."  Dr.  Jarvis,  a  few 
years  later,  after  examining  the  statistics 
of  asylums  in  Great  Britain,  Ireland, 
France,  Belgium,  and  America,  came  to 
the  similar  conclusion  that  "  males  are 
somewhat  more  liable  to  insanity  than 
females."* 

If  we  look  to  the  gross  number  of  luna- 
tics in  the  various  countries  of  Europe,  we 
shall  find  on  the  whole  that  throughout 
the  century,  as  Esquirol  showed,  the 
women  are  more  numerous  than  the  men. 
There  are,  however,  notable  exceptions  ; 
according  to  Haushofer,  male  lunatics  are 
more  numerous  in  Germany,  Denmark, 
Norway,  and  Russia.  In  Italy  in  1888 
there  were  11,895  ™ale  lunatics  to  10,529 
female,  being  a  proportionately  greater 
increase  among  the  men  than  among  the 
women,  but  to  a  very  slight  extent. 

A  relatively  greater  increase  of  male 
lunatics  does  not,  however,  seem  to  be  the 
rule  in  Europe,  and  for  this  country  at 
least  Thurnam's  results  can  no  longer  be 
accepted.  In  Bethlem  from  1786  to  1794 
there  were  4992  men  to  48S2  women 
admitted,  a  very  obvious  excess  of  men. 
At  the  middle  of  the  present  century 
Thurnam  found  it  necessary  to  examine  the 
proportion  of  admissions  in  order  to  show 
the  excess  of  males.  In  the  early  days  of  the 
Lunacy  Commission  (i.e.,  thirty  years  ago) 
the  rate  of  increase  of  insanity  to  popula- 
tion was  greater  among  males  than  among 
females  (as  Mr.  Noel  Humphreys  has 
pointed  out)  ;  in  recent  years  the  rate  of 
increase  among  females  has  slightly  ex- 
ceeded that  among  males.  At  the  present 
time  not  only  is  the  female  population  of 
our  asylums  in  excess  of  the  male,  but  the 
admissions  of  women  are  in  excess  of  the 
admissions  of  men.  Durmg  the  ten  years 
1878-87,  the  total  number  of  admissions  of 
women  to  the  public  and  private  asylums  of 
England  and  Wales  was  69,560,  as  against 
66,918  men  ;  this  shows  an  increase  of 
women,  producing  equality  of  the  sexes.  If 
we  turn  to  the  report  of  the  lunacy  com- 
missioners of  England  and  Wales  for  1890 
we  find  a  larger  proportion  of  female  ad- 
missions. During  that  year  8466  women 
were  admitted  to  the  county  and  borough 
asylijms  to  7690  men;  in  the  registered 
hospitals  and  licensed  houses  the  excess  of 
women  was  equally  well  marked,  and  the 
grand  total  of  admissions  for  1890  was 
10,025  women  as  against  9109  men.  Some 

*  "  On  the  Comparative  Liability  oT  ^falcs  and 
Fem^cs  to  Insanity.'     1850. 


Sex,  Influence  of,  in  Insanity  l     i  154    ]  Sex,  Influence  of,  in  Insanity 


deduction  must  be  made  when  we  take 
into  consideration  the  slight  excess  of 
women  in  the  general  population,  and  the 
greater  frequency  of  recurrence  of  insanity 
in  wotnen.but,  even  with  these  deductions, 
there  is  no  doubt  that  the  incidence  of 
insanity  in  this  country  is  now  greater  on 
women  than  on  men. 

In  the  United  States  of  America  and 
in  the  English  colonies  (as  in  foreign 
countries  generally)  there  is  an  excess  of 
male  lunatics.  The  statistics  for  the  United 
States  are  still  very  imperfect,  but  in 
Pennsylvania,  where  they  receive  most 
attention,  the  excess  is  very  clear;  thus, 
during  18S9,  an  average  year,  there  were 
1017  admissions  of  men  to  836  of  women. 
In  New  South  Wales  the  number  of 
insane  persons  on  the  official  registers  at 
the  end  of  the  year  1890  was  1966  men 
and  1 196  women.  At  the  Cape,  at  the 
same  time,  the  European  and  coloui'ed 
inmates  of  the  asylums  numbered  335 
men  and  240  women,  the  excess  of  men 
being  nearly  as  well  marked  among  the 
white  as  among  the  black  population. 

While  there  is  some  variation  in  differ- 
ent countries  as  to  the  proportion  of  male 
and  female  lunatics,  nearly  everywhere 
there  are  more  male  than  female  idiots. 
The  statistics  are  not  altogether  reliable, 
but  there  seems  to  be  no  doubt  as  to  this 
general  result.  Thus,  in  France,  in 
1866,  while  there  were  24,190  male 
lunatics  and  26,536  female,  there  were 
22,736  male  idiots  to  17,217  female 
idiots.  The  admissions  of  idiots  to  asy- 
lums recorded  by  the  Lunacy  Com- 
missioners were,  during  1890,  165  males 
to  71  females;  and  the  total  number  of 
persons  in  establishments  for  idiots  was 
955  males  to  478  females.  The  number 
of  admissions  here  shows  a  ratio  very 
closely  approximating  to  that  stated  some 
years  ago  by  Langdon  Down  as  that  in 
which  the  sexes  are  affected — e.g. ,2.1  to  0.9. 
Microcephales  are  said  to  be  more  com- 
monly male  than  female.  Cretinism  also, 
unlike  goitre,  is  more  common  in  males 
in  the  proportion  (according  to  Lunier, 
writing  in  Jaccoud's  "  Dictionnaire ")  of 
5  to  4,  varying,  however,  according  to 
region. 

If  we  turn  to  the  causes  of  insanity, 
we  find  that  the  most  frequent  causes, 
according   to    French   statistics,    fell  as 

under : 

Men.  IFomeii, 


Alcoholic  excess. 

Venereal  excess. 

Loss  of  fortune. 

Lovi!  and  jealous}'. 

Destitution  and  misery. 

Pride. 

Violent  emotions. 


Love  and  jealous}', 
Kelig-ion. 

Destitution  and  misery. 
Loss  of  fortune. 
Violent  emotions. 
Loss  of  a  loved  person. 
Venereal  excess. 


^^('n.  Women, 

Deceived  ambition.  Pride. 

Religion.  Alcoholic  excess. 

Loss  of  a  loved  person.  Deceived  ambition. 

According  to  another  classification  of 
French  statistics,  the  results  are  some- 
what similar,  except  that  loss  of  fortune, 
destitution,'.and  misery,  being  combined  as 
pecuniary  causes,  come  at  the  head  of  the 
list  on  the  women's  side,  and  before  love 
on  the  men's. 

During  the  ten  years  1878-87,  136,478 
persons  (66,918  men  and  69,560  women) 
were  admitted  into  all  classes  of  asylums 
in  England  and  Wales.  If  we  consider 
the  causes  of  their  insanity,  the  propor- 
tion per  cent,  to  total  number  admitted 
during  the  ten  years  was  as  follows  : 


Alcoliolic  intemperance  .     . 

Various  bodily  diseases  and 
disorders 

Domestic  troubles  (including 
loss  of  relations  and  friends) 

Adverse  circumstances  (in- 
cluding' business  anxie- 
ties, and  pecuniary  diffi- 
culties)       

Parturition  and  the  puer- 
peral state      

Mental  anxiety,  "  worry," 
and  overwork      .... 

Accident  or  injury 

Religious  excitement . 

Love  affairs  (including^  se- 
duction)     

Frig'lit  and  nervous  shock     . 

Sexual  intemperance  . 

Venereal  disease     .... 

Self-abuse  (sexual)      .     .     . 

Over-exertion 

Sunstroke 

Pregnancy    

Lactation 

Uterine  and  ovarian  dis- 
orders   

Puberty 

Change  of  life 

Fevers 

Privation  and  starvation 

Old  age    

Other  ascertained  causes  ex- 
isted in 

And  the  causes  were  un- 
known in 

There  had  been  previous  at- 
tacks in 

Hereditary  influence  was  as- 
certained in 

Congenital  defect  was  ascer- 
tained in 


M. 


F. 


19.8 

7.2 

II. I 

lO-S 

4.2 

9-7 

8.2 

3-7 

- 

6.7 

6.6 

2-5 

5-5 
1.0 
2.9 

0.7 
0.9 

I.O 

2-5 

1-9 
0.6 

0.8 

0.2 

2.1 

0.2 

0.7 
2.3 

0.4 
0.2 
1.0 



2.2 

0.2 

2-3 

0.6 



4.0 

0.7 

1-7 
3-8 

0-5 
2.1 

4.6 

2-3 

1.0 

21.3 

20.1 

14-3 

18.9 

19.0 

22.1 

51 

3-5 

On  the  whole  it  may  be  said  that  causes 
acting  on  the  brain  are  more  common  in. 
men ;  moral  and  emotional  causes  are  more 
common  in  women :  excesses,  both  intel- 


Sex,  Influence  of,  in  Insanity  [     1 1 55    ]  Sex,  Influence  of,  in  Insanity 


lectual  and  sensual,  are  more  common 
causes  iu  men. 

If  we  turn  to  the  consideration  of  the 
prevalence  of  special  forms  of  insanity  iu 
the  sexes,  the  subject  becomes  somewhat 
more  complex,  but  certain  conclusions 
seem  to  be  fairly  clear.  States  of  exalta- 
tion, speakiug  generally,  belong  to  eai'ly 
age ;  "  mental  exaltation,"  as  Clouston 
remarks,  '*  is  perfectly  natural  iu  child- 
hood. It  is,  in  fact,  the  physiological 
state  of  brain  at  that  period."  States  of 
depression  belong  to  a  somewhat  more 
advanced  age.  Mania,  in  both  men  and 
women,  is  more  common  than  melan- 
cholia. Both  mania  and  melancholia  seem 
to  be  more  common  on  the  whole  in  women 
than  in  men,  but  the  prei^onderance  of 
female  over  male  melaucholiacs  is  much 
more  marked  than  in  the  case  of  the 
maniacal.  Progressive  insanity  with  sys- 
tematised  delusions  (del ire  des  persectt- 
tions)  is  much  more  common  iu  women  ; 
thus.  Gamier  finds  it  in  2.16  per  cent,  of 
male  lunatics,  in  8.64  per  cent,  of  female 
lunatics.  It  is  worthy  of  note  that  while 
melancholia  (as  well  as  folic  du  doute  in 
the  widest  sense)  is  commoner  in  women, 
hypochondria  is  unquestionably  much 
commoner  in  men ;  thus,  Michea  found 
sixty  male  hypochondriacs  to  twenty-one 
female. 

Garnier  ("  La  Folie  a  Paris,"  1890)  gives 
the  following  results  of  his  experience  at 
the  Paris  Prefecture  de  Police  as  to  the 
relative  frequence  of  various  types  of  in- 
sanity in  men  and  women  during  the 
years  1886-88.  He  adopts  Magnan's 
classification,  and  is  dealing  with  8139 
persons  (4831  men  and  3308  women)  ; 
they  are  here  averaged  in  the  order  of 
frequency  for  both  sexes  combined. 


M. 

V. 

Alcoholism  (acute,  sub-acute, 
chrome) 

Mental  degeneration  (idiocy, 
imbecility,  psychic  debility, 
hereditary  dej^eneration)    . 

General  jiaralysis     .... 

Intellectual  ent'eeblement  (due 
to  hxmorrhagc,  softening', 
or  tumour) 

Melancholia 

Mania  and  maniacal  excite- 
ment        

Kpilepsy 

Senile  dementia 

,  Chronic  monomania  (progres- 
sive sy.stematic  psychosis)  . 

1813 

821 
711 

548 
179 

210 

294 
150 

105 

37.6 

644 
288 

438 
509 

321 
169 
287 

276 

Thus  the  order  of  frequency  in  men  is  : 
alcoholism,  mental  degeneration,  general 
paralysis,  intellectual  eufeeblement,  epi- 


lepsy, mania,  melancholia,  senile  de- 
mentia, chronic  insanity.  In  women  it 
is  :  mental  degeneration,  melancholia,  in- 
tellectual alcoholism,  mania,  general  para- 
lysis, senile  dementia,  chronic  insanity, 
epilepsy.  On  the  whole  these  results 
seem  to  correspond  with  those  usually 
found  in  large  urban  populations. 

AVhile  most  forms  of  mental  disorder 
are  fairly  stationary  as  to  their  relative 
frequency  in  the  sexes,  there  are  two  ex- 
ceptions :  alcoholic  insanity  and  general 
paralysis  have  a  tendency  to  progress,  to 
change  their  relative  positions  in  the 
sexes,  and  also  to  some  extent  to  vary  in 
various  countries.  While  alcoholic  in- 
sanity always  stands  at  the  head  of  the 
list  so  far  as  men  are  concerned,  its  exact 
percentage  among  men  varies  considerably 
in  dili'erent  countries,  as  does  also  its  re- 
lative frequency  among  women.  In 
England  there  is,  comparatively,  a  small 
difference  between  men  and  women,  as 
may  be  seen  from  the  table  of  causes 
already  given  ;  and  in  both  sexes  alco- 
holism may  be  said  to  be  the  most  fre- 
quent cause  of  insanity.  The  figures 
given  by  Be  van  Lewis  correspond  very 
closely  with  this  general  table :  of  464 
subjects  of  alcoholic  insanity  studied  by 
him,  344  were  men  and  120  women.  In 
Paris  (according  to  Garnier's  recent 
statistics)  alcoholic  insanity  is,  as  we  have 
seen,  extremely  common  among  men  but 
comparatively  rare  in  women,  while  in 
both  it  is  increasing.  Taking  the  two  sexes 
together,  alcoholic  insanity  in  Paris  has 
doubled  in  fifteen  years,  but  amongwomen, 
taken  separately,  it  has  more  than  doubled ; 
so  that  while  alcoholism  in  men  is  increas- 
ing at  a  tremendous  rate,  the  difference 
between  the  sexes  is  decreasing.  It  is 
worthy  of  note — and  the  fact  has  as  yet 
scarcely  attracted  sufficient  attention — 
that  while  in  men  alcohol  tends  to  affect 
the  brain,  in  women  it  tends  to  affect  the 
cord  and  nerves.  Rayer,  among  170  cases 
of  delirium  tremens,  found  only  7  women  f 
Bang,  at  Copenhagen, found  only  i  woman 
to  455  men;  Hoegh-Gueldberg,  i  woman 
to  172  men  ;  Clifford  Allbutt  in  1882  said 
that  he  had  never  seen  delirium  tremens 
in  a  woman,  while  he  regarded  spinal 
symptoms  in  women  as  common  and 
specifically  alcoholic  ;  and  Broadbent  at  a 
meeting  of  the  British  Medical  Associa- 
tion spoke  to  the  same  effect.  Lancereaux, 
who  has  given  special  attention  to  this 
matter,  states  that  alcoholic  muscular 
paralysis  is  found  in  only  3  men  to  12 
women.  Ball  finds  that  sexual  excite- 
ment is  a  more  frequent  complication  of 
dipsomania  in  women  than  iu  men. 

General  paralysis,  which  by  its  aetiology 

4  E 


Sexual  Insanity 


[    1156    ] 


Sexual  Perversion 


to  some  extent  as  well  as  by  the  character 
of  its  symptoms  is  related  to  alcoholism, 
resembles  it  also  by  its  frequency  and  rate 
of  progression  in  the  sexes.  Its  increase 
among  both  men  and  women  in  England 
has  been  noted  by  Savage  and  many 
others.  Tn  Germany  the  growing  propor- 
tion of  women  among  general  paralytics 
has  been  noted  by  Mendel,  Sander,  and 
others ;  the  proportion  was  formerly 
I  woman  to  5  men ;  it  is  now  i  to  3. 
Siemerling,  who  does  not  consider  that 
the  statistics  of  the  Charite,  in  Berlin, 
show  any  real  increase  of  general  para- 
lysis in  women,  admits  it  for  men  ;  he 
finds  a  sexual  difference  in  the  symptoms, 
which  are  on  the  whole  quicker  in  women, 
with  a  tendency  to  delusions  often  of  a 
sexual  character.  In  France  the  increase 
of  general  paralysis  in  both  sexes  is  well 
marked.  Garnier  finds  that  in  Paris  it 
has  nearly  doubled  in  men  during  fifteen 
years,  and  in  women  considerably  more 
than  doubled  during  the  same  period  ;  so 
that  there  is  i  woman  to  2^  men.  This 
onalaclie  du  siecle,  as  it  has  been  called,  is 
the  disease  of  great  urban  centres  ;  it  is 
largely  the  result  of  nervous  over-strain 
in  efforts  for  which  the  organism  is  not 
naturally  adapted  or  sufficiently  equipped, 
and  it  is  not  difficult  to  account  for  its 
growing  fi^equency  among  women  who 
are  thrown  into  the  competitive  struggle 
for  existence.  A  detailed  consideration  of 
the  sexual  incidence  of  nervous  diseases 
cannot  be  entered  into  here.  It  may  be 
said  genei'ally  that  gross  lesions  of  the 
nervous  system  are  more  common  in  men, 
and  so-called  "  functional "  disorders  more 
common  in  women.  {See  Statistics  of 
Insanity.)  Havelock  Ellis. 

[Reference. — For  some  details  under  this  head, 
see  H.  Campbell's  Difleroiices  in  the  Nervous  Or- 
ganisation of  Men  and  ^Vonien.    i8gi.] 

SEXU.A.I.  XN'SiVN'ZTY.  {See  EROTO- 
MANIA.) Includes  satyriasis  and  n3'^mpho- 
mania. 

SEXUAI.        PERVERSION-.     —    The 

term  "  perverse  sexual  feeling  "  {eontrdre 
Sexualempfindung)  was  first  used  by 
Westphal  (in  Archivf.  Psych.)  to  express 
a  condition  which  had  already  received 
attention  from  Casper  and  others,  and 
which  is  described  as  consisting  of  an 
innate  perversion  or  "  inversion  "  of  the 
sexual  feelings  with  consciousness  of  its 
morbid  nature.  It  is  maintained  that  in 
this  condition  a  passion  for  the  sex  to 
which  the  sufferer  belongs,  instead  of  the 
normal  inclination  to  the  opposite  sex, 
exists  ;  and  that  this  is  a  state  which  is 
innate — i.e.,  appears  as  early  as  the  dawn 
of  sexual  feelings,  and  remains  constant  ; 
is  in  fact,  qtul  the  individual,  a  physio- 


logical state.  The  evidence  to  prove  this 
view,  which  seems  at  a  first  glance  so 
untenable,  is  derived  in  part  from  the 
statements  of  persons  who  have  exhibited 
the  symptoms  of  sexual  perversion.  These 
unhappy  creatures,  for  whom  the  term 
"Urnings"*  was  invented  by  a  certain  Ger- 
man lawyer  who  wrote  on  the  subject  from 
personal  experience,  claim  that  a  large 
number  of  the  human  race  are  born  with 
this  abnormal  appetite,  and  that  they 
have  the  power  throughout  life  of  recog- 
nising each  other  when  they  meet.  Now  it 
is  to  be  observed  that  the  reminiscences  and 
confessions  of  persons  exhibiting  sexual 
disturbance  of  any  kind  are  notoriously 
untrustworthy.  Any  man  who  gives  way 
to  sexual  depravity  in  whatever  form  at 
the  period  of  jDuberty,  and  continues  to 
indulge  in  it,  will  be  disposed  to  feel  that 
he  had  been  led  by  a  natural  tendency. 
And  yet  how  many  cases  of  sexual  depra- 
vity of  various  sorts  occur  in  boyhood  and 
are  followed  by  the  development  of  the 
ordinary  sexual  passion.  A  more  solid 
argument  is  derived  from  the  fact  that 
such  persons  often  spring  from  neurotic 
families — are  themselves  neurasthenic,  and 
frequently  exhibit  temporary  or  perma- 
nent conditions  of  degenerative  mental 
disturbance.  It  is  also  noted  that  the 
sexual  passion  appears  at  an  abnormally 
early  age  in  such  cases.  But  all  this  is 
capable  of  another  interpretation  which 
appears  to  us  to  be,  at  least  in  the  majo- 
rity of  cases,  the  true  one.  In  a  neurotic, 
delicate,  or  ill  brought  up  child,  the  sexual 
passion  appears  early.  The  sexual  passion 
at  its  first  appearance  is  always  indefinite, 
and  is  very  easily  turned  in  a  wrong  direc- 
tion. This  occurs  in  ordinary  cases  of 
masturbation.  As  in  masturbation,  so  in 
other  forms  of  sexual  depravity,  the  vice 
is  more  apt  to  become  permanent  if  it 
begins  early  before  the  higher  faculties 
have  developed,  and  once  the  vicious 
habit  of  mind  is  definitely  organised,  devel- 
opment of  appetite  along  the  normal  lines 
may  fail  to  take  place.  Some  such  expla- 
nation as  this  seems  more  rational  than 
the  belief  that  an  individual  is  born  with 
the  anatomical  characteristics  of  one  sex 
and  the  mental  characteristics  of  another. 
Besides,  it  brings  these  cases  into  line 
with  that  form  of  sexual  aberration  with 
which  we  are  most  familiar,  self -abuse. 
This  view  is  also  borne  out  by  the  fact 
that  these  cases  are  almost  always  com- 

*  The  word  ''  Urning- "  has  no  deriv:ition. 
Ulrich,  who  was  the  Bavarian  jurist  referred  to, 
wrote  several  extraordinary  pamphlets  claiming 
for  people  of  this  liind  the  legal  right  of  marriage 
with  persons  of  the  same  ses.  The  term  lias  eome 
into  general  use  in  Germany. — [Kd.] 


Shock 


[    1157    J 


Shock  from  Fright 


plicated  with  it.  Out  of  seveuteen  cases 
of  so-called  congenital  sexual  perversion 
described  by  Ivrafi't-Ebing,  in  the  third 
edition  of  his  book  on  "  Sexual  Psycho- 
pathy/' in  three  or  four  at  most  the  con- 
dition did  not  seem  to  have  ori<,nnated  in 
masturbation  in  early  life,  and  many  of 
the  histories  are  simply  accounts  of  the 
depraved  habits  unfortunately  common  in 
boyhood  carried  on  into  adult  life. 

Akin  to  sexual  perversion,  in  the  limited 
sense  of  the  word,  are  many  other  aberra- 
tions of  the  venereal  appetite,  all  of  which 
are  probably  to  be  regarded  as  essentially 
of  the  same  nature  and  having  a  similar 
origin.  In  these,  apparently  through 
some  accidental  mental  association  formed 
in  early  life,  some  object  not  directly  con- 
nected with  the  performance  of  the  sexual 
functions  calls  up  sexual  feelings  and 
desires.  Such  cases  in  their  disgusting 
details  seem  hardly  worthy  of  the  minute 
study  that  has  been  given  to  them.  For 
the  purpose  of  the  physician  it  seems 
sufficient  to  look  uj^on  them  as  varie- 
ties of  masturbation.  One  class,  perhaps, 
deserves  special  note  through  its  possible 
importance  from  a  medico-legal  point  of 
view.  In  this  form  sexual  excitement  is 
combined  with  bloodthirsty  tendencies  to 
mutilation,  or  even  murder,  or  to  both. 
It  would  seem  that  in  some  cases  the 
murderous  tendency  appears  as  the 
equivalent  and  representative  of  sexual 
passion.  Some  shocking  crimes  certainly 
seem  to  have  been  due  to  this  association, 
but  here,  as  in  the  previously  considered 
cases,  we  must  not  hastily  assume  that  a 
highly  abnormal  development  of  the  gene- 
rative feelings  necessarily  implies  congen- 
ital perversion.  Those  who  wish  to  follow 
up  the  subject  of  sexual  aberration  in 
its  less  usual  forms  will  find  detailed  in- 
formation in  the  works  of  Casper,  West- 
phal,  KrafFt-Ebing,  Tarnowsky,  Lombroso, 
Charcot,  Moll,  and  others. 

CONOLLY    NORMAX. 

SHOCK. — The  sudden  depression  of 
organic,  vital,  and  nervous  power  pro- 
duced by  injury  either  to  mind  or  body. 

SHOCK    FROM    FRIGHT. —  It    has 

long  been  recognised  that  fright  may  be  a 
cause  of  serious  disturbance  of  health,  and 
the  phenomena  of  shock  induced  by  it, 
like  as  they  are  in  all  respects  to  those 
which  ensue  upon  severe  physical  injury, 
give  evidence  of  a  grave  effect  upon 
the  nervous  system.  Isolated  cases  are 
to  be  found  recorded  in  the  literature 
of  a  former  time  which  show  that  these 
facts  have  been  always  acknowledged,  but 
lai'ger  attention  has  been  paid  to  the  sub- 
ject in  the  present,  both  because  of  the 
widened    study  of  nervous  diseases,  and 


because  of  the  comparative  frequency  with 
which  such  results  are  now  to  be  seen.  It 
is  not  proposed  in  this  article  to  write  a 
description  of  the  symptoms  of  shock,  for 
every  text-book  of  surgery  has  an  ade- 
quate account  of  them,  and  the  monograph 
of  Grooningen  contains  all  that  there  is 
to  be  said  upon  the  subject.  Rather  shall 
a  short  account  be  given  of  the  results, 
both  early  and  remote,  of  shock  to  the 
nervous  system  induced  by  fright,  dealing 
more  especially  with  those  symptoms 
which  are  indicative  of  mental  or  cerebral 
disturbance.  The  siege  of  Strasbourg 
and  the  siege  of  Paris  during  the  last 
Franco-German  war  were  both  productive 
of  many  examples  of  grave  nervous  dis- 
order, even  ending  fatally,  which  clearly 
had  their  origin  in  the  terrible  circum- 
stances to  which  the  sufferers  had  been 
exposed — to  wit,  the  constant  bursting  of 
shells,  the  ever-present  sense  of  danger, 
the  anxiety  as  to  the  safety  of  friends,  the 
inadequacy  of  the  food  supply.  Happily 
in  this  country  we  have  been  spared  such 
experiences,  but  like  sources  of  neurotic 
disturbance  are  to  be  found  very  often  in 
the  events  of  an  ordinary  railway  collision, 
where  we  have  in  combination  everything 
which  is  likely  to  induce  great  terror — 
magnitude  and  violence  of  the  forces,  loud 
noise,  shrieks  of  the  injured,  and  utter 
helplessness  of  individual  jjassengers.  It 
is  not,  therefore,  a  matter  of  any  surprise 
to  learn  that  the  aftei'-effects  of  a  railway 
collision  may  be  very  serious  even  when 
no  bodily  injury  has  been  inflicted.  Of 
the  jjhysical  injuries  sustained  in  railway 
accidents  this  only  need  be  said,  that  at 
no  period  do  they  differ  from  the  same 
injuries  sustained  in  other  ways,  and  the 
symptoms  of  shock  which  accompany  and 
follow  them  are  likewise  of  the  same  kind 
as  are  ordinarily  seen.  There  is,  however, 
the  added  element  of  fright,  which  is 
prone  to  make  the  symptoms  of  shock  of 
somewhat  longer  duration  than  usual, 
although  there  is  this  compensating  ad- 
vantage, that  the  infliction  of  some 
definite  bodily  injury — of  a  broken  leg,  for 
example — is  frequently  antagonistic  to  the 
protraction  of  the  after-symptoms  of 
nervous  disturbance  such  as  have  had 
their  chief  origin  in  fright  alone.  In 
other  words,  it  is  often  to  a  man's  advan- 
tage, as  far  as  the  mental  consequences 
are  concerned,  that  he  should  have  re- 
ceived some  definite  local  injury,  for  expe- 
rience on  this  point  is  perfectly  clear  that 
he  is  thereby  rendered  less  liable  to  suffer 
from  prolonged  neurotic  disturbance.  And 
the  reason  for  this  is  to  be  found  in  the  fact 
that  the  bodily  injury  more  or  less  satis- 
fies the  requirements  of  the  patient  him- 


Shock  from  Fright  [     1158    ]  Shock  from  Fright 


self  in  seeking  an  explanation,  consciously 
and  unconsciously,  of  the  symptoms  which 
were  present  after  the  accident,  and  the 
natural  tendency  each  day  towards  re- 
covery from  the  physical  injury  ^Ji'ovides 
that  element  of  hope  which  is  so  often 
wanting  when  the  cause  of  the  symptoms 
is  entire!}^  hidden  and  obscure. 

Collapse  from  fright  (and  it  is  of  that 
alone  we  have  to  speak  here)  is  met  with 
in  various  degrees  of  severity  after  rail- 
way collisions,  and  we  may  leave  the  cases 
out  of  account  in  which  there  has  been 
some  physical  injury  inevitably  associated 
with  and  giving  rise  to  shock.     The  times 
of  onset  also  differ  widely  ;  there  may  be 
immediate  collapse,  or  collapse  of  which 
the  symptoms  are  delayed,  for  the  simple 
reason   that   they  have  been  warded  off 
by  the  excitement  of  the  scene — warded 
off,   yet    not   prevented,  nay,  rather  in- 
creased by  the  delay,  for  the  excitement 
is  itself  a  cause  of  nervous  prostration, 
which  in  its  turn  may  make  the  symptoms 
not  perhaps  more  pronounced  in  them- 
selves, but  more  persistent  and  less  prone 
to  pass  quickly  away.     Thus  it  is  by  no 
means   uncommon   for   a   man  who   has 
merely  felt  a  little  dazed  and  sick  at  the 
time  of  the  accident  to  break  down  com- 
pletely after  he  reaches  home,  and  then  to 
present   the    symptoms  of  ordinary  col- 
lapse.    And  from  this  period  may  date 
the  beginning  of  more  obvious  cerebral 
and  mental   disturbance.      Soon,  or  not 
until  after  the  lapse  of  a  few  days,  during 
which  the  scene  of  the  accident  may  have 
been  terribly  present  to  him,  both  in  sleep 
and  when  awake,  repeating,    as  it  were, 
the  terror  which  originally  harmed  him, 
he  has  an  attack  of  acute  uncontrollable 
hysterical  crying.     Attacks  of  this  kind 
are   likely  to  recur,  and  in  the  intervals 
there  is  prone  to  be  developed  a  sense  of 
extreme  despondency,  which  is  maintained 
and  increased  by  advancing  bodily  weak- 
ness.    For,  as  a  consequence  of  the  acci- 
dent, whether,  as  some  have   suggested, 
because   of  molecular  disturbance  of  the 
cerebro-spinal  centres  by  the  physical  vio- 
lence of  the  collision,    or    because   of   a 
purely   dynamical  nervous   derangement, 
the  accompaniment  of  fright  alone,  very 
considerable  digestive  disorder  is  liable  to 
ensue.     From  this  cause,  and  from  a  more 
direct  deprivation  in  all  probability  of  the 
normal  stimulus  of  healthy  nervous  tone, 
the   muscular   system   wastes,  and  there 
is  inability   both  to   take   and   to   digest 
food.      Extreme   bodily  weakness    is  the 
result,    and    this    general    condition    of 
feebleness  and  prostration,  to  which  nowa- 
days the  term  neurasthenia  is  often  ap- 
plied,  cannot   act   otherwise   than   inju- 


riously upon  those  parts  of  the  sensorium 
which  have  to  do  with  moral  control,  and 
both  the  hysterical  attacks  and  the  ac- 
companying despondency  are  prone  to  be 
increased  thereby.  A  vicious  circle  has 
obviously  been  established,  and  it  is  no 
ground  for  surprise  that,  as  an  occasional 
outcome  of  these  combined  conditions,  the 
despondency  should  deepen  into  real  me- 
lancholia, that  there  should  be  hallucina- 
tions at  night,  or  that  suicidal  tendency 
should  be  displayed.  There  is  no  ques- 
tion, however,  that  such  results  are  very 
rare  in  this  country,  although  apparently 
common  elsewhere.  Furthermore,  it  may 
be  said  of  these  mental  disturbances  that 
the  time  of  their  continuance  or  disap- 
pearance depends  very  much  upon  the 
state  of  the  bodily  health,  and  that  the 
secret  of  treatment  is  to  improve  the 
general  nutrition.  Do  this,  and  the  men- 
tal disorder  may  in  the  vast  majority  of 
cases  be  left  to  take  care  of  itself. 

There  are  yet  other  manifestations  of 
cerebral  disturbance  resulting  from  the 
terror  which  is  incidental  to  railway  col- 
lisions. Reference  has  already  been  made 
to  the  dazed  sensation  which  a  man  may 
experience  at  the  time  of  the  accident. 
It  may  sometimes  present  more  definite 
and  more  serious  characters.  There  may 
be  complete  and  sudden  unconsciousness 
without  any  blow  upon  the  head,  or  a  con- 
dition of  almost  complete  unconsciousness 
may  supervene  some  hours  after  the  acci- 
dent. In  the  state  of  immediate  uncon- 
sciousness there  is  usually  entire  help- 
lessness, and  the  person  is  carried  from 
the  scene,  and  has  no  subsequent  recollec- 
tion of  what  he  has  gone  through  or  where 
he  has  been.  This  state  of  unconscious- 
ness as  to  the  events  of  the  moment  is  not, 
however,  in  all  instances  associated  with 
the  helplessness  of  coma.  In  a  state 
which  seems  in  itself  to  indicate  complete 
annihilation  of  the  higher  faculties  of  the 
sensorium,  a  man  may  nevertheless  be 
able  to  perform  acts  which  are  apparently 
under  perfect  cerebral  volition  and  control. 
He  may  take  himself  home,  but  have  no 
subsequent  recollection  of  how  he  got 
there ;  or  in  his  unconsciousness  of  what 
really  occurred  he  may  give  a  totally 
erroneous  account  both  of  what  happened 
to  himself  at  the  time  of  the  accident  and 
how  he  conducted  himself  afterwards. 
Cases  of  this  kind  have  been  recorded  by 
Thorburn,  Charcot,  and  others,  and  the 
view  is  now  very  commonly  held  that  the 
dazed  condition  which  has  been  described 
is  very  closely  allied  to,  if  it  be  not  indeed 
identical  with,  the  state  induced  in  pur- 
posive experimental  hypnosis.  The  obser- 
vation of  several  remarkable  cases  after 


Shock  from  Fright 


[     1159    ] 


Shock  from  Fright 


a  railway  collision  ten  years  and  more 
ago  led  the  writer  to  suggest  that 
many  of  the  phenomena  displayed 
were  akin  to  those  of  the  hypnotic 
condition,  and  this  view  has  received 
support  from  many  quarters  by  many 
observers.  To  Charcot,  it  may  be  said, 
and  to  his  disciples,  more  perhaps  than 
to  any  others,  it  is  that  we  owe  a  know- 
ledge of  the  fact  that  the  phenomena  of 
hypnotism  are  jiractically  identical  with 
the  phenomena  of  the  state  which  has 
been  here  spoken  of  as  not  uncommon 
after  railway  accidents  where  fright  acts 
as  an  all-powerful  cause  of  ill.  It  has 
been  shown  by  Charcot,  as  every  student 
of  his  works  knows,  that  in  this  condition 
of  hyi)nosis,  during  which  it  may  be 
assumed  that  the  higher  cerebral  regions 
and  their  combinations  are  in  a  state  of 
torpor  or  temjjorary  inactivity,  by  the 
force  of  "  suggestion "  the  hypnotiser 
may  induce  and  at  his  will  maintain 
various  abnormal  conditions  in  the  hyp- 
notised person,  such  as  hemi-anffisthesia, 
for  example,  contortions  or  pareses,  and 
spastic  rigidity  of  the  trunk  and  limbs. 
And  recognising  the  fact  that  accidents 
accompanied  with  much  terror  are  prone 
to  be  followed  by  what  he  and  others 
of  his  school  call  "  hysterical "  disturb- 
ance of  the  nervous  system,  such  as  the 
various  ana3sthesia3  of  non-anatomical 
distribution,  the  monoplegias  and  kindred 
paralytic  disorders  without  gross  struc- 
tural underlying  lesion,  and  recognising 
also  at  the  same  time  the  hypnotic  condi- 
tion as  being  caused  by  fright,  Charcot 
has  formulated  the  theory  that,  in  the  state 
of  hypnosis  so  induced,  a  local  injury  to  a 
limb,  for  examj^le,  may  act  in  much  the 
same  way  as  the  suggestion  of  the  hyp- 
notiser. In  other  words,  the  abnormal 
sensations  of  pain,  heaviness,  and  numb- 
ness, with  stiffness  and  weakness,  which 
are  the  result  of  a  blow  may  suggest  to 
the  hypnotised  the  fixed  idea  of  jjalsy  of 
the  affected  part,  and  "  traumatic  sug- 
gestion" comes  thereby,  in  his  view,  to 
play  a  large  part  in  the  production  of 
like  symptoms.  The  works  of  Charcot 
himself,  of  Guinon,  and  others  contain 
numerous  examples  of  such  cases,  and, 
although  seemingly  not  with  the  same 
frequency  as  in  France,  they  are  met  with 
in  this  country.  Cases  showing  almost 
every  conceivable,  or  described,  variety  of 
such  neuroses  have  fallen  under  the  notice 
of  the  writer :  in  some  the  hypnotic  con- 
dition has  been  extreme  directly  after 
the  accident,  and  has  been  accompanied 
by  some  special  anajsthetic  disturbance ; 
in  others  the  state  akin  to  hypnosis  has 
been  of  later  development,  and  the  special 


symptoms  have  been  likewise  delayed.  In 
his  judgment  and  experience,  this  se- 
quence of  events  is  due  to  the  fact  that 
lapse  of  time  and  enfeeblement  of  the 
general  nutrition  during  it  are  necessary 
to  prepare  the  nervous  system  for  the  pos- 
sible i-eprosentation  of  such  phenomena. 
It  is  not  every  one  who  can  be  purposely 
hypnotised,  as  it  is  not  every  one  who  is 
dazed  or  rendered  unconscious  by  the  sud- 
den terror  of  a  railway  collision,  but  it  is 
conceivable  that  the  nervous  system  may 
be  reduced  to  the  condition  in  which  such  a 
thing  is  possible  by  the  long  continuance 
and  injurious  agency  of  that  vicious  circle 
which  has  been  already  named.  Suffice 
it  here  to  say  that,  whatever  view  may  be 
taken  of  theorigin  of  these  symptoms,  there 
will  be  no  dispute  that  the  condition  of 
hypnosis  itself  and  the  possibility  of  it, 
together  with  the  special  symptoms  which 
are  prone  to  accompany  or  follow  it,  are 
alike  manifestations  of  cerebral  and  mental 
disorder,  the  result,  in  the  particular  in- 
stances considered  here,  of  fright,  direct 
or  indirect.  By  the  French  school  they 
are  looked  upon  as  largely  "  hysterical," 
but  some  injustice  has  been  done  to 
Charcot  and  his  followers  in  atti'ibuting 
to  them  the  view  that  these  cases  are 
hysterical,  and  hysterical  only,  using  the 
word  as  of  no  more  import  than  is  ordi- 
narily meant  by  it  in  the  case  of  trivial 
derangements  which  have  no  such  deep 
foundation  in  serious  cerebral  disorder. 

Passing  in  the  next  place  to  disturb- 
ances of  a  more  obviously  psychical  char- 
acter, it  is  to  Oppenheim  and  other 
German  authors  to  whom  the  reader  must 
turn  for  detailed  information.  In  his 
masterly  work  on  the  •'  Traumatic  Neu- 
roses "  this  author  has  brought  together 
a  series  of  cases  obviously  very  like  those 
which  are  met  with  in  this  country  and 
in  France,  but  in  which,  as  the  result  of 
causes  similar  to  those  with  which  we  are 
familiar  here,  thei'e  ensue  the  symptoms 
of  much  more  definite  psychical  disturb- 
ance. Thus,  we  find  a  description  of  cases 
in  which  despondency  and  irritability  are 
prominent,  deepening  sometimes  into  hy- 
pochondriasis, accompanied  by  hallucina- 
tions, and  going  on  to  distinct  dementia, 
weakness  of  memory,  and  even  delusional 
insanity.  He  describes  in  full  detail  the 
various  accompanying  bodily  disorders, 
the  muscular  weakness,  the  altered  gait,^ 
the  feeble  speech,  the  pareses,  the  loss  of 
sexual  desire,  the  disturbances  of  the 
special  senses,  of  the  pulse  and  circula- 
tion. With  all  such  things  we  are  per- 
fectly familiar  here,  and  they  have  been 
fully  described  by  the  writer  in  another 
place,  but  it  is  certain  that  we  do  not 


Shock  from  Fright         [     1160    ] 


Sibyls 


meet  anything  like  so  often  in  this  country 
with  examples  of  the  mental  disorders  such 
as  have  been  described  by  Opjienheim. 
There  must  be  some  reason  for  this,  to  be 
found  either  in  racial  peculiarities  and 
habits,  or  in  the  fact  that  Oppenheim's 
description  is  drawn  almost  entirely  from 
the  cases  of  patients  in  hospital.  It 
is  not  inconceivable  that  the  daily  re- 
cord and  observation  of  symptoms  and 
signs  of  disease  in  a  hospital  ward  may 
have  a  good  deal  to  do  with  the  intensity 
and  perpetuation  of  complaints  of  which 
much  less  might  be  thought  in  other 
circumstances.  Oppenheim's  own  cases 
must  be  studied,  and  no  one  will  deny 
that,  as  they  are  presented,  he  has  weighty 
grounds  for  holding  that  it  is  neither  in 
the  narrow  domain  of  traumatic  hysteria, 
nor  in  that  of  traumatic  neurasthenia, 
that  they  are  to  be  placed,  but  that  they 
fall  into  a  special  class  of  their  own,  of 
the  traumatic  neuroses  or  the  traumatic 
neuro-psychoses.  "Traumatic  hysteria," 
"traumatic  neurasthenia,"  "traumatic 
neuroses" — these  three  terms  cover  the 
different  varieties  of  symptoms  which  are 
met  with  as  the  result  of  railway  shock 
or  of  other  accident  where  there  is  cause 
for  terror,  and,  if  it  is  under  these  three 
heads  that  the  chief  descriptions  of  them 
are  to  be  found,  there  is,  it  is  believed,  no 
very  wide  difference  of  opinion  about  them 
nor  any  which  is  not  perfectly  explicable. 
The  views,  at  any  rate,  which  have  been  ex- 
pressed here  as  to  the  prevalence  of  mental 
disorders  after  severe  shock  from  fright 
are  based  on  no  inconsiderable  experience, 
and  support  to  them  is  to  be  found  in  the 
experience  of  asylum  physicians  through- 
out the  country.  And  unquestionably 
the  prognosis  is  distinctly  more  favour- 
able here  than  the  record  of  Oppenheim's 
cases  leads  one  to  conclude.  The  lines  of 
treatment  may  be  sufficiently  indicated  in 
a  very  few  words.  Rest  and  the  avoidance 
of  work,  both  bodily  and  mental,  until 
the  general  nutrition  has  been  restored ; 
absolute  quietude  at  first  and  freedom 
from  all  mental  anxiety  afterwards  ;  above 
all,  the  avoidance  of  litigation  and  the 
early  and  amicable  settlement  of  the  claim 
for  compensation  on  account  of  the  in- 
juries sustained.       Heebeet  W.  Page. 

IReferences. —  Groeningen,  Ueber  den  i^lKjck, 
Wiesbaden,  1885.  Charcot,  Let-tiiros  on  Diseases  of 
the  Nervous  System,  vol.  iii.,  1889,  Xcw  Sydenham 
Soc.  Trans.  Guinon,  Los  AL;ents-provocateurs  de 
I'Hysterie,  Paris,  1889.  Thorlnirn,  A  Contribution 
to  the  Surgery  of  the  Spinal  Cord,  London,  1889. 
Page,  Injuries  of  the  Spine  and  Spinal  Cord,  2nd 
edit.,  1885  ;  Itailway  Injuries,  1891.  Berbez,  Hy- 
st^rie  et.Traumatisme,  These  de  Paris,  1887. 
Vibert,  Etude  m&lieo-legal  sur  les  Aeeidtuts  de 
Cheniiu-de-fer,  Paris,  1888.     Strlimpel,  Ueber  die 


tniumatischen  Neurosen,  Berliner  Klinik,  1888, 
Heft  3.  Oppenheim,  Die  traumatischen  Xeurosen, 
Berlin,  1889.] 

SZAliORRHCEA.     {See  Salivation.) 

SZBYI.S,  THE  {Zeis,  the  ^tolic  form 
of  gen.  being  ^lov,  of  Jove  ;  ^ov\tj,  counsel). 
The  psychologist  cannot  obtain  a  better 
idea  of  what  a  sibyl  must  have  been  when 
in  her  ecstatic  state  than  by  studying 
Virgil's  description  of  the  Cumean  Sibyl 
when  ^neas  saw  her  and  was  told  that  it 
was  a  fit  time  to  consult  the  destinies. 
"  While  saying  these  words  her  counten- 
ance, her  colour,  are  not  the  same ;  her 
hair  uncut,  not  smooth  ;  but  her  breast 
heaves,  and  her  fierce  heart  swells  with 
fury ;  she  appears  larger,  and  speaks  not 
with  mortal  voice,  since  she  is  inspired  by 
the  now  nearer  influence  of  the  divinity." 
Her  excitement  is  then  described  as  out- 
rageous, and  it  is  only  when  her  fierce 
heart  is  somewhat  curbed  that  she  is  fit 
for  her  office.  We  are  told  that  she  chants 
terrific  mysteries,  involving  truths  in 
obscurities,  and  bellows  in  her  cave. 

It  was  the  same  sibyl  who,  about 
550  B.C.,  presented  herself  so  mysteriously 
to  Tarquin,  and  made  him  an  offer  of  nine 
prophetic  books,  which  he  refused,  but 
was  glad  at  last  to  secure  three  after  six 
had  been  burnt. 

As  is  well  known,  the  Christian  Fathers 
accepted  and  applied  the  sibylline  prophe- 
cies to  the  advent  of  Christ.  Lactantius 
says,  "  We  shall  speak  of  '  the  sibyls ' 
without  any  distinction  whenever  we  shall 
have  occasion  to  use  their  testimony " 
(vol.  i.  p.  17).  The  Eev.  M.  Dods,  21. A. 
(the  editor  of  Justin  Martyr's  Works), 
observes,  "  The  sibylline  oracles  are  now 
genei'ally  regarded  as  heathen  fragments 
largely  interpolated  by  unscrupulous  men 
dunng  the  early  ages  of  the  Church." 

If  any  one  visiting  the  churches  in  Italy 
has  felt  surprised  at  the  frequency  with 
which  the  painter's  brush  has  been  em- 
ployed to  depict  the  sibyls,  his  surprise 
will  be  removed  when  he  studies  the  pat- 
ristic writings,  and  finds  how  largely  their 
authors  appealed  to  the  authority  of  the 
sibylline  leaves. 

"  The  painters,  like  the  poets,  have  al- 
ways depicted  the  sibyls  as  women 
agitated  by  the  convulsions  which  pos- 
sessed the  ancient  priestesses.  Raphael, 
however,  has  given  to  his  sibyls  a  calm 
air,  an  attitude  full  of  serenity,  and  quite 
in  harmony  with  the  nature  of  their 
oracles,  since  they  were  to  foretell  the 
coming  of  Christ  ("Les  Galeries  pub- 
liques  de  I'Europe,"  Rome,  p.  395). 

The  consideration  of  the  character  of 
the  sibyls  leads  us  on  to  that  of  the 
whole  system  of  oracular  utterances  which 


Sicchasia 


[     1161     ]      Simulation  of  Hysteria 


played  so  large  a  part  in  the  history  of 
the  aucieuts.  What  is  true  of  the  former 
is  also  true  of  the  priestesses  of  every 
shrine.  If  it  be  asked  whether  there  are 
no  phenomena  familiar  to  ourselves  which 
closely  resemble  those  described  in  the 
classic  descriptions  of  the  oracles  and 
seeresses  of  antiquity,  the  auswer  is  that 
there  certainly  are.  Take  certain  accounts 
of  modei'n  spiritualistic  seances. 

We  are  informed  by  a  writer  in  a  re- 
cent journal  that  he  does  not  believe  in 
what  is  called  "  s|)iritualism,"  and  he  pro- 
ceeds to  give  a  narration  of  a  visit  he  paid 
to  a  medium.  This  modern  seeress  de- 
scribed the  appearance,  the  age,  the  time 
of  death,  and  the  general  characteristics 
of  the  friend  of  his  youth — a  young  man 
who  died  when  about  thirty  years  of  age. 
Like  the  ancient  pythoness,  she  had  in  the 
first  instance  "  convulsive  spasms,"  and 
then  passed  into  a  trance.  In  some  other 
descriptions  of  the  same  class  of  cases  the 
contortions  of  the  limbs  and  the  facial 
spasms  are  of  a  much  more  pronounced 
character.  In  short,  attacks  of  hystero- 
epilepsy  are  induced,  and  in  some  instances 
tliey  resemble  the  striking  figures  de- 
picted by  Paul  Richter  in  his  well-known 
work.  The  study  of  these  and  similar 
modern  phenomena  is  essential  to  the 
psychologist  who  wishes  to  understand 
the  character  of  the  sibyls  and  the  hea- 
then oracles  in  general.  To  this  end  the 
writings  of  Cicero  will  be  found  invalu- 
able.* {See  also  Plato's  "  Phaadrus ''  in 
which  Socrates  discourses  on  the  sub- 
ject.) The  Editor. 

SICCHASIA  {(TLKxaivui,  I  feel  a  loath- 
ing for).  Loathing  or  disgust  for  food,  as 
in  pregnancy,  melancholia,  &c.  (Fr.  sie- 
chdsie;  Ger.  El-el.) 

SICX-CIDDIM-ESS.  —  Seizures  com- 
pared by  Marshall  Hall  to  the  effects  of 
a  swing  on  the  susceptible  medulla  oblon- 
gata, and  i-egarded  by  him  as  intimately  re- 
lated both  to  sick  headache  and  to  epilepsy. 

SIBERATION  {sidus,  a  stat).  This 
term  was  used  by  the  ancients  in  two 
senses :  applied  to  the  apoplexy  and 
paralysis  supposed  to  be  j^roducer.  by  the 
influence  of  the  stars,  and  also  to  erysipe- 

*  "  What  authority  has  this  same  ecstasy,  which 
you  choose  to  call  diviue,  that  enables  the  laadman 
to  foresee  thinj^s  inscrutable  to  the  sage,  anil  which 
invests  with  divine  senses  a  man  who  has  lost  all 
his  human  ones  ?  We  Romans  preserve  with  soli- 
citude the  verses  which  the  sibyl  is  reported  to  have 
uttered  when  in  an  ecstasy, — the  interpreter  of 
which  is  by  common  report  Ijelieved  to  have  re- 
cently uttered  certain  falsities  in  the  senate"  ("De 
divinutione,"  ch.  54).  Cicero  himself  doubted 
whether  the  sibylline  oracles  were  delivered  in  a 
state  of  ecstasy,  on  account  of  their  being  "  far  less 
reniarkal)le  for  enthusiasm  and  inspiration  than 
for  technicality  and  labour." 


las  of  the  face  and  head  under  the  idea 
of  its  being  due  to  the  influence  of  the 
planets. 

SIMPXiX:       V/LANZA.         {See,    ManIA, 
SlMl'LE.) 

SIIVIPI.Z:     iviz:i.ANCHOi.iA.      {See 
Melancholia,  Simi'le.) 

SUVZUXiATIOM*  or  HYSTERIA  by 
ORGANIC  DISEASE  of  TTERVOTIS 
SYSTEIVI. — In  hysteria  there  is  probably 
a  disturbed  or  cougenitally  defective  con- 
dition of  the  cerebral  substance,  involving 
in  all  cases  the  highest  nervous  centres, 
and  in  various  examples  extending  more 
or  less  to  those  which  preside  over  auto- 
matic processes.  Partial  or  complete 
suspension  of  inhibitory  influence  would 
appear  to  be  the  most  prominent  result  of 
the  pathological  condition,  whatever  it  be, 
and  this  is  recognised  as  well  in  regard  to 
the  mental  as  to  the  more  evidently 
physical  processes  belonging  to  cerebral 
function.  The  departures  from  normal 
functioning  of  various  organs  which  occur 
are  apt  to  simulate  those  commonly  aris- 
ing from  definite  alterations  of  structure, 
but  differ  from  the  latter  in  the  fact  that 
they  may  often,  even  when  at  their  worst, 
be  removed  instantaneously,  usually  under 
the  influence  of  strong  emotion.  It  would 
seem  that  the  paralysis  which  is  apt  to 
occur  as  a  symptom  of  hysteria  signifies 
that  the  power  of  the  highest  centres  in 
liberating  movement  is  in  abeyance.  A 
loss  of  power  in  a  limb  is  diagnosed  as  of 
hysterical  origin  when  examination  ap- 
pears to  show  the  absence  of  such  altera- 
tion of  structure  as  would  explain  its 
occurrence  coupled  with  the  fact  of  its 
association  with  emotional  symptoms  of 
various  kinds,  and  with  a  history  of  other 
occurrences  to  which  the  term  hysterical 
is  usually  applied. 

The  grounds  upon  which  any  particular 
condition  can  safely  be  relegated  to  hys- 
teria are  therefore  manifestly  insecure. 
Emotional  disturbance  is  a  frequent  and 
obviously  probable  result  of  organic  dis- 
ease of  the  nervous  system,  and  the  value 
of  certain  physical  symptoms  accompany- 
ing emotional  conditions,  as  tending  to 
support  a  diagnosis  of  hysteria,  will  de- 
pend upon  the  amount  of  accuracy  with 
which  these  can  be  determined  to  be 
independent  of  structural  change. 

There  is  a  form  of  paraplegia  which  is 
easily  supposed  to  be  of  emotional  origin, 
and  the  occurrence  of  which,  therefore, 
along  with  symptoms  of  emotional  dis- 
turbance is,  the  writer  thinks,  continually 
leading  to  an  erroneous  diagnosis  of  hys- 
teria in  young  women.  The  patient's 
gait  is  observed  to  become  gradually  awk- 
ward.    She  walks  in  an  ungainly  fashion 


Simulation  of  Hysteria    [     1162    ]     Simulation  of  Hysteria 


having  lost  the  natui'al  springiness  of  step. 
As  along  with  this  it  is  seen  that  she 
apparently  dances  as  well  as  ever,  and 
that  the  muscles  of  her  lower  extremities 
are  well  developed,  and  the  general  health 
good,  the  contradiction  is  commonly  quite 
enough  to  suggest  that  the  girl  is  hysteri- 
cal, and  that  she  must  be  treated  accord- 
ingly. It  is  found  that  in  going  upstairs 
she  drags  herself  up  by  clinging  strongly 
to  the  banisters,  appearing  unable  to  lift 
the  foot  up,  in  order  to  plant  it  on  the 
stair  above.  She  is  sharply  admonished, 
and  breaks  down  in  tears.  The  examina- 
tion of  a  number  of  such  cases  has  shown 
us  that  there  is  a  form  of  muscular 
atrophy,  sometimes  of  congenital  origin, 
which  commences  in  the  ilio-psoas  muscle, 
and  may  for  a  more  or  less  lengthy  period 
be  confined  to  that  region.  Hence  the 
limitation  of  loss  of  power  to  the  move- 
ment of  fiexion  of  the  thigh  upon  the  trunk. 
In  the  act  of  dancing  this  is  required  only 
to  a  small  extent,  whilst  it  is  most  neces- 
sary in  going  upstairs  or  in  stepping  upon 
a  chair  and  lifting  the  body  up.  As  the 
muscles  which  can  be  tested  electrically 
(the  ilio-psoas  itself  is  out  of  reach)  are 
all  found  normal,  the  reflexes  probably  per- 
fect, the  muscular  nutrition  excellent,  the 
sensory  function  undisturbed,  it  is  evident 
that  a  mistaken  diagnosis  is  very  likely 
to  occur. 

Another  disease  which  often  gives  rise 
to  an  erroneous  diagnosis  of  hysteria  is 
that  which  is  called  rriedreich's  or  con- 
genita.! ataxy.  The  symptoms  are  apt 
to  commence  insidiously  in  youth.  They 
include  ataxic  gait  and  incoordination  of 
upper  extremities,  indistinct  articulation, 
nystagmoid  movements  of  the  eyes,  weak- 
ness of  muscles  of  spine,  and  often  lateral 
curvatare.  In  such  cases  the  knee-jerks 
are  almost  always  absent.  Absence  of 
knee-jerks  never,  in  the  writer's  experience, 
arises  from  hysteria.  In  conditions  of 
rigid  hysterical  contracture  of  the  knee- 
joint  it  may  be  impossible  for  mechanical 
reasons  to  evoke  the  knee-jerk,  but  simple 
absence  of  the  phenomenon,  no  such  ob- 
stacle being  present,  is  a  symptom  of 
structural  change. 

There  is  another  i-eflex,  the  behaviour  of 
which  gives  valuable  information  in  the 
diagnosis  of  hysteria  from  organic  disease 
of  the  nervous  system.  It  almost  in- 
variably happens  that  in  cases  of  hysteri- 
cal paraplegia  the  contraction  produced 
by  tickling  the  sole  of  the  foot  (plantar 
reflex)  is  absent,  or  so  slightly  present  as 
to  be  evoked  with  very  great  difficulty. 
The  presence  of  this  reflex  in  a  doubtful 
case  becomes,  therefore,  of  considerable 
weight  as  pointing  to  structural  disease. 


Insular  or  disseminated  sclerosis,  in 

its  early  stage,  is  the  disease  which  is  most 
liable  to  be  diagnosed  as  hysteria,  and  the 
writer  has  reason  to  believe  that  there  are 
at  the  present  time  large  numbers  of  young 
females  affected  with  this  disease  who  are 
supposed  to  be  simply  "  hysterical." 

The  disease  is  particularly  common  in 
young  females — symptoms  showing  them- 
selves about  the  period  of  puberty.  There 
is  very  often  a  history  of  some  moral  shock 
or  long- continued  anxiety  preceding  the 
first  symptoms.  In  addition  there  are 
few  cases  of  disseminated  sclerosis  in 
females  in  which  emotional  symptoms  are 
not  mixed  up  with  those  belonging  essen- 
tially to  the  disease.  Obviously  this  com- 
bination of  itself  causes  a  peculiar  liability 
to  mistakes  of  diagnosis.  But  there  are 
other  sources  of  error  in  the  fact  that 
many  of  the  symptoms  of  disseminated 
sclerosis  are  supposed  to  suggest  of  them- 
selves an  hysterical  origin.  A  sudden 
alleged  loss  of  power  in  a  limb  of  an  ap- 
parently healthy  young  female,  a  localised 
numbness,  or  "  pins-and-needles  "  sensa- 
tion, complaint  of  loss  of  sight  in  one  eye, 
are  symptoms  familiar  enough  as  exj^res- 
sions  of  functional  trouble.  They  represent 
equally  modes  in  which  organic  disease  of 
the  kind  we  are  discussing  may  make  its 
first  appearance.  These  local  symptoms 
may  clear  off  after  a  short  time,  just  as 
would  be  the  case  if  they  were  of  hysterical 
origin.  The  girl  recovers  her  sight,  or  the 
use  of  her  limb,  and  nothing  more  is  heard 
of  the  numbness.  A  little  later  perhaps 
loss  of  sight  in  the  other  eye  is  complained 
of;  a  "pins-and-needles"  sensation  is  de- 
scribed in  some  other  part ;  another  limb 
is  said  to  be  very  weak.  The  opinion  that 
the  symptoms  are  of  hysterical  origin  may 
very  possibl}'^  ajspear  to  be  absolutely  con- 
firmed by  this  reappearance  of  trouble  in 
other  situations.  Or  the  patient  perhaps 
complains  of  weakness  and  stiffness  in 
both  legs,  which  increase  so  that  in  six  or 
eight  weeks  she  cannot  stand.  Then 
comes  a  rather  rapid  improvement  and 
she  recovers  her  power  completely,  soon, 
however,  to  fail  again.  After  recoveries 
and  relapses  of  this  kind,  the  charac- 
teristics of  confirmed  disseminated  sclero- 
sis show  themselves. 

As  a  rule,  though  this  is  not  without 
some  notable  exceptions,  the  class  of  hys- 
terical paraplegia  is  not  difficult  of  dia- 
gnosis by  those  well  acquainted  with  the 
symptoms  and  course  of  oi-ganic  disease, 
the  surrounding  circumstances,  and  es- 
pecially the  contradictions  palpable  in  the 
symptoms  leaving  one  usually  in  but 
little  doubt.  The  attitude  and  condition 
of  the  lower  limbs  may  vary  exceedingly. 


Simulation  of  Hysteria      [     1163    ] 


Single  Patients 


The  limbs  are  most  often  in  a  state  of  per- 
fect tlaccidity,  a  condition  of  spasticity 
being  comparatively  i-are.  The  feet  are 
frequently  "  dropped."  After  long  disuse 
it  will  not  nnf  requently  happen  that  there 
are  strong  adhesions  in  the  joints.  Hys- 
terical paralyses  are  most  often  complete. 
The  loss  of  power  in  disseminated  sclerosis 
is  very  rarely  (except  in  advanced  stages) 
more  than  moderate.  It  is  probable  that 
the  view  still  generally  held  that  a  shift- 
ing of  loss  of  power  from  one  limb  to 
another  (such  as  that  which  we  have  de- 
scribed) is  really  characteristic  of  hysteria 
is  quite  an  error.  The  hji'sterical  woman 
who  has  lost  all  power  in  her  legs  will,  it 
is  true,  very  often  later  on  (whilst  still 
paraplegic)  lose  the  power  of  one  arm, 
usually  the  left ;  but  she  is  not  prone  to 
lose  the  power  in  a  limb,  then  recover  it, 
and  then  lose  it  in  another.  The  idea 
of  this  shifting  of  powerlessness  being 
strongly  suggestive  of  hysteria  has  in  all 
probability  arisen  from  the  mistakes  in 
diagnosing  as  hysteria  cases  of  dissemi- 
nated sclerosis.  This  must  have  been 
continually  occurring  before  the  latter 
disease  had  been  differentiated.  No  doubt 
the  hysterical  are  prone  to  changes  of  dis- 
order ;  at  one  time,  for  example,  losing 
the  use  of  a  limb  or  limbs,  with  or  without 
profound  ansesthesia,  at  another  time 
losing  the  voice,  or  closing  one  eyelid,  or 
contracting  a  limb,  but  the  shifting  about 
of  a  state  of  more  or  less  powerlessness, 
which  we  see  in  disseminated  sclei'osis, 
would  appear  to  be  sui  generis,  and  should 
save  us  from  error.  And  equally  so  with 
the  occurrence  of  numbness  or  "  pins-and- 
needles  "  sensation,  sometimes  at  one  part 
and  sometimes  at  another,  which  points 
with  considerable  distinctness  to  dissemi- 
nated sclerosis. 

No  doubt  it  is  inconceivable  that  a  con- 
dition of  sclerosis,  characterised  as  it  is 
by  overgrowth  of  connective  tissue,  can  be 
removed.  But  it  is  not  difficult  to  imagine 
the  possible  subsidence  of  the  state  of 
hyperemia,  which  doubtless  precedes  the 
stage  of  sclerosis. 

Where  there  would  appear  to  be  a  little 
moi'e  difficulty, in  regard  to  the  impairment 
of  sight  in  one  eye,  the  ophthalmoscope 
shows  no  change.  But  the  hysterical 
patient  as  a  rule,  when  loss  of  sight  of 
one  eye  is  in  question,  is  quite  blmd  on 
that  side,  whilst  the  patient  with  sclerosis 
has  only  more  or  less  obscurity  of  vision. 
One  does  not  find  cases  of  simple  hysteria 
in  which  first  one  eye  has  lost  some  amount 
of  vision  for  a  time  and  recovered,  and 
afterwards  the  other  eye  has  behaved  in  a 
similar  fashion.  80  that  this  symptom 
may  be  taken  to  point  with  considerable 


force  to  disseminated  sclerosis,  in  which 
disease  an  alternation  of  this  kind  is 
very  apt  to  occur.  When  the  ophthal- 
moscope shows  atrophy  of  disc  (and  it 
is  remarkable  in  what  a  large  proportion 
of  cases  of  disseminated  sclerosis  some 
ati'ophy  is  to  be  found — in  some  a  stage 
of  hyperasmia  preceding  it)  experience 
shows  that  a  diagnosis  of  functional  dis- 
order must  be  discarded. 

The  same  must  be  said  of  nystagmus, 
a  symptom  of  peculiar  value  when  com- 
bined with  others  about  which  there  might 
otherwise  be  some  doubt.  It  is  necessary, 
of  course,  to  remember  the  possibility  of 
chronic  alcoholism  producing  a  temporary 
nystagmus,  but  this  chance  of  error  ought 
not  to  be  difficult  to  avoid. 

The  tremor  on  intentional  movement  is 
probably  of  higher  diagnostic  value  than 
any  of  the  other  symptoms  of  disseminated 
sclerosis.  It  is  true  that  in  the  hysterical 
a  certain  clumsiness  of  movement  of  the 
hand  when  directed  to  an  object  is  some- 
times observed,  but,  noted  carefully,  this 
will  probably  be  found  to  be  dependent 
upon  temporary  loss  of  muscular  sense 
and  be  rather  of  the  nature  of  ataxy  than 
of  the  rhythmical  tremor  which  charac- 
terises disseminated  sclerosis. 

Localised  atrophy  of  muscles  with  loss 
of  electrical  reaction  is  well  known  to 
occur  sometimes  in  the  course  of  dis- 
seminated sclerosis,  and  in  a  case  other- 
wise open  to  doubt  its  presence  is  un- 
doubtedly of  the  highest  value  in  determin- 
ing the  organic  nature  of  the  condition. 
But  it  is  not  generally  known  thatthe  local- 
ised atrophy  may  behave  like  the  tem- 
porary powerlessness  of  a  limb  or  limbs, 
or  the  shifting  numbness.  Cases  of  dis- 
seminated sclerosis  may  be  seen  in  which 
atrophy  of  some  muscles,  with  loss  of  elec- 
trical reaction,  has  cleared  ofi"  entirely,  to 
be  succeeded  some  time  afterwards  by 
a  similar  lesion  in  another  or  the  same 
part. 

Disseminated  sclerosis  is  not  a  new  dis- 
ease, though  but  recently  differentiated. 
It  is  highly  probable  that  many  symptoms 
which  have  come  to  be  considered  charac- 
teristic of  hysteria  will,  if  examined  by 
the  light  of  improved  knowledge  and 
experience,  be  relegated  to  disseminated 
sclerosis.  T.  Buzzard. 

SZIVIUI.ATZON-  OF  ZM'SilN'ITY.  (See 

Feigned  Insanity.) 

szivxui.T.a.Nz:ous  zxrsii.N'ZTY.  {See 
Insanity,  Simultaneous  ;  and  Commu- 
nicated  Insanity.) 

SZircZiE  PATZENTS. — The  question 
of  treating  insane  persons  as  "  single  pa- 
tients," that  is,  as  patients  outside  an 
asylum,  has  at  least  two  aspects.     For  the 


Single  Patients 


[     1164    ] 


Single  Patients 


patients  may  be  those  wliose  insanity  is 
recent,  acute,  and  presumably  curable,  or, 
on  the  other  hand,  the  disease  may  be 
chronic  and  incurable,  and  we  have  to 
consider  what  mode  of  life  will  best  pro- 
mote their  welfare  and  happiness,  accord- 
ing to  the  mental  state  and  pecuniary 
means  available  for  their  maintenance. 
And  first  of  those  whose  insanity  is  recent 
and  acute.  There  are  many  persons 
whom  we  wish,  for  various  reasons,  to  save 
from  the  stigma  which,  rightly  or  wrongly, 
is  unquestionably  attached  to  those  who 
have  been  inmates  of  an  asylum.  Many 
professional  men,  many  fathers  of  families, 
may  be  seriously  damaged  in  position  or 
prospects  by  such  a  step,  or  may  even  lose 
the  position  they  hold.  Many  young  men 
and  young  girls  at  the  outset  of  life  may 
suffer  great  injury  if  placed  in  an  asy- 
lum during  an  attack  of  maniacal  excite- 
ment, which  possibly  will  be  of  brief  dura- 
tion. Many  young  mothers  break  down 
after  their  first  confinement,  but  recover 
rapidly  under  proper  treatment.  The  re- 
putation of  having  been  in  an  asylum  will 
never  be  lost  by  one  of  them.  If  we  can 
cure  such  patients  by  private  care,  we 
shall  confer  an  inestimable  benefit  upon 
them. 

What  are  the  curable  cases  of  insanity 
which  can  be  best  treated  as  single 
patients  ?  Even  very  acute  mania,  or 
maniacal  delirium,  is  capable  of  being 
brought  to  a  successful  termination  in  this 
way  if  proper  means  ai-e  adopted.  It  not 
unfrequently  happens  that  this  very  vio- 
lent mania  is  only  temporary,  and  it  has 
in  this  respect  obtained  the  name  of  mania 
transitoria,  from  its  brief  and  fleeting 
nature.  Where  the  symptoms  begin 
almost  suddenly  without  any  warning  or 
premonitory  stage,  and  where  the  cause  is 
also  of  a  brief  and  sudden  character,  we 
can  reasonably  hope  that  in  a  short  time 
they  will  subside.  Individuals  of  unstable 
equilibrium  are  prone  to  be  upset  by  such 
causes  as  shock,  fright,  or  sudden  religious 
excitement,  yet  the  equilibrium,  though 
easily  disturbed,  is  easily  regained,  and 
much  is  often  learned  from  the  occurrence 
of  previous  attacks  and  previous  recover- 
ies. Other  causes  also  bring  about  a 
delirium  which  may  be  brief  in  dviration. 
There  is  the  mania  which  sometimes  arises 
in  the  course  or  towards  the  decline  of 
acute  febrile  disease,  as  measles  or  scarla- 
tina. 

There  is  the  acute  mania  caused  by 
drink,  not  delirium  tremens,  but  insanity 
with  hallucinations  and  delusions,  often 
subsiding  after  a  brief  treatment. 

Violent  mania  may  follow  epileptic 
attacks,  and  pass  ofl'  quickly.     It  may  be 


desirable  to  give  all  such  patients  a  trial 
before  sending  them  to  an  asylum,  if  it  is 
possible  to  do  so  with  safety  to  themselves. 
Besides  transient  attacks  of  mania  there 
are  those  of  acute  maniacal  delirium^ 
running  a  course  of  some  weeks,  and  even 
months,  and  generally  terminating  favour- 
ably. They  occur  for  the  most  part  in 
young  people,  and  there  will  be  a  strong 
wish  on  the  part  of  relatives  to  avoid 
an  asylum.  If  a  suitable  house  be  taken, 
such  a  patient  can  often  be  successfully 
nursed  through  an  illness  of  this  kind. 
The  plan,  however,  is  costly,  and  unless 
relatives  are  willing  to  incur  expense, 
and  to  follow  the  physician's  orders  in  all 
things,  an  asylum  is  the  only  alternative. 
The  treatment  can  rarely  be  carried  out 
in  a  patient's  own  house ;  therefore  one 
must  be  taken,  detached,  because  of  his 
noise,  of  sufiicient  size  to  give  two  good 
rooms  on  the  bedroom  floor,  and  with 
sufficient  garden  for  exercise  when  the 
time  for  it  comes.  The  bedroom  must  be 
stripped  of  furniture,  the  bed  made  on  the 
ground,  the  windows  protected  by  laths 
nailed  across,  with  sufiBcient  intervals  for 
light  and  air,  and  the  flre  hj  a  guard. 
The  treatment  of  such  a  case  does  not 
consist  of  mechanical  restraint  and  fasten- 
ing in  bed  by  a  strait  waistcoat.  Such 
patients  are  not  usually  dangerous  to 
themselves  or  others,  though  they  may  be 
violent,  noisy,  mischievous,  and  dirty. 
Thej'  require  a  sufficient  staff  of  intelligent 
and  well-trained  attendants  under  the 
supervision  of  an  educated  person,  relative 
or  other.  If  the  expense  ot  all  this  can  be 
borne,  and  borne  for  some  time,  the  malady 
may  be  brought  to  a  favourable  termi- 
nation ;  but  it  not  unfrequently  happens 
that  in  a  few  weeks  the  cost  is  more  than 
can  be  met,  and  recourse  is  had  to  an 
asylum  when  much  money  has  been  spent 
to  little  purpose. 

Less  acute  forms  of  mania,  which  may 
be  called  acute  mania,  as  distinguished 
from  acute  delirious  mania,  are  not  fitted 
for  treatment  as  single  cases.  The  dura- 
tion is  much  longer,  the  necessity  for 
exercise  much  greater,  and  an  amount  of 
repression  and  moral  control  is  urgently 
demanded  which  can  hardly  be  applied  in 
a  private  house.  These  patients  require 
to  be  with  others,  to  be  subjected  to  rules 
and  discipline,  and  if  left  unchecked  in 
private  care  there  is  a  risk  of  their  becom- 
ing chi'onic  lunatics. 

Acute  delirious  melancholia  can 
hardly  be  treated  in  private,  though,  if 
death  be  imminent,  as  it  often  is  in  such 
cases,  it  is  not  wise  to  remove  a  patient  to 
die  in  a  few  days  in  an  asylum.  For 
purposes  of  cure,  if  there  be  hope  of  cure, 


Single  Patients 


[    1165    ] 


Single  Patients 


an  asylum  is  necessary.  There  is  certain 
to  be  an  intense  suicidal  tendency  and  a 
most  obstinate  refusal  of  food.  The 
patient  will  not  remain  in  bed,  and  re- 
quires a  warm  padded  room.  All  food 
and  medicines  have  to  be  administered  by 
force,  and  for  this  the  stall'  of  an  asylum, 
medical  and  other,  is  imj^erativoly  de- 
manded. The  intense  desire  for  suicide 
can  hardly  be  dealt  with  in  a  private  house. 
Such  persons  will  try  to  swallow  glass  or 
anything  they  can  secrete,  will  set  fire  to 
their  dress  or  the  house,  throw  themselves 
over  the  balusters,  and,  in  shoi't,  avail 
themselves  of  every  chance  which  a  private 
house  presents. 

Melancholia  of  a  less  acute  form  may 
ofteu  be  treated  successfully  out  of  an 
asylum.  Patients  of  this  type  may  indeed 
refuse  their  food,  but  with  a  passive  re- 
sistance, allowing  themselves  to  be  fed 
without  much  difficulty,  or  feeding  them- 
selves under  the  threat  of  force  being 
used.  So,  too,  they  may  be  suicidal — that 
is,  they  would  commit  suicide  if  left  entirely 
alone,  but  with  efficient  supervision  this 
can  be  prevented.  It  is  to  be  understood 
that  such  a  person  is  never  to  be  left 
alone.  Indoors  or  out,  by  night  or  by 
day,  in  bed  or  out  of  it,  he  is  to  be  accom- 
panied by  a  vigilant  attendant.  He  is  not 
to  be  allowed  to  fasten  himself  alone  in 
any  place,  and  all  this  implies  the  need  of 
a  sufficient  staff  to  carry  out  such  super- 
vision. With  it,  if  the  expense  can  be 
incurred,  a  favourable  issue  is  often  arrived 
at,  and  the  plan  has  the  advantage  that 
change  of  scene  can  be  effected,  a  move 
being  made  after  a  sufficient  sojourn  in 
one  place,  and  great  advantage  being 
often  derived  from  such  a  step.  Melan- 
cholia, though  curable,  is  generally  tedious, 
so  that  expense  must  be  calculated  in  such 
a  case.  It  is  a  great  pity  to  place  a 
patient  in  an  asylum  just  as  convalescence 
is  commencing  because  funds  for  single 
care  are  no  longer  forthcoming.  If  this 
event  is  likely  to  happen,  it  is  better,  to 
have  recourse  to  the  asylum  at  the  outset 
of  the  attack. 

There  is  a  reason  for  placing  melan- 
cholic people  in  an  asylum,  and  for  not 
treating  them  as  single  patients,  which  is 
important,  and  should  not  be  lost  sight  of. 
They  are  often  possessed  by  an  intense 
egotism  or  self-feeling  which  prevents 
their  thinking  of  anything  or  anybody 
beside  themselves.  They  imagine  that 
there  never  was  a  case  like  theirs,  that 
they  never  can  get  well,  that  no  one  can 
understand  the  symptoms,  and  they  weai'y 
every  one  around  them  by  ceaseless  itera- 
tion of  their  never-ending  complaint. 
Such  patients  must  certainly  be  removed 


from  their  own  home,  but  even  if  placed 
as  single  patients  in  a  family  or  a  doctor's 
house,  they  can  make  themselves  the 
centre  and  focus  of  every  one's  attention, 
and  this  increases  their  egotism  and  self- 
importance,  and  does  nothing  to  cure  iti 
But  place  one  of  these  in  an  asylum  of, 
say,  a  hundred  patients,  and  make  him 
merely  the  hundredth  part  of  the  whole 
community  instead  of  the  one  central  and 
principal  unit,  and  a  wonderful  change 
often  manifests  itself  in  a  very  short  time: 
He  takes  his  food  because  all  around  him 
are  taking  theirs,  and  because,  if  he  re- 
fuses it,  he  knows  he  will  immediately  be 
fed.  He  gives  over  talking  of  his  delu- 
sions, because  the  others  with  whom  he 
sits  pay  not  the  slighest  attention  to  him. 
If  he  can  join  in  no  games  or  employ- 
ment, he  at  any  rate  sees  them  going  on 
around  him.  There  are  newspapers  on 
the  table,  and  as  nobody  begs  him  to  read 
them,  or  cares  whether  he  does  so  or  not, 
he  takes  one  up  to  see  what  is  going  on, 
and  so  recommences  reading.  Such  per^ 
sons  are  not  to  be  cured  out  of  an  asylum, 
and  in  one  they  should  not  sit  alone  in 
their  own  apartments,  but  should  mix 
with  a  number  of  other  patients.  Neither 
are  melancboliacs  the  only  ones  who  are 
egotistical  and  self-important;  many  whose 
malady  is  mania  rather  than  melancholia 
are  exalted  in  ideas,  thinking  themselves 
high  above  others  in  rank  or  wealth  or 
genius.  An  asylum  is  the  place  to  put  an 
end  to  these  high  thoughts,  which  are  more 
likely  to  be  fostered  than  dispersed  by 
care  as  single  patients. 

General  paralytics  are  very  unfit  for 
single  care.  For  the  most  part  men — for 
females  are  only  found  in  the  lower  classes 
— they  are  at  the  outset  strong,  vigorous, 
and  often  very  violent,  and  in  their  vio- 
lence they  are  reckless  and  demented, 
trying  to  escape  and  attacking  those  about 
them  with  no  regard  for  consequences. 
Moreover,  there  is  no  object  in  trying  to 
save  them  from  the  stigma  of  an  asylum, 
for  their  malady  unfortunately  is  incur- 
able. They  are  most  difficult  to  manage 
in  a  private  house  at  the  commencement 
of  their  insanity,  requiring  very  special 
apartments,  and  a  large  staff  of  attend- 
ants. Here  and  there  we  may  find  one  in 
whom  the  facile  and  demented  state  of 
mind  comes  on  very  early.  Being  by 
nature  of  a  quiet  and  easily  controlled 
disposition  and  weakened  by  the  disease, 
he  can  be  treated  from  the  first  in  an 
ordinary  house,  though  not  his  own,  and 
he  declines  gradually  in  mental  and  bodily 
strength  till  the  end  is  reached.  Most 
paralytics  go  through  this  stage,  and  later 
can  be  kept  in  private,  if  the  friends  wish 


Single  Patients 


[     1166    ]      Skin,  Excretion  by  the 


them  to  die  out  of  an  asylum,  and  can 
endure  them  when  wet,  dirty,  and  para- 
lysed in  an  extreme  det^ree. 

Young  people  suft'ering  from  acute 
primary  dementia  can  often  be  managed 
satisfactorily,  and  the  disorder  brought  to 
a  happy  termination  without  recourse  to 
an  asylum  ;  being  young  and  at  the  out- 
set of  life,  this  is  important.  They  are 
neither  dangerous  to  themselves  nor  to 
others.  They  do  not  refuse  their  food, 
though  they  may  require  to  be  washed, 
dressed,  and  fed  like  children.  The  malady 
depends  so  much  on  the  physical  condition 
that  the  environment  is  comparatively  of 
less  importance,  and  change  of  scene  may 
be  beneficial  when  convalescence  has  com- 
menced. 

There  are  many  recent  but  not  acute 
cases  of  insanity  in  which  recovery  takes 
place  by  means  of  change  of  scene  and 
removal  from  home  without  the  aid  of  an 
asylum,  and  without  legal  restraint. 
When  there  is  no  urgency,  it  is  probable 
that  some  such  treatment  may  be  adopted 
in  the  majority  of  such  cases.  In  fact,  it 
is  often  a  great  satisfaction  to  friends  to 
tr}'^  this  method,  even  in  an  unpromising 
case,  before  having  recourse  to  an  asylum. 
Time  and  money  are  important  consider- 
ations. A  patient  who  is  not  going  on 
well  in  private  care  shovild  not  be  allowed 
to  continue  so  long  that  his  cure  is 
jeopardised,  nor  should  his  means  be 
seriously  crippled  by  the  useless  expense 
of  these  proceedings. 

The  greater  proportion  of  recent  and 
curable  cases  of  insanity  will  have  to  be 
treated  in  asylums,  and  for  the  majoi'ity 
a  good  asylum  is  certainly  the  best  place, 
the  safest,  and  the  cheapest,  but  there  are 
large  numbers  of  the  chronic  insane  who 
are  able  to  live  comfortably  and  happily 
in  private  families,  or  in  houses  of  their 
own  under  proper  supervision,  and  the  law 
gives  ample  facilities  for  their  so  doing. 
The  selection  of  a  suitable  home  must 
depend  on  a  variety  of  circumstances:  on 
the  patient's  means,  his  tastes,  habits,  and 
eccentricities.  Some  require  much  exer- 
cise and  long  walks  ;  for  them  the  country 
is  preferable  to  a  town.  Others  like  i^ic- 
tures,  music,  and  the  moving  life  and 
bustle  of  a  town.  Some  are  too  peculiar 
in  manner  and  appearance  to  walk  in 
streets,  and  unfrequented  country  places 
are  better  adapted  to  them.  Wherever 
they  are,  they  should  reside,  if  they  be 
ladies  or  gentlemen,  with  educated  per- 
sons. The  chief  distinction  between  life 
in  a  family  and  life  in  an  asylum  is  that 
in  the  former  the  patient  lives  with  sane 
instead  of  insane  people.  If  he  is  unfit 
for  this,  if  he  is  unable  to  take  his  meals 


with  the  family,  and  mix  with  its  mem- 
bers, he  is  better  off  in  an  asylum.  To 
dwell  in  separate  apartments  and  take  his 
meals  alone,  or  with  an  uneducated  at- 
tendant, is  not  to  have  an  advantage  over 
those  in  an  asylum,  but  to  be  at  a  great 
disadvantage.  Those  who  receive  patients 
into  their  houses  should  not  look  upon 
them  merely  as  lodgers  with  servants  to 
wait  upon  them,  but  as  persons  to  be  re- 
ceived into  the  family,  to  enjoy  as  much 
as  possible  the  life  of  the  family,  that  their 
mental  condition  may  improve  thereby, 
and  not  deteriorate. 

The  law  enacts  that  single  patients 
must  be  placed  under  certificates  like  pri- 
vate patients  in  asylums,  if  those  who 
receive  them,  or  take  care  and  charge  of 
them,  do  so  "for  payment."  Certificates 
are  not  neessary  if  relatives  or  friends  take 
charge,  and  are  not  paid  for  so  doing.  By 
the  Lunacy  Act  of  1890  the  procedure 
whereby  single  patients  are  to  be  received 
under  an  order  of  a  county  coui't  judge, 
magistrate,  or  justice  is  in  all  respects  the 
same  as  that  which  relates  to  patients 
received  in  hospitals  or  private  asylums. 
G-.  Fielding  Blaxdford. 

SlRXilSlS  (Seipto?,  the  dog-star).  A 
name  for  sunstroke  or  inflammation  of  the 
brain.  The  dog-star  was  supposed  to  have 
an  influence  in  producing  it. 

SITOPHOBZA,  SITIOPHOBIA  {airos 
or  (tit'iov,  food  ;  (f)o^eco,  I  fear).  A  morbid 
dread  of  taking  food.     (Fr.  sitophohie.) 

SKIN,  SSXCRETZON*  BY  THE. — 
Ordinai-y  perspiration  consists  of  a  mix- 
ture of  two  secretions,  the  one,  moi'e  or 
less  fatty,  derived  from  the  sebaceous 
glands  ;  the  other,  a  watery  fluid  derived 
from  the  sweat  glands.  The  secretion 
from  the  sebaceous  glands  is  not  unlike  a 
concentrated  milk,  rich  in  fatty  matter, 
and  the  sweat  derived  from  the  sudipa- 
rous  glands  may  be  proved  to  be  analo- 
gous to  a  diluted  urine. 

The  sweat  is  certainly  much  influenced 
by  mental  emotion,  and  therefore  mental 
states ;  it  would  be  well  if  accurate  obser- 
vation were  made  on  the  insane  as  to  its 
variation.  On  the  other  hand,  the  oily 
matters  which  lubricate  the  hair  and  make 
the  skin  supple  have  not  been  proved  to 
be  affected  by  mental  conditions,  but 
probably  are  so. 

The  Sebaceous  Secretion. — The  only 
possible  way  in  which  the  sebaceous  secre- 
tion can  be  collected  apart  from  other 
secretions  is  in  those  rather  frequent 
instances  in  which  the  little  duct  leading 
to  the  surface  of  the  skin  becomes  occluded. 
The  secretion  then  is  collected  in  a  cyst, 
and  there  is  good  reason  to  believe  that 
the   contents    of    these    sebaceous   cysts 


Skin,  Excretion  by  the      [     1167     J       Skin,  Excretion  by  the 


represent  fairly  well  the   normal    secre- 
tion. 

The  author  has  found  the  contents  of  a 
sebaceous  cyst  to  be  of  a  thick  creamy 
consistence,  to  have  a  most  decided  bu- 
tyric acid  odour,  an  acid  reaction,  and  to 
contain  cholestcrin,  butyric  and  caproic 
acids.  The  contents  of  a  cyst  examined 
by  0.  Schmidt*  contained  the  following  : 

I'd-  cent, 

AVator  .....     31.70 

Epitlii'linui  and  albumin  .     61.75 

Fat 4.16 

liutyric  acid       -i 

A'alcrianic  acid    -  .         .        i.2t 

Caproic  acid        I 

Ash 1. 18 

Impure  sebaceous  matter  taken  from 
the  scalp  was  investigated  by  Hoppe- 
Seyler  t ;  this,  rubbed  with  water  and  the 
solution  shaken  with  ether,  gave  a  turbid 
liquid,  which  on  filtration  through  filter 
paper,  gave  a  precipitate  with  acetic  acid, 
the  precipitate  agreeing  in  all  its  charac- 
ters with  casein  ;  on  filtering  off  the  casein 
and  boiling,  the  liquid  is  again  troubled  ; 
it  also  gives  in  the  cold  a  precipitate  with 
ferrocyanide  of  potassium ;  in  short,  it 
gives  the  reactions  of  albumin.  Sugar  is 
absent. 

The  waxy  secretion  of  the  ear  may  be 
considered  as  that  of  a  highly  specialised 
sebaceous  secretion  ;  it  has  never  been 
obtained  free  from  j^erspiration  residues. 
Petrequin  J  and  Chevalier  give  the  follow- 
ing as  the  percentage  composition  of  ear 
wax : 


Ear  wax  taken 
from  a  middle- 
aged  man. 

Ear-wax  taken 

from 

an  old  man. 

Water 10 

Fat 26 

Potash  soap,  solulile  in  alcohol  '      38 

water .    j       14 

Insohible  organic  matters      .          12 

30.5 
17.0 
24.0 
17.0 

It  is  because  the  ear  wax  contains  a  large 
content  of  soap  that  it  is  partly  soluble  in 
warm  water. 

No  researches  have  been  made  as  to  the 
nature  of  the  secretion  of  the  ear  in  the 
insane,  it  is  a  subject  well  worthy  of 
research,  the  more  especially  since  in 
certain  mental  diseases  there  are  profound 
trojihic  changes  in  the  shape  of  the  exter- 
nal ear. 

»  Dent  sell.  f.  kliri.  M<d.,  Hd.  v. 
t  "  I'hysiologische  Clicmic,"  J',crlin,  1881. 
J   Compt.-rend. ,    t.    Ixviii.,    Xd.    16;    t.    Ixix., 
1869. 


Perspiration. — Thedependance  of  per- 
spiration upon  mental  states,  the  heat  or 
cold  of  the  atmosphere,  the  general  con- 
dition of  health  and  its  excitement,  or 
repression  by  drugs,  are  things  of  common 
medical  knowledge.  Especial  interest 
attaches  to  the  experiments  of  Luchsino-er* 
and  others  who  have  shown  how  perspi- 
ration can  be  excited  by  electrical  stimu- 
lation of  the  cei'ebro-si)inal  and  sympa- 
thetic nerves.  The  chief  drugs  which 
excite  the  secretion  of  the  skin  are  pilo- 
carpin,  physostigmin,  muscarine,  and 
nicotine ;  on  the  other  hand,  atropine  has 
a  distinctly  inhibitory  effect. 

The  method  of  collecting  the  perspi- 
ration in  quantity  enough  to  chemically 
examine  it  has  always  been  to  bring  the 
body  to  a  high  temperature  by  the  employ- 
ment of  hot-air  baths  ;  in  this  way 
A.  Kast  t  was  able  to  collect  no  less  than 
twenty  litres  of  sweat  (of  course  mixed 
with  some  of  the  sebaceous  secretion). 
Sweat  has  an  acid  reaction  normally, 
although  Trumpy  and  Luchsinger  have 
described  alkaline  sweat  produced  under 
certain  conditions,  as,  for  example,  by  pilo- 
carpine; this  may  be  an  error,  for  sweat 
rapidly  putrefies,  and  any  urea  changes 
into  amnionic  carbonate ;  hence  a  sweat 
may  be  acid  when  first  secreted,  but 
ammoniacal  decomposition  sets  in,  and 
then  the  liquid  has  an  alkaline  reaction. 
Sweat  contains  the  following  :  urea,  ether- 
sulphatesj  sulphates,  phosphates,  and 
chlorides.  In  a  few  cases  Gamgee  and 
Dewar  %  have  found  cystin,  and  in  the 
sweat  of  diabetics  sugar  has  been 
found,  for  Bizio  §  and  Hoffmann  ||  have 
each  described  cases  in  which  they  have 
discovered  indigo  in  sweat.  Favre  has 
described  a  peculiar  acid,  "  sweat  acid,"  to 
which  he  ascribes  the  formula  CmHir.NjOu, 
but  this  requires  confirmation.  Schottin 
has  recognised  benzoic,  sucfcinic,  and  tar- 
taric acids  in  sweat.  Some  drugs  are 
certainly  eliminated  by  the  perspiration  ; 
sulphur  is  in  some  degree  given  oflfby  the 
skin  after  taking  flowers  of  sulphur ; 
arsenic  has  been  detected  in  the  sweat  of 
persons  taking  arsenic,  and  mercury  in 
the  sweat  of  persons  taking  mercury. 
A.  Kast  has  distilled  the  sweat  and  recog- 
nised phenol  in  the  distillate;  to  another 
portion  he  added  hydrochloric  acid,  and 
by  shaking  up  with  ether  and  subsequent 
evaporation  of  the  ether  extract  and  solu- 
tion in  water,  he  found  the  solution  to 
give  a  red  colour  with  Millon's  reagent, 

*  "Die  Scbweissabsondoruiig-,'"  1880. 

t  Zeit.  physiol.  Chemic,  xi.  pp.  501-507. 

t  ■liinrn.  of  Anat.  and  I'liysioL,  vol.  v.  ]).  \^2. 

§  Wien.  Acadein.  Sitzuugalwr,  Bd.  xxxix.  s.  33  ; 
Alt  I  dell'  Istitato  Veneto  di  Srinizc,  letter!  ed  arti  x. 

II   Wien.  med.  Wochenschrij't,  1873,  b.  292. 


Skin,  Excretion  by  the      [     1168    ]       Skin,  Excretion  by  the 


thus  indicating  the  presence  of  aromatic 
oxyacids.  Jaffes'  test  showed  the  presence 
pf  skatoxyl.  The  same  observer,  operat- 
ing npou  the  hirge  quantities  of  sweat 
before  alhided  to,  established  the  relation 
which  exists  normally  in  sweat  between 
the  ethereal  hydrogen  sulphates  and 
the  mineral  suli^hates  in  the  following 
way : 

The  liquid  was  made  faintly  alkaline  by 
sodium  carbonate,  excess  of  absolute  alco- 
hol added,  the  liquid  filtered,  and  the 
whole  evaporated  on  the  water  bath  to  a 
small  bulk.  In  the  concentrated  liquid 
the  ethereal  sulphuric  acid  and  the 
mineral  sulphuric  acid  were  separately 
estimated,  with  the  following  re- 
sult :  In  200  c.c.  of  the  concenti'ated 
sweat  (equal  to  10  to  12  litres  of 
unconcentrated  sweat),  sulphuric  acid 
A = o. 242 2 ;  ethereal  sulphuric  acid  B  =  .02  2 ; 

-T-= •       In    the   urine  of  the  same 

A     12.009 

individuals   collected   at   the   same   time, 

in  200   c.c.   of  urine   A  =  .71 8;  B  =  .448  ; 

T>  T 

T-~~-p —  ■  By  administering  10  grains  of 
A      16.02         -^  . 

salol  in  three  days  to  the  same  individuals, 
the  quantity  of  the  ethereal  hydrogen  sul- 
phates in  the  urine  was  much  increased  ; 

5  =  1439  whilst  ill  the  sweat  4"=  —  ; 
A        I  B     9.504' 

in  other  vi'ords,  the  sweat,  unlike  the 
urine,  remains  fairly  constant  in  compo- 
sition. With  regard  to  other  salts  the 
following  relation  was  shown  to  exist : 


Chlorides. 

Phosphates. 

Sulphates. 

Sweat 
Urine       .     . 

I 
I 

0.0015 
0. 1320 

0.Q09 
0.397 

Finke  *  made  some  quantitative  re- 
searches on  the  amount  of  j^erspiration 
eliminated  by  three  different  individuals. 
The  quantity  varied  considerably  even 
when  the  temperature  and  other  conditions 
were  equal.  At  temperatures  varying 
from  13°  to  27.5°,  and  with  rest  or  active 
exercise,  the  extremes  of  the  hourly 
secretion  varied  from  53.04  to  815.337 
grammes,  and  the  quantity  of  solid  matter 
from  0.923  grammes  to  6.967  grammes. 
The  inorganic  salts  amounted  from  0.246 
to  0.629  per  cent,  of  the  secretion,  and  the 
amount  was  relatively  the  more  consider- 
able, the  smaller  the  content  of  solid 
matter.  In  one  research  the  hourly  cuta- 
neous excretion  of  urea  was  0.112,  and  in 
the  other   0.199  per   cent,   of  the  sweat, 

*  Hoppe-Seyler,  "  Physiol.  Chcmie,''  s.  769. 


which  would  give  for  the  whole  twenty- 
four  hours  the  large  quantity  of  10.2 
grammes  to  15.1  grammes  of  urea  thrown 
off  by  the  skin. 

In  making  any  experiments  on  elimi- 
nation by  the  skin,  such  experiments  on 
different  persons  are  only  comparable  if 
the  skin  surface  is  estimated.  This  has 
been  done  so  seldom  that  until  a  sufficient 
number  of  individuals  have  been  measured, 
no  generalisation  can  be  laid  down,  but 
there  is  little  doubt  that  if  any  one  will 
only  take  the  trouble  to  measure  a  hundred 
persons,  certain  relations  will  be  found  to 
exist  between  some  dimensions  of  each 
different  part  of  the  body  which  will 
enable  the  surface  to  be  estimated  from 
only  a  few  leading  measurements. 

The  relative  surfaces  of  two  bodies  which 
are  similar  in  form  are  as  the  squares  of 
any  similar  dimensions,  using  the  word 
similar  in  its  strictly  geometrical  sense. 
For  example,  supposing  that  two  arms  and 
hands  were  precisely  similar  in  form,  that 
is  to  say,  that  the  circumference  of  the 
arm  throughout  bore  everywhere  the  same 
proportion  to  the  whole  length  of  the  limb 
in  each  case,  but  that  the  lengths  were 
respectively  as  i  to  1.3,  then  the  relative 
surfaces  would  be  as  1.3  to  i,  that  is  to 
say,  as  i  to  1.69.  But  in  most  cases  it  will 
be  found  that  while  the  general  shape  is 
the  same,  the  proportion  between  the 
length  of  the  limb  and  the  circumference 
is  not  the  same ;  in  this  case  the  surface 
varies  as  the  mean  circumference  multi- 
plied by  the  length  of  the  limb.  To  obtain 
the  skin-area,  the  body  may  be  divided  as 
follows  :  (a)  the  head,  (b)  the  trunk,  (c)  the 
arms,  {d)  the  legs. 

The  simplest  way  of  taking  the 
measurements  accurately  is  to  have 
elastic  bands  which  can  be  put  round  so  as 
to  divide  the  body  into  small  surfaces  ;  for 
instance,  place  a  band  round  the  neck  and 
another  round  the  chest,  just  below  the 
armpits,  then  the  surface  between  these 
two  bands  can  be  determined  by  taking 
measurements  at  equal  distances  apart ; 
the  mean  of  these  numbers  is  to  be  multi- 
plied by  their  number  and  their  common 
distance  apart. 

The  whole  length  of  the  trunk  may 
be  divided  into  some  number  of  equal 
parts,  and  the  circumference  measured  at 
each  of  these  lines  ;  then  the  surface  will 
be  obtained  by  adding  half  the  first  and 
last  measures  to  the  remaining  measures 
of  the  trunk,  and  multiplying  the  sum  by 
their  common  distance  apart.  In  the 
same  way  with  the  limbs.  The  surface  of 
the  hands  is  easiest  taken  by  ripping  up  a 
good  fitting  glove  and  measuring  it.  The 
feet  may  be  divided  into  small  zones  by 


Skull-mapping 


[     ii69     ] 


Skull-mapping 


«lastic  baads,  aud  then  these  small  sur- 
faces are  easily  measured. 

Similar  remarks  apply  to  the  head  and 
face.*  In  these  inquiries  of  course  the 
weight  of  the  person,  the  hei<;ht,  and,  if 
possible,  the  bulk  should  also  be  taken  ; 
the  latter  may  be  done  in  a  bath ;  a  scale 
carrying  a  point,  and  working  with  a 
coarse  and  a  micrometer  screw,  is  so 
arranged  that  the  point  just  touches  the 
water,  then  the  person  is  immersed  therein 
with  the  exception  of  the  nostrils ;  the 
instrument  is  again  adjusted  so  that  the 
point  touches  the  water.  This  gives  an 
indication  by  which  the  experimenter  will 
know  the  bulk  of  the  water  displaced ;  if 
the  bath  is  of  irregular  shape  it  will  be 
convenient  to  find  out  experimentally  the 
amount  of  water  thus  displaced  rather 
than  by  calculation  ;  that  is  to  say,  when 
the  person  has  retired  from  the  bath,  to 
adjust  the  liquid  to  the  heights  indicated. 
In  all  these  instances  the  water  must 
be  reduced  to  the  standard  temperature 
of  15''.  A.  AVynter  Blyth. 

SKiriiii-iucAPPZirG. — A  good  method 
of  delineating  the  skull  line  in  the  two 
directions  corresponding  respectively  to 
the  circumferential  line  of  the  horizontal 
and  perpendicular  planes  at  the  level  of 
their  greatest  areas  is  as  follows  : 

The  calvarium  having  been  removed  in 
the  ordinary  way — care  being  taken  that  it 
is  cut  at  a  level  about  an  inch  above  the 
superciliary  ridges  in  front  and  the  occi- 
pital protuberance  behind,  and  that  the 
line  is  as  straight  as  possible — the  brain 
and  membranes  are  cleared  away,  and  a 
strip  of  lead  17  inches  long,  ^  of  an  inch 


wide,  and  of  the  thickness  of  half  a  crown, 
is  laid  upon  the  basis  cranii  in  the  direc- 
tion of  its  length.  The  anterior  end  of 
the  lead  must  be  slit  for  about  3  inches, 
so  as  to  enclose  the  crista  galli,  and  the 
two  strips  brought  u[)  to  the  cut  margin 
of  the  skull  anteriorly.  The  whole  length 
of  the  lead  included  in  the  skull  is  now  to 
be  pressed  close  down  on  to  the  bone,  and 
pushed  into  all  the  hollows,  bent  over  the 
posterior  clinoid  process  and  into  the  fora- 
men magnum,  then  up  the  occipital  bone 
to  the  cut  margin  posteriorly. 

The  spare  lead  is  to  be  bent  over  for- 
ward, and  its  extremity  placed  against 
the  tips  of  the  anterior  portion,  so  as  to 
prevent  springing. 

The  iDosition  of  the  torcular  Herophili 
having  been  marked  on  the  lead  with 
chalk,  the  strip  may  be  removed  bodily, 
placed  on  a  sheet  of  paper,  and  the  part 
which  has  been  in  apposition  with  the 
skull  drawn  round  with  pencil. 

A  perfect  copy  of  the  basis  cranii  in  its 
median  line  will  be  thus  obtained  ;  and 
the  same  process  being  carried  out  with 
the  calvarium,  and  adapted  to  the  line 
already  drawn,  the  complete  internal 
antero-posterior  circumference  will  be 
shown  (Fig.  II.). 

To  get  the  horizontal  circumferential 
line,  a  ring  of  bone  a  quarter  or  one-third 
of  an  inch  thick  is  carefully  sawn  off  just 
below  the  line  of  incision  made  in  re- 
moving the  calvarium.  If  properly  cut, 
this  ring  will  lie  flat  on  the  table,  and 
should  be  cleaned  and  preserved. 

By  placing  this  ring  on  paper  and 
drawing  closely  round  it  on  both  sides,  the 


Fig.  I. 


-  The  writer  is  indebted  to  Mr. 
matical  scheme. 


Henry  Law,  Mem.    lust.  C.E.,  for  the  working;-  otit  ni  this   matlie- 


Skull-mapping 


[    1 170    ] 


Sleep 


internal  and  external  circumferential  lines 
of  the  skull  are  obtained  as  shown 
(Fig.  I.,  7,  8). 

The  lines  thus  taken  in  the  two  direc- 
tions should  be  drawn  on  the  same  piece 
of  paper  for  purposes  of  comparison. 

A  straight  line  is  now  drawn  on  the 
perpendicular  section  (Fig.  II.,  i,  2),  from 
the  point  corresponding  with  the  torcular 
Herophili  to  the  frontal  bone,  and  just 
touching  the  posterior  clinoid  process 
(Fig.  IL,  3). 

From  I  to  2  will  constitute  the  base 
line  of  the  skull. 

If  a  line  be  now  drawn  at  right  angles 
to  this  base  line  and  with  its  lower  ex- 
tremity touching  the  anterior  margin  of 
the  foramen  magnum  (Fig.  II.,  4),  its  upper 
end  (Fig.  II.,  5)  will  be  found  to  corre- 
spond, almost  absoliately,  with  the  highest 


The  above  method  of  preserving  the 
skull  figure  is  especially  adapted  to  the 
use  of  asylum  superintendents  and  others 
in  like  positions,  and  furnishes  diagrams 
which  add  to  the  value  of  post  mortem 
records.  Crochlet  Clapham. 

SIiAVERiiTG. — Allowing  the  saHva  to 
flow  out  of  the  mouth  and  down  over  the 
chin.     (Fr.  bavant ;  Ger.  geifern.) 

SItEEP.  —  The  relation  of  sleep  to 
medical  psychology  is  important  in  five 
ways  : 

(i)  The  physiology  of  sleep;  (2)  the 
state  of  the  mental  functions  during  sleep  ; 
(3)  The  mental  disturbances  which  may 
arise  during  sleep  ;  (4)  The  loss  of  sleep  as 
a  cause  and  as  a  consequence  of  insanity  ; 
(5)  prolonged  sleep. 

(l)  The  Physiolog-y  of  Sleep.  —  No 
doubt  the  investigations    and  deductions 


Fig.  II. 


point  of  the  antero-posterior  arch  of  the 
skull,  and  to  cut  the  horizontal  circum- 
ferential line  at  its  point  of  greatest 
width. 

This  line  (Fig.  II.,  4,  5)  in  the  point  at 
which  it  cuts  the  base  line  (i  to  2)  deter- 
mines the  relative  size  of  the  anterior 
and  posterior  portions  of  the  brain,  and 
bears,  it  is  believed,  a  relation  to  the 
degree  of  intelligence  of  the  individual. 
The  space  below  the  base  line  is  occupied 
by  the  cerebellar  and  ganglionic  portions 
of  the  brain. 

Taking  the  posterior-clinoid  process  as 
a  fixed  point,  the  line  joining  it  with  the 
anterior  margin  of  the  foramen  magnum, 
and  which  corresponds  pretty  nearly  with 
the  basilar  process  of  the  occipital  bone, 
will  be  more  or  less  inclined  as  the  line 
4,  5,  is  moved  backward  or  forward;  in 
other  words,  the  angle  4,  3, 2,  Fig.  II.,  will 
be  larger  or  smaller. 


made  by  Mr.  Durham  and  by  Mr.  Moore 
are  of  great  importance  in  regard  to  the 
diminished  blood-supply  caused  by  the 
action  of  the  vaso-motor  centre  being  na 
longer  inhibited  by  the  brain  when  it  be- 
comes fatigued.  Although,  however,  this 
unrestrained  action  of  the  sympathetic 
appears  to  be  a  very  plausible  explana- 
tion of  the  phenomena  of  sleep,  it  is  open 
to  doubt  whether  we  may  not  confound 
the  post  with  the  propter  hoc.  Our  active 
mental  work  during  the  day  undoubtedly 
induces  dilatation  of  the  cerebral  vessels. 
Then  the  cortical  corpuscles  become  ex- 
hausted, and,  as  there  is  no  longer  mental 
stimulation,  the  vaso-motor  contractors 
are  free  to  play  on  the  vessels  and  lessen 
their  calibre.  It  does  not  follow,  however, 
that  this  is  the  cause,  although  it  is  the 
accompaniment,  of  sleep.  This  may  be 
induced  by  the  simple  weai-iness  of  the 
corpuscles  and  by  the  excretory  products 


Sleep 


[     1171     ] 


Sleep 


and  carbonic  acid  present  in  the  blood 
after  the  activity  of  the  cei'ebral  functions. 
Dr.  Cappie  (the  subjoined  criticism  of 
whose  views  will  be  found  in  the  JmiDb. 
of  Me)it.  Set.,  Ap.  18S3),  while  holJint^  that 
less  blood  circulates  in  the  arterial  and 
capillary  vessels  of  the  brain,  maintains 
that  there  must  be  an  exactly  correspond- 
ing excess  of  blood  in  the  vcbis.  The 
brain  is  compressed,  and  its  functions 
temporarily  suspended.  Dr.  Cappie  "  be- 
lieves that  the  veins  of  the  pia  mater  be- 
come distended  from  the  back  How  of 
blood  caused  by  the  atmospheric  pressure 
on  the  large  veins  of  the  neck,  and  it  is 
the  compression  on  the  cortex  of  the  brain 
by  these  distended  veins  that  produces 
sleep.  It  is  not  stretching  analogy  too 
far  to  say  that  that  condition  of  the  brain 
which  leads  to  sleep  is  similar  to  the  state 
of  a  muscle  after  severe  work,  and  that, 
just  as  iu  the  latter  case  the  contractions 
grow  feebler  as  the  excretory  products 
accumulate,  so  in  the  brain  the  supply  of 
nerve-energy  gradually  fails  as  the  nerve 
corpuscles  become  moi'e  and  more  ham- 
pered from  the  same  cause.  But  experi- 
ment has  shown  that  exactly  in  propor- 
tion to  the  depth  of  sleep  there  is  marked 
anasmia  of  the  cerebral  cortex,  a  condition 
which  cannot  be  supposed  to  result  di- 
rectly from  the  aggregation  of  fatigue 
products  in  the  cerebx-al  corpuscles,  since 
the  wide  changes  in  the  calibre  of  the 
vessels  could  only  be  produced  by  local 
stimulation  or  through  the  agency  of  the 
vaso-motor  sj'stem.  There  is  no  reason, 
a  ijriori,  why  there  should  not  be  local 
vaso-motor  centres  in  the  brain  just  as  iu 
the  other  viscera  and  tissues,  and  it  is 
conceivable  that  such  vaso-motor  centres 
may  be  influenced  by  the  state  of  the  tis- 
sues, and  so  give  rise  to  the  changes  in 
the  circulation." 

A  recent  writer.  Dr.  Louis  Robinson, 
after  passing  these  and  other  theories  of 
sleep  in  review,  including  that  of  periodic 
brain  rhythm,  observes  that  not  one  of 
these  theories  can  be  accepted  and  not  one 
of  them  ignored  ;  that  taken  together  they 
account  for  most  of  the  phenomena  but 
that  the  explanation  becomes  in  conse- 
quence a  very  complicated  one. 

tState  of  the  Eye  during  Sleep. — Differ- 
ent observers  report  differently  on  a  point 
upon  which  one  would  have  looked  for 
unanimity.  Sander*  finds  that  the  usual 
opinion  that  the  eyeballs  are  directed  up- 
wards and  inwards  is  incorrect;  he  de- 
scribes the  axis  of  the  eyes  as  parallel,  and 
as  if  regarding  a  distant  object.  It  is  true 
that  in  falling  asleep  the  balls  converge 
and  turn  upwards,  and  that  this  condition 
*  Ardiivfur  Psychiatric,  15d.  ix.  Heft  i. 


will  be  reproduced  when  we  disturb  a  per- 
son's sleep  by  trying  to  raise  the  lidy,  and 
hence,  according  to  Sander,  the  error,  one 
into  which  we  confess  we  have  fallen.  It 
was  one  which  Sir  Oharles  Bell  made,  and 
must  be  very  difficult  to  avoid.  Divergent 
eyeballs  may  be  observed  in  profound 
stupor  from  cerebral  disease.  In  ordinary 
mental  stupor  we  have  seen  them  turned 
upwards  and  inwards.  On  arousing  a 
sleeping  person,  the  pupils  are  seen  to 
dilate,  having  been  contracted  during 
sleep,  the  more  so  the  profounder  the  sleep. 
Dr.  Ludwig  Plotke  has  made  extensive 
observations  on  the  pupil  in  sleep.*  He 
confirms  the  statements  of  Sander.  Even 
when  the  pupil  is  dilated  by  atropine  it 
becomes  contracted  during  sleep.  The 
pupil  dilates  most  widely  at  the  moment 
of  waking,  and  this  is  not  prevented  by  a 
strong  light.  During  sleep  the  cornea 
becomes  dull. 

State  of  the  Retina  during  Sleep. — Dr. 
Hughlings  Jackson  has  found  the  disc 
whiter  than  normal,  the  arteries  a  ttle 
smaller,  and  the  veins  large,  thick  and 
almost  plum-coloured.  Dr.  Cappie  natur- 
ally claims  these  appearances  as  favour- 
ing his  views. 

(2)  state  of  IWental  Functions  during^ 
Sleep. — Although  it  is  very  doubtful 
whether  in  ordinary  sleep  the  whole  brain 
is  absolutely  free  from  functional  activity, 
it  must  be  held,  in  theor}^  at  least,  that 
the  faculties  of  the  mind  are  suspended. 
M.  Lemoine  observes  that  however  illusoiy 
may  be  the, object  of  the  pleasui'es  and 
pains  of  sleep,  the  mind  does  not  the  less 
experience  enjoyment  or  suffer  pain — but 
we  here  enter  at  once  ujjon  the  domain  of 
dreamland,  and  refer  the  reader  to  the 
article  Dreaming. 

(3)  Mental  Disturbance  arising:  dur- 
ing- Sleep. — (u)  The  most  serious  mental 
disturbance  which  may  occur  during  sleeji 
is  an  attack  of  epileptic  mania.  Noc- 
turnal epilepsy  must  never  be  overlooked 
as  a  possible  explanation  of  unusual  or 
alarming  occurrences  in  the  course  of 
sleep. 

(6)  There  may  be  a  sudden  outbreak  of 
acute  mania  in  sleep  independently  of 
epilepsy.  Two  gentlemen  conversed  to- 
gether in  the  evening,  and  on  retiring  to 
rest,  A.  had  no  reason  to  expect  what 
actually  happened  to  B.  before  morning. 
He  was  aroused  from  sleep  by  his  friend 
in  a  state  of  excitement,  threatening  his 
life  under  the  delusion  that  there  were 
burglars  in  the  house,  and  that  he  was 
connected  with  them.  It  transpired  that 
he  had  piled  up  various  articles  of  furni- 
titre  upon  the  table,  and  everything  was 
*  Archie,  Bii.  .\-.  Heft  I. 


Sleep 


[     117-     ] 


Sleep 


in  wild  contusion.  He  was  wide  awake. 
Next  day  he  was  removed  to  an  asylum 
and  recovered. 

(c)  'Hie  night  ierrors  of  children,  ((^ee 
Developmental  Insanities.) 

(d)  Hallucinations  in  a  half  asleep  state 
occasionally  occur  and  ought  to  be  in- 
cluded in  this  section.  As  Dr.  Folsom 
observes,  "  an  hallucination  of  sight  oc- 
curring a  single  time  is  not  uncommon  in 
people  in  reasonably  good  health.  Fre- 
quently repeated,  such  hallucinations  are 
less  rare  than  is  supposed,  without  any 
indications  of  mental  or  other  disease. 
Occasionally,  like  flashes  of  light,  they 
are  precursors  of  headache.  I  have  ob- 
served frequent  hallucinations  of  hearing 
only  once,  independently  of  insanity.  If 
of  a  distressing  nature  hallucinations  of 
sight  and  hearing  may  be  a  fruitful  source 
of  insomnia.  They  occur  beyond  the 
power  of  the  will  of  the  individual  to  call 
them  up,  although  it  is  sometimes  able, 
under  some  conditions,  to  cause  them  to 
disappear.  The  hallucinations  of  sight 
constitute  new  arrangements  of  mental 
impressions  which  can  be  more  or  less  re- 
collected, or  they  form  combinations  which 
seem  entirely  new.  Once  I  have  found 
two  sisters  subject  to  them,  and  once  two 
sisters,  a  cousin,  and  a  common  grand- 
mother ;  cui-iously  enough,  the  different 
members  of  the  families  not  knowing  each 
other's  peculiarities,  which,  however,  were 
quite  diff'erent  in  kind,  until  I  began  my 
investigations.  They  had  thought  them 
uncanny,  and  had  concealed  them."  * 

(e)  Ordinary  Sleep-walking  or  Somnam- 
bulism.— A  large  number  of  ipersons  are 
given  to  walking  in  their  sleep.  Practic- 
ally however  it  is  an  affection  peculiar  to 
childhood  and  youth.  It  rarely  affects 
idiots  and  imbeciles. 

We  proceed  to  describe  the  condition  of 
the  special  senses,  general  sensation,  the 
motor  system,  and  the  mental  functions 
in  sleep-walking,  based  upon  a  large  num- 
ber of  observations. 

Sight. — A  general  opinion  prevails  that 
sleep-walkers  have  their  eyelids  closed, 
but  are  able  to  see  clearly  in  consequence 
of  the  exaltation  of  the  sensory  apparatus, 
and  this  was  the  opinion  of  the  late  Dr. 
Guy.  In  the  first  place,  the  eyes  are  very 
frequently  open.  In  the  second  place  the 
visual  sense  is  extremely  acute,  and  the 
dilated  pupil  renders  it  easier  to  perceive 
objects  with  very  little  light.  Thirdly, 
the  sense  of  touch  is  exalted,  and  the  sleejD- 
walker  saves  himself  in  consequence  of  this 
fact  from  running  against  furniture,  &c. 
That    the    subject   may   write    correctly 

*  " Disorders  of  Sleep  :  Insomnia."  By  Ciiarles 
r.  Folsom,  M.D.     1890. 


although  some  object  is  interposed  between 
him  and  the  paper,  is  not  a  proof  that  he 
actually  sees  what  he  js  writing.  Thus, 
if  he  is  asked  to  cross  the  letter  t  or  to 
dot  the  letter  i  which  he  has  written,  he 
may  do  it  accurately,  but  if  the  paper  be 
removed  it  is  found  that  his  corrections 
are  not  in  the  right  places. 

Hearing. — Subjects  vary  in  this  respect. 
Some  do  not  hear  a  word  while  others 
hear  distinctly  and  respond. 

Smell. — The  same  remark  applies.  Some 
have  a  very  distinct  olfactory  perception 
— e.g.,  for  gas.  It  would  be  more  correct 
to  say  in  the  instance  we  have  in  mind 
that  it  was  of  a  subjective  character,  as- 
sociated with  a  di-eam. 

Taste.  —  Observations  are  somewhat 
meagre  upon  this  head,  but  a  subject  may 
enjoy  a  meal  with  apparent  relish  al- 
though not  remembering  the  flavour  after- 
wards. 

Tactile  Sensibility.  —  As  we  have  al- 
ready intimated  this  may  be  hypersesthe- 
sic.  On  the  other  hand,  the  pressure 
employed  when  carrying  the  sleep-walker 
to  bed  may  not  be  felt,  and  we  know  as  a 
matter  of  fact  that  the  subject  is  frequently 
not  aroused  thereby. 

Ansesthesia. — The  somnambulist  may  be 
entirely  insensible  to  pain.  It  is  needless 
to  say  that  this  is  consistent  with  acute- 
ness  of  touch. 

Motility. — The  ordinary  performances 
of  somnambulists,  and  indeed  the  etymo- 
logy of  the  word  sufficiently  show  that 
the  muscular  system  is  intact  and  allows 
of  wonderful  exploits. 

Mentality. — Many  of  the  remarkable 
statements  made  in  regard  to  the  mental 
performances  of  somnambulists  require 
careful  sifting  before  they  can  be  accepted. 
Facts,  however,  within  our  own  knowledge, 
demonstrate  that  not  only  ordinary  men- 
tal processes  ai'e  performed  by  sleep- 
walkers, but  that  much  more  elaborate 
work  may  be  performed,  for  example  pro- 
blems in  Euclid.  Lessons  may  be  learnt 
and  the  scholar  find  in  the  morning  to  his 
or  her  surprise  that  the  lesson  can  be 
correctly  said. 

Breaming. — In  all  pi-obability  a  dream 
immediately  precedes  and  accompanies  the 
action  taken  by  the  somnambulist.  Som- 
nambulism is  an  acted  dream.  In  many 
instances  the  subject  on  waking  can  recall 
accurately  the  particular  dream,  and  con- 
nect it  with  the  deed  which  was  performed 
during  sleep.  Out  of  the  dream  vivid 
hallucinations  arise,  which  may  determine 
the  character  of  the  act  performed. 

Speech. — Speaking  and  singing  are  by 
no  means  uncommon ;  moreover  the  som- 
nambulistic musician    may  jslay    in    liis 


Sleep 


[     1173     ] 


Sleep 


sleep  on  an  instrument  as  well  as  when  he 
i3  asleep  or  awake,  or  even  better. 

Mcdico-legid  RcJalio)is. — Criminal  acts 
have  been  performed  durint;  sleep,  and  an 
expert  realises  this  statement  as  beyond 
contradiction.  It  may  be  veiy  difficult 
if  not  impossible  to  distinguish  between 
ordinary  somnambulism  and  nocturnal 
epilepsy.  The  case  of  Eraser,  the  man 
who  took  away  the  life  of  his  boy  in  his 
sleep  is  perhaps  the  most  important  case 
which  has  found  its  way  into  a  court  of 
law.* 

Trcutmcnt.  —  Decided  measures,  al- 
though anj-^thing  like  cruelty  is  to  be 
severely  condemned,  appear  to  be  more 
effective  than  any  other  measurd  adopted 
to  put  a  stop  to  this  habit.  Boys  at 
school  are  frequently  cured,  especiall}'- 
when  it  assumes  the  character  of  an 
epidemic,  by  pouring  buckets  of  cold 
water  over  them  at  the  commencement  of 
their  attacks.  A  schoolmaster  states  to 
us  that  he  has  always  succeeded  by  the 
following  method:  Shortly  before  the 
3'outhful  somnambulist  retires  to  rest  his 
master  calls  him  aside,  and  speaking  in 
a  firm  and  solemn  tone  says,  "  I  find  you 
were  out  of  bed  and  making  a  disturbance 
in  your  room  last  night."  "  Sir,"  he  re- 
plies, "  I  was  asleep,  I  know  nothing  about 
it."  Then  the  master  replies,  "  I  will  say 
nothing  about  it  on  this  occasion,  but 
such  a  thing  must  not  occur  again." 
"  But  sir,  I  could  not  help  it,  I  was 
asleep."  "  Well,"  the  master  replies, 
"  you  hear  what  I  say.  I  would  not  advise 
you  to  let  it  occur  again."  Our  informant 
adds,  "  the  boy  leaves  me,  possibly  with 
the  feeling  that  he  is  being  somewhat 
hardly  dealt  with,  but  with  an  established 
operative  motive  for  checking  the  ten- 
dency to  somnambulism,  a  motive  which 
doubtless  will  continue  to  actuate  him 
even  in  sleep."  This  is  a  philosophical 
observation  ;  it  is  in  fact  adopting  the 
principle  of  checking  and  over-mastering 
one  automatic  process  occurring  in  sleep  by 
another  process  more  potent.  The  writer 
does  not  wish  it  to  be  inferred  that  moral 
or  corrective  means  alone  are  to  be  em- 
ployed. On  the  contrary,  it  is  important 
to  attend  to  the  general  health,  to  ad- 
minister bromides  in  some  instances,  and, 
more  important  perhaps  than  all,  to  avoid 
over-tasking  the  boy  or  girl  with  mental 
work,  especially  shortly  before  bedtime. t 

♦  .Sec  Journal  <if  Mental  Science,  1878,  p.  454. 

t  The  writer,  anxious  to  obtain  as  larg-e  a  num- 
ber of  cases  of  si)oiitaneou.s  somnambulism  as 
possible,  will  supply  a  printed  form  of  inquiry  to 
any  readir  who  will  oltligc  him  by  lilliui;  it  u]). 
Although  instances  of  the  activity  of  the  mental 
functions  during  sleep,  or  of  acts  performed  dau- 
yevous  to  others  are  of  especial  interest,  there  is  no 


(4)  Iioss  of  Sleep  as  a  Cause  and 
Consequence    of  Insanity. —  I'lHinmnuo 

is  the  indication  of  a  nu)rbid  condition. 
It  is  also,  when  prolonged,  some- 
thing more.  Loss  of  sleep  may  fre- 
quently be  a  cause,  or  one  of  several 
causes,  of  mental  disorder.  To  remove  it 
is  therefore  of  the  greatest  consequence  in 
the  early  treatment  of  the  insane.  In  a 
large  number  of  instances  it  is  doubtless 
the  consequence  and  not  the  cause  of 
mental  trouble.  The  agony  of  mind  asso- 
ciated with  melancholia,  or  the  rapid  flow 
of  ideas  in  acute  mania,  may  render  sleep 
an  almost  unattainable  boon,  and  in  these 
cases  it  requires  great  discrimination  to 
decide  when,  if  at  all,  to  administer  hyp- 
notics,    {ilee  Insomnia,  and  Sedatives.) 

(5)  Prolon§red  Sleep. — A  very  interest- 
ing case  has  recently  been  reported  from 
Germany.  Dr.  Wagner,  of  Konigshiitte 
(O.S,),  has  sent  a  preliminary  report  to 
Prof.  Heidenhain,  of  which  a  detailed 
account  will  shortly  be  pubHshed.  We 
are  indebted  to  Prof.  Heidenhain  for  per- 
mission to  make  use  of  it.  Dr.  Wagner 
states  that  the  account  of  the  sleeping 
luiner,  John  Latus,  as  it  appears  in  the 
pa]3ers  is  quite  true.  As  senior  medical 
officer  to  the  O.S.  Knappschufts-vereins  he 
has  frequently  visited  him  at  the  infirm- 
ary in  Myslowitz,  where  Dr.  Albers  has 
had  the  patient  under  his  special  care. 

The  patient,  with  hereditary  taint  (the 
father  had  hanged  himself)  had  maniacal 
attacks  which  marked  the  onset  of  an 
apparently  long  oncoming  psychosis. 
Shortly  after  he  fell  into  a  state  of  tetanic 
rigidity.  The  whole  musculature  of  the 
body  was  of  such  board-like  hardness  that 
one  could  place  him  in  the  standing  or 
recumbent  position  like  a  stick.  He  had 
to  be  fed  by  the  oesophageal  tube. 

This  condition  was  maintained  during 
four  months,  and  throughout  this  period 
it  was  not  possible  to  elicit  any  response 
whatever,  reaction,  or  sign  of  conscious- 
ness— the  nutrition  remaining  fairly  good. 

Then  he  gradually  awakened,  but  soon 
began  to  suffer  from  an  aspiiation  pneu- 
monia (Sclduck-jJneuvionie)  which  passed 
on  to  gangrene.  On  February  5,  1892, 
about  twenty  days  after  he  had  awakened, 
Dr.  Wagner  operated  on  account  of  this 
gangrene  with  free  resection  of  ribs.  The 
whole  of  the  lower  lobe  of  the  right  lung 
had  completely  sloughed,  and  was  con- 
verted into  a  liquid  of  indescribable  fetor 
— extensive  sloughs  then  came  away — 
neither  this  tissue  nor  the  expectoration 
ever  showed  tubercle  bacilli.  Although 
the   man's   powers   had  suffered  terrible 

case  so  simple  as  not  to  possess  .some  statistical 
value. 


Sleep 


[     1 1 74    ]      Smell,  Hallucinations  of 


depression   lie    j^et    hoped    to    briug  him 
through. 

At  the  present  time  the  patient's  mind 
is  quite  clear,  but  of  the  four  months' 
sleep,  and  of  the  preceding  period,  there  is 
absolutely  no  recollection.  Dr.  Wagner 
adds  that  he  has  not  been  able  to  find  any 
similar  case  in  literature. 

Since  the  foregoing  was  written  this 
patient  has  died.  The  autopsy  showed 
that  death  was  the  result  of  profound  ex- 
haustion. The  most  important  condition 
joresent  was  pulmonary  gangrene,  caused, 
perhaps,  by  hyjiostasis,  or  by  the  aspira- 
tion of  particles  of  food,  with  the  excep- 
tion of  slight  meningitis  of  very  recent 
date.  The  brain  was  perfectly  healthy. 
Deposits  of  a  nature  not  yet  ascertained, 
were  found  surrounding  the  spinal  roots 
of  the  motor  nerves.  These  deposits  have 
not  at  the  present  time  been  examined.* 

A  case  similar  in  many  respects  to  that 
of  Dr.  Albers  was  carefully  observed  by 
the  late  Dr.  Semelaigne  (Paris) :  The  j^a- 
tient,  a  man  of  fifty-six,  slept  for  seven 
months  without  interruption,  then  altei'- 
nating  periods  of  sleep  and  being  awake 
succeeded,  until  the  longest  period  of  all 
(the  thirty-ninth  attack),  which  lasted 
fifteen  months.  When  awake,  no  signs 
of  mental  disorder  were  observed.  When 
asleep  he  was  motionless,  absolutely  mute, 
the  eyelids  closed,  the  eyes  turned  i;p- 
wards.  The  expression  was  calm  and 
emotionless.  Pulse  60,  soft ;  respiration 
normal;  the  temperature  36". 7  (Cent.). 
He  died  July  19,  1883,  after  having  slept 
continuously  from  April  10,  1882,  without 
sign  of  returning  consciousness.  The 
autopsy  revealed  adhesions  and  consider- 
able wasting  of  the  convolutions,  especially 
of  the  psycho-motor  zone.f 

The  Editor. 

[Jie/ercnccs. — !JIaine  de  Biraii,  Nouvelles  con- 
siderations, sur  le  Sommeil,  los  Souges  et  le  Somnam- 
bulisme,  ed.  Cousin.  L.  F.  Alfred  Maury,  Le 
Sommeil  et  les  Keves,  quatrieme  edition,  1878. 
Albert  Lemoine,  Bu  Sommeil  au  jioint  de  ^'ue 
Physiologique  et  PsycliolGgique.  John  Addington 
Syuionds,  Sleep  andDreams,  1851.  Kobert  Macnisli, 
The  Philosophy  of  Sleep,  third  edition,  1831. 
Edward  P>inns,  M.D.,  The  Anatomy  of  Sleep, 
second  edition,  1845.  Max  Simon,  Le  Monde  des 
Keves,  1888.  A.  E.  Durham,  Physiology  of  Sleep, 
Guy'.s  Hosj).  Keps. ,  i860.  C.  A.  Moore,  On  Going  to 
Sleep,  1868.  J.  Cappie,  On  the  Causation  of  Sleep, 
1882.  Idem,  The  Intra-cranial  Circulation  and  its 
Kelation  to  the  Physiology  of  the  IJrain,  1890.] 

*  Lancet,  April  9,  1892. 

f  Annates  Med.  Psi/ch.,  Jan.  1885,  p.  39. 
Among  the  references  to  cases  of  prolonged  sleep 
(narcolepsy)  given  by  Semelaigne  are  "  Diet,  des 
Sci.  Med.,"  t.  iv.  j).  204  :  t.  xxiil.  p.  548  :  Joiirn. 
de  Mi:d.  et  de  Pharin.,  Oct.  1754,  Fev.  1755,  Juiu 
1766  ;  Franck,  '•  Path.  Interne,"  t.  iii.  p.31  ;  Arch, 
gen.  de  Med.,  t.  i.  p.  734,  1863  ;  et  t.  i.  p.  98,1866; 
Legrand   du    Saullc,   Caz.  des  Hop.,  Nov.    1869; 


SIiEEP  -  DZSSiVSZ:,      SIiESP      EPZ- 

IiEPiSVi     Synonyms  of  Narcolepsy  ici.v.). 

SIVIEZiXi,     HAX.XiirCZIO'ATXOlXrS     OF. 

— These  may  occur  in  health  or  in  dis- 
ease. The  very  idea  that  a  substance  will 
smell  badly  may  have  the  effect  of  pro- 
ducing the  sensation ;  thus,  as  in  other 
cases,  hallucinations  may  arise  from  ex- 
pectation. 

In  mental  disease  there  may  be  other 
disorders  of  smell  besides  hallucination. 
Thus  it  has  been  pointed  out  by  Yoisin 
that  in  a  certain  number  of  cases  of 
general  paralysis  of  the  insane,  loss  of 
power  to  detect  the  smell  of  pepper  is 
common  :  and  we  have  met  with  one  case 
of  recurring  insanity  in  which  anosmia 
was  the  first  symptom  in  each  attack. 

Simple  hallucinations  of  smell  are  less 
common  than  are  hallucinations  of  the 
other  senses. 

Hallucinations  of  smell  may  be  simple 
and  isolated  in  a  few  rare  instances,  bat 
it  is  much  more  common  to  meet  them 
associated  with  other  hallucinations ;  thus, 
perversions  of  taste  as  well  as  of  smell 
are  often  associated.  Alterations  in 
cutaneous  sensibility  too  are  common  with 
this ;  thus,  a  patient  may  believe  that  there 
is  a  bad  smell  coming  from  his  body  and 
may  also  complain  of  general  uneasiness 
of  the  skin  ;  in  such  cases  a  constant  de- 
sire to  wash  (the  skin)  is  common.  Next 
in  frequency,  in  association  with  the  hal- 
lucinations of  smell  we  meet  with  those 
of  sight,  and  we  think  that  perversions 
of  hearing  are  but  rarely  so  associated. 

Hallucinations  of  smell  may  appear  as 
2Jrimary,  leading  to  other  symptoms  of 
mental  disorder,  or  they  may  be  secondary, 
brought  out,  as  it  were,  by  the  delusions 
from  which  the  patient  is  already  suffer- 
ing. In  such  cases  expectancy  plays  an 
important  part  allied  with  association  of 
ideas  ;  thus  a  person  who  believes  himself 
to  be  in  hell  may  comjilain  of  the  suffocat- 
ing odour  of  brimstone. 

Hallucinations  of  smell  ma}^  be  pleo.soAit 
or  unpleasant.  It  is  but  rarely,  however, 
that  simple  hallucinations  are  pleasant. 
We  have  met  with  hallucinations  in  plea- 
sant association  ;  thus  a  young  man  who 
used  to  have  communion  with  a  spiritual 
wife  told  me  that  when  alone  with  her 
he  had  the  most  delicious  smells,  but  that 
at  certain  other  times  the  smells  were 
horrid,  when  another  S2:)irit  joined  them. 

The  hallucinations  of  smell  ditfer  in 
character.  Thus  they  may  be  constant ; 
this  is  rarely  the  case,  and  then  is  pro- 

Sandras,  "  Mai.  Xerveuses,"  t.  i.  p.  427.  Prof. 
Gairdner  has  published  a  ease  of  "  Abnormal  Dis- 
position to  Sleep"  in  the  Edin.  Med.  Journ..  July 
1871.     (iaz.  Hcbdom.,  1884,  p.  727. 


Smell,  Hallucinations  of 


1 175     ]        Softening  of  the  Brain 


bably  associated  with  some  organic  cause. 
Tliey  are  comnwiily  rccurreni,  thus  they 
may  recur  with  each  meustrnal  period,  or 
may  be  worse  at  night  or  early  morning. 
Tliey  may  be  simply  diti'usive  or  thoy  may 
occur  in  gusts  or  waves.  Gusts  of  odours 
occur  iu  some  cases  of  epilepsy. 

Hallucinations  of  .smell  may  depend  on 
the  higher  central  nervous  system  or  on 
the  peripheral  sense  organs. 

We  have  met  with  one  case  in  which 
disease  of  the  terni)oral  bone  followed  by 
abscess  in  the  temporo-sphenoidal  lobe 
was  connected  with  hallucinations  of 
smell.  Another  case,  with  abscess  in  the 
corpus  callosuni,  has  also  been  noticed  by 
Cabanis  quoted  by  Morel.  We  have  met 
with  similar  disorder  of  smell  preceding  an 
attack  of  apoplexy,  and  we  believe  it  is 
not  very  uncommon  in  other  forms  of 
coarse  brain  lesion;  such  cases  may  do 
something  towards  defining  the  olfactory 
cortical  centre.  Similar  hallucinations 
may  arise  from  disease  of  the  ethmoid 
plate  :*  and  it  is  certain  that  dryness  of 
mouth  and  gastro-intestinal  catarrh  may 
start  these  hallucinations. 

As  far  as  forms  of  mental  disorder  are 
concerned,  we  do  not  know  any  in  which 
these  hallucinations  may  not  be  present ; 
they  occur  in  delirious  states  and  may  lead 
to  refusal  of  food ;  they  may  arise  in 
melancholia  and  support  the  ideas  of  hell 
or  of  burning  or  torture  which  is  in  store 
for  the  sufferer  ;  they  may  give  colour  to 
the  suspicion  of  the  deluded  patient,  con- 
vincing him  that  poison  is  being  intro- 
duced into  his  food  to  kill  him,  or  that 
some  love  philtre  is  being  used  to  cause 
him  to  commit  some  sexual  fault.  In  a 
few  cases  of  general  paralysis  with  melan- 
cholic symptoms  of  the  hypochondriacal 
type,  there  are  hallucinations  of  smell ; 
they  may  be  present  in  epileptic  insanity. 
The  smells  themselves  are,  as  a  rule,  very 
limited  in  kind.  This  depends  on  the 
restriction  in  our  olfactory  powers  de- 
pending on  partial  neglect.  It  is  note- 
worthy that  this  sense  is  used  but  little  as 
a  factor  of  higher  mind  in  civilised  man, 
and  many  of  its  perversions  appear  to  be 
allied  to  reversions. 

The  pleasant  smells  are  mostly  those  of 
flowers  or  of  artificial  scents.  The  bad 
odours  are  acrid  or  foetid,  the  latter  being 
more  common.  Thus  we  have  smells  of 
faeces,  of  rotting  bodies,  of  burning,  cook- 
ing, of  electricity  or  sulphur.  There  are 
in  some  cases  connecting  links,  or  asso- 
ciated sensations,  so  that  some  complain 
of  "  strangling  smells,"  "  smells  of  human 
blood,"  &c. 

*  Sec  "Records  of  Vienna  A-yliini  Reports," 
1858,  p.  200. 


The  most  interesting  association  to  our 
mind,  is  that  met  with  between  hallucina- 
tions of  smell  and  perversion  of  the  func- 
tions of  the  reproductive  organs.  Whether 
this  is  a  true  reversion  or  not  we  cannot 
say,  but  it  is  interesting  to  recall  the  fact 
that  among  the  lower  animals  the  sense  of 
smell  is  nearly  related  to  the  reproductive 
functions,  smell  acting  with  them  as  sight 
does  with  the  higher  animals  as  a  stimulus 
to  passion.  In  the  lower  classes  there 
still  seems  to  be  a  strong  feeling  in  favour 
of  strong  scents  among  the  younger 
women  as  an  attraction.  But  to  return 
to  the  occurrence  of  hallucinations  of  smell 
in  mental  disorders  associated  with  sexual 
disorders.  It  is  certain  that  these  hallu- 
cinations are  common  in  the  mental  dis- 
orders of  adolescence,  especially  those  in 
which  masturbation  plays  a  part.  Both 
young  men  and  young  women  suffering 
from  insanity  of  adolescence  often  com- 
plain of  filthy  odours  which  seem  to  arise 
near  them,  and  which  they  may  believe  to 
emanate  from  their  bodies  or  from  their 
surroundings. 

In  some  cases  of  puerperal  insanity  we 
have  met  with  similar  complaints  of  un- 
pleasant odours ;  they  are  particularly 
common  at  the  climacteric  period  and  may 
pass  off  at  the  menopause. 

In  one  case  at  least,  hallucinations  of 
this  nature  were  i^resent  in  a  patient 
suifering  from  ovarian  disease,  and  these 
persisted  till  the  diseased  ovary  was  re- 
moved, since  which  time,  though  still 
insane,  the  patient  has  had  no  smell 
troubles.  This  appears  to  us  to  be  a 
crucial  case.  In  one  or  two  senile  cases 
of  melancholia  who  complained  of  suffer- 
ing in  consequence  of  "the  sins  of  their 
youth,"  such  hallucinations  have  been 
present,  but  we  do  not  think  these  due  to 
simple  sensations.  But  in  some  elderly 
men  with  great  development  of  sexual 
desire  we  have  met  with  these  smell  hal- 
lucinations, and  we  think  the  association 
is  noteworthy.  George  H.  Savage. 

SOCIETIES  FOR  THE  STUDV  OF 
PSVCHOIiOGICil.Ii         IVEEBICXIO'E.   — 

These  exist  in  various  European  countries, 
and  in  the  United  States  of  America. 
They  are  named  in  the  Bibliography 
apiDcnded  to  this  work,  together  with  the 
periodicals  published  by  their  authority. 
OS'ee  Medico-Psycuological  Association.) 

SOCORDIA,  or  SECORSIA  {sf,  with- 
out;  cor,  heart).  Without  intellect  or 
understanding.     Heartless. 

SOFTENIiarC  OF  THE  BRAIItJ. — A 
very  loose  term  amongst  the  laity,  mean- 
ing with  them  almost  any  form  of  insanity. 
In  medicine  it  is  a  pathological  state  de- 
pending  on    changes  in   the   circulatory 


Somnambulism 


[     1 1 76    ] 


Sopor 


system,  usually  local  and  with  s^aiiptoms 
varying  according  to  the  part  affected. 
{See  General  Pakatasis.) 

SOMlTiLIVIBUIiXSllI  {somnus,  sleep ; 
amhith^,  1  walk).  Walking  in  one's  sleep. 
(Fr.  somnainhnJisnic  ;  Ger.  Schlaftvan- 
deJn.)  It  is  important  to  recognise 
clearly  the  fact  that  long  prior  to  the 
induction  of  artificial  somnambulism 
phj'sicians  met  from  time  to  time  with 
cases  of  spontaneous  somnambulism,  not 
merely  of  the  common  sleep-walking 
variety,  but  i:)resenting  phenomena  of 
a  remarkable  character,  and  occurring 
in  ihe  day-time.  Lorry  is  said  to  have 
been  the  first  to  have  described  this 
abnormal  condition.  Sauvages  recorded 
cases  of  this  description  under  the  head 
"  Cataleptic  Somnambulism."  One  of 
these  is  to  be  found  in  the  Histoire  de 
1' Academic  des  Sciences  in  the  year  1742.* 
A  female  in  a  hospital  was  subject  to 
attacks  commencing  with  a  fit  of  cata- 
lepsy lasting  about  five  minutes.  She 
then  began  to  yawn  and  sit  up  in  bed. 
Her  conversation  was  animated  in  an 
unusual  degi'ee,  and  she  directed  it  to 
friends  whom  she  supposed  to  be  around 
her.  Her  remarks  were  connected  with 
those  which  she  had  made  in  a  similar 
attack  the  day  before.  Her  eyes  were 
open,  although  a  number  of  experiments 
proved  she  was  fast  asleep.  There  were 
no  signs  of  feeling  or  perception  when  a 
light  was  brought  so  near  to  the  eye  as  to 
singe  the  eyebrows,  when  a  stunning 
noise  was  suddenly  made  near  her,  when 
strong  ammonia  was  placed  under  her 
eyes  or  in  her  mouth,  or  when  a  feather 
or  a  finger  was  applied  to  the  cornea,  or 
when  snuff"  was  blown  into  the  nostrils 
or  she  was  pricked  with  jiins.  She  was 
able  to  walk  about,  avoid  coming  in 
contact  with  the  furniture,  and  would 
then  return  to  her  bed,  and  again  be- 
come cataleptic.  Sometime  afterwards 
she  awoke,  and  had  not  the  slightest 
remembrance  of  what  had  occurred.  In 
a  case  recorded  by  Lorry  a  woman  pi'e- 
sented  very  similar  symptoms.  The  cata- 
leptic condition  of  the  arms  and  fingers 
was  very  marked. 

The  case  described  by  Dr.  Dyce,  of 
Aberdeen,  belongs  to  the  same  class,  and 
is  familiar  to  those  who  have  studied  the 
subject.  A  girl  aged  sixteen  began  to 
fall  asleep  in  the  evening,  and  would  talk 
in  a  coherent  manner.  She  also  sang. 
On  one  occasion  she  thought  that  she  was 
on  her  way  to   the   Epsom   races,   and, 

*  This  and  other  instiinces  of  spontaneous  som- 
nambiilisni  will  bo  found  in  Dr.  Prichard's  '■  Trea- 
tise on  Insanity  and  other  Disorders  alfecting  the 
Mind, '  1835,  pp.  445-452. 


placing  herself  on  a  stool,  rode  into  the 
room.  She  answered  questions  without 
being  aroused,  dressed  the  children  of  the 
family,  and  in  one  instance  prepared  the 
table  for  breakfast,  her  eyes  being  closed. 
In  this  state  she  was  taken  to  church  and 
was  aff'ected  by  the  sermon.  After  coming 
out  of  the  fit  of  somnambulism,  when  she 
returned  home,  she  asserted  that  she  had 
not  been  to  church.  In  a  subsequent 
attack,  however,  she  correctly  stated  the 
text  and  the  substance  of  the  discourse, 
which  referred  to  the  execution  of  three 
young  men. 

In  these  and  many  other  cases  which 
could  be  quoted  on  the  best  evidence,  we 
witness  a  remarkable  condition  of  the 
mental  sensory  and  motor  functions, 
arising  spontaneously,  to  which  vari- 
ous names  have  been  applied,  accord- 
ing as  certain  symptoms  were  most  pro- 
minently marked.  If  the  limbs  can  be 
retained  for  any  length  of  time  in  the 
position  in  which  they  are  placed,  then 
the  case  is  called  one  of  catalepsy.  If  the 
expression  is  fervid  and  suggests  abstract 
contemplation  while  unconscious  of  sur- 
rounding objects,  the  case  is  labelled 
ecstasy.  Again,  both  these  terms  have 
been  employed  in  association  with  the 
somnambulistic  condition  of  the  patient, 
and  then  the  compound  term  "  cataleptic 
somnambulism "  or  "  ecstatic  somnam- 
bulism "  has  been  employed.  The  funda- 
mental condition,  however,  is  the  abnormal 
sleeji.  In  ordinary  sleep-walking  the 
motor  centres  are  awake,  and  locomotion 
is  easily  performed.  In  catalepsy  and 
ecstasy  these  centres  are  asleep,  and  the 
subject  may  be  totally  unable  to  stir  a 
limb.     {See  Sleep,  p.  1172.) 

The  Editor. 

soiviTarAiviBiTi.zsniE:  provoqve. 
French  term  for  the  hypnotic  sleep. 

SOIKCN'Z.A.TZO.  Dreaming.  {See 
Dreaming.) 

SOIVIM'IiiTIO  IVIORBOSA.  In  statu 
vigilii.     Hallucination. 

SOIVIN'II.OQVISIVI,  SOIVIN-ZI.O- 
QUIUIVI  {somnus,  sleep  ;  loqnor,  J  speak). 
Talking  in  one's  sleep. 

sOMiJ'OiiEM'TX.a.  {somnus,  sleep). 
Sleepiness,  somnolence.  (Fr.  assoupisse- 
ment ;     Ger.  Sclih'ifrigl-eit.) 

SOIvnarOPATHV  (.soiuiius,  sleep;  Trace's-, 
suffering.    Magnetic  Scmnambulism. 

SOIWN'OVZGZIi  {somnus,  sleep;  mgilo, 
I  watch).     Somnambulism. 

SOFHOMAN'ZA.  (cro(^6s',  a  wise  man  ; 
fiav'ia,  madness).  A  species  of  megalo- 
mania in  which  the  patient  vaunts  his 
superior  wisdom. 

SOPOR.  Deep  sleep.  (Fr.  asscupis- 
sement ;  Ger.  SchUifrigkeit.) 


Soporarius 


[     1 1 77    ]  Spain,  Provision  for  Insane  in 


SOPORARIUS,  SOPORIFEROUS 

(.s'OjJor.  deep  sleep  ;fero,  I  brius^).    Having 
the  power  of  inducing  deep  sleep. 

SOUNDNESS  or  MIND.  {Src  NON 
COMI'OS  jNIkntis.) 

SOURD  IVIUET.     Doiif-mntisni. 

SOVEREIGN.  INSANITY  OF.  — 
When  the  exorcise  of  the  royal  authority 
is  temporarily  interrupted  by  the  insanity 
of  the  Sovereign  the  constitutional  method 
of  providing  for  the  administration  of 
the  executive  power  with  which  he  is 
entrusted  is  the  appointment  of  a  Regent 
by  the  two  Houses  of  Parliament.  There 
are  two  i^recedents  for  this  course,  cue  in 
the  reign  of  Henry  VI.  (1454),  the  other 
in  tlie  reign  of  George  III.  (1788-1810). 
On  the  latter  occasion  select  committees 
to  examine  the  King's  physicians  touching 
the  state  of  his  health,  to  inquire  into 
precedents,  and  to  report  thereon  to  the 
House,  were  appointed.  The  Prince  of 
Wales  was  appointed  Regent. 

A.  Wood  Renton. 

SPACE. — The  characteristic  of  presen- 
tations of  sense  is  that  they  have  space 
form.  This  distinguishes  them  from  mere 
sensations. 

SPACE,  OPEN.     (See  Agoraphobia.) 

SPAIN,  PROVISION  FOR  THE  IN- 
SANE IN. — The  early  history  of  the  in- 
sane in  Spain,  in  so  far  as  it  is  at  present 
known,  begins  with  the  establishment  of 
an  asylum  at  Valencia  in  1408.  This  was 
accomplished  by  Fray  Gope  Gilaberto.  It 
is  certain  that  four  special  buildings,  pre- 
sumably religious  houses,  were  erected  in 
various  parts  of  the  country  before  the 
end  of  the  fifteenth  century.  The  honour 
of  taking  the  initiative  in  thus  providing 
for  the  insane  has  therefore  been  claimed 
for  Spain,  although  it  is  on  record  that 
six  male  patients  [homines  niente  capti) 
were  confined  in  Bethlem  Hospital  as  early 
as  1403.  But  it  is  ver)--  probable  that  in 
this  sphere  of  charity  the  Spaniards  were 
following  the  lead  of  the  IMohammedans, 
who  founded  and  endowed  similar  estab- 
lishments shortly  after  the  proclamation 
of  Islam.  The  spirit  of  active  philan- 
thropy which  impelled  Fray  Gilaberto 
to  his  efforts  at  Valencia,  was  also  mani- 
fest in  one  of  the  early  caliphs,  who  not 
only  provided  maintenance  for  the  insane 
inmates  of  the  Morestan  at  Cairo,  but  also 
sought  to  make  existence  more  tolerable 
by  a  daily  concert  of  music.  And  we 
may  agree  with  Dr.  Lockhart  Robertson 
that  the  Moor  v/ould  hardly  have  left  such 
a  monument  of  ignorant  neglect  as  the 
Granada  Asylum  lying  under  the  walls  of 
his  much-loved  Alhambra ;  for  whatever 
credit  may  attach  to  the  pious  care  of  the 
Middle  Ages,  the  legislation  and  general 


arrangements  for  the  protection  of  the 
Spanish  insane  are,  at  present,  jsrobably 
more  defective  than  in  any  other  civilised 
state. 

Lunacy  laws,  in  the  ordinary  sense  of 
the  term,  can  hardly  be  said  to  exist;  and 
it  is  only  of  late  years  that  provision  for 
adequate  asylum  accommodation  has  been 
here  and  there  attempted. 

This  brief  article  is  designed  to  ])resent 
a  resmnV'  of  the  laws  dealing-  with  the 
Insane,  and  the  various  ])rojects  of  suces- 
sive  governments  ;  and  also  to  give  some 
accoiint  of  the  asylums  now  open  to 
patients. 

A.  Historical. —  Until  about  forty  years 
ago  the  care  of  the  insane  was  entirely  in 
the  hands  of  private  institutions.  Some  of 
these  date  from  the  Middle  Ages,  and  most 
of  them  are  under  the  control  of  clerical 
corporations.  The  earliest  recorded  foun- 
dations were  due  to  the  Beneficencia 
(Charitable  Corporations),  and  not  to  any 
action  of  the  State  or  local  authorities. 
The  opening  of  the  asylum  at  Valencia, 
already  alluded  to,  was  followed  by  King 
Alfonso  V.  of  Aragon  founding  the  "House 
of  our  Lady  of  Grace,"  at  Saragossa  in 
1425  ;  by  Francisco  Ortiz  founding  the 
Casa  del  Nuncio  at  Toledo  in  1483  ;  and 
by  similar  establishments  at  Seville* 
(1436),  and  at  Valladolid  (1489).  Pinel 
spoke  in  terms  of  high  praise  of  the  asy- 
lum at  Saragossa,  but  had  never  visited  it. 
Later  accounts  of  it  are  distinctly  less 
favourable  ;  but  it  should  be  mentioned 
that  the  institution  referred  to  by  Pinel 
was  burnt  in  1 808  and  replaced  by  another 
building. 

These  fifteenth  -  century  foundations 
were  the  only  regular  lunatic  asylums  in 
Spain  until  a  comparatively  recent  period, 
and  it  was  only  after  the  Napoleonic  wars 
that  modern  ideas  were  introduced  and 
eventually  affected  the  fundamental  laws 
of  the  country.  The  levelling  principles 
of  the  French  Revolution  were  then  ap- 
plied to  the  complex,  medigeval  institu- 
tions which  still  persisted.  A  statute  was 
promulgated  in  1822  affecting  all  charit- 
able properties,  and  the  meagre  provisions 
of  this  law  constitute  the  foundation  of 
the  modern  legislation  in  regard  to  the 
insane.  It  decrees  the  foundation,  in 
every  province,  or  groups  of  two  or  three 
provinces,  of  a  public  asylum  for  the  re- 
ception of  lunatics  of  every  kind.  These 
asylums  are  to  be  managed  by  the  pro- 
vincial authorities,  subject  to  the  super- 
vision of  Government.  They  are  to  be 
managed  on  humane  principles. 

This  law  emjjowers  private  individuals 
to  establish  and  conduct  asylums,  under 
-    CJ.  "  Don  <2ui.xotc',"  part  ii.  ehai).  i. 


Spain,  Provision  for  Insane  in  [     1 178    ]  Spain,  Provision  for  Insane  in 


the  inspection  of  the  provincial  authori- 
ties. The  rules  for  admission,  treatment 
of  patients,  etc.,  were  to  be  provided  by  a 
special  regulation  which  has  never  yet 
been  issued.  The  unhappy  condition  of 
the  country  caused  this  statute  to  remain 
a  dead  letter  until  1836,  notwithstanding 
the  eloquent  remonstrance  of  Sehor  Bur- 
gos, Minister  of  Fomento.  It  was  not 
until  1846  that  Dr.  Don  Pedro  Rubio, 
body  physician  to  Queen  Isabella,  after  a 
visit  to  the  principal  existing  asylums, 
recommended  that  a  Government  inquiry 
into  the  whole  question  should  be  insti- 
tuted. Great  diiSculty  was  experienced 
in  ascertaining  the  facts ;  but  it  appeared 
that  at  that  time  (1847)  in  all  Spain  there 
were  sixty-six  institutions  where  insane 
patients  were  received.  These  were 
classed  as  follows  : — 

4  asylums  exclusively  for  the  insane  ; 

32  common  hospitals; 

10  houses  of  mercy  (religious  hospitals); 
2  hospitals  for  children  and  foundlings; 

16  gaols  ; 
I  nunnery; 
I  convict  establishment. 

The  total  number  of  inmates  was  1626  ; 
of  these  1 5 1  were  supported  by  their  fami- 
lies, and  the  others  by  municipal  or  indi- 
vidual charity.  The  number  of  lunatics 
living  in  private  care  was  stated  at  5651  ; 
but  there  is  reason  to  believe  that  this 
should  have  been  much  greater. 

Dr.  Rubio  then  reported  that  the  state 
of  the  insane  was  most  deplorable,  and 
that  their  condition  did  not  practically 
diifer  from  what  is  described  in  the  pages 
of  Cervantes.  He  found  them  "  worse 
treated  than  the  most  atrocious  felons." 

Briefly,  the  outcome  of  this  I'eport  was 
a  statute,  passed  in  1849,  which  was  de- 
signed to  place  all  lunatic  asylums  under 
the  exclusive  control  of  the  State.  It  was 
supplemented  by  another  law  (18^2),  which 
emphasised  the  position  previously  taken — 
that,  ijiter  alia,  all  asylums  were  national 
as  opposed  to  provincial  or  municipal. 
Moreover,  it  was  determined  to  found  six 
national  lunatic  asylums  —  in  Madrid, 
Saragossa,  Valladolid,  Corunna,  Granada, 
Valencia,  and  Barcelona.  But  only  one 
of  these  was  erected  —  at  Leganes  near 
Madrid.  In  1859  a  royal  decree  was  pro- 
mulgated for  the  erection  of  this  asylum, 
and  the  design  was  thrown  open  to  com- 
petition amongst  architects  of  all  coun- 
tries. In  response  to  the  programme 
then  set  forth,  Dr.  Desmaisons  of  Bor- 
deaux went  to  Spain  and  visited  the  vari- 
ous asylums.  His  experiences  were  set 
forth  in  a  little  book,  published  in  1859 — 
"  Des  Asiles  d'Alienes  en  Espagne  ;  Re- 
cherches  Historiques  et  Medicales."     He 


specially  drew  attention  to  the  fact  that 
it  is  the  custom  in  all  parts  of  Spain  to 
place  the  insane,  when  not  retained  at 
home,  for  a  certain  period  after  the  attack, 
in  the  lunatic  ward  of  a  general  hospital, 
or  hospice  ;  and  to  defer  their  removal  to 
an  asylum  until  the  prospects  of  cure  have 
well-nigh  vanished.  This  custom  still 
survives  to  a  great  extent ;  and,  although 
the  hospital  physicians  of  Spainare  mostly 
trained  in  such  famous  schools  as  Paris, 
the  condition  of  the  insane  under  their 
care  continues  to  be  a  reproach  to  Chris- 
tendom. The  hospital  treatment  of  in- 
sanity in  Spain  cannot  be  regarded  as 
triumphant ;  the  country  is  moving  slowly 
in  the  same  direction  as  other  States,  and 
seeking  success  by  similar  administrative 
expedients.  Dr.  Desmaison's  book  also 
treats  of  the  history  of  the  Spanish  asy- 
lums, and  he  specially  refers  to  the  initia- 
tive taken  by  Spanish  subjects  in  estab- 
lishing similar  institutions  in  Italy, 
among  which  the  asylum  of  Rome  is  cited 
as  a  remarkable  example. 

It  is  unnecessary  to  refer  in  detail  to 
the  shifting  policy  of  unstable  govern- 
ments, which  entailed  contradictory  laws 
and  evanescent  attempts  to  grapple  with 
the  question  successfully.  The  turning- 
point  seems  to  have  been  reached  in  1864, 
when  the  Government  reverted  to  the 
ideas  of  1822,  and  by  circular  urged  the 
provincial  assemblies  to  found  either  asy- 
lums or  lunatic  establishments  in  the  hos- 
pitals of  each  provincial  capital. 

Seven  out  of  the  fourteen  provinces  of 
Spain  found  means  to  carry  this  into 
effect,  and  private  asylums  had  been  es- 
tablished until,  in  1879,  the  following 
institutions  were  reported  to  be  existent: 

1.  National  Asylum,  one  only.  —  At 
Leganes,  near  Madrid;  patients,  179. 

2.  Provincial  Asylums,  seventeen.  — 
((()  Seven  wards  in  seven  hospitals  de- 
voted to  the  cure  of  other  diseases;  pa- 
tients, 298.  (6)  Ten  asylums,  four  of 
which  date  from  the  fifteenth  century  ; 
patients,  2147. 

3.  Private  Asylums,  eight. — (o)  Four 
constituted  by  Royal  order  ;  patients,  762. 
(6)  Four  licensed  by  the  provincial  com- 
mittees for  benevolent  institutions ;  pa- 
tients, at  least  163. 

It  will,  therefore,  be  recognised  that  the 
accommodation  for  insane  patients,  ac- 
cording to  the  latest  procurable  return,  is 
extremely  meagre.  Spain,  with  a  popula- 
tion of  16,500,000,  provides  asylum  treat- 
ment for  less  than  4000  lunatics,  while 
nearly  one-fourth  of  that  number  are 
placed  in  private  asylums,  at  least  two  of 
which  appear  to  be  purely  commercial 
undertakings. 


Spain,  Provision  for  Insane  in  [     1 179    ]  Spain,  Provision  for  Insane  in 


B.  Administrative.—  It  is  not  requi- 
site to  present  in  detail  the  regulations 
governing  these  institutions.  They  are 
cumbrous  and  incomplete. 

Although  there  is  no  law  to  compel  the 
propi'ietors  ot  lunatic  asylums  to  obtain  a 
licence,  Dr.  Esqnerdo  positively  states 
that  one  is  never  established  without  the 
consent  of  the  provincial  committee,  but 
such  consent  is  never  refused.  The  cir- 
cumstances above  detailed  must  make  it 
difficult  for  a  committee  to  withhold  con- 
sent ;  besides,  it  is  to  be  remembered  that 
all  private  asylums  are  subject  to  the  in- 
spection of  the  provincial  committee.  By 
royal  decree  and  subsequent  instruction 
certain  returns  must  be  made  to  the  cen- 
tral Government.  For  instance,  the  Pro- 
vincial committee  must  report  upon  the 
origin,  character,  patrons,  administrators, 
&c.,  of  all  benevolent  institutions. 

The  rules  regulating  the  admission,  de- 
tention, and  discharge  of  patients  vary 
with  the  bye-laws  of  each  asylum.  Ex- 
cei:>t  in  the  case  of  the  one  national  asy- 
lum, they  have  no  statutory  force,  and 
may  be  altered  from  time  to  time  by  the 
provincial  authorities.  As  a  general  rule, 
a  judicial  sentence,  as  well  as  a  medical 
certificate,  is  required,  but  this  is  by  no 
means  without  exception.  The  proprie- 
tors of  most  of  the  private  asylums  re- 
quire a  medical  certificate,  "  to  avoid  in- 
curring resjionsibility."  The  improper 
detention  of  a  person  in  an  asylum  or 
elsewhere  is  punishable  by  the  penal  code, 
and  carries  very  severe  sentences.  It  is  a 
criminal  offence.  The  law  of  1849  ex- 
pressly provides  that  no  one  shall  be  de- 
tained in  any  benevolent  institution  for  a 
longer  period  than  that  necessary  for  his 
treatment  and  relief ;  but  his  departure 
must  be  preceded  by  a  written  licence 
from  the  director.  If  any  question  arises 
as  to  the  improper  confinement  of  a  person 
in  an  asylum,  the  proof  lies  with  the  phy- 
sician who  certified  his  lunac}-  rather  than 
with  the  proprietor  of  the  asylum  ;  and 
it  will  be  at  once  evident  that  judicial 
sentences  are  avoided,  inasmuch  as  they 
mean  formal  and  public  "  incapacitation,*' 
besides  another  judicial  sentence  on  re- 
covery. 

Alcubilla  ("  Diccionario  de  la  Adminis- 
tracion  Espahola  ")  states  that  two  certi- 
ficates are  necessary,  one  a  medical  state- 
ment of  the  patient's  insanity,  and  ano- 
ther emanating  from  the  municipality, 
setting  forth  the  pecuniai'y  circumstances 
of  the  patient.  If  he  is  in  poor  circum- 
stances the  local  authorities  are  em- 
powered to  act. 

The  law  provides  for  the  inspection  of 
every  class   of    asylum,  and   states   the 


authorities  empowered  to  carry  out  the 
work  of  inspection ;  but  it  has  only  the 
appeai'ance  of  completeness.  Briefly,  the 
]\Iinister  of  the  Interior  has  direct  control 
over  the  one  national  asylum,  and  also 
direct  control  over  the  provincial  com- 
mittees. The  chief  of  each  committee  is 
the  civil  governor  of  the  province,  but  his 
duties  are  too  multifarious  and  urgent  to 
permit  of  his  undertaking  the  woi*k  ot 
inspecting  asylums.  It  should  be  noted, 
however,  that  by  a  royal  order  a  ladies' 
committee  of  visitation  was  constituted 
under  the  presidency  of  the  Princess  of 
the  Asturias  in  1875. 

But  there  are  now  no  paid  inspectors, 
and  the  powers  of  visitation  are  only 
optional,  so  that  the  theoretic  efficiency  of 
the  law  is  worsted  by  its  practical  failure. 
The  country  is  poor,  the  Government  un- 
stable, and  the  people  demoralised.  Until 
better  days  dawu  for  Spain,  the  condition 
of  the  insane  will  remain  an  indication  of 
national  disaster.  Now,  however,  there 
are  distinct  signs  of  happy  augury.  The 
more  recent  accounts  of  Spanish  asylums 
show  an  improvement  all  along  the  line. 

0.  Establishments. — The  writer  has 
no  intention  to  recapitulate  the  experi- 
ences of  those  travellers  who  have  de- 
scribed the  backward  state  of  Spanish 
asylums.  He  prefers  to  indicate,  in  few 
words,  what  is  being  done  to  remove  the 
reproach  of  the  past  in  face  of  many  and 
almost  insuperable  difficulties. 

No  one  who  is  interested  in  this  subject 
can  visit  Madi'id  without  coming  in  con- 
tact with  Dr.  Esqnerdo,  who  established, 
unaided,  a  private  asylum  of  excellent  re- 
putation, and  whose  Spanish  courtesy  has 
gained  him  many  friends.  The  Spaniard's 
standard  of  apparent  comfort  differs  so 
much  from  our  ideas  that  too  much  has 
been  made  of  bare  walls  and  darkened 
rooms  by  some  authors.  The  National 
Asylum  at  Leganes,  too,  has  been  much 
improved  of  late  years.  Of  course,  there 
are  abominable  cells  and  much  restraint ; 
no  doubt,  the  sanitation  is  imperfect ; 
but,  in  comparison  with  the  state  of 
matters  a  generation  back,  the  advance  is 
striking  and  encouraging. 

Perhaps  the  most  remarkable  improve- 
ment is  now  taking  place  at  Seville. 
There  a  new  asylum  is  being  built  in  the 
country,  and  the  patients  are  being  moved 
from  the  old  wards  in  the  hospital  as  the 
accommodation  is  completed.  A  drive  of 
three  or  four  miles,  over  the  most  execrable 
roads,  separates  the  new  institution  from 
the  town.  It  is  built  in  pavilions  under 
the  French  influence,  which  is  as  dominant 
in  Spanish  psychiati'y  as  in  other  depart- 
ments of  medicine.     Nothing  better  could 


Sparagmus 


[     1180    ] 


Specimens  of  Brain 


be  desired  for  patients  of  the  lower  class, 
and  no  English  county  asylum  could  be 
more  presentable  in  every  detail.  Only 
the  quieter  classes  of  patients  were  in 
residence  at  the  time  referred  to  (1891). 
Unfortunately,  it  is  only  too  probable 
that  the  apparatus  of  restraint  will  be 
more  in  evidence  when  the  building  is 
completed. 

A  visit  to  the  asylum  of  Granada  re- 
vealed no  material  improvement  on  the 
state  of  the  building  since  Dr.  Lockhart 
Eobertson's  visit  in  1868.  It  was  posi- 
tively stated  that  all  the  insane  patients 
had  been  removed,  and  the  place  seemed 
to  be  devoted  to  children  and  aged  poor. 
It  was  impossible  to  ascertain  how  this 
had  come  about,  or  whither  the  lunatics 
had  been  removed.  The  physician  in 
charge  could  not  be  found,  and  there  was 
an  evident  desire  to  keep  strangers  unin- 
formed. This  may  perhaps  be  accepted 
as  a  good  omen,  for  in  former  days  the 
asylum  at  Granada  was  forced  on  the 
attention  of  every  passing  tourist,  and 
lunatics  in  every  phase  of  wretchedness 
were  kept  on  show. 

The  only  book  on  insanity  written  by  a 
Spaniard  for  Spaniards  is  the  treatise  by 
Dr.  p.  Juan  Gine  y  Partagas.  The 
Spanish  Frenopathic  Academy,  which 
resembles  our  Medico-Psychological  Asso- 
ciation in  constitution,  as  yet  remains  a 
numerically  unimportant  body. 

A.  R.  Urquhart. 

[References. — Papers  in  the  .lounial  of  Mental 
Science:  July  186S,  A  Visit  to  tlie  Lnnatic  Hospi- 
tal at  Granada,  by  Dr.  Lockhart  IJobertson  :  ( )ct. 
1879,  Spanish  Asylums,  hy  Dr.  Donald  Frascr  ; 
July  1885,  A  Glance  at  Lunacy  in  Spain,  by  Dr. 
Jelly  ;  Notes  on  Spanish  Asylums,  by  Dr.  Sequin; 
Des  Asiles  d'Alienes  en  Espagne,  by  Dr.  Desmai- 
sons,  1859  :  Lunacy  in  Many  Lands,  by  G.  A. 
Tucker,  1887 ;  Keport  on  the  Working  of  the 
Lunacy  Laws  in  Foreign  Countries,  l'>luo  Book, 
1885.] 

SPARACiraUS  (a-Trapdao-o),  1  tear).  A 
spasm  or  convulsion  ;  applied  to  epilepsy, 
i'r.  Sjjarogme.) 

SPASM  OPHIIiIiV  {(jTvaa-jxos,  a  convul- 
sion ;  (liikiciy  love  or  aft'ection  for).  Hyper- 
excitability  of  the  nervous  system  leading 
to  a  tendency  to  convulsions. 

SPASMUS  CYNlCUS.  The  Risus 
Sardonicus  {q.v.). 

SPECIFIC    GRAVITY    OP    BRAIM'. 

(>S'ee  Brain,  Specific  Gravity  oi'.) 

SPECIMENS  OF  BRAIN-  OR  CORS 
FOR  IVIICROSCOPE,   PREPARATION* 

OF. — For  those  engaged  in  the  micro- 
scoijic  examination  of  the  brain  or  spinal 
cord  of  persons  dying  insane,  it  will  save 
much  time  and  trouble,  as  well  as  ensure 
the  satisfactory  preparation  of  sections  of 
nervous  tissue,  to  be  in  possession  of  the 


means  which  experience  has  proved  to  be- 
fitted for  the  purjDOse. 

Macerating-  fluids  may  be  used  for 
isolating  nerve  structures. 

Nitric  Acid,  20  per  cent,  solution — place 
small  fragments  of  the  tissue  in  this  fluid 
and  leave  for  twenty-four  hours.  Wash 
well  in  water,  tease,  stain,  and  mount  in 
glycerine.  By  this  method  the  connective 
tissue  is  rendered  softer,  and  the  cells  and 
fibres  are  hardened.  The  following  modi- 
fied fluid  may  be  used  :^ 

Glycerine    .         .         .         ,      i   part 
AVater  .  .  ,3  parts 

Strong-  nitric  acid         .         .     i   part 

Mix  thoroughly.  Place  small  fragments 
of  the  tissue  in  this  fluid,  leave  for  three 
or  four  days  and  then  wash  well  with 
distilled  water. 

Ordinary  Midler's  Fluid,  dilute 
chromic  acid  (i  per  cent,  solution)  or 
Ijerosmic  acid  (i  per  cent,  solution)  may 
be  used  as  macerating  fluids  for  nerve 
tissues,  small  pieces  of  which  are  left  in  a 
few  drops  of  the  medium  for  two  or  three 
days  and  then  teased  out.  They  may 
then  be  examined  in  glycerine,  water  or 
saline  solution. 

The  last-named  fluid  is  especially  use- 
ful for  defining  the  outlines  of  cells  and 
for  fatty  tissues,  degenerations  of  fibres, 
&c.  Tissues  should  be  allowed  to  macerate 
for  from  twelve  to  twenty-four  hours 
before  any  attempt  is  made  to  tease  them 
out. 

Hardening:  Fluids.  General  Directions. 
— Cut  up  the  brain,  cord  or  nerve  with  a 
sharp  knife  or  razor  (taking  care  to  make 
clean  cuts  and  not  to  drag  or  tear  the 
tissue)  into  blocks  about  one  inch  square 
and  half  an  inch  thick,  or  into  cubes,  each 
side  of  which  should  measure  not  more 
than  about  three-quarters  of  an  inch, 
or  into  short  lengths  not  more  than  half 
an  inch  each.  Where  tissues  are  to  be 
hardened  rapidly,  as  in  absolute  alcohol, 
the  small  cubes  should  always  be  prepared. 
These  cubes  should  in  most  cases  be  taken 
from  different  parts  of  the  brain  or  cord, 
but  one  piece  from  the  surface,  with  the 
membranes  still  attached,  should  always 
be  included.  In  cutting  up  the  cord,  cut 
through  the  dura  mater  in  front  but 
leave  the  pieces  arranged  in  series  by  a 
posterior  attachment  composed  of  the 
uncut  dura. 

(a)  The  delicate  pia  mater  is  best  pre- 
pared by  pinnnig  it  down  to  pieces  of 
cork  which  are  then  floated  in  dilute 
hardening  fluids.  Large  sections  of  the 
whole  brain  either  vertical  or  longitudinal 
should  never  be  more  than  5  to  ^in.  in 
thickness ;  they  should  be  laid  in  a  flat- 
bottomed  dish,  or  tied  to  wood  or  glass 


Specimens  of  Brain 


1181     J 


Specimens  of  Brain 


plates,  witli  a  layer  of  cottou  wadding 
between  the  plate  and  the  section,  as  may 
be  found  most  convenient. 

(?')  Put  the  tissues  away  at  once  in  the 
hardening  iluid. 

((•)  Put  a  piece  of  rag  or  some  cotton 
wadding  saturated  with  the  hardening 
iluid  in  the  bottom  of  a  wide-mouthed  jar  ; 
on  this  place  tour  or  five  of  the  blocks  of 
tissue,  or  a  whole  brain  section,  then  a 
second  layer  of  rag  or  wadding,  a  second 
layer  of  tissue,  and  so  on,  the  proportion 
of  tissue  to  fluid  never  being  greater  than 
one  to  twenty.  Fill  the  jar  with  fluid, 
label  distinctly  with  the  name,  age  and 
sex  of  the  patient,  the  organ,  the  supposed 
morbid  condition,  and  the  date  and  time 
at  which  the  hardening  process  is  begun 
and  its  nature.  Put  away  in  a  cool 
dark  place,  such  as  an  underground  cellar ; 
but  immediately  befoi'e  doing  so,  change 
the  position  of  the  pieces  of  tissue  in  the 
bottle.  This  is  especially  necessary  when 
spirit  is  used. 

((/)  At  the  end  of  twenty-four  hours 
pour  out  the  fixing  or  hardening  fluid, 
carefully  wash  out  the  jar  and  rinse  the 
tissue  thoroughly  with  water  to  get  rid 
of  any  blood  or  other  deposit  which  may 
have  settled  on  it,  and  which  would  if  left 
seriously  interfere  with  the  hardening 
process ;  add  fresh  fluid.  As  a  general 
rule  fluids  should  again  be  changed  at  the 
end  of  the  thii-d  day,  and  then  weekly  for 
two  or  three  weeks. 

(e)  Each  time  the  fluid  is  changed  the 
tissue  should  be  carefully  examined  and 
its  consistency  ascertained.  When  har- 
dened properly,  tissues  should  be  tough 
and  firm,  never  brittle,  as  they  are  apt  to 
become  if  the  hardening  process  is  carried 
too  far  or  has  been  done  imperfectly. 

(/)  After  being  hardened  slowly,  the 
tissues  are  I'emoved  from  the  fluid,  gener- 
ally about  the  end  of  the  second  to  the 
eighth  week,  according  to  the  fluid  used, 
and  if  not  hardened  in  spirit  they  are 
washed  for  several  hours  in  water  until 
no  further  yellow  colour  is  given ;  after 
which  they  are  transferred  to  a  mixture 
of  equal  parts  of  methylated  spirit  and 
water  for  two  days  and  then  to  methy- 
lated spirit*  in  which  they  are  left  until 
required.  The  spirit  may  become  cloudy, 
in  which  case  it  must  be  changed  as  often 
as  the  cloudiness  makes  its  appearance. 

ig)  It  is  an  extremely  difficult  matter 
to  give  definite  instructions  as  to  the 
fluid  to  be  used  in  individual  cases,  but 

*  Metliyhitcil  si)irit,  as  now  i)rci)iircd,  always 
becomes  cloudy  on  the  addition  of  watiT,  so  tliat 
these  instructions  only  apply  to  re-distilled  spirit, 
or  to  the  spirit  specially  provided  for  scientific 
purposes. 


the  following  general  rules  will  assist  ma- 
terially in  determining  what  hardening 
fluid  should  be  used. 

(i)  Currnsire  HiihJmiate  solution — satu- 
rated solution — may,  in  some  cases,  be 
used  as  a  preliminary  fixing  re-agent.  It 
stops  putrefactive  processes  and  fixes 
the  protoplasm  at  once.  It  or  Fleming's 
solution  is  most  suitable  for  perfectly 
fresh  material. 

(2)  Where  the  brain  tissue  is  hard  and 
firm,  and  not  likely  to  shrivel  on  the 
abstraction  of  water,  and  where  too  it  is 
not  thought  necessary  to  keep  the  blood 
in  the  organ,  inethijlaied  s^nrit  may  be 
used.  Tissues  hardened  in  spirit  are 
sometimes  distorted  somewhat;  but  this 
method  has  the  advantage,  that  tissues  so 
hardened  are  very  readily  stained  with 
logwood  or  with  the  aniline  dyes. 

(3)  When  the  tissues  are  very  delicate, 
soft,  or  ocdematous,  or  when  there  is  much 
blood  in  them,  use  Mitllers  fluid. 

Mi'tller's  fluid  is  one  of  the  most  useful 
of  all  our  hardening  reagents,  especially 
in  the  preparation  of  delicate  tissues ;  it 
fixes  the  protoplasm  of  the  cells  rather 
than  hardens  them,  and  thus  causes  but 
little  shrinking  of  the  tissues,  so  that 
where  the  organ  is  congested,  or  the  tissue 
delicate,  it  is  invaluable.     Take  of 

2J  parts 

I      part 

TOO    parts 

Use  in  the  proportion  of  i  volume  of  tissue 
to  20  of  fluid  (as  with  all  other  methods). 
Change  the  fluid  at  the  end  of  the  first, 
third  and  seventh  days,  and  then  at  the 
end  of  each  week  till  the  end  of  the  fifth  ; 
transfer  to  water  for  sevei'al  hours  after 
the  tissue  has  been  in  the  fluid  for  six  or 
eight  weeks,  and  then  again  to  dilute 
methylated  spirit  ;  leave  in  this  for  from 
twenty-four  to  forty-eight  hours,  and  then 
preserve  in  strong  methylated  spirit.  The 
great  advantages  of  Miiller's  fluid  are  that 
there  is  no  great  danger  of  over-hardening, 
and  although  the  process  takes  a  consider- 
able time,  the  results  are  almost  invaria- 
bly satisfactory  ;  that  the  red  blood-cor- 
puscles remain  unchanged  in  shape,  and 
take  on  a  greenish  tinge  ;  it  is  not  essen- 
tial that  the  pieces  should  be  small,  and 
this  fluid  may  be  used  where  it  would  be 
inconvenient  to  cut  up  the  tissue  into 
small  cubes.  Begin  the  hardening  pro- 
cess as  soon  as  the  structures  are  taken 
from  the  body,  and  carry  it  on,  for  the 
first  few  days,  at  any  rate,  in  a  cool  dark 
place.  The  hardening  process  may  be 
completed  by  osmic  acid  or  bichromate  of 
ammonia. 

Hamilton  recommends  that  where  large 
slices  are  to  be  made,  the  brain  should  be 


Potassium  bichromate 
Sodium  sulphate 
Water      . 


Specimens  of  Brain         [     1182    ]  Specimens  of  Brain 


carefully  injected  with  Miiller's  fluid, 
tlirough  the  carotid  or  vertebral  vessels, 
which  should  be  injured  as  little  as  pos- 
sible in  removing  the  brain  ;  this  should 
be  repeated  every  day  for  a  week  before 
the  brain  is  cut  up. 

MiUler's  piicl  and  spirit  is  recommended 
by  Hamilton  for  hardening  nerve-tissues, 
brain,  spinal  cord,  and  retina.  It  is  com- 
posed of — 

Muller's  fluid     .         .         •     3  P'^'^s 
3Iethylated  spirit        .  .     i    P^^rt 

Cool  thoroughly  before  using,  and  follow 
the  directions  given  for  hardening  with 
Miiller's  fluid. 

Bichromaie  of  potash  may  also  be  used 
for  hardening  large  pieces  of  the  brain. 
It  must  be  used  in  large  quantities,  to 
which  carbolic  acid  saturated  solution 
(i  or  2  grains  to  the  ounce)  has  been 
added.  The  fluid  is  not  changed,  but  is 
kept  saturated  by  the  addition,  from  time 
to  time,  of  crystals  of  the  bichromate 
salt.  It  hardens  tissues  slowly,  taking 
from  six  to  eight  weeks.  Keep  in  a  cool 
dark  place. 

Gliromic  ^cu?.— Where  it  is  desired  to 
harden  nervous  tissues  more  rapidly,  a 
solution  of  chromic  acid,  not  stronger  than 
one-sixth  per  cent,  may  be  used.  Where 
this  or  any  of  the  following  chrornic-acid 
compounds  are  employed,  the  pieces  of 
tissue  should  never  be  more  than  one- 
sixth  of  an  inch  in  thickness,  and  half  an 
inch  in  diameter.  Use  twenty  volumes  of 
the  fluid  to  one  of  the  tissue.  Change  at 
the  end  of  twenty-four  hours,  again  on 
the  second  and  third  days,  and  then  every 
third  day  until  the  tissue  is  hard  and 
tough.  A  careful  examination  should  be 
made  about  the  eighth  day  to  see  that  the 
hardening  is  progressing  properly  ;  for  if 
the  tissues  be  left  too  long,  or  if  the 
mixture  be  too  strong,  they  become  ex- 
ceedingly brittle.  Wash  well,  allowing  a 
stream  of  water  to  run  over  the  tissues 
for  several  hours;  then  place  in  equal 
parts  of  methylated  spirit  and  water, 
leave  for  twenty-four  hours,  and  transfer 
to  pure  methylated  spirit. 

Erlickis  Fluid.— For  hardening  brain- 
tissue  to  be  stained  by  Weigert's  method, 
Erlicki's  fluid  may  be  used  : — 

Potassium  bichromate    .       2.5  parts 
Cupric  sulphate      .         .       0.5     „ 
Water   ....   100        „ 

At  the  ordinary  temperature  this  fluid 
hardens  tissues  in  eight  or  ten  days.  At 
40°  C.  tissues  are  hardened  in  four  or  five 
days.  With  this  fluid,  however,  the 
tissues  shrink  more  than  with  Miiller's 
fluid. 

Bichromate  of  ammonia  as  a  2  per  cent. 


solution  may  be  used  either  to  harden  or 
complete  the  hardening  of  the  nerve-cen- 
tres. Use  at  least  twenty  volumes  of 
fluid  to  one  of  tissue ;  change  at  the  end 
of  the  first,  third,  and  seventh  days,  and 
at  the  end  of  the  second,  third,  and  fifth 
weeks. 

Perosmic  acid  is  extremely  useful  for 
fixing  and  hardening  small  pieces  of  very 
delicate  tissue,  or  tissue  in  which  the  pre- 
sence of  fatty  degeneration  is  suspected. 
It  is  used  as  a  one-sixth  to  one-half  or 
even  one  per  cent,  solution.  The  tissue  is 
allowed  to  remain  in  it,  carefully  protected 
from  the  light,  for  about  six,  eight,  or 
twenty-four  hours  according  to  its  size  and 
nature.  Then  transfer  it  to  75  per  cent, 
spirit,  in  which  it  may  be  kept  until  re- 
quired ;  or  after  being  well  washed  in  dis- 
tilled water  it  may  be  placed  at  once  in  the 
gum  and  syrup  solution,  frozen,  cut,  and 
mounted  in  acetate  of  potash. 

If  Farrants'  solution  be  used  as  the 
mounting  medium,  the  glycerine  in  it  is 
continually  browned  by  the  acid  unless  the 
sections  before  mounting  are  thoroughly 
washed  in  water,  or  in  water  and  gly- 
cerine. 

Fleming's  fixing  solution  is  extremely 
useful  for  fixing  nuclear  figures  in  fresh 
tissues,  and  for  fixing  these  tissues  gene- 
rally : 


Chromic  acid  (i  per  cent.) 
( ismic  acid  (2  per  cent.)  . 
(ilacial  acetic  acid  . 


15  parts 

4      >. 
I  part 

Use  10  to  20  parts  of  fluid  to  i  of  tissue. 
Allow  tissues  to  remain  in  this  for  from  one 
to  three  days ;  but  they  may  remain  for 
weeks,  even,  exposed  to  sunlight,  with  no  ill- 
effects.  Wash  thoroughly  in  water  before 
cutting.  After  being  fixed  in  this  fluid 
tissues  may  be  hardened  by  being  passed 
through  30,  50,  70,  and  90  per  cent,  spirit 
(one  day  each),  and  then  into  absolute 
alcohol.  Embed  in  paraffine  or  celloidin. 
Golgi's  Hardening  and  Staining 
3Iethods.  — The  method  originally  em- 
ployed by  Golgi*  has  been  modified  by 
Kolliker  as  follows  : — The  cord  is  cut  into 
pieces  of  three  to  four  millimetres  long, 
held  together  by  the  membranes.  _  They 
are  then  placed  in  the  following  mixture  : 
Bichromate  of  potassium  (3  per  cent.) 
4  parts;  perosmic  acid  (i  per  cent.) 
I  part.  Use  30  parts  of  fluid  to  one  of 
tissue,  and  change  after  a  few  hours.  At 
the  end  of  from  one  to  one  and  a  half  days 
the  tissue  is  removed  and  washed  for 
from  a  quarter  to  half  an  hour  in  a  ^  per 
cent,   solution    of  nitrate    of  silver,    and 

«  Hofmann  and  Schwalbo's  "Jahresberichte," 
Bd.  X.  "  Fortsc-hrltte  der  Mediciu,''  Bd.  v.  p.  545, 
1887.     See  also  Journal  of  Aiiatomy,  noI.  :s.xy.-p- 

443- 


Specimens  of  Brain         [     1 1  S3 


Specimens  of  Brain 


then  placed  in  about  twenty  to  forty 
times  its  bulk  of  J  pcr  cent,  nitrate  of 
silver  solution  for  thirty  to  forty  hours. 
They  may  then  be  preserved  in  40  per 
cent,  spirit  for  three  to  six  weeks,  after 
which  they  soon  become  spoiled.  On  re- 
moval, the  pieces  are  ready  for  cutting  and 
examination. 

They  ma}'-  be  rapidly  embedded  in  cel- 
loidin  (one  hour  in  absolute  alcohol,  and 
one  hour  in  celloidiu),  and  should  be  cut 
at  once,  as  they  spoil  after  about  twenty- 
four  hours.  The  sections  are  clarified  in 
creosote  for  a  quarter  of  an  hour,  then  in 
turpentine,  and  are  mounted  in  xylol 
balsam.  The  silver  stains  the  neuroglia 
and  nerve-cells,  especially  in  embryos  and 
3'^oung  animals,  and  brings  into  promi- 
nence all  nerve-fibres  which  possess  no 
nerve-sheath,  and  exist  merely  as  naked 
axis  cylinders. 

Golgi's  Original  Methods. — The  Long 
Method  :  Harden  tissues  for  twenty  to 
thirty  days  in  2  per  cent,  bichromate  of 
potassium,  and  then  place  in  .7^  per  cent. 
nitrate  of  silver.  The  Short  Method : 
Harden  for  four  to  five  days  in  2  per  cent, 
bichromate  of  potassium,  then  for  twenty- 
four  to  thirty  hours  in  I  per  cent,  osmic 
acid  (2  parts),  and  2  per  cent,  bichromate 
of  potassium  (8  parts).  Remove  and 
place  in  .75  per  cent,  silver  nitrate  solu- 
tion. 

IVXetbods  of  Cutting  Sections  (For 
fresh  Freezing  Method  see  p.  11 87). — Of 
the  various  freezing  methods  D.  J.  Hamil- 
ton's is  the  most  perfect,  especially  as  it 
involves  no  danger  of  over  freezing.  To 
prepare  the  tissues  proceed  as  follows  : — 
Remove  the  hardening  fiuid  from  the 
tissue  (especially  if  spirit  has  been  used) 
by  a  prolonged  immersion,  say  for  twenty- 
four  hours,  in  water,  which  should  be  con- 
stantly changed  by  allowing  a  very  small 
stream  from  the  tap  to  fall  into  the  vessel 
in  which  the  tissue  is  being  washed.  Then 
transfer  to  a  mixture  of  gum,  B.P. 
strength,*  one  part  ;  syrup,t  one  part. 
To  each  of  these  fluids  add  three  drops 
of  a  strong  solution  of  carbolic  acid  pre- 
pared by  adding  one  part  of  Calvert's  No. 
4  carbolic  acid  to  two  parts  of  water,  or 
saturate  (boiling)  with  boracic  acid,  to  pre- 
vent the  formation  of  fungi.  If  this  be 
attended  to,  the  tissue  may  be  left  soak- 
ing in  the  solution  for  an  indefinite  length 
of  time,  and  at  the  end  will  "  cut''  per- 
fectly, if  it  has  been  properly  hardened  in 
the  first  instance.    Allow  the  tissue  to  re- 

*  Gum  acacia,  i  lb.,  is  dissolved  lu  80  ozs.  of 
water. 

t  The  syrup  is  made  by  boiling  one  part  of 
crystallised  sui,'ar  iu  one  part  of  distilled  water 
until  tbe  wbole  of  the  sugar  is  dissolved. 


main  in  this  mixture  for  from  twenty-four 
to  forty-eight  hours  or  even  longer.  The 
microtome  is  cooled  down  to  such  a  point 
that  a  drop  of  gum  (B.P.  solution)  placed 
on  the  die  or  disc  is  frozen.  The  tissue 
which  has  been  soaking  in  the  gum  and 
syrup  is  taken  out  with  a  pair  of  forceps, 
carefully  dried  in  a  cloth,  is  put  to  soak 
for  a  few  minutes  in  gum,  and  then  ad- 
justed as  required  on  the  surface  of  the 
cooled  disc ;  gum  is  painted  around  it  to 
keep  it  in  position,  and  to  form  with  it 
a  firm  solid  mass,  which  may  be  cut  in 
a  single  section.  The  mass  is  frozen  just 
so  hard  that  it  will  cut  like  a  piece  of 
cheese  ;  when  softer  than  this,  it  is  not 
sufficiently  frozen,  when  harder,  it  is  very 
difficult  to  cut,  especially  if  the  sections 
are  of  considerable  size. 

Gutting  in  Grlloidin. — Brain  tissue  or 
spinal  cord  after  being  hardened  is  trans- 
ferred to  various  grades  of  spirit,  then 
to  absolute  alcohol,  and  placed  for 
twenty-four  hours  or  longer,  according  to 
the  size  of  the  blocks,  in  a  mixture  of 
equal  parts  of  alcohol  and  ether.  From 
this  the  blocks  are  transferred  to  a  very  thin 
celloidiu  syrup,  made  by  dissolving  shav- 
ings of  celloidiu  in  equal  parts  of  ether 
and  alcohol,  then  to  a  stronger,  and  lastly, 
into  a  good  stiff  syrup  of  the  same 
material.  Then  take  a  piece  of  wood  (not 
cork,  which  gives  slightly  in  the  jaws  of 
the  clamp)  cut  across  the  grain,  and  pour 
over  this  a  quantity  of  ether  until  no  more 
bubbles  make  their  appearance.  Over  this 
prepared  surface  pour  some  of  the  thick 
celloidiu,  and  on  this  embed  the  soaked 
tissues.  Bank  well  up  with  the  thick 
celloidiu  syrup,  allowing  it  to  dry  for 
some  time  until  there  is  a  good  firm  film, 
add  more  celloidin,  again  dry,  and  then 
immerse  in  a  large  quantity  of  methylated 
spirit  until  the  whole  is  thoroughly 
hardened.  Cut  these  sections  under  spirit 
if  possible.  In  any  case  have  a  good  drop 
bottle  containing  methylated  spirit  con- 
stantly playing  on  the  block  of  tissue  that 
is  being  cut. 

Hamilton  (to  whom  we  owe  nearly  all 
the  good  embedding  processes  used  in  the 
freezing  method)  has  succeeded  in  combin- 
ing the  celloidin  with  the  gum  and  sugar 
method.  After  the  tissue  is  hardened  it 
is  placed  (if  it  has  not  already  been  hard- 
ened in  spirit)  in  methylated  spirit  for 
three  or  four  days,  the  fluid  being  changed 
daily.  It  is  afterwards  immersed  in  a 
mixture  of  equal  parts  of  alcohol  and  ether 
in  which  it  is  left  for  two  days,  then  from 
one  to  four  days  according  to  the  size  of 
the  piece  of  tissue  in  a  syrup  of  celloidin 
dissolved  in  equal  parts  of  ether  and  abso- 
lute   alcohol.      Then    pour   a   somewhat 


Specimens  of  Brain         [    1184    ]  Specimens  of  Brain 


stronger  solution  of  celloidin  into  a  paper 
box  or  a  pill  box  and  embed,  in  the  centre 
of  this,  the  piece  of  tissue.  Allow  the 
fluid  to  be  exposed  to  the  air  for  some  time, 
until  it  partiall}'  hardens  (the  longer  it  is 
exposed  the  harder  it  ultimately  becomes), 
then  plunge  the  whole  into  strong  methy- 
lated spirit  and  leave  it  until  the  celloidin 
is  quite  hard,  the  ether  has  been  dissolved 
out.  This  mass  is  now  soaked  in  water 
for  twenty-four  hours  or  longei*,  in  fact, 
until  thei'e  is  no  longer  any  smell  of  alco- 
hol, and  then  in  a  mixture  of  gum  and 
syrup  in  the  proportion  of  one  to  two. 
During  this  latter  part  of  the  process  the 
fluid  may  be  kept  at  a  temperature  of 
about  40^  C.  with  advantage,  as  under 
these  conditions  the  mixture  passes  readily 
into  the  tissues.  The  procedure  is  after- 
wards just  the  same  as  in  the  ordinary 
freezing  method. 

Mounting-  of  Serial  Sections  {Celloi- 
din.)— For  mounting  serial  sections  of 
specimens  cut  in  celloidin  we  now  use 
Al.  Obregia's  modification  of  \yeigert's 
method. 

(i)  Make  a  solution  of  sugar  candy  in 
water  about  as  thick  as  ordinary  syrup. 
To  30  c.c  of  this  add  20  c.c.  of  95  per  cent, 
alcohol  and  10  c.c.  of  a  solution  of  pure 
dextrine  of  the  consistence  of  syrup. 
Spread  a  thin  layer  of  this  over  a  slide  and 
allow  it  to  dry  in  a  warm  place,  protecting 
it  from  dust  ;  keep  for  several  days. 

(2)  Dissolve  photoxylin,  6  grammes,  in  a 
mixture  of  absolute  alcohol  100  c.c,  ether 
(pure),  100  c.c.  ;  allow  it  to  stand,  and  pour 
ofi  the  clear  part.  Both  this  and  No.  i 
will  keep  well  if  preserved  in  stoppered 
bottles.  Thin  celloidin  syrup  may  be 
used  instead  of  No.  2.  Cut  pieces  of 
satin  cooking  paper  (which  is  thin  and 
smooth  on  one  surface  and  leaves  no 
particles  on  the  sections)  the  size  of  the 
slides  and  place  in  a  flat  dish  with  the 
smooth  surface  upwards,  and  moisten  with 
95  per  cent,  alcohol.  Remove  the  sections 
with  similar  paper,  and  arrange  them, 
spreading  them  well  out  on  the  slips  in  the 
dish  with  a  pencil  moistened  with  alcohol. 
Remove  the  paper  and  lay  it,  with  the 
sections  upwards,  on  folded  blotting-paper 
until  all  fluid  is  absorbed,  then  place  the 
paper,  face  downwards,  on  the  prepared 
slide,  the  sections  coming  in  contact  with 
the  dextrine  ;  place  blotting-paper  over  it 
and  press  lightly  with  the  finger  ;  when  the 
paper  is  removed  the  sections  are  left  on 
the  prepared  layer.  Theu  pour  solution 
No.  2  over  the  slide  and  wave  in  the  air 
until  all  cloudiness  disappears. 

When  the  slide  is  put  into  pnre  water 
the  sugar  is  dissolved,  and  the  whole  film 
comes  away  from  the  glass  very  readily, 


leaving  one  side  quite  uncovered,  so  that 
all  processes  of  staining,  washing,  and  de- 
hydrating may  go  on  more  quickly  than 
when  both  surfaces  are  covered  with  a 
celloidin  film.  For  brain  sections  this  is 
an  exceedingly  good  method,  as  the 
medium  is  not  stained  by  either  carmine 
or  hsematoxylin ;  it  is  stained  by  aniline 
colours,  which,  however,  may  be  removed 
by  means  of  comi^aratively  strong  acids. 

The paraffine  embedding  method  is  essen- 
tial where  specially  thin  sections  are  re- 
quired. Small  pieces  of  tissues  that  have 
been  well  hardened  and  then  soaked  for 
twenty-four  hours  in  absolute  alcohol  are 
immersed  in  clean,  pui'e  turpentine  placed 
in  a  covered  porcelain  crucible.  This  is 
put  into  a  warm  chamber,  where  it  is 
gradually  heated  up  to  the  melting-point 
of  the  paraffin  that  is  used  and  left  from 
three  to  twenty-four  hours.  It  is  then 
transferred  directly  to  melted  hard  parafBne 
(melting  at  about  53°  C).  Very  delicate 
objects,  such  as  the  cord  or  brain  of  an 
embryo,  should  be  passed  through  several 
softer  parafiines.  The  tissue  is  allowed  to 
soak  in  the  melted  paraffinef  or  several  hours, 
and  is  then  transferred  to  a  paper  boat,  a 
pill  box,  or  metal  mould,  full  of  melted  par- 
afBne. It  is  kept  in  position  with  warm 
needles,  and  is  cooled  rapidly  by  floating 
on  water.  There  should  be  no  turpentine 
left  either  in  the  tissue  or  in  the  parafEne. 
When  the  specimens  are  to  be  stained  in 
bulk  they  should  be  taken  from  75  per 
cent,  spirit,  stained,  and  then  passed 
through  90  per  cent,  spirit  and  absolute 
alcohol,  after  which  they  are  treated  as 
above  ;  or  they  may  be  taken  from  the 
turpentine  and  first  transferred  to  a  mix- 
ture of  turpentine  and  paraffine  fortwenty- 
four  hours,  after  which  they  are  passed 
into  pure  paraffine. 

In  place  of  turpentine,  benzol  or  chloro- 
form may  be  used  in  parafiine  embedding. 
When  the  tissues  have  been  in  absolute 
alcohol,  either  before  or  after  staining, 
immerse  in  a  small  porcelain  crucible  or 
test-tube  in  equal  parts  of  chloroform  and 
alcohol.  The  specimen,  which  at  first 
floats,  after  a  time  sinks,  when  the  mixture 
should  be  replaced  by  pure  chlorororm. 
As  soon  as  the  specimen  again  sinks  pour 
off  most  of  the  liquid  and  add  to  what  re- 
mains scraps  of  solid  paraffine  ;  place  in  a 
chamber  heated  to  53^  or  54°  C,  and 
gradually  add  more  jDarafiine.  Keep  the 
specimen  at  the  above  temperature  until 
no  smell  of  chloroform  is  given  off,  then 
embed  in  a  paper  boat  or  metal  mould  as 
above  described,  and  cool  at  once  in 
water. 

Sections  embedded  and  cut  in  paraffine 
are  arranged  on  the  surface  of  the  dried 


Specimens  of  Brain 


1 185    ]  Specimens  of  Brain 


syrup  with  a  camel-hair  pencil,  flattened 
out  and  heated  in  a  warm  chamber  ke^^t  at 
from  57°-6o°  C.  for  ten  minutes,  when  the 
sections  have  a  tendency  to  become  more 
perfectly  spread  out.  The  paraffine  is  first 
removed  with  good  blotting-paper,  then 
with  xylol  or  turpentine,  after  which  the 
slide  is  placed  in  absolute  alcohol  for  a 
few  minutes,  and  then  quickly  into  pho- 
toxylin  or  celloidiu  solution;  dry  for  ten 
minutes;  wash  in  water  and  stain.  To 
dehydrate  afterwards  use  95  per  cent, 
spirit,  and  to  clear  use  pure  carbolic  crys- 
tals, I  part  to  xylol  (pure)  3  parts. 

Sections  cut  in  paraffine  may  also  be 
fixed  on  the  slide  with  a  mixture  of  equal 
parts  of  filtered  whites  of  egg  and  glycer- 
ine, to  which  is  added  a  lump  of  camphor. 
Apply  to  the  slide  with  a  glass  rod  and 
scrape  oU  with  another  ground-glass  slide, 
in  order  to  leave  as  thin  a  layer  as  pos- 
sible. Ai'rauge  the  sections  on  this,  heat 
to  the  coagulating  point  of  the  albumen, 
and  then  proceed  as  in  the  previous  case. 
Cariiiine  staining  fluid  is  especially  use- 
ful for  sections  of  the  central  nervous  sys- 
tem.    To  prepare  it,  take  of 

I'ure  carmine    .         .         .       i    part 
."strong  ammonia        .         .       i     ,, 
Water        .         .         .         •     50  parts 

Triturate  the  carmine  in  a  mortar,  add 
sufficient  water  to  form  a  paste,  and  then 
add  the  ammonia,  when  the  paste  will  at 
once  turn  from  a  bright  red  to  almost 
black  if  the  carmine  is  pure.  Add  the 
rest  of  the  water,  and  keep  the  solution  in 
a  glass-stoppered  bottle,  in  which  is  sus- 
pended a  piece  of  camphor. 

After  carefully  washing  out  any  of  the 
chromates  with  water  or  with  a  dilute 
solution  of  carbonate  of  soda,  a  section 
may  be  stained  rapidly  by  spreading  it 
out  on  the  glass  slide,  and  running  a 
drop  or  two  of  the  carmine  solution  over 
it ;  allow  it  to  stand  for  from  three  to 
five  minutes,  and  then  wash  in  water  for 
a  couple  of  seconds,  and  rapidly  transfer 
to  acidulated  water  (eight  drops  of  ace- 
tic acid  to  a  pint  basinful  of  water).  This 
latter  part  of  the  operation  must  never 
be  neglected,  as  the  carmine  is  held  in 
solution  by  an  alkaline  fluid,  and  is  only 
precipitated  in  the  tissues,  when  the  fluid 
is  rendered  acid.  Where  the  stain  is  pro- 
perly selective,  the  nuclei  and  fully-formed 
fibrous  tissue  are  stained  carmine  and  a 
delicate  pink  respectively.  Other  formed 
material  remains  unstained,  or  is  only 
slightly  tinted.  The  axis  cylinders  of  me- 
dullated  nerve  fibres  are  stained  brilliant 
carmine,  as  are  also  the  nerve-cells  of  the 
cord,  &c.,  the  latter  not  so  deeply.  A 
more  selective  stain  is  obtained  by  stain- 
ing the  sections   slowly  in  a  watery  solu- 


tion. They  are  afterwards  treated  in  the 
same  way.  The  sections  so  stained  may 
be  mounted  in  glycerine  or  in  Farrants' 
solution,  or  when  it  is  wished  to  clear  up 
the  section  still  farther  it  may  be  mounted 
in  Canada  balsam. 

Congo  Bed. — A  capital  stain  for  the 
cord  and  for  nerves  is  Congo  red,  as  sup- 
plied by  Messrs.  Squire  &  Sons.  Its  use 
was  suggested  to  me  by  Mr.  A.  Pringle, 
who  used  it  as  a  1-2  per  cent,  watery 
solution,  diluted  as  required;  it  stains 
very  rapidly.  Wash  thoroughly,  dehy- 
drate with  absolute  alcohol,  clear  with 
clove  oil,  and  mount  in  Canada  balsam. 
Axis  cylinders  are  distinctly  stained,  the 
sheath  remains  colourless,  and  all  cells 
and  fibrous  tissues  are  pretty  deeply 
stained. 

Picro-carmine.  —  Picro-carmine,  or  pi- 
cro-carmine  with  osmic  acid,  may  also  be 
used,  especially  when  Hamilton  &  Bram- 
well's  half  clearing-up  method  is  used. 
They  recommend  that  the  dehydration  of 
sections  of  the  cord  or  brain  should  be  ef- 
fected by  means  of  methylated  spirit,  and 
that  instead  of  taking  out  the  whole  of 
the  water,  enough  should  be  left  in  to 
keep  the  denser  parts  and  tissues  of  the 
section  slightly  opaque.  Most  beautiful 
preparations  may  be  obtained  by  this 
method. 

Gold-staining  Method. — An  exceedingly 
useful  method  for  nerve-centres  is  Beck- 
with's  modification  of  Freud's  gold  me- 
thod. Pieces  of  the  tissues  are  hardened 
(not  over-hardened)  in  Erlicki's  fluid,  and 
then  (though  not  necessarily)  in  alcohol ; 
sections  are  made,  rinsed  with  water,  and 
placed  for  three  or  four  hours  ina  i  percent, 
solution  of  gold  chloride ;  they  are  again 
washed  with  water,  treated  with  a  20  per 
cent,  solution  of  caustic  soda  for  three 
minutes,  then  with  a  10  per  cent,  solution 
of  carbonate  of  potash  for  thirty  minutes  ; 
the  superfluous  fluid  is  drained  off,  and 
the  sections  are  placed  for  from  five  to 
fifteen  minutes  in  a  10  per  cent,  solution 
of  iodide  of  potassium.  They  are  washed 
in  water,  dehydrated,  and  mounted  in 
balsam. 

This  method  gives  most  beautiful  re- 
sults, picking  out  the  delicate  nerve  fibrils 
and  axis  cylinders  in  a  most  remarkable 
manner.  One  of  the  great  secrets  of  suc- 
cess is  that  the  specimens  should  be  put 
directly  into  the  gold  solution,  the  second 
that  in  cutting,  sections  should  be  wetted 
with  water  instead  of  with  alcohol. 

Safranin.  —  Adamakiewicz's  Safranin 
Method  for  Nerve-tissues. — First  place 
the  sections  into  water  weakly  acidulated 
with  nitric  acid,  then  into  a  tube  of  con- 
centrated watery  solution  of  safranin  until 


Specimens  of  Brain         [    1186    ]  Specimens  of  Brain 


they  are  well  stained,  wash  iu  methylated 
spirit,  and  then  iu  absolute  alcohol  acidu- 
lated with  uitiic  acid,  and  then  with  water 
similarly  acidulated,  after  which  the  sec- 
tions are  stained  iu  methyl  blue,  and  de- 
hydrated with  alcohol,  cleared  up  with 
clove  oil,  and  mounted  in  balsam. 

^\'cige)•t's  Staining  Jlefhods. — Stain  a 
section  (hardened  in  Miiller's  Huid,  bi- 
chromate of  potash  or  Erlicl%i's  tiuid)  for 
twenty-tour  hours  in  a  concentrated 
watery  solution  of  acid  fuchsin  (soda  salt 
of  rose  aniline  sulphate),  wash  in  water, 
and  transfer  to  an  alkaline  solution  of 
alcohol  witli  10  c.c.  of  a  solution  made  by 
dissolving  i  gramme  of  fused  caustic  pot- 
ash in  100  c.c.  of  absolute  alcohol,  and 
filtering,  for  a  few  seconds  until  the  first 
sign  of  the  grey  nerve-tissue  of  the  section 
becomes  visible;  wash  in  water,  "which 
must  not  be  acid,"  and  dehydrate  with 
absolute  alcohol  saturated  with  sodic 
chloride,  to  j^reserve  the  colour  of  the  sec- 
tion. Clear  with  oil  of  cloves,  and  mount 
in  Canada  balsam.  In  sections  prepared 
in  this  manner,  the  medullated  nerve- 
fibres  stand  out  as  bi'illiant  red  lines  or 
points,  even  those  in  the  anterior  horns  of 
the  spinal  cord.  The  sheath  or  part  of  the 
sheath  is  stained  by  this  method.  "  The 
ganglion  cells  and  connective  tissue  (espe- 
cially iu  sclerosis)  with  those  of  the  pia 
mater  vary  in  tint  from  a  pale  to  an  ex- 
quisite blue,  which  latter  is  increased  by 
rinsing  the  sections  in  a  solution  of  i  part 
of  hydrochloric  acid  to  5  of  water,  and 
then  washing  thoroughly  in  water,  before 
dehydrating  them  with  alcohol.  These 
tissues  can  also  be  stained  blue  with  hasma- 
toxylin,  before  or  after  colouring  with  the 
acid  fuchsin."  For  the  central  nervous 
system,  according  to  Weigert,  this  is  in- 
valuable, but  for  x^eripheral  nerves  it  is  of 
no  use.  To  Weigert  also  we  are  indebted 
for  the  following  method  of  staining  the 
myelin  sheaths  of  the  nerves  of  the  nerve- 
centres.  After  the  tissues  have  been  tho- 
roughly hardened,  and  a  piece  embedded 
in  celloidin,  it  is  transferred  to  a  saturated 
solution  of  neutral  acetate  of  copper, 
diluted  with  one  volume  of  water,  the 
whole  being  kept  at  a  temperature  of  from 
35°  to  45°  C.  The  tissues  become  green 
and  the  celloidin  blueish  green.     Take  of 

(A)  Water 90  parts 

Saturated  solution  of  lithium 

carbonate  .         .         .       i    part 

(B)  Hsematoxyliu        .         .         .       i      „ 
Absolute  alcoliol  .         .         .10  parts 

When  required,  mix  ecjual  parts  of  A.  and 
B.,  and  dilute  somewhat.  Leave  the  sec- 
tions in  this  solution  for  any  length  of 
time  between  one  and  twenty-four  hoars, 
taking  care  to  keep  the  temperature  at 


from  35°  to  45°  C.     Wash  well  in  water, 

and  transfer  to  a  solution  of — 

liorax 2  parts 

Ferrocyanide  nf  potiissiuiii        .     zi 
Water 200 

Allow  the  sections  to  remain  for  from 
half  an  hour  to  two  or  three  hours  accord- 
ing to  the  thickness  of  the  section  and  the 
intensity  of  the  logwood  stain.  Again 
wash  well  in  water,  dehydrate  with  alcohol 
then  clear  with  xylol  aad  mount  in  Can- 
ada balsam  or  Dammar  mounting  fluid. 
The  sheath  takes  on  a  blue  stain,  the 
neuroglia  light  yellow,  and  the  ganglion 
cells  brown. 

Pal's  Modification  of  Weigerfs  Method. 
— Pal  uses  the  same  htematoxylin  stain- 
ing fluid,  but  afterwards  transfers  his 
sections  (previously  washed  in  a  dilute 
lithium  carbonate  solution)  for  about  a 
minute  into  a  quarter  per  cent,  solution 
of  permanganate  of  potash  made  fresh, 
as  required  each  time,  and  then  to  the  fol- 
lowing : 

Oxalic  acid  (pure)     .         .         .       i    part 
Sulphite  of  potash    .         .         .       i      „ 
Distilled  water  .         .         .  200  parts 

for  a  few  seconds  until  the  grey  matter 
loses  all  colour,  the  "  white '"'  matter  re- 
maining pretty  deeply  stained  blue.  Wash 
thoroughly  clear,  and  mount  or  give  a 
contrast  stain  with  eosin  or  picro-carmine. 

Tlie  Pal-Exner  Method. — This  method 
is  specially  valuable  for  obtaining  sections 
rapidly.  The  method  of  procedure  is  as 
follows  : — Fresh  braiu  or  cord  is  hardened 
for  two  days  in  ten  times  its  bulk  of  half 
per  cent,  osmic  acid,  fresh  solution  being 
added  on  the  second  day.  It  is  then 
washed  carefully  in  water,  dipped  for  a 
short  time  into  absolute  alcohol  and  em- 
bedded in  celloidin  or  paraffine.  The  sec- 
tions are  then  j^ut  into  glycerine,  washed 
in  water,  stained  and  differentiated  by 
Pal's  method,  and  mounted  in  the  usual 
manner. 

A.  method  devised  by  Marchi  for  the 
difl'erentiation  of  degenerated  nerve  fibres 
iu  the  cord  and  brain  removed  at  once 
from  experimental  cases,  is  the  follow- 
ing : — 

Harden  for  one  week  in  Miiller's  fluid 
or,  better  still,  plunge  into  hot  Miiller's 
fluid  (Mott)  ;  in  the  case  of  the  brain  use 
Hamilton's  injection  method.  In  the  case 
of  freshly  killed  experimental  animals.  Dr. 
Howard  Tooth,  at  Dr.  A.  E.  Wright's 
suggestion,  passes  a  solution  of  atropine 
through  the  vessels  in  order  to  prevent 
the  contraction  which  takes  place  when 
Miiller's  fluid  is  injected  into  the  brain). 
Then  cut  into  thin  slices,  f  mm.  each,  and 
harden  for  another  week  or  more  in  a 
fluid  made  up  of  2   parts  Miillei-'s  fluid 


Specimens  of  Brain         [     1187    ] 


Sphygmograph 


and  I  of  I  per  cent,  osmic  acid.  Wash 
tlioroughly  in  water.  Then  embed  in 
celloidin  in  the  ordinary  fashion,  after 
l)assing  through  alcohol  and  ether. 
Mount  the  sections  without  any  further 
staining  in  Canada  balsam.  For  the  de- 
scrij-ition  of  this  method,  which  certainly 
gives  admirable  results,  we  are  indebted 
to  Prof.  Schiifer.  Schiifer  has  devised  a 
capital  modirication  of  Pal's  method  for 
staining  the  myelin  sheath.  Harden  for  a 
month  in  Midler's  Huid,  cut  sections,  and 
then  put  into  Marchi's  Midler  and  osmic 
acid  liuid  for  twenty-four  hours.  He 
stains  in  the  following  for  a  few  hours 
(leave  overnight) : — 

llii'iiintoxylin    .  .         .         .      i  yraiii 

(dissolved  in  a  small  quantity 
of  jilisolnte  alcoliol) 

Acetif  acid        ...  .2  c.e. 

Distilled  water  ,         .         .      100  c.e. 

The  sections  become  black.  Bleach  by 
Pal's  method  (p.  1186),  allowing  the  sec- 
tions to  remain  for  as  much  as  ten  minutes 
in  the  i^ermanganate  solution,  and  then 
continue  the  bleaching  in  oxalic  acid. 

Ehrlich's  triple  stain  is  specially  valu- 
able for  nerve  specimens  that  are  to  be 
photographed. 
(.V)  Ha'matoxyliu,  2  i;ramuies.  dis- 
solved in  water        .         .         .   100  p.c. 
Then  add  absolute  alcohol  .         .   100     ,, 

Glycerine 100    ,, 

Glacial  acetic  acid       .         .         .   100     ,, 

I'otash  alum  to  saturation. 

(Allow  this  mixture  to  stand  in  the  sunlight 

for  three  or  four  weeks.) 

(B)  Make  a  saturated  solution  of  ruljin  s.     (One 

of  the  basic  fuchsin  series.) 

(C)  Make  a  similar  solution  of  methyl  oran<;e.    (A 

i,'ood  ground  stain.) 

Stain  the  sections  in  equal  portions  of  the 
logwood  (filtered  and  acidulated  when 
used)  and  distilled  water  for  from  five  to 
fifteen  minutes,  wash  well  in  distilled 
water,  and  then  leave  in  tap  water  until 
the  desired  shade  of  blue  is  obtained ;  or 
wash  with  a  very  dilute  solution  of  am- 
monia, in  which  case,  however,  there  is  a 
risk  of  precipitation.  Then  stain  in  a 
watch  glass  containing  equal  proportions 
of  (B)  and(C)for  from  ten  to  thirty  minutes, 
wash  freely  in  tap  water,  dehydrate,  and 
mount  in  Canada  balsam.  This  method 
is  exceedingly  useful  where  good  contrasts 
are  required. 

Aniline  Hue  black  is  especially  useful 
for  staining  sections  of  the  nerve  centres, 
bringing  into  special  prominence  the  nerve 
cells  which  are  stained  a  slaty  blue  colour 
(Bevan  Lewis). 

It  is  made  as  follows :  Take  of 

Aniline  hlue  black     .         .         .        i  part 

Water 40  i)arts 

Dissolve  and  add  rectilied  spirit  icx)      ,, 


Keep  in  a  stoppered  bottle,  filter  a  few 
drops  into  a  watch  glass,  and  add  eight 
or  ten  volumes  of  alcohol.  Stain  the 
section  from  a  half  to  three  minutes,  and 
mount  in  Canada  balsam.  For  ordinary 
tissues  use  a  i  per  cent,  watery  solution, 
allow  the  sections  to  remain  in  this  for  a 
few  minutes,  and  mount  in  balsam.  If 
the  staining  is  too  deep  Stirling  recom- 
mends soaking  the  sections  for  a  short 
time  in  a  2  per  cent,  solution  of  chloral 
hydrate. 

Fresh  Sections  (Bevan  Lewis). — To 
obtain  sections  of  the  fresh  brain  or  cord, 
dry  carefully  in  the  folds  of  a  clean  soft 
cloth,  and  immerse  for  a  short  time  in  the 
gum  and  syrup  solution  (p.  1184).  Freeze 
in  gum  on  an  ether  microtome.  Cut  sec- 
tions and  remove  them  one  by  one  into 
cold  water,  from  which  spread  out  on  a 
glass  slide  at  once.  With  a  pipette  pour 
on  this  a  few  drops  of  2  per  cent,  osmic 
acid  solution,  leave  it  for  one  or  two 
minutes,  then  wash  thoroughly  in  water, 
and  stain  on  the  slide  with  a  i  per  cent, 
watery  solution  of  aniline  blue  black  for 
one  or  two  hours.  Examine  at  once,  or 
mount  in  acetate  of  potash  or  glycerine. 
Sections  that  are  to  be  mounted  in  balsam 
should  first  be  well  washed  in  water  and 
then,  protected  from  the  dust,  should  be 
allowed  to  dry  thoroughly,  after  which 
they  are  covered  with  balsam  and 
mounted.         German  Sims  Woodhead. 

SPHACXASmUS  {(r4)ayi],  the  throat). 
One  of  Marshall  Hall's  terms  for  the 
phenomena  characteristic  of  an  epileptic 
fit  (see  Odaxesmus),  and  specially  for  the 
spasm  of  the  neck  muscles. 

SPHEItrEII-CEPHAIiVS,  SPHENO- 
CEFHAIiXTS  {cr(f)r]v,  a  wedge ;  KecjioXr],  the 
head).  Wedge-shaped  head.  (Fr.  sploe- 
nocephale  ;  Ger.  Keilhopf.) 

SPHYGMOGRAPH,  USE  OF,  IXr 
THE  VARIOUS   FORMS    OF    ZN'SAIO'- 

ITY. — In  the  various  conditions  of  insan- 
ity the  influence  of  the  nervous  system 
upon  the  heart  and  circulation  is  such 
that  in  nearly  every  case  the  sphygmo- 
graphic  character  of  the  pulse  is  altered 
in  some  way  from  the  normal,  and,  for 
purposes  of  diagnosis  as  well  as  prognosis, 
the  instrument  is  frequently  of  valuable 
service.  The  writer  has  found  that  the 
best  form  of  sphygmograph  for  asylum 
work  is  that  known  as  Dudgeon's,  not 
only  because  of  the  ease  with  which  it 
may  be  adjusted  in  excitable  cases,  but 
also  because  it  can  be  used  in  any  position 
of  the  patient,  whether  sitting,  standing, 
or  lying ;  the  patient's  arm  need  be  bared 
only  above  the  wrist,  and  the  pressure  of 
the  spring  on  the  artery  can  be  increased 
ordiminished  at  pleasure  while  the  instru- 

4  t- 


Sphygmograpli 


[     1188    ] 


Sphygmograph 


ment  is  in  situ.  To  obtain  reliable  records 
of  the  influence  of  different  forms  of 
mental  alienation  on  the  circulation,  we 
must  exclude  cases  in  which  cai-diac 
or  other  physical  diseases  are  known  to 
exist. 

In  maniacal  conditions,  perhaps  from 
exhausted  nerve  centres  and  overstrain  of 
the  cardiac  muscle,  the  arterial  tension  is 
lowered  and  the  sphygmographic  tracing 
reveals  some  dicrotism.  In  the  acute 
forms  of  mania  the  line  of  ascent  of  the 
tracing  is  nearly  always  perpendicular, 
the  apex  sharp,  and  the  descent  line  short, 
with  a  fairly  pi-ominent  dicrotic  wave. 
The  cardiac  systole  is  sudden  and  sharp, 
and  the  vis  a  icnjo  feeble  ;  the  sudden  ven- 
tricular contraction  produces  a  high  ascent 
line,  and,  as  the  systemic  arteries  are 
rapidly  emptied,  the  summit  of  the  tracing 
forms  an  acute  angle,  while,  as  has  been 
noted,  the  descent  line  is  interrupted  by 
a  dicrotism  (Fig.  i).  In  the  chronic  forms 
of  mania  the  tracing  is  not  so  character- 
istic, the  high  upstroke  of  the  acute  cases 
disappears,  the  line  of  descent  is  more 
prolonged,  and  is  interrupted  by  several 
secondary  wavelets. 

In  melancholia  the  pulse,  unless  in 
acutely  melancholic  patients,  where  it  is 
more  rapid  than  normal,  is  slow  and  easily 
compressed,  and  the  sphygmographic 
tracing  in  the  larger  number  indicates  a 
weak  and  feeble  cardiac  systole  and  an  im- 
perfect filling  of  the  vessels.  The  upstroke 
is  short  and  slanting,  and  the  descent  line 
prolonged  considerably,  the  secondary 
wavelets  being  either  indistinct  and  un- 
recognisable, or  not  marked  at  all.  The 
pressure  in  such  cases  has  to  be  very  low, 
or  the  character  of  the  pulse-tracing  will 
be  lost  (Fig.  2).  In  stuporous  melancho- 
lia there  is  usually  arterial  tension,  the 
apex  of  the  tracing  being  prolonged  to 
form  a  "plateau."  Chronic  cases  gene- 
rally show  a  normal  tracing,  arterial 
tension  may  exist,  but  is  never  so  marked 
as  in  some  forms  of  insanity.  Senile  me- 
lancholia is  nearly  always  associated  with 
high  tension  ;  its  removal  by  diminishing 
the  peripheral  resistance  and  by  strength- 
ening the  heart  is  usually  followed  by 
recovery.  When  senile  melancholia  is 
associated  with  low  tension  the  mental 
disease  is  rarely  recovered  from.* 

In  epileptic  insanity,  in  chronic  cases, 
or  in  those  passing  through  a  rapid  suc- 
cession of  fits,  such  as  in  the  status  epi- 
lepticiis,  the  ascent  line  of  the  tracing  is 
seldom  high  or  vertical,  the  percussion 
wave  is  generally  rounded,  and  the  line  of 
descent  either  prolonged  with  secondary 
wavelets  imperfectly  marked,  or  else  short 
*  Broadbcnt,  "  Crooniaii  Lectiires,"  1887. 


and  presenting  a  dicrotic  wave,  which  some- 
times reaches  the  height  of  the  primary 
wave  (Figs.  3  and  4).  The  pulse-tracing 
of  an  epileptic  at  other  times  varies  accord- 
ing to  his  mental  and  physical  condition, 
but  as  a  rule  it  presents  characters  indi- 
cative of  feeble  cardiac  systole  and  a  lax 
condition  of  the  arterial  walls.  During  the 
status  epilepticus,  and  during  the  uncon- 
scious stage  of  an  epileptic  fit,  the  ordi- 
nary characters  of  the  pulse-tracing  are 
lost,  and  it  becomes  mono-  or  dicrotic 
(Fig.  4). 

In    g'eneral   paralysis    of  the  insane 
certain  variations  are  found  in  the  charac- 
ters of  the  pulse  ;  these  changes  have  been 
described  as  those  of  high  tension,  similar 
to  that  found  in  chronic  Bright's  disease. 
In  the  first  stage  of  general  ixirahjsis  th.e 
cardiac   systole  is    generally  strong   and 
sudden,  there  is  low  arterial  tension,  and 
the  descent  line  of  the  sphygmograph  is 
marked  by  several  undulations  probably 
the  result  of  muscular  tremors  from  im- 
paired nerve  impulses.     To   analyse  the 
tracing   more  closely,    we   note   that  the 
upstroke  is  usually  somewhat  slanted,  the 
primary  wave   does   not   form   an   acute 
angle,  the  descent  line  is  of  fair  length,  the 
fall  is  gradual,  and  it  presents  a  number 
of    wavelets  ranging   from  4   to    8 ;    the 
dicrotic  wave  is  not  recognisable,  and  the 
aortic  notch  is  either  imperfect  or  does  not 
exist  (Fig.    5).     In   the  second  stage  the 
percussion  impulse  is  moderately  strong, 
and   evidence   of    arterial  tension  is  well 
marked,  the    apex    in   the   pulse-tracing 
being  rounded  or  ending  in  a  "  plateau  " 
line.     The  ti-acing  shows  the  ascent  line 
to  be  more  perpendicular,  but  seldom  of 
any  great  height ;  the  wave  of  percussion, 
instead  of  being    rounded,   is   prolonged 
horizontally,  forming  in  many  cases  the 
"plateau"  of  Voisin.    In  some  cases  the 
tidal  wave   ascends  higher  than  the  pri- 
mary wave,  the  aortic  notch  is  generally 
well  marked,  the  dicrotic  wave  obliterated, 
and  the  descent  line  short  (Fig.  6).     The 
plateau-like   summit   is  characteristic    of 
the  pulse  at  this    stage,  and  indicates  a 
high  pulse  tension,  sustaining  the  lever  of 
the  instrument  for  some  time,  the  circu- 
lation through  the  systemic  vessels  being 
interfered  with,   as   in   Bright's   disease, 
where,   however,  the  systole  of   a  hyper- 
trophied  left  ventricle  produces  a  high  and 
perpendicular  percussion  line.  In  the  final 
stage  of  the  disease  the  cardiac  muscle  is 
exhausted,  the  ventricular  systole  is  feeble, 
and,   the   weakened   arterial   walls  being 
deficient  in  tone,  the  pulse-tracing  presents 
characters  not  unlike  those  found  during 
the  first  stage.     The  line  of  ascent  is  high 
and  slanting,  the  percussion  apex  sharply 


Sphygmograph 


[     "89    ] 


Sphygmograph 


pointed,  and  the  descent  line  short  and 

iilraostnninterrupted  by  wavelets  (Pig.  7). 
Ill  general  paralysis  occurring  in  females 
the  disease  is  much  more  prolonged  in  its 
course,  and  the  s^'uiptoms  are  rarely  so 
intense  as  in  males  ;  a  low  percussion  wave 
and  a  prolonged  "  plateau  "  summit  can 
be  obtained  in  the  tracing  (Fig.  6). 

In  dementia  the  heart's  action  is  feeble, 
and  the  sjihygmograph  indicates  an  imper- 
fect tilling  of  the  vessels,  probably  due 
to  slow  evolution  of  nerve  impulses  along 
the  vaso-motor  nerves  from  an  impover- 
ished nerve  centre.  The  tracing  shows  a 
slanted  and  short  line  of  ascent,  apex 
pointed,  descent  line  prolonged,  and  in  a 
few  cases  interrupted  by  several  small 
undulations  (Fig.  8).  In  senile  dementia 
the  upstroke  is  slanted  and  not  high,  the 
apex  jn-olonged  and  rounded  somewhat, 
and  the  descent  line  interrupted  by  several 
small  notches,  indicating  a  feeble  cardiac 
condition  and  tense  arterial  walls,  the 
result  of  muscular  hypertrophy  or  ather- 
omatous deposit  alcuig  the  course  of  the 
vessels. 

Zmbecility. — Cases  of  mental  defect, 
where  it  is  inferred  there  is  an  arrest  in 
the  development  of  the  encephalon,  as 
well  as  cases  where  it  is  evident  a  certain 
amount  of  cerebral  wasting  or  atrophy 
exists,  present  tense  arteries,  and  after  a 
time  a  strong  cardiac  systole  from  hyper- 
trophy of  the  left  ventricle.  The  condition 
of  the  pulse  in  these  cases  is  identical  to 


that  found  in  fibroid  degeneration  of  the 
kidney  and  in  aortic  stenosis  (Pigs.  9  and 
10).  We  would  suggest  that  a  possible 
ex})lanation  of  the  high  arterial  tension 
existing  in  cerebral  atrophy  or  congenital 
deficiency  is  to  be  found  in  a  similarity  of 
the  morbid  anatomy  of  these  conditions 
and  that  of  cirrhosis  of  the  kidneys. 
There  is  a  certain  amount  of  tissue desti-uc- 
tion  in  both  cases,  replaced  in  the  one  by 
serous  fluid  or  the  products  of  inflamma- 
tion, and  in  the  other  bj'  fibroid  changes  ; 
in  both  cases  pressure  is  exercised  on  the 
arteries  within  the  parts  affected  ;  this 
obstructs  the  systemic  circulation,  and  to 
overcome  the  obstruction  first  cai'diac 
hypertrophy  and  finally  thickening  of  the 
arterial  muscular  coat  results,  thus  pi-o- 
ducing  the  increased  arterial  tension  so 
common  to  these  closely  allied  pathologi- 
cal conditions. 

In  circular  insanity,  in  the  dull  and 
depressed  stage,  there  is  shortening  of  the 
ascent  line,  the  apex  is  more  or  less 
rounded,  and  the  line  of  descent  prolonged 
and  wavy,  indicating  a  short  and  feeble 
ventricular  systole  and  slight  arterial  ten- 
sion ;  in  the  excited  stage  the  percussion 
impulse  is  high  and  perpendicular,  and 
the  descent  line  short  and  interrupted  by 
prominent  tidal  and  dicrotic  waves,  arte- 
rial tension  being  lowered,  and  the  char- 
acters of  the  tracing  bear  a  likeness  to 
those  of  acute  mania. 

T.   Duncan  Gkeenlees. 


Fii:.  T. — Ai-nte  miiniii  ;  jmlso  loo  ;  pressure  used  90  ^rius 


Fii;.  2. — >Ic'laiiclioli:i  :  imlse  90  ;  pvcssurc  used  30  i^ims 


Fic.  3. — Eiiik'iitic  mania  :  pi'lse  100  ;  pressure  used  40  urnis. 


Fig.  4. — Uyiug  from  a  series  of  epileptic  fits  ;  pulse  130  ;  pressure  used  30  grms 


Spider-cells 


[     1190    J 


Spinal  Cord 


Fit!.  6. — Geiioral  paralysis  (2iid  staiie)  ;  pulse  74  :  pressure  used  120  yrins 


Fk;.  7. — (General  paralysis  (last  stage) ;  pulse  90  ;  pressure  used  40  grms 


Fid.  10. — Congenital  imbecility  ;  pulse  80  :  pressure  used  80  grms 


spiDEit-CEi.i.s.     (See  Pathology.) 

SPIN-AI.      CORB,      CHATTGES      OF, 

IN"  THE  ITTSANE. — As  yet  no  special 
changes  have  been  demonstrated  as  the 
result  of  insanity  in  which  no  paralytic 
symptoms  have  been  present.  Hence  the 
changes  which  are  most  frequently  met 
with  dei^end  on  general  paralysis  of  the 
insane  or  are  secondary  to  some  apoplectic 
attack. 

In  general  paralysis  the  changes  are 
usually  diffused,  in  some  instances 
chiefly  affecting  the  posterior  columns, 
whereas  in  others  the  lateral  are  more 
implicated.  In  these  latter  the  anterior 
median  may  also  suffer ;  in  some  the 
affection  may  involve  the  posterior 
column  on  one  side,  and  the  lateral, 
chiefly,  on  the  other.  Doubtless  some  of 
these  changes  are  secondary  to  cortical 
degeneration,  but  at  present  it  is  not  easy 
to  trace  which  depend  on  primary  and 
which  on  secondary  processes.  In  some 
cases  of  general  paralysis  the  cord  is  very 


much  and  very  generally  wasted,  but  in  a 
few  cases  we  have  met  with  enormous 
increase  in  size  of  the  cord  depending  on 
general  interstitial  changes.  In  some 
cases  marked  syphilitic  changes  have  been 
met  with  in  the  coats  of  the  arteries. 

In  secondary  dementia  depending  on 
old  apoplectic  attacks,  whether  due  to 
hsemorrhage  or  to  local  softening,  changes 
in  the  lateral  column  of  the  cord  may  be 
present.  Id  a  few  cases  of  insanity  we 
have  met  with  syringo-myelia,  but  we 
have  failed  to  trace  any  definite  relation- 
ship between  this  and  the  insanity. 

In  many  conditions  bony  plates  have 
been  met  with  in  the  dura  mater  of  the 
cord,  but  these  occur  in  very  different 
states,  such  as  general  paralysis,  chronic 
epilepsy,  and  chronic  recurrent  insanity. 

Pachymeningitis  of  the  cord  may  be 
met  with  in  general  paralysis  and  also  in 
some  other  conditions  of  progressive  nerve 
degeneration.  Disseminated  sclerosis  may 
occur  in  the  insane,  but  in  our  opinion  it 


Spinal  Cord 


[     119'     ] 


Stammering 


is  excessively  rare;  most  of  the  cases 
tlescribed  as  such  have,  iu  our  experience, 
proved  to  be  cases  of  general  paralysis 
with  spastic  symptoms  and  with  changes 
in  the  lateral  columns  of  tlie  cord  or  else 
cases  of  developmental  general  paralysis 
(Clouston).  In  some  undoubted  cases  seen 
in  general  hospitals,  and  diagnosed  to  be 
suffering  from  disseminated  sclerosis,  there 
have  been  more  or  less  mental  excitement 
tending  to  weakness  of  mind  and  some 
paralysis,  so  that  changes  may  occur  in 
the  brain  associated  with  this  disease  as 
well  as  changes  in  the  spinal  cord.  Besides 
the  changes  in  the  posterior  columns  and 
posterior  roots  which  may  be  present  in 
general  paral3'sis,  similar  changes  may 
occur  in  ordinary  cases  of  locomotor  ataxy 
which  have  become  insane.  {See  Loco- 
motor Atwv.) 

In  chronic  alcoholism  there  may  be 
present  marked  general  changes  in  the 
cord  associated,  as  Bevan  Lewis  has  pointed 
out,  with  changes  iu  the  general  nutrition, 
a  form  of  general  fibrosis  which  he  com- 
pares to  the  changes  in  Bright's  disease. 

The  accompanying  diagrams*  show 
clearly  the  areas  of  the  cord  which  are 
Fu;.  I. 


Spinal  cord,  cervical  re;;ion  ;  de;^eiKTa- 
tioii  of  lateral  and  posterior  coluinns. 

Vui.  2. 


.Spinal  cord,  lumbar  ref,aon  ;  dot;euLiatiori 
of  lateral  and  posterior  columns. 

'  IJotli  diaf^rams  ajjiiear  in  Dr.  It.  S.  Stewart's 
article  iu  Joiinia/  nf  Mtntal  S'-i<-iire,  \\m]  1887, 
"  Ata.xo-Spasmodic  Taljes." 


more  commonly  affected  in  degeneration 
of  the  si)inal  cord  occurring  in  genei'al 
paralysis  with  ataxic  symptoms  in  which 
the  changes  are  not  confined  to  the  pos- 
terior columns.  {Hee  Gknehal  Paralysis, 
Pachv.mkxingitis,  and  Pellagra.) 

( i  KG.  H.  Savage. 

SPORADIC  citETiTrzsM.    {See  Cre- 
tinism.) 

SFRACHi.osxCKz:iT  (Ger.).    Apha- 
sia; alalia. 

STiUVnVXERING Definition.  —The 

term  "  stammering"  is  commonly  used  as 
a  synonym  of  "  stuttering,"  and  as  imply- 
ing a  peculiar  and  well-known  impediment 
to  speech  (dependent  on  a  spasmodic  affec- 
tion of  one  or  more  of  the  mechanisms  con- 
cerned in  that  function)  which  checks  the 
speaker  iu  his  utterance,  and  either  brings 
him  to  a  full  stop  or  causes  him  to  pro- 
long or  drawl,  or  to  repeat  in  rapid  succes- 
sion, the  letter  or  syllable  at  which  the 
check  occurs.  In  a  wider  sense  it  may  be 
taken  to  include  various  defects  of  speech, 
such  as  the  inability,  congenital  or  ac- 
quired, to  pronounce  certain  letters  or 
certain  combinations  of  letters,  the  ten- 
dency to  hesitate  or  stumble  in  utterance, 
or  to  transj^ose  letters  or  syllables,  and 
the  habit  of  interjecting  meaningless 
sounds  or  words  into  the  pauses  which 
occur  in  the  course  of  continuous  speech. 

Causation. — Stammering,  in  the  strict 
sense  of  the  term,  generally  first  shows 
itself  between  the  ages  of  four  or  five 
and  the  time  of  puberty ;  but  it  occa- 
sionally arises  in  adult  life,  and  may  then 
be  due  to  an  attack  of  fever  or  other  acute 
disease,  to  hysteria  or  some  other  nervous 
disorder,  to  nervousness  or  excitement, 
or  even  to  temporary  soreness  of  the 
tongue  or  lips  or  other  parts  engaged  in 
ai'ticulation.  In  most  of  the  latter  cases 
the  defect  is  temporary  only.  But  it  is 
important  to  bear  in  mind  that  confirmed 
stammerers  are  apt  to  have  their  infirmity 
aggravated  under  the  influence  of  similar 
conditions.  Stammering  beginning  in 
childhood  often  undergoes  spontaneous 
improvement  as  age  advances  ;  it  is  some- 
times, but  b}'  no  means  always,  of  here- 
ditary origin ;  and  it  is  a  curious  fact  that 
women  rarely  suffer  from  it.  The  other 
faults  of  speech  to  which  i-eference  has 
been  made  are  due  mainly  to  imperfect 
training,  to  bad  habits  or  slovenliness,  or 
to  some  defect  in  the  relations  between  the 
ear  and  the  organs  of  articulation. 

Description. — Articulate  speech  is  a 
highly  complex  function.  For,  apart  even 
fromitsintellectualrelations,  and  regarding 
it  only  as  a  mechanical  act,  it  involves  the 
perfect  command  over,  and  the  due  co-ordi- 
nation of,  three  distinct  though  correlated 


stammering 


[     "92     ] 


Stammering 


uiechanisms,  namely,  those  respectively  of 
respiration,  of  pbonation,  and  of  articula- 
tion. Of  the  i)arts  j^layed  severally  by 
these  three  mechanisms,  that  of  resj^ira- 
tion  is  the  simj^lest,  inasmuch  as  it  con- 
sists solely  in  keeping  the  lungs  sufficiently 
charged  with  air,  and  so  regulating  the 
force  of  the  exiiirator}^  blast  as  to  cause 
the  vocal  cords  to  vibrate  with  due  inten- 
sity, and  to  render  duly  audible  the  reson- 
ances of  the  mouth  and  nose  on  which  ar- 
ticulation depends.  The  function  of  the 
larynx  is  more  delicate  and  complicated  ; 
inasmuch  as  it  includes  in  rapid  sequence, 
according  to  the  requirements  of  the  differ- 
ent literal  sounds  effected  in  the  mouth, 
the  opening  of  the  rima  glottidis  so  as  to 
allow  unvocalised  air  to  pass,  and  the 
closing  of  the  glottis  for  the  purpose  of 
producing  voice,  and  the  most  delicate 
regulation  of  the  tension  of  the  cords  in 
order  to  the  production  of  different  musi- 
cal notes.  The  part  played  by  the  true 
organs  of  articulation  is  by  far  the  most 
complex  and  varied  ;  for,  although  articu- 
late sounds  are  limited  in  number,  their 
evolution  depends  on  the  nicest  adjustments 
of  the  tongue,  lips,  jjalate,  fauces,  and  jaws, 
and  in  the  utterance  of  words  these  are 
combined  in  sequences  of  extraordinary 
rapidity  and  variety.  It  is,  as  is  well 
known,  chiefly  in  muscular  co-ordinations 
of  great  complexity  and  of  late  acquire- 
ment that  hitches  are  liable  to  occur  and 
to  become  permanent ;  among  familiar 
examples  of  which  fact  may  be  enumer- 
ated writer's  cramp,  and  the  similar  affec- 
tions which  are  liable  to  attack  the  jjiano- 
forte-player  and  the  fencer.  Stammering 
would  seem  to  belong  to  the  same  cate- 
gory- 

The  hitch  in  speech  which  characterises 
stammering  may  occur  in  connection  with 
any  of  the  mechanisms  involved  in  sjjeak- 
ing.  It  may  consist  in  a  sudden  momen- 
tary arrest  of  the  expiratory  act,  or  in  a 
similar  closure  of  the  rima  glottidis. 
But  much  more  frequently  the  hitch 
occurs  in  the  organs  of  articulation  them- 
selves, the  special  features  of  which 
depend  on  the  particular  letter  at  which 
the  impediment  arises.  As  a  general 
rule  stammering  takes  place  in  connection 
with  the  explosive  consonants  ;  but  it  is 
by  no  means  limited  to  them,  for  it  may 
occur  not  only  in  the  utterance  of  the 
continuous  consonants,  but  even  in  that 
of  vowels.  In  its  slightest  degree  stam- 
mering consists  in  a  simple  momentary 
arrest  of  speech  which  may  be  scarcely 
appreciable  by  the  listener,  or  in  the 
occasional  repetition  or  reduplication  of  a 
letter  or  syllable.  In  more  marked  cases 
the  lips,  or  the  tongue,  as  the  case  may 


be,  becomes  arrested  in  the  position  neces- 
sary for  the  evolution  of  the  letter  the 
stammerer  is  about  to  utter,  and  re- 
mains thus  for  some  seconds  while  the 
patient  is  vainly  endeavouring  to  continue 
his  speech ;  or,  in  place  of  the  actual  silence 
which  under  such  circumstances  would 
usually  be  present,  he  may  go  on  repeat- 
ing the  sound  in  stuttering  fashion.  In 
its  worst  form  the  spasm  does  not  re- 
main limited  to  the  organs  of  speech,  but 
in  the  patient's  violent  and  fruitless 
attempts  to  speak  the  spasm  is  apt  to 
extend  to  the  muscles  of  expression,  to 
those  of  the  front  of  the  neck,  and  even 
maybe  to  the  extremities.  It  is  im- 
portant to  observe  that  even  confirmed 
and  bad  stammerers  do  not  always  stam- 
mer in  equal  degree,  and  may  at  times 
not  stammer  at  all.  Stammering  is 
aggravated  by  anything  which  causes 
nervousness  or  hurry  in  speech,  and  by 
states  of  health.  It  is  a  curious  fact  that 
stammerers  rarely  show  their  impediment 
when  singing  or  intoning. 

