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THE PATHOLOGY OF MIND.
THE

PATHOLOGY OF MIND.

BEING THE THIRD EDITION OF THE SECOND PART OF
THE *“ PHYSIOLOGY AND PATHOLOGY OF MIND,”
RECAST, ENLARGED, AND REWRITTEN.

BY

HENRY MAUDSLEY, M.D.

NEW YORK:

D. APPLETON AND COMPANY,
1, 8, asp 5 BOND STREET.
1882.
eee
x LIBRARY. a

 
PREFACH.

Tue first edition of the Physiology and Pathology of Mind was
published in the year 1867, and the second edition in the
year following. A third edition of the first part was published
in the year 1876 as a separate treatise on the Physiology of
Mind. In the order of time and development this volume on
the Pathology of Mind is therefore a third edition of the second
part; but in substance it is a new work, having been recast
throughout, largely added to, and almost entirely rewritten.

The new material which has been added includes chapters on
“ Dreaming” and on “Somnambulism and its Allied States,”
subjects which, although they may not perhaps be thought to
appertain strictly to a treatise on mental pathology, will be
found, when studied scientifically, to throw light upon its
obscure phenomena and to help to bridge the gap between it
and mental physiology. A perplexing impression was produced
on my mind when I first began to study mental diseases—now
upwards of twenty years aco—by the isolation in which they
seemed to be. On the one hand, treatises on psychology made
no mention of them, and gave not the least help towards an
understanding of them; and, on the other hand, treatises on
mental disorders, while giving full information concerning
them, treated their subject as if it belonged to a science en-
tirely distinct from that which was concerned with the sound
mind. Inasmuch as psychological, physiological, and patho-

-
vi PREFACE.

logical studies of mind were actually concerned with the sane
subject-matter, it was obvious that methods of study which
kept the different lines of inquiry entirely apart must be at
fault somewhere, and that it would be a right aim, and one
full of promise, to endeavour to bring them into relation with
one another, and so to make psychology, physiology, and
pathology throw light upon and give help to one another.
The first edition, as stated in its preface, was the firstfruits
of that endeavour, and the present volume, which embodies
the results of deeper studies and more ripened experience, is
the completion of it. The inclusion in it of chapters on the
abnormal mental phenomena which are exhibited in dreams,
hypnotism, ecstasy, catalepsy, and like states, is therefore a just
part of the fulfilment of the general design.

The same reason will, I trust, be held sufficient to justify
the large amount of new and in some regards disputable matter
which is included in the chapters on the “Causation and Pre-
vention of Insanity.” It seemed proper to emphasise the fact
that insanity is really a social phenomenon, and to insist that
it cannot be investigated satisfactorily and apprehended rightly
except it be studied from a social point of view. In that way
only, I believe, can its real nature and meaning as an aberrant
phenomenon be perceived and understood. In recasting the
plan of the work I have thought it right therefore, in the
chapter on Causation, first to treat generally of the etiology of
mental derangement from a social standpoint, so fulfilling the
requirements of its organic relations, so to speak, in the social
organism ; and, secondly, to treat particularly of its patho-
logical causation, so connecting it with the general pathology
of nervous disease, and answering the requirements of scientific
pathology.

In describing the symptoms of insanity, I have thought it
well again, first, to treat it generally as one disease, setting
forth the varieties of symptoms which it presents at different
PREFACE. vii

times and at different stages of its course; and, secondly, to
occupy a separate chapter with the delineation of the different
clinical groups of mental disorders which are met with in practice
and have to be dealt with by the physician. In this way I
hope to have met the obligations of a true scientific exposition
and the more practical needs of those who have to form an
opinion concerning the cause, the course, the probable termina-
tion, and the proper treatment of a particular case of disease.
Had the chapter on Symptomatology been left out, the omis-
sion must needs have entailed a great deal of vague repetition
in the description of the clinical groups, with the certain effect
of blurring their outlines and features, and of confusing the
reader; had the special chapter describing these groups been
omitted, he would have obtained only a vague and general
notion of the symptoms of mental derangement, without that
more definite and practical acquaintance with its clinical
varieties, which, now that we are able, I think, to delineate
their features, ought to form part of a treatise on mental dis-
orders. Whatever be the value of the clinical pictures in this
volume, they have certainly been drawn from life, and had
space permitted I might have illustrated each line of description
by the records of cases.

The full and analytical Index which has been added will
serve not only to make reference easy, but will enable the
reader to judge what sort of fare he may expect if he is
minded to make trial of it.
CONTENTS.

CHAPTER I.

SLEEP AND DREAMING. 2 «© « «© «© © © «© «

.

CHAPTER II.

HYPNOTISM, SOMNAMBULISM, AND ALLIED STATES. .

CHAPTER III.

TUE CAUSATION AND PREVENTION OF INSANITY
(A) ETIOLOGICAL,

CHAPTER IV.

TNE CAUSATION AND PREVENTION OF [INSANITY oe

(A) ETLOLOGICAL (continued).

CHAPTER V.

THE CAUSATION AND PREVENTION OF INSANITY . ,
(B) PATHOLOGICAL.

CHAPTER VI.

TIE INSANITY OF EARLY LIFE . 2 « «

PAGE

50

83

127

175
x CONTENTS.

CHAPTER VII.
PAGE

THE SYMPTOMATOLOGY OF INSANITY . 6 6 © «© © © © © «© «© 296

CHAPTER VIII.
THE SYMPTOMATOLOGY OF INSANITY (continucd) . « » + « « « 356

CHAPTER IX.

CLINICAL GROUPS OF MENTAL DISEASE » « « «6 «© «6 « « « « 402

CHAPTER X.

THE MORBID ANATOMY OF MENTAL DERANGEMENT. 2 » » « « « 489

CHAPTER XI.

THE TREATMENT OF MENTAL DISORDERS . . 4 © «© © « « © « O22
PATHOLOGY OF MIND.

CHAPTER L
SLEEP AND DREAMING,

As we pass neatly the third part of our short lives in sleep it is
pleasing to think that the time so spent is not misspent nor lost.
Sleep marks that periodical suspension of the functions of animal
life, or life of relation, during which the organs that minister to
them undergo the restoration of energy which is necessary after
a period of activity. Waste of substance, which is the con-
dition and the result of active exercise of function, must be
repaired during rest; instead of its being a surprise, therefore,
that we sleep, the wonder would be if we did not sleep. In the
work and thought of the day is given out by degrees the energy
which has been stored up during repose. The need of repair is
as true of the organic functions, which never seem to sleep, as it
is of the animal functions, which sleep through so large a pro-
portion of our lives. For although an organ like the heart seems
not to rest day or night from the first moment of action unto the
last moment when it ceases to beat more, yet it plainly rests
between each stroke, gaining thereby in alternating snatches of
repose the energy for the next stroke; and it is really at rest
during a longer period than it is in action—has rested more than
it has worked when its life-work is ended. If the heart of an
animal which is beating regularly when the chest is opened be
made to beat slowly by stimulation of its vagus nerve it will go
on beating fora long time; but if its beats are quickened by
2 PATHOLOGY OF MIND. ({cuaP.

irritation of its sympathetic nerve it soon comes to a standstill
from exhaustion ; nutritive repair and the removal of the waste
products of activity cannot keep pace with the rapid con-
sumption of energy in the accelerated pulsations ; it is exhausted
as the gymnotus is exhausted when it has been provoked to re-
peated electrieal discharges and can give no more shocks until it
has recruited its energies. The lowest animal forms, which seem
not to sleep at all, probably sleep, like the heart, in similar brief
snatches of rest. The organism is a self-feeding and self-repair-
ing machine, but it cannot do its repairs when it is in full work;
it must have for its parts, as for its whole, its recurring periods of
adequate rest ; and the time comes at last when, like any other
machine, it wears out, is no more capable of repair, and when
the exhaustion which ensues is death—the sleep during which
there is no repair and from which there is no awaking.

The conditions under which we go to sleep, the causes which
promote it, and the ill effects which follow the deprivation
thereof, are proofs of its true purpose in the animal economy.
When we wish to sleep we shut out all external stimuli, as .a
bird puts its head under its wing, banish all subjects of active
thought or feeling, and place our bodies in as complete a state
of muscular repose as possible: so sleep comes on insensibly
as a deeper rest, not as an abrupt change, stealing upon us as
darkness upon daylight. The general causes which produce it
are such as exhaust the energy of the nervous system, either
through suffering or doing, and so occasion fatigue of body and
mind; they are muscular and mental exertion, when not too
prolonged, the weariness which follows great emotional strain,
when not too intense, and severe bodily pain. It is true that
we may by a strong voluntary effort, or under the spell of an
excitement, prolong the usual period of waking, and resist sleep,
although we are very sleepy; but we cannot do so indefinitely,
for torpor and incapacity of mental function, delirium, and death
are the consequences of an entire deprivation of sleep.

Tn this connexion it is interesting to ask why we awake—
why, once asleep, we do not go gn sleeping for ever? Probably
very much as the power of the exhausted clectric eel to give a
shock revives when restoration of energy has taken place by
1] SLEEP AND DREAMING. 3

nutrition during rest. A stimulus to the body, of external or
of internal origin, which would have been unfelt during the
deep sleep of exhaustion, or would have only been enough to
occasion a dream, suffices, as the sleep becomes light through
restoration of energy, to awaken the individual either directly or
by the vividness of the dream which it occasions. We should
not sleep for ever, I believe, if every external stimulus were
shut out; for the accumulation of nervous energy would awaken
us either spontaneously, or on occasion of the least internal
stimulus, which, as the organic functions are not suspended,
though they are more languid, during sleep, could not be shut
out. If these functions regained their full activity they might
directly cause waking: On the time at which we awake habit
notably has a great influence within certain limits; when we
allow the nervous system so many hours for repose, we accustom
it to that allowance, and it learns to do its repairs within the
allotted time.

Of what are the physiological. accompaniments of the occur-
rence of sleep we know nothing more than that the circulation
of blood through the brain is lowered; not as cause probably,
but as coincident effect of the state of nerve-element. Blumen-
bach long ago took notice ina man whose skull had been tre-
panned that the brain swelled with blood and rose into the
opening when he was awake and thinking, and sank down again
when he fell asleep; and the experiments of Mr. Durham, who,
having removed circular portions of the skull in different ani-
mals, and replaced them by suitable watch-glasses, through
which he could observe what happened when the animal was
awake and when it was asleep, convinced him that there was
. considerably less blood in the brain during sleep; its substance
then being paler and sinking down, while it reddened and
became turgid directly the animal awoke. The fontanelles of
young children sink during sleep ; and forcible compression of
the carotid arteries in the neck of the adult will induce it. There
is an active flow of blood to the part where the stimulus of func-
tional energy attracts and needs it, and when active function is
suspended by the recurring necessities of restoring the expended
energy by sleep, the circulation of blood falls to the level of
4 PATHOLOGY OF MIND, [crar.

the mere organic requirements of the brain: the supply answers
in fact to the different states of the brain, being active when its
functions are active, moderate when they are in abeyance. A
short step further has been made in conjecture. Knowing that
different parts of the brain are supplied with blood by different
arteries, the main channels of which go on dividing and sub-
dividing into smaller channels until these become capillary, it
has been surmised that an active circulation may sometimes
be going on in certain vascular areas of the brain while the
circulation in other parts of it is lowered to the level of sleep,
not otherwise than as local blushings occur elsewhere in the
body from vaso-motor dilatations, and that these active local
circulations in the brain are the conditions of that modified and
irregular activity which constitutes dreaming: one part of the
brain is supposed to be more or less awake when the rest of it
is asleep.

Recently the theory has been broached that sleep is caused
by the accumulation of the products of the oxidation which
takes place during activity; they are not presumably removed
so rapidly as they are produced during active function, but are
carried away, like the refuse in some cities, during the repose of
the night. It is not known what is the exact nature of these
combustion-products, but it is assumed that they act upon the
nerve-elements very much as carbonic acid does, causing a sort
of narcosis when they accumulate. Any condition then which
hinders their removal from the brain, such as prolonged activity
thereof, will favour sleep; any condition which accelerates their
removal will tend to prevent it.

Sleep is not a constant, but a fluctuating state. There are
degrees of sleep, not only of the cerebro-spinal system as a
whole, but of its different ._parts—so many intermediate steps
between it and waking; wherefore we may be rightly said to
graduate through a twilight-waking into imperfect sleep, and
from light slumber into profound unconsciousness. It is hard
to say sometimes whether we have been asleep or not; for the
wandering and incoherent ideas and the suddenly arising hallu-
cinations of a grotesque kind which occur just as we are going
to sleep are so like the vagaries of dreams, that we know not at
LJ SLEEP AND DREAMING. 5

all times whether they were part of our waking or of our sleep-
ing life. The stages in the gradually deepening unconsciousness
which is produced by opium illustrate very well the gradations
in the process of going to sleep: there is first a drowsy feeling
which becomes soon an irresistible inclination to sleep; the
person then falls into a slumber from which he may be roused
sufficiently to make a reply to a question put to him in a loud
voice, thereupon sinking back immediately into sleep, which
deepens rapidly into a comatose unconsciousness from which
the severest pinching, slapping, and irritation of all kinds hardly
avail to elicit more than the least sign of feeling or the briefest
responsive movement; finally he sinks into so deep a coma that
he is insensible to anything that may be done to him; all the
tortures which savage ever devised and inflicted upon his enemy,
or Christian upon his fellow-believer of a minutely different
shade of faith, would not touch him—he is in the unconscious-
ness of death before death. One sense goes to sleep after
another, each sinking gradually into a deeper slumber, then
the spinal cord, and, last of all, the respiratory centre in
the medulla oblongata, when the man dies. In the production
of insensibility by the inhalation of chloroform or of ether we
observe evidence that the person hears after he can no longer see,
and that the senses of taste and smell are lost before those of hear-
ing and touch; and in natural sleep it is obvious that there are
similar gradations of unconsciousness, one sense being sometimes
more deeply asleep than another, or the spinal cord being awake
when the special sensory centres are fast asleep. <A lightly-
sleeping person will sometimes hear apt questions that are cau-
tiously put to him in a familiar voice, and make a reply without
waking; and there can be no doubt that a man will sleep on
horseback when the muscles of the-back, among other muscles,
must be in action, or even sometimes when walking; he cannot
sleep when standing still, because the body will be sure to fall for-
wards unless it be supported. In like manner when we awake,
it seldom, if ever, happens that all our senses awake at the
same instant; a sound is heard before the other senscs can
receive impressions ; indeed they appear commonly to wake suc-
cessively. When we consider then that natural sleep is not
6 PATHOLOGY OF MIND. [cuaP.

really a fixed and constant quantity, but a fluctuating bodily
state in which there are considerable differences in the degree of
insensibility of different parts, some being lightly and others
deeply asleep at the same time, it will not appear strange that
in some dreams active imagination is exhibited and skilful bodily
feats performed ; a proof that some mental and motor centres are
awake while others are asleep.

The variations of susceptibility of different parts to impressions
during sleep is shown again by the ease with which a sleeper
may be awakened by a gentle sound or other stimulus to which
he is accustomed to respond, when a louder sound or other
stimulus that is really more powerful, but which he is not
accustomed to take notice of, has no effect upon him. In sleep
as in the waking state the ear hears best what it expects to
hear. Just as the expectation of a particular impression upon
waking sense increases the susceptibility of that sense and the
rapidity with which the message is conveyed from the external
organ to the central ganglion, so the adaptation of sleeping sense
to a particular impression engenders a habit of expectation, so to
speak, in the sense, by which its sensibility to the impression is
heightened, and this, though gentle, acts upon it with the same
efficacy as an extraordinary stimulus would do. If we think of
it, we observe that in our daily life impressions are hourly made
upon our senses of which we are not in the least conscious, unless
for some reason or other we are moved to take particular notice
of them ; we are, as it were, asleep to them habitually ; and it is
hard to conceive what potentialities of knowledge some of these
unperceived impressions contain, and what opportunities of per-
ception we let go by. We live actually in very limited relations
with external nature—relations limited not only by the capacities,
but by the habits of our senses—and become extremely automatic
in our reactions to the few stimuli which are habitually received ;
wherefore our intellectual and practical life runs in the main upon
a few. fixed lines to which we are bound, as animals are constrained
by their particular instincts, and outside which lie vast un-
surveyed regions. We perceive only what we attend to, and we
attend only to that to which we have, by frequent repetition, or-
ganised an adaptation of sense and of suitable motor associations,
1.] SLEEP AND DREAMING, v

Men little consider how mechanical they are in their thoughts,
feelings, and doings. So fully possessed are they with the fixed
but erroneous notion that consciousness is the essential agent in
all the purposive things which they do, that they stand amazed
when they witness any evidence of intelligent action during the
abeyance of consciousness, as in sleep, and look upon it as some-
thing marvellous; whereas the real marvel would be if the
organism were entirely to forget its intelligent habits simply
because they were not lit up by consciousness, As a matter of
fact it does not forget them: it awakes commonly at its ac-
customed hour whether the person went to bed at his usual hour
or later, and awakes at any moment on the occurrence of the
least sound to which it is accustomed to awake, as when the
mother hears her baby’s cry in the night, taking no notice of a
much louder sound which it has learned to disregard ; and it
awakens instantly on the cessation of a sound to the continu-
ance of which it has been accustomed in sleep, as is exemplified
by the well-known story of the miller who awoke when the noise
of his mill, which went on through the night usually, ceased
in consequence of the breakdown of the machinery.

It has been a disputed question whether sleep is ever quite
dreamless, and opposite answers to it have been propounded.
Some writers hold that no state of sleep, however sound it
be, is without dreaming ; not being able apparently to conceive
two different states of sleep so remote from each other as active
dreaming and complete suspension of mental function ; infected
also probably in some degree by the Cartesian dogma that the
mind never can be entirely inactive. Their contention is that
when we declare we have not dreamed, the truth is that we have
dreamed and have forgotten it; and they adduce in support of
their argument such undoubted facts as these—the rapid and
complete way in which the most vivid dream often vanishes
from the memory, so that, although we awake with its features
clear in the mind, they are gone in a few minutes and cannot he
recalled ; the quite accidental way in which some trivial ex-
perience of the day will sometimes bring back the recollection
of a dream which we had entirely forgotten, and which but for
that accident we should have forgotten for ever ; and, lastly, the
8 PATHOLOGY OF MIND. [cHaP

fact that other persons may have observed in our exclamations
and movements during sleep plain evidence that we have dreamt
when we, on waking, should be ready to assert confidently that
we had not. Due weight may be granted to these facts without
admitting that they go the length of proving the position which
it is sought to maintain. The weight of evidence, in a case
which by the nature of things cannot be decided, I believe to be
really on the side of the opinion that the soundest sleep is a
dreamless sleep. The difficulty of conceiving a temporary nullity
of mental function one may take leave to dismiss as a lingering
prejudice from the metaphysical notion of mind as an exalted
spiritual entity whose essence has nothing in common with the
low material necessities of the body. When we make the matter
one of observation, it cannot be denied that we perceive during
sleep all shades of gradation between the most vivid and active
dreaming at the one end and the faintest show of evanescent
activity at the other end of the scale. What difficulty is there,
then, in passing in conception the imperceptible line between
the least flutter of activity and a complete nullity of function ?
Furthermore, in certain cases of suspended animation or apparent
death, as, for instance, when a person is taken out of water in a
completely unconscious state, and revives only after energetic
efforts at. restoration continued for an hour or even for hours, it
-is as certain as anything can well be that all mental function
was abolished from the moment he became insensible unto the
moment when sensibility returned. Take again the remarkable
case of a blow on the head producing depression of the skull,
pressure upon.the brain therefrom, and insensibility therewith ;
with the raising of the depressed bone by surgical means the
person has not only regained consciousness instantly, but has
gone on to finish a sentence which he had begun when he was
struck down unconscious." In profound apoplexy, in the entire
insensibility which is produced by chloroform, and in similar

1 In the American Journal of Nervous and Mental Diseases for April,
1877, Dr. Hoy mentions the case of a youth, aged eighteen years, who was
struck insensible by the kick of a horse, his skull being depressed and
fractured. After trephining the depressed bone he became sensible. Dr.
Hoy took advantage of the hole in the skull to make firm pressure on the
exposed brain after asking him a question, As long as the pressure
1] SLEEP AND DREAMING, 9

states of complete unconsciousness from other causes, there is
not the least reason to suspect that there is any more mental
function going on than there is in an animal which has been
deprived of its cerebral hemispheres. :

Another theory which has been broached with regard to
dreaming is that we only dream just as we are going to sleep or
just as we are coming out of it—in the transition state into and
out of sleep. But this opinion seems on examination to be less
tenable than the opinion that we never cease to dream when we
are asleep. Were the somnambulist not a positive refutation of
it, observation of sleeping persons who show plainly by their
actions or their words that they are dreaming and who still go
on sleeping, and the fact that we sometimes catch ourselves in
the midst of a dream when we are roused suddenly out of deep
sleep, would be sufficient to prove it erroneous. Inasmuch as
sleep is not a constant but a fluctuating state, it stands to reason
that there will often be varying degrees of mental function ac-
cording to the more or less depth and completeness of it ; there
will be sometimes an activity so coherent as to surprise us, at
other times an activity of the most partial and incoherent kind,
and there will be an entire abeyance of mental function during
such deep sleep as that which fell upon Adam when the opera-
tion of taking a rib out of his side was successfully performed.

It has been justly remarked that if we were actually to do in
sleep all the strange things which we dream we do, it would be
necessary to put every man in restraint before he went to bed;
for, as Cicero said, dreamers would do more strange things than
madmen. A dream put into action must indeed look very much
like insanity, as insanity has at times the look of a waking
dream. In dreaming as in insanity there are the most strange
and grotesque deviations from the accustomed sober paths of
continued he remained silent, but the instant it was removed he made a
reply, never suspecting that he had not answered at once.

The same gentleman mentions another case of a youth, aged nineteen,
who was rendered insensible by the kick of a mare named Dolly. As soon
as the depressed bone was removed, he cried, “‘ Whoa, Dolly,” with great
energy, and then stared about him in amazement, wondering what had
happened to him. Three hours had passed since the accident. He was

not conscious the mare had kicked; the last thing which he remembered
was that she wheeled round her heels and laid back her ears.
10 PATHOLOGY OF MIND. [cHaAP.

associations of ideas; the combinations and sequences of ideas
do not follow any definite laws, so far as we can discover, but
appear often to be quite accidental and -transitory ; we justly
therefore set down the loss of all power over the succession
of ideas as one of the leading phenomena of dreaming. It
is not true, however, as is sometimes said, that volition is
always abolished during dreaming ; for it is certain that we may
wake up suddenly out of sleep in consequence of a strong effort
of volition which we have made in our dream, as when we
strike out at a person who has insulted or assaulted us, and
that at other times we do voluntarily restrain the expression
of our feelings. I have been brought to the very verge of being
hanged on two or three occasions in my dreams, having
wakened up at the last moment before the operation was to
be performed, and on each occasion I have been conscious of
a determined suppression of any betrayal of fear or other
emotional agitation during the preparations for the event. A
concrete act of volition of that sort is not impossible in
dreams. It is a fair question, however, how far we succeed
in accomplishing the volition when it is to do something
active, and how near waking we are when we feel it. For
it happens in dreams that we find ourselves straining to do
somethine—for example, to strike a blow, to cry for aid, to
utter a command, and are perfectly impotent to do it; and
the instant we succeed in liberating our paralysed energies
we awake, There is the strongest mental volition, but an
utter impotency of motor outcome; the instant which elapses
between the desire or will to do and the waking state being
long enough for the occurrence of what seems a much longer
drama of impotence in the dream, At the same time it
should not be overlooked that a person does not always
awake who calls out in his dream, and that we remember
dreams in which we imagined ourselves to will and to do
what we willed.

Certainly it is true that volition in its highest sense of
control over the mental operations is abolished in dreaming,
as a moment's reflection will show must needs be the case,
For such volition is neither more nor less than the expression
1] SLEEP AND DREAMING. 11

of the fullest co-ordinate activity of the mental functions,
varying much in quality necessarily according to the develop-
ment of the functions through previous training, and cannot
therefore by the nature of the case consist with the fortuitous
concourse of ideas in dreams. It is impossible there can be
full use of reflection when most of the habitual trains of
thought are suspended in sleep ; an idea that is accompanied
with desire is without the means of becoming a reasoned volition
in the ordinary way; it must remain a particular desire, and
when it is active, instead of the natural results following
through the beaten paths of association, it will rouse some
strange, apparently unrelated idea, which being seen as a vision
will present itself as a sort of abrupt transformation scene.
For the same reason the sense of personal identity, the unity of
individual character, is confused and seemingly lost. We are
ourselves and somebody else at the same moment, as other
persons seem to be themselves and not themselves, and we do
absurd and perhaps transcendently criminal things in the most
matter-of-fact way, all the while mildly surprised or not at all
surprised at ourselves for doing them. How can there be a
clear sense of the unity of the ego, how any conscience, when
there is an entire abeyance of that co-ordination of mental
function, the self-consciousness of which is the feeling of
personal identity? It is probable enough that when we begin
in our dreams to be surprised at the change of identity, and
to think about it as odd, we are on the point of waking; the
commencing restoration of the co-ordination of functions being
in fact the restoration of the feeling of identity and the occasion
of our surprise. But it seems to me that throughout all the
vagaries of dreaming there is generally at bottom an obscure
feeling or instinct of identity, or else we should not ever be
surprised at ourselves when we seem not ourselves, or when we
are doing extraordinary things, or even have the sort of personal
feeling which we have in whatever odd drama we may be
playing a part. The reason I believe to be that the organism
preserves its identity notwithstanding that our conscious func-
tions are in the greatest distraction ; although we are asleep the
different impressions of our organic or systemic sensibility,
12 PATHOLOGY OF MIND, {crrap.

which are not affected directly by external conditions, are carried
to the brain from the internal organs ; and it is this physiological
unity of organic functions, which is something deeper than
consciousness and constitutes our fandamental personality, that
makes itself felt with more or less force in every conscious state,
dreaming or waking. The insane inmate of a pauper lunatic
asylum who is possessed with the delusion that he is the Almighty
and can do in an instant whatever he wills, begs humbly a trifl-
ing favour at the same moment that he proclaims his omnipo-
tence. Such are the inconsistencies of a distracted identity.
The absence of surprise at the extraordinary events which
take place in dreams is sometimes very remarkable. But it is
not always complete. In some instances there is a partial or
particular surprise; not a surprise springing from a consistent
reflection upon the absurdity of the whole affair, such as
a waking man would make, but a surprise at a particular
startling inconsistency, as, for example, at the appearance of a
person whom we remember to be dead, to take part in the events
of the dream. On other occasions, there may be distinct feeling
that we are dreaming; we may say to ourselves—It is only
a dream ; and perhaps resolve at the same time to go on with it
instead of breaking the spell, as we feel we might do at any
moment. When there is not so distinct a consciousness that the
affair is a dream, there is now and then a half-conscious under-
tone of question or doubt of the reality of the images which
flit before the mental vision: a sort of dim and vague feeling
of their unreality, as if they were parts of a dramatic show in
which we were so much interested for the time, so far carried
away, as to lose independence of judgment and even sense of
individuality. If this feeling becomes stronger it probably
produces the conviction that we are dreaming which we have
sometimes before we awake, and in the end awakens us. For I
imagine that we are very near waking when we get this con-
viction: that the co-ordinated functions, from the consentience
of which springs the consciousness of identity, are beginning
to be exercised. The dream-phantoms move across a back-
ground of the unconscious individuality, which, moulded and
fashioned by the habit of our life-experience, necessarily con-
1] SLEEP AND DREAMING. 13

tradicts them absolutely the moment it becomes conscious, and
gives rise when only in a state of nascent consciousness to the
vague subconscious feeling of scepticism before it declares them
positively unreal. It is impossible we should be surprised at
the inconsistencies of a dream when we are in deep sleep,
because it is impossible we should then reflect—in other words,

impossible we should compare them with those organised mental ;

experiences which are the registrations of our observations of the
order of nature, seeing that these experiences are silent; it
would be a wonder therefore if we did not accept as real, and
without surprise, the vagaries of dreams.

The idea which arises in the mind in a dream, being unable
to follow the accustomed paths of reflection, acts downwards
upon the sensory ganglion, and takes shape as a distinct image
or an actual perception, so that a dream-train of ideas is a train
of images. Moreover it is an image which we sce very vividly,
because there is no distraction of consciousness by objects of
external sense or by related ideas, as we seethe stars from the
bottom of a deep well in broad daylight because the line of
vision alone is then illuminated. The result is that what would
be a succession of ideas in the waking state, hardly perhaps
overstépping the threshold of consciousness, becomes a disorderly
succession of images, or, as it were, a series of abrupt transfor-
mation scenes ina drama. Taking Hobbes’ celebrated instance
of asscciation of ideas, one might consider curiously what it
would become supposing it were to occur ina dream. “For in
a discourse,” he says, “of our present civil war, what would
seem more impertinent than to ask, as one did, what was the
value of a Roman penny? Yet the coherence to me was
manifest enough: for the thought of the war introduced the
thought of the delivering up of the king to his enemies; the
thought of that brought in the thought of delivering up Christ ;
and that again the thought of the thirty pence, which was the
price of that treason; and thence easily followed the malicious
question ” (Leviathan, i. ch. iii.). In the dream there would be
so many scenes rapidly following one another, or jumbled con-
fusedly together, and when the dreamer awoke and called to
tind the details of his dream, he might be at a loss to account
14 PATHOLOGY OF MIND. [cnap.

for the strange conjunction of persons and incidents in the spec-
tacles that had been presented to him, and for the sudden trans-
formation of one spectacle into a quite different one. And
whereas in this case we suppose that there were true, though
unperceived, links of association between the ideas, for which
reason the scenes did not follow one another without coherence,
it is probable that in many dreams the ideas which become
transformed into images call up one another in a fortuitous way,
and so produce more incongruous scenes.

The fantastical deviations from the ordinary tracks of associa-
tion of ideas, the loss of volitional power over the ideas, the sus-
pension of conscience, the distraction of the ego, and the seem-
ing reality of the grotesque dream are all parts of the same
effect; they proceed from a discontinuity of function in the
supreme centres of the brain, a temporary suspension of the
bonds of their functional unity, As when a complex assemblage
and series of movements which have been trained to the execu-
tion of certain complicated and special effects can no longer be
performed because of some disorder in the proper motor centres,
but in their stead spasmodic, incoherent, and purposeless move-
ments are displayed, we might say that the usual motor associa-
tions were broken up, volitional power abolished, and their
essential identity as specially purposive functions destroyed, so
it is with the co-ordinated functions of the supreme cerebral
centres in dreaming ; its phenomena express different degrees of
loss of co-ordination—that is to say, different stages in the
resolution or disintegration of the most complex integrations of
mental evolution.

It is sometimes said that in dreaming there is a loss of the
faculty of combining and arranging ideas. True it is that there
is usually a loss of the faculty of combining and arranging them
as we do when we are awake; but one of the most remarkable
features of dreaming, which has hardly had the consideration
which it deserves, is the singular power of combining and
arranging ideas into the most vivid dramas. It would be no
great exaggeration to say that the dramatic power of a dunce in
dreaming exceeds that which is displayed by the most imagina-
tive writer in his waking state. When we reflect upon the
1] SLEEP AND DREAMING. 15

extraordinary creations of dreams, and consider that the most
stupid and unimaginative person often constructs scenes, creates
characters, and contrives events with a remarkable intensity of
conception, distinctness of outline, and exactness of details,
putting into the mouths of his dramatic persons dialogues suited
to their several characters, we might well conclude that there is,
independently of will or consciousness, a natural tendency of
ideas, however stirred, to combine and to arrange themselves into
a kind of drama, even though they have no known associations
and appear quite independent of, if not antagonistic to, one
another. Ideas in this respect might be compared rudely to
such chemical substances as, the moment they are set free to
yield to their affinities, rush together to form a compound of
some kind. The same sort of thing occurs in the waking state
when the succession of thoughts is not controlled by reflection
upon some definite subject, and it constitutes the chief part of
the mental activity of a great number of persons who, when not
engaged in practical work, spend their time in vacant reverie,
or in rambling incongruities of ideas. Were a faithful record
kept of the fantastical play of ideas under these circumstances,
it would often read as wild as any dream. The point, however,
which I desire to lay stress upon, and to fix attention to here,
is the tendency of ideas, however unrelated, to come together,
and to form some sort of mental imagery, wildly absurd or more
or less conformable to nature—the actual constructive power
which they evince ; for it plainly indicates that the plastic power
of mind, its so-called imagination, is at bottom organic function
of the supreme cerebral centres; something which, being dis-
played when will is in abeyance and consciousness a mere
gleam, whenever there is the least display of cerebral mental
function, must plainly lie beneath consciousness and beneath
will. It is, if you will, unconscious mental function. It is not
merely an association of ideas, and is not explained, as some
persons seem to think, when it is referred to that so-called
principle, to which they are in the habit of attributing extra-
ordinary powers. The principle of association of ideas is nothing
more than the statement that ideas which have occurred together
or in sequence, or which have something like in then, will
2
16 PATHOLOGY OF MIND. [cuap.

probably occur together again, one calling up theother, But
we are dealing with something more than that—with an actual
constructive agency, whereby ideas are not brought together
only, but new products are formed out of them. The scene
presented may be one which has never been actually ex-
perienced, nor is it always made up by the combination of
images which have been experienced. Both the scene and the
images are many times new, though suggested by similar scenes
or images seen in part or in whole.

It is noteworthy in this relation how in dreams a general idea
is resolved into suitable concrete images, such as it might have
been derived from by abstraction, but which it never was actually
derived from, although no doubt it was the abstract of somewhat
similar experiences. A casual suggestion in the day—for instance,
that a person has great tact or great courage, may be the occa-
sion of his taking part in the scenes of a dream, and doing things
which we should consider to evince tact or courage, notwith-
standing that the scenes are entire creations of fancy and such
as he never could have mixed in. The general idea creates the
scenes of its appropriate display, being resolved as it were into
the concrete elements out of which it might have been developed.
This is an entirely involuntary operation, and proves, as is
proved also by the formation of the general idea in the first
instance—not in the least a voluntary procedure—that mind is
capable of those intelligent functions which are the essence of
its being, independently of will and of consciousness, or at any
rate that the potentiality of them lies not in consciousness nor
in will, but in the plastic quality of the brain. As the unknown
organic power in a living cell—whatever complexity of intimate
physico- -chemical processes its vitality may connote—assimilates
what is suitable to its growth in its surroundings, and so builds
up by degrees an individual being in conformity with the lines
of development that are laid in its nature; so the special organic
power of the nerve-elements in the supreme centres of the brain
builds up by degrees in adaptation to the co-existences and
sequences of the surroundings, social and physical, the complex
structure of the mental organisation of the individual. But it
cannot transcend the lines that are laid down for it in the
1] SLEEP AND DREAMING. 17

inborn capacities of the individual nature: what the mental
organisation will turn out to be will depend, first and foremost,
upon the inborn capacities which he has inherited from ances-
tors, and, secondly, upon the influence of education and of the
circumstances of life. As with the seed of a tree dropped in a
forest: its original germ-force may be greater or less, its situa-
tion more or less favourable, but it will take root and flourish.
and surpass other trees in growth, according to the advantage of
the position in which it has chanced to drop, and according to
the power which it has, through original strength of stock, of
profiting by opportunity and getting the most out of its sur-
roundings. We rightly look upon mind as the highest force in
nature, but we are wrong to look upon it as a power outside of
and above nature, self-sufficing, without relations of dependence
or affinity ; while looking up to the height of its noblest func-
tions, we ought not to overlook the depths in which their roots
are planted. The intellect is developed out of sensation and
motion, in other words, out of the capacity to receive and assimi-
late suitable impressions and to respond to them by definite
movements, whereby man as a part of nature takes his part in
its evolution, being acted upon by it and reacting upon it; and
will is the impulse which, springing at bottom from the organic
life and displaying itself in desire, is guided by the intellect to
effect improved conscious adjustments to the social and physical
environments. But the capacity to receive and assimilate suitable
impressions, and to reject and eschew unsuitable impressions, is
nowise a peculiar mental endowment; it is a fundamental pro-
perty of organic element. Man is not a mixture or a compound
of body and mind, but one being, having, magnet-like, two
polarities—the one linking him to that which is below him, the
other, representing his spiritual aspirations, having opposite and
higher attractions.

The plastic power of the supreme cerebral centres on which I
insist as something deeper than conscious mental function,
evinces its spontaneous and independent nature in a striking
way by those singularly coherent dreams which everybody has
at one time or another, and in which he sometimes puts forth as
much intellectual power as he ever displays when awake. Many
18 PATHOLOGY OF MIND. [oHaP.

stories have beeu told, on good authority, of persons who have
in their sleep composed poems, solved hard problems in mathe-
matics, discovered the key of a perplexing difficulty, or done
like wonderful things; and while bearing in mind that dream
achievements which seem to us very clever at the time prove
oftentimes to be nonsense when we awake, it may be granted
that one who is fitted by natural abilities and training to do
good intellectual work when awake may occasionally chance to
do it in sleep, getting the good of a good understanding even in
his dreams. These instances illustrate the spontaneous nature
of the process of creative activity, with which consciousness and
will have no more to do as active agents than with the imagina-
tive creations of the inspired poet; for it is only when the pro-
ducts are formed that they rise into clear consciousness, and only
when they are known that they can be willed. Another fact in
regard to the dramatic power displayed in dreaming which
should not pass unnoticed is the apparent rapidity of its action,
whereby is presented in an instant what would take us perhaps
hours to think out consciously, or to describe adequately in
words, A tragedy or comedy of several acts is devised and
performed in a moment; it is no great wonder therefore that it
does not occur to one whose conscious ego is in abeyance that
he is the author of the various characters that figure in it and of
the scenes in which they play. He assists, happy or distressed,
applauding or condemning, at a spectacle which is all his own
creation, and has not the will or the power to modify its course
in the least.

One matter more in relation to. the mental power of the
dreamer I shall take notice of, namely, the singularly vivid
recollection which is sometimes shown of things of which he
has not the least remembrance perhaps in the waking state.
He can lay under contribution the long unused stores of
memory, draw from them things new and old, and so give
variety to his scenes in a way the waking person cannot do by
any strain of conscious recollection; for the details of eventg
long past, the feelings that accompanied them, the features of a
face long dead, the tones of a voice that is still, are reproduced
with a surprising vividness and accuracy. This fact, which has
1] SLEEP AND DREAMING. 19

its parallel in the experience of delirium and in the momentary
flash of recollection which occurs just before the unconscious-
ness of drowning, goes to show certainly, first, that there is no
such thing as forgetting what we have once attentively observed.
and made part of our mental experience, and secondly, how
little consciousness has to do as agent in the essential parts of the
functions of recollection and imagination. When we are awake
our mental energies are engrossed in certain lines of habitual
activity which are determined by our usual pursuits and experi-
ences—they run in certain customary tracks, to which con-
sciousness is almost exclusively attracted; for habits and
external impressions control and’ determine our thoughts much
more than we think, so that in the deepest reverie they never
get so far a-field as when all external impressions are shut out.
But when we are asleep and no external impressions are per-
ceived, the tracks of habitual function are not pursued, ideas
are aroused independently of their associations by physical
causes, and there is not consequently a corner of the brain in
which there is a memory registered that may not be stirred into
unwonted activity. Inasmuch as there is then nothing to dis-
tract consciousness from the idea which emerges into momen-
tary activity, it is remarkably vivid; and inasmuch as its related
ideas are at rest, there is no correction of it and it stands
out in exaggerated proportions.

In searching then for an explanation of the remarkable
revivals of forgotten events in dreams we must take into
account—(1) The absence of external impressions linking the
mind to certain tracks of habitual function which would not be
calculated to lead-to the forgotten events, and, as a probable
concomitant effect, the opening up of disused or neglected
tracks which might lead to them; (2) the direct stimulation of
the remotest nerve elements through the circulation of blood,
which, flowing in multitudes of minute channels through the
most intimate recesses of the structure of the brain, will,
according to its variations in quantity and quality and in rapidity
of flow, stimulate into activity the nerve-cells with which it is in
relation, and obviously act indifferently upon the most remote
and most recent registrations ; and (3) the probable stimulation by
“20 PATHOLOGY OF MIND. [cHaP,

some internal organ of the body of that part of the brain with
which it is in special internuncial relation, or, in other words, in
which it has cerebral representation.

‘Whatever the explanation, the fact is indisputable that persons
recall in dreams names and things which they had entirely for-
gotten, and which, while remembering them, they are not perhaps
conscious are remembrances ; just as thoughts in the day which
appear as new acquisitions may be found to have been entertained
before, or to have been derived from some book which was read
long ago. Maury relates the following amongst other instances.
In his early years he visited Trilport, a village on the Marve,
where his father had built a bridge. Later in life he dreamed
once that he was a child playing at Trilport, and that he saw
aman clothed in a sort of uniform, whom he asked what was
liis name. The man replied C , and that he was gatekeeper
at the bridge, and disappeared. Maury awoke with the name
C in his ears, which he did not in the least remember ever
to have heard. Some time afterwards, however, he inquired of
an old servant, who had been in his father’s service, if she
recollected a person named C ; and she replied instantly
that he was gatekeeper at the Marve when the bridge was built.
Dreams themselves are notably soon forgotten, partly no doubt
because of the little concern which they have with the real
experience of life,-and partly because of their incoherent
character: we cannot recollect one-hundredth part of what we
sce and hear and feel and think and do in a day, and should
be very unwise to attempt to do so within the conditions of our
limited capacity of memory and of our short span of life; and
whoever will listen for a few minutes to the utterly incoherent
talk of a thoroughly demented lunatic, with the resolution to
remember and repeat it immediately afterwards, will learn by
his failure how much incoherence hinders recollection.

We see in our dreams multitudes of faces which we do not
in the least remember to have seen when awake: do we invent
them, or do we recall actually experiences which have been for-
gotten? It is certain that an inhabitant of any large and busy
sity sees in a few days hundreds of faces which he never could
voluntarily recall, and it is possible that some of these may

 

 

 
LJ SLEEP AND DREAMING, 21

come back from time to time as dream faces. It seems to be pretty
certain too that the face of one dream, not remembered in the
waking state, may appear and be remembered in a subsequent
dream. Dream faces may then be reproductions, not inven-
tions; but it is more probable that we invent them, just as we
invent scenes and events, and even words which we imagine we
understand clearly, but which are apt enough, if they remain in
our ears when we awake, to turn out to be nonsense. The action
of imagination in dreams as in the waking state is doubtless
productive as to form, reproductive as to material.

Passing now from these general observations and reflections
concerning dreams, I go on to inquire into the causes and
conditions which seem to determine their origin and their
character ; and I propose to consider and class them under six
principal headings, rather for convenience of discussion than
because the conditions are separate in fact and can be separated
in their working, These are :—

(1) Character and precedent mental experience.
(2) Impressions on a special sense.

(3) The state of the muscular sensibility.

(4) Organic or systemic impressions.

(5) Conditions of cerebral circulation.

(6) The state or tone of the nervous system.

1. Character and Precedent Mental Experience—We should
plainly never dream at all, but sleep the dreamless sleep of the
newborn infant, had we not some mental experience to draw
upon: the material of our dream-fancies, the elements out of
which new products are formed, we derive from experience. It
is a common observation that the thoughts and feelings of the
day reappear under various guises in dreams, the more probably
the more vividly they have affected us at the time; and some
persons are so susceptible that any strong feeling or conception
which they have had inthe day is sure to make itself felt in a
dream at night. Certainly most use is made for dream imagery
of immediately antecedent or comparatively recent experiences,
which are revived by direct associations, old experiences he-
coming indistinct and perhaps even extinct sometimes; still it
22 PATHOLOGY OF MIND. [cuar.

is remarkable how vivid!y we revert now and then to long
distant and forgotten experiences of persons, places, and the like,
either on the occasion of some chance stimulus in the day to old
associations, or in consequence of some unusual perturbation
of the bodily state stirring their substrata into activity. Dr.
Darwin mentions the case of a gentleman who, having been so
deaf for thirty years that he could be’conversed with only in
writing or by the finger alphabet, assured him that he never
dreamt of persons conversing with him except by the fingers or
in writing, and had never had the impression of hearing them
speak, But it is nowise clear that this gentleman’s early ex-
periences of speech were totally lost; they might have been
revived in some dream had a suitable stimulus chanced to occur.
The leading experiences of our early days are certainly often
revived in dreams, many scenes of which notably testify to the
memories of school or college experience. And the character of
the scenes into which the materials, whether recent or old, are
worked will be much affected by the character of the individual
dreamer, who, according as he be proud or humble, aggressive or
retiring, bold or timid, sanguine or melancholic, revengeful or
placable, generous or mean, candid or cunning, will not fail to
find himself in his dreams. In this influence of character there
may be said to be a reversion to ancestral experiences and an
awakening of their substrata to activity; for a person who
exhibits a trait of his grandfather’s character might be said to
repeat or remember what his grandfather felt.

Besides the patent and direct associations which are easily
traced, there are indirect and subtle ways, not easily traced, by
which a suggestion or incident of the day may revive memiories
of the past. A sensation which has been associated with some
mental experience of a long time ago—a particular sound, for
example, or, better still, a particular odour—will sometimes
bring back in a dream the conceptions and feelings of that ex-
perience, although it may have been only a momentary percep-
tion, and may not have awakened any associations in the day ;
aud a particular idea or a particular feeling which has passed
quickly through consciousness as a transient and isolated state
will do the same thing. I get a momentary whiff of some
1] SLEEP AND DREAMING, 23

peculiar odour as I pass along the street, and I dream at night
of scenes of boyhood that were associated with that odour, but
of which I had not even thought in the day: I see a man or
hear his name mentioned in the day, and his wife, of whom I
never thought in the least, has a place in my dream. It is
probable that these passing hints or occasions of the day furnish
much of the explanation of the apparently mysterious manner
in which, with nothing that we can conceive to evoke their
recurrence, we go back in our dreams to scenes and events of
an early period of our lives. Knowing the many influences to
which we are exposed in a day, some of them scarcely conscious,
the multitude of ideas that pass through the mind, the variations
of feeling which we undergo, it is obvious that we have here
the possible explanation of the occurrence of many dreams.
which perplex us mightily. Hidden and unused paths of asso-
ciation are hit upon and pursued, and lead to the recovery of
forgotten experiences. It should be borne in inind in this rela-
tion that an idea, when exciled to activity, does not strike one
chord of association only, but strikes one chord predominantly,
so that the others die away unperceived, which were neverthe-
less in partial vibration: during sleep another than the accus-
tomed chord may respond most actively, and so lead to the
revival of less familiar associations than those which are habitual
in the waking state.

Note this again: that a natural feeling occasioned by some
scene or event of the day will call up in dreams scenes or events
of the past which, when they happened, had caused a similar
feeling, but which are themselves as entirely unconnected with
the recent event as they are distant from it.in time. For ex-
ample, some unpleasant occurrence in the day is a painful rebuff
to our self-love and excites a mingled feeling of depression and
humiliation; the sad feeling, lingering, as such feelings will, as
dull depression after we have ceased to think about it, persists
through sleep and is translated into appropriate imagery; we
thereupon dream of our school-days, if they were unhappy, in
which we underwent similar humiliations of feeling, combining
perhaps the persons and incidents of those days with the persons
and incidents of the event which has affected us painfully. The
24 PATHOLOGY OF MIND. [cuaP.

allied feeling has called up an almost forgotten train of sympa-
thetic ideas, and we are not a little astonished even in our dream
to find our adult selves in such a painful position of school-boy
subordination. In like manner a gay feeling of elation occa-
sioned by some flattering experience of the day will get concrete
interpretation or representation in suitable dream-imagery.

One is apt to think that the images and events of a distressing
dream are the causes of the feeling of distress which is expe-
rienced, but they are not really so; the feeling is more truly
the cause of the images; it is, so to speak, the mother-mood of
them. <A well-known habit of the mind is to seek for and to
create, if need be, with or without distinct consciousness, an
outward object as the cause of its feelings ; if there be no objec-
tive cause of them, it will invest some indifferent objects with
the attributes proper to produce them, or will altogether create
suitable objects; and this tendency is forcibly illustrated in
dreams and in insanity. Coleridge has aptly remarked that
the images of dreams undergo the strangest and most sudden
metamorphoses without causing much or any surprise, and that
they disappear, together with the agonies of terror accompanying
them, the moment we awake ; which would not be the case if
they caused the terror which they appear todo. In like manner
the painful delusions of one who is suffering from that form of
profound mental depression which is known as melancholia
undergo changes sometimes—perhaps from terrible to grotesque
—without the least’ change in his distress ; the latter indeed
may exist for some time as a vague and terrible feeling without
any definite delusion, and it is a matter of accident rather than
of the essence of the disease what shape the delusions take. In
this generation or crystallisation of the images of fear out of
the troubled feeling we perceive a demonstration of the true
nature of so-called ghosts and apparitions: they are the effects
or exponents of the feeling of expectant apprehension which has
been engendered by reading or talking or thinking about them.
When Luther saw the Devil enter his chamber at Wittenberg
and instantly flung the inkstand at his head, he seems to have
been neither horrified nor greatly surprised, and to have re-
sented the visit rather as an intrusion which he had expected
5] SLEEP AND DREAMING, 25

from an adversary with whom he had had many encounters ;
but had the Devil really surprised Luther by walking into his
chamber, I doubt whether he would have been so quick and
energetic in his assault. Those who see ghosts under these
circumstances of mental preparation do not suffer much in con-
sequence, though they may protest when they narrate their
story that their hair stood on end and that they were in an
agony of fright ; whereas those who have been actually scared by
a sudden apparition—by a figure mischievously dressed up as a
ghost, for example—have often suffered seriously from the shock,
having fainted or fallen in a fit, or had a. brain-fever in conse-
quence, or been killed outright by the shock. In the one case
the apparition was to a mind suitably prepared for it by an
antecedent state of feeling, and gave the vague feeling form,
wherefore there was no great surprise; in the other case it came
unexpectedly upon a mind that was not attuned to it, therefore
with a great shock, and was correspondingly disastrous in its
effects,

It would be a long task to deal adequately with the pheno-
mena of dreams, and a book, not a chapter, would be necessary
to set forth the results of a full inquiry. I shall content myself
with relating a dream which was one among several vivid dreams
that followed one another on an unresting night of dreams, in
order to show how the most incongruous circumstances may, if
examined with sufficient care, be traced to incidents in past
experience. I was in a large building crowded with people,
which was partly like a church and partly like a public hall,
when two clergymen who somehow became three walked up a
middle aisle to the pulpit which stood on one side of it, two of
them turning aside to go into it, and the third continuing his
way along the aisle towards the place where the altar would
stand; disappearing, however, mysteriously, aisle and all, after
he had gone some way. One of the clergymen was deformed,
being bent nearly double, and the pulpit, as soon as he got into
it, was transformed into something like the platform of a public
hall with seats rising in rows behind it and crowded with people,
at the end of one of which I stood. One of the clergymen
began the service or the proceedings by reading an opening
26 PATHOLOGY OF MIND. (cap.

verse which I was a little surprised not to recognise, and the
other, instead of going on, as I had expected, with the “ Dearly
beloved ” of the Prayer Book, went on to read a tedious story from
some strange book until I was wearied ; when suddenly, as I was
wondering to myself. what in the world he was reading, an old
man in the body of the church or hall shouted out, “ Beautiful
death be damned, let us handle life,”—-and then began to give
out a hymn like a parish clerk of the olden time. There was a
general start of amazement throughout the congregation, and I
turned round, and, placing one hand before my eyes, laughed
heartily to myself. At that moment a German friend whom
I had not seen for years stood before me, and I awoke.

Such was the dream, and the interpretation of it was as
follows :—The hall was a combination of the old parish church
which I used to attend when a boy, and of St. James’s Hall,
where I had lately been at a crowded public meeting, sitting on
that occasion behind the platform. The deformed clergyman
was like a gentleman whom I had been in the habit of seeing
in the street frequently, ten years ago, as he lived next door to
me, and whose appearance had made an impression upon me.
He was not a clergyman, nor had he the least connection with
any event of my life, and how he came to take part in the
dream I cannot imagine. The long story which he began to
read in the pulpit, instead of the proper address to the people,
was evidently suggested by the fact that I had read that day in
a newspaper a paragraph professing to give an account of Dr.
Newman’s daily life at the Oratory, Birmingham, in which it
was told that while the brethren of the Oratory were at dinner
one of them read aloud the life of some saint or other in-
structive matter. The outburst of the old man who resembled
in manner, though not in face, the parish clerk of my early
days, was derived from my remembrance of a well-known passage
from Jean Paul, which had often been in my mind—* Oh! how
beautiful is death, seeing that we die in a world of life and
creation without end!” and the latter part of his exclamation
was clearly suggested by the familiar lines of Tennyson :—

‘Tis life, not death, for which we pant,
More life, and fuller, that we want,”
1] SLEEP AND DREAMING. 27

The turning round and laughing to myself with my hand
before my eyes was a trick of my German friend when he was
amused; at any meeting with what he called a “capital humbug: ”
my repetition of his movement had brought before me the
image of my friend. The whole dream was the affair of an
instant, for it was on a night when I no sooner got to sleep than
I began dreaming furiously and. was awakened again. A few
nights afterwards I found myself in a dream endeavouring
eagerly to trace the associations of my dream, no doubt in
consequence of the particular attention which I had been lately
giving to the events of my dreams and of my efforts to explain
them. ‘

Under the heading of precedent mental experience, albeit not
personal experience, one might class instances of what seem to
be reversions in sleep to ancestral modes of thought, feeling, and
action, Take, for example, the case mentioned by Darwin,
of the gentleman who used to make a peculiar movement of
the right arm when fast asleep, raising it slowly in front of the
face and then letting it drop heavily on the nose, and whose son
and granddaughter made exactly the same movements when
they were sound asleep.t. Here nervous substrata stimulated in
sleep gave out in motor function what had been embodied in
their constitution by ancestral experiences. What is to prevent
a materialised mental experience being aroused in the same
way? Such a common saying as that “It is his father’s trick
ail over” may be as true of mind as of body, and as true of the
dreaming as of the waking mind.

I pass on now to consider the second class of dream stimuli.
I have said enough to show that the least occasions in the day
may lead to the revival of experiences that have long lain in
oblivion, and to their employment in the strangest and most
novel dramatic constructions, and to prove also that the combin-
ing and creative power which lies at the root of what we call
imagination is something which is spontancous in character,

1 Darwin on The Expression of the Emotions in Man and Animals. See
also a suggestive paper on “Some Organic Laws of Memory,”’ by Dr.
Laycock, in Journal of Mental Science, July, 1875.
28 PATHOLOGY OF MIND.. [onar.

instantaneous almost in its operations, and even more inventive
in sleep than during waking.

2. Impressions on a Special Sense—Inasmuch as the senses
are not always equally deeply asleep when we are asleep, one or
other of them is sometimes so far awake as to be susceptible
to impressions; and it is certain that such impressions may be
the occasion or determine the character of a dream. Dr.
Gregory tells how, having gone to sleep with a bottle of hot
water at his feet, he dreamt that he was walking up the crater
of Mount Etna. Though he had never visited Etna, at an earlier
period of his life he had ascended Vesuvius, and -had felt a
sensation of warmth in his feet when walking up the side of
the crater. The sensation of warmth in his feet was the evident
cause of the peculiar character of his dream. There is an often
quoted story of a person who, having had a blister applied to
his shaven scalp, dreamed that he was being scalped by Red
Indians. A sound in the room or outside it which actually
awakens the sleeper may occasion or take part in a dream
which seems to have occupied a considerable time, but which
must have been over in an instant: the sound is heard before
he is actually conscious, and the mind, hastening to give some
interpretation of it,-calls up probably such ideas as have been
associated with a strong or recent impression upon the waking
mind.t Alfred Maury carried through a series of experiments
upon himself in order to test the influence of impressions made
upon him when he was asleep. He instructed a person to

1 The cerebral reception and assimilation of an impression’ prior to
conscious knowledge, which, when it comes immediately afterwards, is
perforce struck by it as an exactly similar former experience (see Phy-
siology of Mind, p. 33), is a phenomenon of the same kind. In some
morbid states of the brain these illusions of former identical experiences
are very marked. In the Archiv fiir Psychiatrie Dr. Pick records the
case of an insane patient sent to an asylum in consequence of excite-
ment and delusions that people put poison in his food, listened to his con-
versation, &c. ‘From his early years he had a vague consciousness as if
the events he was passing through had been already experienced. At first
these notions were of a dim and uncertain character, but in'the course of
time they got clearer, so that he thought he possessed a double nature,
. . . Visits to pleasure resorts, the sight of public amusements, and casual
interviews with persons so affected his memory that he was convinced
he had already visited the same places and seen the same persons under
exactly the same circumstances,’’ (Bd. vi., H. 2, p. 568).
1] SLEEP AND DREAMING. 29

remain by his side and to make various impressions upon his
senses, without telling him beforehand what he was going to do,
and to awaken him soon after each impression. His lips and the
end of his nose being tickled with a feather, he dreamed that a
pitch plaster had been applied to his face and afterwards torn
away so violently as to bring with it the skin of his lips, nose,
and face. When he was pinched at the back of the neck, he
dreamed that a blister was applied to his neck; and that-
brought to his mind a doctor who had treated him in his infancy.
Other experiments had similar results, but in many of them
there was no connection to be traced between the stimulus and
the dream. Most persons must have dreamed at one time or
another that they were going about in the street naked and have
felt embarrassed or distressed at their unfortunate predicament :
it is probable that the occasion of this dream is a sensation of
cold arising perhaps from an insufficiency of clothing or from
the clothes having fallen off the bed so as to partially expose
the body. Were the sleeper in a feverish state a feeling of
chill might induce the dream without any insufficiency or dis-
arrangement of the clothes. When fever or other bodily
disturbance, such as indigestion, has produced irritation or a
disordered sensibility of the skin, as it will do, itis easy to
understand that impressions upon it will be perverted and will
be likely when they reach the brain and are translated there
into objective forms to undergo extraordinary transformations :
the least touch may become a blow, or a stab, or a bite from some
savage monster, causing the sleeper to wake up in the fright of
a nightmare.

Coleridge was of opinion that the nightmare was not a mere
dream, but that it always occurred just when the waking state
of the brain was recommencing, “and most often during a rapid
alternation. a twinkling, as it were, of sleeping and waking.” He
supposed, in fact, that actual impressions from without enter
into and mingle with the dream images in such case and give
them an air of greater reality; for there is at the moment a
complete loss of power to distinguish between the subjective
images and the objective realities. Without doubt this is what
happens sometimes, but whether always so is not certain. It is
30 PATHOLOGY OF MIND. [crae.

worthy of note, however, that in that form of melancholia in
which the insane person's mind is possessed with some vague,
vast, and horrible delusion, and he is incapable of the least exer-
tion, standing or sitting like a statue wherever he may be placed
—in which he may be truly said to be in astate of lasting night-
mare—impressions from without that are received by the senses
are perverted to suit the horrors of the delusions. The patient
has no power to distinguish between the subjective feelings arising
out of his morbid state and the actual impressions made upon
his senses; and the anxious efforts of friends to rouse him from
his fearful lethargy, to comfort him with kindly assurances, to
sustain him with suitable nourishment which he refuses, appear
to be the malignant jeerings and tortures of devils by whom he
is surrounded and tormented. In less extreme cases of mental
derangement, the misinterpretation of actual sensations is
common enough: a perverted sensation of taste, which may be
the outcome of digestive disorder, originates or strengthens a
delusion in the morbid mind that poisonous substances have
been put into the food; a perverted smell is thought to be pro-
duced by noxious vapours disseminated through the air; a
disordered touch suggests the play of mysterious magnetic in-
fluences. Moreover, once the delusive interpretation has been
made it reacts upon sense and aggravates the disordered sensa-
tion, just as the expectation of a particular sensation being
about to be felt sharpens the sense to feel it. These points of
resemblance between the operations cf the mind in dreaming
and in insanity are of much interest, as shedding light upon
each other’s phenomena; for if we could get at the actual con-
ditions of the former it is certain we should have a valuable
clue to guide our inquiries into the darker recesses of the
latter.

3. Organic or Systemic Impressions—There’ are particular
dreams which I have from time to time, and which I feel sure
originate in certain states of the abdominal viscera. I take it
for granted here ‘that each internal organ of the body has,
independently of its indirect action wpon the nervous system
through changes in the composition of the blood, a specific
action upon the brain through its intercommunicating nerve-
1] SLEEP AND DREAMING. 31

fibres, the conscious result whereof is a certain modification of
the mood or tone of mind. We are not directly conscious of
this physiological ‘action as a definite sensation, but none the
less its effects are attested by states of feeling that we are often
perplexed to account for. In truth these organic effects of the
physiological consensus of organs determine at bottom the play
of the affective nature; its tone is the harmonic or discordant
outcome of their complex interactions; the streneth of the force
which we develop as will and the emotional colour in which we
see life have their foundation in them. This being so, it is
evident that when the external senses are shut in sleep and the
conscious operations of mind in abeyance, these internal effects
will be likely to declare themselves more distinctly, as the stars
come forth brightly when the sun goes down and they are no
longer veiled by his greater light. The sympathetic mood or
feeling aroused by a particular organ, which may from some
cause in itself be exerting a more active influence upon the
brain than is usual in sleep, will call into activity the sympa-
thetic ideas of that mood, furnishing the background on which
the appropriate dream imagery is thrown ; it will determine not
the specific forms of the ideas directly, but the ground-tone,
whether exalted or depressed, of the drama which they con-
struct—that is, the character of the dream in relation to the
personality.

It will not be disputed that we rightly discover in these
operations the occasions of many dreams ; for there are manifold
undefined changes in our systemic feeling which may well have
their different effects in dreams, though we cannot distinguish
and describe them when we are awake. When the breathing is
not free enough in sleep, and the heart’s action is oppressed, as
it eventually is in such case, the sleeper is apt to wake up
suddenly in the greatest apprehension of something terrible
being about to be done to him in his dream. The natural and
involantary motor expression of an oppressed heart is such
action of the muscles of the face and of respiration as betokens
fear and apprehension; but this action cannot take place in
sleep, and in its stead we get an equally involuntary expression
of the physical state in the terrifying dream’ and in the frantic
32 -PATIOLOGY OF MIND, [cHaP.

but bootless desire which is felt to escape from the threatened
danger. For when a passion has been aroused, or rather when
that excitation of the nervous substrata which are its physio-
logical basis has been brought about, the energy may be expended
in one of two principal ways: either by putting in action the
muscles which are its natural exponents, or by calling up
related or sympathetic ideas and putting them in action.
Now if a person has fairly sound sleep I conclude that his
motor nerve centres and his muscular system are so much
asleep that he cannot make use of them to give expression
to his internal state in its appropriate movements, and that the
energy of it is expended mainly in the painful dream imagery.
There is a sort of inverse relation between ideas and movements
in regard to their action: when we are deeply absorbed in
thought the body is still and respiration is slower; when we are
active and are breathing quickly we cannot think; the insane
person whose mind is possessed with some vast and fearful
delusion is passive or statuesque; and the ecstatic, when rapt
in contemplation, is motionless, with scarcely perceptible pulse
and respiration ; the passion that has outlet in abusive speech or
in other movements disturbs not much the thoughts ; the anger
which is suppressed calls up a host of malignant ideas. In like
manner the partially active cerebral state excited by one of the
viscera in sleep becomes the occasion of a dream, when it would
probably be discharged during waking in such simple bodily
movements as yawning, or stretching the limbs, or the like
For there are a great many seemingly purposeless movements of
that kind that are made constantly by us, and hardly noticed
when we are awake, the stimuli of which come from the organic
life. Some such movements as moving the arms, stretching out
the legs, turning the body, we do make when we are asleep, but
on the whole ideas are then much more active than movements.

A heavy and indigestible meal taken a short time defore going
to bed is a well-known cause of a form of nightmare in which
the person dreams that he has a mountain or a monster lying
upon his chest and crushing it by its weight. Whether the
dream be the direct effect of the action of the overloaded
stomach upon the brain or an indirect effect of the oppression
J SLEEP AND DREAMING. 33

of the functions of the lungs and of the heart is not easy to say,
but, whatever the actual mode of operation, it is interesting to
note how well the mental interpretation of the oppression suits
with the cause. The troubles of indigestion seldom fail to cause
a dreaming sleep. Whether the spleen ever gives a specific colour
to a dream is quite uncertain, but there can be no doubt that:
disorders of the liver and of the intestines both occasion dreams
and affect their character. Every stage of the passage of food
through the alimentary canal may indeed affect the impression
made upon the brain, and the impression is thereupon interpreted,
as other feelings of subjective origin are, in accordance with the
objective experiences of the senses. I have several times had a
vivid dream that I was engaged in conducting a post-mortem
examination of a body which came to life and quietly rose up
to a sitting posture on the table as I was at work. On one
occasion I seized a wooden mallet and struck it on the head
with all my might; on another occasion I thrust my hand
into the open chest and tore out the heart; but neither
of these desperate deeds seemed to make it die and behave
as a corpse should. On all occasions, so far as I remember,
there was the same indescribable feeling of puzzled surprise
and apprehension; with a resolution to escape at any cost
the consequences of cutting up a living body; there was
moreover a strong sense of personal repression or humiliation
which I have never had in actual life since I was at school.
This dream seems always to have occurred in connection with
some uncomfortable intestinal state: not that this had anything
to do with the special incidents of the dream, but it probably
had much to do with the fundamental feeling of self-repression
which inspired it. I am acquainted with an eminent gentleman
who, when he is suffering from a certain abdominal trouble,
dreams that he is going in distress from water-closet to water-
closet at a railway station to find them all occupied or in such a
condition as to be unfit for use. There is an indirect way,
moreover, in which abdominal derangements help to affect
mental states in sleep—namely, through the effect which they
produce upon the skin. When there is irritation or other
disorder of the mucous inembrane of the stomach and intestines,
34 PATHOLOGY OF MIND. [cHap.

the outer covering of the body, with which it is really con-
tinuous, sympathises and becomes irritable and has its sensibility
affected, on which account the meaning of impressions made
upon it is more than usually perverted in dreams.

The internal organs which show their specific effects upon the
mind most plainly are the reproductive organs; the dreams
which they occasion are of such a character as leaves no doubt
of the specific character of the stimulus. Without entering
into a detailed discussion of their phenomena, I may deduce
briefly from their striking character certain lessons which are
not so plainly taught by the more obscure effects of other
internal organs. In the first place, it.isa probable inference
from their characteristic effects that specific, though less striking,
effects are produced by other organs. Secondly, it may be noted
that these characteristic dreams, which appear for the first time
when the reproductive organs begin to function, occur to the
individual before there has been any actual experience of the
exercise of these functions or any observation of their exercise.
The experience is in entire accordance with the fact that there
is no need ever to teach young persons how to exercise the
functions; the instinct giveth the understanding necessary for
its gratification. Clearly there are nervous substrata that are in-
active in every person’s brain until he reaches puberty and which
then function for the first time. This might teach us to consider
how many peculiarities of thought, feeling, and behaviour which
differentiate us from other persons are due to nervous substrata
inherited from near or remote ancestors, some of which come
into functional action perhaps in connection with particular
bodily changes that occur at certain periods of life. The
individual who begins to feel, think, and act in accordance with
his kind when the revolution of disposition takes place . at
puberty may also develop for the first-time peculiarities of
thought and feeling which his forefathers have shown, when,
later in life, the functions of the reproductive organs wane or
cease. Lastly, the mental operations of these organs serve
to show of what character the effects produced by internal
organs actually are, and for what factors in mind we are
indebted to them. They engender a particular tone or feeling
I] SLEEP AND DREAMING. 35

of mind which is conducive to the origin and activity of
certain related ideas, and they impart the force of desire by
which conduct is inspired; but they do not, as some have
supposed, directly affect the understanding, which is a function
of the animal life or life of relation, and is developed out of
sensations and motor reactions thereto,—that is, out of the
capacity to receive impressions from without and to make
responsive adaptations to them. The office of the intellect is to
guide and direct, steersman-like, the force of individuality
which is derived actually from the unconscious depths of the
organic life; the sympathetic ideas which a particular mood of
feeling stirs are the appropriate channels or forms in which that
feeling gets expression when it is not translated instantly into
action; and it will depend much upon the education of a
person in youth, and by the experiences of life, whether the
ideational activities shall be wise or unwise expressions of the
fundamental feeling.

I have said enough to indicate how much the physiological
action of the visceral organs has to do with the excitation and
with the character of dreaming. On the whole it is probable
that they are the most active agents in this respect; for the
sleep of the body is not their sleep; they continue their
functions through the night, albeit at a lower rate of activity;
and if the sleep be light, or if one or more of their functions be
so far deranged as to. become an unusual stimulus, their cerebral
sympathies will declare themselves in the irregular activities of
dreams, when they are not so energetic as to cause waking,

4, Muscular Sensibility.—It is nelnied of several holy persons
of old, men and women, that in their spiritual raptures or
ecstasies they rose bodily from the earth and floated in the air ;
and there can be small doubt that some of them felt and believed
that they did. St. Philip Neri, St. Dunstan, St. Christina could
hardly be held down by their friends, while it is told of Agnes
of Bohemia that, when walking in the garden one day, she was
suddenly raised from the ground and disappeared from sight of
her companions, making no answer to their anxious inquiries
but a sweet and amiable smile-on her return to earth after her
flight. Everybody must at one time or another have had a
36 PATHOLOGY OF MIND: [cnap.

similar experience in his dreams. The explanation is not far to
seek : a person may have a motor hallucination, so to speak, and
imagine he makes the movement which he does not, just as he
may have a sensory hallucination and imagine he sees or hears
the thing which he does not. We are the victims of motor
hallucinations when we suffer from what is called vertigo and the
room seems to turn round; the intuitions of movements which we
get from the disordered action of the motor centres, and which
therefore are entirely subjective, are interpreted objectively in
accordance with our ordinary sensory experience, just as sensa-
tions of subjective origin are interpreted objectively, and so
become hallucinations. Certain drugs when taken into the
blood produce vertigo at an early stage, and perhaps convulsions
at a later stage of their operation; they affect the motor and
associated sensory centres moderately in the first instance,
exciting them to a disordered activity, the subjective aspect
of which is vertigo, and afterwards more severely, when the
disordered energy is discharged in actual convulsions. The
drunken person when he shuts his eyes feels the bed to sink
under him, the disorder of his motor intuition being interpreted
objectively in that way, and when he falls on the ground or
runs his head against the wall he perceives the ground to rise
and strike him, or the wall to’ run forward against his head:
his motor troubles and hallucinations are the direct consequences
of the poisoning of his nervous centres by alcohol. One of the
effects of aconite, when taken in poisonous doses, is to produce
a feeling as if the body were enlarged or were in the air, mainly
perhaps in this instance because of the loss of sensibility of the
surface of the body which is an effect of the poison, whereby
the person does not feel himself in contact with what is outside
nim ; the part of the body from which he gets no message when
6 is touched appears therefore to be no longer his, and he
interprets the interruption of feeling between him and the
outside objects as an actual separation of substances such as
would be produced by the body being in the air. These
examples will serve to indicate how considerable a part motor
hallucinations, combined as they commonly are with sensory
disturbances, may play in the phenomena of dreaming.
1] SLEEP AND DREAMING. 37

An uncomfortable position in which the sleeper may chance
to lie becomes the occasion sometimes of a dream that he is
engaged in a desperate struggle, or is clambering for very
life up a steep precipice, and when he has made the convulsive
effort to save himself, which he feels that he cannot probably
do on the instant, he awakes and relieves the constrained attitude.
‘A not uncommon dream is that he is in imminent danger of
falling from a height, and be awakes just as he makes the
frantic effort to prevent himself from falling. It has been sur-
mised that this dream is owing to the gradual relaxation of
the muscles as he goes to sleep and to an ensuing sudden
contraction of them, such as we observe to happen when a
person’s head who is very sleepy sinks gently forwards as the
muscles relax, and then is pulled suddenly up with a jerk by
their contraction ; or it may be owing to the inclined position
of the bed on which the body is lying. After great muscular
exertion in climbing high mountains I have often dreamed, of
‘sliding down precipices, falling into chasms, and the like, and
that so vividly sometimes as to be obliged, on waking, to stretch’
out my hands and grasp the sides of my bed before I could feel
sure where I was; without doubt the wearied muscles were the
occasion, through their motor centres, of the mental drama in
which the sensory experiences of the day were worked up. But
I was once surprised to dream this sort of dream when I had
been making no particular muscular exertion in the day, nor
had been near any mountains, and when I could at first think
of nothing which could have provoked it; on reflection, however,
I called to mind a momentary experience of the day which
seemed to be a sufficient cause ; for I had been driven rapidly
in a, waggonette to a railway station in the country, and as the
horses turned a corner of the road as we went downhill, ny
muscles contracted involuntarily because I felt from the swing
of the carriage a necessity to hold on to the seat. There could
be no doubt that this momentary feeling of a support failing
was the occasion of the night’s dream. When Braid roused in
the minds of persons whom he had put into the hypnotic sleep
ideas associated with certain bodily attitudes by putting the
body into the proper attitudes, he stimulated the mental states
38 PATHOLOGY OF MIND. [cHaP.

through their suitable muscular acts; he might no doubt have
excited them equally successfully without any muscular action by
suitable stimulation, had it been possible, of the motor centres
only ; exciting in this way the motor intuitions without the
actual movements, just as is done when delusive notions as to
different positions of an amputated limb are excited by stimu-
lation of its nerves. There can be little doubt that what Mr.
Braid did experimentally in artificial sleep is a common occur-
rence in natural sleep, and ought to. be taken account of in
prosecuting inquiries into the causation of dreaming.

It may be interesting to speculate whether the movements of
the heart and of respiration, which go on without intermission,
and with only some abatement of energy, during sleep, have
any effect upon dreams. That they have no such effect when
they are not accelerated or retarded is proved by the fact,
if it be a fact, that sleep is sometimes dreamless ; but there is
good reason to think that when they are disordered they testify
of themselves in dreams. On several occasions I have had a
dream in which I felt it urgently necessary to make an instant
exertion in order to go on living, having experienced a vivid
and urgent feeling that if I did not make it I should die; and
although I have resolved after such a dream to remain quite
still when next I had it, in order to test what would happen, I
have never yet succeeded; so overwhelming is the apprehen-
sion at the time, that the necessary convulsive start or gasp has
always been made, and I have awoke in a state of agitation
with my heart beating tumultuously. The dream seems to have
its origin in an impeded action of the heart, which, after en-
during the oppression for a while, makes a violent beat to recover
itself, and then goes on beating rapidly for atime. It may be
presumed that a more rapid action of the lungs and of the heart
than usual, or the ordinary action of these organs perhaps under
some circumstances, will be felt by the brain during sleep, and
so give a character to the ensuing dream. What this character
is I am not able to say, unless there is truth in the conjecture
that the sensation of flying in dreams is owing to a consciousness
of the rhythmical activity of the lungs or of the respiratory
movements, which suggests the rhythm of flying movements;
LJ SLEEP AND DREAMING. 39

but that we have in ‘these continuing movements occasional
factors in the production of dreams is in accordance with general
physiological considerations, and with such positive experience
as we can appeal to in so very obscure a matter.

5. Lhe Cerebral Circulation—When the brain is thinking
there is a more active flow of blood through it than when it is
at rest; but this flow must not be too active, or sound thinking
cannot be done. There are two conditions which experience
proves to be adverse to successful thought—namely, an excessive
and a deficient flow of blood through the brain. There may be
an excess of blood in the brain, however, with a retarded circu-
lation, a passive congestion, which equally hampers thought, as
it prevents the free outflow of vitiated blood and the free inflow
of fresh blood. When the circulation is too active the ideas are
rapid, imperfect, transitory, tumultuous, confused, and scarcely
coherent; and if the physical disturbance be carried a step
further, the tumult of ideas degenerates into actual delirium, as
we plainly observe, for example, when the membranes of the
brain are inflamed. When there is too little blood or impover-
ished blood flowing through the brain, thought is also impeded :
there is languor, apathy, incapacity of concentration of attention,
positive inability to think ; and if the condition of physical dis-
turbance be aggravated, then also there is delirium,.though of a
looser, more feeble, and less energetic kind than the delirium
of hyperemia. Applying these considerations to the state of the
cerebral circulation in sleep, it is easy to understand that fluc-
tuations of it will oftentimes be the occasion of dreams. Notably
these are sometimes very vivid and coherent ; the sleeper awakes
perhaps out of a dream which seemed very real, goes to sleep
again, and is immediately engaged in another equally vivid,
which leads to his waking again; no sooner is he asleep once
more than he is in the middle of another vivid dream, and as
dream thus follows dream in quick succession, making a curse
of slumber; he might well exclaim in the words of Job—* When
I say, my bed shall comfort me, my couch shall ease my com-
plaint ; then thou scarest me with dreams, and terrifiest me
through visions.”

Tt is a probable conjecture that these: vivid and coherent
40 PATIIOLOGY OF MIND. (cHaP.

dreams mark a general activity of the cerebral circulation,
and that they follow one another as long as it continues,
The misfortune is that in this condition cause and effect
seem to act and react so as to keep up each othen’s activity:
the full or rapid blood-stream stimulates the nerve-elements,
and the excited nerve-elements in turn attract and keep up an
active circulation : we could sleep soundly if the stream of blood
would only subside, and the stream of blood would subside if
we could only abate or suspend the race of ideas through the
mind. Meanwhile neither will begin to abate first. The merit
of the several plans which have been recommended as success-
ful means of inducing sleep lies in their fixing attention steadily
upon some object or event that is itself of an unexciting nature
for a sufficient length of time to allow all active ideas to subside.
To imagine a continuing monotonous sound, or a flowing river, or
the rush of a stream of steam from the nostrils, and to hold the
attention to the particular imagination without permitting it to
wander to more exciting ideas, to repeat to oneself slowly lines

of poetry, or to go on counting from one upwards, and the like,.

are all schemes which operate in that way; and in carrying
them into effect success will certainly be more probable, accord-
ing to my experience, if the breathing be deliberately slackened
and the eyeballs rolled upwards voluntarily, as is done in-
voluntarily during sleep.

Local fluctuations of the circulation may in like manner be
supposed to be the causes of dreams more limited in range and
less coherent in character. Certainly such variations occur,
- although we are not able to specify the exact causes of them.
Looking, however, to the many ingoing channels of communica-
tion between the different organs of the body and the brain in
which they are all represented locally, it is easy to conceive that
some trivial disorder of one of them may affect temporarily,
through vaso-motor nerves, the circulation in the cerebral area
in which it is represented: the particular vascular area will
blush or become pale, as it were, in sympathy with the state of
the organ. LBaillarger relates a case which may find a place
here as fitly as anywhere else. A Greek merchant had suffered
for a long time from a hemorrhoidal flux, which was suppressed

 
1.] SLEEP AND DREAMING, 1

at last by treatment. But he began immediately to suffer pains
in his head, without however exhibiting any trace of delirium.
A singular phenomenon too presented itself: every night he
had a dream in which he imagined that he possessed immense
wealth, and that he distributed fortune and honours to all around
him. The recurrence of the dream night after night struck him
as so extraordinary that he spoke about it to his friends. After
a short time delirium broke out, characterised by the sume con-
ceptions as for fifteen days had occurred during sleep: in fact,
the exalted delirium was only a continuation of the dream. It
may be surmised that in this case there was, in consequence of
the suppression of the hemorrhoidal flux, a disturbance of the
cerebral circulation which showed itself first in the troubles of the
head and afterwards in the dream of the night, and that the vas-
cular disturbance, with the special cerebral activity accompany-
ing it, became after atime a chronic and permanent derangement.

The quality of the blood is a4 not less important factor than
the quantity and the distribution of it. Foreign matters bred in
it or introduced into it from without increase, lessen, or pervert
the functions of the supreme cerebral centres, giving rise to
temporary exaltation of mental energy, to stupor and coma, and
to delirium. The constant changes in the constitution of the
blood, which are the consequences of its use and renewal in the
nutrition of the tissues, its life-history being a continued meta-
stasis, will undergo such modifications from time to time as to
generate substances that may act upon the nerve-centres, as
upon other tissues of the body, to excite or to depress or to
derange their functional activity ; and it is obvious that the cir-
culation of such products in the blood may be the active occasion
of dreaming. Blood that is impoverished through deficiency of
one of its essential constituent elements, as in anzemia, where
iron is wanting, or is impure by reason of the retention in it of
some effete products of the tissues which should be excreted, as
when hindered respiration prevents it being properly decar-
bonised, or when some constituent of the bile accumulates in it,
or when the uric acid which should be drained off by the kidneys
is retained in it, may be confidently expected to act upon the
brain in sleep as powerfully as it does when awake.
42 PATHOLOGY OF MIND. [cHar.

Let it not be overlooked in relation to this matter that the viti-
ated or altered blood will act upon any nerve-centre, whether
sensory, motor, vaso-motor, or ideational. Subjective visual sensa-
tions, such as bright spots, circles of light, coloured patches, vague
figures, that are due to direct irritation of the retina or its central
ganglion, and which may be observed almost always just before
going to sleep, if we only take notice of them, will originate a
dream or be woven into it; motor intuitions will be excited in
like manner by the action of the vitiated blood upon their
nerve-centres ; it will act again upon the vaso-motor centres
which regulate the contraction of the blood-vessels, and so affect
secondarily the circulation -within the brain; and by reason of
its distribution through the supreme nerve-centres it will stimu-
late ideas mechanically, independently of the usual links of
association, and so probably occasion very incohereut dreams
marked by rapid transformations and grotesque inconsistencies.

Dreams are sometimes found to go before a severe bodily illness,
which they seem to foretell: before the delirium of fever breaks
out the patient is much disquieted and distressed by vivid and
gloomy dreams, of which the delirium appears as a continua-
tion ; and-during the progress of fever, when he is not actually
delirious, all inclination to sleep is banished, though he would
give all he has to get sleep, painful thoughts chase one another
in rapid succession through the mind, and he is overwhelmed
with a terrible feeling of profound depression and vague dread,
the indescribable misery of which he declares he would not choose
to go through again for all that the world can give. Did the
invention of hell need any explanation the mental sufferings of a
delirious patient in some instances might furnish it. An out-
break of acute mania of an elated character is sometimes pre-
ceded by dreams of a joyous and elated character, and sad and
gloomy dreams in like manner often go before and presage an
attack of melancholia. I was consulted on one occasion by a
lady who had suffered from several attacks of profound melan-
cholia, each of which had lasted for about four months; they
were separated by longer intervals of sane and busy cheerful-
ness, during which she was as unlike as possible what she was
when she was afflicted. The notable circumstance in her case
1] SLEEP AND DREAMING. 43

was that before an attack she invariably dreamed that she was
suffering from it, and before it passed off as invariably dreamed
that she had recovered and was cheerful and well. So certain
were these dream-presages that they had never failed to occur
and had never deceived her. And yet she did not feel more
cheerful just before she recovered, nor more energetic imme-
diately after her recovery; on the contrary, for two or three
days before the attack passed off she was more wretched than
ever, and far more irritable, so that’ she was inclined to smash
everything about her; and immediately after it passed off she
was exhausted, felt very feeble, and was unable to make the
least exertion. Before the attack there always occurred ex-
actly the same symptoms of digestive disorder, which no kind
of treatment—and many things had been tried—assuaged in
the least: the tongue became remarkably red, she could take
little or no food, and there was obstinate diarrhcea. The symp-
toms no doubt pointed to a primary affection of the great sym-
pathetic nervous system, which was followed in a little while by
cerebral disturbance ; and it would certainly appear that the
brain felt the sympathetic trouble in sleep, and so forefelt and
foretold the impending calamity in its dreams, before it had
waking consciousness of it, just as in like manner it forefelt and
foretold recovery. a

I know not certainly whether the state of the blood has any-
thing to do with the dreaming which occurs in connection with
certain diseases, but it is probable enough in some cases. The
inquiry is one which may be set down as having yet to be made.
All that we are meanwhile warranted to conclude positively is
that the quality of the blood is a real factor in the stimulation
and depression of the cerebral and other nerve-centres, and
therefore in the causation of dreaming. It may act directly or
indirectly to produce its effect: directly upon the supreme
cerebral centres so as to excite irregular function in them, or
directly on the sympathetic nervous system, and indirectly on
the brain, whereby a deep disturbance of the affective nature is
produced and gives its predominant tone to the dream.

6. The Condition of the Nervous System.—Little considera-
tion is needed to show how difficult it must be to treat of the
44 PATHOLOGY OF MIND. (chap.

condition of the nervous system separately from the quality and
activity of the blood; in truth, they constitute together a com-
pound state rather than distinct co-operating conditions. The
vital interchanges between the blood and the nerve cell which
are constantly going on are an essential part of the function of
the latter as a living cell; without them it could not exercise
any function at all, being in itself a sort of mechanical frame-
work which is kept in action by the plasma supplied from the
blood that it uses and exhausts in its function ; it feels therefore
the least changes in the quality of the supply. But the structure
itself wears out in time; it wears out naturally with the decay
of old age, and it will wear out prematurely if an undue stress be
put upon it habitually. The blood has not only to supply in the
rich plasma the high potential force which is to be made actual
energy in the discharge of nerve-function, but it has to keep in
‘repair the nerve-structure ; and this it must fail to do when the
latter is subjected continuously to an excessive strain. Because
then of the deterioration which may be produced in nerve-
elements by stress of function as well as by natural decay, and
because also of temporary modifications of nerve-tone which
seem to be produced by unknown atmospheric conditions, I
have thought it fitting to group the facts relating to the direct
state of the nervous system under a separate heading.

A state of moderate nervous exhaustion, whether from the
fatigue of mental or bodily exercise or from some other cause, is
notably most favourable to the induction of sleep. But when
the exhaustion is carried to excess the propitious conditions are
gone, and the person cannot sleep at all, or cannot sleep soundly :
he may get fitful snatches of unrefreshing slumber in which he
is pursued by dreams that are so like the rambling incongruities
of half-waking fancy as to leave him in doubt whether he
actually slept or not. It is a well-known experience that a
moral shock or a great trial which has produced much emotional
agitation or strain in the day will trouble the slumbers of the
night with distressing dreams ; and it is equally certain, though
it is perhaps not so well known, that an exhausted and depressed
state of the nervous system owing to indulgence in excesses of
any kind, and especially sexual excesses, will have the same
| SLEEP AND DREAMING, 45

effect. The dreams which occur under these conditions betray
their origin by their character. They are disagreeable or dis-
tressing dreams of being encompassed by difficulties or troubles
of some kind or other—the exponents of a condition of organic
element which means a reduction of its vitalitv. For a moral
strain or a physical excess is able to produce the same physical
cffects in the cerebral nerve-centres—namely, consumption of
energy and lowered vitality ; and the lowered vitality becomes
in dreams an oppression or a check or a humiliation of self,
just as a bodily pain which we are suffering when we go to
sleep becomes transformed sometimes intv the persecutor of our
dream. We cannot be too mindful of the physical effects of
moral causes ; a moral shock may kill as instantly and surely as
a stroke of lightning, and when it does so its operation and
effect are as certainly physical in the one case as in the other.
Nor can we be too mindful of the effects of exhausting physical
conditions upon mental tone and power.

Whosoever is so unhappy as to have habitually sleepless nights
and bad dreams should bethink him that his health requires
attention ; for in some way or other he is not living wisely. A
prudent man will indeed use his dreams as a sort of health-gauge.
When Hamlet declared that he could live bounded ina nut-
shell and count himself a king of infinite space, were it not that
he had bad dreams, he was suffering from the great moral com-
motion produced by the appalling revelation of his father’s
murder, which his father’s ghost had made to him, and from the
terrible strain of the obligation laid upon him to avenge that
crime; his dreams—if we may take him to mean literally what
he said—were the signs and the effects of an exhaustion of
‘nervous energy which might have overthrown a less strong mind
in madness. Over-work and anxiety are well-known causes of
sleepless nights and bad dreams ; but in some cases of supposed
over-work J am convinced that the evil result which excites
alarm is owing not so much to overstrain of mind as to im-
prudent excess in other respects. The over-indulgences of life
are really more to blame in such cases. The man of business
goes through the daily routine of his work with no more variety
of impressions than is occasioned by an extra cause of worry or
46 PATHOLOGY OF MIND. [CHAP.

by a chance stroke of good or ill fortune; he has no interests
outside it, and when he is not occupied in it he has no resource
but to eat and sleep; probably he eats grossly, drinks freely,
and is not less free in sexual indulgence; and this goes on from
day to day and from yeur to year until, as the elasticity of the
system wanes with advancing manhood, he has to seek advice
from a physician because his sleep fails him, his work tries him
as it never used to do, he is irritable, and he feels overworked.
It is from sensual indulgence and the exhaustion consequent
thereupon, and from a neglect of mental hygiene, that he suffers
primarily; the work of his life might have been done without
strain if he had not exhausted his capital by the steady drain of
habitual slight excesses,and so made a great burden of his daily
duty. But I will not pursue these matters further now; I have
touched upon them by the way only to make plain the similarity
of results as regards sleep and dreaming between the effects of the
moral and the physical causes of exhaustion of nerve-element.
When the nervous structure undergoes impairment in old
age, the decay is natural, and I know not that the dreams of old
persons are particularly distressing. The decay of age is not,
like a disease, an invader against which the organic forces rise
in defence, and defend themselves with more or less success; the
organism acknowledges and accepts it rather as a natural decline
that makes its descent to death easy. What we observe in old
age is that the distinction between sleep and waking is less
marked than in youth and manhood, both being less com-
plete: nature as it approaches its last sleep is fashioned for
the journey. When decay reaches its last stage before death,
and life is flickering before it expires, there are rambling reveries
which are very like dreams, and dreams that show. like feeble
delirious wanderings. Lord Jeffrey, in the last letter which he
wrote the day before his death, gives the following account of
himself: “T don’t think I have had any proper sleep for the
last three nights, and I employ portions of them in a way that
seems to assume the existence of a sort of dreamy state, lying
quite consciously in my bed with my eyes alternately shut and
open,” and seeing curious visions. He saw part of a proof-sheet
of a new edition of the Apocrypha, and all about Barach and the
1] SLEEP AND DREAMING. 47

Maccabees, and read a great deal in it with much interest ; and
a huge Californian newspaper full of all manner of old adver-
tisements, some of which amused him much by their novelty.
“Thad then prints of the vulgar old comedies before Shakespeare’s
time, which were disgusting. I could conjure up the spectacle
of a closely-printed political paper filled with discussions on
free-trade, protection, and colonies, such as one sees in the
Times, the Economist, and the Daily News. I read the ideal
copies with a good deal of pain and difficulty, owing to the
smallness of the type, but with great interest, and, I believe,
often for more than an hour at a time; forming a judgment of
their merits with great freedom and acuteness, and often saying
to myself: ‘ This is very cleverly put, but there is a fallacy in it
for so and so.’”! The literary pursuits of his life gave their
character to the flickering energies of his failing nervous centres,
and the critical habit of his mind showed itself in its final
operations.

The dreams of childhood are sometimes of a painful character,
being accompanied by great terror and distress. The most
terrifying dream which I remember ever to have had, which
made me most unhappy for a whole day and fearful of going to
bed the next night, and the chief incident of which I can yet
recall, was one which I had at the earliest period of life almost
of which I have any recollection. Without doubt the causes of
most of these dreams of childhood are to be found in the bodily
disturbances which are produced by teething, indigestion, un-
suitable food, and the like: the bodily oppression or suffering is
interpreted mentally in such forms of terror and affliction as
the child’s imagination has been indoctrinated with, and it is
accordingly scared with visions of lions or tigers, or wicked old
men that come to carry off naughty children. The emotional
life preponderates much over the intellectual life in children,
who are commonly either in a state of joy or grief, laughing or
crying; they are consequently very susceptible to fear, just as
savages are; indeed it can hardly be otherwise when their
individual helplessness is in such strong contrast with the
seemingly mighty powers of things around them, and when they

1 Jeffrey’s Life and Correspendence, by Lord Cockburn, vol. i. p. 407.
45 PATHOLOGY OF MIND [cHaP,

have not in their minds stored up experiences to enable them
to correct or control by reflection the present image of terror,
which furthermore acquires in dreams an extraordinarily vivid
intensity because of the absence of all distracting or modifying
states of consciousness. We witness a striking illustration of
the isolated intensity of a terrifying dream-image in that form of
nightmare in which a child of a nervous constitution shrieks
out in the greatest apparent distress, staring wildly. at some
imaginary object, and from which it cannot be awakened for
some time notwithstanding its outcry; it is truly in an ecstasy
of terror; there is a convulsive activity of the terrifying idea,
and for the time the nervous centres are entirely insusceptible
to other impressions. In the morning the child has not the
least remembrance of what has occurred: how should it remem-
ber when the mental state was isolated by its convulsive energy ?
Another circumstance to be noted about dreaming children is
that they often talk in their sleep, the ideas being translated
into movements of speech directly as they arise, or, if they are
of a terrifying character, into cries of distress; in the same way
horses neigh and kick, and dogs bark and tremble, in their sleep.
It is probably in some sort a consequence of this dizect reflection
of ideas into movements in children and of the fewness of their
ideas that they seldom remember their dreams ; and it is interest-
ing to note in this relation that there are some grown-up persons
who when they talk much in their sleep cannot remeraber their
dreams, but remember them perfectly well when they do not
talk.

Concerning the atmospheric conditions, whether of electrical
or other obscure nature, which may modify the tone of the nervous
system and so affect the soundness of sleep and the tendency
to dream, there is nothing more to be said than that an influence of
the kind is very probable, although we have not yet any exact
knowledge of it. Systematic observations are entirely wanting.
I am uot aware that any one has yet been at the pains to make
a long series of observations of his sleep and dreams and to
compare it with a corresponding series of meteorological observa-
tions. But I doubt not from my own experience that we do
vibrate in unison with more subtle influnces of earth and
1] SLEEP AND DREAMING, 49

sky than we can yet measure in our philosophy. Dreams
have been a neglected study; nevertheless it is a study which is
full of promise of abundant fruit when it shall be earnestly
undertaken in a painstaking and methodical way by well-trained
and competent observers. To physicians of all men is it likely
that they will prove full of instruction.

1 How great is the effect upon some persons, both in the day and in
the night, of that oppressive state of the atmosphere which precedes and
accompanies a thunderstorm! I have thought sometimes that the brain
of an aged person, who has led a life of great activity—perhaps never
having had a day’s illness, as it is said—las collapsed suddenly in such
atmospheric conditions,
CHAPTER II.
HYPNOTISM, SOMNAMBULISM, AND ALLIED STATES,

Unper such names as mesmerism, animal magnetism, electro-
biology, hypnotism and braidism, have been described, and
more or less carefully investigated, certain abnormal mental
states, of a trance-like nature, which are induced artifically by
suitable means, Too long they were rejected as sheer impostures,
unworthy of serious study, partly because they undoubtedly
yielded easy occasions to knaves to practise deceit for their
pleasure or their profit, and partly because they seemed to be
inconsistent with known physical laws. Had the interpretation
given of them by those who were eager to discover something
marvellous been the only possible one, there would certainly
have been a blank contradiction of known physical laws. But
it was not so: when close and critical attention was given
to the phenomena it was soon perceived that they might
be genuine, though they were interpreted wrongly; and the
scientific study of them, imperfect as it yet is, has shown that
they are consistent with certain other obscure nervous phenomena,
and has been useful in throwing some light upon the manner of
working of nervous functions. A good use of uncommon things
is to force us to look more curiously at the meaning of common
things which we overlook habitually. These abnormal phe-
nomena have not yet, it is true, been brought under the domain
of law, because we have not sufficient knowledge of the exact
conditions of their occurrence to enable us to define the laws
which govern them, and because their changeful, irregular, and
seemingly capricious and lawless character puts great difficulties
cu. 1.) HYPNOTISM, SOMNAMBULISM, AND ALLIED STATES, 51

in the way of systematic inquiries; but it is not seriously dis-
puted now that they will ultimately have their proper place in
an orderly and complete exposition of nervous functions.

When a person was thrown into this sort of abnormal mental
state by the influence of another person upon him, the question
was whether the effect was due to some subtle and unknown
force that emanated from the nervous system of the operator
and was transmitted to the person operated upon, or whether it
was due to the excitement of the latter’s imagination—in other
words, to the condition of extraordinary activity into which his
nervous system was brought. Those who were eager that
strange and mysterious phenomena should have extraordinary
and mysterious causes hastened forthwith to invent new forces
which they called mesmeric, magnetic, odylic, and the like ; they
were loath to believe that they had to do only with phenomena
which, though strange and aberrant, might yet be referred to the
operation of known causes, and to search patiently whether there
were not other phenomena, neglected because less striking, with
which they might be compared and classified. The inquiry, had
it been carefully and candidly made, would have shown that
they were extreme instances of the operation of known laws.

Let us go on to consider then what these abnormal phenomena
are and how they are produced. After being induced to look
intently at the operator, or so-called magnetiser, who attracts his
attention by making a few gentle passes with his hand, or by
holding some bright object before his eyes at a little distance
from them, or by merely looking fixedly at him, after a short
time the person operated upon falls into a trance-like state, in
which the ordinary functions of his mind are suspended, his
reason, judgment, and will being in complete abeyance, and he is
dominated by the suggestions which the operator makes to him.
He feels, thinks, and does whatever he is told confidently that he
shall feel, think and do, however absurd it may be. If he is
assured that simple water is.some bitter and nauseating mixture
he spits it out with grimaces of disgust when he attempts to
swallow it; if he is assured that what is offered to him is sweet
and pleasant, though it is bitter as wormwood, he smacks his
lips as if he had tasted something pleasant; if he is told
52 PATHOLOGY OF MIND. [orar,

that le is taking a pinch of snuff when there is not the
least particle of snuff on his finger, he sniffs it and instantly
sneezes; if warned that a swarm of bees is attacking him
he is in the greatest trepidation, and acts as if he were
vigorously beating them off. The particular sense is dominated
by the idea suggested to the mind, and he is very much in the
position of an insane person who believes tliat he smells dele-
terious odours, tastes poison in his food, or is covered with
vermin, when he has the delusion that he is afflicted in one
or other of these ways ; or in the position of the dreamer who is
entirely under the dominion of the imaginary perception of the
moment, however extraordinary, ludicrous, or distressing it may
be. He will in vain make violent and grotesque exertions to
lift his arm or his leg when he has been confidently tuld that he
cannot do it. In no case could he do this if he had not the
belief that he could do it, and he is impotent therefore to do it
when he has the-strong belief that he cannot do it: the growth
of a cchild’s doings is the growth of its. beliefs that it can do.
His own name he may know and tell correctly when asked to do
so, but if it is affirmed positively to be some one else’s name he
believes the lie and acts accordingly; or he can be constrained
to make the most absurd mistakes with regard to the identities
of persons whom he knows quite well. There is scarcely an
absurdity of belief or of deed to which he may not be compelled,
since he is to all intents and purposes a machine moved by the
suggestions of the operator. It is interesting to note, however,
that he will not commonly do an indecent or a criminal act; the
command to do it is too great a shock to the sensibilities of the
brain, and accordingly arouses its suspended functions. The
sensibilities of the different senses, or of one or more of them,
may be exalted, but at other times they are abolished, the con-
dition being very much that of complete trance, and the
insensibility so great that the severest surgical operations have
been performed without eliciting the least sign of feeling+ When
the person comes back to a state of normal consciousness the

1 In 1859 two eminent French surgeons, Velpeau and Broca, performed
surgical operations upon twenty-four women who had been put in the
hypnotic state by Braid’s method, without pain,
11] HYPNOTISM, SOMNAMBULISM, AND ALLIED ST'ATES, 53

illusions. disappear instantly, his senses recover their natural
sensibilities, and his mental faculties resume their suspended
functions ; but in some cases a little time must elapse before he
regains his natural control over himself, and it will be more easy
to throw him into. the abnormal state on another occasion.

The conditions of the induction of the abnormal state of
consciousness seem to be, first, a nervous system that is more
than usually susceptible and unstable, and, secondly, the exercise
of a fixed and strained attention for a short time. With regard
to the first condition, Baron Reichenbach, who was a sincere
believer in the action of a special force, which he called odie
force, gives testimony which is the more instructive here because
it comes from one who saw in the phenomena something more
than natural nervous function. “TI inquire,” he says, ‘among
all my acquaintances whether they know any one who is
frequently troubled with periodical headaches, especially megrim,
who complains of temporary oppression of the stomach, or who
often sleeps badly without apparent cause, talks in the sleep, rises
up or even gets out of bed, or is restless at night during the
period of full moon, or to whom the nioonlight in general is
very disagreeable, or who is readily disordered in churches and
theatres, or very sensitive to strong smells, grating or shrill
noises, &c. All such persons, who may be otherwise healthy, I
seek after and make a pass with my finger over the palm of their
hands, and scarcely ever miss finding them sensitive.” Nine
out of ten of his “sensitives” he found to be females “ or youths
of the same nervous temperament,” the majority of them under
twenty-five years of age, and they all seemed to have inherited
their sensitiveness from their parents. Obviously then a certain
neurotic temperament is most propitious to the induction of
the mesmeric or hypnotic state. The second condition is the
fixation of the attention for a short time through sight. Mr
Braid used to make the person look upon a disc or some bright
object held in front of aud a little above the level of the eyes
but the’ operator commonly looks him in the face and makes a
few gentle passes with his hand before his eyes; after a little
while there is a tremor of the eyes, the pupils dilate, and he
falls into the mesmeric state, All that the Abbé Faria, a
54 PATHOLOGY OF MIND. [cuar.

successful mesmeriser, used to do was to look fixedly at his
subjects in an impressive manner and to say in an imposing
voice, “ Sleep,” when they instantly fell asleep.

It was long known to jugglers, and two hundred years ago it
was shown by a Jesuit priest, Kischer, who attributed the effect
to magnetism, that if a cock or a hen be grasped firmly in the
hands and held fast for a short.time with its beak on the ground,
a chalk line being drawn straight from the beak so that its eyes
converge upon it, it remains there fixed, motionless, and more or
less insensible ; so much so as not to feel even the pricks of pins
that are thrust into its body. It is in a state of hypnotic sleep,
The chalk-line is not really necessary; the simple handling
or holding of the hen usually suffices to produce the effect,
Morever, as Czermak showed, the experiment may be done
successfully on other animals—on young lobsters, frogs, geese,
ducks, and even on dogs sometimes; the help of an object to
gaze at being necessary in some cases. Something of the same
kind occurs, I believe, when a cat fascinates a bird so that it
cannot make the least exertion to escape, or actually drops from
its perch into the paws of the cat. We perceive then that by
giving a particular strain of fixed activity to the nervous system
its ordinary functions may be suspended, and it may be made
insensible, so long as the isolated activity continues, to the
impressions which ordinarily affect it. What is the intimate
change in the nerve-element which produces this state of non-
conduction between associated nerve-centres, this discontinuity
of function in spite of continuity of connecting fibres, we know
not; it must suffice for the present to know that a particular
form of activity is capable of reaching such a pitch as to suspend
or inhibit, while it lasts, the ordinary functions of the nervous
system, and to know this furthermore by instances in which the
supposition of a transmission of any peculiar force from the
operator to the creature operated upon may be confidently rejected.

The mesmeric or hypnotic subject who is for the moment
entirely under the sway of the idea suggested by the operator and
insensible to other impressions is in a similar condition of par-
tial activity and general incapacity of cerebral function. If we
reflect, we may call to mind gradational states between this
n.] EYPNOTISM, SOMNAMBULISM, AND ALLIED STATES, 55

abnormal form of activity and the entirely normal exercise
of mental function, Take, for instance, the state of profound
reverie in which the brain is so earnestly engaged in an
absorbing reflection, so completely abstracted thereby from the
usual paths of function, as to render the greater part of it
insusceptible to impressions, and the individual therefore un-
conscious of what is going on around him: sounds strike his
ear and he hears them not, incidents happen around him and
he notices them not, the pain of disease may be unfelt in the
deep abstraction of his mind from it. There isa track or an
area of activity lit up by consciousness, while all around are
darkness and inactivity. Without falling into this Archimedes-
like abstraction, any one may notice that when he is reflecting
earnestly on a subject in which he is deeply interested he is
scarcely conscious; it is only the lapses of his attention that
make him conscious ; and the same period of time will appear
to him as a miuute or an hour according as he is deeply
absorbed in his subject or not. An acute pain notably renders
us insensible to a less pain, though the conditions of the latter
continue in operation ; the message sent to the central ganglion
by it no longer awakens any notice, for there is a local suspension
or inhibition of its sensory functions in consequence of the
abstraction of consciousness by a neighbouring predominant
activity. In the same way a severe neuralgia may be replaced
by convulsions, itself ceasing when they come on, and may
return when the convulsions stop, the disordered energy being
transferred, as it were, from one class of nerve-centres to another.
In the excitement of battle a wound is uot perhaps felt at the
time of its infliction, and some animals like frogs and snails
are insensible to pricking or cutting during the act of sexual
copulation: in all animals indeed the acute sensory orgasm
is incompatible with any distraction of thought or feeling, and
silences for the moment of its transport any pang of bodily pain
which there may chance to be. No better example than this
from the physiological life could be given to illustrate a mode of
nervous function which is exhibited pathologically in certain
forms of hysterical ecstasy. The quasi-cataleptic and almost
insensible state of the melancholic patient whose mind is
56 PATHOLOGY OF MIND. (CHAP.

possessed with one terrible delusion which will not let it go,
and the real cataleptic, whose limbs retain for an indefinite
period whatever position may be given to them while he is
insensible to outward impressions, seem to be examples of the
same mode of function,

Many more instances might be mentioned of this kind of
induced discontinuity or disruption of mental function in
the supreme cerebral centres. Ifa nervous person coming toan
anxious interview with a superior is asked abruptly and harshly
what his name is, he may clean forget it, just as a nervous
student at an oral examination may be unable to answer a
question the answer to which he knew quite well a minute
before, and will know quite well a few minutes afterwards.
He is like the hypnotic who when he is told that he cannot
pronounce a certain letter boggles and makes futile attempts
at its pronunciation, but at the same time pronounces it
unconsciously in the very words which he uses to declare
that he cannot do it. How often shall a confident brow and
a bold assertion carry temporary conviction to a mind
which is strugeling all the while to resist belief, and which
is able, only by quiet reflection afterwards, to reassert its
independence and judgment! Nervous and hysterical persons
may be made to believe almost anything that a person to
whom they have yielded their confidence, and who has un-
bounded confidence in himself, affirms to them positively;
and it needs not to be either nervous or hysterical to be power-
fully influenced on the occasion of some anxious and doubtful
enterprise by the confident prediction that we shall succeed
or fail; the prediction, whether well-founded or not, aiding
materially in either case to bring about its own fulfilment.
We may know very well that the person has not adequate
grounds in a full knowledge of the circumstances to warrant
his prediction, but we are none the less affected by it, perhaps
against our better judgment, and cannot help suffering our
energies to be either on the one hand distracted and weakened
or on the other hand concentrated and strengthened by it.
There are some persons whose habit of mind it is to balance
reasons so nicely that they find it very hard to come to a
u.] HYPNOTISM, SOMNAMBULISM, AND ALLIED STATES, 57

decision, and it is an extraordinary comfort to them when
another person will endorse or even only rehearse the reasons on
ohe side in a confident tone so as to give them a preponderant
activity ; they feel the relief and are resolved, notwithstanding
that the person who has helped them is not one whose judgment
they esteem much at heart, and notwithstanding that the con-
flicting reasons, when calmly weiched, are actually just as nearly
balanced as they were before.

It is well known how often a most absurd idea will hold
possession of the mind in dreams, and although it bears but a
very small proportion to the multitude of latent ideas in the
mind, with some of which it is absolutely incompatible, we are
entirely at its mercy for the time being, and have not the least
power to correct it. The wonder would of course be if we did
correct it when it is solely active, and if we did not believe
it when the rest of the mental functions, being suspended in
sleep, are not susceptible to stimulation by it or by the custo-
mary impressions from without: in such case how can they
arise to correct or to contradict it, or to affect it in any way ? In
the hypnotic state the idea is isolated by a similar break of
functional continuity in the supreme centres; the excitation of
the ideational track is such that, like a spasm or convulsion of
muscle, it escapes for a time from the controlling influence of
surrounding functions, and only, as it subsides, can be brought
again into co-ordination with them. We see the reason then of
the forgetfulness which is sometimes shown of what has taken
place in the mind during these abnormal trance-like states ; it
is the result and evidence of the extreme out-of-relationship of

“the active idea, whatever it chanced tu be, with other ideas,
wherefore there is nothing in the ordinary mental operations to
recallit. That it should be remembered, that is to say, should
recur, during these operations, would be exactly as if a particu-
lar convulsive movement should recur and take part in a series of
ordinary natural movements with which it is incompatible: the
irruption of the abnormal movement would be the disruption
and inhibition of the normal movements. Should there be,
during a subsequent trance-like state, a remembrance of what
happened in a former one, as befalls sometimes, it is because
58 PATHOLOGY OF MIND. [cuap.

the same state of things then recurs. Now instability of func-
tions is a character of the so-called nervous temperament; there
is a tendency of ideas and movements to escape from the bonds
of their functional relations, and to act independently—to break
away from coordinate and subordinate consensus of function,
and to become, so to speak, dis-ordinate—not otherwise than as
an insane person is apt to disregard the obligations of the social
state and to break out into anti-social behaviour. It was for this
reason that I formerly described the temperament as the neurosis
spasmodica, ,

It might perhaps be set down as a general law that, given two
nerve-centres of mental function, they cannot be in equally con-
scious function at the same time; if the one is actively conscious
the other will be sub-conscious, or not conscious at all; and if
the one reaches a certain height of activity the effect upon the
other will be entirely inhibitory—it will be rendered temporarily
incapable of function.

