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Full text of "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"

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A DICTIONARY 



PSYCHOLOGICAL MEDICINE 



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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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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.'" 



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[ 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. 



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[ 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 



Pathology 



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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 



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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. 



Pathology 



[ 908 ] 



Pathology 



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 



Pathology 



[ 909 



Pathology 



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 



Pathology 



[ 910 ] 



Pathology 



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 



Pathology 



[ 911 



Pathology 



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 di