Among  defects  of  articulation,  which 
may  perhaps  be  included  in  the  term 
stammering,  are  those  which  characterise 
certain  nervous  diseases,  such  as  general 
paralysis  of  the  insane  and  disseminated 
sclerosis,  and  the  defective  enunciation  of 
certain  letters  for  the  most  part  dating 
from  infancy. 

The  speech  of  general  paralysis  is 
highly  characteristic.  In  its  early  stages 
it  is  marked  by  a  little  tremor  of  the 
lips  which  shows  itself  mainly  as  the 
patient  is  about  to  articulate,  and  at  the 
beginning  therefore  of  words  and  syllables. 
At  this  period  there  may  be  no  appreciable 
defect  of  speech,  there  may  be  even  un- 
wonted deliberation  and  distinctness  of 
utterance.  But  by  degrees  the  tremors  in- 
crease, and  then  speech  obviously  suffers. 
The  tremors  tend  to  spread  from  the  lips 
to  the  muscles  of  expression,  so  that  in 
advanced  cases  articulation  is  attended 
with  the  development  of  muscular  rip- 
ples over  the  whole  face.  And  the  speech 
becomes  more  and  more  hesitating,  and 
more  and  more  marked  by  a  tendency  to 
the  repetition  of  syllables  and  words,  and 
even  to  stammering  in  the  strictest  sense 
of  the  term.  Ultimately  it  becomes  unin- 
telligible. 

In  disseminated  sclerosis  there  is  not  as 
a  rule  any  tremor  of  the  lips,  but  the 
patient  speaks  with  the  so-called  scanning 
or  divided  utterance.  This  peculiarity 
depends  largel}^  on  the  fact  that  he  ex- 
periences more  or  less  impairment  of 
power  in,  or  command  over,  the  organs  of 
articulation,  and  that  he  speaks  with  great 
effort  and  with  more  attempt  at  precision 


stammering 


[     1193    ] 


Statics  of  Mind 


and  accuracy  than  was  his  wont.  As, 
however,  the  disease  progresses  the  diffi- 
culty of  speech  increases  and  he  becomes 
more  and  more  unintelligible  ;  and  then,  as 
also  in  the  case  of  general  paralysis,  moreor 
less  tremor  of  the  lips  may  come  on,  there 
may  be  more  or  less  obvious  stammering, 
and  combinations  of  letters  or  even  indi- 
vidual letters  may  become  unpronounce- 
able. 

In  cases  ofbulbar  paralysis  speech  neces- 
sarily becomes  defective.  Literal  sounds 
gradually  fail  to  be  properly  enunciated, 
and  the  speech  may  present  more  or 
less  resemblance  to  that  of  general  para- 
Ij'sis  or  disseminated  sclerosis.  It  is  an 
interesting  but  easily  explained  fact  that, 
in  all  these  paralytic  affections  of  speech, 
patients  who  cannot  pronounce  combina- 
tion of  letters — that  is, words— intelligibly, 
may  often  nevertheless  be  capable  of  pro- 
nouncing individual  letters  with  perfect 
clearness. 

Of  defects  of  speech  due  to  bad  habits, 
imperfect  education,  and  the  like  it  is  need- 
less to  say  much.  Among  them  may  be 
enumerated  the  habit  of  interpolating 
such  expressions  as  "you  know,"  "don't 
you  know,"  "  I  mean,"  and  meaningless 
drawling  sounds  between  one's  words  ;  the 
tendency  presented  by  some  persons,  and 
not  unusual  in  aphasic  conditions,  to 
transpose  letters  or  syllables;  and  the 
inability  to  pronounce  or  difficulty  in  pro- 
nouncing certain  letters,  such  especially 
as  h,  r,  s.  Some  children  are  very  slow 
to  learn  to  speak,  and,  even  though  they 
ultimately  acquire  facility,  are  long  in 
mastering  the  pronunciation  of  certain 
letters  and  remain  almost  unintelligible 
for  years.  It  is  curious  that  such  de- 
faulters are  very  often  bright  and  intelli- 
gent, and  present  (so  far  as  one  can  dis- 
cern) no  evidence  of  defect  (structural 
or  functional)  beyond  this  inability  to 
pronounce.  Moreover,  contrary  to  the 
opinions  of  some,  such  defects  are  uncon- 
nected with  either  defective  hearing  or  the 
want  or  possession  of  the  musical  faculty. 
In  some  remarkable  cases  children  even 
up  to  the  age  of  ten  or  twelve  habitually 
make  use  of  only  some  half-dozen  letters. 

Treatment. — In  treating  defects  of 
speech  it  is  important  that  any  local  affec- 
tion, such  as  soreness  of  lips  or  tongue, 
bad  teeth,  and  the  like, should  be  remedied; 
for  even  if  it  does  not  cause  the  defects 
it  helps  to  accentuate  and  perpetuate 
them.  For  the  same  reason  it  is  im- 
portant to  attend  to  the  general  health. 
And  it  need  scarcely  be  added  that  when 
defects  are  traceable  to  hysteria,  to  syphi- 
litic affections  of  the  nervous  system,  or 
to  any  other  remediable  condition,  these 


affections  should  be  expressly  treated. 
For  the  rest,  it  is  a  question  of  education. 
Stammering  may  be  largely  benefited,  and 
sometimes  cured,  by  careful  education. 
But  it  is  education  in  which  the  patient 
must  himself  recognise  the  importance  of 
persistent  and  systematic  work.  The 
stammerer  should  be  taught  to  speak 
slowly  and  deliberately  and  without 
excitement,  and,  when  engaged  in  conver- 
sation, never  to  persist  in  fruitless  or 
painful  efforts  to  force  the  word  on  which 
he  is  stammering,  but  rather  at  once  to  stop 
and  then  begin  the  offending  word  afresh. 
He  should  also  be  made  to  read  or  recite 
aloud  for  some  considerable  time  daily, 
uttei'ing  his  words  and  their  component 
parts  slowly  and  deliberately  and  with 
great  distinctness,  using,  in  fact,  in  their 
pronunciation  more  obvious  muscular 
effort  than  he  would  be  inclined  to  do  in 
ordinary  conversation.  He  should  also 
be  made  to  practise  especially  the  utter- 
ance of  those  letters  or  those  combinations 
of  letters  which  he  finds  it  most  difficult 
to  evolve,  and  so  to  regulate  his  inspira- 
tions as  never  to  permit  himself  to  speak 
with  an  insufficient  supply  of  pulmonary 
air. 

With  respect  to  the  other  defects  of 
speech  above  referred  to,  the  only  mode  of 
dealing  with  them  successfully  is  also  by 
education ;  and  for  this  reason  it  is  emi- 
nently desirable  that  children  should  be 
taught  early  to  read  and  speak  and  recite. 
In  dealing  with  this  subject  it  must  be  re- 
collected that,  assuming  the  nervous  and 
muscular  mechanism  to  be  sound,  the  act 
of  speech  is  purely  mechanical ;  that  if  the 
organs  of  speech  be  put  into  certain  definite 
positions,  and  at  the  same  time  respiration 
and  phonation  be  duly  performed,  the  let- 
ters due  to  such  positions  cannot  fail  to  be 
pronounced  ;  and  consequently  that  with 
very  few  exceptions  every  faulty  speaker, 
if  he  can  only  be  taught  to  put  his  organs 
of  articulation  into  certain  positions,  can- 
not avoid  pronouncing  correctly  the  lettei's 
which  he  habitually  fails  to  pronounce. 
But  in  order  to  treat  such  patients  success- 
fully it  is  of  course  necessary  for  the  teacher 
and  pupil  alike  to  study  the  details 
of  letter-enunciation.  It  need  scarcely 
be  said,  however,  that  when  once  bad 
habits  have  become  ingrained  it  is  exceed- 
ingly difficult  completely  to  eradicate 
them.  Even  the  person  who  teaches  him- 
self in  later  life  to  pronounce  the  letter  Ik, 
which  he  had  heretofore  neglected,  rarely 
acquires  the  power  of  uttering  it  without 
manifest  and  painful  effort. 

John  S.  Bristowe. 

STATICS  or  MIND. — The  nature  of 
the  products  of  mind  as  opposed  to  the 


statistics  of  Insanity       [    1194    ]        Statistics  of  Insanity 


dyoamics  of  mind,  that  is,  the  processes 
on  which  the  products  depend. 

STATISTICS  or  ZJrSANlTY. — Ac- 
curacy and  a  correct  basis  and  method  of 
calculation  ai'e  the  only  secure  founda- 
tions of  statistics.  Accuracy,  however 
great,  is  useless,  if  the  basis  or  method  be 
fallacious.  On  the  other  hand,  however 
perfect  the  method,  the  results  are  worth- 
less if  absolute  accuracy  be  not  secured. 
In  no  department  has  there  been  greater 
and  more  misleading  error  disseminated 
from  neglecting  the  most  elementary 
principles  of  statistical  science  than  in 
psychological  medicine. 

We  commence  with  : — 

( I )  The  metbod  of  Calculating^  the  Re- 
lative Iiiability  of  Different  Communi- 
ties to  Insanity. — For  many  years  state- 
ments were  made  and  accepted  as  to  the 
relative  amount  of  mental  disorder  in  dif- 
ferentnationsandatdifferentperiods  of  his- 
tor}"-  without  the  slightest  consideration 
of  various  sources  of  fallacy.  It  was  as- 
sumed that  the  numbers  of  the  insane  re- 
ported in  different  countries  and  at  dif- 
ferent periods  were  obtained  with  equal 
care  and  facility.  This  may  be  laid  down 
as  the  first  source  of  error.  The  second 
fallacy  is  overlooking  the  difference  in 
the  amount  of  provision  made  in  asylums 
for  the  disordered  in  mind.  The  effect  of 
such  provision  is  manifestly  to  lead  to  the 
concentration,  registration,  and  apparent 
increase  of  insanity.  The  third  source  of 
fallacy  is  the  oversight  of  the  inevitable 
accumulation  of  cases  Avhich  occurs,  due 
to  the  excess  of  admissions  over  dis- 
charges. Fourthly,  and  arising  out  of  the 
humane  provision  for  this  class,  is  the 
decrease  in  mortality.  Lastly,  a  great 
mistake  made  until  comparatively  recent 
times  is  the  failure  to  distinguish  between 
the  amount  of  existing  and  occurring  in- 
sanity. Let  us  illustrate  this  by  sup- 
posing that,  in  a  population  of  200,000, 
100  become  insane  every  year  in  England 
and  Wales,  and  that  the  mortality  of 
these  insane  persons  is  at  the  rate  of 
6  per  cent,  residents.  Suppose,  again, 
that  the  ratio  of  occurring  insanity 
in  Scotland  is  precisely  the  same,  but  that 
the  mortality  is  12  per  cent.  It  must  be 
obvious  that  there  will  be  a  much  larger 
number  reported  at  the  end  of  the  year 
in  the  former  than  in  the  latter  country. 
The  English  would  appear  to  the  super- 
ficial observer  to  have  a  much  greater 
liability  to  mental  disorder  than  the 
Scotch.  The  fact,  however,  would  be  that 
there  was  an  accumulation  of  cases  in 
consequence  of  the  greater  care  and  better 
treatment  bestowed  upon  the  patients  by 
the   English.     Yet   the  fallacy   here   re- 


ferred to  is  one  which  is  still  prevalent, 
and  leads  to  serious  mistakes.  The  ewisi- 
iiig  number  of  lunatics  and  idiots  in  dif- 
ferent countries,  and  in  different  localities 
or  periods  in  the  same,  is  continually  made 
the  test  of  the  liability  to  insanity  of 
different  races,  or  of  the  same  race  at 
different  periods. 

(2)  Numbers  of  the  Insane  in  Differ- 
ent Countries,  and  at  Different  Periods 
in  the  Same  Countries. — If  we  were  to 
take  the  returns  of  the  number  of  idiots 
and  lunatics  in  different  countries  we 
should  find  the  ratio  to  the  population 
vary  enormously,  and  the  same  result 
would  be  obtained  if  the  reported  number 
of  these  classes  at  one  period  of  the  his- 
tory of  any  one  nation  were  compared 
with  the  number  alleged  to  exist  at  an- 
other period.  The  main  cause  of  these 
widely  different  statements  is  the  very 
imperfect  returns  in  former  as  compared 
with  recent  periods  in  the  one  case,  and 
the  difference  between  the  perfection  of 
the  methods  of  obtaining  statistical  facts 
in  more  or  less  civilised  countries  in  the 
other.  Thus,  to  compare  the  lunacy  sta- 
tistics of  Turkey  with  those  of  England 
and  Wales  would  be  altogether  mislead- 
ing. And  again,  to  compare  the  statistics 
of  lunacy  in  England  and  Wales  in  1800 
and  1 890  wouldbe  equally  fallacious.  About 
60  years  ago  it  was  estimated  that  in  Italy 
there  was  i  insane  person  to  every  3785 
of  the  population.  At  the  present  time 
the  estimate  is  i  in  1350  ;  but  it  would  be 
absurd  to  conclude  that  any  such  increase 
of  insanity  has  really  taken  place. 

Another  source  of  fallacy  is  the  different 
mortality-rate  at  different  periods  in 
establishments  for  the  insane.  For  ex- 
ample, in  England  and  Wales  the  mor- 
tality, calculated  upon  the  number  resident 
in  asylums,  was  10.26  per  cent,  during  the  6 
years  ending  1879,  whereas  it  was  only  9.30 
per  cent,  during  the  6  years  eDdingi88;. 
If  the  death-rate  had  not  thus  fallen, 
there  would  have  been  above  3000  more 
deaths  in  the  latter  decade  than  really 
occurred.  From  the  year  1776  to  1844 
the  mortality  was  12.12  per  cent,  of  the 
number  resident  in  asylums  in  England 
and  Wales.  Hence  it  is  obvious  that 
returns  of  the  number  of  patients  without 
taking  into  account  the  death-rate  are  no 
proof  of  a  real  increase  of  occurring 
lunacy.  Accumulation  necessarily  fol- 
lows upon  decreased  mortality.  Most  of 
the  statements  made  in  regard  to  the 
increase  of  insanity  fail  to  take  into  ac- 
count this  source  of  fallacy.  K"or  is 
account  taken  of  the  varying  proportion 
of  recoveries  and  consequent  discharge  of 
patients  at  different  periods.     The  effect 


statistics  of  Insanity        [     1195    ]        Statistics  of  Insanity 


of  this,  however,  in  leading  to  mistaken 
conclusions,  is  within  a  comparatively 
small  compass. 

In  the  following  observations  we  take 
the  available  statistics  of  insanity  in  Eng- 
land and  Wales,  as  found  in  the  Ulue- 
Books. 

It  is  greatly  to  be  regretted  that  the 
limit  of  the  past  is  drawn  at  the  year 
1S59.  Indeed,  it  is  impossible  to  obtain 
official  returns  of  admissions  exclusive  of 
transfers  before  1869.  Further,  when  we 
restrict  our  inquiry  to  absolutely  satis- 
factory returns  we  are  unable  to  go  further 
back  than  1878. 

In  1859  (on  January  i)  there  were  in 
England  and  Wales  36,762  insane  and 
idiotic  persons  reported  by  the  Commis- 
sioners in  Lunacy  (including  those  in 
workhouses). 

In  1885  (January  i)  there  were  79)7o_4- 
In  other  words,  for  every  100  insane  in 
1859  there  were  218  under  care  in  1885. 
Making  allowance  for  the  increase  of  the 
population  there  was  a  rise  from  18.674 
per  10,000  to  28.984,  or  55  per  cent. — i.e., 
a  rise  from  100  to  155.  Taking  the  quin- 
tiuennium  1861-65,  ^^^  ^l^o  that  of  188 1- 
85,  there  is  a  rise  from  20.8  to  28.6  per 
10,000,  or  an  increase  of  38  per  cent. 

If  from  the  foregoing  returns  the  uncer- 
tified insane  are  deducted  {i.e.,  omitting 
workhouses,  and  pauper  lunatics  receiv- 
ingout-door  relief),  there  were  on  January 
I,  1859,  23,001  patients,  and  on  January 
I,  1885,  56,525,  that  is  to  say,  an  increase 
of  146  per  cent.  Allowing  for  increase  of 
population  there  was  a  rise  of  76  per 
cent.  If  quinquennial  periods  are  taken 
— namely  1861-65  and  1881-85 — we  find 
the  rise  in  the  certified  insane  to  be  50  per 
cent. 

Such  are  the  figures  representing  the 
comparative  amount  of  existing  lunacy  at 
different  periods  in  England  and  Wales. 
We  proceed  to  give  the  much  more  im- 
portant returns  of  occurring  lunacy.  Here 
we  are  restricted  to  asylums,  because  no 
returns  can  be  procured  of  the  number  of 
cuhnissions  into  workhouses,  nor  the  num- 
ber of  out-door  patients  hecomiag  insane. 
Now,  in  1859  there  were  9310  admissions 
into  asylums  ;  in  1885  there  were  as  many 
as  14,774  ;  allowing  for  increase  of  popu- 
lation these  returns  show  a  ratio  per 
10,000  of  4.7  in  1859  and  5.3  in  1885,  or 
an  increase  of  13  per  cent.  Ui)  to  1878  it 
is  tolerably  steady  ;  subsequently  the  ratio 
of  increase  was  almost  stationary,  while 
during  the  5  years  1881-85  it  was  lower 
than  any  of  the  five  years  preceding. 
During  this  quinquennium  the  admis- 
sions per  10,000  of  the  population  were 
5.20,  while  during  the  five  years  1886-90 


tJiey  were  almost  exactly  the  same — viz., 
5.25.* 

The  next  point  is  to  deduct  the  trans- 
fers, which,  of  course,  mean  nothing  in  an 
inquiry  into  the  actual  numbers  of  the 
insane.  As  already  stated,  the  Lunacy 
Commissioners  did  not  report  transfers 
prior  to  1869.  In  that  year  the  admis- 
sions of  patients  into  asylums  'minus 
transfers  amounted  to  10,617,  while  in 
1885  the  corresponding  number  was 
i3)557>  or  an  increase  of  28  per  cent. 
To  show  the  effect  of  the  elimina- 
tion of  transfers,  it  should  be  stated 
that,  when  these  are  included,  the  rise 
amounts  to  32  per  cent,  during  the  same 
period.  If  we  take  series  of  years,  the 
proportion  per  10,000  of  the  population 
during  1871-75  was  4.9,  while  during  the 
quinquennium  1881-85  it-  rose  to  5.2.  In 
deducting  transfers,  we  are  free  from  the 
disturbing  element  of  a  variable  quantity, 
one  which  ra&y  affect  the  accuracy  of  the 
result  in  either  magnifying  or  minimising 
the  increase. 

The  next  source  of  fallacy  when  we 
are  taking  the  reported  admissions  into 
asylums,  as  representing  the  number  who 
become  insane,  is  the  inclusion  of  the 
re-admissions.  These  are  not  unimportant, 
because,  although  they  stand  for  cases  and 
not  different  persons,  they  may  tell  a  tale 
of  the  action  of  the  existing  causes  of  in- 
sanity at  a  certain  period. 

We  must,  however,  eliminate  re-admis- 
sions for  the  purpose  of  ascertaining  the 
number  of  persons  who  become  insane. 
Obviously,  relapses  do  not  convey  a  correct 
impression  of  this  proportion  of  individuals 
becoming  insane  at  a  given  period.  Now, 
the  ratio  of  first  admissions  to  10,000  of 
the  population  in  1869  was  4.13,  while  in 
1885  it  was  4.21,  being  a  difference  of 
1.94  per  cent.  The  rise  of  fii'st  admissions 
between  1880-85  over  those  between  1870- 
75  was  not  as  much  as  i  patient  in  10,000. 

We  are  now  prepared  to  advance  a  step 
further.  A  moment's  consideration  will 
show  that  the  only  proper  test  of  the  in- 
crease of  mental  disease  is  the  proportion 
of  first  attacks  to  the  population  during 
different  periods.  First  admissions  are 
clearly  not  identical  with  first  attacks, 
seeing  that  a  patient  may  be  admitted 
into  an  asylum  for  the  first  time,  and  yet 
have  had  one  or  more  previous  attacks  of 
insanity.  In  1876,  the  year  in  which  these 

*  Thu  numbers  of  the  insane,  &c'.,  lu  Great 
Uritain  and  Ireland  will  be  found  under  these 
articles.  AVe  are  not  in  possession  of  statistics  for 
1892,  but  we  may  state  that  for  England  and  Wales 
there  was,  on  January  i,  i  lunatic  or  idiot  to  335 
of  tlie  population.  The  census  of  1891,  which  in- 
cludes a  separate  retui-n  of  the  insane,  is  not  yet 
available  for  our  purpose. 


statistics  of  Insanity        [    1196 


Statistics  of  Insanity 


returns  were  first  made,  there  is  some 
element  of  doubtful  accuracy,  and  in  1877 
no  return  was  made,  so  that  we  commence 
with  the  following  year,  1878,  since  which 
the  returns  have  been  regularly  made.  In 
the  last-mentioned  year  the  number  of 
first  attacks  in  England  and  Wales  was 
S354,  while  in  1885  it  was  8527.  Allowing 
lor  mcrease  of  jjopulation,  the  number  of 
first  attacks  per  io,coo  hving  was  2.;^2  io 
1878  ;  in  1879  it  was  slightly  higher,  3.34 ; 
in  1880  it  was  markedly  lower,  3.22  ;  in 
1S81  it  rose  slightly,  viz.,  to  3.25  ;  in  1882 
it  was  nearly  identical ;  in  1883  there  was 
a  fractional  rise,  viz.,  to  3.43  ;  m  1884  the 
number  fell  exactly  to  that  of  1878;  lastly, 
during  1885  it  fell  lower,  viz.,  3.10.  Tak- 
ing the  five  years  1881-85,  the  average 
annual  number  of  first  attacks  was  3.29; 
while  for  1886-90  the  average  annual 
number  was  3.46.  These  figures,  so 
far  as  they  go,  are  extremely  important 
and  interesting,  as  showing  that  statis- 
tics when  carefully  handled  do  not  bear 
out  the  general  opinion  that  there  has 
been  an  alarming  increase  in  the  number 
of  fresh  cases  of  insanity  in  proportion 
to  the  population,  that  is  to  say,  so  far  as 
first  attacks  have  come  under  the  cogniz- 
ance of  the  Lunacy  Commissioners. 

We  are  well  aware  that  outside  the  area 
of  certified  lunacy  there  is  a  considerable 
mass  of  borderland  cases,  the  inclusion  of 
which  might  seriously  affect  our  deduc- 
tions. If  we  allowed  ourselves  to  be  in- 
fluenced by  impressions  derived  from 
general  observations  we  should  be  dis- 
posed to  infer  an  increase  in  this  class ; 
and  if  instances  of  insomnia  and  neuras- 
thenia were  added,  we  should  find  it  difli- 
cult  to  avoid  the  conclusion  that  there 
has  been  an  increase  in  affections  of  the 
nervous  system.  While,  therefore,  not 
denying  the  alleged  increase  of  nervous 
disorders,  we  consider  that  the  only  safe 
course  to  pursue  is  to  adhei-e  to  statistical 
returns  when  grounded  ou  right  methods 
of  calculation.  So  calculating,  we  main- 
tain that  statistics  do  not  support  the 
opinion  that  a  distinctly  larger  number 
of  persons  in  proportion  to  the  population 
become  insane  than  was  formerly  the 
case. 

(3)  Percentag^e  of  Pauper  Xunatics  to 
Total  Paupers  in  Eng-land  and  "Wales, 
and  of  Pauper  Iiunatics  to  Population. 
— Taking  the  earliest  year  in  which  we  are 
able  to  procure  returns,  we  find  that  in 
1859  the  total  number  of  paupers  of  all 
classes  on  the  ist  of  January  of  that  year 
was  1,722,548.  The  total  number  of 
pauper  lunatics  and  idiots  at  the  same 
date  was  31,782,  showing  a  percentage  of 
pauper  lunatics  to  paupers  of  1.85.     This 


ratio  has  gradually  crept  up  to  9.25  per 
cent.,  but,  as  the  ratio  of  total  paupers  to 
the  population  has  fallen  from  4.37  to 
2.82  between  1859  and  1889,  we  must  not 
consider  that  this  proportional  rise  in  the 
number  of  the  accumulated  lunatics  is  any 
proof  of  an  increase  of  occurring  lunacy 
in  proportion  to  the  population. 

Ratio  of  Pauper  Lunatics  to  2'otal  Popu- 
lation.— This  ratio  in  1859  was  i  in  578, 
while  in  1889  it  was  i  in  384. 

That  there  should  be  a  rise  during  the 
last  30  years  in  the  proportion  of  pauper 
lunatics  to  the  population  without  there 
being  necessarily  an  increase  in  occurring 
lunacy  must  be  admitted  when  we  re- 
member two  circumstances  ;  first,  that  the 
insane  poor  are  more  carefully  registered 
at  the  present  time,  and,  secondly,  that  the 
ever  misleading  factor  of  accumulation 
invalidates  the  inference  that  there  has 
been  an  actual  increase  of  insanity. 

(4)  IVIode  of  Calculatingr  tbe  Propor- 
tion of  Recoveries. — Some  diff"erence  of 
opinion  has  been  held  and  divergent  prac- 
tice been  unfortunately  pursued  in  calcu- 
lating recoveries.  They  have  been  calcu- 
lated upon  the  mean  number  resident  in 
institutions,  upon  the  discharges,  upon 
the  curable  cases,  and,  lastly,  upon  the 
admissions. 

(«)  Were  the  average  duration  of  resi- 
dence in  different  institutions  identical, 
the  recovery-rate  might  be  calculated  on 
the  average  number  resident  without  in- 
troducing a  source  of  fallacy  in  comparing 
the  results  obtained  in  various  asylums. 
Dr.  Conolly  adopted  this  method,  but  he 
seems  to  have  overlooked  the  fact  that 
the  period  of  time  which  such  a  method 
embodies  is  an  element  in  the  problem 
which  has  to  be  taken  into  account. 

(b)  The  late  Dr.  W.  Farr,  the  eminent 
statistician,  calculated  recoveries  on  the 
discharges.  Dr.  Thurnam  has  shown  that 
if  the  correct  mode  of  calculation  is  that 
which  is  made  on  the  admissions,  it  is  of 
great  importance  to  avoid  the  method  of 
calculating  the  recoveries  on  the  dis- 
charges, seeing  that  the  results  are  widely 
diff'erent.  Thus,  at  the  York  Eetreat,  the 
recoveries  in  the  course  of  forty-six  years 
amounted  to  46.9  per  cent,  of  the  admis- 
sions, while,  if  calculated  on  the  discharges, 
they  were  54.6.  At  the  Wakefield  Asy- 
lum during  twenty-three  years  the  reco- 
veries were  44.2  per  cent,  reckoned  on 
the  admissions,  and  were  as  high  as  50.6 
reckoned  on  the  discharges. 

(c)  It  is  urged  by  Dr.  Mortimer  Gran- 
ville that  the  true  method  is  to  calculate 
the  recoveries  upon  cases  deemed  curable. 
He  confesses,  however,  that  "  it  is  curious 
to   notice    how    closely    the    percentage 


statistics  of  Insanity        [     1197    ]        Statistics  of  Insanity 


gained  by  this  method  of  computation  I 
suggest,  approximates  to  that  obtained  by 
taking  the  proportion  upon  the  total  of 
'  cases  admitted.'  This  seems  to  show 
the  wisdom  of  the  method  commonly 
adopted."  He  also  allows  that  the  calcu- 
lation upon  the  average  number  resident 
offers  no  advantage  over  that  upon  cases 
admitted.* 

{d)  On  the  whole,  we  consider  that  the 
method  of  calculating  recoveries,  which  is 
based  on  the  admissions,  is  a  fair  one. 
It  is  no  doubt  true  that  the  recoveries  in 
a  given  year  in  an  asylum,  calculated  u2')on 
the  admissions  during  the  same  period,  in- 
clude the  recoveries  of  persons  who  may 
have  been  admitted  during  previous  years, 
and  might  happen  to  exceed  the  admis- 
sions of  that  year  ;  but,  on  the  other  hand, 
it  omits  recoveries,  which  will  probably 
occur  among  the  admissions  of  that  year 
at  a  subsequent  period.  There  is,  there- 
fore, probably  very  little  difference  be- 
tween the  calculation  and  the  final  results 
when  a  series  of  years  is  taken.  This 
source  of  fallacy  disappears  to  a  large  ex- 
tent, and  would  of  course  be  entirely 
avoided  if  the  admissions  terminated,  and 
the  record  of  recoveries  was  continued  for 
some  time  afterwards.  It  has  been  shown 
by  Dr.  Thurnam  that  the  pi'oportion  of 
recovei'ies  is  at  the  minimum  (when  calcu- 
lated on  the  admissions)  during  the  early 
period  of  an  asylum  history,  and  increases 
for  a  considerable  time  after  the  oj^ening 
of  an  institution.  Thus,  at  the  Retreat, 
York,  during  the  first  quinquennium,  it 
was  26.1  percent.;  during  the  first decen- 
nium  it  was  33.9  ;  during  the  first  fifteen 
years,  42.5;  during  the  first  twenty 
years  it  amounted  to  46.0;  during  the 
first  twenty-five  years  it  was  46.8 ; 
during  the  first  thirty  years  it  was  46.2  ; 
during  thirty-five  years,  46.0 ;  during 
forty,  46.5;  and  during  the  first  forty- 
five,  47.8  per  cent. 

At  the  Hanwell  Asylum  the  recoveries 
during  the  first  five  and  one-third  years 
was  as  low  as  19.3  per  cent. ;  during  the 
next  ten  and  one-third  years  it  was  22.2  ; 
during  the  succeeding  twelve  and  one-third 
years  it  rose  to  23.3. 

The  rate  of  recovery,  calculated  on  ad- 
missions (minus  transfers),  in  the  asylums, 
registered  hospitals,  private  asylums,  and 
in  single  houses  in  England  and  Wales 
was,  during  the  ten  years  1879  ^o  1888, 
39.91  per  cent.  In  metropolitan  and  pri- 
vate asylums  it  was  respectively  35.1 1  and 
36.44  per  cent.  Taking  registered  hospi- 
tals alone  it  was  nearly  50  per  cent.  (47.34); 
in  county  and  borough  asylums,  40.16. 

*  "  The  Care  ami  Cure  of  the  Insiuic."  vol.  i. 
P-73- 


Sir  A.  Mitchell's  statistics  *  of  1297  ]ja- 
tients  during  the  term  of  twelve  years 
showed  a  recovery-rate  of  65.6  per  cent. 
If  re-admissions  (499  out  of  85 1  recoveries) 
are  taken  into  account,  the  recovery-rate 
is  reduced  to  47.3.  It  must  be  remem- 
bered that  there  is  very  little  general 
paralysis  in  Scotland,  and  therefore  the 
above  high  rate  of  recovery  cannot  be  ex- 
pected in  England  and  Wales.  In  the 
Surrey  and  Middlesex  asylums,  during  a 
term  of  years,  the  re-admissions  amounted 
to  26.73  P6i'  cent,  of  those  discharged  re- 
covered, im})roved,  or  not  improved.f 

(5)  Mode  of  Calculating^  the  Mor- 
tality.— The  mortality-rate  has  been  cal- 
culated variously  upon  the  admissions, 
the  discharges,  and  the  mean  number 
resident.  The  last-mentioned  method  is 
the  cori-ect  one.  Unfortunately,  some  of 
the  highest  authorities  failed  to  perceive 
this,  and  calculated  it  upon  the  admis- 
sions, or  discharges.  Such  calculations 
could  only  be  correct  if  the  period  of  resi- 
dence were  the  same  in  different  asylums, 
and  if  every  case  remained  in  the  asylum 
up  to  the  time  of  death  or  recovery.  See- 
ing that  the  mortality  of  any  community 
is  only  accurately  exhibited  by  the  propor- 
tion of  deaths  out  of  a  certain  number  of 
people,  or  number  living  for  a  specified 
period,  we  must  obtain  the  average  annual 
number  of  deaths  to  every  hundred  of  the 
people  living  one  year.  Time  must,  in 
this  instance,  be  taken  into  account  as  all- 
important.  We  may  go  further,  and  say 
that  "  the  only  strictly  accurate,  and  un- 
equivocal test  of  the  sanitary  state  of  any 
population,  as  exhibited  by  its  mortality, 
IS  obtained  by  a  comparison  of  the  deaths 
at  each  age,vnth  the  average  numher  living 
at  the  same  ages."X 

(6)  IVIean  Number  Resident.  —  This, 
the  average  population,  is  calculated  from 
a  register  of  the  patients  in  an  asylum. 
Dr.  Thurnam  has  shown  that  at  the  Re- 
treat (and  there  is  no  reason  to  regard  it 
as  exceptional),  the  average  population 
for  44  years,  when  calculated  from  the 
number  of  patients  remaining  in  the 
asylum  at  the  end  of  each  year,  very 
slightly  differed  from  the  results  obtained 
by  daily  enumerations ;  while  at  the  York 
Lunatic  Hospital,  the  average  number 
resident  was  precisely  the  same  during 
2 1  years,  whether  reckoned  on  the  number 
under  care  at  the  end  of  each  year,  or 
upon  the  monthly  register.  In  asylums 
where  the  register  does  not  give  the  num- 
ber of  inmates  at  longer  intervals  than  a 

*  Journal  of  Mental  Science,  1877. 
t  Dr.  M.  Gi-auvillo's  "Care  aud  Cure  of  the  In- 
sane," vol.  ii.  p.  96. 

t  "  Statistics  of  Insanity ,"  by  Dv.  Thurnam,  p.  15. 


statistics  of  Insanity        [     1198 


Statistics  of  Insanity 


mouth,  or  a  quarter,  taking  the  precise 
duration  of  time  passed  in  the  institution 
during  the  whole  period  by  each  patient, 
and  dividing  the  total  by  the  number  of 
years  over  which  the  period  extends,  is  a 
troublesome,  but  the  only  means  of  ob- 
taining the  average  number  resident. 
Even  the  statistician  just  quoted,  who 
revelled  in  figures,  characterises  this 
method  as  "  almost  disheartening."' 

(7)  Method  of  calculatin§r  Averag^e 
Duration  of  Residence. — The  tei"m  of 
years  over  which  the  inquiry  extends,  the 
number  of  patients  admitted  into  an  asy- 
lum, and  the  average  number  resident  dur- 
ing that  term,  constitute  the  data  for 
calculating  the  average  duration  of  resi- 
dence.    Thus : — 


Average      ,^  . 

resideut.    "P«-afon. 
100      X       50       -4- 


Kumber 
admitted. 


Average 
diiratiou  nf 
residcDce. 

-      5  years 


By  the  multiplication  of  the  average 
number  resident  in  an  asylum  by  the 
number  of  years  it  has  been  opened,  the 
years  of  insane  life  passed  therein  are  cal- 
culated. These"  years  of  residence"  (Farr), 
or  "  subjective  time  "  (Thurnam),  amount 
in  the  foregoing  illustration  to  5000  years, 
a  period  which,  divided  by  the  number  of 
patients  admitted,  namely,  1000,  yields  an 
average  duration  of  residence  in  this 
imaginary  asylum  of  5  years. 

The  average  duration  of  residence  varies 
very  considerably  in  different  asylums. 
At  the  York  Lunatic  Hospital  this 
amounted,  taking  the  total  number  ad- 
mitted for  a  certain  term  of  years,  to  2^ 
years.  Taking  the  patients  who  recovered, 
the  period  of  residence  was  8  months; 
while  having  regard  to  those  who  died, 
the  period  extended  to  4  years.  At  the 
Retreat,  York,  corresponding  periods  were 
as  follows  : — (a)  nearly  5  years  ;  (fe)  one 
year  and  4  months;  (c)  nearly  9  years 
(8.83) ;  more  than  one-third  of  those 
who  recovered  were  discharged  within  six 
months  of  their  admission. 

In  the  asylums  of  Middlesex  and  Surrey 
during  a  term  of  years,  more  than  half  of 
those  who  recovered  were  discharged 
within  six  months.  A  little  over  one- 
quarter  of  the  total  number  recovered 
between  six  and  twelve  months  after  ad- 
mission, about  one-eighth  were  discharged 
in  the  second  year  of  residence,  and  nearly 
half  the  remainder  recovered  in  the  third 
year.*  Sir  A.  Mitchell  states  that  a  large 
jjroportion  of  the  recoveries  recorded  by 
him  in  the  Scotch  asylums  occurred  in 
patients  under  care  not  longer  than  from 

*  Dr.  M.  (jraiiville's  '•  Care  and  Cure  of  the  In- 
sane," vol.  ii.  1).  99. 


one  year  to  a  year  and  a  half.  Ninety- 
four  per  cent,  of  those  who  recovered 
were  discharged  during  the  first  two 
years. 

(8)  Period  over  which  Statistical 
Observations  should  extend  to  ensure 
Accuracy. — Seeing  that  the  ratio  of  re- 
coveries tends  to  increase  some  time  after 
the  opening  of  an  asylum,  in  consequence 
of  the  number  of  chronic  cases  admitted 
in  its  earlier  years,  and  that  not  a  few 
cases  do  not  recover  until  after  the  lapse 
of  some  years,  it  is  obviously  necessary,  in 
comparing  the  results  of  treatment  in  dif- 
ferent asylums,  to  extend  the  period  of 
observation  and  comparison  far  beyond 
the  history  of  the  first  few  years.  The 
necessity  for  this  precaution  is  increased 
by  the  more  favourable  mortality-rate 
which  occurs  for  some  time  after  the  es- 
tablishment of  an  asylum.  For  these 
reasons  Di-.  Thurnam  advises  that  a  period 
of  from  twenty  to  thirty  years  should  be 
allowed  to  elapse,  and  a  still  longer  period 
in  the  case  of  a  small  asylum. 

The  rule  may  therefore  be  laid  down 
that  the  prujiortion  of  recoveries,  and  tJie 
mean  annual  mortality,  increase  zoith  the 
age  of  an  asylutn.  Exceptional  circum- 
stances, such  as  a  difference  in  manage- 
ment, or  an  epidemic,  may  in  particular 
instances  affect  this  formula. 

(9)  Conditions  aflfectingr  the  Termina- 
tion of  Mental  Disease  whether  in  Re- 
covery or  Death. 

(ft)  Age. — The  chances  of  recovery  are 
greatest  in  the  young,  putting  aside  cases 
of  weakness  of  mind  or  constitutional 
moral  obliquity.  It  must,  however,  be 
admitted  that  a  large  number  of  cases  of 
pubescent  and  adolescent  insanity  termi- 
nate more  unfavourably  than  the  mental 
physician,  guided  in  his  prognosis  by  the 
general  truth,  has  been  led  to  expect. 

In  regard  to  the  influence  of  age  on 
mortality,  the  latter  increases  with  years, 
as  might  be  expected,  but  increases  more 
rapidly  than  the  mortality  of  the  general 
population.  It  is  a  remarkable  circum- 
stance that  no  tables  of  mortality  bearing 
on  the  relation  between  the  age  and  death 
of  the  insane  wei'e  published  before  those 
of  Dr.  Thurnam,  derived  from  the  Retreat 
and  the  Lunatic  Asylum  at  York.  No 
tables  of  asylums  for  the  insane  can  be 
regarded  as  complete  unless  the  age  at  the 
origin  of  the  attack  of  insanity,  on  ad- 
mission, the  mean  number  resident  at 
diffei'ent  ages,  as  also  the  ages  of  the  pa- 
tients who  recover  and  die,  are  given  in 
decennial  periods. 

(&)  Sex.  —  Statistics  show  that  more 
women  out  of  a  given  number  of  the 
population   in    an   asylum    recover  than 


statistics  of  Insanity        [     1199    ]        Statistics  of  Insanity 


men.*  That  there  are  exceptions  to  the 
rule,  especially  in  some  American  asy- 
lums, must  be  granted,  but  special  rea- 
sons may  be  given  for  these  departures 
from  the  almost  universal  experience  of 
asylums.  Passing  on  to  the  influence  of 
sex  on  mortality,  it  admits  of  statistical 
proof  that  the  advantage  is  on  the  side  of 
women,  as  indeed  it  is  in  the  community 
at  large,  but  to  a  much  greater  degree 
than  in  the  pojiulation  in  asylums  for  the 
insane.  Manifestly  it  would  be  very 
unfair  to  compare  the  mortality  tables 
of  an  institution  in  which  there  is  a  great 
difference  in  the  proportion  of  the  sexes. 

('■)  Previous  Condition  of  Life,  Socially 
itnd  ()therv:ise. — It  is  obvious  that  the 
liability  to  disease  and  death  is  much 
greater  among  patients  taken  from  the 
classes  of  society  where  intemjjerance  and 
want  are  prevalent.  So,  again,  the  re- 
covery-rate is  lower  among  the  insane 
from  the  pauper  classes  of  the  community 
than  in  the  higher  classes  of  society.  Nor 
must  it  be  overlooked  that  the  difference 
in  the  dietary  in  an  asylum  for  the  higher 
and  one  for  the  pauper  classes  would 
materially  affect  the  termination  of  the 
disorder  whether  in  recovery  or  death. 

{d)  Causes  of  Insanity  {as  affecting  Re- 
covery).— It  is  manifest  that  cases  of  de- 
lirium tremens  have  a  much  better 
chance  of  recovery  than  cases  of  sunstroke. 
These  are  extreme  instances,  but  they 
serve  to  illustrate  the  important  relation 
between  the  causes  of  mental  disease  and 
its  mode  of  termination. 

(e)  Form  of  Mental  Disorder. — It  is  not 
necessary  to  prove  that  a  knowledge 
whether  the  disorder  is  in  the  form  of 
imbecility  or  acute  mania  will  determine 
the  physician's  opinion  with  regard  to  the 
recovery  of  the  patient.  Here  again  it  is 
altogether  unfair  to  compare  the  results 
of  treatment  in  institutions  receiving 
totally  different  classes  of  patients  as 
respects  the  form  of  mental  disorder.  For 
example,  to  draw  an  inference  from  the 
statistics  of  the  termination  of  the  cases 
admitted  into  Bethlem  Hospital  and  the 
Hanwell  County  Asylum  would  be  alto- 
gether unwarrantable. 

(/)  Duration  of  the  Attack  on  Admis- 
sion.— This  factor  is  in  the  highest  degree 
important  in  the  comparison  of  the  re- 
sults tabulated  in  the  reports  of  different 
institutions.  The  general  law  may  be 
laid  down  that  the  probability  of  recovery 
is  in  inverse  ratio  to  the  length  of  time 
the  patient  has  laboured   under  mental 

•  III  England  and  Wales  the  i)ercentagc  of  re- 
coveries, calculated  on  the  adiiiissious,  was,  from 
1880-89  inchisive:  Males,  3V47,  and  females, 
43.81. 


disease.  After  three  months'  duration 
the  chance  of  recovery  as  a  general  rule 
diminishes.  On  the  other  hand,  the  lia- 
bility to  death  is  greater  during  the  early 
period  of  the  disease. 

Dr.  Thurnam  found  that  at  the  Retreat 
(Yoi'k)  the  probability  of  recovery  in 
cases  brought  under  care  within  three 
months  of  the  first  Httack  was  as  four  to 
one,  while  it  was  less  than  one  to  four  in 
those  cases  not  admitted  until  more  than 
twelve  months  after  the  attack.  This 
excellent  statistician  appears  to  have  over- 
looked the  circumstance  that  the  figures 
on  which  this  statement  is  based,  whilst 
strictly  correct,  maybe  largely  explained  by 
the  fact  that  many  of  the  cases  admitted  a 
twelve-month  after  the  first  attack  have 
been  treated  elsewhere  within  three  months 
of  its  occurrence.  The  importance  of  early 
treatment  is  not  for  a  moment  called  in 
question,  but  the  evidence  adduced  from 
those  and  similar  statistics  is  very  un- 
satisfactory. Notwithstanding  this  seri- 
ous source  of  fallacy,  it  is  desirable  to 
continue  the  fourfold  division  in  relation 
to  the  duration  of  attack  on  admission 
which  was  introduced  by  the  Retreat.  It 
is  as  follows : 

1st  Class.  Cases  of  the  first  attack,  of 
not  more  than  three  months'  duration. 

2nd  Class.  Cases  of  the  first  attack  of 
more  than  three  but  of  not  more  than 
twelve  months'  duration, 

3rd  Class.  Cases  not  of  the  first  attack 
and  not  more  than  twelve  months'  dura- 
tion. 

4th  Class.  Cases  whether  of  the  first 
attack  or  not,  and  of  more  than  twelve 
months'  duration  when  admitted. 

It  is  ujion  this  classification  that  the 
recoveries  and  the  mean  mortality  in  each 
class  must  be  calculated. 

An  inferior  division  which  no  doubt 
commends  itself  to  those  asylum  officers 
who  dislike  the  trouble  of  preparing  sta- 
tistical tables  is  the  twofold  division  into 
cases  not  exceeding  twelve  months'  dura- 
tion when  admitted,  and  those  extending 
beyond  this  period. 

(g)  Duration  of  Treatmeni  in  Asylum. 
— This  has  already  been  referred  to  (§  7). 
It  is  obvious  that  this  factor  may  greatly 
affect  the  results  of  treatment  in  regard 
to  the  success  of  a  particular  asylum.  It 
is  only  necessary  to  illustrate  this  by  the 
effect  at  Bethlem  Hospital  of  the  rule 
limiting  the  residence  of  curable  cases  to 
twelve  months.  As  some  of  these  cases 
subsequently  recover  at  other  institutions 
the  reported  recoveries  of  the  former  are 
to  that  extent  less  than  they  would  have 
been  if  no  such  rule  had  been  in  force. 
Again,  in  regard  to  the  mortality-rate,  the 


statistics  of  Insanity        [ 


Statistics  of  Insanity 


class  of  cases  admitted  for  only  a  year  are 
of  the  recent  class,  and  therefore  are  more 
likely  to  entail  a  large  mortality. 

In  a  table  prepared  by  Dr.  Thurnam, 
showing  the  average  duration  of  residence 
in  all  cases  admitted  into  certain  asylums, 
he  gives  the  results  at  various  periods 
from  their  opening,  successively  increased 
by  terms  of  live  years.  At  the  end  of  the 
first  quinquennium  such  residence  was  at 
the  Retreat  decidedly  less  than  one-half 
its  amount  after  it  had  been  opened  five- 
and-forty  years.  At  the  close  of  the  first 
decennium  it  was  less  than  two-thirds. 
At  the  end  of  twenty  years  the  average 
duration  of  residence  was  less  than  at  the 
close  of  the  forty-five  years  by  more  than 
six  months.  A  table  constructed  on  these 
lines  is  essential  if  we  desire  to  ascertain 
certain  detailed  particulars  in  connection 
with  the  residence-rate.  A  separate 
statement  of  the  length  of  residence  of 
every  patient  admitted  into  an  asylum  is 
obviously  necessary  before  we  can  demon- 
strate the  fact  that  it  is  "  by  much  the 
lowest  in  the  cases  discharged  recovered  ; 
higher  in  those  which  leave  improved ; 
higher  still  in  those  who  died ;  and  highest 
of  all  in  the  cases  remaining  in  the  insti- 
tution at  any  given  time,  after  a  consider- 
able period  of  operation."* 

(lo)  Mean  TTumber  Resident  under 
Different  Circumstances  of  Sex,  Age, 
Form,  and  Duration  of  Disorder.  — 
The  foregoing  remarks  on  the  influence 
of  the  above-mentioned  conditions  on  the 
success  of  various  asylums,  and  conse- 
quently the  results  of  treatment,  may 
be  supplemented  by  a  few  words  on  the 
methods  employed  for  ascertaining  not 
only  the  mean  number  resident,  but  its 
relation  to  the  several  factors  just  enume- 
rated. The  monthly  register  of  the 
asylum  should  be  taken  as  the  basis,  and 
from  it  must  be  ascertained  the  number 
of  months  passed  in  the  asylum  during  a 
given  year  by  each  patient,  the  figures 
being  ari-anged  in  certain  pei'iods  of  life, 
and  according  to  the  fourfold  division  of 
time  the  attack  of  insanity  has  lasted  at 
the  date  of  admission,  the  sex  of  the 
patient  being  also  stated.  The  subjective 
time  in  months,  obtained  from  the  register 
for  the  year  in  question,  is  ascertained, 
and,  being  divided  by  twelve,  we  obtain  the 
mean  number  resident  during  the  twelve 
months.  Weekly  registers  yield  of  course 
similar  results,  the  divisor  being  in  this 
instance  fifty-two. 

(ii)  Recoveries. — In  addition  to  the 
statistics   already  given    (§  4)    we    may 

*  "  statistics  of  the  Ketreat,"  p.  89,  Tables  18 
aud  19  ;  and  Appendix  I.,  Table  J'..,  Tbuniau),  op. 
cit.  p.  66. 


add  the  formula  laid  down  by  Dr.  Thur- 
nam, which,  when  he  wrote,  was  regarded 
as  too  unfavourable,  but  which  subse- 
quent experience  has  shown  to  be  only 
too  correct,  namely,  "  as  regards  the  re- 
covei'ies  in  asylums  which  have  been  estab- 
lished during  any  considerable  period, 
say  twenty  years,  a  proportion  of  much 
less  than  40  per  cent,  of  the  admissions, 
including  re-admissions,  is  under  ordinary 
circumstances  to  be  regarded  as  a  low 
proportion,  and  one  much  exceeding  45 
per  cent,  as  a  high  proportion"*  No 
statistics  of  recovery,  however,  would  be 
complete  without  a  consideration  of  the 
number  of  relapses. 

(12)  Relapses. — Statistics  of  the  York 
Retreat  have  shown  that  a  relapse  occurred 
in  two  of  every  three  cases  in  which  there 
had  been  recovery  in  the  first  attack. 
Dr.  Thurnam's  conclusion  from  a  general- 
isation of  the  history  of  the  patients  at 
the  York  Retreat,  subsequent  to  their 
discharge,  was  exjaressed  as  follows  :  "  In 
round  numbers,  of  10  persons  attacked 
by  insanity,  5  recover,  and  5  die  sooner 
or  later  during  the  attack.  Of  the  5  who 
recover  not  more  than  2  remain  well  dur- 
ing the  rest  of  their  lives ;  the  other  3 
sustain  subsequent  attacks,  during  which 
at  least  2  of  them  die."t  This  formula 
would  be  more  accurately  expressed,  hav- 
ing regard  to  the  statistics  upon  which  it  is 
based,  as  follows  :  Of  1 1  persons  attacked 
by  insanity,  6  recover,  and  5  die  sooner  or 
later  during  the  attack.  Of  the  6  who 
recover,  not  more  than  2  remain  well 
during  the  rest  of  their  lives  ;  the  other 
4  sustain  subsequent  attacks,  during 
which  3  of  them  die.  A  very  valuable 
contribution  to  the  life-history  of  the 
insane  has  been  made  by  Sir  Arthur 
Mitchell.  He  recorded  the  condition  of 
1297  patients  admitted  into  Scottish 
asylums  for  the  first  time,  and  in  no 
asylum  before,  twelve  years  afterwards, 
with  this  result:  851  recovered,  261  did 
not  recover,  412  died,  499  were  re-admitted, 
and  273  remained.  Now,  of  the  851  re- 
coveries, 538  persons  recovered,  or  41.5 
per  cent,  of  the  admissions;  of  these,  316 
(or  59  percent,  of  538)  relapsed  for  a  time, 
leaving  109  who  either  remained  or  died 
insane.  The  remaining  429  permanently 
disappeared  as  recovered,  being  33  per 
cent,  of  the  original  number  admitted.  As 
412  died  and  273  remain,  685,  or  53  per 
cent.,  were  accounted  for,  while  612,  or  47 
per  cent.,  had  disappeared  at  the  end  of 
the  twelve  years.  These  were  traced  as 
far  as  possible,  and  it  was  found  that  42 
had  died  insane,  78  sane,  94  were  leaving 
insane,  and  197  in  a  state  of  sanity. 
*  oj).  cit.  p.  136.  t  Op,  cit.  p.  123. 


statistics  of  Insanity        [     i2or    ]        Statistics  of  Insanity 


Although  the  remaining  201  were  not 
traced  it  is  reasonable  to  assume  that  they 
would  terminate  in  the  same  proportion. 
Thus,  in  twelve  years,  of  1297  persons — 

36.6  per  cent,  died  insane. 

31.7  ,,     „       ai-o  still  alive  and  insane. 

31-7     ,,     .,       are  eitlier  still  alive  and  sane,  or 

died  sane. 

100.0 

Thus,  after  twelve  years  there  were  68.3 
per  cent,  of  those  admitted  either  still 
living  insane  or  who  had  died  insane.  Of 
the  former  few  would  recover,  and  of  those 
living  in  a  state  of  sanity  some  would  un- 
doubtedly relapse.*  The  tinal  result  will 
therefore  be  less  favourable.  The  writer 
has  elsewhere  conjectured  that  at  least  T^^ 
per  cent,  would  at  death  be  insane,  leaving 
only  27  per  cent,  of  the  total  i^ersona 
admitted  likely  to  die  sane. 

Very  valuable  as  these  statistics  are  it 
must  be  remembered  that  Di*.  Thurnam 
was  able  to  trace  the  after-history  of 
every  patient  who  had  been  at  the  Retreat 
in  loJiom  death  had  occurred,  and  that 
therefore  his  conclusions,  although  based 
on  a  much  smaller  number  of  cases, 
possess  especial  value. 

(13)  Mortality  (see  §  5). — The  Lunacy 
Eeport  for  England  and  Wales  (1S89) 
gives  the  annual  rate  of  mortality  during 
ten  years  ending  December  31,  1888  ;  the 
deaths,  calculated  on  the  mean  number 
resident,  amounted  to  9.70  per  cent.  In 
registered  hospitals  it  was  6.56;  in  pro- 
vincial licensed  houses  it  was  8.41 ;  in 
meti'opolitan  licensed  houses  it  was  10.83  5 
in  county  and  borough  asylums  9.95  ;  and 
in  the  naval  and  military  hospitals  and 
Royal  India  Asylum,  6.61.  At  the  York 
Retreat,  from  its  opening  to  1891,  the 
annual  mortality  has  been  5.53.  Taking 
the  county  and  borough  asylums  in  York- 
shire, we  find  that  the  percentage  of  deaths 
on  the  mean  number  resident  from  1818 
to  January  1889  was  12.09. 

The  fall  in  the  rate  of  mortality  in  asy- 
lums in  England  and  Wales  in  recent  as 
compared  with  former  years  is  jjfoved 
by  statistics.  We  have  prepared  a  table 
showing  the  percentage  of  deaths  calcu- 
lated on  the  mean  number  resident 
during  1818-67,  1868-77,  and  1878-87, 
in  the  county  and  borough  asylums  in 
Yorkshire.  The  result  is  as  follows  : — 
The  deaths  were  13.87  per  cent,  during 
1818-67  and  11.42  during  1868-77,  being 
a  decrease  between  the  two  periods  of 
2.45.  During  1878-87  the  deaths  were 
1 1 .04,  the  decrease  being  slight. 

Mr.    Noel  Humphreys   gives    a    table 

»  "Contributions  to  the  Statistics  of  Insanity," 
by  Arthur  Mitchell,  3I.D.,  LL.D.,  ./oin-itti/  0/  Men- 
tal Science,  Jan.  1877. 


showing  the  annual  death-rate  per  cent, 
of  average  number  resident  in  the  asy- 
lums of  England  and  Wales  for  thirty 
years,  1859-88,  dividing  the  period  into 
three  decades.  During  1 859-68  the  death- 
rate  was  10.31,  during  1869-78  it  was 
10.17,  and  during  1879-88  it  was  9.55.* 

The  question  of  the  relative  liahilitij  of 
the  sane  and  insane  to  death,  must  be  now 
referred  to.  It  may  at  once  be  stated  that 
the  mortality-rate  is  higher  among  the 
insane  than  in  the  sane. 

Mr.  Humphreys  has  given  a  table 
which  shows  the  annual  rate  of  mortality 
per  1000  idiots  and  imbeciles  living  at  dif- 
ferent age-periods  in  the  Metropolitan 
District  Asylums  for  the  three  years  1886- 
88  inclusive,  compared  with  the  mortality 
in  the  general  London  population,  at  the 
same  age-periods,  and  in  the  same  years. 

The  result  is  thus  summarised  by  Mr. 
Humphreys  : 

"The  mean  annual  death-rate  at  the 
age-periods  dealt  with  in  the  table  in- 
creased from  42.8  per  1000  among  the  im- 
beciles aged  20-40,  to  56.8  among  those 
aged  40-60,  to  178.2  among  those  aged 
60-80,  and  to  457.3  per  1000  among  those 
aged  upwards  of  80  years ;  or  if,  on  account 
of  the  small  numbers  living  over  80  years 
of  age,  we  treat  the  numbers  aged  upwards 
of  60  years  as  one  age-period,  the  annual 
rate  of  mortality  is  195.7  per  1000.  The 
table  also  shows  that,  compared  with  the 
London  rates  at  the  same  ages,  the  mor- 
tality of  the  inmates  of  the  asylums  for 
imbeciles  was  six  times  as  high  in  the  ao-e- 
period  20-40,  three  times  as  high  at  40- 
60,  rather  less  than  three  times  at  60-80, 
and  not  much  more  than  twice  as  high  at 
80  and  upwards  ;  moreover,  it  was  less 
than  three  times  as  high  among  all  the 
inmates  of  these  asylums  aged  upwards  of 
60  years.  Speaking  more  generally,  it 
may  be  said  that  between  20  and  40  years 
(at  which  age  the  bulk  of  the  admissions 
takes  place,  and  in  which  period  is  found  a 
larger  proportion  of  the  inmates  than  in 
any  other)  the  rate  of  mortality  is  six 
times  that  which  prevails  in  the  general 
population,  whereas  at  subsequent  ages 
the  mortality  is  less  than  three  times  the 
normal  rate  among  the  general  popula- 
tion. These  metropolitan  asylums  for  im- 
beciles are  mainly  tilled  with  chronic  and 
harmless  cases,  which  probably  are  liable 
to  rates  of  mortality  varying  very  con- 
siderably from  those  that  prevail  among 
the  inmates  of  county  asylums  "  (op.  cit.). 

The  class  of  patients  here  referred  to 
must  be  borne  in  mind. 

Taking     the    whole     of    England   and 

*  Paper  read  before  the  Koyal  Statistical  Society, 
Feb.  18,  1890. 


statistics  of  Insanity        [    1202    ]        Statistics  of  Insanity- 


Wales,  the  annual  average  mortality 
at  all  ages  for  the  thirty  years  ending 
1890  was  22.2  per  iocx>  for  males,  and 
19.8  for  females  ;  the  mortality  for  the 
ages  above  twenty  was  21.0  per  1000  for 
males,  19.3  for  females.  We  give  the 
latter  period  as  more  nearly  correspond- 
ing to  the  period  of  insane  life.  The 
lowest  mortality  in  asylum  reports  is  more 
than  double  the  foregoing.  At  the  Re- 
treat (York)  the  average  age,  at  the  origin 
of  the  disorder,  of  the  patients  dying  there 
during  a  term  of  years  was  about  39 
years.  Now  at  this  age  the  expectation 
of  life  is  at  least  28  years.  The  average 
age  at  death  of  these  patients  was,  how- 
ever, only  56,  whereas  it  should  have  been 
67  {39  +  28)  had  the  mortality-rate  been 
tbe  same  as  in  the  population.  It  was 
even  lower  than  this  at  the  York  asylum, 
namely,  49L  The  following  Table*  exhibits 
the  high  moi'tality  of  lunatics  at  various 
ages  in  asylums  as  compared  with  that 
of  the  general  population  : — 


Insane  Asylums. 

General 
Population. 

Males. 

Females. 

Males. 

Females. 

15-25 
25-35 

35-45 
45-55 
55-65 
65-70 

70-75 
70  and 
upwards 

75-85 
85-95 

8.26 
10.36 

14-35 
14.44 
13.70 
22.41 

31.16 

7.87 
7.17 
7.66 
7-36 
10.35 
17.22! 

25.76 

0.77 
0.95 
1.26 

1-77 
3-06 

6.65 

11.83 
14.67 
30.72 

0.81 
0.99 
1.20 
1.50 

2-75 
5.68 

11.09 

13-39 
28.12 

Sir  Arthur  Mitchell  has  compared  the 
mortality  in  the  Scotch  lunatic  asylums 
with  that  of  the  general  population  above 
the  age  of  ten  years,  from  which  it  appears 
that  the  mean  annual  death-rate  for  the 
latter  is  1.7  percent.,  as  compared  with 
8.3  per  cent,  in  asylums.  His  table  shows 
that  at  all  the  quinquennial  periods 
between  ten  and  fifty,  patients  die  pretty 
nearly  at  the  same  ratio,  excepting  between 
twenty-tive  and  thirty,  when  the  death- 
rate  falls.  On  the  contrary,  in  the  general 
population, for  all  the  quinquennial  periods 
between  ten  and  fifty  it  increases  in  geome- 
trical progression  as  the  ages  rise.  The 
death-rate  in  asylums  after  the  age  of 
fifty  rises  quinquennially  in  an  irregular 
manner,  while  in  the  general  population 
the  rise  is  rapid  and  steady.f 

*  "Manual  of  Psychological  Medicine,"  4tli 
edit.,  p.  133. 

t  See  Table  in  Journal  qt'  Mental  Science,  1879. 


(14)  Relative  Iilability  to  Insanity  at 
Different  Ages. — It  is  quite  unnecessary 
to  prove,  what  no  one  now  would  deny,  the 
fallacy  of  determining  this  liability  by  a 
comparison  of  the  number  of  insane  ex- 
isting at  each  period  of  life  with  the 
number  of  individuals  existing  in  the  same 
periods  in  the  general  population.  We 
must,  on  the  contrary,  compare  occun'ing, 
and  not  existing,  cases  of  mental  disorder 
at  various  periods  of  life,  with  the  numbers 
living  at  the  corresponding  periods  in  the 
community  at  large.  Recurrent  attacks 
ought,  strictly  speaking,  to  be  excluded. 
Again,  cases  occurring  under  ten  years  of 
age  are  so  generally  examples  of  congeni- 
tal mental  defect,  that  they  cannot  pro- 
perly be  compared  with  the  population  at 
the  same  period,  but  with  the  number  of 
births.  Further,  it  is  very  dilficult  to 
ascertain  the  age  of  patients  at  the  time 
of  the  attack,  and  consequently  it  is  usual 
to  take  the  time  of  admission  into  asylums. 
It  is  evident,  however,  that  the  result  will 
be  the  throwing  forward  of  the  liability  in 
question  to  a  somewhat  later  term  of  life 
than  that  which  is  actually  correct.  Dr. 
Thurnam  was  not  able  to  obtain  any  ex- 
tensive statistics  prepared  in  accordance 
with  a  system  theoretically  correct.  He 
felt,  however,  authorised  to  conclude  that 
"there  can  be  little  or  no  doubt  that  the 
period  of  life  most  liable  to  insanity  is 
that  of  maturity,  or  from  twenty  to  fifty 
or  sixty  years  of  age.  From  thirty  to 
forty  years  of  age  the  liability  is  usually 
the  greatest ;  and  it  decreases  with  each 
succeeding  decennial  period,  the  decrease 
being  gradual  from  thirty  to  sixty  years, 
and  after  that  much  more  rapid."  *  At  the 
same  time,  had  the  age  when  the  attack 
first  occurred  been  ascertained,  the  decade 
of  greatest  liability  to  attack  might  have 
been  between  twenty  and  thirty  years,  as 
is  actually  the  case  in  the  experience  at 
the  York  Retreat ;  at  any  rate,  if  this  is 
saying  too  much,  large  numbers  of  the 
cases  tabulated  as  occurring  between 
thirty  and  forty  would  be  thrown  back  to 
the  period  between  twenty  and  thirty. 
We  have,  elsewhere,  shown  that  in  Ameri- 
can asylums  the  liability  to  an  attack  is 
greatest  between  twenty  and  thirty. 

The  Tables  of  the  Commissioners  in 
Lunacy  indicate  a  somewhat  later  age- 
period  for  first  attacks  than  we  have  stated 
above,  the  incidence  falling  most  heavily 
during  the  decade  35-45. 

(15)  Relative  Iilability  to  Insanity  In 
Males  and  Females. — Although  the  ac- 
tual admissions  of  male  and  female  luna- 
tics into  asylums,  excluding  transfers,^ 
showed  an  excess  of  the  latter  during  the 

*    O/i.  n't.  p.  164. 


statistics  of  Insanity        [     1203    ]        Statistics  of  Insanity 


seventeen  years  1869  to  18S5  inclusive,*  it 
is  necessary  to  correct  this  result  by  tak- 
ing the  ratio  (per  10,000)  of  admissions  to 
the  population,  as  resrards  the  two  sexes. 

Up  to  the  year  1S79  there  was  a  slight 
excess  of  male  over  female  admissions. 
In  1879  an^  1880,  however,  there  was  a 
slight  excess  in  the  proportion  of  female 
admissions.  Taking  the  mean  of  the  next 
five  years,  1881-85,  the  male  admissions 
were  equal  to  5.22  per  10,000  of  the  popula- 
tion, against  5.1S  female  admissions,  thus 
showing  a  very  slight  excess  of  males.  In 
the  aggregate  of  the  succeeding  live  years, 
1886-90,  the  reverse  was  the  case;  for 
while  the  male  admissions  averaged  5.24 
per  10.000  during  that  period,  the  female 
admissions  averaged  5.26,  showing  a  slight 
excess  of  females.  If  these  two  quin- 
quennial periods  be  taken  together,  the 
proportions  of  the  two  sexes  were  almost 
identical,  being  5.23  for  males  and  5.22 
for  females. 

In  the  preceding  ten  years,  1871-80,  the 
male  admissions  were  equal  to  5.13,  and 
the  female  admissions  to  4.96,  per  10,000 
persons  living,  showing  an  excess  of  male 
admissions,  among  equal  numbers  of  both 
sexes  living  of  3.4  per  cent. 

We  append  a  tabular  statement  of  the 
admissions  of  both  sexes  from  1881  to 
1890  inclusive,  separately  and  in  certain 
terms  of  years.f 


Admissious  per 

10,000  of  Population. 

Yuar. 

Males. 

Females. 

I'ursons. 

1 881 

5-25 

5-12 

5-J3 

1882 

5.20 

5-14 

S-'^7 

1883 

5-42 

5-45 

5-44 

1884 

5-37 

5-24 

5-30 

1885 

4.86 

4-95 

4.91 

1886 

4.98 

4.88 

4-93 

1887 

5-21 

5-07 

5-14 

1888 

5-23 

5-24 

5-24 

1889 

5-21 

5-37 

5-29 

1890 

5-55 

5-71 

563 

5  years,  1881-85 

5.22 

5- 18 

5.20 

5  years,  1886-90 

524 

5.26 

5-25 

10  years,  1881-90 

1 

5-23 

5-22 

5.22 

These  statistics  appear  to  show  that, 
while  working  the  admissions  of  the  two 
sexes  upon  the  population  reduces  the  a])- 
parently  large  excess  of  female  over  male 
admissions,  there  has  been  occasionally, 
and  during  the  last  three  years  uniformly, 
a  slightly  greater  number  of  admissions  of 

*  Fortieth  Report  of  the  Commissioners  in 
Lunacy,  1886  (Table  III.). 

t  See  Sr.x.  Im  i,ien<k  oi-.  i\  lNSANn'\. 


female    lunatics.      The    natural   inference 

would  be  that  with  the  increased  tendency 

of  women  to  enter  into  intellectual  i)ursuit3 

and  to  take  part  in  political  life,  there  had 

been  injuriouii    results  in  the  direction  of 

mental  disorder.      It  may  be  so,  and  there 

would   be  nothing  remarkable  in  the  cir- 

{  cumstance  that  the  relative  liability  of  the 

I  sexes  to  insanit}'^  had  undergone  a  marked 

change  in  the  course  of  recent  years.     It 

I  remains  to  be  seen  whether  the  returns  of 

;  coming  years  will  be  in  accordance  with 

I  those  which   we  have   given,  or  whether 

I  circumstances  of  which  we   are   ignorant 

I  have  temporarily  interfered  with  former 

experience,  and  so  may  not  be  of  a  lasting 

character. 

(16)  Cases  as  dlstingruished  from  Per- 
sons.— The  importance  of  this  distinction 
j  will  be  obvious  to  any  one  who  will  take 
I  j^ains  to  calculate  the  recoveries  of  pa- 
tients admitted  into  asylums,  with  and 
without  regard  to  this  distinction.  If 
of  100  cases  discharged  recovered  one- 
third  consists  of  the  same  persons  who 
have  I'ecovered  more  than  once,  it  is 
obvious  that  althcmgh  the  number  of 
recoveries  is  correctly  reported,  a  much 
too  favourable  impression  is  conveyed  as 
regards  the  number  of  i:)er.sons  restored  to 
health  and  enabled  to  take  their  place  in 
the  world.  For  a  detailed  notice  of  this 
source  of  fallacy,  and  the  proper  mode  of 
calculating  the  recoveries  on  admission, 
see  CuKABiLiTY  ur  Insanity. 

(17)  Relative  Frequency  of  the  Vari- 
ous Forms  of  Mental  Disorder. — In  con- 
sequence of  the  personal  equation  which 
influences  the  classification  of  mental  dis- 
oi-ders,  the  reports  of  asylums  vary  to  a 
certain  extent  in  this  matter,  even  when 
the  tabular  arrangement  is  similar,  and 
the  difficulty  is  increased  when  such  state- 
ment greatly  differs  in  its  divisions.  Re- 
cent efforts  which  have  been  made,  dating 
from  the  action  first  taken  at  the  Ant- 
werp Congress  of  Mental  Medicine,  and 
culminating  in  the  resolution  unanimously 
adopted  at  the  Paris  Congress  in  1889, 
will  tend,  it  is  hoped,  to  minimise  these 
divergent  systems,  but  we  fear  a  complete 
unanimity  is  impossible.  In  the  mean- 
time we  must  content  ourselves  with  the 
statistical  tables  of  the  forms  of  mental 
disorder  admitted  into  British  asylums, 
which  are  at  hand. 

Taking,  in  the  first  instance,  the  43rd 
Report  of  the  Commissioners  in  Lunacy, 
we  find  that  of  14.336  patients  (private  and 
pauper)  admitted  into  county  and  borough 
asylums,  registered  hospitals,  naval  and 
military  hospitals,  State  asylums,  and 
licensed  houses,  during  one  year  (1887), 
the  proportion  per  cent,  was  divided  as 

411 


statistics  of  Insanity       [    1204    ]        Statistics  of  Insanity 


follows  between  the  forms  of  mental  dis- 
orders adopted  by  the  Lunacy  Board  : — 


Male. 

Female. 

Total. 

Mauia  ..... 
Melaucbolia  .     .     . 

Dementia  IJf'-''?"'^'-^- 

Congenital    insanity 
(includiiiii'      idiocy 
anil   other    mental 
defects  from   birth 
or  infancy)   .     .     . 

Other   forms   of  in- 
sanity     .... 

46.1 
21. 1 

13-9 

4-7 

6.3 
7-9 

52-1 
28.6 

8.3 
3-4 

4.2 

3-4 

49.1 
24.9 
ir.i 

4.0 

5-3 
5-6 

1 
1 

100 

100 

The  late  Dr.  Boyd  prepared  an  elabo- 
rate table  based  on  a  large  number  of  first 
admissions  into  the  Somerset  County 
Asylum,  the  result  being  the  following 
proportions  per  cent. : — Mania,  42.9  ;  me- 
lancholia, 18.4;  dementia.  10.6;  mono- 
mania (delusional  insanity),  5.3  ;  general 
pai'alysis,  5.1  ;  moral  insanity,  i.i  ;  epi- 
lepsy, 10.9;  delirium  tremens,  1.4.  We 
omit  idiocy  (4.3)  because  it  can  bear  no 
relation  to  the  frequency  of  congenital  de- 
fect. As  to  age.  Dr.  Boyd's  figures  con- 
firmed the  observation  of  Esquirol,  that 
"  insanity  may  be  divided  into  imbecility 
of  childhood,  mania  and  monomania  for 
youth,  melancholia  for  mature  age,  and 
dementia  for  advanced  life."  From  a 
large  number  of  asylum  returns  which  we 
threw  together  some  years  ago,  melan- 
cholia appeared  to  be  much  more  frequent 
than  in  l)r.  Boyd's  table.  Thus,  of  100 
admissions,  half  were  cases  of  acute  and 
chronic  mania  ;  melancholia,  30  ;  demen- 
tia, 1 1  ;  monomania,  9.  From  a  Table  in 
the  same  report  (p.  52)  we  note  that  the 
proportion  (per  cent,)  of  epileptics  and 
paralytics,  admitted  into  the  same  insti- 
tution, during  tlie  same  period,  to  the 
total  number  of  patients  admitted  was  : 
Epileptics,  9 ;  general  paralytics,  also  9. 
In  both,  the  male  sex  predominated  ;  thus, 
in  the  former  there  were  10.9  males 
against  7.1  females,  and  in  the  latter  15 
against  3.3  per  cent. 

(18)  Causation. — As  the  Lunacy  Com- 
missioners adopt  a  classification  of  the 
causes  of  insanity,  which  is  fairly  work- 
able, and  have  collected  together  a  large 
number  of  returns  from  English  asylums, 
it  is  desirable  to  give  the  results  here  for 
what  they  are  worth.  As  is  well  known, 
the  entries  made  by  the  friends  of  pa- 
tients in  the  statutory  "  statement  "  are 
extremely  unreliable  and  constantly  con- 
found cause  and  effect,  the  Commissioners 


state  that  they  have  not  relied  ujion  these 
but  upon  statements  verified  by  the  medi- 
cal officers  of  the  asylum.  {See  Table  on 
p.  1205.) 

(a)  Condition  in  Reference  to  Marriage. 
—  Two  sources  of  fallacy  at  least  may 
vitiate  the  inference  drawn  from  mere 
figures  in  regard  to  the  number  of  pa- 
tients in  a  state  of  celibacy.  In  the  first 
place  it  may  be  the  mental  condition  of 
an  individual  which  has  prevented  mar- 
riage, and  not  celibacy  which  has  caused 
or  favoured  his  mental  condition.  It  is 
extremely  difficult  to  distinguish  the  se- 
quence of  the  two  events,  celibacy  and  in- 
sanity, in  a  statistical  inquiry.  Secondly, 
there  is  the  fallacy  arising  from  taking 
the  condition  in  regard  to  marriage  of  the 
insane  without  comparing  it  with  the 
proportion  of  unmarried,  married  and 
widowed,  in  the  general  population.  Now, 
the  condition,  in  1881,  of  the  population  of 
England  and  Wales,  aged  twenty  and 
upwards,  was  in  respect  to  marriage  as 
follows  : — 


— 

Unmarried. 

3Iarried. 

Widowed. 

per  cent. 

per  cent. 

per  cent. 

Males 

27.12 

66.09 

6.79 

Females  . 

25-85 

60.55 

13.60 

Total .     . 

26.45 

63.19 

10.36 

If  with  these  figures  the  corresponding 
condition  of  the  insane  admitted  into  asy- 
lums be  compared,  it  will  be  found  that 
the  proportion  of  celibates  is  much  greater 
in  the  latter.  It  is  true  that  the  propor- 
tion of  married  persons  between  twenty- 
five  and  forty,  a  term  of  life  in  which 
there  are  so  large  a  number  of  admis- 
sions into  asylums,  is  less  than  between 
twenty  and  upwards,  and  that  hence  a 
slight  allowance  should  be  made  on  this 
account,  probably  to  the  extent  of  7  per 
cent.  What  the  Table  in  the  Lunacy 
Commissioners'  Report  (1889),  in  regard 
to  the  condition  of  patients  admitted  into 
the  asylums  of  England  and  Wales,  shows, 
is  that,  at  marriageable  ages,  and  in  pro- 
portion to  the  popitlation,  considerably 
more  single  than  married  or  widowed  per- 
sons are  admitted  (p.  48).  The  general 
conclusion  from  a  study  of  the  whole  sub- 
ject leads  to  the  conclusion  that  celibacy 
is  more  likely  to  favour  mental  disease 
than  the  married  condition.  At  the  same 
time  the  result  cannot  be  absolutely 
stated  in  figures  on  account  of  the  impos- 
sibility of  measuring  the  extent  of  the 
source  of  fallacy  first  mentioned. 


statistics  of  Insanity        [     1205    J        Statistics  of  Insanity 


Table  fihciviiKj  the  Cnw^es  of  Lmuiitij  in  Patients  Admitted  into  the  Asylums  and 
lieijisfen'd  HoK2)it((h  in  Emilnnd  and  Wales  during  the  Ten  Years,  1878 
to  1887. 


Proportion  per  cent,  to 

the  Admissions. 

«  ;iUM's   iif   llis;iuil3'. 

1 

Male. 

Female. 

Total. 

Moral : 

Domi'stif  iii>iil)k>  (im-liidin^  loss  of  reliiiives  aud  I'rkuils) 

4.2 

9-7 

7.0 

Adverse  cin'mnstiinccs  (iii<-ludiui;  business  anxieties  and  pecuuinry   | 
difflculiies)                                                                                                     1 

8.2 

3-7 

5-9 

Meutal  anxiety  iiiid   -  worry  "   (not    inclmled    under  I  lie    :ilio\('    two   | 
heads)  and  oviTwork                                                                                        J 

6.6 

5-5 

6.0 

Kelijiious  exritemeni        .....-•■• 

2-5 

2.9 

2.7 

Love  affairs  (inclndinL;  seduction)    .... 

■     ■     ■  ! 

0.7 

2-5 

1.6 

Frifiht  and  nervous  slioek         ..... 

0.9 

1.9 

1-4 

/'hiisiail: 

Intemperance  in  drink     ...... 

19.8 

7.2 

134 

Intemperance  (sexual  1 

I.O 

0.6 

0.7 

Venerciil  disease; 

0.8 

0.2 

0-5 

Sell'-almse  (sexual)  .... 

2.1 

0.2 

1.2 

( »ver-exertion                               .          . 

0.7 

0.4 

0-5 

Sunstroke 

2.3 

0.2 

r.2 

.\ccideut  or  injury   .... 

5-2 

1.0 

3-0 

I'rejruancy        ..... 

— 

1.0 

o-S 

Tarturition  and  the  pueri)eral  state  . 

— 

6.7 

3-4 

Lactation         ..... 

— 

2.2 

I.I 

I'terine  and  ovarian  disease.*    . 

— 

2-3 

1.2 

Puberty 

0.2 

0.6 

0.4 

('hang-e  of  lite           .... 

— 

4.0 

2.0 

Fevei-s     ...... 

0.7 

0-5 

0.6 

Privations  and  starvation 

1-7 

2. 1 

1-9 

Ohl  ase 

3-8 

4.6 

4.2 

Other  bodily  diseases  or  disorders    . 

11. 1 

10.5 

10.8 

Previous  attacks      .... 

14.3 

18.9 

16.6 

Hereditary  intluence  ascertained 

19.0 

22.1 

20.5 

C'onL;enital  delect  ascertained  . 

5-1 

3-5 

4-3 

<  )ther  ascertained  causes  . 

2-3 

1.0 

1-7 

Inknown         ..... 

21.3 

j     20.1 

20.7 

The  above  fcible  is  based  upon  136,478  admissions  (male,  66,918  ;  female,  69,560).  These  totals 
represent  the  entire  number  of  instances  in  which  the  several  causes  (either  alone  or  in  combination 
with  other  causes)  were  stated  to  have  produced  the  mental  disorder.  The  aggregate  of  these  totals 
(including  "  unknown  " )  of  course  exceeds  the  whole  number  of  patients  admitted.  The  excess  is 
owing  to  combinations  (.sf'c  Forty-third  Iteport  of  the  Commissioners,  1889,  p.  67). 


(h)  Mural  and  Flujsical  Causes.  — 
Aluch  has  been  written  on  the  relative 
influence  of  moral  and  physical  causes-  in 
the  production  of  insanity.  The  real  diffi- 
culty lies  in  determining  the  area  of  the 
one  and  the  other.  Many  causes  are  of  a 
mixed  character — partaking  of  both  the 
moral  and  physical.  For  the  sake  of 
uniformity  it  is  better  to  follow  the  classi- 
fication of  causes  adapted  by  the  Commis- 
sioners in  Lunacy,  given  in  the  foregoing 
Table.  It  may  be  pointed  out,  however, 
that "  privation  and  starvation,"  tabulated 
under  physical  causes,  contain  a  strong 
element  of  moral  agency  as  well,  and 
other  similar  combinations  might  be  men- 
tioned. 

Moral  causes  have  been  regarded  by  the 
French  school,  and  some  English  writers, 


as  in  the  majority.  On  the  other  hand, 
at  the  York  Retreat,  the  physical  are  in 
excess  of  the  moral  causes  to  a  considerable 
extent.  So  at  the  York  Asylum,  The 
same  result  is  reached  in  the  statistics 
prepared  by  Dr.  Earle.  In  the  annexed 
causation  table  the  physical  causes,  even 
after  omitting  previous  attacks,  amount 
to  75  per  cent.,  and  the  moral  to  only  25 
percent.  If,  then,  statistics  maybe  trusted, 
moral  causes  exert  decidedly  less  influence 
than  physical  causes. 

Dr.  Major  has,  in  the  annual  reports  of 
the  West  Riding  Asylum,  attempted  to 
improve  upon  the  ordinary  mode  of  tabu- 
lating the  causes  of  insanity.  He  com- 
bines the  causes  of  the  attacks  in  a  manner 
shown  in  the  following  Table  in  which  the 
factor  of  alcoholic  excess  is  present  in  all 


statistics  of  Insanity        [     1206    ]        Statistics  of  Insanity 


instances,  but  is  in  manj'  combined  with 
other  causes  : 


I 

Alcoholic  excos!* 

0 

(*5 

3 

3 

0 

(sinji'ly)  .     .     . 
Alcoholic  e.xci'ss 

30 

5 

35 

7-5 

with  beri'clitary 

tendeiic)'  to  in- 

sanitj-     .     .     . 
AJcoLolie  excess 

M 

5 

19 

4.0 

with  other  phy- 

sical causes 

9 

4 

13 

2.7 

Alcoholic  excess 

comliineil   with 

moral  causes    . 

13 

I 

14 

3-0 

66 

15 

81 

17.2 

The  importance  of  endeavouring  to 
differentiate  the  causes  of  attacks  of  in- 
sanity in  the  foregoing  way  is  obvious, 
and  it  is  to  be  regretted  that  so  few  of 
those  who  prej^are  asylum  statistics  take, 
in  this  respect,  as  much  trouble  as  Dr. 
Major  has  done. 

(c)  Freclisposincf  and  Exciting  Causes. 
— In  the  annual  report  of  the  Com- 
missioners in  Lunacy,  from  which  the 
causation  table  is  extracted,  separate 
columns  are  given,  indicating  the  number 
of  instances  in  which  the  cause  is  supposed 
to  have  been  predisposing,  and  the  number 
in  which  it  is  suj^posed  to  have  been 
exciting.  It  is  no  doubt  very  difficult  in 
many  instances  to  distinguish  between 
these  two  classes,  and  some  writers  have 
rejected  the  distinction  as  worthless.  At 
the  same  time  there  are  many  cases  in 
which  the  distinction  is  very  clear.  Thus, 
the  individual  who  has  a  strong  here- 
ditary taint  has,  it  must  be  allowed,  a 
predisposition  to  mental  disorder.  Sub- 
ject this  person  and  one  who  comes  of  a 
perfectly  healthy  stock,  to  a  reverse  of 
fortune  or  other  calamity  ;  the  former  will 
probably  succumb  and  the  latter  escape 
the  overthrow  of  reason.  The  exciting 
cause  is  altogether  distinct  from  the  pre- 
disposing one.  It  must  be  admitted  that 
the  predisposing  causes  are  the  more  im- 
portant of  the  two, 

(d)  Occu'paiion.  —  The  Commissioners 
(Table  xiv.)  give  the  professions  or  occu- 
pations of  the  population  of  England  and 
Wales,  and  of  the  patients  admitted  into 
asylums  during  the  year.  It  is  doubtful, 
however,  whether  it  is  safe  to  draw  infer- 
ences from  these  figures,  and  we  there- 
fore do  not  give  them. 


(e)  Moon. — The  popular  belief  in  the 
influence  of  this  luminary  has  never  beeu 
established  by  careful  observation.  The 
experience  of  the  York  Eetreat  has  been 
brought  to  bear  ujDon  this  subject,  but  the 
result  has  been  entirely  negative.  {See 
Moox.) 

(/)  Civilisation.  —  It  may  be  stated, 
without  danger  of  contradiction,  that  the 
prn2:)ortion  of  idiots  and  lunatics  to  the 
population  in  uncivilised  nations  is  less 
tban  in  those  who  are  civilised.  At  the 
same  time  there  are  many  reasons  why 
the  actual  number  accumulated  in  the 
latter  should  be  vastly  greater  than  in 
the  former  without  a  corresponding  differ- 
ence in  the  liability  to  mental  disorders. 
If  we  consider  only  this  liability  we  should 
recommend  savages  to  remain  uncivilised, 
but  on  the  other  hand  we  should  decidedly 
recommend  the  class  corresponding  to 
savages  (city-arabs,  &c.)  in  a  civilised 
community  to  enter  the  ranks  of  the  edu- 
cated and  well-fed  classes. 

Age  and  sex  fall  under  causation,  but 
we  have  already  considered  their  relative 
liabilities  (p.  1203). 

Heredity  is  discussed  at  length  in  the 
article  by  Dr.  Mercier  under  that  head. 
In  the  Cause-Table  of  the  Commissioners 
it  stands  at  20.5  per  cent,  of  the  admis- 
sions, but  the  reluctance  of  the  relatives 
of  patients  to  give  information  on  this 
painful  point,  leaves  the  proportion  un- 
doubtedly far  too  low. 

Conclusion. — In  concluding  this  article 
we  would  acknowledge  the  great  service 
rendered  to  the  statistics  of  insanity  by 
Mr.  Noel  Humphreys'  contribution  to 
a  difficult  inquiry  in  his  paper  already 
referred  to.  Notwithstanding  the  diffi- 
culty arising  from  the  imperfect  data 
given  in  the  Reports  of  the  Lunacy  Com- 
missioners, he  has  concentrated  all  avail- 
able knowledge  and  brought  it  up  to  as 
recent  a  period  as  possible.  He  entirely 
confirms  the  conclusion  arrived  at  by  the 
writer,  that  statistics  fail  to  prove  au}" 
real  increase  in  occurring  insanity.  On 
other  points  wpon  which  this  article  treats 
his  figures  are,  without  excei:>tion,  in  full 
accord.  It  is  further  reassuring  that  the 
princi25les  laid  down  by  Dr.  Thurnam  in 
regard  to  the  preparation  of  the  statistics 
of  insanity,  and  to  which  the  writer  has 
repeatedly  expressed  his  indebtedness,  are 
entirely  borne  out.  The  Editor. 

^References. — Blue  Books  of  the  Commissionei-s  in 
Limacy.  Yaw,  Report  on  the  Jlortality  of  Luna- 
tics, Royal  Stat.  Soc.  Joiini.  1841.  Thuruam,  Sta- 
tistics of  Insanity,  1844.  Lockhart  Koljertson, 
Alleged  Increase  of  Insanity,  Journal  of  Mental 
Science,  1869  and  1871.  Hack  Tuke,  Insanity 
and  its  I'revention  (Appendices),  1878  ;  Idem,  The 
Alleged   Increase  of  Insanity,  Journal   of  Mental 


status  Epilepticus 


[ 


Stultitia 


Scii'ucf,  Oct.  1886;  lilem,  The  Past  ;uul  Present 
Provision  lor  tlic  Insane  I'oor  in  Vdrksliire,  with 
Sii<;<,a'stions  for  the  l''uture  Trovisiou  for  this  Class, 
i88g.  N.  Uinnphrcys,  Statistics  of  Insanity  in 
Knt^land,  witli  special  reference  to  evidence  of  its 
iilleyetl  increasing  prevalence,  lloyal  Statistical 
Society  Joiirn.  1890.  ^lorlinier  ("iranville,  Care 
and  Cnre  of  the  Insane,  2  vols.  1 

STATUS  SPIIiEPTZCUS. — A  name 
given  to  a  rapid  succession  of  epileptic 
tits  without  intervening  consciousness.  It 
is  a  rare  but  dangerous  symptom  espe- 
cially if  with  deepening  coma  the  intervals 
between  the  tits  become  shorter.  The 
temperature  is  said  by  Bourneville  to  rise 
in  some  cases  as  high  as  105°  to  107",  and 
death  is  caused  by  collapse,  or  the  occur- 
rence of  meningitis.  Recovery  may  how- 
ever take  place.  Sir  James  Crichton-Browne 
has  recommended  the  inhalation  of  amyl 
nitrite.  Chloral,  j^cr  aiium,  with  subcu- 
taneous injections  of  morphia,  and  spinal 
icebags  appear  to  be  the  most  efficacious. 

STSHIiSUCHT.  —  The  German  term 
for  kleptomania. 

STEZFSVCHT  (Ger.).  Catalepsy  or 
tetanus. 

STICIVIATA  (o-rt'y/xo,  a  hole  Or  mark 
made  by  an  instrument,  a  brand-mark). 
In  pathology  applied  to  small  red  spots 
on  the  skin  either  natural  or  acquired. 
They  are  of  interest  in  psychological 
medicine  owing  to  cases  such  as  that  of 
Louise  Lateau,  the  Belgian  girl,  where 
these  red  spots  seem  to  have  appeared  on 
parts  of  the  body  to  which  the  mind 
had  been  intensely  directed.  Brewer 
(*' Dictionary  of  Phrase  and  Fable'')  gives 
a  list  of  men  and  women  who  have 
claimed  to  be  able  to  show  the  impres- 
sions or  marks  corresponding  to  some  or 
all  of  the  wounds  received  by  Christ  in  his 
trial  and  crucifixion. 

Dr.  Coomes,  Louisville,  Ky.,  has  re- 
corded, in  the  Medical  Standard,  a  case 
of  stigmatisation  in  a  devout  Catholic,  a 
female,  whom  he  personally  watched  along 
with  others  appointed  to  assist  him.  The 
first  bleeding  occurred  in  June  1891. 
During  attacks  of  hysterial  unconscious- 
ness blood  frequently  flowed  from  the 
right  hand,  the  feet  and  foi'ehead.  After 
watching  her  for  three  hours,  "  the  crusts 
of  the  wounds  began  to  be  lifted  u]i,  and 
in  a  few  moments  the  serous  portions  of 
the  blood  began  to  ooze  from  beneath  the 
crusts,  and  slowly  run  down  across  the 
right  foot.  In  a  few  minutes  the  blood 
began  to  assume  a  pinkish  and  then  a  red 
colour,  until  it  had  the  appearance  of 
ordinary  blood.  There  were  but  a  few 
drops  from  this  foot  on  this  occasion.  The 
left  foot  has  now  commenced  pouring  out 
serum,  which,  like  that  from  the  right 
foot,  soon   became  red,  and,  after  a  few 


drops,  had  issued,  the  flow  ceased."  More 
remarkable  stigmata  are  recorded  in  this 
case,  but,  as  the  blood  was  not  seen  flow- 
ing by  Dr.  Coomes  himself,  it  would  not 
be  safe  to  accept  the  report,  although  "  no 
evidences  of  fraud  have  been  detected,  and 
she  has  been  watched  closely  during  the 
unconscious  state."  Dr.  Coomes  stuck 
needles  again  and  again  into  her  limbs, 
dashed  her  face  with  water,  and  tickled 
her  feet,  and  found  complete  anaesthesia 
and  absence  of  reflex  action.  In  this  and 
similar  cases  it  is  more  than  i^robable  that 
genuine  and  pretended  wounds  and  hae- 
morrhages are  mixed  up  together.  M. 
Warlomont,  a  member  of  the  commission 
appointed  by  the  Hoyal  Academy  of 
Medicine  of  Belgium  to  inquire  into  the 
phenomena  alleged  to  occur  in  the  case  of 
Louise  Lateau,  gave  credit  to  them.  The 
conclusion  at  which  this  commission  ar- 
rived was  unanimous — viz.,  that  "  The 
stigmata  and  ecstasies  are  real.  They  can 
be  explained  physiologically."  The  late 
Mr.  Critchett  was  present  at  one  examina- 
tion of  Louise  Lateau,  and  believed  that 
the  phenomena  were  jjerfectly  genuine. 
Thk  Editor. 

[Itcf'cinia's. — Dictionnaii-e  ile  ^lystique  Chre- 
tieune,  art.  Extases,  Stigmates,  &c.,  I'aris,  i8=;8. 
JIaury,  Les  Mystiques  Extatiques  et  les  Stigma- 
tises, Ann.  Medico-Psych.,  tome  i.  Jules  Parrot, 
Etude  sur  la  Sueur  de  Sang  et  les  Heniorragies 
iie'vropathiques,  Paris,  1859.  Louise  Lateau,  de 
Bois  d'Haiue,  hy  Dr.  F.  Lefehvre,  Prof,  of  Patho- 
log:y  in  the  Louvain  University,  Physician  to  the 
Lunatic  Asylums  in  that  town ;  translated  and 
edited  by  llev.  .1.  Spencer  Northcote,  D.D.,  Lon- 
don, 1873.  Louise  Lateau,  la  Stigmatisec  de  Bois 
d'Haine,  Warlomont,  Jiruxelles,  1873.  Illustra- 
tions of  the  Influences  of  the  Mind  upon  the  Body, 
vol.  i.  pp.  119-126,  292,  London,  1884.] 

STOI.ZSITAS,  STOX.IDXTY.  —  A 
term  meaning  stupidity,  imbecility  ;  or 
merely  describing  the  characteristic  of  the 
phlegmatic  temperament.  A  synonym  of 
Amentia. 

STRAIT  -  'WAISTCOAT.  —  A  short 
coat  of  strong  material  which  confines 
the  arms  of  the  violently  insane ;  some- 
times without  sleeves,  and  sometimes 
with  long  sleeves  without  openings, 
which  can  be  tied  together  behind  or 
before.  (Fr.  camisole  da  force ;  Ger. 
Zwangsjacke.) 

STRIDOR  DEN-TZXTM. — Teeth-grind- 
ing. A  symptom  in  certain  cerebral 
diseases.  Among  the  insane  it  is  by  far 
the  most  frequent  in  general  paralysis. 

STRYCHSrOIVIAN-IA  {(rTpvxvos,  night- 
shade ;  fiavia,  madness).  An  ancient  term 
for  the  delirium  resulting  from  eating  the 
deadly  nightshade.     (Fr.  drychnomanie.) 

STITZ.TITZA  {duUus,  foolish).  Fool- 
ishness. Duluess  of  the  mind.  (Fr. 
siupidiit' ;  Ger.  Xarrlteit).     (Sec  Iniotjv.) 


Stupemania 


1208    ] 


Stupor,  Mental 


STVPEMASTXA. — A  name  sometimes 
applied  to  mental  stupor. 

STUPOR  {stujiio,  I  am  stupefied).  A 
state  of  mental  torpor. 

STUPOR,  ATTERGIC— Term  substi- 
tuted for  acute  dementia  by  Dr.  Hayes 
Newington.     (.SVe  Stupok,  Mkntal.) 

STUPOR,  MEMTAI..  —  I.  Anergric. 
ZX.    X>elusional. 

I.  Anergric.  (Syn.  Acute  dementia ; 
Dt'mence  uitjue,  Esquirol.)  So-called 
"  acute  dementia "  is  seen  either  as  a 
primary  affection  following  a  definite 
course  and  ending  in  death  or  recovery, 
or  as  an  accidental  and  intercurrent 
symptom  in  other  forms  of  acute  or  of 
long-continued  insanity,  for  instance,  in 
epilepsy,  puerperal  insanity,  ordinary 
acute  mania,  or  melancholia  (especially  if 
accompanied  with  masturbation),  general 
paralysis,  &c.  After  attacks  of  acute  in- 
sanity that  do  not  end  in  recovery  a  con- 
dition is  often  found  where  the  patient, 
though  still  exhibiting  much  intelligence, 
does  not  regain  his  normal  standard  of 
mind  ;  but  this  must  not  be  confounded 
with  genuine  stupor. 

Symptoms. — The  patient  seems  con- 
tented to  remain  in  an  apathetic  condition, 
taking  little  interest  in  his  surroundings, 
making  no  inquiries  about  his  friends  or 
family,  but  given  up  entirely  to  the  mere 
routine  of  living  and  doing  as  he  is  told. 
He  may  or  may  not  retain  a  few  delusions 
and  hallucinations,  and  possibly  is  inco- 
herent and  at  times  uncertain  in  his 
disposition,  but  he  will  work  or  remain 
idle  according  as  he  is  told,  and  this  con- 
dition may  last  a  considerable  time 
without  much  change,  or  periodical  attacks 
of  excitement  or  of  depression  may  arise, 
ending  eventually  in  a  pronounced  state 
of  real  mental  stupor.  This  state  is  one 
phase  in  the  course  of  an  attack  of  acute 
insanity,  but  it  must  not  be  supposed  that 
an  antecedent  state  of  acute  excitement 
or  depression  is  always  present.  In  well- 
marked  cases  of  acute  dementia  the  symp- 
toms usually  come  on  suddenly,  and  are 
essentially  negative  in  character,  for  the 
patient  seems  to  be  deprived  of  all 
manifestations  of  mental  and  motor 
energy.  He  will  stand  or  sit  in  the  same 
position  for  hours  without  moving,  there 
is  a  blueness  and  swelling  of  the  hands 
and  feet  (although  the  thermometer  does 
not  invariably  show  a  fall  of  temperature), 
slow  and  feeble  circulation,  vacant  expres- 
sion, retention  (in  some  cases  incontinence) 
of  urine  and  f£eces,  complete  absence  of 
mental  function  in  the  region  of  will,  per- 
ception, memory,  and  often  even  of  con- 
sciousness, for  the  patients  as  a  rule  on 
recovery  remember  nothing  of  the   con- 


dition. The  refiex  system  too  is  deeply 
involved,  for  muscular  response  to  electri- 
cal stimuli  is  either  lessened  or  absent,  the 
respiratory  movements  are  diminished  in 
extent  and  frequency,  and  sensitiveness 
to  light,  sound,  taste  and  smell,  is  almost 
abolished.  In  fact  there  is  very  little  to 
sejiarate  the  condition  from  that  of  actual 
death,  and  the  patient  is  entirely  depen- 
dent upon  others  for  his  care  and  support. 
There  may  be  either  refusal  of  food,  or 
everything  may  be  freely  taken,  and  no 
diminution  in  the  bodily  weight. 

Some  of  the  patients  are  resistive,  they 
will  stand  or  sit  in  the  same  place,  and 
will  strongly  resist  any  attempt  made  to 
move  them  or  to  flex  their  muscles.  It 
would  seem  that  some  amount  of  con- 
sciousness is  present  here,  for  after  being 
moved  forcibly  away  from  a  place  they 
make  strong  efforts  to  return  to  it,  and 
they  often  appear  to  consciously  resent 
interference  with  their  fixed  attitude.  So 
rigid  in  some  of  these  resistive  cases  may 
be  the  muscular  system  that  we  have 
known  the  finger-nails  driven  into  the 
palm  of  the  hand  from  the  tonic  spasm. 

A  true  cataleptic  state,  on  the  other 
hand,  is  often  present,  and  the  limbs  of 
the  patient  will  retain  for  some  time  any 
position  in  which  they  are  placed,  giving 
just  the  appearance  of  an  artist's  lay 
figure.  Another  symptom  frequently 
present  is  the  great  susceptibility  of  the 
skin  to  the  development  of  taehe  cerebrale, 
shown  by  drawing  the  blunt  end  of  a 
pencil  lightly  along  the  skin  of  the  chest, 
abdomen,  or  extremities,  when  a  red  mark 
immediately  follows  the  impression  and 
remains  for  some  time.  AVe  have  found 
in  some  of  these  cataleptic  states  that  the 
power  of  the  extended  limbs  to  support 
weight  is  greater  in  degree  and  duration 
than  in  ordinary  persons.  The  condition 
in  many  respects  resembles  that  produced 
in  hysterical  persons  by  hypnotism.  Acute 
dementia  may  terminate  as  suddenly  as  it 
began,  or  it  may  develop  into  acute  mania, 
and  the  time  of  duration  of  the  demented 
state  may  vary  from  a  few  hours  to  weeks, 
months,  or  even  years.  This  condition  is 
often  confounded  with  "  melancholia  atton- 
ita,'"  from  which,  however,  it  is  distin- 
guished by  the  presence  in  the  latter  of 
delusions  and  a  greater  degree  of  con- 
sciousness, whilst  the  above  -  described 
states  of  catalepsy  and  vaso-motor  sensi- 
tiveness are  absent.  We  have  met  with 
profound  states  of  acute  dementia  much 
more  frequently  among  females  than  males, 
and  in  both  sexes  it  is  very  frequently 
connected  with  masturbation  or  some 
genital  irritation.  Young  persons  are 
most  liable  to  this  form  of  stupor,    and 


stupor,  Mental 


[     I 2oy     ] 


Stupor,  Mental 


hereditary  taint  is  frequently  present. 
The  pathologry  is  uncertain,  but  stupor 
is  generally  believed  to  be  due  to  vaso- 
motor disturbance,  and  is  not  connected 
with  organic  cerebral  lesion,  in  view  of  the 
suddenness  of  onset  and  dej^arture  of  the 
symptoms  and  the  large  percentage  of 
recoveries.  All  the  symptoms  point  to 
stagnation  in  the  circulation. 

Treatment. — Massage,  with  regulation 
of  diet  and  attention  to  the  bowels  and 
bladder,  are  indicated  as  the  best  lines  of 
treatment,  and  special  attention  should  be 
devoted  to  prevent  masturbation  if  possi- 
ble. The  use  of  the  continued  current  and 
Turkish  baths  may  be  recommended>  and 
we  have  found  cupping  over  the  region  of 
the  ovaries  very  useful  in  young  women, 
where  (as  generally  happens)  menstru- 
ation is  imperfect  or  irregular.  The  form 
of  acute  dementia  or  stupor  that  is  often 
found  as  an  intercurrent  symptom  in 
epilepsy  or  even  in  general  paralysis  calls 
for  no  special  form  of  treatment,  as  it  is 
generally  of  short  duration. 

T.  Claye  Shaw. 

XI,  Delusional  *  (Fr.  stupidite). — It  is 
unfortunate  that  medical  psychologists 
have  differed  so  much  in  the  terms  applied 
to  the  condition  which  that  of  "  Mental 
Stupor  "  is  intended  to  indicate.  There 
is  no  doubt  a  reason  for  the  obscurity  and 
vagueness  of  definition  which  have  pre- 
vailed in  reference  to  it.  It  arises  out  of 
the  difficulty  of  diagnosis.  The  expression 
and  conduct  of  the  patient  may  seem  to 
indicate  absolute  dementia. 

xromenclature,  —  There  are  cases  in  i 
which  the  ablest  alienist  is  unable  to  de- 
cide whether  the  mind  is  what  the  out- 
ward expression  would  lead  us  to  infer — a 
complete  blank — or  the  seat  of  such  intense 
depression  and  painful  delusion  as  only 
to  simulate  dementia.  "Mental  stupor" 
may  be  employed  to  cover  both  conditions 
until  it  is  ascertained  which  of  the  two  is 
present.  When  evidence  is  forthcoming 
that  a  melancholy  delusion  dominates  the 
mental  activity,  we  may  speak  of  melan- 
cholia cu7n  stupore,  or  of  mental  stupor 
with  delusion,  or  melancholia  attonita. 
If,  on  the  contrary,  we  are  able  to  satisfy 
ourselves  that  this  is  not  tbe  case,  we 
may  speak  simply  of  mental  stupor.  We 
prefer  this  term  to  acute  dementia,  which 
conveys  the  idea  of  mental  degeneration, 
thus  confounding  it  with  dementia  of  the 
genuine  type.     It  has  been  justly  said  by 

*  Althou<.''h  it  is  coiivfiiicnt  to  rec<mnise  two 
(livisioiis  of  Jlciital  Stupor,  the  anergic  and  the 
ilL'ltisioiial  or  luelaiicLolic,  we  shall  not,  under  the 
present  section,  restrict  ourselves  to  the  delusional 
form  of  stupor,  followin;,'-  in  this  respect  the 
clinical  fact,  as  the  two  are  ot)ser\"ed  to  occur  in 
I  he  same  patient  in  a  larue  nuniher  of  cases. 


Baillarger  that  acute  dementia  and  stupi- 
dity are,  in  the  majority  of  cases,  only  the 
highest  degree  of  melancholia  c?(?>i  stiq^orc 
French  alienists  agree  in  rejecting  the 
former  term  {dcmenrc  <iigue),  introduced 
by  Esquirol.  No  one  psychologist  has 
done  more  to  show  the  true  nature  of  the 
condition  under  consideration  than  Bail- 
larger,  but  the  observer  first  in  the  field 
was  Etoc-Demazy,  who  wrote  a  thesis  on 
stupor  in  1835. 

In  an  article  upon  this  affection  which 
Dr.  Hayes  Newington  contributed  to  the 
Journal  of  Mental  Science  (Oct.  1874),  he 
applied  the  term  anergic  stupor  if  so- 
called  acute  dementia  is  the  form  as- 
sumed, and  that  of  delusional  stupor  if  it 
is  not. 

Of  one  thing  there  can  be  no  doubt, 
that  the  delusional  stupor  of  to-day  may 
be  the  anergic  stupor  of  to-morrow.  In 
such  a  case  the  mental  condition  has 
melancholia  for  its  basis. 

The  writer  has,  in  a  paper  read  before 
the  Psychological  Section  of  the  Interna- 
tional Medical  Congress  1881,  given  his 
reasons  for  believing  that  there  is  a  kind 
of  auto-hypnotism  in  those  cases  in  which 
the  dwelling  intensely  upon  an  all-absorb- 
ing delusion,  is  followed  by  mental  stupor. 
A  case  was  reported  of  a  female  patient  in 
Bethlem  Hospital,  in  whom  the  manipu- 
lations calculated  to  awaken  a  person  in 
the  hypnotic  sleep  restored  the  patient  to 
normal  consciousness  of  her  surroundings 
and  a  corresponding  healthy  expression. 
Unhappily  this  lasted  only  a  very  short 
time,  but  the  experiment  was  very  sugges- 
tive. 

Symptoms. — In  the  first  place,  it  will 
clear  the  road  to  state,  what  no  one  ac- 
quainted with  the  insane  will  deny,  the 
clinical  fact  that  there  are  patients  who, 
under  intense  mental  depression  with  de- 
lusions, and  possibly,  but  rarely  without, 
do  not  speak,  eat,  dress  themselves,  but 
may  attend  to  the  calls  of  nature ;  do  not. 
in  short,  respond  to  the  outer  world,  and 
would  die  if  left  to  their  own  resources. 
The  eyes  are  closed  or  only  halC  opened, 
the  facial  expression  is  indicative  of  de- 
pression. There  is  muscular  tension,  as 
shown  when  one  takes  hold  of  the  patient's 
arm ;  the  muscles  are  felt  to  contract  and 
may  become  rigid.  In  this  state  it  is  very 
difficult  to  dress  and  undress  a  patient. 
He  stands  and  sits  in  the  same  immovable 
attitude.  On  recovery,  he  remembers 
what  has  been  the  predominating  thought 
in  his  mind  and  much  of  what  has  been 
addressed  to  him. 

To  the  above  mental  affection  the  names 
melancholia  cum  stupore,  melancholia  at- 
tonita, and  delusional  stupor  are  applied. 


stupor,  Mental 


[      I2IO      ] 


Stupor,  Mental 


It  has  been  doubted  whether  "  stujior  " 
conveys  a  correct  impression,  seeing  that 
we  do  not  connect  voluntary  resistance 
with  stupor.  For  this  reason  some  alien- 
ists prefer  the  term  melancholia  attonita. 

Another  clinical  fact  is  tliis:  A  man 
may  receive  a  mental  shock  which  para- 
lyses his  powers  of  mind  and  reduces  him 
to  the  level  of  vegetable  life.  His  muscles 
are  passive  instead  of  resistant.  He 
slavers ;  the  nasal  mucus  collects  and 
trickles  down  unheeded.  Flies  crawl  over 
his  face  without  his  regarding  them ;  he 
never  speaks,  and  his  existence  is  only  pre- 
served by  forcible  feeding.  His  muscles 
may  remain  for  an  indefinite  time  in  a 
position  in  which  they  are  placed.  The 
extremities  are  cold,  the  hands  blue,  and 
apt  to  have  chilblains.  He  is  dirty  in  his 
habits.  His  pujjils  are  generally  dilated. 
On  recovery,  he  has  no  memory,  or  a  very 
confused  one,  of  the  state  from  which  he 
has  emerged.  It  is  to  this  condition  to 
which  the  terms  acute  dementia,  anergic, 
and  apathetic  stupor  are  attached  Such 
are  two  very  different  mental  states,  the 
one  with  and  the  other  without  conscious 
depression  and  delusions,  the  former  being 
by  far  the  most  common. 

As  we  have  said,  the  difficulty  lies  in  the 
diagnosis.'^  There  may  be  no  symptom 
distinctly  evidencing  consciousness  of  sur- 
roundings, and  the  presence  of  mental 
distress  and  delusions — the  condition  most 
frequently  and,  some  would  hold,  exclu- 
sively found  in  the  melancholy  form  of 
stupor.  A  female  patient  at  Bethlem 
Hospital  became  markedly  cataleptic  for 
at  least  half  an  hour  at  a  time,  and  the 

*  Although  Dr.  Newington  has  given  a  table 
showing  the  differential  symptoms  in  the  two 
forms  of  mental  stupor,  we  fear  that  they  will  not 
always  enable  ns  to  arrive  at  a  correct  diasnosis. 
At  the  same  time,  it  is  well  to  have  them  in  view. 
Anergic:  Invasion  very  rapid,  intellect  evidently 
greatly  impaired,  memory  gone,  no  sign  of  emo- 
tion, features  relaxed,  ej-e  vacant  and  not  con- 
stantly fixed,  volition  al)sent,  motor  system  weak, 
catalepsy,  sensory  system  and  refiexes  dull,  ])upils 
dilated,  extreme  emaciation,  vascuhir  system  pro- 
foundly affected,  as  shown  l)y  the  pulse  being  very 
slow  and  by  cyanosis  :  tongue  clean,  or  if  not  it  is 
moist;  habits  dirty.  Delusional:  Invasion  slow, 
intellect  not  impaired,  memory  preserved,  features 
contracted,  eyes  fixed  on  one  point,  usually  up- 
wards or  downwards,  or  obstinately  closed ;  presence 
of  volition  shown  by  great  stubbornness,  motor 
system  little  interfered  with,  jiatient  standing  or 
Itneeling  from  time  to  time,  more  ability  to  l)ear 
pain,  pupils  contracted,  nutrition  affected  pari 
passu  with  mental  state  ;  the  disturbance  of  tlie  vas- 
<'ular  system  is  less  marked  and  comes  on  later; 
tongue  very  dry,  furred  ;  refusal  of  food,  constipa- 
tion ;  habits  rarely  dirty.  Dr.  Xewington  lays 
great  stress  on  anergic  stu])or  following  acute 
mania  in  women  only,  or  at  least  far  more  fre- 
<iuently  than  in  men.  Heredity  is  a  marked  feature 
in  the  history  of  both  forms  of  mental  stupor. 


muscular  resistance  was  at  any  time  very 
slight.  There  was  anassthesia ;  she  had 
to  be  fed ;  she  slavered  ;  she  was  wet  and 
dirty ;  there  was  oscillation  of  the  pupils, 
which  were  of  normal  size  and  equal ;  the 
eyeballs  were  usually  fixed,  looking  in 
front  and  occasionally  up ;  the  eyelids 
shut  and  tremulous  at  times,  whilst  at 
others  they  were  wide  open ;  she  would 
wink  if  anything  was  suddenly  brought 
near  her  eyes;  the  patella  reflex  was 
slightly  brisk  ;  she  did  not  move  unless 
pulled  along,  when  she  walked  mechani- 
cally ;  she  did  not  speak ;  she  had  to  be 
dressed.  In  stupor  with  delusions,  it  is 
said  the  patient  resists,  but  this  was  not 
the  case  here,  and  yet,  as  proved  by  the 
patient's  statement  after  recovery  and  the 
proof  which  test-questions  afford  of  the  pa- 
tient's memory,  there  had  been  no  blank. 

Such  cases  are  common;  hence  the  fre- 
quent mistake  of  labelling  a  case  as  one 
of  acute  dementia,  when  it  is  one  in  reality 
of  melancholia  attonita.  We  are  able  to 
give  instances  in  which  patients  have 
manifested  apathy,  silence,  immovability, 
disregard  of  flies  settling  on  the  face,  and 
the  saliva  dribbling  down  the  dress,  and 
the  hands  blue  and  cold,  and  yet  able  to 
give  subsequently  a  coherent  account  of 
the  delusions  under  which  they  were 
labouring  at  the  time  when  they  were 
apparently  simply  stupid.  Dr.  Clouston, 
in  filling  up  a  form  which  the  writer  drew 
up  and  distributed  a  few  years  ago  in 
reference  to  mental  stupor,  added  :  "  Here 
is  a  case  in  which  all  the  symptoms  were 
those  of  so-called  acute  dementia,  but  the 
case  was  really  one  of  melancholia  cuiii 
stuiMre.  I  cannot  find  any  case  in  which 
the  initial  stage  was  pure  stupor  without 
consciousness,  with  no  depressed  state  of 
mind,  but  which  terminated  in  stupor  with 
depressed  feeling  and  consciousness.  I  do 
not  think  I  ever  met  with  such  a  case, 
and  indeed  I  am  very  scejjtical  that  ever 
such  exists.  I  should  prefer  to  believe 
that  it  was  melancholic  stupor  to  begin 
with  except  I  myself  had  an  opportunity 
of  watching  the  case.  It  is  most  difficult 
from  outward  symptoms  merely  to  tell 
real  '  anergic '  from  melancholic  stupor. 
I  have  seen  a  case  of  melancholic  stupor 
end  in  dementia  just  as  any  kind  of  mental 
disease  may  so  end." 

It  must  be  evident  from  the  foregoing 
that  it  is  not  always  possible  to  difier- 
entiate  the  symptoms  belonging  respec- 
tively to  melancholy  stupor  and  anergic 
stupor  or  so-called  acute  dementia.  Thus, 
in  regard  to  loss  of  sensation,  it  is  very 
certain  that  a  pin  introduced  into  the  skin 
will  fail  to  induce  any  sign  of  pain  in  both 
conditions.     Then  again,  as  to  catalepsy, 


stupor,  Mental 


[     J^>i     ] 


Stupor,  Mental 


we  find  it  present  in  both  states,  but  it  is 
not  likely  to  occur  when  there  is  much  re- 
sistance. 

Although  we  have  taken  great  pains  to 
show  that  the  more  carefully  patients  are 
examined  in  regard  to  their  mental  condi- 
tion when  labouring  under  mental  stupor, 
the  more  frequently  will  it  be  found 
that  some  form  of  dehision  was  present, 
we  do  not  deny  that  delusions  may  be  ab- 
sent and  thoutrht  be  practically  suspended. 
The  probability  of  a  jiatient  having  passed 
into  this  condition  may  be  suspected  if  the 
facial  expression  is  vacant,  listless,  stupid, 
mouth  often  open,  the  saliva  trickling  on 
to  the  beard  or  dress,  the  breath  offensive, 
the  pupils  dilated,  the  appetite  bad,  re- 
fusal to  take  food,  evacuations  passed 
involunlaril}^,  skin  cold  and  clammy, 
hands  blue  and  swollen,  pulse  very  feeble 
and  slow,  diminished  sensibility,  respira- 
tion slow  and  shallow,  eyes  frequently 
half  closed,  the  eyeballs  turned  up,  mus- 
cular activity  slight,  sometimes  nil,  patient 
remaining  in  the  same  condition  all  day, 
more  or  less  cataleptic,  in  many  instances 
mute  or  only  repeating  a  few  words,  auto- 
matic, apathetic,  frequently  unaware  of 
what  is  passing  around,  the  mind  being 
more  or  less  a  blank. 

Such  a  condition  as  this  may  succeed  to 
acute  mania :  a  shock  which  at  once  de- 
prives the  brain  of  its  power  of  sponta- 
neous action,  or  fever,  or  starvation,  or 
exhausting  diseases.  It  may  be  inferred 
that  a  female  patient  whom  we  knew  in 
St.  Luke's  Hospital,  who  passed  into  this 
condition  after  acute  mania,  was  free  from 
delusions.  There  was  mutism,  mental 
stupor,  and  marked  catalepsy.  She  had 
to  be  treated  as  a  child,  and  was  fed  and 
dressed.  She  was  dirty  in  her  habits. 
Again  we  should  be  disposed  to  infer  a 
like  mental  vacuity  in  a  young  man  in 
the  same  institution,  in  whom  religious 
depression  and  delusions  appeared  to  have 
entirely  passed  away,  and  he  became  taci- 
turn, refused  food,  and  could  not  dress 
himself.  He  stared  vacantly  about ;  some- 
times standing,  sometimes  sitting,  and  in 
either  position  as  immovable  as  a  stone. 
Ko  resistance  was  offered  when  the  writer 
extended  his  arms,  but  there  was  no  cata- 
lepsy. He  was  discharged  from  the  hos- 
pital unimproved. 

Among  the  indications  of  profound 
stupor  we  have  mentioned  the  absolute 
indifference  of  the  patient  to  Hies  crawling 
over  the  face  or  to  the  conjunctiva  being 
touched.  This  ought  to  count  for  some- 
thing, and  yet  in  a  recent  case  in  which 
this  symptom  was  present  it  was  ascer- 
tained that  his  memory  and  consciousness 
were   perfectly  vivid  "during   his   illness. 


Thus,  he  remembered  seeing  a  friend,  and 
that  he  (the  patient)  would  not  speak  to 
him  as  he  was  suspicious  of  his  intentions. 
He  recollected  being  pricked  in  the  legs  and 
arms,  and  that  it  hurt  him  excessively, 
but  that  he  would  not  show  any  signs 
of  feeling  "  through  obstinacy."  He  knew 
who  the  attendant  was,  and  he  felt  that 
he  was  kind  to  him.  He  said  he  remem- 
bered various  occurrences  and  incidents  as 
well  as  he  would  be  able  to  recall  events 
which  had  happened  five  months  pre- 
viously at  any  other  period  of  his  life.  He 
was  apprehensive  of  mischief  being  done 
to  him  when  he  was  asleep,  for  he  would 
wake  up  with  cuts  on  his  fingers  and  face, 
and  is  still  of  ojoinion  that  they  were  real 
and  that  they  were  done  during  sleep. 
He  was  under  the  influence  of  great 
dread,  and  the  force  necessarily  used  to 
feed  him  appeared  to  him  to  be  done 
to  injure  him.  He  had  a  reason  for 
sitting  still — namely,  lest  if  he  walked 
about  there  were  violent  patients  who 
would  knock  against  him  or  hit  him.  He 
recovered. 

Dr.  Whitwell  has  shown  that  the  cha- 
racter of  the  pulse  is  reflected  in  the  sphyg- 
mographic  tracing  taken  by  him  in  cases 
of  mental  stupor.  "  It  would  at  first  sight 
appear   that  the   pulse  was   exceedingly 

weak   and    feeble It   is   certainly 

small,  but  is  apparently  only  weak  and 
feeble  in  that  the  fluctuations  of  the  vessel 
are  comparatively  small,  and  the  varia- 
tions in  its  bulk  and  volume  are  only 
within  narrow  limits  and  gradual.  A 
sphygmographic  tracing  shows  a  typically 
high  tension  pulse,  in  which  the  cardiac 
factor  is  not  very  active.  The  line  of  ascent 
is  short  and  sometimes  somewhat  oblique, 
the  latter  being  masked  by  its  shortness. 
The  apical  angle  is  wide,  and  the  line  of 
descent  gradual ;  the  dicrotic  wave  and 
aortic  notch  are  usually  almost  absent, 
and  there  is  frequently  a  pre-dicrotic  wave 
present  which  may  tend  to  blend  with  the 
apical  angle  to  form  a  plateau,  probably 
on  account  of  the  feebleness  of  the  cardiac 
factor.  In  fact,  the  tracing  indicates  a 
pulse  of  considerable  tension,  suggesting 
difficulty  in  the  peripheral  outflow  and 
diminished  vigour  or  power  of  the  ventri- 
cular contraction."  Dr.  Whitwell's  trac- 
ings during  a  period  in  which  a  patient  be- 
comes clearer  in  mind  show  quite  an  oppo- 
site condition  of  the  circulation.  Even 
the  stage  of  transition  may  be  shown. 
We  are  indebted  to  him  for  permission  to 
use  the  interesting  sphygmograms  which 
are  ajijiended,  and  with  which  he  has 
illustrated  a  paper  in  the  Lancet,  Oct.  17, 
1891,  entitled,  "A  Study  of  the  Pulse  in 
Stupor"  (•'  Stenotic  Dystrophoneurosis") 


stupor,  Mental 


[      I2I2      ] 


Stupor,  Mental 


The  descriptions  below  indicate  the  pa- 
tient's state  when  the  tracine  was  taken. 


derangement,   the   essential   part  of  the 
malady,  and  has  studied  rigidity,  spasm. 


Fic.  I. —  rrai'iuii  of  pulse  during  stiigc  oi  stupor,  froiu  case  of 
iutfrmitteut  stupor. 


FKi.s.  2  AND  3. — Same  case  under  administration  of  aniyl  nitrite 
during  staye  of  stupor. 


Figs.  4  AND  5. 


-Same  ease  duriny:  transition  sta^e  between 
stu]iidity  and  lueidity. 


Fk;.  6. — S.ime  ease  during  period  ol  liieiility 


Fig.  7. — Effect  of  amyl  nitrite  on  pulse  during-  stage  of  lucidity. 


Age, — Usually  between  twenty  and 
thirty. 

Sex.— Young  men  are  especially  liable 
to  pass  into  mental  stupor.  These  cases 
are  generally  associated  with  sexual  vice. 

Causes, — Any  circumstance  involving 
brain  exhaustion  or  strain ;  shock  from 
fright ;  loss  of  relative ;  sexual  excess. 
Cases  of  mental  stupor  following  mania, 
&c.,  general  paralysis,  and  epileptic  at- 
tacks, belong  to  the  anergic  form. 

Circularity,  —  "  By  approaching  the 
disease  (stupor)  from  the  physical  side, 
Dr.  Kahlbaum  has  made  the  disorders 
of  motility,  and  not  the  form  of  mental 


choreic  movements,  and  catalepsy,  as  they 
occur  in  the  insane,  as  affections  analo- 
gous to  the  occurrence  of  general  paralysis. 
But  I  think  he  carries  his  views  too  far, 
and  that  as  the  morbid  mental  state  con- 
ditions the  motor  trouble,  it  is  right  to 
take  the  former,  and  not  the  latter,  as  the 
basis  of  classification  ;  at  the  same  time, 
it  is  very  important  that,  in  view  of  the 
psycho-motor  centres,  these  motor  and 
psychical  (as  also  the  sensory)  troubles 
should  be  brought  into  relation.'"* 

*  From  writer's  article  "  Mental  Stupor,"  in  the 
"  Transactions  of  tlie  International  Jledical  Con- 
gress, 1881."     Subsequent  experience  has  strongly 


* 


stupor  Vigilans 


[     1213    ]    Suggestion  and  Hypnotism 


Patbologry. — Brain  exhaustion,  vaso- 
motor disturbance,  and  trophic  changes. 
Using  the  term  mental  stupor  in  its 
broader  sense,  cases  published  by  Dr. 
Whitwell,*  in  which  the  cerebral  vessels 
were  examined,  go  to  prove  that  they  were 
diminished  in  calibre.  Cardiac  complica- 
tions favour  the  theory  of  arterial  stenosis. 
So  does  also  pallor  of  the  disc  in  mental 
stupor,  as  observed  by  Dr.  Aldridge  and 
Dr.  Whitwell.  Dr.  Wiglesworth  thinks 
that  a  group  of  cases  can  be  distinguished, 
the  prominent  symptom  of  which  is  self- 
absorptiou  passing  into  vacuity,  with 
muscular  tremors  and  afterwards  rigidity. 
He  regards  the  pathological  basis  as  a 
primary  inflammatory  affection  of  nerve 
cells,  markedly,  but  not  exclusively,  the 
motor  ones,  followed  by  swelling  of  the 
cells  with  displacement  of  the  nucleus. 
The  microscopical  appearances  of  the  cor- 
tical cells,  answering  to  this  description, 
in  two  cases  of  mental  stupor,  are  given 
by  Dr.  Wiglesworth.  who  admits,  however, 
that  more  observations  are  necessary .f 

In  his  remai'kable  thesis  on  Stupidity, 
Ktoc-Demazy  adduces  evidence  of  general 
cerebral  cedema  from  the  post-mortems  of 
patients  dying  in  this  mental  condi- 
tion. 

Prog-nosis, — The  prognosis  of  mental 
stupor  with  melancholy  delusions  is  not 
veiy  good.  Even  in  those  cases  in  which 
the  mental  cloud  is  dispersed,  serious 
bodily  symptoms  are  frequently  developed. 
Pulmonary  disease  insidiously  creeps  in. 
Emaciation  becomes  more  and  more 
marked,  and  the  patient  succumbs. 

Treatment. — In  a  large  number  of  cases 
a  considerable  time  will  elapse  before 
remedies  are  likely  to  take  effect.  Shower 
baths  have  often  proved  beneficial.  The 
prolonged  bath  has  appeared  to  be  the 
means  of  cure  when  most  other  remedies 
have  been  tried  and  failed.  Nitro-glycerine 
has  been  known  to  remove  mental  stupor, 
but  with  only  temporary  results  so  far  as 
we  are  aware.  A  moderate  form  of  drill 
in  the  form  of  being  placed  between  two 
attendants  who  wa'k  at  a  good  pace  is 
effectual  in  some  instances.  Galvanism 
applied  with  care  to  the  head  may  be  use- 
ful.    (See  Katatoxia.)        The  EnrxoK. 

STUPOR  VIGZI.Aia-S  (rigiJcuH,  wake- 
ful).    A  synonym  of  Catalepsy. 

STXJPOROXTS         ZM'SAXa'ZTY.  {Sri- 

Stui'ou,  Mr.xTAL.) 

STVTTERZM'G.      (See  STAMMERING.) 

confirmed  the  view  here  expressed.  See,  in  con- 
Hrmation,  an  able  article  in  the  Journal  of  Mi- ntal 
Scienci-,  April  1892,  by  Dr.  (ioodall,  I'atholoi^ist  at 
the  Wakefield  ('ounty  Asylum. 

»  Journal  of  Mi'iita/  Sriencc,  Oct.  1889. 

t  .See  ./oitriial  of  Mmt(il  Science,  Oct.  1883. 


SVB-BEiiiRZUlvx.  —  A  low  lethargic 
state  complicated  with  muttering  de- 
lirium. 

SUBTECTXVi:  CON'SCIOVSTrESS. — 

In  this  mental  state,  that  which  occupies 
the  consciousness  is  something  contem- 
plated as  the  ego.  "That  ohjective  force 
differs  in  nature  from  force  as  we  know 
it  sithjpctively  is  intellectually  intelligible, 
yet  to  conceive  of  force  in  the  non-ego 
different  from  the  conception  of  force  in 
the  ego  is  iitterly  beyond  our  power " 
(Spencex").  Subjective  science  is  the  the- 
ory of  that  which  knows. 

SVBJECTZVE  SEirsATZOUS. — Sen- 
sations caused  by  internal  stimuli,  and 
not  due  to  any  external  object. 

SVCCURSAIi  ASYIiVIvis. — Term  used 
(especially  in  Ireland)  for  a  provincial 
asylum  appropriated  to  one  particular 
class  of  lunatics,  namely  the  insane  poor 
who  are  incurable  and  tranquil. 

SUFFOCATZO  HYSTERIA,  SUPPO- 
CATXO     IVIUI.ZERVIVt,     SUPPOCATIO 

UTERZITA. — Terms  for  globus  hystericus. 
(See  Hysteria.) 

SUFFUSZO  DIMZDIAN-S  (suffusio,  an 
overspreading  or  clouding ;  dimidians, 
halving).  A  symptom  in  migraine,  in 
which  only  one-half  of  the  field  of  vision 
is  perceived  by  the  mind. 

STrGGESTzoia*  AJrn  hypttotzsivi. 
— We  shall  endeavour  in  this  short  article 
to  give  in  a  condensed  form  our  views  on 
suggestion  and  hypnotism. 

Definition. — Suggestion  in  its  widest 
sense  may  be  defined  as  the  act  by  which 
an  idea  is  introduced  into  and  accepted  by 
the  sensorium.  Every  idea  is  transmitted 
to  the  brain  by  a  sense  organ,  but  it  does 
not,  however,  become  a  suggestion  unless 
it  is  accepted,  and  this  accej^tance  often 
takes  place  by  reason  of  the  tendency  to 
credence  inherent  in  the  human  mind. 

1 .  The  idea  may  be  transmitted  directly 
by  the  suggested  speech  to  the  brain  as  a 
direct  suggestion  ;  or,  again,  it  may  be 
created  by  the  brain  in  consequence  of  an 
impression  received — indireet  suggestion. 
In  the  latter  case  psychical  individualism 
comes  into  play,  so  that  the  same  impres- 
sion may  give  rise  to  different  suggestions, 
because  each  brain-reaction  in  its  own 
peculiar  way  transforms  the  impression 
differently.  The  first  impression  is  the 
germ  of  the  suggestion,  and  is  elaborated 
by  the  fertile  mental  soil. 

2.  The  suggestion  having  been  made, 
and  the  idea  accepted  by  the  brain,  there 
then  follows  a  centrifugal  phenomenon — 
every  suggested  idea  which  has  been  ac- 
cepted tends  to  become  an  act— i.e.,  sen- 
sation, visual  image,  movement,  action, 
passion,  &c.,  or  in  other  words,  every  cere- 


Suggestion  and  Hypnotism    [     12 14    ]    Suggestion  and  Hypnotism 


bral  cell  stimulated  by  an  idea  stinn;lates 
those  nerve-fibres  which  are  to  realise  this 
idea.  This  is  the  law  of  ideo-dynamism 
as  we  call  it.  No  one  has  understood  this 
law  better,  and  illustrated  it  by  more 
numerous  examples,  than  Dr.  Hack  Tuke 
in  his  "  lufiuence  of  the  Mind  on  the 
Body."  The  idea  thus  may  become  a  sen- 
sation— e.g.,  the  idea  of  having  tieas  causes 
the  sensory  phenomenon  of  itching.  The 
idea  may  become  an  image — e.g.,  halluci- 
nations during  sleep  and  when  awake. 
The  idea  may  become  a  visceral  sensation 
or  organic  action — e.g.,  the  administration 
of  bread-pills  as  a  purgative,  vomiting  by 
a  substance  believed  to  be  an  emetic,  &c. ; 
or  the  idea  may  become  movement  or  ac- 
tion— e.g.,  table-turning  and  the  pheno- 
mena of  thought-reading  are  based  on  this 
fact. 

3.  In  Medicine  suggestion  may  be  util- 
ised for  therapeutic  purposes  ;  the  brain 
stimulated  by  a  certain  idea  tends  to  real- 
ise it  as  far  as  possible ;  it  sends  addi- 
tional motor  impulses  to  paralysed  mus- 
cles; it  neutralises  painful  sensations;  it 
stimulates  nerves  of  secretion ;  it  acts  in 
an  inhibitory  and  dynaraogenic  manner, 
thus  presiding  over  all  the  functions  and 
organs  of  the  body. 

4.  In  order  that  an  idea  shall  be  ac- 
cepted by  the  brain  and  realised  by  it,  it 
is  necessary  for  the  sug-g^estion  to  be 
efficient.  In  the  normal  condition  the 
realisation  as  well  as  the  cerebral  automa- 
tism which  tend  to  transform  the  idea  into 
an  act  are  limited.  They  are  moderated 
by  the  higher  reasoning  faculties  of  the 
brain,  which  constitute  the  controlling 
power;  reason  struggles  with  the  tendency 
to  credence  and  cerebral  automatism. 
Everything  which  diminishes  the  action 
of  the  reasoning  faculties  and  weakens  the 
inhibitory  control  increases  the  credence 
and  cerebral  automatism.  Thus,  natural 
sleep,  by  extinguishing  the  attention, 
leaves  free  play  to  the  imagination,  and 
allows  the  impressions  which  arise  in  the 
sensorium  to  become  images,  and  to  be  ac- 
cepted as  realities.  In  the  waking  state 
credence  is  inci-eased  by  religious  faith 
(religious  suggestion,  miraculous  cures), 
and  by  faith  in  medicines  or  medical  prac- 
tices (cure  by  fictitious  medicines,  mag- 
nets, metals,  electricity,  hydrotherapeutics, 
the  tractors  of  Perkins,  massage,  the  sys- 
tem of  Mattel,  &c.).  The  idea  of  cure  sug- 
gested by  these  practices  may  cause  the 
psychical  organ  to  act  and  obtain  from  it 
the  curative  effect,  not  that  the  sum  total 
of  these  practices  is  suggestion,  but  that 
suggestion  is  a  factor  in  every  one  of  them. 

Among  the  means  which  increase  cre- 
dence and  facilitate  the  transformation  of 


the  idea  into  action,  the  most  powerful  is 
hypnotism.  Hypnotism,  then,  is  only  an 
adjuvant  to  suggestion. 

5.  Hovr  shall  we  define  Hypnosis? — 
Is  it,  as  Braid  says,  a  nervous  sleep  pro- 
duced by  the  concentration  of  the  sight  on 
a  bright  point,  and  by  the  concentration 
of  the  mind  on  one  idea  ?  Among  the  sub- 
jects influenced  in  this  way,  there  are,  it 
must  be  noted,  some  who  are  not  aware  of 
their  hypnosis,  who  yet  preserve  the 
memory  of  everything  that  happened 
when  they  were  in  the  hypnotic  condition, 
and  in  whom  we  obtain  without  any  appa- 
rent sleep  all  the  phenomena  constituting 
hypnosis,  such  as  catalepsy,  anaesthesia, 
and  even  hallucinations  and  curative 
effects.  In  those  individuals  who  are 
susceptible  to  real  hypnotic  sleep  with 
amnesia  on  waking,  the  series  of  sugges- 
tions, instead  of  commencing  with  that  of 
sleep,  may  begin  with  sensory  or  motor 
phenomena,  or  with  uuinduced  images  or 
actions.  The  sleep  may  be  added  to  the 
other  phenomena,  or  it  may  be  dissociated 
from  them.  lu  one  word,  sleep  is  itself  a 
Ijhenonienon  obtained  by  suggestion, 
which,  although  it  cannot  be  produced  in 
all  individuals,  if  obtained,  increases  the 
suggestibility,  but  is  not  indispensable  to 
the  production  of  the  other  phenomena  of 
hypnosis  ;  sleep  is  in  the  same  way  as  the 
others,  a  phenomenon  of  suggestibility. 
It  would  be  best  completely  to  suppress 
the  word  "  hypnotism,"  and  to  replace  it 
by  the  term  "  condition  of  suggestion." 
If  the  words  hypnotism,  hypnosis,  and 
hypnotic  state  are  to  be  retained,  they 
may  be  defined  as  a  -peculiar  psychical 
condition  ivhicli  may  be  artificially  pro- 
duced, and  ivliicli,  if  brought  into  play,  in- 
creases in  various  degrees  the  suggestibility 
— i.e.,  the  tendency — to  he  influenced  by  an 
idea  which  is  accepted  and  realised  by  the 
bmin. 

6.  Ko-w  is  this  Psychical  Condition — 
i.e..  Hypnosis — produced? — All  the  pro- 
ceedings of  ancient  mesmerists  and 
modern  hypnotists,  the  haquet  of  Mesmer, 
the  tree  of  Puysegur,  the  passes  and 
different  manipulations,  the  staring  at  a 
bright  object  as  practised  by  Braid,  the 
revolving  mirror  of  Luys,  &c.,  may  be  re- 
duced to  one  factor — viz.,  the  endeavour 
to  make  an  impression  on  the  subject,  and 
induce  in  his  sensorium  the  idea  of  the 
phenomenon  which  we  desire  to  obtain, 
namely,  sleep.  The  best  and  simplest 
means  is  sj^eech.  In  very  susceptible 
subjects  a  simple  word  is  sufficient ;  in 
most,  however,  it  must  be  enforced  by 
gestures,  by  a  firm  manner  of  address,  by 
gentle  or  by  strong  insinuation,  by  the 
operator    fixing    the    subject's    eyes    or 


Suggestion  and  Hypnotism    [ 


]    Suggestion  and  Hypnotism 


closing  his  eyelids,  and  by  direct  com- 
mand. In  hospital  practice,  where  this 
command  is  very  easy  on  account  of  the 
authority  of  tlie  physician,  it  is  possible 
to  intinence  nine  subjects  out  of  ten,  and 
to  bring  almost  all — live  out  of  six — into 

firofonnd  sleep,  with  amnesia  on  waking, 
n  private  practice,  however,  success  is 
only  obtainable  in  a  smaller  ]>ro]iortion  of 
cases  ;  amnesia  on  re-awaking  is  produced 
but  in  one  out  of  four  or  five  patients 
operated  upon ;  in  most  cases,  however, 
we  are  able  after  one  or  more  aiances  to 
produce  a  variety  of  the  phenomena  of 
suggestibility — viz.,  motor  suggestions. 
such  as  catalepsy,  paralysis,  movements, 
and  various  actions  ;  suggestions  of  sensi- 
bility, such  as  ana3sthesia,  analgesia,  sen- 
sations of  cold,  heat,  tkc.  ;  suggestions 
affecting  the  senses,  such  as  deafness, 
blindness,  anosmia,  &c. ;  sensory  images, 
as  hallucinations  of  the  different  senses  ; 
suggestions  of  actions,  passive  obedience, 
robbery,  murder,  &c.  ;  post-hyimotic  sug- 
gestions —  i.e.,  suggestions  which  are 
realised  a  shorter  or  longer  time  after 
waking. 

7.  The  sugrgestibility  is  variable,  and 
the  so-called  hypnotic  condition  comprises 
various  stages.  These  have  been  classi- 
fied as  follows  by  Liebault : — 

(a)  Sovinolenri/,  difficulty  in  raising  the 
eyelids ;  in  1888,  6.06  per  cent,  of  his  sub- 
jects presented  this  first  stage. 

(6)  Light  sleep,  commencement  of  cata- 
lepsy ;  the  subjects  are  able  to  alter  the 
position  of  their  limbs  if  challenged  ;  17.48 
per  cent,  of  the  patients  treated  presented 
this  stage. 

(c)  The  light  sleep  becomes  deeper ; 
dulness  and  catalepsy  ;  ability  to  execute 
automatic  movements ;  the  subject  has  no 
longer  sufiicient  will-power  to  arrest  the 
suggested  automatism ;  35. 89  per  cent,  are 
thus  influenced. 

{d)  Intermedin ry  iigld  sleep;  the  sub- 
jects are  unable  to  fix  their  attention  on 
any  one  but  the  hy2:)notist,  and  can  recol- 
lect only  what  has  passed  between  them- 
selves and  him  ;  7.23  per  cent,  of  the  pa- 
tients. 

(e)  Ordinary somnamhuViHi if  .s7eejf>, cha- 
racterised by  complete  amnesia  on  awaking 
and  by  hallucinations  during  sleep ;  sub- 
mission to  the  will  of  the  hypnotist ;  24.94 
per  cent. 

(/)  Profound  soumambulistie  sleep, 
characterised  by  amnesia  on  awaking,  and 
by  hypnotic  and  post-hypnotic  hallucina- 
tions ;  absolute  submission  to  the  hypno- 
tist ;  4.66  per  cent. 

Our  own  observations  have  not  led  us 
to  observe  the  exclusive  rapjport  between 
subject  and  hypnotist  in  profound  sleep  j 


noted  by  Liebault,  and  we  have  established 

the  following  classification, 

(I.)  Hypnotic  conditions  with  persist- 
ence of  memory. 

(<o)  Torpor,  somnolence  or  partial  sug- 
gestibility (of  heat,  cold,  &c.). 

(h)  InahiWy  to  open  the  eyes  spontane- 
ously. 

{e)  Catalepsy  (by  suggestion)  with  pos- 
sibility of  breaking  it. 

(d)  Irresistible  eatalepsy. 

{e)  Muscular  contractions  and  analgesia, 
(by  suggestion). 

(/)  Automatie  obedience. 

(II.)  Hypnotic  conditions  with  sleep 
and   amnesia   on   a'waking^. 

{a.)  Amnesia,  on  waking,  absence  of  hal- 
lucinations. 

(b)  Hallucinations  during  sleep. 

(c)  Halluciuations  during  sleep,  as  well 
as  post-hypnotic  hallucinations  and  sug- 
gestibility in  tlie  awake  condition. 

Every  one  of  these  stages  shares  the 
symptoms  of  the  preceding  ones.  This 
classification,  however,  is  purely  schematic. 
Everything  is  individual,  and  every  sub- 
ject has  his  sjjecial  susceiitibility. 

We  call  artificial  somnambulism  that 
condition  of  suggestion  in  which  there  are 
active  hallucinations. 

8.  We  shall  now  briefly  consider  the 
different  manifestations  of  hypnosisr. 
The  subject  to  whom  sleep  has  been  sug- 
gested rests  usually  with  his  eyes  closed, 
the  eyelids  often  tremulously  agitated ;  he 
is  mostly  inert,  like  an  ordinary  sleeper, 
except  when  he  is  made  to  act.  Respira- 
tion and  pulse  are  not  altered;  if  they  are, 
it  is  due  to  emotion,  and  suggestion  is 
able  to  suppress  any  phenomena  of  emo- 
tion after  one  or  two  sittings.  The  sub- 
ject is  never  unconscious,  he  hears  every- 
thing that  is  said,  and  even  if  he  is 
amnesic  after  waking  we  may  by  simple 
affirmation  awake  the  recollection  of 
everything  that  has  happened  during 
the  apparent  unconsciousness.  The  sub- 
ject can  always  be  made  to  talk  during 
sleep. 

An  arm  elevated  and  kept  suspended 
for  a  few  seconds  often  remains  in  this 
position  spontaneously.  If  it  does  not 
remain  there,  it  may  be  brought  about 
by  saying,  "  You  are  not  able  to  bring  it 
down."  This  is  catalepsy,  and  is  purely 
suggestive.  The  subject  retains  the  posi- 
tion which  he  is  made  to  assume,  either 
because  he  has  not  sufficient  psychical 
initiative  to  change  it,  or  because  on 
account  of  real  or  imagined  suggestion, 
he  is  convinced  that  he  cannot  alter  it. 
Some,  if  challenged,  are  able  to  make  an 
appeal  to  their  dulled  energy,  and  to 
break  through  the  spell,  while  others  are 


Suggestion  and  Hypnotism    [    1216    ]    Suggestion  and  Hypnotism 


quite  unable  to  do  so.  The  catalepsy  may 
be  tlabby,  waxen  or  tetanic. 

Analgesia  aud  anaesthesia  may  be  spon- 
taneous, due  to  the  fact  that  the  nervous 
force  is  concentrated  in  the  brain,  and  de- 
tracted from  the  periphery.  On  the  other 
hand,  they  may  not  be  spontaneous,  but 
ma}'  be  suggested;  they  may  also  be 
absent.  The  subjects  may  be  susceptible 
to  illusions — i.e.,  we  may  be  able  to  per- 
vert their  sensory  images — e.g.,  we  may 
give  water  the  taste  of  wine.  We  may 
also  "hallucinate"  them — i.e.,  pi'oduce  in 
their  brains  sensory  images  ot  all  kinds, 
visual,  auditory,  olfactory,  gustatory, 
tactile,  visceral,  and  complex.  The  hallu- 
cinations may  be  passive,  as  in  ordinary 
dreams ;  the  subject  may  be  present  at 
the  scene  which  his  imagination,  prompted 
thereto  by  the  suggestion,  produces,  with- 
out corporeally  taking  part  in  it.  The 
hallucination  may  be  active,  spontaneous, 
or  brought  about  by  the  suggestion,  as  in 
natural  somnambulism.  The  snbject,  e.g., 
sees  a  dog,  is  frightened,  tries  to  get  out 
of  danger,  feels  himself  bitten,  gives  evi- 
dence of  pain,  puts  his  hand  to  the  sup- 
posed wound,  &c.  These  hallucinations 
may  be  more  or  less  vivid  as  in  a  dream, 
and  the  image  may  be  indistinct  or  it  may 
be  very  real.  All  degrees  are  possible, 
according  to  the  impressionability  of  the 
subject,  and  it  may  be  increased  by  hyp- 
notic training. 

A  suggestion  is  ijost-hiiimotic  when  it 
is  suggested  during  the  hypnosis  and  is 
realised  in  the  waking  condition  after  a 
shorter  or  longer  time.  Some  subjects 
may  realise  the  suggestion  after  several 
months  or  even  after  a  year. 

Negative  hallucinations  consist  in  the 
elfacement  of  existing  sensory  images  from 
the  mind — e.g.,  the  subject  on  waking  does 
not  perceive  a  certain  person ;  the  latter 
may  pinch  or  prick  him  or  undi'ess  him, 
but  he  appears  unaffected  by  his  presence. 

Retro-active  hallucinations  consist  in  the 
creation  in  the  mind  of  the  subject  of  all 
kinds  of  illusory  recollections  which  do 
not  correspond  to  reality.  The  subject 
may  be  made  to  believe  that  he  has  seen 
something — e.g.,  that  he  passed  through  a 
certain  street  a  week  ago,  and  that  he  has 
been  knocked  down  and  robbed ;  the  image 
exists  in  the  brain  as  if  the  event  in  ques- 
tion had  really  happened.  Thus,  one  may 
produce  in  the  waking  condition  false 
witnesses  who  thoroughly  believe  what 
they  say. 

Amnesia  on  ivahing  may  be  the  result 
of  the  concentration  of  nervous  activity 
in  the  sensorium  upon  the  suggested  im- 
pression during  the  hypnotic  sleep.  On 
waking,  this  nervous  activity  is  redistri- 


buted over  the  whole  organism  ;  the  im- 
pression is  no  longer  sufficiently  illumi- 
nated by  the  nervous  influx  to  persist  as  a 
conscious  one.  In  order  to  revive  it  and 
make  it  once  more  perceptible,  it  is  neces- 
sary only  to  illuminate  it  by  concentrating 
the  nervous  activity  upon  it,  and  the  re- 
collection of  the  impression  will  revert  to 
the  subject.  Thus,  we  may  convince  our- 
selves that  the  suggested  negative  hallu- 
cination is  but  apparent;  we  may  make 
the  subject  recollect  everything  he  has 
seen,  although  in  reality  he  has  seen  no- 
thing. The  physical  and  mental  eye  had 
the  power  of  pei'ception,  but  the  imagina- 
tion neutralised  all  perceptions  as  soon  as 
they  were  produced. 

A  subject  who  accomplishes  a  suggested 
action  after  a  long  time  without  having 
remembered  the  suggestion  during  the 
interval  has  only  apparently  lost  the  re- 
collection. This  recollection  may  reappear 
on.  every  occasion  when  he  concentrates 
his  attention  upon  himself  and,  no  longer 
distracted  by  his  senses,  enters  sponta- 
neously into  the  second  condition  of  con- 
sciousness with  predominance  of  the  ima- 
ginative faculty.  When,  however,  the 
consciousness  is  normal,  when  we  speak 
to  him,  and  when  the  nervous  activity  is 
diffused  toward  the  periphery,  the  recol- 
lection is  extinct.  After  the  act  has  been 
accomplished,  he  does  not  remember  the 
suggestion  of  the  act ;  he  fully  believes 
what  the  suggestion  has  produced  to  be 
his  own  intentional  act,  because,  as  we 
have  said,  the  normal  and  conscious  mental 
state  does  not  recollect  the  suggestion, 
but  the  second,  the  concentrated  and  som- 
nambulistic mental  state,  does. 

(9)  The  doctrine  of  suggestion  offers, 
from  a  sociological,  historical,  psycholo- 
gical, legal,  and  therapeutic  view,  such  a 
large  field  for  contemplation  that  space 
does  not  permit  us  to  enlarge  on  it  here. 
We  must,  however,  say  a  word  or  two 
about  criminal  sugrgrestions.  It  has  been 
averred  that  suggested  crimes  cannot  be 
committed,  that  the  experience  of  such  is 
but  the  experience  of  the  laboratory.  Some 
somnambulists,  it  is  true,  play  their  role 
without  conviction  ;  as  in  a  natural  dream, 
they  do  not  lose  the  sense  of  their  identity. 
Moreover,  the  moral  sense,  either  innate 
or  suggested  by  education,  may  act  as  a 
primary  suggestion  which  does  not  allow 
contrary  suggestions  to  enter  the  brain. 
Other  somnambulists,  however,  like  other 
dreamers,  identify  themselves  with  their 
role ;  their  true  moral  consciousness  is 
abolished,  and  they  will  commit  some 
evert  act.  Some  conduct  themselves  like 
impulsive  epileptics ;  a  blind  instinctive 
impulse  leads  them  to  the  suggested  action. 


Suggestion  and  Hypnotism 


1217 


Suicide 


Others  act  under  the  iudueiice  of  au  insane 
delusion  or  halhicinatiou — c.</.,  they  will 
commit  murder  because  they  desire  re- 
venge or  believe  it  to  be  their  duty.  If 
the  moral  sense  is  absent,  and  if  the  suf;- 
gestibility  is  great,  the  soil  is  naturally 
prepared  for  insane  ideas.  An  honest 
man,  however,  may  also  commit  a  crime 
by  suggestion,  dragged  into  it  by  an  im- 
pulsive vertigo  or  guided  by  au  insane 
idea. 

(10)  The  therapeutical  use  of  sugges- 
tion, or  psycbotherapeutlcs,  as  it  has 
been  well  termed  by  Dr.  Hack  Tuke,  who 
has  so  well  comprehended  its  importance, 
is  a  most  valuable  application  of  sugges- 
tion, for  which  hypnotism  is  the  most 
efficient  adjuvant.  Although  suggestion 
may,  through  the  vaso-motor  nerves,  pro- 
duce remarkable  modifications,  as  redness, 
blisters,  stigmata,  &c.,  suggestion  em- 
ployed therapeutically  is  almost  exclu- 
sively functional  in  its  action.  It  is  of 
service  especially  in  certain  neuroses  when 
there  is  no  organic  change,  or  when  the 
latter  is  produced  by  a  functional  dis- 
order ;  hysteria,  chorea,  spasms,  tetanus, 
nervous  vomiting,  nervous  pains,  arthral- 
gia, visceralgia,  and  neuralgia  may  very 
often  be  treated  by  hypnotic  suggestion. 
Suggestion  is  often  useful  in  organic  dis- 
ease when  functional  disorder  accom- 
panies, supervenes  upon  the  lesion,  or 
underlies  it,  or  when  the  dynamical  dis- 
orders surpass  those  of  the  organic  lesion. 
In  this  manner  it  cures  sometimes  chronic 
articular  pains,  and  by  suppressing  the 
pain  and  re-establishing  the  articular 
movements  and  the  muscular  play,  it  re- 
stores the  function,  and  thus  also  the 
organ.  Suggestion  often  cures  hemian- 
sesthesia,  and  sometimes  even  paralysis,  of 
cerebral  oi-igin  when  the  seat  of  the  lesion 
does  not  make  it  incurable ;  it  often  brings 
about  remarkable  improvements  in  mye- 
litis, ataxy,  disseminated  sclerosis,  &c.  It 
may  diminish  oppressive  sensations  in 
diseases  of  the  chest ;  it  may  restore  the 
appetite  and  favourably  influence  tuber- 
cular affections  by  modifying  the  soil 
affected.  Even  if  it  does  not  cure  the 
disease  it  may  give  considerable  relief, 
and  it  therefore  finds  its  application  in  all 
diseases.  It  is  powerless,  so  far  as  our 
experience  extends,  against  mental  aliena- 
tion ;  there  the  auto-suggestion  is  pre- 
dominant. 

Braid  made  use  of  hypnotism  as  a 
therapeutic  agent,  but  not  i-ecognising 
the  role  of  verbal  suggestion,  he  proceeded 
with  empirical  manipulations.  Liebault, 
of  Nancy,  first  discovered  the  therapeutical 
value  of  suggestion,  and  ap^ilied  it  in  a 
systematic  method  of  treatment ;  we  our- 


selves have  introduced  it  into  the  official 
(■Unique.  To  the  Nancy  school  belong  the 
numerous  jihysicians  who  disseminate  in 
two  worlds  the  benefits  of  suggestive  the- 
rapeutics. H.  Bernukim. 

[/.'':/(.;•(  /(C-C.S-. — Iteruheini,  Dc  I;i  Su-yestion  et  lU;  ses 
;il))(liciiti(iii8:i  la  ThtTiiiK'iiti(iuc,  third  edit  ion,  Paris 
1891  ;  Ilypiiotisme,  Sim^estion,  I'sycho-tlicrapie' 
I'iiris,  1891.  Lieljcault,  l.f  Sommeil  i)rovo(iin-  etles 
(-■(ills  analogues,  Paris,  1889  :  Tlierapeuti(iue suygi's- 
tive,  Paris,  1891.  Liei;e(>is,  Dc  la  Su<,'gi;stioii  vt  du 
Soiimaiiibiilisnic  dans  Icurs  rapports  avec  la  Juris- 
prudence I't  la. ^ledieine  I-egale, Piiris,i889.  Beaunis, 
LeSomnambulisuie  1  irdvoipie, etudes  pli  vail  )loK-iquc8 
et  psyehologiques,  Paris,  1887.  K(prel,ber  iTypno- 
tisnins  uiid  seine  Haudllal)nnJ,^  Stuttgart,  "1891. 
Wetterstraud,  Der  Hypiiotisnius  und  seine  An- 
weiidung  in  der  praktisclien  Mediciii,  AVien  und 
Leipzig,  189 [.  Kinkier,  Erfoli^e  dcs  therapeu- 
tisclien  Hypnotisnius  in  der  Landi)raxis,  Munich, 
1891.  Moll,  Der  Ilypnotismus,  Berlin,  1889. 
lici-illon,  Hclvue  de  I'Hypnotisme  experimental  et 
thtjrapeuti(iue,  Paris,  1887  ;i.i892.] 

SUICIDE  (sui,  of  self;  avdo,  I  kill). 

Sidcidium.  The  Abbe  Desfontaines  has 
the  credit  of  having  introduced  this  word 
in  the  last  century. 

History. — There  has  been  no  period  in 
authentic  history  in  which,  so  far  as  we 
know,  there  has  been  immunity  from  the 
practice  of  self-destruction.  Further, 
among  the  instances  which  have  occurred, 
there  have  been  many  which  do  not  fall 
under  the  suspicion  of  mental  disease. 

In  the  history  of  the  J&ws,  of  the  six 
cases  recorded  in  the  Old  Testament  that 
of  Abimelech,*  shows  an  attempt  at  sui- 
cide completed  by  another  person. 
Zimri,t  after  the  murder  of  the  King  of 
Israel  discovered  that  he  had  a  rival  in 
another  candidate  for  the  throne,  and  in 
consequence  destroyed  his  palace,  and 
himself  by  fire.  The  death  of  Samson  by 
his  own  action  has  led  to  much  discussion 
among  the  Fathers  and  other  writers,  its 
true  character  admitting  of  various  inter- 
pretations. From  any  point  of  view  it  is 
a  mixed  case.  The  primary  object  of  the 
act  was  revenge.  In  carrying  out  his 
intention,  he  was  willing  to  perish  him- 
self. The  suicide  of  Saul  |  is  sufficiently 
simple  in  its  character,  and  was,  so  to 
speak,  a  natural  course  to  follow  in  order 
to  save  himself  from  the  insults  of  the 
Philistine  "  lest  these  uncircumcised 
come  and  thrust  me  through  and  abuse 
me."  The  suicide  of  Saul's  armour- 
bearer  was  the  natural  sequel.  The  last 
example,  that  of  Ahithophel,§  is  as  free  as 
the  others  from  mental  disorder.  We 
put  aside  the  ingenious  explanations  given 
by   certain   Jewish   writers,   in    order  to 

■   Jud;;es  ix.  3,  54  ;  and  2  Sam.  xi.  21. 

t  I  Kings  xvi.  9-18. 

t   I  Sam.  xxxi.  6  ;  2   Saui.   iv.  10;   i   Cliron.   x. 

4.5- 

5>  2  Sam.  xvii.  2"?. 


Suicide 


[    1218    ] 


Suicide 


show  that  the  cause  of  death  was  mental 
emotion  and  not  suspension. 

The  "  History  of  the  Jewish  War,"  by 
Josephus,  contains  many  examples  of 
self-destruction.  "  Phasajlus  killed  him- 
self ;  the  wife  of  Pharoras  carried  poison 
about  her  as  a  provision  against  the  un- 
certain future,  and  attempted  self-de- 
struction ;  also  Herod  the  Great  made  an 
attempt  upon  his  own  life  ;  some  hundreds 
were  induced  by  the  pro-suicidal  eloquent 
oration  of  the  Jewish  captain,  Eleazar,  to 
die  by  each  other's  and  their  own  hands, 
and,  finally,  the  almost  equally  eloquent 
anti-suicidal  oration  of  Josephus  himself 
could  not  dissuade  or  prevent  thi'ee  or 
four  dozen  Jewish  captains  from  willing 
and  compassing  death  in  the  same  man- 
ner."* 

The  suicide  of  Judas  Iscariot  need  not 
detain  us.  The  amount  of  patristic  lore, 
and  of  learned  but  fantastic  commentary, 
which  has  been  expended  ujwn  this  event, 
is  prodigious. 

Greeks  and  Eomans.  —  The  ancient 
Greeks  do  not  appear  to  have  regarded 
suicide  as  a  crime.  Plato,  however,  al- 
though in  his  Utopia  he  does  not  forbid 
burial  to  those  who  commit  suicide,  does 
order  that  the  spot  where  they  are  laid 
should  be  in  a  lonely  place,  unmarked  by 
any  stone.f  The  suicide  of  Lycurgus,  de- 
liberately done,  and  for  a  well-intended 
object,  would  seem  to  justify  the  opinion 
that  the  Spartans  did  not  regard  suicide 
with  aversion. 

The  examples  of  suicide  recorded  in  the 
classics  are  numeroiis,  the  well-known 
case  of  Cato  standing  prominently  out 
from  others  of  less  note.  Cicei'o  has 
spoken  of  the  act  as  the  result  of  his 
l^eculiar  character.^ 

The  self-destruction  of  Cleombrotus, 
the  Ambraciote,  has  been,  along  with 
that  of  Cato,  charged  iipon  Socrates 
by  some  of  the  Fathers.  "  If  an  irresis- 
tible eagerness  to  bathe  in  the  ocean  of 
immortal  life  seized  upon  Cleombrotus, 
after  he  had  contemplated  that  image  of 
the  Blessed  which  the  pencil  of  Plato, 
guided  by  the  revealings  of  Socrates,  had 
sketched  on  the  pages  of  Phaedo,  we 
must,  I  presume,  conceive  him  to  have 
been  an  enthusiastic  and  religious,  rather 
than  a  reflective  and  mati;red  person, 
whether  young  or  old.  He  simply  had 
not  rightl}'-  understood  the  distinction 
which  Socrates  so  broadly  draws  in  this 
very  Dialogue   between    the   philosophic 

*  "  Suicide,  chiefly  in  reference  to  I'liilosophy, 
Theology,  and  Legislation."  Uy  H.  (i.  Jlig-anlt. 
Heidelberg-,  1856,  p.  137,  fourth  section,  p.  IC57. 

t  ■■  De  Legibus,"  lib.  9. 

t  "  De  Offic."  i.  0.  31. 


death  and  actual  self-destruction."*  It 
should  be  stated  that  Kallimachos  in 
the  third  century  B.C.  referred  to  the  rash 
act  of  Cleombrotus  as  due  to  a  longing 
for  immortality  born  of  the  perusal  of 
Plato's  pages.  This,  however,  is  a  very 
different  position  from  the  charge  made 
by  i^atristic  writers.  It  appears  clearly 
proved  that  Socrates  and  Plato  were 
opposed  to  suicide.  The  same  may  be 
said  of  Aristotle.  The  opposite  opinion 
has  been  maintained  in  regard  to  his  sen- 
timents, however,  as  well  as  those  of  the 
philosophers  above  mentioned. 

It  would  be  a  serious  omission  not  to 
refer  to  the  opinions  expressed  by  Seneca. 
He  beld  that  suicide  was  an  actual  duty 
under  certain  circumstances,  as  in  great 
poverty,  slavery,  grief,  in  old  age,  or  hope- 
less disease.  Or,  again,  when  a  cruel 
death  was  in  prospect.  Two  other  jus- 
tifications remain,  satiety  of  life,  and  the 
inability  to  maintain  a  position  in  accord- 
ance with  the  individual's  principles.  An- 
other Stoic,  Marcus  Aurelius  Antoninus, 
held  that  a  man  should  end  his  existence 
when  his  life  was  no  longer  in  accord 
with  his  own  conviction.  Approaching 
old  age  was  a  reason  for  terminating  life 
before  it  actually  came  and  weakened  the 
power  to  form  a  reasonable  judgment. 

Epictetus  has  expressed  in  his  Disser- 
tation a  limited  approval  of  suicide.  He 
is  not,  however,  very  lucid  in  determining 
the  exact  line  between  causeless,  and 
therefore  criminal,  self-murder,  and  justi- 
fiable suicide.  By  Tacitus,  suicide  was 
regarded  as  "  mors  opportuna  '' — a  very 
proper  and,  indeed,  meritorious  mode  of 
escaping  from  the  sorrows  and  suffering 
of  this  life.  Pliny  the  younger  thoroughly 
approved  of  suicide  under  certain  circum- 
stances. He  expressed  his  surprise  that 
a  man  of  whom  he  speaks  who  was  old 
and  ill  should  have  chosen  to  live  {vivehat 
iamen  et  rirere  volehat.  Epp.  lib.  viiL  ep. 
18,  p.  107  Migault). 

With  regard  to  Cicero,  his  opinions  ap- 
pear to  have  wavered,  and  passages  may 
be  quoted  on  either  side.  In  the  "  De 
Officiis  "  occurs  a  pro-suicidal  utterance  in 
connection  with  the  death  of  Cato.  In 
the  "  De  Senectute,"'  however,  the  very 
same  act  is  condemned.f 

The  same  uncertain  sound  is  noticeable 
in  the  works  of  Plutarch.  It  is  said  by 
Migault,  whose  work  is  eminently  thought- 
ful, that  he  did  not  so  much  "combat 
suicide  per  se  as  suicide  a  la  Zeno,  and 
Chrysippus,  and  that  though  he  certainly 
did  not  approve  of  the  dictum  that  the 

*  Migault,  op.  cif.,  "  Classical  Paganism,"  p.  30. 
t  See  the  question  fully  and  ably  discussed  by 
Migault.  np.  rlt..  pp.  T08-T27. 


Suicide 


[     1219    ] 


Suicide 


wise  and  happy  as  such  ought  to  die 
voluntarily,  it  does  not  by  any  means 
follow  that  he  would  liave  been  equally 
loath  to  affirm  that  the  over-tried  and 
ill-starred  ought  not  occasionally  to  do 
so.''* 

In  respect  to  Roman  law  relating  to 
suicides  there  has  been  much  discussion. 

It  appears  that  the  clearest  notice  of 
ancient  punishment  for  self-destruction 
among  the  Romans  is  contained  in  Pliny's 
"Natural  History,'' t  where  he  writes. 
"  Tarquinius  Priscus  built  the  Cloaca  by 
the  hands  of  the  people.  The  labour, 
however,  was,  one  knew  not  whether 
more  wearisome  or  dangerous  ;  and  occa- 
sionallj'  a  Quirite  escaped  from  the  tedium 
of  it  by  suicide.  This  king  now  invented 
a  new  remedy  which  had  not  occurred  to 
anybody  before  him,  and  has  not  occurred 
to  anybody  after  him.  He  ordered  the 
corpses  of  all  who  died  in  this  manner  to 
be  fastened  to  crosses  exposed  to  the  pub- 
lic gaze  of  the  citizens,  and  at  the  same 
time,  left  to  be  torn  in  pieces  by  wild 
beasts  and  birds."  J 

Reference  should  be  made  here  to  the 
remarkable  suicidal  epidemic  among  the 
Milesian  virgins  who  were  seized  with 
an  irresistible  propensity  to  hang  them- 
selves, "  all  the  entreaties  and  tears  of  their 
parents  availed  just  as  little  as  the  re- 
presentations of  friends.  They,  in  their 
suicide,  eveii  eluded  all  attention  and  cun- 
ning of  their  guards.  Thus  the  evil  was 
considered  a  divine  punishment  against 
which  human  aid  would  not  be  at  all  able 
to  prevail ;  but  at  last  a  proposal  was 
made  by  the  advice  of  a  clever  man,  ac- 
cording to  which  those  who  hanged  them- 
selves should  be  carried  naked  across  the 
market-place  to  the  place  of  burial.  This 
proposition  was  approved  of,  and  it  not 
only  checked  the  evil,  but  likewise 
destroyed  in  the  virgins  the  desire  for 
death."  § 

T/te  East. — Among  so-called  barbaric 
nations  in  the  East,  one  feature  of  suicide 
was,  and  is,  remarkable,  and  offers  a  con- 
trast to  the  way  in  which  the  act  was 
regarded  among  the  Greeks  and  Romans. 
This  has  been  well  brought  out  by  Migaiilt 
in  the  following  passage  : — "  Whereas, 
the  Greek  and  Roman  writers  viewed 
suicide  at  the  utmost  as  a  human  rujlit, 
an  undoubted  privilege,  by  the  using  of 
which  the  ills  and  discomforts  of  the 
present  life  might  be  escaped  from,  a 
decorous   means  of  self-deliverance  from 

*   Op.  cit.,  p.  132. 
t  Lib.  36,  ch.  XV.  sec.  24. 
t  Migrult,  op.  rif.,  173. 

§  Plutarch,  "  Ue  virtutibus  mulieruui,''  Opera, 
torn.  vii.  ]).  22. 


temporal  evils,  a  deed  of  philosophical 
heroism  or  physical  nerve  which  the 
Divinity  might  be  presumed  to  sanction, 
and  Reason  be  atlirmed  even  to  command  ; 
suicide  on  the  contrary,  assumed,  and  in 
part  still  assumes,  under  the  teaching  of 
sundry  barbaric  creeds,  the  developed 
character  of  a  religioKs  rite,  a  path  lead- 
ing on  to  greater  extra-terrestrial  bliss,  a 
deed  unto  which  a  sure  divine  recompense 
is  vouchsafed  in  a  future  state  of  exist- 
ence, a  thing  specially  well-pleasing  and 
even  meritorious  according  to  the  estimate 
of  the  Godhead,  and  as  such  not  only  per- 
mitted and  vindicated,  but  even  promul- 
gated and  prescribed."* 

Zoroaster  is  cited  as  asserting  that 
"  man  is  not  to  compel  the  soul  to  emigrate 
out  of  the  body." 

Ariaspes,  in  the  fourth  century  B.C., 
took  poison  in  consequence  of  having 
understood  that  he  would  be  executed  by 
his  father.  The  mother  of  Darius, 
Sisygambis,  when  she  heard  of  the  death 
of  Alexander,  committed  suicide.  Suttee- 
ism  among  the  Hindoos,  and  similar 
practices  among  the  Ethiopians  and  other 
peoples,  must  be  regarded  as,  with  few 
exceptions,  practically  involuntary  suicide. 
It  would  be  quite  beyond  our  purpose  to 
enter  fully  into  this  remarkable  develop- 
ment of  religious  forms  of  suicide. 

The  teaching  of  the  Koran  is  opposed  to 
suicide.  "  Neither'slay  yourselves,  for  God 
is  merciful  towards  you ;  and  whoever 
does  this  maliciously  and  wickedly,  he 
will  surely  cast  him  to  be  broiled  in  hell- 
tire,  and  this  is  easy  with  God."t  No 
proof  is  forthcoming  that  theMohammedans 
ordered  any  difference  to  be  made  in  re- 
gard to  the  funeral  rites  for  those  who 
committed  suicide.  It  is  suggested  by 
Migault  that  the  rarity  of  the  deed  ren- 
dered it  unnecessary  to  make  any  special 
law  among  Mussulmans. 

Among  Chridians. — We  believe  that  the 
earliest  Christian  law  against  an  attempt 
to  commit  suicide  was  a  decree  of  the 
Council  of  Toledo  in  693. J  The  punish- 
ment consisted  of  excommunication  for 
two  months  (duorum  mensium  spatio,  et  a 
catholicorum  coUegio,  et  a  corpore  ac 
Christi  sanguine  sacro  manebit  omnimodo 
alienus). 

At  the  latter  end  of  the  fourteenth  cen- 
tury, letters  of  indulgence  were  granted  by 
the  Parliament  of  Paris  to  those  who  had 
attempted  suicide.  The  interesting  fact 
is  stated  that  they  were  on  some  occasions 
treated  as  if  possessed  (demoniaci),  in  an 

*  Op.  cit.,  •'  Barbaric  Pai^auism,"  p.  4. 
t  Sale'.s translation,!.  99. 

t  Mansi,  t,  xii.  p.  71  :  Concilium  Toletanum, 
xvi.  c.  4. 

41 


Suicide 


[       I220      ] 


Suicide 


abbey  where  cases  of  possession  were 
cai'ed  for.  It  is  clear  that  we  have  here 
oeuuiue  cases  of  suicidal  melancholia. 
Migault  quotes  from  Carpentier*  the 
curious  passage  on  which  this  statement 
is  founded: — "  Nostris  Demoniacle.  lii- 
sanus,  demens.  Lit.  remiss,  ann.  1384  in 
Eeg.  125.  Chartoph.  reg.  ch.  120 :  Pierre 
Nagot  a  este  le  plus  du  temps,  et  par 
especial  en  temps  d'este,  fol  et  Demon- 
iacle, et  s'est  plusieurs  foys  voulu  noyor  ; 
.  .  .  .  et  pour  cause  de  ses  folies  .  .  .  . 
il  fu  prins  .  .  .  .  et  portc  en  nue  abbaye 
nommee  S.  Sever,  ....  en  laquelle 
abbaye  I'on  maine  les  Demoniacles." 

Hugh  Grotius  regarded  suicide  as  a 
felonj'-,  and  therefore  deserving  of  severe 
notice. 

Hume,  Voltaire,  Rousseau,  Montes- 
quieu, Montaigne,  Gibbon,  as  also  Sir 
Thomas  More  in  his  "  Utopia,"  have  de- 
fended suicide  under  sjjecial  circumstances. 

Blackstonef  says,  "  Now  the  question 
follows,  what  punishment  can  human  laws 
inflict  on  one  who  has  withdrawn  himself 
from  their  reach  ?  They  can  only  act  upon 
what  he  has  left  behind  him,  his  reputa- 
tion and  fortune.  On  the  former  by 
an  ignominious  burial  in  the  highway, 
with  a  stake  driven  through  his  body  (and 
without  Christian  rites  of  sepulture) ;  on 
the  latter  by  a  forfeiture  of  all  his  goods 
and  chattels  to  the  King." 

The  Rubric  for  the  Order  for  the  Burial 
of  the  Dead  was  composed  in  1661.  Ac- 
companying it  is  the  note :  "  The  ofHce 
ensuing  is  not  to  be  used  for  any  who  die 
unbaptised  or  excommunicate,  or  have 
Iciid  violent  hands  tipon  themselves."  On 
this  passage  Shepperd  remarks  that  "  it 
must  not  be  considered  a  new  law,  but 
merely  as  explanatory  of  the  ancient  canon 
law,  and  of  the  previous  usage  in  Eng- 
land." 

The  clown  in  "  Hamlet"  assumes  that 
Ophelia  will  not  receive  Christian  burial 
on  account  of  committing  suicide. 

The  law  in  regard  to  the  treatment  of 
the  corpse  of  the  suicide  was  rescinded  in 
the  year  1823  (4  Geo.  IV.  c.  52)  having 
for  some  years  gone  into  desuetude. 

Acts  43  &  44  Vict.  c.  41,  45-46  Vict.  c. 
19,  provide  that  the  body  of  a  suicide  may 
be  interred  either  silently,  or  with  any 
such  orderly  or  Christian  religious  service 
at  the  grave  as  the  person  in  charge  of  the 
body  thinks  fit.+ 

Sir   James    Fitzjames     Stephen   says : 

*  I'l'de  "  Glossarium  novum  ad  sciiptores  inedii 
aevi,"  s.  v.,  Daemoniaci. 

t  "  Commentaries  on  the  Laws  of  England," 
1765,  book  iv.  ch.  14. 

i  "  Suicide,"  by  \V.  Wynn  AVestcott,  M.D.  Lon- 
don, Deputy  Coroner  for  Central  Middlesex,  1885, 
P-  45-  ' 


"  Suicide  may  be  wicked,  and  is  certainly 
injurious  to  society,  but  it  is  so  in  a  much 
less  degree  than  murder.  The  injury  to 
the  person  killed  we  cannot  estimate,  the 
injury  to  survivors  is  generally  small.  It 
is  a  crime  which  produces  no  (public) 
alarm,  and  which  cannot  be  repeated.  It 
would,  therefore,  be  better  to  cease  to 
regard  it  as  a  crime,  and  to  provide  that 
any  one  who  attempted  to  kill  himself,  or 
who  assisted  any  other  person  to  do  so, 
should  be  liable  to  secondary  punish- 
ment."* 

rrequency. — The  formula  in  regard  to 
the  increase  of  suicide  has  been  thus  laid 
down  by  Morselli :  "  In  the  aggregate  of 
the  civilised  states  of  Europe  and  America, 
the  frequency  of  suicide  shows  a  growing 
and  uniform  increase,  so  that  generally 
voluntary  death  since  the  beginning  of 
the  century  has  increased,  and  goes  on 
increasing  more  rapidly  than  the  geome- 
trical augmentation  of  the  population  and 
of  the  general  mortality."  f 

In  view  of  the  erroneous  inferences 
which  have  been  drawn  from  statistics  in 
regard  to  the  increase  of  insanity,  we 
naturally  feel  great  doubt  whether  due 
allowance  has  been  made  for  the  sources 
of  fallacy  which  affect  the  conclusions 
arrived  at,  but  we  append  the  following  : 

Table  J.,|  shoiving  the  Numher  of  Suicides 
per  1,000,000  in  the  different  European 
States,  and'  the  Increase  or  Decrease 
during  certain  Terms  of  Years. 


Number 

Year. 

Country. 

of 

Suicides 

Increase 
per 

Term 
of 

per 

Million. 

Years. 

aiillion. 

1880 

Portugal 

16 

3 

5 

1880 

Spain 

19 

2 

5 

1883 

Ireland 

24 

6 

5 

1878 

Russia  and  \ 
Finland  J 

35 

1.2 
(dec.) 

6     ' 

1881 

Italy 

44 

7 

5     1 

1881 

Scotland 

48 

II 

5 

1880 

Holland 

5^ 

Stationary 

10 

1882 

England 

74 

7 

10 

1875 

Norway 

75 

33  (dec.) 

13 

1879 

Belgium 

90 

22 

5 

1877 

Sweden 

lOI 

15 

5 

1880 

Bavaria 

102 

II 

5 

1877 

Austria 

144 

24 

3 

1880 

Hanover 

150 

10 

5 

1877 

Prussia 

168 

34 

4 

1880 

France 

216 

56 

5 

1881 

Switzerland 

240 

25 

5 

1878 

Denmark 

265 

32 

5 

1878 

Saxony 

469 

170 

5 

*  Quoted  by  Wcsti'ott,  op.  ci'f.,  p.  49. 
t  "  Suicide,'"  by  Henry  Morselli,  JI.D. :  Interna- 
tional Scientific  Series,  London,  1881,  p.  29. 
t  From  AVestcott,  op.  cit.,  p.  60. 


Suicide 


I22I      ] 


Suicide 


We  are  on  safe  grt-oand  when  we  take 
the  annual  returns  of  suicides  in  England 
and  Walos  duriu<T  acei-tain  period,  as  from 
iS6i  to  1 888.  Table  II.  exhibits  the  in- 
crease which  has  taken  iilace.  Taking  the 
first  five  years  (1S61-1865)  and  comparing 
the  frequency  of  suicide  during  that  period 
with  its  frequenc}'-  during  the  quinquen- 
nium, 1 884- 1 888,  \vc  iind  that  there  were 
sixty-five  suicides  to  a  million  j^ersons 
living,  in  the  former,  and  seventy-eight  in 
the  latter,  term  of  years,  and  that  the  rise 
was  fairly  progressive.  Again,  taking 
the  jieriods  1861-1870  and  1881-1888,  we 
find  the  increase  per  cent,  to  be  as  fol- 
lows : — All  ages:  persons,  15.2;  males, 
19.2 ;  females,  8.8. 

Table  II.,  slioiving  tJie  Annunl  Niimher  of 
Suicides  in  England  and  Walc.'^  to  a 
Million  Persons  Living,  1861-1888. 


Date. 

Male. 

Female. 

Persons. 

67    1 

1861 

100 

35 

1862 

97 

34 

65    ' 

1863 

97 

33 

64 

1864 

98 

32 

64 

1865 

99 

34 

66    , 

1866 

9T 

34 

62 

1867 

91 

32 

6r 

1868 

105 

35 

69    1 

1869 

109 

36 

71 

1870 

106 

34 

69    i 

1871 

99 

34 

66 

1872 

97 

35 

66 

1873 

99 

32 

65 

1874 

104 

32 

64 

1875 

lOI 

34 

67 

1876 

i[i 

37 

73 

1877 

109 

31 

69 

1878 

107 

36 

70 

1879 

123 

40 

80 

1880 

120 

37 

77 

1881 

116 

36 

75 

1882 

"3 

38 

74 

1883 

III 

38 

73 

1884 

117 

35 

75 

1885 

"4 

34 

73 

1886 

125 

39 

81 

1887 

122 

39 

79 

1888 

1 

124 

39 

80  . 

Suicide  in  British  Jjif^m.— Suicide  is 
favoured  by  the  Brahmins.  It  is  on  the 
contrary  discouraged  by  the  disciples  of 
Mahomet.  It  is  stated  by  Dr.  Westcott 
that  "the  floating  British  population  exhi- 
bits a  slightly  higher  ratio  than  that  of  the 
British  at  home."*  We  may  state  on  his 
authority  that  the  laws  bearing  upon  vol- 
untary deaths  in  British  India  are  enacted 
by  the  Indian  Penal  Code,  cap.  xvi.  ss.  300, 
305,  306,  and  309.  Other  regulations  will 
be  found  in  s.  19  of  Reg.  xix.  of  1807  ;  a^nd 
Nizamut  Adawlut  Reports,  vol.  iii.  of  1833. 
»  Oj).  cif.,  p.  i6i. 


The  same  authority  estimates  the  average 
suicide-rate  in  India  at  about  40  per 
million.  The  causes  of  suicide  among  the 
natives  are  mainly  four,  namely  :  revenge 
or  accusation,  religion,  physical  sutfering, 
grief,  shame,  and  jealousy.  It  is  stated 
that  women  nearly  always  make  a  choice 
of  drowning,  more  particularly  in  wells. 
Under  the  head  of  religion  would  of  course 
fall,  death  by  being  crushed  under 
the  car  of  Juggernath.  Self-immolation 
(chaudi)  for  the  purpose  of  spiting  another 
person,  and  making  some  imaginary 
charge  calculated  to  turn  the  neighbours 
against  a  person,  is  said  to  be  still  re- 
sorted to. 

JBtiology  of  Suicide  (predisposing  and 
exciting).  Climate.  —  Morselli  deduces 
from  the  statistics  of  suicides  in  Europe 
that  the  South  (Italy,  Spain,  and  Portugal) 
gives  the  minimum  proportion,  while  this 
seems  to  rise  by  degrees  as  the  centre  is 
approached,  which  is  at  50°  of  latitude. 
Suicides  predominate  in  the  centre  of 
Europe  between  47°  and  5  7° of  latitude,  and 
20° and  40°  of  longitude — a  region  covering 
942,000  square  kilometres.  The  countries 
nearest  this  area  have  more,  those  more 
distant  fewer,  suicides.  The  suicidal  area, 
so  to  speak,  is  in  the  temperate  zone.  It  is 
obvious  that  it  is  impossible  to  isolate  the 
influence  of  climate  from  such  elements 
as  civilisation,  &c.,  which  are  concomi- 
tants of  diS'ering  thermal  regions.  At 
the  same  time  climate  would  seem  to  be  a 
most  important  factor.  Exti'emes  of  cli- 
mate would  seem  to  minimise  the  tendency 
to  suicide.  In  Italy  the  highest  averages 
are  in  the  upper,  the  lowest  in  the 
southern  regions.*  A  similar  difi'erence  is 
observed  in  France,  but  the  fact  that 
Paris  is  in  the  north,  introduces  at  once 
a  source  of  fallacy.  Belgium,  Switzerland, 
Austria,  and  Bavaria  present  the  same 
relative  liability  when  northern  and 
southern  regions  are  compared.  The 
general  conclusion  arrived  at  is  that  "  in 
the  centre  of  Europe,  from  the  north-east 
of  France  to  the  eastern  borders  of  Ger- 
many, a  suicidigenous  area  exists,  where 
suicide  reaches  the  maximum  of  its  inten- 
sity, and  around  which  it  takes  a  decreas- 
ing ratio  to  the  limits  of  the  northern  and 
southern  states."  f 

Telluric  Conditions. — It  is  said  that 
there  is  an  inverse  ratio  between  oro- 
graphy and  the  frequency  of  suicide.  The 
highest  proportion  is  alleged  to  occur  in 
the  plain  of  the  Po,  and  after  the  valleys 
of  Piedmont,  Lombardy,  Emilia,  and 
Valicia,  comes  Latium.  The  lowest 
])roportion  is  found  in  the  mountain 
*  3IorseIli,  op.  <i(.,  ji.  41. 
t   Op.  ci't.,  p.  50. 


Suicide 


[      1222      ] 


Suicide 


regions  of  Italy.  The  same  holds  good 
in  France.  In  our  own  country  it  appears 
that  Scotland  and  Wales,  which  to  a  large 
extent  are  mountainous,  yield  a  muchlower 
proportion  than  the  less  hilly  England.  In 
the  region  of  the  Alps  there  is  a  minimum 
of  suicides,  while  in  the  valleys  of  the 
Danube,  Bohemia,  &c.,  the  proportion 
of  suicide  is  larger.  In  Switzerland,  the 
mountainous  cantons  follow  the  same 
rule,  and  present  a  contrast  in  this  par- 
ticular to  the  valleys  of  the  Rhine,  the 
Aar,  and  the  Rhone.  It  is  only  necessary 
to  add,  that  in  Belgium,  Sweden,  and 
Norway,  the  same  fact  holds  good. 

Turning  from  the  alleged  influence  of  I 
high  and  low  countries  to  that  of  rivers, 
it  seems  that  the  countries  where  these 
are  on  a  large  scale  are  those  in  which  the 
proportion  of  suicide  is  high,  while  in 
marshy  low  lands  suicides  are  less  common, 
as  in  certain  provinces  in  Italy,  the 
Landes  in  France,  Ireland,  the  districts 
around  the  Zuyder  Zee,  as  also  in  Jutland. 
Germany  presents  the  same  association 
of  suicides  with  the  distribution  of  large 
rivers.  Further,  it  is  maintained,  that 
the  suicidigenous  regions  are  formed  by 
compai'atively  recent  alluvial  deposits, 
as  Denmark,  Poland,  the  valley  of  the 
Thames,  &c.  Scotland, Ireland,  and  Wales, 
most  of  Spain  and  Portugal,  are  examples 
of  an  opposite — that  is,  an  earlier — geo- 
logical formation,  anda  lowerproportion  of 
suicides,  Morselli,  to  whom  we  must  refer 
for  more  detail,  asserts,  "  that  the  number 
of  suicides  always  presents  a  lower  average 
on  the  chalk  and  slate  soils  of  the  second- 
ary period.  Lastly,  will  be  found  those 
few  countries  on  the  lime,  gneiss,  slate  and 
granite  rocks  of  the  great  Alpine  sys- 
tem."* 

Interesting  as  all  these  statements  are, 
we  confess  that  we  accept  the  conclusions 
with  considerable  reserve,  first,  because 
the  returns  of  suicide  in  different  countries 
may  differ  in  their  completeness,  and 
therefore  maybe  misleading;  and  secondly, 
because  the  elements  of  the  problem  are 
so  exceedingly  comj^lex  that  we  are  in 
great  danger  of  referring  a  maximum 
amount  of  suicides  to  the  wrong  cause. 

Seasons  and  I^onths. — As  is  well 
known,  it  was  formerly  supposed  that 
dark  damp  weather  favoured  the  occur- 
rence of  suicide.  It  is  not  surprising  that 
the  gloomy  month  of  November  in  our 
own  country  was  believed  to  be  a  specially 
obnoxious  one  in  this  respect.  Statistics 
in  this  instance  appear  to  be  tolerably 
free  from  fallacy,  and  to  allow  us  to  set 
aside  the  jaopular  impression,  and  to 
prove  the  association  of  the  maximum 
*   Op.  c(Y.,p.  55. 


amount  of  suicides  with  the  warm  season, 
Guerry*  found  that  the  maximum  number 
of  85,334  suicides  in  France  between 
1835-60  occurred  under  the  summer,  and 
the  minimum  under  the  winter  solstice. 
The  order  in  which  suicide  appears  to  be 
influenced  by  the  seasons  is  as  follows : 
Summer,  spring,  autumn,  and  winter. 
This  result  is  based  upon  large  statistical 
data  in  Europe,  and  justifies  that  they  are 
"  among  the  surest  and  most  incontrover- 
tible results  of  statistics."  The  elaborate 
Tables  given  in  the  work  upon  which,  as 
the  highest  authority,  we  rely,  ought  to  be 
carefully  studied  by  all  who  wish  to  pro- 
secute this  important  inquiry  more  tho- 
roughly. One  Table  is  given  to  show  the 
influence  of  madness  on  suicide  according 
to  months,  in  Italy,  France,  and  Belgium. 
"  The  result  agrees  with  the  opinion  which 
attributes  the  greater  number  of  suicides  of 
the  spring  and  summer  months  to  the 
development  of  more  numerous  mental 
affections.  The  proportion  of  suicides 
through  madness  does  not,  however,  ex- 
plain entirely  the  higher  ratio  of  voluntary 
deaths  from  other  crtwses  during  spring  and 
summer ;  the  reason  is  that  the  cerebral 
change  may  be  brought  on  either  by  an  in- 
herent suicidal  tendency,  or  by  a  tendency 
to  madness.  It  is  then  to  be  noted  that 
suicide  and  madness  are  not  influenced  so 
much  by  the  intense  heat  of  the  advanced 
summer  season  as  by  the  early  spring  and 
summer,  which  seize  upon  the  organism 
not  yet  acclimatised  and  still  under  the 
influence  of  the  cold  season.  And  this 
also  applies  to  the  first  cold  weather  in 
October  and  November,  when  the  change 
from  the  warm  to  the  cold  season  is  more 
severely  felt  by  the  human  constitution, 
and  especially  by  the  nervous  system."  f 

As  regards  England  and  Wales  [0],+  no 
statistics  can  be  obtained.  For  London, 
however,  they  are  available,  and  of  great 
interest.  Singular  as  it  may  seem,  the 
amount  of  suicide  increases  with  the  in- 
crease of  daylight.  At  its  minimum  in 
December  when  the  day  is  shortest,  it 
rises  month  by  month  with  a  slight  excep- 
tion in  February,  till  it  reaches  its  maxi- 
mum in  June,  when  it  falls  gradually,  with 
a  very  slight  exception  in  October,  until  it 

*  Quoted  by  Morselli,  vp.  cif.,  p.62. 

t  Morselli,  oj).  cit.,  p.  72. 

t  In  this  and  other  instances  in  which  [O]  oc- 
curs, the  statement  is  Dr.  (Ogle's,  being  taken  from 
his  valuable  paper  read  before  the  Statistical 
Society,  Feb.  16,  1886,  entitled  "  Sucides  in  Ewji- 
land  and  Wales,  in  relation  to  Age,  Sex,  Se;isou, 
and  Occupation."  His  statistics  have  their  own 
value,  and  if  they  dilYer  from  those  which  we 
give  in  preceding-  paragraphs  when  they  refer  to  the 
same  period  and  country,  the  reader  will  do  well  to 
take  them  as  the  more  correct. 


Suicide 


[       1223      ] 


Suicide 


reaches  its  minimum  in  the  dark  days  at 
the  end  of  the  year.  Even  slight  excep- 
tions would,  Dr.  Ogle  believes,  disappear, 
were  the  numbers  on  a  larger  scale.  Why 
this  greater  amount  of  suicides  in  the 
summer  than  iu  the  winter  months  is  not 
very  easily  explained.  It  is  no  explana- 
tion to  say  that  there  is  more  insanity  in 
the  hot  than  in  the  cold  mouths.  Although 
there  are  more  admissions  to  asylums  in 
summer  than  in  winter,  it  does  not  follow 
that  the  attacks  commence  in  the  warm 
weather.  While,  however,  we  do  not  dis- 
pute that  this  may  be  the  case,  we  do  not 
find,  as  might  have  been  expected,  that 
mental  disorders  are  more  frequent  in  hot 
than  in  cold  climates,  a  circumstance 
pointed  out  by  Guislain. 

nXeteorologrical  Changes  and  Influ- 
ence of  the  Moon. — The  number  of  ob- 
servations made  is  limited,  and  inference 
must  be  drawn  with  caution.  We  attach 
so  little  importance  to  the  observations 
recorded,  bearing  on  the  changes  in  the 
barometer  in  relation  to  suicide,  that  we 
jDass  them  by.  As  to  the  lunar  influence, 
a  Table  is  given  in  Morselli,  but  only  for 
a  single  year,  in  regard  to  the  number  of 
suicides  in  the  different  phases  of  the 
moon.  The  proportion  per  thousand 
was  as  follows :  New  moon,  246.8  ;  first 
quarter,  255.8;  full  moon,  238.6;  last, 
258.8.  If  this  experience  is  confirmed 
by  more  numerous  I'eturns  it  would  indi- 
cate an  increase  in  suicides  in  the  second 
and  fourth  lunar  phases,  and  a  decrease  in 
the  first  and  third. 

Time  of  Day. — Of  1 1,822  suicides  which 
happened  in  Prussia  during  four  years, 
1869-72,  the  higher  proportion  per 
thousand  occurs  in  the  night.  From 
other  Tables  (France  and  Switzerland) 
it  appears  that  "  the  tnaxi'immi  occurs 
from  6  A.M.  to  12 ;  at  first  there  is  a  de- 
crease in  the  hours  p.m.,  then  an  increase 
which  falls  away  from  3  to  6  o'clock, 
after  which  the  number  of  suicides  con- 
tinues to  diminish  regularly  in  the  evening 
hours  until  midnight ;  however,  the  inini- 
vfiwm  is  not  reached  until  the  hour  pre- 
ceding the  rising  of  the  sun.  The  daily 
distribution  of  suicides  is  parallel  to  acti- 
vity in  business,  to  occupations  and  work ; 
in  short,  with  the  noise  which  charac- 
terises the  life  of  modern  society,  and  not 
with  silence,  quiet,  and  isolation."  * 

Ethnology. — The  influence  of  race  is 
no  doubt  a  marked  factor  in  the  causation 
of  suicide ;  at  the  same  time  it  is  very 
difficult  to  distinguish  from  the  associated 
geographical  conditions,  not  to  mention 
others  which  help  to  determine  voluntary 
death.     The   annual  number  of    suicides 

■    Morst'lli,  op.  cit.,  p.  79. 


per  1,000,000  of  the  population  is  given  by 
Morselli  ■'  as  follows  : 


Sfiini/iiKifid. 
Dt'iiiiiark 
Norwiiy  . 
Sweden    . 


127.8 


150 


165 


70 


I 


Geriiiajis  of  tlic  Xortlt. 
Prussia  iiiul  its  Con(inests 
Hainburof 
Ducal  Hesse,  &c. 

Germans  of  the  Smith. 

Bavaria  . 

I'.udeu 

Wiirtemberg-    . 

Saxony    . 

Austria    . 

German-Swiss,  &c.  . 
.Inglo-Saxons. 

England  (cxcludin!;'  Wales) 

United  States  .... 

South  Australia 

Fleinint/s. 
Netherlands     .... 
Flemisli  Province  of  Belgium,  &c, 

Celts. 

Wales 

Scotland  .... 

Britain    ..... 
Ireland    .  .  .  .         .         .    ) 

Celto-Ji'omans. 
France  (Frencli  Province  of  Belgium)  \ 
French-Swiss  .  .  .  •    r " 

Northern  Italy  .  .         .         .    ) 

Westtni  lionianx. 
Spain       .... 
Peninsular  and  Lower  Italy 
Italian-Swiss  . 

Eastern  Hotnans. 
Transylvania  . 
Koumania 

Slavs  of  the  Xorfh-  West. 
Russia     .... 
P.oheniia .... 
Miiravia  .... 
Gnlicia — Buekoviua 

Stars  of  the  South. 

Carniola  .... 
Croatia  and  Slavonia 
Dalmatia 

Magyars. 

Hungary 
Finns  and  Lapps. 

Finland  .... 

Norrland 

liussian  Baltic  Province 

Slavo- Mongols. 

South-East  JJnssia  . 


5" 


30 


I 


27 


[50 


42 


30 


52 


40 


51 

"  The  peoples  with  the  highest  average 
inhabit  the  central  regions,  the  chosen 
zone  of  the  suicide,  and  after  these  the 
other  peoples  are  arranged  almost  in 
direct  ratio  with  the  ethnical  distance 
which  separates  them  from  the  Germanic 

'■    Oji.  lit.,  p.  84. 


Suicide 


[     1224    ] 


Suicide 


iiiitious  ;  thus  the  Germaus  and  the  Latius 
will  be  found  at  the  two  ends  of  the  scale, 
for  although  having  come  forth  from  the 
common  Indo-Germanic  stock,  in  the 
descent  of  European  peoples,  they  will  be 
found  from  time  immemorial  at  the  extrem- 
ities  of   their    two    principal  and    most 

distant  branches The  lov/  position 

in  point  of  numbers  held  by  the  English 
peoples,  with  regard  to  suicide,  in  com- 
parison with  the  Germanic,  whilst  the 
first  place  in  the  civilised  world  as  regards 
power  and  riches  belongs  to  them  without 
dispute,  is  astonishing  ;  it  is  not  modern 
Eome,  it  is  not  England,  which  gives  the 
greater  number  of  suicides.  Admitting 
that  in  statistics  we  have  to  deal  with 
deficiencies  and  want  of  exactness,  it  is 
not  possible  that,  even  if  perfectly  correct, 
we  should  ever  have  the  German  averages 
lower  ;  nevertheless  the  Anglo-Saxons 
undoubtedly  proceeded  from  the  same 
stock  as  the  Saxons,  Dutch,  and  Low- 
Germans The  divergence  between 

England  and  the  countries  whei'e  the 
Celtic  or  Gaelic  race  remains  most  pure, 
that  is  to  say,  Scotland,  Ireland,  and 
Wales,  will  prove  the  influence  of  the 
Germanic  element  infiltrated,  especially  in 
the  first  of  these.  And  it  is  not  to  be 
wondered  at  if,  under  diverse  climatic  and 
social  conditions,  the  English  colonies  in 
North  America,  producing  a  race  so  dis- 
tinct from  the  mother-stock  as  that  of 
the  Yankees,  still  reveal  in  the  excessive 
average  of  suicides  so  great  a  difference 
from  their  original  European  brethren. "f 

Civilisation.' — Guided  by  the  statistics 
which  we  have  given,  we  must  conclude 
that  "  madness  and  suicide  are  met  with 
the  more  frequently  in  proportion  as  civil- 
isation progresses."*  Once  more  we  may 
point  out  the  eff'ect  of  civilisation  in 
securing  fuller  returns  than  can  possibly 
be  the  case  in  uncivilised  countries.  It 
is  simply  impossible  to  make  allowance 
for  this  sonrce  of  error  with  any  degree  of 
certainty.  All  that  we  are  justified  in 
concluding  is  the  apparent  greater  liability 
of  the  more  cultured  races  of  mankind. 

Relig-ion. — Jews  are  shown  to  be  less 
prone  to  suicide  than  Christians.  When 
Protestantism  and  Eoman  Catholicism 
are  compared,  it  appears  that  those  who 
profess  the  faith  of  the  former  are  the 
most  liable  to  resort  to  self-destruction. 
Saxony,  Denmark,  Scandinavia,  and 
Prussia,  are  cited  by  Morselli  as  presenting 
an  unfavourable  contrast  to  the  lower 
rate  of  suicide  in  Italy,  Spain,  and  Por- 
tugal. It  is  stated  that  in  Protestant 
States  the  average  number  of  suicides  per 

*  Morsulli,  op.  cit.,  p.  117. 
t  O}).  cit.  pp.  83-86. 


million  is  190,  while  on  the  other  hand 
in  Catholic  States,  it  falls  as  low  as  58. 
On  the  other  hand,  in  countries  where 
there  is  a  mixture  of  many  forms  of  the 
Christian  religion,  the  average  number  of 
suicides  per  million  is  96.  "  The  influence 
of  Protestantism  may  partly  be  ascribed 
to  its  facilitating  the  development  of 
intellectual  culture ;  it  is  the  Protestant 
countries,  and  any  country  with  Protestant 
inhabitants,  who  are  always  pre-eminent 
both  in  instruction  and  suicide." 

Culture. — This  brings  us  to  another 
element  of  the  complex  problem  before  us, 
the  effect  of  culture.  A  Table  has  been 
prepared  classifying  the  population  of 
various  countries  according  to  age,  sex, 
and  education.  The  following  results  are 
given  :*  Of  four  European  nations, 
Prussia  stands  first,  both  as  to  education 
and  suicides.  France  comes  next,  second 
in  both  characteristics.  Thirdly,  Italy 
and  Hungary  have  about  the  same 
number  of  suicides,  although  in  the  pro- 
portion of  the  uneducated  the  former 
stands  in  a  worse  position  than  the  latter 
by  about  10  per  cent.  It  is  a  very  gloomy 
picture,  and  one  still  more  highly  coloured 
by  a  more  extensive  collection  of  data, 
for  the  result  establishes  the  general 
rule  that  suicide  occurs  in  inverse  ratio  to 
ignorance.  At  the  same  time  we  are  far 
from  thinking  that  it  is  safe  to  take  these 
statistics  as  altogether  correct  guides. 

Sex. — The  Table  referred  to  in  the  fore- 
going section  shows  a  low  proportion  of 
female  suicides  to  male  suicides.  Here, 
however,  it  behoves  us  to  remember 
that  sex  is  itself  a  complex  fact;  i'or 
example,  it  includes  the  relative  degree  of 
male  and  female  education  as  well  as  the 
differences,  bodily  and  mental,  between 
the  sexes.  Morselli  confidently  states  that 
"  in  every  country  the  proportion  of  sui- 
cides is  one  woman  to  three  or  four  men  ; 
as  in  crime,  it  is  also  one  in  four  or  five."  t 
This  disparity  is  attributed  to  the  difficul- 
ties of  existence — the  struggle  for  life 
which  is  so  much  greater  among  men. 

In  Englaud  and  Wales  [Oj,  the  rate 
for  males  during  twenty-six  years  was  104 
annually  per  million  living,  while  the  rate 
for  females  was  only  41,  or  in  the  propor- 
tion of  254  to  100.  Indeed,  when  correc- 
tion is  made  for  the  difference  between 
the  age-distribution  of  males  and  females, 
the  proportion  becomes  still  more  strik- 
ing, namely,  267  to  100.  If  the  female 
rate  at  each  age-jDeriod  is  taken  as  100, 
and  the  male  rate  reduced  to  the  corre- 
sponding figure,  the  male  and  female  rates 
diverge  more  and  more  widely  with  the 

*  Morselli,  op.  cit.,  p.  132. 
t   Op.  cit.,  p.  189. 


Suicide 


1225     ] 


Suicide 


advance  of  age,  but  the  regularity  of  the 
scale  is  broken  at  two  periods,  namely,  in 
the  15-20  and  in  the  45-55  years'  periods, 
and  in  the  earlier  ot'  these  two  periods, 
the  female  is  actually  higher  tlian  the 
male  rate. 

The  break  in  the  scale  at  45-55  marks 
the  sudden  shock  given  to  the  female  sys- 
tem by  the  mcno2Jaiisc;  while  the  excep- 
tional inversion  of  the  male  and  female  rates 
in  the  15-20  years' period  marks  the  conver- 
sion of  the  girl  into  the  woman.  Dr.  Ogle 
points  out  tliat  this  period  is  not  only  that 
in  which  the  suicide-rate  for  females  is 
higher  than  that  for  males,  but  is  also 
the  only  period  in  which  the  general 
death-rate  is  higher  in  the  former  sex, 
and  is  also  marked  by  an  exceptionally 
higher  rate  of  lunacy  for  females  than  for 
males.  These  three  concomitant  features 
of  the  15-20  period  in  regard  to  suicide, 
death,  and  insanity  among  females  are  due 
to  puberty,  but  the  tendency  to  suicide  in- 
creases with  age,  so  that  though  a  girl  and 
boy  are  at  the  same  period  of  age,  yet 
physiologically  and  pathologically  the  girl 
is  the  elder  of  the  two  in  sexual  maturity 
and  stature. 

No  doubt,  as  Dr.  Ogle  says,  the  total 
chance  of  dying  by  suicide  is  much  greater 
than  is  generally  supposed  ;  for  i  out  of 
every  119  young  men  who  reach  the  age 
of  twenty  kills  himself. 

Tables  we  have  published  in  the  Journal 
of  Mental  Science  (Jan.  1890)  show  that 
in  this  country,  from  1 861 -1888,  the  re- 
sult as  to  the  liability  of  the  sexes  to  sui- 
cide may  be  stated  thus  :  Among  equal 
numbers  living  of  both  sexes  there  wei'e 
almost  exactly  three  male  suicides  to  one 
female  suicide. 

iviorality. — Of  the  various  social  influ- 
ences under  consideration,  that  of  public 
morality  must  not  be  overlooked,  but  the 
tests  are  in  the  highest  degree  illusory. 
Tables  showing  the  difference  in  the 
number  of  illegitimate  children  in  different 
countries  are  altogether  untrustworthy 
tests  of  comparative  international  moral- 
ity. It  is  apparently  well  established 
that  where  the  annual  average  of  suicides 
undergoes  a  very  marked  increase,  a  corre- 
sponding increase  of  crime  occurs.  It  is  a 
matter  of  common  observation  that  the 
murderer  frequently  endeavours  to  end 
his  own  life.  And  yet  in  some  countries 
statistics  show  that  "  those  that  are  pre- 
eminent in  crimes  of  blood  are  those  where 
suicide  is  scarce."*  Italy  and  Spain  are 
examples  in  point  when  compared  with 
other  European  nations.  It  is  certainly 
almost  incredible  that  where  crimes 
against  property  predominate,  suicides  are 
*  Morselli,  up,  cit.,  p.  49. 


more  frequent  than  where  crimes  of  blood 
are  freciuent.* 

Depression  of  Trade. — There  is  no 
doubt  that  agricultural  distress  increases 
the  number  of  suicides.  Machinery  in 
place  of  hand-labour  has  e.xerted  a  bad 
influence  in  this  direction.  It  has  been 
shown  by  Morselli  that  there  is  no  direct 
relation  between  the  cost  of  bread  and  the 
number  of  suicides,  although  in  twenty- 
four  provinces  in  Italy,  in  which  wheat 
rose  in  price  very  considerablj^,  suicides  in- 
creased in  number  in  half  these  districts — 
to  fifty  per  cent.,  remaining  stationary  in 
three,  and  diminishing  in  nine.  On  the  con- 
trar}^  in  thirty-four  provinces,  where  the 
jirice  fell  considerably,  in  eighteen  of  thejn 
the  number  of  suicides  declined,  in  three 
it  remained  stationary,  while  lastly,  in 
twelve,  there  was  an  increase  of  suicides. 
In  the  year  1869  a  favourable  condition 
was  enjoyed  in  Italy,  and  there  was  a 
decided  fall  in  the  number  of  suicides. 
The  same  relation  between  prosperity  and 
fewer  acts  of  self-destruction  was  observed 
in  1875,  in  the  same  country.  Again,  if 
the  efiect  of  railways  on  voluntary  deaths 
be  examined  into,  it  would  seem  that 
"  the  States  that  are  most  advanced  in 
railway  development,  are  those  that  gene- 
rally have  the  larger  averages  of  sui- 
cides." t  We  are  assured  that  "  in  France 
the  kilometrical  maximum  development  of 
railways  is  in  the  northern  zone,  as  is  the 
case  in  Italy,  and  in  these  regions  the 
prevalence  of  suicide  corresponds  with 
that  of  the  networks  of  railways  and  of 
their  commercial  and  passenger  trafiic 
compared  to  the  j^opulation  and  the  geo- 
graphical superficies."  +  It  must  be  re- 
membered that  this  relationship  does  not 
necessarily  mean  that  railways  jjer  se 
exert  an  injurious  influence  on  the  brain. 
They  may  be  only  one  of  other  indications 
of  modern  civilisation. 

Political  Iilfe. — It  is  stated  that  al- 
though a  predisposing  cause  of  suicide 
is  to  be  found  in  the  increased  individual 
interest  taken  by  a  large  number  of  the 
l^eople  in  political  life,  in  great  revolu- 
tions, as  those  in  Europe,  1848-49,  there 
were  fewer  suicides  throughout  the  greater 
part  of  Europe.^:  Something  should  be 
said  as  to  the  influence  of  the  prevalent 
thoughts  and  speculations  of  any  par- 
ticular age,  but  this  study  is  extremely 
open  to  erroneous  deductions,  and  definite 
facts  are  obtained  with  difliculty.  Two 
opposite  forces  may  be  at  work  at  the 
same  time,  and  among  the  same  people. 
For  example,  in  England,  the  Salvation 

»  ,SVe  an  elaborate  Table  iu  Morselli,  op.  cit., 
p.  151. 

t  <>ii.  (■il..X)-  1^8.  t   '>/>.<•'■/..  p.  159. 


Suicide 


[     1226    ] 


Suicide 


Army,  and  a  largely  increasing  body  of 
Agnostics  might,  and  no  doubt  do,  exert 
their  opposite  influences  on  thought  at  the 
same  epoch. 

Density  of  Population. — It  appears 
impossible  to  establish  any  relation  be- 
tween this  factor  and  the  number  of 
suicides.  Belgium,  for  example,  stands 
first  as  regards  the  number  of  inhabitants 
to  the  square  mile,  while  it  is  thirty-second 
in  national  liability  to  suicide.  It  is  not 
necessary  to  burden  the  consideration  of 
the  causation  of  suicide  with  elaborate 
statistics  when  the  net  result  fails  to  show 
any  causal  relationship  between  dense 
populations  and  voluutai'y  deaths. 

City  and  Country  Iiife. — The  following 
formula  is  laid  down  by  Morselli :  "  The 
proportion  of  suicides  in  all  Europe  is 
greater  amongst  the  condensed  population 
of  urban  centi-es  than  amongst  the  more 
scattered  inhabitants  of  the  country."  * 
This  seems  opposed  to  the  negative  results 
of  the  investigation  referred  to  in  the 
last  section.  Comparisons  have  been 
made  between  the  inhabitants  of  centres  of 
more  than  2000  and  the  rural  population. 
Paris  has  an  unenviable  predominance  in 
the  scale  of  capitals  in  relation  to  suicide. 
The  researches  of  Guerry,  Lisle,  and 
Legoyt  are  cited  by  Morselli  as  showing 
that  the  suicides  increase  regularly  and  in 
every  direction  in  the  depai-tments  of 
France,  according  to  their  vicinity  to  the 
capital.  Decaisne  states  that  while  there 
is  I  suicide  to  160  deaths  in  Vienna,  i  in 
175  in  London,  i  in  712  in  New  York, 
there  is  the  large  proportion  of  i  in  72  in 
Paris.  It  appears  that  as  regards  London 
and  the  provinces,  there  has  always  been 
a  larger  proportion  of  suicides  in  the 
former.  In  Berlin  the  same  difference 
has  been  observed.  In  Vienna  there  is  a 
lower  proportion  of  suicides  than  in  other 
European  capitals.  In  St.  Petersburgh 
the  suicides  are  very  much  greater  than  in 
the  country  at  large.  So  in  Copenhagen, 
Stockholm,  Brussels,  Munich,  and  Frank- 
fort-on-the-Main,  where  it  stands  at  a  very 
high  rate,  and  is  said  to  be  on  the  increase. 


The  influence  of  large  towns  in  causing 
suicide  seems  fairly  deducible  from  the 
large  mass  of  figures  which  have  been 
collected  together  by  statisticians  in 
various  countries.  The  general  survey  of 
the  foregoing  conditions  accompanying  the 
occurrence  and  range  of  suicides,  cannot 
but  have  the  effect  of  inducing  consider- 
able caution  as  to  the  comparative  action 
of  these  causes,  seeing  that  they  are  almost 
inextricably  mixed.  We  have  therefore 
erred,  if  at  all,  in  minimising  the  influences 
at  work  in  society,  from  the  fear  lest  we 
should  be  led  astray  by  the  formidable 
array  of  figures  which  are  to  be  found  in 
the  numerous  works  which  have  appeared 
on  the  subject. 

Agre. — The  tendency  to  suicide  increases 
in  both  sexes  in  direct  ratio  with  age. 
This  conclusion  has  been  arrived  at  after 
making  due  allowance  for  the  difference  in 
their  numbers  in  the  general  population 
at  different  ages.  According  to  Morselli's 
statistics,  the  stage  of  life  comprising  the 
ages  between  twenty-one  and  fifty  is  the 
most  favourable  to  this  tendency,  the 
maximum  number  occurring  between  forty 
and  fifty,  but  in  our  own  country  statis- 
tics show  that  suicides  are  most  common 
between  fifty-five  and  sixty-five  in  both 
men  and  women.  As  stated  by  Dr.  Ogle : 
In  England  and  Wales  [0],  after  the 
tenth  year  of  age,  the  rate  of  suicide 
reaches  whole  numbers,  and  rises  steadily 
until  the  maximum  is  reached  during 
the  decennium  55-65,  when  after  being 
almost  stationary  for  another  decade,  the 
rate  falls. 

Admissions  to  asylums  show  in  general 
a  somewhat  similar  decrease  at  the  more 
advanced  ages.  Taking  the  whole  period 
of  life,  however,  the  lunacy-rate  reaches 
its  maximum  at  an  earlier  period  than  the 
suicide-rate,  and  its  decline  afterwards  is 
not  so  regular. 

We  have  given  the  following  table  in 
the  Jourmd  of  Mental  Science  (Jan.  1890) 
showing  the  suicides  to  a  million  persons 
living  at  different  ages  in  England  and 
Wales,  1861-1888: 


Table  III. — Number  of  Suicides  at  Different  Ages  in  England  and  Wales,  i86i-i888. 


All 
Ages. 

Under 
15 

IS 

20 

25 

35 

45 

55 

65 

75  and 

up- 
wai-ds. 

Persons  .  . 

47^704 

261 

1858 

2887 

6914 

9000 

TO.  308 

9576 

5340 

1560 

Males .  .  . 

35^501 

148 

875 

1797 

4915 

6735 

7813 

7669 

4306 

1243 

Females  . 

12,203 

"3 

983 

1090 

1999 

2265 

2495 

1907 

1034 

317 

*  Morselli,  cp.  cit.,  \>.  169. 


Suicide 


1227    ] 


Suicide 


Suicides  by  children  five  years  of  age 
Lave  been  recorded,  and  it  is  said  even 
tliree,  but  this  is  diflicult  to  believe. 
Of  240  suicides  committed  by  children  in 
France,  94  wei'e  fifteen  years  old,  60  were 
fourteen,  38  were  thirteen,  1 1  were  twelve, 
16  were  eleven,  6  were  ten,  4  were  nine, 
3  were  eight,  and  8  were  seven  only. 
Eighty-one  suicides  in  England  and  Wales 
during  ten  years  ( 1 865-74)  were  committed 
between  ten  and  fifteen,  there  being  as  many 
as  45  males  as  against  36  females.  Again, 
in  Prussia  during  the  three  years  1873-75 
8  children  terminated  their  existence  under 
ten  years  and  above  five.  The  antagonism 
between  suicide  and  crime,  as  regards  age, 
is  shown  in  one  of  the  Tables  prepared  by 
Morselli,  who  proves  that  in  France  during 
a  certain  term  of  years  the  tendency  to 
suicide  was  greatest  at  above  seventy  in 
both  sexes,  while,  on  the  contrary',  crime 
manifested  the  greatest  intensity  under 
twenty-five.  The  two  curves  display  an 
inverse  parabolic  development.* 

Celibacy. — Due  correction  being  made 
for  the  i^roportion  of  married  to  unmarried 
persons  to  the  general  population,  sta- 
tistical proof  is  forthcoming  of  the  evil 
effect  of  celibacy  and  widowhood  as  re- 
gards the  prevalence  of  suicide.  Sex, 
however,  affects  the  result,  for  in  Italy, 
France,  and  Switzerland  there  apjDcar  to 
be  fewer  suicides  among  the  unmarried, 
while  there  are  more  among  the  married 
and  those  in  a  state  of  widowhood.  The 
latter  condition  favours  suicide  among 
men  more  than  among  women.  Celibacy, 
on  the  other  hand,  is  not  so  injurious  to 
women  as  to  men.t  It  is  a  melancholy 
reflection  that  the  unhappy  state  to  which 
marriage  brings  a  large  number  of  women 
causes  among  this  class  so  large  a  number 
of  violent  deaths.  It  would  seem  that 
divorce  exercises  a  more  injurious  influence 
on  the  male  than  on  the  female  sex.  It 
should  be  stated  that  in  the  case  of  widows 
a  family  has  an  appreciable  effect  in  les- 
sening the  tendency  to  suicide. 

Occupation. — More  extended  statistics 
have  had  the  effect  of  disproving  an 
opinion  long  entertained  of  persons  re- 
siding in  agricultural  districts  as  more 
prone  to  commit  suicide  than  those  who 
live  in  towns.  We  have  in  the  "  Manual 
of  Psychological  Medicine"  endeavoured 
to  expose  the  old  fallacy  on  this  point — 
the  relative  liability  of  rural  and  urban 
populations.  It  has  been  found  in  Italy 
that  the  highest  figures  of  suicides  are 
associated  with  those  industries  which 
are  the  least  necessary  to  human  exist- 
ance — e.g.,  objects  of  luxury,  scientific  and 

*  Morselli,  oj).  cit.,  ]>.  226. 
t  Op.  cit.,  pp.  226,  232. 


musical  instruments,  fabrication  of  arms 
and  ammunition,  printing,  lithographing, 
and  toilet  industries.  Among  such  in- 
dustries as  weaving,  spinning,  buikling, 
stone  cutting,  tailoring,  shoemaking, 
hat  manufacturing,  &c.,  there  are  fewer 
instances  of  voluntary  death.  The  pro- 
portion rises  among  those  concerned  in 
food,  including  wine-merchants  and  beer- 
sellers. 

Among  the  class  devoted  to  religion  in 
Italy,  including  nuns,  convent  maids,  and 
lay  sisters,  the  number  of  suicides  is  small. 
Among  those  who  use  their  intellectual  fa- 
cultiesinore  severely,  journalists,  engineers, 
in  short,  the  literary  and  scientific  classes, 
there  is  a  distinct  increase  in  the  number 
of  suicides.  The  condition  of  teachers  in 
Italy  appears  to  be  particularly  depress- 
ing, and,  as  might  be  expected,  occasions 
a  frequent  resort  to  a  violent  termination 
of  life  as  an  escape  from  an  unhappy  pro- 
fession. Fortunately,  schoolmisti'esses 
have  a  better  time  of  it,  and  do  not  follow 
this  course.  The  commercial  classes,  in- 
cluding large  merchants  and  bankers, 
yield  a  large  proportion  of  suicides.  Still 
greater  is  the  number  among  the  lawyers 
and  doctors. 

In  England  and  Wales  [0],  the  deatb 
registei's  during  six  years  (1878-83)  ex- 
hibit 9000  suicides  of  males  with  known 
occupations.  The  suicide-rate  at  each 
age-period  is  calculated  separately  for  each 
occupation,  and  the  rates  thus  obtained 
are  ajjplied  to  a  standard  population,  that 
is,  to  one  with  a  certain  fixed  age-distribu- 
tion. At  the  bottom  of  the  list  are  those 
occupations  (the  clergy  excepted)  which 
entail  severe  manual  labour,  and  are 
mostly  carried  on  out  of  doors  by  unedu- 
cated men.  At  the  top  of  the  list  are  se- 
dentary occupations,  and  they  comprise  a 
number  of  callings  which  lead  to  intem- 
perance. By  far  the  majority  of  suicides 
of  servants  were  among  butlers.  In  the 
comparatively  happy  medium  is  found  the 
gi'eat  class  of  sho])keepers.  Soldiers  may 
be  supposed  to  enjoy  their  pre-eminence 
in  self-destruction,  chiefly  on  account  of 
their  intemperate  habits  of  life,  and  partly 
on  account  of  their  being  taken  from  the 
dregs  of  the  po])ulation,  not  to  mention 
the  well-known  {psychological  influence 
associated  with  the  sight  of  an  instrument 
of  destruction.  The  high  rate  among 
medical  men  and  lawyers  is  attributed  to 
undue  indulgence  in  the  pleasures  of  the 
table,  and  the  strain  of  the  nervous  system 
from  prolonged  mental  work.  On  the 
whole,  suicide  is  more  prevalent  among 
the  educated  than  the  uneducated.  This 
is  confirmed  by  its  increase  in  recent 
years.     To  some  extent  higher  education 


Suicide 


] 


Suicide 


is  only  indirectly  to  blame,  since  it  fre- 
quently leads  to  higher  living  as  well  as 
less  exercise,  and  a  less  simple  and  healthy 
mode  ot  life.  Of  those  among  whom  the 
standard  of  education  is  not  high,  nor  the 
amount  of  healthy  exercise  small,  but  who 
are,  notwithstanding,  prone  to  suicide,  it  is 
obvious  that  they  are  not  only  an  imbibing 
section  of  the  population,  but  have  had  to 
pass  through  frightfully  hard  times.  The 
failures  of  farmers  were,  in  1879,  suddenly 
doubled.  Taking  this  and  the  following 
year,  they  were  83  per  cent,  above  the 
average  of  four  other  years  (1878,  1881- 
1883),  and  it  turns  out  that  in  1879  and 
1880  suicides  among  farmers  attained 
their  maximum. 

In  referring  to  the  Annual  Keport 
of  the  Lunacy  Commissioners  for  a  com- 
parison of  suicide-rate  with  insanity-rates, 
in  England  and  Wales,  Dr.  Ogle  observes 
that  while  they  give  the  average  annual 
admissions  into  asylums  per  10,000  males, 
returned  in  each  occupation  at  the  census 
of  1881,  "they  unfortunately  have  taken 
no  account  of  differences  of  age-distribu- 
tion in  the  different  occupations,  and  con- 
sequently the  rates  given  by  them  are  of 
very  little  use  for  purposes  of  comparison  ; 
for  the  insanity-rates,  like  the  suicide- 
rates,  increase  vastly  with  age,  and  the 
age-distribution  differs  greatly  in  different 
professions  and  industries."  "  On  the 
whole,  there  is  quite  as  close  a  parallelism 
between  the  two  series  of  rates  as  could 
be  fairly  exijected,  seeing  on  what  differ- 
ent principles  the  two  sets  of  rates  have 
been  calculated." 

Social  Condition.— To  a  considerable 
extent  the  object  of  this  section  has  been 
anticipated  by  the  observations  made  in 
a  previous  one.  Much  stress  is  laid  by 
Morselli  upon  the  excessive  tendency 
among  the  military  to  suicide.  The  fol- 
lowing sentence  may  be  quoted  in  full : — 
"  Whether  this  is  owing  to  distance  from 
home  and  disgust  for  military  life,  or  to 
the  severity  of  discipline,  this  is  not  the 
place  to  discuss,  but  in  the  meantime, 
whenever  the  psychological  conditions  of 
the  army  are  studied,  there  the  heaviest, 
and  we  may  even  say  an  exceptional,  loss 
may  be  perceived.  And  in  the  comparison 
which  may  be  made  between  the  soldiers 
and  sailors  of  different  countries,  there  is 
such  a  similarity  of  data  that  a  still 
greater  value  must  be  attributed  to  the 
psychological  interpretation  of  the  num- 
bers. The  military  service  is,  in  fact, 
everywhere,  except  in  England,  regulated 
by  the  same  rules  of  conscription,  and  of 
the  obligation  of  the  citizens,  and  every- 
where the  social  and  material  conditions 
of  soldiers  are  equalised,  either  by  custom 


and  rule,  or,  which  is  more  important,  by 
disciplinary  orders."* 

In  1868  statistics  were  published  show- 
ing that  in  the  north  of  Germany  there  was 
I  suicide  out  of  2238  soldiei's  ;  in  Denmark 
I  in  3900;  in  Saxony  i  in  5000;  Baden, 
Norway,  and  Prussia  had  each  i  in  900a  ; 
Wiirtemberg  i  in  9748;  France  i  in  10,000: 
Sweden  and  Bavaria  i  in  about  15,000; 
and  Belgium  i  in  17,800.  "From  1862 
to  1 87 1  the  mortality  by  suicide  in  the 
English  army  was  0.379  pei*  thousand  of 
the  forces  ;  and,  comparing  it  with  that 
of  men  between  twenty  and  forty-five 
years  of  age,  which  during  that  period 
was  0.107,  'we  find  it  of  more  than  treble 
intensity.  This  intensity,  moreover,  aug- 
mented as  time  advanced;  from  1862  to 
1 87 1  it  grew  from  278  per  million  to  400  (in 
the  first  quinquennial,  an  average  of  31 5 ;  in 
the  second,  443),  and  even  reached  569  in 
1869.  The  tendency  then  increases  with  the 
sending  away  the  troops  from  Europe,  so 
that  in  the  kingdom  (at  home)  the  number 
is  339  per  million,  but  in  the  English  pos- 
sessions in  India  it  rises  to  468.  We  may 
suppose  that  here  nostalgia  and  the  fatal 
influence  of  the  climate  play  a  large  part."t 

Some  important  observations  have  been 
made  in  regard  to  the  influence  of  im- 
prisonment on  the  tendency  to  suicide. 
This  influence  appears  to  be  suificiently 
well  marked,  especially  in  prisoners  under 
thirty  years  of  age. 

According  to  returns  in  Italy,  those 
guilty  of  crimes  against  the  person  con- 
stitute more  than  half.  Naturally,  those 
prisoners  sentenced  to  long  imprisonments 
most  frequently  commit  self-destruction. 
Morselli  arrives  at  the  conclusion  that 
"  solitary  confinement  produces  a  greater 
pi'oportion  of  suicides  than  associated 
imprisonment  and  the  system  of  mixed 
prisoners."  Thus,  under  the  cellular 
system  practised  in  Belgium,  Denmark, 
some  prisons  in  Great  Britain,  and  Italy, 
the  average  number  of  suicides  in  prison 
is  in  the  ratio  of  1370  per  million  prisoners; 
under  the  Auhuni  system,  where  practised 
in  Great  Britain  and  Italy,  the  average  is 
400 ;  in  those  prisons  where  the  'mixecl  sys- 
tcm  is  adopted,  as  in  Saxony  and  in  some 
places  in  Great  Britain,  the  average  is  800  ; 
and,  lastly,  where  the  associated  system 
has  been  introduced,  as  in  Austria,  Hun- 
gary, France,  Italy,  Prussia,  and  Sweden, 
the  average  amounts  to  350.  Morselli, 
therefore,  disagrees  with  Baillarger,  Mor- 
eau,  and  the  French  Parliamentary  Com- 
mission (1875)  that  "solitar\^  confinement 
cannot  be  pronounced  injurious  to  the 
mind  and  health  of  the  prisoner."  J 

-   Op.  cit.  p.  257.  t  Op.  cit.,  p.  269. 

I  Op.  cit.  p.  264. 


Suicide 


L     1229     J 


Suicide 


Intemperance. — The  intiuence  of  al- 
cohol or  beer  in  the  production  of  suicide 
is  not  disputed.  It  is  stated  by  Biittchcr 
that  56  per  cent,  are  due  to  alcoholic 
excess.*  Suicides  have  risen  and  fallen  in 
number  in  Sweden  according  to  the  strin- 
gency of  prohibitory  laws  as  regards  drink. 

Heredity.  —  Eemarkable  examples  of 
hereditary  suicide  have  occurred  (pp.  1230, 
1231). 

Connection  of  Suicide  ivlth  Insanity. 
— It  is  absolutely  impossible  to  determine 
the  number  of  suicides  due  to  mental  dis- 
ease. That  this  number  is  very  large  is 
unquestionable,  but  it  cannot  be  admitted 
for  a  moment  that  the  suicidal  act  taken 
alone  is  any  sign  of  insanity.  The  custom- 
ary verdict  of  juries  in  cases  of  suicide — 
"  temporary  insanity '' — has  fostered  the 
idea  that  voluntary  deaths  are  necessarily 
committed  by  madmen.  Dr.  Westcott 
made  a  careful  inquiry  into  the  cases  of 
suicide  falling  under  his  notice,  and  has 
found  that  in  20  per  cent,  only  was  there 
any  proof  that  the  deceased  had  shown 
symptoms  of  mental  disease,  so  far  at 
least  as  his  friends  were  aware  of  the  fact. 

Of  male  lunatics  admitted  into  asylums 
in  England  and  Wales,  in  the  course  of 
one  year — 1887 — there  were  25.8  percent, 
manifesting  a  suicidal  iendcncy,  while 
there  was  a  larger  proportion  of  females — 
namely,  32  per  cent. — which  at  first  sight 
seems  strange  in  view  of  the  statistics 
given  as  regards  suicides  in  the  general 
population.  When,  however,  we  take  the 
actual  deaths  from  suicide  in  English  asy- 
lums during  one  year  (1890)  we  find  there 
were  ten  males  and  four  females,  showing 
that  inside  asylums  as  well  as  out  of  them 
there  are  more  of. the  former  sex  who  com- 
tnit  suicide. 

As  to  the  form  of  mental  disorder  of 
those  admitted  into  asylums  with  suicidal 
tendency,  in  1887,  the  gi'eat  majority 
(59.6  per  cent.)  were  cases  of  melancholia, 
then  mania  (20  per  cent.),  and  lastly  de- 
mentia (16  percent.). 

It  is  unnecessary  to  pursue  this  aspect 
of  suicide  further,  as  it  is  treated  by  Dr. 
Savage  in  the  article   Suicide  and  In- 

SAKITY  {q.v.). 

Modes  of  Seatb. — These  vary  to  some 
extent  according  to  nationality.  Thus  in 
Paris  charcoal  is  largely  employed  to 
cause  asphyxia.  Certain  poisons  are  par- 
ticularly fashionable  in  England.  In 
Italy  there  exists  a  strong  predilection  for 
drowning,  and  so  on.  As  has  been 
pointed  out,  the  certainty  of  effect  and 
the  minimum  amount  of  pain  mainly 
determine  the  form  of  suicide  resorted  to. 
With  the  insane  this  by  no  means  holds 
*  Morselli,  oji.  cit.,  p.  290. 


good,  for  a  powerful  reason  is  often  found 
in  the  delusion  under  which  the  patient 
suffers,  for  intensifying  the  suffering  in 
accordance  with  a  morbid  fanaticism.  The 
order  in  which  various  modes  of  violent 
death  occurred  during  ten  years  (1866-75) 
was  as  follows  :  Hanging,  drowning,  fire- 
arms, asphyxia,  arras  for  ci;tting  and 
stabbings,  falls,  i^oisou,  crushing  by  rail- 
way train.  In  Italy  drowning,  to- 
gether with  gunshot  wounds,  comes  first, 
then  we  have  suspension,  falling  from 
heights,  wounds  by  cutting  or  stabbing, 
and  poisoning  being  about  equal,  and 
lastly  charcoal,  and  crushing  under  rail- 
way trains.  In  Prussia  and  Bavaria, 
there  is  great  uniformity  in  the  preference 
for  suspension,  asphyxia  being  the  last  on 
the  list.  Attention  has  been  drawn  to 
the  remarkable  regularity  which  in  succes- 
sive years  marks  the  choice  of  methods  of 
deaths  resorted  to  by  suicides  in  England. 
Thus,  from  185S  to  1876,  the  annual  aver- 
age number  of  suicides  per  million  inhab- 
itants ranged  from  66  to  y^,'  Fire-arms 
were  resorted  to  in  an  almost  uniform  pro- 
portion every  year,  varying  only  from  2  to  5 
per  million  ;  cutting  and  stabbing  from 
II  to  16;  poison  from  6  to  8 ;  drowning 
from  10  to  16;  hanging  from  22  to  30; 
otherwise  from  3  to  7.  It  is  a  remarkable 
fact  that  a  gi'eatly  increased  prefei'ence 
has  been  manifested  in  Euroj^e  for  death 
by  hanging.  It  might  have  been  expected 
that  poison  and  asphyxia  by  charcoal 
would  have  been  regarded  with  more 
favour,  and  indeed  this  has  been  the  case 
in  North  America  and  some  other  coun- 
tries. 

The  order  in  which  the  various  poisons 
have  been  made  use  of  in  England  dur- 
ing one  decennium  is  as  follows:  Prussic 
acid,  cyanide  of  jjotassium,  laudanum, 
oxalic  acid,  arsenic,  strychnine,  the  vermin 
killer,  and  oil  of  bitter  almonds  ;  whilst  in 
the  second  and  third  places  occur  caustic 
acids,  mercury,  preparations  of  opium  and 
morphia,  vegetable  narcotics,  phosphoi'us, 
and  salts  of  copper.  Then,  in  the  last 
place,  there  are  chloral,  chloroform, 
paraffine,  and  belladona,  ammonia,  cantha- 
rides,  salts  of  lead,  zinc  and  potassium. 

In  Dr.  Ogle's  statistics  of  suicides  for 
England  and  Wales,  strangulation  heads 
the  list :  then  follow  drowning  and  cut- 
throat. A  long  way  down  comes  poison ; 
the  order  of  frequency  being  mainly  deter- 
mined by  the  comparative  facility  of  access 
to  the  means  of  destruction,  although, 
strange  to  say,  the  sailor  prefers  hanging 
to  drowning,  A  razor  is  easily  procured, 
a  river  or  pond  is  generally  near,  while  a 
rope  is  always  handy. 

Hanging  is  selected  by  men,  women  pre- 


Suicide 


L      1230     J 


Suicide  and  Insanity 


fer  drowning,  and  elect  to  take  poison 
ratlier  than  stab  themselves.  As  might 
be  expected,  they  rarelj^  shoot  themselves, 
jumping  from  a  height  being  more  com- 
mon. With  men,  as  age  advances,  there 
is  an  increasing  comparative  distaste  to 
the  use  of  the  gun,  poison  and  drowning, 
and  an  increasing  preference  for  the  knife 
and  cord. 

Morselli  emphasises  the  rareness  of  vio- 
lent death  by  drowning  the  nearer  we  ap- 
proach the  north  of  Europe.  "The  Slav 
race  is  the  one  which  shows  less  inclination 
than  others  to  seek  death  by  drowning, 
not  only  in  Russia,  but  also  in  the  Slav 
provinces  of  Austria-Hungary  (Galicia, 
Buckovina,  the  military  frontiers,  and 
Slavonia).  Where  the  Slavic  race  mingles 
with  others,  as  in  Transylvania  (Slavo- 
Magyar),  or  in  Bohemia  and  Moravia 
(Czech-German),  suicide  through  drown- 
ing is  somewhat  more  frequent,  still 
always  below  that  of  any  other  country. 
Let  us  note,  however,  that  in  later  times, 
even  in  Austria,  suicide  by  drowning, 
especially  amongst  women,  is  seen  to 
increase.  In  all  the  rest  of  central  and 
northern  Europe,  death  by  drowning  is 
chosen  in  nearly  the  same  number  of 
cases ;  in  Belgium  and  Ireland,  however, 
it  is  more  frequent  than  in  Germany  and 
Scandinavia.  Of  the  German  countries. 
Saxony  and  Wiirtemberg  have  the  greatest 
decrease  of  cases  by  drowning,  and  in 
Denmark  among  Scandinavian  countries. 
In  the  aggregate  of  Europe,  however, 
deaths  by  drowning  come  after  those  by 
hanging,  except  in  the  north  of  Russia. 
The  preference  given  to  drowning  in 
southern  climates,  and  especially  in 
France,  Italy,  and  Spain  (of  which  to  tell 
the  truth,  we  possess  only  incomplete 
data),  shows  how,  even  in  his  self-destruc- 
tion,the  suicide  adapts  himself  to  the  place 
and  season.  This  is  certainly  not  the 
only  reason  of  the  phenomenon,  but  thei'e 
is  an  undoubted  relation  between  the 
annual  average  temperature  and  the 
number  of  deaths  by  drowning."  * 

It  has  been  observed  that  death  by- 
suspension  and  by  drowning  occur  in 
inverse  ratio  to  one  another.  In  Russia 
the  latter  is  rare,  while  four-fifths  of  the 
suicides  are  brought  about  by  hanging. 
Other  members  of  the  Slav  race,  the  Tran- 
sylvanians  and  Galicians,  manifest  the 
same  preference  for  this  mode  of  death. 
The  Scandinavians  also,  in  the  case  of 
Denmark,  prefer  hanging  to  other  forms 
of  suicide.  The  Swedes  prefer  poisoning. 
Death  through  the  infliction  of  wounds  is 
highest  in  our  own  country.  The  German, 
whether  at  home  or  abroad,  shows  a 
*  Morselli,  oji.  cit.,  p.  324. 


marked  choice  for  hanging.  We  must 
refer  the  reader  to  Morselli's  laborious 
work  for  a  mass  of  information  on  inter- 
national preferences  in  regard  to  the  mode 
of  death  chosen. 

Doubtless  the  most  remarkable  feature 
of  suicides  throughout  the  world  is  the 
reg-ularity  with  which  they  occur  under 
certain  conditions,  so  that  general  laws 
can  be  deduced  from  a  study  of  the  phe- 
nomena, and  the  extent  of  violent  deaths 
can  be  predicated  with  tolerable  accuracy. 
Those  who,  like  Morselli,  refer  suicide  to 
the  general  principle  of  evolution,  regard 
it  as  an  "  effect  of  the  struggle  for  ex- 
istence and  of  human  selection."  This 
doctrine  of  course  assumes  that  it  is  the 
weak  who  are  destroyed  by  their  own 
hands  in  the  struggle  for  life. 

The  Editok. 

[licfi'reiices. — Bareuc,  Reflexions  sur  le  Suicide, 
1789.  Brierre  de  Boismont,  Du  Suicide,  1856. 
IJucknill  and  Tuke,  A  Manual  of  Psycliolog-ical 
Medicine,  fourth  edit.  1879.  Buckle,  H.  T.,  His- 
tory of  Civilisation  in  England,  1869.  Buonafede, 
Appiano,  Histoire  de  Suicide,  1762  and  1843. 
C'aro,  E.,  Le  Suicide  dans  ses  rapports  avec  la  civi- 
lisation, 1856.  Casper,  J.  L.,  Forensic  Medicine, 
translated  from  the  German,  by  J.  W.  Balfour, 
1861-5.  Cazauvieilh,  J.  B. ,  Du  Suicide,  1840. 
Espine,  Marc  de,  Essai  analytique  de  Statistique 
Jlortuaire  Comparee*  1858.  Jaccoud,  Xouveau 
Dictionnaire  de  Medicine,  Art.  Suicide,  1883. 
Maudsley,  Henry,  Insanity  and  Crime,  1864,  and 
Body  ;ind  Mind,  1873.  Migault,  H.  G.,  Suicide 
cliiefly  in  reference  to  Philosophy,  Theology,  and 
Legislation,  Heidelberg,  1856,  Psychological  Medi- 
cine, Journal  of,  1859,  1878,  1879, 1882.  Quetelet, 
L.  A.  J.jDe  THomme,  1835,  and  Essai  de  Statistique 
Morale,  1866.  Registrar-General,  Reports  of.  An- 
nual. Winslow,  Forbes,  The  Anatomy  of  Suicide, 
1840.  Westcott,  W.  Wynn,  Suicide,  its  History, 
Literature,  .Jurisprudence,  Causation,  and  Preven- 
tion. London,  1885.] 

svicxDi:  Atrn  im'sam-zty. — Sui- 
cide may  occur  in  persons  who  have  shown 
no  other  sign  of  insanity.  The  notion  of 
suicide  varies  with  the  education  and  sur- 
roundings of  the  individual.  Suicide  is 
more  common  in  some  forms  of  insanity 
than  in  others,  but  there  is  hardly  a  dis- 
tinct group  of  cases  deserving  the  term  of 
suicidal  mania.  Suicide  may  be  accidental 
or  intentional. 

In  mania  and  general  paralysis  of  the 
insane  if  suicide  occur  it  is  generally  as 
the  result  of  accident. 

In  some  cases  of  slight  emotional  dis- 
order there  may  be  an  intention  to  pre- 
tend to  commit  suicide  which  may  by 
accident  become  eifective. 

In  some  neurotic  persons,  whether 
the  neui'osis  result  from  heredity,  alco- 
holism, previotis  attacks,  injuries  to  the 
head,  or  in  connection  with  some  bodily 
ailment  such  as  asthma,  gout,  &c.,  slight 
moral  causes  may  lead  to  suicide ;  such 
cases  may  be  called  neurotic  suicides,  and 


Suicide  and  Insanity 


II     ]        Suicide  and  Insanity 


in  these  we  frequently  meet  witli  a 
history  of  suicide  in  other  members  of  the 
family. 

Suicide  in  insane  states  may  be  acci- 
dental or  Intentional.  Intentional  suicide 
may  be  imptolsive  or  deliberate. 


Impulsive  suiciile  may  Ih' 


Deliberate  suicide 
may  depend  on  \ 


Egotistical  . 
feeliiiiis 


Altruistic 
feelinss 


Neurotic. 
Hysterical. 
."Matiiiical. 
Alcoliolic. 
Epileptic. 
/  I'ain. 
Worry. 
Slecplessuess. 
Kuiu. 
Shame. 