In the hypnotic state the individual is on the whole less sen-
sible to external stimuli than in natural sleep, but more sensible
to the particular stimulus of the operator’s voice than he is to
any stimulus in natural sleep, although, as I have before pointed
out, there are considerable variations in the degree of natural
sleep, and stories are told of some persons who have heen almost
as susceptible to the suggestions of others as the hypnotic sub-
ject is. That he should be sensible to the operator's suggestions
with whom he is in sympathetic relation, and not sensible to the
suggestions of a bystander, agrees with the experience that a
person who is dreaming will sometimes hear and weave into his
dream, and perhaps even reply to, a question which happens to be
in relation with the idea of his dreams, or which is put to him by
a familiar voice. It agrees also with the fact that in the waking
state we habitually abstract consciousness from what we are not
thinking about, admitting only such impressions as are in rela-
tion with our reflections, and rejecting those which are not; and
this we do not only voluntarily, but often without knowing what
we are doing, much more without specially willing it; it is at
bottom an unconscious process, like that by which a strong
feeling arouses and fosters its sympathetic ideas, ignores and
11] HYPNOTISM, SOMNAMBULISM, AND ALLIED STATES, 59

excludes unsympathetic ideas. We have only to exaggerate in
imagination this condition of normal reflection—to suppose it
to deepen through different depths of reverie, until it reaches
the morbid degree of hypnotism—and we shall have a partial
mental function with susceptibility to related impressions and a
complete inhibition of the rest of the mental functions.

When a person has been so unwise as to suffer himself to be
thrown many times into the hypnotic state he is very easily af-
fected ; the expectant idea will induce the state without anything
whatever being put before the eyes. Reichenbach’s experiments
on his sensitive subjects whom he kept in his house proved, in a
ludicrous way sometimes, that there was hardly-any circumstance
whatever, however trivial in itself, which might not occasion it
in persons who expected it and were accustomed to it. The habit
grew upon them, as we know that habits of nervous action, good
or bad, normal or abnormal, will do if they are encouraged. In
the first instance, however, a fixing of the attention through
vision seems to be helpful or even necessary, and if the object
gazed at be something so placed a little above the level of the
eyes as to necessitate a greater strain of the ocular muscles it
will be more effectual. By fixing consciousness in this way, in
other words, by keeping up a single act of undivided attention,
there is a subsidence of the general activities of the brain, which
thereupon goes to sleep. Were consciousness prevented from
wandering by being held in any other act of undivided attention,
whether it were by a mental image or by a muscular strain, the
result would no doubt be the same. The reason why the hyp-
notic subject is best affected through sight probably is that his
attention is easily arrested so, and that in no other way would
he be so capable of an undistracted act of voluntary attention for

‘any length of time: ask him to think of one thing steadfastly
for a few minutes, without ever allowing his attention to stray,
he would fail to do so; but when his attention is fixed in a
steadfast gaze upon some object to which it is solemnly directed,
with the expectation of something extraordinary being about to
happen, it is held involuntarily—distraction of consciousness is
prevented.

It is not a mere harmless amusement for one who is suscep-
60 PATHOLOGY OF MIND, [cuap.

tible to the hypnotic trance to suffer himself to be frequently
practised upon, for there is danger of his mind being weakened
temporarily or permanently. Indeed were his will strong and
well-fashioned the operation could not succeed, for its success is
a surrender of the subject’s will to the will of the operator, and
he is sometimes plainly conscious of a lessening resistance to the
latter’s commands before he is completely subdued and yields
unconditionally. After coming out of the trance, a little time
must elapse before his will recovers its power; for a while he
remains unduly susceptible to the suggestions of others, and too
easily influenced by commands. In the end, if the practice be
continued, he is kely to lose all control over his own mind and
to become insane ; the compact consensus of the supreme centres
has been broken up, a dis-ordinate tendency fostered, and the
dissociated centres are prone to continue their abnormal and
independent action. And assuredly that way madness lies.

I have only to remark further with regard to hypnotism that
it or a similar trance-like state is produced sometimes by
entirely physical causes. It has occurred now and then in con-
sequence of injury and of disease of the brain, without our being
able to trace the connection between the particular injury or
disease and the singular affection of consciousness. It is not
difficult, however, to conceive that a physical cause of irritation
in the brain may easily suffice for the induction of a state of non-
conduction, general or partial, in its delicate structural elements,
and that strange aberrations of consciousness will ensue in con-
sequence ; but of what really happens we know nothing definite
at present. :

The condition which most resembles the hypnotic state is
natural somnambulism; indeed the former might not unjustly
be described as an artificial somnambulism. We observe great
differences in the conditions of the senses in natural as in artifi-
cial somnambulism : the person may see without hearing, or hear
without seeing; his eyes may be shut or wide open; apparently
he may see some things and not see other things that are equally
within the field of vision ; the sensibility of one or more of the
senses may be considerably increased ; indeed, the gradations of
sense in different cases are such that the somnambulist may be
u.] HYPNOTISM, SOMNAMBULISM, AND ALLIED STATES, 61

on the one hand almost as clearly conscious of his surroundings
as when awake, or, on the other hand, almost as unconscious as
when fast asleep. Like the hypnotic, he sometimes remembers
during one attack the events of a former attack, although he has
no remembrance of them while he is in his normal state of con-
Sciousness. At other times he forgets altogether everything
that happened during the attack: a fact which is in accordance
with the experience that the dreams in which a sleeper talks are
those which are least remembered. In a few instances he rernem-
bers something of his dream, imperfectly and confusedly, espe-
cially when a scene or incident in the day chances to recall it.
Because the somnambulist plainly does not see things near
him sometimes, though his eyes are open, and nevertheless shows
by his behaviour that he does perceive other things that are
not so close to him, it has been supposed that he has the power
to perceive through some other channel than the ordinary senses.
If he manifestly does not see one thing which is right before his
eyes, how can he see another, it may be reasonably asked ? The
answer is that he sees what is in relation with the ideas of his
dream: the avenue of sense is open to the apprehension of an
object the idea of which is active in his mind, and shut to those
objects which are not in relation with the images of his dream,
In like manner he may not hear some sounds, though they are
pretty loud and startling, and yet may hear other sounds which
are woven into the fabric of his dream and perhaps give a new
direction. to it. The occlusion of sense to what is not necessary
to the immediate business is the main reason probably why he
is able to walk cleverly and fearlessly over roofs of houses and
other dangerous places where he would not like to venture if
he was broad awake. Seeing only what he requires to see for
his purpose, he is not distracted by seeing other things which
might dissipate his attention, and his undivided energies are
given unreservedly to the accomplishment of what he has to do.
The way to do a difficult thing which is feasible is not to see
vaguely the difficulties, but to see definitely the means of success ;
the energies are then undistracted by any halting considerations.
The hypnotic, whom we may consider to be in a single state of
consciousness, has been known sometimes to execute feats of
62 PATHOLOGY OF MIND. [cHaP.

muscular strength or agility which he would have found it
hard or impossible to do in his normal state. Another reason
of the fearless feats of the somnambulist—fearless, but not so
safe for him always as is popularly supposed—is perhaps the
heightened sensibility of his muscular sense, by virtue of which,
like a blind man, he is susceptible to finer impressions, and
receives more precise and certain information to guide his move-
ments. There is reason to believe that the sensibility of the
other senses may be increased sometimes, as is undoubtedly the
case in artificial somnambulism ; through a keener sensibility of
the retina he may get an advantage of discriminating objects in
the dark equal to that possessed naturally by such nocturnal
creatures as owls and cats ; and the increase of auditory or tactile
sensibility, by enabling him to apprehend such slight impressions
as he could not discriminate in his normal state, might well
give a miraculous semblance to his perceptions. Of one of his
so-called “ sensitives” Reichenbach relates that “all common
light was a burthen to her, pained her, and dimmed the clearness
of her perception. Her sight was good in proportion to the
depth of darkness about her.” But we have more sober and
trustworthy authority, were it needed, in the testimony of -
Cabanis and others who have witnessed quickened sensibility
of each sense in different cases of artificial somnambulism.
Notwithstanding the high authority of Sir W. Hamilton, who
declared that, however astonishing, it was “now proved beyond
all rational doubt that in certain abnormal states of the nervous
system perceptions are possible through other than the ordinary
channels of sense,” it would not be profitable to discuss at
length the question whether somnambulists, natural or artificial,
ever perceive otherwise than by their natural senses—whether,
for example, they ever read, as is sometimes affirmed, through
the pit of the stomach or through the back of the head.’ With-
out doubt they sometimes imagine they do: having perhaps,
as hysterical women often have, anomalous sensations about the

1 «Tt is quite indifferent,’ says Reichenbach, ‘‘to the high-sensitives
whether their eyes are bandaged and glued over or not; it is for them
about the same as it would be to bandage the elbow of a non-sensitive
who has good eyes to keep him from seeing a camel.”’
n.] HYPNOTISM, SOMNAMBULISM, AND ALLIED STATES, 63

epigastrium or in other parts of the body, they misinterpret
their character, and attribute to them perceptions which have
been got actually in the ordinary way through the natural
channels. But it invariably happens, when the extraordinary
powers which they imagine or affirm themselves to have, and
which credulous folk believe them to display, are rigidly tested
by competent inquirers, that the miracle explodes. They will
claim a power of looking into the bodies of other persons or
into their own bodies, and will describe with measured utterance,
as if their speech followed the gradual disclosures of the eye,
the conditions of the internal organs and the nature and position
of any disease which may be going on, raising much wonder
and entire belief in the minds of persons who are ignorant of
anatomy, or who have only a dim book-knawledge of it; but
when their statements are tested by a competent physician they
will be found to be vague and absurd, such as might have been
easily founded on the remembrance of some anatomical drawing,
and it will commonly be possible, by affecting an air of entire
belief, and betraying not the least sign of suspicion of their
powers, to lead them to the description of all sorts of im-
possible diseases in impossible places. They follow the sugges-
tions made to them in the leading questions that are put, and
express the vulgar notions of diseases and their treatment, just
as the spirit of a great philosopher or a great poet, when it re-
visits earth to assist at a spiritualistic séance, utters the vulgar
sentiments and thoughts of the medium who has summoned it.
The predictions of future events which some of these somnam-
bulistic performers rise by degrees to the audacity of making
are equally fanciful; when soberly tested, the prophetic insight,
like their medical insight, proves to be delusive. They usually
grow to the height of their presumption step by step as they
succeed in imposing upon the amazed believers in their preten-
sions, whose credulity to the end keeps pace with their audacity :
Reichenbach was convinced that no secret act done in his house
escaped “the all-piercing eye of the acute sensitive,” and after
saying that they are sometimes of service in the medica] art,
by discovering the nature of disease and foretclling its future
course, and by telling such things as whether there is a prospect
4
64 PATHOLOGY OF MIND. : {cHar.

that a woman will become a mother and what the sex of her
offspring will be, he naively tells a story to show how dangerous
or useful this faculty may be :—“ In my own house it happened
that a somnambulist whom I introduced there denounced a
servant girl for immoral conduct, in which nobody believed, and
the truth of her declaration was only established after months;
and other revelations which she made caused a revolution in the
‘house and resulted in the dismissal of several servants.”

It will not be amiss to consider briefly what are the causes
that have given rise to the belief in the prophetic and other
singular powers of these somnambulists.

a, First of all, then, there are the genuine impostors, who out
of an itching desire of notoriety or for purposes of gain made a
profitable trade of the business of deceit. From the earliest times
of which we have record unto the present time there have not
been wanting knaves to practise upon the credulity of fools, and
they have perforce found the choicest fields for their enterprise in
those dark places of nature where mystery begets wonder, and
wonder in turn begets credulity. Where the forces and the laws
of nature are not known, there has always been a class of
persons claiming supernatural relations and pretending perhaps
to supernatural powers, who have made their advantage out of
the ignorance and fears of their fellows ; and so it no doubt will
be until it comes to pass, if it ever shall come to pass, that all her
secrets are won from nature, and no dark place is left in which
superstition can lurk,

b. Secondly, there are the impostors who impose upon them-
selves as well as upon others; whose self-deception is in truth
the main factor of their success in imposing upon others. It
has never been sufficiently taken into account, I think, that
deception is not a constant but a variable quantity, and that
there are manifold gradations between the most deliberate and
wilful deceit on the one hand and on the other hand a deception
which is unconscious and innocent. One of the arguments
upon which believers in the miraculous perceptions of the
hypnotic lay the greatest stress is that they are exhibited and
attested sometimes by persons whom they know to be utterly
incapable of fraud and on whose sincerity and veracity they
nm.) HYiNOTISM, SOMNAMBULISM, AND ALLIED STATES. 65

would hazard all that they possess. Agreeing with them as to
the sincerity, one may still properly call in question the com-
petence, of the witness, who may speak the truth as he knows
it, without thinking the truth as it is; for the question is not
merely whether he is deceiving us, but whether he is himself
deceived. His consciousness, no doubt, testifies truly as to its
own states; but it may not testify truly as to the causes of
them. It is not amiss to reflect when weighing beliefs that belief
is very much a matter of temperament, and that there are persons
of a certain temperament who are prone to believe anything that
has passed vividly through their imaginations without con-
sidering sufficiently how it came there; solemn asseveration of
a fact by them meaning no more than a conviction of a vivid
mental experience. The temperaments of such persons are
unstable in this respect—that the members of that congeries of
supreme nerve-centres which constitute the cerebral convolutions
are not bound together in compact communion of function, but
are apt easily to take on in-coordinate action, not perhaps of an
actually incoherent kind, although that is a further stage of
degeneration, but of too isolated and independent a character.
Thus it comes to pass that when a vivid conviction takes hold
of the mind it vibrates there intensely, and does not feel the
controlling and modifying influences, consciously or uncon-
sciously working, of the neighbouring mental elements with
which it isin physiological union ; nay, it may even inhibit tem-
porarily their functions altogether, It becomes then an intense
belief which is never properly tested and corrected by sound
observation and sober reflection. To say that the great majority
of men reason in the true sense of the word is the greatest non-
sense in the world; they get their beliefs, as they do their instincts
and their habits, as a part of their inherited constitution, of
their education, and of the routine of their lives.

It is evident that this sort of temperament lends itself easily
to self-deception. If an idea reach that persistent and exclusive
action which entails an inhibition of the functions of the other
ideational centres, as it notably does in the hypnotic and its allied
states, it is plain that when the person comes out of.the exclusive
state of consciousness he or she may be oblivious of what was
68 PATHOLOGY OF MIND. _ [omaP

thought or done when in it, and so may, with perfect sincerity,
deny his or her deeds and misdeeds, or assert them to have been
inspired and directed by some power more than natural.
Alienated for the time being from his full self, he feels the
alienated self to have been a strange or another self, and cannot
realise responsibility for its doings, even if he remembers them.
Between the abnormal state of consciousness which belongs to
the hypnotic state and the state of consciousness which accom-
panies the most deliberate deception there are transitional
grades, whence the manifold gradations that are actually met
with between wilful deception and innocent self-deception, and
the reason why persons whose sincerity their friends recoil from
suspecting do nevertheless dupe themselves and others of sym-
pathetic temperament in the grossest manner. Just as the string
of a harp vibrates to and gives back the note that is in unison
with it, so the dupe vibrates to and gives back the note which
the impostor strikes.

ce. It is certain that a large, though not certain how large, a
margin for error should be allowed to defective observation in
these matters. True observation comes not by instinct, but is
gained painfully by training. Were a list made of the common
fallacies to which observation is liable, and to each one assigned.
its proper share in these wonderful phenomena, there would be
little left unallotted to dispute about. It is a well-known
tendency of the human mind, which has been the foundation of
the credit of prophets in all ages, to be impressed strongly by
agreeing instances, and to overlook or neglect disagreeing or
opposing instances. When the mesmeric subject makes a hit
the effect is startling and the admiration unbounded, while his
manifold failures are ignored and forgotten, or attributed to
the unfavourable conditions of the experiment. Moreover, the
observation of a particular experiment is commonly partial and
defective, the observer seeing an effect which strikes his atten-
tion and overlooking the essential conditions on which it
depended: he may, as he earnestly asserts, have seen the thing
with his own eyes, but what we require to have noticed are the
various cooperating conditions or coefficients which he did not
see and take notice of, and which a cooler, more wary and skilful
11.] HYPNOTISM, SOMNAMBULISM, AND ALLIED STATES. 67

observer would have seen, noted, and weighed. It is beyond ques-
tion, as Voltaire truly remarks, that magic words and ceremonies
are quite capable of most effectually destroying a whole flock of
sheep, if the words be accompanied by a sufficient quantity of
arsenic. The proper answer to the person who has seen miracles
is certainly in nine cases out of ten a direct declaration that not
the least reliance can be placed upon his observing powers, and
a blank refusal to discuss his observations ; for life is too short
to permit the waste of time which would be required in order
to teach the alphabet of observation and reasoning to each
new-comer.

Obviously persons of the neurotic temperament described will
be most liable to this sort of defective observation. Possessed
vividly with an idea, the faculties of their minds are benumbed
or suspended: they can see only what is in relation with the
predominant idea. It is notorious that the observer who starts
with a preconceived idea or with a strong desire is so far dis-
qualified rather than qualified for his work; for although his
special observation may be sharpened by the idea or the desire
to see what is agreeable to it, his general powers are blunted, and
he is very likely to be deluded; but these neurotics are particu-
larly liable to be dupes of a partial observation, because of that
easily induced solution of continuity of functions by which an
idea, when unusually active, escapes from the restraints und
corrections of the communion of nerve-centres of which its
centre is a member. These considerations teach how gradaticnal
is the transition from the simplest instances of defective obser-
vation, such as are continually exhibited by all men, to the
extreme instances of entire incapacity of observation which the
mesmeric or somnambulistic subject displays. Not to suffer
apy present mental state to reach an inordinate activity, but to
maintain a free play of all the various chords of association
which a wise culture has made as many and complete as pos-
sible, and so to preserve the sound balance of the judgment,
is the mark of a large and well-trained intellect.

d. It may be alleged that, after making full allowance for de-
ception and for errors of observation, there is still an unexplained
residuum of the wonderful in the foresight displayed by some
68 PATHOLOGY OF MIND. (cHar.

of these mesmeric subjects. They have predicted clearly, it is
said, a disease from which they themselves would suffer, and
eventually did suffer, although there was not the least sign of the
discase at the time when they foretold it. If this were true, and
the coincidence were not accidental, it may be supposed, before
acknowledging a supernatural event, that a heightened sensibility
had rendered them more susceptible to the earliest indications
of disease—its mute premonitions, so to speak—than they were
in their normal state cf consciousness, just as a person will feel
a sensation when his attention is free which passes unnoticed
when he is actively employed. Or, if that explanation is not
accepted, it may be supposed that the disease occurred as the
result of a fixed idea in a sensitive mind that it would occur, the
prophecy having fulfilled itself, not otherwise than as the idea
of gaping, of pain, of paralysis, of convulsions, will sometimes
induce gaping, pain, paralysis, convulsions. It cannot be too
clearly apprehended that there is a sort of innate tendency to
mimicry in the nervous system: one observes the most striking
manifestations of it in apes and in children, and less striking
instances of it in the way in which a person oftentimes adopts
unconsciously some of the tricks of manner or of expression of
another with whom he associates; and certainly the simulatiou
or mimicry of disease by so-called nervous or hysterical persons
is common. As in such persons the idea of a particular disease,
if it takes hold of them, will be likely to reach that prepon-
derating and persistent activity when it cannot be moderated by
reflection, which it inhibits, it may be expected to act with excep-
tional power upon the organic functions, if its energy takes that
channel, just as the exclusive idea of the hypnotic subject when
it has a motor outlet nerves him to a feat of muscular strength
or skill of which he is incapable in his normal state.

e. When the artificial somnambulist succeeds in reading what
is in the mind of another person who utters not a word of what
he is thinking, as is sometimes the case, his success is due in
the main to an acute apprehension of slight outward indications
of his thought, which the person may be entirely unconscious
that he is exhibiting; the proof of this being that the experi-
ment fails when it is tried with one who, being incredulous,
11] UMYPNOTISM, SOMNAMBULISM, AND ALLIED STATES, 69

carefully suppresses the least expression of what is in his
mind, or of set purpose puts on a different expression of features.
There are very few persons who are skilful enough to prevent
their thoughts and feelings affecting their movements. Let it
be considered how quickly children and animals read our moods
of mind in our faces, and what acute perceptions of the motions
of a speaker’s lips a deaf and dumb person is trained to attain,
so that he can understand the mute motions as well almost as if
he heard the words spoken, and it will appear probable that a
vivid thought may manifest itself unconsciously in slight move-
ments of lips or features which, unperceived by an ordinary
observer, do not escape the acute apprehension of the so-called
sensitive. This is without doubt the explanation of the so-
called inuscle-reading which has lately attracted notice. I am
not sure, however, that the knowledge is not obtained in some
of these cases without the conscious agency of the subject—to
wit, by an unconscious imitation of the attitude and expression
of the person, whose exact muscular contractions are instinct-
ively copied; the result being that, by virtue of a well-known
law, the same ideas and feelings of which the muscular contrac-
tions are the proper language, are aroused in the subject’s mind.
Another explanation, but a fanciful one, may possibly be true
of occasional instances of success. They may be owing to the
sympathy of similar constitutions under the same external con-
ditions whereby their thoughts and feelings chime, the two
natures striking the same notes independently, like two clocks
striking the same hour at the same time. LDefore rejecting the
hypothesis, let it be fairly considered that there are a great many
persons who are pretty nearly automatic repetitions of one
another so far as regards the range and character of their
thoughts; they think the same thoughts just as all parrots and
children constantly make the same noises and go through the
same performances without imitating one another; and when they
are under the same external conditions, when their feelings are
attuned to the same note, when their minds are acted upon by
the same suggestions, as is the case where both are engaged in
one experiment, it is not perhaps to be wondered at that there
should be an independent chiming of thoughts and feelings
70 PATHOLOGY OF MIND. [CHAP.

occasionally. Two such persons would probably make the same
movements in order to escape if they were exposed together
suddenly to a common pressing danger, without consulting with
one another; and I doubt not that a young man and maiden,
when they fall in love with one another, naturally think the
thoughts, feel the sensations and emotions, and do the things
which young men and maidens have always thought and felt and
done in similar circumstances, without having to learn their
lesson either from one another or from any one else. The
Siamese twins who, being bodily bound together, perforce lived
under the same conditions, were united in a close mental
sympathy for a great part of their lives ; they generally had the
same thoughts at the same moments, made the same resolves and
did the same things without previous communication with one
another; unfortunately the happy harmony did not last, for one
of them became addicted to intemperance, a vice which led to
frequent bickerings and disputes, and in the end to an earnest
desire to be separated. The close sympathy of feeling and
thought sometimes shown by ordinary twins is well known, and
there are one or two remarkable instances on record of twins who
were attacked with the same form of insanity at the same time,
while several cases have been recorded of brothers or of sisters
who, having lived much together in the same external conditions,
have become similarly deranged.

Another of the intermediate states which bridge the gap
between the most abnormal and the normal states of conscious-
ness, and closely allied to the abnormal states already described,
is ecstasy or trance. This ecstasy is a condition into which the
enthusiast of every religion, Buddhist, Brahmin, Christian,
Mahometan, has contrived to throw himself, and is truly, as
the word means literally, a standing out of himself. The
symptoms are very much alike in all cases: after sustained
concentration of the attention on the desire to attain to
an intimate communion with heavenly things, the self-absorp-
tion being aided perhaps by fixing the gaze intently upon
some holy figure or upon the aspirant’s own navel, the soul
is supposed to be detached from the objects of earth, and
to enter into direct converse with heaven; the liinbs are then
1.] HYPNOTISM, SOMNAMBULISM, AND ALLIED STATES. 71

motionless, flaccid, or fixed in the maintenance of some attitude
which has been assumed, general sensibility is blunted or
extinguished, the special senses are insusceptible to the impres-
sions which usually affect them, the breathing is slow and feeble,
the pulse is scarcely perceptible, the eyes are perhaps bright and
animated, and the countenance may wear such a look of rapture,
the fashion of it be so changed, that it seems to be transfioured
and to shine with a celestial radiance.

Ecstasies of this kind are much less common nowadays
than they were in past ages, when religious feeling and belief
had a more vital hold of human thought and conduct: when
numerous monasteries were scattered over the land; when
austerilies and asceticism were in vogue; when prayers,
penances, meditations, and religious ceremonies filled up the
main business of life; when a disunion from the things of
earth and the closest union with the things of heaven was
set forth as the end to be perpetually aimed at in order to
escape everlasting torment. However, as Maury has pointed
out, these trances in which supernatural communications took
place did not befall saints only, for the wicked were sometimes
seized by them, and gave blasphemous recitals of their visions.
Hence it became necessary to make two classes of ecstatics—
the holy and the demoniacal, or, as I might fitly call them,
theoleptics and diaboleptics. It would be rash to venture to
say to which class are to be referred the ecstatics who from time
to time are heard of at the present day, famous among whom
is Louise Lateau, known as the Belgian stigmatic, because
during her often-recurring trances marks of bleeding from the
forehead, from the left side, and from the palms of the hands,
are seen.

Obviously the ecstatic state is very:much like the hypnotic
state both in its mode of occurrence and in the character of its
phenomena. There is such a vivid exaltation of a particular state
of consciousness that sensibility is suspended, voluntary move-
ment inhibited, and vital function itself lowered. St. Theresa
described her state of rapture as one in which “the body loses all
the use of its voluntary functions and every part reniains in the
same posture without fecling, hearing, or secing, at least so as to
72 PATHOLOGY OF MIND, [CHAP.

- perceive it.” When she had a mind to resist these raptures “ there
seemed to be somewhat of a mighty force under my feet which
raised me up that I knew not what to compare it to”; in other
words, when the energies of the unstable nerve-centres were not
suffered to discharge themselves in the tension of a particular
strain of consciousness they troubled the centres of muscular
sensibility, and produced the motor hallucination of an eleva-
tion from the ground, just as they might on another occasion
have produced vertigo. There is not in all cases an entire
insensibility to external impressions; like hypnotics, these
ecstatics are sometimes sensible to impressions that are in
relation with the ideas of their visions, and then mix the real
with the imaginary ; they may gaze, for example, on a crucifix
on which a Christ is suspended until they hear him speak or
see him descend and approach them, and they will show them-
selves conscious sometimes of the presence and of the words of
one whose sacred character or function suits the strain of their
rapture. But the insensibility to pain sometimes is very re-
markable. Rapt in his gay vision of unreal bliss, the religious
fanatic of India is indifferent to the wounds and injuries that
are inflicted upon him and will, without wincing in the least,
suffer his body to be tortured in a way that must, were he in a
normal state of consciousness, produce intolerable pain. The
natives of India and all primitive races are more susceptible to
these trance-like states than are Europeans, as was shown by
numerous experiments to perform surgical operations on persons
put into the mesmeric state ; for while it was easy to throw the
natives into the proper state of insensibility for the operation,
the experiment was usually unsuccessful with the European
soldier. Among the North American Indians it was the custom
to tie the prisoner of war to a stake before he was executed and
to subject him for several hours to all the means of torture which
savage ingenuity and ferocity could devise, women and children
joining with eager delight and acclamation in the cruelties
practised upon the victim, He, meanwhile, scornful of their
impotent efforts and disdaining to show the least sign of pain,
defied his tormenters with the bitterest irony and the most in-
sulting sarcasm, boasting exultantly how many of their kindred
i.)  MYPNOTISM, SOMNAMBULISM, AND ALLIED STATES. 73

he had slain, how horribly he had tortured them, and jeecring
them contemptuously for their futile attempts to make him
suffer. His transport of mental exaltation made futile their
hellish efforts. I doubt not that the Christian martyr, ina like
condition of mental exaltation, has sometimes borne the flames
of the stake, when burned to death, or the other tortures under
which he has expired, with an indifference and acomposure that
seemed to onlookers the proof of a supernatural support. When
one thinks of the fearful record of man’s inhumanity to man
which human history is, it seems a happy thing that there has
been mercy enough in the dispensation to put bounds to the
power of human malignity to inflict torture, whereby achieve-
ment has fallen so far short of desire—first, in the limit which
there is to man’s capacity to suffer, whereby pain itself kills,
and, secondly, in the power of enthusiasm to defy torture.
The dancing manias of the middle ages, the so-called con-
vulsionists of St. Médard, and similar mental epidemics in
which an infection of enthusiasm spread through persons placed
in the same conditions, have furnished many instances of
general insensibility to violent blows and to other severe
handlings while the mind was rapt in the ecstasy of the
particular excitement. The only remark which it remains to
make concerning these cestatics is that while they oftentimes
remember what has happened during their visions and angelic
communions they sometimes, like somnambulists, have only
a confused remembrance or no remembrance at all; their
experience cannot be recalled and described, for, as they imagine
and declare, it was of such a character as to transcend ordinary
thought and expression, truly ineffable.

A disease which is closely allied to the abnormal states de-
scribed, holding an intermediate place between them and epilepsy,
is catalepsy. The person who is subject to cataleptic attacks
falls suddenly into a state of seeming unconsciousness, but does
not fall down ; he maintains the attitude in which he was at
the time when he was seized, just asif he had been thrown
suddenly into the brownest of “brown studies,” continuing to
stand if he was standing, to sit if he was sitting, to kneel if he
was kneeling. The act he was doing is suspended midway in
74 PATHOLOGY OF MIND. [CHAP.

its execution. To all appearance he is little more than a half-
animated statue while the paroxysm lasts. He seems partially
or completely insensible to external impressions, and when his
arm or any other part of the body is put into a certain position
that position is retained for an indefinite time, or until he comes
to himself again. The pulse is usually more feeble and the
respiration more slow than in the natural state. The fit may
last for a few minutes only, or for a few hours, occasionally for
a yet longer period, and when it is over there is no memory of
what has happened during it. No particular: mental state,
voluntary or involuntary, seems to have anything to do with the
induction of the cataleptic state, although it is probable enough
that a moral shock might be the occasion of an attack in one
who was subject to the disease ; it has occurred where there was no
reason to suspect actual disease of the brain, and it has occurred
where there was grave organic disease thereof; but concerning
the actual conditions of its occurrence we know nothing.

I go on now to direct particular attention to the strange
‘abnormal states of consciousness that are sometimes witnessed
in persons who suffer from epilepsy. It is well known that one
who is a victim of that form of epilepsy which is called le petit
mal will sometimes, during the temporary suspension of con-
sciousness, continue without interruption the mechanical work
which he was doing at the moment when he was seized—will go
on walking if he was walking, sewing if he is a tailor who was
occupied in sewing, playing on the violin if he is a musician who
was so employed. It has furthermore been observed that the
suspension of ordinary consciousness may be more than mo-
mentary in certain so-called masked epileptic states, and that
during its suspension the person, to onlookers appearing as if he
were conscious of what he was doing, may go through a train
of new and more or less coherent acts which when he comes to
his natural self he is unconscious of having done. Like the
somnambulist, he has been in an abnormal state of conscious-
ness, during which he acted as if he were another being, knowing
not what he did, or, if he did know it at the time, not re-
membering it afterwards. But it is most probable that he did
not know it; for what he does, although it may have method in
au.) HYPNOTISM, SOMNAMBULISM, AND ALLIED STATES, 75

it, is commonly inappropriate and foolish, and nowise called for
by the external conditions of aS surroundings, of which he
seems unconscious.

On one occasion I was consulted by a gentleman, aged
twenty-three, of good muscular development, brisk intelligence,
and unusual energy of character, who had for some time
worked very hard at a business which involved considerable
strain and excitement. For five years he had suffered from
epileptic or quasi-epileptic attacks ; at first he had fallen down
in them in the ordinary way, but after a time they came
on with a feeling of trembling and of loss of power in the
knees, immediately upon which the unconscious state supervened,
but he did not fall down; on the contrary, while this abnormal
state lasted, which it did for an hour usually, and sometimes for
hours, he did strange acts, not knowing what he was doing, or if
he was in the street went along in such a dazed and uncertain
way that the police, thinking him drunk, interfered with him.
A few days before his visit to me he had had an attack in the
street, and he remembered nothing whatever of what occurred
from the beginning of it until he found himself in his office
to which a friend who had seen him, and recognised his
plight, had conducted him. From another friend who resided
with him I learned that when he was in the attacks he seemed
to be partly aware that he was not well, told them what should
be done to him, and spoke of whatever might be in his mind,
not always quite coherently, but usually tolerably so. On two
occasions he had been restive, as if he wished to get away; once
he had behaved as if he were going to be drowned, and at another
time he had acted as if he were going to get up the chimney.
Before or after the attacks he suffered from bad headaches,
which were formerly so severe as to compel him to lie down
wherever he chanced to be until they passed off, but the pain
had not been so severe lately. The immediate occasion of his
visit to me was a great nervousness which had come upon him;
he was apprehensive of going about alone or of sleeping alone,
and was much distressed by absurd impulses which tormented
him and which he could hardly control, although he knew very
well how absurd they were, and tried hard to laugh himself out
76 PATHOLOGY OF MIND. [cHaP.

of them. Of late the impulse to get up the chimney had
tormented him for no reason whatever, and it had grown so
strong that sometimes he had the greatest mental struggle to
prevent himself from yielding to it. Other morbid impulses
had afflicted him: at one time he had felt. impelled to drown
himself in the washhand basin, and at another time to throw
himself in front of a railway train when he saw one approach-
ing; when one impulse left him another took its place. From
time to time a black curtain or cloud seems to fall before his
eyes, is accompanied by a peculiar sensation or pain in the head,
and for the moment he is scarcely conscious; but the attack,
which is doubtless of an epileptic nature, quickly passes off.
The morbid impulses which reason inhibits with difficulty no
doubt mark a condition of nerve-centres of the same kind as,
but less morbid in degree than, that which exists when reason
and will are entirely suspended and the persistence of conscious-
ness even is doubtful.

I forbear to quote other similar cases in which odd, stupid,
and even dangerous acts have been done during the epileptic
suspension of normal consciousness, or to attempt a speculative
explanation of them. To call the person’s conduct during the
paroxysms automatic does not help us much to understand it ;
it is so like much of his conduct when he is not in a paroxysm
that one is inclined to ask whether that is not automatic also.
Plainly his state is most like an acted dream, and bears out the
sagacious opinion of old medical writers that there is a kinship
between somnambulism and epilepsy; a kinship which reaches
not merely to a resemblance of phenomena, but has a deeper
basis in a common neurotic temperament. In truth ail these
lepsies or peculiar nerve-seizures—epilepsy, catalepsy, theolepsy,
aud somnambulism, betray in most cases a neurotic inheritance,
and may justly be suspected to be very likely to leave a neurotic
lezacy. By bringing them together, as I have done in this
chapter, it has been shown that the most extreme and abnormal
instances of double consciousness are not so widely separated
from states of normal consciousness as they appear to be at first
sight, and that we may, if we will, pass from one extreme to
the other over a bridge of many arches. It is certaiuly impos-
1.] HYPNOT.:SM, SOMNAMBULISM, AND ALLIED STATES, 77

sible to realise the state of mind of a person who is in one of
these states of abnormal consciousness; conscious one’s self or
unconscious, one cannot form accurate conceptions of the inter-
mediate anomalous states; but the experience of a person who,
when taking chloroform in order to be rendered insensible,
struggles, kicks, shouts in a sort of nightmare after he has
ceased to see or hear, but before he is completely passive and
insensible to external constraint, feeling it but not in the least
realising its true nature, may convey an imperfect idea of the
quasi-unconscious state of the epileptic who does strange things
that he wots not of. The main features which the abnormal
states present in,.common are:: first, that coincident with a
partial mental activity there is more or less inhibition, which
may be complete, of all other mental function; secondly, that
the individual in such condition of limited mental activity is
susceptible only to impressions which are in relation with its
character and are consequently assimilated by it; and, thirdly,
that when he comes out of his abnormal state he may have only
the most dim and hazy remembrance of what happened when
he was in it, or may not remember it in the least.

If any one will be at the pains to examine the phenoniena
of *the modern epidemic of superstition which is known as
spiritualism by the light of the foregoing exposition, he will be
able to weigh at its true value much of what seems to be the in-
contestable evidence of eye-witnesses who vouch for miraculous
phenomena. A great proportion of them are undoubtedly the
work of impostors consciously duping their victims, who, pre-
disposed by temperament and a want of training in observation
to believe the wonderful, are an easy prey. If the performer is
skilful by reason of natural aptitude and long practice, he
may easily, like a conjuror, frustrate the attempts of even
a good observer to detect his mode of operation. We are
unable to discover how the conjuror does his tricks, although
we know them to be tricks, partly because he is clever enough
to distract attention in some way from what he is doing at
the critical moment of the feat, and partly also probably
because a muscular act may be quicker than perception-—so
quick, in fact, as to be imperceptible, as the twinkling of an eye,
78 PATHOLOGY OF MIND, (cHaP.

which is a muscular act, commonly is. Then there are the
unconscious impostors who, like the hypnotics, get their minds
into a sort of convulsive activity of certain ideas with a
temporary paralysis of all other ideas, and are unconscious
themselves of the fraud which they are practising, or at any rate,
like one in a dream, morally insensible to the guilt of it.

The extraordinary revelations of names, of events, and the
like, which the “medium” makes sometimes under spirit-
guidance, and which it is supposed could not possibly have been
known in any natural way, are of the same nature as the similar
wonders of. the mesmeric trance. A heightened sensibility of a
particular sense, giving information which it could not have
given in its ordinary state, will account for some extraordinary
perceptions ; a revival in memory of forgotten facts which the
individual himself may not remember that he had ever known,
such as notably occurs sometimes in dreams, will furnish the key
sometimes to knowledge which looks marvellous to onlookers ;
an increased muscular power owing to the concentration of the
whole nervous energy upon an act, and to the full faith that he
can do it, may enable the medium to perfurm a feat of strength
or of skill which he would not find it easy to do ‘in his natural
state, when some distraction would prevent the fulness and mar
the unity of the effect. Of course if it be true, as the spiritual-
ists allege, that a table will rise from the floor and float about
the room when the medium neither touches it nor has any sort
of physical connection with it, another explanation must be
sought for. One may venture to conclude in accordance with
experience of known phenomena that the person who sees a
table float through the air, or feels it rise from the ground when
his hands are placed upon it, is labouring under a motor hallu-
cination of eye or of touch, a sort of hallucination which it is
easier to have than most persons think. Possessed with the
expectant idea that a movement will take place, he has the
vivid motor intuition or mental presentation of that movement
stirred into activity, and the motor intuition, which has been
thus excited subjectively, is projected objectively and takes
sensible form as an actual movement, not otherwise than as
a giddy person sces the room turn round: it is the objective
u.] | HYPNOTISM, SOMNAMBULISM, AND ALLIED STATES, 79

aspect of his subjective state. If he conceive the idea of a
rising or of a floating table so vividly that it excites the corre-
sponding motor intuition to the pitch of hallucination, it is
impossible he should not actually feel or see the movement; no
wonder therefore he asserts solemnly that he saw it with his
own eyes. As I have pointed out already, many saints are
alleged on the testimony of eye-witnesses to have floated in the
air, among whom may be mentioned St. Philip Néri, St. Dunstan,
St. Christina, and lastly St. Seraphina, a nun in whom the
tendency to rise was so great that six nuns could not hold
her down. These flights took place during the zaptures or
ecstasies into which these holy persons fell; and it will hardly
be doubted by those who class the phenomena scientifically
with the rides of witches through the air that some of the
saints had the conviction, which persons in dreams have some-
times, that they did actually float in the air during their
ecstasies. What then with the motor hallucinations of the
saints themselves, and what with the motor hallucinations of
the admiring observers who, being not of little faith, did not
doubt, there is quite enough to account for the stories of the
flights, without appealing to supernatural aid.

It has been proved amply by experiment, as it might
have been predicted safely would be the case, that faith is
necessary to the manifestation of the phenomena of spiritualism;
the presence of a sceptic renders the conditions unpropitious,
and nothing extraordinary takes place. That has been so with
miracles of all sorts from the beginning of the world unto the
present day; they have chanced to occur in the presence of
believers who were so full of faith that they needed not to have
their faith strengthened, and they have not chanced to occur
in the presence of unbelievers, whose doubts might have been
dispelled by their most potent evidence. The spiritualists
refuse to submit their marvels to the rigorous and critical
examination of sceptics who are competent to test them; they
insist upon making conditions which render satisfactory inquiry
impossible ; and when the sceptics refuse to be handicapped by
such conditions, and insist upon the same perfect freedom of
doubt and of experiment which they would use in any truly
80 PATHOLOGY OF MIND. [cHLAP.

scientific inquiry, they forthwith charge them with prejudice
and a refusal to investigate. They appeal too to the testimony
of their own witnesses, who, being ardent believers, are quite
incapable, notwithstanding the best intentions, of observing
correctly and of detecting fraud which is not glaring; for they
are like the hypnotic or the somnambulist, who sees only that
which is in relation with his ideas and will assimilate with
them. Faith in things unseen and spiritual that are believed
to act upon things seen and material is incompatible with true
observation of things seen, for observation is vitiated funda-
mentally, and cannot be unbiassed and adequate.

In concluding the chapter one thing may be noted with
regard to spiritualists: that many of them, especially the most
eager and intense among them, have the neurotic temperament,
which goes along with epilepsy or insanity or other allied
nervous disease in the family. I need not repeat what I said
before concerning the outcome of this temperament in belief:
the lame, the halt, the blind, the warped in intellect, who follow
eagerly dark by-paths of belief, may be gathered together into
one fold: their aberrant and fanatic beliefs, over which reason
has no sway, betray the character of their temperaments. To
strive by argument to modify their convictions is a vain
imagination and a futile labour: it is to labour to argue away
a temperament ; and that is work which a wise man does not
undertake.

“You may as well
Forbid the sea for to obey the mcon
As or by oath remove or counsel shake
The fabric of his folly, whose foundation is

Piled upon his faith, and will continue
The standing of his body.”

 

1 The London Dialectical Society appointed a committee to investigate
the subject of spiritualism. The committee took the evidence of a great
many spiritualists and published a report. However, ‘of the compara-
tively small number of persons who were conspicuous either as advocates
or ‘mediums,’ one became the subject of well-marked mental illness, and
another liad to be confined in a lunatic asylum. A third person, who was
an eager member of one of the sub-committees, was seized with a
mysterious form of paralysis, although comparatively a young man.”—
Report on Spiritualism, p. 80.
1.] HYPNOTISM, SOMNAMBULISM, AND ALLIED STATES, 81

APPENDIX.

Some years ago there appeared in several American journals the
report of an extraordinary case of sommambulism—it was that of a
boy who, while in a state of somnambulism, had killed another boy.
But no exact scientific account of it was ever given, so far as I
know. In April of this year, however, an undoubted case of
somnambulistic homicide occurred in Glasgow, the account of which
has been published since the foregoing chapter was written. A man
named Fraser, twenty eight years of age, seized his child who was
in bed with him, and dashed its head against the wall or floor,
believing that he had seized a wild beast which had risen through
the floor and jumped upon the bed to attack the child. His wife’s
screams awoke him, and he was horrified to find that he had fatally
injured his child, whom he was passionately fond of.

He was a pale and dejected looking man of nervous temperament,
dull, and somewhat childish, but able to earn his livelihood as a
saw-grinder, being a good workman. His mother had suffered
nearly all her life from epileptic fits, and had died in one; her
father, whom Fraser was said to be very like, also died in a fit.
His maternal aunt and her son were both insane. His brother
died from convulsions in infancy, and his own child had been
dangerously ill from convulsions at one time. There was, therefore,
an unquestionable neurotic family history. From his earliest years
he had himself been troubled by bad dreams and nightmares, and
had often walked in his sleep. He was particularly liable to do
so after he had undergone excitement and agitation in the day.
For example, having a little sister whom he had often warned
against falling into the water, he got up in his sleep several times
and went down to the water-side, where he called her loudly by
name, and grasped with his arms as if he were rescuing her.
Sometimes he awoke, but sometimes went back to bed without
awaking. He remembered nothing about these nocturnal excursions
unless he was awakened at the time, but suspected he had made
one, in consequence of feeling weary and unrefreshed in the morning.
After his marriage in 1875 the attacks assumed a different

1 Journal of Mental Science, October, 1878,
82 -PATHOLOGY OF MIND. [onap. 17,

character: a great terror would seize upon him, and he would start
out of bed under a vivid feeling that the house was on fire, that his
child was falling into a fit, that a wild beast of some kind had got
into the room ; roaring like an animal, he would drag his wife and
child out of bed in order to save them, or would chase the supposed
beast frantically through the room, throwing the furniture about,
and striking at it with any weapon he could lay hold of. He had
on different occasions seized his wife, his father, a fellow lodger by
the throat, and nearly strangled them, believing that he had got
hold of the beast. During the seizures his eyes were open and
staring ; and it was plain he saw and seized chairs or any con-
venient weapon, albeit he was blind to what was not in relation
with his delusive ideas; sometimes he could hear and answer
questions, speaking distinctly, at other times not.

It was in one of the attacks that he killed his child. His wife
was awakened by hearing him roaring and furiously dragging at
her; he then leaped out of bed, and as she followed him, as she
used to do on these occasions, she heard him smashing something
against the wall, which she was horror-struck to find was the child;
its skull was so severely fractured that it soon died. Awakened by
her cries, he showed the utmost distress, ran for water, roused the
neighbours, and hastened to fetch a doctor. Put on his trial for
murder, he was acquitted on the ground of being unconscious of
the nature of his act by reason of somnambulism,

The case much strengthens the opinion of old medical writers
that there is a close affinity between somnambulism and epilepsy.
In truth, looking to the history of epilepsy in the family, and to the
character of the nocturnal seizure, the latter might justly be looked
upon as a nocturnal epileptic fit, in which the discharge took a
mental instead of a motor channel, as we know to happen in some
cases of epilepsy during the daytime.
CHAPTER III.
THE CAUSATION AND PREVENTION OF INSANITY.
A. Ltiological.

THE causes of mental derangement, as they are usually de-
scribed in books, are so vague and general, so little serviceable
for use, that the knowledge of them yields us very little help
when we are brought face to face with a concrete case and
endeavour to gain a clear conception of its causation. The
impossibility of getting precise information arises in most in-
stances from the insuperable difficulties under which we are of
knowing a person’s character and history fully, intimately, and
exactly. We cannot go through the complex and often tangled
web of his whole life, following the manifold changes and
chances of it, and, seizing the single threads out of which its
texture has been woven, unravel the pattern of it. No man
knoweth his own character, which is ever under his inspection:
how then can he know that of his neighbour, when he has only
brief and passing glimpses into it?

Great mistakes are oftentimes made in fixing upon the
supposed causes of the disease in particular cases ; some single
prominent event, which was perhaps one in a train of events,
being selected as fitted by itself to explain the catastrophe.
The truth is that in the great majority of cases there has been
a concurrence of steadily operating conditions within and
without, not a single effective cause. All the conditions,
whether they are called passive or active, which conspire to the
production of an effect are alike causes, alike agents; all the
conditions, therefore, which co-operate in a given case in the
B4 PATIIOLOGY OF MIND.  [owar.

production of disease, whether they lie in the individual or in
his surroundings, must be regarded as alike causes. When we
are told that a man has become mentally deranged from sorrow,
need, sickness, or any other adversity, we have not-learned much
if we are content to stay there: how is it that another man
who undergoes an exactly similar adversity does not go mad?
The entire causes could not have been the same where the
effects were so different. What we want to have laid bare is
the conspiracy of conditions, in the individual and outside him,
by which a mental pressure, inoperative in the one case, has
weighed so disastrously in the other; and that is information
which a complete and exact biography of him, such as never yet
has been written of any person, not neglecting the consideration
of his hereditary antecedents, could alone give us. Were all
the circumstances, internal and external, scanned closely and
weighed accurately it would be seen that there is no accident in
madness; the disease, whatever form it had, and however many
the concurrent’ conditions or successive links of its causation,
would be traced as the inevitable consequence of its ante-
cedents, just as the explosion of a train of gunpowder may be
traced to its causes, whether the train of events of which it is
the issue be long or short. The germs of insanity are most
often latent in the foundations of the character, and the fina]
outbreak is the explosion of a long train of antecedent
preparations.

As the causation of insanity may thus reach back through
a lifetime, and even have its root far back in foregoing genera-
tions, it is easy to perceive how little is taught by specifying a
single moral cause, such as grief, vanity, ambition, which may
after all be, and often is, a prominent early symptom of the
disease which, striking the attention of observers, gets credit for
having caused it. I am apt to think that we may learn more of
its real causation by the study of a tragedy like Lear than from
all that has yet been written thereupon in the guise of science.
A great artist like Shakespeare, penetrating with subtle insight
the character of the individual and discerning the relations
between him and his circumstances, apprehending the order
which there is amidst so much seeming disorder, and disclosing
i1,] THE CAUSATION AND PREVENTION OF INSANITY. 85

the necessary mode of evolution of the events of life, embodies
in the work of his creative art more real information than can
be obtained from the vague and general statements which
science in its.defective state is compelled to put up with.

Life in all its forms, physical and mental, morbid and healthy,
is a relation; its phenomena result from the reciprocal action of
an individual organism and of external forces: health is the
consequence and the evidence of a successful adaptation to the
conditions of existence, and imports the preservation, the well-
being, and the development of the organism, while disease marks
a failure in organic adaptation to external conditions and leads
to disorder, decay, and death. It is obvious that the harmonious
relation between the organism and its environment which is the
condition of health may be disturbed either by a cause in the
organism or by a cause in the environment, or by a cause, or
rather a.concurrence of causes, arising partly from the one and
partly from the other. When itis said then that a person’s
mind has broken down in consequence of adverse conditions of
life, social or physical, there is presupposed tacitly some infirmity
of nerve element, inherited or acquired, which has co-operated ;
were the nervous system in a state of perfect soundness, and
in possession of that reserve power which it then has to adapt
ivself within certain limits to varying external conditions, it is
not likely that unfavourable circumstances would be sufficient
so far to disturb the relation as to initiate mental disease. But
when unfavourable action from without conspires with an in-
firmity of nature within, then the conditions of disorder are
established, and the discord, which a madman is, is produced.

It has been the custom to treat of the causes of insanity as
physical and moral, but it is not practicable to make the dis-
crimination in many cases, Where the existence of a hereditary
taint, for example, is the physical cause of some moral defect or
peculiarity of character which issues at last in insanity, one
writer, looking to the mental aspect, will describe the cause as
moral, while another, looking to the bad inheritance, describes
it as physical. Certainly, where there is visible defective
development of brain in consequence of a bad inheritance, as in
idiocy sometimes, all persons are agreed as to the physical nature
86 PATHOLOGY OF MIND. [cHar,

of the defect; but when the cerebral defect is not gross and
patent, making itself known only by some vice of disposition,
most people will consider it to be of a moral nature. The
truth is, on the one hand, that in the great majority of cases in
which a so-called moral cause operates there is something in
the physical constitution which co-operates essentially, and, on
the other hand, that every moral cause operates in the last
resort through the physical changes which it produces in the
nerve-centres. These may be sudden and of the nature of a
commotion, as when a mental shock causes instant convulsion,
or paralysis, or madness; or they may be gradual and of the
nature of organic growth, as when a fault of character grows
with a person’s growth, until the balance of his mind is over-
thrown. It was set forth at almost superfluous length in the
first volume that thoughts, feelings, and actions leave behind
them residua which are organized in the nerve-centres, and
thenceforth so modify their manner of development as to con-
stitute an acquired nature, wherefore what we habitually feel,
think, and do foreordains in great part what we shall feel, think,
and do; and as moral manifestations throughout life thus deter-
mine corresponding physical organization, it is evident that a
steadily acting moral cause of insanity is all the while producing
its physical changes in the occult recesses of the supreme nerve-
centres of mind. In fact the brain that is exercised so
regularly in a.given manner as to acquire during health a
strong peculiarity or bias of action is sometimes more liable to
disorder in effect of this bias; and when the disorder is produced
by an independent cause, the bias or habit will, according to its
good or evil character, help to overcome or to aggravate its
effect. When, for example, insanity is the consummate ex-
aggeration of a particular vice of character, the morbid symp-
toms mark a definite habit of morbid nutrition in the supreme
nerve-centres—a gradually effected modification of the mental
organization along a morbid line. On the other hand, the brain
that is exercised habitually in the best way acquires a strong
and healthy habit of thought, feeling, and volition, which
counteracts the effects of a morbid strain. On the whole,
perhaps, a man had more need to practise good habits than to
ul] THE CAUSATION AND PREVENTION OF INSANITY. 87

meditate sound principles, if it were a question between the
two; but it is not, forasmuch as meditation on sound principles
is a preparation for the formation of good habits that have not
been taught.

With these preliminary remarks I go on to consider those
general conditions which are thought to predispose in some
way or other to insanity. In the outset I may make two general
assertions: that a man is what he is at any period of life,
first, by virtue of the original qualities which he has received
from his ancestors, and, secondly, by virtue of the modifications
which have been effected in his original hature by the influence
of education and of the conditions of life. But what a complex
composition of causes and conditions do these simple statements
import! Hereditary predisposition is a general term which
connotes, but certainly does not yet denote, various intimate con-
ditions of which we know nothing definite ; we are constrained,
therefore, to deal in general disquisitions concerning it instead
of describing exactly its varieties and setting forth precisely the
laws of its action.

Heredity—Whether it be true or not, as is sometimes said,
that no two leaves nor two blades of grass are exactly alike,
there can be little doubt that no two persons in the world are
now or ever have been exactly alike. However close the re-
semblance between them, each one has some characteristic
marking his individuality which distinguishes him from every-
body else, and which affects the course of his destiny. By the
circumstances of life the development of this intrinsic quality
may be checked in one direction or fostered in another direction,
but it can never be got rid of; it is always there, a leaven
leavening the whole lump. In olden times it was attributed to
the influence of the particular star which was in ascendant at
the time of the mortal’s birth; but the blow to that easy theory
of causation was that twins born under the same planetary
influence sometimes evinced very different dispositions: the two
twin-sisters of Hungary, who were united by the bottom of
their backs and had the same blood, were of extremely different
temperaments, and the last years of the Siamese twins were
made miserable by the quarrels arising from the different tastes

5
88 PATHOLOGY OF MIND. (CHAP,

of the brothers, and the different views which they took of the
American Civil War.

Whence comes this individuality of nature? Without doubt
it comes from the same source as the individuality of bodily
conformation, of gait, of features—that is to say, froni ancestors.
There is a destiny made for each one by his inheritance ; he is
the necessary organic consequent of certain organic antecedents ;
and it is impossible he should escape the tyranny of his organi-
zation. All nations in all ages have virtually confessed this
truth, which has affected in an important manner systems of
religion, and social and political institutions. The institution of
caste among the Hindoos owed its origin to it; and there can be
little doubt that the philosophy of that large sect among them
which taught the perpetual re-birth of mortals and the develop-
ment in this life of the deeds done in a former state of being,
holding the antecedent life of a being to be his destiny, was
founded on a recognition of hereditary action—of the fact that
the present nature has descended from the past by regular laws
of development or of degeneration. The dread, inexorable
destiny which plays so grand and terrible a part in Grecian
tragedy, and which Grecian heroes are represented as struggling
manfully against, knowing all the while that their struggles
were foredoomed to be futile, embodied an instinctive perception
of the law by which the sins of the father are visited upon the
children unto the third and fourth generations. Deep in his
inmost heart everybody has an instinctive feeling that he has
been predestined from all eternity to be what he is, and could
not, antecedent conditions having been what they were, have
been different. It was a proverb in Israel that when the
fathers had eaten sour grapes the children’s teeth were set on
edge; and Solomon justly proclaimed it to be one of the.virtues
of a good man that he left an inheritance to his children’s
children. In village communities, where the people remain
stationary, and where the characters of fathers and grandfathers
are remembered or are handed down by tradition, peculiarities of
character in an individual are often attributed to some here- °
ditary bias, and so accounted for: he got it from his fore-elders,
it is said, and the aberration has allowance made for it.
in] THE CAUSATION AND PREVENTION OF INSANITY. 89

In modern days we hardly take due account of this great truth
which ancient sages recognised, and which the experience of all
ages has confirmed, but it is vastly important to us, if we would
do well for our race, to acknowledge and confess it: we are deter-
mining in our generation much of what shall be predetermined in
the constitution of the generation that will come after us, and it
depends greatly upon us whether it shall be well or ill with it.
Certainly no one has power to change materially the funda-
mental tendencies of his own nature; the decrees of destiny
have gone forth, and he cannot withstand nor reverse them;
but if he conteuds manfully against bad impulses, as the hero
of Greek tragedy who, in the grasp of fatality and foredoomed
to failure, abated no effort to win an impossible victory, he will
by degrees modify his character in part, and at any rate he will
do that which, being embodied as an aptitude in the constitu-
tion of his posterity, may happily be a stay and present help to
them in time of trouble and temptation. His efforts to over-
come what he cannot overcome successfully may haply endow
their natures with strength to be victorious in a similar struggle,
his pains being their gain, his sowing their harvest.

The least observation of a young child’s mind, as its faculties
are, unfolded by education, shows how much it owes to here-
ditary action. How easily does a well-born European child
learn in a short time what, were it not that it has in its consti-
tution the benefit of ages of human culture—the quintessential
abstract thereof, so to speak—it would not learn in years, if it
ever learned at all! Just as it inherits muscles suited to
perform particular movements, and ready, after a little train-
ing, to perform them with ease, so it inherits in its brain
neryous substrata that embody the acquisitions of the culture
of its kind, and are ready, after a little training, to discharge the
function which has determined their formation through the gra-
dual experience of the race from age to age. Whoever doubts
this, let him take the child of an Australian savage and the child
of an ordinary European parent, and let him bestow the same
pains to give them the same education ; in the one case he will
find that he is playing upon a complex instrument, culture-
tuned, and ready to give forth harmony on the occasion of a
90 PATHOLOGY OF MIND, [cHap.

suitable touch, and in the other case that he has to do with a
very imperfect instrument, harsh and untuned, out of which he
can only get a few notes, and never the highest notes, with all
the skill that he can employ.

I might say, perhaps, that every human being has four
natures—his animal nature, his human nature, his family
nature, and his individual nature. Beneath the individual
characteristics lies the family nature, so that it will happen
that in two brothers whose every feature differs we perceive
intuitively the family identity—a fundamental identity in
diversity, and, on the other hand, in two strangers who are very
like in features we perceive intuitively a fundamental differ-
ence, albeit we cannot describe it in words. Beneath the family
nature is the more general human nature, and beneath that
again the still deeper lying and more general animal nature,
which, long way as man is from his nearest of animal kin, has
by no means been worked out of him. Here we have to do
only, but enough to do, with the inheritance of the family.

Many familiar examples go to prove that a person inherits
not only the general characters of the family, but pecu-
liarities of manner and of disposition: tricks of thought, like
tricks of manner, moods of feeling like humours of body, are
inborn and come out usually at one period or another of his
life. Not only are the ways and looks of immediate ancestors
thus reproduced sometimes, but those of ancestors who are
remote and not perhaps in the direct line of descent; it
would seem in fact that every parent has latent in him the
abstract potentialities of his ancestors, for I know not how
many generations back along the line of descent, and that
these may undergo development again in his posterity if they
chance to meet with suitable stimuli. To understand what
these latent potentialities are, he would do well to study their
developments in father, brothers, sisters, uncles, children—in
all branches of the family tree: explicit in them he shall
read what is implicit in himself. And here I may fitly take
notice that inherited qualities shall appear only at certain epochs
of life, the ancestral nervous substrata being then stirred to
function for the first time. At puberty, for example, a bodily and
ni] THE CAUSATION AND PREVENTION OF INSANITY. 91

mental revolution takcs place, new mental substrata are aroused
to function, and ancestral characters show themselves which were
not noticed before, and probably never would have been noticed
had the person been made a eunuch; during pregnancy there
may be distinct manifestations of her mother’s character in a
daughter which no one had observed before; and at the change
of life, when a woman’s special functions are over, and she tends
towards a masculine character of body and mind, there may be
evinced peculiarities which call to mind a male ancestor. It is easy
to understand that particular experiences in life may, like these
changes in the bodily evolution, be fitted to awaken to function
latent or quiescent ancestral nervous substrata, and that in this
way the accident of an accident in life may chance to bring out
an ancestral character which otherwise, like a seed not brought to
bear, would have remained dormant, As it is with the origin
and the decay of instincts among animals, so it is with the
development and the decadence of these ancestral nervous sub-
strata: conditions of life suited to their activity will stimu-
late them to action and will foster also the development of new
adaptive tendencies with their appropriate substrata ; conditions
of life unsuited to their activity will cause by degrees the
waning and the ultimate disappearance of old tendencies with
their substrata. In this way a slow evolution takes place through
the ages, and the thoughts of men are gradually transformed.
One consideration more with respect to an individual’s legacy
from his parents : he inherits not only their general family nature
and their original individual nature, but something from their
individual characters, as these have been modified by their
sufferings and doings, their errors and achievements, their
development or their degradation. Thus the work of one
generation with its consequences, good or ill, is continued in the
constitution of the next generation, living on in it, and the life
of a person is the unbroken continuation of the life of his
forefathers. No wonder that men have invented doctrines of
predestination and metempsychosis.

Very little observation, however, is needed to show that the
reproductions of the qualities of ancestors is but one side of
the action of heredity—that it does not copy merely, but also
92 PATHOLOGY OF MIND. [cHar,

invents; so that an individual often exhibits marked differences
from any known ancestor. Its operation includes a law of
variation as well as the reproduction of the like. It is true it
might be said that the variations which an individual presents
are not what they seem, but repetitions of qualities of remote
ancestors who have been forgotten, but it is an assertion’ which
is opposed to what we know of the correiations between variety
of character and increasing complexity of social conditions, and
to the evident fact that men in the long run advance by evolu-
tional variations upon what they have inherited from their
forefathers, or go back upon it by retrograde morbid varieties,
The existence of different moral dispositions and intellectual
capacities in twins and in double monsters is sufficient proof
that ‘hereditary action is not of the nature of a mere
mechanical copy; it is rather of the nature of a complex
chemical combination, whereby compounds not resembling in
properties their constituents are oftentimes produced. Un-
happily we are yet as ignorant of the laws by which combina-
tions of germinal elements take place and of the manifold varia-
tions of products which ensue therefrom, as people of old
were of the combinations of chemical elements and of the com-
plex chemical products which result from them. Nature buiids
up a multitude of different complex chemical products out of
.a few simple elements; it can be no cause of surprise then
that out of the combinations of the highly complex organic
bodies which the sperm and the germ elements are she builds
up all the varieties of individual character. Consider the com-
plexity of these germinal elements! There is not an organ of
the parent’s body, we have reason to think, not a tissue of which
an organ is formed, not an element probably of a tissue, which
has not its idiosynerasy represented in the minute germ in some
latent and mysterious way, and which may not therefore come
out in its full traits of character in the developed offspring ; or,
if it does not come out in its own character, serve to neutralise,
supplement, or modify some quality in the combining germ
from the other parent. Moreover, if it is neither developed
after its own kind nor utilised in combination, it may lie com-
pletely dormant in that generation and come out in the off-
ut) THE CAUSATION AND PREVENTION OF INSANITY. 93

spring’s offspring, or even in a later generation; for we know not
in the least how long it may remain latent before it is extinct.

This skipping of one generation and reappearance in a suc-
ceeding one has been called Atavism, and has excited surprise
when it has been observed in morbid heredity: it is so striking
sometimes in insanity that Ludovicus Mercatus, a Spanish phy-
sician, who wrote a book on hereditary diseases, was of opinion
that the insanity appeared in every other, or every third, indi-
vidual in lineal descent. But it is not so extraordinary as it
seems; for we have a familiar physiclogical instance of the
same thing when a daughter of a house transmits to her son
any of the special masculine qualities of her family, which of
necessity cannot be developed in her body, or when a son of the
house transmits to his daughter any of the special feminine
qualities of his family. In these cases the special sexual
qualities must have been latent in the intermediate generation.
Other qualities, healthy and morbid, that are not bound to sex
may in like manner be latent in a generation, if they meet not
in the circumstances of the individual's life with the conditions
fitted to stimulate them into active display. We assume them
to be latent when they do not show, but of course we cannot
really say that they are then perfectly inactive; they inay, for
anything we know, be held in check by, or hold in check, some
quality of the combining germ from the other parent, or have
entered into combination with it to form a new product with
qualities different from either of its constituents. Organic com-
bination being a matter of such exceeding complexity of
elements, of the nature and laws of union of which we have
not at present the least notion, but in comparison with which
we may be sure the most complex chemical combination known
is simple, we see reason enough why children are not mere
stereotyped copies of their parents, but always exhibit in
their mental and bodily constitutions and features more or less
distinct evidence of a law of variation.

Not only have we to take note of the complex character of
organic combinations, but we ought further to note that com-
bining germs may be well or ill-fitted to combine, being in the
one case of such a character as to make a strong and stable
94 PATHOLOGY OF MIND. [cxar.

compound, and in the other case of a character to make a feeble
and unstable compound. These greater or less affinities of the
formative germs for one another I take to be a necessary conse-
quence of the observation that two persons may be very well
suited or may be very ill suited to produce healthy offspring ; for
we may look on the germs as the essential abstracts of the indi-
viduals from whom they proceed, containing in the innermost all
that is explicitly displayed in features of body and mind, and
exhibiting the affinities and repulsions which the individuals
exhibit. It was an Oriental idea that a complete being had
in primeval times been divided into two halves, which have
ever since been seeking to join together and to reconstitute the
divided unity. The desire and pursuit of this unity is love,
and it is accomplished in the happy union of the sexes, and in
the production of the new being who proceeds therefrom.
Clearly the completest attraction ought to exist between the
individuals ; for if there be indifference or repulsion, as happens
sometimes where interest instead of affection makes a marriage,
there cannot be that full and harmonious co-operation of all the
conditions which is necessary to the best propagation; not that
elective affinity by which two beings are drawn together and
combine in marriage, like two elements in nature, to form a stable
compound. As good an author as Burdach maintained that the
beauty and ugliness of children were not dependent so much
upon the beauty and ugliness of their parents as upon the love
or aversion which they had for one another ; and to this opinion
Lucas heartily subscribes. One would have hesitated less to
assent to it had. it referred mainly to beauty and ugliness of
moral character ; for an ugly and unhallowed union of antipa-
thies can hardly fail to have consequences in the inexorable
logic of natural law.

All men are of the same species, and yet the varieties are so
great that the extremes do not combine well together; if a man
of the highest civilised race has intercourse with a woman of
the lowest race, the probability is that the intercourse is sterile,
or if there chance to be offspring it is so much the hybrid
that it is itself infertile. Degenerate or morbid varieties
of civilised races evince a similar incapacity of procreation;
ui.) TIE CAUSATION AND PREVENTION OF INSANITY. 95

sterile idiocy being the natural termination and extinction of
degenerate varieties of the human kind. In vain might the
most curious despot attempt to propagate a race of idiots. These
extreme instances of a positive unaptness or repugnance of germ
elements to combine will serve to bring home to the mind the
conception of the existence of laws of combination which are
in constant operation, and which we are yet ignorant of, though
we may expect them to be known some day. Is it not easy to
conceive that, without being so incompatible as to actually refuse
to combine, the germ elements may be so far unsuited to one
another that when they combine they do so in a half-hearted way
and produce an unstable compound? One frequently sees an
illustration of this in the outbreak of insanity in the offspring
of parents, one or the other of whom has been insane at some
time, and I believe it to be the explanation of the distinct pre-
disposition to insanity which appears, so far as the parents are
concerned, to be generated de novo in the offspring; they may
not themselves have ever been insane, nor may they come from
families that have any marked taint of insanity, yet they may,
by reason of their mental or bodily characters, be as unfitted to
breed together successfully as if they were positively insane.
If the popular notion be true, which the instincts of all nations
seem to confirm, that consaneuineous marriages breed degenerate
offspring, the case is one of this kind: germs subsuming the
qualities of the same ancestors, with such little admixture of
new elements as may chance to come from the non-related
parents, lack the variety of composition which is necessary to
the best combinations, and so are unfitted to produce a stable
compound, Any one who will may make the observation that
when two persons of narrow and intense temperament, having
great self-feeling, distrustful of others, and prone themselves to
cunning ways aud hypocritical dealings, mean in spirit as in
habits, perhaps deceiving themselves all the while by an in-
tense affectation of religious zeal of evangelical, ritualistic, or
other extreme type, unite in marriage and have children, they
lay the foundations of insanity in offspring more surely often
than an actually insane parent does. In truth there are certain
varieties of temperament which, not reaching the degree of
96 PATIIOLOGY OF MIND. [cHAP.

insanity, but tending more to criminal type, are as likely by their
union to generate it as is the most positive mental derange-
ment in one or other of the parents; and foremost amongst
them I hesitate not to place the union of essentially false and
hypocritical natures.

It is a common belief that genius is seldom inherited, and
it is certainly true that many wise men have had foolish sons,
and that many distinguished men have proceeded from common
and unknown families. One writer has gone so far as to declare
’ that giants in mind, like giants in body, are unfruitful. One
may conceive the reason why these extraordinary developments
of mind or body are not inherited to be because they are extra-.
ordinary varieties ; being acquired rather than natural characters
of organization, so far therefore special deviations from the type,
they are less likely to be inherited than is some family character
which belongs to the stock, goes along with it in all its individual
outcomes, and requires no special external conditions to aid its
‘development. There is a repugnance in nature te extreme
deviations from the type, and when such a deviation has occurred
the tendency is to revert to the ordinary type. Monsters deviate
so far from the normal type that they are either not viable or
cannot propagate themselves ; so it is with actual diseases, which
are truly morbid varieties; they are not propagated as actual
diseases when they do descend from father to son, but as ten-
dencies to disease, and they are likely tu be extinguished eventu-
ally in that line of descent, either by the operation of the
constant disposition which the organism shows to revert to a
sound type, or, if they get the better of the healthy forces, by
their increase until they put a stop to propagation. Mr. Galton,
who wrote a book to prove that genius is hereditary, counting
among his many examples hardly more than two or three cases
of true genius, has since perceived that all extraordinary
characters in families tend to revert to mediocrity, whether the
deviation be in the direction of plus or minus, and that in a
generation or two this reversion is to the equilibrium from which
the family variability had deviated. If it be true that genius
is apt to be infertile, as the giant certainly is, we must
suppose that the deviation from the common type has been so
un] THE CAUSATION AND PREVENTION OF INSANITY. 97

great as to render the germ incapable of combination with a
germ that is cast in the common mould, and that so nature at
once prevents by strong measures, as she does in the case of
idiocy, the necessity of a gradual return in the course of genera-
tions to the average standard of mediocrity. Were genius in-
heritable the result would soon be the development of a higher
species of man separating itself widely from a lower species.

In the pathological action of the law of variation or invention
of which I have spoken we have an explanation of the de novo
production of a predisposition to insanity, which must manifestly
have taken place once, and which takes place now from time to
time. Were all madness swept from the face of the earth to-
morrow, past all doubt men would breed it afresh before to-
morrow’s to-morrow. Two subjects concerning which information
may be set down as wanting, and which urgently need exact
investigation at the present time, are (@) The different ante-
cedent conditions of the generation of a predisposition to in-
sanity; and (0) The different signs, mental and bodily, by
which such a predisposition betrays itself. Of the latter I
shall treat in due course; respecting the first, when it comes to
be studied seriously, I may note that besides the law of variation
which is manifested in the results of the combinations of germ-
elements, we shall have to take account—secondly, of the un-
questionable influence of the particular mental and bodily state
of one or both parents before and at the time of propagation;
thirdly, of the important influence upon the child’s constitution
which is exerted for good or ill by the mental and bodily state
of the mother during gestation; and, fourthly, of the influences
brought to bear upon the child during the first years of growth
and development of its susceptible nervous system. The
neutralization of a tendency to insanity, through which it comes
to pass that it sometimes becomes extinct, is due, first, to the
favourable influence of a happy marriage, that is to say, one
which is antagonistic, not consentient, to its development, and
secondly, to the beneficial effect of conditions of life suited to
check its development. There is yet a third weighty cause to
be taken into account, namely, the natural tendency of the
organism to revert to the sound type. Were it not for these
98 PATHOLOGY OF MIND. ‘ [omap.

hygienic agencies all the world must become mad sooner or
later. But as a matter of fact, in the unceasing flow of the
stream of life ill tendencies are being constantly formed and
unformed, as chemical compounds are formed and unformed.

I go on now to consider the meaning of insanity as an
aberrant phenomenon in nature and of the general conditions
which lie at its foundation, before entering upon the discussion
of its particular causes. Aberrant or abnormal, as it may be
thought and called, it comes by law, and is just as natural as the
normal phenomena of sanity. Itis the clear business of man
in the world to adapt himself to the surrounding conditions of
his existence and to profit by them. “The gradual increase of
knowledge and skill, which we call progress of science and art, is
the gain which he makes as he succeeds in more close and exact
adaptation to external nature by means of improved methods
of observation of it and corresponding action upon it. The
mechanical conquests of the age are no more than systematie
improvements of what we do in consequence of more accurate
and systematic observation of what we have to do with: we
observe in order to foresee, and foresee in order to modify and
direct, so gaining victories through obedience. Progress in
physical science and in the arts which are based upon it is made
then by getting into closer and closer harmony with nature and
by informing our actions with the insight so gained—by making
them, in fact, a developmental advance upon nature. Progress
in poetry and in fine art has the same basis and should have
the same aim—to get closer insight into the beauties and har-
monies of nature and to construct new art combinations which
shall be a development of them—to make nature better by
human means, the means itself being still nature. To bring
self by systematically improved adaptation of feeling, insight
and doing into the most intimate possible harmony with nature,
so as almost to lose the sense of self in the larger sense of
oneness with it, must be the means, I take it, and should be
the aim, of human evolution. Failure in this aim, when it falls
below a certain level, is punished by manifest degeneration and
disease ; for nature is sure to take vengeance upon those who
ignore or transgress its laws, cbserving not its commandments
ul} THE CAUSATION AND PREVENTION OF INSANITY. 99

to do them. Certainly it would not be well for any one to
mortify self so far as to get a disdain of it, for he might not then
care to strive at all; he will find that to do the best for himself
and to do the best for nature are one, and that the highest re-
sults of his wisest strivi ing culminate in a more or less complete
self-surrender—in a nearer and nearer approach to Nirwina.
Inasmuch as a large part of the nature with which man has
to come into some sort of harmony is not what we call physical
nature, but human nature, it is plain that a main business of
his life will be to adjust his relations to his kind. That he
cannot help doing in the rudest form of primitive society; the
control of his own passion from fear of the recalcitrant kick
of his neighbour’s passion is a solid foundation of a primitive
sort of social feeling; but in a higher development of the social
organism his relations as a social element become much more
complex and special. Sympathy with his -kind and well-doing
for its welfare, direct or indirect, are the essential conditions of
the existence and development of the more complex social
organism; and no mortal can transcend these conditions with
any success. Let him feel, as he well may, that the play of
human life is a dreary farce, that he aud his fellow-workers are
but a little higher than the brutes, and like the brutes will
soon perish everlastingly—that all in the end is vanity and
vexation of spirit, he must still feel and work with his kind if
he would have health of mind. Misanthropy is commonly
madness in the making. Hence it is that humour, which always
is imbued with sympathy, is a higher and more wholesome
quality than cynicism, which is always inspired by contempt.
If an individual fails to bring himself into sympathetic
relations, conscious or unconscious, with surrounding human
nature, he becomes a sort of discord, and is on the road, though
he may not reach the end of it, which leads to madness or to
crime: he may be likened unto a morbid element in the
physiological organism, which cannot join in function with the
surrounding elements, is an alien among them, and must either
be extruded from it or be made harmless by sequestration in it:
he is truly an alien from his kind, and with equal truth he is
said to be alicnated from himself, because it is the function of a
100 PATHOLOGY OF MIND. [uAP.

normal self to be one with its kind. Ezcentricities of character,
when they are not counterbalanced by a strong judgment, are
apt to ripen into insanity either in the individual or in his
offspring, and the most appalling crimes of which history keeps
record, deeds of horror at which the world turns pale, have been
perpetrated by those who, having gained or inherited authority
and power, were so entirely emancipated from the social bonds
of human feeling as to be sometimes veritable madmen. A
scientific view of the conditions of human evolution simply
brings us back to the old story which prophets have seen and
proclaimed—to obey the commandments of God as they are
written in the laws of nature, and to love one’s neighbour as
oneself, to conform humbly, that is, to physical and social laws.
If it be true that it is the aim and the condition of a just
development to bring the individual into sympathetic relations
with the sufferings and the doings of his kind, it is plain that
he who, distrustful of every one, pursues eagerly his own selfish
schemes, having uo regard to his altruistic functions as a unit in
the social organism, must be on the road to initiate degeneracy of
some kind. Intense egoism of this sort does in fact divide into
two main branches, as the degeneracy increases through genera-
tions—namely, the insane and the criminal types, each of which
has its various subdivisions. That the children’s teeth are set on
edge when the fathers have eaten sour grapes was not the mere
dream of a seer’s fancy, but the piercing insight into a natural
law by which degeneracy increases through generations. Crime
and madness are the active outcome of antisocial tendencies.
It is well known how hard a thing it is sometimes to distinguish
between these two forms of human degeneracy. There are, on
the one hand, many criminals who exhibit such evident signs of
defect or unsoundness of mind that it is impossible to say con-
fidently whether they ought to be sent to an asylum or to a
prison ; and, on the other hand, there are insane persons who
evince such criminal and vicious tendencies that one cannot help
feeling that the discipline of a prison would be the best treat-
ment for them: both proceed in descent from the same anti-
social stem, and it is no wonder that their varieties intermingle
indistinguishably in, the borderland where they touch.
m1.) THE CAUSATION AND PREVENTION OF INSANITY. 101

Those who have had much to do with the treatment of
insane persons have not failed to note the marked mental pecu-
liarities of-their near relations in many instances, and to lament
that they oftentimes show themselves more distrustful, more
difficult to reason with, more impracticable, than the member of
the family who is confessedly insane. In the first place, they
have such an intimate radical sympathy of nature with those
tendencies of character which have culminated in insanity in him,
that they cannot sincerely see alienation which is patent to all
the rest of the world: they will minimise bit by bit, finding
reason or excuse for each strange act, feeling, or idea, until they
have accounted for all the strangeness of it, and it only remains
for the patient listener to confess that the palpable madness was
after all very natural in him, and that their relative is not mad
like other mad persons, or at any rate that what would be great
madness in all the rest of the world is not madness in him.
In the second place, as a consequence of their essential likeness
and sympathy of nature, they will question, dispute, carp at
every restraint which those under whose care he is may find it
necessary to place upon him; notwithstanding that they may
have been obliged to send him from home'and to put him under
control heasuge he was an intolerable trouble or an actual
menace and a danger, they will talk as if they would exact a
mode of treatment which entirely ignored his insanity, and will
end probably, if he does not get better, in the firm belief that
his disease has been caused and kept in action by the improper
treatment to which he has been subjected. The worst of them
would risk the chance of his attendant being killed by a lunatic
rather than suffer what they call his sensitive disposition to
be hurt by the necessary means of control, and if such a cata-
strophe happened their genuine sympathies would be with
him, not with the victim of his violence. Their intensely
suspicious and distrustful natures, their tortuous habits of
thought, their wiles and insincerities, their entire absorption in
a natrow selfishness, mark a disposition which is incapable of
coming into wholesome relations with mankind; it is of a
character to lead to guile in social intercourse, to petty fraud in
business, and, when the conditions of life are hard aud tempt
102 PATHOLOGY OF MIND. [cmae,

to evil-doing, even to c1ime, and which in any case is pretty
sure to breed insanity or crime in the next generation. Moral
feeling is based upon sympathy; to have it one must have
imagination enough to realise the relations of others and to
enter ideally into their feelings; whereas these persons have
not the least capacity of going in feeling beyond the range of
their family, unless it be to embrace a favourite cat or dog, and
are governed by an intense and narrow family selfishness,
They are capable sometimes of an extraordinary self-sacrifice for
one another within that small circle, but they are completely
shut up within it. Being in such slight and unstable relations
with their kind, what weondien that a son or daughter who has
descended from such an unsound stock, and who most likely
sucked in suspicion and egoism with the mother’s milk, should
get. so far astray as to be loosened from wholesome bonds of
social relation and to become insane or criminal !

Good moral feeling is to be looked upon as an essential part
of a sound and rightly developed character in the present state
of human evolution in civilised lands; its acquisition is the
condition of development in the progress of humanization.
Whosoever is destitute of it is to that extent a defective being ;
he marks the beginning of race-degeneracy; and if propitious
influences do not chance to check or to neutralize the morbid
tendency, his children will exhibit a further degree of degeneracy
and be actual morbid varieties. Whether the particular outcome
of the morbid strain shall be vice, or madness, or crime, will
depend much on the circumstances of life, but there is no doubt
in my mind that one way in which insanity is generated de
novo is through the deterioration of nature which is shown in
the absence of moral sense. It was the last acquisition in the
progress of humanization, and its decay is the first sign of the
commencement of human degeneracy. And as absence of moral
sense in one generation may be followed by insanity in the
next, so I have observed that, conversely, insanity in one
generation sometimes leaves the evil legacy of a defective moral
sense to the next. Any course of life then which persistently
ignores the altruistic relations of an individual as a social unit,
which is in truth a systematic negation of the moral law of
ut] THE CAUSATION AND PREVENTION OF INSANITY. 103

human progress, deteriorates his higher nature, and so initiates
a degeneracy which may issue in actual mental derangement in
his posterity.

When we make a scientific study of the fundamental meaning
of those deviations from the sound type which issue in insanity
and in crime, by searching inquiry into the laws of their genesis,
it appears that these forms of human degeneracy do not lie so
far asunder as they are commonly supposed to do. Moreover,
theory is here confirmed by observation; for it has been
pointed out by those who have made criminals their study that
they oftentimes spring from families in which insanity, epilepsy,
or some allied neurosis exists, that many of them are weak-
minded, epileptic, or actually insane, and that they are apt to
die from diseases of the nervous system and from tubercular
diseases. One might venture to describe, and to place side by
side as having near relations to one another, three neuroses—the
epileptic, the insane, and the criminal neurosis—each of which
has its corresponding psychosis or natural mental character.
In like manner as the form of every living creature answers to
its habits, it desiring only what it can attain by means of its
organs, constructed as they are, and its organs never urging it to
that which it has not a desire for, so it is with the particular
neurosis of that congeries of nerve-centres which constitute
specially the organ of mind; it inspires a desire for and deter-
mines a tendency to that form of mental activity, in other
words, to that development of the psychosis, which is the fullest
expression of its function. The sufferer from any one of these
neuroses represents an initial form of degeneracy, or a com-
mencing morbid variety, of the human kind, and life to him
will be a hard struggle against the radical bias of his nature,
unless he minds not to struggle and leaves it to the free course
of a morbid development. He is sadly weighted in running the
race that is set before him, since he has an enemy in bis camp,
a traitor in his own nature, which is ever ready to conspire with
external adversities, and often lends them a secret help, without
which they would be powerless to overcome him.

When the criminal inmates of a prison are studied, as they
need to be more scientifically than they have yet been, they are
104 PATHOLOGY OF MIND. [cHaP.

not found to be quite so much alike as a common name would
imply ; indeed, they may rightly be divided into three principal
classes—(a) the first class, consisting of those who, not being
really criminally disposed, have fallen in consequence of the ex-
traordinary pressure of exceptionally adverse. circumstances ;
(b) the second class, of those who, having some degree of criminal
disposition, might still have been saved from crime had they had
the advantages of a fair education and of propitious conditions
of life, instead of the disadvantages of an evil education and of
criminal surroundings ; (c) the third class, of born criminals,
whose instincts urge them blindly into criminal activity, what-
ever their circumstances of life, and whom neither kindness,
nor instruction, nor punishment will reform, they returning
uaturally to crime when their sentences are expired, like the
dog to its vomit or the sow to its wallowing in the mire. It
illustrates the strength of the instinctive repugnance to anti-
social beings that while compassion is oftentimes felt for a
criminal of the first class, and apology made for his crime, not
the least pity is felt nor the least allowance made for the
fearful tyranny of his bad organization under which the
criminal of the third class groans and succumbs. Clearly
society might justly commiserate the criminal at the same time
that it deliberately punished him by sequestration for its own
certain protection and for his possible reformation.

In this relation it is interesting to note how much a desire of
concealment and a feeling of disgrace still attach to the occurrence
of insanity in a family, despite all that may be said with regard
to its nature as a defect or a disease calling for compassion.
The feeling has at bottom a certain justification in the truth
that insanity is a mark of family degeneracy, the initiation of a
morbid variety of the human kind, a proclamation of failure in
adaptation to the complex social and physical conditions of
civilised life. The sufferer is an outcast from the social system,
being unable to conform to the laws which govern social organi-
zation and function. There always has been, and for a long
time to come there will no doubt still be, a feeling of distrust
of and repugnance to the anti-social unit who has fallen from
his high rational estate as a being who can feel, think, and act
us] THE CAUSATION AND PREVENTION OF INSANITY. 105

with his kind, and whose thoughts and deeds are incompatible
with the social well-being; he will lie under a social ban, and
the family to which he belongs will feel the reflected stigma.

The foregoing considerations make it plain that if all sorts
and conditions of insanity were swept clean from the face of.
the earth at one stroke, so that hereditary predisposition could
not work as a factor in its production, no long time could
elapse before a new start was given to one or other of its forms
of degeneracy. It is a mere question of time when a deviation
from the laws of social well-being shall reach such a pitch that
the individual who is the outcome is unfit to take his place and
perform his functions as a social element, and must be treated
as a morbid variety ; degeneracy of the moral being must ensue
in‘consequence of a persistent disregard of these laws as surely
as disease or-death of body will ensue from a persistent disregard
of the laws of physical health; and he who is going the way
of degeneracy from the ideal type of wholesome manhood
plainly cannot help, but will hinder that evolution of the social
organism which, as it is the effect, we may take to be in the
purpose, of nature’s development. All those who are going this
downward way, along whatever special path, we might class
together under the head of anti-socaal elements; there would
be many varieties of them, ranging from the first beginnings
of degeneracy to the extremest forms thereof.

It would not perhaps be teo absolute a statement to make—
That one of two things must happen to an individual in this
world if he is to live successfully in it: either he must be
yielding and sagacious enough to conform to circumstances, or
he must be strong enough, a person of that extraordinary
genius, to make circumstances conform to him. If he cannot
do either, or cannot manage by good sense or good fortune to
make a successful compromise between them, he will either go
mad, or commit suicide, or become criminal, or drift a helpless
charge upon the charity of others.

Having thus set forth the meaning of insanity as an aberrant
phenomenon in the social organization, and so hinted at the
conduct of life which is best suited to prevent it, 1 go on now
to treat more particularly of that definite predisposition to it
106 PATHOLOGY OF MIND. [oHAP.

which is produced by similar or allied disease in one ar other of
the immediate ancestors.

Morbid Heredity—This is a subject respecting which it is
not possible to get exact and trustworthy information. So
strong is the feeling of disgrace attaching to the occurrence of
insanity in a family, and so eager the desire to hide it, that
persons who are not usually given to saying what is not true
will disclaim or deny ostentatiously the existence of any here-
ditary taint, when it is known certainly to exist or is betrayed
plainly by the features, manner, and thoughts of those who
are denying it. Not even its prevalence in royal families has
sufficed to make madness a fashionable disease. The main
value of the many doubtful statistics which have been collected
by authors in order to decide how large a part hereditary taint
plays in the production of insanity is to prove that with the
increase of opportunities of obtaining exact information the
greater is the proportion of cases in which its influence is
detected; the more careful and exact the researches the fuller
is the stream of hereditary tendency which they disclose.
Esquirol noted it in 150 out of 264 cases of his private patients ;
Burrows clearly ascertained that it existed in six-sevenths of the
whole of his patients; on the other hand, there have been some
authors who have brought the proportion down as low as one-
tenth. Some years ago I made a tolerably precise examination
of the family histories of fifty insane persons taken without
any selection ; thete was a strongly marked predisposition in four-
teen cases—that is in 1 in 3°57, and in ten more cases there
was sufficient evidence of family degeneration to warrant more
than a suspicion of inherited fault of organization. In about
half the cases then was there reason to suspect morbid predis-
position, I have recently inquired into the histories of fifty
more cases, all ladies, the opportunities being such as could only

1 Elaborate statistical tables which have been gathered from public
asylum reports, in order to exhibit the proportions of instances in which
hereditary predisposition has existed, have never been of any value, except
so far as they served to occupy or amuse those who were at the pains to
compile them; only where the inquirer is brought into the most intimate
relations with the friends of the patients can he make an approach to
accuracy, and even then it will be an approach only.
m.] TILT CAUSATION AND PREVENTION OF INSANITY. 107

occur in private medical practice, and with these results: that
in twenty cases there was the distinct history of hereditary pre-
disposition ; in thirteen cases there was such evidence of it in
the features of the malady as to beget the strongest suspicion
of it; in seventeen cases there was no evidence whatever of it.
In the second fifty cases my opportunities of getting informa-
tion were more favourable in consequence of more frequent per-
sonal intercourse with the friends, and it sometimes happened
that the information sought for was obtained quite accidentally
after heredity had been denied, What is the exact proportion of
cases in which some degree or kind of hereditary predisposition
exists must needs be an unprofitable discussion in view of the
difficulty and complexity of the inquiry ; suffice it to say broadly
that the most careful researches agree to fix it as certainly not
lower than one-fourth, probably as high as one-half, possibly
as high even as three-fourths.

Two weighty considerations have to be taken into account in
relation to this question : first, that the native infirmity or taint
may be small or great, showing itself in different degrees of
intensity, so as on the one hand to take effect only when con-
spiring with more or less powerful exciting causes, or on the
other hand to give rise to insanity even amidst the most favour-
able external circumstances; and, secondly, that not mental
derangement only in the parents, but other forms of nervous
disease in them, such as epilepsy, paroxysmal neuralgia, strong
hysteria, dipsomania, spasmodic asthma, hypochondriasis, and
that outcome of a sensitive and feeble nervous system, suicide,
may predispose to mental derangement in the offspring, as,
conversely, insanity in the parent may predispose to other forms
of nervous disease in the offspring. We properly distinguish
in our nomenclature the different nervous diseases which are
met with in practice according to the broad outlines of their
symptoms, but it frequently happens that they blend, combine,
or replace one another in a way that confounds our distinctions,
giving rise to hybrid varieties intermediate between those which
are regarded as typical.

This mingling and transformation of neuroses, which is ob-
served sometimes in the individual, is more plainly manitest
103 PATHOLOGY OF MIND. [CHAP

when the history of the course of nervous disease is traced
through generations; if instead of limiting attention to the
individual we go on to scan and track the organic evolution
and decay of a family—processes which are sometimes going
on simultaneously in different members of it, one displaying
the outcome of its morbid, another of its progressive tendencies
—it is seen how close are the fundamental relations of certain
nervous diseases and how artificial the distinctions between
them sometimes appear. Epilepsy in the parent comes ous
perhaps as some form of insanity in the offspring, or insanity
in the parent as epilepsy in the child. Estimating roughly the
probable breeding results of a number of epileptic parents,
one might say that they would be very likely to lose many
children at an early age; that the chances were great that
some children would be epileptic; and that there was almost
as great a risk that some would become insane. Chorea or
other convulsions in the child may be the consequence of great
nervous excitability, natural or accidentally produced, in the
mother. In families where there is a strong predisposition to
insanity, one member shall sometimes suffer from one form of
nervous disease, and another from another form : one perhaps has
epilepsy, another is afflicted with a severe neuralgia or with
hysteria, a third may commit suicide, a fourth becomes mania-
cal or melancholic, and it might even happen sometimes that a
fifth evinced remarkable artistic talent. Neuralgic headaches
or megrims, various spasmodic movements or fics, asthma and
allied spasmodic troubles of breathing will oftentimes be dis-
covered to own a neurotic inheritance or to found one. The
neurotic diathesis is fundimental; its outcomes are various, and
determined we know not how; but they may, I think, be
either predominantly sensory, or motor, or trophic in character.
Were we only as exact as we could wish to be in our re-
searches we ought then, in studying hereditary action and its
issues, to mark the different roads. It is plain there may be
(a) Heredity of the same form—that is, when a person suffers
from the same kind of mental derangement as a parent had
which he seldom does except in the cases of suicide and dipso-
mania; () Heredity of allied furm, as when he suffers from
ut] THE CAUSATION AND PREVENTION OF INSANITY. 109

another kind of mental derangement than that which his parent
had—is maniacal, for example, when he or she was melan-
cholic ; and (c) Heredity with transformation of neurosis—when
the ancestral malady was not mental derangement of any
sort, but some other kind of nervous disease. Whatever the
exact number of cases of mental disorder in which hereditary
predisposition of some degree or kind, derived from the preced-
ing or from a more remote generation, is positively ascertained,
it may be asserted broadly that in the majority there has been
a native instability or infirmity of nervous element in the in-
dividual whereby he has been unable to bear the too heavy
burden of his life, and has broken down in mind. Complex and
various as the constitutional idiosyncrasies of men notably are,
it is obvious that statistics can never yield exact and conclusive
information concerning the causation of insanity ; here, as in so
many other instances of their employment, their principal value
is that they make known distinctly the existence of a certain
tendency, so to speak, which, once we have fairly grasped it,
furnishes a good starting-point for further and more rigorous
researches: they indicate the direction which a more exact
method of inquiry should take.

It will not be amiss to take note here that the filiation of
nervous disease is displayed more plainly in the so called
functional disorders, in which we are not able to detect any
morbid change of structure after death, than in the so called
organic diseases, in which there is visible deterivration of
structure. The reason probably is this: functional diseases
mark an intrinsic disorder of nerve element itself, of ultramicro-
scopical delicacy—intranervine so to speak—while the gross
destruction of nerve-structure which we observe in organic
disease is usually a secondary effect, extranervine, the primary
disease having originated in the walls of the blood-vessels or in
the elements of the connective tissue. For example, when an extra-
vasation of blood breaks down the nerve structure in the neigh-
bourhood of the burst vessel, it is the degenerate artery which is
at fault; and when a syphilitic or a cancerous tumour grows in
the brain to the detriment of the nervous structure on which it
encroaches steadily, it has had its origin not in the nerve
110 PATHOLOGY OF MIND, (CHAP.

element, but in the perivascular spaces or in the elements of the
connective tissue. In both cases we have to do with a disease of
nutrition rather than with an essential disease of nerve element.
‘The mental and nervous symptoms which occur are incidental
to the progress of the disease, not of its essence, being due
either to the direct destruction, or to the irritation, direct
or reflex, of nerve structure by the extravasated blood or the
morbid growth; and hereditary action, if it showed itself at
all, might be expected to show itself in degenerate blood-
vessels or in similar morbid growths in the brain or elsewhere
in the body.

Nevertheless it must have chanced to every physician who
has had much to do with nervous diseases to have seen cases in
which a parental apoplexy has seemed to have distinctly pre-
disposed to insanity in the offspring. I call to mind an instance
in which four grown up members of a family of ten children
are already insane, and more will probably become so. I know
nothing more of their hereditary antecedents than that neither
father nor mother was insane; both were extremely energetic
and industrious, and they built up from the humblest beginnings
by their joint exertions a large and lucrative business in Londen.
The mother was of an anxious, inconstant, impatient, and some-
what irritable temperament, always actively employed and an
eager woman of business, and she died at a good age. The
father, who was of a sanguine, choleric, and active temperament,
died two years after her from apoplexy, having had a previous
attack from which he had recovered. Though warned very gravely
after the first attack to be careful and temperate in work and in
habits, he paid not the least revard to the admonition, but was
eagerly employed in extending his business to the moment
when he was struck down by the fatal attack. In this case
the apoplectic catastrophe was plainly not the beginning of the
line of pathological degeneracy ; account ought to be taken of
the neurotic temperament which went before it, the eager, con-
tinued, and somewhat turbulent function of which, involving a
full and brisk determination of blood to the brain, might well
produce a too great and unintermitting strain upon the walls of
the bloodvessels, and so occasion degeneration of their structure ;
un] THE CAUSATION AND PREVENTION OF INSANITY. 111

wherefore it was not the actual bursting of the weakened
vessel, but the antecedent conditions of nerve element, which
should be accounted the true predisposing cause. This has
been the real order of events, I believe, in other cases in which
apoplexy has appeared to predispose to insanity : in one genera-
tion might be noted irritability, a tendency to cerebral conges-
tion, with passionate and violent outbreaks, ending perhaps in
an apoplectic stroke; in the next generation a tendency to
cerebral hemorrhage, and the appearance of such neuroses as
epilepsy, suicidal disposition, and some form or other of mental
derangement.

There is reason to think that an innate taint or infirmity
of nerve-element may modify the manner in which other
diseases commonly manifest themselves ; for example, where it
exists, gout flying about the body will occasion obscure nervous
symptoms which puzzle the inexperienced practitioner, and it
will sometimes issue in a downright attack of insanity, instead
of showing itself by its ordinary inflammations. On the other
hand, there is no doubt that a parental disease which does not
affect specially the nervous system may notwithstanding be at
the foundation of a delicate nervous constitution in the off-
spring: scrofula, phthisis, syphilis perhaps, gout and diabetes
appear sometimes to play this part. On going through an idiot
asylum the appearance of scrofula among its inmates is suffi-
ciently striking; perhaps two-thirds, or even more, of all idiots
are of the scrofulous constitution Lugol, who wrote a treatise
on scrofula, professes to have found insanity by no means un-
common amongst the parents of scrofulous and tuberculous
persons, and in one chapter he treats of hereditary scrofula
from paralytic, epileptic, and insane parents. In estimating the
value of observations of this kind, however, we may easily be
deceived unless we are careful to reflect that, independently of
any special relation between the two diseases, the enfeebled
nutrition of scrofula would be likely to light up any latent pre-
disposition to insanity which there might be, and so might seem
to have originated it when it was only a contributory factor,
and, on the other hand, that insanity, and especially those

1 On Idiocy and Imbecility. By Wiliam W. Ireland. 1877, p. 24.

6
112 PATHOLOGY OF MIND. [cHae.

forms of it in which nutrition was much affected, would foster
the development of a predisposition to scrofula or phthisis.
Several writers on insanity have taken notice of a connection
between it and phthisis which they have thought to be more
than accidental. Schroeder van der Kolk was confident that
a hereditary predisposition to phthisis might predispose to or
develop into insanity, and, on the other hand, that insanity pre-
disposed to phthisis. With phthisis, however, there commonly
goes, as is well-known, a particularly eager, intense, impulsive,
and sanguine temperament, which may breed a more insanely
disposed temperament in the offspring, apart from any influence
which the actual tubercular tendency may be supposed to have
or to have not. I am the more apt to think this the explanation,
because there is a third-rate artistic or poetic temperament,
altogether wanting in sobriety, breadth, and repose, and mani-
festing itself in intense but narrow idealisms, of an extrava-
gant or even grotesque character sometimes, or in caterwauling
shrieks of emotional spasm, put forth as poetry, which closely
resembles the phthisical temperament, and which is very likely
to breed insanity. There is no question in my mind that
insanity and phthisis are often met with as concomitant or
sequent effects in the course of family decadeuce, whether they
predispose to one another or not; they are two diseases through
which a family stock that is undergoing degeneracy gradually
becomes extinct, especially in those cases. where the degeneracy
is the outcome of brecding in and in until all variety and vigour
have been bred out of the stock. When we are searching for the
predisposing conditions of a morbid neurosis in a particular
case, and fail to discover any history of antecedent insanity or
epilepsy, we shall do well then to inquire whether phthisis is a
family disease. It is alleged that as many as two-thirds of all
idiots die of phthisis. According to Dr. Clouston’s observations,
made at the Morningside Asylum, tubercular deposit is twice as
frequent in the bodies of those who die insane as it is in the
bodies of those who die sane, and he professes to have found a
distinctly greater frequency of hereditary predisposition to in-
sanity among the tubercular than among the non-tubercular
patients. There is not, I think, sufficient reason to suppose that
m1.) THE CAUSATION AND PREVENTION OF INSANITY. 113

the remarkable remission of the symptoms of insanity which un-
doubtedly takes place often during the exacerbation of phthisis
in a patient who has the two diseases, with the active recur-
rence of the mental symptoms when the signs of phthisical
activity abate, testifies to any special connection between them ;
for it appears to be no more than an instance of such abatement
of mental symptoms as is observed when other acute disease
befalls in an insane patient.

Diabetes is a disease which often shows itself in families in
which insanity prevails: whether the one disease predisposes
in any way to the other or not, or whether they are independent
outcomes of a common neurosis, they are certainly found to run
side by side, or alternately with one another, more often than
can be accounted for by accidental coincidence or sequence.
For the present I am content to note the fact that the children
of a diabetic parent sometimes manifest neurotic peculiarities,
without devising an explanation which must be hypothetical.
This we know: that diabetes is sometimes caused in man by
mental anxiety; that it is produced artificially in animals by
irritation of the fourth ventricle and some adjacent parts of the
brain; and that a great many diabetic patients die of phthisis.
Perhaps I might set it down as a true generalization that the
morbid neurosis, when it is active and gets distinct morbid
expression, may manifest itself in four ways—(qa) in disorder of
sensation—for example, paroxysmal neuralgia; (6) in disorder
of motion—for example, epilepsy; (¢) in disorder of thought
feeling, and will—mental derangement; (d) in disorder of
nutrition, whereof diabetes: is the earlier and phthisis the later
stage.

The late M. Morel of Rouen prosecuted some original and in-
structive researches into the formation of degenerate or morbid
varieties of the human kind, showing the steps of the descent
by which degeneracy increases through generations, and issues
finally, if unchecked by counteracting influences, in the extinc-
tion of the family. When some of the unfavourable conditions
of life which are believed to originate disease—such as the
poisoned air of a marshy district, the unknown endemic carses
of cretinism, the overcrowding and starvation of large cities,
{14 PATHOLOGY OF MIND. [cvar.

continued intemperance or excesses of any kind, frequent inter-
marriages in families—have engendered a morbid variety, it is
the beginning of a calamity which may gather force through
generatiuns, until the degeneration has gone so far that the con-
tinuation of the species along that line is impossible. Insanity,
of what form soever, whether mania, melancholia, moral in-
sanity, dementia, may be looked upon then philosophically as
a stage in the descent towards sterile idiocy ; as might be proved
experimentally by the intermarriage of insane persons for two
or three generations, and as is proved undesignedly sometimes
by the disastrous consequences of frequent intermarriages in
foolish families. The history of one family which Morel in-
vestigated with great care may be quoted as an extreme
example of the natural course of degeneration when it goes on
unchecked through generations. Were it an invention only,
it would be one of those inventions that teach excellent truth.
It may be summed up thus :—

First Generation—Immorality, depravity, alcoholic excesses,
and great moral degradation in great-grandfather, who was
killed in a tavern brawl.

Second Generation Hereditary drunkenness, maniacal attacks
ending in géneral paralysis in the grandfather.

Third Generation.—Sobriety, but hypochondriacal tendencies,
delusions of persecution, and homicidal tendencies in the
father.

Fourth Generation.—Defective intelligence. First attack of
mania at sixteen years of ace; stupidity and transition to com-
plete idiocy. Probable extinction of the morbid line; for the
generative functions were as little developed as those of a child
of twelve years of age. He had two sisters, who were both
defective physically and morally, and were classed as imbeciles,
To make the proof of morbid heredity more striking, it may be
added that the mother had an adulterous child while the father
was confined in the asylum, and that this child did not exhibit
any signs of degeneracy.

In this history of a family we have an instructive example
of a retrograde movement of the human kind, ending in so wide
a deviation from the normal type that sterility ensues ; it is the
wu.) THE CAUSATION AND PREVENTION OF INSANITY. 115

oppusite of that movement of progressive specialization and
increasing complexity of relation with the external which mark
advancing development. All the moral and intellectual acqui-
sitions of culture which the race has been slowly putting on by
organized inheritance of the accumulated experience of count-
less generations of men are rapidly put off in a few generations,
until the lowest human and fundamental animal elements only
are left in an abortive state: in place of sound and proper
social elements which may take their part and discharge their
function harmoniously in the social organism we have morbid
elements fit only for excretion from it. The comparison of the
social fabric with the bodily organism is well founded and in-
structive. As in bodily disease there is a retrograde meta-
morphosis of formative action whereby morbid elements are
produced which cannot minister to healthy function, but will, if
not got rid of, occasion disorder or death ; so in the social fabric
there is likewise a retrograde metamorphosis whereby morbid
varieties or degenerations of the human kind are produced,
which, being antisocial, will, if not rendered innocuous by
sequestration in it, or if not extruded violently from it, give
rise to disorder incompatible with its stability. How exactly
do the results of degeneracy accord with what was said concern-
ing the aim of human progress and the fundamental meaning
of insanity!

Let it be noted that however much: man may degenerate
from his high estate he never actually reverts to the exact
type of the animal, though he may sink in idiocy to a lower
stage of degradation than it; when he has been stripped of
all his essential human qualities and degraded almost to his
bare animal instincts, he certainly presents an animal like-
ness which may justify the description of his condition as a
thervid degeneracy ; but he is unlike in these respects—first, that
his mental wreck yields evidence of the height from which he
has fallen, and, secondly, that the fundamental instincts want
the vigour and wholesome activity of the animal, or are actually
debased. The latter can, by virtue of its healthy instincts,
adjust itself successfully to its surroundings and flourish; he,
unable to do so by reason of the debasement of his instincts cr
116 PATUOLOGY OF MIND. (crap.

of their unfitness to cope with the complexity of his surround-
ings, would perish soon but for the helpful care of his kind.

In the lowest forms cf insanity and idiocy there are sometimes
exhibited remarkable animal-like instincts and traits of cha-
racter, which may even go along with corresponding conforma-
tion of body: witness the stories told—I know not how truly
of idiot mothers who, after delivery, have gnawed through the
umbilical cord; the idiot described by Pinel, who was much
like a sheep in appearance, in habits, and in his cry; the idiot
described by Dr. Mitchell, who presented a singular resemblance
to a monkey in his features, in the conformation of his body, and
in his habits ; the habit of rumination of food which has been
observed in some insane persons and idiots, and the savage fury
and the bestialities exhibited by others :—all these testify to
the brute brain within the man’s, and may be looked upon as
instances of partial reversion, proofs that the animal has not
yet completely died out of him, faint echoes from a far distant
past testifying to a kinship which he has almost outgrown. It
may be thought a wild notion that man should even now dis-
play traces of his primeval kinship when countless ages have
confessedly elapsed since he started on the track of his special
development, but a little consideration will take from the
strangeness of it. In the first place, long way as he is from
the animals, he still passes in the course of his embryonic de-
velopment through successive stages at which he resembles not
a little the permanent conditions of certain classes of them; he
may be said, in fact, to represent in succession a fish, a bird, a
quadruped in his course before he becomes human; and these
transitional phases are presumably to be interpreted as the
abstract and brief chronicle of the successive throes or stages
of evolution through which nature went before man was brought
forth. Whether that be so or not, the metamorphoses are proofs
at any rate that the foundatioris of his being are laid upon
the same lines as those of the vertebrate animals, and that he
has deep within him common qualities of nature which, when
the higher qualities of his special nature are gone, will manifest
themselves in animal-like traits of character. In the second
place, let any one consider curiously the fundamental instincts

 
mu] THE CAUSATION AND PREVENTION OF INSANITY. 117

of self-conservation and propagation, resolutely laying bare their
roots, taking note of their intimations in children long before
their meaning is understood by them, and giving attention to their
manifestations among all sorts and conditions of men, savage and
civilised, he will not fail to perceive and confess how thoroughly
animal is man at bottom. He will apprehend this the more clearly
if he goes on to trace, as he may, the development of many
of the highest qualities of human intelligence and feeling from
their roots in these fundamental instincts. Our sympathies with
other living things, our interests in their sufferings and doings,
our success in understanding them and making ourselves under-
stood by them, our power to train and use them for our services,
would be impossible but for a common foundation of nature.