To  avoid  persecu- 
tion, &c. 
f  To    save     others 
T      from  sulVeriut;-. 
(  To  benefit  others. 


or  be 


Indifferent 
to  these 


'As       I'esult       of 

"  voices." 
As  result  of  fi.xed 

delusion. 
As  result  of  weak 

mind. 


Suicide  in  children  almost  always  oc- 
curs in  hereditarily  neurotic  children  in 
whom  suicide  may  be  impulsive  or  de- 
liberate and  is  almost  always  due  to  some 
trivial  cause.     In  some,  it  is  accidental. 

In  maniacal  states  suicide  is  rarely 
the  result  of  deliberate  purpose.  It  may 
restalt  from  impulse  or  in  mania  of  the 
delirious  type,  it  may  follow  or  depend  on 
hallucinations  of  the  senses,  and  be  due  to 
dread  of  being  injured  by  some  one. 

In  some  slight  cases  of  mania  of  the 
emotional  or  hysterical  type  there  is  a 
tendency  to  exaggerated  mental  reflexes, 
so  that  the  means  to  commit  suicide 
suddenly  suggest  the  act,  such  as  knives, 
pistols,  trains  and  heights. 

Buoyant  feeling  in  mania  or  auEesthesia 
in  general  paralysis  may  lead  to  accidental 
suicide ;  thus  a  patient  may  believe  that  he 
can  fly,  and  jump  from  a  window,  or  being 
insensitive  to  pain  may  lacerate  or  burn 
himself. 

Patients  who  are  suffering  from  acute 
alcobolism  often  kill  themselves,  and 
many  who  are  suffering  from  secondary 
depression  after  alcoholic  excess  are  sui- 
cidal; some  who  having  had  attacks  of 
insanity  following  alcoholic  excesses  com- 
mit suicide  from  dread  of  a  recurrence  of 
ordinary  insanity,  some  suffering  from 
partial  weakness  of  mind  due  to  alcohol 
commit  suicide,  while  others  develop  hallu- 
cinations of  persecution  and  have  sensory 
hallucinations  which  drive  them  to  their 
end. 

In  epilepsy  suicide  is  not  frequent  but 
may  result  from    morbid    self-conscious- 


ness as  to  the  fits ;  it  may  occur  in  the 
automatic  stage  of  epilepsy,  or  as  the  re- 
sult of  uncontrollable  impulse. 

It  is  generally  accepted  as  an  axiom 
that  no  patient  suffering  fi'om  melan- 
cholia should  be  trusted.  Yet  some  such 
patients  are  much  more  suicidal  than 
others.  The  majority  of  hypochondiiacal 
melancholiacs  are  not  suicidal,  though 
many,  like  a  sea-sick  man  believe  they 
wish  for  death.  The  hypochondriac  who 
is  chiefly  concerned  with  his  "  brain  feel- 
ings "  is  rarely  suicidal,  nor  is  he  who  is 
chiefly  concerned  with  some  general  bodily 
feeling  such  as  that  of  impending  death. 
Patients  who  believe  there  is  some  radical 
disease  of,  or  obstruction  of,  the  throat  or 
bowels  may  be  suicidal,  or  they  may  com- 
pass their  death  by  some  mutilation  which 
they  perform  with  the  idea  of  giving  them- 
selves relief.  In  some  cases  in  which  there 
are  marked  waves  of  mental  depression, 
suicidal  impulses  may  occur  at  the  rise  of 
those  waves.  In  woman,  suicidal  tenden- 
cies do  not  frequently  occur  with  uterine 
hypochondriasis,  though  with  disorders  of 
the  reproductive  system  they  are  very 
common  both  in  men  and  in  women. 

We  believe  no  woman  suffering  from 
amenorrhoea  and  melancholia  is  free  from 
danger,  and  no  man  who  believes  he  is 
suffering  from  impotence  or  spermator- 
rhoea, or  is  syphilophobic  is  trustworthy. 

In  young  people  suffering  from  melan- 
cholia the  danger  is  generally  due  to  im- 
pulsive acts  ;  after  childbirth  both  homi- 
cidal and  suicidal  impulses  often  arise ; 
at  the  climacteric,  suicide  especially  in 
women,  is  very  common  ;  in  unmarried 
women  and  in  widows  there  is  a  great 
tendency  to  suicide  if  melancholia  de- 
velop. 

In  young  men  the  fear  of  spermator- 
rhoea is  potent  as  a  cause.  Syphilis,  real 
or  imaginary,  may  also  be  equally  dan- 
gerous. 

Senile  melancholia,  especially  in  men, 
is  highly  dangerous.  Melancholia  related 
to  gout  is  also  generally  suicidal. 

Simple  melancholia  of  very  slight  depth 
is  a  very  common  cause  of  suicide. 
Melancholia  with  stupor  is  more  rarely  a 
cause ;  active  melancholia  leads  to  impul- 
sive acts  of  suicide.  Melancholia  with 
persistent  hallucinations  is  also  frequently 
suicidal.  With  the  onset  of  recurring 
melancholia  and  with  the  entry  on  con- 
valescence suicidal  attempts  are  common. 
Pain  of  body  or  mind,  or  sleeplessness  may 
lead  to  suicide  in  melancholic  j^atients. 
The  early  morning  is  the  period  of  greatest 
danger. 

Delusional  Insanity  frequently  gives 
rise  to  suicide.     Almost  all  patients  who 


Suicide  and  Life  Insurance    [     1232    ]      Sunstroke  and  Insanity 


believe  that  they  ai-e  being  watched, 
followed,  or  spoken  about,  are  likely  to  be 
suicidal.  The  danger  is  greater  in  men 
than  in  women,  and  is  greater  in  younger 
men  than  in  many  of  middle  life. 

Delusional  insanity  associated  with 
ideas  of  persecution,  of  jealousy  and  the 
like  are  dangerous. 

Simple  delusions  which  have  not  be- 
come organised  into  delusional  insanity 
may  lead  to  suicide.  Thus  patients,  more 
especially  women  who  believe  they  are 
either  injurious  to  their  husbands  or 
children,  or  that  they  are  in  the  way, 
may  sacrifice  themselves. 

Similar  are  those  who  seek  their  death 
for  some  religious  objects. 

Hallucinations  of  the  senses  may  lead 
to  suicide.  Voices  may  command.  Visions 
may  entice.  Misery  produced  by  constant 
occurrence  of  hallucinations,  may  act  like 
constant  pain. 

Suicide  occurs  in  imbeciles  and  occa- 
sionally in  idiots,  but  in  these  latter  it  is 
usually  accidental.  In  dements  and  im- 
beciles it  may  result  from  accident  or  im- 
pulse or  may  be  the  outcome  of  some 
insane  train  of  thought.  In  such  cases  a 
very  slight  cause  may  give  rise  to  the  sui- 
cidal act. 

All  melancholic  patients  must  be  con- 
sidered suicidal  till  they  are  fully  known, 
and  as  such  must  be  never  trusted. 

Some  risk  must  be  run  sooner  or  later, 
and  it  is  necessary  in  curable  cases  to  re- 
cognise that  the  too  constant  presentation 
of  the  idea  of  distrust  to  the  patient's 
mind  keeps  up  the  morbidly  suicidal  state. 
Hence  we  are  inclined  to  question  the 
free  use  of  suicidal  dormitories ;  they  are 
more  preventive  than  curative. 

Most  patients  who  believe  themselves 
to  be  watched  and  followed  must  be  treated 
as  suicidal. 

Waves  of  depression  occur  in  many  neu- 
rotic but  otherwise  sane  people,  which  often 
lead  to  suicide.  Geo.  H.  Savage, 

svzcxDz:  IN  Ri:i:ii\.Tioii'  to  XiZfe 
INSURANCE.     {See  Life  Insurance.) 

suiiPKONAli.     {See  Sedatives.) 

SUNSTROKX:     AND    INSANITY. — 

The  relationship  of  sunstroke  and  insanity 
has  received  only  a  comparatively  small 
amount  of  attention  at  the  hands  of 
medico-psychologists  in  this  and  other 
countries,  and  our  knowledge  of  the  men- 
tal defects  and  aberrations  of  intellect, 
met  with  as  sequela?  of  an  attack  of  sun- 
stroke, is  as  yet  ill-deiined  and  unsystem- 
atised. 

Authors  resident  in  hot  climates  have 
concerned  themselves  largely  with  the 
study  of  the  effects  of  a  continued  high 
degree  of  temperature  upon  the  vital  pro- 


cesses of  man,  and  we  are  mostly  indebted 
to  them  for  our  knowledge  of  acute  se- 
quels, such  as  ardent  fever  with  acute  de- 
lirium, remittent  or  intermittent  fevers 
com25licated  with  dysenteries,  hex^atic  in- 
flammations, congestions,  &o. 

All  observers  have  experienced  the 
same  difficulty  in  estimating  the  exact 
effects  of  the  solar  rays,  and  this  diffi- 
culty has  arisen  not  only  from  the  absence 
of  a  sufficient  number  of  experiments,  but 
by  the  common  presence  of  other  condi- 
tions, such  as  hot,  rarefied,  and,  perhaps, 
impure  air,  heat  of  the  body  produced  by 
exercise  which  is  not  attended  by  perspira- 
tion, and  other  conditions  too  numerous  to 
mention. 

It  would  be  out  of  place  here  to  dwell 
upon  the  varieties  of  sunstroke,  which 
have  been  graphically  described  by  Sir 
Joseph  Fayrer, Duncan,  Moore,  and  others, 
so  for  the  present  we  purpose  to  accept  the 
convenient  classification  of  Morache,  who 
divides  the  forms  of  sunstroke  into  two 
classes — viz. : 

(1)  Coup  de  Soleil— due  to  direct 
beat  of  the  sun. 

(2)  Coup  de  Chaleur — indirectly  due 
to  heat  and  other  influences. 

Some  writers  uphold  the  view  that  the 
direct  influence  of  the  sun  has  probably 
little  or  nothing  to  do  with  the  hypersemia 
discovered  after  death,  which  they  con- 
sider to  be  venous  in  character,  and  a 
secondary  phenomenon  immediately  de- 
pendent upon  a  diminished  power  of 
activity  of  the  heart.  If  this  view  be  cor- 
rect, the  substitution  of  the  term  "heat- 
stroke "  for  the  generic  term  "  sunstroke  " 
would  be  advantageous,  and  would  convey 
a  more  accurate  notion  as  to  the  actual 
condition. 

On  the  other  hand,  the  assumption  that 
the  direct  impingement  of  the  sun's  rays 
upon  the  head  may  be  attended  with  an 
active  congestion  may  possibly  be  true  in 
some  cases,  but  we  do  not  think  this  is  by 
any  means  proved  apart  from  the  pre- 
sence of  other  important  factors. 

Dr.  Handfield  Jones,  writing  upon 
functional  nervous  disorders,  remarks  that 
"  any  man  of  experience  in  the  manifold 
disorders  of  jaded  and  exhausted  nervous 
systems  will  recognise  at  once  how  close 
is  the  resemblance  between  the  results  of 
tropical  heat  and  those  produced  by  the 
ordinary  causes  in  operation  among  the 
struggling  miiltitude  in  our  large  towns," 
and  it  is  with  the  factors  which  aid  in  pro- 
ducing such  exhaustion  of  the  nervous 
system  that  we  have  chiefly  now  to  deal. 

The  relative  values  of  the  atmospheric 
influences,  such  as  heat,  humidity,  winds, 
&c.,   as   causes   are   interesting,   but   the 


Sunstroke  and  Insanity     !     i 

bodily  causes,  such  as  fatigue,  bodily 
habits,  excesses — either  alcoholic,  dietetic, 
or  sexual — and  syphilis  are  the  most  im- 
portant, and  have  an  influence  specially 
upon  the  general  vigour  of  the  constitu- 
tion ;  and,  in  rendering  a  person  moi'e  or 
less  susceptible  to  heat,  so  far  predispose 
him  to  sutfer  from  it. 

Solar  heat  as  an  immediate  or  exciting 
cause  is  said  to  act  in  two  ways,  causing 
(i)  prostration  of  the  nervous  powers 
and  syncope,  symptoms  of  debility,  with 
vertigo,  weariness,  nausea,  and  inconti- 
nence of  urine  ;  or  (2)  venalisation  of 
blood,  with  absence  of  perspiration,  sup- 
pression of  urine,  and  constipation.  This 
latter  state,  however,  is  chielly  aided  by 
fatigue,  impure  air,  alcohol,  disorders  of 
viscera,  and  retained  secretions  ;  and,  fur- 
ther, although  the  heat  of  the  sun  may 
possibly  aflect  the  vaso-motor  centre  in 
the  medulla  oblongata,  especially  by  strik- 
ing on  the  unguarded  occiput  and  neck, 
yet  the  same  symptoms  arise  when  there 
is  no  direct  influence  of  the  sun  upon  the 
person  attacked. 

The  recognition  of  this  fact  is  important 
to  us,  as  formerly  many  cases  were  not 
returned  in  India,  but  were  overlooked, 
owing  to  the  fact  that  only  those  cases 
occurring  after  direct  exposure  to  the  sun 
were  recorded  ;  and,  moreover,  when  we 
investigate  the  previous  histories  of  our 
cases  of  insanity  this  source  of  error  is 
always  open  to  us. 

Undoubtedly,  hot  climates  eventually 
sap  the  foundations  of  life  amongst  Euro- 
peans, and  although  the  hypothesis  of 
acclimatisation — i.e.,  "that  an  injurious 
effect  is  first  produced  and  then  accommo- 
dation of  the  body  to  the  new  condition 
within  a  limited  time,"  is  to  a  certain  ex- 
tent true,  yet  the  rule  does  not  extend  in 
its  application  from  the  individual  to  the 
progeny. 

It  appears  that  acclimatisation  of  Euro- 
peans in  India  depends  largely  upon  in- 
termixing by  marriage  with  the  natives, 
otherwise  they  are  apt  to  degenerate  into 
strumous  or  nervous  types,  and  fail  to 
reach  beyond  the  third  or  fourth  genera- 
tion. 

The  effects  of  a  tropical  climate  are,  so 
to  speak,  relative  ;  and  beyond  the  influ- 
ences of  fatigue,  over-exei"tion,  over- 
crowding, bad  ventilation,  unsuitable 
dress,  retained  secretions,  unsuitable 
diets,  &c.,  we  have  to  consider  malaria, 
syphilis,  and  alcohol,  all  of  which  tend  to 
debilitate  or  contaminate  the  system,  and 
predispose  the  individual  to  the  occur- 
rence of  sunstroke.  From  literature,  and 
a  limited  experience  gained  by  an  analysis 
of  fifty-five   cases   of   insanity  following 


Sunstroke  and  Insanity 


sunstroke,  we  have  been  led  to  the  belief 
that  India  is,  perhaps,  the  country  most 
productive  of  that  affection  amongst 
Europeans,  for  no  less  than  twenty-three 
of  the  cases  were  said  to  have  occurred 
there.  In  eight  cases  there  was  a  history 
of  malaria,  and  in  five  of  syphilis,  whilst 
any  tendency  to  alcoholism  could  only  be 
traced  in  seven  of  the  fifty-five  cases. 
What  the  relationship  of  malaria  and 
syphilis  is  to  sunstroke  we  are  not  pre- 
pared to  say.  Undoubtedly  syphilis  (as 
first  pointed  out  by  Mr.  Hutchinson)  pre- 
cedes attacks  of  sunstroke.  Possibly  the 
special  and  primary  syphilitic  brain 
lesions  affecting  the  meninges  or  vessels, 
or  encephalic  nervous  substance,  may 
predispose  to  heat-stroke  by  weakening 
the  resistive  power  of  the  organism  and 
j  brain,  particularly  to  the  efi"ects  of  heat ; 
,  but  this  is  mere  supj^osition  on  our  part, 
j  and  much  information  is  yet  wanted  be- 
fore we  can  assign  to  syphilis  a  definite 
part  in  the  retiology. 

Alcohol  esjiecially  predisposes  to  the 
indirect  form  of  heat-stroke,  and,  as  before 
stated,  is  a  powerfully  co-operating  aid 
to  the  external  and  bodily  causes,  but 
possibly  some  observers  tend  to  give  this 
I  agent  too  great  a  prominence  as  a  factor. 
With  these  brief  general  considerations 
as  to  the  getiology,  we  will  now  pass  on  to 
what  is  to  us  the  more  important  part  of 
I  the  subject.  The  most  abiding  results  of 
sunstroke  are  all  referable  to  impaired 
functional  energy  of  the  cerebro-spinal 
system,  and  this  impairment  shows  itself 
either  in  motor  paralysis,  sensory  para- 
lysis of  common  or  special  sensation, 
hyper-  and  dysEesthesige  of  the  nerves  of 
common  and  special  sensation,  in  debility', 
and  undue  excitability  of  the  emotional 
centres,  and  in  similar  states  of  the  cere- 
bral hemispheres  and  spinal  cord ;  or 
more  commonly  in  some  nervous  defect  or 
jaerversion  consisting  in  a  functional  para- 
lysis of  one  or  more  of  the  great  nerve 
centres.  In  addition  to  these,  the  extreme 
sensitiveness  of  a  patient  to  the  rays  of 
the  sun,  or  to  excessive  heat  ever  after- 
wards, and  the  eS'ect  exercised  upon  them 
by  alcohol,  all  point,  according  to  Sir 
Josejih  Fayrer,  to  an  unstable  condition 
of  the  great  vaso-motor  centre  in  the  me- 
dulla oblongata. 

The  same  author  states  that  undoubt- 
edly an  attack  of  insolation  is  often 
attended  with  meningitis,  or  cerebral 
changes,  which  may  destroy  life  or  intel- 
lect sooner  or  later,  or  permanently  com- 
promise the  whole  health  or  that  of  some 
important  function. 

The  mental  sequelae  are  interesting, 
and  of  the  syncopal,  asphyxial,  and  hyper- 


Sunstroke  and  Insanity     [    1234    ]     Sunstroke  and  Insanity 


pyi'exial  forms  of  sunstroke,  the  two  latter 
appear  to  be  the  most  important  and  dan- 
gerous. 

In  many  cases  the  sequelae  may  be  at- 
tributed to  the  injury  which  the  brain  has 
received  during  the  primary  attack,  and 
in  the  case  of  the  syncopal  variety,  the 
temporary  loss  of  nutrition  of  the  brain 
may  result  in  mental  or  even  physical 
weakness,  which  may  continue  through  life. 

In  infancy  heatstroke  is  certainly  a 
cause  of  accidental  idiocy  or  imbecility. 
Dr.  Langdon  Down  states  that  he  has 
seen  a  notable  number  of  feeble-minded 
children,  who  owe  their  disaster  to  sun- 
stroke, while  making  the  passage  of  the 
Ked  Sea  and  Suez  Canal  en  route  from 
India  ;  or  from  exposure  in  that  country, 
and  he  attributes  the  mental  decadence  as 
originating  without  doubt  from  the  actual 
exposure  to  heat.  Dr.  Shuttleworth  has 
kindly  allowed  us  to  copy  the  records  of 
six  cases  of  imbecility  following  sunstroke 
admitted  to  the  Royal  Albert  Asylum  at 
Lancaster.  The  parents  of  idiots  and 
imbeciles  are  extremely  ready  to  attribute 
the  mental  affections  of  their  children  to 
accidental  causes  ;  but  in  these  cases  the 
non-existence  of  hereditary  neuroses,  the 
absence  of  fits  and  other  diseases  or  acci- 
dents likely  to  have  been  the  cause,  as  well 
as  the  nature,  extent,  and  immediate  con- 
sequence of  the  attack  of  sunstroke,  aided 
us  in  a  great  measure  in  coming  to  the 
conclusion  that  the  damage  to  the  mental 
power  was  undoubtedly  dependent  upon 
sunstroke. 

The  amount  of  injury  to  the  mental 
powers  was  variable,  but  all  the  patients 
were  simple-minded  or  imbecile,  rather 
than  belonging  to  the  lower  grades  of 
idiocy. 

Sometimes  the  mental  symptoms  are 
found  intercurrent  with  the  sopor  and 
coma  following  the  shock,  and  they  may 
then  take  the  form  of  delirium  or  excite- 
ment with  hallucinations,  passing  into  a 
condition  somewhat  similar  to  that  of 
primary  dementia.  As  a  general  rule, 
however,  although  there  may  be  some 
trace  left  of  the  primary  injury  to  the 
brain,  the  progress  of  the  case  is  more 
favourable  than  when  the  psychosis  de- 
velops some  months,  or  even  years,  after 
the  injury.  In  children,  as  in  adults,  the 
neuroses  following  sunstroke  are  some- 
what similar  to,  and  have  much  in  com- 
mon with,  the  traumatic  neuroses.  In 
none  of  the  six  cases  was  there  any  here- 
ditary, neurotic,  or  strumous  taint,  and, 
moreover,  until  the  period  of  the  actual 
attacks  of  sunstroke  nothing  abnormal  or 
defective  had  been  detected  by  the 
parents. 


The  chief  clinical  features  noted  were : — 
(i)  The   ordinary  aspect  of  the    child 
with  absence  of  bodily  deformities  ; 

(2)  The  full  development  and  compara- 
tively normal  dimension  of  the  muscular 
and  osseous  systems  (including  the  shape 
of  the  head,  jaws,  and  teeth,  &c.)  ; 

(3)  The  absence  of  any  physical  defects 
or  affections  of  the  nervous  system,  such 
as  paralysis  or  chorea  ; 

(4)  The  good  use  of  all  the  special 
organs  of  sense,  and  absence  of  illusions 
or  hallucinations  ; 

(5)  The  special  affections  of  speech, 
either  of  a  temporary  character  imme- 
diately following  the  attack,  or  as  a  con- 
tinued impairment  or  failure  in  develop- 
ment of  the  faculty ; 

(6)  The  frequency  of  the  occurrence  of 
fits  immediately  after  the  attacks,  lasting 
for  a  short  period  but  not  continued 
through  life ; 

(7)  The  limited  or  perverted  moral  state 
as  seen  in  various  grades,  from  mere  dis- 
obedience to  propensities  peculiar,  dan- 
gerous, or  even  homicidal,  and  sometimes, 
though  rarely,  habits  of  a  degraded  nature: 

(8)  The  small  mental  capacity,  with 
failure  to  improve  much  by  the  ordinary 
educational  methods ; 

(9)  The  attachments,  antipathies,  and 
Ijeculiarities  which  were  in  most  cases 
retained  through  life  :  their  absolute  ina- 
bility to  compete  with  their  fellow-beings, 
and  their  mental  unfitness  to  aid  in  their 
own  survival. 

Epilepsy  is  one  of  the  most  common  of 
the  sequelce  of  sunstroke,  and  occurs  in 
various  degrees  of  severity,  from  slight 
epileptiform  convulsions  to  the  severest 
forms  of  the  disease.  Maclean,  wi-iting 
upon  diseases  of  tropical  climates,  states 
that  immense  numbers  of  soldiers  were 
invalided  home  from  India  for  this  affec- 
tion following  sunstroke,  but  in  a  large 
proportion  of  cases  the  attacks  disappeared 
before  arrival  at  Netley,  particularly  in 
the  long  voyage  round  the  Cape  of  Good 
Hope. 

As  a  rule  the  disease  appeared  to  be 
amenable  to  treatment.  The  same  author 
also  noted  a  few  examples  of  chorea-like 
movements  of  the  muscles  of  the  forearm 
and  hands,  probably  due  to  nerve  irri- 
tation. 

Dr.  Mickle  is  inclined  to  the  belief  that 
the  apoplectiform  seizure  or  the  epilepti- 
form petit  mal  of  general  paralysis  has 
been  mistaken  for  sunstroke.  While  ac- 
knowledging that  such  an  error  may 
2)0ssibly  occur,  our  experience  has  led  us 
to  believe  that  it  is  more  common  for  the 
sequelfB  of  sunstroke  to  be  mistaken  for 
general  paralysis. 


Sunstroke  and  Insanity     [    1235    ]      Sunstroke  and  Insanity 


The  frequent  occurrence  of  epilepsy  is 
suggestive,  iiud  as  in  the  case  of  the 
periodical  psychoses,  the  disorder  seems 
to  be  a  manifestation  of  an  unstable  vaso- 
motor state. 

Both  idiocy  and  imbecility  may  be  de- 
pendent upon  early  epilepsy,  but  the 
absence  of  spastic  contractures,  oculo- 
motor anomalies,  deformities  and  other 
conditions,  together  with  the  absence  of 
progressive  mental  deterioration  associ- 
ated with  the  occurrence  of  the  convulsions, 
is  suggestive  rather  of  an  acquired  psy- 
chosis ;  and  further,  in  cases  of  epilepsy 
following  upon  sunstroke,  the  mental 
defect  and  convulsious  appear  to  be  colla- 
teral phenomena,  both  depending  upon  a 
common  cause,  whilst  the  positive  signs 
of  alienism,  such  as  anomalies  of  charac- 
ter and  moral  perversions  with  defective 
or  one-sided  development  of  special  facul- 
ties, appear  to  be,  in  a  large  measure, 
different  from  the  progressive  deteriora- 
tion of  ordinary  idiopathic  or  hereditary 
epilepsy. 

In  adults  we  have  seen  the  occurrence  of 
episodical  attacks  somewhat  analogous  to 
epilepsy  in  which  there  was  a  periodical 
attack  of  depression  or  excitement,  or  even 
conditions  closely  resembling  the  epilep- 
tiform and  apoplectiform  attacks  of  pa- 
retic dementia. 

Insanity  arising  from  sunstroke  is 
much  like  that  due  to  traumatism,  but 
as  a  rule  progressive  deterioration  termi- 
nating in  dementia  is  far  more  common 
in  the  latter  than  in  the  former.  An 
attack  of  sunstroke  seems  to  form  an 
acquired  predisposition  to  insanity,  and, 
as  in  the  case  of  traumatism,  the  most 
serious  psychoses  are  developed  months  or 
even  years  after  the  injury. 

Dr.  Clouston  believes  that  few  English- 
men become  insane  in  hot  climates  in 
whom  sunstroke  is  not  assigned  as  the 
cause,  and  that  that  cause  gets  the  credit 
of  far  more  insanity  than  it  produces. 
At  the  Morningside  Royal  Asylum  only 
twelve  cases  were  admitted  in  nine  years 
which  could  be  said  to  have  been  due  to 
traumatism  or  sunstroke)  being  only  one- 
third  per  cent,  of  the  admissions. 

In  the  case  of  Eethlem  the  percentage 
is  much  higher,  for  of  1974  admissions  no 
less  than  49  (or  2.6  per  cent.)  were  attri- 
buted to  sunstroke.  Possibly  this  high 
percentage  may  have  been  due  to  the 
admission  of  large  numbers  of  officers  and 
others  who  have  seen  foreign  service. 

Dr.  Mickle  believes  that  sunstroke  is 
not  uncommonly  a  cause  of  general  para- 
lysis among  British  soldiers  in  India,  and 
he  quotes  the  authority  of  Meyer,  Victor, 
Berstens,  and  others.    On  careful  analysis 


of  the  aforesaid  forty-nine  cases,  we  have 
only  been  able  to  find  one  case  in  which 
general  paralysis  really  existed,  whereas 
the  number  that  simulated  that  disease 
was  remarkaljle.  The  symptoms  in  four- 
teen cases  consisted  in  associated  mental 
and  physical  defects,  which  rendered  the 
differential  diagnosis  one  of  extreme  diffi- 
culty. The  physical  symptoms  consisted 
in  tongue  tremors,  thickness  or  slurring 
of  speech,  pupillar  anomalies,  altered 
reflexes  (chiefly  exaggerated),  shaky  and 
interrupted  handwriting,  tottering  or  weak 
gait,  loss  of  control  over  bladder  and 
rectum,  hallucinations,  or  perversion  of 
all  or  some  of  the  senses  (that  of  smell 
least  commonly),  and  mental  conditions, 
such  as  melancholia  or  hypochondriasis, 
but  more  commonly  exaltation,  extrava- 
gance, excitement,  or  even  acute  mania. 
With  such  a  combination  of  symjotoms 
the  diagnosis  of  general  paralysis  appeared 
to  be  warrantable,  but  the  cases  proved  to 
be  deceptive,  for  after  a  time  the  physical 
signs  disappeared,  and  the  patient  re- 
covered mentally  ;  or  the  mental  health 
remained  in  a  weak  and  permanently 
impaired  condition,  as  shown  by  some 
irrelevancy  or  inattentiveness ;  or  more 
commonly  by  some  trace  of  exaltation  or 
fixed  delusions,  with  a  smiling,  self-satis- 
tied  manner. 

Such  jjatients  become  docile,  cheerful, 
tractable,  and  industrious,  and  are  perhaps 
in  a  condition  to  resume  work,  and  so 
they  may  go  on  for  years,  with  no  motor 
or  special  sensory  disturbances,  and  no 
marked  change  mentally  from  year  to 
year. 

A  very  common  symptom  is  cephalalgia, 
which  may  occur  periodically  or  persis- 
tently, and  is  probably  dependent  upon 
chronic  meningitis,  with  some  thickening 
or  opacity  of  the  membrane.  Such 
patients  cannot  tolerate  heat,  and  a  close 
or  heated  atmosphere  will  cause  an  exa- 
cerbation of  the  sensory  symptoms,  or 
even  recurrence  of  the  mental  disturbance. 
Alcohol  is  apt  to  aggravate  the  symptoms, 
and  although  possibly  in  some  cases  it 
has  played  a  considerable  part  in  the  pro- 
duction of  the  insanity,  yet  we  believe  it 
is  far  more  effective  in  cases  where  the 
brain  has  been  previously  rendered  weak 
by  sunstroke,  for  in  many  cases  the  pri- 
mary affection  or  attack  of  sunstroke  has 
not  been  preceded  by  alcoholic  excesses, 
and,  moreover,  has  not  been  followed  by 
any  immediate  mental  or  motor  defect, 
but  it  has  formed,  nevertheless,  a,  predis- 
position to  the  disastrous  effects  of  other 
exciting  causes,  such  as  alcohol. 

The  symptoms  arising  from  locomotor 
ataxia,  varioi;s  paralyses   (either  general 

4  K 


Sunstroke  and  Insanity      [     1236    ]     Sunstroke  and  Insanity 


or  circumscribed),  epilejjsy,  senile  demen- 
tia, and  man>-  other  conditions  may,  in 
some  particulars,  render  the  diagnosis 
difficult,  but  the  greatest  difficulty  is 
experienced  with  such  affections  as  (i) 
general  paralysis;  (2)  syphilitic  disease 
of  the  brain  and  membranes ;  (3)  alco- 
holic insanity  ;  (4)  dementia,  with  para- 
lysis Irom  local  lesions,  or  circumscribed 
brain  lesions,  with  dementia  and  paralysis 
(from  softening,  hajmorrhage,  embolism, 
and  thrombosis.) 

It  is  not  our  intention  to  discuss  the 
differential  diagnosis  of  these  affections, 
lor  there  are  few  motor,  sensory,  or  i)sy- 
chical  elements  which  can  be  said  to  be 
symptomological  of  sunstroke. 

It  is  rather  by  the  history,  the  combi- 
nation and  character  of  the  symptoms, 
and  the  subsequent  course  of  the  case, 
that  we  are  able  to  define  a  group  within 
which_  the  cases  have  some  common  cha- 
racteristics ;  and,  moreover,  the  possession 
of  this  knowledge  may  materially  guard 
us  in  giving  our  prognosis,  and  aid  in  the 
course  of  treatment  pursued. 

General  Pathology.— The  pathology 
of  the  affection  is  somewhat  indefinite. 
Many  writers  uphold  the  view  that  expo- 
sure of  the  uncovered  head  to  the  scorching 
rays  of  the  sun  may  give  rise  to  purulent 
meningitis j  but  the  question  may  be 
asked,  "  Why,  when  so  many  people  are 
exposed  to  the  injurious  infiuences,  so  few 
suffer  from  it  ?  "  The  difficulty  in  answer- 
ing this  question  is  increased  by  the  want 
of  a  satisfactory  physical  explanation  of 
the  fact. 

Obernier  has  endeavoured  to  show,  by 
both  clinical  and  experimental  observa- 
tions, that  the  causes  and  nature  of  sun- 
stroke are  to  be  sought  in  the  abnormal 
increase  of  temperature  in  the  body  ;  and 
Liebermeister  has  further  shown  that  the 
cerebral  symptoms  associated  with  high 
temperatures  are  only  to  a  limited  degree, 
if  at  all,  dependent  upon  cerebral  hyper- 
aemia.  Sufficient  facts  are  not  yet  estab- 
lished to  justify  any  decided  opinion  as  to 
the  pathology.  Experiments  have  shown 
that_  moderate  heat  directed  upon  the 
cranium  causes  dilatation  of  the  vessels, 
and  we  must  conclude  that  the  initial 
congestion  of  sunstroke  is  due  in  part  to 
heat,  and— with  due  regard  to  the  autho- 
rity of  Liebermeister — there  is  some 
probability  that  on  the  onset  of  the 
symptoms  there  is  some  hyperasmia  of 
the  pia  and  brain,  or,  more  Accurately 
speaking,  a  distension  of  the  whole  venous 
system,  and  the  changes  found  after  death 
may  further  assume  the  existence  of  a 
cerebral  congestion  similar  to  the  con- 
gestion found  in  other  organs.     Buck  is 


of  opinion  that  a  tendency  to  capillary 
stasis  IS  induced— the  heart  labours  to 
overcome  the  obstruction,  and,  failing, 
gives  us  the  syncopal  or  cardiac  variety  ; 
or  the  nervous  system,  resenting  the 
increased  abnormity  of  the  circulation, 
develops  convulsions  and  coma,  as  the 
cerebro-spinal  variety  of  the  disease. 

Special  Pathology.- The  post-mortem 
appearances  vary  in  the  different  forms 
of  the  disease.  In  ardent  fever,  serous 
effusions  in  the  ventricles  and  between  the 
membranes  of  the  brain  have  been  noted, 
with  turgescence  of  vessels,  and  conges- 
tion of  the  pulmonary  system.  The  cause 
of  death  is  said  to  be  most  commonly 
asphyxia,  and  not  apoplexy,  and  the  most 
important  changes  are  found  in  connection 
with  thoracic  viscera. 

When  the  medulla  is  affected  accumu- 
lation of  blood  takes  place  in  the  right 
side  of  the  heart  and  lungs,  with  second- 
arily (as  a  consequence)  a  want  of  that 
fluid  duly  arterialised  in  the  brain.  Roth 
and  Lex  state  that  death  in  the  majority 
of  cases  occurs  from  cardiac  paralysis,  and 
only  occasionally  from  cerebral  disturb- 
ance. Arndt  speaks  vaguely  of  a  "  diffuse 
encephalitis,"  as  explaining  the  cerebral 
symptoms,  which  often  remain  after  the 
acute  attack  ;  and  he  points  out  that 
during  an  attack  of  sunstroke  the  blood  is 
acid,  very  rich  in  urea  and  white  globules, 
and  shows  very  little  tendency  to  coagu- 
lation. Koster  and  Fox  have  called 
attention  to  the  occurrence  of  hgemor- 
rhages,  separation  and  destruction  of  the 
nerve  fibres,  and  extravasation  in  both 
vagi  and  phrenic  nerves. 

In  children,  Dr.  Shuttleworth  has  found 
meningitis,  with  effusion  and  traces  of 
old-standing  disease  of  the  membranes  in 
one  case,  and  in  another  the  membranes 
were  thickened  and  somewhat  opaque, 
especially  at  the  vertex. 

In  the  adult  we  found  in  one  case  marked 
opacity  of  the  arachnoid,  with  an  excess 
of  serous  fluid  between  the  convolutions 
and  in  the  ventricles.  The  dura  mater 
was  apparently  normal,  and  not  adherent 
to  the  skull-cap.  The  inner  membranes 
stripped  readily,  and  in  one  coherent  film, 
leaving  the  surface  of  the  convolutions 
intact.  The  vessels  at  the  base  were 
healthy,  and  normal  in  arrangement. 
There  was  no  marked  congestion  of  the 
venous  system.  The  convolutions  them- 
selves were  well  formed,  and  the  cortex 
was  of  good  depth  and  colour.  Striation, 
however,  was  ill  defined,  and  there  was 
a  considerable  amount  of  oedema  of 
the  white  substance.  On  microscopic 
examination  of  the  cortex  cerebri  we 
found  a   considerable    number  of   spider 


Surdi- Mutism 


^237 


Switzerland,  Insane  in 


cells    and  other  evidences   of  degenera* 

tion. 

lu  another  case,  reported  to  the  Medico- 
Psycholocjical  Association  by  Dr.  K.  Percy 
Smith,  the  dura  mater  was  tound  normal, 
but  there  was  great  excess  of  sub-arach- 
noid Huid  over  the  surface  of  the  brain, 
especially  at  the  upper  ends  of  the  ascend- 
ing frontal  and  parietal  convolutions.  Tlie 
pia  mater  was  soft,  but  peeled  reatlily 
from  the  upper  surface  of  the  brain, 
leaving  the  convolutions  intact.  The  con- 
volutions were  somewhat  wasted,  and  the 
arteries  at  the  base  were  slightly  athero- 
matous. On  section,  the  grey  matter  was 
pale  and  ill-detined,  especially  over  the 
whole  of  the  frontal  region,  and  the  left 
lateral  venti-icle  was  dilated.  The  condi- 
tion of  the  spinal  cord  was  interesting — 
the  dura  mater  being  distended  by  Huid  in 
its  lower  parts,  whilst  along  the  cervical 
and  dorsal  regions  there  were  numerous  ha^- 
morrhagic  patches  on  its  outer  surface,  con- 
sisting principally  of  clotted  blood  lying  in 
the  meshes  of  thin  gelatinous  material. 

In  the  lower  cervical  region  the  anterior 
surface  of  the  dura  mater  was  adherent  to 
the  posterior  surface  of  the  bodies  of  three 
cervical  vertebras  by  old  firm  adhesions. 
No  compression  of  the  cord  or  caries  of 
bone  could  be  detected,  and  the  spinal  cord 
itself  was  firm  and  healthy,  and  did  not 
show  any  signs  of  degeneration.  Koster 
has  described  a  hyperasmic  condition  of 
the  brain,  and  the  occurrence  of  several 
small  ecchymoses  under  the  peri-  and  sub- 
cardium  of  the  left  ventricle  in  a  case  of 
death  from  sunstroke ;  but  he  has  also 
described  similar  results  found  in  the  case 
of  a  syphilitic  woman  where  excessive  in- 
crease of  temperature  could  not  have  been 
the  cause  of  death ;  and  he  fui'ther  calls 
attention  to  the  possible  occurrence  of 
disturbances  of  the  vaso-motor  and  respi- 
rntory  nerve-centres,  which  must  take 
place  in  a  pronounced  form  in  patients 
suffering  from  sunstroke.  In  the  only 
other  case  which  we  have  to  report  the 
dura  mater  was  found  normal,  but  the 
veins  of  the  pia  mater  were  deeply  con- 
gested and  full  of  dark-coloured  blood. 
The  inner  membranes  peeled  readily,  and 
left  the  convolutions  intact.  There  was 
slight  excess  of  sub-arachnoid  fiuid,  and 
the  white  substance  of  the  brain  was 
oedematous;  otherwise,  beyond  consider- 
able injection  of  the  choroid  plexus,  the 
brain  appeared  to  be  fairly  healthy.  Both 
lungs  were  deeply  congested. 

TiiEO.  B.  HvsLOi'. 

SURDI-MUTZSIVI.  Ueaf-mutism  {q.v.). 

SURBZTAS  VERBAIiZS  {mrditcis, 
deafness  ;  rerbalts,  jiertaining  to  words). 
A  synonym  of  Word-deafness. 


STrRSOMUTlTiis  (surdus,  deaf;  mu- 
tilan,  dumbness).  A  synonym  of  Deaf- 
mutism. 

SXTRGERY,     BRAIN-.      (Sec  TkkPIIIN- 

SURIVXEN-Aci:  (i^'r.).  The  bodily  or 
mental  condition  ])roduced  by  over-exer- 
tion or  overpressure. 

susPETiTDEi}    ANiiviATioiir.     (6'ee 

TuANCi;,) 

SAVITZERIiAND,  Provision  for  the 
Insane  in. — The  care  of  the  iusane  in 
Switzerland  is,  like  most  other  branches 
of  public  administration,  jjlaced  under  the 
supervision  of  the  government  of  each 
canton,  which  is  charged  with  this  duty, 
which  forms  part  of  its  public  health  pro- 
vision. As  the  resources  and  needs  of 
different  cantons  vary  greatly,  their  ac- 
tivity in  respect  to  the  relief  afforded  and 
to  public  and  private  beneficence  varies 
proportionally,  and  this  will  explain  how 
it  is  that  several  cantons  appear  more 
advanced  and  better  equipped  than  others. 

The  history  of  the  provision  for  the  in- 
sane in  the  several  cantons  has  not  been 
dissimilar  to  that  of  other  countries  during 
past  centuries.  Very  little  concern  was 
apparently  felt  regarding  those  who  were 
not  dangerous  to  society.  If  dangerous, 
they  were  located  iu  the  various  houses  for 
lepers,  which  had  been  established  near 
the  large  and  small  towns  and  boroughs  in 
different  parts  of  the  country  from  the 
days  of  the  Crusades,  houses  that  were 
called  maladiei-es  or  maladaires,  or  "  Sie- 
chenhauser"  in  the  German  districts. 
In  these  houses,  situated  generally  on 
the  confines  of  those  centres  in  which  the 
necessities  of  isolation  were  apparent, 
there  were  often  to  be  found  congregated 
all  those  sufi'ering  fi-om  disagreeable  or 
dangerous  diseases,  such  as  the  violent 
and  paralytic  insane,  &c.  At  a  later  date 
the  insane  sometimes  found  refuge  in 
hospitals,  where  a  few  rooms  or  cells  were 
set  apart  for  them,  either  as  a  safeguard 
for  the  public  weal  or  to  afford  them,  if 
not  special  care,  at  least  shelter.  The 
earliest  trustworthy  date  of  the  construc- 
tion of  a  special  building  for  the  insane 
was  in  1 749,  when  a  building  was  erected 
near  Berne  as  an  annexe  to  the  exterior 
hospital,  formerly  used  as  a  house  for 
lepers.  This  asylum,  to  which  later  two 
wings  were  added,  still  exists,  and  was 
the  only  public  establishment  in  the 
canton  of  Berne  for  the  special  treatment 
of  the  insane  under  the  care  of  a  i^hysi- 
cian  till  1850. 

The  Bernese  Government  also  had  in  the 
ancient  convent  of  Kcunigsfelden  (at  that 
time  part  of  the  territory  of  Berne)  in 
Aargau  some  specially  constructed  rooms 


Switzerland,  Insane  in      [    1238    ]      Switzerland,  Insane  in 


for  the  reception  of  lunatics,  in  connection 
with  the  hospital  for  physical  ailments. 
Ziirich  and  Basle  in  the  same  manner  set 
apart  accommodation  in  buildings  adjoin- 
ing the  hospitals  to  receive  the  more  dan- 
gerous of  the  insane  of  those  towns. 

In  iSio  the  first  asylum  at  Lausanne 
for  the  Canton  Vaud  was  constructed 
for  seventy  patients  and  joined  to  the  can- 
tonal hospital.  In  1838  the  Asylum  des 
Verults  for  sixty-six  patients  was  erected 
n  ear  G  eneva,  constructed  after  ^Dlan  s  revised 
by  S.  Tuke  of  York.  From  the  same  year 
date  also  the  laws  for  the  reception  and 
supervision  of  the  insane,  the  provisional 
administration  of  their  property,  and  for 
the  supervision  by  the  State  of  private 
asylums. 

It  was  from  1830  to  1840,  in  consequence 
of  the  development  of  liberal  political  and 
administrative  ideas  in  the  different  can- 
tons of  Switzerland,  that  the  lot  of  the 
unhappy  insane  became  everywhere  ame- 
liorated. 

To  this  end  measures  were  taken  at 
Zurich,  Basle,  St.Gall,  Aargau,  Vaud,  and, 
as  we  have  seen,  at  Geneva  and  Neufchatel, 
to  improve  the  organisation  of  the  existing 
asylums  or  refuges,  and  with  the  special 
object  of  affording  adequate  medical  treat- 
ment, and  several  cantons  made  prepara- 
tory studies  of  plans  for  the  construction 
of  such  asylums  for  the  insane. 

In  consequence  of  a  decision  of  the 
Grand  Council  of  the  canton  of  St.  Gall, 
the  new  hospital  and  asylum  of  St.  Pir- 
minsberg  (St.  Gall),  erstwhile  a  convent, 
but  rebuilt  and  re-arranged  for  its  new 
destination,  was  opened  in  1847,  capable 
of  accommodating  one  hundred  patients. 
It  was  situated  at  an  elevation  of  826 
metres  above  the  level  of  the  sea,  300 
metres  higher  than  the  valley  of  the  Rhine, 
and  near  the  baths  of  Ragatz.  Although 
from  a  hygienic  point  of  view  it  offered 
many  advantages,  the  close  proximity  of 
rocky  elevations  rendered  the  future  en- 
largement of  the  asylum  difficult,  but 
even  these  difficulties  were  overcome  when 
reconstruction  became  necessary  to  meet 
the  growing  wants  of  the  community,  and 
at  the  present  day  the  asylum  is  capable 
of  receiving  three  hundred  patients  of 
both  sexes.  Large  sums  were  needed  for 
this  purpose,  and  over  a  million  francs 
have  been  expended  on  its  reconstruction 
and  renovation.  At  some  distance  from 
the  hospital  a  farm,  St.  Margarethenberg, 
has  been  established  for  the  employment 
during  summer  months  of  a  certain  num- 
ber of  patients  in  agricultural  labour,  es- 
pecially haymaking. 

The  State  Council  of  Neufchatel,  the 
insane    of    which    had    previous)}^    been 


drafted  to  the  asylums  of  St.  Stephans- 
feld  (Alsace)  and  Dole  (France),  framed  a 
regulation  in  1843  as  to  the  reception  of 
its  insane  in  proper  asylums.  This  regu- 
lation enacted  that,  without  express  licence 
from  the  State  Council  no  insane  person 
should  be  confined  for  more  than  three 
months  in  any  public  or  private  asylum. 
Every  house  is  deemed  to  be  a  lunatic 
asylum  if  several  lunatics,  or  even  a  single 
insane  person,  is  placed  there  and  super- 
vised by  strangers.  For  each  admission 
a  certificate  given  by  a  licensed  physician 
is  needed,  the  date  of  which  is  not  to  be 
earlier  than  a  fortnight  before  the  actual 
admission  of  the  patient.  In  cases  where 
the  relatives  do  not  apply  for  admission 
of  an  insane  person  who  is  dangerous  to 
the  public  safety,  the  State  Council  inter- 
feres on  the  demand  of  the  local  authori- 
ties. 

A  few  years  later,  in  1849  (January  i), 
the  building  of  a  new  lunatic  asylum 
(Prefargier)  was  commenced  through  the 
generosity  of  M.  de  Meuron,  who  had  it 
constructed  and  fitted  up  entirely  at  his 
own  expense,  and  entrusted  its  working 
to  a  committee  chosen  by  the  founder  and 
the  State  Council  of  the  canton.  The 
asylum  of  Prefargier,  which  is  built  from 
plans  prepared  by  the  French  architect 
Philippon  and  executed  by  M.  Chatelain, 
is  arranged  to  accommodate  from  one 
hundred  and  twenty  to  one  hundred  and 
thirty  j^atients  (male  and  female)  under 
the  managment  of  a  directing  physician. 

For  the  reception  of  private  patients  a 
villa  has  been  built  accommodating  six 
patients  and  an  assistant  physician.  The 
house  is  under  the  control  of  the  State 
Council. 

The  town  of  Basle  had  erected  a  hospital 
for  its  insane  in  1834  adjoining  the  general 
hospital,  capable  of  accommodating  thirty- 
two  patients,  while  there  was  additional 
room  for  thirty-five  to  forty  incurables. 
Here  it  was  that,  between  18  50  and  i860,  the 
director.  Dr.  Brenner,  instituted,  for  the 
first  time  in  Switzerland,  clinical  lectures 
for  the  students  of  the  University  of  Basle. 

As  this  hospital  in  time  became  inade- 
quate for  the  needs  of  a  rapidly  increas- 
ing population,  the  canton  of  Basle 
passed  a  legal  enactment  for  the  erection 
of  a  new  building  for  two  hundred  and 
forty  patients.  This  hospital,  built  on  the 
pavilion  system,  was  inaugurated  in  the 
autumn  of  1886;  each  block  is  destined 
for  a  special  class  of  jjatients.  The  cen- 
tral building  contains  the  administrative 
offices  and  the  apartments  for  a  surgical 
clinic.  Two  blocks  are  reserved  for  quiet 
patients  of  both  sexes,  two  for  epileptics 
and  the  paralytic  insane,  two  for  excited 


Switzerland,  Insane  in      [     1239    ]      Switzerland,  Insane  in 


patients,  and  two  for  private  patients  of  a 
superior  class.  The  kitchens  and  wash- 
houses  are  in  a  S2:)ecial  buildiuir  in  an 
extension  of  the  central  block.  This  new 
establishment  meets  all  the  requirements 
of  such  special  institutions,  though  it 
leaves  a  good  deal  to  be  desired,  as  do  all 
isolated  buildings,  in  regard  to  the  facility 
for  adequate  supervision.  All  these  build- 
ings are  lighted  by  gas  and  heated  by 
steam. 

In  1839,  the  canton  of  Thurgau  inaugu- 
rated its  asylum  for  the  insane  in  a  section 
of  the  cantonal  hospital  of  Miinsterlingen, 
formerly  a  convent.  As  this  building  did 
not  meet  the  needs  of  the  canton,  the 
former  convent  of  Katharinenthal  on  the 
Khine  was  fixed  upon  in  1871  to  receive 
the  incurable  cases.  Miinsterlingen,  on 
the  borders  of  the  Lake  of  Constance, 
can  accommodate  one  hundred  and  fifty, 
Katharinenthal  two  hundred  to  two  hun- 
dred and  fifty  patients  of  both  sexes. 

In  1S46  the  Grand  Council  of  the  can- 
ton of  Berne  decided  on  the  erection  of  a 
new  hosjiital  and  asylum  for  230  patients 
of  both  sexes.  This  house,  called  the 
Waldau,  which  was  built  on  the  rect- 
angular system,  with  vertical  separation 
of  the  special  divisions,  was  opened  in 
November  1855.  -^^  it  had  to  meet  the 
needs  of  a  population  of  more  than  450,000 
it  was  soon  entirely  filled,  and  arrange- 
ments had  to  be  made  with  other  hospi- 
tals to  place  in  them  those  of  its  poor 
{assistes)  insane,  who  could  no  longer  be 
accommodated  in  the  Waldau,  while  the 
authorities  have  set  about  the  building 
of  a  new  hospital  and  asylum  at  Miinsin- 
gen,  where  a  large  estate  has  been  bought 
for  this  purpose.  An  adjoining  estate 
has  afforded  the  asylum  of  Waldau  the 
opportunity  of  usefully  and  profitably 
emj^loying  its  patients. 

Clinical  lectures  have  been  given  here 
to  the  students  at  the  University  of  Berne 
since  1861. 

Waldau,  constructed  to  hold  230  pa- 
tients, has  since  been  enlarged  by  several 
annexes  to  accommodate  the  numerous 
patients  belonging  to  the  canton,  so  that 
on  an  average  350  to  360  insane  have 
during  the  last  tew  years  been  in  resi- 
dence there. 

In  i860  the  canton  of  Soleui-e  opened 
a  new  hospital  and  asylum  (the  Rosegg) 
for  1 50  to  200  patients  of  both  sexes, 
excellently  situated,  at  li  kilometres 
from  the  town.  The  funds  for  this  build- 
ing have  been  for  several  years  obtained 
through  annual  collections  made  in  the 
churches. 

The  canton  of  Ziirich,  having  in  18 14 
to  1816,  built  their  first  lunatic  asylum 


near  the  old  hospital,  used  it  to  the  best 
advantage,  while  recognising  it  as  but  a 
tempoi'ary  and  inefficient  means  of  relief. 
But  about  the  year  i860  the  suppression 
of  the  convent  of  Rheitiau  afforded  the 
canton  an  excellent  opportunity  to  ar- 
range this  vast  building,  whicli  was  in 
excellent  condition,  for  the  reception  of 
the  incurable  insane. 

Situated  as  it  was  on  an  island  of  the 
Rhine,  surrounded  by  a  large,  well-culti- 
vated estate  of  100  hectares  of  land,  it  was 
enlarged  yet  more  to  receive  about  600 
patients  of  both  sexes. 

After  having  thus  amply  provided  for 
the  most  pressing  needs,  the  canton  de- 
cided on  the  construction  of  a  new  estab- 
lishment for  the  reception  of  curable  cases. 
The  estate  of  BurghiJlzli,  admirably  situ- 
ated at  a  distance  of  two  miles  from 
the  town  of  Ziirich,  was  chosen  for  the 
site  of  the  new  building.  It  was  opened 
in  1870  for  260  patients  of  both  sexes,  and 
the  superintendence  was  entrusted  to  Prof. 
Gudden,  who  shared  the  calamitous  fate 
of  King  Louis  II.  of  Bavaria,  in  1886. 

In  1872  the  canton  of  Aargau  inaugu- 
rated the  new  hospital  and  asylum  of 
Koenigsfelden  for  300  patients,  by  the  side 
of  and  on  the  territory  of  the  ancient  con- 
vent of  that  name.  It  was  built  and  ar- 
ranged chiefly  after  the  plans  and  direc- 
tions of  its  first,  and  till  1891  only  director, 
M.  Schaufelbiihl.  It  is  admirably  situ- 
ated at  a  few  minutes'  distance  from  the 
station  of  Brugg,  on  the  Aar,  between 
Aarau  and  Ziirich.  The  buildings  of  the 
old  cantonal  hospital  having  been  aban- 
doned for  several  years,  are  still  available 
for  the  reception  of  a  number  of  incur- 
ables. 

In  1873  Bois  de  Cery  was  opened  near 
Lausanne  for  the  requirements  of  the 
canton  of  Vaud  for  360  patients  of  both 
sexes.  This  building  is  beautifully  situ- 
ated on  an  eminence  affording  a  view  of 
Lake  Leman,  and  the  greater  part  of  the 
canton  of  Vaud  to  the  Jura  mountains. 
Up  to  the  present  it  still  suffices  for  the 
needs  of  the  canton,  and  as  it  is  sur- 
rounded by  a  large  tract  of  land,  it  affords 
considerable  scope  for  the  manual  em- 
ployment of  its  patients. 

In  the  same  year  were  established  the 
hospital  and  asylum  of  St  Urbain,  near 
Langenthal-Olten,  in  the  canton  of 
Lucerne.  This  vast  building,  formerly  a 
convent,  which  was  suppressed  in  1848, 
was  bought  by  the  Lucerne  Government 
in  1870  with  the  object  of  creating  an 
asylum.  The  immense  buildings  were 
found  to  be  admirably  adapted  for  this 
purpose,  while  the  construction  could  be 
accomplished  at  very  little  cost.     It  was 


Switzerland,  Insane  in      [     1240    ]       Switzerland,  Insane  in 


opened  lu  jN'ovember  1873  *^i'  200  patients, 
but  within  thi'ee  years  this  number  was 
exceeded,  so  that  an  addition  to  the  num- 
ber of  beds  became  necessary.  An  exten- 
sive farm  of  1 20  hectares  belonging  to  the 
hospital  serves  to  employ  with  labour  the 
numerous  patients  drawn  from  an  agri- 
cultural district.  In  furtherance  of  this 
object,  which  gave  excellent  results  in 
1 88 1,  an  agricultural  colony  has  been 
organised  in  one  of  the  two  farms,  con- 
taining about  40  hectares. 

The  pecuniary  affairs  of  this  colony 
have  improved  notably,  and  as  it  is  the 
first  that  has  been  organised  in  Switzer- 
land, it  is  worthy  of  record,  as  the  earliest 
attempt  to  diminish  the  cost  of  main- 
tenance to  the  State  and  charitable  com- 
munities. 

Thanks  to  this  diminution  of  expenses, 
and  to  other  favourable  circumstances  of 
an  economic  nature,  the  hospital  of  St. 
Urbain  has  been  able  to  lay  aside  during 
the  last  ten  years  of  administration  more 
than  200,000  francs,  while  at  the  same 
time  the  terms  for  the  very  poor  have 
been  considerably  reduced.  The  number 
of  patients  has  in  the  last  ten  years  risen 
to  400. 

As  the  hospital  of  St.  Urbain  by  reason 
of  its  extensive  accommodation  is  more 
than  suiEcient  for  the  needs  of  the  canton, 
the  Lucerne  Government  has  entered  into 
an  agreement  with  six  neighbouring 
cantons  —  namely,  Berne,  Uri,  the  two 
Unterwalden,  Zug,  and  Schaffhausen — 
for  the  reception  of  their  poor  insane  at  a 
low  rate. 

The  last  of  the  hospitals  and  asylums 
to  be  enumerated  is  that  of  Marsens,  near 
Bulle,  in  the  canton  of  Fribourg.  It  was 
opened  by  the  authorities  of  this  canton 
in  1875,  and  can  accommodate  100  patients 
of  both  sexes,  and  is  built  in  separate 
blocks.  Unfortunately,  the  cost  of  con- 
struction has  been  so  great  that,  instead 
of  eight,  four  only  of  the  planned  blocks 
have  been  built. 

Besides  these  fourteen  hospitals  and 
aBylums  established  in  Switzerland  since 
1838,  there  are  two  in  process  of  erection 
for  the  cantons  of  Schaffhausen  and 
Grisons,  for  about  120  beds.  The  first  is 
under  the  direction  of  Dr.  Aug.  Miiller, 
near  Schaffhausen,  and  the  other  is  situ- 
ated near  Coire. 

Some  cantons,  such  as  St.  Urbain,  re- 
ceive patients  under  agreements  made 
with  an  existing  hospital,  while  others 
again  subsidise  their  pauper  insane  by 
providing  for  their  admission  into  the 
hospitals  of  other  cantons,  as,  for  example, 
Glaris,  Zug,  and  Appenzell. 

Besides  the  State  provision  for  the  in- 


sane, there  are  large  numbers  of  private 
asylums  or  maisons  de  santo,  viz. : — 

Miinchenbuchsee,  at  seven  miles'  dis- 
tance from  Berne,  the  most  important,  on 
account  of  the  number  of  patients,  100 
beds,  under  the  direction  of  Dr.  Glaser. 

La  Metairie,  near  Nyon  (Vaud),  at 
twenty -two  kilometres  distance  from 
Geneva,  thirty  to  thirty-five  beds,  admis- 
sion to  which  is  placed  under  the  control 
of  the  government  of  Vaud,  especially  of  a 
council  of  administration.  It  is  under 
the  direction  of  Dr.  Fetscherin,  formerly 
director  of  St.  Urbain,  for  persons  in  easy 
circumstances ;  also 

Bellevue,  at  Kreuzlingen,  near  Con- 
stance, for  forty  to  sixty  patients,  the 
property  of  Dr.  Binswanger. 

Bellevue,  near  Landeron  (ISTeufchatcl), 
for  ten  or  twelve  patients.  Proprietress, 
Madame  Scherrer. 

Stammheim,  near  Winterthur,  for 
twelve  patients.     Proprietor,  Dr.  Orelli. 

Spiez  (Mariahalden),  on  the  lake  of 
Thun,  for  twelve  patients.  Proprietor, 
Dr.  Mutzenberg. 

Two  special  asylums  for  epileptics 
have  been  established  for  some  years 
near  Ziirich  on  the  Riitli,  with  from  forty 
to  fifty  beds  for  children  of  both  sexes, 
and  in  a  new  building  forty  to  fifty  beds 
for  young  girls.  The  other  is  at  Tschougg, 
near  Cerlier  (on  the  lake  of  Bienne),  canton 
Berne,  for  twenty  epilej^tics  of  both  sexes. 

In  the  cantons  of  Ziirich  (at  Hottingen), 
of  Berne  (near  Berne),  of  Basle  and 
Vaud  (Etoy,  near  Aubonne),  there  exist 
small  philanthropic  private  asylums  for 
idiots  (children).  A  large  number  are 
placed  in  other  asylums  for  the  poor,  or  in 
general  hospitals  or  in  the  poor-houses  of 
the  difterent  cantons. 

The  cantons  of  Geneva  and  Xeufchatel 
are  the  only  ones  that  have  established 
laws  for  the  provision  of  the  insane,  while 
those  cantons  possessing  hospitals  have 
been  content  with  regulations  as  to  the 
reception  and  maintenance  of  the  patients 
in  the  hospitals  and  asylums. 

The  fourteen  hospitals  and  asylums  that 
now  exist,  with  the  excei)tion  only  of  those 
of  Geneva  and  Katharinenthal,  are  placed 
under  the  superintendence  of  a  directing 
physician,  who  resides  in  the  house  and  is 
responsible  for  the  attendance  on  and 
entire  management  of  the  patients,  as 
well  as  for  the  internal  economj^  of  the 
hospital.  He  is  generally  assisted  by  a 
second  physician  and  sometimes  one  or 
several  house  pupils.  The  household 
management  {V econoiiiie)  is  entrusted  to 
a  house-steward,  aided  in  some  establish- 
ments by  a  farm-stewai'd. 

The  work  of   these  fourteen  hospitals 


Switzerland,  Insane  in 


1241     ]      Switzerland,  Insane  in 


has  become  more  and  more  considerable. 
During  the  decade  cndinf^  1886  these  hos- 
pitals, constrncted  to  receive  about  3300 
patients,  have  admitted  15,927  patients, 
while  51,105  have  uudersrone  treatment  in 
them  during  this  period.  The  discharges 
for  the  same  time  reached  1 1,982,01'  whom 
3025  (5.91  percent,  of  the  number  treated) 
died.  Of  the  admissions,  11.7  per  cent, 
were  due  to  alcoholic  influence. 

In  accordance  with  the  observations  of 
other  countries,  the  number  of  admissions 
on  the  register  and  of  the  annual  dis- 
charges shows  a  more  or  less  regular  in- 
crease from  year  to  year,  the  increase  in 
discharges,  however,  being  proportionately 
less  than  that  of  the  admissions,  a  fact 
which  accounts  for  the  overci'owding  that 
is  taking  place  almost  everywhere  in 
asylums.  Regular  statistics  giving  the 
total  amount  of  the  work  of  Swiss  asylums 
for  ten  years  (1877  to  1886)  show  an 
annual  increase  of  2.317  per  cent,  in  the 
number  of  resident  patients,  in  that  of 
admissions  an  increase  of  1.23  per  cent. 
]ier  annum,  and  an  increase  of  0.943  per 
annum  in  the  discharges,  irrespective  of 
deaths. 

The  number  of  insane  treated  in  asy- 
lums proportionately  to  the  number  of 
inhabitants  has  also  risen  from  i.i  133  per 
thousand  of  the  population  in  the  decade 
ending  1S80  to  1.3378  per  thousand  in 
1886. 

A  general  census  of  insane  persons  in 
the  entire  territory  of  the  Confederation 
has  only  been  taken  once — in  1870 — at  the 
time  of  the  general  census.  This  census 
placed  the  number  of  insane  at  7764, 
which  is  probably  much  below  the  mark, 
and  which  in  proportion  to  the  population 
of  2,669,147  inhabitants  in  1870  would  in- 
dicate I  insane  in  343.78,  or  2.908  per 
thousand  of  the  inhabitants. 

Besides  this  general  census  several  can- 
tons have  at  various  times  organised 
others  within  their  boundaries.  But  these 
censuses  have  not  sufficiently  fulfilled 
their  purpose,  seeing  that,  by  the  faul- 
tiness  of  organisation  and  laxity  as  to 
proper  interrogation,  the  end  projiosed  was 
not  sufficiently  kept  in  view. 

No  census  of  the  insane  can  fulfil  its 
object  which  does  not  from  the  outset  dis- 
tinguish between  and  include  the  two  large 
classes  of  insane,  the  idiots  or  cretins, 
that  is  to  say,  those  who  have  suffered 
from  congenital  mental  derangement,  or 
derangement  originating  during  the  first 
years  of  life,  and  those  who  acquire  men- 
tal aflfections  during  adult  life  {<\g.,  the 
simple  mental  maladies,  curable  and  in- 
curable, paralytics,  ei>ileptics,  &c.). 

The  only  cantonal  census  that  has  thus 


distinguished  between  these  forms  of 
mental  affection  previous  to  1880,  was 
that  of  the  canton  of  Berne,  organised  in 
1 87 1,  and  based  on  the  results  of  tlio 
federal  census  of  1870. 

The  results  of  this  measure  were  to 
chronicle  the  existence  of  2804  insane, 
idiots  and  cretins,  or  5.53  per  thousand, 
or  I  insane  for  every  180  of  the  popula- 
tion ;  in  1870  the  census  taken  in  the 
same  canton  without  distinguishing  be- 
tween these  two  categories,  gave  only  202 1 
insane,  or  4.02  per  thousand.  The  most 
complete  census  of  the  insane  that  has 
been  made  in  Switzerland  was  that  of  the 
canton  of  Ziirich,  taken  in  December 
1888.  While  the  latest  and  most  reliable 
it  furnishes  us  with  certain  very  startling 
results,  for  it  indicates  i  insane  person  to 
every  103  of  the  population,  or  3261  in- 
sane (properly  speaking,  idiots,  cretins, 
and  insane)  for  339,014  inhabitants,  or 
9.610  per  thousand. 

Of  the  3261  insane  persons  (1542  men, 
1 719  women)  in  the  canton  of  Ziirich, 
there  are  79.3  per  cent,  unmarried,  10.5 
per  cent,  married,  6.4  per  cent,  widowed, 
3.8  -per  cent,  divorced;  31.1  per  cent,  are 
treated  in  the  public  hospitals  and  asy- 
lums, 1 1.4  per  cent,  in  private  asylums, 
and  41.4  per  cent,  in  their  own  homes. 

Besides  these  two  censuses  of  real 
value,  others  have  been  promoted  for  fur- 
nishing the  cantonal  authorities  with  ne- 
cessary and  important  data  for  the  pro- 
vision for  their  insane  during  the  years 
1830  to  1885:  in  St.  Gall  (1836),  Soleure 
(1846),  Lucerne  (185 1  and  1868),  Neuf- 
chatel  (1854),  Aargau  (1857),  Grisous 
(1874),  and  Schaffhausen  (1885). 

Side  by  side  with  the  census  of  the  in- 
sane, statistical  researches  have  been  in- 
stituted since  1836  in  several  of  the  can- 
tons with  respect  to  cretins.  Dr.  Guggen- 
biihl  undertook  the  establishment  of  an 
asylum  for  the  purpose  of  curing  them,  or 
at  least  ameliorating  their  condition.  He 
founded  this  asylum  on  the  Abendbei'g, 
near  Interlaken,  where  it  existed  for  ten 
or  twelve  years,  without,  however,  bring- 
ing about  any  remarkable  results,  as  was 
to  be  expected  with  a  malady  that  be- 
comes incurable  as  soon  as  it  has  reached 
a  certain  develop! mental  stage.  But  the 
question,  having  once  been  raised,  did  not 
remain  without  fruitful  result.  Public 
societies  took  it  up,  and  there  resulted 
from  their  investigations  a  statistical 
table  of  the  cretins  and  idiots  in  Switzer- 
land. From  this  it  has  been  deduced  that 
there  are  certain  districts  which  appear 
more  favourable  to  the  development  of 
cretinism  than  others,  and  from  later  cen- 
suses, taken  especially  in  the  canton  of 


Switzerland,  Insane  in       [    1242    ]        Sympathetic  Insanity 


Berne,  it  has  been  found  that  there  at 
least  the  number  of  true  cretins  has  of 
late  sensibly  diminished.* 

In  order  to  furnish  a  few  more  notes  on 
the  number  of  assisted  persons  in  the 
hospitals  and  asylums,  we  mention  the 
following  figures : — 

In  the  public  asylums  of  Switzerland 
there  were,  under  treatment  on  January  i , 
1S89,  4- '4  patients  (1986  male,  and  2228 
female),  on  December  31,  18S9,  4343»  oi"  a 
proportion  of  1.48  insane  persons  treated 
in  the  hospitals  for  every  thousand  of  the 
entire  Swiss  population,  or  if  we  include 
the  150  patients  treated  in  the  different 
private  asylums,  we  shall  obtain  4500  in- 
sane residents,  or  1.53  per  thousand  of  the 
entire  population. 

In  1885-89,  the  annual  cost  of  mainten- 
ance of  these  fourteen  hospitals  and  asy- 
lums, representing  a  population  of  i ,  5  6 1 ,686 
inhabitants,  was  1,782,357  francs,  or  1.14 
francs  for  each  inhabitant.  The  different 
cantons  have  expended  in  the  construction 
and  fitting  up  of  their  hospitals  and  asy- 
lums a  round  sum  of  from  14  to  15  million 
francs. 

As  the  official  assistance  of  the  State 
and  the  committees  cannot  fully  provide 
for  all  the  requirements  for  the  ameliora- 
tion of  the  lot  of  the  insane,  societies  of 
patronage  have  been  formed  in  Switzer- 
land, as  in  Germany,  with  the  object  of — 

(i)  Combating  the  jirejudices  existing 
in  regard  to  mental  maladies  ; 

(2)  Looking  after  the  social  interests  of 
persons  leaving  asylums,  and  thus  facili- 
tating their  return  to  society  ; 

(3)  Expediting  by  all  useful  means  or 
other  necessary  measures  the  admission 
into  asylums  of  all  recent  cases  ; 

(4)  Watching  over  the  moral  and  mate- 
rial interests  of  patients  while  in  asylums 
and  during  their  absence  from  their 
homes,  and  eventually  furnishing  them 
with  jjecuniary  assistance. 

These  societies  of  patronage  having 
originated  in  private  enterprise  and 
created  resources  for  themselves  by 
annual  assessments,  as  well  as  by  gifts 
and  legacies,  soon  became  of  great  im- 
portance in  the  domain  they  had  chosen 
for  their  field  of  action.  In  the  nine  can- 
tons— Zurich,  Berne,  Lucerne,  Basle 
(Ville),  Appenzell  (Rh.  ext.),  St.  Gall, 
Grisons,  Aargau,  Thurgau — which  reckon 

*  We  must  mention  lieru  ;i  remarkable  work  by 
Dr.  H.  Birc-her  (Aargau)  on  endemic  goitre,  auditi^ 
relation  to  deaf-mutism,  and  to  cretinism,  based  on 
numerous  observatiouii,  and  on  the  material  fur- 
nished by  the  examination  of  military  recruits. 
By  his  observations  he  is  led  even  to  admit  a  ]no- 
pagation  of  the  g(jitre  and  cretiuic  deoemration 
through  the  influence  of  water  in  certain  geological 
formations. 


such  societies  among  their  beneficent  in- 
stitutions, the  number  of  members  at  the 
end  of  1887  was  about  13,000,  and  they 
possessed  at  that  time  a  sum  of  363,259 
francs,  part  of  which  was  to  be  utilised 
for  the  construction  of  an  asylum  (Gri- 
sons and  Appenzell).  For  the  varied 
needs  of  one  year  32,023  francs  were 
spent  by  them.  It  remains  only  to  add 
that  the  activity  of  these  societies  of 
patronage  grows  in  importance  from  year 
to  3'ear,  and  fulfils  its  philanthropic  pur- 
pose with  much  success. 

F.  Fetscherin. 

SYDEN-HATC'S  CHOREA. — The  ordi- 
nary form  of  chorea,  so  called  to  distin- 
guish it  from  chorea  magna,  or  chorea 
Germanorum. 

SVI.I.ABX.E  STUMBI.IM-G. — A  para- 
lytic dysphasia,  in  which  there  is  difficulty 
in  speaking  a  word  as  a  whole,  although 
each  letter  and  syllable  can  be  distinctly 
sounded.     It  occurs  in  general  paralysis. 

SYMBOIiISISrC  INSANITY.  {See 
Insanity,  Symbolising  ;  and  Symbolism.) 

SYIVIBOItlSIVI. — In  some  forms  of  in- 
sanity, especially  delusional  and  halluci- 
national  insanity,  it  is  not  uncommon  for 
patients  to  interpret  almost  everything 
they  see  as  a  sign  or  symbol  of  their 
own  feelings  and  ideas  ;  for  instance,  that 
the  clock  in  the  room,  or  the  stars  in  the 
heavens,  bear  a  special  relation  to  them- 
selves. 

SYIVIPATHETIC  IM-SANITY. — The 
definition  of  sympathetic  insanity  lies  in 
the  word  itself.  It  is  a  disorder  of  the 
brain  connected  with  the  disease  of  a  more 
or  less  distant  organ  which  has  no  appa- 
rent biological  relation  with  the  cerebrum. 
We  shall  not  deal  here  with  the  doctrine 
of  sympathies  ;  it  will  suffice  to  keep  in 
mind  that  sympathy  is  either  physiolo- 
gical or  abnormal.  Sympathetic  insanity 
is  a  morbid  sympathy  which  has  its  seat, 
secondarily,  in  the  brain. 

This  mental  derangement  has  been 
known  from  the  most  ancient  times. 
Homer  mentions  it  in  his  "  Iliad,"  and 
Aristophanes  in  his  Comedies.  Hippo- 
crates investigated  the  relation  between 
mania  and  irritation  of  the  stomach,  and 
has  described  the  mental  disorder  con- 
nected with  menstruation  in  young  women. 
Aretius,  of  Cajipadocia,  places  the  seat  of 
mania  and  melancholia  in  the  intestines. 
Lastly,  Galen  enunciated  his  famous 
theory  of  humorism,  and  attributes  in- 
sanity to  the  injurious  action  of  the  bile. 

Galen's  views  have  reigned  supreme 
for  centuries,  and  the  fact  that  insanity 
originates  in  the  intestines  has  been  ad- 
mitted by  Aetius,  Soranus,  Celsus,  Ori- 
basius,    Alexander   of    Tralles,    Paul    of 


Sympathetic  Insanity        [     1243    ]        Sympathetic  Insanity 


^gina,  and  the  Arabian  physicians.  The 
schools  of  Alexandria,  Salerno,  Cordova, 
Salamanca,  ]\[ontpcllier  and  Paris  all 
professed  during  the  Middle  Ages  tlio 
doctrine  of  humoral  pathology,  which  still 
had  an  adherent  in  the  eighteenth  century 
in  the  person  of  the  famous  IJoerhaave. 

This  doctrine  was  rejected  by  Stahl, 
who  considered  insanity  as  the  result  of 
stasis  of  the  blood,  although  he  attributed 
to  the  liver  a  certain  role  in  its  production. 

The  doctrine  of  insanity  by  sympathy 
counted  in  the  sixteenth  and  seventeenth 
centuries  as  many  adversaries  as  adhe- 
rents. Lepois,  Willis,  and  Cullen  rejected 
it,  but  still  at  the  end  of  the  eighteenth 
century  it  was  defended  by  men  like  Lorry, 
Tissot,  Sauvages,  Sec. 

The  enumeration  of  the  different  views 
held  up  to  our  own  times  affords  little 
interest.  We  must,  however,  mention  the 
antagonism  in  Germany  between  the 
spiritualistic  and  somatic  schools  at  the 
commencement  of  the  nineteenth  century. 
Heinroth  and  Ideler,  on  the  one  hand, 
declare  the  preponderant  influence  of  the 
mind  and  deny  systematically  the  material 
origin  of  insanity,  while  this  view  is  re- 
jected by  Nasse,  Friedreich,  Amelung, 
and  by  Maximilian  Jacobi,  who  was  the 
most  vigorous  and  able  adherent  of  the 
somatic  doctrine,  and  in  fact  became  the 
actual  founder  of  the  school  of  sympa- 
thetic insanity  (B.  Ball). 

In  1856  and  1857  the  Medico-Psycholo- 
gical Society  of  France  held  several  meet- 
ings for  the  discussion  of  a  thesis  of  Dr. 
Loiseau  on  sympathetic  insanity.  His 
work  is  very  complete  and  carefully 
written,  and  is  the  most  important  which 
we  possess  on  this  subject.  This  mono- 
graph gave  the  learned  assembly  an 
opportunity  for  brilliant  speeches.  "  Is 
there  a  sympathetic  insanity  ?"  About  the 
middle  of  July  1857  the  discussion  was 
closed  without  any  result  being  arrived  at. 
The  adherents  of  this  new  morbid  state — 
Archambaut,  Belhomme,  and  Legrand  du 
SauUe — did  not  succeed  in  convincing 
their  medical  brethren  in  spite  of  their 
eloquence  and  abundant  arguments,  and 
the  question  was  adjourned  without  hav- 
ing been  solved,  and  in  truth  it  is  much 
more  difficult  than  it  might  seem  to  be  at 
first  sight. 

When  one  morbid  condition  appears  at 
the  same  time  as  another  which  affects  a 
more  or  less  distant  organ,  it  is  not 
necessary  to  see  herein  sympathy,  for  it 
may  be  merely  coincidence,  except  when 
their  course  and  constant  form  prove  their 
causal  connection.  We  repeat  that  this 
relation  to  each  other  does  not  always 
include  sympathy.     It  may  exist  between 


two  morbid  conditions  which  are  parts  of 
the  same  aggregate  of  symptoms,  and  this 
becomes  evident  when  the  clinical  study 
proves  clearly  a  bond  between  the  two 
])henomena.  In  other  words,  a  mental 
disorder  may  be  found  to  be  merely  symp- 
tomatic after  a  su])erticial  examination 
had  made  it  appear  to  be  psyclinse  ijar 
consensus.  This  is  the  case  with  mental 
disorders  observed  in  connection  with 
neui-oses,  with  organic  central  affections, 
with  intoxication,  and  with  a  morbid 
diathesis.  Also,  as  one  of  the  speakers  at 
the  debate  of  1856  pointed  out,  the  number 
of  sympathetic  mental  disorders  becomes 
i-ingularly  reduced  if  examined  more 
closely.  If  we  submit  them  to  a  severe 
analysis,  we  begin  altogether  to  doubt  the 
existence  of  these  disoi'ders  as  a  distinct 
nosological  species. 

To  give  some  examples  : — 

A  woman  becomes  insane  during  preg- 
nancy, but  recovers.  Ten  years  later  she 
has  a  fresh  attack  of  mental  derangement 
and  is  believed  to  be  again  pregnant ; 
however,  a  uterine  polypus  is  discovered. 
The  woman  undergoes  a  surgical  operation 
and  completely  recovers  her  mental  health 
(Ct.  de  Caulbry). 

A  man  has  had  two  attacks  of  frenzy 
with  an  interval  of  several  years ;  each 
of  these  attacks  is  cured  by  the  expulsion 
of  ascarides  (Vogel). 

A  melancholiac  has  an  hepatic  abscess, 
puncture  of  which  restores  physical  and 
mental  hetdth. 

A  girl  has  become  insane  in  conse- 
quence of  the  suppression  of  the  menses ; 
one  morning  on  getting  up  she  declares 
that  she  is  quite  well.  The  menses 
have  returned,  and  with  them  reason 
(Esquirol). 

A  man  suffers  from  cai'diac  disease; 
during  the  exacerbation  he  suffers  from 
delire  des  grandeurs  with  .hallucinations, 
while  lucidity  returns  in  the  intervals 
(Loiseau). 

A  phthisical  patient  notices  that  the 
symptoms  of  his  j)ulmonary  affection  im- 
prove, but  at  the  same  time  he  becomes 
agitated.  Then  his  sentiments  become 
altered ;  he  becomes  suspicious  and  un- 
sociable (Clouston). 

These  are  some  cases  from  the  number 
of  those  of  sympathetic  insanity  which 
are  least  disputed.  Uterine  affections, 
intestinal  worms,  hepatic  suppuration, 
catamenial  disorder,  heart  disease,  and 
tubercular  diathesis — such  wei'e  the  mor- 
bid conditions  which  determined  a  re- 
action of  the  cerebrum.  Tlie  question  is 
now,  of  what  nature  is  this  reaction.'^ 

When  our  ancestors  in  medicine  in- 
vented the  hypothesis  of  sympathy,  they 


Sympathetic  Insanity        [     1244    ]        Sympathetic  Insanity 


had  iu  view  two  phenomena,  phj-siological 
or  morbid,  united  by  a  mysterious  link, 
which  the  science  of  their  days  did  not 
allow  them  to  discover.  This  gap  between 
the  two  conditions  mentioned  was  filled 
up  by  ••  sympathy."  To-day  anatomical 
and  clinical  discoveries  have  cleared  up 
these  formerly  obscure  relations.  Chemical 
analysis  and  the  study  of  the  nervous 
system  account,  at  least  theoretically,  for 
the  connection  of  the  two  phenomena. 
Where  our  ancestors  discovered  "  sym- 
pathy," there  we  see  faulty  nutrition,  in- 
toxication, or  cerebral  reflex  action.  We 
even  might  say  that  the  term  "  sympathy  " 
is  no  longer  justified. 

Among  the  examjiles  quoted  above  there 
is  not  one  which  could  not  be  interpreted 
clinically.  Uterine  disorders  are  specially 
capable  of  determining  by  reflex  action 
profound  derangement  of  the  cerebral 
functions.  Nobody  doubts  that  altera- 
tions in  the  nutrition  of  the  brain  may  be 
caused  by  cardiac  and  hepatic  disease  and 
by  menstrual  disorders."  That  form  of 
sympathetic  insanity  which  has  been  the 
least  discussed,  and  which  is  connected 
with  helminthiasis,  is  it  sympathetic  in 
the  sense  understood  in  former  times  ? 
Is  there  no  connection  between  the  intes- 
tine and  the  brain  ?  The  knowledge  we 
possess  of  reflex  actions  compels  us  to  be 
very  reserved  on  this  point.  The  constant 
irritation  of  the  mucous  membrane  causes 
a  profound  derangement  of  the  splanch- 
nics,  which  in  its  turn  radiates  towards 
the  cortical  cells  :  such  is  the  theory  which 
is  partly  proved  by  facts,  since  the  epi- 
lejjsy  which  is  so  frequently  associated 
with  insanity  of  helminthiac  origin,  could 
not  be  explained  without  a  somatic  lesion 
of  the  central  nervous  system. 

Lastly,  diathesis  has  such  an  evidently 
liarmful  effect  on  the  nutrition  that  it  is 
almost  impossible  to  conceive  that  the 
brain  could  be  exempt  from  this  influence. 
To  mental  disorders  in  consequence  of 
diathesis  is  logically  due  the  epithet 
"  symptomatic,'"  which  a  number  of  medi- 
cal men  would  now  desire  to  apply  to  all 
forms  of  "•  sympathetic  "  alienation. 

We  have  thus  arrived  at  an  unexpected 
result:  there  is  no  sympathetic  insanity. 

However,  although  this  term  will  have 
to  be  completely  abandoned  some  day,  we 
must  nevertheless  recognise  the  fact  that 
there  are  certain  mental  disorders  whose 
course  is  parallel  to  that  of  certain  peri- 
I^heral  and  visceral  diseases,  or,  in  other 
words,  that  there  are  mental  derange- 
ments whose  form,  course,  and  frequent 
repetitions  show  complete  solidarity  with 
extra-cerebral  disorder  without  allowing 
us  to  consider  them  as  parts  of  the  same 


syndrome.  For  these  forms  of  disorder  we 
retain  in  this  article,  in  order  to  conform 
with  usage,  the  term  "  sympathetic  in- 
sanity."' 

Heredity  favours  the  formation  of  such 
disorders  as  it  does  all  forms  of  mental 
derangement,  but  it  need  not  be  neces- 
sarily present.  A  curious  observation 
which  medical  men  have  frequently  made 
is  precisely  this — the  absence  of  heredity 
in  most  cases  examined,  so  that  in  them 
the  origin  of  the  disorder  becomes  still 
more  evident. 

Do  these  psychoses  possess  a  constant, 
well-determined  form,  and  do  diseases  of 
one  region  or  of  one  organ  always  produce 
cerebral  reactions  with  a  character  so 
invariable  that  we  are  enabled  to  make 
our  diagnosis  from  them  alone?  Most 
observers  deny  this,  and  are  of  opinion  that 
a  peripheral  disease  produces  merely  a 
mental  disorder,  the  form  of  which  always 
varies.  We  ourselves  regard  this  opinion 
as  too  absolute.  This  is  certain,  that  if 
in  describing  an  attack  of  insanity  we 
confine  ourselves  to  stating  only  an  insane 
conception — e.g.,  ideas  of  persecution — we 
find  that  this  symptom  is  present  in  a 
great  number  of  cases  with  such  monotony 
that  we  certainly  could  not  make  use  of  it 
for  the  purpose  of  difi^erential  diagnosis ; 
but  a  mental  disorder  is  composed  of  com- 
plex elements,  which  we  must  take  into 
account,  and  the  ensemble  of  which  gives 
the  derangement  its  proper  character. 
The  form  of  the  disorder,  its  mode  of 
appearance,  its  course,  and  its  duration 
are  valuable  indications  for  its  character- 
isation ;  utilising  these,  we  might  perhaps 
arrive  at  better  conclusions  with  regard  to 
the  disorders  with  which  we  are  occupied 
here.  This  part  of  mental  science  is  as 
yet  little  advanced,  and  much  remains 
still  to  be  discovered,  but  we  must  not 
neglect  the  results  already  obtained.  In 
England  we  mention  the  work  of  Skae ; 
this  great  alienist  has  in  his  essay  on 
classification  sketched  with  great  aptitude 
most  species  of  mental  disorder  of  a  sym- 
pathetic nature.  We  also  mention  the 
noteworthy  books  of  Clouston,  Maudsley, 
&c.,  on  insanity  connected  with  phthisis, 
menstruation,  chorea,  and  neurotic  condi- 
tions. 

Sympathetic  insanity  may  be  naturally 
divided  into  two  categories  : 

(1)  Insanity  produced  by  functional 
disorder,  and 

(2)  Insanity  produced  by  morbid 
conditions. 

The  disorders  of  the  former  class  (dis- 
orders of  puberty,  puerperal,  menstrual, 
ovarian,  and  climacteric  insanity)  and  a  cer- 
tain number  of  disorders  of  the  latter  cate- 


Sympathetic  Insanity        [     1245    J        Sympathetic  Insanity 


gory  (insanity  from  diathesis,dei'angement 
connected  with  general  diseases  and  with 
neurotic  conditions)  will  be  found  in  special 
articles  in  this  Dictionary.  AVe  shall  there- 
fore limit  ourselves  to  describe  summarily 
some  forms  of  mental  alienation  which 
have  their  origin  in  visceral  and  organic 
affection  s. 

Mental  disorders  connected  with  de- 
rangements of  the  f/)V/('s/i're  urtjCDift  have 
at  all  times  attracted  the  attention  of  the 
medical  world.  Hut'eland  described  an 
abdominal  insanity.  It  is  quite  true  that 
derangement  of  almost  an}''  abdominal 
organ  ma}'  produce  mental  disorder 
(Friedreich).  It  is  well  known  that  normal 
digestion  already  iTiHuences  certain  indi- 
viduals intellectually  and  morally ;  why 
should  not  costiveness  or  a  functional  dis- 
order have  an  influence  on  the  brain  ? 
Guislain  relates  the  case  of  a  woman  who 
had  auditory  and  visual  hallucinations 
every  time  she  had  constipation. 

Lorry,  Esquirol,  Louyer-Villermay,  and 
Bayle  have  investigated  the  intellectual 
disorders  of  gastric  origin.  Esquirol  has 
described  after  Wichmann,  Hesselbach, 
and  Greding  disjjlacpment  of  tlie  transverse. 
colon  as  a  common  cause  of  alienation. 
As  a  matter  of  fact,  this  view  has  been 
contradicted  by  Sir  "William  Lawrence, 
and  its  value  is  doubtful. 

Hypochondriacal  depression,  ideas  of 
discouragement  with  a  tendency  to  sui- 
cide, and  refusal  to  take  food  are  the 
most  important  of  intestindl  psijchoses. 
Regis  has  justly  recommended  washing 
out  the  stomach  in  the  case  of  dyspeptic 
lunatics. 

Mental  symptoms  in  cases  of  duodendl 
catarrli  have  been  described  by  Holtorff. 
The  symptoms  are  those  of  simple  hypo- 
chondriasis, but  they  often  border  on 
actual  lypemauia  with  morbid  exaggera- 
tion of  the  conscience  and  extreme  irrita- 
bility. 

Moral  perversion  has  sometimes  been 
observed.  A  patient  has  been  known  to 
be  very  quarrelsome  and  vicious,  who  after 
an  evacuation  again  became  sociable. 

Although  in  former  times  the  influence 
of  the  liver  as  an  aetiological  element  has 
been  greatly  exaggerated,  it  is  neverthe- 
less real  and  frequent ;  organic  lesions  of 
the  liver  are,  however,  rare  in  the  insane 
(Loiseau).  It  is  diiferent,  however,  with 
inflammation  of  the  organ. 

Functioned  alterations  of  liver  and  hile- 
ducts  are  a  recognised  caiise  of  melancho- 
lia. Wiedmann  and  Greding  have  pointed 
out  the  frequency  of  numerous  calculi  in 
the  gall-bladder  of  lunatics.  The  sci- 
entific observations  on  the  splee^o  which 
we    possess,   and   on    the    pancreas,   are 


neither  numerous  nor  conclusive  enough 
to  allow  of  our  drawing  conclusions  with 
regard  to  mental  derangement  connected 
with  lesions  of  these  organs.  The  pcri- 
lonewin  however  seems  to  have  frequently 
been  the  cause  of  mental  disorders  of  a 
sympathetic  nature.  We  owe  the  proofs 
of  this  latter  fact  to  Bonet,  Greding,  and 
S.  Pinel.  Dr.  J.  A.  Campbell  has  pub- 
lished a  case  of  sitiophobia,  where  the 
post-mortem  examination  disclosed  chronic 
peritonitis. 

Ltental  disorder,  due  to  liehnintliiasis, 
is  of  common  occurrence  ;  Esquirol  found 
this  to  be  the  case  in  twenty-four  patients 
among  144,  at  the  Sulpetriere.  At  the 
commencement  of  this  century  Frost 
reported  numerous  cases  of  helminthiac 
insanity.  This  physician  even  maintains 
that  intestinal  worms  are  one  of  the  most 
frequent  causes  of  insanity.  Esquirol, 
Ferrus,  Frank,  and  Vogel,  have  published 
most  interesting  observations  on  cases  of 
this  kind.  An  extensive  monograph  on 
this  subject  has  been  written  by  a  German 
physician,  Dr.  Ernst  Vix,  This  author 
describes  a  special  symptomatology  in 
connection  with  helminthiasis — disorders 
of  sensibility  of  various  kinds,  perversion  of 
taste,  sexual  excitement,  and  a  propensity 
to  scatophagia ;  hemeralopia  has  been 
observed  in  some  cases.  Of  these  symp- 
toms, perversion  of  taste  is  the  most 
common ;  it  is  accompanied  by  maniacal 
excitement,  and  becomes  complicated  with 
the  refusal  of  food.  We  think  it  is  neces- 
sary to  add  various  disorders  of  the 
nervous  system.  We  have  thus  observed 
in  some  cases  pali:)itations  with  a  tendency 
to  lypothymia.  Dr.  Vix  thinks  that  hel- 
minthiac insanity  is  more  frequent  in  the 
female  sex  than  in  the  male. 

Legrand  du  SauUe  quotes  numerous 
examples  of  insanity  caused  by  irritation 
due  to  the  presence  of  hirrn}  in  i\i.e  frontal 
sinus.  The  form  observed  was  mania 
fi-equently  complicated  with  epilepsy. 

In  spite  of  Griesinger's  scepticism  with 
regard  to  psychoses  of  renal  origin,  the 
latter  has  been  observed  by  several  authors, 
among  whom  sve  mention  Savage,  Wilks, 
Scholtz,  Petrone,  Erlangen.  The  last- 
mentioned  regards  insanity  in  albuminuria 
as  the. first  consequence  or  stage  of  urajmic 
intoxication.  Without  deciding  whether 
this  opinion,  which  holds  this  form  of 
insanity  to  be  merely  symptomatic,  be 
right  or  wrong,  we  wish  to  mention  that 
the  principal  characteristic  of  this  disorder 
is  maniacal  excitement  with  painful  hallu- 
cinations, soon  followed  by  a  quiet 
dementia,  to  which  has  been  given  the 
name  of  "tranquil  stupor."  This  mental 
depression  must  be  distinguished  from  the 


Sympathetic  Insanity        [     1246    ]  Sympathetic  Nervous  System 


apoplectic  state.  The  lace  is  calm,  the 
pulse  normal.  The  patient  wakes  up  from 
his  stupor  when  he  is  called.  Later  on 
other  more  serious  symptoms  ajapear, 
which  hasten  the  termination. 

"We  know  little  as  yet  about  men- 
tal derangement  in  Addiso)i''s  disease. 
Griesinger  says  that  patients  affected 
with  it  are  profoundly  depressed.  The 
melancholic  form  with  conditions  of 
anxiety  and  emotion  has  been  observed 
by  Dr.  Rutherford  Macphail.  The  patient 
whose  case  is  described  had  attacks  of 
religious  exaltation  ;  he  refused  food,  and 
died  in  a  state  of  marasmus. 

Although  diabetes  is  not  actually  an 
affection  of  the  kidneys,  we  shall  say  a 
word  or  two  about  mental  disorders  in 
diabetic  patients.  Marchal  de  Calvi  was 
the  first  to  write  on  this  subject  in  1864. 
Later,  Legrand  du  SauUe  has  given  a 
most  characteristic  description  of  diabetes, 
of  the  mental  symptoms  of  which  he 
sj)eaks  in  the  following  terms:  "There  is 
at  first  an  invincible  apathy,  a  complete 
suspension  of  the  will,  or  there  may  be 
comparative  optimism.  The  patient  sees 
his  sexual  appetite  disappear,  and  with  re- 
signation passes  into  a  condition  of  impo- 
tence. He  becomes  sleepless  and  spends 
his  nights  in  soliloquies  without  insane 
concejitions  {sans  delire).  At  last  there 
appears  a  morbid  excitement,  terminating 
in  a  desire  to  sleep,  which  not  being  satis- 
fied, causes  attempts  at  suicide." 

Lallier  makes  the  interesting  remark 
that  thirst  and  polyuria  are  frequently 
absent  in  insane  patients  affected  with 
diabetes. 

Affections  of  the  bladder  (cystitis, 
retention  of  urine,  stone)  frequently 
influence  the  mental  functions,  but  the 
disorders  thus  produced  pertain  mostly  to 
the  moral  faculties.  In  some  patients  a 
tendency  to  suicide  is  observed. 

Psychoses  connected  with  cardiac  affec- 
tions frequently  present  the  forms  of 
mania  or  depression.  Mildner  asserts 
that  lesions  of  the  aorta  produce  mania, 
and  those  of  the  mitral  valve  melancholia. 
Our  opinion  is  that  it  is  necessary  to 
attach  more  importance  to  the  remittent 
course  of  the  mental  disorder  which  may 
improve  at  the  same  time  that  the  cardiac 
disease  becomes  modified  under  treatment. 
The  mania  is  generally  remarkably  acute 
and  accompanied  by  extremely  violent 
acts.  Ambitious  ideas  often  appear  and 
make  it  especially  difficult  to  treat  the 
patient.  A  patient  suffering  under  these 
circumstances  from  melancholia  is  anxious, 
he  has  painful  hallucinations  and  ideas  of 
persecution,  and  he  also  shows  a  tendency 
to  despair,  to    murder,    and    to    suicide. 


Some  patients  are  themselves  afraid  of 
becoming  insane.  In  all  varieties  of  in- 
sanity associated  with  heart  disease  thei'e 
is  an  irresistible  desire  to  be  in  motion. 

The  cutaneous  affections  observed  every 
day  in  patients  in  asylums  are  generally  a 
product  of  the  mental  disease  in  the 
course  of  which  they  appear.  They  must 
be  regarded  as  trophic  derangements.  In 
a  few  rare  cases,  however,  a  herpetic  dia- 
thesis is  complicated  secondarily  by  intel- 
lectual and  moral  disorders.  These  forms 
of  mental  derangement  are,  with  regard  to 
their  symptoms,  almost  uniform,  and 
follow  faithfully  the  phases  of  the  cuta- 
neous affection,  so  that  their  sympathetic 
nature  appears  evident.  An  insane  patient 
had  an  old  eczema  on  his  ears  and  the 
nape  of  the  neck,  with  exacerbations.  He 
attributed  this  eruption  to  the  sorcery  of 
a  priest  who  had  touched  his  ears  with  a 
breviary.  This  priest  continued  to  cause 
him  sufferings  by  piercing  and  burning 
him  at  the  points  which  were  the  seat  of 
the  itching.  The  excitement  increased  or 
decreased  according  to  the  course  of 
the  eczema.  Later  on  ambitious  ideas 
apjjeared,  the  patient  was  a  saint  and  then 
God  himself.  Suddenly  all  the  insane 
conceptions  disappeared  simultaneously 
with  the  appearance  of  a  serious  com- 
plication ;  an  ulcerous  enteritis  has  by 
metastasis  replaced  the  eruption.  Death 
occurred  in  consequence  of  repeated  intes- 
tmal  hasmorrhage.  This  example  seems 
to  us  conclusive.  We  have  ourselves 
observed  several  patients  with  mental 
disorders  in  connection  with  herpetic  affec- 
tions, and  we  admit,  with  Guislain,  this 
form  of  sympathetic  insanity,  in  spite  of 
the  objections  raised  against  this  view. 

Herpetic  insanity  presents  definite  cha- 
racteristics by  which  it  may  be  recognised. 
At  first  there  is  hypochondriacal  excite- 
ment, according  to  the  generally  remittent 
course  of  the  eruption,  then  there  are  ideas 
of  persecution  based  on  disorders  of  cuta- 
neous seusibility.  One  patient  feels 
insects  creeping  over  his  skin,  another 
feels  himself  "  ravaged  "  by  a  demon,  Slg. 
Chronicity  sets  in  and  presents  as  a 
characteristic  form  ideas  of  grandeur  with 
aberration  of  personality.  The  patient 
denies  his  family,  and  maintains  that  he 
has  been  changed  in  his  youth  ;  he  is  a 
prince,  God,  &c.  This  mental  symptom, 
the  aberration  of  personality,  may  well  be 
pathognomonic  of  this  form  of  mental 
disorder.  J.  Poxs. 

syivipa.thz:tic  nervous  sys- 
TEXVI,  PHYSZOIiOGY  OP. — Distribu- 
tion of  Sympathetic  TTerves. — The  phy- 
siology of  the  sj'^mpathetic  nerve  is  so 
dependent  on  its  anatomical  distribution, 


Sympathetic  Nervous  System  [     1 247    J  Sympathetic  Nervous  System 


that  it  is  necessary  to  make  a  short  state- 
ment as  to  the  position  it  occupies  in  the 
body.  FoUowing  mainly  Dr.  Gaslcell's 
investigation,  it  is  found  that  the  white 
rami  commuuicantes  are  formed  by  an 
outflow  of  medullated  nerves  from  both 
the  anterior  and  the  ]iosterior  roots  of  the 
spinal  nerves  between  the  second  thoracic 
and  the  second  lumbar  inclusive,  which 
medullated  nerves  ])ass  not  only  into  their 
metameric  symiiathotic  (^lateral)  ganglia, 
but  also  form  three  main  streams,  u])- 
wards  into  the  cervical  ganglia,  down- 
wards into  the  lumbar  and  sacral  ganglia, 
and  outwards  into  the  collateral  ganglia, 
passing  over  the  lateral  ganglia  to  form 
the  main  portion  of  the  sjilanchnic  nerves 
and  the  other  rami  eiferentes.  The  struc- 
ture of  these  visceral  nerves  is  diffei'ent 
from  that  of  the  tirst  nine  spinal  nerves. 
These  latter  agree  in  structure  with  the 
nerves  lying  between  the  second  lumbar 
and  the  first  sacral  nerves.  But  below 
this  point  again,  the  structure  of  the 
nerves  is  the  same  as  that  of  the  thoracic 
visceral  nerves.  At  the  second  and  third 
sacral  roots  arise  the  pelvic  splanchnic 
nerves,  called  by  other  observers  the  nervi 
erigentes,  that  pass  directly  to  the  hypo- 
gastric plexus  without  communicating 
with  the  lateral  ganglia ;  from  this  plexus 
they  branch  upwards  to  the  inferior  me- 
senteric ganglion  (collateral  ganglion),  and 
downwards  to  the  distal  ganglia  of  the 
bladder,  uterus,  and  generative  organs. 

The  upward  stream  of  these  visceral 
nerves  is  seen  in  the  spinal  accessory 
nerve. 

In  the  spinal  cord  itself  these  visceral 
nerves  seem  to  be  formed  of  two  rami, 
one  a  ganglionated  root  in  connection 
with  the  cells  of  Clarke's  column,  the 
other  a  non-gauglionated  root  in  connec- 
tion with  the  cells  of  the  lateral  hoi-n. 

The  origin  of  all  vaso-motor  nerves  is  to 
be  found  in  the  central  nervous  system. 
They  pass  down  from  the  medulla  oblon- 
gata, from  a  sjiot  known  as  the  antero- 
lateral nucleus  of  Clarke,  run  down  the 
cord  in  lateral  tracts,  leave  the  cord  by 
way  of  the  anterior  roots  of  the  nerve, 
and  so  pass  to  lateral  ganglia,  and  on- 
wards to  the  heart  and  vessels  in  many 
directions,  some  of  their  non-meduUated 
fibres  being  reflected  back  from  the  lateral 
ganglia  to  the  membranes  and  vessels  of 
the  cord  itself.  In  their  passage  through 
the  lateral  ganglia,  by  way  of  the  rami 
viscerales,  they  lose  their  medulla  in  these 
ganglia,  and  pass  to  their  various  destina- 
tions on  the  vessels  as  non-medullated 
fibres.  The  blood-vessels  of  every  por- 
tion of  the  head  and  face  receive  their 
vaso-constrictor  nerves  from  the  cervical 


sympathetic.  The  blood-vessels  of  all 
the  abdominal  organs  derive  their  con- 
strictor nerves  by  way  of  the  splanchnic 
nerves,  and  the  corresponding  rami  efl'er- 
entes  of  the  upjjer  lumbar  ganglia. 

The  accelerator  nerves  of  the  heart  leave 
the  spinal  cord  by  the  rami  viscerales  of 
second,  third,  and  even  lower  thoracic 
nerves,  i>ass  to  the  ganglion  cardiacum 
basale,  and  thence  reach  the  heart  directly, 
or  indirectly  by  way  of  the  inferior  cervi- 
cal ganglion  and  the  annulus  of  Yieussens. 
I  n  the  lateral  ganglia  they  also  lose  their 
medulla. 

The  nerves  that,  stimulated,  cause  jjeri- 
staltic  movements  in  a  large  portion  of 
the  gastro-intestinal  canal,  leave  the  me- 
dulla oblongata  in  the  roots  of  the  vagus, 
lose  their  medulla  in  the  ganglion  of  the 
trunk,  and  thence  run  to  the  intestinal 
muscles,  resembling  the  vaso-motor  nerves 
in  structure  and  distribution.  The  lower 
portion  of  the  intestinal  canal  is  innervated 
from  two  sources,  one,  the  thoracic  stream 
of  visceral  nerves,  the  other,  the  pelvic 
splancbnics  abov^e  mentioned. 

Sympathetic  Cang'lia. — The  ganglia 
are  of  four  kinds:  (i)  The  ganglia  of  the 
posterior  roots,  root  ganglia;  (2)  The 
lateral  ganglia,  the  main  sympathetic 
chain;  (3)  Collateral  ganglia,  such  as 
semi-lunar,  inferior  mesenteric  ;  and  (4 ) 
Terminal  ganglia,  the  ganglia  of  organs, 
as  of  heart,  stomach,  &c.  The  root  gan- 
glia and  the  lateral  ganglia  may  be  called 
proximal ;  the  collateral  and  the  terminal 
ganglia  may  be  called  distal. 

The  functions  of  these  ganglia  vary. 
The  root  ganglia  are  probably  centimes  of 
nutrition,  and  centres  of  reflex  arcs  in  a 
small  degree.  Gaskell  considers  the  late- 
ral ganglia  are  only  nutritive  centres,  and 
not  centres  of  reflex  action.  Their  size 
alone  makes  it  probable  that  they  possess 
other  functions  than  that,  of  nutrition  of 
nerves. 

Dr.  Hale  White's  investigations  seem  to 
show  that  in  the  human  adult  the  colla- 
teral ganglia  hold  no  specific  function. 
He  is  inclined  to  look  upon  them  as  de- 
generate organs  in  man,  like  the  ganglion 
of  the  trunk  of  the  vagus,  the  pituitary  in 
the  pineal  bodies,  and  probably  also  the 
medullary  jiortion  of  the  human  sujjra- 
renal  body,  derived  as  it  is  from  the  sym- 
pathetic system.  The  terminal  ganghaof 
organs  have  an  automatic  function;  the 
secretory  nerves  of  the  intestine  have  the 
small  ganglia  of  the  solar  and  superior 
mesenteric  plexuses  for  their  centres  ;  the 
cells  of  Auerbach's  and  Meissner's  plexuses 
have  an  automatic  influence  on  the  intes- 
tine :  the  ganglia  of  the  uterus.  Fallopian 
tubes,  and  of  the  blood-vessels  have  an 


Sympathetic  Nervous  System  [     1248    J  Sympathetic  Nervous  System 


automatic  iiidueuce  upon  the  organ  on 
which  they  lie  (Hale  White). 

The  raso-diJt(tor  nerves  are  the  inhibi- 
tory fibres  of  the  heart,  the  fibres,  with 
their  functions,  contained  in  the  chorda 
tympani  and  small  petrosal  nerves,  and 
the  nervi  erigentes.  Anatomically,  they 
differ  from  vaso-constrictor  nerves  by  not 
losing  their  medulla  until  they  reach  more 
terminal  ganglia.  Their  orgin  is  from  the 
cranio-cervical  and  the  sacral  cord. 

Double  JS'erve  iSitjjphj  io  Glands,  &c. — 
It  is  probable  that  all  tissues  are  connected 
by  efferent  nerves  of  these  two  kinds. 
This  double  supply  has  been  found  in  the 
submaxillary,  parotid,  and  lachrymal 
glands.  Thus  Michael  Foster  speaks  of 
two  sets  of  fibres  employed  in  the  secre- 
tion of  saliva,  one,  cerebro-spinal,  vaso- 
dilator, stimulation  of  which  produces  a 
copious  flow  of  limpid  saliva  free  from 
mucus,  anabolic;  the  other,  sympathetic, 
vaso-constrictor,  coming  from  the  cervical 
sympathetic ;  its  stimulation  giving  rise 
to  a  secretion  rich  in  organic  matter, 
katabolic. 

Influence  on  the  Jri.s.— There  seems  to 
be  no  need  for  a  dilator  muscle  of  the  iris. 
It  cannot  be  demonstrated  in  most  ani- 
mals. The  si^hincter  muscle  of  the  iris 
is  supplied  by  two  nerves  of  opposite 
character,  the  one  the  third  nerve  that 
contracts  the  pupil,  the  other  the  sym]5a- 
thetic  that  inhibits  this  contraction.  The 
dilatation  of  the  pupil  on  stimulation  of 
the  sympathetic  nerve  is  thus  brought 
about  by  inhibition  of  the  tonic  contrac- 
tion of  the  sphincter  muscle,  if  only  the 
radial  fibres  of  the  iris  possess  a  sufficient 
amount  of  elasticity. 

There  is  no  evidence  that  the  same 
nerve  fibre  is  sometimes  capable  of  acting 
as  a  motor  nerve,  sometimes  as  a  nerve  of 
inhibition. 

Influence  on  the  Heart. — '"The  primary 
efiect  of  the  stimulation  of  the  sympathe- 
tic (accehirator)  of  the  heart  is  an  increase 
both  in  the  rate  and  strength  of  the  auri- 
cular and  ventricular  contractions  ;  these 
nerves,  therefore,  may  be  justly  called 
motor,  because  they  augment  the  activity 
of  the  cardiac  muscle,  and  that  augmen- 
tation is  followed  by  exhaustion.  Gaskell 
prefers  the  term  '  katabolic '  to  motor, 
Ijecause  when  a  muscle  is  set  in  action 
by  stimulation  of  its  motor  nerve  or  other- 
wise, there  is  a  great  increase  in  the  de- 
structive changes  with  subsequent  ex- 
haustion. On  the  other  hand,  any  expla- 
nation of  inhibition,  which  is  to  hold  good, 
must  not  confine  itself  merely  to  the  ces- 
sation of  rhythmical  action,  but  must  also 
explain  the  diminishiid  contraction  and 
the  relaxation  of  the  cardiac  muscle.    The 


result  of  stimulation  of  these  nerves  is 
exactly  opposite  to  that  of  the  sympathe- 
tic nerves ;  there,,  increased  activity  fol- 
lowed by  exhaustion,  symptoms  of  kata- 
bolic action ;  here,  diminished  activity 
followed  by  repair  of  function,  symjjtoms 
of  anabolic  action."  This  inhibition  can 
be  set  in  action  reflex ly  by  an  afferent 
nerve. 

Reflex  Action. — It  will  be  seen,  in 
speakiug  of  vascular  tone,  that  reflex  ac- 
tion plays  an  important  part.  Although 
the  lateral  ganglia  are  nutritive  centres 
rather  than  reflex,  their  structure  does  not 
prevent  the  possibility  of  their  acting  as 
reflex  centres.  But  whether  or  no,  a 
lai'ge  amount  of  action  of  the  sympathetic 
nerve  seems  to  be  under  reflex  influence, 
the  centre  of  the  reflex  arc  being  the  me- 
dulla oblongata  or  the  spinal  cord.  Some- 
times a  sensory  nerve  is  the  eisodic  nerve, 
and  the  sympathetic  the  exodic ;  some- 
times the  relation  is  reversed.  I^or  is  the 
perception  of  a  sensory  impression  neces- 
sary. Some  impression  is  made  on  the 
peripheral  termination  of  a  nerve ;  the 
molecular  motion  it  sets  up  is  propagated 
along  the  nerve  until  it  reaches  a  gan- 
glion. In  many  cases  the  propagated 
impulse  reaches  the  ganglion  by  means  of 
a  nerve  that  is  only  in  close  apposition  to 
the  actual  nerve  that  is  connected  with 
the  ganglion.  The  large  quantity  of 
molecular  motion  thus  disengaged  dis- 
charges itself  along  another  nerve  pro- 
ceeding from  the  ganglion  to  a  muscle. 

Many  examples  of  such  a  reflex  arc  are 
themselves  illustrations  of  the  part  played 
by  the  sympathetic  in  numerous  diseases. 

Illustratiuns  of  Synijxithetic  Reflex  Ac- 
tioH.^Thus,  facial  neuralgia,  causing  con- 
gestion of  conjunctiva  and  lachrymation  ; 
salivation  occurring  in  pregnancy  ;  faint- 
ness  or  constipation  due  to  irritation  of 
hej^atic  or  renal  calculus  ;  contraction  of 
vessels  and  arrest  of  urine,  set  up  by  cal- 
culus in  the  kidne}'- ;  pai'tial  cramp  of 
vaso-motors,  confined  to  the  extremities  of 
the  flcgers,  seen  sometimes  in  angina 
pectoris  ;  the  effects  of  cold  on  the  vessels 
of  the  extremities,  explaining  various  neu- 
roses of  the  extremities.  Perhaps,  too, 
Yulpian's  experiment  should  come  under 
this  head,  in  which,  after  transverse  sec- 
tion of  the  sciatic  nerve,  or  of  the  brachial 
plexus,  when  the  corresponding  pulp  of 
the  paw  of  an  animal  had  become  quite 
pale  and  angemic,  he  was  able,  by  slightlj' 
rubbing  these  pulps,  to  cause  a  reflex  con- 
gestion. In  mammals,  after  section  of 
the  cord  at  the  mid-dorsal  region,  sensory 
excitation  of  one  posterior  limb  will  cause 
I'eflex  heat-phenomena  in  the  other. 
Maragliano's  observation  in  fever,  testing 


Sympathetic  Nervous  System  l     1 249    J  Sympathetic  Nervous  System 


the  variation  in  the  pulse  by  sealing  the 
forearm  in  a  glass  vessel,  ami  taking 
si)hygmographic  tracings,  irritating  the 
other  arm  meanwhile  by  an  electrical  cur- 
rent, showed  the  vascular  reaction  in 
patients  with  fever  to  be  generally  indica- 
tive of  constriction,  but  souietimes  of 
dilatation,  aud  generally  more  energetic, 
Ijrompt,  and  persistent  than  in  the  afe- 
brile period.  Flux  from  the  intestinal 
vessels  is  a  sequence  of  the  irritation  of 
some  foreign  body  in  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  jwsterior 
roots  of  the  sciatic  or  other  spinal  nerves. 
Sciatica  may  induce  saccharine  urine,  the 
fourth  venti'icle  being  here  the  centre  of 
the  reflex  arc.  There  is  the  pulse  of  lead 
colic.  Local  dilatation  of  vessels  (paresis  of 
vaso-constrictors),  aud  even  evanescent 
erythema,  may  result  from  the  action  of  in- 
tense light — e.g.,  the  electric  light.  Lan- 
douzi  and  Nothnagel  have  described  an 
angina  pectoris  vaso-motoria,  which  they 
referred  to  a  general  arterial  spasm,  often 
produced  rellexly,  especially  by  exposure 
to  cold,  the  secretion  of  milk  induced  by 
foetal  movement  in  utero,  by  the  touch  of 
the  finger,  or  of  the  child's  mouth,  and  the 
heemorrhage  from  a  fibrous  tumour  of  the 
uterus  are  refiex,  or  the  eisodic  nerve  may 
be  sensory-sympathetic.  From  investiga- 
tions made  by  Dr.  F.  Edgeworth,  of  Bris- 
tol, it  is  seen  that  large  medullated  fibres 
are  found  in  very  many  of  the  sympathe- 
tic nerves,  from  the  upper  dorsal  to  the 
third  lumbar  vertebrae,  but  in  greatest 
abundance  in  the  uppermost  dorsal  rami, 
and  in  the  lower  dorsal  and  upper  lumbar. 
They  pass  through  the  gangUon  cells  of 
the  ganglia  on  the  lateral  sympathetic 
chain,  without  giving  off  any  branch  to 
them,  and  they  can  be  traced  up  to  the 
posterior  roots  of  the  spinal  nerves,  to  be 
connected  with  cells  in  the  posterior  gan- 
glion. It  seems  therefore  certain  that 
these  fibres  are  sensory. 

Vascular  Tone. — But  a  chief  illustra- 
tion is  the  refiex  action  of  the  blood  upon 
vascular  tone.  Goltz  says  the  tone  of  the 
arteries  is  maintained  by  local  centres, 
situated  in  their  own  immediate  vicinity ; 
but  though  such  distal  ganglia  exist,  the 
spinal  system  is  really  the  centre  of  the 
reflex  arc,  except  perhaps  for  the  feeblest 
impulses.  Vascular  tone  is  due  to  a  refiex 
mechanism,  a  mechanism  brought  into 
action  by  incessant  centripetal  excitations, 
which  are  probably  the  blood  waves  ;  as 
regards  a  vessel  the  factors  of  this  arc 
exist — the  middle  tunic  of  the  vessel,  the 
centripetal  nerve  fibres  in  the  vascular 


walls,  the  bulbo-spinal  centre,  aud  the 
centrifugal  vaso-motor  nerves. 

All  the  phenomena  of  rellex  congestion 
and  of  refiex  dilatation  of  the  vessels  from 
any  cause  are  only  instances  of  enfeeble- 
ment  or  abolition,  more  or  less  complete, 
more  or  less  persistent,  of  the  vascular 
tone. 

Influence  of  Heart  on  Arteries,  and 
of  Arteries  on  Heart. — The  infiuence  of 
the  sympathetic  is  specially  seen  in  the 
mutual  relationship  of  the  heart  and  arte- 
ries. Let  there  be  from  any  cause  a 
constriction  of  most  of  the  small  arteries 
of  the  body,  there  is,  as  a  consequence, 
increase  in  the  arterial  tension.  The  heart 
strives  to  overcome  this  excess  of  tension, 
and  must  employ  more  energy  for  this 
purpose  ;  its  contractions  become  more 
vigorous,  more  rapid.  This  effect  is  not 
purely  mechanical,  but  is  under  the  infiu- 
ence of  the  sympathetic  accelerators. 
Under  increased  intra-arterial  pressure  the 
blood  in  the  ventricle  also  undergoes  at 
the  moment  of  systole,  and  of  the  opening 
of  the  sigmoid  valves,  an  excess  of  tension. 
This  impresses  some  excitation  at  the 
endocardial  extremities  of  the  centripetal 
nerve  of  the  heart;  this  impression  is 
carried  up  to  the  bulb,  from  which  down 
through  the  cervical  cord  is  reflected  a 
centrifugal  irritation  by  way  of  the  sym- 
pathetic to  the  intra-cardiac  ganglia,  and 
so  result  increased  energy  and  increased 
rajjidity  of  the  cardiac  movements. 

Reversing  the  order  of  the  phenomena, 
if  the  left  ventricle  from  any  cause  be 
abnormally  full  of  blood,  the  special  im- 
pression on  the  peripheral  extremities  of 
the  cardiac  nerves  is  carried  up  by  the 
depressor  nerve,  a  branch  of  the  vagus, 
to  the  bulb,  and  thence  by  means  of 
dilator  nerves  a  general  reflex  dilatation  of 
vessels  takes  place,  and  especially  by  way 
of  the  splanchnic  nerves  on  the  vessels  of 
the  mesentery,  and  the  heart  is  relieved 
of  its  pressui-e ;  or  the  dilatation  of  the 
abdominal  vessels  is  brought  about  by 
inhibition  of  the  vaso-constrictors. 

So  once  again,  if  an  abnormally  small 
amount  of  blood  be  in  the  heart,  the  reflex 
action  originates  from  the  cardiac  nerves, 
and  will  react  on  the  vaso-constrictors  ; 
the  vessels  contract,  and  the  blood,  re- 
ceiving an  increased  vis  a  terc/i>,  flows  more 
abundantly  to  the  heart.  Thus  the  heart 
may,  up  to  a  certain  point,  play  the  part 
of  regulator  of  the  vessels,  or  at  least 
exercise  a  certain  influence  on  their  tone, 
whilst  inversely  the  vessels  rule,  up  to  a 
certain  point,  the  energy  and  frequency 
of  the  movements  of  the  heart. 

Nutrition. — 1 1  is  probable  that  the  part 
played  by  tiie  sympathetic  Tierv(!  on  nutri- 


Sympathetic  Nervous  System  [     1250    ]  Sympathetic  Nervous  System 


tiou  is  only  iu  so  far  as  the  heart's  action 
is  kept  normal  by  its  inHuence,  and  the 
tone  of  the  vessels  preserved.  It  is  certain 
that  section  of  a  nerve  supplying  the 
blood-vessels  of  an  area  of  mucous  mem- 
brane, or  of  skin,  causes  ulceration  and 
destruction  of  the  part.  But  not  only  are 
the  phenomena  of  partial  atrophies,  of 
infantile  paralysis,  of  progressive  muscular 
atrophy,  constantly  met  with  without  any 
lesion  of  the  sympathetic,  except  in  so  far 
as  variations  in  the  blood-supply  are  con- 
cerned, but  the  peculiar  symptoms  of  pro- 
gressive hemi-atrophy  of  the  face  seem  to 
have  little  or  nothing  to  do  with  distinct 
sympathetic  lesion. 

Animal  Heat. — The  inHuence  of  the 
sympiathetic  on  animal  heat  is  exercised  : 
(i)  By  the  vaso-motors  of  the  whole  body 
regulating  the  amount  of  blood  for  com- 
bustion in  the  tissues  ;  (2)  B}^  the  vaso- 
motors of  the  cutaneous  vessels  partially 
regulating  transpiration  from  the  skin  ; 
(3)  By  the  vaso-motors  of  the  lungs,  regu- 
lating pulmonary  transj^iration ;  (4)  By 
the  accelerator  nerve  of  the  heart  ruling 
not  only  in  part  the  amount  of  blood  in 
the  tissues,  but  especially  regulating  the 
amount  passed  through  the  lungs,  and  so 
indirectly  the  quantity  of  oxygen  assimi- 
lated by  the  blood.  The  first  act,  that  of 
heat  creation,  is  the  consequence  of  the 
chemical  phenomena  of  nutrition.  The 
distribution  of  the  heat  created,  the  vari- 
ation of  it  by  constriction  of  vessels,  or  by 
restraining  chemical  action,  ai'e  among  the 
functions  of  the  sympathetic. 

Inflammation. — This  nerve  plays  an 
important  pen't  in  inflammation,  both  by 
altering  vascular  tone  under  reflex  irri- 
tation, and  probably  by  influencing  the 
molecular  (chemical)  changes  in  the  vas- 
cular walls,  changes  that  favour  the 
migration  of  leucocytes.  For  the  due 
understanding  of  microbic  pathology  this 
influence  of  the  sympathetic  deserves  to 
be  recognised  as  causing  in  some  cases  at 
least  a  preliminary  condition,  without 
which  germ  growth  would  be  difficult  or 
impossible.  Vaso-motor  paresis  does  not, 
in  the  absence  of  other  factors,  cause 
inflammation,  but  it  is  an  important  ac- 
cessory. 

Oldema. — It  is  on  the  increased  poros- 
ity or  permeability  of  the  vessel  that 
oedema  depends.  The  endothelium  of  a 
vessel  is  a  living  tissue  with  ar.  active 
metabolism.  Whilst  even  for  mechanical 
dropsy  we  are  compelled  to  assume  a 
peculiar  influence  exerted  by  the  wall  of 
the  vessel,  the  latter  acquires  a  still  greater 
importance  in  other  varieties  of  hydi'ops. 
Tbis  modification  of  the  vascular  endo- 
thelium is  partly  influenced  by  the  con- 


dition of  the  circulating  blood,  partly  by 
vaso-motor  paresis. 

General  Patholog^y. — The  sympathetic 
system  may  be  said  to  possess  a  very 
special  pathology,  but  by  no  means  in  all 
cases  a  recognised  pathological  anatomy. 
As  a  general  rule  the  cells  of  the  semi- 
lunar and  the  superior  cervical  ganglia  are 
wasted  in  wasting  diseases,  but  with  many 
exceptions.  The  most  usual  lesions  are 
l^igmentation,  colloid  degeneration  with 
proliferation  of  endothelial  cells,  and 
secondary  fatty  metamorphosis,  intersti- 
tial hyperplasia  leading  to  atrophy,  and 
sclei'osis  of  nerve  elements. 

Given  a  recognisable  lesion  of  a  sympa- 
thetic ganglion  or  nerve,  certain  pheno- 
mena are  found  following  this  as  a  conse- 
quence. On  the  other  hand,  given  these 
same  phenomena  without  a  coarse  lesion 
of  the  sympathetic  nerve  or  ganglion,  it  is 
justifiable  to  say  that  these  depend  upon 
a  morbid  condition  of  these  structures, 
even  though  such  a  condition  cannot  be 
recognised  by  the  usual  means  of  investi- 
gation. A  ganglion  (and  we  include 
Clarke's  cells  under  this  category)  appa- 
rently healthy,  may  be  changed  in  some 
occult  way  by  the  sun's  rays,  by  the  circu- 
lation of  abnormal  blood,  by  what  is 
called  "irritation"  carried  to  it  from 
disease  in  a  distant  organ,  or  by  emotion. 
It  cannot  be  doubted  that  these  influences 
change  in  some  way  the  equipoise  of  the 
ganglion;  for,  as  their  result,  are  seen 
phenomena  precisely  corresponding  to  the 
effects  of  coarse  expei'iments  upon  the 
sympathetic  in  animals,  and  of  easily 
recognised  lesion  of  these  oi'gans  in  man. 
The  starting-point  of  this  irritation  is 
seen,  the  channels  by  which  the  irritation 
is  conveyed,  the  consequences  of  the  irri- 
tative action  beyond  the  ganglion ;  but  the 
absolute  condition  of  the  ganglion  itself, 
in  so  far  as  it  diff"ers  trom  its  state  in 
health,  is  incapable  of  being  in  all  cases 
demonstrated.  Moreover,  it  is  a  matter 
of  experience  that  irritations  which  induce 
sympathetic  phenomena  are  generally 
reflex  rather  than  direct. 

Effects  of  Iiesion  on  Cervical  Sympa- 
thetic.— Section  of  the  cervical  sympa- 
thetic nerve  causes  paralysis  of,  and  there- 
fore dilatation,  of  the  vessels  of  the  head 
and  face,  with  some  I'ise  of  temperature  of 
the  same  regions.  The  pupil  is  contracted 
from  the  inhibitory  influence  of  the  sym- 
pathetic on  the  iris  being  cut  off.  The 
contraction  of  the  pupil  is  due  to  the 
unimpeded  influence  of  the  third  nerve. 
Not  quite  so  certainW  result  interference 
with  the  secretion  of  tears,  sweat,  and  saliva, 
on  the  affected  side,  narrowing  of  the 
palpebral  fissure,  and  retractiojx  of  the  eye- 


Sympathetic  Nervous  System  [     1251     J  Sympathetic  Nervous  System 


ball.  Myosis  may  be  due  to  the  pressure 
of  a  tumour  on  the  cervical  sympathetic. 
It  is  met  with  in  sclerosis  of  the  medulla 
oblont^uta,  and  iu  some  diseases  of  the 
spinal  cord,  as  tabes  cervicalis  and  pro- 
gressive muscular  atrophy. 

Exophthalmic  Goitre. — Exojdithalinic 
goitre  is  described  elsewhere  in  these 
pages.  It  may  be  allowable  to  point  out 
the  small  part  played  by  the  sympathetic 
in  the  causation  of  this  disease.  The 
phenomena  may  own  a  central  orij^iu. 
As  a  matter  of  experiment,  exophthalmos 
has  been  found  to  be  a  result  of  section  of 
the  restiform  bodies,  and  therefore  may 
be  expected  to  manifest  itself  from  any 
destructive  lesion  of  that,  if  not  of  other 
i:)ortions,  of  the  medulla  oblongata.  Lesion 
also  of  a  portion  of  the  door  of  the  fourth 
ventricle  would  account  for  any  inter- 
ference with  the  independent  or  co-ordinate 
action  of  the  levator  palpebra3,  as  one 
portion  of  the  origin  of  the  fourth  nerve 
can  be  traced  into  a  grey  nucleus  at  the 
upper  part  of  the  floor  of  the  fourth 
ventricle,  close  to  the  origin  of  the  fifth 
nerve.  Lesion  too  of  a  small  portion  of  this 
ventricle  on  each  side  of  the  middle  line 
will  include  the  chief  vaso-motor  centre 
of  the  body,  whilst  a  partial  paralysis  of 
the  vagus,  from  lesion  of  its  nucleus,  would 
set  free  the  accelerator  nerves  of  the  heart 
to  act  without  vagus  inhibition,  and  thus 
induce  palpitation. 

Headache. — The  influence  of  the  sym- 
pathetic is  sometimes  seen  in  that  form  of 
headache  that  is  caused  by  reflex  irri- 
tations from  the  stomach,  intestine  or 
uterus. 

IMCigraine. — No  morbid  condition  of  the 
sympathetic  will  account  for  the  symptoms 
of  migraine,  although  this  nerve  is  con- 
siderably affected.  It  is  closely  allied  to 
a  nerve  storm,  described  by  Dr.  Buzzard, 
affecting  the  medulla  oblongata,  in  which 
the  nuclei  of  the  fifth  nerve,  the  portio 
mollis,  the  vagus,  and  often  the  bulbar 
vaso-motor  centre  are  implicated,  associ- 
ated with  tinnitus,  neuralgia,  vertigo, 
faintness,  and  vomiting. 

Epilepsy. — The  sympathetic  takes  no 
part  in  the  causation  of  epilepsy,  except 
that  it  is  partially  responsible  for  the 
altered  nutrition  of  the  centre  or  centres 
from  which  the  local  discharge  emanates. 

Iiesion  of  ITervous  Centres.  —  In 
lesions  of  the  brain  and  spinal  cord  sym- 
pathetic phenomena  are  often  found  as 
secondary  consequences,  or  as  involved  in 
the  causation  of  inflammation.  Probably 
a  paresis  of  vaso-motorsmay  beone  factor 
in  the  increased  constriction  of  which,  in 
some  cerebral  lesions,  a  high  temperature 
is  the  manifestation. 


Ang-lna  Pectoris. — The  forms  of  angina 
pectoris  are  various  :  (i)  with  spasm  of 
heart,  and  arterial  constriction;  (2)  a  pure 
neuralgia,  which  may  or  may  not  be  associ- 
ated with  disease  of  the  heart  or  the  aorta; 
(3)  a  condition  of  vaso-motor  paresis  from 
a  central  origin,  or  excited  by  rellex  irri- 
tation, or  under  the  influence  of  emotion. 
In  causation  and  pathology  they  are 
separate  diseases,  and  demand  wholly 
different  treatment.  The  sympathetic 
takes  part  in  the  first  form,  and  is  almost 
wholly  responsible  for  the  third. 

Diabetes  iviellitus.  —  Diabetes  melli- 
tus  is  discussed  elsewhere  in  these 
pages.  But  it  may  be  remarked  here  that 
the  condition  of  general  arterial  pressure 
and  the  dilatation  of  the  hepatic  artery, 
and  in  a  less  degree  of  the  portal  vein,  are 
under  the  government  of  the  vaso-motor 
centre,  and  thus  this  system  of  nerves  may 
be  associated  with  diabetes.  The  con- 
nection is  almost  invariably  reflex,  and 
the  vaso-motor  S3'stem  generally  affects 
the  centre  of  the  reflex  arc  and  the  exodic 
nerve.  Dr.  Pavy  found  that  injury  to  the 
inferior  cervical  ganglion  gave  rise  to 
glycosuria. 

ireurasthenia. — Neura<sthenia  is  also 
the  subject  of  a  special  article.  But  as 
to  one  form  of  it,  Rosenthal  sums  up  the 
whole  nature  of  the  disorder  when  he  says, 
"  L'hysterie  n'est  qu'une  faiblesse  de 
resistance  congenitale  ou  acquise  des 
centres  vasomoteurs." 

Flg:iuentatloii.  —  Morbid  development 
of  pigment,  or  unusual  positions  of  it,  are 
only  abnormalities  of  a  normal  condition. 
The  exciting  cause  may  be  a  diseased 
state  of  blood  acting  directly,  as  in  ague, 
syphilis,  carcinoma,  chronic  rheumatism, 
&c.,  or  irritation  acting  in  a  reflex  manner 
from  a  distant  organ,  and  by  preference 
from  pelvic  or  intestinal  viscera,  or  emo- 
tion. The  irritation,  whether  direct  or 
reflex,  primarily  affects  the  solarplexug,and 
through  it  partially  paralyses  the  splenic 
plexus.  The  effect  of  this  is  first  an  enlarge- 
ment of  thespleen,aud  secondlyanincrease 
in  the  formation  of  pigment.  Except  in 
some  instances  of  intense  emotional  storm, 
chronicity  is  an  invariable  element  in  pig- 
mentation. For  the  abnormal  deposit  of 
pigment  in  the  skin  three  factors  are 
necessary :  a  well-developed  i^apilla,  the 
healthy  influence  of  the  sensory  nerve,  a 
dilatation  of  the  local  vessel.  The  latter 
factor  is  generally  induced  by  a  diminu- 
tion of  vascular  tone  caused  by  paresis  of 
the  vaso-constrictors.  This  pai'esis,  like 
the  effect  on  the  sj^lenic  nerves,  can  be 
effected  by  the  direct  action  of  morbid 
blood,  by  reflex  irritation,  and  by  emo- 
tion. 


4  r^ 


Sympathetic  Nervous  System  [     1252    ]        Syphilis  and  Insanity 


Addison's  Disease. — The  fact  that  the 
symptoms  of  Addison's  disease  do  not 
follow  the  removal  of,  or  other  diseases  of 
the  supra-renal  capsules,  seems  to  be  new- 
proof  against  the  possibility  of  the  irrita- 
tion of  bacilli  tuberculosi  in  the  supra- 
renal capsule  exciting  the  phenomena  of 
Addison's  disease.  But  the  part  played 
by  the  sympathetic  in  the  direct  causation 
of  Addison's  disease  is  still  uncei'tain. 

The  variation  in  the  size  of  the  sym- 
pathetic ganglia  in  health  is  so  great 
that  the  reported  hypertrophy  of  certain 
ganglia  in  acromegaly  seems  of  little  im- 
portance. 

IVeuroses  of  the  Extremities. —  The 
dilatation  of  tbe  vessels  of  the  extremities 
and  the  more  usual  neuroses  attended  with 
vaso-consti-iction  and  local  diminution  of 
temperature  depend,  the  first  on  paralysis 
of  the  vaso-motor  of  the  pai't  affected, 
and  the  latter  on  over-excitation  of 
the  vaso-motor  centre.  In  the  lesser 
degi'ees  it  is  not  unusual  in  this  country. 
In  one  form  or  other  it  is  common  among 
the  coolies  who  take  service  in  Natal.  The 
contractile  form  of  the  neurosis  may 
determine  symmetrical  gangrene  of  the 
extremities.  This  seems  to  be  due  to 
chronic  spasm,  such  as  might  readily  be 
set  up  in  the  vessels  by  prolonged  irrita- 
tion. This  condition  may  easily  exist 
in  the  vaso-motors  that  run  in  the  course 
of  the  nerves  of  the  extremities,  if  these 
nerves  are  in  a  state  of  peripheral  neu- 
ritis, a  fact  that  has  been  found  in  a 
certain  number  of  cases.  It  is  a  true 
tetanus  of  the  vaso-motors.  In  one  case 
recorded,  in  which  only  the  vaso-motor 
fibres  of  the  arms  were  affected,  a  growth 
was  found  post-mortem  in  front  of  the 
spine,  involving  the  first  dorsal  nerve  and 
the  sympathetic  trunk.  This  disease  is 
pre-eminently  connected  with  the  sympa- 
thetic system. 

In  many  other  maladies  the  sympa- 
thetic plays  an  important  part  by  means 
of  its  physiological  action  on  circulation, 
nutrition,  secretion,  and  inflammation.  It 
is  thought  by  some  to  be  the  structure 
specially  involved  in  sea-sickness,  and  in 
fatal  chorea  with  great  distension  of  vessels. 
In  diabetes  insipidus,  in  many  of  the  vis- 
ceral— especially  the  uterine — neuroses,  in 
purpura  hsemorrhagica,  in  some  affections 
of  the  skin,  this  system  of  nerves,  so 
bound  up  in  the  cerebro-spinal  centres, 
takes  either  a  primary  or  secondary  place. 
It  is  certain  that  anatomical  abnormal- 
ities of  many  of  the  sympathetic  ganglia 
may  exist  without  any  corresjDonding 
symptoms  ;  and  that  the  sympathetic  is 
constantly  in  a  state  of  vulnerability,  of 
abnormal   excitability  to  impulses,  often 


from  a  distant  organ,  and  very  frequently 
affecting  it  by  a  reflex  mechanism. 

E.  LoxG  Fox. 

ilif'ferences. — Dv.  Gaskell,  Journal  of  I'hysio- 
loi>y,  vol.  vli.  Dr.  Hale  Wliite,  Journal  of  Phy- 
siology, vols.  viii.  and  x.  :  Guy's  Hospital  Reports, 
vol.  xlvi.  Dr.  Cliapin's  Fiske.  Fund  Prize  Essay. 
I'oincare,  I>e  Systeme  nerveux  periplierique.  Dr. 
Broadbent  and  Dr.  Saundby,  Ou  Vascular  Tone, 
lirit.  Med.  Journ.,  1883,  vol.  ii.  Michael  Foster, 
Text-book  of  Physiology.  Eulenbern'  and  Gutt- 
niau,  Sympatlii'tic  System  of  Xcrves.  Soeliijmiiller, 
Lehvbuch  drr  Krankheiten  der  iieriplicren  Nerven 
nnd  des  Synipathicus.  Wiinderlich,  Das  Verhalten 
der  Eigenwarrae  in  Krankheiteu.  Vulpian,  L'Ap- 
pareil  Vasomoteur.  Dr.  Greenhow,  Internat.  ]Med. 
Congress  Reports.  Dr.  Weir  Mitchell  and  others, 
American  .Journal  of  Science,  1878.  E.  Long:  Fox, 
The  Influence  of  the  Sympathetic  on  Disease,  1885.] 

SYiviPTOiviATic  iviATariA.  {See 
Mania,  Symptohatic.) 

SYNAImGXA. — By  this  term  Henry  de 
Fromentel  ("  Les  Synalgies  et  les  Synes- 
thesies,"  Paris,  1888)  designates  the  phe- 
nomenon, previously  described  several 
times,  that  by  the  irritation  of  some  point 
of  the  body  pain  is  experienced  in  another 
pai't,  often  widely  separated  from  the  first. 
He  has  deduced  laws  which,  as  he  believes, 
hold  good  not  for  a  definite  person  only 
but  for  all  who  experience  synalgias,  ac- 
cording to  which,  for  example,  an  irrita- 
tion of  the  skin  over  the  patella  produces 
a  synalgia  in  the  hypochondrium  of  the 
same  side.  The  undersigned  has  for  many 
years  observed  synalgias  on  himself,  but 
his  experience  does  not  confirm  the  laws 
given  by  de  Fromentel.        E.  Bleuler. 

SYNOSTOSIS  ((TVP,  with ;  ocrreou,  a 
bone).  The  joining  together  of  the  bones 
of  the  skull.  The  early  or  defective  closing 
of  the  cranium  has  a  great  effect  on  the 
mental  development  of  the  individual. 
(See  Idiocy,  Pathology  of.) 

SYPHZI.IDOIVIAM-IA,  SYFHZI.0- 
jaANXA.  (syphilis  ;  mania,  madness). 
A  form  of  mental  derangement  due  to 
syphilis.  (Fr.  syphilomanie ;  Ger.  Lust- 
seuchenvndli.) 

SYPHXI.ZDOPHOBZA,  SYPHII.O- 

PHOBZA  (syphilis ;  (pajSos,  fear).  Morbid 
dread  of  syphilis.  A  -form  of  hypochon- 
driasis, in  another  sense  it  means  fear 
of  giving  syphilis  to  others ;  an  occa- 
sional symptom  in  insanity. 

SYPHZI.ZS  ATTD  IN-SANZTY,  RE- 
Z.ATZOM-SHZPS  BET-WT-EEN. — We  pur- 
pose concisely  to  consider  the  possible 
connections  which  may  exist  between  sy- 
philis in  its  different  phases  and  the  dif- 
ferent forms  of  mental  disorder  and  disease 
of  the  higher  nervoiis  organs.  We  pur- 
pose taking  the  symptoms  of  syphilis  as 
they  are  met  with  at  various  ages,  and 
also  as  it  affects  the  different  organs  of 
the  body,  and  we  shall  make  as  clear  as 


Syphilis  and  Insanity        [     1253    ]        Syphilis  and  Insanity 


possible  the  distinction  between  the  moral 
or  intellectual,  and  the  physical  or  physio- 
logical action  of  tlie  disease  in  the  pro- 
duction of  mental  disturbance. 

We  shall  point  out  the  effects  of  ac- 
quired and  of  congenital  syphilis,  and 
shall  incidentally  have  to  notice  that  there 
is  no  distinct  and  direct  relationship  be- 
tween the  severity  of  the  primary  diseases 
and  that  of  the  secondary  insanity.  It  is 
more  frequent  than  not  to  find  that  pa- 
tients who  are  sufferint?  from  neurotic 
disoi'ders  related  to  syidiilis  have  had  bnt 
slight  constitutional  and  local  syphilitic 
disease. 

It  is  not,  however,  correct,  in  our 
opinion,  to  infer  from  this  that  the  syjihi- 
lis  has  been  imperfectly  treated,  and  so 
had  developed  unchecked  in  consequence, 
and  that  more  thorough  treatment  would 
certainly  have  prevented  the  development 
of  nervous  symptoms.  In  many  of  the 
cases  in  which  the  nervous  symptoms 
have  followed  constitutional  syphilis  treat- 
ment has  been  regularly  and  continuously 
applied  before  the  nervous  symptoms  ex- 
hibited themselves,  and  the  continuance 
of  the  treatment  did  not  affect  the  course 
of  the  nervous  disorder  in  any  way. 

Syphilis  may  produce  mental  disorder 
by  causing  loss  or  destruction  of  nerve- 
tissue,  such  as  organic  dementia;  it  may 
cause  sensory  troubles  leading  to  mental 
disorder ;  or  it  may  cause  disorder  of 
nutrition  and  function,  which  may  lead  to 
ordinary  insanity  or  epilepsy. 

Syphilis  does  not  affect  all  patients 
similarly.  It  is  certain  that,  whatever 
may  be  the  cause  of  contagious  diseases, 
the  nature  of  the  soil  greatly  influences 
the  character  of  the  gi-owth.  In  those 
who  are  specially  unstable  on  the  nervous 
side  it  may  be  that  syphilis  and  other 
similar  diseases  may  affect  the  nervous 
sj-stem  most  seriously.  Our  own  experience 
inclines  us  to  believe  that  syphilis  does 
affect  the  nervous  system  of  those  who  by 
age,  habit,  or  inheritance  are  nervously 
weak,  and  in  many  such  cases  it  seems  to 
avoid  the  tissues  more  affected  in  others, 
such  as  the  skin  and  mucous  membrane. 

Other  questions  are  involved,  and  we 
have  to  learn  under  what  conditions  the 
cord  and  what  the  brain  bear  the  brunt 
of  the  disease  ;  how  far  primarily  and  how 
far  secondarily  these  suffer. 

A  great  deal  of  what  has  to  be  said  is 
only  to  be  considered  as  provisionally 
true ;  the  fact,  however,  remains  that 
there  are  certain  relationships  between 
syphilis  and  nervous  disorder,  though  we 
cannot  fully  define  them.  We  are  not  in 
a  position  to  show  bow  many  of  the  popu- 
lation   suffer  from   syphilis,  and  cannot  , 


say  therefore  what  proportion  of  the 
population  who  would  under  any  circum- 
stances break  down  mentally,  owe  nothing 
to  syphilis  as  a  cause  of  their  disorder. 
We  have,  for  years,  not  only  asked  male 
patients  whether  they  have  had  sy])hilis, 
but  have  personally  examined  them,  with 
the  result  of  sometimes  discovering  signs 
of  the  disease  which  the  patient  was  him  ■ 
self  ignorant  of  having  had.  Syphilis 
may  be  present  in  patients  whose  insanity 
does  not  depend  upon  it,  and  we  know  no 
form  of  insanity  deserving  the  name  of 
"  syphilitic  insanity."  Syphilis  rarely 
acts  as  the  only  cause  of  insanity ;  alco- 
holic or  other  excesses,  strain,  injury,  or 
general  modes  of  life  act  as  contributing 
conditions. 

We  propose  considering  the   relation- 
ships after  the  following  scheme  : — 
(i)  Insane  dread  of  syphilis. 

(2)  Insane  dread  of  results  of  syphilis. 

(3)  Syphilitic  fever, delirium,  and  mania. 

(4)  Acute  syphilis  leading  to  mental 
decay. 

(5)  Syphilitic  cachexia  and  dyscrasia, 
and  mental  disorder. 

(6)  Syphilitic  neuritis  (optic),  suspicion, 
mania. 

(7)  Syphilitic  ulceration,  disfigurement 
and  morbid  self-consciousness. 

(8)  Congenital  syphilis,  cranial,  sensory 
or  nerve-tissue  defects. 

(9)  Congenital  syphilis,  epilepsy,  idiocy. 

(10)  Infantile  syphilis,  acquired. 

(11)  Constitutional  syphilis,  (a)  vascu- 
lar or  fibrous;  (?j)  epilepsy;  (c)  hemiplegia ; 
(d)  local  palsies;  (e)  general  paralysis, 
cerebral,  spinal  (spastic  and  tabetic),  peri- 
pheral. 

(12)  Locomotor  ataxy  (a.)  with  insane 
crises,  (b)  with  insane  interpretation  of  the 
ordinary  symptoms. 

Moral  Effects  of  Syphilis.  Insane 
Dread  of  SijpltiJis. — This  shows  itself  in 
several  distinct  ways.  A  man  contracts 
sy2)hilis  before  marriage,  and  from  general 
causes  becomes  sleepless  and  depressed ; 
he  may  become  possessed  by  the  idea  that 
it  is  all  due  to  the  syphilis  of  the  past. 
He  may  become  truly  melancholic,  being 
very  sleepless  and  suicidal. 

Or  a  married  man  may  contract  syphilis, 
and  be  harassed  by  the  fear  of  giving  it  to 
his  wife  or  to  his  children. 

In  the  above  cases  syphilis  acts  as  the 
idea  around  which  the  melancholic  feelings 
group  themselves,  the  whole  being  but  an 
exaggeration  of  a  real  fact. 

In  other  cases  the  syphilis  is  the  inter- 
pretation of  morbid  feelings  without  the 
disease  having  been  contracted.  This  is 
true  syphilophobia,  and  is  common  in 
young  men  who  usually  have  been  lead- 


Syphilis  and  Insanity        [     1254    ]        Syphilis  and  Insanity 


ing  unsocial,  solitary,  and  self-conscious 
lives ;  they  may  have  been  absolutely  con- 
tinent, but  more  frequently  they  have 
indulged  in  self-abuse.  In  these  cases 
there  is  generally  complaint  of  uneasy 
feelings  in  the  skin  which  lead  to  fre- 
quently washing  themselves ;  they  also 
often  have  hallucination  of  smell,  which 
makes  them  believe  that  others  can  and 
do  detect  their  syphilitic  state.  In  some 
the  presence  of  acne  adds  weight  to  the 
delusion,  as  they  believe  the  eruption  to 
be  due  to  syphilis.  Such  symptoms  are 
most  common  in  men.  They  are  very  rare 
indeed  in  young  Englishwomen,  because 
they  are  happily  ignorant  of  the  features 
of  the  disease.  They  may  occur  in  women 
about  the  menopause,  and  may  lead  to 
false  accusations  and  jealousy  of  the 
husband. 

We  have  met  with  similar  ideas  in 
elderly  women  who  almost  always  had 
some  vaginal  or  uterine  discharge,  which 
seemed  to  give  rise  to  the  notion  of  syphi- 
litic infection.  Elderly  widows  suffer 
from  disorders  of  this  class.  In  these 
cases  general  treatment  and  change  of 
air  and  scene  is  preferable  to  too  definite 
specific  treatment,  though  in  patients  who 
know  they  have  had  the  disease  we  some- 
times advise  a  visit  to  Aix-la-Chapelle 
and  a  complete  course  of  baths  and  treat- 
ment, as  this  acts  beneficially  on  the 
general  health,  and  may  thus  enable  the 
patient  to  throw  off  his  dread.  There  is, 
however,  considerable  risk  in  sending  such 
patients  abroad  without  skilled  and  watch- 
ful attendants. 

In  some  cases  the  dread  of  syphilis 
gives  rise  to  ideas  of  impotence,  or  at  least 
to  unfitness  for  marriage,  and  this  may  be 
the  foundation  of  melancholia  of  a  very 
dangerous  type. 

We  saw  a  strong,  vigorous  young  ofl&cer, 
full  of  promise  in  his  profession,  who  was 
invalided  for  nervousness  and  sleepless- 
ness. On  arrival  in  England  he  was 
treated  for  syphilis,  which  disease  he  had 
contracted  some  years  before,  and  for 
which  he  was  then  carefully  treated.  No- 
thing could  persuade  him  that  he  was  not 
really  suffering  from  syphilis,  and  that, 
though  attached  to  a  lady  suitable  to  be 
his  wife  in  every  way,  he  had  any  prospect 
of  ever  being  able  to  marry.  His  friends 
could  not  recognise  the  danger  of  his 
symptoms,  and,  though  they  at  length 
obtained  an  attendant,  they  would  not 
give  him  the  authority  required  to  control 
the  patient,  and  the  result  was  his  most 
determined  suicide. 

To  sum  up:  this  class  of  cases  needs 
patient  general  treatment ;  in  young  cases 
the  termination  may  be  in  recovery,  but 


often  is  dementia.  At  the  menopause  re- 
covery may  take  place,  but  chronic  mania 
with  ideas  of  persecution  is  more  common. 
In  old  cases  chronic  mania  or  dementia 
generally  result,  and  apoplexy  is  not  un- 
common. 

Syphilitic  fever  may  be  associated  with 
delii'ium,  and  this  may  form  the  starting- 
point  of  a  maniacal  attack.  We  cannot 
ourselves  remember  coming  across  any 
case  quite  answering  to  this,  but  we  have 
met  with  some  cases  which  convince  us 
that  certain  nervously  weak  people  who 
have  worried  and  drugged  themselves  into 
nervous  instability  may  develop  delirious 
symptoms  out  of  proportion  to  their 
bodily  state,  and  from  this  further  mental 
disorder  may  grow. 

It  is  more  common,  though  by  no  means 
really  common,  to  meet  with  cases  inv^liichj 
tmtli  the  developynent  of  syijliilitic  disease, 
general  ijhysical  and  mental  weakness  is 
'manifested. 

Dr.  Wigles worth  recorded  one  fatal  case 
of  this  kind  at  the  International  Medical 
Congress  at  Washington,  1887.  We  can- 
not explain  the  pathology  of  these  cases  ; 
they  seem  to  depend  on  general  nutri- 
tional disorder  rather  than  on  any  special 
vascular  or  nervous  changes,  and  they 
therefore  deserve  to  be  placed  with  cases 
in  which  the  mental  symptotns  depeml 
on  general  cachexia.  It  was  long  sup- 
130sed  that  the  treatment  of  syphilis  by 
mercury  led  to  some  of  the  worst  cases 
of  constitutional  syphilis,  and  there  is  no 
doubt  but  that  serious  harm  was  done  by 
profuse  salivation  and  by  too  free  and  too 
prolonged  mercurial  treatment.  We  have 
met  with  several  cases  of  constitutional 
syphilis  in  which  the  general  health 
having  been  seriously  affected,  the  mind 
has  also  become  disordered ;  in  these  cases 
melancholy  of  the  stuporose  form  or  asso- 
ciated with  suspicion  were  most  common. 
In  other  cases  more  or  less  complete 
mental  weakness  was  apparent.  If  the 
patients  with  general  symptoms  be  young, 
there  is  a  fair  chance  of  recovery ;  but  if 
past  middle  age,  the  prognosis  is  un- 
favourable. Only  general  measures  are  of 
any  avail. 

In  the  course  of  syphilis  local  troubles 
may  occur  which  may  give  rise  to  insanity. 
These  may  be  nervous  or  nutritional. 

M'euritis. — It  is  not  uncommon  to  meet 
with  optic  neuritis  in  the  course  of  the 
disease,  and  we  have  met  this  associated 
with  temporary  defect  of  sight,  and  this 
caused  the  patient  to  be  suspicious  and 
violent  against  those  whom  he  took  for 
his  persecutors.  Ideas  of  annoyance,  fol- 
lowing, poisoning,  and  the  like  may  arise. 
Symptoms  somewhat  like  those  associated 


Syphilis  and  Insanity        [     1255    ]        Syphilis  and  Insanity 


with  peripheral  neuritis  of  alcohol  or  lead 
may  be  met  with. 

The  treatment  of  these  cases  differs  ; 
in  some  we  have  had  the  best  results  from 
producing  rapid  effects  from  mercurial 
inunctions  or  inhalations,  while  in  some 
the  iodides  did  good,  and  in  others  general 
treatment  and  the  withdrawal  of  specific 
treatment  led  to  recovery.  The  prognosis 
in  these  cases  depends  greatly  on  the  dura- 
tion of  the  disease,  provided  there  are  no 
signs  of  general  paralysis  ;  the  neuritis 
and  its  conset[uences  may  pass  away. 

STutrltional  cbanges  may  occur  de- 
pending on  local  gummata,  specific  intiam- 
mations  affecting  vessels  or  the  nervous 
system.  As  a  result  of  the  above  there 
may  be  disfigurement,  and  this  may  give 
rise  to  ideas  that  the  patients  are  pointed 
at  or  shunned,  or  scoffed  at,  as  lepers. 

The  development  of  this  to  an  insane 
degree  is  slow  as  a  rule,  the  patient  being 
at  first  self-conscious  and  given  to  solitary 
occupation.  He  avoids  strangers,  and 
later  even  shuns  his  relations.  He  may 
take  to  vices  such  as  drink  or  masturba- 
tion ;  then  develop  hallucinations  of  his 
senses,  which  rapidly  lead  to  delusions  of 
persecution.  In  these  cases  violence  is 
common,  and  there  is  a  considerable  risk 
of  homicide  or  suicide. 

As  these  symptoms  generally  develop 
before  middle  life,  there  is  a  prospect  of 
amelioration  if  change  and  occupation 
with  treatment  to  counteract  the  dis- 
figurement are  procured. 

Congenital  Syphilis. — There  is  a  con- 
siderable difference  of  opinion  as  to  the 
part  played  by  this  in  the  production  of 
idiocy.  Medical  ofl&cers  of  asylums,  such 
as  Drs.  Langdon  Down,  Shuttleworth, 
Fletcher  Beach,  only  rarely  obtain  certain 
evidences  of  congenital  syphilis  or  specific 
histories  among  their  patients,  but  physi- 
cians to  children's  hospitals  meet  with 
cases  of  partial  weak-mindedness  associ- 
ated in  many  instances  with  this  disease. 

We  believe  that  congenital  syphilis 
causes  death  from  convulsions  and  from 
other  diseases,  in  children  who  would  pro- 
bably have  been  mentally  defective  had 
they  lived,  and  that  many  minor  nervous 
disorders  occur  in  such  children  who  are 
managed  at  home  because  they  are  physi- 
cally weak,  and  that  these  lesser  neuroses 
are  seen  by  out-patient  physicians  in 
many  patients  who  die  before  maturity. 
But  besides  this,  all  physicians  connected 
with  idiot  asylums  recognise  that  some  of 
their  patients  are  idiotic  as  the  result  of 
congenital  syphilis.  l)r.  Langdon  Down 
puts  the  proportion  as  not  more  than 
2  per  cent.  Dr.  Ireland  takes  no  special 
notice  of  this  as  a  cause.    We  have  met 


with  several  cases  in  which  the  correlation 
was  evident.  The  cases  which  have  come 
specially  under  our  notice  may  be  classi- 
fied under  three  heads :  (a)  those  with 
general  defect  of  development  with  moral 
and  intellectual  want ;  (b)  those  with 
sensory  defect,  and  consequent  mental 
want ;  (c)  those  with  epilepsy  or  paraly- 
sis, and  consequent  epileptic  or  paralytic 
idiocy. 

The  first  class  is  the  least  definite,  and 
contains  children  who  may  be  grouped 
among  the  various  forms  of  idiots,  the 
only  special  feature  being  a  distinct  his- 
tory of  parental  syphilis  with  evidences 
of  the  disease  in  the  patient.  We  have 
met  such  children  fairly  well  formed  as  to 
head,  but  who  after  early  infancy  have 
not  developed ;  they  have  learnt  to  walk, 
but  not  to  talk,  and  are  restless  and  mis- 
chievous, and  only  to  a  very  small  degree 
educable.  They  require  to  be  removed 
from  home  for  the  sake  of  the  other  chil- 
dren and  for  special  training. 

The  group  (6)  contains  cases  in  which 
specific  infiammation  lias  caused  deafness, 
or  blindness,  or  both,  in  early  infancy, 
these  defects  leading  to  idiocy  by  depriva- 
tion of  sensory  stimulation.  In  some  of 
these  cases  special  edncation  for  deaf  and 
dumb  and  blind  fails  to  develop  any  really 
useful  mind,  and  with  the  growth  of 
sexuality  and  desire  much  serious  trouble 
may  arise,  and  the  small  mental  gain 
effected  may  be  ruined  very  rapidly.  The 
probable  end  of  these  cases  is  early  death 
from  some  physical  disease  such  as  phthi- 
sis. 

In  group  (c)  we  have  two  divisions,  the 
epileptic  and  the  paralytic ;  the  former 
frequently  begin  with  convulsive  seizures 
in  early  infancy,  and  these  fits  recurring 
become  habitual  and  prevent  mental  de- 
velopment. In  some  cases  the  fits  cease 
at  some  period  of  life,  say  about  seven  or 
fourteen  years  of  age,  but  as  a  rule  the 
mind  has  been  too  seriously  damaged  to 
recover,  and  the  patient  remains  a  quiet 
non -epileptic  idiot.  In  the  paralytic  cases 
and  in  some  epileptic  ones  local  lesions 
about  the  cranium,  the  membranes,  and 
the  brain  itself  are  the  cause  of  the  convul- 
sive or  paralytic  symptoms.  As  a  rule, 
these  paralytic  idiots  are  hopelessly  weak, 
and  need  asylum  care,  and  they  usually 
live  but  a  short  time.  In  a  few  cases  the 
general  symptoms  of  congenital  syphilis 
only  affect  the  mind  later.  Thus,  defect 
of  sight  or  of  hearing  may  act  in  the 
same  way  that  disfigurement  did  in  making 
the  patient  morbidly  solitary,  self-con- 
scious, and  suspicious ;  in  the  end  becom- 
ing deluded  and  insane.  These  cases 
generally  are  met  with  in  young  women, 


Syphilis  and  Insanity        [     1256    ]        Syphilis  and  Insanity 


and  the  prospect  of  cure  is  very  slight, 
most  of  the  patients  passing  into  chronic 
weak-mindedness  or  delusional  insanity. 
We  have  met  with  one  case  in  which 
infantile  acquired  syphilis  seemed  to  be 
associated  with  defective  mental  growth. 
A  young  man  who  bore  about  him  all  the 
marks  of  acquired  syphilis,  which  was 
traced  clearly  to  his  wet-nurse,  broke 
down  soon  after  adolescence,  and  suffered 
from  stupor  with  recurring  attacks  of 
excitement,  the  whole  tending  to  dementia. 
He  belonged  to  a  typically  healthy  family, 
and  there  did  not  seem  to  be  any  probable 
cause  for  his  malady  other  than  the  con- 
stitutional syphilis  which  was  manifest, 
and  it  seems  to  us  to  be  likely  that  it 
should  thus  be  possible  to  produce  a 
nervous  instability  which  showed  itself  at 
the  first  critical  period  of  the  man's  life. 

Insanity  associated  with  Constitu- 
tional Syphilis. — While  studying  this 
group  of  cases  we  shall  take  it  for  granted 
that  syphilis,  when  it  is  considered  as  con- 
stitutional, affects  by  preference  certain 
tissiies,  and  that  nervous  and  mental 
disorders  will  be  found  to  be  related  to 
the  nature  and  seat  of  the  diseased  pro- 
cess. Fibrous  tissues  appear  to  be  very 
liable  to  syphilitic  disease,  and  we  find  the 
periosteum,  the  pericranium  and  dura 
mater  liable  to  thickenings  due  to  syphilis. 
Vessels  also  suffer  in  various  degrees  from 
inflammatory  changes  and  the  thickenings 
of  their  coats  ;  it  is  doubtful  whether  the 
nervous  elements  in  the  skull  themselves 
suffer;  the  syphilitic  growths  are  more  com- 
mon along  the  superior  and  central  parts, 
the  parts  represented  by  the  chief  arterial 
supply.  In  the  spinal  cord  the  posterior 
part  seems  to  be  more  liable  than  the 
anterior.  The  symptoms  may  be  due  to 
nutritional  changes  leading  to  disorder  or 
to  degeneration  leading  to  functional  de- 
fect. We  shall  have  to  refer  first  to  the 
cases  in  which  the  relationship  is  clear,  and 
after  that  to  some  of  the  cases  in  which  the 
connection  is  not  so  easily  established. 

Syphilis  may  give  rise  to  epilepsy, 
and  this  ej^ilepsy  may  lead  to  mental 
disorder  of  the  epileptic  type.  (*S'ee  Epi- 
lepsy.) 

Sjrphilis  may  grive  rise  to  hemiplegria, 
which  again  may  be  followed  by  dementia. 

Syphilis  may  be  followed  by  local 
palsies  which  may  be  associated  with 
mental  disorders. 

Syphilis  may  give  rise  to  pseudo- 
greneral  paralysis  of  the  insane. 

Syphilis  may  give  rise  to  true  gene- 
ral paralysis  of  the  insane,  (l)  of  the 
cerebral;  or  (2)  spinal — (a)  spastic,  (b) 
ataxic — type ;  or  (3;  of  a  type  beginning 
with  i:)eri]jlieral  disease. 


Syphilis  may  give  rise  to  epilepsy.     If 

a  middle-aged  man  who  has  had  syphilis 
has  a  series  of  epileptic  fits  not  associated 
with  injury  or  alcohol,  it  is  probable  that 
syphilis  is  the  cause,  and  the  benefit 
which  follows  treatment  confirms  the 
diagnosis. 

In  these  cases  there  is  considerable  risk 
of  the  development  of  paralytic  symptoms, 
and  of  dementia,  and  if  these  occur  the 
prognosis  is  iinfavourable,  as  they  point 
to  real  organic  brain  injury.  It  must  be 
remembered  that  epileptiform  fits  under 
the  same  conditions  may  point  to  the 
development  of  general  paralysis. 

Epilepsy  may  result  from  local  irrita- 
tive thickening  of  the  membranes,  from 
some  local  gummatous  swelling  growing 
into  the  surface  of  the  brain,  or  to  some 
vascular  lesion  of  a  specific  knd.  We  believe 
too  that  a  dynamical  change  may  occur  in 
patients  suffering  from  syphilis  which 
renders  them  epileptically  unstable,  like 
some  of  the  guinea-pigs  experimented  upon 
by  Brown-Sequard. 

In  our  experience  the  epilepsy  of  syphi- 
lis tends  to  stupidity  rather  than  vio- 
lence, so  that  it  is  rare  to  meet  with  the 
regular  epileptic  maniac  whose  epilepsy 
resulted  from  syphilis.  If  not  cured  by 
ti'eatment  the  tendency  is  to  local  para- 
lysis and  to  dementia. 

Syphilis  and  Hemiplegia  -with  De- 
mentia.— A  very  large  number  of  patients 
are  admitted  into  the  general  hospitals 
with  hemiplegic  systems,  and  a  fair  pro- 
portion depend  on  syphilis.  Many  of 
these  cases  recover  under  treatment,  but 
some  remain  with  permanently  contracted 
limbs  and  with  other  motor  defects ;  some, 
especially  of  the  latter  group,  are  pro- 
gressively weaker  in  mind,  and  become 
jiermanent  dements.  The  general  history 
is  as  follows  :  A  middle-aged  patient  who 
has  had  syjihilis  a  variable  number  of 
years  before,  after  some  causes  of  physical 
or  nervous  exhaustion,  has  a  fit  followed 
by  hemiplegia  ;  there  is  a  partial  recovery 
of  power,  but  the  j^atient  has  lost  all  his 
energy,  he  is  placid  and  perhaps  childish  ; 
he  may  be  irritable  and  emotional;  his 
memory,  though  at  first  not  much  affected, 
fails  apparently  from  lack  of  attention ; 
sleep  is  generally  good  and  appetite  large; 
the  bodily  weight  often  increases.  This 
state  of  mental  weakness  often  remains 
unchanged  for  years,  and  just  as  such  a 
patient  may  have  a  useless  and  con- 
tracted limb  which  never  becomes  more 
palsied,  so  the  mental  powers  may  degrade 
to  a  certain  point,  and  there  remain 
stationary. 

In  some  cases  the  stage  of  dementia  is. 
preceded  by  mental  excitement,  so   that 


Syphilis  and  Insanity        [     1257    ]        Syphilis  and  Insanity 


patients,  after  a  fit,  are  paralysed  and 
quiet  for  a  time,  and  then  become  wild, 
emotional,  and  maniacal ;  this  stage  may 
lead  to  I'apid  dissolution,  or  may  be  re- 
placed by  mental  weakness  similar  to  the 
last  described,  liecurring  fits  may  be 
present  leading  to  more  raj^id  degeneracy. 

]Local  Paralysis  due  to  Sypbilis  fol- 
loived  by  Insanity. — We  believe  that  it 
is  fully  recognised  that  syphilis  has  a 
special,  almost  characteristic,  way  of 
causing  isolated  local  losses  of  power  in 
which  the  cranial  nerves  suffer  very  fre- 
quently, and  it  is  noteworthy  that  such 
paralyses  may  be  associated  with  or 
tbllowed  by  various  forms  of  mental  dis- 
order. When  later  discussing  the  relation- 
ship existing  between  general  paralysis  of 
the  insane  and  syphilis  we  shall  have  to 
point  out  the  frequency  with  which  one 
meets  in  the  last  disease  with  a  preceding 
history  of  local  syphilitic  paralysis. 

After  a  cranial  nerve-paralysis,  or  after 
specific  afiection  of  the  sjjecial  senses, 
treatment  may  be  followed  by  removal  of 
all  the  visible  symptoms,  and  yet  the 
patient  may  slowly  from  that  time  exhibit 
changes  in  character  and  habits  which 
tend  to  eccentricity  or  insanity.  In  some 
of  these  there  is  a  blunting  of  the  higher 
moral  sense  so  that  low,  vulgar,  or  vicious 
acts  are  done  quite  in  opposition  to  the 
ordinary  habits  of  the  individual  ;  sober 
men  take  to  drink,  and  moral  men  to  vice ; 
active  men  become  indolent,  truthful  ones 
become  untrustworthy,  and  social  men 
may  become  morose.  At  first  the  changes 
are  nearly  always  modifications  of  the 
finer  social  adjustments.  Patients  who 
have  thus  begun  to  degenerate  often 
rapidly  go  down  hill,  their  powers  of 
resistance  as  well  as  their  powers  of  control 
failing,  or  temporary  improvement  may 
occur. 

General  Paralysis  of  tbe  Insane  and 
Sypbilitic. — Probably  there  is  no  point 
about  which  there  is  more  difference  of 
opinion  among  neurologists  than  as  to  the 
part,  if  any,  played  by  syphilis  in  the 
production  of  this  disease.  Those  chiefly 
concerned  in  the  treatment  of  syphilis 
have  been  inclined  to  think  that  syphilis 
is  not  a  frequent  cause ;  while  those  who 
have  good  opportunities  of  watching  the 
origin  of  general  paralysis  of  the  insane 
seem  to  be  impressed  by  the  belief  that 
it  is  a  very  important  factor  in  the  disease. 
It  is  noteworthy  that  among  the  more 
educated  classes  in  whom  accurate  his- 
tories can  be  more  readily  obtained,  a 
specific  history  is  more  frequently  met 
with  than  among  the  inhabitants  of 
pauper  asylums.  Physicians  in  large  con- 
sulting  practice,  and  medical  officers  to 


asylums  for  the  better  classes,  as  a  rule 
attribute  a  good  deal  of  importance  to 
syphilis  in  the  production  of  the  disease. 
Genei'al  paralysis  is  most  common  where 
syphilis  is  most  common,  but  this  only 
means  that  it  is  a  disease  most  frequently 
met  with  in  the  centres  of  highly  civilised 
populations.  It  has  been  said  that 
syphilis  is  very  common  among  certain 
nomadic  tribes  among  whom  general 
paralysis  is  unknown.  We  cannot  say 
we  trust  either  of  these  statements.  We 
believe  that  at  least  seventy  per  cent,  of 
our  private  cases  of  general  paralysis  have 
clear  histories  of  constitutional  syphilis. 

We  do  not  look  upon  general  paralysis 
as  necessarily  of  specific  origin,  but  we 
consider  syphilis  is  one  of  its  most  com- 
mon causes.  We  believe  it  acts  in  differ- 
ent ways  in  different  persons,  and  affects 
different  parts  of  the  nervous  system,  but 
that  its  tendency  is  to  start  a  process  of 
degeneration  which  ultimately  produces 
the  ruin  we  recognise  as  general  paralysis, 
and  that  it  may  play  the  sole  or  only  a 
partial  cause. 

Sypbilis  may  give  Rise  to  Pseudo- 
or  True  General  Paralysis. — There  is  a 
grouji  of  interesting  cases  in  which  a  history 
of  syphilis  is  followed  in  the  course  of  years 
by  symptoms  of  motor  and  mental  insta- 
bility. As  a  rule  the  symptoms  are  more 
physical  than  mental  at  the  outset,  but 
they  vary  widely,  but  generally  are  dia- 
gnosed with  assurance  of  certainty  as 
typical  general  paralytics  ;  the  symptoms 
run  the  ordinary  course,  and  may  confirm 
the  opinion  already  formed,  but  at  some 
period  in  the  development  of  the  symp- 
toms there  is  a  distinct  arrest,  so  that, 
though  permanently  damaged,  the  patient 
may  live  for  years  in  a  state  of  restricted 
intellect.  We  have  met  with  cases  of  this 
kind  in  which  the  handwriting  and  gait 
were  affected  to  some  extent,  while  the 
memory  was  defective  and  exaggeration 
of  ideas  was  also  well  marked,  and  yet 
tbese  symptoms  remained  unchanged  for 
several  years.  In  others,  the  patients 
passed  into  a  fat  and  partly  weak- 
minded  state,  and  there  remained  for  many 
years,  and  we  have  even  seen  patients  who 
appeared  to  be  in  the  third  and  paralytic 
stage  with  epileptiform  fits,  in  whom  the 
disease  stopped,  and  the  paralysed  patient 
regained  a  good  deal  of  physical  as 
well  as  some  mental  power.  In  referring 
to  the  above  cases  we  must  admit  that 
similar  arrests  of  symptoms  may  occur  in 
other  cases  of  general  paralysis  than  in 
those  depending  on  syphilis,  but  in  our 
experience  the  syphilitic  cases  provide  the 
more  common  examples. 

In  these  cases  some  acute  bodily  dis- 


Syphilis  and  Insanity        [     1258    ]        Syphilis  and  Insanity 


ease  or  some  cause  of  profuse  suppuration 
may  be  associated  with  the  amelioration. 
When  referring  to  these  cases  we  wish  to 
add  that  the  relief  is  not  only  temporary, 
but  is  in  some  cases  persisting  after  eight 
or  ten  years. 

True  general  i:)aralysis  associated  with 
syphilis  may  be  (i)  cerebral  and  (3)  sinned 
— (a)  spastic  or  (b)  ataxic. 

The  cerehral  again  divides  itself  into 
that  of  general  and  that  of  local  origin. 

A  certain  number  of  cases  begin  with 
progressive  loss  of  power  and  of  self- 
control,  there  being  a  steady  loss  from 
the  highest  and  last  acquirements  to  the 
more  organic. 

There  is  nothing  to  separate  these  cases 
from  similar  ones  due  to  other  causes,  and 
the  pathology  is  in  no  way  special.  In 
another  group  of  cases  to  which  allusion 
has  already  been  made  a  local  syphilitic 
lesion  occurs,  and  may  be  recovered  from, 
and  yet  later  a  degeneration  may  arise 
from  the  eai-ly  local  lesion. 

In  our  experience  it  is  very  common  to 
meet  with  such  a  history  as  the  follow- 
ing:— A  middle-aged  man  who  has  suf- 
fered slightly  from  syphilis  years  before  is 
exposed  to  causes  of  mental  and  physical 
exhaustion,  and  then  for  the  first  time 
has  a  local  cranial  nerve  defect,  the  most 
common  being  ptosis,  external  strabismus, 
and  mydriasis.  In  some  cases  optic  neu- 
ritis is  present.  Energetic  treatment  is 
followed  by  cure  of  all  or  most  of  the 
local  symptoms  ;  the  patient  returns  to 
work,  but  sooner  or  later,  generally  within 
two  years,  irritability  and  change  of  dis- 
position, followed  by  distinct  loss  of 
mental  power,  point  to  the  disease  which 
is  making  progress.  The  course  of  the 
disease  may  be  either  that  of  excitement 
or  of  depression,  but  dementia  with  fits  is 
the  general  end. 

We  have  met  with  so  many  of  these  cases 
that  we  cannot  but  associate  the  general 
disease  with  the  evidences  of  local  disease. 
In  some  respects  the  pathology  is  allied 
to  that  of  general  paralysis  following  con- 
cussion of  the  brain.  As  in  a  ripe  pear, 
general  degeneration  rapidly  follows  a 
slight  local  injury. 

General  Paralysis  of  Syphilitic 
Origin  with  (a)  Spastic  Spinal  Symp- 
toms. —  We  recognise  a  considerable 
number  of  cases  of  this  variety  of  general 
paralysis  with  a  distinct  syphilitic  his- 
tory. Some  of  the  youngest  cases  of 
general  paralysis  which  have  come  under 
our  care  belong  to  this  group  as  well 
as  many  of  the  cases  in  women.  The 
early  symptoms  are  of  the  ordinary  tyjje, 
but  we  believe  that  in  most  the  pupils 
will  be  found  rather  large  and  unequal. 


irregular  in  outline  ;  the  skin  of  the  face 
is  less  greasy,  and  there  are  commonly 
capillary  stigmata  over  the  malar  pro- 
cesses, the  reflexes  are  very  much  exag- 
gerated, speech  is  early  and  severely 
implicated,  and  the  handwriting  is  very 
shaky  ;  the  gait  is  jerky.  Though  there 
may  be  arrest  of  this  disease,  in  our  expe- 
rience it  runs  often  a  rapid  course,  causing 
great  conti-action  of  limbs  and  a  tendency 
to  bedsores ;  grinding  of  the  teeth  and 
movements  as  of  swallowing  are  common  ; 
fits  may  be  present,  and  post-mortem 
excess  of  fluid  in  membranes  and  lateral 
ventricles  is  more  common  than  adhe- 
sions ;  there  are  specially  wasted  areas, 
and  the  pyramidal  tracts  of  the  cord  are 
degenerated.  It  must  be  remembered 
that  this  description  in  no  way  differs 
from  general  paralysis  produced  by  some 
other  causes,  but  it  has  been  so  frequently 
met  with  by  us  in  young  sisecific  cases 
that  we  believe  it  should  be  here  recorded. 

We  believe  that  the  local  convolutional 
waste  and  the  secondary  cord  degenera- 
tions are  related  and  may  be  found  con- 
nected with  the  specific  cause. 

General  Paralysis  of  Specific  Origin 
■with  (b)  Ataxic  Symptoms. — Suffice  it 
to  say  that  the  mental  symptoms  may 
precede  the  ataxy,  may  coincide  with  it, 
or  they  may  follow  the  fully  developed 
symptoms. 

It  is  pretty  generally  accepted  in  Eng- 
land that  locomotor  ataxy  has  very  com- 
monly a  specific  origin.  On  the  Continent, 
in  France  especially,  this  disorder  is  more 
commonly  considered  as  allied  to  the  neu- 
roses, but  in  any  case  the  coincidence  of 
ataxy  with  syphilis  is  common. 

It  is  noteworthy  that  this  is  more  com- 
mon in  men  than  in  women,  and  that 
general  paralysis  with  ataxy  is  also  more 
common  with  men,  that  ataxy  and  ataxic 
symptoms  are  rare  in  women. 

There  is  nothing  special  in  the  form  of 
general  paralysis  with  ataxy,  but  it  is 
noteworthy  that  in  some  of  these  cases 
there  is  a  marked  tendency  to  remissions 
or  to  alternations,  so  that  both  ataxy  and 
mental  defect  pass  oif  in  part,  or  the  one 
develops  while  the  other  is  in  abeyance. 

We  are  sometimes  inclined  to  think 
that  there  is  a  cerebral  or  inti'a-cranial 
ataxy  apart  from  the  changes  in  the 
spinal  cord,  and  that  just  as  in  the  spastic 
general  joaralysis  the  degeneration  of  the 
cord  is  secondary,  so  in  ataxic  general 
paralysis  the  same  may  be  true  {see  Loco- 
motor Ataxy  as  allied  to  Neuroses). 

General  Paralysis  of  Specific  Origin 
and  Peripheral  Disease. — At  one  time  a 
good  deal  was  written  about  general  para- 
lysis "  par  propagation,"  and  though  one 


Syphilitic  Disease 


[    1259    ] 


Syphilitic  Disease 


recognises  local  intra-cranial  lesions  as 
eflBcient  causes  for  genei'al  paralytic  de- 
generation, and  also  believes  that  sjjinal 
lesions  may  lead  to  the  same,  it  is  hard 
to  prove  that  local  peripheral  neuritis 
of  a  specific  or  other  nature  may  cause 
similar  changes. 

We  only  suggest  the  possibility,  though 
we  cannot  give  any  cases  fully  supporting 
the  theory. 

Syphilis  may  lead  to  iincomplicated 
locomotor  ataxy  which  may  exhibit  insane 
crises  or  insane  interpretation  of  symp- 
toms (see  LocoMOTOK  Ataxy  as  allied  to 
Neukoses).  Geo.  H.  Savage. 

SYPHZI.ZTXC  (HERUBZTARY) 
SZSEiiSi:  OF  THE  NETtVOVS  SVS- 
TX:i>X. — The  labours  of  Hutchinson  on 
certain  diseases  of  the  sense  organs, 
especially  interstitial  keratitis  and  specific 
deafness,  and  their  association  with  a  cha- 
racteristic altei'ation  of  the  upper  median 
permanent  incisors,  gave  the  first  great 
impulse  to  the  study  of  the  subject  with 
which  we  are  concerned  in  this  article. 

The  subsequent  discovery  of  the  fre- 
quency of  disseminated  choroiditis  in  the 
subjects  of  congenital  syphilis  was  a 
further  step  in  advance.  Hydrocephalus 
was  assumed  to  be  present  in  some  syphi- 
litic children  on  account  of  the  large 
massive  head  sometimes  found  in  such 
children,  but  the  anatomical  proof  was 
not  forthcoming,  and  it  was  generally 
agreed  that  in  marked  contrast  with 
acquired  syphilis  there  was  exceedingly 
little  proneness  to  affection  of  the  central 
nervous  system  in  the  hereditary  form. 
The  publication  of  Heubner's  work  on 
syphilitic  affections  of  the  cerebral  arteries, 
although  it  referred  only  to  the  acquired 
disease,  gave  a  fresh  impulse  to  the 
investigations  in  morbid  anatomy,  and 
within  the  last  fourteen  years  a  great 
number  of  examples  of  disease  of  the 
central  nervous  system  in  hereditary 
syphilis,  have  been  described  by  various 
observers. 

It  may,  indeed,  now  be  said,  in  contrast 
to  the  early  views,  that  nearly  every  variety 
of  nervous  affection  of  acquired  syphilis 
has  its  parallel  amongst  congenital 
examples,  albeit  there  are  indications  of  a 
few  broad  differences  which  may  be  made 
out  as  to  the  relative  frequency  alike  of 
lesions  and  symptoms  between  the  two 
groups. 

It  is  convenient  to  consider  the  subject 
of  hereditary  syphilitic  disease  of  the 
nervous  system  from  the  side  of  (A) 
morbid  anatoioy  ;  and  (B)  symptomato- 
logy. 

The  multiplicity  of  co-existing  lesions  is 
often  so  great  that  it  is  difficult  to  corre- 


late the  anatomical  and  clinical  features ; 
but  the  two  sets  of  observations  nkay  be 
broadly  grouped  as  follows  : — 

(A)  IVIorbid  Anatomy. 

Lesions  of  the  following  tissues  :  Bones 
of  cranium  ;  membranes  (dura  mater  and 
pia  arachnoid) ;  blood-vessels  ;  brain  sub- 
stance (cortex,  ventricles,  great  ganglia, 
pons,  medulla) ;  cerebral  nerves  ;  organs 
of  special  sense  ;  associated  spinal  disease 
(bones,  membranes,  cord,  spinal  nerves). 

(B)  Symptomatologry. 

(a)  Convulsions  ;  (6)  headache  and  irri- 
tability ;  (c)  i^aralysis,  aphasia,  affections 
of  cranial  nerves  ;  (d)  psychical  delects ; 
(e)  spinal  symptoms. 

(A)  Morbid  Anatomy.     Ci'anial bones: 

(i)  Early  Fodhs. — The  two  varieties 
which  have  come  under  our  own  observa- 
tion have  been  (a)  small  definite  gum- 
matous infiltrations  of  the  skull  bones 
causing  a  varying  amount  of  absorption 
of  tissue,  and  in  one  case  eroding  down  to 
the  surface  of  the  dura  mater  (this  form 
we  believe  to  correspond  with  Parrot's 
early  localised  gelatiniform  transforma- 
tion of  the  skull) ;  (&)  small  areas  of  caries 
affecting  the  inner  plate  of  the  bones 
of  the  vault,  but  also  in  some  instances 
the  basis  cranii.  In  connection  with 
both  forms  exfoliation  of  small  plates  of 
bone  may  occur. 

(2)  Late  Forms. — Localised  gummatous 
infiltrations  also  occur  in  the  skull  in 
older  children,  and  they  may  lead  to 
ulceration  and  some  loss  of  substance ; 
sometimes  there  occurs  a  certain  amount 
of  localised  atrophy  without  lesion  of  skin. 
Thickening  is  more  common.  In  syphi- 
litic children  massive  thickening  of  the 
bones  of  the  skull  has  been  recognised 
ever  since  Mr.  Hutchinson  drew  attention 
to  the  prominent  frontal  present  in  many 
of  the  subjects  of  interstitial  keratitis  first 
described  by  him.  This  massive  thicken- 
ing, though  most  common  in  the  frontal 
region,  tends  in  older  children  and  young 
adults  to  be  diffused,  and  all  parts  of  the 
skull  may  show  it.  Thus,  in  a  case  under 
the  care  of  Dr.  Henry  Humphreys  so 
marked  was  the  thickening  at  the  base 
that  many  of  the  basal  foramina  were 
distinctly  narrowed  in  consequence.  There 
is  good  reason  to  believe  that  this  thicken- 
ing is  sometimes  slowly  progressive  over 
considerable  periods.  Sections  of  such 
bone  show  great  compression  of  Haversian 
systems,  and  the  Haversian  canals  in 
parts  may  be  almost  obliterated. 

It  must  still  remain  an  open  question 
as  to  the  relation  between  these  cases  of 
massive  thickening  of  the  skull  and  the 
hyperostosis  of  cranial  bones,  which  are 
often   present  in   young   children.     The 


Syphilitic  Disease 


[     1 260    ] 


Syphilitic  Disease 


cranial  bosses  of  soft  vascular  bone  situ- 
ated around  the  foutanelle,  but  extending 
to  a  varying  degree  along  the  parietals  and 
frontal,  were  claimed  by  M.  Parrot  as 
syphilitic  manifestations.  Such  masses, 
which  generally  become  obvious  within 
the  first  or  second  year  of  life,  increase 
to  a  varying  amoimt,  then  sometimes 
undergo  absorption  and  sometimes  ossify 
into  spongy  lens-shaped  osteoj^hytes. 
These  osteophytes  may  undergo  absorp- 
tion, but  not  unfrequently  result  in  a 
light  porous  form  of  osseous  deposit,  and 
occasionally  dense  hard  bone  is  the  final 
outcome. 

With  regard  to  the  car/^  cranial  bosses, 
we  are  now  convinced  that  M.  Parrot's 
view  is  incorrect.  It  is  true  that  syphilis 
and  rickets  often  co-exist,  and  it  is  pro- 
bable that  syphilis,  as  a  chronic  hindrance 
to  good  nutrition,  is  one  amongst  other 
factors  of  rickets.  Thus,  the  cranial 
bosses  are  often  present  in  syphilitic  and 
rickety  children,  but  they  occur  in  chil- 
dren in  whom  syphilis  can  be  absolutely 
negatived,  and  the  balance  of  evidence  is 
in  favour  of  their  being  rickety  manifes- 
tations of  the  skull  accompanied  by  other 
signs  of  rickets  in  the  skeleton,  but  occa- 
sionally out  of  all  proportion  to  changes 
in  the  ribs  and  long  bones.  The  perma- 
nent light  spongy  hyperostosis  of  skull 
bones  we  also  believe  to  be  rickety  in 
derivation.  But  when  there  is  definite 
massive  sclerosis  of  skull  in  a  child  over 
five  years,  or  in  adolescence,  we  believe 
the  presumption  to  be  in  favour  of  syphi- 
lis in  addition  to  rickets. 

Asymmetry  of  the  cranium  is  sometimes 
found  both  in  rickets  and  in  rickets  com- 
bined with  congenital  syphilis.  A  common 
form  presents  flattening  of  one  parietal 
occipital  region  with  some  prominence  of 
the  opiDosite  frontal,  so  that  a  horizontal 
tracing  of  the  skull  presents  a  somewhat 
lozenge-shaped  contour. 

Craniotahes,  by  which  is  meant  a  form 
of  atrophy  commencing  in  small  areas  on 
the  inner  table  and  extending  through  to 
the  outer  surface  affecting  predominantly 
the  postero-lateral  regions  of  the  skull,  is 
a  condition  practically  confined  to  the 
first  eighteen  months  of  life.  It  is  cer- 
tainly very  common  in  sj'philitic  children, 
but  it  occurs  in  infants  in  whom  syphilis 
may  be  excluded,  and  the  old  view,  accord- 
ing to  which  it  was  considered  a  manifes- 
tation of  rickets,  is  probably  the  correct 
one. 

The  typical  hydrocephalic  skull,  cha- 
racterised by  gaping  sutures,  large  fonta- 
nelles,  thinning  of  bones,  and  more  or  less 
spherical  contour,  is  sometimes  found  in 
children  the  subjects  of  congenital  syphi- 


lis. It  must  also  be  noted  that  hydro- 
cephalus, only  moderate  in  amount  and 
probably  stationary,  has  also  been  found 
post-mortem  in  some  cases  where  massive 
thickening  of  skull  bones  was  present 

A  Iterations  of  the  nasal  hones  deserve 
enumeration,  for,  although  no  anatomical 
proof  is  forthcoming,  it  is  quite  possible 
that  in  some  cases  syphilitic  damage  to 
these  bones  may  give  the  starting-point 
to  meningeal  disease.  Caries  of  the  nasal 
bones  occurs  rarely  in  congenital  syphilis. 
The  commoner  conditions  are  : 

(i)  Stunted  growth,  which  seems  to 
result  from  the  early  interference  with 
nutrition  in  connection  with  the  prolonged 
nasal  catarrh  of  the  infantile  period ;  and 

(2)  Chronic  periostitis  and  sclerosis  of 
these  bones,  leading  to  thickening. 

Dura  Mater. — This  has  been  found 
greatly  thickened,  assuming  an  almost 
cartilaginous  consistency  in  spots.  Also 
hteniorrhage  has  occurred  in  connection 
with  pachymeningitis,  giving  rise  to 
laminee  of  fibrine.  Inflammatory  deposits 
also  have  been  observed  in  various  stages, 
and  likewise  adhesions  generall)'  localised,, 
of  bone,  dura-mater,  pia  arachnoid,  and 
brain  tissue. 

The  presumption  is  that  in  the  majority 
of  cases  the  diseased  process  begins  with 
an  internal  periostitis  of  one  or  other 
cranial  bone. 

In  some  of  the  cases  (referred  to  in  the 
previous  section)  of  caries  of  the  inner 
table  the  connection  with  pachymeningi- 
tis is  obvious.  It  seems  probable  (though 
it  cannot  be  proved)  that  the  initial  bone 
change  may  in  some  cases  undergo  repair 
so  as  to  leave  little  obvious  sign,  whilst 
the  meningeal  disease  once  initiated  is 
slowly  progressive. 

(3)  Fia  Anichnoid. — All  varieties  of 
inflammatory  deposit  have  been  found  in 
the  pia  arachnoid  in  hereditary  syphilis. 
Thus,  patches  of  green  lymph  in  the 
meshes  of  the  pia,  both  on  convexity  and 
at  anterior  and  posterior  base,  have  been 
found  in  varying  amount.  Simple  acute 
meningitis  is  a  condition  so  easily  set  up 
in  infancy  that  its  presence  in  a  child  the 
subject  of  hereditary  syphilis  is  not  neces- 
sarily to  be  attributed  to  the  syphilitic 
virus.  The  more  chronic  forms  show 
great  variety  and  admit  of  greater  certi- 
tude. The  simplest  form  is  a  milky  tur- 
bidit}^  sometimes  widely  spread  and  accom- 
panied by  brain  and  nerve  changes  to  be 
presently  described.  Another  form  shows 
extreme  fibroid  thickening,  and,  as  we  have 
seen  in  one  infantile  case,  even  a  little  cal- 
careous change.  The  fibroid  cases  may  be 
accompanied,  as  in  Siemerling's  remark- 
able example,  by  actual  gummata  situated 


Syphilitic  Disease 


[     1261     ] 


Syphilitic  Disease 


in  the  iuHammatory  deposit,  or,  as  in  one 
of  the  earliest  recorded  examples  described 
by  one  of  us,  small  arteries  may  be  found 
in  the  intiltrated  meninges,  showing 
partial  thrombosis  and  Heubner's  changes 
in  the  inner  and  middle  coat.  Traces  of 
old  hannorrhage  have  also  been  found  in 
intiammation  of  the  pia  as  well  as  in 
affection  of  the  dura. 

(4)  Aricrics. — The  characteristic  endo- 
arteritis  affecting  the  inner  and  middle 
coats  described  bj'  Heubuer  in  acquired 
brain  S3'philis  has  been  subsequently 
observed  in  a  considerable  number  of 
hereditary  cases,  and  the  gratuitous  sug- 
gestion by  a  French  writer  that  some  of 
the  early  examples  were  really  acquired, 
and  not  hereditary,  scarcely  merits  con- 
sideration. 

Not  only  in  the  basal  arteries,  but,  as 
mentioned  above,  in  some  of  the  small 
arteries  on  the  convexity  in  the  midst  of 
meningeal  thickening,  similar  changes 
have  been  found.  The  small  arteries 
may  be  diseased  when  the  large  ones  are 
healthy,  or  vice  versa,  or  both  may  be 
affected  together.  They  stand  out  like 
cords  having  a  milky-looking  surface,  or 
may  closely  resemble  dirty  white  threads. 
Also  in  the  smaller  vessels  especially 
associated  with  inHammatory  deposits 
peri-arteritis,  as  well  as  endo-arteritis,  has 
been  demonstrated. 

(5)  Brain  Proper. — The  most  striking 
and  in  every  way  important  changes  have 
been  found  in  the  cortex.  Softening  has 
been  occasionally  found  (Angel  Money), 
but  far  more  frequently  hardening.  The 
sclerosis  has  in  our  experience  occurred  in 
some  cases,  in  small  nodular  masses,  not 
bigger  than  split  peas,  in  other  cases  it 
has  "  i^icked  out "  convolutions  in  the 
same  fashion  as  diffuse  glioma  but  with- 
out increase  of  bulk ;  but  in  the  majority 
of  examples  it  has  affected  large  tracts  of 
one  or  both  hemispheres  to  a  varying 
amount  in  different  regions.  Not  unfre- 
quently  sclerosis  has  been  found  associated 
with  a  certain  amount  of  atrophy.  The 
narrowing  of  separate  convolutions,  the 
alteration  of  consistency  to  that  of  carti- 
lage, and  the  very  slight  alteration  of 
colour  towards  a  brownish  pink,  are  very 
characteristic  features. 

The  sclerosis  may  extend  for  a  short 
depth  into  the  white  matter,  and  in  a  case 
aged  two  years  four  months,  shown  to  one 
of  us  by  Dr.  Robert  Bridges,  this  condi- 
tion also  affected  both  optic  thalami  and 
part  of  the  roof  of  the  lateral  ventricles. 
But  predominantly  and  often  exclusively, 
sclerosis  of  congenital  syphilis  is  cortical. 
Microscopic  examination  shows  an  exten- 
sive overgrowth   of  neuroglia  and  disap- 


pearance of  nerve  cells.  Some  accom- 
panying alteration  of  the  pia  arachnoid  is 
almost  invariable,  and  in  not  a  few  cases 
there  is  symphysis  (as  Fournier  designates 
it)  between  dura,  pia  arachnoid,  and  scle- 
rosed cortex.  The  hypothesis  that  the 
initial  change  is  meningitis,  and  that  the 
hbroid  induration  and  limitation  of  growth 
of  the  cortex  arc  duo  to  the  chronic  menin- 
gitis is  a  very  tempting  one.  But  this 
hypothesis  will  not  always  apply,  for  in 
some  cases  the  implication  of  the  pia 
arachnoid  only  amounts  to  a  slight 
opacity.  The  other  hypothesis  that  the 
atrophy  and  fibrosis  are  the  result  of  de- 
ficient blood  supply  in  consequence  of  as- 
sociated peri-arteritis  and  endo-arteritis  of 
the  basal  or  cortical  arteries  is  also  attrac- 
tive, but  is  inadequate  inasmuch  as  the 
arterial  changes,  though  frequently  pre* 
sent  are  not  constant. 

Amongst  other  lesions  of  the  brain 
substance  may  be  mentioned  a  few  cases 
of  small  haBmorrhages  into  the  white  sub- 
stance and  one  case  of  extensive  haemor- 
rhage (Gowers)  in  a  syphilitic  boy  aged 
eight  years.  "  The  hajmorrhage  had  ap- 
parently commenced  in  the  right  ventri- 
cular nucleus  or  outside  it,  and  had  burst 
into  the  ventricles."  There  was  no  visible 
aneurysm,  but  there  was  syphilitic  disease 
of  the  vertebral  and  cerebellar  arteries. 

There  have  also  been  recorded  a  few- 
cases  of  small  yellow  indurated  foci  in 
different  parts  of  cerebrum  and  cerebellum 
(Rochebrune,  Chiari,  Henoch),  which 
must  be  regarded  as  small  gummata. 
Large  gummata  are  exceedingly  rare. 

Ventricles. — Hydrocephalus  has  been 
found  in  several  cases.  The  effusion  has 
generally  in  our  experience  been  moderate 
in  amount.  The  character  of  the  effusion 
has  been  recorded  in  different  cases  as 
serous,  sanguineous,  turbid,  or  purulent. 
In  the  long  standing  cases  the  ependyma 
has  been  found  thickened  ('y^c^e  description 
by  Angel  Money).  There  has  been  often 
associated  meningitis  at  the  posterior  base 
or  chronic  change  in  other  parts  of  the 
brain. 

Cerebral  Nerves. — Symmetrical  gum- 
mata have  been  found  by  Barlow  on  the 
third,  fifth,  sixth,  seventh,  and  eighth 
pairs  in  a  boy  aged  fifteen  months  old. 
Microscopic  sections  showed  atrophy  of 
nerve  cylinders  and  infiltration  with 
granulation  cells  and  a  very  fine  stroma. 
The  new  growth  was  less  abundant  in  the 
interfunicular  tissue  than  in  the  funiculi 
themselves.  Thickening  of  the  fifth  and 
seventh  nerves  has  been  found  by  Dowse 
in  a  girl  aged  twelve  years,  the  subject  of 
congenital  syphilis.  Chiari  also  reports  a 
case  in  wJiich  the  right  seventh  was  tiiick- 


Syphilitic  Disease 


[     126: 


Syphilitic  Disease 


ened,  and  Engelstedt  one  ia  which  he 
found  the  left  third  nerve  diseased,  and 
the  muscles  supplied  by  it  pale  and 
wasted. 

Organs  of  S2^ecial  Sense,  (i)  Eye. — Mr. 
Hutchinson  enumerates  the  following  dis- 
eases of  the  eye  as  occurring  in  hereditary 
syphilis  :  acute  iritis,  interstitial  keratitis, 
choroiditis  and  choroido-retinitis,  and  op- 
tic neuritis.  For  accounts  of  their  morbid 
anatomy,  so  far  as  it  has  been  studied,  we 
refer  to  the  special  treatises.  We  may 
quote  with  regard  to  the  microscopic  ap- 
pearances of  early  choroiditis  some  obser- 
vations of  Mr.  Nettleship.  The  case  on 
which  they  were  based  was  a  syphilitic 
infant  under  the  care  of  Dr.  Barlow.  The 
child  died  just  under  ten  months,  and  the 
choroiditis  was  detected  by  us  at  the  age 
of  eight  months.  "The  changes  in  the 
choroid  consist  in  the  presence  of  small 
isolated  collections  of  corj)uscles  in  the 
chorio-capillaris ;  sections  of  several  of 
these  were  found  in  the  part  of  the  choroid 
which  had  shown  during  life  little  flecks 
of  exudation  and  none  were  found  else- 
where." "  The  corpuscles  are  about  as 
large  as  pus  corpuscles  and  stain  deeply 
with  logwood."  "  They  stand  in  no  evi- 
dent relation  to  the  blood-vessels,  and 
none  of  them  occur  in  the  deeper  part  of 
the  choroid.''  "  In  all  these  particulars 
they  differ  from  tubercle."  "  The  elastic 
lamina  over  these  deposits  is  slightly 
raised  and  sometimes  a  little  puckered." 
"  In  several  instances,  at  the  seat  of  the 
deposits,  a  thin  layer  of  flatfish  cells  is 
present  on  its  inner  (retinal)  surface  im- 
mediately beneath  the  pigment  epithelium, 
but  in  no  sections  could  any  perforation 
of  the  lamina  be  detected."  "  The  epi- 
thelium itself  appears  morbidly  adherent." 
"  It  may  be  mentioned  that  these  changes 
(circumscribed  deposits  in  the  chorio-ca- 
pillaris with  a  thin  layer  of  flat  cells  on 
the  retinal  surface  of  the  elastic  lamina) 
are  precisely  similar  to  what  we  found  in 
a  case  of  choroiditis  from  acquired  syphi- 
lis in  which  the  eye  was  excised  during  the 
progress  of  the  disease."  * 

(2)  The  Ear. — To  the  pathological  condi- 
tion underlying  the  symmetrical  deafness 
first  described  by  Mr.  Hutchinson,  we 
have  as  yet  no  adequate  clue,  but  it  is 
probably  a  progressive  degeneration  of 
the  internal  ear  or  of  some  part  of  the 
auditory  nerve. 

Associated  Spinal  Lesions. — In  a  case 
under  the  care  of  Dr.  Bury  in  which,  post- 
mortem, chronic  meningitis  with  sclerosis 
of  the  cortex  cerebri  and  endo-arteritis  were 
found,  there  was  also  present  distinct 
sclerosis  of  the  lateral  columns  and  of  the 
*  Patli.  Traus.  xxyiii.  p.  290. 


internal  aspect  of  the  anterior  columns. 
Besides  such  descending  lesions,  of  which 
there  are  a  few  other  cases  on  record,  there 
are  a  few  examples  of  independent  spinal 
affections  in  the  hereditar}'  form  of  the 
disease.  Thus  Kahler  found,  post-mortem, 
in  a  syphilitic  child,  five  months  old,  an 
area  of  degeneration  in  one  lateral  column 
which  presented  atrophy  of  cells  and 
nerve  fibres,  a  fine  reticular  growth  and 
vessels  with  Heubner's  change  well 
marked. 

Bartels  gives  details  of  a  remarkable 
case  of  a  young  woman,  aged  twenty-two, 
who  was  the  subject  of  congenital  syphilis, 
and  Avho,  amongst  other  illnesses,  suffered 
from  two  separate  attacks  of  paraplegia 
which  yielded  to  anti-syphilitic  treatment. 
When  ultimately  she  died  from  other 
causes  the  vestiges  of  a  caseous,  partly 
softened,  gumma  were  found  in  front  ot 
the  articulation  between  the  atlas  and  the 
skull,  and  between  the  atlas  and  axis.  It 
was  clear  that  the  cord  had  been  some- 
what flattened,  and  that  the  paraplegia 
had  been  caused  by  compression  and  mye- 
litis. 

In  the  case  of  a  marasmic  syphilitic  in- 
fant, examined,  post-mortem,  by  Bar- 
low, there  was  found  extensive  perios- 
titis of  several  laminte  of  the  cervical 
ve^tebrge,  which  it  was  easy  to  see  might, 
if  the  child  had  survived,  have  led  to  cord 
symptoms.  Siemerling,  in  the  case  al- 
ready mentioned,  found  marked  gumma- 
tous proliferation  of  the  pia  mater  all  along 
the  spinal  cord,  tap-shaped  processes 
dipping  into  the  white  substance,  and  the 
antero-lateral  and  posterior  columns  all 
more  or  less  softened. 

Jiirgens  reports  two  cases  :  In  one  case 
there  was  slight  pachymeningitis  and 
chronic  fibrous  arachnitis ;  in  the  other 
case  he  found  a  gummatous  tumour  in  the 
cervical  region  which  involved  half  of  the 
right  lateral  column,  and  also  partly  in- 
vaded the  posterior  roots. 

(B)  Symptomatology. 

(a)  Convulsions.  —  We  have  already 
stated  what  we  believe  on  post-mortem 
evidence  to  be  the  physical  substratum  of 
this  symptom  in  syphilitic  children,  viz., 
meningeal  and  cortical  changes  varying 
in  degree  from  extensive  sclerosis  down  to 
mere  opacity  of  membranes.  Although, 
as  in  adults,  these  may  be  associated  with 
lesions  of  the  calvaria,  we  have  insisted 
on  their  frequent  occurrence  in  syphilitic 
children  independently  of  any  true  speci- 
fic disease  of  the  skull.  Looking  at  the 
subject  clinically  we  now  point  out  the 
frequency  of  early  convulsions  in  syphili- 
tic children.  Buzzard  and  Fournier  have 
drawn  attention  to  this,  and  we  have  re- 


Syphilitic  Disease 


[     1263    ] 


Syphilitic  Disease 


cords  of  several  family  syphilitic  grou]5s 
in  which  many  members  have  died  of  early 
convulsions.  The  earliest  case  of  convul- 
sions, with  subsequent  post-mortem  veri- 
fication of  extensive  meningeal  changes, 
was  observed  by  one  of  us  in  a  child  four 
months  old,  but  we  have  notes  of  several 
at  the  age  of  three  months  without  post- 
mortem veritication,  and  one  of  a  S3'phi- 
litic  infant  who  had  ten  or  twelve  tits 
daily  from  the  age  of  fourteen  days  to 
seven  months.  A  great  many  cases  of 
convulsions  have  been  noted  within  the 
first  two  years  of  life.  As  to  the  charac- 
ter of  the  fits  the  early  cases  have  been 
mostly  bilateral  with  tonic  and  clonic  con- 
tractions. In  some,  laryngismus  and  car- 
popedal  spasm  liave  been  marked  (vide  in 
this  connection  observations  by  Horsley 
and  Semon  on  cortical  origin  of  laryngis- 
mus). In  some  recurrent  attacks  of  opis- 
thotonos spasms  have  been  observed,  fol- 
lowed by  persistent  head  retraction  for 
varying  periods,  suspected  to  be  due  to 
infiaramatory  processes  at  the  posterior 
base.  In  one  infantile  case  this  was 
proved  post-mortem,  and  what  was  pro- 
bably a  small  softening  gumma  was  found 
in  the  neighbourhood. 

In  one  case,  aged  sixteen  months,  con- 
vulsive seizures  occurred,  in  which  the 
mouth  was  widely  opened  and  the  child 
became  very  dusky.  No  cortical  changes 
of  convexity  were  found,  but  symmetrical 
gummata  on  several  cranial  nerves.  We 
have  seen  no  case  of  limited  one-sided 
clonic  spasm  under  the  age  of  twelve 
months  in  a  syphilitic  infant,  but  we  think 
it  is  very  important  to  note  that  syjDhilitic 
infants  may  have  bilateral  fits  and  laryn- 
gismus within  the  first  year  associated 
with  or  shortly  succeeding  the  snuffles  and 
rash,  and  may  then  have  a  period  of 
latency  for  months  or  years,  and  subse- 
quently present  either  one-sided  spasm  or 
paralysis. 

Examples.  —  (i)  T.  Holloway  (under 
care  of  Drs.  Gee  and  Barlow),  snuffles  at 
four  weeks,  and  probably  pemphigus. 
Bilateral  fits  three  or  four  a  month  up  to 
one  year.  Could  not  sit  up  till  three 
years,  and  could  not  walk  till  four  years. 
At  four  years  had  two  right- sided  fits 
within  six  months. 

At  six  years  fell  down  without  convul- 
sion being  observed.  Paralysed  on  right 
side  after  this,  and  speech  for  a  time  thick 
and  indistinct.  Somewhat  irritable  sub- 
sequently. When  seen  at  age  of  ten  years 
eight  months  by  Dr.  Barlow,  the  child 
was  undergrown  and  pale,  had  typical 
scars  at  corners  of  mouth  and  pegged 
upper  median  permanent  incisors.  The 
right  eye  was  blind,  and  there  was  exten- 


sive detachment  of  retina.  The  left 
showed  atrophy  of  disc  and  old  choroid- 
itis. There  was  some  ]:)are3i3  of  the 
right  upper  and  lower  limbs,  but  no 
spasm,  and  there  was  a  slight  arrest  of 
development  (as  shown  in  length  and  cir- 
cumference) in  right  forearm  compared 
with  left.  There  was  no  evidence  of  para- 
lysis of  any  cranial  nerve.  She  heard  and 
understood  many  things  which  were  said 
to  her,  and  answered  some  questions,  but 
could  not  be  trusted  in  her  replies  to 
questions  testing  common  sensation  and 
special  sense.  There  was  slight  articula- 
tory  defect,  as  of  a  young  child  who  had 
not  long  learned  to  talk.  She  was  docile, 
but  distinctly  retarded  in  her  intellectual 
development  for  a  child  nearly  eleven.  She 
died  of  nephritis,  and  at  the  post-mortem 
her  brain  showed  remarkable  sclerosis  of 
both  hemispheres,  the  left  being  more  af- 
fected than  the  right,  with  marked  shrink- 
age in  both  transverse  and  longitudinal 
measurement.  There  was  also  extensive 
endo-arteritis  of  all  the  arteries  of  the 
circle  of  Willis  and  their  branches. 

(2)  Ada  Hare  (Barlow).  Laryngismus 
sixteen  months  old  to  three  years.  From 
three  years  to  seven  years  free  from  fits. 
At  seven  years  had  a  fit  affecting  left  side 
of  face  and  left  limbs.  After  this,  liable  to 
headaches  and  to  occasional  fits. 

At  eight  years  and  nine  months,  when 
seen,  had  just  ])assed  through  a  sei'ies  of 
almost  daily  fits  for  period  of  three  months ; 
the  left  side  predominantly  affected.  She 
presented  characteristic  pegged  upper 
median  permanent  incisors.  Intelligence 
below  the  average.  Could  tell  her  name, 
but  not  her  age.  Had  never  been  able  to 
learn  anything  at  school  beyond  her 
letters. 

There  are,  it  must  be  noted,  some  cases 
in  children  and  adolescents  in  which  to 
all  intents  and  purposes  we  have  to  do 
with  idiopatMc  epilepsy  plus  an  early 
specific  history  or  a  few  characteristic 
signs,  like  pegged  permanent  incisors,  in- 
terstitial keratitis,  choroiditis  and  specific 
deafness.  There  are  some  cases  even  in 
which,  as  Fournier  points  out,  the  only 
specific  element  is  the  family  history. 
The  question  in  these  cases  may  well 
arise,  and  indeed  has  been  stated  by  Dr. 
Jackson  in  one  of  his  papers,  whether  we 
are  justified  in  considering  them  as  in  any 
true  sense  syphilitic.  The  therapeutic 
test  is  of  some  value.  We  can  both  of  us 
recall  such  cases  which  had  not  responded 
to  administration  of  the  bromides,  but 
which  under  grey  powder  and  iodide  re- 
covered or  markedly  improved. 

But  in  a  vei'y  large  number  of  cases 
after  a  shorter  or  longer  interval,  fits  in  a 


Syphilitic  Disease 


[    1264    ] 


Syphilitic  Disease 


syphilitic  child  will  be  replaced  or  accom- 
panied by  other  cerebro-spinal  symptoms. 
A  very  early  sign  noticed  by  Bury  has 
been  the  exaggeration  of  knee-jerks,  but 
sooner  or  later  one-sided  spasm,  paresis 
of  one  or  more  limbs,  ocular  palsy,  and 
progressive  mental  defect  come  into 
.evidence. 

(b)  Headache  and  Irritahility. — Four- 
nier  lays  great  stress  on  headache  and  its 
increased  sevei-ity  during  the  night  in  the 
affections  of  the  nervous  system  dependent 
on  congenital  syphilis. 

In  our  experience  complaints  of  definite 
headache  in  these  affections  have  only 
been  made  by  adolescents  and  children 
over  ten  years  old. 

But  we  have  repeatedly  obsei'ved  evi- 
dences of  great  irritability  (probably  in 
part  dependent  on  head  trouble)  in  syphi- 
litic infants.  It  is  a  matter  of  every-day 
expei-ience  that  syphilitic  infants  sleep 
very  badly.  Phases  of  continuous  scream- 
ing have  been  noticed  by  us  in  instances 
in  which  subsequently  diseased  mem- 
branes have  been  proved,  and  we  have 
also  known  cycles  of  one-sided  convulsion, 
paresis,  and  torpor  ushered  in  by  exces- 
sive irritability  and  stiffness  of  the  neck 
either  with  the  head  retracted  or  held  to 
one  side. 

Demme  records  a  case  of  a  syphilitic 
child  who  had  attacks  of  headache  fol- 
lowed by  outbursts  of  rage,  then  by 
stupidity,  then  by  diabetes  insipidus.  In 
connection  with  this  may  be  mentioned  a 
case  observed  by  Bury  of  a  syphilitic 
boy,  aged  two  years,  who  developed  dia- 
betes insipidus,  but  without  any  history 
of  headache. 

(c)  Paralysis,  (i)  Hemiplegia.  —  The 
physical  substrata  of  this  symptom  in  the 
congenital,  as  in  the  acquired,  form  of 
syphilis  are  multiple.  Endo-arteritis,  with 
sclerosis  and  meningeal  thickening,  is 
most  common  in  children.  Endo-arteritis 
with  softening  also  occurs,  but  massive 
haemorrhage  is  rare,  and  large  cerebral 
gumma  is  rare. 

Clinically,  so  far  as  we  have  seen,  hemi- 
plegia has  most  commonly  been  preceded 
by  one-sided  convulsion,  and  has  been 
often  succeeded  at  varying  intervals  by 
convulsion  limited  to  the  paretic  side. 
But  it  may  occur  without  obvious  initial 
spasm.  The  patient,  without  previous 
warning,  may  fall  down  and  lose  con- 
sciousness for  a  varying  period.  In  other 
cases  there  is  some  prodromal  restlessness, 
irritability,  vomiting,  or,  if  the  child  is  old 
enough,  complaint  of  headache,  and  then, 
without  loss  of  consciousness,  the  patient 
suddenly  loses  power  down  one  side  of  the 
body  and  some  degree  of  articulate  speech. 


Attacks  of  inherited  as  well  as  of 
acquired  syphilitic  hemiplegia  may  be 
sometimes  followed  by  marked  torpor. 
Example :  A  woman,  aged  twenty-eight, 
under  the  care  of  Dr.  Bury,  attended,  on 
account  of  slight  speech  defect  with 
paresis  of  right  side  of  face  and  right 
upper  and  lower  limbs,  and  some  anaes- 
thesia of  the  right  side.  She  had  scars 
at  the  corners  of  the  mouth,  deafness, 
choroiditis,  and  blindness  on  the  right 
side ;  also  keratitis  and  old  iritis.  The 
history  was  that  she  had  had  a  stroke 
seven  years  ago,  and  was  unconscious  for 
nine  weeks,  and  lost  her  power  of  speech 
for  twelve  months.  Five  weeks  before 
she  attended,  she  had  had  another  stroke, 
and  had  been  unconscious  for  three  days. 

In  many  of  the  initial  attacks  of  hemi- 
plegia paresis  of  limbs,  so  far  as  its  gross 
indications  are  concerned,  clears  up  to  a 
great  extent,  and  the  paresis  of  the  face 
to  a  marked  extent.  The  only  vestige 
may  be  that  the  child  does  not  use  the 
arm  and  hand  which  have  been  affected 
quite  as  freely  as  those  of  the  opposite 
limb.  But  there  is  a  great  proneness  to 
subsequent  attacks,  after  which  a  spastic 
condition  may  supervene,  and  there  is  a 
marked  liability  to  supervention  of  para- 
lysis of  the  other  side  of  the  body,  after 
which  one  side  may  be  limp  and  the  other 
spastic,  or  more  commonly  both  sides 
more  or  less  spastic.  It  has  been  proved 
post-mortem,  in  one  of  our  cases,  that  the 
pai'alysis  was  due  to  descending  degene- 
ration from  both  sides  of  the  damaged 
brain  of  both  pyramidal  tracts. 

(2)  Ai^hasia. — In  the  hemiplegias  of  chil- 
dren alterations  of  speech  are,  as  a  rule, 
more  transient  than  in  the  hemiplegias  of 
adults.  Hemiplegia  as  caused  by  heredi- 
tary syphilis  is  no  exception  to  this  general 
rule,  at  all  events  in  the  early  stage, 
though  at  a  later  period,  when  extensive 
degeneration  and  mental  failure  have 
supervened,  speech  may  be  lost. 

In  the  following  example  there  were  : 

(i)  Speech  defect  occurring  with  a  slight 
attack  of  right-sided  paralysis ;  and  (2) 
subsequent  attack  of  left-sided  partial 
paralysis,  loss  of  speech  with  defective 
control  of  lips,  loss  of  power  of  protruding 
tongue,  and  difficulty  in  the  first  part  of 
deglutition. 

Charles  Pohlmann,  aged  10  years  (Bar- 
low), with  marked  family  and  infantile 
history  of  congenital  syphilis,  was  brought 
to  hospital  with  the  following  statement 
from  the  mother.  Twenty  days  ago  began 
to  suffer  from  severe  headache  ;  ten  days 
ago  whilst  at  dinner  found  suddenly  that 
he  could  not  ask  for  what  he  wanted, 
made  a  sound  but  could  not  utter   such 


Syphilitic  Disease 


[     ^26s     ] 


Syphilitic  Disease 


words  as  bread,  milk,  &c. ;  pointed  to  the 
objects  required  ;  could  call  his  brothers 
and  sisters  by  name.  Speech  trouble  in- 
creased, and  four  days  after  onset  mother 
noticed  that  liquids  ran  out  of  his  mouth 
and  that  he  could  notholdthings  properly 
■with  his  right  hand.  Has  complained  of 
pain  in  the  right  leg  to-day  but  was  not 
noticed  to  drag  it.  The  boy  was  poorly 
nourished,  had  typical  pegged  upper 
median  incisors,  there  was  a  little  tlatten- 
iug  of  the  right  naso-oral  fold  when  he 
smiled,  and  the  left  corner  of  the  mouth 
was  drawn. 

The  grip  of  the  right  hand  was  dis- 
tinctly weaker  than  that  of  the  left. 
He  used  the  left  hand  by  preference. 
There  was  no  alteration  of  gait.  Seemed 
to  understand  what  was  said  to  him. 
Pointed  to  left  parietal  region  in  reply  to 
question  as  to  seat  of  pain.  Could  only 
answer  "  yes  "  and  "  no  "  to  questions. 
Seemed  unable  to  answer  questions  involv- 
ing replies  other  than  yes  or  no. 

A  few  days  after  admission  was  able  to 
utter  his  first  name,  Charlie,  but  could  not 
give  his  surname,  and  when  it  was  uttered 
to  him  he  could  not  repeat  it.  When 
asked  about  his  address  said  "  yes"  when 
it  was  rightly  and  "  no  "  when  wrongly 
stated.  After  some  hesitation  he  was  in- 
duced to  write  with  a  pencil.  He  wrote 
the  letters  of  his  name  on  dictation,  but 
afterwards  when  asked  to  write  it  with- 
out dictation  he  wrote  it  with  many 
letters  altered.  After  about  four  months  of 
mercurial  treatment,  the  slight  paresis  of 
the  right  side  of  the  face  and  of  the  right 
hand  had  almost  disappeared,  and  the 
only  fault  of  speech  was  slight  hesitancy, 
and  he  was  discharged.  Six  months  after 
the  beginning  of  the  first  seizure  he  again 
complained  of  headache,  and  it  was  found 
that  he  could  not  ask  for  what  he  wanted. 
The  day  after  this,  weakness  of  the  left 
band  appeared.  He  could  lift  it  up  but  he 
could  not  raise  anything  in  the  hand.  The 
speech  became  worse,  he  could  not  put  his 
tongue  out  and  his  swallowing  became 
difficult.  When  re-admitted  he  apparently 
understood  what  was  said  to  him  but  he 
could  not  speak.  He  was  unable  to  close 
his  left  eye  or  his  lips.  The  left  naso- 
oral  ridge  was  flat  when  he  smiled.  When 
bread  was  given  to  him  he  could  not 
bite  it.  He  could  not  protrude  his  tongue 
and  had  some  difficulty  in  swallowing ;  the 
food  seemed  to  remain  in  the  back  of  his 
mouth.  He  was  unable  to  grasp  with  the 
left  hand,  or  supinate  with  the  left  wrist. 
The  hand  was  dropped.  The  knee  jerks 
were  equal ;  the  gait  was  good.  So  far  as 
could  be  ascertained  there  was  no  anaes- 
thesia.    After  a  few  days  he  was  induced 


to  ^vrite  his  name,  which  he  did  with  trans- 
positions and  omissions  of  some  of  the 
letters,  often  being  unable  to  get  beyond 
the  first  two  letters.  The  difficulty  in  mas- 
tication, protrusion  of  tongue,  and  in  the 
first  part  of  swallowing  very  slowly  im- 
proved. He  used  to  frequently  assist  the 
bolus  down  his  throat  by  pushing  it  back- 
wards with  his  finger. 

At  the  end  of  a  fortnight  he  began  to 
make  definite  vocal  sounds  as  an  attempt 
at  speech— r. (J.,  "hah-ih"  represented 
"  Charlie.  At  the  end  of  a  month  speech 
was  much  improved,  the  difficulty  being 
chiefiy  with  labials.  As  he  got  able  to 
protrude  his  tongue  it  deviated  slightly  to 
the  left.  For  several  months  there  was 
defective  control  over  the  lips.  His  writing 
for  some  months  showed  transposition  of 
letters,  but  at  the  end  of  twelve  months 
he  wrote  a  long  letter  nearly  correctly. 
The  left-hand  paresis  had  practically  re- 
covered. He  was  treated  with,  mercurial 
inunction  until  the  gums  became  a  little 
spongy. 

The  pathology  of  this  case  is  probably 
endo-arteritis  of  symmetrical  branches  of 
the  middle  cerebral  arteries  and  degenera- 
tion of  the  cortical  centres  especiall}'-  of  the 
third  frontal  on  both  sides.  The  speech 
defect  recovering  after  the  first  right-sided 
hemiplegic  attack,  but  recurring  with  in- 
volvement of  lip  and  tongue  movements 
after  the  second  (left-sided)  attack,  is  re- 
markably similar  to  a  case  of  embolic 
arterial  disease  recorded  by  Barlow  in 
which  there  was  symmetrical  softening  of 
Broca's  convolution,  and  the  convolution 
corresponding  to  it  on  the  opposite  hemi- 
sphere. Pohlmann's  case  illustrates  also 
several  of  the  points  to  which  we  have  re- 
ferred in  the  earlier  part  of  the  section  on 
symptomatology. 

Cranial  Nerves. — The  nerves  may  be 
affected  apart  from  disease  of  the  brain 
and  membranes.  As  we  have  pointed  out 
in  the  section  on  morbid  anatomy,  they 
may  be  affected  with  gummata  and  with 
interstitial  neuritis.  The  nerve  affection 
may  be  symmetrical,  affecting  both  sides 
and  several  pairs,  or  it  may  be  unilateral, 
aflPecting  one  or  more,  and  remain  station- 
ary for  long  periods.  Mr.  ISTettleship  has 
recorded  a  case  of  a  syphilitic  girl  aged 
fourteen,  in  whom  there  existed,  along 
with  keratitis  and  characteristic  teeth, 
paralysis  of  the  third,  fifth,  and  sixth 
nerves  on  one  side.  The  condition  did  not 
alter  during  four  years.  In  one  of  our 
cases,  probably  syphilitic,  the  paralysis  of 
the  third  nerve  had  not  changed  during  a 
period  of  seven  years. 

It  is  noteworthy  that  separate  portions 
of  both  the  third  and  fifth  nerves  may  be 


S3rph.ilitic  Disease 


[    1266    ] 


Syphilitic  Disease 


affected,  leaving  the  other  portions  intact. 
Thus  ptosis,  or  loss  of  the  retlex  to  light, 
may  be  the  only  sign  of  involvement  of 
the  third,  and  ana3sthesia  the  only  sign  of 
involvement  of  the  fifth.  Mr.  Hntchiu- 
son  records  two  cases  of  ophthalmoplegia 
externa  in  congenital  syphilis.  In  one  of 
them  it  was  associated  with  atrophy  of  the 
optic  discs. 

The  comparative  immunity  of  the 
seventh  nerve  from  syphilitic  disease  is 
dwelt  upon  by  Mr.  Hutchinson.  It  is  no 
doubt  rare  in  the  acquired  form.  In 
hereditary  S3^philis  we  have  each  seen  one 
case  in  a  young  infant  with  concomitant 
specific  rash,  &c.  In  the  case  before  re- 
ferred to  of  symmetrical  gummata  (proved 
post-mortem),  evidence  during  life  of  de- 
generative electrical  reactions  of  the  facial 
was  obtained.  In  another  case  of  a 
child  aged  two  years  and  six  months, 
who  was  profoundly  syphilitic,  in  addition 
to  localised  convulsions  and  other  symp- 
toms, there  was  a  persistent  one-sided 
facial  palsy  of  both  upper  and  lower 
branches,  which  gave  degenerative  reac- 
tions. In  this  case  it  was  assumed  as 
probable  that  there  was  a  separate  lesion, 
gummatous  or  otherwise,  of  the  facial 
nerve. 

Organs  of  Special  Sense,  (a)  The  Eye. 
— For  the  account  of  the  characteristic 
signs  of  the  early  iritis,  interstitial  kera- 
titis, and  choroiditis  of  congenital  syphilis, 
we  refer  to  the  invaluable  researches  of 
Mr.  Hutchinson.  Concerning  choroiditis, 
the  form  which  is  commonest  (to  quote 
Mr.  Hutchinson)  "  is  characterised  by 
atrophic  and  pigmented  changes,  near  to 
the  periphery  of  the  fundus.''  "  They  are 
sometimes  seen  in  both  eyes,  sometimes 
only  in  one."  "  In  other  cases  patches 
may  be  seen  in  all  parts  of  the  fundus." 
"  There  is  yet  another  form  in  which  no 
large  patches  occur,  but  a  great  number 
of  small  ones,  and  in  which  numerous 
dotted  and  striated  accumulations  of  pig- 
ment are  seen  in  the  retina,  simulating 
the  condition  of  retinitis  pigmentosa." 

We  desire  to  draw  attention  to  the  im- 
portance of  (i)  looking  for  choroiditis  in 
syphilitic  infants  within  the  first  year  of 
life.  We  have  seen  it  as  small  flecks  of 
brownish  exudation,  without  atrophy  or 
massive  aggregations  of  pigment,  subse- 
quently verified  post  mortem,  and  also  as 
small  white  rounded  areas  very  like  tuber- 
cles. (2)  In  older  children  (of  five  or  six 
years,  &c.)  it  is  noteworthy  what  a  large 
extent  of  choroidal  disease  may  be  found 
in  the  periphery  consistently  with  mode- 
rate vision.  The  importance  of  choroiditis 
disseminata  as  a  diagnostic  help  cannot 
be  overstated.     (3)  It  seems  probable  that 


the  atrophy  of  the  disc  found  in  many 
cases  of  congenital  syphilitic  disease  of 
the  nervous  system  is  for  the  most  part 
due  to  the  participation  of  the  disc  in  a 
general  choroido-retinitis.  We  have  re- 
ferred previously  to  one  case  of  extensive 
detachment  of  retina,  where  probably  the 
starting-point  was  a  choroido-retinitis. 
(4)  Observations  are  much  needed  on  cases 
of  intra-cranial  congenital  syphilitic  dis- 
ease, in  which  papillitis  or  atrophy  of  disc 
occurs  without  concomitant  choroiditis. 

(6)  The  Ear.— There  is  little  to  be  added 
to  Mr.  Hutchinson's  clinical  account  given 
thirty  years  ago,  of  the  frequently  rapid 
and  intractable  form  of  deafness  depend- 
ent on  hereditary  syphilis,  which  comes  on 
mostly  between  the  periods  of  five  years 
before  and  five  years  after  puberty,  is  bi- 
lateral, painless,  and  independent  of  otor- 
rhoea.  In  many  cases  the  conduction 
through  the  bone  becomes  lost,  which  sug- 
gests damage  to  internal  ear  or  nerve,  but 
the  pathology  of  the  affection  is  still  un- 
explained. 

Psycliical  Defects. — We  have  pointed 
out  in  the  section  on  morbid  anatomy 
(i)  that  the  most  common  brain  lesion  in 
cases  of  hereditary  syphilis  is  a  diffuse 
affection  of  the  cortex,  in  which  certain  of 
the  convolutions  become  hardened  and 
shrunk,  and  their  cells  atrophied  in  conse- 
quence of  an  overgrowth  of  the  neuroglia. 
(2)  That  this  condition  may  (a)  be  second- 
ary to  a  chronic  meningitis,  itself  started 
by  a  syphilitic  periostitis  or  occurring  in- 
dependently ;  or  (&)  occur  as  a  result  of  a 
specific  endo-arteritis  ;  or  (c)  gradually  de- 
velop apart  from  disease  either  of  the 
vessels  or  membranes.  And  we  have  seen 
that  the  symptomatology  of  brain  syphilis 
in  the  child  is  largely  made  up  of  pheno- 
mena which  might  be  expected  to  occur 
during  the  progress  of  such  cortical 
changes ;  the  instability  of  the  large 
nerve  cells  of  the  grey  matter  being  ex- 
pressed clinically  by  headache,  screaming 
and  convulsions,  their  destruction  by 
paralysis,  aphasia,  and,  as  some  of  the 
related  cases  have  already  indicated,  by 
mental  deterioration.  Mental  impair- 
ment, indeed,  in  our  experience,  is  not 
exceptional,  as  writers  on  insanity  have 
frequently  stated,  but  is  one  of  the  pro- 
minent features  of  hereditary  syphilitic 
brain  disease.  From  an  analysis  of  ninety 
reported  examples  of  brain  disturbance  in 
congenital  syphilis,  we  find  there  are  forty, 
or  nearly  half,  in  which  some  failure  of  the 
mental  functions  is  noticed,  and  we  believe 
that  this  proportion  under-  rather  than 
overstates  the  actual  facts. 

The  clinical  type  of  intra-cranial  here- 
ditary  syphilis   may   be   stated  to   be   a 


Syphilitic  Disease 


[     1267    ] 


Syphilitic  Disease 


spastic  paresis  of  the  limbs,  plus  convul- 
sive attacks,  and  a  moderate  degree  of  de- 
mentia. In  these  respects  it  closely  re- 
sembles cases  of  "  birth  palsy,"'  in  which, 
as  a  result  of  meningeal  hannorrhage,  cer- 
tain portions  of  the  cortex  are  compressed 
and  the  convolutions  iu  tlie  afiected  region 
become  small  and  indurated  ;  the  child  is 
backward  or  demented,  has  spastic  limbs, 
and  is  subject  to  attacks  of  ejiileptiform 
convulsions. 

In  both  classes — viz.,  the  syphilitic  and 
the  "  birth  palsy  "  cases — the  most  pro- 
nounced cortical  change  is  to  be  found  iu 
the  motor  area,  that  is,  in  the  middle  zone 
of  the  hemisphere,  the  fore  and  hind  parts 
of  the  cerebrum  being  comparatively 
spared.  This  fact  is  of  interest  in  con- 
nection with  the  location  of  mental  func- 
tions, and  gives  support  to  the  view  that 
mental  processes  are  not  subserved  by  tbe 
frontal  lobes  alone  but  probably  depend 
on  the  healthy  action  of  all  portions  of  the 
cortex. 

The  mental  disturbance  in  hereditary 
syphilis  may  be  considered  according  to 
the  time  of  its  development  under  two 
headings — viz.,  idiocy  and  juvenile  de- 
mentia. 

Idiocy.  —  Congenital  deficiency  of 
mind  from  inherited  syphilis  is  rarer  than 
mental  failure  coming  on  in  childhood  ; 
this  may  be  owing  to  the  number  of  infants 
who  die  from  the  severity  of  the  cerebral 
mischief.  But  we  have  seen  cases  of 
syphilitic  children  who  were  truly  idiots, 
that  is,  whose  mental  functions  have  never 
j^erfectly  developed.  Such  children  may 
subsequently  be  seized  with  eclampsia  or 
other  symptoms  of  brain  disease.  The 
idiocy  may  be  the  result  of  a  foetal  or  an 
early  infantile  meningo-encephalitis,  or  of 
hydrocephalus. 

It  is  also  possible  but  difficult  to  estab- 
lish that  a  syphilitic  taint  may  weaken 
nerve  elements  apart  from  demonstrable 
changes,  and  so  lead  to  idiocy,  just  as  the 
virus  of  acquired  syphilis  predisposes  to 
degeneration  of  the  nerve  elements  of  the 
posterior  columns,  and  so  becomes  the 
chief  aetiological  factor  in  locomotor  ataxy. 
Also  it  must  be  borne  in  mind,  as  Hugh- 
lings  Jackson  pointed  out  in  a  case  of  his 
own,  that  syphilis  may  be  grafted  on  to  a 
brain  already  imperfect  in  consequence  of 
insanity  in  the  parents. 

Juvenile  Detnentia. — In  the  vast 
majority  of  cases  mental  failure  comes  on 
in  childhood;  the  child  when  young  is  as 
bright  and  sharp  as  other  children  of  the 
same  age,  he  learns  to  read  and  write  and 
cannot  in  anywise  be  called  backward, 
then,  at  an  age  varying  from  five  to  ten 
his  intellect  becomes  arrested  in  its  deve- 


lopment. The  parents  or  teachers  notice 
that  he  no  longer  learns  his  lessons  as  cor- 
rectly as  formerly,  that  his  memory  is 
failing,  that  he  is  less  vivacious,  takes  no 
interest  iu  his  work  or  his  play,  and  gra- 
dually he  i)roceeds  to  a  condition  of  more 
or  less  complete  dementia.  As  a  rule,  the 
dementia  is  i)receded  and  associated  with 
convulsive  attacks,  hemiplegia  or  other  in- 
dications of  cerebral  mischief.  This  com- 
mon variety  is  illustrated  by  the  following 
cases : — 

(i)  Mary  A.  (Under  care  of  Dr.  Bury.) 
Healthy  as  a  baby  till  vaccinated,  when 
she  became  covered  with  brown  spots, 
also  snuffled  in  the  nose — she  talked 
sensibly  and  played  with  other  children, 
and  had  a  good  memory  till  eight  years 
old  ;  used  to  learn  hymns  and  sing  them, 
and  was  fond  of  music.  When  about 
twelve  years,  had  a  fit,  in  which  the  right 
side  was  chiefly  drawn  up  ;  "she  lay  for 
about  twenty-four  hours  partly  uncon- 
scious, and  drew  herself  up."  After  the 
fit  the  right  foot  trailed  in  walking,  and 
then  the  right  side  became  pai'alysed. 
She  often  had  pain  in  the  head — she  had 
two  more  similar  fits  before  her  death ; 
after  the  third  fit  she  never  spoke,  that  is 
about  nine  months  before  she  died.  A 
strong  family  history  of  syphilis  but  none 
of  insanity  or  other  nervous  disorder. 
When  fourteen  and  a  half  years  old,  she 
was  lying  in  bed  and  quite  demented ; 
there  was  paresis  of  the  right  limbs  but 
no  marked  rigidity.  The  upper  central 
incisors  were  pegged,  there  were  old  scars 
at  the  angles  of  the  mouth,  and  a  charac- 
teristic physiognomy.  The  child  was  seen 
again  a  few  months  later ;  she  was  lying 
crouched  up  in  bed,  her  arms  and  legs 
rigidly  flexed.  There  was  extreme  ema- 
ciation and  advanced  dementia.  She  died 
a  few  weeks  later,  aged  fifteen  years. 

The  autopsy  revealed  thickening  of  the 
pia  arachnoid,  atrophy  and  sclerosis  of  the 
convolutions,  and  thickening  of  cerebral 
arteries.  On  microscopical  examination 
typical  endo-arteritis  and  atrophy  of  the 
pyramidal  cells  of  the  cortex  (see  figures) 
were  conspicuous,  and  the  cord  showed  a 
bilateral  descending  degeneration  of  both 
pyramidal  tracts. 

In  the  case  of  Dr.  Hum23hreys  already 
mentioned,  similar  changes  were  found 
post  mortem  together  with  hoBmorrhagic 
pachymeningitis  and  enormous  thicken- 
ing of  the  skull.  The  patient  was  well 
till  three  years  old,  then  had  a  fit  in  which 
the  right  side  worked,  this  being  followed 
by  other  fits.  She  was  unable  to  walk  at 
seven  years,  lost  her  speech  at  nine  3'ears, 
and  when  seen  aged  eleven,  she  was  a  com- 
plete idiot.     There  was  spastic  paralysis 

4  M 


Syphilitic  Disease 


[     i: 


] 


Syphilitic  Disease 


of  all  the  limbs.  The  eyes  showed  optic 
atrophy  aud  choroiditis  disseminata,  and 
the  teeth  were  notched  and  pegsjed. 

(2)  Hannah  H.  Seen  in  1882  by  Dr. 
Bury,  aijed  sixteen  years,  parents  dead; 
the  father  died  of  hemiplegia,  probably 
syphilitic.  The  patient  presented  typical 
teeth  ;  signs  of  old  iritis,  symmetrical  dis- 
seminated choroiditis,  and  symmetrical 
deafness.  She  was  deaf  and  had  bad  sight 
five  years  ago,  but  was  then  quite  sensible. 
Her  mind  began  to  fail  when  fifteen  years 
old.  Now,  if  left  alone  patient  sits  still 
and  does  not  attempt  to  do  anything,  will 
not  offer  to  get  food  for  herself,  is  bad 
tempered,  uses  very  filthy  language,  but 
did  not  do  so  before  her  mental  failure. 
She  is  very  frightened  at  times,  tries  to 
catch  at  something  in  the  air.  Is  very 
restless  at  night,  will  jump  out  of  bed 
screaming,  but  the  nurse  can  soon  quiet 
her.  Staggers  in  walking.  This  patient 
was  seen  again  last  year,  then  twenty-four 
years  old,  and  it  is  important  to  observe 
that  her  mental  condition  was  not  materi- 
ally worse  ;  she  could  walk  a  little,  but  the 
lower  limbs  were  somewhat  rigid  and  the 
knee-jerks  exaggerated. 

(3)  Georgina  T.  Aged  eleven  years 
eleven  months,  under  care  of  Dr.  Barlow. 
Well  marked  parental  and  family  history 
of  syphilis.  The  patient  was  the  result  of 
the  sixth  pregnacy.  Had  a  rash  all  over 
the  body  when  six  weeks  old  with  "  snuf- 
fles," was  under  medical  treatment  for 
eight  months.  Subsequently  got  on  well 
up  to  seven  years  old.  Learnt  well  at 
school  aud  was  able  to  do  many  things 
which  she  is  now  incapable  of  doing — e.g., 
she  could  scrub  the  steps  and  hem  a  hand- 
kerchief and  put  the  younger  sister  to 
bed.  It  was  noticed  that  after  this  time 
she  gradually  "  went  back  "  in  intelligence. 
Would  laugh  without  reason  and  for  a 
long  time  continuously.  Her  schoolfellows 
began  to  call  her  silly.  She  became  fright- 
ened at  the  least  thing.  When  seen  at  the 
age  of  eleven  years  eleven  months,  she  was 
fairly  grown  and  free  fi'om  signs  of  vis- 
ceral disease.  She  had  typical  pegged 
upper  median  permanent  incisors.  There 
■were  characteristic  fissui-es  round  the 
mouth.  The  nose  bridge  was  good  and 
there  was  no  deafness.  She  was  blind 
with  the  left  eye,  the  left  pupil  was  small 
and  immobile  to  light ;  under  atropine  it 
dilated  without  revealing  any  bridles. 

Her  knee-jerks  were  exaggerated,  and 
in  walking  she  held  her  legs  rather  stiff 
and  carried  her  head  too  far  forwards. 
The  movements  of  her  hands  were  good. 
There  was  no  atrophy. 

Mental  Condition. — She  was  irrepres- 
sibly    cheerful    and     quite   docile.       Her 


memory  could  not  be  trusted  to  carry 
messages.  Her  speech  was  natural,  but 
in  answering  a  question  she  burst  into  a 
meaningless  laugh.  She  could  do  addi- 
tion sums.  She  slept  well,  and  would 
often  desire  to  go  to  bed  at  five  o'clock  in 
the  afternoon.  She  had  been  fond  of 
taking  long  walks  alone  but  could  not  be 
induced  to  do  any  housework  for  more 
than  a  few  minutes.  When  seen  again 
eighteen  months  subsequently  her  gait 
was  much  more  spastic,  but  her  mental 
state  had  not  altered  to  any  extent. 

In  other  cases  dementia  may  exist  for  a 
long  time  without  any  marked  evidence  of 
brain  disease,  or  paralytic  defects  may  not 
come  into  relief  in  consequence  of  the  pro- 
minence of  mental  defects. 

And  for  diagnosis  and  treatment  it  is 
just  as  important  to  recognise  this  fact  as 
we  have  already  pointed  out  with  regard 
to  instances  of  epilepsy  existing  alone. 

Example :  *  Annie  L.,  aged  fourteen 
years,  came  under  Dr.  Bury's  care  in 
February  1882.  Strong  family  history  of 
syphilis.  The  patient  when  a  baby  was 
one  mass  of  spots,  had  snuffles,  and 
screamed  a  great  deal.  Subsequently  was 
pretty  well  till  her  weak  state  of  mind 
came  on  about  four  years  ago  (ten  years 
old).  For  the  last  twelve  months  her 
walking  has  been  bad,  power  to  hold  her 
water  has  been  getting  less,  and  her 
hands  and  mouth  have  occasionally 
twitched.  She  is  a  well-nourished  girl, 
has  a  pleasant  face  and  well-shaped  head. 
There  is  well-marked  disseminated  cho- 
roiditis, most  advanced  in  the  right  eye. 
The  corneas  are  clear,  and  the  teeth  are 
not  typical.  The  knee-jerks  are  exag- 
gerated. This  and  her  mental  condition 
are  the  only  indications  of  disease  of  the 
central  nervous  system. 

Mental  Condition. — She  is  easily  fright- 
ened, cries  readily,  starts  at  the  least 
noise,  does  not  speak  unless  spoken  to, 
then  talks  of  things  that  happened  long 
ago.  She  cannot  read  letters,  though  she 
could  two  years  ago,  but  was  never  able 
to  read  a  book.  She  can  name  a  few 
common  objects,  such  as  a  doll,  a  watch; 
she  calls  all  coins  either  a  "  penny  "  or  a 
"  sovereign  ;  "  she  has  no  idea  how  many 
fingers  she  has  after  she  has  counted 
them  ;  she  does  not  notice  what  is  going 
on  around  her,  does  not  as  a  rule  indicate 
her  wants  in  any  way,  is  not  vicious,  but 
is  timid  now,  and,  when  frightened,  mus- 
cular tremors  are  noticed. 

Varietij  of  Insanity. — There  are  many 
degrees   of    intellectual   failui-e,   but   not 

"  This  case,  cases  i  and  2,  and  Dr.  Humphrey's 
case,  are  reported  in  full   in  the   April  number  of 

lira  in  for  T88q. 


Syphilitic  Disease 


[     1269    ] 


Syphilitic  Disease 


many  varieties  of  insanity.  In  some 
cases  maniacal  attacks  are  recorded,  or 
there  are  fits  of  excitement,  or  the  patient 
is  bad  tempered  and  vicious  ;  frequently 
there  is  evidence  that  the  patient  sutlers 
from  hallucinations  or  illusions.  But,  as 
a  rule,  the  cases  fall  into  the  class  of 
simple  intellectual  failure  ;  they  are  pas- 
sive, apathetic,  deprived  of  memor}',  do 
not  understand  what  is  said  to  them,  and 
lapse  into  a  purely  vegetative  existence. 
These  cases  rarely  reach  asylums ;  thej' 
are  not  sufficiently  vicious  or  troublesome, 
they  are  apathetic  and  inofiensive,  and 
are  to  be  found  dragging  on  an  existence, 
aimless  and  devoid  of  interest  and  intelli- 
gence, at  their  own  homes  or  in  our  union 
hospitals.  We  may  picture  the  type  as  a 
little  child,  bright,  active,  and  intelligent, 
who  passes  step  by  step  into  a  state  of 
hopeless  dementia,  a  child  whose  fondness 
for  play,  whose  interest  in  all  its  surround- 
ings, whose  sharp  memory  and  bright  in- 
telligence are  gradually  blotted  out  by  the 
thick  mist  which  slowly  but  surely  settles 
down  upon  and  closes  in  the  developing 
brain,  arresting  its  growth  and  benumb- 
ing or  paralysing  its  highest  functions. 

If,  in  conclusion,  we  contrast  brain  dis- 
ease due  to  hereditary  syphilis  with  that 
due  to  acquired  syphilis,  we  find  that 
amentia  in  association  with  eclampsia  and 
spastic  limbs  are  to  be  regarded  as  typical 
of  hereditary  syphilis ;  hemiplegia,  with 
or  without  unilateral  convulsions,  as 
typical  of  acquired  syphilis  in  the  adult. 
The  morbid  anatomy  of  the  foi'mer  con- 
sists mainly  of  chronic  meningitis,  endo- 
arteritis,  and  cortical  sclerosis  and  atrophy; 
whereas  the  common  lesions  in  acquired 
syphilis  are  gummata  and  central  soften- 
ing from  arterial  disease  and  thrombosis. 
Sx^iud  Affections.  —  We  have  re- 
ferred in  the  section  on  morbid  anatomy 
to  (i)  sjjinal  lesions,  the  result  of  descend- 
ing degeneration  from  cerebral  disease  ; 
(2)  independent  lesions  in  the  cord,  pre- 
sumably starting  in  vascular  disease  in 
the  cord  ;  (3)  lesions  of  the  cord  and  its 
membranes,  consecutive  to  damage  of  the 
spinal  canal,  either  of  the  nature  of  gum- 
mata or  periostitis. 

The  above  categories  probably  explain 
the  majority  of  the  cases  of  spinal  affec- 
tion in  congenital  syphilis  which  have  re- 
covered completely,  or  (what  is  more  com- 
monly) have  recovered  partially  with 
relapses,  but  in  which  post-mortem  veri- 
fication has  not  been  oblained. 

Thus  Dixon  Mann  has  recorded  a  case 
of  a  syphilitic  boy  aged  fifteen,  who  suf- 
fered from  lumbar  pain,  paraplegia  with 
exaggeration  of  deep  and  superficial  re- 
flexes, paralysis  of  bladder,  and  sacral  bed- 


sore. Under  anti-syphilitic  treatment  the 
boy  recovered,  and  Dr.  Maun  ascribed  the 
condition  to  a  local  thi-ombosis  of  the 
vessels  of  the  cord,  which  had  led  to 
softening,  and  interfered  with  couductivity 
for  a  time,  but  had  not  produced  actual 
destruction  of  tissue. 

Dr.  Moncorvo  has  recorded  three  cases 
of  syphilitic  children  who  presented  the 
clinical  features  of  disseminated  sclerosis, 
and  in  two  of  them  he  observed  notable 
improvement  under  anti-syphilitic  treat- 
ment. 

Fournier  and  Laschkewitz  have  each 
recorded  a  case  of  hyperostosis  of  verte- 
brae in  congenitally  syphilitic  subjects, 
with  symptoms  pointing  to  compression 
myelitis.  Under  s])ecific  treatment  rapid 
diminution  of  the  hyperostosis  and  of  the 
paraplegia  occurred  in  Fournier's  case, 
and  Laschkewitz's  case  was  cured  in  two 
months. 

With  respect  to  locomotor  ataxy,  Re- 
mak  gives  details  of  two  cases,  one  a  girl 
of  twelve  years  and  the  other  a  boy  of 
sixteen  years,  in  whom  many  of  the  symp- 
toms of  this  disease  were  pi-esent. 

Fournier  also  describes  three  cases  of 
ataxy  in  young  people,  in  whom  there 
was  reason  to  suspect  congenital  syphilis, 
though  the  evidence  was  not  quite  con- 
clusive. 

We  have  no  post-mortem  evidence  as 
yet  throwing  light  on  the  question  as  to 
whether  the  spinal  symptoms  depended 
on  definite  syphilitic  lesions  or  whether, 
as  in  some  cases  of  acquired  syphilis,  the 
specific  jjoison  may  have  acted  as  a  power- 
ful predisposing  cause. 

Sinned  Xerves. — Dr.  J.  A.  Ormerod  has 
recorded  one  remarkable  case  of  a  woman 
aged  twenty-three,  who  was  the  subject  of 
hereditary  syphilis,  and  who  presented  a 
fusiform  enlargement  on  the  median 
nerve,  which  was  attended  with  paralysis, 
atrophy  and  anajsthesia. 

Prognosis. — The  course  of  the  various 
nervous  manifestations  of  congenital 
syphilis  is  exceedingly  varied. 

A  few  lesions  appear  to  go  through  a 
cycle  and  undergo  spontaneous  and  com- 
plete subsidence.  Others,  so  far  as  clini- 
cal observation  extends,  are  the  outcome 
of  a  storm  which  comes  to  an  end  with 
some  irreparable  damage  done  but  with- 
out tendency  to  further  progress.  But  of 
many  of  the  severe  manifestations  in  con- 
genital as  well  as  in  acquired  syphihs,  we 
may  say  that  they  are  more  commonly 
scotched  than  cured. 

It  is  remarkable  how  promptly  active 
symptoms  respond  to  proper  treatment, 
but  post-mortem  investigationshows  again 
and    again   the   existence   of   widesjDread 


Syphilitic  Disease 


[     1270    ] 


Syphilitic  Disease 


damage  which  has  not  been  eradicated, 
although  its  active  phases  may  have  been 
controlled. 

Examples  of  spontaneous  and  some- 
times complete  subsidence  are  some  cases 
of  interstitial  keratitis. 

Examples  of  definite  mischief  are  some 
of  the  cases  of  probable  peripheral  para- 
lysis of  one  or  more  cranial  nerve,  and 
some  cases  of  choroiditis  disseminata. 

An  instance  of  rapidly  progressive  irre- 
parable mischief  is  the  deafness  of  here- 
ditary syphilis.  Damage  to  vessels  with 
thrombosis  is  probably  recoverable  to  a 
great  extent,  and  the  symptoms  referable 
to  it  show  often  remarkable  and  rapid  im- 
provement. 

The  irritability  and  convulsions  depend- 
ent on  meningeal  disease  may  be  controlled, 
but  they  are  often  the  harbingers  of  pro- 
gressive degeneration,  and  what  may  be 
called  the  degradation  of  the  functions  of 
both  brain  and  cord.  The  psychical 
affections  are  always  to  be  looked  upon  as 


of  grave  import.  For  although  there  may 
be  periods  of  quiescence  yet  the  ultimate 
issue  tends  sooner  or  later  to  dementia. 

Treatment. — We  are  of  opinion  that 
the  paramount  lesson  of  congenital  braia 
syjihilis  is,  that  the  earliest  exanthem 
stage  of  the  disease  should  be  vigorously 
treated.  The  desideratum  is  not  only  to 
get  rid  of  the  affections  of  skin  and  mu- 
cous membrane  which  will  spontaneously 
subside,  but  to  limit  if  possible  the  early 
damage  to  tissues  which  not  improbably 
gives  a  substratum  for  later  mischief. 

We  believe  that  mercurial  inunction 
ought  as  a  rule  to  be  employed  in  the 
early  stage  of  the  disease.  For  the  later 
manifestations  grey  powder  is,  we  believe, 
the  best  vehicle  of  giving  mercury  inter- 
nally ;  but  whenever  active  signs  appear 
mercurial  inunction  'should  again  be 
employed.  The  iodides  may  ba  given  as 
intermediate  treatment,  but  we  have  not 
found  them  so  well  tolerated  or  so  obvi- 
ously effective  in  children  as  mercury. 


Fig.  I. 


Fig.  2. 


^:^Mf 


Section  of  cerebral  cortex 
from  uppiT  end  of  motor 
region — from  the  same  case 
as  Fig-.  I.  The  drawing 
shows  a  group  of  atrophied 
pyramidal  cells  with  wide 
peri-cellular  spaces  :  in  many 
sections  of  the  cortex  not  a 
single  cell  could  be  found. 
Sections  of  the  spinal  cord 
showed  descending-  sclerosis 
of  the  pyramidal  tracts.  (Dr. 
Hury,  liraiii.  1883,  p.  16.) 


Section  of  middle  cerebral  artery  from  a  girl 
aged  fifteen  years,  the  subject  of  hereditary 
syphilis  and  dementia.  The  letter  a  is  placed 
in  the  lumen  of  the  vessel,  h  in  the  middle  of 
a  growth,  composed  of  round  and  fusiform 
cells,  and  situated  between  the  endotlielium 
and  the  fenestrated  membrane.  (Dr.  Hury's 
case,  Brain,  April  1883,  p.  17.) 


Syphilitic  Disease 


[     1271 


Syphilitic  Disease 


Kic.    3. 


^iliV^h. 


f-f^ 


YiG_  3. — Third  nerve  proseutiug  a  fusiform  gumm;i  near  its  superficial  origin. 
From  a  child  aged  fifteen  moutlis,  the  subject  of  eonueuital  sypliilis. 

Kio.  4. — Section  of  gumma  of  motor  root  of  fifth  nerve  from  the  same  case. 
//,  funiculi  showing  destruction  of  axis  cylinders  and  infiltration  with  granulation 
cells,  which  are  most  abundant  at  periphery.  /,  interfuuicular  tissue  infiltrated  to 
less  extent  with  granulation  cells.  Symmetrical  gummata  were  present  on  both 
third  nerves,  and  on  the  fourth,  fifth,  sixth,  seventh,  and  eighth  pairs  at  their  super- 
ficial origin.  There  was  extensive  endarteritis  of  the  basilar,  and  all  the  arteries 
forming  the  circle  of  AVillis.  Stellate  cicatricial  patches  were  found  on  tlie  surface  of 
the  liver  with  some  subjacent  cellular  infiltration,  and  there  was  a  cicatrix  on  the 
capsule  of  the  spleen  and  adhesion  of  the  peritoneum  to  it.  (Dr.  Barlow's  case, 
"Path.  Trans.,"  vol.  xxviii.  p.  291.) 


Fia.  5. 


w  "i-r-.".-"- 


Fig.  5. — Peri-arteritis  and  endarteritis  of  arteriole  from  a  syphilitic  infant,  who 
died  aged  ten  months.  There  was  extensive  chronic  meningitis  of  the  convexity,  with 
a  few  adhesions  of  bone,  dura  mater,  and  pia  arachnoid,  and  one  small  thin  patch  of 
calcification.  There  was  a  small  area  of  recent  green  lymph  at  the  anterior  base.  In 
the  meningitis  of  the  convexity  small  arteries  could  be  traced  like  opaque  white  threads. 
These  on  section  showed  a  gradually  narrowing  lumen,  and  for  varying  distances  they 
were  thrombosed.  The  arteries  of  the  circle  of  \Villis  were  natural.  There  were  a 
few  spots  of  superficial  softening  in  the  cortex,  and  the  lateral  ventricles  were 
slightly  enlarged.  There  was  extensive  choroiditis  in  the  exudation  stage.  The 
meningeal  disease  probably  started  when  the  child  was  four  months  old.  The 
choroiditis  was  first  detected  when  8he  was  eight  months  old.  (Dv.  15arlow"s  case, 
"Path.  Trans.,"  vol.  xxviii.  p.  287.) 


Syphilitic  Disease 


[    1272    ] 


Ssrphilitic  Disease 


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,.5   i)     . 
K  3  « 


SVSTEMATISED    MANIA.      (>S'ee  MaMA,  SystEMATISED.) 


Tabes  Dorsalis  and  Insanity    [     1273    ]        Tears,  Psychology  of 


TABES  SORSAX.ZS  A-NH  ZN- 
SASTZTY.  — •  Occasionally  tabes  dorsalis 
or  locomotor  ataxy  is  complicated  with 
general  paralysis  of  the  insane.  In  other 
cases  of  tabes  dorsalis,  cerebral  symptoms 
sometimes  supervene  and  the  patient  be- 
comes insane.  {See  Locomotor  Ataxy  as 
ALLIED  TO  Neuroses.) 

tabz:tzc  gazt  in  geiteraii 
PARAI.VSZS.  {See  General  Para- 
lysis.) 

TACHE  CEREBRAIiE.  —  A  pheno- 
menon tormei'ly  supposed  to  be  a  patho- 
gnomonic sign  of  meningitis,  but  now 
known  to  occur  in  many  diseases.  It  con- 
sists in  the  production  of  a  bright  red 
line  by  drawing  the  tinger-nail  over  the 
skin  of  the  patieut,  this  line  lasting  longer, 
appearing  earlier,  and  being  broader  and 
deeper-coloured  than  would  be  the  case 
in  a  healthy  person. 

TACHYPHRASZA  (raxvf,  rapid; 
(f)pa(ris,  speech).  Synonym  of  Logo- 
diarrhoea  {q.v.). 

TANAS  ZIVI  OTTO  SOPH  OBOIVXANZE. 
(Fr.)  Michea'.s  term  for  hypochondriasis. 

TANZKRANKHEZT,  TANZSVCHT, 
TANZWUTH,   St.  "Vitus's  dance.  Chorea. 

TAPEZN-OCEPHAXiZC  (raTTeii/os,  low 
or  debased ;  Ke^aXi^,  the  head).  A  term 
applied  to  skulls  whose  conformation 
shows  a  low  type  of  development. 

TARANTZSM.     (See  Tarantulism.) 

TARAN-TUI.A,  TAREITTUIiA 

(Taranto,a  city  of  Apulia,  where  the  spiders 
abounded). — The  name  of  a  venomous 
spider  whose  bite  was  said  to  produce  a 
state  of  melancholy  and  stupor  which  could 
only  be  relieved  by  music,  the  patient  then 
being  excited  into  a  kind  of  dancing  fit 
called  Tarantulism  {q.v.}. 

TARAM-TUI.ZSiyi,  TARENTISIVIUS, 
TARENTUIiZSIVI  (Tarantula,  a  spider, 
originally  from  Taranto,  the  city  in  the 
vicinity  of  which  venomous  spiders  were 
found). — An  epidemic  dancing  mania  oc- 
curring in  Italy  in  the  sixteenth  and 
seventeenth  centuries,  the  dancing  and 
excitement  being  adopted  as  a  remedj'' 
for  the  bite  of  the  tarantula.  Owing  to 
the  number  of  epidemics  prevalent  at  the 
time,  there  existed  great  fear  of  the  bite 
of  the  tarantula  as  causing  symptoms 
ending  either  in  death  or  permanent  in- 
jury ;  accordingly,  a  bite  of  any  sort  in- 
duced intense  depression.  Music  and 
dancing  were  found  to  relieve  the  de- 
pression and  it  was  stated  that  by  these 


means  the  poison  was  dispersed  and  ex- 
pelled. The  remedy  induced  great  nervous 
excitement,  which  spread  by  infection, 
and  very  many  people  became  affected  by 
this  dancing  mania.  People  danced  till 
they  dropped  from  exhaustion,  every 
emotion  seemed  excited  and  suicides  oc- 
curred. After  a  time  the  dancing  became 
annual,  but  died  out  towards  the  end 
of  the  seventeenth  century.  The  taren- 
tella  were  the  tunes  or  songs  composed  to 
cure  this  dancing  mania.  (Fr.  tarantisnie  ; 
Ger.  Tarantismus).  {See  Epidemic  In- 
sanity.) 

TASTE,     HAIiIiUCZN'ATZONS      OF. 

(See  Hallucination.) 

TASTE,     ZI.I.VSZON'S     OF.       {See 

Illusion.) 

TAVBSTVIVIMHEZT  (Ger.).  Deaf- 
mutism. 

TAUSCHUITG  (Ger.).     Illusion. 

TEARS,  PSYCHOLOGY  OF.— Adjec- 
tives the  most  various  have  been  used  to 
express  the  psychological  q  ualities  of  tears. 
They  have  been  called  "  hot,"  "  cold," 
"languid,"  "gushing,"  "silent,"  "wearied," 
"  wanton,"  and  we  know  not  what  else. 
They  are  waves  of  emotion,  and,  as  a 
general  expression,  they  are  said  to  spring 
always  from  the  heart,  an  expression 
singularly  truthful,  for  no  one  ever  wept 
from  the  head ;  that  is  to  say,  no  one  ever 
reasoned  himself  or  herself  into  tears 
except  through  an  appeal  back  to  an 
emotion.  There  are  very  few  persons  who 
do  not  under  some  emotions  shed  tears, 
and  it  is  probably  quite  true  that  they 
who  can  always  restrain  them  are,  accord- 
ing to  the  common  opinion,  of  a  hard  and 
unimpressionable  nature.  The  statement 
often  made  that  insane  persons  do  not 
shed  tears  is  not  all  true,  but  there  is 
some  truth  in  it.  We  have  seen  the  in- 
sane weeping,  but  we  must  admit  that  on 
visiting  the  wards  of  great  asylums  there 
is  a  remarkable  absence  of  weeping  in 
comparison  with  the  noise,  irritation,  and 
wandering  of  intellect  that  is  forced  on 
the  attention.  Also,  we  have  known  a 
sane  person  who  became  insane,  owing  to 
a  great  calamity  of  grief,  overwhelmed 
with  weeping  while  the  sanity  remained, 
but  perfectly  and  persistently  tearless 
when  the  insanity  was  manifested,  a 
result  that  may  appear  natural  when  the 
physiology  of  weeping  is  properly  under- 
stood. 

Tears  are  the  result  of  a  nervous  storm 


Tears,  Psychology  of       [    1274    ]        Tears,  Psychology  of 


in  the  central  nervous  system,  under 
which  there  is  such  a  change  in  the  vas- 
cular terminals  of  the  tear-secreting  glands 
that  excretion  of  water  from  the  glands  is 
profuse.  Some  excretion  is  always  in 
process  in  order  that  the  surface  of  the 
eye  may  be  laved  and  cleared  of  foreign 
matters  which  may  come  in  contact  with 
it ;  but  the  controlling  centre  is  at  a  dis- 
tance. As  the  muscular  power  that 
extends  or  flexes  a  finger  is  at  a  distance 
from  the  part  moved,  so  the  excitement 
to  tears  is  from  an  irritation  in  a  distant 
nervous  centi-e,  and  is  removed  when  the 
nervous  centre  is  either  soothed  or  ex- 
hausted. The  persons  who  weep  say 
that  tears  afford  relief.  Nothing  is  more 
perfectly  true,  nothing  more  clear  when 
the  facts  are  understood.  The  relief 
comes,  not  from  the  mere  escape  of  tears, 
which  is  only  a  symptom,  but  from  the 
cessation  of  the  storm  in  the  nervous 
chain.  If  the  storm  be  calmed  by  sooth- 
ing measures,  as  when  we  soothe  a  child 
that  is  weeping  from  fear,  annoyance,  or 
injury,  we  quiet  the  nervous  centres,  upon 
which  the  effect  ceases.  In  children  the 
soothing  method  succeeds,  and  sometimes 
it  succeeds  in  adults,  although  in  adults 
the  cessation  of  tears  is  more  commonly 
due  to  actual  exhaustion  following  a 
period  of  nervous  activity.  In  grief,  the 
afflicted  weep  until  they  can  weep  no  more ; 
then  they  become  calm,  or,  like  children, 
cry  themselves  to  sleep.  Thus  tears  in- 
dicate relief,  and  show  that  the  nervous 
system  has  fallen  into  the  repose  of  weari- 
ness. Persons  subjected  to  many  and 
repeated  griefs  shed  in  time  fewer  tears, 
and  the  aged,  compared  with  the  younger, 
are  almost  tearless.  The  poor  insane 
jDatient  who  ceases  to  weep  becomes  grief- 
less  ;  under  the  continued  excitement  the 
grief  centre  fails  or  dies.  If  this  were  not 
the  case,  tears  would  flow  in  such  a  person 
so  long  as  life  lasted.  Tears  have  their 
value  in  the  life  of  mankind  ;  they  are  of 
value  not  as  tears,  although  their  actual 
flow  gives  relief,  but  as  signs  that  the 
grief  centres  are  being  relieved  of  their 
sensibility,  and  that  the  nervous  organi- 
sation is  being  fitted  to  bear  up  against 
sorrow. 

We  once  crossed  the  Thames  in  a  boat 
at  Putney  with  a  man  eighty-four  years  of 
age.  He  told  us  :  "  It  is  sixty  years  since 
I  last  made  this  passage  in  this  same 
place,  and  then  it  was  to  fetch  the  famous 
Dr.  Hooper  "  (author  of  Hooper's  "  Physi- 
cian's Yade  Mecum")  "  to  see  my  child  Tom 
lying  at  death's  door  with  scarlet  fever.  I 
was  so  heart-broken,  and  cried  so  terribl}^ 
that  the  men  in  the  ferry-boat,  which  then 
plied  here,  tried  to  console  me.     Tom  re- 


covered and  lived  until  last  year,  when  he 
went  before  me.  If  he  had  died  of  the 
scarlet  fever  when  he  was  young,  I  verit- 
ably believe  I  should  have  died  too  of 
tears  and  grief,  and  yet  when  he  died 
fifty-nine  years  later,  during  all  which 
period  he  and  I  had  been  affectionately 
attached  to  each  other,  I  could  not  shed  a 
tear,  nor  could  I  again  feel  the  poignancy 
of  that  early  grief.  I  accuse  myself  of 
being  without  feeling,  and  yet  I  cannot 
help  it.  Can  you  doctors  explain  the 
reason  ? "  We  explain  it  as  above,  and 
we  think  the  explanation  as  merciful  in 
fact  as  it  is  clear  in  theory. 

Respecting  the  nervous  excitation  which 
calls  forth  tears,  we  have  noticed  how 
little  it  is  due  to  physical  pain.  It  is 
called  forth  by  fear,  by  anxiety,  by  affec- 
tion, by  grief,  but  not  even  by  pain  ex- 
tending to  agony.  In  the  days  preceding 
the  use  of  ansesthetics  we  have  seen 
patients  who  were  undergoing  surgical 
operations  faint ;  we  have  heard  them  cry 
out  and  scream  until  they  made  the  by- 
standers sick  and  j^ale,  but  they  rarely,  if 
ever,  shed  tears.  The  parturient  woman 
in  the  acme  of  her  "  great  pain  and  peril " 
may  suffer  the  extremest  physical  agony, 
under  which  her  cries  are  piercing,  but 
she  rarely  sheds  tears.  Indeed,  we  never 
recollect  seeing  the  most  nervous  of  her 
class,  under  such  circumstances,  shedding 
a  tear.  Strangely,  however,  during  the 
sleep  induced  by  an  anaesthetic  like  chloro- 
form or  ether,  we  have  seen  profuse  tears, 
not  from  suffering,  but  from  some  emo- 
tional dream  induced  by  the  narcotic. 

A  very  slight  emotional  disturbance 
will  induce  the  nervous  irritation  leading 
to  tears  in  susceptible  subjects ;  and  this 
although  the  catastrophe  has  nothing  to 
do,  intrinsically,  with  the  person  affected. 
Hence  the  commotion  of  tears  conjured 
up  in  a  play.  Hamlet,  it  will  be  remem- 
bered, seizes  aptly  this  point  when  the 
player  weeps.  "  What's  Hecuba  to  him,  or 
he  to  Hecuba  .P"  Of  course  nothing,  yet 
the  player  weeps,  and  maybe  the  audience 
weeps  with  the  player.  By  art  another 
remembrance  may  be  used  to  call  forth 
tears  on  the  proper  occasion.  A  well- 
known  player  was  asked  how  he  managed 
to  weep  when  he  willed.  He  replied,  ''  I 
call  up  the  remembrance  of  my  dear 
father,  who  is  dead."  On  the  other  hand, 
anything  that  produces  diversion  of  mind, 
when  the  disturbance  is  not  severe  may 
keep  back  the  outbreak.  John  Hunter 
tells  us  that  once  when  he  went  to  the 
play  to  see  Mrs.  Siddons  perform,  in  a 
moving  exposition  of  her  great  jiowers,  he 
could  not  join  the  I'est  of  the  house  in 
their  tears  "  because  he  had  forgotten  his 


Tears,  Psychology  of       [     1275    ] 


Temperament 


pocket-handkerchief;"  and  a  friend  of  my 
own,  an  emotional  man,  told  me  that  at  a 
funeral,  where  he  expected  to  be  over- 
whelmed with  tears,  ho  was  completely 
checked  by  an  absurd  reading  which  the 
parish  clerk  gave  to  a  sentence  of  the 
service.  In  these  facts  there  is  nothing 
incompatible,  because  the  more  intense 
the  nervous  vibrations,  the  more  easy  is 
the  diversion  of  the  impulse  from  one 
centre  to  another. 

As  a  rule,  the  escape,  and  free  escape, 
of  tears  relieves  the  heart  and  saves  the 
body  from  the  shock  of  grief.  Tears  are 
the  natural  outlets  of  emotional  tension. 
But  there  are  exceptions  to  this  rule,  and 
we  have  more  than  once  seen  iiucontrol- 
lable  weeping  followed  by  serious  systemic 
disturbance,  affecting  principally  the  heart 
and  circulation.  We  have  known  inter- 
mittency  of  the  heart  induced  in  this  way 
and  assume  the  most  serious  character. 

Change  of  scene,  mental  diversion  and 
outdoor  life  are  the  best  remedies  for  the 
tearful,  but  an  opiate  judiciously  pre- 
scribed is  often  the  sovereign  remedy. 
Other  narcotics  are  injurious.  Alcohol, 
so  often  resorted  to,  is  fearfully  injurious. 
It  disturbs  and  unbalances  the  nervous 
system,  keeps  up  a  maudlin  and  pitiful 
sentimentality,  and  sustains  the  evil. 
Alcohol  is  the  mother  of  sorrow.  There 
are  other  narcotics  which  are  similar  in 
effect,  notably  chloral :  but  an  opiate 
given  at  night-time,  under  necessity,  not 
only  soothes,  but  controls,  and,  when  pre- 
scribed so  that  the  use  of  it  shall  not  pass 
into  habit,  is  a  divine  remedy. 

As  tears  are  secreted  by  glands  which 
lie  between  their  nervous  centre  and  the 
mucous  surface  of  the  eyeball ;  as  they 
have  two  functions  or  duties,  one  the 
function  of  relieving  nervous  tension,  the 
other  of  laving  the  eyeball ;  so  these 
functions  may  be  called  into  over-action 
by  internal  nervous  impulses  or  vibrations, 
and  by  external  excitations  or  what  are 
sometimes  called  retiex  actions.  The  first 
is  seen  in  the  act  of  weeping  under  emo- 
tion, the  vibration  starting  in  the  nervous 
centres,  and  extending  to  the  gland  from 
behind,  urging  it  to  action ;  the  second  is 
seen  in  the  act  of  shedding  tears  from 
direct  irritation  of  the  mncous  surface  of 
the  eyeball,  as  when  an  irritating  sub- 
stance "  gets  into  the  eye,"  and  the  vibra- 
tion extends  from  the  mucous  surface 
back  to  the  gland,  exciting  it  to  action 
and  causing  emotionless  tears.  In  these 
ways  tears  afford  a  good  illustration  of 
the  mode  in  which  the  nervous  fibres  are 
capable  of  conveying  to  a  secreting  organ 
exciting  impulses  from  both  sides  of  a 
gland  lying  in  their  course,  and  having  in 


connection  with  it  afferent  and  efferent 
communications.  In  both  cases  the  ex- 
citing impulse  is  a  vibration ;  and  as 
when  the  impulse  sets  forth  from  a  mere 
external  irritation,  as  from  a  particle  of 
dust  on  the  conjunctiva,  the  effect  is  in 
the  truest  sense  mechanical ;  so,  ])robably, 
in  the  case  of  the  emotional  irritation, 
which  calls  forth  tears,  the  process  is  as 
purely  mechanical. 

In  the  human  animal  tears  are  most 
easily  wrought  where  the  sympathetic 
nervous  system  is  most  developed  and 
most  impressionable,  and  when  the  three 
great  emotions,  fear,  grief,  and  joy,  are 
most  active.  Hence,  women  generally  are 
more  given  to  tears  than  men,  and  under 
the  peculiar  state  called  hysteria,  in  which 
the  nervous  system  is  at  highest  tension, 
are  often  seen  moved  to  tears  by  the  three 
emotions,  in  turn,  during  one  paroxysm. 
B.  W.  Richardson. 
TEI..a:STHi:SZS  (r^Xe,far  off;  aiadrjais 
})erceptiou).  Tact,  or  perception  from 
remote  grounds  or  circumstances.  (Fr. 
telaestliese ;  Ger.  Fernfnlden). 

TEI.EPATHY  (rryXe,  afar;  TTcidos,  a 
suffering).  The  supposed  power  of  one 
mind  to  inHuence  or  be  influenced  by 
another  by  other  channels  than  those  of 
the  senses.  Also  a  synonym  of  Thought- 
reading  or  Thought-transference.  (Fr.  teU- 
Ijathle.) 

TEiviPER,  CHANCE  OP. — An  early 
symptom  in  insanity,  especially  moral 
insanity. 

TEIVIPERAIVIEN'T  {tempera,  I  mingle; 
Fr.  ieuqjerameiit  ;  Ger.  Korperanlage.) — 
The  theory  of  temperaments  as  under- 
stood in  the  present  day  implies  a  definite 
relation  between  the  physical  qualities  of 
an  individual,  such  as  size  and  form  of 
body,  size  and  shajDC  of  head  and  face, 
complexion,  colour  of  hair  and  eyes,  and 
on  the  other  hand,  his  mental  character- 
istics, his  tastes,  disposition,  and  tendency 
of  conduct,  his  mode  of  being  affected  by 
external  impressions  and  by  disease,  and 
so  on. 

By  this  theory  individuals  are  arranged 
in  groups  according  to  their  charact  jristics, 
and  it  is  claimed  that  those  belonging  to 
any  particular  group  on  account  of  their 
physical  qualities,  willbe  found  to  resemble 
one  another  in  their  mental  and  other 
qualities.  These  groups,  although  few  in 
number  are  so  comprehensive  that  most 
individuals  can  be  classed  in  one  or  other 
of  them,  and  the  name  summarising  the 
characteristics  belonging  to  each  one  of 
these  grouj^s,  is  the  name  of  the  tempera- 
ment of  each  member  of  the  group. 

The  word  temperament  as  met  with  so 
frequently  in  every-day  literature  andcon- 


Temperament 


[     1276    ] 


Temperament 


versatiou,  is  unt'ortunately  used  in  so  many 
varied  senses  that  it  is  quite  incajjable  of 
definition,  and  has,  in  fact,  no  distinct 
meaning.  From  such  sources  it  would 
seem  that  the  number  of  temperaments 
can  be  indefinitely  multiplied  merely  by 
prefixing  different  adjectives  to  the  word, 
and  the  common  non-scientific  use  of  the 
word  is  therefore  of  no  help  whatever  in 
endeavouring  to  understand  the  real  theory 
of  temperaments. 

The  word  temperament  was  originally 
used  almost  entirely  in  connection  with 
physical  qualities.  The  earlier  physicians 
had  to  rely  much  more  on  external  appear- 
ances as  an  aid  to  diagnosis  than  those  of 
the  present  day  have  ;  we  find,  therefore, 
that  the  idea  of  dividing  men  into  groups 
according  to  their  general  ajjpearance 
dates  from  a  very  early  age  in  medicine. 
In  the  writings  of  Hippocrates,  evidence 
of  the  conception  is  frequently  met  with, 
and  at  a  somewhat  later  date  the  theory 
was  arranged  on  a  scientific  basis  by 
Galen,  who  wrote  a  work  on  temperaments 
which  has  been  translated  into  Latin  by 
Linacre.  Since  the  time  of  Galen  the 
theory  has  been  variously  modified  and 
extended  in  detail  from  time  to  time,  but 
the  basis  of  his  teaching  has  been  the 
basis  of  all  teaching  and  writings  on  the 
subject  from  his  time  to  the  present. 

Galen  describes  nine  different  varieties 
of  temperament;  there  were  four  simple 
uncomplicated  temperaments,  the  dry,  the 
moist,  the  hot  and  the  cold  :  then  there 
were  four  temperaments  formed  by  mix- 
tures of  these  qi;alities,  the  hot  and  moist, 
the  hot  and  dry,  the  cold  and  moist,  and 
the  cold  and  dry,  which  from  their  descrip- 
tions appear  to  correspond  to  the  later 
sanguine,  bilious,  phlegmatic  and  melan- 
cholic temperaments  respectively.  Finally 
there  was  a  ninth  temperament  named  the 
"  balanced  "  in  which  no  quality  was  in 
excess,  but  the  individual's  characteristics 
were  so  arranged  and  evenly  balanced  that 
be  was  perfect.  It  served  as  a  basis  from 
which  to  describe  the  others. 

The  names  used  later  on,  sanguine, 
bilious,  &c.,  were  derived  from  the  humoral 
pathology.  It  was  supposed  that  a  per- 
son's temperament  depended  on  the  pre- 
sence in  his  system  of  an  excess  of  one  of 
the  humours,  or  of  a  preponderating  in- 
fluence of  the  organ  concerned  in  the  pro- 
duction of  that  humour.  Four  main  tem- 
peraments were  described  therefore,  accord- 
ing as  the  heart  and  blood,  the  liver  and 
bile,  the  spleen  and  black  bile  (the  spleen 
being  then  supposed  to  secrete  black  bile) 
or  the  brain,  jjituitary  body  and  phlegm 
were  more  infiuential  in  determining  the 
qualities  of  the  individual ;  the  names  were 


respectively:  Sanguine,  bilious  or  choleric, 
atrabilious  or  melancholic,  and  pituitous, 
lymphatic  or  phlegmatic. 

Since  these  early  times  the  number  of 
temperaments  described  has  remained  as  a 
rule  at  four.  Some  authors  since  it  has 
been  known  that  the  spleen  does  not 
secrete  black  bile,  and  that  black  bile  is 
bile  in  another  form,  have  dropped  the 
melancholic  temperament,  considering  it 
to  be  a  mixture  of  the  others ;  some  have 
added  another,  the  nervous  temperament, 
and  so  have  kept  the  numbers  at  four,  and 
others  have  added  the  nervous  and  dropped 
the  bilious  and  melancholic  temperaments. 
The  main  temperaments,  like  Galen's 
balanced  temperament,  are  used  as  types, 
for  it  is  obvious  that  very  few  individuals 
correspond  exactly  to  the  typical  descrip- 
tion ;  a  person  is  said  to  have  one  or  other 
of  the  temperaments  according  as  his 
characteristics  most  closely  correspond  to 
the  description  of  the  ideal  of  that  one. 

The  names  and  descriptions  of  the  divi- 
sions have  been  so  often  re-arranged  that 
it  is  difficult  to  find  two  authors  agreeing 
altogether  in  detail,  but  the  four  main 
temperaments  described  below  have  definite 
characters  and  are  those  usually  de- 
scribed; the  melancholic,  according  to  this 
classification,  being  properly  a  mixture  of 
the  bilious  and  the  nervous. 

(l)  The  Sang^uineTemperament. — Indi- 
viduals of  this  temperament  vary  inheight 
but  are  of  tener  short,  and  usually  not  stout 
until  later  on  in  life,  when  they  have  a  ten- 
dency in  that  direction.  The  head  and 
bones  are  small,  features  well  defined,  nose 
rather  short,  and  lips  of  medium  thickness, 
not  thin ;  neck  short.  Complexion  fair 
and  bright,  often  ruddy,  hair  reddish  and 
jDlentiful  in  early  life,  eyes  blue.  Men- 
tally persons  of  this  temperament  are 
characterised  by  great  susceptibility  to 
external  impressions  and  to  the  feelings  of 
pleasure  or  psLUi  attached  to  these  impres- 
sions ;  their  mental  movements  are  rapid 
but  shallow,  they  are  impulsive,  emotional 
and  excitable,  easily  provoked  and  as 
easily  forgetting.  They  lack  persistence 
and  have  bad  memories.  They  have 
often  jiowerful  imaginations  and  clever 
thoughts.  The  sanguine  temperament  is 
useful  in  preventing  narrowness  of  mind, 
and  in  initiating  new  ideas,  but  is  not 
suitable  to  an  older  age  than  that  of  child- 
hood, and  lacks  the  steadiness  necessary  in 
life.  The  diseases  said  to  be  especially 
common  in  those  of  this  temperament  are 
diseases  of  the  circulatory  S3'stem  and 
heart,  hasmorrhages  ajid  acute  iufiamma- 
tions.  Illnesses  in  these  individuals,  in- 
cluding insanity,  generally  run  an  acute 
course. 


Temperament 


[    ^^-n   ] 


Temperament 


(2)  The  Nervous  Temperament. — la 

persons  of  this  tomperameut  the  figure  is 
slight  but  otteu  tall.  The  head  is  small 
aud  narrow,  the  forehead  being  propor- 
tionately large.  The  features  are  small 
and  sharply  cut,  the  uose  and  chin  pointed 
and  the  lips  thin.  The  skin  is  dark  and 
dull,  the  complexion  sallow,  the  hair  is 
usually  brown  and  the  eyes  dark  or  grey. 
They  are  restless  and  active;  speech  rapid. 
Mentally  their  activity  is  great,  but  they 
are  characterised  by  too  much  change- 
ability. They  think  readily,  but  have  bad 
memories  ;  suffer  much  from  emotions  of 
hope  aud  fear,  but  easily  get  over  them 
afterwards.  They  imagine  well  and  are 
much  iutiuenced  by  their  environment. 
They  have  tender  feelings,  but  can  forget 
easily ;  very  susceptible  to  sensations. 
They  seem  to  be  particularly  liable  to 
insanit}^  esjDecially  mania,  and  to  dis- 
eases of  the  nervous  system. 

(3)  Tbe  Bilious  or  Choleric  Tempera- 
ment.— Individuals  of  this  temperament 
are  usually  short  and  thickly  built,  and 
even  if  tali  they  are  correspondingly  big. 
The  head  is  large  and  square  ;  features 
large  and  not  well  detined,  nose  outspread, 
mouth  wide,  skin  rough  and  hairy.  Com- 
plexion, hair  and  eyes  dark  in  colour. 
Voice  rough.  Movements  clumsy  but 
strong.  Mentally  they  are  capable  of 
much  exertion  ;  they  are  not  impulsive, 
but  steady  in  thought  and  judgment ; 
memory  good ;  speech  deliberate  but 
decided ;  they  make  up  their  minds  about 
anything  and  stick  to  it.  They  are 
passionate  and  jealous,  and  do  not  forget 
an  injury  ;  their  feelings  are  not  easily 
excited,  but  are  strong  when  roused. 
Affection  strong.  They  are  perhaps  less 
liable  to  disease  than  those  of  any  other 
temperament,  but  are  said  to  be  more 
frequently  affected  with  the  symptoms 
usually  included  under  the  heading,  "lithic 
acid  diathesis."  There  is  no  particular 
form  of  insanity  assigned  to  individuals  of 
this  temperament,  but  they  are  possibly 
more  liable  to  general  paralysis  or  mania 
than  the  other  forms.  The  question  of 
the  connection  between  temperament  and 
insanity  has  never  been  adequately  gone 
into. 

(4)  The  Phlegmatic  or  Iiymphatic 
Temperament. — Men  of  this  type  are,  as 
a  rule,  thick  set,  short-necked,  bulky  in- 
dividuals with  want  of  proportion  in  their 
build.  The  head  is  not  large,  the  features 
are  not  well  defined.  The  hair  is  light  or 
sandy  and  often  thin,  the  eyebrows  light. 
The  complexion  is  colourless  and  pasty, 
the  eyes  have  a  washed-out  ajjpearance, 
often  greyish  in  colour.  The  skin  is  un- 
healthy looking  ;  speech  is  slow  and  move- 


ments sluggish.  Mentally,  individuals 
•with  this  temperament  have  good  judg- 
ment, but  are  slow ;  common  sease  fairly 
good  and  memory  good  ;  not  emotional  ; 
heavy  and  plodding ;  feelings  persistent, 
thought  not  powerful.  Much  lack  of 
energy.  Persons  of  this  temperament  are 
liable  to  chronic,  strumous  diseases,  and 
to  chronic  catarrhs.  In  them  disease  runs 
a  slow,  atypical  course.  They  are  liable 
to  dementia  rather  than  to  other  forms  of 
mental  affection. 

Since  the  commencement  of  the  idea 
the  theory  of  temperaments  has  been 
variously  applied,  sometimes  fancifully, 
sometimes  with  a  firm  basis  of  fact. 
Among  the  common  modes  of  application 
are  the  following  : — Each  age  of  man, 
childhood,  youth,  middle  age  and  old  age 
has  a  particular  temperament  assigned  to 
it,  the  sanguine,  bilious,  melancholic,  and 
phlegmatic  respectively;  a  particular 
temperament  has  been  supposed  to  prevail 
at  each  season,  the  sanguine  in  spring, 
and  the  bilious,  melancholic  and  phlegm- 
atic in  summer,  autumn  and  winter  re- 
spectively. Nations  and  races  have  also 
had  a  ijarticular  temperament  ascribed  to 
each  of  them.  More  important  from  a 
medical  point  of  view  are  the  following  : — 
Climate  is  supposed  to  influence  tempera- 
ment, to  be  a  predisposing  cause  to  certain 
diseases  in  persons  of  particular  tempera- 
ments, and  to  affect  persons  differently 
according  to  their  temperament.  Men  of 
different  temperaments  are  also  said  to  be 
liable  to  different  diseases,  to  different 
classes  of  diseases,  and  to  be  differently 
affected  by  the  same  disease  ;  and  if  an 
individual  becomes  insane,  the  form  the- 
insanit}'  takes  is  said  to  depend  partly  on 
his  temperament,  as  mentioned  in  the 
description  of  the  different  varieties. 

In  the  time  of  the  humoral  pathology  it 
was  supposed  that  the  organ  and  humour 
concerned  in  the  formation  of  an  indivi- 
dual's temperament  were  especially  prone 
to  disease,  and  we  occasionally  find  some 
sort  of  evidence  of  this  in  the  present  day. 

It  must  be  confessed  that  the  theory 
of  temperament  is  not  of  much  use  in 
medicine  at  present,  as  far  as  diagnosis 
and  treatment  are  concerned.  In  the 
earlier  days  of  medicine  when  fewer  means 
of  diagnosis,  such  as  the  thermometer, 
stethoscope,  and  other  instruments,  were 
known,  the  patient's  appearance  was  of 
more  value  as  an  indication  for  treatment. 
However,  even  without  any  special  know- 
ledge of  a  theory  of  temperament,  no 
thoughtful  practitioner  in  the  present  day 
prescribes  for  a  patient  without  involun- 
tarily reminding  himself  thatthe  same  drug 
may  affect  two  persons  in  quite  a  different 


Temperature  in  Nerves      [     1278    j      Temperature  in  Nerves 


way, and  be  judges  what  its  effect  maybe 
very  much  by  the  physical  and  mental 
qualities  of  the  individual.  It  is  also  a 
matter  of  ordinary  experience  that  the 
course  of  the  same  disease  may  be  quite 
diftereut  iu  two  different  people,  and  the 
treatment  is  varied  accordingly.  More- 
over, even  now,  certain  diseases  are 
occasionally  associated  with  particular 
physical  appearances,  for  instance,  in  ex- 
amining a  case  of  diabetes,  we  almost  in- 
variably look  to  see  if  the  hair  is  of  a 
reddish  colour. 

Granted  that  the  theory  of  tempera- 
ments as  above  given  proved,  it  is  clear 
that  a  knowledge  of  it  can  be  made  useful 
in  lorophylactic  medicine.  If  people  of  a 
certain  temperament  are  liable  to  certain 
diseases,  or  if  diseases  run  particular 
courses,  according  to  the  temperaments 
of  the  i^atients  affected,  the  causes  of  the 
diseases  can  be  avoided  in  the  former 
cases,  and  in  the  latter  we  can  treat  ac- 
cordingly. If  it  be  known  that  certain 
climates  are  dangerous  to  individuals  of 
any  one  temperament,  they  can  be  advised 
either  to  remove  from  the  dangerous  place 
or  to  be  on  their  guard  against  the  affec- 
tions to  which  they  are  liable.  In  the 
case  of  insanity  also,  if  it  be  true  that 
men  of  particular  temperaments  are 
liable  to  corresponding  particular  forms 
of  madness,  one  can  know  what  to  expect 
and  provide  accordingly  ;  moreover  the 
treatment  of  that  and  any  other  disease 
must  be  adapted  to  the  temperament  of 
the  patient,  if  it  is  clear  that  the  way  in 
which  the  disease  affects  the  individual, 
and  the  sort  of  treatment  the  disease  is 
amenable  to  in  his  case,  depends  on  his 
temperament. 

It  has  been  said  that  in  the  inherit- 
ance of  i^hysical  qualities,  corresponding 
mental  characteristics  and  liability  to 
disease  are  also  inherited ;  the  recording 
of  the  temperament  of  the  parent,  might, 
if  this  be  the  case,  influence  the  bringing 
up  and  career  of  the  child. 

AViLLiA:\r  Geo.  "Willoughby. 

TSIVIPERATURZ:  ITT  FERZPHSRiLIi 
NERVES. — The  conditions  of  tempera- 
ture in  the  trunks  of  peripheral  nerves 
may  be  considered  under  two  heads  : 
First,  as  to  the  question  whether  any 
heat  is  evolved  when  a  nervous  impulse 
travels  along  a  nerve  trunk;  andsecondly,as 
tothequestionwhetherauy  heat  is  given  off 
from  a  nerve  during  the  process  of  dying. 

(i)  The  question  as  to  wliether  heat  is 
set  free  during^  the  passage  of  a  ner- 
vous impulse  was  attacked  as  long  ago 
as    1848  by   Helmholtz.*      This  observer 

*  Mliller's  Archiv  Aiiat.  it.  Physioloff.,  1848' 
6.  158. 


worked  with  a  thermopile,  and  using  two 
sciatic  nerves  of  a  frog  failed  to  find  any 
evidence  of  heat  being  evolved  from  a 
nerve  during  the  passage  of  a  nervous  im- 
pulse. His  instrument  was  sensitive  to 
one-thousandth  of  a  degree  Centigrade. 

Heidenhein*  repeated  these  experi- 
ments with  a  similar  result.  On  the  other 
hand  Oehlf  and  Valentin, ;J;  employing 
much  the  same  method,  obtained  evidence 
pointing  to  the  production  of  heat  in  a 
nerve  trunk  during  the  passage  of  a  ner- 
vous impulse.  Schiff  §  experimenting 
with  a  thermopile  on  the  nerves  of  warm- 
blooded animals  such  as  cats,  rabbits  and 
white  rats  obtained  a  similar  positive 
result. 

The  invention  of  an  instrument  for 
measuring  with  extreme  delicacy  any 
variation  in  temperature  by  Callendar  || 
provided  the  writer  with  a  very  reliable 
method  for  re-investigating  this  question. 
The  electrical  resistance  thermometer  de- 
pends on  the  principal  that  the  electric 
resistance  of  a  metal  wire  varies  approxi- 
mately as  its  temperature.  If  the  term- 
i:)erature  of  the  metal  wire  be  altered  its 
resistance  to  the  passage  of  a  constant 
current  can  be  observed  by  niieans  of  a 
galvanometer.  By  those  means  very  small 
variations  of  temperature  can  be  calcu- 
lated. The  degree  of  sensibility  which  it 
was  usually  found  convenient  to  work  with 
was  one  five-thousandth  of  a  degree  Centi- 
grade. In  this  research^  the  sciatic  nerves 
of  frogs  were  used,  and  taking  pains  to 
eliminate  all  sources  of  error  it  was  found 
that  there  was  no  evidence  of  any  heat 
being  evolved  from  a  nerve  trunk  when  a 
nervous  imijulse  was  generated  in  the 
nerve. 

The  fact  that  no  heat  can  be  detected 
by  an  instrument  so  delicate  as  to  show 
variations  ofone  five-thousandth  of  a  degree 
Centigrade,  or  less  if  desired,  is  of  interest  in 
comparing  the  activity  of  muscle  with  that 
of  nerve.  In  the  case  of  muscle,  energy 
when  liberated  appears  as  work  done,  and 
as  heat  liberated  in  the  proportions  vary- 
ing under  different  conditions  ;  whereas 
in  the  case  of  a  nerve  trunk  there  is  no 
evidence  of  the  energy  of  a  nervous  im- 
pulse appearing  in  any  form  but  that  of 
the  impulse. 

(2)  As  to  the  Production  of  Heat  in  a 
Nerve  during:  the  Process  of  Syingr. — 
Using     Callendar"s    electrical    resistance 

*  Stiidicn  (h'  Phi/.iioloff.  Institut  s«  Breslnu,  iv. 
s.  250,  1868. 

t   (rdz.  Med.  dc  Paris,  p.  225,  1866. 

t  Archiv  f.  J'atholog.  Anat.,  xxviii.  s.  i,  1863. 

§  Arch.  d.  Physiolog.  Kormalet  Patholoy  ,  p.  ii^j, 
1869. 

[|   Phil.  Trans.,  1887,  A.,  p-  161. 

^  Journul  iif  Phi/siolof/y,  p.  208,  1890. 


Temperature  of  the  Body    [     1279    J    Temperature  of  the  Body 


thermometer  the  writer  found  that  if  the 
thermal  condition  of  a  nerve  trunk  be 
continuously  observed  it  will  be  found  that 
— due  pi-ecautions  being  taken — heat  is 
evolved  from  the  nerve  as  it  loses  its 
irritability  and  dies. 

The  technique  of  the  erperiment  cannot 
be  gone  into  here,  Init  it  is  enough  to  state 
that  the  vitality  of  the  nerve  can  be  esti- 
mated by  the  amount  and  existence  of  the 
natural  nerve  current.  The  natural  nerve 
current  disappears  on  the  death  of  the 
nerve,  andso  forms  a  criterion  of  its  vitality. 
Experiment  goes  to  show  (i)  that  a  nerve 
in  dying  evolves  heat,  and  (2)  that  this 
evolution  of  heat  corresponds  roughly 
with  the  intensity  of  the  natural  nerve 
current ;  this  relation  is  not,  however,  ab- 
solutely constant. 

HuMi'URv  Daw  Eolleston. 

ti:i>ipz:raturi:  of  the  bodv  zio- 

IN-SATfZTY,  A.TfD  THE  USE  OF  THE 
THERIVTOMETER     IN     ITS    TREAT- 

T/lTlNT. — The  older  authors  frequently 
attributed  the  more  acute  varieties  of  in- 
sanity to  "inflammation"  of  the  brain, 
and  Bayle  in  his  first  account  of  general 
paralysis  in  1822  called  it  an  inflammation 
of  the  membranes.  But  no  scientific  ob- 
servations were  made  on  the  temperature 
of  the  body  in  any  form  of  insanity  until 
after  the  clinical  thermometer  was  brought 
into  use  by  Wunderlich,  and  his  results 
had  been  j^ublished  in  his  classical  work. 
Dr.  Saunders,  of  the  Devon  Asylum,  was 
the  first  to  use  the  instrument  in  asylum 
practice,  and  to  publish  in  1865  a  general 
estimate  of  its  future  importance,  with  a 
case  of  general  pai-al3'sis,  in  which,  after  a 
congestive  attack,  the  temperature  as 
tested  by  the  thermometer  was  shown  to 
be  106°.  In  1867  we  made  a  series  of  ob- 
servations on  the  temperature  of  the  body 
in  the  insane,  as  tested  by  the  thermometer 
in  305  patients  in  the  Carlisle  Asylum,  the 
results  being  compared  with  observations 
on  forty  sane  persons  living  under  the 
same  conditions.  The  chief  results  ob- 
tained, which  have  not  been  upset  by  any 
subsequent  observations,  were  the  follow- 
ing : — The  average  temperature  of  the 
body  is  higher  in  the  insane  than  in  the 
sane.  It  is  highest  in  general  paralysis, 
falling  gradually  in  the  following  mental 
diseases  :  viz.,  acute  mania,  epileptic  in- 
sanity, melancholia,  simple  mania,  and 
dementia.  Subsequent  observations  have 
shown  ns  that  puerperal  insanity  has  a 
higher  average  temperature  than  even 
general  paralysis,  there  being  a  large 
number  of  cases  of  the  former  disease — 
23  per  cent,  of  the  whole  number — with  a 
temperature  over  100%  some  of  them  even 
reaching  106^.     Dementia  is  the  only  form 


of  insanity  the  average  temperature  of 
which  is  below  that  of  health.  The  great 
characteristic  of  every  form  of  insanity  is 
that  the  difference  between  the  night  and 
day  temperatures  is  less  than  that  of 
health,  and  this  is  owing  to  the  rising  of  the 
night  temperature  and  not  to  the  lowering 
of  the  morning  temperature.  In  general 
l^aralysis  the  night  temperature  is  nearly 
always  higher  than  the  morning  tempera- 
ture, if  a  sufficient  number  of  observations 
are  taken  in  all  the  stages  of  the  disease 
in  any  case.  The  night  temperature  of 
every  form  of  insanity  is  higher  than  that 
of  health.  The  greatest  differences  of 
temperature  are  found  in  j^uerperal  in- 
sanity, general  paralysis,  epileptic  in- 
sanity, and  acute  mania  in  difierent  cases. 
Increased  mental  exaltation  and  excite- 
ment to  any  great  extent  alwa3's  raised 
the  temperature  from  1°  to  5.8°  in  differ- 
ent cases.  In  folie  circulaire  there  is  a 
different  temperature  for  the  depressed, 
the  sane,  and  the  elevated  periods,  the 
last  being  the  highest  by  2.2 ''  in  some 
cases.  The  congestive  attacks  of  general 
paralysis  are  almost  always  accompanied 
or  followed  by  a  rise  in  temperature,  this 
commonly  passing  over  100°.  We  once 
had  a  case  in  which  it  reached  before 
death  107. 4-.  A  continuous  and  marked 
rise  in  the  average  temperature  in  any 
case  commonly  shows  acute  brain  excite- 
ment or  advancing  cerebral  disease.  The 
average  frequency  of  the  pulse  in  insanity 
corresponds  with  the  mean  temperature, 
but  the  rises  in  the  evening  temijerature 
have  no  necessary  corresponding  rises  in 
the  evening  pulse.  The  differences  in  the 
temperature  between  the  insane  and  the 
sane  are  actually  not  great  in  amount,  on 
the  average  being  under  i^  when  a  large 
number  of  cases  are  taken.  Though  this 
difference  seems  small  yet  it  is  very  sig- 
nificant and  very  important.  It  indicates 
how  profoundly  the  brain  action  is  affected 
in  insanity,  the  changes  extending  not 
only  to  the  mental  functions  but  to  the 
thermic  centres.  These  differences  of 
temperature  are  partly  explained  by  the 
recent  observations  of  E,oy  and  Sherring- 
ton and  others  as  to  the  vaso-motor  centres 
of  the  brain  being  situated  in  the  cortex ; 
each  functional  area  thus  includes  such  a 
centre  for  itself,  thi'ough  the  action  of 
which,  with  that  of  the  cortical  cells,  there 
results  an  automatic  arrangement  through 
which  those  areas  receive  an  increased 
supply  of  blood  and  produce  increased 
heat  when  active,  and  have  a  diminished 
supply  with  a  lessened  temperature  when 
functionally  at  rest.  Many  observers  have 
demonstrated  by  the  use  of  delicate  sur- 
face thermometei's  that  functional  activity 


Temperature  of  the  Body    [     1280    ]    Temperature  of  the  Body- 


in  individual  brain  areas  causes  increased 
temperature  there. 

We  have  found  a  few  cases  of  very  low 
and  very  high  "  neurotic  ''  temperatures 
among  the  insane,  that  were  quite  excep- 
tional and  apart  from  general  experience. 
Bechterew  found  that  the  insane  generall}' 
have  not  the  same  resistive  power  as  the 
sane  against  low  temperatures,  their 
bodies  losing  heat  more  ra]>idly  when  sub- 
jected to  great  cold. 

Many  observers  in  this  country,  in 
France,  Germany,  Italy,  and  America, 
have  since  made  observations  on  the  tem- 
perature in  the  insane,  especially  in  gene- 
ral paralysis.  Among  those  may  be  men- 
tioned Macleod,  Miclde,  Turner,  Bech- 
terew, and  Croemer,  and  their  results 
confirm  generally  our  observations  in 
1867. 

To  any  one  engaged  in  practice  in  the 
depai'tment  of  mental  diseases  the  ther- 
mometer is  of  the  greatest  service.  It  is 
useful  and  often  essential,  (i)  in  the  differ- 
ential diagnosis  of  those  diseases  from  the 
continued  fevers,  inflammation  of  the 
nei'vous  centres,  traumatism,  and  from 
other  diseases ;  (2)  in  the  diagnosis  of 
many  acute  brain  affections,  accidents, 
and  bodily  diseases  among  the  insane  ; 
and  (3),  in  the  treatment  of  most  cases  of 
acute  mental  disease.  Before  deciding  to 
send  any  patient  to  an  asylum  we  think 
the  temperature  should  always  be  taken. 
We  have  known  cases  of  the  delirium  of 
typhus  and  typhoid  fevers,  scarlet  fever, 
meningitis,  septica3mia,  urasmic  delirium, 
cerebro-spinal  meningitis,  drunkenness, 
and  opium  poisoning  sent  to  asylums  as 
labouring  under  technical  insanity,  and 
some  of  the  cases  were  so  sent  by  able  and 
experienced  men  in  our  profession.  The 
use  of  the  thermometer  would  in  most 
of  these  cases  have  averted  such  mistakes. 
Then,  every  medical  man  with  expei'ience 
among  the  insane  knows  how  in  certain 
cases  bodily  disorders  of  every  kind  may 
occur  without  any  complaint  on  the  part 
of  the  patient.  The  sensory  ana3sthesia 
and  reflex  dulness  that  so  often  accompany 
acute  and  chronic  insanity,  together  with 
the  disturbed  reasoning,  will  often  abolish 
or  inhibit  the  pain  of  acute  pleurisy  or  peri- 
tonitis, will  stop  the  cough  of  pneumonia 
and  phthisis,  and  prevent  a  maniacal  pa- 
tient with  broken  ribs  or  serious  internal 
injuries  from  complaining  or  saying  that 
anything  is  wrong.  We  have  to  think, 
and  feel  and  reason  for  the  patient,  and 
come  to  conclusions  from  his  objective 
signs  alone.  The  thermometer  helps  us 
greatly  to  do  this,  for  its  indications  are 
absolute  so  far  as  they  go.  We  think  it  a 
safe  rule  that  whenever  the  temi)erature 


of  any  insane  patient  is  found  to  be  above 
99.5°,  a  careful  physical  examination 
should  be  made  to  discover  bodily  disease 
or  injury  ;  not  that  such  a  temperature  as 
that  may  not  be  caused  by  cortical  brain 
excitement.  We  have  known  a  purely 
maniacal  and  neurotic  temperature  of 
104°  to  occur  in  a  case  that  was  not  a 
general  paralytic,  had  no  organic  brain 
disease,  and  was  not  a  puerperal  case. 

It  is  in  the  third  department  mentioned 
however — viz.,  the  ordinary  diagnosis, 
prognosis,  and  treatment  of  mental  dis- 
eases, that  we  would  say  the  regular  use 
of  the  thermometer  was  most  important 
of  all.  We  do  not  consider  the  clinical 
history  of  any  case  of  insanity  complete 
except  the  morning  and  evening  tempera- 
tures have  been  taken  several  times  in  the 
course  and  different  stages  of  the  disease. 
The  difference  between  the  morning  and 
evening  temperature,  and  that  between 
one  stage  and  another  may  be  very  slight, 
but  yet  may  be  very  important.  We  always 
estimate  that  in  psychiatry  a  diflference 
of  a  degree  of  temjiierature  may  have  an 
equal  significance  with  two  or  three  degrees, 
in  fevers  and  inflammations.  If  the  tem- 
perature of  a  maniacal,  melancholic,  or 
general  paralytic  patient  is  found  to  have 
risen  from  98.4°  to  99.4',  it  will  in  most 
cases  be  as  important  an  indication  for 
diagnosis  and  treatment  in  a  case  of  in- 
sanity, as  an  increase  of  three  degrees  in  a 
case  of  fever  or  inflammation.  In  melan- 
cholia neurotic  rises  of  temperature  over 
100°  are  uncommon,  and  only  occur  in  the 
very  acutely  excited  and  some  stuporose 
cases.  Such  cases  are  commonly  serious. 
In  mania  the  temperature  often  rises 
above  100°  from  the  cortical  excitement 
ah)ne.  We  have  seen  it  rise  from  98.5° 
to  103°  in  two  hours,  and  fall  again  to 
normal  in  the  next  five  hours,  though 
that  is  uncommon.  In  acute  mania,  es- 
pecially of  the  delirious  type,  a  tempera- 
ture about  100''  is  not  necessarily  alarm- 
ing, but  when  it  keeps  day  by  day  over 
100^  it  is  more  serious.  In  the  melan- 
cholic variety  of  stupor  the  temperature 
of  the  body  is  often  half  a  degree  or  even 
more  over  the  normal.  In  the  "  anergic  " 
variety  ("  acute  dementia ")  it  is  com- 
monly lowered,  but  in  a  few  cases  the  heat 
of  the  body  and  cavities  is  slightly  raised, 
while  the  extremities  may  be  as  low  as 
94°  or  95°.  In  puerperal  insanity  the  use 
of  the  thermometer  is  essential  to  diagnose 
septic  conditions,  metritis,  peritonitis, 
pelvic  inflammation  and  abscesses  ;  and, 
apart  from  these  complications,  to  show 
how  the  case  is  pi'ogressing.  The  cases 
with  the  highest  temperatures  are  always 
those  where  there  is  greatest  risk  of  death. 


Temperature  of  the  Head    [     1281     ]    Temperature  of  the  Head 


We  have  fouud  large  doses  of  quinine  have 
immediate   effects   in  reducing    the  tem- 
perature  and   benefiting   the   patient    in 
these  puerperal  oases  and  in  others  also, 
while  the  reduction  by  antipyrin  seemed 
to  be  accompanied  by  lowered  vital  energy. 
"We    have   seen    jiuerperal  cases   recover, 
whose  temperature  had  been    over  105^. 
In  phthisical  insanity  most  valuable  indi- 
cations are  given  by  the  thermometer.    In 
rheumatic  insanity  the  temperature  rises 
and  falls  as  in  articular  rheumatism,  and 
should  be  watched  in  the  same  way.     In 
epileptic  insanity  an  ordinary  tit  or  series 
■  of  fits,  or  even  an  access  of  epileptic  mania 
seldom  raises  the  temperature  much  and 
then  only  for  a  short  time.     The  thermo- 
meter is  of  great  use  in  the  acuter  varie- 
ties of  alcoholic  insanity,  and  after  alco- 
holic convulsions,  the  temperature  being 
often  found  then  to  be  increased.     It  is  in 
general  paralysis    that  the    temperature 
has  been  most  studied,  both  in  this  country 
and   abroad.     Its  indications  have  given 
rise  to  very  different  conclusions.  Bland- 
ford    saying   that  the    disease    must    be 
essentially   an  inflammatory  jjrocess  be- 
cause it  is  high,  and  Turner  coming  to  an 
opposite  opinion.    Mickle's  careful  investi- 
gations agree  in  the  main  with  ours.     All 
agree  that  in  the  acuter  stages  of  the  dis- 
ease the  temperature  is  high,  and  that  it  is 
increased  in  the  evening,  that  before,  dur- 
ing and  after  congestive  attacks  it  rises 
to  a  truly  febrile  stage,  commonly  over 
101°,  sometimes  even  to  107°,  and  that  for 
a  certain  time  in  the  second  stage  of  the 
disease  when  there  is  hebetude,  fattening, 
and  muscular  torpor,  the  temperature  may 
fall  below  the  normal.     We  pointed  out  in 
1868  how  valuable  a  means  of  diagnosis 
between  the  congestive  attacks  of  general 
paralysis,    of   locomotor   ataxia,    and    of 
other  cerebral  organic  disease  and  ordin- 
ary epilepsy,  we  had  in  the  thermometer, 
and  also  that  by  it  we  could  frequently 
detect  organic  brain  disease.     The  regular 
use  of  the  thermometer  has  unquestionably 
marked  a  distinct  advance  in  psychiatry, 
and  it  seems  i^robable  that  its  extended  use 
with  more  delicate  instruments  will  still 
further   help  the   mental    physician   and 
benefit  the  insane.  T.  S.  Clouston. 

[Befercnci's. — Wuiiik'rlich,  Das  Verlmlten  der 
Eigenwarmp  in  Krankhciton,  Trans,  by  Wooduian, 
New  Syd.  Soc.  f^auudert:,  Keport  of  tlie  Devon 
Asylum,  1865.  Clouston,  Journ.  Mint.  Sci., 
April  1868.  Mickle,  Journ.  Jlent.  Sci.,  April 
1872  ;  Macleod,  Lancet,  Nov.  19,  1870.  Croenier, 
Zeitsch.  fiir  Psychiatric,  1879.  Turner,  .lourn. 
Ment.  Sci.,  1889.  Voisin,  Traite  de  la  J'aralysie 
Generalc  des  Aliene.<,  1879.] 

TEMPSRATVRE  OF  THE  HEAD, 
xrORMAIi. — Sect.  I.  —  In  studying  the 
temperature    of  the  head,  under  the  cir- 


cunristances  which  concern  us  in  this 
article,  we  have  only  to  do  with  the  central 
nervous  mass,  and  with  the  tissues  lying 
between  it  and  the  exterior.  We  can  go 
still  further,  and  make  our  limit  interiorly 
the  cerebrum. 

Now  there  is  no  question  that  the  brain 
has  the  highest  temperature  of  any  organ 
in  the  body  except  the  liver.  Butiu  man 
we  cannot  examine  the  temperature  of 
the  brain  by  any  direct  process.  We  are 
consequently  forced  to  examine  it  from 
the  skin  of  the  head.  The  question,  there- 
fore, which  at  once  arises  is  this:  Can 
the  temperature  of  the  brain  make  itself 
felt  on  the  exterior  surface  through  the 
intervening  tissues  ? 

Transmission  of  Heat  from  Brain  to 
Skin. — Contrary  to  former  belief,  none 
of  the  animal  tissues  can  come  under  the 
designation  of  rmlli/  bad  conductors  of 
heat.  Bone,  brain-tissue  (white  or  grey), 
skin,  liver-tissue,  kidney-tissue,  all  con- 
duct more  or  less  readily.  Even  fat, 
whether  in  the  solid,  semi-solid,  or  semi- 
liquid  condition,  is  not  nearly  so  bad  a 
conductor  as  has  been  supposed. 

Thus,  for  a  difference  of  temperature  of 
0.1°  C.  (o.iS°  r.)  between  the  two  sides  of 
pieces  10  mm.  (0.39  inch)  thick,  the  fol- 
lowing are  the  average  percentages  of 
conduction  : — 

Bono  (compact  tissue)  .  .  ,  77.77 
Hone  (spongy  tissue;     .         .  .     89.78 

Bone  (compact  spongy)  .         .     y,  7 , 

Brain  (grey  .and  white  tissue)  .  85.00 
Muscle  (par.allel  to  fibres)  .  .  82.73 
3Iuscle  (across  fibres)    .  .         .76.  "o 

^'^'^■^  •••...  93.00 
Kidney  (cortical  substauce)  .  .  97.70 
Kidney  (medullary  su1)stance)        .     91.9; 

Fat  (solid) 50^00 

Fat  (semi-solid)     .         .  .         .40.00 

Fat  (semi-liquid)  .         .  .  .     36.00 

But  the  conductivity  of  skin  remains 
to  be  considered.  In  earlier  observations, 
experimenting  on  3  mm.  (0.118  inch)  of 
the  scalp  of  sheep,  the  writer  came  to  the 
conclusion  that,  through  this  thickness, 
the  average  transmission  was  only  67.5 
per  cent.  Later  experiments  have  shown 
that  through  /o  mvi.  the  conduction  is  70 
per  cent.  As  this  thickness  could  not  be 
obtained  naturally,  pieces  of  skin  were 
laid  one  upon  another,  and  pressed  closely 
together.  This  method  is  decidedly  ad- 
verse to  the  power  of  conductivity  of  the 
tissue,  so  it  may  safely  be  assumed  that 
70  per  cent,  is  below  the  mark. 

Now,  taking  the  compact  spongy  tissue 
of  bone  as  an  example,  a  change  of  tem- 
perature of  0.1°  C.  (o.iS°  F.)  on  one  side 
of  a  piece  10  mm.  (0.39  inch)  in  thick- 
ness would  cause  a  change  of  tempera- 
ture on  the  opposite  side  of  0.07474°  C. 
(0.1345^  F.). 


Temperature  of  the  Head    [    1282    ]    Temperature  of  the  Head 


It  is  therefore  evident  that,  so  far  as 
conductivity  is  concerned,  there  is  not  the 
sh'ghtest  difHculty  in  detecting  changes  of 
temperature  on  the  surface  of  the  brain — 
and  even  deeper,  brain  tissue  being  itself 
so  good  a  conductor — by  examinations 
made  ou  the  outer  surface  of  the  skin.  It 
follows  inevitably  that  the  tenii^erature  of 
the  brain  is  always  influencing  the  tem- 
peratiire  of  the  exterior  of  the  head.  The 
real  difHculty  is  in  locating  on  the  skin 
thermal  points  of  the  cerebral  surface. 
The  conduction  of  heat  not  being  recii- 
linear,  the  jmrt  of  the  cerebral  surface 
directly  underlying  a  given  point  of  the 
skin  may  not  affect  in  the  greatest  degree 
the  temperature  of  that  particular  point, 
but  the  temperature  of  some  other  point 
more  or  less  distant;  simply  because  the 
easiest  path  of  transmission  is  to  this 
latter  point. 

We  now  pass  to  the  examination  of  the 
temperature  of  the  skin  of  the  head  taken 
in  detail. 

Sect.  II. — Divisions  of  the  Head. — It 
is  necessary,  at  the  outset,  to  pick  out  and 
to  define,  as  far  as  possible,  certain  points 
of  the  skin  in  which  the  examinations  are 
to  be  made.  Different  observers  have 
done  this  in  different  ways.  Our  method 
was  as  follows :  First,  the  surface  was 
divided  into  three  main  portions,  called 
respectively,  anterior,  iniddle,  and  pos- 
terior recjions.  The  anterior  region  was 
thus  formed :  A  line  was  drawn  across 
the  top  of  the  head  between  the  angles 
made  by  the  frontal  and  zygomatic  pro- 
cesses of  the  malar  bones  of  the  two 
sides,  this  line  touching  the  fronto-parietal 
suture  on  the  longitudinal  median  line. 
All  the  portion  of  the  head  in  front 
of  this  line  was  included  in  the  anterior 
region.  The  middle  region  was  bounded 
in  front  by  the  line  just  described ;  its 
posterior  boundary  was  formed  by  a  line 
drawn  parallel  to  the  last  line,  between 
the  mastoid  processes  of  the  two  sides. 
The  posterior  region  included  the  portion 
of  the  head  lying  behind  the  posterior 
boundary  of  the  middle  region.  The 
longitudinal  median  line  of  the  head  di- 
vided each  of  the  three  regions  into  right 
and  left  symmetrical  halves.  Each  region 
was  subdivided  by  horizontal  and  perpen- 
dicular lines  forming  smaller  sjiaces. 
These  spaces  varied  in  their  measure- 
ments ;  a  fair  average  would  be  about  20 
mm.  (0.787  inch)  vertically  by  about  16 
mm.  (0.63  inch)  horizontally.  In  the 
anterior  region  there  were  on  each  side 
27  of  these  spaces,  in  the  middle  region 
34,  and  in  the  posterior  region  27,  making 
a  total  of  88  on  each  side  of  the  head. 

Commencing  with  the  anterior  region, 


we  will  compare  symmetrically  situated 
spaces  of  the  two  sides. 

Now  the  first  thing  of  importance  that 
is  found  in  such  a  comparison,  when 
thoroughly  carried  out,  is  this  : — In  no  one 
of  the  subdivisions  of  this  region  is  the 
temperature  uniformly  higher  on  one  side 
than  on  the  other ;  on  the  contrary,  in 
every  space  it  may  be  higher  on  the  right 
side  or  on  the  left  side,  in  turn. 

We  must,  therefore,  seek  on  which  side, 
in  the  majority  of  cases,  the  higher  tem- 
perature is  found.  Now,  of  the  twenty- 
seven  spaces  eighteen  are  in  favour  of  the 
right  side,  and  nine  are  in  favour  of  the 
left  side.  But,  still  further,  equality  of 
temperature  is  found  in  sixteen  spaces. 
The  number  of  comparisons  of  each  pair 
of  spaces  was  100,  making  a  total  for  the 
whole  region  of  2700  observations.  Of 
these  2700  cases,  1343  are  in  favour  of  the 
right  side,  1 1 37  are  in  favour  of  the  left 
side,  and  220  show  equality  of  tempera- 
ture. The  percentages  of  these  results 
are  as  follows : — In  favour  of  the  right 
side  49.74,  in  favour  of  the  left  side 
42.1 1 1,  in  favour  of  equality  8.149.  If 
we  take  alone  the  cases  in  which  either 
the  right  side  or  the  left  side  predomi- 
nates, thus  leaving  out  the  cases  of 
equality  of  temperature,  we  have  54.153 
per  cent,  in  favour  of  the  right  side,  and 
45.847  per  cent,  in  favour  of  the  left  side. 
But,  if  we  take  the  averages  of  all  the 
proportionate  numbers  of  times  in  which 
each  side  is  superior  in  temperature  to 
the  other,  we  find  that  the  left  side  has 
the  greater  average  ;  the  mean  for  the  left 
side  being  75.069  per  cent,  while  the  mean 
for  the  right  side  is  68.117  per  cent.,  that 
is  to  say,  in  the  spaces  in  which  the  left 
side  has  the  larger  number  of  cases  of 
higher  temjierature  the  average  majority 
is  greater  than  the  average  majority 
found  in  the  spaces  in  which  the  right 
side  has  the  larger  number  of  cases  of 
higher  temperature. 

The  part  of  the  region  in  which  the 
sj^aces  are  situated  which  show  a  majority  in 
favour  of  the  left  side  is  roughly  bounded 
by  the  longitudinal  median  line,  on  the 
inside  ;  by  a  line  drawn  upward  from  the 
external  angular  process,  on  the  outside  y. 
and  by  a  horizontal  line  touching  the 
upper  border  of  the  frontal  eminence. 

We  next  proceed  to  consider  the  therino- 
metrie  values  of  the  differences  of  tem- 
perature bet-ween  the  two  sides.  It  is 
found  that  the  mean  difference  of  temper- 
ature is  not  far  from  the  same,  whether 
the  right  side  or  the  left  be  the  warmer. 
Thus  the  mean  difference  of  temperature 
in  favour  of  the  right  side  is  0.255"  ^• 
(0.459^^  F.) ;  and   the   mean   difference  in 


Temperature  of  the  Head    [     12S3    ]    Temperature  of  the  Head 


favour  of  the  left  side  is  0.241°  C. 
(0.434^  F.)  The  greatest  difference  noted 
was  0.461"-'  C  (0.83^^  F.)  and  was  in  favour 
of  the  left  side;  the  smallest  difference 
noted  was  0.076"^  C.  (0.137°  F.),  and  was 
in  favour  of  the  right  side. 

Coming,  in  the  next  place,  to  the  middle 
region,  we  have,  as  before  stated,  34 
spaces  on  each  side  to  compare.  We  find 
here,  as  in  the  anterior  region,  that  every 
space  may  be  of  higher  temperature  on 
either  the  right  side  or  on  the  left  side,  in 
turn.  Seeking  for  the  side  of  the  head  on 
which  the  majority  of  cases  of  superiority 
of  temperature  occurs,  we  find  that  seven- 
teen spaces  are  in  favour  of  each  side, 
the  two  sides  being  thus  equal  in  this 
respect.  Fifteen  spaces  show  equality  of 
temperature.  The  number  of  compari- 
sons of  each  pair  of  spaces  was,  as  in  the 
case  of  the  anterior  region,  100,  making  a 
total  of  3400  observations.  Of  this  num- 
ber, 1637  are  in  favour  of  the  right  side, 
1956  are  in  favour  of  the  left  side,  and  107 
show  equality  of  temperatiire.  The  fol- 
lowing are  the  percentages  of  these 
figures: — In  favour  of  right  side  48.147, 
in  favour  of  left  side  48.706,  in  favour  of 
equality  3.147.  Omitting  the  cases  of 
neutrality,  we  have :  For  right  side 
49.711  per  cent.  ;  and  for  left  side  50.289 
per  cent.  The  mean  percentage  in  favour 
of  the  right  side  in  the  seventeen  spaces 
which,  in  the  majority  of  cases,  are  of  a 
higher  temperature  on  this  side  is  65.634, 
and  the  corresponding  percentage  in 
favour  of  the  left  side  is  66.852. 

With  regard  to  the  position  of  the 
different  spaces  showing  majorities  in 
favour  of  one  side  or  the  other,  it  may  be 
stated  in  a  general  way,  that,  in  the  case 
of  the  left  side,  they  cover  a  part  of  the 
region  extending  downward  from  the  lon- 
gitudinal median  line  for  about  92  mm. 
(3.6  inches),  taken  on  a  line  passing 
through  the  external  auditory  meatus,  and 
forward  from  the  posterior  boundary  of 
the  region  to  within  about  16  mm.  (0.63 
inch)  of  the  anterior  boundary.  Below 
and  in  front  of  this  tract,  the  right  side 
predominates,  with  one  signal  and  impor- 
tant exception,  which  exists  in  a  spot 
lying  just  back  of  the  angle  formed  by  the 
frontal  and  zygomatic  processes  of  the 
malar  bone,  where  the  higher  temperature 
is  in  favour  of  the  left  side  by  a  decided 
majority. 

Taking  the  thermometric  differences 
observed  in  the  middle  region,  we  find  that 
the  mean  difference  of  temperature  in 
favour  of  the  right  side  is  0.0589^  C. 
(0.106°  F.)  ;  and  the  mean  difference  in 
favour  of  the  left  side  is  0.1103°  C.  (0.198° 
F.)     The  greatest  difference   of  tempera- 


ture noted  was  0.264°  C.  (0.475°  F.),  and 
was  in  favour  of  the  left  side  ;  the  smallest 
difference  noted  was  0.016  C.  (0.028°  F.), 
and  was  in  favour  of  the  right  side. 

We  will  now  examine  tlie  last  of  the 
regions — the  posterior.  We  have  twenty- 
seven  spaces  on  each  side  to  compare. 
We  find  in  this  region,  as  in  the  anterior 
and  middle  regions,  every  space  sometimes 
warmer  on  one  side,  and  sometimes 
warmer  on  the  other.  In  eleven  spaces 
the  average  superiority  of  temperature  is 
on  the  right  side  ;  and  in  sixteen  spaces  it 
is  on  the  left  side.  In  eleven  spaces 
equality  of  temperature  is  found.  Of  the 
2700  comparisons — 100  on  each  pair  of 
sj^aces  as  before — 1 191  are  in  favour  of  the 
right  side,  1429  are  in  favour  of  the  left 
side,  and  80  show  equality  of  temperature. 
The  percentages  of  these  results  are  as 
follows: — For  right  side  44.112,  for  left 
side  52.926,  for  equality  2.962.  If  we  leave 
out  the  cases  of  equality  of  temperature, 
we  have: — For  right  side  44.458  per  cent., 
and  for  left  side  54.542  per  cent.  The 
mean  percentage  in  favour  of  the  right 
side,  in  the  eleven  spaces  which  show 
superiority  of  temperature  on  this  side,  is 
66.449  ;  aiicl  the  mean  pei'centage  in  favour 
of  the  left  side,  in  the  sixteen  spaces  which 
show  left  superiority  of  temperature,  is 
69.102. 

It  is  almost  impossible,  even  approxi- 
mately, to  designate,  without  the  aid  of  a 
diagram — and  a  far  more  detailed  account 
of  the  method  of  measuring  spaces  than 
has  been  given  in  this  article — the  posi- 
tion of  the  spaces  of  this  region  which  are 
in  favour  of  the  right  and  left  sides  re- 
spectively. The  best  that  can  be  done  is 
to  try  to  point  out  the  position  of  the 
eleven  spaces  which  are  in  favour  of  the 
right  side.  Start  from  a  point  about  20 
mm.  (0.78  inch)  distant  horizontally  from 
the  occipital  protuberance,  and  draw  a  line 
upward,  parallel  to  the  longitudinal  median 
line,  for  a  distance  of  about  63  mm.  (2.48 
inches)  ;  then  from  the  summit  of  this  line 
draw  another  line  horizontally  to  the  an- 
terior boundary  of  the  region  (posterior 
boundary  of  the  middle  region)  ;  in  the 
tract  thus  enclosed  will  be  found  the 
eleven  spaces  in  question. 

With  regard  to  the  thermometric  differ- 
ences of  temperature  found  in  this  region, 
the  mean  difference  in  favour  of  the  right 
side  is  0.186°  C.  (0.334°  F.);  and  the  mean 
difference  in  favour  of  the  left  side  is 
0.066°  C.  (o.  1 1 8°  F.)  The  greatest  differ- 
ence was  0.386°  C.  (0.694°  F.),  and  was  in 
favour  of  the  right  side;  the  smallest  dif- 
ference was  0.008°  C.  (0.0144°  F.),  and  was 
in  favour  of  the  left  side. 

Having  considered  the  relative  tempera- 

4  N 


Temperature  of  the  Head 


2S4    ]    Temperature  of  the  Head 


tures  of  symmetrically  situated  spaces  of 
the  two  sides  of  the  head,  we  must  next 
look  at  the  relative  temperatures  of 
spaces  on  one  and  the  same  side,  in  the 
same  and  in  different  regrions.  This 
pai-t  of  our  subject  will  be  summarily 
dealt  with,  as  its  investigation,  in  any 
degree  approaching  detail,  would  lead  into 
complications  tit  only  for  a  special  experi- 
mental essay.  First,  all  the  comparisons 
must  be  condensed  into  comparisons  of 
the  three  regions  taken  in  their  totalities. 
Second,  the  results  on  the  two  sides  of  the 
head  are  best  taken  together,  as  the  error 
in  so  doing  is  of  slight  importance.  Acting 
on  these  conditions,  we  have  the  following 
values  for  the  three  regions : — In  favour 
of  anterior  region,  34.344  per  cent.;  in 
favour  of  middle  region,  33. 8  per  cent. ;  in 
favour  of  posterior  region,  31.856  per  cent. 

We  have  finally  to  deal  with  the  abso- 
lute thermometric  values  of  the  three 
regrions.  The  following  hgures  give  the 
average  temperatures  of  both  sides  of  the 
head  taken  together  : — Anterior  region, 
33.824°  C.  (92.883°  F.);  middle  region, 
33.785°  0.  (92.093°  F.)  ;  posterior  region, 
33.505°  C.  (92.309°  F.)  These  figures  re- 
present the  results  of  observations  made 
under  strictly  experimental  conditions  ; 
but,  taking  individuals  at  random,  they 
may  not  always  hold  good.  A  tempera- 
ture of  36.1°  C.  (96.98°  F.)  is  of  common 
occurrence  in  the  anterior  and  middle 
regions,  and  35°  C.  (95°  F.)  may  be  found 
in  the  posterior  region. 

Sect.  III.  —  Effect  of  intellectual 
"Work. — Nearly  every  one  of  the  eighty- 
eight  spaces  on  each  side  of  the  head  has 
been  examined  with  regard  to  the  effect 
on  its  temperature  of  intellectual  work  ; 
and  every  space  thus  examined  has  shown 
a  rise  of  temperature  following  the  mental 
exertion.  The  rise  of  temperature  under 
these  circumstances  would,  therefore, 
seem  to  be  universal,  and  not  confined  to 
any  particular  locality.  Different  kinds 
of  mental  work  were  employed,  but,  what- 
ever the  nature  of  the  work,  it  was  always 
found  necessary  that  it  should  present 
some  difficulty  in  its  accomplishment,  or 
should  decidedly  excite  the  interest.  But 
although  the  whole  of  the  surface  is  thus 
affected,  yet  certain  parts  appear  to  have 
their  temperatures  raised  more  readily 
and  in  a  higher  degree  than  others,  and 
this,  too,  no  matter  what  kind  of  work  is 
done.  The  parts  in  question  may  be 
said,  in  a  general  way,  to  lie  over  a  tract 
of  the  surface  of  the  brain  formed  by  the 
posterior  portions  of  the  i  st  and  2nd  fron- 
tal, and  the  anterior  ascending  parietal 
(4th  frontal)  convolutions  ;  and,  possibly 
— crossing    the   fissure   of   Rolando — the 


anterior  portion  of  the  posterior  ascending 
parietal  (ascending  parietal)  convolution. 

With  regard  to  the  thermometric  value 
of  the  rises  of  temperature  observed,  the 
following  are  the  averages  for  the  three 
regions  :  —  Anterior  region,  0.034°  C. 
(0.0612°  F.);  middle  region,  0.0375°  C. 
(0.0675°  F.) ;  posterior  region,  0.0296°  C. 
(0.0533°  F.j.  Higher  rises,  however,  fre- 
quently occur,  such  as  0.085°  ^-  (°- 1 53°  ^0 
in  the  anterior  region ;  0.092°  C. 
(0.1656°  F.)  in  the  middle  region;  and 
0.044°  0.  (0.0792°  F.)  in  the  posterior 
region. 

We  have  next  to  examine  the  compara- 
tive effect  of  intellectual  work  on  the  two 
sides  of  the  head.  The  general  result  of 
experiments  made  on  this  point  is  as  fol- 
lows :  66.346  per  cent,  of  the  observations 
show  that  the  rise  of  temperature  is  higher 
on  the  leftside;  19.231  per  cent,  are  in 
favour  of  the  right  side ;  and  14.423  per 
cent,  show  that  the  rise  is  equal  on  the 
two  sides. 

The  thermometric  differences  may  be 
thus  briefly  stated: — Average  for  left  side, 
0.00439°  ^-  (0.007092°  F.) ;  average  for 
right  side,  0.00234°  C.  (0.00421°  F.). 
Here  also,  as  in  the  case  of  the  compari- 
son of  spaces  on  one  and  the  same  side, 
the  rises  of  temperature  may  be  much 
greater  than  the  averages  just  given  ;  they 
may,  in  fact,  be  nearly  doubled. 

Effect  of  Emotional  Activity. — It  is 
exceedingly  difficult  to  bring  emotional 
conditions  of  the  mind  under  experimental 
control.  Only  one  class  of  these  condi- 
tions has  been  found  available  for  the 
purpose.  It  is  that  condition  of  mind 
which  is  induced  in  many  persons  by  the 
reading  or  recitation  of  poetry  or  prose  of 
an  emotional  character.  Such  reading  or 
recitation  may  be  either  aloud  or  to  one's 
self.  Moreover,  listening  to  the  reading 
or  recitation  of  another  person  may  pro- 
duce the  same  effect.  When  the  mental 
condition  in  question  is  thoroughly  es- 
tablished, the  writer  has  never  failed  to 
find  a  rise  of  temperature.  Like  intellec- 
tual work,  emotional  activity  produces  a 
rise  of  temperature  in  all  parts  of  the  sur- 
face ;  also  the  portion  of  the  head  which 
appears  to  be  most  affected  in  intellectual 
work,  seems  to  be  most  affected  during  the 
emotional  condition. 

The  following  are  the  average  rises  of 
temperature  in  the  three  regions  : — An- 
terior region,  0.0385°  C.  (0.0693°  F-)  ? 
middle  region,  0.041°  C.  (0.0738°  F.)  ; 
posterior  region,  0.036°  C.  (0.0648°  F.). 
Rises  of  temperature  of  0.1°  C.  (0.18°  F.), 
and  even  0.2°  C.  (0.36°  F.),  are  not,  how- 
ever, uncommon  in  the  anterior  and  middle 
regions. 


Temporary  Insanity         [     1283 


Testamentary  Capacity 


Although  the  investitjatiou  of  such  an 
emotion  as  anger — or,  in  a  milder  form, 
vexation — cannot  easily  or  safely  be  made 
the  object  of  a  delibei'ate  experiment,  yet, 
in  a  number  of  instances,  the  writer  has 
had  the  unexpected  ojiportunity  of  wit- 
nessing, in  the  course  of  experiments 
having  other  objects  in  view,  the  effect  of 
this  state  of  mind.  The  result  has  been  a 
marked  and  rapid  rise  of  temperature — 
0.3°  C.  (0.54^^  F.),  and  0.4^  C.  (0.72^  F.)— 
but  its  position  with  reference  to  particular 
parts,  and  its  comparative  effect  on  the 
two  sides  of  the  head  have  never  been  satis- 
factorily determined. 

We  come,  lastly,  to  consider  the  com- 
pardtive  efect  of  emotiomil  (irticltij  o)i  the 
two  sidcfi  of  the  head.  The  following  is 
the  general  result  of  comparing  symme- 
trically situated  spaces  : — The  rise  of  tem- 
perature is  higher  on  the  left  side  in 
60.416  per  cent,  of  the  observations; 
21.528  per  cent,  are  in  favour  of  the  right 
side;  and  m  the  remaining  18.056  per 
cent,  the  temperature  rises  equally  on  the 
two  sides. 

The  average  thermometric  differences 
of  rise  of  temperature  are  as  follows : — 
Left  side,  0.0059°  C.  (0.0106°  F.)  ;  right 
side,  0.00495°  C.  (0.0089°  F.). 

J.  S.  Lombard. 

[References. — J.  !?.  Lombard  :  Hegioual  Tem- 
perature of  the  Head,  1879,  aud  Exiierirafntal  lie- 
searches  on  the  Teuiperature  of  the  Head,  1881. 
l'roceediiiy;s  of  Koyal  Society,  Nov.  17,  1881,  p\). 
173-198  ;  aud  .lau.  7,  1886,  pp.  1-6  :  also  unpub- 
lished experiuients.  H.  C.  Hoyer,  Archives  de 
Neurologic,  1880,  fasc.  i«^r.  Boeck  et  \'erhoogeD, 
Circulation  Cerebrale  (Inst.  .Solvay,  Bruxelles, 
iSgoX  Dorta,  Sur  la  Temperature  Cerehrale,  .Vc. 
Geneve,  1889.] 

TSMPORARV  INSAN^ITV. — A  name 
applied  to  short  outbreaks  of  insanity  ;  its 
most  common  use  is  as  a  jury's  verdict  in 
suicide.     (See  Maxia  Tkansitokia.) 

TEIVXTJIiETrCE  {teviulentus,  drunken). 
A  term  generally  used  as  synonymous 
with  drunkenness.  It  is  sometimes  used 
to  describe  any  state  in  disease  resembling 
drunkenness. 

TENTZCO  VENEREA  {tentum,  the 
penis).     A  synonym  of  Nymphomania. 

TENTZCO  VERETRI. — A  synonym 
of  Satyriasis. 

TERRORS,  iflCHT.  (.See  Night 
Tekroks.) 

TESTAIVZEIUTARY  CAPACZTT  IN 
IvxEMTAIi  DISEASE. — There  are  three 
well-marked  stages  in  the  history  of  the 
law  of  testamentary  capacity  in  mental 
disease:  (i)  From  the  earliest  recorded 
decisions  to  1848,  each  case  of  disputed 
testamentary  capacity  was  determined 
upon  its  own  merits;  (2)  from  1848  to 
1870,  the  doctrine  promulgated  by  Lord 


Brougham     in     ]V<irin>j    v.     Waring     (6 
Moo.  P.    C.   341,  et  scq.),  that  the  "least 
degree  of  insanity  would  vitiate   a  will 
made   under  its   iiiHuence,  jirevailed;  (3) 
since  the  judgment  of  Lord  Chief  Justice 
Cockburn  in  Banks  v.   GuodfeJlow  {1870 ; 
L.  R.  5  q.  B.  549)*  the  Courts  have  recurred 
to  the  earlier  aud  sounder  criterion — was 
the  capacity  adequate  to  the  act  ?     It  will 
be  convenient  to  trace  the  historical  de- 
velopment  of   our   law   of   testamentary 
capacity  before  we  attempt  to  enunciate 
its  leading  doctrines,  or  to  illustrate  their 
practical  appreciation,  at  the  present  day. 
(i)  One  of  the  earliest  and  most  satis- 
factory definitions  of  testamentary  capa- 
city in  mental  disease  proceeded  from  the 
Star  Chamber.     In  Combe's  Case  (Moor. 
7S9,  4  Burn's  E.   L.  61 ;  3  Jac.  L)  it  was 
argued  by  the  judges  in  that  famous  tri- 
bunal "that  sane  memory  for  the  raakino- 
of  a  will   is  not  at  all   times  when  the 
party   can  speak    'yes'  or   *no,'    or  had 
life  in  him.  nor  when  he  can  answer  to 
anything  with  sense ;  but  he  ought  to  be 
of  judgment  to  discern  and  to  be  of  perfect 
memory ;  otherwise  the  will  is  void  "  (cf. 
Winchesters  Case,  6  Co.  23  a.  Trin.  41  Eliz. 
K.  B.).     In  the  beginning  of  the  reign  of 
Charles  I.,  Herbert  v.  Loinis  (i   Ch.  Rep. 
24,  3    Car.   I.)    carried    the    doctrine    of 
Combes  Case  a  little  further.     "To  a  dis- 
posing memory  it  is  necessary  there  be  an 
understanding  judgment,  fit  to  direct  an 
estate."     In  the  time  of   Charles  11.  we 
find  a  will  made  by  "  a  sickly  child,  newly 
piibes,  and  without  the  knowledge  of  his 
curators  ....  in  the  absolute  favour  of 
the  nurse  under  whose  care  he  had  been," 
reduced  as  inofficious   (Nisbet's   Doubts, 
temp.  Car.  II.  207).     Deio  v.  Clark  (1826, 
3  Add.  79-209,  and  Add.  123   et   seq.)  is 
the  next  case  of  importance  in  the  history 
of  the  definition  of  testamentary  capacity 
The    facts   were   these:    Ely' Stott   died 
ISTovember  18,  1821,  leaving  a  widow  and 
a  daughter  by  his  first  wife.     The  amount 
of  his  ])ersona]  estate  was  nearly  ^40,000. 
By  his  will,  dated  May  26,   18 18,  Stott 
gave  to  his  daughter,  to  whom   he  had 
conceived  a  violent  and  irrational  aversion, 
a   life   interest   only  in  a  comparatively 
small   portion   of  his    property.     It   was 
held  by  Sir  John  Nichol  that  this  un- 
founded   antipathy    had    prevented    the 
testator  from   properly   appreciating   his 
daughter's  claims  upon  him,  and  that  the 
will    must   be   pronounced    against.      In 
JIarivuod  v.  Baker  (1840,  3  Moo.  P.  C.  282) 
the  criteria  of  testamentary  capacity  are 

*  An  interesting'  discussion  upon  this  case  before 
the  Medico-Psycholojiriciil  Association  in  1881,  will 
be  found  reported  in  the  ./oi/rnal  <;t'  Mental  Science, 
No.  cxix.  new  series.  No.  83,  jip.  471-4. 


Testamentary  Capacity     [     1286    ]      Testamentary  Capacity 


stated  by  Evskinej  J.,  iu  the  following 
tei'ms :  "In  order  to  constitute  a  sound 
disposing  mind,  a  testator  must  not  only 
be  able  to  understand  that  he  is  by  his 
will  giving  the  whole  of  his  property  to 
one  object  of  his  regard,  ....  but  he 
must  also  have  capacit}'  to  comprehend 
the  extent  of  his  property  and  the  nature 
of  the  claims  of  others  whom  by  his  will 
he  is  excluding  from  all  participation  m 
that  property.  The  protection  of  the  law 
is  in  no  cases  more  needed  than  it  is  in 
those  where  the  mind  has  been  too  much 
enfeebled  to  comprehend  more  objects 
than  one,  and  more  especially "  (which 
was  the  case  in  Harivood  v.  Bal-er)  "  when 
that  one  object  may  be  so  forced  upon  the 
attention  of  the  invalid  as  to  shut  out  all 
others  that  might  require  consideration  " 
{uhi  supra  at  p.  290).  "With  the  exception 
of  one  or  two  points  of  detail,  mainly  sug- 
gested by  recent  American  decisions,  the 
language  of  Erskine,  J.,  is  a  complete  and 
accurate  statement  of  the  modern  law  of 
testamentary  caj^acity.  (C/.  also  Gillespie 
V.  Gillespie,  Fac.  Dec.  February  11,  181 7; 
Burling  v.  Loreland,  1839,  -  Curt.  225  ; 
Durneil  v.  Gorfield,  1844,  i  Rob.  E.  R.  51.) 
But  the  period  under  consideration 
enriched  our  law,  not  only  with  an  ex- 
haustive definition  of  testamentary  capa- 
city, but  also  with  a  philosophic  analysis 
of  "  lucid  interval "  and  "  insane  delusion," 
and  a  clear  statement  of  their  legal  conse- 
quences. 

Thus,  in  e.v  parte  Hohjland  (1805,  11 
Ves.  10)  Lord  Chancellor  Eldon,  dissent- 
ing from  a  dictum  of  Lord  Thurlow, 
declared  that  complete  restoration  to  pre- 
vious mental  vigour  is  not  necessary  to 
the  existence  of  a  lucid  interval :  while 
in  Toivart  v.  Sellars  (18 17,  5  Dow,  p.  56) 
it  was  impliedly  held  that  the  question 
for  consideration  in  such  cases  was,  Has 
the  testator  recovered,  not  a  sound,  but  a 
disposing  mind  ?  The  modern  definition 
of  "  insane  delusion  "  also  belongs  to  this 
period.  In  Mudway  v.  Groft  ( 1 843,  3  Curt. 
671)  the  following  passage  from  Dr.  Ray's 
"Medical  Jurisprudence"  (p.  131)  is  ex- 
pressly adopted :  "  It  is  the  departure 
from  the  natural  and  healthy  character, 
temper,  and  habits  which  constitutes  a 
symptom  of  insanity,  and  in  judging  of  a 
man's  sanity  it  is  consequently  as  essen- 
tial to  know  what  his  habitual  manifesta- 
tions were  as  what  his  present  symptoms 
are."  The  interest  of  this  quotation,  thus 
incorporated  into  the  law  of  England,  lies 
in  the  fact  that  it  does  away  with  all 
rigid  objective  standards,  provides  that 
each  case  shall  be  tried  on  its  own  merits, 
and  assigns  to  a  man's  mental  constitu- 
tion and  history  their  proper  j^lace  in  an 


inquiry  into   his   testamentary  capacity. 
(Gf.  GhaDihers  v.  YaAmaa,   1840,  2  Curt. 

448.) 

The  medico-legal  relations  of  lucid  in- 
tervals, insane  delusions,  and  insanity 
generally  were  clearlj'  formulated  in  our 
early  case-law.  Insanity  was  held  to  be 
primd  facie  evidence  of  testamentary 
incapacity.  {Gf.  Hall  v.  Warren,  1804,  per 
Sir  W.  Grant,  M.R.,  1804;  In  re  Watts, 
1837,  I  Curt.  594;  and  Snook  v.  Watts, 
1848,  per  Lord  Langdale,  M.R.,  11  Beav. 
105.)  It  was  not,  however,  conclusive 
{Eodd  V.  Leivis,  1755,  2  Cas.  temp.  Lee, 
176),  and  the  presumption  arising  from 
an  inquisition  de  lunatico  inquirendo,  or 
from  residence  in  an  asylum,  might  be 
rebutted  by  proof  of  a  lucid  interval,  or 
that  the  insanity  or  delusions  were  irrele- 
vant or  immaterial.  Gnrtvrirjht  v.  Cart- 
^vriglit  (1793-95,  I  Phillim.  90,  122)  is  an 
instructive  instance.  A.,  a  patient  in  an 
asylum,  made  a  will  in  which  she  left 
practically  her  whole  fortune  to  her  nieces. 
The  circumstances  under  which  the  will 
was  executed  were  as  follows  :  On  August 
14,  1775,  A.  was  supj^lied  with  pen,  ink, 
and  paper  by  Dr.  Battle,  the  superinten- 
dent of  the  asylum,  to  quiet  and  gratify 
her,  though  he  considered  her  at  the  time 
quite  incajiable  of  making  a  will.  Her 
attendants  retired,  but  watched  her.  She 
was  so  agitated  and  furious  that  they 
were  fearful  she  would  attempt  some  mis- 
chief to  herself.  At  first  she  wrote  upon 
several  jDieces  of  paper,  and  got  up  in  a 
wild  and  furious  manner,  and  tore  the 
same,  and  threw  them  in  the  fire ;  and, 
after  walking  up  and  down  the  room 
many  times  in  a  wild  and  disordered 
manner,  muttering  and  speaking  to  her- 
self, she  wrote  the  paper  which  was  the 
will  in  question.  Probate  was  granted 
upon  the  grounds  that  (a)  the  will  was 
originated  and  executed  by  the  testator, 
and  [h)  the  provisions  were  "  wisely  and 
orderly  framed."  This  decision  has  fre- 
quently been  cited  in  support  of  the  con- 
tention that  the  law  at  one  time  made  the 
instrument  in  dispute  the  best,  if  not  the 
sole,  criterion  of  the  caj^acity  to  execute  it. 
But  it  is  doubtful  whether  Sir  William 
Wynne  intended  to  lay  down  any  such 
rule  {cf.  Ghamhers  v.  Yatman,  1  Curt. 
415,  447),  and,  if  he  did,  it  has  long  since 
been  distinctly  repudiated  (Brogden  v. 
Broivn,  1825,  2  Add.  441).  Other  authori- 
ties of  the  same  character  as  Cartwriglit 
v.  Gart-wright  are  Clarke  v.  Lear  (Mar. 
1 791),  Cogldan  v.  Coglilan,  of  which  the 
date  is  not  recorded. 

Laing  v.  Bruce,  a,  Scotch  case  (183S,  i 
Dunlop,  59),  may  be  consulted  as  an  illus- 
tration of  an  insane  delusion  which  was- 


Testamentary  Capacity      [     1287    ]      Testamentary  Capacity 


lield  insufficient  to  suspend  testamentary 
capacity.  A.,  the  testatrix,  was  under 
delusions,  which  were  intermittent  and 
considered  ti'itliiig  by  her  friends,  about 
her  money  matters.  It  was  decided  that 
her  capacity  to  irvokc  a  will  was  not 
destroyed. 

(2)  For  more  than  twenty  years,  a  doc- 
trine, or  perhaps  we  should  rather  call  it 
a  dictum,  of  Lord  Brougham's  perplexed 
English  judges  in  administering  the  law 
testamentary,  viz. :  In  Warim/ v.  W'tiriiig 
(1840,  6  Moo.  P.  C.  ct  seq.)  an  elderly  lady, 
excessively  penurious  and  eccentric,  very 
irritable  and  quarrelsome,  had  disinherited 
her  brother  under  an  insane  delusion  that 
he  had  joined  the  Komau  Catholics,  to- 
wards whom  she  entertained  a  strong 
aversion.  In  accordance  with  the  deci- 
sion of  Sir  John  NichoU  in  Bew  v.  Chirh 
the  facts  of  which  have  already  been 
stated,  and,  it  may  be  added,  in  strict 
■obedience  to  the  existing  law,  the  testa- 
trix's will  was  set  aside.  But  Lord 
Brougham,  in  giving  judgment,  went  out 
•of  his  way  to  criticise  the  jDopular  defini- 
tion of  vionomunia,  declared  that  the 
mind,  being  one  and  indivisible,  if  un- 
sound upon  a  single  subject,  could  not  be 
really  sound  upon  other  subjects,  and 
impliedly  held  that  a  person  partially  in- 
sane was  incompetent  to  make  a  will. 
In  ^mitlt  V.  Tehhitt  (1867,  I  P.  and  D. 
401),  Lord  Penzance,  then  Sir  J.  P.  Wilde, 
construed  Lord  Brougham's  language  in 
this  sense,  and  said  :  "  If  disease  be  once 
shown  to  exist  in  the  mind  of  the  testator, 
it  matters  not  that  the  disease  be  dis- 
coverable only  when  the  mind  is  addressed 
to  a  certain  subject,  to  the  exclusion  of 
all  others,  the  testator  must  be  pronounced 

incapable The  same  result  follows 

though  the  particular  subjects  upon  which 
the  disease  is  manifested  have  no  connec- 
tion whatever  with  the  testamentary  dis- 
position before  the  Court." 

Now,  with  reference  to  these  proposi- 
tions, it  must  be  observed  (i)  that  they 
are  not  established  by  the  earlier  cases  to 
which  we  have  referred,  and  (2)  that  both 
in  Waring  v.  Wariaij  and  S'init.h  v, 
Tehhitt  the  presence  of  insane  delusions, 
distinctly  operating  upon  the  mind  of  the 
testator,  reduces  any  metaphysical  discus- 
sion of  the  degree  of  mental  disease  which 
destroys  testamentary  capacity  to  the 
proportions  of  an  obiter  dictum.  Lord 
Brougham  in  the  one  case,  and  Sir  J.  P. 
Wilde  in  the  other,  had  to  decide,  not 
whether  a  monomaniac  is  incapable  in 
law  of  making  a  will,  but  whether  a  par- 
ticular will  made  under  the  influence  of 
insane  delusion  was  valid.  The  testa- 
trix  in    Waring   v.    Waring   disinherited 


her  brother  under  an  erroneous  and  in- 
sane belief  that  he  had  become  a  Koman 
Catholic.  The  testatrix  in  Sniiih  v. 
Tcbhi/t  thought  that  her  sister,  to  whose 
prejudice  the  will  in  dispute  was  made, 
was  a  child  of  the  devil,  for  whom  the 
deity  had  reserved  the  hotte^^t  place  in 
hell.  These  cases  clearly  fall  within  the 
ratio  decidendi  of  dJeiv  v.  Clark,  and 
neither  called  for,  nor  gave  judicial  au- 
thority to,  any  deliverance  upon  the  legal 
consequences  of  monomania  in  general. 

(3)  Lord  Chief  Justice  Cockburn  in 
Banks  V.  GoodJ'ellaw  (1870,  L.  R.  5  Q.  B. 
549),  and  Sir  James  Hannen  in  Boughton 
V,  Kuiyht  (1873,  3  P.  and  D.  64),  have  re- 
established the  earlier  and  sounder  cri- 
terion— "  was  the  capacity  adequate  to  the 
act  p"  (0/.  Blewittv.  Bleivitt,  1833,  per  Sir 
J.  Nicoll,4Hagg.  E.II.410;  and  il/on'soji  v. 
Maclean's  Trustees,  1862,  24  Dunlop  265  ; 
per  Lord  Justice  Clerk  luglis,  at  p.  631.) 

In  Banks  v.  Goodfellow,  A.  had  made 
a  will  in  favour  of  B.,  his  niece,  who  had 
lived  with  him  for  many  years,  and  to 
whom  he  had  always  expressed  an  inten- 
tion to  leave  his  property.  At  the  time 
of  executing  this  will  A.  was  under  a  delu- 
sion that  C.,to  whom  he  had  borne  a  violent 
hatred,  and  who  was  actually  dead,  was  still 
alive.  C.  had  no  claim  whatever  upon  A. 
It  was  left  to  the  jury  to  say  whether  A. 
had  made  that  will,  uninfluenced  by  his  de- 
lusions. The  jury  found  in  favour  of  the  will, 
and  probate  was  granted,  the  Court  of 
Queen's  Bench  refusing  to  reverse  the  find- 
ing of  the  jury.  "  It  is  essential,"  said  the 
Lord  Chief  Justice  Cockburn,  "  to  the  exer- 
cise of  the  powers  of  making  a  will  that  the 
testator  shall  understand  the  nature  of 
the  act  and  its  effects  ;  shall  understand 
the  extent  of  the  property  of  which  he  is 
disposing ;  shall  be  able  to  comprehend 
and  appreciate  the  claims  to  which  he 
ought  to  give  effect;  and  \vith  a  view  to 
the  latter  object  that  no  disorder  of  the 
mind  shall  poison  the  affections,  ])ervert 
his  sense  of  right,  or  prevent  the  exercise 
of  his  natural  faculties,  that  no  insane 
delusion  shall  influence  his  will  in  dispos- 
ing of  his  property,  and  bring  about  a 
disposal  of  it  which  if  the  mind  had  been 
sound  would  not  have  been  made.  Here 
then  we  have  the  measure  of  the  degree 
of  mental  power  which  should  be  insisted 
on.  If  the  human  instincts  and  affections 
of  the  moral  sense  become  perverted  by 
mental  disease,  if  insane  suspicion  or 
aversion  take  the  place  of  natural  affection, 
if  reason  and  judgment  are  lost,  and  the 
mind  becomes  a  prey  to  insane  delusions 
calculated  to  interfere  with  and  disturb 
its  functions,  it  is  obvious  that  the  con- 
dition of  testamentary  power   fails,  and 


Testamentary  Capacity      [    1288    ]      Testamentary  Capacity 


that  a  will  made  under  such  circum- 
stances ought  not  to  stand."  In  a  later 
passage,  the  Lord  Chief  Justice  said : 
"  No  doubt,  when  the  fact  that  a  testator 
has  been  subject  to  any  insane  delusion  is 
established,  a  will  should  be  regarded  with 
great  distrust,  and  every  presumption 
should,  in  the  first  instance,  be  made 
against  it.  Where  insane  delusion  has 
ever  been  shown  to  have  existed,  it  may 
be  difficult  to  saj'  whether  the  menta.1  dis- 
order may  not  possibly  have  extended 
beyond  the  particular  form  or  instance  in 
which  it  has  manifested  itself.  It  may  be 
equally  difficult  to  say  how  far  the  delu- 
sion may  not  have  infiuenced  the  testator 
in  the  particular  disposal  of  his  property. 
And  the  presumption  against  a  will  made 
under  such  circumstances  becomes  addi- 
tionally strong  when  the  will  is,  to  use 
the  term  of  the  civilians,  an  inofficious 
one,  that  is  to  say,  one  in  which  natural 
aftection  and  the  claims  of  near  relation- 
ship have  been  disregarded." 

In  Boughton  v.  Knight,  Sir  James 
Hannen  laid  down  the  law  of  testamen- 
tary capacity  to  the  jury  in  language 
which  sounds  like  an  echo  from  Hdrvoorl 
V,  Butler  (see  ante).  "  There  must  be  a 
memory  to  recall  the  several  persons  who 
may  be  fitting  objects  of  the  testator's 
bounty,  and  to  comprehend  their  relation- 
ship to  himself,  and  their  claim  upon  him. 
....  A  sound  mind  does  not  mean  a 
perfectly  balanced  mind,  free  from  all  in- 
fluence of  prejudice,  passion,  or  pride. 
The  law  does  not  saj'  that  a  man  is  inca- 
pacitated from  making  his  will  if  he  proposes 
to  make  a  disposition  of  this  property 
moved  by  caj^ricious,  frivolous,  or  even 
bad  motives.  .  .  .  Eccentricities  as  they  are 
commonly  called  of  manner,  of  habit,  of 
life,  of  amusements,  of  dress  and  so  on 
must  be  disregarded.  But  there  is  a  limit 
beyond  which  one  feels  that  it  ceases  to  be 
a  question  of  harsh  iinreasonable  judg- 
ment of  character,  and  that  the  repulsion 
which  a  parent  exhibits  towards  one  or 
more  of  his  children,  must  proceed  from 
some  mental  defect  in  himself "'  (cf.  The 
Hopper  Will  Case,  33  N.  Y.  619  ;  8mee  v. 
Smee  1879,  5  P-  D.  84).  In  concluding 
this  part  of  our  subject,  we  propose  to 
contrast  very  shortly  the  development  of 
English  with  that  of  American  testamen- 
tary law.  Both  started  from  the  same 
point.  Both  have  reached  the  same  goal. 
In  the  United  States,  as  in  England,  tes- 
tamentary capacity  was  originally,  and  is 
now,  treated  as  a  question  of  fact.  Even 
in  the  intermediate,  or  as  we  might  ]>er- 
haps  not  improperly  call  it  the  meta- 
physical period,  the  laws  of  England  and 
America  had  the  same  postulate — viz.,  the 


difficulty  of  determining  where  sanity 
ended  and  insanity  began.  But  from  this 
postulate  the  English  and  American 
Courts  drew  widely  different  conclusions. 
According  to  Lord  Brougham  and  Lord 
Penzance,  mental  disease  was  so  subtle 
and  intangible  that  no  legal  tribunal  could 
with  safety  undertake  to  define  its  degrees, 
and  the  only  prudent  course  was  to  hold 
any  degree  of  insanity  fatal  to  civil  capa- 
city. American  lawyers,  on  the  other 
hand,  seem  at  one  time  to  have  inclined 
to  the  view  that  the  proper  inference 
from  the  common  postulate  was  that  the 
mere  possession  of  understanding  was 
enough  to  create  testamentary  power. 
The  case  of  Alice  Lispenard  (26  Wendell 
255)  went  furthest  in  this  direction.  The 
mental  characteristics  of  the  testatrix  were 
these  :  she  was  washed  and  dressed  like 
a  child  even  when  thirty-five  years  of 
age  ;  her  head  wagged  from  side  to  side  ; 
she  dribbled  at  the  mouth ;  had  sud- 
den fits  of  anger,  so  that  she  would  strike 
children  ;  would  sit  for  hours  in  front  of 
a  window,  and  continue  in  that  position 
even  after  the  shutters  were  closed,  &c. 
The  rule  of  testamentary  capacity  adopted 
in  this  case  was  that  in  pronouncing  upon 
the  validity  of  a  will,  the  Courts  will  not 
measure  the  understanding  of  the  testator, 
but  if  he  have  any  reason  at  ail,  and  be 
not  an  absolute  idiot,  totally  deprived  of 
reason,  he  is  the  lawful  disposer  of  his 
own  property,  and  his  will  stands  as  a 
reason  for  his  actions.  Senator  Ver- 
planck,  in  delivering  the  judgment  of  the 
Supreme  Court  in  this  case  said:  "To 
establish  any  standard  of  intellect  or  in- 
formation beyond  the  possession  of  reason 
in  its  lowest  degree,  as  in  itself  essential 
to  legal  capacity,  would  create  endless  un- 
certainty, difficulty,  and  litigation  ;  would 
shake  the  security  of  projDerty,  and  wrest 
from  the  aged  and  infirm  that  authority 
over  their  earnings  or  savings  which  is 
often  their  best  security  against  injury 
and  neglect.  If  you  throw  aside  the  old 
common  law  test  of  capacity,  then  proofs 
of  wild  speculations  or  extravagant  and 
peculiar  opinions,  or  of  the  forgetfulness 
or  the  prejudices  of  old  age,  might  be  suffi- 
cient to  shake  the  fairest  conveyance  or 
impeach  the  most  equitable  will.  The  law 
therefore  in  fixing  the  standard  of  positive 
legal  competency  has  taken  a  low  stand- 
ard of  capacity ;  but  it  is  a  clear  and  defi- 
nite one,  and  therefore  wise  and  safe ;  it 
holds  ....  that  weak  minds  differ  from 
stroug  ones  only  in  the  extent  and  power 
of  their  faculties  :  but  unless  they  betray 
a  total  loss  of  understanding,  or  idiocy, 
or  delusion,  they  cannot  properly  be  con- 
sidered    unsound."'      These  observations 


Testamentary  Capacity      [    1289    J      Testamentary  Capacity 


were  somewhat  qualitied  by  other  parts  of 
the  judgment,  but  they  are  sufficiently 
strong  to  show  the  tendency  of  the  Ameri- 
can Courts  at  tliat  time.  The  doctrine 
suggested  in  the  Li's/)e»t(t>-(Z  trial  was,  how- 
ever, repudiated  in  tlie  famous  Parish  Will 
Case  {l)el((Jichl  v.  rarish,  1S62,  25  N.  Y. 
9),  in  whicii  it  was  laid  down  that  the 
testator  must  have  sufficient  capacity  to 
comprehend  perfectly  the  condition  of  his 
property,  his  relations  to  the  persons  who 
were,  or  should,  or  might,  have  been  the 
objects  of  his  bounty,  and  the  scope 
and  bearing  of  the  provisions  of  his  will : 
he  must  have  sufficient  active  memory 
to  collect  in  his  mind  without  prompting 
the  particulars  or  elements  of  the  busi- 
ness to  be  transacted,  and  to  hold  them 
in  his  mind  a  sufficient  length  of  time  to 
perceive  at  least  their  active  relations  to 
each  other,  and  to  be  able  to  form  some 
rational  judgment  in  relation  to  them 
{Converse  v.  Converse,  per  Redfield,  J.  21 
Verm.  11.  Blancliarcl  v.  JSiestJe,  3  Denio 

37)- 

The  leading  doctrines  in  the  modern  law 
of  testamentary  capacity  in  mental  disease 
may  be  shortly  stated  in  the  form  of  pro- 
positions. 

I.  A  testator  must  be  able  at  the  time 
when  he  makes  his  will  both  to  recall,  and 
to  keep  clearly  before  his  mind  (a)  the 
nature  and  extent  of  his  property,  and  (b) 
the  persons  who  have  claims  upon  his 
bounty;  and  his  judgment  and  will  must 
be  suiiiciently  unclouded  and  free  to  en- 
able him  to  determine  the  relative  strength 
of  these  claims. 

IZ.  An  insane  person  can  make  a  valid 
will  if  (('.)  in  spite  of  his  insanity  he  has  a 
disposing  memory,  judgment  and  will  as 
defined  above,  or  {h)  he  is  enjoying  what 
is  called  a  hicid  interval  at  the  date  of  its 
execution. 

The  case  of  Banks  v.  GoodfcUow,  ah-eady 
noted,  is  an  illustration  of  a  delusion  which 
was  foreign  to  the  subject-matter,  and  did 
not  therefore  affect  the  validity  of  a  will. 
A  curious  rider  might,  however,  be  added 
to  the  doctrine  established  by  that  case. 
Suppose  that  A.  makes  a  will  disinheriting 
B.,  C.,  and  D.,  to  whom  he  had  no  insane 
dislike,  and  who  had  strong  claims  upon 
his  bounty.  At  the  time  of  executing  this 
will,  the  name  of  E.,  towards  whom  A. 
had  a  violent  and  insane  hatred,  but  who 
had  no  claims  whatever  upon  him,  had 
been  mentioned  to  A.,  and  had  rendered 
him  incapable  of  estimating  the  compara- 
tive claims  of  B.,  C,  and  D.  The  delusion 
in  such  a  case  would  be  foreign  to  the  sub- 
ject-matter of  the  will,  but  there  can  be 
little  doubt  that  it  would  destroy  for  the 
time  the  capacity  of  the  testator.     {Cf. 


CreagJi.  v.  Blood,  2  J.  &  La  Touche,  Irish, 
per  bir  Edward  Sugden,  L.Ch.  at  \).  515.) 
A  fortiori,  testamentary  capacity  is  not 
destroyed  by  a  delusion  which  quickens 
tlie  testator's  faculties.  Jenkins  v.  j\[orri.s 
(1880,  14  Ch.  D.  674),  a  decision  ui)on  the 
contract  of  a  lunatic,  is  a  case  in  point. 
A.  leased  a  farm  to  B.  At  the  date  of  the 
lease  A.  laboured  under  the  delusion  that 
the  farm  was  impregnated  with  sulphur 
and  was  anxious  to  get  rid  of  it  for  this 
reason.  Rational  letters  written  by  A.  in 
reference  to  the  lease  were  put  in  evidence, 
and  it  was  proved  that,  in  spite  of  his  de- 
lusion, he  was  a  shrewd  man  of  business. 
The  lease  was  held  valid. 

III.  A  lucid  interval  is  not  necessarily 
a  complete  restoration  to  mental  vigour 
previously  enjoyed ;  nor  is  it  merely  the 
cessation  or  suppression  of  the  symptoms 
of  insanity  {I)>jce  Sombre  v.  Frinseps, 
1856,  per  Sir  John  Dodson,  I  Deane,  at 
p.  1 10) ;  it  is  the  recovery  of  testamentary 
"memory,  judgment  and  will." 

IV.  An  insane  delusion  is  not  merely 
an  unfounded  though  colourable  suspicion, 
nor  even  a  belief  which  no  rational  per- 
son would  have  entertained ;  it  is  a  per- 
sistent and  incorrigible  belief  that  things 
are  real,  which  exist  only  in  the  imagina- 
tion of  the  patient,  and  which  no  rational 
person  can  conceive  that  the  patient  when 
sane  would  have  believed. 

V.  Neither  subsequent  suicide  nor 
supervening  insanity  will  be  reflected 
back  upon  previous  eccentricity  so  as  to 
invalidate  a  will.  (0/.  Hohy  v.  Rohy, 
1828,  per  Sir  John  Nichol,  i  Hagg.  146; 
aliter  in  the  case  of  previous  insanity, 
Symes  v.  Green,  1859,  i  S.  &  T.  401.) 

VI.  Affective  or  moral  insanity  does 
not  generally  destroy  testamentary  capa- 
city. 

Frere  v.  Beacocke  (1846,  i  Rob.  E.  R. 
442,  per  Sir  H.  Jenner  Eust,  at  p.  456) 
appears  to  be  the  chief,  if  not  the  sole, 
authority  for  this  proposition.  A.,  the 
validity  of  whose  will  was  in  question, 
took  an  irrational  pleasure  in  heai'ing  of 
the  sufferings  of  others,  rubbing  his  hands, 
grinning  and  otherwise  manifesting  his 
gratification  at  evil  tidings.  Probate  of 
the  will  was  granted.  There  can,  however, 
be  little  doubt  that  insanity  of  character, 
if  sufficient  to  unhinge  the  disposing  mind, 
would  destroy  testamentary  capacity. 

VII.  Upon  the  executor  who  propounds 
a  will  rests  the  burden  of  proving  («)  tes- 
tamentary capacity,  (h)  knowledge  and 
approval  of  its  contents,  and  (c)  due  exe- 
cution. 

The  reason  for  this  rule  cannot  be  better 
stated  than  it  was  in  an  American  case, 
Cruicninyshield  v.  Crowni)iyshiehl  (2  Gray 


Tetanoid  Epilepsy 


[     1290    ] 


Therapeutics 


526).  "'The  heir-at-law  rests  securely 
upon  the  statutes  of  descent  and  distribu- 
tion until  some  legal  act  has  been  done  by 
which  his  rights  under  those  statutes  are 
lost  or  impaired." 

A  testatrix  gave  instructions  for  her 
will,  which  was  prepared  in  accordance 
therewith.  At  the  time  of  execution,  the 
testatrix  merely  recollected  that  she  had 
given  those  instructions,  but  believed  that 
the  will  which  she  was  executing  accu- 
rately embodied  them.  Sir  James  Hannen 
held  that  the  will  was  valid.  (Parker  v. 
Felgate,  1883,  8  P.  D.  171,  173,  174.)  If 
the  testatrix  had  merely  authorised  her 
solicitor  to  make  a  will,  and  had  she  said, 
"  I  do  not  know  what  you  have  put  down, 
but  I  am  quite  ready  to  execute  it,"  the 
will  would  be  invalid.  {Hastilotv  v.  Stohie, 
1865,  I  P.  &  D.  64,  overruling  dicta  of  Sir 
Creswell  Creswell  in  (a)  Middlehtirst  v. 
Johnson,  i860,  30  L.  J.  Prob.  14;  and  (6) 
Cunliffe  V.  Gross,  1863,  3  S.  &  T.  36. 

VIII.  Prima  facie,  an  executor  is  justi- 
fied iu  propounding  his  testator's  will,  and 
if  the  facts  within  his  knowledge  at  the 
time  he  does  so  tend  to  show  eccentricity 
merely  on  the  part  of  the  testator,  and  he 
is  totally  ignorant  at  the  time  of  the  cir- 
cumstances and  conduct  which  afterwards 
induce  a  jury  to  find  that  the  testator  was 
insane  at  the  date  of  the  will,  he  will,  071 
the  principle  that  the  testator  s  conduct 
was  the  cause  of  litigation,  be  entitled  to 
receive  his  costs  out  of  the  estate,  although 
the  will  be  pronounced  against.  {Of. 
Houghton  v.  Knight,  1873,  per  Sir  James 
Hannen,  3  P.  &  D.  pp.  77-80;  and  Smee 
V.  Smee,  1875,  5  ^'-  &  D.  at  p.  90.) 

A.  Wood  Renton. 

TETANOID    EPII.EPS'X'.  —  A   name 

given  by  Pritchard  to  those  epileptic  fits 
in  which  there  is  only  one  form  of  spasm, 
the  tonic.  The  patient  falls  unconscious,  is 
rigid  for  a  few  moments  and  then  recovers. 

TETANUS  H  YDROPHOBICUS 
{reravos,  a  state  of  tension  ;  hydrojjhobia, 
q.v.).  A  form  of  pharyngeal  spasm  at 
every  act  of  deglutition,  simulating  the 
muscular  spasms  of  hydrophobia.  Rose 
has  described  a  variety  as  occurring  after 
injury  to  the  pneumogastric  and  other 
cranial  nerves. 

THANATOPHOBIA  (dcivaros,  death; 
(j)6^os,  fear).  A  morbid  fear  of  death. 
(Fr.  and  Ger.  Thanatophohie.) 

THEFT  IN  GENERAI.  PARAI.V- 
SIS,  &.C.  (/b'ee  Genekal  Paualysis,  and 
Kleptomania.) 

THEIiYGONIA  {Brikvs,  female;  yovla, 
race  or  off'spring).  A  term  very  loosely 
used  for  nymphomania,  2)roperly  emjiloyed 
for  female  offspring  or  the  procreation  of 
female  children. 


THEOIVIANIA  (Gf df,  God  ;  fxavia,  mad- 
ness). Religious  madness.  The  form  of 
mental  disease  in  which  patients  believe 
themselves  to  be  the  Deity,  or  to  be  inspired 
to  proclaim  his  will  infallibly  to  mankind. 
Under  one  variety  of  monomania,  Esquirol 
placed  "  those  who  believe  themselves 
gods,  profess  to  be  in  communication  with 
Heaven,  and  believe  they  have  a  celestial 
mission.  They  pi'oclaim  themselves  to  be 
prophets  or  soothsayers.     Such  are  theo- 

maniacs The  tnelancholia  enthusi- 

astica  of  Paulus  .iEgineta  belongs  to  the 
same  variety "  ("  Mai.  Ment."  ii.  p.  7). 
(.S'ee  Religious  Insanity.)  (Fr.  theo- 
'manie  ;  Ger.  der  religiose  Wahnsinn.') 

THERAPEUTICS. — The  reader  is  re- 
ferred to  the  observations  on  the  treat- 
ment of  the  various  forms  of  mental  dis- 
order made  under  their  several  heads  by 
the  contributors  of  these  articles.  He  is 
also  referred  to  the  following  articles : 
Baths;  Diet;  Electricity;  Feeding 
(Forcible)  of  the  Insane  ;  Neuroses, 
Functional  (Massage);  Prevention  of 
Insanity;  Sedatives. 

A  few  remarks  may,  however,  be  offered 
here  which  may  serve  to  assist  the  student 
and  general  practitioner. 

The  first  question  which  the  mental 
physician  asks  is,  whether  there  is  a  dis- 
tinctly abnormal  condition  of  the  bodily 
organs  the  removal  of  which  will  favour 
the  disordered  brain  functions — the  proxi- 
mate cause  of  the  attack  of  insanity.  It 
was  to  this  point  that  Max  Jacobi  directed 
all  his  endeavours  from  the  moment  a  pa- 
tient was  placed  under  his  care.  If  he 
carried  his  somatic  doctrines  too  far  it  re- 
mains true  that  the  leading  idea  of  medi- 
cal treatment  must  centre  in  this  doctrine. 
So  long  as  a  disordered  liver  disturbs  the 
healthy  action  of  the  mind,  so  long  as  a 
disorderof  the  colon  occasions  melancholia, 
so  long  as  suppressed  gout  causes  the 
patient  to  regard  himself  as  a  miserable 
sinner;  in  short,  so  long  as  any  of  the 
viscera  are  the  seat  of  disease,  and  the 
physician  disregards  such  disorder  of  the 
bodily  organs,  he  clearly  fails  to  fulfil  the 
first  indication  of  treatment.  Were  it 
necessary,  many  illustrations  could  be 
given  of  the  importance  of  ascertaining 
in  the  first  instance  the  condition  of  other 
organs  of  the  body  than  the  brain — in- 
stances in  which  the  removal  of  disease  in 
a  distant  organ  has  been  followed  by  rapid 
mental  recovery,  but  it  may  sufiice  to  refer 
to  the  action  of  emmenagogues  in  re- 
lieving some  cases  of  insanity. 

Although  hellebore  has  been  extolled 
in  addition  to  the  time-honoured  remedies 
for  amenorrhcea,  there  can  be  no  doubt 
that  the  most  effectual  drug  is  the  per- 


Therapeutics 


1291     ] 


Therapeutics 


manganate  of  potash  in  doses  of  2  or  3  grs. 
three  times  a  day.  That  larger  doses 
may  be  advautageously  employed  is  shown 
by  the  efiect  produced  by  some  patients 
having  taken  in  mischief  the  whole  con- 
tents of  the  pill-box  amounting  to  at  least 
30  grs.,  but  with  the  desired  effect.  We 
should,  however,  not  feel  justified  in  pre- 
scribing such  large  doses.  This  treat- 
ment should  be  accompanied  by 

Counter-irritation.  —  Following  the 
well-known  aphorism  that  active  disease 
in  one  organ  or  part  of  the  body  is  incom- 
patible with  disease  in  another,  medical 
men  have  endeavoured,  not  without  a  cer- 
tain amount  of  success,  to  set  up  inflamma- 
tion or  irritation  of  the  skin  in  order  to 
divert  the  morbid  action  of  the  central 
organ  to  the  periphery.  The  remarkable 
recoveries  from  insanity  following  upon  a 
carbuncle  in  the  neck  have  led  to  the 
employment  of  setons  or  blisters  on  the 
skin.  It  must  be  admitted  that  beneficial 
results  do  not  follow  so  frequently  from 
artificial  as  spontaneous  infiammation. 
At  the  same  time  the  imitation  of  nature 
in  this  respect  is  not  unfrequently  followed 
by  satisfactory  results.  Counter-irritation 
is  therefore  one  mode  of  treatment  which 
it  is  the  duty  of  the  mental  physician  to 
employ  whenever  it  seems  indicated. 

Depressant  Treatment. — (l)  Dejjletion 
is  rarely  justifiable.  The  lancet  so  much 
in  favour  as  a  remedy  in  former  days 
under  the  mistaken  idea  that  infiamma- 
tion of  the  brain  or  its  membranes  caused 
the  symptoms  of  insanity  cannot  be  said 
to  be  within  the  range  of  practical  mental 
therapeutics.  AVe  hesitate  to  attribute 
the  change  which  has  taken  place  in  the 
treatment  of  the  insane  altogether  to  an 
alteration  in  the  sthenic  character  of  dis- 
ease. Certain  it  is  that  the  indiscri- 
minate bleeding  which  was  practised  up 
to  the  early  part  of  this  century  and  even 
later,  was  injurious.  It  would  be  pleasant 
to  think  that  the  profuse  depletion  prac- 
tised by  the  estimable  Rush,  was  justified 
by  the  more  robust  type  of  the  constitu- 
tion in  his  day,  but  the  reaction  which  set 
in  against  it  was  not,  so  far  as  we  are 
aware,  based  upon  this  convenient  theory, 
but  upon  the  mischief  it  had  done.  That 
there  are  cases  in  which  the  local  abstrac- 
tion of  blood,  as  by  leeches  behind  the  ear, 
may  be  of  service  is  no  doubt  true,  and  of 
course  intercurrent  disorders  may  require 
topical  bleeding,  as  for  example  the  appli- 
cation of  leeches  in  amenorrhoea. 

(2)  Antimony  is  not  a  depressant  which 
is  justifiable  save  in  the  rarest  instances ; 
yet  not  only  was  it  employed  a  century  ago 
in  almost  all  cases  of  maniacal  excitement 
but  in  much  more  recent  times  it  has  to 


our  knowledge  been  the  sheet-anchor  in 
at  least  one  public  asylum.  When  we 
speak  of  the  non-employment  of  this  drug, 
we  do  not  exclude  its  use  in  very  small 
doses  in  combination  with  morphia.  In 
fact,  although  very  rarely  resorting  to  it 
even  in  this  torm,  we  have  seen  valuable  re- 
sults from  its  exhibition  in  cases  of  mania 
where  morphia  was  prejudicial  without, 
but  useful  with,  tartrate  of  antimony.  The 
combination  of  a  grain  of  morjihia  with 
one-eighth  of  a  grain  of  tartar  emetic 
was  for  many  years  a  favourite  remedy 
at  the  York  Retreat.  Dr.  Bucknill  found 
that  the  benefit  to  be  derived  from  anti- 
mony did  not  occur  in  those  cases  in  which 
it  produced  nausea,  but  that  on  the  con- 
trary it  bore  a  close  relation  to  the  toler- 
ance the  patient  had  for  it,  and  that  the 
results  were  most  satisfactory  with  those 
patients  labouring  under  acute  mania  and 
of  strong  constitution  in  whom  there  was 
little  general  disturbance  of  the  health. 

(3)  Purgatives. — Although  the  old-fash- 
ioned administration  of  purgatives  was 
excessive  thei-e  can  be  no  doubt  that  occa- 
sionally they  are  useful,  and  no  form  is 
better  than  a  pill  containing  calomel  i  gr., 
aq.  ext.  aloes  2  grs.,  pil.  col.  co.  2  grs. ;  to 
be  taken  twice  a  week  at  bedtime.  By 
this  means  the  action  of  the  liver  is  suffi- 
ciently excited  in  cases  of  mental  depx'es- 
sion  in  which  it  is  sluggish.  Mercurials 
may  be  said  to  be  iincalled  for,  except 
as  an  occasional  alterative  and  purgative, 
and  as  an  anti-syphilitic  remedy.  Their 
abuse  in  former  da3's  is  well  known. 
There  is  no  encouragement  for  their  em- 
ployment in  the  early  stage  of  general 
paralysis,  where  one  might  have  expected 
it  to  be  beneficial. 

Tonics  and  Stimulants. — {a)  Tonics. — 
The  indications  for  the  use  of  tonics  in 
mental  disorder  are  the  same  as  those  in 
disease  accompanied  with  weakness  in 
non-mental  aft'ections.  Cases  of  ana3mia 
obviously  call  for  the  exhibition  of  iron. 
Amongst  tonics  we  may  enumerate  the 
following  as  specially  valuable :  Iron, 
arsenic,  phosphorus,  quinine,  strychnia. 
A  good  form  of  tonic  is  Easton's  syrup, 
which  combines  several  of  these  bodies. 
(For  the  action  of  quinine  vide  article.) 

(fc)  /Stimulants. — The  use  of  stimulants 
to  procure  sleep  in  cases  of  maniacal  in- 
somnia has  been  already  referred  to.  The 
form  of  mental  disorder  in  which  they  are 
imperatively  called  for  is  that  of  acute 
delirious  mania  ((/.i-.).  In  some  instances 
of  melancholia,  rum  and  milk  may  be 
given  to  the  patient  if  he  wakes  early 
with  great  depression,  but  in  the  majority 
of  cases,  food,  especially  Braud's  extract 
of  meat,  is  better  than  any  stimulant. 


Therapeutics 


[    1292    ] 


Therapeutics 


Narcotic  Treatment,  —  (a)  Opiates 
have  imquestiouably  a  highly  important 
place  in  the  treatment  of  mental  disorders. 
"When  to  use  and  when  to  refrain  from 
using  opium  is  indeed  one  of  the  most  difB- 
cult  and  delicate  problems  for  the  mental 
physician  to  solve.  Monstrous  doses  have 
been  administered,  but  such  a  practice  is 
reprehensible.  That  opium  in  increasing 
doses  within  moderate  limits  may  be  ad- 
vantageously employed  in  acute  mania  is 
supported  b}^  considerable  evidence.  In 
melancholia  again,  it  may  be  allowed  that 
opium  exerts  a  calmative  and  in  the  end 
a  curative  influence,  but  that  it  fails  in 
many  instances  where  previous  experience 
indicates  its  use  is  but  too  certain.  It  is 
of  great  importance  to  remember  that  the 
use  of  opiates  for  either  mania  or  melan- 
cholia requires  careful  attention  to  the 
dietary  in  use  at  the  same  time.  A  plenti- 
ful supply  of  food,  and  in  some  cases 
stimulants,  will  ensure  a  success  of  this 
treatment  when  it  would  otherwise  en- 
tirely fail ;  and  if  the  appetite  is  decidedly 
interfered  with  by  opium,  the  objection 
to  its  use  may  be  so  great  as  to  counter- 
indicate  its  administration. 

(&)  Hypodeniiic  injections  of  ^morpliia, 
commencing  with  as  small  a  dose  as  one- 
tenth  of  a  grain  of  morphia  on  account  of 
possible  idiosyncrasies,  may  be  employed 
with  great  benefit.  It  has  been  admin- 
istered in  enormous,  and  we  think  dan- 
gerous, doses  by  Aug.  Voisin  in  some 
cases  of  melancholia,  the  maximum  dose 
having  been  fifteen  grains.  We  should 
not  care  to  go  beyond  two  grains,  and 
then  only  after  cautiously  raising  the  dose. 
Vomiting  is  likely  to  occur  from  the  use 
of  large  doses,  or  if  this  does  not  happen, 
the  special  symptoms  of  opium  poisoning 
may  alarm  the  physician. 

The  hypodermic  injection  of  remedies 
has  during  the  last  few  years  greatly  ad- 
vanced, and  has  certainly  not  always  been 
accompanied  by  the  care  which  is  desirable. 

(c)  Hyoscyamns  retains  its  high  posi- 
tion as  a  hypnotic  in  the  treatment  of  the 
insane.  One  or  two  drachms  of  the  tinc- 
ture may  be  given  at  bedtime,  or  a  con- 
siderably larger  dose.  It  is  generally 
better  to  combine  it  with  other  drugs,  as 
the  bromides  or  choral. 

The  hypodermic  injection  of  hyoscya- 
mine  and  hyoscine  needs  great  caution, 
and  the  effect  of  these  drugs  should  be 
carefully  watched.  It  is  allowable  to  use 
it  in  institutions  in  cases  in  which  it  would 
be  unsafe  to  employ  it  when  the  patient 
is  subsequently  left  in  the  hands  of  non- 
medical persons. 

Sedatives,  as  choral,  paraldehyde,  the 
bromides,  sulphonal,  &c. 


Chloral  is  justly  I'egarded  with  more 
or  less  apprehension,  but  although  fre- 
quently abused,  it  has  its  place.  We  can- 
not commend  the  large  doses  which  have 
been  given  in  some  asylums,  and  that 
some  ninety  pounds  were  given  by  the 
late  Dr.  Gray,  of  Utica  Asylum,  to  370 
patients  in  the  course  of  eighteen  months, 
would  find  no  justification  at  the  present 
day,  when  we  know  its  injurious  as  well 
as  beneficial  effects.  The  excuse  for  its 
employment  is  the  less  now  that  we  have 
a  drug  like  sulphonal,  which,  in  the  large 
majority  of  cases,  exerts  the  desired  influ- 
ence in  the  insomnia  of  the  insane,  the 
dose  being  from  fifteen  to  forty  grains.  In 
some  cases  a  drachm  is  well  borne  by  the 
patient.  Paraldehyde  in  doses  of  one 
or  two  drachms,  repeated  if  necessary,  is 
undoubtedly  a  valuable  addition  to  our 
hyjonotics  in  the  treatment  of  the  insane. 

Cannabis  Indica. — This  drug  has  been, 
very  frequently  employed  to  induce  sleep 
or  to  allay  maniacal  excitement.  We 
have,  however,  found  the  effect  somewhat 
uncertainly  beneficial  in  consequence  of 
the  special  action  of  the  drug  becoming 
complicated  with  the  mental  symptoms. 
Effects  may  follow  the  administration 
of  a  moderate  dose,  which  are  in  the  first 
instance  alarming,  but  are  not  likely  to 
be  of  a  serious  nature,  and  will  probably 
disappear  on  the  administration  of  a  stim- 
ulant. The  tincture  (B.P.)  may  be  given 
in  doses  of  from  ten  to  twenty  minims. 

Bro'hiide  of  potassium  and  hroonide  of 
ammonium  retain  a  high  position  in  asy- 
lum practice,  apart  from  epilepsy,  al- 
though a  note  of  wai-ning  in  regard  to 
their  deteriorating  influence  when  too  long 
continued  has  not  been  wanting. 

The  whole  subject  of  hypnotics  and  se- 
datives is  fully  considered  in  the  article 
{(pv.)  by  Drs.  Ringer  and  Sainsbury. 

Baths. — Their  use  in  various  forms  is 
described  by  Dr.  Duckworth  Williams  in 
a  special  article  {q.v.).  It  is  needless  to 
point  out  the  cruel  use  which  may  be  made 
of  the  cold  water  douche,  as  we  do  not 
believe  that  it  is  ever  so  iised  in  England, 
nor,  we  trust,  at  the  present  day,  on  the 
Continent,  where  many  years  ago  we 
witnessed  its  abuse.  That  it  should  have 
been  resorted  to  in  order  to  foi'ce  a  patient 
to  give  up  a  delusion  is  not  perhaps  sur- 
prising, considering  the  multitude  of 
means  employed  to  frighten  the  insane 
out  of  their  delusions.  We  onl}-  mention 
the  practice  here  to  reprobate  it. 

Electricity. — The  reader  is  referred  to 
Professor  Arndt's  article  on  this  remedy 
in  mental  disorders. 

Feeding-. — The  extreme  importance  of 
supplying  not  merely  an  ample  diet  for  the 


I 


Therapeutics 


[     1293    J 


Things 


insane,  but  an  exceptionally  large  amount 
in  the  exhaustion  so  frequently  associated 
with  acute  mauia,  must  be  here  insisted 
upon  in  the  strongest  possible  manner. 
We  refer  the  reader  to  the  article  on 
acute  delirious  mania.  The  stimulus 
which  Dr.  Clouston  has  given  to  the 
copious  use  of  nutritious  food  has  been  of 
the  greatest  value.  Again,  the  enforce- 
ment of  some  form  of  nourishment,  as 
beef  tea,  Ac,  on  waking  in  the  morning, 
in  cases  of  melancholia,  must  be  emjiha- 
sised.  Attention  to  this  one  point  will 
often  render  sedatives  unnecessary. 

We  conclude  this  article  by  singling 
out  the  treatment  of  one  form  of  mental 
disorder — mania — on  account  of  its  im- 
portance and  the  necessity  for  instant 
treatment.  It  is  contributed  by  Dr. 
Conolly  Norman  as  sui>plementary  to  his 
article  on  mania. 

"The  diet  requires  careful  regulation. 
It  must  be  always  borne  in  mind  that 
with  great  mental  excitement  there  is  apt 
to  be  combined  digestive  trouble  and  a 
tendency  to  exhaustion.  The  food  should 
generally  be  of  a  light  and  nutritious 
nature.  The  state  of  the  tongue  and  so 
forth  will  indicate  more  exactly  what  is 
desirable  in  each  case.  In  severe  cases 
there  is  often  refusal  of  food  from  inatten- 
tion or  mere  excitement.  This  is  a  symptom 
which  must  on  no  account  be  neglected, 
otherwise  the  patient's  strength  will  run 
down  rapidly  and  dangerously.  Artificial 
feeding  should  therefore,  in  severe  cases, 
be  adopted  early.  Concentrated  predi- 
gested  foods,  with  the  addition  of  alcohol, 
are  indicated. 

To  procure  sleep  is  of  the  first  import- 
ance in  the  treatment  of  acute  mania. 
The  induction  of  rest  by  day  is  often 
followed  by  sleej)  at  night,  but  in  the 
majority  of  cases  insomnia  is  a  very 
troublesome  symptom.  Regulated  exer- 
cise in  the  open  air  when  the  ])atient's 
strength  permits  it,  is  invaluable  in  this 
respect.  Two  hours'  steady  walking  out 
of  doors  seems  to  produce  more  healthy 
weariness  and  disposition  to  sleep  than  a 
whole  day  spent  in  aimless  motor  excite- 
ment. But  in  many  cases,  especially  the 
more  severe,  this  is  out  of  the  question. 
Packing  in  the  wet  sheet  is  often  of  great 
service.  The  prolonged  warm  bath  is 
sometimes  useful.  A  tepid  bath  at  bed- 
time, or  a  cold  bath  followed  by  a  thorough 
rubbing,  will  sometimes  act  well.  Of 
drugs,  the  best  are  morphia,  sulphonal, 
and  paraldehyde.  Methylal  is  useful  in 
alcoholic  cases.  Morphia  is  not  indicated 
in  mild  cases.  In  very  severe  cases  where 
there  is  an  urgent  need  of  sleep,  it  should 
be  used  in  full  doses,  guarded  with  ether 


or  alcohol.  Sulphonal  is  generally  remark- 
ably safe.  Its  i)rolonged  use  is  no  doubt 
somewhat  depressing.  Paraldehyde  re- 
quires the  dose  to  be  constantly  increased. 
Chloral  is  sometimes  useful,  but  its 
depressing  effect  on  the  heart  must  be 
carefully  watched,  and  it  must  be  remem- 
bered that  if  it  fails  to  iiroduce  sleep  it 
is  likely  to  increase  excitement.  The 
"  chloral  habit "  also  is  very  easily  and 
rajiidly  formed.  Something  may  be  hojied 
from  hypnotism  in  mild  cases,  especially 
of  a  recurrent  type. 

Of  calmatives,  as  distinct  from  sopo- 
rifics, the  most  valuable  is  probably 
digitalis.  Sulphonal  in  small  repeated 
doses  is  certainly  effectual  in  producing 
temporary  sleep  in  some  cases.  The 
bromides  are  chieHy  useful  in  cases  in 
which  there  is  marked  sexual  excitement. 
Their  indiscriminate  use  has  undoubtedly 
done  much  harm,  and  they  share  with  the 
opium  preparations  the  evil  credit  of 
having  turned  many  acute  maniacs  into 
chronic  dements,  at  least  prematurely. 

Of  late  years  hyosciue  has  attained 
some  reputation  in  the  treatment  of  excite- 
ment. It  is  a  drug  which  requires  to  be 
used  with  great  caution.  Ajiart  from  its 
mere  depressing  action  it  appears  dis- 
tinctly to  have  a  specific  effect  in  dimin- 
ishing motor  restlessness.  Its  chief  virtue, 
however,  seems  to  be  owing  to  the  decided 
'  shock  '  which  results  from  its  adminis- 
tration. It  may  occur  that  in  exception- 
ally favourable  circumstances  the  inter- 
ruption to  the  morbid  current  thus  effected 
may  be  followed  by  permanent  improve- 
ment, but  the  experience  of  most  of  those 
who  have  used  this  drug  has  been  disap- 
Ijointing."  *  The  Editor. 

THERMO  -  AM-.a:STHZ:SIiV  {depfjios, 
warm  :  uvaiadr^cria,  want  of  sensation). 
The  loss  of  perception  of  heat  and  cold 
by  the  skin  and  mucous  membranes. 
This  may  vary  in  degree  from  absolute 
inability  of  perception  to  the  loss  of  recog- 
nition of  slight  differences  in  temperature ; 
it  may  accompany  ordinary  sensory  anaes- 
thesia or  exist  apart  from  it,  or  there  may 
be  a  perversion  of  the  sensations,  cold 
applications  giving  a  sensation  of  warmth 
and  vice  versa ;  or  electrical  stimulation 
may  give  rise  to  the  sensation  of  cold  or 
heat.  Its  pathology  is  still  obscure,  but 
it  usually  occurs  in  lesions  of  the  cord  in- 
volving the  lateral  columns. 

THZWCS.  —  In  psychology  "  things  " 
are  opposed  to  sensations.  Sensations 
are  modes  of  the  brain  being  affected, 
while  "  things  "  are  the  results  of  mental 
synthesis    of    sensations;   each    "thing" 

*  The  uencral  or  moral  ireatuH'iit  of  ni;uiia  is 
uivi'ii  uiidi'v  Tkkatmknt. 


Thlapsis  Depressio 


[    1294    ] 


Ticklishness 


implies  sensations  and  uniting  energy  of 
miud. 

THI.APSIS  DEPRESSIO  (dXaco,  I 
break).     Depression,  melancholy. 

THOUGHT.  {See  CoxsciousxEss  ; 
PHiLosoruv  o¥  Mind,  p.  27-) 

THOUCHT-READIITG,  THOUGHT- 
TRANSFERENCE. — The  fictitious  power 
claimed  by  some  of  being  able  to  read  the 
thoughts  of  others  by  personal  contact. 
The  phenomena  are  due  to  the  practised 
art  of  muscle-reading ;  that  is  to  say,  that 
the  operator  can  divine  by  the  muscular 
movements  of  the  person  who  is  the  sub- 
ject of  experiment  the  direction  in  which 
his  thoughts  tend.  It  is  an  interesting  in- 
stance of  the  mind  acting  on  the  body 
during  intense  mental  concentration,  the 
corresponding  involuntary  movements 
being  appreciated  by  another. 

THYMOPATHZA  {Bvixos,  the  mind  ; 
TTados,  an  affection).  Term  for  mental 
affection  or  derangement.  (Pr.  and  Ger. 
Tliy'ino'patliie.) 

THYROID  GIiAND  TN  REI.ATION- 
TO  MEM-TAIi  DISEASE. — The  Com- 
mittee of  the  Clinical  Society  of  London, 
nominated  December  14,  1883,  to  investi- 
gate the  subject  of  myxoedema  (Dr.  Ord, 
Chairman),  arrived  at  these  conclusions 
amongst  others  :  That  clinical  and  patho- 
logical observations,  respectively,  indicate 
in  a  decisive  way,  that  the  one  condition 
common  to  all  cases  is  destructive  change 
of  the  thyroid  gland ;  that  the  most 
common  form  of  destructive  change  of 
the  thyroid  gland  consists  in  the  substi- 
tution of  a  delicate  fibrous  tissue  for  the 
proper  glandular  structure ;  that  intersti- 
tial development  of  fibrous  tissue  is  also 
observed  very  frequently  in  the  skin,  and 
with  much  less  frequency  in  the  viscera  ; 
the  appearances  presented  by  this  tissue 
being  suggestive  of  an  irritative  or  in- 
flammatory process ;  that  pathological 
observation,  while  showing  cause  for  the 
changes  in  the  skin  during  life,  for  the 
falling  off  of  the  hair  and  the  loss  of  the 
teeth,  for  the  increased  bulk  of  the  body, 
as  due  to  the  excess  of  subcutaneous  fat, 
affords  no  explanation  of  the  affections  of 
speech,  movement,  sensation,  conscious- 
ness, and  intellect,  which  form  a  large 
part  of  the  symptoms  of  the  disease  ;  that 
the  full  analysis  of  the  results  of  the  re- 
moval of  the  thyroid  gland  in  man  de- 
monstrates, in  an  important  proportion 
of  the  cases,  the  fact  of  the  subsequent 
development  of  symptoms  exactly  corre- 
sponding with  those  of  myxosdema ;  that 
in  no  inconsiderable  number  of  cases  the 
opm'ation  has  not  been  known  to  have 
been  followed  by  such  symptoms,  the  ap- 
parent immunity  being,  in   many  cases, 


probably  due  to  the  presence  and  subse- 
quent development  of  accessory  thyroid 
glands,  or  to  accidentally  incomplete  re- 
moval or  to  insufficiently  long  observation 
of  the  patient  after  operation  ;  that 
myxoedema,  as  observed  in  adults,  is 
practically  the  same  disease  as  that  named 
sporadic  cretinism  when  affecting  children ; 
that  it  is  probably  identical  with  cachexia 
strumapriva  and  that  a  very  close  affinity 
exists  between  myxoedema  and  endemic 
cretinism  ;  that  while  these  several  condi- 
tions aj^pear  in  the  man  to  depend  on,  or 
to  be  associated  with,  destruction  or  loss 
of  the  function  of  the  thyroid  gland,  the 
ultimate  cause  of  such  destruction  or  loss 
is  at  present  not  evident.*  ((See  Cretinism 
and  Myxcedema.) 

TICKI.ISHM-ESS,  AND  THE  PHE- 
NOMENA or  TICKI.ING. — The  seve- 
ral forms  of  special  irritability  exhibited 
by  the  peripheral  endings  of  sensory 
nei'ves  known  as  ticklishness,  seem  to 
have  attracted  the  attention  of  some  of 
the  older  writers  on  physiology,  and  Sca- 
liger  proposed  to  class  "  titillation  "  as  a 
sixth  and  separate  sense.  Although  no 
modern  observers  have  followed  up  this 
view,  there  can  be  no  question  that  the 
general  phenomena  of  ticklishness  are 
distinct  and  characteristic  enough  to  be 
differentiated  from  those  of  ordinary  sen- 
sation and  of  the  pei-ipheral  irritability 
which  gives  rise  to  afferent  impulses  neces- 
sary for  reflex  action. 

Ticklishness  becomes  of  interest  to  the 
student  of  jjsychology  because  it  appears 
to  be  something  superadded  to  the  simple 
capability  for  receiving  stimuli  suitable 
for  provoking  unconscious  reflex  results 
observable  among  some  of  the  lowest 
organisms,  and  yet  falls  short  of  the  more 
definite  sensory  impressions  which  enable 
the  higher  centres  to  judge  of  the  nature 
and  properties  of  external  objects. 

It  is  distinctly  an  appeal  to  conscious- 
ness, but  at  the  same  time  one  of  an  ele- 
mentary and  primitive  order.  As  such  it 
appears  to  be  one  of  the  simplest  develop- 
ments of  mechanical  and  automatic  ner- 
vous processes  in  the  direction  of  the  com- 
plex functioning  of  the  higher  centres 
which  comes  within  the  scope  of  psycho- 
logy. 

In  several  ways  does  tickling  differ  from 
ordinary  sensation.  In  the  fii'st  place  it 
almost  invariably  involves  and  accompa- 
nies an  impulse  to  movement  of  the  usual 
reflex  character.  But  this  conscious  im- 
pulse, though  at  times  strong,  is  not  of 
the  same  emphatic  nature  as  that  which 
gives  rise  to  actual  pain.     Indeed,  it  may, 

*  Supplement  to  vol.  xxi.  of  tlic  C'liiiic:il  Society's 
Triiiisaetioiis. 


Ticklishness 


[     1^95     ] 


Ticklishness 


and  often  does,  lead  to  muscular  contrac- 
tions beyond  the  control  of  the  will  with- 
out produciucr  any  consciousness  of  pain 
whatever.  Again,  we  iind  that  the  parts 
where  tactile  sensation,  which  enables  us 
to  determine  the  character  of  external  ob- 
jects by  contact,  is  most  acute,  such  as 
the  tijis  of  the  lingers  or  of  the  tongue, 
are  scarcely  at  all  sensitive  to  titillation. 
That  sensitiveness  to  tickling  is  not  locally 
coincident  with  sensitiveness  to  pain  is 
evident,  since  those  ])arts  of  the  body 
where  pain  is  caused  by  a  slight  degree 
of  violence  such  as  the  u]iper  part  of  the 
tip  of  the  nose,  are  far  from  being  the 
most  ticklish. 

In  endeavouring  to  classify  the  various 
phenomena  of  ticklishness  for  the  purposes 
of  more  detailed  study,  we  find,  as  is  so 
frequently  the  case  with  regard  to  natu- 
ral phenomena,  that  no  sharp  and  rigid 
partition  lines  can  be  drawn. 

A  convenient  classification  may  be 
attempted  by  dividing  the  nerves  con- 
cerned into  (i)  those  close  to  the  sur- 
face, and  (2)  those  more  deeply  situated. 

(i)  The  superficial  irritability  or  tick- 
lishness responds  in  nearly  all  cases  to  very 
slight  stimuli.  It  is  commonly  but  not 
always  associated  with  the  nerves  supply- 
ing the  minute  hairs  which  cover  the  skin 
of  the  body  and  of  the  extremities,  with 
the  exceptions  of  the  palms  and  soles,  and 
the  last  joint  of  the  digits.  These  sensi- 
tive hairs  are  especially  abundant  in  such 
situations  as  the  orifices  of  the  ear  and 
nostril. 

The  ticklishness  associated  with  hair 
may  be  again  subdivided  in  accordance 
with  its  subjective  characters  into  (a)  that 
which  is  distinctly  distasteful,  and  {h)  that 
which  is  rather  agreeable  than  otherwise. 
The  former  appears  to  have  to  do  with 
warning  intimations  of  the  presence  of 
parasites  and  other  noxious  insects. 
There  can  be  no  doubt  that  the  struggle 
for  existence  between  man  and  the  minute 
parasites  which  prey  upon  him  has  been 
a  very  sharp  one  in  the  past,  so  that  we 
might  reasonably  expect  to  find  traces  of 
it  in  his  structure  and  habits.  Even  in 
modern  times  in  some  parts  of  the  world 
where  cleanliness  is  neglected,  and  other 
circumstances  favour  the  increase  of  ver- 
min, there  is  still  a  conflict  of  clashing 
interests  of  this  nature  which  is  quite  keen 
enough  to  leave  a  permanent  impress  on 
the  race  through  the  action  of  the  laws  of 
natural  selection. 

The  small  hairs  on  the  integument, 
while  they  are  probably  the  remains  of  a 
thick  natural  coat  which  formerly  har- 
boured the  enemy,  may  now  be  regarded 
as   so   many  minute   sentinels  which  in- 


stantly notify  an  invasion,  and  by  the 
irritation  caused  by  the  movements  of  an 
insect  among  them,  induce  us  to  rid  our- 
selves of  its  presence  before  it  becomes  a 
source  of  danger  to  comfort  and  health. 

The  ajjreeable  sensations  which  accom- 
pany a  light  touch  as  of  a  hand  stroking 
the  hirsute  surface  of  the  skin  may  be 
owing  to  several  causes.  In  some  in- 
stances the  sensations  are  i^robably  con- 
nected with  the  sexual  appetite,  and  may 
be  the  vestigial  relics  of  the  caresses  of 
courtship  referable  to  some  out-of-date 
methods  of  making  love.  We  find  that  in 
some  animals  local  titillation  of  the  skin, 
althoiagh  in  parts  remote  from  the  repro- 
ductive organs,  plainly  acts  indirectly 
upon  them  as  a  stimulus.  Thus  Harvey 
records  that  by  stroking  the  back  of  a 
favourite  parrot  (which  he  had  possessed 
for  years,  and  supposed  to  be  a  male),  he 
not  only  gave  the  bird  gratification — which 
was  the  sole  intention  of  the  illustrious 
physiologist — but  also  caused  it  to  reveal 
its  sex  by  laying  an  eg^. 

The  pleasure  derived  from  caresses  may 
often  be  due  to  obscure  association  of 
sexual  feelings,  even  although,  owing  to 
the  many  complications  of  the  primary 
instinct  due  to  the  cultivation  of  the 
higher  faculties  and  changed  habits  of 
life,  both  individual  and  social,  it  might 
be  scarcely  recognisable  as  such.  In 
short,  the  beaten  track  of  an  old  reflex 
may  remain  open,  although  its  original 
purpose  is  a  thing  of  the  remote  past. 
There  are  without  doubt  certain  vestigial 
reflexes  of  this  and  parallel  kinds  still 
occasionally  manifest  which  are  legacies 
of  an  earlier  state  of  development,  but 
which  may  even  yet  be  of  serious  import 
in  stimulating  or  directing  the  bodily  and 
mental  energies  {see  Eeflex  Action). 

Doubtless  another  reason  why  caresses 
of  the  nature  of  gentle  titillation  are 
pleasurable  may  be  attributed  to  the  bene- 
ficial effect  in  previous  ages  of  the  assidu- 
ous care  bestowed  by  the  parent  upon  the 
offspring,  and  by  the  several  animals  of  a 
troop  upon  one  another,  which  conduced 
to  cleanliness  and  freedom  from  parasites, 
and  therefore  to  physical  well-being.  If 
the  conflict  with  parasitic  enemies  were 
ever  as  severe  as  seems  to  have  been  the 
case,  a  group  of  animals  which  habitually 
and  systematically  freed  themselves  and 
one  another  from  a  common  foe,  as  we 
constantly  see  monkeys  do,  would  be  more 
healthy,  and  therefore  more  likely  to  sur- 
vive in  times  of  stress  than  another  group 
the  members  of  which  were  too  stupid  or 
indiffei-ent  to  act  in  this  manner.  It  is 
obvious  also  that  if  an  animal  found  such 
services  immediately  pleasurable,  it  would 


Ticklishness 


1296 


Tic  non  Douloureux 


be  tlie  more  ready  to  submit  to  them,  and 
would  derive  corresponding  beneiit. 

Another  and  distinct  form  of  sujierficial 
sensitiveness  to  tickling  appears  to  be 
closely  associated  with  certain  reflexes 
partially  under  the  control  of  the  will. 
This  is  found  where  the  small  hairs  are 
absent,  in  connection  with  the  smooth 
skin  of  the  palms  and  soles,  and  mucous 
surfaces,  such  as  the  palate  and  fauces, 
the  interior  of  tlie  nose,  conjunctivae, 
glans  penis,  and  other  parts. 

In  these  situations  appropriate  stimula- 
tion provokes  certain  movements  and 
other  reflex  phenomena.  As  a  rule,  the 
sensation  produced  when  the  part  is 
slightly  tickled  is  subjectively  unpleasant 
unless  associated  with  these  movements, 
ami  becomes  intolerable  if  the  irritation  is 
increased.  The  special  form  of  ticklish- 
ness her-e  displayed  appears  to  find  its 
raison  cVetre  in  provoking  and  coercing  the 
higher  centres  to  cease  from  all  inhibitory 
action,  and  to  allow  the  reflex  mechanism 
free  play.  Every  one  who  will  try  the 
experiment  of  tickling  his  palate  or  the 
soles  of  his  feet,  and  at  the  same  time 
endeavouring  by  an  effort  of  will  to 
restrain  ail  movements,  will  experience 
the  strength  of  this  prompting  sensation  of 
tension  and  discomfort.  The  ticklishness 
of  the  palm  and  sole  seems  to  be  to  a 
great  extent  vestigial,  and  probably  origi- 
nally had  to  do  with  conditions  of  life  now 
obsolete  (see  Eeflex  Action). 

(2)  We  now  come  to  the  ticklishness 
which  apparently  is  attributable  to  a 
special  function  of  nerves  more  deeply 
situated,  since  it  is  not  called  forth  by  a 
Hght  touch  on  the  skin,  but  is  generally 
most  manifested  when  stimulation  is  of 
such  a  character  as  to  affect  the  deeper 
structures. 

This  form  is  what  is  most  generally 
spoken  of  as  "  ticklishness  "  in  popular 
parlance,  and  to  the  physiologist  it  is  very 
interesting  from  the  remarkable  and  uni- 
form series  of  phenomena  which  accom- 
pany it.  It  is  plainly  an  altogether 
difi'erent  thing  from  the  superficial  forms 
already  dealt  with,  since  light  touches  on 
the  integument,  even  where  the  small 
hairs  are  most  abundant  and  sensitive,  do 
not  produce  the  results  following  stimu- 
lation, for  which  this  form  of  ticklishness 
is  especially  noteworthy.  Certain  regions 
of  the  body,  such  as  the  axillae,  and  con- 
tiguous parts,  the  flanks,  lower  ribs,  &c., 
are  most  ready  to  respond  to  appropriate 
provocation.  Children,  as  soon  as  they 
become  active,  are  more  sensitive  than 
adults.  It  is  observable  that  the  accom- 
panying sensation  is  at  first  distinctly 
pleasurable,  and  one  may  say  that  there 


is  an  actual  appetite  for  this  kind  of  nerve 
irritation,  since  a  child  will  invite  its  play- 
mate to  tickle  it.  But  after  a  few  moments, 
especially  if  stimulation  has  been  at  all 
vigorous,  a  reverse  feeling  is  exhibited. 
The  proceeding  becomes  distasteful,  and 
the  child  will  writhe  and  twist  about  to 
avoid  it.  Yet  the  moment  it  is  desisted 
from  the  child  will  again,  by  gesture, 
attitude,  and  speech,  invite  its  repetition, 
and  again  as  before,  after  a  certain  point, 
show  its  distaste  by  movements  of  avoid- 
ance. The  muscular  results  of  this  reflex 
stimulation  may  be  slight  and  controllable 
by  a  moderate  inhibitory  effort,  or  they 
may  be  violent  and  convulsive,  and  totally 
beyond  the  power  of  the  subject  to  check 
them.  The  movements  also  are  invariably 
accompanied  with  laughter,  generally  of 
an  uncontrolled,  open-mouthed,  and  spas- 
modic character. 

To  any  physiologist  who  seeks  to  dis- 
cover the  reason  for  these  and  similar 
obscure  facts  concerning  the  bodily  func- 
tions and  attributes  by  an  appeal  to  evolu- 
tionary laws,  it  is  evident  that  such  pro- 
nounced and  noteworthy  phenomena  as 
the  above,  following  a  like  cause  in  all 
cases  and  universally  prevalent,  cannot  be 
explained  on  any  other  ground  than  that 
they  either  are,  or  have  been,  of  some  de- 
finite utility.  For  it  appears  to  be  a  law 
that  whenever  any  salient  characteristic  is 
observable  and  is  universally  distributed 
among  the  members  of  a  species,  it  must 
either  be  of  undoubted  use  in  the  life 
economy  at  the  present  time,  or  must  in 
the  past  have  played  an  important  part 
in  preserving  the  race  from  extinction,  or 
in  furthering  its  more  perfect  development 
and  adaptability  to  environment. 

Now,  since  no  present  pi-obable  useful 
office  can  be  discovered  for  this  curious 
appetite  and  the  extraordinary  pheno- 
mena which  accomjaany  the  act  of  tickling, 
it  seems  more  than  likely  that  we  have 
here  one  of  those  strange  vestigial  reflexes 
which  were  of  vital  importance  in  the 
remote  past.  What  the  utility  can  have 
been  is  an  interesting  and  obscure  prob- 
lem, and  one  which  seems  well  worthy  of 
the  attention  of  competent  observers.  The 
close  and  invariable  association  of  laughter 
with  this  form  of  tickling  gives  some 
promise  that  the  solving  of  the  question 
at  issue  will  throw  light  on  the  curious 
and  important  psychological  problems 
respecting  the  origin  and  primary  basis  of 
latighter  and  the  sense  of  the  ludicrous. 
Louis  Robixsox. 

TIC  WON  3>oui.ouRi:ux  (Charcot). 
A  hysterical  affection  of  the  face  usually 
one-sided,  characterised  by  frequently  re- 
peated spontaneous  paroxysms  of  twitch- 


Tigretiei*,  Tegretier 


[     1297    ] 


Tobacco 


ing  of  the  facial  muscles,  and  hemi-aiues- 
thesia  of  the  same  side  of  the  face. 
Though  as  a  rule  spontaneous,  the  par- 
oxysms are  occasioually  brought  on  by 
stimuli,  as  in  a  case  of  Charcot's  where 
energetic  spasm  occurred  on  exposure  of 
the  eye  on  the  same  sitlo  of  thv  face. 

TICRETXER,  TEGRETIER.  —  A 
psychopathy  of  h3'sterical  origin  first  de- 
scribed by  Nathaniel  Vearce  ("  The  Life 
and  Adventures  of  Nathauiel  Pearce," 
Loudon,  I  S3 1,  i.  290)  occurring  amoug 
the  native  women  of  Abyssinia.  The 
subjects  became  imbued  with  a  religious 
emotionalism  in  which  delusions  of  demo- 
niacal possession  giving  rise  to  paroxysms 
of  excitement  were  prominent.  Oourbon 
{Progrl-.'i  Mi'dirdl,  18S4,  39,  774),  while 
denying  the  truth  of  Pearce's  account, 
remarks  that  severe  forms  of  hysteria  are 
common  among  the  women  of  Abyssinia 
and  that  they  find  exjiression  in  strange 
mental  delusions  (Hirsch). 

TINWITUS  AURIUM  (tiiinitus,  a 
ringing  or  tinkling  ;  anri.s,  the  ear).  The 
humming  or  other  noises  heard  in  the 
ear  and  not  due  to  external  sounds.  It 
gives  rise  to  illusions  of  hearing  in  the 
insane. 

TZTVBATZOM'  {iitiiho,  I  stagger).  A 
staggering  gait,  sometimes  dependent  on 
disease  of  the  nervous  system.  (Fr.  titu- 
batioii ;  Ger.  W^anJcen.) 

TOBA.CCO,  Effect  of,  on  the  Nervous 
System. — The  influence  of  tobacco  on  the 
nervous  system,  and  on  the  production  of 
cerebral  nervous  disorders,  must  be  attri- 
buted to  the  two  substances,  nicotine  and 
l^yridine,  which  are  contained  in  tobacco, 
and  which  belong  to  the  strongest  poi- 
sons. Nicotine  might  be  compared  to 
hydrocyanic  acid.  Different  sorts  of  to- 
bacco contain  different  quantities  of  these 
substances.  Cigars  from  Havanna  con- 
tain two  per  cent,  of  nicotine. 

Pbysiological  ilction  of  Tficotine. — 
Nicotine  produces  in  cold-blooded  animals 
restlessness,  rapid  disturbance  of  con- 
sciousness, clonic  spasms,  loss  of  reflexes 
and  arrest  of  respiration,  and  lastly  death. 
In  small  warm-blooded  animals  a  very 
small  dose  causes  death  in  a  few  seconds 
with  sympjtoms  of  paralysis.  Large  warm- 
blooded animals  after  a  full  dose  fall 
down  dead  without  any  convulsions ; 
small  doses  cause  tonic  and  clonic  spasms, 
which  return  at  intervals,  and  afterwards 
death  through  inspiratory  tetanus  or 
paralysis.  In  man,  doses  from  0.00 1  to 
0.003  grammes  are  poisonous,  and  cause 
headache,  vertigo,  somnolency,  indistinct- 
ness of  vision  and  hearing,  general  weak- 
ness with  fainting,  difficulty  of  breathing, 
a  sense  of  cold,  vomiting  and  lastly  tremor 


and  spasms  in  the  extremities.  All  these 
symptoois  are  direct  nervous  symi)tom8, 
and  ai'c  not  due  to  any  change  in  the 
blood.  in  very  minute  doses  nicotine 
stimulates  the  brain  and  nerves  (tlius 
favourably  influencing  mental  work,  and 
promoting  peristaltic  action  of  the  intes- 
tines). It  is  striking  how  soon  the  sys- 
tem becomes  accustomed  to  this  dangerous 
poison. 

Physiolog^ical  /Action  of  Pyridine. — 
Excitement  of  the  medulla  oljlougata  with 
violent  spasms  of  the  whole  body,  and 
excitement  of  the  spinal  cord  and  of  the 
intra-muscular  nerve  terminations  with 
ra])id  paralysis. 

There  are  two  ways  in  which  these 
poisonous  substances  may  be  brought  into 
the  human  body  :  (i)  by  inhaling  the  dust 
of  tobacco  in  cigar  and  tobacco  manufac- 
tories ;  (2)  by  smoking  or  by  taking  snuff. 
The  nicotine  being  soluble  in  water  is  ab- 
sorbed from  the  aqueous  smoke  of  the 
tobacco  and  is  mixed  with  the  saliva  and 
the  inhaled  air  of  the  smoker. 

Of  disorders  among^  the  labourers  in 
tobacco  manufactories  we  know  con- 
gestion of  the  brain,  several  forms  of 
neurosis,  praDcordial  oppi-ession,  palpita- 
tion, ancemia.  general  weakness  and  in- 
somnia ;  we  also  sometimes  find  very  severe 
cases  of  anasmia  with  weakness  of  the 
muscles  of  the  lower  extremities,  and  with 
dragging  gait.  Another  symj^tom  is  s^jasm 
of  the  muscles  of  the  forearm,  the  cause 
of  which  is  undoubtedly  intoxication,  be- 
cause other  labourers  who  exert  their 
hands  and  arms  much  more  than 
labourers  in  the  tobacco  factories,  never 
sufi"er  from  these  spasms. 

As  diseases  of  smokers  must  be  con- 
sidered:—  (i)  chronic  hypertemia  (ca- 
tarrh) of  the  pharynx  and  stomach,  with 
all  its  consequences  ;  (2)  diseases  of  the 
brain,  spinal  cord  and  nerves;  (3)  disease 
of  the  sensory  nerves.  We  have  to  deal 
with  the  latter  two  conditions  only.  It  is 
an  undoubted  fact  that  the  abuse  of  tobacco 
may  produce  elementary  and  complicated 
mental  disoi-ders  with  anxiety,  illusions  or 
hallucinations  of  vision,  and  depression. 
Some  authors  (Jolly,  Simon,Kraff't-Ebing) 
attribute  to  the  tobacco  a  rule  in  the  astio- 
logy  of  general  paralysis.  Other  symp- 
toms of  the  brain  affection  are :  insomnia, 
vertigo,  loss  of  memory  and  severe  head- 
ache. If  the  spinal  cord  is  affected  we  find 
a  compound  of  symptoms  which  are  so 
similar  to  locomotor  ataxy  that  they  may 
easily  be  confounded  :  lancinating  pains 
in  the  legs,  parajsthesia,  ataxic  gait, 
Komberg's  symptom,  tlisorder  of  the  in- 
testines and  bladder,  and  loss  of  sexual 
appetite.     It  is  of  importance  for  the  dif- 


Tobacco 


[     1298    ] 


Tort  in  Lunacy 


ferential  diagnosis,  thatthe  knee-jerk  is  not 
absent.  Among  the  symptoms  of  disorder 
of  the  nervous  system  we  find  neuralgia 
and  spasms  in  various  nerve  tracts  ;  also 
disorders  of  sensibility  in  the  form  of  hyp- 
a3sthesia,  byperEesthesia,  and  parassthesia 
of  the  skin,  and  muscular  tremor.  Allo- 
rythmia  of  the  heart  and  cardio-steuosis 
(angina  pectoris)  must  also  be  reckoned 
among  these  symptoms,  because  nicotine 
influences  the  automatic  ganglia  of  the 
heart.  Of  great  imjiortance  are  the  disor- 
ders of  the  sensory  nerves,  among  which  we 
find  temporary  hyperasthesia  of  the  acous- 
tic and  optic'nerve ;  a  characteristic  symp- 
tom is  also  amblyopia,  which  is  always  bi- 
lateral. The  papilla3  appear  at  first  nor- 
mal but  afterwards  slightly  discoloured  in 
the  macular  half.  The  cause  of  the  visual 
derangement  is  a  well-defined  paracentral 
scotoma,  which  includes  the  fovea  cen- 
tralis, and  extends  from  here  in  an  oval 
form  as  far  as  or  even  beyond  the  yellow 
spot.  Inside  this  scotoma,  white  appears 
as  grey,  red  as  dark,  and  green  as  grey  ; 
the  acuteness  of  vision  decreases  to  one- 
third,  one-sixth  or  even  one-thirtieth  of 
that  of  normal  vision.  The  periphery  of 
the  visual  field  is  normal.  This  ambly- 
opia never  passes  over  into  amaurosis. 
Closely  related  to  this  amblyopia  pro- 
duced by  tobacco  is  alcoholic  amblyopia. 
The  abuse  of  tobacco  mostly  going  hand 
in  hand  with  that  of  alcohol,  it  is  often 
difficult  to  decide  which  of  the  two  is  the 
actual  cause.  Amblyopia  caused  by  to- 
bacco was  first  observed  in  1835  by  Mac- 
kenzie, and  accurately  described  in  1S64 
by  Hutchinson. 

All  the  morbid  phenomena  caused  by 
the  abuse  of  tobacco  appear  the  earlier  if 
the  proportion  of  nicotine  in  tobacco  is 
greater.  The  prognosis  is  favourable,  if 
we  succeed  in  loreventing  the  further  in- 
gestion of  the  poison,  that  is  to  say,  if  the 
patient  abstains  from  smoking.  This 
statement  includes  the  most  important 
point  of  the  treatment,  which  in  addition 
should  be  tonic  (quinine,  iron,  strychnine, 
hydro-therapeutics.)  Relapses  very  easil}' 
occur  after  renewed  smoking. 

The  Europeans  learned  the  use  of 
tobacco  from  the  American  Indians  ; 
Columbus  and  his  successors  found  them 
smoking.  Tobacco  is  said  to  be  an  Indian 
word,  whilst  the  word  nicotine  is  derived 
from  Jean  Nicot,  who  was  in  1 560  French 
ambassador  at  Lisbon,  and  promoted  the 
importation  of  tobacco.  About  the  middle 
of  the  seventeenth  century  the  use  of  to- 
bacco had  become  general ;  many  people 
began  to  protest  against  it,  and  most  Sove- 
reigns attempted  to  prohibit  it.  James  I. 
himself  wrote  a  work  against  it:  "  Miso- 


capnus  (KaTTvos,  smoke),  seu  de  abusu 
Tabaci  lusus  regius,"  which  appeared  in 
1603  in  London.  A.  Erlen'.meyer. 

TOBSTJCHT  (Ger.).     Mania. 

TODTEN'SCHI.VIVIIVXER,  (Ger.). 
Trance  or  catalepsy. 

TOIiIi  (Ger.).  Mad,  furious,  distracted, 
raging  or  delirious. 

TOIiIiHEZT,  TOIiIiKRAIfKHEZT, 
TOIiIiSIN'N'IGKEZT,  TOIiIiSUCHT 

(Ger.).  Various  terms  denoting  maniacal 
fury,  madness,  insanity. 

TOIiliTVVTH  (Ger.).  A  term  applied 
to  acute  mauia,  also  hydrophobia. 

TOIVI  CBEDIiAMS. — A  race  of  men- 
dicants who  levied  charity  on  the  plea  of 
insanity.  The  Bethlem  Hospital  was 
made  to  accommodate  six  lunatics,  but  in 
the  year  1644  the  number  admitted  was 
forty-four,  and  applications  were  so  nu- 
merous that  many  inmates  were  dismissed 
half  cured.  These  used  to  wander  about 
as  vagrants,  chanting  mad  songs,  and 
dressed  in  fantastic  clothing  to  excite 
pity.  Under  cover  of  these  harmless 
"  innocents "  a  set  of  sturdy  rogues  ap- 
peared called  Abram  men  who  shammed 
lunacy,  and  committed  great  depredations. 
(See  Abram  man.) 

•'  With  a  siiih  like  ;i  Tom  o'  Bedlam." 

King  Lear. 

TON-QPSYCHACOGXA  {rovos,  vigour, 
strength  :  ■v/'vxV'  ^^^^  mind ;  ayco,  I  do  or 
act).  Term  denoting  the  act  of  inducing 
l^roper  tone  to  the  mind.  (Fr.  and  Ger. 
Tonopsychd  (jngie.) 

TORPSBO  [tnrpeo,  I  am  numbed), 
i^arcosis  or  numbness. 

TORFEFi^CTIO  UITZVERSAIiZS. — 
Torpidity  of  the  whole  body. 

TORPID  (torpeo,  I  am  numbed).  In- 
capable of  e-^iertion.     Benumbed. 

TORPIDITAS  {torpeo,  1  am  numbed). 
Incapability  of  exertion.     Numbness. 

TORPOR  {torpeo,  I  am  numbed).  De- 
ficient sensation,  numbness,  torpidity. 
(Fr.  impeur.) 

TORPOR,  MEWTAli. — A  term  applied 
to  the  slowness  of  feeling  or  action,  the 
mental  numbness  and  lack  of  response 
characteristic  of  pronounced  melancholia, 
especially  its  stuporous  form. 

TORT  ITT  liUTTACY. — A  tort  may  be 
defined,  with  sufficient  accuracy  for  the 
present  purjjose,  as  a  wrong  independent 
of  contract. 

The  authorities  bearing  upon  the  lia- 
bility of  a  lunatic  in  tort  are  both  ancient 
and  meagre,  but  the  following  points  have 
been  settled  : 

(i)  If  a  lunatic  commit  an  assault  he  is 
liable  in  trespass.  In  the  case  of  Weaver 
V.  Ward  (Hob.  134,  Pasch.  14  Jac.)  it 
was  said  that  "  if  a  lunatic  hurt  a   man 


Touch,  Hallucination  of      [     1299    ] 


Toxiphobia 


he  shall  be  liable  to  trespass,  though  if 
he  kill  a  man  it  is  not  felony." 

The  meanint^  of  this  statement  a2)i>ear3 
to  be  that  a  degree  of  unsoundness  of 
mind  which  wonld  offer  a  complete  defence 
to  a  charge  of  murder  is  no  answer  to  a 
civil  action  for  assault.  The  reason 
assigned  for  the  rule  is,  that  "  wherever 
one  person  receives  an  injury  from  the 
voluntary  act  of  another,  this  is  a  trespass, 
although  there  were  no  design  to  injure  " 
(Bac.  Abr.  Trespass,  G.  I.).  It  would  be 
out  of  place  to  comment  here  npon  the 
absurdity  of  applying  the  word  "volun- 
tary "  to  the  act  of  a  lunatic.  Probably 
the  true  explanation  is  that  the  lunatic 
was  capable  of  paying  damages,  which  it 
was  the  object  of  the  action  to  obtain 
(cf.  Hobart,'Rep.  181). 

(2)  In  Gross  V.  Andrevs  (Cro.  Eliz.  622) 
it  was  decided  that  "  if  an  innkeeper  be  so 
distempered  that  he  \snon  sanx  memorix, 
and.  a  gnest,  knowing  thereof,  inns  there, 
when  his  goods  are  stole,  an  action  upon 
the  case  lies  against  the  inkeeper ;  for  if 
the  defendant  will  keep  an  inn  he  ought 
at  his  peril  to  keep  safely  his  guests'  goods, 
and  if  he  be  sick  his  servants  ought 
carefully  to  look  to  them."  {Of •Mason 
V.  Keeling,  arg.  12  Mod.  332,  Mich.  11 
"Will.  3  ;  Bidler  v.  Bidler,  Abr.  Eq.  Cas. 
279,  Mich.  1729;  Haycraft  v.  Greasy,  2 
East  104.) 

(3)  In  Mordaunt  v.  Mordaunt  (39  L.  J. 
P.  &  M.  57),  it  was  said  in  argument  that 
a  lunatic  is  liable  to  an  action  for  false 
representation,  and  Kelly,  C.B.,  added, 
"  and  also  for  a  libel,"  but  without  citing 
any  authority  for  the  assertion. 

It  appears,  therefore,  to  be  the  law  that 
a  lunatic  is  liable  for  torts  ;  but  there  can 
be  little  doubt  that  in  England,  as  in 
America  {cf.  Dickenson  v.  Barber,  9  Mass. 
225),  the  mental  state  of  a  defendant 
would  very  properly  be  considered  by  the 
jury  in  awarding  damages. 

A.  Wood  Renton. 

TOUCH,       Hi\.IiI.UCIM'ATIOM'       OF. 

(.S'ee  Hallucixatiox.) 

TOUCH,  iliiiUSiON  or.  (See  Illu- 
sion.) 

TOUCH,   INSATTITY    OP.      {See  De- 

LiRE  Du  TouciiEii;  Doubt,  Insanity  of.) 
TOXIC  IDIOCY.    {See  IniocY,  Toxic.) 

TOXIC   IWSANITY.      {See   INSANITY, 

(Toxtc;  and  Pathology.) 

TOXIPHOBIA.  —  Many  people  are 
under  the  impression  that  some  person 
or  persons  desire  to  poison  them.  Such 
a  suspicion  may  occasionally  have  some 
justification,  but  in  the  vast  majority  of 
cases  it  is  groundless.  In  a  paper  pub- 
lished in  the  Dublin  Journal  of  Medical 
Science,     for   February    1876,    we    have 


stated  that  we  are  constantly  consulted  by 
persons  who  aver  that  they  are  being 
poisoned,  or  that  attempts  to  poison  them 
are  being  made.  So  common  is  this 
apprehension  of  poison  that  we  regard 
it  as  a  well-defined  form  of  monomania, 
and  propose  to  term  it  Toxiphobia.  In 
our  paper  we  give  an  account  of  sixty- 
three  cases  of  toxiphobia,  of  which  we 
have  taken  notes.  The  persons  who 
consulted  us  belonged  to  all  classes  of 
society,  not  excejiting  the  very  lowest, 
and  they  did  not  embrace,  with  two  excep- 
tions, recognised  lunatics.  Some  of  them 
were  persons  discharging  important  official 
and  professional  functions.  The  sixty- 
three  cases  did  not  include  any  in  which 
there  was  a  reasonable  suspicion  of  poison. 
The  following  is  a  rough  classification  of 
the  sixty-one  cases  :  Eight  men  imagined 
that  women  were  administering  love 
potions  or  philters  to  them,  but  no  woman 
made  a  similar  complaint.  Twelve  men 
felt  certain  that  their  wives  were  trying 
to  get  rid  of  them  by  means  of  poison, 
whilst  nine  women  were  equally  satisfied 
that  their  husbands  were  animated  by  a 
similar  desire.  Three  female  and  two  male 
domestics  alleged  that  fellow-servants 
were  attempting  their  lives  by  poison. 
One  man  and  four  women  believed  that 
their  families  were  endeavouring  to  poison 
them.  Two  persons  stated  that  certain  of 
their  relatives  had  been  made  away  with 
by  means  of  slow  poison  in  order  that  their 
projDerty  might  pass  into  the  hands  of  the 
poisoners.  In  eight  cases  jjersons  alleged 
that  the  people  with  whom  they  lodged 
invariably  tried  to  poison  them  in  order 
to  get  hold  of  their  effects.  A  Petty 
Sessions  clerk  thought  that  the  disap- 
pointed candidates  for  the  office  to  which 
he  had  recently  been  appointed  were, 
through  a  revengeful  feeling,  trying  to 
murder  him.  A  gentlemati  believed  that 
an  unsuccessful  rival  in  a  love-affair  had 
bribed  the  servants  of  the  former  to 
poison  him.  The  wife  of  a  labourer  in 
gas  works  insisted  that  a  female  of  her 
husband's  acquaintance  sought  to  poison 
her  so  that  she  might  marry  her  husband. 
A  person  who  supposed  himself  an 
important  witness  for  the  plaintiff  in  a 
long-pending  Chancery  suit,  lived  in  con- 
tinual apprehension  of  being  murdered 
by  emissaries  of  the  defendant.  He  was 
constantly  changing  his  lodgings,  cooked 
his  own  food,  would  not  use  milk  or  other 
articles  into  which  poison  could  be  readily 
introduced,  but  nevertheless  seems  to 
have  plied  his  business  (that  of  an 
attorney's  clerk)  intelligently  and  credit- 
ably. The  wife  of  a  barrister  believed 
that  her  husband  was  anxious  to  get  rid 

40 


Trachelismus 


[ 


] 


Trance 


of  her  in  order  that  he  might  marry  a 
yoanger  woman.  She  asserted  that  he 
was  in  the  habit  of  pressing  her  to  drink 
wine,  which  to  her  seemed  always  to 
possess  a  peculiar  flavour ;  the  wine,  how- 
ever, when  exa.mined,  was  found  devoid  of 
l^eculiar  flavour,  or  of  toxic  qualities.  This 
lady  entertained  her  suspicions  for  many 
years,  but  kept  them  to  herself,  until  she 
divulged  them  to  her  analyst.  It  would 
appear  that  her  mental  aberration  was 
not  suspected  by  her  friends  or  relatives. 
Another  woman  who  suspected  that  her 
husband  was  poisoning  her  slowly,  suc- 
ceeded, by  false  representations,  one  of 
which  was  that  poison  had  been  detected 
in  her  food,  in  persuading  her  relatives  to 
share  her  opinion.  In  this  case,  the  hus- 
band and  wife  were  separated.  Subsequent 
events  proved  his  innocence  ;  but  though 
the  toxiphobiac's  relatives  recanted  their 
opinion  of  her  husband's  conduct,  she  did 
not,  and  refused  to  return  to  him.  This 
lady  was  clever,  agreeable,  and  on  every 
point,  save  one,  apparently  perfectly  sane. 
The  Petty  Sessions  clerk  above  referred 
to  had  some  whimsical  notions  relative 
to  what  he  termed  the  attempts  to  get  the 
'poison  into  him.  He  produced  a  night- 
cap and  shirt,  which  he  said  were  charged 
with  some  subtle  poison,  for  when  he  used 
them  they  made  his  "skin  creep,"  and 
jjroduced  a  pain  like  the  sting  of  a  nettle. 
He  believed  that  his  persecutors  came  at 
night  and  blew  into  his  room  through  the 
window  (if  open),  through  the  keyhole, and 
even  down  the  chimney,  a  white  powder, 
which,  when  inhaled,  caused  irritation  of 
the  lungs,  followed  by  "  weakness."  This 
man  did  his  duty  properly,  and  no  doubt 
no  one  sus^Dected  that  he  was  a  mono- 
maniac. Some  toxiphobiacs  constantly 
bring  articles  for  analysis,  and  seem  satis- 
tied  when  informed  that  they  are  free 
from  poison.  On  the  other  hand,  they 
are  sometimes  incredulous  when  informed 
of  the  negative  result  of  the  analysis.  A 
young  gentleman  formed  the  idea  that  a 
young  woman,  who  had  matrimonial 
designs  upon  him,  was  in  the  habit  of 
drugging  his  food.  He  always  expressed 
doubt  when  informed  that  nothing  could 
be  detected  in  the  articles  which  he  sus- 
pected. On  one  occasion,  however,  some 
fine  shreds  of  tobacco  were  found  in 
some  tea  which  he  produced  for  analysis, 
but  when  taxed  with  having  put  the 
tobacco  in  himself,  he  confessed  that  he 
had  done  so  with  the  view  of  testing 
whether  analysis  was  capable  of  discovering 
minute  traces  of  foreign  articles  in  food. 
Charles  Cameron. 
TR.aCKX:iiISIVXUS,  or  TRACHEX.!- 
ASlvxirs     {Tpuxr}\iC(i>,    I    bend    back  the 


neck).  A  bending  back  of  the  neck. 
This  name  was  proposed  by  M.  Hall  to 
designate  the  first  symptoms  of  epilepsy, 
believed  to  be  contraction  of  the  muscles 
of  the  neck  with  consequent  distension 
of  the  veins,  causing  cerebral  congestion. 
(Fr.  tracheliame.) 

TRACTIOTT.     {See  Perkinism.) 

TRACTORiVTlON*.  —  Same  as  Per- 
kinism. 

TRACTORS. — The  metallic  rods  used 
in  Perkinism. 

TRABE  -  IMARKS,  insane  persons 
may  apply  for  (Patents  Act,  1883,  s. 
99,  quoted  supra  under  Pate.vtees,  In- 
sane). 

TRANCE. — Under  Lethargy  (q.v.)  and 
Ecstasy(5'.r.)we  have  described  and  defined 
the  condition  which  is  present  in  trance. 
The  French  words  letliargie  and  extase  are 
terms  synonymous  with  trance.  Accord- 
ing to  Parrot,  letliargie  occupies  a  posi- 
tion between  coma-vigil  and  earns,  but  it 
is  very  certain  that  the  distinction  between 
all  these  terms  is  far  from  definite.  It 
has  been  pointed  out  in  the  article  on 
Ecstasy  that  Prichard  employed  the  term 
in  precisel)--  the  same  sense  as  that  of 
trance.  At  the  same  time  thex'e  may  be 
a  condition  of  prolonged  semi-unconscious- 
ness, partaking  of  the  character  of  pro- 
found sleep  which  characterises  trance, 
without  there  being  that  mental  attitude 
and  significant  facial  expression  which  we 
associate  with  genuine  ecstasy.  "When 
this  mental  state  is  present  the  comjjound 
term  "  ecstatic  trance "  is  expressive. 
Two  cases  of  a  striking  character  are  re- 
corded in  this  work  (p.  525). 

AlcoJwJic  trance  has  been  described  by 
Dr.  T.  D.  Crothers  in  its  relation  to 
criminal  cases,  of  which  he  has  recorded 
several  well-marked  examples.  His  con- 
clusions may  be  briefly  summarised.  In 
inebriety,  a  state  of  trance  may  arise,  in 
which  the  condition  of  the  brain  involves 
the  suspension  of  all  memory  and  con- 
sciousness of  acts  and  words,  the  indi- 
vidual going  automatically  about,  with 
little  or  no  indication  of  his  actual  state. 
The  higher  brain  centres  are  in  abeyance 
as  in  spontaneous  or  artificial  somnam- 
bulism. This  condition  may  last  for 
several  days  or  only  for  a  few  moments. 
Crime  may  be  committed  without  motive 
or  apparent  plan,  but  when  carefully 
studied  the  details  and  methods  of  execu- 
tion will  be  imperfect.  After  this  condi- 
tion has  passed  away  there  is  no  remem- 
brance of  what  has  occurred.  This  con- 
dition cannot  be  successfully  simulated. 
A  person  labouring  under  alcoholic  trance 
is  for  the  time  being  a  dangerous  and 
irresponsible  madman,  who  should  not  be 


Trance 


[     1301     ] 


Trance 


puuished   as   a   criminal,    but   should  be 
confined  in  an  asylum.* 

A  striking  case  of  trance  or  letliargy 
has  been  recorded  bv  Dr.  Clark,  Medical 
Superintendent  of  the  Kingston  Lunatic 
Asylum,  Ontario. 

\Ve  give  a  condensed  rejiort  of  the  case. 
Having   heard  of  a  female  patient   who 
had  been  in  a  trance  for  years,  all  efforts 
to   arouse  her  being  without  results,  he 
visited  her  and   found  a  thin  old  woman 
in   bed,  about  sixty-nine,  apparently  fast 
asleep.     Respirations  were  irregular,  and 
varied  from  24  to  44  per  minute.     The 
pulse  quickened  and   rose  from  about  80 
to  120.     The  eyes   were  half  closed,  and 
the  woman  appeared  to  be  oblivious   to 
everything  that  was  going  on.     Both  her 
father  and  mother  had  suffered  from  in- 
sanity.    The  patient  married  when  very 
young,  although  she  had  the  character  of 
being   peculiar ;    she  had   a   family,    and 
three  years  after  the  birth  of  her  last  child 
her  disposition   changed,  and  she  became 
untruthful,  whimsical,  and  easily  worried. 
There  is  a  history  of  fits,  probably  hys- 
tero-epileptic  in  character.     In  1862  the 
woman  fell  into  a  state  of  trance  which 
lasted  for  seven  years  or  more.     The  con- 
dition was  one  of  almost  continual  sleep, 
the  patient  occasionally  waking  up  for  a 
few    minutes    and   conversing   rationally. 
She  was  informed  of  the  death  of  a  par- 
ticular   friend,    and    the    announcement 
aroused   her,    but   her  return  to  normal 
health    was   very  gradual.     For   another 
period  of  seven  years  of  wakefulness,  she 
interested  herself  in  her  daily  affairs.     She 
seemed   astonished   to    find    people    and 
places  changed.      About    thirteen   years 
before  Dr.    Clarke's  visit   she   gradually 
passed  into  the  trance  state  in  which  he 
saw   her.      When  examined   in   1S90  by 
Professor  T.  Mills  and  Dr.  Clarke,  there 
was  marked  rigidity  of  the  right  knee  and 
leg — e.g.,  the  patellar  refiexes  were  absent. 
The  left  foot  was  drawn  as  if  the  tendo 
Achilles   was   contracted,  the   right   foot 
being  drawn    down,   but   not  in    such    a 
marked  manner  as  the  left.     Tickling  the 
soles  of  the  feet  did  not  cause  any  i-eaction. 
Orbicular  refiexes  were  brisk,  but  it  was 
noticed  that  files  crawling  over  the  face 
did  not  excite  them  ;    the  pupils  reacted 
to  light.     Bread  was  put  into  her  mouth, 
but  remained    there  without  any   effort 
being  made  to  swallow. 

On  October  9,  1890,  she  was  placed 
under  Dr.  Clarke's  care.  Efforts  were 
made  to   arouse  hei",    but  without   avail. 

«  See  reprint  of  paper  read  by  Dr.  Crothcrs, 
editor  of  tlie  Journal  n/  Iiicbriety,  before  tbc  In- 
ternational Con;;TeHs  of  ]*[edico-LoK-al  Si-ience,  beld 
in  Jiew  York,  June  1889. 


Her  friends  stated  that  she  had  been  in 
this  state  of  trance  for  more  than  eleven 
years.      She  remained  in    this   condition 
until    February     1891,    when    she   died; 
during  these  four  months  she  was  closely 
watched,  and  until  the  last  week  of  her 
life  gave    little    indication    that  she  had 
the  slightest  knowledge  of  the  fact  that 
she  lived.     Her  temperature  was  almost 
always   sub-normal,  sometimes   falling  to 
95  degrees.     She   was  very  clean  in"her 
personal   habits.      The    amount   of  urine 
passed   was   very    small,  and  the  bowels 
were  seldom  moved.     It  was  possible  to 
arouse   her  for    a  few    moments,    to   the 
extent    of   making  her    open   her    eyes, 
but  she  gave  no  indication  of  conscious- 
ness.    The  facial  expression  was  almost 
death-like.     Early   in    February    1891,  a 
marked  change  took  place,  diarrhcea  de- 
veloped and  the  woman  evidently  suffered 
pain.     On  the  4th,  she   was  undoubtedly 
awake,  and  in   the    evening    spoke    in  a 
hoarse   whisper  asking  for  a  sour  drink. 
This  was  the  second  time  of  sjjeaking  in 
the   course    of  thirteen    years.      On  the 
following  day  she  fell  asleep  again.     In 
the  afternoon  she  again  awoke,  and  fed 
herself,  and  in  the  evening  spoke  natur- 
ally.    On  the  7th  Dr.  Clarke  found  her 
lying  on  the  fioor ;  she  could  not  speak. 
On    the    1 6th  of  February    she    steadily 
grew  worse,  and  died  on  the  26th.     On 
examining      her    brain    after    death     it 
weighed  35  ozs.,  and  presented  a  perfectly 
healthy  appearance ;    there  were   no  ad- 
hesions with   one    slight    exception  ;    the 
ventricles    were  free   from   disease.      JSo 
microscopical     examination     was    made. 
There     were    ante-mortem   clots    in    the 
longitudinal  and  lateral  sinuses,  the  clots 
in  the  lateral  sinuses  being  particularly 
well  organised.     Heart  weighed   3f   oz.  ; 
walls  of  right   auricle  and  ventricle  un- 
usually thin ;     valves    normial ;    walls    of 
left  ventricle  hypertrophied.     Ascending 
aorta  dilated  into   a  fusiform  aneurism, 
capacity  about  twice  that  of  normal.     No 
atheroma  and  no  pressure  effects  noticed, 
abdominal     aorta     atheromatous ;     ante- 
mortem    clots    in    abundance.      Apex    of 
right   lung  a  mass  of  tubercle  ;  in  fact, 
tubercles  were  found  scattered  throughout 
the  whole  lungs,  and  in  the  apex  a  small 
cavity    existed ;      hypostatic     congestion 
marked.     In  the  left  lung  a  few  tubercles 
were  found,  and  there  was  some  hypostatic 
congestion  ;   nutmeg  liver.     The  stomach 
was  large,  and  about  two  inches  from  the 
pyloric  orifice  was  a  constricted  portion, 
which  was  undoubtedly  not  the  result  of 
infiammatory    action,    but     the    natural 
shape  of  the  viscus,  suggestive  of  a  rudi- 
mentary second  stomach.     The  intestines 


Transference 


C    1302   ] 


Transitory  Mania 


were  small,  adhesions  everywhere,  and 
there  were  several  constricted  portions, 
without  there  being  complete  stricture, 
and  above  the  constrictions  there  was 
miich  distension.  The  kidneys  were  small. 
The  value  of  this  case  of  trance,  which 
certainly  did  not  present  any  indication 
of  ecstasy,  is  greatly  enhanced  by  the 
report  of  the  autopsy.  {See  Sleep,  p. 
1 173.)  The  Editok. 

[A  highly  instructive  case  of  "  Sus- 
pended Animation "  or  Trance  was  re- 
ported by  the  late  Mr.  Dunn  (London) 
and  was  eximined  by  Dr.  Todd  at  his  re- 
quest (Xo?icef,  Nov.  15  and  29,  1845).  See 
Prof.  Gairdner's  case.  Lancet,  Dec.  1883]. 
TRANsrEREWCB.— The  act  of  carry- 
ing thoughts  from  one  person  to  another, 
applied  to  so-called  mind-reading  or 
thought-reading.  It  is  also  used  in  hyp- 
notism to  denote  the  passage  of  sugges- 
tions from  the  operator  to  the  subject. 
Charcot  has  employed  the  word  to  indi- 
cate the  change  from  one  part  of  the  body 
to  another  of  certain  jihenomena  of  hys- 
teria, such  as  ana3sthesia,  by  the  action  of 
certain  agents,  such  as  blisters,  faradism, 
or  magnets  and  metals.  The  transfer  is 
seldom  lasting,  and  the  so-called  agents 
undoubtedly  act  suggestively  to  the  pa- 
tient. Sensitiveness  to  certain  metals  by 
certain  individuals  has  been  described  by 
Burg,  Dumontjiallier,  and  others,  but 
these  evidently  act  in  the  same  manner. 

TRAirsiTORY  ursAiriTV.  —  At- 
tacks of  insanity  are  frequently  of  short 
duration  and  in  a  general  sense  may  be 
called  transitory,  that  is,  passing  away 
(transHus)  quickly,  but  the  term  is  used 
in  a  more  definite  and  technical  sense,  and 
especially  is  this  the  case  with  transitory 
mania  (g.v.).  Attacks  of  mental  dej^res- 
sion  sometimes  come  and  go  in  the  same 
day,  and  are  frequently  associated  with 
intestinal  derangement. 

TRiLNSITORV  V/tANIA  (Mania 
Transitoria),  OR  FREN'ZV  {Transi- 
torische  Tohsuclit).  —  We  understand  by 
transitory  mania  that  kind  of  acute 
frenzy  (Tobsuchi)  which,  developing  sud- 
denly and  rapidly,  soon  reaches  its  climax 
under  symptoms  of  severe  active  cerebral 
hyperaemia,  of  ungovernable  spontaneous 
motor  impulses,  and  of  violent  anger  with 
complete  absence  of  consciousness.  The 
paroxysm  does  not  change  in  intensity, 
and,  after  a  comparatively  short  time, 
mostly  not  more  than  twelve  hours,  the 
attack  subsides,  after  a  profound  sleep  of 
several  hours,  without  leaving  any  recol- 
lection of  the  events  during  the  paroxysm 
and  without  leaving  behind  any  patho- 
logical change  of  the  brain  or  mental 
defect.     The  attack  does  not  seem  to  be 


at  all  connected  with  previous  mental 
derangement  or  with  any  discoverable 
heredity ;  lasting,  more  or  less  violently, 
a  shorter  or  longer  time,  it  usually  dis- 
appears without  medical  aid  and  termi- 
nates in  complete  recovery.  It  does  not 
leave  behind  any  somatic  or  psychical 
changes,  nor  does  it  injure  mental  integ- 
rity, and,  as  a  rule,  it  never  returns.  This 
form  of  mental  alienation,  equally  impor- 
tant from  a  forensic  and  clinical  point  of 
view,  is  not  a  sudden  attack  of  ordinary 
mania  with  a  rajiid  course,  but  it  is  a 
special  form  of  mental  disorder  with  an 
aetiology,  pathogenesis,  and  course  of  its 
own.  It  is  closely  related  to  ordinary 
mania,  but  its  character  and  symptoms 
distinguish  it  typically  from  all  other 
maniacal  forms,  so  that  it  has  a  just  claim 
to  a  place  in  the  science  of  mental  dis- 
orders as  a  psychosis  sui  generis. 

In  most  cases  it  was  formerly  considered 
to  be  an  acute  maniacal  phenomenon,  as 
is  sufficiently  indicated  by  the  terms  which 
are  still  in  use:  mania  transitoria  (acuta, 
acutissima) ;  mania  bi-evis,  ephemera, 
furiosa  ;  mania  subita  acutissima,  mania 
ferox,  furor  maniacus,  rajitus  maniacus, 
&c. 

Transitory  frenzy  (Tohsucht)  has  no- 
thing in  common  with  mania  (manie),  but 
it  bears  unmistakably  the  fundamental 
character  of  frenzy.  We  ourselves  lay 
special  stress  on  calling  it  transitory 
frenzy,  from  purely  scientific  reasons,  as 
well  as  because  all  the  most  important 
arguments  against  the  existence  of  the 
disorder  in  question  have  been  taken  from 
the  incorrect  term,  transitory  "  mania." 

The  symptoms  of  transitory  mania 
originate  from  a  certain  somatic  basis;  as 
in  all  other  psychoses,  it  would  be  impos- 
sible to  explain  them  from  a  purely  psy- 
chological point  of  view.  It  is  certain 
that  we  know  the  clinical  picture  only, 
not  the  deeper  anatomico-pathological 
reasons  and  the  minute  morbid  changes 
which  temporarily  take  jjlace  in  the  brain  ; 
but  from  the  fact  tliat  the  disorder  is 
always  accomi)anied  by  an  unmistakable 
cerebral  hyj^erajmia  we  may  safely  con- 
clude that  the  morbid  mental  and  somatic 
phenomena  are  caused  by  an  irritation  of 
the  central  nervous  system.  We  know 
that  the  brain  does  not  alone  influence  and 
originate  mental  acts,  and  that  there  are 
mental  disorders  which  do  not  directly  ori- 
ginate in  the  central  nervous  system,  but 
that  many  somatic  factors,  especially 
disorders  of  circulation,  may  by  their  in- 
fluence on  the  cerebrum  produce  deutero- 
pathic  mental  derangement.  In  such 
cases  the  psychosis  has  not,  as  we  have 
pointed  out,  a  direct  origin  in  the  central 


Transitory  Mania 


[    1303    ] 


Transitory  Mania 


nervous  organ,  but  hl  extra-cerebral  factor 
(the  circulation)  determines  in  a  predis- 
posed brain  to  an  outbreak  of  some  mental 
disorder.  In  transitory  mania  the  blood 
flowing  into,  but  not  being  able  to  How  out 
of,  the  cranial  cavity,  causes,  in  conse- 
quence of  the  vascular  dilatation,  a  condi- 
tion of  extreme  cerebral  irritation,  which, 
extending  over  all  the  sensory  and  motor 
tracts,  produces  mental  excitement,  a 
temporary  aberration  and  a  wild  motor 
discharge,  which  disappear  as  soon  as 
normal  circulation  is  restored.  Compared 
with  other  jisychoses,  in  which  we  are 
unable  to  guess  during  life  or  even  to  find 
after  death  the  slightest  material  change, 
transitory  mania  gives  us  at  least  a  clue 
to  its  somatic  origin,  and  shows  us  pretty 
clearly  the  cause  of  the  pathological 
changes  which  temporarily  take  place  iu 
the  brain.  The  theory  is  accepted  by 
Emminghaus  that  the  symptoms  of  mania 
as  a  whole  have  their  origin  in  conges- 
tion. A  most  ardent  representative 
of  this  vaso-motor  theory  is  Professor 
Meynert,  and  the  circumstance  that 
attacks  of  frenzy  may  appear  in  condi- 
tions of  anaemia  (in  consequence  of  hyper- 
a;mia  in  some  parts  of  the  brain)  does  not 
constitute  an  objection  to  the  theory.  We 
certainly  believe  that,  as  a  rule,  the  tyj^ical 
'mania  transitoria  is  produced  by  liyijer- 
iemia  of  the  cortex  of  the  anterior  lobes  of 
the  hrain.  This  view  is  supported,  not 
only  by  the  well-known  results  of  post- 
mortem examination  in  pure  frenzy,  as 
well  as  in  dementia  2JaraI ytica  with,  symp- 
toms of  frenzy  (Simon),  but  also  by  the 
fact  that  even  the  most  scrupulous  physi- 
cal examination  of  individuals  labouring 
under  typical  transitory  mania  yields  a 
perfectly  negative  result. 

This  fact,  however,  does  not  at  all  ex- 
clude the  view  that  hypera^mia  in  conse- 
quence of  somatic  changes  may  cause 
transitory  mania. 

Transitory  mania  is  produced  by  the 
co-operation  of  predisposing  and  occasional 
causes.  The  latter  sometimes,  the  former 
rarely,  may  be  proved  to  be  present ;  not 
unfrequently,  however,  it  is  impossible  to 
state  at  all  the  actual  causes,  and  to  find 
out  among  the  various  influences  which 
reciprocally  act  upon  each  other  which 
was  first  and  which  was  last. 

The  reason  that  the  aetiology  and  patho- 
genesis of  transitory  mania  are  much  less 
known  than  we  should  desire,  lies,  not  so 
much  in  the  difficulty  of  the  subject,  as  in 
the  circumstance  that  the  disorder  in 
question  is  comparatively  much  more 
rarely  the  object  of  medical  treatment 
than  any  other  psychosis.  There  not  being 
any  prodromic  stage  the  alienist  is  not 


j)resent  at  its  outbreak.  Moreover,  the 
disorder  takes  such  a  rapid  course  that 
the  physician,  if  he  is  not  altogether  too 
late  on  account  of  its  short  duration,  is 
only  able  to  observe  the  paroxysm  on  the 
siddiwiti  decremetiti,  and  has  to  confine 
himself  to  the  observation  of  symptoms. 
In  most  cases  the  patient  and  his  antece- 
dents are  completely  unknown  to  him, 
and,  instead  of  any  history,  he  has  no- 
thing but  the  scarce  and  unreliable  data 
of  the  patient  and  his  relatives,  so  that 
he  is  unable  to  write  a  thorough  and 
objective  history  of  the  case  and  to  find 
with  anything  like  scientific  certainty  the 
aetiology  of  the  derangement. 

The  ajtiological  factor,  however,  does 
not;  merely  lie  in  external  influences,  as 
all  occasional  factors  have  been  proved  to 
be  only  of  comprehensive  and  individual 
value  ;  the  external  factor  tiiay,  but  does 
not  necessarily,  lead  to  transitory  mania. 

Any  constitutional  abnormality  which 
influences  the  circulation,  and  thus  creates 
a  tendency  to  active  hyperasmia  and  habi- 
tual congestion  of  the  head,  predisposes 
an  individual  to  transitory  mania.  Inter- 
current secondary  diseases  exercise  a  pre- 
disposing influence  only  when  they  act 
quantitatively  upon  the  circulation  of  the 
blood  and  produce  cerebral  hypera^mia. 

In  addition  to  these,  we  have  to  consider 
as  a  predisposing  factor  anything  which 
tends  to  decrease  the  power  of  cerebral 
resistance  against  hj'peraBmia,  produced 
by  occasional  causes,  and  to  increase 
cerebral  excitability — e.g.,  any  weakness 
or  exhaustion  of  the  nervous  system. 
Such  an  irritable  weakness  may  be  ac- 
quired by  excessive  physical  and  mental 
work,  especially  nightwork,  by  a  fast  life, 
by  long-continued  or  frequently  repeated 
excitement,  as  grief  or  distress,  and  by 
l>assions  of  any  kind  which  impede  nutri- 
tion, consume  vital  energy,  aud  do  not 
allow  the  brain  to  rest  from '  its  condition 
of  irritation  ;  also  by  insomnia,  by  former 
attacks  of  mental  derangement,  by  acute 
diseases  of  the  central  nervous  system 
during  infancy  or  later  (inflammation  or 
concussion  of  the  brain),  Ity  injury  to  the 
head,  by  typhoid  and  intermittent  fever, 
and  by  former  or  existing  nervous  dis- 
eases— in  short,  by  any  condition  entailing 
physical  and  mental  exhaustion. 

Heredity  does  not  seem  to  have  any 
appreciable  influence  on  the  pathogenesis 
of  transitory  mania;  it  is  certainly  not  a 
conditio  sine  qvA  noit.  We  have  not 
been  able  to  prove  it  in  any  cases  which 
have  come  under  our  observation.  Of  much 
greater  importance,  however,  is  the  sex, 
men  being  much  more  predisposed  to  the 
disorder,  while  women  are  so  only  during 


Transitory  Mania 


1304 


Transitory  Mania 


puberty.  The  reason  for  this  does  not 
seem  to  lie  iu  the  difference  between  the 
male  and  female  organism,  but  rather  in 
the  dift'erenee  of  their  relative  social  posi- 
tion, and  in  the  habits  of  life  of  the  female 
sex,  where  all  those  influences  which  sei've 
to  diminish  the  power  of  cerebral  resist- 
ance are  mostly  absent,  as  overwork  and 
all  kinds  of  excess,  which  in  the  male  sex 
so  fi'equently  prepare  the  soil  for  transi- 
tory mania.  This  is  not  extraordinary, 
for  the  female  sex  is,  in  consequence  of  the 
conditions  mentioned,  protected  to  a  con- 
siderable extent  against  some  other  forms 
of  psychosis,  as — e.gr.,  progressive  paralytic 
dementia. 

With  regard  to  special  individual  pre- 
disposition, military  men  seem  to»  be 
specially  liable;  we  must,  howevei',  take 
into  consideration  that  in  no  other  class 
of  people  are  the  circumstances  mentioned 
above  so  frequently  present. 

With  regard  to  age,  we  may  safely  say 
that  transitory  mania  only  occurs  in  j^er- 
sons  between  about  twenty  and  sixty  years. 
In  children  we  know  of  only  one  case ;  in 
old  people  we  have  not  heard  of  any  case 
at  all. 

Climate  and  nationality  do  not  seem  to 
be  in  any  way  connected  with  predisposi- 
tion ;  neither  is  any  special  formation  of 
the  cranium,  nor  any  special  stages  of  life 
or  phases  of  development,  which,  like 
puberty,  menstruation,  pregnancy,  and 
lactation,  so  frequently  predispose  to 
mental  disorder. 

For  the  production  of  transitory  mania 
it  is  necessary  that,  in  addition  to  the 
predisposition  of  the  central  nervous  sys- 
tem, there  should  be  present  an  exciting 
cause,  an  external  influence.  The  less  the 
predisposition,  the  stronger  must  it  be. 
The  disorder  in  question  being  based  on 
active  cerebral  hypersemia,  it  is  evident 
that  any  condition  must  be  considered  an 
occasional  cause  which  influences  the  cir- 
culation and  tends  to  j^roduce  a  deter- 
mination of  blood  to  the  brain,  such  as 
strong  drhiks,  viental  exciteinent,  physical 
and.  mental  overtvorlc,  rapid  change  of 
temperature,  indigestion  and  gastric  dis- 
orders, and  poisoning withcarhonmoiioxide. 
In  addition  to  these,  there  are  also  other 
more  distant  etiological  elements,  like 
sexual  excitement,  bad  ventilation,  stimu- 
lants, &c.,  whilst  climate  and  especially 
the  season  of  the  year  may  be  of  some 
influence.  In  any  case,  transitory  mania, 
like  all  other  psychoses,  does  not  develop 
from  a  single  cause,  but  is  produced  by  a 
complication  of  causes. 

Transitory  mania  or  frenzy  differs  from 
ordinary  frenzy  as  well  as  from  all  other 
mental  disorders,  bv  the  absolute  absence 


of  any  prodromic  symptoms  which  usually 
precede  all  other  psychoses.  Without  any 
special  somatic  disorders  or  mental  abnor- 
malities having  been  j^resent,  there  is 
suddenly  an  outbreak  of  extreme  motor 
excitement,  loss  of  consciousness,  and  a 
paroxysm  of  the  wildest  anger. 

If  there  are  any  prodromic  signs  at  all 
they  are  more  of  a  somatic  than  psychical 
nature — e.g.,  flushing  of  the  face,  intense 
headache  and  sense  of  pressure  and  ham- 
mering in  the  head,  a  sense  of  discomfort, 
palpitation,  asthma,  vertigo,  perspiration 
on  the  forehead,  tinnitus  aurium,  and  chro- 
matopsia. 

The  principal  characteristic  of  transi- 
tory mania  is  the  spontaneous  and  un- 
governable intense  excitement  produced 
by  the  cerebral  irritation  and  the  morbidly 
exaggerated  motor  impulse,  which,  how- 
ever, does  not  consist  as  in  other  and 
milder  forms  of  frenzy,  of  a  more  or  less 
harmless  restlessness,  but  in  a  wild 
paroxysm  with  a  blind  desire  of  destruc- 
tion. The  excitement  extends  with  great 
intensity  over  the  whole  of  the  motor 
sphere,  so  that  not  single  muscles  but  the 
whole  muscular  system  is  under  its  influ- 
ence. All  the  wild  motor  discharges  are 
without  any  purpose  and  object. 

We  have  specially  to  remark  that  the 
cerebral  excitement  discharges  itself  also 
through  the  organ  of  speech,  so  that  every 
idea  is  at  once  expressed  either  by  words, 
or  by  inarticulate  cries,  screams,  and 
shouts. 

In  transitory  mania  there  is  no  connec- 
tion with  the  external  world,  so  that  ex- 
ternal events  are  either  not  at  all  appre- 
ciated, or  they  are  misunderstood  and 
misinterpreted  in  a  subjective  sense.  The 
formation  of  ideas  is  here  exactly  the 
same  as  in  acute  delirium  in  certain  con- 
ditions of  fever  and  intoxication,  when  the 
formation  of  ideas  corresponds  to  the 
motor  impulse,  and  the  brain  produces 
with  an  enormous  rapidity,  but  without 
any  logic  and  without  association,  a  mul- 
titude of  contradictory  ideas,  which  do 
not  become  fixed,  and  disappear  as  rapidly 
as  they  came. 

An  attack  of  transitory  mania  is  always 
accompanied  by  an  outbreak  of  anger  and 
rage,  which,  like  all  aff"ections  oi'iginating 
in  a  pathological  soil,  is  specially  ener- 
getic and  ungovernable,  and  is  nourished 
by  the  false  apperception  of  the  external 
world  and  even  by  the  outrages  committed 
by  the  patient  himself  in  this  condition. 

Some  somatic  symptoms,  accompanying 
the  condition  in  question,  are,  pressure 
and  a  sense  of  heat  in  the  head,  lively  and 
sparkling  eyes,  which  protrude  from  the 
orbits,    redness    of    the    conjunctiva,     a 


Transitory  Mania 


[    1305    ] 


Transitory  Mania 


threateniui]r  or  stariii<^  look,  dihitatiou  or 
irregularity  of  pupils,  roduess  of  the  face 
and  contraction  of  the  facial  muscles, 
grimaces,  foul  tongue,  increased  salivary 
secretion,  exaggerated  and  irregular  re- 
spiration, rapid  heart  beat  and  pulse 
(from  100  to  120),  fulness  of  the  vessels, 
high  temperature,  painful  sensations  in 
the  contracted  muscles,  and,  lastly,  ab- 
sence of  urmary  secretion  and  intestinal 
movements. 

There  may  also  be  various  forms  of 
cephalalgia,  spasm  of  the  pharynx,  burn- 
ing pains  in  the  epigastrium,  asthmatic 
or  gastric  troubles,  nausea  and  muscular 
tremor.  Symptoms  of  paralysis,  how- 
ever, never  occur. 

Transitory  mania  is  the  only  psychosis 
which  finds  its  termination  in  sleep.  As 
rapidly  and  suddenly  as  the  attack  came, 
so  suddenly  it  also  disappears.  The  tre- 
mendous excitement  and  irritation  of  the 
nervous  system  and  the  exaggerated  mus- 
cular effort  are  naturallj'  followed  by  a 
reaction  in  the  form  of  absolute  exhaus- 
tion and  a  desire  for  rest.  All  symptoms 
calm  down,  and  profound  uninterrupted 
sleep  ensues,  during  which  the  pulse  sinks 
to  its  normal  condition. 

We  quite  agree  with  the  words  of 
Emminghaus  that  we  have  here  a  process, 
in  which  the  whole  energy  accumulated  in 
the  cerebral  cortex  is  rapidly  used  up,  and 
the  cells  having  become  exhausted  and 
unexcitable  in  consequence  of  energetic 
discharges,  during  a  profound  sleep  all  the 
energy  consumed  during  the  excitement  is 
renewed. 

The  amnesia  following  the  disorder  is 
specially  intense.  Emminghaiis  explains 
it  thus  :  that  during  the  attack  but  little 
internal  work  is  done  by  the  cortical  cells, 
which  at  once  discharge  themselves,  so 
that  afterwards  peripheral  influences  and 
their  central  effects  are  unable  to  awaken 
any  recollection  of  the  time  of  the  attack, 
the  perceptive  and  apperceptive  function 
of  the  cells  acted  much  too  feebly  at  the 
time.  Eecollection  generally  reaches  as 
far  as  the  moment  of  the  outbreak,  and 
perhaps  includes  darkness  before  the  eyes, 
&c.,  but  then  completely  ceases. 

There  are,  however,  many  varieties  in 
the  characteristic  symptoms  of  transitory 
mania,  such  cases  being  called  imperfect 
cases.  One  of  the  most  frequent  abnor- 
malities is  that  the  disorder  does  not  take 
the  usual  course  of  one  single  attack  of 
uniform  intensity  terminating  in  a  pro- 
found, uninterrupted  sleep,  but  is  resolved 
into  a  series  of  short  attacks  interrupted 
by  intervals  of  exhaustion  and  compara- 
tive rest.  Neither  is  the  termination  of 
the  attack    in    sleep    always    the    same. 


Sleep  is  never  absent,  but  its  duration 
varies  (from  two  to  sixteen  hours),  and  it 
also  may  be  very  slight  and  often  iuter- 
ruj)ted. 

Another  abnormality  of  transitory 
mania  is,  that  its  duration  may  be  very 
much  i)rotracted,  there  being  cases  in 
which  the  attack  lasted  several  days. 

Lastly,  the  paroxysm  may  be  slight, 
amnesia  may  be  incom]:>lete,  and  a  mental 
defect  may  remain  behind. 

It  will  now  be  necessary  to  state  the 
ditt'erence  between  transitory  mania  and 
allied  i)sychoses,  of  which  we  mention  : 

(i)  Ordinary  raving  mania; 

(2)  Periodical  frenzy ; 

(3)  Raptus  melancholicus ; 

(4)  Raptus  epilepticus  ; 

(5)  Conditions  of  transitory  neuralgic 
dysthymia ; 

(6)  Pathological  anger ; 

(7)  Other  transitory  disorders  of  con- 
sciousness in  general,  and,  in  particular, 
during  a  half-awake  condition  {Schlaf- 
trunkenlieit).*' 

As  sub-species  of  transitory  frenzy  we 
mention  : 

(i)  Transitory  mania  j^roduced  by  alco- 
hol (mania,  or  ferocitas  ebriosa ;  mania 
a  potu). 

(2)  Transitory  mania  during  confine- 
ment (mania  a  partu  ;  or,  mania  puerper- 
alis  ti'ansitoria),  which  has  been  described 
by  Krafit-Ebing  as  well  as  by  ourselves 
{loc.  cit.). 

With  regard  to  therapeutics,  we  may 
briefly  say  that  the  treatment  of  tran- 
sitory mania  can  only  be  symptomatic. 

It  would '  be  impossible  to  administer 
any  medicines  during  the  pai-oxysm,  and 
afterwards  we  must  trust  to  the  vis  medi- 
catrix  nature.  The  patient  must  be  iso- 
lated, and  anything  that  might  irritate 
him,  carefully  avoided.  He  must  be  kept 
away  from  bright  light  or  loud  noise,  and 
he  must  be  allowed  to  divest  himself  of 
his  clothing  if  it  molests  him.  We  have 
tried  the  usual  treatment  of  cold  baths, 
hypodermic  injection  of  morphia,  &c.,  but 
only  with  very  moderate  success.  Tran- 
sitory i)iania  tvill  fake  its  own  course, 
and  cannot  he  cut  short  hy  any  remedies. 
It  is,  however,  impossible  to  generalise, 
and  the  physician  will  have  to  take  into 
consideration  the  individuality  of  his 
patient. 

As  the  term  "transitory"  mania  im- 
plies, the  disorder  terminates  in  recovery, 
so  that  there  can  be  no  question  as  to  the 
results  of  post-mortem  examinations.  It 
is  not  impossible  that  death  might  occur, 

*  Our  8i)iicc  (Iocs  not  allow  us  to  ilescribo  the 
dilTcTciict's  minutely,  but  we  refer  the  reader  to  our 
treatise  on  lr;iusiii)ry  ni;ini;i  (imi.  71-119). 


Transitory  Mania 


[     1306 


Traumatic  Factor 


not  through  the  attack  itself,  but  by  a 
secondary  disease,  and  even  if  in  such  a 
case  the  autopsy  should  not  reveal  any 
signs  of  hypera3mia,  it  does  not  follow 
that  the  latter  was  not  present,  because, 
as  Emminghaus  says,  any  signs  of  cortical 
congestion  may  disappear  after  or  even 
during  the  agony  of  death.  We  also  can- 
not believe  that  dilatation  of  the  cortical 
vessels,  or  liEemorrhage  into  the  cortical 
substance,  will  be  found,  as  it  occurs  in 
severe  forms  of  frenzy,  for  our  opinion  is 
that  death  can  only  occur  in  some  rare 
cases  if  the  attack  extends  to  centres  im- 
portant to  life,  and  even  then  scarcely 
any  pathological  changes  would  be  found. 
Death  might  occur  in  consequence  of  the 
bursting  of  a  miliary  aneurism  through 
the  hyperaamia  which  causes  the  attack, 
but  we  must  remember  that  the  occur- 
rence of  miliary  aneurism  in  the  cortical 
vessels  is  extremely  rare. 

With  regard  to  the  medico-legal  as- 
pect of  the  question  we  remark  : 

How  the  motor  and  mental  excitement 
expend  themselves  depends  mainly  on 
accidental  external  circumstances  and  the 
surroundings  of  the  patient.  If  the  latter 
are  unfavourable  it  may  happen  that 
during  the  paroxysm  the  patient  commits 
acts  which  make  him  liable  to  be  jDunished 
by  law,  especially  if  the  antecedents  of 
the  patient  are  such  as  to  indicate  that  be 
might  be  capable  of  committing  them. 
Thus  it  may  happen  that  persons,  in  con- 
sequence of  there  being  trace  of  prior 
mental  disorder,  and  the  deed  being  in 
accord  with  their  mental  history,  are  con- 
victed, although  innocent,  and  perhaps 
even  condemned  to  death. 

Therefore  transitory  mania,  and  espe- 
cially those  forms  of  it  connected  with 
alcohol  and  parturition,  are  of  great  fo- 
rensic importance.  It  is  a  condition  of 
unconsciousness  which  excludes  free  will, 
and  makes  the  individual  irresponsible 
while  the  condition  lasts,  because  there  is 
no  possibility  of  free  choice  pro  or  contra; 
in  addition  to  this  the  motives  for  the 
deed  are  merely  organic  and  lie  in  the 
morbid  motor  excitement  and  the  patho- 
logical frenzy.  The  patient,  driven  by 
the  morbid  impulse,  could  not  help  acting 
as  he  did. 

Although  in  some  cases  the  intellect 
may  be  less  deranged  and  consciousness 
less  obscured,  and  the  patient  may  seem 
to  have  a  certain  method  in  his  doings, 
we  must  bear  in  mind  that  the  association 
of  certain  ideas  takes  place  mechanically 
and  as  a  matter  of  habit,  so  that  never- 
theless the  patient  was  not  master  of  him- 
self and  his  actions,  and  was  unable  to 
avoid  doing  what  he  did.   The  wrong  he  did 


was  not  intentional,  but  was  brought  about 
by  powers  over  which  nobody  has  any  con- 
trol. Therefore  an  individual,  although 
doing  wrong,  under  such  circumstances  is 
not  punishable. 

Otto  von  Schwartzek. 

{Refvrences. — K.  von  KrafEt-Ebinu,  Die  Lehre 
von  der  Mania  transitoria,  1865  ;  Die  tnin.sitori- 
scben  Stijrung-en  des  Selljstbewusstseins,  1868. 
Ott(j  von  Scliwartzer,  Die  transitorische  Tobsucht, 
eino  klinisc-li-forcnsisehe  Studie,  1880.  Stark, 
Fall  V.  M.  tr.,  Irrcnfreund,  1871,  vii.  Von  Krafft, 
Fall  V.  M.  tr.,  Allg.  Zeitschrift  f.  Psyct.,  1871, 
xxviii.  Braun,  M.  tr.,  Allg-.  Z.  f.  Psych.,  1868, 
XXV.  Cook,  M.  tr.,  Philad.  Med.  and  Surgical  Re- 
jiortfr,  1873,  xxviii.  Van  Holsbeck,  De  la  Folic 
subitf,  ])assagtre  au  point  de  vue  medico-leg^ale. 
Bullet,  de  I'Academie  de  Jled.  de  Belg.,  Nro.  10, 
1869.  Lotz,  Fall  V.  Melaneh.  tr.,  Allg.  Z.  f.  Psych., 
XXV.,  i860.  Hofmann,  Fall  von  M.  ir.,  Mithl.  des 
Med.  Doctoren  Coll.,  1879,  10,  ii.  Chatelain,  2  f. 
Jour.  Psych. ,  Anual.  Med.  Psych.  ,1871.  iloniteur, 
23,  ii.,  1868,  Fall  v.  tr.  furrib.  Delir.  Erhardt, 
Mania  acutiss.,  Allg.  Z.  f.  Psych.,  xxiii.  Von 
Krafft,  Ueber  eine  Form  d.  Rauschcs  welclie  als 
Mauie  verljiuft,  D.  Z.  f.  Staatsarzueikunde,  1869, 
xxvii.  Ettmiiller,  Cas.  Viertelj.  f.  g.  M.,  1872,  xvi. 
Bonnet,  Cas.  Annal.  med.  Psychol.,  1874-5.  Biich- 
ner,  Cas.  Friedreich's  Blatter,  1867-5.  Otto  von 
.Sohwartzer,  Be\vusstlosigkeitszustande,i878.  Lehr- 
biicher  der  gericht.  Psychopath,  und  Psychiatrie. 
Von  Blichner,  Balfour  Browne,  Blandford,  Eaj',  Cas- 
per-Liman,  von  Krafft,  Maudsley,  Arndt,  Schiile, 
Meynert,  Griesinger,  Lombroso,  Leidesdorf,  Krae- 
peliii,  Tardieu,  Savage,  Liman,  Zweifelhafte 
(ieisteszustande,  1869.  Lombroso  e  Solgi,  Diag. 
med.  1.  1874.  Motet,  Zurech.  d.  Geistkr.  Gaz.  d. 
Hopitaux,  1870.  Tuke,  F.,  Beurth.  d.  Geisteszstd.  v. 
Gericht.  British  Med.  Journ.,  1875.  v.  Miraglia, 
Sulla  procedura  nci  giudizii  cr.  c  civ.  p.  riconoscere 
I'alienazione  mentale,  Napoli,  1870.  Laj-cock,  D. 
gericht.  Beurth.  Geistesgestorter  Med.  Times  and 
(iaz.  1867,  x.-xi.  Eastwood,  Medico-legal  Uncer- 
tainties, Journal  of  Mental  Science,  1869,  iv.  Und 
die  einschlagigen  Arbeiteu,  von  Adamkievicz,  Brierre 
de  Boismont,  Schlager,  Lippe,  Mendel,  Emmincjhaus, 
Carrara,  Tyler,  Kussell  Reynolds,  Everett,  Legrand 
du  SauUe,  Verga,  Jacoby,  Livi,  Browne,  Delasiauve, 
Meschede,  Zule,  Mosing,  Hagen,  Lombroso,  Voisin, 
Laurent,  Kicolson,  Telman,  Erlenmeyer,  Laehr, 
Scrzcska,  Bonnet  and  Bulard,  Otto,  Simon,  Koch.] 

TRAM'SITORT         MEIiAXTCHOXiia. 

(See  Melaxcuolia  Transitoria.) 

TRAUMATIC  FACTOR  IN  MEIT- 
TAIi  DISEASE,  THE.  —  Under  the 
above  head  may  rightly  be  included  all  in 
juries  produced  by  external  violence  affect- 
ing the  nervous  system,  so  as  to  become 
factors  in  the  production  of  mental  disorder 
or  defect :  and  it  is  narrow  and  unscientific 
to  limit  the  scope  of  the  subject  to  direct 
injury  of  the  head.  And,  contrary  to  the 
classification  of  many,  we  do  not  include 
insolation  under  the  head  of  traumatic 
injury.  The  clinical  similarity  of  some 
examples  of  the  two  does  not  justify  us  in 
huddling  all  cases  from  injury  and  from 
insolation  promiscuously  together.  Nor 
do  we  deal  with  the  surgical  aspects  of  the 
subject. 

From  the  shock  of  a  blow,  several  events 


Traumatic  Factor 


[     '307    ] 


Traumatic  Factor 


may  follow,  perhaps  successively.  As  a 
})rimary  effect,  there  may  be  jar,  shake, 
violent  vibration  of  the  brain,  or  brain  and 
cord  ;  and  this — when  occurring  in  con- 
cussion— chietly  through  the  medium  of 
the  excessive  commotion  and  propulsion 
of  the  cerebro-spinal  liuid,  dashed  to  and 
fro  by  the  external  impact,  as  shown  by 
Duret.  The  practical  result  is  more  or 
less  suspension  of  fewer  or  more  of  the 
functions  of  the  brain,  or  brain  and  cord. 
Next,  there  ma}''  follow  the  molecular 
alteration  and  the  perversions  of  function 
manifested  as  ordinary  i^sycho-neuroses  ; 
or  as  traumatic  neurosis,  or  neurasthenia, 
or  hysteria ;  and,  finally,  there  may  be 
sub-acute  or  chronic  organic  disease  of  the 
brain,  and  sometimes  of  other  parts  of  the 
nervous  system. 

In  the  later  and  more  typical  cases  a 
neurosis  is  first  engendered,  and  on  this 
basis  the  resulting  insanity  or  deteriora- 
tion of  mind  is  formed  by  further  nervous 
and  mental  reductions. 

If  cranial,  the  original  injury  may 
chiefly  affect  the  bony  structure,  or  the 
brain  itself,  or  the  intra-cranial  blood- 
vessels. 

Even  in  some  of  the,  clinically,  so-called 
functional  cases,  the  brain  may  really 
have  undergone  some  fine  material  dam- 
age ;  and,  in  them,  paralysis  of  ordinary 
type  affecting  the  limbs  on  the  side  the 
same  as  the  cranial  hurt  is  very  sugges- 
tive of  damage  to  the  opposite  cerebral 
hemisphere  by  counterstroke. 

The  morbid  conditions  arising  from  the 
incidence  of  external  force,  and  constitut- 
ing a  factor  in  the  production  of  mental 
disease,  may  either  be  immediate,  or  be 
secondary,  and  more  or  less  remote.  The 
immediate  morbid  conditions  may  be 
concussion  of  the  brain  (molecular  per- 
turbation) ;  or  bruise,  crush,  or  rupture 
of  its  substance  ;  or  ha3morrhage  into  it,  or 
into  the  sub-dural,  sub-arachnoid  and  ven- 
tricular spaces  ;  or  vaso-motor  results  of 
damage  to  brain,  cord,  or  sympathetic. 
Compression  of  brain  may  come  from 
effused  blood,  inflammatory  products,  or 
depressed  bone.  Local  anaemia  or  oedema 
of  brain  may  quickly  follow  some  of  these 
conditions. 

The  secondary  conditions  following 
injury,  and  promoting  mental  disease, 
may  be  slow  nutritive  alteration  of  brain, 
acute  or  chronic  inflammation,  and  exuda- 
tion, suppuration,  sclerosis,  secondary 
degeneration,  and  the  destructive  changes 
following  ha3morrhage,  softening,  inflam- 
mation or  ischa3mia  of  brain.  Even  tu- 
mour of  the  brain  may  arise  out  of  injury, 
and  in  its  turn  influence  the  jn-oduction 
of  mental  disease. 


As  a  factor  of  mental  disease,  injury 
may  act  either  as  a  predisponent  or  as  an 
excitant.  Nervous  and  mental  abnor- 
malities may  promptly  follow  injury,  and 
then  disappear ;  but  may  leave  behind 
them,  either  some  impress — manifest  or 
latent — which  inclines  to  the  production 
of  mental  disorder ;  or  else  some  progres- 
sive organic  change,  which  ends  in  a 
similarly  disastrous  effect  on  mind.  On 
the  contrary,  the  mental  symptoms  may 
spring  from  the  moment  of  injury,  or 
merely  separated  therefrom  by  a  short  in- 
terval characterised  only  by  slight  indica- 
tions of  impending  nervous  and  mental 
failure  or  perversion. 

The  operation  of  the  traumatic  factor 
is  thus  seen  to  be  in  some  cases  slow, 
slight,  and  simply  predisposing  ;  or  it  may 
lead  to  the  production  of  neurasthenia 
or  of  hysteria,  or  of  both— or  of  a  traumatic 
neurosis  not  always  quite  the  same — 
and,  on  the  basis  of  any  of  these,  to  an 
established  morbid  psychosis  of  traumatic 
origin ;  or  it  may  be  expressed  either  in 
primary  coarse,  or  else  fine,  subtle,  brain- 
damage,  and  secondary  organic  and  often 
destructive  brain  disease.  Or  this  opera- 
tion of  the  traumatic  factor  may  merely 
be  to  i^recipitate,  and  somewhat  modify, 
an  already  partially  prepared  or  nascent 
insanity  ;  or  it  may  be  the  direct  excitant 
of  an  insanity  formed  and  ready  equipped 
to  spring  forth  on  the  stroke. 

The  traumatic  factor  frequently  is  co- 
operative with  other  factors  in  the  pro- 
duction of  mental  disease ;  its  action 
modifies,  and  is  modified  by  theirs  ;  and 
the  cases  often  have  mixed  features  as  the 
result. 

The  age  of  the  patient  has  some  influ- 
ence on  the  type  of  insanity  of  traumatic 
origin,  which,  indeed,  evinces  a  tendency 
to  take  the  forms  of  insanity  most  frequent 
at  the  same  particular  stage  in  life. 

The  tendency  to  the  production  of  in- 
sanity by  injury  is  increased  in  neurotic 
subjects  ;  in  those  of  the  insane  diathesis  ; 
in  the  irritable,  wayward,  sensitive,  im- 
pulsive :  in  the  syphilitic,  or  those  de- 
teriorated by  other  disease,  or  by  mental 
overwork,  anxiety,  insomnia  or  privation  ; 
and  in  those  given  to  alcoholic  or  sexual 
excesses. 