It has been a question whether a father or a mother was more
likely to transmit an insane bias to the children, Esquirol
found that it descended more often from the mother than from
the father, and from the mother to the daughters more often
than to the sons; and to this opinion Baillarger subscribes.
From an elaborate report to the French Government by M.
Béhic it would seem that it is most likely to pass from
father to son and from mother to daughter; for out of 1,000
admissions of each sex into French asylums he found that 264
males and 266 females had suffered from hereditary predispo-
sition; that of the 264 males 128 had inherited the disease
from their fathers, 110 from their mothers, and 26 from both
parents ; and that of the 266 females, 100 had inherited from
fathers, 130 from mothers, and 36 from both parents. It might
be questioned whether the sex of the parent in itself has much
directly to do with determining the line of descent to son or
daughter ; it is not perhaps that the male inherits preferenti-
ally from the male, and the female from the female, by virtue of
sex, but that there is more insanity inherited from one or the
other according as there are more male or female children among
the offspring. If male children have preponderated in the
family of the father who transmits the insanity to his children,
and if he displays in marriage that superior potency in propa-
gation by which his family tendency obtains and male children
preponderate among his offspring, there will most likely be more
118 PATHOLOGY OF MIND. [omar.

cases of insanity descending from father to son, but if female
children preponderate among his offspring, it is probable that
there will be a stronger stream of descent from father to daughter
To get at real information we should have to go deeper and to
discover the unknown causes which determine sex. It is hard
to understand that a daughter who resembles an insane father in
her whole temperament of body and mind more than a son does
should be less likely than the son to inherit a morbid taint of
character from him. Mr. Galton’s! first inquiries concerning
hereditary genius led him to the conclusion that, contrary to
common opinion, the female influence was inferior to the male
in transmitting ability, but when he came to revise his data
more closely, he saw reason to conclude that the influence of
females is but little inferior to that of males in such transmis-
sion. It may be said with equal truth probably both of ability
and insanity that while transmission to the same sex and trans-
mission to the other sex are common enough, the relative
frequency of their occurrence.is yet uncertain.

Some writers subscribe to the plausible theory which has come
down from antiquity, that madness, like other hereditary diseases,
is most likely to be transmitted to the child which resembles
most in features and disposition the insane parent, and that a
person who has the misfortune to be so descended may therefore
take comfort to himself if he is unlike that parent. However,
the conclusion must not be made absolute; it does not follow
that a child who resembles a parent in features shall have a
similar disposition, since there is assuredly no constant relation
between resemblance of features and of moral disposition; and
of course it is not where the bodily features are alike, but where
the mental disposition is of the same kind, that we should expect
to observe such operation of the law of heredity. I have noticed
too in some cases that a likeness to one parent or to his or her
family type which comes out strongly at one period of life may
wane gradually and be replaced by a greater likeness to the other
parent or to his or her family type at a later period of life; the
son who calls to mind his mother at twenty years old perhaps
calls his father to mind at forty; and the daughter who was

1. Hered. Gen. p. 63,
m.] THE CAUSATION AND PREVENTION OF INSANITY. 119

like her father at twenty puts on more of her mother’s simili-
tude at forty. It is plain then that a son or a daughter who had
been unlike the insane parent might as time went on take up
with the family resemblance a tendency to the parental disease.!
In any case there is no doubt that a child born after an
outbreak of parental insanity is more likely to suffer from
insanity than one that was born before the outbreak.

In considering the period of life at which a hereditary predis-
position to insanity or any other such predisposition will sho w
itself in actual disease, it should be borne in mind that certain
organs or systems of organs are particularly active at certain
ages, when they will naturally be more prone to fall into that
disordered action to which they are intrinsically disposed. In
like manner they may be less predisposed to one and more pre-
disposed to another kind of morbid action when their. decay and
the decline of their functions begin in old age. In infancy, as
Petit has pointed out, the lymphatic and the nervous systems
predominate, for which reason scrofula and epilepsy are the
hereditary diseases which then most show themselves. As
years go on the muscular system undergoes great development,
the sexual organs begin their function, and the whole vascular
system is very active ; wherefore inflammatory diseases are most
apt to occur, pulmonary diseases to accompany or to follow
the development of the chest, and nervous derangements of a
hysterical or allied nature to attest the revolution which
the development of the sexual organs produces in the entire
economy. Before puberty nature’s chief concern has been with
physical development ; but with the new desires and impulses
which spring up after puberty, when the individual life begins
to expand into social life, the mind undergoes a transformation,

1 Aman may get great help in self-knowledge sometimes by observing
and reflecting on the characters of the different members of his family—
father, mother, uncles, brothers, sisters, &c., for he may see in them the
developed outcomes of hidden tendencies in himself, the written-out expo-
sition, as it were, of what is understood in him. When he cannot under-
stand why he should have acted in a certain way on a particular occasion,
a trait in his brother’s or his child’s character may furnish the explanation.
Note in this relation how the same face in different aspects and expres-
sions suggests the features of different members of the family, and how the
dead person’s face sometimes shows a likeness scarcely perceived in life.
120 PATHOLOGY OF MIND. Touap.

and the consequence is that hereditary insanity may declare
itself; if not directly after puberty as the result of the natural
physiological action becoming pathological, still in the years
that immediately follow it, when the mind is most tried, being
under a strain of energy in the novel adjustment to the condi-
tions of active life, or when overworked in the subsequent years
of eager competition during manhood. Many men break down
too in these years from the enervating effects of sexual excesses
upon an excitable and feeble nervous system, and of course
women may break down under the trials of pregnancy and par-
turition. In later manhood rheumatism and gout attest, the former
perhaps a muscular system which, having reached the prime of
its energy, now discovers a strain of weakness or begins to
decline ; the latter, a decay of the powers of assimilation and
nutrition which is not acknowledged prudently by giving them
less to do. Ata more advanced age still the abdomen seems to
take up the tale: the energy of feeling and desire, which has its
physiological source in the visceral organs and inspires vigorous
self-assertion and practical will, abates gradually as they become
dull and weary; the result being a tendency to sombre and
gloomy feelings which may pass into hypochondria aud melan-
cholia. Lastly in old age the tissues degenerate and the cerebral
vessels give way in apoplexy ; or the brain shrinks in decay and
senile dementia ensues.

Consanguineous Marriages.—Whether these marriages breed
degenerate offspring is a question which has been much dis-
puted, some writers having impugned the general opinion that
their effects are bad. It is a subject concerning which it is
difficult to make exact inquiries, and impossible to arrive at
trustworthy results ; and Mr. G. Darwin, who undertook a series
of painstaking inquiries lately, was obliged to abandon them
without having reached conclusions which he could put forward
with any confidence; so far as they went, however, his inquiries
seemed to show that there was not good reason to declare that
such marriages had any ill effect.1_ Inasmuch as the wisdom of
mankind is greater than the wisdom of any individual in any
matter of common ‘experience, where no special means of

1 Journal of Statistical Society, June 1875,
m1.] THE CAUSATION AND PREVENTION OF INSANITY. 121

observation have been used, because the area thereof is so much
greater, the numerous springs which feed it flowing into the
common receptacle from all quarters and in all ages, I cannot
help thinking that we ought justly to attach great weight to the
prohibitions of intermarriages of near of kin which have been
made by all sorts of peoples in all times and places: they are
apparently an argument of the universal belief of their ill
effects. Amongst the lower races the range of prohibition is
much greater than in the civilised world, extending to the most
distant relatives by blood. Certainly the popular conviction
nowadays is that such intermarriages are more prone than not-
akin marriages to breed idiocy, insanity, and deaf-mutism. Who-
soever wishes to test the opinion with animals let him try
experiments with a select breed of pigs, breeding in and in for
several generations, and never crossing them with any strain
from without, and he will find in full time, if his experiments
coincide with mine accidentally made once, that his sows have
no young or only two or three at a litter, and that they are
very likely to savagely worry those which they have: that he
must, if he would go on keeping pigs, cross or change his breed.
For the last dozen years or so a record has been kept of the
number of mares among racers which have proved barren or
have prematurely slipped their foals; and it deserves notice,
Mr. Darwin says, as showing how infertile these highly nurtured
and closely interbred animals have become, that not far from
one third of the mares fail to produce living foals.

The main or only argument which those who reject the
popular belief put forward is to point to some remarkable in-
stances, such as the celebrated racehorse Eclipse, of the higher
qualities of the kind in the products of close interbreeding.
Granting the special qualities developed in these cases to be of
as high a nature as they are assumed to be, all that the ex-
amples really prove is that sometimes interbreeding has no bad
effect; they prove nothing with regard to the question whether
the general results of interbreeding are not bad. The lesson
which we ought to learn from them is to go beneath the general
fact of interbreeding, and to search for those more intimate
and special conditions which determine good results in a few
122 PATHOLOGY OF MIND. (crap.

instances, and bad results in many other instances; not to stay
satisfied with the bare experience of interbreeding, but to dis-
cover the ill conditions which, sometimes failing, commonly
accompany it.

A theory that has been propounded to explain the different
effects of interbreeding is that when there is any strain of weak-
ness in the family, such as madness, or deafness, or consumption,
it intensifies the bad elements, and so causes disastrous results ;
wherefore when the sexual elements which combine are per-
fectly sound and stable no ill consequences ensue. Mr. Darwin’s
recent patient and careful inquiries into the effects of cross and
self-fertilization in the vegetable kingdom are most instructive
in this relation. They have shown that plants gain distinct
advantages from cross-fertilization in larger and better growth,
in increased capacity to resist adverse external circumstances,
and in increased fertility ; and that the introduction of a fresh
stock to remedy the evils of interbreeding is as marked in
plants as it has long been known by breeders to be in animals,
He has come to the conclusion that the advantages of cross-
fertilization are the result, not of any mysterious virtue in the
union of distinct individuals, but of the different conditions
to which the individuals have been subjected during pre-
vious generations, and to the differentiations which have been
thereby produced in them ; for he has noticed that cross-fertili-
zation by plants that have been in similar external conditions
is not beneficial. From want of such differentiations he believes
it is that self-fertilization works injuriously. Applying this
doctrine to the interbreeding of animals we shall conclude
that the bane of near-akin intermarriages springs—first, from the
persons having inherited similar peculiarities of nature, and,
secondly, from their having been brought up in similar external
conditions, whereby the peculiarities have been fostered and no
variation has been elicited. This being so, it is plain that the
results need not always be bad; if there are innate essential
differences between cousins, or if, not being much different
essentially, they have been bred and reared in very different
conditions, there will be such wholesome differentiations of
natureS as to obviate any tendency to the exaggeration of
wu] THE CAUSATION AND PREVENTION OF INSANITY. 123

peculiarities by intermarriage, and the results may be excellent,
Breeders are accustomed to separate male and female animals
of the same offspring early in life, and to put them in
widely different conditions, when they intend them to inter-
breed; then they get good results. This agrees with the
aphorism of Hippocrates, that we ought to change the constitu-
tions of individuals in order to prevent the diseases to which
they are hereditarily predisposed, which is to be done, he
says, by placing them in different circumstances from those
by which their parents were surrounded.

It will not be amiss to bear in mind, when drawing con-
clusions from observation of the results of animal interbreeding,
that the breeder’s object often is to exaggerate and fix a parti-
cular variation or peculiarity of the animal which is advanta-
geous not to it, but to him, or only to it through him, not to
breed the completest animal of its kind, or to cultivate a varia-
tion which might suit the animal best: a racehorse is not fit for
much else besides racing, nor a certain breed of sheep fit for
much else except to get fat upon turnips. We cannot apply that
principle incontinently to human beings, in whom on the whole
it would seem best not to exaggerate a particular quality, but
to breed as complete a nature as possible, a being capable of
fair development all round.

Another caution may fitly be suggested—namely, to take
heed not to over-estimate the range of the limited differentia-
tions which different conditions of life can produce, within the
terms of their lives, in two persons of the same family whose
natures are alike fundamentally ; for development can only pro-
ceed upon the lines laid in the nature, following its radical
tendencies, and all variations which different external con-
ditions can produce will be superficial and transitory, having
small influence in interbreeding compared with the deep and
permanent sameness of nature. Try as hard as one can to
quell nature, one cannot quench it; it will come out in the
critical moments of life, and will show itself in hereditary
transmission. It is possible that a man may resemble his aunt
more than his father or mother, and that his female cousin,
whose mother the aunt is, may be very like her mother ; and if
124 PATHOLOGY OF MIND. [caap.

they two marry, the result might conceivably be as bad as if
brother and sister married ; but if the two were as unlike as
two persons who were not in the least akin to one another, by
reason of their representing different lines of the ancestral
pedigree, then there might be little or no risk. Even in that
case, however, it is proper to remember what has been said con-
cerning the latency of qualities in the individual of one genera-
tion which may nevertheless blossom in his offspring ; and the
possibility that the union of two unlike cousins might chance to
issue in the development of some of these latent like qualities.
Prudence would dictate the avoidance of intermarriages of near-
a-kin in all cases, and particularly so in those cases in which
there is not distinct evidence of radical differences so great as
those which there are between persons not in the least related
to one another.

This theory of the mode of operation of interbreeding agrees
with what was previously said concerning the sexual union of
unsuitable natures who were not related to one another by
kinship. When two persons of mean, suspicious, and distrust-
ful character marry they are likely to intensify the antisocial
peculiarity, which may culminate in such a want of balance in
the offspring that he cannot mix at all with his kind, is a com-
plete discord in nature. In like manner when marriage takes
place between two persons of an intense but narrow artistic or
poetic temperament, whose thin idealistic aspirations, miscalled
great imagination, are not informed by that sincere and whole-
some converse with realities which lays up a capital of sober
sense—in whose minds the emotional element has, so to speak,
run to seed—they are likely enough to breed an unstable pro-
duct, which may be looked upon as a pathological evolution of
their natures. The further misfortune is that the natural
tendency to an intensification of the neurotic type, declaring
itself by a sympathy of feelings, tastes, and pursuits, draws such
persons to cultivate each other’s society and so to fall in love
and marry. Or if a person of this temperament should marry
a woman of sounder and more sober temperament who takes a
wholesome view of the exigencies and enjoyments of life, his
narrow self-feeling will be much hurt, he will wail at what he
ul] THE CAUSATION AND PREVENTION OF INSANITY. 125

suffers from want of sympathy and of appreciation, and will
perhaps separate from his wife on the ground of incompatibility.
Then again these persons choose by a natural affinity those
external circumstances of life which are suited to foster rather
than to check the special tendencies of their natures, not
enduring repugnant circumstances and getting the benefit of
them in wholesome discipline and self-culture, as a sounder and
wiser nature would; they solicit not differentiations but in-
tensify peculiarities of nature until these become pathological.
They do consciously, in fact, what is done blindly when family
peculiarities are intensified by intermarriages of near of kin.
Lastly, they mismanage their children as they.mismanage them-
selves, training them, wittingly or unwittingly, along the lines
of their abnormal tendencies. No wonder, after such prepara-
tion and training, that a being is developed eventually of so
irregular and unstable a nature that he is practically a morbid
element and can take no part in the functions of the social
organism.

Those who have made a study of the causes of deaf-mutism
are satisfied of the ill effects of blood-kinship of parents. Some
affirm that there are more cases of congenital deafness from
the marriage of first cousins than from all other causes put
together; while others think congenital deafness in one or
both parents a more fruitful source of congenital deafness than
any other. Certain it is that it is a common thing, when
enquiring about the relatives of pupils in the different institu-
tions for the deaf and dumb, to hear that a parent, or an uncle,
or an aunt, or a cousin was congenitally deaf. It is obviously
in those cases in which there is a tendency to deafness in the
family that the marriage of first cousins will be most in-
jurious, because it will be likely to intensify the defect, but
why such intermarriage by itself, when there was no tendency
to deafness in the family, should occasion it, we know not any
more than we know in the least why blue-eyed cats should be
deaf. There are correlations of organic structure and function,
physiological and pathological, which we must be content to
observe and note for the present without being able to give the
least explanation of them. Deaf persons are prone to marry
126 PATHOLOGY OF MIND. (cu. 111.

those who are similarly afflicted ; being unable to mix com-
fortably with persons who can hear, they are drawn tu others
like themselves with whom they can converse on equal terms,
and so intermarry, propinquity and sympathy breeding love, and
transmit the evil from generation to generation. The advocates
of the “German” system of teaching and training the deaf
and dumb—the system which is based upon articulation and
lip-reading—claim one advantage of it to be that it tends
to prevent such intermarriages, as it enables the deaf to ap-
prehend what is said by perception of the movements of the
lips, and so to mix better with their fellow-creatures. In like
manner, it is a right training to remove a person of an in-
sane temperament from habitual intercourse with a person of a
similar temperament, and to subject him to quite other external
influences, inasmuch as the change is fitted, by fostering
variations of character, to produce a more stable nature, and, by
widening his circle of social intercourse, to lessen the proba-
bility of marriage with a similarly constituted person.

With these remarks concerning consanguineous marriages I
pass from the consideration of the antecedent conditions which
lay the foundation of a predisposition to insanity in the indi-
vidual, and go on to consider the conditions of life which
favour its development. One may take it to be broadly true
that the circumstances which augment a predisposition to in-
sanity, so that the disease ultimately breaks out, are just the
circumstances which are calculated to generate it de novo—
namely, all those things which help to put an individual out
of healthy relations with his social and physical surroundings.
CHAPTER IV.
THE CAUSATION AND PREVENTION OF INSANITY (continued).

Conditions of Life.—In dealing with the subjects which may
be brought under this comprehensive heading it will be necessary
to be as brief and concise as is consistent with clearness.

A question has been much discussed, and is not yet settled
satisfactorily, whether insanity has increased with the progress
of civilisation and is still increasing in the community out
of proportion to the increase of the population. Travellers
are agreed that it isa disease which they seldom meet with
amongst barbarous peoples. But that is no proof that it does
not occur, Among savages those who are weak in body or
in mind, the sick and the helpless, who would be a burden
to the community, are often eliminated, being either killed
or driven into the bush and left to pevish there ; certainly the
weak units are not carefully tended, as they are among civilised
nations. In this way not only is the amount of existing insanity
rendered small, but its propagation to the next generation is
prevented. Admitting the comparative immunity of uncivilised
peoples from insanity, it is not difficult to conceive reasons for it.
On looking at any table which sets forth the usual causes of the
disease, we find that hereditary predisposition, intemperance,
and mental anxieties of some kind or other cover nearly the
whole field of causation. From these three great classes of
causes savages are nearly exempt. They do not intermarry,
the prohibition of marriage extending among them to distant
blood-relations, and, as I have just pointed out, they do not
much propagate the disease from one generation to another,
128 PATHOLOGY OF MIND. [cHaP.

because it is got rid of to a great extent among them by natural
or artificial means of ‘elimination. Secondly, they do not
poison their brains with alcohol, at any rate not until the
white man brings it to them; when they do obtain it, they no
doubt abandon themselves to great debauches, but they cannot
obtain the regular supply which would enable them to keep
their brains day after day in a state of artificial excitement ;
and it may fairly be questioned whether alcohol, however and
in whatever quantities it may be taken, is so likely to produce
mental derangement in the undeveloped brain of a savage,
which has so little mental function to perform, as in the more
complex and specialized structure of a civilised brain.1 Lastly,
the savage has few and simple wants springing from his appetites,
and them he gratifies: he is free from the manifold artificial
passions and desires which go along with the multiplied indus-
tries, the eager competitions, the social ambitions of an active
civilisation ; he is free too from the conventional restraints upon
his natural passions which civilisation imposes, and suffers not
from a conflict between urgent desire of gratification and the
duty to suppress all manifestations thereof, a conflict which
sometimes proves too great a strain upon the mind of a civilised
person.

On the other hand, it may be thought that the savage
must suffer ill consequences from the unrestrained indulgence of
his fierce sensual passions. But it might not be amiss to con-
sider curiously whether savage nudity provokes sensuality so
much as civilised dress, especially dress that is artfully designed
to suggest what it conceals. There is no scope for the imagina-
tion where nothing is concealed and suggested, and it may be that
clothing is sometimes a stimulus to immodest thoughts, and that,
like the conventional covering of the passions, it infames desire,
Be that as it may, the savage is not disquieted by fretting social
passions: with him there is no eager straining beyond his
strength after aims that are not intrinsically worth the labour

1 Cameron, in his Journey across Africa, says that he met with one man
only who was suffering from delirium tremens: it was the only instance-
of this disorder which he saw in Africa, though drunkenness was common,

The supply of pombé, the intoxicating liquor, often falls short, because the
corn from which they make it is not abundant,
iv.) THE CAUSATION AND PREVENTION OF INSANITY. 129

and vexations which they cost, no disappointed ambition from
failure to compass such aims, no gloomy dejection from the
reaction which follows the successful attainment of an over-
rated ambition, no pining regrets, no feverish envy of com-
petition, no anxious sense of responsibility, no heaven of
aspiration nor hell of fulfilled desire; he has no life-long
hypocrisies to keep up, no gnawing remorse of conscience to
endure, no tormenting reflections of an exaggerated self-
consciousness ; he has none, in fact, of the complex passions
which make the chief wear and tear of civilised life. His
conscience is a very primitive affair, being no more than a
sense of right attaching to the beliefs and customs of his tribe,
but such as it is he seldom goes against it; he may cheat, lie,
steal, violate all the dictates of a true moral sense, especially
in his relations with the members of other tribes; but he obeys
his tribal conscience, as the animal obeys its instinct, without
feeling a temptation to violate it. He is extraordinarily con-
servative, the custom of his fathers being for him the fullest
justification of any belief or practice, however monstrous or
irksome; he is free therefore from the perils which to unstable
natures lie in the excitement produced by revolutionary change
and in the adjustment to new relations exacted thereby. So it
comes to pass that he is not subject to the powerful moral
causes of mental derangement which act upon the civilised
person, and that he cannot suffer from some of the forms of
derangement which afflict the latter.

These considerations favour the accepted notion that insanity
is legs common among uncivilised than among civilised peoples,
and that there is an increased liability to mental disorder going
along with an increase in the complexity of the mental organiza-
tion. Certainly it is in accordance with common sense to
suppose that a complex machine, like the civilised brain, which
is constructed of many special and delicate parts working
together in the most nicely adjusted relations, will be exposed
to more risk of derangement of action and be more likely to
go wrong than a simpler and coarser machine, the less various
parts of which have less fine and complicated relations. As
there is a greater liability to disease and the possibility of
130 PATHOLOGY OF MIND. (cHaAP.

many more diseases in a complex organism like the human body,
where there are many kinds of tissue, an orderly subordination
of parts, and a working of the whole in every part and of every
part in the whole, than in a simple organism where there is
little differentiation and less complexity of structure; so in the
complex mental organization having the manifold special and
complex relations with the external which a state of civilisation
implies there are plainly the occasions of more easily produced
and more varied derangements than in the comparatively simple
mental organization of the savage. We might expect that
mental sufferings would be as few and simple in an infantile
stage of society as they are in the infancy of the individual,
and the morbid outcomes of them as few and simple also.
The native Australian, who has not in his language any words
for vice and justice, nor in his Jife any true moral relations,
having no such ideas as the words express and no such senti-
ments as social relations stir in an ordinarily intelligent
European, cannot ever present an example of true moral
insanity; before he can undergo such moral degeneration he
must first be humanized and then civilised; mental organiza-
tion must precede mental disorganization! That degenerate
nervous function in young children manifests itself in convul-
sions rather than in mental disorder; that the lower animals
seldom suffer from mental disorder; that it is of comparatively
rare occurrence among savages, and that it takes one of two
or three simple forms when it does occur among them—are
facts which are owing to one and the same cause, namely, a
want of development of the mental organization. As is the
height so is the depth, they are opposite and equal: with the
progress of mankind to a higher stage of evolution there are cor-
relative possibilities of retrograde change; the weaker members
who cannot bear the strain of progress will fall by the wayside;
and an increased quantity as well as an increased variety of

1 A particular sense, it is true, may be more acute in a savage than in
a civilised person, e.g. sight, hearing, or smell, as is the case also in the
animal ; but neither in savage nor animal has any one of these senses the
delicate shades and varieties of susceptibility which it has in the civilised
person, who may accordingly have varieties of hallucinations of them,
when disordered, which the savage cannot have,
w.] THE CAUSATION AND PREVENTION OF INSANITY. 181

mental derangement will bear witness that the individual
perishes, while the race grows more and more.

Rising some steps higher than savages to a people which,
having long ago reached a certain level of civilisation, has ever
since remained stationary at it, we find it stated that though
diseases of the nervous system are by no means uncommon
among the Chinese, cases of mental alienation are comparatively
few—that is to say, if suicides are not counted as madness;
for the Chinese will go to his death by suicide as quietly and
methodically as he would go to his bed! Perhaps this in-
frequency of insanity is what might have been expected from
the natural character of the Chinaman, who is placid, steady,
equable, nowise disquieting himself about business, religion, or
politics, but doing his work in a calm methodical way, and
accepting good or ill fortune alike with equanimity. It must
be borne in mind, however, that lunatics are very harshly
treated in China, being usually tied up, sadly neglected, and
cruelly used by their friends and relations; and this sort of
treatment cannot fail to lessen the number of existing cases,
apart from any question as to the number of occurring cases.

Alarming statements are often made concerning the rapid
increase of insanity which is supposed to be going on year by
year in civilised countries; and the figures which are quoted
certainly look formidable. In 1844 there were in England and
Wales 20,611 registered insane persons; in 1859 the number
had risen to 36,762; in 1869 it was 53,177; and on the Ist
January, 1878, it was 68,538. Or, calculating the proportion of
idiots and lunatics to the increasing population, it was, in 1859,
18:67 to 10,000; in 1869, 23:93; on the 1st January, 1878,
27572 The broad truth is that there is about one registered
insane person to 365 of the population now, while the propor-
tion in 1859 was one in 540. The very greatness of this
increase, however, might well raise a suspicion that it has not
been due mainly to an increased production of insanity in the
population ; for whether the course of human events during the
last quarter of a century has been good or bad, it certainly has

1 Journal of Mental Science, 1875, p. 31.
2 Thirty-Second Report of the Lunacy Commissioners, 1878,
a
227

132 PATHOLOGY OF MIND. [cHAP,

not differed so much from that of former times, or differed so
much and so capriciously during the quarter of a century, as
such a difference in the quantity of insanity, were it due to it,
would mean. Without doubt the main part of this increase is
owing to the more stringent regulations which from time to time
have been made and enforced for the registration and protection of
insane persons, whereby many that were never heard of officially

- at one time are now duly registered and counted. When the

admissions of each year into asylums are examined, which re~
present pretty fairly the numbers of occurring cases, it is observed
that a marked rise in the numbers has followed the enactment
of some new Act of Parliament, the direct effect of which has
been to force insane paupers into asylums: the increase has not
been steadily progressive, but has taken place rather by leaps
and bounds which have answered the stimulus of each fresh
parliamentary enactment. It will be noted furthermore that
the increase is mainly among paupers, since the ratio of private
lunatics to the population (per 10,000) has been as follows :—

Year— 1859. 1865. 1873. 1874. 1875. 1876. 1877. 1878.
Males 2°81 3°16 3°43 3°49 3°47 3°44 3°42 3°45
Females 2°26 2°34 2°61 2°69 2°72 297 2°78 2°76

Total 2°5 2-74 3°01 3°08 3°09 3°10 3°09 3°09

Thus there has been little change during the last five years—an
increase of only half a lunatic in 10,000 persons since 1859.

On examining the admissions of private patients each year
and calculating their ratio to the increasing population of the
country, it will be found that the figures do not point to a
steadily increased production of insanity in the non-pauper
class; and they are the more significant when it is borne in
mind that the more numerous and powerful causes which are
supposed to be at work to augment the liability of the com-
munity to mental disease will affect the classes from which
private patients come at least to an equal degree with, and
probably to a greater degree than, the classes which supply the
pauper patients. It cannot be said that they yield real support
to the opinion of the alarmists that so many more persons go
mad now than in the days of our grandfathers.
1v.] THE CAUSATION AND PREVENTION OF INSANITY. 133

Agricultural counties furnish a larger proportion of lunatics
than manufacturing districts, and those counties in which the
wages are low, like Wilts, a larger proportion than those in
which the wages are high. Low wages of course mean poverty
and bad nourishment, and lunacy shows a distinct tendency to
go hand in hand with pauperism. Moreover the stagnant, un-
intellectaal life of an agricultural labourer is less conducive to
mental health than the more active and varied intellectual life
evoked by the pursuits and interests of a manufacturing town.
Mental exercise is the true foundation cf mental health; and
when a person who by virtue of being born of civilised parents
has inherited the mental organs and aptitudes fitting him for a
certain height and variety of moral and intellectual development,
makes no use of them, but allows them to waste and degenerate,
so initiating decay of his higher nature, he is in favourable
conditions for the occurrence of some form or other of more
positive mental derangement. He is not like the savage who,
having no such inheritance, suffers not any ill consequences
from mental stagnation; being the heir to ages of culture, he
has the responsibilities of his inheritance; he cannot divest his
nature of the privileges of its higher birth, nor himself of the
duty to exercise them fitly, nor exempt himself or his posterity
from the sure penalties of neglect of them.

The candid observer who surveys the ways of men in the
state of modern civilisation cannot choose but confess that
many of their most cherished aims are unworthy of the zeal
and energy with which they are pursued. They may be summed
up compendiously in the words “to get on in the world,” by
which is mostly meant to get rich and to rise a step or two in
the social scale. Without doubt it is a good and excellent
thing that there should be so much desire and energy displayed
in straining for an aim of some sort, forasmuch as, were there
not, no progress could be made; but it is oftena grievous thing
as regards the individual and his family that his aims and work
are not more consciously and systematically altruistic ; that he
does not realise plainly that he 1s a member of a social body
whose individual functions are subordinate to the welfare of the
whole. His practical worship being to get money and enjoy it,
134 PATHOLOGY OF MIND. (cap,

attested as real religion is, by faith and works, and his professed
religion, not attested by faith and works, being to despise the
things of this world and to look upon his sojourn in it as merely
a preparation and a discipline for a life to come, his actual aim
is to serve two masters who require quite opposite services,
holding to the one without despising the other. Unhappily for
success in this course, such a divided allegiance has been pro-
nounced by high authority to be impossible; and the result of
the radical inconsistency of aims is a want of fundamental
harmony and sincerity of nature, which is a poor defence against
the assaults of adversity: like a house, the foundations of which
are not. solidly laid on one consistent plan, it will be likely to
fall when the storm comes. A sincere and searching examina-
tion of the quality of the aims upon which he concentrates the
real hopes, aspirations, and energies of his life, and of the
foundations of the beliefs which, professing, he does not act
upon, and of those which, professing not, he does act upon,
were he capable of it, could not fail to reveal to many a
one how unstable is the foundation of his mental structure,
and how ill fortified it is to withstand the stealthy advances
and direct onslaughts of disease.

It cannot be disputed that the pursuit in which a man is
engaged habitually, which is ever in his thoughts, and to suc-
cess in which he bends all his energies, does modify his character,
and that the reaction upon character of a life spent solely in
the business of getting rich is- hurtful. It is not only that
the fluctuations of fortune sometimes disturb or overthrow the
balance of a mind that is engaged in large speculations, or
that failure in some great crisis, frustrating the hopes and the
work of a life, prostrates the individual’s energies and drives him
melancholic, but it is that the narrow selfishness of his life-aim,
sapping with steady certainty the feelings and responsibilities
of a larger human brotherhood than mere family clannishness,
weakens and withers the altruistic elements of his nature, and
so in his person deteriorates the nature of humanity. There is
no more efficient cause of mental degeneracy, perhaps, than the
mean and vulgar life of a tradesman whose soul is set entirely
upon petty gains; who, under the sanction of the customs of
v.] THE CAUSATION AND PREVENTION OF INSANITY. 185

his trade, practises systematic fraud and theft; and who thinks
to outweigh the iniquities of the week by the sanctimonious
observance of the Sabbath. Such an one is not likely to beget
children of sound moral constitution; and for him to hope to
found a family which shall last is little better than to hope to
build on quicksand a house which shall stand. The deteriora-
tion of nature which he has ‘acquired will, unless a healthier
female influence chance to countervail it, be transmitted as an
evil heritage to his children, and show itself in some form ol
moral or intellectual deficiency ; perhaps in extreme duplicity
and vice, perhaps in outbreaks of positive insanity.

The maxims of morality which were proclaimed by holy men
of old as lessons of religion indispensable to the well-being and
stability of families and nations, are not really wild dreams of
inspired fancy, nor the empty words which preachers make
them; founded on a sincere recognition of the laws of nature
working in human events, they were visions of eternal truths
of human evolution. Assuredly the “everlasting arms” are
beneath the upright man who dealeth uprightly, but they are
the everlasting laws of nature which sustain him who, doing
that which is lawful and right, leads a life that is im faithful
harmony with the laws of nature’s progress; the destruction
which falls upon him who dealeth treacherously and doeth
iniquity, “observing not the commandments of the Lord to
obey them,” are the avenging consequences of broken natural
laws. How long will it be before men perceive and acknow-
ledge the eternity of action, good or ill, and feel the keen sense
of responsibility and the strong sentiment of duty which so
awful a reflection is fitted to engender? How long before they
realise vividly that under the reign of law on earth sin or error
is inexorably avenged, as virtue is vindicated, in its consequences,
and take to heart the lesson that they are determining by their
conduct in their generation what shall be predetermined in the
constitution of the generation after them? Crime, vice, mad-
ness, every unwelcome sort of ill-doing, comes by law, not by
chance, not by casualty but by causality: “Shall there he evil
in a city, and the Lord hath not done it?”

Religion.—Among the conditions of life which have a vital

7
136 PATHOLOGY OF MIND. [CHAF,

influence upon character, either to strengthen or to weaken it,
must be reckoned the religious atmosphere in which a person is
born and reared. The mighty question of the working of reli-
gion generally, apart from any particular form of religion, upon
the minds of men for good or evil I forbear to enter seriously
upon, not only because of the difficulty and delicacy of the sub-
ject, but because it would be impossible to do justice to a matter
of such transcendent importance in a brief and incidental manner,
even were the occasion and the ability ready. In the outset it
would be necessary to consider what effect a belief in the super-
natural, as almost universally harboured by mankind, has had
upon the growth and development of human thought and upon
the formation of human character; whether its tendency on the
whole has been and is now to strengthen the understanding and
to further its development, or to weaken and stunt it. When
one looks at the desolating effects of superstitious customs based
upon beliefs in the supernatural among savages at the present
day, which must plainly shut out any chance of progress so long
as they last, and must from the first have instantly and ruth-
lessly quenched any impulse of progress that might show itself
in a particular individual, the indisputable answer might seem
to be that the tendency had been baneful. If we look again to
the earlier ages of Christendom, when Rome was ascendant and
its persecuting fires were in full blaze, and reflect that any
deviation from the routine of the established belief, were it ever
so good, was zealously extinguished as a pernicious thing,—the
logical theory of the Roman Church being that new doctrine
should be stamped out as a dangerous centre of infection,—we
may imagine in a lame fashion how many excellent impulses to
new developments of thought were extinguished as soon as they
showed themselves.

Furthermore, the celibacy of the priesthood and the numerous
monasteries that were thickly scattered over the country with-
drew from freedom of thought, from the true service of man-
kind, and from a legitimate share in the propagation of, the
race, many of the best men and women of the age; and the
rigid system of a uniform and changeless belief which was
forced and fixed upon the minds of men, barring all inquiries
Iv.) THE CAUSATION AND PREVENTION OF INSANITY. 187

into the phenomena of nature, could not fail to prevent intel-
lectual development. Poetry, painting, sculpture, and architec-
ture were the channels through which men of genius found
compensating outlets for the productive energies of their nature.
But notwithstanding that in their great works mankind happily
gained some compensation, the sceptical inquirer may ask
whether the art of a great painter might not have been put to
better purposes of human elevation than to paint the same
saints over and over again; and may hold that a few extraordi-
nary developments along the paths that were left open were not
an adequate set-off for the vast amount of intellect which was
systematically repressed by the prohibitions of authority. Full
freedom for the entire race to search, and know, and work in
whatever direction inclination may urge or occasion invite
would seem to be now the most certain foundation of human
progress.

But it is certainly not to be denied that a belief in a super-
natural intervention in human affairs might be useful at one
stage of human evolution, and indeed essential to social progress,
just as it is essential to a child’s welfare to believe in and respect
its own parents, who may nevertheless be actually unworthy of
respect, and yet may be mischievous at a later stage when it
has done its work and undergoes decay, the intellect having
outgrown it; the more so when it has been corrupted by the
interests of priestcraft and used to promote the ends of organized
imposture. The only present concern with the belief is to know
whether its influence upon the human mind is good or ill now;
whether it helps or hinders intellectual and moral progress. How
can it help if it be not true and be known to be not true? To
affirm that the course of nature may be capriciously interfered
with at any moment by a power which is outside nature, and that
the observed sequence of events is but a sequence at will, would
be, were it more than lip-doctrine, to take from man the most
urgent motive to study patiently the laws which are at work, in
order that he may bring his life into conformity with them, and
to weaken much or to destroy altogether the responsibility which
he should feel to make nature better through his means, which he
will do best by making the best of himself. It is the plain duty,
138 PATHOLOGY OF MIND, [cHap.

and should be the steadfast aim of man, to carry on in his future
evolution the evolution which has gone on in the past; and this
he can do only by recognition of the uniformity of nature.
Prayers and sacrifices to fetishes, material or spiritual, will not
help, for neither prayer nor sacrifice will obviate the consequences
of want of foresight or want of self-discipline, nor will reliance
on supernatural aid make amends for Jack of intelligent will.
Herein lies the imputable mischief of prayer, that it is an imbe-
cility of will; and when it acts, as it commonly does act, by
strengthening will in a reflex way to accomplish what is prayed
for, that is to say, through the energy imparted to will by the belief
that the prayer will be specially answered if it be well it should
be so answered, the sceptic might question how far it is a benefit
to get such effects by an illusion—in a way which is like what
children “make believe”? Whoever solicits by sacrifice or
prayer a happy issue of some venture, if he gets his wish, gets
it by the ordinary operation of natural law; the god whom he
addresses may be deaf, asleep, on a journey, it matters not in
the least to the result. Nor is there any more evidence that the
affairs of the spiritual world are not equally matters of law and
order; he who prays for the creation of a clean heart and for the
renewal of aright spirit within him, if he gets at last what he
prays for, gets it not as a miraculous gift from on high, but
through the ordinary laws of moral growth and development, in
consequence of painstaking watchfulness over himself and the
continual exercise of good resolves. Were he to fall down upon
his knees in the same way once or twice a day without praying,
and thereupon to calmly review his past conduct and to make
firm resolutions to do well for the future in that wherein he had
done ill before, the result would be the same. Nor could it fail
to be better for the strength and wholeness of human character
in the end that there should be entire sincerity in this matter.
‘Whatever then may have been its use in times past, what the
free inquirer has to consider now is, whether a belief in a fetish
does not mark a certain perversion or defect of intellectual deve-
lopment, and prayer or sacrifice founded upon it a certain per-
version or defect of will; whether the fostering of it does not
produce insincerity or mar unity of character; aud whether, as
iv.] THE CAUSATION AND PREVENTION OF INSANITY. 139

the human mind rises to a higher evolution, growing in insight
by more exact knowledge of, and in power by corresponding
adjustment to, those all-pervading laws of order and harmony
through which alone the supernatural is manifest, the invisible
made visible, a belief which is the prohibition of intelligent
inquiry and fatal to an independent human bearing will not
help but hinder intellectual development, will not strengthen but
weaken moral character. By holding notions which are not
founded on reason and cannot be reasoned about, inasmuch as
they are assumed to transcend or may actually contradict reason,
as a part of the common stock of its belief, the mind goes
counter to the very principles of its intellectual being, under-
mines its own foundations, proceeds with a fundamental incon~
sistency declaring itself in every phase of its growth. What
wonder that with the way so prepared and made ready it accepts
with ease, when illness comes, extravagant delusions that are
utterly contrary to reason !

But there is another side to the question which it would not
be right for the free inquirer to leave out of sight. It will be
said that the belief in an ever-present help in time of need is
a priceless stay and comfort in all the sorrows, needs, afflictions
and other adversities of life, and that it sustains in the hour of
trial many a sore-stricken and heavy-laden soul which, but for it,
would give way and strive no more. Certainly there are few ills
that have not some compensating element of good, and it were
strange indeed if a creed which has plainly been a necessary
phase of thought in the progress of mankind had been all mis-
chief. Here again, however, comes the solemn question for men,
whether it can be well for mankind now and in the long run to
have the help of so consoling a belief if it be not true? If it
be confessed practically, as it is by the daily course of every
man’s life, that no miraculous intervention ever disturbs the
serene and stern uniformity of natural law, that no helping
hand from on high is ever held out specially to raise up them
that have fallen, is not the harbouring of a belief in supernatural
aid likely to produce weakness by blunting the sense of respon-
sibility which a man has to be strong with his own strength,
and the profession of it liable to become an insincerity or a
140 PATHOLOGY OF MIND. [cHAP,

hypocrisy injurious to character? It may be a sad thing to
strike away that crutch which alone seems to support the feeble-
ness of humanity, but it is plain that for man to lean habitually
and heavily on a crutch is not the way to learn to walk firmly;
ke will do that best by risking many falls and by making more
skilful trials after each fall; and in like manner he who has to
learn and to do in a world of natural law will find his true
good in getting strength through suffering, skill through trial,
victory through obedience, and not in reliance on supernatural
interposttiens: which have hitherto occurred for the most part
where there was no need for their occurrence, the work being
done without them, and have failed to occur where they were
most wanted—where their help would have been not superfluous,
but serviceable. Itis easy to perceive that the savage is no better,
but worse, for the prayers and sacrifices which he makes to his
fetish ; and when the reason why he is not better but worse for
such ignorant reliance is sincerely considered, it will be seen
that it applies with equal truth to any one who puts faith in
any sort of fetish, it matters not whether spiritual or material.
That a supernatural power will interpose to save a man’s soul
alive who is not doing his own best to save it for himself is
as mischievous a superstition, guoad the soul’s welfare, as the
savage’s superstition that his fetish will preserve his body from
disease when he takes no pains to keep it in health himself is
hurtful to his bodily welfare: mental hygiene is impossible in
the one case as bodily hygiene is in the other.

No doubt it may be said’ that it would be impossible to
cultivate and satisfy the emotional element in human nature
and to kindle moral enthusiasm for the arduous toil of virtue
without a personal object of love and reverence; but it is an
assertion which may plausibly be disputed. Buddha had no per-
sonal God, yet he was filled with a deep and calm emotion which,
diffusing itself through every fibre of his being, inspired a life
of unparalleled self-renunciation and virtue. Spinoza had no
personal God, being deemed an atheist by most persons, but he
was unequalled in the simplicity and virtue of his humble life,
in his sincere love of truth, and in his earnest devotion to it,
An assembly of freethinkers and atheists will be sure to applaud
v.] THE CAUSATION AND PREVENTION OF INSANITY. 141

enthusiastically all expressions of human sympathies, moral
sentiments, and virtuous reflections. So long as man has
organic viscera he will have emotion enough, whatever his
beliefs or disbeliefs may be: there need be no fear that he
will lose his emotional nature and become a hard intellectual
machine when he no longer puts up prayers or offers sacrifices
to a personal God of like nature and passions with himself. If
he apply himself systematically to that reverential study of
nature which it is the aim of science to pursue; to that close
observation of and sympathy with her multitudinous and ever-
changing moods which artist and poet cultivate; if he cherish
that living interest in human sufferings, and aspirations, and
doings of which every being has more or less, but which rises
in some men to a lofty height of moral enthusiasm; if he culti-
vate that sense of oneness with all nature which philosophy
opens, and to which poetry gives its sublimest expression—he
will have room enough for all the emotion which he can profit-
ably feel and express. When I consider this matter it always
appears to me that Shakespeare was not wanting in depth of
feeling or in profitable application of it, and I cannot sympathize
therefore with the apprehension that human nature will be robbed
of its emotion so long as it has the whole of nature, physical
and human, to spend it upon.

It is purely a gratuitous and unfounded calumny to impute that
man who has risen to the height of his present moral stature by
feeling with his kind and working for it, will cease to feel with
it and to work for it when he ceases to pray to a personal God
who has created countless multitudes of his kind to foredoomed
torture through all eternity for sin of which they are innocent!
If a crowd is assembled to see a brave man fling himself into
the raging sea and battle with its wild waves in order to save
human life, or do any other feat of danger and skill—be it only
to climb a greasy maypole—we observe how excited and sym-
pathetic it becomes; and shall we suppose that the long toil of
humanity along that most steep and arduous moral path which
leads to its higher evolution—the failures of those who fail and
the successes of those who succeed—will quicken no feeling,
kindle no enthusiasm? It is absurd to think that mankind
142 PATHOLOGY OF MIND. [CHAP

will cease to feel emotion, even though it should say in its heart
that there is no personal God; it cannot help firing morality
with emotion ; and it may be that a healthier feeling will be
quickened and a sounder emotion stirred when it is no longer
infected by the taint of superstition. If it come to pass that
man is robbed of that narrow and intensely personal feeling
which is poured out in apprehensive wails about the salvation
of his own soul, or in emotional shrieks by writers of the
spasmodic and fleshly school of poetry, or in morbidly subtile
analysis of overstrained feelings of any sort, there will be no
harm done; for it is a sort of emotion that is as unwholesome
as a hysterical ecstasy. Let him attain instead to that calmer,
deeper, wider, and healthier emotion which is subordinated to
pure insight into the harmonies of nature and to philosophical
survey of its serene order, and is applied objectively to give
warmth of tone and colour to their expression in words. The
creed of nature is not shrieking self-assertion, but serene self-
swirender ; not man against the universe, but man as a part of
the universe ; not individual life with the single aim of securing
a blissful immortality, but individual life in wholesome subordi-
nation to the general life.

In matter of fact it may be doubted whether any one ever
does feel the strong personal love of a supernatural power which
he persuades himself that he feels; whether it is not a delusion
and asnare; whether, when he imagines he has wrought himself
into the proper emotional mood of mind, he has not really
wrought himself into an artificial, vague, and somewhat morbid
state of feeling, which is by no means so holy as he believes.
How there can be'the definite relation of a genuine healthy feel-
ing between a finite natural being and an infinite supernatural
being passes comprehension when the attempt is sincerely made
to realize what is meant. It would be to feel the unfeelable,
to know the unknowable, to limit the illimitable—a contradic-
tion in terms, a nonsense.

Here I am brought to take notice of what appears to be
sometimes a great evil incident to the ordinary teachings of
religion—namely, the extreme stress which is laid upon the
importance of the individual, the consequent habit of looking
v.}) THE CAUSATION AND IREVENTION OF INSANITY. 148

to the welfare of his own soul as his chief concern, and the
cultivation of a regular introspection of his feelings as a means.
All these things are adapted to develop an exaggerated self-feeling.
The probings of the heart, the gloom of repentance, the stings of
remorse, the musings of meditation upon matters of conscience,
which are fostered as signs of a keen and sensitive conscience,
are often the unwholesome outcome of an exaggerated self-con-
sciousness, and are more likely to lead to madness than to good
relations and sound work in the world. One notices a marked
subjective phase of feeling in most persons soon after the
development of puberty, shown in indefinite longings, dreamy
poetical moods, and all sorts of vague aspirations ; consequently
it is a period of life when the mind is in a state favourable to
introspection, when it easily acquires the habit, and when the
habit runs quickly to excess. Women are naturally more prone
to religious worship than men, and more apt to fall into a
morbidly subjective habit, first, because of the preponderance
of the affective life in them, and, secondly, because they have
not the distracting and correcting and intellectually hardening
influences of outside interests and pursuits which men have.
Hf unmarried women chance to come, as by reason of these
conditions they are apt to do, under the ignorant and misap-
plied zeal of unwise priests who mistake for deep religious
feeling what is really morbid self-feeling springing at bottom
from unsatisfied instinct or other uterine action upon mind,
the mischief is greatly aggravated.

It were well if those who make it their business to guide
the consciences of mankind through the manifold changes and
zhances of life were to be at the pains to inquire how much
supposed religious feeling may be due to physiological causes,
before they sanction or enjoin a repeated introspection of the
feelings. He whose every organ is in perfect health knows not
that he has a body, and only becomes conscious that he has
organs when something wrong is.going on; in like manner
a healthy mind in the sound exercise of its functions is little
conscious that it has feelings, and only gets very self-conscious
when there is something morbid in the processes of its activity,
The ecstatic trances of such saintly women as Catherine de
144 PATHOLOGY OF MIND. [cuar.

Sienne and St. Theresa, in which they believed themselves to
be visited by their Saviour and to be received as veritable
spouses into his bosom, were, though they knew it not, little
else than vicarious sexual orgasm; a condition of things which
the intense contemplation of the naked male figure, carved or
sculptured in all its proportions on a cross, is more fitted to
produce in young women of susceptible nervous temperament
than people are apt to consider. LEvery experienced physician
must have met with instances of single and childless women
who have devoted themselves with extraordinary zeal to
habitual religious exercises, and who, having gone insane as a
culmination of their emotional fervour, have straightway ex-
hibited the saddest mixture of religious and erotic symptoms
—a boiling over of lust in voice, face, gestures, under the pitiful
degradation of disease. On such persons the confessional has
had sometimes a most injurious effect, more especially in those
churches which, aping Romanism in their ritual, have not placed
confession under the stringent regulations and safeguards with
which the Roman Catholic Church surrounds it. The fanatical
religious sects, such as the Shakers and the like, which spring
up from time to time in communities and disgust them by the
offensive way in which they mingle love and religion, are
inspired in great measure by sexual feeling: on the one hand,
there is probably the cunning of a hypocritical knave or the
self-deceiving duplicity of a half-insane one, using the weak-
nesses of weak women to minister to his vanity or to his lust
under a religious guise; on the other hand, there is an exag-
gerated self-feeling, rooted often in sexual passion, which is
unwittingly fostered under the cloak of religious emotion, and
which is apt to conduct to madness or to sin. In such case the
holy kiss of love owes its warmth to the sexual impulse which
inspires it consciously or unconsciously, and the mystical
religious union of the sexes is fitted to issue in a less spiritual
union,

Without doubt an excessive development of the emotional life
in any other direction would be equally pernicious. All that the
unwise religious teacher can be blamed for is his disposition to
foster the egoistic development of emotion, without considering
v.] THE CAUSATION AND PREVENTION OF INSANITY, 145

its real origin, by the overwhelming importance which he
teaches the individual to attach to himself and his destiny.
Instead of urging him to lessen the gap between himself and
nature until he loses self in a sympathetic oneness with nature,
he stimulates him to widen it more and more until he rises to
the insane conceit of himself as something entirely distinct from
nature—an unrelated, spiritual essence, for whose benefit: the
universe and all that therein is has heen specially created.
Assuredly were not man now, as he always has been, instinc-
tively wiser than his creeds, were he not moved by a deeper
impulse than consciousnesss can give account of, he would
make no progress in evolution.

On comparing the best pagan modes of thought with Christian
modes of thought a doubt might be raised whether the latter
have not sometimes been less favourable to a calm and stable
mental development. Contrast, for example, the widely different
views and feelings with which death was regarded, To the pagan
it was the twin brother of sleep, the youth with inverted torch,
the natural rest at the end of the long day’s task of life which
the wise man would not fear, but welcome; to the Christian it
was presented in all the horrors imaginable, as the consequence
and the punishment of sin, the king of terrors, the last enemy,
the opportunity of exulting fiends to clutch their shrieking prey,
the possible gate to unspeakable torments through all eternity. I
find it impossible to conceive the countless hours of torment,
the unspeakable agony of mind, which this doctrine must have
caused since it was first propagated: what quivering reflections,
what keen anguish of remorse, what agonizing apprehensions,
what torturing self-examinations, what appalling fears have been
occasioned in anxious and tender consciences by a doctrine
which, far outdoing in barbarity the most barbarous superstition
that savage ever conceived, is still preached from a thousand
pulpits in every civilised country, notwithstanding that there
is not a person of sincere understanding who rigorously analyzes
his thoughts and sternly realizes what the doctrine means can
say from the bottom of his heart that he believes it. Hope and
fear, which are based upon the self-conservative instinct in its
relation to the future, are two most powerful passions in human
146 PATHOLOGY OF MIND, [citap.

nature, and it is upon them that religion has fastened and works
with all the powerful machinery of its system; its aim and
effect being to produce not wholesome subordination of feeling
to reason, but an unwholesome predominance of emotion.
Happily human conduct has again shown itself wiser than
human creed: men concern themselves more about the most
trivial events of the actual to-morrow than about the most
momentous issues of the possible life to come; motives lose in
force in proportion as they recede in distance; and the fear of
punishment and the hope of reward after death, which always
seem to be possibilities afar off,do not work with any force
upon the hearts of the vast majority of those who profess to be
affected by them. Without doubt it does happen from time to time
that a person of anxious and foreboding temperament, brooding
over his sins, falls into a sort of spasmodic horror of the dread
eventuality of eternal damnation, and becomes melancholy-mad,
believing himself to have sinned beyond possibility of forgive-
ness and to be eternally lost; but in such case the religious
delusion is oftentimes no more than the convenient and suffi-
cient shape which the mental depression takes in order to get
adequate expression, and it is not unlikely that the person
would have ‘equally gone insane and have had some other
gloomy delusion if he had not known religious doctrine. A
more deep and widespread mischief attributable to the doctrine
of future rewards and punishments, is the deadening of the
feelings and the blinding of the intelligence of men to the
certain laws by which their sins, errors, and ill doings of
all sorts are avenged upon themselves or upon others in this
world, and to the stern responsibilities to observe and obey
which the reign of natural laws imposes upon them.

One consideration more, and I pass from this subject. Look-
ing to the exalted moral code which is inculcated as the essen-
tial rule of Christian practice, some attempt should be made to
weigh the actual effect on character of the solemn profession of
principles and precepts which appear to be too exalted to be
reconciled with the exigencies of practical life. The Christian
religion is a religion of passivity rather than of activity; it
teaches mankind how to suffer better than how to do in the
iv.] THE CAUSATION AND PREVENTION OF INSANITY. 147

world; and if its principles were faithfully carried wut in prac-
tice they could not fail in the end to leave the good man at the
mercy of the knave. It was a gospel which could be preached
with more consistency and sincerity to a world which was thought
to be close upon its end, when nothing better could be done than
to prepare for it, than it can be to a world which has gone on,
and goes on, as if it were never coming to an end. In commerce,
on the excliange, in political life, in all the departments of prac-
tical activity, a man must have another creed and another prac-
tice. On the one hand, then, he fulfils, as essential to his present
well-being, the law of natural selection, by which the strong
takes advantage of his strength and the weak is made to pay
the penalty of his weakness; on the other hand he professes, as
essential to his eternal well-being, the altruistic doctrine that he
should not lay up for himself treasure on earth, that he should
prefer his brother in all things to himself, that when he is smit-
ten on one cheek he should meekly turn the other also to the
smiter. But it cannot be conducive to the strength and harmony
of intellectual and moral character that there should be a funda-
mental contradiction between faith and works whereby life is
made a shifting compromise, or a systematic inconsistency, or
sometimes an organized hypocrisy ; and one cannot help thinking
that it would be well that, instead of a rule of life consisting
of natural selection irregularly and occasionally tempered by
Christianity, there should be established a fundamental. harmony
between religion and practice. If accepted doctrines will not
grow to new requirements they must be changed, since no doc-
trine can claim to bind rigidly the belief of mankind for all time,
or can so bind it without putting a stop to mental development.

These general reflections upon the working of religion upon
human character will indicate how little use it is to discuss, as
is sometimes done, whether insanity occurs more often in one
sect of Christians than in another. There are no statistics upon
which we can venture to place the least reliance to decide the
question. Any sect which fosters habitual emotional excitement,
or lends its authority to extraordinary displays thereof, will
favour the production of instability of mind and so predispose
fo the easy overthrow of its balance. When the religion is
148 PATHOLOGY OF MIND. [CHAP.

mainly a social observance which it beseems a person of respecta-
bility, willing to stand well with his neighbours, to conform to,
it will in this country most likely be the religion of the Church
of England, which suits well success in life and a respectable
sucial position; not exacting any show of zeal from nor im-
posing any galling yoke upon its members, for the most part
eschewing anything that is extreme, claiming only from its
bishops that they should evince no tendency to deviate into
originality or zeal, and, as an established religion in alliance with
social institutions and the governing classes, aiming to preserve
the established state of things. But it’ must honestly be ad-
mitted that this Church does not reach those who are in poverty
and affliction, whose daily lives are daily hard struggles to live,
who most need a gospel or glad message to solace and sustain
them. These, if they profess any religion at all, belong mostly
to one or other of the two religious divisions into which the two
extreme and opposite parties in the English Church insensibly
pass—to Roman Catholicism at the one end, or to one of the
sects of Dissenters at the other end; for the Church of England
stands as a Church of passage between Roman Catholicism and
Dissent, as all forms of Protestantism are logically creeds of
passage between Roman Catholicism and a complete emancipa-
tion from belief in the supernatural. In weighing, then, the
effect of religion as predisposing or not to insanity, we have
practically to do with Roman Catholicism, actual or abortive,
or with Dissent in one or other of its forms.

There is no reason to believe that the Roman Catholic religion
has any special tendency to produce insanity among those who
are within its pale. It does not encourage throes of emotional
spasm, its infallibility is a fast anchor for distressed souls to
hold by, and the morbidly tender conscience is eased sometimes
of the burden which weighs upon it by the clear sense, calm
judgment, and trained sympathy of an experienced priest who
dissipates exaggerated apprehensions and administers fitting
spiritual remedies.! Moreover, the assured belief that sins can
be remitted through penances, and that the priest is divinely

1 That is one side of the matter: an injudicious or dishonest priest,
encouraging morbid outpourings, may do infinite 1ischictf.
Wv.] THE CAUSATION AND PREVENTION OF INSANITY. 149

empowered to grant absolution from them, will not fail to have
a like comforting effect. A priesthood standing as mediator
between the trembling slave and his offended master, and in-
vested with a delegated authority to mitigate terrors, may not
be an altogether hurtful institution where a belief in the capri-
cious intervention of a supernatural power in human affairs
prevails: it is a compensating artificial support for the intellec-
tual feebleness and moral impotence produced by a debilitating
creed, the necessary complement of it. No unbiased mind can
doubt that the unquestioning faith demanded by priests and
accorded by disciples, and the pretence that all truth has been
delivered into the keeping of the Church from the beginning,
are inimical to the true interests of mankind, a hindrance to its
progress, and a standing menace to its dignity ; not a whit less
so than the unquestioning credence and trembling submission
which the savage yields to the claims of his fetish. Savage and
Catholic may boast of being untroubled by doubt, but they gain
their peace of mind at the cost of an arrest of the development
of the understanding.

The philosophical observer who has given close attention to
the extremer forms of Protestantism in their relation to charac-
ter, such as are known as Evangelicalism, must have noticed
how often they go along with an extraordinary insincerity or
actual duplicity of character. I mean not to insinuate that the
tendency of an evangelical faith is to engender duplicity of
character; the reason of the connexion probably is that per-
sons of that character are attracted naturally to a form of creed
which, making large use of the sort of emotion that springs
from self-feeling, yields them the gratification of a suitable
emotional outlet, and by the habitual employment of a con-
ventional religious phraseology keeps out of sight, or at any
rate veils thickly, the gross variance between high profession

_. and low practice which the use of a common language could

not well fail to bring clearly home. They use conventionai
language without ever sincerely analyzing its meaning, because
they find in it fit expression for certain narrow feelings that
have been associated with it, and are more comforted by the
phraseology than if they really understood it; it has become a
150 PATHOLOGY OF MIND. (crap,

shibboleth to them, the sign of special grace, like that blessed
word Mesopotamia, the sound of which yielded so much comfort
to the old woman of the village. They are not the conscious
hypocrites which they seem; they are inconsistent without
really feeling their inconsistency ; the two diverse developments
of their nature do not interwork, and they go on with an in-
coherence of character which they never realise, not otherwise
than as an insane person will go on quietly in a daily routine
of life that is utterly inconsistent with a fixed delusion which
he has all the while concerning himself. A nature of this sort
is well fitted to breed insanity; my experience, indeed, has led
me to look upon it as a singularly effective cause of degeneracy
in the next generation.

Admitting that a person’s religious profession is very much
the expression of his character aud of its mode of development,
and no more therefore the real cause of his insanity, if he falls
insane, than religion is the real cause of the insanity of one
whose overweening self-conceit has culminated in a delusion
that he is an inspired prophet—the fundamental tendency in
each case having fallen upon conditions favourable to its morbid
growth in the religious views and practices adopted—it might
still be argued that any body of men which separates itself
from the rest of the world as a specially favoured relisious
sect, hugging itself in the belief of the exclusive possession of
vital spiritual truths which the rest of mankind fail to apprehend,
and living apart as a sort of chosen people, adopts a course
which is injurious to character and errs from the true path of
healthy progress. The pride of opinion, the conceit of supe-
riority, the narrow and complacent spirit of the sect react upon
the characters of the individuals who compose. it, and, isolating
them from wholesome relations with their kind, instigate these
sectaries to a special and unsound mode of thought concerning
the world and their position in it. Moreover, their conduct is
apt to suffer: there is no small danger of their devotion being
not to truth, but to sect in the first instance, and of their
acquiring an esoteric and an exoteric conscience ; the former for
use among their co-religionists, and the latter, of quite another.
kind, for use among the rest of mankind. These sectarian divi-
v.] THE CAUSATION AND PREVENTION OF INSANITY. 151

sions in the intellectual and moral sphere are as injurious to
true religious progress as the divisions of a nation into tribes
suspicious of or hostile to one another would be to the true
interests of the nation: we may compare them to the divisions
into scattered tribes which prevailed among mankind in the
early stages of its progress, before it had reached the height of
national union and had grown to the apprehension of the higher
moral relations which such an union involves. What the
strength of the religious bond is, how effectual to hold a people
together, is well shown by the example of the Jews, who,
having no state, no country, no common language, no bond of
unity except a common religious belief kept alive by a common
ceremonial, have remained a distinct people until this day. The
Armenians furnish another but less striking instance of the
strength of the religious tie.
Theoretically religion should be the bond of unity to gather
all mankind into one brotherhood, linking them in good-will and
good work to one another; whereas practically it has hitherto
been that which has most divided men, and the cause of more
hatreds, more wars, more disorders, more persecutions, more
bloodshed than all other causes put together. In order to pre-
serve peace and order, therefore, the state in modern times has
been compelled to divorce itself practically from religion and to
leave to each sect liberty to do as it likes so long as it meddles
not by its tenets and its ceremonials with the interests of civil
government. Toleration of all religious doctrines and practices,
so long as they do not touch the practical concerns of life, has
become the necessary maxim of state policy ; very much as ina
lunatic asylum, where it is found impossible to make the inmates
think in a common way to common ends, full liberty of delusions is
left to each inmate so long as he does not act upon them in such
a way as to interfere with the order of the establishment. It is
not a little inconsistent that the sects should raise the outcry
they do against irreligion which are themselves the negation of
true religion. Then again, what high treason against humanity
have their partizans perpetrated! They have robbed it of its
highest achievement, the most perfect life of self-renunciation
which has been lived on earth, by translating it from a human to
152 PATHOLOGY OF MIND. [cuar.

a divine category, and so have done their best to wither its
hopes and paralyze its efforts to repeat that great achievement.

But I must not continue reflections which would carry me far
beyond the scope of this work: the end of the whole matter
for the present is that if the prime condition of true religion be
to get quit of the belief of special supernatural interventions
in human affairs, physical or moral, the maintenance of such
belief cannot be a strength but a weakness to the mind, and so
far will predispose to derangement of it.

Lducation—Next in importance to the inborn nature is the
acquired nature which a person owes to his education and train-
ing: not alone to the education which is called learning, but to
that development of character which has been evoked by the
conditions of life. Undoubtedly a person may be well-educated
by experience who can hardly read or write, as it happens
sometimes that a person has a great deal of learning and is
nevertheless very ill-educated. Writers on insanity discuss the
question whether educated persons are more liable to go mad
than uneducated persons, agreeing not always in their conclu-
sions ; and in the reports of lunatic asylums numerous statistics
are given to show how many patients have received a “good”
education and how many have had little or no education. The
statistics are of no value, and the speculations founded on
them, how ingenious soever, must be vain until there is some
agreement as to what is meant by good education.

Many persons consider it no true education which does not
instil into the mind of youth from the earliest dawn of intelli-
gence the doctrines and the stories of the Bible as most sacred
truths, having an authority which reason can add nothing to if it
confirm them, nor take anything from, if it contradict them; and
until lately it was generally thought to be a proper and suffi-
cient education to teach boys to understand the Greek and Latin
languages and some mathematics, and girls not even so much as
that. If what has been before said concerning a belief in the
supernatural be true, and if man’s power of acquiring knowledge
and weighing evidence through reason is not checked and con-
trolled in the most arbitrary manner by revelation, it is plain
that a great part of the human race, instead of being educated,
v.] THE CAUSATION AND PREVENTION OF INSANITY. 158

has been persistently miseducated for a long time; and if recent
reforms in the kind of instruction given in schools be just, it is
plain that past generations had nothing like a proper education
in that wherein they were not miseducated. The right questions
then for writers to discuss would be not whether education has
increased or lessened the liability to insanity, but whether the
iniseducation in vogue has enervated or vitiated human thought .
and feeling and so predisposed to disorder of them, and whether
a better education may not counteract the evil. For it will be
admitted on all hands that the best education would be the
strongest barrier against mental derangement which it would be
possible to raise; a pity it is therefore that men are not agreed
as to what is the best system of education.

For my part I desire to think that there is a great deal of
undeveloped mentality in the mass of mankind which past
education has scarcely touched, but which an improved and ex-
tended system of education will bring by degrees into activity,
to the great profit of the race in its future travail. The basis
of a better system must be a sincere recognition of the reign of
law throughout nature, mental as well as physical, and of the
momentous responsibility to act in conformity with knowledge.
No one can doubt that the study of the natural sciences, by
which are made known the complex operations of laws in the
various domains of nature, does furnish a valuable training of
the intellect by teaching how to observe accurately, to reason
soundly from facts, and to think sincerely ; truth in them being.
pursued entirely for its own sake without regard to preconceived
opinion or to the claims of authority, and patience in inquiry,
humility of attitude, and veracity of thought being essential
qualities in the true servant and interpreter of nature. More-
over, new insights into the secrets of nature lead to new adjust-
ments on the part of man to his complex surroundings and to
corresponding new gains in power: his best gains are to the
best gain of nature, and the best gains of nature are his true
gain. If he fails by searching to find out a law and so acts in
ignorance of it, or if, knowing it, he disobeys it recklessly or
wilfully, he certainly brings punishment upon himself or upon
others; he is contending with an adversary who neither makes
154 PATHOLOGY OF MIND. [cuap.

mistakes nor overlocks them, foregoes no advantage, feels no pity,
inexorably exacts the full forfeit of failure, and who is not to be
bribed by offerings nor placated by prayers: he must suffer for
his sin, and, learning wisdom through suffering, do more wisely
for the future in that wherein he erred in the past. What moral
discipline can be better than that; what more suited to make
men take earnest pains to do well? Actual intercourse with
nature is the best schoolmaster, teaching, as it does, the lessons
of experience which actually do guide men in the conduct of
life; for the maxims of worldly prudence according to which
they act in their dealings with one another and in their worldly
affairs are sincerely held and faithfully observed ; being founded
upon experience of the harm which ensues from disregard of
them, they have a real and constant influence upon conduct
which the maxims of philosophy and even the doctrines of
relicion have not. Were these doctrines based securely and
plainly upon the same positive basis of experience, aud were
they to appeal as directly to the reason of mankind, it is pro-
bable that there would be the same unwillingness to perpetrate
the folly of disobeying them.

It may be alleged, no doubt, that the formation of character
implies much more than a mere increase of knowledge, whether
by the inductive or other method, and more than an increase
of the intellectual power which increased knowledge confers ;
but the answer to that objection is that the knowledge of the
reign of law in nature does guide our impulses to wiser and
therefore better action, that good action promotes in time corre-
sponding moral development of character in the race, and that
this moral effect is multiplied by the recognition of the reign of
moral law in the Gomain of human evolution. The repetition

1 TI have not the least intention to argue that the study of the pliysical
sciences is a moral regenerator of the individual who pursues it, or tliat
scientific men are any more free than other people from envy, jealousy,
vanity, and other mean passions. On the contrary, they seem more prone
to them, probably because they are few and come into close competition,
Moreover, I do not fail to recognize the folly of the scientific superstition
entertained by some persons, that scientific study is a particularly exalted
labour, which is of unspeakable value, and should be held in supreme re-
verence apart froin its bearing on human welfare. Science is simply
knowledge, and is neither more nor less valuable than other knowledge
Iv.] TIE CAUSATION AND PREVENTION OF INSANITY. 155

of good action generates the habit of doing well, function de-
veloping structure, and the habit of doing well generates a
moral feeling in regard to such action, which it becomes at last
a pain to go against. Those who, following Comte, insist that
the impulses to action come not from the understanding but
from the feelings, and thereupon go on to affirm unreservedly
that the understanding has nothing to do with the springs of
human conduct, have stopped at a half-truth which Comte
would have repudiated. “Man,” he said, “becomes more
sympathetic in proportion as he becomes more synthetic and
more synergetic :” in other words, in proportion as he constructs
for himself a truer and more complete theory of his relations to
nature, physical and human (synthesis), and acts more faithfully
with and for his kind (synergy), so will he develop in his nature
a quicker and fuller human sympathy and have stronger moral
impulses springing therefrom. The enforcement of sanitary
measures to improve the dwellings and the condition of the
poor might have been preached in vain had not infectious fevers
bred in pestilent quarters taught the lesson of a common
humanity by a very effective sort of sympathy between man
and man—the contagion of disease; but now that the laws of
health are becoming known and public efforts are being sys-
tematically made to get some observance of them, we perceive
that a feeling of repugnance to disease-breeding conditions, a
sort of sanitary conscience, is gradually being engendered, out
of which we may expect to spring more urgent impulses to do
away with them.

This example of what is going on now may serve to illustrate
how the moral sense of mankind was originally developed out
of moral action ; for the moral sense embodiés in its nature and
displays in its function the kind of action through which it
has in the long course of ages been ingrafted as an instinct or
feeling in the human heart; the altruistic action having been first
entered upon in a feeble way from a dim perception of its ser-
vice to the social life, and continued because of the unity and

that helps men how to live. Moral progress must be looked for particularly
in the pursuit of social and moral science, and in the working of general
scientific knowledge upon the race gradually through generations.
156 PATHOLOGY OF MIND. [emap.

strength which it gave to the community. In like manner we may
observe in the process of deterioration of character how habitual
action modifies feeling and desire : no one ever becomes suddenly
a monster of baseness, losing all sympathy with goodness and
evincing a positive relish for iniquity in an instant, any more
than he gets any other acquired taste in an instant; but by a
course of wicked deeds, the first of which was done perhaps
against the grain under some strong temptation, the next with
less repugnance, and the next more easily still, such a deteriora-
tion of nature is wrought by degrees in him that the evil stirs
not a repugnant feeling, but an actual desire to do it. Good
impulses to act come out of good feelings as bad impulses come
out of bad feelings, and good feelings are slowly ingrained in
human character, become instinct in it, by a course of wise
doings. Should it ever come to pass that mankind attains to so
complete a knowledge of all the laws of nature in its manifold
and complex operations as to perceive instantly the right way
of obedience for wisdom to take in any event and to take it,
there will be developed a conscience so calm, so strong, so all-
embracing that to sin against it will be looked upon as crime
or madness: the freedom of the will will be the freedom of
madness.

It may be objected that men obey the law of gravitation
every moment of their lives without having any moral feeling
generated with regard to it; but the objection, when fairly con-
templated, is not of much weight. In the first place, the law of
gravitation is a physical law, the violation of which is followed
directly by punishment to the individual, whereas the conse-
quences of the violation of a moral law necessarily affect others
and are usually remote; the individual who breaks it injures
not only himself, but the society of which he is a member—~
that is the essence of the transgression: he strains the bond of
the social state. By reason of the community of kind in men
and of the sympathy which there is between them as members
of a common body who, though having different offices, serve
a common end, and therefore suffer in common from individual
wrong-doing, their sympathies and antipathies are necessarily
stirred, and feelings of approbation of what is done right and
Iv.] THE CAUSATION AND PREVENTION OF INSANITY. 157

of disapprobation of what is done wrong accompany obedience
to and infraction of moral law. The difference between a
physical law and a moral law in this relation is much like the
difference between a mechanical structure and a living organisin :
the whole house may not be much hurt by the decay or injury
of one or two of the bricks of which it is built, but the whole
body will not fail to be affected by the decay or injury of one.
or two of the organs which constitute it. To violate the law
of gravitation is a folly ; to violate the moral law is a sin, for it
is an injury to the social organism: the former offence is a sin
against science, that is, knowledge; the latter is a sin against
con-science, that is, that essential human feeling which has been
sublimed out of the relations of the communion of men in the
social state. Of the social communion of men the moral sense
is the highest fragrance, as the religious conscience is the highest
fragrance of the communion of the saints.

When Christians assemble together in holy communion to
break bread in memory of the life and sufferings of their
Saviour, they solemnly renew and attest their conviction of
the essentiality to human welfare of the sublime moral truths
which he proclaimed in speech, realised in his life, and suf-
fered for in his death, and quicken their sense of them, which
is apt to grow dull in the rude conflicts of the world. They
get strength and comfort to go on the narrow way of upright-
ness from this assembling of themselves together in solemn
meeting, out of their consent of faith and the infection of
sympathy; for they are beings of the same kind, struggling
with the same trials, bearing the same sorrows, and looking
forward to the same end of their labours under the sun. But
it cannot therefore be argued that there is anything which
does not come by ordinary mental laws, anything supernatural,
in the moral enthusiasm which is kindled in these circum-
stances; if a number of persons were gathered together in
the same sympathetic way to fan some unwise emotional ex-
citement and to do some foolish thing, as for example to dance
and shake furiously after the manner of the Shakers until
they were exhausted, the excitement would be augmented, and
the infection of it would spread by sympathy in the- same way.
158 PATHOLOGY OF MIND. [cmap.

The infection of emotion has, as history shows, given rise to
many moral epidemics. However plainly we acknowledge the
operation of law in human thought, feeling, and conduct, there
must always be, so long as men continue to be of the same
kind, and susceptible therefore to the infection of a common
emotion, so long as no favoured ones among them rise to the
level of a higher kind from which they can contemplate apart
with God-like serenity the doings of their former fellows, a
quick feeling of personal and social concern with respect to
the operation of moral law which there is not with respect
to the operation of physical law ; and from this feeling it is
that we derive the ethical impulse, the imperative moral man-
date, which accompanies the perception of the right way to take
to promote human weal and dictates the duty to take it.

It may be anticipated perhaps that the time will come, though
it is yet afar off, when the feelings of anger and retuliation
which are now roused by criminal and vicious doings will be
extinct, and when those who perpetrate them will be thought so
irrational as to be looked upon with the same feelings with
which lunatics are looked upon now. In this relation it is
instructive to take notice how complete a revolution in the
feeling with regard to the insane has taken place within the
last half century, with increase of knowledge of what insanity is:
their irrational beliefs and turbulent deeds roused indignation
formerly, and were dealt with by harsh measures of punishment,
as if they were voluntary ; now, however, since better kuow-
ledge of insanity has been gained, those who have to do with
the insane look upon their delusions with curiosity or compas-
sion, and are not moved to anger by their perverse and violent
deeds; however much annoyed or distressed by them, they
would no more think of getting angry and retaliating by
punishments than they would think of punishing an unwelcome
rainy day; but it is instructive also to note that the old
sentiments still linger in the breasts of ignorant people, and are
vigorously expressed in outbursts of angry vengeance whenever
an insane person who has done homicide is rescued from the
gallows. It were a good thing if men could reach the same
height of philosophy in contemplating the evil doings of their
v.] | TIE CAUSATION AND PREVENTION OF INSANITY. 159

fellows who are not in lunatic asylums: if instead of being
embittered by treacherous dealing, afflicted by evil speaking and
slandering, soured by ingratitude, made revengeful by wrong,
angered by stupidity, they could look upon such things as
natural and inevitable events, much as they look upon the
vagaries of insanity or upon bad weather, and be nowise dis-
quicted by them. Such attitude of mind need not in the least
preclude suitable steps being taken to frustrate acts of treachery
and to render criminals harmless, any more than it now pre-
cludes the adoption of the necessary measures to place lunatics
under proper care and control.

Passing from consideration of the general method and aim of
true education, I may point out that the sound and strong
character which it might be expected to form would be well
fortified against some of the most common exciting causes of
insanity—those passions, namely, which often make shipwreck
of the mental health ; for the passions are like the wind which
‘swells the sail, but sometimes, when it is violent, sinks the ship.
To get rid of an overweening conceit of self, by bringing home
to the individual true conceptions of his humble relations and
subordinate purpose in nature—which I take to be one good use of
the overwhelming immensity of the heavens and of the revolving
multitudes of stars—would help to moderate and control the
emotional or affective element in his nature, inability to moderate
and control which is real slavery; and to do that would be to
get rid at one stroke of the so-called moral causes of mental
disease. Sorrow for loss of fortune or loss of friend, envies,
hatreds and jealousies, disappointed ambition, the wounds of
exaggerated self-love, anxieties and apprehensions, and similar
heartaches, all of which have their footing in a keen self-feeling,
and gain undue activity from the want of a proper development
of the rational part of the nature, would not then produce that
instability of equilibrium which goes before the overthrow of
the mental balance, What hold “could disappointed ambition
have upon him’ who soberly weighed at their true value the
common aims of worldly ambition, who perceived the degrada-
tion to be gone through in order to attain them, who foretasted
the bitterness of achieved success when they were attained, and

8
160 PATHOLOGY OF MIND. [CuAP,

who set before himself definitely as his true aim in life, for
which he worked definitely, the highest development of which
his intellectual and moral nature was capable? His heart
could never be deeply corroded by envy who cared not whether
he did a great thing or whether somebody else did it, the only
true concern being that it should be done, whose imagination
realised the littleness and the transitoriness of the greatest of
great fames, and whose clearly conceived and steadfastly pursued
aim it was to reach a passionless serenity of mind. There could
be no overwhelming grief from loss of fortune in him who
appraised at its true value that which fortune can bring, and
that which fortune can never bring; nor would he be hurt by
the pangs of wounded self-love who saw before him as final end
absorption of self into the all, and had learned and practised as
means thereto the lesson of self-renunciation.

If it be said that this ideal of education is hardly within the
reach of any one, and far beyond the reach of the great mass of
mankind, who would drift from all moral anchorage were they
loosed from the bondage of religious creed, IJ answer that it is
not really more out of reach than the ideal of Christian life and
doctrine ; that it is seen to be the goal of the road on which
men are actually travelling so far as they go forward in evolu-
tion, and not, like the Christian ideal of doctrine, a point which
is more and more divergent with every step forward which they
make in real life and thought; and finally, that a high ideal to
aim at, so long as it is not absurdly impracticable, is an excellent
means of training, it being the pursuit and not the achievement
which makes the pleasure and profit of labour. Any one who
makes a searching examination of the varieties of human feeling
which are correlated with the different sorts and conditions of
human life may convince himself that it is a baseless opinion
that men would cease to have moral feeling if they ceased to
believe in heaven and hell; they never can, nor ever do, free
themselves from the ever- presale and ever-working influence of
the social organization of which they are units; being of the
same kind, the kind is in them, and shows dtsell in common
feeling. If the social medium be no better than one of thieves
and harlots, there will still be formed, as there always is, a
Wv,]) THE CAUSATION AND PREVENTION OF INSANITY. 161

particular thief’s conscience or harlot’s conscience, to violate
which will oceasion uneasiness of mind or be thought to bring
ill-luck : the peculiar sort of honour which exists among thieves
and among prostitutes is not derived from any perverted abstract.
feeling of right and wrong, but is developed as a necessary con-
dition of their living together in any sort of social harmony.
It is notorious that a man of honour, so-called, would be more
disgraced among his fellows by his refusal to pay a gambling
debt than he would be by perpetrating a heartless seduction : the
conventional feeling of the society in which he moves is more
powerful than a higher moral feeling. Men are found every-
where to seek that which brings them fame and reputation, and
to avoid that which brings them shame and dishonour among
their kind, although that which is esteemed may be profoundly
immoral, and that which is despised may be essentially noble.
“Where riches are in credit,” says Locke, as though he had
forethought of the England of to-day, “knavery and injustice
that produce them are not out of countenance, because, the
state being got, esteem follows it, as in some countries the crown
ennobles the blood.” These examples go to show the error of
the opinion that the formation and the power of a moral sense
depend upon a belief in a supernatural power and in a future
life; it is impossible that men should dwell together in unity,
as they do in complex society, without the development and
function of moral sense.

It will be the aim of a wise self-training to develop true
thoughts and sound feelings in the mind, and so to coordinate
them in exercise that they shall be available, when required, as
the best volition ; and the means to this end are not observation
and reflection only, but more particularly action. The formation
of character is a slow and gradual process which goes on in
relation with the circumstances of life: what men do habitually
that they will be. It is useless to give advice that runs counter
to the affinities of a character which has been formed by a Jife-
exercise ; it cannot assimilate it. He who has always done ill
will find it as hard to amend his ways and do well as one who
has always spoken English to speak another language; as he
must learn speech by speaking, so he must learn well-doing by
162 PATHOLOGY OF MIND. (CHAP,

doing well. “Cease to do evil, learn to do well,” is the maxim
of a sound mental philosophy. The proper counsel of a
physician to one who consults him concerniug what he shall do
to be saved, because of a well-grounded apprehension that his
mind will give way, would, were it candid and compendious,
oftentimes be—Learn to unlearn. I have often felt despair when
I have been asked anxiously by such a one what books he
should read in order to fortify his mind against insanity ; for the
hopeless problem presented was how to efface in a day the
growth of a life—nay, perhaps of a line of lives—how to undo a
mental organization. If there has not been sound discipline to
ouide the growth of character through the stages of its gradual
formation, there will be small hope of bending it, when it is
formed, to new trains of thought and feeling.

Every nature has its particular tendencies of development
which may be fostered or checked by the circumstances of life,
and which, according as they are of good or bad kind, and
according to the external influences which they meet with, may
minister to his future weal or woe. Too often it happens that
an injudicious training aggravates an inherent fault. Parents
who, having themselves a weak strain in their nature, have
given their children the heritage of a morbid bias of mind, are
very apt unwittingly to foster its unhealthy development; they
sympathise so essentially with it that they do not perceive its
vicious character if they do not actually admire it, as men are
not offended by the bad odours of their own bodies, and leave it
to grow unchecked by a wise discipline, or perhaps stimulate it
by the force of a bad example. “He is so spoiled,” says the silly
mother placidly of her child, as though she was saying some-
thing that was creditable to it, or at any rate that was not very
discreditable to her, little thinking of the terrible meaning of
the words, and of the awful calamity which a spoiled life may be.
It may justly be questioned whether the whole system of edu-
cation at the present day does not err on the side of dangerous
indulgence. No doubt such harshness and neglect as might be
likely to repress cruelly a child’s feelings, and to drive it to take
refuge in a morbid brooding, or in vague and visionary fancies,
would he a great wrong, but a fcolish indulgence, through which
v.] TITE CAUSATION AND PREVENTION OF INSANITY. 1653

it never has infixed in its nature the important lessons of re-
nunciation and self-control, is not less pernicious, Can it be
wondered at that persons whose minds, when they are young,
have never been trained to bear any unwelcome burden, should
break down easily into insanity under the strain of severe trials
in later life? The aim of early education ought to be sound
intellectual and moral discipline rather than much learning of
any sort; to fill a child’s mind with details of knowledge in
order to make it a prodigy of learning is likely enough to
prepare for it an early death or an imbecile manhood; but
nothing can be better than the careful fashioning of its intellect
into a trained instrument by which knowledge may be acquired
readily, and with habits of accuracy, and the formation of a
stable character, which, through the constant practice of self-
denial, obedience, self-control, shall embody those lessons of a
good moral experience which the events of later life will not
fail to enforce rudely.

The common system of female education, which is now
falling. fast to pieces, was ill adapted to store the mind with
useful knowledge and to train up a strong character; had it
been designed specially to heighten emotional sensibility and to
weaken reason it could hardly have been more fitted to produce
that effect. Its whole tendency has been to increase that predo-
minance of the affective life in woman which she owes mainly to
her sexual constitution, and the intellectual and moral outcome
of which is seen in judgment by feelings, in intuitive per-
ceptions rather than rational appreciation, and in conduct
dictated by impulse rather than by deliberate will. Hitherto
she has been trained to no outlook but marriage, and to culti-
vate only such accomplishments as might be most useful to
attain that end; through generations her character has been so
informed ; when therefore the end is missed all else is missed.
Disappointed of marriage, to which her whole nature tends, there
has been no.ontlet of action in which the energies of her feel-
ings might be discharged vicariously, and she is ill fitted to
bear the stress of disappointment with the long train of conse-
quences, physical and moral, which it draws after it.

Undoubtedly cases do occur from time to time of mental]
164 PATHOLOGY OF MIND, (cuar,

derangement“in unmarried women, especially of the upper and
middle classes which appear to have been caused mainly by the
frustration of this fundamental instinct of their béing, and by
the want, in the present social system, of suitable spheres of
activity in which its energy might have vicarious expression.
Between the instinctive impulses with the emotional feelings
that are connected with them and the conventional rules of
society which prescribe the strictly modest suppression of any
display of them, a hard struggle is not unfrequently maintained.
The keen self-feelings and passionate longings, heightened to a
morbid pitch by continual brooding, perhaps take a religious
guise as the only channel through which they can be expressed
freely without impropriety ; and the occasional result is a form
of mental derangement marked by a strange mixture of erotic
feelings and religious visions or delusions. With the improve-
ment of female education and with the new openings for female
labour we may expect the predominance of the affective life to
be somewhat lessened, the resources for work to be systematically
used, and higher aims than frivolous amusements to be pursued ;
and the reaction of a different mode of life upon female educa-
tion and upon female nature cannot fail to be considerable.
Thus much concerning education in its bearing on the pro-
duction of insanity. If the foregoing opinions be correct, it is
clear that any increase of the disease which may be taking place
now is no proof that education will always fail to check such
increase; it is an argument only that a method of education
which is faulty at its foundation does not help to prevent insanity,
if it does not actually help to produce it. It is still in the
working of a sound education and training that we expect not
only to neutralize a predisposition to mental derangement in
the individual, but to counteract any tendency to an inerease
thereof in the community which may spring from the evils
accompanying the benefits of civilisation ; the external advan-
tages of which may naturally lead in the end to a better in-
ternal culture, so furnishing in its higher stages a remedy for
some of the mischief which it produces in its earlier stages,
Sex—It has been a disputed question, which is not yet settled
definitely, whether more men than women go mad. Esquirol
1\.] THE CAUSATION AND PREVENTION OF INSANITY. 165

thought that men more often went wrong, but he omitted in his
calculations to take sufficient account of the preponderance of
women in the population, that preponderance being greatest
between the very ages of twenty and forty, when insanity most
often occurs, and he was also led astray by drawing his con-
clusions from a comparison of the existing cases instead of the
occurring cases in the two sexes. It is worthy of remark that
more male than female children are born: in England during
ten years (from 1857 to 1866) the proportion of male children
born alive to females was about 1045 to 100; in France
during 44 years it was 1062 to 100; in Russia the average
proportion was 1089 to 100; among Jews it is higher still;
but inasmuch as more males are stillborn than females, as more
die early, especially during the first year of life, and as more
perish by accident or emigrate, it comes to pass in the end that
females preponderate in old settled countries. Out of a popu-
lation of 24,854,397 in England and Wales there were 12,097,547
males, and 12,756,850 females, and of these on January Ist, 1878,
31,024 males and 37,514 females were known to be insane. The
ratio of male lunatics to the population was 25-64 per 10,000,
that of female lunatics 29°40 ; and pretty nearly the same rela-
tion will be found to hold for the corresponding ratios of the
last eighteen years. We may take it then that the excess of
female lunatics is greater than is accounted for by the excess of
the female population, and that some other cause or causes must
be sought for to explain it. In matter of fact the number of
men actually admitted into asylums, which may be taken
roughly but fairly to represent the number of occurring cases
among men, is found, when the records of asylums are ex-
amined, to be considerably above that of female admissions.
One cause of the preponderance of female lunatics certainly is
the.much greater proportionate mortality among male lunatics,
this being due mainly to the fatality of a single disease, namely,
general paralysis, which is almost confined to men, seldom

1 Among private lunatics the ratio is, and always has been, higher for
males, being 3°45 against 2°76 for females per 10,000. One reason pro-
bably is that it is easier tv keep insane females at liome among classes

above paupers,
166 PATHOLOGY OF MIND. [cHaP.

attacking women; and to this main cause may be added another
subsidiary cause, namely, the greater proportion of relapses which
has been observed to take place in women. For these reasons
it is that women accumulate in asylums more than men; and
this accumulation, taken in connection with the excess of
females in the population, is probably enough to account for the
excess of existing female insanity.

Dr. Thurnam concluded at the end of his patient inquiries
that men were more liable to mental derangement than women ;
and that is the general belief now. Granting it to be true, it
must not therefore be supposed that it is because of anything
in the constitution of men which renders them more liable to
such derangement; on the contrary, there are obviously dis-
turbing conditions peculiar to the female constitution which are
more fitted to be occasions of mental disorder—to wit, the con-
stitutional change at puberty, pregnancy, child-bearing and its
sequences, and the climacteric change, with each one of which.
we can connect a definite variety of insanity. The true reason
no doubt why more men go mad is that they are exposed in the
strugges of life to more numerous, varied, and powerful causes
of mental disturbance. The strain of work for competence or
wealth, the anxieties and apprehensions of business, the burden
of family responsibilities weigh more heavily as a rule upon
men who are the bread-winners than upon women ; intemperance
again, which is one of the most active causes of insanity, is a
much more active cause among men than among women; and
there are other excesses, especially sexual excesses, to which
they are more prone and which do them more hurt than they
do women. In fact these three classes of effective causes are
enough to outweigh the greater tendency to mental disorder
which lies in the nature and functions of the female organization,
as well as the nervous instability which women acquire in the
present social system hy reason of defective education, aimless
lives, frivolous amusements, and the lack of resources of work.
The right conclusion at the end of the whole matter would
seem to be that while there is no very sensible and certain
difference between the proportions of men and women who
become insane, as the causes actually operate, men are exposed
Iv] THE CAUSATION AND PREVENTION OF INSANITY. 167

to more numerous and powerful extrinsic causes, and women,
by virtue of their sexual organization, to more numerous and
powerful intrinsic occasions, of insanity. In proportion as
women invade those departments of work which men have
hitherto appropriated they will expose themselves more and
more to those extrinsic causes of derangement, and it is a grave
question whether they will not find themselves overborne by
the joint action of the weight from without and the weakness
within.

Age.—I have pointed out already that the relative activity of
different organs and tissues at different ages plays some part in
the occurrence of particular diseases at those ages, and that
it ig especially so when there is an organic predisposition to
disease. It is not surprising then that mental derangement is
uncommon before puberty; for up to that time the part of the
nervous system which ministers to muscular action is in active
‘function, and the consequence is that epilepsy is the most
common nervous disease. Still all forms of insanity except
general paralysis do occur even so early in life. Most often it
has then the character of mental defect, and may be classed
under idiocy or imbecility; the mental organization being iu-
complete, its disorders bear witness to its undeveloped state.
Even those cases which are described as examples of mania,
because of great excitement and activity of mind and body,
might in most instances not unfitly be classed as cases of
idiocy or imbecility with maniacal excitement. At first sight
it is surprising enough that striking examples of moral insanity
should be met with in quite young children; but it is certain
that instances do occur not of true moral imbecility only, where
the unfortunate beings, who are perhaps not of quite normal
intelligence, have been born without the least capacity of moral
feeling, but instances also of active display of all sorts of
immoral impulses with acute intelligence of the purely selfish
and cunning type. Between the ages of sixteen and twenty-
five insanity is more frequent, because of the great revolution
which then takes place in body and mind, of the new passions
which spring up, and of the fresh start in mental development
which is made; but it is most frequent of all during the period
168 PATIIOLOGY OF MIND, [cuar.

of full mental and bodily development—from twenty-five to
forty-five years of age—when the functions are most active and
when there is the widest exposure to causes of disorder. The
internal revolution which takes place in women at the climac-
teric period leads to many outbreaks of melancholic derangement
between forty and fifty ; and it has been thought that a sort of
climacteric change occurs in men also, usually between fifty and
sixty, when insanity sometimes shows itself. In old age senile
dementia is the most common form of derangement; it is the
pathological term of the natural decay of mind which occurs
when nature—

“ As it grows again towards carth,
Is fashioned for the journey, dull and heavy.”

Occupation and Condition in Life-—Whether one profession,
trade, or pursuit more than another favours the occurrence of
insanity is not really so much a question of the effect of the
particular pursuit as of the habits of those who follow it and of
the spirit in which they follow it. Among the lower classes of
society it is for the most part a question of sobriety and tem-
perance against intemperance and riotous living, In the classes
that are above the lower, when a man sets before himself as
his aim in life riches or social position, not-for any good use of
what he gets by his toil and cares and heartburnings, but as
an end in itself, let his business be what it will, he is pursuing
a not very worthy end, and will be likely to do so in an in-
temperate way, if not by actually unworthy means. If the
social system be one in which riches are held in great esteem,
and his passionate ambition is to get rich, he will not boggle
much at the knavery which helps him to his end, and which
will be overlooked by such a society in the admiration which
it bestows upon success. JEven when a man has made success
or reputation in business the exclusive aim of his life, not out
of a mere desire to become rich, but out of an eager energy
and honest love of doing his work well; when he has by long
concentration of desire and work upon it grown so completely to
it as to make it the entire current of his life, that to which all his
thoughts, feelings, and actions turn habitually, and in which they
Iv.) THE CAUSATION AND PREVENTION OF INSANITY. 160

are engrossed—other interests being as it were little and acci-
dental eddies that escape fora short time only the attraction of
the main stream—he is ill fortified by mental culture against
the shock when hope is shattered, his pride of opinion brought
low, and the fabric which he has raiscd with all the eagerness
and energy of an iritense egoism levelled to the ground by a
crushing blow of misfortune. Nay, the belief only that such a
catastrophe is threatened may be enouch to overthrow him ; for
if nine out of ten parts of his being and energies are absorbed
in the successful prosecution of his work, and that has had a
severe check, where is an adequate recuperative and distracting
force to come from? He is not unlikely to sink into an agitated
apprehension, and from that state to lapse into despairing
melancholy.

It was a common notion ode one time that governesses were
victims of insanity out of all proportion to their numbers, and
much sympathy was spent upon them in consequence. But the
opinion was not well founded. It originated in the observation
that a great number of governesses were received into Bethlehem
Hospital—as° many as 110 in ten years; the reason of which
was not that so many more of them than of other classes went
mad, but that they were just the persons who fulfilled best the
conditions of charitable admission into that hospital, being poor
enough to be unable to pay for care and treatment in private
asylums, but yet not poor enough to be paupers and suitable
for admission into county asylums.

If it be true, as is said, that persons who work with the head
are more liable, on the whole, to mental disease than those who
work with the hand, and that they are less likely to recover when
they have had an attack, we may easily understand the reason
to be that a more complex and delicate mental organization, with
its greater variety and activity of function, will furnish more
frequent occasions of disorder, and that the disorder will do
greater hurt to the finer and more delicate instrument. But it
would probably be a fuller statement of the truth to supplement
it by adding that those who work with the heart are more likely
to fall insane than either headworkers or handworkers; for the
causes of the derangement are to be found not so much in the
170 PATHOLOGY OF MIND. [cuap.

strain of the intellectual work as in the passion and feeling
which are put into it, and which are the real wearing force. It
is not in fact the nature of the occupation, but the temperament
of the individual, which determines mainly what emotional wear
and tear there shall be; one person may fret and consume his
heart with anxiety in the small cares of a petty business, while
another shall conduct the complex affairs of a mighty nation
with unconcern of feeling,

All privileged or so-called aristocratic classes have in their
privileges the conducive elements of corruption and decay, and
degeneracy of one sort or another is likely, sooner or later, to
appear and spread among them. Doubtless it is a good and
praiseworthy thing to reward eminent service to the state by
conferring honours. and privileges upon the deserving individual ;
but that such privileges should descend as a heritage to his pos-
terity for ever, whatever their quality, is a custom which, were it
proposed to be established now for the first time, would pro-
bably be encountered with incredulous amazement. The matter
is of course worse when the honour is conferred for services
which mark the dishonour of those who have rendered them.

A nation which wishes well to itself will aim to unite its
people in the bond of unity, brotherhood, and equality, not to
divide them into privileged social castes and orders. It is im-
possible to say positively what degree of truth there is in the
often made statement that insanity is of disproportionate fre-
quency among the so-called aristocracy of this and other countries,
If it be true, one reason may be too close and too frequent inter-
marriages such as are likely to occur where clanship prevails,
and do occur certainly in royal families. In this country, how-
ever, we observe powerful causes silently working to break down
the exclusive barriers of caste and to widen the area of selec-
tion for breeding ; a wealthy banker, brewer, gin-distiller, con-
tractor, manufacturer, or person of that kind of consequence,
who has gained all the wealth which his heart desires, is com-
monly an unsatisfied man until he has wriggled into a higher
social position, and, more blessed still, has allied himself or his
family by marriage to some titled family ; and the younger sons
and the daughters of titled fuinilics who, owing to the law of
w.] THE CAUSATION AND PREVENTION OF INSANITY. 171

entail and the privileges of primogeniture, are needy in proportion
to their pretensions, gladly seek by marriage into wealthy com-
mercial families the means to support their social position. It
may be doubted whether such marriages commonly turn out
well so far as health and vigour of offspring are concerned.
The reasons I take to be these: first, that men who have made
it the sole work of their lives to get money, and having got it
have had no higher aim than to use it to gratify a contemptible
social passion, are not such as are likely to breed sound moral
constitutions in their children; and, secondly, that the needy
members of titled families who sell themselves for subsistence
instead of earning it by honest labour are as little likely to be
fitted to breed well.

There seems to be no doubt that, other things being equal,
insanity is more frequent among unmarried than among married
persons: a fact of which it is not difficult for an ingenious
person to invent several theoretical explanations.

One consideration more it will be proper to take notice of
before leaving this subject. Over-population, which prevails in
some civilised countries, is the cause of numerous ills to man-
kind, amongst which we may probably reckon an increase of
mental disorders. In the eager and active struggle for existence
which goes on where the claimants are many and the supplies
are limited, and where the competition therefore is fierce, the
weakest must needs suffer, and some of them, oppressed by
poverty, fretted by constant cares, and overwhelmed by anxieties,
will break down into madness. Moreover the overcrowded and
unhealthy condition of dwelling-houses which over-population
occasions cannot fail, in conjunction with insufficient nourishi-
ment, to lead to deterioration of the health of the community,
and so to predispose to disease of different sorts. Not fevers
only and epidemic diseases, but scrofula, phthisis, and other
constitutional states marked by general deterioration of nutrition,
are engendered and transmitted as evil heritage from generation
fo generation.

It is not that the child inherits necessarily the particular
disease from which the parent suffered, but it inherits probably
a constitution in which there is an inherent aptitude to some
172 PATHOLOGY OF MIND. [cuar.

kind of morbid degeneration, or which is destitute of the
reserve force necessary to meet successfully such extraordinary
strains as the trying occasions of life cannot fail to exact some-
times. Disease not being, as it was so long thought to be, a
specific morbid entity which, like some evil spirit, takes hostile
possession of the body or of a particular part of it, and must
be expelled by some specific drug, but a state of greater or less
degeneration from healthy life in an organism whose different
parts constitute a complex and harmonious whole, it is plain
that a disease of one part. of the body will not only affect
the whole sympathetically at the time, but may well lead to a
more general infirmity of constitution in the next generation:
Whatever weakens the organism of the mother may certainly
be a cause of idiocy of the offspring, especially when the debili-
tating cause acts during pregnancy. No doubt the special
morbid outcomes of the inborn infirmity will be determined
in some measure by the external conditions of life: we ought
always to take into account the without as well as the within.
If a person has inherited a generally feeble constitution, and if
the circumstances of his life chance to be such as put a great
strain upon his brain and nervous system, he is not unlikely
to suffer from some form of mental or nervous disorder: the
man, for example, who has responsibilities to which he feels him-
self unequal, or is harassed by pecuniary anxieties or by domestic
troubles, or the woman whose life a worthless husband makes a
daily round of dreary suffering, will show the general want of
constitutional reserve force by the derangement of the special
organ on which the strain falls,

It is natural to feel sympathy with madmen when one sees
how the fine and sensitive nature of one has broken down
under the wearing grind of the coarse and rude experiences of
life; how the thoughts of another have oftentimes deviated
from the beaten track into brilliant flashes of quick insight ;
how eagerly animated with the spirit of enthusiasm a third has
shown himself; but while sympathizing with their sufferings
and their fate, we must still confess that their failure meant
weakness, and that they succumbed because it was right they
should succumb. Albeit it is asad thing to see a person fall
W.J TILE CAUSATION AND PREVENTION OF INSANITY. 173

from a height and break his neck, it would perhaps be a sadder
thing for the law of gravitation to be suspended for a moment
in order to save his neck, and for the universe to go to wreck.
It is sad to contemplate the spectacle of Lear, driven mad by
his daughters’ ingratitude, and shrieking to the pitiless heavens
in shrill senile lamentations, but it would be a sadder thing
in the end if so little insight into character, so little prudence,
and so little self-control as he showed were to issue in a
prosperous and peaceable old age. The aim of man’s develop-
ment being to bring himself gradually into more and more
special and complex relations with his social and physical
environment, by intelligent observation of the laws which
govern these relations and by corresponding adaptations on his
part, he must fail if he is unequal to the struggle imposed upon
him, whether it be from inherited weakness or from any
other cause, just as a tender plant must wither and die in a
poor soil where hardier plants compete with it. Nay, he may
fail if he is not weak, but only unfortunate; for as one seed
may be as sound and vigorous as another seed and yet perishes
if it fall upon barren ground, so may a fairly strong man un-
haply chance upon evil circumstances against which he con-
tends in vain. The benevolent observer could have wished him
to have fallen upon better times and among kinder surround-
ings, but it is useless to repine ; he has passed away as an abortive
being, and must be counted one of those countless germs which
nature sheds in lavish profusion, and never brings to develop-
ment.

In a certain sense then one may take comfort and be glad
intellectually that failures should fail; for if the weak were not
defeated in the struggle for existence, it would be because the
strong, holding back to the slower pace of their infirmities, used
not their strength, and so robbed the world of the right which
it has to, and the advantage which it would get from, the full
use of their superior powers. An increase of mental disease in
a country means not necessarily the degeneracy of the people;
the capability of development being the capability of degenera-
tion, like height and depth opposite and equal, it is not hard to
understand that when progress is going on actively retrograde
i74 PATHOLOGY OF MIND, [cmae. tv,

action may be going on side by side with it, that madness may
be a waste of the individual to the profit of the race—dead
reason thrown off by vigorous mental growth—a seeming evil
which is truly a phase in the working out of higher good.
Man rises in humanization at the cost of his kind, mounting
upwards over the ruins of the races that have successively come
and gone before him, and it would be as absurd to lament the
disappearance of the once mighty nations whose places now
know them no more as to lament the mental degeneracy which
correlates mental progress.

Thus much concerning the remote or predisposing causes of
insanity. It remains now to set forth the direct or proximate
causes of defect or derangement of the suprenie centres of intel-
ligence. In doing this it will be most convenient, and in the
end most scientific, to group them as the causes of disorder of
the sensori-motor and spinal centres have been grouped —in
other words, to treat of the causation of msanity from a patho-
legical point of view.

1 The Physiology of Mind.
CHAVTER V.

THE CAUSATION AND PREVENTION OF INSANITY (Continwed).

B. Puthological.

The Proximate Causcs of Disorder of the Idcational Nervous
Centres,

In proceeding to consider those causes or intrinsic conditions
which, more immediately going before mental disorder, may be
called proximate, I shall first treat briefly of the actual defects,
observed or inferred, of structure and of development in the in-
tellectorium commune. I treat of them because it is necessary
to give a general idea of what is known concerning them now,
and I treat of them briefly only, because what is known yet
is but a hint, as it were, of what remains to be discovered
hereafter.

1. Original Differences in the Constitution of the Supreme
Nervous Centres—Undoubtedly there exist great natural differ-
ences between different people in respect of the development of
their cerebral convolutions. In the lower races of men these are
visibly less complex and more symmetrical than in the higher
races ; the anatomical differences going along with differences in
intellectual and moral capacity. Ifa Bushman, with his inferior
type of brain, were placed in the complex circumstances of civil-
ised life, though he might represent a high grade of development
of his lower type, to all intents and purposes he would he, as
Gratiolet allows, an idiot, and would, unless otherwise cared for,
inevitably perish in the severe competition for existence. Were
176 PATIIOLOGY OF MIND. [ciraP.

a person born amongst civilised people with a brain of no higher
order than the natural brain of the Bushman, in consequence
of some arrest of its natural development, it is plain that he
would be more or less of an idiot; a higher type of brain,
arrested by morbid causes at a low grade of development, is
brought to the level of a lower type of brain which has reached
its full development. As Von Baer long ago pointed out, the
actual position of a particular animal in the scale of life is
determined, not by the type alone, nor by the grade of develop-
ment alone, but by the product of the type and the grade of
development. ;

The principal varieties of defective brain met with cannot
be described in detail here; suffice it to say that all sorts and
conditions of incomplete growth and development have been
observed in different instances.

There are idiots of the microcephalic type, in whom an arrest
of cerebral development has taken place, and a palpably defec-
tive brain is met with in consequence. Malacarne was at the
pains carefully to count the lamine of the cerebellum in idiots
and in men of intelligence, and he found them to be less
numerous in the former than in the latter. Now these lamine
are less numerous in the chimpanzee and the orang than in
man, and still less numerous in other monkeys; so far, there-
fore, there is an approximation in some idiots to the simian
type of brain. Mr. Paget has described an idiot’s brain in
which there had been a complete arrest of development at the
fifth month of foetal life: there were no posterior lobes, the
cerebellum being only half covered by the cerebral hemispheres,
as is the case normally in many of the lower animals. Dr. Shut-
tleworth found in the microcephalic brain of an imbecile that
although the frontal and parietal lobes were fairly developed
the temporo-sphenoidal lobes were small and deficient in front, and
their convolutions and fissures incompletely marked; the occipital
lobes were quite rudimentary, exhibiting no fissures and convolu-
tions, so that the greater part of the cerebellum was uncovered.?
Gratiolet found in the brain of a microcephalic idiot, aged
seven, the under surface of the anterior lobes much hollowed,

1 Journal of Mental Science, October, 1878.
v.] THE CAUSATION AND PREVENTION OF INSANITY. 177

with great convexity of the orbital arches, as is the rule io
the monkey.?

Mr. Marshall has carefully examined, and described in
an elaborate paper, the brains of two idiots of European
descent: the convolutions were fewer in number than in the
apes, individually less complex, broader, and smoother—“In
this respect,” he observes, “the idiots’ brains are even more
simple than the brain of the gibbon, and approach that of the
baboon (Cynocephalus) and sapajou (Ateles).”2 Though he
agrees with other observers that the condition of the cerebra in
the idiots is neither the result of atrophy nor of a mere arrest
of growth, but consists essentially in an imperfect evolution of.
the cerebral hemispheres or their parts, dependent on an arrest
of development, he points out the strong grounds there are for
inferring that, after the cessation of evolutional changes, the
cerebra experience an increase of size generally, or a mere
growth of their several parts. Consequently the cerebra are
much larger than fcetal cerebra in which the ‘convolutional
development is at a similar stage ; the individual convolutions
themselves, though the same in number, are necessarily broader
and deeper; and the result might conceivably be a brain of fair
size which was still imperfectly developed. Many more in-
stances have been recorded of idiots’ brains in which there was
a defect of convolutions when compared with a normal Cau-
casian brain; the principal convolutions being more simple and
symmetrical, and the secondary ones sometimes wanting. What-
ever its defects, however, an idiot’s brain never resembles a
monkey’s exactly, any more than an idiot ever resembles exactly
a monkey in mind: it is not a complex mechanism brought to
the condition of a simpler mechanism, but a complex mechanism
imperfectly constructed, and less fit for its purposes therefore
than the simpler mechanism.