The  prognosis  is  extremely  unfavour- 
able in  the  organic  cases.  But  a  number 
of  the  functional  cases  recover.  Severe 
mental  symptoms,  immediately  following 
the  injury,  may  clear  up  well ;  those  be- 
ginning late,  and  slowly  progressive,  pre- 
sent an  unfavourable  forecast ;  so  does 
convulsion,  tending  to  become  habitual ; 
and  so  do  cases  of  the  paranoiac  type. 
After  cessation  of  the  immediate  effects 


Traumatic  Factor 


[     130S    ] 


Traumatic  Factor 


of  tlie  blow,  there  is  ordinarily  an  interval 
— often  long — before  the  onset  of  super- 
venient mental  disease.  In  this  interval, 
somedeviations  from  the  normal  are  nsually 
manifest.  Frequently,  thei-e  is  a  change 
in  character  and  disposition.  Unusual 
impatience,  irascibility,  overbearing  domi- 
neering urgency,  outbursts  of  rage,  or 
moody  taciturnity  and  suspicion,  may  be 
evinced,  or  an  uneasy  nervous  state ; 
downcast  sadness  and  hypochondriacal 
notions  enthral  the  subject;  nightmare 
and  painful  dreams  break  the  rest.  Par- 
tial or  general  failure  of  memory  and  of 
mind  may  come ;  or  fatigue  on  the  slight- 
est mental  exertion  or  strain  of  attention  ; 
or  a  dazed,  bewildered,  confused  state  of 
mind.  Addiction  to  alcohol  and  coition 
are  apt  to  be  maiufested ;  and,  in  the 
traumatic  neurotic  state  now  existent,  the 
effects  of  sexual  indulgence,  drink,  nar- 
cotics, extreme  heat,  physical  exertion, 
mental  overwork,  agitation  or  anxiety,  are 
easily  produced  and  iinusually  severe. 
Gradually  deepening,  these  conditions 
may  form  the  prodromic  stage  of  the 
supervenient  psychosis ;  or,  now,  there 
may  be  great  disquietude,  tremor,  head- 
ache, suicidal  and  homicidal  impulses,  in- 
somnia, and  possibly  an  expansive  phase. 
Pain  in  the  head  may  be  general,  or 
chiefly  at  the  site  of  old  injury,  or  ra- 
diating thence,  and  associated  with  cra- 
nial tenderness  or  numbness,  &c.  As  to 
the  special  senses,  there  may  be  the  most 
various  sensorial  (a)  failure  and  loss ;  or 
(b)  morbid  over-acuteness  ;  or  (c)  perver- 
sion. Early  or  late,  may  be  paresis,  para- 
lysis, spasm,  convulsion,  tremor,  chorea, 
ataxia,  contracture,  vertigo. 

The  symptoms  and  course  of  the  mental 
disease  vary,  partly  with  the  many  varie- 
ties of  situation,  kind,  extent,  and  severity 
of  the  brain-injury,  and  of  every  accom- 
panying, primary,  or  secondary  functional 
cerebral  impairment;  and  partly  with  the 
particular  nervous  and  mental  tendencies 
of  the  individual. 

The  TiiAUJiATic  Factor  at  Different 
Stages  of  Life. — External  violence  may 
affect  the  evihryo  or  fcetus  in  idero.  The 
grave  effects — upon  the  development  of 
the  young — of  injury  of  the  germ-layers 
of  the  embryo  of  lower  animals  prepares 
us  for  the  possibility  of  something  analo- 
gous in  the  human  being.  And  striking 
examples  are  forthcoming  in  which  severe 
physical  shocks,  sustained  by  the  pregnant 
mother,  and  j^artially  conveyed  to  the 
womb,  have  wrought  disaster  to  the  ner- 
vous and  mental  development  of  the  com- 
ing child  ;  as  in  the  case  of  pregnant 
women,  in  besieged  towns,  subjected  to 
the  violent  shocks,  vibration  and  tumul- 


tuous commotion  of  the  modem  bombard- 
ment. 

In  being  born,  also,  the  infant  is  liable 
to  sustain  cranial  and  cerebral  injury, 
hurtful  to  its  future  mental  state.  For, 
in  difficult  child-hirth  the  suspension  of 
vitality,  the  prolonged  asphyxial  state  to 
which  the  infant  may  be  exposed ;  the 
ecchymosis,  hasmorrhage,  or  contusion,  its 
brain  may  suffer  in  the  expulsive  efforts, 
or  from  distortion,  depression,  or  even 
fracture  of  the  skull  bones — all  may  strike 
at  the  very  foundations  of  the  integrity  of 
the  nascent  mind.  Even  the  intervention 
of  the  forceps  does  not  always  avert  this 
disaster,  and  their  unskilful  use  has  to 
answer  for  many  an  indented  skull,  dam- 
aged brain,  and  maimed  intellect.  And 
these  ill-results  of  difficult  labour  occur 
chiefly  in  civilised  luxurious  races,  with 
their  bigger  child-heads,  and  more  fragile 
delicate  women. 

In  infancy  and  cliildhood  the  risks  of 
brain-injury  are  freely,  and  often  need- 
lessly, incurred.  At  these  stages  of  life, 
injury  to  the  skull  and  brain  is  apt  to 
be  the  starting-point  of  idiocy,  imbecility, 
convulsion,  choreiform  or  athetosic  move- 
ments, hemiplegia,  contracture,  talipes, 
wasted  limbs  ;  irritable,  quarrelsome  tem- 
per, proneness  to  aggressive  tendencies, 
violence,  impulsive  excitement,  destruc- 
tiveness  and  automatism ;  these  latter 
symptoms,  in  some  cases,  immediately  of 
ej)ileptoid  origin.  The  tendency  is  to 
progressive  mental  failure,  fatuity,  and 
death.  The  necropsies  present  traces  of 
old  meningeal  hEemorrhage,  destructive 
local  lesion,  or  local  atrophy,  of  the  cere- 
bral cortex ;  or,  often,  wasting  of  one  cere- 
bral hemisphere  only,  or  chiefly,  and 
more  extreme  in  some  parts  of  it  than  in 
others. 

After  incurring  head-injuries,  some 
children  take  convulsions,  as  the  predom- 
inant symptom  ;  these  convulsions  tend  to 
become  inveterate  ;  and  the  subjects  per- 
haps grow  up  exhibiting  mental  fluctua- 
tions, irritability,  violence,  occasional 
delusions,  mental  automatism,  and  irregu- 
larly progressive  dementia,  much  as  in 
the  epileptic.  Eventually  dying,  they 
may  show  some  wasting  of  the  brain,  with 
developmental  irregularity  of  gyri  and 
sulci.  And  they,  like  the  last  cases,  may 
present  cranial  bone-changes  following  the 
injury. 

In  youth,  as  an  outcome  of  injury,  may 
be  cases  like  those  described  for  child- 
hood ;  or  quasi-maniacal  attacks  of  ex- 
citement may  occur  with  mischievous, 
violent,  destructive  tendencies,  the  attacks 
often  being  either  recurrent  or  sub-con- 
tinuous ; — or  there  may  be  moral  insanity, 


Traumatic  Factor 


[     1309    ] 


Traumatic  Factor 


ideo-impulsive  insanity,  hebephrenia,  and 
a  variety  of  paranoia. 

In  the  adult,  and  especially  following 
cranial  injnrjs  we  have  chietly  found  four 
great  groups  of  mental  disorder : — 

(i)  One  consisting  of  the  ordinary  forms 
(even  if  modified)  or  functional  mental 
perversions  of  the  more  simjde  type 
(psycho-neuroses) ; 

(2)  A  second,  constituted  of  paranoia 
and  its  iunnediate  congeners; 

(3)  A  third,  comprising  mental  and 
other  symptoms  dependent  on  severe 
traumatic  organic  brain-disease  and  alter- 
ation, whether  due  to  secondary  morbid 
processes,  or  to  these  as  well  as  to  primary 
damage  of  the  brain  ; 

(4)  And  the  foui'th,  consisting  of  func- 
tional neuroses  of  certain  types,  with  men- 
tal symptoms.  They  may  also  be  incident- 
ally present  in  the  other  groups. 

The  second  and  third  groups  comprise 
the  cases  more  fully  and  characteristically 
of  traumatic  nature. 

Special  Semeiography  and  Necro- 
scopy IN  THE  Adult. — (i)  The  first  great 
group,  then,  consists  of  functional  mental 
disorders,  modified  it  may  be,  but  in  a 
general  way  of  the  ordinary  type  of 
psycho-neuroses.  And  it  is  only  necessary 
to  mention  them  briefly.  According  to 
our  observation  the  traumatic  cases  prac- 
tically consist  of  : — 

(a)  Examples  of  a  kind  ofcei-ebro-men- 
tal  automatism  ; — consciousness  becoming 
greatly  obscured  for  a  considerable  space 
of  time,  or  more  briefly  and  recurrently, 
although  the  individual  affected  moves 
about  amongst  his  fellows,  perhaps  at- 
tracts no  special  notice,  perhaps  makes 
long  journeys,  and  for  a  time  lives  a  life  of 
which  he  retains  no  recollection,  or  pei'- 
haps  unconsciously  commits  himself  by 
various  acts — e.g.,  larcenies. 

(b)  Modified  symptoms — i.e.,  varieties, 
of  stuporous  insanity  may  occur. 

(c)  Acute  hallucinatory  insanity  with 
unsystemised  delusions  is  not  infrequent. 
The  hallucinations  are  chiefly  of  sight  and 
hearing,  are  of  imi)ort  hostile  to  the  suf- 
ferer, and  the  delusions  are  such  as  those 
of  being  derided,  of  mockery,  of  accusa- 
tions as  to  moral  or  legal  wrongdoing, 
of  impending  disaster,  of  annoyance,  per- 
secution, evil  design  or  conspiracy  against 
the  patient.  Emotional  dejection  and 
lack  of  control  may  culminate  in  raplus, 
with  explosive  violence  directed  against 
self  or  others. 

(d)  Melancholic  depression  forms  the 
last  sub-group  to  name  here,  and  may 
present  the  symptoms  of  simj^le  melan- 
cholia, with  suicidal  attempts ;  or  delu- 
sions of  wickedness  or  uselessuess,  vivid 


hallucinations  with  harmonising  delusions, 
chiefly  of  depressive  kind,  morbid  fears, 
and  in  some  a  failure  of  memory. 

(2)  The  second  groat  group  contains 
paranoia  and  its  immediate  congeners, 
injury  in  early  life  may  assist  in  forming 
a  natural  bent  to  paranoia.  Unsystem- 
ised delusional  insanity,  with  hallucina- 
tions coming  at  first,  may,  or  may  not, 
gradually  be  replaced  by  the  systemisa- 
tiou  of  established  paranoia.  In  this 
group  there  may  also  be  symptoms  of 
organic  brain  or  cord  disease,  of  trau- 
matic origin. 

Some  traumatic  subjects  become  moody, 
unsociable,  impatient,  ill-tem^iered,  irri- 
table, and_  gradually  may  pass  into  a 
state  of  acute  excitement,  with  suicidal 
attempts  or  homicidal  assaults,  and  per- 
haps convulsions.  These  acute  symp- 
toms may  pass  off,  and  leave  a  suspicious, 
resentful,  embittered,  morose,  surly, 
taciturn  state,  with  delusions  of  conspiracy 
against  the  subject.  Or  a  period  of  early- 
excitement  may  give  place  to  a  chronic, 
depressed,  hypochondriacal,  persecutory, 
aggressive,  dangerous,  often  homicidal 
^tate,  with  suspiciousness,  irascibility, 
and  paroxysmal  transports  of  fury,  some- 
times on  a  convulsive  (eioileptoid)  basis. 
Exj^ansive  symptoms  may  commingle 
with  these.  The  end  is  usually  dementia 
and  death.  Or,  after  the  change  of 
character  already  described  as  often  pre- 
ceding psychoses  of  traumatic  origin, 
there  may  be  marked  headache,  insomnia, 
irascibility,  suspiciousness,  suicidal  or 
homicidal  impulses,  or  assaults  under  de- 
lusions of  identity,  failure  of  memory,  or 
its  recurrent  obscuration  in  connection 
with  convulsions. 

Persecutory  and  hypochondriacal  delu- 
sions are  frequent.  Those  of  poisoning 
of,  or  conjugal  infidelity  to,  the  subject,  if 
present,  mark,  in  some  examples  at  least, 
a  complication  of  the  traumatic  factor  by 
the  alcoholic. 

In  many  cases  are  dissolute  excesses  of 
various  forms,  brutality  to  spouse,  chil- 
dren or  friends,  moral  perversity,  and 
eventually,  perhaps,  still  graver  outrages, 
violent  brutal  impulses,  and  occasional 
outbursts  of  acute  mental  excitement. 

The  course  is  long  and  changeful  in 
clinical  aspect  and  in  degree  of  severity. 
Frequent  as  symptoms  are  insomnia, 
headache,  vertigo,  local  pareses  ;  various 
sensory  and  sensorial  anomalies  which 
may  consist  of  perversion,  or  of  morbid 
increase,  diminution  or  loss,  of  sensibility. 

(3)  The  third  great  group  is  a  large  one, 
including,  inter  alia,  "  organic  "  dementia, 
which  sometimes  is  of  the  senile  form 
— i.e.,   senile  dementia,  precipitated  and 


Traumatic  Factor 


[     1310    ] 


Tramnatic  Factor 


modified  by  injury; — focal  brain-lesions 
often  with  epileptoid  states  ;  diffuse  brain 
disease,  including  general  paralysis.  Long, 
or  considerably,  atter  severe  skull  fracture, 
may  come  epileptiform  seizures,  of  either 
the  graver  or  milder  type,  or  both,  which 
increase  in  frequency,  and  are  associated 
■with  violence  and  mental  automatism 
similar  to  those  so  often  manifest  in 
epileptic  mental  disorder,  and  with  pro- 
gressive incoherence,  mental  confusion  and 
dementia.  Turning  movements  may  occur, 
or  tonic  spasm,  or  spasmodic  twitches,  or 
local  paralyses  ;  hemiparesis  or  hemiplegia 
may  be  joartial  or  general  on  the  side 
affected,  and  either  persistent,  and  aug- 
mented for  the  time  being,  after  the  con- 
vulsive seizures,  or  only  appearing  then 
and  temporarily.  Partly  in  dei^endence 
on  these  seizures,  the  mental  state  fluc- 
tuates from  the  noisy,  restless,  incoherent, 
to  the  op23ressed,  inert  or  semi-comatose. 
Similarly  related  to  the  convulsive  attacks, 
and  similarly  lluctuating,  are  the  most 
varied  disorders  and  defects  of  speech, 
comprising  many  examples  from  all 
of  the  gi-eat  orders  of  speech  affections, 
namely,  those  of  intellection,  those  of  dic- 
tion, and  those  of  articulation.  Vision, 
or  other  of  the  special  senses,  may  fail  or 
cease. 

At  the  necropsy,  are  changes  in  the 
bone  at  the  site  of  the  old  fracture,  with 
bony  bosses  on  the  inner  surface,  local 
chronic  pachymeningitis,  perhaps  cohesion 
of  dura,  pia  and  brain  cortex ;  or  cortical 
atrojahy,  and  various  old  destructive  or 
indurative  lesions  of  the  cortex  beneath 
the  seat  of  cranial  injury  ;  sequeku  of  old 
sub-dural  hgemorrhage,  and  of  the  usual 
type,  or  of  old  sub-arachnoid  or  pial 
hismorrhage,  the  latter  ai^pearing  partly 
as  atrophic  degenerate  portions  of  the 
cortex.  As  evidence  of  counter-stroke  at 
the  time  of  the  original  injury — and 
situate  at  the  opposite  pole  of  the  cranial 
sphere — may  be  the  traces  of  bruise  or 
crush  of  the  cortex,  or  traces  of  menin- 
geal haemorrhage,  or  of  local,  acute,  or 
chronic  meningitis  —  e.g.,  old  adhesion- 
bands,  and  meningeal  thickening,  and 
areas  of  adhesion  and  decortication, 
chiefly  affecting  the  base  of  the  brain. 
Atrophy,  more  obvious  in  the  grey  than 
in  the  white,  has  befallen  the  cerebral 
hemisphere  chiefly  affected ;  and  the  ven- 
tricular ependyma  is  often  granvilated. 

In  some  traumatic  cases,  with  marked 
meningeal  thickening  and  opacity,  cerebral 
atrophy,  pallor,  and  fine  changes,  chiefly, 
and  irregularly  distributed,  in  one  hemi- 
sphere— is  gradual  dementia,  and  some- 
times a  mild  esi^ansive  state  reminding 
one  of  general  paralysis. 


Conditions,  at  least  resembling  general 
paralysis,  may  also  come  gradually  some 
months  after  severe  cranial  injury.  Pre- 
ceded by  strangeness  of  manner,  emotional 
depression,  severe  cranial  pain,  hallucina- 
tions and  delusions — come  physical  symp- 
toms as  of  general  paralysis,  mental 
failure  with  large  ideas  (although  of  some 
fixity)  completiug  the  resemblance.  But 
under  active  treatment  such  cases  may 
vastly  improve  for  years,  eventually  de- 
teriorating, however,  on  the  lines  of  de- 
mentia, spastic  paraparesis,  and  various 
sj^eech  affections.  At  the  necropsy,  are 
slight  brain  wasting,  some  chronic  me- 
ningeal thickening  and  opacity,  slightly 
increased  dural  adhesions  to  the  calvaria, 
the  traces  of  old  heemorrhage  into  the 
sub-dural  space ;  and  degeneration  of  the 
pyramidal  tracts  of  the  spinal  cord. 

In  these  last  two  sub-groups  we  have 
cases  at  least  closely  allied  to  general 
paralysis,  or  forming  the  links  between 
it  and  some  other  organic  brain  diseases, 
or  perhaps  to  be  taken  as  modified 
varieties  of  general  paralysis  itself.  And 
there  are  other  cases  holding  a  somewhat 
analogous  position,  but  the  limits  of  space 
will  scarcely  permit  us  to  more  than 
mention  them. 

Such  are  cases  v:ith  (a)  indistinctly  or 
moderately  marked  signs  as  of  general 
paralysis  in  speech,  face  and  tongue,  &c., 
and,  besides, either  loith  [b)  suicidal  attempt 
and  slightly  dangerous  tendencies,  emo- 
tional dejection,  delusions  of  melanchoUc 
and  hypochondriacal  type ;  hallucinations 
and  delusions  as  to  hostility  against  him, 
annoyance  and  persecution  ;  severe  cranial 
l^ain,  and  some  symptoms  of  hystero- 
neurasthenia ;  or  else  with  (b)  severe 
cranial  pain,  emotional  depression,  weep- 
ing, or  excitement  under  delusions,  and 
especially  under  vivid  hallucinations,  as  to 
hostility  towards  him,  his  persecution  in 
various  ways,  his  condemnation  and  im- 
pending death;  or  else  tcitJi  ^^ 6)  a  dazed 
confused  state  of  mind,  hallucinations, 
and  some  self-satisfaction.  In  the  last 
case,  the  considerable  clearing  up  of  these 
symptoms  links  it  with  a  sub-group, 
there  is  not  space  to  describe,  in  which 
the  mental  and  physical  symptoms  fol- 
low quickly  or  comparatively  soon  after 
the  injury,  simulate  general  paralysis  of 
the  expansive  and  excited,  or  of  the  de- 
pressed type;  but  soou  clear  up  or  vastly 
meliorate. 

We  next  take  unquestionable  cases  of 
general  paralysis  of  the  insane. 

Traumatic  General  Paralysis. — In  some 
examples  at  least,  one  cerebral  hemisphere 
is  much  more  affected  than  the  other  by 
adhesion    and     decortication,    and   by   a 


Traumatic  Factor 


[     >3>i     ] 


Traumatic  Factor 


greater  exteat,  degree  and  duration  of  the 
other  conditious  of  the  cerebral  lesion]  of 
general  paralysis,  including  secondary- 
wasting,  sometimes  slight  and  moderately 
diffuse  induration,  and  in  some  a  state  of 
lesion  partially  like  that  of  the  demented 
convulsive  cases  described  at  the  begin- 
ning of  this  third  groat  group.  In  some 
there  are  old  meningitic  thickening  and 
adhesion  bauds,  and  cerebro-meniugeal 
cohesions,  about  the  base  of  the  brain  and 
the  anterior  portion  of  the  mesial  surface 
of  the  cerebral  hemispheres.  The  optic 
nerves  are  often  involved,  and  secondary 
descending  systematic  spinal  degenera- 
tions are  frequent. 

Other  cases  follow  much  moi'e  closely 
the  usual  general  paralytic  type  of  dis- 
tribution of  the  cerebral  lesions,  and 
of  their  respective  degrees  in  dilFerent 
parts. 

The  patients  may  be  dangerous,  in- 
clined to  violence,  and  perhaps  suicidal 
or  homicidal  in  jiaroxysms  of  excitement. 
Hallucinatory  voices  are  apt  to  threaten, 
or  pronounce  danger  or  harm  to  the  sub- 
ject. The  earlier  symptoms  may  subside 
and  leave  some  self-satisfaction  in  posses- 
sion. But  expansive  symptoms  may  be 
prominent  in  phases,  or  throughout,  while 
before  and  with  them  is  the  fundamental 
failure  of  mind.  And  now  and  then  come 
paralytic  seizures,  with  mental  dulness, 
oppression,  and  increase  of  the  impair- 
ment of  speech  and  writing.  In  many 
cases  there  is  severe  pain  in  the  head,  es- 
pecially in  the  earlier  stages.  Increased 
tendon  reflexes  and  cloni  are  often  found 
in  the  later  stages,  also  hemiparesis,  and 
contractured  limbs — chiefly  on  the  more 
paretic  side. 

Some  examples  are  marked  by  the  rela- 
tive predominance,  or  striking  nature,  of 
such  symptoms  as  excitement,  noisy 
raving,  violence,  destructiveness,  in  the 
earlier  stages ;  vivid  hallucinations  of 
hearing  and  of  other  special  senses  ;  often 
a  long  precedent  change  of  character  and 
disposition ;  irritability  of  tempei",  readi- 
ness to  outbursts  of  anger  and  aggi-essive- 
ness.  Also,  frequent  recurring  apoplecti- 
form and  epileptiform  seizures  with  (left) 
hemiplegia,  increased  knee  jerks,  and 
ankle-cloni.  In  these  the  brain-lesions  and 
wasting  are  often  chiefly  of  the  rirjht 
cerebral  hemisphere. 

Or  the  clinical  aspect  may  be  different, 
presenting  mental  depression  and  symp- 
toms of  hypochondriacal  or  melancholic 
type,  or  other  delusions  of  hostility,  poi- 
soning and  persecution ;  perhaps  vivid 
and  terrifying  hallucinations  and  illusions 
of  special  sense,  besides  quarrelsomeness, 
irritable    morose   ill-temper,  hatefulness, 


urgent  and  protracted  cursing,  reviling  or 
threatening  language,  (right-side)  epilep- 
tiform seizures  with  post-convulsive  re- 
curring (dextral)  hemiplegia, and  increased 
embarrassment  of  speech,  delusional 
refusal  of  food,  obstinate  constipation. 
Here  the  adhesion  and  decortication  and 
other  lesions,  as  well  as  the  atrophy, 
sometimes  at  least,  predominate  in  the 
left  cerebral  hemisphere. 

(4)  The  fourth  great  group  comprises 
many  examples  of  traumatic  neurosis 
which  is  engendered  with  especial  facility 
if  there  is  already  a  neurasthenic  or  hys- 
teric basis,  but  which  may  be  produced 
independently  of  the  pre-existence  of 
these  ;  and  which,  on  the  other  hand,  may 
become  manifest  as,  or  may  occasion, 
traumatic  neurasthenia,  and  then,  on 
this  basis,  hysteria.  Elements  of  mental 
perversion  or  failure  are  jjresent.  Here 
come  a  considerable  number  of  the  ex- 
amples of  so-called  "  railway-brain,"  or 
"  railway  spine,"  "  spinal  concussion," 
"functional,"  "ideal,"  "psychical," paraly- 
ses, &c.,  accompanied  by  psychic  change, 
occasioned  by  injury.  The  injury  may  be 
slight.  Cases  with  definite  organic  lesions 
and  symjDtoms  are  here  excluded  from  this 
group,  although  often  attended,  also,  by 
similar  symptoms. 

The  overt  psychosis  is  closely  preceded 
by  symptoms  such  as  loss  of  memory  of 
the  time  immediately  following  the  acci- 
dent, and  perhaps  of  that  immediately 
preceding  it ;  back  pains  from  sacrum  to 
nape,  headache,  malaise,  uneasy  disqui- 
etude, insomnia. 

The  morbid  psychosis  established,  there 
are  melancholy — ^often  of  hypochondriacal 
type  with  great  irritability — sadness,  in- 
difference to  friends  and  family,  distress, 
oppression,  sombre  feeling  rising  into  fear 
and  culminating  perhaps  in  seizures  ot 
terror  or  in  suicidal  attempts;  desi^air, 
often  with  prsecordial  pain,  oppression 
and  palpitation ;  variable,  fickle  and 
tumultuous  emotional  changes ;  vivid  and 
terrifying  recollections  and  dreams  of  the 
accident  or  injury.  Frequent,  are  self- 
study  as  to  symptoms,  and  concentration 
of  mind  upon  them,  irascibility,  anxiety, 
inclination  to  delusive  notions  about  being 
annoyed,  vague,  torpid,  confused,  easily 
fatigued  mental  action,  rapid  fatigue  in 
attention  and  confusion  in  the  exercise  of 
reading,  silence,  slow  replies,  limitation  of 
volition,  hallucinations,  insomnia,  failure 
or  loss  of  memory — general,  or  partial,  or 
severe  ;  often  many  hysteric  symptoms ; 
and  a  host  of  sensorial,  sensory,  motor, 
vaso-motor  and  trophic  symjitoms,  on 
which  thei'e  is  not  s])ace  to  dwell. 

Wm.  Julius  Mickle. 


Traumatic  Idiocy 


[     13 1 2    ]      Traumatism  and  Insanity 


TRA.VMA.TZC  IBIOCV  (see  IdIOCY, 
TkU- MAI- U).  TRAUMATIC  ITTSANITY, 
TRAUMATIC  EPIIiEPSV,  TRAU- 
MATIC HYSTERIA  (r/jttr7:xa,  awoimd). 
Idiocy,  insanity,  epileps}',  and  hysteria 
following  injury. 

TRAUMATISM  AN*!)  IWSArriTY. 
— Under  this  term  may  be  comprised 
those  cases  of  mental  disorder  in  which 
either  the  immediately  exciting  cause  is 
traumatic,  or  in  which  the  symptoms  ai'e 
directly  referable  to  a  traumatic  origin. 
Cases  in  which  the  actual  declaration  of 
an  impending  mania  was  due  to  some 
injury  are  not  classed  under  this  head- 
ing. It  may  be  pointed  out  that  so  large 
is  the  proportion  of  cases  in  which  there 
is  absence  'of  heredity  that  they  may 
not  unequally  be  divided  into  two  great 
classes,  in  one  of  which  there  is  heredity 
and  in  the  other  not.  It  is  with  the  latter 
that  this  article  chiefly  deals.  The  trau- 
matism may  be  of  every  variety,  and  the 
disorder  appears  to  be  but  little  influenced 
by  the  degree  of  its  severity.  The  subject 
as  a  whole  will  be  discussed  under  thi-ee 
heads: — (i)  insanity  following^  head 
injuries;  (2)  following-  other  kinds  of 
injuries;  (3)  following  surgical  opera- 
tions. 

In  all  these  varieties  the  onset  may  be 
either  acute  or  chronic — i.e.,  it  may  date 
practically  from  the  injury,  or  may  occur 
after  an  indefinite  period  of  quiescence. 
In  the  acute  or  direct  form  the  insanity 
would  seem  to  be  but  the  morbid  develop- 
ment of  disturbances  which,  showing  first 
as  traumatic  fever,  next  pass  on  to  deli- 
rium, and  then,  progressively  as  it  were, 
into  some  form  of  insanity.  Nothing  is 
commoner  in  hospitals  than  to  see  de- 
lirium tremens,  j^roduced  by  a  slight  acci- 
dent, occur  in  an  intemperate  person. 
True  delirium  tremens  however  is  much 
more  often  diagnosed  than  actually  seen  ; 
and  the  different  varieties  of  delirium  met 
with  in  alcoholic  patients  require  to  be 
much  more  carefully  distinguished  from 
each  other  than  has  hitherto  been  the 
case.  The  vast  majority  of  these  patients 
recover  wholly  from  their  mental  dis- 
turbance, but  in  a  certain  small  propor- 
tion, even  though  with  total  absence,  as 
far  as  can  be  ascertained,  of  heredity,  the 
psychosis  persists  for  a  greater  or  less 
length  of  time,  and  in  patients  who  are 
prematurely  old  or  broken  down  may  pass 
on  into  chi-onic  dementia.  Cases  of  trau- 
matic insanity  following  the  delirium  of 
drink  are  only  more  frequent  than  those 
following  the  delirium  of  the  specific 
fevers  or  pneumonia  in  that  intemperance 
is  the  commonest  of  vices  in  adults.  In 
the  treatment  of  all  these  cases,  the  great 


object  to  keep  in  view  is  to  feed  the  patient. 
So  long  as  abundance  of  food  is  taken 
and  digested  the  case  is  hopeful;  but  with 
refusal  or  inability  to  take  food  rapid 
wasting  sets  in  and  death  frequently  fol- 
lows, sometimes  occurring  with  extreme 
suddenness. 

(i)  Head  injuries  are  especially  prone  to 
be  followed  by  traumatic  insanity.  There 
are  no  cases  in  which  it  is  less  possible  to 
predict  the  amount  of  mental  disorder 
likely  to  become  permanent.  The  most 
severe  cerebral  lesions  may  result  in  com- 
l^lete  mental  recovery,  while  veiy  slight 
disturbances  ofttimes  lead  to  the  gravest 
results.  Strangely  enough  cerebral  in- 
juries in  which  the  patient  has  remained 
for  days  or  weeks  in  a  state  of  coma  are 
little  likely  to  be  followed  by  any  form  of 
insanity.  Loss  of  memory  or  some  one 
or  more  functional  impairments  rather 
than  any  general  psychosis,  will  probably 
constitute  the  permanent  lesions.  Yet  this 
is  far  from  being  an  absolute  rule.  In  a 
case  under  the  writer's  care  a  patient  re- 
mained for  some  weeks  in  a  state  of  in- 
sensibility, with  occasional  explosions  of 
violence.  Recovery  slowly  ensued  :  then 
great  irritability  of  temper  developed. 
Some  years  after  the  original  accident  he 
had  an  attack  of  acute  mania.  In  such  a 
case,  however,  the  synaptoms  might  more 
properly  be  regarded  as  dating  from  the 
traumatism,  and  persisting  throughout, 
though  with  intervals  of  improvement. 
Amnesia  and  ajDhasia  may  occur:  if  re- 
covery takes  place  from  these  conditions 
it  is  usually  gradual,  though  sometimes 
sudden. 

The  principal  psychoses  occurring  at  a 
late  stage  are  associated  with  traumatic 
epilepsy.  In  these  instances  distinct 
pathological  changes  will  be  found,  such 
as  ostitis  of  the  skull  or  pachymeningitis. 
The  period  of  quiescence  may  extend  over 
several  years.  The  nature  of  the  patho- 
logical lesion  will  determine  its  duration. 
No  cases  of  insanity  offer  more  hopeful 
prospect  of  relief  by  operation,  especially 
of  course  when  the  starting-point  of  the 
epilepsy  can  be  sharply  localised  in  the 
cerebral  cortex.  There  is  a  close  relation 
in  aetiology  between  these  cases  and  the 
reflex  insanity  to  be  presently  mentioned. 
Insanity  in  any  form  may  follow  this 
traumatic  epilepsy  as  it  may  ordinary 
epilepsy.  Of  the  other  psychoses  due  to 
cerebral  lesion,  and  not  associated  with 
epilepsy,  the  forms  are  manifold,  so  that 
it  is  impossible  to  say  with  truth  that  one 
is  more  ajst  to  occur  than  another,  and  no 
general  rules  can  therefore  he  laid  down 
either  for  treatment  or  prognosis.  But 
whatever  the  form,  it  will  always  be  wise 


Travunatism  and  Insanity     [     1313    J     Traumatism  and  Insanity 


and  will  often  be  profitable  to  seai'ch  for 
some  retlex  cause.  If  such  be  diaj>'uosed 
the  treatment  resolves  itself  into  one  of 
surgical  possibilities.  If  no  operative 
measure  can  benefit  the  results  of  the 
traumatism,  each  instance  must  be  con- 
sidered and  treated  apart  from  its  trau- 
matic origin.  There  is,  however,  in  all, 
broadly  speaking,  an  intolerance  of  alco- 
hol. A  glass  of  wine  or  beer  may  induce 
an  ii'ritable  explosion,  and  suffice  to  turn 
these  patients  from  apparently  sane 
beings  into  irresponsible  criminals.  One 
of  the  best  tests  of  complete  recovery  from 
head  injuries  is  the  absence  of  any  vertigo 
in  stooping  or  looking  down  from  a  small 
height.  The  existence  of  any  amount  of 
glycosuria  is  au  unfavourable  symptom. 
A  large  proportion  of  the  cases  tend,  ac- 
cording to  Lasegue,  to  general  paralysis 
and  dementia. 

(2)  With  regard  to  the  other  injuries 
insanity  is  an  extremely  rare  but  still  an 
occasional  sequel.  These  psychoses  may 
be  considered  with  those  following  sur- 
gical operations,  for  the  main  features  of 
both  are  similar.  It  is  desirable,  however, 
to  mention  at  once  the  retlex  psychoses 
occasionally  met  with.  These  are  usually 
connected  with  the  presence  of  a  foreign 
body,  an  adherent  cicatrix  involving  a 
nerve  or  such  like  cause,  and  manifest 
themselves  as  attacks  of  delirium,  niarkedly 
periodic  in  their  occurrence.  Thus  a  case 
has  been  described  by  Wendt  in  which 
the  auriculo-teraporal  nerve  was  involved 
in  a  scar,  and  the  irritation  gave  rise  to 
periodic  attacks  of  an  epileptic  nature. 
Brown- Sequard  has  mentioned  an  instance 
in  which  the  presence  of  a  foreign  body  in 
the  foot  set  up  similar  disturbance.  The 
treatment  of  such  psychoses  is  obvious 
and  satisfactory.  Such  occurrences  indi- 
cate the  necessity  of  considering  every 
case  of  mania  from  a  surgical  as  well  as 
from  a  medical  point  of  view. 

(3)  As  a  rare  sequel  of  surgical  opera- 
tions insanity  occurs.  Less  closely  allied 
to  traumatic  insanity  than  might  at  first 
be  supposed,  though  possessing  some 
features  in  common,  it  is  of  even  greater 
importance,  for  the  probability  of  its  oc- 
currence might  contra-indicate  operation. 
Up  to  the  present,  however,  so  few  cases 
have  been  recorded  that  it  is  wiser  to 
note  facts  than  to  draw  conclusions.  It  is 
eminently  desirable  that  every  instance 
should  be  made  known,  and  the  compli- 
cation will  probably  then  be  found  far 
more  common  than  at  present  suspected. 
This  variety  of  insanity  presents  certain 
features  :  ( i )  It  is  especially  prone  to 
occur  with  complete  absence  of  heredity 
and   even  in   individuals  free    from   any 


neurotic  taint;  (2)  there  is  always  a 
period  of  quiescence  after  the  operation, 
usually  from  three  to  eight  days  ;  the 
longest  period  known  to  the  writer  was 
eight  weeks ;  (3)  the  onset  of  the  in- 
sanity 2^(i^  se  appears  to  exercise  no  in- 
jurious influence  on  the  progress  of  the 
wound  ;  (4)  when  the  mania  is  acute 
and  the  operation  has  been  grave  in  de- 
gree rather  than  in  accidental  complica- 
tions, death  may  follow,  though  the  wound 
progresses  normally. 

In  the  less  remarkable  variety  there  is 
either  heredity  or  a  neurotic  tendency. 
The  writer  is  of  opinion  that  when  the 
latter  takes  the  hysterical  form  the  patient 
is  less  likely  to  have  any  grave  mental 
disturbance  after  operation.  The  hysteri- 
cally disposed  are  in  fact  good  subjects  ; 
a  somewhat  remarkable  fact.  In  those 
who  are  eccentric  rather  than  insane, 
operations  will  not  infrequently  be  fol- 
lowed by  transitory  mania  of  no  gravity. 
If  the  psychosis  is  influenced  by,  or  origi- 
nates in,  any  surgical  malad}^,  the  removal 
of  this  is  likely  to  improve  the  mental 
condition.  Thus,  hallucinations  of  smell 
have  been  known  to  cease  after  ovari- 
otomy performed  on  a  girl  who  was  insane, 
and  other  surgical  operations  performed 
on  the  insane  have  met  with  success 
as  good  as  in  persons  of  normal  mental 
stability. 

It  seems  unquestionable  that  mania 
may  be  set  up  by  an  anassthetic  in  persons 
free  from  any  predisposition  to  insanity. 
No  aneesthetic  known  appears  free  from 
this  possible  risk.  Here  the  cause  is  toxic 
not  traumatic.  Insanity,  however,  of  this 
variety,  follows  directly  on  the  admin- 
istration of  the  anaesthetic  and  persists. 
There  is  no  quiescent  period.  The  patient 
really  never  recovers  from  the  loss  of  con- 
sciousness into  which  for  weeks  or  months 
the  anassthetic  had  plunged  him.  But 
when  complete  recovery  from  the  anses- 
thesia  has  taken  place,  and  the  mind  fully 
reverts  to  and  remains  in  its  normal  con- 
dition for  a  varying  ]3eriod,  the  anaesthetic 
cannot  be  held  accountable.  Moreover, 
insanity  has  followed  operation  when  no 
aniEsthetic  was  employed,  and  mental  dis- 
turbance has  been  observed  to  follow 
wounds  before  auEesthetics  were  even  in- 
vented. Again,  the  drugs  often  used  in 
surgical  dressings,  such  as  carbolic  acid, 
or  iodoform,  might  be  thought  the  true 
factors.  Or  the  morphia,  so  often  em- 
ployed in  after-treatment,  or  the  trau- 
matic fever  in  the  manner  already  de- 
scribed, might  evoke  the  disturbance.  All 
these  possibilities  must  be  admitted,  but 
still  cases  of  insanity  occur  after  surgical 
operation  when  no  one   of  these   agents 


Tramnatism  and  Insanity     [     13 14 


Treatment  (General) 


has  been  used.  In  a  perfectly  aseptic 
operation  there  is  often  no  pain  whatever, 
and  no  ti-aumatic  fever.  Seeing,  how- 
ever, that  one  form  of  pvierperal  insanity- 
is  associated  with  a  septic  condition,  it  is 
possible  that  failure  to  maintain  asepsis 
during  the  after-treatment  may  pre- 
dispose. 

The  writer  has  not  been  able  to  trace 
clearly  any  such  connection  in  any  in- 
stance. When  a  wound  unites  by  first 
intention,  there  can  be  no  appreciable 
absorption  of  any  drug  such  as  iodoform 
or  carbolic  acid,  and  insanity  has  followed 
abdominal  operations,  such  as  herniotomy 
and  ovariotomy,  in  which  no  cavity  was 
washed  out  by  any  drug,  and  in  which  the 
union  was  perfect.  The  emotional  state, 
induced  by  the  anticipation  of  an  opera- 
tion, may  be  a  predisposing  factor.  It  is 
extremely  difficult  to  estimate  the  degree 
of  this  mental  condition,  but,  none  the 
less,  an  endeavour  should  always  be  made 
to  do  so.  We  have  here  to  judge,  not  by 
the  mental  symptoms  shown  beforehand, 
but  by  the  degree  of  control  the  patient 
is  exercising  in  order  to  subdue  them. 
Relaxation  of  the  mental  tension,  when 
the  subject  of  anticipation  is  over,  may 
be  very  great,  and  will  seem  all  the 
greater,  if  the  mental  condition  has  not 
previously  been  taken  into  account.  A 
certain  degree  of  mental  excitement,  if  not 
undue  in  amount,  is  not  unfavourable. 
Those  who  have  neither  hope  nor  fear  are 
not  the  best  subjects  for  operations. 

Coincidently  with  the  mania  the  wound 
may  progress  in  a  perfectly  normal 
manner,  but  the  temperature  will  com- 
monly be  raised,  so  that  the  chart  does 
not  give  a  true  picture  of  the  surgical 
aspect  of  the  case.  Should  mental  dis- 
order follow  surgical  operation,  it  would 
be  desirable  to  substitute  other  dressings 
for  those  in  use,  to  abstain  from  employ- 
ing iodoform,  belladonna,  eserine,  or  an}' 
such  drugs  which  have  been  known  to  set 
up  delirium.  The  urine  should  be  ex- 
amined, for  renal  disturbance,  such  as 
might  be  produced  by  carbolic  acid,  might 
have  given  rise  to  the  insanity.  Should 
any  anaesthetic  be  required  during  the 
after-treatment,  it  would  be  wise  to 
employ  one  different  from  that  originally 
given.  There  is  no  reason  why  an 
anaesthetic,  if  necessary,  should  be  with- 
held. Chloroform  is,  speaking  generally, 
the  best  to  employ  in  persons  actually 
insane. 

This  insanity  may  occur  at  any  period 
of  life.  The  youngest  case  in  the  writer's 
knowledge  was  a  boy  ten  years  old,  who 
after  excision  of  the  knee-joint  suffered 
from  sub-acute  mania,  with  melancholia 


and  delusions  running  a  chronic  course 
and  followed  by  recovery.  The  oldest  was 
a  woman  aged  sixty-five,  who  was  attacked 
with  chronic  mania  after  an  amputa- 
tion, and  drifted  on  into  dementia  which 
promised  to  be  incui*able. 

With  regard  to  prog-nosis  the  present 
state  of  our  knowledge  does  not  warrant 
us  in  speaking  very  decidedly.  In  the 
majority  of  cases,  where  the  mania  is  of 
moderately  acute  type  and  the  wound, 
does  well,  complete  recovery  follows.  In 
2)atients  whose  constitution  is  broken 
down  by  alcoholism,  renal  disease,  or  such 
like,  the  mental  disorder  is  likely  to  persist 
and  prove  incurable,  though  the  wound 
may  recover  slowly.  When  the  operation 
has  been  a  grave  one,  such  as  ovariotomy 
or  lithotomy,  death  will  often  ensue,  if  the 
attack  of  mania  is  acute,  even  though 
the  wound  progresses  perfectly.  Several 
cases,  however,  of  acute  mania  following 
amputation  of  the  thigh,  have  ended  in 
recovery.  It  follows,  therefore,  that  the 
mental  and  the  surgical  aspect  of  the 
case  must  be  to  a  great  extent  considered 
apart ;  the  mental  being  the  more  impor- 
tant of  the  two.  Throughout,  however, 
the  possibility  of  the  insanity  being  of  the 
reflex  kind  already  mentioned,  must  be 
kept  in  view,  especially  if  the  attacks  are 
periodic.  In  many  cases  the  hair  will  be 
found  to  become  coarse  and  stiff,  and  the 
return  of  the  normal  condition  in  this 
respect  is  a  favourable  indication  that  re- 
covery is  commencing.  If  a  wound  has 
become  aseptic,  it  would  be  proper  to 
adopt  any  further  surgical  procedure  that 
might  be  thought  necessary  to  improve 
the  condition  in  this  respect.  For  ex- 
ample, if  an  excision  of  the  knee-joint  had 
failed  and  the  wound  had  become  septic, 
amputation  might  be  resorted  to,  and 
would  be  more  likely  to  benefit  than  injure 
the  mental  condition.  {See  Traumatic 
Factor  ix  Mental  Disease.) 

Clinton  T.  Dent. 

TREATiviEM-T  (gesteraIi). — Gene- 
ral or  moral  treatment  is  conveniently  se- 
parated from  the  medicinal,  although  in 
practice  they  are  so  intimately  connected. 

We  shall  consider  in  this  article,  rest 
in  bed,  occupation,  exercise  and  amuse- 
ments, schools,  appeals  to  reason,  seclu- 
sion, mechanical  restraint. 

Rest  in  Bed. — Rest  has  been,  there  can 
be  little  doubt,  too  much  neglected  in  the 
treatment  of  the  insane,  notably  in  melan- 
cholia, and  mischief  has  been  done  in 
some  instances  by  forcing  the  patient  to 
take  exercise  or  to  amuse  himself.  Es- 
pecially does  this  hold  true  in  those  cases 
of  mental  depression  which  are  the  result 
of  family  trouble,   and    poverty,  loss   of 


Treatment  (General) 


[     1315    ] 


Treatment  (General) 


memoi'y  and  the  power  of  application  in 
consequence  of  over-stndy  and  other  forms 
ot"  mental  strain  in  the  first  instance.  The 
brain  craves  repose,  and  it  is  worse  than 
useless  to  attempt  to  restore  its  exhausted 
energies  and  tone  by  the  excitement  of  the 
theatre  or  the  concert,  however  useful 
these  may  be  at  another  stage  of  the  dis- 
order. We  are  not  aware  that  any  i^hy- 
sician  at  the  head  of  an  asylum  has  carried 
out  this  mode  of  treatment  more  effec- 
tively than  Dr.  Rayner,  the  late  super- 
intendent of  the  Hanwell  Asylum  (Male 
Department)  where  the  writer  has  known 
cases  markedly  benefited  by  it.  In  a  paper 
read  at  the  International  Lledical  Con- 
gress, Berlin,  1S90,  Dr.  Neisser  (Leubus) 
advocated  tliis  treatment. 

Occupation,  Exercise  and  Amuse- 
ments.— Imijortant  as  under  some  circum- 
stances is  the  complete  rest  of  mind  and 
body,  it  is  no  less  important  to  distract 
the  attention  of  patients  from  themselves 
by  various  forms  of  amusement  and  by 
daily  exercise  in  the  open  air. 

If  idleness  is  a  curse  to  the  sane,  it  is 
the  parent  of  mischief  and  ennui  to  the 
insane,  and  especially  to  the  pubescent 
and  adolescent  cases.  The  lives  of  the 
idle  insane  are  miserable  and  without  in- 
terest: their  morbid  fancies  riot  unchecked, 
while  evil  habits,  quarrelling  and  destruc- 
tiveness  are  all  encouraged  by  the  absence 
of  any  definite  amusement  or  occupation. 
Walks,  games,  and  entertainments  must 
be  encouraged,  but  these  may  not  aiford 
a  sufficient  object,  and  should  be  supple- 
mented by  some  useful  occupation  or  they 
are  apt  to  pall.  The  insane  are  idle  from 
various  causes — from  apathy,  incapability 
of  sustained  attention,  mental  pre-occupa- 
tion  from  delusions,  and  it  may  some- 
times be  said  from  perverse  laziness. 
Employment,  Nature's  universal  law  of 
health,  alike  for  body  and  mind,  is  spe- 
cially beneficial  to  the  insane,  seeing  that 
it  displaces  insane  ideas  by  new  and 
healthy  thoughts,  revives  the  familiar 
habits  of  daily  activity,  restores  selt- 
respect  by  showing  the  patient  that  he  is 
good  for  something,  while  it  promotes  the 
general  bodily  health.  Out-door  employ- 
ment is  no  doubt  the  best,  and  the  garden 
and  farm  are  invaluable  means  of  treat- 
ment. All  kinds  of  workshops  are  need- 
ful for  amateurs  as  well  as  for  artisans. 
Painting  and  YJrinting  also  furnish  in- 
teresting occupation.  We  have  found  the 
latter  of  great  utility  in  concentrating  the 
attention.  The  kitchen  and  laundry  are 
the  workshops  for  female  patients  of  the 
humbler  grades,  while  the  employments 
of  the  higher  class  are  mainly  those  to 
which  they  are  accustomed  at  their  own 


homes.  Nursing  their  fellow  patients  is 
a  valuable  occupation  for  both  sexes,  ao 
far  as  it  can  be  safely  introduced.  Drill- 
ing is  very  useful,  especially  for  the  class 
referred  to  by  Dr.  Shuttle  worth  in  his 
article.  Idiots  and  Imbecilks  (q.v.).  For 
those  who  are  incapable  of  better  em- 
ployment, even  their  whims  should  be 
taken  advantage  of  to  encourage  employ- 
ment, for  the  immediate  object  is  not  the 
value  of  the  labour  but  the  benefit  of  the 
patient.  The  latter  and  the  general 
health  should  determine  the  nature  and 
duration  of  the  work.  Great  risks  must 
often  be  run  in  the  employment  of  pa- 
tients in  placing  tools  and  lethal  weapons 
in  their  hands.  This  risk  is  inevitable 
before  the  patient  can  be  allowed  to  re- 
turn to  the  outer  world  and  it  is  a  risk 
which  the  public  scarcely  appreciate. 

Employment  will  be  encouraged  and 
fostered  by  a  healthy  tone  of  activity  per- 
vading the  whole  asylum,  by  praise,  extra 
privileges,  and  in  certain  cases  by  small 
money  payments.  If  inexcusable  idleness 
may  sometimes  be  met  by  deprivation  of 
privileges,  this  must  never  have  reference 
to  food.*  Insanity  is  as  a  rule  of  an 
asthenic  type,  and  those  who  labour 
under  it  require  ample  support,  the  idlers 
not  excepted. 

One  thing  must  never  be  forgotten, 
that  occupation  and  amusements  are 
sovereign  remedies  for  the  destructive 
habits  of  many  patients.  Pent-up  nervous 
energy  must  have  vent,  and  if  it  does  not 
find  relief  in  occupation  of  some  kind,  or 
in  games,  it  will  assuredly  be  discharged 
upon  animate  or  inanimate  objects,  often 
involving  great  destruction  of  clothing. 
Doubtless  the  greater  recognition  of  this 
fact  would  frequently  make  all  the  differ- 
ence in  the  amount  of  violent  excitement 
in  an  asylum,  and  so  prevent,  in  many 
cases,  the  resort  to  seclusion  and  to 
mechanical  restraint. 

Farm  labour,  a  most  useful  resource  in. 
our  county  asylums,  and  a  universally 
recognised  mode  of  employment,  may,  it 
is  granted,  be  carried  too  far,  but  the  evil 
arising  from  excess  of  work  is  small  indeed 
compared  with  the  far  greater  evil  of  an 
idle  objectless  life. 

However  easy  it  may  be  to  intro- 
duce occupation  in  asylums  for  the 
poor,  this  is  by  no  means  the  case  in 
institutions  for  the  insane  of  the  educated 
class.  A  few  years  ago  an  American 
asylum  physician  requested  us  to  take 
him  to  Bethlem  Hospital  for  the  special 

*  It  would  seem  needless  to  say  that  uotbiug  can 
ever  justify  the  punishmeut  of  the  ineane  for  refus- 
ing- to  work,  yet  such  a  course  has  been  advocated 
within  a  recent  period. 

4P 


Treatment  (General)        [    1316    ]        Treatment  (General) 


piirpose  o£  ascertaining  the  various  ways 
in  which  the  male  patients  were  occupied, 
as  he  had  found  it  extremely  ditScult  to 
secure  this  desirable  result.  He  soon 
became  aware  that  pi-ecisely  the  same 
difficulty  was  experienced  iu  this  hospital, 
notwithstanding  the  strongest  conviction 
tliat  occupation  is  of  the  utmost  utility. 
Some  of  the  patients  were  at  that  time 
engaged  in  bringing  out  a  manuscript 
journal,  Tlie  Betlileliem  Star,*  which 
excited  considerable  interest,  and  diverted 
the  minds  of  many  from  morbid  self-inspec- 
tion. Again,  a  few  patients  were  occupied 
in  drawing  or  painting.  Many  were 
reading  books  and  newspapers.  At  the 
same  time  there  were  no  means  of  healthy 
outdoor  occupation  in  addition  to  games 
of  skill.  On  the  other  hand,  for  the 
female  i^atients,  the  American  visitor  saw 
no  lack  of  work,  in  sewing,  needlework, 
&.C.,  in  addition  to  the  musical  practice 
on  the  piano.  Amusements  ai-e  no  doubt 
more  readily  introduced  than  definite 
occupation.  There  are  games  of  chance 
and  skill — chess,  draughts,  billiards,  and 
then  there  are  the  periodical  concerts  and 
private  theatricals.  Out  of  doors  there 
are  raquets,  tennis,  and  croquet,  cricket, 
football,  and  skittles.  Lectures,  the  magic 
lantern,  and  recitations,  have  their  place, 
and  are  greatly  appreciated  by  some 
patients.  JSTowhere  have  we  seen  them  so 
systematically  carried  out  as  in  some 
asylums  in  the  United  States.! 

Scbools  in  .A.syluius. — The  most  suc- 
cessful and  continuous  endeavour  to 
occupy  a  certain  number  of  patients  in 
an  asylum  by  means  of  imparting  school 
knowledge  was  carried  on  at  the  Richmond 
Asylum,  Dublin,  by  the  late  Dr.  Lalor, 
into  the  working  of  which  we  carefully 
inquired  some  years  ago.  It  has  always 
appeared    to   us   that    asylum  chaplains 

*  This  Journal  first  appeared  in  1875,  expired 
in  seven  weeks  after  a  delicate  and  critical  state  of 
health,  and  was  resuscitated  in  1879,  but  soon 
came  to  an  untimely  end.  In  1880  it  returned  to 
life,  only  to  expire  after  a  brief  career.  In  1889  a 
new  journal  appeared,  Under  the  Dome,  which  for  a 
considerable  time  was  a  success,  and  lasted  nearly 
a  year.  We  are  glad  to  add  that  it  is  now  resumed, 
and  is  for  the  first  time  printed,  the  editor  being 
the  medical  superintendent,  Dr.  Percy  Smith.  At 
the  Edinburgh  Itoyal  Asylum,  the  Morningside 
Mirror,  and  at  the  Montrose  Koyal  Asylum  the 
Sunnyside  Chronicle  have  long  flourished. 

t  At  the  British  Medical  Association  Meeting 
1883,  Dr.  Yellowlees  brought  forward  in  the  Psy- 
chology Section  the  subject  of  occupation  in 
asylums,  but  unfortunately  it  was  an  extemporary 
address  and  has  not  appeared  in  print.  The 
Editor  is  glad  to  find  from  the  rough  notes  with 
which  the  speaker  has  kindly  favoured  him,  that 
the  remarks  he  has  made  are  in  full  accordance 
with  the  sentiments  of  the  superintendent  of  the 
Gartnavel  Asylum. 


might  do  very  good  service  in  superin- 
tending this  mode  of  occupying  the  time 
and  attention  of  patients,  but  unfortu- 
nately the  number  who  take  any  interest 
in  the  subject  is  quite  insignificant. 
Surely  the  gloomy  monotony  which  is  apt 
to  creep  into  these  institutions  would  be 
greatly  lessened,  if  not  prevented,  by  sys- 
tematic instruction  imparted  in  an  able 
and  interesting  manner,  and  by  the  more 
frequent  use  of  musical  instruments.  One 
great  advantage  of  united  tuition  is,  that  it 
brings  a  number  of  patients  together,  and 
subjects  them  to  a  certain  amount  of 
wholesome  rivalry.  It  excites  whatever 
desire  to  excel  may  remain  iu  the  breast  of 
a  lunatic,  rouses  sluggish  faculties,  and 
stimulates  laudable  emulation.  The  atten- 
tion is  diverted  for  at  least  some  hours  from 
the  delusions  under  which  the  patient 
labours,  and  is  concentrated  upon  other 
subjects.  It  seems,  indeed,  impossible 
that  the  occupation  and  diversion  of  the 
mind  which  a  school  (including  music, 
singing,  &c.)  provides,  can  be  other  than 
beneficial.  The  immediate  effect  in  caus- 
ing actual  recovery  may  not  be  apparent, 
and  Dr.  Lalor  did  not  pretend  that  such 
was  the  case,  but  we  are  satisfied  that  an 
excited  patient  not  unfrequently  becomes 
tranquil  after  being  brought  into  the 
class.  It  may  even  avert,  or  at  least 
postpone,  the  period  when  a  patient 
threatened  with  fatuity,  sinks  into  hopeless 
dementia.  As  regards  incurable  cases, 
upon  which  educational  eflForts  may  seem, 
at  first  sight,  entirely  thrown  away,  we 
must  think  that  vicious  habits  are  in 
many  instances  broken,  and  the  direction 
of  the  thoughts  turned,  for  a  time  at  least, 
into  a  healthier  channel.  We  believe  that 
more  has  been  done  in  asylums  to  induce 
the  Greek  scholar  to  read  his  Homer,  the 
German  scholar  his  Goethe,  and  to 
encourage  the  artist  and  musician  to 
interest  themselves  in  the  pursuits  they 
followed  before  they  entered  the  asylum, 
than  to  teacli  those  who  are  more  or 
less  ignorant.  In  short,  more  has  been 
attempted  among  private  patients  than 
among  the  pauper  class.  And  it  is  to 
this  point-^the  introduction  of  well  quali- 
fied, and  therefore  well  paid,  schoolmasters 
and  mistresses  into  some  county  asylums 
— that  we  are  anxious  to  attract  fresh 
attention.*  The  head  inspector  of  national 
schools  (Ireland)  stated,  ten  years  after 
the  Dublin  school  had  been  iu  operation, 
that  "the  experiment  of  bringing  lunatics 
under  regular  instruction  has  been  attended 
in  this  place  with  great  success." 

*  See  article  on  the  Kichmond  Asylum  Schools 
(Dublin),  in  the  Journal  or'  Mental  Science,  Oct. 
1875- 


Treatment  (General) 


13 1 7    ]        Treatment  (G-eneral) 


It  may  be  added,  that  long  ago  Dr. 
Brigham  instituted  winter  classes  in  the 
State  Lunatic  Asyhim,  near  Utica 
(N.Y.),  and  that  Dr.  Pliny  Earle  actively 
enconraged  the  introduction  of  schools 
into  asylums.  The  late  Dr.  Kirkbride 
(Philadelphia)  informed  us  that  he  con- 
sidered a  well-orgauised  school  would  be 
valuable  in  any  large  hospital  for  the 
insane,  as  at  least  an  useful  occupation  of 
the  mind.  Instead  of  having  a  schoolroom 
he  employed  the  ''  companions  "  of  patients 
to  encourge  them  in  reading  and  conver- 
sation every  day. 

In  Scotland  Dr.W.  A.  F.  Browne  formed 
classes  in  the  Dumfries  Asylum.  In  these 
classes  drawing  was  taught,  and  the 
patients  were  instructed  in  Greek  and 
Latin. 

Appeals  to  Reason. — It  has  been  laid 
down  over  and  over  again  that  it  is  of  no 
use  to  attempt  to  argue  an  insane  man 
out  of  his  delusions.  As  a  general  rule 
this  is  no  doubt  true,  but  it  may  be  too 
broadly  stated  and  too  invariably  acted 
upon.  The  rule  may  hold  good  at  one 
stage  and  be  no  longer  applicable  at 
another.  It  will  be  always  open  to  the 
objector  to  the  employment  of  reason  in 
all  cases  to  say  that  it  only  succeeds  when 
the  patient  would  have  recovered  with- 
out having  resorted  to  this  mode  of 
moral  treatment — one  form  of  legitimate 
rationalism.  We  can  only  set  against 
this  facile  objection,  that  we  have  known 
instances  in  which  success  followed  the 
appeal  to  reason  when  other  means  have 
failed  and  there  was  no  indication  of  re- 
covery. Thus,  the  patient  who  believes 
that  her  husband  has  been  killed  by  an 
imaginary  plot,  will  sometimes  recover 
her  senses  when  she  really  sees  him.  At 
any  rate  it  is  certainly  a  duty  to  make 
the  experiment  of  bringing  actual  facts 
to  bear  upon  the  delusion  under  which 
the  patient  labours.  Instances  to  the 
point  will  be  found  recorded  in  the  Journal 
of  Mental  Science  (Oct.  1886),  in  a  paper 
read  before  the  Annual  Meeting  of  the 
Medico-Psychological  Association,  by  Dr. 
Savage.  M.  Parant  has  written  an  able 
defence  of  this  mode  of  treating  the  insane. 

It  is  an  abrupt  transition  from  rational 
methods  of  treatment  to  pass  to  seclusion 
and  mechanical  restraint. 

Seclusion. — That  many  of  the  objec- 
tions which  apply  to  mechanical  restraint 
apply  also  to  seclusion  must  be  admitted. 
That  it  may  be  terribly  abused  is  very 
certain ;  at  the  same  time  its  use  was  one 
of  the  means  by  which  Dr.  Conolly  felt 
himself  enabled  to  dispense  with  restraint 
of  the  mechanical  kind.     His  model  of  a 


padded  room  was  before  him,  as  he  lectured 
at  the  Hanwell  Asylum  on  the  substitutes 
for  restraint,  and  at  the  end  of  the  course 
of  his  lectures  he  presented  the  writer 
with  it  as  a  memorial  of  the  importance  he 
attached  to  seclusion  used  in  moderation. 
When  M.  Battelle,  of  Paris,  insisted  on  the 
impossibility  of  introducing  non-restraint 
into  the  Paris  asylums,  his  reply  was  that 
one  of  the  important  if  not  essential  means 
of  introducing  it — the  placing  an  excited 
patient  in  a  padded  chamber — was  not  re- 
sorted to.  Even  at  the  ^^resent  day  it  is 
rare  to  see  a  padded  room  in  use  in  foreign 
asylums.  In  our  own  country  there  are 
superintendents  who  never  resort  to  seclu- 
sion and  have  no  padded  room.  We  cannot 
but  think,  that  if  OonoUy  attached  too 
much  importance  to  this  mode  of  treating 
certain  patients,  the  other  extreme,  of  i-e- 
garding  the  padded  room  as  never  useful, 
is  a  very  questionable  position  to  take. 

IVCechanical  Restraint.  —  The  most 
prominent  feature  of  the  reformed  method 
of  treatment  of  the  insane  has  unques- 
tionably been  the  reduction  of  the  amount 
of  personal  restraint.  When  the  first  blow 
was  struck  at  the  barbarous  treatment 
of  lunatics  a  century  ago,  the  chains 
were  removed  from  the  limbs  of  the  pa- 
tients for  whose  safety,  or  the  safety  of 
those  around  them,  they  were  employed. 
Under  the  old  system  the  employment, 
amusement,  and  rational  treatment  of  the 
insane  were  almost  out  of  court — they 
seemed  absurd.  In  the  course  of  time, 
the  milder  forms  of  restraint  which  had 
been  substituted  for  iron  fetters  were 
deemed  not  only  unnecessary,  but  ab- 
solutely cruel.  That  it  was  possible  to 
conduct  an  asylum  without  them  was 
proved  by  Gardiner  Hill,  Charlesworth, 
and,  above  all,  by  John  Conolly.  But  it 
was  not  sufficient  to  prove  that  it  was 
possible  to  do  without  any  mechanical 
restraint,  it  was  also  necessary  to  show 
that  it  was  distinctly  better  for  the  patient, 
under  all  circumstances.  The  scientific 
physician  had  to  show  that  medical  and 
moral  treatment  sufficed  to  either  remove 
the  disorder  which  led  to  the  resort  to 
restraint,  or  to  combat  successfully  the 
outbreaks  of  violence  to  which  the  insane 
are  liable.  He  found  it  difficult  to  do 
this.  By  the  employment  of  a  number  of 
attendants  he  was  indeed  able  to  coerce 
the  most  violent  patients  in  an  asylum. 
In  some  instances,  however,  he  was  doubt- 
ful whether  this  jjrolonged  physical 
struggle  was  not  as  irritating  to  the  pa- 
tient as  the  strait-waistcoat ;  whether 
the  tiesh  and  blood  which  contested  for 
mastery  did  not  excite  more  resentment 
in  the  breast  of  the  patient  than  the  un- 


Treatment  (General)         [    131 8    ]        Treatment  (General) 


conscious  garment  to  which  the  patient 
could  not  attribute  personal  animosity. 
It  was  also  felt  that  a  physician  ought  not 
to  be  called  upon  to  bind  himself  in  the 
treatment  of  his  patients  to  pursue  or  to 
eschew  any  one  form  of  treatment. 

It  has  thus  come  to  pass  that  the  whole 
question  of  mechanical  restraiut  has  been 
re-discussed  in  these  latter  days,  and  there 
has  been  undoubtedly  a  certain  reaction 
against  the  iron  rule  to  which  the  super- 
intendents of  asylums  had  been  subjected 
since  the  triumph  of  ConoUyism.  Re- 
actions mark  the  history  of  medicine  no 
less  than  that  of  nations  in  their  religion 
and  politics.  They  are  sanctioned  by  an 
experience  of  the  disadvantages  as  well  as 
the  advantages  which  flow  from  the  ex- 
treme position  originally  taken.  A  more 
moderate  one  would  have  been  better  in  the 
first  instance,  but  then  all  reforms  are 
themselves  reactionary  jorotests  against 
some  abuse,  audit  would  seem  almost  im- 
possible to  start  such  a  movement  without 
an  amount  of  enthusiasm  which  is  apt  to 
override  a  strictly  logical  and  scientific 
demand.  The  dread  of  the  return  to  evil 
ways  from  which  there  has  been  an  escape, 
naturally  induces  good  men  to  shut  their 
eyes  to  the  value  of  some  practices  which 
have  been  swept  away  along  with  those  of 
a  highly  objectionable  character.  In  the 
present  instance,  it  may  well  be  that  an 
excellent  man,  penetrated  by  an  intense 
admiration  of  what  had  already  been 
achieved  in  the  amelioration  of  the  condi- 
tion of  the  insane,  and  with  the  fervent 
desire  to  extend  it,  went  too  far  in  his 
iconoclastic  fervour,  and  like  the  English 
Puritans  under  Cromwell  destroyed  some 
things  which  might  have  been  usefully 
retained,  and  proclaimed  as  a  dogma  ad- 
mitting of  no  exception  (unless  surgical), 
that  which  involved  a  difference  of  degree 
rather  than  of  kind.  Thus,  whether  a 
violent  patient  should  be  held  down  by  the 
strong  hands  of  attendants,  or  secured  in 
bed  by  certain  appliances,  involved  a  ques- 
tion of  the  kind  of  material  employed  and 
not  a  principle,  seeing  that  both  practices 
were  examples  of  restraint.  It  was  so,  at 
any  rate  in  those  cases  in  which  the  one 
form  of  restraint  was  substituted  for  the 
other,  for  it  would  be  falling  into  a  grave 
error,  and  doing  a  great  injustice  to  Conol- 
lyism,  to  assume  that  there  were  no  other 
alternatives.  It  is  the  legitimate  boast  of 
those  who  abolished  the  strait-waistcoat 
that,  to  a  very  large  extent,  suitable  moral 
and  medical  treatment  humanised  the 
maniac,  and  that  occupation,  exercise, 
amusements  and  humanity,  were  the  true 
substitutes  of  the  mechanical  restraint 
which  was  so  rampant  half  a  century  ago. 


\Ve  are  most  anxious  to  emphasise  this  in- 
justice to  a  movement  for  which  we  feel  so 
much  sympathy  and  to  which  the  insane 
are  so  much  indebted.  It  is  only  against 
the  fanaticism  which  makes  a  fetish  of 
the  non-restraint  system,  that  we  ought 
to  protest.  We  have  lived  to  see  the  day, 
at  one  time  little  expected,  when  the 
Legislature  has  jjassed  an  Act  which, 
among  other  things  recognises  restraint 
and  lays  down  regulations  in  regard  to  it. 
The  Lunacy  Board  has  from  time  to  time 
admitted  the  necessity  of  some  form  of 
bodily  restraint. 

The  occasions  in  which  mechanical 
restraint  is  employed  by  those  who  occa- 
sionally use  it  are  as  follows  : 

(i)  Cases  of  intense  desire  in  patients 
to  take  away  their  own  life.  In  some  pa- 
tients the  consciousness  of  loss  of  control 
is  accompanied  by  the  demand  to  be 
restrained  from  self-injury.  A  voluntary 
patient  was  admitted  at  Bethlem  Hospital 
with  self-applied  mechanical  restraints. 

(2)  Cases  of  self-mutilation  other  than 
from  suicidal  impulse,  namely,  from  the 
influence  of  delusion  to  mutilate. 

(3)  Some  cases  of  self-abuse  in  which 
during  an  acute  stage  it  becomes  neces- 
sary to  save  the  patient  from  the  con- 
sequence of  his  own  acts. 

(4)  Surgical  cases  in  which  the  patient 
would  interfere  with  the  necessary  treat- 
ment of  wounds,  &c. 

(5)  Some  cases  of  extreme  violence  in- 
volving danger  to  others. 

(6)  Oases  of  intense  and  ceaseless  rest- 
lessness threatening  fatal  exhaustion. 

We  conclude  this,  as  well  as  the  allied 
article  on  Therapeutics  {q.v.},  with  a 
special  reference  to  the  treatment  of 
mania,  by  the  writer  of  the  article  on  that 
form  of  insanity.  It  is,  as  already  inti- 
mated, supplementary  to  Dr.  Conolly 
Norman's  article. 

"  In  no  branch  of  lunacy  practice  haa 
more  advance  been  made  of  recent  years 
than  in  the  ti*eatment  of  the  maniacal  con- 
dition. Violent  purgation  and  free  deple- 
tion, which  were  once  esteemed  panaceas, 
on  the  supjDOsition  that  the  affection  was 
symptomatic  of  sthenic  inflammation, 
are  now  as  obsolete  as  the  swing-chairs 
and  surprise  baths  of  a  somewhat  earlier 
23eriod,  methods  which  no  doubt  rested  on 
the  implicit  assumption  that  excitement 
is  the  indication  of  a  moral  and  not  a 
physical  aberration.  More  recently  the 
practical  difiiculties  which  attend  the 
management  of  mania  were  too  often  met 
by  the  prolonged  use  of  seclusion  and  by 
the  stupefying  effects  of  calmatives  and 
narcotics.  The  dangers  attendant  upon 
the    indiscriminate    use    of    both    these 


Treatment  (General)         [     13 19 


Tremor 


methods  are  now  at  length  fully  recog- 
nised by  alienist  physicians. 

The  first  great  indication  in  dealing 
with  a  case  of  mania  is  to  procure  rest. 
In  the  majority  of  ca,ses  this  can  undoubt- 
edly be  best  eflected  by  means  of  treatment 
in  an  asylum.  Mild  cases  may  be  treated 
under  special  circumstances  in  a  private 
house,  or  better  in  a  general  hospital. 

The  primary  object  is  to  separate  the 
patient  as  thoroughly  as  possible  from  his 
old  suiToundings.  Only  in  this  way  can 
we  obtain  for  the  brain  such  relative  rest 
as  that  organ  is  capable  of  enjoying. 
There  must  be  not  merely  a  cessation  of 
business  worries,  but  a  freedom  from  the 
bustle  and  anxiety  of  ordinary  tlomestic 
life.  The  over-acuteness  of  sensibility, 
characteristic  of  the  maniac,  renders  him 
liable  to  excitement  from  the  most  trivial 
sources  of  irritation.  Our  aim  must  be  as 
far  as  is  possible  to  free  him  from  all  care, 
to  shut  him  off  from  all  objects  with  which 
he  has  formed,  or  is  likely  to  form,  morbid 
mental  associations.  We  find  from  ex- 
perience that  the  sight  of  home  surround- 
ings perpetually  recalls  home  cares  and 
duties,  and  that  the  enormous  mass  of 
associations  connecting  the  patient  with 
relations  and  immediate  friends  renders  it 
difficult  for  him  to  procure  mental  tran- 
quillity in  their  midst.  For  this  reason  it 
is  generally  essential  to  isolate  the  sufferer. 
It  is  also  true  that  friends  are  often  not 
judicious  in  their  treatment  of  the  maniac, 
and  that  to  play  the  part  of  nurse  to  a 
relative  in  a  state  of  mental  excitement 
is  such  an  entire  reversal  of  the  ordinary 
relations  of  life  (not  to  say  such  a  mental 
and  physical  strain)  that  it  is  quite  out  of 
most  people's  power.  Isolation  may  then 
be  carried  out  in  a  jjrivate  house,  seldom 
in  the  patient's  own  residence,  or  in  a 
hospital,  provided  there  is  abundant  at- 
tendance and  medical  care,  and  if  the 
structural  arrangements  are  suitable,  pro- 
vided that  the  case  be  a  mild  one.  Severe 
cases  (i.e.,  cases  in  which  excitement  is 
very  high,  or  in  which  the  general  phy- 
sical symptoms  are  serious)  are  best 
treated  in  an  institution  devoted  to  the 
care  of  the  insane. 

Rest  in  bed  is  the  best  treatment  for  a 
large  number  of  early  cases,  and  should  be 
adopted  in  all  cases  where  the  general 
strength  is  markedly  failing.  It  should 
be  accompanied  by  careful  watching.  It 
is  the  exjDerieuce  of  the  writer  that  a  large 
number  of  cases  of  mania,  whether  prim- 
ary or  recurrent,  can  be  cut  short  by  rest 
in  bed  with  careful  nursing  and  the  ut- 
most quiet  possible. 

Akin  to  the  treatment  by  rest  in  bed  is 
the  question  of  seclusion.     This  is  a  m.ode 


of  dealing  with  maniacal  disturbance 
which  has  been  unduly  discredited  l)y 
having  been  long  abused.  It  is,  neverthe- 
less, of  the  greatest  value  when  carefully 
carried  out.  Undoubtedly  there  are  many 
cases  in  which  seclusion  brings  comfort 
to  the  patient,  and  for  the  time  an  imme- 
diate alleviation  of  his  urgent  symptoms. 
It  should  therefore  be  unhesitatingly 
adopted  with  the  object  above  indicated,  of 
procuring  rest.  It  should  never  be  carried 
out  except  under  the  strictest  medical 
control.  It  should  never  be  resorted  to 
merely  to  give  relief  to  attendants  or  to 
promote  the  tranquillity  of  the  wards. 
Care  must  be  taken  that  the  secluded 
patient  does  not  develop  habits  of  mas- 
turbation, dirtiness,  or  destructiveness. 
Tendencies  this  way  must  be  regarded  as 
indications  unfavourable  to  sechxsion  or 
as  signs  that  it  has  been  too  much  pro- 
longed. The  room  must  be  kept  at  a 
genial  temjDerature,  and  it  must  be  seen 
that  the  patient  is  warmly  clad,  particu- 
larly in  winter,  and  in  the  case  of  persons 
who  are  exhausting  themselves  by  con- 
tinuous excitement.  It  may  be  necessary 
to  provide  clothes  of  some  strong  material, 
wool-lined,  and  locked  at  the  back. 

With  convalescence  or  the  passage  into 
a  more  or  less  chronic  condition,  care 
should  be  taken  to  provide  employment 
for  the  sufferer.  Occupation,  of  course, 
of  a  non-exciting  kind,  is  an  agent  of  the 
utmost  value  whether  in  preparing  pa- 
tients for  a  return  to  the  world  or  in 
steadying  and  tranquillising  those  whose 
recovery  will  never  be  so  complete  as  to 
enable  them  to  regain  their  place  in  society. 
Mania  is  perhaps  that  form  of  mental 
disturbance  which  most  severely  tries  the 
capabilities  of  those  who  are  in  immediate 
charge  of  the  patient.  Nowhere  are  pa- 
tience and  tact  more  requisite.  Nowhere 
is  discipline,  tempered  with  sympathy, 
more  valuable.  Kindness,  good  humour, 
and  readiness  of  resource  on  the  part  of 
attendants  will  often  render  tractable  a 
patient  otherwise  intractable,  while,  on 
the  contrary,  inconsiderate  language  and 
the  injudicious  exercise  of  authority  pro- 
duce irritation  and  disturbance.  This 
element  of  personal  influence,  so  hard  to 
reckon  up,  is  yet  of  inestimable  value. 
The  general  rules  for  the  treatment  of  all 
forms  of  insanity  have  here  a  special  ap- 
plication, and  must  be  ever  in  the  mind  of 
any  one  who  would  successfully  treat 
maniacal  conditions."  The  Editor. 

TREMEirs.  Trembling.  (*S'ee  Deli- 
rium Tkeiiexs.) 

TREIVIOR  {tremor,  a  trembling). — 
Definition. — Tremor  may  be  defined  as  a 
tine  or  coarse  clonic  spasm  of  regular  or 


Tremor 


[     ^320    ] 


Tremor 


irregular  distribution  and  of  limited  range, 
occurring  either  as  the  iihysiological  ex- 
pression of  certain  nerve  states,  or  as  a 
symptom  of  certain  pathological  condi- 
tions. 

No  one  can  study  cases  of  general  para- 
lysis, hysteria,  SiC,  without  having  his 
attention  forcibly  directed  to  muscular 
tremor,  its  diagnostic  imi^ort,  and  the 
different  forms  which  it  assumes.  It  is 
absolutely  necessary,  however,  to  bear  in 
mind  that  tremor  may  arise  in  the  course 
of  other  disorders  altogether  free  from 
mental  disorder  ;  hence  the  importance  of 
endeavouring  to  differentiate  as  far  as 
possible  between  tremors  arising  from 
different  causes.  To  the  superficial  ob- 
server one  tremor  does  not  differ  from 
another  in  character,  but  further  observa- 
tion will  show  that  distinctions  exist  and 
must  be  recognised. 

For  the  purposes  of  description  the 
subject  may  be  considered  (i)  physiolog-i- 
cally,  when  it  may  be  (a)  of  purely  physi- 
cal oi'igin  (as  in  shiverings  and  rigors),  or 
(fe)  of  tncntcd  derivation  (as  in  grief,  anger, 
fear,  &c.)  ;  (2)  clinically,  as  a  symptom 
(a)  of  certain  toxic  conditions  (such  as 
poisoning  by  alcohol,  lead,  mercury,  and 
arsenic,  or  in  the  abuse  of  alcohol,  opium, 
chloral,  tobacco,  arsenic,  tea,  and  coffee), 
{h)  of  certain  neuroses  (such  as  general 
paralytic  conditions,  paralysis  agitans, 
chorea,  insular  sclerosis,  general  paralysis 
of  the  insane,  exophthalmic  goitre,  hys- 
teria, cerebral  tumours,  &c.),  or  (c)  as 
evidence  of  exhaustion  whether  muscular 
or  nervous  (such  as  febrile  deliriums, 
general  asthenic  states,  &c.)  ;  and  lastly, 
we  have  to  investigate  it  (3)  as  a  heredi- 
tary affection,  and  (4)  as  occurring  in  the 
ag-ed  apart  from  muscular  weakness  or 
nervous  degeneration.  It  may  thus  repre- 
sent the  spasmodic  hyper-activity  of  nerve 
cells  in  health,  or  be  the  exponent  of  the 
exhaustion  or  deterioration  of  nerve  cells 
in  disease.  In  dealing  with  these  varie- 
ties of  tremor,  we  shall  reserve  a  fuller 
description  for  such  forms  as  occur  in  dis- 
eases allied  to  insanity. 

The  induction  of  tremor  by  cold  is  a 
physical  phenomenon  due  in  all  probability 
to  the  stimulation  of  the  sensory  cutane- 
ous nerve-endings,  whereby  an  irritation 
of  the  cerebral  motor  centres  is  engen- 
dered, these  being  further  incited  to  action 
by  the  temporary  cerebral  hyperasmia 
which  follows  the  action  of  cold  on  the 
skin.  Its  indications  are  a  rapid,  at  times 
tumultuous,  movement  of  the  muscles  of 
mastication  (chattering)  and  the  arms, 
the  trembling  extending  later  on  to  the 
head  and  trunk,  and  last  of  all  affecting 
the   lower  extremities.      Its  jDeculiarities 


are  the  irregularity  of  the  tremor,  which  is 
now  of  small  now  of  wide  range,  the  hori- 
zontal tremor  of  the  head,  and  at  periods 
the  approach  of  the  clonic  contractions  to 
a  tonic  spasm  in  the  trunk  muscles.  The 
fingers  individually  show  little  or  no 
tremor,  the  spasms  being  confined  to  the 
larger  limb  and  trunk  muscles  and  the 
muscles  of  mastication.  In  rigors  due  to 
other  causes,  such  as  irritation  of  mucous 
tracts,  puriform  accumulations,  or  at  the 
commencement  of  symptomatic  or  idio- 
pathic fevers,  tue  cause  and  expression  of 
the  tremor  are  exactly  the  same.  The 
mental  causes  of  tremor  will  be  found  to 
lie  in  those  agitated  states  wherein  the 
patient  gives  vent  to  an  emotional  over- 
flow of  grief,  anger,  fear,  &c.  Here  the 
tremors  are  usually  excessive  in  degree, 
and  last  only  so  long  as  the  mental  per- 
turbation is  extreme ;  there  is  usually 
tremor  of  the  outstretched  arms  and 
hands  mostly  in  a  perpendicular  direction, 
and  in  excessive  states  of  terror  there  is 
tremor  of  the  lower  jaw,  while  emotional 
and  twitching  fibrillation  of  the  lips  and 
tremor  of  the  flexor  and  extensor  muscles 
of  the  legs  are  not  uncommon.  The 
tremor  here  appears  to  be  due  to  a  loss  of 
that  controlling  power  of  the  motor  cen- 
tres subserving  the  muscular  tonicity  by 
the  exercise  of  such  emotional  states,  and 
this  loss  of  tone  control  is  further  illus- 
trated by  the  occurrence  of  sphincteric 
relaxation  during  great  fear  or  excite- 
ment. 

In  disease  tremor  is  of  frequent  occur- 
rence, and  we  may  consider  it  systemati- 
cally according  to  the  above  classification. 

In  toxic  states  the  tremor  may  be  the 
outcome  of  an  acute  or  chronic  action  of 
a  drug. 

Alcohol. — In  the  sub-acute  form  of  de- 
lirium tremens,  the  tremor  occurs  early 
in  the  affection,  is  present  only  on  move- 
ment, and  is  fibrillar,  irregular,  and  wide 
in  range,  affecting  usually  the  superficial 
strata  of  muscles  of  the  upper  extremities, 
the  face  and  tongue,  being  frequently  as- 
sociated with  occasional  twitchings  of  the 
trunk  muscles.  In  the  acute  form  the 
tremors  are  much  more  pronounced,  and 
the  oscillatory  movements  are  not  limited 
to  the  superficial  but  extend  to  the  deeper 
muscular  planes,  so  that  the  tremors 
assume  a  more  general  type,  and  may 
become  so  extensive  as  to  be  transformed 
into  clonic  convulsions  simulating  epilep- 
tiform seizures.  In  the  chronic  forms  of 
alcoholism  the  tremor  ranges  from  slight 
fibrillar  oscillations  on  exertion,  and  after 
drinking  bouts,  to  the  permanent  extensive 
tremors  of  all  the  superficial  muscles  of 
the  arms,  face,  neck,  and  even  the  trunk. 


Tremor 


[     ^321     ] 


Tremor 


The  tremor  as  one  of  the  earliest  signs  of 
alcoholic  excess  may  be  limited  to  the  lin- 
gers, or  ali'cct  the  hands,  forearms,  arms 
and  lips  as  well.  In  the  hands  there  is 
tine  individual,  generally  vertical,  tibrilla- 
tion  of  the  fingers,  which  is  most  marked 
when  the  patient  is  told  to  extend  the 
hand  and  separate  the  fingers ;  that 
affecting  the  forearms  is  also  vertical, 
fine  and  irregular,  the  individual  clonic 
spasms  varying  in  degree,  while  when  the 
neck  muscles  are  affected  the  tremor  is 
most  evident  during  speech,  and  in  the 
erect  posture.  The  levator  anguli  oris 
and  ala3  nasi  show  marked  tremor  in  old 
drunkards  (Pieters),  and  the  tremor  of  the 
lips,  at  first  slight,  increases  with  continu- 
ance of  alcoholic  excesses  until  it  be- 
comes so  marked  as  to  distinctly  aflect  the 
speech,  to  which  the  tongue  tremor  also 
lends  the  quavering  and  stuttering  cha- 
racteristic of  alcoholic  ingestion.  All 
these  tremors  are  exaggerated  on  move- 
ment, and  as  the  system  becomes  more 
and  more  impregnated  with  the  poison,  so 
the  groups  of  muscles  sharing  in  the 
tremor  increase  in  number,  while  the 
tremor  itself  grows  in  severity.  The  dia- 
gnosis between  chronic  alcoholism  and 
general  paralysis  by  means  of  the  tremor 
alone  is  difficult  and  well-nigh  impossible. 
It  is  mainly  through  the  association  of 
other  symptoms  that  the  distinction 
between  these  affections  can  be  drawn. 

Mercury. — The  tremors  of  mercurial 
poisoning,  popularly  known  as  "  metallic 
tremors "  and  "  the  trembles,"  are  very 
distinctive  ;  they  commence  in  the  face 
and  tongue,  then  proceed  to  the  hands 
and  arms,  coming  on  gradually  and  being 
increased  by  excitement  or  emotion 
(Gowers)  ;  they  may  exist  for  years  with- 
out causing  much  inconvenience,  but  when 
they  become  aggravated  through  the  con- 
tinued exposure  to  mercurial  infiuence, 
they  extend  to  all  parts  of  the  muscular 
system,  involving  the  extremities,  the 
head  and  neck,  the  facial  muscles,  the 
tongue,  muscles  of  deglutition  and  the 
trunk  muscles,  as  well  as  the  muscles  of 
respiration.  The  degree  of  tremor  in- 
creases on  movement,  so  that  ultimately 
walking  becomes  jerky  or  choreic,  and 
the  patient  makes  involuntary  grimaces, 
while  the  speech  is  indistinct,  stammer- 
ing, and  tremulous.  The  tremor  at  first 
ceases  on  lying  down,  and  in  the  absence 
of  voluntary  effort,  but  in  the  later  stages 
is  constant  though  lessened  on  rest.  There 
is  no  nystagmus.  When  constant  it  re- 
sembles paralysis  agitans,  but  differs  in 
that  it  ati'ects  the  muscles  of  the  head  and 
neck,  is  much  more  marked  on  movement, 
and  that  there  is  no  fixity  or  rigidity  of 


feature,  or  festination.  The  tremor  is  less 
wide  and  less  irregular  than  in  dissemi- 
nated sclerosis,  wliere  there  is  also  marked 
nystagmus.  From  general  paralysis  it  is 
to  be  diagnosed  by  the  excess  of  the  tre- 
mor and  the  presence  of  stomatitis  ;  from 
plumbism  by  the  blue  line  on  the  gums 
and  the  special  palsy  in  the  latter. 

Iiead. — The  tremor  in  plumbism  is  not 
very  frequent  in  its  occurrence  ;  it  may  be 
fine  as  in  the  senile  variety,  but  it  may 
also  resemble  that  of  paralysis  agitans, 
though  the  increase  on  movement  distin- 
guishes it  from  that  affection;  it  is  also 
slower,  wider,  and  more  irregular  in  its 
distribution;  it  may,  as  pointed  out  by 
Gowers,  affect  chiefiy  the  flexors  of  the 
elbow  and  wrist,  and  the  supinator  longus 
— the  muscles  which  escape  paralysis. 
The  lips  and  tongue  may  also  be  impli- 
cated, and  if  there  is  no  paralysis,  the  dis- 
tinction between  it  and  the  tremor  of 
mercury  poisoning  is  difficult. 

Opium  and  Chloral. — Thetremor found 
in  chronic  poisoning  from  these  drugs  offers 
no  special  characteristics,  being  merely  the 
expression  of  an  enfeebled  exhausted  mus- 
cular system  coupled  with  aueemia,  and 
the  fibrillar  oscillations  are  therefore  like 
those  of  asthenia.  The  loss  of  co-ordina- 
tive  power  which  follows  the  abuse  of 
chloral  may  in  a  measure  assist  in  the 
production  of  the  tremor. 

Arsenic. — The  tremor  in  the  chronic 
abuse  of  this  drug,  as  well  as  in  slow 
poisoning  by  its  means,  closely  approxi- 
mates to  the  alcoholic  variety.  In  other 
cases  it  simulates  that  of  lead,  especially 
when  extensor  palsy  co-exists.  In  many 
cases,  however,  it  is  not  due  to  any  spe- 
cific action  of  the  drug  itself,  but  is  a  con- 
sequence of  the  muscular  degeneration. 

Tea  and  CoflFee. — Max  Kohn  has  de- 
scribed a  sensory  disturbance  which  he 
designates  the  delirium  tremens  of  coffee, 
in  which  there  is  delirium  with  abnormali- 
ties of  the  sensory  functions  and  tremor. 
Tea  taken  in  excessive  quantities  causes 
similar  disturbances,  and  acting  as  these 
agents  do  by  stimulating  the  cutaneous 
sensibility,  and  causing  excitement  of  the 
motor  functions  even  in  small  quantities, 
the  phenomena  they  induce  when  taken 
in  large  quantities  are  easily  explainable. 
The  tremors  offer  no  sjjecial  character- 
istics. 

Coming  now  to  tremor  as  a  symptom 
of  certain  neuroses,  we  have  to  consider 
its  occurrence  in  various  paralytic  condi- 
tions. 

In  hemiplegia,  the  condition  known 
as  post-heniiplegic  chorea  is  sometimes, 
but  rarely,  met  with,  and  consists  of  a 
somewhat     irregular,     minute,   fibrillary 


Tremor 


[     1322    ] 


Tremor 


quivering,  usually  limited  to  the  arm  af- 
tected,  and  best  seen  in  those  forms  of 
hemiplegia  {e.g.,  the  infantile)  in  which 
recovery  is  taking  place ;  it  is  also  seen 
occasionally  in  cases  of  muscular  atrophy, 
in  certain  forms  and  stages  of  cerebral 
and  cerebellar  disease,  such  as  tumours, 
softening,  &c.,  and  in  locomotor  ataxy. 
Another  form  of  tremor,  not  choreic  in 
character,  being  more  rhythmical  and 
limited,  is  to  be  met  with  in  paralysed 
limbs.  Athetosis  is  a  slow  mobile  sjmsm 
of  intermittent  tyj^e,  unintluenced  by  re- 
pose, and  inco-ordinate  in  its  natui'e  ;  it  is 
limited  as  a  rule  to  the  fingers  and  wrists, 
to  the  feet  and  toes,  though  occasionally 
it  has  been  observed  in  the  face  and 
eyelids. 

Paralysis  agritans  affords  us  a  typical 
illustration  of  rhythmical  tremor.  It 
varies  in  range  from  a  minute  continuous 
fibrillation  to  a  severe  oscillation,  and  as 
its  amplitude  increases  its  rate  lessens, 
diminishing  from  about  7  to  4.8  contrac- 
tions per  second.  In  the  early  stages  of 
the  affection  the  tremor  is  tine,  increas- 
ing in  range  as  the  malady  progresses ;  it 
is  continuous  during  rest,  and  at  first  it 
can  be  controlled  for  a  very  short  period 
by  a  strong  effort  of  will ;  in  the  early 
stage,  too,  the  fibrillation  may  not  be  ap- 
parent during  rest.  Its  other  peculiarities 
are,  the  horizontal  tremor  of  the  arms, 
the  significant  attitude  of  the  hand,  the 
thumb  oscillating  against  the  index  finger 
forming  the  so-called  pill-roUing  move- 
ment, the  bent  attitude,  the  fixed  and  va- 
cant facial  expression,  and  the  unsteady 
festinating  gait.  There  is  a  slight  increase 
in  amplitude  of  range  of  the  tremor  on 
movement,  but  this  is  by  no  means  so 
marked  as  in  insular  sclerosis  or  the  toxic 
forms  of  tremor.  The  groups  of  muscles 
affected  are  mainly  those  of  the  hand  and 
fingers  and  of  the  wrist,  while  those  of  the 
upper  arm  are  less,  and  those  of  the 
shoulder  least  concerned  in  the  tremor. 
This,  as  above  mentioned,  is  generally 
horizontal,  but  it  may  be  lateral  or 
antero-posterior  in  direction,  occasionally 
supinatory  and  pronatory  movements 
predominate.  In  some  few  cases  the 
shoulder  muscles  are  mainly  affected,  the 
degree  of  muscular  implication  diminish- 
ing downwards  instead  of  upwards.  In 
the  lower  extremities  the  intensity  of 
tremor  diminishes  from  below  upwards. 
The  trunk  muscles  are  occasionally  af- 
fected, but  the  head  is  generally  free  from 
tremor,  such  oscillations  as  are  to  be  ob- 
served being  due  to  the  tremor  of  the 
arms.  The  tremors  of  paralysis  agitans 
and  disseminated  sclerosis  are  slow  oscil- 
lations as  distinguished  from  the  tremors 


of  alcoholism,  general  paralysis,  exoph- 
thalmic goitre  and  mercurial  poisoning, 
which  are  far  more  rapid.  The  speech 
presents  the  peculiarity  observed  in  the 
gait ;  there  is,  as  it  were,  an  articulatory 
festination,  a  tendency  to  run  words  into 
one  another. 

Chorea.  —  Though  the  purposeless 
movements  of  chorea  are  not  strictly  to 
be  included  among  tremors,  they,  save 
for  their  amplitude,  partake  of  the  nature 
of  irregular  tremor  of  extremely  wide 
range  and  slow  action.  It  was  this  con- 
sideration that  led  Duchenne  at  first  to 
regard  cases  of  insular  sclerosis  as  in- 
stances of  chorea  in  which  the  irregular 
oscillations  had  increased  in  rapidity 
while  diminishing  in  amplitude.  It  will 
not  be  necessary  for  us  here  to  enter  on 
the  characteristics  of  choreic  and  chorei- 
form movements  and  habit  spasm — they 
will  be  found  described  in  other  parts  of 
this  work. 

Insular  Sclerosis. — The  tremor  pecu- 
liar to  this  affection  presents  certain 
peculiarities ;  in  the  first  place  it  occurs 
only  on  attemi^ted  movement,  it  is  jerky, 
extremely  irregular  and  increased  by 
effort,  emotion,  and  attention  directed  to 
the  movement.  The  tongue  shows 
tremors  of  a  jerky  inco-ordinate  character 
when  protruded,  but  the  facial  muscular 
action  is  generally  calm.  Ocular  muscular 
tremor  or  nystagmus  is  common.  Arti- 
culation has  been  called  "  syllabic,"  stac- 
cato or  scanning,  with  a  tendency  to  clip 
the  ends  of  words.  The  tremor  in  the 
early  stages  is  limited  to  the  hands,  but 
later  on  the  legs  share  in  the  spasms,  in- 
ducing a  peculiar  gait  which  has  originated 
another  name  for  the  malady  —  spastic 
paraplegia. 

General  Paralysis.  —  The  muscular 
tremors  in  a  typical  case  of  general  para- 
lysis are  frequently  indicative  of  the 
hyper-emotional  mental  condition  and  the 
lack  of  controlling  power.  In  the  earliest 
stages  there  is  to  be  noted  an  irregular 
loss  of  restraining  power,  an  inability  to 
gauge  correctly  the  amount  of  force  neces- 
sary to  be  expended  in  carying  out  fine 
movements,  hence  the  smile  becomes  a 
quivering  expanded  grin,  the  tongue  is 
projected  with  a  jerk  with  coarse  fibrillar 
tremors  when  kept  out  for  a  while,  and 
the  hands  and  arms  are  moved  through 
wider  ranges  than  necessary  for  the  ac- 
complishment of  actions.  Later  on  the 
muscular  tremors  grow  more  prominent 
and  assume  a  fibrillar  type,  becoming  as- 
sociated with  the  earlier  ataxy;  the  tongue 
when  protruded  exhibits  a  fine  rippling 
tremor,  irregulai-,  and  at  times  spas- 
modic; the  lips  show  twitchiugs,  wave-like 


Tremor 


[     1333    ] 


Tremor 


fibrillations,  jelly-like  but  unrhythmic 
oscillations  on  exertion,  like  those  of  a 
person  in  a  state  of  intoxication  and  who 
is  on  the  verge  of  tears  ;  there  is  tremor  of 
the  head  on  movement,  and  the  facial 
muscles  show  a  spasmodic  tremulation  as 
soon  as  they  are  called  into  action,  now 
on  one  side,  now  on  another,  or  on  both  ; 
the  occipito-frontalis,  zygomatici  and 
levatores  labii  twitch  and  quiver,  while  at 
rest  the  face  is  quiescent  and  lacks  life 
and  expression.  The  hands  show  rhyth- 
mic twichings,  especially  in  the  small 
palmar  muscles,  while  convulsive  spasm  of 
the  wrist  and  elbow  muscles,  or  of  the 
muscles  of  the  thigh  and  arm,  are  not 
uncommon.  All  these  involuntary  move- 
ments are  mainly  to  be  noted  during 
voluntary  action  or  on  passive  movement, 
and  may  become  so  extreme  as  to  involve 
both  sides  of  the  body  in  a  quivering  con- 
vulsive tremor.  The  hand  when  extended 
also  trembles,  generally  with  slight  dashes 
and  jerks  of  inco-ordination.  The  speech 
demonstrates  not  only  the  muscular 
tremor  and  inco-ordination,  but  also  the 
deteriorating  mental  state.  With  the  for- 
mer only  can  we  concern  ourselves  here, 
referring  the  reader  for  a  detailed  de- 
scription of  the  latter  to  the  article  on 
General  Paralysis.  The  hesitating,  slur- 
ring, slovenly  articulation  with  its  quiver- 
ing tremulous  dwelling  on  vowels  and  its 
blurring  of  consonants,  the  shuffling, 
stumbling  and  sliding  over  dentals,  and 
the  stuttering  repetition  of  labials  and 
gutturals,  all  indicate  the  unsteadiness 
and  insubordination  of  the  articulatory 
muscles  during  speech.  The  handwriting, 
too,  is  a  mirror  of  the  mental  and  bodily 
retrogression,  the  shaky,  imperfectly- 
formed  letters,  the  inco-ordinate  jerkings 
and  unexpected  dashes,  the  blots  and 
smears,  are  all  indications  of  the  muscular 
incompetency,  while  the  elision  of  letters, 
the  re-duplications,  misspelt  words  and  the 
running  of  words  into  one  another  denote 
the  mental  imperfection.  As  the  disease 
advances,  the  groups  of  muscles  impli- 
cated become  larger,  and  the  tremors  grow 
coarser  and  of  larger  amplitude,  the  speech 
becomes  mumbling,  shaky,  quivering, 
stammering,  and  very  iiidistinct,  the 
fibrillations  become  spasmodic  upheavals 
of  muscular  masses,  the  power  of  volun- 
tary movement  gradually  grows  less,  and 
the  patient  slowly  becomes  more  and  more 
enfeebled,  sinking  into  a  helpless  incapa- 
city, the  facial  muscles  being  the  last  to 
retain  a  vestige  of  the  familiar  tremors  of 
the  early  stages. 

Exophtbalmlc  Goitre. — The  tremor  is 
fine,  rapid,  regular  or  ii-regular,  and  occurs 
only  on  movement.      At  times  the  fibril- 


lation may  be  so  regular  as  to  resemble 

paralysis  agitans,  and  again  it  may  be  so 
irregular  as  to  simulate  chorea.  It  may 
be  general  or  partial,  and  has  been  known 
to  be  unilateral  when  the  goitre  and  exojih- 
thalmos  were  also  unilateral  (Gowers). 
Marie  has  noted  that  in  the  regular  form 
the  tremor  is  more  rapid  than  in  paralysis 
agitans. 

Hysteria. — Tremor  may  occur  in  this 
affection  either  as  a  fine  irregular  oscil- 
lation, increased  or  only  present  during 
movement,  or  it  may  be  coarse  and  rhyth- 
mical, continuing  during  I'est,  and  being 
influenced  by  voluntary  movement.  In 
whatever  form  it  may  be  present  it  varies 
greatly  not  only  in  rate  but  also  in  ampli- 
tude, and  is  nearly  always  associated 
with  those  motor  disturbances  known  as 
hysterical  paralysis  and  conti-actures, 
when  in  all  probability  it  is  but  an 
expression  of  the  weakness  of  the  affected 
muscles,  since  it  is  usually  only  after 
maintained  muscular  effort  that  the  tremor 
commences.  It  is  by  no  means  constant, 
being  present  at  one  time  and  easily 
evoked,  and  absent  at  another.  When 
present,  attention  directed  to  the  limb,  or 
handling  it,  increases  the  tremor.  The 
coarse  form  may  consist  of  a  rapid  rhyth- 
mical oscillation  of  the  head  or  hands,  and 
in  the  legs  the  tremor  may  be  brought 
about  by  attempts  to  straighten  the 
contracted  joints.  Emotion  necessarily 
increases  the  tremor,  and  there  may  be 
isolated  tremors  of  a  group  of  muscles  of 
one  side  of  the  face,  &c.,  but  these  are  rare. 
Hysterical  chorea  may  here  be  mentioned, 
an  imitative  representation  of  chorea  minor, 
coloured  by  hysteria.      {See  Hysteria.) 

Convulsive  Tremor,  a  name  given  by 
Prichard  to  the  condition  known  as  myo- 
clonus multiplex,  is  characterised  by 
shock-like  jerkings  of  the  trunk  and  larger 
limb  muscles,  and  it  may  vary  from  very 
slight  to  extremely  intense  clonic  contrac- 
tions. They  may  be  constant,  or  cease 
during  sleep,  or  occur  only  in  paroxysms. 
Gowers  regards  the  affection  as  allied  to 
senile  chorea.     {See  Convulsivk  Tremor.) 

Acute  disease  inducing  muscular  weak- 
ness brings  about  in  consequence  a 
tine  form  of  tremor,  which  occurs  only  on 
movement  and  is  but  an  expression  of 
the  imperfect  response  to  highly  energised 
cortical  centres  (as  in  the  delirium  of 
fevers,  acute  mania),  or  of  the  easily 
fatigued  muscular  fibre  conjoined  with 
the  action  of  an  exhausted  nerve  cell  (as 
in  convalescence  from  severe  illness,  the 
prostration  of  starvation,  &c.).  In  old 
standing  heart  affections  slight  muscular 
tremors  are  to  be  met  with,  and  esjjecially 
tremor  of  the  head  and  hands  on  exertion. 


Tremor 


[     1324    ] 


Trephining 


The  pulsatile  jerking  of  the  extremities  in 
heart  disease  must  uot  be  mistaken  for  a 
rhj'thmic  tremor. 

Old  agre  presents  us  with  a  peculiar 
form  of  tremor;  we  are  not  speaking  of 
the  tremor  due  to  muscular  weakness,  but 
an  extremely  tine  regular  and  rapid  oscil- 
lation which  at  first  occurs  only  during 
muscular  exertion,  ceasing  entirely  during 
rest  and  sleep.  It  is  earliest  observed  in 
the  arms  and  hands,  the  neck  muscles 
being  affected  later  on.  After  some  time 
it  occurs  both  during  rest  and  on  exer- 
tion, and  presents  so  close  an  analogy  to 
paralysis  agitans  (except  that  the  other 
signs  of  the  affection,  the  peculiar  gait, 
the  fixed  look,  and  the  affected  speech,  are 
absent)  that  it  has  been  regarded  as  a 
modified  form  of  that  disease.  It  is 
especially  to  be  noted  in  the  writing,  a 
typical  example  of  which  is  furnished 
by  Fig.  I.  in  the  article  on  Handwriting 
iq.v.). 

Another  form  of  tremor,  apparently 
independent  of  disease,  but  in  all  proba- 
bility due  to  bereditary  nervous  weak- 
ness, has  been  described  by  Gowers  and 
others.  It  is  usually  fine  in  range,  some- 
times irregular  and  unequal  in  degree  of 
movement,  and  there  is  no  concomitant 
muscular  weakness  or  rigidity,  which  dis- 
tinguishes it  from  the  tremor  of  paralysis 
agitans.  It  occurs  in  young  or  middle- 
aged  persons,  is  capable  of  being  con- 
trolled by  the  will,  so  that  it  does  not 
show  itself  in  the  writing,  and  occasionally 
it  ceases  during  rest.  The  hands  and  neck 
muscles  are  those  mainly  affected,  but  the 
face  and  tongue  may  also  share  in  the 
tremor,  such  cases  being  frequently 
mistaken  for  early  general  paralysis. 
Emotional  states,  especially  if  severe  or 
long-continued,  have  been  assigned  as  the 
direct  cause,  while  an  inherited  neurotic 
disposition,  either  from  gross  nervous 
lesion  or  functional  nervous  disorder,  has 
been  found  in  most  cases. 

Diagnosis. — This  is  involved  and  has 
been  anticipated  in  the  description  of  the 
several  varieties  of  tremor.  It  would  be 
extremely  difficult  in  some  cases,  did  not 
the  affections  in  which  they  severally 
occur  present  other  symptomatic  evidences 
of  distinction,  and  it  is  merely  for  the 
purpose  of  description  and  not  for  differ- 
entiation that  they  have  been  thus  grouped. 
The  broader  forms  of  tremor  are  certainly 
distinctive,  though  even  in  these,  unless 
great  caution  is  exercised,  ei'rors  of  diag- 
nosis may  be  made.  The  handwriting 
illustrating  varieties  of  tremor  will  be 
found  in  a  separate  article.     (See  Hand- 

WKITING  OF  THE  IlSSAXE.) 

J.    F.    G.    PlETEKSEN. 


{licfcnnccx. — Gowers,  Diseases  of  the  Nervous 
System.  Quain,  Dictiouary  of  Medicine.  Charcot, 
Diseases  of  the  Nervous  System,  .Syd.  .Soc,  1889. 
Kristowe,  Theory  and  I'r.ictice  of  Medicine. 
IJoberts,  The  Theory  and  Practice  of  Medicine. 
Finlayson.  Clinical  JIanual.  Bevan  Lewis,  Text- 
book of  Mental  Disease,  London,  1889.  Bucknill 
and  Tuke,  I'sychological Medicine,  f^avage,  Insanity. 
Clouston,  Mental  Disease,  London,  1887.  J 

TREPHIUING.— Those  conditions  of 
mental  disease  in  which  sui'gical  inter- 
ference has  been  employed  for  relief  or 
cure  are  those  of  (x.)  injury  to  the  brain  and 
skull,  (11.)  general  paralysis,  (lH.)  imbe- 
cility when  resulting  from  microcephaly, 
hydrocephalus,  &c.,  (IV.)  hallucinations 
(cerebral  sensory  disorders),  and  (v.)  chro- 
nic epilepsy.  In  the  following  brief  state- 
ments reference  will  not  be  made  to  details 
of  surgical  technique,  since  these  are 
all  contained  in  well-known  text-books  of 
operative  surgery  and  monographs  on  the 
surgical  treatment  of  diseases  of  the 
central  nervous  system,  it  being  sufl&cient 
to  remark  in  passing,  that  no  operative 
interference  is  justifiable  without  conform- 
ity with  the  Listerian  principle  of  asepsis 
and  antisepsis.  Further,  to  profitably 
discuss  the  application  of  operative 
measures  to  the  above-stated  disease 
states,  allusion  will  first  be  made  to  the 
pathological  condition  which  it  is  desired 
to  relieve,  and  then  will  follow  a  discussion 
of  the  treatment  which  it  is  suggested 
should  be  at  present  adopted.  Finally,  no 
space  will  be  occupied  in  discussing  the 
question  of  risk  to  life,  except  where  spe- 
cially prominent  (see  IZZ.),  since  the  con- 
dition of  all  these  cases  is  one  of  hopeless 
incapacity  and  death,  unrelieved  if  surgery 
can  do  nothing  for  them.  For  this  reason 
the  mortality  percentage,  after  such  ope- 
rations, although  extremely  small,  is  of 
no  scientific  value  or  interest  to  the  com- 
munity. 

The  difficult  question  of  estimating  the 
value  of  the  results  of  such  treatment  is 
considered  last. 

I.  Injury  to  the  Brain  and  tbe 
Skull. — PatluAofjy. — Cases  in  which  vari- 
ous forms  of  insanity  have  followed  severe 
injury  to  the  brain  or  skull  are  commonly 
spoken  of  as  cases  of  traumatic  insanity, 
a  very  unfortunate  expression.  The  first 
and  most  complete  account  of  cases  in 
which  surgical  treatment  was  resortedto  for 
the  direct  purpose  of  relieving  the  mental 
condition  are  those  recorded  by  Skae  and 
others,  later  by  Bacon,  Hartmann,  and 
Talcott  (see  also  Mickle).  In  all  these  cases 
there  was  a  direct  injury  to  the  head, 
resulting  in  the  production  of  a  localised 
lesion  in  the  skull  and  a  cicatrix.  The 
cortex  of  the  brain  consequently  was 
damaged  in  each   instance,  and    further, 


Trephining 


[     1325 


Trephining 


adhesions  necessarily  termed  between  the 
dura  mater,  bone,  and  brain.  The  dis- 
orders of  lunctiou  caused  by  these  struc- 
tural conditions  were  iri  three  cases  mania, 
in  two  cases  morose  depression  and 
delusions.  The  })redominance  of  mania 
is  of  course  in  accord  with  the  observations 
of  Krati't-Ebing  in  regai'd  to  symptoms  in 
chronic  epilepsy.  In  each  case  the  injured 
bone  was  removed,  consequent  upon  which 
recovery  commenced  and  was  obtained  in 
each  of  the  recorded  instances ;  one  case 
being  observed  for  four  years  and  another 
six  years. 

Operative  Procedure.  —  The  surgical 
treatment  of  these  cases  has  hitherto  been 
limited  to  the  removal  of  the  injured  bone, 
and  api:)arently  with  remarkably  good 
results  ;  in  fact,  the  latter  are  so  good  as 
almost  to  suggest  that  unfavourable  cases 
have  not  been  published,  were  it  not  for 
the  results  of  operating  for  chronic  epi- 
lepsy (q.v.).  In  each  instance  the  improve- 
ment in  the  j^atient  commenced  from  the 
time  of  the  operation,  so  that  the  relation 
of  cause  and  effect  is  well  marked  in  such 
cases. 

In  accordance  with  the  experience  of 
the  last-mentioned  condition  it  would  cer- 
tainly seem  that  the  reparation  of  the 
seat  of  mischief  should  not  be  confined  to 
removing  the  bone,  but  also  that  the  opera- 
tion should  be  extended  to  the  dura  mater 
and  excision  of  the  affected  cortex,  since 
this  is  usually  the  starting-point,  sooner 
or  later,  of  epileptic  convulsions. 

In  any  case  there  can  be  no  doubt  that 
early  operation  should  be  resorted  to  in 
all  cases  of  obvious  traumatic  lesion  and 
in  which  mental  disease  has  developed. 

ZZ.  General  Paralysis. — Pathology. — 
The  condition  known  as  general  para- 
lysis is  still  a  terra  incognita  so  far  as  the 
early  stages  of  the  disease-changes  in  the 
central  nervous  system  are  concerned.  It 
is  assumed  by  some  that  there  is,  con- 
currently with  the  degenerative  changes 
in  the  brain,  an  increase  of  the  intra- 
cranial tension,  and  evidence  of  the  same 
in  the  shape  of  increased  pressure  under 
which  the  cerebro-spinal  fluid  escapes  when 
the  dura  is  punctiared  ,is  stated  to  have  been 
observed  during  the  operation  of  trephin- 
ing. It  has  further  been  assumed  that 
this  pressure  prevents  the  proper  empty- 
ing of  the  peri- vascular  lymphatics  and 
consequently  induces  secondary  degenera- 
tive changes.  It  cannot  be  conceded  that 
these  statements  concerning  the  patho- 
logy of  the  disease  have  been  established, 
though  there  has  doubtless  been  observed 
an  apparent  excess  of  cerebro-spinal  fluid. 
The  degenerative  changes  are  of  them- 
selves of  a  nature  that  could  not  be  ex- 


pected to  improve  as  a  result  of  operation, 
if  they  are,  as  is  generally  considered, 
primary  in  the  development  of  the  con- 
dition. 

Operative  Procedure. — Claye  Shaw  and 
Batty  Tuke  have  respectively  operated 
upon  these  cases  or  caused  them  to  be 
operated  upon.  In  each  case  simple 
trephining  with  puncture  and  partial  ex- 
cision of  the  dura  mater  was  performed. 
In  Claye  Shaw's  first  case  there  was  un- 
questionably considerable  improvement, 
the  patient  becoming  coherent  and  having 
no  delusions,  the  speech  remaining  un- 
altered. Seven  months  after  the  opera- 
tion the  patient  died  after  the  onset  of 
convulsions  which  had  commenced  only 
twelve  days  previously.  In  the  second 
case  in  which  there  was  in  addition  the 
symptom  of  great  pain  in  the  head, 
similar  treatment  also  produced  so  much 
change  as  to  enable  the  patient  to  be 
discharged.  He  was  subsequently  re- 
admitted six  montlis  later  and  died  three 
months  afterwards  from  convulsions. 
These  two  cases  commence  the  epoch  of 
trephining  for  the  deliberate  relief  of 
general  paralysis,  and  as  the  result  of 
empirical  treatment  must  be  regarded 
as  noteworthy.  The  propriety  of  the 
more  general  employment  of  operation 
will  be  discussed  directly,  but  it  must 
be  admitted  that  Claye  Shaw's  results 
are  gratifying  in  view  of  the  hopeless 
nature  of  the  disease.  It  was  proposed 
by  Shaw  and  also  by  Batty  Tuke  to  keep 
the  drainage  wound  open  so  as  to  prolong 
the  escape  of  the  cerebro-si^inal  fluid. 
There  would  be  no  difficulty  in  doing  this, 
and  in  view  of  the  considerations  ex- 
pressed above  it  would  be  quite  justifiable. 
In  Batty  Tuke's  case  the  patient  re- 
lapsed in  a  few  days  from  the  mental 
amelioration,  but  did  not  again  suffer 
from  headache.  The  general  adoption  of 
this  pi'ocedure  has  been  disputed  by 
Adam,  Revington,  and  Percy  Smith  on 
the  ground  that  the  improvement  may 
have  been  due  to  spontaneous  remission 
of  the  disease  and  on  account  of  the  want 
of  exact  knowledge  of  the  conditions  which 
the  operation  is  supposed  to  relieve.  The 
cases  in  which  it  would  seem  that  this 
empirical  treatment  is  likely  to  be  at  all 
successful  in  palliating  the  disease  are,  as 
has  been  previously  suggested  by  Claye 
Shaw,  those  in  which  there  is  notable 
pain  in  the  head  and  convulsior  s.  Finally 
he  thinks  that  operative  treatment  should 
be  undertaken  during  the  early  stages  of 
changes  in  speech. 

To  sum  up:  Since  the  operation  in  itself 
cannot  be  considered  dangerous  and  since 
the  condition  is  universally  regarded  as 


Trephining 


L    1326   ] 


Trephining 


tatal,  and  fiirtlier,  since  simple  trejjhining 
can  unquestionably  relieve  the  pain  when 
that  is  present,  it  might  be  tried  purely 
empirically. 

XIZ.  Imbecility  (iVXicrocephaly,  &.C.). 
— Pailiology. — Since  Lannelongue's  well- 
known  communication  on  the  advisability 
of  opening  the  skull  in  cases  of  micro- 
cephaly, that  treatment  has  been  freely 
adopted  in  those  i>atients  in  whom  it  was 
reasonable  to  assume  that  there  was 
either  defective  development  of  the  exten- 
sible bony  envelope  of  the  brain,  or  patho- 
logical increase  of  the  intra-cranial  tension 
with  no  corresponding  compensation  on  the 
part  of  the  growth,  of  the  skull.  Putting 
aside  such  states  as  cannot  be  shown  to 
satisfy  either  of  these  two  conditions,  we 
are  left  to  consider  the  propriety  of  sur- 
gical interference  in  cases  of  microcephaly 
and  hydrocephalus.  While  speaking  on 
the  question  of  pathology  it  is  perhaj^s 
hardly  necessary  to  do  more  here  than 
allude  to  the  necessity  of  excluding  in  any 
given  case  the  possibility  of  the  particular 
condition  under  observation  being  due, 
either  in  part  or  in  the  main,  to  that  very 
obscure  but  commonly  spoken  of  class 
of  cases  in  which  encejjhalitis  is  considered 
to  have  occurred  in  early  life  and  to  have 
been  the  starting-point  of  the  mental 
degradation  {cf.  Strilmpell,  &c.).  To 
return  to  the  cases  of  (i)  Microcephaly 
and  (2)  Hyclroceijlialus  -.  the  former  of 
whicb  must  be  considered  at  some  length, 
(i)  Microcephaly.  —  This  is  not  the 
place  to  introduce  the  academic  discussion 
(Broca  and  Virchow)  as  to  whether  the 
brain  condition  or  skull  condition  in 
microcephaly  {q.v.)  is  more  strictly  j^ri- 
mary.  It  is  sufficient  to  remark  that  in 
microcephaly  a  read}'  distinction  may  be 
drawn  between  the  cases  according  as  they 
are  of  greater  or  less  severity.  Thus,  as 
regards  the  cranium,  in  the  former  case, 
the  fontanelles  close  within  the  first  few 
months  of  birth,  synostosis  of  the  sutures 
occurs,  and  hyperostosis  of  their  margins, 
while  the  bone  subsequently  increases  in 
thickness,  but  not  or  only  very  slightly  in 
superficial  area.  In  the  less  severe  cases 
the  fontanelles  do  not  close  so  early. 
Synostosis  may  be  confined  to  one  suture 
producing  plagiocephaly,  or  only  to  parts 
of  sutures  ;  the  bones  of  the  cranium 
extend,  but  very  slowly,  and  individual 
bones  may  cease  growing  after  the  first 
year  or  two  of  extra-uterine  life.  As 
regards  the  brain  in  a  certain  proportion 
of  the  former  cases,  the  arrangement  of 
the  cortical  mantle  has  been  found  to  be 
primarily  defective  and  no  direct  evidence 
of  intra-cranial  tension  present.  In  the 
remainder  there  is  an  obvious  crowding 


of  the  elements  of  the  encephalon  and 
apparently  an  inhibited  tendency  of  devel- 
opment. In  the  latter  cases  (the  less 
severe),  and  in  whicb  the  cerebral  devel- 
opment has,  as  suggested,  proceeded 
further,  the  defect,  so  far  as  the  brain  is 
concerned,  is  that  due  to  want  of  space. 
Next,  as  regards  other  structural  con- 
ditions observed  in  microcephalic  idiocy, 
these  may  be  summed  up  as  consisting  of 
arrest  of  development  of  the  other  parts 
of  the  body,  and  in  addition  of  anomalies 
of  development.  Coming  next  to  dis- 
orders of  function,  in  the  worst  cases  there 
is  great  difl&culty  in  procuring  the  educa- 
tion of  simple  acts  necessary  to  life — e.g., 
swallowing.  There  is  at  first  contracture 
of  usually  all  the  limbs,  and,  if  this  passes 
off  and  normal  movements  are  not  estab- 
lished, the  condition  becomesone  of  flaccid 
paralysis.  Finally  a  severe  form  of  func- 
tional disturbance  not  infrequently  pre- 
sent is  that  of  convulsions. 

Operative  Procedure. — The  operation 
for  the  relief  of  microcephaly  so  far  has 
been  designed  towards  cutting  away  the 
synostosed  sutures,  thus  giving  room  as 
well  as  allowing  for  the  natural  disten- 
sion of  the  bony  capsule.  The  technique 
of  the  operation  has  been  variously  de- 
scribed, and  performed.  We  believe  that 
the  best — i.e.,  the  least  distui'bing — is  the 
following.  The  plan  must  include  the  per- 
formance of  the  operation  piecemeal,  since 
we  believe  we  have  shown  that  a  danger  to 
lite  in  the  shape  of  hyperpyrexia  may 
thus  be  avoided,  and  it  goes  without  say- 
ing that,  similarly,  shock  is  much  excluded 
thereby.  The  first  operation  consists  of 
a  simple  incision — i.e.,  one  about  4  centi- 
metres long,  parallel  with  and  close  to  the 
middle  line.  A  disc  of  bone  averaging 
I  to  1.5  centimetres  is  removed,  the  wound 
is  closed,  and  treated  in  the  ordinary  way. 
On  subsequent  occasions  further  portions 
are  removed  as  follows  :  Parallel  incisions 
are  made  with  a  small  saw,  in  the  skull 
one  centimetre  apart,  and  continued  for  4 
to  6  centimetres,  according  to  the  condi- 
tion of  the  patient.  In  this  manner  long 
strips  of  bone  are  removed  along  the  lines 
of  the  s\;tures,  so  as  to  free  one-half  of 
the  parietes  of  the  skull  from  the  middle 
line.  If  this  be  insufiicient,  as  evidenced 
by  the  after-condition  of  the  patient  {vide 
infra),  the  other  side  may  be  similarly 
operated  uj^on.  The  procedure  thus  de- 
scribed is  not  the  usual  one,  nor  that 
which  is  employed  by  several  surgeons  at 
the  present  time,  some  preferring  to  cut 
away  the  bone  by  pushing  forceps  between 
the  dura  and  the  bone,  and  so  conveniently 
dividing  the  latter.  While  believing  that 
this  may  be  utilised  in  later  operations  we 


Trephining 


[     1327    ] 


Tristitia 


cannot  help  feeling  that  at  the  commence- 
ment, at  any  rate,  it  is  a  source  of  danger. 
The  wound  ought  invariably  to  heal  in  a 
few  days  by  the  first  intention. 

Results  of  t]io  Operation.  —  Lanne- 
longne  in  his  second  communication,  i-e- 
counting  the  general  results  of  operation 
in  twenty-five  cases,  considered  that  he  had 
thereby  obtained  permanent  improve- 
ment in  the  mental  condition,  that  edu- 
cation before  impossible  became  easy,  and 
in  cases  where  pain  was  obviously  present 
that  it  appeared  to  be  relieved.  From  our 
own  observations,  which  are  confirmator}-^ 
of  those  made  by  the  American  surgeons, 
but  especially  Keen's,  the  first  effect  of 
the  operation  is  to  produce  noteworthy 
amelioration  of  the  mental  symptoms.  If 
the  patient  were  restless  before,  he  is  after- 
wards unquestionably  quieter,  does  not 
scream  or  have  apparent  attacks  of  pain 
as  before  the  operation,  and  is  more 
amenable.  As  regards  changes  in  the 
other  disturbances  of  function  referred  to, 
contracture  diminishes,  and  use  of  the 
hands  and  prehension  commence.  It 
learns  to  swallow  and  to  eat.  Even  in 
partial  operations  we  have  noticed  this  im- 
provement to  continue  for  six  months 
where  the  operation  was  undertaken 
within  the  first  year  of  life.  It  remains 
now  to  consider  whether  the  improve- 
ment is  permanent  or  whether  it  will 
relapse,  and  finally  whether  it  is  possible 
to  obtain  it  in  individuals  who  have 
arrived  at  the  fourth  or  fifth  year.  Of  the 
latter  case,  a  single  experience  of  our  own 
shows  that,  as  Maunoury  found,  when  only 
a  partial  operation  is  performed,  the  con- 
dition becomes  stationary,  or  may  re- 
lapse into  its  former  condition  three  to 
six  months  later.  At  the  present  time  it 
is  impossible  to  speak  definitely  on  this 
matter  until  the  after-examination  of 
cases  shall  have  extended  over  several 
years.  As  regards  the  influence  of  age  in 
deciding  upon  the  pei*formance  of  the 
operation  it  is  obviously  most  advisable 
to  treat  the  case  as  early  as  possible — i.e., 
three  months  after  birth.  There  can  be 
little  doubt,  on  the  other  hand,  that  the 
operation  is  not  promising  after  the  eighth 
or  ninth  year  on  account  of  the  growth  of 
the  skull  (Merkel).  It  would  be  advisable 
therefore  to  propose  if  possible  a  limit  of 
age  after  the  passing  of  which  it  is  un- 
likely that  any  improvement  would  result 
from  surgical  interference. 

(2)  Hydrocejjlialus. — Its  pathology  and 
treatment  need  no  examination  here,  it 
being  sufficient  to  state  that  relief  by 
operation  is  called  for. 

IV.  Operative  Interference  for  Hal- 
lucinations.— Burckhardt   has  proposed 


to  remove,  in  cases  of  very  definite  halluci- 
nation, the  special  sense  receptive  centre 
which  can  be  determined  to  be  the  seat 
of  disturbance,  or  at  least  to  divide  the 
communicating  channels  between  such 
centres.  He  has  excised  with  this  object 
in  view  portions  chiefly  of  the  verbal 
auditory  sense  centre.  From  his  care- 
fully published  cases  it  is  clear  that  (i) 
the  hallucinations  were  diminished,  and 
the  mental  state  improved ;  (2)  the  cases 
were  not  cured. 

Further  evidence  however  is  required 
before  this  procedure  can  be  generally 
adopted. 

V.  z:£E°ects  of  Surg^ical  Treatment  in 
cases  of  Chronic  Epilepsy.  —  Patho- 
logy. —  Any  reference  to  surgical  treat- 
ment of  cases  in  which  mental  defi- 
ciency or  aberration  is  present  would  be 
incomplete  without  brief  mention  of  the 
results  of  operating  in  cases  of  chronic 
epilepsy,  as  to  the  changes  produced  in  the 
intellect.  The  mental  deficiency,  which  is 
so  characteristic  of  chronic  epilepsy,  is 
commonly  attributed  to  two  distinct 
causes  :  (a)  the  cerebral  exhaustion  pro- 
duced by  the  fits ;  (6)  the  interference 
with  the  cerebral  functions  generally 
by  the  action  of  the  original  epilepto- 
genic lesion.  The  operations  under- 
taken for  the  treatment  of  chronic  epilepsy 
have  hitherto  been  performed  in  cases 
where  either  there  has  been  a  cicatrix  in- 
volving the  bone,  &c.,  or  where  the  focal 
lesion  has  been  sought  for  and  excised. 

The  epilepsy  in  some  of  these  cases  has 
not  been  cured,  but  in  all  those  carefully 
reported  there  has  been  observed  for  a 
period  very  shortly  after  the  operation  a 
distinct  improvement  in  the  mental  state. 
The  patient  becomes  brighter,  takes  an 
intelligent  interest,  is  more  careful  and  at- 
tentive, and  more  receptive  of  instruction. 
As  just  stated,  this  has  been  noted  even 
where  the  fits  have  not  been  arrested. 
The  improvement  cannot  therefore  be 
invariably  attributed  to  the  abolition  of 
the  exhausting  attacks,  but  it  must  be  due 
to  the  removal  of  some  factor  by  the 
oj^eration. 

It  has  been  surmised  that  the  changes 
in  the  conditions  of  intra-cranial  pressure 
which  are  induced  by  the  opening  of  the 
skull  is  the  source  of  this  improvement. 
At  present,  however,  it  is  impossible  to 
satisfactorily  explain  the  causation  of  the 
alteration.  Victor  Horslet. 

TRISTEMANIA,  TRISTIMAiriA. 
Synonyms  of  Melancholia.  (Fr.  triste- 
'manie.) 

TRISTITIA  {tristis,  sad).  A  synonym 
of  Melancholy  as  distinguished  from  me- 
lancholia (tristemania). 


Tromomania 


[     1328    ] 


Turkey  and  Egypt 


THOVfLOT/lAHTXA.  {rpofiiw,  I  tremble; 
/Liafia,  madness).  A  synonym  of  Delirium 
Tremens. 

TROPHOM'EUROSZS  {rpoc^rj,  nourish- 
ment ;  vevpov,  a  nerve).  Atrophy  of  a 
part  from  interference  with  the  nervous 
influence  connected  with  its  nutrition. 

TRUBSXM'N'  (Ger.).  Melancholia.  (Fr. 
iwplioneurose.) 

TRVCBlIiD  (Ger.).     An  illusion. 

TRUNK SUCHT  (Ger.).  Habitual 
drunkenness,  dipsomania  (q-v.). 

TROPHIC  IiESIOSrS  IN  THE 
INSANE.  {See  Bedsokes  ;  H.ematoma 
AuRis,  &c.) 

TRUSTS  (liiiW  OF)  IN  REIi.aTION 
TO  IiUNACY. — The  Trustee  Acts  1850- 
1852  enable  the  proper  Court 

(i)  To  divest  a  trustee  (or  mortgagee) 
who  is  lunatic  or  of  unsound  mind  of  pro- 
perty vested  in  him  ; 

(2)  To  appoint  a  new  trustee  in  place 
of  a  trustee  who  has  become  lunatic  or  of 
unsound  mind ; 

(3)  To  appoint  a  new  trustee  where  a 
person  in  whom  a  power  of  appointment 
is  vested  becomes  of  unsound  mind. 

The  most  recent  work  on  this  subject  is 
Williams's  ''  Petitions  in  Chancery  and 
Lunacy,"  to  which  the  reader  is  referred. 
A.  Wood  E-enton. 

TUBERCUIiOSZS.        {See     PHTHISICAL 

Insanity.) 

tumours  on  the  brain  and 
INSANITY.     {See  Pathology.) 

TUMUIiTUS  SERMONIS. — An  irre- 
gular or  stuttering  manner  of  reading. 

TURBATIONES  ANIIVII  {turhcitio, 
a  disturbance ;  animus,  the  mind).  Mental 
aii'ections. 

TURKEY  and  Egypt. — It  appears  that 
in  1560  an  asylum  called  the  Suleimanie 
was  founded  at  Constantinople.  It  was 
erected  by  Sultan  Suleiman  near  the 
Mosque  and  the  Tib-Khane,  or  School  of 
Medicine.* 

The  original  name  for  asylums  in  Tur- 
key was  Dar-ul-Shifa.  Subsequently 
they  were  termed  Timar-Khane,  or  nurs- 
ing establishments.  Since  1873  ^he  Turks 
have  called  them  Timar-Khaue  (Homes  for 
Invalids).  In  Mr.  Burdett's  recent  work 
it  is  stated  that  after  the  cholera  of 
1873  all  patients  till  then  confined  in  the 
Suleimanie  asylum  were  transferred  to 
the  Toptaschi  building  at  Scutari,  and 
there  they  remain.  It  is  maintained  by 
the  prefecture  of  Constantinople.  In  it 
are  confined  men  and  women  belonging 
not  only  to  the  Ottoman  Empire  but 
other  nationalities.  In  March  1884 
there  were   492  patients,    of   whom    441 

»  "  Hospitals  and  Asylums  of  the  Workl,"  by 
Henry  C.  Burdett,  1891,  vol.  i.  p.  58. 


were  Mussulmans,  35  Christians,  and  16 
Jews. 

The  description  given  of  the  former 
state  of  the  Scutari  asylum  is  deplorable 
in  the  extreme,  the  patients  being  chained 
by  the  neck  to  their  cells,  while  wild 
beasts  were  kept  in  the  same  place.  Even 
in  1884  in  the  civil  hospital  at  Brussa, 
insane  patients  were  very  badly  treated, 
two  were  chained  by  the  neck  to  the  floor 
of  the  passage  leading  from  the  door  of 
the  hospital  to  the  wards  of  the  patients  ; 
another  was  chained  to  the  floor  at  the 
entrance  to  one  of  the  rooms  occupied 
by  the  ordinary  patients  ;  while  another 
was  secured  in  the  same  manner  to  the 
flooring  of  a  cell  in  the  court-yard.  Mr. 
Burdett,  from  whose  laborious  work  these 
particulars  are  taken,  states  that  all  the 
chains  were  long,  massive  and  heavy,  and 
attached  to  the  neck  by  thick  strong  iron 
rings.  A  fifth  was  hypochondriacal,  but 
was  not  chained.  It  is  added  that  the 
shrieks  and  bowlings  of  the  others  were 
heard  throughout  that  quarter  of  Brussa 
and  greatly  disturbed  the  inhabitants,  and 
there  seems  no  reason  to  suppose  that  the 
terrible  condition  of  the  inmates  of  the 
hospital  has  been  ameliorated. 

Dr.  J.  H.  Davidson,  the  medical  super- 
intendent of  the  County  Asylum,  Che- 
shire, communicated  to  the  Journal  of 
Mental  Science^  April  1875,  ^^  interesting 
account  of  a  visit  to  the  asylum  at  Con- 
stantinople (Toptaschi  in  Scutari),  under 
the  charge  of  the  visiting  physician,  Dr. 
Mongeri.  There  were  two  medical  assist- 
ants, a  surgical  assistant  and  a  dispenser. 
There  were  300  males  and  74  female 
patients  in  the  asylum  at  the  time  of  Dr. 
Davidson's  visit.  The  disparity  of  the 
sexes  is  due  to  a  religious  scruple  as  to  not 
placing  females  in  a  lunatic  asylum.  Some 
lunatics  ramble  about  the  streets  without 
clothing,  and  are  regarded  with  venera- 
tion. All  the  inmates  of  the  institution, 
Mussulmans  or  Christians,  rich  or  poor, 
must  be  dressed  in  the  asylum  uniform. 
The  costume,  it  seems,  resembles  that 
worn  by  the  dervishes.  Acts  of  insubor- 
dination at  the  time  of  the  medical  visit 
are  immediately  suppressed  by  a  shower 
bath,  given  in  the  presence  of  a  numerous 
staft"  in  order  to  overawe  the  patient. 
There  are  preserved  in  the  asylum  the 
chains,  collars and/a7?(fcco, in  use  in  former 
times.  These  are  replaced  by  the  cami- 
sole, which  is,  however,  stated  to  be  rarely 
used.  Reil's  belt  is  sometimes  resorted  to. 
The  prolonged  bath  for  ten  or  twelve 
hours  is  frequently  employed,  as  is  also  the 
Turkish  bath.  There  is  little  or  no  em- 
ployment for  the  ])atients.  Dr.  Davidson 
states  that  Dr.  Mongeri  has  reformed  the 


Turkey  and  Egypt    [  1329  J 


Turkey  and  Egypt 


asylum  :  "  He  had  many  difficulties  and 
prejudices  to  contend  with,  but  these  have, 
in  a  great  measure  been  happily  overcome 
by  his  unflagging  energy  and  indomitable 
perseverance,  and  the  patients  now  con- 
fined in  the  Tiniar-Khane  experience  a 
judicious  and  humane  treatment." 

Bgrypt. — The  asylum  at  Cairo  has  from 
time  to  time  been  described  by  English 
visitors.  In  1877  it  was  visited  by  Dr. 
Urquhart,  and  by  Mr.  W.  S.  Take  in  1S78. 
In  1888  Dr.  F.  M.  Sand  with  described  its 
condition.* 

They  agreed  in  regard  to  its  miserable 
condition.  Mr.  Tuke  spoke  of  the  dirt 
and  squalor  which  at  once  struck  any  one 
familiar  with  an  English  county  asylum. 
The  impression  received  by  him  was  most 
unfavourable.  At  the  Coptic  Church  of  St. 
George,  at  Old  Cairo,  the  visitor  is  shown 
a  pillar  to  which  a  chain  is  attached. 
To  this  pillar  a  person  labouring 
under  acute  mania  is  fastened  for  three 
days  without  food — a  procedure  which  is 
regarded  as  almost  a  certain  cure  of  the 
malady." 

Dr.  Urquhart  wrote  :  "The  whole  place 
is  so  utterly  beyond  the  ken  of  civilisa- 
tion, that  it  remains  as  hideous  a  blot  on 
the  earth's  surface  as  is  to  be  found  even 
in  the  Dark  Continent.''  * 

Dr.  Sandwith  states  that  the  patients 
were  removed  in  1880  from  the  asylum, 
or  more  correctly,  warehouse,  to  the  re- 
mains of  a  palace  in  the  suburbs  of  Cairo. 
In  1884  the  chiefs  of  the  department 
which  controls  the  asylum  and  hospitals 
retired,  and  a  native  pasha  and  Dr.  Sand- 
with succeeded  them.  He  found  "  240  men 
and  60  women  clothed  in  rags,  sitting  all 
day  long  upon  their  beds,  without  exer- 
cise and  without  occuj^ation.  Any  men 
who  had  the  reputation  of  having  been 
dangerous  were  made  to  wear  chains 
similar  to  those  used  in  Egypt  for  hard 
labour  convicts.  These  chains  are  six 
feet  long,  are  fastened  by  a  key  round 
both  ankles,  and  weigh  5f  lbs.  On  the 
ground  floor  with  stone  pavement,  were 
the  dormitories — some  excellent  rooms  on 
the  first  floor  being  unused  ;  and  in  a  se- 
cluded corner  of  the  ground  floor,  on  the 
male  side,  were  four  dark,  barred  dungeons, 
each  provided  with  a  central  hole  leading 
direct  into  a  cesspool  beneath.  In  the 
walls  and  floors  of  these  dungeons  were 
fixed  iron  rings  for  fastening  the  ankles, 
and  either  the  waist  or  the  wrists  of  the 
unfortunate  patient ;  while  under  him  was 
placed  a  wooden  plank,  with  a  red  leather 

cushion  for  his  head  fastened  to  it 

But  perhaps  the  worst  things  noted  were 

*  Journal  of  Mental  Science,  Jan.  i88g,  p.  473. 
t  Jbid.  April  1879,  p.  48. 


the  latrines.  These  were  triangular  holes 
in  the  flooring,  communicating  dii'ectly, 
by  means  of  a  shaft  inside  the  wall,  with 
the  numerous  rectangular  cesspool  pas- 
sages, which  honeycombed  the  old  palace 
and  its  grounds.  The  smell  from  these 
latrines,  even  when  kept  externally  clean, 

could  be  traced  for  several  yards 

There  were  no  ofiicial  visitors  to  the  asy- 
lum, strangers  were  refused  admission,  and 
patients'  friends  could  rarely  obtain  en- 
trance. The  attendants  were  effete  and 
useless  men  and  women  drafted  from  the 
general  native  hospital."  Dr.  Sandwith 
proceeds  :  "  I  had  already  had  the  pleasure 
of  striking  the  chains  off  all  prisoners, 
treated  in  the  twenty-three  hospitals 
under  the  control  of  the  Sanitary  Depart- 
ment, audi  now  removed  all  chains  from 

the  asylum As  a   substitute    we 

provided  camisoles  made  in  Cairo,  after 
the  pattern  of  some  kindly  sent  to  me  by 
Dr.  Savage.  I  may  mention  here  that 
these  were  very  seldom  required,  but  when 
used  for  acute  mania,  they  answered  the 

purpose    admirably The    patients 

wei-e  induced  to  employ  themselves  in  the 
kitchen,  &c.,  and  in  six  months  the  male 
airing  yard  had  become  a  flourishing  gar- 
den. Good  bath  rooms  were  provided. 
The  drainage  was  attended  to.  In  short 
the  whole  place  was  transformed.  As  is 
well  known,  the  most  common  cause  of  in- 
sanity in  Egypt  is  smoking  Indim  hemp. 
Religious  excitement  is  another  cause, 
but  it  is  often  difficult  to  distinguish  be- 
tween cause  and  effect.  The  asylum 
generally  contains  two  or  three  Mussul- 
man fanatics  who  believe  themselves  pro- 
phets. One  patient  believed  himself  to  be 
the  great  Mahdi  from  the  Soudan.  An- 
other patient,  a  chronic  melancholiac,  had 
been  an  officer  in  Arabi's  army.  Dr. 
Sandwith  notes  with  satisfaction  how  the 
attendants  control  their  patients  with 
good-humoured  chaff.  He  has  never  seen 
anything  like  unkind  treatment.  A  very 
small  number  of  the  lunatic  population 
are  sent  to  the  asylum  because  the  native 
retains  his  relative  at  home  as  a  religious 
duty.  The  word  employed  for  an  insane 
person  is  magzoob  (struck  by  the  wrath), 
or  magnoon  {the  victim  of  ginua  or  mad- 
ness.) Alcohol,  Indian  hemp,  and  domes- 
tic trouble  are  the  chief  causes  of  insanity 
among  women.  Dr.  Sandwith  makes  the 
observation,  that  general  paralysis  appears 
to  be  unknown  to  the  cereal-eating  natives, 
although  they  frequently  have  syphilis, 
and  indulge  in  great  excesses.  It  is 
occasionally  met  with  among  well-to-do 
Orientals  in  good  circumstances,  "  who 
eat  meat  freely,  iise  their  brains  more 
than  their  hands,  and  are  not   strict  tee- 


Turkish  Baths 


[     1330    ] 


Twins,  Insanity  in 


totallers."  He  has  found  among  the 
Cairo  insane,  several  with  trembling  of  the 
lips  and  tongue,  without  other  symptoms, 
while  others  with  ideas  of  grandeur  turn 
outto  be  haschisch  cases.     The  Editok. 

TURKISH    BATHS.      {See  Batiis.) 

"  TURN  OF  I.ZFE,"  AND  IN- 
SANXTY.     (»S'ee  Climactekic  Insanity.) 

T'WIM'S,  nrSANlTV  ITX  (Fr.  folie 
gemeUnire).  —  The  extraordinary  resem- 
blances that  exist  between  twins  when 
they  have  attained  the  adult  age  have 
long  attracted  attention,  and  if  in  some 
cases  there  is  absolutely  no  likeness,  and 
in  others  the  likeness  is  no  more  striking 
than  might  be  expected  in  children  of  the 
same  parents,  and  necessarily  akin  to  one 
another  in  character  and  organisation,  we 
are,  on  the  other  hand,  compelled  to  re- 
cognise that  there  is  so  close  a  resemblance 
between  some  twins,  either  intellectually, 
as  regards  the  physiognomy  and  the  ex- 
pression of  the  face,  or  in  respect  to  states 
of  health  and  disease,  that  it  seems  almost 
to  amount  to  identity. 

It  is  not  only  in  external  likeness  that 
these  resemblances  exist ;  it  is  also,  and 
especially,  in  the  intimate  organisation  of 
the  nervous  system,  and  in  the  physio- 
logical consequences  that  result. 

The  same  disease  has  sometimes  been 
known  to  occur  in  twins,  almost  at  the 
same  moment,  and  following  the  same 
course — a  proof  of  the  close  relationship 
between  the  two  natures.  When  the 
disease  in  question  is  a  mental  aberration 
the  proof  acquires  a  greater  force,  and 
leads  naturally  to  the  conclusion  that  the 
cerebral  organisation  of  the  two  individuals 
must  have  the  deepest  analogy. 

Some  few  cases  of  insanity  of  twins 
have  been  placed  u])on  record.  By  this  is 
meant  the  mental  aberration,  developed 
almost  simultaneously  in  both  twins,  ex- 
hibiting the  same  kind  of  delirium,  and 
outside  of  the  usual  conditions  of  occur- 
rence of  communicated  insanity,  or  foJie 
a  deux.  As  a  matter  of  fact  twins  may, 
like  any  other  members  of  an  insane 
family,  become  the  subjects  of  mental 
derangement  one  after  the  other,  and 
manifest  the  same  symptoms  of  perturb- 
ation of  the  intelligence. 

But  by  insanity  of  twins  is  to  be  espe- 
cially understood,  the  mental  derange- 
ment developed  in  conditions  peculiar  to 
twins,  and  characterised  by  the  three  fol- 
lowing peculiarities : 

(1)  Simultaneity  of  occurrence ; 

(2)  Parallelism  of  insane  conceptions 
and  of  otber  psycbolog-ical  disturb- 
ances ; 

(3)  Spontaneity  of  tbe  delirium  in 
eacb  of  tbe  individuals  affected. 


These  three  characteristics  are  to  be 
found  in  the  highest  degree  in  the  follow- 
ing cases  : 

Case  I. — Acute  Mania  with  Predomin- 
ance of  Mystical  Ideas,  and  Multiple 
Hallucinations  occurring  almost  simul- 
taneously in  Tivin  Sisters. 

(a,)  Family  History. — The  father  was 
a  sober,  healthy  man,  a  gendarme,  he  had 
married  early,  and  had  six  children,  four 
girls  and  two  boys.  All  the  children  had 
been  healthy  up  to  the  date  of  the  com- 
mencement of  this  observation.  The 
father  died  at  the  age  of  fifty- two  of  sud- 
den apoplexy,  without  ever  having  pre- 
sented cerebral  symptoms,  or  intellectual 
disturbances. 

The  mother's  history  is  wanting.  She 
died  in  childbed  at  an  eai'ly  age. 

The  twins,  left  orphans  at  five  years  of 
age,  were  brought  up  together  in  Lorraine 
until  they  were  fourteen.  They  had 
always  presented  the  closest  physical  re- 
semblance, so  much  that  it  is  not  easy  to 
distinguish  one  from  the  other.  They 
are  both  tall,  of  robust  constitution,  and 
of  sanguine  temperament.  They  have  a 
fresh  colour,  high  cheekbones,  round  faces,, 
brown  hair  and  eyes. 

With  respect  to  character,  Louise  is 
more  serious,  and  even  sadder  than  Laure, 
who  has  always  been  of  a  gay  disposition. 
Louise,  however,  has  always  lived  a  hard 
life,  and  since  her  husband's  illness,  besides 
the  unhappiness  that  it  had  caused  her,  she 
has  undergone  frequent  privations,  some- 
times even  wanting  for  food. 

The  two  sisters  have  always  been  united 
by  the  most  tender  affection ;  their  edu- 
cation has  been  the  same,  and  it  is  worth 
while  noting  that  exaggerated  devotion 
formed  no  part  of  their  training.  This  is 
an  important  point,  inasmuch  as  the 
delusions  in  both  are  essentially  of  a 
mystical  nature. 

From  the  age  of  fourteen  their  exist- 
ences become  sejjarate.  They  are  both 
twenty-nine  years  old  at  the  present  time. 
Louise  came  at  once  to  Paris ;  Laure  re- 
mained in  the  country  for  some  years. 
Louise  married  in  Paris  when  she  was 
twenty-one.  She  has  a  delicate  child 
seven  years  old. 

Existence  for  this  woman,  in  business 
as  a  greengrocer,  has  been  a  long  strug- 
gle. Her  husband  fell  seriously  ill,  with 
albuminuria,  three  years  ago.  During 
the  whole  of  this  time  the  wife  has  tended 
her  husband  devotedly,  but  without  neg- 
lecting the  interests  of  her  little  business. 
On  the  evening  of  the  i6th  of  November 
1883,  a  priest  was  called  to  administer  the 
last  sacraments  to  the  husband. 

The  wife  dismissed  him  because  she  did 


Twins,  Insanity  in 


L     1331    '] 


Twins,  Insanity  in 


not  like  tbe  look  of  his  face.  This  may- 
have  been  the  beginning  of  mental  dis- 
turbance. At  any  rate,  in  the  course  of 
the  night,  the  insanity  broke  out  in  all  its 
intensity.  She  threw  herself  on  her  hus- 
band's neck,  kissed  him,  and  exclaimed, 
"  Jean  is  cured,  I  see  the  good  God." 
From  this  moment  she  became  more  and 
more  agitated ;  she  went  to  the  window 
to  sing  hymns,  broke  the  panes  of  glass, 
insulted  those  ])resent,  and  struck  the 
doctor  who  was  standing  at  the  patient's 
bedside.  The  police  having  arrived  to  re- 
move her,  she  rushed  down  into  the  street 
upon  seeing  them,  and  tried  to  prevent 
them  entering  the  house,  crying  :  "  I  am 
death,  you  shall  not  pass."  It  must  be 
said  that  for  six  days  she  had  been  watch- 
ing her  husband,  almost  without  eating. 
She  had  never  exceeded  the  bounds  of 
moderation  in  the  use  of  alcoholic  bever- 
ages. 

Upon  removal  to  the  Prefecture  (Cen- 
tral Police  Station)  she  exhibited  all  the 
symptoms  of  maniacal  agitation,  giving 
way  to  an  unceasing  loquacity,  stating 
that  she  was  the  Virgin  Mary,  and  that 
she  could  resuscitate  the  dead.  Insomnia 
absolute. 

During  this  time  a  new  complication 
occurs  in  this  domestic  drama.  Laure, 
the  twin  sister  of  Louise,  is  seized  with  a 
lit  of  mental  aberration  almost  at  the 
same  moment. 

Called  to  the  bedside  of  her  brother-in- 
law,  she  had  already  watched  there  one 
night,  when  Louise,  in  her  presence,  had 
suddenly  become  insane.  Two  days  later 
the  man  had  died,  and  Laui'e  had  been 
to  the  funeral.  At  her  brother-in-law's 
grave  she  had  begun  to  talk  nonsense,  and 
no  sooner  had  she  been  conducted  home 
than  an  attack  of  furious  delirium  broke 
out.  Four  days  after  the  fit  of  insanity 
that  had  necessitated  the  removal  of  her 
sister,  she  was  taken  to  the  Asile  Ste.- 
Anne,  under  the  care  of  Dr.  Bouchereau. 
The  following  are  the  separate  histories  of 
these  two  patients  : 

(b)  Case  of  Louise. — Removed  to  the 
Clinique.  Louise  was  admitted  on  No- 
vember 17,  1883.  Treatment,  chloral  4 
grammes  (one  drachm).     Prolonged  bath. 

The  day  after  admission  the  ])atieut  is 
calmer,  she  asks  for  news  of  her  husband; 
and  has  no  longer  any  delusions. 

The  9th  of  December  she  is  still  calm. 
She  is  told  with  the  greatest  caution  of  the 
death  of  her  husband,  and  appears  very 
resigned. 

On  December  11,  as  she  appeared  quite 
restored  to  reason,  she  was  taken  to  see 
her  sister.  She  was  kind  and  affectionate 
to   Laure,  who  is  still  in    full   maniacal 


delirium.  Towards  the  end  of  the  visit, 
Louise  became  excited ;  she  would  not 
leave  her  sister,  and  it  was  with  some 
difficulty  that  she  was  conducted  back  to 
her  ward.  The  rest  of  the  day  she  talked 
nonsense,  and  was  unreasonable. 

December  14. — The  patient  is  seized 
with  irresistible  impulses.  She  throws 
herself  on  those  who  come  neai",  bites  the 
attendants,  and  kicks  them. 

At  the  same  time  she  appears  to  have 
hallucinations  of  hearing.  She  hears 
accusations  to  which  she  replies  by  the 
acknowledgment  of  an  imaginary  guilt. 

December  21.^ — Appearance  of  menses  ; 
agitation  increasingly  violent.  She  strikes 
an  attendant ;  placed  in  a  separate  room, 
she  removes  a  panel  of  the  door.  She  re- 
fuses food,  spits  out  her  medicine,  passes 
the  night  without  sleep.  Treatment  : 
Prolonged  baths,  bromide  of  potassium, 
chloral,  &c. 

The  agitation  did  not  cease  for  a  moment 
until  January  2,  when  there  was  an 
interval  of  calm,  but  on  the  4th  of  January, 
the  symptoms  returned  in  all  their  in- 
tensity. 

January  12. — Hallucinations  of  sight. 
Thinks  she  sees  her  husband  running 
about  in  his  nightdress,  calls  him  by  his 
name,  says  she  is  a  bee,  that  she  has  a 
great  deal  of  work  to  do.  Does  not  cease 
for  a  minute  to  sing  and  shout,  and  to 
knock  against  the  walls  of  the  cell. 

January  17. — Shouted  and  jumped  all 
the  day.  At  dinner-time  she  escaped 
from  the  attendants  and  rushed  into  the 
garden,  round  which  she  ran  three  times, 
allowing  herself  afterwards  to  be  recon- 
ducted to  her  cell. 

January  19. — Still  excited.  Throws 
herself  against  the  walls  ;  sees  trees  upon, 
which  are  birds,  calls  them,  and  tries  to 
catch  them. 

The  agitation  continues  until  Feb.  5. 
At  this  date  she  is  feverish  and  obliged 
to  remain  in  bed.  Milk  diet — saline 
purgative,  which  operated.  The  patient 
began  to  grow  calmer  from  this  time, 
asked  if  her  family  inquired  after  her,  and 
wanted  to  go  and  nurse  her  sick  husband. 
Not  being  allowed  to  do  so,  she  exclaimed, 
"  I  am  here  for  the  remainder  of  my  life." 
Sleep  is  fairl}-  good. 

February  24. — Return  of  agitation  ; 
patient  breaks  everything,  tears  her 
clothes,  loses  her  sleep.  This,  with  few 
intermissions,  is  her  condition  until  the 
end  of  March. 

April  3. — She  is  calmer ;  saw  her 
brother-in-law  for  a  quarter  of  an  hour, 
and  talked  with  him  in  the  parlour. 
Appeared  gay  and  contented. 

April  6. — The  patient  was  shown  to  the 


Twins,  Insanity  in 


[     1332    ] 


Twins,  Insanity  in 


class  at  the  Clinic  ;  her  sister  was  also 
brought  in,  and  the  meeting  was  most 
att'ectionate,  but  after  a  few  minutes  they 
became  agitated  and  were  removed. 

Louise  was  excited  until  the  21st  of  the 
month,  when  she  became  relatively  calm. 
May  3. — The  patient  still  calm  ;  works 
and  sleeps  well ;  she  eats  gluttonously, 
her  appetite  being  insatiable.  The  affec- 
tive sense  is  much  blunted.  She  makes 
no  inquii'ies  about  her  child,  and  I'emains 
iuditferent  to  her  position,  except  that  she 
claims  her  liberty  on  the  ground  that  she 
has  been  here  long  enough,  and  finds  it 
tiresome. 

June  7. — The  patient  is  calm,  and  she 
no  longer  appears  insane.  She  manifests, 
however,  an  unnatural  indifference  to  her 
position,  only  expressing  from  time  to  time 
a  fear  of  a  return  of  the  agitation.  "  It 
seems  to  me,"  she  says,  "  as  if  it  wei'e 
going  to  retui'n." 

(e)  Case  of  Laure. — This  patient  was 
admitted  under  the  care  of  Dr.  Bouchereau 
on  November  27, 1883,  in  a  state  of  violent 
maniacal  excitement.  She  broke  the 
windows,  banged  the  doors,  and  declaimed 
in  an  incoherent  manner,  mystical  and 
ambitious  ideas  being  predominant.  She 
is  the  Virgin  Mary,  the  Queen  of  Fi-ance, 
&c.  She  crosses  herself  frequently,  goes 
on  her  knees,  lifts  up  her  arms  and  turns 
her  face  upwards  in  the  attitude  of 
prayer. 

During  the  following  weeks  the  excite- 
ment continues,  her  movements  are  sudden 
and  her  acts  purposeless.  She  has  sudden 
fits  of  agitation,  threatening,  biting,  strik- 
ing, throwing  herself  upon  the  attendants, 
and  committing  other  acts  of  impulsive 
violence.  She  gives  way  to  insults  and 
bad  language,  and  often  sings  for  hours 
together.  Occasionally  she  undresses  her- 
self. She  always  goes  barefooted,  refusing 
to  wear  anything  on  the  feet.  At  times 
she  throws  herself  at  full  length  in  her 
cell  and  pronounces  an  incoherent  mono- 
logue, or  else  she  will  be  found  ujion 
her  knees  praying.  She  often  sees  the 
Saviour,  the  saints  and  angels.  Some- 
times, however,  it  is,  on  the  contrary, 
serpents  that  appear.  She  has  several 
times  repeated  that  it  is  sought  to  make 
her  swallow  poison. 

She  often  breaks  out  into  sudden  and 
prolonged  fits  of  laughter.  Her  appetite 
is  generally  good.  Insomnia  is  almost 
absolute.  She  talks,  sings,  and  makes  a 
noise  at  night. 

The  maniacal  excitement  and  impulsive 
phenomena  remained  about  the  same  until 
the  middle  of  February.  From  this  date 
her  acts  became  less  disorderly,  and 
although  still  more  or  less  excitable,  she 


was  no  longer  violent,  and  could  work  at 
sewing :  the  incoherence  of  ideas  remained 
unchangecl.  There  were  all  kinds  of 
hallucinations — strange  noises  and  varied 
visions.  Sometimes  the  sky  would  open, 
and  she  would  see  the  doctors  who  spoke 
and  made  signs  to  her.  Sometimes  she 
saw  women  hanged,  or  cut  up  in  pieces. 
From  time  to  time  she  had  genital  hallu- 
cinations. 

March  20. — The  patient  is  calmer  and 
occupies  herself  more  than  before,  but 
there  is  still  the  same  incoherence  of  ideas. 
She  often  laughs  without  being  able  to- 
assign  a  reason. 

April  I. — Her  attitude  is  better.  The 
patient  is  civil  and  works  fairly  well. 
She  exhibits  real  pleasure  when  she 
receives  a  visit  from  her  husband  or 
children. 

From  time  to  time  she  has  a  slight 
agitation  with  shrieks  and  cries,  but  these 
last  only  a  few  minutes,  and  are  not  fre- 
quent. 

April  6. — She  is  brought  into  the  pre- 
sence of  her  sister  in  the  lecture-theatre 
of  the  Clinic,  and  the  two  patients  recip- 
rocally exciting  one  another  have  to  be 
separated. 

May  4. — Laure  is  fairly  calm,  her  mem- 
ory is  good,  and  she  remembers  some  facts 
in  connection  with  her  admission  to  St. 
Anne.  She  is,  however,  far  from  being 
completely  cured ;  her  attitude  is  often 
singular,  and  her  ideas  incoherent  or  con- 
fused. She  imagines  that  she  is  being 
"  worked  ;"  she  feels  a  weight  in  the  abdo- 
men and  uterus,  and  disagreeable  sensa- 
tions in  other  parts  of  the  body ;  she  wiU 
not,  however,  explain  more  fully  as  v;e 
hnow  hetter  than  herself  ivhat  is  the  cause 
of  it. 

She  believes  that  she  is  descended  from 
an  illustrious  family,  perhaps  even  from  a 
royal  one.  She  knows  that  the  heavens 
and  eai'th  belong  to  her  because  the  devil 
has  crowned  her. 

It  is  more  particularly  in  the  interme- 
diary condition,  between  sleep  and  waking, 
and  chiefly  in  the  morning  that  she  has 
visions.  She  sees  children,  and  quarters- 
of  the  moon  descending  from  heaven. 
Three  days  ago  she  saw  a  big  man  with  a 
big  woman  in  a  complete  state  of  nudity. 

She  appears  to  be  greatly  concerned 
about  her  twin  sister,  for  whom  she  has- 
always  had  the  warmest  affection.  She 
is  constantly  asking  to  be  dischai-ged,  as 
her  presence  is  necessary  at  home,  her 
husband  being  obliged  in  her  absence  to 
place  the  till  in  the  hands  of  a  stranger. 

Menstruation  is  regular,  lasting  last 
time  about  thi-ee  days.  There  is  some 
anaemia,  a  soft  systolic  murmur  at  the 


Twins,  Insanity  in 


[     ^333     ] 


Twins,  Insanity  in 


base,  and  a  continuous  musical  hrmt  in 
the  two  carotids. 

May  II. — Examined  again  from  a  psy- 
chological point  of  view.  Tlic  patient 
persists  in  her  delusions.  She  has  visions 
particularly  towards  the  morning;  slie 
believes  that  she  is  queen,  having  been 
crowned  by  the  devil  and  another  person ; 
she  also  believes  that  she  is  a  spirit.  She 
says  that  her  father  is  dead  ;  he  was  the 
Wandering  Jew. 

To  recapitulate :  these  twin  sisters, 
very  alike  both  morally  and  physically, 
were  both  seized  with  delirium  accom- 
panied by  maniacal  excitement,  halluci- 
nations of  the  sight  and  of  other  senses, 
ambitious  and  mystical  ideas,  and  general 
intellectual  disturbance.  The  symptoms 
broke  out  under  circumstances  in  which 
each  had  been  painfully  shocked,  but 
without  its  being  possible  to  explain  the 
coincidence  by  contagion. 

Louise  had  been  sepai'ated  from  her 
sister  as  soon  as  the  delirium  commenced. 
It  is  evident  that  the  delirium,  which  oc- 
curred at  four  days'  interval  in  the  two 
sisters,  must  be  atti-ibuted  to  one  and  the 
same  cause,  that  is,  to  the  same  moral 
traumatism.  And  it  is  only  by  the  most 
intimate  resemblance  of  cerebral  organisa- 
tion that  we  can  explain  so  striking  a 
parallelism  of  symptoms  under  the  in- 
fluence of  this  cause. 

Cases  like  the  preceding  are  not  com- 
mon, but  several  authentic  observations  of 
the  kind  have  been  recorded.  The  follow- 
ing are  sufficiently  conclusive  to  be  worth 
quoting  : 

Case  II. — " Belire  cle  Persecution"  oc- 
curring simultaneouslij  in  Twin  Brothers.* 
— I  have,  at  the  present  time  in  my 
wards,  says  Moreau  de  Tours,  two 
brothers,  twins,  afiected  with  monomania. 
Their  mother  was  mad.  A  maternal  aunt 
is  at  the  Salpctriere.  Their  eldest  sister 
has  a  son,  nineteen  years  old,  remarkable 
for  his  intelligence  and  for  a  singular 
aptitude  for  mathematics.  For  the  last 
two  years  this  young  man  has  by  himself 
done  all  the  bookkeeping  of  one  of  the 
most  important  houses  in  Paris.  When 
he  was  four  or  five  years  old  it  was 
noticed  that  the  whole  of  the  left  side  of 
the  body  was  much  less  develo^^ed  than 
the  right.  The  same  want  of  symmetry 
exists  at  the  present  time,  and  is  suffi- 
ciently evident  to  attract  attention. 

The  twins  resemble  one  another  physi- 
cally to  such  a  degree  that  they  might 
easily  be  taken  one  for  the  other.  Morally, 
the  likeness  is  no  less  complete,  and  pre- 
sents the  most  remarkable  peculiarities. 

*  Moreiiu  de  Tours.  "  h;i  I'sycholoj^ie  Morbide,'' 
PI'-  139  (note;  aud  172. 


For  instance,  the  dominant  ideas  are 
the  same.  Both  believe  that  they  are  the 
objects  of  imaginaiy  persecutions,  the 
same  enemies  have  sworn  their  ruin,  and 
they  adopt  the  same  means  to  this  end. 
Both  of  them  have  hallucinations  of  hear- 
ing. Unhappy  and  morose  they  never 
speak  a  word  to  anybody,  and  answer 
with  reluctance  such  questions  as  are 
addressed  to  them.  They  always  keep 
alone,  and  never  speak  to  one  another. 

A  veiy  cui'ious  fact  has  been  observed 
over  and  over  again  by  the  attendants, 
and  also  by  ourselves.  From  time  to 
time,  at  irregular  intervals  of  two,  three 
or  more  months  by  the  spontaneous  effect 
of  the  disease,  and  without  any  appreci- 
able cause,  a  marked  change  occurs  in  the 
state  of  the  two  brothers. 

Both  of  them  come  out  of  their  stupor 
and  habitual  prostration  at  the  same 
period,  and  sometimes  the  same  day. 
They  utter  the  same  complaints  and  come 
of  their  own  accord  to  beg  the  doctor  to 
restore  them  to  liberty.  We  have  known 
this  to  occur,  strange  as  it  may  appear, 
even  when  they  were  separated  by  several 
miles  :  the  one  being  at  Bicetre,  the  other 
at  Ste.-Anne.  The  closest  parallelism  is 
here  seen,  bringing  the  twin  brothers  into 
symjDathy  as  to  one  and  the  same  mental 
disorder,  both  suffering  from  the  mono- 
mania of  persecution.  They  presented  the 
paradoxical  phenomenon,  which  has  pre- 
viously been  noted  in  other  cases,  of  mani- 
festing at  the  same  day,  and  at  the  same 
hour,  recurrences  and  transformations  of 
their  delirium.  Lastly,  there  existed,  as  we 
have  seen,  hereditary  antecedents  point- 
ing without  doubt  to  mental  disease  in 
the  family.  The  importance  of  this  fact 
will  be  seen  further  on. 

A  most  remarkable  case  of  the  same 
kind  was  recorded  by  Dr.  Baume  iu  the 
Annales  Medico-psycliologiqucs  for  1863, 
which  is  as  follows : — 

Case  III. — Singular  Case  of  Insanity. 
Sidcide  of  Tivin  Brothers.  Strange  Goin- 
cidences.  —  Mental  pathology  gives  rise 
to  the  most  inexplicable  problems,  but 
the  following  case,  says  the  author,  has 
appeared  to  me  peculiarly  strange. 

Two  brothers,  twins,  fifty  years  of  age, 
Martin  and  Francois,  worked  as  contrac- 
tors on  the  railsvay  from  Quimper  to 
Chateaulin. 

Martin  had  given  signs,  five  years  pre- 
viously, of  temporary  mental  alienation, 
and  two  months  ago  he  had  experienced  a 
relapse,  but  of  short  duration.  His  family 
declare  that  there  is  no  hereditary  pre- 
disposition. 

Towards  the  15th  of  January  (the 
present  month)  the  brothers  were  robbed 


Twins,  Insanity  in  [     1334    ]         Twins,  Insanity  in 


of  thi-ee  hnndred  francs,  the  mouey  having 
been  removed  from  a  trunk  in  which  they 
placed  their  common  savings.  During 
the  night  of  the  23rd,  Francois,  who  lodged 
at  Quimper,  and  Martin  who  resided  with 
his  children  at  the  Lorette  (five  miles 
from  Quimper),  dreamt  at  the  same  hour, 
three  o'clock  in  the  morning,  the  same 
thing,  and  both  awoke  suddenly  crying 
out,  "  I  have  him;  I've  got  the  thief ;  they 
are  hurting  tny  brother!''  giving  way 
to  the  same  extravagances,  and  mani- 
festing their  great  agitation  by  dancing 
and  jumping  on  the  floor.  Martin  seized 
upon  his  grandson,  whom  he  took  for  the 
thief,  and  would  have  strangled  him  had 
he  not  been  prevented  by  his  children. 
This  agitation  became  gradually  worse  ; 
he  complained  of  violent  headache,  declar- 
ing that  he  was  lost.  On  the  24th  it  was 
with  great  difficulty  that  he  was  persuaded 
to  remain  at  home,  and  towards  four  in 
the  afternoon  he  went  out,  followed 
closely  by  his  son.  He  kept  along  the 
side  of  the  river  Steir,  uttering  inco- 
herent sentences,  and  attempted  to 
drown  himself.  He  was  only  prevented 
by  the  energetic  interference  of  his  son. 
The  police,  upon  the  warrant  of  the 
neighbouring  mayor,  brought  him  to  the 
asylum  at  seven  in  the  evening,  Martin, 
then  insane,  being  in  the  greatest  state  of 
agitation. 

Whilst  Martin  had  reached  at  the  outset 
the  extreme  limits  of  acute  insanity,  his 
twin  brother,  Francois,  j^romptl}'  enough 
calmed  on  the  morning  of  the  24th,  passed 
the  day  in  seeking  after  the  perpetrator 
of  the  robbery.  Towards  six  o'clock  in 
the  evening  it  so  hapj^ened  that  he 
encountered  his  brother,  just  as  he  was 
struggling  with  the  gendarmes,  who  were 
taking  him  to  the  asylum.  He  exclaimed : 
"  Oh,  my  God !  my  brother  is  lost !  if  they 
take  him  for  the  thief  they  will  murder 
him  ! "  After  gesticulating  wildly  he 
proceeded  to  the  Lorette,  to  the  ambulance 
of  the  railway  works,  comj^lained  of  violent 
pains  in  the  head,  and  said  it  was  all  over 
with  him,  using  some  of  the  same  inco- 
herent expressions  as  his  brother.  He 
requested  to  be  attended  to,  which  was 
done.  He  soon  said  he  felt  better,  and 
left  under  the  pretence  of  business,  going 
and  drowning  himself  at  the  very  same 
place  where  his  brother  had  unsuccessfully 
attempted  to  do  the  same  thing  some 
hours  before.  He  was  recovered  from  the 
water  but  did  not  survive. 

Martin,  admitted  into  the  asylum  on  the 
evening  of  the  24th,  died  suddenly  on  the 
morning  of  the  27th.  During  this  jieriod 
of  time  there  was  no  lucid  interval,  and  the 
first  two  nights  were  passed  in  a  state  of 


extreme  agitation,  the  patient  thinking 
that  he  was  God,  the  emperor,  &c. 

On  the  26th,  after  a  bath  of  several 
hours'  duration,  with  cold  affusions  on  the 
head,  he  was  somewhat  calm  ;  but  at 
ten  p.Ji.  the  excitement  returned  with 
renewed  violence.  He  dashed  his  head 
several  times  against  the  wall,  and  also 
attacked  the  attendants.  Finally,  the 
overseer  of  the  section  had  just  got  him 
back  to  bed  in  the  same  state  of  excite- 
ment, when  without  any  appai'ent  cause 
he  expired  in  our  presence.  The  strongest 
restoratives  had  been  used  to  no  effect. 

At  the  post-mortem  examination,  thirty- 
eight  hours  after  death,  we  found  a  venous 
hEeinorrhage  between  the  two  layers  of 
the  arachnoid,  over  the  posterior  half  of 
the  encephalon.  There  were  about  four 
hundred  grammes  of  dark  fluid  blood 
mixed  with  soft  granular  clots.  The  has- 
morrhage  due  to  the  excitement  of  the 
patient  and  his  attempts  to  dash  out  his 
brains  against  the  walls,  had  probably 
occurred  but  a  few  moments  before  the 
fatal  issue. 

So  died  these  twins.  Their  mental 
aberration,  due  to  the  same  cause,  mani- 
fested the  same  peculiai'ities,  and  after 
breaking  out  at  the  same  time  would  have 
ended  by  the  same  kind  of  suicide,  at  the 
same  spot,  had  not  one  of  the  brothers 
been  prevented  from  executing  his  impulse 
by  circumstances  independent  of  his  will. 

The  Journal  of  Mental  Science  con- 
tains three  cases  of  the  same  kind. 

Dr.  Savage  *  relates  two,  and  it  is 
worthy  of  note  that  in  each  instance  there 
was  a  condition  of  profound  lypemania. 

The  third  was  observed  by  Dr.  Clifford 
Gill.  Twin  sisters,  twenty  years  of  age, 
and  bearing  the  greatest  resemblance  to 
one  another  both  physically  and  morally, 
became  insane  almost  simultaneously.  A 
most  remarkable  parallelism,  both  physio- 
logical and  pathological,  had  previously 
existed.  On  one  occasion  one  of  the  sisters 
being  at  Scarborough,  and  the  other  at 
York,  the  latter  suffering  from  headache 
and  biliousness,  said  to  her  mother  that 
her  sister  was  suffering  in  the  same 
way,  and  the  supposition  turned  out  to  be 
quite  correct.  One  of  the  sisters  mani- 
fests symptoms  of  maniacal  excitement 
with  a  predominance  of  erotic  ideas :  the 
other  has  attacks  of  mania  with  halluci- 
nations, and  a  predominance  of  religious 
delusions.  In  both  cases  the  mental 
symptoms  are  intermittent. 

Dr.  Flintoff  Mickle,  in  the  same  journal, 
relates  the  case  of  twin  sisters,  who,  like 
the  preceding,  showed  the  greatest  re- 
semblance both   morally  and  physically. 

*  Journal  of  Mental  Science,  January  1SS3. 


Twins,  Insanity  in 


[     1335    ] 


Typhoid  State 


The  symptoms  are  exactly  the  same  in 
each  subject,  being  those  of  melancholia 
of  the  religious  type.  Both  imagine  that 
they  are  damned,  have  a  tendency  to 
suicide,  and  suUer  from  hallucinations  of 
the  sight.  But  whilst  one  became  insane 
for  the  first  time  at  the  age  of  twenty- 
nine,  the  other,  who  went  to  America  after 
her  marriage,  instead  of  remaining  like 
her  sister  in  England,  did  not  lose  her 
reason  until  twelve  years  later.  This 
makes  it  all  the  more  remarkable  that  her 
delusions  should  be  identical  with  those 
of  her  sister,  and  that  their  religious 
terrors  should  be  expressed  in  the  same 
terms. 

Cases  such  as  the  above  are  not  fre- 
quent in  medical  literature,  but  it  is  pro- 
bable that  they  would  be  more  so  if  the 
twins  were  not  separated  from  one  an- 
other in  most  instances  when  the  insanity 
has  occurred.* 

As  the  interest  of  the  observations  re- 
sides chiefly  in  the  parallelism  between 
the  two  subjects,  it  is  evident  that  most 
cases  of  the  kind  fail  to  be  recorded.  It 
is  probable,  however,  that,  once  the  atten- 
tion of  alienists  is  drawn  to  the  question, 
cases  will  become  more  numerous — so 
much  so  as  to  no  longer  be  exceptional. 

As  it  is,  some  interesting  conclusions 
may  be  deduced  from  the  documents  that 
we  possess. 

If  insanity  in  twins  were  only  to  be 
looked  upon  as  a  natural  curiosity,  and 
worthy  of  record  in  the  chapter  of  casus 
rariorcs,  it  would  be  of  little  interest  to 
science,  but  such  is  certainly  not  the 
case. 

It  must  first  be  observed  that  the  like- 
ness between  twins  may  vary  extremely  in 
degree.  Sometimes  it  exists  in  the  most 
striking  manner  ;  in  most  instances  it  is 
much  less,  and  in  some  twins  there  is  as 
much  diti'erence  as  in  the  ordinary  children 
of  the  same  family. 

Now,  in  all  the  cases  of  insanity  of  twins 
that  we  have  collected,  the  closest  physical 
and  moral  resemblance  has  always  been 
noted.  Not  only  have  the  features  been 
alike,  but  the  intellectual  and  moral  dis- 
positions have  also  coincided  in  a  remark- 
able degree.  The  nature  of  the  delirium 
has  been  essentially  the  same,  and  with 
the  exception  of  Dr.  F.  Mickle's  case,  the 
date  of  the  first  symptoms  was  the  same, 
so  that  it  is  rational  to  see  in  these  intel- 
lectual disturbances  the  evidence  of  a  deep 
analogy  in  the  cerebral  organisation  and 
the  physiological  function. 

»  See  a  very  interesting  case  reported  by  Dr. 
McDowall  (Morpeili)  in  tLu  Journal  of  Mental 
Science,  July  1884,  witli  portraits  showing  the 
most  marked  resemljlance. — Ed. 


Sometimes,  as  in  the  case  of  Moreau  de 
Tours,  the  attacks  occur  at  the  same  time 
in  both  patients,  and  are  separated  by 
intervals  of  remission  common  to  both. 

Some  of  these  patients  have  a  family 
history  of  insanity,  but  others  are  entirely 
free  from  any  hereditary  taint  of  the  kind. 
There  exists  then  an  intellectual  and 
moral  affinity,  extending  beyond  the  ordi- 
nary limits  of  consanguinity. 

Nothing  is,  of  course,  more  common  than 
the  same  kind  of  insanity  in  different  chil- 
dren of  the  same  parents  constituting  a 
family,  but  at  the  root  of  these  morbid 
manifestations  we  generally  find  heredity, 
and  we  cannot  wonder  at  different 
branches  of  the  same  tree  bearing  the 
same  fruit. 

Twins  are  brothers  with  a  closer  tie. 
Born  at  the  same  time,  conceived  under 
identical  circumstances,  they  have  experi- 
enced the  same  influences  during  the  whole 
period  of  gestation,  and  in  some,  if  not 
in  all  cases,  there  has  resulted  a  striking 
resemblance  of  cerebral  organisation  and 
of  physical  health.  Such  can  be  the  only 
possible  origin  of  these  pathological 
symptoms  which,  breaking  out  at  the 
same  moment,  follow  an  absolutely  iden- 
tical course,  characterised  by  the  same 
phases  and  same  observations. 

Some  accessory  points  complete  the 
likeness,  and  confirm  these  conclusions. 
The  affection  and  proverbial  sympathy 
existing  between  twins  are  developed  to 
the  highest  degree  in  the  subjects  of  these 
pathological  observations  ;  their  infiuence 
upon  one  another  morally  is  not  beneficial ; 
nearly  always,  in  the  course  of  their 
illness,  the  contact  of  the  two  individuals 
has  been  most  harmful  to  both. 

In  these  phenomena  may  be  seen  a  still 
more  convincing  proof  of  the  profound 
likeness  of  the  two  organisations,  which 
react  with  such  a  deep  intensity  upon  one 
another. 

To  sum  up  in  a  word  our  conclusions, 
we  may  say  that  heredity  dominates  the 
whole  question,  and  that  insanity  in  twins 
is  but  the  highest  and  most  striking 
manifestation  of  this  force,  which  kneads 
living  matter  at  its  will,  and  reigns 
through  the  whole  series  of  organised 
beings.  B.  Ball. 

TYPHOID  FBVER.  {See  Fever, 
Enteric  ;  Post-Febrile  Insanity.) 

TVPHOIB  STATE.— A  name  given  to 
the  symptoms  characteristic  of  the  late 
stages  of  typhoid  and  typhus  fever,  but 
which  occur  also  in  other  diseases.  The 
patient  lies  on  his  back,  unable  to  move 
himself,  in  a  state  of  low  muttering  deli- 
rium, subsultus,  the  pulse  feeble,  and  the 
mouth  and  lips  covered  with  sordes. 


Typhomania 


[    1336    ] 


Undue  Influence 


TVPHOIWAN'IA  {tv(})Os,  stupoi" ;  jj-avta, 
madness).  Hippocrates  employed  the 
word  Tv(f)Ofj.avia  to  denote  a  state  of 
stupefaction  in  which  the  patient  is 
suddenly  deprived  of  his  senses  as  if 
thunderstruck,  in  which  sense,  accord- 
ing to  Hippocrates,  it  may  have  been 
immediately  derived  from  tv4>q)v  or 
mcpms,  a  whirlwind).     A  state  of  lethargy 


complicated  with  low  mattering  delirium. 
The  term  has  been  also  applied  to  acute 
mania  running  a  raj^id  course  and  attended 
by  exhaustion.  Dr.  Luther  Bell  first  de- 
scribed it  in  1844 ;  hence  it  is  called  Bell's 
disease.  (Fr.  typhoDianie.)  [See  Acute 
Delirious  Mania.) 

TYRIASXS. — A  term  meaning,  among 
other  things,  satyriasis. 


u 


VM-CONSCIOUS   CEREBRATION. — 

That  activity  of  intellect  and  mental  modi- 
fication which  goes  on  without  the  con- 
sciousness of  the  subject.  It  is  analogous 
to  the  automatic  unconscious  movement 
of  the  limbs  from  habit,  as,  for  instance, 
the  movement  of  the  legs  in  going  up- 
stairs. A  frequently  occurring  example 
of  unconscious  cerebration  is  the  follow- 
ing : — Occasionally  during  conversation 
one  forgets  a  name  or  a  phrase,  which 
baffles  all  attempts  at  recollection  at  the 
time,  but  when  the  subject  has  been 
dropped,  and  the  mind  is  engaged  with 
something  else,  the  name  or  phrase  will 
spontaneously  recur. 

We  have  under  Automatism  referred  to 
the  very  early  enunciation  by  Laycock  of 
the  refies  action  of  the  brain,  and  the  later 
adoption  of  a  similar,  although  not  alto- 
gether identical,  doctrine  by  Dr.  Carpen- 
ter, under  the  designation  of  unconscious 
cerebration.  It  should  be  added  that 
Griesinger,  at  a  somewhat  later  period 
than  Laycock,  but  prior  to  Carpenter, 
recognised  psychical  reflex  action  in  an 
article  contributed  to  the  Arcliiv  filr  Phy- 
siolog.  Ileilkimd,  entitled  "  Ueber  psy- 
chische  Reflexactionen,  mit  einem  Blick 
auf  das  Wesen  der  psychischen  Krank- 
heiten." 

The  following  are  Dr.  Laycock's  earliest 
contributions  to  the  subject: — The  Edin- 
hurgh  Medical  and  Surgical  Journal, 
July  1838;  "Treatise  on  the  Nervous 
Diseases  of  Women,"  1840;  Paper  read 
before  the  British  Association  for  the  Ad- 
vancement of  Science,  1844,  published  in 
the  British  and  Foreign  Medical  lievieiv, 
January  1845,  entitled,  "On  the  Reflex 
Function  of  the  Brain."  Laycock  always 
referred  to  the  original  views  of  Unzer  and 
Prochaska,  who  appear  to  have  recognised, 
although  dimly,  the  refiex  action  of  the 
ganglia  at  the  base  of  the  brain. 

Keflex  action  of  the  cerebrum  might 
presumably  occur  with  or  without  con- 
sciousness. The  point  to  which  Carpenter 
specially  directed  attention  was   its  un- 


conscious action.  His  views  were  first 
enunciated  in  the  fourth  edition  of  "  Human 
Physiology,"  1852.  He  maintained  that 
while  "  the  extension  of  the  doctrine  of 
reflex  action  to  the  brain  was  first  advo- 
cated by  Dr.  Laycock,"  he  had  not  clearly 
stated  that  such  action  might  be  uncon- 
scious. He,  however,  accepted  Dr.  Lay- 
cock's  statement  that  he  had  fully  in- 
tended to  convey  that  idea.  He  regards 
unconscious  cerebration  as  synonymous 
with  the  "  Mental  Latency "  of  Sir 
William  Hamilton.* 

UNTCON-SCIOVS  KIN'.SSTHETZC 
IMPRESSIONS  (Ktj'eco,  Imove  ;  aiadrja-is, 
sensation ;  kinassthesis,  meaning  there- 
fore sense  of  movement).  Unconscious 
kinjesthetic  impressions  are  those  impres- 
sions pertaining  to  our  sense  of  movement 
which,  though  at  first  necessary,  can  from 
habit  be  dispensed  with,  as  far  as  con- 
sciousness of  their  existence  is  concerned, 
in  the  guidance  of  our  actions. 

VM-conrsciousN-ESS. — The  antithe- 
sis of  consciousness  (^.r.). 

VM'CON-TROZ.IiABI.E  IIVIPVI.SES. 
— In  most  mental  diseases  self-control  is 
lost,  but  in  some  forms  the  loss  of  power 
of  self-control  is  the  main  feature  of  the 
case.  The  commoner  impulses  are  to- 
wards suicide,  homicide,  destruction,  steal- 
ing, drinking  and  immorality.  (.S'ee  De- 
structive AND  Impulsive  Acts.) 

UNDUE  iKmuENCE. — It  is  neces- 
sary, in  considering  the  law  of  undue  influ- 
ence, to  draw  a  clear  distinction  between 
gifts  inter  vivos  and  testamentary  disposi- 
tions. 

(i)  Undue  Influence  in  Procuringr 
Gifts  Inter  Vivos. — Here  there  are  two 
groui^s  of  cases. 

(a)  The  first  group  consists  of  those 
cases  in  which  there  has  been  some  unfair 
and  improper  conduct,  some  coercion  from 
outside,  some  over-reaching,  some  form  of 
cheating,  and  generally,  though  not 
always,  some  personal  advantage  obtained 
*  "rrinciples  of  Mental  Plij'siology,"  1S74,  pp. 
515-543- 


Undue  Influence 


[     ^327     ] 


Undue  Influence 


by  a  donee  placed  in  some  close  and  con- 
fidential relation  to  the  donor.*  Lijou  v. 
Homef  may  be  taken  as  an  illustration. 
A.,  a  widow,  aged  75,  within  a  few  days 
after  first  seeing  B.,  who  claimed  to  be  a 
*'  spiritnal  medium,"  was  induced  from  her 
belief  that  she  was  fulfilling  the  wishes  of 
her  deceased  husband,  conveyed  to  her 
through  the  'iiicdinm  of  B.,  to  adopt  him  as 
her  son,  and  transfer  ^24,000  to  him  ;  to 
make  her  will  in  his  favour;  afterwards  to 
give  him  a  further  sum  of  _2{^6ooo;  and 
also  to  settle  upou  him,  subject  to  her 
life  interest,  the  reversion  of  ^30,000— 
these  gifts  being  made  without  considera- 
tion and  without  power  of  revocation. 
Giff"ard,  V.C.,  decided  that  the  gifts  were 
fraudulent  and  void. 

(b)  The  second  group  consists  of  cases 
where  the  relations  between  the  donor  and 
the  donee  have  at,  or  shortly  before,  the 
execution  of  the  gift  been  such  as  to  raise 
a  presumption  that  the  donee  had  influ- 
ence over  the  donor.  In  such  cases  the 
Court  throws  upon  the  donee  the  burden 
■of  proving  that  he  has  not  abused  his  posi- 
tion, and  that  the  gift  made  to  him  has 
not  been  brought  about  by  any  undue  in- 
fluence upon  his  part.  In  this  class  of 
cases  it  has  been  considered  necessary  to 
show  that  the  donor  had  independent  ad- 
vice, and  was  removed  from  the  influence 
of  the  donee  when  the  gitt  to  him  was 
made.  This  proposition  may  best  be  illus- 
trated by  a  few  cases.  In  Hiujuenin  v. 
BciseJeij  (1807,  i4Ves.  Jun.  273),  a  volun- 
tary settlement  by  a  widow  upon  a  clergy- 
man, who  had  not  only  acquired  consider- 
able spiritual  influence  over  her,  but  was 
entrusted  by  her  with  the  management  of 
her  property,  was  set  aside.  The  ratio  de- 
cidendi in  this  and  similar  cases  appears 
to  have  been  that  a  confidential  relation 
being  proved  to  exist  between  the  donor 
and  the  donee,  the  Court  will  presume 
that  it  continued  up  to  and  at  the  time  of 
the  gift,  unless  this  inference  is  clearly  dis- 
proved by  tJie  donee.  It  seems,  however, 
that  this  statement  of  the  law  must  be 
taken  with  the  following  qualification. 
"  When  a  gift  is  made  to  a  person  standing 
in  a  confidential  relation  to  the  donor,  the 
Court  will  not  set  the  gift  aside  //  of  a 
small  amount  simply  on  the  ground  that 
the  donor  had  no  independent  advice.  In 
such  a  case  some  jiroof  of  the  exercise  of 
the  influence  of  the  donee  must  be  given. 
....  But  if  the  gift  is  so  large  as  not  to 

*  Per  Lindley,  L..J.,  in  Allcard  v.  Skinner,  1887, 
36  Ch.  D.  at  p.  181. 

t  1868,  L.  K.  6  Eq.  655,  682.  Mr.  Hume 
AViJliams's  bo(jk  oil  "  Uiisouudiiess  of  Mind  "  cou- 
tains  an  amusing  and  instructive  account  of  this 
and  similar  cases. 


be  reasonably  accounted  for  on  the  ground 
of  friendship,  relationship,  charity,  or 
other  ordinary  motives  on  which  ordinary 
men  act,  the  burden  is  iipon  the  donee  to 
support  the  gift "  (per  Lindley,  L.J.,  in 
Allcard  v.  Slcinner,  ^lh^  sup.  at  p.  185  ; 
(/.  Bhodes  v.  Bate,  L.  R.  1  Ch.  258). 

In  Bainhrigge  v.  Brotvne  (1881,18  Ch.  D. 
188),  it  was  held  by  Fry,  J.,  that,  when  a 
deed  conferring  a  benefit  on  a  father  is 
executed  by  a  child  who  is  not  emanci- 
pated from  the  father's  control,  if  the  deed 
is  subsequently  impeached  by  the  child, 
the  onus  is  on  the  father  to  show  that  the 
child  had  independent  advice,  and  that  he 
executed  the  deed  with  full  knowledge  of 
its  contents,  and  with  a  free  intention  of 
giving  the  father  the  benefit  conferred  by 
it.  If  this  onus  be  not  discharged  the 
deed  will  be  set  aside. 

The  case  which  has  carried  the  doctrine 
under  consideration  to  the  furthest  extent 
is  Allcard  v.  Skinner  (1887,  36  Ch.  D. 
144-193). 

In  1868,  A.  was  introduced  by  N.,  her 
spiritual  director  and  confessor,  to  S.,  the 
lady  superior  of  a  sisterhood,  and  became 
an  associate  of  the  sisterhood.  N.  was 
one  of  the  founders,  and  also  the  spiritual 
director  and  confessor,  of  the  sisterhood, 
which  was  an  association  of  ladies  who 
devoted  themselves  to  good  works.  In 
1 87 1 ,  A.  having  passed  through  the  grades 
of  postulant  and  novice,  became  a  pro- 
fessed member  of  the  sisterhood,  and 
bound  herself  to  observe  {inter  alia)  the 
rules  of  poverty,  chastity,  and  obedience 
by  which  the  sisterhood  was  regulated, 
and  which  were  made  known  to  her  when 
she  became  an  associate.  These  rules  were 
drawn  up  by  N.  The  rule  of  poverty  re- 
quired the  member  to  give  up  all  her  pro- 
perty either  to  her  relatives,  or  to  the  poor, 
or  to  the  sisterhood  itself;  but  the  forms 
in  the  schedule  to  the  rule  were  in  favour 
of  the  sisterhood,  and  provided  that  pro- 
perty made  over  to  the  lady  superior 
should  be  held  by  her  in  trust  for  the  gene- 
ral purposes  of  the  sisterhood.  The  n;le 
of  obedience  required  the  member  to  regard 
the  voice  of  her  supei'ior  as  the  voice  of 
God.  The  rules  also  enjoined  that  no 
sister  should  seek  the  advice  of  any  extern 
without  the  superior's  leave.  A.,  within 
a  few  days  after  becoming  a  member,  made 
a  will  bequeathing  all  her  property  to  8., 
and  in  1872  and  1874,  handed  over  and 
transferred  to  S.  several  large  sums  of 
money  and  railway  stock.  In  May  1879, 
A.  left  the  sisterhood,  and  immediately 
revoked  her  will,  but  made  no  demand  i'or 
the  return  of  her  property  till  1885,  when 
she  commenced  an  action  against  S.  for 
that  purpose,  on  the  ground  that  she  had 


Undue  Influence 


[    1338    ] 


Undue  Influence 


disposed  of  her  property  while  acting 
under  the  paramount  and  undue  influence 
of  S.,  and  without  any  independent  and 
separate  advice.  It  was  held  by  the  Court 
of  Appeal  that  although  A.  had  volunta- 
ril}^  and  while  she  had  independent  ad- 
vice, entered  the  sisterhood  with  the  inten- 
tion of  devoting  her  fortune  to  it,  yet  as, 
at  the  time  when  she  made  the  gifts  she 
was  subject  to  the  inHuence  of  S.  and  N"., 
and  to  the  rules  of  the  sisterhood,  she 
would  have  been  entitled  on  leaving  the 
sisterhood  to  claim  restitution  of  such  part 
of  her  property  as  was  still  in  the  hands 
of  S.,*  if  her  own  delay  and  acquiescence 
since  leaving  the  sisterhood  had  not  barred 
her  claim. t 

"  The  equitable  title  of  the  donee,"  said 
Lindley,  L.J.,  "  is  imperfect  by  reason  of 
the  influence  inevitably  resulting  from  her 
position,  and  which  influence  experience 
has  taught  the  Courts  to  regard  as  undue. 
Whatever  doubt  I  might  have  had  on  this 
point,  if  there  had  been  no  rule  against 
consulting  externs,  that  rule  in  judgment 
turns  the  scale  against  the  defendant.  In 
the  face  of  that  rule  the  gifts  to  the  sister- 
hood cannot  be  supported  in  the  absence 
of  proof  that  the  plaintiff  could  have  ob- 
tained independent  advice  if  she  wished 
for  it,  and  that  she  knew  she  would  have 
been  allowed  to  obtain  such  advice  if  she 
had  desired  to  do  so.  I  doubt  whether 
the  gifts  could  have  been  supported  if  such 
proof  had  been  given,  unless  there  was 
also  proof  that  she  was  free  to  act  on  the 
advice  which  might  be  given  to  her.  But 
the  rule  itself  is  so  oppressive  and  so 
easily  abused  that  any  person  subject  to 
it  is  in  my  opinion  brought  within  the 
class  of  those  whom  it  is  the  duty  of  the 
Court  to  protect  from  possible  imposition. 
The  gifts  cannot  be  supported  without 
proof  of  more  freedom  in  fact  than  the 
plaintiff  can  be  supposed  to  have  actually 
enjoyed."  J 

(2)  Undue  Influence  in  Procuring 
Testamentary  Dispositions.  —  Here  a 
very  different  rule  of  law  prevails.  In 
the  case  of  gifts  or  other  transactions 
inter  vivos  it  is  considered  by  the  courts 
of  equity  that  the  influence  arising  from 
natural  or  professional  relationships,  if 
exerted  by  those  who  possess  it  to  obtain 
a  benefit  for  themselves,  is  an  undue  in- 
fiuence.       Gifts     or     contracts    brought 

*  It  was  admitted  on  the  appeal  that  as  rcijards 
money  ^iven  by  A.  to  S.,  and  applied  by  the 
latter  to  the  charitable  purposes  which  A.  and  S. 
were  equally  anxious  to  promote,  there  was  uo 
equitable  claim  to  restitution. 

t  Cotton,  L. J.,  dissented  from  the  opinion  of  the 
majority  of  the  Court,  and  held  that  A.'s  claim  was 
not  barred  by  her  delay. 

I   Ubi  sup.,  pp.  184,  185. 


about  by  it  are,  therefore,  set  aside,  unless 
the  loarty  henejitecl  by  it  can  shoiv  affirmct/- 
tively*  that  the  other  party  to  the  trans- 
action was  placed  in  such  a  position  as 
would  enable  him  to  form  an  absolutely 
free  and  unfettered  judgment.  Upon  the 
other  hand,  the  natural  influence  of  the 
parent  or  guardian  over  the  child,  or  the 
husband  over  the  wife,  or  the  attorney 
over  the  client,  may  lawfully  be  exerted 
to  obtain  a  legacy  so  long  as  the  testator 
thoroughly  understands  what  he  is  doing, 
and  is  a  free  agent. 

The  mere  existence,  therefore,  of  a  re- 
lationship which  renders  "undue  influ- 
ence "  possible  will  not  invalidate  a  testa- 
ment in  favour  of  the  person  who  is  in  a 
position  to  exercise  such  influence.  There 
must  be  proof  that  he  did  exercise  it. 

In  Farfitt  v.  Laivless  {uhi  supra)  the 
plaintiff,  a  Roman  Catholic  priest,  had 
resided  with  the  testatrix  and  her  husband 
many  years  as  chaplain,  and  for  a  part  of 
the  time  as  confessor.  He  was  confessor 
at  the  time  when  the  will  in  dispute  was 
made.  There  was  no  evidence  that  the 
plaintiff  had  interfered  in  the  making  of 
such  will,  or  had  procured  or  brought 
about  by  coercion  or  spiritual  dominion,  a 
gift  which  it  contained  of  the  residuary 
estate  to  himself.  It  was  held  by  Lord 
Penzance  that  there  was  no  evidence  to 
go  to  a  jury  upon  an  issue  of  undue  influ- 
ence. 

In  Parker  v.  Duncan  (1890,  Imiv  Times 
May  10),  the  will  of  a  female  pauper  was 
propounded  by  the  Chairman  of  the  Board 
of  Guardians  of  the  Union  in  which  she 
resided.  The  property  consisted  wholly 
of  policies  of  insurance  upon  the  life  of  the 
deceased,  and  these  the  testatrix  disposed 
of  absolutely  to  the  plaintiff.  It  was 
shown  that  the  plaintiff  had  himself 
taken  the  alleged  instructions  for  the  will 
and  had  got  it  prepared  by  his  own  solici- 
tor, whom  he  refused  to  allow  to  see  the 
testatrix.  Of  the  attesting  witnesses,  one 
was  a  friend  of  the  plaintiff's,  the  other 
was  a  nurse  in  the  workhouse  infirmary 

*  The  reason  of  this  rule  appears  to  be  that  in 
cases  of  gifts  and  contracts  there  is  a  transjictiou 
in  which  the  person  benefited  at  least  takes  part ; 
in  calling  upon  him  to  explain  the  part  he  took 
and  tlie  circumstances  that  brought  about  the  gift 
or  obligation,  the  Court  is  plainly  requiring  of  him 
an  explanation  within  his  knowledge.  But  in  the 
case  of  a  legacy  under  a  Avill,  the  legatee  may  have, 
and  in  point  of  fact,  generally  has,  no  part  in  or 
even  knowledge  of  the  act  ;  and  to  cast  upon  him, 
oil  tlie  bare  proof  of  the  legacy  aud  his  relation  to 
the  testator,  the  burden  of  showing  how  the  thing 
came  about,  and  under  what  influence  or  with  what 
motives  the  legacy  was  made,  or  wliat  advice  the 
testator  had,  would  be  to  cast  a  duty  on  him  which 
ill  many,  if  not  most,  cases  he  could  not  possibly 
discharge  (per  Lord  I'enzance,  J'arjitt  v.  Lawless, 
1872,  2  r.  &  D.  469). 


Unempfindlichkeit 


[    1339    1 


Urinary  Bladder 


in  which  the  testatrix  had  died.  The  will 
was  declared  to  bo  invalid. 

The  mere  fact  that  iu  niakiujf  his  will  a 
testator  was  inthienced  by  immoral  con- 
siderations does  not  amount  to  "  undue 
influence  "  so  lons^  as  the  dispositions  of 
the  will  express  the  wishes  of  the  testator 
{Wi7igrove  v.  Wiiigrovc,  1886,  1 1  P.  D, 
81). 

As  to  "  undue  intluence  "  in  procurins^ 
marriage,  sec  Makuiage,  supra. 

A.  Wood  Ren  ton. 

tTN'EIVXPFXN'OX.XCHXEIT  (Ger.).  De- 
fect or  absence  of  sensibility.  Dysass- 
thesia,  ana3sthesia ;  apathy. 

iTiirxTz:!)  STATES.  '  {See  A-merica, 
Pkovision  rou  Insane  in.) 

UN-PARDON-ABI.E  SIN. — A  common 
delusion  of  patients  sufi"ering  from  melan- 
cholia, especially  iu  connection  with  re- 
ligion, is  that  they  have  committed  the 
unpardonable  sin  mentioned  in  the  Bible. 
The  oi^inion  as  to  what  the  sin  is  varies 
with  different  patients,  but  it  is  generally 
connected  with  blaspheming  against  the 
Holy  Ghost  as  they  are  led  to  infer  from 
the  Bible ;  or  else  connected  with  sexual 
acts.  It  seems  that  the  idea  of  impossi- 
bility of  forgiveness,  and  the  idea  that  the 
patient  alone  has  committed  it,  make  the 
"  unpardonable  sin "  a  favourite  delu- 
sion. 

UNSEEM-  AGEN-CV,  TflONOT/LAJriA 

OP.  {See  Monomania  OF  Unseen  Agency, 
and  Monomania.) 

UNSlN-NiG  (Ger.).     Mad,  irrational. 

UNSIN-M-IGKEIT  (Ger.).  Madness, 
insanity. 

UNSouN-s  iviiM'S.  {See  NoN  Compos 
Mentls.) 

USrSOUN^DN^ESS     OF    IVIZND.       {See 

Definition.) 

VXrTERSCHEIBUM'GSZEIT.  —  Per- 

ception-time. 

UN"WOXtTHlM'ESS. — A  common  de- 
lusion in  religious  melancholia. 

VRAN'OIVIAM'ZA  {ovpavos,  hea,ven  ; 
^avia,  madness).  Monomania  involving 
the  idea  of  a  divine  or  celestial  origin  or 
connection  ;  a  species  of  megalomania. 

URGEM-CY    CERTIFICATES.       {See 

Certificates,  Medical.) 

URINARY  BXABDER,  Influence 
of  the  IVXind  on  the. — The  influence  of 
pyschic  activity  in  promoting  contraction  of 
the  bladder,  resultinginmore  or  less  urgent 
desire  to  micturate,  is  well  known.  The 
emotion  of  fear  produces  an  especially 
strong  and  often  immediate  efl'ect  on  the 
bladder  as  well  as  sometimes  on  the  bowels ; 
this  fact  has  not  escaped  the  observation  of 
Kembrandt,  who,  in  his  picture  of  the 
youthful  Ganymede  in  the  clutches  of  the 
eagle,  represents  the  child  as  both  crying 


and  urinating.  Intellectual  activity  pro- 
duces a  slighter  degree  of  vesical  contrac- 
tion. Mental  suspense  has  a  well-marked 
continuous  action  in  causing  contraction 
of  the  bladder  ;  this  action  is  familiar  to 
public  speakers,  to  students  awaiting  ex- 
amination, to  criminals  expecting  execu- 
tion. (Such  action  is  frequently  combined 
with  stimulation  of  the  kidneys ;  thus 
Casanova  in  his  instructive  Mcmoires 
refers  to  the  excessive  flow  of  urine  he  ex- 
perienced on  the  evening  of  the  day  he 
was  imprisoned  at  Venice.) 

The  immediate  reaction  of  the  bladder 
to  external  stimulus  has  been  experienced 
by  most  persons  on  putting  the  hands  into 
cold  water ;  even  the  sight  of  the  cold 
bath  is  sufficient  in  some  individuals  to  pro- 
duce the  desire  for  micturition.  Any  sug- 
gestion in  the  normal  condition  of  the  idea 
of  micturition  is  often  sufficient  to  produce 
conti-action  of  the  bladder,  and  the  usual 
accompanying  sensations ;  iu  this  way 
children  and  young  girls,  the  hypochon- 
driacal, hysterical,  and  nervous  persons 
generally,  frequently  experience  spasmodic 
contractions  of  the  bladder,  which  are  liable 
to  become  habitual ;  such  contractions  may 
become  a  constant  source  of  trouble  and 
anxiety  to  the  individual  affected  by  them. 
The  bladder  may  also  be  influenced  by 
suggestions  received  during  the  hypnotic 
state ;  Binet  and  Fere,  Moll  and  others 
have  in  this  way  caused  subjects  to  urinate 
one  or  more  times  on  awakening  from  the 
hypnotic  condition.  In  various  morbid 
nervous  conditions  the  bladder  may  be 
affected  ;  thus,  in  attacks  of  petit  mal 
the  central  nervous  convulsion  may  not 
uncommonly  terminate  in  a  powerful  vesi- 
cal contraction.  Trousseau's  magistrate, 
who  unconsciously  urinated  in  a  corner  of 
the  council-chamber,  is  well  known.  Dr. 
Colman*  mentions  the  case  of  "  a  respect- 
able girl,  twenty  years  old, who  came  under 
observation  recently.  She  had  attended 
the  hospital  for  twelve  months  for  ordinary 
epileptic  fits,  and  frequent  attacks  of 
petit  mal,  consisting  chiefly  of  sudden 
desire  to  pass  urine.  Usually  the  sensa- 
tion had  been  transient,  and  she  had  been 
able  to  retain  control  over  her  bladder. 
On  a  recent  occasion,  however,  when  she 
was  at  a  public  entertainment,  the  attack 
oi  petit  ■}/iaZ  was  of  longer  duration  than 
formerly,  and  while  in  the  unconscious 
condition  she  deliberately  lifted  her  clothes 
and  began  to  void  urine  in  public  ;  and  it 
was  with  the  greatest  difficulty  that  her 
friends  prevented  the  authorities  from 
handing  her  over  to  the  police." 

While  such  facts  as  these  here  briefly 
*  "  rost-Kpilei)tic  Unconscious  Automatic  Ac- 
tions," Lancet,  July  5,  1890. 


Urinary  Bladder 


[     1340    ] 


Urine 


summarised  have  long  been  open  to  obser- 
vation, it  is  only  within  recent  years  that 
accurate  and  ]>recise  demonstration  has 
been  brought  forward  as  to  the  delicate 
chai-acter  of  the  reactions  of  the  bladder 
to  psychic  stimuli.  To  Mosso  and  Pella- 
cani,  by  their  classical  and  decisive  inves- 
tigations on  the  human  subject  in  1882, 
is  due  thecredit  of  demonstrating  that  con- 
tractions of  the  bladder  result  directly  from 
the  irritation  of  any  sensory  nerve;  and  also 
that  all  conditions  of  the  organism  which 
raise  the  blood-pressure  and  excite  the 
respiratory  centres,  produce  an  immediate 
and  measurable  effect  upon  the  bladder. 
Some  preliminary  experiments  with  dogs, 
by  means  of  the  plethysmograph,  showed 
that  a  caress  or  an  affectionate  look  i^ro- 
duced  an  immediate  contraction  of  the 
bladder.  Several  series  of  observations 
were  then  made  with  young  girls  about 
the  age  of  twenty.  A  catheter,  connected 
with  a  tube  leading  to  a  plethysmograph, 
was  inserted  into  the  bladder,  the  subject 
lying  quietly  on  her  back  with  her  legs 
slightly  open  and  raised.  On  lightly 
touching  the  back  of  the  first  subject's 
hand  with  the  finger  a  notable  contraction 
of  the  bladder  was  at  once  registered. 
On  winding  up  the  instrument  which  turns 
the  registering  cylinder  in  connection  with 
the  plethysmograph  there  was  another  less 
marked  and  less  rapid  contraction ;  while 
the  bladder  was  dilating  after  this  con- 
traction Mosso  addressed  a  trivial  remark 
to  the  girl,  a  trifling  contraction  at  once 
occurred  and  was  repeated  when  she  spoke 
in  reply ;  it  was  ascertained  that  these 
contractions  were  not  due  to  the  abdom- 
inal movements  of  respiration.  Some 
experiments  were  then  made  on  a  very 
intelligent  girl  as  to  the  effect  of  the 
psychic  representation  of  pain  in  produc- 
ing contraction  of  the  bladder.  On 
saying,  "Now  lam  pinching  you,"  but 
without  pinching,  there  was  immediately 
a  manifest  contraction,  without  respira- 
tory change.  When  the  girl  spoke  there 
was  a  still  stronger  contraction,  and  this 
was  repeated  when  a  pleasantry  was  ad- 
dressed to  her.  "  These  phenomena  may 
be  considered  as  the  most  delicate  ex- 
amples of  reflex  movement  which  are  pro- 
duced in  the  organism,  and  they  corre- 
spond to  what  we  have  already  remarked 
in  animals."  On  another  girl  similar 
experiments  were  carried  out  to  show 
the  effects  of  mental  exertion.  On  making 
some  unimportant  remark  to  her  there 
was  a  trifling  contraction ;  when  the 
object  of  the  experiment  was  explained, 
by  telling  her  that  she  would  have  to 
multiply  figures  to  see  what  would  happen 
in  her  bladder,  there  was  a  more  powerful 


contraction;  she  was  then  asked  how  many 
eggs  it  took  to  make  seven  dozen.  During 
eight  or  nine  respii'ations  the  question 
produced  no  effect,  then  contraction  slowly 
began,  and  when  she  had  found  the 
answer  the  bladder  slowly  dilated  to  its 
original  volume.  "  From  these  experi- 
ments which  we  have  repeated  on  a  large 
number  of  persons,  it  must  be  concluded 
that  every  psychic  event  and  every  mental 
effort  is  accompanied  by  a  contraction  of 
the  bladder." 

It  was  found  that  every  influence  which 
contracted  the  blood-vessels  contracted 
also  the  bladder,  and  shortly  afterwards 
Pellacani  made  some  allied  investigations 
as  to  the  effect  of  drugs  in  producing 
vesical  contractions.*  He  found  that 
alcohol  and  cofi'ee,  active  agents  on  the 
heart,  vessels  and  nervous  system,  also  in- 
fluence the  bladder  walls.  "  For  alcohol 
we  have  observed  a  short  period  of  dilata- 
tion, followed  by  a  longer  period  of  pro- 
gressive augmentation  of  tonus,  particu- 
larly when  the  person  is  in  a  state  of 
intoxication.  The  action  of  cofi'ee  on  the 
bladder  of  man  is  much  prompter  than 
that  of  alcohol."  Gallic  acid  produces 
powerful  contraction  of  the  bladder  by  its 
astringent  action  on  the  vessels.  Pilocar- 
pine produces  very  powerful  and  rapid 
contraction. 

Francois-Franck  and  Pitres  took  up 
this  question  so  far  as  animals  are  con- 
cerned, and  declared  their  results  at  the 
College  de  France  in  1884-5.  They  ex- 
perimented on  dogs,  and  observed  simul- 
taneously the  curves  of  arterial  pressure 
and  of  pressure  in  the  bladder.  They 
found  that  the  bladder  frequently  con- 
tracted before  the  manometer  indicated 
any  vascular  contraction  ;  that  the  bladder 
contraction  usually  ended  before  the  vas- 
cular; and  that  not  seldom,  under  the 
influence  of  feeble  cerebral  excitation,  there 
was  an  energetic  vesical  contraction  inde- 
pendently of  all  vaso-motor  contraction. 
Their  experiments,  they  concluded,  fully 
contirmed  the  results  reached  by  Mosso 
and  Pellacani. 

There  is,  therefore,  no  doubt  that  "  the 
bladder,"  in  Mosso's  words,  "  is  an  Eesthe- 
siometer  more  certain  than  the  blood 
pressure,  and  not  inferior  even  to  the 
iris."  Havelock  Ellis. 

[References.  — Mosso  et  Pellacaui,  8ur  les  Fonc- 
tions  de  la  Vest^ie,  Archives  Italieunes  de  Bioloi;ie, 
tome  I,  1882.  Article,  Eiicepliale  (Pliysiologie),  ia 
Dictioiinaire  eucylopedique  des  Sciences  Medieales. 
D.  Hack  Tuke,  Influence  of  the  Mind  upon  the 
Body,  vol.  ii.  pp.  61-62.] 

VRXNU.  Physical  Characters.  — 
Normal  urine  is  a  fully  clear  fluid,  of  an 

*  "Archives  Italienncs  de  Biologie,"'  tome  ii. 
1882. 


I 


Urine 


[     1341     ] 


Urine 


amber  or  light  pale  yellow  colour,  of  sp. 
gr.  1020,  reaction  slightly  acid  and  with 
a  well-known  peculiar  odour. 

Quantity  varies  according  to  temi^era- 
ture,  amount  of  liquid  taken,  action  of  the 
skin  and  other  causes,  but  it  is  usually 
stated  to  range  under  our  ordinary  life 
conditions  between  1000  and  1500  cubic 
centimetres  per  day.*  There  ai'e  dif- 
ferences between  the  urine  secreted  at 
different  hours.  The  minimum  is  secreted 
between  two  to  four  a.m.,  and  the  maxi- 
mum between  two  and  four  I'.Ji.  (Weige- 
lin),  but  these  differences  are  not  important 
for  our  pur2:)0se.  The  amount  is  dimiu- 
■isltcd  by  profuse  sweating,  diarrha3a,  thirst, 
non-nitrogenous  food,  diminution  of  the 
blood  pressure,  and  in  some  diseases  of 
the  kidneys.  In  severe  maniacal  attacks 
the  decrease  appears  to  have  an  inverse 
relation  to  the  rapidity  of  development 
and  the  intensity  of  the  paroxysm,  for  in 
milder  cases  it  is  not  nearly  so  great 
(Addison).  Lombroso  made  observations 
in  cases  of  mania,  epilepsy,  idiots,  and 
dements,  and  found  that  the  quantity  was 
less  than  usual.  Rabowf  found  the  quan- 
tity diminished  in  melancholiacs.  With 
advancing  dementia  the  quantity  dimin- 
ishes as  well  as  the  absolute  amount  of 
urea  and  chlorides. 

It  is  increased  by  copious  drinking,  by 
increase  of  the  general  blood  pressure,  or 
of  the  pressure  within  the  area  of  the 
renal  artery.  The  passage  of  a  large 
amount  of  soluble  substances  (urea,  salts 
and  sugar)  into  the  urine,  a  large  amount 
of  nitrogenous  food,  and  by  various  drugs. 
Nervous  excitement  in  hysteria  and  like 
conditions  is  apt  to  be  followed  by  polyuria. 
In  states  of  mental  anxiety  or  suspense, 
the  amount  is  sometimes  increased,  but 
this  must  be  distinguished  from  mere 
frequency  of  micturition.  We  may  have 
polyuria,  without  the  presence  of  sugar  in 
the  urine,  following  injury  to  a  certain 
part  of  the  floor  of  the  fourth  ventricle 
(CI.  Bernard).  Ebstein  J  collected  a  series 
of  cases  in  which  polyuria  was  developed 
in  connection  with  or  in  consequence  of 
primary  disease  of  the  brain.  The  occur- 
rence of  polyuria  in  epileptics  is  frequent. 
After  each  tit,  in  addition  to  the  increased 
quantity  of  urine  passed,  it  is  richer  in 
chlorides  and  more  deficient  in  urea  than 
a  corresponding  volume  taken  from  the 
total  quantity  passed  in  twenty-four 
hours.  When  the  fits  occur  at  greater 
intervals,  the  quantity  excreted  in  twenty- 

*  Yogcl  reckons  a  centimetre  fur  each  kilo  of 
body  weight. 

t  Archil- f.  Psych.  Mnrf  J\e/TeMtr.,  ]5d.  vii.  Heft  i. 

X  DeuUch.  Archiv  J'ilr  Klinische  Med.,  lid.  xi. 
1873- 


four  hours  is  usually  markedly  reduced 
after  each  one.  The  quantity  of  urea  is, 
as  a  rule,  not  great,  and  occasionally  there 
is  an  increase  of  xanthin  (Rabow).  In 
general  paralysis  in  the  earlier  stages 
there  is  an  increase  in  the  quantity  of 
urine,  but  as  dementia  advances  the  quan- 
tity lessens  (Rabow).  In  the  melancholic 
first  stage,  however,  Mendel  estimated 
that  the  quantity  of  urine  is  lessened. 

The  specific  gravity  varies  consider- 
ably under  different  mental  conditions. 
Merson*  estimated  that  in  general 
jiaralysis  the  inean  specific  gravity  did  not 
materially  differ  from  that  of  health,  and 
that  the  absolute  quantity  of  urine,  though 
slightly  below  that  of  health,  was,  in 
truth,  slightly  in  excess  of  the  latter,  if 
estimated  according  to  body  weight.  The 
most  concentrated  urine  is  excreted  at 
night.  Sutherland  and  Rigbyt  stated 
that  the  specific  gravity  in  mania  and 
melancholia  ranges  most  usually  between 
1 02 1  and  1030  in  the  former,  and  fre- 
quently exceeds  1030  in  the  latter,  whereas 
in  dementia  it  is  usually  found  to  be 
between  loii  and  1020.  Sediments  of 
one  sort  or  another  occur  in  almost  every 
case  of  mania  and  melancholia,  especially 
the  latter  ;  in  dementia  not  so  frequently. 
It  may  be  stated  generally  that  in  periods 
of  excitement  the  relative  amount  of  solids 
is  increased,  but  that  during  periods  of 
freedom  from  excitement,  both  in  mania 
and  melancholia,  there  is  a  diminution. 
In  dementia,  considei-ing  the  large  amount 
of  food  consumed,  this  diminution  may  be 
considered  as  an  evidence  of  slow  chemical 
change.  Lombroso  found  the  specific 
gravity  diminished  in  melancholia,  almost 
normal  in  mania,  and  increased  in  de- 
mentia previous  to  an  attack  of  excite- 
ment. He  also  states  that  urea,  chloride 
of  sodium,  and  phosphoric  acid  are 
diminished  in  maniacs  and  melancholies 
during  their  periods  of  freedom  from  ex- 
citement. Rabow  found  the  specific 
gravity  increased  in  melancholia,  urea 
diminished  and  chloride  reduced  to  a 
minimum.  In  advancing  paralysis  with 
dementia  the  specific  gravity  appears  to  be 
increased,  and  a  turbidity  due  to  urates  is 
common. 

In  jjolyuria,  due  to  mental  states  or 
other  nervous  conditions,  the  urine  is  very 
dilute  and  copious,  while  the  specific 
gravity  may  be  as  low  as  looi.  The  mean 
specific  gravity  of  the  urine  (^f  248  cases 
admitted  to  Bethlem  and  estimated  within 
a  week  of  their  admission  was  acute  mania 
(66  cases),  1026 ;  melancholia  (68  cases), 
1025  ;    partial   dementia    and    delusional 

a  "'West  Hiding-  Asylum  Iteports,"  vol.  iv.  p.  63. 
t  Lancet,  vol.  ii.  1845,  p.  241, 


Urine 


[    1342    ] 


Urine 


(54  cases),  1020  ;  general  paralysis  of  the 
insane  (60  cases),  102 1. 

The  colour  ot'  the  urine  depends  largely 
upon  the  colouring  matters  in  it,  and  upon 
variations  in  the  amount  of  water.  In  the 
sudden  polyuria  occurring  after  an  attack 
of  hysteria,  it  may  be  as  clear  as  water. 
The  urine  passed  after  an  epileptic  tit  is 
sometimes  remarkably  clear  owing  to  the 
tendency  to  increase  of  the  water.  In 
mania  and  melancholia  during  the  acute 
periods  the  prevailing  colour  of  the  urine 
is  high  ;  in  dementia  it  is  light. 

The  reaction  is  visually  acid,  and  this 
is  markedly  so  where  there  is  excitement  or 
prolonged  muscular  exertion.  Suther- 
land and  Rigby  found  it  to  be  acid  in  at 
least  So  per  cent,  of  the  maniacal  and  melan- 
cholic cases,  but  in  dementia  the  propor- 
tion was  much  smaller,  viz.,  63.54  per  cent. 
A  twenty-four  hours'  collection  of  urine 
is  normally  acid,  but  if  portions  of  the 
twenty-four  hour  urine  be  examinee!  as  it 
is  secreted,  certain  portions  are  normally 
slightly  alkaline  or  neutral ;  for  instance, 
the  urine  secreted  after  a  meal  is  often 
alkaline,  the  accepted  explanation  being 
that  hydrochloric  and  other  acids  are 
poured  out  into  the  stomach  for  the  pur- 
poses of  digestion,  hence  a  temporary  in- 
creased alkalinity  of  the  fluids  within  the 
circulatory  system  and  the  separation  of  a 
greater  proportion  of  base  than  acid 
through  the  kidneys,  so  also  the  ingestion 
of  a  purely  vegetable  diet  renders  the 
urine  alkaline,  as  is  ever  the  case  with  the 
herbivoras ;  on  the  other  hand  the  urine  of 
the  carnivora3  has  a  high  degree  of  acidity, 
and  people  who  consume  much  animal 
food  secrete  urine  the  acidity  of  which  is 
greater  than  that  of  persons  eating  less 
meat. 

The  cause  of  the  normal  acidity  used  to 
be  referred  to  acid  phosphate  of  soda,  but 
the  more  correct  view  is  to  consider  it  due 
to  loose  combinations  of  organic  acids  and 
salts ;  for  instance,  if  the  ordinary  sodic 
phosphate,  NaoEPO^,  which  has  an  alka- 
line reaction,  be  dissolved  with  an  equiva- 
lent weight  of  hippuric  acid  (142  :  179)  a 
strongly  acid  re-acting  fluid  is  obtained 
which  may  be  considered  with  equal 
justness  either  a  solution  of  acid  phos- 
phate of  soda  and  hippurate  of  soda,  or 
a  solution  of  neutral  sodic  phosphate 
and  free  hippuric  acid.  Similar  reactions 
are  obtained  from  the  union  of  uric  acid 
with  the  alkaline  phosphates  ;  in  other 
words  the  acid  reaction  of  the  urine  mainly 
depends  upon  loose  combinations  between 
the  uric  and  hippuric  acids  and  the  alka- 
line phosphates.  The  acid  reaction  given 
by  the  urine  of  the  aforementioned  cases 
admitted  to  Bethlem  was  in  mania  83  per 


cent. ;  dementia  and  delusional,  88.3  per 
cent. ;  general  paralysis,  90  j^er  cent.  ; 
melancholia,  99  per  cent.  (This  estimate 
is  open  to  objection,  for  in  many  instances 
the  specimens  obtained  did  not  represent 
the  amount  passed  during  the  twenty-four 
hours.) 

The  constituents  of  the  urine  to  be 
studied  mainly  divide  themselves  into 
six  divisions. 

(1)  Uitrogrenised  Bodies  of  the  Na- 
ture of  Urea:  Urea,  uric  acid,  allantoin, 
ammonia,  oxaluric  acid,  xanthin,  guanin, 
kreatin,  kreatinine,  sulphocyanic  acid. 

(2)  Fatty  Nitrogren  Free  Bodies : 
Fatty  acids  of  the  series  CoH^O.,  oxalic 
acid,  lactic  acid,  glycero-phosphoricacid. 

(3)  Carbohydrates  :  Inosite,  gum. 

(4)  Aromatic  Substances :  Hippuric 
acid,  the  ether-sulphates  of  phenol,  cre- 
sol,  pyrocatechin;  indoxyl,  scatoxyl  and 
others. 

(5)  IVIineral  Constituents:  Chlorides 
of  sodium  and  potassium,  sodic  phosphate, 
phosphates  of  calcium  and  magnesium, 
calcic  carbonate,  potassium  sulphate,  and 
others. 

(6)  Colouring'  IMCatters. 

In  disease  there  are  also  albumins, 
grape  and  milk  sugar,  bile  acids  and  bile 
colouring  matters,  methaBmoglobin,  hsema- 
toporphyrin,  oxymandelic  acid,  leucin, 
tyrosin,  cholesterin,  fat,  cystin.  A  great 
number  of  medicinal  agents  are  also  sepa- 
rated, changed,  or  unchanged,  by  the 
urine.  We  shall  not  refer  further  to  the 
6th  section. 

(i)  Urea  and  Allied  Bodies.  Urea, 
CO(NHo)<,.— Since  more  than  half  the 
nitrogen  excreted  by  the  kidneys  is  in  the 
form  of  urea,  its  excess  or  diminution  is  a 
measure  of  nitrogen  changes  in  the  body  ; 
in  order  therefore  to  appreciate,  or  even  to 
detect, deviations  from  normal  elimination, 
it  is  first  necessary  to  understand  fully 
the  variations  according  to  body  weight, 
age,  sex,  food,  rest,  or  exertion,  which  may 
be  considered  normal.  In  the  outset  it 
may  be  premised  that  ordinary  clinical 
determinations  of  urea  excretion,  so  many 
of  which  ai-e  to  be  found  published  in 
clinical  literature,  have  but  a  restricted 
value  ;  this  is  epecially  true  of  those  which 
are  unaccompanied  with  exact  details  of 
diet.  Quite  independent  of  all  other 
circumstances,  the  urea  excretion  varies 
much  according  as  nitrogen  is  taken  into 
the  body  in  large  or  small  quantities. 
For  example  :  the  same  individual,*  other 
conditions  being  similar,  excreted  (during 
twenty-four  hours)  the  following  quanti- 
ties of  urea  on  different  diets  : 

*  O.  V.  Fraiique,  "  Dissert."  Wurzbur^.  1855. 


Urine 


[     1343    ] 


Urine 


Purely  animal  food      .         .  51  92  i>Tins. 
Mixed  food, animal  and  voyc- 

tal)lc  .         .         .         .  36-38      „ 

Vegetable  food     .         .         .  24-28      „ 
Xitrog'eu  free  food       .         .  16      „ 

In  the  adult  male  the  urea  is  estimated 
by  Vogcl  to  be  from  .2,7  to  .60  gramme 
per  kilo  of  body  weight ;  a  smaller  uumber 
than  this  represents  the  female  excretion. 
The  greatest  urea  excretion  is  to  be  found 
in  men  who  are  undergoing  excessive 
exertion  with  a  full  animal  diet.  Under 
ordinary  conditions  of  adult  life,  with 
gentle  daily  exercise,  and  in  a  state  of 
health,  there  is  approximately  nitrogenous 
equilibrium,  that  is,  the  output  of  nitrogen 
is  equal  to  the  intake.  During  a  few  days 
there  may  be  some  nitrogen  storage,  but 
this  is  followed  by  an  increased  excretion, 
sooner  or  later.  On  the  other  hand, 
severe  muscular  exertion  considerably 
increases  nitrogenous  excretion,  and  then 
if  a  period  of  rest  should  follow  there  is 
nitrogen  storage  ;  for  example,  in  a  i^ro- 
longed  period  of  mania  with  excessive 
activity,  followed  by  a  lull,  one  would 
expect  the  nitrogen  stores  in  the  body  to 
be  drawn  \ipon  considerably,  and  the 
nitrogenous  output  to  considerably  exceed 
the  nitrogenous  intake,  while  in  the  lull, 
there  would  be  more  or  less  quiescence, 
and  in  consequence  there  should  be  theo- 
retically nitrogen  storage ;  hxit  whether 
this  is  so  or  not,  information  from  an 
accurate  research  is  much  needed.  0  ppen- 
heim  *  has  shown  that  the  increased  urea 
excretion  on  exertion  is  in  part  due  to 
the  dyspnoea  which  accompanies  such 
exertion. 

Dr.  Campbell  Clark  found  a  diminution 
of  urea  in  some  degree  in  all  his  cases  of 
puerperal  insanity,  although  in  one  case 
only  was  that  diminution  at  all  striking. 
If  at  any  time,  however,  there  was  a  ten- 
dency to  increase,  that  increase  was  in 
proportion  to  the  degree  of  sleeplessness 
and  mania  in  the  case. 

Excretion  of  Urea  under  Abnormal  Con- 
ditions.— All  fever  is  accompanied  by  a 
loss  of  nitrogenous  balance  ;  the  nitrogen 
stores  are  attacked,  and  a  greater  excre- 
tion of  urea  follows  than  can  be  accounted 
for  by  the  food  given.  In  diabetes  there 
is  also  increased  excretion  of  urea  and  loss 
of  nitrogenous  balance.  In  all  diseases 
accompanied  by  dyspnrea  there  is  loss  of 
nitrogenous  balance,  the  output  being 
greater  than  the  intake.     In  progressive 

Eernicious  anaemia,  leuccemia,  scurvy, 
yperaamia  of  the  kidneys,  and  in  phos- 
phorous poisoning,  there  is  increase  in 
the  excretion  of  urea.  Many  drugs  also 
increase    urea    elimination.      It    is    also 

*  rfliiyer,  Archivf.  I'hijs.  Bd.  xxiii. 


stated  that  breathing  in  compressed  air, 
or  any  artificial  rise  of  temperature,  has 
the  same  result. 

Lessened  Urea  E.(rrction. — At  the  end  of 
acute  fevers,  when  the  temperature  goes 
down  and  convalescence  commences,  there 
is  generally  some  nitrogen  storage,  which 
is  necessary  to  replace  the  nitrogen  lost 
during  the  fever.  In  most  maladies  of 
the  kidney  and  liver  there  is  decreased 
urea  excretion,  the  diseased  organs  are  not 
capable  of  carrying  on  their  functions 
properly,  and  if  the  diminished  excretion 
passes  a  certain  limit  the  condition  known 
as  ursemia  arises.  In  gouty  conditions  of 
the  body  the  urea  output  is,  as  a  rule, 
smaller  than  in  health.  RalDow  *  found 
in  a  case  of  melancholia  a  daily  excretion 
of  urea  from  6  to  20  grammes,  but  when 
the  same  person  recovered  the  excretion 
rose  from  9.9  to  20  grammes.  In  mania 
he  found  in  one  case  an  excretion  of  14.59 
grammes  as  a  daily  average  during  a 
pei'iod  of  excitement,  and  23.5  grammes 
during  a  period  of  quiet ;  but  no  details  as 
to  diet  are  given.  It  therefore  may  well 
be  that  during  the  excitable  joeriod  but 
little  food  was  taken,  and  during  the  quiet 
period  much  taken  ;  if  such  were  the  case 
the  nitrogenous  output  may  have  been 
greater  in  relation  to  the  intake  in  the 
first  (excitable)  period  than  in  the  second 
(quiet)  period.  Johnson  Smyth  t  has 
found  in  thirty  cases  of  secondary  demen- 
tia a  remarkable  decrease  of  urea,  as  com- 
pared with  healthy  men  living  on  the 
same  diet.  Addison  %  investigated  sixteen 
cases  of  mania,  and  his  summary  of  these 
cases  is  as  follows  : 

(i)  Quantity  diminished  ; 

(2)  Specific  gravity  high  ; 

(3)  Intensely  acid  ; 

(4)  Sodic  chloride  less  during  mania 
than  in  convalescence ; 

(5)  Diminution  of  urea; 

(6)  Phosphoric  acid  less  during  states 
of  mental  excitement; 

(7)  Sulphates  in  eleven  cases  greater  in 
convalescence  than  during  the  attack. 

Mania  {Averages). 


During 

During 

Attack. 

Couvale.scencc. 

Quantity  . 

664.6  c.c. 

1584  c.c. 

Specific  gravity 

1025 

1016     ,, 

grammes. 

grammes. 

Urea    .... 

21. 2t; 

30.80 

Sodium  chloride 

2-33 

3.88 

r()5    .... 

1-43 

1.98 

SO3    .    .    .    . 

1-39 

1.49 

*  Archivf.  Psych.  11.  Xercenkr.,  lid.  vii. 
t  Jonrii.  Mciit.  Sci.,  vol.  xx.vvi.  p.  517. 
t  Ibid.,  vol.  xi.  p.  262. 


Urine 


[    1344    ] 


Urine 


In  this  otherwise  careful  research  there 
are  no  exact  data  as  to  the  composition 
of  the  food. 

In  g-eneral  paralysis,  there  is  some 
discrepancy  of  opinion,  Addison  found 
less  nrea  excreted  than  in  health.  Mer- 
soii,*  on  the  other  hand,  considei'ed  the 
daily  average  showed  an  increase.  San- 
derf  found  the  excretion  to  be  small  in 
general  paralysis.  Rabow  found  relatively 
more  urea  in  the  first  stage  and  with  the 
advance  of  dementia  a  diminution  in  the 
amount.  In  the  melancholic  first  stage 
the  urea  is  less  increased  as  a  rule.  In 
dementia,  and  especially  where  the  vitality 
is  low,  all  observers  agree  that  the  urea  is 
diminished  below  the  normal  standard. 

In  cases  of  hysteria  and  catalepsy, 
StrubingJ  found  during  the  seizures  a 
diminution  of  urea.  The  most  recent  re- 
searches on  the  amount  of  urea  excreted 
by- general  paralytics  are  those  made  by 
Dr.  John  Turner,§  and  Dr.  W.  Johnson 
Smyth.  II  Turner's  cases  were  all  on  a  diet 
■which  it  is  computed  was  equivalent  to 
1 2.2  grammes  of  nitrogen  and  342  grammes 
of  carbon.  The  number  of  cases  in  which 
it  was  possible  to  collect  complete  samples 
of  the  urine  for  twenty-four  hours  was 
61,  and  the  mean  daily  quantity  of  urea 
excreted  by  these  was  24.5  grammes.  In 
eighteen  cases  in  the  first  stage  of  the 
malady  the  mean  was  24.7  grammes, 
maximum  33.4;  minimum  18.2.  In 
thirty-five  cases  in  the  second  stage,  the 
mean  was  24.6  grammes  ;  maximum  42.0, 
minimum  13.4.  In  eight  cases  in  the 
third  stage  the  mean  was  23.6  grammes  ; 
maximum  34.0  ;  minimum  15.6.  He  there- 
fore concludes  that  there  is  a  real  diminu- 
tion of  urea  excretion  among  general  j^ara- 
lytics.  Smyth's  cases  were  ten  in  number, 
and  the  observations  were  continued  for 
seven  days.  The  observations  seem  to 
have  been  made  with  especial  care  and  the 
results  compared  with  those  obtained 
from  two  healthy  men  living  on  the  same 
diet. 

Tbe  mean  results  are  as  follows : 


Two 

Mean  of  ten 

heiilthy 

cases  of  i^ene- 

men. 

ral  paralj-sis. 

Total  amount  of  urine  1356  c.c. 

...     1578  c.c. 

grammes. 

grammes. 

Total  solids  per  clay  ,    37. 8 

...     47.0 

Urea,  per  day  .     .     .    23.2 

...     26.0 

Uric  acid      ....       0.9 

...       3.1 

I'hosphoric  acid   .     .       1.2 

...       1.6 

*  "West  Kidint;'  Asylum  Keports." 

t  Griesinger,  "  Mental  Pathology  and  Tlicrapeu- 
tics"  (New  Syd.  Soc.  Transl.),  1867. 

t  Deiitsch.  Arch.f.  Klin.  Med.,  1880,  lid.  xxvii. 
p.  125. 

§  .lourv.  Menf.  Sci.,  Oct.  1889. 

II  Ibid.,  Oct.  1890. 


These  observations  do  not  agree  with 
Turner's,  for  the  urea  is  not  diminished 
but  rather  increased.  The  quantity  of 
urine,  the  total  solids,  and  especially  the 
uric  acid  also,  all  show  a  considerable  in- 
crease. 

In  an  analysis  of  the  urine  in  three 
cases  of  epilepsy,  Gibson*  found  the 
average  twenty-four  hours'  secretion  of 
water  a  little  above,  of  urea,  chloride  of 
sodium  and  phosphoric  acid  below  the 
normal  amount.  The  nightly  average  of 
water  and  NaCJl  was  less  than  the  daily ; 
of  urea  equal ;  of  phosphoric  acid  greater. 
No  constant  change  in  the  urine  of  the 
fit  nights,  but  a  tendency  to  increase  of 
water,  urea  and  chloride  of  sodium.  There 
was  also  increase  of  all  the  constituents 
in  the  hours  following  fits.  With  regard 
to  other  maladies  :  In  osteomalacia,t  in 
lepra,  pemphigus,J  impetigo,§  in  chronic 
rheumatism,  and  generally  in  chronic 
anasmic  diseases,  a  lessened  excretion  of 
urea  has  been  observed. 

Uric  Acid. — A.  B.  Garrod||  considers 
that  a  man  excretes  one  part  of  uric  acid 
per  120,000  parts  of  body  weight ;  hence  a 
man  weighing  56.5  kilos  would  excrete  nor- 
mally 0.47  grammes  during  the  twenty- 
four  hours.  Thudichura  puts  it  at  0.5 
gramme,  and  Neubauer  and  Vogel,  in 
saying  that  the  excretion  varies  between 
0.2  and  i.o  gramme,  also  put  the  mean 
daily  excretion  for  persons  of  standard 
weight  at  0.5  gramme.  The  eating  of  a 
highly  nitrogenous  diet  raises  the  excretion 
of  uric  acid ;  under  these  circumstances, 
Ranke  found  as  much  as  2.1  grammes, 
the  urea  itself  being  much  increased. 
Ranke  considered  that  gentle  bodily  move- 
ments diminished  the  excretion,  and  ex- 
cessive movements  raised  it.  It  is,  indeed, 
doubtful  whether  muscular  activity  has 
much  to  do  with  increase  or  diminution 
of  uric  acid.  The  old  idea  also,  that  sugar 
produces  an  excess  of  uric  acid,  is  pretty 
nigh  exploded,  for  direct  experiment  has 
shown  no  increase  so  long  as  the  digestion 
is  not  affected,  even  when  large  quantities 
of  sugar  have  been  consumed.  The  gene- 
ral consensus  of  opinion  at  present  is  that 
the  varying  quantities  of  uric  acid  depend 
in  the  main  upon  individual  peculiarity. 

Since  uric  acid  closely  follows  urea,  in 
all  the  cases  previously  mentioned  in  which 
urea  has  been  found  in  excess  or  the 
reverse,  uric  acid  will  also  be  found  in 
excess  of  normal  or  below  normal.  Thus 
an  increase  has  been  noted  in  pyrexia,  in 

*■  Roy.  Med.  Chirurg'.  Soc,  1867. 

t  Schnniziger  and  Leube,  Peters,  Med.  Wochen- 
schrift,  1882,  p.  361. 

t  Kaposi,  "  Kautkrankheiten,"  p.  481. 

§  Beueke,  Arch.f.  Wiss.  Heiltunde,  Bd.  ii.  36. 

II  "  Proc.  Koy.  Soc,"  vol.  xl.  pp.  484,  485. 


Urine 


[     1345    ] 


Urine 


which  there  is  an  increase  in  the  number 
of  respirations,  especially  in  croupous 
jineumonia.  Scheube  found  the  t^reatest 
amount  of  uric  acid  the  day  following  the 
highest  fever.  R:inke,  Virchow,  Mosler, 
Saikowski,  Petteukofer,  and  Yoit,  with 
others,  have  found  in  leucaemia  a  great  in- 
crease of  uric  acid.  In  one  case  recoi'ded 
by  Bartels  it  is  said  to  have  reached  the 
quantity  of  4.2  grammes  in  the  twenty- 
lour  hours.  In  splenic  anaimia  uric  acid 
has  also  been  found  abnormal  in  quantity. 
Coignard*  in  a  case  of  dyspepsia  found  as 
much  as  1.38  gramme  of  uric  acid  excreted 
within  the  twenty-four  hours.  The  re- 
searches of  Garrod  have  shown  that  in 
gout  there  is  a  deci'eased  kidney  elimina- 
tion, while  there  is  a  normal  or  possibly 
increased  secretion  of  uric  acid  in  the 
tissues.  The  uric  acid  is  decreased  in 
diabetes,  in  antemia,  in  many  affections  of 
the  kidney,  and  in  some  other  diseases. 
The  influence  of  mental  states  and  dis- 
eases upon  the  secretion  of  uric  acid  is 
very  little  known,  Johnson  Smyth  found 
that  uric  acid  was  increased  in  mental 
diseases  generally,  the  increase  being 
greatest  in  general  paralysis,  epilepsy  and 
melaiicholia ;  on  the  other  hand,  uric 
acidsBmia  is  said  to  give  i-ise  to  a  variety 
of  disorders  of  the  nervous  system.  In 
his  Croonian  Lectures  (1874)  upon  func- 
tional derangements  of  the  liver,  Murchi- 
son  associated  with  lithtemia  aching 
pains  in  the  limbs  and  lassitude,  pain 
in  the  shoulder,  hepatic  neuralgia,  severe 
cramps  in  legs,  &c.,  headache,  vertigo  and 
temporary  dimness  of  sight,  convulsions, 
paralysis,  noises  in  the  ears,  sleeplessness, 
depression  of  spirits,  irritability  of  temper, 
cerebral  symptoms  and  the  typhoid  state. 
Haigf  found  that  "  when  the  urine  ex- 
creted during  a  headache  is  carefully 
separated  from  that  before  the  headache 
began,  or  after  it  left  off,  an  excess  of  uric 
acid  relative  to  urea  is  always  found  (say 
the  relation  of  i  to  20  or  i  to  25).  Before 
the  headache  begins  there  is  often  a  re- 
lation of  I  to  40 — i.e.,  diminished  uric  acid, 
and  after  it  ends  the  same.  If  we  have  a 
mixture  of  before  or  after  with  the  head- 
ache urine,  the  excess  in  one  direction 
may  balance  that  in  the  other,  and  the  re- 
sult comes  out  near  i  to  2>3j  or  normal." 
The  same  author  found  that  in  epilepsy, 
just  as  in  migraine,  "  the  excretion  of 
uric  acid  is  greatly  diminished  before  the 
attack — that  is,  mental  exaltation  corre- 
sponds to  a  minus  excretion  of  uric  acid 
and  headache,  an  epileptic  fit  or  mental 
depression  corresponds  to  a  plus  excretion, 
which  is,  to  some  extent,  the  result  of  the 


»  Jahresh./.  Thierchem.,  li 
t  Brain,  part  i.  1891. 


p.  247. 


previous  minus  excretion  (retention)." 
Migraine,  or  the  headache  of  uric  acid- 
ajmia,  is  looked  upon  as  a  local  vascular 
effect  of  uric  acid.  "  Epilepsy  resembles 
migraine  in  the  mental  brightness  and 
well-being,  with  scanty  excretion  of  uric 
acid,  which  may  precede  both,  in  the  ex- 
cessive excretion  of  uric  acid  and  mental 
depression  which  may  accompany  both, 
and  in  the  subnormal  temperature  which 
is  often  found  in  both."  Hysteria  is  also 
regarded  as  one  of  the  mental  effects  of 
uric  acid,  and  as  a  variety  or  mixed  con- 
dition between  ordinary  epilepsy  and 
simple  mental  depression.  Haig  does  not, 
however,  agree  with  Broadbent  that  the 
high  arterial  tension  is  '•'  probably  the 
most  important  factor  in  the  secretion  of 
the  pale  and  watery  urine  which  accom- 
panies an  hysterical  attack,"  but  states 
that,  as  a  matter  of  fact,  "  during  the 
high  ai'terial  tension  and  contraction  of 
arterioles  and  capillaries  in  the  attack, 
the  urine  is  scanty  and  of  high  specific 
gravity,  containing  much  uric  acid ;  and 
it  is  only  when  the  tension  falls  and  the 
capillaries  are  relaxed  at  the  end  of  the 
attack  that  it  becomes  pale  and  watery. 
Further,  he  believes  that  the  unconscious- 
ness which  follows  epileptic  fits  will  last 
a  long  or  short  time  according  as  the  uric 
acid  which  occasioned  them  is  slowly  or 
quickly  driven  out  of  the  blood,  and  that 
the  stupor  is  not  really  due  to  exhaustion 
of  the  nerve-centres  any  more  than  the 
heavy,  languid,  and  sleepy  feeling  so  often 
met  with  in  the  morning  hours  during  the 
plus  excretion  of  uric  acid,  is  due  to  want 
of  sleep  in  the  previous  night.  The  same 
author  has  noticed  the  presence,  absence, 
or  alteration  in  amount,  of  certain  forms 
of  tremor  in  a  fairly  constant  relation 
with  the  amount  of  uric  acid  in  the  blood. 
He  also  ascribes  uric  acidaamia  as  being 
an  important  factor  in  the  production  of 
some  forme  of  aphasia,  vertigo,  and  in- 
somnia. 