Not only is the brain-weight in microcephalous idiocy very
low absolutely, as the instructive tables of Dr. Thurnam show,
but the relative amount of brain to body is “ extraordinarily ”
diminished. Thus in the two idiots described by Mr. Marshall

1 Anatomie Comparée du Systeme Nerveux.
2 Philosophical Transactions, loc. cit.
178 PATIIOLOGY OF MIND. [cuar.

the proportion of brain to body was only as one to 140 in
the female, and as one to sixty-seven in the male, the normal
proportions being as one to thirty-three and as one to fourteen
respectively.

It is not necessary that I quote more authorities to prove
that small-beaded idiots have small brains, and sometimes
even fewer and more simple convolutions than the chim-
panzee and the orang; that man made a morbid kind by an
arrest of development may be brought to a lower level than
that of his nearest of kin among animals. A strict examination
of the stories of so-called wild men, as of Peter the Wild Boy and
of the young savage of Aveyron, has proved that these were really
cases of defective organization—pathological specimens.? The
interést of them lies in this, that as idiots show a rude re-
version sometimes towards a lower type of brain which is
natural to a lower animal, so in their habits and instincts they
sometimes exhibit evidence of a reversion to the fundamental
instincts of animal nature.

In some idiots and imbeciles, especially those of the Cretin
type, where the morbid condition is endemic, the defect seems
to depend on certain morbid changes which affect primarily the
skull rather than the brain. -Injurious influences, affecting the
general processes of the bodily nutrition, prevent the normal
growth of the bones, which undergo a premature ossification of
their sutures; the consequence of which is that the general
expansion of the skull, which should take place as the
brain grows, is prevented, or that a narrowing of the skull is
produced at the part where this happens. Secondary wide
interference with the development of other parts of the skull
and compensating enlargements in other directions follow the
primary evil when it is partial, and give rise to cranial defonni-

1 Absence or defect <f the corpus callosum has teen sometimes met with
after death, but seldom ; other cerebral deficiencies will commonly coexist
with it; and in most of the cases of this sort there was idiocy or some
degree of mental weakness during life. Dr. Julius Sander has collected
ten cases, which appear to be all the cases hitherto recorded of this defect,
and described them in Griesinger’s Archiv fir Psychiatrie und Nerven-
krankheiten, b. 1. 1868.

2 Observations on the Deranged Manifestations of the Mind. By J. S.
Spurzheim, M.D. Also Lectures on Man, By W. Lawrence, F.R.S.
v.] THE CAUSATION AND PREVENTION OF INSANITY. 179

ties of various kinds. It is common to observe in imbecile
children, especially in such as are of a scrofulous tempera-
ment and in those who have an insane inheritance, a very
narrow and deeply arched palate, which is described as saddle-
shaped ; it is a deformity which seems to be connected with a
defective growth of the bones at the base of the skull; and
when it exists without actual imbecility it usually goes along
with only a slender understanding. Of necessity the natural
growth of the brain is hindered by those morbid changes; and
it is no wonder that the deformed head is accompanied with a
torpid, apathetic character and with great mental deficiency.
However, the defects of brain and bone may be concomitant
effects. As the evil changes are commonly not manifest until
a year or more after birth, an objection might well be made to
the description of them as original defects; but whatever the
real nature of the deterioration of nutrition which is at the
bottom of the mischief, whether it be of malarious or scrofulous
nature, it admits of no question that it acts upon the child
through the mother perniciously, and predetermines its defect.

An arrest of the development of the brain occurring soon after
birth may give rise to idiocy just as certainly as an arrest which
has taken place some time before birth. Specious objection
might be made to the description of the defect as original; but
when we reflect that the important development of the brain as
the supreme organ of the conscious life, as subserving the mental
organization, really takes place after birth,we may admit that
a defect which frustrates development is practically original,
albeit not strictly congenital. There are not a few idiots in
whom the brain and body appear to be well formed, while the
mental development remains at the lowest stage. Epilepsy
is oftentimes such a cause of idiocy, but it is not possible in
all cases to assign a definite cause of the arrest.

In some instances of apparently normal brains with deficient
intellect, it is found on examination that the ventricles are
more or less dilated and contain more thau their normal quan-
tity of serous fluid ; intermediate conditions, indeed, are met
with between the normal state in this respect and the vastly
dilated ventricles and expanded cerebral substance of the
180 PATHOLOGY OF MIND. [cHaP.

extremely hydrocephalic brain. In other instances where the
brain looks normal to the naked eye, or is actually hypertrophied,
microscopic examination has shown that its normal or abnormal
size is owing not to the natural quantity or to a natural increase
of its proper elements—namely, the nerve-cells and fibres,—
but to an abnormal increase of the connective substance, entail-
ing perhaps eventual atrophy of them.and their capillaries, In
other instances the pathologist cannot find the hidden defect in
the seemingly perfect organ; nor need we wonder much at
that when we reflect that most important intimate physical and
chemical changes may exist without being detected by any
means of research that we are yet in possession of, There is
nothing indeed to prevent whole territories of cells in the cere-
bral convolutions being wanting without the pathologist being
able to find it out. Lastly, the fault may lie in the distribution,
quality, and activity of the blood circulating in the brain; the
active supply of good blood which is necessary to full and quick
intelligence being prevented, either by a defective quality of the
blood occurring as a part of the general defective nutrition, or
by a feeble or defective heart, which is not very uncommon
in idiocy.

Other idiotic creatures have the development of body as well
as mind arrested. The extremest cases of the kind are those in
which there has been a complete cessation of growth at an early
period of childhood, without any observable deformity. Dancel
has recorded the case of a girl, aged twenty-four, who had deve-
loped normally up to the age of three and a half years, after
which no further growth took place until she reached eighteen
and a half years, her bodily and mental condition being that of
a child of three anda half years eld. At twenty-one she in-
creased a little more in size, and then remained unchanged for
the rest of life. Baillarger exhibited, in May, 1857, to the French
Academy of Medicine, a young woman aged twenty-seven, who
had only the intelligence and inclinations of a child four years
old, and who was about three feet high. I have seen a some-
what similar instance in an idiot man. Such extreme cases are
well suited to excite surprise and curiosity ; they are, however,
only gross results of a deficiency in developmental power which
v.] THE CAUSATION AND PREVENTION OF INSANITY. 181

is often met with in a less degree, and which is actually wit-
nessed in every degree. The truth is, that every element of
the body shares usually in the defective vitality of idiocy. In
any large idiot asylum idiots are to be found who, without any
particular deformity, without any observable disease or defective
development of brain, are generally sluggish both in bodily and
mental development ; their size is small; their sexual develop-
ment takes place late in life, or perhaps does not take place
at all; their circulation is languid, and their sensibilitics are
extremely dull; their movements are not brisk, but feeble and
heavy, and sometimes partially paralyzed; their skin gives off
an offensive odour; their teeth are carious and soon drop out.
In mental capacity they are in advance of the true idiots,
for they can learn a little, are capable of remembering, and
perhaps imitate cleverly: some of them constitute the “show-
cases” of the idiot asylum when they are in it; and, when
they are not, they may become difficult cases for medico-legal
inquiry, if, in consequence of the strength of their passions
and of their deticiency of moral power, they do some deed of
criminal violence, as they are more likely to do after puberty
than before it. All the concern that we have with them here is to
draw from them the certain conclusion that there may, by reason
of unknown conditions affecting nutrition, be every degree of
imperfect development of mind and body down to actual incapa-
city to develop at all; wherefore imbecility cannot be measured
by any constant standard, but must always be a matter of degree.

The causes of the defective cerebral development which is the
physical condition of idiocy are often traceable to parents. Fie-
quent intermarriage in families seems in some cases to lead to
a degeneration which manifests itself in individuals by deaf-
mutism, albinoism, and idiocy. Parental intemperance and
excess, according to Dr. Howe, hold high places as causes of
convulsions, idiocy, and imbecility in children; out of 300 idiots
in the State of Massachusetts, whose histories were investigated by
him, as many as 145 were the offspring of intemperate parents.”

1 On Consanguineous Marriages.” By Arthur Mitchell, M.D.—Edin-

burgh Medical Journal, 1865.
2 Report on the Causes of Idiocy in the State of Massachusetts.
182 PATHOLOGY OF MIND. [cHaP.

But other inquirers who have been at the pains to critically test
his statistics have not been able to accept so high a proportion.
It is not doubted that the parent who makes himself a temporary
lunatic or idiot by his degrading vice does sometimes propagate
his kind in procreation, and entail on his children the curse of a
hopeless fate. Many remarkable instances have been recorded
by different authors. Guislain mentions a family of maniacs
born of a woman who was drunk every day. Inthe Mechanics’
Institution at Manchester are the casts of the small heads of
seven idiots ; their father was a desperate drunkard, and as he
kept a public-house, he was almost always drunk, or had just
been sv, or was about to become so. Nothing particular was
known of the habits of his wife. They had eight children, the
first seven of whom, who were the idiots in question, were born
while the father was under the influence of his drunken habits.
Having dissipated his property he had no longer the means to
get drunk, and the last child, a daughter, which was born while
he was sober from compulsion, was perfectly sane, and was
married in due course “ A man,” says Marcé, “who had several
times, in consequence of excessive drinking, had symptoms of
insanity, married twice: with his first wife he had sixteen child-
ren, fifteen of whom died within a year of convulsions; the
survivor is epileptic. With his second wife he had eight
children; seven have fallen victims to convulsions, and the
eighth is scrofulous.”* The natural term of insanity proceeding
unchecked through generations is, as Morel has shown, sierile
idiocy. When man frustrates the purposes of his being, and
selfishly ignores the laws of hereditary transmission, nature takes
the matter out of his hands and puts a stop to the propagation
of degeneracy. Great fright or other mental agitation affecting
the mother during gestation, or irregularities and excesses on
her part, and injury to the child’s head during parturition, may
occasion a congenital mental defect init, But many of the causes
of idiocy operate after birth up to the third or fourth year.
They are epilepsy, the acute exanthemata, perhaps syphilis, and
certainly starvation, dirt, and overcrowding.

1 Dr. Noble, Elements of Psychological Medicine.
2 Traité Pratique des Maladies Mentales. Dr. L. V. Mareé, 1862.
v.]) THE CAUSATION AND PREVENTION OF INSANITY. 168

When there are no such signs of degeneracy as warrant the
suspicion of idiocy or imbecility, there is still large room for
physical causes of psychical defect which we cannot detect. The
sensibility of nervous structure, whereby an impression made
at one point is almost instantaneously felt at any distance, is
the consequence of delicate, active, but occult movements of
its molecules, which, like thermal oscillations or undulations of
light, or the intimate molecular conditions of colour, belong to
that inner life of nature that is still impenetrable to our most
delicate means of investigation, still inaccessible to our most
subtile inquiries. Who can declare the nature of those hidden
molecular activities which are the direct eauses of our different
tastes and smells? Could we but learn what these intimate
operations essentially are, we might perhaps attain to a know-
ledge of the intimate constitution of bodies which we hardly
dream of now ; indeed it seems not impossible that in the scien-
tific cultivation and development of the senses of taste and
smell, as the eye, the ear, and the touch have been cultivated
and developed, we may ultimately gain some means of insight
into the inner recesses of nature.

A second reason why there may be numerous and serious
defects of nervous structure which cannot yet be discovered
is based upon the infinitely complex and exquisitely delicate
structure of the cortical layers of the hemispheres. It must
be confessed that many physical paths of nervous function in
the supreme centres may be actually obliterated without our
being any the wiser, for it was only yesterday, so to speak,
that men succeeded, after infinite patient research, in demon-
strating a direct communication between the different nerve-
cells, and between nerve-fibres and cells. The obliteration
of such a physical communication in the supreme centres
might plainly render impossible a certain association of ideas,
or the transference of the activity of the idea to an out-
going nerve-fibre—a particular function and expression of
mind. The convolutions being formed of several delicate
superimposed layers, it is natural to suspect that the defective
intelligence of idiocy may be due to a defective development
or to an entire absence of one or other of the higher of these

9
184 PATHOLOGY OF MIND. [cHar.

layers, which may be presumed to minister to the more abstract
functions of mind.

Thirdly, it must be admitted that, all question of defect of
physical structure put aside, the extremest derangement of func-
tion may be due to chemical changes in the complex constitution
of nerve-element—changes which, in the present state of know-
ledge, are still less discoverable than physical changes. Examine
the cells of a man’s brain at the end of a day of great mental
activity, and at the beginning of a day after a good night's
rest; what difference would be detectable? None whatever;
yet the actual difference is between a decomposition and a
recomposition of nerve-element—between a capacity and an
incapacity of function.

It is beyond question, then, that there may be modifications of
the polar molecules of nerve element, changes in its chemical
composition, and defects in the physical constitution of nervous
centres, which, entirely undetectable by us, do nevertheless
gravely affect function, and are so attested. As defective sensi-
bility and motility betray defective motor and sensory centres,
so defective intelligence betokens defective mind-centres,

This is a conclusion which ought to be kept well in mind
when we are tempted to speculate concerning the unknown
physical conditions of an inherited predisposition to insanity.
To affirm that all men are born equal, as is sometimes heedlessly
done, is to make as untrue a proposition as it is possible to
make in so many words. There is as great a variety of minds
as there observably is of faces and of voices: as no two faces
and no two voices are exactly alike, so are no two minds exact
counterparts of one another. Each person presents a certain
individuality, characteristic marks of features and disposition
which distinguish him from any other person who may resemble
him ever so closely ; and I hold it to be true that every special
character which is displayed outwardly is represented inwardly
in the nerve-centres—that it is the outward and visible sign of
an inward and invisible constitution of nerve-structure. Men
differ greatly, then, both in original capacity and in quality of
brain: there is a continuity of intelligence between the highest
genius and the lowest stupidity, distinguished men being raised
v.J TIE CAUSATION AND PREVENTION OF INSANITY. 185

as much above the average standard of ability as idiots are sunk
below it. In some persons there is the potentiality of great and
varied development, whilst in others there is the innate inca-
pacity of any development. There are manifest differences
in the fundamental functions of reception and retention: in
some the mental reaction to impressions is sluggish and in-
complete, and, without being idiots, they are slow at perception
and stupid; in others, the reaction, though not quick, is very
complete, and they retain ideas firmly, although they are slow
in acquiring them; in some, again, the reaction is rapid and
lively, but evanescent, so that, though quick at perception, they
retain ideas with difficulty; while in others the just equili-
brium between the internal and external exists by which the
reaction is exactly adequate to the impression, and the conse-
quent assimilation is most complete. These natural differences
in the taking up of impressions plainly hold good also of the
further processes of digestion and combination of ideas, which in
the progress of mental development follow upon the concrete
perception. It is easy to perceive then that we have, as original
facts of nature, every kind of variation in the quality of mind
and in the degree of reasoning capacity, and that it is as gross a
mistake to endow all persons with a certain fixed mental poten-
tiality of uniform character as it would be to endow them with
the potentiality of a certain fixed bodily stature.

Viewed on its physical side, as it rightly should be, a predis-
position to insanity means an-actual defect or fault of some kind
in the constitution or composition of the nerve element which
functions as mind; there is an instability of organic composition,
which is the direct result of certain unfavourable physical ante-
cedents. The retrograde metamorphosis of mind, manifest in
the different kinds of insanity, and proceeding as far as actual
extinction in extreme dementia, is the further physical conse-
quence of the hidden defect. I have insisted much that the
physical structure of the mental organization embodies in its
nature and gives out in its function the kind of activity which
determined its formation, and I desire now to have it particu-
larly noticed that the defective nerve-structure of an insane
predisposition is an example of this truth. Jt owes its unstable
186 PATHOLOGY OF MIND. [cHar,

nature to the unstable and ill-regulated conduct of parents or
other ancestors; being the materialization of past, it is the
potentiality of future, irregularities. It is easy to point, on the
one hand, to the nervous substance of the infertile idiot’s brain,
and on the other hand, to that of the philosopher’s, and to main-
tain that the kind of nerve-structure of which they are con-
stituted is the same, as it certainly appears to be; but so long
as we have no exact knowledge of the constitution of nerve-
element such an assertion is an unwarrantable assumption,
and, while the functional effects are so vastly different in the
two cases, there are valid reasons to contradict it.

The conclusion, then, which we have reached is, that an indi-
vidual who, by reason of a bad descent, is born with a predis-
position to insanity has a native nervous constitution which,
whatever name may be given to it, is unstable or defective,
rendering him unequal to bear the severe stress of adverse
events. In other words, the man has what I have called the
insane temperament. Were it thought fitting to give a name to
this temperament or diathesis, as in algebra we use a letter to
represent an unknown quantity, it might properly be described
as the Diathesis spasmodiea or the Neurosis spasmodica ; such
names expressing very well an essential character of the tem-
perament—that is, the want of equilibrium between the different
nervous centres, their tendency to in-coordinate and disruptive
action. There is some inherent instability of nervous element
whereby the mutual reaction of the nerve-centres in the higher
-walks of nervous function does not take place properly, and due
consent or co-ordination of function is replaced by irregular
and purposeless independent action. The person is prone under
all circumstances to strange or whimsical cranks of thought and
caprices of feeling, or to eccentric or extravagant acts, and likely
under the pressure of extraordinary circumstances to suffer an
entire overthrow of his mental equilibrium: there is, as it were,
a loss of the power of self-control in the nerve-centres, an inca-
pacity of calm, self-contained activity, subordinate or co-ordinate,
and energy is dissipated in explosive discharge, which, like the
impulsive action of the passionate man, surely denotes an irrit-
able weakness. For here, as elsewhere, co-vrdination of function
v.]) THE CAUSATION AND PREVENTION OF INSANITY. 187

signifies power, innate or acquired, and marks exaltation of
organic development; self-restraint being a higher power than
self-abandonment.

Is it not plain how impossible it is to do full justice to any
individual, sane or insane, by considering him as an isolated
fact? Beneath his conscious activity and reflection there lies
the unconscious inborn nature which all unawares mingles con-
tinually in the events of life—the spontaneity whence spring
the sources of desire and the impulses of action; for the con-
scious and the unconscious, like warp and woof, together con-
stitute the texture of life. No one, be he ever so patient and
aptin dissimulation or crafty in reticence, can conceal or mis-
’ represent himself always; in spite of consummate art his real
nature reveals itself constantly by slight and passing signs, of
which he is himself unaware, in the movements of the part
which he plays, and bursts out of the restraints of hypocrisy
in the most earnest pulsations of his life. The inborn nature
constitutes the foundation upon which all the acquisitions of
development must rest; it is the substratum in which all con-
scious mental phenomena are rooted. When it is defective
radically, no systematic labour will avail to counterbalance
entirely the defect: if the attempt be made to build the super-
structure of a large, vigorous, and complete culture upon the
rotten foundations which an inherited taint of nerve element
implies, something will be wanting; some crack in the building
will betray the cuatirbility of the foundations, even when the
whole structure does not fall “in ruin hurled.” Any mental
philosophy which takes not notice of the foundations of the
character, but ignores the important differences of individual
nature, does not truly reflect the facts, and must be provisional
and transitory. It is guilty of the same error as that into which
an introspective psychology falls when, isolating the particular
state of mind, and neglecting the antecedent conditions upon
which it has followed, it pronounces the will to be free; by
isolating the individual, and forgetting that he is but a link in
the long chain of nature’s organic evolution, it transforms him
into an abstract and impossible entity, and often judges his
actions with an unjust judgment
188 PATHOLOGY OF MIND. [cwar.

Here I have the misfortune to be in seeming contradiction
with so sound and sober a thinker as Locke, who, admitting
natural faculties to be great gifts, declares acquired habits to be
of more value, and many excellences which: are looked upon as
natural endowments to be, when examined into more narrowly,
the product of exercise. “Defects and weaknesses in men’s un-
derstandings,” he says, “come from a want of right use of their
minds. There is often a complaint of want of parts, when the
fault lies in a want of a due improvement of them.” No doubt
that is so; at the same time it is certain that there is often-
times a want of parts which no training will make good, and
that the hope of training rests upon a possession of the ordinary
gifts of nature. If a-man’s nature have a radical flaw in it, he
can no more get entirely rid of it by training than the idiot,
whose want of parts is incontestable, can raise his intelligence
to the average level by much study, or than a short man can, by
taking thought, add one cubit to his stature. Acquired habits
may do much to compensate natural deficiencies, but the mis-
fortune is that the deficiency often shows itself in a constitutional
inability to acquire the habit. Moreover, superior excellences
of parts can only be built upon corresponding foundations.

2. Quantity, Quality, and Distribution of the Blood.—The grey
centres of the brain, and the cortical layers of the hemispheres
especially, are richly supplied with blood-vessels, even when
comparison is made with the notably abundant supply of the
spinal centres; fully one-fifth of the whole quantity of the
blood in the body going to the head. The ideational centres
need for the due exercise of their functions a rapid renewal ot
arterial blood, an active interchange of some kind continually
going on between it and their elements; indeed, as I have pre-
viously argued, the life of a nerve-cell may be looked upon as a
continual metastasis, its substance being decomposed during
function and recompounded during rest, and the blood being the
agent that brings what is wanted for repair and carries away
what is effete after function, The quantity and quality of the
blood, therefore, circulating through the supreme centres, must
affect their functions in an important manner, as will appear
more clearly when it is considered that they are the most sensi-
v.] THE CAUSATION AND PREVENTION OF INSANITY. 189

tive elements of the body in this regard. When the most expert
chemist is unable to detect anything unusual in the atmosphere
of a room in which many people are met together, a delicate
woman may get a headache and actually faint away. If a mix-
ture of air and carbonic acid in certain proportions be inspired
like chloroform, it will, like it, act as an anesthetic, paralyzing
consciousness ; and if the blood be charged with a stronger dose
of the gas, the nerve-elements are stifled outright.

Weken there is a rapid flow of healthy blood through the
supreme cerebral centres, a quick interchange goes on between it
and the nerve-cells, and the excitation and interaction of ideas
proceed with vivacity. The effect of active thought is to produce
such a determination of blood, which in turn is the necessary
condition of the continuance of the active function. But when
a natural determination of blood degenerates into a greater or
less stasis or congestion, as it may easily do when intellectual
activity is too much prolonged, or when congestion is other-
wise produced, then there is an inability to think ; torpor and
confusion of thought, depression and irritability, swimming in the
head, disturbance of sight and of hearing, delirium and convul-
sions in the worst event, testify to a morbid condition of things.
It is striking how completely a slight congestion of the brain
will incapacitate a person for mental activity, and how entirely
the strong man is prostrated thereby: an afilicting stagnation of
ideas accompanies the stagnation of blood; and he, heretofore
so strong and self-confident, realizes in vivid affright on how
slight a thread hangs the whole fabric of his intellect. If the
morbid state should, instead of remaining passive, or passing
away altogether, become active, as it does when actual inflam-
mation occurs, then the function of the cerebral centres becomes
irregular and degenerate; co-ordination is lost, as it is in the
spinal cord under like circumstances, and a wild and incoherent
delirium attests the independent and, if I might so speak, con-
vulsive action of the different cells: the delirious ideas are the
expression of a condition of things in the supreme centres which
is the counterpart of that which in motor centres utters itself
in spasmodic movements or convulsions. The destruction of
co-ordination of function is the abolition of volition; and such
190 PATHOLOGY OF MIND. [cap,

purposeless or dangerous acts as the delirious being performs are
dictated by the morbid ideas that are excited by the abnormal
physical condition. Some writers have thoughtlessly spoken of
this degenerate activity in its earlier stages as increased mental
activity, as they have also spoken of active inflammation as
increased vital action; not otherwise than as if convulsions
were accounted signs of strength, or as if the tale of an idiot,
because it is full of sound and fury, though signifying nothing,
were the index of high mental activity.

Dr. Mason Cox pointed out long ago that the pulses in the
radial and carotid arteries sometimes differed from one another
in the insane, being soft and weak in the former—for it is seldom
much affected at the wrist even in active madness—when it was
full and hard in the latter; and Dr. Burrows, who also called
attention to irregularities and discrepancies in arterial pulsa-
tion, took notice that the carotids might differ from each other,
and both or either of them from other arteries. Of no small
interest, in relation to the influence of the supply of blood to the
brain, are the vigour and revival of function that are sometimes
imparted by an attack of fever to brain enfeebled by chronic
insanity ; patients in even advanced state of disease may be-
come quite rational for a time during fever, and relapse after
its subsidence; or a demented patient, who usually exhibits no
spark of intelligence, may quicken into acertain mental activity.

1 Examples of such temporary revival of cerebral functions during
fever have been related by various authors, and are well known to physi-
cians who have much to do with the insane. The following may suffice
here :—‘* The following case, related to me by a medical friend, will serve
to show that even in idiocy the mind may be rather suppressed than
destroyed. A young woman, who was employed as a domestic servant by
the father of the relater when he was a boy, became insane, and at length
sank into a state of perfect idiocy (dementia). In this condition she
remained for many years, when she was attacked by a typhus fever; and
my friend, having then practised some time, attended her. He was sur-
prised to observe, as the fever advanced, a development of the mental
powers, During that period of the fever when others are delirious, this
patient was entirely rational. She recognized, in the face of her medical
attendant, the son of her old master whom she had known so many years
before ; and she related many circumstances respecting the family, and
others which liad happened to herself in her earlier days. But, alas! it
was only the gleam of reason; as the fever abated, clouds again enveloped
the mind ; she sank into her former deplorable state, an.l remained in it
v.] THE CAUSATION AND PREVENTION OF INSANITY. 191

Several cases have been recorded in which actual recovery from
insanity has followed an intercurrent attack of typhvuid fever,
scarlatina, and variola; but the rule certainly is that the ame-
lioration or modification of the mental state which commonly
occurs during the fever passes away as the fever subsides. It
may be presumed that the excitement and the quickened circu-
lation of the brain either stimulate the indolent and exhausted
nerve-cells in which force is generated, or open up obstructed
paths of association, not otherwise than as the stimulus of alcohol
stirs up forgotten ideas in a healthy brain and quickens their
associations. If this be so, it is an interesting proof that the
nerve-cells and the paths of normal association are not so
damaged or broken up as to be beyond restoration even in ad-
vanced madness ; the former are deadened and the latter blocked,
as it were, but the continuity of structure is preserved; and
both are capable of doing their proper work again when reani-
mated by a strong stimulus of a suitable kind.

Since the time of Hippocrates it has been known that when
there is too little blood in the brain symptoms are exhibited very
like those which are produced by a congestion of blood: pain and
swimming in the head, mental torpor and confusion of thought,
affections of the senses and of movement, and ‘in extreme cases
convulsions and delirium, occur in consequence of anemia of the
brain as certainly as they do in consequence of congestion. In
both cases the due nutrition of the nerve-cell, which is the agent
of cerebral function, is greatly hindered; and much of the ill
effect is similar, though the cause appears to be so different.
The intimate causes are not so different as they seem, when we
proceed to analyze the conditions comprised under the terms
anemia and congestion. In that unceasing active relation
between the organic element and the blood by which the due
reparative material is brought and waste matter carried away,
1U amounts to much the same thing whether, through congestive
stasis of the blood, the refuse is not carried off and reparative
material brought to the spot where it is wanted, or whether a

until her death, which happened a few years afterwards.”—Description of
the Retreat near York, p. 137. By Samuel Tuke. 1813. See also Journal
of Mental Science, July, 1872.
192 PATHOLOGY OF MIND, [-map.

like result ensues by reason of a defective blood and deficient
circulation: it is little matter to the inhabitants whether the
street is blocked, or whether its entrance is closed, so long as
free circulation is prevented.

If the carotid arteries of a dog be tied, and pressure be then
made on its vertebral arteries, as was done by Sir A. Cooper,
the functions of the brain are entirely suspended; the animal
falls into a deep coma, its respiration ceases in a few moments,
and it appears to be dead; but if the pressure be removed from
the vertebral arteries, the manifestations of life reappear, and
the animal regains rapidly the integrity of its cerebral functions.
In like manner sleep may be produced in the human subject by
strong pressure upon the carotid arteries in the neck; and if we
may believe the authority of an old writer on insanity, such
pressure has, while it was continued, actually suspended mental
excitement sometimes, and restored intelligence. In melan-
cholia and in dementia the laigtid ‘circulation in the cold and
livid hands and almost insensible skin is very notable; and it
is plain that if the cerebral circulation is in anything like the
same relaxed and feeble state there is quite enough to account
for the mental symptoms. The wanderings of mind just before
going to sleep, the delirium which breaks out sometimes as
convalescence from fever sets in, the distress of the melancholic
patient when he wakes in the morning, are perhaps due in part
to a diminution of the proper blood-supply to the brain, It
shouldbe noted that an irregularity in the blood-supply with
consequent derangement of nutritive action will lead to a con-
dition of brain comparable with what we call zrritation in other
organs ; falling short of, actual inflammation, it is marked by
an undue impressionability, a diminution of proper functional
energy, a ready excitability to action of a perverted kind; and
it is the exact counterpart in the highest centres of a similar
condition in the sensory and motor centres which, similarly
caused, shows itself in those perversions of sensation and motion
which are classified as hypersesthesia and hyperkinesia.

Temporary irregularities in the supply of bleod to the
supreme nervous centres may, and often do, pass away without
leaving any ill consequences behind them ; but when they recur
v.] THE CAUSATION AND PREVENTION OF INSANITY. 193

frequently, and beco:ne more lasting, their disappearance is by
no means the disappearance of the entire evil: the effect has
become a cause which continues in action after the original cause
has been removed; and permanent mental disorder may be thus
established. Once the habit of morbid action is fixed in a part,
it continues as naturally as, under better auspices, the normal
physiological action. It is always, therefore, of great import-
ance to give timely heed to the earliest warning of its presence
which morbid action gives; but it is of paramount import-
ance to do so in the case of organic element so exceedingly
susceptible and so exquisitely delicate as nerve element.

It is a question whether one has not to do with local rather
than with general irregularities of the circulation in most cases
of mental derangement in which there is reason to suspect
vascular disturbance. So little do we yet know exactly of the
intimate physiology of the vaso-motor system that we can only
guess at the precise character and mechanism of these local
irregularities; but we know enough to be sure of a wide-reach-
ing and important function of the vaso-motor system in the
economy. Mental causes may no doubt occasion them ; itis pro-
bable that all active emotions are accompanied by changes in
the circulation through vaso-motor inhibition, and that such
vascular disturbances may be produced by them within the
brain very much as blushing is produced over the face and neck
by shame, or as relaxation of the sphincters is sometimes caused
by fear. Then again circulation-disturbances within the brain
will react upon the innervation-centres of the heart and large
vessels within the medulla oblongata, and so affect the pulse
secondarily : in melancholia, for instance, we sometimes notice
a slow, irregular, and intermittent pulse, while the patient is
depressed and anxious and apprehensive, which becomes full
and regular so soon as the anxiety and apprehension pass off.
Severe primary disease of the brain probably acts upon the
pulse through the same mechanism; for a pulse of about sixty-
eight, quick and jerky, not actually intermittent, but irregular,
being now faster and now slower, without any evident regularity
in its irregularities, is thought to warrant a strong suspicion
of the existence of such disease. -\bdominal disturbances will
194 PATHOLOGY OF MIND. [cuap.

also gravely affect the cerebral vaso-motor centres ; in relation to
which an experiment by Goltz is instructive. On tapping
sharply on the abdomen of a frog the heart and vessels of which
he had previously exposed, he found that after a tap or two the
heart stopped, beginning to beat again after a short pause. At
the same time the abdominal vessels, especially the veins,
dilated widely. The tapping irritates the mesenteric nerves ;
the impression is transmitted by them to the inhibitory centres
in the medulla; and the consequence is, first, inhibition of the
heart, and, secondly, of the vaso-motor centres of the intestinal
vessels, What is to hinder disorder of an abdominal organ
from producing in like manner a local circulation-disturbance
within the brain? We know it will produce a condition favour-
able to certain emotional moods, and we suspect such moods
to be accompanied by vascular changes. The more closely we
look, the more clearly it appears that the phenomena .of the
whole mental and bodily economy form one circle of operations,
essentially interworking, and ever coming back upon one another.
. A vitiated blood quickly affects the function of the supreme
cerebral centres. Alcohol yields the simplest instance in illus-
tration of the disturbing action on mind of a foreign matter
introduced into the blood from without: here, where each phase
of an artificially produced insanity is passed through suc-
cessively in a brief space of time, we have the abstract and brief
chronicle of the history of insanity. Its first effect is to pro-
duce an agreeable excitement, a lively flow of ideas, and a
general activity of mind—a condition not unlike that which
oftentimes precedes an attack of mania; then there follow, as
in insanity, sensory and motor troubles and the automatic exci-
tation of ideas which start up and follow one another without
order, so that more or less incoherence of thought and speech is
exhibited, while at the same time passion is easily excited,
which takes different forms according to the individual tempera-
ment; after this stage has lasted for a time—in some longer, in
others shorter—it passes into depression and maudlin melancholy,
as convulsion passes into paralysis; the last scene of all being
one of dementia and stupor. The different phases of mental
disorder are compressed into a short period of time because the
v.] THE CAUSATION AND PREVENTION OF INSANITY. 195

action of the poison is quick and transitory ; but we have only
to spread the poisonous action over years, as the regular
drunkard does, and we get a chronic and enduring insanity in
which the foregoing scenes are more slowly acted. Or, if death,
cutting short the career.of the individual, puts a stop to the
full development of the tragedy in his life, we may still have it
played out in the lives of his descendants; since the drunkenness
of the parent sometimes becomes the insanity of the offspring,
which thereupon, if not interfered with, goes through the down-
ward course of degeneracy described. It is worth while to take
note by the way how differently alcohol affects different people
according to their temperaments, ever bringing forward the
unconscious real nature of the person: one it makes a furious
maniac for the time being; another it makes maudlin and
melancholic; and a third under its influence is stupid and
heavy from the beginning. So it is with insanity otherwise
caused: the individual constitution or temperament, rather than
the exciting cause of the disease, determines the form which the
madness takes. An exact differential pathology would involve
the vastly difficult knowledge of what constitutes individual
temperament. .

Other poisons besides alcohol, such as opium, belladonna,
Indian hemp, stimulate and ultimately derange the function of
the supreme cerebral centres. It is interesting to notice that the
different nervous centres of the body evince elective affinities
for particular poisons: while the spinal motor centres have a
special affinity for strychnine, the cerebral centres seem to -be
untouched by it ; belladonna, on the other hand, rather depresses
spinal activity, but acts powerfully upon the centres of con-
sciousness, giving rise, at an early period of its action, to
delirium characterized by hallucinations and illusions; and
Indian hemp seems to act mainly on the sensory centres,
exciting remarkable hallucinations, That medicinal substances
do display these elective affinities is a proof, at any rate, that
there are important intimate differences in the constitution or
composition of the different nervous centres, notwithstanding
that we are unable to detect the nature of them; and it may
be we have in these different effects of poisons on the nervous
196 PATHOLOGY OF MIND. [cizap.

system the promise of a useful means of investigation into the
constitution of the latter. Albeit the rapid recovery which
takes place from the effects of these poisons proves that the
combinations which they form with nerve element are tem-
porary, it must be borne in mind with regard to them, as with
regard to alcohol, that’ the nervous system, when repeatedly
exposed to their poisonous influence, acquires a disposition to
irregular or morbid function, even when they are not present ;.
so that more or less marked mental disorder ensues sometimes
from their continued abuse: they are efficient to initiate a de-
generacy which then goes on of itself. The paralysis produced
by lead and mercury in workmen who have been long exposed
to their poisonous effects, and the utter mental prostration and
fatuity that are witnessed in the worst cases, are further proofs
of the injurious action upon nerve-centres of poisons that may
be detected in, and extracted from, the tissues.

Bui the condition of the blood may be vitiated by reason of
something bred in it, or by reason of the retention in it of some
substance which should rightly be excreted from it. Without
any change whatsoever having taken place in his external
relations, the presence of bile in his blood shall drive a person
to regard his surroundings and his future in the gloomiest light
imaginable ; he may know that a few hours ago things looked
quite otherwise, and may believe that in a few hours more they
will again have a different aspect, yet for the time being he is
a victim of a humour which he cannot withstand. Philosophy
is of little avail to him; for philosophy cannot rid him of that
condition of nervous element which the impure blood has
engendered, and which is the occasion of his gloomy feelings
and painful conceptions. Carry this morbid state of nervous
element to a further stage of depression and make it last, there
ensues the genuine melancholia of insanity. In like manner the
presence of some product of incomplete nutrition in the blood
of a gouty patient gives rise to an irritability of temper which
no strain of mental control can remove, though it may succeed
sometimes in suppressing its manifestations. The mental tone
being, as already set forth, the expression of a physical condition
of nervous element, is sometimes beyond conscious mauagemeut,
v.] THE CAUSATION AND PREVENTION OF INSANITY. 197

just as the delirium and convulsions of the patient dying from
uremic poisoning are beyond control. All writers on gout are
agreed that a suppressed gout will produce severe mental dis-
order, and that the sudden disappearance of a gouty swelling is
sometimes followed by such an outbreak. After the cessation
of the inflammation of the joints gouty mania sometimes occurs,
characterized by acutely inaniacal symptoms, with heat of head
and fever; ending favourably in the slighter cases, but in
severer cases passing into inflammation of the membranes,
serous effusion, and coma. Lord Chatham, who was so great a
martyr to the disease, had an attack of distressing melancholy
lasting for nearly two years, from which he only recovered after
an attack of the usual gouty paroxysm, which had not occurred
once during the season of his mental disorder. Most writers on
insanity and on gout make mention of persons subject to fre-
quent attacks of gout who had none while sutfering from an
attack of insanity.

It admits of no question that every degree of mental disorder,
from the mildest feeling of melancholic depression to the extrem-
est fury of delirium, may be due to the non-evacuation from the
blood of the waste matters of the tissues ; but as we know very
little at present of the nature of those waste products of retro-
grade metamorphosis, and of the different transformations which
. they undergo in the body before they are eliminated by excre-
tion, we must rest content with the general statement, and set
ourselves in practice to prosecute rigorous inquiries into the par-
ticular instances. Irregularities of menstruation, which are so com-
mon in insanity, are of importance in regard to this question;
the return of the function at its due season not unfrequently
heralding recovery, and, on the other hand, severe exacerbations
of epilepsy and insanity coinciding often with the menstrual]
period. Whether the case be one of mere retention in the
blood of what should be excreted from it, or whether nervous
sympathy plays the greater part in what takes place, I know
not; but there can be no doubt of the fact that menstruation is
oftentimes suppressed during an attack of mental derangement,
and of the second fact that cases are on record, morc or less
like that well-known one related by Esquirol of an insane girl
198 PATHOLOGY OF MIND. [cuar.

whose menses had ceased for some time, and who recovered her
senses directly they began to flow.

When we reflect that the blood is itself a living, developing
fluid—that, “burnished with a living splendour,” it circulates
through the body, supplying the material for the nutrition of
the various tissues, receiving again their waste matter and
carrying it to those parts where it may either be appropriated
by nutrition or eliminated by secretion,—it is plain that multi-
tudinous changes are continually taking place in its constitution
and composition ; that its existence is a continued metastasis.
There is wide possibility, thérefore, as there is partial evidence,
of abnormal changes in some of the manifold processes of its
complex life and function, such as may generate products
hurtful or fatal to the nutrition of the different tissues. The
blood itself may not reach its proper growth and development
by reason of some defect in the function of the glands that
minister to its formation, or, carrying the cause still further
back, by reason of insufficient food and of wretched conditions
of life; there is in consequence a defective nutrition generally,
as in scrofulous persons, and the nervous system shares in the
general delicacy of constitution; though quickly impressible
and lively in reaction, it is irritable, feeble, and easily exhausted.
Poverty of blood, without doubt, plays the same weighty part
in the production of insanity as it does in the production of
other nervous diseases, such as hysteria, chorea, neuralgia, and
even epilepsy. In the condition known as anzmia, we have an
observable defect in the blood and palpable nervous. suffering
in consequence ; headaches, singing in the ears, sparks of light
before the eyes, giddiness, low spirits, and susceptibility to
emotional excitement reveal the morbid effects. The exhaustion
produced by lactation in some constitutions is a recognized
cause of mental derangement; and a great loss of blood during
childbirth has sometimes occasioned a sudden outbreak. The
delirium of starvation is probably an anemic delirium; it
is marked by mental prostration and imbecility in the
beginning, and then by maniacal delirium, perhaps with visual
hallucinations, which is followed by coma and death, with or
without convulsions,
v.] THE CAUSATION AND PREVENTION OF INSANITY. 199

While we can detect an evil so obvious as a great loss of blood
or a deficiency of iron in the blood, there are good reasons to
think that other graver defects in its constitution or develop-
1ent, of which we can give no account at present, do exist and
give rise to secondary nervous degeneration. It is in this way
probably that ill conditions of existence,—as overcrowding, bad
air, insufficient food and light, intemperance, and the like,—lead
to defects of nervous development, or to actual arrest thereof,
and thus produce mental as well as physical deterioration of the
race. Leucocythemia, oxaluria, and phosphuria are states of de-
fective nutrition owing to imperfect digestion and assimilation,
in which symptoms of mental discomfort or distress are common
and notable. Persons who suffer from oxaluria are usually much
depressed, anxious or apprehensive about themselves, hypochon-
driacal, nervous and susceptible; in phosphuria there is coim-
monly also great nervous irritability ; and the late Dr. Skae
thought that there was a form of insanity of a melancholic type
associated with or directly dependent upon each of these condi-
tions. I know not under what more fitting heading than deterio-
ration of blood to place the mental derangement which occurs
in pellagra, and is called pellagrous ; for, being caused by the
use of diseased Indian corn as an article of food, it is a condition
of great bodily and mental debility. The symptoms are usually
those of melancholy and fatuity with propensity to suicide;
sometimes they are maniacal ; and some cases are said to evince
a singular dislike to the sight or touch of water because of the
vertigo which it instantly produces.

There is no want of evidence that organic morbid poisons,
bred in the organism or introduced into it from without, will
act in the most baneful manner upon the supreme nervous
centres. With what quick destructive force certain morbid
materials bred in the blood, or passing into it, may act, is
shown in certain cases of so-called putrid infection in which
the patient dies after an injury or a surgical operation before
there has been time to feel the after-consequences, or in some
cases of malignant typhus where the virus is directly fatal to
nerve element before the fever has had time to develop itself.
It is probable. enough that a virus which, when concentrated,
200 PATHOLOGY OF MIND. [c1ap.

produces fatal results, will, when acting with less intensity,
give rise to nervous derangement which stops short of death.
That organic poisons do act in a definite manner on the organic
elements, and give rise to definite morbid actions, is proved by
the constant symptoms of such diseases as syphilis and smail-
pox. Now the general laws observable in the actions of morbid
poisons appear for the most part to be like those which govern
tle action of medicinal substances; and as the Woorara poison
completely paralyzes the ends of the motor nerves and does not
affect the muscles or the sensory nerves, or as strychnia poisons
the spinal centres, and leaves the cerebral centres unaffected, so
it is conceivable that a particular organic virus may have a
predominant affinity for a particular nervous centre and work
its mischievous work there. Whether that be so or not, what
we do notice is that in some conditions, natural or acquired, of
the nervous system a morbid poison docs act with particular
intensity upon it or show a particular affinity for it. The
syphilitic virus usually affects the nervous system more or less
severely at one period or other of its action; but in some
instances it appears to attack the nervous system specially, or
to concentrate its action upon it, giving rise to an acute mania
at an early stage of its course. Commonly, however, it is at a
much later stage that the brain suffers, when syphilitic pro-
ducts, so-called gummata, are formed on its surface, or within
its substance, and dementia gradually ensues in consequence.
There are cases on record, again, in which mental derangement
has appeared as the intermittent symptoms of ague; instead of
the usual symptoms of ague the patient has had an interntittent
insanity in regular tertian or quartan attacks, and has been cured
by the treatment for intermittent fever.! Sydenham observed and

1 A young man in an agueish district suffered from five brief attacks of
mental derangement, one occurring every other day. The attacks began
with an indescribable feeling of pain in thé region of the heart, and with
strong pulsations of the heart. ‘This was the starting-point of the deli-
rium, from which the patient recovered after a deep sleep. He was cured
by quinine.—A strong peasant, aged thirty, who had never had ague
though he lived in an agueish district, was suddenly attacked with insanity.
He believed himself to be Jesus Christ, and those near him to be witches,
and acted with violence towards them. His head was hot; his eyes were
ted and wild; his pulse was quick and his tongue white. After cupping
y.J THE CAUSATION AND PREVENTION OF INSANITY. 201

described a species of mania supervening on an epidemic of in-
termittent fever; contrary to all other kinds of madness, he says,
it would not yield to plentiful venesection and purging; slight
evacuations producing the relapse of a convalescent, and vio-
lent ones inevitably rendering the patients idiotic and incurable.

Griesinger and others direct special attention to cases in
which mental disorder has occurred in the course of acute
rheumatism, the swelling of the joints meanwhile subsiding.
The patient ceases to complain of pain in the joints and be-
comes delirous; the excitement which he shows is of an in-
tense kind, too raging to leave him sensible to impressions ;
he evinces acute fear, and would jump out of the window
or do some other act of unreasoning violence to himself. After
the excitement is over there is much mental torpor and
confusion, or there is depression with taciturnity and moody
suspicions. Choreic movements of all the voluntary muscles,
sometimes of a violent character, may accompany the mental
symptoms, and are in a few cases followed by temporary para-
lysis. It is by no means certain, however, that a delirium of
this sort is due to the action of a morbid or other poison; it
may be due to an actual transference or so-called metastasis of
the disease, or to other causes; for we know by other experience
that morbid action in one part may overpower and suspend
morbid action in another part of the body, as when an attack
of insanity suspends the progress of phthisis or the paroxysms
of asthma, while it lasts, or as when a violent mania occasions
the suppression of an accustomed discharge.

The viruses of acute fevers, as typhus and typhoid, scarlatina
and smallpox, may notably act in the most positive manner
on the supreme nervous cells, giving rise to mental torpor and
stupidity, or to an active delirium; and, where they do not act
directly at the height of the fever to produce delirium, they still
predispose sometimes to an outbreak of insanity during the de-
cline of the acute disease—a post-febrile insanity. Not only may
and the application of ice to the head, he recovered, and for two days
remained quite sound in mind. On the fourth day, however, exactly at
the same time, he had a similar attack, and again a third, after three days

more. He was cured by quinine.—Die Pathologie und Therapie der
psychischen Krankheiten, Von Dr, W. Griesinger.
202 PATHOLOGY OF MIND. [cnaP

a morbid poison thus attack the nervous system, or a part of it,
but it should be borne in mind that a particular virus will
most likely have its special effect, not otherwise than as tea
and coffee produce wakefulness, while opium produces sleep.
The first and mildest mental effect of a perverted state of
blood is not positive delusion or incoherence of thought, but a
derangement of the mental tone. Feelings of singular discomfort
or depression, of irritability or uneasiness, testify to some modili-
cation of the statical condition of nervous element ; and a great
disposition to uneasy emotion is the subjective side of this
state—the psychosis which is the expression of the disturbed
neurosis. It may exist in different degrees of intensity, from
the slight irritability or gloom which goes along with a sluggish
liver, or the greater irritability which the urea in the blood of
the gouty subject produces, to that profound depression which
we describe as melancholia, or that active degeneration of
function which we designate mania. Though there may be no
positive delusion, the emotional perversion existing by itself,
the ideas which arise under such circumstances do not fail to
show the influence of the morbid feeling with which they are
strongly tinctured ; they are obscure, or painful, or, at any rate,
not clear and faithfully representative of external circumstances.
The morbid character of the depression lies, not in the depres-
sion itself, which would be natural or normal so long as there
was an adequate external cause of it, but in its existence
without any external cause—in the discord between the indi-
vidual and his cir¢umstances. But as it is an irresistible dis-
position of the mind to represent its feelings as qualities of the
external object; as in all our mental life we continually make
this projection outwards of our subjective states—it commonly
happens after a while that the victim of an internally caused
emotional perversion seeks for an objective cause of it,
and, thinking to find one, gets a delusion: being in discurd
with the external, he establishes an equilibrium between himself
and it by creation of ideal surroundings in harmony with his
inner life. The form which the delusion takes may be a natural
crystallization or con Jensation, so to speak, of the particular mor-
bid emotion which prevails, in which case the most: trivial event
v.] THE CAUSATION AND PREVENTION OF INSANITY. 203

may be overcharged with disproportionate emotion, and magnified
into a mighty trouble; or it may be suggested, as it often is, by
some prominent external event. What we have to bear in mind
with regard to the organic nature of the delusion is, that certain
ideational tracks have now entered upon the habit of a definite
morbid action; that the general commotion of nerve element,
which the emotional disturbance implied, has now brought itself
to a head in a particular form of diseased action ; not otherwise
than as general inflammatory disturbance of some part of the
organism issues in a definite morbid growth there. For although
a temporary emotional disturbance produced by bad blood may
completely pass away with the purification of the blovd, yet
the prolonged continuance or frequent recurrence of such mor-
bid influence will inevitably end in the ideational centres, as
elsewhere, in chronic morbid action, which, once established, is
not easily got rid of.

‘We may compare the growth of a delusion with the mode of
production of a general idea. As the general idea is formed by
assimilation of the like and by rejection of the unlike in
impressions—by respondence, that is, to similar and indifference
to dissimilar vibrations; so in the growth of a delusion in the
mind there is a respondence to, and therefore an affinity for or
natural selection of, impressions that harmonize with it, while
those that are not in harmony with it are ignored. It is useless
to argue against an insane delusion ; it has taken a predominant
possession of consciousness, and there is a discontinuity of
function between its tract and surrounding parts; reasoning
can gain no hold of it any more than surrounding healthy
nutrition can gain hold of a tumour or other morbid growth to
check it. But the gradual influence of favourable surroundings
—to wit, a suitable moral atmosphere, distracting occupations,
diverting amusements, a steady reasonableness of life—will exert
an unconscious beneficial influence upon the uninfected mental
organization, until the large part of it which lies outside the
morbid area gains strength enough to have a controlling hold
of the morbid action and to bring it by degrees inte subordina-
tion to the laws of healthy function. Then the quasi-cataleptic
bondage of consciousness is loosened, and discontinuity of
204 PATHOLOGY OF MIND. [cHar.

function is at an end; the individual first suspects, then doubts,
finally disbelieves his delusion.

It appears from what I have said that the first effect of the
chronic action of impure blood is to produce a general disturb-
ance of the psychical tone, or indefinite morbid emotion; and
that the further effect of its continued action. is to engender a
chronic delusion of some kind—a systematization of the morbid
action. But a third effect of its more acute action, as witnessed
in the effects of acute fevers and of certain poisons, is to
produce more or less active delirium and general incoherence
of thought: the poison is distributed generally through the
supreme centres by the circulation, and, acting directly upon
them, excites ideas rapidly and without order or coherence: the
delirium is not systematic, and there is good hope of its pass-
ing away. The approaches of this sort of delirium in fever
illustrate many of the phenomena of insanity. First, there are
wandering thoughts and visions, known to be unreal, which are
described by the patient, who recognizes their character, as
nonsense ; then there follow vague rambling talk, from which
he may be aroused by talking to him, though he falls back into
it as soon as he has answered, and visions, about the reality of
which he is uncertain and confused, assenting, perhaps, when
assured that they are unreal, but relapsing instantly afterwards
into belief in them; afterwards, as the disorder gets deeper
hold, a state of complete delirium ensues, when he cannot
distinguish between the real] and the unreal, and the mind is
entirely possessed by unreal images and false thoughts uncon-
trolled by impressions from without. It is a singular fact that
notwithstanding this febrile delirium resembles mania in many
respects, when its phenomena are analyzed, and notwithstanding
that its seat in the brain must be the same as that of mania, it
never does run on without intermission into that post-febrile
mania which sometimes occurs during convalescence. The febrile
delirium is clearly an incident or attribute, so to speak, of the
morbid process of the fever, coming and going therefore with
it; the post-febrile mania is essentially a derangement of mind,
to which the fever has been a powerful predisposing cause, as
any other severe bodily illness might have been. It is to be
v.] THE CAUSATION AND PREVENTION OF INSANITY. 205

noted, however, that a fixed idea has continued sometimes for
a considerable time after the general delirium of fever: take,
for example, the case of the physician who, after an attack of
typhus fever, believed for six months that he possessed a
country house and a white horse, neither of which had any
existence except in his imagination.

It is necessary to apprehend clearly, and to keep steadily in
mind, that the relation between the supreme nervous centres and
the blood is fundamentally of the same kind as that between
other parts of the body and their blood-supply; and that the
disordered mental phenomena are the functional exponents of
morbid organic action. Firmly grasping this just conception,
as we may do by calling to mind the mode of nutritive action
in other parts of the body, we get rid of the notion of a delu-
sion as some abstract, ideal, and incomprehensible entity which
comes, we know not how, and recognize it as the mental
expression of a definite morbid action in one or other of the
supreme centres ; neither more nor less wonderful, therefore, than
the persistence of a definite morbid action in any other organ.
If at a time when there is defective or disordered nutrition
of the brain some striking event or some powerful shock pro-
duces an extraordinary impression on the mind, constraining it
into a particular form of activity—in other words, engrossing
its whole energy in a particular gloomy reflection; or if the
individual’s natural habit of thought be of a suspicious, of a
vainly conceited, or of a despairing character; what more in
accordance with analogy than that the predominant activity,
temporary or habitual, should take on a chronic morbid action,
and issue in the production of adelusion? Any great passion
in the sound mind notably calls up kindred ideas, which there-
upon tend to keep it up; the evil eye of envy, the green eye of
jealousy sees only what feeds the passion; and it is plain that
the morbid exaggeration of this natural process must lead in a
weakened brain to the production of insane delusion.

3. Sympathy or Reflex Irritation—Like every other nervous
centre, or like any other part of the organism, the ideational
centres may be deranged by a morbid irritation in a distant
part of the body. Why such morbid effects should be produccd
206 PATHOLOGY OF MIND. [ciap.

at one time and not at another, or in one person and not in
another, when the cause of irritation appears to be of the same
strength and character in each, it is impossible to say, just as it
is impossible to explain how it is that a wound in the hand or
elsewhere gives rise to tetanus at one time and at another time
to no such desperate consequence, or why epilepsy should be
caused by an eccentric irritation in one case and not in another.
“A fever, delirium, and violent convulsions,” says Dr. Whytt,
“have been produced by a pin sticking in the coats of the
stomach ; and worms affecting either this part or the intestines
occasion a surprising variety of symptoms.” }

Hippocrates ascribed to sympathy the occurrence of certain
disorders which seemed to have no other cause than disease
. elsewhere in the body, and both Areteeus and Galen were aware
that the mind might be deranged by disease in other parts of
the body than the brain. On the whole, perhaps sympathy was
as good a seeming explanation of these effects as the modern
doctrine of reflex action; for the doctrine of a pathological
sympathy certainly brought into proper light the momentous
truth that the living organism is not mere mechanism, but a
physiological unity having an intimate and entire consent of
function. When we speak of reflex action, what is usually
meant is the transference of excitement from a sensory to a
motor nerve; but the reflexion may be in the opposite direction
—from the motor to the sensory nerve, as, for example, when
severe pain along the spine follows violent coughing, or a
tickling of the throat is felt after long speaking, or facial
neuralgia is increased by muscular exertion. Moreover, the
reflexion may be from sensory nerve to sensory nerve: witness
the pain in the knee which betrays disease in the hip-joint, the
facial neuralgia which is excited by a toothache, and the pain
of a toothache that is felt in a neighbouring or in an opposite
tooth. So many and various are these pathological and physio-
logical reflex actions that we shall perhaps for the present do
best to embrace them under the wide term—sympathy.

1 Observations on the Nature, Causes, and Cure of Nervous, Hypochon-
driacal, or Hysteric Disorders. By Robert Whytt, M.D, 1765.
2 Henle, Handbuch der Rationellen Puthologie. 1846.
| THE CAUSATION AND PREVENTION OF INSANITY. 207

Amongst many other instances which might be quoted to
illustrate this manner of pathological action is a striking case
recorded by Baron Larrey. A soldier, who had been shot in
the abdomen, had a fistulous opening on the right side, which
passed inwards and towards the left. When a sound was intro-
duced into this opening and made to touch the deeper parts, im-
mediately singular attacks supervened: first there was a feeling
of coldness and oppressive pain, then a convulsive contraction of
the abdomen and spasm of the limbs took place; after which the
man fell into a sort of somnambulism, and talked incoherently,
this stage ending after about thirty minutes in a melancholy
depression which from the time of the wound had been habitual.
Larrey attributed the hypochondria and other nervous symptoms
to the injury which the celiac axis had suffered from the ball.
The direct effect of the sympathetic system upon the brain, of
which this case yields a striking illustration, Schroeder van der
Kolk once verified painfully in his own experience! After
great mental exertion and an unaccustomed constipation of a
few days, he was attacked with a fever, for which his physician,
deeming it nervous, would not sanction any purging. When
the fever had lasted for two days, hallucinations of vision
occurred; he saw distinctly a multitude of people around him,
‘although he was quite conscious that they were only phantasms.
The hallucinations continued for three days and increased, until
he got a thorough evacuation of a quantity of hardened feces
from his bowels, when they vanished instantly. A man who
came under my observation, having suffered for more than a
year from profound melancholia, and who had become greatly
emaciated, passing at intervals pieces of tape-worm, recovered
almost immediately after the expulsion of the whole of the
worm by means of a dose of the oil of male-fern.? Many like

1 Die Pathologie und Therapie der Geisteskrankheiten auf Anatomisch-
Physiologischer Grundlage. Von J. I. C. Schroeder van der Kolk. 1863.

2'Griesinger has seen deep melancholia occur in a hysterical woman
after accidental wound of the eye by a splinter. Herzog relates an instance
of insanity after the operation for strabismus. Jdérdens tells of a boy who
was attacked with furious insanity in consequence of a splinter of glass in
the sole of his foot, which disappeared directly it was removed.—Up, cit.,

p. 183. See also a case related in Physiology of Mind, p. 253.
“ In two instances,” says Dr. Burrows, in his Commentaries on Insanity,

10
208 PATHOLOGY OF MIND, [cHAP.

cases are on record in medical books; but it is not necessary to
multiply instances in order to prove that a morbid irritation
in some distant part or organ of the body may be the cause
of secondary functional and organic disorder of the supreme
nervous centres.

Affections of the uterus and its appendages afford notable
examples of a powerful sympathetic action upon the brain, and
not unfrequently play an important part in the production of
insanity, especially of melancholia. Perhaps the best oppor-
tunity of studying the early stages of the genesis of melancholia
is afforded by the mental depression accompanying certain
uterine diseases. M. Azam investigated the histories of seven
cases of lypemania with suicidal tendencies, of one case of
simple lypemania with dangerous tendencies, and of one case of
hysteromania. He professed to have found granulations of the
neck of the uterus in five cases; anteversion of the uterus, with
congestion of its neck and ulceration of the inferior lip, in one
case ; in three cases fungous and fibrous growths of the uterus;
and in one case painful engorgement of it with leucorrhea.
Schroeder van der Kolk relates the case of a profoundly melan-
cholic woman, who suffered at the same time from prolapsus
uteri, and in whom the melancholia used to disappear directly
the uterus was restored to its proper place ; Flemming mentions
two similar cases in which the melancholia was cured by the
use of a pessary, in one of them returning regularly whenever
the pessary was removed ; and in one instance I saw severe
melancholia of two years’ duration disappear after the cure of
a prolapsus uteri. Instances are on record in which a woman
has regularly become insane during each pregnancy; and, on

‘¢T have known sudden mania originate from the irritation of cutting the
dentes sapientia.” . . . ‘* Violent nausea also from sea-sickness, con-
tinued for a few hours, has produced mania in three instances within my
knowledge.”

M. Laurent (Annales Medico-Psychologique, 1867) relates a case of acute
delirium with refusal of food ending in death, which he ascribed to an
ascaris lumbricoides that was found, after death, in the woman’s esophagus.
A sister had died insane. On making literary researches he found cases
recorded by Esquirol and other authors in which the presence of the worm
in the stomach or cesophagus had concurred with violent delirious excite-
ment, The worm in such place seems to bea most powerful reflex irritant.
v.J THE CAUSATION AND PREVENTION OF INSANITY. 209

the other hand, Guislain and Griesinger mention a case re-
spectively in which insanity disappeared during pregnancy,
the patient at that time only being rational. I have met with a
similar case in which a melancholic and rather weak-minded
woman was never sane except when she was pregnant; and
another instance of a young married woman who, much tor-
mented by homicidal feelings, was free from them during
pregnancy. The late Dr. Skae included among his varieties of
mental disorder one which he called the insanity of pregnancy;
the chief special characteristic of which seems to have been
that it occurred during pregnancy, and might sometimes be
looked upon as a morbid exaggeration of the peculiar mental
moods exhibited by some women when in that state!

It is uncertain whether the puerperal state acts as the occa-
sional cause of a maniacal outbreak by a kind of sympathetic
action, or whether it acts in some other way; but there can be
no doubt of the fact that a woman is sometimes attacked with
mental alienation during or immediately after delivery, and that
her child may fall a victim to her frenzy. This form of puer-
peral insanity is different from the insanity of pregnancy ; dif-
ferent again from that which occurs at a later period after
delivery, and which is then probably due either to some sort of
blood-poisoning, or to a moral or physical shock undergone when
the nervous system is in a very susceptible state; and different
again from that mental disorder occurring some weeks or months
after, and due seemingly to the exhaustion produced by lactation,
together with depressing moral influences. Under the name of
Puerperal Insanity have been generally confounded three morbid
states—namely, the Insanity of Pregnancy, Puerperal Insanity,
and Insanity of Lactation. Of 155 cases of so-called Puerperal
Insanity admitted into the Edinburgh Asylum, 28 or 18-06 per
cent. were cases of the Insanity of Pregnancy ; 73 or 47:09 per

1 Shenck relates the history of a pregnant female, in whom the sight of
the bare arm of a baker excited so great a desire to bite and devour it,
that she compelled her husband to offer money to the baker to allow her
only a bite or two from his arm. He mentions another pregnant female,
who had such an urgent desire to eat the flesh of her husband, that she
killed him and pickled the flesh, that it might serve for several banquets.
(Prochaska on the Nervous Sysiem, Syd. Soc. translation.)
210 PATHOLOGY OF MIND. (crap.

cent. were cases of Puerperal Insanity proper; 54 or 34°8 per
cent. were cases of Insanity of Lactation. Now these varieties,
differently caused, often present some differences of features."
However it be that disorders of menstruation act, certain it is
that they exercise great influence on the causation and on the
course of insanity. Most women are susceptible, irritable, and
capricious at those periods, any cause of vexation then affecting
them much more seriously than usual; some exhibit a dis-
turbance of character which mounts almost to disease; and, in
the insane, exacerbations of the disease frequently occur then.
In a few cases, a sudden suppression of the menses has been
followed by an outbreak of acute madness; but more often the
suppression has occurred some time before the insanity, and
acted as one link in the chain of causes. It should not be for-
gotten, however, that the suppression is not seldom an effect of
the mental derangement—whether as the result of a strong
sympathy with the mental trouble, or whether it be an instance
of the same sort as the suppression of a profuse bronchitic
discharge and of other morbid fluxes by an outbreak of mania ;
for there is no small truth in the remark of Heberden that
madness, like gout, absorbs other distempers and turns them
to its own nature. When menstruation ceases entirely at the
change of life, a revolution takes place in the system, which
favours the production of insanity in those predisposed to it,
and is sometimes enough to produce it. There is a variety of
melancholic derangement occurring at this period which has
been described as climacteric insanity. Most women suffer
some change of moral character in consequence of the
revolution which the whole economy of the constitution under-
goes at the change of life. The age of pleasing is past, but not
always the desire ; morbid jealousy, exaggerated religious senti-
ments, wearisome hypochondriacal sufferings, a propensity to
stimulants are apt to show themselves: the main gratification of
life having been to attract attentions and to enjoy admiration,
new sources of indulgence and excitement must now be sought.

1 See a very careful paper in the Edinburgh Medical Journal, 1865, on

the Insanity of Pregnancy, Puerperal Insanity, and Insanity of Lactation,
by Dr, J. B. Tuke,
v.] THE CAUSATION AND PREVENTION OF INSANITY. 211

The earliest effect of sympathetic morbid action will be, as with
vitiated blood, a modification of the tone of nerve element, which
is manifest functionally in disordered emotion. But the con-
tinued operation of the morbid cause will lead to a systematized
disorder in the supreme cerebral centres: in other words, to the
production of a delusion or of a definite derangement of thought,
which then perhaps betrays a distinct relation to the primary
morbid cause. When, for example, a woman with morbid irri-
tation of the sexual organs has salacious delusions, believing
herself to be violated night after night, or with uterine or
ovarian disease believes herself with child by the Holy Ghost
or other supernatural means, the secondary derangement of the
cerebral centres testifies to the special effect of the particular
diseased organ, as well in the ideational as in the affective
derangement; the delusive interpretation of the disordered
action, when it forces itself into consciousness, witnesses to the
nature of the primary morbid cause. Dr. Wright? has published
the particulars of a case of cancer of the ovaries, uterus, and
omentum in which the afflicted woman had horrible delusions
that spirits, who gained entrance into her body, were tearing her
entrails, and that unknown persons violated her person during
the night; and Dr. Skae mentions another case of a woman
who complained piteously for many months that she was re-
peatedly violated every night through the rectum, and in whose
body, after death, extensive cancer of the rectum was found. He
proposed to make a special group of the cases of insanity asso-
ciated with ovarian and uterine disease; one of the most common
symptoms presented by them being sexual hallucination.

There is the most perfect harmony, the most intimate con-
nection or sympathy, between the different organs of the body
as the expression of its organic life, a unity of the organism
beneath consciousness; it is a connection which, as Hunter
said, might be called a species of intelligence, and the brain
is quite aware that the body has a liver or a stomach, and
feels the effects of disorder in any one of the organs, without
declaring in consciousness the cause of what it feels. This
unconscious but important cerebral activity, which is the ,

1 Edinburgh Medical Journal, 1871.
212 PATHOLOGY OF MIND. [cmar.

expression of the organic sympathies of the brain, cannot fail,
when rightly apprehended, to teach the lesson, that every
organic motion, visible or invisible, sensible or insensible,
ministrant to the noblest or to the humblest uses, does not pass
away issueless, but has its due effect upon the whole, and thrills
throughout the most complex recesses of the mental life.?

It often happens that no information is given by this species
of organic intelligence until the primary and secondary mischief
is far advanced, and it is then only given indirectly in language
which must be interpreted by the light of pathological know-
ledge; for while there is entire unconsciousness of the primary
disease in the distant organ, and an entire unconsciousness of

. the secondary morbid action in the brain, the effect may never-
theless be positively attested by melancholia, delusion, or some
other form of mental disorder. Esquirol graphically tells
the story of a woman who thought she had in her belly the
whole tribe of apostles, prophets, and martyrs, and who, when
her pains were more than usual, railed at them for their greater
activity. After death her intestines were found glued together
by a chronic peritonitis. I have seen a patient suffering from
chronic insanity who fancied that he had got a man in his
inside, and who, when his bowels got much constipated, as they
were apt to do, made the most desperate attempts, by vomiting
and otherwise, to get rjd of him. After a purgative, however,
he was quite comfortable for a time, and his delusion subsided
into the backeround.? In the insanity which occurs in connec-

t “Man is all symmetrie,

Full of proportion one limb to another,

And all to all the world besides,

Each part calls the further brother.

For head with foot hath private amity,

And both with moon and tides.”—Grorce HErbrrr.

2 In the Leicester asylum was a male patient who had been there for
many years, and who had been in the habit of stating that there was a
hundredweight of iron in his abdomen; he would occasionally put his
hands to his abdomen, as if to support the weight of metal which he
believed to. be there; it was impossible in any way to shake his rooted
delusion. He suffered from melancholia, was often very reticent, and
never communicative. Some time before his death he was observed not
to take his food so well.as usual: he more frequently pressed his hands
against his abdomen ; and when standing he leaned slightly forward; but
v.j THE CAUSATION AND PREVENTION OF INSANITY. 213

tion with phthisis, appearing about the same time and going
along with it, there are often delusions of suspicion which
appear to have their foundation in the anomalous feelings
incident to the advance of the tubercle: one such patient under
my care fancied that he was maliciously played upon by secret
fire, misinterpreting in this way the actual increase of bodily
temperature or the perversion.of sensibility which he felt; he
also imagined. that a filthy disease had been produced in his
mouth, the delusion probably having its origin in the perversion
of smell or of taste resulting from the disease. Not only is the
remote pathological effect of a diseased organ thus revealed
mentally by the development of some form of insanity, but, as
already pointed out, a special effect of the particular morbid
organ is sometimes manifest in the character of the delusion
which is formed. It is by virtue of this kind of sympathetic
action that a person has dreamed sometimes that he had a
particular internal disease, and the dream has turned out to be
prophetic. The recurrence of 4 certain mood of mind, or of
exactly the same train of thought and feeling, or of the same
hallucination, before an outbreak of recurrent insanity or of
epileptic fits, such as has uniformly gone before former attacks,
and the revival of particular morbid ideas, feelings, and desires
during the insane paroxysm, may be, and probably often are,
owing to a. periodical revival of the morbid irritation in the
distant organ. In those women whose mental dispositions are
much affected sympathetically at the menstrual periods, the
same sort of feelings, susceptibilities, caprices, and fancies
notably recur. There is indeed good reason to believe that the
he never even once complained of pain or other uneasiness. He was per-
suaded to go to bed. Afterwards the symptoms increased in severity : the
abdomen became very tender on pressure, the appetite failed, the pulse
became weak and thready. During the whole of his illness he was very
silent and uncommunicative, so that no information could be obtained by
asking him questions. He died a few days after taking to bed, and a post-
mortem examination revealed a perforation of the intestine, near the
junction of the ascending and transverse colon, sufficiently large to admit
the tip of the little finger. Through this opening some of tle liquid faces
had passed into the peritoneal cavity. There were signs of inflammatory
action in the neighbourhood of, and for some distance around, the aperture,

but not to the extent which might have been expected. The gradually
perforating ulcer was probably the occasion of his delusion.
214 PATHOLOGY OF MIND, [ciraP.

brain retains something of the impressions received from the
organic life, even when they are morbid; and though it may
forget them in its normal state they will be revived when the
morbid state of the organ recurs, just as the experience of a
dream which has been forgotten in the waking state may be
remembered in a subsequent dream.

The disorder of an internal organ of the body notably pro-
duces in all persons some affection of the mood of mind—in
some more, in some less; but when it goes beyond affective
disturbance to produce actual derangement of intellect, we are
constrained to assume an individual predisposition to such de-
rangement, inasmuch as it has not such effect in all cases; and
this we commonly find when we make proper inquiries. But
what I would have particularly noticed here is that when persons
have what is called a sensitive or susceptible nervous tempera-
ment, it is not merely that they are more powerfully affected in
mind and body by external impressions, but that the physio-
logical sympathy of their bodily organs is more acute and direct,
whereby these answer more easily and more actively to one
another’s sufferings. The idiosyncrasy of a person means not
his nervous constitution only as a separate thing, but the whole
temperament of his body, in which every part is knit together
in the closest unison, the least element being felt in the whole
and the whole in each element. He may have no special pre-
disposition to insanity or to any other nervous disorder, and yet,
by virtue of the intensity of his intrinsic organic sympathies,
declaring themselves in the functions of his nervous system as
the great co-ordinating mechanism of the body and in the
mental organization as the crown thereof, he may be prone to
suffer seriously in mind from disorders of internal organs which
another person would feel to be hardly more than inconveni-
ences. For the same reason, when actual derangement of mind
exists the disorder of the internal organ will colour the symp-
toms more strongly in one person than in another. The philo-
sophy which enables one to bear an abdominal trouble patiently
may not suffice to do the same service for another, although he
exercises as much of it, because of his more acute organic sym-
pathies. Too close and direct a relation of dependence between
vj THE CAUSATION AND PREVENTION OF INSANITY. 215

the parts and the supreme authority is probably an ill thing
in the bodily, as in the political, organism.

Between the organic feelings just considered—the vital senses,
as they are sometimes called—and the lower special senses, the
closest relations exist; in truth, they run insensibly into one
another, as the skin covering the outside and the mucous mem-
brane lining the inside of the body do. Thus the digestive
organs have the closest syrnapathy with the senses of taste and
smell, as we observe in the bad taste accompanying indigestion,
and especially perhaps in the avoidance of poisonous matters by
animals; the respiratory organs and the seuse of smell are in
like manner intimately associated; and the sense of touch has
close relations with the ccenesthesis. In insanity these physio-
logical sympathies become the occasions or the food of delusions :
derangement of the digestive organs, perverting the taste, gives
tise to the delusion that the food is poisoned; disease in the
respiratory organs is sometimes the cause of disagreeable sub-
jective smells, which are thereupon attributed to an objective
cause, such as the presence of offensive emanations or of a dead
body in the room; and more or less loss or perversion of sensi-
bility in the skin, which is not uncommon amongst the insane,
is the frequent occasion of extravagant delusions. A woman
whose case Esquirol relates, had complete anesthesia of the
surface of the skin: she believed that the devil had carried off
her body. A soldier who was severely wounded at the battle
of Austerlitz considered himself dead from that time: if he
were asked how he was, he invariably replied, that “ Lambert
no longer lives; a cannon-ball carried him away at Austerlitz.
What you see here is not Lambert, but a badly imitated machine,”
—which he failed not to speak of ast. The sensibility of his
skin was lost.

In the same way motor hallucinations occur. A striking
instance of delusion in connection with defective sensibility
and loss of motor power occurred in an amiable and genial
patient who was once under my care, suffering from general
paralysis. As the disease approached its end, the end of life,
he had severe epileptiform convulsions, which latterly affected
the left side only, and were followed by paralysis of that
216 PATHOLOGY OF MIND. [cHaP,

side. But although the power of movement and feeling were
entirely gone, there were frequent spasmodic twitchings of the
muscles, and sometimes convulsive contractions so strong as
to raise the arm and leg of the paralyzed side from the bed.
The poor man had the most singular delusions respecting these
movements: he thought that another patient, who was perfectly
demented and harmless, had got hold of him and was torment-
ing him, and accordingly, without real anger, but with an
energy of language that was habitual to him, he thus solilo-
quized aloud :—“ What a power that damned fellow has over
me!” Then after a convulsive paroxysm,— He has got me
round the neck, and you dare not touch him, not one of you.
Oh! but it is a burning shame to let a poor fellow be murdered
in this way in a public institution. It’s that boy does this to
me.” Told that he was mistaken, he replied—“ You may as
well call me a liar at once: he has got me round the neck and
he has me tight. Oh! it is a damned shame to treat me in this
way—the quietest man in the house.” Then after a while
“ It’s a strange power these lunatics have over one. That boy
is playing the devil with me: he stinks worse than a polecat :
he'll take my life, sure enough.” And so on continually, until
the stupor of death overpowered him.

Laudably anxious to give due weight to the perversions of
sensibility which are met with in insanity, Griesinger made
five groups of mental disorder connected with different anoma-
Kes of sensibility, and more frequently than not, he thought,
actually dependent upon them. The first of these is the pra-
cordial form, where there are morbid sensations, sense of pres-
sure, or of constriction, or of coldness, or of fluttering, or of
actual pain about the epigastrium, upon which follow fear
and mental anguish, with corresponding ideas and habits of
thought ; it is a disorder of sensibility which is common enough
in some forms of apprehensive and hypochondriacal melan-
cholia, and is often accompanied by an extraordinary alarm
and helplessness. The second is the veréiginous form, in which
some anomaly of muscular sensibility exists. In the third,
which he calls the paresthetical form, there are anomalous
sensations in different parts of the body, attributed by the
v.] THE CAUSATION AND PREVENTION OF INSANITY. 217

patients commonly to external machinations. The fourth is
the anesthetic form, in which absence of sensibility is often the
cause of self-mutilation. . Lastly, there is the hallucinatory form,
which obviously needs no further explanation here. It is un-
doubtedly of great importance to bestow scrupulous attention
upon all the disorders of sensibility, as well as upon those of
nutrition and movement, which occur in the different sorts of
insanity ; to do so is an essential part of the physician’s duty in
studying the entire natural history of the disease ; but it is not
possible to make perversions of sensibility alone the basis of a
system of classification. Such a classification could not fail to
have an extremely artificial character and an entirely theoretical
foundation.

The centre of morbid irritation which gives rise to secondary
disorder by reflex or sympathetic action need not be in some
distant organ; it may be in the brain itself. A tumour, an
abscess, a clot of blood, a cysticercus, a local softening in the.
brain, will nowise interfere with the mental operations at one
time, when it produces grave disorder of them at another time ;
and it is not uncommon in abscess of the brain for the symptoms
of mental derangement, when there are any, to disappear entirely
for a time, and then to return suddenly in all their gravity.
When the motor, sensory, and ideational centres are not directly
damaged by the disease, they can continue their functions in
spite of it; accordingly they sometimes do so even when there is
the most serious mischief going on in the brain; but they may
at any moment be affected by a sympathetic or reflex action, and
a secondary derangement or abolition of function may thus
supervene without warning, the gravest symptoms perhaps
coming and going in a surprising manner. Instances now and
then occur in which a sudden loss of consciousness, or a sudden
incoherence, or sudden mania, or even sudden death, takes place
where no marked premonitory symptoms have indicated grave
local disease of the brain.

Furthermore, a limited disorder of the ideational centres, such
as is manifest functionally in the fixed delusions of the so-called
monomaniac, is not usually without effect upon the other
elements in the supreme centres. So delicately sympathetic
218 PATHOLOGY OF MIND, [ctae.

and sensitive as nerve-element is, it is not probable that a centre
of morbid action will fail. to affect, by direct or by reflex action,
neighbouring parts that are not immediately involved in the
disease. In matter of fact a greater or less disturbance of the
tone of the whole mind does commonly accompany the limited
delusions of a so-called partial insanity; the condition of things
is something like that which has already been described as the
first stage of the affection of mind by other causes of its derange-
ment—namely, a modification of the mental tone. This baneful
effect of a limited local disorder is not of course a case of meta-
stasis, since the primary disease disappears not, but a case of so-
called sympathy, where the primary disease continues in action ;
in other words, it is produced by direct or reflex irritation.
Hereafter we shall have occasion to describe instances of the
sudden and entire transference of active disorder of one nervous
centre to another; for, as Dr. Darwin long ago observed, “in
some convulsive diseases a delirium or insanity supervenes and
the convulsions cease; and, conversely, the convulsions shall
supervene and the delirium cease.”

It is necessary here, as in the spinal, sensory, and motor
centres, to distinguish between the degrees of secondary disorder
to which a distant morbid cause may give rise. The sudden
way in which extreme mental symptoms appear, and the equally
sudden way in which they disappear sometimes, as in abscess of
the brain, prove that extreme derangement may be what is
called functional; for it is impossible to suppose that serious
organic change has been and gone in such cases. Although,
therefore, the functional disorder necessarily implies a molecular
change of some kind in the nervous element, the change may be
assumed to be one affecting the polar relations of the molecules,
such as the experiments of Du Bois Reymond and others have
proved may rapidly be induced and as rapidly disappear. Cer-
tainly the induction of recognizable temporary changes in the
physical constitution and function by experiments, warrants the
belief in similar modifications by causes which are not artificial,
but which are just as abnormal as if they were. If the modifi-
cation of nervous element be too great or too prolonged, it fails
not to degenerate into actual nutritive change and structural
vJ THE CAUSATION AND PREVENTION OF INSANITY. 219

disease, just as an emotion which alters a secretion temporarily
may, when long enduring, lead to actual nutritive change in the
organ. The longer a functional derangement lasts, the more
danger is there of structural disease; and when this serious
change is once definitely established, the removal of the primary
morbid cause will not get rid of an effect which has now become
an independently acting cause.

4, Excessive Functional Activity—As the display of function
is the consumption of matter, it is obvious that, if the due inter-
vals of periodical rest be not allowed for the restoration of the
statical equilibrium of nerve-element, degeneration of it must
take place as surely as if it were directly injured by a morbid
poison, or by a mechanical or chemical irritant. It is sleep
which thus knits up the ravelled structure of nerve-element;
for during sleep organic assimilation restores, as statical or
potential, the power which has been expended in functional
energy. The brain, like any other organ of the body, is endowed
with a limited power of work and endurance only, a limit which
cannot be exceeded without danger ; and its strength and weak-
ness measure the-strength and weakness of the mind. The
strongest mind, if continually overstrained, will inevitably break
down; one of the first symptoms that foreshadows the coming
mischief being sleeplessness. That which should heal the breach
is rendered impossible by the extent of the breach. Like Ham-
let, according to Polonius’s fruitful imagination, the individual
fails into a sadness, thence into a watch, thence into a lightness,
and, by this declension, into the madness wherein he finally
raves. To provoke repose in him is the first condition of re-
storation ; sound sleep closing the “ eye of anguish,” and cuing
the “ great breach in the abused nature” of nervous element.

It is, however, when intellectual activity is accompanied with
great emotional agitation that it is most enervating—when the
mind is the theatre of contending passions that its energy is
soonest exhausted. The instability of nerve-element which
great emotional susceptibility means enables us to understand
how this destructive effect is wrought. When an exceedingly
painful event produces great sorrow, or a critical event great
agitation, or an uncertain event great apprehension and anxiety,
220 PATHOLOGY OF MIND. fouar,

the mind is undergoing a passion or suffering; there is not an
equilibrium between the internal state and the external circum-
stances; and until the mind is able to react adequately, either
in consequence of a fortunate lessening of the outward pressure,
or by a recruiting of its own internal forces, the passion must
continue—in other words, the wear and tear of nervous element
must go on. Painful emotion is in truth psychical pain; and
pain here, as elsewhere, is the outcry of suffering organic element
——a prayer for deliverance and rest.
The same objects or events notably produce very different
impressions upon the mind according to its condition at the
time—according perhaps as something pleasant or something
unpleasant has just.happened. If there be a temporary depres-
sion of the psychical tone by reason of some recent misfortune,
or because of some bodily derangement, then an event, which
under better auspices would have been indifferent, will rouse
painful emotion, and, calling up congenial ideas of a gloomy
kind, perpetuate and add to the mental suffering; just as
reflex action that is provoked or increased by a morbid cause
sometimes aggravates in turn the original disorder. If there
be a lasting depression of the psychical tone by reason of
some continuing morbid cause, then every event is apt to ag-
gravate the suffering, being seen through the distorting medium
of the sad feeling ; and a particularly unfavourable event, or a
succession of painful events, may be enough to cause actual
derangement of mind. After a piece of good news, or after a
man has just drunk a glass of wine, or taken a dose of opium,
the psychical tone is so much animated that there isa direct
and adequate reaction to an unfavourable impression, and he will
not suffer; wherefore comes the temptation to have recourse in
time of trouble to stimulants like opium and alcohol.. Herein
the supreme centres of thought do not differ from the inferior
nervous centres; when the spinal centres are exhausted, ex-
citability is increased, a state of irritable weakness being pro-
duced, and an impression, which under better auspices would
have had no bad effect, gives rise to the degenerate activity of
spasmedic movements: an explosion not unlike that which in
the higher centre is manifest as emotion, or as an ebullition of
y.]. _THE CAUSATION AND PREVENTION OF INSANITY. 221

passion, since emotional outbursts may justly be considered to be
of the. nature of molecular explosions or commotions. Excess is,
however, a relative term; and a stress of function which would
_be no more than normal to a powerful and well-ordered mind,
and conducive to its health, might be fatal to the stability of a
feeble and ill-regulated mind in which feeling habitually over-
swayed reason, or even to that of a strong mind which was
temporarily prostrate. Thus it is that in pursuing inquiries
into the causation of insanity in any case it is not enough to
examine only the concurrence and. succession of influences to
which the individual has been exposed, but it is necessary also
to look to the capacity he had of bearing them at the time.

In weighing the operation of moral causes to produce insanity
we find too their effect to be in proportion to the suddenness
and intensity with which they strike as well as to their actual
power; for a sudden shock, like a violently imposed burden, will
break down the strength when a heavier burden would have
been borne had it been adjusted gradually. The violence of the
shock is determined by the suddenness and weight of the moral
impression—by the momentum, in fact, with which it strikes the
mind. In the same way, the lavish expenditure of a great deal
of energy in a short time, such as takes place in a financial
crisis, in a political revolution, in a religious revival, and on
similar occasions of agitation of feeling and exaltation of energy,
when the whole power of the mind is stimulated unduly and
used unsparingly within a brief period, will be followed by a
deep exhaustion that may end in disease ; notwithstanding that
the same amount of energy might have been used without grave
danger if its expenditure had been prudently regulated. A per-
son should deal with his vital force very much as he deals with
his finances, and live on the interest of his capital; for should
he make demands on the capital, whether in a large sum to meet
an occasional emergency, or in accumulating dribblets to meet
daily slight excesses of expenditure over income, he must be
bankrupt in the end.

I take the actual mode of operation of a moral cause to be
just as physical as the operation of a stroke of lightning, which,
like it, may produce paralysis or sudden death, and perhaps in
222 PATHOLOGY OF MIND. {cwap.

the same way ; and I look upon the derangement of mind which
grief causes as just as much a physical result brought about by
physical causes as is the delirium of starvation. When any
great passion causes all the physical and moral troubles which
it will cause, what I conceive to happen is that a physical im-
pression made upon the sense of sight or of hearing is propa-
gated along a physical path to the brain, and arouses a physical
commotion in its molecules; that from this centre of commotion
the liberated energy is propagated by physical paths to other
parts of the brain; and that it is finally discharged outwardly
through proper physical paths, either in movements or in modi-
fications of secretion and nutrition, The passion that is felt is
the subjective side of the cerebral commotion—its motion out
from the physical basis, as it were (e-motion), into consciousness
—and it is only felt as it is felt by virtue of the constitution of
the cerebral centres, into which have been wrought the social
sympathies of successive ages of men: inheriting the accu-
mulated results of the experiences of countless generations, the
centres manifest the kind of function which is embodied in
their structure. The molecular commotion of the structure is
the liberation of the function: if forefathers have habitually
felt, and thought, and done unwisely, the structure will be
unstable and its function irregular.

The foregoing reflections show that, from a pathological point
of view, the so-called moral causes of insanity fall fitly under
the head of excessive stimulation or excessive functional action :
the mind is subject to a stress beyond that which it is able
to bear, either because of the weight of the pressure from with-
out or because of the weakness within. Of necessity the
depressing passions are the most efficient causes of exhaustion
and consequent disease: grief, religious anxiety, loss of fortune,
disappointed affection or ambition, the wounds of an exaggerated
self-love, and, above all perhaps, the painful feeling of being
unequal to responsibilities, or other like conditions of mental
agitation and suffering, are most apt to reach a violence of action
which issues in the overthrow of the mental equilibrium. Great
intellectual activity, when unaccompanied by emotion, does not
cften lead to insanity; it is when the feelings are anxiously
v.] THE CAUSATION AND PREVENTION OF INSANITY. 223

engaged that the mind is most moved and its stability most
endangered: on the stage of mind as on the world’s stage the
great catastrophes are produced by passion. Moreover, when an
individual has, by a long concentration of thought, interest, and
desire upon a certain aim, grown into definite relations with
regard to it, and made it, as it were, a part of the inner life, a
sudden and entire change, shattering long-cherished hopes, is
not unlikely to produce insanity; for nothing is more fraught
with danger to the stability of the mind than a sudden great
change in external circumstances, without the inner life having
been gradually adapted thereto. Thence it comes that a great
exaltation of fortune, as well as a great affliction, rarely fails to
disturb for a time the strongest head, and sometimes quite over-
turns a weak one; the former succeeding after a time in
establishing an equilibrium between itself and its new sur-
roundings which the latter cannot do. When exhausting
passion does not act directly as the cause of a sudden outbreak
of insanity, it may still act banefully by its long-continued
depressing influence on the organic life, and thus in the end
lead to mental derangement.

Automatic function I‘have shown to mean stored-up power
—abstract of former function—inherent as original faculty of
the individual or acquired by his own cultivation and exercise.
Whether then he shall be equal to the work and responsibilities
of his position in life will depend, first and mainly, upon his
native powers of mind, and, secondly, upon the special training
which he has had to fit him for what he has to do: either will
supplement in large measure the deficiencies of the other.
Accustomed duties are discharged with ease, while new duties
exact much expenditure of anxious energy, because the special
automatic power has to be built up by laborious training in
accordance with a law of structuralization of function. It is
easy then to see why the assumption of important new func-
tions for which the individual is not fitted by original power or
by previous special training will be especially trying to his
mental stability : there is not only a large call upon cerebral
energy to make the adaptation, but there is the exhausting
emotion produced by the nervous apprehension of unfitness.
224 PATHOLOGY OF MIND. (CHAP.

Here is made manifest the wisdom of a sound general culture
by which the mind is made a fitting instrument to adapt itself
easily to any form of special activity; if a person make it his
pains to have good habit of judgment, good habit of thought,
good habit of feeling, good habit of doing, by continual practice
of good judgment, good thought, good feeling and good doing,
so that he needs not on each new occasion to consider minutely,
to feel apprehensively, to do anxiously, but can judge, think,
feel, and do quickly and, as it were, instinctively, he will have
an excellent stability of nature to enable him to cope with the
duties and trials of his life in whatsoever position he may be
placed.

Another class of moral causes of insanity acts quite differently
from the depressing causes which I have just considered: these
are the elated passions. It is not often that men become insane,
though they sometimes die, from the commotion which excess
of joy occasions; and when one of the expansive passions, as
ambition, religious exaltation, overweening vanity in any of its
Protean forms, leads gradually to mental derangement, it does
not, like a painful passion, act directly as the cause of an out-
break, nor indirectly by producing organic disorder and sub-
sequent-insanity ; its morbid effects are the exaggerated develop-
ment of a certain peculiarity or vice of character—the morbid
hypertrophy, so to speak, of a bad quality of character. Each
indulgence in passion, caprice, even oddity or perversity, notably
makes easier the next step in the same direction: what a person
sows hourly, good or ill, that shall he reap: the hypertrophy of
passion and prejudice is the atrophy of principle and judgment.
In the Edinburgh asylum was a blacksmith who imagined him-
self to be King of Scotland ; his daughter, who was an inmate
of the same asylum, believed herself to be a royal princess ;
not because she shared her father’s delusion, for she perceived
clearly enough that he, poor man, was only a blacksmith who
had an insane delusion, as he also on his part recognized that his
daughter was not a princess, but a lunatic. The daughter’s delu-
sion then was not a specific inheritance by her nor had she got
it by logical inference ; it was probably the morbid outgrowth
of a fundamental quality of character common to her and to her
v.] THE CAUSATION AND PREVENTION OF INSANITY. 225

father. It is this development of insanity as the morbid growth
of a disposition which often makes it hard to say where disease
begins, and harder still to cure it. When a depressing passion
due to external causes overthrows the mind, the derangement
is, so to speak, accidental or extrinsic, and the delusion which is
the outgrowth of it fades and finally vanishes as the emotional
tone improves and mental power is restored; when an egoistic
passion grows into a morbid delusion, the derangement is
essential or intrinsic, and the delusion which is its essential
outcome cannot be got rid of except by rooting out the dis-
position: it is not an instance of excessive functional activity,
but an instance of morbid development.

A fatal drain upon the vitality of the higher nervous centres
is in certain cases the consequence of the excessive exercise of
a physical function—an excessive sexual indulgence, or a habit
of self-abuse. Nothing is more plain than that either of these
causes will produce an enervation of nerve element which, if
the exhausting vice be continued, passes by a further declension
into degeneration and actual destruction thereof. The flying
pains and the startings of the limbs, which follow an occasional
sexual excess, are signs of instability of nerve element in the
spinal centres, which, if the cause is in frequent operation, may
end in softening of the cord and consequent paralysis. Nor do
the supreme centres always escape: the habit of self-abuse
notably gives rise to a particular and disagreeable form of
insanity, characterized by intense self-feeling and conceit, loss
of mental energy, hypochondriacal brooding, pitiful vacillation,
extreme perversion of feeling, and corresponding derangement
of thought, in the earlier stages; and, later, by failure of in-
telligence, nocturnal hallucinations of a painful character, and
suicidal or homicidal propensities. The mental symptoms of
general paralysis—a disease often caused by sexual excess—
betray a degenerate condition of nerve element in the higher
centres, which is the counterpart of that which in the lower
centres is the cause of the loss of co-ordination of movement
and of more or less spasm or paralysis. The great emotional
exaltation, the busy excitability with feebleness, of the general
paralytic, no less than the extravagance of his ideas, mark a
226 PATHOLOGY OF MIND. (crap.

degeneration of the ideational centres; there is accordingly an
inability to co-ordinate and perform his ideas successfully even
before there are actual delusions, just as there is an inability
to perform movements successfully in the later stages of the
disease, because the spinal centres are similarly affected. It is
not usual, however, for sexual excesses to cause other sorts
of insanity than general paralysis; their tendency is to produce
epilepsy or some form of paralysis, Self-abuse is a cause 2f
insanity which appears to be more frequent or more effective
in men than in women, and in them to require usually the
co-operation of a particular neurosis. Apart from all question
whether the vice be so common among women, they bear its
effects, as they do sexual excesses, better than men. On the
other hand, privation of sexual function is more injurious to
women than to men.

5. Injuries and Diseases of the Brain and Nervous System not
necessarily, but occasionally, producing Insanity.—Injuries of the
head, when not followed by immediate ill consequences, may
nevertheless lead to mental derangement, through the degenera-
tive changes which they ultimately set going in the cortical
layers of the hemispheres.1 The changes are often of a slow
and insidious character, going on for years perhaps before they
produce very marked mental effects, At first there is nothing
more noticed than a change of temper and disposition in the
person ; he is prone to outbursts of anger on trivial occasions, or
to excesses foreign to his former character ; a moderate quantity

1 Professor Schlager, of Vienna (Zeitschrift der k. hk. Gesellschaft der
Aerzte zu Wien, xiii. 1857), has made some valuable researches regarding
mental disorder following injury of the brain. Out of 500 insane, he
traced mental disorder to injury of the brain in 49 (42 men and 7 women).
In 21 cases there had been complete unconsciousness after the accident ;
in 16, some insensibility and confusion of ideas ; in 12, simple dull head-~
ache. In 19 cases the mental disorder came on in the course of a yeai
after the injury, but not till much later in many others, and in 4 cases after
more thanten years. In most of the cases the patients were disposed to con-
gestion of the brain, excitement and great emotional disturbance, from the
time of the injury, on taking a moderate quantity of spirituous liquor;
frequently there was singing in the ears, or difficulty o£ hearing, or hal-
lucination; and very commonly the disposition was thanged, and the
patient was prone to outbursts of anger or of excesses. The prognosis
was very unfavourable ; the issue in 7 cases was dementia with paralysis,
while 10 went on to death from the progress of the brain disease,
v.] THE CAUSATION AND PREVENTION OF INSANITY. 227

of alcohol produces an extraordinary excitement, making him
perhaps not drunk, but actually mad for the time being, so that
he may get into trouble for assault or other breach of the law.
Years sometimes pass before graver symptoms show themselves.
Dr. Skae mentions the case of a woman who, having suffered a
fracture of the skull, evinced a change in tempef and disposition
afterwards and some other symptoms which were referred to the
accident, and who, after twenty years, became insane and violent.!
An outbreak of acute mania, or an epileptic fit followed by
mania, may be the climax of a long series of slow changes, and
be followed by gloomy depression with suspicious delusions and
impulsive violence, and by increasing dementia.

A most interesting case has been put on record by Dr. Holland
Skae2 A collier was struck insensible by a mass of falling coal
which fractured his skull about three inches above the outer angle
of the left eyelid. After four days he regained consciousness, and
in a few weeks was able to resume work in the pit. Soon after
doing so a change was noticed in his character and behaviour:
instead of being, as formerly, cheerful, sociable, good-natured,
gentle to wife and children, he was moody, taciturn, and irritable,
repelling the attentions of his wife’s and the demonstrations of
his children’s affection. Gradually he got worse ;he was often
excited, used threatening language to his wife, children, and
neighbours ; finally he became maniacal and violent, attempted
to take his own life and his wife’s life, and had a succession of

‘epileptic fits. He was sent to an asylum. After he had been
there two months he was trephined, a depressed portion of bone
at the place where he had been struck being removed. Soon
after the operation he began to mend, returning gradually to his
natural self; in the end he became a cheerful, active, and oblig-
ing person, with all his family affections restored. He was able
to support his wife and family by his labour when he left the
asylum, and four years after his discharge was still quite sane.

Insolation notably acts injuriously on the supreme cerebral
centres, either by causing, as some imagine, acute hyperemia
aud serous effusion, or, as is more probable, over-stimulation

1 Report of the Morningside Asylum, 1867.
2 Journal of Mental Science, vol. xix., p. 552.
228 PATHOLOGY OF MIND. [cuaP.

and consequent exhaustion of nerve element. In most instances
of the kind there is reason to think that an imprudent indul-
gence in alcoholic stimulants has co-operated.

Hysteria undoubtedly slides into insanity in some instances.
There seem to be two varieties of mental derangement present-
ing hysterical characters, which may, however, pass into one
another. An acute attack of maniacal excitement, with great
restlessness ; perverseness of conduct, which is pretty coherent
and wilful; loud and rapid conversation, sometimes blasphemous
or obscene; laughing, singing, or rhyming—may follow the
ordinary hysterical convulsions, or may occur instead of them.
Or the ordinary’ hysterical symptoms may pass by degrees into
a chronic insanity: the patient loses more and more energy and
self-control; becomes more fanciful about her morbid sensations,
to which she gives exaggerated attentions; is extremely egotistic,
wilful, and exacting; gets more and more impatient of all advice
or interference, and indifferent to social obligations; and often-
times shows a singular aptness for deceit. The body becomes
anemic and emaciated, and there are usually irregularities of
menstruation. An erotic element is sometimes evinced in the
manner and thoughts; and occasionally ecstatic or quasi-cata-
leptic states occur. The symptoms are often worse at the
menstrual periods.

Under the head of nervous diseases which may become occa-
sions of insanity must be placed chorea and epilepsy, although
we know not yet what are their exact seats in the nervous
system. Chorea in the adult is not unapt to terminate in mental
disorder ; but it is not at all apt to do so in the child, although
some dulness and weakness of mind often accompany it.
Different sorts of insanity are met with in connection with
epilepsy. When the fits have recurred frequently, and the
disease has continued for a long time, it undoubtedly produces
loss of memory, failure of mental power, and ultimately com-
plete dementia, That is one form. Secondly, a succession of
severe fits may be followed by a condition of acute dementia
which lasts for a short time, or by an acute, violent, and most
dangerous mania, which usually passes away in a few days.
Not only may acute mania thus follow epilepsy, but an attack
v.J THE CAUSATION AND PREVENTION OF INSANITY. 229

of acute transitory mania—a true mania transitoria—may take
the place of the epileptic paroxysm, being truly a masked
epilepsy. Some writers maintain, however, that in these cases
a brief attack of epileptic vertigo or petit mal has passed un-
observed. Lastly, in some cases a profound moral disturbance
—an irritability, moroseness, and perversion of character, lasting
for months, with periodical exacerbations in which vicious or
criminal acts may be perpetrated— precedes the appearance of
the regular epileptic fits, which then throw light upon the
hitherto unaccountable moral perversion. It is another phase
of a kind of abortive or undeveloped epilepsy.

Here I may fitly take occasion to adduce certain observations
with regard to the striking manner in which diseased action of
one nervous centre is sometimes transferred suddenly to another :
a fact which, though it has lately attracted new attention, was
long since noticed and commented on by Dr. Darwin :—“ In
some convulsive diseases,” he writes, “a delirium or insanity
supervenes, and the convulsions cease; and, conversely, the
convulsions shall supervene, and the delirium cease. Of this
Ihave been a witness many times a day in the paroxysms of
violent epileptics ; which evinces that one kind of delirium is a
convulsion of the organs of sense, and that our ideas are the
metions of these organs.” Miss G., one of his patients, a fair
young lady with light eyes and hair, was seized with most
violent convulsions of her limbs, with outrageous hiccough, and
most vehement efforts to vomit. After nearly an hour had
elapsed this tragedy ceased, and a calm, talkative delirium
supervened for about another hour, aud these relieved each
other at intervals during the greater part of three or four days.
“After having carefully considered this disease,” he says, “I
thought the convulsions of her ideas less dangerous than those
of her muscles ;” and thereupon he adopted such treatment as
resulted in the young lady’s recovery. In another case which
came under his observation, “these periods of convulsions, first
of the muscles and then of the ideas, returned twice a day for
several weeks.” “Mrs, C.,” again, “ was seized every day, abont
the same hour, with violent pains in the right side of her bowels,
about the situation of the lower edge of the liver, without
230 PATHOLOGY OF MIND. (cHar,

fever, which increased for an hour or two, till it became totally
intolerable. After violent screaming she fell into convulsions,
which terminated sometimes in fainting, with or without stertor,
as in common epilepsy; at other times a temporary insanity super-
vened, which continued about half an hour, and the fit ceased.”?

Brodie relates the case of a lady who suffered for a year
from persistent spasmodic contraction of the sterno-cleido-mas-
toid; suddenly it ceased, and she fell into a melancholy; this
lasted a year; after which she recovered mentally, but the
cramp of the muscle returned, and lasted for many years. In
another case mentioned by him, a neuralgic condition of the
vertebral column alternated with true insanity. Dr. Burrows
met with similar cases: one “in a very eloquent divine, who
was always maniacal when free from pains in the spine, and
sane when the pains returned to that site.”2 A patient in St.
Mary's Hospital, who was convalescent from typhoid fever, had
hypereesthesia of the legs, which ceased when maniacal delirium
set in, but returned with great intensity when the delirium sub-
sided.2 Without doubt the delirium, which was the outcome of
a disorder of the supreme centres, was the equivalent of the
hypereesthesia which was the outcome of disorder of the sensory
centres. Whether there is an actual transference of the morbid
action from one set of nerve-centres to another in these cases;
or whether an independently lighted disorder in the latter over-
powers and suspends the disorder of the former, as a greater
pain inhibits a less pain, or as an attack of mania sometimes
suspends an asthma or a chronic discharge, it is not easy to say.
We must accept the fact, whatever may be its exact pathological
explanation.

One of the most frequent observations which the clinical
observer has to make in respect of tumours, abscess, cysticercus.
and such gross products of cerebral disease, is the absence of
symptoms of mental disturbance. The fact at first seems
striking, because the presence of so much disease in its midst
might be thought incompatible with the undisturbed function of
the brain as the organ of mind. After giving a careful report

1 Zoonomia, vol. i. pp. 25, 26. 2 Commentaries on Insanity.
3 Dr Handfield Jones in St. George's Hospital Report, vol. ii, 1867.
vy.) THE CAUSATION AND PREVENTION OF INSANITY. = 231

of ten cases of tumour of the brain, Dr. Ogle calls attention to
the fact that, “in no case was there during life anything of the
nature of mental imbecility, or any symptom of the various
phases or forms of insanity.” An examination of what was
found after death in these cases furnishes a sufficient reason for
the non-affection of the intelligence. In none of the ten was
there any observed implication of the nervous centres of intel-
ligence by the morbid action; the mischief was more or less
central, and the hemispherical ganglia continued their functions,
as they well might, in spite of it. If there is one thing which
pathological observation plainly teaches, it is the slight irrita-
bility of the adult brain; the gradual growth of a tumour
allows the brain to accommodate itself to the new conditions ;
and a closely adjacent nervous centre may be entirely undis-
turbed in function until the morbid action actually encroaches
upon it. Not disease in the interior of the brain, but disease of
the membranes covering it and containing the blood-vessels
which go to the convolutions, is most likely to produce disorder
of the intelligence; in the latter case it lies close to the delicate
centres of intelligence, and seriously interferes with their supply
of blood. Whatever be the explanation, there can be no doubt
of the fact that a large tumour may exist in the brain, or that
a considerable amount of the brain-substance may soften and
undergo purulent degeneration—the pus even becoming incap-
suled—without the presence of a single symptom to lead us to
suspect disease in the brain.2 It has even happened that a
patient in hospital, who has complained only of langour, general
debility, and inability to exert himself, has been suspected of
feigning and accused of indolence because there were no marked
symptoms of disease, when a sudden and quick death has
proved at the same time the existence of an abscess of the
brain and the injustice done to the sufferer

1 Journal of Mental Science, July 1854: Cases of Primary Carcinoma of
the Brain.

2 For examples of extensive injury to the brain, without mental dis-
turbance, see a paper by Dr. Ferriar in the first volume of the Memoirs of
the Literary and Philosophical Society of Manchester.

3 Ueber Gchirnabscesse, von Prof. Dr. Lebert, Virchow’s Archiv, vol. x.
1856,

11
232 PATHOLOGY OF MIND. (cuap.

Certainly it sometimes happens that mental disturbance goes
along with disease in the brain, even though the mischief is
quite central; in that case we must think that the disease acts
as a centre of irritation, and that the mind-centres are affected
secondarily; the disturbing action being either directly upon the
nerve elements, or indirectly upon them through direct vaso-
motor commotions. Two things will often be observed then
with regard to the mental symptoms:—(1) that they are inter-
mittent, so that they may disappear altogether for a while; and
(2) that they have the character either of an incoherent
delirium, or of greater or less mental imbecility.

(1) The entire disappearance of all symptoms of mental dis-
order for a time is evidence that they are not due to organic
structural change in the nervous centres which directly minister
to mind ; for, if such change existed, the recovery could not be
so sudden and complete. But if the disturbance of the cortical
cells is secondary, being a reflex effect of the primary morbid
action that is going on in the neighbourhood, it is easy to
conceive that it may come and go suddenly, just as epileptiform
convulsions, similarly excited, notably do. This is perhaps a
more probable explanation of the transitory disorder than the
‘supposition of vascular disturbances which come and go, albeit
these may be brought about by the morbid irritation, and no
doubt play their part sometimes in producing the mental dis-
order. Why a reflex pathological effect is produced in one case
and not in another, or why it is not permanent when once pro-
duced, we can no more say than we can say why an eccentric irri-
tation should sometimes give rise to convulsions or paralysis,
and sometimes not. “What reason,” asks Dr. Whytt, “can be
given why sometimes, after cutting off an arm or a leg, those
muscles which raise the lower jaw should be affected with a
spasm, rather than other muscles ?”

(2) Not less consonant with the interpretation of the mental
disorder as a reflex effect is the character of it; for it is manifest
mainly and mostly either in (a) great mental torpor or imbe-
cility, deepening into blank mindlessness in the worst cases; or
(b) in delirium. That we do not usually meet with the recog-
nized forms of insanity is a fact of some interest and importance;
v.] THE CAUSATION AND PREVENTION OF INSANITY, 233

indicating, as it does, the existence of different morbid condi-
tions from those of true insanity. A systematized mania or
melancholia represents a certain organized result of abnormal
character, a definite morbid action—the organization, if you will,
of disorder; the incoherent delirium, or the mental imbecility,
with which we have now to do, indicates, on the other hand, a
general disturbance of the supreme centres of intelligence, with-
out any systematization of the morbid action. Hence, though
the delirium may be active, it is commonly extremely inco-
herent, exhibiting an entire absence of co-ordination : it suggests
an agitation of the ganglionic centres of the hemispheres in
consequence of an irritation from without. So also with regard
to the imbecility when the mental disturbance has that form: it
is a general weakness without any definite character, wanting
the wrecks of systematic delusions which are usually met with
in the dementia following mania or melancholia. I much doubt,
however, whether it is possible ever to diagnose the disease
satisfactorily by its mental symptoms only: we must look rather
to such symptoms as intense paroxysmal headaches, giddiness,
affections of one or other of the special senses, loss of power in
the muscles of the eye or of speech, optic neuritis, and finally
epileptiform or apoplectiform attacks, and coma.

When the local disease directly implicates the supreme centres
of intelligence, there may be extreme mental disorder, or there
may not. When there is mental disorder it is not a little
remarkable how capriciously intermittent: the symptoms some-
times are; in fact, so strangely may they come and go, that one
runs no little risk of suspecting a patient of feigning them. At
one time he will assert that he is blind, or that he is deaf, or
that he cannot walk, when it is plain at another time that he
sees, or hears, or walks well. The following case illustrates well
the intermittence and the seemingly hysterical character of the
symptoms. A young lady aged sixteen, whom I saw two or three
times, complained of blindness, imperfect hearing, and loss of
power in the legs. Her father, a clever man of business, was
very excitable, and had had more than one attack of mania.
An aunt was peculiar, and her sisters were nervous and hysteri-
cal. She had been an unusually sharp, cunning, and precocious
234 PATHOLOGY OF MIND. [curar.

child, always very naughty, destructive, and pleased to play
mischievous and malicious tricks. She menstruated at the age
of eleven, and had exhibited erotic tendencies and ideas, not
behaving with modesty in the company of her young brother,
and showing a knowledge of sexual matters which was sur-
prizing. She was expelled from school. At another school
to which she was sent her general conduct was bad; she was
extremely cunning and wilful, and at various times. had hys-
terical fits of laughing and crying. One day, after being cor-
rected for bad conduct, she declared that she was blind, but the
schoolmistress and a medical man who saw her thought she
was malingering. In a few days she recovered her sight. After
a time she declared again that she was blind and deaf also,
remaining so for some weeks, when her hearing, but not her
sight, returned. All the medical men who saw her thought she
was badly hysterical. Later on the deafness returned, and she
said she could not walk, her limbs being so weak. It was plain
that sometimes she could both see and hear. Then attacks of
excitement occurred from time to time in which she shouted,
laughed. cried, threw herself about, struck her nurse; and at
last total blindness, deafness, and paralysis of the limbs were
indisputable. She complained of violent headache, became
wildly delirious, and died. After death a tumour, supposed to
be cancerous, about the size and shape of a hen’s egg, was found
in the right hemisphere.

Another example: a young man, et. twenty-four, suffered
from frequent and severe paroxysinal pains in the head,
weakness of vision, anxiety, extreme feeling of debility and
loss of power in the limbs; there was also confusion of
thought. After a time he had a maniacal attack; saw balls
of fire falling about him; thought himself pursued by mon-
strous forms; was very violent. The excitement lasted for
three days and nights without sleep, when he fell into a deep
sleep which lasted for twenty-four hours, awaking from it quite
conscious, with no remembrance of his previous excitement.
Again headache came on, with noise in the ears, and more or
less paralysis of the voluntary muscles; the maniacal excite-
ment recurred, becoming more continuous, and the paralysis
v.] THE CAUSATION AND PREVENTION OF INSANITY. 235

and mental stupor increased. One day he cculd neither stand
nor move his arms ; but after a tranquil night he could do both
quite well, and could return intelligent answers to questions.
In the evening he was again restless and excited; after which
he became comatose and died. Numerous cysts of cysticercus
cellulosus were found in the brain, five of them being fixed to
the inner surface of the dura mater and the rest dispersed
throughout the grey matter. By far the greater number were
found in the grey layers of the hemispheres, being collected
here and there into dense groups. In another case, in which
twelve cysticerci were found after death in the brain, the
symptoms were those of gradually increasing dementia with
paralysis.

It is well known that a person may lose a part of his brain,
and yet not exhibit any mental deficiency or disorder. Indeed
eases have been recorded which go to show that one hemisphere
may do the work of the whole brain; the only apparent
consequence of the destruction of the other hemisphere being a
quicker exhaustion by exercise and perhaps a greater irrita-
bility. This being so, it is easy to understand that a direct
encroachment upon the grey layers of the convolutions by
disease may take place without causing mental derangement.’

Much has been written lately concerning a so-called syphilitic
insanity, but syphilitic products have no more special tendency

1 The following case is reported by Dr, A. Schwarzenthal in the JWiener
Medizinische Presse for August 20, 1871: A woman, et. 30,4 day-labourer,
who had previously been under treatment for syphilis and leucorrhoea, was
admitted to the hospital in Zolkiew, suffering with hcadache, which was at
that time of several weeks’ duration, with prostration and with diminution
of appetite. Febrile exacerbations occurred sometimes in the mo:ning
and sometimes in the afternoon, and it was consequently thought that she
had intermittent fever. In time her condition had so much improved that
she was discharged. She returned to her occupation, doing as hard work
as before her illness, and occasionally frequenting houses of ill repute, at
one of which she died suddenly a month after her discharge from the
hospital. The posterior half of the right hemisphere of the brain was
found converted into a large abscess, while the left hemisphere was doughy
to the feel, and the cerebellum was softened. From the history of the

atient, Dr. 8, thought that the abscess of the brain must have existcd for
three months, notwithstanding that during all that time there had been no
loss of consciousness, and that during part of it she had been able to do
hard work.
236 PATIIOLOGY OF MIND. [cuar.

to produce insanity, than any other tumour or gross morbid
product in the brain. Caries of the skull from syphilis may de
mischief by extension of morbid action, just as caries from
disease of the bones of the ear may do.

CONCLUDING REMARKS.

A pregnant but very difficult question, of which little or no
thought has ever been taken by writers on insanity, is—What is
the cause of the particular form which the disorder takes ina
given case? Why does it assume one complexion rather than
another? At the outset it is certain that what appears to be
the same cause shall occasion different forms of insanity in
different persons, and even in the same person at different
periods of life, and that the same form of disorder shall be pro-
duced by different causes; this being so, it is plain that the
special determining conditions lie hidden in that unknown
region which we call by such names as temperament and idio-
syncrasy. Unfortunately these big words are at present little
better than cloaks of ignorance; they are symbols representing
unknown quantities rather than words denoting detinite con-
ditions; and no more useful work could be undertaken in
psychology than a patient and systematic study of individuals—
the scientific and accurate dissection and classification of the
minds and characters of particular men in correlation with
their features and habits of body. How vast a service it
would indeed be to have set forth in formal exposition the
steps of the quick process by which the shrewd and experienced
man of the world intuitively judges the characters of those
whom he has to do with, and refers them in a moment instinct-
ively to their proper classes in his mind! Our systems of
psychology are too abstract and ideal to be serviceable ; disdain-
ing to concern themselves with the individual, or shirking the
tedious work of observation for the easier work of speculation,
they give no help whatever in the education of the sane or in
the treatment of the insane mind.

Inasmuch as no two persons in the world are exactly alike in
their mental character and development, no two cases of mental
v.] THE CAUSATION AND PREVENTION OF INSANITY. 287

derangement will be exactly alike; the varieties of their morbid
features may well be as many as the varieties of individual
character. The brain stands not on the same footing as other
organs of the body in regard to its development as the special
organ of mind; while their respective development and function
are very much, the same in all persons, requiring no training to
do their work, and their diseases accordingly are closely alike,
the real evolution of the brain as the organ of mental function
takes place after birth in relation with an individual’s circum-
stances, and so gives rise to some variety of function in each
person with corresponding variety of structure in the delicate
fabric of thought; wherefore it is that each of two cases of
deranged mind which resemble one another in the general
features of exaltation or of depression, and perhaps also in
the character of the delusions, will still display its particular
features. Notwithstanding these superficial varieties of details,
however, there is great sameness in the leading types of insanity,
which makes it in the end monotonous and oppressive; the
patients fall into one or other of a few classes, and those who
consort with them may justly complain of the lack of invention ;
the manifold differences are superficial and incidental, the same-
ness is fundamental and essential ; and it is certain that he who
has studied well the inmates of ‘ine large asylum will know the
essential character and main features of the madness of all ages,
of all countries, and of all classes of men. Productive, in the
sense of creative, activity is the highest function of the best
endowed and most soundly developed mind.

As a general thing it may be presumed that the melancholic
temperament will predispose to a melancholy madness, the san-
guine temperament to a more expansive variety of derangement,
the suspicious temperament to a derangement in which delusions
of persecutions prevail. But this is not always so: a melan-
cholic person may rage, and a sanguine person may mope in
madness. The seat of the primary disease sometimes affects
the result ; injury to the head and gross disease of the brain
tend to cause intellectual rather than emotional disorder, while
abdominal disease favours the occurrence of emotional depres-
sion; the organic conditions of the intellect being, as Miillcr
238 PATHOLOGY OF MIND. (cmap,

remarked, mainly in the brain itself, and “the clem2nts which
maintain the emotions or strivings of self, in all parts of the
organism.” However, this is true only of disease of brain which
has made some progress, since the derangement caused by injury
and gross disease is often mainly emotional in its early stages;
the probable reason being that at this stage the initial disturb-
ance in the nerve-centres is very much the same as that which
is caused by irritation from a distant organ or by vitiated blood.
It has not, at any rate, gone beyond the stage of functional
derangement, which has emotional expression, into the farther
stage of disorganisation of structure which implies intellectual
derangement. When disease of the heart goes along with mental
disorder, not seemingly as an accident, but in an essential con-
nection with it, as it sometimes does, the latter usually takes the
melancholic form with extreme apprehensions and fears—a sort
of panphobia ; it yields indeed a striking contrast to the more
or less active mania which goes along with tubercular disease
of the lungs in some instances. Notable in this relation is the
extremely sanguine disposition of the phthisical patient who,
not being in the least insane in mind, is buoyant with unfailing
hope in spite of fast-failing strength, and perhaps projects on
the very edge of his grave what he will do many years after he
shall have been laid in it.

The bodily changes that accompany the changes of age have
something to do with the form which the disease takes. No one
feels and thinks concerning the things of this world at fifty
years of age as he did at thirty; what wonder then that the
character of the mental derangement befalling at these ages
should differ? Breaking out in youth and active manhood, when
the circulation of the blood is vigorous and the energies of the
body are at their full height, mania will be more common than
melancholia, unless the health has been brought low by long
suffering of body or mind previous to the outbreak ; in old age,
when the circulation is languid and the vessels are undergoing
degeneration, and when bodily energy is waning, some variety of
melancholia or some degree of decay of mind is more often met
with, Sex again will obviously impress its mark upon the
mental disorder in some instances, although it docs not make so
Vv.) TUE CAUSATION AND PREVENTION OF INSANITY. 239

much difference in the main types thereof as one not considering .
the uniformity of passion in the sexes might expect. It is clear
as day that temporary bodily conditions, hovever they may have
been brought about, will play their part ; and it may well be that
future researches will discover the causes of the characteristic
features of some varieties of mental derangement in the diathetic
states and the actual bodily disorders which are associated with
them. Should this come to pass, we may hope to be put in
possession of more exact and complete medical histories than
we have now, upon which may be raised in due time a natural
classification of insanity that shall furnish definite information
concerning the cause, course, probable termination and most
suitable treatment of a particular case which belongs to one of
its classes.

The degree of development which the mind has reached cannut
fail to imprint some marks upon the phenomena of its derange-
ment; these will be more various and complex in proportion as
it is more cultivated. A child soon after its birth could not
manifest true ideational disorder; it must acquire ideas before
it can have them deranged. For the same reason the madness of
an Australian savage will be a simpler matter than that of a
normal European, which may be expected to exhibit evidence of
the wreck of culture and perhaps of its degree also. The belief
in witchcraft is common among savages, and it is not surprising
therefore that a melancholic savage oftentimes has the delusion
that he is bewitched. Had an insane person in this country
that delusion, we might feel sure that he was not very enlight-
ened; if he had more knowledge he would probably ascribe his
sufferings to persecution by magnetism or by some mysterious
chemical agency. The delusions of the insane present broken
reflections of the principal beliefs of the age, and of the social
and political events of the time; so much so that Esquirol
affirmed he could trace the history of the French Revolution
from the taking of the Bastile down to the last appeararce of
Buonaparte in the character of the insanity which occurred
during its successive phases. Any striking incident, or any
ereat personage who is much before the public gaze, is apt to be
laid hold of by the insane mind and to be made the occasion of
240 PATHOLOGY OF MIND. [cHar.

a delusion. It is of little moment then in most cascs what the
particular delusion is ; the important thing is the affective mood
in which it is rooted, and from which it draws its life. The
vain and ambitious person may claim to be an inspired prophet
or even Jesus Christ, if his thoughts have been much given to
religious matters; to be a king ora prime minister, if he is a
politician ; to have solved the problem of perpetual motion, if
he has a smattering of physics: it matters not what he thinks
himself; no cure will be found for his delusion of greatness so
long as he is swollen with the conceit of which the delusion is
the morbid outcome,

Whosoever surveys madness as a whole, considering within
himself that there must be at bottom something which all cases
have in common, and asks what is the quality of nature which
shows most in those who become its victims, shall have occasion
for some instructive reflections. One thing fails not to be
brought forcibly home to those who live among the insane—
namely, how completely they are wrapped up in self, and what
little hold the cares and calamities of those who have been
living intimately with them ever take of them. It would be
no exaggeration to say that a person might live for years with a
company of insane people who were far from being demented,
and, appearing no more among them because of sickness or of
death, hardly be asked for more than once out of a transitory
curiosity. Living together for years they, as a rule, show no
interest in, and no sympathy with, one another. It is not a
conscious selfishness on their part; their own morbid feelings
aud morbid thoughts engross their attention so entirely that
nothing that affects others touches them deeply. Another
observation which those who have to do with insane persons
have frequent occasion to make is, that when they are recovered
they seldom evince any gratitude for what has been done for
them, however much attention and anxiety their sufferings may
have claimed and received; with some rare exceptions they are
quick to forget services and hasten to ignore any sense of obli-
gation. No doubt this is owing partly to the social prejudice
against insanity; it is natural that they should shun all
v.] THE CAUSATION AND PREVENTION OF INSANITY. 241

reference to a calamity which their relatives, who perhaps share
their peculiarity of temperament, are nervous unwilling they
should refer to, and which the world looks upon as something
like disgrace. But this is not the whole, nor always the main
reason: some of them cannot sincerely recognise that they have
been as ill as people have thought them, perhaps in their hearts
ascribe their insane doings to the treatment which they under-
went, and while remembering acutely every particular of what
they suffered, forget entirely what they made others undergo.
Nor can we wonder at it when we reflect how strong is the ten-
dency of any sane person whose passions are stirred or whose
interests are deeply engaged to see things from his own point of
view exclusively, and to transform his own perturbed feelings
into qualities of the object, and how complete his incapacity is
to take an opponent’s standpoint and to enter into his feelings.
It has been said that anger is a short madness; it would be no
less, true to say that madness is sometimes a long passion.
Having noted this extreme development of what may be
called selfhood or self-feeling among the insane—for it is not
that conscious self-love which is properly selfishness—one may
fitly inquire whether it is not oftentimes the morbid develop-
ment of a natural disposition. It will be found, I think, that a
great many persons who have gone insane have had intense
self-feeling without a counterbalancing intellectual grasp. The
friends of such a one will say of him perhaps that he was of a
very sensitive nature, that he could not bear criticism or opposi-
tion, that they found it necessary often to keep disagreeable
things from him, and the like; and this they will say sometimes
not by way of apology for an infirmity, but as if it were a
virtue of a finer nature than common, and as if it were not
every person’s business in the world to have and to bear all
sorts of impressions. There is a class of persons who are unabie
to bring themselves into sober and healthy relations of sincerity
with the circumstances of life; who let feeling loose and give
rein to imagination on all occasions; who are wanting in quiet
reasonableness, and cannot apprehend the notion, much less do
the practice, of the subordination of self as an element in a com-
plex whole; some of them turn all impressions to suspicion,
242 PATHOLOGY OF MIND. (cap.

take offence easily, brood over slights, magnify trifles, feel
acutely that opposition hurts their self-love, and, identifying their
selfhood with truth and right, persuade themselves that they
are suffering great wrong. They are sometimes very insincere,
though not always consciously so; assenting eagerly, effusively,
and for the time being sineerdly, to some “proposal or advice,
immediately aierwands the habitual distrust of their self-
regarding tendency invites its sympathetic ideas, and they begin
to discover hidden motives of self-interest in the adviser’s counsel,
and repent of their assent. Acute in their suspicions, they in-
variably overreach themselves and fall into the hands of plausible
charlatans who play upon their weaknesses. That is one reason
why ignorant but audacious impostors have a success in lunacy
practice which they could not have if real medical knowledge
and skill were required of them.

‘Others who are not entirely wrapped up in themselves are
almost wholly wrapped up in their families; it is a sort. of
vicarious gratification of self. One hears it said of some woman
who has fallen melancholic, and who thereupon displays all the
self-indulgent habits so common in such cases, that she was a
most amiable person, singularly devoted to her husband and
children, not in the least regardful of self, and that she is now
as unlike her true self as can possibly be imagined. But hus-
band and children do not really constitute the world, and an
excessive devotion to them might in such case be the most
thorough gratification of self, and too exclusively absorbing to
mark a wholesome reasonableness of life. So again a person
who is generous in giving away money may have been extremely
self-regarding, self-fostering, perhaps little scrupulous in the
getting of it; and if he becomes a moaning hypochondriac or
melancholic who can do nothing but think and talk of himself
and his sufferings, it is not perhaps quite true to say tlfat lis
present self is not in the least like his former self.

It is a common but by no means indisputable opinion that
the philanthropist is the least selfish of men; it would be moie
true to say that he is commonly a person of extraordinary self-
feeling who finds gratification thereof in his philanthropic
labours. Touched acutely in his feelings by the spectacle of
v.J THE CAUSATION AND PREVENTION OF INSANITY. = 243-

suffering and of wrong, he reacts with an intensity of immediate
energy in the endeavour to make things better, and he obtains
a relief of his lacerated feelings as well in proclaiming to the
world how much he is afflicted and in depicting vividly the
wrongs which afflict him, as in active works of benevolence.
All the while he may be minutely and habitually exacting and
self-indulgent in his family relations, The philanthropy which
embraces mankind is indeed too apt to overlook the family; and
there are not wanting examples to prove that the martyrs in the
cause of mankind can make martyrs of those who are in daily
intimate relations with them. The humble and irksome duties
and abnegations of daily life exact quiet and steady self-disci-
pline, yield no striking occasions for the ease of outraged senti-
ment, claim not public attention and sympathy, necessitate an
unostentatious subordination of self and its affections. They do
not suit well, therefore, with the sentiment-nursing character of
the philanthropist and with the vanity which the public pursuit
of his ends is apt to foster. The world does well, no doubt, to
applaud the philanthropist for the work which he does, in order
to the encouragement of men to set before themselves high aims
of human welfare, but on the whole it is well for the world that
it is not composed entirely of philanthropists.

The religious ascetic of former times, who fled from the society
of men to some hole in the rocks or to some desolate place of
the desert, and there inflicted upon himself all the sufferings
which his invention could devise, mortifying his body with long
fastings and many stripes, was persuaded that he did a very
holy thing, and was applauded by the world as a great saint.
The truth was that he had nursed an exaggerated selfhood into
something like madness. So far from having the merits which he
imagined himself to have, he would have found it a much harder
penance for him, as well as a more wholesome discipline, to have
done his modest work, like other people, as a humble meinber of
society. As it was, by bringing his body into a state of emacia-
tion, and by engaging his thereby enfeebled mind in continual
meditations on what Satan would do specially to tempt and to
torment him, or God would do miraculously to comfort and to
sustain him. he bred hallucinations which he belicved to be actual
244 PATHOLOGY OF MIND. [cuap.

apparitions to him of the Holy or of the Evil One. If he did
not truly see visions of that sort, he had brought hiniself to so
unstable and spasmodic a state of mind as to declare he did
without being sincerely conscious of his insincerity ; not other-
wise than as hysterical women, morbidly eager to gain sympathy
and notoriety, will counterfeit all sorts of diseases, or, if their
minds have dwelt much on sexual matters, will accuse innocent
persons of criminal assaults upon them, without being themselves
sincerely conscious of their duplicity and fraud. Were we to
believe the accounts which some of these saints gave of their
encounters with the devil, we should be driven to conclude that
he had put aside all other business in order to use his utmost
and undivided energies to shake their steadfast righteousness.
Their fanatical follies were really the outcomes of insane self-
hood which had identified itself with religion, just as the sancti-
monious and self-righteous Pharisee identifies his pride with
religion, and thanks God that he is not as other men are. Bui
as an ape seems more deformed from its resemblance to man, so
the aping of humility by religious pride makes it more odious.
We perceive then that a character which persons who become
insane often have in common is an exaggerated and ill-tempered
self-feeling, by reason of which they are unable to see things in
their true relations and proportions to themselves and to one
another. Great self-feeling with little self-knowledge and little
self-control is the soil most propitious to the growth of egoistic
passion: either to such passion as marks the striving of the indivi-
dual for increased gratification of self, as, for example, ambition,
avarice, love; or to such passion as marks the reaction of self
against that which opposes its gratification, as, for example,
envy, jealousy, wounded self-love, despondency. And the natural
outcome of such a passion grown to excess is delusion. But
there is countervailing advantage in great self-feeling—that it
imparts great earnestness and intensity to character: what is an
evil sometimes in supplying strength to narrow convictions aud
fire to intemperate zeal is a benefit to the individual in enabling
him to make a stand undaunted against opposition, though he
stand alone. The good side of this we see exemplified in the
reformer ; the bad side of it in the lunatic. A conviction gains
v.] THE CAUSATION AND PREVENTION OF INSANITY. 245

infinitely in strength, as Novalis remarked, when another person
believes it, as another person will not fail to do if it be based
upon sound experience and be a true evolution of thought.
But the lunatic’s conviction needs not in the least the increase
of strength which sympathy of thought gives; assent adds
nothing to its force, nor does dissent take anything from it; he’
would not believe more firmly in it if all the world believed
with him, and he holds fast to it notwithstanding that all the
world scorns it. One might say then of great self-feeling that
it confers the power of becoming a reformer or the liability of
becoming a lunatic according as the circumstances of life are
propitious or not, and according to the greater or less capacity
of intellectual insight and of self-control by which it is
accompanied.

It was Aristotle who took notice that great men are inclined
to be melancholy and hypochondriac. In them the self-feeling
is great; they do not easily subordinate themselves to things as
they are, but would have them as they should be; accordingly,
when their energies are directed outwards to the accomplishment
of some aim under the guidance of their superior insight, the
earnestness of great feeling inspires their convictions aud is
infused into their actions; such happy use of their energies
freeing them from their melancholy. When they are not actively
employed, having no more great things to do, they are prone to
fall back into melancholy, although they have commonly, by
virtue of their great intellectual power, sufficient self-control to
prevent it from passing into actual insanity,

Weighing well the manner of its causation, as set forth in the
foregoing pages, it is obvious that mental derangement must
needs be a matter of degree. There may be every variety (a)
of deficient original capacity, that is of deficient development
of the substratum of the mental organisation, whereby the indi-
‘vidual is born incapable of successful adjustment to his environ-
ment, ancestral antecedents being to blame; (0) of deficient
development of the mental organisation after birth, the cause
thereof lying in some injury or disease, or in faulty education-—
that is, in unfavourable conditions of the environment; and (c)
+

246 : PATIOLOGY OF MIND. (orar

of degree of degeneration, attesting the divers resuits of deranged
interaction between the individual and his environment. Be-
tween the lowest depths of idiocy and madness and the highest
reach of mental soundness there are numerous varieties shading
so insensibly into one another that observation may pass along
the whole series by a gentle gradient, and it will be impossible
for any one to draw a definite line to mark where sanity ends
and insanity begins. It is no wonder then that the question of
civil and criminal responsibility in these cases should be a most
difficult one to answer: on the one hand, there are insane
persons who are responsible for what they do, inasmuch as they
are plainly determinable by considerations of self-interest, and are
capable of much self-contrul and of keen foresight when they
have strong enough motives to exercise them ; on the other hand,
some sane persons are plainly not responsible for what they do
in certain circumstances, since no motive can take hold of them
at the time to move them to do otherwise than as they do.
There are two views of insanity prevalent which, in order to
clearness of thought, ought to be distinguished—namely, the
medical view of it as a disease requiring treatment, and the
legal view of it as an affliction incapacitating an individual from
knowing his obligations and from performing his functions as a
citizen. From a medical point of view a person may be so insane.
as to justify his being put under care and treatment in order to
be cured—particularly as experience has proved beyond all
question that the sooner suitable treatment is used the better is
the chance of recovery, and the longer it is put off the less likely
is recovery ever to take place—who, at the same time, may not
be so dangerous to himself or to others as to render him unfit to
be at large and to have the care of his own property. The law
almits the medical view of the necessity of treatmeit by sanc-
tioning the placing of a person of unsouud mind under restraint
as “a proper person to be placed under care and treatment” ; but
it goes beyond this special view of his welfare to a wider con-
sideration of his responsibilities as a member of society: it does
not accept unsoundness of mind by itself as a discharge from
responsibility for criminal acts or as sufficient evidence of in-
capacity to do civil acts, but exacts proof of such a degree ox
v.] THE CAUSATION AND PREVENTION OF INSANITY, 247

kind of insanity in a particular case as it holds to be sufficient
to abrogate responsibility. In the eye of the law then a man
may be mad, and yet not mad enough to be irresponsible as a
citizen—medically, not legally mad; he may be a proper subject
for medical treatment because of derangement of mind, and at
the same time a fit subject for judicial condemnation if he
breaks the law. So far the legal doctrine is theoretically just,
although its practical application is beset with difficulties.

But the English law is not satisfied to rest there; it goes on
to set up authoritatively an artificial criterion of- responsibility
in criminal cases, and insists on trying every case by it, notwith-
standing that the test it sets up is unphilosophical in theory,
and discredited on all hands by practical experience of insanity ;
in fact, contrary to all true legal principles, it goes out of its
way gratuitously to lay down as sound law an exploded psycho-
logical dogma, which is not law at all, but false doctrine —to wit,
that the insane person is responsible for his criminal act if at
the time of doing it he knew he was doing wrong, or knew that
the act was contrary to law. We may bring home to our minds
in the clearest way the meaning and the working of this test,
when strictly applied, by considering what would be the pro-
bable working of an enactment that every person sulfering from
convulsions of any sort, whose consciousness was not entirely
suspended while they lasted, should be held strictly responsible
for not stopping them. As no one who knows anything of
mental philosophy believes impulses to action to come from the
intellect, and to be always under its sway, and as no one who
bas had much to do practically with insanity has the least doubt
that a person Jabouring under it is constrained sometimes by his
disease to do what he knows to be wrong, having perhaps gone
through -unspeakable agony in his efforts to withstand the
morbid impulse before he yielded to it at the last, all suitable
occasions should be taken, in order that right and justice may in
the end prevail, to declare how unjust is the legal maxim, and
to protest against its application.

Another but less serious fault in the law concerning lunacy is
the want of proper provision for the discriminative treatment of
those who have been pronounced by it to be persons of unsound
248 PATHOLOGY OF MIND. [u mar.

mnind ; for the judgment is made in all cases to carry with it the
conclusion, not always well founded, that they are both inca-
pable of taking care of themselves and of managing their affairs.
Nevertheless, an insane person is sometimes competent to manage
his affairs who is not fit to be entirely ut large; and, on the
other hand, there are some who, not being competent to manage
their affairs, might very well be permitted to be at large after
fitting legal provision had been made for the proper management
of their property. We are getting too much into the habit of
looking upon insanity as a special and definite thing, which
either is or is not, and which, if it is, puts the sufferer at once
out of the category of ordinary men; unmindful that we are
dealing not with a constant entity, but with a multitude of
insane individuals who manifest all degrees and varieties of un-
soundness. A consequence of this habit is an undue readiness
to pronounce insane, and to confine in asylums, persons who
exhibit deviations from the usual tracks of thought and conduct,
which in former times would have been considered harmless, or
in some instances actually received as inspirations. Thus the
world is now robbed of the good which it might get from eccen-
tric ideas and novel impulses; for assuredly in the past it has
been greatly indebted to those who have broken away from the
automatic grooves of thought and conduct, even when their
originality has perhaps been only the beginning of insanity,

With these observations I conclude what I have to say con-
cerning the causation of insanity. They will have shown
perhaps the necessity of taking wider views of the origin and
nature of the disease than has been done hitherto. They may
admonish us too not to let these abortive minds pass without
taking to heart the lessons which they are fitted to teach.
Examples of failure of adaptation to the conditions of life, they
trace in suffering the downward path of degeneracy, and indicate
at the same time the opposite path of evolution ; thus they teach
that, not wasting strength in vain regrets over calamities that
are past remedy, men should apply themselves diligently to
get understanding of the laws of nature, and to bring their
lives into faithful harmony with them.
vd THE CAUSATION AND PREVENTION OF INSANITY. 249

APPENDIX.

In order to illustrate more fully this chapter on the causation
of insanity, I appended in former editions the short notes of fifty
cases, all of which were under my care at one time, and in which I
laboured to satisfy myself of the conspiring causes of the mental
disease. I might adduce a great many more cases, but do not, as
those which follow cover pretty well the field of causation, and,
being quoted without any selection, are sufficient for purposes of
illustration,

1. A captain in the army, and the only surviving son of his
mother, who was a widow. She suffered very much from scrofulous
disease, and he was wasting away with suspected phthisis. Mental
state, that of demented melancholia, with manifold delusions of
suspicion as to pernicious vapours and other injurious agencies that
were employed against him. He was the last of his family, two
brothers having died very much as he seemed likely to die. His
grandfather began life as a common porter, ultimately became
partner in a great manufacturing business, and, having amassed
enormous wealth, made a great display in London on the strength
of it. His high hopes of founding a family on the wealth which it
was the sole aim of his life to acquire thus issued.

2, There was direct hereditary predisposition, and the tempera-
ment was notably excitable through life. There was no evidence
of excesses of any kind, but there had been great business anxietios.
The mental disease was general paralysis.

3. An amiable gentleman, on the death of his wife, formed an
immoral connexion with a woman of loose character. Continual
sexual excesses, with free indulgence in wine and other stimulants,
ended in general paralysis.

4, A conceited Cockney, the son of a successful Lendon tailor
and money-lender, mean in look as in mind, stronzly imbued with
the tradesman’s spirit, and with offensive Dissenting zeal. Iope-
lessly addicted to self-abuse, and suffering from the disagreeable
form of mental derangement which follows that vice sometimes.

5. Two ladies of middle age, unmarried, and cousins. They both
suffered from extreme moral insanity, both revealing in their con-
duct the tyranny of a bad organisation. There was much insanity
250 PATHOLOGY OF MIND. [cuar.

in the family, in one case the father being actually insane; and in
both cases the parents being whimsical, capricious, and very in--
judicious as parents. A bad organisation made worse by bad
training.

6. An unmarried lady, aged 40, addicted to the wildest and
coarsest excesses, though of good social position and of independent
means ; justifying in every respect her conduct, though it more than
once brought her to gaol. Family history not known, but insane
predisposition suspected strongly, as there was plainly not the least
moral element in her mental organisation. No aim nor occupation
in life, but extreme egoistic development in all regards.

7. A publican, wt. 31, had done little for some time but stupefy
himself with brandy in his own bar-parlour. The consequence was
furious mania and extreme incoherence: acute mania from con-
tinued intoxication, not delirium tremens.—Recovery.

8. A woman, et. 47; of dark complexion, sallow skin, and bilious
temperament, who was said to have suffered much from her hus-
band’s unkindness and domestic anxieties, underwent “the change
of life,’ and became extremly melancholic. Nothing more was
known about her.—Recovery.

9. Hereditary predisposition marked. First attack, et. 38, when
unmarried. Second attack, et. 58, she having a few years before
married an old gentleman in need of a nurse. She was given to
taking stimulants, fancied herself ill, and was always having the
doctor to talk over her ailments and to recommend her some stimu-
lant ; in fact, hypochondriacal melancholia grew gradually by indul-
gence into positive insanity.— Recovery.

10. A married lady, et. 31, without children, and having grcat
self-feeling. She went on one occasion to a Methodist meeting,
where she was much excited by a violent sermon; immediately
afterwards went mad, fancying her soul to be lost, and making
attempts at suicide.—Recovery.

11. A young lady, et. 25, who had undergone some anxieties at
home, suffered a disappointment of her affections. Blank depression
and vacuity, having all the look of acute dementia.—Recovery.

12. A married woman, et. 44, of dark and bilious temperamcnt,
had never had any children. At the “change of life” profound
melancholia came on.

13. A gentleman, aged 60, of fine sensitive temperament, whose
mother was said to have been very flighty and peculiar, had himself
v.] THE CAUSATION AND PREVENTION OF INSANITY. 25!

been noted for peculiar‘ties through life. He became profoundly
melancholic, thinking himself ruined, and was intensely su‘cidal.
Refusal of food. Everything taken, however, was vomited, and
diagnosis of organic abdom‘nal disease, probably malignant, was
made.—Death fo exhaustion.

14. A bookseller, at. 41, temperate, of considerable intellectual
capacity, but of inordinate conceit; advocated a general division of
property and other extreme theories. Ultimately he got the notion
that there was a conspiracy against him on the part of the Govern-
ment, and tried to strangle his wife as a party to it. After an
illness of two years he died of phthisis, with many of the symptoms
of general paralysis) The bodily disease seemed to have conspired
with a great natural egoism, and thus to have made the mental
derangement one of its earliest symptoms.

15. A married man, wt. 50, of anxious temperament. Profound
melancholia ; refusal of food. Second attack. Apart from the pre-
disposition established by a former attack, the cause seemed to be
great self-feeling, assuming a religious garb, or at any rate getting
its discharge in religious emotion. Very fervent always in devo-
tion, but intense egoistic feeling; entire reference of everything to
self, and natural incapacity to take an objective view.— Recovery.

16. A single lady, «xt. 38, fancied herself under mesmeric in-
fluence, in a state of clairvoyance, and had a variety of anomalous
sensations about her body: Rubbed her skin till it was sore in
places, bit her nails to the quick, scratched her face; &ce. Quasi-
hysterical maniacal exacerbations, in which she could not contain
herself, but tossed on a couch or even rolled on the floor in violent
unrest. Irregularity of menstruation, and suspected self-abuse.—
Recovery.

17. A lady, wt. 45, but looking very much older, having had an
anxious life. Hereditary predisposition; change of life; melan-
cholic depression, passing into destructive dementia. Convulsions,
paralysis, death. Here softening of the brain was preceded for
some weeks by mental symptoms.

18. Hereditary predisposition. Great excesses. General paralysis.

19. Habitual alcoholic excesses; pecuniary difficulties; mania.
After some years hemiplegia of right side, muscular power being
partially regained after a time. The patient lived for years thus.
Paralysis of long duraticn was the usual family disease and cause
of death.
252 PATHOLOGY OF MIND. (crap,

20. Suicidal insanity in a married lady. Strong hereditary pre-
disposition to insanity. Exhaustion produced by lactation, and
mental depression occasioned by the long absences of her husband
from home.—Recovery.

21. Third or fourth attack of acute moaning melancholia in a
woman, aged 40. Intense self-conceit and selfishness natural to
her. Gastric derangement, and obstinately constipated bowels.
Whenever bodily derangement reaches a certain pitch, or adversity
occurs, it seems to upset the equilibrium of an ill-balanced mind,
predisposed to disorder by an exaggerated egoism and by former
attacks.—Recovery.

22. Gambling, betting, drinking, and sexual excess. General
paralysis.

23. A bad organisation plainly—not due to actual insanity in
family, but to the absence of moral element. A life of great ex-
citement, and of much speculation in Australia. Alcoholic and
sexual excesses (1). General paralysis.

24, A widow, et. 58, the daugher of one who had begun life as a
labourer at a coal-wharf, but who had risen to be an employer, and
had made a great deal of money. He was without education, so
that his daughter, brought up‘as a rich person, but without cultiva-
tion of body or mind, did not get opportunely married: ‘‘ She was
too high for the stirrup, and not high enough for the saddle.”
When 50 years old, she married an old gentleman, whose former
manner of life had made a nurse needful to him. He died, and left
her the income of a large property for her life. She now got
suspicious of his relatives, to whom the property was to revert on
her death ; was harassed with her money, which she did not know
what to do with, but fancied others had designs on; and finally
went from bad to worse until, believing all the world was con-
spiring against her, she got a revolver, and threatened to shoot her
fancied enemies.

25. The daughter of a common labourer, who had become very
rich in the colliery business, xt. 32, single. At her father’s death
she inherited wealth ; was without any real education, very vulgar,
and spent the greater part of her time in drinking gin and reading
sensational novels. Great hereditary predisposition, not to insanity
only, but to suicidal insanity. Suicidal melancholia, with an in-
coherence approaching dementia.

26. A gentleman, wt. 34. Steady, quief drinking, on all possible
v.] THE CAUSATION AND PREVENTION OF INSANITY. 253

“

occasions. The ‘“ne’er-do-weel” of the family, having tumbled
about the world in Mexican wars and South American mines, and
in other places, as such persons do. General feebleness of mind and
specially marked loss of memory. An uncle had been very much
the same sort of person, and had died in an asylum. In speaking
of himself—if describing what he had been doing, for example—
always spoke of himself as “you,” as though he were addressing
himself as some one else.

27, A married woman, aged 49, gaunt, and seemingly of bilious
temperament. After a fever of five weeks’ duration, called “gastr‘c,”
probably typhoid, acute maniacal excitement, violence, incoherence,
&ce.—Recovery within a fortnight.

28. Dementia after epilepsy, the fits occurring at the catamenial
period. Brother maniacal. and sister without the moral element in
her disposition.

29. The young lady before mentioned as No. 11 was removed by
a penurious father from medical care before recovery was thoroughly
established, and in opposition to advice. The return to home
anxieties brought on an attack of acute man‘a, with endless gabbling
of incoherént rhymes.—Permanent recovery this time.

30. A warehouseman, aged 35, a Primitive Methodist, much
addicted to preaching. He had accomplished some self-education
but had a boundless conceit, and infinite self-feeling. Indigestion,
pyrosis, frequent vomiting after meals. Melancholia, with delusion
that he had committed the unpardonable sin and endless moaning.
Very remarkable was the evidence of self-feeling in his case—self-
renunciation not being a word that entered into his vocabulary.
This man, for example, though well aware that vomiting followed
eating, and sufficiently afflicted thereby, could not be induced to
regulate his diet voluntarily, but ate gluttonously unless prevented

31. A married woman, et. 32, of stout habit of body, and with
habitually locked secretions. The sudden death of a son brought
on severe moaning melancholia.

32. A single lady, aged 57, who had been insane for thirty years.
There was the strongest hereditary taint.

33. A young man, extremely delicate, aged 22, had acute de-
mentia, following acute rheumatism. There was valvular disea-e
of the heart, with loud mitral regurgitant murmur.—Issue of the
case unknown.

34, A tradesman’s daughter, et. 24, brought up in idleess,
254 PATHOLOGY OF MIND. [cnap.

and in habits unsuited to her station. Slight hereditary predis.
position, much aggravated by her injudicious education. Domestic
troubles and anxieties after marriage, she being unequal to the
management of a household. Mania.—Recovery.

35. A woman, xt. 30, Wesleyan, single. Suicidal melancholia
with the delusion that her soul is lost. Menstrual irregularity.
Extreme devotional excitement, with evidently active sexual feelings.
—Recovery.

36. A young woman, xt. 25, single, Wesleyan. Mania. Cause,
same probably as in the last case.—Recovery.

37. A respectable, temperate, and industrious tradesman, et. 40,
Wesleyan, a teetotaller, and much superior to a vulgar wife. Second
attack, His father committed suicide; h’s brother was very flighty.
General paralys's.

38. A sober, hardworking, respectable bookseller, not given to
excesses of any kind, so far as was ascertained. But here, as in
many other cases, one lacked knowledge with respect to possible
marital excesses. Slight hereditary predisposition. General paralys’s.

In both these last cases there was general paralysis in men who
had not been intemperate. In both, however, there were large
families of children, and the struggle of life had plainly been very
anxious and severe.

39. A woman, et. 32. Acute mania eame on two months after
childbirth.

40, A lady, et. 34, single, without other occupat‘on or interest
than religious exercises. Suic'dal melancholia, with the delusion
that she had sold herself to the devil. Amenorrhcea.—Recovery.

41, A married woman, et. 40. Sudden outbreak of mania, after
going to a revival meeting. Amenorrhea —Recovery.

42, A married man with a family, et. 52, a Dissenter, holding
an office of authority in his church, and most exact in his religious
duties. Secretly, he had of late kept a mistress, however, and
lived a rather dissipated life. Outbreak of acute mania, with
a threatening of general paralysis.—Recovery; for a t'me at any
rate.

43. Acute mental annihilation in a young man about a year and
a half after marriage. One or two intervals of a few hours of
mental restorat’on.—Death in epileptiform convulsions. Softening
of the brain in extreme degree, but lim’ted ‘n extent. Excess:ve
sexual indulgence.
v.] THE CAUSATION AND PREVENTION OF INSANITY. 255

44, A married woman, xt. 44, who has had several children, and
who has become insane after each confinement. Extreme maniacal
incoherence and excitement, with unconsciousness that she has had
a child.— Recovery.

45. Hereditary predisposition. A Dissenter of extreme views,
narrow-minded and bigoted. He was married when thirty-six
years old, and became melancholic a short time after the birth of
his first child.—Recovery.

46. Complete loss of memory and of all energy of character, and
failure of intelligence, in a man, et. 36, single, from continual
intemperance in drinking and smoking. Has previously had two
attacks of delirium tremens.

47. An extremely good-looking young widow, who had been a
s:nger at some public singing-rooms and the mistress of the pro-
prietor of them. Sexual excesses. General paralysis.

48. Attack of acute violent mania in a young surgeon, et. 27.
Afterwards three days of heavy stertorous sleep; then seeming
recovery for twenty-four hours; but on the next day recurrence
of mania, followed soon by severe epileptic fits.— Recovery.

49, Extreme moral perversion, with the most extravagant conceit
of self and unruly conduct in a young man, a clerk. Alternations
of deep depression and suicidal tendency. Cause, self-abuse.

50. A single lady, aged 41, who, on her return from school when
fifteen years old, was queer, listless, and from that time had been
rather peculiar. Hereditary predisposition. Acute melancholia,
with the delusion that she is lost because she has refused an offer
of marriage from a clergyman, such offer never having been thought

of by him.

12
CHAPTER VI.
THE INSANITY OF EARLY LIFE,

How unnatural! is an exclamation of pained surprise which
some of the more striking instances of insanity in young
children are apt to provoke. However, to calla thing unnatural
is not to take it out of the domain of natural law, notwithstand-
ing that when it has been so designated it is sometimes thought
that no more need be said. Anomalies, when rightly studied,
yield rare instruction ; they witness and attract attention to the
operation of hidden laws or of known laws under new and
unknown conditions ; and so set the inquirer on new and fruit-
ful paths of research. For this reason it will not be amiss to
occupy 2 separate chapter with a consideration of the abnormal
phenomena of mental derangement in children.

The first movements of the child are reflex; but sensorial
perceptions with motor reactions thereto follow these early
movements so soon that we can make only an ideal boundary
between reflex and sensori-motor acts. The aimless thrusting
out of a limb brings it in contact with some external object,
whereupon it is probable that a sensation is excited. The particu-
lar muscular exertion must also be the condition of a muscular
feeling of the act; so that the muscular sense of the moVement
and the sensation of the external object are associated, and for
the future unavoidably suggest one another: a motor intuition
of external nature is thus organised, and one of the first steps
in the process of mental formation accomplished. The same
educational process goes on in the exercise of the movements of
CHAP. V1.] TUE INSANITY OF EARLY LIFE. 257

the lips and tongue, which are the parts first exercised by a
child, and in the motion of its hand, which it puts to its moutl:
in order to suck it. Afterwards, whatever is grasped in the
hand is similarly carried to the mouth, Thus the sensibility
and motion of the lips are the first inlets of knowledge; the
child having got thereby some perception of an external object
as the occasion or accompaniment of a certain association of sen-
sations and movements, immediately brings any object which
it grasps with its fingers into relation with these. means of
instruction, In this way the hand is used to exercise the sen-
sibility and motions of the lips, and the knowledge previously
gained through them is applied to instruct the hand, which at
a later period, when it has been taught by its own experience, is
applied to other parts of the body, in order to help to interpret
and localise their sensations. But it is long before the infant can
localise a sensation in another part of its body than its lips and
hand; when a pin in its dress is pricking it, for example, it can
only cry out helplessly ; it cannot make a definite effort with
the hand to remove it, as it will do later on, when it has learnt
to know the geography of its own body. If we call to mind
how, when discussing actuation, it was shown, in the case of the
eye, that a sensation was the direct cause of a certain accommo-
dating movement, and that the definite movement thereupon
imparted the intuition of distance, we shall perceive how the
organic association of a sensation from without with an associ-
ated muscular act builds up by degrees definite intuitions of
external objects in the young mind.

Suppose now that an infant becomes insane soon after birth,
what sort of insanity must it exhibit? The range and variety
of mental disorder possible are clearly limited by the extent of
existence of mental faculty; which is almost nothing. In this
regard the observed facts agree with theory; for when a child
is, by reason of a bad descent or of baneful influences during
uterine life, born with such an extreme degree of instability of
nerve element that, on the first play of external circumstances
its nervous centres react in convulsive fashion, it mostly dies
in convulsions. The disordered action proceeds from the ner-
vous centres of reflex action—those which alone at this time
258 PATHOLOGY OF MIND, [crap.

have power of function ; the convulsions are the equivalent in
them of the delirium which is the exponent of derangement
of the ideational centres,—might be said to represent their
insanity, as insanity, on the other hand, represents, so to speak,
convulsive action of the higher nervous centres.

In consequence of the close connection of sensorial action
with reflex action in the infant—the actual continuity of
development which exists—there is commonly evidence of
some sensori-motor disturbance in the earliest nerve-troubles.
An impression on the sense of sight, for example, is not quietly
assimilated so as to persist as an organised residuum in the
proper nervous centre, but immediately stimulates the un-
stable cells of the associate motor centres to irregular and
violent actions, which may be of a more or less purposive
character; and the consequence is that the phenomena of a
true sensorial insanity are intermixed with the morbid manifes-
tations of the lower nervous centres. Instances of such morbid
action so soon after birth are certainly rare; nevertheless they
are met with now and then, and have been recorded. Crichton
quotes from Greding a well-known case of a child which, as
he says, was raving mad as soon as it was born. “A woman,
about forty years old, of a full and plethoric habit of body,
who constantly laughed and did the strangest things, but who,
independently of these circumstances, enjoyed the very best
health, was, on the 20th January, 1763, brought to bed, without
any assistance, of a male child who was raving mad. When he
was brought to our workhouse, which was on the 24th, he pos-
sessed so much strength in his legs and arms that four women
could at times with difficulty restrain him. These paroxysms
either ended in an uncontrollable fit of laughter, for which no
evident reason could be observed, or else he tore in anger every-
thing near him,—clothes, linen, bed-furniture, and even thread,
when he could get hold of it. We durst not allow him to be
alone, otherwise he would get on the benches and tables, and
even attempt to climb up the walls. Afterwards, however,
when he began to have teeth, he died.”

If there be not exaggeration in this description it must be
allowed to be very surprising that a child so young should have
vi.] TIIE INSANITY OF EARLY LIFE. ; 259

been able to do so much; and those who advocate innate mental
faculties might well ask how it is possible on any other sup-
position to account for so extraordinary an exhibition of more
or less co-ordinate power by so young a creature. Two con-
siderations may be suggested by way of lessening the extra-
ordinary character of the phenomena: first, that the mother of
the child was herself peculiar, so that her infant inherited an
unstable nervous organisation, and consequently a disposition to
irregular and premature reaction on the occasion of an external
stimulus; and secondly, that there are innate in the constitution
of the human nervous system the aptitudes to certain co-ordinate
automatic acts, such as correspond in man to the instinctive acts
of animals. Many young animals are born with the power of using
their muscles together in complex ways for definite ends directly
they are exposed to suitable stimuli, and the human infant is
not destitute of the germ of a like power over voluntary
muscles, while it has the complete power of certain co-ordinate
automatic acts; one can conceive, therefore, that, without will,
and even without consciousness, it may display, when insane, in
answer to sensations, actions which have more or less semblance
of design in them1—in other words, convulsions that are more or
less co-ordinate. If people would keep open minds and not begin
to observe with a pre-existent idea that the function of the
highest nerve-centres means something essentially different from
the functions of lower nerve-centres, they would not have the
difficulty they have in recognising co-ordinate convulsion. We.
have in fact convulsive display of innate co-ordinate faculty in
irregular, violent, and destructive movements, and in precocious
acts which would be natural in a more restrained form at a later
stage of normal development, such, for example, as “uncon-
trollable fits of laughter without any evident reason.” 2? Without
.} “That they do this by instinct, something implanted in the frame, the
mechanism of the body, before any marks of wit or reason, are to be seen
in them, I am fully persuaded ; as I am likewise that nature teaches them
the manner of fighting peculiar to their species ; and children strike with
their arms as naturally as horses kick, dogs bite, and bulls push with their
lorns,’’—MANDEVILLE’s Fable of the Bees, vol. ii. p. 352.
2“ The youngest person whom I have seen labouring under mania,”’ says

Sir A. Morison, “was a little girl of six years old, under my care in
Bethlehem Hospital. I have, however, frequently met with violent and
260 PATHOLOGY OF MIND. [ouar.

doubt the paroxysms of violent laughter were provoked by the
morbid condition of the motor centres, not by any mental
conceit of the infant.

As the earliest stages of the infant’s mental development cor-
respond in a general way with the permanent condition of mind
of those animals whose actions are reflex and sensori-motor, it
is no wonder that their morbid phenomena are comparable.
Being in both cases mainly referable to disorder of the sensorial
and associate motor nervous centres, the insanity might not
unfitly be described as sensorial. The impressions made upon
animals, and the sensations or at most the few simple and im-~
perfect ideas that follow them, are transformed immediately
into movements, as they are also in children; nothing like
true reflection is possible, except it be in a few of the higher
animals ; consequently when the impressions are morbid they
are answered instantly by morbid movements. The elephant,
usually a gentle enough creature, is subject at certain seasons to
attacks of furious madness, in which it rushes about in the
most dangerous way, roaring loudly and destroying everything
within its reach ; and other animals are now and then affected
with similar paroxysms of what might be compared with an
epileptic fury. There is far more power in the insane elephant
than in the insane infant, and it is able to do a great deal more
mischief, but there is no difference in the fundamental nature
of the madness; the furious acts are the reactions of morbid

‘unmanageable idiots of a very tender age.” Dr. Joseph Frank records
having seen, on a visit to St. Luke’s Hospital, in 1802, a case of mania
occurring at the age of two years.—Lectures on Insanity, by Sir A. Mori-
son, M.D. In the Appendix to one of the Reports of the Scotch Lunacy
Commissioners, mention is made of a girl aged six years, who was said to
be afflicted with congenital mania. She was illegitimate, and her mother
was a prostitute. She could not walk, paraplegia having come on when
she was a year old; she was incoherent, and subject to paroxysms of
violent passion ; at all times very intractable; slept little and ate largely.
All such cases may be viewed as partial idiots from birth. The cerebral
organisation at so early an age is so delicate that it does not bear severe
morbid affections without losing ‘its fitness for mental development and
endangering life. Indeed it might fairly be said of the cases.of insanity
in very young children, that some are examples of intellectual deficiency,
the rest examples of moral perversion or deficiency, with or without excite-
ment. Epilepsy goes along with the mania sometimes, and the tendency
is to burn, tear, injure, destroy, &c,
v1.] THE INSANITY OF EARLY LIFE. 261

motor centres to impressions made on morbid sensory centres ;
and the whole mind, whether of the infant or of the animal, is
engulfed in the convulsive reaction. Dogs being ag a rule
very intelligent animals, because of their intimate association
with men through countless ages, exhibit something more thau
sensorial disorder when they go mad, although a great part of
the phenomena are sensorial. Their disposition and habits
notably suffer a great change; they become sullen, dull, irri-
table, solitary in their habits; afterwards hallucinations evidently
occur, and they bite alike friends who are kind to them and
strangers who take no notice of them or who threaten them.
M. Magnan has produced experimentally very vivid hallucina-
tions in dogs by injecting alcohol into their veins: the animal
starts up, stares wildly at the bare wall, barks furiously, and
seems to rush into a combat with an imaginary dog; after a while
it ceases to fight, retires, growling once or twice in the direction
of its discomfited adversary, and settles down quietly.

So soon as we have recognised the existence of insanity which
is mainly sensorial, we become sensible of the value of the dis-
tinction. Not only does it furnish an adequate interpretation of
the violent phenomena of the insanity of the animal and of the
infant, but it alone suffices to explain that desperate fury which
semetimes follows a succession of epileptic attacks in the human
subject. When the furious epileptic maniac strikes and injures
whatsoever and whomsoever he meets, and, like some destructive
tempest, storms through a ward with convulsed energy, he has
no notion, no consciousness, of what he is doing; to all intents
and purposes he is an organic machine set in the most destruc-
tive motion ; all his energy is absorbed in the convulsive explo-
sion. And yet he does not rage quite aimlessly, but makes more
or less determinate attacks upon persons and things: he sees
what is before him and destroys it; there is that method in his
madness; his convulsive fury is more or less co-ordinate. His
desperate deeds are respondent to morbid sensations in which his
consciousness is entirely engulfed; often there exist terrible
hallucinations, such as blood-red flames before the eyes, loud
roaring noises or imperative voices in the ears, sulphurous smells
ia the nostrils; any real object which does present itself before
262 PATHOLOGY OF MIND. [caap.

the eyes is seen with the strangest and most unreal characters ;
lifeless objects seem to threaten his life, and the pitying face of
a friend becomes the menacing face of a devil. His frantic
deeds therefore do not answer to the realities around him, but
to the unreal surroundings which his sensorial anarchy has
created :1-they are the motor exponents of his fearful hallucina-
tions. For the time being there is a true sensorial insanity, the
functions of higher nervous centres being in abeyance; and
after the frantic paroxysm is over there is complete forgetful-
ness of what has happened during it, as there is forgetfulness of
sensori-motor action in health. Differences between this epi-
leptic fury and infantile insanity arise out of the residua, sensory
and motor, which, wanting in the child, have been acquired and
organised through experience in the nerve centres of the adult:
the sensory residua render possible in the adult special halluci-
nations which the infant cannot have; while the residua in the
motor centres which are the basis of the secondary automatic
faculties render possible, in like manner, a degree and variety
of violence which the infant, possessing only such germs of
co-ordinate function as are original, must needs fall short of.
The transformation of disordered sensation into disordered
movement is not so quick and violent in all cases. As the
child adds day by day to the number of its definite perceptions,
and accumulates the materials of reflection, the distracting and
inhibitory operations of which come into play, there is a less
strong tendency to instant motor expression of sensory states,
Hallucinations may therefore come and go, or persist for a
time, without provoking any violent movements. I might
indeed justly distinguish two classes of cases: one class in
which a violent and convulsive reaction, the result of the in-
stant transformation of impressions into movement, masks all
other features of the disease, and gives it an epileptiform charac-
ter ; another class in which the active sensory residua persist in

1 An epileptic, under my care, usually amild and gentle being, used to
become a most violent and dangerous maniac after a series of fits, and to
commit terrible destruction. He thought at these times that he was
fighting for his life against a lion, and his desperate actions were the
exponents of his mental chaos,
VI.J THE INSANITY OF EARLY LIFE. 263

consciousness as hallucinations, giving rise, if they give rise to
answering movements, to such as are more choreic in character.
A variety of insanity in children, then, which we may next
consider, is that form of sensorial insanity in which hallucina-
tions occur, and in which the motor reactions are not convulsive
and epileptiform, but spasmodic rather and choreic. There is
reason to think that temporary or fugitive hallucinations are
not uncommon in infancy, and that the child when stretching
out its hand and appearing to grasp at an imaginary object is
deceived sometimes by a subjective sensation which has been
excited by an internal bodily state, just as a smile or a frown
on its face is excited oftentimes by a purely bodily state. Ex-
perimental proof of this manner of origin is not wanting: Dr.
Thore mentions the case of an infant, aged fourteen months and
a half, which had accidentally been poisoned by the seeds of
the Datura stramoniwm, a drug which, like belladonna, is well
known to disorder the sensory centres; hallucinations of sight
occurred, as shown by the motions of the child, which seemed
to be constantly seeking for some imaginary objects in front of
it, stretching out its hands and clinging to the sides of the
cradle in order to reach them better! The most remarkable
example of such condition of hallucination is afforded, kow-
ever, by that form of nightmare which some children suffer so
much from: possessed with a vivid hallucination, they begin
to shriek out in the greatest terror without being awake, though
their eyes are wide open; they tremble or are almost convulsed
with fright, and do not recognise their parents or others who
attempt to calm them; and it is some time before the paroxysm
subsides and they can be pacified. In the morning they know
nothing of the fright which they had, but have forgotten it, as
the somnambulist forgets his midnight walk, or as sensation is
commonly forgotten. Strictly speaking, however, it is not right
to say that they forget the experience, because the activity was
all the while sensorial; and as there was no conscious perception,
as the child did not perceive that it perceived, there could be
no conscious memory. The undoubted and not uncommon occur-
rence of these vivid hallucinations in children, when the matter

L Annales Médico-Psychologique, 1849.
264 PATHOLOGY OF MIND. [umar.

has certainly passed beyond ordinary dreaming, will serve to
show how probable it is that they have sometimes, when awake,
positive hallucinations. And if a very young child is affected
with hallucinations, it cannot help believing in them any more
than the dreamer can; it cannot correct sense by reflection,
since the higher nervous centres of thought have. not yet entered
upon their function. They may therefore exist temporarily
in children without indicating any serious disturbance of the
health; the organic residua of a sensation being stimulated to
activity by some trifling and transient bodily derangement.

It is in conformity, then, with pathological observation as
well as with physiological principles, to affirm the existence in
children of a variety of sensorial insanity which is characterised
by hallucinations, most frequently of vision, and sometimes by
answering irregular movements. Fits of involuntary laughter
are often witnessed in such cases: the langh, or rather smile, of
the infant is an involuntary sensori-motor movement, before ‘it
has any notion of the meaning of the smile or any consciousness
that it is smiling; consequently we meet with an irregular and
convulsive manifestation of this function as the motor expres-
sion of a morbid state of things. Dr. Whytt relates the instance
of a boy, aged 10, who, in consequence of a fall, had violent
paroxysmal headaches for many days. After a time there
occurred “fits of involuntary laughter, between which he com-
plained of a strange smell and of pins pricking his nose; he
talked incoherently, stared in an odd manner,” and immediately
afterwards fell into convulsions. He recovered on this occasion,
but two years afterwards was similarly attacked: he had severe
headache, saw objects double, and suffered from a severe pain in
the left side of his belly, confined to a spot not larger than a
shilling ; “sometimes it shifted, and then he was seized with
fatiguing fits of involuntary laughter.” Ultimately he recovered
partially, but never completely. One ought to take particular
pains in all cases of hallucination in children to make a close
examination of the state of the general sensibility of the body ;
for perversions or defects of it will frequently be found both
where there are corresponding perversions of movements and

1 Qp. cil. p. 144,
v1.] THE INSANITY OF EARLY LIFE, 265

where there are not. Because, however, this form of sensorial
insanity is often associated with movements of a more or less
choreic character, and because, as compared with the previously
illustrated epileptiform variety, it has relations not unlike those
which chorea has to epilepsy, I have described it as the chorete
variety of sensorial insanity.

With each succeeding presentation of an object to a child
the impressions made on the different senses by it are more
exactly felt and more perfectly combined, so that an adequate
idea of the object is at last organised in the higher ideational
centres; there is a consilience of the sensory impressions into
the idea, which thenceforth makes it possible for the child to
think of the object when it is not present to the senses, or to
have a definite and adequate perception of it when it is. As
development proceeds, one idea after another is thus added to
the mind until many simple ideas have been organised in it;
for a long time, however, these ideas remain more or less isolated
and imperfectly developed ; there are not definite and complete
associations between them expressing their relations, and the
child’s discourse is consequently incoherent; there is not more-
over a complete organisation of residua at first, and its memory
is consequently fallacious. Children, like brutes, live in the
present, their happiness or misery being dependent upon im-
pressions made upon the senses: the idea or emotion excited
does not remain in consciousness and call up other ideas and
emotions, so modifying the sense of. present pleasure or pain
by memories of what has been felt before, which may tend to
inhibit action, but it is directly uttered in outward action.
Such a condition of development, which is natural to the child
before the fabric of its mental organisation has been built up,
and to the animal, in which the constitution of the nervous
system renders a higher mental development impossible, would,
were it met with in an European adult, represent idiocy, or an
arrest of mental development from morbid causes.

So soon as definite ideas have becn organised in the child’s
mind delusions are possible. But as ideas are at first compara-
tively few in number, and as their organic associations are very
imperfect, a derangement of the function of their centres must
266 PATHOLOGY OF MIND. {cuar.

needs be characterised by very incoherent delirium. Divers
morbid ideas will spring up without coherence ; and the morbid
phenomena, wanting system, will correspond, not so much with
those which in the adult we describe as mania, where there is
a more or less systematized derangement, some method in
the madness, as with those which are known as delirium,
when ideas spontaneously arise in consviousness in the most
incoherent way. Let me proceed then to test these principles
by an examination of such facts as are available.

As a morbid idea in the child’s mind has, by the nature of
the case, but a small range of action upon other ideas, it tends
to utter itself by its other paths of expression; namely, by a
downward action upon the sensory ganglia or upon the move-
ments. When it acts downwards upon the sensory ganglia it
gives rise to a hallucination ; and in such cases, as may easily be
imagined, it will not always be possible to determine whether
the hallucination is really secondary or primary—whether, that
is to say, it is engendered indirectly by the action of the morbid
idea upon the sensory ganglion, or directly by the excitation of
the sensory residua by some organic irritation. Ifa child which
is only a few years old sees strange figures of some sort on the
wall, which have no real existence, but disappear with apparently
as little reason as they came there, the hallucinations are most
likely owing to some organic cause of disturbance which affects
directly the sensory ganglia. But if a child of eight or nine
years old, whose head has been filled with foolish and dangerous
notions concerning the devil, or who has, when naughty, been
threatened by its nurse with the terrors of a black man who
will come and carry it off, suddenly sees a devil or a black man
appear and shrieks in terrified agony, then the hallucination is
secondary to the recklessly implanted delusion. Doubtless this
sort of idea-produced hallucination occurs frequently enough
in those nightmares of children which have been already
mentioned,

The secondary generation of hallucinations again is strikingly
illustrated by the occurrence of phantasms before the eyes of
certain precocious children of nervous temperament who create
for themselves scenes and dramas which appear to be visible
vi] THE INSANITY OF EARLY LIFE, 267

representations of the thoughts that are passing through their
minds: what they think, that they actually see, just as the
dreamer does. Accordingly a sort of drama is represented
before their eyes in which they take their part, and they live for
the time in a scene which is purely visionary as though it were
quite real. “What nonsense you are talking, child!” the
mother perhaps exclaims ; and thereupon the pageant vanishes.
Or they talk of imaginary scenes of the kind as if they had
actually occurred, and are accused of, or even punished for, false-
hood in consequence : not always wisely, seeing that on account
of the vividness of the hallucinations and the absence of a
store of registered ideas in their minds they are more apt to
believe them real events, and less qualified to correct them, than
older persons are. In delicate and highly nervous children,
predisposed to or affected with meningeal tubercle, it sometimes
happens that great anxiety is caused to the mother by the
strange way in which, during the night, when outer objects are
shut out by the darkness,*they will talk as if they were sur-
rounded by real events, or, as the mother perhaps puts it, as if
they were light-headed. They are dreaming while they are
awake; though the outer world is shut out, the morbid deposit
within acts as an irritating stimulus to the ganglionic nervous
centres, and thus gives rise to an automatic activity of them.
In one case, which came under my notice, of a scrofulous child
with large, irregularly formed head, terrific visions of the kind
occurred in the night when it was wide awake. It would
shriek out in fright, exclaiming that there was something in the
bed. The moonlight was.especially obnoxious to it, because, it
said, ‘it makes so much noise.” There was a well-marked
frown on the forehead when it looked towards the window or
the light—a less degree of the photophobia which occurs in
tubercular meningitis. These children of a tubercular tempera-
ment are sometimes extremely precocious in mind; so much so
that old women shake their~heads gravely, and justly remark
that they are too forward to live. They show excessive
nervous apprehension in one way or another, and at the same
time perhaps an extraordinary absence of natural fear in another
relation: one delicate little creature used to shriek with fright
268 PATIIOLOGY OF MIND. (car.

if another child or a dog came towards it in the street, and yet
delighted in a stormy wind, no matter how high; and another
child would go up instantly, without the least fear, to any strange
dog that it met and seize hold of it, never coming to harm.
Hallucinations may undoubtedly be fugitive events in the
history of any child endowed with a highly nervous tempera-
ment, as in William Blake, the engraver, and may not denote
any positive disease ; but if the habit grows upon the child by
indulgence, and the phantasms are regularly marshalled into a
definite drama,—as, for example, was the case with Hartley
Coleridge,—then a condition of things is initiated which will in
all likelihood issue ultimately in some form of meutal disorder.}
For it is not the natural course of mental development that
ideas, so soon as they are fashioned in the mind, should operate
directly downwards upon the sensory ganglia, and thus create a
visionary world; on the contrary, it is necessary to the progress
of mental development that ideas should be completely organ-
ised within the centres of consciousness, and act upon one
another there; that thus, by the integration of the like in
perceptions and the differentiation of the unlike, accurate con-
ceptions of nature should be formed and duly associated in the
mental fabric; and that the reaction upon external nature
should be a definite, aim-working, volitional one. Men like
Hartley Coleridge cannot have a will, because the energy’ of
their supreme nervous centres is prematurely expended in the
construction of toy-works of the fancy; the state of things
corresponding in some sort with that which obtains in the
spinal centres when, by reason of an instability of nerve ele-
ment, direct reactions take place to impressions, so that definite
assimilation and acquired co-ordination are rendered impossible.
In both cases an arrest of right development, commonly
the forerunner of more active disease, is indicated; in both
cases there is the incapacity for a true education. The pre-

1“ Blake’s first vision was said to be when he was eight or ten years
old; it was a vision of a tree filled with angels. Mrs. Blake, however,
used to say—‘ You know, dear, the first time you saw God was when you
were four years old, and He put His head to the window and set you
screaming.’ ”—-Gilchrist’s Life of Blake.
VL] THE INSANITY OF EARLY LIFE. 269

cocious imagination, or rather fancy, of childhood should be
checked asa danger rather than fostered as a wonderful evidence
of talent ; the child being solicited and trained to regular inter-
course with the realities of nature, so that by continued internal
adaptation to external impressions there may be laid up in the
mind good stores of material, and that, by an orderly training,
this may be moulded into true /orms, according to which a
rightly informed imagination may hereafter work in true and
sober harmony with nature.

The difference between fancy and imagination, as Coleridge
aptly remarked, corresponds with the difference between deliriwm
and mania. The fancy brings together whimsically images
which have no natural connection, but which it yokes together
by means of some accidental coincidence, so making creations
that are oftentimes essentially inconsistent or untrue ; while the
imagination combines images like or unlike, by their essential
relations, and so gives unity to variety. Now the precocious
imagination of a child, which is sometimes the delight of foolish
parents, cannot possibly be anything more than lying fancy ;
and this for exactly the same reason that the insanity of
children must be a delirium and cannot be a mania—the in-
complete formation of adequate ideas and the absence of
definitely organised associations between them. Those, there-
fore, who consider closely and without prepossession the funda-
mental meaning of the character which the delirium of children
has, will not fail to perceive in it the strongest evidence of the
gradual organisation of mind; the fancy of the sane and the
delirium of the insane child both testifying to the same condi-
tion of things—that which the habitual incoherence of a child’s
discourse also evidences.

In order to set forth clearly the manner of action of morbid
idea in children, and to educe therefrom a physiological lesson,
its operation has been artificially separated from other morbid
phenomena which usually accompany it. In young children it
is practially rare to meet with disorder limited to the supreme
nervous centres ; the other centres are almost certain to be more
or less affected. In chorea, for example, besides the disordered
movements which are its common characteristic. there may be
270 PATHOLOGY OF MIND. [omar.

hallucinations marking disorder of the sensorial centres, and
motiveless weeping or laughing, or acts of mischief and violence,
marking disorder of some of the higher motor centres ; there are
furthermore in some cases mental excitement and incoherence,
which may pass into maniacal delirium and end fatally, or into
chronic delirium and end in recovery. The different nerve
centres sympathise with one another; and, according as they
minister to ideation, sensation, or movement, express their
disorder in delirium, hallucination, or spasmodic movements.

Having treated of the phenomena of mental derangement in
young children generally from a pathological point of view, I
now go on to arrange in suitable groups the different forms that
are met with in practice.

Corresponding with the principal varieties of motor dis-
order that oceur in children as in adults, three nearly allied
groups of mental disorders might be described and called respec-
tively choreic insanity, cataleptoid insanity, and epileptic insanity.
They are not of course distinctly separate groups, since inter-
mediate cases between one group and another prevent a plain
line of division being made, but the greater number of cases in
each group have common characters which render it convenient
to bring them together.

Choreie Insanity—There is a choreic mania sometimes met
with in children which appears to be the exact counterpart of
the choreic spasms that occur. What is sufficiently striking,
even to an ordinary observer of this mania, is its marked in-
coherence and its manifestly automatic character. It seems as if
the connections of the primary nerve centres had been dislocated,
and as if each centre were acting on its own account, giving rise
thereby to a sort of mechanically repeated and extremely inco-
herent delirium. A boy of about eleven years of age, who came
under my care, was, after a slight and not distinctly described
sickness, suddenly attacked with this form of delirium; he
moved about restlessly, throwing his arms about and repeating
over and. over again such expressions as—“The good Iord
Jesus,” “They put Him on the cross,” “They nailed His hands,”
&c. It was impossible to fix his attention for a moment; for
he turned away when the attempt was made, wandered aimlessly
v1] THE INSANITY OF EARLY LIFE. 271

about, pointing to one hand and then to the other, and babbling
his incoherent utterances. So far as could be made out, there was
considerable insensibility of the skin over certain parts of the
body, as there commonly is in this form of insanity. In two
days, after appropriate treatment, the delirium passed off, and
the boy was quite himself again. I once saw an interesting
case of insanity in a girl, et. fourteen, who was lively, pretty,
and intelligent. From time to time she would suddenly jump
up in the evening in a paroxysm of excitement, exclaiming,
“Mother, I’m dying!” and begin praying frantically in a
mechanical manner. The paroxysm lasted for three or four
hours, and left her pale, cold, exhausted, and trembling like a
leaf. A brother had died after being similarly afflicted. When
I saw her she looked somewhat strange and was forgetful ; she
used to imagine sometimes too that she saw the bed on fire and
dead bodies on the ground, knowing all the while that the
visions were hallucinations. The mother suffered for months at
one time from speechless melancholia, and nearly all her family
had died from phthisis. She had had fourteen miscarriages,
and three children who died at early ages, this girl being the
only one left ; when pregnant with her she had a terrible fright
from seeing one child accidentally killed, and the girl was born
affected with constant choreic movemeuts, which continued
until six months after birth. Before the paroxysms of mental
excitement came on, she had been subject to periodical attacks
of depression, in which she would cry for hours; and all her life
she had suffered more or less from pain in the head, especially
in the left temple, with paroxysmal exacerbations thereof.

A boy, aged twelve, was admitted into tlhe Devon Asylum,
who had been afflicted all his life to some extent with chorea.
A few days before admission he had attempted to hang himself.
and there was the mark made by the rope upon his neck. On
admission he was acutely maniacal, attempted to dash his head
against the walls, and, when put in the padded room, lay on the
floor, crying—“ Oh, do kill me! Dash my brains out! Oh, do
let me die!” He kicked and bit the attendants, and tried in
every way to kill himself: his head was hot, his pulse quick,
272 PATHOLOGY OF MIND, . (caar.

he refused food, and did not sleep. He completely recovered
under proper treatment after a few days.

The most striking example of mental derangement in a child
which Morel ever saw was in a little girl, et. eleven, who, after
the sudden disappearance of a disease of the skin, suffered from
choreic movements, and soon afterwards was attacked with a
maniacal fury. She attempted to kill her mother, and nearly
drowned one of her sisters by throwing her into a pond of
water. In her paroxysms she displayed a strength almost
incredible, and it is scarcely possible to communicate, says
Morel, an adequate idea of the destructive tendencies of this
little being. She recovered after a fever when all medical treat-
ment had failed.

These cases will suffice as illustrations of choreic insanity. It
is only necessary to bear in mind that, as with cboreic move-
ments every degree of convulsive violence is met with in
different cases, so with choreic mania every degree of excite-
ment and incoherence is met with. Hallucinations of the
special senses and perversions of general sensibility frequently
accompany the delirium.

Cataleptoid Insanity.—Another form which insanity takes
sometimes in childhood is that of a more or less complete
ecstasy; and this may be fitly described as the cataleptoid
variety. It generally occurs in young children. The little patient
lies perhaps for hours or days seemingly in a sort of mystical
abstraction, with limbs more or less rigid, or fixed in strange
postures ; sometimes there is insensibility to impressions, while
in other instances vague answers are given, or there is utterly
incoherent raving, with sudden outbursts of wild shrieks from
time to time. These attacks are of variable duration, and are
repeated at varying intervals. They would seem to represent
a sort of spasm of certain nervous centres engrossing the whole
nervous energy, so that for the time being the body becomes an
automatic instrument of their exclusive activity, all voluntary
power being in abeyance. While, on the one hand, there are
intermediate conditions between this form of disease and chorea,
its attacks, on the other hand, sometimes alternate with true

1 Manual of Psychological Medicine, by Drs, Hack Tuke and Buckunill,
v1.J THE INSANITY OF EARLY LIFE, 273

epileptic seizures, and at other times pass gradually into them:
it represents a class of hybrid seizures that stand midway
between chorea and epilepsy. In a girl who came under Dy.
West’s treatment at the age of ten years and ten months, there
had been first an attack of general convulsions without any
obvious cause, when she was eight years old. Afterwards she
was subject to occasional attacks of great excitement of behaviour,
and for six months there was a sort of cataleptic state in which
she stood immovable for one or two minutes, staring wildly or
fixedly, and murmuring unconnected words that had reference
to any object which she might happen to see. About eleven
months from the commencement of these attacks their charac-
ter changed; they became truly epileptic, the child’s conduct
in the intervals between the seizures, though sometimes quite
reasonable, having mostly something insane about it. The
example shows the close relations of disorders of the different
nervous centres in children, their hybrid nature at times, and
the artificial character of the divisions usually made between
them.

Epileptic Insanity.—Not only are the different forms of
epilepsy met with in children, but also the different forms of
insanity that occur in connection with epilepsy. The petit mal
sometimes lasts for many months in children, and then passes
into regular attacks of convulsive epilepsy; its usual effect
being to produce loss of memory and more or less imbecility of
mind, But whether epilepsy in children has the less patent
form of vertigo or the declared form of regular convulsions,
there is always great danger that it will occasion an arrest of
that cerebral development which is the basis of a good mental
organisation. In the case of a young girl, aged eight years,
of good physical conformation, who came under my care,
epilepsy seemed to have produced an arrest of mental develop-
ment at the sensorial stage: she was a most mischievous little
machine, never quiet, running about aimlessly and seizing, or
attempting to seize, whatever she saw; nowise content with

1 “Ueber Epilepsie Blédsinn und Irrsein der Kinder,” von Charles West,
M.D.—Journal fiir Kinderkrankheiten, vol. xxiii. 1854. See also a paper
by M. Delasiauve in Annales Afédico-Psychologique, vol. vii. 1855.
274 PATHOLOGY OF MIND. [cHaP.

what she canght hold of, but throwing it down directly she had
got it, and struggling for something else which drew her notice ;
not in the least amenable to correction or instruction, and de-
manding the whole energies of one person to look after her.
She was an automatic machine incited by sensory impressions
to mischievous and destructive acts.

As in adults, so in children, an attack of violent mania, a
Juror transitorius, may precede, or take the place of, or follow
an attack of epilepsy, being in reality a sort of mental epilepsy.
When the mania takes the place of the epileptic attack, oc-
curring in its stead, it is described sometimes as a masked
epilepsy—epilepsie larvée. Children of three or four years old
are sometimes seized with sudden attacks of violent shrieking,
desperate stubbornness, or furious rage, when they bite, tear,
and destroy whatever they can; these seizures come on periodi-
cally, and may either pass in the course of a few months into
regular epilepsy, or may be found to alternate with epileptic
attacks. They are a sort of vicarious epilepsy. Morel has met
with two cases in which children fell into convulsions and lost
the use of speech in consequence of a great fear; afterwards a
maniacal fury, with tearing, destroying, and continual turbu-
lence, occurred: in one case, the child being ten years and a
half old, epilepsy followed; in the other child, aged five years,
it did not. One of the boys in a school was attacked in the
night, without evident cause, with a sudden furor transitorius :
he rushed wildly up and down the dormitory, speaking loudly
but inarticulately, so that another of the pupils got up to quiet
him ; but he seized the latter with great violence, and, but for
the interference of others, would have strangled him. With
some difficulty he was got to bed; a true epileptic attack’
followed; and in the morning he knew nothing whatever of
what had happened, but felt weary and exhausted.? Dr. Ludwig
Meyer, who relates this case, relates another case of a boy, et.
13, who was subject to periodical attacks of fury, followed by

1 Traité des Maladies Mentales, 1860, p.102. He relates also the before-
mentioned case of the girl, et. 11, who had furious maniacal attacks, during
which she attempted to kill her mother and injure her sisters.

2 « Ueber Mania Transitoria,” von Dr, Ludwig Meyer. Virchow’s Archiv,
vol. viii. art. ix.
VL] THE INSANITY OF EARLY LIFE. 275

epileptic convulsions, and who often had the furious maniacal
excitement without the convulsions, illustrating the transition
of mania transitoria into epilepsy.

Some writers hold that when the mania seems to occur in the
stead of epilepsy the truth is that it has been preceded by an
unobserved attack of epileptic vertigo. No doubt such an attack
oftentimes passes without being noticed, but it is only a surmise
that it is so in all cases; and as the maniacal outbreak which
frequently precedes a fit may undoubtedly occur sometimes
without a following fit, why must it be supposed never to
occur without a preceding fit ?

Again, in children, as in adults, regular attacks of maniacal
excitement may follow epilepsy. Many such instances are on
record ; but I shall content myself here with a singular example
of insanity, more cataleptoid perhaps than epileptic, followiny
convulsions, which is quoted by Griesinger from Kerner :—
Margaret B., et. 11, of a passionate disposition, but a pious
Christian child, was, without any previous illness, seized on
January 19th with convulsive attacks, which continued, with
few and short interruptions, for two days. So long as the con-
vulsions lasted the child was unconscious, twisted her eyes,
made grimaces and strange movements with her arms: from
the 21st January a deep bass voice proceeding from her kept
repeating the words, “They are praying for thee.” When the
girl came to herself, she was wearied and exhausted, but knew
nothing of what had happened, only said that she had dreamed.
On the evening of the 22nd January another voice, quite
different from the bass one, spoke incessantly while the crisis
lasted—for half an hour, an hour, or several hours; and was
only now and then interrupted by the former bass voice regu-
larly repeating the recitative. The second voice manifestly
represented a different personality from that of the girl, dis-
tinguishing itself in the most exact manner, and speaking of
her in the third person. In its utterances there was not the
slightest confusion nor incoherence observable, but all questions
were answered by it coherently. What, however, gave a dis-
tinctive character to its expressions was the moral or rather
immoral tone of them—the pride, arrogance, scorn, and hatred
276 PATHOLOGY OF MIND. [cuaP

of truth, God, Christ, that were avowed. “I am the Son of
God, the Saviour of the world: me ye shall worship,” the former
voice frequently repeated. Scorn of all that is sacred, blasphemy
against God and Christ, violent dislike of everything good, and
extreme rage at the sight of any one praying, or even of hands
folded as in prayer, expressed by the second voice—all these,
says the reporter, might well betray the work of a strange spirit
possessing her, even if the pious voice had not declared it to be
the voice of a devil. So soon as this demon spoke, the fashion
of her countenance changed in the most striking manner,
and assumed a truly demoniacal look. She ultimately quite
recovered, a voice crying out—‘“ Get thee out of this girl, thou
unclean spirit.” The case shows how naturally would arise the
once general but now abandoned notion that mania was due to
possession by an evil spirit or devil.

Although the delirium of childhood is commonly conneéted
with some form of convulsive disease, yet it sometimes occurs
without convulsion, from other recognised causes of mania; in
children these usually are blows on the head, intestinal worms,
and self-abuse. Worms in the intestines, like other eccentric
irritations, certainly act sometimes upon the supreme centres to
derange them, just as they act upon the motor centres to excite
convulsions. Children of a certain nervous temperament, who
have plainly inherited a tainted neurosis, now and then evince
a singularly active and precociously vicious sexual tendency
at very early ages, which is usually followed by or associated
with great moral perversity and passionate outbreaks of temper
that are almost maniacal in some instances. Whatever their
nature, they are of bad omen for the child’s future. Under the
name of Monopathie furicuse Guislain describes maniacal attacks
ina young girl et. 7, which were due to caries of the nose
following a blow. Other like cases are recorded by Haslam,
Spurzheim, Frank, Burrows, Perfect, and Friedreich.1 Certain
acute diseases, as for example typhus, may give rise to delirium
in the child just as in the adult during their course, and to

1 See also a paper “On the Psychical Diseases of Ea-ly Life,” in tho
Journal of Mental Science, 1859, by Dr. Crichton Browne,
v1.] THE INSANITY OF EARLY LIFE. 277

disorder of mind during convalescence. In all these cases of
mania in children, however caused, we shall not fail to notice a
mixture of imbecility, due to their state of imperfect mental
development, and of great moral perversion. And we may take
note, if we will, that an outbreak of passion in some imbeciles
is, in its mental aspect, almost a temporary mania, and, in its
physical aspect, a convulsive paroxysm.

Affective Derangement—Thus far I have given illustrations of
conditions of mental excitement with incoherence of ideas; I
now go on to notice conditions of mental depression in children,
with or without corresponding morbid impulses and delusions
—cases in which the affective derangement is the predominant
symptom. The affective tone is fundamental, due to the sympa-
thetic system of the organic life, and is the medium which gives
colour to the ideas; and while the more lately acquired words
are the language of ideas, its more primitive language is crie:,
exclamations, modifications of the tones of the voice and of
the bodily features. It is by these that feeling expresses itself
directly before the child has acquired ideas; and when the child
has acquired ideas and is able to utter them in words, it still
expresses itself in the primitive way, but also indirectly through
ideas and their words. Without doubt children differ naturally
in liveliness of disposition; but it sometimes happens that
depression reaches such a pass even in very young children as
to constitute a genuine melancholia. In such case the child
whines and wails on all occasions ; whatever impression is made
upon it seems to be followed by a painful feeling; the mother
takes it for medical advice, for, as she complains, it thrives not,
it rests not either by night or day, it is pining and crying con-
tinually, and nothing calms it; there is no living with it, and
she is almost worn out with anxiety. Such symptoms mark
a constitutional defect of nerve element, whereby an emotional
or sensational reaction of a painful kind follows all impressions ;
the nervous or psychial tone is radically infected with sume vice
of constitution, so that every natural impression, instead of
being pleasing, is painful. The cause of the defect in some
instances is inherited syphilis; at any rate beneficial results
follow the treatment for hereditary syphilis. No doubt, how-
278 PATHOLOGY OF MIND. [cHap.

ever, other causcs besides syphilis may cause a like morbid
condition of nerve element.

With the deep melancholic depression there may be, in older
children, a distinct delusion of some kind. A boy who from
his fifth year had been rather peculiar in his behaviour, standing
still at times in the street without apparent reason and not
-moving again without considerable pressure, was, when twelve
years of age, afflicted with positive melancholia and delusions of
suspicion, He was extremely depressed, and his manner in-
dicated the greatest fear: he was prone to weep constantly, and
was in great dread of his fellow-scholars and of his teacher, all
of whom, he thought, suspected him of anything wrong that
happened to be done—if a theft were committed, he was sure
that he was suspected to be the thief. He was restless at night,
and often sighed and uttered unconnected words in his sleep.
In five weeks he was said to have recovered, but there still
remained eccentricities of conduct: if he kicked a stone, he
must return to kick it twice more; if he spat once, he must
spit twice more; if he had written a word incorrectly, he must
repeat the correction. Of these peculiarities he was quite con-
scious, and struggled against them, but without avail; after
great restlessness and mental disquietude he was ultimately
obliged to give way to them. In other like cases, morbid
notions with regard to religion may be the exponents of the
emotional disturbance of psychical tone.

There are boys who, being somewhat stupid and of a melan-
choly, moody, and perhaps morose disposition, habitually keep
apart from their fellows, whom they join not in play. They
are often hypochondriacal, complaining of strange morbid sen-
sations in abdomen, generative organs, heart or head ; and when
these morbid feelings are very active they become paroxysm-
ally excited so as to quite lose self-control, and perhaps imagine
that the devil has got hold of them. Or some other foolish or
insane idea or impulse springs up in the apt soil of their affective
perversion and instigates them to foolish or insane conduct.
When they reach puberty they show more insanity, and perhaps
vot into trouble; in a stupid way they attempt to kill them-

1 Trrsein bei Kinder, von Dr. Beckham,
v1.] THE INSANITY OF QARLY LIFE. 278

selves or some one else, or do some other act of criminal
violence.

Perhaps the most striking form in which the melancholia
of children manifests itself is by suicide. So strange anil
unnatural does it seem that a child of eight or nine years of
age should, world-weary, put an end to its own life, that one
is apt to declare the thing to be against nature and to consider
it inexplicable. Such act of suicide is done sometimes under
a sudden impulse from the dread of punishment or after the
infliction of punishment, or it is perhaps deliberately resolved
upon in a state of sadness and depression consequent upon
continued ill treatment by a brutal schoolmaster or parent.
Falret mentions the case of a boy of eleven years of age, who
was driven by the ill treatment of his teacher into such a state
of melancholia that he determined to starve himself, and made
repeated attempts at suicide by drowning. But it may be
carried into effect out of a constitutional indifference or disgust
of life, or from a momentary impulse of disappointment when
there has been no real ill treatment, nothing more perhaps than
a slight rebuke or censure: one boy, aged nine years, killed
himself because he lost a bird which he was very fond of;
another boy, aged twelve, hanged himself because he was no
higher than twelfth in his class; and a boy, aged twelve, hanged
himself because he was shut up in a room with a piece of dry
bread, as a punishment for having accidentally broken his
father’s watch.2 This premature disgust of life is most often
the result of some ancestral taint, by reason of which the child’s
nervous constitution is inherently defective, unapt to accom-
modate itself to its surroundings, and disposed to perverted
likings and dislikes and irregular reaction. The impulse which
springs up out of the deranged feeling, and is fed by it, is some-
times homicidal: an instance occurs from time to time in which
achild drowns, hangs, or otherwise kills another child, with an
amazing coolness and insensibility, and from no other motive
than a liking to do it; and there have been a few cases recorded
in which more than one murder has been done in this way by

1 «© Fitude sur le Suicide chez les Enfants,” par Durand Fardel — Annales
Meédico-Psychologique, 1855 » Durand Fardel, op. cit.

13
280 PATIIOLOGY OF MIND. (CHAP.

the same child. The question of hereditary taint is in reality
the important question in those cases, as it is in all cases of
insanity of early life.

In the majority of instances the affective insanity of early
life might justly be described as hereditary; but there are
some cases in which the morbid condition of nerve element
which manifests itself in extreme moral perversion is not in-
herited, but acquired by reason of vicious habits of self-abuse.
It is not correct, therefore, to describe all cases of so-called
moral insanity in children as examples of hereditary insanity,
although the precocious sexual feeling which leads to self-abuse
is commonly the result of an inherited taint. I prefer using
the word affective to the word moral, as being a more general
term and expressing more truly the fundamental condition of
nerve-element, which shows itself in affections of the mode of
feeling generally, not of the special mode of moral feeling only ;
in other words, as pointing to that deepest affection of conscious-
ness in its primordial elements which makes it true to say that
his affective life betrays the real nature of the individual.

The examples of affective insanity in early life fall naturally
into two divisions: (a) the first includes all those instances in
which there is astrange perversion of some fundamental instinct,
or a more strange appearance of some quite morbid impulse; (0)
the second division comprises all those cases of complete moral
perversion which often seem to the onlooker to be wilful wicked-
ness. The former might be described as the instinctive or
impulsive variety of affective insanity; the latter as moral
insanity proper.

(a) Instinctive Insanity—What are the inbern instincts of
mankind ? The instinct of self-conservation, which is truly the
law of the existence of living matter as such, and the instinct
of propagation, which provides for the continuous existence of
life, and is, therefore, in some sort a secondary manifestation of
the self-conservative instinct. The instinct to activity which the
organs of relation, that is, the organs of the so-called animal
life, evince, and to the particular sorts of activity which, being
adapted .thereto by their form and structure, they accomplish,
tay be looked upop as meaus which the two fundamental
¥1.] THE INSANITY OF EARLY LIFE, 281

instincts make use of in order to attain their ends, Now the
instinct of self-conservation is displayed not only by the in-
dividual creature, whether of low or hivh degree, but is implicit
in the life of every organic element of which it is built: it is,
as already seen, at the root of the passions, which are funda-
mentally determined by impressions according as they are
pleasing or painful to self. Children are of. necessity extremely
selfish ; for it is the instinct of their being to appropriate from
without, to the end that they may grow and develop: a baby is
the only king, as has been said, because everybody must accom-
modate himself to it, while it accommodates itself to nobody.
The necessary correlate of the instinct of appropriation where-
by what is pleasing to self is assimilated, is a destructive or
repulsive instinct or impulse whereby what is not grateful is
rejected, got rid of, or destroyed. The infant rejects the mother’s
breast when from some cause, internal or external, the milk is
distasteful to it; by crying and struggling it strives to get rid of
a bodily impression which may happen to be paining it, as the
Gregarina shoots away from a stimulus, as the snail retracts its
protruded horns when they are’ suddenly touched, as a person
of tender sensibility shrinks from a painful spectacle; and
when it is a little older, it rejects, destroys, or attempts to destroy
what is not pleasing to it.

To talk about the purity and innocence of a child’s mind is
a part of that poetical idealism and willing hypocrisy by which
men ignore realities and delight to walk in vain shows; in so far
as purity exists it testifies to the dbsence of mind; theimpulses
which actually move the child are the selfish impulses of passion.
It were as warrantable to get enthusiastic about the purity and
innocence of a dog’s mind. “A boy,” says Plato, “is the most
vicious of all wild beasts” ; or, as some one else has put it, “a boy
is better unborn than untaught.” By nature sinful and vicious,
man acquires a knowledge of good through evil: not how evil
entered into him first, but how good first came out of him, is the
true scientific question: his passions aie refined and developed
in a thousand channels through wider considerations of interest
and foresight ; the history of mental development begins with
the lowest passions, which fiow as un under-current in every
282 PATHOLOGY OF MIND. [cuap.

life, and frequently come to the surface in a very turbulent way
in many lives. Evil is good in the making as vice is virtue in
the making.?

In the insanity of the young child we meet with passion in all
its naked deformity and in all its exaggerated exhibition. The
instincts, appetites, or passions, call them as we may, manifest
themselves in unblushing, extreme, and perverted action; the
veil of any control which discipline may have fashioned is rent;
it is like the animal, and reveals its animal nature with as little
shainefacedness as the monkey indulges its passions in the face
of all the world. Inasmuch as there is present only the instinct
to gratify itself, the concomitant of which is the effort to reject
or destroy what is not agreeable, its disease, if it become insane,
will be exhibited in a perverse and unceasing appropriation of
whatever attracts its notice, and in destructive attacks upon
whatever it can destroy. Refuse it what it grasps at, and it will
scream, bite, and kick with a frantic energy: give it the object
which it is striving for, and it will smash it if it can: itisa
destructive little machine which, being out of order, lays hold of
what is suitable and what is unsuitable, and subjects both alike
to its desperate action. Haslam reports a case of this kind in a
girl, aged three and a quarter years, who had become mad at two
and a half years of age, after inoculation for small-pox. Her
mother’s brother was, however, an idiot, though her parents were
sane and undiseased. This creature struggled to get hold of
everything which she saw, and cried, bit, and kicked if she was
disappointed. Her appetite was voracious, and she would devour
any sort of food without discrimination ; she would rake out the
fire with her fingers, and seemed to forget that she had been

1 “T cannot praise,” continues Milton, after saying that we know good
by evil, “a fugitive and cloistered virtue, unexercised and unbreathed,
that never sallies out and sees her adversary, but slinks out of the race
where that immortal garland is to be run for, not without dust or heat.
Assuredly we bring not innocence into the world, we bring impurity much
rather: that which purifies us is trial, and trial is by what is contrary. ...
That virtue therefore which is a youngling in the contemplation of evil,
and knows not the utmost that Vice promises to her followers, and rejects
it, is but a blank virtue, not a pure; her whiteness is but an excremental,
rdventitious whiteness,”
vi] THE INSANITY OF EALLY LIFE, 283

burnt ; she passed her evacuations anywhere. She could not be
taught anything, and never improved.!

The most striking exhibition of the destructive impulse which
sometimes reaches an extreme degree in the madness of cbild-
hood is afforded by a homicidal tendency. “A girl, aged five
years, conceived a violent dislike to her stepmother, who had
always treated her kindly, and to her little brother, both of whom
she repeatedly attempted to kill”? Here wasa sort of conscious
design apparent in the act; but it is obvious that the further
back in mental development we go, the less of conscious design
will there be in the morbid impulse. Moreover, in the case of
homicidal impulse in a young child, the consciousness of the end
or aim of the act must at best be very vague and imperfect : it
is driven by an impulse of which it can give no.account to a
destructive act, the real nature of which it does not appreciate ;
a natural instinct being exageerated and perverted by disorder of
the nerve-centre. It matters not much, so far as its nature is
concerned, what is the particular form of the destructive impulse
—whether it be homicidal or suicidal, or to set fire to the house,
or to kill a cat ora canary, or to smash crockery or other perishi-
able ware; the impulse which dominates it is. as unreasoning
and apparently uncontrollable as the convulsion of its limb is
in chorea. Many cases are on record of older children who have
displayed an incorrigible propensity to acts of pure cruelty and
destruction, practised on such creatures as were not too powerful
to be their victims.

Thus much concerning those phenomena of insanity in children
which spring from the gross perversion of the self-conservative
impulse. Let me now say a few words concerning the perversion
of the instinct of propagation. It is necessary to guard against
a possible objection that this instinct is not felt until puberty.
There are certainly frequent manifestations of its existence
throughout early life, both in animals and in children, before
there is a consciousness of the aim or design of the blind im-
pulse. Whosoever avers otherwise must have paid very little
attention to the gambols of young animals, and must be strangely

1 Observations on Madness,
2 Esquirol, Traité des Maladies Mentules,
284 PATHOLOGY OF MIND. [cuar

or hypocritically oblivious of the events of his own early life.
At puberty the instinct makes its appearance in consciousness,
and thereupon attains to knowledge of its aim and craves means
of gratification ; in like manner as, in the course of development
through the ages, the blind procreative instinct which is im-
manent in animal nature undergoes a marvellous evolution
within human consciousness, blossoming into all the glories of
human love.

As there are exhibitions of this blind impulse in the healthy
child, it is not surprising to meet with exaggerated and per-
verted manifestations of it in the insane child. The enthu-
siastic idealist, greatly shocked by disgusting exhibitions of
unnatural precocity in children of three or four years of age,
exclaims against them as if they were unaccountable and
monstrous; but they are not without interest to the scientific
observer, who sees in them valuable instances on which to base
his generalisations concerning man, not as an ideal but as a real
being, and concerning his origin, not as a special creation, but
as the supreme product of natural evolution. In the PAzio-
sophical Transactions for 1745 is the account of a boy, aged only
two years and eleven months, who displayed a remarkable
sexual precocity. Esquirol quotes the case of a girl, aged three
years, who was constantly putting herself into the most indecent
attitudes, and used to practise the most lascivious movements
against any convenient piece of furniture. At first the parents
thought nothing particular of it, but finding the practice con-
tinued, and of unmistakable significance, they tried every
means in their power to check it, but without avail. In church
or anywhere, at the sight of an agreeable object, there was the
same abandonment, ending in a general spasm. The child con-
fessed to a positive pleasure from the acts, continued them as
she grew up, and, though ultimately married, was a regular
nymphomaniac. The greatest salacity was always manifested
from the beginning to the end of spring! Other similar
examples of this sort of instinctive insanity might easily be
adduced; for there are few physicians in practice who could not
relate instances of young children of three or four years of age

1 §ce also Morel’s Etudes Cliniques sur les Maladies Mcntales. 1852.
vi] THE INSANITY OF EARLY LIFE. 285

who have perplexed and distressed their parents by the preco-
cious display of active sexual tendencies. The afflicted creature
has no definite consciousness of the import of its precocious
acts ; certain attitudes and movements are the natural gesture-
language of certain internal states—their motor exponents; and
it is little more than an organic machine automatically impelled
by disordered nerve-centres.

(b) Moral Insanity—This variety of affective insanity might
be illustrated by numerous examples of all degrees of severity,
ranging from what might, not without reason, be described as
simple viciousness to those extremer manifestations which pass
far beyond the bounds of what any one would call vice. In the
spring of 1827, Dr. Prichard was asked to see the daughter of a
farmer, in some members of whose family insanity existed. She
was a little girl, aged seven, and was described as having been
quick at apprehension, lively, affectionate, and intelligent. A
great change, however, took place in her conduct: she became
rude, vulgar, abrupt, and perfectly unmanageable; doing no
work, running about the fields, and, if rebuked, very abusive
and extremely passionate. Her appetite was perverted so that
she preferred raw vegetables to her proper food; and she would
sleep on the cold and wet ground rather than upon her bed.
Her parents had no control over her, and she was persistently
eruel to her sisters, pinching them when she could do so without
being observed. She had a complete knowledge of persons and
things, and recollected all that she had learned. Her eyes
glistened brilliantly; the conjunctiva was reddened; her head
was hot, her extremities were cold, and her bowels disordered ;
there was a disagreeable odour of the body. Dr. Prichard saw
her in the house of a medical man where she had been placed
because she was getting worse at home. “At this time she had
taken to eat her own feces, and to drink her urine, and she
would swear like a fishwoman and destroy everything within
her reach; yet she was fully conscious of everything she did,
and generally appeared to know well that she had done wrong.”
After doing something wrong she would exclaim, “Well, Mrs.
IL, I have done it. I know you will be angry; but I can’t help
it, and I could not let it alone until Thad.” Among her plea-
286 PATHOLOGY OF MIND. [cuap.

sures was that of dirtying herself as frequently as she had clean
clothes put on; indeed, “she would rarely pass her excrements
into the proper place, but reserved them for the carpet of the
sitting-room, or for her own clean clothes.” ‘At other times
she was so far conscious of her situation as to cry bitterly; and
express her fears that she would become like her aunt, who was
a maniac. In addition to all these indications she had stolen
everything which she thought would be cared for, and either
hid or destroyed it; and swore in language which it is difficult
to imagine that such a child could ever have heard.” There
was no fixed idea which influenced her conduct; she acted
“from the impulse of her feelings, and these were unnatural,
and perverted by disease.” After two months she recovered.

Haslam relates the following case of a young gentleman, aged
ten, in whose ancestors no insanity was acknowledged, When
only two years old, he was so mischievous and uncontrollable
that he was sent from home; and until he was nine years old
he continued ‘‘the creature of volition and the terror of the
family,” and was indulged in every way: he tore his clothes,
broke whatever he could break, and often would not take his
food. Severe discipline was tried, but in vain; and the boy
was ultimately sent to a lunatic asylum. There was deficient
sensibility of the skin. He had a very retentive memory with
regard to matters which he had witnessed, but was attracted
only by fits and starts, so that he would not learn methodically :
he was “the hopeless pupil of many masters,” breaking windows,
crockery, and anything else which he could break. A cruel
trick of his was, whenever the cat came near him, to seize it,
pluck out its whiskers with wonderful skill and rapidity, saying,
“I must have her beard off,’ and then commonly to throw it on
to the fire or through the window. He was quite insensible to
kindness, and never played with other boys. “Of his own
disorder he was sometimes sensible: he would often express
a wish to die, for he said very truly, ‘God had not made him
like other children;’ and when provoked he would threaten to
destroy himself.” No improvement took place.

1 On the Different Forms of Insanity in relation to Jurisprudence. By
J. C. Pritchard, M.D., 1842.
v1.] THE INSANITY OF EARLY LIFE, 287

A case in some respects similar is quoted by Moreau from
Renaudin, under whose care it was:—A boy, whose intelligence
and behaviour were usually of an ordinary character, was subject
every now and then to a positive mania of acts, without any
mental incoherence.1_ When these attacks came on him he was
quite incorrigible, and he had been expelled from different
schools in consequence of thém. After several unsuccessful
trials at discipline, he was at last sent to an asylum. There he
answered quite intelligently, but wept and was silent when
spoken to about his bad conduct: pressed upon this subject, he
said that he could not help it. The interesting circumstance
was that there was a complete insensibility of the skin at the
time of the attacks of irresistible violence, and that in his docile
and affectionate intervals the sensibility of the skin was natural.
The acts of violence were of so extreme a character that, says
the reporter, “we were able to satisfy ourselves that they might
go as far as murder.” ?

The special defective sensibility of skin in these cases is full
of instruction in relation to the profound and general defect or
perversien of the sensibility or receptive capacity of the whole
nervous system which is shown in their perverted likings and
dislikes, in their inability to join with other children in play or
work, and in the impossibility to modify their characters by
discipline ; they cannot feel impressions as they naturally should
feel them, nor adjust themselves to their surroundings, with
which they are in discord; and the motor outcomes of the
perverted affections of self are accordingly of a meaningless
and destructive character. The insensibility of skin is the out-
ward and visible sign of a corresponding inward and invisible
defect, as it notably is also in idiocy.

These examples may suffice to illustrate a form of derange-
ment which undoubtedly occurs in early life, and which,
indecd, is more readily acknowledged when it is met with in
young children than when it is met with in the adult, in
whom it is more apt to be thought vice. The extreme acts of
precocious wickedness seem so inconsistent with the immaturity

1 Moreau's Psychologie Morbide, p. 313.
2 Thave related a case of motal insanity in a young girl in my work
On Responsibility in Mental Disease, p. 180, third edi.ion.
288 PATHOLOGY OF MIND. [cHap.

of childhood that they are readily accounted unnatural, and
ascribed to disease. However, to call them disease is not to
explain them, nor to cancel the need of an explanation. Who-
soever scrupulously traces the acts as the necessary consequences
of certain coefficient causes implied in the vitiated constitution
of the nerve element of the child, and thus banishes, as he must
do, the notion of witting and wilful vice, will be brought to own
in theory, as he will discover in practice, that like physical
conditions in the adult may be the agents in producing like
morbid effects.

There are children of a defective mental capacity, not reaching
the degree of idiocy, or even of positive imbecility, wliom it is
very difficult to know what to do with sometimes. They are
dull, heavy, stupid, appear indolent, indifferent, and as if they
will not try to learn anything, and display low or vicious tastes ;
when sent to a respectable school, they are commonly after some
time sent home again as impracticable. Their inability to learn
looks very much like stupidity and obstinacy, when it is really
the result of disease, and marks a certain measure of imbecility.
Their nervous centres are ill fitted, by reason of some defect of
constitution or of some gross morbid condition, to receive and to
retain impressions ; they lack, therefore, the disposition or desire
and the aptitude which are natural in a sound bodily state to
get into closer relations with the objects producing them; and
the motor reactions are not purposely made to repeat and to
vary the impressions until the objective causes of them are
thoroughly apprehended. It is sometimes the misfortune of
boys of this sort to be sent, after failing at the usual schools, to
some one who advertises for unruly pupils, and who represents
himself as possessed of some specific for managing and training
them. Some years since a boy of this kind was said to have
been flogged to death by his master, who was put upon his trial
for manslaughter, found guilty, and received a severe sentence.
Without doubt the poor boy was harshly and cruelly used, but
there were some medical reasons for thinking that the case was
uot quite so bad as it was represented in the public papers at
the time. In some of these cases of semi-imbecility or stupidity
there is an abnormal quantity of serum in the-ventricles of the
vu} THE INSANITY OF EARLY LIFE. 289

brain, and death may take place suddenly in consequence of
the increase of the fluid beyond a certain amount. In the case
referred to an unusual quantity of serum was found in the
ventricles of the brain after death; and the medical man who
was called for the prosecution gave it as his opinion that this
was the result of the ill treatment to which the boy had been
subjected, and the probable cause of death. In reality, the
morbid condition of things may have been the cause of the
youth’s stupidity, and so his death have been occasioned by a
punishment which would not have seriously injured a healthy
child. When we reflect on the possible state of things in the
brain, it will be obvious that no good, but much mischief, will
be done by harsh measures: patience and gentleness, kindness
and encouragement, good diet and regular habits, proper bodily
exercise, and the regular control of some judicious person, will
be the best means to employ. Above all things, it is well to
forego attempts to make such defectively organised beings reach
a degree of mental development which they are by nature
incapable of ; they should be put to some humble occupation
for which they are fitted, and in which they may succeed
fairly.

There is another class of boys who cause great trouble and
anxiety to their parents and to all persons who have to do with
them. Afflicted with a positive moral imbecility, they are
inherently vicious; they are instinctive liars and thieves,
stealing and deceiving with a cunning and a skill which could
never be acquired; they have no trace of affection for their
parents or of good feeling for others; the only care which they
have is to contrive means to indulge their passions and vicious
propensities, and this they will do with singular ingenuity and
acuteness. Intellectually some of them are defective also, for
they read no better when they are sixteen years old than a
healthy child of six years of age would do; and yet these are
very cunning in deception and in gratifying the desires of their
vicious natures. Others show no evident defect of intelligence;
their general education may be fairly good, and some of them
shall display extraordinary cleverness of a particular kind ;
the surprising thing being that, having so acute an intelligence,
290 PATHOLOGY OF MIND. (crap.

they should be so utterly incapable as they aie of seeing how
much their conduct is against their true interest. However, so
it is: their self-feeling is so intense and engrossing, that they
cannot look beyond the present gratification, and their intellect
is enlisted entirely in its service. Oftentimes they are exceed-
ingly plausible, having a good address, impose skilfully upon
people whom they meet, and get out of scrapes in an extraordi-
narily clever way. When they are in trouble they express
the most bitter regret, write the most penitent letters, make the
most solemn promises of amendment, without the least sincerity,
or at any rate without making the least effort to do right on the
next occasion when temptation comes. In one case a boy, who
was not fourteen years old when I saw him, had been a trouble
to his parents for years: he was most cunning and ingenious in
lying, showing a marvellous precocity therein, and a persistent
passion for it; used to abandon himself to paroxysms of violent
passion, and threaten or pretend to commit suicide; was acute
enough as regarded his personal interests, but could not learn
like other boys, nor did he associate with them; evinced no
trace of moral element nor of social sympathy. He would
stand for an hour at a time before a map of the world while
other boys were at play, and could tell every place upon it where
a ship must call; he could also tell every train in Bradshaw’s
Railway Guide on the Midland line. Another boy, who was the
son of a gentleman of high social position, and had at command
everything a boy could wish for, could not be prevented from
stealing wherever he went.

After puberty matters usually get worse in these cases: they
give themselves up to intemperance, licentiousness, self-abuse, or
are guilty of stealing, of forgery, of unnatural offences, and of
other vices or actual crimes. If they are females, they abandon
themselves to sexual indulgence ; or if they are prevented from
that by the restraints of their position in life, they may make
gross charges of immorality against innocent persons, perhaps
writing the filthiest anonymous letters. In a perverse mood they
may set fire to the house, or kill their employer’ s child, if they are
in service, rather than have the trouble to look after it. They are
truly bedevilled. When these degenerate beings belong to the
v1.] THE INSANiLY OF EARLY LIFE£. 291

lower classes, they find their way to prison many times—indeed,
they go to swell the criminal population of the country; when
they belong to the better classes they are an infinite trouble, and
in order to keep them out of prison there is nothing for it but to
seek out some firm and judicious person who, for suitable remu-
neration, will take care of them, keep them out of mischief, and,
while checking their vicious propensities, try to discover and
foster any better tendencies which they may have in them.

In all cases of affective insanity, and especially of that variety
which I have described as moral insanity, the question of ques-
tions is hereditary taint. As the nature of man has grown
slowly to what it now is by a progressive fashioning through
generations, so by a retrogressive degeneration it passes back-
wards to a lower stage; the stage to which it sinks being worse
than a corresponding stage of deficient development, because
while the latter marks an absence of, it is a corruption of,
the higher. The progress of organic development through the
ages is a progressive internal specialisation in relation to external
nature; the human organism, as the highest organic develop-
ment, has the most special and complex relations with the
external; and the highest mental development, as the supreme
development of the human organism, represents the completest
expression of the most special and complex harmony between
man and nature. Now this concord will plainly be destroyed,
and a discord produced instead, by that inherent defect of nerve
element which an hereditary taint implies; for it implies, as we
have seen, a predisposition to discordant action. Accordingly,
there is witnessed in the infant, long before any responsibility
attaches to its acts, either a congenital inability to respond to
external impressions, whereby idiocy of greater or less degree is
the consequence, or a defective nervous constitution, whereby
the natural assimilation of impressions and the fitting reaction
to them are seriously interfered with. In the worst cases there
would seem to be a positive defect in the composition or consti-
tution of nervous element; its fundamental self-conservative
impulse, as living matter of specific quality, to be abolished.
The strange perversions of the child’s appetites and instinctive
strivings evince this; instead of displaying an aversion from
292 PATHOLOGY OF MIND. [cHar.

what is injurious and rejecting it, the young creature positively
seizes with eager appetite what is most baneful.