Allantoin  and  oxaluric  acid  are  both 
bodies  which  occur  rarely,  if  at  all,  in 
human  urine ;  whilst  xanthin,  guanin, 
hreatin,  hreatinin,  sulpliocyanic  acid,  &c., 
are,  for  our  purposes,  comparatively  un- 
important. 

(2)  Oxalic  acid  (CoHoO^  +  2H2O),  in  the 
form  of  oxalate  of  lime,  is  found  in  the 
urine  invariable  quantity;  sometimes  it 
is  absent.  Its  presence  is  evidently  rather 
due  to  the  nature  of  the  food  eaten  than 
to  special  decompositions  within  the 
organism.  Oxalate  of  limo  is  also  found 
in  the  intestinal  contents,  but  the  urine  is 
the  only  secretion  in  which  it  is  found 
normally.  Oxalate  of  lime  is  a  very  in- 
soluble salt ;  it  occurs  whenever  a  solution 


Urine 


[    1346    ] 


Urine 


of  oxalic  acid  or  o£  a  soluble  oxalate  is 
mixed  with  an  aqueous  solution  of  a 
soluble  lime  salt.  The  precipitate  may- 
be amorphous  or  it  may  be  in  a  crystalline 
form,  such  as  dumb-bells,  octahedra,  or 
sometimes  as  four-sided  prisms,  rarely  as 
spheroids.  The  crystals  are  insoluble 
in  acetic,  soluble  in  hydrochloric,  acid. 
Hence,  to  find  readily  oxalate  of  lime 
crystals  in  a  urinary  sediment,  it  is  well 
to  treat  the  sediment  with  acetic  acid, 
which  will  dissolve  phosphates  and  leave 
oxalate  of  lime  and  uric  acid  sediments 
undissolved.  The  reason  why  so  insoluble 
a  salt  as  lime  oxalate  can  exist  in  solution 
in  the  urine  was  discovered  by  Neubauer, 
who  found  that  it  was  soluble  in  a  solu- 
tion of  acid  phosphate  of  soda.  If  to  a 
solution  of  hydrosodic  phosphate  a  few 
•drops  of  chloride  of  lime  are  added  and 
followed  by  a  solution  of  amnionic  oxalate, 
no  i^recipitate  occurs ;  but  if  sufficient 
soda  solution  is  added  to  neutralise  the 
acid  phosphate,  then  down  comes  the 
lime  oxalate.  A  similar  change  takes 
place  in  the  urine  on  standing  ;  the  acid 
phosphate  of  soda  and  the  sodic  urate 
interact,  first  forming  acid  urate  of  soda, 
and  little  by  little  the  acid  phosphate  of 
soda  disappears  from  the  urine,  and  the 
oxalate  falls  slowly  down,  the  slow  deposit 
being  most  favourable  for  the  production 
of  crystalline  forms.  A  similai*,  perhaps 
identical,  process  takes  place  occasionally 
in  the  bladder,  and  then  there  is  a  forma- 
tion of  urinary  calculus. 

At  one  time  it  was  supposed  that  a 
particular  disease  known  as  oxaluria 
existed,  but,  although  it  may  be  that  in 
one  human  body  more  oxalic  acid  is  ex- 
creted through  the  kidneys  than  another, 
there  is  great  doubt  whether  as  a  distinct 
malady  oxaluria  exists.  Beneke  stated 
that  under  continued  depressing  mental 
influences  oxalic  acid  crystals  appeared 
in  the  urine  constantly  and  in  very  large 
numbers,  and  at  the  same  time  the  quan- 
tity of  lithic  acid  became  increased,  while 
no  change  had  taken  place  in  the  manner 
of  living. 

Glijcero-plwsplioric  Acid.  —  Since  the 
brain  and  nervous  system  are  so  largely 
made  up  of  combinations  of  glycero- 
phosphoric  acid  united  with  complex  albu- 
minoids, it  is  only  reasonable  to  imagine 
it  possible  that,  if  there  should  be  any 
actual  loss  by  wasting  of  the  nervous 
tissues,  there  would  be  an  excretion  of 
phosphorus,  either  in  the  form  of  phos- 
phoric acid  or  of  glycero-phosphoric  acid, 
the  latter  being  the  more  jDrobable.  Al- 
though there  have  been  many  estimations 
of  total  phosphates  in  the  urine  of  persons 
affected  with  general  paralysis  and  other  , 


brain  diseases,  and  although  there  is  a 
widespread  belief  that  phosphates  are 
generally  increased  in  these  maladies,  the 
researches  hitherto  have  been  far  from 
satisfactory  because  the  all-important 
factor  has  been  usually  neglected  of  care- 
ful previous  estimation  of  the  intake  in 
the  food  of  phosphates.  This  remark  does 
not,  however,  apply  with  the  same  force 
to  glycero-phosphoric  acid,  which  has 
been  ascertained  to  be  excreted  in  such 
small  quantities  in  health  that,  in  order 
to  estimate  it,  10  litres  of  the  normal 
urine  require  to  be  operated  upon.  Hence, 
if  found  in  sufficient  quantity  to  weigh 
when  operating  upon  a  quarter  or  half  a 
litre  of  urine,  we  may,  in  our  present 
state  of  knowledge,  consider  such  a  quan- 
tity pathological. 

A  series  of  researches  on  the  excretion 
of  glycero-phosphoric  acid  in  the  urine  of 
the  insane  would  be  of  the  highest  value, 
and  it  is  strange  that  it  has  not  been 
more  often  undertaken.  The  most  im- 
portant work  in  this  direction  of  late 
years  has  been  done  by  Dr.  E.  Birt,  at  the 
West  Kiding  Asylum,  Wakefield,  and  his 
results  published  in  Brain  (October  1886). 
In  1884  Zuelzer*  maintained  that  "from 
the  nervous  tissue  when  in  a  state  of 
lowered  irritability  the  delivery  of  material 
is  augmented,  and  that  it  is  lessened  in 
conditions  of  exalted  irritability.  Further, 
that  each  of  these  series  of  conditions  is, 
in  respect  to  the  tissue  change,  differen- 
tiated by  urinary  qualities  peculiar  to  it, 
and  of  such  kind  that,  in  depressed  con- 
ditions (traumatic  or  pathological  de- 
structive brain  lesions,  chloroform,  ether, 
morphia,  narcosis,  &c.),  the  phosphoric 
and  glycerin  phosphoric  acids  of  the 
urine  are  increased  ;  whereas  excited  con- 
ditions (as  induced  by  strj'chnia,  phos- 
phorus, alcohol  in  small  doses)  are 
attended  by  a  diminished  amount  of  those 
products  in  the  urine."  According  to 
Zuelzerf,  the  normal  graviraetinc  propor- 
tion of  the  PoOj  to  the  N  in  the  twenty- 
four  hours'  urine  of  the  adult,  is  18  or  20 
to  100.  In  blood,  the  mean  proportion  is 
as  4  to  100 ;  in  muscle,  15  to  loo ;  in  brain 
and  other  nervous  organs  which  contain 
the  greatest  amount  of  lecithin,  45  to  100. 
Lepine  and  Eymounet|  estimated  the 
normal  amount  of  glycerin  phosphoric 
acid  in  grammes  at  0.25  to  100  X,  or  about 
I  per  cent,  of  the  total  P^Oj.  They  also 
noted  "  an  increase  in  the  renal  excretion 
of    the   phosphorus    compounds  —  parti- 

*  "  Uutersueh.  iiber  die  Semeiologie  des  Hani," 
8.  57,  n.  ft.  (quoted  from  Hirt). 

t  Birt,  Brain,  Oct.  1886. 

X  Comptes  liendii.'!  des  Sffances  de  VAcmI.  des 
Sciences,  t.  xcviii.  1884,  No.  4,  p.  239,  vide  Birt. 


Urine 


[    1347    ] 


Urine 


ciilarly  the  glycerin  phosphoric  acid — as 
a  result  of  gross  cerebral  lesions,  epilepsy, 
and  use  of  chloral  or  bromides.  Thus,  in 
a  case  of  ha3morrhage  into  the  external 
capsule  and  outer  part  of  the  lenticular 
nucleus,  the  urine  excreted  during  the  first 
six  hours  contained  per  litre." 


N 

I'jO,, 

It 

2-5 

0.0268 

0.54* 
1.07 

21.6 

"  Forty-eight  hours  later,  the  proportion 
■was  normal."  In  one  case  of  general 
l)aralysis  of  two  years'  duration  in  which 
there  was  exaltation,  Birt  found  a  large 
absolute  quantity  of  the  glycerin  phos- 
phoric acid,  then  during  a  period  of  stupor 
an  increased  elimination  of  the  inorgani- 
cally combined  P^O^.  In  two  other  cases 
there  existed  a  notable  discharge  of 
glycerin  phosphoric  acid  in  connection 
■with  the  occurx-ence  of  i^aralytic  motor 
phenomena,  which  contrasted  strongly 
with  the  absence  of  that  compound  when 
the  patients  had  regained  their  normal 
state.  Birt  says,  "  One  does  not  constantly 
find  an  excretion  of  glycerin  phosphoric 
acid  following  the  convulsive  attacks  of 
general  paralysis."  Similarly  in  epilepsies, 
€ven  when  an  enormous  series  of  fits 
rapidly  proceeds  to  a  fatal  issue. 

Lepine  and  Jacquin  t  "  found  the  pro- 
portion of  the  P0O5  to  the  N  much  below 
normal  on  the  days  between  the  fits,  once 
as  low  as  8.6  per  cent.  In  those  patients 
the  proportion  notably  increased  imme- 
diately after  a  fit,  the  rise  being  absolute, 
and  chiefly  due  to  an  increase  of  the  earthy 
phosphates.  An  augmentation  of  the 
earthy  phosphates  was  also  noted  when 
the  patients  had  merely  experienced  sensa- 
tions of  a  fit  being  imminent,  or  had 
undergone  an  attack  of  vertigo."  In  a 
case  of  recurrent  mania,  Birt  found  the 
ratio  of  PgO^  to  the  N  was  constantly 
lower  when  excitement  was  absent.  "  No 
organically  combined  P^O^  was  found 
while  the  mental  aifection  ran  its  usual 
course.  As  soon,  however,  as  a  depressed 
condition  became  established  (partial 
collapse  from  peritonitis,  so  far  induced  by 
morphia),  a  large  ehmiuation  of  glycerin 
phosphoric  acid  occurred."  In  a  case  of 
severe  melancholia,  there  was  excess  of 
■discharge    of    glycerin    phosphoric    acid 

*  In  IMrt's  paper  the  quantities  found  by  ana- 
logies are  expressed  in  {iranmies,  or  parts  of  a 
gramme.  Wliere  two  series  of  figuri's  are  given, 
under  tlie  heading  I'i*  >.-„  tlie  first  indicates  the 
phosphoric  acid  in  combination  with  alkalies  of 
iilkaline  earths,  the  second  the  glycerin  phosphoric 
acid.  Tlie  numbers  under  K  denote  the  gravi- 
metric ratio  of  the  respective  P_>* ».:;  to  100  X. 

t  Heme  Mensiielle  de  M(d.  ct  dc  Cliir.,  tome  iii. 
1879,  Nos.  9  ct  12,  quoted  from  ISirt. 


when  the  disturbance  of  cerebral  function 
was  greatest. 

(3)  Carbohydrates, — Inosite,  gum. 

(4)  The  Aromatic  Substances. — Hip- 

puric  acid.  The  ether  sulphates  of 
phenol,  cresol,  pyrocatechm,  indoxyl, 
scatoxyl  and  others,  are  comparatively 
unimportant. 

(5)  I>Ilneral  Constituents. — These  de- 
pend mainly  upon  the  food  ;  it  is  pretty 
certain  that  soluble  salts  of  the  alkalies 
and  the  alkaline  earths,  and  in  fact  all  salts 
which  enter  the  circulation,  are  excreted 
by  the  kidneys,  bitt  most  of  the  earthy 
phosphates  in  wheat  meal,  and  all  the 
silica,  and  most  of  the  iron,  are  excreted  by 
the  bowel. 

Dr.    Adam    Addisoti    found    that    the 
quantities  of   chloride   of    sodium,  phos- 
phoric    and     sulphuric     acids,     excreted 
during  the  course  of  a  maniacal  paroxysm, 
occurring     in     acute     mania,     epilepsy, 
general  paralysis,  melancholia  or  demen- 
tia, are  less  than  the  amounts  excreted  in 
an  equal  time  during  health.     In  chronic 
melancholia  the  quantities  of  chloride  of 
sodium,  phosphoric  and  sulphuric  acids 
are   reduced  below  the  mean,  and  some- 
times the  minimum  of  health.     In  idiocy, 
dementia    (jaaralytic    and    common),  the 
urea,  chloride  of   sodium  and    sulphuric 
acid  range   above  and  below  the  normal 
mean    of    health ;     in    some    cases    the 
amount  of  phosphoric  acid  is  greater  than 
the  mean  according  to  weight,  but  in  the 
majority  of  cases  it  ranges  between  the 
minimum    and   mean  found    in    healthy 
adult  men.     Sutherland  and  Rigby  found 
crystals  of  triple  phosphates  in  dementia 
at  the  rate  of    25  per  cent. ;    crystals  of 
oxalate  of  lime  were  seen  in  every  fourth 
case  of  melancholia,  or  at  the  rate  of  25 
per  cent.     In  mania  the  proportion  was 
17.85,  and  in  dementia  only  2.08  per  cent. 
Mendel*  estimated  that  the  quantity  of 
phosphoric  acid  excreted  by  the  kidneys 
under  the  influence  of  brain  disease,  and 
compared   proportionately    to   the    other 
solid  principles  of  urine,  varies  consider- 
ably from  2.49  to  3.93  per  cent.     The  sub- 
stance is  excreted  in  greater  quantity  at 
night    than    during    the   day.      In    the 
chronic  maladies  of  the  encephalon  there 
is  a  decrease  in  the  absolute  quantity  of 
phosphoric   acid   excreted   every  day,    as 
well  as  the  relative  quantity  in  connection 
with  the  other  solid  principles  of  urine. 
In  cases  of  maniacal  excitement  there  is 
an  increase  in  the  absolute  and  relative 
quantity  of  the  substance.     Increase  in 
the  quantity  is  also  observed  during  at- 
tacks of  epilepsy  and  apoplexy,  and  after 
the  administration  of  chloral  and  bromide 

*  Archivj'ur  Psi/chiatrie,  IJd.  iii.  Heft  3. 
4  R 


Urine 


1348    ] 


Urine 


of  potassium.  The  decrease  of  the  sub- 
stance in  chronic  cases  of  brain  disease 
must  be  attributed  generally  to  diminu- 
tion of  muscular  activity,  dependent  on 
the  protracted  course  of  the  disease.  In 
other  cases  it  may  be  ascribed  to  the 
general  weakness  or  exhaustion  of  the 
nervous  system,  the  result  of  imperfect 
assimilation.  Bence  Jones  has  endea- 
voured to  show  that  a  distinction  between 
inflammation  of  the  brain  and  delirium 
tremens  is  to  be  found  in  the  increased 
amount  of  phosphoric  acid  (alkaline  and 
earthy  phophates)  in  the  urine  of  patients 
with  inflammation  oE  the  brain.  This 
test  is  of  little  practical  value,  for  the 
sources  of  phosphoric  acid  in  the  urine 
are  so  numerous  that  it  would  require 
the  evidence  of  a  vast  number  of  analyses 
to  convince  one  that  inflammation  of  brain 
tissue  would  so  much  increase  the  amount 
of  phosphoric  acid  in  the  urine  that 
this  fact  alone  would  suffice  for  the  dia- 
gnosis between  an  inflamed  and  non- 
inflammatory condition  of  the  brain.  In 
delirium  tremens  Bence  Jones  found  ex- 
cess of  urea,  sulphates  and  albumen. 

In  jiuerperal  insanity  Dr.  Campbell 
Clark  found  chlorides  were  scai'cely  trace- 
able, being  so  low  as  0.36  grammes  in 
twenty-four  hours  ;  for  fourteen  hours  of 
day  urine  the  minimum  was  0.09  gramme, 
and  for  ten  hours  of  night  urine  0.24 
gramme.  He  concludes  that  "  the  de- 
ficiency of  chlorides  may  be  partially,  but 
insufiiciently  accounted  for,  by  (a)  the 
anorexia  and  atonic  dyspepsia  ;  (b)  saline 
deficiency  in  the  food  administered ;  (c) 
sluggish  digestion,  owing  to  artificial, 
instead  of  natural,  alimentation  ;  (d)  the 
pyrexia,  which  must  in  these  cases  be  re- 
garded as  only  of  moderate  import ;  (e) 
moisture  of  the  skin."  He  also  considers 
that  "  it  is  exceedingly  probable  that  in 
some  way  yet  to  be  ascertained  chlorides 
accumulate  in  the  system,  and  have  some 
pathological  significance  in  this  disease, 
which  we  know  not.  The  loss  to  urine 
and  mucous  secretions  have  three  possible 
explanations:  (a)  Chlorine  starvation; 
(b)  chlorine  infiltration  of  tissues;  (c) 
chloringemia.  Campbell  Clark  found  a 
decrease  in  the  quantity  of  phosphoric 
acid  in  jjuerperal  insanity,  being  as  low  as 
0.2  gramme  in  twenty-four  houi's,  the 
minima  being  0.07  for  day  urine,  and  0.25 
gramme  for  night  urine,  and  he  considers 
that  the  quality  rather  than  the  quantity 
of  mental  excitement  is  more  likely  to 
account  for  the  changes  in  the  excretion 
of  the  phosphoric  acid. 

Albumen. — Rabenan*  has  several  times 

*  Archiv  von  I'sycli.  uiid Xcrventr.jBd.iv.ii.ySj. 


observed  the  occurrence  of  albumen  in 
many  cases  of  paralysis  at  some  time  or 
another.  Richter*,  however,  states  that 
this  constituent  is  not  frequently  present, 
and,  if  it  is,  is  not  connected  with  the  cere- 
bral disease.  In  epileptics,  quantitative 
and  qualitative  changes  occur.  Formerly 
it  was  repeatedly  stated  that  sugar  and 
albumen  occur  immediately  after  the  fits. 
The  sugar  question  is  now  settled,  since- 
all  recent  works  on  this  subject  agree  that 
urine  passed  after  the  epileptic  attacks 
is  free  from  it.  On  the  contrary  in  regard 
to  albumen,  Huppertt  found  that  a  certain- 
amount  is  found  after  every  attack. 
Rabow  found  albumen  in  eight,  but  no 
sugar  in  the  urine  of  ten,  epileptic  lunatics 
immediately  after  the  tits.  Sometimes 
the  reaction  was  so  slow  and  feeble  that 
it  might  have  been  easily  overlooked. 
Huppert  arrived  at  the  conclusion  that 
albumen  appears  in  the  urine  after  every 
well-marked  fit  of  epilepsy.  It  is  not 
found  in  tirine  which  is  passed  just  before 
or  during  a  paroxsym.  It  continues  to  be- 
present  in  urine  passed  from  three  to  eight 
hours  after  a  fit.  The  more  severe  the  fit 
the  more  abundant  the  albumen.  Mere 
cases  of  epileptic  vertigo  may  be  quite  un- 
attended by  this  phenomenon  unless  the 
attacks  follow  one  another  rapidly.  The 
amount  excreted  is  never  large  ;  there  may 
be  suflicient,  however,  to  form  the  ordinary 
flocculi  with  heat  and  nitric  acid,  but  often 
there  is  only  a  white  cloudiness  or  mere 
opalescence,  especially  after  mild  epileptic 
fits.  The  largest  quantity  of  albumen  is 
found  in  the  first  urine  passed  after  the 
fit,  and  the  greatest  average  amount  in 
those  patients  who  have  long  suffered  from 
severe  attacks.  Such  urine  is  remarkable 
for  its  clearness  and  increased  quantity  ; 
its  specific  gravity  generally  ranges  from 
1012  to  1020.  In  severer  forms  of  epilepsy 
there  are  sometimes  hyaline  cylinders  and 
(in  males)  spermatozoa  in  the  urine.  The 
cylinders  are  found  in  the  first  or  second 
urine  after  the  fit,  but  they  do  not  remain 
present  so  long  as  the  albumen  does. 

The  spermatozoa  also  occur  in  the  first 
urine  after  severe  attacks,  and  in  about  a 
tenth  of  the  cases  exist  in  such  numbers 
that  the  conclusion  is  inevitable  that  a 
definite  though  slight  ejaculation  of  semen 
is  coincident  with  the  fit.  It  probably  is- 
due  to  a  direct  nerve  irritation,  that  is, 
one  which  bears  the  same  relation  to  the 
central  nervous  centres  as  the  convulsions 
do.  A  true  seminal  emission  is  not  a 
phenomenon  of  epilepsy  in  Dr.  Huppert's 
experience.  Red  blood  coi'puscles  are 
seldom  present  in  the  urine  after  epileptic 

*  Archiv  von  Psi/ch.  u/ul  Xervenkr.,  Bd.  vi. 

t  Virchow's  Archie,  Bd.  lix. 


Uriue 


[    1349    ] 


Urine 


attacks,  or  their  number  if  present  is  so 
small  that  they  can  be  considered  of  no  sig- 
niticanco.  Even  where  there  were  sub- 
conjunctival petechiiu,  Dr.  Huppert  could 
not  find  an  increase  of  red  blood  cells  in 
the  urine  even  with  the  most  careful  micro- 
scopic examination  ;  while  blood  cells  on 
the  other  hand  are  almost  always  present. 
This  absence  of  red  corpuscles  points  to  the 
arteries  as  the  source  of  albumen  in 
epilepsy.  Since  Liebermeister,  Cohnheim 
and  Hering  have  shown  that  nervous  con- 
gestion, even  withovit  rupture  of  blood- 
vessels, is  always  accompanied  with  an 
abundance  of  red  corpuscles  in  the  urine  as 
soon  as  albuminuria  commences.  While 
the  urine  of  patients  with  progressive 
paralysis  of  the  insane,  after  epileptiform 
or  apoplectiform  attacks,  agrees  with  that 
of  epileptics  in  containing  albumen  and 
hyaline  casts,  it  differs  from  the  latter  in 
containing  red  blood  cor2)uscles  in  some 
quantity  either  isolated  from  one  another 
or  in  groups  of  six  to  twelve  of  each. 

Fiirstner*  found  albumen  in  the  urine 
of  those  labouring  under  delirium  tremens, 
and  that  the  quantity  of  albumen  was 
jiroportioned  to  the  intensity  of  the 
delirium.  Albumen  is  sometimes  found 
in  the  urine  of  habitual  drinkers. 

The  same  author  considers  that  albu- 
men is  far  from  being  a  constant  symptom 
of  epileptic  fits ;  a  transitory  reaction  of 
albumen  is  often  found,  but  not  always. 
In  three  cases  of  status  epilepticus  which 
ended  fatally,  no  ti'ace  of  albumen  could 
be  found.  Rabenan  found  albumen  to  be 
present  more  commonly  in  paralytic  in- 
sanity than  in  any  other  cerebral  disease, 
and  thinks  it  independent  of  alteration  of 
the  kidneys.  De  Witt  found  albuminuria 
after  the  convulsions  of  general  paralysis, 
while  Konig,  Richter,  and  Mendel,  on  the 
other  hand,  usually  found  it  absent. 

Dr.  Campbell  Clark f  found  albumen 
was  present  in  9  out  of  23  cases  of  puer- 
peral insanity  ;  the  precipitate  was  usually 
slight. 

Sugar.  {See  Diabetes.) — Sugar  in  the 
urine  has  been  found  in  several  cerebral 
diseases  and  cerebral  lesions,  in  which 
there  were  no  evident  pathological  changes 
in  other  organs.  Recklinghausen  J  found 
melituria  in  the  case  of  a  tumour  of  the 
fourth  ventricle ;  Dompeling§  in  a  tumour 
of  the  medulla ;  Giovanni  ||  in  sclerosis  of 
the  right  cerebellum  ;  Zenker^  in  disease 

*  Archiv,  Bd.  vi.  Heft  3. 

t  Jonrn.  Aleut.  Sci.  Oct.  1887  and  Jan.  1888. 
X  "S'lrchow's  Archir,  Bel.  xxx.  s.  360.     1864. 
§  Kef.  Ceiitralbl.fiir  diemed.  IVisse iischa/t,  i86g, 
8.  144. 

n  Jahreshericht,  1876,  Bil.  ii.  s.  269. 

1[  "  Ueber  die  Xatiir.  Vers,  in  Speyer,''  1861. 


of  the  fourth  ventricle :  Hosier*  in  a  case 
of  softening  of  the  nucleus  dentatus  in 
the  cerebellum.  Diabetes  coincided  with 
a  case  described  by  Mosler.f  in  which 
there  was  a  new  formation  in  the  fourth 
ventricle,  with  a  case  of  tubercle  in  both 
hemispheres  described  by  Roberts,^  with 
chronic  infiammatory  changes  in  one  of 
the  calamus  scriptorius  (Lancereaux)  with 
cysticercus  in  the  brain  (Prerichs)§  with 
encephalitis  of  the  fourth  ventricle 
and  its  surroundings  (Pribram)  ||  with 
carcinoma  of  the  glandula  pituitaria 
(Massot).1[ 

Gooden**  found'that  there  was  sugar  in 
many  cases  of  epilepsy,  paralysis,  and 
chorea,  but  that  this  disappeared  as  symp- 
toms were  relieved  by  treatment.  Ordi- 
narily there  was  no  diuresis ;  urine  often 
turbid  and  ammoniacal. 

Glycurouic  acid,  CgHioO^,  also  reduces 
copper.  Glycuronic  acid  when  pure  is  in 
the  form  of  white  amorphous  granules,  its 
anhydride  forms  fine  colourless  acicular 
crystals.  In  urine  it  is  in  combination 
with  urea,  probably  as  uroglycuronic  acid. 
It  rotates  a  ray  of  polarised  light  35°  to 
the  right.  It  is  doubtful  whether  glycu- 
ronic acid  is  present  in  normal  urine,  but 
its  presence  has  been  ascertained  as  a 
result  of  taking  certain  drugs — e.g.,  brom- 
beuzol,  tt  nitro-benzol,:J:J  quinine  deriva- 
tives,§§  phenol,  benzol  and  indol.||||  Ac- 
cording to  Ashdown,^1[  the  best  way  is  to 
ferment  the  urine  after  the  manner  of 
Salkowski,  and  thus,  after  having  de- 
stroyed the  sugar,  to  see  whether  it  reduces 
copper,  if  it  does,  glycuronic  acid  is  pro- 
bably present.  Salkowski's  method  of 
fermentation  is  to  simply  fill  a  tube  very 
similar  in  shape  to  the  ureometer  of 
Doremus,  with  the  urine,  and  put  a  little 
mercury  in  the  bend ;  a  little  good  yeast 
is  passed  up  by  means  of  a  curved  pipette, 
and  the  urine  kept  for  a  number  of  hours 
at  a  fermentation  temperature.  *** 

*  Beutscli.  Arch.  f.  Jclin.  Med.,  Bd.    xv.   s.  229, 

1875- 

t  Virchow'.s  Archiv,  Bd.  xliii.  s.  225. 

t  Arch,  (ji'ii.  1866,  torn.  ii. 

§  Charitc  Antmlen,  Bd.  ii.  1877,  s.  653. 

II  Prager  Mertcljahrschrift,  1871,  Bd.  cxii.  s.  28. 

If  Lyon  Med.,  1872. 

**  Lancet,  1854,  p.  656. 

ft  Zeitschrift /.  physiiil.  Chemie,  1879,  Bd.  iii.  p. 
156  :  188 1,  Bd.  V.  p.  309.  JafEe,  Ber.  d.  Deutsche h 
Oesell.,  Bd.  xii.  p.  306. 

tt  Ceidr.f.  Med.  T^('s.sp«.,  1875,  No.  Iv. 

§§  Zeitsch.  /".  Physiol.  Chemie,  1880,  Bd.  iv.  p. 
296. 

III!  Baumann,  Archiv  f.  ges.  Physiol.,  1876,  Bd. 
xili.p.  299;  Zeitscfi.  f.  Physiol.  Chem.,  1877,  Bd.  i. 
p.  68. 

Ifl  "  Laboratory  lli'ports,  Koyal  College  of  I'hy- 
sicians,  Edinburgh,"  vol.  ii. 

*■'•''  On  the  reduction  of  copper  solution  bykrcati- 
niue,  See  ante. 


Urine 


[    1350    ] 


Uterine  Disorders 


Examples  of  Urixe  Analysis.  —  The 
following  few  analyses  of  urine  are  added 
as  examples  of  the  possibility  of  deter- 
mining quantitatively  several  of  the  or- 
ganic principles  in  the  collection  of  twenty- 
four  hours'  renal  secretion.* 

l^ania. — Acute  Mania  with  Refusal  of 
Food.  —  Female,  height  about  5  feet ; 
weight,  8st.  8  lbs.  =  54.45  kilos.  Food 
consumed:  Bread,  2.5  ozs.  ;  tea,  i  pint; 
milk,  2  ozs.;  sweetened  arrowroot,  i  pint 
(made  by  thickening  milk  with  arrowroot). 
Analysis  of  the  urine  of  twenty-four  hours 
Nov.  4-5,  1889:  Quantity,  770  CO. ;  re- 
action, slightly  acid ;  specific  gravity, 
1007  ;  sugar  and  albumen,  absent.  Total 
solids,  13.04  grms. ;  ash,  2.42  grms.; 
volatilised  chlorine  calculated  as  NaCl, 
1.6  grm,;  organic  solids,  9.02  grms.  SO^ 
as  mineral  sulphate,  .60  ;  uric  acid,  not 
estimated  ;  hippuric  acid,  .03  ;  kreatinine, 
.05 ;  nitrogen  by  soda  lime,  3.39  grms. 
(  =  7.26  grms.  urea). 

Melancholia. — Female  patient,  height 
5  feet  2  inches;  weight,  6st.  I2lb.  =  43.5 
kilos.  Food  consumed:  Bread,  14  ozs.; 
butter,  I  oz. ;  tea,  2  pints ;  milk,  2  ozs. ; 
potatoes,  5  ozs.  ;  meat,  3  ozs.;  3  ozs.  of 
a  pudding  made  of  rice  and  milk; 
water,  8  ozs.  Analysis  of  the  urine  of 
twenty-four  hours  Nov.  4-5,  1889: 
Quantity,  1688  c.c. ;  reaction,  slightly 
acid;  specific  gravity,  loio  ;  sugar  and 
albumen,  absent.  Total  solids,  32.72 
grms.  ;  ash,  7.76  grms. ;  volatilised  chlo- 
rine calculated  as  NaCl,  9.32  grms. ;  total 
organic  solids,  15.64  grms.  SO3  as 
mineral  sulphate,  .31  ;  ether  sulphate,  .06; 
organic  sulphur,  .05  ;  hippuric  acid,  not 
estimated ;  kreatinine,  .053  ;  nitrogen  by 
l'iypobromite  =  4.9i  equal  to  10.51  urea; 
nitrogen  by  soda  linie  =  5.57  equal  to 
11.93  ;  phosphoric  acid,  not  estimated. 

General  Paralysis. — J.  A.,  male,  aged 
43,  height  5  feet  7  inches;  weight,  I2st. 
13  lbs.  =  77.6  kilos;  patient  in  the  first 
stage  of  general  paralysis :  a  complete 
collection  of  twenty-four  hours  Nov.  4- 
5,  1889.  Food  consumed:  Tea,  1.5  pint 
with  sugar  and  milk  (milk  3  ozs.) ; 
cocoa,  1.5  pint;  water,  i  pint;  bread,  16 
ozs.  ;  butter,  i  oz. ;  potatoes,  13  ozs. ;  meat 
pie,  17  ozs.  (contains  about  6  ozs.  meat, 
1.5  ozs.  haricot  beans,  also  flour  and  suet). 
Composition  of  the  urine  :  Total  quantity, 
2475  c.c.  ;  reaction,  slightly  acid;  specific 
gravity,  10124.  Total  solids,  67.32  grms. ; 
ash,  20.54  grms. ;  volatilised  NaC!,  16.43 
grms.  Mineral  sulphate,  2.40  ;  ether  sul- 
phate, 0.30;  organic  sulphur,  0.14;  chlorine, 

*  The  cases  were  patients  in  tlie  Berrywood 
As.ylum,  under  tlie  care  of  Dr.  Greene,  tu  whom  \vc 
are  indebted  for  the  opportunity  of  making-  these 
analyses. 


14.89  ;  uric  acid,  0.03  (?);  phosphoric  acid, 
2,16;  kreatinine,  ,113;  nitrogen  by  soda 
lime,  10.08  =  urea  21  grms. 

A,  Wynteb  Blyth. 

TiiEo,  B,  Hyslop, 

UTSRZN-i:  DISORDERS  ANH  XJT- 
SANITV. — We  may  first  point  out  the 
influences  of  disordered  functions  of  the 
sexual  organs  not  depending  upon  serious 
organic  change.  One  of  the  most  obvious 
of  these  is  what  is  best  described  as  dys- 
menorrhoea  from  obstruction  thatis  caused 
by  mechanical  impediment  to  the  natural 
flow  of  the  menses.  Stenosis  or  contrac- 
tion of  the  OS  externum  uteri  is  the  most 
obvious  impediment.  "With  or  without 
this,  may  exist  acute  flexion  of  the  neck 
of  the  uterus.  When  this  condition  exists 
the  normal  hyperemia  of  menstruation 
culminates  in  intense  congestion.  Hy- 
pera^mia  often  entails  hyperplasia.  Acute 
pains  due  to  tension  of  the  swollen  tissues 
and  spasmodic  contraction  follow  ;  and  the 
sympathetic  and  reflected  action  upon  the 
ganglionic,  spinal  and  cerebral  centres  is 
often  greater  than  can  be  borne. 

With  or  without  dysraenorrhoea,  an- 
other trying  condition  is  menorrhagia. 
The  loss  of  blood  entails  alteration  in  the 
quality  of  the  blood.  The  nervous  centres 
are  ill-nourished,  and  therefore  prone  to 
morbid  action. 

It  is  important  to  form  a  definite  and 
rational  idea  of  the  terms  hysteria  and 
neurosis.  Too  often  they  are  mere  words 
used  to  conceal  ignorance.  This  is  an 
asylum  ignorantim  which  ought  to  be 
closed.  Hysteria  is  not  an  independent 
entity.  It  is  a  symptom.  Tf  we  cannot 
trace  the  symptoms  and  its  cause,  com- 
monly tinderlying  disorder  of  the  sexual 
system,  the  rational  course  is  to  infer 
that  our  skill  is  deficient,  and  not  to  bow 
down  before  an  idol  of  the  imagination. 
This  is  certain,  that,  in  many  cases,  hys- 
teria is  the  forerunner  of  insanity.  This 
also  is  certain,  as  the  result  of  large  clini- 
cal experience,  that  h3'-steria  is  cured  by 
removing  the  causes  of  dysmenorrhoea. 
Our  case-books  teem  with  cases  o£  syn- 
cope, loss  of  memory,  epilepsy,  perversion 
of  senses,  hallucinations,  associated  with 
dysmenorrhcBa,  many  of  which  were  re- 
lieved or  cured  by  removing  the  cause  of 
the  dysmenorrhoea.*  The  study  of  the 
influence  of  diseased  ovaries  opens  another 
field  of  inquiry.  Negrier  aflirmed  that 
the  influence  of  the  ovaries  and  the  activ- 
ity of  their  function  is  in  direct  propor- 
tion to  their  volume.     This  is  difficult  to 

*  This  STibjeet  is  discussed  with  some  fulness  in 
the  Lumleian  Lectures  on  the  Convulsive  Diseases 
of  Women,  before  the  Koyal  College  of  Physicians, 
1874. 


uterine  Disorders 


[     135 1     ] 


Uterine  Disorders 


prove.  But  when  we  pass  to  diseased 
ovaries  we  are  ou  more  certain  ground. 
]\[arked  increase  of  size  is  presumptive 
evidence  of  disease.  Negrier  relates  a 
remarkable  case  of  mutilation  and  suicide 
at  the  last  day  of  menstruation  in  which 
the  ovaries  were  much  above  the  normal 
size. 

There  may  be  an  acquired  neurotic 
diathesis,  the  relic  of  disease  in  childhood, 
as  chorea.  In  our  Lumleian  Lectures  we 
specially  illustrated  this  point,  adducing 
cases  of  malarious  infection,  from  which 
the  subjects  had  apparently  recovered. 
"When  menstruation  or  pregnancy  super- 
vened the  latent  disease  was  evoked,  and 
ague  fits  recurred.  "We  have  noted  similar 
examples  in  which  epilepsy  and  chorea, 
apparently  cured,  returned  under  the 
stress  of  menstruation  or  jDregnancy. 

The  connection  between  amenorrha3a, 
chloro-ana3mia  and  nervous  disorders  is 
deserving  of  careful  study.  Trousseau 
said  that  chlorosis  was  essentially  a 
nervous  disease.  Certainly  we  have  seen 
reason  to  conclude  that  in  some  cases 
nervous  disturbances  have  preceded  the 
chlorosis.  IMore  frequently  what  is  called 
angemia  with  amenorrhoea  is  the  ante- 
cedent condition.  The  arrested  function 
is  commonly  associated  with  disorder  or 
perversion  of  the  intestines  or  homogene- 
tic functions.  And  this  cannot  last  long 
without  entailing  weakness  or  perversion 
of  the  nervous  functions.  The  word 
anfBmia  conveys  a  very  imperfect  idea  of 
the  state  of  the  blood.  Toxtemia  with 
spaneemia  would  express  the  state  more 
nearly.  The  blood  becomes  not  only 
deficient  in  red  globules,  but  it  becomes 
contaminated  by  the  absorption  and  re- 
tention of  matters  that  ought  to  be  ex- 
creted. 

If  we  examine  the  neuroses  that  attend 
morbid  conditions  of  the  uterus  and  ovaries 
we  obtain  striking  evidence  of  causation. 
A  frequent  state  is  displacement  of  these 
organs,  not  necessarily  diseased  in  tissue. 
The  most  common  is  retroflexion  or  retro- 
version, with  or  without  prolapsus  of  the 
uterus.  These  can  hardly  exist  without 
entailing  some  disorder  of  menstruation, 
and  this  is  enough  to  disturb  the  nervous 
equilibrium.  But  in  addition  to  this,  the 
displaced  organ  presses  upon  other  organs, 
as  the  bowel  and  bladder,  impeding  their 
functions,  and  especially  it  presses  upon 
the  saci'al  plexus,  and  so  causes  constant 
irritation  of  the  lower  segment  of  the 
spinal  cord,  a  j^art  of  the  nervous  system, 
as  we  have  seen,  more  highly  organised 
than  it  is  in  the  male.  So-called  sympa- 
thetic, reflex,  or  diastaltic  phenomena  are 
frequent.     In  not  a  few  instances  these 


minor  nervous  disorders  culminate  in 
melancholia  and  mania.  We  have  the 
histories  of  cases  in  which  the  subjects 
had  been  insane  for  long  periods,  with  no 
sign  of  amendment  until  they  came  under 
our  care.  We  discovered  pronounced  re- 
troflexion with  hyperplasia  of  the  uterus. 
This  being  corrected  by  surgical  treatment 
ra])id  recovery  ensued.  In  one  most 
striking  case,  the  subject  returned  to  her 
home,  bore  twins,  and  has  since  been  in 
perfect  physical  and  mental  health.  Dr. 
Bennington  brought  before  the  British 
Gyna3cological  Society*  a  case  equally 
remarkable.  Dr.  C.  E.  Louis  Mayerf  in 
a  memoir  on  the  relations  of  the  morbid 
conditions  of  the  sexual  organs  and  psy- 
choses, relates  some  instructive  cases. 
Schroeder  van  der  Kolk  relates  the  case 
of  a  profoundly  melancholic  woman  who 
suffered  from  prolapsus  uteri,  in  whom 
the  melancholia  used  to  disappear  directly 
the  uterus  was  restored.  Fleming  men- 
tions two  similar  cases,  in  which  the  melan- 
cholia was  cured  by  the  use  of  a  pessary, 
in  one  of  them  returning  whenever  the 
pessary  was  removed.  "  In  one  instance," 
says  Maiidsley,  "I  saw  severe  melancholia 
of  two  years'  duration  disappear  after  the 
cure  of  prolapsus  uteri."  This  case  was, 
we  think,  treated  by  us.  Dr.  Arbuckle, 
of  the  "West  Riding  Asylum,  communi- 
cated to  us  (1882)  a  most  interesting  case 
of  inversion  of  the  uterus  which  he  re- 
duced after  our  method,  after  many 
attempts  by  other  plana  had  failed.  The 
inversion  had  lasted  a  year.  She  was 
very  anaemic,  emaciated,  with  mind  en- 
feebled. She  got  perfectly  well  after  the 
restoration  of  the  uterus.  It  is  probable 
that  inversion  of  the  uterus  entails  pressure 
upon  the  ovaries  and  disturbance  of  their 
function.  Griesinger  says  he  has  observed 
very  successful  cases  of  recovery  from 
hysterical  insanity  by  means  of  local 
treatment  of  the  genital  organs  after  all 
other  means  had  failed. 

Examples  of  nervous  disorder  have  been 
observed  in  connection  with  displacement 
of  the  ovaries.  Occasionally  one  ovaiy 
sinks  down  in  Douglas'  pouch  getting 
below  the  level  of  the  uterus.  Severe 
nervous  symptoms  follow,  and  have  been 
relieved  by  maintaining  the  ovary  in  its 
projjer  place,  or  by  removing  it.  Trouble 
is  especially  liable  to  occur  when  the 
ovary  is  enlarged  to  the  size  of  an  orange 
or  even  less.  In  such  a  case  removal  by 
operation  is  clearly  indicated. 

The  influence  of  disease  of  the  ovaries 
is  not  less  remarkable.     Physiology  points 

*  Brit.  Gyn.  Jom-ii. 

t  ]'erhandluti(ji'H  der  Gesellschaff  fiir  Geburtsh. 
1869. 


uterine  Displacements       [    1352    ] 


Vampirism 


to  tbe  ovary  as  the  rulino^  organ  in 
woman,  "  Propter  ovaria  mulier  est  quod 
est."  Accordingly  we  might  expect  that 
the  disease  of  this  organ  would  cause 
most  disturbance  of  the  nervous  system. 
Evidence  bearing  upon  this  conjecture 
has  been  growing  of  late  years.  But  it 
has  long  been  foreshadowed.  Thus  Icard* 
relates  that  Professor  Coste  had  brought 
together  in  the  Musee  de  France  a  fine 
collection  of  uteruses  and  ovaries  taken 
from  women  of  all  ages  who  had  committed 
suicide  during  menstruation. 

The  following  history  is  doubly  instruc- 
tive. Boyer  relates  the  case  of  a  lady 
who,  during  her  first  pregnancy,  became 
insane.  Ten  years  later  the  mental  alien- 
ation having  returned  it  was  concluded 
that  she  was  pregnant.  Boyer  removed  a 
polypus  from  the  uterus  and  she  quickly 
recovered.  This  is  an  illustration  amongst 
many  of  the  analogies  between  ordinary 
gestation,  and  the  carrying  an  intra- 
uterine tumour. 

There  is  one  form  of  insanity  which  is 
of  extreme  importance  in  its  medico-legal 
aspects.  Dr.  Skae  refers  to  cases  of  can- 
cerous disease  of  the  uterus  and  rectum 


accompanied  by  the  delusion  of  violation. 
But  this  form  of  sexual  hallucination  is 
not  always  associated  with  recognisable 
disease  of  the  sexual  organs,  nor  even  with 
other  indications  of  mental  disorder.  It 
is  this  feature  which  makes  the  subjects 
of  sexual  hallucination  the  more  danger- 
ous. I  have  been  consulted  in  several 
cases  of  false  charges  of  rape  or  seduction 
of  this  kind.  It  is  often  difficult  to  dif- 
ferentiate depravity  from  disease.  {See 
Climacteric  Insanity  ;  Menstruation  ; 
Ovariotomy.)  R.  Barnes. 

TTTERIN'X:  SISPIiACEMEN-TS  A.NJ> 
HYSTERIA;  —  The  derivation  of  the 
word  hysteria  indicates  the  connection 
that  existed  in  the  minds  of  ancient 
medical  men  between  the  womb  and  the 
disease  hysteria.  The  symptoms  of  slight 
uterine  displacements  such  as  anteversion 
and  anteflexion,  and  retroversion  and  re- 
troflexion are  so  indefinite,  if  they  exist  at 
all,  that  it  seems  very  fanciful  to  connect 
the  hysterical  state  with  the  supposed 
displacements.  {See  Climacteric  Insa- 
nity; Hysteria;  Menstruation  anb  Insa- 
nity ;  Pathology  ;  and  Uterine  Dis- 
orders and  Insanity.) 


VAGABUKrsEiar'WAHTrsiTi'N-  (Ger.). 
Insanity  with  special  tendency  to  travel 
or  wander  about  from  place  to  place. 

VAIiEITTZM'SKRAU'KHEZT  (Ger.). 
A  term  used  for  epilepsy. 

VAMPIRISM.— The  belief  in  vam- 
pirism was  the  result  of  a  mixture  of 
ignorant  superstition  and  actual  sensory 
hallucination.  It  was  believed  that  the 
bodies  of  the  dead  left  their  graves  by 
night  and  returned  to  their  old  haunts — 
on  these  occasions  they  sucked  the  blood 
of  men,  women,  and  children  in  large 
quantities.  According  to  Dom  Calmet, 
"  Onditque  le  vampire  a  une  espece  de  faim 
qui  le  i:)orte  a  manger  le  Huge  qu'il  trouve 
autour  de  lui  dans  son  cercueil.  Ce  redi- 
vive  sorti  de  son  tombeau,  ou  un  demon 
sous  sa  figure,  va  la  nuit  embrasser  et 
sei'rer  violemmeut  ses  proches  ou  ses 
amis,  et  leur  suce  le  sang  au  point  de  les 
afi"aiblir,  de  les  extenuer  et  d'entrainer  leur 
mort.  Cette  persecution  ne  s'arrete  pas 
a  une  seule  personne  ;  elle  s'etend  jusqu'a 
la  derniere  personne  de  la  famille,  a 
moins  qu'on  n'en  iuterrompe  le  cours  en 
coupant  la  tete  ou  en  ouvrant  le  coeur  du 

*  "  La  femme  pendant  la  periode  menstruelle,'' 
Etude  de  Psjjchologie  morhide  et  de  Mtdeciiie  lec/ale. 


revenant,  dont  on  trouve  le  cadavre  dans 
son  cercueil,  mou,  flexible,  enfle  et  rubi- 
cond,  quoiqu'il  soit  mort  depuis  long- 
temps." 

The  naturalist,  Tournefort,  in  his  "Voy- 
age de  Levant,"givesaremarkable  account 
of  what  he  witnessed  in  the  island  of  Micon, 
in  1701.  He  and  his  companions  saw 
the  corpse  of  an  islander  exhumed  whose 
supjiosed  return  to  life  and  nightly  jirowl- 
ing  about  in  search  of  blood,  had  rendered 
him  an  object  of  dread.  Everybody,  he 
says,  had  lost  their  heads.  The  higher  class 
were  as  much  carried  away  as  the  unedu- 
cated. "  It  was  a  genuine  disorder  of  the 
brain,  as  dangerous  as  mania  and  hydro- 
phobia. Families  left  their  houses  and 
went  to  the  outside  of  the  town  to  pass 
the  night  there." 

It  was  a  common  thing  in  countries 
where  vampires  were  credited,  to  open 
the  grave  of  the  suspected  vampire  and 
burn  the  corpse.  If  the  body  was  less 
decomposed  than  might  have  been  ex- 
pected, a  confirmation  of  the  superstition 
was  obtained.  Many  persons  died  from 
the  fear  created  by  the  belief  of  having 
been  visited  and  attacked  by  vampires. 

Calmeil  records  the  case  of  a  female 
patient  in  an  asylum  who  laboured  "^nder 


Vapeurs 


[    1353    ]        Veratrum  or  Hellebore 


the  delusion  that  she  was  visited  at  night 
by  a  vampire. 

In  the  morniug  she  was  free  from  any 
fear  or  painful  sensations ;  when  she  re- 
tired to  rest  and  wished  to  sleep,  a  naked 
figure  appeared  and  sitting  upon  her 
■chest  sucked  blood  from  her  breast.  She 
consequently  endeavoured  to  keep  awake 
and  besought  the  attendants  to  prevent 
her  from  falling  asleep.  Sometimes  the 
same  spectre  prowled  about  her  bed,  and 
she  redoubled  her  exertions  to  put  the 
vampire  to  flight  by  blowing  loudly  at  him 
and  shaking  the  curtains.  Visual  and 
tactual  hallucinations  were  clearly  the 
cause  of  her  delusion.  Her  physical  health 
was  robust. 

French  alienists  call  those  who  accuse 
themselves  of  having  sucked  blood  from 
others,  vampires  iictifs.         The  Euitok. 

ilieferences. — Dom  Calmet,  Traite  sur  les  appari- 
tions, les  esprits,  &c'.,  tome  ii.  p.  88.  Caliiieil, 
De  la  Folie  consideree  sous  le  poiut  de  viie  patho- 
logique,  philosopliique,  historique  ct  judiciairc, 
1845,  tome  ii.  p.  425.] 

VAPEURS  (Fr.).  Hysteria  or  hypo- 
chondriasis. 

VAFORES  UTERIWI.  (From  the 
ancient  idea  that  vapours  arose  from  the 
uterus  and  passed  into  the  brain.)  Hys- 
teria. 

VAPOURISH.  —  Hypochondriacal  or 
hysterical. 

VAPOURS. — Popular  term  for  hypo- 
chondriasis, or  hysteria. 

VECORDZA.  (Lat.  t-ecordia.)  Idiocy. 
Insanity. 

VElTSTAurz  (Ger.).  A  term  used 
either  for  chorea  major  or  tarantism. 

VEN-EREAI.  DISEASES  AND  IN- 
SANITY.— Venereal  diseases  are  often 
the  causes  of  insanity,  and  influence  the 
delusions  and  other  symptoms  of  insanity. 
{See   Syphilis   and   Ixsanity  ;    and   Sy- 

PHILOPUOBIA.) 

VERATRUnX     or     HEI.IiEBORE.  — 

The  celebrated  remedy  for  madness  cnong 
the  ancients.  We  have  already  cited  the 
story  of  Melampus  and  his  cure  of  the 
daughters  of  Proetus.  "Wliat  was  the 
hellebore  to  the  use  of  which  tradition 
refers  the  success  of  Melampus  and 
others  ? 

The  term  hellebore — derived  by  some 
from  fXe'iv,  to  slay,  and  /3opd,  food — was 
formerly  supposed  to  be  the  same  species 
as  our  black  hellebore  or  Christmas  rose, 
designated  ■iiidamjwdhmi  in  old  pharma- 
copoeias. Tournefort  and  Bellouius,  how- 
ever, who  found  the  true  hellebore  of 
antiquity — the  eXXf/3opos  ^eXas  of  Dios- 
corides  —  growing  abundantly  in  Aspro- 
spezzia  (the  ancient  Anticyra)  and  Mount 
Olympus, pointed  out  thatitwasadifferent 


species.*  Black  hellebore  does  not  con- 
tain veratria,  differing  in  this  from  white 
hellebore,  a  plant  of  an  entirely  different 
order.  It  is  no  longer  officinal.  Wood- 
ville  says  of  the  hellebore  which  was  found 
in  Anticyra,  and  which  he  considers  to  be 
a  species  of  Hellehorus  niger,  though  dif- 
fering from  it  in  having  a  large  branched 
stem,  that  Tournefort  tried  the  effect  of 
simple  doses  of  the  extract  with  the  result 
that  violent  spasms  and  convulsions  were 
induced.  It  is  very  probable  that  the 
ancients  used  both  black  and  white  helle- 
bore. Stevenson  and  Churchill  t  in  their 
work  already  referred  to,  state  that  Mayern 
administered  from  two  to  three  grains  of 
the  extract  of  the  root  of  white  hellebore, 
H.  albus  vulgaris,  Veratrum  alhwm, 
(Die  Weisse  Nieswurzel)  which  grows 
in  Greece  as  well  as  the  black  hellebore, 
with  considerable  advantage  in  maniacal 
cases,  and  that  Greding  employed  it  in 
twenty-eight  instances  of  mania  and 
melancholia,  of  which  five  recovered,  some 
were  relieved,  while  others  derived  no 
benefit.  It  was  formerly  officinal,  con- 
stituting the  Vinui)i  Veratri,  185 1. 

We  may  add  that  SowerbyJ  in  his 
"  Botany  "  says  :  that  both  H.  viridis  and 
H.  foetidus  (the  only  British  hellebores) 
have  been  often  used  instead  of  the  true 
ancient  or  Greek  Ilellehoriis  officinalis  or 
H.  niger  orientalist  of  Sibthorp. 

Gilbert  Burnett,  once  Professor  of  Botany , 
King's  College,  London,  observes  that 
Tournefort  was  correct  in  supposing  the 
H.  niger  orientalis  of  Dr.  Sibthorp  to  be 
the  hellebore  of  the  ancients  "  as  he  found 
it  in  the  island  of  Anticyra."  As  it  may 
not  be  easily  procured,  he  regards  H. 
viridis  as  the  safest  substitute  for  it, 
though  less  active  and  as  more  nearly 
allied  to  the  ancient  Greek  plant  than  H. 
ftetidtis. 

Pliny's  references  to  hellebore  in  his 
"  Natural  History  "  are  of  much  interest. 
"  It  is  the  black  hellebore  which  is  known 
as  the  melampodium.  It  purges,  while 
the  white  hellebore  acts  as  an  emetic.  || 
In  former  days  hellebore  was  regarded 
with  horror,  but  more  recently  the  use  of 
it  has  become  so  familiar  that  numbers  of 
studious  men  are  in  the  habit  of  taking  it 
for  the  purpose  of  sharpening  the  intel- 
lectual powers  required  by  their  literary 
investigations.      Carniadis,  for    instance, 

*  See  Stevenson's  and  Cliurchiirs  "  Medical 
Botany,"  vol.  i. ;  and  AVoodvilles  "  JSotany,"  vol.  ii. 
p.  276. 

t  Vol.  iii.  p.  cxxxvi. 

t  "  Botany,"  vol.  i.  p.  58. 

§  <xKap4>r]  of  the  Aloileru  Greek;  zo/^/.-Hic  of  the 
T\u-ks. 

II  He  adds  that  the  difference  between  them 
applies,  according  to  most  writers,  to  the  root  only. 


Veratrum  or  Hellebore        [    1354    ] 


Verbigeration 


made  use  of  hellebore  when  about  to 
answer  the  treatises  of  Zeno  ;  Drusus,  too, 
among  us  the  most  famous  of  all  the 
tribunes  of  the  people,  and  whom  in  par- 
ticular the  public  rising  from  their  seats 
greeted  with  loud  applause — to  whom 
also  the  patricians  imputed  the  Marsic 
war — is  well  known  to  have  been  cured  of 
epilepsy  in  the  island  of  Anticyra  ;  a  place 
in  which  it  was  taken  with  more  safety 
than  elsewhere  from  the  fact  of  Sesamoides 
being  combined  with  it.  In  Italy  the 
name  given  to  it  is  Yeratrimi. 

"  The  ancients  used  to  select  those  roots 
the  rinds  of  which  were  the  most  Heshy 
from  an  idea  that  the  pith  extracted  there- 
from was  of  a  more  retined  nature.  This 
substance  they  covered  with  wet  sponges 
and  when  it  began  to  swell  used  to  split 
it  longitudinally  with  a  needle,  which  done, 
the  filaments  were  dried  in  the  shade  for 
future  use.  At  the  present  day,  however, 
the  fibres  of  the  root  with  the  thickest 
rinds  are  selected  and  given  to  the 
patient  just  as  they  are.  The  best  hel- 
lebore is  that  which  has  an  acrid,  burn- 
ing taste,  aud  when  broken  emits  a  sort 
of  dust. 

"  Black  hellebore  is  administered  for  the 
cure  of  paralysis,  insanity,  dropsy — pro- 
vided there  is  no  fever,  chronic  gout  and 
diseases  of  the  joints  ;  it  has  the  effect, 
too,  of  carrying  off  the  bilious  secretion 
and  morbid  humours  by  stools.  It  is 
given  also  in  water  as  a  gentle  aperient, 
the  proportion  being  one  drachm  at  the 
very  utmost,  aud  four  oboli  for  a  moderate 
dose."  * 

One  of  the  disputed  treatises  of  Hippo- 
crates is  on  hellebore.  We  find  no  mention 
in  it  of  its  employment  in  mental  disorders. 

The  correspondence  between  Hippo- 
crates and  Democritus  makes,  however,  a 
distinct  reference  to  its  use  in  this  disease. 
The  latter  says  :  "  I  am  persuaded  that 
if  to  me  you  should  give  hellebore  to  drink, 
as  to  the  insane,  it  would  be  right  that 
the  insane  shoiild  escape  it,  and  according 
to  your  art  you  would  have  blamed  it  as 
being  itself  the  cause  of  madness.  For 
hellebore,  when  given  to  the  sane  pours 
darkness  over  the  mind,  but  for  the  insane 
it  is  very  profitable."  f  Whether  this  was 
written  by  Democritus,  or  not,  the  pro- 
duction is  unquestionably  very  ancient 
and,  as  such,  of  great  interest.  In  favour 
of  its  genuineness,  it  may  be  mentioned 
that  no  one  disputes  Hippocrates  having 
visited  Abdera,  the  residence  of  the  philo- 
sopher, and  that  he  was  on  familiar  terms 
with  him. 

As  will  be  seen  from  the  foregoing,  much 

*  Bohu's  trans.,  vol.  v.  p.  99. 

t  Works  of  Hippocrates,  I'rankfort  eilit.  17 


confusion  has  arisen  in  regard  to  the 
varieties  of  hellebore  used  in  ancient  and 
modern  times,  and  we  fear  that  in  spite  of 
the  attempts  which  have  been  made  to 
elucidate  the  subject,  some  obscurity  still 
I'emains.  The  Editok. 

VERBAIi  AMN'ESZii. — A  synonym 
of  Amnesic  Aphasia.  {See  Aphasia  ; 
Post-Epileptic  Insanity. 

VJBRBIGERiiTZOn'.  —  Definition.  — 
A  psycho])athic  symptom  first  exactly  de- 
scribed and  appreciated  in  its  clinical 
aspect  by  Kahlbaum,  finds  its  external  ex- 
pression in  the  frequent  repetition,  either 
spoken  (in  which  case  it  is  done  in  a  weari- 
some monotone)  or  written,  of  one  and  the 
same  word  or  sentence,  or  of  one  and  the 
same  sound. 

Diag^nosis. — It  is  necessary  also  that 
the  cause  of  the  phenomenon  should  not 
be  a  'psijcliic  one,  and  to  distinguish 
whether  this  is  so  or  not  is  in  many  cases 
difficult,  but,  nevertheless,  'monotonous 
utterances  of  insane  persons  which  appear 
to  simulate  verbigeration,  may  in  most 
instances  be  difi"erentiated  from  genuine 
verbigeration  by  an  eliminative  diagnosis. 
We  have  to  point  out  primarily  that  such 
distinctions,  which  seem,  at  first,  to  puzzle 
the  observer,  are  not  uncommon  in 
mental  science,  if  we  call  to  mind  the  fact 
that  every  alienist  has  to  distinguish  ab- 
normal euphoria,  as  seen  in  a  maniac  or 
general  paralytic,  from  the  sense  of  well- 
being  of  a  paranoiac;  or  the  depi'ession  of 
a  melancholiac  from  the  degree  of  mental 
exhaustion  which  approximates  closely  to 
melancholic  depression,  and  from  the  de- 
pression due  to  delusions,  which  is  but  an 
analogue  of  the  depression  of  normal 
mental  life.  In  all  the  mental  phenomena 
evinced  by  the  insane,  the  observer  must 
grasp  the  difficulty  he  has  to  encounter, 
whether  such  are  the  immediate  primary 
consequences  of  a  pathological  process  or 
whether  they  represent  secondary  symp- 
toms, induced  by  a  psychic  evolution  from 
some  primary  mental  affection  by  the  in- 
fluence of  association  of  ideas.  An  ex- 
ample will  illustrate  this.  Melancholia  is 
an  immediate  primary  production  of  cer- 
tain morbid  conditions,  even  as  micro- 
mania, which  represents  a  different 
clinical  symptom  of  that  affection.  But 
the  expectation  of  punishment  and  hang- 
ing is  a  mental  process  resulting  from  an 
association  of  ideas,  and  corresponding  to 
the  normal  experience  of  the  individual, 
and  is  therefore  a  secondary  symptom — 
not  verbigeration.  This  division  of  mental 
phenomena  into  primary,  immediate  and 
direct,  and  secondary,  mediate  and  indi- 
rect, is  of  great  importance.  Without  it 
mental  science  will    never   be   kept   free 


Verbigeration 


[    1355     J 


Verbigeration 


from  romance  and  become  an  exact 
medical  scieuce. 

Symptoms. — We  now  return  from  these 
prefatory  remarks,  which  should  help  us 
to  take  a  correct  clinical  view  of  the  sub- 
ject, to  verbigeration  itself.  The  fii'st 
quality  we  have  to  attribute  to  the  symp- 
tom of  verbigeration  is,  that  it  is  a  _p>'i- 
Diary  or  direct  pathological  phenomenon. 
It  originates  without  any  process  of  con- 
sciousness, and  is  as  little  or  only  in 
the  same  degree  subject  to  will-power 
as  the  flight  of  ideas  is.  We  shall  later  on 
show  that  there  is  likewise  a  certain  re- 
lationship between  the  mode  of  origination 
of  verbigeration  and  that  of  the  genesis  of 
the  flight  of  ideas,  in  so  far  as  we  have  to 
regard  two  factors  as  co-operating  for  the 
production  of  either  symptom. 

Verbigeration  is  an  abnormal  and  un- 
necessary repetition  of  words.  It  can  only 
take  place  when  the  normal  flow  of  ideas 
is  deranged,  and  the  repetition  is  uncou- 
troUable  (this,  however,  does  not  imply 
that  the  individual  himself  feels  it  to  be 
so).  From  this  unconscious  compulsion 
we  derive  another  descriptive  characteris- 
tic of  verbigeration — viz.,  that  for  its  re- 
production we  have  to  apply  the  form  of 
direct  oratio.  If  there  is  a  reproduction 
in  obliqtie  oratio,  it  loses  its  peculiar  cha- 
racter. A  female  patient,  who  constantly 
stationed  herself  at  the  main  gate  of  the 
asylum,  used  to  call  out  all  the  day  long 
to  every  passer-by,  whether  jDhysiciaD,  at- 
tendant, or  fellow-patient,  "Please,  my 
golden  doctor  do  give  me  the  keys."  For 
the  sake  of  experiment  we  once  gave  her 
the  keys,  but  she  nevertheless  remained 
unchanged  in  her  attitude  with  the  keys 
in  her  hand,  saying  in  the  same  tone  as 
before,  "  Please,  my  golden  doctor,  do  give 
me  the  keys."  It  is  clear  that  an  entry 
in  a  journal  such  as  this,  "The  patient 
constantly  stations  herself  at  the  door, 
ivants  to  get  home,  and  asks  for  the  keys," 
would  be  incorrect.  In  reality,  all.  one 
can  state  is  that  the  patient  repeats  in 
a  verbigerating  monotone  the  sentence, 
"  Please,  do  give  me  the  keys."  It  is  also 
clear  that  from  this  aspect  the  diagnosis 
of  the  case  becomes  quite  different,  for 
there  is  no  delusion  causing  it. 

We  have  selected  the  above  example, 
although  it  does  not  exhibit  a  good  de- 
velopment of  the  symptom  in  question, 
because  it  serves  to  explain  why  the 
symptom  of  verbigeration  is  so  often  dis- 
regarded or  misinterpreted,  for  we  believe 
that  the — one  might  almost  say — instinc- 
tive tendency  of  the  observer  naturally 
leads  him  to  the  endeavour  to  find  out 
the  subject-matter  of  the  ideas  of  the 
patient  trom  his  utterances,  and  in  conse- 


quence those  slight  anomalies  which  lie 
in  the  sphere  of  imagination  and  speech, 
are  easily  overlooked.  Verbigeration  aa 
a  symptom,  is  not  rare,  and  nearly  always 
occurs  combined  with  other  derangments 
of  the  iiiolof  sphere.  At  other  times  we 
find  verbigeration  alternating  with  com- 
plete taciturnity  (so-called  mutism)  in  the 
same  subject.  The  voluntary  motility  in 
the  locomotor  apjiaratus  seems  in  most 
patients  also  greatly  affected  ;  they  show 
conditions  of  rigid  immobility  and  cata- 
leptic flexibility  (see  Katatonia).  This 
combination  of  psychomotor  phenomena 
is  so  frequent,  that  Kahlbaum  has  called 
verbigeration  a  pathognomonic  symptom 
of  katatonia.  Verbigeration,  however, 
also  occurs  in  epileptics  (in  the  post-con- 
vulsive stage),  as  well  as  in  the  course 
of  general  paralysis.  In  association  with 
the  latter,  the  whole  clinical  picture 
is  generally  a  peculiar  one,  in  so  far  as 
other  conditions  of  motor  inhibition,  pecu- 
liar to  katatonia,  may  be  also  developed 
(mental  stupor). 

After  what  we  have  said  in  our  intro- 
ductory remai'ks,  it  is  not  difficult  to  dis- 
tinguish the  verbal  repetitions  produced  by 
persons  insane  in  other  ways  from  genuine 
verbigeration.  If  persons  with  hallucina- 
tory ideas  give  vent  to  their  a.nger  under 
the  influence  of  continual  molestation,  in 
always  the  same  stereotyped  bad  language, 
if  melancholiacs  always  reiterate  the  same 
lamentations  and  self-accusations,  or  if 
persons  with  religious  paranoia  always 
repeat  the  same  formulee,  these  and  all 
other  analogous  phenomena  are  psijcliolo- 
(/u'ttZ??/induced,they  are indirectsecowcZary 
symptoms.  Their  peculiar  qualities  are 
not  lost  by  reproduction  in  oblique  oratio. 
We  have  to  mention  here  that  weak- 
minded  individuals  and  children  will  often 
repeat  the  same  phrases  to  wearisomeness, 
but  this  is  primarily  so  different  from 
verbigeration  that  we  do  not  deem  it 
necessary  to  add  remarks  as  to  the  dif- 
ferential diagnosis.  We  find  the  same  in 
idiots,  imbeciles,  hebephrenics,  and  in 
cases  of  terminal  dementia  and  functional 
psychoses  as  well  as  in  general  para- 
lysis. In  the  last  named,  loss  of  memory 
is  of  great  moment,  as  supporting  the  de- 
velopment of  the  phenomenon.  In  the 
rare  cases  of  extreme  general  amnesia, 
such  as  is  described  as  occurring  in  heavy 
drinkers,  phenomena,  similar  in  their 
external  manifestations,  have  been  ob- 
served. 

The  theory  of  the  astiology  of  verbigera- 
tion has  not  yet  been  clearly  formulated. 
Kahlbaum  referred  the  contradistinctive 
phenomena  of  verbigeration  and  mutism 
occurring  in  one  and  the  same  individual 


Verbigeration 


[    1356    ] 


Verriiektheit 


to  a  condition  of  alternating  clonic  and 
tonic  spasm  of  the  cerebral  apparatus  of 
speech.  But,  according  to  our  view,  this 
furnishes  us  only  with  a  clever  picture,  but 
no  ph5'siological  explanation  whatever.  On 
the  other  hand  it  seems  thoroughly  justifi- 
able to  look  for  a  common  pathological 
source  of  verbigeration  and  mutism. 
Those  who  would  draw  a  parallel  between 
verbigeration  and  recurring  comjjulsory 
ideas,  and  refer  verbigeration  to  a  condi- 
tion of  recurrent  irritation  in  the  speech 
centre,  have  not  taken  into  consideration 
the  incontestable  clinical  fact  of  the  coin- 
cedent  occurrence  of  verbigeration  and 
mutism  ;  this  comparison,  moreover, 
would  leave  unexplained  the  j^henomenon 
of  which  we  have  not  yet  made  mention, 
that  in  verbigeration  the  words  are 
forcibly  enunciated  in  an  extremely 
strained  inanner  and  toitli  evident  diffi- 
culty. We  are  therefore  inclined  to  the 
supposition  that  two  factors  co-operate 
in  the  production  of  this  symptom  :  first, 
that  there  exists  in  the  speech  centre,  as 
well  as  in  the  other  parts  of  the  sphere  of 
voluntary  motion,  a  state  of  inhibition  in 
which  a  pathological  factor  is  assumed 
to  influence  the  psychical  part  of  that 
apjaaratus.  One  phenomenon  of  this 
state  of  more  or  less  general  inhibition,  is 
the  psychomotor  inability  of  speech  or 
mutism.  If  now  a  stimulus  of  sufiicient 
strength  influence  the  speech  centre,  the 
inhibition  may  perhaps  be  broken 
through.  The  effort  necessary  for  this  is 
seen  in  mimetic  co-movements,  and  in 
the  forced  tone  with  which  the  words  are 
communicated.  Later  on,  this  state  of 
general  inhibition  will  result  in  the  ina- 
bility to  replace  by  new  ideas  the  ideas 
first  put  into  action  in  thought  and 
speech.  If,  then,  this  state  of  irritation 
becomes  permanent,  the  patient  will  not 
be  able  to  rid  himself  of  the  first  words  or 
sound,  and  will  be  comjoelled  to  repeat 
them,  the  consequence  being  the  origina- 
tion of  verbigeration. 

With  regard  to  prog-nosis,  verbigera- 
tion is  a  symptom  of  some  importance. 
Generally  it  occurs  in  the  middle  of  a 
state  of  stupor  (see  Katatoxia),  and  then 
we  are  unable  to  draw  any  conclusion 
with  regard  to  its  further  progress.  Some- 
times it  precedes  that  condition,  and  then 
associates  itself  with  a  peculiar  pathos 
(pathetic  verbigeration),  which,  if  it  de- 
velops from  a  state  of  depression,  is  a 
reliable  indication  that  a  condition  of 
general  motor  inhibition  or  mental  stupor 
is  coming  on. 

With  regard  to  the  treatment  of  this 
symptom  nothing  is  as  yet  known. 

Clemens  Neisser. 


VERFOI.GtXM-CS'W^AHM-,  VERFOZi- 
CUN-CSlvii:i.ANCHOl.lz:  (Ger.)  Delu- 
sions of  persecution.  A  general  term  for 
insanity  of  persecution, 

VERGZFTUN-GSZRRESEIir  (Ger.). 
Insanity  due  to  toxic  agents  such  as 
alcohol,  lead,  &c. 

VERRttCKTHEZT. — Syn.,  Paranoia. 
Folic  systematisee  progx-essive  (Regis) ; 
I^sychose  systematisee  progressive  (Gar- 
nier)  ;  delire  chronique  (Magnan). 

Putting  aside  for  a  moment  the  cloud 
of  verbiage  with  which  this  term  has  been 
enshrouded,  and  the  hopeless  confusion  in 
which  specialists  have  contrived  to  leave 
it,  we  simply  define  it  as  a  mental  condi- 
tion, the  essential  and  constitutional  cha- 
racteristic of  which  is  a  systematised  de- 
lusion or  group  of  delusions  persistently 
held.  It  is  almost  always  primary  and 
constitutional,  and  not  consecutive  to 
other  mental  disorders. 

Under  Paranoia  we  have  given  the  de- 
finition, symptoms,  course,  and  prognosis 
of  this  form  of  mental  disorder,  but  there 
remain  a  few  points  to  which  it  may  be 
well  to  refer  under  this  heading.  Judging 
from  recent  German  psychological  litera- 
ture, the  term  appears  to  be  less  in  use 
than  formerly,  while  that  of  paranoia  is 
more  in  favour.  Profs.  Wille  and  Meynert, 
while  admitting  a  primary  mental  affec- 
tion (j^rMiiareFerr/fcfci/teitV),  corresponding, 
from  the  standpoint  of  nomenclature,  to 
mania  or  melancholia — i.e.,  truly  primary 
and  without  mental  weakness,  affirm  that 
there  are  many  cases  in  which  it  is  diffi- 
cult to  determine,  in  the  early  stage, 
whether  they  belong  to  primary  YerriicM- 
lieit,  or  to  melancholia.  Meynert  main- 
tains that  the  former  is  more  frequent  in 
his  experience  than  the  latter.  Some 
years  ago  this  assertion  would  have  been 
regarded  as  impossible,  for  the  majority 
of  German  psychologists  were  unwilling 
to  accept  this  classification,  although  it 
had  been  for  long  maintained  by  certain 
French  alienists,  and  they  maintained 
that  there  was  no  such  thing  as  Verriiekt- 
heit, as  a  primary  psychosis,  but  that  it 
was  always  secondary — i.e.,  consecutive 
to  a  state  of  melancholia  or  mania,  and  a 
symptom  or  result  of  enfeeblement  of  the 
mental  faculties.  Having  regard  to  the 
French  synonym  already  given,  M.  Mag- 
nan  believes  that  there  are  two  forms  of 
systematised  insanity:  (i)  folie  systema- 
tisee progressive,  always  developed  in  dis- 
tinct periods,  and  (2)  folic  systematisee  des 
degeneres,  which  is  irregular  in  its  course 
and  atypical  in  character.  M.  Ball,  on 
the  other  hand,  does  not  admit  that  the 
latter  constitutes  a  separate  form  of  men- 
tal disorder,    holdincr  that  the  former  is 


Verrvicktheit 


[     1357    ] 


Verwirrtheit 


itself,  as  the  terra  progressive  "  implies, 
destined  to  degenerate,  According  to  M. 
Kegis,  "  both  views  are  to  a  certain  extent 
correct ;  it  is  right  to  admit  that  there 
exists  a  typical  systematised  insanity, 
characterised  by  a  iinit'orm  development 
in  three  periods,  the  most  important  of 
which  is  that  met  with  among  the  degene- 
rated." Healsoi^oints  out  that  the  Italian 
school  of  psychologists  have  anticipated 
the  French  in  the  discussion  of  this  sub- 
ject and  that  "  they  include  all  systema- 
tised insanities  under  the  genus  '  para- 
noia,' which  they  divide  into  two  distinct 
forms — degenerative,  and  psycho-neurotic" 
(see  }:>.  S87  of  this  Dictionary).  If  this 
grouping  is  in  accordance  with  the  divi- 
sion proposed  by  the  French,  it  is  even 
more  complete  ;  the  Italian  alienists  main- 
tain, in  short,  that  systematised  is  always 
consecutive  to  generalised  insanity,  of 
^vhich  it  forms  a  more  advanced  stage ; 
when  it  is  primary  in  the  patient  himself, 
it  has  succeeded  a  generalised  insanity  in 
the  ancestor;  when  it  is  secondary,  the 
transformation  from  generalised  to  special- 
ised insanity  has  taken  place  in  the  same 
individual.*  M.  Eegis'  definition  of  folie 
systematisee  iwogressive  (paranoia  pri- 
maria)  is  more  lucid  than  that  frequently 
given — namely,  a  chronic,  distinct  form  of 
insanit}-  without  disturbance  of  the  general 
mental  functions,  characterised  by  hallu- 
cinations, esijecially  of  hearing,  the  mental 
affection  tending  to  become  systematised 
and  terminating  in  a  transformation  of 
the  personality.  It  forms  an  integral 
part  of  the  individual.  Patients  have  in- 
deed received  the  germ  of  the  disease  at 
birth,  but  this  is  developed  under  the  in- 
fluence of  the  slightest  cause — e.g.,  want, 
domestic  trouble,  &c.  It  is  more  frequent 
among  women  and  the  unmarried.  It 
especially  attacks  gloomy,  defiant,  proud 
and  misanthropic  characters.  We  cannot 
follow  in  detail  M.  Regis'  description  of 
the  several  stages  or  forms  of  progressive 
systematised  insanity,  but  may  state  that 
he  embraces  under  the  term,  (i)  a  stage  of 
subjective  analj'sis  or  hypochondriacal  in- 
sanity ;  (2)  a  stage  of  insane  development, 
■which  includes  (n)  jiersecution-mania, 
treated  of  in  this  Dictionary  in  a  special 
article  by  M.  Paraut ;  (b)  religious  in- 
sanity, and  another  subdivision  (c)  charac- 
terised by  eroticism,  jealousy,  and  political 
schemes;  (3)  stage  of  complete  transfor- 
mation, marked  by  exaltation,  or  megalo- 
mania, finally  ending,  it  may  be,  in  de- 
mentia. 

A   very   similar   classification  is  given 

*  "Manufl  pratiinie  de  Mtdecine  meiitale,"  par 
le  Dr.  E.  Kegis  (with  a  preface  by  Prof.  Ball),  2uu 
edit.,  I'arls,  1892. 


under  the  head  of  paranoia,  or  primary 
Verriicktheit,  in  the  new  edition  of  Grie- 
singer,  edited  by  Dr.  Levinstein-Schlegel, 
and  may  be  regarded  therefore  as  reflect- 
ing German  as  well  as  French  opinion,  so 
far  at  least  as  they  are  represented  by 
their  alienists. 

It  appears,  however,  to  the  writer  that 
clinical  observation  scarcely  justifies  the 
belief  in  so  definite  and  invariable  a 
scheme  as  that  here  laid  down,  very  fasci- 
nating as  it  certainly  is.  Thus,  to  men- 
tion no  other  instance,  we  are  satisfied 
that  cases  of  persecution-mania  occur  not 
unfrequently  quite  apart  from  this  alleged 
order  of  mental  events.  That  it  may  be 
found  as  one  stage  of  so-called  Verriickt- 
heit he  does  not  deny,  but  he  claims  for 
it  an  independent  existence  also. 

The  essentially  chronic  character  of  this 
form  of  mental  disease  has  been  insisted 
upon,  although  it  is  true  that  some  alien- 
ists have  admitted  an  acute  form  of  para- 
noia {paranoia  acuta),  but  this  view  seems 
to  us  to  militate  altogether  against  the 
really  systematised  character  of  the  dis- 
order and  to  confound  it  with  a  state  of 
temporary  delusion  from  which  we  have 
always  supposed  it  was  the  intention  of 
those  who  have  introduced  the  term  to 
differentiate  it.  The  Editor. 

\_R('f('rcnci'!i. — Griesing-cr,  I'athologle  u.  Therapie 
dor  psychischen  Kranklii'iten  I'iir  Arzte  uud  Stu- 
direude,  2nd  ed.  1861.  Idem,  5111  ed.,  edited  by 
Dr.  W.  Levinstein  Schlegcl,  Berlin,  1892.  Arndt, 
Lehrbuch  der  Psychiatrie  fur  Arzte  und  Studir- 
ende,  1883.  Sander,  Leber  eine  speeielle  Form 
der  primareu  Verriicktheit,  Uriesinger's  Archiv, 
1868,  Bd.  i.  Heft  2.  Snell,  Die  Leberschiitzungs- 
ideen  der  Paranoia,  Jahres-Ver.sanimliing  in  Han- 
nover, 1889.  Schiile,  Klinische  Psychiatrie,  1886. 
Krafft-Ebiug,  I>ehrbuch  der  Psychiatrie.  Salgo 
(Weiss),  Compendium  der  Psychiatrie,  1889.  Mey- 
nert,  Klin.  Vorlesiingen,  p.  140.  Kraepclin,  Psy- 
chiatrie, 2nd  ed.  iVeisser,  Leber  die  originare 
Verriicktheit,  Archiv  fiir  Psych.,  Bd.  i.  Heft  2. 
Werner,  Leber  die  Psychiatrische  Xomenclatur, 
Verriicktheit  und  Wahnsimi.] 

VERSTANDESXRAN-KHEZT  (Ger.). 
Mental  disease. 

VERST.aNSESSTbRTTIirG; 
VER  STAND  E  S  VER'WZR  RU  ir  G 

(Ger.).     Derangement  of  intellect. 

VERTIGO  {verto,  I  turn  around). 
Dizziness  with  fear  of  falling ;  giddiness; 
swimming  of  the  head.  (Fr.  vertige  ;  Ger. 
ScJivsindelsncht.) 

VERTIGO,  EPIIiEPTIC.  (See  EPI- 
LEPTIC Vertigo  ;  Epilei'.sv.) 

VERWIRRTHEIT.  —  Syn.  Confu- 
sional  insanity. 

Definition. — This  term  is  applied  to 
confused  mental  conditions  in  several 
forms  of  insanity.  Sometimes  it  is  ap- 
plied  to  the  incoherent  condition  present 
in  acute  delirious  mania  ;  at  other  times 


Verwirrtheit 


[     1358    ] 


Verwirrtheit 


it  is  employed  to  describe  a  mild  phase  of 
ordinary  mania.  It  is  also  used  to  de- 
scribe some  sub-acute  states  of  paralysis. 
More  frequently  it  is  employed  to  charac- 
terise mental  confusion  with  hallucina- 
tions {ludlucinaiorische  VerrncMlieit).  It 
is  said  that  hallucinations  in  this  condi- 
tion are  generally  auditory  and  less  fre- 
quently visual ;  voices  are  heard  of  a 
threatening  character.  From  this  may 
arise  depression  and  attempts  at  suicide. 
A  patient  recently  admitted  into  Bethlem 
Hospital  (before  admission,  he  himself 
complained  to  us  of  mental  confusion)  said 
he  could  not  understand  what  had  hap- 
pened to  him  ;  he  was  unable  to  concentrate 
his  thoughts ;  felt  impelled  to  commit 
motiveless  acts,  and  to  injure  those  around 
him  without  any  feeling  of  malice.  He 
was  also  suicidal.  He  had  no  delusions, 
strictly  speaking,  and  his  case  could  not 
be  placed  under  acute  mania  ;  his  general 
condition  was  one  to  which  the  term  in 
question  would  be  applied  by  some  Ger- 
man alienists,  but  we  should  rather  regard 
it  as  an  early  stage  of  impulsive  and 
suicidal  insanity.  In  not  a  few  cases  of 
persons  charged  with  the  commission  of 
criminal  acts  there  exists  a  real  mental 
confusion,  apart  from  epilepsy,  which  may 
be  confounded  with  feigning  insanity. 

Esquirol  did  not  distinguish  confusional 
insanity  from  actual  dementia  (demence). 
Ideler  (1838)  considered  that  confusional 
insanity  and  dementia  differed  only  in 
degree,  and  held  that  although  it  might 
be  a  primary  mental  affection,  it  v/as  far 
more  frequently  the  secondary  result  of 
other  forms  of  insanity.* 

The  term  was  employed  by  Griesinger 
to  represent  mental  coniusion  without 
actual  dementia  on  the  one  hand,  or  any 
specialised  delusion  on  the  other. 

We  have  spoken  of  mental  confusion  in 
connection  with  jsaralysis.  Meynert 
applies  it  to  certain  states  with  aphasia 
and  amnesia. 

Chronic  confusional  states  have  been 
clearly  described  by  Fiirstner  (1876)  who 
distinguishes  confusional  insanity  with 
hallucinations  from  acute  mania  and  acute 
primary  Verrilcktlieit  or  paranoia  (with 
which  Westphal  appears  to  confound  it), 
while  according  to  him  the  transition  to 
stupor  is  very  characteristic. 

Too  much  importance  is  attached  to 
the  term  when  it  is  made  use  of  in  the  sense 
of  a  primary  and  distinct  form  of  insanity, 
and  English  alienists  for  this  reason 
rarely  employ  the  term  confusional  in- 
sanity, although,  of  course,  they  frequently 

*  Cf.  Wille  in  Archiv  fiir  Psychiatrie,  I>d.  xix. 
Heft  2,  to  which  paper  wc  are  indebted  for  several 
of  the  statemeuts  in  this  article. 


speak  of  confusional  mental  states  when 
they  occur  as  symptomatic  of  various 
forms  of  mental  disease.  The  same  oj^inion 
is  held  by  Jolly,  the  successor  to  West- 
phal at  the  Charite,  Berlin. 

Wille,  on  the  other  hand,  has  treated 
Verwirrtheit  as  a  distinct  disorder,  and 
describes  its  causation,  course,  symptoms, 
diagnosis,  prognosis,  and  treatment. 

With  regard  to  dlfiferential  diagrnosis, 
he  distinguishes  it  from  transitory  mania, 
mental  epilepsy  (e^ji'Zep^/sc/ie.s  ^qtiivalent), 
and  post-epileptic  insanity,  from  acute 
mania,  melancholia  agitata,  acute  para- 
noia, primary  dementia,  and  some  stages 
of  general  paralysis.  It  can  hardly  be 
confounded  with  ti'ansitory  mania  ;  the 
history  of  the  case  should  serve  to  prevent 
a  mistake  in  diagnosis  between  confusional 
insanity,  epilej^sy,  and  acute  mania. 

With  regard  to  so-called  acute  paranoia, 
there  is  wanting  the  essential  symptom  of 
systematised  delusions.  As  regards  pri- 
mar}'  dementia,  there  is  no  doubt  a  very 
strong  resemblance  in  the  main  symptoms 
when  it  occurs  in  a  mild  form,  but  when 
it  is  well  pronounced,  it  ought  to  be 
readily  distinguished  from  confusional 
insanity,  when  the  term  is  correctly  used. 
The  course  of  the  two  forms  of  disorder 
would  serve  to  distinguish  them,  seeing 
that  primary  dementia  (more  correctly 
"  anergic  stupor ")  either  passes  into 
genuine  incurable  dementia  or  ends  in 
recovery,  while  confusional  insanity  recurs 
in  the  same  form — i.e.,  without  passing 
into  either  of  the  terminations  just  men- 
tioned. 

Some  statistics  show  that  confusional 
insanity,  understood  as  a  distinct  affection, 
is  followed  by  recovery  in  a  large  number 
of  cases  (according  to  Krafft-Ebing  as 
many  as  70  per  cent.) ;  on  the  other  hand, 
Meynert  and  Wille  do  not  give  such 
favourable  results,  the  proportion  of  re- 
coveries not  exceeding  46  per  cent. 

Treatment. — This  must  obviously  be 
directed  towards  strengthening  the  S3'stem 
generally  by  means  of  generous  diet,  proba- 
bly stimulants,  and  if,  as  is  frequently  the 
case,  insomnia  is  present,  by  sedatives  and 
hyjjnotics  —  e.g.,  paraldehyde,  sulphonal, 
or  the  bromides.  If  the  mental  condition 
has  arisen  from  overwork,  complete  men- 
tal rest  is  obviously  indicated,  or  if  it  is 
associated  with  masturbation,  the  treat- 
ment recommended  in  the  article  thereon 
iq.v.)  must  be  adopted.     {See  Mama  Hal- 

LUCIXATOKIA.)  ThE  EdITOR. 

[lieferences.  —  Schiile,  Klinische  Psychiatric, 
1886.  Wille,  Die  Lchre  von  der  Verwirrtheit,  in 
Archiv  fiir  Psychiatric,  Bd.  xix.  Knitft-Ebing-, 
Lelirbuch  dcr  Psychiatric.  Griesicger,  Die  Patho- 
loi;ie  uud  'I'herapic  dcr  ]>sychischeu  Kranliheiten. 
Ivraepeliu,  Psychiatric,  1887.] 


Verworrenheit 


[     1359    ] 


Visionary 


VER'WORRETil'HXilT  (Ger.).  A  term 
employed  to  express  a  highei*  degree  of 
coufusional    insanity    than    Verwiniheit 

VESASTZ/i.  {ve,  a  privative  particle, 
saniis,  souud).  Madness,  fury  or  rage, 
unsoundness  of  mint!.  Vesaniie  —  the 
name  of  an  order  in  Cullen's  nosology  and 
the  eighth  class  of  Sauvages  in  his  "Noso- 
logia  Methodica,"  of  1763.  (Fr.  vesanie  ; 
Ger.  ^\'l]nl>:ilrll.) 

yr±SATTiqytiS  (Fr.).  Individuals  who 
present  a  perfectly  characteristic  abnor- 
mal mental  condition,  but  whose  insanity 
is  not  connected  with  obvious  material 
lesions.  They  have  nearly  the  same 
chance  of  life  as  that  of  other  men  (Ball). 

VETERNOMAN-IA  {vctcnius,  leth- 
argy ;  iiavia,  madness).  The  same  as  Ty- 
phomania.     (Fr.  vcfenioiiianie.) 

VETEBNOSITAS  (vctenius,  aged — 
old  people  being  somnolent).  Coma- 
vigil. 

VETERNUS. — Lethargy. 

vzGlIiAN'CE  {vigilo,  I  watch).  In- 
somnia. 

VZCZI.ATIO,  vzGIIiZii.  {oigilo,  1 
watch).     Morbid  loss  of  sleep. 

vicilil.s:  NiTa.zJE. — Morbid  loss  of 
■sleep. 

VIS  lyXENTAlils. — Mental  power.  A 
term  for  the  power  proper  to  the  brain, 
in  distinction  from  Vis  TTervosa,  or  the 
power  peculiar  to  the  rest  of  the  nervous 
■system.     (Fr.  la  force  mentale.) 

VZSCERAI.  HYPOCHOXTBRZASIS, 
VXSCERAIi  MEIiAHrCHOIalA. — Com- 
mon delusions  in  melancholia  and  common 
morbid  fears  in  hypochondriasis  are  those 
connected  with  the  abdominal  organs,  such 
as  fears  of  or  delusions  of  intestinal  ob- 
struction. {See  Hypochondriasis,  and 
Melancholia.) 

VZSCERAI.  INSANITY.  {See  SYM- 
PATHETIC Insanity.) 

VISION,  PUNCTIONAI.  DISTURB- 
ANCES or.  {See  Hallucinations,  and 
Illusion.) 

VISIONARY. — Visionary  means  a 
person  who  is  in  the  habit  of  seeing  spec- 
tres, which  are  classed  as  subjective, 
because  no  one  else  can  see  them  at  the 
same  time.  The  word  is  sometimes  also 
used  to  designate  a  person  of  a  fanciful 
and  credulous  turn  of  mind.  Many 
people  have  experienced  visual  hallucina- 
tions at  some  period  of  their  lives,  gene- 
rally in  a  condition  of  nervous  strain  or 
bad  health ;  but  it  is  only  when  such 
visions  occur  frequently,  or  their  commu- 
nications seem  to  have  a  definite  import, 
or  connected  purpose,  that  they  begin  to 
interest  others.  Of  such  kind  are  the 
phantoms   of   the  dead,   spirits    bearing 


messages  from  the  unseen  world,  angels, 
or  demons.  Some  treat  all  such  appari- 
tions as  entire  delusions,  mere  symptoms 
of  brain  or  nervous  disease  ;  others  con- 
sider that  occasional  revelations  take 
place  from  the  unseen  world  either  by 
the  exercise  of  faculties  inherent  in  man, 
but  only  brought  into  action  under  very 
unusual  conditions,  or  by  some  divine  or 
spiritual  power  exercised  by  beings  who 
wish  to  enter  into  communication  with 
living  men.  On  examining  a  series  of 
narratives  of  ghosts  and  other  phantoms, 
we  soon  perceive  that  they  collectively 
support  no  particular  description  of  the 
world  beyond  the  grave,  but  reflect  the 
prejudices,  ignorance  and  credulity  of  the 
ghost-seer.  We  have  a  Greek  who  sees 
the  shade  of  a  drowned  mariner  mourning 
that  he  cannot  cross  the  river  Styx  till  his 
body  is  buried;  or  the  phantom  of  an  un- 
baptised  child  who  bewails  the  misery  it 
is  suffering  from  having  died  before  the 
rite  necessary  to  salvation ;  or  a  Mussul- 
man who  sees  in  the  jungles,  or  the  desert, 
the  green  mantle  of  the  Iman  Ali  mounted 
on  his  charger ;  or  a  Hindoo  ghost  who 
complains  that  low  caste  men  have  pol- 
luted his  tomb.  These  stories  are  some- 
times strangely  well  attested,  but  never 
more  firmly  than  the  narratives  of  witch- 
craft, which  within  less  than  two  hundred 
years  formed  the  subject  of  judicial  in- 
quiries under  which  thousands  of  innocent 
people  were  condemned  to  death.  It  is 
certain  that  some  of  these  unfortunates 
really  fancied  that  they  had  communion 
with  evil  spirits.  Visions  are  not  unfre- 
quently  accompanied  by  voices,  or  some- 
times voices  alone  are  heard.  Probably 
auditory  hallucinations  are  commoner 
than  visual  ones. 

One  of  the  earliest  visionaries  of  which 
we  have  record  was  Epimenides  of  Crete, 
an  epic  poet,  who  lived  in  the  days  of 
Solon.  He  was  reputed  to  have  the  power 
of  leaving  his  body  and  conversing  as  a 
spirit  with  spirits.  Religious  visionaries 
were  very  common  during  the  Middle 
Ages.  Many  of  them  were  female  devo- 
tees who,  through  severe  penances,  se- 
clusion, and  spiritual  exercises,  had  ren- 
dered their  nervous  system  at  once  weak 
and  excitable,  thus  becoming  liable  to 
hysteria  and  religious  ecstasies.  Amongst 
the  most  noted  of  female  visionaries  were 
St.  Theresa,  St.  Hildegarde,  and  Joan  of 
Arc.  Coming  to  our  own  century,  we 
have  Catherine  Emmerich,  a  German 
nun,  and  Frederika  Haufie,  the  seeress  of 
Prevorst,  whose  manifestations  are  de- 
scribed by  Dr.  Justinus  Keruer. 

The  Catholic  Church  admitted  that 
men  might  see  good  or  bad  spirits.     If 


Visionary 


[    1360    ] 


Visual  Memory 


the  seer  had  visions  of  saints  or  angels, 
and  his  revelations  were  agreeable  to  the 
faith,  they  canonised  him;  it"  he  were 
visited  by  demons,  they  exorcised  him  ;  if 
he  set  himself  against  the  Pope,  they 
burned  him,  as  they  did  Savonarola. 
Sometimes  they  took  advantage  of  the 
morbid  zeal  of  a  missionary  to  send  him 
on  dangerous  missions,  as  they  did  to 
]\larcello  Mastrilli.  He  was  the  son  of 
the  Marquis  of  San  Marzano,  and  at  an 
early  age  took  religious  vows.  While  in 
a  church  at  Naples  a  workman  let  fall 
from  a  great  height  a  hammer,  which 
struck  Mastrilli  on  the  head,  causing 
compression  of  the  brain.  During  his 
illness  and  convalescence  he  had  several 
visions  of  St.  Fi-ancis  Xavier,  who  held  in 
one  hand  a  bell,  in  the  other  a  taper, telling 
him  to  choose.  Mastrilli  made  his  way 
to  Goa,  where  he  opened  the  tomb  of 
Xavier,  and  put  between  the  fingers  of  the 
dead  Saint  a  jiaper  saying  that  he  was 
his  servant,  and  would  follow  his  example. 
The  Father  Mastrilli  then  went  as  a 
missionary  to  the  Philippine  Islands, 
where  he  committed  a  number  of  pious 
extravagances.  With  great  difficulty  he 
got  landed  in  Japan  at  the  height  of  the 
persecution,  in  the  hopes  of  converting 
the  Siogun  Dayfusaraa.  He  was  seized 
and  beheaded  after  undergoing  many  cruel 
tortures  (1637). 

Visionaries  were  common  in  the  fervent 
state  of  feeling  at  the  rise  of  the  Reforma- 
tion, and  during  the  prolonged  contest 
with  Catholicism.  Luther  was  himself, 
at  least  during  his  residence  at  the  Wartz- 
burg,  subject  to  visual  and  auditory  hal- 
lucinations, which  he  attributed  to  the 
persecution  of  devils.  During  the  strug- 
gles of  the  Puritans  in  England,  and  the 
Presbyterians  in  Scotland,  against  the 
Stuarts,  the  claim  to  have  inspirations 
and  visions  was  often  made,  and  some- 
times gained  great  influence  with  heated 
devotees.  Emanuel  Swedenborg  may  be 
said  to  be  the  prince  of  visionaries,  and 
there  is  still  a  considerable  sect  who  accept 
his  revelations ;  those  who  reject  them 
have  no  choice  but  to  regard  him  as  the 
subject  of  delusional  insanity. 

Even  m  our  own  day  many  claim  to 
have  communication  with  the  souls  of  the 
departed,  but  the  old  credulous  and  un- 
critical spirit  now  generally  shelters  itself 
under  quasi-scientific  forms.  We  have 
the  spiritualists  especially  strong  in  the 
United  States,  who  boast  of  a  stray  scien- 
tific man  among  their  number.  Allied 
with  them  is  a  host  of  magnetisers,  clair- 
voyants, mediums,  and  spirit-rappers, 
who  claim  toestabhsh  a  regular  commerce 
with  the  world  of  souls,  and  will  tell  the 


whereabouts  of  lost  lovers  and  stray  dogs. 
These  doctrinaires  have  a  large  occult 
literature  of  periodicals  and  books,  a  key 
to  which  may  be  found  in  the  "  Journal 
du  Magnetisme."  Many  of  these  persons 
still  preserve  sufficient  mental  balance  to 
manage  their  own  worldly  affairs,  and  not 
unduly  to  interfere  with  those  of  others. 
What  may  be  said  to  be  common  to  most 
of  them  is  a  longing  or  groping  towards 
the  unseen  world,  a  decided  taste  for  the 
wonderful,  a  disposition  to  read  symbols 
in  nature,  or  to  find  mystic  meanings  in 
Scripture,  with  a  condition  of  the  nervous 
system  passing  from  heightened  sensi- 
bility into  actual  disease,  sometimes 
manifested  by  hallucinations  of  the 
senses,  motor  spasms,  and  a  tendency  to 
chimerical  ideas  and  strange  conduct. 
WiLLiAii  W.  Ibeland. 

[Jififerences. — History  of  the  Supernatural,  by 
W.  Howitt,  London,  1863.  Ennemoser's  History 
of  Magic.  Le  Estasi  Umane  da  Paolo  Mante- 
gazza,  ililan,  1887.  Through  the  Ivory  Gate : 
Studies  in  History  and  Psychology,  Edinburgh, 
1889,  by  W.  W.  Ireland,  containing  accounts  of 
Swedenborg,  VT.  I'.lake,  and  <;.  Malagrida. 

VZSVAI.  HAI.X.VCZirATZON-S.    (See 

Hallucixations.) 

VISVAI.  »1E1VI0RY.*— Memory  by 
means  of  mental  imagery ;  objects  and 
their  attributes  being  seen  "  in  the  mind's 
eye.''  Mr.  Galton  found  by  means  of  a 
series  of  questions  addressed  to  various 
individuals  that  the  faculty  of  memory  by 
mental  imagery  occurs  to  a  varying  extent 
in  almost  every  person,  especially  in  non- 
scientific  people.  Asa  sex  women  possess 
the  faculty  to  a  greater  extent  than  men 
do.  He  came  to  the  conclusion  that  "  an 
over-ready  perception  of  sharp  mental 
pictures  is  antagonistic  to  the  acquirement 
of  habits  of  highly  generalised  and  ab- 
stract thought ;  "  that  the  highest  minds 
are  those  in  which  the  power  is  subor- 
dinated for  use  when  necessary.  From 
the  rei^lies  to  his  questions  by  one  hun- 
dred men,  at  least  half  of  whom  were 
distinguished  in  intellectual  work,  Galton 
found  that  the  power  of  mental  imagery 
varied  from  that  of  those  who  could  "  see  " 
the  image  "brilliant,  distinct,  and  never 
blotchy,"  to  that  of  those  who  had  merely 
a  general,  vague,  uncertain  "  idea,"  and 
some  could  recollect  the  objects  yet  never 
"  see  "  them  at  all  "  in  their  mind's  eye." 
The  intermediate  answers  were  nearer  ta 
the  replies  of  those  possessing  the  highest 
powers,  than  to  those  whose  powers  were 
zero.  One  out  of  every  sixteen  spoke  of 
their  mental  imagery  as  being  clear   and 

*  The  Editor  is  indebted  to  Mr.  Galton  for  per- 
mission to  use  the  diagrams  in  this  article,  and  ta 
Messrs.  Macmillan,  the  publishers  of  y^aiure,  for 
the  blocks  from  which  they  are  printed. 


Visual  Memory 


[    1361     ] 


Visual  Memory 


bright.  The  replies  as  to  colour  represen- 
tation showed  a  smaller  power  of  complete 
mental  imagery.  There  was 
a  larger  percentage  of  those 
whose  power  was  7(i7.  In- 
stances of  unusually  power- 
ful mental  inuigery  are  com- 
mon. Some  artists  have 
painted  from  a  mental  image ; 
chess  players,  as  is  well 
known,  can  sometimes  play 


-  -     rit 

games  blindfolded,  and  have  ,to\   ^'' 
more  than  one  game  sroing  on 


Every  number  (at  least   within  the  first 
thousand,  and  afterwai'ds  thousands  take 


Fic.  I. 


&  1 
ay 


at  the  time  ;  musicians  have 
occasionally  mental  images 
of  their  music,  and  some  speakers  have 
images  of  their  manuscript.  Sharp  sight 
is  not  necessarily  accompanied  by  clear 
visual  memory,  nor  are  the  visualising 
aud  identifying  powers  necessarily  com- 
bined ;  some  jjersons  can  combine  in  one 
perception  more  than  can  in  reality  be 
seen  at  one  time  by  the  two  eyes.  As  a 
rule  images  do  not  become  stronger  by 
dwelling  on  them  ;  the  first  mental  image 
usually  remains  unalterable,  even  though 
the  need  of  its  correction  be  afterwards 
recognised.  The  visualising  faculty  being 
a  natural  gift  has  a  tendency  to  be  in- 
herited ;  some  young  children  possess  it 
strongly.  It  can  be  developed  by  practice. 
As  a  nation  the  French  possess  it  in  a  high 
degree. 

Mr.  Galton  could  find  no  closer  relation 
between  high  visualising  power  and  the 
intellectual  faculties  than  between  verbal 
memory  and  those  same  faculties.  In 
some  professions  the  power  is  of  great 
help,  especially,  for  example,  in  that  of  an 
inventive  mechanician. 

To  imaginative  people  numerals  almost 
invariably  appear  in  the  form  of  mental 
imagery.  In  some  cases  the  reproduction 
almost  amounts  to  hallucination.  Galton 
found,  in  connection  with  this  mental 
imagei'y  of  numerals,  that  in  almost  one 
in  thirty  adult  males,  and  one  in  fifteen 
females,  an  invariable  "form "  appeared 
whenever  a  numeral  was  thought  of,  in 
which  each  numeral  had  its  jjroper  place. 
"  Forms "  of  this  kind  are  of  various 
shapes  and  outline  in  different  individuals, 
aud  in  Xature*  and  elsewhere  Mr.  Galton 
gives  various  diagrams  of  these  "forms." 

(i)  One  form  is  that  contributed  by  Mr. 
George  Bidder,  Q.C.,  the  son  of  the  well- 
known  "  calculating  boy."  As  already  in- 
timated, heredity  is  frequently  observed. 
His  account  is  as  follows  : — 

"  One  of  the  most  curious  peculiarities 

in  my  own  case,  is  the  arrangement  of  the 

arithmetical  numerals.     I  have  sketched 

them    to  the  best  of  my   ability  (Fig.  i.) 

*  Jan.  15,  i88o. 


the  place  of  units)  is  always  thought  of 
by  me  in  its  own  definite  place  in  the 
series,  where  it  has,  if  I  may  say  so,  a 
home  and  an  individuality.  I  should, 
however,  qualify  this  by  saying  that  when 
I  am  multiplying  together  two  large  num- 
bers, my  mind  is  engrossed  in  the  opera- 
tion, and  the  idea  of  locality  in  the  series 
for  the  moment  sinks  out  of  prominence. 
You  will  observe  that  the  first  part  of  the 
diagram  roughly  follows  the  arrangement 
of  figures  on  a  clock-face,  and  I  am  inclined 
to  think  that  may  have  been  in  part  the 
unconscious  source  of  it,  but  I  have 
always  been  utterly  at  a  loss  to  account 
for  the  abrupt  change  at  10  and  again  at 
12." 

Mr.  Galton  suggests  that  this  is  due  to 
the  wrench  given  to  the  mental  picture  of 
the  clock-dial  in  order  to  make  its  duo- 
decimal arrangements  conform  to  the 
decimal  system. 

(2)  Another  correspondent  thus  de- 
scribes his  own  visualised  numerals  : — 

"The  representation  I  carry  in  my 
Fig.  2. 


Visual  Memory 


[     1362    ] 


Visual  Memory 


mind  of  the  numerical  sei-ies  is  quite  tlis- 
tiuct  to  me,  so  much  so  that  I  cannot 
think  of  any  number  but  I  at  once  see  it 
(as  it  were)  in  its  peculiar  place  in  the 
diagram.     My  remembrance  of 
dates  is  also  nearly  entirely  de- 
pendent on  a  clear  mental  vision 
of    their    loci   in   the   diagram. 
This,  as  nearly  as  I  can  draw 
it,  is  reproduced  in  Fig.  2. 

"  It  is  only  aj^proximately 
con-ect  (if  the  term  '  correct '  be 
at  all  applicable).  The  numbers 
seem  to  approach  more  closely 
as  I  ascend  from  10  to  20,  30, 
40,  &c.  The  lines  embracing  a 
hundred  numbers  also  seem  to 
approach  as  I  go  on  to  400,  500, 
to  1000.  Beyond  1000  I  have 
only  the  sense  of  an  infinite  line 
in  the  direction  of  the  arrow, 
losing  itself  in  darkness  towards 
the  millions.  Any  special  num- 
ber of  thousands  returns  in  my 
mind  to  its  position  in  the 
l^arallel  lines  from  i  to  1000. 
The  diagram  was  present  in  my 
mind  from  early  childhood;  I 
remember  that  I  learnt  the 
multiplication  table  by  reference  r:j 

to  it,  at   the  age   of  seven    or 
eight.   I  need  hardly  say  that  the  impres- 
sion is  not  that  of  perfectly  straight  lines; 
I  have  therefore  used  no  ruler  in  drawing 
it." 

(3)  The  next  example  (Fig.  3)  is  thus 
described  by  the  contributor  :— 

"Fromthe  very  firstlhave  seen  numerals 
up  to  nearly  200  range  themselves  always 
in  a  particular  manner,  and  in  thinking 
of  a  number  it  always  takes  its  place  in 
the  figure.     The  more  attention  1  give  to 
the  properties  of  numbers  and  their  inter- 
pretations, the  less  I  am  troubled  with 
this  clumsy  framework  for  them, 
but  it  is  indelible  in  my  mind's 
eye  even  when  for  a  long   time 
less  consciously  so.     The  higher 
numbers  are    to   me  quite   ab- 
stract and  unconnected  with    a 
shape.      This  rough  and  untidy  ^ 

production  is  the  best  I  can 
do  towards  representing  what 
I  see.  There  was  a  little 
difl&culty  in  the  performance,  ^^ 
because  it  is  only  by  catch- 
ing oneself  at  unawares,  so  to 
speak,  that  one  is  quite  sure 
that  what  one  sees  is  not  affected  by 
temporary  imagination.  But  it  does 
not  seem  much  "like,  chiefly  because  the 
mental  picture  never  seems  on  the  fiat, 
but  in  a  thick,  dark  grey  atmosphere 
deepening    in    certain    parts,    especially 


where  i  emerges,  and  about  20.  How  I 
get  from  1 00  to  120  I  hardly  know,  though 
if  I  conld  require  these  figures  a  few  times 
without  thinking  of  them  on  purpose,  I 

Fig.  3. 


should  soon  notice.  About  200  I  lose  all 
framework.  I  do  not  see  the  actual 
figures  very  distinctly,  but  what  there  is 
of  them  is  distinguished  from  the  dark  by 
a  thin  whitish  tracing.  It  is  the  place 
they  take  and  the  shape  they  make  col- 
lectively which  is  invariable.  Nothing 
more  definitely  takes  its  place  than  a 
person's  age.  The  person  is  usually  there 
so  long  as  his  age  is  in  mind." 

(4)  A  lady  thus  writes  : — 

"  Figures  present  themselves  to  me  in 
lines  (as  in  the  annexed  diagram).     They 


Fig.  4. 


fSC 


etc       Oo 


110 

WO 


are  about  a  quarter  of  an  inch  in  length, 
and  of  ordinary  type.  They  are  black  on 
a  white  ground,  200  generally  takes  the 
place  of  100  and  obliterates  it.  There  is 
no  light  or  shade,  and  the  picture  is  in- 
variable." 


Visual  Memory 


C    1363   1 


Vox  Abscissa 


(5)  A  sister  of  this  lady  contributes 
another  diagram  representing  her  visual- 
ising experience : — 

*'  Figures  always  stand  out  distinctly  in 
Arabic  numerals ;  they  are  black  on  a 
white  ground,  of  this  size  [the  specimen 

Fig.  5. 


was  clear  and  round,  and  in  rather  large 
ordinary  handwriting],  but  the  numeral 
19  is  smaller  than  the  rest." 


Fig.  6. 


WOOjOOO 


10.  ceo 


4,C00 


20  T 


tooo 


30.000 


100 


K^ 


lOO.C'O 


^rooo.coo 

(6)    Figure  6  represents  a  diagram  of 
visualised  numerals  seen  by  a  lady. 


'lOO.OCO 
2d 


"  The    accompanying    figure    lies  in  a 
vertical  plane,  and  is  the  picture  seen  in 
counting.     The  zero  point  never  moves  ; 
it  is  uh  my  mind ;  it  is  that  jjoint  of  space 
known  as  "  here,"  while  all  other  points 
are  outside,  or  "  there."     When  I  was  a 
child  the  zero  point  began 
the  curve  ;  now  it  is  a  fixed 
— -....itr^_.    point  in  an  infinite  circle. 
....    I     have    had    the 
curious  bending  from  o  to 
30  as  long  as  I  can  remem- 
ber,    and     imagine     each 
bend  must  mark  a  stage 
in  early  calculation.     It  is 
absent  from  the  negative 
side  of   the   scale,    which 
has  been  added  since  child- 
hood." 
(7)  The  last  diagram  representing  vis- 
ualised numerals  is  thus  described  by  Mr. 
Galton's  correspondent : — 

"As  far  as  12  the  numerals  ajspear  to  be 
concealed  in  black  shadow  ;  from  12  to  20 
is  illuminated  space,  in  which  I  can  dis- 
tinguish no  divisions.  This  I  cannot 
illustrate,  because  it  is  simply  dark  and 
light  sj^rtce,  but  with  a  tolerably  sharp 
line  of  division  at  12.  From  20  to  100  the 
numerals  present  themselves  as  follows, 
but  less  distinctlv." 


Fig. 


SO 


1  Ilk 


50 


%\ 


W.  G.  WlLLOUGHBY. 
\Ileferences. — F.    Galton,  Visualised  Numerals, 
Journ.    of    Anthropoloy:.    lustit.,  1880;    Nature, 
Jan.  15,  1880  :  Human  Faculty,  1883.] 

VZTVS'S  SAN-Ci:,  ST.,  AITD  ITiT- 
SANZTV.      (6'ee    ClIORE.\   AND    INSANITY  ; 

Saint  Vitus's  Dance.) 

VOIX  BE  FOI.ZCHZia-£I.I.x: ;  or, 
PUNCH'S  VOZCE. — A  bell-like  tone  of 
voice  occasionally  noticed,  as  in  a  case  of 
Morel's,  just  before  and  during  a  periodical 
outbreak  of  violent  homicidal  mania. 

voiiZTioir.  (S'ee  Philosophy  of 
Mind,  p.  40.) 

VOIiZTZON'AIi  ZTrSANZTY.  (.Sec  IN- 
SANITY, Volitional.) 

VOI.UN-TARY  BOARDERS.  {See 
Law  of  Lunacy  ;  Scottish  Lunacy  Law, 
&c.) 

VOMZTING,     HYSTERZCAI..        {See 

Hysteria,  Motor  Disturbances  in, 
p.  622,  and  Digestive  Apparatus  in, 
p.  636.) 

vox  ABSCZSSA.  {See  Aphonia,  Hys- 
terical.) 


4S 


Wahlzeit 


[     1364    J 


Walinsinn 


w 


-WAHI.zi:zT  (Gei-.).     Will  time. 
-WAHM*  (Ger.).     A  delusion. 
-WA.HN-BXIiI>  (Ger.).     An  illusion. 
'WAHM'XDEE  (Ger.).     An  insane  idea, 
a  delusion. 

-WAHIflVItTTH  ;  "W  A  H  TCP  S  I  N"  TJ  ; 
'WA.HirSZM-N-IGKEZT  ;  -WAHNV/^ITZ 
(Ger.).  Various  terms  for  insanity  or 
madness. 

'WAHM'SZM'N'. — This  term  was  defined 
by  Griesinger  as  comprising  "  states  of 
exaltation  characterised  by  assertive, 
expansive  emotions  {affirmaiiver,  en'pan- 
siver  Affect),  associated  with  persistent  ex- 
cessive self-estimation  (anhalteude  Selhst- 
uherscJiatzung)  and  extravagant  fixed 
delusions  {ausscliiveifende  undfixe  Walin- 
rorsiellungen),  which  arise  therefrom."  * 
The  New  Sydenham  Society's  translation, 
by  Drs.  Lockhart  Robertson  and  James 
Rutherford  (1867),  renders  Walinsinn 
monomania.  As  stated  by  Griesinger, 
Heinroth  included  almost  all  the  mental 
symptoms  of  this  form  of  disorder  under 
the  term  "  ecstasis  paranoica,"  and 
Jessen  under  Schivarmerei,  and  partly 
under  Aberwitz.  Griesinger's  Wali7isinn 
does  not  correspond  to  Jacobi's  Wahn- 
sinn,  as  the  latter  psychologist  comjirised 
under  this  term  melancholia  with  delusions. 
Most  French  alienists  term  these  con- 
ditions, "  monomanie  (aigue)  d'ambition, 
d'orgueil,  de  vanite,"  and  also  adopt 
Rush's  term,  amenomania.  Great  stress 
was  laid  by  Griesinger  upon  recognising 
a  distinct  form  of  exaltation  apart  from 
the  megalomania  of  the  first  stage  of 
general  paralysis,  in  which  recovery  fre- 
quently follows  without  any  symp- 
toms of  paralysis.  It  should  be  stated 
that  the  recent  edition  of  Griesinger's 
work  (1892),  edited  and  greatly  altered  in 
form  and  substance  by  Dr.  Levinstein- 
Schlegel,  does  not  treat  M^almsinn  as  a 
separate  form  of  insanity,  as  Griesinger 
himself  did,  and  only  refers  to  it  inci- 
dentally in  the  chapter  on  Parano'esien. 

When  the  burning  question  of  the  defi- 
nition of  "  Verriicktheit "  was  discussed 
at  the  Congress  at  Hamburg,  in  1876, 
Westphal  proposed  a  certain  classification 
of  the  primary  forms  of  this  system- 
atised  mental  disorder,  but  Hertz  shortly 
afterwards  opposed  Westphal's  proposal, 
and  adopted  the  term   Walinsinn  instead 

*  "  Die  I'iitliolog'ie  und  Therapie  der  psycluselien 
Krankheiten,"  von  Dr.  W.  Griesinger.  Stuttgart. 
1861. 


of  Verrilcldlieit.  He  maintained  that  it 
was  undesirable  to  eliminate  the  former 
term  from  psychological  nomemjlature, 
because  "  A^erriicktheit  "  does  not  signify 
the  acute  primary  and  curable  forms, 
and  also  because  it  does  not  express  the 
essential  element  of  the  disorder,  which 
begins  and  ends  with  delusion  (TFa/m). 
Again,  Wahnsinn  is  an  old  recognised 
term.  Although  we  have  already  treated 
of  Verruckilieit  in  a  separate  article,  it  is 
necessary  for  the  complete  understanding 
of  the  term  at  the  head  of  our  present 
article  to  refer  freely  to  the  history  of 
the  word  in  consequence  of  its  relation 
to  Walinsinn.  It  must  be  understood  that 
Verrilcktheit  in  colloquial  German  means 
only  insanity,  without  any  differentiation. 
In  1845  Griesinger  first  used  the  expression 
in  the  sense  of  an  incurable  secondary 
mental  affection,  more  especially  marked 
by  delusions  of  persecution  and  of 
grandeur ;  he  qualified  the  term  by  the 
addition  of  the  word  "  partial,"  which 
corresponds  to  the  delire  partieloi  French 
alienists.  He  recognised  also  an  allge- 
meine  Verrilcktheit,  that  is,  a  general  con- 
fusion of  ideas  passing  into  actual 
dementia.  Prior  to  Hertz,  Snell,  in  1865, 
applied  the  term  Walinsinn  to  a  mental 
condition  answering  to  that  of  Griesin- 
ger's Verriicktlieit.  It  closely  resembles  the 
monomania  of  Esquirol.  Griesinger  him- 
self subseqiiently  modified  his  original  view 
in  the  sense  of  the  contention  of  Snell, 
Hertz,  and  also  ISTasse,  all  of  whom  regarded 
the  subject  from  the  same  jjoint  of  view. 

Schiile  adopts  the  term  Walinsinn,  and 
divides  it  into  acute  and  chronic.  He  sub- 
divides further  into  (i)  systematised  acute 
primary  insanity,  (2)  chronic  systematised 
depressive  insanity,  (3)  chronic  systema- 
tised expansive  insanity. 

At  the  annual  meeting  of  German 
medical  psychologists  in  1889,  Dr.  Werner 
introduced  a  discussion  on  the  various 
terms  now  under  consideration,  andrejected 
them  all  in  favour  of  the  term  "paranoia," 
which,  as  we  have  seen,  is  adopted  by  Dr. 
Levenstein-Schleger.  Adopting  this  all- 
embracing  term,  he  gives  the  following 
subdivisions  of  what  formerly  would  have 
been  called  Walinsinn  :  (a)  acute  primary, 
(6)  chronic  primary,  (c)  acute  halluci- 
natory (e.g.,  Kraii't-Ebing's  Walinsinn 
from  inanition),  (d)  chronic  hallucinatory, 
and  (c)  secondar}'  paranoia,  following  other 
forms  of  insanity. 


Wahnsinnig 


[     1365    ] 


Werwolf 


As  refleoting  German  medical  opiuioa 
it  is  important  to  note  that  those  who 
■took  part  in  the  debate  which  folhnved, 
expressed  their  concurrence  with  Werner 
in  adoptins^  the  term  jxrranoia  to  the 
•exclusion  ot'  Walinsiim,  'Verr/irkfheif,  and 
Feri';ir/-//(C!7,withthe  excoptionof  Kirn  and 
Kraepelin.who  maintained  that  this  course 
would  confound  together  curable  WaJm- 
■siun,  and  incurable  Verriicliheil.  To  this 
Mendel  replied  that  prognosis  should  not 
be  made  the  basis  of  classification. 

We  are  quite  in  accord  with  Werner 
and  the  new  German  school  in  the  clean 
sweep  they  would  make  of  these  disastrous 
terms,  to  which  we  gladly  add  that  of 
katatonia.  They  deserve  a  decent  burial 
— nay,  to  be  buried  with  j^sychological 
honours,  and  a  salute  from  ever^'  medical 
association  in  Europe  devoted  to  psychi- 
atry. How  long  the  substituted  term 
paranoia  will  maintain  its  pi-esent  proud 
position  we  dare  not  undertake  to 
prophesy.     {See  Paranoia.) 

The  Editor. 

[References. — Griesinger,  Die  Pathologic  uud 
Tberapie  des  psyehischen  Krankheitcn,  1861. 
Krafft-Eljiu<r,  Lebrljuch  der  Psychiatrio,  1883. 
Schiilc,  Kliiiische  Psychiatric,  Spccielle  Patliologie 
iind  Therapie  der  Geisteskraiikheitcn,  1886.  Ar- 
•cliives  dc  Xeurolot;ie,  1890,  Xo.  Ivii.  p.  418.  Dr. 
AVlllibald  Lcviustein-Schlcgel's  Griesiiiucr,  1892, 
vol.  i.  p.  388,f?.sT(/.] 

-WAHirSXN-NIG  ;    AXTAHNSUCKTIG 

(Ger.).     Mad,  maniacal,  insane. 

■WAHNSINNIGER  (Ger.).    A  lunatic. 

-WAHM'VORSTEI.I.irN-C  (Ger.).  A 
hallucination. 

'WAISTCOAT,  STRAIT. — Formerly 
a  favourite  means  of  restraining  violent 
lunatics.  {See  Treatment,  and  Strait 
Waistcoat.) 

'WAKEFXTXN'ESS.  A  common  symp- 
tom in  the  insane.     {See  Insomnia.) 

'WARNINGS. — The  popular  term  for 
the  aura  of  epilepsy. 

-WASSER'WVTH  (Ger.).  A  form  of 
insanity  in  which  the  patient  seeks-  to 
commit  suicide  by  drowning. 

'WEAKM'ESS  OF  TlfllND.  {See  IM- 
BECILITY, and  Demkntia.) 

'WEANING  AND  INSANITY.     {See 

Lactational  Insanity,  and  Puerperal  In- 
sanity.) 

'WEIGHT  or  BRAIN.— Dr.  Crochley 
Clapham  has  given  in  his  article  (p.  164) 
the  main  results  of  investigations  into  the 
weight  of  the  brain  in  the  sane  and  the 
insane.  We  add  to  his  bibliographical 
references  the  following  :  Sims,  "  Med.- 
Chir.  Trans."  1835,  ^^^-  ^i-"^ ;  Clen- 
dinning,  "  Recherches  sur  I'Encephale," 
1886,  "  Traito  de  la  folia  "  1841  ;  "  Med.- 
Chir.  Trans."  1838,  vol.  xxi.  ;  Goodsir, 
"Edin.    Med.    Surg.    Journ."    1845,    vol. 


Ixiii.  ;  Peacock,  "  Monthly  Journ.  of 
Med.  Science,"  vol.  vii.  (N.  S.  i.)  1847; 
"Edin.  Monthly  Journ."  Oct.  1854  (with 
Dr.  Reid);  "Path.  Trans."'  1859,  vol.  x. 
and  vol.  xii.,  1860-61  ;  "Memoirs  of  An- 
throp.  Soc.  of  London,"  vol.  i.  1865  : 
Skae,  ''  Ann.  Rep.  Roy.  Edin.  Asylum  for 
1S54,  Appendix;"  Bucknill,  "Path,  of 
Insanity,"  Brit,  and  For,  Med.-Chir,  Rev. 
1855,  vol.  XV. ;  Bucknill  andTuke,  "  Psych. 
Med."  1862,  p.  419;  Boyd,  "  Phil.  Trans." 
1861.  vol.  cli.  ;  "  Brit,  and  For.  Med.-Chir. 
Rev."  Jan.  1865;  "  Journ.  of  Ment.  Sci." 
Jan.  1865,  vol.  X. ;  Broca,  "  Sur  le  volume 
et  la  form  du  cerveau,"  Bull,  de  la  Soc. 
d'Anthrop.  1861,  t.  iii. ;  John  Marshall, 
"Phil. Trans."  1864,  vol.cliv.  ;"Anthropo]. 
Rev.''  1863,  vol.  i.;  Thurnam,  "  Journ.  of 
Ment.  Sci."  1866;  "  Wagner,  das  Hirnge- 
wicht  der  Menschen,"  1870;  A.  Mercier 
(Ziirich),  "  Journ.  of  Ment.  Sci."  Appen- 
dix, 1891. 

Dr.  Thurnam  gives  as  the  average 
weight  of  the  brain  in  1030  English, 
Scotch,  and  Germans  as  47.7  ozs.  average. 
The  same  for  women  is  given  as  42.7  ozs. 
With  regard  to  the  weight  of  insane 
brains,  he  gives  the  average  weight  of  the 
brain  in  257  men  at  the  Wilts  Asylum  as 
46.2,  while  the  average  weight  of  the  brain 
in  213  women  was  41  ozs. 

After  the  brain  of  Cuvier,  which  weighed 

64.5  ozs.  comes  that  of  Dr.  Abercrombie 
(Edin.)  63  ;  next  Spurzheim,  55.06;  then 
Dirichlet,  the  celebrated   mathematician, 

53.6  ;  Daniel  Webster,  53.5  ;  Lord  Chan- 
cellor Campbell,  53.5  ;  Dr.  Chalmers,  53  ; 
Gauss,  52.6 ;  Dupuytren,  surgeon,  50.7  ; 
Whewell,  49  ;  Tiedemann,  44.2.  The  aver- 
age of  ten  distinguished  men  between 
fifty  and  seventy  years  of  age  amounted 
to  54.7  oz.     (Thurnam  ojp.  cit.  p.  32.) 

The  Editor. 

'WER'WOI.F  ;  or,  'WERE-'WOI.F  (A.S. 
■li-er,  a  man  ;  and  wolf).  A  superstition,  at 
one  time  common  to  almost  all  Europe, 
and  which  still  lingers  in  Brittany, 
Limousin  and  Auvergne,  existed  that  an 
animal,  sometimes  under  the  form  of  a 
wolf  followed  by  dogs,  sometimes  as  a 
white  dog,  sometimes  as  a  black  goat,  and 
occasionally  in  an  invisible  form,  prowled 
about,  carrying  oft'  and  devouring  chil- 
dren ;  its  skin  was  said  to  be  bullet-proof, 
unless  the  bullet  had  been  blessed  in  a 
chapel  dedicated  to  St.  Hubert.  In  the 
fifteenth  centui-y  a  council  of  theologians 
convoked  by  the  Emperor  Sigismund 
gravely  declared  that  the  were- wolf  was 
a  reality.  The  French  equivalent  loup- 
garou  is  probably  a  corruption  of  loup- 
ivcr-ou  or  ivar-ou,  the  ou  being  for  ore,  an 
ogre.  (For  classical  allusions,  sec  Lycan- 
turopy.)     Herodotus  also   describes   the 


Wet-Brain 


[     1366    ] 


Will,  Disorders  of 


Neuri  as  sorcerers  -who  had  the  power  of 
assuming  once  a  year  the  shape  of  wolves. 
Pliny  relates  that  one  of  the  family  of 
Antaeus  was  chosen  annually  by  lot  to  be 
transformed  into  a  wolf,  in  which  shape 
he  continued  for  nine  years.  St.  Patrick, 
we  are  told,  converted  Vereticus,  King  of 
Wales,  into  a  wolf.  Giraldus  Cambrensis 
tells  us  (Opera,  vol.  v.  p.  119)  that  Irish- 
men can  be  changed  into  wolves.  Nennius 
asserts  that  the  "  descendants  of  wolves 
are  still  in  Ossory,"  and  re-transform 
themselves  into  wolves  when  they  bite 
("Wonders  of  Erin,"xiv. ;  Brewer, "Phrase 
and  Fable  "). 

■WET-BBAlWi — Excessive  serosity  of 
brain  and  membranes,  seen  in  general 
paralysis,  &c. 

■WET-PACKi     {See  Baths.) 

'WHISPERIM'G,    (See  Aphonia,  Hys- 

TEillCAL.) 

■WHYTT'S  DISEASE.  —  A  name 
given,  in  compliment  to  Dr.  R.  Whytt,  of 
Edinburgh,  to  hydrocephalus. 

wxiiii.     {See  Philosophy  of  Mind,  p. 

40.) 

"WIIiIi,  Disorders  of.— The  study  of 
the  disorders  of  tbe  will  is  very  obscure, 
and  can  only  be  brought  forward  as  an 
attempt.  If  we  were  only  to  state  facts, 
the  task  would  be  easy,  but  if  we  try  to 
penetrate  into  their  reasons  and  causes, 
we  soon  enter  the  region  of  hypothesis. 
We  shall  not  go  into  the  inextricable 
problem  of  free-will,  which  dominates  the 
whole  subject,  because  we  think  that  we 
may  safely  leave  it  alone  as  being  purely 
speculative.  Indeed,  whether  we  are 
thorough  fatalists,  or  enthusiastic  believers 
in  free-will,  we  cannot  deny  that  there  is 
a  moment  when  these  two  hostile  theses 
find  a  ground  of  reconciliation  —  the 
moment,  when  a  voluntary  act  commences, 
in  other  words,  when  a  certain  psycho- 
logical mechanism  comes  into  play.  What- 
ever the  antecedents  of  a  voluntary  act 
are,  whether  it  results  from  the  freewill, 
as  some  maintain,  or  whether  it  is  the 
result  of  a  rigid  connection  of  cause  and 
effect,  as  others  suppose,  we  must  admit, 
that  the  voluntary  act  exists  as  a  fact, 
and  that  from  a  practical  standpoint  at 
least,  its  antecedents  and  causes  are  but  of 
secondary  importance.  We  will  commence 
our  subject  at  the  exact  moment  when  the 
voluntary  act  begins.  Thus  defined,  the 
mechanism  of  a  voluntary  act  requires 
three  essential  factors : — 

(i)  A  previous  decision,  a  choice  (free 
or  not)  ; 

(2)  The  activity  of  certain  images  or 
motor  intuitions  ; 

(3)  The  usual  movements  effected  by 
the  different  i^arts  of  our  body. 


We  generally  consider  the  beginning 
and  the  end  only,  and  neglect  the  inter- 
mediate phase,  that  of  the  motor  image. 
This  is  a  great  mistake,  because,  if  we  do 
not  take  it  into  account,  we  cannot  under- 
stand the  disorders  of  the  will.  We  are 
too  much  inclined  to  believe  that  it  is 
sufficient  to  will  in  order  to  be  able  ta 
carry  out  our  ideas.  It  is,  however,  suffi- 
cient to  reflect  upon  the  matter  in  order 
to  see  that  every  one  of  our  voluntary 
actions,  even  the  simplest,  must  heleamt. 
To  take  a  glass  of  water  and  to  swallow  it, 
is  an  operation  very  difficult  and  often 
impossible  for  a  little  child.  For  a  volun- 
tary action  to  be  safely  executed  it  is 
necessary  that  the  movements  required  for 
it  be  inscribed  in  our  brain  in  consequence 
of  trials  and  former  experiences.  These 
motor  residua  (potential  movements)  con- 
stitute what  has  aptly  been  called  a  moto- 
rium  com-JiiunejWithout  which  our  volitions 
and  desires  would  never  be  realised. 

The  will,  regarded  as  the  powerto  govern 
ourselves  and  to  co-ordinate  our  actions 
with  one  purpose  in  view,  is  far  from 
possessing  all  the  power  which  many 
authors  attribute  to  it.  A  rapid  glance 
at  its  lesions  will  furnish  the  proof  of  this. 
We  shall  divide  the  disorders  of  the  will 
into  two  groups:  (i)  Those  cases  which 
result  in  a  want  of  impulse,  and  (2)  those 
which  result  in  a  want  of  inhibition. 

(i)  Aboulia  may  be  regarded  as  the 
type  of  the  disorders  of  the  will,  caused  by 
want  of  impulse.  The  patients  have  the 
latent  will,  but  they  are  unable  to  bring 
it  into  action.  One  of  the  earliest  obser- 
vations of  this  kind  is  due  to  Esquirol ;  it 
is  that  of  a  distinguished  and  eloquent 
magistrate  who  was  perfectly  well  aware 
of  his  sad  position.  "If  they  spoke  to 
him  about  travelling  or  about  looking 
after  his  business,  he  would  answer:  'I 
know  that  I  ought  to  do  it,  but  also  that 
I  cannot  do  it  ;  your  advice  is  very  good, 
and  I  wish  I  could  follow  it,  but  give  me 
will,  give  me  that  will  which  decides  and 
executes.  It  is  quite  certain  that  I  have 
a  will  only  in  order  not  to  will.'"  All 
observations  of  aboulia  are  but  varieties 
of  one  and  the  same  type.  The  condition 
of  depression  may  advance  into  complete 
torpor.  During  the  last  influenza  epi- 
demic, which  raged  in  France,  a  great 
number  of  cases  of  aboulia  occurred.  A 
distinguished  literary  gentleman,  well 
known  by  his  activity,  confessed  to  us  that 
he  had  been  for  several  days  in  a  condition 
of  complete  aboulia.  The  most  simple 
volitional  actions  (taking  a  journal  from  a 
table,  or  writing  his  signature)  could  not 
be  realised  and  seemed  to  him  an  enor- 
mous effort. 


Will,  Disorders  of 


[     1367    ] 


Will,  Disorders  of 


This  condition  seems  to  be  the  result 
not  of  a  weakening  of  the  motor  centimes 
■but  of  the  stimuhition  they  receive.  There 
existsinall  abouliac  patients  a  comparative 
insensibility,  a  general  depression  of  the 
affective  and  emotive  life,  and  thus  the 
active  life  tinds  itself  deprived  of  its  main- 
spring. 

With  abonlia  we  may  connect  certain 
morbid  conditions  often  met  with  in  the 
degenerated,  such  as  insanity  of  doubt 
^folie  dit  (Joute,  Grnbelsurht)  and  agora- 
phobia. The  hesitation  and  impotence  of 
will  are  extreme.  Cordes  {Archiv  f'dr 
JPsychiatric,  iii.)  who  suffered  himself 
from  agoraphobia,  and  was  able  to  study 
it  in  himself,  regards  it  as  a  functional 
paralysis,  which  indicates  certain  altera- 
tions in  the  motor  centres.  The  primitive 
cause  is,  according  to  him,  "  a  paresic 
exhaustion  of  the  motor  nervous  system 
of  that  part  of  the  brain  which  presides 
not  only  over  locomotion,  but  also  over  the 
muscular  sense." 

Lastly,  we  have  to  mention  the  psychi- 
cal paralyses  (paralyses  from  ideas)  which 
have  first  been  studied  by  Russell  Rey- 
nolds, and  of  which  a  certain  number  of 
■cases  have  since  become  known  ;  they  may 
even  be  artificially  produced  in  hypnotised 
individuals.  The  jjatient's  mind  becomes 
gradually  possessed  by  the  fixed  idea  that 
one  of  his  limbs  is  paralysed,  and  he 
becomes  unable  to  move  it.  It  appears 
that  this  imaginary  paralysis  is  due  to  a 
condition  of  temporary  inertia  of  the  motor 
images  which  are  indispensable  for  the 
•carrying  out  of  an  intended  movement ; 
for  to  imagine  a  movement  is  already  the 
commencement  of  this  movement,  and  to 
think  a  movement  impossible  is  to  inhibit 
the  motor  images  from  rising,  or  at  least 
from  attaining  such  an  intensity  as  to 
bring  about  the  movement. 

(2)  Impulses. — The  alterations  of  the 
will  which  we  have  just  mentioned,  repre- 
sent different  degrees  of  non-acting ;  the}'' 
are  forms  of  inertia.  In  the  second  groiip, 
which  comprises  the  phenomena  known  as 
irresistible  im-pidses,  great  activity  is  dis- 
played either  with  or  without  the  will. 
The  power  of  control  is  still  reduced  to 
impotency,  but  in  all  cases  of  this  group 
the  inhibition  or  arrest  fail.  The  will,  in 
fact,  is  the  power  not  only  to  do  some- 
^,hing,  but  also  to  leave  somethmg  un- 
done; it  not  only  produces  impulse,  but 
also  inhibition.  The  power  of  mhibition 
seems  to  represent  a  superior  degree  in 
the  evolution  of  the  will :  in  the  child  the 
impulsive  form  reigns  at  first  exclusively, 
and  according  to  I'reyer  it  is  only  about 
the  tenth  month  that  inhibition  shows 
itself  in  the  very  humble  form  of  volun- 


tary arrest  of  the  natural  evacuations. 
We  have  also  to  remark,  that  like  all  the 
higher  forms  of  mental  activity,  the  inhi- 
bitory will-power  has  but  an  unstable  and 
precai'ious  existence  :  the  commencement 
of  drunkenness,  somnolentia,  even  simple 
fatigue  are  sufficient  to  I'ender  us  unable 
to  control  our  reflexes.  It  must  also  be 
noted  how  difficult  voluntary  attention  is 
to  most  people,  and  how  few  are  capable 
of  it  for  any  length  of  time ;  therefore 
attention  on  one  subject  can  only  be 
maintained  by  a  constant  act  of  inhibition. 
The  iiitimate  mechanism  of  inhibition  is 
unfortunately  very  little  known,  in  spite 
of  the  researches  of  several  distinguished 
physiologists,  and  the  obscurity  which 
reigns  over  this  question  in  physiology 
l^revents  any  attempt  to  explain  the 
psychological  mechanism. 

However  this  may  be,  inhibition  exists 
as  a  fact  in  our  normal  life,  and  it  dis- 
appears in  cases  of  irresistible  impulse.  It 
is  necessary  to  draw  attention  to  the  fact 
that  the  transition  from  the  sane  condi- 
tion to  the  pathological  forms  is  almost 
imperceptible.  Even  people  who  are  com- 
pletely sane  have  their  brains  traversed 
by  foolish  abnormal  impulses,  but  these 
sudden  and  unusual  conditions  do  not 
pass  into  action,  because  they  are  bound 
down  by  a  contrary  force.  In  other  cases 
there  are  6 ir-'arre  actions,  which  escape  the 
controlling  power  of  the  will  (tics,  whims, 
&c.),  and  are  in  themselves  neither  repre- 
hensible nor  dangerous,  or  there  are  also 
simple  volitions — still  restrained,  however 
— of  more  serious  actions  (to  bite  or  to 
strike).  Such  is  the  case  of  an  amateur 
artist,  who,  finding  himself  in  a  museum 
before  some  valuable  picture,  felt  the  in- 
stinctive desire  to  tear  the  canvas. 

We  find  a  further  stage  of  impulse  in 
those  patients  who,  alone  or  with  the  help 
of  another  person,  strive  against  the 
attack  of  some  violent  proclivity  and  suc- 
ceed in  mastering  it.  Lastly,  in  its  highest 
degree,  the  impulse  is  comj^letely  iri-esist- 
ible ;  it  has  the  blind  and  unconscious 
power  of  an  instinct,  and  the  will  as  well 
as  the  inhibitory  power  is  annihilated. 
The  symptoms  of  this  species  (robbery, 
incendiarism,  suicide,  homicide,  &c.)  have 
been  so  often  studied  that  it  will  suffice 
to  have  mentioned  them  here. 

The  will  is  therefore  not  an  imperative 
entity,  reigning  in  a  world  of  its  own,  and 
distinguishing  itself  by  its  actions,  but  it 
is  the  last  expression  of  an  hiei'archical 
co-ordination  of  tendencies,  and  as  every 
movement  or  group  of  movements  is  re- 
presented in  the  nervous  centres,  it  is 
clear  that  with  the  paralysis  of  each  single 
group,  one  element  of  co-ordination  dis- 


Willenlosigkeit 


[     1368    ] 


Witchcraft 


ai-)pears.  Dissolution  of  the  will  is  absence 
of  co-ordination,  which  terminates  in  an 
independent,  irregular  and  anarchical 
action.  Moreover,  we  may  ask,  whether 
in  certain  human  beings  (not  to  speak  of 
idiots  and  individuals  labouring  under 
dementia)  the  will  has  ever  constituted 
itself,  so  that  we  might  speak  in  such 
cases  not  of  disease  of  the  will,  but  of  con- 
genital atrophy.  A  great  number  of 
hysterical  patients  seem  to  belong  to  this 
class  ;  their  prodigious  instability,  their 
caprices,  which  incessantly  apj^ear,  keep 
them  in  a  permanent  condition  of  dis- 
equilibration  and  of  moral  ataxy.  There 
is  a  constitutional  imjwtency  of  the  will ; 
it  is  unable  to  develop  because  the  con- 
ditions necessary  to  its  existence  are 
wanting. 

Annihilation  of  the  will  shows  itself  also 
in  most  hypnotised  individuals,  and  this 
is  due  to  the  exclusive  predominance  of 
the  idea  or  action  suggested  by  the 
operator,  who,  occupying  the  place  of  the 
conscience,  does  not  allow  of  any  con- 
sideration or  of  any  choice.  Several 
authenticated  cases,  however,  of  obstinate 
resistance,  have  been  reported ;  some  sub- 
jects do  not  accept  suggestions  on  certain 
points,  and  preserve  during  the  hypnosis 
that  power  of  personal  reaction  which  is 
the  foundation-stone  of  the  will. 

Th.  Eibot. 

'Wzi.XEia-i.oszGKEiT.  {See  Aboulo- 
MANiA,  or  Abulia.) 

"WziiXs,  {See  Testamentary  Capa- 
city.) 

vriM-E-MADN-Ess.    {See  Oixomaxia.) 

"WIT, — The  wit  in  mania  is  sometimes 
better  than  in  the  same  person  when 
healthy,  due  probably  to  the  rapid  associa- 
tion of  ideas  common  in  mania  (Savage). 

WITCHCRAPT.— Speaking  with  his- 
torical exactitude,  the  subject  of  witch- 
craft is  a  psycho-pathological  phenomenon 
which  includes  numerous  forms  of  the 
mental  alienation  of  the  early  and  middle 
ages.  Demonomania,  theomania,  lycan- 
thropy,  choreomania,  vampirism,  and  hys- 
terical anomalies,  are  all  examples  of  the 
vai-ious  developments  of  witchcraft.  In 
this  article,  however,  we  shall  more  par- 
ticularly study  demonolatria,  or  the  mor- 
bid subjection  and  subordination  of  the 
subject  to  the  devil,  and  devil-worship. 
The  transition  from  demonolatria  to 
lycanthropy,  choreomania,  or  hysterical 
insanity,  is  easy  of  comprehension,  but 
we  will  discuss  these  separate  manifesta- 
tions apart. 

Those  mentioned  in  the  New  Testament 
as  being  possessed  of  the  devil,  or  afJiicted 
with  a  malignant  spirit,  do  not  come  under 
the  same  category  as  the  voluntary  and 


wicked  devil  -  worshippers.  Until  the 
twelfth  and  thirteenth  centuries  the 
possessed  were  pitied,  and  were  even 
considered  as  inspired,  so  long  as  they 
did  not  devote  body  and  soul  to  the 
demon's  service,  or  use  him  as  their  instru- 
ment. Later  on,  demon-worshippers  and 
those  afflicted  with  evil  spirits  were  looked 
upon  as  one  class ;  the  bewitched  and 
witches  were  also  similarly  regarded, 
while  even  the  later  representatives  of  the 
prophets  and  magicians,  who,  under  the 
supposed  influence  of  good  spirits,  had 
been  favourably  regarded  in  former  times, 
came  to  be  accused  of  the  practice  of 
witchery  and  were  called  heretics,  so  that 
they  fell  under  the  ban  and  persecution  of 
the  Church. 

Demonolatria  or  witchcraft  considered 
psychologically,  especially  under  lycan- 
thropic  colouring,  tends  oftenest  to  forms 
of  melancholia,  of  melancholia  with  delu- 
sions, and  a  confused  personal  identity,  or 
even  its  abolition.  That  witchcraft  may 
generally  be  considered  as  a  form  of 
melancholia,  a  morbid  mental  affection 
due  to  the  influence  of  those  times,  with 
loss  of  personality,  delusions  of  guilty 
conscience,  morbid  self-accusations,  and  a 
desire  for  exj^iation,  is  proved  in  fact  by 
the  confessions  of  the  supposed  witches 
and  sorcerers  at  their  trials.  AVe  find 
that  those  who  in  the  estimation  of  others 
were  really  witches,  or  believed  themselves 
such,  not  only  confessed  all  their  evil 
deeds,  but  complicated  their  trials  with 
confessions  that  even  to  their  judges 
seemed  exaggerated  and  imjjossible,  ac- 
cusing themselves  of  horrible  and  unnatu- 
ral crimes,  such  as  the  wholesale  murder 
of  hundreds  of  children,  and  other  deeds 
that  could  not  be  proved.  We  must  there- 
fore regard  demonolatria  in  the  light  of  an 
insane  delusion  of  guilt,  an  active  me- 
lancholia with  a  morbid  craving  after 
self-accusation,  self-humiliation,  and  an 
uncontrollable  impulse  to  pretend  to  have 
committed  the  most  absurd  and  nefarious 
crimes.  We  do  not  wish  to  convey  the 
impression  that  all  were  instances  of 
melancholia,  but  certainly  a  goodly  pro- 
portion evinced  melancholic  tendencies, 
while  others  were  maniacal,  paranoic, 
epileptic,  or  hysterical  subjects.  Demono- 
latric  witchcraft  has  always  been  a  more 
or  less  complex  form  of  psychosis,  even  as 
melancholia  itself  frequently  is  ;  it  reflects 
all  the  tendencies  of  those  times  modified 
by  the  influence  of  Christianity.  It  might 
almost  be  said  that  the  mythology  of  the 
early  people  with  its  gods  of  good 
and  evil,  but  still  always  gods,  pre- 
cociously foreshadowed  the  absolute  mono- 
theism which  admits  of  only  one  God,  that 


Witchcraft 


[    1369    ] 


Witchcraft 


of  good,  while  evil  not  having  its  gods  in 
the  Christian  doctrine,  declared  itself 
anachrouistically  in  the  actions  of  these 
unfortnuate  beings.  Their  belief  was  not 
an  absurd  improbable  outcome  of  isolated 
minds,  such  as  that  of  those  voluntarily 
practising  witchcraft,  for  their  excited 
imagination  was  the  result  of  the  admix- 
ture of  the  new  Christian  religion  with 
the  blind  and  mistaken  beliefs  of  their 
ancestors.  The  practice  of  witchcraft, 
even  when  newly  disguised  under  the  in- 
fluence of  Christianity,  was,  as  we  find  it 
in  the  earliest  times,  anything  but  Chi'is- 
tian  in  its  aspects,  being  in  fact  twin 
sister  to  polytheism.  Indeed,  the  two 
principles  of  good  and  evil  are  to  be  found 
in  all  the  religions  brought  from  Asia  in 
times  much  anterior  to  Grasco-Roman 
civilisation,  as  well  as  in  the  Jewish,  Chal- 
dean, Indian,  and  Egyptian  traditions. 
The  Greeks  also,  in  their  fv8aifiuvai  and 
KaKo8aifj.6vai,  possessed  geniuses  of  good 
and  evil,  and  the'}nanes  of  Rome  were  but 
the  /ca/coSai/xoi/at  of  the  Greeks.  The 
satyrs,  sylvans,  and  fauns,  were,  like  the 
Greek  centaurs,  so  many  witches  who 
were  nevertheless  respected  as  part  of 
that  ancient  polytheistic  religion  which 
tolerated  all  divinities,  when  the  people 
of  one  country  sometimes,  through  super- 
stitious fear,  even  sacrificed  to  the  gods  of 
a  neighbouring  State,  though  such  were 
not  officially  included  in  their  religion. 
That  which  the  poor  witches  of  Christian 
lands  merely  fancied  that  they  had  done, 
all  those  horrors  of  the  witch-revels  (sab- 
bat)  that  their  diseased  imaginations 
could  suggest,  was  openly  performed  by 
the  Greeks  and  Romans  in  the  excesses  of 
their  Bacchanalian,  lycean,  and  luper- 
calian  feasts.  It  is  certain  that  the  nebu- 
lous legends  of  German  mythology,  which 
came  to  us  fresh  from  their  Asiatic  origin, 
and  which  had  to  bear  a  severe  shock  in 
their  encounter  with  Christianity — when 
the  gods  of  the  Greeks  and  Romans  were 
already  overturned,  and  the  Christian 
religion  raised  on  their  ruins  after  some 
centuries  of  strife — had  a  strong  influence 
on  the  development  of  that  witchcraft 
which  flourished  in  subsequent  times,  and 
reached  its  acme  at  the  commencement  of 
intellectual  and  scientific  progress.  Magic 
must  not  be  confounded  with  witchcraft, 
as  Bodin  remarks,  for  magic  is  of  Persian 
origin,  signifying  the  divine  and  natural 
sciences.  Under  the  Romans,  magicians 
were  punished  only  when  it  was  believed 
that  they  caused  death  by  poison  or  other 
means. 

From  the  Laws  of  Moses,  published 
fifteen  hundred  years  before  Christ,  it  is 
seen  (says  Bodin)  thatChaldea,  Egypt, and 


Palestine,  were  infested  with  witches. 
Indeed,  Asia  Minor,  Greece  and  Italy,  then 
only  half  populated,  were  equally  troubled. 
God's  anger  was  turned  against  the  land  of 
Canaan,  not  for  the  idolatrous  and  other 
misdeeds  common  to  all  peoples  of  those 
times,  but  on  account  of  the  abominable 
witchcrafts  and  sorceries  that  were  then 
practised  (Deuteronomy  xviii.).  After 
the  Trojan  war,  which  occurred  200  years 
after  the  Law  of  God,  we  have  all  the  cruel 
witchery  of  ]\Iedea,  the  transformation  of 
Circe  and  Proteus,  and  the  Thessalian 
sorceries.  From  these  facts  it  may  be 
deduced  that  the  belief  in  witches  need 
not  have  been  introduced  by  the  German 
invasion,  although  the  latter  may  subse- 
quently have  exercised  an  influence  on 
the  common  Greek  and  Roman  fables 
that  were  dying  out  amongst  the  people. 

We  will  not  attemj^t  to  describe  at  any 
length  the  acts  of  the  witches  or  the 
horrors  of  their  midnight  meetings.  In 
their  revels  lycanthropy  and  demono- 
latria  are  fused  together.  The  grossest 
crimes  and  most  barbarous  cruelties  were 
practised  at  their  orgies,  which  were  pre- 
sided over  by  some  representative  of  their 
common  deity,  the  devil ;  infants  were 
sacrificed,  and  their  fiesh,  after  having 
been  boiled  with  toads,  serpents,  and  the 
like,  was  made  into  an  ointment,  which 
was  reputed  to  possess  bewitching  and 
mysterious  qualities.  Sometimes,  to 
render  the  ceremony  more  sacrilegious 
and  impious,  the  presiding  sorcerer  re- 
peated an  infernal  mock  mass,  uttering 
the  most  fearful  blasphemies  over  the 
consecrated  wafer,  which  was  subse- 
quently mixed  with  their  powders  and 
unguents  to  render  the  profanation  more 
diabolical.  At  the  end  of  the  ceremonies 
great  banquets  were  eaten,  in  which 
infants'  flesh  was  a  prominent  dish,  after 
which  the  witches  returned  to  their  ordi- 
nary occupations  quietly,  and  without 
leaving  any  trace  of  their  revels. 

Towards  the  end  of  the  sixteenth  cen- 
tury a  medical  explanation  was  given  by 
some  of  this  ecstatic  state,  and  of  its  audi- 
tory visual  and  sensory  hallucinations. 
Houllier  declared  the  bewitched  to  be 
simply  suffering  from  a  form  of  melan- 
cholia, and  that  the  supposed  influences 
by  evil  spirits  were  simply  sensory  hallu- 
cinations. Even  in  the  third  and  fourth 
centuries  it  was  believed  that  the  appear- 
ance of  flying  witches  was  purely  imagi- 
nary, and  due  to  an  ecstatic  state  or  a 
melancholic  pliantasm.  The  fact,  how- 
ever, that  in  Norway,  Livonia,  and  Ger- 
many, where  there  were  more  converts, 
there  were  also  more  witches  than  in  the 
southern  countries,  tended  to  maintain  an 


Witchcraft 


[     1370    ] 


Word-Deaf  aess 


error  which  ah-eady  had  largely  taken 
root  in  religious  fanaticism.  In  the  first 
centuries  of  the  Christian  era,  witchcraft 
was  tolerated  among  the  French,  Ger- 
mans, Goths,  Lombards,  and  Saxous,  and 
it  was  only  in  the  fifth  century  that 
the  French  began  by  the  Salic  laws  to 
punish  witches,  but  their  punishments 
were  only  slight,  except  when  serious 
crimes  were  committed,  a  fine  being  im- 
posed on  those  who  attended  the  witches' 
revels.  As  yet  the  devil  did  not  appear 
in  witchcraft,  and  it  is  only  in  the  eighth 
and  ninth  centuries  that  he  was  supposed 
to  be  present  at  their  festivities,  and  the 
Church  then  began  to  take  serious  notice 
of  these  practices.  In  the  ninth  century 
we  find  mention  made  of  a  trial  for  witch- 
craft in  Spain,  but  the  condemnation  of 
witches  to  the  stake  in  any  considerable 
numbers  only  began  in  the  thirteenth 
century  ;  the  number  of  victims  increased 
in  the  fourteenth,  and  reached  its  greatest 
height  in  the  sixteenth  centui-y,  from 
which  time  such  punishment  gradually 
died  out,  but  in  the  eighteenth  century 
was  still  in  vogue.  The  institution  of  the 
Inquisition  in  1183  by  Pope  Innocent  III. 
marked  the  commencement  of  a  perfect 
epidemic  of  trials  and  torturings  of  those 
who  were  accused  of  witchcraft ;  the  arbi- 
trary proceedings  of  the  inquisitors  who, 
to  satisfy  their  private  revenge,  gratify 
their  cupidity,  or  place  out  of  power  those 
whom  they  feared,  condemned  both  the 
innocent  and  guilty  to  the  flames,  further 
raised  popular  indignation  against  the 
practices  in  which  these  unfortunate 
beings  were  sujjposed  to  indulge.  Many 
of  the  trials  reveal  the  fact  that  perfectly 
sane  persons  were  made  to  suffer  in  com- 
mon with  those  poor  hallucinated  melan- 
choliacs  who  were  but  too  ready  to  confess 
to  diabolical  practices.  The  so-called 
witches  of  those  times  may  conveniently 
be  classified  into  two  groups,  (i)  those 
with  visions  or  hallucinations  of  the 
senses  who  were  affected  with  mental  de- 
pression, and  (2)  those  who  actually  in- 
fested the  country  killing  men  and  boys, 
and  hiding  in  the  woods  with  lycanthropic 
impulses.  We  can  hardly  consider  these 
as  similar  to  the  howlers  and  jumpers  of 
later  years,  in  that  their  affection  was  not 
a  truly  epidemic  one  ;  they  are  rather  ex- 
amples of  cynanthropia  with  demoniacal 
colouring.  Such  cases  xmder  the  inter- 
pretation of  those  times  may  be  considered 
as  appertaining  to  witchcraft.  About 
1436  in  Switzerland  there  arose  a  class  of 
men  living  in  Vaud  who  worshijjped  the 
devil  and  ate  human  flesh  ;  they  infested 
the  country  about  Berne  and  Lausanne ; 
unbaptised  infants  were  specially  prized 


by  them  for  their  hideous  practices,  and 
the  real  acts  committed  by  them  under 
the  influence  of  a  morbid  impulse  were 
mixed  up  with  hallucinations  to  which 
they  freely  confessed  at  their  trials.  One 
witch  declared  that  at  their  meetings 
they  made  ointments  and  unguents  of 
infants'  flesh  with  which  the  novices  were 
anointed  when  they  were  initiated  into 
their  horrible  mysteries.  In  England,  ia 
Leicester,  in  1340,  a  like  epidemic  of  demo- 
niacal and  impulsive  character  occurred, 
while  Kn3'ghton  speaks  of  another  epi- 
demic of  impulsive  and  demoniacal  cynan- 
thropia, which  broke  out  in  this  country 
in  1355.  Witch  trials  and  witch  execu- 
tions became  so  common  after  the  famous 
Bull  of  Pope  Innocent  VIII.  ("  Summis 
desiderantes  affectibus"),  of  December  5, 
1484,  issued  at  the  request  of  two  fanatics 
named  Heinrich  Institor  and  Jacob 
Sprenger,  who  had  published  a  treatise, 
(The  "  Malleus  Maleficarum  ")  systema- 
tising  the  whole  doctrine  of  witchcraft, 
and  laying  down  a  regular  form  of  trial, 
that  it  has  been  estimated*  that  as  many 
as  nine  thousand  (?)  persons  suffered  death 
subsequently  to  that  edict.  Through  the 
spread  of  civilisation  and  the  reformed 
religion,  and  not  the  barbarous  cruelties 
of  the  Church,  witchcraft  gradually  died 
out  among  the  European  nations  towards 
the  end  of  the  seventeenth  century,  after 
having  existed  for  over  three  hundred 
years.  A.  TAiiBURixi. 

S.   TONNINI. 

"WOB  (Saxon).     Insane. 

'WODM'ES  (Saxon).  Insanity,  mad- 
ness. 

'WroiiF-lVIABM'ESS.  —  An  occasional 
delusion  in  the  insane  is,  that  a  patient 
considers  himself  changed  into  an  animal. 
AVhen  this  occurs  with  regard  to  a  wolf, 
it  has  been  called  wolf-madness.  {See 
LycA^'T^RO^Y.) 

V7-OOBM-ESS  (Saxon,  i'.-oef?).  Madness. 
(Used  by  Spenser.) 

-WORD-BS.IM-Dirsss.— The  state  of 
mind  of  a  patient  to  whom  the  sight  of 
a  word,  previously  understood,  conveys 
no  idea  of  its  meaning.  He  may  at  the 
same  time  perfectly  understand  the 
spoken  word.  There  is  almost  always 
some  organic  cerebral  lesion.     (See  Mixd- 

BLINDXESS.) 

'MVORS-CIiXPPIN'C — A  symptom  in 
general  paralysis  of  the  insane  (q.v.). 

'WORB-DEAFN-ESS.  —  The  state  of 
mind  of  a  patient  to  whom  the  sound  of 
a  word,  previously  understood,  conveys 
no  idea  of  its  meaning.  The  sight  of 
it  may  still  convey  the  idea,  and  the  rest 
of  the  patient's  mental  power  may  be 
*  Sprenger,  '•  Life  of  Mobammed." 


Workhouses 


[    1371    ] 


Workhouses 


perfectly  sound.  The  cause  is  usually  aa 
organic  cerebral  lesion.  (See  Mind-Deaf- 
ness, and  PosT-ArorLKCTic  Insanity.) 

IVORKHOUSES.  —  Though  work- 
houses or  poorhouses  in  some  form  are  of 
rather  ancient  date,  and  since  the  reign  of 
Elizabeth  have  been  recognised  parochial 
institutions,  it  was  not  until  the  year  1834, 
and  the  adoi>tion  of'tho  Poor  Law  Amend- 
ment Act,  William  IV.,  c.  76,  that  they 
came  into  any  special  relation  with  the 
care  and  treatment  of  the  insane,  though 
doubtless  large  numbers  of  the  insane 
l>oor  were  detained  in  the  older  work- 
houses. 

From  a  much  earlier  date  than  1834 
considerable  attention  had  been  given  to 
the  condition  of  the  insane.  Several  re- 
ports of  committees  of  the  House  of 
Commons  before  this  date  had  disclosed 
by  abundant  evidence  that  on  the  whole 
the  condition  and  treatment  of  the  insane 
of  every  class,  and  not  the  poor  only,  were 
far  from  satisfactory. 

The  observations  of  Pinel  in  France, 
and  the  valuable  experience  of  such  insti- 
tutions as  the  Retreat  at  York  and  some 
other  asylums  of  a  similar  character  had 
shown  by  actual  experience  how  much  the 
comfort  and  well-being  of  this  class  of 
sufferers  might  be  improved  and  their 
recovery  facilitated  by  a  more  humane  and 
rational  treatment  than  that  hitherto 
adopted.  In  this  way  the  public  mind 
had  become  prepared  to  accept  and  to 
enforce  if  possible  a  new  departure  in  all 
that  belonged  to  the  care  and  treatment 
of  the  insane.  Many  active  and  philan- 
thropic minds  combined  to  give  effect  to 
these  new  principles  of  treatment.  JSTever- 
theless  abuses  lingered,  and  long  after 
1834  much  remained  to  be  done.  By 
the  influence  of  the  Poor  Law  Commis- 
sioners appointed  under  the  Act  of  1834, 
larger  and  better  workhouses  began  to  be 
erected,  and  a  more  strict  oversight  was 
maintained  over  the  administration  of  the 
Poor  Law  than  had  ever  existed  before!  The 
visits  of  the  inspectors  appointed  by  the 
Commissioners  disclosed  many  evils,  and 
much  deplorable  neglect  in  the  care  of  the 
insane  jjoor  in  workhouses  as  well  as 
with  those  boarded  out  or  maintained  in 
their  own  homes.  Notwithstanding  these 
disclosures  the  condition  of  the  insane 
poor  detained  in  workhouses  remained  in 
the  main  very  unsatisfactory  for  many 
3'ears  after  the  passing  of  the  Poor  Law 
Amendment  Act. 

The  paucity  of  asylum  accommodation, 
the  unwillingness  of  guardians  to  in- 
crease the  expenditure,  to  say  nothing  of 
the  fact  that  for  many  years  the  chief 
object  in  the  minds  both  of  the  central  and 


the  local  authorities  was  the  suppression 
of  voluntary  pauperism,  diverted  special 
attention  from  the  insane.  To  these  various 
causes  may  be  assigned  the  explanation 
of  that  neglect  which  undoubtedly  existed. 
Abundant  evidence  that  such  neglect  was 
common  is  disclosed  in  the  second  Report, 
1836,  of  the  Poor  Law  Commissioners.  At 
this  time,  much  of  the  neglect  was  of  a 
gross  and  scandalous  character.  That 
the  condition  of  the  insane  poor  detained 
in  workhouses  remained  unsatisfactory 
after  a  fjuarter  of  a  century  of  Poor  Law 
Administration  may  be  gathered  from  a 
Report  of  the  Commissioners  in  Lunacy  in 
1859  appended  to  their  twelfth  annual 
report.  This  Report  was  made  after  an 
inspection  of  the  great  majority  if  not  the 
whole  of  the  workhouses  in  England 
and  Wales. 

Since  the  date  of  that  Report  there  has 
been  on  the  whole  a  steady  improvement 
in  the  arrangements  made  for  the  care  and 
custody  and  pi'oper  selection  of  such  in- 
sane persons  as  seem  fit  to  be  detained 
in  workhouses. 

The  periodical  visits  of  the  Commis- 
sioners in  Lunacj'',  and  the  inspectors  ap- 
pointed by  the  Poor  Law  Board  (now  the 
Local  Government  Board),  combined  with 
the  good  example  set  by  many  Boards  of 
Guardians,  have  done  much  to  elevate  the 
character  of  the  great  majority  of  work- 
houses, probably  of  all.  Many  have  made 
special  provision  in  wards  set  apart  for  the 
insane  with  properly  trained  attendants. 

The  battle  with  voluntary  pauperism 
having  been  won,  the  authorities  dis- 
covered that  there  existed  a  vast  number 
of  impotent  poor,  whose  impotence  arose 
through  no  fault  of  their  own  ;  this  view 
being  recognised,  increased  and  increasing 
attention  has  of  late  years  been  paid  to 
ameliorate  the  condition  of  this  class,  of 
which  improvement,  increased  accommoda- 
tion and  comfort,  with  better  nursing  and 
supervision  of  the  insane  inmates  form  no 
smallpart.  Thatthe  improvement  has  been 
general  and  satisfactory  may  be  inferred 
from  the  forty -third  report  of  the  Commis- 
sioners in  Lunacy,  in  which  they  say  of 
workhouses,  "We  are  able  to  give  on  the 
whole  a  fairly  satisfactory  report  of  the 
arrangements  and  provisions  made  in 
these  institutions  for  the  patients  who 
reside  in  them."  The  Report  further  says 
that  1 1,259  insane  persons  were  resident  in 
these  workhouses  on  January  i,  1891. 
This  number  is  probably  double  the 
number  resident  in  these  institutions  at 
the  time  when  the  Commissioners  in  their 
annual  report  gave  such  an  unfavourable 
account  of  their  treatment  and  condition. 

It  may  not  be  out  of  place  here  briefly 


Workhouses 


[     ^Zl^    ] 


Workhouses 


to  refer  to  the  legislation  affecting  paupers 
(including  the  insane)  and  their  reception 
and  treatment  in  workhouses. 

By  the  8  &  9  of  George  IV.  c.  40,  jus- 
tices might  require  overseers  to  furnish 
lists  of  insane  poor  when  mentioned,  and 
their  condition  certified  by  a  medical  prac- 
titioner. 

By  the  4  &  5  William  IV.  c  76,  sec.  45, 
1834,  DO  dangerous  lunatic  shall  be  kept 
in  any  workhouse  for  a  longer  period  than 
fourteen  days.  This  jarovision  was  no 
doubt  violated  for  many  years,  no  defini- 
tion of  the  word  dangerous  being  given. 

By  the  8  &  9  Vict.  c.  100,  sec.  3., 
Commissioners  are  directed  to  visit  and 
examine  the  insane  inmates  of  workhouses 
at  least  once  in  each  year.  By  the  16  &  17 
Vict,  these  j^owers  are  much  enlarged. 

By  the  16  &  17  Vict.,  pauper  lunatics, 
not  in  any  asylum,  but  residing  at  their 
own  homes,  are  to  be  visited  and  their  con- 
dition reported  on  once  in  each  quarter  by 
the  district  poor-law  medical  ofiicer.  For 
this  a  fee  is  paid.  The  medical  officer  of 
the  workhouse  is  to  make  a  like  return  as 
regards  the  insane  inmates  of  the  work- 
house, but  without  fee.  By  the  25  &  26 
Vict.  c.  3,  sec.  20,  the  form  of  the  list  as 
regards  the  workhouse  is  altered,  and  the 
medical  officer  is  required  in  each  case  to 
say  whether  it  is  a  fit  one  to  remain  in  the 
workhouse  or  not,  how  the  patient  is  em- 
ployed— if  restrained  or  not — and  whether 
the  accommodation  therein  is  or  is  not 
sufficient. 

By  the  25  &  26  Vict.  c.  3,  sec.  20, 
no  person  being  a  lunatic,  or  alleged 
lunatic,  shall  be  detained  in  any  work- 
house for  more  than  fourteen  days,  unless 
the  medical  officer  of  the  woi'khouse  shall 
certify  in  writing  that  he  or  she  is  a  pro- 
per person  to  be  detained,  and  that  the 
accommodation  is  sufficient. 

By  the  16  &  17  Vict.  sec.  67,  the  re- 
lieving officer  is  bound  after  receiving 
notice  that  a  pauper  residing  within  his 
district  is  insane,  within  three  days  to 
have  him  taken  before  a  justice  with  a 
view  to  his  removal  to  an  asylum.  This 
is  modified  by  the  48  &  49  Vict.,  which 
authorises  the  relieving-officer  to  remove 
such  joerson  to  the  workhouse  in  the  first 
instance,  where  he  may  be  further  detained 
provided  the  medical  officer  of  the  work- 
house shall  certify  in  writing  that  he  or 
she  is  a  fit  person  to  be  so  detained.  This 
might  be  done  without  the  intervention  of 
a  magistrate. 

By  the  Lunacy  Act  of  1890,  these 
provisions  are  modified.  The  relieving- 
officer  or  constable  may  still  remove  an 
insane  person  to  the  workhouse,  where  he 
may  be  detained  for  three  days,  at  the  ex- 


piration of  which  time  he  must  be  taken 
before  a  magistrate,  who  may,  if  he  thinks 
fit,  remit  the  case  to  the  workhouse.  For 
the  permanent  detention  of  an  insane 
pauper  in  any  workhouse,  the  magistrate 
must  have  the  certificate  of  the  medical 
officer  of  the  workhouse  (for  which  no  fee 
is  paid),  and  an  independent  medical  cer- 
tificate saying  the  case  is  a  suitable  one 
to  be  so  detained.  This  is  to  be  confirmed 
at  the  end  of  fourteen  days  by  the  certifi- 
cate of  the  medical  officer  of  the  work- 
house. This  magisterial  order  is  only 
in  force  for  fourteen  days,  unless  the 
medical  officer  shall  certify  that  it  is  a 
proper  case  to  be  detained,  in  which  case 
the  magistrate's  order  becomes  of  con- 
tinuing force. 

Such  are  the  provisions  now  in  force  as 
regards  the  detention  of  insane  persons 
in  workhouses.  It  will  be  seen  from  this 
brief  retrospect,  that,  stage  by  stage,  the 
legislature  has  shown  an  increasing 
desire  to  protect  the  liberty  and  promote 
the  protection  of  the  insane  pauper.  This 
contrasts  favourably  with  the  neglect  of 
the  early  part  of  the  century. 

Future  legislation,  will,  in  all  proba- 
bility tend  more  and  more  to  assimilate 
workhouses  in  all  that  relates  to  the  insane 
poor  with  asylums,  to  the  great  advantage 
of  the  insane  pauper  and  the  ratepayer. 
The  Commissioners  will  probably  reserve 
for  themselves  some  power  to  define  the 
sort  of  cases  which  each  workhouse  is  fit 
to  retain  ;  it  is  obvious  that  one  workhouse 
may  diS'er  widely  from  another  in  this 
respect.  The  Commissioners  in  Lunacy 
have  absolute  power  to  discharge  any  in- 
sane inmate  of  a  workhouse,  or  to  direct 
his  removal  to  an  asylum. 

A  brief  consideration  of  the  mental 
condition  of  a  large  proportion  of  the 
cases  which  come  under  the  observation 
of  the  medical  officers  of  everj'  large  work- 
house will  be  useful  and  will  enable  us  to 
deduce  some  reasons  why  a  much  greater 
use  might  be  made  of  our  woi-khouses  than 
has  hitherto  been  done  in  the  care  and  at 
least  preliminary  custody  of  large  groups 
of  the  insane. 

(i)  Large  numbers  of  men  and  women 
in  every  stage  of  dementia — ^arising  from 
the  numerous  forms  of  gross  brain  dis- 
ease. Paralysis,  softening  of  the  brain 
so-called — the  dementia  stages  of  epilepsy 
— the  dementia  due  to  alcoholic  and  sy- 
philitic poisoning,  and  lastly  every  form 
of  senile  decay. 

(2)  Imbecility  in  every  stage,from  simple 
weak-mindedness  to  idiocy.  Many  of 
these  cases  are  aggravated  in  their  aspect 
on  admission  by  drink,  want  of  food, 
fatigue,    and   general   privation.      Large 


Workhouses 


[    1373    ] 


Wud 


nwmbers  improve  under  the  iutiuonce  of 
warmth,  rest,  and  wholesome  food.  This 
includes  numerous  imbecile  and  epileptic 
children  of  all  ages. 

(3)  Cases  of  dementia  following  acute 
mania  or  melancholia,  for  the  most  part, 
persons  discharged  from  asylums. 

(4)  Cases  of  acute  excitement  of  a 
maniacal  character  due  to  alcohol.  A  small 
proportion  of  cases  of  active  insanity, 
mania  and  melancholia. 

No  one  familiar  with  the  condition  of  a 
large  proportion  of  persons  admitted  into 
workhouses,  especially  those  situated  near 
large  centres  of  population,  can  fail  to 
observe  the  inevitable  difficulty  of  dealing 
with  this  class  with  strict  adhesion  to  the 
letter  of  the  law.  The  mental  conditions, 
for  the  most  part  transitory,  set  up  by 
drink  and  want,  are  well  calculated  to 
mislead  an  officer  zealous  for  a  strict 
adhesion  to  legal  requirements  —  hence 
the  period  of  probation  allowed  under  the 
Act  of  1S90  becomes  most  valuable.  It 
would  have  been  well  and  of  great  advan- 
tage had  the  period  of  detention  under 
the  order  of  the  relieving-officer,  who  for 
the  most  part  acts  on  medical  advice,  been 
extended  from  three  days  to  seven  and  the 
medical  officers  been  bound  to  certify  in 
every  case.  In  this  way  the  somewhat 
hasty  manner  in  which  doubtful  cases  have 
to  be  dealt  with  would  have  been  to  a 
great  extent  avoided,  and  asylums  would 
have  been  less  likely  to  be  burdened  with 
a  class  of  cases,  needing  but  rest  and  good 
food,  than  they  are  under  the  hasty  action 
now  in  force.  Patients  in  the  independent 
class  are  never  sent  to  an  asylum  on  such 
brief  notice,  but  in  the  great  majority  of 
cases  abundant  time  is  taken  to  form  a 
correct  medical  opinion  as  to  the  nature 
and  prospects  of  the  case.  This  period 
of  probation  is  as  necessary  in  the  case 
of  the  indigent  poor  as  it  is  amongst  the 
self-maintaining  class. 

The  continued  increase  in  the  number 
of  rate-supported  asylums,  the  constant 
extension  of  others,  and  the  steady  in- 
crease in  the  population  detained  in  them 
is  likely  under  the  influence  of  the  re- 
presentative bodies  who  now  have  the 
management  of  these  institutions  to  lead 
to  some  inquiry  as  to  how  far  it  may  be  pos- 
sible to  reduce  the  cost  of  pauper  lunacy. 

A  very  superficial  inspection  of  every 
large  pauper  asylum  is  enough  to  satisfy 
a  skilled  observer  that  there  must  be 
hundreds  of  persons  retained  in  these  asy- 
lums who  do  not  require  the  special  organi- 
sation of  an  asylum  for  their  safe  custody 
and  care,  or  cure.  The  cost  of  the  erection 
of  an  asylum  is  of  necessity  great,  and 
its  maintenance   a  heavy  burden  on  the 


ratepayers.  Whilst  a  wise  philanthropy 
and  Christian  sympathy  alike  I'equire 
that  the  sick  and  afflicted  should  receive 
all  needful  care  and  comfort,  they  fail  to 
see  why  this  should  be  given  in  needless 
excess  to  one  group  of  cases  only,  long 
after  all  hope  of  cure  has  passed  away. 

The  victims  of  cancer,  rheumatism, 
phthisis,  and  a  host  of  other  disabling 
diseases  and  infirmities  seem  to  be  as 
deserving  of  and  to  require  as  much  com- 
fort as,  if  not  more  than,  a  hopeless  imbecile 
or  a  chronic  dement.  The  experience  of 
numerous  workhouses  has  abundantly 
shown  that  the  wants  of  this  class  of  in- 
sane persons  may  be  well  and  cheaply  met 
in  a  well-managed  workhouse.  It  seems 
most  probable  that  in  the  near  future  some 
effort  will  be  made  to  more  largely  utilise 
our  workhouses  or  other  economically  con- 
ducted institutions  as  a  relief  to  the  over- 
burdened asylums  than  has  hitherto  been 
done. 

No  one  who  is  familiar  with  the  legis- 
lation affecting  the  insane  during  the 
present  century  can  fail  to  be  satisfied 
that  it  has  on  the  whole  been  dictated  by 
prudence  and  benevolence,  and  that  it  has 
surrounded  an  afflicted  class  with  safe- 
guards and  comforts  which  do  credit  to 
our  liberality  and  Christian  charity.  The 
asylums  erected  and  managed  for  the  sole 
benefit  of  the  insane  poor  are  amongst 
the  noblest  institutions  of  any  age  or 
country.  In  recent  legislation  there  is  not 
wanting  evidence  to  show  that  in  the 
desire  to  maintain  the  liberty  of  the  sub- 
ject, the  fact  that  insanity  is  a  disease 
requiring  to  be  met  by  all  the  aid  which 
medical  science  can  bring  to  bear  upon  it, 
has  been  somewhat  forgotten.  There  need 
far  more  care  and  far  more  discretion  in 
dealing  with  the  cases  of  mental  disturb- 
ance which  come  under  the  cognisance  of 
the  Poor  Law  authorities.  There  seems  a 
prospect  that  an  immense  burden  will  be 
cast  upon  pauper  asylum  management  in 
mere  details  of  administration  ;  and  that 
the  exercise  of  medical  skillin  the  treatment 
of  this  disease  is  likely  to  be  replaced  by 
constant  and  wearing  attention  to  minute 
and  numberless  legal  details.  The  cause 
of  medical  science  and  its  full  and  free  ap- 
plication to  the  habits  of  the  insane  cannot 
fail  to  starve  under  too  minute  legal  restric- 
tions which  serve  only  to  hamper  that  free- 
dom of  action  without  which  the  full  benefit 
to  be  derived  from  treatment  is  impossible. 
The  tendency  of  the  legal  mind  in  its 
anxiety  to  protect  the  liberty  of  the  subject 
is  to  forget  the  fact  that  insanity  is  a  sick- 
ness as  little  amenable  to  legal  dicta  as 
fever  or  consumption.  S.  W.  North. 
"WUD  (Scotch).     Mad. 


Xanthopsia 


[     1374    ]        Zwangsvorstellungen 


X 


XANTHOPSIA  (^di'i^os.greenishyellow; 
o-jns,  vision).  Yellow  vision,  a  subjective 
visual  disturbance  due  to  the  ingestion 
of  certain  drugs — e.g.,  santonin.  The  dis- 
turbance is  evidently  central,  as  no  stain- 
ing of  the  ocular  media  has  been  ob- 
served, and  the  retina  betrays  only  a 
slight  hypereemia.  There  is  first  an  ex- 
aggerated appreciation  of  the  violet  spec- 
tral rays,  but  ultimately  the  reflection  of 
light  from  white  objects  is  tinged  yellow ; 
with  this  there  is  a  diminished,  or  even 
abolished,  appreciation  of  the  violet  rays 
of  the  spectrum.  Lassitude  and  mental 
depression  are    accompaniments  of    this 


condition,  and  if  the  drug  has  been  taken 
in  large  quantities,  tetanic  spasms  and 
coma  may  result.  This  visual  phenome- 
non is  said  to  occur  in  patients  suffering 
from  jaundice,  but  if  so  it  is  rare,  at  least 
in  a  highly  marked  form. 

XEXTEIiASZA  (^evrjXa(TLa,  from  ^evos,  a 
stranger ;  eXavvco,  I  expel  or  banish). 
There  was  a  law  among  the  ancient  Spar- 
tans thus  named,  by  which  strangers  of 
doubtful  reputation  or  morality,  were  ex- 
cluded from  their  society  for  fear  of  cor- 
rupting the  youth  and  contaminating  them 
with  foreign  vices.  It  was  essentially  a  law 
for  the  prevention  of  criminal  contagion. 


YOUia-G-HX:i.IVEHOX.TZ    THEORV. — 

A  theory  brought  forward  by  Young  and 
elaborated  by  Helmholtz  to  account  for  the 
quality  of  visual  colour  sensations.  Ac- 
cording to  it  there  are  three  fundamental 
colour  tones,  by  admixture  of  which  all 
colours  are  formed.  These  colour  tones 
are  green,  red,  and  violet.  It  is  then 
assumed  that  in  every  part  of  the  retina 


susceptible  to  colour  three  kinds  of  nervous 
elements  exist,  each  coi-responding  to  one 
of  the  above  three  sensations  of  colour. 
Every  colour  sensation  is  therefore  a  com- 
plex affair  whose  character  is  determined 
by  the  relative  intensities  of  excitation  of 
the  three.     (Ladd.) 

YOUTH,      INSANITY      IN.      {See 

Developmental  Ixsaxiiies.) 


ZEIiOTYPIA  iCr]Xos,  emulation  ;  tvtvos, 
impress  or  type).  A  morbidly  passion- 
ate zeal  in  mental  or  bodily  exertion.  (Fr. 
zeloty2ne.) 

ZITTER-WAHNSINN  (Ger.).  Deli- 
rium tremens. 

ZOANTHROFIA  (fwoi/,  an  animal ; 
<iv6punTos,  a  man).  A  melancholy  mad- 
ness with  fixed  ideas.  It  is  a  general 
name  for  those  forms  of  insanity  where  a 
man  imagines  himself  an  animal.  {See 
Cynanthropia  ;  Lycanthropia,  &c.)  (Fr. 
zoanthropie.) 

ZOANTHROPIC  »«:i.ANCHOI.IA. 
(»S'ee  Melaxcholla.  ZoA^TiuioficA  ;  Cvnax- 
THROPL^  ;  Lycanthropia.) 


ZOARA,  ZOARE. — Insomnia. 

ZO61VXACNETISIVI  {(oiov,  an  animal ; 
magnetism).     Animal  magnetism. 

ZObPSYCHOIiOGIA  {Cmov,  an  animal ; 
\//-u;^?},  the  mind  or  soul ;  \6yos,  a  discourse). 
The  doctrine  of  the  existence  of  the  mind 
in  animals.  (Fr.  zijopsycliologie ;  Ger. 
TJiierseelenkunde.) 

ZORN-WUTH  (Ger.).  Maniacal  fury, 
frenzy. 

ZWANGSBE-WECUNGEN  (Ger.). 
Compelled  movements. 

ZVrANGSJACKE,  ZWANGS- 

-WAMIVIS. — Strait-jacket. 

Z-WANGSVORSTEI.1.UNGEN  (Ger.). 
Imperative  ideas. 


APPENDIX. 


BRAZNT,  ikUiLTOIviV  OP. — The  ac- 
companying figure  (borrowed  by  kind  per- 
mission of  Dr.  Gowers  from  his  "  Diseases 
of  the  Nervous  System,"  vol.  ii.)  is  inserted 
here  to  iUustrate  the  description  given  on 
page  1 68  of  the  motor  and  sensory  types 
of  the  cerebral  cortex. 

The  drawings  were  made  from  frozen 
sections  of  the  fresh  brain  stained  by 
Bevan  Lewis's  method  with  aniline  blue 
black.  The  motor  type  is  tive-laminated, 
and  is  taken  from  the  ascending  frontal 
convolution  ;  the  sensory  type  shows  six 
layers,  and  is  taken  from  the  first  annec- 
tant  gyrus.  The  method  of  staining 
brings  out  the  connective  tissue  and 
nerve-cells  with  their  nuclei  and  nervous 
processes  so  long  as  these  are  uncovered 
by  myelin.  In  the  superficial  layer,  there- 
fore, we  see  merely  the  neuroglia  cells. 
The  layer  of  fibres  arranged  parallel  to 
the  surface,  and  the  felted  layer  under- 
neath it,  may  be  demonstrated  either 
by  Exner's  osmic  acid  method  or  by 
Weigert's  or  Friedmann's  haemotoxylin 
method. 

The  small  pyramid  layer  is  slightly 
thicker  than  the  superficial  layer.  Its 
cells  are  closely  compacted,  and  they  are 
surrounded  by  a  fine  network  of  medul- 
lated  fibres,  which  is  not  shown.  The 
third  layer  of  large  pyramids  is  rather 
more  than  twice  the  thickness  of  the 
small  pyramid  layer,  and  is  broader  in  the 
motor  than  in  the  sensory  area.  The  cells 
are  further  apart  from  each  other  than  are 
the  small  jjyi'amids.  They  normally  con- 
tain near  their  nucleus  yellowish  brown 
granular  pigment,  in  greater  or  less  quan- 
tity. Besides  their  apical  and  basal  pro- 
cesses, lateral  processes  arise  from  these 
and  from  the  body  of  the  cell,  and  pass  out- 
ward, dividing  dichotomously,  and  forming 
a  felt- work  loose  in  the  outer,  close  in  the 
inner  (Baillarger's  outer  stripe),  part  of 
the  lamina.  The  fibres  throughout  the 
lamina  begin  to  be  arranged  in  bundles 
directed  radially. 

The  ganglion-celled  layer  in  the  five- 
laminated  type  shows  the  mixed  character 
of  its  large  and  small  irregular  multipolar 
cells.  The  "  giant "  cells  of  Betz,  or  motor 
cells  of  Lewis,  are  seen  in  tlie  motor  type 
(left  hand) ;  but  are  absent  from  the  sen- 
sory tyi3e(right-handsection).  In  this  layer 


Vie.  I. 


JiicenJln^  Frontal 


ayQ'' 


■Si  I A 


mmM 
mm 


Laige  Pyrawid 
Layer 


^•M 


if.ai 


•i'^i) 


Mm 


mm 


Granule 
i-iyer ' 


Ganolion-Cell 
Layer. 


Risirona 


"ill' 


im 


Central  WWfe, 
SubstaJice 


1376 


APPENDIX. 


the  nerve-fibres  are  arranged  in  bundles 
radiating  outwards.   Between  the  bundles 


the  third  cortical  layer  of  the  ascending 
frontal  convolution.     We  are  indebted  to 


Fig.  2. 


A 


A. 


I:  0 


Third  cortical  layer  of  ascciuling-  frontal  convolution. 
H.  C.  M.  ad  nat.  del. 


X    200. 


in  the  outer  part  of  the  lamina  the  nerve- 
fibres  form  an  open  meshwork.  In  the 
inner  portion  they  are  closely  compacted 
so  as  to  form  a  stripe  visible  to  the  naked 
eye  (Baillarger's  inner  stripe).  The  gan- 
glion-celled layer  is,  in  the  motor  region, 
not  sharply  separated  from  the  large 
pyramid  layer ;  but  in  the  sensory  region 
the  granule  layer  lies  between  them.  In 
the  occipital  lobe  the  ganglion-cell  layer  is 
very  small,  and  is  almost  entirely  replaced 
by  the  granule  layer.  In  the  frontal  lobe 
the  granule  layer  is  present,  but  not  so 
well  developed  as  it  is  behind  the  motor 
region. 

The  fusiform  layer  presents  much  the 
same  appearance  in  both  motor  and  sen- 
sory regions.  Its  cells  are  separated  by 
bundles  of  fibres  passing  into  the  white 
matter  of  the  centrum  ovale. 

The  structure  of  the  cornu  Ammonis 
differs  materially  from  either  of  the  above 
types,  but  it  is  not  possible  to  describe  it 
in  the  space  allotted  to  anatomy. 

Fig.  2  shows  very  clearly  the  cells  of 


the  late  medical  superintendent  of  the 
Wakefield  Asylum,  Dr.  Herbert  Major, 
for  the  drawing.  Alkx.  Bruce. 

CONTRACTS  OP  IiUNATICS. — The 

judgment  of  Lord  Esher,  M.R.,  in  The 
hnperial  Loan  Company  v.  Stone  (1893, 
8  Times  L.  R.  408),  adds  an  impoi'tant 
rider  to,  if  indeed  it  does  not  materially 
modify,  the  doctrine  laid  down  in  2Ioidion 
V.  Camroux  (18  L.J.  Ex.  68).  The  facts 
were  as  follow :  The  plaintiffs  sued  to 
recover  the  balance  due  upon  a  ]  iromissory 
note  signed  by  the  defendant  as  surety. 
The  defendant  pleaded  that  when  he 
signed  the  note  he  was — as  the  jilaintif's 
v-ell  knew — of  unsound  mind,  and  inca- 
pable of  understanding  what  he  was  doing. 
The  action  was  tried  before  Mr.  Justice 
Denman  and  a  jury.  The  jury  found  that 
the  defendant  was  not  of  sane  mind,  but 
could  not  agree  as  to  whether  or  not  the 
plaintiffs  were  aware  of  the  fact.  There- 
upon Mr.  Justice  Denman  entered  judg- 
ment for  the  defendant,  being  of  opinion 
that  the  onus  lay  upon  the  plaintiffs  to 


APPENDIX. 


1377 


show  that  they  did  not  know  that  the 
defendant  was  of  unsound  mind.  This 
decision  was,  however,  revei'sed  by  the 
Court  of  Aj^peal,  and  the  judgment  of 
Lord  Esher  contained  the  following  re- 
markable passages  :  "  If  one  went  through 
all  the  cases,"  said  his  loi-dship,  ''and 
endeavoured  to  point  out  the  grounds  on 
which  they  rest,  one  would  get  into  a  maze. 
The  time  has  come  when  this  Court  must 
lay  down  the  rule.  In  my  opinion  the 
result  of  the  cases  is  this  :  When  a  person 
•enters  into  a  contract  and  afterwards 
alleges  that  he  was  insane  at  the  time  he 
entered  into  the  contract — I  mean  an 
ordinary  contract — and  that  he  did  not 
know  what  he  was  doing,  and  proves  that 
this  was  so  by  the  law  of  England,  that 
contract  is  as  binding  upon  him  in  every 
respect,  wliether  executed  or  executory,  as 
if  he  were  sane,  unless  he  can  prove  that 
at  the  time  he  made  the  contract  the 
plaintiff  knew  that  he  was  insane,  and 
so  insane  as  not  to  know  what  he  was 
about."  A.  Wood  Renton. 

GAI.I.-STON-Z:S  XN   THE   XlXSAJIJi. 

— At  the  Quarterly  Meeting  of  the  Medico- 
Psychological  Association,  May  19,  1892, 
Dr.  Beadles  (Colney  Hatch  Asylum)  read 
a  paper  with  this  title.  He  found,  out  of 
fifty  consecutive  post-mortems  performed 
on  female  lunatics,  that  gall-stones  were 
present  in  eighteen  cases — i.e.,  thirty-six 
per  cent.     He  does  not,  however,  maintain 


that  insanity  is  a  cause  of  their  occurrence. 
Other  factors  have  to  be  considered.  On 
inquiry  he  was  not  able  to  find  that  gall- 
stones are  at  all  frequent  among  male 
lunatics.  Amongthe  cases  above  mentioned 
there  was  not,  as  might  perhaps  have  been 
anticipated,  a  larger  ])roportion  of  melan- 
choliacs.  It  must  be  remembered  that 
among  the  sane  gall-stones  are  much 
more  frequent  in  the  female  than  the 
male  sex.* 

UTEBRIATE  RETREiiTS. — The  ex- 
tent to  which  institutions  have  been  estab- 
lished under  the  Inebriates  Acts,  1879, 
1888,  is  very  limited,  as  will  be  seen  from 
the  following: — 

Dalrymple  House,  Eickmansworth, 
Hertfordshire. 

St.  Veronica's  Retreat,  Chiswick. 

High  Shot  House,  Twickenham. 

Old  Park  Hall,  Walsall,  Stafford- 
shire. 

Tower  House  Retreat  and  Sanatorium, 
Westgate-on-Sea,  Kent. 

The  Grove,  Fallowfield,  near  Manches- 
ter. 

They  are  licensed  to  receive  100  persons, 
but  there  are  only  about  60  inmates. 
Compulsory  powers  are  required  to  render 
the  "Inebriates  Act,"  18S8,  a  success. 
{See  Habitual  Drunkards,  Legislation 
Affecting.) 

XRRSIM'M'. — Idiopathic,  constitutional 
and  organic  psychosis. 


Masters  to 
make  orders. 


Appeal  from 
orders  of 
Masters. 
Forms  2,  3. 


RVIiES  IN"  IiUNACY. — The  Rules  in  Lunacij,  1892,  came  into  operation  on 
March  i,  1892,  and  from  that  date  the  rules  of  1890  and  the  orders  of  March  5  and 
of  August  1891  are  annulled.f  The  rules  of  1892  are  in  the  main  a  consolidation  of 
the  old  rules  (see  Changeky  Lunatics).     The  following  provisions  and  forms  are  new  : 

The  Masters. 

10.  The  masters  may  make  orders  as  regrards  administration  and  manage- 
ment, and  they  may  direct  by  whom  and  in  what  manner  the  costs  of  any 
proceedings  are  to  be  paid. 

1 1.  Any  person  affected  by  any  ordei",  decision,  or  certificate  of  a  master 
may  appeal  therefrom  to  the  judge  without  a  fresh  summons,  upon  giving 
notice  of  appeal  within  eight  days  from  the  date  of  the  ordei',  decision,  or 
certificate  complained  of,  or  such  further  time  as  may  be  allowed  by  the 
judge  or  master.  The  notice  of  appeal  shall  be  given  to  the  persons,  if 
any,  interested  in  supporting  the  order,  decision,  or  certificate,  and  a  copy 
thereof  shall,  within  the  aforesaid  period  of  eight  days,  be  left  at  the 
masters'  office,  and  the  masters  shall  thereupon  bring  the  matter  before 
the  judge. 

14.  The  masters  shall  inquire  into  the  circumstances  of  any  delay  in 
the  conduct  of  proceedings  before  them  or  in  proceeding  upon  their  orders, 
certificates,  and  directions,  and  for  that  purpose  may  call  before  them  all 
parties  concerned,  and  may  certify  accordingly  where  it  seems  to  them 
expedient. 

54.  In  any  case,  where,  pending  the  appointment  of  a  person  to  exercise 
in  relation  to  the  property  of  a  person  of  unsound  mind  not  so  found  by 
inquisition  any  of  the  powers  of  a  committee  of  the  estate,  it  appears  to 
the  masters  desirable,  that  temporary  provision  should  be  made  for  the 
expenses  of  the  maintenance,  or  other  necessary  purposes  or  requirements 
•of  the  lunatic,  or  any  member  of  his  family,  out  of  any  cash  or  available 

*  Sec  Journal  of  Mental  Science,  July  1892.         t  Aud  see  Lunacy  Act  of  1891  (54  &  55  Vict.  c.  65). 


Jlasters  to 
inquire  into 
delay. 


Temporary 
provision  for 
mainten- 


1378 


APPENDIX. 


securities  belonging  to  him  ia  the  hands  of  his  bankers  or  of  any  other 
person,  the  masters  shall  be  at  liberty  by  certificate  to  authorise  such 
banker  or  other  jDerson  to  pay  to  the  person  to  be  named  in  such  certificate 
such  sum  as  they  certify  to  be  proper,  and  may  by  such  certificate  give 
any  directions  as  to  the  proper  application  thereof  by  that  person,  who 
shall  be  accountable  for  the  same  as  the  masters  direct. 

55.  In  all  cases  not  otherwise  herein  specially  provided  for,  the  provisions 
of  these  rules  relating  to  lunatics  so  found  by  inquisition  and  the  other 
general  provisions  of  these  rules  shall  apply  to  applications  relating  to  the 
l^roperty  of  persons  of  unsound  mind  not  so  found  by  inquisition,  except 
that  the  certificate  referred  to  in  Rule  32  shall  not  be  made,  and  that  the 
masters  may  make  orders  appointing  persons  to  exercise,  in  relation  to  the 
property  of  persons  of  unsound  mind  not  so  found  by  inquisition,  the  powers 
of  a  committee  of  the  estate. 


Provisions 
as  to 

lunatics  so 
found  by 
iuquissition 
to  apply. 


Applica- 
tions as  to 
persons 
incapable 
tlirough 
disease  or 
ase  of  man- 
aprin?  their 
affairs. 
Forms  10, 


Ap2)lications  as  to  Fersons  mentioned  in  s.  116(1)  (cZ)  of  the 
Lunacy  Act,  1890,  not  being  lunatic. 

56.  The  provisions  of  these  rules  as  to  persons  of  unsound  mind  not  so 
found  by  inquisition  shall  apply  to  applications  respecting  the  property 
of  any  person  who  though  not  a  lunatic  is  through  mental  infirmity  arising 
from  disease  or  age  incapable  of  managing  his  affairs. 


Masters  to 
keep  a 
register  of 
Committees 
and  Ee- 


Master  to 
inform  Com- 
mittees of 
person  of 
allowance 
for  main- 
tenance. 

Committee 
of  person  to 
report  to 

Visitors  as 
to  expendi- 
ture. 


Committee 
of  person  to 
report  to 
Visitors  as 
to  healtli  of 
lunatic. 


Power  to 
Visitors  to 
summon 
Committee 
of  person. 


74.  The  masters  shall  keep  a  book  or  books,  in  which  shall  be  made,  in 
respect  of  every  committee,  receiver,  or  other  person  liable  to  account,  entries 
showing  in  a  tabular  form  the  following  particulars,  that  is  to  say : — 

(i)  The  title  of  the  matter. 

(2)  The  names   of  the  committees,  receivers,  or  other  persons  liable  to 

account. 

(3)  The  date  fixed  for  the  delivery  of  accounts  or  of  affidavits  in  lieu  of 

accounts. 

(4)  The  date  in  each  successive  year  when  the  accounts  or  affidavits  are 

delivered  into  the  master's  office. 

(5)  The  date  in  each  successive  year  when  the  accounts  are  passed. 

(6)  The  balance  or  sum,  if  any,  in  each  successive  year  directed  to  be 

paid  into  Court  by  the  committee,  receiver,  or  other  jjerson  liable 
to  account. 

(7)  The  date  fixed  for  the  last-mentioned  payment. 

(8)  The  date  of  the  actual  payment  into  Court. 

(9)  The  dates  of  all  orders  made  in  the  particular  matter,  and  also  such 

other  particulars  as  the  Lord  Chancellor  may  from  time  to  time 
by  writing  direct. 

106.  The  masters  shall  inform  the  committees  of  the  person  upon  their 
appointment  of  the  annual  amount  allowed  for  the  maintenance  of  the 
lunatic,  or  shall  supply  them  with  a  copy  of  the  scheme  for  maintenance, 
where  a  scheme  has  been  ]irovided. 

107.  Each  committee  of  the  person  of  a  lunatic  shall  annuallj^  or  from 
time  to  time  and  as  often  as  may  be  required  of  him  render  to  the  board  of 
visitors  an  accurate  statement  in  writing  of  the  various  sums  expended  by 
him,  the  better  to  enable  the  visitors  to  ascertain  and  rejDort  whether  the 
lunatic  is  being  suitably  maintained  and  whether  any  additional  comforts 
can  be  provided  for  him.  The  visitors  may  dispense  wholly  or  partially 
with  the  requirements  of  this  rule  if  in  any  case  they  think  it  desirable 
so  to  do. 

108.  Each  committee  of  the  person  of  a  lunatic  shall  half-yearly  make 
a  report  to  the  board  of  visitors  as  to  the  mental  and  bodily  health  of 
the  lunatic.  ]f  there  is  a  medical  attendant  of  the  lunatic  such  medical 
attendant  shall  either  countersign  the  report  of  the  committee,  or  shall 
make  a  separate  report  which  shall  accompany  that  of  the  committee  to 
be  forwarded  direct  to  the  board  of  visitors. 

109.  The  board  may  summon  the  committee  of  the  person  of  the 
lunatic  to  attend  before  them  and  to  give  such  information  in  his  possession 
relating  to  the  lunatic  as  they  may  require. 


APPENDIX.  1379 


129.  The  following  fees  shall  be  payable  in  respect  of  proceedings  under  Fees, 
the  Lunacy  Acts,  1890  and  1891  : — 
In  addition  to  the  old  fees  on  certificates  and  attendances,   and  the  fee 

of  £,z  on  every  order,  the  following  fees,  where  the  clear  annual  income 

of  the  person  to  whose  property  the  order  relates  amounts  to  ^100  and 

upwards  : 

is.    ,J. 

(a)  On  an  order  authorising  a  particular  lease  an  amount 

equal  to  one-fourth  the  stamp  duty  payable  on  the 
lease ; 

(b)  On  an  order  authorising  a  sum  of  money  to  be  raised 

by  mortgage  or  charge  for  every  ^100  or  fraction  of 

^100  of  the  amount  to  be  raised  .         .         .         .020 

((')  On  an  order  approving  or  authorising  a  contract  for  sale 
of  any  property  for  ever^'  ^100  or  fraction  of  ^100  of 
the  amount  of  the  purchase  money      .         •         .         .020 
{d)  On  an  order  authorising  a  sale  by  auction  where  the 
reserve  price  is  fixed  or  approved  by  the  masters  for 
every  ;({^ioo  or  fraction  of  /,ioo  of  the  amount  of  the 
reserve  price  .         .         .         .         .         .         .         .020 

(e)  On  an  order  conferring  a  general  authority  to  sell  or 

grant  leases  .         .         .         .         .         .         .         .  10     o     o 

Provided  that  the  fees  payable  under  the  heads  a,  b,  c,  and  d,  shall  not 
exceed  ^^lo. 

Provided  also  that  the  fees  payable  under  the  heads  a,  b,  c,  d,  and  e 
shall  not  be  payable  upon  any  order  made  while  percentage  is  payable 
upon  the  income  of  the  person  to  whose  property  the  order  relates. 


THE  SCHEDULE 
Keferred  to  in  the  Foregoing  Rules. 


FoKM  1. 
Title  of  Proceedings. 

(a)  Application  as  to  alleged  lunatic  : — In  lunacy  :  In  the  matter  of 
A.B.,  a  person  alleged  to  be  of  unsound  mind. 

(b)  Application  as  to  lunatic  so  found  by  inquisition  : — In  lunacy  :  In 
the  matter  of  A.B.,  a  person  of  unsound  mind. 

(c)  Application  as  to  lunatic  not  so  found  by  inquisition  : — In  lunacy  : 
In  the  matter  of  A.B.,  a  person  of  unsound  mind  not  so  found  by  inquisi- 
tion, 

(d)  Application  in  lunacy  and  in  the  Chancery  Division  : — In  lunacy 
and  in  the  High  Court  of  Justice,  Chancery  Division  :  In  the  matter  of 
A.B.,  a  person  of  unsound  mind  {or  (is  the  case  vwij  be). 

(e)  Application  as  to  person  through  mental  infirmity  arising  through 
disease  or  age  incapable  of  managing  his  afi"airs  :  In  the  matter  of  A.B-, 
and  in  the  matter  of  the  Acts  53  Vict.  c.  5,  and  54  &  55  Vict.  c.  65. 

(/)  Application  for  vesting  order  :  —In  lunacy  :  In  the  matter  of  the 
trusts  of  an  indenture  dated  the  and  made 

between  and  .     In  the 

matter  of  A.B.,  a  person  of  unsound  mind  (or  (is  the  case  matj  be),  and  in 
the  matter  of  the  Lunacy  Acts,  1890  and  1891. 


Form  2. 

Notice  of  Appeal  from  an  Ouuek  of  a  Master. 

[Insert  the  Title  of  the  Froceedings.'] 

Take  notice  that  of  desires  to  appeal 

to  the  judge  from  the  order  of  the  master  made  in  this  matter,  dated  the 
[if  Ijart  onhj  is  uppcided  from  (uhl :  so  far  as  it 
directs  that  ]. 

4T 


13S0  APPENDIX. 


And  that  he  intends  to  ask  that  the  said  order  may  be  discharged  [or 
varied]  and  that  it  may  be  ordered  that 
Dated  the  day  of 

(Signed) 
To  ,  Solicitors  for 

and  to  Messrs. 
his  solicitors. 

FoRJi  3. 
Notice  of  Appkal  i'koii  a  Certificate  of  a  Master. 

[Insert  the  Title  of  the  Proceedings.'] 

Take  notice  that  of  intends  to 

appeal  from  the    certificate  of   the  master   made  in   this  matter,  dated 
the 

And  that  he  intends  to  ask  that  the  said  certificate  may  be  varied  as 
follows  :  istate  the  variation]. 

And  that  such  consequential  directions  may  be  given  or  corrections  and 
alterations  made  in  the  said  certificate  as  may  be  necessary. 

Dated  the  day  of 

(Signed) 

To  ,  Solicitors  for 

and  to  Messrs. 
his  Solicitors. 


FoKii  10. 

Notice  to  Person  through  Mental  IxpiRMiTr  arising  froji  Disease 
OR  Age  incapable  of  Managing  his  Affairs. 

llr.A.B., 

Take  notice  that  a  summons,  of  which  a  copy  is  within  written,  was  on 
the  day  of  issued  by  me  {or  by  G.B. 

of  ),  and  that  in  pursuance  thereof,  orders  may 

be  made  on  the  ground  that  you  are,  through  mental  infirmity  arising  from 
disease  [or  age],  incajiable  of  managing  your  affairs,  for  the  purpose  {state 
the  purpose) — e.g.,  of  rendering  your  property,  or  the  income  thereof,  avail- 
able for  the  maintenance  or  benefit  of  yourself  [or  of  yourself  and  your 
family,  or  for  carrying  on  your  trade  or  business],  and  that  if  you  intend 
to  object  to  such  orders  being  made  notice  of  such  objection  must  be  signed 
by  you  and  attested  by  a  solicitor,  and  filed  at  Room  No.  at  the  Royal 
Courts  of  Justice,  Loudon,  within  seven  clear  days  after  your  receipt  of 
this  notice. 

Dated  the  day  of 

(Signed)  C.B., 

(or)  xr., 

Solicitor, 

Form  ii. 

Notice  of  Ojuection  by  Person  through  Mental  Infirmity  arising 
FROM  Disease  or  Age  incapable  of  Managing  his  Affairs. 

I,  A.B.,  of  ,  having 

been  served  with  a  notice  of  a  summons  for  an  order  respecting  my  pro- 
perty under  the  Acts  53  Vict.  c.  5,  and  54  &   55   Vict.  c.  65,   hereby  give 
notice  of  my  intention  to  object  to  such  order  being  made. 
Dated  the  day  of 

A.B. 
Witness, 
M.N., 

Solicitor. 

A.  Wood  Renton. 


APPENDIX. 


1381 


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BCBS^^OccHOPSa-H:^       WOO 


BIBLIOGRAPHY. 

In  compiling  the  following  Bibliography,  illustrative  of  the  history  of  the  literature  of 
insanit}',  the  writer  has  been  fully  aware  of  the  difficulties  of  the  task.  In  the  first 
place,  it  could  not  have  been  accomplished  at  all,  without  the  generous  co-operation 
of  those  who  were  interested  in  the  subject  and  who  rendered  valuable  assistance. 
In  the  second  place,  it  was  necessary  to  keep  it  within  the  limits  imposed  by  the 
general  scheme  of  the  Dictionary.  The  Bibliography,  therefore,  is  confined  to  works 
written  in  the  English  language,  and  does  not  include  what  has  appeared  in  journals 
devoted  to  this  special  subject.  But,  although  this  broad  rule  was  laid  down  as  funda- 
mental, it  will  be  found  that  certain  important  reprints  and  articles  are  named ;  and  a 
Catalogue  of  the  psychiatric  periodicals  of  the  world  is  appended. 

The  reader  will  find  references  attached  to  the  articles  in  the  body  of  the  Dictionary. 
which  will  in  some  measure  remedy  the  inevitable  omissions  for  which  the  writer  craves 
indulgence. 

To  those  in  search  of  further  information  it  may  be  stated  that  references  and  authori- 
ties will  be  found  in  these  valuable  works  : — 

BibUotheca  Britannira,  a  general  index  to  British  and  Foreign  Literature,  by  Dr.  R. 
Watt,  4  vols.  4to,  Edin.  1824.  The  first  and  second  volumes  give  authors  ;  the  second 
and  third  give  subjects. 

Also  the  Indeo:  Cataloj/ice  of  the  library  of  the  Surgeon  General's  Office  of  the  United 
States  Army.  Published  under  the  superintendence  of  Dr.  J.  S.  Billings,  during  the  last 
decade.     Vol.  vi.  contains  "  Insanity,"  with  very  full  references  to  periodical  literature. 

Besides  the  British  Museum,  there  are  various  medical  Libraries  of  the  first  importance. 
The  library  of  the  Faculty  of  Physicians  and  Surgeons  in  Glasgow  is  specially  rich  in  old 
works,  and  a  very  complete  Catalogue  is  published  by  Alexander  Duncan,  B.A.,  London, 
librarian  of  the  Faculty  ;  4to,  Glasgow,  1885.     It  is  preceded  by  an  index  of  subjects. 

The  Library  of  the  Royal  College  of  Surgeons,  England ;  and  the  Library  of  the  Royal 
College  of  Physicians,  Edinburgh,  are  now  in  the  process  of  being  catalogued  under 
authors  and  subjects.  Both  libraries  are  worthy  of  the  distinguished  corporations  to 
which  they  belong. 

The  Medical  Di</est  by  Dr.  Neale  is  indispensable  in  searching  for  information  regard- 
ing what  has  been  written  during  the  last  fifty  years. 

The  Journal  of  Mental  Science,  which  has  been  published  regularly  since  1853,  contains 
many  valuable  papers,  reviews  and  very  complete  references  (Index  Medico-Psychologicus, 
&c. )  to  the  current  literature  of  insanity.  As  a  detailed  index  to  the  contents  is  now 
being  prepared  by  Dr.  Rayner,  in  addition  to  that  by  Dr.  Blaudford  (published  in  1879), 
the  stores  of  information  contained  in  the  Journal  will  be  much  more  accessible. 

The  periodical  published  for  the  Neurological  Society  of  London,  Brain  ;  and  also  Mind, 
which  is  described  as  a  Quarterly  Review  of  Psychology  and  Philosophy,  are  the  other 
English  magazines  in  this  sphere. 

The  quarterly  Bulletin  of  the  Societe  de  la  Medecine  Mentale  of  Belgium  is  valuable 
in  indicating  the  current  course  of  continental  work  ;  while  for  standard  information 
regarding  foreign  bibliography,  these  works  may  be  named: — '•Versuch  einer  Literar- 
geschichte  der  Pathologie  und  Therapie  der  psychischen  Krankheiten,"  by  Dr.  J.  B.  Fried- 
reich, 1830;  "  Le(;ons  Orales  sur  les  Phrtjnopathies,"  by  Di\  J.  Guislain  (2nd  ed.  by 
Dr.  Ingels),  1880;  "  Dictionnaire  encyclopedique  des  Sciences  Medicales,"  publi<^  par 
Dechambre,  1864-78. 

There  is  no  mention  of  ^Isi/lum  Beports  in  this  Bibliography.  They  are  published 
annually  by  nearly  all  the  institutions  of  this  country.  Sometimes,  but  of  late  more  rarely, 
they  have  included  scientific  expositions  on  diet,  and  kindred  subjects.  The  recent  tend- 
ency, however,  is  to  reserve  scientific  discussions  for  scientific  journals  ;  and  to  deal  with 
the  events  of  the  asylum  year  from  a  popular  or  domestic  point  of  view.  The  laborious 
statistics  appended  to  these  reports  still  await  resurrection  and  orderly  arrangement. 

The  Beports  of  the  Commissioners  in  Lunacy  for  England,  Scotland,  and  Ireland  are 
published  annually,  and  are  documents  of  the  first  importance.  A  general  index  to  these 
Blue  Books  would  be  valuable,  but  too  lengthy  for  insertion  here. 

Certain  of  the  Reports  of  the  Committees  of  Liinacy  of  the  British  Colonies  and  of  the 
I'nited  States  are  useful  discussions  on  the  present  condition  of  asylums  and  the  insane. 


i;iJ5LI0GKAPHY. 


li'^S 


For  instance  the  fifth  Kepoit  (1887)  of  the  Pennsylvania  Committee  is  an  ample  volume 
profusely  illustrated  with  plans.  These  works  are  so  numerous,  however,  that  only  a  few 
of  the  more  important  are  named  in  this  Bibliography. 

The  English  literature  of  insanity  assumes  a  specialised  form  about  the  end  of  the 
eighteenth  century,  and  it  will  be  observed  that  public  interest  in  the  subject  varies  much 
from  time  to  time.  Although  tliere  is  a  sj^rinkling  of  books  from  the  end  of  the  sixteenth 
•century  onwards,  it  is  really  since  the  beginning  of  the  century  that  the  bulk  of  the 
literature  increases. 

The  general  treatises  of  a  few  authors  who  dealt  with  insanity  in  some  special  way, 
are  named  here,  but  the  ordinary  routine  authorities  in  medicine  need  not  be  cited.  It  is 
unnecessary  to  print  the  names  of  Hippocrates,  Aretaeus  and  Galen  in  this  connection. 

The  i)lan  of  the  Bibliograj'hy  is  chronological.  Under  each  year  are  placed  the  names 
of  tlie  authors  in  alphabetical  ordei',  with  the  titles  of  their  works. 

It  is  to  be  noted  that,  unless  otherwise  stated,  all  the  works  named  have  been  pub- 
lished in  London,  and  that  the  size  is  octavo. 

The  following  contractions  are  used  : — 


B.  M.  J. — British  Medical  Journal. 

D.  M.  J.— Dublin  Medical  Journal. 

E,  M.  J.— Edinburgh  Medical  Journal. 
G.  M.  J. — Glasgow  Medical  Journal. 
111.— Illustrated. 

L. — The  Lancet. 


M.  T.  &  G. — Medical  Times  and  Gazette. 
N.  D. — No  date  of  publication  given. 
N.  P. — No  place  of  publication  given. 
P. — Pamphlet  under  100  pages. 
P.  P. — Privately  printed. 
Trans. — Translation. 


Other  contractions  are  self-explanatory. 


1584.— Scot,  Reginald.— The  discoverie 
of  witchcraft  wherein  the  lewde  dealing 
of  witches  and  witchmongers  is  notablie 
detected,  &c.  &c. 

1586.  Bright,  T. — A  treatise  of  melan- 
cholic, containing  the  causes  thereof — 
with  the  phisicke,  care  and  spirituall 
consoUation  for  such  as  have  thereto 
adjoyned  an  afflicted  conscience.  (Also 
1613.)     i2mo. 

1621.  Burton,  R.— The  Anatomy  of  Mel- 
ancholy. 

1640.  Fekeand,  J.— Erotomania,  EPiiTO- 
MA2^  lA,  or  a  treatise  discoursing  of  the 
essence,  causes,  symptoms,  prognosticks, 
and  cure  of  love,  or  erotique  melancholy. 
(Trans,  fr.  French  by  Ed.  Chilmead.) 
Oxford. 

1648.  Donne,  John.— BIAOANATOS  ;  a 
declaration  of  that  paradoxe  or  thesis, 
that  selfe  homicide  is  not  so  naturally 
sinne  that  it  may  never  be  otherwise,  &c. 
4to. 

1649.  BuLWEE,  J. — Pathomyotomi ;  or  a 
dissection  of  the  muscles  of  the  alt'ec- 
tions  of  the  mind. 

1662.  Helmont,  J.  B.  Van.— Oriatrike, 
or  physic  refined.     Fol. 

1666.  Harvey,  G. — Morbus  Anglicus,  or 
the  anatomy  of  consumption  with  dis- 
courses on  melancholy  and  madness 
caused  by  love. 

1682.  "Willis,  Thomas. — Opera  omnia. 
4to.  Amst. 

1689.  Harvey,  G.— The  art  of  curing 
diseases  by  expectation  ;  with  remarks 
on  a  supposed  great  case  of  Apoplectick 
Fits.     32mo. 

1695.  Ridley,  H. — The  anatomy  of  the 
brain,  containing  its  mechanism  and 
physiology  together  with  some  new  dis- 
coveries and  corrections  of  ancient  and 
modern  authors,  upon  that  subject.  To 
which  is  annexed  a  particular  account 
of  animal  functions  and  muscular  mo- 


tion.    The  whole  illustrated  with  sculp- 
tures after  life.     lUus. 

1700.  Brydall,  John  (of  Lincoln's  Inn). — 
Non  Compos  Mentis ;  or  the  law  relating 
to  natural  fools,  mad  folks,  and  lunatick 
persons. 
Herwig,  H.  M.— The  art  of  curing  sym- 
pathetically or  magnetically  proved  to 
be  most  true,  with  a  discourse  concern- 
ing the  cure  of  madness,  and  an  appendix 
to  prove  the  reality  of  sympathy.  (Trans, 
fr.  Latin.)     i2mo, 

1705.  FalLOWES,  T. — 'H  /cpaTtcrrr?  tojv  /jL€- 
Xayxo^i^v  tuv  kul  fiaivofievui'  larpeia  ;  or 
the  best  method  for  the  cure  of  lunatics. 
With  some  account  of  the  incompar- 
able Oleum  Cephalicum  used  in  the  same. 

1711.  Mandeville,  B.  De.— A  treatise  of 
the  hypochondriack  and  hysterick  pas- 
sions. 

1717.  Blakeway,  R. — An  essay  towards 
the  cure  of  melancholy. 

1722.  Anon.— A  description  of  Bedlam 
with  an  account  of  its  present  inhabit- 
ants both  male  and  female.  To  which 
is  subjoined  an  essay  upon  the  nature 
causes  and  cure  of  madness. 

1723.  Perry,  Charles. — On  the  causes 
and  nature  of  madness.  As  also  the 
natures  and  properties  of  opium  and 
volatiles  considered  in  a  remonstrance 
to  Dr.  Herm.  Lufneu,  on  his  behaviour 
touching  a  late  case.  To  which  is  added 
a  postscript.     P. 

1725.  Blackmore,  R.— Treatise  of  the 
spleen  and  vapours,  or  hypochondriacal 
and  hysterical  affections.  With  three 
discourses  on  the  nature  and  cure  of  the 
cholick,  melancholy  and  palsies. 

1729.  Robinson,  N.— A  new  system  of  the 
spleen,  vapours  and  hypochondriacal 
melancholy,  wherein  all  the  decays  of 
the  nerves  and  lowness  of  the  spirits  are 
mechanically  accounted  for  ;  to  which  is 
subjoined   a   discourse   on   tlie    nature, 


1384 


BIBLIOGKAFHY. 


cause,  and  cure  of  melancholy,  madness 
and  lunacy. 

1730.  Mandeville,  B.— A  treatise  of  the 
hypochondriack  and  hysterick  diseases. 
In  three  dialogues.     2nd  ed. 

1733.  Chey^e,\t.— The  English  malady 
or  treatise  of  nervous  disease  of  ail 
kinds.     (5th  ed.  1735.) 

1742.  Cheyxe,  G.— The  natural  method 
of  cureing  the  diseases  of  the  body,  and 
the  disorders  of  the  mind  depending  on 
the  body.  Pt.  i.  General  reflections 
on  the  oeconomy  of  nature  in  animal  life. 
Pt.  2.  The  means  and  methods  for  pre- 
serving life  and  faculties.  Pt.  3.  Ee- 
flections  on  nature  and  cure  of  chronical 
distempers. 

1746.  Frings,  p. — A  treatise  on  Phrensy. 
(Trans,  fr.  Latin.) 
Mannixgham,  Sir  K. — The  symptoms, 
nature,  causes  and  cure  of  the  febricula 
or  nervous  or  hysteric  fever,  vapours, 
hypo,  or  spleen. 

1748.  Mead,  E. — A  treatise  concerning 
the  influence  of  the  sun  and  moon  upon 
human  bodies,  and  the  diseases  thereby 
produced.  (Trans,  from  Latin  by  T. 
Stack.) 

1755.  Billings,  P. — Folly  predominant, 
with  a  dissertation  on  the  impossibility 
of  cuiing  lunatics  in  Bedlam. 
Mead,  T. — Medica  Sacra  ;  or  a  comment- 
ary on  the  most  remarkable  diseases 
mentioned  in  the  Holy  Scriptures. 
(Trans,  hj  T.  Stack.) 

1758.     Battie,    W. —  A   treatise  on  mad- 
ness.    4to. 
Haller,  a.  von. — Medical  Cases. 
Monro,    J.  —  Eemarks    on    Dr.    Battle's 
treatise  on  madness.     i6mo. 

1765.  Whytt,  E.— (i)  Observations  on  the 
dropsy  in  the  brain,  experiments  with 
opium,  lime  water,  and  the  effects  of 
blisters.  (2)  Observations  on  the  nature, 
causes  and  cure  of  those  disorders 
which  have  been  commonly  called  nerv- 
ous, hypochondriac  or  hysteric.  To 
which  are  prefixed  some  remarks  on  the 
sympathy  of  nerves.    Edin.     (Also  1768.) 

1774.  Brucksiiaw,  S.—  One  more  proof  of 
the  iniquitous  abuse  of  private  mad- 
houses. 

1776.  Wilson,  A.— Nature  and  origin  of 
hysteria. 

1777.  PoMJiE,  P.— On  hysterical  and 
hypochondriacal  disease.     (Trans.) 

1779.  EOBINSON,  N.— On  the  spleen, 
vapours  and  hypochondriack  melan- 
choly. 

1780.  Fawcett,  B.— Observations  on  the 
causes  and  cure  of  melancholy,  espe- 
cially of  that  which  is  commonly  called 
religious  melancholy.     Shrewsbury. 

1782.  Arnold,  T. — Observations  on  the 
nature,  kinds,  causes  and  prevention  of 
insanity.  2  vols.  Leicester.  (2nd  ed. 
Lond.  1806.) 

1783.  Anon. — An  historical  account  of  the 
origin,  progress,  and  present  state  of 
Bethlem  Hospital.     4to. 


Monro,  A.  (2)  —  Ob.servations  on  the 
structure  and  functions  of  the  nervous 
system.     111.     Fol.     Edin. 

1787.  Perfect,  W. — Methods  of  cure  in 
some  cases  of  insanity,  epilepsy,  &c. 
Eochester. 

Perfect,  W. — Select  cases  in  the  different 
species  of  insanity,  lunacy  or  madness, 
with  the  modes  of  practice  as  adopted 
in  the  treatment  of  each.     Eochester. 

1788.  Falconer,  W. — Influence  of  the 
passions  upon  disorders  of  the  body. 

EpwLEY,  W. — Treatise  on  female  nervous, 
hysterical,  hypochondriacal,  convulsive 
diseases,  apoplexy  and  palsy,  with 
thoughts  on  madness,  suicide,  &c. 

1789.  Faulkner,  B. — Observations  on  the 
general  and  improper  treatment  of  in- 
sanity, with  a  plan  for  the  more  speedy 
and  effectual  recovery  of  insane  persons. 
P. 

Harper,  And. — A  treatise  on  the  real 
cause  and  cure  of  insanity,  in  which  the 
nature  and  distinctions  of  this  disease 
are  fully  explained,  and  the  treatment 
established  on  new  principles.     P. 

Lavater,  J.  C. — Essays  on  physiognomy. 
(Trans.)     3  vols. 

1791.  Brandreth,  Jos. — On  the  use  of 
large  doses  of  opium  in  insanity.  (Med. 
Com.) 

Perfect,  W. — A  remarkable  case  of  mad- 
ness, with  the  diet  and  medicines. 

1792.  Ferriar,  J. — Medical  histories  and 
reflections.  3  vols.  Warrington,  1792-8  ; 
also  Lond.,  1810-13. 

FOTHERGILL,  A. — On  the  effects  of  hyo- 
scyamus  or  henbane  in  certain  cases  of 
insanity. 

Pargeter,  W. — Observations  on  maniacal 
disorders.     Eeading. 
1796.    Anderson,  A. — On  chronic  mania. 
New  York. 

Belcher,  W. — Address  to  humanity  ;  con- 
taining a  letter  to  Dr.  Munro,  a  receipt 
to  make  a  lunatic,  and  seize  his  estate  ; 
and  a  sketch  of  a  true  smiling  hyoena. 
1798.  Crichton,  A. — An  enquiry  into  the 
nature  and  origin  of  mental  derange- 
ment, comprehending  a  concise  system 
of  the  physiology  and  pathology  of  the 
human  mind.     2  vols. 

Haslam,  J.— Observations  on  insanity, 
with  practical  remarks  on  the  disease, 
and  an  account  of  the  morbid  appear- 
ances on  dissection. 

Haslam,  J. — Observations  on  madness 
and  melancholy,  including  practical 
remarks  on  those  diseases,  together 
with  cases,  and  an  account  of  morbid 
appearances  on  dissection.  (2nd  ed. 
Lond.  1809.) 

1800.  Johnstone,  J. — Medical  jurispru- 
dence :  on  madness,  with  strictui-es  on 
hereditary  insanity. 

1801.  Perfect,  W. — Annals  of  insanity. 

1802.  Beddoes,  T. — Essays  on  some  of 
the  disorders  commonly  called  nervous. 
Part  II.  containing  observations  on  in- 
sauitv.     Bristol. 


BIBLIOGKAPHY. 


1385 


1804.  Beown,  J.— Works,  edited  by  W. 
Cullen  Brown. 

Cox,  J.  M.  —  Practical  observations  on 
insanity  ;  in  which  some  suggestions  are 
offered  towards  an  improved  mode  of 
treating  diseases  of  the  mind,  and  some 
rules  proposed  which  it  is  hoped  may 
lead  to  a  more  humane  and  successful 
method  of  cure,  with  remarks  on  medical 
jurisprudence  as  connected  with  diseased 
intellect.     (2nd  ed.  1806;  3rd  ed.  18  ij.) 

Rowley,  W.  A. — Treatise  on  madness  and 
suicide  ;  with  the  modes  of  determining 
with  precision  mental  atfections  from  a 
legal  point  of  view,  and  containing  ob- 
jections to  vomiting  opium  and  other 
malpractices.     (3rd  ed.  1813.I 

Trotter,  T. — An  essay,  medical,  philoso- 
phical and  chemical,  on  drunkenness. 

1805.  Bakewell,  S.  G.— The  domestic 
guide  in  cases  of  insanity.     Stafford. 

1806.  Anon. — A  short  letter  to  a  noble 
Lord  on  the  present  state  of  lunatic 
asylums  of  Great  Britain.     P.     Edin. 

PiNKL,  P. — Treatise  on  insanity.  (Trans.) 
Sheffield. 

1807.  Duncan,  Andrew  (attributed  to). — 
Address  to  the  public  respecting  the 
establishment  of  a  lunatic  asylum  in 
Edin.     4to.  Edin. 

HiGHMORE,  N. — Treatise  on  the  law  of 
idiocy  and  lunacy. 

Eeport. — Parliamentary  Committee. 

Stark,  W.  (architect).  —  Remarks  on 
public  hospitals  for  the  cure  of  mental 
derangement.    (Glasg.  1810.)    4to.  Edin. 

Trotter,  T. — A  view  of  the  nervous  tem- 
perament ;  a  practical  inquiry  into  the 
increasing  prevalence,  preventive  treat- 
ment of  those  diseases,  &c. 

1809.  Duncan,  A. — Observations  on  the 
architecture  of  hospitals  for  lunatics. 
Edin. 

1810.  Black,  W.  —  A  dissertation  on 
insanity,  extracted  from  between  two 
and  three  hundred  cases  in  Bedlam, 
with  tables.     (2nd  ed.  1811.) 

Ckowther,  Bryan. — The  Rabies  Pira- 
tica,  its  history,  symptoms,  and  cure ; 
also  the  Furor  Hippocraticus,  or  Gracco- 
mania,  with  its  treatment. 

Halloran,  W.  S. — An  enquiry  into  the 
causes  producing  the  extraordinary 
addition  to  the  number  of  the  insane. 
Cork. 

Haslam,  J. — Illustrations  of  madness. 

1811.  Beck,  T.  R.— On  Insanity.  New 
York. 

Crowe,  A,  M.— A  letter  to  Dr.  R.  D. 
Willis. 

Crowther,  B.  —  Practical  remarks  on 
insanity,  to  which  is  added  a  commen- 
tary on  the  dissection  of  the  brains  of 
maniacs,  with  some  account  of  diseases 
incident  to  the  insane. 

Parkinson,  J. — Observations  on  the  Act 
for  regulating  madhouses,  and  a  correc- 
tion of  the  statements  of  the  case  of 
Benjamin  Elliot,  convicted  of  illegally 
confining  Mary  Daintree,  with  remarks 


addressed     to    the    friends    of    insane 

persons.     P. 
TuKE,  S. — On  the  state  of  the  insane  poor. 

(Philanthropist.)     Lond. 
Tuke,    S. — On    the    treatment    of    those 

labouring  under  insanity,   drawn   from 

the  experience  of  the  Retreat.     Phil. 

1812.  CoLLiNSON,  G.  D. — A  treatise  on 
the  law  concerning  idiots,  lunatics,  and 
other  persons  noii.  compotes  mentis.  2  vols. 

Duncan,  A. — On  the  progress  and  present 
state  of  the  Edinburgh  Lunatic  Asylum. 
Edin. 

Paul,  Sir  G.  O.  —  Observations  on  the 
subject  of  lunatic  asylums.     Gloucester. 

Rush,  Benjamin.  —  Medical  inquiries 
and  observations.  Vol.  2  contains, 
influence  of  physical  cause?  on  the 
moral  faculty  ;  also  articles  upon  dis- 
eases of  the  mind.     Phil.  (5th  ed.  1835.) 

1813.  Sutton,  T. — On  delirium  tremens. 
Tuke,    Samuel.  —  Description     of    the 

Retreat,  an  Institution  near  York  for 
insane  persons  of  the  Society  of  Friends, 
containing  an  account  of  the  origin  and 
progress,  the  modes  of  treatment,  and  a 
statement  of  cases. 

1814.  Adams,  J. — Treatise  on  the  supposed 
hereditary  properties  of  disease,  with 
notes,  particularly  on  madness  and 
scrofula. 

Anon. — A  new  governor  of  the  asylum."  A 
vindication  of  Mr.  Higgins  from  the 
charges  of  "Corrector."    York. 

ATKiNS0N,Mr.  (late  Apothecary  to  the  York 
Asylum). — Retaliation  ;  or  hints  to  some 
of  the  governors  of  the  asylum,  York. 

"Corrector."  —  A  few  remarks  on  Mr. 
Higgins'  publication.     Y'ork. 

Higgins,  G. — A  letter  from  Mr.  Higgins 
to  Earl  Fitzwilliam,  on  the  subject  of 
the  abuses  of  the  York  Asylum.     York. 

Hill,  G.  N. — An  essay  on  the  prevention 
and  cure  of  insanity,  with  observations 
on  the  rules  for  the  detection  of  pre- 
tenders to  madness. 

1815.  Adams,  J. — Hereditary  peculiarities 
of  the  human  race,  witla  notes  on  gout, 
scrofula,  and  madness,  and  on  the 
goitres  and  cretins  of  the  Alps  and 
Pyrenees. 

Bakewell,  S.  G.  —  Letter  on  mental 
derangement.     Stafford. 

Eddy,  T. — Hints  for  introducing  an  im- 
proved mode  of  treating  the  insane  in 
the  asylum,  &c.     P.     New  York. 

Ellis,  Sir  W.  C— A  letter  to  Thomas 
Thompson,  Esq.,  M.P.,  containing  con- 
siderations on  the  necessity  of  proper 
places  being  provided  by  the  Legislature 
for  the  reception  of  all  insane  persons,  &c. 
Hull. 

Forster,  T. — Sketch  of  the  new  anatomy 
of  the  brain,  with  its  relation  to  insanity. 

Gray',  Jon  a.— A  history  of  the  York 
Lunatic  Asylum,  containing  the  minutes 
of  the  evidence  on  the  cases  of  abuse 
lately  inquired  into  by  a  committee, 
addressed  to  Wm.  Wilberforce,  Esq. 
York. 


1386 


BlBLlOGKArilY. 


LuCETT,  J. — An  exposition  of  the  reasons 
which  have  prevented  the  process  for 
relieving  and  curing  idiocy  and  hmacy, 
and  every  species  of  insanity  from  having 
been  further  extended,  with  an  appendix 
of  attested  cases,  and  extracts  from  the 
reports  of  the  committee,  consisting  of 
their  Royal  Highnesses  the  Dukes  of 
Kent  and  Sussex,  and  several  noblemen 
and  gentlemen. 

Marshall,  R. — The  morbid  anatomy  of 
the  brain  in  mania  and  hydrophobia, 
with  the  pathology  of  these  two  diseases, 
and  a  sketch  of  the  author's  life,  by  S. 
Sawrey. 

SPUEZHEiM,S.E.'^Physiognomical  system, 
by  Drs.  Gall  and  Spurzheim.  (2nd  ed.) 
Lond, 

TUKE,  S. — Practical  hints  on  the  construc- 
tion and  economy  of  pauper  lunatic  asy- 
lums :  including  instructions  to  the 
architects  who  offered  plans  for  the 
Wakefield  Asylum.  111.  4to  and  8vo. 
York. 

1816.  Anon.  —  Observations  on  the  laws 
relating  to  private  asylums,  and  particu- 
larly on  a  Bill  for  their  alteration,  which 
passed  the  House  of  Commons  in  the 
year  181 3. 

Bethlem.  —  Observations  of  physician 
and  apothecary  upon  evidence.     Lond. 

Bethlem. — Observations  by  the  govern- 
ors of  Bethlem  Hospital  on  a  report  by 
the  Commissioners  in  Lunacy.     N.  D. 

Halliday,  Sir  A. — A  letter  to  Lord 
Binning,  containing  some  remarks  on 
the  state  of  lunatic  asylums  in  Scotland. 
P.    Edin. 

Reid,  J. — Essays  on  hypochondriacal  and 
other  nervous  affections.  (3rd  ed.  1823.) 

Report  of,  and  evidence  taken  before 
the  Select  Committee  of  the  House  of 
Commons,  to  consider  of  provision  being 
made  for  the  better  regulation  of  mad- 
houses in  England.     (8vo,  181 5.)     Fol. 

Rogers,  J.  W. —  A  statement  of  the 
cruelties,  abuses  and  frauds  which  are 
practised  in  madhouses.     2nd  ed. 

Upton,  J. — A  letter  upon  the  treatment 
and  dismissal  of  the  late  medical  officer 
of  Bridewell  and  Bethlem. 

1817,  Burrows,  G.  M.— Cursory  remarks 
on  a  Bill,  now  in  the  House  of  Peers,  for 
regulating  of  madhouses,  with  observa- 
tions on  the  defects  of  the  present 
system. 

Cappe,  Catherine.— On  the  desirable- 
ness and  the  utility  of  ladies  visiting  the 
female  wards  of  hospitals  and  lunatic 
asylums.     P.    York. 

Forster,  Th. — Observation  on  the  casual 
and  periodical  influence  of  peculiar  states 
of  the  atmosphere  on  human  health  and 
disease,  particularly  insanity.  With  a 
table  of  reference  to  authors. 

Forster,  Th. — Observations  on  the  i^heno- 
mena  of  insanity,  being  a  supplement  to 
the  above.     P. 

Haslaji,  J. — Considerations  on  the  moral 
management  of  insane  persons.     P. 


Haslaji,  J. — Medical  jurisprudence  as  it 
relates  to  insanity  according  to  the  law 
(jf  England. 

Mayo,  T. — Remarks  on  insanity.  Founded 
on  the  practice  of  John  Mayo,  M.D., 
and  tending  to  illustrate  the  physical 
symptoms  and  treatment  of  that 
disease. 

Parkman,  C. — On  the  management  of 
lunatics,  with  illustrations  of  insanity. 
Boston. 

Report. — Select  Committee  on  Lunatic 
Poor,  Ireland. 

Returns  by  Clergy  of  Scotland  as  to 
Lunatics. 

Spurzheim,  S.  E. — Observations  on  the  de- 
ranged manifestations  of  the  mind,  or 
insanity.     (Also  1835.) 

1818.  Duncan,  A.  —  A  Letter  to  His 
Majesty's  Sheriffs-Depute  in  Scotland, 
recommending  the  establishment  of  four 
national  asylums  for  the  reception  of 
criminal  and  pauper  lunatics.     P. 

Halloran,  W.  S. — Practical  observations 
on  the  causes  and  cure  of  insanity. 
Cork. 

Haslam,  J — A  Letter  to  the  Governors  of 
Bethlem  Hospital,  containing  an  account 
of  their  management  of  that  institution 
for  20  years,  elucidated  by  original 
letters  and  documents,  with  a  correct 
narrative  of  the  confinement  of  James 
Norris,  &c. 

1819.  Cooper,  T.  —  Tracts  on  Medical 
Jurisprudence.  Including  Haslam's 
treatise  on  insanity  :  with  a  preface, 
notes  and  a  digest  of  the  Laws  relating 
to  Insanity  and  Nuisances,  &c.     Phil. 

Haslam,  J. ^ — On  sound  mind;  contribut- 
tion  to  the  natural  history  and  physio- 
logy of  the  human  intellect. 

Wadd,  W. — On  the  malformations  and 
diseases  of  the  head.     111.     4to. 

1820.  Burrows,  G.  M. — An  inquiry  into 
certain  errors  relative  to  insanity. 

1822.  Prichard.  J.  C. — A  treatise  on  dis- 
eases of  the  nervous  system.  Part  I. 
[no  more  published].  Convulsive  and 
maniacal  affections. 

1823.  Haslam,  J.— A  letter  to  the  Right 
Hon.  the  Lord  Chancellor  on  the  nature 
and  interpretation  of  unsoundness  of 
mind  and  imbecility  of  intellect.     P. 

Willis,  F. — A  treatise  on  mental  de- 
rangement (Gulston  Lect.  for  1S22). 

1824.  "WiLDE,  R.  H.— Conjectures  and  re- 
searches concerning  the  love  madness 
and  imprisonment  of  Torquato  Tasso, 
2  vols.     i2mo.     New  York. 

1825.  MORISON,  Sir  A.— Outlines  of  lec- 
tures on  mental  diseases.  111.  (2nd 
ed.  1S26.) 

1826.  Hooper,  R. — The  morbid  anatomy 
of  the  human  brain,  being  illustrations 
of  the  most  frequent  and  important 
organic  diseases  to  which  that  viscus  is 
subject.     Fol. 

Mill.  —  Account  of  morbid  appearances 
on  dissection  in  various  disorders  of  the 
brain. 


J5IELI0GKAPHY. 


1387 


1827.  CULLKN,  W.— The  works  of  William 
CuUen  (contain  chapters  on  insanity). 
2  vols.     Ediu. 

Knight,  P.  S. — Observations  on  the  causes, 
symptoms  and  treatment  of  derange- 
ment of  the  mind,  founded  on  an  exten- 
sive mora!  and  medical  practice  in  the 
treatment  of  lunatics.  Together  with 
the  particulars  of  the  sensations  and 
ideas  of  a  gentleman  during  his  mental 
alienation,  written  by  himself  during  his 
convalescence.     111. 

Syek,  J. — A  dissertation  on  the  features 
and  treatment  of  insanity.  Containing 
a  retrospect  of  the  most  important 
modern  theories  on  the  subject,  &c. 

1828.  Abercrombik,  J. — Pathological  and 
practical  researches  on  diseases  of  the 
brain  and  spinal  cord. 

Anon. — A  few  observations  on  the  Bill 
now  in  progress  through  Parliament  to 
regulate  the  cure  and  treatment  of  in- 
sane persons. 

Burrows,  G.  M. — Commentaries  on  the 
causes,  form,  symptoms  and  treatment, 
moral  and  medical,  of  insanity. 

Charlesworth,  E.  p. — Remarks  on  the 
treatment  of  the  insane  and  the  manage- 
ment of  lunatic  asylums  ;  being  the  sub- 
stance of  a  return  from  the  Lincoln 
Lunatic  Asylum  to  the  circular  of  His 
Majestv's  Secretary  of  State.  [With  a 
plan.]  'P. 

Combe,  G. — The  constitution  of  man  con- 
sidered in  relation  to  external  objects. 
i6mo.     Edin. 

CONOLLY,  J. — Introductory  Lecture,  Uni- 
versity of  London. 

Halliday,  Sir  A. — A  general  view  of  the 
present  state  of  lunatics  and  lunatic 
asylums. 

J.  W.  (late  a  keeper  at  a  lunatic  asylum). 
— Practical  observations  on  insanity  and 
the  treatment  of  the  insane,  addressed 
particularly  to  those  who  have  relatives 
or  friends  afflicted  with  mental  derange- 
ment. Also  hints  on  making  the  stud}' 
of  mental  disorders  a  necessar}'  adjunct 
to  medical  education. 

MORISON,  Sib  A. — Cases  of  mental  disease, 
with  observations  on  the  medical  treat- 
ment, for  the  use  of  students. 

1829.  HALLIDAY',  Sir  A.  —  A  letter  to 
Lord  Robert  Seymour,  with  a  report  of 
the  number  of  lunatics  and  idiots  in 
England  and  Wales.     P. 

Prichard,  J.  C. — A  review  of  the  doc- 
trine of  a  vital  principle,  with  observa- 
tions on  the  instrumentality  of  the  brain 
and  nervous  system  on  the  operation  of 
the  mind. 

RicirARDS. — On  nervous  disorders. 

1830.  CoNOLLY,  J. — An  inquiry  concern- 
ing the  indications  of  insanity,  with 
suggestions  for  the  better  protection 
and  care  of  the  insane. 

Crowtheb,  C. — Some  observations  res- 
pecting the  management  of  the  pauper 
lunatic  asvlum  at  Waketieki.  P.  Wake- 
field. 


Faru,  W. — On  the  statistics  of  English 
lunatic  asylums,  and  the  reform  of  their 
public  management.     P. 

Haslam,  J. — Jjctter  to  metropolitan  com- 
missioners in  lunacy.     P. 

Nkwniiam,  W.— Essay  on  superstition, 
being  an  inquiry  into  the  effects  of  phy- 
sical influences  on  the  mind,  in  the  pro- 
duction of  dreams,  visions,  ghosts  and 
supernatural  appearances. 

Palmer,  W. — An  enquiry  as  to  the  expe- 
diency of  a  county  asylum  for  pauper 
lunatics.     Exeter. 

Report. — Minutes  of  evidence  taken  by 
the  conmiittee  appointed  to  enquire  into 
the  charge  preferred  against  Dr.  Wright, 
apothecary  and  superintendent  of 
Bethlem  Hospital. 

Tate,  G. — A  treatise  on  hysteria. 

Trevelyan,  a.  —  The  insanity  of  man- 
kind.    P.     Edin. 