In all degrees and kinds of healthy life we witness in opera-
tion the attraction of what is suitable to growth and development
and the repulsion of what is unsuitable: in the lowest forms of
life we describe them simply as attraction and repulsion, or
assijnilation and rejection ; as we rise higher in the scale of life
the attraction becomes appetite and the repulsion becomes aver-
sion ; higher still the attraction is desire or love, the repulsion is
dislike or hate, although if there is any character of uncertainty
about the event, hope and fear are used to express the opposite
tendencies; and the last and highest development of them is
willingness and unwillingness. But in the child which is born with
so strong a predisposition to insanity that it cannot develop, there
is an absence of this pre-established harmony between the in-
dividual constitution and external nature: the morbid creature
devours with eager appetite the greatest trash, and rakes out the
fire with its fingers; it desires passionately and struggles franti-
cally for what is detrimental to it, and rejects or destroys what
is suitable and should, were it rightly constituted, be agreeable ;
it loves nothing but destructive and vicious acts, which are the
expressions of an advanced degradation, and hates that which
would further its development and is necessary to its existence
as a social being. As it grows older, perversities of social feel-
ing and conduct mark its discordant bias. By reason of its
physical constitution it is a fundamental discord in nature; and
its perverse desires and doings are the outcome of a gradually
proceeding course of deterioration whereby it ultimately goes to
destruction. It cannot assimilate nature, and nature will there-
fore, sooner or later, assimilate it. Meanwhile, as a diseased
element in the social organism, it must be isolated or removed
for the good of the organism.

As the mad acts of the insane child mark a degenerate state
of nerve element, so it represents a deyencrate variety or morbid
kind of human being. However low such a being may be
brought he never reverts to the exact type of any animal; the
fallen majesty of mankind appearing even in the worst wrecks.
There is sometimes a general resemblance to one of the lower
v1] THE INSANITY OF EARLY LIFE, 293

animals, but the resemblance is no more than a general and super-
ficial one ; all the special differences of mental qualities are more
or less manifest just as all the special differences of anatomical
structure remain, The idiot, with hairy back, may go on his knees
and “bah” like a sheep, as did one of which Pinel tells; but as
he does not get the wool and conformation of the sheep, so he does
not get its psychical characters : he is not adapted to the relations
of the sheep, and if placed in them, would surely perish, and he
does evince traces of adaptation to his relations as a human being
which the best developed animal never would. So also with
regard to man’s next of kin, the monkeys: no possible arrest of
development, no degradation of human nature through genera-
tions, will bring him to the special type of the monkey: a
degenerate kind of human being is produced, but it is a morbid
kind, wanting the instincts of the lower animals, and the uncon-
scious upward aspirations of their nature, as well as the reason
of man and his conscious aspirations. It is a very rare thing,
for example, to meet among idiots with that instinctive discri-
mination of poisonous matters which some beasts have; on the
other hand, it is very common to meet among them with a per-
verted craving for improper food or injurious substances, which
is in reality the unconscious display of nature’s effort to extin-
guish a morbid variety, and which, but for charitable interference
and fostering care, would soon accomplish its aim.

Man exists in an intimate correlation with nature at its pre-
sent stage of development—is, as it were, the outgrowth at this
stage of its evolution, and therefore flourishes well under existing
conditions: the monkey, on the other hand, is not in harmony
with the complexity of surrounding nature, modified as this has
been so mightily by man, and is rapidly becoming extinct, the
stronger species surely superseding it. Were it desired to bring
man to the monkey level, it would be necessary to undo the
latest mighty changes in nature, and to restore the condition of
. things which prevailed ages before he appeared, and of which
the monkey was the natural outgrowth. While, then, the monkey
type, and every other pure animal type, represent stages in the up-
ward development of nature, the theroid degenerations of man-
kind are pathological specimens, which, not being serviceable.
294 PATILOLOGY OF MIND, (cuar.

for development, are cast off by the stream of progress, and
are on their way to destruction, for re-issue by nature under
better form. By such examples of delumanisation men are
taught how best to promote the progress of humanisation through
the ages.

The foregoing considerations help us to understand how it is
that we sometimes witness such a precocity of seeming vice in
the insane infant or child. Innate in its human constitution
lurks the potentiality of a certain development, the latent power
of an actual evolution which no monkey ever has; for in it is
contained, as by involution, or implicitly comprehended, the in-
fluence of all mankind that has gone before. When such a being
is insane, there is not an individual creature only, but there is
human nature, in perverse action, in retrograde metamorphosis ;
we have actualised in morbid display certain potentialities of
humanity ; accordingly exhibitions of degenerate human action
are presented, which so far as regards the individual infant
seem to mark prematurity of vice. Humanity is contained in
the individual; and in these strange morbid displays there is
an example of humanity undergoing resolution. Whatever act
of vice, of folly, of crime, of madness one man has perpetrated,
there is in every man the potentiality of perpetrating ; if it were
not so, why repeat the decalogue? In the sense of anything in
nature being self-determined and self-sufficing, there is no indi-
viduality: as in one word are summed up the foregoing ages of
human cultivation, so in one mortal are summed up the foregoing
ages of human existence. Both in his knowledge and in his
nature each one is the inheritor of the acquisitions of the past—
the heir of all the ages. Take the word which represents the
subtile and, as ib were, petrified thought of a high mental culture,
and trace back with analytical industry its genesis,—resolve it
into its elementary production,—what a long succession of human
experiences is unfolded! What a gradual process of growth,
rising in speciality and complexity up to that organic evolution
which the word now marks, is displayed! Take, in like manner,
the individual being, and trace back in imagination through the
long records of ages the antecedent steps of his genesis, or observe
intelligently the resolution of his cssential human nature as it
vI.] THE INSANITY OF EARLY LIFE, 295

is exhibited in the degenerate acts of the insane child—in this
experiment thus obtruded on the attention by nature—and there
will then be no cause for surprise at phenomena which the young
creature could never have individually acquired, and which, so
far as its conscious lifé is concerned, appear strangely precocious
and inexplicable. There is the rapid undoing of what has been
slowly done through the ages; the disruption and degenerate
manifestation of faculties which have been tediously acquired ;
the resolution of what has been the gain of a long process cf
evolution; the formless ruin of carefully fashioned form. We
are sad witnesses of the operation of a pathological law of
dehumanisation in producing dehumanised varieties of the
human kind.
CHAPTER VII
THE SYMPTOMATOLOGY OF INSANITY,

Movc# discussion, into which I shall not enter here, has taken
place at different times concerning the proper method of classify-
ing the varieties of mental derangement, and as many as forty
or fifty different systems of classification have been propounded :
a sufficient proof that no one has yet been found to be satis-
factory. Some writers desire to have an exact pathological
basis for each of the varieties which they recognise, and throw
scorn on anything short of that, before they have done more
than cross the pathological threshold, and while they still
know nothing of what is going on in the intimate and inac-
cessible workings of nerve element. Doubtless, their day will
come a long time hence; in the meantime we may pass them
by as persons whose eager aspirations have outrun practical
needs, and whose enthusiasm oftentimes forestalls observation.
The commonly received classification is the least ambitious,
since it is founded upon the recognition of the obvious differ-
ences of the mental features—that is to say, is entirely sympto-
matological; it is simply a convenient scheme for grouping
together into some sort of provisional order phenomena which
resemble one another, without regard to their real nature, their
origin, and their essential relations, concerning all which it gives
no information. We group together under the name of Melan-
cholia a number of cases in which the symptoms are those of
great depression, and under the name of Mania other cases in
which the symptoms are those of exaltation and excitement,
notwithstanding that what seems to be the same cause may
produce the depressed form in one person and the excited form
CH. VIL] THE SYMPTOMATOLOGY OF INSANITY. 297

in another, and that the disease may go through both forms in
the same person before it has run its natural course, Clearly
such a classification of symptoms must be looked upon as pro-
visional ; but for the present it is convenient, and in truth neces-
sary. Were there no methodical classification of symptoms, an
author would be compelled on each occasion, when describing a
variety of mental derangement, to set forth the symptoms in.
detail instead of denoting them by the general name of the
class, and there would be no end of his labour. This necessity
of calling up by a general term the conception of a certain co-
existence and sequence of symptoms is a reason why the old
classification holds its ground against classifications that are
alleged to be more scientific: it is good so far as it goes, but it
by no means goes to the root of the matter; whereas the classifi-
cations which pretend to go to the root of the matter go beyond
what knowledge warrants, and are radically faulty.

Some persons exhibit eccentricities of thought, feeling, and
conduct, which, not reaching the degree of positive insanity,
nevertheless make them objects of remark in the world, and
cause difficulty sometimes when the question of legal or moral
responsibility is concerned. They are so unlike other people in
their feelings and thoughts, and do such odd things, that they
are thought to have a strain of madness in them; they have
what may be called the insane temperament,—in other words,
a defective or unstable condition of nerve element, which is
characterised by the disposition to sudden, singular, and im-
pulsive caprices of thought, feeling, and conduct. This con-
dition, in the causation of which hereditary taint is commonly

detectable, may be described as the Neurosis spasmodica or
Neurosis insana.

The Insane Temperament or Neurosis insana.

It is characterised by singularities or eccentricities of thought,
feeling, and action. It cannot truly be said of any one so con-
stituted that he is mad, but he is certainly strange, or “ queer,”
or, as it is said, “ not quite right.” What he does he must often do
ina different way from all the rest of the world. If he thinks about
anything, he is apt to think about it under strange and novel
298 PATHOLOGY OF MIND. (omar,

relations, which would not have occurred to an ordinary person ;
his feeling of an event is unlike that which other people have
of it; he has perhaps the strangest twists and cranks of thought,
and is given to punning on words; and now and then he does
whimsical and apparently quite purposeless acts. There is in
the constitution an innate tendency to act independently as an
element in the social system, and there is a personal gratification
in the indulgence of such disposition, which to lookers-on seems
to mark great self-feeling and vanity; he, however, is so exclu-
sively engrossed in the affection of self that he gratifies his
eccentric impulses without being conscious of the way in which
his conduct affects other persons. Such an one, therefore, is
Inoked upon by those who perform their duties in the social
system with equable regularity, thinking and feeling always
just as other people think and feel, as odd, queer, strange,
crochety, not quite right.

This peculiarity of temperament, which is the sign and
perhaps the sanitary outlet of a predisposition to insanity,
borders very closely upon genius in some instances; it is the
condition of the talent or wit which is allied to madness, being
only divided from it by thin partitions. The novel mode of
looking at things may be an actual advance upon the accepted
system of thought, and occasion a flash of true insight; the
individual may be in a minority of one, not because he sees less
than, or not so well as, all the world, but because he happens to
see deeper, and to have the intuition of some new truth. He
may differ from all the world, not because he is wrong and all
the world is right, but because he is right and all the world is
wrong. Of necessity every new truth is at first in a minority
of one; it is a deviation from or a rebellion against the existing
system of belief ; accordingly, the existing system, ever thinking
itself a finality, strives with all the weight of its established
organisation to crush it out. By the nature of things that ust
happen, whether the novelty be a truth or an error. It is only
by the work of rebels in the social system that progress is
achieved, and precisely because individuality is a reproach, and
sneered at as an eccentricity, is it well for the world, as Mr.
J. 8. Mill pointed out, that individuality or eccentricity should
vil.] THE SYMPTOMATOLOGY OF INSANITY. 299

exist. It will not be amiss to set this matter forth at greater
length, to the end that we may, if possible, get a just conception
of the real relation of certain sorts of talent to insanity.

The genius is in the van of his age: in that wherein he is
ahead of it he necessarily differs from his age, and is often-
times therefore pronounced mistaken, unpractical, mad; in that
wherein he agrees with his age, he is necessarily not original;
and so appears the truth of an observation of Goethe, that
genius is in connection with its century only by its defects—
that in which it is not genius. Certainly the originality of a
man of true genius will grow out of the existing system, and
may be traced as a genetic evolution of it; he is in radical con-
nection with his ceutury ; but the more forward he has gone in
his development, the more he will outshoot his age and differ
from it. Accordingly, many a man of genius who has appeared
before his time—in other words, before the social organism has
reached that height of evolution which his thought marks—has
made little impression upon the world, and perhaps been alto-
gether overlooked or soon forgotten by it, having most likely
been thought more or less mad in his lifetime; and the person
who usually gets most reputation, and whose name is made to
mark an epoch in development, is he who systematises and
definitely sets forth—that is, brings into illuminated conscious-
ness—the method which mankind has for some time been
instinctively and unmethodically pursuing. A Bacon or a
Comte, being not really much in advance of his time, but having
eyes to discern the tendencies of development, and a capacity
of co-ordinating knowledge, is he who gets the most honour,
But even he is not honoured so much by his own age as by a
posterity which has grown to his level. We never see how high
the mountain is until we get some distance from it.

Aa inherent disposition ef nature which renders a man dis-
satisfied with the existing state of things and urges him to
novel strivings, is really an essential condition of originality :
to suffer greatly, and to react with corresponding force, being a
means of dragging the world forward at the cost of individual
comfort. Consider, however, what an amount of innate power

1 Essay on Liberty.
300 PATHOLOGY OF MIND, [enar.

@ man must have in order to do that, without himself sinking
under the huge weight of opposition! Many eager and intense
reformers, whose vital energies have been swallowed up in the
passion and the promulgation of a truth, which was perhaps an
important one, have notoricusly broken down in face of the
crushing force of the organised opposition. They have been so
much engrossed in their idea, so carried away by it, so blind to
the force of the circumstances with which they have had to
contend, so abandoned to its propagation, so one-sided and
fanatical, as to be almost as heedless of the manifold relations
of their surroundings as actual madmen are; accordingly they
have often been called, and sometimes perhaps were, mad.
Certainly their failures prove that they had not sufficient in-
sight, patience, and capacity for the task which they had under-
taken: that they did not succeed is scientific proof that they
did not deserve to succeed. Howbeit they had not imme-
diate success, their work may not have been all in vain. The
heroes that have fallen in the lost field of the fight for the cause
that seemed to perish with them have oftentimes risen to
memory after many years of oblivion during which no man
spake of them; they had struck a rift in the false doctrine,
and dropped a seedling of new truth into it, which, as it grew,
opened gradually a wider and wider gap, and in full time
shattered and silenced it.

It is undoubtedly true that where hereditary taint exists in
a family one member sometimes exhibits considerable genius,
when another is insane or epileptic. The fact proves no more
than that in both there has been a great natural sensibility
which, under different outward conditions of life, or different
internal conditions of body, has issued differently in the two
cases: the one has been better endowed by nature or more
favoured by: fortune than the other. We may properly look at:
the function of unstable nerve element from two aspects—first,
as regards the reception of impressions; and, secondly, as
regards the reaction to them. In the first case we may have
one who is equal to the ordinary events of a calm life, but who,
quick to feel and slow to govern quick feeling, possessing no
reserve force of inherited or acquired endurance and energy,
VII] THE SYMPTOMATOLOGY OF INSANITY. 301

incapable alike of a steady subordination of self to events, and
of the power to subordinate events to self, is unequal to the
strain, and breaks down under the stress of adversity. And yet
his extreme nervous susceptibility may render him sensible of
finer shades and more subtile delicacies of feeling and thought
than a more vigorously constituted being of coarser sensibilities
is. The defect, then, is in some respects an advantage, although
a rather perilous one, since it may go near the edge of madness.
Such men as Edgar Allan Poe and De Quincy illustrate this
great subtility of sensibility amounting almost to disease, and
so far give colour to the extravagant assertion of a French
author (Moreau de Tours), that a morbid state of nerve element
is the condition of genius. It must not be lost sight of, how-
ever, that a person so constituted is nowise an example of the
highest genius; for he lacks, by reason of his great sensibility,
the power of calm, steady, and comprehensive mental assimila-
tion, and must fall short of the highest intellectual development.
Feeling events with a too great acuteness, he is incapacitated
from the calm discrimination of the unlike, and the steady
assimilation of the like, in all sorts of them, grateful or ungrate-
ful, by which the integration of the highest mental faculties is
accomplished,—by which, in fact, the truly creative imagination
of the greatest poet and the powerful and almost intuitive ratio-
cination of the greatest philosopher are fashioned. His insight
may be marvellously subtile in certain cases, but he is not
sound and comprehensive. Albeit it might be said by one not
caring to be very exact that the genius of an acutely sensitive
and subjective poet betokened a morbid condition of nerve
element, yet no one, after a moment’s sober reflection, would
venture to speak of the genius of such men as Shakspeare and
Goethe as arising out of a morbid condition! The impulse

1 “So far from the position holding true, that great wit (or genius, in
our modern way of speaking) has a necessary alliance with insanity, the
greatest wits, on the contrary, will ever be found to be the sanest writers.

_ It is impossible for the mind to conceive of a mad Shakspeare. The
greatness of wit, by which the poetic talent is here chiefly to be under-
stood, manifests itself in the admirable balance of all the faculties. Mad-
ness is the disproportionate straining or excess of any one of them.”—
Sanity of True Genius, by Charles Lamb.
302 PATHOLOGY OF MIND. [cHar.

which urges these men to their high striving is not so much
one of dissatisfaction as one of non-satisfaction—a craving, in
fact, for appropriation; they want to feel and know ever more
and more of nature in all her multitudinous moods and aspects,
and to get into ever nearer and nearer relations of concord with
her; their internal potentialities speak by a feeling of want, a
craving, an unsatisfied instinct, not otherwise than as the lower
organic elements manifest their sense of hunger, or as the
sexual instinct reveals its want at puberty. The difference
between the desires which are the motives to action of the
highly-endowed, well-balanced nature of the genius, and the
desires which inspire the eccentric and violent acts of the inci-
pient madman, is indeed very much like the difference between
the natural feeling of hunger in the healthy organism, and the
vitiated appetite for garbage and dirt which the hysterical
person displays occasionally. In the former case the aspiration
is sound, and acts to perfect a harmony between the individual
and nature; in the latter, it is unsound, and tends to the pro-
duction of an irreconcilable discord. The good organisation
hardly needs a long training; it will make the means of its
own best training by the operation of its excellent affinities ;
and it will thus, directly or circuitously, attain to its best de-
velopment. The bad organisation, on the other hand, can only
be saved from degeneration by suitable training; if unguarded
by watchful control its natural affinities will drag it downwards
to destruction.

A no less important difference between the highly-endowed
nervous constitution of the genius and the morbid nervous con-
stitution of the hereditary madman will appear when we look to
the reactive instead of the receptive side. The difference is not
unlike that which there is between a quiet aim-working voli-
tional act and a spasmodic movement. The acts of the genius
may be novel, transcending the established routine of thought
and conduct; but, however original and startling they appear
to those who work on with automatic regularity in the social
organisation, they contain, consciously or unconsciously, well-
formed design: implicit in them are the intuitive recognition of
and the intelligent respondence to outward relations; in other
vu.] THE SYMPTOMATOLOGY OF INSANITY. 303

words, they are aim-working for the satisfaction of an inherent
impulse, which operates none thé less wisely because there may
not be a distinct consciousness of its nature and aim. Jnspira-
tion is the exact opposite in this regard of habit or custom-—that
“tyrant custom ” which completely enslaves the whole manner
of thought and action of the majority of men: in the inspiration
of a great thought or deed there is the sudden starting forth inte
consciousness of a new combination of elements unconsciously
present in the mind; these having been steadily fashioned and
matured through previous experience. On the other hand, the
acts of the person who has the evil heritage of an insane tem-
perament are irregular, capricious, impulsive, and aim at the
satisfaction of no beneficial desire ; the outcome of a predisposi-
tion which is itself the materialisation of ancestral irregularities,
they tend to increase that discord between himself and nature
of which the aberrant acts are themselves evidence, and they
must end at last in-his destruction.

I have lingered thus upon the relations which a form of
talent bears to insanity, in order to mark, if possible, the
character of each—so like on the surface, at bottom so unlike—
and its true position in the social organisation. A large genius
is plainly not in the least akin to madness; but between these
widely separated conditions a series of connections is made by
persons who stand out from the throng of men by the possession
of special talents in particular lines of development; and it is
they who, displaying a mixture of madness and genius at the
same time, have given rise to the opinion that great wit is allied
to madness. They are said perhaps to have too much imagina-
tion; by which is meant not that they have a large, calm, well-
stored, and truly informed imagination, but a narrow, intense,
ill informed imagination that works wildly without due nourish-
ment of facts and undisciplined by habitual obedience to law—
in other words, a one-sided and defective imagination! With

1 There never was a truly great imagination without great understand-
ing : and it is ridiculous to attempt to separate them. To say that women
have more imagination than men, and that the savage has more imagina-
tion than the civilised man, is nonsense; for it is to call by the higher
name what is a negation of the best imagination, and the product of in-
tellectual barrenness and want of training in observation and reflection.

14
304 PATHOLOGY OF MIND. [cuar.

true genius there may be an uncommon deviation from the usual
course of things; but there is the full recoghition of the existing
organisation as the basis of a higher development, a fusing of the
past through a new mould into the future; in insanity there is a
capricious rebellion, as the initiation of a hopeless discord. A
man of deep insight and comprehensive view may penetrate be-
neath the masks of things, and see into the real nature of many
of the illusions set up by common consent to be worshipped,
but he still finds a real truth and meaning beneath the fleeting
phenomena, and he accepts with equanimity the present, not as
the end, but as means to an end, perceiving in it the prophecy of
a completer future: he subordinates his self-hood to the system,
works quietly and sincerely in his sphere, and is moved by no
passion springing from offended self-love to set the world vio-
lently right. He can perceive the urgent need of reform, and
long for its coming, without going mad with vexation and injured
self-love because it plainly will not come to pass in his day and
by his means. The man of great self-feeling, on the other hand,
may penetrate the incompleteness, the inadequacy, the empti-
ness of many existing doctrines and practices, but he is too apt
to find the whole ridiculous, not having calm enough apprehen-
sion to lay hold of the degree of truth which lies often at the
bottom of seeming shams ; he deems himself thoroughly emanci-
pated when he is actually the unconscious slave of an extrava-
gant self-feeling, by reason of which he is made angry with the
comedy of life, is instant to do some great thing, passionately
earnest to set the world right with a one-sided vehemence:
there is the reaction of a great self-love which incapacitates its
possessor, or rather its victim, from subordinating his self-hood
to the laws of the existing organisation. Has not Goethe put
this truth tersely and well in the words, “The man of under-
standing finds almost everything ridiculous; the man of reason
hardly anything ” ?

When the heritage of an insane temperament exists, it will of
course depend much on the internal bodily conditions and the
external circumstances of life whether the mischief shall remain
dormant or shall issue in positive insanity. In favourable cir-
cumstances it may manifest itself only in harmless eécentricities
vit.J THE SYMPTOMATOLOGY OF INSANITY. 305

and caprices; but if the person is placed under conditions
of great excitement, or subjected to severe mental strain, the
inherent propensity is apt to display itself in an impulsive
act of violence, or in an outbreak of some form of mental de-
rangement. One sees from time to time brothers who have
presumably had the same neurotic inheritance go very different
ways, and reach very different ends, in life, according to the
different conditions on which each has chanced to light; the
one perhaps gaining position and fortune, the other ending in
suicide or in a lunatic asylum. The great internal disturbance
produced in young girls at the time of puberty is well known
to be an occasional cause of strange morbid feelings and extra-
ordinary acts, particularly where the insane temperament exists:
in such case irregularities of menstruation, always apt enough
to disturb the mental equilibrium, may give rise to an outbreak
of mania, or to extreme moral perversion more afflicting to the
patient’s friends than mania because seemingly wilful. The
stress of a great disappointment, or any other of the recognised
causes of mental disease, will meet with a powerful co-operat-
ing cause in the constitutional predisposition. On this matter,
however, enough has already been said when treating of the
causation of insanity.

A description of the peculiarities of mind and body which
mark the varieties of the insane temperament would assuredly
be both interesting and useful. But the study, which has yet
to be made, will be difficult, and the description more difficult
still, for it will mean the exact delineation of glances, gestures,
attitudes, turns of thought, of feeling, and of expression, which,
albeit they are distinctly recognised when they are seen, cannot
well be set forth by a verbal description.

A quality of mind which is pretty well common to all the
varieties of the temperament, but marks one variety of it in
particular, is an intense self-feeling, which has various sorts of
expression in character. One might name this the egoistic
variety. Everything is looked at in the light in which it affects
self; there is a, singular and serenely unconscious incapacity to
look at self or the incidents which affect it from any outside
standpoint. What will be noted in some instances is that the
306 PATHOLOGY OF MIND. [cnap.

self-feeling widens to embrace the family without going a step
farther in expansion. There is then an intense family feeling;
the members constitute, as it were, one self, feel with one another
in a close and narrow sympathy, measure all their doings and
other persons’ doings by the standard of family feeling, and are
little or not at all affected by the opinions which outsiders may
entertain or by the interests which they may have. Such per-
sons think how things will affect their sensibilities and judge
them accordingly, instead of ever thinking how they may be
fitted to discipline and improve their sensibilities, and how welt
it might be that they were used for that end; exact with serene
unconsciousness of selfishness the labour and sacrifices of others,
as if it were in the natural order of events that they should use
all men and be used of none, should be considered of all and
should consider none; are so entirely engulfed in exaggerated
family feeling that they do not perceive the family oddities and
failings of character, but perhaps look upon and even foster
them as something higher than the virtues of other families ;
are shut off by their narrow sympathies from anything like a
large and healthy hold on the wide and manifold interests of
human life, and from the beneficial discipline of thought and
feeling which a wider experience would exert upon them.
Withal they are capable sometimes of extraordinary self-sacrifice
for one another.

The fact is that they are too much akin in character; they
have been bred too much alike; the strain wants variety ;
and their best chance to go through life without breaking
down into mental derangement themselves, or without breeding
such derangement in the next generation, is to be separated
widely from one another, and to be placed in different condi-
tions of life, whereby more healthy differentiations of cha-
racter may be produced. One notices perhaps in families of
this kind that the member who has been abroad in the world,
and has mixed among men in various parts, and participated
in their interests and doings, is the only one who displays a
fairly rational and healthy tone of mind; and for the same
reason the men of these families, who, being obliged in their
intercourse with the world to check the gross ‘display, have so in
vir] TUE SYMPTOMATOLOGY OF INSANITY. 307

some measure cliecked the growth, of the habit of morbid
suspicion and exacting selfishness, are better disciplined in mind
than the women who stay at home and nurse their narrow
sympathies in a narrow sphere. However, let the stress be great
enough, the fundamental feeling will seldom fail to come out
even in those who have undergone the most varied discipline.
A more marked variety of an insane temperament shows
itself in an extremely suspicious and distrustful nature; it
might be named the suspicious variety, for the suspicion is
morbidly acute and intense. Persons of this disposition often-
times show not less, if not more, distrust when they meet with
fair and open dealing, which is antipathetic to their natures,
than when they are in face of fraud and duplicity, with which
their natures are sympathetic; not being able to divine the
interested motive which they cannot help believing to instigate
the most candid advice, they cannot digest it, and imagine it to
.be too deep and inscrutable for them, whilst fraud is a congenial
flattery of their characters ; so it comes to pass that they become
the easy dupes of plausible impostors, who, pandering to their
foibles, play upon their infirmities. Moreover, any strange doc-
trine which is based upon a distrust of what the majority of men
believe, and is a rebellion against the accepted system of thought
and practice, has a pathological attraction for their intensely
distrustful natures; not because they have anything like an
adequate knowledge of the errors of what they reject or of the
merits of what they embrace, but simply because the latter is
heterodox. With this suspicion of others goes insincerity in
themselves; distrustful, they are untrustworthy. Having little
or no sympathy with their own healthy kind, they sometimes
display extraordinary affection for a cat or a dog, and arrogate
to themselves a superior humanity because of their greater affec-
tion for animals than for men. J need not repeat what I said
formerly of the secret ways, the suspicious imaginings, the
exacting distrusts, the duplicity of those near relatives of insane
persons who, having this unhappy temperament, ask advice,
follow it not faithfully, and then blame the giver when the
issue is not happy. With the morbid habit of mind goes some-
times a corresponding habit of bodily expression—a downcast,
308 PATHOLOGY OF MIND. [cHap.

furtive glance, an unsteady, vacillating eye which cannot look
full and frankly into another person’s eye; a stealthy, cat-like
step and sneaking attitude; nothing like frank outlook, erect
bearing, firm and manly gait. In some instances an effusive can-
dour and an apologetic humility of manner beguile the unwary
into a belief of their sincerity, which is after all perhaps genuine
at the moment. Entirely possessed for the time by the feeling
which the occasion kindles, they express it freely; their whole
conscious state is, as it were, the vibration of the momentary
emotion, an exclusive energy; but when its flame subsides, as it
quickly does, and reflection begins, their normal suspicious
functions regain their hold, and they act as if the previous de-
monstrative expression of feeling had been false and hypocritical.
It was as much out of relation with their normal mental func-
tions as a muscular spasm is out of relation with normal mus-
cular action. Hypocritical without doubt it was so far as real
sincerity of the whole nature was concerned, but not quite
consciously so at the time.

It has been noticed in several instances that members of the
same family who have become insane have laboured under the
same form of disease or under similar actual delusions. In one
family three brothers and a sister, who were all the members of
it of their generation, went mad one after another, and they all
had similar delusions of conspiracy and persecution. Their
mother, who was not supposed to be insane, was the most
suspicious and distrustful person whom I have ever met: on
one occasion she declared to me, in an outburst of momentary
sincerity, that she never trusted anybody, for she had been so
often deceived. There was no reason to believe that she had
fared worse in the world in that respect than other people, and
naturally her words stirred the sad reflection how much better
for her family it would have been had she trusted more and
suspected less.t I call to mind another case in which three

1 This lady was much hurt, aud never forgave me for having been
thoroughly candid with her. She had buoyed hersclf up with hopes, that
had no real foundation, that a demented son would recover, and had gladly
accepted the half promises of cure which different doctors whom she had
consulted had given her, abusing them afterwards for deceiving her.
When T told her that his case was truly hopeless, and that she should
VIL] THE SYMPTOMATOLOGY OF INSANITY. 309

sisters became insane, and all had similar delusions that they
were poisoned by chemical fumes and tortured by magnetism :
it was the more remarkable an instance because they had
married and had been separated in their lives. Everybody must
have noticed how exactly like one another in thoughts, feelings,
and ways two or three maiden sisters who have always lived
together become; so that when one of them falls insane it is a
long time before the others perceive or acknowledge it, and not
always easy for an observer to say offhand which is the patient.

A writer in a German medical journal gives an account of
a whole family who became insane! The family consisted of
father, mother, and six grown-up children. From time to time
they used to appear before the central authorities of the depart-
ment to complain that they had been plundered of their property
by the magistrates of their district. It was entirely a delusion.
They had shut themselves up in their house, abandoning the
cultivation of their land, and would listen to neither entreaties,
arguments, nor remonstrances from their neighbours, who out of
compassion had gathered in their crops for them. They lived in
a miserable manner, used no fire, and washed their clothes with-
out soap in a neighbouring brook; a deputation of them going
from time to time to the authorities to complain of the injury
that had been done to them. This went on for nine years.
Eventually two of the younger members left home to take
situations, and another died. At last, the father died in the
winter of want and cold, and one winter's night the mother died
on the road as she was returning from one of her fruitless
expeditions to obtain redress. The three who were left, two
sisters and a brother, were then sent to a lunatic asylum. One
of the sisters, who was microcephalic and somewhat weak-
minded, got rid of her delusions of persecution at the end
of eight months and became a useful servant. The brother tvo
left the asylum and obtained employment; but the eldest sister
~ remained under the influence of her delusion, and was angry and

make her plans accordingly, she was indignant, exclaiming, “ Why do you
tell me that!” and no doubt had recourse to some one who was willing to
deceive her again.

1 Zeitschrift f. Psychiatrie, B. 29, H. 2.
310 PATHOLOGY OF MIND. : [errar.

abusive when contradicted. The conclusion of the physician who
inquired carefully into the history of this family was that the
mother and daughter had been genuinely insane, having the
delusion that they were persecuted, and that they had succeeded
in infecting with it the other members of a not strong-minded
family, who would no doubt have escaped had the mother and
Jaughter been removed to an asylum at the outset.

In the Annales Médico-Psychologiques, 1863, Dr. Bonnet gives
a remarkable account of suicidal insanity in twin brothers,
Martin and Francis. They were robbed of 300 francs. One
morning afterwards the brothers, who lived several miles apart,
had a similar dream at the same hour, three o’clock a.M., and
awoke in great agitation, shouting, “I catch the thief; he is
injuring my brother.’ Martin’s agitation increased; he com-
plained of violent pains in his head, declared he was lost, and,
eluding observation, ran to the river and attempted to drown
himself, but was rescued. In the evening he was removed to
an asylum. Francis, who had become calm after his first
excitement, shcuted that his brother was lost, on seeing lim
taken away, that he was mistaken for the thief, that they were
going to kill him; complained soon after of violent pains in
his head, declared he was lost, and attempted to drown himself
at the same spot where his brother had done. He was soon got
out of the water, but could not be restored. Martin died three
days after his admission into the asylum, having remained in a
continuous state of excitement unto the end.?

The form of mental derangement which is most likely to be
communicated in this way by a sort of infection or sympathy is
that which is characterised by groundless apprehensions and

1 In different numbers of the Annales Médico-Psychologiques are related
several cases of this sort of communicated insanity. Among the rest the
case of twin sisters, one of whom, afflicted with fears and delusions of
persecution, infected the other, who soon recovered her senses when
separated from her sister. In the Annales Médico-Psychologiques of July,
1875, is mentioned the case of a French soldier who imagined himself son
of the Emperor of Austria, and that he would be crowned in Paris or in
Rome: he travelled in Italy, Spain, and France to attain hisend. His
twin-brother, who accompanied him in his travels, believed in his delusions,
and had exactly similar ones, imagining that he would be crowned at
ltome when his brother was crowned at Paris,
vit] THE SYMPTOMATOLOGY OF INSANITY. 311

delusions of persecution. No wonder, considering how easily
suspicion is stirred up in some minds, and how quickly, once
raised, it creates imaginary proofs of hostility, and feeds itself
upon the delusive evidences thereof. How much more is this so
in the suspicion of the insane temperament! The explanation
of such infections is to be sought, as before indicated, partly in
the essential likeness of nature in members of the same family,
whereby they are disposed to feel and think alike, and to foster
one another’s habits of thought and feeling by sympathy; and
partly in the absence of external differentiating influences, owing
to the fact that they live in the same narrow conditions of life,
have the same mean hopes and fears, and pursue the same petty
ends by the same means. By a sort of pre-established harmony
of nature their minds are attuned to chime together, and they
naturally do so when they are struck by the same impressions.
Habits of thought may thus grow side by side in two persons,
andaat the same rate, into a common delusion, or—what is more
likely—the stronger character succeeds in impressing its delusion
upon the weaker mind.

Another variety of the insane temperament is characterized
by extreme irresolution and vacillation; it might be truly
described as the vacillating or self-tormenting variety. Those
who have this temperament are distressed beyond measure
when they have to decide anything, however trivial, cannot
come to a decision out of apprehension lest it should be wrong,
and worry themselves and others with the many times reiterated
arguments for and against. Although the decision is not of tle
least consequence, whichever way it goes, it causes them the
utmost mental tribulation, and engages them hour after hour in
over-anxious considerations of a really puerile character; and
when the decision has been made there is an instant fear that it
has been wrong, and an instant relapse into the self-torturing
ingenuity of discovering objections to what has been decided
and of conjuring up the best reasons in favour of what was not
decided. Whatever they have done they persuade themselves
they ought not to have done, and what they have left undone
that they think they ought to have done. Thus they go on
from day to day, from month to month. a plague to themselves
512 PATHOLOGY OF MIND. (caar.

and to others with their brain-sick scruples and fears. If it were
some great thing concerning which they dubitated and wavered,
one would not think it anywise strange, for the habit of thinking,
Hamlet-like, too precisely over the event, which sicklies o’er the
native hue of resolution with the pale cast of thought, belongs
to certain minds of great capacity in which the intellectual pre-
dominates over the affective element; but it is about the meanest
and most insignificant affairs of daily life, as, for example, what
dress shall.be put on, which side of the street they shall take,
whether they shall travel by one train or another, what order
shall be given to the cook for dinner, and the like, that they are
thus mightily concerned. I call to mind one lady, whose father
had committed suicide, and who herself had been afflicted with
a great weariness of life and with frequently upstarting ideas
how well it would be if it were over, who positively dreaded to
rise from her bed in the morning, because of the suffering which
she knew she must undergo in settling what dress she wéuld
wear, and who declared that she went through agonies each
morning before she could summon resolution to give orders for
the day’s dinner; and the case of a gentleman having both
mother and brother hopelessly insane, who, although he had no
profession, nor business, nor real work of any kind, was rest-
lessly busy all day in deliberating upon the trifles of domestic
concern which he did not find time enough to settle. For when
the matter had been gone into fully, and all the reasons on one
side and on the other set forth elaborately, and the course of
action at last fixed upon, he would, notwithstanding that he
was aware of his teasing infirmity, begin again at the beginning
as if nothing had been said.

Nearly akin to this variety of unsound temperament is that
in which an idea or impulse, oftentimes of a trivial or even
ridiculous nature, springs up in the mind and takes such hold of
it that it gives the person no rest until he has yielded to it; I
may call it, for distinction’s sake, the impulsive variety of self-
torment. In one case a man’s life was a series of successive
struggles to resist ideas which were always annoying, oftentimes
distressing, and sometimes ridiculously foolish ; he must enter a
house with a certain foot first, for if he succeeded by a strong
vir.J THE SYMPTOMATOLOGY OF INSANITY. 313

effort over himself to conquer the whim by putting the other
foot first, it was a terrible wrench to him, and he had no rest of
mind until he had gone out of the house and re-entered it with
the proper foot first; he must take particular notice of a name
or of a number over a shop-door, and if he resolutely turned
his eyes away as he passed the door, he was obliged in the end
to turn back in order to look at the name or number, having
gone back more than a mile on one occasion to do so after he
had made a supreme effort to be master of the absurd impulse;
if it came into his mind that he must move a particular book or
piece of paper on the table for no reason whatever—and whims
of that kind were.constantly coming into his mind—he had
learned by long experience that he would have no peace of mind
until he succumbed. He was not an idle man who had nothing
to do but brood over these impulses and so magnify them, but
gained his livelihood by manual labour ; was moreover unusually
intelligent, and quite as conscious of their morbid character,
and of the propriety of withstanding them, as any one else
could be, but he came of a family in which there was mental
disease. .

In another case a gentleman of good means and position,
having an insane brother, was tormented with similar impulses of
a ridiculous nature. In all outward seeming he was so sound that
no one of his acquaintances except.one or two friends to whom he
had confided his troubles had the least notion how he was afilicted.
Many were his battles against the tormenting impulses, but he
was forced to succumb to them in the end, for after prolonged
struggle he would become extremely agitated and distressed,
break out into a violent perspiration, and tremble as much as if
he had just had a terrible fright. Once when driving along the
public road he chanced to notice two stones on the top of a high
wall, whereupon it instantly came into his mind that he must
lave them down. The wall was too hich for him to reach them,
and the absurdity of taking a ladder there in the day-time in
order to get at them helped ‘him to resist the impulse, which he
did during what he described as a most miserable fortnight; but
at the end of that time he went secretly out of the town by
night to the wall, taking with him a long whip, with the lash of
314 PATHOLOGY OF MIND. [cuaP.

which he succeeded, after several attempts, in dragging the ef
down. After that he had rest of mind until a new impulse took
hold of him.

I shall mention only one instance more of this self-torturing
habit of mind, which shows itself in all sorts of whims, of the
absurdity of which the person is perfectly aware—for example,
in thinking constantly of particular numbers or particular words
und then noticing that they appear with mysterious frequency
on all sorts of occasions; in asking himself the reason of some
very common thing, and the reason again of that, and so going
back in questioning without end ; in groundless apprehensions of
having said or done something which, although perfectly innocent
of harm and not of the least consequence, may have injured
some one; in fears lest he should be made to do unconsciously at
some time a ridiculous or improper act, to which he feels an
impulse that he is resisting successfully for the present. The
loss of control over the ideas and feelings of which he has such
painful experience brings home to him the alarming conviction
that he is at the mercy of an accident and may be precipitated
into doing some day what he apprehends with fear and trembling ;
and he will burst into tears and sob piteously as he tells the sad
story of his fears and struggles.

The following story is in the words of a gentleman who con-
sulted me, and who had written it out for me when he came :—

“T inherit from my father's family a troublesome liver ; from my
mother’s a singularly nervous temperament, which has exhibited
itself in several members of the family. One of my uncles was
subject to strange hallucinations, which took what I believe is the
not uncommon form of the fear of a design upon his life, even from
his own family ; he had also a belief that some hostile supernatural
agency was at work to frustrate his designs.

As far back as I can remember, my life has been troubled by
some form or other of nervous irritation.

“Asa very little child, I remember, I attached a peculiar import-
ance to certain numbers ; this or that trivial action must be accom-
panied by counting so many, or the action must be repeated so many
times ; later, certain of these numbers assumed a special importance :
vil.] THE SYMPTOMATOLOGY OF INSANITY. 315

three, or any multiple, must be avoided in ordinary act’ons as being
in some sort sacred to the Holy Trinity. An imperative necessity
seemed laid upon me to touch or move this or that object, though
I might have no desire to do so; and, as I think is related of Dr.
Johnson, I would submit to no little inconvenience to avoid tread-
ing upon the joins of the paving stones. Generally I may say that
that which was least pleasant seemed most strongly obligatory ; for
example, if I chanced to be walking with any one, the impulse to
pick up a chance straw in the path was greatly stronger than if I
were alone, though (or perhaps, because) I was very sensitive to fear
of my peculiarities being known; and, again, though I was fantav-
tically particular as to cleanliness, I was especially impelled to touch
some dirty or offensive object. I remember putting myself to con-
siderable trouble to go out again after reaching home to move some
trifling thing I had chanced to notice on the pavement. To resist
these impulses was very painful, though to yield was of little ad
vantage, as the one satisfied was quickly followed by another. I
read, as I remember, one of those weird German tales, which made
a strong impression upon my mind; it was the story of one of those
compacts with the devil which form the subject of so many legends ;
the one, I think, on which Der Freischiitz is founded. For a long
time the formula which was to constitute the contract was constantly
recurring to my thoughts, and a sort of necessity seemed imposed
upon me to give it mental assent. As it was necescary that it should
be thought, I was obliged, if I may so express myself, to think it
negatively, and so to avoid, as it seemed to me, taking the terrible
pledge. Fora very long time after this particular fancy had lost
its hold, the phrase thus reversed was continually recurring to my
mind. Ina similar way a promptirig to say or to think some sen-
tence of malediction against God had to be met by adding a nega-
tive and some expression of blessing or praise. Later, as a youth of
cighteen or thereabouts, an imaginary obligation under fancied oaths
of a terrible character to do any trifling thing was the source of no
little trouble to me. Ido not mean that I believed that I had at
some former time taken such an oath, but that the mere occurrence
of the thought of the oaths, though without the assent of my will,
seemed, to my disordered sense of conscienticusness, to make it
binding upon me ; under the influence of this feeling, I would re-
peat some remark in conversation which I had al: eady made, I would
take a turning in the street, which was out of my way, or buy an
316 PATHOLOGY OF MIND. [cHap.

article I saw in a shop window for which I had no use. Trifling as
such things may seem in the recital, the amount of inconvenience
caused was often very considerable, and the terrible sense of one of
these obligations unfulfilled would cause me often the most intense
unhappiness.

“Though these things could scarcely help being noticed, yet I
think not even those of my own family ever knew the extent to
which J was troubled. I was living, as it were, a kind of double
life, one part full of wretchedness, the other that of a reserved and
studious boy; and in spite of lengthy absences from school from
ill-health, which prevented anything like scholarship, I was com-
monly regarded as intelligent in ordinary affairs, both at school and
at home. For some years after entering my profession, though never
quite free from mental excitement, I was much less disturbed than
in my boyhood, so much as to lead me to hope that I was growing
into a normal state of mental health. For some time past, however,
I have had a recurrence of the old affection in a new form. Thera
is, except when the mind is fully occupied by any quite engrossing
employment, a prompting which reaches almost to a physical neces-
sity, to give utterance to some blasphemous or obscene speech. As
T pass through the streets, or on any one entering the room in which I
may be, some phrase of this character presents itself to my mind,
and, as it were, insists upon being spoken ; any conscious effort seems
to increase the evil, and evidently, though Iam compelled to keep a
constant watch upon myself, that very fact tends to increase the
nervous excitement. Jam unconscious sometimes whether I have
spoken.or not, for, unnatural as it seems, the thought is so vividly
present to my mind, or the uneasiness it produces so absorbs my
whole attention, that I cannot trust either to my own ears or my
lips. The only sort of assurance I can give myself is by literally
holding my tongue, the tip firmly between the teeth, and so render-
ing it physically impossible to utter distinct speech.”

The last case which I have to mention is that of an exceedingly
intelligent and accomplished elderly gentleman who had served
with distinction in the army; he had been an opium-eater
in his younger days, and not temperate in other respects. He
had now abandoned the taking of opium, and was most temperate
in habits and careful in diet. He lived in two rooms. out of
vu] THE SYMPTOMATOLOGY OF INSANITY. 317

which he could not bear to go, from fear of occasioning bodily
suffering to himself by exposure to sun or wind or from some
other cause; could not read himself, although a well-cultivated
person, because he thought it injured him to do so, and accord-
ingly engaged some one to read to him daily. His mind was
extremely active, but he was tormented by what he called
“fads ;” something came into his mind to be said or done, gene-
rally of the most trifling nature, as, for example, to move a lamp
on the table a few inches from where it stood, or to touch some
object as he passed it, and he had thereupon an irresistible im-
pulse to go on repeating the act over and over again; however
long and resolutely he resisted, he was obliged to succumb, for he
had no peace of mind until he did. He could relinquish a “fad”
of this sort at last in an indirect way by writing it down ina
book after he had repeated it so many times, and he had accord-
ingly made long records of pacified “fads”; but the misfortune
was that he had no sooner got rid of one in this way than another
would take its place and similarly harass him. THe was obliged
thereupon to go through the same process of repetition with it
until he could turn it, so to speak, and so get past it. He had
consulted several physicians about his state, and had taken counsel
with clergymen; the latter he had called to his aid because,
being a religious person, he was unspeakably tormented by ap-
prehensions that he had not used exactly the right word in his
prayers, and by impulses to go on repeating words. Oftentimes
when he touched something the idea occurred to him that his
hands must be soiled, and he felt that he must then touch some-
thing else, and so was obliged to go on touching one thing
after another until he was wearied. In consequence of this ten-
dency his morning offices occupied him for a long time every day.
No one could have had a more exact knowledge of his state than
he had, or perceived more clearly the absurdity of his bondage,
but he had not the least power to deliver himself from it.
Another mode of outcome of the insane temperament is an
extreme miserliness. With a remarkable unconsciousness of
any display of selfishness the individual tenaciously claims and
takes and holds to all he can get in a way which would rouse
some sense of shame in a person who had not the temperament ;
318 PATHOLOGY OF MIND, [cttar.

he, however, engrossed in the narrow desires of an intense self-
hood, without a touch of generosity, feels not the least sense of
shame. He persistently accumulates and lays up money which
he needs not, without designing to make any use of it either for
his own benefit or for the benefit of others; acting in fact as if
he were carefully laying by stores which he would take with him
when he went down to the grave and have great use of on the
other side thereof. He loses all sight of the end in the means,
and meanly toils for the means as if they were the end. “Thou
fool! this night thy soul shall be required of thee,” would be too
flattering a speech to one whose life is proof of the absence of a
soul in the true sense ofthe word. He is not one with his kind;
shut up in a narrow selfishness, he fulfills not the functions of a
sound element in the social organisation ; he is on the way to, if he
does not actually reach, morbid degeneracy. So long as grapes
do not grow on thorns nor figs on thistles, we cannot expect such
a one to beget healthy children; if he has any, they will most
likely run in either an insane or a criminal groove.

The last variety of the insane temperament which I shall
mention is that which is characterised by a complete or almost
complete absence of the moral sense. Of course the varieties
which have gone before might in one sense be called instances of
defective moral sense, but in them there has been an extravagant
growth of some egoistic passion, the hypertrophy of which has
entailed an atrophy of sound social feeling; not an original
privation of moral sensibility, a moral imbecility, such as I
am convinced is sometimes the consequence of a bad descent.
T have already described instances of young children sprung
from insane families who have presented a complete moral
imbecility, or have precociously displayed very definite immoral
tendencies, and I shall have occasion, later on, to describe a
genuine moral insanity in adults, and to point out its hereditary
antecedents. Short of actual derangement which calls for in-
terference, we meet with all degrees of moral deficiency in
individuals, and sometimes with an extraordinary deficiency
going along with a superior intelligence, It is easy to under-
stand that this should be when we call to mind what has been
said in foregoing pages concerning the evolution of the moral
vit] THE SYMPTOMATOLOGY OF INSANITY. 319

sense in mankind; concerning the fundamental meaning of
insanity as an aberrant phenomenon; concerning the near rela-
tions which sometimes subsist between crime and insanity ; and
lastly concerning the fundamental characteristic of an insane
temperament. This temperament really means nothing more of
course than an unsound temperament; the unsoundness con-
sists in some defect or exaggeration of qualities which unfits
it to adapt itself thoroughly to its social surroundings, and so to
take its proper part in the social organisation, predisposing it
to go the downward way of neurotic degeneracy until an actual
morbid variety is produced either in its generation or in the
generation which follows it. It will be found as a matter of
experience, however, that the person who has it does not usually
go actually mad himself; he is proof of madness in his family
and is not unlikely to beget madness, but he remains himself
much the same peculiar being all his days—near the border
of madness, but not over it—and combining even sometimes
extraordinary talent with his peculiarities.

There is a peculiar infirmity which I have noticed once or
twice in persons who have had a marked neurotic inheritance,
namely, an inability to look over a large space such as a wide
expanse of sea or plain without feeling very giddy and strangely
apprensive. One gentleman who consulted me about the in-
sanity of his brother could never bear to look from a height
over a large plain of country because of the distressing vertigo
which it occasioned him: it was not any fear of. falling from
a height but the spacious view which produced the effect, for
he had the same feeling if he were on the sea-shore or on a
mound only, from which there was no possibility of falling.
T observe that Reichenbach had noticed something of the same
kind in some of his so-called sensitives: one of them could
not look at a large plain because it made her sick; another
always avoided an open square, and preferred to go through
the alleys rather than cross it; to another a waving field of
corn was disagreeable, because she felt as though she were
being rocked by it and would vomit if she did not turn
away. Dr. Westphal has described as agoraphobia a species of
insanity which is characterised by the inability to cross an
320 PATHOLOGY OF MIND. [cuar.

open square. The condition marks a natural instability of motor
centres like that which is acquired by the drunken man who
steadies himself to cross a street by fixing his eyes intently on
some object on the opposite side. The vertiginous feeling is the
subjective aspect of the instability of the motor centres.

With the mental peculiarities which mark an insane tempera-
ment usually go peculiarities of features, of manner, of gait,
and of other bodily movements that are modes of mental ex-
pression. Were we only clever enough to read the language, past
ull doubt a man’s mind might always be discovered in his fea-
tures and his bodily attitudes. In the insane temperament
these characters are oftentimes so peculiar as to attract instant
notice. “This fatal heritage,” says Esquirol, speaking of extreme
cases, “is painted upon the physiognomy, on the external form,
on the ideas, the passions, the habits, the inclinations of those
who are victims of it.” It is hard to describe special traits of
address and expression, which are nevertheless easily perceived
when they are met with. A so-called “ nervous manner,” which
is a common enough expression, covers in reality a variety of
peculiarities: one person’s address is uncertain, abrupt, jerky,
and when he offers his hand it is with the air of a person who
presents a pistol at you; another's is shy, hesitating, awkward,
and instead of looking towards the person whom he approaches
as he enters a room, or whom he is addressing, he rolls his eyes
away strangely to the right or left or directs his gaze aimlessly
to the ceiling ; in other cases the movements are constant, rest-
less, purposeless, or sometimes grotesque and uncouth.

There is occasionally a fixed, full, unfathomable look or stare
which I have noticed in the eyes of persons who have inherited
a decided predisposition to insanity ; I recognise it, but cannot
describe it; it is as though they were preoccupied with some
undercurrent of thought different from that which is cou-
cerned in the conversation which they are holding. One feel-
instinctively that what one says to them is not going sincerely
to the bottom of their minds. I have noticed it particularly in
cases of mental depression in which there has been a suicidal
feeling, and eventually perhaps a suicidal deed.

In some instances a singular inconsistency or incoherence
ViI.] THE SYMPTOMATOLOGY OF INSANITY. 521

of features may be noticed; one part of the face shall be
wreathed in smiles while the rest of the features are not in
harmony with it, but have perhaps a grave and sober ex-
pression ; or, in spite of what is being talked about being of a
serious nature, there may be a nervous laugh on the face which
is quite out of harmony with the mood of mind. Again I have
noticed sometimes that a smile or laugh over the face shall not
pass away gradually and change into a sober expression, as it
naturally should, but shall be arrested abruptly in the middle
of it and changed suddenly into a blank, abstracted, and rather
vacant look of seriousness, without any corresponding abrupt
change in the mental mood, so far as can be judged, This
abrupt supervention of a vacant and abstracted look in the
midst of ordinary conversation, without anything having been
said to provoke it, may justly excite suspicion of a person’s
heritage. Lastly, one may remark in other cases an extra-
ordinary mobility of features, which fall into as many and
meaningless grimaces as those of an excited monkey, and
especially of the eyes, which roll about or oscillate aimlessly as
if they had broken loose from the bonds of ordinary expression
and were making revolutions on their own account. With such
grimacing features goes a grimacing mind—a twisted-minded-
ness, if I may so speak. When one eye rolls about out of
accord with the other, as it does in some persons, I am nos
aware that it is the mark of an insane temperament, but is it
not associated frequently with a duplicity of character? The
peculiarities of physiognomy which I have indicated seem to fall
mainly under two heads—first, an incoherence between moods of
mind and their natural facial expressions, and, secondly, an in-
coherence of the special features which constitute the natural
expression of a mood—a sort of dislocation or discontinuity of
vouscular function. The mind’s expressions, like its functions,
evince a tendency to incoherence.

These traits of expression are consisteut with sanity of mind;
they are not adduced as evidence of actual mental derangement,
but as signs of a temperament which will usually be seen on
inquiry to own a neurotic inheritance or be observed to found
one. But in extremer cases of hereditary degeneracy the physical
B22 PATHOLOGY OF MIND. (ciaP.

signs of defect are more marked. The physiognomy has not
regularity and harmony, but shows irregularity, discordance, or
actual distortion of features; there is sometimes an uregular
conformation of the head, one side of which may be larger than,
or differently shaped from, the other; the ears are not well and
regularly planted, nor perhaps properly formed in all their parts,
and there may be actual deformity of one or both of them, as
Morel has pointed out; convulsions have perhaps occurred in
early life, and some sort of spasmodic movement or tic of certain
muscles may continue throughout life. In the worst cases,
where degeneracy has reached the depth of imbecility, the walk
is vacillating and uncertain, and there is sometimes a dispro-
portion between the limbs. It would be true probably to say
that no one who lacks power to use and govern his muscles will
be capable of good power of attention. Arrest of development
of the sexual organs is not very uncommon ; slight diseases
readily take on a fatal character, so little is the power of vital
resistance; and the mean duration of life among those strongly
marked by this fatal heritage is less than the average.

There are corresponding peculiarities of disposition: Morel, of
Rouen, to whom we are most indebted for the scientific investi-
gation of these victims of degeneracy, described them as purely
instinctive beings; they display instinctively certain remarkable
talents, as for music, drawing, calculation, or exhibit a prodigious
memory for details; but they are incapable of sustained thought
and work—they cannot bring anything to a steady perfection,
“do not know that they know, do not think that they think;”
and under any great strain they are almost certain to break
down into insanity, or to explode in some act of violence. It is
remarkable nevertheless how much talent of a particular kind
may coexist sometimes with these extreme forms of degeneracy ;
as if to show how much of the acquisitions of countless ages of
mankind is now contained in the most degenerate specimens—
what an infinitely sublimed heritage of eons of culture belongs
to the essence of any human being of civilised parentage, I
once saw a little girl, et, five, imbecile from birth by reason of
hereditary degeneracy, who could not speak a word, screamed
frightfully, and was so mischievous and destructive that she
vIL.] THE SYMPTOMATOLOGY OF INSANITY. 323

could not be left alone for a minute; yet she could hum
correctly many tunes—her mother counted as many as twenty.
As the result of his elaborate researches, Morel came to the
conclusion that “in the inferior varieties of degenerate beings a
like physical type is to be observed amongst all the individuals
that compose these varieties, and a certain conformity in their
intellectual and moral tendencies. They betray their origin by
the manifestation of the same character, the same manners, the
same temperament, the same instincts. These analogies establish
amongst degenerate individuals under the same causes the bond
of a pathological relationship.” forget not that between the
extreme forms of this degeneracy and those slight eccentricities
compatible with high talent there are to be met with cases
marking every shade of the long gradation.

Closely allied to the insane temperament is that which exists
in those more or less hysterical women, mostly under thirty
years of age, who are the favourite subjects of mesmeric experi-
ments and of religious revivals, and who commonly exhibit some
peculiarity of nervous constitution, such as catalepsy, paralysis,
somnambulism, or spasmodic affections. Having no well-formed
will of their own, they become the easy victims of ideas forcibly
impressed upon them by others. Their spasmodic temperament,
unfavourable to the proper co-ordination of ideas and feelings,
is eminently favourable to the morbid exaggeration of some
feeling or idea and to spasmodic movements. A further con-
sequence of this bad. organisation in most of these cases is a
strangely perverted or defective moral nature. Certain women
exhibit a desire for and a love of imposture. which approaches
a moral insanity: will blacken their eyelids with some pigment
in order to look and be thought ill, when they are in good bodily
health; will lie in bed for months or even years, affirming that
they are paralysed, when the only paralysis they have is one of
moral energy ; will undergo extraordinary sufferings and priva-
tions in order to substantiate some outrageous fraud which they
are practising; openly refuse all food for weeks, in order to
produce the belief that they live without food; drink what
urine they clandestinely pass, in order to have it believed that
they never pass any’; and burn or blister their arms and bodies
324 PATHOLOGY OF MIND. [caaP.

with some corrosive fluid, in order to fabricate a peculiar skin-
disease. The religious ecstatics of the middle ages belonged
doubtless to this class; the miraculous stigmata which they
exhibited being as fictitious as the diseases which their sisters
of the present day fabricate or counterfeit. When the vagaries
of hysteria affect the mind rather than the body, as they are apt
to do where the insane temperament exists, they occasion many
extraordinary symptoms.

Hysteria is notably a very vague term used to include a mass
of functional nervous disorders of all sorts and degrees, which
are certainly not as distinctly marked out from one another as
it is desirable they should be. One character they have in
common, namely, that they suggest the notion of a counterfeit-
ing of disease: a group or succession of symptoms which would
be of grave omen otherwise are known not to be of grave omen
when it can be said of them that they are only hysterical;
wherefore, not having the significance which they seem or affect
to have as the exponents of serious disease, they necessarily
have the look of pretence or feiguing. The appearance of un-
reality is further strengthened by the fact that in many cases the
malady can be checked instantly by the will when it is vigor-
ously roused by a strong enough motive, and that in other cases
it may be gradually suppressed, as will is strengthened steadily
by a suitable moral discipline, such discipline being the best
treatment of the malady. The two principal features then
which attract notice in all so-called hysterical cases are a
seeming simulation of disease in protean forms and an ener-
vation of will. Let it not be supposed, however, that the
simulation is voluntary or even conscious in the majority of
cases; although the symptoms do not mark the disease which
they seem to mark, do not mean epilepsy, for example, when
they are violent convulsions of an epileptiform character, they
are none the less the outcome of a genuine disorder of the
nervous system, and of a disorder which is nearly allied to that
which exists in catalepsy, in ecstasy, and in those hybrid forms
of convulsive seizures which we are at aloss sometimes whether
to call hysteria or genuine epilepsy.

For the most part we hardly take sufficient account of the fact
VIL] THE SYMPTOMATOLOGY OF INSANITY. 325

that mimicry is a natural function of the nervous system, consti-
tuting the very basis of its culture, and that the tendency in many
nervous disorders is to exaggerate much and even to simulate
symptoms, apart from any question of intentional deceit. This
tendency it is which will can combat and sometimes inhibit or
hold entirely in check, whence the universal counsel to so-called
nervous patients not to give way to distressing feelings and in-
clinations to do nothing, but to fight against them : it is counsel
easily given, but hard to follow, since the misfortune is that the
disorder which strengthens the tendency weakens the will, and
so leaves less power to control what is more difficult of control.
Be this as it may, however, it is plain that there may be all
degrees of apparent or of real simulation in different instances
—a gradation, in fact, ranging from an entirely unconscious
mimicry down to deliberate fraud. We are in the habit of
making in our conceptions so complete a separation between the
physical and the volitional action of the nervous system, looking
upon the will as something constant, psychical, and entirely
apart, that we cannot help holding that it either absolutely is
or is not in any given function; we find it hard or impossible to
conceive that it may present all degrees of degradation and that
its basis is truly physical. Involuntary perverse conduct of a
voluntary kind, convulsions of voluntary movements, perverse
pleasure in self-torture, are expressions which would convey the
best notion of the behaviour of some hysterical patients, if they
were not self-contradictory ; but self-contradictory as they seem,
I am inclined to think that they are not so mutually exclusive
as the received doctrines of psychology would indicate. How-
ever, they will certainly be thought so; for it will be a long
time yet before it will be possible to bridge the gulf betwecn
physiological conceptions of the functions of mind and the usual
conceptions of it.

Thus much concerning some peculiarities of an insane teim-
perament which stop short of actual insanity. I go on now to
treat of the varieties of actual mental derangement from a
symptomatological point of view.
326 PATHOLOGY OF MIND. [cHaP.

Varieties of Symptoms of Actual Insanity.

A passing survey of the inmates of a lunatic asylum could
hardly fail to strike the mind of an unskilled observer with the
perception of two principal classes of opposite symptoms: he
would notice that there were some whose every attitude, word,
and thought betokened the deepest depression of mind, and
others who betrayed an opposite state of exaltation of mind in
their look, their gait, and in everything which they said and did.
These opposite symptoms mark the two great divisions of Jfelan-
cholia and Mania, which correspond again to the two funda-
mental affections of self in which all the passions have their
roots: on the one hand, a painful affection of self which shows
itself in sad feelings, thoughts, and conduct; and, on the other
hand, an expansion or elation of self which is expressed in
answering feelings, thoughts, and deeds.

A closer examination would show the observer that while the
derangement of mind was complete in some patients and be-
trayed itself in almost everything which they said and did, in
others it was limited apparently to a few fixed ideas, apart from
which they thought, felt, and acted very much like other men.
Marking these differences by another division, we have, first,
Mania divided into general and’ partial, the latter known com-
monly as Monomania, because of the opinion that the maduess
is limited to one subject; and secondly, Melancholia, divided
likewise into General and Partial, the latter, although not now
commonly distinguished, being what Esquirol described as
Lypemania, In regard to both these forms of so-called partial
insanity it may be noted at once that while the intellectual dis-
order is certainly limited toa few ideas, the same thing can
seldom, if ever, be said truly of the feelings; they are more
generally and deeply affected, and yield a constant nourishment
to the delusion which is rooted in and fed by them.

Were our observer to reside long enough in the asylum to
watch the course which these mental disorders went through,
he would notice that there took place in some instances a
gradually increasing failure of mental power with an increasing
incoherence of ideas, the feeling that inspired the delu-
Vil.] THE SYMPTOMATOLOGY. OF INSANITY, 327

sions waning in force, while the delusions themselves persisted
and perhaps became more in number and more extravagant in
character. All such cases of wreck of mind consequent upon
some other form of insanity are grouped together under the
name of Dementia; which means, therefore, the destruction or
loss of mind, as distinguished from Amentia, which is used to
denote idiocy, or the privation of mind occasioned by causes
that have acted before or soon after birth—that is to say, before
there has been a chance of its development. A moment’s re-
flection proves that there must needs be all degrees of dementia
as of amentia, ranging from chronic mania or melancholia, in
which the first signs of mental weakness show themselves,
through varied conditions of incoherence or craziness, down to
actual fatuity : in fact any one might represent, if he chose, the
deepening degrees of mental deterioration as (a) chronic mania ;
(b) craziness ; (c) fatuity.

Here then appear the lines of the symptomatological classi-
fication of Esquirol which is in practical use at the present day.
We have only to add to it General Paralysis of the Insane, a
disease the special characters of which have been observed and
defined since Esquirol’s time, and we have the commonly recog-
nised varieties of mental derangement. It is obvious that they
are not properly varieties of disease at all; they are grouped
classes of symptoms, all of which may positively occur in the
same patient at different stages, and as different phases, of his
disease. For it may commence in melancholic depression, pass
thence into acute mania, go afterwards through a chronic stage
of depression or of excitement, and end in dementia. Such
might indeed be considered its typical course. Atthe same time
a patient will oftentimes go through his malady presenting only
one of these well-marked groups of symptoms; and until we
know exactly the obscure constitutional conditions which are at
the bottom of the differences of symptoms—of which we know
nothing yet—we cannot dispense with a symptomatological
classification.

When the phenomena of mental derangement are examined
with a more patient and scientific attention than the unskilled
observer is able to give to them, it is found that the foregoing

15
328 PATHOLOGY OF MIND. [cHar.

classes do not include, or rather do not define adequately, all the
varieties of symptoms. It is past all question that there are
certain distressing and dangerous conditions of unsoundness of
mind in which the feelings and the conduct are mainly or only
disordered, the intellect being little or not at all affected. They
have been described as insanity without delusion, insanity of
feeling and conduct, affective insanity, mania sine delirio, melan-
cholia simplex. All these names indicate that the perversion
of feeling so overtops any disorder of intellect which there may
be as to attract predominant or exclusive notice. Like the
recognised disorders of intellect these affective disorders may
take the form of exaltation or depression ; they might therefore
be justly included in the ordinary groups of mania and melan-
cholia ; but since in common apprehension the terms mania and
melancholia have come to mean positive intellectual derange-
ment, and would not adequately define these cases, which have
furthermore a medico-legal interest and importance of their
own, it is proper to describe them separately. This is the more
necessary because delusion has sometimes been authoritatively
proclaimed to be the criterion of insanity. Most unwarrantably ;
for on closely scanning the relations and the course of develop-
ment of the symptoms of mental derangement it will be seen
that the affective disorder has been the fundamental trouble in
almost all cases that have not been produced at once by direct
physical injury ; that it notably precedes intellectual disorder in
the majority of cases; that it co-exists with the latter during
its course ; and that it often persists for a time after this has
disappeared. Esquirol rightly declared “moral alienation to be
the proper characteristic of mental derangement.” “There
are madmen,” he says, “in whom it is difficult to find any trace
of hallucination, but there are none in whom the passions and
moral affections are not perverted and destroyed. I have in
this particular met with no exception.” To insist upon the
existence of delusion as a criterion of insanity, as is done sqme-
times, is to ignore those most grave forms of affective mental
disease in which, notwithstanding the absence of positive intel-
lectual derangement, dangerous impulses to homicide, to suicide,
or to other destructive deeds are most apt to arise.
vit] THE SYMPTOMATOLOGY OF INSANITY. 329

It will be most convenient then that I should treat generally
of the symptomatology of insanity in the order of the sub-
joined classification, and afterwards describe particularly the
principal clinical varieties.

ATFECTIVE INSANITY « 2 « : INSTINCTIVE.
oR

INSANITY WITHULUT DELUSION b. Moran,
ACUTE.
MELANCHOLIA Cannnies
ACUTE.
IDEATIONAL INSANITY . . MANIA. . CHRONIC.
MoNoMANIA

AcuUTE.

DEMENTIA. { Curae

.

ImBECILITY | MoraL AND

AMENTIA. « 6 0 «© o
INTELLECTUAL,

Ipiocy .

I might abolish the division of affective insanity altogether,
and place the varieties belonging to it under mania and melan-
cholia, dividing these respectively into mania with delusion and
mania without delusion, and into melancholia with and without
delusion; but for the reasons just mentioned I think it better to

classify them separately.

Affective Insanity — Insanity without Delusion — Insanity of
Feeling and Action.

The feelings reveal the real nature of the individual; it is
from their depths that the impulses of action spring, the func-
tion of the intellect being to guide and control. Consequently
derangement of them means a profound derangement of the
individual’s nature ; his whole manner of feeling, the mode of
his affection by objects and incidents, is perverted and unnatural,
and the springs of his action are disordered. The intellect
certainly does not escape entirely, since itis affected indirectly
or secondarily ; it cannot contemplate things in the white light
of a calm understanding, but sees them in the colours of the
distempered feelings; moreover it is unable to check or to control
330 PATHOLOGY OF MIND. [cwar.

the morbid manifestations, just as, when there is disease of the
spinal cord, a person may be afflicted with convulsive move-
ments, of which he is conscious, but which the will cannot
restrain. In dealing with this kind of derangement it will be
most convenient, as in the investigation of the insanity of early
life, to distinguish two varieties—impulsive or instinctive in-
sanity, and moral insanity proper.

(a) Impulsive Insanity —Fixing attention too much upon the
insane impulse, or upon the act which it instigates, to the neglect
of the fundamental perversion of the feelings which exists also,
many writers have helped unwittingly to augment the confusion
and uncertainty which prevail with regard to these obscure
varicties of mental disorder in which violent insane impulses
are displayed without corresponding insane thought. Already
it has been pointed out, at sufficient length, that the first symp-
tom of an oncoming insanity commonly is an affection of the
psychical tone—in other words, a perversion of the whole
manner of feeling, producing a marked change—that is, an
alienation—of character and conduct; and it will be seen ata
later period that morbid impulses spring up irregularly and,
so far as motives can be detected, unaccountably in all forms of
insanity, and are of the very essence of the disease. What we
have to fix in the mind is that the mode of affection of the indi-
vidual by events is entirely changed by the disordered state of
nerve-element: this is the fundamental fact, from which flow
as secondary facts the insane impulses, whether mischievous,
erotic, homicidal, or suicidal. In place of that which is for his
good being agreeable and exciting a correspondent desire to
acquire it, and that which is injurious being painful and
exciting an answering desire to eschew it, the evil impression
may be felt and cherished as a good, and the good impression
telé and eschewed as an evil. The morbid appetites and feelings
of the hysterical woman and the singular longings of pregnancy
are mild examples of a perversion of the manner of feeling and
desire which may reach the outrageous form of morbid appetite
exhibited by the pregnant woman who killed her husband and
pickled his body in order to eat it. The sexual appetite may
likewise suffer painful perversions, which of necessity involve
vu] THE SYMPTOMATOLOGY OF INSANITY. 331

the destruction of all those finer feelings of affection and pro-
priety in the social system that are based upon it.

The morbid perversion of feeling is either general, when all
sorts and conditions of abnormal feelings and desires are exhi-
bited, or it is specially displayed in some particular mode, when
one persistent morbid feeling or desire predominates. We meet
with occasional instances of madness in which there is a morbid
desire to be hanged, without particular intellectual disorder, and
the victim of the diseased feeling is actually impelled to a homi-
cidal act to satisfy his unuvatural craving ; or, again, such insanity
as that of the father or mother who in a state of morbid gloom
kills a child from no better motive than to send it to heaven.
The act of violence, whatever form it takes, is the outcome of a
deep morbid perversion of the nature of the individual ; a state
which may at any moment be excited into a convulsive activity,
either by a great moral shock, or by some cause of bodily dis-
turbance, such as intemperance, sexual exhaustion, masturbation,
or menstrual disturbance. There are women, sober and tem-
perate enough at other times, who are afflicted with an uncon-
trollable propensity for stimulants at the menstrual periods; and
every large asylum furnishes examples of exacerbation of in-
sanity or epilepsy coincident with that function. In fact, where
there is a condition of irritable weakness or unstable equili-
brium of nerve element, any cause, internal or external, exciting
a certain commotion will upset its stability. Internal states
have utterance by acts as well as by speech, gesture-language -
being the primitive language of feeling, as natural a mode of |
expression as speech and prior to it in the order of development;
and it is in insanity of action that this form of affective insanity
is expressed—most dangerous, indeed, because so expressed.

Many examples might be quoted to illustrate the character
of this impulsive madness ; but a fe shall suffice.

A married lady, aged thirty-one, who had only one child a
few months old, was for months afflicted with a strong and per-
sistent suicidal impulse, without any delusion or any disorder
of the intellect. After some weeks of zealous attention and
anxious care from her relatives, who were all most unwilling
to send her from among them, it was found absolutely necessary
332 PATHOLOGY OF MIND. [crap

to send her to an asylum; so frequent were her suicidal attempts,
so cunningly devised, and so determined. On admission she
was very wretched because of her terrible impulse, and often
wept bitterly, deploring her own state and the great grief and
trouble which she was to her friends. She was quite rational,
even in her great horror and reprobation of the suicidal pro-
pensity; all the fault that could be found with her intellect
was, that it was enlisted in its service. With as complete a
knowledge of the character of her attempts at self-destruction
as any indifferent bystander could have, she was powerless to.
resist them. At times she would seem quite cheerful, so as to
throw her attendants off their guard, and then would make with
quick and sudden energy a cunningly precontrived attempt. On
one occasion she secretly tore her night-dress into strips while
in bed, though an attendant was close by, and was detected in
the attempt to strangle herself with them. For some time she
endeavoured to starve herself by refusing all food, and it was
necessary to feed her with the stomach-pump. The anxiety
which she caused was almost intolerable, but no one could
grieve more over her miserable state than she did herself. From
time to time she would become cheerful and seem quite well
for a day or two, but would then relapse into as bad a state
as ever. After she had been in the asylum for four months
she appeared to be undergoing a slow and steady improvement,
and it was generally thought, as it was devoutly hoped, that one
had seen the last of her attempts at self-destruction. Watch-
fulness was somewhat relaxed, when one night she slipped out
of a door which had been carelessly left unlocked, climbed a
high garden-wall with surprising agility, and ran off to a reser-
voir of water, into which she threw herself headlong. She was
got out before life was quite extinct; and after this all but
successful attempt she never made another, but gradually re-
gained her cheerfulness and her love of life. Her family was
saturated with insanity. In face of such an example of uncon-
trollable impulse, what a curious mockery of justice it is to
measure the lunatic’s responsibility by his knowledge of right
and wrong, as some English judges still think it the perfection
of judicial wisdom to do!
vit] THE SYMPTOMATOLOGY OF INSANITY. 333

Such cases of desperate suicidal impulse without any manifest
disorder of intellect are well known to those who take charge of
insane persons, and are most unwelcome to them; for they are
almost sure to succeed in the end in doing what they so fran-
tically desire, so cunningly plan, so resolutely attempt. I have
known one case of a lady, descended from a very insane family,
who was afflicted with an overpowering impulse of the kind,
without the least sign of any derangement of her understanding,
‘and who, after having been frustrated in manifold suicidal at-
tempts, was removed from the asylum in which she was residing
to another asylum where it was thought the arrangements would
be more suitable to the special care which her case demanded ;
but she had not been there long before she succeeded in com-
mitting suicide. Cases of the kind are to be distinguished from
those cases of ordinary melancholia in which the suicidal feel-
ing is common and the suicidal deed attempted from weariness
of life, from despair, or from a delusion of some sort: in these
latter cases the suicidal impulse is one among other symptoms
of derangement, and has mostly a motive of some sort; but in
the former cases the suicidal impulse is the disease, has no
motive, is a sort of convulsive energy of the whole being, and
the patient’s misery is the result of the horror and agony of
being so dreadfully possessed.

Cases of the same class occur in which the morbid impulse
is not suicidal, but homicidal, and have been recorded by differ-
ent authors. On several occasions I have been consulted by a
married Jady, the mother of several children, who is afflicted
with recurring impulses to kill her youngest children, of whom
she is most fond; she cannot bear sometimes to be in the room
with them when there are knives on the table and no one else
is present; and she is driven to retire to her bedroom, where
she weeps in an agony of despair because of what she calls her
wicked thoughts, and prays frantically to be delivered from
them. In her paroxysms of despair she wishes a thousand
times she were dead, and exclaims that there can be no God, or
He would not allow her to suffer so. A gentleman, who is em-
ployed in a public office, has for some time been miserable
because of impulses which he has to kill himself and his wife ;
334 PATHOLOGY OF MIND. cHar.

he has gone into society, applied himself to hard work, and
travelled about in order to free himself from their torments, but
in vain; and he now consults me not only that he may be told
what to do to be delivered from them, but that he may be in-
formed whether there is a real danger that he will some day
give way to them. It seems ridiculous, he says, to speak of
them, but no one can believe the agony which they occasion
him, and the misery which his life is in consequence. Another
gentleman, who was obliged to leave a house near the Crystal
Palace because the high tower in view provoked such vivid
suggestions of suicide that he feared he could not always resist
them if he continued to live near it, was subsequently afflicted
with impulses to kill his children; generally subactive, but
distressing, from time to time they reached the height of a
convulsive mental paroxysm and caused unspeakable suffering.
He used to lock himself in his bedroom at night, and put the
key on the window-sill outside the window when he went to
bed, so that if he were overtaken unawares in the night by a
paroxysm he might instantly push the key off the sill beyond
his reach before he had time to determine to unlock the door.
An old lady, aged seventy-two, several members of whose
family were insane, was afflicted with recurring paroxysms of
convulsive excitement, in which she always made desperate
attempts to strangle her daughter, who was very kind and atten-
tive to her, and of whom she was very fond. Usually she sat
quiet, depressed and moaning because of her condition, and was
apparently so feeble as scarcely to be able to move. Suddenly
she would start up in great excitement, and, shrieking out that
she must do it, make a rush upon her daughter that she might
strangle her. During the paroxysm she was so strong, and
writhed so actively, that two persons could scarcely hold her;
but after a few minutes of struggling she sank down quite ex-
hausted, and, panting for breath, would exclaim, “ There, there !
I told you; you would not believe how bad I was.” No one
ever detected any delusion in her mind; the paroxysm had all
the appearance of a mental convulsion; and had she succeeded
in her frantie attempts, it would not have been possible to say
honestly that she did not know that it was wrong to strangle
Vil.] THE SYMPTOMATOLOGY OF INSANITY. 835

her daughter. In fact, it was because of her horrible propensity
to so wrong an act that she was so wretched.

In the Report of the Morningside Asylum for 1850, Dr. Skae
relates a somewhat similar case of a female who was tormented
with “a simple abstract desire to kill, or rather (for it took a
specific form) to strangle,” without any disorder of the intellec-
tual powers, and who “ deplored, in piteous terms, the horrible
propensity under which she laboured.” The existence of this
kind of disease is placed beyond doubt by the concurrent testi-
mony of all those whose practical knowledge of insanity gives
weight to their opinions and authority to their words; the denial
of it for theoretical reasons based upon the deliverances of a
sane self-consciousness is reckless and unwarrantable. The only
fault that can be found with the intellect in some of these cases
is, that it is enlisted in the service of the morbid propensity,
devising means to give it free play, instead of devising means to
hold it in check—that it is governed by it, instead of governing it.

The next case may serve io illustrate a multitude of insane
acts without corresponding intellectual disorder: there was not
the impulse to any particular insane act, but there were generally
perverted feelings and corresponding impulses to different strange
and foolish acts. I quote it at length because it is a fair ex-
ample of a form of mental derangement which occurs not un-
frequently in young unmarried women who have inherited a
neurotic temperament, and which seems sometimes to be con-
nected with unsatisfied or wrongly satisfied sexual feelings. A
young lady, aged twenty-nine, of good appearance and manners,
and well connected, was, after long and patient trial at home,
sent toan asylum. From the age of twenty-two there had been
a tendency to lowness of spirits without apparent cause. Lately
she had become worse, and was now described as wilful, im-
pulsive, passionate, and quite unlike her former self, having
lost all affection for her parents, though formerly most affection-
ate and amiable. Her habit of body was sluggish, the circulation
being languid and the extremities often cold and livid; men-
struation was very irregular. She complained of feeling strange,
quite unlike herself, and ill, and would buy all kinds of queer
compounds at the chemist’s and take them; sometimes she
336 PATHOLOGY OF MIND. [cHap.

wrapped a wet sheet round her body and put her clothes on
over it. She entertained a high opinion of her talents, way
exceedingly vain, seeming to think herself a peculiar person,
and angrily complained that she was treated most shamefully if
her inclinations were anywise thwarted. And her inclinations
were peculiar, and suddenly manifested: she would all of a
sudden scale a high garden wall and run off into the fields, or
sit down by the roadside when walking out, and refuse to move
for a long time, or stand still in the middle of the road, or jump
up in the middle of the service and walk out of church. She
was continually writing letters to her parents, relatives, and
people whom she did not know, complaining of her confinement,
sometimes angrily, at other times humorously. Usually the
letters were not finished, but broken off abruptly, sometimes in
the middle of a sentence, and sent for posting: one was ad-
dressed to “Tout le Monde.” They often contained witty and
vigorous remarks, but the sentences were rarely connected, each
one being, as it were, an independent shot; as the thought came
automatically into the mind, so it was automatically expressed.
Now and then she would refuse to take any food for a day or
two, and at other times would eat far more than was good
for her. She always exhibited extreme religious feeling, was
fond of distributing tracts as she went along the road, and
would sometimes read to the unfortunate patients who were
more severely afflicted ; notwithstanding which benevolence, she
would, if she had not the exact seat at church which she might
happen to desire, burst into tears and sob with passion, or rise
up in the midst of the service and wall out; at other times she
would not move after the service was over, in spite of all the
entreaties and reproaches of those who attended upon her. Ad-
jured beforehand to behave properly, she would promise to try
to do so; remonstrated with at the time of her extravagances, or
after she had indulged in them, the reply usually was that her
inotives were not understood; when in a better mood she con-
fessed that she was a great trouble, acknowledged the attention
which she received, and said that she was prompted by Satan ;
sometimes she wished heartily that some one would give hera
good beating so as to rouse her from her apathy. If any reason
VIL] THE SYMPTOMATOLOGY OF INSANITY. 337

was given for her impulsive deeds at the time, it usually was
that “it was revealed to her” that she was to do so, by which
. was plainly meant that it came into her mind to do so; and it
was remarkable that, though usually overcome with languor,
and behaving as if scarcely able to move, she would, when the
impulse seized her, scale a high brick wall with a cat-like agility,
though she seemed to have no definite notion what she was going
to do when she had got over and had run for a certain distance.
In all her conduct she exhibited an odd combination of reason of
thought and of dementia of action ; a stranger conversing with her
would not have discovered that her mind was at all affected ; but
avy one living with her for a time could not fail to perceive how
exceedingly insane she really was. Her case might not-unfitly be
described as one of Dementia sine delirio—demented feeling and
conduct without intellectual dementia; with good natural en-
dowments and general powers of reasoning unimpaired, there
was a thorough insanity of feeling and of action, evincing funda-
mental derangement of her mental nature. Hereditary taint was
denied, but it ultimately turned out that two near rela-
tives were in confinement and incurably insane—a fact which
might have been affirmed with confidence from the character of
her disease; and it is perhaps not uninteresting to add that an
uncle was the most distinguished architect of his day.

In most of the cases of this kind of impulsive or convulsive
mental disorder it will be found on making careful inquiry into
the family history that there is a decided hereditary taint; and
in those cases in which no actual insanity can be detected by
inquiry it is probable that epilepsy will be found in the family
or in the individual himself. The two main predisposing con-
ditions in which I believe the disease to occur are—(a) an
insane neurosis, and (2) an epileptic neurosis. Acting as exciting
causes in co-operation with the fundamental neurosis, such
bodily disturbances as irregularities of menstruation will some-
times occasion an attack of the derangement. A woman who
was in the deepest despair because she was afflicted with the
idea that she must kill her children, and frequently ran actively
up and down stairs so as to endeavour to drive away the idea
by producing exhaustion, perfectly recovered on the return of
338 PATHOLOGY OF MIND, [cilap.

the menses, which had stopped. “We have, amongst others,”
says Dagonet, “observed a patient who was seized at each men-
strual period with violent impulses. Under the influence of
this disposition she had killed her three children a short time
before her arrival at Stephansfeld.”1 Other occasions of bodily
disturbance, such as pregnancy, childbirth, the climacteric
change, may act similarly as exciting causes, as also will moral
causes that have rapidly or by degrees produced great nervous
exhaustion and irritability. The degeneration of nerve element
induced by habits of self-abuse, or by great sexual excesses,
sometimes manifests itself in these morbid impulses. A gentle-
man who was acute and energetic in business, witty and agree-
able in society, so that he was the life and soul of every dinner-
party he went to, and was invited everywhere, was neverthe-
less so afflicted with disgusting impulses to indecently expose
himself, to make indecent assaults upon women in the streets,
or to do some other act of obscenity, that his life was made
miserable ; he feared that they might become uncontrollable, since
they sometimes brought him to veritable despair and to suicidal
thoughts. He was of a highly nervous temperament, having a
sister and other members of his family insane, and suffered from
spermatorrhoea and loss of virility. Lallemand relates several
striking cases in which patients suffering from spermatorrhea
were afflicted with painful homicidal and suicidal impulses.
The most desperate instances of homicidal impulses are un-
doubtedly met with in connection with epilepsy. Sometimes an
attack of mania immediately precedes an epileptic fit or a series
of epileptic fits; but more often the mental derangement so
occurring has the form of profound affective disorder with sud-
denly arising impulses to violence, and with or without corre-
sponding sudden hallucinations, but without notable intellectual
derangement. It is a genuine mania sine delirio. A shoemaker
was subject to severe epileptic fits, and was often furious for a
while immediately after them; but in the intervals he was
sensible, amiable, and industrious. One day, while in the
gloomy and morose frame of mind that often goes before and

1 Traité Elémentaire et Pratique des Muladics Mentales, par H. Dagonet,
862.
VIL] THE SYMPTOMATOLOGY OF INSANITY. 339

foretells an attack of epileptic fits, he met the superintendent
of the asylum, to whom he was much attached, and suddenly
stabbed him to the heart. He had not had a fit for three
weeks, but in the night following his homicidal deed he had a
severe fit, and for some time the attacks coutinued to be fre-
quent and severe. In such cases, as indeed there was in this
case, there are often sudden and vivid temporary hallucinations.

Again, the mental disorder which sometimes takes the place
of an epileptic attack, being in fact a masked epilepsy, may
appear as simple impulsive insanity. A peasant, aged twenty-
seven, had suffered from epilepsy since he was eight years old ;
but when he was twenty-five the character of his disease changed,
and instead of epileptic attacks he was seized with an irresistible
impulse to commit murder. He felt the approach of his out-
break sometimes for days beforehand, and then begged to be
restrained in order to prevent acrime. “ When it seizes me,”
he cried, “I must kill some one, were it only a child.” Before
the attack he complained of great weariness; he could not
sleep, felt much depressed, and had slight convulsive movements
of his limbs.?

The connection of homicidal insanity with epilepsy is of much
importance from a medico-legal point of view, and has only
lately received the attention which it deserves; it will not be
amiss, therefore, to give additional examples, and to give them
in the words of those who have related them. The first case is
one mentioned by Dr. Burrows :—

“A very sober, quiet, and industricus man, et. thirty, subject to oc-
casional fits of epilepsy, who had lately been much inclined to religious
devotion, was sitting calmly reading his Bible, when a female neigh-
bour came in to ask for a little milk, He looked wildly at her,
instantly seized a knife, and attacked her and then his wife and
daughter. His aim appeared to be to decapitate them, as he com-
menced with each by cutting on the nape of the neck.” He was
secured, remained maniacal for three days, and then recovered,
“but never had the least recollection of the acts he had committed.

1 De la Folie considéré dans ses Rapports avec les Questions Médico-juci-
ciaires, par OC. C. H. Mare.
340 PATHOLOGY OF MIND. [ciar,

Nine years have since elapsed without a recurrence of the epilepsy,
or disturbance of his mental faculties.” 1

Griesinger gives the following instance of the explosion of the
epileptic aura, not in the usual epileptic seizure, but in terrible
violence :—

“A man who was a brandy drinker lay in a room with his five
children, who were that morning asleep. It came into his mind
that he must then destroy the children ; but how could it be most
conveniently done? He said, ‘It rose into my head like foam; it
went through the chamber like a shot, or like a strong gust of
wind ; a strong odour of marjoram filled the chamber and took away
my senses; my thoughts vanished, so that I sank down.’ He soon
rose again, however, seized an axe, and hacked right and left among
the children, three of whom fell victims to his violence. If nothing
else had been known than the deed and these details furnished
by himself, the epileptic might almost with certainty be recog-
nised; but the medical investigation revealed actual and well-defined
epileptic attack.’’ ?

Dr. Skae relates the instructive case which follows :—

“One of the patients admitted afforded a highly instructive and
interesting example of homicidal and suicidal impulses without any
intellectual derangement or delusions. His case is classed among
those of epileptic mania; for although he never suffered from an
epileptic fit properly so called, he laboured under symptoms which
closely approached to those of an epileptic seizure of the milder form
known as the petit mal. He described a feeling like the aura epi-
leptica, beginning at his toes and rising gradually upwards to his
chest, producing a sense of faintness and constriction, and then
going up to his head, and giving rise to a momentary loss of con-
sciousness. This aura was accompanied by an involuntary jerking
—first of the legs, then of the arms. It was at the times when he
suffered from these attacks that he felt impelled to commit some act
of violence to others or to himself. On one occasion he attempted
to commit suicide by throwing himself into the water; more

1 Commentaries on Insanity, p. 156. The same author mentions another
case in which an attack of epileptic insanity marked by mischievous ten-
dencies was followed by an attack in which murderous tendencies were
displayed.

* Introductory Lecture, Journal of Mental Science, 1866.
v1.J THE SYMPTOMATOLOGY OF INSANITY. 341

frequently the impulse was to attack others, and was at one time
accompanied by such impetuous violence that it required the
strength of several men to restrain him. He deplored his malady,
of which he spoke with great intelligence, giving all the details of
his past history and feelings. His attacks, which had been frequent
and severe at about the age of sixteen years, had for a long time
almost disappeared, but had lately recurred at intervals, until it
was found necessary to send him to the asylum. Sleeplessness and
constipation almost invariably preceded his seizures. The state of
the patient was greatly improved by the use of bromide of potas-
sium and other remedies, and, with the exception of one or two
very transient and slight attacks, he has kept well for some months.”
In a subsequent report he tells how the case had undergone an in-
teresting physiological development, “the patient now having almost
daily a vivid spectral hallucination in the form of a newspaper. He
can see it for a short time so distinctly as to be able to read a long
paragraph fromit. He continues to suffer from the awra epileptica
and other symptoms allied to epilepsy.” 4

Trousseau cites several instances out of a number of cases
that he has seen in which the vertigo of epilepsy was followed
by transitory fury, during which violence was done without any
recollection afterwards of what had happened, Indeed he
asserts that “sudden and irresistible impulses are of usual oc-
currence after an attack of petit mal, and pretty frequent after a
regular convulsive fit.” ?

I have already alluded incidentally to the profound. moral or
affective disturbance which oftentimes goés before epileptic con-
vulsions. The patient who at other times is cheerful, amiable,
industrious, and pleased to converse, is now all of a sudden
quite changed in character; he becomes moody, morose, sus-
picious, apprehensive of calamity, leaves off work, and, if
addressed, answers surlily, or not at all, or only with a blow.
His mental atmosphere is charged with sullen, gloomy feeling,
which is discharged (a) by the convulsions which follow, as a
thundercloud is discharged by the thunderstorm, and after their

1 Report of the Edinburgh Asylum, 1866.
2 Lectures on Clinical Medicine, By A. Trousscau.
B42 PATHOLOGY OF MIND. [cuaP

effects have passed off he returns to his natural state of amia-
bility. But in some cases there shall be no convulsions: instead
of them (0) a violent mania ensues—an ideational in lieu of a
motor discharge; and in a few other cases (c) a convulsive im-
pulse to violence is the channel of discharge, which may then
be as uncontrollable as the convulsions or the mania that are
the two other modes of discharge. Let this also be noted well
—that not only may epileptic insanity appear as homicidal
impulse, but that in this form it may go before, take the place
of, or follow the usual convulsions.

Because the deep perversion of the whole manner of Jecling
which commonly exists in these cases has been overlooked,
attention being fixed exclusively on the morbid act, a great re-
pugnance has been excited in the public mind to admit what
seemed to be the dangerous theory of instinctive insanity. The
word “ instinctive,” again, was not well chosen, since it naturally
seemed absurd to imply that there is in man an instinct to
commit homicide or suicide. Moreover, it is quite evident in
some cases of impulsive insanity that the sufferer has the idea
that he must kill some one; the idea starts up involuntarily
in a mind whose affective autre is profoundly deranged, and
becomes convulsive; he is conscious of the horrible nature of
it, struggles to escape from it, and is miserable with the fear
that it may at any moment prove tco strong for his will, and
hurry him into a deed which he dreads, yet cannot help dwell.
ing upon. He never feels sure of himself. So desperate some-
times is the fear of yielding to the morbid impulse, so intense
the horror of doing so, and so extreme the mental agony, that a
mother, afflicted with the impulse to kill her child, has killed
herself to prevent a worse consummation. In most cases the
patient succeeds in controlling the morbid idea by calling up
other ideas to counteract it, or warns his probable victim t»
cet out of the way, or gets out of his way himself, or begs

earnestly to be put under some restraint; but it may happen’

at last that owing to perliaps a further deterioration of nervous
element through bodily disturbance the morbid idea acquires a
fatal predominance; the tension of it becomes excessive; it is
no longer an idea, the relations of which he can contemplate,

4
5

.

A
vu] THE SYMPTOMATOLOGY OF INSANITY. 343

but a violent and exclusive impulse, in which the whole mind is
engulphed, and which utters itself irresistibly in action.

That a person so afflicted can, and sometimes does, resist the
diseased idea or impulse, causes many to think, and some to

argue, that it might always be successfully resisted. The word

raresistitle offends much their theoretical notions of the power
and dignity of human will. The truth is that it is a simple
question of the degree of morbid degeneration of nerve element
whether the idea shall remain in consciousness and be under
subjection, or become uncontrollable and realise its energy in
action; and bodily conditions will very much affect that ques-
tion. By an act of the will a person may prevent involuntary
movement of his limbs when the soles of his feet are tickled,
but the strongest will cannot prevent spasmodic movements
of the limbs on tickling the fect if the excitability of the spinal
cord be increased by strychnia or by disease. The experience
of the desperate homicidal impulse of epilepsy is proof enough
that the impulse is sometimes beyond all doubt uncontrollable.
It is impossible that true conceptions of mental disease can be
acquired until men cease to regard its phenomena entirely from
a psychological point of view, and consent to study them by aid
of the established principles of physiology and pathology. So
long as they judge them by the revelations of sane self-conscious-
ness, they do-what is not a whit less absurd than it would be to
base conclusions concerning convulsions on the recognised power
of the will over voluntary movements.

The behaviour of a person who, carried away by an uncon-
trolled impulse, has done a homicide, after the convulsive par-
oxysm is over, may show something like a positive sense of
relief. He is perhaps a little dazed and stupefied at first before
he comes to himself and realises what he has done, but when
he has come to himself he does not evince the horror and re-
morse which might, be expected ; the reasons whereof I conceive
to be,—first, because his previous mental agony was so great
that his present state is a relief by comparison, He would will-
ingly have been hanged twice over, if that were possible, to
escape from his horrible impulse before he yielded to it: how,
** then, can he fear or much care what may happen to him after
344 PATHOLOGY OF MIND. (cmap.

he has done so? Secondly, because he feels that he was truly
possessed by a demoniacal impulse which was not himself, and
that what he did in consequence, being done under superior
compulsion, or, as it were, in a dream, was not really his deed
any more than had it been actually done in a dream or by an
evil spirit that had seized upon his will. In other cases there
is plainly no more than a vague, hazy, dreamlike consciousness
of what has been done; while in a few cases there would seem
to be a complete forgetfulness of the actual paroxysm. I am
unable to say from personal knowledge whether such a patient
would try to hide his deed or to escape from the consequences
of it when he came to realise its character; he might or might
not; but in any case probably his course would be decided more
by his own character than by the character of his disease.
Before passing from the consideration of the different varieties
of impulsive insanity I ought to mention that there are some-
times manifested other morbid impulses which have special names
given to them—for example, an impulse to set fire to property
or a so-called Pyromania, an impulse to steal or a Kleptomania, a
frantic erotic impulse or an Lrotomania, and the like. It willbe
found, I think, that the impulses to steal and to set fire to
property usually go along with some degree of mental imbe-
cility, the persons manifesting them being at any rate true moral
imbeciles; but they are sometimes manifested by young women
of average understanding at or after puberty, when they are
undergoing the mental revolution’ which accompanies sexual
evolution. From time to time one hears of cases in which such
women have set fire to their masters’ houses in a fit of ill-
humour, or have strangled or poisoned their masters’ children
rather than be at the trouble to take care of them, or have done
some other act out of all proportion to its motive, or without any
other motive than the reckless relief of a painful mood. In the
same way a youth sets fire to a haystack, not out of revenge,
but merely to gratify a destructive impulse springing from a
present morbid mood, or makes a criminal assault upon a woman,
or commits suicide without apparent motive. Careful inquiry
in these cases will commonly disclose either a measure of actual
imbecility or the existence of a decided predisposition to mental
vu.) THE SYMPTOMATOLOGY OF INSANITY. 345

derangement. The cases occupy the borderland between crime
and insanity: whether they are unsound enough to be treated
as insane and irresponsible, or sound enough to be treated as
sane and criminal, must be settled, not by any general rule, but
by the particular consideration of each case on its merits.

(b) Moral Insanity.—Here the moral perversion is evident’
and cannot be overlooked, while the acts of the individual, being *
less convulsive in character, answer more exactly to the morbid
feelings and desires than they seem to do in impulsive insanity.
They look so witting and wilful that it is difficult to eschew the
suspicion that moral insanity is anything more than vice. Much
as the assumption of it as a disease has been reprobated, proper
weight must be given to the fact that all the eminent men who
have had practical knowledge of insanity, and whose authority
we habitually accept, are entirely agreed as to the existence of
a form of mental disorder in which, without hallucination, illu-
sion, or delusion, the symptoms are exhibited in a perverted
state of those mental faculties that are usually called the active
and moral powers, or included under feeling and volition—that
is to say, the feelings, affections, propensities, temper, habits, and
conduct. As, however, feeling lies deeper in the mind than
thought, the understanding is not entirely unaffected, albeit
there may certainly be no positive delusion: the whole manner
of thinking and reasoning concerning self is tainted by the
morbid self-feeling, The person may judge correctly of the
relations of external objects and events, and may reason very
acutely with regard to them; but no sooner is self deeply con-
cerned, his real nature touched to the quick, than he displays in
reasoning the vicious influence of his morbid feelings and an
answering perversion of judgment. He sees everything from
the standpoint of the narrowest selfishness, gratifies each vicious
desire of the moment without the least sense of shame or thought
of prudence, extenuates and excuses or justifies his bad conduct
as if others and not he were to blame for it, and lies most shame-
lessly and plausibly ; leading in the end a life of suffering and
shame which a low prudential self-regard, were he capable of it,
would make him perceive to be folly. He cannot truly realise
his relations as an element in the social system, and his whole
316 PATHOLOGY OF MIND. [cuar.

manner of thought, feeling, and conduct in regard to himself is
more or less false. The social fabric is held together by moral
laws; but we have here a being who, by reason of his insensi-
bility to them, is practically outlawed from the social domain.

This disordered or literally distempered condition of mind often-
times precedes an outbreak of unquestioned insanity in a more
or less marked form ; in other cases it is a condition that per-
sists for a time after the intellectual derangement of an attack
of madness has disappeared. The disappearance of hallucination
or delusion is a sure sign of convalescence only when the patients
return at the same time to their natural and healthy feelings.

‘Some patients never do, although they seem in other respects

quite sane: when that is the case, the experienced physician
fears that the persistent bad feeling forebodes a recurrence of
the malady.

When moral insanity exists by itself, and constitutes the disease,
as it may do, it would be wrong to assume that a particular vicious
act or crime, or even a series of vicious acts, proved its exist-
ence. No competent physician ever does that, although lawyers
and the general public are apt to think he does, and to charge
him therefore with confounding vice with madness. In the pre-
vious history of the patient there will be evidence of a sufficient
cause of disease having been followed by an entire change of
manner, feeling, and acting; the vicious act or crime will be
traceable through a chain of symptoms to disease as cause, as
the acts of the sane man are traced to or deduced from his
desires and motives. ‘“ There is often,” says Dr. Prichard, who
first called special attention to this form of mental derangement,
“a strong hereditary tendency to insanity; the individual has
previously suffered from an attack of madness of a decided
character; there has been some great moral shock, as a loss of
fortune; or there has been some severe physical shock, as an
attack of paralysis or epilepsy, or some febrile or inflanmatory
disorder, which has produced a perceptible change in the habit-
ual state of the constitution. In all these cases there has been
an alteration in the temper and habits.” +

1A Treatise on Insanity and other Disorders of the Mind. By J. ©
Prichard, M.D.
vir] THE SYMPTOMATOLOGY OF INSANITY. 347

When called upon to give an opinion touching a particular
case of suspected moral insanity, it is well to bear in mind that
the individual is a social element, and to take account there-
fore of his social relations. That which would not be offensive
or unnatural in a person belonging to the lowest strata of society
—certainly nowise inconsistent with his relations there—would
be most offensive and unnatural in one holding a good position
in society, and entirely inconsistent with his relations in it:
words which, used in the latter case, would betoken grave mental
disorder, may be familiar terms of address amongst the lowest
classes. There would be nothing strange in an Irish labourer
going about the streets without his coat, or in his using coarse
language to his wife; but if a grave and reverend bishop were to
walk about the town in his shirt-sleeves and to use to his wife
such language as the labourer uses habitually, there would be
good cause to suspect that his mind was deranged. Between
individuals, as elements in the social organism, there is in this
regard a difference not unlike.that which there is betw7en the
different kinds of organic elements in the bodily organism, which
have more complex and refined relations as they rise in histo-
logical dignity. As it is chiefly in the degeneration of the social
sentiments that the symptoms of moral insanity manifest them-
selves, it is plain that the most typical forms of the disease can
be met with only in those persons who have had some social
cultivation.

The following cases, which are samples of many others that
have come under my observation, may serve to illustrate the
character of this sort of mental derangement :—

A single lady, aged thirty-eight, was the only child of indul-
gent parents who were ina good social position and wealthy.
Her father was harmlessly insane; nearly imbecile, and it was
necessary, after every means of controlling her at home had been
tried in vain, to send her to an asylum. She was given over
to drink when she could get spirituous liquors of any sort, and
would bribe the servants or any one else she could bribe to buy
them for her; nor was she capable of any self-restraint in other
regards, making no scruple to indulge whatever passion she
found means of indulging. When excited she was extremely
348 PATHOLOGY OF MIND. (cuap,

violent in conduct, and on more than one occasion threatened
her father’s life with a pistol. When she could not get spirits,
she was abusive, mischievous, quarrelsome, full of complaints
of the injustice done to her, and truly intolerable. She had not
the least appreciation of truth, saying whatever she thought
would answer her purpose best at the moment; albeit the lie
was gross and palpable at the time, or must plainly be detected
instantly. In the asylum she was the cause of endless disturb-
ances; she made continual complaints against the attendants,
ingeniously perverting and exaggerating real facts so as to make
of them monstrous iniquities, did the most mischievous things
for the sole purpose of giving trouble and annoyance to the ser-
vants, and was delighted with her success ; sometimes she would
refuse to take her food, and at the same time would bribe the
attendants to secrete it for her so that she might take it with-
out any one else knowing. Removed from the asylum, partly
in consequence of her manifold complaints, she was tried at
home unsuccessfully, then sent back to the asylum, where she
went on just as before, was removed again after a time, sent
to a different asylum, taken away from that, and sent again to
another ; indeed her wanderings were many, and she was the
hopeless patient of every doctor who had the misfortune to
have anything to do with her.

Another single lady, et. forty-five, was a cousin of the above
. patient, and also of good social position. Her appearance was
anything but attractive; she was withered, sallow, blear-eyed,
with an eminently unsteady and untrustworthy eye. So improper
and immoral was her conduct that she was obliged to live apart
from her family in lodgings; for she seemed incapable in certain
regards of any control over her propensities. Whenever she was
able, she left her lodgings to spend days together at a brothel
with a common fellow, whom she supplied with money, frequently
pawning her clothes for that purpose. When at home, she
generally lay in bed for most of the day. No appeal was of any
avail to induce her to alter her mode of life. She was prone
to burn little articles, impulsively throwing them into the fire,
saying that she could not help it, and then cutting and pricking
her own flesh by way of penance. Now and then she would all
vi1.] THE SYMPTOMATOLOGY OF INSANITY. 349

of a sudden pirouette on one leg, and throw her arms about;
and, with like sudden impulsiveness, would not unfrequently
break a pane of glass. When reasoned or remonstrated with
about her foolish tricks, she professed to feel them to be very
absurd, expressed great regret, and talked with exceeding plausi-
bility about them, as though she was not responsible for them,
but was an angel in difficulties which she could not overcome.
It was of no use whatever speaking earnestly with her, since she
admitted her folly to a greater extent than accusation painted it,
and spoke of it with the resigned air of an innocent victim.
Her habits were unwomanly and often offensive. The more
sensible of the other patients amongst whom she was, used to
get very angry with her, because they thought that she could
behave better if she would. “One can bear with Miss ;
because, poor girl, she does not know what she does, and cannot
help it; but Miss knows quite well what she is about, and
I am quite sure she can help it if she likes,” was the style of
complaint made against her. There could be no doubt that
she did know perfectly well what she was about, but her un-
conscivus vicious nature, ever prompting, surprised and over-
powered conscious reflection, which was only occasional.

It is quite certain that these women, so lost to all sense of
the obligations and responsibilities of their position, could not
restrain their immoral extravagances and vicious acts for any
length of time; punishment had no effect, except in so faras .
it was a restraint for the time being. They knew quite well the
difference between right and wrong, but no motive could be
roused in their minds to induce them to pursue the right and
eschew the wrong; their conduct revealed the tyranny of a
vicious organisation, whose natural affinities were evilwards;
the world’s wrong was their right. Naturally, therefore, such
patients feel no shame, regret, nor remorse for their conduct,
however flagrantly unbecoming and immoral it may be, never
think that they are to blame, and consider themselves ill-treated
by their relatives when they are interfered with. They cannot
be fitted for social intercourse. Friends may remonstrate, en-
treat, and blame, and punishment may be allowed to take its
course, but in the end both friends and all who know them

 

 
350 PATHOLOGY OF MIND. [cHar.

recognise the hopelessness of improvement, and acknowledge
that they must be placed under control. The moral agency
which shall turn them from the errors of their ways has not
been discovered ; in order to do that it would be necessary that
they should be literally born again and made new creatures.!

It is where hereditary taint exists that we meet with the most
striking examples of this kind of derangement. There is much
aversion to admit that an extreme hereditary taint may be as
certain a cause of defect or disease of mind as an actual injury
of the head; and yet it is the fact. It signifies some unknown
defect of nervous constitution declaring itself in a disposition to
irregularities in the social relations ; the acquired infirmity of
the parent having become the natural infirmity of the offspring,
as the acquired habit of the parent animal observably becomes
sometimes the instinct of the offspring. If a person who has
the nerve tracts of moral function naturally but little developed
in his brain does nothing to strengthen them by moral exercise,
but leads a life in which they are not brought into habitual
action, they undergo further atrophy, and his children or his
children’s children are likely to be born with them in such a
state of defect that they cannot be developed by exercise, are
incapable of function, mark a moral imbecility. I do not say
that a deficiency or an absence of moral sensibility will be found
in the parents in all cases ; sometimes it is hard to say why the
_ children should have been so afflicted; but as a rule we shall
note some extremely suspicious strain or other peculiarity of
disposition in one or both of the parents, if we do not find
actual insanity. One must look to the fact that the parent who
fosters eccentricities of feeling, thought, or conduct until they
grow out of healthy relations with other mental functions, is
likely enough to breed a child in which the mental equilibrium
is unstable in some way—an instability not necessarily showing
itself simply in an exaggerated reproduction of the parental
peculiarities, however, but perhaps in some other form of de-
generacy. Hence comes the impulsive or instinctive character

1 See also the case of Christiana Edmunds, who distributed poisoned
sweetmeats to the children of Brighton, as related in Responsibility in
Mental Disease, and was tried for murder,
yit.] TILE SYMPTOMATOLOGY OF INSANITY. 351

of the phenomena of hereditary insanity, the conduct being
frequently startling, regardless of social usages, and seemingly
quite motiveless. “Appeal calmly to his consciousness, the indi-
vidual may reason with great intelligence, and secm nowise
deranged ; but if he be left to his own ; davies, or placed under
conditions of excitement, his unconscious life appears to get the
mastery, and to drive him to immoral, extravagant, and danger-
ous acts. He perpetrates some singular act of eccentricity
because all the world will be astonished at it, or even commits
a murder for the sole purpose of being hanged. It is not right
for a sound mind to fathom with its line the mad motives which
spring up in a madman’s mind, nor is it just to measure his
actions by a standard based upon the results of an examination
of sane self-consciousness; only long experience and careful
study of actual cases of mental disease will suffice to give an
adequate notion of what a madman really is.