UwiNS,  D. — Remarks  on  nervous  and 
mental  disorder  with  special  reference 
to  recent  investigations  on  insanity.     P. 

Wyman,  R. — A  discourse  on  mental  philo- 
sophy as  connected  with  mental  dis- 
orders.    Boston. 

1831.  Combe,  A.  — Observations  on  men- 
tal derangement,  being  an  application 
of  the  principles  of  phrenology,  and  the 
elucidation  of  the  causes,  sj'mptoms, 
nature  and  treatment  of  insanity. 
i2mo.     Edin.     (Also  1834,  &c.) 

Dunne,  Charles. — Brand's  lunacy  case, 
a  full  report  of  this  most  interesting  and 
extraordinary  investigation. 

NiMMO,  W.— Illustrations  of  the  theory  of 
mental  derangement.     Glasgow. 

1832.  Alison,  Sir  A. — The  Criminal  Law 
of  Scotland.     2  vols. 

Seymour,  E.  J.  —  Observations  on  the 
medical  treatment  of  insanity. 

Winslow,  F. — Suggestions  for  an  im- 
proved treatment  of  mental  derange- 
ment.    P. 

1833.  Allen,  M. — Essay  on  the  classifica- 
tion of  the  insane.     111. 

Allen,  M. — Cases  of  insanity  with  medi- 
cal, moral,  and  philosophical  observa- 
tions on  them. 

Allen,  M. — Observations  on  the  Lunatic 
Act,  entitled  an  Act  for  the  better  cure 
and  protection  of  insane  persons  in 
England,  including  views  and  general 
information  on  the  moral  and  medical 
treatment  of  insanity.     N.  D. 

Ay'Re,  J. — Researches  on  dropsy  in  the 
brain,  chest  and  abdomen. 

Bakewell,  S.  G.  —  Essay  on  insanity. 
(2nded.  1836.)     Edin.     P. 

Broussais,  F.  J.  V. — On  irritation  and 
insanity,  a  work  wherein  the  relations 
of  the  physical  with  the  moral  condi- 
tions of  man  are  established  on  the  basis 
of  a  physiological  medium.  To  which 
are  added  two  tracts  on  materialism  and 
an  outline  of  the  association  of  ideas. 
(Trans,  by  T.  Cooper.) 

EsQUiROL,  J.  E.  D. — Observations  on  the 
illusions  of  the  insane,  and  on  the  medico- 


I3SS 


iUr.LlOGKArHY. 


legal  question  of  their  confinement. 
(Trans.)     P. 

ITaeBEX.  —  Essays  on  the  varieties  in 
mania  exliibited  by  the  characters  of 
Hamlet,  Oi^helia,  Lear  and  Edgar. 

Fletcuei!,  lu— t^ketches  froni^the  case- 
book, to  illustrate  the  intiuence  of  the 
mind  on  the  body,  with  the  treatment 
of  some  of  the  more  important  nervous 
disturbances  which  arise  from  this  in- 
fluence. 

Halford,  Sir  H.  -Essays  and  orations. 
i2mo.     2nd  ed.     111. 

Madden,  R.  11. — Tlie  infirmities  of  genius. 

Peichakd,  J.  C. — A  treatise  on  insanity. 
From  the  Encyclopaedia  of  Practical 
Medicine.     i2mo. 

Shelfoed,  L.  — Practical  treatise  cu  the 
law  concerning  lunatics. 

UwiNS,  D. — A  treatise  on  those  disorders 
of  the  brain  and  nervous  system  which 
are  usually  considered  and  called  men- 
tal. 

1834.  Axon. — Reasons  for  establishing  and 
further  encouragement  of  St.  Luke's 
Hospital  for  lunatics.     4to. 

Mayo,  T. — Clinical  facts  and  reflections, 
also  remarks  on  the  impunity  of  murder 
in  some  cases  of  presumed  insanity. 
(Also  1S47.) 

Mayo,  T. — An  essay  on  the  relation  of  the 
theory  of  morals  to  insanity.     P. 

1835.  Gall,  F.  J. — On  the  "origin  of  the 
moral  qualities  and  intellectual  facul- 
ties of  man  and  the  conditions  of  their 
manifestations.  (Trans,  by  W.  Lewis.) 
6  vols.     Boston. 

Seville,  W.  B. — On  insanity,  its  nature, 

causes,  and  cure. 
Philip,  A.  P.  W. — A  treatise  on  the  more 

obscure  all'ectious  of  the  brain. 
Prichaed,  J.  C. — A  treatise  on  insanity 

and  other  disorders  aftecting  the  mind. 

1837.  Barlow,  H.  C— A  dii-sertation  on 
the  causes  and  eft'ects  of  disease,  con- 
sidered in  reference  to  the  moral  consti- 
tution of  man.     Edin. 

Browne,  W.  A.  F. — What  asylums  were, 
are,  and  ought  to  be.  Lectures  delivered 
before  the  Managers  of  the  Montrose 
Royal  Lunatic  Asylum.     Edin. 

CoLQUHorN,  L.— Report  of  proceedings 
under  a  brieve  of  idiotry.   2nd  ed.  Edin. 

Farr,  W. — Statistics  of  insanity. 

Hill,  R.  G.— Total  abolition  of  personal 
restraint  in  the  treatment  of  the  insane  ; 
a  lecture  on  the  management  of  lunatic 
asylums. 

1838.  Crowthee,  C.  —  Observations  on 
the  management  of  madhouses,  illus- 
trated by  occurrences  in  the  West  Riding 
and  Middlesex  Asylums. 

Ellis,  Sir  W.  C— A  treatise  on  the 
nature,  symptoms,  causes  and  treat- 
ment of  insanity,  with  practical  obser- 
vations on  lunatic  asylums,  and  a  de- 
scription of  the  Pauper  Lunatic  Asylum 
for  the  county  of  Middlesex  at  Hanwell, 
with  a  detailed  account  of  its  manage- 
ment. 


Mayo,  T. — Elements  of  the  pathology  of 
the  human  mind.     lamo, 

Mo.seley',  W.  W.— Eleven  chapters  on 
nervous  or  mental  complaints,  and  on 
two  great  discoveries,  by  which  hun- 
dreds have  been,  and  all  may  be  cared 
with  as  much  certainty  as  water 
quenches  tb.irst,  or  bark  cures  ague. 

Stock. — A  practical  treatise  on  the  law  of 
non  comjiotes  mentis,  or  persons  of  im- 
sound  minds. 

Walker,  A. — Intermarriage,  (and  ed. 
1S41.) 

1839.  Anon.  —  Documents  and  dates  of 
modern  discoveries  in  the  nervous 
system. 

Burgess,  Thomas  H. — The  physiology  or 
mechanism  of  blushing  :  illustrative  of 
the  intiuence  of  mental  emotion  on  the 
capillary  circulation,  with  a  general  view 
of  the  sympathies,  and  the  organic  re- 
lations of  those  structures  with  which 
they  seem  to  be  connected. 

Cooke,  W. — Mind  and  emotions  in  rela- 
tion to  health  and  disease. 

Earle,  Pliny.— a  visit  to  thirteen  asylums 
for  the  insane  in  Europe  ;  to  which  are 
added  a  brief  notice  of  similar  institu- 
tions in  transatlantic  countries  ;  and  an 
essay  on  the  causes,  duration,  termina- 
tion and  moral  treatment  of  insanity, 
with    copious    statistics.       (Also    Phil. 

1845-) 

Hill,  R.  G. — On  the  management  of  luna- 
tic asylums,  and  the  total  abolition  of 
personal  restraint,  with  statistical 
tables. 

Holland,  Sir  H. — Medical  notes  Eind 
reflections. 

Milling  EN,  J.  G. — Aphorisms  on  the 
treatment  and  management  of  the  in- 
sane, with  considerations  on  public  and 
private  lunatic  asylums,  pointing  out  the 
errors  in  the  present  system.  i2mo. 
(2nded.  1842.) 

Percy*,  John.  —  An  experimental  en- 
quiry concerning  the  presence  of  alcohol 
in  the  ventricles  of  the  brain.  ^Sotting- 
ham. 

Ray.  L— a  treatise  en  the  medical  juris- 
prudence of  insanity. 

1840.  Blake,  A.— A  practical  essay  on 
delirium  tremens.     2nd  edit,  revised. 

Laycock,  T.^ — Treatise  on  the  nervous 
diseases  of  women  ;  comprising  an  en- 
quiry into  the  nature,  causes  and  treat- 
ment of  spinal  and  hysterical  disorders. 

MoEisON,  Sir  a. — The  physiognomy  of 
mental  diseases. 

Pagan.  J.  M. — The  medical  jurisprudence 
of  insanity. 

Perceval.  J. — A  narrative  of  the  treat- 
ment experienced  by  a  gentleman  during 
a  state  of  mental  derangement,  designed 
to  explain  the  causes  and  nature  of  in- 
sanity. 

Review. — Organisation  and  management 
of  lunatic  asvlums.  (B.  and  F.  Med. 
Chir.  Rev.) 

WiNSLOW,  F.— The  anatomv  of  suicide. 


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1845.  CosTELLO,  AV.  B.— A  letter  to  Lord 
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ESQUIROL,  J.  E.  D.  —  A  treatise  ou  insanity. 
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Nevvxham,  W. — Human  magnetism,  it.-< 
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Steward,  J.  B. — Practical  notes  on  in- 
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THUEXAii,  J. — Observations  and  essays  on 
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treatment  in  establishments  for  the  in- 
sane, to  which  are  added  statistics  of  the 
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Williams,  Joseph.— An  essay  on  the  use 
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Hoou,  Sir  W.  C— Statistics  of  insanity. 
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Moore,  G.— The  use  of  the  body  in  rela- 
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Noble,  D. — The  brain  and  its  phy.siology. 

TwiXlXG,  W. — On  cretinism. 

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the    pathological    aspects   of    insanity. 

in. 

Savage,  G.  H. — Pathology  of  chronic 
alcoholism.     (Trans.  Path.  Soc.) 

Savage,  G.  H. — Handwriting  in  insanity. 
(111.  Med.  News.) 

Savage,  G.  H. — Septic  puerperal  insanity. 
(Med.  Soc.  Trans.) 

Spitzka,  E.  C. — Insanity,  its  classifica- 
tion, diagnosis  and  treatment.  New 
York. 

Stewart,  James. — Treatment  of  inebriety 
in  the  higher  and  educated  classes. 
P. 

Suckling,  C.  W.— Syphilis  of  the  nervous 
system.     (Birm.  Med.  Rev.) 

Tuckey,  C.  L. — Psycho-therapeutics  or 
treatment  by  sleep  and  suggestion. 

TuKE,  J.  Batty. — Lunatics  as  patients, 
not  prisoners.     (Nineteenth  Century.) 

Tuke,  D.  Hack. — The  past  and  present 
provision  for  the  insane  poor  in  York- 
shire, with  suggestions  for  the  future 
provision  for  this  class. 
1890.  Anon.  —  Mad  doctors  ;  by  one  of 
them.     P. 

Barnes. — On    the    correlations    of    the 


I4C4 


BIBLIOGEAPHY. 


sexual  functions  and  mental  disorders 
of  -women.     (Brit.  Gynajcological  Soc.) 

Beard,  G-.  M. — Nervous  exhaustion  (neur- 
asthenia), its  symptoms,  nature,  se- 
quences and  treatment.  (Ed.  by  Dr. 
Kockwell.) 

Bristowe,  J.  S.— Art.  on  Insanity  ;  Q'rea- 
tise  on  the  theory  and  practice  of  medi- 
cine,   (ist  ed.  1S76.)     (7th  ed.) 

Brown-Sequaed. — Have  we  two  brains  or 
one?     (Forum.) 

Browne,  Sir  J.  Crichton.— Responsi- 
bility and  disease. 

Brushfield,  T.  N.— Some  practical  notes 
on  the  .symptoms, treatment,  and  medico- 
legal aspects  of  insanity.  P.  (P.  P.)  Edin. 

Campbell,  Harry.— Flushing  and  mor- 
bid blushing,  their  pathology  and  treat- 
ment.    111. 

COWLES,  E.  —  Training  schools  of  the 
future  :  Rep.  of  Nat.  Conf.  of  Charities 
at  Baltimore. 

Elkins,  F.  a. — A  case  of  homicidal  and 
suicidal  insanity.     111.     Edin. 

Elkins.  F.  A. — Report  on  an  epidemic  of 
influenza  (140  cases)  at  Royal  Edinburgh 
Asylum.  (With  Dr.  G.  M.  Robertson.) 
P. 

Ellis,  Havelock.— The  criminal. 

FOLSOJi,  C.  F. — Insomnia,  disorders  of 
sleep. 

Fraser,  a. — A  guide  to  operations  on  the 
brain.     (Plates  42,  atlas.)     Large  fol. 

Fry,  D.  p. — The  lunacy  laws  :  containing 
the  statutes  relating  to  private  lunatics, 
pauper  lunatics,  criminal  lunatics,  com- 
missioners of  lunacy,  public  and  private 
asylums,  and  the  commissioners  in 
lunacy  ;  with  an  introductory  comment- 
ary, notes  to  the  statutes,  &c.  (Ed.  by 
G.  F.  Chambers.)  3rd  ed.  (See  also 
1864.) 

Jackson,  J.  Hughlings.— Lumleian  lec- 
tures on  convulsive  seizures.     (B.  M.  J.) 

Mantegazza,  p. — Physiognomy  and  ex- 
pression.    (Trans.) 

Merciee,  C.  a. — Sanity  and  insanity. 

Moll,  A. — Hypnotism.'    (Trans.) 

Needham,  F. — Thirty  years  of  lunacy. 
(Presidential  address.  Psychological 
Section,  Brit.  Med.  Assoc.) 

Obeesteiner,  H. — Anatomy  of  central 
nervous  organs  in  health  and  disease. 
(Trans).     111. 

Pope,  H.  M.  R.  —  Law  and  practice  of 
lunacy.     (Ed.  by  Boome  and  Fowke.) 

Report  of  committee  appointed  by  the 
medico-psychological  association  to  en- 
quire into  the  question  of  the  systematic 
training  of  nurses  and  attendants  on  the 
insane. 

Robertson,  G.  M.— Report  on  an  epi- 
demic of  influenza  (140  cases)  at  Roval 
Edinburgh  Asylum.    (With  Dr.  Elkins.) 

Stare,  M.  A. — Familiar  forms  of  nervous 
disease.     New  Yoi-k. 

Street,  C. — Lunacy  Act  of  1890.  P. 
Edin. 

Slx'KLIng,  C.  W. — On  the  treatment  of 
disease  of  the  nervous  system. 


Tiffany,  F.— Life  of  Dorothea  Lynde 
Dix.     111.     Boston,  U.S.A. 

Tuke,  J.  Batty.— The  surgical  treatment 
of  intra-cranial  pressure.      (B.  M.  J.) 

Warner,  F. — A  course  of  lectures  on  the 
growth  and  means  of  training  the 
mental  faculty. 

Williams,  J.  W.  Hume. — Unsoundness  of 
mind  in  its  legal  and  medical  considera- 
tions. ( Vide  1856.) 
1891.  Beach,  Fletcher. — Psychological 
medicine  in  John  Hunter's  time,  and  the 
progress  it  has  since  made.  (Hunterian 
Oration. ) 

Bernheim,  H. — Suggestive  therapeutics  : 
a  treatise  on  the  nature  and  uses  of 
hypnotism.     (Trans.)     Edin. 

Bramwell,  Byrom.  —  Atlas  of  clinical 
medicine  (includes  mental  diseases). 
Edin. 

Browne,  Sir  James  Crichton. — On  old 
age.  (Introductory  lecture,  Victoria 
University,  Leeds.)     (L. ) 

Burdett,  H.  C— Hospitals  and  asylums 
of  the  world,  their  origin,  history,  con- 
struction, administration,  management 
and  legislation.     111.     2  vols. 

Campbell,  Harry. — Difi'erences  in  the 
nervous  organisation  of  man  and  woman, 
physiological  and  pathological.     111. 

Campbell,  J.  A.  —  The  utilisation  of 
county  hospitals  and  asylums  for  teach- 
ing purposes.     P. 

Caelsen,  J.  —  Statistical  investigations 
concerning  the  imbeciles  in  Denmark, 
1888-9. 

Clouston,  T.  S. — The  neuroses  of  develop- 
ment. (Morisonian  lecttires  for  1890.) 
111.     Edin. 

Elkins,  F.  A. — On  a  case  of  phosphorus 
poisoning,  the  mental  symptoms  and 
pathological  appearances.  ^With  Dr.  J. 
Middlemass.) 

Felkin,  R.  W. — Hypnotism  ;  or,  psycho- 
therapeutics.    Edin. 

Geeene,  R, — Construction  and  arrange- 
ment of  asylums.     (7th  Int.  Cong.  Hyg.) 

Geeene,  R. — Hospitals  for  the  insane,  and 
clinical  instruction  in  asylums.     P. 

Hoesley,  Y. — On  craniectomy  in  micro- 
cephaly.    (B.  M.  J.) 

Keee,  Norman. — Inebriety  and  criminal 
responsibility. 

Kerr,  Norman. — Should  hypnotism  have 
a  recognised  place  in  ordinary  thera- 
peutics ?     P. 

Page. — Railway  injuries. 

Report  of  committee  of  the  Medico- 
psychological  Association,  to  formulate 
propositions  as  to  the  care  and  treatment 
of  the  insane. 

Report,  Charity  Organisation  Society,  on 
the  feeble-minded,  epileptic,  deformed 
and  crippled. 

Robertson,  A. — On  insanity.  (In  Finlay- 
son's  Clinical  Manual.)     3rd  ed.     Glasg. 

Savage,  G.  H. — Insanity  and  allied  neu- 
roses, practical  and  clinical.     3rded.    III. 

Savage,  G.  H. — The  warnings  of  general 
paralysis  of  the  insane.     (B.  M.  J.) 


BIBLIOGRAPHY. 


1405 


Savage,  G.  H. — Post-graduate  lectures. 
(M.  P.  &  G.) 

Savage,  G.  H.  —  Glj'cosuria,  diabetes  and 
insanity.     (Med.  Soc.  Trans.) 

Strahan,  S.  a.  K.  —  Consanguineous 
marriages.     (Westminster  Kev. ) 

Strahan,  S.  a.  K. — Instinctive  Crimi- 
nality: its  true  cliaracter  and  rational 
treatment.     P. 

TuKE,  J.  Batty. — A  plea  for  the  scientific 
study  of  insanity.     i^B.  M.  J.) 

TuKE,  D.  Hack. — Prichard  and  Symonds 
in  especial  relation  to  mental  science, 
with  chapters  on  moral  insanity.     111. 

Walmslky,  F.  H.— The  desirableness  of 
throwing  open  our  asylums  for  the  post- 
graduate study  of  insanity.     P. 

Warxer,  F. — Keport  on  50,000  children 
in  schools.  (Charity  Organisation 
Society. ) 

Weatherly",  L.  a.  —  The  supernatural. 
(With  Mr.  Maskelyne). 

Weismax,  a. — Essays  on  hereditj-  and 
kindred  biological  problems.  "\'ol.  I. 
2nd  ed.  (^Trans.) 
1892.  Blaxdford,  G.  F. — Insanity  and 
its  treatment,  lectures  on  the  treatment, 
medical  and  legal,  of  insane  patients. 
4th  ed.     (See  1871.)     Lond.  and  Edin. 

Cajipbell,  .J.  A. — On  pneumonia  in  asy- 
lums.    (L.) 


Campbell,  J.  A. — A  case  of  tumour  of 
the  brain,  the  result  of  an  apoplexv. 
(With  Dr.  J.  Coats.) 

Clouston,  T.  S.  —  Clinical  lectures  on 
mental  diseases,  (isted.  18S3.)  111.  3rd 
ed. 

Elkins,  F.  A. — Concerning  the  kinsmen 
and  friends  of  insane  patients.    P.    Edin. 

Hertel,  Dr.  —  Overpressure  in  High 
Schools  in  Denmark.  (Introd.  by  Sir  J. 
Crichton  Browne.) 

HowDEN,  J. — Pathological  index  for  use 
in  hospitals  and  asylums.     P. 

Savage,  G.  H. — Inlluenza  and  neuroses. 
(Trans.  Med.  Soc.) 

Shaw,  J. — Epitome  of  mental  diseases, 
with  the  existing  regulations  as  to  single 
patients. 

Strahan,  S.  a.  K.  —  Marriage  and  dis- 
ease. A  study  of  heredity  and  the  more 
important  family  degenerations. 

TuKE,  J.  Batty. — The  surgical  treatment 
of  intra-cranial  pressure.     (B.  M.  J. ) 

TuKE,  D.  Hack. — Dictionary  of  Psycho- 
logical Medicine.     111.    2  vols. 

TuKE,  D.  Hack. — Retrospective  glance  at 
the  early  history  of  the  Retreat,  York  ; 
its  objects  and  influence.     111. 

Walmsley',  F.  H. — Outlines  of  insanity. 

A.  R.  Urquhart. 


PSYCHOLOGICAL   SOCIETIES. 


Societies  for  the  Study  of  Psychological 
I\ledicine  have  been  established  in  various 
countries.  Some  of  them  publish  jour- 
nals, a  list  of  which  will  be  found  in  the 
Bibliography  incorporated  with  this  work. 
The  following  societies  are  all  interested 
in  psychiatry,  more  or  less  directly  : — 

Eiujland. — Medico-PsA'chological  Associa- 
tion of  Great  Britain  and  Ireland.  {See 
Article.)  It  may  be  added  to  the 
article  that  nearly  200  now  hold  the 
certificate  of  proficiency  in  psycholo- 
gical medicine.  The  examination  of 
attendants  has  been  only  lately  opened 
to  those  engaged  in  nursing  the  insane, 
yet  there  are  nearly  300  who  have  been 
trained,  and  who  have  successfully 
passed  the  examinations.  The  Report 
of  a  Committee,  adopted  at  the  annual 
meeting  of  1 891,  formulates  propositions 
as  to  the  care  and  treatment  of  the  in- 
sane, and  sets  forth  the  current  opinion 
of  the  members  at  the  present  time. — 
The  Neurological  Society  of  London, 
founded  in  1886.  This  Society  now 
numbers  about  150  members  ;  the  meet- 
ings are  held  in  London.  The  organ 
of  the  Society  is  "  Brain,  a  Journal 
of  Neurology." — The  Psychological  Re- 
search Society.     {See  Article.) 

France. — Societe  Medico-Psychologique  de 
Paris.  Founded  in  1852,  and  named  a 
Society  of  public  utility  by  a  decree  of 
December  11,  1867.  This  Association 
gives  four  prizes  for  the  best  work  in 
psychiatry.  —  Societe  de  Psychologie 
physiologique  ;  founded  in  1SS5  ;  meets 
monthly  in  Paris. — Societe  de  Hypnot- 
isme. — Societe  Medico-legale  de  France. 

Behjium. — Societe  de  Medecine  mentale  de 
Belgique;  founded  in  1S69 ;  meetings 
held  four  times  a  year. 


Holland. — Xederlandsche  Vereeniging  voor 
Psychiatrie;  founded  in  1871  ;  two  meet- 
ings are  held  annually. 

Germany. —  Gesellschatt  fiir  Psychiatric 
und  Nervenkrankheiten.  This  Society 
meets  eight  times  a  year  in  Berlin,  and 
numbers  about  180  members. — Psychia- 
tric Verein  ;  meetings  in  Berlin  three 
times  yearly,  with  130  membsrs. — Verein 
deutscher  Irreniirzte  ;  one  meeting 
annually,  with  about  360  members. — 
Psychiatrischer  Verein  derRheinprovinz; 
about  60  members  ;  two  meetings  annu- 
ally in  Bonn. — Ostdeutscher  irreuiirzt- 
licher  Verein  ;  about  50  members  ;  two 
meetings  annually  in  Breslau. — Verein 
siidwestdeutscher  Neurologen  und 
Irrenarzte  ;  one  annual  meeting  in 
Baden-Baden,  with  about  60  members. 
— Verein  der  Irreniirzte  Niedersachsens 
und  Westphalens  ;  one  yearly  meeting  in 
Hanover. 

Austria. — Wiener  Verein  fiir  Psychiatrie. 

Italy. — Societii  Freniatrica  Italiana,  Milan. 

Spain.  — Academia  Frenopatica. 

America.  —  The  Association  cf  Medical 
Superintendents  of  American  Institu- 
tions for  the  Insane.  This  association 
was  founded  in  1S44,  and  holds  meetings 
annually.  A  noteworthy  utterance  of 
opinion  in  reference  to  the  treatment  of 
the  insane  was  published  by  this  Society 
in  1S76,  under  the  title  of  "  Propositions 
and  Resolutions."  —  The  Medico-Legal 
Society  of  New  York,  founded  in  1883, 
is  supported  by  the  professions  of  law 
and  medicine,  and  now  numbers  many 
members. — The  National  Association 
for  the  Insane,  and  the  Prevention  of 
Insanity,  Philadelphia.  —  The  New 
England  Psychological  Association. 

A.  R.  U. 


PSYCHOLOGICAL    LITERATUKE. 


Asylum  IWagrazines. 

(In  (it  Jlritiiiii  : — Eethleiu  Kojal  Hospi- 
tal: The  Bethlehem  Star  (1S75-1S79), 
Under  the  Dome  (1SS9-1892)  ;  Dumfries 
Royal  Asjlum  :  The  New  Moon,  or  Crichton 
Koyal  I^^titution  Liteiary  Register  (1844)  ; 
Edinburgh  Royal  Asylum  :  The  Morning- 
side  Mirror  (1845) ;  Perth  Royal  Asylum  : 
Excelsior  (1857)  ;  York  Asylum,  Boo- 
tham  :  The  York  Star  (1857)  ;  Church 
Stretton  Asylum :  Loose  Leaves  (occa- 
sional) ;  Glasgow  Royal  Asylum :  The 
Chronicles  of  the  Cloister,  Tlie  Gartnavel 
Gazette.     (A  few  numbers.) 

America  : — The  Retreat  Gazette,  Hart- 
ford, Conn.  (A  few  numbers.)  The  Asy- 
lum Journal,  BrattJeboro',  Vt.  (1842-6)  ; 
The  Opal,  Utica  (i  851 -61)  ;  The  Meteor, 
Tuskaloosa,  Ala.  (1872-6)  ;  The  Friend, 
Harrisburg,  Pa.     (Two  years.) 

Periodical  Xiteraturei  —  •  Allgemeine 
Zeitschrift  fur  Psychiatric  undpsj'chisch- 
gerichtliche  Medicin,  herausgegeben  von 
Deutschlands  Irrenilrzten,  Ed.  Laehr 
and  others,  1S44  (Berlin)  ;  Alienist  and 
Neurologist,  Ed.  C.  H.  Hughes, 
quarterly,  18S0  (St.  Louis) ;  American 
tfournal  of  Insanity,  Ed.  Med.  Off.  of 
New  York  State  Lunatic  Asylum, 
quarterly,  1S44  (Utica);  American  Jour- 
nal of  Neurology  and  Psychiatry,  Ed. 
by  Drs.  McBride,  Gray,  and  Spitzka, 
quarterly,  1882-5  (New York);  American 
Journal  of  Psychology,  Ed.  Stanley 
Hall,  quarterly  (Mass.);  AnnalesMedico- 
Psychologiques,  Journal  de  I'alienation 
mentale  et  de  la  Medecine  legale  des 
Alienes,  Ed.  Ritti  and  others,  every 
two  months,  1843  (Paris)  ;  L'Anomalo, 
Gazzetino  antropologico,  psichiatrico, 
medico-legale  con  jaagina  di  letteratura 
dei  folli  ed  appendice  varia  del  medico 
generico,  monthly,  Ed,  Dr.  Angelo  Zuc- 
carelli  (Naples)  ;  Archiv  der  deutschen 
Gesellschaft  fiir  Psychiatric  und 
Gerichtliche  Psychologic,  Ed.  Erlen- 
meyer  and  others,  1858-66  also  1872 
(Neuwied)  ;  Archiv  fiir  Psychologic,  fiir 
Aerzte  und  Juristen,  Ed.  Friedrich,  1834 
only,  afterwards  as  Bliltter  fiir  Ps}'- 
chiatrie,  1837-8  (Erlangen)  ;  Archiv  fiir 
Psychologie  und  Nervenkrankheiten, 
Eel.  Grashey,  von  Krafft-Ebing,  Pelman, 
Schuchardt,  Schiile.  1868  (Berlin);  Archiv 
psichiatrii,  neurologii,  i  sudebnoi  psicho- 
patologii,  Ed.  Kovalewski,  quarterly, 
1883  (Charcov)  ;  Archiv  sudebnoi  Medi- 
tsini,  quarterly,  1869-71  (St.  Petersburg)  ; 
Archives  de  Neurologic,  revue  des  Mala- 


Periodical  Xiiterature  {continued) — 

dies  ner\euses  et  mentales,  Ed.  Char- 
cot, every  two  months,  1880  (Paris)  ; 
Archivio  di  psichiatria  scicnze  penali  ed 
antropologia  criminale,  per  servire  alio 
studio  deir  uomo  alienato  e  delinquent e, 
Ed.  Prof.  Lombroso,  quarterly,  1880 
(Turin  and  Rome)  ;  Archivio  Italiana  per 
le  malattie  nervose  e  piu  particolarmente 
per  le  alienazioni  mentali  organo  della 
Societil  Freniatrica  Italiano,  Ed.  Dr. 
Andrea  Yerga  e  Serafino  Biffi,  1863 
(Milan) ;  Beitriigezurexperimentellen Psy- 
chologie von  Hugo  Miinsterberg  (Mohr, 
Freiburg) ;  Brain — a  journal  of  neuro- 
logy, Ed.  by  Dr.  de  Watteville,  for  the 
Neurological  Society  of  London,  quar- 
terly, 1878  (London);  Bulletin  de  la 
Societe  de  Medecine  Mentale  de  Belgique, 
Ed.  Dr.  J.  Morel,  quarterly,  1873  (Ghent); 
Bulletins  de  la  Societe  de  Psychologie 
Physiologique,  President,  Prof.  Charcot 
(Paris)  ;  Centralblatt  fiir  Nervenheil- 
kunde  und  Psychiatrie  fiir  die  gesammte 
Neurologic  in  Wissenschaft  und  Praxis 
mit  besonderer  Beriicksichtigung  der 
Degenerations-anthropologie,  Ed.  Erlen- 
meyer,  monthly,  1S77-1878,  Coblenz. 
Centralbl.  f.  Nervenheilkuncle,  &c..  Ed. 
Kurella.  L'encephale,  Journal  des  Mala- 
dies mentales  et  nerveuses,  Ed.  Prof.  Ball 
and  others,  quarterly,  1881  (Paris);  Fried- 
reich's Bliitter  fiir  gerichtliche  Medicin 
und  Sanitiits-Polizei,  Ed.  v.  Meeker, 
fortnightly,  1S63  (Niirnberg)  ;  Giornale 
di  Neuropatologie,  Ed.  Dr.  Vizioli,  fort- 
nightly, 18S2  (Naples)  ;  Der  Irrenfreund 
Psychiatrische  Monatsschrifte  fiir  prak- 
tische  Aerzte,  Ed.  Brosius,  monthh", 
1859  (Heilbronn)  ;  Jahrbiicher  fiir 
Psychiatrie,  Ed.  Drs.  Gauster  and  Mey- 
nert,  formerly  Psychiatrisches  Centrals- 
blatt,  1871-8,  1879  (Yienna) ;  Journal  de 
Medecine  Mentale.  Ed.  Dr.  Dela- 
siauve,  monthly,  1861-1870  (Paris)  ;  The 
Journal  of  Mental  and  Nervous  Disease, 
Ed.  Dr.  Brown  1876,  monthly  (New 
York)  (formerly  Chicago)  ;  The  Journal 
of  Mental  Science  (formerly  The  Asylum 
Journal,  <S:c.),  published  by  authority  of 
the  Medico-Psychological  Association  of 
Great  Britain  and  Ireland,  Ed.  Drs. 
Hack  Tuke  and  Savage,  quarterly,  1853, 
(London)  ;  The  Journal  of  Nervous 
and  Mental  Disease,  Ed.  Dr.  Jewell, 
quarterly,  1S74  (Chicago)  ;  The  Journal 
of  Psychological  Medicine  and  Mental 
Pathology,  Ed.  F.  Winslow,  184S-60 
(London),  also  ed.  F.  L.  S.  Winslow, 
1S75-82;  II  Maniconico  Moderno  Gior- 


I40S 


PSYCHOLOGICAL  LITERATURE. 


Periodical  Xiterature  (continued) — 

nale  di  Psichiatria,  Organo  del  Manico- 
nico  Iiiterp.  Y.  E.  H.,  Ed.  Dr.  Limoncelli 
1S44  (Tip.)  ;  The  Medico-legal  Journal, 
by  authority  of  the  Medico-legal  Society 
of  New  Yorlc,  Ed.  Clark  Bell,  quarterly, 
1883  (New  York)  ;  Mind,  a  quarterly 
review  of  psychology  and  philosophy, 
Ed.  G.  F. Stout,  quarterly,  1876  (London); 
Nederlandsch  Tijdschrift  voor  Genees- 
kunde  tevens  Orgaan  der  Nederlands- 
che  Maatschappij  tot  Bevorderung 
der  Geneeskunst,  1S88  (Amsterdam)  ; 
Neurologisclies  Centralblatt,  iibersicht 
der  Leistungen  auf  dem  Gebiete  der 
Anatomic,  Physiologic,  Pathologic  und 
Therapie  des  Nervensystems  einschlies- 
slich  der  Geisteskrankheiten,  Ed.  Prof. 
Mendel,  monthly,  1 882  (Leipzig);  Nouvelle 
Iconographie  de  la  Salpetriere,  Director, 
Prof.  Charcot,  bi-monthly  (Paris)  ; 
La  Psichiatria,  la  neuropatologia  et  le 
scienze  aflini,  Ed.  Dr.  Bianchi,  quarterly, 
1S83  (Naples);  Psychiatrische  Bladen, 
uitgegeven  door  de  Nederlandsche 
Vereeniging  voor  P^yclnatrie,  Ed.  Dr. 
Tcllegen,  J.  van  De  venter,  &c.,  quar- 
terly, 1883  (Amsterdam)  ;  The  Psycho- 
logicalJournal,  Ed.  E.  Mead,  bi-monthly, 
1753  only  (Cincinnati)  ;  The  Psycho- 
logical  and    Medico-legal  Journal,  Ed. 


Periodical  Iiiterature  {continued) — 

W.  A.  Hammond,  2  vols,  yearly,  1874-6  ; 
also  as  The  Quarterly  Journal  of  Psycho- 
logical Medicine  and  Medical  Juris- 
prudence, 1867-9  (New  York);  Rivista 
frenopitica  Barcelonesa,  Ed.  J.  G.  j 
Partagus,  monthly,  1881  1  Barcelona) ; 
Rivista  Sperimentale  di  Freniatria  e  di 
Medicina  Legale  in  relazione  con  Tantro- 
pologia  e  le  Scienze  Giuridiche  e  Sociali, 
Ed.  Prof,  Aug.  Tamburini  and  others, 
monthly,  1875  (Reggio  Emilia)  ; 
Rivista  Sperimentale  di  freniatria  e  di 
medicina  legale  in  relazione  con  I'antro- 
pologia,  Ed.  Dr.  Livi  and  others, 
monthly-,  1875  (Reggio  Emilia)  ;  Yest- 
nik  Sudebnoi  Meditsini  i  abchestvennoi 
gigien,  quarterly,  1882  (St.  Petersburg); 
Vierteljahrsschrift  fiir  Psychiatrie  in 
ihren  Beziehungen  zur  Morphoiogie, 
Pathologie  des  Central-nervensystems, 
&c.,  Ed.  Drs.  Leidesdorf  and  Meynert, 
1867-9  (Leipzig) ;  West  Riding  Asylum 
Medical  Reports,  Ed.  by  Sir  J.  Crich- 
ton  Browne,  yearly,  1871-6  (London); 
Zeitschrift  fiir  die  Authropologie  (form- 
erly Z-  fiir  psychische  Aerzte},  Ed.  Dr. 
Nasse,  1816-26;  Zeitschrift  fiir  Psy- 
chologic und  Physiologic  der  Sinnes- 
organe,  Eds.  Ebbinghaus  und  Konig, 
bi-monthlv  (Hamburg). 

A.  R.  U. 


TABLE   OF   LEGAL   ABBREVIATIONS. 


Abr.  Eq.  Cas. 

Add.      . 

A.  &  E. 

App.  Cas. 
Atk.      . 
Bac.  Abr. 

B.  &  Ad. 
B.  &  C. 
Beav.    . 
Bins-.  X.  C. 
Bli^h,  N.  S. 

B.  &  B. 
BuUer,  N.  P 
Camp.  . 

C.  &  K. 
C.  &P. 
Ch.  Cas. 
Cas.  (temp. 
CI.  &  F. 
Co.  Litt. 

C.  B.     . 
Com.  Dig. 
Cox,  C.  C. 
Cro.  Eliz. 

C.  M.  &  R. 

Curt.  E.  R. 

Deane  . 
De  Gex 

D.  M.  &  G. 

Denio   . 

Den.  C.  C. 

Dow 

Dowl.  Rep. 

D.  &R. 

D. 

East      . 

Ex. 

F.  C.     . 

Fonbl.  . 

F.  &  F. 

Gray     . 
Hagg.  C.  R. 

Hagg.  E.  R. 

Hale,  P.  C. 

Hawk.  P.  C. 


Leci 


Abridgement,  Equity 
Cases. 

Addams'  Reports. 

Adolphus  and  Ellis'  Re- 
ports. 

Appeal  Cases. 

Atkyns'  Reports. 

Bacon's  Abridgement. 

Barne  wall  and  Adolphus. 

Barne  wall  and  Cress  well. 

Beavan's  Repoi'ts. 

Bingham's  New  Cases. 

Bligh,  New  Series. 

Broderip  and  Bingham. 

Buller's  Nisi  Prius. 

Campbell's  Reports. 

Carrington  and  Kirwan. 

Carrington  and  Payne. 

Cases  in  Chancery. 

Cases  temp.  Lee. 

Clark  and  Finnelly. 

Coke  on  Littleton. 

Common  Bench. 

Comyn's  Digest. 

Cox's  Criminal  Cases. 

Croke  temp.  Elizabeth. 

Crompton,  Meeson,  and 
Roscoe. 

Curties'      Ecclesiastical 
Reports. 

Deane's  Reports. 

De    Gex's     Reports     in 
Bankruptcy. 

DeGex,  McNaghten,and 
Gordon. 

Denio's  Reports  (U.S.). 

Denison's  Crown  Cases. 

Dow's  Reports. 

Dowling's  Reports. 

Dowling  and  Ryland. 

Dunlop's  Reports. 

East's  Reports. 

Exchequer  Reports. 

Faculty  Cases  (Scotch). 

Fonblanque's  Equity. 

Foster    and     Finlason'g 
Reports. 

Gray's  Reports  (U.S.). 

Haggard's     Consistorial 
Reports. 

Do.    Ecclesiastical    Re- 
ports. 

Sir       Matthew      Hale's 
Pleas  of  the  Crown. 

Hawkins'   Pleas  of   the 
Crown. 


Hob.      . 
How.  St.  Tr. 
H.  &  N. 
Irvine    . 
Jacob    . 
J.  &  Lat. 

K.  &  J. 

Kel. 

L.  J.,  N.  S.,  Ch.    . 

L.  J.,  N.  S.,  C.  P.  . 
L.  J.,  N.  S.,  Ex.  . 
L.J.,  N.  S.,P.M.  & 
A.  .  .  . 
L.  J.,  N.  S.,  Q.  B. 
L.  R.,  Ch.  D. 

L.  R.,  Eq.  . 
L.  R.,  Ex.  . 
L.  R.,  Ir. 

L.  R.,  P.  &  D.        .) 
L.  R.,  P.  &  M.        . ) 
L.  R.,  P.  D.  . 
L.  R.,  Q.  B.   . 

L.  R.,  Q.  B.  D.       . 

L.  R.,  Sc.  &  Div.  . 

L.  T.      .         .         . 

Leach    . 

Lew. 

Mac.  &  G.      . 

Macph. . 

M.  &  G. 

Mass.     . 

:\L  &  W. 
Mod.       . 
Moo.  P.  C.     . 
M.  &  Rob.     . 
Moor.     . 
Myl.  &  Cr.     . 
M.  &  K. 
N.  Y.      . 

Phill.,  E.  R.  . 

Plowden 

P.  (1892)        .        . 

R 


Hobarfs  Reports. 

Howell's  State  Trials. 

Hurlstone  and  Norman. 

Irvine's  Reports. 

Jacob's  Reports. 

Jones  and  Latouch's  Re- 
ports. 

Kay  and  Johnson. 

Kelynge's  Reports. 

Law  Journal,  New  Series 
(Chancery). 

Do.  (Common  Pleas). 

Do.  (Exchequer). 

Do.   (Probate,   Matrimo- 
nial, and  Admiralty). 

Do.  (Queen's  Bench). 

Law  Reports  (Chancery 
Division). 

Do.  (Equity  Cases). 

Do.  (Exchequer  Cases). 

Do.  (Ireland). 

Do.    (Probate    and    Di- 
vorce). 

Do.  (Probate  Division). 

Do.      (Queen's      Bench 
Cases). 

Do.  (Queen's  Bench  Di- 
vision). 

Do.     (Scotch    and     Di 
vorce). 

Law  Times  (Reports). 

Leach's  Reports. 

Lewin's  Crown  Cases. 

McNaghten     and    Gor- 
don's Reports. 

Macpherson's  Reports 
(Scotch). 

Manning  and  Granger's 
Reports. 

Massachusetts    Reports 
(U.S.). 

.^leeson  and  Welsby. 

Modern  Reports. 

IMoore's  Privy  Council. 

Moody  and  Robinson. 

Moore's  Reports. 

Mylne  and  Craig. 

Mylne  and  Keen. 

New       York       Reports 
(U.S.). 

Phillimore's     Ecclesias- 
tical Reports. 

Plowden's  Reports. 

Probate  Reports,  1892, 

Rettie's         Reports 
(Scotch). 


I4IO 


TABLE    OF   LEGAL   ABBREVIATIONS. 


Eep.       . 

.     Coke's  Reports. 

Eidg..  r.  C.   . 

.     Eidgway's  Pleas  of  the 

Crown. 

Eob.,  E.  R.    . 

.     Robertson's  Ecclesiasti- 

cal Reports. 

Roberts. 

.     Robertson's  Reports. 

Russ.     . 

.     Russell's  Reports. 

Salk.      . 

.     Salkeld's  Reports. 

Sav. 

.     Saville's  Reports. 

S. 

.     Shaw'sReports  (Scotch). 

Sid. 

.     Siderfin's  Reports. 

Sim. 

.     Simons'  Reports. 

Str. 

,     Strange's  Reports. 

S.  &  T.  . 

.     Swabey  and  Tristram. 

Times  L.  R.    . 

Times  Law  Reports. 

Ventr.    . 

Ventris's  Reports. 

Verm.     . 

Vermont  Reports  (L'.S.} 

Ves.        . 

Vesey's  Reports. 

V.  &  B.  . 

A'esey  and  Brames. 

Ves.  Jun. 

Reports  of  Vesey, 

Junior. 

W.  N.     . 

AVeekly  Notes. 

W.  R.    . 

Weekly  Reporter. 

Wendell 

Wendell'sReports(U.S.) 

W.  &  S. 

Wilson  and  Shaw's  Re- 

ports (Scotch). 

Y.  &  Coll.      . 

Younge     and    CoUyer  s 

Reports. 

TABLE    OF   LEGAL   CASES. 


Allcard  r.  Skixnkk  . 
Amicable  Society  v.  Bollaiul 
Anon.    .... 
Ai-nold,  R.  V. 
Ashton  ;;.  Poynter 

Bagster  v.  Portsmouth 
Bainbrigge  ;>.  Bainbrigge 
Baines,  llcg.  v. 
Baker  r.  Baker 
Baker  v.  Cartwright 
Banks  v.  Goodfellow     .    30^ 
Bannatyne  r.  Bannatyne 
Bartholomew  r.  George 
Bawden  r.  Bawden 
Beavan  r.  McDonnell    . 
Bellingham,  R.  r.  . 
Bempde  v.  Johnstone    . 
Bennett  v.  Taylor . 
Bervl  (The)    / 
Bethell,  Be    . 
Betts  v.  Clifford     . 
Beverley's  Case 
Blanchard  /•.  Nestle 
Blewitt  V.  Blewitt 
Bolland  r.  Disney 
Bonelli,  //(  re 
Bootle  V.  Blundell 
Borrodaile  r.  Hunter 
Boughton  i\  Knight        462 
Bowler,  R.  v. 
Brocklehurst,  Reg.  v.    . 
Browning  v.  Reane 
Bryce  v.  Graham  . 
Brydges,  E.c  parte 
Buckley  v.  Rice  Thomas 
Burrows  v.  Burrows 
Burt,  Reg.  v. 

Cannon  v.  Smalley 
Carroll,  Reg.  /;. 
Carter  v.  Boehm    . 
Cartwright  *■.  Cartwright 
Chambers  r.  Queen's  Proctor 
Chambers  c.  Yatman     . 
Clarke  0.  Lear 
Cleaver  c  Mutual  Reserve  F 
Clift  V.  Schwabe    . 
Cloudesley  v.  Evans 
Coghlan  v.  Coghlan 
Collier  v.  Simpson 
Collins  V.  Godefray 
Combe's  Case 
Converse  v.  Converse    . 
Ccoke  17.  Clayworth 
Cory  V.  Cory 


462 


24 


12S7 


12S8 


749 
891 
298 


268 
480 
686 

781 

779 

1289 

267 

464 

781 

2,  26S,  462 

301,  302 

•  396 

•  464 
.     480 

.  778 
.  481 
266,  267 
.  1289 
.   1287 

•  749 
.     480 

•  463 
749.  750 

1288,  1290 
302 
316 

77^ 
238 

553 
479 
463 
320 


315^ 
779,  780^ 

463, 


und  Life 


749: 


,783 
686 

479 
1286 

463 

1286 

1286 

749 

750 

777 

1286 

481 

4S2 

12S5 

1289 

685 

685 


Creagh  v.  Blood    .         .         .         . 

1289 

Cross  V.  Andrews  . 

266, 

1299 

Crowningshield  /'.  Crowningshieli 

1  1289, 

1290 

Cullam,  Reg.  v.      .   '      . 

318 

Cunliffe  u.  Cross    . 

1290 

Currie  i\  Child 

464 

Davies.  Reg.  V.    . 

294 

Davies,  Reg.  v.      .         .         . 

315 

Davis,  Reg.  v.         .         .         . 

686 

Delafield  v.  Parish 

1289 

Dew  V.  Clark 

1285, 

1287 

Dewar  r.  Dewar  and  Reid      . 

238 

Dickenson  v.  Barber 

1299 

Drew  V.  Nunn  .  .  59,  60,  268,  462,  993 
Dufaur  v.  Provincial  Life  Insurance  Co.  750 
Durham  v.  Durham  .  .  462,  778,  780 
Durling  v.  Loveland  ....  1286 
Durnell /'.  Corfield  ....  1286 
Dyce  Sombre  v.  Prinseps  (also  reported 
as  East  India  Co.  v  Dyce  Sombre)  462,  1289 

East  India  Co.  /'.  Dyce  Sombre  (also 
reported  as  Dyce  Sombre  v.  Prinseps)    462, 

1289 
Elliott  V.  Ince 267 


Faulder  /'.  Silk  . 
Fennell  v.  Tait 
Ferguson  v.  Barrett 
Ferrers,  R.  r. 
Frank  v.  Frank 
Frere  v.  Peacocke 
Fry  17.  Fry     . 

Galoway,  R.  v.    . 
Gamlen,  Reg.  v.     . 
Garnier,  In  re 
Gillespie  v.  Gillespie 
Goode,  Reg.  v. 
Gore  V.  Gibson 
Granger,  H.M.  Advocate 
Greenslade  c.  Dare 
Grimwood  v.  Bartels 
Grindley,  R.  v. 
Grove  v.  Johnston  . 

Hadfield,  R.  v.     . 
Hall  V.  Hall     . 
Hall  V.  Warren 
Hanbury  v.  Hanbury 
Hancock  /'.  Peaty  . 
Harford  *;.  Morris  . 
Harrod  v.  llarrod  . 
Harwood  r.  Baker  . 
Hassard  v.  Smith    . 


463 


267 
464 
462 
298 
267 
1289 
780 

463 
686 
396 
1286 
294 
685 
686 
464 
396 
686 

59 


299,  301 

.  782 

267,  1286 

xvi 

2,  778,  780 

■  777 

•  778 

1285,  1288 

.  267 

4X 


46 


I4I2 


tai;le  of  legal  cases. 


Hastilow  r.  Stobie  . 
Hastings,  Ux  parte 
Haycraft  v.  Creasy 
Hayward  r.  Hayward 
Helmore  r.  Smith  . 
Hepburn  v.  Skirving- 
Herbert  r.  Lowns  . 
Hethersal,  K.  r. 
Hill,  Reg.  V.    . 
Hoby  V.  Hoby 
Hodges,  Reg.  v. 
Holy  land.  Ex  jKirtc 
Horn  /•.  Anglo-Australian,  <S:c 

Co.       .         .         . 
Houston,  Be  . 
Huguenin  i-.  Baseley 
Hume  V.  Burton 
Hunter  v.  Edney     . 
Huntig  r.  Railing  . 
Hyde  v.  Hyde 


IMPEE1A.L  Loan  Co.  r. 

James,  Re 
Jenkins  v.  Morris    . 
Johnstone  v.  Marks 
Jones  r.  Lloyd 
Jones  r.  Noy  . 

KiNLOCH,  R.  V. 
Knight  V.  Young     . 

Laing  v.  Bruce 
Larkin     . 

Layton,  Ex  parte    . 
Lee,  Be   . 
Lee  V.  Everest 
Lightfoot  V.  Heron 
Lispenard  (Alice),  Case 
Lovatt  /'.  Tribe 
Lyon  V.  Home 


Stone 


MacAdabi  v.  Walker 

McNaghten,  Reg.  v.    90,  296,  304-3 

Manby  v.  Bewicke  . 

Marsli  v.  Tyrell 

Martin  (Jonathan),  R 

Martin  v.  Johnston 

Mason  v.  Keeling    . 

Matthews  i\  Baxter 

Maxsted  v.  Morris  . 

Meakin,  Reg.  v. 

Middlehurst  r.  Johnson 

Mills  V.  Mills  . 

Molton  '0.  Camroux      242,  266,  268 

Monkhouse,  Reg.  /'. 

Mordaunt  v.  Moncrieffe  .     780,  78 

Morison  v.  Maclean's  Trustees 

Morison  v.  Stewart 

Morrison  v.  Lennard 

Mountain,  Reg.  r.   . 

Mudway  r.  Croft    . 


NiELL  V.  Morley     . 

OCEAX  S  S.  Co,  r.  Apca: 
Oxford,  Reg.  r. 

Palmer,  Reg,  r,     , 


.  1290 

•  133 

•  1299 
.  782 
.     891 

•  396 
.  1285 
.  463 
.  464 
.  1289 
.  293 
.  1286 

Insurance 

•  749 
.     396 

•  1337 
.     267,  464 

779,  780,  782 

100 

.         .     778 

1376,  1377 

.     116 

267,  462,  1289 

.     268 

.     891 

.     268,  890 


12 


of 


&  Co. 


464 
463 


1287 

.     238 

.     116 

.     116 

.     482 

267,  685 

1288,  1289 

462,  480 

1337 


20,46 

268, 

,685 

.78 


463 

480 

995 
463 
309 
480 

1299 
685 
48 1 
686 

1290 
476 

1377 

686 

1299 

1287 

777 

464 

687 

1286 


267,  685 

.    480 
293,  303-4 

480,  481 


Parker  v.  Felgate 
Parker  v.  Parker 
Pearce,  Reg.  v. 
Phillips,  Be     . 
Pitt  V.  Smith  . 
Portsmouth  r.  Portsmouth 
Price  V.  Berrington 
Pritchard,  Reg.  '•.  , 

R (Mary),  Reg,  /•, 

Read  r,  Legard 
Reibey,  Ex  parte     . 
Rennie  (Wm.),  Case  of 
Rhodes  v.  Bate 
Ridler  v.  Ridler 
Roberts  v.  Kerslake 
Robertson  -v.  Locke 
Rodd  V.  Lewis 
Ruston,  R.  r.  . 

Selby  r,  Jackson 
Scott,  Be 
Scott  r.  Bentley 
Scott  V.  Sebright 
Sergeson  i\  Sealey 
Sharpe  v.  Crispin 
Smee  r,  Smee 
Smith  V.  Tebbitt 
Snook  r.  Watts 
Somervile's  Case 
Southey,  Ree,  v. 
Spittle  V.  Walton 
Stamp,  Ex  2)arte 
Stanhope  v.  Stanhope 
Stroud  V.  Marshall 
Sussex  Peerage  Case 
Symes  /■,  Green 

TOOGOOU  r.  Wilkes 

Towart  r.  Sellars  , 

Turing,  Ex  parte  . 

Turner,  Ex  parte  . 

Turner  r.  Meyers  , 
Turton,  Reg.  r. 
Tyrell  v.  Jenner 

i  Vavasour,  Re 

!  'VA'ADE,  R,  r.    , 

AA'are,  Reg.  r. 
\  AVaring  t'.  Waring  .         -319 
I  Watson,  Ex  parte 
j  Watts,  In  re  . 
I  Weaver,  Be     . 

Weaver  v.  Ward 

Webb  V.  Manchester,  &c.,  Ry 

Webb  r.  Page 

Wenman's  Case 

White  r.  British  Empire,  &c 

White  r.  White 

Whitefoot,  Doe  r.  . 

Williams  v.  Wentworth 

Willis  r.  Peckham  . 

Winchester's  Case 

Windham,  Be 

Wright  r.  Doe  d.  Tatham 

Yarrow  r.  Yarrow 
Yates  V.  Boen 


778, 

Co. 
Co. 


.  1290 

•  777 

•  293 

■  476 

266.  685 
779,  780 
268 
294 

687 
268 
889 
686 

1337 
1299 

463 

891 

1286 

464 

267 

463 

396 

780 

464 

396 

1288,  1290 

778,  1287 

463,  1286 

293 

293 

464 

116 

781 

266 

481 

1289 

190 
[286 

777 
100 

111 
294 

463 


56 

464 

315 
1287 

666 
1286 

26S 
1298 

479 
481 
666 

749 
782 

463 
268 

482 
1285 

;,  464 
464 

xvi 
266 


128! 


462,  46. 


INDEX. 


A-iOKM  clironoscoiiu  (Galtoii),  1018 
AI)a<li.  iiK'tliiHl  of  exiiiiiiiiiitioii  of  criminals,  292 
Abasia  and  astasia,  liystcrical.  635 
Abdominal  liypochondriasis,  615 

insanity,  1245 
Aberdeen  l{oyal  Asyltiin,  1095 
Abnormal  forms  of  alcoholism,  72 
Abnormalities  in  jiosture  in  mental  states,  991 
Aboiilia,  1366,  1367 
Abscesses   and    accidental  deformities,  and    deaf 

nnitisni,  327 
Absence,  leave  of,  of  patients,  736 

Scotland,  1123 
Absence  of  mind,  420 
Abstinence  from  morphia  abuse,  818 

sudden,  818 

protracted,  818,  819 

sexual,  and  satyriasis,  1109 
Access  to   patients,   reiiiilations    as   to,    Scotland, 

1117 
Accidental  idiocy,  643,  645 

causes  of  idiocy,  659 

suicide  in  the  insane,  1231 
Accidents  at  birth  causing  idiocy,  663 
Account,   action    of,  period  of   limitation  of,  and 

lunacy,  994 
Acefalcs,  the,  436 
Acetal,  action  of,  1137 
Achromatopsia  in  chronic  alcoholism,  75 

hysterical,  621,  632 
Acidity  of  urine  in  mental  affections,  1342 
Acquired  diathesis,  384 

insanity,  694 

characteristics  inherited  and  instinct,  704 
Acrosesthesia  in  neurasthenics,  845 
Acrophobia,  678,  679 
Actions,  consensual,  265 

in  diagnosino;  insanity.  378,  379 

automatic,  397,  822 

recurrent,  821 

comiiound,  822 

adai)ted,  824,  825 

in  iiersecntion  mania,  929,  930 
Actions,  legal,  limitation  i)eriod  of,  in  lunacy,  994 

for   improi)er   detention,    limitation   of,  Scot- 
land, 1 121 
Active  delirium,  332 

scut  and  mental  disorder,  548,  549 

melancholia,  790,  796 
Activities,  recreative,  248 

a-sthetic,  248 
Acts,  constructive,  356 

mechanical,  43 

impulsive,  379 

as  evidence  of  lunacy,  463 

as  proof  of  insanity,  242 

insanity  of,  697 

cerebral  reinforcement  of,  823 

corresponding'  to  mental  i)heiiomena,  1025 


Acts,  leyal,  relatini;-  to  certification,  189,  190,  191 

to  criminal  responsibility,  295 

to  chancery  patients,  195,  196,  197 

to  idiots,  665,  666 

to  commissioners  in  lunacy,  240 

to  county  councils,  275 

to  the  insane,  Ireland,  714,715 

to  the  insane,  Scotland,  1115,  1124,  1125 

to  registered  hospitals,  1079 

to  the  burial  of  suicides,  1220 

to  the  insane  in  workhouses,  1371,  1372 
Acute  cerebral  atrophy  in  senility,  872 
Acute    delirious    mania,   compared    witli    typical 
mania,  766 

prognosis  of,  1007,  1008 

diagnosed  from  septic  mania,  1039 

pulse  conditions  in,  1046 

post-rheumatic,  1093 
Acute  delirious  melancholia,  prognosis  of,  1009 
Acute  delirium  due  to  marriage,  776 
Acute  dementia,  348,  349 
Acute  general   paralysis,  microscopic  changes  in, 

537 
Acute  mania  arising  during  sleep,  1171 

followed  l)y  stupor,  121 1 

teni])erature  in,  1279,  1280 

occurring  simultaneously  in  twins,  1330  et  seq. 

diagnosis  from  delirium  tremens,  71 

simulation  of,  503 

and  general  paralysis,  diagnosis  between,  533 

in  folie  circulaire,  220 

due  to  cocaine  abuse,  236 

hallucinations  in,  567 

handwriting  in,  567 

masturbation  in,  784 

hyoscine  in,  1143 

in  senility,  871 

prognosis  of,  1008 

pulse  conditions  in,  1046 

irritation  mydriasis  in,  1055 
Acute  melancholia,  790 

Acute  syphilis  and  mental  decay,  1253,  1254 
Acute  intoxicating  poisoning,  972 
Adam,  James,  self-mutilation,  1147 
Adamites,  the,  436 

Adamkiewicz,  trifacial  paralysis,  1106 
Adams,  ojjerative  procedure  in  general  paralysis, 

1325 
Adaptive  reactions,  1069 
Addison,  delirium,  333 

urea  in  mania,  1343 

mineral  constituents  in  urine,  1347 

excretion  of  urea  in  general  paralysis,  1344 
Addison's  disease  and  insanity,  1246 

the  sympathi'tic  in,  1252 
Adelaide  Asylum,  iii 

Adhesions,  cortical,  in  general  paralysis,  536 
Adhesiveness,  law  of,  T028 
Adipsia  in  neurasthenia,  845 


'  This  Index,  which  has  been  prepared  by  Dr.  Pietersen,  omits  words  which  are  already  given  in  the 
Dictionary  siih  voc.  For  example,  only  sucli  references  are  given  under  "acute  delirious  mania"  as  are 
not  found  in  the  article  bearing  that  title. 


I4I4 


INDEX. 


Adjustments,  intentional,  and  instinct,  704 

Administrator,  lunacy  of  an,  476 

Admiralty  suits,  limitation  i)eriod  of,  and  lunacy, 

994 
Admission  rate  and  statistics,  1195 

voluntary,  to  asylums,  France,  516 

of  ])atieuts,  resnlations  as  to — 
Holland,  591 

England  and  Wales,  731,  739  et  seq. 
Scotland,  1018  et  set/. 
Ireland,  710,  711,  713 
France,  516,  517 
Gei-mauy,  546 
Austria,  115 
United  States,  87 
Spain,  1 179 
Adolescence,  training'  during,  999 
Adolescent  insanity,  heredity  in,  362 
masturljiition  in,  366 
mental  imperfection  after,  369 
remissions  in,  365,  366 
menstruation  in,  365 
symptoms  of,  363 
statistics  of,  362 
signs  of  recovery  in,  369 
treatment  of,  370,  371 
reaction-time  in,  1066 
mania,  364 
melancholia,  366 
Adolescents,  normal  jisychology  of,  367 

secondary'  dementia  of,  369 
Adult,  brain  injury  in  the,  1309 
Adult  cretinism,  286 
Advowsons,  i-ecovery  of,  limitation  period  of,  and 

lunacy,  994 
Adynamic  type  of  acute  delirious  mania,  53 
Aeby,  study  of  microcephalous  brains,  805 
^sculapius,  temples  of,  and  treatment  of  insanity, 

12 
^Esthetic  activities,  248 

feelings,  failure  of,  in  general  paralysis,  529 
AfEection  vaporeuse,  841 
Affection,  weeping  due  to,  1274 
jiffective  life  in  children,  disturbances  of  the,  203 
faculties,  per\ersion  of,  in  early  general  para- 
lysis, 521 
insanity,  694 
monomania,  8ix,  812 
Affidavits,  medical,  for  petition  de  lunatico  inqui- 
rendo,  198 
non-medical,    for    ])etition  de  lunatico  inqui- 
rcndo,  198 
After-care  of  the  insane,  Switzerland,  1242 
Age  as  ])redisposing-  cause  of  general  paralysis,  534 
influence  of,  in  brain  weight  in  the  insane,  165 
influence    of,    in   occurrence     of    persecution 

mania,  933 
influence  of,  on  size  of  head,  578 
in  development  of  hysteria,  629 
influencing  recovery  in  asylums,  1198 
and  mortality  in  asylums,  1198 
and  relative  liability  to  insanity,  1202 
and  mental  stupor,  1212 
and  suicide,  1226,  1227 
tears  in  old,  1274 
and  temperaments,  1277 
in  transitory  mania,  1304 
in  traumatic  injury  of  brain,  1307,  1308 
influencing  varieties  of  apoplexy,  976 
in  prognosis  of  insanity,  1006 
and  puerperal  insanity,  1036 
and  size  of  pupils,  1054 
influeuce  of,  in  reaction-time,  1069 
Aged,  the  psycho.-es  of  the,  869 

tremor  in  the,  1324 
Agent,  lunacy  of  an,  59 
Aggressiveness  in  i)ersecution  mauia,  930 


Agitated  melancholia,  796 

states  of  katatonia,  724 
Agitation,  mental,  without  delusions,  in  folie   cir- 

culaire,  218 
Agnate  and  cognate  (Scots  Lunacy  Law),  238 
Agonia,  378 

Agorajihobia,  678.  844,  1367 
Agraphia,  800,  980 

mental  condition  in,  983 
in  general  paralysis,  527 
Agreements  between  local    authorities  (asylums), 

279 
Ague,  the  leaping,  748 

and  insanity,  756,  757 
Sydenham.  21 
Aitken,  specific  gi'aviry  of  brain,  158 
Ajax,  insanity  of,  7,  8,  553 
Akataphasia,  379 
Akinesia  in  neurasthenics,  845 
Albertoni,  salivation  in  epilepsy,  1106 
Albumen  in  urine  in  mental  states,  1348,  1349 
Albuminoids  in  brain,  146.  151 
Albuminuria  and  puerperal  insanity,  1037 

in  iusanity,  172 
Alcohol  and  sunstroke,  1233 
in  grief,  1275 

abuse  of,  in  neurotic  adolescents,  999 
abuse  of,  and  iiuerperal  insanity,  1037 
effects  of,  on  nervous  system,  74 
influence  of,  on  attention,  110 
abuse  of,  62 

conse(iuences  of  abuse  of,  65 
influence  of,  in  malarial  insanity,  757 
habit,  Weir  Jlitchell  treatment  of,  852,  853 
and  syphilis,  different  action  of,  on  nervous 

system,  915 
as  a  hypnotic,  1133 
derivatives  of,  as  sedatives,  1132 
tremor  in  poisoning  by,  1320 
Alcoholic  causes  of  insanitj',  Denmark,  11 14 
delirium.  66,  340 
dementia,  78 

principles  in  brain,  146,  151 
base,  influeuce  of,  on  form  of  drunkenness,  416 
erethism,  340 

delirium,  incoherence  of,  343 
mental  di.sease,  diagnosed  from  general  para- 
lysis, 532 
excess  as  exciting  cause  of  general  paralysis, 

535 
insauity,  694 
melancholia,  796 

poisoning,  the  pathology  of,  912,  913,  915,  918 
paralysis,  923 

paralysis,  motor  sjiuptoms  in,  923 
pai-alysis,  sensory  symptoms  in,  923 
paralysis,  catamenia  in,  923 
Insanity  diagnosed    from   persecution-mania, 

933 
type  of  insanity  in  toxic  states,  971 
insanity,  prognosis  of,  1012 
insanity,  reaction-time  in,  1064 
insanitj',  temperature  in,  1281 
trance,  1300 
Alcoholism  and  dipsomania  differentiated,  391,  393, 

394 
chronic,  impulse  in,  389 
chronic,  the  exaltation  of.  473 
diagnosis  of,  71 

diagnosis  of  abnormal  forms  of,  72 
prophylaxis  of,  72 
at  the  climacteric,  235 
and  male  hysteria.  624 
and  insane  jealousy,  722 
and  kleptomania,  727 
parental,  as  cause  of  idiocy,  661 
and  plumbism,  747 


INDEX. 


1415 


Alceholisiii.  acute  luaiiia  after,  767 

haeuiatoma  of  dura  uuiter  i»,  879 

occurrence  of,  iu  the  sexes,  1155 

elironic,  cord  elianyes  iu,  1191 

suicide  iu,  1231 

sub-acute,  tlie  treiuor  of,  1320 

acute,  (lie  treiu(u- of,  1320 

dirouic,  the  tremor  of,  1320,  1321 
Ak'oolisiue  cerebro-siiiual  aiL;u  (l^aiiceraux),  415 
Aldersou,  ISarou,  jilea  of  iusauity,  294 
Aldiui,  electricily  in  mental  alVuctions,  427 
Aldridue,  oplitlialuiic  signs  in  stupor,  1045 
Alexuuderisin,  61 
Alexia  in  insanity,  384 

in  general  paralysiti,  527 
Algiers,  latliyrisni  in,  730 

Alglave's  system  for  diminisbiuL;  drunkenness,  73 
Alienation  iiartielle  (Falret),  406 

mentale,  508 
Aliones  niiyrateurs,  931 
Alimentary  functions,  anomalies  of,  in  melancholia, 

788 
Alkaloids  in  Ijrain,  151 

Allbutt,  T.  Clift'ord,  ophtlialmic  changes   in  acute 
mania,  492,  1047 

ophthalmic  cliaiiiies  in  melancholia,  492 

insanity  in  children,  202 

optic  atrophy  iu  general  paralysis,  490 

percentage  of  insane  with  ocular  symptoms, 
491 

alcoholism  in  the  sexes,  1155 
Alliteration  of  siieocb  in  insanity,  379 
Alopecia  iu  the  insane,  564 
Alpdriicken,  433 
Alternating  consciousness,  378 

insanity,  694 

memory,  799 

states  of  excitement  and  depression,  toxic,  970, 
971 
Alternations  of  insanity  and  febrile  states,  987 
Altruistic  symjjathies,  development  of,  367 
Alt-Scherbitz  Asylum,  103 

Amadei  and  Tonnini,  classification  of  paranoia,  887 
Ambition,  ideas  of,  iu  persecution  mania,  929 
Ambitious  insanity,  694 

type  of  delirium  tremens,  70 
Amblyopia  due  to  idbacco  abuse,  1298 

in  general  paralysis,  491 

in  alcoholic  insanity,  492 

alcoholic,  75 
Ambulatory  automatism  (Tissie),  402 

hysterical,  638 
"  Ambulatory  typhoid,'"  mental  disturbance  iu,  506 
Amendment  of  certificates,  734 
Amenorrhoca  and  nervous  att'ectious,  1351 
America,  training  ot  asylum  attendants  in,  861,  862 
American- Indian  type  of  idiocy,  647 
Amido-aeids  in  brain,  151 

-lipotides  in  brain,  150 
Amidomyelin,  148 
Ammonium  bromide,  action  of  1130 
Amnesia,  980 

in  toxic  states,  968 
hystero-epilcptic,  377 

somnambulous,  377 
post-liypuotic,  1216 
following  transitory  frenzy,  1305 
total,  798 
partial,  799 
progressive.  800 
Amnesia;,  partial,  377 
Amuck,  running,  1097 
Amusements  in  treatment  of  insane,  1315 

United  States,  88 
Amylene  hydrate,  action  of,  1139 
Amyloid  deg^eneration  of  cord,  161 
of  medulla,  161 


Amyloid  degeneration,  specific  gravity  jind,  161 
Auauiia  of  optic  disc  in  general  paralysis,  490 

cerebral,  iu  i<liocy,  649 

in  general  paralysis,  802 

of  brain,  morbid  suspicion  in,  942 

in  phthisical  insanity,  947 

cerebral,  during  sleep,  1170,  1171 
Anaemic  states  and  delirium,  338 

insanitj',  695 
An.Tsthcsia,  alcoholic,  75 

in  criminals,  2i)0 

of  alcoholic  delirium,  343,  344 

iu  hysterical  demonomania,  354 

gustatory,  554 

in  cataleptic  stage  of  hypnotism,  607 

iu  hystero-epilepsy,  631 

of  special  sense  organs  in  hysteria,  632 

in  hysterical  paralysis,  633 

in  mania,  763 

in  neurastiieuia,  845 

during  somnambulism,  1172 

of  hypnotism,  1216 
Anaesthetic  areas  iu  melancholia,  836 
Auicsthetics,  mental  effects  of,  92,  205,  1313 

employment  of,  in  ophthalmic  examination  of 
the  insane,  485 
Analgesia  in  clironic  alcoholism,  75 

in  criminals,  290 

of  alcoholic  delirium,  343,  344 

of  hypnotism,  1216 
Anaphrodisiacs  in  nymphomania,  866 
Anatomy  of  brain,  168 
Anatomy  of  Melanch<ily,  Hurton's,  22 
Anatomy  of  the  sympathetic  system,  1246,  1247 
Anceaume,  circular  insanity,  215 
Ancient  records  of  liypnotism,  603 

of  insanity,  683,  684,  752 
Ancients,  extent  of  mental  abtrratiou  among  the, 
I,  2,  434 

suicide  among  the,  1217 
Anderson.  .1.,  epilepsies  and  insanities, 

440 
Andral.  blood-supply  and  functional  disturbances, 

135 

specific  gravity  of  brain,  158 

cerebral  hyperlroiihy  in  idiocy,  649,  650 
Aneccrisia  in  neurasthenia,  846,  847 
Anergic  stupor,  1208 
Aneurism  and  mental  symiitoms,  179 
Anger,  nervous  action  of,  837 
Angina  pectoris,  hysterical,  637 

the  sympathetic  in,  1251 
Aniline  blue-black  staining  fluid,  117 
Animal  and  hunnm  psychology,  29 

impulse,  681 

heat,  sympathetic  nerves  and,  1250 
Animals,  madness  in  (  I'lularch),  17 
Auisocoria,  1054 
Anointers,  the,  437 
Anorexia  nervosa,  624,  636,  852 

alternating  with  insanity,  80 

moral  treatment  of,  495 

insane  causes  of.  494 

in  neurasthenia,  845 
Anosmia  in  mental  disi'ase,  1174 
Ante-natal  development  of  cretinism,  284 
Ante-nui)tial  insanity  and  mari'iage,  775 
Anterior  iiolio-myelitis,  aculc,  and  idiocy,  656 
Anthrov>ology,  criminjil,  288 
Anthroi)omori)hon,  759 
Anthropophobia,  844 

Antimony  in  treatnieiil  of  insanity,  1291 
Antiperiodics  in  circular  insanity,  227 
Antithetical  nu'ntal  states,  825 

spontaneous  postures.  991 
Anuria,  hysterical,  637 
Anxiety,  facial  expression  of,  483 


I4I6 


INDEX. 


Auxiety,  wecpiiiL;  dm'  Id,  1274 
Aortic  disease  and  mania,  1246 

regurgitation  and  mental  symptoms,  178 

stenosis  and  mental  symptoms,  178,  179 

and    mitral    disease   conjoined,    and    mental 
symptoms,  179 
Ai)cpsia  hysterica,  624.  852 
Apliasia  due  to  hereditary  syphilis,  1264,  1265 

handwriting  in,  573 

in  toxic  states,  968 

civil  responsibility  in,  983,  984 

in  the  insane,  984 

motor,  979 

sensory,  980 

mixed  forms  of,  982 
Aphasie  disorders  in  senile  dementia,  873 
Apbemia,  799,  980 

mental  condition  in,  983 
Aphonia,  hysterical,  623,  636 
ApoUodorns,  the  insanity  of  Hercules,  8,  9 
Apomyelin,  148 
Apoplectiform  seizures  in  chronic  alcoholism,  76 

of  general  paralysis,  520,  530,  544 
Apoplexy,  u^^eof  the  term,  974,975 

in  the  insane,  978 
Apparatus    for     reaction-time  experiments,    1020 

et  seq. 
Apparitions,  1359 

Appeal  judges  and  Chancery  patients,  195 
Appetence,  31 
Appetite  in  mania,  762 

loss  of,  in  the  insane,  494 
Appetites,  failure   of,    in  initial  stage  of  general 

paralysis,  521,  522 
Appetitive  action,  42 

in  mental  health  and  disease.  1075 
Apprehension  in  post-apoplectic  mental  weakness, 

977 

mental,  38 
Apraxia  in  general  paralysis,  527 
Aprosexia,  1046 

pulse  conditions  in,  1046 
Arabic  classification  of  insanity,  830 
Arachnoid,  anatomy  of  the,  168 

cysts,  877 

hsematoma,  877 

the,  in  general  paralysis,  536 
Arachno-pia,   inflammatory  evidences    in,    in    the 

insane,  902 
Ararat  Asylum,  iii 

Arbnckle,  uterine  displacements  and  insanity,  1351 
Arc  en  cercle  in  convulsive  hysteria,  630 
Archbishop,  lunacy  of  an,  135 
Aretjeus,  lead  poisoning  and  epilepsy,  745 

sex  in  insanity,  1152 
Aretius,  sympathetic  disorders,  1242 
Argyll-Kobertson  pupil,  488,  489 
Aristotle,  dreams,  412 

on  insanity,  11,  12 

on  hallucinations  and  illusions,  12 

on  suicide,  1218 
Aristotle's  philosophy,  11,  44 
Arithmomania,  678 
Armagh  Asylum,  710 

Arndt,  Rudolf,  post-mortem  appeai-ances    of  sun- 
stroke lesions,  1236 

electricity,  uses  of,  in  insanity,  426 

neurasthenia,  840 
Arnold,  case  of  Engelbracht  the  ecstatic,  425 

classification  of  insanity,  231 
Arnold,  Edward,  case  of,  298 
Aromatic  substances  in  urine,  1347 
Arrest  of  general  paralysis.  S32 
Arsenic  abuse,  the  tremor  of,  1321 
Arsenical    poisoning,     diagnosed     from     delirium 

tremens,  71 
Arterial  atheroma  in  the  insane,  178 


Arterial  cerebral  disease  in  old  age,  872 

plugging,  inducing  cerebral  atrophy,  906 

thickening  in  idiocy,  655 
Arteries  and  heart,   sympathetic   relationship  be- 
tween, 1249 

cerebral,     affections     of,    due     to    congenital 
syphilis,  1261 

pathological  changes  in.  in  the  insane,  179 
Arthralgia,  hysterical,  633 
Articulation,  disorders  of,  in   established  general 

piiralysis,  527 
Artificial  feeding,  494 

by  mouth  .and  nose,  495,  498 

diets  for,  498 

nasal,  501 

contra- indications  to,  496 

position  in,  496 
Artistic  evidences  of  posture  in  mental  states,  991, 

992,  993 
Ascadogrites,  the,  436 
"  Ascending  general  paralysis,"  519,  523 
Ascher,  duration  of  general  ])aralysis,  ^jig,  520 
Asclepiades,  treatment  of  insanity,  14 

hallucinations,  565 

treatment  of  mental  disease,  715 
Ashe,  Isaac,  lunacy  laAvs  of  Ireland,  708 
Aspect,  the  epileptic,  454,  485 
Asphyxia  neonatorum  as  cause  of  idiocy,  663 
Assassins,  the,  437 
Assault,    actions   for,  period    of    limitation,    and 

lunacy,  994 
Assessors,  medical  men  as.  in  early  law  cases,  479 
Assimilation,  31 

Associated  accommodative  pupillary  reaction,  1053 
Association  of  superintendents.  United  States,  90 

of  medical  officers  of  hospitals  for  the  insane, 
786 
Association   times    in   reaction-time    experiments 
1071,  1072 

unlimited,  1072 

laws  of.  35.  36 
Assurin,  149 

Astasia  and  .ibasia,  hysterical,  635 
Asthenic  gangrene  in  the  insane,  129 
Asthma,  alternating  with  insanity,  81.  82,  loi 

gouty,  alternating  with  insanity,  83 

and  hypochondriasis,  615 
Astraphobia.  679,  844 
Asylum-farms,  France,  514 
Asylum-ear,  557 
Asylums,  early,  in  Spain,  1177 

in  Spain.  1 178.  1179 

in  Switzerland,  1238  et  seq. 

in  Turkey  and  Egypt,  1328 

in  Sweden,  11 10 

in  Norway,  mi 

in  Denmark,  1113 

regulations  as  to,  in  Scotland,  1118,  1122 

in  Russia,  1099 

private.  England  and  Wales,  1002 

private,  restraint  in,  in  the  eighteenth  century, 

23 
for  drunkenness,  73,  78 
in  Australia,  114 
chaplains  in.  201 

appointment  of  chaplains  to,  201,  280 
residence  of  chaplains  in,  201 
removal  of  chai>lains  from,  201 
superannuation  of  chai)lains  in,  201 
duties  of  chaplains  in,  201,  202,  280 
burial  grounds  of,  201 
legal  definition  of,  277 
private,  legal  definition  of,  277 
provision  of,  278 
enlargement  of,  279 
maintenance  of,  279.  280 
management  of,  280 


INDEX. 


1417 


Asylums,  lii)!iiu-i;il  nianiigciiicnt  of,  280,  281 

medical  ollicirs,  !ii)pointiiu'iit  of,  280 

paui)er,  staiulard  dictavy  for,  386,  387 

entcM'ic  ft^ver  in,  507 

in  Franc..,  513,  514 

private,  in  France,  5 16 

private,  in  Holland,  592 

early,  in  Germany,  544 

use  of  alcohol  in,  61 

paui)cr,  supervision  of,  by  county  councils,  276 

pauper,  visitation  of,  by  connty  council    com- 
mittee, 281 

in  Italy,  716,  718.  720 
Asymmetrical  skulls,  mode  of  measuicmeiil  of,  283 
Asymmetry  of  facial  balance,  482 

facial  muscular,  948,  949,  950 

in  microcei)halous  brains,  805 
Atavism,  361 
Atavistic  criminal,  288 
Ataxic    spinal    general    paralysis   due;  to    svpliilis, 

1258 
Ataxic  locomotrice  i)rogressive,  and  insanity,  750, 

751 
Ataxy  due  to  peripheral  neuritis,  751 

alcoholic,  751 

in  general  paralysis,  520 
pathology  of,  542 

cous'c'nital,  simulating'  hysteria.  1162 
Atlicroma,  arterial,  and  apoplexy,  975 

cerebral  arterial,  in  clironic  alcoholism,  76 

of  aortic  valve,  and  mental  symptoms,  179 

aortic,  and  mental  symptoms,  179 
Athetosis,  1322 
Atkins,  KiugTose,  iusanit.v  duo  to  lead,  745 

the  a>tioloiiy  of  lia;matoma  auris,  561 
Atrophy,  cerebral,  in  idiocy,  650,  651,  652 

of  the  brain,  general  aiul  local,  906 

optic,  in  general  paralysis,  490 
Atropism,  133 
Attendants  on  the  insane,  860,  861,  862,  863 

training'  of.  United  States,  88 

trainiug'  of,  England  and  Wales,  692,  693 

examinations  for,  693 

certiticates  for,  693 

register  of  certified,  693 

register  of,  Scotland,  1122 
Attention,  40,  467,  1367 

aptitude  for,  in  children,  467 

failure  of,  in  prodromic  stage  of  general  jiara- 
lysis,  522 

failure  of,  in  established  general  paralysis,  524 

reflex,  107 

and  memorv,  35 

in  mania,  763 

in  apliasics,  980 

in  reaction-time  experiments,  1069 
Attitude,  bodily,  in  melancholia,  788 
"Attitudes   ])assionelles  "  of   convulsive  hysteria, 

630 
Attonita  state  of  katatonia,  724 
Attorney,  power  of,  lunacy  of  a  grantor  of  a,  60 

of  a  lunatic,  993 
Attributes,   parental,  time   of  appearance  of.  ^84, 

585 
preponderance  of,  at   dillerent  times   ol   life, 
586 
Atypical  criminal,  288 
Audition  colorec,  11 25 
Auditory  activities  in  dreams,  413,  414 

and  visual  impressions,  and  word-deafness,  982 

aiul  word-blindness,  982 
liallui'inations,  566 

hallucinations  in  per.secution  mania.  927 
Augustin,  early  uses  of  electricity,  426,  427 
Aura  in  homicidal  impulse,  595 
in  convulsive  hysteria,  629 
Aural  disease  iind  insanity,  328 


Auricle,  couliguration  of  the,  418 
l)loody  tumour  of  the,  557 
congenital     hypertroiihy    of,     an<l    hamatoma 

auris,  diagnosis,  !^59 
l)ericliondritis  of  the,  5,57 
perichondritis  and  ha  luatouia  amis,  diagnosis, 

559 
Auto-hypnotism  in  stuporous  iMclaucholia,  1209 
Automatic  actions,  397,  822 

nu)vements  in  katatonia,  724 
Antomatisin,  ambulatory,  402 

jiost-epileptic,  798,  984 
Aiizouy,  use  of  electricity  in  mental  disease,  427 
Aversa  Asylum,  716 
Avertineux,  1102 

Awakening  from  hypnotic  sleep,  method  of,  607 
Awards,    action   ujion,   period  of    limitation,  and 

lunacy,  994 
Azam,  F.,  double  consciovisness,  401 

tht!  cataleptic  stage  of  hyjiHotisui,  609 

Bacchantes,  the,  553 

Bacon,  McKenzie,  handwriting  in  the  insane,  568. 

574 
cancer  and  insanity,  177 
Bacon,  trephining  in  mental  affections  due  to  brain 

injury,  1324 
Haillarger,  atropism,  133 

per.sistence  of  delnsions  after  chloroform  di  - 

lirium,  205 
folic  circulairc,  215,  216 
insanit.y  of  doubt,  407,  410 
duration  of  a  c.vcle  in  folie  circulairc,  222 
signs  of  transition  in  folie  circulaire,  224 
cupping  in  folie  circulaire,  227 
protective  societies  for  the  insane,  515 
remissions  in  general  paralysis,  532 
pathology  of  hallucinations,  568 
insanity  of  intermittent  fever,  756 
psychical  hallucinations,  928 
erysipelas  and  insanity,  986 
general  paralysis  following  erysipelas,  988 
melancholia  cum  stupore,  1209 
Baillou,  ptyalism  iu  the  insane,  1107 
Bain,  Alex.,  the  senses  and  the  intellect,  45,  46 
sensation,  46 
intellect,  46,  47,  1031 
feelings,  253 

Baker,  J. ,  kleptomania,  726 

pyromania,  1056 
Baker,  K.,  Turkish  baths,  126 
Balardini,  toxic  products  of  diseased  maize,  919 

progress  of  psychology  in  Italy,  717 
Baldness  in  the  insane,  564 
Balcnsky,  Prof.,  clinical   instruction    in    insanity, 

Kiissia,  1099 
Balfour.  o])ium  in  cardiac  mental  affections,  1141 
Ballard  and  Baily,  blood  in  malaria,  758 
Ball,  K.,  hyperactivity  iu   early  stage  of  general 
paralysis,  522 

hci'edity  .-is  a  factor  iu  general  paralysis,  534 

hallucinations  and  illusions,  565.  566 

classilication  of  dipsomania,  392 

insanity  of  doubt,  406 

illusions,  675 

delirium,  700 

dementia  of  i)aralysis  agitans,  885 

insanity  of  paralysis  agitans,  885 

paroxysms  of  excitement  in  paralysis  agitans, 

886 
frequency  of   insanity    in    paralysis    agitans, 

886 
elementary  hallucinations,  927 
phthisical  insanity,  942 
pulse  tension  in  mi'lancholia,  1044 
alcoholism  in  the  sexes,  1155 
tw^ins,  insanity  in,  1330 


I4i8 


INDEX. 


Ball.  11..  systcmiitised  insanity,  1356 
Ballinasloe  Asylum,  710 
Bamherfjer,  saltatoric  spasm,  1108 
lianu.  alc'oliolism  in  the  scxi'S,  1155 
BaiiUruiit,  huiacy  of  a,  116 
Bannistt'v,  monomania,  812 
Bardet,  liypuone,  1137 

action  of  hypnal,  1137 
Barlow.    T..    and    Bury,  Jndson    S.,    syphilitic 

hereditary     disease     of     nervous 

systera,  1259 
Barnard,  iusanity  of  doubt,  410 
Barnes,  K.,  climacteric  insanity,  234 

ovariotomy  and  oophorectomy  in 
relation  to  epilepsy  and  insa- 
nity, 87.S 

uterine  diseases  and  insanity,  1350 

Barnwood  llt>nse  Asylum,  104,  1087 
Bartels,  anomalous  trichosis,  128 

post-influcnzal  psychoses,  690 

cord  lesions  due  to  coni;enitnl  syjihilis,  1262 
Bartens,  insanitj-  due  to  lead,  745 
Basal  cerebral  lesions  and  paralytic  mydriasis,  1054 

Lianglia,  functions  of  the,  157,  158 
Basedow's  disease,  and  insanity,  476 
Basle  Asylum,  1238 

Bastian,  Charlton,  specilic  gravity  of  brain,  161, 
162 

cerebral  lesions  and  insanity,  976 
Baths,  use  of,  in  adolescent  insaniiy,  371 

hot  air  and  vapour,  in  youty  insanity,  551 

in  idiocy,  669 

hot  air  in  plumbism,  748 

in  treatment  of  neurasthenia,  849 

in  stupor,  1209,  1213 

in  treatment  of  insanity,  1292 
B.atophobia,  844 

Baume,  simultaneous  insanitj'  in  twins,  1333 
Bayle,  intestinal  disturbance  and  insanity,  1245 
Beach,  Fletcher,  shapes  of  heads  in  idiots,  579,  580 

weight  of  brain  in  the  insane,  164,  165 

pathology  of  idiocy,  649 

histology  of  microceplialy,  806 

and  G.  siiuttiewortii,  aetiology  of  idiocy 
and  imbecility,  659 
Beadles,  L;all-st(>nes  in  the  insane,  1377 
Beard,  neurasthenia,  841,  842 

adipsia  in  neurasthenics,  845 

oxaluria  in  neurastlienics,  846 
Beatson,  paralysis  of  malaria,  756 
Beaufort  Asylum,  Canada,  175,  176 
Beauuis,  therajieutical  uses  of  hypnotism,  605 

salivary  centre,  11 05 
Bechterew,    effect   of  temperature   on   the  insane, 
1280 

pupillary  nerve  fibres,  1053 
Becker,  post-influenzal  psychoses,  690 
Beddoe,  colour  of  hair  in  the  insane,  563 
Bed-sores  in  general  paralysis,  treatmciit  of,  543 
Beechworth  Asylum,  in 
Beer  in  asylums,  61,  62 

Beevor,  c.  E.,  physiology  of  brain,  152 

Begeisteruny,  433 

Begriff,  242 

Behier,  pathology  of  post-typlious  insanity,  987 

Belastnng,  382 

Belfast  As3ium,  710 

Belhorame,  classification  of  insanity,  231 

Bel),  Chirk,  the  use  of  the  term  monomaida,  308 

Bell,  Graham,  congenital  deaf-mutism,  327 

Bell,  treatment  of  the  insane,  88 

Bell's  disease,  52,  1336 

Belladonna,  delirium  due  to,  336 

Bellerophon,  insanity  of,  7,  553 

Bellingham,  .lolm,  case  of,  301,  302,  303 

Belmondo,  pathology  of  typhus  pellagrosus,  922 

Belonephobie,  678 


Benedikt,  disvulnerability  of  criminals,  290 

patliological  classification  of  criminals,  288 
electricity  in  mental  affections,  428 
craiiiometry,  283 
brains  of  criminalB,  320 
Bennett,  Alice,  Bright's  disease  and  insanity,  172 
Bennington,    uterine    displacements   and  insanity, 

1351 
Berger,  Oscar,  insanity  of  doubt,  407 

stimulus  in  reaction-time,  1068 

"incomi)lete  reaction,''  1070 
lierkeley,  Hishop,  psychology,  45 
Uerkhan,  microccphales  in  Germany.  806 
Hermago,  asylum  at,  716 

r>ernard,  Claude,  nervous  mechainsm  of  salivation. 
1 105 

salivary  centre,  1105 
Berne,  asylnnis  at,  1237,  1238 
Bernheim,  H.,  suggestion  and  hypnotism, 
1213 

thera])eutieal  uses  of  hypnotism,  605 
Berthiev,  the  insanity  of  cancer,  177 

mental  disturl)ances  in  gouty  states,  548 

gout  alternating  with  insanity,  549 

spitting  in  the  insane,  1107 
Berthold,  in-emonitory  myosis  in  cerebral  ha?mor- 

rhage,  1056 
Bethel  Hospital,  Norwich,  1079 
Bethlem  Hospital,  1079 

early  history  of,  25 

transfusion  in  tlie  treatment  of  insanity,  22 

recoveries  in,  1006 
Bettencourt-Kodriguez,  reflexes  in    general    para- 
lysis, 530 

diagnosis  of  general  paralysis.  532 
Bewegnngsstereotypic  in  katatonia,  724 
Bianchi,  reflexes  in  general  paralysis,  530 

clinical  instruction  in  insanity,  717 
Biblical  evidences  of  witchcraft,  1369 

references  to  insanity,  3,  4,  5 

terminology  of  insanity,  2,  3.  4 
Bicetre,  and  humane  treatment  of  the  insane,  24,  25 

reforms  at  the,  511,  512 
ISichroniate  solution  for  hardeiung  sections,  1182 
Bielakotf,  sight  of  criminals,  290 
Bitli,  progress  of  psychology  in  Italy,  717 
Bilious  temperament,  characteristics  of  the,  1277 
Bills  of  exchange,  period  of  limitation,  and  lunacy, 

994 
Binder,  tlie  configuration  of  the  external  ear,  419 
Binet,  effect  of  suggestion  on  the  bladder,  1339 
Binz,  brain-cell  changes  in  to.xic  poisoning,  913 
Biological  function,  109 
Biology,  criminal,  288 
Birch,  John,  early  uses  of  electricity,  426 
J5irt,   E.,  glycero-i)h()spliorie  acid  in  urine  of  the 

insane,  1346.  1347 
Birth,  causes  at,  inducing  idiocy  and  imbecility,  650 

causes  after,  inducing  idiocy  and  imbecility,  659 
Bischoff,  C.  H..  electricity  in  mental  affectioiis,  427 

study  of  microcephalous  brains,  805,  806 
Bizio,  composition  of  sweat,  1167 
Bizzcrzos,  chromoeytometer,  137 
Bjcirck,  Thure,  the  insane  in  Sw^eden.  mo 
Blackburn.  Lord,  criminal  responsibility  of  the  in- 
sane, 316,  317 

definition  of  insanity,  318 
Blackburn,  spinal  cord  lesions  in  general  paralysis, 

539 
Blackstone,  criminal  lunatics,  299 
definition  of  a  lunatic,  330 
capacity  of  the  insane  to  plead.  951 
suicide,  1220 
Bladder,  affections  of,  and  insanity,  1246 
influence  of  mind  on  action  of  the,  1339 
post-mortem  appearance  in  general  paralysis, 
537 


INDEX. 


1419 


'■  Itlniiivilli's  ciir,"  ^icj 

Hliinc,  II..  raw  beef  in  ai-tificial  I'eciliiii:,  498 

Jilaiu-lie.  oei'cbral  I'.xaltatioii  in   ii'i-fci'iitimi   mania, 

930 
Blandfonl,  G.  KieldinL;,  ncuti'  dcliriuu.-^  mania.  53,54 
dyspeiisia  in  mt'lant'IiDliacs,  793 
prevention  ofineaniiy,  996 
prognosis  of  insanity,  1006 
single  patients.  1 103 

opium  in  mental  alVcctions.  iT4t 
teiniicralnrc  in  ?;(  iKTal  paralysis,  1281 
Bleeding  ill  lic-iimcnl  of  iii>anily.  1291 

Blcuicr,  K.,  secondary  sensations,  1125 
synalgia.  1252 

and  Lc'hmann,  iilionisms  and  idiotisms,  1127 

Blindness,  liystcrical,  (541 

in  i)n)dronial  stauc  of  iiencral  iiaralysis,  523 
psychical,  in  sf'tral  paralysis,  528 

Blisterinii',  in  aural  lucmatoma,  560 

Block  form  of  asyhim.  103 

Blocq,  Paul,  salivation,  1 103 

Blood  in  plunibisni,  748 

in  malarial  poisoning,  757 
-poisoniny  ami  jmerperal  insjmity,  1037 
-pressure  and  bhulder  contraction,  1340 
stasis  in  stupor,  use  of  electricity  in,  431 
states  causing  insanity  in  febrile  conditions,  987 
-supi>ly  of  brain,  169,  170 

-vessels,  cerebral,  microscopic  chanijes  in  general 
paraly.sis,  537,  538 

Bloody  tumour  of  ear,  557 

Blooniiugdale  Asylum,  United  States,  85 

"Blue  wdeuia"  ol  hysteria,  634,  638 

Blyth,  A.  Wy liter,  and   Tlieo.  B.  llyslop,  urine, 
1340 
excreta  of  the  insane,  474 

poisonous  action  of  lead.  746 

excretion  by  the  st«in,  1166 

Board  of  Lunacy.  Scotland,  1116,  1120 
Boarders,    voluntary,    in     asylums,     Eni^laud    and 
Wales,  737 

notice  of  reception  to  commissioners,  jyj 

con.-ent  to  admission  of,  744 

voluntary,  in  Scotland,  T122 
Bocliefontaine,  cerebral  centres  of  salivation.  1105 
Bodiii,  lycanthropy,  753 

witchcraft,  1369 
Bodily  symptoms   during   transiir)rv    mania,    1304, 

1305 

trainiut;  of  idiots,  671 

symptoms  of  mania,  762 

symptoms  of  morphia  habit,  817 

symptoms   of  slow    deprivation    in    muridiia 
habit,  8i3 

attitude  in  nielancliolia,  788 

conditions  aftectinL;'  prognosis  of  melancholia, 
796 

causes  of  mor])hia  habit,  817 

causes  of  i)ueriieral  insanity,  1035 

peculiarities  in  criminals,  289 
Body  and  mind,  27,  28,  43,  430,  447,  938 

Aristotle  on  the,  11,  12 
Boekel  Asylum,  593 
Bois  de  Cerv  Asylum,  1239 
Bois-le-duc  Asylum,  593 
Boismont,  Brierre  de,  prolonged  warm  baths,  118 

insanity  of  doubt,  407 

prodromatii  of  general  iiaralysis,  521 
Boldine,  action  of,  1  146 
Boldo-filycerine,  action  of,  1 146 
Bologna,  asylum  at.  717 

Bonaniaison,  hysterical  somnambulism.  403,  404 
Bond,  Thomas,  amelioration  in  tlie  condition  of  the 

insane,  I'nited  States,  85 
Bonds,  period  of  legal  limitation  of,  and  lunacy,  994 
Bone,  conductivity  of.  in  brain  temperature,  1281 

formation  of,  in  othtcmatomata,  560 


B(nies  in  congenital  cretinism.  284 

Bonnet,  the  aMiolo^y  of  lucmalomii  auria,  561 

|)sycho.ses  of  inlluen/.ii,  687 

action  of  hypiial,  i  137 
Bono,  sight  of  criminals,  290 
Borboryumi  in  hysteria,  636 
Hordcr  centres  of  tlie  cortex,  155 
Borough  asylnins,  the  insane  in,  277 
Bosauquet,     .Justice,   plea   of   insanity  in  criminal 

cases,  293 
Bouchai-il  and  I'roust,  lathyrism,  7^0 

Boiichereaii,  (iiisiave,  erotic  insanity  and 
erotomania,  701 

nymphomania,  863 

satyriasis,  1 108 
Boucliiii,  eiiidemic  convulsions,  677 

miasmatic  contagion,  677 

neuraslbenia,  841,  842 

urine  in  neurasthenia,  846,  847 
Bonlimia  in  katatouia,  725 
Bourneville,  sporadic  cretinism,  285 

consan<;uineous  marriages,  662 
r.ouzol,  mimetic  chorea,  213 
Bovos,  284 

Bowditch  neurania-bimeler,  the,  T015,  T016 
Bowler,  Thomas,  case  of,  302,  303 
Boyd,  I'reqiiency  of  fovuis  of  insanity,  1204 

■wei.u'ht  of  brain  in  the  insane,  164,  165,  167 
Boyle,  erysipelas  iind  insanity,  986 

general  paralysis  followin<i  erysipelas,  988 
Bradylalia,  378 
Braid,  hypnotism,  603,  604 

method  of  inducing  hypnotism,  606 
Brain  .■ilfections  due  to  congenital  syphilis,  1261 

action  and  head  temperature,  1284 

and  cord,  immediate  and  secondary  effects  of 
injury  to,  1307 

fatty  de;;eiieratioii  of,  160,  16 1 

post-mortem  a])pearance  of,   in    general   para- 
lysis, 536 

weight  of,  in  cerebral  hypertrophy,  650 

weight  of,  in  cerebral  atrophy,  6=0,  651,  653 

action  of  lead  on  the,  748 

in  microcephaly,  805 

degeneration,  nymphomania  in,  864 

chanLjes  in  senile  dementia,  873 

blood  supply  of,  894,  895,  896,  897 

atroiihy  of,  906 

tubercle  of,  in  phthisical  insanity,  947 

-hypochondriasis,  613,  614 

injury,  trephining  in,  1324 

weight  of,  bibliography.  1365 

anatomy  of,  1375 
Bramwell,  anastlietic  effects  of  hypnotism,  604 
Bramwell,  Lord,  criminal   resjionsibilit.v  of  the  in- 
sane, 313,  314 

insanity  of  a  i)rincii)al,  60 
Brandstiftungsmonomanie-lust  or  -trieb,  1056 
Breacli  of  promise,  plea  of  insanity  in,  779 
Breast,  hysterical,  632 
Bregenin,  150 

Bremand,  "fascination,"  493 
Breschet  and  Cruveilhier,  blood  in  malaria,  757 
Brewster,  pathology  of  hallucinations,  567,  568 
Bricheteau,  mimetic  chorea,  209,213 
Brieve  of  idiolry,  238 

of  furiosity,  238 
Brighain,  educational  instruction  in  asylums,  1317 

treatment  of  the  insane,  88 
Bright,  blood  in  malaria,  758 
liright's  disease,  delirium  of,  336 
Brillat-Savarin,  gustatory  iiiid  olfactory  iiclivities 

In  dreams,  413 
Briquet,  hysterical  ataxy,  106 
Brissaiid,  iihonation  in  hysterics,  635 
Bristowe,  .1.  S.,  acute  mania  jireceding  typhoid,  985 

Stammering,  119 1 


1420 


INDEX. 


Broadbent,  pathology  of  chorea,  210 

alcoholism  in  the  sexes,  1155 

pulse  ti'usion  iu  Iiypoehondriasis,  1043 

pulse  tinslon  in  iiiolaiieholia,  1044 

virtual  pulst'  ti'iisioii  in  general  paralysis,  1048 

pulse  in  petit  mal.  1050 
Broadmoor  Asylum,  551,  1088 

statistics  as  to  criminal  cases,  963 
Hroca,    rise    of  temperature    in  activity  of  hemi- 
spheres, 399 
Hrocklehurst,  case  of,  316 
Urodic,  hysterical  coxaltiia,  633 
Bromal  liydrate,  action  of,  7135 
Hromiaes,  influence  of,  on  blood  in  epileptics,  139 

in  climacteric  insanity.  23s 

in  dii)somania,  395,  396 

action  of,  1130,  1131.  1132 

in  treatment  of  insanity,  1292 
Brookwood  Asylum,  103 

Brougham,  Lord,  criminal  responsibility  of  the  in- 
sane, 309 

testamentary  capacity  of  the  insane,  1285,  1287 
Brown,  Campbell,  and  Rogers,  diemical  analysis  of 

bones  in  general  jiaralysis,  143 
Kro\vu-Se(iuard,  duality  of  brain  function,  398 

artificial  oth;ematoma,  562 

weight  of  cerebral  hemispheres,  166 

experimental  epilepsy,  457 

cardiac  states  in  epilepsy,  1049 

combined  bromide  salts  in  epilepsy,  1132 

action  of  physostigmine,  1146 

reflex  psychoses,  1313 
Browne,  L.,  ajtiology  of  haematoma  auris,  561,  562 
Browne,   Sir  James  Crichton,  brain  weight  in  the 
insane,  164,  165.  166,  167 

(liets  for  artificial  feeding,  498 

mental  disor<lers  and  undeveloped  gout,  548,550 

l)seudocyesis,  234 

hiematoma  of  dura  mater  in  general  paralysis, 
879 

UTdlateral  hannatoma  of  dura  mater,  879,  880 

cause  of  (lural  hematoma,  881 

cortical  hypera-mia  during  mentalisation,  894 

physostigmine  in  general  paralysis,  1146 
Browne,    W.    A.    F.,    educational    instruction    in 
asylums,  1317 

nursing  of  the  insane,  860 
Bruce,  Alexander,  anatomy  of  brain,  168, 1375 
Brugia,  sphygmographic  tracings  during  hypnot- 
ism, 1042 
Brugnatelli,  early  applications  of  electricity,  427 
Bruhl-Cramer,  classification  of  dipsomania,  392 
Bi-unton,  T.  Lau<ler,  mustard  baths,  118 
physiological  action  of  lead,  745 

salicylic  acid,  1102 

action  of  i)iscidia  erythrina,  1139 

action  of  jihysostigmine,  1146 
Brushfield,  alcohol  iu  asylums,  62 
Buck,  pathology  of  sunstntke,  1236 
Bucknill,  antimony  in  treatment  of  insanity,  1291 

asthenic  gangrene,  129 

specific  gravity  of  brain,  158,  159 

bruises  on  the  insane,  173 

classification  of  insanity,  232 

eccentricity,  420 

electricity  in  mental  affections,  427 

posture  in  artificial  feeding,  496 

frequency  of  insanity  in  paralysis  agitans,  886 

study  of  facial  expression,  947,  948 

procedure  in  cases  of  alleged  insanity,  T004 
Bucknill's  reclining  bath-chair,  117 
Bucknill  and  Tuke,  specific  gravity  of  brain  tissue, 
160 

classification  of  dipsomania,  392 
Buffalo  .State  Asylum,  86,  103 
Buhl,  pathology  of  post-typhous  insanity,  987 
Bulltar  paralysis,  speech  defects  in,  1193 


Buller,  Justice,  contractual  capacity  of  a  drunkard, 

685 

Buonomo,  clinical  instruction  in  insanity,  717 

IJurckhardt,   operative   interference  for    hallucina- 
tions, 1327 

Burdett,  Turkish  asylums,  1328 

Hurghi'ilzli  Asylum,  1239 

Burke,  on  the  treatment  of  the  insane,  24 

Burmau,  kleptomania  in  general  paralysis,  728 
heart  weight  in  chronic  mania,  1047 
cardiac  condition  in  general  paralysis,  1048 

Burnett,  G.,  the  helleljore  of  the  ancients,  1353 

Burns   of  ear,  and  hiematoma   auris,    differential 
diagnosis,  559 

Burrows,  G.  M.,  recoveries  in  insanity,  322 
sex  in  insanity,  1153 

Burt,  William,  case  of,  315 

Burton's  Anatomy  of  Melancholy,  22 

Bury.   Judson    S.,    and    Barlow.    T.,    syphilitic 

hereditary    disease    of  nervous 
system,  1259 
Buswell,  criminal  insane  law  in  United  States,  90 
Butt,  Justice,  insanit.v  of  a  principal,  60 
Butyl  choral  hydrate,  action  of,  1135 
Buzzard,  T.,  early  convulsions  in  sjiihilitic  children, 
1262 
peripheral  neuritis,  923 
siraulation  of  hysteria,  1161 

Cachectic  diseases  and  insanity,  911 
Cachexia  struma  priva,  828 
Cachexie,  841 

Callus  Aurelianus,  sex  in  insanity,  11 52 
treatment  of  the  insane,  15,  716 
hallucinations,  565 
Cicsium  bromide,  action  of,  1131 
"  Cagot  ear,"  418 
Cailleux,   Girard  de,  frequency   of   occurrence   of 

folie  circnlaire,  226 
Calabar  beau,  action  of,  1145 
Calcium  bromide,  action  of,  1131 
Caligula,  epileptic  imbecility  of,  17 
Callan  Park  Asylum,  in 

Callendar,  electrical  resistance  thermometer,  1278 
Calmoil,  delusions  as  to  vampirism,  1352,  1353 

the  insanity  of  Xebuchadnezzar,  5 
Calmet,  vampirism,  1352 
Cambyses,  epileptic  insanity  of,  5,  6 
Cameron,  legislation  for  habitual  drunkards,  555 
Cameron,  Sir  Charles,  toxiphobia,  1299 
Camoset,  hysterical  somuamljulism,  403 
Camphor  monobromide,  action  of,  1131 
Campbell,  shower  baths.  120 

Campbell,    Attorney-General,     criminal   responsi- 
bility of  the  insane,  303 
Campbell,    Colin,  enteric     fever    and   in- 
sanity, 506 
Campbell,  Lord,  "jiartial  insanity,"'  309 

case  of  McXaghten,  310 
Cane  Hill  Asylum,  103 
Cannabis  indica,  action  of,  1143 

in  treatment  of  insanity,  1292 

toxic  action  of  varieties  of,  1097 

delirium  due  to,  336 
Caunabinin,  1143 
Cannabinon,  1143 

Cantharides  supposed  to  induce  nymphomania,  865 
Capacity  for  marriage,  legal  views  of,  tjj,  778 
Cappie,  vascular  causes  of  sleep,  1171 

retina  daring  sleep,  1171 
Carbo-hydrates  iu  brain,  146, 151 

in  urine,  1347 
Carbon    monoxide    poisoinng   causing    transitory 

frenzy,  1304 
Carbuncle,  arresting  general  paralysis,  80 
Cardiac  disease  and  insanity,  911,  1244,  1246 

clfcct  of  weeping,  1275 


INDEX. 


1421 


Cardiac  disoasc  diii'  to  tobaci'o  atinsc,  1298 
disease  in  insiiiiitv,  diL;italis  in,  387 
disease,  insanity  of,  vascular  cliani^c  in.   1043 
eoniplications  in  stupor,  1045 
conditions  in  epileptie  insnniiy,  1049,  IC50 
lesions  in  querulantenwalni,  io6i 

Cardiac  muscular  deiiciieration.  mental  symptoms 

ill,  179 
liyii'Tlropliy  and  dilatation.  179 
Cardona  and  Adriaiidi,  case  of  microcephaly,  S08. 


I'stiiiial  >f\n:il  reflexes,  1295 
ii8^ 


Caresses  rci;arded  :i 
Carlow  Asylum,  710 
Carmine  staining-  lor  section; 
Carpenter,  illusions,  no 

unconscious  cerebration,  115 
automatic  action,  397 
mental  pliysiolosy.  804 
psychical  retiex  action,  1336 
Carpoloiiia.  179  {sec  Cakimiologv) 
Casimir,  folic  circulaire.  with  an  annual  cycle,  223 
Casper,  responsibility  in  pyromania.  T056 

the  fre(iuency  of  simulated  insanity,  502 
Cassandra,  in.sanity  of,  20 

Castiglioni.  progress  of  psycholoi;y  in  Italy,  717 
Castlebar  .Vsylum,  710 
Castration,  and  physical  and  mental  development. 

876 
Cat,  delusion  of  lieini;  a.  (galeanthropy ).  519 
Catalepsy,  excretion  of  urea  in,  1344 
hysterical,  609 
in  children,  35q 
of  ]iyi)notism,  1215 
Cataleptic  ecstasy,  424 
melancholia,  796 
somnambulism,  1176 
states  iu  stupor.  1208,  1210 
stage  of  hypnotism,  607 
Cataleptoid  insanity,  695 
Catamenia.  and  the  psychoses  of  adolescence,  365 

iu  alcoholic  paralysis,  923 
Catani.  lathyrismus,  729 

Catarrhal  affections,  and  accidental  deaf-mutism.  327 
Cathelineau,  urine  in  hypnotic  states,  610 
Cathetometer,  283 

Cattell,  variations  in  intensity  of  stimulus  iu  reac- 
tion, 1068 
distraction  in  reaction-time  experiments,  1069 
comi)lex  reaction,  1069 
"  incomplete  reaction,"  1070 
Cattivo  male,  918 

Caulbry,  G.  de,  sympathetic  insanity,  1243 
Cause  of  iiLsatnty,  in  prognosis,  1007 
Causes  of  insanity  intluenciiig  recovery  in  iisylums, 
1199 
statistics  of  the,  1204,  1205,  1206 
predisjiosing-,  1206 
exciting,  1206 
in  the  sexes,  11 54 
Cavallo,  the  early  uses  of  electricity,  426 
Cave,  Justice,  criminal  responsibility  of  the  insane, 

316 
Cazaiivieilh.  protective  societies,  515 
Celibacy  and  suicide,  1227 
Celloidiii,  section  cutting  in,  1183 

section  mounting  in,  1184 
Cells,  cortical,  in  idiots,  658,  659 

piginentation  of,  in  insanity,  904,  Q05 
disintegration  of,  905 
Celsus,  treatment  of  insanity,  14,  15,  135 
hallucinations,  565 

corporal  punishment  of  the  insane,  14.  1=; 
Cephalic  index,  575 
Cerebellum,  functions  of  the,  158 
weight  of  the,  167,  168 

microscopical  changes  in,  in  general  paralysis, 
539 


Cerebellum,  atroidiy  of,  in  i<li()cy,  656 

tumours  of,  in  idiocy,  656 
Cerebral  aiKcniia  during  sleep,  1170,  1171 

apiiearance  of  sunstroke  lesions,  1236,  1237 

L;eiicral  i)aralysis  of  syi)hilitic  origin,  1258 

arteries,  MlVeclions  (if,  due  to  coniicnital  syphi- 
lis, 1261 

softening  of  <-oiigenil:il  syjihilis,  T261 

Nclerosis  of  congenital  syi)hilis,  1261 

IiaMiiorrhage  due  to  congenital  syphilis,  1261 

giimmata,  1261 

nerves,  lesions  of,  due  to   congenita]    syphilis, 
1261 

lesions  due  to  alcoholism,  77 

hyperactivity  a  prodromi^  of  delirium  tremens, 
340 

hemispheres,  corresponding  functions  in,  398 

reinforcements,  466 

ha'iiKn-rhage,  diagnosed  from  general  paralysis, 

534 

luemorrhage,  ])aralytic  mydriasis  in,  1054 

hamorrhag-e,  varieties  of,  975 

arteries,  minute  changes  in  the,  T79 

symptoms  in  e.xcited  jihase  of  folic   circulaire, 
221 

convolutions,  268 

exaltation  antecedent  to  delirium  tremens,  343 

changes  in  secondary  dementia,  350 

changes  in  senile  dementia,  350,  351 

inhibition,  development  of.  in  the  infant,  466 

congestion  theory  of  gener.il  paralysis,  540 

ana?mia  in  idiocy,  649 

hypertrophy  in  idiocy,  649,  650 

hyperannia  in  idiocy,  469 

atrophy  in  idiocy,  650,  651,  652 

softening  iu  idiocy,  652,  653 

sclerosis  iu  idiocy,  653 

tumours  in  idiocy,  654 

asymmetry  in  idiocy,  655 

thrombosis  in  idiocy,  655,  656 

affections  causing  idiocy,  665 

causes  of  insomnia,  703 

injury,  amnesia  after,  799 

reiuforcement  of  actions,  823 

subsidence  of  actions.  823 

atrophy,  acute,  in  senility,  872 

hamiatoma,  877 

localisation  of  mental  disease,  892 

pathological  hypera^mia,  897 

atroi)hy,  906 

vascularity  in  toxic  iioisoning,  913,  914 

reactions  to  drugs,  966 

diffuse  reactions  to  drugs,  966 

localised  reactioiis  to  drugs,  967 

intoxication,  968 

centres   involved  in  varieties  of  aphasia,  980, 
981 

centres  for  pupillary  reaction,  1053 
'•  Cerebral  irritation,''  844 
Cerebration,  unconscious.  115.  1336 

compound,  466,  1027.  1030 
Cerebraux  (.sec  ahi)  article  on),  382,  384 
Cer(ibria  (Elani),  384 
Cerebrinic  acid,  150 
Cercbro-galactosides,  149 
Cerebrose,  149,  150 
Cerebrosides,  149 
Cerebro-spinal  meningitis,  the  delirium  of.  335 

system  and  consciousness.  257,  258 
Cerebrum.  ])athological  jji-ocesses  in,  893 
Certificates  for  attendants,  693 

lunacy,  Ireland,  711,  713 

lunacy,   England  and  Wales,  amendment    of, 

734 

lunacy,  England  and  Wales,  in  case  of    trans- 
ference, 734 

lunacy,  England  and  Wales,  forms  of,  741 


1422 


INDEX. 


Ccrtiticiites.   lunacy,  Eiiyland  aud   Wales,  of  i)cr- 
sonal  iiitorview,  741 

htiiacy.    Kii-hmd   ami  Wales,  of  coiitiimation 
of  insanity,  744 

lunacy,  Scotlauil,  1120 
Certified  insane,  persons  ineligible  to  receive,  734 
Cerumen,  composition  of,  1167 
Chancery  luuaiics,  Ireland,  713 

patients  contiiuiation  certificates,  734 
Cbapin,  J.  I!.,  the  insane  in  the  United 

States, 84 
Chaplain,  appointment  of,  to  asylums,  280 
Chapman,  T.  A.,  recovery  in  the  insane,  323 
Character,  chaniie  of,  in  diagnosing  insanity,  373 

and  disposition,  changes  in,  after  brain  injury, 
1308 

indecision  of,  in  eccentrics,  422 
Charcot,  J.  M.,  artificial  cataleiisy,  185 

liysteria  in  cerebraux,  i8g 

pathology  of  chorea,  210 

dyssesthesia',  417 

facial  expression,  485 

clinical  evidence  of  cortical  functions,  152 

rhytlimical  cliorea,  214 

hypnotism,  604 

stages  of  hypnotism,  607 

hysterical  atTections  of  joints,  723 

hypnotic  state  due  to  fright,  1158,  1159 

transference  in  hysteria,  1302 

and  (iilles  de  la  Tourette,  hypnotism  in 
the  hysterical,  627 

and  3Iagnau,  onomatomania,  678 

and  Pierre  Marie,  hysteria  and  hystero- 
epilepsy,  627 
Charitable  institutions  for  the  convalescent  insane, 

56.  515-  553 
Charlesvvortli,  mechanical  restraint,  1317 

non-restraint,  25,  26 
Chartered  asylums  of  Scotland,  1094,  in8 
Chaslin,  sudden  transition  stage  of  folic  circulaire, 
221 

and  Seglas,  not  eon  katatouia,  725 
Chauflard  and  ^ongnes  on  sex  and  hysteria,  629 
Chemical  constituents  of  Ijrain,  146 
Chevalier,  composition  of  cerumen,  1167 
Cheyne,  dysphoria,  507; 
Chiarngi,  V.,  reform  in  the  treatment  of  the  insane, 

716 
Child,  Gilbert,  consanguineous  marriages,  327 
Child-birth,  hallucinatory  mania  after,  767 

melancholia  at,  792 

insanity  of,  697 

traumatic  effect  of,  on  infant,  1308 
Childhood,  brain  injury  in,  1308 

development  of  cretinism  in  early,  28;; 

epilepsy  in,  452,  454,  455 

insanity  of,  697 
Children,  persistent  speech  defects  in,  1193 

suicide  by,  123 1 

imbecility  in,  due  to  sunstroke,  1234 

weak  and  deformed,  among  the  ancients,  2 

delirium  of,  357,  359,  360 

night  terrors  of,  358,  359 

eccentricity  in,  422 

spinal  discharging-  lesions  in,  444 

low  developmental  expression  In,  484 

transitory  psychoses  in,  358 

catalepsy  in,  359 

hysteria  in,  624 

theft  in,  727 

moral  perversity  in,  727 

masturbation  in,  785 

neurotic  instability  in,  997 

training  of  neurotic,  997,  998 

education  of  neurotic,  998 

precocity  in  neurotic,  998 

religious  delusions  in,  1091 


Children,  bromides  for,  1132 

alcohol  as  liyjniotic  for,  1133 

chloral  in  convulsions  of.  1135 

nrethane  as  a  liyi)notic  for,  1136 
Chiron,  ancient  treatment  of  the  insane,  12 
Cliloral  abuse,  tremor  of,  1321 

action  of,  1134 

poisoning  b}-,  1134 

habit,  symptoms  during,  1135 

amide,  action  of,  1135 

amide  in  acute  delirious  mania,  5; 

-ammonium,  action  of,  1136 

habit,  ANeir  Jlitchell  treatment  of,  852,  853 

in  chronic  insanity,  212 

in  treatment  of  insanity,  1292,  1293 

-urethane,  action  of,  1137 
Chloralimide,  action  of,  1136 
Chlorides  in  urine  in  mental  states,  1348 
Chlor()-ana>mia  and  nervous  affections,  1351 
Chloroform  derivatives  as  sedatives,  1132 

as  a  soporific,  1133 

in  artificial  feeding,  500 

insanity  following  the  use  of,  92 
Chlorosis  in  neurasthenia,  847 
Choay,  hypnotic  action  of  cldoralimide,  1136 
Choice,  the    result    of  competing    representations, 
32,  41,42 

in  reaction-time,  1069 
Cholera,  insanit.y  following,  987 
Choleric  temperament,  characteristics  of  the,  1277 
Cholesterin,  151 
Chorea  and  hysteria,  625 

facial  expression  of,  485 

handwriting  in,  573 

a  hereditary  factor  of  insanity,  582 

delirium  in,  335 

gravidarum,  206 

senilis,  206 

post-hemiplegic,  206 

hysterical,  635 

the  tremor  of,  1322 
Choreic  idiocy,  643.  648 

mania,  210,  211 
Choroid,  examination  of  the,  487 
Choroiditis,  disseminated  sji)hilitic,  1259,  1266 
Christian,  atropism,  133 

relatiAc  frequency  of  forms  of  insanity  after 
fevers,  986 

ambitious  delusions  after  tnihoid,  986 

heredity  in  persecution  mania,  933 

hyperactivity  in  early  stage  of  generiil  para- 
lysis, 522 

auditory  hallucinations,  566 

pathology  of  hallucinations,  568 
Christians,  ancient,  suicide  among  the,  1219 
Chromic  acid  solution  for  hardening  sections,  1182 
Chromidrosis,  hysterical.  624,  637 
Chronic  alcoholism  and  general  paralysis  differen- 
tiated, 914,  915 

the  excitation  of,  473 
Chronic  bronchitis   alternating  with  insanity,  28, 

lOI 

Chronic  dementia  as  result  of  mania,  767 

Chronic  diseases,  delirium  due  to,  336 

Chronic  general  paralysis,  microscopical  changes 

iu.  537 
Chronic  insanity,  ha-matoma  of  dura  mater  in,  879 

handwriting  in.  573 

simulated,  504 
Chronic  mania,  hair  in,  563 

the  exaltation  of,  470 

pulse  conditions  in,  1047 

religious  delusions  in,  1092 
Chronic  melancholia,  790,  796 

pulse  tension  in,  1044, 1045 
Chronic  mental  defect,  a  rare  sequela  of  general 
paralysis,  532 


INDEX. 


1423 


Chronic  toxic  poisoning,  972 
ChronoiJciipc,  lUi;  llip)),  1017 
Cliiin-li,  ilTdils  ot  tho,  til  su])i)rcss  witchcnil't,  1370 

the  early  Cliristian,  and  the  insane,  432,  433 
Chnrehill,  the  hellel>ore  of  the  aneients,  1353 
Cicero,  hallneinatious,  565 

suicide,  1218 
Circulaere  Irresein,  das,  215 
Circular  form  of  general  paralysis,  526 
Circular  insanity,  nyiiiphoniania  in,  864 

s))hyuiiioi;raphie  traciii;;s  in,  1189 
Circulation,  cerehral.  and  insanity,  13^  136 

iiiHueiu'eot,  in  ])roductiou  of  transitory  frenzy, 
1302 

in  stupor,  1208 

means  of  measuring,  964 

iuflucncinji'  post-apoplectic  conditions,  975 

of  brain,  169,  170 

general,  in  the  insane,  179 
Circulatory  disturbances  in  hysteria,  624,  637 
Civilisation  and  causation  of  insanity,  1206 

and  suicide,  1224 
Civil  responsibility  iu  aphasia,  983,  984 
Clapham,  Crochley,  weight  of  braiu  liemlsphcres, 
166 

"Weight  of  brain  in  the  insane,  164 

size  and  shape  of  head  in  the  in- 
sane, 574 

skull  mapping,  1169 
Clark,   (anipbiU,   chlorides  iu  urine  of  puerperal 

iusauiry,  1348 
Clark,  Sir  A.,  opium  in  nieiital  alt'ections,  1141 

convulsive  cough  of  puberty,  272 

nieutal  disturbances  iu  gouty  states,  548,  550 

physi(i-|iatlioliiuy  of  gout.v  insanity,  550 
Clarke,  Adam,  epileps.v  of  David,  4 
Clarke,  case  of  trance,  1301,  1302 
Clarke,  Campbell,  the  training  of  asylum  atten- 
dants, 861 

albuminuria  in  puerperal  insanity,  1037 
Classitication,  natural,  of  insanities,  446 

of  patients  in  asylums,  105 
.Claustrophobia,  678,  844 
Cleanliness,  education  of,  iu  idiots,  668 
Cleistrophobia,  844 

Cleomeues,  insane  self-rautilatiou  of,  1148 
Clergyman,  beneficed,  lunacy  of,  133 
Clermont  colonies,  the,  508 
Climacteric,  insane  jealousy  at  the,  721 

melancholia  at  the,  792 

influence   of,   on    chronic  puerperal   insanity, 
1040,  104 1 

insanity,  religious  delusions  in,  1092 
Climate  and  temi)erament,  1277 

and  transitory  frenzy,  1304 
<'Iiniatic  influences  on  suicide,  1221 
Clinical  instruction  iu  insanity,  Ital,v,  717 
Clithrophobia,  678 
Clonmcl  Asylum,  710 
Clothing  of  idiots,  668 

of  the  insane,  414 
Clouston,  T.  S..  acute  delirious  mania,  54 

secondary  dementia,  349 

Bright's  disease  and  insanity,  172 

dassiflcation  of  insanity,  232 

climacteric  insanity  in  males,  236 

insane  diathesis,  382 

mental  enfeeblement,  433 

forcible  feeding,  494 

posture  in  forcible  feeding,  496 

gagging  for  forcible  feeding,  497 

diets  for  artilicial  feeding,  498 

developmental  insanities,  357 
cancer  and  insanity,  177 
primary  exaltation,  470 

prognosis    of  exalted  states  in  chronic   alco- 
holism, 474 


Cloustou,  T.  S.,  training  of  attendants,  694 

psyclamp-iia,  701 

phthisical  insanity,  937 

asylum  attendants,  860 

spinal  durlwmatoma  in  general  paralysis,  883 

concealment  of  insanity  in  persecution  mania, 

932 
insanity  following  rheumatism,  987 
recoveries  in  puerpiTal  insanity,  loi  i 
recoveries  in  lactational  insanity,  1012 
bromides  in  ej)ilcpsy,  1 132 
paraldehyde,  1134 
chloral,  1 135 
sidphonal,  1 138 
opium  in  mental  states,  1141 
caujiabis  indica,  1 144 

temperature    of  the    body  in    in- 
sanity, 1279 

melancholia  cum  stu])ore,  1210 

frequency  of  sunstroke  as  cause   of  insanitv, 
1235 

s.vmpathctic  insaiiit.v,  1243 
"Clovvnism"  stage  in  convulsive  hysteria,  630 
Cobbold,  othicraatoma  in  idiots,  559 
Cocaine-poisoning  diagnosed  from  delirium  tremens, 
72 

habit,  236 

and  mori)hia  habit,  236 

■■  buii,"  tiie,  237 
Cockburu,    Lord   ('liief    Justice,  defence    of  JIc- 
Naghten,  305 

legal  aspect  of  tlie  judges'  summary  as  to  crim- 
inal responsildlity,  311 

testamentary   capacitv  of   the    insane,    1285, 
1287.  1288 
Cocoa  iu  diet  of  the  insane,  387 
Codeine,  action  of,  1142 

Coenwsthetic  anomalies  in  general  paralysis,  529 
Coffee  abuse,  tremor  of,  1321 

in  diet  of  the  insane,  387 
Cognate  and  agnate  (.Scots  lunacy  law),  238 
Coire  Asylum,  1240 
Coke,  the  insane  criminal,  296 

contracts  of  lunatii-s,  266 

definition  of  insanity.  330 

definition  of  uu  idiot,  666 

contractual  capacity  of  a  drunkard,  684 
Cold  baths,  prolonged,  118 

dip,  119 

surprise,  119 
Cold,  tremor  due  to,  1320 

effect  of,  on  bladder,  1339 
Coleridge,  Lord,  the  law  as  to  criminal  responsi- 
bility of  the  insane,  309    ■ 
Collapse  during  treatment  of  morphia  habit,  820 

from  fright,  1158 
Collateral  inheritance  in  diagnosing  insanity.  373 
Collin,  H..  and  Gamier,  P.,  homicidal  m.ono- 

mania,  593 
Collinson.  the  history  of  law  relating  to  idiots,  66b 
Colloid  bodies  in  cerebral  degenerations,  906,  907, 

908 
Colman,  bladder  contraction  after  petit  mal,  1339 
Colonies  for  the  insane,  Clermont,  508 

A'illiers,  508 

fitzjames,  507 

Gheel,  547 

in  Italy,  719 

in  Switzerlainl,  1240 
Colonies,  statistics  of  sex  in  insanity  in  the,  ii!;4 
Colour  and  word  associations,  1012 

of  hair,  and  insanity,  563 

the  influence  of,  in  tarantism,  439 

-blindness  in  chronic  alcoholism,  75 
in  mind-blindness,  809 

sensaticjns  and  sense  perceptions,  1125 
Coma  of  i)liimbism,  747 


14-^4 


INDEX. 


Coiuu  in  toxic  states,  971 

Conium,  action  of  1144 

Comatose  drunkeiiiiess,  416 

(oiiolly,  iletinition  of  insanity,  330 

Commissioners    in    Liiuaey.  England  and    "Wales. 

ecci'utricity  and  insanity,  420 

power  of,  in  provision  of  asylums,  278 

forcible  feeding,  494 

and  chancery  i)atients,  199 

evidence  in  case  of  Edward  Oxford,  303,  304 

reception  order  by,  733 

and  non-restraint.  26 

inability  of.  to  sign  certilicates,  734 

mechanical  restraint,  1317,  1318 

duties  of.  733,  734,  735,  736 

method  of  calculatinu  i-ecoveries,  1196 

substitute  lor  petitioner  appointed  by.  735 

Consanguineous  marriages,  retinitis  pigmentosa  in 

Ireland,  714 

the  offspring  of,  487 

report  on  attendants  for  the  insane,  860 

imbecility  in  the  offspring  of,  661 

authority  over  hospitals,  1079 

and  hereditary  affections,  997,  looi 

reports  as  to  workhouses,  1371 

Conscience  in  dipsomaniacs.  391 

liowers  of,  as  to  the  insane  in  workhouses.  1372 

in  dreams.  412 

Scotland,  tii6p?  se<i. 

Consciousness,  28,  32,  377,  378 

Commissioners  of  Control,  Ireland,  709 

of  effort,  42 

Commitment  of  the  insane.  United  States,  87 

in  alcoholic  delirium,  342,  343 

Committees  of  Chancery  patient,  198 

occasional    loss   of,   in   Jacksonian    epilepsy. 

duties  of,  199,  200 

445 

powers  of,  242 

confusion  of,  325 

law  as  to,  resident  abroad,  396 

self-,  disorders  of,  345 

Committees  of  hospitals,  persons  disqualified  from 

alteration  of,  346 

acting  on,  1079 

complete  loss  of,  378 

Common,  rights  of  claim  to,  lei^al  limitation   and 

of  the  ego,  378 

lunacy,  994 

double,  378 

Commons,  House  of,  efforts  to  amend  law  of  crimi- 

alternating. 378 

nal  responsibility,  309 

dual,  401 

select  committee  on  homicidal  law  amendment 

in  toxic  states,  969,  971 

act,  313 

olifnscation  of,  due  to  brain  injury,  1309 

inquiry  into  state  of  the  insane,  Ireland,  707 

Consecutive  chorea,  206,  207 

Como,  asylum  at,  717 

primary  insanity,  695 

Comparison,  reaction-time  of,  1071 

Consensual  motion,  265 

Complete  somnambulism,  401 

reflex  pupillary  reaction,  1052,  1053 

Complex  reactions,  1069-1071 

Constables,  actions  against,  period  of  limitation  and 

Complexion  and  size  of  cranium,  578 

lunacy,  994 

Complications  of  g-eneral  jjaralysis,  520 

Constans,  epidemic  demonomania,  352,  353,  354 

Compound  cerebration,  466,  1027,  1030 

legislation  for  the  insane  in  France,  ,13 

series  of  acts,  822 

Constipation  in  melancholiacs,  265.  794 

Comprehension,  mental,  38 

in  the  insane,  electricity  in,  431 

Compression,     ovarian,    in  treatment    of    hystero- 

influencing  post-apoplectic  states,  975,  976 

epilepsy,  640 

Constitutional  primary  insanity,  695 

Comte,  Aususte,  altruism,  83 

Constructive  acts,  356 

Conation,  31 

Contact,  morbid  dread  of,  with  surrounding  objects, 

Concealment  of  insanity,  699,  700 

407-410 

in  persecution-mania,  932 

Contagion,  mental,  676 

Concentration  of  consciousness,  106 

Contesse,  articular  rheumatism  and  insanity,  986 

Concept,  37 

general  jiaralysis  following  articular  rheuma- 

Conception, mental,  37,  38 

tism,  988 

original,  493 

Contiguity,  law  of,  36 

delirante,  242 

Continuation  certificates,  744 

Conceptualism,  29 

Continued  fevers  and  accidental  deaf-mutism,  327 

Concomitance,  doctrine  of  (H.  Jackson),  446,  447 

Contraction,  somnambulistic,  608 

Concurrent  insanity,  695 

lethargic,  608 

Concussion  of  the  brain,  the  delirium  of.  333 

Contracts  between  local  authorities  for  provision  of 

Conduct,  abnormalities  of,  in   prodromic' stage  of 

asylums,  279 

general  paralysis,  522 

of  lunatics,  1376 

anomalies  in  melancholia,  788,791 

Contractual  capacity  of  an  inebriate.  684 

Conduction  apliasia,  91 

Contracture  in  chronic  alcoholism,  75,  76 

Confusion,  mental,  325 

hysterical,  628,  629,  630 

Confusional  insanity,  1357 

Contra-indications  to  forcible  feeding  496 

diagnosed  from  dementia,  1358 

Coutriire  Sexualempfindtmg,  1156 

primary  insanity,  695 

Control  of  thought,  42 

stupor,  767 

of  feeling,  42 

Congenital  S3i)hilis,  1259 

of  emotion,  42 

neuroses  in  children  due  to,  1255 

Controllability  of  nerve  centres  by  physical  means. 

form  of  cretinism,  284 

821,  822 

criminal,  the,  288 

Convalescents,  establishment  for  (to  Bcthlem  Hos- 

ocular anomalies.  489 

pital),  134 

insane,  hair  of  the,  564,  565 

from  insanity,  the  blood  of,  139 

idiocy,  643,  645 

protective  societies  for,  515 

causes  of  idiocy  :ind  imbecility,  659 

letter  writing  of,  574 

Congestion-myosis,  1055 

Convolutions,  specific  gravity  of  the.  i6i 

Congestive  symptoms  in  folie  circulaire,  221 

asymmetry  of,  in  idiocy,  655 

insanity,  695 

imperfect  development  of,  655 

mania,  760 

Convulsionnaires,  439 

Congo-red  staining  foi'  sections,  118  3 

Convulsions  due  to  congenital  syphilis.  1255,  1262, 

Coniine,  action  of,  1144 

1263,  1270 

INDEX. 


1425 


Couviilsidiis  diu'  til  inimiiatisin  in  vouth,  1308 
reliitionslii))  of.  lo  eiiilcpsy,  4:;2 
centre  for.  186 
cpilcptiforni.  457 
iluo  lo  U;ui  poisonillfj:,  745,  747 
Convulsive  ilriinkenuess.  67.  416 

attacks  in  cliroiiic  aleoliolisni.  75,  76 
delirium  tremens,  344 
spasin  in  erpotisn*.  458 
attacks  in  epidemic  insanity,  435 
seiznres  in  >;cueral  i)aralysis,  528,  530 
liysteria,  628,  629.  630 
melancholia.  796 
seizures  in  pellagra,  920 
liand,  I  lie,  qSi) 
IreuKir,  1323 
Cook,  Canon,  the  insanity  of  Saul,  3 
Coonu's,  hysterical  stigmata,  1207 
Co-ordinative  training  of  idiots,  671 
Copridalia,  679 
Copro-eeholalie,  212 
Copyhold  fine,  action  for,  period  of  limitation  and 

lunacy,  904 
CopyriL;hl.  action    for   iufrini;ement  of,    period  of 

limitation  and  hinacy,  994 
Cord,  amyloid  dei,'eneration  of  the,  i6x 
lesions  in  eri^otism,  459 
lesions  complieatini;  <>eneral  i>ara lysis,  530 
affections  of  the,  in  idiocy,  656 
affections  of  thi',  in  microcephaly,  806 
changes  in  alcoholic  insanity,  914 
changes  in,  duriii<^  insanity,  1190 
Cordcs,  aiioraphohia,  1367 
Cork  Asylum,  708,  710 
Cornea,  examination  of  the,  487 
Cornil  and  Raiivier,  osteoporosis,  144 
Cornish,  the  treatment  of  starvation,  773 
Cornutin  (ergot  of  rye),  con\^llsive  action  of,  458 
Coroner,  notice  of  death  to,  737 
Corpora  quadrigemina,  functions  of  the,  158 
Corpus  striatum,  functions  of  tlie,  157 

callosum,  functions  of  the,  399 
Corpuscles,  blood,  in  the  licalthy  sane,  137 
in  mania,  137 
in  melancholia,  137 
in  dementia,  138 
in  !,''eneral  paralysis,  138 
in  epileptic  insanity,  138,  139 
in  puerperal  insanity.  139 
in  pellagrous  insanity.  139 
during-  maniacal  excitement,  139 
Corre.'^poudence,  notice  as  to,  in  asylums,  735 
Corridor  form  of  asylum,  103 
Corrosive  sublimate  solution  for  hardening-  sections, 

1181 
Cortex,  motor  areas  of  the,  152.  153,  154,  156,  186 
.sensory  areas  of  the,  155.  156 
fiinctions  of  the.  156 
localisation  of  sight  in  the,  156 
localisation  of  smell  in  the,  156 
excitable  areas  of  the,  153,  154 
non-excitable  areas  of  the,  155,  156 
liistoloLzy  of  the,  169,  1375 
in  general  jiaralysis,  536 
blood-supply  to  the,  894 
Cortical  degeneration  in  senile  dementia,  351 
action,  normal.  362,  363 
reductions  in  idiocy,  653,  655 
hyperaMuia  durini,^  psychical  action.  894 
hypera;mia,  vascular   apparatus    causing-,  894, 

895 
Lyperaemia, nervous  apjjaratus causing', 894, 895 
cells,  changes  in  toxic  jwisoning,  913,  914 
hyiieraemia  in  transitory  frenzy,  1303 
Cast  of  maintenance  in  asylums.  United  State's.  87 
of  maintenance  in  asylums,  Australia,  113 
of  boarding  out.  L'nited  States,  143 


Costa,  Christophe  A.,  daturism.  325 
Cotard,  .Inles,  diilire  des  negations,  832 

classification  of  insanity  of  negation,  833,  834 
Cofoit  Jlill  Institution,  1084 
Cottage  form  of  asylum,  103 

treatnienl  in  Australia,  113 
Cottenhani,  Lord,   criminal    responsibility    of   I  he 

insane,  3o() 
Cotlou,  Lord  Justice, insanity  of  a  principal,  60 
Condewater  Asylum,  ^^93 
Cough,  ccmvulsive,  of  puberty,  272 

hysterical,  635 
Counter-irritants  in  treatment  of  general  paralysis, 

543 

in  gouty  insanity,  551 

in  treatment  of  insanity,  1291 
County  asylums,  the  insane  in,  277 

councils,  Scotland,  authority  of,  1118 
Coup  de  soleil,  1232 

de  chaleur,  1232 

Couplaiid,  W.  C,  philosophy  of  mind,  27 

Courboii,  tigretier,  1297 

Court  of  Chancery,  United  States,  89 

Cousins,  intermarriage  of,  588 

Covenants,  actions  upon,  period  of  limitation  and 

lunac.v,  994 
Cowan,  F.  M.,  insane  in  Holland,  590 
Cowles,  E.,  nursing,  859 
Coxalgia,  hysterical,  633 
Craig,   Sir    Thomas,   early    laws    relating-   to    the 

insane,  Scotland,  11 15 
Cramps  in  chronic  alcoholism,  75,  76 
Cranial  index,  575 
Cranial  injuries,  inipjiry  as  to, in  diagnosing  insanity, 

373 
ami  their  consequences,  187,  188 
a  predisposing-  cause  of  general  paralysis,  188, 

189,  534 
an  exciting  cause  of  general  paralysis,  535 
and  impulsiveness.  188 
vertigo  following,  187 
and  folic  circulaire,  226 
Cranial  nerves,  lesiitns  of,  due  to  congenital  syphi- 
lis, 1261,  126=; 
Craniectomy  in  niicrocephalisni,  670 
Crauiofixator,  283 
Craniotabes  and  sy])Iiilis,  1260 
Cranium,  anomalies  of.  in  idiocy,  657 
normal  patency  of  the,  893 
size  and  shape  of,  in  the  insane,  574 
measurements  of  the,  574 
syphilitic  affections  of  the,  1259,  1260 
of  criminal,  288 
"  Crank,"  a,  887 
Craving,  alcoholic,  390 
for  drugs,  972,  973 
Cretinism,  menstruation  in,  801 
sporadic,  657 
and  myxoedema,  1294 
Cretinoid  idiocy,  643,  648 
Cricliton,  classification  of  amentia,  84 
Crichton,  Alexander,  instances  of  trance.  425 
Crichton  Royal  Institution,  1096 
Crime  and  insanity  (I'lato),  11 
Crimes  during  drunkenness,  67 
Criminal  acts  and  mental  confusion,  1358 

asylums,    Ireland,  provisions  relating  to,  710, 
711,  713 
Italy,  719 
Scotland,  1119 
England.  1088 
United  States,  87 
the  insane  in,  277 
by  passion,  288 
the  occasional,  288 
the  habitual,  288 
the  professional,  288 


1426 


INDEX. 


Criminal,  the  iiistinctive,  288 

D'Ablxdo,  chronic  cystitis   in  general  paralysis, 

the  iusiiuc,  288 

537 

the  atavistif  instinctive,  288 

Daemmerznstaeude,  psychische,  378 

the  atypical  instinctive,  288 

Dagonet,  classification  of  dipsomania.  392 

the  morhid  instinctive,  288 

gout  alternating  with  insanity,  549 

psyclioloiiy,  288 

ptyalism  in  the  insane,  1107 

biology,  288 

Dahl,  L.,  progress  of  psychology  in  Norway,  iiii 

cerebrinn,  288,  320 

Ualrymple,  Donald,  legislation  for  habitual  dmnk- 

cases,  insanity  as  a  delence  in,  Uni 

ed  States, 

!irds,  555 

89 

Dalton,  cases  of  microcephaly,  807 

responsibility   of  the    insane,    United    States, 

Damagetus,  origin  of  insanity,  14 

89 

Dancing  mania,  438 

insane,  Acts  relating  to  the,  Ireland 

,  712 

Darwin,  expressions  of  the  emotions,  55 

insane,  law  as  to.  United  States,  89, 

90 

antithesis,  96 

insane,  law  as  to,  Anstralia,  113 

instincts,  705 

insane,  law  as  to,  Scotland,  1123 

Darwin,  G.  H.,  consanguineous  marriageg,  248 

resp(nisibility  in  i)ersecution  mania. 

934 

consanguineous  marriages  and  idiocy,  662 

resjionsiliility  in  pyroniania,  1056,  i 

d6o 

"  Darwin's  ear,"  419 

suiiiiestions,  1216,  1217 

Daturism,  325 

Criminals,  excitable  ont  bursts  in,  291 

David,  feigned  dementia  of,  4 

classification  of,  288 

cpilei)sy,su]ii)osed,  of,  4 

crania  of,  288 

Davidson,  condition  of  the  iusjine  in  Turkey,  1328 

heredity  of,  289 

Davies,  Pritchard,  effect  of  coloured  light  on  the 

motor  anomalies  in,  289 

insane,  239 

sensory  anomalies  in,  289,  290 

Davis,  David,  case  of,  315 

moral  insensibility  of,  290 

Day,  Justice,  crimimd  resiwnsibilitv  of  drunkards. 

intelligence  of,  290 

686,  687 

emotional  characteristics  of,  291 

cai)acity  of  insane  to  plesul,  953,  945 

method  of  examining,  291 

Day,  period  of,  and  suicide,  1223 

remorse  in,  290 

terrors,  360 

self-mutilation  by,  1148 

Deaf,  auditory  hallucinations  in  the,  566 

facial  type  of,  289 

-mutes  as  witnesses,  464 

bodies  of,  289 

-mutism  in  diagnosing  insanity,  380 

viscera  of,  289 

Deafness,  symmetrical,  due  to  congenital  s\iihilis, 

by  instinct,  726 

1262,  1270 

natural,  727 

in  prodromic  stage  of  general  paralysis,  523 

Criminalogy,  288 

Death,  causes  of,  in  general  paralysis,  532 

Crimiuel-ne,  288 

modes  of.  in  suicide,  1229 

Crises,  tabetic,  insane  interpretation  of. 

750 

rate,  mode  of  calculating,  1197 

mental,  in  locomotor  ataxy,  750 

rate  and  duration  of  attack,  1199 

nocturnal,  in  insanity,  857 

rate  and  duration  of  treatment,  1199,  1200 

Crisis  of  hysterical  demonomania,  353 

of  a  patient,  737 

Cristiani,  284  (sec  Cretinism) 

Debt,  action  of,  period  of  limitation,  and  lunacy, 

Cross-breeding,  the  product  of,  589 

994 

Crothers,  T.  D.,  alcoholic  trance,  1300 

actions  for,  and  interdiction,  Scotland,  11 16 

Croton  chloral  hydrate,  action  of,  1135 

Debilitating  causes  of  neurasthenia,  848 

Crying,  psychology  of,  1273 

Debility  due  to  mon)hia  abstentiim,  819 

"  Crystallisation  mentale,"  Foville,  928 

Decortication,  cerebral,  in  gcnenil  paralysis,  536 

Cullen,  definition  of  insanity,  330 

Dedoublement  de  la  personnalite,  401 

Culture  and  suicide.  1224 

Deduction,  39 

Cummin,  possible  duration  of  complete 

abstinence 

Deed,  action  upon,  i)eriod  of  limitation,  and  lunacy. 

from  food,  772 

994 

Cuneiform  shaped  head,  579 

Deeds,  validity  of,  unimpeached,  996 

Cup-feeding  by  the  nose,  501 

Defatigatio  mentis,  20 

Curator  bonis,  1115 

Degenerative  alfections  and  glycosuria,  372 

appointment  of  a,  324,  238 

brain  states  due  to  brain  injury,  1309,  1310 

resident  abroad,  law  as  to,  396 

paranoia,  887 

Current,  electric,  strength  of,  for  treatment  in  in- 

Degeneration, mental,  and  satyriasis,  1109 

sanity,  428 

stages  of  hereditary  mental,  370 

electric,  duration  of,  for  treatment  in  insanity, 

mental,  occurrence  of,  in  the  sexes,  1155 

428 

the  insane  diathesis  and,  382 

electric,  varieties  of,  for  treatment 

in  insanity. 

Degrees  of  attack  in  circular  insanity.  222 

429 

Di-  Haen,  the  early  uses  of  electricity,  426 

Cutaneous  afEectiinis  and  insanity,  1246 

Deiter's  cells,  functions  of  (Lewis),  903 

perception,  a  knowledge-giving  sensation,  33 

Delarive,  the  humane  treatment  of  the  insane,  25 

sensibility,     derangements     of,     in 

delirium 

Delasiauve,  delirium  tremens  superacutum,  343 

tremens,  343 

insanity  of  doubt,  407 

symptoms  due  to  salicylic  acid,  1103 

ambitious  delusions  after  typhoid,  986 

Cyanosis,  iiisanitj'  of,  697 

Delay e,  reform  in  treatment  of  insane  in  France, 

peripheral,  in  katatonia,  725 

512 

Cybelenes,  self-mutilation  by  the,  1147 

Delayed  expression,  1026 

Cyclische  I'sychose,  die,  215 

of  impressions,  821,  822 

Cycloplegia,  488 

Delbriick,  excitable  outbursts  in  criminals,  291 

in  general  paralysis,  489 

Delft  Asylum,  Holland,  592 

bilateral,  490 

Deliberation,  42 

Cynobex  hebetis,  272 

Deliberative  processes,  32 

Cynorexia  in  neurasthenics,  845 

Delinquente-nato,  288 

INDEX. 


1427 


Delire  aigu,  52 

Delirium  tremens,  incubative  period  in,  69 

doux.  340 

delusions  in,  6q 

h  foi'mes  altcrues,  215 

superacntum,  343 

ties  actes,  in  dipsomania,  391 

febrile,  343 

emotif,  392 

of  cofiee,  238 

des  degeiicres  (Jragiiaii)>  332 

use  of  digitalis  in,  388 

emdtif  (Jlorel),  681 

diagnosed  from  acute  delirious  mania,  54 

amoureiise,  701 

sub-acute  alcoholic,  66,  69 

des  persecutions,  925 

after  traumatic  injury,  7312 

ambitieux,  after  typhoid.  986 

albumen  in  tirine  in,  1349 

do  la  chicane,  1006 

Delivery,  insanity  of,  697 

aigu,  pulse  conditions  in,  1046 

De  lunatico  inquirendo,  196 

ehroni(juc,  1356 

method  of  proi'cdnre  in,  198 

Delirious  mania,  52 

Delusional  insanity,  post-apoplectic,  978 

ideas  iu  drunkards,  67 

puerperal,  1040 

melancholia,  796 

lactational,  104 1 

Delirium,  acute,  52 

and  refusal  of  food,  494 

gnive,  52 

and  hallucinations,  567 

alcoholic,  67 

simulated,  504 

of  heat  stroke,  335 

melancholia,  790,  796 

of  dysentery.  335 

insanity,  887 

of  facial  erysipelas,  335 

insanity,  prognosis  of,  888 

of  meningitis,  335 

secondary  insanity,  695 

cf  measles,  334 

stupor,  1209 

of  milk  fever,  334 

insanity  and  suicide.  1231,  1232 

of  acute  meningitis.  335 

"  Delusion  of  suspicion,"  925 

of  pneumonia,  334 

Delusions,  appeals  to  reason  in,  1317 

of  pleurisy,  334 

in  delirium  tremens,  69 

of  peritonitis.  334 

"  partial,"  use  of  the  term,  306,  307,  308,  310 

of  poisons,  336 

3".  312 

cbrietatis,  337 

of  suspicion,  in  deaf  persons,  328 

of  acute  rheumatism,  334,  335 

of  persecution,  329 

of  acute  delirious  mania,  53 

in  certification,  193 

sub-acute  alcoholic,  66,  69 

in  children,  203 

of  scarlet  fever,  334 

persistent,  due  to  chloroform,  205 

of  small-pox,  334 

melancholic,  in  circular  insanity,  217 

of  sunstroke,  335 

of  epileptics,  453 

of  tjiJhus,  334 

as  cause  of  refusal  of  food,  494 

acute,  prognosis  of,  1008 

exalted,  in  primary  stage  of  general  paralysis 

alternating  with  acute  rheumatism.  1093 

524 

of  denial,  832 

of  persecution  in  general  paralysis,  525 

of  salicylic  acid,  1102 

relating  to  the  hair.  564 

of  sj-philitic  fever,  1254 

of  persecution  in  sub-acute  alcoholism, [69 

of  typhoid,  334 

in  diagnosis,  375 

and  temperature,  338 

simulating-  errors  of  the  sane,  375 

of  yellow  fever,  334 

correct  ideas  at  times,  375 

of  intermittent  fever.  334 

genesis  of  important,  375,  376 

of  influenza,  334 

forbidding  speech,  380 

of  glanders,  334 

and  unequal  hemispherical  action,  401 

of  cerebro-spinal  meningitis,  335 

in  mania,  764 

acute  choreic,  211 

iu  hysterical  mania,  769 

of  children,  357,  358,  359,  360 

in  melancholia,  788,  789 

expansive,  376 

of  suspicion,  in  moral  insanity,  814 

expansive,  with  persecution-mania,  376 

influenced  l)y  abnormal  sensiitions,  835,  836 

negationis,  376 

insanity  without,  699 

sexual,  376 

concealment  of,  700 

maniacale,  376 

in  insanity  of  negation,  833 

metabolicum,  376 

of  religious  type,  1091 

hallucinatorium,  381 

causing  self-mutilation,  1149 

palingnosticum,  376 

in  stuporous  states,  1210,  1211 

persecutionis,  376 

and  suicide,  1232 

of  general  paralysis,  its  pathology,  542 

insane,  and  testamentary  capacity,  1286,  1287 

of  camphor  jjoisoning,  175 

1289 

of  cantharides  poisoning,  177 

Demaisons,  insane  in  Spain,  11 78 

of  children,  202 

Demange,  clinical  evidence   of  cortical  functions 

of  chlorofonn  inhalation,  205 

.        ^56 

epilepticum,  335 

Demence  aigue,  1208 

inflammatory,  use  of  digitalis  in,  388 

Dementia,  Hippocratic  view  of,  13 

of  influenza,  687 

blood-corpuscles  in,  138 

of  j)08t-influenzal  collapse,  688 

haemoglobin  in,  138 

of  lead  poisoning,  745,  746,  747 

simple  adolescent,  367,  369 

of  malaria,  756,  757 

secondary,  of  adolescence,  369 

acute,  of  infective  fevers,  pathology,  911 

ophthalmic  changes  in,  492 

primary,  in  ])Ost-apoplectic  insanity,  976 

in  primary  stages  of  general  paralysis,  524 

of  collapse,  987 

of  later  stages  of  general  paralysis,  526 

febrile,  alcohol  in,  1133 

of  established  general  ])aralysis,  529 

Delirium  tremens,  337 

of  general  paralysis,  its  pathology.  541 

4  V 


1428 


INDEX. 


Dementia,  liaDdwriting  in,  573 
chronic  alcobollc,  78 
Turkish  baths  iu,  126 
bed  sores  in,  129 
cliroiiic,  destructive  acts  in,  355 
secondary,  381 
organic,  382 
gouty,  548 
prsecox,  63 

affectata,  legal  view  of,  686 
chronic,  after  mauia,  767 
diagnosed  from  melancholia,  792 
menstruation  in,  801,  802 
of  myxa'dema,  829 
of  paralysis  agitans,  885 
])atholog-y  of,  899 
of  pellagra,  920 
of  phthisical  insanity,  944 
following  persecution-mania,  931,  932 
toxic,  973 

progressive  post-apoplectic,  978 
primary,  varieties  of,  loio,  loii 
secondary  varieties  of,  prognosis  of,  loii 
pulse  conditions  in,  1050 
])yromania  in,  1059 
religious  delusions  in,  1092 
ptyalism  iu,  1107 

acute  primary,  and  single  care,  1166 
sphygmographic  tracings  in,  11 89 
secondary,  cord  changes  in,  1190, 
acute,  1208 

epileptic,  due  to  syphilis,  1256 
liemiplegic,  due  to  syphilis,  1256 
juvenile,  1267 
temperature  in,  1279 
forms  of,  due  to  brain  injury,  1309,  1310 
specific  gravity  of  urine  in,  1341 
colour  of  urine  in,  1342 
urea  iu,  1343 

mineral  constituents  in  urine  in,  1347 
Dements,  phthisis  in,  940,  941,  942 
Demme,  neuroses  in  hereditary  syphilis.  1264 
Democritus,  the  mental  effect  of  hellebore,  13 
Demoniacal  possession,  records  of,  2,  3,  20 
Demonolatria,  1368 
Demouology,  epidemics  of,  436 
Demonomaniacal  insanity,  695 
"  Denial,  delirium  of,''  832 
Denis,  transfusion  in  treatment  of  insanity,  22 
Denman,  Justice,  criminal  responsibility  of  the  in- 
sane, 293,  298,  304 
cai)acity  of  the  insane  to  plead,  9^1 
Denmark,  the  insane  in,  1112 
sexes  iu  insanity,  11 53 

Dent,  Clinton    T.,   traumatism    and    in- 
sanity, 1312 

Dentition  in  neurotic  children,  358 
Depilation  in  anomalous  trichosis,  129 
Depletion  in  treatment  of  insanity,  1291 
Depressant  treatment  of  insanity,  1291 
Depression,  346 

melancholic,  376 

hypochondriacal,  376 

a  sign  of  recovery  in  mania,  766 

mental,  in  certitication,  193 

mental,  in  toxic  states,  969,  970 

stage  of  drunkenness,  416 
Depressive  insanity,  695 
Deprivation,  idiocy  due  to,  644 

in  morphia  habit,  slow,  819 
quick,  819 
sudden,  819 

of  senses,  insanity  from,  696 
Deputy  Commissioners,  Scotland,  11 17 
Derangements  of  instinct,  706 
De-'cartes,  rationalism,  1062 
D'Kscayrac  de  Lanture,  le  ragle,  748 


Descourtis,  sensory  illusions,  676 

Desert,  hallucinations  of  the,  748 

Designs,  the  property  of  a  lunatic,  891  (see  Paten- 
tees, Insane) 

Desire,  40,  41 

Desires  in  initial  stage  of  general  paralysis,  521, 
522 

D'Espine,  imitation,  676,  677 

disappearance  of  instinct  in  adults,  677 

imitation  in  criminal  acts,  677 

moral  insensibility  of  criminals,  290 

and  I'ieot,  cerebral  hn^ertrophy  in  idiocy,  650 

Destructive  im])ulse,  681 

lesions  of  nervous  system,  443 

Destructiveness  in  insane  jealous}',  722 

Detention,  illegal,  law  as  to,  Scotland,  1122 

Detinue,  action  of,  period  of  limitation,  and  lunacy, 

994 
Development,   mental,  in   adolescent    males,  360. 
368,  369 

females,  360,  368,  369 
Developmental  causes  of  idiocy,  659 

forces,  failure  of  the,  586,  587 

idiocy,  643,  646 

process  of  adolescent  psychoses,  369,  370 
Deventer  Asylum,  Holland,  592 
Devon  County  Asylum,  103 
Dewar,  composition  of  sweat,  1167 
Diabetes,  as  cause  of  acute  delirious  mania,  52 

alternating  with  insanity,  82,  371,  372 

course  of,  influenced  by  general  paralysis,  82 

and  insane  jealousy,  722 

and  insanity,  1246 

the  sympathetic  in,  1251 

iTisipidus  in  hysteria,  372 

in  hypochondriasis,  372 
Diagnosis  of  criminal  types,  291 
Diagnostic  value  of  temperature  in  insanity,  1280 
Diarrhoea,  as  cause  of  acute  delirious  mania,  52 
Diatactic  action,  1027 
Diathese  nerveuse,  841 
Diathesis,  melancholic,  798 
Diathetic  insanity,  695 

Dickinson,  H.,  glycosuria  in  the  insane,  371 
Diction,  disorders  of,  in  general  paralysis,  527 
Diet    as  an  exciting  cause   of   general   paralysis, 

535 
in  examination  of  the  excreta  of  the  insmo. 

474.  475 

in  idiocy,  667,  668 

of  lunatics,  statutory  reg^ilations  as  to,  736 
Dietary  standard  for  pauper  asylums,  386,  387 

in  treatment  of  adolescent  insanity,  370 
Diets,  formulje  for,  in  artificial  ft'eding,  498 
Dietz,  action  of  amylene  liydrate,  1139 
Differential  diagnosis  of  insanity,  380,  381 
Diffuse  cerebral  sclerosis  in  idiocy,  653 
Digestive   organs,  derangements  of,  and  insanity. 

1245 

tract,  hypochondriasis  of  the,  615 

functions,  hysterical  disturbance  of  the,  636 
Digitalis  iu  climacteric  insanity.  235 

in  delirium  tremens,  388 
Dinitrogenised  diphosphatides  in  brain.  149 
Dioscorides.lead  poisoning  and  delirium.  745 
Diplopia,  homonymous,  in  paralysis  of  the  f  lurth 

nerve,  488 
Dipsomania  in  circular  insanity,  219 

and  alcoholism  distinguished,  393,  394 
Dipsomaniacal  impulse,  389,  390,  391 

relapses  in.  392 
Dipsomaniacs,  65 
Direct  reflex  pu])illary  reaction,  1052,  1053 

suggestion,  12 13 
Director  of  public  prosecutions,  report  on  cajatal 

charges,  313 
Disability,  certificates  of,  194 


INDEX. 


1429 


I)i<(',    optic,    simple    liyperaMiiia    of,    in    t^cncral 
jiaralysis,  490 

■aincuiia  of,  in  n-cneral  paralysis,  490 

prim:iry  atrophy  of,   in  generiil  paralysis,  490, 
491 

post-papillitic  atrophy  of,  in  geueral  paralysis, 
491 
Dischuri;i'  of  patients,  Kng-laiul  and  Wales,  'j'^-j 

Scotland,  11 23 

ordered  by  coniuiissioiiers,  734,  7315,  737 
Dischart;iuf;-  lesions  of  Tiervous  system,  443,  444 

spinal,  444 
Discrimination,  31 
Disease,  influence  of,  ou  size  of  head,  578 

mental,  inHueuce  of,  in  brain  weight,  165,  166 

and  temperaments,  1277,  1278 

simultaneous  occurrence  of,  in  twins,  1330 
Disorders  of  consciousness,  262 
Disponirt,  382 
Disseminated  cerebral  sclerosis  in  idiocy,  653 

sclerosis  in  insanity,  1190,  1191 

speech  defects  in,  1192,  1193 

the  tremor  of,  1322 

the  tremor  of,  and  mercurial  tremor  diai;  nosed, 
1321 

simulatint^-  hysteria,  1162,  1163 
Dissimulation  of  insanity,  381 
Dissolution  of  partnership  in  insanity  of  a  partner, 

890 
"Distinction  time"  in  reaction-time,  1070 
Distraction  in  reaction-time  experiments,  1069 
Distress    for    rent-charge,    legal    limitation,    and 
lunacy,  994 

for  other  rents,  legal  limitation,  and   lunacy, 

994 
District  asylums,  Ireland,  709,  710 

Scotland,  11 18 
Disvulnerability  of  criminals,  290 
Dittmar,  treatment  of  circular  insanity,  227 
Divination  and  madness,  17 
Divine  service  in  asylums,  515 
Divorce,  action  for,  period  of  limitation  of,    and 
lunacy,  994 

proceeding's  during  insanity,  780,  781 
Diwangi,  831 
Dix,  Miss,  improvement  in   the  condition   of  the 

insane,  90,  552 
Dods,  Rev.  M.,  sibyls,  1160 
Dog,  delusion  of  being  a  (cynantliropia),  324 
Domatophobia,  844 

Donaldson,    H.     H.,    psycho-physical 
methods,  1014 

Donath,  Julius,  ethylene  Ijromide  in  epilepsy,   1131 
Donders,  normal  acoustic  reaction-time,  1063 

complex  reactions,  1069 

incomplete  reactions,  1070 

Donkin,  Jl.  15.,  hysteria,  618 
Doppeldenkeu.  401 

Doppelempfindungen  (ilual  sensations),  1125 
Dordrecht  Asylum,  Holland,  592 
Dorridge  Grove  Idiot  Asylum,  552 
Double  action  Iti  nerve  centres,  821,  822 
consciousness,  265,  378 

and  double  brain  action,  401  {fiec  aho  art. 

Double  Coxsciolsness) 
due  to  salicylic  acid,  1103 
insanity,  240 
Doubt,  insanity  of,  handwriting  in,  574 
Douche  treatment,  iig,  120 
Dower,  arrears  of,  action  for,  period  of  limitation 

of,  and  lunacy,  994 
©own,  J.  Langdon,  asphy.xia  as  cause  of  idiocy,  663 
(•onsan^uineous  marriages,  248 

deaf-dumbness,  326 

othamalomata  in  idiots,  559 

idiocy,  forms  of  644 

develoimieutal  causes  of  idiocy,  659,  665 


Down,  .1.  Langilon,  phthisis  causing  idiocy,  660 
insanity  causing  idiocy,  660 
parental  alcoliolism  and  idiocy,  661 
syphilis  an<l  idiocy,  661 
aetiology  of  sporadic  cretinism,  662 
priiniparous  idiots,  663 
idiocy  due  to  sunstroke,  1234 
congenital  syphilis  and  idiocy,  1255 
Downpatrick  Asyhun,  710 
Drains  in  asylums,  104 
Dreaming  and  double  consciousness,  401 

during  somnambulisni,  1172 
Dreams,  35 

of  the  insane,  414 
the  remembrance  of,  412 
olfactory  centres  in,  413 
thought  in,  412 
conscience  in,  412 
judgment  in,  412 
uu'mory  in,  412,  413 
change  of  personality  in,  413 
sensory  centre  in,  413 
gustatory  centre  in,  413 
effect  of  external  stimuli  on,  413,  414 
sensations  in,  835 
"  Dreamy  state,"  the,  453 
Drinkers,  morbid  mental  state  in,  64 
intermittent,  65 
subject  to  alcoholic  delirium,  68 
types  of,  388 
melancholia  of,  68 
ilelirious  ideas  in,  68,  69 
Drug  abuse,  nymiihomania  following,  864 
craving',  972,  973 
-habit  in  neurasthenics,  849 
treatment  by  Weir  Mitchell  process,  852 
Drugs,  influence  of,  on  bladder  contractions,  1340 

on  reaction-time,  1069 
Drunkards,  intellectual  disequilibration  in,  67 
mental  state  of,  64 
habitual,  legislation  for,  554 
habitual,  deliuition  of,  555 
liabitnal,  offences  against  the  act  relating  to, 

556,  557 
and  pseudo-dipsomaniacs  differentiated,  395 
double  consciousness  in,  401 
the  law  relating  to,  684 
criminal  responsibility  of,  685,  686 
involuntary,  criminal  responsibility  of,  687 
Drunkenness,  predisposition  to,  66 
and  irresistible  impulse,  65,  66 
and  neuroses,  65 
melancholy,  67 
convulsivi!,  67 
maniacal.  67 
of  ei)ileptics,  67,  70 
and  insanity,  similarity  between,  448 
modes  of  suppression  of,  73 
Dry  pack,  123 
Dual  sensations,  11 25 
Duality   of   brain    function   and    unilateral  braia 

lesions,  400 
Duboisine,  sulphate  of,  1143 
Duchennc,  medical  uses  of  electricity,  437 
Ducpetiaux,  asylum  reforms,  132 
Dudgeon,  s])hygmograph,  1187 
Dufay,   double  consciousness    of    somnambulism, 

402 
Dujardin-Heaumetz,  narcotics  and  hypnotics,  1129 
liypnoue,  1137 
coninm,  i  145 
Dumlmess  due  to  defective  brain  development,  326 
to  iiccidental  deafness,  327 
in  insanity,  827 
in  criminal  pleading,  961 
Dumenil,    legislation    for   the   iu'^aiie   in    France, 
513       ' 


I430 


INDEX. 


Dumfries  Royal  Asylum,  1096 

Duncau,  provision  for  the  insane  in  Scotland,  552 

Dimcan,   Matthews,    the    advent    of    adolescence, 

361 
Dundee  Royal  Asylum.  1096 
Duodenal  catarrh  and  insanity,  1245 
Duperi^,  numerical  estimate  of  blood   corpuscleg, 

137 
Dur:i  mater,  adhesions  of.  in  insanity,  900 

affections  of,  due  tn  conyeuital  sypliilis,  1260 
anatomy  of  the,  t6S 
in  general  ])aralysis,  535 
hematoma  of  the,  877 
appearance  of.  in  cerebral  haematoma,  180 
Dural  ha^matoma,  877 

formation  of  membrane  in,  878 
in  males,  879 
in  general  paralysis,  879 
in  chronic  insanity,  879 
unilateral,  879 
in  chronic  alcoholism,  880 
pathology  of,  880 
symptoms  of,  882 
treatment  of,  882,  883 
Durand.  Le  Gros.  hypmitism,  604 
Duration  of  attack    inliueiicini^   recovery  in    asy- 
lums, 1 199 
of  attack  and  mortality  in  asylums,  1199 
of  treatment  influencing-  recovery  in  asylums, 

1 199 
of  treatment  and  mortality  in  asj'lums,  1 199, 

1200 
of  cycle  in  circular  insanity,  222 
period  of  general  paralysis,  519 
Duret,  arterial  distribution  in  brain,  170 

cause  of  prodromal  headache  in  insanity,  900 
Durliam,  cerebral  anaemia  during  sleep,  1170 
Duvay.  consanguineous  marriages,  327 
Dwelshavers,  expectation  in  reaction-time,  1068 
Dyce,  somnambulistic  conditions,  1176 
Dyschromatopsia  in  chronic  alcoholism,  75 
Dysentery,  tropical,  delirium  of,  335 
Dysmenorrhoea  inducing  mental  alfections,  1350 
Dysolo^ical  speech  derangements,  378 
Dyspepsia  alternating  with  insanity,  80 
in  hypochondriasis,  615 
in  melancholia,  793,  794 
Dysphagia,  hysterical,  636 
Dysphasia  vesana,  378 
Dyspncea,  hysterical,  635 

Ear  affections  due  to  congenital  syphilis,  1262, 1266 
Earle,  Pliny,  educational  instruction  in   asylums, 
1317 

curability  of  insanity,  321 

Eales,  centre  for  pupillary  reaction,  1053 
Earlswood  Asylum,  551,  552 
Eastern  Counties  Idiot  Asylum,  552 
Ebstein,  iwlyuria  in  brain  affections,  1341 
Kccentrics,  mental  indecision  in,  422,  423 
Eccentricity  no  evidence  of  lunacy,  462 
Echelon  system  of  asylum  construction,  103 
Echeverrla,  echo  sign  in  epileptics,  424 

bromides  in  epilepsy,  11 32 
Echolalia  in  general  paralysis,  526 
Eckart,  saUvary  centre,  1105 
Eclampsia,  dentitional.  358 

infantile,  causing  idiocy,  665 
Edampsic  idiocy,  643 
Eclipsis,  359 
Ecstasis  paranoica,  1364 
Ecstasy,  pulse  condition  in,  1045 

and  catalepsy,  differential  diagnosis,  184 
iOcstatic  melancholia,  207 

trance,  424,  1300 

somnambulism,  1176 
Eczema,  alternating  with  insanity,  82,  83 


Edgeworth,  sensory  fibres  in  the  s\Tnpathetic,  1249 
Edinburgh  Royal  Asylum,  1094,  1095,  1096 
Education,  siammerlni;'  cured  by,  1193 

and  suicide,  1227,  1228 

and  chorea,  209 

and  hysteria,  620 

and  erotomania,  702 

of  idiots  and  imbeciles,  667 

in  asylums,  Ireland.  711 

of  microcephales,  807 

of  neurotic  children,  998 
Educational  instruction  in  asylums,  1316 

speech  defects,  1193 
Effort,  moral,  42,  43 

intellectual,  tlie  consciousness  of,  42,  107 
Eg  Asylum,  iiii 
Ego,  consciousness  of  the,  378 
Egotism,  morbid,  in  hysterical  mania,  768 
Egressing  insanity,  695 
Euypt,  the  insane  in,  1329 
Egyptians,  insanity  among  the  ancient,  i,  2,  3 

microcephaly  among  the  ancient,  805 
Ehrlich's  staining  fluids  for  sections,  1187 
Eisselberg,  treatment  of  cretinism,  287 
Ejectment,   action   for,  period   of  limitation    and 

lunacy,  994 
Ekel,  1 161 
Electric  chorea,  212 

light  in  asylums,  105 

neurosis,  428 
Electrical  reaction  in  the  insane,  428. 

in  pellagTa,  920 
Electricity  in  forcible  feeding,  500 

in  treatment  of  hysteria,  640,  641 

in  stupor,  1209,  1213 

in  treatment  of  neurasthenia,  849 

in  functional  neuroses,  853,  855 
Elgin  District  As.vlnm,  1095 
Elkins,  F.,  influenza,  691 
Elislier,  pathology  of  chorea,  210 
Elliotson,  hypnotism.  603 

Ellis,  Haveiock,  criminal    anthropology, 
288 

plethysmograph,  964 

influence  of  sex  in  insanity,  1152 

influence  of  the  mind  on  the  uri- 
nary bladder,  1339 
Elmer,  J.,  Chancery  lunatics,  195 
Embarrassment,    mental,    a   prodrome    of     acute 

chorea,  207 
Embryo,  effect  of  external  violence  on  the,  1308 
Emergency  certificates,  Scotland,  1120,  1121 
Emetics  in  treatment  of  drunkenness,  417 
EmmenaLiOgues  in  insanity,  1290 
Emminuhaus,  exoplithalmic  goitre   and    insanity, 
476 

sleep  following  transitory  frenzy,  1305 

congestion  theory  of  transitory  ft-euzy,  1303, 
1306 

amnesia  after  transitory  frenzy,  1305 
Emotion,  40.  1029 

and  sensation,  254 

liicial  expression  of,  483 

anomalies   of,  in   prodromic    stage  of  general 
paialysis,  522 

sensory  disturbances  and,  837 

cerebral  conditions  of,  837 

sjinpathetic,  and  tears.  1274 
Emotional  abnormalities  in   hereditary  defenera- 
tion, 597,  59S 

causes  of  hysteria,  625.  628 

exaltation  in  mania.  764 

states  in  hallucinatory  mania,  767 

hyperesthesia  in  hysterical  mania,  768 

balance  at  menstrual  periods,  S03 

shocks,  52 

characteristics  of  criminals,  291 


INDEX. 


143 1 


EniDtional  centres,  186 

control  in  aphasies,  9S2 

control,  42 

salivation,  1105,  rio6,  1107 

hysterical  disturbances,  1161 

storms,  weeping'  in,  1274 

activity  and  liead  temperature,  1284,  1285 
Emotions,  39,  260,  447 

and  blood  circulation,  136 

in  cretinism,  286 

adolescent,  development  of,  367 

excitability  of  the,  376 

painful,  376 

absence  of,  376 

perversion  of,  yjl 

in  general  jiaralysis,  529 

in  insane  diathesis,  383 

in  post-apoplectic  mental  weakness,  977 
Empliysema,  influence  of,  on  pulse,  in  insanity,  1044 
Employment,  influence  of,  on  cranial  development, 
578 

in  treatment  of  the  insane,  1315 
Encephalitis,  complicating-  general  paralysis,  520 
Endemie  forms  of  mental  disorder  in  India,  682,  683 

insanity,  435 

insanity  and  religion,  1090 
■'  Endormie,"  325  (s-ee  Datura-stramonium) 
Energetic  hand,  the,  989 
Energy,  outlet  for  mental,  244 

excessive  demand  of,  245 
Enfeeblement,  mental,  as  evidence  for  certification, 

193 
Engelbracht  the  ecstatic,  case  of,  425 
England,  associations  for  after-care  in,  58 

history  of  hj'pnotism  in,  603,  604,  605,  606 

and  Wales,  lunacy  laws,  730 
sex  in  insanity  in,  1153 
provision  for  insane  in,  551,  552 
English  malad}',  the,  756 
Ennis  As.ylum,  710 
Enniscorthy  Asylum,  710 
Enteric  fever  and  insanity,  506 
Environment,  adaptability  of  conduct  to,  243 

delusions  as  to  relation  between  self  and,  347 
Ephemeral  insanity,  post-parturient,  1036 
Epi-cerebral  space  of  His,  171,  902 
Epictetus,  suicide,  1218 
Epidemic  chorea,  213 

ergotism,  457 

insanity,  ancient  record  of,  20 
absence  of,  in  India,  682 
and  reliirion,  1090 
Epidemics  of  suicide,  12 19 

Epigastric  sensations   attending   displeasing  emo- 
tions, 253,  260 

attending  pleasing;'  emotions,  253,  260 

in  hypochondriasis,  615 
Epilepsy,  albumen  in  urine  after  fits,  1348, 1349 

sugar  in  urine  in,  1349 

verbigeration  in,  1355 

Hippocratic  view  of,  12,  14 

due  to  absinthe,  51 

diagnosed  from  delirium  tremens,  71 

alternating  with  insanity,  80 

as  cause  of  folie  circulaire,  226 

at  the  menopause,  235 

])0st-eclampsic,  358 

masked,  453,  454 

and  melancholia,  454 

Jacksonian,  444 

and  general  i)aralysis  differentiated,  534 

n'lation  of,  to  insanity,  582 

alcoholic,  77 

autifebrin  in,  95 

in  children,  204 

and  infantile  convulsions,  association  between, 
271 


Epilepsy,  delirium  in,  335 

degree  of,  due  to  various  nervous  levcl.s,  444 

and  hysterical  lit  diagnosed,  622,  639 

in  liyslerical  children,  624 

and  hysteria,  62^ 

causing  idiocy,  665 

among  th(^  ancient  Jews,  715 

du(^  to  iilunibisiii,  745,  746 

moral  insanity  in,  815 

nymphomania,  in,  864 

and  ovariotomy,  875,  877 

paralytic  mydriasis  in,  1054 

l)yromania  in,  ios9 

religious  delusions  in,  1092 

salivation  in,  1 106 

bromides  in,  1130,  1131,  1132 

occurrence  of,  in  the  sexes,  1155 

suicide  in,  1231 

following  sunstroke,  1234,  1235 

the  sympathetic  in,  1251 

due  to  constitutional  syphilis,  1256 

idiopathic,  and  congenital  syphilis,  1263 

tetanoid,  1290 

traumatic,  1312 

chronic,  operative  interference  for,  1327 

excretion  of  solids  in  urine  of,  1344 

polyuria  in,  1341 

colour  of  urine  in,  1342 

uric  acid,  excretion  in,  1345 

glj-cero-phosphoric  acid  in  urine  of,  1347 

mineral  constituents  in  urine  of,  1347 
Epileptic  fit,  analysis  of  an,  449 

idiocy,  455,  643,  648 

insanity,  ophtlialmic  changes  in,  492 

insanity,  weiLjht  of  hemispheres  in,  400 

insanity,  exaltation  of,  472 

furor,  homicide  in,  595 

insanitj',  696 

insanity,  masturbation  in,  784 

insanity,  menstruation  in,  8or,  802 

vertigo,  total  amnesia  in,  798 

insanity,  pathological  chani;es  in,  909,  910,  911 

seizures,  early  myosis  in,  1056 

status,  chloral  in,  1134 

insanity,  ancient  records  of ,  4,  6,  10,  11,  12,  14 
blood-corimscles  in,  138,  139 
h<emoglobin  in,  139 
vascular  conditions  in,  1049 
reaction-time  in,  1064 
prognosis  of,  1012 

mania  arising  during  sleep,  1171 

insanity,  sphyg-mographic  tracings  in,  1188 

status,  1207 

asylums,  Switzerland,  1240 

idiocy  due  to  congenital  syphilis,  1255 

insanity,  temiteratnre  in,  1279 
Epileptics,  echo  sign  in,  424 

delusions  of,  453 

facial  expression  of,  485 

drunkenness  of,  67,  70 

sub-acute  alcoholism  in,  70 

destructive  impulses  in,  355 

hair  of,  564 

statistics  as  to,  453 

kleptomania  in,  728 

I)hthisis  in,  942 

cardiac  com])lications  in,  1049 

pulse  conditions  in,  1049,  1050 

incendiarism  by,  1057 
Epileptiform  attacks  in  chronic  alcoholism,  76,  TJ 

fits  and  insanity,  455 

seizures,  444 

fits  due  to  brain  injury,  1310 

seizures  in  general  jiaralysis,  520,  530,  543,  544 

fits,  Jacksonian,  444 

fits,  in  general  paralysis,  treatment  of,  543 

impulse,  681 


143= 


INDEX. 


Epili'ptifonu  convulsion^  uftir  ni;il;n-i;i,  756,  758 
Ei)ik'ptoid  hallufiniitions,  373 

attacks  of  ceivbraux,  188,  1S9 

convulsions  in  crs>otism,  458 

stag'C  of  convulsive  hysteria,  630 

neurasthenia.  840 
Episodical  syndromes  (MaL;nan),  595,  597 
Equililirium  sense,  psychological  method  of  regis- 
tering, 1015 
Erection  of  hair  in  the  insane,  564 
Erethism,  alcoholic,  340 
Ei^otine.  in  acnte  delirious  mania,  55 
Ergotism,  lathyrism,  ami  pellagra  compared,  922 
Erlauger,  renal  atfectious  and  insanity,  1245 
Erlenmeyer,  A.,  coeoniania,  236 

handwriting  of  the  insane,  568 

morphiomania,  817 

treatment  of  morphia  habit,  819 

nostalgia,  858 

combined  bromide  salts  in  epilepsy,  1132 
snlphonal,  1138 

tobacco,    effects    of,    on    nervous 
system,  1297 

Eriicki's  fluid  for  hardening  sections,  1182 
Erotic  insanity,  696 

developing  after  marriage,  783 
Eroticism  in  folie  circnlaire,  220 

in  mania,  764,  765 
Errors  and  delusions,  375 
Erskine,  the  defence  of  Hadfield,  300,  301 
Erskiue,  Lord,  suicide  and  life  insurance,  749 

testamentary  capacity  of  the  insane,  1286 
Eructations  in  hysteria,  636 
Eruption  due  to  bromides,  1132 

due  to  chloral  amide.  1136 

due  to  snlphonal,  1138 
Erysipelas,  mental  improvement  after,  80 

facial,  the  delirium  of,  335 

of  ear  diagnosed  from  aural  hicmatoma,  559 

and  accidental  deaf-mutism,  327 

followed  by  insanity,  988 
Erythema,  solar,  diagnosed  from  pellagra,  921 
Escape  of  patients,  737 

recapture  after,  737 
Esdaile,  anaesthetic  effect  of  hjpnotism,  604 
Esher,  Lord,  contracts  of  lunatics,  1377 
Esquirol,  sympathetic  insanity,  1243 

intestinal  disturbance  and  insanity,  1245 

intestinal  worms  and  insanity,  1245 

aboulia,  1366 

the  causes  of  insanity,  135 

demonomauia,  352 

moral  emotion  as  cause  of  folie  circnlaire,  226 

classification  of  insanity,  230,  231 

classification  of  dipsomania,  392 

treatment  of  the  insane  in  France,  512 

classification  of  the  insane  in  asylums,  514 

colour  of  hair  of  the  insane,  563 

hallucinations,  565,  566 

pathology  of  hallucinations,  567 

appearance  of  parental  attributes,  584 

monomania,  84,  594,  811 

insanity  of  doubt,  407,  409 

cireidar  insanity,  215,  223 

homicidal  proclivities  of  the  insane,  594 

menstruation  and  insanity,  801 

menstruation  and  mania,  801 

erotomania,  702 

lunar  influence  in  causing'  insanity,  813 

the  nursing  of  the  insane,  859 

eroticism,  863 

delusions  of  suspicion,  925 

religion  and  forms  of  insanity,  1091 

remissions  in  insanity,  1092 

ptyalism  in  the  insane,  1107 

sex  in  insanity,  1153 
Essex  Hall  Idiot  Asylum,  552 


Established  stage  of  general  paralysis,  523 
Etat  delirante  of  degeneration,  331 

nerveux,  841 
Ethene  bromide,  action  of,  1131 
Ether,  insanity  following  the  use  of,  92 

as  a  soporific,  1133 
Ethiopian  idiocy,  647 

Ethnology,  influence  of,  on  suicide,  1223,  1224 
Ethj'l  carbamate,  action  of,  it 36 
Ethylene  bromide,  action  of,  1131 
Etiology  of  insanity  in  children,  204 

of  choreic  insanity,  208 

of  folie  circnlaire,  225 
Etoc-Demazy,  pathology  of  mental  stupor,  1213 
Ettmuller,  melancholia  sine  delirio,  594 
Eulenberg,  the  pathology  of  catalepsy,  185 
p]uripides,  the  insanity  of  Hercules,  9 
European  countries,  frequency  of  suicide  in,  1220 
Evans,  early  uses  of  electricity,  426 
Everest,  the  legal  aspect  of  delusions,  313 
Evidence  of  insanity  admissible  as  proof  of  lunacy, 

462 
Evolution,  levels  of,  in  nervous  system,  443 
Ewald,  hysterical  globus,  548 
"Exaggerated  sensibility,"  841 
Exaltation,  193,  345 

in  the  insanity  of  plumbism,  474 

of  general  paralysis,  pathology  of,  542 
Examination,    method   of,    in   concealed  insanity. 
700 

of  criminals,  291,  292 

of  supposed  insane  patients,  180,  181 
Examinations  for  attendants,  693 
Exanthem  of  pellagra,  919,  920,  922 
Excitable  outbursts  in  criminals,  291 

phases  of  folie  circulaire,  218 
Excitability  in  toxic  conditions,  968,  969 
Excitable  stage  of  drunkenness,  415,  416 

of  hydrophobia,  600 
Excitation  of  brain  function  as  cause  of  insanitv. 

893 
Excited  melancholia,  796 
Excitement,  periods  of,  in  persecution-mania,  931 

maniacal,  incoherent,  in  folie  circulaire,  220 

sudden,  in  primary  dementia,  349 

in  secondary  dementia,  349 

as  evidence  for  certification,  192 

maniacal  use  of  digitalis  in,  387,  388 

mental,  of  established  general  paralysis,  ^24 

in  katatonia,  725 
Exciting  cause  of  idiocy,  659 
Executed  contracts.  267  (see  Contracts) 
Executor,  duties  of,   in  propounding  wills,    1289, 
1290 

lunacy  of  an,  476 
Executory  contracts,  267  (see  Contracts) 
Exercise  in  idiocy,  669 

in  melancholia,  794 

in  neurasthenia,  849 

in  treatment  of  the  insane,  1315 
Exhaustion,  facial  exjiression  of,  483 

as  cau.se  of  hysteria,  625,  628 
Exhibitionists,  377 
Existing  lunacy  and  occurring  lunacy  in  statistics, 

1194,  1195 
Exner,  cerebral  atrophy  in  senile  dementia.  873 

variations  in  inteusit.y  of  stimulus  in  reaction- 
time,  1068 
Exophthalmic  goitre,  delirium  in,  336 

the  sympathetic  in,  1251 

tremor  of,  1323 
Exorcism  in  demonomauia,  353 

in  treatment  of  insanity,  133,  432,  433 

in  Ireland,  707 
Expansive  delirium  of   established  general  para- 
lysis, 524 
Expectant  attention,  no.  1017 


INDEX. 


1433 


Expectatiou  in    reiictiou-tiuie   experimuuts,    1068, 

1070 
ExpiTimcutatioii,  mi'iitul,  avtilioiiil,  29.  108,   1014 

uatural,  29 
Exporiuieiits  on  attfiitioii,  108 
Expert  eviileiK-o,  jiuliciiil  ruling:  as  to,  953 
Expression,  delayed,  1026 
Exstiise,  1300 

Extension  theory  of  general  paralysis,  540 
Extra-ocular  muscles,  examination  of,  487 

affection  of,  in  general  paralysis,  487 
Eye,  state  of,  during  sleep,  1171 

affections  due  to  couiionital  syphilis,  1262,  1266 

-movements  in  infants,  465,  466 
mental  value  of,  484 
Eymounet,  giycero-pliosphorie  acid  in  urine,  1346, 
1347 

Face,  confonuation  of,  in  general  i)aralysis,  528 

hair  ou  the,  in  the  insane,  564,  565 

type  of,  in  criminals,  289 
Facial  appearance  in  transitory  mania,  1304,  1305 

expression  in  diagnosing  insanity,  378 
polymorphous,  in  mania,  378 
incongruity  of,  378 
in  melancholia,  787,  788 
in  the  insane,  947 

muscles,  action  of,  482 

expression,  rapidity  of,  484 

expression,  march  of,  484 

expression,   indicating-    mental    development, 
484 

paralysis,  salivation  in,  1106 

wrinkling'  in  plumbism,  746,  747 
Faculties  of  the  miud,  31,  493 
Fasces,  examination  of,  474,  475 
Falret,  prolonged  warm  baths  in  insanity,  118 

folie  circulaire,  215,  216 

the  agitated  state  of  folie  circulaire,  218,  219 

maniacal  stage  of  folie  circulaire,  220 

congestive  symptoms  in  maniacal  stage  of  folie 
circulaire,  221 

gradual  transition  in  folie  circulaire,  221 

successive  oscillatory  transitions  in  folie  cir- 
culaire, 222 

lucid  intervals  in  folie  circulaire,  222 

diagnosis  of  folie  circulaire,  224 

prognosis  of  folie  circulaire,  225 

influence  of  sex   in  occurrence  of  folie  circu- 
laire, 226 

pathological  lesions  in  folie  circulaire,  227 

pathology  of  hallucinations,  567 

insanity  of  doubt,  407 

persecution-mania,  925 
Falret,  J.,  protective  societies,  515 

hyper-activity  in  early  stages  of  general  para- 
lysis, 522 
False  sialorrhoea,  1104 

Family  history,  essential  inquiries  into,  180 
Fanaticism,  1089 

and  self-mutilation,  1147 
Fantasies,  the  basis  of  a  child's  mind,  203 
Fantonetti,  progress  of  psycholoi^y  in  Italy,  717 
Faradism  in  the  treatment  of  hysteria,  626 
Farm  labour  in  asylums,  1315 
Farms  attached  to  asylums,  514 
Farr,  Vi'.,  method  of  calculating  recoveries,  1196 
Farrant's  solutions  for  hardening  sections,  1182 
Fascia,   local   increase  of    temperature  in   hemi- 
spherical activity,  399 
Fasting  mania,  the,  770 

gii'ls,  773 
Fatigue,  facial  expression  of,  483 

in  reaction-time,  1069 
Fatty  degeneration  of  brain,  160,  161 
Fajter,  Sir  J.,  neuroses  due  to  solar  heat,  1233 


Fear,  447 

nervous  action  of,  837 

weeping  due  to,  1274 

efVecl  of,  on  bladder,  1339 
Febrile  delirium  tremens,  344 

diseases  as  cause  of  idiocy,  665 
of  insanity,  985 

insanity,  696 

causes  of  insomida,  703 

atrophy  of  olil  men  (N'irchow),  872 
Febris  intermittens  ex  niorphinisnio.  818 
Fcchner,  psychophysics,  49,  1C24 

psychophysical  methods,  1025 
Feeble  haiul,  the,  989 
Feeding-cup,  use  of,  in  forced  alimentation,  499 

nasal,  501 
Feeding-  in  the  treatment  of  functional  neuroses, 
853.  S55-  856 

in  treatment  ol  insanity,  1292,  1293 

per  rectum,  1073 
Feeling,  31,  32,  39,  40,  250,  251,  252,  253 

control  of,  42 

and  environmental  conditions,  260,  262,  263 

disorders  of,  262 
Feelings,  remembrance  of,  253,  259 

corporeal,  39 

perceptive,  39 

emotional,  39 

associated,  39 

sentimental,  39 
Fees  for  certification,  Scotland,  1121 

of  medical  experts,  481,  482 
Fehr,  H.,  post-influenzal  psychoses,  690 
Feigned  general  paralysis,  505 

insanity,  ancient  records  of,  4,  6,  7 
Feigning,  indications  of,  505 
Females,  general  paralysis  in,  520 
Fere,  Ch.,  facial  exi)ression  anil  hallucinations,  949 

salivation  in  epilepsy,  1106 

poisonous  action  of  bromides,  1131 

effect  of  suggestion  on  bladder,  1339 
Ferocitas  ebriosa,  1305 
Ferrarese,  Luigi,  progress  of  psychology  in  Italy, 

717 
Ferrers,  Earl,  case  of,  298 
Ferri,  Enrico,  clinical  classification  of  criminals, 

288 
Ferric  bromide,  action  of,  1131 
Ferrier,  cortical  motor  areas,  152,  153,  154,  156, 
186 

functions  of  corpus  striatum,  157 

functions  of  cerebellum,  158 

functions  of  corpora  r|uadrigemina,  158 

cerebral  lesions  and  insanity,  976 

psychical  centres,  892 
Ferrus,  reform  in  treatment  of   insane  in   France, 
512,  513,  516 

Fetscheriii,  F.,  provision  for  the  insane  in 

SAvitzerland,  1237 
Fever,  hysterical,  637 
Fevers,  as  cause  of  acute  delirious  mania,  52 

mental  improvement  after,  80 

hallucinatory  mania  after,  767 

insanity  following,  985,  986 

insanity  preceding,  985,  986 

insanity  during,  985,  986 
Fidgets,  the,  relation  of,  to  insanity,  582 
Field,  Justice,  mala  fides  in  certification,  190 

capacity  of  insane  to  plead,  956,  958 
Finke,  quantity  of  sweat  eliminated,  n68 
Finland,  the  insane  in,  1 1 13 
Fire-brigades  in  asylums,  104 
Fireproof  constructions,  104 

Fischer,    Franz,  the   frequency   of  occurrence    of 
othematoma,  559 

the  a;tiology  of  othiematoma,  561 
Fish  in  the  diet  of  the  insane,  387 


1434 


INDEX. 


Kisb-tail  l:;il;',  497 

Fi;«siires  of  brains  in  criminals,  320 

Fits,  hysterical,  641 

Fitzherbert,  Koyal  jurisdiction  over  idiots,  666 

Fixed  idea,  375 

Flagellants,  the,  437 

Fleiseh's  hsemonn'ter,  137 

Fleming;-,  responsibility  in  pyromania,  1056 

uterine  displacements  and  insanity,  1351 
Fleming's  fixiny  solution  for   hardening:  sections, 

1182 
Flemming-,  classilication  of  insanity,  231 
FU'xibilitas  cerea  in  hysterical  children,  624 

iu  katatonia,  724 
Florence,  asylum  at,  717 
Flourens,  brain  functions,  152 

functious  of  cerebellum,  158 
Fluid  pressure  prodnciny  cerebral  atrophy,  906 

exudation  of,  in  general  paralysis,  909 
Fodere,  ptyalism  in  the  insane,  1107 
Foetus  in  utero,  effect  of  external  violence  on  the, 

1308 
Folic  circulaire,  ago  at  development  of,  226 

pathology  of,  227 

treatment  of,  228 

nymphomania  iu,  864 

in  pellagra,  920 

melancholic  delusions  in,  217 

dipsomania  iu,  219 

excitable  phases  of,  218 

eroticism  in,  220 

excitement  of,  220 

aetiology  of,  221 

epilepsy  as  caujc  of,  226 

moral  emotion  as  cause  of,  230,  231 

auditory  hallucinations  in,  217 

hypochondriacal  melancholia  iu,  217 

heredity  iu,  225 

cranial  injuries  and,  226 

Meptomauia  in,  219 

lucid  intervals  in,  222 

melancholic  phases  of,  216 

menstruation  iu,  218 

moral  causes  of,  226 

medico-legal  aspect  of,  228 

physical  causes  of,  226 

diagnosed  from  general  paralysis,  225 

stuporous  melancholia  iu,  217 

suicidal  desires  iu,  217 

quinine  in,  227 

development  of,  221 

sudden  transition  of  stages,  221 

gradual  transition  of  stages,  221 

transition  iu  successive  oscillations,  222 

degrees  of  the  attack  in,  222 

duration  of  the  attack  iu,  222 

development  of,  223 

forms  of,  223 

modes  of  termination  of,  223,  224 

signs  of  transition  in,  224 

hysteria  as  cause  of,  226 

physical  causes  of,  226 

moral  cause  of,  226 

sex  in  causation  of,  226 

temperature  iu,  1279 

sphygTuographic  tracings  in,  1189 
Folic  des  degdneres  (Morel),  331  ;  (Legrain),  332 

circulaire,  214 

a  double  forme,  214 

k  formes  alternes,  214 

muscuhiire,  208 

a  double  phase,  215 

induite,  240 

k  quatre,  241 

avec  conscience,  377 

lucide,  400  ;  (Trelat),  594 

du  doute  avec  delire  du  toucher,  406 


Folic  k  deux,  240 

simultance,  240 

imj)osee,  240 

lucide,  and  duality  of  brain  function,  400 

raisounantc  melanchollque,  6n 

morale,  697 

lucide  raisonnante,  813 

des  persecutions,  925 

gemellaire,  1330 

systematis^e  progressive,  1356 

systematis^e  des  degeneres,  1356 

du  doute  and  aboiilia,  1367 
Folsom,  hallucinations  iu  the  sane,  1172 

prognosis  of  acute  delirious  mania,  54 

causes  of  insomnia,  703 
Fomentation  treatment  of  insanity  by  the  ancients, 

14.  15 
Foussagrives,  mental  effects  of  coffee,  238 
Fontan,  anaesthetic  effects  of  hypnotism,  604 
Food-preheusiou  a  normality  of  conduct,  243 
Food,  refusal  of,  method  of  treatment,  495 

for  the  insane,  384 

refusal  of,  in  hypochondriasis,  616 

refusal  of,  in  insanity  of  negation,  883 

refusal  of,  in  phthisical  insanity,  943 

refusal  of,  in  katatonia,  725 

abstention  from,  in  neurotic  adolescents, 
999,  ICX)0 

quantity  necessary  for  sustenance,  773 

administration  of ,  iu  melancholia,  793 

in  the  treatment  of  neurasthenia,  849 
Formic  acid  in  brain,  151 
"  Form  ideas  "  (Galtou),  1128 
Forms  of  certificates,  741 

of  petition,  738 

of  order,  739 

of  urgency  order,  739 

of  personal  interview  certificate,  740 

of  notice  of  right  to  interview  justice,  740 
Foster,  M.,  course  of  vaso-constrictor  fibres,  895 

of  vaso-diiator  fibres,  895 
Fothergill,  M.,  vascular  changes  in  morbid  mental 
states,  1042 

cardiac  condition  in  general  paralysis,  1048 
Fournier,  early  convulsions  in  syphilitic  children, 
1262 

epilepsy  and  congenital  syphilis,  1263 

headache  iu  hereditary  syphilis,  1264 

spinal  lesions  due  to  congenital  syphilis,  1269 

ataxy  due  to  congenital  sj^jhilis,  1269 

syphilitic  epilepsy,  451 
Fourth  nerve,  paralysis  of  the,  in  general  paralvsis, 

488 
Foville,  diagnosis  of  folic  circulaire,  225 

frequency  of   occurrence   of   folic  circulaire, 
226 

conformation  of  the  external  ear,  418 

reform  in  treatment  of  insane,  France,  512 

work  in  asylums,  514 

othsematoma,  560 

prognosis  of  folie  circulaire,  224 

heredity  in  folie  circulaire,  225 

classification  of  dipsomania,  392 

persecution-mania,  925 

fully  developed  persecution-mania,  928 

grandiose  ideas  in  persecution-mania,  929 

alienes  migrateurs,  931 

mental  effects  of  tyiihus,  987 

ptyalism  in  the  insane,  1107 
Fo\'ille,  Ach.,  legislation  for  the  iusanc  in  France, 

513 

Fox,  post-mortem  appearances  of  sunstroke  lesions, 
1236 

Fox,  Bonville,  exaltation,  469 

Fox,  E.  Long,  physiology  of  the  sympa- 
thetic nervous  system,  1240 

Fragilitas  ossium  in  the  insane,  143 


INDEX. 


1435 


Franco,  associations  for  after-care,  ^y 

liislory  of  liypiiotism  in,  604,605 

lathyrisiu  iu,  730 

sex  ill  insanity  iu,  1153 

Meilico-rsycholoL;ical  Associiitiou  of,  dubiitu  on 
sympathetic  insanity,  1243 
Franck,  F.,  salivation  in  epilepsy,  1106 

cerebral  inliuence  on  salivary  secretion,  1105 

and  Pit  res,  blood-pressure  and  bladder  contrac- 
tion, 1340 

functions  of  the  internal  capsule,  157 

functions  of  the  basal  ganglia,  157 
Fnineker  ^V-sylum,  592 
Frankford  Asvlum,    I'hiladelphia,  United    States, 

S5 
Fninkfon-on-.AIaine,  early  asylum  at,  544 
Fraser,  .1.,  boarding  out  in  Scotland,  140 
Free-will,  1366 

Freezim;-  methods  for  section  cuttin'^-,  1183,  1187 
Frenzy,  transitory,  1302 
Fresh  section  cutting,  1187 
Fretfuluess  amoral  insanity,  815 
Freudensehmerz,  763 
Fricke,  early  treatment  of  the   insane  in  Germany, 

544 
Friederich,  subjective  distinction  time,  1070 
Frietlerich's  disease  simulating  hysteria,  1162 
Friedlander,  early  application  of  electricity,  427 
Friends  of  thelntirni  iu  Mind,  Guild  of,  553 
Friends,  Society  of,  influence  iu  the  improvement  of 

the  condition  of  the  insane,  25,  85 
Fright  as  cause  of  idiocy,  665 

shock  due  to,  1157 

postiu'e  of  the  hand-  in,  989 
Fromentel,  de,  synalgia,  1252 
Fronmliller,  action  of  codeine,  1142 

cannabin  as  a  Inpnotic,  1144 
Frontal  lobes,  weight  of,  231 
Fry,  Justice,  undue  iuttuence  in  procuring-  gifts, 

1337 

Fuerstuer,  classification  of  psychoses  of   senility, 
870,  871 

Fulminating- psychoses,  loa^ 

Functional  disorder  inducing-  insanity,  1244 
disturbances  iu  mania,  762 
diseases  and  organic  change,  842 
psychoses  of  old  age,  870,  871 
irritability  in  the  insane  diathesis,  383 
disorders,  early  uses  of  electricity  in,  426,427 
mental  disorders   due   to  brain   injury,  1309, 
1311 

"  Functional  union,"  1027 

Funnel,  uasal,  for  feeding,  501 

Furious  insanity,  696 

Furor  maniacus,  1302 

Fiirstuer,  albumen  iu  urine  iu  delirium  tremens, 

1349 
ckrouic  confusional  states,  1358 

Gabersee  Asylum,  103 

Gacken,  284 

Gag,  Sutherland's,  497 

Gairdner,  reform  iu  the   treatment  of  the  insane, 

24.25 
legislation  for  habitual  drunkards,  555 
criminal  responsibility  of  drunkards,  686 
Gait,  incoordination  of,  in  prodromic  stage  of  gene- 
ral paralysis,  523 
in  established  general  paralysis,  527,  528 
disorders  in  general  paralysis,  pathology  of, 

S42 
in  lathyrism,  730 
Galactorrha-a,  hysterical,  637 
Galen,  humoral  theory  of  insanity,  1242,  1243 
temperaments,  1276 
pathology  of  insanity,  16 
treatment  of  insanity,  16 


Galezowski, colour-blindness  in  chroui<-  alcoholism, 

75 
Gall,  the  brain  as  the  organ  of  mind,  21 

classification  of  insanity,  229 
Gallopain,the  blood  of  convalescents  from  insanity, 

139 

cancer  and  insanity,  177 
Galloping  general  paralysis,  519,  525 
Gall-stones  in  the  insane^  1377 
Galton,  psycho-physical  experiments,  29 

inheritance  of  ancestral  attributes,  665 

A-form  chronoscope,  ioi8 

secondary  sensations,  1128 

visual  memory,  1360 
Galvanism  as  a  mental  sedative,  430,  431 

as  a  mental  excitant,  431 
Gamgee,  conipositiou  of  sweat,  1167 
Ganglia,  sympathetic,  1247 
Gangrene,  asthenic,  iu  the  insane,  129 

of  the  lungs  in  the  insane,  941,  945 
Gangrenous  ergotism,  458 
Ganstad  Asylum,  mi 

Gamier,  Paul,  female  proclivity  to  persecution  in- 
sanity, 1 1 55 

bibulation  of  forms  of  insanity  in  the  sexes,  1155 

alcoholic  insanity  iu  the  sexes,  1155 

increase  of  general  paralysis,  1156 

and  Collin,  H.,  homicidal  monomania, 

598 

Garrod,  Sir  A.,  excretion  of  uric  acid,  1344,  1345 

retrocedent  gout  and  insanity,  549 
Garrulity  iu  mania,  764 
Gartuavel  Royal  Asylum,  1097 
Gaskell,  course  of  vaso-constrictor  fibres,  894 

course  of  vaso-dilator  fibres,  895 

functions  of  lateral  sympathetic  ganglia,  1247 

prize,  regulations  for  the,  787 

Gasquet,  J.  K.,  religion,  relations  of,  to 
insanity,  io88 

the  personification  of  madness  by  the  ancient 
Greeks,  9 
Gastro-enteric  insanity,  696 

-intestinal  disturbances  in  pellagra,  919,  921 

-intestinal  lesions  in  ergotism,  456 
Gavas,  284 

General  hypochondriasis,  612,  613 
Generalisation,  493 

General  paralysis,  iliagnosed  from  delirium  tremens, 
71,72 

blood-corpuscles  in,  138 

haemoglobin  in,  138 

andfolie  cireulaire, diagnosis  between,  224,  225 

electricity  in,  430 

and  exophthalmic  goitre,  476,  478 

oculo-motor  symptoms  of,  487 

ophthalmoscopic  signs  in,  490 

feigned,  504 

handwriting  in,  568,  573 

bed-sores  in,  129 

leucocythsemia  in,  138 

cerebral  arterioles  iu,  179 

in  cerobraux,  188,  1S9 

destructive  acts  in,  355 

diabetes  in,  372 

digitalis  iu  the  excitement  of,  387,  388 

weight  of  hemispheres  in,  400 

and  epilepsy,  455 

and  ergotism,  differential  diagnosis,  459 

and  chronic  alcoholism,  differential  diagnosis, 

474 
and  exophthalmos,  476,  477,  478 
oi)hthalnioplegia  externa  in,  487 
pupillary  abnormalities  iu,  488,  489 
hair  in,  564 

simulated  by  post-iufluenzal  psychoses,  689 
loss  of  inhibitory  control  in,  692 
and  kleptomania,  727,  728 


1436 


INDEX. 


Geuenil  paiiilysis  associated  with  locomotor  atuxy, 

751 

l)rccedecl  by  locomotor  ntaxy,  750 

followed  by  locomotor  ataxy,  751 

simulated  after  malaria,  757 

eroticism  of,  leadiiii;  to  marriage,  783 

luasturbatiou  iu.  784 

proL;ressive  amnesia  in,  800 

simple  paramnesia  in,  800 

menstruation  in,  801,  802 

nymphomania  in,  864,  865 

occurrence  of,  in  senile  dementia,  872 

haematoma  of  dura  mater  in,  879 

pathological  changes  in,  908 

inflammatory  engorgement  stage  of,  908 

and  alcoholic  dementia,  differentiated,  914,915 

diagnosed  from  grandiose  stage  of  persecution- 
mania.  933 

phthisis  in,  944 

lymph  connective  tissue,  development  in,  908, 
909 

general    fibrillation   and  shrinkage    stage   of, 
908,  909 

diagnosed  from  pellagrotis  insanity,  921 

operative  treatment  of,  909,  1325 

post-parturient,  1040 

pulse  conditions  in,  1047 

paralytic  mydriasis  in,  1054 

paralytic  myosis  in,  1055 

pyromania  in,  1059 

visual  and  acoustic  reaction  iu,  1063 

religious  delusions  in,  1092 

satyriasis  in  earlj'  stage  of,  1109 

physostigmiue  in,  1146 

occurrence  of,  in  the  sexes,  1155,  1156 

cases  of,  unfit  for  single  care,  1165 

sphy!;mographic  tracings  in  stages   of.  1188, 
1189 

temperature  in,  1279,  1280,  1281 

spinal  cord  changes  in,  1190 

due  to  tobacco  abuse,  1297 

articulatory  defects  in,  1192 

suicide  in,  1230 

and  sunstroke,  1234,  1235 

due  to  constitutional  syphilis,  1256, 1257,  1258 

syphilitic  origin  of,  1257 

due  to  brain  injury,  1310 

tremor  of,  diagnosed  from  mercurial  tremor, 
1321 

tremor  of,  1322,  1323 

trephining  in,  1325 

increased  intra-cranial  tension  in,  1325 

among-  natives  in  Egypt,  1329 

quantity  of  urine  secreted  in,  1341 

excretion  of  urea  in,  1344 

excretion  of  uric  acid  in,  1345 

glycero-phosphoric  acid  iu  urine  of,  1347 

mineral  constituents  in  urine  of,  1347 

albumen  in  urine  in,  1349 

urine  analysis  in,  1350 
General  paresis  in  chronic  alcoholism,  76 
Genital  sensory  disorders,  836 

causes  of  nymphomania.  864 
Genito-tirinary  disturbances  iu  lathyrism,  730 
Genius,  and  the  insane  diathesis,  383 

and  epilepsy,  455 
Genetous  idiocy,  643 
Genoa  Asylum,  716 

Gentili,  the  early  applications  of  electricity.  427 
Geological  formation  and  suicide,  1221,  1222 
George  III.,  insanity  of,  23,  24 
Georget,  sex  in  insanity,  1153 
Germ,  physiological  features  of  the,  586,  589 
Germain-See,  cla.'sitication  of  insomnia,  703 
German  schools  of  metaphysics,  48 
German}-,  hypnotism  in,  603,  605 

sex  in  insanity  in.  1153 


Gervais,  lycauthropy,  754 

GescheitUen  and  Laugeudorf,  alkaline  reaction  of 
brain  tissue,  895 

Gestation,  insanity  of,  697 

Gestures  indicative  of  misery  in  melancholia,  788 

Ghent,  asylum  of,  131 

Ghosts,  1359 

Giacomini,  study  of  microcephaloiLS  brains,  805 

"  Gibberish  aphasia,"  982 

Gibbon,  suicide,  1220 

Gibson,  cortical  hyperamia  duringpsvchical  action, 
894 

Gifts,  undue  influence  in  procuring,  1336 

Gilaberto,  Gope,  reform  in  treatment  of  insane, 
Spain,  1 177 

Gilbert,  sulplional  habit,  1138 

Gilet  de  force,  23 

Gill,  Clifford,  simultaneous  insanity  in  twins,  1334 

GiraUlus  Cambrensis,  influence  of  the  moon  in  pro- 
ducing in.sauity,  813 
lycanthropy,  1366 

Giraud,  pyromania  and  sexual  disorder,  1057 

Gladesville Asylum,  iii 

Glanders,  the  delirium  of,  334 

Glands,  nerve-supi)ly  to,  1248 

Glasgow  Eoyal  Asylum,  1095,  1097 

Glaucoma,  paralytic  mydriasis  in,  10541 

Glen-na-galt,  Ireland,  707,  708 

Gley,  influence  of  mental  processes  on  pulse,  1042 

"  Globus  "  in  prodromic  stage  of  general  paralysis, 

523 
Gloss  of  hair  in  the  insane,  564 
Glosso-labial  hemispasm,  hysterical,  634,  635 
Glycero-phosphoric  acid  iu  urine  in  mentaf  states, 

1346 
Glycosuria,  cerebral,  161 

and  insanity,  371,  372 

and  mental  degeneration.  372 

in  puerperal  insanity,  373 
Glycitronic  acid  in  urine,  1349 
Gnauck,  hyoscine,  1143 
Gnostics,  the,  436 
Goddess  of  madness,  the,  19 
Gold  bromide,  action  of,  1131 

staining  for  sections,  11 85 
Golgi,  the  pathology  of  chorea,  210 

hardening  and  staining  fluid  for  sections,  1182, 
1183 
Goltz,    corresponding   fimctions    in    hemispheres, 

398 
Gombault,  action  of  lead  on  nerves,  746 
Goodna  Asylum,  iii 

Goubert,  bromide  of  gold  in  epilepsy,  1131 
Gout,  alternating  with  insanity,  82 

and  hypochondriasis,  615 

and  plumbism.  747 

and  insanity,  912 
Gotity  headache,  alternating  with  insanity,  81 
Governors,  Board  of  (Ireland),  powers  of.  710 
Gowcrs,  hjemacytometer,  136 

paral3-sis  of  the  ocular  muscles,  488 

haemoglobinometer,  137 

clinical  evidence  of  cortical  functions,  156 

functions  of  the  cerebellum,  158 

mercurial  tremor,  1321 

tremor  of  plumbism,  1321 

hereditary  tremor,  1324 
Grabham,  phthisis  causing  idiocy,  660 

insanity  causing  idiocy,  660 
Gradenigo,  the  hearing  of  criminals,  290 
Graham,  hjematoma  auris  in  idiots,  559 
Granada  Asylum,  1180 
Grand  climacteric  in  males,  235 
Grandeur,  delusions  of,  347 

insanity  of,  697 

ideas  of,  in  persecution-mania,  928,  929 
Grandiose  ideas  in  folic  circidaire.  220 


INDEX. 


1437 


Grant,  ;?ir  W.,  contractual  capacity  i>f  11  ilniukaril, 

685 
Gninville,   Mortimer,   nictliod   of   calculatiug   re- 
coveries, 1 196,  1197 
Grapciigiesser,  the  intlueuce  of  galvanism,  427 
Gratiolet.  cerebral  convolutions,  268,  290,  291 

symmetrical   cerebral   convolutions  in  idiots, 
"  268 

convolutions  in  microcephalous  idiots,  270 

comparison  of  simian  and  liumau  brains,  805 
Graves'  disease  and  insanity.  476 
Gream,  diets  for  ;irlilicial  feeding',  498 
Greding.  hepatic  alTcctions  and  insanity,  1245 
Greeks,  ancient,  demonolatria  among  thi',  1369 

suicide  amonu;  the,  1218 

insanity  amonu  the,  6-8 
Green,  bruises  in  the  insane.  173 
Greenlield.    mental     disorder    during   pneumonia, 

985 

insanity  and  delirium  during  fevers,  985,  986 

acute  maniacal  delirium  lollowing-  febrile  dis- 
orders, 986 

insanity  following  typhus,  986,  987 

post-choleraic  insanity,  987 

rheumatic  afl'ections  and  insanity,  988 
Grcenlees,  T.  D..  cardiac  disease  and  in- 
sanity, 177 

sphygmographie  tracings  in  stupor.  1045 

vascular  conditions  in    congenital    imbeciles, 
105 1 

sphygmograpli  in  various  forms 
of  insanity,  1187 
Grey  bair  in  the  insane,  563 
Grey  tissue,  chemical  compression  of,  151 

specific  gravity  of,  161 
Grief,  tears  in,  1274 

refusal  of  food  through,  494 

nervous  action  of,  837 

in  paralysis  agitiins.  884,  885 
Griesinuer,  Addison's  disease  and  insanity,  1246 

distinction  between  delirium  and  post-febrile 
insanity,  333 

Bright's  disease  and  insanity,  172 

folie  eirculaire,  215 

classification  of  insanity,  232 

insanity  of  doubt,  407,  408 

rheumatic  insanity,  210 

exalted  states  in  chronic  alcoholism,  473 

hypochondriasis,  611 

menstruation  and  mania,  801 

insanity  of  negation,  832 

use  of  the  term  Verriicktheit,  887 

mental  diseases,  892 

phthisis  in  the  insane,  941 

pathology  of  febrile  insanity,  987 

insanity  following  rheumatic  aflectious,  987 

neuroses  following  rheumatic  affections,  988 

vascular  effect  of  emphysema,  1044 

pyromania,  1056,  1060 

cardiac  sounds  during  acute  mania,  T047 

psychical  reflex  action,  1336 

uterine  displacements  and  insanity,  1351 

AVahnsinn,  1364 
Grotius,  suicide,  1220 
Growth  of  hair  in  the  insane,  563 
Griibelsucht  (I5erger),  406 

and  aboulia,  1367 
Gruber,  ha!matoma  auris,  558 
Guarneris,  A.,  witchcraft,  716 
Gubler,  atropism,  133 

pyrexia!  states  and  insanity,  986 
Gnerry,  seasonal  influence  on  suicide,  1222 
Giiggenbiihl,  amelioration  of  condition  of  cretins. 
1241,  1242 

treatment  of  idiots,  667 
Guinon.  hysteria  in  men,  624 

exciting  causes  of  hysteria,  628 


(iuinou,  traumatic  suggestion,  1159 

Guislaiu,  iiiteslinal  disturbance  and  insanity,  1245 

surprise  batlis.  119 

douche  trc  atment,  120 

asylum  reforms,  132 

circular  insanity,  215 

relationship  between    phthisis   and    ins.inity. 

939 

phthisis  in  the  insane,  941 
Gull,  Sir  Wm.,  nervous  anorexia,  94 

myxa-dema,  828 
Gustatory  activities,  absence  of,  in  dreams.  413 

paresthesia^,  554 

hallucinations,  567 
Guy,  sight  during  somnambulism,  1172 
Guye,  apro.sexia,  1046 
Gymnastic  stage  of  convulsive  liypnotism,  630 

Haarlfm  Asylum,  the,  591 
Habgood,  the  insane  in  Korway,  1112 
Habit,  43,  255 

speech  defects  due  to,  1193 
Habitation  of  idiots  and  imbeciles,  667 
Habits  of  dements,  349,  350 

us  evidence  of  lunacy,  463 

motor,  of  children,  823 
Habitual  criminals,  288 
Habitus  .senilis.  869 
Hadfield,  James,  case  of,  299,  300 
Haemacytomcter,  Gowers',  136 
Hamateuiesis,  hysterical,  621 
Hffimatoidin  perivascular  deposits,  905 
Hematoma  of  the  dura  mater,  877 
Hiemoglobin,  estimation  of,  137 

in  mania,  137 

in  melancholia,  137 

in  dementia,  138 

in  imbecility,  138 

in  general  paralysis,  138 

in  epileptic  insanity,  139 

in  puerperal  insanity,  139 

in  pellagrous  insanity,  139 

during  maniacal  excitement,  139 
Haemorrhage  into  sub-dural  space,  877 
Hjemorrhages,  delirium  in,  336 

in  hysteria,  624 

anomalous,  in  hysteria,  637 
Hague  Asylum,  the,  592 
Haig,  pulse  tension  in  melancholia,  1044 

uric-acid  excretion  and  epileptic  fits,  1049 

uric-acid  excretion,  1345 
Hair-growth  and  ticklishness,  1295 
Hale,  Sir  M.,  criminal  responsibility,  293,  297 

plea  of  insanity  in  criminal  cases,  294 

criminal  rcspcusibility  of  drunkards,  686 
Halliday,  blood  in  malaria,  758 
Hallucinations,  263 

persistent,  in  delirium  tremens,  71 

auditory,  in  deaf  persons,  328,  329 

characteristics  of,  in  alcoholic  delirium,  342, 

343 
evidence  for  certification,  193 
in  children,  203 

auditory,  in  folie  eirculaire.  217 
in  cocaine  poisoning,  237 
epileptoid,  373 

in  diagnosis  of  insanity,  373,  375 
concealed,  diagnosis  of,  374 
electricity  in,  431 
in  epilepsy,  455 
as  cause  of  refusal  of  food,  494 
in  exalted  states,  471,  472,  473 
in  general  paralysis,  524,  525,  529 
visual,  566,  567 
visual  alcoholic,  567 
of  toucli,  567 
pathology  of,  567.  568 


UjS 


INDEX. 


Hallueiujitious  iu  cocomauia,  237 

due  to  stramonium,  326 

in  the  delirium  of  children,  360 

in  the  sane,  373 

in  hysteria,  373 

in  hypochondriasis,  373 

in  epileptics,  373 

in  intoxication,  373,  374 

unequal  action  of  hemispheres  in,  401 

in  epidemic  insanity,  435 

as  epileptic  aur*,  453,  566 

in  exaltation  of  chronic  insanit}',  471 

in  exaltation  of  masturbatic  insanity,  472 

in  exaltation  of  epileptic  insanity,  473 

in  exaltation  of  chronic  alcoholi^-m,  473 

caused  by  Indian  hemp,  1144 

causing  self- mutilation,  1149 

in  hydrophobia,  600 

in  hypochondriasis,  612,  615 

in  insane  jealousy,  722 

in  katatouia,  725 

iind  illusions,  relation  between,  675 

in  mania,  764 

in  senile  psychoses,  871 

in  melancholia  of  paralysis  a^itaus,  885 

sensory,  in  persecution-mania,  927,  928 

unilateral,  927 

and  facial  expression,  949 

in  phthisical  insanitj-,  945 

in  toxic  states,  971 

.sensory,  in  puerperal  mania,  1038 

in  puerperal  melancholia,  1040 

in  lactational  insanity,  1042 

in  regicides,  1077 

due  to  salicylic  acid,  1102 

hypnagogic,  1172 

of  smell,  1 174 

of  hj'puotism,  1216 

and  suicide,  1232 

operative  interference  for,  1327 

sexual,  iu  uterine  disease,  1352 

in  coufusioual  iusaiiitj,  1358 

visual,  iu  visionaries^  1359 
Halluciuatorischc  Verriicktheit,  1358 
Hallucinatory  insanity  due  to  brain  injur}',  1309 

insanity,  simulation  of,  503 

mania,  767 
Hamilton,  colloid  bodies  in  the  cord  after  inflam- 
mation, 907 

scavenger  cells,  903 

freezing  methods  for  section  cutting,  1183 
Hamilton  Asylum,  Canada,  175 
Hamilton,  Sir  AV.,  philosophy  of  mind,  48 
Hammern,  758 
Hammond,  delirium  of  plumbism,  747 

blood  in  malaria,  758 
Hand  postures  in  mental  states,  989,  990,  991 
Handwriting  in  prodromic  stage  of  general   i)ara- 
lysis,  523 

in  established  general  paralysis,  527 
Hanuen,  Sir  J.,  testamentary  capacity  and  insanity, 

1287,  1288 
Hardening  fluids  for  microscopical  sections,  1180, 

1181 
Hartford  Retreat,  Connecticut,  85 

recoveries  in,  322 
Hartley,  doctrine  of  vibrations,  45 
Hartman,  early  use  of  electricity,  426 
Hartmann,  trephining  iu  mental  affections  due  to 

brain  injury,  1324 
Haschich,  delirium  due  to,  336,  1098 
Haslam,  sex  iu  insanity,  11 53 
Hasse,  insanity  and  chorea,  206 
Hawkins,  Justice,  the  law  as  to  criminal  responsi- 
bility, 314 

Hawkins,  Rev.  H.,  after-care  of  the  insane, 

1:6 


Hawkins,  Kev.  H.,  ch.apiains  in  asylums, 

201 

guild  of  friends  of  the  infirm  in 
mind,  553 
Hay  asthma  alternating  with  insanity,  81,  82,  loi 
Hayem,  the  size  of  blood-coriuiscles,  137 

action  of  paraldehyde  on  the  blood,  1133 
Haziyan,  831 
Head,  conformation  of,  in  the  insane  diathesis,  383 

injuries  followed  by  insanity,  1312 

shape  of,  in  microcephaly,  805 

postures  in  mental  states,  989 

temperature  of  the,  1281 

mapping   of  the,  for  brain  temperature,  1282, 
1283 
Headache  in  prodromic  stage  of  general  paralysis, 

523 
alternating  with  insanity,  81 
periodical  or  persistent,  due  to  sunstroke,  1235 
the  sjTupathetic  in,  1251 
due  to  congenital  S3"philis,  1264 
Head-hypochondriasis,  613,  614 
Hoarder,  treatment  of  othsematoma,  560 
Hearing,  33 

disorders  of,  in  mania,  763 
in  persecution-mania,  927 
psycho-physical    method   of    registering, 
1015,  1021,  1022 
disturbances  of,  due  to  salicylic  acid,  1103 
during  somnambulism,  1172 
localisation  of,  in  the  cortex,  156 
iu  cretinism,  286 
of  criminals,  290 

in  prodromic  stage  of  general  paralysis,  523 
hallucinations  of,  566 
education  of  the  sense  of,  in  idiots,  672 
Heart  disease  and  impulsive  acts,  354,  355 
forms  of,  in  the  insane,  178 
mental  symptoms  in  various  forms  of,  178 
opium  in,  1141 
nerve-supply  to,  1248 
and  arteries,  sjTnpathetic  relationship  betwecu, 

1249 
effect  of  weeping  on  the,  1275 
post-mortem  appearance  in  general  paralysis, 

537 
Heat  stroke,  1232 

delirium  of,  335 

animal,  sympathetic  nerves  and,  1250 

and  cold,  loss  of  perception  of,  1293 

exposure    to   excessive,    and   acute    deUrious 
mania,  52 
Heating  of  asylums,  104 
Hebrews,  insanity  among  the,  3 
Heckcr,  dancing  mania,  438,  439 
Hecquet,  ferric  bromide  in  epilepsy,  1131 
Hector,  insanity  of,  7 
Hedonia,  psychical,  376,  JHI 
Heidenhain,  hypnotism,  605 

Heidenhein,  nerve  heat  during  nerve  action,  1278 
Height,  dimiuution  of,  in  the  insane,  145 

influence  of,  in  size  of  head,  578 
Heinroth,  classification  of  insanity.  231 

concealed  delusions,  700 

causation  of  insanity,  1243 
Hellebore,  1353 

in  amcnorrhoea  of  insanity,  1290 

iu  the  treatment  of  insiinity  b}^  the  ancients, 
12,  15,  18,  19,  20,  95,  135,  553,  1353 
Helmholtz,  nerve  heat  during  nerve  action,  1278 
Helminthiasis  and  insanity,  1244,  1245 
Helmont  on  insanity,  21 

hypnotism,  603 
Hemi-aujesthesia  in  chronic  alcoholism,  75 
Hemi-catalepsy  iu  hypnotism,  608 
Hemi-lethargy  in  hypnotism,  608 
Hemi-ueurastheuia,  847 


INDEX. 


1439 


Ht'miplcg:i!i  !uul  insjuiity  due  to  constitutional  syphi- 

Heredity, elTcct  of,  on  prognosis,  796 

lis,  1256,  1257 

in  neurasthenia,  847,  848 

due  to  congenital  syphilis,  1264 

influence  of,  in  jirodnction  of  insanity.  893 

facial  expression  in,  485 

Ilcrgt,  ntero-ovarian  disease  and  insanity,  911 

of  general  paralysis,  pathology  oT.  542 

Hermits  considered  as  eccentrics,  421 

handwriting  in,  573 

Herodotus,  the  insanity  of  C.ambyses,  5,  6 

hysterical,  634 

lycanthroi)y,  1366 

and  true  hemiplegia,  622,  623 

"Herpetic  insanity,"  1246 

salivation  in,  uo6 

Herscliel,  blood  in  malarial  poisoning,  757 

trenuir  of,  1321 

Hertz,  'NValinsinn,  1364 

Hemispheres  ol'  brain,  weight  ol,  in  the  insane,  166 

Ileubner,  arterial  distribution  in  brain,  170 

functions  of  the,  398 

syphilitic  alTection  of  cerebral  arteries,  1259 

unequal  action  of,  in  insanity,  400,  401 

Hewett,l'rescott,  i)athology  of  cerebral  false  mem- 

weight of,  400 

branes,  880 

asymmetry  of,  in  idiots,  655 

Hiccough,  hysterical,  635 

Hemlock,  action  of,  1144 

High  treason  and  plea  of  insanity,  294,  299 

Henke,  pyromania,  1056 

Highest    levels     of    nervous     system    (Jackson), 

Henoch,  infantile  convulsions,  358 

442 

hysterical  atTections  of  children,  358,  359 

Hill,  Gardiner,  mechanical  restraint,  1317 

delirium  of  cliildreu,  360 

non-restraint,  25,  26 

Henocqne,  action   of  paraldehyde   on   the   blood. 

Himak,  831 

"33 

Hindoos,  psvchological  characteristics  of  the,  682, 

Hensen,  centre  for  pupillary  reaction,  1053 

683 

Hepatic  affections,  delirium  due  to,  336 

suicide  among  the,  1219,  1220 

diseas(>  and  insanity.  911,  1244,  1245 

Hipp  chronoscope,  1017 

affections  and  insanity,  1245 

Hippocrates,  insanity,  12,  13,  14 

Herbart,  the  soul,  48 

mania,  13 

Hercules,  epileptic  homicidal   insanity  of,  8,  9,  10, 

melancholia,  13,  14 

11.553 

dementia,  13 

Hereditary  predisposition  in  delirium  tremens,  69 

epilepsy,  12,  14 

chorea,  209 

hallucinations,  565 

degeneration  and  monomania,  594 

cerebral  functions  and  affections.  13 

insanity,  696 

lathyrism,  730 

taint  in  kleptomania,  726,  727 

neurasthenia,  841 

syphilitic  disease  of  nervous  system,  1259 

sjTiipathetic  disorders,  1242 

tremor,  1324 

temperaments,  1276 

Heredity  and  causation  of  insanity,  1206 

references  to  hellebore,  1354 

and  suicide,  1229,  1230,  1231,  1232 

Hippus  (or  pupillary  unrest),  1053 

in  sympathetic  insanity,  1244 

Histology  of  the  cerebral  cortex,  169 

in  mania  transitoria,  1303 

of  brain  in  idiocy,  658 

in  the  insanity  of  twins,  1335 

of  normal  brain,  1375 

and  idiocy,  893 

Historical  records  of  insanity,  2 

and  nervous  diathesis,  893 

History  of  patients,   essential  inquiries   into  the, 

influence    of,    in   occurrence    of    persecution 

180,  181 

mania,  933 

of  epidemics  of  insanity,  436 

influencing  post-apoplectic  conditions,  975 

of  the  insane,  i 

in  post-influenzal  i)sychoses,  688 

Hitzig,  cortical  functions,  152 

varieties  of,  and  prophylaxis,  997  et  seq. 

Hwgh-Gueldberg,  alcoholism  in  the  sexes,  1155 

neurotic,  in  prognosis,  1006,  1007 

Hoil'mann,  composition  of  sweat,  1167 

neurotic,  in  puerperal  insanity,  1034 

Holland,  hypnotism  in,  605 

morbid,  in  regicides,  1078 

Holland,  Sir  H.,  mental  physiology,  804 

in  secondary  sensations,  1127 

Holloway  Sanatorium,  St.  Ann's  Heath,  1087 

in  alcoholism,  64,  65,  66 

Holmboe,    M.,    the    insane    in   Norway, 

of  criminality,  288,  299 

mo 

in  folic  circulaire,  225 

Hoist,  Fr.,  improvement  in  the  condition  of  the 

in  cretinism,  286 

insane,  Norway,  iiii 

of  impulsive  acts,  356 

Home,  Sir  Everard,  venesection  in  insanity,  24 

in  neuroses  of  early  life,  357,  361,  362,  368 

Home-sickness,  858 

neurotic,  357,  358 

treatment  of  the  insane  in  France,  515 

and  abnormal  cortical  action,  363 

Homer,  evidences  of  insanity  among  the  ancients, 

in  diagnosis  of  insanity,  372,  373 

6,7.8,553 

in  dipsomaniacal  im])nlse,  393 

Homes  for  convalescents,  58 

as  evidence  of  lunacy,  463 

Homicidal  acts  in  persecution  mania,  930 

predisposing  to  general  paralysis,  534 

impulse,  681 

influencing  the  forms  of  delirium  tremens,  67, 

impulse  in  epilepsy,  454,  455 

68,69 

mania,  simulated,  505 

in  adolescent  insanity,  362 

iuii)ulse,  medico-legal  view  of,  355,  356 

in  insanity  of  doubt,  411 

insanity,  696 

in  epilepsy,  452,  455,  456 

inclinations  in  insane  jealousy,  721,  722,  723 

in  insanity  of  children.  204 

melancholia,  797 

and  homicidal  imijulse,  597 

Homicide  in  children,  202 

in  hysteria,  625.  628 

in  delirium  tremens,  343 

neurotic,  in  imi)erative  ideas,  681 

in  various  forms  of  insanity,  595 

in  the  transmission  of  instinct,  704 

Hommes-singes,  les,  805 

in  mental  disease,  705,  706 

Hoppe-Seyler,   composition   of  sebaceous    matter. 

in  erotomania,  702 

1 167 

in  melancholia,  791,  792 

Horace,  references  to  madness.  18,  19,  135 

1440 


INDEX. 


ITorsley,  Victor,  cortical  functions,   153,  154,   1555 
is6 
functions  of  the  internal  capsule,  157 

cretinism,  284 

hydrophobia,  599 

craniectomy  in  microcephaly,  670,  809 

trephining,  1324 

Hospital,  lunatic-,  detiuitiou  of  a,  277 
Hospitals,  registered,  for  the  insane,  1079 

the  insane  in,  277 

erysipelas  in,  460,  461 
Hot-air  baths,  123,  124,  125,  126,  127 

in  treatment  of  cretinism,  287 
Hot  baths,  prolonged,  117 

Houcin,  paralysis  of  one  extra-ocular  muscle,  488 
HouUier,  witchery  considered  as  insanity,  1369 
House  form  in  asylum  construction,  103 
Houses  of  industry,  Ireland,  709 
Howard,  pulse  in  acute  mania,  1047 
Howden,  Bright's  disease  and  insanity,  172 

cases  of  self-mutilation,  1149 
Hiibertz,  reform  in  asylums,  Denmark,  it  13 

treatment  of  idiots,  Denmark,  11 14 
Hufeland,  abdominal  insanity,  1245 

classification  of  dipsomania,  392 
Hugiieniu,  pathology  of  cerebral  false  membranes, 
880 

cause  of  dural  h.-ematoma,  881 

symptoms  of  dural  lia?matoma,  882 
Hull  Borough  Asylum,  103 
Hume,  suicide,  1220 
Humoral  pathology  and  temperaments,  1276 

theory  and  insanity,  16,  21,  22 
Humphreys,     basal    thickening   due    to    syphilis, 

1259 
dementia  due  to  congenital  s.n'hilis,  1267 
Humphreys,   Noel,   mortality  rate  of  the   insane, 

"93 
Hundshunger,  325 

Huntingdon,  hereditary  chorea,  209,  213 
Huppert,  albumen  in  urine  in  epilepsy,  1348 

blood-cells  in  urine  after  epileptic  fits,  1349 
Hurd,  H.,  religious  delusions  in  the  insane,  1091, 

1092 
Huron,  the  insanity  of  Cambyses,  5 
Hutcheson,  classification  of  dipsomania,  392 

"  chronic  dipsomania,"  394 
Hutchinson,  nerve  tone  and  size  of  pupils,  1054 

"  spinal  pupil,"  1055 

congenital  syphilitic  lesions,  1259 

frontal  thickening  due  to  syphilis,  1259 

ocular  lesions  due  to  hereditary  syphilis,  1262 

cranial  nerve  lesions  due  to  hereditary  syphilis, 
1266 
Hutchinson,  J.,  temperament,  382 

diathesis,  383 
Hutchinson,  W., evidence  in  the  case  ofMcXaghteu, 

306 
Hath,  the  marriage  of  near  kin,  248 
Huxley,  pathology  of  hallucinations,  567 
Hydrobromic  acid,  acti<m  of,  1131 
Hydroceplialic  idiocy,  644.  647,  654 

idiots,  shape  of  head  in,  580 
Hydrocephalus,  chronic,  654 

acute,  656 

due  to  syphilis,  1260,  1261 
Hydropathy  in  insanity,  117 
Hydropliobia,  delirium  in,  335 
Hydropholiic  tetanus,  1290 
Hydrophobic  cantharidique,  177 
Hydrotherapeutics    in   treatment   of    dipsomania, 

395 

in  hysteria,  640 
Hygienic  treatment  of  idiots  and  imbeciles,  667 
Hyoscine,  action  of,  1142 
Hyoscyamine,  delirium  due  to,  336 

action  of,  1142 


Hyoscyamus  preparations  In  treatment  of  insanity, 

1292 
Hypaesthesia  in  neurasthenia,  845 
in  delirium  tremens,  342,  343 
Hyperactivity,   cerebral,   a   i)rodrome  of  delirium 
tremens,  340 
meutal  and  motor,  in  prodromic  stage  of  gene- 
ral paralysis,  =;22 
Hyperaemia  of  optic  disc  in  general  paralysis,  490 

cerebral,  in  idiocy,  649 
Hyperesthesia,  alcoholic,  75 

sensorial,  a  prodrome  of  delirium  tremens,  340 
gnistatory,  554 
hysterical,  621,  623 

in  mania,  762,  765 

of  netirasthenia,  843,  844,  845 
Hyperaesthetic  areas  in  melancholia,  836 
Hyperalgesia  in  chronic  alcoholism,  75 

in  neurasthenia,  845 
Hyperalgia  in  neurasthenia,  845 
Hyperamuesia  in  mania,  377 
Hypercrinia,  1106 

Hypereccrisia  in  neurasthenia,  846,  847 
Hyperidrosis  in  neurasthenia,  846,  847 
Hyperkinesia  in  neurasthenia,  844,  845 
Hypermnesia,  800 

general,  800 

partial,  800 
Hyperostosis,  cranial,  due  to  syphilis,  1259,  1260 
Hypertrieliosis  localis,  128 
Hypertrophic  idiocy,  644,  647 

Hypertrophy  and  dilatation  of  the  heart  and  men- 
tal symptoms,  179 

cerebral,  in  idiocy,  649,  650 

cerebral,  brain  weight  in,  650 

cerebral,  and  chronic  hydrocephalus  diagnosed, 
650 
Hypnagogic  hallucinations,  414,  567 

in  prodromic  stage  of  delirium  tremens,  341 
Hypual,  action  of,  11 37 
Hypnoue,  action  of,  1T37 

in  acute  delirious  mania,  54 
Hypnotic  alternating  memory,  799 

condition  due  to  fright,  1159 

suggestion,  1213 
Hypnotics  in  acute  senile  psychoses,  872 

in  prodromata  of  insanity,  looi 

and  narcotics,  1129 
Hji)notism  iu  demonomania,  353,  354 

as  cause  of  hysteria,  625 

in  the  treatment  of  hysteria,  640 

definition  of,  1214 

mode  of  production  of,  1214 

illegal  acts  induced  by,  865 

iu  treatment  of  ueurasthenia,  850 

vascular  changes  during.  1042 

will  annihilation  in,  1368 
llypnotismo-spoutaneo-autonomo,  610 
Hypochondriacal    melancholia  in  folic   circulalre, 
217 

paranoia,  374 

illusions,  375,  376 

melancholia,  prognosis  of,  loio 

melancholia,  reaction-time  in,  1066 

melancholia  and  suicide,  1231 

neurasthenia,  840 

symptoms  in  general  paralysis,  525,  542 
Hypochondriasis  and  intestinal  affections,  1245 

diabetes  insipidus  in,  372 

diagnosed  from  male  hysteria,  625 

moral,  iu  insanity  of  negation,  832,  833 

nymphomania  in,  864 

in  the  aged,  870 

antecedent  to  persecution  mania,  926 

pulse  changes  in,  1042,  1043 

of  general  paralysis,  pathology  of,  542 

of  njasturbatiou,  784 


INDEX. 


1441 


Hypochondriasis  and  inclimcliolia,  792,  793 

Ideas,  34 

Hypodipsia  in  nourastlicuia,  845 

abnormal  acceleration  of,  374 

Hypomaiiia,  374 

correct,  sometimes  delusions,  375 

Hyiiokiiii'sia  in  ucurasthciiia,  845 

dominant,  397 

Hypoxaniliin  in  brain,  151 

imperative,  678 

Hypsophobia,  844 

of  grandeur  in  persecution-mania,  928 

929 

Hyslop,  Theo.  15.,  syringe  fcodiuf::  by  the  nose,  501 

of  persecution  and  persecul  ion-mania, 

933 

malaria  and  insanity,  756 

Ideation,  32,  34 

post-febrile  insanity,  985 

in  toxic  states,  970,  971 

sunstroke  and  insanity,  1232 

Ideatioinil  attention,  107 

and  A.  Wxiitir  lilylli,  urine,  1340 

insanity,  696 

Hy.sU'ria  altt'ruating  with  insanity,  80 

Idec'njagd,  643 

diabetes  insipidus  in,  372 

Ideler,  causation  of  insanity,  1243 

as  cause  of  foli<'  circulaire,  226 

Identity,  personal,  delusions  of,  346 

and  oalalepsy.  diagnosis  between,  184 

Ideo-dynamisni,  law  of,  1214 

relation  of,  to  iiis.inity,  582 

Idiocy,  pos^t-eclauipsic,  358 

ataxy  in,  106 

diagnosis  of,  381 

in  cerebraux,  189 

epileptic,  455 

and  one-sided  deafness,  329 

due  to  plumbism,  746 

delirium  in,  335 

menstruation  in,  80 r 

destructive  im]>ulses  in,  355 

nymphomania  in,  864,  865 

and  ecstasy,  426 

and  scrofula,  939 

electricity  in,  427 

presumption  of,  legal,  995 

epileptiform,  457 

vascular  conditions  in,  1051 

and  hypnotism,  609,  610,  625 

sex  in,  1154,  1155 

and  hypochondriasis,  611,  617 

and  heat  stroke,  1234 

minor.  631 

due  to  congenital  syphilis,  1255,  1267 

salivation  in,  1105 

due  to  traumatism  in  youth,  1308 

traumatic.  1160 

mineral  constituents  in  urine  in,  1347 

simulation  of,  by  disease,  1161 

Idiopathic  insanity,  696 

followed  by  post-conuubial  insanity,  775 

Idiosyncrasy  to  mental  poisons,  967,  968 

and  melancholia,  793 

Idiot  asylums,  Switzerland,  1240 

Weir  Mitchell  treatment  of,  852 

Idiots,  othrematomata  in,  559 

nymphomania  in,  864 

hydrocephalic  shape  of  head  in,  580 

and  pellagra  diagnosed,  921 

Kalmuck  shape  of  head  in,  580 

vascular  changes  in,  1043 

care  of,  Australia,  113 

the  tremor  of,  1323 

chorea  in,  212 

polyuria  in,  1341 

destructive  impulses  in,  355 

nrea  excretion  in,  1344 

savants,  649 

nric  acid  excretion  in,  1345 

provision  for,  Italy,  719 

due  to  dysmenorrha?a,  1350 

palate  in,  883 

and  nterine  displacements,  1352 

disqualified  to  act  as  members  of  Pai 

•liament, 

will  incompetency  in,  1367,  1368 

889 

Hysterical    attacks  diagnos2d  from   delirium    tre- 

incapacity of,  to  vote,  890 

mens,  71 

pyromauia  by,  1059 

impulsive  acts,  355 

salivation  in,  1106,  1108 

globus.  547 

provision  for,  in  Sweden,  11 10 

chorea.  209,  213 

provision  for,  in  Denmark,  11 14 

hydrophobia,  599.  600 

suicide  by,  1232 

hypnotism  in  the,  606 

Ignis  saccr,  457 

fit  and  epilepsy  diagnosed,  622 

St.  Antonii,  457 

con\-iilsive  attacks,  post-epileptic,  985 

Iliad,  allusions  to  insanity  in  the,  7 

emotion  and  weeping,  1275 

Ilio-psoas  atrophy  simulating  hysterical  paraplegia. 

megalopia.  787 

1 162 

insanity,  vascular  changes  in,  1043 

Illegal  acts,  independent  of  contract,  by 

lunatics. 

seizures,  early  myosis  in,  1056 

1298 

states,  conium  in,  1145 

during  alcoholic  trance,  1300 

states  following  fright-collajise,  1158 

Illegitimacy  and  puerperal  insanity,  1035 

sjTuptoms  following  brain  injury,  1307 

Ill-treatment  of  the  insane  regarded  as  a 

remedy, 

Hj-steriform  seizures  in  general  paralysis,  520,  530 

23,  24,  25 

Hy.storo-demonomania,  epidemics  of,  352 

Illusions,  264 

ana'stliesia  in,  354 

of  sight  in  chronic  alcoholism,  71; 

Hystero-ejiileiisy,  alTernation  of  selfs,  346 

sensorial,  in  prodromic  stage  of  delirium  tre- 

destructive imi)ulse  in,  35^ 

mens,  341 

digitalis  in  the  excitement  of,  388 

in  diagnosis  of  insanity.  373 

Hystero-epileptic  impulsive  acts,  3t;5 

hypochondriacal,  375,  376 

amnesia,  377 

in  general  paralysis,  529 

attack,  treatment  of  a,  640 

sensory,  in  sub-acute  alcoholism,  69 

Hysterogenic  points,  632 

in  delirium  tremens,  342 

Hysteroid  neurasthenia,  840 

in  hypochondriasis,  612 

Hysteroidal  forms  of  insanity,  simulation  of,  503 

in  the  sane,  675 

Hystero-traumatic  paralysis,  633 

in  mania,  764 

sexual,  in  senile  ps.vchoses,  871 

ICARD,  mental  disturbances  at  menstrual  periods, 

sensory,  in  toxic  states,  971 

803 

of  hypnotism,  1216 

Idea,  fixed,  375 

Images,  mental,  34 

Ideal  insanity,  696 

Imagination,  32,  34,  35,  493 

1442 


INDEX. 


Iiuag'inatioii,  the,  in  toxic  states,  970 
Imbeciles,  shape  of  head  of,  578 

destructive  impulses  of,  355 

kleptomauia  in,  728 

training  institutions  for,  Scotland,  11 19 

suicide  by,  1232 
Imbecility,  haemoglobin  in,  138 

blood-corpuscles  in,  138 

ocular  symptoms  in,  492 

cerebral  hypertrophy  in,  649,  650 

vascular  conditions  in,  1051 

pyromania  in,  1059 

sex  in,  1155 

sphygTuoyraphic  tracings  in,  11 89 

and  heat  stroke,  1234 

due  to  traumatism  in  youth,  1308 

micro-  or  hydroccphalous,  operation  in,  1326 
Imides,  151 
Imitation,  1030 

spread  of  eroticism  by,  703 
Imitative  insanity,  696 

life  in  children,  disturliances  of  the,  203 
Immediate  chemical  principles  of  brain,  146 
Imola,  asylum  at.  717 

Imperative  concept  in  hysterical  mania,  768 
Imposed  insanity,  696 
Impotence,  delusions  of,  in  post-connubial  insanity, 

776 
Imprisonment  and  suicide,  1228 
Impulse,  866 

and  obsession,  866,  867 

in  relation  to  chronic  alcoholism,  389 

patholot;ical  detinition  of,  389 

dipsomaniacal,  389,  390,  391,  392 

uncontrollable,  in  cerebraux,  188 

suicidal,  355,  356 

homicidal,  355,  356 

dipsomaniacal,  physical  signs  of,  390 

homicidal,  593,  596 

medico-legal  aspect  of  homicidal,  598 

uncontrollable,  pathology  of,  598 

irresistible,  and  kleptomania,  726 

in  hysterical  mania,  768 
ImptiLses,  destructive,  in  rheumatic  insanity,  355 

in  general  paralysis,  355 

in  chronic  dementia,  355 

in  imbeciles,  355 

in  idiots,  355 

in  epileptics,  355 

in  hysteria,  355 

in  hystero-epilepsy,  355 

irresistible,  1367 

primitive,  32 

intellectual,  407,  410 

dipsomaniacal,  relapsing,  392 

violent,  in  deaf  persons,  328 

destructive,  354 
Impulsions  intellcctuels,  678 
Impulsive  accessions  in  persecution-mania,  930 

actions,  354,  355,  356.  379 

in  cocaine  poisoning,  237 

and  heart  disease,  354,  355 

hysterical,  35^ 

hystero-epilei)tic,  355 
heredity  of,  356 
in  masturbators,  355 
medico-legal  view  of,  355,  356 
and  tachycardia,  354 
homicidal,  in  epilepsy,  455 

acts  in  nostalgia,  859 

accessions  in  nymphomania,  865 

insanity  and  the  strumous  diathesis,  356 

acts  of  inebriates,  340 

accessions  in  pyromania,  1056,  1057 

violence  of  tran?.itory  mania,  1304 
Impulsiveness  following  cranial  injuries,  188 
Impurities  in  blood,  and  insanity,  136 


Inanition,  delirium  of,  336 
Incendiaries,  criminal,  1057,  1058 

insane,  1056 
Incoherence,  evidence  for  certification,  193 

in  general  paralysis,  526,  527 

in  the  delirium  of  children,  359 

in  mania,  763 

in  hallucinatory  mania,  767 

in  toxic  states,  970,  971 

of  alcoholic  delirium,  343 
"  Incomplete  reaction,"  1069,  1070 
Increase  of  insanity,  alleged,  1194  et  seq. 
Incubative  period  in  persecution-mania,  925,  931 

of  delirium  tremens,  69 
Indecision,  mental,  in  eccentric^*,  422.  423 
Index,  cranial,  575 

cephalic,  187,  575 
India,  hypnotism  in,  604 

lathjTism  in,  730 
Indian  hemp,  action  of,  1097,  1143 
Indirect  suggestion,  1213 
Induction,  38 
Inebriate  retreats,  1377 
Inebriates,  contractual  capacity  of,  684 

criminal  responsibility  of,  685,  686 

impulsive  acts  of,  340 

legislation  affecting,  554 

retreats  for,  555,  1377 
Inequality  in  size  of  pupils,  1054 
Infancy,  brain  injury  in,  1308 

cretinism  of,  285 
Infant,  evolution  of  mental  faculty  in  the,  465,466 

early  movements  in  the,  465,  466,  467 

spontaneous  thought  in  the,  469 

spontaneous  movement  in  the,  825 
Infantile  insanity,  697 

paralysis  and  idiocy,  6=;6 

convulsions  causing  idiocy,  665 
Inflammation,  sympathetic  nerves  and,  1250 
Inflammatory  action  in  insanity,  899 
in  skull,  900 

in  cerebral  membranes,  500 
in  neuroglia,  902 
in  cells,  902 
in  blood-vessels,  902 

affections" in  children,  delirium  following,'359 

affections  in  mania,  762 

doctrine  of  general  paralysis,  540 

exudation  producing  cerebral  atrophy,  906 

idiocy,  644 
Influence,  undue,  in  consent  to  marriage,  779,780 
Influenza,  delirium  of,  334 
Inheritance,  the  law  of,  583 
Inhibition,  1367 

of  thought  antecedent  to  chorea,  207 
Inhibitory  action,  mode  of  exercise  of,  691 

control,  loss  of,  in  prodromic  stage  of  general 
paralysis,  522,  523 
Injuries,  recovery   or  remission  of  mental  ^symp- 
toms after,  80 

cranial,  and  their  consequences,  187,  188 

cranial,  and  folie  circulaire,  226 

in  diagnosis  of  insanity,  373 

in  children,  delirium  following,  359 
Injury,  cranial,  a  predisposing  cause   of   general 
paralysis,  534 

an  exciting  cause  of  general  paralysis,  535 

self-preservation  from,  a  normality  of  conduct, 

243.  244 
and  accidental  deaf-mutism,  327 
as  a  factor  of  mental  disease,  1306,  1312 
Inorganic  principles  of  brain,  146,  147,  151 
Inosite  in  brain,  151 
Inquests,  fees  to  medical  men,  482 

on  the  insane  optional  to  coroner,  737 
Inquisition,  England  and  Wales,  reception  oruer 
after,  732 


INDEX. 


1443 


Inquisition,  contiuimtioii  cortittcivtcs  aftiT,  734 
testiiiuintary  ojipacily  after,  1286 
ill  liiuacy,  uicIIkhI  of  obtaining,  198 
in  Scotland,  238,  239 
juries  in  oases  ol',  198 
in  Ireland,  714 
Insane,  aphasia  in  the,  984 

religious  intliieiice  on  the,  1091 

salivation  in  the,  1106,  1107 

hed-sores  in  the,  I2g 

bruises  in  the,  173 

enratory  of  tlie,  324 

constipation  in  the,  265 

coiiiiition  of  the,  238 

eriiniiial,  the,  288 

criminal  vesiionsiliility  of  the,  294 

teiniierament,  382 

dreams  of  the,  414 

as  witnesses,  464 

i^ar,  557 

rhito's  provision  for  the,  in  the  "  liepublio,"  11 

states  of  eoiisciousness,  261 

legal  lial>ilities  of  the  (.see  Liinacj") 

double  consciousness  in  the,  401 

crysijielas  in  the,  460 

type  of  head,  tlie,  578 

influenza  alTecIiiii;'  the,  691 

klejjtomania  in  the.  728 

interpretation   period     in    persecution-mania, 

925,  926,  931 
phthisis  in  the,  938,  939 
apoplexy  in  the,  978 
physiognomy  of  the,  947 
capacity  of,  to  plead,  951 
nursing-  of  the,  859 
conditions  in  toxic  states,  970 
specific  gravity  of  tlie  brains  of  the,  158,  159, 

161,  162 
examination  of  the,  180 
death  rate  in  the,  1201,  1202 
accidental  suicide  in  the,  1231 
intentional  suicide  in  the,  1231 
dread  of  syphilis,  1253 
weeping-  in  the.  1273 
delusion  in  testamentary  capacity,  1286,  1287, 

1289 
diathesis,  382 

definition  of,  383 

latency  of,  383 

eccentric  form  of,  383 

imbecile-like  form  of,  383 

emotions  in,  383 

moral  sense  in,  383 

reasoninii  faculties  in,  383 

functional  irritability  in,  383 

head  conformation  in,  383 

acquired,  384 
the,  in  workhouses,  1371 
gtill-stones  in  the,  1377 
treatment  of  the,  in  Japan,  720 
IiLsanities  ol  epilei)sies,  445,  452 
Insanity,  delinition  of,  330 

alternating  with  hysteria,  80 

with  epilepsy,  80 

witli  niegrim,  81 

witli  asthma,  81 

with  hay  asthma,  81 

with  clironic  bronchitis,  81 

with  rheumatic  fever,  82 

with  g-out,  82 

with  diabetes,  83,  371 
and  diabetes,  82 
"partial,"  use  of  the  term,  230,  297,  298,  305, 

307,  309.  331 
recovery  from,  321 
and  deafness,  329 
••  total,'"  297 


Insanity  and  delirium,  diag-nosis  between,  338 
of  Uright's  disease,  172 
of  cancer,  177 
of  cardiac  disease,  178 
of  (i raves'  disease,  476 
of  gout,  548 
crises  in,  320 
curability  of,  321 
ill  children,  202 
and  cliorea,  206 
and  soinnanibulism,  582 
muscular,  208 
double,  240 

plioto-chroniatic  treatment  of,  239 
communicated,  240 
and  nervous  diseases,  373 
classifications  of,  20,  229,  233,  446,  448,  449 
and  facial  expression,  378 
actions  in  diagnosing,  378,  379 
deaf-mutism  iu  diagnosing,  380 
of  doubt,  406 

absence  of  speecli  in  diagnosing,  379,  380 
leaping,  397 
post-epileptic,  454 
prc-epileptic,  453 
endemic,  435 
and  ei>ileptic  ttts,  455 
and  enteric  fever,  506 
and  lunacy,  distinction  between,  461,  462 
and  eccentricity,  distinction  between,  419 
and  drunkenness,  similarity  between,  448 
simulated,  502 

followed  by  general  paraljsis,  520 
causes  of,  135 

and  undeveloped  gout,  549,  550 
and  retrocedent  gout,  549 
and  suppressed  gout,  549,  550 
forms  of,  and  hallucinations,  567 
chronic,  handwriting  in,  573 
acute,  handwriting  in,  573,  574 
and  hysteria,  582 
and  "nervousness,"  582 
degree  of,  among  the  ancients,  1,  2 
alternating  witli  headaches,  81 
attention  in,  109 
of  belladonna  poisoning,  133 
brain  weight  in  various  forms  of,  165,  166 
consecutive  to  chorea,  206,  207,  210 
antecedent  to  cliorea,  207 
and  acute  rheumatism,  210 
plea  of,  in  criminal  cases,  292 
after  commission  of  crime,  293,  294 
criminal  responsibility  in  relation  to,  294 
of  puberty,  357,  360 
of  adolescence,  357,  360 
forms  of,  diagnosis  of,  381,, 382 
unequal  action  of  hemispheres  in,  400 
use  of  electricity  in,  427,  428,  430,  431 
the  early  development  of,  434 
modern  and  epidemic  forms  of,  434 
and  epilepsy,  452 
and  exoplithalniic  goitre,  476,  478 
ophthalmoscopic  signs  in,  490 
the  hair  in,  564 
and  hysteria,  621,  625 
in  idiots,  649 

as  predisposing  cause  of  idiocy,  660 
among  the  Hindoos,  683,  684 
of  influenza.  687 
of  instinct,  706 
jealousy  as  a  symptom  iu,  721 
of  lead  poisoning,  745 
of  masturbation,  784 
and  locomotor  ataxy,  association  between, 750, 

751 
alteriuiting-  with  locomotor  ataxy,  750 
and  malaria,  756,  757 

4  z 


1444 


INDEX. 


Insiinity  and  marri;ii;e,  775,  777 
aud  ineiistruatii>n,  801 
post-couiiubial,  law  as  to,  780 
due  to  morphia  abuse,  818 
dunibnoss.  in,  827 
classification  of,  Arabic,  830 
and  neuralgia,  835 

nymphomania  in  various  forms  of,  864 
and  ovariotomy,  875 
detinitiou  of,  892 
causes  of,  893 

factors  in  production  of,  897 
vascular  and  nutritional  brain  chang-es  iu,  897 
phai^ocytosis  in  various  forms  of,  904 
due  to  use  of  diseased  maize,  918 
periodicity  iu,  923 
and  phthisis,  939,  940,  942 
unopposed  plea  of,  951 
opposed  plea  of,  953 

plea  of,  opposed  by  criminal  himself,  959 
plea  of,  in  which  criminal  remains  mute,  961 
aud  aphasia,  978 
of  myxcedema,  828 
of  negation,  832 
of  paralysis  agitans,  884 
phthisical,  937 
of  persecution,  925 
post-apoplectic,  975 
following  typhoid  fever,  986 
following'  small-pox,  987 
following  erysipelas,  988 
following  diphtheria,  988 
following  typhus,  987 
following  scarlatina,  987 
following  rheumatism,  987 
following  pneumonia,  988 
prevention  of,  996  et  seq. 
prophylaxis  of,  996  et  seq. 
alleged,  method  of  legal  procedure  in,  1003 
prognosis  of,  1006 
pulse  in,  1042 

reaction-time  in  forms  of,  1063,  1067 
of  regicides,  1078 
and  religion,  1088 
religious,  1091 
remittent,  1092 
and  rheumatic  fever,  1093 

alternating  witli  acute  rheiimatism,  1093,  1094 
and  self-mutilation,  1148 
influence  of  sex  in,  1152 
forms  of,  in  the  sexes,  11 55 
due  to  fright,  1159 
Ciises  of,  fit  for  single  care,  1164 
of  a  Sovereign,  1177 
statistics  of,  1194 
fallacies  iu  statistical  computation  of,  1194  et 

seq. 
frequency  of  various  forms  of,  1203,  1204 
and  suicide,  1229 
and  sunstroke,  1232 
sympatlietic,  1242 
due  to  fuiictioual  disorder,  1244 
due  to  uiorbid  conditions,  1244 
and  syphilis,  1252 
due  to  congenital    syphilis,   1255,  1256,  1268, 

1269 
due  to  constitutional  syphilis,  1256,  1257,  1258 
bodily  temperature  iu,  1279 
temporary,  1285 

and  testamentary  capacity,  1285,  1286 
subsequent  to  will-making,  1289 
due  to  tobacco  abuse,  1297 
increase  of,  alleged,  1194  et  seq. 
due  to  traumatism,  1306  et  seq.,  1312 
followiug  surgical  operations,  1313 
treatment  of,  1314 
■of  twins,  1330  et  seq. 


Insanity  and  uterine  disease,  1350 
confusioual,  1357 

suitable  cases  of,  for  workhouses,  1372,  1373 
Insolatio,  insanity  of,  pathology,  911,  1236 

and  acute  delirious  mania,  52 
Insomnia,  antifebrin  in,  95 

in  the  insane,  electricity  in,  431 
as  cause  and  consequence  of  insanity,  11 73 
in  mania,  762 
a  precursor  of  mania,  765 
iu  melancholia,  795 
treatment  of,  1129 
bromides  in,  1130,  1131,  1132 
in  toxic  states,  969,  970 
of  iusanity,  pathology  of,  898 
Inspector  of    the   poor  and  pau])er   certification, 

Scotland,  1121 
Inspectors  in  lunacy,  Holland,  592 

of  lunatics,  Ireland,  711,  713 
Instinct,  1029 

Instinctive  criminal,  the,  288 
insanity,  697 
monomania,  811,  812 
Instrumental  labour  and  idiocy,  649 
Insular    cerebro-spinal   sclerosis  diag-nosed    from 
general  paralysis,  533 
sclerosis  simulating;  bvbteria.  1162,  1163 
sclerosis,  the  tremor  of,  1322 
Intellect,  acute   and   sub-acute   disturbance  of,  in 
cerebral  Intoxication,  968 
partial  disturbance  of,  in  cerebral   intoxica- 
tion, 965 
defect  of,  in  initial  stage  of  general  paralysis 

521,  522 
disorders  of,  in  chronic  alcoholism,  77 
in  cretinism,  286 
morbid  affection  of,  374 
imperfect  development  of,  374 
weakening  of,  in  paralysis  agitans,  885 
Intellection,  31 

Intellectual  activity,  effect  of,  on  bladder,  1339 
confusion  in  hallucinatory  mania,  767 
enfeeblement  in  tlie  sexes,  1155 
effort  and  head  temperature,  1284 
faculties,  weakness  of,  in  drunkards,  65 
excesses  as  cause  of  Insanity  of  doubt,  411 
impulses,  407,  410 

faculties  and  physical  conditions,  1026 
insanity,  65,  697 

disequilibration  iu  drunkards,  67 
monomania,  811,  812 
Intelligence,  1029 

of  criminals,  290 
Intemperance  and  suicide,  1229 

parental,  as  cause  of  idiocy,  661 
Intemperates,  obliteration  of  moral  sense  in,  64 

weakness  of  intellect  iu,  65 
Intentional  suicide  iu  the  insane,  1231 
Interdiction  in  Scotch  Lunacy  Law,  11 15 
Interdictors  in  Scotch  Lunacy  Law,  11 15,  11 16 
Intermarriage,  588 

aud  deal-mulism,  326,  327 
Intermittent  drinkers,  65 
drunkards,  394 

fever  and  accidental  deaf-mutism,  327 
fever,  delirium  of,  334 
stupor,  sphygmographic  tracings  in,  1046 
Internal  capside,  fuuctious  of  the,  157 
Intestinal  disorders  aud  insjinity,  1244 
lesions  in  dementia,  350 
spasms  in  neurasthenia,  846 
tract,  action  of  opium  on  the,  1140 
"Intestinal  psychoses,"  1245 
Intoxicant  agents  and  diagnosis  of  insanity,  373 
Intoxicants  inducing  nymphomania,  865 
Intoxication,  as  cause  of  insanity,  recognised  by  the 
ancients,  i,  2 


INDEX. 


1445 


Intoxiciitioii,  alcoliolic,  62,  447 
iibnoniial  I'oriiis  of,  66 
convulsivp,  410 
cerebral,  968 

acute  intellectual  disturbance  in,  968 
sub-acute  iiilellectual  disturbance  in,  968 
partial  intellectual  disturbance  in,  965 
diagnosed  from  general  i)ariilysis,  534 
insanity  from,  696 
morpliia,  817 

lutra-crauial  tumour  diagnosed  from  general  para- 

l.V=^>^  533 
Intra-ocular  muscles,  affection  of,  in  general  para- 
lysis. 48S 
Intra-uterine  cretinism,  284 
Introspection,  29 

Invasion  stage  of  general  paralysis,  523 
Iodides  in  i)lnmbism,  748 
Irascibility  a  moral  insanity,  815 
Ireland,  associations  for  after-care,  57 
Ireland,  Thomas,  Bright's  disease  and  insanity, 726 
Ireland,  w.  w.,  double  brain,  397 

epileptic  idiocy,  455.  456 

microcephaly,  805 

scrofula  and  idiocy,  939 

visionary,  1359 
Iridopk'gia,  1054 

reflex,  488 
Iris,  examination  of  the,  487 

nerve-sui)i)ly  to  the,  1248 
Iritis  due  to  Ik  reditary  syphilis,  1266 
Irregular-shaped  head,  579 
Irresistible  impulse  and  drunkenness,  65,  67 
Irritability  due  to  ccjngenital  syiihilis,  1264,  1270 

in  chronic  alcoholism,  "j-; 

in  toxic  states,  970 

mental,  in  hysterical  mania,  768 
Irritation,  cerebral,  187 

mydriasis,  1055 

myosis,  1055 
Irrsinn,  1377 
Ischemic  insanity,  697 
Jshk,  831 
Isolation  in  the  treatment  of  hysteria,  626 

in  the  treatment  of  functional  neuroses,  853, 

854 
Israelites,  recognition  of  insanity  by  the,  3 
Italy,  hypnotism  in,  605 

lathyi'ism  in,  730 

sex  in  insanity  in,  1153 

Jaborandi  in  treatment  of  cretinism,  287 
Jaccoud,  articular  rhenmatism  and  insanity,  986 
post-typhoidal  paraplegia,  986 
general  paralysis  following  articular   rheum- 
atism, 988 
Jackson,  Hughlings,  epilepsy  and  congenital  syphi- 
lis, T263 
cougeiulal  sjiihil'!' and  insanity,  1267 
localisation  of  brain  functions,  152,  153,  155, 

reflex  action  in  cerebral  processes,  157 
higher  Sfnsori-motor  centres,  157 
<:erebellar  lesions,  158 
functions  of  hemispheres,  398 
physiological  division  of  nervous  system,  441, 

442 
higher  nervous  centres,  442 
relation   of   mind  to   nervous  activities,  446, 

447 

the  "dreamy"  state,  453 

post-epileptic  paralysis,  456 

cerebral  lesions  and  insanity,  976 
•Jacksonian  epilepsy,  444,  453 

in  ergotiym,  438 

contrasted  with  true  epilepsy,  449,  450 
Jacobi,  douche  treatment,  120 


.lacobi,  classilication  of  insanity,  231 

progress  of  psychology  in  Germany,  545 

training  schools  for  nurses,  859,  860 

sympathetic  insanity,  1243 

Walinsiun,  1364 
Jac(|uelin-l)ubuissou,  circular  insanity,  215 
.lakoweuki,  pathology  of  chorea,  210 
Jamaica,  dogwood,  action  of,  1139 
James,  phthisis  in  adolescents,  361 

early  applications  of  electricity,  427 

mortality  due  to  phthisis,  938 

hereditary  relationship  between  phthisis  and 
insanity,  939 
James,    I'roftssor,  mental    i)rocesses    in    reaction- 
time  experiments,  1017 
James,  Sir  Ili'nry,  method  of  procedure  in  alleged 

insanity,  1003,  1004 
Jamieson,  forcible  feeding,  494 
Janet,  I'ierre,  psychological  automatism,  116 
Jarvis,  sex  in  insanity,  1153 
Jastrow,  Joseph,  reaetion-tinie  in  the  sane, 

1067 
Jastrowitz,  hypnotic  action   of  amylene  hydrate, 

"39 
Jealousy,  insane,  post-connubial,  776 
Jennings,  pulse-tension  in  melancholia,  1044 
Jervoice,  case  of,  421,  422 
Jessen,  pyromania,  1056 
Jewish  Asylum,  Holland,  593 
Jews,  ancient,  insanity  among  the,  3 

self-mutilation  among  the,  1147 

suicide  among  the,  1217 
Johnson's,  Dr.  Samuel,  delire  du  toucher,  410 
Johnstone, Carlyle,  cxo])hthalmic  goitre  and  mania, 

477.  478 
Joints,  hysterical  affections  of,  633 
Jolly,  imitation,  instinctive  and  intellectual,  677 
Jones,  Bence,  phosphoi-io  acid  excretion  in  cerebral 

inflammation,  1348 
Jones,  Haudfleld,  malarial  paralysis,  756 

intellect,  affections  of,  due  to  malaria,  756 

nervous  disorders  and  sunstroke,  1232 
Jong,  pregnanc.v  and  klei)t(miania,  727 
Josat,  the  C]iile])tic  insanity  of  Hercules,  9 
Josephus,  suicide  among-  the  ancient  Jews,  1218 
Journal  of  Mental  Science,  787 
Joy,  facial  expression  of,  483 

Judges,  summary  of  the,  as  to  criminal  responsi- 
bility. 310,  311,  312,  313 
JudgTuent,  38 

in  dreams,  412 

in  post-apoplectic  weak-mindedness,  977 

in  aphasics,  983 

reaction-time  of,  107 1 
Judicial  factors,  11 15 

interdiction,  Scotland,  11 15 
Julius  Csesar,  epilei)sy  of,  455 
Jurauville,   boldo-glycerine   in    mental    affections, 

1 147 
Jiirgcns,  cord  lesions  due  to  hereditary  syphilis, 

1262 
Juries  in  eases  of  inquisition,  198 
Justices  of  the  peace,  duties  of,  under  Inebriates 
Act,  566 

specially  appointed,  England  and  Wales,  duties 

of,  731.  732,  733 
actions    against,    period    of     limitation,    and 

lunacy,  994 
Juvenal,  the  epileptic  insanity  of  Caligula,  18 
Juvenile  dementia,  1267 

Kahlbaum,  katatonia,  724,  725 

verbigeration,  1355 
Kahler,   cord    lesions    due    to  hereditarf   sji>hilis, 

1262 
Kalamazoo  Asylum,  Michigan,  86 
Kalmuc  idiocy,  644 


1446 


INDEX. 


Kahnuc  idiots,  shape  of  head  of,  580 

Kankakee  Asylum,  Illinois,  104 

Kant,  apiH'veeiilion,  99 

Kast,  A.,  eolleclion  of  sweat  for  exinnination,  1167 

eomposition  of  sweat.  1167,  n68 
Katatonia,  sphynmouraphie  traein^s  in,  1045 

verbigeration  in,  1355 

niitis,  724 

protracta,  724 
Katharinenthal  Asyluui,  1239 
Kava,  725  (see  Kam'a,  art.) 
Kazan  Asyluiii,  1099 
Keen,  operative  treatment  of  microcephaly,   809, 

1327 
Keith,  T. ,  insanity  f()llowin<>-  ovariotomy,  876 
Keller,  Chr.,  imbeciles  in  Denmark,  1114 
Kenj'oii,  Lord,  criminal  resiwnsibility,  301 
Keiihalin,  148 

Kerlin,  parental  alcoholism  and  idiocy,  661 
Kesteven,  miliary  sclerosis  in  cerebral  defenera- 
tion, 906 
Kew  Asylum,  Victoria,  Australia,  iii 
Kidneys,  iiost-mortem  a,i)pcarance  in  ^jeneral  para- 

l.^'^i^  537 
Kilkenny  Asylnm,  710 
Killarney  Asylum,  710 

Kiiiiesthetic  imi)ressions,  nnconscions,  1336 
Kind,  ille;.atimacy  and  idiocy,  663 
Kingston  Asylnm,  Canada,  17^ 
Kinship  in  the  prodnction  of  offsprim;',  588 
Kirkbride,  asylnm  construction,  88 

cdncational  instruction  in  asylums,  T317 

Kirn,  L. ,   influenza,  mental    disorders 

followring,  687 
Klebs,  origin  of  microcephaly,  809 
Klein,  retinitis  paralytica,  491 
Kleptomania  in  folic  circulaire,  219 

in  insane  jealousy,  722 

in  senile  psychoses,  871 
Klikoushy,  1098 
Klopsophobia,  844 
Knee-jerk  in  general  paralysis,  531 
Knccht,  inequality  of  ])Uiiils  in  insanity,  489.  491 

retinitis  i)aralytlca,  491 
Knoblauch,  cuumlativc  action  of  sulplional,  1138 
KnowiuK',  39 
Knowledge,  39 
Kobert,  alkaloids  of  erijol,  458 

action  of  hyoscinc,  1143 
Koch,  heredity  in  criminals,  289 

the  insane  diathesis,  382,  383 

Verriicktheit,  887 
Koenigsfelden  Asylum,  T239 
Kohu,  Jlax,  coiTee  abuse,  238 

the  tremor  of  tea  and  coffee  abuse,  1321 
Kolk,  S.  van  der,  uterine  displacements  in  insanity, 

1351 

cliissification  of  insanity,  231 

treatment  of  the  insane  in  Holland,  590,  591 

phthisis  and  insanity,  938,  939 

phthisis  in  epileptics,  942 
Kbnig'  and  Otto,  action  of  uretliane.  ti36 
Konradsbcr^-  Asylum,  iiio 
Konstantinovsky,  the  bones  of  tlie  insane,  144 
Koran,  suicide  interdicted  by  tlic,  1219 
Kbster,    post-mortem     appearances     of    sunstroke 

lesions,  1236 
Kraepclin,  ])ost-in)luen7.al  psychoses,  690 

influence  of  druLis  on  reaction-time,  1069 

urethane  in  mental  afTections,  ti36 
Kraflt-Ebinj,'',  acute  delirious  mania,  52,  53,  54 

sopor,  53 

classification  of  dipsomania,  392 

homicide  in  acute  choreic  delirium,  212 

outbursts  of  excitement  in  criminals,  291 

hallucinatory  mania,  767 

delusions  in  paranoia,  888 


KratYt-Ebing',  heredity  in  i)erseciition-mania,  933 

cerebral  salivation,  1106 

l)ly;ilism  in  the  insane,  1107 

action  of  paraldehyde  on  the  blood,  7134 

hyi>uone,  1137 

methylal,  1138 

sulplional,  1138 

piscidia  erythrina,  1139 

opium  in  mental  affections,  1141 

cannabin,  1144 

sexual  perversion,  11 57 
Krayenhof,  early  uses  of  electricity',  426 
Kreidlin;:;s,  284 
Kretins,  284 
Kriebelkrankheit,  457 
Krinosin,  151 

Krysinski,  patholofjy  of  eruotism,  459 
Kruiiclstein,  suicide  during  catamenial  periods,  803 
Kussmaul  and  Maicr,  action  of  lead  on  nerves,  746 

Laache,  numerical  estimate  of   blood-corpuscles, 

,137 
Labbee,  daturism,  326 
Labile  currents,  431 
Laborde,  action  of  boldo-ylucinc,  1 147 
Lacaon,  insanity  of,  435 
Lactantius,  sibyls,  1160 
Lactation,  melancholia  duriuii,  792 

insanity  of,  1041 
Lactational  delirium.  336 

insanity,  697 

insanity,  ]n-oL;iiosis  of,  1012 
Lactic  acid  in  brain,  1:^1 
Ladd,  mental  iiliysioloi:y,  804 

Laehr,  H.,  the  insane  in  Germany,  544 

Laehr-Uurkardt,  method  of  dealinj^  with  morphia 

habit,  819 
Lafontaine,  treatment  of   epidemic   denionoinania 

by  hypnotism,  354 
Lallier,  diabetes  and  insanity,  1246 
Lalor.  educational  instruction  in  asylums,  1316 
Lancereaux,  alcohol,  63 

classification    of    symptoms    of    chronic    alco- 
holism, 74 

alcoholic  anaesthesia,  75 

})ara])lef>ie  douloureuse,  76 

alcoholism  in  the  sexes,  1155 
Land,  action  tor  recovery  of,  period  of  limitation, 

and  lunacy.  994,  995 
Landouzi,  reflex  sym])athetic  action,  1249 
Lanye,  N.,  attention  in  reaction-time,  1069 
Lani>endorf  and  rxescheidlen,  alkaline  reaction  of 

brain-tissue,  895 
Lanticrmau,  treatment  of  the  insane  in  Germany. 

545 
Lan^iias'e,  37 

Lanii'u.ase  in  initial  stai>e  of  i^eneral  paralysis,  521 
Lannow,  hereditary  chorea.  209 
Lannelouiiue,  craniectomy  in   microcephaly,  670, 

809,  1326,  1327 
Laqueur,  pupillary  unrest,  1053 
Laschi,  suicide  in  regicides,  1077 
Laschkewitz,    spinal    lesions    due    to    cotig'enital 

sy])liilis,  1269 
Laseg'iie,  nervous  anorexia,  94 

cranial  injuries  and  insanity,  187,  188 

alcoholic  symptoms  in  dipsomania,  391 

alcoholic  visual  hallucinations,  567 

method  of  inducinii'  hv^motism,  606 

kleptomania,  726 

delusions  of  suspicion,  925 

premimitory  .symptoms  of  persecution-mania, 
926 

visual  hallucinations  in  persecntion-manla,  927 

sub-acute  alcoholism,  69 

pyromania  in  imbeciles,  10^7 
liatent  thought,  187 


INDEX. 


1447 


Liitcncy  of  insane  tlinihi'sis,  383 

Lntliyrisiii,  oryotisni.  ami  poUa^ni  comiKiretl,  922 

L.atiu  iioets.  lolcrcnccs  ti>  insanity,  i8 

LaUiililcr,  r:icl;il  cxiircssjon  nf.  483 

LaniH'iit,  luTi'ility  in  criminals,  289 

action  of  liyoscyaminc,  1143 
Lausiiiim' Asylum,  1238 

Law  of  hinacy  rchitiny  to  >in;:Ie  paticnls.  Kiii;l;iii(l 
ami  Wales,  1106 

Kvanc<'.  515,  :^i6,  517,  518 

(ii'rmauy.  546 

Holland,  590 

rnitcil  States,  84 

Swollen,  11 10 

Norway,  1 1  n 

Canada,  176 

Italy,  719 

Ireland,  708 

Enuland  and  Wales,  730 

Scotland,  II 15 

Spain,  1177,  1178 

Switzerland,  1238  cr  scq. 

Lawiovd.  J.  B..  eye  symptoms  in  insanity, 

485 
pupils,  reactions  of,  in  health  and 
disease,  1052 
Lawrence,  ]iosition  in  feedinii,  496 

artilicial  feediniT.  500 
Law-suits,  insane  cravinu'  after,  1060,  1061 
Laws  relating-  to  the  criminal  insane,  Eu;^land  and 
Wales,  292,  293,  294,  295,  296 
Ireland,  710  et  seq. 
Scotland,  11 19 
Laycock,  ])sychical  reflex  action,  1336 
reflex  function  of  brain,  115 
reflex  action  in  cereljral  processes,  157 
classification  of  insanity,  230 
effect  of  phthisis  on  insanity,  941 
Leach,  Sir.!.,  dissolution  of  partnershi])  in  insanity 

of  a  partner,  890,  891 
Lead,  ataxy  dne  to,  751 

poisoning-,    chronic,  diaiiiiosed   from    delirium 

tremens,  72 
lioisoiiinii-,  delirium  in,  335 
poisoniny-  insanity,  exaltation  of,  474 
tremor  due  to  i)oisonin<;  by,  1321 
"  Lead  encephalopathy,"  74:^ 
Leah,  W.,  inflammatory  doctrine  of  general  jKiraly- 

sis,  541 
Leaping"  insanity,  397 
Leave  of  absence  to  patients,  Eni^land  and  Wales, 

Le   Blanc,  Justice,  criminal  responsibility  of  the 

Insane,  302 
Le  Brnn,  endemic  psychopathy  in  India,  682 
Lecithin,  148 
Leech,  sul])honal,  1 138 

sedative  action  of  alcohols,  1132 
Left -handedness  in  criminals,  289 
LegTicles,  suits  for,  period  of  limitation,  and  lunacy, 

994 
Legiil  presumi)tions  relatiiiL;-  to  insanity,  995 

test  of  lunacy,  461 
Lesjf.nies  Asylnm,  1178 
Leyislatiini,  early,  for  the  insane,  24 
Lejiraiii,  M.,  symjHoms  of  dej^eneration,  331 

absinthism,  51 
alcoholism,  62 

toxic  effects  of  belladonna,  133 
toxic  effects  of  betel,  134 
toxic  effects  of  camphor,  175 
toxic  effects  of  cantharides,  177 
toxic  effects  of  chloroform,  205 
toxic  effects  of  coffee,  238 
delirium  tremens,  340 
dipsomania,  3S8 
drunkenness,  415 


Le-iTaiii,  M..  kaAVa,  725 

obsession  and  impulse,  866 
poisons  of  the  mind,  96^^ 
alcoholism,  chronic,  74 

Leurandilu  S.'iulle,  kleiilomania  in  epilciilics,  728 
l;irv8D  in  frontal  sinus  and  insanity,  1245 
diabetes  and  insanity,  1246 

Leibnitz.  ai)l)ercel)tion,  99 

lycil  unu:saiihasic,  91 

Lelul,  the  palholoLiy  of  hallucinations,  567 

l>(iiioine,  mental  functions  diirinj^  slee]i,  1171 

and  Chaumier,  delirium  of  intermittent  fever, 

757 
Le  Panlmier.  mental  disease  and  undeveloped  ^iout, 

548 
Lepine,    i;lycero-phosi)horic    acid    in    urine,    1346, 

1347 
Leprosy,  mental  affections  of,  715 
Leptomeninucs,  the  anatomy  of  the,  168 
L'esthesiomaiiie  (IJerlhier),  594 
Letcliworth,  the  Fitzjames  colony,  508 
Letharuic  state  of  hypnotism,  607,  608 
Lethargic,  1300 
Letterkenny  Asylnm,  710 
Letters  as  evidence  of  insanity,  574 

writiii;^  of,  during-  convalescence,  574 

writing   of,  a   premonitory  sign  of  recurrent 
insaidty,  574 

of  patients,   regulations  as    to,   England  and 
Wales,  735 

of  patients,  Scotland,  1118 
Lencin  in  brain  tissue,  151 
Leucocytes,  iihagocyte  action  of,  904 
Leucocythamia  in  general  paralysis,  138 
Lc\ator  alse  nasi,  tremor  of,  in  chronic  alcoholism, 

75 
Levels,  nervous,  influence  on  one  another  in  cere- 
bral lesions,  443,  447, 448 

in  chronic  alcoholism,  447,  448 
Lc\-inge,  weight  of  brain  in  the  insane,  164 
Levinstein,  treatment  of  morphia  habit,  819 
Lewald,  action  of  diilioisine,  1143 
Lewes,  G.  H.,  study  of  mental  development,  30 

consciousness  and  low  types  of  activity,  447 
Lewis,  Bcvan,  the  lymph  system  of  the  brain,  171 

lieredity  in  adolescent  ins.-inity,  362 

recovery  in  develoinneutal  insanity,  369 

pupillary  iihenomeua  of  general  paralysis,  489, 
490 

liathology  of  acute  delirious  mania,  54 

the  blood  in  i>uerperal  insanity,  139 

histology  of  tlie  cortex,  169 

localising  value  of  ])ui)illary  phenomena,  490, 
491 

cerebral  vascular  supply,  896 

cell-degeneration,  898 

adhesions  of  dura  uuiter  to  skull,  900 

inflammatory  evidences  in  the  pia  mater,  902 

"scavenger  cells,"  902,  903 

association  of  various  parts  of  the  cortex,  905 

cerebral  atrophy,  906 

nuliary    sclerosis     in     cerebral    degeneration, 
906,  907 

cellular  changes  in  epileptic  insanity,  910 

pathology  of  epilepsy,  910 

scavenger  cells  in  alcoholic  insanity,  913 

]>athological    changes   in    alcoholic  insanities, 

913-  914,915 
pathological  dilVerentialion  of  general  paraly- 
sis and  chronic  alcoholism,  914.  915 

psycho-physical  methods,  1022 
reaction-time  in  insanity,  1063 

recoveries  in  jjueriieral  insanity,  loil 
recoveries  in  lactational  insanity,  1012 
arterial  tension  in  general  paralysis,  1048 
pulse  in  chronic  cerebral  atrophy,  1050,  1031 
alcoholism  in  the  sexes,  11 55 


1448 


INDEX. 


Lex,  post-mortem  appearances  of  suiistroki?  lesions, 

Lords,  House  of,  debate  on  criminal  respousibility 

1236 

of  the  insane,  308,  309,  310 

Lcxiujitou  Asylum,  Kentucky.  83 

questions  to  the  judges  on  criminal  responsi- 

Liability, lejial,  in  mental  disease,  462 

bility,  310 

Libel,  action  of,  pevioil  of  limitation,  and  lunacy. 

Lords  Justices  and  Chancery  patients,  195 

995 

Lorry,  intestinal  disturbance  and  insanity,  1245 

Licences  for  private  asylums,  Enyiand  aiid  Wales, 

somnambulistic  conditions,  1176 

1003 

Lotze,  psychology,  48 

Scotland,  11 19 

Louis,  brain  pathology  in  phthisical  insanity,  947 

for  patients  under  jirivate  care,  Scotland,  1119, 

Loup-garou,  753,  1365 

1120 

Louyer-Villermay,   intestinal   disturbance  and  in- 

Licensed houses,  detinition  of,  277 

sanity,  1245 

Li^banlt.  stages  of  h.\-])notic  condition,  1215 

Lovel,  early  uses  of  electricity,  426 

therapeutic  uses  of  hypnotism,  604,  605 

Lo-i\'est  levels  of  nervous  system  (Jackson),  441 

Liebermeister,  pathology  of  sunstroke,  1236 

Liibeck,  early  asylum  at,  544 

Liebreich,  crott)n  chloral,  1135 

Luchsiuger,   perspiration    and  nerve  stimulation. 

Liegeois,  therapeutic  uses  of  hypnotism,  601^ 

1 167 

Light-lieadedness,  333 

Luciani,  functions  of  the  cerebellum,  158 

Lighting- of  asylums,  105 

Lucid  insanity,  697 

Light  phonisms,  1125 

interval  and  testamentary  capacity,  1286,  1289 

Limerick  Asylum,  710 

intervals  in  folic  circulaire,  222 

Limitation  of  actions,  legal,  and  insanity,  993 

and  contracts,  267 

Linas,  the  treatment  of  catalei)sy,  185 

bankrui)tcy  during,  116 

classification  of  dipsomania,  392 

not  presumed  legally,  996 

Lincoln  As)lum,  non-restraint  in,  25,  26 

Ludwig,  nervous  mechanism  of  salivation,  1 105 

Lunatic  Hos]iital,  1085 

Lunacy  inquisition,  England  and  Wales,  ig8 

Lindlev,  Justice,  uiulueintinence  in  ])ecuniary  gifts. 

inquisition  in  Scotland,  238,  239 

1338 

masters  in,  240 

Lindsay,  .1.  Murray,  alcohol  in  jisylums,  62 

of  a  partner,  268,  890 

Lindsay,  Lauder,  the  blood  of  the  insane,  136 

and  insanity,  distinction  between,  461,  462 

Liouville,  ambitious  delusions  after  typhoid,  986 

habits  as  evidence  of,  463 

Lithium  bromide,  1130 

heredity  in  evidence  of,  463 

Littr^,  individuality,  401 

of  an  agent,  59 

and  Robin,  cephalic  index,  187 

of  a  principal,  59 

Livelihood,  the  activities  subserving-  the  earning 

of  an  apprentice,  100 

of,  230 

of  a  master  of  apiu-enticc,  ico 

earning  of,  a  normality  of  conduct,  244 

of  arbitrator,  100 

Liver  .affections  and  insanity,  1245 

of  a  bankrupt,  116 

post-mortem  appearance  in  general  paralysis, 

of  a  beneficed  clergyman,  133 

537 

of  a  bishop,  135 

Local  authorities,  276 

of  an  archbishop,  135 

Locke,  introspective  psychology,  45 

ci\al  procedure  in  relation  to,  229 

Locomotor  ataxy  and  general  paralysis,  1258 

of  a  shareholder,  242 

and  congenital  syphilis,  1269 

plea  of,  in  criminal  cases,  292 

and  insane  jealousj',  722' 

evidence  in  relation  to,  461 

diagnosed  from  perii)heral  neuritis,  924 

of  an  executor,  476 

I/Oiseau,  sympathetic  insanity,  1243 

law  of,  relating  to  executors  and  administra- 

Lombard, J.  s.,  temperature  of  the  head. 

tors,  475 

1279 

of  a  guardian,  553 

Lombroso,  quantity  of  urine   secreted  in  insanity. 

suicide  as  evidence  of,  463 

1341 

commissioners  in,  240 

specific  gravity  of  urine  in  mental  affections, 

county  councils  and  laws  of,  275 

1341 

legal  test  of,  461 

reflexes  in  criminals,  289 

legal  definition  of,  461 

excitable  outbursts  in  criminals,  291 

and  insanity,  461,  462 

crimin;il  antln-opology,  288 

and  eccentricity,  462 

electricity  in  mental  affections,  428 

habits  as  evidence  of,  463 

the  instinctive  criminal,  288 

writings  as  e\idence  of,  463 

criminal  anthropology,  717 

inquisition  as  evidence  of,  464 

toxic  product  of  diseased  maize,  919 

of  a  trustee,  242 

retinal  affections  in  pellagra,  920 

of  a  judge,  723 

and  Mario,   general  sensibility   in  criminals, 

of  a  parent,  889 

290 

of  a  member  of  rarliament,  889,  890 

London  Asylum,  Canada,  175 

of  a  patentee,  891 

Londonderry  Asylum,  710 

of  the  owner  of  trade-mark.  891 

Longings  of  pregnancy  and  kleptomania,  727 

and  prescrii)tion  and  limitation  of  actions,  993 

and  insanity,  1035 

legal  presumptions  relating  to,  995 

Longue  Pointe  Asylum,  Canada,  175,  176 

tort  in,  1298 

Lordat,  speech  defects,  61 

of  a  testator,  1285 

Lord  Chancellor,  England  and  Wales,  inquiry  as  to 

of  a  Sovereign,  1177 

pro])ertj'  of  a  lunatic,  736 

Lunacy  laws,  Australia,  113 

England  and  Wales,   jjower  in  the  matter  of 

Austria,  114,  115 

advowson,  55 

Belgium,  132 

and  Chancery  ])atients,  195,  196 

United  States,  84 

Ireland,  powers  in  lunacy,  713,  714 

Ireland,  708 

Lord-Lieutenant,  Ireland,  powei-s  in  lunacy,   710, 

England  and  Wales,  730 

711,712,713 

Scotland,  11 15 

INDEX. 


1449 


I>unar  influence  on  snicitlc,  1223 
Lunntic,  criminal,  a,  292 

(loinicil  of  a,  396 

as  witness,  464 

Chancery,  19:5 

conunittci's  of  person  an<l  estate,  of  a,  198 

I)roj)erty  of  a,  200,  201 

leual  iiroceeilinus  ai;ainsl  a,  229 

conlractini;-  C!ii)acity  of  a,  266 

detinition  of  a  criminal,  296 

(letiiiition  of  a,  297 

committee  or   curator  of    a,   resident  uliroad, 
39t> 

a  minor,  396 

evidence  of  a,  as  to  Iiis  own  sanity,  463 

power  of  attorney  of  a,  993 

Sovereign,  a,  i  \.-j-j 

testator,  a,  1285 

trustee,  a,  1328 

person  enterinfif  into  a  contract,  a,  1376 
Lunatics,  leg-al  definition  of,  330,  461 

property  of,  199,  200 

persons  ineli-iible  to  receive,  734 
Lan^s,  post-mortem  aiipearance   in  general    i)ara- 

lysi«,  537 
disease  of,  and  mental  symptoms,  938 

Lunier,  legislation  for  the  insane  in  France,  513 

Lupo  manaro,  753 
marino,  753 

Luther  as  a  visionary,  1360 

Luys,  inequalities  in  weight  of  hemlsiiheres,  400 
heredity  as  a  factor  in  general  jiaralysis,  534 
the  pathology  of  general  paralysis,  541,  542 
case  of  disai)pearance  of  aphasia,  398 

Lycanthropy,  435 

Lycaon,  lycanthropj'  of,  753 

Lycophrou,  the  feigned  insanity  of  Ulysses,  6,  7 

Lymph  effusion  in  toxic  states,  913 
system,  cerebral,  896 
in  insanity,  898 
of  brain  cells,  898 

Lymphatic  circulation  of  brain,  170 
system  of  brain,  171 
system  of  brain  in  insanity,  897,  898 
temperament,  characteristics  of  the,  1277 

Lyndhurst,  Lord,  criminal  resiwnsibilitj"  of  the  in- 
sane, 301,  302,  306,  307,  309 

Lypemania  including  delusions  of  suspicion,  925 

Lyssji,  the  Fury  of  Madness,  9 

MAjVSTRICH  Asylum,  593 

Macurio,  olfactory  sense  in  dreams,  413 

MacCabe,  monomania,  747 

McDowail,  T.  w.,  bearded  women,  128 

erysipelas  in  asylums.  460 
Macerating  fluids  lor  microscopical  sections,  1180 
Macfarlane,  bromides  in  epilepsy,  1132 
McGrath,  piscidia   erythrina    in   nervous    excite- 
ment, 1 139 
Mackenzie,    Sir    JI(n-i'II,  the   convulsive   cough  of 

puberty,  273 
McKinnon,  phthisis  and  insanity,  938 
McLean  Asylum,  United  States,  85,  321,  322 
Maclean,  epilepsy  diu'  to  sunstroke,  1234 
Madeod.  asthenic  gangrene,  129,  130 
McNaghtcn,  case  of,  304,  305,  3C7,  308 
Macnish,  hysterical  somnambulism,  404 
Macphail,  K.,  Addison's  disease  and  insanity,  1246 

Macphaii,  •><.  K.,  blood  of  the  insane,  135 

Macrocephalic  idiocy,  644,  647 
Macromania  and  sensory  disorders,  836 
Mad  regicides,  1076 
Madness,  derivation  of  the  term,  3 

deified  by  the  ancicTits,  9,  10,  18 
Magendie,  early  api)lication  of  electricity,  427 
Magnan,  hcmi-anaestliesia  in  chronic  alcoholism,  75 

chi'ouic  alcoholism,  78 


Magnan,  unilateral  colour-))lindness  in  alcoholism, 

75 
symi>toms  of  degeneration,  331 
till'  cliaractcrs  of  alcoholic  delirium,  343 
morbid  impulse,  389 
tlie  desire  for  alcoholic  drink,  390 
classilicalion  of  dipsomania,  392 
hereditary  degeneration  and    monomania,  594, 

595 

jirogressive  systematised  insanity,  931 

boldo-gluciiie  in  mental  alfections,  1147 

sysleniatiscd  iiisMnily,  1356 
Magnus  Jluss,  alcoholism,  62 

auipsthetic  alcoliolism,  75 

hyperastlietic  alcoholism,  75 

alcoholic  paralysis,  75 
Mahaffy,  ancient  records  of  insanity,  2 

mention  of  mental  alfections  in  ancient  papyri, 
2 
Mahomet,  epilepsy  of,  455 
Maidismus,  918 
j\Iaisons  de  sante,  513 
^laize,  diseased,  neurosis  due  to,  gi8 
Majochi,  micro-organisms    in    typhua   ])ellagrosus, 

922 
Major,  H.,  improvement  in  the  condition  of  the  in- 
sane, Norway,  irii 

microscopy  of  cerebral  atrophy,  652 

tabulation  of  causes  of  insanity,  1205,  1206 
]Maladie  du  doiite,  406 
Mai  della  rosa,  rosso,  de  sole,  del   padrone,  della 

vipera,  918 
3Ialaise,  mental,  346 

Malarial  conditions,  ((uinine  in,  1061,1062 
Malayan  idiocy,  644,  647 
Males,  hysteria  in,  624,  639 

employment  of,  in  restraint  of  female  patients, 
736 
Malikholia  a  maraki,  831 
Maltine  in  the  dietary  of  the  ins:ine,  384 
Maltreatment  of  the  insane,  law  as  to,  Scotland, 

1122 
Manchester  Koyal  Lunatic  Hospital,  1080 
Manduyt  de  la  Yarenne,  early  uses  of  electricity, 

426 
Mania,  chronic,  pulse  conditions  in,  1047 

chronic,  pyromania  in,  1059 

recurrent,  pjTomania  in,  1059 

conium  in,  1145 

occurrence  of,  Iti  the  sexes,  1155 

varieties  of,  fit  for  single  care,  1164 

Hii)i)ocrates  on,  13 

acute  delirious,  52 

gravis,  52 

of  i)ersccution  in  delirium  tremcTis,  69 

blood-cori)uscles  in,  137,  139 

haemoglobin  in,  137,  139 

paroxysms  of,  in  children,  203 

choreic,  210,  21  r 

acute,  in  cocaine  poisoning,  237 

in  adolescent  insainty,  364 

digitalis  in,  387 

dancing,  438 

and  exojilithalmic  goitre,  476 

olilitlialniii-  cliaii^zcs  in,  492 

of  general  paralysis,  treatment  of,  543 

acute,  handwriting  in,  573 

transitory,  during  drunkenness,  67 

sub-acute,  ])rolonged  warm  baths  in,  117 

acute  delirious,  iirolonged  warm  baths  in,  117 

acute,  wet  ]iacl\  in,  122 

recurrent,  wet  pack  in,  122 

Turkish  baths  in,  126 

and  delirium  diagnosed,  338 

memory  in,  377 

diagnosis  of,  381 

in  ergotism,  458 


I4SO 


INDEX. 


Mania,  cliroiiie,  tlie  exaltation  of,  470 

I'bronif,  ilia^iioscd   from    clironie  alculiolism, 

471 
chrouie,  primary  exaltation  in,  470 
chronic,  secondary  exaltation  in,  470 
periodic,  and  exophtlialniic  Lioilrc,  476,  477 
and  exophthahnic   goitre,   concnrrent  attacks 

of,  476,  477,  478 
acute,  simnlation  of,  503 
hallucinatory,  simnlation  of,  503 
chronic,  simnlation  of,  504 
o-outy.  548 
post-iutlnenzal,  688 
inhibitory  centres  in,  692 
self-restriiint  in,  699,  700 
and  locomotor  ataxy,  750 
due  to  ajiue,  757 

gTavls  compared  with  tj-pical  mania,  766 
of  masturbation,  784 
menstruation  in,  801,  802 
of  susiiicion  in  myxoedema,  829 
furiosa,  838 

sensory  nerve  disturbances  in,  838 
njTuphomauia  in,  864 
in  the  ayed,  870,  871 
patholo;:y  of,  899 
of  pellajj;i'a,  920 
of  phthisical  insanity,  943 
post-apoi)lectic,  977 
of  hydro])hobia  in  animals,  600 
prognosis  of,  1007,  1008,  1009 
hysterical  puerperal,  1038 
puerperal,  1038 
lactational,  1041 
due  to  septic  causes,  1039 
vascular  changes  in,  1046 
salivation  in,  1107 
trausitoria,  post-parturient,  1036 
acute  delirious,  i)nlse  conditions  in,  1046 
acute,  pulse  ccniditions  in,  1046    . 
pyromania  in,  1059 
sphygmo^^raiihic  tracinos  in,  1188 
suicide  in,  1230,  1231 
temperature  in,  1279,  1280 
treatment  of,  1293 
moral  treatment  of,  1318,  1319 
specific  (gravity  of  urine  iu,  1341 
colour  of  urine  iu,  1342 
urea  iu,  1343 
recurrent,  glyccro-jiho-iphorie  acid  in  urine  of, 

1347 

mineral  constituents  of  urine  in,  1347 

urine  analysis  in,  1350 

transitoria,  1302 

brevis,  1302 

subita  acntissima,  1302 

ferox,  1302 

a  partu,  1305 
Maniacal  attacks  in  hysteria,  621 

delirium  of  iJlumbism,  747 

drunkenness,  67 

stage  of  folic  circulaire,  220 

exaltation  and  typical  mania  compared,  766 

excitement  in  toxic  states,  971 
Manie  blasphematoirc,  679 

raisonnante,  594 

in  folic  circulaire,  218 

sans  deli  re,  594 

in  folic  circulaire,  218 
Manitoba,  asylum  in,  176 

Mann,  Dixon,  spinal  lesions  due  to  congenital  s)i)hi- 
lis,  1269 

Manning,  F.  N.,  the  insane  in  Australia, 

no 
Manouvrier,  face  type  in  criminals,  289 
Mansfield,  Chief  Justice,  criminal  responsibility  of 

the  insane,  302 


Manson,  paralysis  due  to  malaria,  756 
Manual  instruction  of  deaf  mutes,  328 
Mapping-  of  skull,  post-mortem,  1169,  1170 
Maragliano,  reflex  sympathetic  action,  1249 
Marasuie,  841 
Marc,  monomania,  308,  594,  595 

recognition  of  insanity,  594 

kleptomania,  726 

pregnancy  and  kleptomania,  727 

l)yromania,  responsibility  in,  1056 
Marce,  signs  of  transition  in  folic  circulaire,  224 

constipation  in  melancholiacs,  265 

the  insane  diathesis,  382 

classification  of  dipsomania,  392 

kleptomania,  726 

pregnancy  and  kleptomania,  727 
Marchi,  microscopical  preparations,  1186,  1187 
Marcus  Aurelius  Antoninus,  suicide,  1218 
Marie,  Pierre,  and  Charcot,  J.  M.,  hysteria  and. 

hystero-epilepsy,  627 
Marital  conditions,  predis])osing  cause  of    general 

paralysis,  534 
Marriage,  consanguineous,  248 

of  neurotics,  1000,  looi 

contra-indicated  in  masturbation,  786 

in  erotic  insanity.  702 

in  nymphomania,  866 

statistics  as  to,  and  insanity,  1204 
Marro,  heredity  in  criminals,  289 

motor  anomalies  in  criminals,  289 

intelligence  of  criminals,  291 

pjromania  and  sensory  lesions,  1057 
Marsens  Asylum,  1240 
Martin,  Jonathan,  case  of,  309 
Martin,  Sir  K..  mental  elfects  of  malaria,  756 
Martins,  expectation  in  reaction-time,  1068 
Maryborough  Asylum,  710 
Masius,  pyromania,  1056 
Masked  epilepsy,  453,  454 
Massabiani.  the,  436 
Massachusetts,  Iioarding  out  iu,  142 
Massage  employed  by  the  ancients  in  insanity,  14, 

IS 

in  anorexia  nervosa,  624,  626 

in  hysteria,  640 

in  melancholia,  794 

in  stupor,  1209 

in  treatment  of  functional  neuroses,  853,  855 

of  neurasthenia,  849 
Master  of  an  apprentice,  lunacy  of  a,  100 
Masters  in  lunacy,  duties  of,  196,  197,  198,   199, 
240 

rules  affecting  the,  1377  et  seq. 
Mastrilli  tlic  visionary,  1360 
Masturbatic  insanity,  the  exaltation  of,  471,  472 
Masturbation  in  adolescent  insanity,  365,  366,  367 

causing  hypochondriasis,  617 

in  children,  998 

in  neurotics,  11 56 

in  mania,  765 

in  hysterical  mania,  768,  769 

and  post-ct)nnubial  insanity,  776 

iu  erotomania,  702,  703 
Masturbatlonal   insjinity   and  olfactory  h:illuclna- 

tions,  1 175 
Masturbators  and  impulsive  acts,  355 
Maternal  causes  of  idiocy,  662 
Mathey,  gout  alternating  with  insanity,  549 
"  Matters  in  pais,"  266 
"  blatters  of  record,"  266 

Mandsley,    relationship  between  diabetes  and  in- 
sanity, 82,  371 

ouiotions  and  blood  circulation,  136 

the  insane  diathesis,  382,  383 

eccentricity,  419 

prognosis  of  exalted  states,  471 
in  chronic  alcoholism,  474 


INDEX. 


1451 


Maiulslcy,  hcroilitJirv  tvaiisiiiissiou,  661 

Melancliolia  ecstatica,  207 

;i  iilitliisical  lisyclloloyy,  947 

in  adolescent  insanity,  366 

lUeriiic  (lisidaccineiils  aiul  insanity,  1351 

prodromata    of,    disliiiguislied    I'roni    those    of 

:Maiili',  .Iiistii'c,  criiiiinal    ii'sponsihiliiy  ol    llic   in- 

dipsomania,  394 

saiii',  31 1 

ele<-lricity  in,  431 

Mauuoury,  oiieratioii  in  inicn)c'i'i)lialy,  1327 

posl-eiiileplic,  454 

Maury,  ancient   sootlisayevs  in   mental  all'ections, 

oiihth.almic  changes  in,  492 

14 

simulation  ol',  503 

coi-yhautes,  275 

of  general  paralysis,  pathology  of,  542,  543 

Mauthner,  retinitis  paralytica   ol'  general  paralysis. 

Turkish  baths  in,  126 

491 

true,  in  folic  circulaire,  217 

Mayer,    C.    E.    L.,    nterinc    ilisiil.icenu  nts   and  in- 

cum stupore  in  folic  circulaire,  217 

sanity,  1351 

at  the  climacteric,  235 

Measles,  the  delirium  of,  334 

in  the  deaf,  329 

and  accidental  deal-mutism,  327 

diagnosis  of,  381 

Measurements,  cranial,  574 

agitata,  digitalis  in,  387 

Mechanical  restraint  in  delirium  ti'emeus,  344 

and  duality  of  brain  function,  400 

in  treatment  vi  insane,  1317.  1318 

forms  of,  in  epidemic  insanity,  435 

present  day,  in  Uniteil  States,  88 

of  ergotism,  458 

Meckel,  hlood  in  malarial  ixiisoninji',  757,  758 

folhjwing  enteric  fever,  506 

imindsive  incendiarism,  1056 

gouty,  548 

Medea,  insanity  of,  553 

hair  in,  563 

Medemblik  Asylum,  Holland,  592 

handwriting  in,  573 

Medical  atti-ndanls  of  patients,  Kufilaud  and  Wales, 

sine  delirio,  594 

liersons  ineli^jible  to  act  as,  735 

homicide  in,  595 

cortiticates,  Kni;land  and  Wales,  requirements 

of  hypochondriasis,  611,  612 

as  to,  733 

and  hypochondriasis,  612 

jiersons  liieliKihle  to  siyii,  733 

post-intiuenzal,  688 

forms  of,  741,  742 

self-restraint  in,  700 

Scotland,  1120,  1121 

Insomnia  in,  703 

amendment  of,  Scotland,  1121 

of  plnmblsm,  746 

experts  in  legal  cases,  479 

preceding  mania,  765 

certificates,  189 

of  masturbation,  784 

affidavits  for  petition  de  lunatico  iiiquirendo, 

menstruatlou  in,  801,  802 

198 

nervous  action  in,  837,  838 

officers  iu  asylums,  aiipointment  of,  280 

vaso- motor  phenomena  in,  838 

signatories  of  eertiticatcs,  England  and  Wales, 

in  the  age<l,  870,  871 

731.  733.  735 

of  paralysis  agitans,  885,  886 

visitoi'S    to    private     asylums,     England    and 

patliology  of,  899 

Wales,  1003 

of  pellagra,  920 

examiiuition  of  alleged  insane  criminals,  1005, 

in  phthisical  insanit.v,  943 

1006 

post-apoplectic,  977 

works  admissihle  in  evidence,  481 

blood-corpuscles  in,  137 

Medicinal  treatment  of  hysteria,  640,  641 

hEemoglobiii  in,  137 

Medicines  in  food,  384 

prognosis  of,  1009,  loio 

Medico-legal  relations  of  somnambulisin,  1173 

due  to  septic  causes,  1039,  1040 

asjjcct  of  transit(n-y  Insanity,  1306 

puerjjeral,  1039,  1040 

view  of  impulsive  acts,  355 

lactational,  1041 

aspect  of  folic  circulaire,  228 

pulse  changes  in,  1044 

of  fasting,  722 

pyromaiiia  in,  1059 

of  post-connubial  Insanity,  775,  776,  777 

religious  delusions  In,  1092 

of  nostalgia,  859 

remissions  in,  1092 

of  njTuphouiania,  865 

resistive,  1093 

of  advancing  senility,  870 

post-rheuinatlc,  1093 

of  persecution-mania,  934,  935 

spitting-  in,  1107 

of  satyriasis,  1109 

attotiita,  pulse  conditions  in,  1045 

of  self-mutilation,  1 149 

agitated,  1055 

of  masturbatic  criminals,  11 57 

senile,  ]mlse  conditions  In,  1045 

Medico-Psychological  Association,   classification   of 

occurrence  of,  in  the  sexes,  1155 

insanity,  233 

hallucinatory,    following    fright    collapse, 

training  of  attendants,  692,  693,  864 

1 158 

Medium  in  reaction-time  experiments,  1068 

varieties  of,  fit  for  single  care,  1164,  1165 

Medulla,  weight  of,  167,  168 

opium  ill,  794,  1141 

microscopical  changes  of,  in  general  paralysis. 

sphygmographle  tracings  In,  1188 

539 

attonlta,  1209 

Medullary  lesions,  salivation  in,  1106 

suicide  in,  1231 

reduction  in  idiix-y,  653,  655 

temperature  in,  1279,  1280 

Mcerenbcrfr  Asylum,  Holland,  592 

due  to  brain  injury,  1309 

Megalocephalous  brains,  weight  of,  164 

treatment  of,  by  rest,  1314,  1315 

Megalomania  and  general  paralysis  ditferentiatcd, 

specific  gravity  of  urine  in,  1341 

533 

colour  of  urine  in,  1342 

in  agitated  phases  of  folic  circulaire,  220 

urea  in,  1343 

Megalopsy,  hysterical,  632 

uric  acid  in,  1345 

Megrim  alternating  with  insanity,  81 

glyceid-]>hosphoric  acid  in  urine  of,  1347 

Melainpus,  treatment  of  insanity,  12 

urine  analysis  in,  t350 

Melancholia,  Hippocrates  on,  13,  14 

delusional,  in  demonolatria,  1368 

suicidal,  329 

mineral  salts  in  urine  of,  1347 

1452 


INDEX. 


Meliint'holic   symptoms  in  insanity  of  preg'nancy, 
1035,  1036 

tyiie  of  delirium  tremens,  70 

ph.ases  of  folie  eireulaire,  216 

sjTiiptoms  in  primary  sta^c  of  i>enernl  para- 
lysis, 525 

staiic  of  folie  eireulaire,  218 

affections  followinL;-  malaria,  757 
Melancholy  ilruukenness,  67 

drunkenness  diagnosed  fnmi  melancholia,  793 

type  of  insanity  in  toxic  states,  971 
Melancolie  impulsive  ou  anxieuse,  392 
Mellor,  Justice,  plea  of  insanity  in  criminal  cases, 

293 
Member  of  Parliament,  insanity  of  a,  889,  890 
Membrane,  formation  of,  in  dural  hematoma,  878, 

880,  883 
Membranes,  cerebral,  inflammatory  action   in,  in 

insanity,  900 
Memory,  29,  32,  35,  252,  259,  493-  103° 

loss  of,  in  dements,  349,  350 

loss  of,  as  evidence  for  certification,  194 

disorders  of,  264 

loss  of,  in  cerebraux,  188 

in  the  a<>itated  phases  of  folie  eireulaire,  219 

loss  of,  in  senile  dementia,  350,  377 

in  mania,  377,  763 

in  hystero-eitileptic  conditions,  377 

in  epileptic  conditions,  377 

in  frenzy,  377 

in  stupor,  377 

in  ambulatory  automatism,  402,  403,  404 

loss  of,  in  general  paralysis,  522,  529 

in  hypochondriasis,  612 

in  myxoedema,  828 

in  post-apoplectic  conditions,  977 

in  dreams,  412,  413 

in  aphasics,  979,  980 

reaction-time  of,  1071 

in  stuporous  states,  1211 

post-hypnotic  loss  of,  1216 

loss  of,  after  brain  injury,  1308 

visual,  1360 
Men,  hysteria  in,  624 

insane  jealousy  in,  722 
Menckel,  hereditary  transmission,  661 
Mendel,  E.,  emotional  exaltation  in  mania,  764 

increase  of  general  ])aralysis,  1156 

diagnosis  of  insanity,  372 

mania  hallucinatoria,  767 

mineral  salts  in  urine   in   mental  conditions, 

1347 

vascular    changes    in    morbid    mental    states, 
1042 
Meninges,  disease  of  the.  in  idiocy,  656,  657 

in  old  age,  872 
Meningitis,  acute,  complicating  general  paralysis, 
520 

acute  and  chronic,  in  idiocy,  656 

chronic,  and  cerebral  atrophy,  652 

acute,  the  delirium  of,  335 

irritation  mydriasis  in,  1055 

spasmodic  myosis  in,  1055 

and  accidental  deaf-mutism,  327 
Menopause,  insanity  at  the,  234 

epilepsy  at  the,  235 

neurotic  symptoms  at  the,  235 
Menorrhagia  inducing  mental  afEection,  1350 
Menston  Asylum,  104 
Menstruation,  disorders  of,  and  insanity,  1350,  1351 

in  folie  eireulaire,  218 

and  the  psychoses  of  adolescence,  365 

and  hysteria,  620,  637 

in  mania,  762 

as  affecting-  prognosis  of  mania,  762 
Mental  conditions,  posture  in,  988 

excitement,  1030 


Mental  action,  nonnal  and  abnonnal,  1034 

causes  of  puerperal  insanity,  1035 

disorders  com])licated  by  satyriasis.  1108, 
1 109 

phenomena  following  fright  collapse,  1158 

shock  and  physical  injury,  1157 

development  and  attention,  109 

disease  and  attention,  109,  no 

confusion,  325 

malaise,  346 

processes,  cortical  localisation  of,  1 1;6 

failure  after  cranial  injuries,  188 

anomalies  in  acute  chorea,  207 

capacity  of  cretins,  286 

imperfection  after  adolescent  insanity,  369 

hereditaiy  degeneracy,  stages  of,  370 

derangement,  antecedent,  in  diagnosLs  of  in- 
sanity, 373 

function,  morbid  change  of,  in  diagnosis  of  in- 
sanity, 373 

phenomena  of  dipsomauiaeal  impulse,  390,  391 

action,  aptitude  for,  467 

pain,  facial  expression  of,  483 

stupor,  503 

symptoms  of  general  paralysis,  520 

phenomena  in  established   general   paralysis, 

523 
disturbances  in  gouty  states,  548 
aberration,  51 
abstraction,  51 
state  of  drunkards,  64 
exhaustion,  attention  in,  no 
automatism,  115 
capacity,  177 

state,  essential  inquiries  in  examining,  181 
depression  in  folie  eireulaire,  216 
degeneration,  331 

aberration,  anomalous  forms  of,  382 
instability  in  acquired  diathesis,  384 
processes,    divergent,  acting    simultaneously, 

397.  400 
symptoms  of  epilepsy,  450,  452,  454,  455 
symptoms  of  ergotism,  458 
automatic  acts,  468,  469 
dis(n-der  and  enteric  fever,  506,  507 
characteristics  of  hysteria,  620,  621 
disorders  in  hysteria,  638 
education  of  idiots,  670 
contagion,  676 
causes  of  insomnia,  703 
symptoms  of  mania,  762 
dulness  a  sign  of  reet)very  in  mania,  766 
enfeeblement  after  mania,  766 
conditions  during  fasting,  774 
degeneration  due  to  masturbation,  784 
exhaustion  and  melancholia,  792 
conditions  affecting  prognosis  in  melancholia, 

796 
development  in  microcephalus,  806,  807 
causes  of  morphia  habit,  817 
symptoms  of  morphia  habit,  818 
symptoms  of  morjihia  deprivation,  819 
of  pellagra.  920 
of  peripheral  neuritis,  923,  924 
action,  movements  as  signs  of,  820 
movement,  824 
antithetical  states,  825 
effects  of  myxoedema,  828 
disorders  and  neurasthenic  conditions,  844 
phenomena  of  senile  involution,  869 
condition  in  aphasics,  981,  982,  983 
functions  during  sleep.  1171 
disturbance  during  sleep,  1171 
stupor  and  melancholia  cum  stupore,  1209 
sequela?  of  sunstroke,  1233,  1234 
defect  due  to  congenital  sj-pliilis,  1255,  1266, 

1267 


INDEX. 


1453 


Mental  torpor,  1298 

(Icviiitious  after  brain  iiyury,  1308 

cjvuses  of  tremor,  1320 

suspense,  effect  of,  on  bladder,  1339 

Imagery,  1360 

improvement  after  upeviition   in  niicrocrplialy, 
1327 

irritability  in  paralysis  agitans,  884,  885 

poisons,  966 

poisons,  geiieral  symptoms  of,  967 

dulling-  in  toxie  states,  970 

defects  following'  apoplexy,  976 

exciting-  causes  of  general  paralysis,  535 

stimuli  to  impulse,  596 

reproduction,  35 

cbanges  due  to  chronic  alcoliolisni,  77 
Mentalisation,  elfects  of,  on  tlie  blood,  136 

interventit)!!    of,    in    retiex    iilieuoniena,    1074. 

1075 
Mentality  during  soninambiiHsni,  T172 
"Merchants'  accounts,"    i)cri<>d  of  limitation,  and 

lunacy,  995 
Mercier,  C.    W.,   similarity   between  dniiikeiincss 
and  insanity,  448 
sleep,  448 
senile  decay,  448 

natural  classiflcation  of  insanity,  448,  449 
conduct,  242 
consciousness,  249 

disorders  of  ct)nsciousness,  262 

delusion,  345 
heredity,  582 
insatuty  and  hysteria,  621 
inhibition,  691 
melancholia,  787 

Mercurial    poisoning     diagnosed     from     delirium 

tremens,  72 
Mercury,  tremor  in  ])oisoning  by,  1321 
Mericourt,  Le  Roy  de,  mate  drinkers,  973 
Mering-,  V.,  croton  chloral,  11 35 

amyleue  hydrate,  1139 
Merivale,  the  insanity  of  t'aligula,  18 
Merlcel,  age  for  operation  in  microcephaly,  1327 
Mersou,  specific  gravity  of  urine  in   mental  condi- 
tions, 1341 

excretion  of  urea  in  general  paralysis,  1344 
Mesmcr,  hypnotism,  603 

Mesnct,    double    consciousness   of    somnambulism, 
402 

mental  hydrophobia,  600 

anesthetic  effects  of  hypnotism,  604 
"  Metallic  tremors,"  1321 
Metaphysical  pliilosophy,  27 
Metaiihy-ieians.  the.  409 
Metai)hysics,  German  sc1kk)1  of,  48 
Meteorological  changes  and  suicides,  1223 
Methylal,  action  of,  1137,  1138 
Methyl-coiuine,  1144 
Methyl-phenyl-ketone,  1137 
Methylate<l  spirit  for  hardening  sections,  1181 
Meyer,  Ludwig,  chorea  and  insanity,  206 

pathology  of  hsematoma  amis.  560 

responsibility  in  pyromania,  1056 
Meyer,  Moritz,  medical  uses  of  electricity,  427 
MejTiert,   congestion  theory  of  transitory  fi-enzy, 

1303 
primare  Verriicktheit,  1356 
hallucinatory  mania,  767 
the  pathology  of  chorea,  210 
classification  of  insanity,  229,  230 
Miasmatic  diseases  and  insanity.  756 
Mickle,  v.,  insanity  in  twins,  1334,  133=; 
Mickle,    W.  J.,  sunstroke   and   general   paralysis, 
1234,  1235 
temperature  in  general  paralysis,  1281 
the  association  of  mental  and  cardiac  disease, 
178 


Mickle,-W.  J.,  puiiillarv  signs  in  general  i)aialysis, 
489 

antifebrin,  95 

digitalis  in  insanity,  387 

general  paralysis,  519 

s|)inal    dnrliainaloinala  in   general   paralysis, 
883 

quinine,  io6r 

general    i)aralysis   following   rlieumatic   affec- 
tions, 988 
diagnosis  »(  post-febrile  ])aralysis,  988 
treatntent  of  acuti^  mania,  1047 

traumatic   factor   in  mental   dis- 
ease, 130') 

Microcephalic  idiocy,  644,  647 

Microcephalism,  580 

Microcephalous  idiots,  convolutions  in,  268 

brains,  weight  of,  164 
Microcephaly,  operative;  ])rocedure  in,  1326 
Microkinesis,  465,  466,  467,  468,  821,  825,  826 

reversion  of,  468 

reversion  of,  in  adults,  469 
Jlicromania  and  sensory  disorders,  836 
■Micromyclia  associated  with  microcephaly,  806 
Micropsy,  hysterical,  632 
Jlicropsychosis,  468,  469 

reversion  of,  in  adults,  469 

compared  with  microkinesis,  469 
Microscopical  brain  changes   in  general   paralysis, 

537.  538 

spinal  cord  changes  in  g-eneral  paralysis,  539 

preparations  of  brain  and  cord,  1180 
Microscopy  of  diiral  hicmatoma,  878 

of  normal  brain,  1375 
Middle  Ages,  psychology  during  the,  44 

epidemic  insanity  in  the,  436 

the  insane  in  the,  716 
Middlefort  Asylum,  1113 

Middle  levels  of  nervous  system  (.Jackson),  441 
Mierzejewski,  hypertrophic  idiocy,  644 

Russia,  provision  for  the  insane 
in, 1098 

Miganet,   suicide    among  the  ancients,  1218,  1219, 

1220 
Migraine  in  jn-odromie;  stage  of  general  paralysis, 

523 

and  hysteria,  625 

the  sympathetic  in,  125T 
Migratory  insanity,  931 

Mildner,  cardiac  affections  and  insanity,  1246 
Miles,  A.,  colloid  bodies  in  cerebrum   alter  trau- 
matic inflammation,  907 
Miliary   sclerosis   in   cerebral    dcg-eueration,  906, 

907 
"Milk  fever,''  delirium  of,  334 
Mill,  J.  Stuart,  doctrine  of  association,  45 
Millar,  diets  for  artificial  feeding,  498 
Milman,    Dean,    self-mutilation    among   Orientals, 

1 147 
Mimetic  chorea,  209,  213 

stage  of  convulsive  hysteria,  630 
Mind,  science  of,  27 

means  for  studying-  the  nature  of,  29,  30 

faculties  of  the,  31 

absence  of,  420 

evolution  of  the,  in  infant,  465,  466 

relation  of  nervous  activities,  446,  447 

development  of  the,  33 

development  in  man  and  animals,  37 

in  the  highest  nervous  centres  (Jackson),  442 

and  nervous  activities,  relation  between,  446 

and  body  reacting,  938 

blindness,  982 
Mindcrwertigkeit,  382 
Mineral  acids  in  brain,  151 

constituents  in  urine.  1347 
Minor,  insanity  of  a,  c(nitiuuing  through  life,  396 


1454 


INDEX, 


Miraglia.  Biagio.  pro-rcss   of  psychdlo-v    in  Italv, 

717 
Mirror-writiiigr,  399,  573 
Misanthropical  nii'laucliolia,  797 
Misor,  till'  ect'oiitrio.  423 
Jlisericordo  Hosi)ilaI,  St.  I'oti'i-sburg,  1099 
31ispolbauin,  F.,  post-intiucnzal  psychoses,  690 
Mistaken  states  of  consciousness,  261 
Mitchell,  Sir  A.,  consanguineous  marriages,  248 

ultimate  recoveries  in  insanity,  323 

illegitimacy  and  idiocy,  662 

recovery  rates  in  Scotland,  1197,  1198 

relapses  in  Scotch  asylums,  1200,  1201 

mortality  rate  in  Scotch  asylums,  1202 
Mitchell,  Weir,  treatment  of  functional  neuroses, 
8  no 

bromide  of  lithium  in  epilepsy,  1130 
Mitral  disease  and  melancholia,  1246 

regurgitatiou  and  mental  symptoms,  178 

stenosis  and  mental  symi)toms,  178 

and  aortic  atfectiou  and  mental  symptoms,  179 
Mali,  diagnosis  of  general  paralysis,  532 

andUhthoir,  ophthalmic  changes  in  epileptics, 
492 
in  alcoholic  insanity,  492 
optic  atrophy  in  general  jiaralysis,  490 
ocular  symptoms  in  the  insjine,  491 
Mohammedism,  61 

Molcschott,  standard  diet  in  health,  387 
Moll,  effect  of  suggestion  on  the  bladder,  1339 

self-mutilation,  11 50 
Mombello  Asylum,  717 
Monaghan  Asylum,  710 
Monakow,  action  of  lead  on  nerves,  746,  747 
Moncorvo,  spinal  lesions  due  to  congenital  syphilis, 

1269 
Mongolian  idiocy,  644,  645,  662,  663 
Mongol-like  idiocy,  644 
Monks,  treatment  of  the  insane  by,  20 

erotic  insanity  in,  702 

acedia  in,  51 
Moiiobromide  of  ciimphor,  1131 
Monoehloral  antipyriiie,  1137 
Monocular  polyopia,  hysterical,  632,  642,  811 
Monoideism,  no 
Monomania,  homicidal,  593 

instinctive,  594 

intellectual,  594 

affective,  594 

of  being-  iwisoned,  1299 

simulated,  1^04 

of  grandeur  and  general  paralysis  diagnosed, 
533 

use  of  the  term,  471,  593,  811,  812 

of  suspicion,  925,  926,  927,  928 

of  persecution,  925 

of  suspicion  in  phthisical  insanity,  943 

pyromania  in,  1059 

occurrence  of,  in  the  sexes,  115  5 
Monomanie  d'ivresse,  811 

homicide,  811 

suicide,  812 

hypochondriaque,  812 

iucendiaire,  1056 

raisonnante  (Esquirol),  406,  811 

avec  conscience  (Baillarger),  406 
Monophobia,  844 

Monophosphatides,  non-nitrogenised,  In  brain,  149 
Monoplegia,  hysterical,  633,  634,  813 

ocular,  488 
Monro,  evidence  in  case  of  3IcXaghten,  306,  307, 

308 
Montaigne,  suicide,  1220 
Montanists,  the,  436 
Montesquieu,  suicide,  1220 

Mouths,  prevalence   of  suicide  during  particular, 
1222 


Montrose  Ituyal  Asylum,  104,  1094,  1097 
Montyel,  de,  conceal mentjof  insanity  in  persecution- 
mania,  932 
Moon  and  causation  of  insanity,  1206 

changes  of  the,  and  suicide,  1223 
JNIoore,  cerebral  anainia  during  sleep,  1170 
Morache,  forms  of  sunstroke,  1232 
Moral  causes  of  insanity,  893,  1205 

effects  of  syphilis,  1253 

insanity  and  testamentary  capacity,  1289 

degeneration  due  to  masturl)ation,  784 

treatment  of  masturbation,  785 

obliquity  at  menstrual  periods,  803 

lai)ses  antecedent  to  insanity,  814,  815 

causes  of  persecution-mania,  933,  934 

etfort,  43 

insensibilitj'  of  criminals,  290 

causes  of  folic  circulaire,  226 

conduct  in  aphasics,  983 

causes  of  ])ueriK'ral  insanity,  1037 

insanity,  assumed,  503,  504 

sense  failure  in  initial  stage  of  general  para- 
lysis, 521,  529 

exciting-  causes  of  general  iiaralysis,  535 

sense  obliteration  in  drunkards,  64 

conduct,  affection  of.  in  chronic  alcoholism,  •]■] 

perversity  in  agitated  phases  of  folic  circulaire, 
219 

perversity  at  puberty,  364 

sense  in  insane  diathesis,  383 

control,  loss  of,  in  dipsomaniaeal  impulse,  391 

insanitj^  among-  the  ancient  Jews,  715 

insanity  and  epilepsy,  453 

changes  after  rheumatic  fever,  1093 

training  and  satyriasis.  1109 

perversion  in  hysteria,  621 

treatment  of  hysteria,  640 

education  of  idiots,  670,  674 

treatment  of  functional  neuroses,  857 

insanity,  incendiarism  in,  1057,  1060 

treatment  of  the  insane,  1315,  1316,  1317 
3Ioralische  Irresein,  697 
Morality  and  suicide,  1225 
Morally  insane  drunkards,  the,  64 
Morbid  conditions  inducing  insanity,  1244 

criminal,  the,  288 

imitation,  678 

emotional  impulse,  681 

intellectual  impulse,  681 

introsjiection.  707 

irritability,  841 

mental  states,  effect  of  religion  on,  1089,  1090 
Morbus  bellerophonteus,  7 

herculeus,  10 

saccr,  Hippocrates  on,  12 

ruralis,  457 

climactericus  (Lobstein),  872 
More,  Sir  Thomas,  description  of  a  lunatic,  25 

suicide,  1220 
Moreau,  hereditary  transmission,  661 

sleep,  413 

hyi)eractivitj-  in  early  general  paralysis,  522 
Morel,  prolonged  warm  bath  treatment,  118 

definition  of  degeneration.  331 

classification  of  insanity,  231 

classification  of  dipsomania,  392,  393 

the  insane  in  Belgium,  131 
colony  of  Gheel,  547 

insanity  of  doubt,  407,  410 

heretlitary  transmission,  660,  661 

menstruation  and  insanity,  801 

lycanthn)py,  754 

hypochondriasis   in    persecution-mania,   926, 

928 
erotomania,  702 

effect  of  phthisis  on  insanity,  941 
douche  treatment,  120 


INDEX. 


1455 


Mori'l,  res])oiisiliiliiy  in  ])yr(iiii)iiiiii,  1056 

piyalisiii  in  tin-  iiisiinc,  1107 
"  Jlori'l's  (';ir,"  419 

MorL;;iuiii,  .1.  H.,  iiroiircss  of  i)sychi)l<iyy,  716 
Moniiii!:si(l<'  Asylmii,  552.  1094,  1096 
Mori)lii;i  ill  iri'iitmoiit  cil'  insanity,  1292,  1293 

pnisoniiiL:'  (lia'aiiiwecl  limn  ilclii'imu  tvi'Uii'iis,  7 

lialiit  and  cocaiiu'  lialiit  diatiiiosi'd,  237 

liahit.  Weir  Mitclu-11  ti-fatini-nt  (if,  852,  853 

haliit,  aniyliMU'  hydrate  in,  1139 

action  of,  1 139,  1140,  1141 
Morselli,  frequency  of  suicide,  1220 

intliience  of  climate  on  suicide,  1221 

telluric  intluenees  on  suicide,  1222 

ctliiioloi;icaI  influence  on  suicide,  1223,  1224 

sex  and  suicide,  1224 

urban  and  rural  life  and  suicide,  1226 

a>;e  and  suicide,  1227 

cclibticy  and  suicide,  1227 

social  condition  and  suicide,  1228 

inil)risoiinu'iiI  and  suicide,  1228 

modes  of  coinniittini;  suicide,  1230 
Mortality  in  United  States  asylums,  88,  89 

rate  and  statistics,  1194 

rate,  method  of  calculating.  1197 

in  asjhuns,  1198  ct  seq. 
Mortya<.;e,  redeiniition  or  foreclosure  of,  or  recovery 
of  money  secured  by,  period  of  limitation, 
and  lunacy,  995 
Morzines,  epidemic  demoiiomania  at,  352 
Mosso,  bladder  contraction  following  sensory  stimu- 
lation, 1340 

cortical    hvperwmia   during'  psychical   action, 
894 

circulatoiy  chau-jes  during;  emotion,  964 

jilctlaysmosraph,  964 

balance,  965 

influence  of  mental  processes  on  pulse,  1042 
Most,  early  apiilicatious  of  electricity,  427 
Motet,  A.,  tlie  insane  diathesis,  382 

c^rebraux,  187 

resiionsiliility  in  pyroiiiania,  1056 
Motility  durini;  somnambulism,  1172 
Motions,  consensual,  265 
Motive.  40,  42 

in  incendiarism,  1058.  1060 

in  feiuued  insanity,  504,  505 

in  self- mutilation,  1147 
Motor  area  lesions  in  Jacksonian  epilepsy,  445 

and  mental  symptoms  in  general  paralysis  com- 
pared, 520 

anomalies   in  <;cncral  jiaralysis,  pathology  of, 

542 
symptoms  in  i)eri)ilieral  neuritis,  923 
excess  in  toxic  states,  970,  971 
disturbances  in  alcoholism,  75 

in  criminals,  289 

of    general    paralj'sis,   520,.  523, 

527 
of  chorea,  208 
in  ergotism,  458 
in  hysteria,  622,  633 
in  morphia  habit,  817 

aphasia,  979 

aphasia,  mental  conditions  in,  983 

intuitions  in  word-deafness,  982 

affections  after  tJ^)hoid,  986 

affections  after  ty])lius,  987 

expression  anrl  mental  faculty,  1027 

excitement,  coniiini  in,  1145 

excitability  in  hysterical  mania,  769 

innervation  and  .attention,  107 

inhibition  and  attention,  107 

obsessions,  679 

restlessness,  mechanical  restraint  in,  1318 
Mount  Hope  Retreat,  I'.altimore,  85 
Mountainous  districts  ami  suicide,  1221,  1222 


Mounting  of  sections  in  celloidiii,  1184 

Mousse],  rcsiionsiiiilily  in  iiyromania,  1056,  1057 

.Moulli,  mellioils  of  opening   for  artificial  feeding, 

497 
methods  of  feeding  by  the.  498 
Movements,  early,  in  infants,  465,  466,  467 
exnggeiMled.  in  children,  206 
unconlrollable,  206 
colli rol  of,  in  infanis,  465,  466 
Moxey,  funnel-feeding  by  the  nose,  501 
JMoxon,  cerebral  \;isciilar  siipjily,  896 
Miillcr,  Jlax,  tlioii-hl  and  ianiiiiage,  979 
Mnller"s  fluid  lor  hardening;  specimens,  Ii8r 
Mullingar  Asylum,  710 
Multiple  cerebral  sclerosis  in  idiocy,  653 
Miink,  centres  of  general  sensibility,  186 
mind  blindness,  809 
mind  deafness,  810 
Miinsterlingen  Asylum,  1239 
JIurchisoii,  acute  mania  preceding  typhoid,  985 

uric  acid  excretion,  1345 
Murphy,  mental  faculties,  493 
Murrao  souda,  831 
Jfurray,  atropism,  133 
JIurray's  Royal  Asylum,  T095,  1097 
Muscular  aberrations  in  the  insanity  of  childhood, 
204 
atrophy  in  disseminated  sclerosis,  1163 
power,  loss  of,  shifting,  in  disseminated  scle- 
rosis, 1 162 
insanity,  208 

atrophy  complicating  general  paralysis,  520 
sense,  disorders  of,  in  general  paralysis,  529 
twitchings  in  general  jiaralysis,  527 
atrophy  in  hysteria,  634,  638 
balance  indicative  of  mental  states,  988 
affectiotis  of  plumbism,  747 
sense,  a  knowledge  giving  sensation,  33 
loss  of,  91 

hysterical  disorders  of,  632 
psycho-physical   method    of    registering, 
1015 
weakness  in  neurasthenia,  843 
spasms  in  neurasthenics.  845 
latent  period  in  reaction-time,  1068 
Music,  treatment  of  the  insane  bj-,  2,  3,  15 
in  the  training  of  idiots,  671,  672,  673 
and  colour  sensations,  11 25 
Musical  tones  and  colour  sensations,  1125 
^luskelwahnsinn,  208 
Mustard  baths  in  the  treatment  of  the  insane,  118 

pack,  123 
Mutilation  in  hysterical  mania,  769 

self-,  1 147 
Mutism  in  general  paralysis,  526 
hysterical,  636 
in  katatonia,  724 
Mydriasis,  artificial,  1054 
paralytic,  1054 
spasmodic,  1054 

bilateral,  in  general  paralysis,  489 
Myelin,  148 

Myelitis,  transverse,  and  idiocy,  656,  657 
Myers,  A.  T.,  history  of  hypnotism,  603 
^Myoclonus  multiplex,  1323 
Myosis,  .artiticial,  1055 
paralytic,  1055 
spasmodic,  1055 
various  forms  of,  489 
5Iyotatic  excitability  of  lathyrism,  730 
Jlysticism  in  tyjiical  regicides,  1077 
^lytholoLiical  evidences  of  insanity,  753 
Myxoilema,  facial  expression  in,  950 
and  cretinism  compared,  285 
and  sporadic  cretinism.  657,  658 
and  thyroid  degeneration,  1294 
-like  appearances  in  cretinism,  284,  285 


1456 


INDEX. 


X^vi  diagnosed  from  aural  hajmatoiiiata,  559 

Nervous  lesions  inducing  salivation,  1105 

Nancy  school  of  hypnotism,  604 

lesions  inducing  satyriasis,  1108 

Naples,  asylum  at,  717 

lesions,  the  sympathetic  in,  1251 

Xapoleoii  I.,  insanity  of  doubt,  410 

temperament,  characteristics  of  the,  1277 

epilepsy  of,  455 

impulse,  heat  during  passage  of  a,  1278 

Nai'cosis  iu  toxic  depression,  970 

system,  effect   of   alcoholic   sedatives   on,  74, 

Narcotics  and  hypnotics,  1129 

1 132 

in  treatment  of  insanity,  1292 

system,  action  of  conium  on,  1144,  1145 

Narcotism,  Weir  Mitchell  treatment  of,  852,  853 

system,  action  of  phjsostigTnine  on,  1146 

N.asal  bones,  affections  of,  due  to  congenital  syphi- 

action of  croton  chloral,  1135 

lis,  1260 

states  due  to  fright,  1159 

feeding,  indications  for,  501 

"  Nervousness,"  840,  841 

tube,  method  of  passing,  for  artificial  feeding. 

and  insanity,  582 

501,  502 

Netherlands,  the  insane  in  the,  590 

Nasse,  ]>rogress  of  psychology  in  Germany,  545 

Nettleship,  interstitial   choroiditis  due  to  heredi- 

mental affections  due  to  fevers,  985 

tary  syphilis,  1262 

Natal  causes  of  idiocy  and  imbecility,  659,  663 

cranial  nerve  lesions  due  to  congenital  syphilis. 

Nationality  and  modes  of  committing  suicide,  1229, 

1265 

1230 

Neubauer,  excretion  of  uric  acid,  1344 

Natural  classification  of  insanities,  446 

oxalates  in  urine,  1346 

selection  and  instinct,  704 

Neumann,  effect  of  phthisis  on  insanity,  941 

Nebuchadnezzar,  insanity  of,  4,  5 

Neural  states  and  mental  action,  1026 

loss  of  personal  identity,  5 

Neuralgia,  electricity  iu,  431 

"Necessaries,"  law  relating  to,  268 

autifebrin  in,  95 

Necromimesis  iu  primary  stage  of  general  para- 

antipyrin in,  96 

lysis,  525 

due  to  agiie,  757 

Necrophobia,  844 

trifacial,  salivation  in,  1106 

Neediuini,  F.,  diet  for  the  insane,  384 

Neuralgia  iu  prodromic  stage  of  general  paralysis, 

dress  for  the  insane,  414 

523 

rectal  feeding,  1073 

Neuramoebimeter,  the  Bowditch,  101=5,  1016 

Negation  in  persecution-mania,  928 

Neurasthenia,  625 

Negative  hallucinations,  1216 

spinalis,  625 

lesions  of  nervous  system,  443 

diagnosed  from  pellagi'a,  921 

Negativism,  muscular,  in  katatonia,  724 ' 

salivation  in,  1105 

Negrier,  ovarian  causes  of  insanity,  1350,  135 1 

l)ulse  changes  in,  1042 

Negro-like  idiocy.  644,  647 

traumatic,  1160 

Neisser,  C,  katatonia,  724 

the  sympathetic  in,  1251 

verbigeration,  1354 

Neur.asthenic    symptoms  following   brain   injury, 

Nerve  action  and  consciousness,  254 

1307 

centres,  evolution  in,  467 

Neuritis,  peripheral,  923 

tension,  reduction  of,  449 

mental  symptoms  of,  923 

tension,  excess  of,  449 

syphilitic,  and  suspicion  mania,  1254 

action,  failure  of,  449 

Neuroglia,  microscopical  changes  in  general  para- 

centres, inhibition  of,  691 

lysis,  538 

centres,  loss  of  inhibition  of.  692 

inflammatory  action  in,  902 

degeneration  due  to  plumbism,  747,  748 

Neuro-muscular  excitability  a  prodi'ome  of  delirium 

energy,  loss  in  tension  of,  791 

tremens,  340 

centres,  double  action  in,  821,  822 

hyper-excitability  in  hj^pnotism,  608 

centres,  physical  control  of.  821.  822 

Ncuroplastin,  157 

tone  and  size  of  pupils,  1054 

Neuroses  and  drunkenness,  65 

-cells,  microscopical  changes  in  general  jiara- 

hereditary,  causing  idiocy,  660 

iysi«,  538,  539 

of  influenza,  687 

centres,  effect  of  weei)ing  on,  1274 

in  offspring  of  sufferers  from  plumbism,  746 

heat  during  nerve  action,  1278 

of  malarial  poisoning,  756 

-tissues,  action  of  lead  on,  746,  747 

following  rheumatic  alfections,  988 

Nerves,  peripheral,  temperature  in,  1278 

traumatic,  1160 

heat  of,  during  action  of,  1278 

due  to  solar  heat,  1233 

heat  production  in,  during  death  of,  1278,  1279 

of  the  extremities,  the  sympathetic  in,  1252 

Nervosismus,  841 

and   insanity   due  to  constitutional   syphilis. 

Bouchut's  varieties  of,  847 

1256,  1257 

Nervous  anorexia,  94 

in  children  due  to  congeuital  syphilis,  1264 

diseases  in  the  diagnosis  of  insanity,  373 

due  to  tobacco,  1297 

affections,  digitalis  iu,  388 

traumatic,  1307,  1308 

activities  and  mind,  relation  between,  446 

tremor  in  various,  1321,  1322 

contagion,  677 

iu  microcephaly,  1326 

over-action  and  inhibitory  loss,  692 

due  to  uterine  abnormalities,  1351 

symptoms  of  mania,  762 

Neurosis  electrica,  428 

affection  in  emotional  states,  837 

Neurotic  disposition  and  suicide,  1230 

fatigue  in  neurasthenia,  842,  843 

temperatures  in  the  insane,  1280 

excitability  iu  neurasthenia,  842,  843 

symptoms  at  the  menopause,  235 

stimulants  in  neurasthenia,  849 

hereditary  degeneracy,  stages  of,  370 

exhaustion,  851 

types,  357 

diathesis  and  heredity,  893 

degeneration,  362,  363 

disturbances  in  pellagra,  919,  920,  921 

Neurotics,  prophylaxis  in  susceptible,  371 

hand,  the,  989 

Nevralgie  g^nerale,  841 

impulse,  rate  of,  in  reaction-time,  1068 

Nevropathie,  841 

eialorrhoea,  1104 

proteiforme,  841 

INDEX. 


1457 


Nevrospasinie,  841 

Nowcoiiibe,  duration  of  ^eiuTiil  imrnlysis,  519 
Newiu^toii,    Hayes,   iliftoreutial  syiiiijtoins  ol"  an- 
»'rj,rie  and  delusional  stuiior,  1210 

certificates,  189 

county  councils  and  lunacy  lav\rs, 

275 

coiifusional  stiii)or,  767 
Newiujiton,  S.,  mustard  ])ack,  123 
"Newness,"  tho  doctrine  of,  421 
New  Norfolk  Asylum,  111 

Newth,  A.  H..  case-taking,  i8o 

New  York  < 'oufiTi lice  of  Alienists,  classilication  of 

insanity.  233 
Niehol,  Sir  .1.,  "partial  insanity,"  964 
Nicolson,  excitable  outbursts  in  criminals,  291 
Nicotine,  physiological  action  of,  1297 
Night  terrors  of  children,  202,  203,  335,  337,  338 
Nig-htiugale,  Miss,  training  of  nurses,  859 
Nitrouenous  non-pliosphorised  i)rinciples  in  brain, 

146,  147,  149 
Nitro-glycerine  in  mental  stujior,  1213 
Nitrous  oxide,  insanity  following  the  use  of,  92 
Nisyan,  831 
Nocturnal  exacerbations  of  prodromataof  delii-ium 

tremens,  341 
Nominalism,  29 

Non  compos  mentis,  296,  297,  330 
Non-convulsive  li.vsteria,  628 
Non-restraint,  25,  26 

among' the  ancients,  14,  15 

in  Holland,  593 

in  Italy,  719 

in  Russia,  iioo 

in  Denmark,  1114 
Norman,  Conoll.v,  feigned  insanity,  502 

insanity,  concealed,  699 

mania,  761 

mania  hallucinatoria,  767 

mania,  hysterical,  767 

sexual  perversion,  1156 

hypnone,  1137 

treatment  of  mania,  1293,  1318,  1319 
North,  S.  W.,  workhouses,  1371 
Norway,  the  insane  in,  11 10 

sexes  in  insanity  in,  1153 
Nose,  methods  of  feeding  by  the,  498 
Notes,  reference  to,  admissible  at  trials,  480 

synopsis  of,  for  examination  of  patients,  180, 
181,  182,  183 
Nothnagel,  pathology  of  epilepsy,  138 

functions  of  cerebellum,  158 

chloral  in  delirious  states,  1135 

opium  in  mental  affections,  1141 

use  of  morphia,  1142 

reflex  sj-mpathetic  acti(m,  1249 
Notices  as  to  correspondence  in  asylums,  735 
Notional  insanity,  697 
Nottingham  Lunatic  Hospital,  1087 
Novara,  asylum  at,  717 
Nova  Scotia  Asylum,  176 
Novgorod  Asylum,  1098 
Noyes,  cases  of  delusional  insanity,  888 
Nuclear  disease  in  epileptic  insanity,  910 
Nullity  of  marriage,  plea  of,  on  account  of  insanity, 

775-783 

actions  for,  on  the  ground  of  insanity,  780 
Numerals  in  mental  imagery,  1361 
Nutrition,  derangements  of,  in  hysteria,  638 

sympathetic  nerves  and,  1249,  1250 
Nutritional  changes  in  mania,  762 

in  morphia  habit,  818 

due  to  fright,  1158,  11 59 
Nutritive  defects  in  melancholia,  788 

defects,  pathology  of,  791 

processes  in  neurasthenia,  846,  847 

treatment  of  acute  senile  psychoses,  871,  872 


Nutritive  brain  changes  in  pathological  hvperaMnia, 

897 
Nyctophobia,  844 
Nystagmus   in  diagnosis  of    disseminated  sclerosis 

from  hysteria,  1163 

Om'.itMKU,  pathology  of  sunstroke,  1236 
Obersti'in(M-.    reaction-time    in    general    paralysis, 

1069 
Objective  diagnostic  signs  of  insanity,  380 
Oblong-sha|)e(l  head,  579 
Oliotichow  Hospital,  1098 
Obovate-shaped  bead,  579 
O'lJrii'u,  Justice,  insanity  of  an  agent,  59 
Obsession,  homicidal,  593,  596 

pathological,  definition  of,  389 

a  syndrome  of  degeneration,  331 
Obsessions  mentales,  678 
Obstruction,  delusions  as  to,  616 
Occasional  criminal,  the,  288 
( )ccipital  lobes,  weight  of,  167 

Occupation  a  predisposing  factor  of  general  para- 
lysis, 534 

in  causation  of  insanity,  1206 

and  suicide,  1227 

in  treatment  of  the  insane,  1315 
Occupations  of  the  insane,  88 

training  of  idiots  for,  674 
Occurring  lunacy  and  existing  lunacy  in  statistics, 

1 194,  119s 
Ocular  monoplegia,  488 

muscles,  paralysis  of  the,  488 

symptoms  in  imbecility,  492 
in  general  paralj^sis,  487 
in  mania,  491 
in  melancholia,  492 
in  dementia,  492 
in  epileptic  insanity,  492 
in  alcoholic  insanity,  492 
"  Odic  force"  (von  Keichenbach),  603 
Odour  photisms,  1125,  1126 
Odyssey,  allusions  to  insanity  in  the,  7,  8 
(Edema  of  glottis  due  to  bromides,  1132 

s.^^npathetic  nerves  and,  1250 
"OEdematous"  cells  (IMeynert),  905 
(Edipus,  insanity  of,  553 
Oehl,  nerve  heat  during  nerve  action,  1278 
Offspring,  the  rearing  of,  245 
Ogdenburg  Asylum,  New  York,  86 
Ogle,  seasonal  influence  on  suicide,  1222,  1223 

sex  and  suicide,  1224,  1225 

age  and  suicide,  1226 

occupation  and  suicide,  1227 

suicide  and  insanity  rates,  12^28 

modes  of  committing  suicide,  1229 
Oikophobia,  679 
Oinomaniacs,  394 
Old  age,  eccentricity  in,  423 

tears  in,  1274 
Olfactory  activities,  absence  of,  in  dreams,  413 

hallucinations,  567,  1174 
Oligoria,  376,  377 
Oliguria,  h^vsterical,  637 

in  the  insane, 134 1 
Onanism,  784 

operative  treatment  for,  785 

medicinal  treatment  for,  786 
Onomatomania,  678 
Onomatopoiisis,  378 
Operations  on  the  insane,  legal  opinion  as  to  assent, 

876,  877 
Ol)erative  treatmcnit  of  masturbation,  785 

of  microceiihaly,  809 

of  nym](homania,  866 

of  general  paralysis,  909 
Ophites,  the,  436 
Ophthalmic  changes  in  general  paralysis,  487 


I45S 


INDEX. 


(.>phth:ilniii-  chiiugcs  in  mimi;i,  491 

in  ineliiucholia,  492 

in  lieuiontia,  492 

in  epileptic-  insanity,  492 

in  iiU'Oholii'  insanity,  492 

in  imbecility,  492 

in  pellagra,  920 
OphthalniopU'^iia  externa  in  general  paralysis,  487 
Ophthalnioscoiiic  examination  of  the  insane,  485, 
486,  487 

signs  in  insanity,  490 
Opiates  in  treatment  of  insanity,  1292 
Opinm  abuse,  the  tremdr  of,  1321 

in  chronic  insanity,  212 

in  melancholia,  794,  1147 

habit,  817 

insanity,  the  exaltation  ol'.  474 

action  of,  1139 
Oppenheim,   psychical   disturbances  due  to   fright, 

T159,  1160 
Optic  atrophy  in  general  paralysis,  490 

atrophy,  paralytic  mydriasis  in,  1054 

disc,  anieiuia  of,  in  general  paralysis,  490 

disc,  hyperemia  of,  in  general  paralysis,  490 

thalamus,  functions  of  the,  157 

disturbances  in  plumbism,  746 

impressions  and  colour  sensations,  1128 

neuritis,  syphilitic,  and  suspicion  mania,  1254 
Optical  defects  in  cocaine  habit,  237 

convergence  and  pupillary  contraction,  1053 
Oracles,  ancient,  1161 
Oral  treatment  of  deaf-mutes,  327,  328 
Orange,  W.,  criminal   responsibility  of 
the  insane,  294 

masked  epilepsy,  453,  454 

capacity  of  insane  to  plead,  951 

procedure  in  alleged  insanity,  1003 
Orbictdaris  palpebrarum,  tone  of,  in  brain  states, 

483 
Orbital  disease,  paralytic  mydriasis  in.  1054 
Ord,  transient  glycosuria  in  puerperal  insanity,  372 
Order  for  reception  of  a  patient,  England  and  AValcs, 

731 

after  inquisition,  732 

by  commissioners,  733 

duration  of,  734 

to  visit  a  patient,  735 

to  examine  a  patient,  736 

to  search  records,  736 

for  reception,  form,  739 

urgency,  739 

summary  i-eception,  form,  744 
Orestes,  insanity  of,  135,  553 
Organic  acids  in  brain,  146,  151 

disease  and  olfactory  hallucinations,  1175 

disease  in  hypochondriasis,  612,  615,  616,  618 

disease,  hj'steria  grafted  on,  623 

causes  of  hysteria,  625,  628 

causes  of  neurasthenia,  84B 

melancholia,  797 

disease,  neurasthenia  antecedent   to,  842,  843, 
848 

psychoses  of  old  age,  872 
Origen,  self-mutilation  by,  1147 
Original  conception,  493 
Ormerod,  bone  degeneration  in  the  insane,  143 

spinal  nerve  lesions  due  to  congenital  syphilis, 
1269 
Osljorne,  "  malarial  margin  '  of  tongue,  757 
Osteo-porosis  in  the  insane,  143 
Otitis  media  and  accidental  deaf-mutism,  327 
Otto  and  Konig,  action  of  urethano,  1136 
Ottolenghi,  facial  type  of  criminals,  289 

genital  anomalies  in  criminals,  289 

sight  lit  criminals,  290 

sense  of  smell  in  criminals,  290 

sense  of  taste  in  criminals,  290 


Ondet,  amesthetic  etfect  of  hypnotism,  604 
Ovarian  disease  and  insanity,  912 

aur.c  in  convulsive  hysteria,  629 
Ovaries,  displacement  of  the,  and  insanity,  1351 

disease  of  the,  and  insanity,  1352 
Ovate-shaped  head,  579 
Over-action  due  to  unantagonigcd  cerebellar  influx, 

443 
Over-pressure  and  chorea,  209 

as  cause  of  idiocy,  665 
Ovid,  alltisions  to  insanity,  753 
Oxalates  in  urine,  1345 

in  urine  of  neurasthenics,  846 
Oxaluria,  1346 

Oxford,  Edward,  case  of,  293,  303 
Oxyaesthesia  in  neurasthenics,  845 

I'ACin  MENEN'oiTis  in  senile  dementia,  872 

intlammatory  thi'iiry  of,  900,  901 
Pack,  wet,  121 

dry,  123 

mustard,  123 
Paederasty  in  satyriasis.  1109 

I'age,  iieritert  w..  shock  from  fright,  1 157 
Pain,  31,  32,  40,  252,  253,  2S9 

facial  expression  of  mental,  483 

absence  of  tears  in,  1274 

and  pleasure,  influence  of,  on  conduct,  252 

photisms,  1 125 
I'ainful  sensations  in  neurasthenia,  844,  845 
Pjilazzi,  early  applications  of  electricity,  427 
Palermo  Asylum,  716 

Pal-Exner,  staining  methods  for  sections,  1186 
Palpitation,  hysterical.  624,  642 
Pal-Woigert,  staining  methods  for  sections,  1186 
Pancreas,  affections  of,  and  insanity,  1245 
Panduriform-shai>ed  head,  579 
Panophobia  in  delirium  tremens,  342 
Paiitoi>hobia,  844 

Papillitis  in  general  i)aralysis,  490 
Paracelsus  on  insanity,  20 
Parsesthesije  in  chronic  alcoholism,  74 

gustatory,  554 

hypera?sthetic,  electricity  in,  431 

psychical,  838 
ParaflSne,  embedding  of  sections,  1184 
Paraldehyde,  hypnotic  action  of,  1133.  1134 

in  acute  deliriotis  mania,  55 

in  treatment  of  insanity,  1292,  1293 
Paralexia,  379 
Paralyse  der  Irren,  510 
Paralyses,  hysterical,  633,  634 
Paralysie  generale  des  ali^nes,  519 

progressive,  519 
Paralysis  agitaus  diagnosed  from  general  paralysis,. 

533.  534 

handwriting  in,  573 

the  tremor  of,  1322 
Paralysis,  alcoholic,  75,  923 

partial,  unrecognised,  443 

unilateral  hysterical,  581,  582 

hysterical.  622,  633,  634 

hysterical,  compared  with  true,  623 

jtsychical,  633 

dependent  on  idea,  633 

by  imagination,  633 

due  to  lead  poisoning,  746 

due  to  malarial  poisoning,  756 

in  toxic  states,  972 

following  febrile  afEections,  988 

due  to  hereditary  syphilis,  1264 
I'aralytic  attacks  in  chronic  alcoholism,  76 

dementia,  351 

retinitis.  491 

idiocy,  644,  648 

seizures  complicating  general   pamilysis,  520, 
530 


INDEX. 


1459 


Paralytic  syiiiptoins  in  m'lieral  paralysis,  528 

Pathological  ob>ession  and  imiiulse,  867,868 

stjiiji'  of  liydvophohiii,  600 

Pathology  in  relation  to  mind,  30 

idiocy  duo  to  coiit^enital  syphilis,  1255 

of  nu'ntal  stupor,  1213 

seizures  in  pellayra,  920 

of  sunstroke  neuroses,  1236,  1237 

mydriasis,  1054 

of  the  symi)Mtlietic  system,  1250 

niyosis,  1055 

of  general  piiralysis,  535.  539,  540.  541 

Paralytil'onn  neurasthenia,  840 

of  mc'lancholia,  790,  791 

I'aralytische  lilinlsinn,  519 

special  (see  under  arti<'les,  and  P.V'rtl()l.i)(;\  1 

I'aranuiesia",  377 

Pathopliol)ia,  844 

simple,  800 

Patients,     order     from     comndssioners     to     seiii-cli 

by  identilication,  801 

records  lor,  736 

associated,  801 

single  (sec  .Single  iiatients) 

Panimyeliu,  148 

private,  provision  for,  in  ;isylnms,  282 

Paranoia,  1356 

Iiaiil)er,  iirovision  for,  in  asylums,  278 

primaria,  1357 

supposed  insane,  iiu-thod  <»f  examination,  r8o 

acute,  1357 

18 1 

due  to  brain  injury,  1309 

under  supervision  of  county  <'onncil  in  county 

Jlippoenitic  nieanini;-  of,  13 

asylums,  277 

hy])ocliondriaciil,  374 

under  supervisiim  of  county  cottncil  in  borough 

simulated,  504 

iisylnms,  277 

diagnosis  of,  381 

under  supervision  of  county  council  in  hos])i- 

in  the  aged,  871 

tals,  277 

religious  delusions  in,  1091 

under  supervision  of  county  council  in  licensed 

Paranoic    c()n<liti()ns    and    peri])heriil    sensory    dis- 

houses, 277 

turbances,  838,  839 

under  sui)ervision   of  connty  council  in  work- 

Paraut, Victor,  the  insane  in  France,  51° 

houses,  277 

hyperactivity  in  early  general  paralysis,  520, 

under   su])ervision   of   county   council  in    cri- 

530 

nunal  asylums,  277 

paralysis    agitans,   insanity  asso- 

under   supervision     of    county    council    under 

ciated  with,  884 

single  care,  277 

mania  of  persecution,  925 

Patriotic  activities,  247 

Paraphasia,  379 

Paul,  Constautin,  chloral  in  deliri(ms  states,  1135 

I'araples'ia,  complete,  in  chronic  alcoholism,  76 

Paul,  E.  B.,  the  insane  in  Japan,  720 

hysterical,  simulated,  1161,  1162 

Pauliis,  JEgineta,  lead  ixiisoniiig  and  e]iilei)sy,  745 

I'arapleyie  douloureuse,  76 

Pauper  lunatics,  statistics  of,  1196 

Parchappe,  pathological   classification  of  insauit.v. 

in  workhouses,  1371 

229 

under  private  care,  141 

insanity  of  doubt,  407 

boarding  out,  in  Scotland,  140 

legislation  for  the  insane  in  France,  513,  516 

patients,  deflniti(ui  of,  276 

weight  of  brains  of  the  insane,  164 

l)rovision  for,  bj'  county  councils,  278 

sex  in  insanity,  1153 

powers  of  visiting  committee  over,  282 

I'arentage,  influence  of,  585 

diet  of,  385,  387 

Parental  contributions  to  the  offspring,  246 

procedure  for  certification  of,  England  and 

Parents,  suitability  of,  a  factor  in  heredity,  586 

Wales,  732,  733,  734 

Paresis,  alcoholic,  75 

leave  of  absence  of,  736 

general  progressive,  in  chronic  alcoholism,  76, 

discharge  of,  736,  737 

77 

certificate,  forms  for,  742,  743 

of  general  paralysis,  pathology  of,  542 

nnd(;r  single  care,  Scotland,  1120 

and  ataxy  in  general  paralj'sis,  520 

mode  of  certification,  S(-otland,  1121 

Paretic  conditions  in  neurasthenia,  846 

location  of,  Scotland,  1122 

symptoms  due  to  salicylic  acid,  1102 

transference  of,  Scotland,  1123 

Pargeter,  the  treatment  of  the  insane  in  1792  :   24 

escape  of,  Scotland,  1 123 

Parietal  lobule,  weight  of,  167 

death  of,  Scotland,  11 24 

Paris  Congress,  1889,  classification  of  insanity,  233 

restraint  or  seclusion  of.  Scotland,  1  123 

Parkes,  standard  diet  in  health,  385 

discharge  of,  Scotland,  1123 

I'arkinsou's  disease,  insanity  associated  with,  884 

removal  of,  Scothmd,  11 23 

I'arochial  asylums,  Scotland,  11 18 

liberation  of,  on  probation,  Scotland,  1123 

Paroxysmal  excitement,  digitalis  in,  387 

recovery  of,  Scotland,  1123 

forms  of  insanity  in  i)arMlysis  agitans,  886 

I'avia,  Hsylutn  at,  717 

Parrot,  lethargic,  1300 

Pavilion  system  of  asylum  construction,  103 

Parrot's  nodes,  1260 

Pavor  nocturnus,  359 

Parthogenesis,  586 

diurnus,  359 

Partial  amnesiip,  377 

Payley's  feeder,  499 

"  Partial  delusion,"  use  of  the  term,  306.  307.  308, 

I'eacock,  brain  weight  in  the  sane.  165 

310,  311,  312 

Pearce,  Nathaniel,  tigrc^tier,  439,  1297 

"  Partial  insanity,"  use  of  the  term,  230,  297,  298, 

Peau  autogTa])hi(iue,  637 

305.  307.  309-  331-471.  698.  8n 

Pecuniary  i)ositio7i,  a  predisposing  cause  of  general 

Partner,  lunacy  of  a,  268 

paralysis,  534 

Parturition  and  hysteria,  620 

Peetcrs,  alcoholic  tremor,  j6 

l)rolonged,  as  cause  of  idiocy,  663 

Pellacani,   bladder  contraction    following   sensory 

insanity  of,  1036 

stimulation,  1340 

Passion,  criminal  by,  288 

"  Pellagra  sint;  pellairra,"  921 

Passive  melancholi.a,  790,  797 

Pellagrous  insanity,  blood-corpuscles  in,  139 

Paternal  causes  of  idiocy,  662 

lupinoglobln  in,  139 

Pathetic  insanity,  698 

and  general  jiaralysis,  different  iai  diagnosis  {Ate 

Pathogenic  function  of  neuralgi.-is,  837 

Pellagra,  art.i 

Pathological  classifications  of  insanity.  229.  230 

I'cnusylviinia  ilo^jiital  Inr  the  Insane,  85 

1460 


INDEX. 


Peunsylvjiuhi  University,  psychical  researcli,  1019 
Pensions  in  rciiistei'ed  hospitals,  1079 

vesiulntious  as  to  the  i^rautiiig  of,  280 
I'euta.  heredity  in  criminals,  289 
I'epsine  in  the  dietary  of  the  insane,  384 
Peptonoids  in  the  dietary  of  the  insane.  384.  385 
Perception.  31.  32,  33,  493 

disorders  of,  263 

in  ai)hasies,  980 

in  mania,  763 
Perceptional  insanity,  698 
Percepts,  ^^.  252 

Percy,  convulsive  drunkenness,  67,  41b 
Peretti,  hereditary  chorea,  209 
Perfect,  ptyalism  in  the  insane,  1 107 
Perichondritis  aurieuhe,  557 

idiopatliic,  diagnosis  frotu  otlia^matoma,  559 
Periodic  oscillations  of  attention,  108 
Periodicity  of  insanity  and  i)ri>gnosis,  1007 
Peripheral  neuroses  and  syiihilitic  general  paralysis, 
1258,  1259 

nerves,  temperature  in,  1278 
Peritoneum,  affections  of,  and  insanity,  1245 
Peritonitis,  tlie  delirium  of,  334 
Perivascular  sub-inflaiuniation,  902 
Permanganate  of  potas.siuni  in  anieuorrliu;i  of  in- 
sanity, 1291 
Perosmic  acid  solution  for  hardening  sections.  1182 
Persecution,  delusions  of,  329,  347,  348 

-mania,  376 

delusions  of,  and  exophtlinlmic  tioitre,  476 

delusions  of,  in  general  parnlysis,  525 

melancholia  of,  797 

mania  diauiiosed    from    insanitx'    of    neg;itiou, 
832,  833 

mania,  sensory  nerve  disturl)auces  in,  838 

delusions  of,  in  Insanity  of  paralysis  agitans, 
885 

mania,  spitting  in.  1107 

insanity,  occurrence  of,  in  the  sexes,  1155 

insanity  in  twins,  1333  et  aeq. 

mania  in  delirium  tremens,  69 

insanity,  honucide  in.  ^95 
Persians,  insanity  among  the  ancient,  5 
Personal  equation  iu  reaction-time,  1069 
Personal  interview  by  justice,  right  of  a  lunatic  to 

732 

forms  for,  740 
Personality,  change  of,  in  dreams,  413 

dual,  and  unequal  hemispherical  action,  401 

unconscious,  and  homicidal  impulse,  597 

doubling  of,  928 
Perspiration,  composition  of,  n66,  1167 

and  mental  states,  11 67 
Perth  Criminal  Asylum,  11 19 
Penivian  bark  in  the  treatment  of  insanity,  23 
Peterson,  cases  of  delusional  insanity,  888 
I'etetiu,  pathology  of  catalepsy,  185 
Petition  for  reception  (tf  i)atient,  Scotland,  1120 

forms,  738 
Petitioner,  the,  in  eertilication, England  and  Wales, 

731 

substitute  for  a,  735 
Petit  mal  attack,  analysis  of  a,  450 

bladder  contraction  after,  1339 
Pctrequin,  composition  of  cerumen,  1167 
Pfleuger,  medical  uses  of  electricity,  429 
Phagocytic  cells,  903 
Phagocytosis,  903,  904 

inducing  cerebral  atrophy,  906 
I'hantasia,  1565 

Phenyldimethylpyrazolon,  96 
Philistines,  recognition  of  insanity  by  the,  4 
Phillimore,  cup-feeding  by  thi'  nose,  501 
Philosophy  of  mind,  27 

historical  sketch  of,  44 

in  the  Middle  Ages,  44 


Phl(>gmasiae,  delirium  of,  334 

Phlegmatic   temperament,    characteristics   of    the, 

1277 
Phobophobia,  844 
Phonation  in  general  paralysis,  527.  528 

hysterical,  anomalies  of,  635,  636 
Phonisms  with  light  sensations,  1125,  1127 
Phonopsie,  1125  (see  art.  Secondary  .Sensations) 
Phosphates  in  urine  in  mental  states,  1346 
Phosphatides  in  brain,  147,  148 
Phosphorised  principles  in  brain,  146,  147 
Photisms  with  sound,   taste,  &c.,  sensation^,  11 25. 

1 126 
Photochromatic  treatment  of  insanity.  239 
Phrenalgia,  376 
Phrenitis,  52 

diagnosed  from  delirium,  338 
Phreno-plexia,  pulse  in,  1045 
Phrenosin,  149 
Phthisical  insanity,  prognosis  of,  1012 

temperature  in,  1281 
Phthisis,  mental  improvement  after.  80.  82 

symptoms  of,  during  insanity,  82 

antifebrin  in,  95 

substitution  of,  for  insane  diathesis,  383 

and  colour  of  the  hair,  563 

hereditary,  as  cause  of  idiocy,  660 

in  the  insane,  938,  939 

latent,  in  the  insane,  940,  941,  945 

appearance  of,  in  phthisical  iusauity,  944 

mental  peculiarities  of,  apart   from    insanity, 

947 
in  insanity,  influence  of,  on  pulse,  1044 
in  Querulantenwahn,  1061 
Physical  causes  of  folic  circulaire,  226 
examination  of  patients,  182,  183 
examination  in  the  diagTiosis  of  insanity,  380 
conditions  for  forcible  feeding,  495 
phenomena   of  established  general   jKiralysis, 

526 
ailments  as  cause  of  insanity  of  doubt.  411 
degeneration,  331 
symptoms  of  mania,  762 
exhaustion  and  melancholia,  792 
persecution  mania,  836 
debility  in  neurasthenics,  847 
symptoms  of  nostalgia,  858,  859 
disorders  in  senile  dementia,  873 
cause  of  persecution  mania,  934 
disease  and  mental  conditions,  937 
symptoms  in  phthisical  insanity,  943 
characteristics  of  neurotic  heredity,  358 
conditions  and  intellectual  faculties,  1026 
affection  in  pyromania,  1058 
phemmiena  following  fright  collai)se,  1158 
causes  of  insanity,  1205 
phenomena  of  hypnotism,  1215 
conditions  predisposing   to  transitory  frenzy, 

1303'  1304 
Physicians,  College  of,  and  the  appointment  of  com- 
missioners, 240 
Physiological  substratum  of  attention,  107 
classifications  of  iusauity,  229,  230 
basis  of  consciousness,  254 
division  of  nervous  system,  441 
pathology  of  general  paralysis,  54 1 
functions,  consciousness  of,  in  hypochondriasis, 

611,  612,  613 
obsession  and  impulse,  867 
equivalents  of  mental  processes,  1031 
Physiology  and  psychology,  27,  28 
of  adolescence,  367,  368,  369 
of  sleep,  1 170 
PhysostigTiiine,  action  of,  1145 
Pia   arachnoid,    affections    of,  due    to    congenital 

syphilis,  1260,  1261 
Pia  mater,  anatomy  of  the,  168 


INDPLX. 


1461 


I'ia  in:iter  in  ^^onrral  itaralysis,  536 

si^iis   of  iiiUiiimiuitory   action    in,  in   insanity, 
901 

adhesions  of,  902 

adhesions  of,  in  jicnrral  i)aralysis,  008 
l'ic<)t  and  d'Es])ine  curi-bral  liypertrophy  in  idiocy, 

650 
Picrocarmino  staining-  for  sections,  11 85 
Pidoux,  atroi)isni.  133 
Pieters,  tremor  in  chronic  alcoliolisin,  1321 

Pietersen,  .1.  ]■'.  (;..  haeniatoma  auris,  557 
othaematoma,  874 
post-epileptic  automatism,  984 
tremor,  1319 

PigTiUMitJiry  deposit  in  cereln-al  cells,  904,  905,  914 
in  pellagra,  921 

collections  in  the  blood  of  malaria,  757.  758 
Pigmentation,  abnormal,  the  sympathetic  in.  1251 
I'llocarjiine  in  treatmenl  of  cretinism,  287 
Pilosis,  alinormal,  128 
Pinel,  the  causes  of  insanity,  135 

classilicalion  of  insanity,  230 

treatment  of  the  insane,  510,  511 

circular  insanity,  215,  223 

manic  sans  d^lire,  594 

suicidal  insanity  in  malarial  jxHsoning,  756 

nursing  of  the  insane,  859,  860 

delusions  of  suspicion,  925 

ptyalism  in  the  insane,  1107 
Piorrj',  period  of  appearance  of  parental  attributes, 

584 
Piscidia  erythrina,  action  of.  1139 
Pitres,  hypnotism,  604 

classification  of  sensory  disturbances  in  hysti^ria, 
631 

and  Franck,  blood-pressure  and  bladder  con- 
traction, 1340 
Planches,  Tanqiierel  des,   sialorrhoea    in    hysteria, 

1 105 
Planer,  blood  in  malaria,  758 
Plans  of  asylums,  103 

Uuite(l  States,  86 
Plater,  Felix,  classification  of  insanity,  20 
Plainer,  pyromania,  1056 
Plato,  allusions  to  insanity,  11 

crime  and  insanity,  11 

suicide,  1218 
Platzangst,  60 

Plautus,  references  to  insaidty,  19,  20 
I'layfair,  W.  S.,  cravings  of  pregnancy,  727 

functional  neuroses,  850 
riea  of  guilty  by  an  insane  criminal,  959,  960,  961 
Pleasure,  31,  32,  40,  252,  253.  259 

and  pain,  influence  of,  on  conduct,  252 
Pleurisy,  the  delirium  of,  334 
Pliny,  mandragora,  759 

suicide,  1218,  1219 

references  to  hellebore.  1353,  1354 

lycanthropy,  1366 
Plotke,  Ludwig,  pupils  during  sleep,  1171 
Plumbism  diagniosed  from  delirium  tremens,  72 

the  insanit.v  of,  745 

antecedent  mental  symptoms  of,  746 

physical  evidences  of,  746 

due  to  inhalation,  746 

the  tremor  of,  1321 
Plumptree,  E.  H.,  exorcists  in  the  early  Cliristiau 

Church,  433 
Plutarch,  religious  melancholia,  16 

e])ilepsy,  16 

insanity,  17 

the  madness  of  the  lower  animals,  17 

di\iniition  and  madness,  17 

mental  anomalies,  16.  17 

suicide,  1218 
I'neumonia  as  cauie  of  acute  delirious  mania,  52 

mental  improvement  after,  80 


I'neumonia,  llie  delirium  of,  334 

in  insanity,  influence  of,  on  jndse.  1044 
followed  by  insanity,  988 
Podagrous  insanity,  548 
Podaleirius,     treatnu'ut    of     insanily     among     the 

ancients,  12 
Points  hyst^roi:^n<'s,  632 

hysterofrenateurs,  632 
Poisoners,  the,  437 
Poisoning,  delusions  of,  in  persecution  mania,  930 

delusions  as  to,  1299 
Poisons,  delirium  ihu^  to,  336 

forms  of,  used  by  suicides,  1229 
I'olicies,  life,  snicidt^  in  relation  to,  748 
Poliomyelitis,  anlerior,  diagnosed   from   i)eripheral 

neuritis,  924 
Political  relationship  a  normality  of  conduct,  247 
Politics  and  suicide,  1225 

Pollock,  Baron,  capacity  of  the  insane  to  plead,  953 
Pollock,  Sir  F.,  conlraclnal  capacilv  of  a  drunkard, 
685 
law  of  ]iarlnersliiii   in    insanity   of  a   jiartner, 
891 
Polydipsia  in  neurasthenia,  845 
Polyopia,  hysterical,  811 

monocular,  hysterical.  632, 642 
Polyuria  in  katatcniia  (Arndt),  725 

in  mental  atfections,  1341 
Tons,  weight  of,  167,  168 

Pons,  J.,  sympathetic  insanity,  1242 

I'ontiac  Asylum,  104 

Poutopi)i(hin,    Knud,     Scandinavia,      pro- 
vision for  the  insane  in,  mo 

I'ouza,  ert'ect  of  coloure<l  light  on  the  insane,  239 
Poor-houses,  the  insane  in,  Scotland,  1119 
Population,  increase  and   rates  of  first  attacks  of 
insanity,  1195,  1196 
and  suicide,  1226 
Porenceiihalus,  654 

Porporati,  progress  of  ])sychology  in  Italy,  717 
Porta,  .1.  B.,  treatment  of  the  insane,  716 
Position  for  forcible  feeding,  496 
Possession,  demoniacal,  delusions  of,  352 
Post-connubial  insanity,  legal  view  as  to  nullity  of 

marriage,  781,  782 
Post-eclampsic  idiocy,  358 

epilepsy,  358 
Post-epile])tic  insauity,  454 

paralysis,  456 
Post-febrile  insanity,  698 

insanity,  iiafhology  of,  91T 
insanity  and  delirium  diagnosed.  333 
idiocy  and  imbecility.  987 
Post-hemii)legic  chorea,  206 
Post-hypnotic  suggestion,  1216 
Post-hystero-epileiitic  aberration,  630 
Post-influenzal  psychoses,  688,  689 

simulating  general  paralysis,  689 
Post-maniacal  reaction,  ^3 

Post-mortem  evidence  of  insanity    legally  admis- 
sible, 463 
examinations,  scheme  for.  916.  917 
signis  in  senile  demcMitia,  873 
Post-natal  causes  of  idiocy  and  imbecility,  659,  663 
Post-nuptial  insanity,  775 
Post-parturient  insane  jealotisy,  721 
Potassium  bromide,  action  of,  1130 
Poughkeepsie  Asylum,  New  York,  86 
Poiilet,  bromides  in  eidlepsy,  1  132 
Power  iind  Sedgwick,  ataxic  aphasia,  98 
Practice,  influence  of,  on  reaction-time,  1069 
Pra'cordial  an,\iety,  836 
Pricjiarturient  insanity,  698 
Pneimerperal  insanily,  698 
Pr;esumi)tiones  juris  et  de  jun,  995 

juris  tantiini,  995 
Predisposing  causes  of  iiliocy  ami  imljecility,  659 


1462 


INDEX. 


l*redisiiosition,  iih-oholic,  66,  67,  68 
l*i'e-opileptic  insanity,  453 
rrdfiiii'icr  AsyUun,  1238 
I'rcjjUiincy,  lU'liviuui  in,  335 
and  liystiM-ia,  620 
•  insanity  of.  689 
insimo  jciilunsy  durinL;'.  721 
kli'ptoniania  durinu,  727 
mclanrluilia  during-,  792 
insanity  of,  1035,  1036 
proiznosis,  1012 
PrcininuiT.  V.,  actinn  of  duboisiiie,  1143 
Prcniaturi'  birth  as  causu  of  idiocy,  663 
Pre-natal    causi's    of   idiocv   and    imliociliiv.    659, 

663 
Prepotency,  583.  :;85 
Preston,  early  uses  of  electricity,  426 
l*reycr.  inhibitory  elforts  in  children,  1367 
Priehard,  ecstasy,  424,  1300 
moral  insanity,  594 
classification  of  insanity,  231 
self-mutilation,  T150 
I'ride  and  urandeur,  inononiania  of,  812 
Primary  dennntia,  348,  349 

post-a]iopIectic  insanity,  976 
J'rimitive  inii>ulses,  32 
I'riinogeniture  in  idiots.  663 
Primordial  insanity,  6q8 
Prince  Edward's  Island,  asylum  in,  176 
PiTiicipal,  lunacy  of  a,  54 
Prin^'le,  alcohol  in  asylums,  62 
Prisons  as  asylums,  no,  1 11 

Prisse  papyrus,  nu'iition  of  senile  psychoses  in.  2 
Private  asylums  in  1790  :  22 
in  United  States,  87 
Australia,  113 
Austria,  114 
parliamentary  committee  on,  24 
in  Canada,  176 
definition  of,  277 
in  France,  516 
Holland,  593 

Ireland,  Acts  relatim;  to,  713 
Italy,  717,  718 
Scotland,  11 19 
Spain,  1177,  1 178 
Switzerland,  1240 
Private  patients,  England  and  AVales,  di  Hnition  of, 
277 
provision  for,  in  asylums,  282 
in  county  asylums,  282 
procedure  for  certification,  Englaml  and  Wales, 

731.  732.  733.  734 
(n-d(n-  to  visit,  735 
order  to  examine,  736 
leave  of  absence  of,  736 
transference  ol,  736 
dischariie  of,  737 

certificate-forms  for,  738,  739,  740,  741 
Scotland,  regulations  as  to,  1119,  1120 
transference  of,  1123 
escai)e  of,  11 24 
death  of,  1 1 24 

restraint  or  seclusion  of,  1124 
discharge  of,  1123 
removal  of,  11 23 
liberation  on  probation  of,  1123 
recovery  of,  11 23 
7'rivy    Council   rules,  &c.,  for  criminal   asylums, 

Ireland,  713 
Probation,  liberation  on,  Scotland,  11 23 
Procedure  as  to  curatory  of  tbc  insane,  324 
Proehaska,  i)athology  of  insanity,  21 

mental  automati.sni,  115 
Procurator-fiscal,  duties  of,  as  to  the  insane,  Scot- 
land, 1 1 22 
Pnidroni.ita  of  pubescent  insanity,  364 


Prodromata.  mental,  of  general  paralysis,  521,  <^zz 
])hysical,  of  general  i)aralysis,  523 
of  conNTilsive  hysteria,  629 
Pra'tides,  insanity  of  the,  553 
Profession  and  transitorv  mania,  1304 

choice  of,  for  neurotics,  1000 
Professional  criminal,  the,  288 
"  Professional  intoxicaids,"  973 
"  J'rofessional"  motility  in  delirium  tremens.  34 
ProgTCSsive  general  paralysis,  519 
"  I'rogressive  systeuiatised  insanity,"'  931 
Prolonged  sleep,  1173,  1174 
Prost,  intestinal  worms  and  insanity,  1245 
Prostate,   post-mortem    appearance   of,  in  genera' 

paralysis,  537 
Propert.v  of  lunatics,  199,  200,736 
Prophylactic  treatnunt  of  alcoholism,  72.  73,  74 
treatment  of  insanitv.  996  et  seq. 
religious  traiidng,  1090 
Proph.vlaxis,  temjierament  in,  1278 
Provision  for  the  insane  (see  articles  on  different 

countries) 
Pseudoc,\'csis,  234 
Pseudo-ilipsomania,  394 

Pseudo-general    paralysis    due    to    con>titutional 
syphilis,  1256,  1257,  1258 
following  l.v]>h(>id,  986 
Psendo-h.vdrophobia,  600 
Pseudo-hypertrophic  paralysis  and   menial  defect, 

656 
Pseudo-influenzal  psychoses,  688 
Pseudomonomanies  (Delasiauve),  594 
Psendo-paral.vsis,  general  alcoholic,  78 

pelhigrosa,  921 
Psychalgia,  376,  377 

Psychic  infiuence  on  bladder  contraction.  1340 
Psychical  blindness  in  general  paralysis.  ^^28,  ^30 
centres,  186,  892 

contagion  and  e])idemic  insanity,  435 
condition  and  epidemic  insanity,  43:; 
Research  Societ.v,  605 
disturbances  in  h.vsteria,  619,  620,621 
phenomena  of  convulsive  h.vsteria.  630 
paralysis,  633 
causes  of  insomida,  703 
symptoms  of  maiua,  762 
"  nerves,"  837 
symptoms  of  n<istalgia,  859 
hallucinations  in  persecution  mania,  928 
])oisons,  966,  967 

defects  due  to  hereditary  syj)hilis.  1266,  1267 
effects  of  attention,  107 
hedonia,  376,  377 
oligoria,  376,  377 
paralyses,  1367 
Psychische  Zartheit  (Koch  ).  383 
Psychological  automatism,  116 
classification  of  insanity.  231 
sig'iufican<'e  of  consciousness,  260,  261 
Psychology.  27 

and  physiology,  27,  28 
animal  and  human,  29 
as  a  subject -object  science.  32 
criminal,  288 
of  adolescents,  367 
of  dipsomaniacal  impulse,  390 
Psychomotor  centres,  186 

sensory  disturbances  in  prodromata  of  general 
paralysis.  523 
Psycho-neurosis  mai'dica,  918 
Psycho-neurotic  paranoia,  887 
Psycho-physical  function  of  neuralitias.  837 
Psycho-physics,  27,  49,  108 
Psycho-therapeutics,  1217 
Ps.vchose  systematisee  progressive.  1356 
Psychoses  of  children,  358 
of  jnibescents,  364 


INDEX. 


1463 


r-iych»si's  of  lulok'sci'iiis,  357 

(if  oldiiyv,  870 

line  to  fright,  1 159 
rsMlio>iii,  i^q,  150 
I'lo-is  a  siuii  of  ln-iiiii  fati^iiu'.  485 
I'lyaliMii,  1 104 

linpi;in»tii'  value  of,  1107 

as  a  crisis  ill  insanity,  1107 
I'liliert.w  ('(iiivnlsivc  conjili  of,  272 

insniiit\  of,  363,  698 

ami  kltf)itiiiiiaula,  727 

iiR-lancliolia  at.  792,  794 

traiiiiiiL;'  of  chililreii  diirini;.  999 

pyroniania  at,  1057 

reliy:ioiis  delusions  at,  1091 

sexual  perversion  at,  1156 

stamuiering- arising  <luriiig,  1191 
ruliesccnt  insanit.v,  iiriHlroni.nta  of.  3O4 

syin])tonis  of,  363 
ruliesccnts,  psyi'hoses  of.  364 
I'ublic   Prosecutor,  duties   of,  in  cases  of  allet;ed 

insanity,  icx)3,  1004.  1005 
i'uerporul     insanity    and    olfactory    hallucinations. 

1175 
temperature  in.  1279,  1280 
chlorides  in  urine  iu,  1348 
alliumen  in  urine  in,  1349 
state  as  cause  of  acute  delirious  maiua,  52 
iiisiinity,  blood-corpuscles  in,  139 
hieuu)L;lol)in  in,  139 
transient,  i;lycosnri:i  in.  372 
chorea,  206 

iusiinity,  patholoy.v  oi'.  911 
prot;nosis  of,  101 1 
varieties  of.  1037.  1038 
I'ulmonary  disease  and  insanity,   \ascnlar  cliaiiy:es 

in,  1044 
Pulse  in  cocoinania,  236 
iu  mania,  762 
in  -ieiieral  i)aralysis.  531 
Pulse  traciug's  in  mental  stupor,  1211 

and  temperature  in  the  insane,  1279 
■"  Punch's  voice  "  in  insanity,  1363 
Pupillary  nerve  fibres,  1053 

symptoms  in  mental  aUections,  491 
I'upillometer,  486 
l*upils  duriiiL;  sleeji,  1171 
examination  of  the,  486 
alteration  in  size  and  shajM-  of,  488 
in  y:ener;il  paralysis.  488,  489,  528 
alteration  in  reaction  of.  488 
iiieiiuality  of.  and  ins.inity.  489 
in  early  stage  of  general  paralysis,  523 
iueiiuality  of,  iu  the  insane,  491 
action  <jf  opium  on  the,  1140 
Pure  dipsomania,  389 

duration  of,  391 
termination  of,  391 
])rodromata  of,  389,  390 
relapses  of,  392 
s.vmptoms  of,  390,  391,  392 
aetiology  of,  392 
Purgnitives  in  treatment  of  insanity,  1291 
Purkinje,  early  applications  of  electricity,  427 
Pye-Smith,  eruption  due  to  chloral  amide,  1136 
Pviidiuc,  ph\siologic;il  action  of,  1297 
Pyriform-shaped  head,  579 


QUANTATION  of  Bpeciflc  i:ravity  of  cei-ehral  tissue, 

162,  163,  164 
i^ulckness  of  exjiression,  484 
Quiet  delirium,  332 
i^uinine,  use  of,  in  folie  cir<'ulaire,  227 

in  hyperpyrexia  of  i)uerperal  insanity,  1281 
<2uinqiniiHl.    action   of   ]iai'aldeh.\de  on   the    blood, 

••33 


K.viutAs  and  Garnier,  8ulphonal,  1138 

Kabenan,  albunu'u  in  urine  in  menial  states,  1348 

IJabow,   quantity   of    urine    secreted    in    insanity, 

1341 
specilic  gravity   of  urine   in    ineutal  alVections, 

1341 

urea  in  melancholia,  1343 

urea  in  general  paralysis,  1344 

albumen  in  urine,  in  epilejisy,  1348 
Kabuteaii,  classilicaiiou  of  mental  poisons,  967 
Itiici's  and  temperaments,  1277 
Racial  intlin'nces  on  tlevelopmeiil  of  hysteria,  629 
Kaggi,  the  blood  of  till!  convalescent  insane,  139 

clinical  psychology  in  Italy.  717 
Kagle,  le,  748 
Kailway  accidents  and  male  hysteria,  624,  625 

and  fright  shock,  1157,  1158 
Kailway  develoiiments  and  suicide,  [225 
Kauuulier  and  Scrieux.  hyoscine  in  insanity,  1143 
Iliimlot,  tactile  sensibility  of  criminals,  290 
liiiniollisseuieiit,  cerebral,  specific  gravity  of,  160 
l{andolph,ri8e  of  temperature  in  cerebral  activity, 

399 
Kanke,  uric-acid  excretion,  1344 
Kaoomit,  831 
Raphjinia,  457 
Kaptiis  maniacns,  1302 

melancholicns,  379,  838 
Ratiocinations,  252 
Rawlinson,  the  insanity  of  Cambyses,  5 

ancient  record.s  of  insanity,  4,  5 
Ray,  legal  capacit.y  of  the  insane,  1286 

the  treatment  of  the  insane,  87,  88 
Rayer,  erysipelas  in  hosiiitals,  460,  461 

sialorrlKca  in  hysteria,  1  105 

alcoholism  in  the  .sexes,  i  j  1^5 
Rayun)nd,  titaxy  due  to  plumhism,  746 

Dii    Hois,    medical    uses    of    electricity,    437, 
439 

Rayner,  H.,  insane  diathesis,  382 
goiit  and  insanity,  548 
mental  disorder  from  lead  poison- 
ing, 745 

frequency  of  insanity  in  jiaralysis  agitans,  886 

rest  in  bed  in  melancholia,  131 5 
Reaction,  i)ost-maiiiacal,  53 

-tinu!,  psycho-physical  method  oi   legisteriug', 
1015 
Reading  as  a  test  in  diagnosis  of  insanity.  379 
Re-admissions  and  statistics,  1195 
Realists,  the,  409 
Reasoning-,  38,  251,  252,  259,  493 

<lisorders  of,  264 

faculties  in  the  insane  diathesis,  383 

powers  iu  toxic  states,  970 

powers  in  aphasics,  979,  983 

lypemania  (IJillod),  594 
'•  Reasoning  monomania,"  681 
U^camier,  anaesthetic  ell'ects  of  hypnotism,  604 
Uecapture  of  escaped  lunatics,  737 
Reception  orders  of  pjitients,  Knglaml   and  Wales, 

731 

after  inquisition,  732 

by  commissioners.  733 

requirements  as  to,  733 

duration  of,  734 
Receptive  dysipsthesia-.  417 
Reckoners,  the,  410 
Recognition  in  memory,  36 
Recollection,  jiowcr  of,  377 

decei)tion  of  identifying:,  376 
Records,  ancient,  of  insanity,  2 
Recoveries  in  United  States  usylnuis,  88 

method  of  calculating  the  proportion  of,  1196, 
1 197 
Recovery,  condition^  airecliuL:.  in   a~ylnnis,  1198  e< 

Si'J. 


1464 


INDEX. 


Recovery  fi-oiii  insanity,  321,  382 

Renal  affections  and  insanity,  1245,  1246 

ill  psycliosos  of  .-idolescenco,  369 

disease  and  insanity,  911 

from  iusjuiity,  state  of  blood  in,  139 

Rent  by  lease  or  deed,  action  for,  period  of  limita- 

in i,''cner:il  paralysis,  532 

tion  of,  and  lunacy,  995 

from  insanity  not  prt'siuned  loiially,  99M 

not  by  lease  or  deed,  action  for.  period  of  limi- 

Recrentive ai-tivitii's,  248 

tation  of,  and  lunacy.  995 

Recurrences  in  transitory  frenzy.  1305 

Kenton.  A.  Wood,  advOWSOn,  55 

Recurrent  actions,  821 

agency,  law  of,  59 

insanity  and    recnrrent  cxoplitlialniic  goitre, 

apprentices,  100 

478 

arbitrator,  lunatic  as,  100 

insanity,  prevention  of,  1002 

bankruptcy,  law  of,  1 16 

Recurring-  utterances  in  epilepsy,  454 

beneficed  clergy,  insanity  of,  133 

in  apliasia,  981 

bishop,  insanity  of,  135 

Reduction,  action  of,  fseotland.  u  r6 

civil     procedure    in  "relation     to 

Reflex  action,  syni])atlietic,  1248,  1249 

lunacy,  229 

excitation  by  tickliui;-,  1296 

cognition  of  the  insane,  Scotland, 

attention,  107 

238 

action,  157 

companies,  law^  of,  in  relation  to 

iridopleyia.  488 

lunacy,  242 

psyclioses,  13 13 

contracts  of  lunatics,  266.  1376 

Reflexes  exayyerated  in  congenital  syphilis.  1264 

criminal  cases,  plea   of  insanity 

in  crinnnals.  289 

in,  292 

in  i;eneral  paralysis,  530 

curatory  of  the  insane,  324 

in  lathyrisni,  730 

domicil  and  insanity,  396 

in  pellaLira,  920 

Emilisli  and  continental  criminal  hnv.  1005 

in  peripheral  neuritis.  928 

evidence  in  relation  to  lunacy,  461 

Refusal  of  food  in  acute  delirious  mania,  ^3 

executors  and  administrators  in 

Reygio-Emilia  Asylum,  717 

relation  to  lunacy,  475 

R^gis,  E.,  systematised  insanity,  1357 

experts,  medical,  479 

diai;nosis  between  folic  circulaire  and  ueneral 

guardian,  insane  person  as,  553 

paralysis,  225 

habitual  drunkards,  legislation  as 

alienation  and  folic,  508,  509 

to,  554 

general  paralysis  in  wt)men,  520 

idiocy  in  its  legal  relations,  66^ 

hyper-activity  in  early  general  paralysis,  522 

inebriety,  lave  of,  684 

treatment  of  obsession,  681 

judge,  insanity  of  a,  723 

unilateral  auditory  hallucinations,  927 

life  insurance,  suicide  in  relation 

actions  in  persecution  mania,  929 

to,  748 

suicide  in  persecution  uiaTua,  931 

marriage  in  relation  to  insanity. 

regicides,  1076 

the  law  of,  776 

Register  of  certitied  attendants,  693 

parents,  insane,  and  marriage,  889 

Registrar  in  Lunacy,  Ireland,  714 

Parliaraent,  law  of,  in  relation  to 

Regression  stage  of  delirium  tremens,  70,  71 

insanity,  889 

Reid,  Scotch  school  of  metaphysics,  45 

partnership,  law  of,  in  relation  to 

Reil,  progress  of  psychology  in  Germany,  545 

insanity,  890 

Reinforcements,  467 

patentees,  insane,  891 

Reinhold,  early  api)licaiions  of  electricity,  427 

pow^er  of  attorney,  993 

Reisesucht,  423 

prescription     and     limitation    of 

Relapses,  frequency  of  occm-rence  of,  1200 

actions,  993 

in  dipsomaniacal  impulse,  392 

presumption,  legal,  relating  to  in- 

in melancholia,  789 

sanity,  995 

in  morphia  habit,  820 

rules  in  lunacy,  1377 

Religion,  suicide  reg-arded  as  a  rite  of.  1219 

Sovereign,  insanity  of  a,  1177 

influence  of,  on  suicide,  1224 

testamentary  capacity  in  mental 

Religious  delusions,  1290 

disease, 1285 

transitions  and  witchcraft,  1368,  1369 

tort  in  lunacy,  1298 

melancholia  (I'lutarch),  6 

trusts,  law  of,  in  relation   to  lu- 

observances, a  normality  of  conduct,  247 

nacy,  1328 

ecstasy,  439 

undue  influence,  1336 

feeling,  failure  of,  in  general  ])aralysis.  52q 

Reports,  due  to  commissioners,  from  medical  officers 

tendencies  in  epilei)tic  insanity,  455,  472 

of  asylums,  &c..  735 

insanity,  699 

Reproduction  ami  mental  distui-bance.  246,  247 

excitement  in  mania,  765 

Resemblance,  the  recognition  of,  36 

excitement  in  hysterical  mania,  769 

Residence,  average  duration  of,  in  asylums,  1198 

training  of  neurotics,  1000 

change  of,  in  jierseeution  insanity,  701 

Remak,  medical  use  of  electricity,  427 

Residents  in  asylums,  mean  number  of,  1197,  I200 

Remax,  locomotor  ataxy  due  to  congenital  syphilis. 

Resistance,  forcible,  in  katatonia.  724 

1269 

Resistive  s.^-uiptoms  in  stupor,  1208,  1210 

Remembering,  31 

Resolution,  42 

Remembrance,  251 

Resolve,  32 

of  thoughts,  259 

Respii-ation,  influence  of,  on  circulation,  96b 

of  feelings,  259 

influence  of,  on  pupils,  1053 

the  loss  of,  36 

Kespirator.v  abnormalities  in  neurastlii'uics,  846 

Remissions  in  adolescent  insanity,  365,  366 

Responsibility,  crinunal,  309 

in  general  paralysis,  531,  532 

ci\'il,  of  aphasics,  983,  984 

in  persecutioTi  mania,  Q31 

of  morphiomaniacs.  820 

Remorse  in  criminals,  290 

Rest  in  the  treatment  of  insanity.  1314,  1319 

and  self-mutilation,   t  148 

Restraint,  Asclepiades  on,  14 

INDEX. 


1465 


Hcstniiiil  ill  |>rivMtr  :is>  liiiiis  in  fiL;litfi'iith  ci'iitur|. 

'■'•••"'•<1  "I'.  735 

rcLiillnlioiis  as  fci,  Sfiitlainl,    1  i  2.\ 

ri'i;uliitii>iis  iis  to,  Klijiliiiiil  and  \\alcs,  735 

rofjuhitions  as  to,  Ivflaml,  713 
Kt'ti'iitivencss,  fori'linil,  and  niovciiiciit,  821 
Uetina  (luviiig:  sloc]),  1171 
Hctinilis  naialvtica  iKlcin),  491 

piuuioiitosa  ill  Ilio  citVspriiiL;  ciT  consaiiLiiiiin'ous 
-lUJiiTiauvs.  487 
Ketrcat.  tin-.  York.  1082 
Uetn-ats  lor  im-briatos.  1377 

n-iilations  lor.  555.  556.  557 
Ketro-Mctivc  lialliu-inatioiis,  1216 
Ketroci'ileiit  i;'out  and  nioiital  disovdiw,  549 
Ketrotlfxion  of  uterus  and  nervous  disturbances, 

1351 
Ketrovorsion  of  uieriis  and  ik 


•vous  disturbiinci,'; 


1351 


Returns,  iuiiu'rleei,  atVectiiii;  statistics,  1194 
Kcversioii  of  ancestral  I)'pes,  584 
KeviuLiton,  lattney  of  insane  diathesis,  383 
Key,  aeneral  paral.vsis  in  women,  520 
Reynolds,   Russell,  uientiil  disturbances  in    jiouty 
states,  548 

liliysio-patlioloi;'y  of  gouty  insanity,  550 

cannabis  indica  in  mental  affections,  1144 

jjaralyses  from  ideas,  1367 
Rheumatic  fever  alternatint;"  with  insanity,  82 

insanity,  destructive  impulse  in,  355 

fever,  insanity  of  doubt  after,  410,  411 

affections  associated  with  iusanity,  988 

insauit.y,  temperature  in,  1281 
Rheumatism,  acute,   as    cause   of   acute   delirious 
mania,  52 

acute,  the  delirium  of,  334,  33s 

and  chorea,  210 

and  insanity.  912 

acute,  followed  by  insanity.  987 

Ribot,  Th..  -will,  disorders  of  the,  1366 

voluntary  attention.  109 

disorders  of  memory,  798 
Kiciiardson.  B.  w..  fasting  m.anias,  770 

experiments  willi  maudraLiora,  759 

psychology  of  tears,  1273 

Richet,  Ch.,  liyiniotic  somnambulism,  604 
Richel.  P..  hyimotism,  (304 

the  ](henomena  of  convulsive  hysteria,  631 
Richmond  Asylum,  Ireland,  708,  710 
Eichter,  albumen  in  urine  in  mental  states,  1348 
Rickets  and  chronic  hydrocephalus  diatinosed,  654 
Rickety  nodes  distinLtuished  from  syphilitic,  1260 
Rigby,  specific    gravity  of  urine  in   mental  condi- 
tions, 1341 

mineral  .salts  in   urine  in  mental  conditions, 

1347 
lligors,  the  tremor  of,  1320 

Riuger.  .Sydney,  and  Harrington  Sainsbury,  seda- 
tives, 1 128 
Kitti,  the  frequency  of  occurrence  of  folic  circulaire, 
226 
classilication  of  dipsomania,  392 
electi'icity  in  artificial  feeding,  500 

circular  insanity,  214 

iiyperactivity  in  early  general  jiaraly.sis,  522 

patholog'y  of  Jiallucinations,  568 

insanity  of  doubt,  407,  410 

persecution  mania,  925 

persicnl  loll  mania,  the  ;ctiolog:y  of,  933,  934 

perseciiiion  mania,  heredity  in,  933 
Rivers,  suicide  in  the  region  of,  1222 
Rivingttm,  operative  procedure  in  general  parjilysis, 

1325 
Robertson,  Alexander,  jctiologvof  lia.Miiatonia  anris, 

561 
insanity  due  to  lead,  745,  747 


Robertson,  Aie.xandi  r.  post-apoplectic  in- 
sanity, 974 
Robertson,  G.  .M.,  hair  of  the  insane,  562 

and    KIkins,  K.,  intluen/.a   among   the   insane, 
691 
Robertson,  J.ockharl,  post-cpili'pl  ic  jiaralysis.  45O 
the  insane  in  Spain.  1177 
the  wet  i)ack,  121 
Turkish  ballis,  125,  127 

Robinson,    i.oiiis.    reflex    action,    physio- 
logical, 1074 
tickiishness   and  the   phenomena 
of  tickling,  1294 

physiology  of  sleep.  1  171 
Rockwell,  intluence  ol  galvanic  currents.  430 

medical  uses  ol'  electricity,  430 
Roilinck,  jityalisni  in  the  insane,  1107 
Rogdestwensky  Hospital,  Moscow,  1099 
Rogers  and  Campbell    lirown,  chendcal  analysis  of 

bones  of  general  paralytics,  143 
Rokilansky,  ]iatlu)Iogy  ol'  cliorea,  210 

cerebral  hypertrophy  in  idiocy,  649 

chronic  hydi-ocephalns,  654 

RoUestou,  H.  Davy,  temperature  in  peri- 
pheral nerves,  1278 

Romanes,  G.  J.,  instinct,  704 

choice.  1031 
Roman  law,  puiiishnient  lor  suicide,  1219 
Romans,  method  of  dealing  with  the  insane.  19 

emplo.vment  of  imbecile  and  idiotic  children, 

15 
suicide  among  the  ancient,  1218 
demonolntria  among  the  ancient,  1369 
Komberg,  echo  sign  in  epileptics.  424 

insanity  and  chorea,  206 
Rome,  asylum  at,  716 
Eorie,  forcible  feeding.  494 
Rosegg  Asylum.  1239 
Rosenthal,  cannabis  indica,  1144 
Ross,  cerebellar  tumours  in  idiocy,  656 
Rossbach,  opium  in  mental  afifections,  1141 
use  of  morphia.  1142 
use  of  chloral  in  delirious  st;ites,  1135 
Rossi,  heredity  in  criminals,  289 

method  of  examination  of  criminals,  291 
Rossiguol,  uterine  disease  and  insanity,  803 
Rostau,  reform  in  the  treatment  of  the  insane  in 

France,  512 
Roth,  post-mortem  appearances  of  sunstroke  lesions, 

1236 
Rotterdam  Asylum,  592 
Rotund-shaped  head.  579 
Rotvold  Asylum,  iiii 
Rousseau,  pyromania   and  sexual   disorder.  ios7. 

1058 
Rousseau,  .Jean  .).,  suicide.  1220 
R(mssel,  transfusion  in  the  treatment  of  insanity, 

22 
fioy  and  Sheri'ington.  elVect  on  cerebral  vessels  of 

metabolic  products.  895 
Royal    Commissioners'   Rejinrt   on    Criminal    Code 

J'.ill,  318 
Royal  Edinburgli  Asylum,  104 
Royal  Manchester  Asylum,  104 
Royer, neuroses  in  ofl'spring  of  subjects  of  jiluuibism, 

746 
Rubidium  bromide,  action  of,  1131 
Rubio,  I'edro.  I  he  insane  in  Spain,  1177 
Rules  in  lunac.\.  1377 
Rnpopholjia,  844 
Rural  life  and  suicide.  1226 
Rii.sb,  the  treatment  ol  the  insane,  87 
amenomania,  84 
partial  hypei-mnesia,  800 
Russell,  cajiacity  oi'  insane  to  plead,  964 
Russia,  sexes  in  insanity,  1153 
Russian  baths,  127 


1466 


INDEX, 


Kuthorlovil   and   Batty  Tuki-,  miliary   sclerosis  in 
cerebral  doLieueratiou,  906 

Sacred  disease,  Hiiipocrates  on  the.  i^ 
Safrunhi  stainlui;-  of  sections.  1185,  i  [86 
Suinsbm-y,  Harrini^ton.  antipyrin,  9b 

and  Sydney  Ringer,  sedatives,  1128 
St.  Andrew's  Hospital.  >yorthaniptoii,   1084 
St.  Benedict  Asylnni,  716 
St.  Boniface  Asylum,  716 
St.  Clemente  Asylnni,  717 
St.  Hans  Hospital,  11 12 
St,  John's  Asylum,  New  Brunswick,  176 
St.  John's  Asylum,  Xewfonndland,  176 
St.  Lawrence  State  Asylum,  104 
St.  Luke's  Hospital,  1080 
St.  Martin,  Pan  de,  treatment  of  catalejisy.  i8s 

pathology  of  catalepsy,  1 85 
St.   Mary's  Hosi)ital,  London,  psychical    research, 

1021 
St.  Nicholas  Asylum,  716 
St.  Nicholas  Hospital,  St.  Petersburg,  1099 
St.  Panteleimon  Hosjiital,  1099 
St.  Petersburii'  Asylnms,  1099 
St.  Pirminsbers'  Asylum,  r238 
St.  Urbaiu  Asylum,  1239,  1240 
St.  Ursula  Asylum,  716 
St,  Vitns's  dance,  214,  438 
Sainte  Anne  Asylum,  farm  of,  512.  513 
•Saliva,  chemical  properties  of.  in  i)tyalism,  1104 
.Salivation  in  mania,  762 
Salpetriere,  reforms  at  the,  511,  512 

school  of  hypnotism,  604,  605 
Salsotto,  remorse  in  crimin.als,  290 
"Salutation  "  sta^e  of  convulsive  hysteria,  630 
Salvatori,  classification  of  diiisoniania,  392 

Sanborn,  F.  B.,  boarding  out  in  the  United 
States,  America,  142 

Saudbery,  progress  of  psychology  in  Norway,  iin 
Sander,  increase  of  general  ])aralysis,  1156 

optical  axes  during  sleep,  1171 
Sanders,  ataxic  aphasia,  98 
Sandwith,  condition  of  insane  in  Egypt,  1329 
Sane,  reaction-time  in  the,  1067 
Sanger-Brown,  cortical  functions,  156 
Sanguine  temperament,  characteristics  of  the,  1276 
Sauguinity,  law  of,  586 
Sanity,  certificates  of.  195 

legal  i)resnmpti(m  of,  995,  996 
Sankey,  specific  gravity  of  brain,  159,  161.  162 

specific  gravity  of  brain  in  disease,  161 

Bright's  disease  and  insanity,  172 

diets  for  feeding,  498 

s])oon  feeding,  499 

aetiology  of  otha^matoma.  561 

melancholia  antecedent  to  insanities,  789 
Sarlandiere,  atropism,  133 

early  applications  of  electricity,  427 
Saturnism,  chronic,  diagnosed  from  alcohohsm,  72 
Satyriasis  in  locomotor  ataxy.  751 
Saufsucht,  388 
Saul,  insanity  of,  3 
Saulle,  Legrand  du,  quinine  in  folic  circnlaire.  227 

insanity  of  doubt,  407,  409,  410 
Saunder,  excretion  of  urea  in  general  i)aralysis, 

1344 
Saunders,  thei-mometer  in  the  insane,  1279 
Sauvages,  somnambulistic  conditions,  1176 
Savage,  G,  H.,  depilatiou  in  anomalous   tricliosis, 
129 
Briiiht's  disease  and  insanity.  172 

alternation  of  neuroses,  79 
anaesthetics  and  insanity,  92 
asthma  and  insanity,  loi 
deafness  and  insanity,  328 
diabetes  and  insanity,  371 
epilepsy  and  insanity,  452 


Savage,  G.  H.,  exophthalruic  goitre  and 
insanity,  476 

handwriting  of  the  insane,  568 

l>rognosis  of  exalted  states.  471 

hypochondriasis  and  insanity,  610 

jealousy  as  a  symptom  of  insanity, 
72  [ 

locomotor  ataxy  as  allied  to  neu- 
roses, 750 

marriage  and  insanity,  association 
betwreen,  and  post-connubial  in- 
sanity, 775 

plea  of  nullity  of  marriage  on  the 
ground  of  insanity,  782 

my:xcedema  and  insanity,  828 

insanity  due  10  lead,  745 

s]iinal    durha;matomata  in   general  paralysis, 

883 
phthisical  insanity,  942,  943 
puerperal  insanity,  1034 
rheumatic  fever  and  insanity,  1093 
pyromania  in  moral  insanity,  1057 
conium  in  recurrent  mania,  1145 
increase  of  general  paralysis,  1156 
hallucinations  of  smell,  1174 
spinal  cord  changes  in  the  insane, 

1 190 
suicide  and  insanity,  1230 
syphilis  and  insanity,  1252 
simultaneous  insanity  in  twins,  1334 

Savage,  T.,  insanity  following  ovariotomy,  876 

Sav(maroIa,  epilepsy  of,  455 

Scalia,  B.,  criminal  insane  in  Itah',  719 

Scalp  temperature  in  brain  temperature,  1282 
1283 

Scaphocephalic  head,  580 
idiocy,  644,  645 

Scarlatina,  delirium  of,  334 
insanity  follovving,  987 

Scavenger  cells,  903,  904 

Schafer,  cortical  functions,  153,  155,  156 

Schaffhausen  Asylum,  1240 

Scheming  insanity,  699 

Schitf,  heat  of  nerves  during  nerve-action,  1278 
treatment  of  cretinism,  287 
nervous  mechanism  of  salivation,  1105 

Schmidt,  C,  composition  of  sebaceous  matter,  1167 

Schmiedeberg,  sedatives,  1129,  1132 
action  of  opium,  1140 

Schmieden,  758 

Schmitz,  ])ost-influenzal  psychoses,  690 

Schmoulewiteh,  irritable  muscular  weakness,  1046 

Schnauzkrampf  in  katatonia,  724 

Schneider,  douche  treatment,  120 

School  education  for  children,  998 
in  asylums,  1316 

Schottin,  comjwsition  of  sweat,  1167 

Schiile,   H.,   anomalous   forms  of  acute    delirious 
mania,  54 
classification  of  dipsomania,  393 
vaso-motor  theory  of  general  paralysis,  540 
neuralgia     and    mental    derange- 
ment, 835 
the  frequency  of  simulated  insanity,  502 
pulse  tension  in  hypochondriasis,  1043 
religion  and  insanity,  1089 
opium  in  mental  affections,  1141 
use  of  morphia,  1142 
Wahnsinu,  1364 

Schultze,  trional  and  tetronal.  1130 

Schwartzer.  utto  von,  transitory  mania,  1302 

Schweich,  post-iuflnenzal  psychoses,  090 

Science  of  Mind,  27 

Sclerosis,   insular   cerebro-spinal,  diagnosed   from 
general  paralysis,  533 
lateral,  in  senile  dementia,  872 

Scotland,  associations  for  after-care,  ^,7 


INDEX. 


1467 


Snitlimd.  oxjiort  rvidenco  in.  480.  481 

Senile  chorea,  206 

provision  for  tlie  iiisjiiii.'  in,  552 

pulse  in  emphysematous  conditions,  1044 

U'i;islatioii  for  iuelu'ioty  in,  557 

melancholia,  jiulse  in,  1045 

lioanliiiK  out  system  in,  140 

decay,  ancient  recogialion  of,  2 

ciTtificuti's  in,  191 

decay,  psycliology  of,  448 

Royal  Asylums  in.  1094 

dementia,  350,  872,  873 

Scotoma,  (lisscmiuatod.  in  coiainc  haliil.  237 

ideas  of  persecution  in,  933 

Scott,  viscidia   crytlirina  iu   nervous   f.xcitcmcut. 

dementia  in  tlie  sexes,  1 155 

'139 

melancholia,  797,  870,  871 

Scottish  school  of  metaphysics.  45 

(lemeiitia,  amnesia  in,  8cx3 

"  Scourgers,"  the,  437 

involution  in  tlie  sexes,  869 

Scriptural  references  to  insanity,  3 

involution,  pathological  changes  in.  869 

Scrofula  and  idiocy,  939 

involution,  mental,  phenomena  in,  869 

"  Scrupulous,"  the,  409 

hypochondriasis,  870 

Scutari  Asylum,  1328 

mania,  870,  871 

Seasons,  influence  of,  on  suicide,  1222 

paranoia,  871 

and  temperanients,  1277 

Senility,  advent  of,  869 

and  transitory  frenzy,  1304 

constitutional  changes  in,  869 

Sebaceous  secretion  of  the  skin,  n66 

Sennet,  Daniel,  delinition  of  mania,  21 

Sebastian,  mania  of  tertian  a^uc.  757 

delinition  of  melancholia,  21 

a^ue  alternating  with  insanity,  987 

Sensation,  29,  32.  33.  34,  44,  46,  260 

Socchi,  I'lTects  of  coloured  linht  on  the  insane,  239 

<lisorders  of,  in  hysteria,  621,  631,  632,  633 

Seclusion,  re^jiilations  as  to,  Scotland,  1 124 

in  special  sense  organs,  632 

regulations  as  to,  Kn^^land  ■•ind  Wales,  735 

in  lead  poisoning,  746 

regulations  as  to.  Ireland.  713 

in  mania,  762,  763,  765 

in  treatment  of  insanity,  1317,  1319 

in  myxcEderaa,  829 

Secondary  dementia,  349 

neuralgic,  835 

of  adolescence,  369 

in  peripheral  neuritis,  923 

post-apoplectic  insanity,  976 

in  persecution  mania,  928 

"Secondary  stupor"  in    adolescent  insanity,  30O, 

loss  of,  hysterical,  581 

369 

ordinary,  distinguished  from    tickling,    1294, 

Secret  societies  and  epidemic  insanity,  435 

1295 

Secretary  of  State,  power  as  to  criminal  luuatiis. 

and  emotion,  254 

29s 

lihotisms,  1 127 

as  to  provision  of  asylums,  278,  279 

Sense  impressions  and  attention,  107 

power  of,  under  Inebriates  Act,  556 

presentations.  995 

jiowers  of,  iu  luuacy,  736,  737 

organs  in  reaction-time,  1067,  1068 

powers  of,  with  respect  to  hospitals,  1079 

Senses,  education  of  the,  in  idiots,  671 

Secretions,  hysterical  abnormalities  of,  624.  637 

special,  after  brain  injury,  1308 

Secretory  disturbances  in  morpliia  habit,  817 

Sensibility,  disorders  of,  in  chronic  alcoholism,  74 

in  neurasthenia,  846 

centres,  186 

Section-cutting  for  microscopy  of  brain,  &c„  1183 

Sensorial   hypera^sthesia,  a  prodrome  of   delirium 

Secimdiiremptindungen,  11 25 

tremens,  340 

Sederunt,  Acts  of,  relating  to  cognition  of  the  in- 

idiocy, 644 

sane,  238 

illusions  in    jirodromata  of  delirium   tremens, 

Seduction,    action   for,   period    of   limitation,   and 

341 

lunacy,  995 

Insanity,  699 

Seglas  and  Cliaslin,  note  on  katatonia,  724 

Sensori-motor  symptoms  of  epilepsy,  449 

Se'gTiin,  massage  in  idiocy,  669 

Sensory  abnormalities  in  criminals,  290 

physiological  training  of  idiots,  670 

areas  in  cortex,  155 

education  of  the  senses  in  idiots,  671 

disturbances  in  cocaine  habit,  237 

recovery  in  idiocy,  675 

activities  in  dreams,  413,  414 

salivary  secretion  in  idiots,  1108 

affections  in  ergotism,  458 

Self-abuse,  784 

aphasia,  980 

iu  idiots,  means  of  correcting,  669 

aphasia,  mental  condition  in,  983 

religious  delusions  and,  1091 

and  mental  defect  due  to  congenital  syphilis, 

insanity  of,  698.  784 

1255 

mechanical  restraint  in,  1318 

anomalies  in  general  paralysis,  527,  528,  542 

Self-accusation,  delusions  of,  347 

in  ergotism,  458,  459 

Self-conscious  feeling,  disorders  of.  345 

disorders  in  chronic  alcoholism,  74 

Self-consciousness,  anomalies  of,  in  general  para- 

disorders in  hysteria,  621 

lysis,  529 

mistranslations,  835,  839,  840 

disorders  of,  345 

ex<-itability  in  neurasthenia,  843 

Self-control,  42 

disturbances  in  paralysis  agitans  misconstrued, 

Self-cross-examination,  morbid.  407 

885,  886 

Self,  delusions  of  knowledge  of,  346,  347 

disturbances   associated   with  olfactory  hallu- 

delusions of  the  relation  of,  to  surroundings. 

cinations,  1 174 

347 

obsessions,  679 

Self-knowledge,  28 

Seppilli,  the  blood  in  general  paralysis,  138 

Self-mutilation,  mechanical  restraint  in,  1318 

blood  in  pellagrous  insanity,  139 

Self-preservation,  243,  244 

vascular  dianges  during  hypnotism,  1042 

Self-restraint  in  insanity,  699 

Septic  poisoning  inducing  insanity,  pathology  of, 

Self-will,  morbid,  363,  364 

913 

Selmer,  reform  in  asyhmis,  Denmark   1 1 1 

causes  of  puerperal  insanity,  1038,  1039 

Seneca,  employment  of  idiots  by  tlie  Uomans.  17 

Septnagint,  allusions  to  insanity  in  the,  3,  4 

treatment  of  insanity,  135 

Sequehe  of  acute  delirious  mania,  54 

suicide,  1218 

Sequence  of  movements,  821 

1468 


INDEX. 


Sequential  insanity,  699 

S^rieux  and  Kamadier,  hyoscine  in  insanity,  1143 

Seton,  Sir  A.,  detinition  of  self-mutilation,  1148 

Sewage  gas  and  erysipelas,  460,  461 

Sex,  influence  of,  on  brain  weight,  165 

in  occurrence  of  persecution  mania,  933 

influence  of,  on  development  of  hysteria,  629 

in  convulsive  cough  of  puberty,  273 

influencing  recovery  in  asylums,  iigS 

and  mortality  in  asj-lums,  1199 

liability  to  insanity  and,  1202,  1203 

and  mental  stupor,  1212 

influence  of,  on  suicide,  1224 

and  modes  of  committing-  suicide,  1229,  1230 

in  transitory  frenzy,  1303,  1304 

predisposing  to  general  paralysis,  534 

size  of  head  influenced  liy,  578 
Sexes,  suitabilities  of,  for  propagation,  587,  588 
Sexual  act,  normal  and  abnormal  indulgence  in. 
246 

anomalies  in  protlromal  stage  of  general  para- 
lysis, 521,  522 

disorders  and  insanity,  234 

disorders  and  nervous  phenomena,  234 

disorders  and  olfactory  hallucinations,  1175 

elements,  influence  of,  in  progenitors,  582 

excess,    exciting  cause  of    general  paralysis, 
535 

excess  as  cause  of  folic  du  doute,  411 

ballucinations,  567 

hypochondriasis,  617 

influences  and  hysteria,  620 

functions  in  hysteria,  637 

excitement  in  mania,  764,  765 

causes  of  hysterical  mania,  769 

exhanstion  as  cause  of  post-connubial  insanity. 
776 

storms  in  neurotics,  784 

melancholia,  797 

functions  of  microcephales,  807 

functions  in  erotomania,  702 

feelings  in  neurasthenics,  845 

illusions  in  senile  psychoses,  871 

abstinence  and  satyriasis,  1109 

perversions,  377 

abnormalities  and  pyromania,  1058 

stimulation  by  tickling,  1295 

balluci nations  in  nterine  disease,  1352 
Shaftesbury,  Earl  of,  provision  for  the  insane,  26, 

195 
Shakespeare,  suicide,  1220 
Shame,  nervous  action  of,  837 
Shape  of  the  head  in  the  insane,  578 
Shareholder,  lunatic  as  a,  242 
Sharkey,  S.  J.,  clinical  evidence  of  cortical  functions, 

156 
Shaw,  J.  C,  action  of  hyoscyamine,  1143 
Shaw,  T.  Clave,  dementia,  348 

mental  stupor,  anergic,  1208 

destructive  impulses  and  acts,  354 

operative  treatment  of  general  paralvsis,  909. 
1325 
Shepperd,  suicide,  1220 

Sheritr's  order  for  reception  of  patient,  Scotland, 
1120 

duties  in  respect  to  lunatics,  Scotland,  1121 

order,  limitation  of,  Scotland,  1123 

order,  power  of  discharge  by,  1123 
Sherrington,   C.    S.,   descending    degeneration    in 
lesion  of  motor  cortex,  399 

and  Koy,  cdect  of  metabolic  products  on  cere- 
bral vessels,  895 
Shivering  in  neurasthenia,  846 
Shock,  moral,  as  cause  of  catalepsy,  185 

as  cause  of  Insanity  of  doubt,  411 

nervous,  and  male  hy?teria,  624,  625 

as  cause  of  hysteria,  625,  628 


(Shock  due  to  traumatic  violence,  1306 
Shower-bath,  120 

Shuttleworth,  G.  E.,  idiocy  dne  to  sunstroke,  1234 
post-mortem  ai)i)earances  of  sunstroke  lesious, 

1236 
the    ameliorative    treatm.ent    and 
educational    training    of    idiots 
and  imbeciles,  667 
case  of  porencephalus,  654 
cases  of  microcephaly,  808 
shape  of  the  head  in  idiots,  580 
and  Fletcher  I'.each,  ffitiology  of  idiocy 
and  imbecility,  659 
Sialorrhd'a,  1104 

h.ysterical.  637 
Sichard,  heredity  in  criniiiuils,  289 
Siderodnmiophobia,  844 

Siemerling,    E.,  cord   lesious    due    to    hereditary 
syphilis,  1262 
mind  blindness,  809 

increase  of  general  paralysis.  1156 
Siena,  as.ylum  at.  717,  719 
Sight,  a  knowledge-giving  sensation.  33 

localisation  of,  in  cortex,  156 

in  sporadic  cretinism,  286 

in  criminals,  290 

in  prodromic  stage  of  general  paralysis,  323 

lialliicinations  of,  566 

loss  of,  h.vsterical,  83 

in  somnambulism,  406 

in  hysteria.  621,  631.  632 

in  lead  poisoning.  746 

in  mania.  763 

in  hallucinatorv  mania.  767 

in  persecution  mania.  927 

education  of,  in  idiots,  672 

phonisms,  1125,  1127 

in  disseminated  sclerosis  diagnosed  from  hys- 
terical loss  of  sight,  1 163 

during  somnambulism,  1172 

loss  of,  due  to  tobacco  abuse,  1298 
Sign-phm  of  treatment  of  deaf-mutes,  327,  328 
Silbenstolpern,  379 

'•  Silent  excitement  "  in  established  general  paraly- 
sis, 524.  525,  526 
Silk,  an  ancient  therapeutic  agent,  1152 
Simian  and  microcephalous  brains  compared,  805 
Similarity,  law  of.  36 
Simmaehians,  the,  436 

Simon,  3Iax,  gustatory  and  olfactory  activities  in 
dreams.  413 

ambitions  delusions  after  tji)hoid.  986 
Simple  melancholia.  790,  797 

reaction-times.  1067.  1068.  1069 
Simpson.  Sir  J..  al1)nniinuria  in  puerjieral  insanity, 

1037 
Simulated  insanity.  :;o2 

catalepsy,  184 

melancholia.  503 

mental  stupor.  503 

hallucinatory  insanity.  503 

h.vsteroidal  forms  of  insanity,  503 

moral  insanity,  504 

general  paralysis,  504 

chri)nic  insanity,  504 

delusional  insanit.v,  504 

persecution  mania,  932 
Sin,  the  unpardonable,  1339 
Single  care,  277 

patients.    J-Iugland  and  Wales,  regulations  as 

t"-  731-736 
certiti cation  of,  731,  732,  733,  734 
regulations  as  to  reports  on,  734,  735 
treatment  of,  735 
leave  of  absence  of,  736 
general  regulations  as  to,  735.  736 
remov.'il  of.  736 


INDEX. 


1469 


Single  piitk'iits,  Eii-l;ni(l  ami  Wiilo.  <ii^cllill•;;l•  of, 

Scotland,  ri'Liulations  as  in.  i  1 19.  1120 

Site  of  iisyhnns.  102 

Sitz-batlis,  warm,  118 

Sixth  nei-ve,  paralysis  of  the,  in  ueiieral  parah  sis. 
488  ■ 

Size  of  head.  574 

Skae,  sj)eci(ic  j^nwity  of  brain,  159,  i6i 
elassilication  of  insanity,  232 
elassilieatioii  of  dii)somani;i,  392 
"recurrent  dipsomania."  394 
use  of  the  term  "  mania."  761 
utero-ovarijin  dise:ise  .•uul  insjiniiy,  912 
braiu,   speeilie   i;ravit.v,  in   phthisical  insanity, 

947 

Aveis'ht  of  hraiu  in  llie  insane,  164.  165 

trephininy  in  mental  att'cctious  due  to   brain 
injury,  1324 
Skin  affections  and  insanity,  1246 

conductivity  in  brain  temperature,  1281 

condition  of  tlie,  in  melancliolia,  788 

.sensations,  i)syeho-physical  method  of  reuisler- 
iug\  1014.  1021.  1022 

area,  method  of  measurini;.  1168 
Skopophobia,  844 
Skopzki,  the,  435.  436 
Skull  in  i;eneral  paralysis.  535 

siijns  of  inflanimator.v  action  in,  goo 

injury,  trephining  in,  1324 
Slander,   action  of,    ])eriod    of   limitation    of.    and 

lunacy,  995 
Slavering  in  idiots,  means  of  correcting,  669 
Sleej),  257 

facial  expression  in.  485 

attention  in.  no 

psychology  of  (ilereier),  448 

phenomena  of,  and  hysteria  compared.  623 

the  hysterical,  638 

in  myxoedema.  828 

considered  iihysiologieall.v,  1128 

after  transitory  freuz.v,  1305 
Sleeplessness,  causes  of,  703 
Sligo  As.vlum,  710 
Small-pox,  the  delirium  of,  334 

and  accidental  deaf-mutism,  327 

insanity  following,  987 
Smell,  33 

localisation  of,  in  cortex,  156 

in  sporadic  cretinism,  286 

hallucinations  of.  567 

sense  of,  in  delirium  tremens,  342 

in  hallucinatory  mania,  767 

in  persecution  mania.  927,  928 

education  of,  in  idiots,  672 

during'  somnambulism.  1172 

])sycho-physical  method  of  registering,  loi^ 

photisms,  1 1 25,  1 1 26 
Smith,  K.  Tercy.  enteric  fever  in  the  insane,  507 

acute  delirious  mania,  52 

spinal  durha-matcmiata  in  general  paralysis,  883 
post-mortem  appearances  of  sunstroke  lesions, 

1237 
operative  procedure  in  general  paralysis,  132:; 
Smokers,  diseases  of,  1297,  1298 
Smollett,  the  c.-ise  of  Earl  Ferrers,  298.  299 
Smyth,  Johnson,  urea  in  dementia.  1343 
urea  in  general  paralysis.  1344 
uric  acid  in  mental  affections.  1345 
Sneezing,  hysterical,  635 
Snell,  Wahnsinn,  1364 
Snow,  cancer  and  insanity,  177 
Social  conditions,  &c.,  intlueucin;:    reco\ei-y  in  asy- 
lums, 1 199 
and  mortality  in  asylums,  1199 
and  suicide,  1228 
and  causes  of  general  itai'alysis,  ^34 


Social  conditions  .-nid  erotomania.  702 

reiationslii)),  a  noi-malit.v  of  conduct,  247 
l)osilion  of  cretins,  287 
"Societies  of  patronai;e,"  Switzerland,  1242 
Societies,  protective,   for   patients  leaving  asylums, 

515 
Society  for  I'sycliieal  Uesearch,  1013 
Socrates,  suicide.  1218 
Sodium  bromide,  iictioii  of,  1130 
Softening  of  the  brain  and  its  si)ecilic  gravity,  160 

chemical  changes  in,  152,  160 
Solar  heat,  action  of,  on  organism,  1233 
.Solicitor,  Treasury,   action    of.  in   cases  of  alleged 

insanit.\.  1004.  1005 
Somatic  elassilication  of  insanit.v.  231 
ei)i<lemics  and  insanity,  437 
origin  of  transitory  frenzy.  1303 
])rodromata  of  delirium  tremens,  342 
Somato-a'tiological  elassilication  of  insanity,  231 
Somnal.  action  of,  1137 
.Somnambulism,  1172 

and  doul)le  consciousness,  401-406 
and  insanity,  582 
in  children.  203 

and  hyi)notism,  relation  between,  006 
Somnambulistic  stage  of  hypnotism,  607,  608 
Somnauibulous  amnesia,  377 
Sonden,  epidemic  religious  ecstasy,  439 
Soothsayers  in  mental  maladies,  14 
Sophocles,  description  of  insanity,  8 
tlie  insanity  of  Hercules,  8 
the  insanity  of  Ajax,  7,  8 
Sopor.  53 

Sorcerv  auiong  the  ancient  Jews,  715 
Souda  ;i  tabee,  830 
Sound  i)hotisms,  1125.  1126 
Sowerby,  the  hellebore  of  the  ancients.  1353 
Spasmodic  ergotism,  458 
mydriasis,  105^ 
myosis,  1055 
Spasmophilia,  neurasthenic,  843 
Spasms,  h.vsterical,  634,  635 

muscular,  in  uenrastheuia,  845,  846 
muscular,  in  chronic  alcoholism,  75 
Spastic  paraplegia  and  idiocy,  656 
of  lathyrism,  730 
spinal    general    paral.vsis    due    to    congenital 

syphilis,  1258 
sjinptoms  in  later  stages  of  general  paralvsig, 
508 
Special  sense  areas  in  cortex,  156 
disorders  in  toxic  states,  972 
.Specific  fever  diagnosed  from  typhus  pellagrosiis, 
921 
fevers,  delirium  of,  334 
gravity  of  brain,  158.  162,  163 
of  convolutions.  161 
of  brain   tissue  in  the  insane,  158,   159, 

161,  162 
of  brain  in  phthisical  insanity,  947 
of  urine  in  mental  conditions,  1341 
Speech  defects.  61 

derangements  in  chronic  alcoholism.  76 
in  sporadic  cretinism,  286 
in  diagnosis  of  insanity,  378,  379 
absence  of,  in  diagnosis  of  insanity,  379,  380 
alfections  in  ergotism,  458 
co-ordination  imi)aired  after  enteric  fever,  506 
in  prodromic  stage  of  general  paralysis,  523 
in  general  paralysis,  527 

changes  after  acnti^  fevers  and  in  general  para- 
lysis diagnosed.  534 
disorders  in  general   paralysis,  pathology  of, 

542 
in  general  paralysis,  520,  523.  526,  527,  542 
centres.  186 
early,  of  children,  468 


I470 


INDEX. 


Speech  in  congenital  idiocy.  645 

Spontaneous  hypnotism,  609,  610 

in  toxic  states,  968 

Spoon-feeding,  499 

education  of,  in  idiots,  672 

Sporadic  cretinism,  285 

sounds  and  colour  sensations,  1 126 

pathology  of,  286,  287 

during  somnambulism,  1172 

hereditary  forms  of,  286 

mechanism  of,  iigi.  1192 

treatment  of,  287 

defects  in  iieneral  paralysis.  1192 

.social  aspect  of.  287 

in  disseminated  sclerosis.  1192.  1193 

development  of,  285 

in  bulbar  paralysis,  1193 

thyroid  atrophy  in,  285 

defects  due  Ui  habit,  1193 

mental  deficiencies  in,  285,  286 

defects,  educational,  1193 

skeletal  development  in,  286 

defects  due  to  hereditary  syphilis.  1264.  1265 

cranial  development  in,  286 

in  transitory  frenzy.  1304 

cutaneous  structures  iu,  286 

defects  due  to  brain  injury,  1310 

physiological  activity  in,  286 

Spencer,  Herbert,  the  jirinciples  of  iisycboloiiy,  47 

Spurzheim,  tlie  brain  as  organ  of  mind,  21 

self-preservative  conduct,  243 

Stabile  currents,  431 

pleasures  and  pains,  252 

Stages  of  general  paralysis,  521 

moral  insanity,  815 

Stahl,  sympathetic  origin  of  nisanitj-,  1243 

Spendthrift,  the  eccentric,  423 

"Stahl's  ear,'  419 

Sperm,  physiological  function  of  the,  586,  589 

Stahlians,  94 

Spermatozoa  in  urine  after  epileptic  lits,  1348 

Star-cross  Idiot  Asylum,  552 

Spes  phthisica,  937 

Staring,  484 

Sphacelinie  acid,  gangrenous  action  of.  458 

Starck,  diagnostic  value  of  pt3-alism  in  insanity, 

Sphsero-cerebrin,  150 

1107 

Sphiuiiomyclin,  148 

State  Asylums,  United  States,  85 

SphiuLiosin,  149 

States  ;nid  changes  of  consciousness,  250,  251 

Sphygmo^raphic  tracings  in  neura>tlieiiia,  1042 

Statistics  of  the  insane  in  United  States,  85,  86 

in  hjiJnotism,  1042 

in  Australia,  iii,  112,  113 

in  hypochondriasis,  1043 

of  causes  of  idiocy,  659,  660,  664 

in  hysteria,  1043 

of  the  insane,  Ireland,  708 

in  Insanity  with  cardiac  lesions,  1043 

Italy,  718 

in  insanity  with  pulmonary  lesions.  1044 

of  insanity  and  phthisis,  944 

in  stuporous  conditions,  1045 

of  the  insane,  Russia,  iioi 

in  acute  delirious  mania,  1046 

Sweden,  mo 

in  acute  mania,  1047 

Norway,  iiir 

in  general  paralysis,  1049 

Denmark,  1113 

in  epileptics,  1049 

Scotland,  1124 

in  dementia,  1050 

Spain,  1 178 

Spinal  cord,  post-mortem    appearances  in  i^eneral 

Switzerland,  1240,  1241,  1242 

paralysis,  536,  539 

as  to  sex  in  insanity,  1153 

lesions,  paralytic  niyosis  in,  1055 

Status  epilepticus,  sphygmographictracinus  during, 

affections  of,  and  nymphomania,  864 

1 188 

lesion  of,  in  pellagra,  921,  922 

in  ergotism,  458 

reactions  to  drugs,  971 

Steinlacher,  Alex.,  histology  of  microce])haly,  806 

luematoraa,  883 

Stephen,  Sir  James,  criminal  responsibilitj'  of  the 

posture  iu  mental  states,  991 

insane,  297,  300,  301,  315,  316,  319 

lesions  due  to  hereditary  syphilis.  1262,  1269 

medical  examination  of  alleged  insiine  crimi- 

nerves, lesions  of,  due  to  hereditary  sjiihilis. 

nals,  1005 

1269 

suicide,  1220 

'■  Spinal"  form  of  general  paralysis,  519,523 

Sterson,  irritable  muscular  weakness,  1046 

"  Spinal  irritation,"  843,  844 

Stevenson,  the  hellebore  of  the  ancieuts,  1353 

"Spinal  pupil,"  the,  1055 

Stewart,  Dugald,  Scotch  school  of  metaphysics,  45 

diagnosed   from   the  Argyll-Kobert>oii   impil. 

mental  faculties,  493 

1055 

hypnotism,  603 

"Spinal  system  "  of  Marshall  Hall,  441 

Stiff,  the  a'tiology  of  othaeunitonui,  561 

Spirits  seen  by  visionaries,  1359 

Stigmata  of  hysteria,  628,  629 

Spiritualistic  mediums,  1161 

and  self-mtitilation,  1148 

Spiritualists,  1360 

.*<tigmates  psychiques  (Magmm),  331 

Spitting  in  the  insane,  1107 

Stimulants  in  treatment  of  drunkenness,  417 

Spitzka,  the  delirium  of  acute  delirious  mania,  53 

iu  melancholia,  795 

post-maniacal  reaction,  53 

iu  treatment  of  insanity,  1291 

sequelae  of  acute  delirious  mania,  54 

Stimulus,    intensity   of,   in   reaction-time   experi- 

])rognosis of  acute  delirious  mania,  54 

ments,  1068 

exophthalmic  goitre  and  insanity,  476 

association  of,  and  reaction-time  experiments. 

feigned  general  paralysis,  504 

1070 

pulse  in  early  stages  of  general  paralysis,  1047 

Stoeber,  "oinomaniacs,"  394 

Spleen  aiTectious  and  insanity,  1245 

Stomach,  reference  of  painful  and  pleasurable  emo- 

atrophy of,  in  pellagra,  922 

tions  to  the,  260 

post-mortem  apjiearances  in  general  paralysis, 

Stomach-purap,  feeding  by  the,  499 

537 

Stopford,  Archd.,  the  Kevivalists  of  Ireland,  1090 

Spontaneity,  1026 

Strahan,  paraldehyde.  1134 

cerebnil,  and  movement,  821,    823,  824.  825, 

chloral  amide,  1135,  1136 

826 

Strain,  mental,  as  exciting  cause  of  general  para- 

Spontaneous movements,  821 

lysis.  535 

in  young  animals,  465,  468 

Stramonium,  delirium  due  to,  336 

postures  in  mental  states,  989 

Stridor  dentiuni.  173 

actions,  controllability  of,  1026 

Strontium,  bromide  action  of,  1131 

INDEX. 


147 1 


Strumous  diiithesis  inul  iiiiiinl^i\c  .•u-ts,  356 

ididcy,  644 
Stupidite,  1209 

Stupor,  iiitt'rinittoiit.  sijliygiiinj^r.-ipliic  tniciiig^   in. 
1045 

melancholic,  tiMiiiiorature  in,  1280 

mental,  and  suicidal  acts,  354,  355 

electricity  in,  430 

anergic,  in  adolescents,  366,  361) 

simulation  of,  503 

lotharuic,  748 

in  senility,  871 

in  phthisical  insanity,  943 

in  toxic  states,  971 
Stuporous   forms  of  insanity  in    pU'-rpciMl    st.'iles. 
1040,  1041 

melancholia,  pulse  conditions  in.  1045 

insanity  due  to  bmin  injury,  1309 

melancholia  in  folie  circuhiire,  217 

form  of  general  paralysis,  525,  526 

melancholia  in  crjjotism,  458 

melancholia  in  iiOut,.548 

states,  post-connubial,  776 
Sturges,  the  association  of  clioreii  ;nid  insanity.  208 
Stuttering  in  ijeneral  paralysis,  526 
Sub-acute  alcoholic  delirium,  66,  69 

genei-al  paralysis,  microscopic  clianiics  in.  537 
"Subjective    distinction    lime"     in    iCMctinn-linie. 

1070 
Subjective  observation,  30 

sen.sorial  perception  in  di;ignosis,  373 

sensory  disturbance   in  prodromata,  of  Lienenil 
paralysis,  523 
.Suetonius,  the  epileptic  insanit.v  of  Caligul.i.  17.  1 8 
Suffusion,  tepid  and  cold,  119 
Sugar  in  urine  in  brain  lesions,  1349 
Suggestion,  eiTect  of,  on  bladder,  1339 

and  attention,  1 10 

in  hj-pnotism,  605 

hypnotic,  a  patliologiciil  phendnienon.  bo6.  610 

in  cataleptic  stage  of  hypnotism,  607,  609 

in  lethargic  stage  of  hypnotism.  607 

in    somnambulistic    stage  of  hyi>noti>in.    608. 
609 

in  hysterical  states,  610 

criminal,  in  hypnotism,  608 

by  gesture,  609 

influence  of,  in  imperative  ideas,  679,  680 

treatment  of  obsession  by,  681 

of  phj'sical  injury  in  fright  hypnosis,  ir59 

increased  salivaiV  flow  due  to.  1105,  1 106 

during  normal  sleep.  405.  406 
Suggestive  treatment  of  somnambulism.  1173 
Suicide,  449,  790 

in  delirium  tremens,  70,  343 

in  children,  202,  203,  364 

as  evidence  of  lun.acy,  463 

in  ambulatory  enteric  fever,  506 

in  dipsomaniacal  impulse,  391 

in  prodromal  stage  of  enteric  fev(>r.  506 

in  general  paralysis,  525 

in  hypochon<lriasis,  614,  616.  617 

among  the  Hindoos,  683,  684 

in  relation  to  life  insurance.  748 

in  hysterical  mania,  769 

post-connubial,  776 

during  catamenia,  803 

in  insanity  of  negation,  832 

in  phthisical  insanity,  945 

in  persecution  mania,  931 

in  drunkenness,  67 

in  climacteric  insanitj',  235 

in  secondary  dementia,  349,  350 

in  senile  dementia,  350 

in  regicides,  1077 

mechanical  restraint  in,  1318 

in  syphilophobia,  1254 


Suicide,  testamenl.'ii'y  capacity  iind,  1289 
Snicidiil  melancliolia,  329 

ads  in  menlMl  stupor,  354,  355 

desires  in  liilie  circulaire,  217 

impulse,  rccurrc^nce  of,  355 

impulse,  nu'ilico-legal  view  of,  355,  356 

violence  in  epileptics,  551,  555 

inijiulse,  681 

incliniitions  in  insane  jealousy,  722 

meljincholia,  790,  795,  797 

tendencies   in    insanitv    of   paralvsis   agitans, 
886 

impulses  in  pellagra,  920,  921 

inelinjitidiis  in  puerperal  insanity,  1039 

inclinaIion>  in  Inctalional  insanity,  1041,  1042 

cases  under  single  care,  1165 
Suitabilit.v.  sexual,  for  jiropagation,  587.  588 
Suleimaui^  Asylum,  1328 
."^ullivan,  neui'oses  of  malnria,  756 
Snlly,  .Tames,  attention,  106 

illusions,  675 
Sulplialides,nitrog-eni.sed  phosphatide,  in  brain.  149 
Snlphonal  in  acute  delirious  mania.  55 

action  of,  1138 

liabit,  1138 

in  treatment  of  insanity,  1292,  1293 
Sulphur  baths  in  i)lumbism,  748 
Summary  order  I'or  reception,  England  and  'Wales, 
732.  733 

Scotland,  1 122 
Sunstroke  as  cause  nf  acute  delirious  mania.  ,2 

delirium  of.  335 

as  cause  of  idioc.v,  665 

insanity  of,  911 
Superintendents,   medical,  in   Irish   asylums.  710 
711,  712 

of  county  asylums,  appointment  of,  280 

of  hospitals,  liabilities  of,  1079 

of  asylums,  Scotland,  duties  of,  1121 
Supersedeas  of  inquisition,  199 
Sn])erstition     in     the    treatment     of    the     insane, 

Ireland,  707 
Suppressed  gout  and  mental  disorder,  549 
Snpra-renals,   afTcction    of    the,    in  exophthjilmic 

goitre,  477 
Snrdi-mutisme,  326 
Surexcitation  nerveuse.  841 
Surgical  operations,  insanity  following,  1313.  1314 

cases,  mechanical  restraint  in,  1318 

treatment  of  forms  of  insanity,  1324 

treatment  in  general  paralysis,  544,  132:; 
Surprise  baths,  119 
Surprise  c^rebrale,  187 
Susceptibility  to  hypnosis,  1215 
Suspicion,  delusions  of,  in  deaf  persons,  328 
in  phthisical  insanity,  945 

monomania  of,  812 

delusions  of,  in  moral  insanity,  814 
Sutherland,  H.,the  blood  of  general  paralytics.  138 

cancer  and  insanitj',  177 

forcible  feeding,  494 
menstruation  and  insanity,  801 

mineral  salts  in  urine  in  mental  states,  1347 

specific  gravity  of  urine  in  mental  states,  1341 
Sutton,  alcoholic  delirium,  337 
Sutures,  the  cranial,  in  microcephaly,  805 
Sweat,  excess  of,  in  neurasthenia,  847 

composition  of,  1166 

and  mental  states,  1167 
Sweating  system,   insanity  among  the  victims  of 

the,  245 
Sweden,  hyiniotism  in,  605 

the  insane  in,  11 10 
Swcdenborg  as  a.  visionarj',  1360 
Swift,  Dean,  provision  for  tln^  insane,  Ireland,  708 
Switzerland,  hypnotism  in,  605 

cretinism  in,  286 


1472 


INDEX. 


Sydeiihaui,  uicutiil  allet-tious.ai 

ti-eatmeut  of  insanity.  21.  22.  24 

nionlal  effects  of  gout,  548 

chorea.  214 

mania  of  (|uai'tau  ajjiic.  757 

iuteruiitteiit  ffvei's  and  insanity,  98b 

patliology  iif  post-tyiilionsinsauit.v,  987 
Symmetrical  movements.  1026 
Sympatlietic  ptyalism.  1104 

sj'stem  ill  Lieiieral  paralysis,  539 

disease,  irritation  mydriasis  in.  10,5 
Symptomatic  insanity,  1244 

treatment  of  idiots,  669,  670 

treatment  of  insanity,  1290 
S.NTuptomatolouicalclassitication  of  insanity,  230 
Symptoms,    duration   and   mode    of    on^-et   of,   and 

prognosis,  1006 
Syiicliresis,  466 
Syncope  in  toxic  states.  971 

Syiidromesepis(i(li(|uis  de  la  folie  des  degeneres,  389 
Synonyms,  foreign,  of  terms  in  mental  disease,  1381 
Synostosis  in  microcephaly,  1326 
S>nitrophy,  law  of,  1028 
Syphilis  and  sunstroke,  1233 

of  brain  diagnosed  from  general  paralysis,  533 

an  exciting  cause  of  jieneral  paral.ysis,  535 

in  the  insanity  of  cliildren,  204 

and  locomotor  ataxy,  751 

influence  of,  in  malarial  insanity,  757 

and    alcohol,     diverse    action   of,    in     nervous 
system,  915 
Syphilitic  antecedents  and  idiocy,  665 

poisoning    inducing    insanity,  pathology.    913. 
915,  918 

fever  and  delirium,  1253,  1254 

and  mania,  1253,  1254 

insanity,  1253 

insanity,  the  exaltation  of,  474 

tubercular   disease  of  auricle  diagnosed  from 
othaematoma,  559 
Syphilophobia.  1253.  1254 
Syringe,  feeding  by  the  nose.  501 

Tabes  dorsalis  in  general  paralysis,  520 

mental  associations  of.  750 

diagnosed  from  peripheral  neuritis,  924 

jiaralytic  myosis  in,  1055 
Tabetic  symptoms  in  senile  dementia,  872 
Tabiform  neurasthenia,  840 
Taclie  cdrebrale  in  stupor.  1208 
Tachycardia  and  impulsive  acts.  354 
Taciturnity  in  diagnosis  of  insanity,  379,  380 
Tacitus,  suicide,  1218 
Tactile  sense,  a  knowledge-giving  sensation,  ^^ 

hallucinations,  567 

sensibility  during  s(minambulism,  1172 
Tagnet,  treatment  of  the  insane  by  coloured  light. 

239 
Tait,  Lawson,  insanity  relieved  by  hysterectomy.876 
Talcott,  trephining  in  mental  affections  due  to  brain 

injury,  1324 
Tamburini,  A.,  experimental  researches   into  in- 
sanity, 717 
vascular  changes  during  hypnotism.  1042 
and  Tonnini,  S.,  insane  in  Grreece,  553 
India,  682 
Israelites,  715 
lycanthropy,  732 
witchcraft,  1368 
Tanzwnth,  choreomania,  214 
Tarantism,  337,  438 
Tardieu,  atropism,  133 

pregnancy  and  kleptomania,  727 
classification  of  mental  poisons.  967 
pjTf)maiiia  in  imbeciles,  1057 
and  Dcchanibre,  the  insanity  nf    cantliarides 
poisoning,  177 


Taste,  a  knowledge-giving  sensation,  33 

localisation  of,  in  cortex,  156 

hallucinations  of,  567 

sense  of,  in  delirium  tremens,  342 

in  persecution  mania,  927,  928 

education  of  the  sense  of,  in  idiots,  672 

psycho-physical  method  of  registering,  1015 

])hotisms,  1125,  1126 

during  somnambulism,  1172 
Taubsttimmheit,  326 
Taylor,  exophthalmic  goitre,  476 

microscopy  of  cerebral  atrophy,  652 

mutism  of  insane  criminal,  961 
Tea  abuse,  the  tremor  of,  1321 

in  the  diet  of  tlie  insane,  387 
'I'ebaldi,  optic  atro]iliy  in  general  paralysis,  490 
Teeth  in  congenital  idiocy,  645 
Teilleux,  use  of  electricity  in  mental  affections,  427 
Telluric  influences  on  suicide,  1221 
Temperament,  insane,  382,  694 
Temjierance  societies,  influence  of.  on  drunkenness. 

73 
Temperature  and  delirium,  338 

in  general  paralysis,  531 

local  rise  of,  in  cerebral  action,  399 

hysterical  change  of,  624 

in  mania,  762 

during  fasting,  774 

in  phthisical  insanity,  94^ 

sense,  psycho-physical  method  of  registering, 
1014 
Tempero-sphenoidal  lobe,  weight  of,  167 
Tendon  reflexes  in  criminals,  289 

in  ergotism,  459 

in  neurasthenia,  846 
Testamentary  caiiacity  of  eccentrics,  420 

dispositions,    undue    influence   in     procuring, 
1338 
Testator,  insanity  of  a,  1289 

Tetaniform  seizures  in  general  paralysis,  520,  530 
Tetano-cannabin,  1143 
Tetanoid  convulsions  after  malaria,  756 
Tetanus  and  catalepsy  differentially  diagnosed.  184 

delirium  in,  335 

physostigmine  in,  1146 
Tetronal,  action  of,  1138 
Tlianatophobia,  844 
Thebain,  action  of,  1140 
Theft  in  general  paralysis,  529 

distinguished  from  kleptomania,  726 
Themison,  the  treatment  of  the  insane,  14 

venesection  in  insanity,  14 
Theomania,  352.  1091 
Therapeutical  use  of  suggestion,  1217 
Thermometer,  use  of,  in  insanity,  1280.  1281 
Thierseelenkunde,  1374 
Thinking.  31,  32.  1027,  1031 

neural  action  of,  468 
Third  nerve,  paralysis  of  the,  in  general  paralysis, 
487,  488 

lesious  of  the,  and  paralytic  mydriasis,  1054 
Thirst  in  dipsomaniacal  impulse,  390 
Thompson.  G..  pulse  tracings  in  general  paralysis, 
1048 

arterial  states  in  epilepsy,  1049 
Thompson.  Theophilus,  the  effect  of  mental  labour 

on  blood,  136 
Thoms(m,  Bruce,  remorse  in  criminals,  290 
Thorburu,  unconsciousness  due  to  fright,  1158 
Thorc,  acute  mania  preceding  pneumonia,  985 

acute  maniacal  delirium  following  fevers,  986 

mania  following  typhus,  986,  987 
Thought.  37,  38,  250,  251,  1027 

and  language,  29,  979 

disorders  of,  263,  346 

in  prodnmiic  stage  of  chorea,  207 

latent.  187 


INDEX. 


1473 


Thought  ill  ilreams,  412 

uiicimlnillcil.  46S 

cercbriil  iii-i>ct'>-»'s  of.  (;-., 

ami  occiipatioiis,  Q71) 

coutiiiuous.  ill  motor  iiiiha-ia.  i)8o 

ill  sensory  ajihusia,  y8i 
Thou<;hts,  ivmerabraiici'  of,  25c; 

and  I'livironiiicutal  coiulitions.  201.  ^nn 

and  feeliuL;,  258 
Throuiliosis.  ciTfldal.  in  idiocy,  655,  656 
Tliiidii'huin.  .1.  W.  I...  I'xcn'tloii  nf  uric-  .'iriil.  1344 

chemical  composition  of  brain,  146 
specific  gravity  of  brain,  158 

Thurnani.  iiu'lhod  of  calculatini;    ivcoVfries.    1196. 
1 197 

lui'an  iinnilior  ri-sident  in  nsyluins.  1197.  I2cxj 

jRMUxl  for  correct  statistical  observation,  1200 

frequt'iicy  of  occurrinci'  ol'  rclaiiscs.  1200 

aye  and  lialillity  to  insanit.v,  1202 

braiu  weight,  1365 

recovery  from  insanity,  322 

brain  \veiL;ht  in  the  insane,  164,  163 

sex  ill  insanity,  1 153 
Tliyroid  gland  in  cretinism,  284,  285,  287 

coiiLienital  absence  of,  284 

congenital  malt'orniation  of.  284 

atrophy  of.  285 
Ti>>erstedt,  subjective  ilistiuction  time.  1070 
Ti;rretier,  439 

Tilt,  mental  instability  at  the  climacteric.  234 
Time,  psycho-physical,  1024 

and  memory.  36,  37 

-sense,  psycho-physical  method  of  reuisterin^;, 
1015 
"  Timid,"  the,  409 
Tindal,  Chief  Justice,  criminal  responsibility  of  the 

insane,  306,  307 
Tlscher,  subjective  distinction  time,  1070 
Tissi^,  somnambulistic  double  consciousness.  402, 

403 
Titillation,  1294  (nc  art.  Ticki.isuness) 
Titus,  the  treatment  of  the  insane.   14 
Tober-na-ualt,  707 
Tobsucht,  transitorische,  1302 
Tod,  the  treiitment  of  the  insane.  87 
Toledo  Asylum.  Ohio.  86 
Tongue  in  mania.  762 
Tonics,  effect  of,  on  the  bliMid,  140 

in  melancholia,  794 

in  neurasthenia,  849 

in  treatment  of  insanity,  1291 
Tonuini,  s.,  treatment  of  the  insane  in 
Italy, 715 

and  Amadei.  classilication  of  paranoia.  887 

and  Tamburini.  A.,  insane  in  Greece,  553 
India,  682 
Israelites,  715 
lycanthropy,  752 
■witchcraft,  1368 
Tontos,  284 
Tooth-ache,  cjises  <jf  iiurmanent  i-iire  of  acute  mania 

by,  80 
Toowoomba  Asylmii,  111 
Topophobia,  679 
Toptaschi  Asylum,  1328 
Toronto  Asylum,  175 
"Total  insanity,"  297 
Totolas,  284 
Touch,  insjvnity  of,  4  lo 
hallucinations  of,  567 
education  of  the  sense  of,  in  idiots.  672 
Tourette,  Gilles  dc  la,  sialorrlKca  in  hysteria.  1105 

and  Charcot,  J.  M..  hypnotism   in  the 
hysterical,  606 

Touruefort,  vampirism,  1352 
Toxic  causes  of  insouinia.  703 

insanity,  pathology  of,  912.  (,13 


Toxic  chronic  poisoning,  972 

insanity,  characteristics  of,  967,  973,  974 

insanity,  religious  delusions  in,  1092 

causes  of  tremor,  1320 
Tracy,  Justice,  insanity  of  a  criminal,  298 
Trade  dei)ressioii  and  suicide,  1225 

-marks,  8gi  {nee  ratentees.  Insane) 
Training,  social,  and  hysteria,  620 

of  the  liysteii<'al.  624 

of  idiots  and  imbeciles,  667 

non-parental,  in  idiocy,  667 

institutions    for  imbecile    children,    .Scotland, 
tug 

of  attendants,  692,  693 
Trance,  ecstatic.  424 
Trance-like  states  in  children,  203 
■•Transference"  in  hysteria,  621,  641 
Transference  of  a  patient  from  paujxT  to  private, 

734 
from  private  to  pauper,  734 
from  one  asylum  to  aiiotlier,  734 
Scotland.  1123 
Transfers  and  statistics,  1195 
Transfusion  of  blood  in  insanity,  22 
Transition,  mode  of,  in  folie  circnlaire,  221,  222 
Transitorische  Tobsucht,  1302 
Traumatic  general  jiaralysis,  1310 
idiocy,  644,  665 
j  causes  of  idiocy,  665 

injury  and  insanity,  912 
j  insanity,  trephining  in,  1324,  1321; 

nenral^ia  and  maniacal  states,  839 
I  suggestion,  1159 

hysteria,  1160 
neurastlienis.  1160 
neuroses,  1160 
■■  Traumatic  neurosis,"  639 
Traumatism  ;uid  kleptomania,  727 

as  cause  of  hysteria,  625,  628,  639 
Traverse  of  inquisition,  199 

Ireland,  714 
Treasury  Solicitor,  action  of,   in  cases  of  alleged 

insanity.  1004,  1005 
Treatment,  medicinal,  of  insanity,  1290 

of  the  insane  among  the  ancient  (ireeks,  10,  12, 

14 
of  the  insane  among  the  ancient  Romans,  itr, 

i8 
of  insaiiitj-,  early,  21,  22,  24,  131,  175 
of  private  patients  in  the  eighteenth  century, 

23 
of  insanity,  present  day.  United  States,  88 
of  the  insane,  early,  in  Canada,  175,  176 
of  iiLsanity,  by  ex(n'cism,  43^,  433 
of  insanity,  home  and  asylum,  compared,  1165 
of  the  insane,  Italy,  719 
regulations  as  to,  England  and  Wales,  736 
Tr^lat,  classification  of  dii)somaiiia,  392 

insanity  of  doubt,  407 
••  Trembles,"  the,  1321 
Tremor,  convulsive,  275 

in  handwriting,  568,  569 
muscular,  in  hysteria,  635 
of  disseminated  sclerosis  in  diagnosis  of  hys- 
teria, 1 1 63 
of  chronic  alcoholism,  75,  76 
of  head  after  typhoid  fever,  986 
■"Trespass"  bv  a  lunatic,  1298 
friakaidekapliobia,  844 
Trichopliobia,  678 
Trichosis,  anomalous,  128 
Tripier,  pulse  in  petit  mal,  1050 
Trismus,  hysterical,  642 
'I'rophic  anomalies  in  mania.  762 
in  morphia  habit.  818 
in  the  insane,  144.  173,  129,  329,  557 
in  hysteria,  624,  637 


1474 


INDEX. 


Trophic  ck'raiii;enit'nts  jiuil  iiiauiiic:il  states.  839 

clistiir bailees  in  pellagra,  920 

cliauii'es  ill  liraiii  stjiti's,  938 
Tropical  climates,  effect  of,  on  races,  1233 
Trostwyk,  van.  early  uses  ol'  elct-tricity.  426 
Trottelii.  284 
Trousseau,  atropism.  133 

daturism.  326 

insanity  of  yout,  549 

patholo;j;y  of  post-typhous  insanity.  987 

vascular  conditions  of  febrile  states.  987 

insanity  foUowins  rheitmatism,  987 

chlorosis,  1351 
Trnnksuclit.  388 
Trustee,  insanity  of  a,  1328 
Tube  for  artificial  feediiii;.  499 

method  of  passing-,  for  artificial  feeding;.  500 
Tubercular  affections  in  idiocy,  654,  656 

lunt;  affections  in  the  insane,  941 

cerebral  deposit,  absence  of,  in  ]ihtliisiciil   in- 
sanity. 947 
Tuberculosis  and  insanity,  912 
Tiibini,  density  (if  saliva  in  sialnrrlioca.  1104 

Tuczek.  F.,  ergotisra,  457 
lathyrism,  729 
pellagra,  918 

Tuke,  1).  Hack,  spdiiii-feediiiL;-  by  the  nose.  ^01 

historical  sketch  of  the  insane,  t 

use  of  alcohol  in  asylums,  m 

the  insane  in  Austria,  114 

bed-sores  in  the  insane,  129 

Bethleni  Hospital,  134 

bile,  supposed  influence  of,  in  in- 
sanity, 134 

Bright  s  disease  and  insanity,  172 

bruises  in  the  insane,  173 

the  insane  in  Canada,  175 

cancer  and  insanity,  177 

catalepsy,  184 

China,  the  insane  in,  205 

classification  of  insanity,  229 

coloured  light  in  the  treatment  of 
the  insane,  239 

Commissioners  in  Lvinacy,  240 

communicated  insanity,  240 

consanguinity,  248 

constipation  in  the  insane,  265 

convolutions  of  the  brain,  268 

definition  of  insanity,  330 

degeneration,  331 

demonomania,  352 

dreaming,  412 

conformation  of  the  external  ear, 
418 

eccentricity,  419 

ecstasy,  424 

energumens,  433 

colony  of  Fitzjames,  507 

the  insane  in  Great  Britain,  551 

hallucinations,  565 

change  of  colour  in  hair  in  recurrent  insanity, 

563 
illusion,  675 

imitation  or  mental  contagion,  676 
imperative  ideas,  678 
India,  insanity  in  (note  diu,  683 
influenza,  mental  disorder  follow- 
ing, 688 
attendants  on  the  insane,  692 
provision  for  the  insane  in  Ireland, 

707  .      ^ 

provision  for  the  insane  m  Japan, 

720 
mandragora   and    mandragorites, 

759 
Medico-Psychological  Association 
of  Great  Britain  and  Ireland,  786 


Tuke,  1).  Uiiek,  mental  physiology,  804 
monomania,  811 
moon,  813 

moral  insanity,  813 
Wajab  ud  din  Unhammad,  830 
mutism,  827 

insanity  of  negation,  832 
paranoia,  887 

physiognomy  of  the  insane,  947 
registered  hospitals,  1079 
religious  insanity,  1091 

pulse  ill  acute  mania,  1047 
note  111!  insane  in  Norway,  1112 

the  Sibyls,  1160 

private  asylums,  1002 

sleep,  1 170 

somnambulism,  1176 

statistics  of  insanity,  1194 

stigmata,  1207 

mental  stupor,  delusional,  1209 

suicide,  1217 

therapeutics,  1290 

trance,  1300 

treatment,  general,  1314 

Turkey  and  Egypt,  the  insane  in, 

1328 
vampirism,  1352 
veratrum  or  hellebore,  1353 
Verriicktheit,  1356 
Verwii-rtheit,  1357 
Wahnsinn,  1364 

Tuke,  Harrinutoii,  feedini^  the  insane,  495 

diets  for  feedin<4-  the  insane,  498 
Tuke,  J.  Batty,  the  lepto-meninges,  168 

operative  treatment  of  i;enei"al  paralysis,  909, 

1325 

and  Rutherford,  miliary  sclerosis  in  cerebral 
deoeneration,  906 

and  G.  Sims  Woodhead,  pathology,  892 
Tuke,  AVilliam,  and  The  Ketreat  at  York.  24.  25 

nursinji-  of  the  insane,  860 
Tuke,  W.  8.,  Cairo  Asjdum,  1329 
Tnniiiurs,  cerebral,  in  idiocy,  654 

cranial,  myosis  in,  1056 

phantom,  936 

cerebral,  paralytic  mydriasis  in,  1054 

cerebral,  irritation  mydriasis  iu,  1055 

Turin  Asylum,  716 
Turkish  baths  in  treatment  of  cretinism,  287 

in  treatment  of  the  insane,  123,  127 
Turner,  cerebral  convolutions,  268 

muscular  asjiiimetry,  948,  949 

temperature  in  general  paralysis.  1281 

excretion  of  urea  iu  general  panilysis,  1344 
Tussis  caninus  pubertatis,  272 
Twin-birth  causiny-  idiocy.  663 
Tynipaiiites  in  hysteria,  636 
Tjiihoid  fever,  the  delirium  of,  334 

influence  of,  in  mental  disorders,  506,  507 

insanity  following-,  986 
Typhi  iiuania,  52 
Typhus  fever,  the  delirium  of,  334 

insanity  followiuL;-,  986,  987 

pellagrosus.  920,  921,  922 
Typical  regicides,  1077 
Tyriine  Asyhim,  710 
Tyrosin  in  brain,  151 
Tzetzes,  the  feigned  insanity  of  Ulysses,  7 

Ulceration,  syphilitic  and  morbid  self- conscious- 
ness, 1255 
Ulysses,  feigned  insanity  of,  6,  7 
Umpfenbach,  sulphonal,  1 138 
Unconscious  cerebration,  115,  187 
UiicDnsciousness  due  to  friiiht,  1158 

of  transitory  mania,  the,  1304 
Uncontrollable  impulse,  681 


INDEX. 


1475 


Undeveloped  «<)Ut  mid  iiiental  disorder,  548 
United   .Slates,   law  of   testaineiitary   capnelly   In, 
1288,  1289 

])i-ovisiiin  for  Insane  in,  84 

sexes  in  ins-mity  In,  1154 
rnniiidii,  the  ni;iclness  nl'  tlic  llindiM)s,  683 
Unseen  iiueiicy,  uioncini;ini:i  of,  812 
Unsound  niiiiil.  legal  ilcllnilion  oT.  331 
rnverrielit.  ninseuliir  nerve-supply,  398 
Unil,  aetion  of,  11 37 
frhan  life  iind  suicide,  1226 
l'rl>antscliit-cli,  |)li(inisuis  anil  pliotlsnis.  1127 
Urea  in  liealtli  and  disease,  1343 
Uretluine,  aetion  of,  1136 
Urifeney  eertifleates,  194 

order  forms,  739 

•  irders  for  admission  of  private  patients,  Kn;;'- 
land  and  Wales,  731 

of  pauper  patients,  Kuiiland  and  Wales,  733 
Uric  aeid  exeretinn  in  mental  alfections,  1344 

arid  in  the  lilood.  elTeet  of.  13O 
Urinary  functions,  action  of  ()i)iuin  on  the,  1141 

hysterical  disturbances  of,  637 
Urine  in  hyimotic  conditions,  610 

in  neurasthenia,  846,  851 

oxalates  in  certain  nervous  conditions,  877 

and  sweat  composition  coniiKired.  1 168 
"  UrnincTs,"  1156 

Uri|uhart,  A.  K..  asyluin  construction,  102 
Royal  Asylvims  in  Scotland,  1094 
provision  for  the  insane  in  Spain, 

1 177 
Cairo  Asylum,  1329 

Scottish  lunacy  la"w,  n  15 

Urticaria,  hysterical,  637 

Uterine  disease  and  insanity,  803,  912 

disease  and  pseudo-c.vesis.  235 

disorder  in  ecstasy,  426 

causes  of  puerperal  insanity,  104T 

disorders  and  insanit.v,  1244 
I'trecht  Asylum,  593 


V-siiAPED  palate  in  neurotic  adolescents,  367 
Vacuolation,  cerebral,  in  insanity,  905 

cellular,  in  ejiileptic  insanity.  910 
Vaifinisuiiis  in  hysteria.  637 
Valencia  Asylum.  1177 
Valentin,  temperature  of  nerves  during  in>rveact 

1278 
Vali,  tlie  confiyfuration  of  the  external  ear.  418 
Valleix'  points,  835 
Vanity  in  eccentrics.  420 
Vapeurs,  841 
Vajxinr  baths.  127 
Va-icular  causes  of  sleep,  1170.  1 171 

cerebral  chany^es  in  dementia,  350,  35 r 

changes  in  mental  stiites,  1042 

effects  of  cociiine  abuse,  236 

nervous  condition,  di;iitalis  in,  387 

lesions  in  ertrotisni,  458,  459 

lesions  in  chronic  alcoholistn,  76 

cerebral  chaiiLres  in  alcoholic  insanity.  914 

spasm  and  dilatation  in  neurasthenia.  846 

effect  of  iih'oholic  sethitives,  1132 

effect  of  methylal,  1138 

effect  of  opium,  1140 

effect  of  physostitnnine,  1146 

tone,  1249 
Va-o-constrictor  centres.  894,  896 

fibres,  distribution  of.  894 
\'u«o-dilator  centres.  894,  895,  896 

flbre>,  distribution  of.  89:; 
Vaso-motur  nerve-.  1247.  1248 

cortical  centres  jind  temiieiatnre  ehan-es  In 
insane,  1279 

symptoms  in  prmlroinie  stiye  of  general  jia 
lysis,  523 


ion, 
4^9 


Vaso-niotor  psycho-neuroses,  1014 

iinninalies  in  general  jiaral.vsis,  ^27 

inllnenc<'s  of tical  blood-supply,  894,  896 

theory  of  i;<'ner;il  jiaralysis,  540 

neuroses  in  melancholia,  836 

action  in  eniolional  states,  837 

disturl)anccs  in  ju'llatira,  920 
Venesection  in  cliniacieri<'  insanity,  235 

in  the  tre.itnu'nt  of  insanity.  14,  15.  21,  22,  24, 
87.  235 
Ventilation  of  asylums,  105 

Ventricles,  f^ranulatlons  in  floor  of,  in  epilei)lic    in- 
sanity, 910,  91  1 
Ventur<5,  the  blood  in  pcUaura,  139 
Verbal  aphasia,  799 

expressions  of  misery  in  nndancholia,  788 

rei)elitions,  involuntary,  1354 
Verbigeration,  379 

in  katat  mia.  725 
Verbosity  in  the  insanity  of  cocaine  abuse,  237 
\'erf(iliun;^s\vahn,  390 

Vei'ga,  Andrea,  ])rog-ress  of  psj-choloey  in  Itnly.  717 
Verlnst  dor  Ekol<i-efiihlc,  502 
Verona  Asj'lum,  717 
Veri)lanck,   testamentary    capacity    and    insanity, 

1288 
^'errii(•ktheit,  secundilre,  695 

and  Wahnsinn.  1364 
\'erstandeskriifte,  707 
Vertigo  followinj;  cranial  injuries,  187 
Verults,  Asylum  des,  1238 
Verwivnheit  (Meynert),  767 
"  Vesanic  conditions"  in  toxic  states,  971 
Vestii;ial  reflexes,  1075 
Viborg  Asylum,  11 13 
Vilesians,  the,  436 
Villejuif  Asylum,  104 
Villiers,  colony  of,  508 
Violence,  mechanical  restraint  in,  1318 
Virchow,  the  pathology  of  hocniatoma  auris,  560 

cerebral  hypertrophy  in  idiocy,  649 

earl.v  synostosis  of  the  sphenoids  in  cretins,  657 

blood  in  m.alarial  poisoning,  757,  758 

patholog-y  of  cerebral  false  membrane,  880 
Vii'gil,  allusions  to  insanity,  753 

description  of  the  Cumean  Sibyl,  1160 
Virjiilio,  heredity  in  criminals,  289 
Visceral  peculiarities  of  criminals,  289 

neuralgia  in  hypochondriacal  melancholia.  836 

motor  disturbances  in  hysteria,  622 

neurastheni.T,  845 

insanity,  699 

causes  of  insomnia,  703 
Vision,  affection  of,  in  pellafiT.'i,  920 

psycho-physical  nu'thod  of  registering',   1015, 
1021,  1022 

in  disseminated  sclerosis  and  hj'sterical  loss  of 
vision.  T163 
Visitation  order  from  commissioners,  735 
Visiting  conmiittee  of  county  councils,  277,  281,  282 
A'isit(n-s,  asylum.   England  and  AVales,  inability  to 
sign  certificati's,  734 

duties  of.  735,  736,  737 

discharge  ordered  by,  737 
Visual  centres  in  disease,  413 

defects,  method  of  testing,  in  the  insane,  486 

defect  and  mind-l)lindness,  810 

images,  loss  of  the  mennn-y  of,  8og 

field,  concentric  narrowing  of.  in  hysteria.  632 

hallucinations,  566,  567 

hallncinations  in  ])ersecution  mania,  927 

projections,  voluntary,  982 

and  auditory  impressions  and  word-deafness, 
982 

and  auditory  iniiiressions  and  word-blindness, 


defect  and  si/c  of  i)ui)ils.  10^4 


5   B 


1476 


INDEX. 


Vix,  Ernest,  intestiiiiil  worms  and  insanity,  1245 
VizioH,  spontaneous  hypnotism,  609,  610 
Vogel,  classification  of  amentia,  84 
pyromania,  1056 
siiTiipatlietic  insanity,  1243 

excretion  of  uric  acid,  1344 
A'oghera  Asylum,  717 
Vogt,  Cbarles,  microcephaly,  805 
Voisin,  anosmia  in  general  paralysis,  1174 

morphia  in  melancholia,  1292 

paralysis  of  the  inferior  rectus  oeuli,  4S8 

hysterical  somnambulism,  403 

suggestion  in  idiocy,  674 

acute  pj'rexia  of  phlogoses  and  insanity,  986 

general  paralysis  following  articular  rheumat- 
ism, 988 

genei'al  paralysis  following  erysipelas,  988 

morphia  in  mental  affections,  1142 
Vcilckers,  centre  for  pupillary  reaction,  1053 
Volition,  32,  40,  41,  1029 

overt,  41 

in  cretinism,  286 
Volitional  insanity,  699 
Voltaic  electricity  in  insanity,  427 
Voltaire,  suicide,  1220 
Voluntary  action,  42 

attention,  107,  109 

movement,  824 

acts  and  will,  1366 

admissions  into  asylums,  France,  516 

boarders  in  asylums,  Phigland  and  Wales,  737 

notices  of  reception  of,  to  commissioners,  737 

consent  to  admission  of,  744 

in  asylums,  Scotland,  11 22 

interdiction,  Scotland,  11 15 
Vomiting,  hysterical,  622,  636,  637 
Vught  Asylum,  593 
Vulpian,  ataxy  due  to  plumbism,  746 

nervous  mechanism  of  salivation,  1105 

Wagner,  case  of  prolonged  sleep,  1173 
Wakefield  Asylum,  psycho-physical  laboratory.  1022 
Waldan  Asylum,  1239 
Walking,  823 

Waller,  A.  1).,  psycho-pliysieal  methods, 

1020 

Wandering  lunatics,  certification  of,  732,  733 
Warlomont,  hysterical  stigmata,  1207 
Warm  baths,  prolonged,  117 

with  cold  to  the  head,  118 

sitz,  118 

mustard,  118 
Warneford  Asylum,  Oxford.  1086 
Warner,  F.,  facial  expression,  485 

evolution  of  mental  faculty,  464 

case  of  cerebral  h\  i)ertrophy,  652 

movements    as    signs    of  mental 

action,  820 
postures     indicative     of     mental 

states,  988 
psychosis,  1025 

Washington  Asylum,  86 

Water,  sustaining  power  of,  in  fasting,  jt^,  774 
Water-supply  in  asylums,  104 
Watcrford  Asylum,  710 
Watson,  Eben,  physostigmine,  1146 
Watson,  Sir  Thomas,  the  delirium  of  acute  rheum- 
atism, 334 

the  early  uses  of  electricity,  426 
Webber,  pulse  tension  in  neurasthenia,  1043 
Weber,  acute  transitory  mania  after  typhus.  987 

pneumonia  followed  by  insanity,  988 

psycho-physical  law,  1025 
Weeping  in  melancholia,  788 

psychology  of,  1273 
Weigert's  staining  methods  for  sections,  it86 
Weight,  influence  of.  on  size  of  head,  578 


Weir  Mitchell  treatment  of   functional   neuroses, 

850 
Weismann,  heredity  and  instinct,  704 
Welcker,  numerical   estimate  of  blood-corpuscles, 

137 
Wells,  Sir  Spencer,  mania  after  ovariotomy,  876 
Wendt,  reflex  psychoses,  1313 
Wensleydale,  Lord,  the  legal  aspect  of  the  judges' 

summary  on  criminal  responsibility,  311 
Werner,  Wahusinn,  1364 
AVernicke,  Leltungsaphasie,  91 
Werwolf,  753 

Wesley,  John,  early  uses  of  electricity,  426 
West,    cerebral    hypertrophy    and  hydi'ocephalus 

diagnosed,  652 
Westcott,  Insanity  and  suicide,  1229 
Western  Counties  Idiot  Asylum,  552 
Westphal,  paralysis  of  ocular  muscles,  488 

agoraphobia,  678 

action  of  lead  on  nerves,  746 

tremors  of  head  after  typhoid,  986 

mental  effects  of  tj-phus,  987 
Wet  pack,  121 

Wey,  H.,  thoracic  abnormalities  in  criminals,  289 
White,  Hale,  collateral  sympathetic  ganglia,  1247 

functions  of  corpus  striatum,  157 

glycosuria  in  the  insane,  371 
White  tissue  of  brain,  specific  gravity  of,  151.  152 
Whitwell,  .1.  R.,  pulse  in  mental  stupor,  121 1 

pathology  of  mental  stupor,  1213 

pulse  in  insanity,  1042 

Wiedmann,  hejiatic  affections  and  insanity,  1245 
Wiglesworth,  J.,  pathology  of  mental  stupor,  1213 
mental  decay  due  to  syphilis,  1254 

bone  degeneration  in  the  insane, 

143 
optic  neuropathy  in  early  general  paralysis. 

523 
diagiiosis  of  general  paralysis,  532 

pachymeningitis  interna  haemor- 

rhagiea,  877 
and  Bickerton,  ophthalmic  changes  in  general 
paralysis,  490 
ophthalmic  changes  in  acute  mania,  492 
ocular  symptoms  in  the  insane,  491 
Wilde,  Sir  J.  P.,  testamentary  capacity  and  in- 
sanity, 1287 
'•  Wildermuth's  ear,"  419 
Wilkinson,  the  insanity  of  the  ancients.  3 
Wilks,  S.,  Bright's  disease  and  insanity.  172 
delirium,  332 
moral  perversion  in  hysteria.  621 
Will.  31.  32,  40,  1029 
abstraction  of,  35 
strength  of,  42 
rational,  42 

in  dipsomaniacal  impulse.  390 
in  homicidal  impulse.  596.  598 
in  impiilse  and  obsession.  867.  868 
Wille.  Ludwig.  primiire  Verriicktheit.  1356 
confusional  insanity.  1358 
old  age  and  its  psychoses,  869 
Williams,  S.  W.  D.,  po^^ture  in  feeding.  .^.96 

baths  in  the  treatment  of  the  in- 
sane, 117 

Williamsbnrgh  Asylum.  United  States.  85 
Willing.  .31 

Willis,  physician  to  George  III.,  22.  23 
Willis,  Thos.,  douche  treatment.  120 

on  functions  of  the  brain.  21 

circular  insanity.  215 

Willoughby.  w.  G..  temperament,  1275 

visual  memory.  1360 
Wills,  undue  influence  in  the  execution  of.  1338 
Wisconsin,  boarding  out  in.  143 
Wise,  the  insane  in  China.  205 
AV'it  in  mania,  763 


INDEX. 


1477 


WitcluTilft  in  ludia,  683 
Witnesses,  the  insani'  as,  464 

iloal'-muti's  as,  464 
Witticli,  von,  normal  acoustic  rcat'tion-tiine,  1063 
Wittiugliani  Asyhini,  104 
WollT.  i)ulsus  tardus  in  incurable  insanity,  1050 

u>ori)liia  in  mental  alTcctions,  1142 
Wollener,  patholojjical   lesions  in   folic  circulaire, 

227 
^Vomcn,  general  paralysis  in,  520 

insane  jealousy  in,  721 

masturbation  in,  785 
Wonford  House  Asylum,  1083 
AVood,  H.  C,  administration  of  chloral,  1135 

of  morphia,  1142 

action  of  hyoscine,  1143 

CAunabin  as  a  hypnotic.  1144 

action  of  conium,  1145 

Wood,  T.  Ouiterson,  law  of  lunacy,  730 
Woodhcad,  (i.  Sims,  microscopical  prepa- 
rations of  brain  and  cord,  1180 

and  Hatty  Tuke,  pathology,  892 

colloid  bodies  in  cord  in  locomotor  ataxy, 
907 
Woodville,  the  hellebore  of  the  ancients,  1353 
Woodward,  the  treatment  of  the  insane,  87 

ultimate  recoveries  in  insanity,  323 
Worcester   Hospital,  United   States,   recoveries  at 

the.  321,  322 
Word-blindness,  799,  982 

and  mind-blindness,  809 

mental  condition  in,  983 
Werd-dciifness,  799,  981 

mental  condition  in,  981,  983 
"  Word  method  "  of  teaching-  speech  in  idiots,  674 
Word  photisms,  11 26 
Words,  presence  or  absence  of,   in  ajihasics,  979, 

980,  981 
Work  in  asylums.  514,  515 
Workhouses,  the  insane  in,  277 

in  Ireland,  711 

in  England  and  Wales,  732,  733,  735 

removal  of  lunatics  to,  Kngland   and   Wales, 

733 
diet   and    accommodation    in,    England    and 

Wales,  736 
power  of  guardians  in,   England  and   Wales, 

736.  in 
certificates  as  to  pauper  lunatics  in,  742 
order  for  detention  in,   England  and    Wales, 

742 
the  insane  in,  Scotland,  11 19 
Working  associates  for  after-care  of  the  insane,  58 
Workman,  reforms  in  the  treatment  of  tlu^  insane, 

Canada,  175 
Worms,  intestinal,  and  insanity,  124^ 
Worry  a  ca,use  of  insanity,  245 
Wound-conditions   and    traumatic  insanity,   1313, 
1314 


Wrinkling  of  face  typical  of  i)lumbism,  746,  747 
Wi'iting  in  the  diagnosis  of  insanity,  379 

mirror-,  399,  573 

of  the  insane,  568 

in  chronic  insanity,  573 

in  acute  insanity,  573,  574 

in  panilysis  agitans,  573 

tremor  in,  568,  569 

in  g-eneral  paralysis,  527 

evidence  in  concealed  insanity,  701 

in  locomotor  ataxy,  751 

in  myxiedcma,  828 

power  of,  in  aphasics,  980 
Writings  as  evidence  of  lunacry,  463 
Wundt,  physiological  psychology,  48 

the  action  of  motor  on  sensory  centres  in  at- 
tention, 108 

stimulus  in  reaction-time,  1068 

expectation  in  reaction-time,  1068 

distraction  in  reaction -time,  1069 

mental  processes  iu  reaction-time  experiments, 
1017 

frequency  of  secondary  sensations,  1127 

Yarra  Bend  Asylum,  m 
Yawning,  hysterical,  635 
Yeats,  hiematoma  auris,  559 

the  .-etiology  of  haematoma  auris,  561 
Yellow  fever,  the  delirium  of,  334 
Yellowlees,  D.,  artificial  feeding,  500 

masturbation,  784 
York  Asj'lum,  the  old,  25 
York  Lunatic  Hospital,  1082 

York  Retreat  and;humane  treatment  of  the  insane, 
24,  25 

recoveries  in  the,  322 
Yourodivie,  1098 
Youth,  brain  injury  in,  1308 

Zacchia,  Paolo,  treatment  of  the  insane,  716 
Zeigler,   inflammatory  theory  of  sub-dural   hiema- 
toma, 900,  901 

scavenger  cells,  903 
Zitterkriimpfe,  275 
Zittern,  das,  275 
Zoanthropia,  352 

Zola,  early  applications  of  electricity,  427 
Zones  hn)nog^nes,  607 
Zoophobia,  679 
Zornmanie,  835 
Zoroaster,  suicide,  1219 
Znchthaus-Ivnall,  291 

Zuelzer,  glycero-phosphorie  acid   in    urine  of  the 
insane,  1346 

the  causation  of  erysipelas  by  sewer  gas.  461 
Zungen  delirium,  378 
Zntphen,  the  asylum  of,  592 
Zwangsvorstellungen,  678 
Zymotic  diseases  in  children,  the  delirium  of,  359 


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