When hereditary taint is not detectable in a case of so-called
moral insanity, it is necessary to traverse carefully the whole
physical and mental life of the patient, by exact research into
his previous history and the closest examination of his present
state. Let it. be ascertained whether there has been any pre-
vious attack of insanity; since it sometimes happens that after
oue or two attacks of genuine melancholia, from which recovery
has taken place, the patient suffers from true moral insanity,
which may pass at last into intellectual disorder and dementia.
The extremest example of moral insanity which I ever saw was
in an old man aged sixty-nine who had been in one asylum or
another for the last fifteen years of his life. He had no little
intellectual power, could compose well, write tolerable poetry
with much fluency, and was an excellent keeper of accounts
There was no delusion of any kind, and yet he was the most
hopeless and trying of mortals to deal with. Morally he was
utterly depraved; he would steal and hide whatever he could,
and several times made his escape from the asylum with mar-
vellous ingenuity. He then pawned what he had stolen, and
begged and lied with such plausibility that he deceived many
people, until he finally got into the hands of the police, or was
discovered in a most wretched and dirty state in the company

16
352 PATHOLOGY OF MIND. (car.

of the lowest mortals in the lowest part of the town. In the
earlier part of his insane career, which began when he was
forty-eight years old, he was several times in prison for stealing.
In the asylum he was a most troublesome patient. He could
make excellent suggestions and write out admirable rules for
its management, and was very acute in detecting any negligence
or abuse on the part of the attendants, when they displeased
him; but he was always on the watch himself to evade the
regulations of the house, and, when detected, he was most
abusive, foul, and blasphemous in his language. He was some-
thing of an artist, and delighted to draw obscene pictures of
naked men and women, and to exhibit them to other patients.
He could not be trusted with female patients, for he would have
attempted to take indecent liberties with the most demented
creature. In short, he had no moral sense whatever, while all the
fault that could be found with his very acute intellect was that.
it was entirely engaged in the service of his depravity. It might,
no doubt, be argued that he was a desperately wicked person,
and that his proper place was the prison. But the prison had
been tried many times, and tried unsuccessfully. And there
was another reason why prison-discipline could not rightly be
permitted to supersede asylum-treatment. At’ long intervals,
sometimes of two years, this patient became profoundly melan-
cholic for two or three months, refused to take food, and was as
plainly insane as any patient in the asylum. It was in an attack
of this sort also that his disease first began.

There is, in fact, a class of cases in which a state of deep
genuine melancholia alternates with a state of mental excitement.
the symptoms of which are principally those of moral insanity.
In some cases the intellect may so far share in the derangement.
as to enable us to call the excited phase true mania, but in
others it is so little deranged that we certainly cannot speak of
anything more than moral mania. The patient displays an
excitement which is very like that of intoxication, and an ex-
traordinary sense of buoyant happiness: though modest and
reserved naturally, talks incessantly and addresses familiarly
persons whom he would not have thought of addressing when in
his natural state; prudent and careful in business, he now spends
VIL] THE SYMPTOMATOLOGY OF INSANITY. 353

money recklessly and enters into unaccustomed speculations ; of
grave and sober demeanour, he disregards conventional proprieties
and even moral restraints; he listens to no advice nor remon-
strance, and will not brook the least interference; his whole
character is changed and his conduct entirely at variance with
the habits of his natural life. Neither delusion nor incoherence
goes along with this excitement and moral perversion; all the
disorder of understanding which there is being shown in the
incapacity of the patient to understand how unlike himself he
is in his feelings and conduct. After lasting perhaps for months
the state of excitement passes away and is followed by deep and
genuine melancholy. In one case of the kind that I saw the
change from the one state to the other used to take place
suddenly and completely.

In other cases of moral alienation there has been more or
less congenital moral defect or moral imbecility from the first ;
maniacal exacerbations of positive moral insanity occurring per-
haps at puberty, perhaps at the menstrual periods, perhaps after
severe disappointment. Again, moral insanity may come on alter
acute fevers, after injury to the head, after some form of organic
brain disease; in some cases it is the first stage of mental de-
generation consequent on self-abuse, lasting as such for some time
before the intellect shows any signs of being directly damaged ;
now and then it occurs in consequence of a severe moral shock
as the forerunner of a genuine attack of marked insanity; and
it not unfrequently precedes general paralysis. But the disease
with which it is most commonly found in conjunction is epi-
lepsy. I have more than once adverted to the extreme change
in moral character in some epileptics which precedes and fore-
bodes the convulsions, when they become sullen, moody, sus-
picious, morosely melancholic; in others, however, the moral
change is of an opposite and elated kind—they are animated,
loquacious, active, borne up with an exalted feeling of physical
and moral well-being, and eager to undertake anything. I may
go on to point out that attacks of moral alienation, of variable
duration and of periodical recurrence, sometimes come on
regularly for months, and seem quite inexplicable until the
characteristic convulsions make their appearance, proving them
354 PATHOLOGY OF MIND. [ctar.

to have been a sort of abortive or suppressed epilepsy; or
again, the epileptic convulsions shall cease, and in place of them
attacks of moral insanity with more or less maniacal excite-
ment occur. There can be no question in the minds of those
who have studied mental diseases that certain unaccountable
criminals belong to the class of epileptics.?

Thus much concerning the group of symptoms which I have
made into a second variety of affective insanity—Jforal Insanity.
When we look into its antecedent conditions we perceive them
to be such as are known to be hurtful to the brain or to mark
disorder of it: the destruction of the moral sentiment is an
early effect of such deterioration of the mental organisation, as
any one may recognise, if he will, in the demoralisation which
alcoholic excesses and the excessive use of opium notably pro-
duce. The facts being what they are, it is not a little surprising
that people should go on maintaining that the moral sense is
independent of physical organisation. All observation shows that
it is as essentially dependent upon a physical basis as is the
humblest mental function of man or animal. If the evidence
drawn from the nature and causation of moral alienation were
insufficient, the fact that it is often the immediate forerunner of
the severest mental disease might suffice to teach its true patho-
logical interpretation. When, therefore, a person in good social
position, possessed of the feelings that belong to a certain social
state, and hitherto without reproach in all the relations of life,
does, after a cause known by experience to be capable of pro-
ducing every kind of insanity, suddenly undergo a great change
of character, lose all good feelings, and from being truthful,
temperate and chaste, become a shameless liar, profligate, in-
temperate, and perhaps a thief, then it will certainly be not an
act of strained charity, but an act of bare justice, to suspect the
effects of disease. At any rate it behoves us not to be misled
in our judgment by the evident existence in such a patient of a
full knowledge of the nature of his acts—of a consciousness, in
fact, of right and wrong; but to remember that disease may

? Morel, D’une Forme de Délire suite Pune Surexcitation nerveuse se rat-
tachant &@ une Vuriété non encore déerit W@Epilepsie: 1860. J. Falret, De
U Etat Mentale a’ Epileptiques.
vi] THE SYMPTOMATOLOGY OF INSANITY. 355

weaken or abolish moral feeling and the power of volition with.
out impairing consciousness. Fortified by this just principle, we
shall be in better case to interpret rightly tle facts than when
biassed or blinded by the opposite erroneous principle.

T pass now from the consideration of the symptoms of affective
derangement, which exist alone in some cases and in so many
other cases go before distinct intellectual derangement. By con-
sidering them apart, as I have done, before going on to treat of
the varieties of intellectual alienation, we get a truer conception
of the evolution of insanity, and therefore a more natural history
of morbid psychology, than if we were to proceed otherwise.
Moreover, there is the practical gain of bringing into prominent
relief grave phases of mental derangement which oftentimes fail
to obtain due attention, albeit they have certainly not been
overlooked ; for the Mania sine delirio of Pinel, the Monomanie
raisonnante ou sans délire of Esquirol, the Monomanie affective of
the sanre author, and the Moral Insanity of Prichard are different
names that have been used to denote them. From a social point
of view these morbid states are more alarming than positive
intellectual derangement; for they mark a condition in which,
dangerous hallucinations and impulses are apt to occur suddenly,
and the tendency of which is, feeling-like, to express itself in
dceds rather than in words.
CHAPTER VIIL
THE SYMPTOMATOLOGY OF INSANITY—(continucd),
Melancholia,

WE believe not, as did the ancients when they gave it its name,
that melancholia is caused by black bile (uéXas yoAx), but there
is no doubt that the depression of mind which oftentimes goes
before a genuine attack of the malady is very like that mood of
gloom which a sluggish, ill-secreting liver occasions; when,
without any change in external circumstances, the only change
being in him, the person feels irritable, gloomy, apprehensive,
suspicious. The antecedent symptoms of melancholia may
indeed be summed up concisely as lowness of spirits, groundless
forebodings of coming evil, and brooding abstraction. There is
much mental suffering during this preliminary stage: the in-
dividual’s self-confidence in thoroughly shaken, and he is ina
distressing state of exaggerated susceptibility; apprehensive
vaguely of some calamity being about to happen to him, and
fearful of hearing or reading of any painful incident because it
makes a terrible impression upon his mind and he dreads lest
the like may happen to him; cannot go near a railway engine
or a precipice or over a bridge lest the idea of putting an “end
to himself should take possession of him and overpower him;
if he reads or hears mention of a disease is in instant distress
for fear he shall have it; is afraid of doing something trivial
and innocent lest he should be doing wrong, conscious all the
while how foolish his fears are, which, nevertheless, he cannot
shake off; imagines that preachers whom he hears are preaching
en, VII] THE SYMPTOMATOLOGY OF INSANITY. 357

at him, and books that he reads write at him; thinks of some
mistake or omission, real or fancied, that he has made in his
business, magnifies it mightily, and torments himself continually
with remorseful reflections thereupon. He has lost all estimate
of proportion, and his mind is fascinated by the very horror or
anguish which a painful idea, holding it in its grasp, occasions
him; not because there is ground for the exaggerated idea, but
simply because it is of a painful character. Before he fell into
this “nervous” condition, as he calls it, he has had bad sleep
and bad dreams, and has probably suffered some slow drain upon
his vital energies, physical or mental,—from worries in business,
from pecuniary anxieties, from domestic troubles, frora exhaus-
tion by illness or by excesses, and the like ; but because of the
sadness which is the main feature of his condition there is
always a disposition on the part of friends to look out for grief
as a cause, and when no cause of grief is discovered to suspect
or to assume a secret cause thereof.

This is the common mode of onset of melancholia, but in
some instances it has come on very suddenly, in consequence of
a severe mental shock, such as the abrupt announcement of the
sudden death of one who was very near and dear: the person
has been thrown instantly into a state of apathetic stupor and
despair,—a sort of tonic spasm of mental anguish with paralysis
of all other mental functions. JI remember the case of a gentle-
man’s coachman who fell into that state of apathetic melancholy
which is known as melancholia cum stwpore, or melancholia
attonita, on making the startling discovery of his wife in the
act of adultery with his master. More often, however, the
natural grief which a sad bereavement occasions passes by slow
degrees into a morbid depression, in which the person accuses
himself or herself of imaginary sins of omission or commission,
broods over them continually, is full of self-reproach, abandons
occupations and interests, and is at last quite indifferent to
family, to affairs, and to all other urgent present claims. Before
the profound change of feeling took place the patient has some-
times been distressed hy a strange giddiness or numbness or other
indescribable sensation in the head, or has perhaps felt as if
something had suddenly cracked there.
358 PATHOLOGY OF MIND. [cHap,

At the beginning of melancholia in most cases, and through-
out the disease in some cases, there is no definite delusion ;
the person is simply morbidly melancholic, suffering from
meluncholia simplex or melancholia sine delirio, as this condition
of affective disorder has been called. But he is profoundly
changed notwithstanding: his feelings regarding persons and
events are strangely perverted, so that impressions which would
naturally be agreeable are painful, and the attentions of his
relatives occasion irritation or actual distress; he has no interest
in his family or in his affairs, feels as if a cloud had settied
upon him, or a veil had been let down between him and them,
since things seem not real, as formerly, and it appears to him
that he moves about in a sort of dream ; he shuns society, which
is distressing to him, cares not to do any work, neglects his
personal appearance, sinks into inactive brooding, and ends,
perhaps, if permitted, by lying in bed all day. All this while
he is quite conscious of his unnatural state, and perhaps bursts
into tears as he bewails it; he torments himself with reproaches
because he has lost all natural affection; he would give any-
thing in the world to be himself again, and cannot conceive why
he is so miscrably changed from what he was. After a time,
commonly by degrees, but it may be suddenly, an overwhelming
idea takes form in his mind that he is ruined in business, or that
he has been guilty of some crime, or that he has committed
“the unpardonable sin,” or that he is a burden upon his family
and ought to rid them of it by suicide; the vast and vague
feeling of profound misery has taken form as a concrete idea of
wrong-doing—has condensed, as it were, into a definite delusion
which is the fitting expression of it. Sometimes the horror of
the condition is aggravated by the sudden and startling way in
which the delusion has arisen and taken hold of the mind;
instead of having been gradually evolved, as it usually is,
coming and going several times, so as to be divested of some of
its horrors by familiarity before it is mature, it has started into
activity instantly and unexpectedly—perhaps on the person’s
awaking out of sleep—entirely overwhelming reason and produc-
ing an alarming feeling of utter helplessness. I have known a
suicidal and a homicidal idea to surprise and take captive the
Vili.| THE SYMPTOMATOLOGY OF INSANITY. 359

mind in this sudden way and to mount almost instantly to the
convulsive energy of a scarcely controllable impulse ; the very
suddenness and vividness of the revolting idea exciting such a
paralysing horror as helped to fix it in the mind.

The apparently spontaneous origin of the morbid idea is
another reason why it is accepted so unreservedly by the patient,
who feels himself unable to give any account of it, or to offer
any resistance to it. Had it come by the accustomed paths of
association its origin might have been partially traced, its rela-
tions noted, its validity weighed by comparison and reflection ;
- but coming, as it did, unexpectedly, fully formed, independently,
without any discoverable relations to external impressions or
to other ideas, it could not be tested by comparison, and might
well seem to be the suggestion of an evil spirit, or otherwise of
supernatural origin. Certainly it cannot be wondered at that a
person should lose all self-confidence and be paralysed by a
feeling of extraordinary helplessness who finds his mind playing
him such alarming tricks. But it is not to be supposed that the
idea has really arisen, or that the ideas of insanity ever arise,
spontaneously ; we may not know the secret chords by which
they have been made to vibrate, but we are none the less sure
that they have had their causes and their laws of morbid growth.
As in dreams, other causes than normal impressions and habitual
associations must be sought. There is, first, a possible organic
suggestion coming from a particular organ of the body in con-
sequence of the special sympathies which the brain has with the
different organs; secondly, there is that constant unconscious
mental operation—more active perhaps when the brain is in an
abnormal state—whereby the revival of latent ideas and feelings
frequently takes place without our being able to give any account
of it; thirdly, impressions from without, which seem so trivial
as to be hardly noticed at the time, may still have their effects
upon the mind, and, when the brain functions are disordered and
overclouded by gloomy feeling, may Le worked up into strange
morbid ideas ; and, lastly, an idea may be excited sympathetically
by another idea to which it has no apparent relation, particularly
in a morbid brain, just as the muscular contraction of a group of
muscles may notably be sympathetically excited sometimes by

\
366 PATHOLOGY OF MIND. ; (car.

the contraction of certain other muscles with which they have
no normal functional connection. Persons whose nerve-centres
are constitutionally unstable and mobile are most likely to have
ideas start suddenly into consciousness in this seemingly sponta-
neous and independent way,

For any of these causes to act with much effect there must
be a basis of disordered nerve element showing itself in that
depression or perversion of the mental tone or mood which,
known as simple melancholia, precedes the formation of the
morbid idea. The common notion that the person is wretched
because of the painful delusion is usually a mistake; the latter
has been precipitated, as it were, out of the vague feeling of un-
speakable misery which is the medium in which its gestation or
incubation has taken place ; and it takes different forms according
to the person’s culture and habits of thought, and according to
the prevailing social and religious opinions of the time. Among
barbarous nations now, as was the case among European nations
in the middle ages, witchcraft is laid hold of by the distempered
mind as the cause of its woes; at the present day in European
countries the fear of being pursued by the police for some crime
has dispossessed and superseded the delusion of persecution by
witchcraft. The conviction of having committed the unpardon-
able sin, and of having incurred in consequence the doom of
eternal damnation, has been a common delusion of melancholics
since the disciples of Christ introduced that doctrine to man-
kind; but an ancient Greek who was suffering from the same
form of disease could not have had that delusion: he would
have imagined himself, Orestes-like, to be pursued by the Furies.
In some instances it is plain that the delusion which the patient
believes to be the cause of his gloom is ludicrously dispropor-
tionate to the extreme mental anguish evinced, and quite in-
adequate to explain it: a trivial act is thought to have been a
sin or a crime charged with consequences of endless woe. One
person who was under my care asserted that his great affliction
was owing to his having drunk a glass of beer which he ought
not to have done, and another was lost: for ever because on one
occasion he had muttered a curse when he ought to have uttered
a prayer. With him who believes that his soul is lost, it is not
VIL. TUE SYMPTOMATOLOGY OF INSANITY. 361

the delusion which is the fundamental evil and occasions his
despair, but the affective derangement out of which the con-
gruous delusion grows; he thinks he has got his adequate
explanation, whereas he has -got no definite idea in his mind
at all, but is content with a form of words, or at most with a
vague notion of terrible sin and terrible punishment, without
ever attempting to apprehend sincerely and clearly what he
thinks he believes. The finite cannot possibly form a definite
idea of the infinite or eternal, which so-called idea must always
be really a negation or imbecility of thought; and the insane
delusion of eternal damnation is no more than the vague and
futile attempt to interpret an utterable feeling of misery—a
feeling by which it.is nourished and strengthened, in accordance
with the law that any passion, sane or insane, calls up and
intensifies ideas that are congrucus with it.

Some melancholics are in a state of panic fear without
knowing what they fear, and exhibit an excessive susceptibility
to every kind of impression: whatever is proposed, said, or
done causes acute alarm and apprehension, expressed perhaps
in such repeated exclamations as, “Oh! don’t say that! don’t
do that!” or in actual shrieks of distress; the most trivial
thing, the opening of a window or a door, occasions exaggerated
protestations ; they resist being washed, dressed, and undressed.
and when pressed to eat protest earnestly that it is too dreadful,
and perhaps retch as though they would be sick; they cannot
walk out of the house, and are in despair if forced to do so;
they resist the simple and necessary offices of attention to them
with an energy which would suit more an attack upon their
lives, putting into their resistance a great deal of passionate
self-will Their physiognomy, words, and actions alike betray
the vague and acute apprehension which has taken possession
of them.

It is worthy of note that the mental suffering is oftentimes
actually less when the vast and undefined feeling of dread has
been condensed into a definite delusion. This accords with the
experience of the sane mind, which ever suffers more from
uncertain apprehension and from suspense which paralyses its
energies, than from knowledge of a ceitain evil to which it can
362 PATHOLOGY OF MIND. - [cHar.

begin forth with to make some sort of mental accommodation.
The murderer notably sleeps better after he has been sentenced
to death than he did before his fate was decided. In like
manner doubts and uncertainties about coming to a resolution
on some point often cause more mental worry and distress than
the execution of the resolution come to, however painful it may
he; for the very act of resolving imparts a comparative calmness
and repose to the mind by systematising its energies. When
the vague morbid feeling of the melancholic has been embodied
in a fixed delusion of some kind, he is not only less miserable,
but, as a rule, he is more easy and safe to deal with than when
his whole moral atmosphere is disturbed ; for it is in this latter
condition that painful ideas are especially apt to spring up in
the mind, without apparent associations and in a quite unfore-
seen manner, and to become dangerous impulses of a suicidal or
homicidal character. Superficial observers comfort themselves
with the notion that the patieut is not mad because he has
no delusion, whereas he is more dangerously mad sometimes
than if he had the most extravagant delusions, since his mad-
ness is likely to show itself in deeds rather than in thoughts,

The following cases may serve as ordinary illustrations of
melancholia :-—

A gentleman, et. thirty-six, married, had always been of an
extremely religious character and of exemplary behaviour.
After he had been married for about a year his illness began
with great depression and with the involuntary appearance in
his mind of blasphemous ideas in spite of all his efforts to repel
them; he was much distressed by this state of things, his gloom
Increased more and more, and at last he coneluded that “he
had done it,”’—namely, committed the unpardonable sin. Here
were, first, a morbid affection of nerve element revealed in the
emotional depression, then au automatic and spasmodic activity
of certain ideational tracts manifest in the involuntary and
irrepressible ideas that arose, and finally the concentration or
systematisation of the morbid action into a definite delusion.
The patient was further very hypochondriacal, and fearful that
he should die soon; but, although his heart’s action was feeble,
and his pulse remarkably slow, there was no evidence of organic
viii] TUE SYMPTOMATOLOGY OF INSANITY. 363

disease. The feebieness of cardiac action was duc to the de-
pressing effects of the morbid state of the nerve centres upon
the organic functions, all which shared more or less in the
prostration. Apart from his delusions his reasoning powers
were nowise affected ; he was fully alive to all business relations,
and could converse intelligently and even cheerfully on indif-
ferent matters. But the moment his attention was no longer
diverted from his own suffering and otherwise engaged, the
morbid idea returned in all its force and engrossed conscious-
ness; his countenance became overcast, and he—just now so
cheerful—presented the characteristic dejected appearance of
profound melancholy. He lived, as it were, two separate lives
—at one moment that of a sound, reasonable being, and the
next moment that of a morbid automatic being; he was quite
aware of his affliction, and could reason about it as a man
might reason about @ peculiarity of his character or a particular
conformation of his body, though he could not be persuaded of
its true morbid nature; so soon as the train of mental ideas and
feelings excited by external impressions was past, the morbid
train of thought recurred. He was made so miserable by his
sufferings that he more than once attempted suicide. Herein
we have an example of the error of the statement that the
monomaniac reasons correctly from false premisses; believing -
that he has committed the unpardonable sin, and that his soul
is for ever lost, he does that which may soonest precipitate the
result which he so much dreads. An uncle had been similarly
afflicted, and had died insane.

Intelligently as this patient could talk, and rational as he
seemed, apart from his delusion, it would not have been correct
to have pronounced him perfectly sensible under such limitation.
There was no sufficient reason in his intellectual disorder why
he should not have gone on with his business, but he could not;
he thought he was too weak in body to do so, whereas he was
too weak in will to make a sustained attempt; he could not
take interest in that, in his family, or in anything else but
himself; every impression was more or less painful to him, his
whole manner of feeling being perverted, and he sought there-
fore to avoid society, to be alone, and to nurse his sorrow. At
B64 PATHOLOGY OF MIND. [cuap.

times, too, his anguish increased to a veritable acute paroxysm,
and then he looked very helpless and insane.

The case which follows, very similar to the foregoing in
general symptoms, illustrates, by an important additional symp-
tom, a dangerous feature in some of these cases.

J. B., set. fifty-one, married, had made a small fortune by
his own energies, and had brought up a family respectably. He
was a stout, hard-faced, big-browed man, of surly appearance
and melancholic temperament. Of the Wesleyan persuasion,
he had always been very attentive to his religious duties; in-
deed, religious devotion was said to be the cause of his illness,
which certainly began with doubts as to his religious state. He
became gloomy, morose, and depressed, and took to his bed five
weeks previous to his being sent to an asylum. He would not
get up, however much entreated: why should he? He was
dying, and there was no salvation for him, for his soul was lost.
He slept fairly and ate well, though he professed at times that
he could not eat. In the asylum he was listless, gloomy, and
exceedingly averse from exertion of any kind, always main-
taining that he was dying. “It’s of no use, J tell you, doctor,
asking me how Iam: you know I’m dying.” Apart from the
delusions as to his soul and his body, he was intellectually
- rational, although his affective life was much perverted. After
a month’s residence, there was some improvement in his state;
he walked outside the grounds regularly after having been
forced to go on the first occasion much against. his will; he was
more cheerful too, and would talk a little. It was thought that
he was going on very favourably. One night, however, without
any warning, he suddenly started out of his bed, rushed at a
window, through which it would have been thought impossible
that .a man of his size, or indeed of any ordinary size, could
have squeezed himself, struggled through it, and fell from a height
of twenty feet, fortunately on his feet, so that he was only
grievously shaken. He was, however, in a state of fearful
excitement, fancying that the world had come to an end, writh-
ing, and erying frantically, “Let me go, let me go!” Like
sudden desperate paroxysms seized him periodically for the next
three weeks; after which he began to improve. He became
vin} THE SYMPTOMATOLOGY OF INSANITY. 365

talkative, cheerful, and interested in his family, though main-
taining for a time, for the sake of consistency seemingly, that he
was no better, and only reading or employing himself when he
thought that no one was observing him. In three months more
he was discharged quite recovered.

‘These paroxysms of anguish or panic, which are a notable
feature in some cases of melancholia—paroxysms of melancholic
panic they might be called—deserve careful notice. They often
come on quite suddenly; the patient has perhaps been lying
down to rest, and after a short period of repose, in which he has
dozed or not, he starts up in great agitation, his heart beating
tumultuously, his senses distraught, and rushes wildly to the
window to throw himself out of it; he is overwhelmed for the
time being, driven to desperation, and hardly knows what he
does ; the frenzy has all the characters of a convulsion affecting
the mental nerve-centres. In some cases the convulsive panic
is preceded by an anomalous and alarming sensation of distress
about the region of the stomach or of the heart, a sensation
which, appearing to rise thence to the head, is accompanied by
an indescribable terror and a dreadful feeling of helplessness.
The condition is insupportable, and he feels that he must go
mad or rush out of the house and do something dreadful to
himself or to some one else; no one can conceive the terrible
agony which he underwent, i will say afterwards; and when
the paroxysm is past he trembles from head to foot, is bathed
in perspiration and completely exhausted. The whole affair is
suggestive of the onset of a mental epilepsy, and the deed of
violence that may be done is like that which is done sometimes
in the transitory mania that occurs in connection with epilepsy.
Whether the explosion of violence in such case shall be directed
against the patient’s own person or against the person of another
will probably be determined in the main, partly by his own
character, and partly by the character of his malady. If he
has laboured under delusions that he was slandered, persecuted,
or otherwise injured, and has had a hard task hitherto to with-
stand the impulses to retaliate against his supposed enemies, he
will be most likely to attack one or other of them during the
fury of his frantic panic; if his delusion, on the other hand, be
366 PATHOLOGY OF MIND. mes {emat.

that he is himself a very wicked person who ought no longer to
live, the probability is that he will do injury to himself. More-
over, if he is of a self-asserting temperament, which reacts
passionately, against opposition, answering blow with blow,
meeting threats with defiance, he is more likely to be homicidal;
if he is of a self-distrustful temperament, which shriuks from
contests, foregoing his own claims rather than assert them
defiantly, he is more likely to be suicidal. For the same reason
a homicidal tendency is less likely to be present, and if present,
less likely to be dangerous, in women than in men, and in old
aud feeble persons, the self-asserting energy of whose natures has
abated, than in young and vigorous persons.

It is noteworthy, in some cases of melancholia, how sudden
and complete may be the change from the deepest anguish and
despair to a state of temporary calm and sanity; indeed it is
not very uncommon to observe brief intervals of respite, like
momentary breaks of blue in an overcast sky, during which the
person is himself again. One of my patients, suffering from
acute melancholy, who usually wandered about moaning griev-
ously, or sat weeping profusely, and. who had ‘made several
attempts upon her own life, awoke one morning seemingly quite
well, rational, cheerful, and wonderfully pleased at her recovery,
remaining so for the rest of that day. It was evanescent, for
next morning she had entirely relapsed, and it was some
months before she finally recovered. And I have met with one
extraordinary case in which for a long time there were daily
alternations of profound melancholy and complete lucidity.
Griesinger mentions the case of a woman with melancholia and
delusions as to loss of property and persecution, who for. the
space of a quarter of an hour was quite herself, and then
relapsed. Such instances are of interest in regard to the patho-
logy of the disease, as they prove that there is no ‘serious
organic disease so far; the condition of nerve element is a
modification which, whatever its nature, may quickly come and
quickly go, not unlike, perhaps, the electrotonic state that may.
be artificially produced in nerve.

In conversing with patients so afflicted it is impossible to
avoid being surprised at the strange discord or incoherence
vit1.] THE SYMPTOMATOLOGY OF INSANITY. 367

which their mental character exhibits, and difficult to help
thinking that they could do more to control their morbid moods
than they do. Certainly the self-control which they will exer-
cise for a time, especially before strangers, is so great sometimes
that a short interview might produce a very erroneous impres-
sion of their real state; for when alone or in the company of
those who are accustomed to be with them, they will yell,
moan, weep, and become pictures of despair. They seem to be
double beings—at one time more rational than insane, at ‘another
time utterly insane: the two beings cannot be brought into
intimate intercommunication and beneficial reaction upon one
another, for the persistence of the delusion implies the cutting
off of such healthy interaction: as conscious manifestations
they are independent, isolated. One day the sound being is in
predominant or exclusive action; another day, the unsound
being; on different occasions one might say—“ Now I am
talking with the rational being; now with the morbid being.”
Herein we have the explanation of the doubt which such
patients sometimes have of themselves; they are not uniformly
confident, and appear only to half believe in their delusion at
times, because they are not then under its entire influence:
their rational nature is in predominant action, and they act in
their relations as if their delusion really was a delusion. It
would be a mistake, however, to put reliance on such seeming
hesitation on their part: let the morbid feelings be stirred up
and the delusion excited into activity, all doubts vanish, and the
sound being is brought into dangerous bondage to the unsound
being; and it would certainly be unsafe to conclude that a
person who did some deed of violence must needs have known
what he was doing at the time, because he plainly knew very
well what he was doing half an hour before.

The profound depression of the mental tone which charac-
terises melancholia and inspires the gloomy delusion makes
itself felt throughout the bodily functions; and it will be con-
venient to consider its effects (v7) upon sensation, (b) upon the
processes of nutrition and secretion, and (¢) upon the acts or
general conduct of the patient.

The general sensibility of the skin is commonly much
368 ‘ PATHOLOGY OF MIND. [crmap.

affected, being either blunted or perverted. The diminution
may be general, no part of the body showing its natural acute-
ness of feeling, or it may be local, when there is sometimes a
complete loss of it. Hence it comes to pass that melancholics
oftentimes inflict severe mutilations and other injuries upon
themselves which they would hardly do if their sensibilities
were normal; a delicate young lady who would shrink from
undergoing the least pain when in health may thrust a needle
or a patr of scissors into her heart in order to commit suicide ;
another patient gouges out his eyes with his finger as a pen-
ance for his wickedness and in obedience to the Scriptural
injunction, “If thine eye offend thee, pluck it out;” a third
thrusts his hand into the fire and holds it there until it is
charred, or mutilates himself sexually in such a determined
way that it is hard to believe any one possessed of normal
sensibility would have the courage to do it. In some cases it
is plain that the loss or lessening of sensibility helps to keep
up, if it does not actually occasion, the delusions in the mind.
Our sensibilities are our chanuels of communication with the
external world, and we are so constantly and habitually depen-
dent upon their normal functions, without thinking in the
least of them, that we do not realise, until they fail us, how
much we owe to the messages which we receive by them every
moment of our lives. A person who has lost sensation in the
sole of his foot feels as if his foot were enlarged and heavy and
did not belong to him, or can hardly be persuaded that some-
thing cushion-like has not been interposed between it and the
ground; in like manner, a poison like aconite, which deadens
or paralyses general. sensibility, produces a sensation of extra-
ordinary enlargement or weight of the whole body. Such being
the experiences of the sound mind, it is not difficult to conceive
that losses or perversions of sensation may contribute materi-
ally to the generation and the maintenance of delusions in the
unsound mind; they will be worked up by it into the strangest
products, as we know sensations oftentimes are in dreams.
Perversions of sensation frequently occasion great distress.
Strange feelings of precordial discomfort or pain in some in-
stances, disquieting epigastric or abdominal sensations in other
ViII.] THE SYMPTOMATOLOGY OF INSANITY. 369

instances, or anomalous sensations in the head and along the
spine, such as dull pain, coldness, pressure, and the like, keep
the patient in a cloud cf despair or in a fever of apprehension
about himself. A noteworthy fact in connection with these
strange sensations, which are seldom actual pain, but more
alarming than if they were pain, is that’ when they reach a
certain pitch of intensity they cause an indescribable apprehen-
sion and distress, so that the patient feels as if the foundations
of his being were giving way, and is perhaps driven to do some
wild act of violence in order to deliver himself from his insup-
portable state. Itis probable that they originate in a disorder
of those organic sensibilities to which the sympathetic nervous
system ministers, and which, though we are not directly con-
scious of them and have no power over them, are essential
conditions of the physiological unity of the organism; if this
be so, it is no wonder that a disorder of them which thrusts
itself into consciousness, threatening, as it seems to do, a
physiological disintegration, should be accompanied by a com-
plete loss of self-confidence and an extraordinary display of
anxiety and helplessness. It is seldom that any actual disease
can be found to account for the disquieting sensations, but they
are unquestionably sometimes more distressing, more disabling,
than the pain of severe organic disease. Let it be noted that
the disorders of organic sensibility in insanity are of more im-
portance, and deserve closer attention, than has generally been
thought hitherto. When a general paralytic patient alleges that
he has no mouth, no throat, no stomach, no intestines, or that
he is dying or is dead, it is worth inquiry whether his delusion
is not due to a deadening of his organic sensibilities, the per-
fectness and union of which have so much to do with the
consciousness of the physiological unity of the organism. In
like manner, when the hypochondriac complains unceasingly
of the distressing anomalous sensations in his interior, it is a
question whether he has not cultivated such a ‘hyperesthesia
of his organic sensibilities by constant attention to them as to
be rendered sensitive to the functions of his organs or even
tothe passage of food through the intestines.

When the melancholia takes a hypochondriacal form as it
370 PATHOLOGY OF MIND. . [orar.

notably does sometimes, I think, in persons who break down in
middle age after sexual excesses of youth and early manhood,
there may be an exaggerated sensibility to almost every impres-
sion made upon sense—a sort of painful mental hyperesthesia.
They have so nursed their sensibilities that these have become
their tyrants. The person cannot perhaps enter a room unless
it has been very well aired, and at the same time he dreads the
least draught of air, or fears to expose himself to the rays of
the sun; he cannot read, he says, because his eyes immediately
suffer, or bear to hear much conversation for fear it may pro-
duce pain and confusion of head; he is afraid of making any
real exertion because of the pains and exhaustion which he
declares that he feels if he does; walks, perhaps, as if his body
were glass which would be shivered by a shock; is troubled
about the sensations which he has after taking food, lest per-
chance he has taken something which disagrees with him; com-
plains that his mind is a perfect void, that he has no memory,
and that he cannot make the least intellectual exertion, Ex-
hausted sexual sensibilities and powers have taken out of life
that which was its main aim and gratification and the backbone
of its interests; there is no capacity to feel and to respond to
stimuli of a higher order, which have never been cultivated, and
continual attention to bodily sensations has exaggerated them by
degrees until they have become morbid and overpowering. A
condition of morbid sensibility very like this in many respects
is met with sometimes in young women soon after puberty, or in
unmarried women at a later period of life who suffer from melan-
cholia with hysterical features. Whatever the immediately active
cause of their state, it is past all doubt that sexual feeling has
had something to do with its production: perhaps it is that an
ungratified instinct, having not vicarious diversion of its ener-
gies in a busy life of work and interests, has shown itself in
the increase of the general sensibilities of the organism, claiming
and obtaining its gratification in the fostering of them; or it
may be that an illicit indulgence of the instinct is at the bottom
of the mischief.

Tllusions and hallucinations of the special senses are common
in melancholia, and those of hearing more common than those
VIII] _ THE SYMPTOMATOLOGY OF INSANITY. 871

of sight. Why auditory hallucinations should be the most
frequent in this as in other forms of insanity is a question
which has apparently not been considered; but the main
reason, perhaps, is that we do most of our thinking by means
of words, the thoughts as they arise being instantly translated
into their proper words; consequently, when a morbid thought
is vividly conceived and acts intensely upon the sensory centre,
the words into which it is forthwith translated are heard as
actual sounds or voices, and thereupon attributed, in accordance
with normal experience, to an external cause. Solitary habits
and brooding thoughts would be likely to favour this transfor-
mation of thoughts into heard words. Secondly, hallucinations of
hearing cannot be tested and corrected by touch, as a perception
of sight can; we build up our visual perceptions by the aid of
touch, so that they become a language which is interpreted
instantly by past experience, and we correct habitually the
inferences of sight by the mother-experience of touch; but we
cannot test a voice by touch, and are mcre disposed, therefore,
to let it pass unchallenged. Thirdly, the suspicious and dis-
trustful nature of insanity comes in to strengthen the hold of
an auditory hallucination, since it operates to check or with-
hold that reliance upon the testimony of others which every-
body must practise in matters of which he cannot have personal
experience; it adds to the person’s confidence in his own
opinion at the same time that it takes from his trust in the
authority of others. After all, the last foundation of knowledge
is to feel and to do, to be susceptible to external stimuli and to
make respondent actions, —in other words, it is truly a grasp-
ing or apprehension of external nature, social and physical, as
the result of close and sincere relations with it; whosoever,
therefore, is separated from his kind by a barrier of distrust,
being among them but not of them in feeling and doing, cannot
apprehend truly concerning them, and is on the way to become
a morbid social element.

Auditory hallucinations will be found to differ in character
when they are closely examined; and these differences will
throw some light upon their mode of origin. Some patients are
much distressed by the involuntary upstarting in their minds of
372 PATHOLOGY OF MIND. [cuap,

painful ideas which are often of a blasphemous or obscene
nature; if they are of a religious disposition they are the more
alarmed by what they describe as dreadfully wicked thoughts,
and cannot help thinking them proof that they are given over
to Satan on account of their sins. So far there is not actual
hallucination: morbid ideas start up against the will in dis-
ordered mind-centres, just as convulsions or spasms proceed
from disordered motor centres, and are interpreted in accordance
with the person’s habit of thought. The next step in misinter-
pretation, however, is to imagine that the wicked thoughts are
the suggestions of others—either of evil spirits or of corporeal
enemies—who have got possession of their thoughts in some
mysterious way, know everything that passes in their. minds,
dictate what they shall think, and reply to it before it is
distinctly conceived by them: no actual voices are heard, but
the conviction is that their persecutors have made themselves
masters of their thoughts by some extraordinary trickery, and
direct them as they please. It is the only explanation which
they can conceive of the origin of thoughts which are painful
and hateful to them, which they feel strongly are not the
thoughts of their true selves, and which certainly come to them
against their will.

The next step is that the ideas as they arise are transformed
into words heard; they strike upon the auditory ganglia, become
actual hallucinations, and are heard distinctly as the voices of
persons uttering them. In vain we attempt to convince the
patient so afflicted that the thoughts momentarily precede and
really cause the voices; he hears them as plainly as he hears
our words, and has the same certitude of their reality; and
he is not expert introspectionist enough to be able to watch
his ideas and to catch them at the instant of their rise before
they are transformed into sounds. The late Sir H. Holland
mentions the case of a gentleman who believed in and acted
upon illusive sounds and conversations of this kind, being
treated as deranged in consequence, and who after a while
recovered so far as to recognise and treat them as hallucinations.
When he was asked to explain how it was that he had come to
look upon them in that sensible light, he said that it was partly
VIIt.] THE SYMPTOMATOLOGY OF INSANITY. 373

by never discovering any person in the places from which the
voices seemed to come, but chiefly by finding himself able, on
trial, to suggest the words which appeared to be uttered by some
one to him. Without doubt he was already on the way to
recovery from his malady when he was able to make. this
successful self-examination and to detect the tricks which his
mind was playing upon itself. In dreams a person is similarly
self-fooled. The apt replies and admirable arguments of the
person with whom the dreamer talks ,are of course his own
replies and arguments,—his own thoughts which he hears spoken
—though he is not aware of it at the time; coming not by the
regular paths of association, but. in a way quite independent
of will and consciousness, they meet him as strangers and are
ascribed to some one else whom he sees and hears. The habitual
co-ordination of thoughts and feelings, which is the basis of the
consciousness of personal identity, is suspended in sleep, and it
i3 only when the normal co-ordination is being re-established,
as was the case with Sir H. Holland’s patient when he was able
to suggest the words which were seemingly uttered by another
person, or as is the case with the dreamer who is just about to
awake, that he recovers his sense of personal identity and begins
to suspect or to perceive the true nature of the hallucinations.
It is a common observation that hallucinations of hearing
abate or disappear for a time with change of scene, those who
have them being most free from then: when travelling from
place to place: insulted by offensive remarks in one hotel or
town, they leave it in consequence, ‘and in the new hotel or city
which they arrive at they are free from trouble fora day or two.
Then, however, the insults are renewed. Delieving that they
have left their persecutors behind them, they expect not to
hear them when they reach the new place, wherefore their minds
are not running on the train of morbid thoughts; the diversion
of thought is further aided by the interest of the new surround-
ings ; soon, however, this source of interest is exhausted, the
morbid habit of suspicion revives, attracting and holding. the
attention, the hallucinations recur, and the unfortunate persons
declare that their enemies have followed them and are at their
evil work again. One gentleman who consulted me because of
374 PATHOLOGY OF MIND. [cuar.

persecutions of the kind found himself much relieved when
travelling in Norway, especially so-in its wilder parts, where he
seldom met any one; as soon as he returned to populated
countries his afflictions were as bad as ever. Another gentleman
could only make life endurable by wandering from place to
place day after day, not staying more than one night in the same
hotel; when in England he bought a horse and gig, and drove
from town to town, leaving in the morning the place where he
had slept at night and carrying food with him which he took by
the roadside or in a field. He had got into various troubles on
account of his vagrant life: once the police had taken him in
charge and locked him up; once he had been brought before a
magistrate for cruelty to his horse, which had a neglected sore
on its shoulder; twice his horses, wearied of standing, had run
away with his gig while he was taking his midday meal and
had done injury, the one to itself, the other to the conveyance;
but he had got over that danger by buying a London cab-
horse, which would stand still for any length of time. He had
tried most of the best hotels in London, had fancied himself
persecuted in all of them, and having had quarrels in con-
sequence, was hard put to it to go where he would be received
again.

At an early stage, before the hallucinations are fixed, travel
in a foreign country, the language of which the patient does
not understand, may help much to dispel them ; but when they
are fixed and he has ceased to have any doubt about them he
sees threats and insults in looks and gestures, interprets in an
ill sense words which he does not understand, or hears reproaches
uttered in his own language which he declares his persecutors
understand. A gentleman I once saw who knew three lan-
guages besides his own was always most persecuted in his own
language, very seldom in the language which he knew least,
more often in the other foreign languages with which he was
well acquainted. And Esquirol mentions the case of a gentle-
man who heard reproaches in all the languages of Europe, which,
being an accomplished linguist, he understood; he had, how-
ever, most difficulty in understanding those which’ were made
in the Russian language, which he himself spoke with most
vil.] THE SYMPTOMATOLOGY OF INSANITY. 375

difficulty! “For the rest,” he said, “ the language is of no con-
sequence; one may communicate many things by a look or a
gesture, even when one is a long way from the person.” +

The secondary production of hallucination through the agency
of morbid idea is not the only mode of production ; there can be
no doubt that hallucination may originate directly in a deranged
sensory ganglion. There are several poisons which, when intro-
duced into the blood, act through it upon the nervous system to
excite distinct subjective sensations, chief among them being
belladonna, which gives rise to very remarkable visual halluci-
nations; in fevers again we observe hallucinations and illusions,
the characters and manner of origin of which certainly indicate
that they proceed immediately from disordered sensory centres ;
and reasons have already been brought forward to show that
the hallucinations which occur in dreams and just before going
to sleep are often provoked by internal affections of the sensory
organs or their ganglia. It is easy to understand then that the
hallucinations of insanity are sometimes excited directly in the
same way. Whenever an impression from without is made
upon the senses, of which the person is distinctly conscious, it
stirs up an idea of some kind; naturally therefore the stimula-
tions of sense by internal causes will similarly excite idegs,
which may be true or, more likely, untrue interpretations of
them. <A bad taste in the mouth owing to disordered digestion
may generate the hallucination of poison in the food; a neu-
ralgic pain in the face that of torture by electricity or by some
more mysterious agency ; a bad smell the hallucination of poi-
sonous vapours diffused through the room; and so with the
other senses. Although the morbid sensation is truly the occa-
sion of the hallucination in these cases, this would never be
believed in as denoting an objective reality and take rank in the
mind as a distinct perception, without the co-operation of dis-
order in the higher centres of thought; since were they perfectly
sound they could not fail to correct the evidence of the deranged
sense and to perceive the true nature of the hallucinatiou—as
was done indeed by the celebrated Nicolai of Berlin and many
others who, like him, suffered from hallucinations of purely

1 Dictionnaire des Sciences Médicales, t. xvi, p. 154.

1%
376 PATHOLOGY OF MIND. [cmar.

bodily origin. In most cases there is without doubt a combined
action, or, so to speak, a conspiracy of disordered thought and of
disordered sense in the production of the hallucination; the
illusive sensation excites a morbid idea, which thereupon plays
back upon the sensation, giving it a morbid interpretation;
and we can no more mark the respective limits of the function
of idea and of that of sensation in the false perception, than we
can mark their respective limits in sound perception. The
major part of every perception, true or false, is inference. It
may be set down then as established by experience: first, that
the primary occasion of a hallucination or an illusion may be
either in the subordinate sensory ganglia or in the superordinate
centres which minister to ideas: and, secondly, that although
sensory and ideational centres are commonly in an intimate
conspiracy to produce it, yet they sometimes do not agree, the
one contradicting and correcting the other. Certainly it were
an excellent thing if a man could always keep his ideas sound
when his senses are disordered, and his senses sound when his
ideas are disordered.

Hitherto I have dealt almost exclusively with hallucinations
of hearing, which are the most frequent in mental derangement,
but most of what I have said concerning them is true of the
hallucinations and illusions of the other senses which occur.
The patient sometimes has hallucinations of taste, his food has
a poisonous or disgusting taste, and he believes that he is being
poisoned or being fed on carrion ; his smell is disordered, and he
imagines that stinking odours or pestilential vapours proceed
from his own body or are diffused through his room by his
persecutors ; he has illusions of sight and no longer recognises
his nearest relations, believing them to have been changed in
some extraordinary way, and, worse still, he sometimes sees
them as devils and resists violently the attentions which he
receives from them as tortures which they are inflicting upon
him. I was once consulted by an old gentleman who, perfectly
intelligent in other respects, believed that offensive odours
emanated from his body to such a degree as to cause great dis-
tress to all who were brought near him in his business, which
he nevertheless conducted with skill and judgment. So bad
VIII] THE SYMPTOMATOLOGY OF INSANITY. 377

was this smell, he declared, that the persons in the next house
were annoyed by it and he could often hear them cough in
consequence ; that the cab-horses standing on the cabstand moved
restlessly as he passed them; and that those who did business with
him were obliged from time to time to put their handkerchiefs
to their noses, being too polite, however, ever to say anything to
him on the subject. To prevent the excessive accumulation
of these odours in one room, he used to sleep for the first part
of the night on the ground-floor of his house, mounting higher
at a later period of the night. He was very depressed because
of his sufferings, took his walks in solitary places where he
might meet as few persons as possible, and sometimes felt
inclined to put an end to them by suicide. AJ this time his
partners in business had not the least, notion that there was
anything specially wrong with him. At the end of several
months an abscess formed at the lower part of the sternum, and
after this had burst, discharging a large quantity of pus, he
recovered entirely from his delusions. It would seem that an
offensive smell of subjective origin, due probably to some latent
disease which eventually caused the abscess, was so strong as
to overpower reason and to fix firmly in the patient’s mind the
delusive conviction that everybody else smelt what he smelt.

Let it be noted with regard to hallucinations that they
sometimes originate apparently as the remembered hallucina-
tions of dreams which are taken to be real. One lady whom I
saw had visions of a person entering her room in the night; at
times she was uncertain whether the occurrence was a dream,
but at other times was positive that it was real. If one studies
carefully the beginnings of hallucinations it will be found that
they are oftentimes first experienced in the night or in the
intermediate stage between sleeping and waking, and afterwards
only as they gain strength get possession of the mind in
the day.

The processes of nutrition and secretion are usually much
affected in melancholia, the depression of tone making itself
felt throughout them. Considering the profound depression and
extreme prostration of energy which are witnessed in some
instances, it is almost a wonder that the organic life goes on as
378 PATHOLOGY OF MIND. [cuar.

well as it does. The heart’s action is often much lowered, the
circulation being languid, the extremities cold and livid, the pulse
slow, feeble, and irregular, or actually intermittent. It will be
noted sometimes that the pulse is very irregular or actually
intermittent during a paroxysm of melancholic depression, and
that it recovers its natural beat as the depression passes off.
The respiration, in sympathy with the heart, is slow, interrupted
by frequent sighs, and perhaps moaning. The temperature of
the body is lowered. The skin loses its freshness, becoming
sallow, dry, and harsh, and in this, as in idiocy and some other
forms of insanity, its excretions have a disagreeable odour,
which will hang about a room in which several patients have
been assembled. I doubt not that an acute nose might be
trained to recognise insanity by its odour in some instances.
The excretions from the bowels are sometimes particularly
offensive. Digestion is often deranged, the tongue being coated
—like a piece of chamois leather in a few cases ; flatulent eruc-
tations are frequent, and there is sometimes great distress or
actual sickness after food. The patient does not improve matters
perhaps by his mode of eating, since he is apt to take food
hastily and indifferently, without taking any care to masticate
it properly.

The bowels are usually constipated; owing partly to defective
secretions of their lining membranes, partly to indolent action
of their toneless muscles, and partly to the obtuse sensations of
the patient, and to his want of energy to attend to them. In
some cases the urine is abundant in quantity and very pale in
colour; in others it is scanty, thick, and high-coloured; these
differences betoken, I believe, different states of nutritive de-
rangement and prescribe different constitutional treatment.
Menstruation is commonly irregular or suppressed. In a few
cases I have known the hair to turn quickly grey during an
attack, becoming less so again after recovery from it. Every-
thing shows the depressing influence of the gloom of mind, or
rather of the disordered nervous function which is the condition
of the gloom, upon the organic life. There is often great want
of sleep, at any rate before the disease has become chronic,
but these patients are apt to affirm that they have not slept a
VIII] TU SYMPTOMATOLOGY OF INSANITY. 379

wink when they have slept tolerably well; the sleep having
been imperfect, or disturbed by vivid and painful dreams, they
feel unrefreshed and tired when they awake, and can hardly say
whether they have slept or not. The early morning is usually
the worst time with melancholics, who become more cheerful
towards the evening, when they may for a short time be almost
themselves. This may he owing to the diminution of the blood
in the brain during sleep and to the delay or difficulty of re-
storing an active: supply because of the enfeebled heart; or it
may be simply the despair of a mind undistracted by external
impressions and concentrated upon its gloomy thoughts, on
awakening anew to them from the blessed repose of a temporary
oblivion. In some cases, on the other hand, the terror and dis-
tress are greatest at night, amounting perhaps to a veritable panic
when the time comes to retire to bed. It is remarkable too
that a good night of sleep is sometimes followed by a worse state
of things than is a sleepless night: the sleep has seemingly
restored more sensibility to feel the sufferings and more energy
to express the distress in conduct.

Refusal of food is common and is sometimes very persistent:
it may be owing to delusions—such as that the food is poisoned,
that the throat or the bowel is closed and will not let it pass—
whence violent exclamations perhaps against the eruelty of being
obliged to take it—or that the patient is unworthy to live and
ought to die of starvation; it is sometimes the mere outcome of
a morbidly perverse humour to resist everything that ought to be
done, and of a crossgrained pleasure in doing the contrary ; and
it is at other times, in great part or in whole, the expression of
a want of appetite and of the general sluggishness of nutrition.
Even when the refusal is associated with decided delusions which
appear to have instigated it, both it and the delusions will be
aggravated, the latter being more active and the refusal more
determined, whenever the tongue is coated and the digestion out
of order. I once had under my care a lady who refused food
entirely for a week at the beginning of her illness under the
delusion that her throat was closed up, the refusal being over-
come only by the use of the stomach-pump; for some time after-
wards in her case the old delusion, at low-water mark usually,
380 PATHOLOGY OF MIND, [cuar.

became full and active, and the disposition to refuse food re-
turned, whenever the digestion was disordered.

The movements and conduct of the melancholic share the
languor and accord with the character of his other functions,
He is commonly averse from exertion of any kind, slow, languid,
and heavy in his movements, and disposed to sit, lie, or stand for
any length of time without caring to move until he is prevailed
upon by much importunity or by actual force to do so. He has
no interest in what is going on, and neither desire nor energy to
take part in it. In that extreme form of depression which I
have already spoken of as melancholia attonita, he sits, lies, or
stands almost motionless in one position, not moving, even
though it be a constrained one; he allows flies to scttle on his
face without brushing them away; he must be moved or carried
from place to place, must have his food put into his mouth, and’
must be cared for by others in every respect ; his muscles are gene-
rally relaxed, or some of them—those of the arm, for example—-
are fixed in a quasi-cataleptic rigidity ; he is in a waking night-
mare, so to speak, or like a person paralysed by a great fright
who cannot stir a foot, and he cannot realise the true nature of
his surroundings nor command the volition to exert himself in the
least. The fact is that his mind is fixed in the cataleptic rigidity
of some terrible delusion : he believes himself to be the cause of
all the horrors in the world, and to be a wretch too vile and
loathsome to be touched by any human being; or he imagines
that he is surrounded by flames of fire, or that he is standing on
the edge of a vast sea of fire or of blood and will be precipitated
headlong into it if he moves a step forward; or he has the
delusion that he is actually in hell, sees devils about him, and
hears shrieks of sufferers ringing in his ears. He is not always,
however, so unconscious of external realities as he appears; if
his nose or his feet be tickled with a feather, or if his skin be
pinched or pricked, he will sometimes show by a grunt or a
groan, or by a shrinking movement, that he feels pain; and
when he comes out of his trance-like state he may prove that he
was a great deal more keenly alive to what was going on than he
was thought to be, by remembering exactly most of what was
said or done in his presence. Many times I saw a gentleman
VILL. ] THE SYMPTOMATOLOGY OF INSANITY. 381

who lay in this state of suspended mental animation for upwards
of two years, being carried from bed to couch and back again
each day, never speaking a word all that time, taking no food
except fluid nourishment which was forced into his mouth,
altogether inattentive to the calls of nature; at the end of this
long period, when he was in an extremely emaciated and feeble
state, he startled his attendant one day by asking him in a weak
whisper for a cup of tea, which he drank willingly; thence-
forward he was perfectly rational, and went on rapidly to entire
recovery of bodily strength. We had believed that he was in
hell, and that those who attended on him were devils who were
mocking and tormenting him; that he was a horribly disgusting
object and must not be approached or touched ; and that he could
not possibly or must not for the life of him make the least sign
or exertion. But what was very remarkable was that when no one
was in his room, and he believed that he was entirely unobserved,
he would assume a more comfortable position as he lay, or
swould actually raise himself on his bed or couch so as to look
out of the window; and when his wife visited him or some-
thing deeply affecting him was said in his hearing, he showed by
a slight twittering of the closed eyelids or by a shrinking move-
ment that he was not so insensible as he looked. Moreover
when he came to himself at the end of his long nightmare he
had a very fair remembrance of what had taken place while he
was under its spell: the Franco-German war had broken out and
run its course, and he had gathered from the conversation of his
attendants a general notion of the events of it. Once he had
lost his reckoning of the month for a time, but had managed to
regain it by seeing the date on a newspaper.

In other melancholics, movements that seem to be almost
automatic serve to give monotonous expression to their grief:
they moan or groan piteously with each expiration; repeat in a
whisper or aloud the same ejaculation of distress; rock their
bodies to and fro continually ; wring their hands ; pace backwards
and forwards over the same piece of ground with sad eyes
fixed blankly upon it. The nervous irritability of some is so
great that they cannot refrain from rubbing or picking their face
or scalp until disfiguring sores are formed, or from pulling out
382 PATHOLOGY OF MIND. [crar.

their hair in patches, or from gnawing their hands and fingers,
They are hardly conscious of what they do; if vigorously re-
monstrated with they may refrain for a moment, but soon the
movements, which have become a morbid habit, begin again.
They illustrate the steps of the gradual transition from voluntary
to involuntary acts, for it is hard to say sometimes whether they
are voluntary or not. They certainly may be checked usually by
arousing a strong enough motive in the patient’s mind to exert
his will steadily, as may be done by placing an attendant by
his side with instructions to hold his hands or to quietly take
hold of them each time that they go up to his head or face,
After a while he will get tired of that process of restraint and
control his impulses.

We pass by gradations from these cases of irritable and restless
melancholia to those cases of more acute melancholia in which
there is an active expression of the internal anguish by voice,
gesture, and behaviour—a sort of melancholia agitans,; the
patient rushing continually about in aimless agitation, wringing
his hands wildly, crying out in loud lamentations or shrieking
violently, and writhing in frenzy if restrained. The excitement
is so great that one does not observe the symptoms of bodily
depression that belong to most of the forms of chronic melan-
cholia;.in fact, the features generally are like those of acute
mania, so much so sometimes that it is a chance whether the
case is classed under mania or under melancholia. What may
be noted, however, with regard to acute melancholic activity—
whether of delirious ideas or of frenzied conduct—is that, although
very great, it is of a more uniform or even monotonous character
than the corresponding activity of acute mania; it is limited to
the expression of the mental suffering, or to the frequent attempt
to escape from it by suicide, and, when surveyed as a whole, is
strongly suggestive of a machine in deranged action. It must
not be supposed, however, that a distinct line can be drawn
between the group of symptoms which it is the custom to
describe as melancholia and those which are called mania; in
some instances they pass insensibly into one another, while in
other instances they alternate.

The following case may serve as an example of ordinary acute
vit} TIIE SYMPTOMATOLOGY OF INSANITY. 383

melancholia. A young woman, et. twenty-fiu', whose parents
were Dissenters in’a respectable position, had been religiously
brought up; she had been much engaged in Sunday-school work,
and had written several little tracts of more or less merit.
When first seen by me she was said to have been ill for two
months, but there was reason to believe that she had suffered
for a longer period. She was miserably restless and unhappy,
and wandered about moaning and exclaiming, “ My poor father!
My poor father!” She also spoke incoherently of the house
being burnt down, and of every one in it being lost ; and she
made several attempts at suicide. There was a background of
anguish behind the excitement, marking a difference from acute
mania, where the mood is elated, or, if the elation disappears
during a remission, is sullen, moody, and morose. After a little
while she became still worse: she was much excited during the
day, rushing wildly at any door the moment it was opened,
grasping at the clothes of any one who might enter, and clinging
to them with offensive tenacity ; and at night she slept not, tore
to pieces bed-clothes, nightdress, and whatever else she could
tear, and plastered herself and her chamber with her excrement.
Day by day she seemed to get, if possible, worse and worse, gab-
bling automatically some such sentence as “ Let me see my poor
father ; let me kiss my poor father,” and making the most frantic
rushés at any door that was opened, no matter where it led to.
Night was not the time for sleep, but for the awakening of a
more disgusting frenzy. Withal it was clear that, notwithstand-
ing her terrible and distressing excitement, she knew what she
was doing, and could control herself in some measure for a time;
she did not like, for example, to be put in seclusion, and the
threat or employment of that means of treatment had a calming
effect upon her. On the whole, there was certainly an appear-
ance of wilfulness in the worst acts of this poor woman, whom
an ordinary observer would have pronounced the maddest person
that he could imagine; she was perfectly couscious whether
she was doing what she should do or should not do; and if a
sufficiently powerful motive was excited, she could sometimes
restrain the automatic utterance of her convulsive frenzy. Had
the supremely absurd question whether she knew the difference
 

 

 

 

 

 

384 PATHOLOGY OF MIND. [cHAP,

between right and wrong been put to a medical witness in her
case, the reply, so far as rational answer ‘could be made to
irrational question, must needs have been that she did. In this
case the so-called asylum ear,! which is ever of evil augury,
appeared first on one side and then on the other, and the end
was the natural end of such cases,—namely, dementia: the fury
had raged out, and the calm of mental extinction followed: by
making a desert of the mind peace was made in it. As in the
natural order of events convulsion is the forerunner of paralysis,
so maniacal fury is the forerunner of dementia in the regular
course of mental degeneration.

Suicidal feelings and attempts are common in melancholia;
so much so that one suspects their actual or possible existence
even when they have not been openly manifested. Suicide is
sometimes attempted or accomplished in consequence of a hallu-
cination, which perhaps occurs very suddenly to the depressed
mind—it may be at the instant of awaking from sleep: the
patient hears distinctly a voice commanding him to kill himself;
so mysterious, so entirely independent of himself, so imperative
does it seem, that he thinks it a command from heaven or a
temptation from hell. In the latter case he may withstand and
overcome it for a time. or altogether; in the former he is not
unlikely to yield early obedience to it. Again, suicide may be
the consequence, direct or indirect, of a’ delusion, or it may be
sought as an escape from a misery which is intolerable. The
two delusions which are most often accompanied by suicidal
tendencies are the delusions of eternal damnation and of im-
pending worldly ruin. It has been truly said that the fear of

1 The “Insane Kar”’—Hematoma auris, or Othematoma—is produced
by gradual effusion of blood under the perichondrium, which is stripped
from the cartilage, or, in some cases, by an effusion within the cartilage.
The effused blood may remain some time in the cystic stage, absorption
finally taking place, and the ear becoming dry and shrivelled. When this
bloody swelling appears, the prognosis is very unfavourable. Some have
attributed it to a traumatic cause, but its gradual manner of coming on,
its symptoms and duration, are widely different from those of a contusion.
Dr, Stiff, who has investigated its nature most carefully, believes that
there is no foundation for supposing it to be produced by injury.—
(‘‘ Hematoma auris,” Brit. and For. Review, 1858.) At the beginning its
progress may be checked sometimes in a remarkable manner by painting
the ear with a solution of cantharides,
vit] THE SYMPTOMATOLOGY OF INSANITY. 385

poverty has caused more suicides than any insane delusion
except the fear of hell. Certainly it seems curiously inconsistent
that the patient who is unspeakably miserable because he has
sinned beyond hope of pardon, and expresses the utmost agony
because his soul is doomed to eternal damnation, should be so
frequently driven to precipitate the fate which he dreads, and
the dread of which he believes to be the entire cause of his
misery on earth. Therein nature shows itself deeper and
stronger than creeds; by an impulse whose roots go far down
below any conscious motive it declares its certainty, and seeks
the relief, of the annihilation of a tormented self. One may point
out to the unhappy sufferer that, by his own showing, suicide
will only be the entrance to a greater and an eternal weight of
anguish ; he will acknowledge that he knows it too well; never-
theless he is urged irresistibly by an inspiration from the depths
of his being to get quit of the intolerable burden of life. In the
same way an exaggerated fear of poverty oftentimes causes the
melancholic to put an end to his apprehensions by suicide: he
may be deemed to act from an implicit certitude that there is
nothing in life of such worth, and nothing after it of such
account, as to make it reasonable to bear so great suffering.

It is most certain that the happiness of living is constitutional,
and very different in different persons, some having but little of
it, while others feel it so keenly that they cannot conceive any
one should feel weary of the sun, or believe him if he says so.
However miserable they may be they have not the least inclina-
tion or desire to end their sufferings by death: so long as they
breathe it is a happiness to breathe. Little as they can conceive
it, however, there are persons afflicted with a constitutional
melancholy who have no sense of positive enjoyment in living,
who go through with life as with a task that is to them at best
indifferent, at worst burdensome and painful, and who at certain
times, when more out of tune than usual, are oppressed with a
desponding sense of the dreary emptiness of life, with a deep
disgust of the meanness and meaninglessness of its strifes, with a
weary apathy from all its interests. If wise, they betake them-
selves to steady work, wherein they gain a refuge from the
thoughts and feelings which come of idleness and reflection;
386 PATHOLOGY OF MIND. [cmar.

if unwise, they may resort to alcoholic stimulants in order to
counteract their depression and to get the joy of a temporary
exaltation of mind—a treacherous remedy, which yields transient
relief at the cost of a future misery that may end in suicide. On
persons of this melancholic temperament the suicide of a relative
or an acquaintance, if such chance to occur, fastens and has a
singularly powerful effect; it strikes the note of life-weariness
which is inbred in their nature and vibrates habitually in their
feelings, and they feel themselves urgently impelled to follow
the example set them.

The essential difference between an optimistic and a pessi-
mistic view of life is simply a question of temperament, and
arguments as to which is the right view between persons
who have no common ground to meet upon may be amusing
literary exercises, but they are not profitable. One person, as
he gazes into the fathomless depths of the heavens on a calm
and cloudless night when all around is silence, or, in a stillness
that is almost felt, looks down from some Alpine height upon
a mighty range of snowclad mountains resting one upon
another in their eternal and majestic repose, is oppressed
with so overwhelming a sense of the vastness and duration of
that which is not himself and of the petty meanness and insig-
nificance of life, that he wishes its fitful fever were over, and
his individuality merged into the great whole whence in an evil
hour its elemental atoms took component form: it is a desire to
be one with nature which is the outcome of a want of sympathy
‘vith the fleeting aspirations and achievements of his kind.
Another persou in similar circumstances has no more sense of
such a mood than a blind man has of colour or a deaf man of
sound: the glory of a fine night to him is that he can walk out
and smoke his pipe, the grandeur of a mountain height that he
can rest and eat comfortably after a long climb. If we justly
weigh these differences of temperament it will appear that when
the man hanged himself in order that he might be no longer at
the trouble of putting off and putting on his clothes each day,
his deed did not outgo the motive so disproportionately as is
commonly assumed.

Whe: T have reasoned with melancholics who felt themselves
iL] THE SYMPTOMATOLOGY OF INSANITY. 387

impelled to suicide against the right of any one, however
miserable, to put an end to his life, and have pressed upon
them the commonplace arguments—that it is base for a soldier
to desert his post; that each one is bound to stay and pro-
vide and care for the children whom he has brought into the
world, whatever may be his own desire to get out of it; that
it will be a wicked thing on his part to leave to his family the
stigma which he will do if he kills himself; that he will do in a
moment of despair an irreparable act which, did he go on living,
he might have a thousand occasions bitterly to regret—and the
like; I have found the reasoning, though assented to probably
with the lips, to have little practical weight with them in their
calmer moments, and no weight at all when the paroxysm of
ancuish overwhelmed them. The penalties which society has
attached to suicide, in order to express its condemnation of it as
an antisocial offence, a criminal desertion of duty on the part of
one of its members, a revolt against the conditions of human
progress, will not touch one who thinks meanly of society and its
highest aims, and foresees in imagination the time when the
countless myriads of the human race withits work and worries
will have disappeared as completely as so many myriads of
creeping ants with their works and worries.

The real effective force against suicide is the instinctive love
of life, and when a man has lost that he has no appreciation of
the good reasons that may be given for living ; they fail to touch
and to take hold of him. Just as the movements necessary to life—
those of the heart and of respiration—are independent of human
moods and will, so there is infixed in the intimate constitution of
man’s being a stronger power than could ever come of delibera-
tion or be exerted by will to ensure the continuance of life.
The instinct is the ontcome in consciousness of the fundamental
property of all living organic elements to assimilate and to in-
crease, without which it would not be living matter—a property
which, declining with bodily decay, extinguishes gradually the old
man’s love of life. When a person’s temperament is such that
he cares not to live, it marks a defect of that furtdamental organic
nisus or energy; if, under the spell of a morbid depression, he
actually commits suicide, it is proof that the organic element
388 PATHOLOGY OF MIND. [ctAP.

was then so wanting in this fundamental quality that it. could
not assimilate and increase, but must be assimilated and decrease ;
wherefore an act of self-destruction is always proof of a sufficient
reason, and there is no more to be said. The one great argument
against suicide I take to be the instinctive love of life; the one
convincing argument in favour of suicide is the loss of that
instinct.

Some melancholic patients show by despairing expressions
that the idea of suicide is in their minds, or they utter their
fear or conviction that they shall do it some day. Albeit it is
a common, it is an erroneous, notion that those who talk of it in
that way will not go on to act; they may talk of it for a long
time and yet commit suicide at last. The idea is familiar to
their minds; it has lost the horror with which it startles the
mind when it first occurs to it; opposing feelings and consider-
ations are not so actively roused to combat it; during an acute
paroxysm of misery, when the despair is overwhelming, the
ever present idea, which has perhaps been toyed with in the
first instance rather than seriously entertained, is carried into
convulsive effect. Everybody learns by experience that, if he
would not have an unwelcome idea grow in his mind until it
gains undue power over it, it is of the first importance to dismiss
it while it is yet a stranger; and assuredly constant thinking
about death makes the way to suicide easier. Very few persons
have committed suicide who have not pathetically hinted or
expressed on some occasion or other the danger in which they
were; but having been met by incredulity, or banter, or a
boisterous and unsympathetic encouragement to get rid of such
foolish ideas, they have shrunk back from making further con-
fidences, and have shown by the sad event how earnest their
slighted fears were. Oftentimes the balance shall oscillate for
a long time between the impulse to live and the impulse to end
life, and it may be that a slight change of mood, a very straw,
will turn it this way or that. As I have said already, the early
morning, when they awake too soon to renewed suffering and,
tossing about in misery, go through in imagination the apprehen-
sions and fears of their morbid state, is a particularly dangerous
time for melancholic patients who are suicidally disposed.
viuL.] THE SYMPTOMATOLOGY OF INSANITY, 389

Different from the ordinary melancholic who commits suicide
in consequence of a delusion or in order to escape from the
intolerable misery of his state is he who, free from delusion of
any kind, is possessed by a single, strong, dominant impulse to
do it. He is the most dangerous to himself of all melancholics :
he may reason about the morbid impulse almost as wellas a
perfectly sane man could, he may deplore it, be in despair about it,
and may even pretend a thankfulness to have got quit of it; but,
notwithstanding his own knowledge of its nature, and notwith-
standing the greatest watchfulness on the part of those around
him, he usually succeeds in the end in carrying it into effect,
either suddenly at the instigation of a favourable occasion, the
sight of means to do the ill deed making the ill deed done, or
methodically with cunning foresight in plan and ingenuity in
execution. It is where some other member of the family ina
former generation has committed suicide, and where the impulse
therefore has its roots deep in the foundations of the person’s
nature, that it is most powerful, most independent of reflection,
most persistent, and most likely to have its way in the end.

Other dangerous impulses displayed by some melancholics
are homicidal. Like suicide, homicide may be done in conse-
quence of a hallucination or of a delusion: in a few instances
the patient hears a voice commanding him directly to kill, or
has some extravagant delusion that he must sacrifice life in
order to confer a great benefit on the world; most often he
believes himself to be the victim of a malignant and persistent
persecution, by which he is driven at last to such a frenzy that
he attacks and perhaps kills his imagined persecutor. Poisonous
fumes or vapours are diffused through his room in the night, or
indecent assaults are made upon him in his sleep; strangers
call him offensive names, or make abominable accusations, or
use insulting gestures as they pass him in the’ streets; his
enemies have caused him to have some obscure disease which
is slowly wasting his manly vigour, or prowl around his premises
and interfere in his affairs, so that nothing prospers with him;
if he has a smattering of education he will say that his nerves
are tortured by the secret use of electricity or by some more
mysterious agency; but if he is ignorant and superstitious he
390 PATHOLOGY OF MIND. [cuap.

fancies tl.at he has been bewitched, Worn out by what he
suffers, he appeals to the police or to the magistrates to protect
him, and, getting no redress from them, arms himself in self-
defence with dagger or revolver ; changes his lodgings frequently
in order to elude, or tries all sorts of schemes to frustrate, the
machinations of his persecutors; goes on from week to week,
from month to month, and perhaps from year to year, suffering,
complaining from time to time to the authorities, scheming to
protect himself, and at last is brought to such a pitch of despe-
ration, or so far loses self-control under the influence of a
temporary bodily disorder, that he makes a fatal attack upon
some person who is innocent of having done him the least harm.
A suspicious husband is sure that his wife is unfaithful to him,
on grounds that are ludicrously inadequate to warrant the sus-
picion, and, sensible as he seems in-other respects, sees proof of
what he grossly imagines in the most trivial and innocent inci-
dents, believing adultery to be committed in almost impossible
situations; he broods over his calamity until it becomes an
insupportable wrong, and in the end perhaps takes a fatal
revenge upon her or upon her supposed paramour.

Patients who, having such delusions of being wronged or per-
secuted as I have described, exhibit deep brooding depression,
and especially those of them in whom the depression is of a
hy pochondriacal, sullen, and moody character, are often very dan-
gerous to others and ought not to be suffered to go at Jarge; for
it is impossible to predict at what moment the fury bred of
their insane feelings and ideas may sweep away self-control and
hurry them into a deed of desperate violence. However, not
every one who has delusions of persecutions is necessarily a
dangerous lunatic: each case ought to be judged upon its merits,
the character of the patient and the special features of his
depression being weighty facts to be taken into account. Some
who are thus wrong-minded are of an open disposition, talk
freely of their troubles, and are for the most part tolerably
cheerful: they proclaim their grievances loudly to all the world,
declaim vigorously against their enemies, appeal repeatedly to
the police and to courts of justice, write to the Queen,
threaten what they will doif a stop is not put to the persecution,
vu] THE SYMPTOMATOLOGY OF INSANITY. 391

are great social nuisances, but do no serious mischief, being
satisfied for the most part to proclaim their wrongs. Moreover,
women are less dangerous than men, since it is not the custom
of women to resort to personal violence to avenge their wrongs ;
old men are less dangerous than men who are in the turbulent
vigour of youth or in the more sedate vigour of manhood, since
with the decay of passion and energy that marks the decline of
old age it becomes more easy to endure and less easy to retaliate.
Persons of an energetic, self-asserting, and dictatorial tempera-
ment are more dangerous than persons of an opposite self-dis-
trusting temperament, since they will be disposed to attack others
while the latter will be more likely to do harm to themselves.
So far I have taken notice of homicide done in two conditions
—unamely, directly at the instigation of delusion, and under the
compulsion of passion bred of insane delusion. In the latter
case the passion, be it jealousy, envy, anger, revenge, is so much
like ordinary passion that it is sometimes hard to think a person
who yields to it is not perfectly responsible for what he does ;
sane or insane, it may be thought, it was his duty to have con-
trolled a passion whose evil nature he was conscious of. But
he might know its nature and yet not be able to control it.
Because an insane person feels the same passions as a person
who is in his right mind, it by no means follows that he is
therefore sane, as many persons seem incontinently to assume,
or that he has the same power of control over them. The
passion is easily kindled in a diseased mind, smoulders there in
consequence, and from time to time is inflamed by the insane
delusion which accompanies it; and before we venture to assume
that he could and should always check or quench it, we ought
to be sure that the disease from which it has sprung has not so
inflamed it and so weakened the will as to render the contest
between them an unequal and forlorn one. It is notorious that
a sane person when under the dominion of strong passion is
carried out of himself to do acts which he would never do in
his temperate moments—that his passion is truly a short mad-
ness: how absurd then is it to exact that in the unsound mind,
where consensus of functions is weakened or destroyed by
disease, the morbid passion should be always under control !
392 PATHOLOGY OF MIND. [cHaP,

As a matter of fact it is not: just as when there is disease of
the nervous system a movement is easily provoked and made
convulsive which is perfectly under control when the person is
in good health, so when there is disease of mind a passion is
easily provoked and made uncontrollable which is kept in
subjection when the mind is sound.

I ought not to omit to mention that homicide, like suicide, is
done in some instances during a paroxysm of melancholic panic,
without premeditation, without reflection, without distinct mo-
tive, almost without consciousness at the time. The unfortunate
sufferer is so overwhelmed with the anguish of the moment that
it must find an outlet in some discharge of frantic energy ; and
when the act is done, he obtains ease and calm, comes to himself,
and for the first time realises the gravity of what he has done.
So far from evincing the distress and remorse which might then
be expected, he has perhaps the apathetic look of a person who
is exhausted or stupefied by violent emotional agitation.

Closely akin to these cases are those in which a melancholic
father or mother kills one or more of their children from
motives which, if an attempt be made to give an account of
them afterwards, seem singularly inadequate. The sort of
alleged motive is perhaps that they could not bear to see them
starve, and felt it would be better for them to be dead; or they
may not be able to say what motive they had to kill them ; the
truth being probably that there was not a clearly conceived
motive at the time, that the act was done in a paroxysm of
melancholic anguish, and that the person, when pressed for an
explanation, lays hold of any gloomy idea that he may have
had, however inadequate, which appears to be an explanatory
motive. Perhaps it was that just before the deed a frenzied
idea that they must do it started up suddenly out of the sub-
stratum of deeply despondent feeling under which they laboured
and hurried them into the homicidal act.

Lastly, there are those more chronic cases of which I have
already spoken under the head of impulsive insanity, where the
unfortunate person is afflicted by a homicidal idea, sometimes
quiescent, at other times so active that he is in an agony of ap-
prehension lest he shall yield to it, but hardly ever leaving him
VIIL.] THE SYMPTOMATOLOGY OF INSANITY. 333

free from its tormenting impulses. He may be so much depressed
in some instances as to present a picture of genuine melancholia ;
but in other cases it is remarkable how little evidence of his
sufferings is presented to outsiders, who may be quite ignorant
of what he undergoes until he confides his sorrows to them.
The course which melancholia runs is to recovery in half or
more than half the cases. In almost all cases there are great.
variations from time to time in the intensity of the symptoms,
and these variations sometimes take place very suddenly: a
patient shall be calm and composed in the afternoon who was
in a perfect frenzy of agitated distress in the morning. Some-
times there are complete intermissions of the symptoms for a few
hours or for a day, and then they return in all their intensity.
For the most part these sudden conversions from deep gloom to
apparent sanity are not to be relied upon to be lasting; but I
have met with two instances in which the recovery was quite
sudden and yet was lasting, the acute melancholic symptoms
having ceased abruptly, without the least sign of so happy an
event having been noticed beforehand. Usually when recovery
really takes place, it does so by very gradual steps, the patient
going up and down, but on the whole making an ascent: he
begins to notice and to interest himself in what is going on
around him, although he is probably very unwilling to have it
observed that he is doing so, and may abandon these hopeful
beginnings if they are imprudently commented upon in his
presence as proofs of improvement; he will take up a news-
paper and look at it if no notice be taken, putting it down
at once if attention is drawn to him or declaring that he is
not interested in it and cannot even understand it; he is less
averse from being made personally clean and tidy, or begins
himself to have a little care for his appearance; he employs
himself in some way, and evinces the return of his natural
affections and interests by inquiring, at first timidly as if he were
ashamed of his new-born interest, and afterwards openly, about
his family and his affairs. These indications of natural feeling,
though slight, are happy omens; they are breaks in the dark
mist of feeling which has overspread the intellect, but which
is now beginning to rise and will probably go on to do so until
394 PATHOLOGY OF MIND. (CHAP,

the whole mind is clear. Meanwhile the delusions lose energy
and abate in activity; he speaks less often and less openly of
them, and shows by his behaviour a commencing doubt or dis-
trust of them, though he will still_probably hold to them when
directly challenged; by degrees they fade away, as healthy
thoughts and work engage more and more of the attention,
and at last he comes to himself entirely, as one who has
awakened with joy out of a dreadful dream which was incon-
ceivably real while it lasted. An animation of the bodily
functions goes along with the brightening of mind: digestion
improves, the bowels act more regularly of their own accord,
the skin and hair lose their dryness and harshness, the nutrition
generally is better, the circulation is more vigorous, and the
suppressed menstrual functions in women are restored. The
recovery in most cases is within from three to twelve months
from the outbreak of the illness; after twelve months have
passed without signs of amendment it is less probable, but still
not hopeless; for many instances are on record in which it
has oceurred at a later period, and there have been a few ex-
ceptional instances of recovery after years of suffering. Some
melancholics, particularly those who have had delusions of
persecution, never return entirely to good feelings and abandon
their suspicions even when they are supposed to be recovered :
they will not sincerely admit that they have been ill, are hostile
to those who have put them under treatment or who have
treated them, and maintain that there was no reason whatever
for interfering with them.

The‘course of melancholia, when it is not to recovery, is to
one of four issues: either it lapses into a chronic state which
continues for the rest of life; or it goes on to such increasing
mental weakness as to become actual dementia; or it ends in
death from exhaustion, aided commonly by some intercurrent
disease—phthisical, cardiac, or abdominal—and especially phthi-
sis; or lastly, it now and then passes into the opposite condition
of mania, the patient disappointing the confident expectations of
recovery which his symptoms of returning animation raise,
by the supervention of an extreme elation and by getting more
and more excited until he is actually maniacal,. When this
vulr.] THE SYMPTOMATOLOGY OF INSANITY. 395

transformation takes place it is not of good augury, for it is too
probable that there will be a return of the depression after the
excitement has subsided. Death is owing in some cases to
exhaustion consequent upon persistent refusal of food, the fatal
event being hastened at last either by diarrhcea or by a low
form of pneumonia, which sometimes passes quickly into gan-
grene of the lung. It is obvious that the great and general
depression of nervous tone is very suited to increase, very
unsuited to check, any disease that may be going on in other
organs than the brain; wherefore the prognosis concerning such
disease will always be more grave than where there is no
nervous depression. aes

Mania.

I go on now to describe the class of symptoms of mental
derangement which it is agreed to call mania. The dominant
note of them is an excitement or exaltation of the self-feeling,
which finds outlet in a sense of extraordinary well-being, in
elated ideas, and in self-confident actions of the most extrava-
gant kind. In a féw cases acute mania has come as a sudden
explosion without any premonitory symptoms, after some
powerful moral impression, or after great physical exhaustion,
or after excesses of some sort; but this sudden outbreak is un-
usual, and when it has occurred there has probably been a
strong hereditary predisposition to insanity. Most often there is
a forewarning of the calamity—a precursory stage of depression,
of shorter or longer duration, sometimes so short as to escape
notice, at other times lasting for weeks or even months; the
patient feels sad, ill, apprehensive, without knowing why,
having a vague foreboding of some misfortune being about to
happen; perhaps he has a definite fear that he will go mad, and
anxiously seeks medical advice for himself. Like the unac-
countable sadness which sometimes goes before the outbreak of
a fever, his depression is the projected shadow of a coming
calamity, a forefeeling of it which is replaced after a time by an
opposite state of great excitement, sleeplessness, restlessness,
unbounded self-confidence, extravagance of conduct, rapid flow of
imperfectly associated or entirely incuberent ideas, and by hallu-
396 PATHOLOGY OF MIND. [cHaP.

cinations and delusions of various kinds, with utter scorn of the
suggestion of medical advice; for he is now as exultant as he
was down-hearted a little while ago. In a few instances I have
noticed that ecstatic visions during the night, perhaps of a very
vivid character, have gone before an acute maniacal outbreak ;
insomuch that if an elated patient has seen in the night an
angel who has brought a message from heaven, or has heen
visited by Jesus Christ, I look forward to a very acute attack
with great excitement and violence, and possible death by ex-
haustion. Lastly, the outbreak of acute mania may be the
gradual development of a chronic state of moroseness, sus-
picion, restlessness,—the outcome of a sort, of subacute state
which has increased by degrees until it has culminated in an
acute attack. The experienced physician is not always sorry to
see the frantic outbreak in such case, since he feels a hope that
after the mind has gone through the furious storm it may be
found free from the morbid thoughts and feelings which, while
the malady was chronic, could not be gathered to a head and
dispersed ; the result being much as when a chronic inflamma-
tion which has defied treatment is found to have gone after the
supervention and disappearance of a more acute inflammation.
It is impossible to describe adequately the conduct of a
person during acute mania; for it is all that imagination can
picture of the ridiculous, the noisy, the fantastic, the furious,
the violent, the disgusting, in different cases. The distempered
moods and ideas are translated instantly into excited acts, which
may be,of a harmless kind, as singing, shouting, dancing, writing
endless letters to great personages, rearranging in methodical
disorder the furniture of the room, tearing up grass, and the like
meaningless, busy activity; or may be threatening, abusive,
violent, and destructive, especially where opposition is offered
to the instant gratification of the mood, or to the realisation of
the scheme of the moment. Between the sane and insane being
the contrast is so extreme that it is not easy to realise that they
are the same person: at one time, for example, we have the
graceful, modest and delicately-nurtured young lady, whose
every word and act are gentle and refined ; at another time we
are amazed and horrified at the coarse and indecent gestures of a
Vul.] THE SYMPTOMATOLOGY OF INSANITY. 397

furious virago, her volubility in the use of abusive, blasphemous
and obscene words, which it is hard to believe she ever could have
heard, her bold and ferocious mien, her violent and destructive
acts. She is morally naked and not ashamed, as she would make
no scruple to be corporeally in some instances. Day after day
and week after week this demoniacal state continues; at last
it subsides, passes off, and once more we have the modest and
gentle lady whom it seemed inconceivable we should ever see
again.

Before matters have reached this height of incoherent fury
there are symptoms which it will be well to consider briefly.
The patient, in the first instance, is often happy beyond
measure in an extraordinary feeling of unfettered mental power,
evinces a supreme self-confidence and elation, and acts and
looks very much like a person who is half intoxicated. His
natural reserve and prudence are replaced by contident address,
by vainglorious pretensions, by bold and reckless projects;
nothing is difficult to him; he conceives and is eager to put
into action grand schemes of pecuniary speculation, or of politi-
cal reform, or of scientific discovery; he will sing who knows
nothing of music, or will frequently and confidently speak at
public meetings, though a speech in public would be the last
thing he would try to make were he in his sound senses; withal
he is sly, crafty and untruthful! It cannot be denied that he
sometimes evinces acute insight, recalls forgotten ideas, makes
witty and satirical remarks, puns cleverly upon words, strings
together rhymes, hits upon acute comparisons, and displays
eloquence of speech, after a fashion that transcends the range
of his sane capacities. So far there is a resemblance between
mania and the prophetic frenzy—pavin and pavtixy; in both
there is an inspiration which giveth an unaccustomed under-
standing, an inspiration which, being involuntary and not in
the least due to any conscious exercise of faculty, but due to
the exaltation of feeling arising from the organic state, shows

1 “¢T then felt so happy! my memory was clear and facile, and nothing
fettered my mind, but at the same time I was crafty and sly, nay mali-
cious.’? These were the words of a patient after his recovery to Dr,
Willis,
398 PATHOLOGY OF MIND, [cuaP.

how little consciousness and will have to do directly with the
highest products of mental activity. This stage of premaniacal .
brilliancy in no case lasts long; impatient of interference, the
patient is easily irritated by opposition, however gentle it be, and
gets much excited if it be at all serious; and in any case his
state of exaltation is likely to run quickly into incoherent frenzy.
Let it be particularly noted here how the overthrow of
reason is accompanied and, indeed, preceded commonly by a
perversion or destruction of moral feeling ; the last acquisition
of social culture in the most advanced races of men being the
first to show the effects of the disorder whose end is to make
the individual a social discord. Candour is supplanted by craft,
veracity by cunning misrepresentation or actual falsehood, re-
serve by impudence, modesty by indecency, refinement of feeling
by coarse indelicacy, family affection by indifference or even by
hatred and malice. The delicate and refined inhibitory feelings,
which are the last acquisitions of culture, are submerged while
the storm in the supreme centres lasts, and the coarse and
deeper-rooted impulses of the animal nature, and of the human
nature in its lower relations, come to the front and dominate
the conduct. One sees a similar illustration of this early para-
lysis of the highest inhibitory functions of mind in the tem-
porary changes which an alcoholic excess produces in the moral
characters of most persons; for moral feeling and the highest
will are notably weakened at an early stage of intoxication.
And just as it is with the person who is not too far gone in
intoxication, so it is with the insane person who is not too far
gone in acute mania; he may on occasion pull his scattered
ideas together by a strong effort of will, stop his irrational
doings, and for a short time talk with an appearance of calm-
ness and reasonableness that may well raise false hopes in in-
experienced persons. It is a deceptive calm; although a strong
impression, rousing and holding the attention, will balance the
mind for a short time, the turmoil of wild and whirling ideas
soon recurs and is expressed in an answering incoherent volu-
bility of speech and endless freaks of conduct. All the while
the patient knows well what he is doing, and will say, after his
recovery, that he was quite aware of the consternation which he
a

THI] THE SYMPTOMATOLOGY OF INSANITY. 399

caused, but had an indescribable pleasure in yielding to his
impulses and no desire whatever to check them.

There is probably no definite and abiding delusion ; an idea is
no sooner conceived than it is either discharged in action or
thrust out of attention by another, so that there is not time,
even were there the inclination, to examine its bearings and see
that it is a true idea. Jllusions are frequent, the patient mis-
seeing oftentimes what he sees; for while a true perception is
the resultant of the external object plus the fitting idea, it is
now a chance what idea may be active at the moment when the
external’ object presents itself to sense, and how, therefore, the
object is interpreted. Hallucinations, too, come and go, for the
sensory centres of the excited brain are stimulated to sensa-
tions which, as in dreams, are transformed into external realities.
Patients will imagine that they hear voices address them, and
will answer them angrily; or they see persons who have no
actual existence, or more commonly they declare those whom
they do see to be others than they are; or they smell strange
odours and taste strange substances in their food; or they feel
singular pains or shocks in their bodies, which they attribute to
the malignant agency of enemies who are playing tricks upon
them. There can be no doubt also that some have motor
illusions and hallucinations: one who is lying in his bed fancies
perhaps that he or it is moved upwards or downwards, or that
his limbs are flying through the air; the disordered motor
centres give rise to the sensations of such movements, and these
are thereupon imagined to be real. I think that the great
restlessness of the patient who frequently cannot remain still
for a minute betrays also the excitement of the motor centres ;
for he seems to be overpowered by veritable impulses to be
continually on the move without having definite motives for
his movements. In truth, the whole nervous mechanism is in
a disordered commotion: the person is maniacal to the ex-
tremities of his nerves. Therein we have the explanation of
the facts which led Pinel to think that the primary seat of
mania was usually in the abdominal organs, and that the intel-
lectual disorder was propagated thence by a kind of irradiation;
appealing in support of his opinion to the voracious and capri-

18
400 PATHOLOGY OF MIND. [cHAP.

cious appetite and to the abnormal intestinal sensations which
lead to the drinking of large quantities of water or of other
liquids; to the restlessness, sleeplessness, agitation and panic
fears; to the disorder and confusion of ideas shown, not in
what the patient says and does only, but in his gestures,
demeanour and aspect.

The following example of ordinary acute mania will serve to-
illustrate what I have said concerning its symptoms :—A mer-
chant, of some originality of thought and of much energy of
character, became insane, after making a considerable fortune
entirely by his own abilities. His mother had died insane.
After slight depression, followed by certain speculative trans-
actions in business which rather astonished his friends as being
opposed to his usual cautious manner of doing things, he broke
out into eccentricities and extravagances of behaviour, with
which was associated an unaccustomed liveliness; he acted
very much as if he were intoxicated, turning his pictures with
their faces to the wall, putting chairs in queer positions, walk-
ing about the garden bareheaded and singing: he was, indeed,
singularly elated, talkative in a rambling way, and eccentricly
and aimlessly industrious. If spoken with, he was lively,
witty, original, and satirical, laughing with a laugh of peculiar
harsh and metallic ring: still he could control himself for a
time, assume instantly an aspect of grave deliberation, and
speak with a marvellous assumption of calmness if he pleased.
He would listen to advice, appear to consider it deeply, and
perhaps profess to approve it; after which he immediately fell
back into his eccentricities. There was so far much more
insanity of feeling and conduct than of thought: his condition
might be said to represent an acute form of that stage of
disease which has already been described as the mildest form
of hereditary insanity, Degeneration proceeding, however, he
became in a few days much worse: he raved incoherently in
conversation, was violent in action, and not amenable to con-
trol; his language was obscene and disgusting, his behaviour
not less so; and he represented very completely the condition
of a furious maniac whose habits were of the worst kind. His
tastes were depraved, and he would eagerly seize and swallow
VIII.) THE SYMPTOMATOLOGY OF INSANITY. 401

the filthiest matters; and he occupied himself busily in doing
the dirtiest. acts, chanting a wild chant or talking in rapid in-
coherence the while. In the worst extremity of his frenzy,
however, there were plain indications of a consciousness of his
extravagances and a capacity to control his actions in cer-
tain regards, which could not fail to give his conduct the
semblance of a witting and wilful defiance of the feelings and
opinions of those who had to do with him. As the fury of
this stage somewhat. subsided, various delusions—as that he
was made the victim of medical experiments by night and by
day, but especially by night—were exhibited: the strange
disease-produced feelings nowise conforming to the order of
his previous experience, and a vague feeling probably that he
was the agent of acts not truly his own, were interpreted as
the results of external malicious agencies, as they were plainly
not within the compass of his knowledge and voluntary
control.

This condition of things lasted for more than a week, after
which, as the excitement and delusions disappeared, there en-
sued a state of gloom and profound moral disturbance. He was
possessed with a great hatred of all his friends; was sullen,
morose, and gloomy ; misrepresented in the unfairest way every-
thing which had been done to control him—and he had an
excellent memory of what had been done—as deliberate cruelty;
misinterpreted any kindness or act of attention from his rela-
tives; refused his food or took it most capriciously; and,
although all positive delusions seemed to have vanished, it
was plain he looked upon others as responsible for all his
sufferings and extravagances. One might reason with him, but
even if he acknowledged the justice of the arecuments, which he
sometimes did, it was a hypocritical affectation ; for to another he
would immediately afterwards set forth his unparalleled griev-
ances in the most perverse and untrue manner—more untrue
because he ingeniously twisted and perverted some little truth.
When well, he was said to have displayed a scrupulous regard
for truth. There was no intellectual incoherence: he told his
story so coherently and with such an appearance of moderation
in his complaints, accusations, and statements as to actually
102 PATHOLOGY OF MIND, [crap.

succeed in imposing upon an influential friend, who, himself a
most honourable man, was so much impressed by the plausible
way in which he accounted for all his peculiarities as conse~
quences of the position in which he was placed, or slurred them
over, that he represented in the strongest. possible manner to his
immediate relatives the injustice of keeping him any longer
under restraint. Accordingly, in this condition of imperfect
convalescence—of unquestionable moral or affective insanity—
and in opposition to medical remonstrances, he was released
from restraint; all the people in his neighbourhood thinking that
he had been most unjustly confined. The consequence was that
in the course of a few weeks he so managed, or rather mis-
managed, his property—selling stock at great loss and giving
away large sums of money under the most absurd pretences—
as to afford an excellent harvest to the lawyers, and greatly to
impoverish his children. It was found necessary to place him
under restraint again. The event proved that the mania was
recurrent, for after he had been in an apparently rational state
for three or four weeks the excitement used to return and to go
through exactly the same course.

In this case then we note a short period of unquiet and un-
accountable depression which was the foreshadow of the coming
calamity ; quickly followed by a stage of so-called exaltation, in
which the patient seemed to be in an exuberantly happy state,
as though transported with some joyful tidings, and perpetrated
various extravagances of speech and action as though from an
overflow of life. Some have not hesitated to describe this
condition as one of increased mental power and activity. The
real state of the patient is rather one of irritable weakness: he
is unduly impressible, abnormally excitable, and reacts in sudden
impulses of feeling, thought, speech, and action, which, though
they may be sometimes brilliant, more resemble spasms than
anything else; he is entirely unequal to a calm reception and
discrimination of impressions and a subsequent quiet reflection
and final intelligent act of volition—to that complete co-ordina-
tion of mental function which is implied in the highest mental
activity. The condition of nerve element which is the basis
of this excitability is a reaction after the preceding depression,
Vill.) THE SYMPTOMATOLOGY OF INSANITY. 403

and it marks the beginning of a degeneration which, if not
checked, will go on to the further stage of positive maniacal
degeneration of mental function—like as the reaction of other
kinds of organic element that have been chemically or mechani-
cally injured passes into inflammation and purulent degenera-
tion: it isa state of instability of constitution not unlike that
which is the condition of the mildest forms of hereditary in-
sanity, where, as already pointed out, striking exhibitions of
particular talents occur sometimes.

Striking in this case was, what is often heard in other cases,
the harsh ring of the strangely altered voice. This maniacal
change in the tone of voice, which is apt to grate on the sen-
sibilities of those unaccustomed to hear it, testifies, like the
deranged thought, perverted sensibility, and furious conduct, to
the profound and general disturbance of the nervous system,
In almost every disease, but especially in insanity, there are a
great many unobtrusive and almost entirely overlooked symp-
toms in which nature speaks, attention being fixed on a few
prominent symptoms. In insanity, for example, besides the
changed tone of the voice, there are peculiarities in the expres-
sion of the countenance, in the look of the eye, in the posture
of the body, constituting the physiognomy of the disease, which
deserve exact study. Such signs may show whether the patient
is suicidal, and in what degree—whether there is a desperate
impulse that, like an evil fate, governs his mind and waits and
watches for opportunities, or whether a fluctuating impulse is
excited to activity by opportunities. Again, there are great
diversities in the character of what we confound under the
general name of pai, as well as in the character of those mani-
fold modifications of sensibility which fall short of pain, so much
complained of in some forms of mental disorder, all which have
their specific meanings had we but the knowledge to interpret
them. Two circumstances, noteworthy in many cases of in-
sanity, were marked in the case under consideration: these
were the peculiar indescribable odour of the patient—the
bouquet de malades of lunatic wards—and the intensely offen-
sive character of the intestinal excretions. Most likely there
is some unknown chemical change produced in the excretory
404 PATHOLOGY OF MIND. [cnap.

functions by the profound nervous disturbance, not otherwise
than as secretions are altered in composition by passion; the
effect attesting, as other effects just mentioned do, the essential
interaction of the mental life in the whole bodily life, and the
impossibility of separating, save in thought, mental and bodily
phenomena. It behoves the inquirer therefore to carry with
him to the investigation of every case of insanity a deep sense
of the importance of scrupulously studying every sign of
physical disturbance, motor, sensory, or nutritive, as welk as
the prominent mental symptoms.

The third stage of degeneration exhibited by the patient was
that of acute maniacal fury; of which it is not necessary to say
more than to direct attention to the evidence of the persistence
of a certain amount of self-consciousness, and to the occasional
manifestation of a certain power of self-control for a moment.
This is the more necessary because of the ill-founded criterion
of responsibility sanctioned by English law, or rather by Eng-
lish lawyers. Certainly this patient, at all but his very worst
moments, and perhaps even then, was conscious of what he was
doing at the time, as he had an exact and complete memory of
it afterwards, and was quite aware that it was disgusting and
offensive to those around him; he had even some power of self-
control at times, as he would not do before me offensive acts
which he would not scruple to do before attendants; so that
if the legal criterion of responsibility had been strictly applied
to his conduct, he, though suffering the extremity of mania,
ought not to have escaped punishment. As the frenzy sub-
sided and delusions appeared, the disease becoming more
chronic, we might say that a fourth brief stage was passed
through—a stage characterised by the persistence of ideational
disorder ; that is, not only of morbid ideas, but of the morbid asso-
ciation of ideas, after excitement of conduct had ceased. From
this state the patient soon passed into a well-marked stage of
affective insanity, a condition which usually lasts for some time
after ideational disturbance has disappeared. The result of his
premature removal, while so suffering, affords an excellent illus-
tration of the truth of the observation of Esquirol, that the dis-
appearance of hallucination or delusion is only a certain sign of
VIII] TIIE SYMPTOMATOLOGY OF INSANITY. 405

convalescence when there is a return to the natural and original
affections. To this moral disorder an interval of apparent sanity
succeeded before the supervention of a new attack.

Now, if one chose to suppose each of the stages of disease
gone through by this patient to exist separately in some indi-
vidual and to be the disease in him—to conceive in fact the
progress of degeneration through generations instead of through
an individual life—then one might form a tolerably correct idea
of the varieties of mania that are met with. In one person
the fury of action may be most marked; in another, the de-
lirium of thought, chronic or acute; in a third there is a pre-
dominance of the affective disorder; and according to the pre-
dominance of one or other of these characters will the features
‘of the variety be determined. Eliminating the element time in
considering the nature of mental disease, and looking upon it
as a degeneration whose course may be through generations or
within the compass of a single life, we shall certainly get more
correct views of the relations which the different forms bear to
one another; a morbid phase, which would barely be noticed or
might be entirely passed over on account of its rapidity and
briefness in the individual, will be distinctly evolved and repre-
sented in the course that extends through generations; and a
phase of disease which might have too great importance or an
independent character assigned to it in the generation will re-
ceive its right interpretation by a consideration of the course
of the disease in the individual. Had this principle been at all
times clearly apprehended, it may be justly questioned whether
any one would have been found to doubt or misinterpret those
obscurer forms of mental disease which have been the cause of
so much unprofitable contention and angry feeling.

It must suffice to have indicated the main features of the
differences which acute mania exhibits in different patients,
according as it runs more in a motor, or ideational, or affective
groove, since a separate description of them would be a long
task and must entail a great dealof repetition. But there is one
variety of acute mania which is very like the delirium of acute
disease, and claims particular notice. It is really an acute
delirium rather than a systematised mania—the délire aigué of
406 PATHOLOGY OF MIND, [cuarP.

French authors—and is characterised by great excitement, entire
incoherence, apparently little or no consciousness of what is
going on around, extreme restlessness, and violent and utterly
unreasoning resistance to treatment; the course of the disease
being swift either to recovery or to death. The following ex-
ample will serve to illustrate it :—

A cook in a gentleman’s family, whose age was not known,
though plainly somewhere between forty and fifty, was rather
suddenly attacked with acute mania. Nothing was known of
her previous history, but she had been considered by her fellow-
servants to be a little peculiar, and she had suffered from a
chronic erysipelatous inflammation of one leg, which had dis-
appeared a short time before her attack of imsanity. She
had been ill seven day when admitted into the hospital, and
during the whole of that time had been noisy, violent, and utterly
incoherent; and she had taken no food for several days. On
admission her state was one of extreme delirious mania: she was
noisily incoherent, stripped off her clothes, rolled on the floor, was
unconscious of the calls of nature, and seemingly unconscious also
of what was said or done to her; she was continually spitting
frothy and sticky saliva, and her countenance was haggard, wild,
and painful to behold. She could not be got to take food, and it
was with the greatest difficulty that beef-tea, eggs, and brandy
were administered to her at frequent intervals. Morphia made
her sick, and did not make her sleep. This went on night and
day for a week, when she was reported to have become quiet;
but it was the quiet of complete exhaustion. Her pulse was so
feeble and rapid that it could not be counted, though up to the
moment of the collapse she had been as excited, noisy, and
restless as ever, and she still rolled about on the floor, tossing
her arms about and pulling at her clothes. Next day the heart
beat feebly 160 times in a minute, so far as could be made out
where no exact examination was possible. The skin was hot
and dry; there was extreme jactitation; and she drank fluids
eagerly, as she had never done before. There seemed to be
some abdominal tenderness on pressure, but one could not be
sure of it, Next day she was clearly sinking fast, and muttered
words which, so far as could be made out, were a request for
VIL] THE SYMPTOMATOLOGY OF INSANITY. 407

holy water: she was a Roman Catholic. Pressure on the
abdomen now produced evident shrinking. On the following
day she died. Though the issue was fatal in this case, it is not
so in all cases of acute delirious mania; it is however a disease
of the gravest omen, because of its liability to end in fatal
exhaustion. Whoever asks why the mania should take this
acute delirious form what peculiarity of individual tempera-
ment or of constitutional state is the cause that it breaks out
rather than the ordinary systematised mania—will ask in vain.

It is noteworthy in many cases of mania how complete and
acute is the memory which there is of the past during the
attack, and of all that has happened during it after it has
passed off; in other instances, however, the thoughts, feelings,
and events of the paroxysm are only remembered indistinctly
and confusedly, as though they had occurred in a dream. This
persistence of memory is a fact which it is well for those to
bear in mind who have the thankless office of taking care of
insane persons, since an impatient utterance, a harsh word or
act, a tone of ridicule, a sneering remark, a look of disgust, an
angry speech, may be remembered bitterly, and leave a sore
feeling in the mind when the frenzy has passed away. However
great the caution used, it will not be possible in every case
to avoid giving offence, for the patient, confounding persons and
things with his delusions, sometimes imagines those who have
the care of him to be the sole cause of his sufferings, and, after
his recovery, fails to recognise sincerely the true nature of his
frantic doings, which he will extenuate, excuse, or explain, as
having been provoked by the ill treatment which he underwent.
This is most likely to happen in recurrent mania and in those
cases in which the mental disorder is a pathological intensifica-
tion of a selfish, suspicious, and unamiable character—the
outcome, in fact, of ill-regulated thought and feeling fostered by
unwise habits of life. In such case he can hardly be said to
have been actually alcenated from himself, seeing that he has
not been radically changed; it is no wonder therefore that,
although seemingly recovered, he does not heartily acknowledge
his past morbid condition, but explains his incane feeling and
conduct as natural, and contends that though he may have been
£08 PATHOLOGY OF MIND. [cHap.

a little excited there was no insanity in it. In a few cases
of acute mania, especially those that run into the form of,
delirium, the patient forgets altogether the events of his mad-
ness, like as a dream is sometimes forgotten. A second or
third attack of mania will often bring back the same thoughts
and feelings which were displayed in a former attack, but have
been latent siuce, so that even attendants, when they perceive
them coming back, know well that an outbreak is at hand.
Herein we note a resemblance to what happens in epilepsy when
the aura forerunning the convulsions is the recurrence of an
idea or feeling, or the vivid recollection of an event, which has
uniformly gone before the fit on former occasions.

Looking to the extreme and long continued agitation, mental
and bodily, and to the loss of sleep in acute mania, the bodily
functions suffer less seriously than might be expected. In the
early stage the pulse is perhaps quicker, but this is owing to
the muscular exertions rather than to any febrile disturbance,
and it is afterwards scarcely accelerated. The temperature of
the body is only slightly, if at all, raised in ordinary cases,
except when it is hot from exertion; but in cases of a typhoid
type, where there is muttering delirium and the tendency is to
death from exhaustion, it may rise from three to five degrees
above the natural standard. In the insanity occurring during
convalescence from acute disease, Dr. Weber found only a
slight increase of temperature, although it had been raised
considerably during the acute disease, and rose again directly
in those cases in which there was a febrile relapse. When it
does rise notably in mania there is just reason to suspect the
supervention of some other disease or a tendency to fatal
exhaustion. Notwithstanding that the temperature is pretty
nearly normal, it is plain that the patient has oftentimes a
feeling of heat or of bodily discomfort which urges him te
do such things as strip off his clothes in the daytime ; to lie
naked at night on the floor; to wet his clothes in water and
wear them without evincing the least suffering on a cold day ; to
expose himself to the severest weather in the lightest clothing.
Moreover he does not suffer in health from this sort of conduct
while animated and vigorous at the beginning and at the height
Vill.] THE SYMPTOMATOLOGY OF INSANITY. 409

of his attack; but although he continues throughout it seemingly
insensible to cold, his body does not, since he may be attacked
with pneumonia or other severe disease at a later stage when his
vigour is exhausted. His body usually becomes thinner and
the countenance haggard and aged, contrasting so much perhaps
with its natural expression that he would ‘hardly be known
sometimes for the same person. It is generally pale and sallow,
although reddened during an acute paroxysm, and the eyes are
wild, bold, sparkling, sometimes bloodshot, and at the same
time vacant and unsettled. The physioenomy—proud, defiant,
suspicious, expansive, or expressive of some other passion—
betrays the character of the ideas and moods. The skin is
commonly dry and harsh, as is also the hair, which cannot
easily be made to lie smooth, not because it is being frequently
rubbed with the hands only, but because it is harsh and disposed
to stand on end. It sometimes goes rapidly grey during an
attack. The menstrual function in women is usually sup-
pressed, but not in all cases.

Acute maniacs do not commonly refuse food; they eat with
voracity, hastily, and without discrimination. It is plain that
their tastes and organic feelings are profoundly vitiated, since
they will eagerly devour refuse and drink the most unclean
liquids. Some of them cannot be induced to take food: either
they are so violently delirious that they are insensible to the
feeling of hunger and incapable of a momentary attention ; or
they suspect its nature and misconstrue the attentions of those
who offer it ; or they reject it in direct consequence of some
such delusion as that they are exalted beings who can live
miraculously without food. It is seldom that the refusal of
food is persistent in acute mania; for the delirium abates from
time to time, the moods change rapidly, the delusions come and
go with kaleidoscopic transformation, and as a foul tongue
becomes clean and gastric disturbance subsides the natural
craving for food comes back. They will mostly take it there-
fore at one time when not at another. However, those who
will not eat must be fed by force if they seem likely to
persist in their refusal: first, because of the risk which they
run to sink from exhaustion, which may come on rather
410 PATHOLOGY OF MIND. [cuap.

suddenly in the midst of a fury that seemed up to that moment
to be unabated; secondly, because the downward tendency
is to dementia, that is to say, to exhaustion and destruc-
tion of mind through exhaustion and degeneration of nerve
element—a result which obviously will be more likely to
happen when the bodily strength has not been properly
supported during the paroxysm. Divergent and contradictory
statements have been made respecting the condition of the
urine in this as in other forms of insanity, some observers
having professed to discover an excess of phosphates in it,
which they have thought to be proof of an abnormal disintegra-
tion of nerve-tissue, while others have found no such happy
chime of fact and theory. This divergence of statement need
not excite surprise when we reflect that in some cases of acute
mania there is positively little or no derangement of the bodily
functions throughout ; the tongue being clean, the pulse normal,
the digestion strong, and the sleep fairly good, notwithstanding
the mental turmoil.

I know not what satisfactory explanation can be given of the
fact that some maniacs are able to keep up an unceasing activity
so long as they do with little or no sleep. Certainly some of
them sleep fairly well and regularly, being wound up thereby
to greater excitement when they wake; others shall sleep only
on alternate nights, and they are oftentimes more excited on the
day after a good night’s sleep than after a sleepless night; but
there are others who, continuing their turbulent activity day and
night, hardly seem to sleep at all, Itis easy to say that there
is an excessive production of nervous energy, the exhaustion of
which in ordinary circumstances occasions sleep, but the explana-
tion does not carry us any more forward. Excess of production
means excess of consumption; expenditure of energy must be
balanced by a corresponding supply in the maniac as in the
steam-engine ; and if this supply in him is procured from the
blood without sleep, where is the necessity of sleep in order
that resturation of energy may take place in a person who is in
good health? Two considerations may be offered as fitted to
lessen in some measure the seeming strangeness of the phe-
nomenon. First, we ought to take note of the kind of energy
vinl.} THE SYMPTOMATOLOGY OF INSANITY. 411

displayed by the maniac; it is the large and explosive outburst
of an inferior energy, many equivalents of which are needed to
balance one equivalent of the higher energy of a calm and co-
ordinated mental and bodily activity : it may be looked upon in
fact as proceeding from the decomposition of the higher energy.
As convulsion is not strength of body, so mania is not strength
of mind, notwithstanding that several men cannot hold the
person who is writhing in the one, nor reason with the person
who is labouring in the other. All the energies of the being
are absorbed in the disordered activity of mind and body;
there is an almost entire suspension of all those inhibitory
functions which are in quiet but constant use by a sane person,
and form so large a part of his habitual expenditure of
energy; and the consequence is that there is a greater show
of excess of energy than there really is, a display of sound
and fury which does not signify strength. The turbulent
fury and weltering ideas are the outcome of an inferior grade
of nervous functions, the highest co-ordinating functions of
the mental organisation not being in action at all. Secondly,
there can be no doubt that a prolonged mania without sleep
does in the end produce exhaustion of mind and some weak-
ness of body, though less soon than one might theoretically
expect; in most cases there is considerable mental prostration
left for a while after the excitement has subsided, and in
not a few cases permanent mental feebleness is the result.
Acute mania is seldom uniformly progressive in its course:
there are great variations in its phases as well as in its
duration in different cases. Sometimes it quickly reaches its
height, like a thunderstorm, and continues active, with scarcely
notable remissions, up to its termination. Most often several
longer or shorter remissions give promise of convalescence
which is mocked by relapses into renewed fury. In some
instances there take place almost complete intermissions or
so-called lucid intervals; the mania recurring perhaps with
singular regularity after a few days of lucidity, or every
month, or every three months, or once or twice a year, and
oftentimes without any one being able in the least to say
why it should thus recur. In one remarkable case which
£12 PATIIOLOGY OF MIND. . [cuap.

came under my notice a lady was always sane one day and
maniacal the next day, and this regular alternation of states
had gone on for several months when I saw her. Everything
that could be thought of was tried in order to break the
chain of morbid habit, but in vain; on every other day she
continued to wake in the morning sane or deranged according
as it was the turn of the one or the other state.

When the attacks of mania are separated by considerable
intervals of sanity it is called periodic or recurrent, and the out-
look is then very unfavourable. Noteworthy in these cases is the
exact repetition which one attack is of another: the person be-
comes unusually elated, talkative, restless, or busily mischievous ;
passes thence into a state of incoherence and greater excitement
marked by the usual symptoms of mania which lasts for two
or three weeks or longer ; and then sinks into a brief condition
of depression or confusion of mind from which he ‘wakes up
to lucidity: after a sane interval, of varying length in different
cases, there occurs another attack, which is ushered in by the
recurrence of the same feelings and thoughts that went before
the former attack; goes through the same phases during which the
same sort of feelings are evinced and the same sort of insane
acts are done, and ends in the same way—to be followed in due
course by other attacks, until the mind is permanently weakened
and the lucid breaks that occur are shorter and less complete.

Another variety of mania in which the excitement alter-
nates with periods of depression, described by French writers
as Folie circulaire or Folie & double forme, is also of an un-
favourable character. In this form, as in the recurrent mania,
the phases of the attacks are close repetitions of the phases of
former attacks, and intervals of sanity intervene that may last
for a few weeks only or for years, coming either after the excite-
ment and before the depression, when they are apt to be short,
or more often, as I think, after the depressed stage, when they
are of longer duration. Let it be noted in these cases that the
excitement generally has the form of an extreme moral elation
and alienation rather than of an actual intellectual incoherence,
and that the depression is as completely opposite a state of
moral prostration and self-distrust as it is possible to imagine.
VIL] THE SYMPTOMATOLOGY OF INSANITY. 413

The duration of acute mania is very variable: it is for a few
hours or a few days only in occasional instances, for a few weeks
or months in most cases, for several months in some cases. A
transitory mania, mania transitoria, lasting for a few hours only,
and terminating perhaps in a heavy sleep from which the person
wakes calm and rational, certainly sometimes follows or takes
the place of an attack of epilepsy. But a similar passing mania
may occur where there is neither evidence nor suspicion of
epilepsy ; it has followed a drunken excess now and then; and
I have known two instances in which acute mania was the
result of the moral and physical excitement of the first night
of marriage, in one of them passing off in a short time, Again,
a kind of acute hysterical mania will sometimes come on in
consequence of a strong moral impression, especially if the
shock be coincident with some functional irregularity, and may
pass off in a few hours or days. In most of these cases of
transitory mania it will be found on inquiry that there was a
decided predisposition to mental disorder; and the brief storm,
though it has happily passed quickly this time, may justly raise
appreliension for the future. The duration of acute mania is
under three months or under six months in most cases where
recovery takes place; it may be prolonged by the remissions
which are so common in its course to nine months or a year and
still end in recovery; but when it has lasted beyond nine months
or a year the prognosis is very bad. The longer the disease
lasts the worse generally is the prognosis, which is always bad
in the recurrent form, whether the attacks are short or long.

It may be truly said that nearly half the cases of simple
acute mania get well if placed under proper treatment in good
time; but the longer suitable measures of treatment are put off
the worse becomes the prospect of recovery. The return of
reason is foretokened by the steady waning of the excitement ;
ly the discontinuance of senseless acts; by a shrinking from
noisy parleys which before were courted; by an increasing co-
herence of talk; by a reviving sense of decency and propriety ;
by less disregard of dress and demeanour; by an occasional
curious or anxious inquiry about friends or affairs, or by some
other rational question; and in some instances by periods of
414 PATHOLOGY OF MIND. (cHap.

depression. It is an excellent omen when the patient begins to
recognise that he has been ill and is depressed; a bad sign, as
foreboding relapse, when he is much elated, exultantly talks of
his perfect recovery, and ignores his serious illness. When the
mania is entirely past a patient sometimes falls into a state of
apathetic depression which looks like fatuity and occasions
alarm; he seldom speaks, betrays confusion of mind and im-
paired memory when he does, is without the least energy, and
evinces little or no interest in anybody or anything: it is not,
however, a state of true dementia, but a temporary prostration,
and the mental power may be regained by degrees as the ex-
haustion following the mental storm is recovered from. One
sees a similar effect after the acute delirium produced by a
seriously poisonous dose of Datura stramonium has disappeared ;
apathy and confusion of mind and great impairment of memory.
remain, which are not recovered from for some days. In like
manner the effects of the delirium of typhus fever are some-
times evident for a considerable time in a damaged memory.
The return of an accustomed discharge, healthy or morbid, such
as the menses, or a leucorrhceal, hemorrhoidal, or bronchial
discharge, which has been suspended during the paroxysm of
mania; or the recurrence of a neuralgia, of an asthma, or of
some other wonted bodily suffering from which the patient has
been free during his derangement—not unfrequently accompanies
the return to a right mind.

When recovery does not take place the disease either declines
into a chronic mania or dementia ; or it is followed by an attack
of melancholy and enters upon the bad circle of a so-called
folie circulaire ; or it ends fatally. Death is most often the
result of exhaustion, but it may be due to some intercurrent
and rapidly spreading disease such as pleurisy, pneumonia, peri-
tonitis, erysipelatous inflammation and sloughing of some
wound. When maniacal exhaustion proves fatal the end is
sometimes sudden and unexpected, leaving in the mind an
anxious fecling of doubt whether a more energetic treatment
might not have prevented death, or, if sedatives have been given
largely, whether they have not helped to hasten the fatal issue.
More often after continuing in a state of unabated frenzy for
VII] THE SYMPTOMATOLOGY OF INSANITY. 415

some time, the patient suddenly collapses, not dying immedi-
ately, but tossing about in a feeble and prostrate state, with
quick and hardly perceptible pulse and inability to take food,
until he sinks gradually from exhaustion. I have never seen in
these cases a return of reason before death, such as novelists are
apt to depict in their so-called brain-fevers, but I have noticed
sometimes a little more consciousness of their surroundings
before the end than was ever shown during the frenzy.

When acute mania has declined into a chronic mania, the
latter exhibits varied features according to the degree and extent
of mental degeneration. If the general disease has localised
itself in a part of the mental organisation, leaving the rest of it
comparatively free from disorder—not otherwise than as a general
disturbance of nutrition localises itself in a particular morbid
growth—there are delusions limited to one class of subjects, apart
from which the patient for the most apprehends, feels, reasons,
and acts like the rest of mankind; the case then falls under
the head of monomania or partial mania. When there is a
greater loss of mental power, together with delusions and general
incoherence, the morbid action implicating the whole of the
mental organisation in a chronic form, as is more likely to
happen when the primary attack has been produced by a
physical cause or has lasted long in a fecble mental constitution,
the case may be referred to chronic mania or to one of the
groups of dementia. For the difference between chronic mania
and dementia is only a difference of degree of mental disorgani-
sation, and examples perpetually occur that render it impossible
to makea definite line of division between them. At the one
end then chronic mania has the partial or circumscribed char-
acter of a so-called monomania; at the other end it passes
insensibly into dementia.

Monomania,

The best examples of partial ideational insanity, so-called,
are undoubtedly furnished by those cases of melancholia in
which the mind labours under a particular delusion of a gloomy
£16 PATHOLOGY OF MIND. (cap.

nature and is in other respects singularly rational—those cases,
in fact, to which Esquirol gave the name of Lypemania, in
order to distinguish them from the cases of partial intellectual
derangement in which the inspiring passion was of an elated or
expansive nature. To these last it is that the term monomania
is now limited by custom, the former class being described
under chronic melancholia; and it is with them that I am
concerned now.

In the outset it is proper to point out that Esquirol, who
first used the word monomania, applied it to three different
classes of symptoms of incomplete mental derangement: to
those which, now commonly known in this country as cases of
moral insanity, he designated monomanie affective; to those
which, described by me in a previous chapter under the head
of impulsive or instinctive insanity, he called monomanie tn-
stinctive or monomanie sans délire ; and to those which I have
to deal with now, and which he distinguished as monomanie
intellectuelle.

Although this intellectual monomania is often secondary to
acute mania, it is not so in all cases ; sometimes it is a primary
derangement which has been developed by deerees as an
exaggeration of a fundamental fault of character. A vain and
aspiring person, for example, whos2 pretensions far outrun his
powers, or in whom the pride of some natural powers has been
nursed by success and flattery, may grow into the delusive
belief that he is a prophet, an emperor, a great discoverer, or
some other extraordinarily distinguished character, without ever
having had an attack of acute mania. Any one who reads with
competent insight the history of Edward Irving, so distinguished
as a preacher in the early part of his career in London, cannot
fail to perceive that the mental derangement in which it ended
was the natural and inevitable morbid outcome of his character
in the fostering circumstances in which it was placed. The
lesson of Swedenborg’s life is perhaps still more instructive ;
the son of a father whose placid assurance of his own singular
worth was remarkable, he displayed from the earliest period
of his intellectual activity a serene and boundless self-suffi-
ciency, undertaking without the least hesitation or self-restraint
VU] THE SYMPTOMATOLOGY OF INSANITY. A1T

the most difficult problems of scientific speculation in mag-
netism, in chemistry, in astronomy, in anatomy, in any other
subject, and solving them to his own satisfaction with a self-
confidence incapable of doubt; and the period of his life when
he relinquished all scientific studies and worldly learning, de-
voting himself to the sacred office to which he believed the Lord
Himself had called him, “who,” he says, “was graciously |
pleased to manifest Himself to me, His unworthy servant, in a
personal appearance in the year 1743; to open in me a sight of
the spiritual world, and to enable me to converse with spirits
and angels,’—was coincident with what was evidently an attack
of acute mania. When the acute attack passed away a mono-
mania was left behind which was the morbid evolution of his
self-sufficient character; and thenceforth he occupied himself
in intercourse with the spirits of heaven and of hell, and in
recording the revelations which he received, declaring calmly
and seriously that through him the Lord Jesus Christ had made
his second advent for the institution of a new church described
in the Revelation under the figure of the New Jerusalem.!
There is no large asylum for the insane in which patients will
not be found who imagine themselves to be kings, princes, great
lords, or other highly placed personages; who nevertheless con-
verse sensibly on all subjects that, being outside the sphere of
their delirium, do not stir their morbid trains of thought, and
who behave themselves with habitual propriety. It may be a
hard matter to elicit from some of them in conversation any
evidence of derangement if they have a motive to conceal it;
and they are quite ‘able sometimes to exercise self-control enough
to do that successfully for a time. Others believe themselves to
be in direct communication with God or with angels, and re-
ceive messages which they write down and deliver or address to
their medical attendants, always speaking with the same quiet
or energetic assurance on these matters when they are touched

1 I may refer for a fuller exposition of the character of his derangement
to my essay on Swedenborg in Body and Mind, second edition, It has
provoked violent criticisms and angry letters from some of his disciples.
I am sorry to have hurt their feelings, but until the evidence of his own
Diary be proved false, I cannot alter my opinion,
418 PATHOLOGY OF MIND. (crap.

upon, and evincing no unsoundness in ordinary conversation on
other subjects. All these people, however, are easily irritated
by contradiction of their claims or by arguments against them ;
their faces then flush, their eyes sparkle, they become passion-
ately energetic and denunciatory and perhaps actually inco-
herent in their language, and it may be some time before they
forgive the offence done to their dignity.

Tam acquainted with a gentleman, the inmate of an asylum,
who has the delusion that he is Jesus Christ; he mixes little
with other patients; seldom speaks except when addressed, when
he answers intelligently and with great courtesy; walks in a re-
tired part of the grounds with a calm dignity that arrests notice,
dressing with scrupulous care and wearing a long white beard ;
and never gives utterance to any insane ideas that are not ex-
tracted from him by close questionings. At one time his wife,
having wished for his discharge, had him visited and examined
by two eminent physicians, who, after a long conversation with
him, could find no insanity in him and recommended his dis-
charge. This was not granted by the authorities,—first, because
he had been sent to the asylum in the first instance in conse-
quence of his having struck a cabhorse violently on the head
with an axe as he drove past it, and this he had done in order
to obtain a public trial and so enforce the world’s attention to
his claims; and, secondly, because it was certain that notwith-
standing the failure of the eminent physicians to detect his de-
lusion he was still as firmly convinced that he was Jesus Christ
as he ever had been. In fact, he has never abandoned the
belief, to which, his mind being weaker, he now gives utter-
ance more readily than formerly. Moreover, it is apparent now,
when a real examination of his mental state is made, that the
infection of his main delusion has spread into much secondary
delusion of thought.

} Dr. Hood, formerly Superintendent of Bethlehem Ifospital, had a pa-
tient there who had been sent to the asylum for annoying the Queen in
Rotten Row. He had been twenty years in confinement,, during the last
fifteen of which he had not presented any symptom of his particular delu-
sions, nor during eight of them any symptom of insanity, After perse-
vering efforts Dr. Hood obtained his discharge. Five months afterwards
he received a letter from Lord Palmerston, asking if he was aware tliat
VIL] THE SYMPTOMATOLOGY OF INSANITY. 419

Were the most experienced physician asked to say beforehand
what cases of mania were likely to end in monomania, I doubt
whether he would be able to answer the question satisfactorily
in any case. This much he might say—that a person of moderate
self-esteem, regulated temper and desires, habituai self-com-
mand, who had the misfortune to be driven maniacal by some
powerful exciting cause, would not fall into monomania after
the acute paroxysm; and that he who would be most likely to
do so would be one in whose character some exaggerated passion
of an egoistic nature, such as pride, ambition, envy, had been
fostered before the attack—in whom, in fact, the madness was
not something, as it were, extrinsic and accidental, but intrinsic
and essential. It will be noticed in some instances that the
patient who begins with a doleful delusion that he is the victim
of a persistent and mysterious persecution ends by imagining
himself to be some very great personage, and the persecutions
which he undergoes to be done to him on that account ; he can-
not conceive that so many mysterious signs should be made
wherever he goes, or that so much trouble should be taken to
do him hurt and mischief, unless he is a person of far greater
consequence than it is pretended he is; and he grows perhaps
to the notion that he is of royal descent and has been deprived
of his birthrights by an extraordinary conspiracy. It is a quasi-
logical explanation of the primary delusion, a pathologically
logical evolution of it.

I think it will be noticed again that the most characteristic
examples of monomania are commonly met with in persons
who have a decided insane inheritance; for it is in them
certainly that we find an outrageously extravagant delusion or
the strangest conduct coexist quietly side by side with a degree
of reason that could not fail, it might be thought, to correct it.
The individual embodies in his constitution the insanity of
previous generations which, when it comes out, coming out as
a sort of natural evolution, is accentuated in character, self-
sufficient and self-dependent, neither requiring the support nor
such a man was at large, and sending three or four letters to the Queen
which he had received from the patient, asking for the hand of the Princess

Alice. He was really as insane as ever he had been, and had delusions
of the same kind as he had twenty years before,
420 PATHOLOGY OF MIND. (cmap,

susceptible to the criticism of adjacent mental functions, which,
on their part, are not greatly disturbed by it. What wonder
indeed that it does not seem very strange to the reason whose
potent alities have “lain in the same egg” with it through
successive generations! Of notable eccentricities of thought
and conduct which cause it to be said off-hand of the person
who displays them that he must be mad, one hears it remarked
sometimes that they do not mean madness in him, and need not
be taken notice of as if they were of any consequence, be-
cause he comes of a peculiar family who have always been
accustomed to think and to do some very odd things; and it is
quite true that eccentricities of thought and conduct which
would be ominous signs of madness in a person who had no
such peculiar inheritance and would certainly portend a grave
ultimate issue may continue in him unto the end of his days
side by side with a lucidity of reason in other respects with
which they might seem utterly incompatible, and without
causing further derangement. The most typical example of
monomania is only an extremer illustration of this character
of hereditary insanity. Lastly, it will be noticed that mono-
mania is apt to occur in some weakminded persons whose
intelligence, if not actually defective enough to constitute them
imbeciles, is of a low order and has been little cultivated.; for
a weak strain of intense vanity commonly goes along with a
feeble intellect both in idiot asylums and outside them.

The course of monomania is not often towards recovery. The
reasons are plain: in the first place, when it is secondary to
mania or melancholia it signifies a chronic morbid nutrition
which is a further stage of degeneration of the delicate organi-
sation of mind; in the second place, when it is primary, it is
the morbid outgrowth of a fundamental quality of character, so
that to get rid of it would be to undo the very character from
its foundations. Nevertheless, there is occasionally a recovery
under the influence of a steady and systematic moral discipline
or in consequence of some great shock to, or change in, the
system—whether a shock of an emotional character, such as
the announcement of the sudden illness or sudden death of
one who was most near and dear; or a change in the system
VITL.] THE SYMPTOMATOLOGY OF INSANITY. 421

produced by some intercurrent severe bodily disease of an acute
character, which, having just missed being fatal to life, has
restored the reason; or the great bodily change which takes
place naturally in women at the climacteric period. I have
known recovery to take place in each of these circumstances,
I call to mind in particular the case of a gentleman who had
laboured under a long-standing delusion of a gloomy nature,
which was thought to be fixed and never likely to leave him,
but who recovered in consequence of a severe attack of pleurisy
which necessitated the tapping of the chest and the subsequent
insertion of a drainage tube for some time. When recovery
does not take place the mind is apt to get slowly weaker, and
the disease so to decline into dementia: the more the exagger-
ated self-feeling which underlies and inspires the delusion wanes,
and the more this, losing the inspiration which gave a sort of
unity and coherence to its manifestations, becomes a mere
form of words, the more plainly the patient sinks into an in-
coherent dementia. Recovery is at all times more likely to
take place in this chronic insanity when the delusion is gloomy
than when it is exalted; in the former case the derangement is
more extrinsic in its origin, the system evinces its suffering, is
depressed thereby and sensible, so to speak, of the need of
amendment, while in the latter case the malady is more intrinsic
in its origin, the system is abundantly satisfied with its condi-
tion, exalted, and not sensible of anything to amend.

For the most part there is more derangement than appears on
the surface in any case of monomania, however circumscribed
the range of the delusion may seem to be, and one may feel
pretty sure that the application of a sufficient test will discover
it at one time or another. Hallucinations of sense, especially of
hearing, exist sometimes when not suspected. The faculties of
the mind are not independent, but work together in a vital
harmony, so that when a part suffers the whole suffers more
or less with it: when an insane delusion persists in spite of
evidence of its absurdity it is proof that the whole mind is
overpowered or weakened and cannot exert upon it that con-
trolling and corrective influence which, were it sound and strong,
it would not fail todo. If a person who has hitherto lived on

_— ait iinet
422 PATHOLOGY OF MIND, [ouar.

the best possible terms with his wife, loving and trusting her
entirely, conceives the insane idea, without the least reason in
fact, that she is dishonouring him by adulterous intercourse
with other men, the very existence of a delusion so foreign to
the whole habit of his healthy thought and feeling marks a deep
and general derangement of mind, notwithstanding an appear-
ance of entire sanity in all other matters, and it will be impos-
sible to foresee the influence it riay have eventually upon his
thoughts and upon his conduct. Locke’s description, so often
quoted, of the lunatic as a person who reasons correctly from
false premises is a notion of the closet, not one that is founded
on experience. The monomaniac is far from deducing the logi-
cal consequences from his delusions and acting in accordance
with them ; he deduces not logical but pathological conclusions;
the same lack of reason which is shown in the existence of
the delusion in his mind is shown in irrational inferences,
in incoherent ideas, and in inconsistent conduct. Accepting the
premises of his delusion and reasoning correctly from them, a
sound understanding could not foretell what he will think and
do. It is strange, however, how long an extravagant delusion
may co-exist with apparent sanity on all matters outside its
range in a person who has a decided insane mental heritage ; in
whom, in fact, there is a natural tendency to a want of harmony,
or to a sort of dislocation or discontinuity, of mental functions.
Wheu the monomaniac, so-called, comes under the observa-
tion of one who is not only competent to observe, but has suffi-
cient opportunities to do so, it will commonly be found that
there is a bluntness or loss of his natural affection and social
feelings in consequence of his being so entirely centred in his
morbid self; that his character and habits have undergone some
change; and that he exhibits an excitability of mind with loss
of self-control in circumstances which would not formerly have
provoked .it. His mind generally is in that condition of dis-
turbed moral tone in which unforeseen whims and feelings and
impulses are apt to start into spasmodic activity abruptly. What
is sufficiently remarkable too is that when a patient of this kind
is placed in an asylum, instead of being surprised at his position,
and distressed by what he sees around him, as so seemingly sane
vul.J THE SYMPTOMATOLOUY OF “INSANITY. 423

a person might be expected to be, he adapts himself to his new
surroundings with remarkable equanimity and as if he had lived
in them all his life; moreover, he evinces little or no anxiety to
know why he is there, or how he is to get away, and an imper-
fect appreciation of the derangement of the other patients. Inside
the asylum, where his life is ordered in a quict and regular way,
and there is no strain upon his mental resources, he will go on
calmly from day to day and from week to week without any
outbreak of excitement; but if he be at large in the world, free
to follow his own devices and exposed to occasions of excite-
ment, then he is likely to show paroxysms of unreason and
even outbursts of dangerous frenzy. It is surprising what
extreme unreason and “incoherence ou these occasions may be
exhibited sometimes by one whose general manner and conver-
sation would not be thought to forebode anything of the sort,
During the Franco- German war, when Paris was being besieged,
Dr. Foville noted the effects of the commotion upon some pa-
tients in his asylum whose insanity was of the partial sort which
is usually described as monomania; and the result was to dis-
credit strongly in his mind the theory of a partial lesion of
the understanding. One patient, who read the newspapers
regularly, and appeared to follow the events of the war intel-
ligently, declared nevertheless that he was not fool enough to
be taken in either by the accounts which he ‘read or by the
incessant rear of the artillery which he heard; he affirmed that
all the noise was produced by some fools who pretended to fire
the cannon to amuse themselves, but whose real object was to
make a pretext for causing him to die of hunger by reducing
more and more the allowance of food. A still more remarkable
case was that of a captain of the Imperial Guard, who had been
admitted into Charenton a few weeks only before the outbreak
of the war, labouring under delusions of persecution. From his
profession, from the fact that he had several relatives in the
army, from his perfect lucidity on many subjects, it might have
been expected that he would follow the events of the war with
interest. Nothing of the kind: all the defeats and sieges, the
fall of the empire, the investment of Paris, the conflicts before
it, various apligtes of which he saw, the bombardment of the
424 PATHOLOGY OF MIND. [cuar.

forts which he heard incessantly, the capitulation of Paris and
its deplorable consequences—all were met with entire incre-
dulity. He would not believe a word of what he was told,
although every means was employed to convince him, but de-
clared that all the noise made by the cannonading was the
work of certain officers of his regiment—-his persecutors—who
were bent upon annoying him, and that the authorities of the
asylum made common cause with them by refusing to forward
his letters to his relatives, and by withholding from him their
replies. He was one day shown five or six newspapers, all of
the same date and relating the same facts; he read them with
incredulity, alleging that they were sham newspapers, printed
for him alone by his persecutors, who were determined not to
desist from their persecution, cost them what it might. When
a person has got so completely out of sane relations with his
surroundings as to cherish the sort of extravagant delusion
which the monomaniac has the plainest evidence affects him
not in the least if it goes against his opinion; his judgment
upon all matters that concern himself is utterly disorganised
and rotten: it is engulfed in the morbid self.

The insane person who believes himself to be Jesus Christ is
commonly, while in the asylum, well-behaved, courteous, digni-
fied in manner, evincing in bearing, gait, and speech a placid
exaltation and serene self-confidence; but he is very likely to
be dangerous if he be left at large. By a pathological logic he
develops some otlier great delusive notion—that he must dis-
cover or attest his divinity, or draw an unbelieving generation’s
attention to it by some mighty deed; accordingly he may sacri-
fice his own life or the lives of others in order to give proof
of his divine mission, or perhaps to redeem mankind by the
baptism of blood; or he may do some other desperate deed.
from an equally insane motive. At all times he is possessed
with a thoroughly insane exaltation, and there can be no certi-
tude felt that it may not explode in equally insane conduct.

The foregoing considerations render it easy to understand
that a fixed monomania which ends not in recovery will pro-
bably entail eventually an increasing impairment of mind;
like a cancer or other morbid growth that has fixed itself in
VILL] THE SYMPTOMATOLOGY OF INSANITY, 425

some tissue of the body, it is nourished at the cost and to the
detriment of the sound elements, which dwindle and degenerate,
and the result is a state of mental disorganisation and decay,
which may be justly described either as chronic mania or
dementia, according as the degree of degeneration is less or
greater.

Dementia,

Most of the permanent inmates of asylums are persons who
after a more or less acute mental derangement have sunk into a
condition of permanent mental feebleness and ineoherence. To
describe in detail the different varieties of degeneracy which are
met with would be an endless and barren labour. It would be
as tedious as to attempt to describe particularly the exact cha-
racter of the ruins of each house in a city that had been
destroyed by an earthquake: in one place a great part of the
house may be left standing, in another place a wall or two, and
in a third the ruin is so great that hardly one stone is left upon
another. So with respect to the mental wrecks that are seen in
long-standing insanity: one person will talk reasonably and
calmly for a while on most subjects, until, his enfeebled attention
being exhausted or the trains of his many morbid ideas hit upon,
he breaks off into rambling and incoherent nonsense; the con-
versation of another is habitually incoherent, although he may
for a short time or on some occasions so far hold his attention
as to answer rationally simple questions put directly to him; a
third is utterly crazy and scarcely ever utters a word of sense,
Between what is described as chronic mania and what is known
as dementia it is evident then that the distinction must be
theoretical.

Three principal groups may be made of these cases of mental
disorganisation. The first will consist of those who, representing
the terminal dementia of monomania, still exhibit a few striking
delusions, which now, however, seem to be automatically ex-
pressed ; for the strong self-feeling which formerly underlay and
inspired them is extinct, and there is none of the earnestness, con-
sistency, and self-assertion which there was once. They quietly
426 PATHOLOGY OF MIND. (crap.

sive utterance to the most extravagant delusions as if they were
saying the most trivial commonplaces, and seldom show any
feeling when they are contradicted. The paths of mental asso-
ciation are obstructed or broken up, so that the delusions are cut
off from any systematic and active influence upon such mental
functions as are left, and the incoherence is extreme. Family
and social feelings are pretty nigh extinct; they ask not and
care not for relations, and all real interest in the past and present
is abolished. How can there be a past when its organic regis-
trations are disorganised ; how can there be a present when there
are no linked memories of the past to give it meaning and in-
terest ? Their acts exhibit a corresponding imbecility. Several of
them are capable of employing themselves in useful mechanical
labour under suitable supervision; but the industry of others is
confined to strange antics and monotonous gestures, to walking
backwards and forwards for a certain distance over a particular
path, to crouching or standing in a particular corner, or to gather-
ing stones, pieces of paper, and the like. Some of the movements
witnessed which are definite and uniformly repeated, albeit
strange in character, are probably dictated by the remains of an
extraordinary delusion or hallucination: one person, for example
who day after day licks with his tongue a certain place on the
wall or on some other object imagines that he is tasting some-
thing of delicious savour; another, the singular movements of
whose arms perplex the observer, is busy spinning sunbeams
into threads; a third is constantly shouting in answer to voices
which he alone hears ; a fourth keeps up violent movements of
his arms in order to prevent his blood from coming to a stand-
still, Other strange movements which we cannot account for
might probably have been similarly explained had we been able to
watch carefully the evolution of the insanity and to follow closely
the steps of the mental dissolution that has taken place. For
the explanation of others it might be necessary to search even
yet further back— to make the reversion to ancestral experiences
which they perhaps represent. The bodily health is usually
good, there being not unfrequently an improvement in this
respect as the frenzy of mania or of melancholia subsides into
the peace of dementia. The mood of mind, which appears to be
VUI.] TILE SYMPTOMATOLOGY OF INSANITY. 427

determined in great measure by the patient’s former disposition,
may be surly and gloomy, or brisk and cheerful, or even and
placid. '

In a second group of cases there is more general incoherence—
a genuine craziness in fact—without the expression of particular
delusions, but with a greater display of outward activity. Their
incoherent drivel or their senseless parrot-like repetitions of
certain words may discover the wrecks of delusions which existed
in the preceding maniacal stage. The fact is that the mental
disorganisation has gone so far that not only are the paths of
association broken up, but the centres themselves of ideas also ;
there is an incapacity to receive accurately and to fashion into
ideas the impressions made upon the senses, as well as a great
loss of memory; and in extreme cases the capability of a dis-
tinct delusion and of a definite passion is gone. An entire in-
difference to what is going on around, reaching a placidity beyond
what philosophy can attain unto, would certainly warrant it
being said of him more truly than of the just and self-contained
man—

“ §i fractus illabatur orbis
Impavidum ferient ruina.,”

The extinction of all emotional feeling of the higher sort is
frequently accompanied by a bluntness of sensation, in conse-
quence of which the patient shows himself singularly insensible
to pain, being very little affected by so severe an injury as a
broken arm or a broken leg. Sometimes the sensations are
manifestly vitiated; as shown by tendencies to swallow stones,
live frogs, worms, and the like; these perverted appetites coming
on or being more marked perhaps at certain times and then dis-
appearing or abating for a while. In some cases paroxysms of
excitement occur from time to time, and there are outbursts of
incoherent passion and fury or even of desperate homicidal
violence without any apparent cause in external circumstances
to provoke them. A demented person under my care who was
utterly incoherent, used to walk about muttering to himself,
without any one ever being able to understand what he mut-
tered or to get an intelligent answer from him; from time to
time, without giving the least warning, and without anything
428 PATHOLOGY OF MIND. [cHar.

having happened to provoke his anger, he would rush upon some
one and strike him violently or make a furious attempt to strangle
him; so sudden and dangerous were these outbreaks that nothing
would induce an attendant who knew his propensities to sleep in
the same room with him. Another instance: a heavy, wild-look-
ing, hopelessly demented woman, who usually did no more than
laugh vacantly when spoken to, and seemed not to comprehend
what was said, used to begin every now and then, without ap-
parent reason, to shriek and howl furiously, and to stamp on the
ground violently, her whole body being agitated convulsively ;
the paroxysm would end either in a violent attack upon some
one, made with the rush of an avalanclie, or she would throw
herself down on the ground and lie there shrieking and kicking
for some minutes ; after which she would, with maniacal drawl,
murmur, “I beg pardon,” “ I’m very sorry.”

Some of the homicides that are done in asylums are done by
demented patients of this class: one who has worked side by
side with another for months without ever having shown the
least ill-will suddenly smashes his skull one day with a spade
or a hammer; and it will most likely be impossible to get from
him any explanation of the murderous deed. The probable
explanation is that some bodily derangement has occasioned a
painfully uneasy disturbance of the affective tone, and that a
straggling idea of a suspicious nature arising into activity in
this atmosphere or medium of gloomy feeling, and unrestrained
by other ideas from which it is cut off by the disorganisation of
the paths of association, acquires a delusive character and a
convulsive energy. The tendency of the gloomy mood is to
outward expression, and the upstarting idea has determined the
direction of its discharge and discharged it in the deed of
violence.

The prevailing mood of these dements is different in different
cases: some are gay, happy, and chatter and laugh incessantly ;
others are gloomy and display the mimicry of grief; while
others, again, are malicious, spiteful, destructive, and addicted
to a purposeless mischief with a monkey-like cunning and per-
sistence. The bodily health is usually good and the bodily
functions are well performed ; some of them get fat, and remain
Vill.] THE SYMPTOMATOLOGY OF INSANITY. 429

so until an outbreak of excitement and agitation, to which
they are liable periodically, reduces them. The physiognomy is
blank and expressionless, especially when the patient is spoken
to, or it expresses only in coarse traits the predominant mood ;
it is often also prematurely aged.

Lastly, there is a group of demented patients in whom nearly
all traces of mind are extinguished: they must be fed, moved,
clothed, and cared for in every way; they evince little or no
sensibility ; their only utterance is a grunt, a moan, a whine, or
acry; and the only movements which they make of their own
accord are to rub their heads, their hands, or other parts of their
bodies, or to continue some other meaningless and monotonous
movements. They represent the lowest of the degrees of de-
mentia—the last term of mental degradation to which it is
possible for a human being to sink. Their life is in truth little
more than a vegetative existence; mental dissolution has anti-
cipated bodily dissolution ; and if they are not carried off ‘by
pneumonia, tubercle, or some other welcome bodily disease, as
they sometimes are, they die from effusion on the brain, serous
or hemorrhagic, or from atrophy thereof, or from the effects of
accident to which, in consequence of their apathetic helpless-
ness, they are much exposed. It is a robust faith which infixes
the certitude of a resurrection to life eternal of this mind which
is seen to dawn with the opening functions of the senses, to
grow gradually as the body grows, to become mature as it
reaches maturity, to be warped as it is warped by faulty inhe-
ritance, to be sick with its sicknesses, to decay as it decays,
and to expire as it expires,

Before leaving this subject it will be proper to take notice
that dementia is not always chronic, secondary, and incurable,
but sometimes acute, primary, and curable. Acute dementia,
when it occurs, is usually the effect of some severe mental or
bodily shock. It has followed the shock of a serious attempt at
strangulation. One observes it in greater or less degree after
an epileptic fit or a succession of such fits, occasionally in an
extreme form; for example, in one case that came under my
notice—that of a delicately constituted person who was said to
have had “fits” from time to time—what was called a slight
430 PATIIOLOGY OF MIND. [craP.

“faintness,” but was probably an epileptic vertigo, was fol-
lowed by a blank confusion of mind, an entire incoherence, and
a complete inability to recognise anybody or anything—a con-
dition, in fact, of extreme dementia, which lasted for a few days.
After a severe attack of acute mania, as after the delirium of
fever in some instances, a condition of mental confusion and
feebleness may be left, which is truly a temporary dementia
and is gradually recovered from. Again, acute dementia is
sometimes caused by a moral shock. A pale, delicate, fragile,
blue-eyed young lady once came under my care after she had
been ill fora week. She had scarcely taken any food, and was
much exhausted. Her vacant, wandering eyes were devoid of
all intelligent perception, and her countenance was blank and
expressionless. There was a restless, agitating movement to
and fro of the body generally, and of the head in particular,
with a low monotonous moaning. She was speechless, and it
was impossible to fix her attention or to elicit any kind of intel-
ligent response. She took no food except what was forced into
her mouth, and was inattentive to the calls of nature. Within
three months she recovered under suitable treatment. She had
suffered a great disappointment of her affections ; menstruation
had ceased; and acute dementia had followed. In another
case, a young gentleman, nineteen years of age, of pale and
delicate appearance, with large prominent grey eyes, who had
been hard worked as clerk in an office, and whose life ont of it
had not been satisfactory to his friends, was suddenly attacked
with a quasi-bysterical attack of incoherence. There was blank
confusion of mind; he neither uttered nor otherwise expressed
anything indicating intelligence in his mind, and showed no
sign of understanding what was said to him by others; and
there were occasional periods of confused excitement. He took
no food except what was forced upon him, and he was inatten-
tive to the ealls of nature. Tecovery took place within a
month,

The late Dr. Skae described, under the name of sexual insanity,
a form of acute dementia met with according to him both in the
male and female sex, but more often in the latter, which he be-
lieved to be produced by the moral and physical effects of sexual
vill] THE SYMPTOMATOLOGY OF INSANITY. 431

intercourse upon the nervous system. There is some reason to
think that habits of excessive self-abuse have been the cause
of a similar form of derangement sometimes in persons of feeble
constitution and highly nervous temperament.

The examples which I have given wiil serve to exhibit the
general features of acute dementia, and to indicate the favourable
character of the prognosis. The mental functions are abolished
for the time by reason of some severe shock to their nerve-
centres, and the abeyance of them is shown by the expression-
less countenance of the patient, his passive attitude of body or
meaningless movements, perhaps by an occasional aimless and
confused excitement, by his inability to understand what is said
or to say what can be understood, and by loss of general sensi-
bility. If recovery does not take place soon, as in most cases
it does, there is danger lest the disease pass into chronic and
incurable dementia,

NOTE.

In mentioning, at p. 319, the species of insanity which has been
described as agoraphobia, reference should have been made to three
cases described in the Archiv f. Psychiatrie uw. Nervenkrankheiten,
Band VII., 2 Heft, and to the Annales Médico-Psychologique, No-
vember, 1876, p. 405. One of the patients says of himself :—“ From
my early youth—in my sixteenth year—I could scarcely cross a
large open space alone, or even a large open space in a church or in
a concert-room, without suffering from an overwhelming feeling of
distress.” To cross a square alone he must go round the houses. If
he had a companion and was engaged in conversation he had no
difficulty. If he attempted it alone, he must fix his eye upon a
cart, carriage, or ‘person in the middle of the square as a point to
be aimed at, and so get across from one object to another. In vain
he had tried to overcome his fears. It was not actual giddiness, but
an indescribable distress that affected him. I have recently seen a
similar case of a nervous gentleman who cannot cross a square, but
must go round by the houses, unless he is accompanied.
CHAPTER IX.
CLINICAL GROUPS OF MENTAL DISEASE.

WHEN we have to do with insanity in medical practice—that is
to say, when we have to think how a particular case has been
caused, what course it will run, how it will end, and what sort of
treatment should be used, we do not so much consider whether
the symptoms are mania or melancholia as we do what consti-
tutional diathesis underlies, or what bodily disturbance accom-
panies, the derangement. It is certain that we get more help
generally from the exact. observation and appreciation of such
bodily states than we do from the mental symptoms alone: for
example, whether a mental disorder is maniacal or melancholic
is not of much moment, but the recognition of a gouty dispo-
sition, of a syphilitic infection, of a commencing paralysis, of a
puerperal cause, and the like, will help us much. It is proper,
therefore, to enumerate and describe the principal clinical varie-
ties of mental disorder. To the late Dr. Skae belongs the merit
of having insisted strongly upon this clinical classification of
mental diseases, and of having been the first to sketch, although
vaguely, the leading features of numerous groups.

General Paralysis of the Insane.

For many years now—since Bayle first distinguished them—
a croup of cases presenting characteristic features have been
described under this head, and they unquestionably constitute
the most definite and satisfactory example of a clinical variety
o7, ix.] CLINICAL GROUPS OF MENTAL DISEASE. 433

of mental disease. For that reason I begin with them. They
represent a form of disease which is characterised by a progres-
sive diminution of mental power, and by a paralysis which
creeps on stealthily, increases gradually, and invades progres-
sively the whole muscular system. The concurrence and con-
current increase of mental and mctor disorder are not accidental
but constant: the patient loses the power of performing both
ideas and movements, and gets worse and worse gradually in
both respects until he dies. In the great majority of cases
there are extremely exalted delusions of personal power, or
wealth, or grandeur; but as they are not present always, it is
impossible to make the character of the delusion a necessary
part of the definition of the disease. Indeed. all the varieties of
mental symptoms—melancholia, mania, monomania, dementia—
may be met with in different cases of general paralysis ; but what
will be observed always is, that whether the symptoms are
melancholic or maniacal, there is a marked weakness of the
understanding and memory which there is not in ordinary cases
of melancholia and mania.

General paralysis gets a painful interest from the fact that it
attacks those who seem to be in the prime of life and at the full:
height of their energy, and that it selects so many of its victims
in the better classes of society. Hereditary predisposition is
less often met with than in other forms of mental disease; and
there is no little uncertainty as to what is the most frequent
exciting cause. Sexual excesses I hold confidently to have that
evil pre-eminence, but I doubt not that a certain temperament,
oftentimes of a genial and expansive kind, must co-operate. :
Those who reject this opinion object that the sexual excitement
observed is really an effect of the malady, and that it counts
among its victims more respectable married persons than un-
married persons of incontinent lives. Neither objection has
the weight which at first sight it appears to have. No doubt
there is oftentimes increased sexual excitement at the beginning ,
of the disease—I overlook not that—but there is not even then
corresponding sexual power, and very soon the excitement
vanishes in complete impotence. It is not to this temporary
excitement that I refer, but to the steady sexual excesses which
134 . PATHOLOGY OF MIND. [cuap.

have gone before the first symptoms of illness and have by
degrees sapped the vitality of the nervous system. He can
have but little experience and little insight as a physician who
does not know that this sort of steady sapping excess is as.
common or even more common among married persons, with
whom provocation and opportunity are constantly at hand,
than among unmarried persons who have often to seek or to
make the oecasions of indulgence. Not a few married persons,
moreover, are so innocent as to believe that there cannot be such
a thing as sexual excess when the Church has consecrated the
union, and they yield to habitual indulgence which is gross ex-
cess, without thought of harm to themselves. General paralysis
is emphatically a disease of manhood, being seldom met with
before thirty or after sixty years of age. In two cases I have
known it to occur alter sixty: one gentleman had married late
in life, after he had made a large fortune in active business, a
woman much younger than himself who was evidently of large
receptive capacity; the other, who had made his fortune by
persevering industry and an almost miserly carefulness, had
betaken himself in the evening of his life to politics and to
keeping a mistress.

It isa noteworthy fact that women very seldom suffer, and
women of the better classes hardly ever, from general paralysis:
perhaps it is that women are not subjected to such severe and
constant mental strain as men are; that they are not so much
addicted to alcoholic intemperance, either in the shape of acute
excesses or in that more dangerous form of habitual indulgences
in small quantities of wine and spirits throughout the day by
which some active men of business endeavour to spur their
overtasked energies; or, lasily, that they are not so prone to,
and suffer not so much from, sexual excesses as men do. Another
noteworthy fact is that the disease is very rare in some parts of
the country; for example, it is said to be very uncommon in
many parts of. Ireland, and hardly ever to be met with in the
Ilighlands of Scotland, where of course there is no deficiency
eithes of women or of whisky. I doubt, however, whether
persons who spend most of the day in the open air, going
through a great deal of bodily exercise, are so easily provoked
IX.] CLINICAL GROUPS OF MENTAL DISEASS. 435

to indulgence or so inclined to excesses, sexual or alcoholic, or
again suffer so easily from them, as the dwellers in town, who
have another source of drain of energy in their habitual greater
mental strain and anxiety. Some writers deem syphilis, others
intemperance, to be the most frequent cause of the disease.

It has been disputed whether the mental symptoms precede
the paralytic symptoms, or whether the latter occur first—
whether, in fact, the insanity is essentially primary, or whether
the paralysis is the primary and main affection, the mental
disorder being secondary. A barren controversy: observation
certainly shows that the mental symptoms are evinced in many
cases before there is a trace of paralysis, and that in other
cases the mental and motor symptoms appear simultaneously.
Instances again do occur occasionally in which the paralytic
phenomena appear first; and some have been recorded in
which the disease undoubtedly began in the spinal cord and
spread thence to the brain. In cases which begin so it will be
noticed sometimes that the walk is that which is characteristic
of so-called tabes dorsalis—uncertain, swaying, the feet being
raised and thrown forward abruptly or outwards to the right
and left, and brought down with a jerk on the ground. It is
certain, in fact, that some cases begin as tabes dorsalis and end
as general paralysis ; but this sequence is not usual, for the mind
is commonly cheerful and unaffected unto the end in the former
disease. I take it to be certain also that in a few cases of
general paralysis the motor symptoms, which were not those
of tabes dorsalis in the first instance, became the motor
symptoms of that disease later on. Dr. Skae was of opinion
that the paralysis was the essential part of the disease, and that
it might go on to a fatal ending sometimes with only a slight
impairment of the mental functions, or without any affection of
them ‘at all; and in support of this view he related the case of
a gentleman who laboured under the peculiar paralysis of the
discase for many years, during all which time he was esteemed
aman of great intelligence, “Ultimately he was attacked with
the extreme delusions of grandeur, and died with all the signs
of general paralysis running its usual course. Before asserting
that there is no trace of paralysis, or no trace of mental dis-
436 PATHOLOGY OF MIND. [cuap,

order in a particular case, it will be well to observe the patient
when he is emotionally excited or after a sleepless night; for as
both motor and mental symptoms may come and go at the
beginning of the malady, there may then be evidence of tremu-
lousness and uncertainty about the muscles of speech or signs
of mental impairment which would not be observed when he is
calm and collected.

The motor symptoms are noticed first in the tongue-and lips,
which have to execute so many delicate and complex move-
ments with exact precision, and especially in the articulation of
words abounding in consonants, where the most complex co-
ordination of movements is necessary; when the patient speaks
earnestly, he does not articulate clearly, and there is a certain
pause or thickness or stumbling in his utterance, as if there was
a difficulty in bringing out the syllables; in some cases the
speech is slower, more deliberate, with a strong accentuation of
and a lingering on the syllables, as if he were speaking with great
consideration. When the tongue is put out, which it is with
some difficulty, there may be a fibrillar quivering of its muscles,
or a trembling of the whole of it, but it is not pulled to one side.
There is a tremulousness also in the muscles of expression when
they are put in action, especially in those of the lips, which
quiver as in one just about to burst into tears. The tone of
the voice is often altered, although this may be noticeable only
by those who have known the patient well before he was taken
ill; it becomes harsher and loses its various shades of expression.
These symptoms are more evident when there is any mental ex-
citement. An inequality in the size of the pupils is often an
early symptom, but it is not a characteristic one; it is some-
times present in other forms of insanity, and it is not always
present in general paralysis. Ina few cases the pupils are con-
tracted to a pin’s point. A transitory squint is observed ‘occa-
sionally at the commencement of the disease, and at a later
period perhaps a slight ptosis of the upper eyelid.

As the disease advances the muscles of the limbs and trunk
are affected; in walking, the feet are not quietly raised and
firmly planted on the ground, and the gait is somewhat feeble
and shuffling; the patient will find some difficulty in mounting
i] CLINICAL. GROUPS OF MENTAL DISEASE, 437

on-to a chair, easily stumbles at a step or on uneven ground,
and; if asked suddenly to turn round when going straight for-
ward, he sometimes sways or staggers like a drunken man.
Nevertheless he may be energetic in walking, setting about it
earnestly, as if it were his business, and pleased with his per-
formance of it; he does not want muscular power, but the power.
of using his muscles; he is unaware of his deficiencies and com-
monly thinks himself wonderfully well and strong. Precise co-
ordination of movement, such as is necessary for writing, sewing,
playing upon a musical instrument, and like acquired automatic
acts, is much impaired or quite lost. At the outset of the
disease it is sometimes very difficult for one unacquainted with
the patient before his illness to perceive anything peculiar in his
walk; but when no symptoms of paralysis are detected, there
may be something stiff, proud, abrupt about it; the steps shorter
and quicker, and the foot being set down more sharply. One set
of muscles may be more affected in one case, and another set in
another ; arid it is noticed sometimes that the articulation is most
impaired when the legs and arms are scarcely touched, or again
that there is no impairment of articulation when there is marked
paralysis of the legs. Like the mental symptoms, the motor symp-
toms may disappear almost entirely for a time, As the disease
advances towards its end, the articulation becomes less distinct ;
the walk more and more tottering; the knees fail; the patient
frequently tumbles, and finally is unable to get up at all. The
contractility of muscles for the electric stimulus is retained. At
last the primary automatic or reflex movements fail; the pupils
become dilated, but unequal in size; the sphincters lose their
power; and the patient, who is very apt to swallow his food
without masticating it properly, may be choked by a lump of it
sticking in the paralysed pharynx and blocking up the opening
of the larynx or even getting into the larynx. Transitory con-
tractions of an arm or leg cccur sometimes, and a persistent
grinding of the teeth is not uncommon in the last stages of the
disease.

Cutaneous sensibility is diminished in the early stages, and
towards the end it is sometimes almost lost. These patients
when injured by violence make no complaint perhaps, and go
438 PATHOLOGY OF MIND. (cap.

about even with broken ribs without showing any sign of pain.
A sudden local perversion or loss of sensation may be the occa-
sion of an extravagant delusion—eg. that one half the face or
chest has been torn away. In some cases transitory attacks
of extreme hyperesthesia of parts cause the patient to shriek
out in agony; and before the disease shows itself it is not very
uncommon for the person to have suffered from neuralgic pains
—perhaps from intense headaches, or from facial neuralgia, or
from pain in other parts of the body, all which were forebodings
of the evil tc come. The muscular sense is especially affected—
exalted at first so as to give a false feeling of great bodily
strencth, but impaired much afterwards, so that the sufferer,
having lost all power of executing the more delicate and complex
movements, is quite unaware of his impotence, and deems
himself not less skilful than when at his best state. Reflex
excitability is lessened in both cerebral and spinal nerves as
the disease advances; but it is not impaired at the beginning,
and it may appear to be even increased in the spinal cord when
the brain is affected notably and it is not. The special senses
are not usually affected until near the end, when smell and taste
are diminished or lost, and vision fails. Sometimes, however,
the impairment of smell and taste shows itself much earlier.
Perversions or defects of the organic sensibilities may be the
cause of delusions that the intestines are closed or destroyed.
A great increase of sexual desire and an excited display of it
are not unfrequent at the beginning of the disease, but there is
not corresponding sexual power; and this is soon quite lost.

The bodily nutrition is differently affected at different staves
of the disease. At the beginning the patients often lose weight
and become thin, but later on, particularly when they reach the
stage of placid dementia, they get stout and flabby, and sores or
wounds on them heal remarkably well. At a still later stage,
when nervous energy is nearly extinguished, bedsores are easily
caused, and after death the tissues are soft and flabby, while the
bones, and especially the ribs, are softened and friable so as to
be easily broken.

The mental disorder which goes along with the motor impair-
meut is remarkable usually for an extraordinary feeling of
1x.] CLINICAL GROUPS OF MENTAL DISEASE. 439

elation and well-being with corresponding delusive ideas. But
here also, as in so many cases of insanity, a period of initial de-
pression often goes before the outbreak of excitement; a period
which is brief and transient in some instances, but in other
instances lasts for a few weeks. It is a state in which the
patient, conscious of a threatening mental trouble, complains
of impairment of memory, of inability to think, of incapacity to
do his work, sometimes of difficulty to pronounce his words,
is depressed and apprehensive, and perhaps expresses gloomy
fears that he will go mad. He is willing enough to consult a
doctor now. But after a while a remarkable change takes place
in his feelings and ideas—from the depths of sadness he rises
to an extravagant pitch of elation: he is in a state of exuberant
joy, “hail fellow well met” with everybody ; full of projects to
benefit himself and mankind; reckless in spending money, all
sense of the value of which he seems to have lost; eagerly buys
pictures which he declares to be Michael Angelos or Raphaels,
or jewellery and other things which he does not need and cannot
afford to pay for; breaks out into sexual excesses that are quite
foreign to his natural character; and rushes into extravagantly
absurd commercial speculations by which he is sure he will
make an enormous fortune. If pressed to sce a doctor, he may
consent out of the excess of his geniality and his gladness to talk
of his great schemes to everybody, but he laughs at the idea of
there being anything the matter with him and protests that he
was never in stronger and better health in his life. Notable is
the mental weakness which prevents him from seeing through
transparent schemes to divert him from his projects and renders
it comparatively easy to approach and manage him. With the
ordinary maniac, who presents at first somewhat similar but
less extreme symptoms, great caution and address are necessary
to avoid rousing his suspicion and anger; but it is commonly
easy to approach the general paralytic, who hardly asks his in-
tervicwer who he is and why he has come, or, if he does, is easily
satisfied with almost any sort of explanatory or apologetic
answer, shows no suspicion or resentment, hastens to tell him of
his great projects, perhaps offers to make his fortune for him,
and invites him when he leaves to come again soon.
440 PATHOLOGY OF MIND. [owar.

As the mental disorder increases it issues in the most extrava-
gant delusions conceivable of wealth, power, or grandeur : he can
talk all the languages of the world ; has a superb musical voice,
can sing better than Mario ever could, and will make a thousand
pounds a night on the stage; is as strong as Hercules, an accom-
plished athlete, and can perform muscular feats which no othez
man ever could; is possessed of inexhaustible wealth and gives
away cheques for millions to any one who asks for them; is a
duke, a prince, a king, or sometimes even king of kings, and will
confer dukedoms or greater honours with lavish generosity; is
going to marry a princess or a queen, or to have a harem of all
the finest women in the world. There is no limit to the absurd
extravagance of his delusions, which he will utter placidly with-
out the least show of feeling, or with only a feeble smile of
self-complacence, or with a burst of imbecile laughter. When
he is sent to an asylum he is delighted with everything, his
accommodation is capital, and he is determined to buy the place
and to make a great palace of it. His great mental weakness is
shown in an extreme loss of memory, in glaring inconsistency
between his ideas and conduct, or even between his gross delu-
sions themselves, and in his fatuous insensibility to ridicule; he
is going to marry a princess, forgetting that he has a wife, whom
nevertheless he acknowledges when she visits him; he gives
cheques for millions at the same time that he begs for a little
tobacco; he cannot perceive the insanity of other patients in the
asylum, however outrageous it is, and is insensible to their
ridicule of his absurd pretensions. In the Edinburgh asylum
was a general paralytic under Dr. Skae’s care who thought
himself king of kings and had other characteristic delusions
of grandeur, and who was most lavish in presenting millions of
money. Before he was sent to the asylum he had £1 in the
savings bank, the interest of which had risen to 3s. 4d. He
always kept this sum distinct from the immense sums which he
believed he had in the Bank of Scotland, and would never part
with a penny of it. Moreover, he calculated interest at twenty-
five per cent. on his supposed wealth and made a muddle of it,
but he calculated the interest on his actual property at five per
cent. and correctly.
1x.] CLINICAL GROUPS OF MENTAL DISEASE. 441

Outbreaks of acute maniacal excitement accompanied by
violent resistance to control occur frequently during the pro-
gress of the disease, each of them being usually followed by a
notable increase of the mental weakness; and it is not unusual
for intervals of melancholic depression and gloomy irritability to
interrupt from time to time the usual strain of exaltation. As
the end approaches, the dementia is extreme; there is scarcely
a sign of intelligence noticed, and the face is an expressionless
mask across which flickers now and then the broken ripple of a
smile, or it is fixed in a sardonic grin; but even in the last stage
of mental disorganisation, when delusions are shattered, the few
words which he mutters may bear witness to the wreck of his
grand notions about carriages, diamonds, millions of pounds.

This is the form which general paralysis most commonly
takes, and which is suggested when its name is mentioned, but
there are considerable varieties in the mental symptoms in some
cases. For example, in one form there is a steady decline of
intelligence from the first without any marked delusions—in
fact, a gradually increasing stupidity of a good-natured sort,
although the prevailing good-humour is apt to be interrupted
from time to time by periods of depression or by intervals of
irritable and gloomy temper. In another variety painful delu-
sions of an extreme character with corresponding depression
prevail throughout the course of the disease: the patient pro-
tests that he is blind and cannot sce, that he is completely deaf,
that his throat is closed so that he cannot swallow any food,
that he has no stomach, that his intestines have passed from
him, that he is dying or is actually dead. I have observed in one
instance the disease begin with all the characteristic symptoms
of elation, so that no one who saw the patient had the least
doubt of its nature, and after a time pass into the melancholic
form, the exalted delusions being superseded by the sad delusions
that he could not swallow and had no inside and by refusal of
food in consequence. In this state the patient has remained for
years, the disease making no progress. Whether the disease
shall take the exalted or the depressed form in a particular
case is probably in the main a question of original tempera-
ment: a person who is self-confident, boastful, proud of his
£12 PATHOLOGY OF MIND, [cmap

powers and possessions, prone to ambitious day-dreams, confi-
dent that his geese are all swans, is likely to become exalted,
whereas a person of the opposite temperament will be more
likely to fall melancholic. Dr. Clouston thinks he has noticed
an intimate relationship between general paralysis with depres-
sion and tuberculosis, and believes that the melancholic variety
will be found chiefly among those who are also phthisical.

The course of the disease is towards death, an end which it
usually reaches within two or three years from its commence-
ment. It is extremely doubtful whether an instance of real
recovery has ever taken place, although such a one has been
put on record from time to time. I have read in a medical
journal the exultant report of the complete recovery, so-called,
of a gentleman who however died not long afterwards with
the usual symptoms of general paralysis. What happens in
these cases is that when the patient is placed under proper
treatment and taken away from occasions of excitement, the
progress of the disease is arrested, the symptoms disappear
almost completely, and it is hoped that he is recovered; but
it is seldom, if ever, a real recovery, for after a time the symp-
toms come back—very soon probably if control has been re-
moved—and the disease goes through its ordinary course. These
symptomless intermissions are certainly so long in some few
cases that the duration of it is prolonged much beyond the
usual two years. The melancholic cases almost always last
longer than the exalted, and the disease runs a slower and
quieter course in women. In the more advanced stages, when
its progress has made it plain what its early end will be, apo-
plectiform or epileptiform attacks with loss of consciousness,
and with or without convulsions, occur from time to time; they
soon pass off, leaving behind them probably more or less para-
lysis or convulsion of one side, which itself again after a few
days disappears in gieat part or entirely; but aiter each of
these attacks the general feebleness of mind and body is found
to be increased. They are often preceded by symptoms of
determination of blood to the head, and by more or less mental
excitement, and during them there is great heat of body, the
temperature of which may rise several degrees. Death may
x.] CLINICAL GROUPS OF MENTAL DISEASE. 448

take place in one of these attacks, or soon after one; or itis the
result of gradual exhaustion, large bedsores forming notwith-
standing the best care, and some such disease as diarrhea,
bronchitis, or pneumonia helping to make an end of the
miserable spectacle. The evening temperature is usually higher
than the morning temperature in general paralysis ; a great rise
thereof—as much perhaps as 5:8” sometimes—precedes and
always accompanies the excited and epileptiform attacks, abating
only gradually after them; and the occurrence of pulmonary
complications or of hectic exhaustion is marked by an increased
temperature.!

Such are the symptoms of a remarkably definite group of
cases in which mental impairment and motor paralysis proceed
together with pretty equal steps. As Bayle pointed out long ago,
no one can fail to observe in them an interesting resemblance
to those of drunkenness ; the exaltation of ideas and the good
humour at the outset, the incoherence of ideas and embarrassed
speech later on, and finally the inability to walk properly, the
loss of sensibility, and the increasing stupidity are common to
both conditions and render it probable that alcohol produces
a rapid sequence of temporary morbid changes in the nerve-
centres very like that which is slowly wrought in general
paralysis. Certainly there are some persons who when drunk
present an exact miniature picture of the disease. Definite and
characteristic as its symptoms mostly are, it ought not to be
supposed that it is marked off from all other forms’ of mental
disorder by a barrier which is never crossed. There are cases
of syphilitic dementia which look so like it that one is decided
what to call them by the result only, Again, some cases of
the so-called circular insanity, where melancholic depression
follows a period of mental excitement marked by extreme exalta-
tion of feeling, ideas, and conduct, may be mistaken for it in
the first instance; and it might perhaps be fairly argued that some
of the supposed genuine cases of general paralysis in which
melancholy has taken the place of mania, and the duration of
the disease has been much prolonged, were really examples of

1 Journal of Mental Science, April, 1868, Dr. Clouston. Ibid. 1872,
Dr. Mickle.
444 PATHOLOGY OF MIND, [cuaP.

circular insanity. Lastly, as I have pointed out already, all the
motor symptoms of tlie disease may occur and go on to death,
without any marked mental.symptoms or with such symptoms
noticeable only for a short time before the fatal end. Diseases
are not morbid entities, but more or less definite deviations from
healthy life; in a particular case, therefore, it may chance that
the usual limits of deviation are not reached, or are exceeded,
or are irregular in character, insomuch that two allied, or,
as we might call them, adjacent diseases, have their symptoms
intermingled and are no longer exactly distinguishable.

Epileptic Insanity.

The symptoms of the mental derangement which is met with
in connection with epilepsy are those of mania, of monomania,
and of dementia. Most marked are the symptoms of acute
mania, which generally comes on after an epileptic fit or a suc-
cession of epileptic fits, and is of a very violent and destructive
character, showing itself in a blind impulsive fury during which
the patient is scarcely, if at all, conscious of his real surround-
ings and not in the least affected by any exhibition of restrain-
ing power. Most maniacs yield something to the show of
authority when it is great enough, or evince a transient appre-
ciation of what is said to them, but the epileptic maniac takes
not the least notice of remonstrance, entreaty, or control; he
yells and shrieks, knocks his body about violently, rushes
furiously, strikes whatsoever or whomsoever is in his way,
destroys blindly—is, in truth, sometimes a mere embodicd
fury ; and when he comes to himself he is not conscious or has
only the haziest memory of what he has done, Before the
attack he is.often extremely irritable, silent and surly, morosely
suspicious, and is apt to strike suddenly or otherwise injure
any unoffending person who comes near him—in a mood which
impels him to an act of violence on the least occasion; and during
it he makes the most desperate attacks without provocation and
without warning. The storm is usually over in a few hours,
but it may last a few days; when it is past the patient is left:
for a short time in a state of great mental confusion, a sort.of
1X.] CLINICAL GROUPS OF MENTAL DISEASE. 445

transitory dementia, and then comes to himself, remaining quite
sane perhaps until the next epileptic attack.

In some cases of epileptic insanity the mental symptoms are
those of monomania. Tlie surly, irritable, suspicious mood gets
expression in a delusion that is in keeping with it, as, for example,
that some one threatens or attempts his life, and he is then
a most dangerous person because very apt to defend or revenge
himself in a violent way. Perhaps a vivid hallucination of
sight or of hearing, in harmony with the suspicious mood or
delusion, starts forth and determines or strengthens the impulse
to retaliation. The morbid impulses may be either hornicidal
or suicidal, but. are more often homicidal than suicidal, conform-
able to what we know of the great energy of epileptics. It is
not always possible to connect the homicidal impulse or act
with any definite delusion; it seems to be sometimes nothing
more than a mere blind impulse to destroy; at the same time
it is always difficult to be sure that there was not some obscure
and vague suspicion or delusion at the time, of which the
person can give no clear account afterwards, any more than the
dreamer can of some of the strange impulses of his dream.
The mental disorder is usually periodical at first, like the fits,
coming on in connection with them, and the patient during
the intervals between them is amiable, industrious, and fairly
rational, although weakened in mind.

In other cases the disorder takes the form of good humour
and exaltation and is then exhibited in an. excessive vanity
with corresponding exalted delusions, which are oftentimes of
a religious, character. It is worthy of notice, as Dr. Howden
has pointed out, how much addicted at certain periods the
epileptic lunatic in an asylum is to reading his Bible, and
how frequently he evinces some such delusion as that he is
actually God, Christ, or some great personage of Scripture, or
that he has had revelations from one of these great personazes,
There is no doubt that immediately before an epileptic fit, or
during the epileptic trance before normal consciousness is
restored, these patients do sometimes see visions, having very
vivid hallucinations, and that the remembrance of what they
saw or heard may remain as positive delusion afterwards, It
446 PATHOLOGY OF MIND. [cuap,

is a fact of much interest in relation to the origin of certain
religious creeds, the promulgators of which, being epileptic, had
visions or revelations which they and their disciples deemed to
be supernatural. Anne Lee, the founder of the so-called Shakers,
an epileptic, had visions of the Saviour, who, she declared,
“became one with her in body and spirit.” Swedenborg, who
professed to receive manifoid holy revelations and to have
habitual intercourse with the inhabitants of heaven and hell,
suffered from seizures which were closely akin to, if they were
not actually, epilepsy. Mahomet was epileptic, and it is not
improbable that the ecstatic trances in which he saw the angel
Gabriel, and, like Swedenborg, visited heaven, were of that
nature: and it has been surmised that the trance which con-
verted Saul the persecutor into Paul the Apostle of the Gentiles
was of a similar character. At the present day the Siberian
Schamans or medicine men, who pretend to intercourse with the
invisible powers and with the spirits of the dead, and to other
dealings with supernatural powers, working themselves, like the
priests of the ancient Delphic oracle, into a state of frenzy in
which they foam at the mouth and are convulsed, prefer always
for pupils of their mysteries boys who are subject to epileptic
attacks. It cannot be disputed that some epileptics have that
function of mind which we call imagination strongly developed
in the lower walks of its exercise, and that in certain conditions
of excitement it may reach an extraordinary activity of a quite
involuntary kind. The interesting chapter of human history
has yet to be written which shall set forth the relations between
alleged supernatural experiences and the abnormal functions of
the nervous system, and again between the divine fury or so-
called inspired enthusiasm of the prophet (6 Oeds év iv) and
that extraordinary activity of its normal functions in which the
whole affective and highest intellectual energies of the individual
are united in some great achievement.

Hallucinations of all the senses are more frequent and more
vivid in epileptic than in any other form of mental disorder.
During a paroxysm of its blind fury all the senses are in tur-
bulent commotion; there are roaring noises in the ears, bright

1 Oscar Peschel, Vilkerkunde, p. 275.
CLINICAL GROUPS OF MENTAL DISEASE. 447

or crimson halos or black cloud-like spectra before the eyes,
stinking or stifling sulphurous odours in the nostrils, fearfully
poisonous tastes in the mouth. In the less acute and more
partial forms of epileptic insanity there are commonly chronic
hallucinations of the same sort; the person hears distinctly a
voice which insults him or commands him peremptorily to do
some deed, or sees actual figures which exhort or threaten him,
or smells poisonous fumes; and these false perceptions of the
senses may abide through the intervals between the fits, as well
as occur immediately before them. One patient who consulted
me used always to hear before a fit a noise in the ear which was
just like the puffing of a locomotive engine when it starts; the
noise lasted long enough to give him time to make preparations
for the fit which it heralded—for example, to walk into a house,
take off his collar, and lie down. Dr. Gregory has recorded the
case of a gentleman in whom the paroxysm was preceded by
the apparition of an old woman in a red cloak leaning on a
crutch, who appeared to come close up to him and to strike
him on the head with her crutch, when he instantly fell down
unconscious. A few years ago a labourer in the Chatham dock-
yard suddenly, without provocation, split the skull of a labourer
near him with an adze; he had formerly been confined in an
asylum on account of epilepsy and mental disorder; and it
came out after his trial, when he had been placed in an asylum,
that he believed he had received the Holy Ghost some time
before the homicide, that it had come to him like a bright light,
and that his own eyes had been taken out and balls of fire put
in their places, In the well-known aura epileptica—the abnormal
_ sensation which, appearing to spring from some internal or ex-
ternal spot of the body, so often precedes an epileptic fit—we
have a striking example of the disturbance of general sensation
and organic sensibility; and I have no doubt that a more
general and violent disorder of these general functions of
organic sense during a paroxysm of epileptic fury is a main
condition of the person’s loss of feeling of personal identity,
and of the remarkable unconsciousness of what he has done
during the attack. For the time being the intimate physio-
logical sympathy and synergy of the organs of the body, by
20
448 PATHOLOGY OF MIND. (cHAP,

virtue of which it is an organism, and which, as I have else-
where argued, are the real foundation of the ego, are suspended ;
it is a chaos of abnormal sensations which are translated imme-
diately in a chaos of irregular movements. Not unworthy of
notice in this connection is it that loss of consciousness has
been observed to occur soonest in those epilepsies in which the
aura proceeds from the epigastrium, just as the most distressing
paroxysms of helpless anguish and apprehension are witnessed in
those cases of melancholia in which a morbid sensation appears
to rise in the epigastrium and mount thence to the head.

Another form which epileptic insanity takes is dementia. It
ig the termination which it gradually reaches when it is not
cured; as the paroxysms of derangement recur, the memory
fails, the feelings are deadened and desires wane, the sensations
are dull and slow, the intellect becomes weaker and weaker,
and there ensues a condition of dementia which differs only
from the dementia that follows other forms of insanity in the
greater frequency of its hallucinations and of its outbursts of
irrational and impulsive violence.

In all these forms of insanity the outlook is bad, and it is so
because we cannot as a rule cure the epilepsy. Could we do
that soon we might fairly expect a good result, for a considerable
mental improvement has taken place in a person far gone in
dementia, when by some happy chance or measure of treatment
the fits have been stopped. Indeed, the mental derangement
may be looked upon as the dark shadow of the epilepsy which
will disappear usually when it disappears; a fact which puts it
in a somewhat special clinical category, seeing that we could not
justly look for recovery from a similar monomaniacal or de-
mented form of insanity when there was no epilepsy to complicate ~
matters. A few striking cases are recorded in which epilepsy,
due to a depressed or damaged portion of the cranium by injury,
was cured by the surgical removal of the injured piece of bone,
and the accompanying insanity cured at the same time. The
administration of large doses of bromide of potassium will sus-
pend and sometimes cure the fits at an early stage, and will
much lessen their frequency even in advanced cases; but I
carmot say that I have observed permanent benefit from its
ix.] CLINICAL GROUPS OF MENTAL DISEASE. 449

persevering use in cases of long standing epilepsy with mental
disorder. Certainly the attacks may be suppressed for a time
by it, but they seem to accumulate in the system until it is
charged with explosive forces—very much as a Leyden jar is
charged with electricity—and to burst out eventually in longer
paroxysms of fearful excitement and violence, insomuch that it
has seemed better on the whole to suffer them to have their
natural course unchecked. Nor is the least good done in these
cases by attempts to stifle or cut short the maniacal excitement
by the use of large doses of chloral, opium, or any other narcotic
drug. The patient may commonly be overpowered by the drug
and thrown into a stuporous sleep of an hour or two if the doses
given be large enough, but he will be likely to be in a worse
state of excitement when he wakes, and the paroxysm will last
longer in the end.

¢
Insanity of Pubescence.

The great changes which take place in the nervous system at
puberty coincidently with the development of the reproductive
organs make themselves. known by a complete revolution,
or, more correctly speaking, evolution, of the mind. New
ideas and feelings and impulses come to the individual, he
knows not whence or how; there is a decided emotional
ground tone of purely subjective origin, showing itself in
vague longings and pleasing moods of melancholy, and craving
for something objective to attach itself to. This strongly sub-
jective mood necessarily implies a condition of somewhat un-
stable equilibrium of mind, which is not then in exact and
adequate adjustment to its surroundings, and may well become
critical. In some instances the physiological evolution of puberty
passes into a pathological revolution. Moreover, as it is
the unfailing tendency of the mind to project its affections
outwards and to transfer them to objects as qualities—
to exteriorise its states as qualities—a person at puberty
who is possessed with a new feeling which craves for external
attachment is apt to invest unfit objects with qualities which
‘they are altogether destitute of, or even to create the object in
450 PATHOLOGY OF MIND. [cHap.

extreme cases. For these reasons it is that the development of
puberty is now and then the occasion of an outbreak of mental
disorder, especially where there is a strong predisposition to
such disorder. Girls are more liable to suffer at this period,
I think, than youths; and it is not difficult to understand why.
In the first place, the affective life is more developed in propor-
tion to the intellect in the female than in the male sex, and the
influence of the reproductive organs upon mind more powerful ;
secondly, the range of activity of women is so limited, and
their available paths of work in life so few, compared with those
which men have in the present social arrangements, that they
have not, like men, vicarious outlets for feeling in a variety of
healthy aims and pursuits; in the third place, social feelings
sanction tacitly for the one sex an illicit indulgence which is
utterly forbidden to the other ; and, lastly, the function of men-
struation, which begins at puberty in women, brings with it
periodical disturbances of thé mental tone which border closely
on disease in some cases, while the irregularities and suppres-
sions to which it is lable from a variety of mental and bodily
causes may affect the mind seriously at any time.

I know not that there is anything in the insanity which occurs
at this period so characteristic as to enable me to give a special
description of it. It may have the complexion of mania or of
melancholia. In the former case, the mental excitement, which
perhaps breaks out rather suddenly, is not of a very acute
character, being shown rather in a ludicrous exaltation of the
natural self-conceit of that age, in excitedly pert and extrava-
gant talk, in the absence of all diffidence of thought, feeling,
and of demeanour, and in restless, absurd, and mischievous acts
which, having much the air of being wilful and capricious, are
apt to be called hysterical. Nevertheless, when we proceed to
observe them carefully, we perceive that they are too un-
reasoning and automatic to be entirely wilful. They illustrate
that mixture of the voluntary and involuntary which is often
observed at the beginning of mental disorder ; which there would
be no difficulty in recognising were it not for the metaphysical
conception of will as an immaterial entity; and which I know
not how better to describe than by such incongruous term as
1x.] CLINICAL GROUPS OF MENTAL DISEASE, 451

“involuntarily wilful.” The attacks of mental excitement may
be paroxysmal, the person being apparently quite well in the
intervals between them, and they are sometimes accompanied
by movements which seem to be of a quasi-spasmodic or choreic
nature, such as a continuons jerking of the bedy in a peculiar
way, strange motions of the hands and arms, a2 extraordinary
erimacing, fits of crawling on the floor, quasi-somnambulistic
seizures, and the like.

In other cases the symptoms are those of melancholia: the
person becomes dull and listless, is silent and moody, relin-
quishes occupations and pleasures, weeps perhaps without ap-
parent reason, gets an unfounded notion that he or she is an
object of dislike, or of suspicion, or of persecation, or has done
something very wrong, tears clothing in a seemingly wilful and
perverse way, and perhaps makes objectless starts away from
home, or absurd and bungling attempts at suicide. Recovery
usually takes place in these, as in the maniacal cases, when
suitable treatment is put in force, but a similar attack is not
unlikely to occur. Where hereditary predisposition is strong,
and of a bad type, the disease may go on from year to year, the
mind becoming gradually weaker, until it passes eventually into
dementia; a dementia, however, which differs from ordinary
dementia in the evidence which there is for a long time of clear
understanding if the person can only be moved to exercise it,
notwithstanding the extreme apathy of feeling, deadness of will,
and insanity of conduct which are shown. It is, in fact, more
a moral than an intellectual dementia.

In order to treat such patients successfully, it is necessary in
most cases to remove them from home and the care of their
parents, who, with the best intentions, either fail to manage
them properly or positively mismanage them, and to put them
under the care of some one with whom their morbid outbreaks
make no commotion, and who will exercise systematically a
kind and thoughtful but firm control, And that is a course
which is seldom adopted as soon as it ought to be, if it is
adopted at all; sympathetic parents of a like constitutional type
are apt to declare earnestly that their son or daughter is
peculiarly sensitive, and that they are sure it would have the
452 PATHOLOGY OF MIND [cnaP.

worst effect upon them to send them away from home, and ‘so
let the favourable opportunity of early cure go by. No marvel
that it is so since those who instinctively keep them in the
morbid train are those who bred in them the disposition to it.

The difficulty of giving an exact clinical picture of the
symptoms of insanity of pubescence, of marking distinctly the
territory which it occupies, so that all men may know it, is
heightened by its frequent complication with self-abuse and
the mental derangement which results therefrom. This vice is
particularly apt to befall, and particularly injurious in, persons
who have the neurotic temperament, for in them the sensibility
is more acute and urgent, the power of control feeble and
spasmodic in its exercise, and the consequence of the self-
indulgence specially exhausting and harmful. In young women,
again, the mental disturbance that occurs in connection with
pubescence is often mixed up with that which is the effect of
disordered and suppressed menstruation, so that it is not prac-
ticable to distinguish them. In the present state of knowledge
it would perhaps be more satisfactory to make a large group of
the cases of mental disorder which attest the operation of the
reproductive organs upon mind, and to be then content to in-
dicate varieties rather than to attempt to describe their features
exactly. It should be clearly borne in mind with respect to
these, as with respect to all other varieties of insanity, that the
most important factor in the determination of their special
features is not the supposed bodily cause nor the actual bodily
condition, but the particular mental character of the individual,
as built up by inheritance, education, and experience.

Insanity of Self-abuse.

The most striking features in this varicty of mental derange-
ment are the intense selfishness and self-conceit that are shown.
The patient is completely wrapped up in self, egotistically in-
sensible of the claims of others upon him and of his duties to
them, hypochondriacally occupied with his sensations and his
bodily functions, abandoned to indolent and solitary self-
IX] CLINICAL GROUPS OF MENTAL DISEASE, 453

brooding; he displays a vanity and self-sufficiency quite un-
becoming his age and position; exacts the constant indulgence
of others without the least thought of obligation or gratitude,
and is apt, if he gets not the consideration which he claims, to
declare that his family are unfeeling and do not understand
him, or are actually hostile to him. They meanwhile urge him
to apply himself to some work, seeing no reason why he should
not, but in vain; he may talk largely of projects engendered of
his conceit, but he is either too ill to attempt to work, he asserts,
or the work which is recommended to him he rejects con-
temptuously as unsuitable and degrading. Without actual
intellectual derangement, he presents a singular deadness of the
moral sentiments and the coldest inertness of will; family and
social feelings seem to be extinguished; there is no sensibility
to altruistic stimuli, and no reaction therefore in answering
feeling and will. Perhaps it may be looked upon as an instance
of fitting retribution that the completest destruction of the
moral sense should have its cause in the vicious abuse of that
instinct in which it had its origina] root.

With the mental degradation there go in many cases, but not
always, an averted eye, a dull expression, a sallow complexion,
cold and clammy hands, and a languid circulation. As I have
already said, a neurotic temperament is a powerful, if not an
essential, co-operant in the production of the effect. The worst
effects of the vice are not so much to be feared in the openly
vicious as in youths who, having been brought up strictly at
home, have not been exposed to other temptations, and who
perhaps to all appearances have been most moral and exemplary.
in their conduct; insomuch that an indignant parent protests
against the bare suggestion of such immorality, forgetting mean-
while in his haste that the sexual instinct has:no need of in-
struction in order to: manifest and gratify itself, and that the
inclination to unnatural indulgence is not likely to be more
urgent where there are frequent occasions of natural indulgence.
On the other hand, schools are sometimes centres of infection.

Let it be noted with regard to these disagreeable cases of
insanity that the symptoms differ somewhat according as the
mental breakdown takes place very soon after puberty, that is.
454 PATHOLOGY OF MIND. [cHAP.

to say, before the sexual life has really entered into the mental
life and there has been time for the character to exhibit its
influence, or according as it takes place at a later period, when
the ideas and feelings bear witness to the sexual evolution in
mind, and the revolution of character has been carried through.
In the former case we have degenerate beings who, as regards
moral character, are very much what eunuchs are said to be—
namely, selfish, cunning, deceitful, liars, destitute of moral
sentiment, and who furthermore exhibit marked impairment of
intellectual and bodily vigour; in the latter case there is not so
marked and exclusive a moral perversion, but the mental de-
rangement betrays more plainly the degradation of the sexual
instinct. I propose to describe in greater detail these two classes
of cases, in order to present a complete picture of the course of
this variety of mental degeneracy.

Medical advice is sometimes sought concerning youths of
eighteen or nineteen years of age who are causing no little
anxiety to their parents. The story told is of this kind: they
are not doing any good at the work to which they have been
put, whether it be at school or in some business, and their
masters complain that they can make nothing of them. It is
not that they cannot do the work, if they really try, for they
may have done it very well for a time, and can do it still when
they are in the mood, but for the most part they are moody,
careless, absent, forgetful, indolent, and apathetic, showing no
interest and putting no energy in their task, wasting a great
deal of time in doing badly very Mipla things, perhaps
muttering or laughing to themselves, or doing silly acts in a
way which makes everybody think that they do them wilfully
while really knowing better. Their behaviour has all the look
of bad disposition and wilful laziness, and at the outset is sure
to be regarded in that light, but after persuasion, remonstrance,
and severity have been tried in vain, and after the work or the
master has been changed—perhaps more than once—the con-
viction is gradually brought home to those who have to do with
them that they cannot be right in their minds. In their families
they are selfish, exacting, deceitful, vain beyond measure, capri-
cious, and passionate; entirely wanting in natural affection for
1X.] CLINICAL GROUPS OF MENTAL DISEASE. 455

their parents, and. in common consideration for, others; and
their pretensions and conceit are outrageous. They do not
acknowledge that they are at all in fault, but make some excuse,
no matter low poor, for their conduct by putting the blame of
it upon others, whom they allege to be jealous of them or hostile
to them, or to have injured their character by what they have
said of them; or they persistently deny that they have done
anything to warrant the least complaint against them; or they
declare that the work to which they have been put is unworthy
of their position and attainments, although they may have been
put to it because they failed in higher work and the result is
exactly the same whatever occupation be tried. They are much
disposed to solitary ways, wandering about listlessly alone, or
spending a great deal of time in their bedrooms, if permitted.
The manner is usually downcast and suspicious, and it is not
easy for them to look any one straight in the face; the dress may
be untidy and slovenly, or foppish and expressive of the priggish
conceit of their characters; the pupils are sometimes dilated,
the hands often cold and clammy, the complexion is perhaps
sallow, the breath bad, and the body rather thin.

Questioned about their vicious habits, they seldom confess
them, and perhaps pretend not to understand what is meant.
Some of them are too chaste for belief, for they will deny ever
having had nocturnal emissions; others admit, when pressed
hard, that they fell into the practice of self-abuse when they
were at school, but will affirm positively that they have not
continued it. Seldom can faith be put in their most positive
asseverations touching that matter, or in their most solemn
promises to relinquish the vice when they confess to it. If it
be not checked, they get worse; the general suspicion of the
ill-feeling or hostility of persons to them takes special forms,
and they come to think that their relations or others attempt to
poison them or otherwise injure them, that they are maliciously
worked upon by galvanism or electricity, or that persons make
offensive remarks or call out obscene or abusive words after
them as they pass in the streets,

1 The extract which follows, from a letter by a father concerning a son,
gives a fair notion of the early symptoms: “The case is this: the boy,
456 PATHOLOGY OF MIND. [cuar.

When the mental failure caused by self-abuse takes place at
a later period, that is to say, after the sexual life has entered
into the circle of the ideas and feelings and transformed them,
the character of the symptoms evidences the transformation
which has taken place. The patient. is extremely shy of the
society of women, and silent and constrained when in their
company, but is apt to fall in love, or to think he does, with
some woman with whom he may chance to be brought into
occasional intercourse. If he becomes engaged to her, which is
not the case often, since his so-called attachment is in the main
a piece of self-flattery by which he strives to persuade himself
that he is like other men, his unpleasantly close attentions
betray a want of manliness of feeling and a nasty lewdness of
ideas: in fact, his behaviour evinces a morbid sexual feeling, in
the excitement of which he finds pleasure and to the subsequent
solitary gratification of which he probably yields, and a lack of
restraint or manliness which most likely means a real sexual
impotence. Apprehensive of such impotence, or alarmed at the
consequences of his vice, or otherwise troubled about his health,
he consults medical men, whom he usually asks whether they
would advise him to marry, and always wearies with stories of
his dubitations respecting what he should do, and regrets about
what he has not done, and with endless repetitions of his multi-
tudinous vacillations; not in the least resolved when the matter
has been well considered and apparently settled at last. He is
fond of talking about getting married without having the serious
intention of doing more than talk, and if he has got actually
engaged he is likely enough to break off the engagement on

born in 1857, left school about three years ago, and he has been in my
office and warehouse ever since, off and on. I have reluctantly come to
the conclusion that his intellect is weak, perhaps from bodily weakness.
He does not appear to be able to apply himself to business, is of a rathér
romantic turn of mind, fond of writing poetry, writes a diary, very
egotistical, thinks himself far superior in mind to his brothers and sisters,
has a long-continued habit of picking and gnawing his fingers, continually
looks in the looking-glass, admires his face and figure, very gentlemanly if
he chooses, very restless at his meals, good appetite, but bolts his food,
rubs his face and hair with his hands, restless at night, sometimes crying,
often laughs or rather grins at nothing, fond of the theatre, and, I sup.
pose, thinks he could perform on the stage.”
x] CLINICAL GROUPS OF MENTAL DISEASE. 457

some pretext or another. Perhaps he withstands successfully
for a time his vicious propensity, after the perils of indulgence
have been pointed out forcibly to him, but before long he falls
back into evil, and is afterwards depressed, gloomy, troubled
with all sorts of anomalous sensations, and full of fancies and
fears about his health. Does he get so far as to be engaged, it
is when the wedding-day is to be fixed, or is fixed, that his
doubts and agitations reach their height; he is anxious, full of
hesitations and apprehensions respecting his fitness to marry,
and puzzles and troubles his betrothed or his friends with his.
vacillations, his fears of incompatibility, and the like; in the
end he probably breaks off the engagement, or runs away from
marriage at the last moment, on some pretext of overstrained
religious scruple, or because he is overwhelmed with the thought
of the serious responsibility of bringing children into the world.
Perhaps he discovers that the consummation of marriage is the
degradation of love, and will none of it. Very remarkable is it:
what a strain of exalted sentiment and lofty idealism is pro-
fessed in some of these cases: the world is too coarsely selfish
and rudely practical for their fine sensibilities and nice aspira-
tions, and notwithstanding that they are sunk in.a degrading
self-indulgence, and perhaps emasculated by it, they will pour
out loftily pitched moral sentiments, and take it hotly to task in
high conceited fashion for its low aims and gross ways. They
may project some great mission of social reform without true
practical resolve, as they have abundant self-conceit without
self-knowledge, a spasmodic sort of self-will without true will,
a thin intellectual eagerness without breadth and calmness of
understanding, a morbid intensity of self-feeling which they
mistake for altruistic. feeling. It is a mistake which many
medical men make to recommend marriage to these persons in
the hope of curing them, for seldom does anything but sorrow
and misery come of it. Marriage is by no means a certain
cure ; the confirmed sinner has little desire or power of natural
intercourse, finding no pleasure in it; the indulgence of a
depraved appetite has destroyed the natural appetite. Cold-
ness and indifference to his wife, discord, quarrels and threats
of violence, separation from bed or house, suicide, and even.
458 PATHOLOGY OF MIND, [cuaPr,

madness are more probable results of such a marriage than
domestic peace and happiness.

Up to this point one can hardly pronounce these persons to
be actually insane, although they are far on the road to insanity.
Some of them remain for several years in the state deseribed
—perhaps for the rest of their lives—without getting worse, im-
proving even as age increases and passion wanes. When matters
go on from bad to worse and actual derangement cannot be dis-
puted, this is the state of things: the feelings and conduct are
more deranged than the understanding ; they exhibit an intense
conceit of self in a quiet or in a priggish and offensive way ;
large discourse concerning their superior feelings and aims which
other people are too gross-minded to appreciate; paralysis of
moral feeling with, at the same time, excited enunciation of
exalted sentiments that are the expression of their assumed
superiority in noble feelings and aspirations; a disorder of
intelligence not manifest in actual incoherence, save when they
are in a passion, but in outrageously exaggerated notions of
their own dignity and importance, and ultimately perhaps in
positive delusions of persecution by reason of the envy and
jealousy of their relations and others who are inferior to them.
The patient has the insolent conceit to write to his mother
perhaps as “madam,” to declare that his brothers shall bow
down to and honour him, and to lecture his father, whom he
considers to be much his inferior in intellect and moral feeling,
on the lowness of his aims and the insufficient respect which
he shows him. Some of these patients betray by their gait, by
a turkey-like strut, the vanity with which they are inflated,
others shuffle about in an indolent and apathetic way, with
slouching gait and slovenly look, and head bent towards the
ground: the former evince, so to speak, the convulsion of con-
ceit, the latter the paralysis of self-respect. When they are
challenged with their vicious practices, or are rebuked for some
impropriety of conduct, or hurt in their pride in any other way,
they may, if not dead to any touch of feeling, explode in stormy
outbursts of offended dignity and angry abuse, intermingling a
great deal of religious rant with their abusive and incoherent
raving. Hallucinations are common: they hear voices which
1x,] CLINICAL GROUPS OF MENTAL DISEASE, 459

interfere with their thoughts, reply to or comment upon them,
continually say ridiculous, abusive, or obscene things, and per-
haps make offensive accusations against them; they see insults
in innocent gestures, and imagine that people make grimaces
at them in the streets; they have strange morbid bodily feelings
which, caused really by their enervating vice, they ascribe to
mesmeric, electric, or other mysterious agency; and some of
them fall from time to time into a sort of trance or ecstasy, a
quasi-cataleptic state in which they see visions that are perhaps
of a religious character. Homicidal and suicidal impulses are
not at all uncommon, and are the cause of much mental distress ;
for they arise in the patient’s mind against his will, and although
he is quite aware of their nature, he is terrified by them and
fearful that he may some day succumb to them. It is seldom,
however, that patients of this class do yield to such impulses ;
they are for the most part too fearful of pain to hurt themselves,
and too wanting in resolution to hurt others.

When, degeneration going on, they reach the last and worst
stage of degradation, they sink into an apathetic state of moody
and morose self-absorption with extreme loss of mental power.
They sit or lie all day, or saunter lazily about, muttering or
smiling to themselves, lost to all healthy feeling and human
interests, slovenly and dirty; if they enter into any conversa-
tion, they probably reveal delusions of a suspicious or obscene
nature. They believe that they are subjected to strange in-
fluences which sap their vigour, especially during the night, and
perhaps declare that persons get into their rooms while they are
asleep, and indecently assault them or perpetrate unnatural
offences upon them; their perverted sexual passion still gives
the colour to their thoughts. So they linger on, pitiable wrecks
of degradation, from year to year, becoming weaker in mind
and body, until they die from complete nervous prostration or
from some intercurrent disease to which they fall easy victims
at last.

Such is the natural history of the physical and mental de-
generacy which is produced in men of a certain neurotic
temperament by solitary vice. Certainly it is a sad picture
which I have painted, but the colours are not exaggerated. Let
460 PATHOLOGY OF MIND. (cuap

it be noted once more that there must be the temperament as
well as the vice in order to have this characteristic degeneracy
produced. In another sort of temperament the vice is the
exciting cause of an attack of ordinary acute mania or melan-
cholia, and it is certainly sometimes practised for a long time
without any mental ill effects. It must be confessed that there
is little to be done for persons whose minds have once become
seriously affected. If they can be constrained by any means to
relinquish the vicious habit at the beginning of their troubles
there is good hope for them ; but if not, they will not eschew it at
a later period, for with the decay of mind they have less and less
desire and power to overcome an ever-present temptation which
has become stronger through habitual indulgence. Again and
again I have known the best considered means, moral and
inechanical, which anxious ingenuity could devise and the most
patient care apply, to be brought to bear upon cases of this kind
in order to rescue them from themselves, but seldom with a
success that was worth the pains. Were it legitimate in any
case to entertain or express the feeling that the sooner a de-
graded being becomes the nothing that he was the better for
himself and for the world which is well rid of him, it would be
so here. But the worst wrecks of humanity have these uses at
any rate—that they teach a scientific lesson by their study, and
nurture humane feeling by the care which they exact.

‘It is not certain that the vice in women produces a form of
mental disorder so characteristically featured as in men, or that
it is so injurious to them. But I cannot doubt the existence
of a variety of mental disease in them, having some special
features, which owes much of its origin to sexual causes and is
usually accompanied by this vice. A young lady begins to lose
her interest in her accustomed occupations and amusements,
which she abandons; is depressed and weeps at times without
apparent cause, and is uncertain and capricious in her beha-
viour; complains of strange and distressing bodily sensations ;.
ceases to exhibit affection or consideration for her parents and
others near and dear to her, whom she afflicts by her perverse
moods, her capricious temper, and her self-will; perhaps she
forsakes their society in order to spend a great deal of time in:
1X] CLINICAL GROUPS OF MENTAL DISEASE, 461

her bedroom, where she occupies herself for long periods with-
out weariness in doing nothing or in doing very trifling things ;
or she pertly insists upon pursuing an independent course of.
action which is not befitting her sex and position. The state
of matters is oftentimes worse during the menstrual periods.
Nothing more than this painful change of disposition and
caprice of conduct may be noticed at the outset, but in the end
morbid fancies of some kind are evinced: she imagines perhaps
that her hands are soiled whenever she touches anything, and
must be continually washing them, or has a tormenting fear
that her clothes are infected with insects and must be all day
inspecting and brushing them; she gets some peculiar word or
ridiculous thought into her mind and is distressed because slie
cannot get rid of it, and fancies that it has some indecent
hidden meaning; she declares that she cannot do some very
simple thing, and that she suffers agonics in consequence of
her inability ; she believes that some gentleman whom she has
met, but who has hardly even spoken to her, is in love with
her, and has been hindered by her friends or others from pro-
posing to her, and accordingly throws herself in his way or even
writes him affectionate letters. Perhaps the morbid idea is
that she is followed and watched by persons who say offensive
things of her and call her improper names; and that they have
contrived some extraordinary seeing or hearing apparatus -by
which they can watch or listen to all that goes on in her room.
Patients of this class are apt to make unfounded charges of
attempts upon their virtue, and have sometimes written secretly
with diabolical cunning a series of letters containing the most
abominable accusations against innocent persons. Sometimes the
patient gets the delusion that her soul is lost because of her
wickedness, and has paroxysms of weeping and seeming despair ;
but it is noticed that the misery is not of that deep, genuine,
and continuous kind which usually accompanies that delusion

it is inconstant and is mixed up with a great deal of hysterical
caprice and waywardness of conduct, which perhaps also dis-
covers an erotic flavour. In the midst of what would seem to
be the most acute distress, when she is so prostrate with grief
as to appear to notice nothing or is sobbing as if her heart must
462 PATHOLOGY OF MIND. [CHAP,

break, she will take quick perception of the situation by a sharp
glance or will look up quite calmly and make a suitable answer.
She does no work, is extremely irritable and passionate, uses
bad language, perhaps threatens her mother, and speaks of
suicidal ideas. Anomalous sensations or actual pains in the
head, side, or other parts of the body are complained of, and lead
to all sorts of strange doings for their alleviation. Whilst her
daily conduct is such that those who live with her and see her
from hour to Hour have not the least doubt that she is down-
tight insane, persons who see her only for a short time or receive
quite sensible letters from her may not notice anything wrong.
As matters get. worse, there are more paroxysms of greater
excitement, which may be accompanied by much screaming,
more wilful perversity of conduct, less and less evidence of
natural feelings, increasing weakness of mind, and perhaps a
delusion that she has had a baby or has been accused of having
had one.

If these patients are taken in hand by suitable persons and
firmly handled at the beginning of their illness, they may be
restored to health of mind. But it is necessary to remove them
without delay from among their relations, whom they can affect
by their tears, distress by their caprices, frighten by their threats,
master by their self-will, to the care of strangers who will exer-
cise a watchful supervision and a firm control over them, strive
with patient insistence to engage them in work of some kind
and in interests outside themselves, and systematically oppose
to their wayward moods and morbid caprices the surroundings
of a healthy tone of thought and feeling and an orderly activity
of life. If they are placed where they perceive that their pecu-
liarities stir no commotion and are not permitted to disturb the
quiet order of the household, and where there is everything
about them to arouse and foster healthy feeling and activity, they
are infected slowly by the surrounding tone, and the inclination
to indulge their morbid feelings and whims decreases gradually
until it becomes a greater pain than pleasure to do so. If, how-
ever, they are not taken firmly in hand, but, being thought to
be only hysterical, are suffered to go on at home from weet to
week and month to month without proper control, as commonly
1x.] CLINICAL GROUPS OF MENTAL DISEASE, 463

happens, they slide by an easy descent into incurable dementia;
the real gravity and ominous import of the symptoms being out
of all proportion to their seeming insignificance. Were mind-
slaughter an indictable offence, many a too affectionate parent
would have to stand his trial for an unwise indulgence of
feeling against the stifled convictions of judgment.

Although I have described this form of mental derangement
in women under the head of insanity of self-abuse, inasmuch
as the vice certainly prevails in most cases, I should be loth
to say that a similar mental breakdown does not happen‘some-
times when there is not sufficient reason to suspect its exist-
ence, as the effect of a developing and unfulfilled sexual
life upon a certain nervous temperament whose stability it over-
throws. These cases in women differ from the corresponding
cases in men in this—that while the latter seem to care not for
women and shyly avoid them, being satisfied with secret self-
indulgence, the former evince often by their feelings and conduct
a desire formen. But the difference is not so real as it appears
on the surface. Sinners of the male sex shrink from female
society not so much because they actually dislike it, as from an
extreme shyness and self-distrust ; they have not the courage to
pay attentions to a woman whom in their hearts they would like
to address ; instinctively they feel themselves to be unmanned;
their vicious indulgence has deprived them of the source of
energy and manliness which emboldens the male to a confident
address. On the other hand, female sinners who show an incli-
nation towards men sometimes exhibit quite an opposite feeling
when they have become engaged or have been married; they
may break otf the engagement or display an acute repugnance
to sexual intercourse, which they refuse, or fall into melancholy
or mania; and a marriage which was perhaps schemed and
made with infinite cunning as a means of cure serves only to
make plain their sad state.

Hysterical Insanity.

Without doubt hysterical symptoms sometimes run on by
degrees into actual insanity, but considering how common a
disease hysteria is, it must be confessed that this issue is rare.
464 PATHOLOGY OF MIND. [cHar.

More often certain forms of mania, especially those that occur
in connection with sexual development, present what are called
hysterical features. Mention has already been made of the
strange and extreme moral perversion shown by such hysterical
young women of a nervous temperament as imagine that their
limbs are paralysed and lie in bed or on a couch day after day,
pretend that they cannot speak at all or can speak only in
feeble whispers, affirm that they never pass water and that they
live without food, exhibit strange substances which they protest
they have passed by the bowel or otherwise, fabricate so-called
stigmata or singular diseases of some kind. It seems probable
that their extremely perverted moral state has its principal or an
actively co-operating cause in the effect of some condition of
the reproductive organs on the brain, since it so frequently
occurs in young unmarried women, presents erotic features, and
is likely to be cured outright by marriage. What is the actual
condition of things underlying the temperament which is
designated hysterical, I know not, nor shall I venture to con-
jecture; it shall suffice here to direct and claim attention to the
profound moral disturbance which it may undoubtedly occasion.
Hysterical mental disorder in other instances is of a much
more active kind, taking the form of acute mania. Then we
shall notice great excitement and restlessness of somewhat noisy
and tumultuous kind, with laughing and constant chattering ;
the patient perhaps recognises those who address her and calls
them correctly by their names, but instantly runs off into
incoherent and voluble talk; if asked to show her tongue she
thrusts it out and draws it back rapidly, hardly interrupting her
turbulent flow of talk, or refuses pertly, perhaps bursting out
into wild laughter, or saying or doing something of an indelicate
character. In her best moods she is apt to be mischievous—will
incontinently kick the washhand basin, bath or other utensil
over out of a pure spirit of mischief; but her laughing and good-
humoured jabbering are likely to alternate with periods of
irritability, weeping, and ill humour, and with fits of screaming
when her humours are opposed. And opposition cannot is
avoided, since she may ring the bell continually if she can get at
it, tear her clothes, expose herself indecently, attempt to run out
IX.] CLINICAL GROUPS OF MENTAL DISEASE. 465

of the house and do similar illegitimate things. Perhaps she
will suddenly throw herself back on her bed or on the floor and
lie there motionless in a sort of quasi-cataleptic state in which
she seems to be insensible to impressions; or she falls into
paroxysms of violent shudderings in which all the voluntary
muscles are spasmodically contracted, the contractions, which
have the air of exaggerated voluntary action and of having been
wilfully set a-going, being accompanied with consciousness. The
habits are apt to become unclean. Sexual excitement reveals
itself sometimes in her eyes, in her gestures, in her speech, even
- in the odour of her body, and she is apt to speak of persons
being in love with her, of being married, of having babies and
the like, Mixed up with the erotic features in some cases is no
little religious exaltation, and the incoherent talk shows that
those passages in the Bible which bear on the secret relations
of the sexes have not been overlooked.

Recovery takes place in the greater number of cases of this
form of acute mania when it is taken vigorously in hand at the
commencement, and then usually within three months of its
outbreak. The prognosis becomes unfavourable when it subsides
into a subacute phase and goes on from month to month with
alternating periods of excitement and moody apathetic depres-
sion ; it is unfavourable also when the mania is recurrent, as it
is somewhat apt to become. When the disease is going the
wrong way the mind is gradually weakened and the decline is
into dementia. ;

The late Dr. Skae proposed to class a group of cases of mental
derangement under the designation of Amenorrhcal Insanity,
meaning thereby to bring together those in which the suppres-
sion of the menses was the immediate and essential cause of
the disease. He did no more, however, than sketch vaguely the
outlines of the symptoms of this proposed clinical variety, and
I have failed to perceive that his outlines are in the least
characteristic. Without doubt an outbreak of insanity may
follow a suppression of the menses and be directly due to it,
disappearing with the return of them, but I know nothing in
the symptoms of the derangement so caused to distinguish it
from mania or melancholia otherwise caused. The features, so
466 PATHOLOGY OF MIND. [ctae.

far as they are special, are determined by the temperament of
the individual and by the state of his mind and body at the
time, rather than by the exciting cause of the outbreak. It is
common enough for the menses to be irregular or suppressed in
acute insanity, the derangement of the function being an effect,
or a concomitant, or one among other co-operating conditions of
the insanity; but he must be an acute observer who can detect
the difference between the effect produced upon the features of
the mental disease by the suppressed function when it is looked
upon as concomitant rather than cause, accidental rather than
essential, and the effect produced by it when it is thought to be
the immediate and essential cause. Certainly we cannot venture
to classify the varieties of insanity by their supposed causes.
The characteristic features of the clinical varieties which have
been just described as occurring in connection with sexual de-
velopment bear witness in the main to two predominant bodily
states rather than to a special cause in each case—namely, first,
to the youth of the patient, whence the liveliness, the wilful-
ness, the laughing incoherence, the tumultuous energy when the
disease is maniacal, and the conceit, the ignorant pretensions,
vnl the moral perversion and caprice when it has a melancholic
form ; and, secondly, to the irruption and activity of the sexual
system, whence the erotic features.

Puerperal Insanity.

This might be described as prepuerperal and post-puer-
peral, A woman sometimes falls insane during pregnancy, and
although it is probable that she who-does so has inherited a
strong predisposition to the derangement, one naturally looks
upon the bodily condition as the exciting cause. Proof of the
remarkable effects which pregnancy can exert upon the mind
is afforded by the strange cravings and longings for particular
articles of food and by the morbid fears which pregnant women
not unfrequently display during its earlier months. On the other
hand, I have met with three instances in which women who were
melancholic when not pregnant became cheerful and apparently
we!l when they fell into that condition, The form which the
Ix.] CLINICAL GROUPS OF MENTAL DISEASE, 467

mental derangement of pregnancy most often takes is melan-
cholia, and those women are most likely to suffer from it who
have married late in life, and whose system, having lost much
of its suppleness, is less able to accommodate itself to the new
conditions. Its features do not differ specially from those of
melancholia otherwise caused: there are often vague apprehen-
sions and fears, despairs and suicidal feelings. Recovery takes
place in the greater proportion of cases ; some, however, decline
into dementia; and in a few. cases the morbid depression, having
continued up to parturition, has been then followed by an out-
break of acute insanity, commonly acute mania, One cannot
justly look forward to that event with the sanguine hopes that
are commonly entertained in such case; a gradual recovery
during pregnancy is worth more than the most confident anti-
cipations of a sudden recovery at its termination.

Puerperal insanity is the name properly given to that form of
mental disorder which comes on within a month or two after -
childbirth. When it comes on within a fortnight of delivery
the symptoms are usually maniacal; when after the lapse of a
fortnight they are most often melancholic. The mania is of an
acute, turbulent, and incoherent kind; the patient being noisy,
restless, sleepless, and evincing very little method in what she
does, and very little coherence in what she says; she snatches
at anything near her, tosses the bedclothes off, starts up and will
not remain in bed, catches up in a quick but utterly meaning-
less way a word or two of what is said to her or in her hearing,
whirling it into the chaotic turmoil of her speech, and not un-
frequently. exhibits some lasciviousness of thought and behaviour.
Hallucinations of vision are betrayed by the way in which she
stares at imaginary objects or speaks to imaginary persons, and
by the gross mistakes which she makes respecting the identities
of persons about her, whom she calls by wrong names and
perhaps addresses in familiar or even endearing terms, although
they are strangers to her. The bodily symptoms accord not
usually with the violence of the mental disorder, the pulse
being often quick, small, and irritable, the face pale, drawn, and
pinched, and the general condition feeble. Suicide may be done
in a purposeless way; it is then rather an incident in the
468 PATHOLOGY OF MIND. [erap.-

unreasoning fury of her behaviour than a designed or even clearly
conscious act. If her child, incautiously left in her charge, falls
a victim to her frenzy, the homicide is an act of much the same
character. One lady whom I saw was not aware, after her re-
covery from an attack of acute puerperal mania, that she had
borne a child; and another lady could not be persuaded, when
she had recovered, that the child which she had had was hers,
and although she suffered it to be brought up with her other
children, and afterwards bore a child which she made not the
least doubt to be hers, she held to her opinion with respect to
it and never showed it a mother’s affection.

Puerperal mania furnishes a large percentage of recoveries,
generally within from three to six months from the outbreak
of the malady ; where it lasts some months longer the outlook
is unfavourable. As the excitement subsides it sometimes
leaves behind a good deal of confusion and apparent feebleness
of mind—a hazy, dreamlike, or demented-looking state—from
which the patient awakens by degrees to restored reason. Com-
plete recovery coincides oftentimes with the normal return of
the menstrual function.

I have nothing special to say concerning the features of the
melancholia that occurs soon after parturition. The depression,
which begins with dislike or suspicion of husband, nurse, and
those about her, is generally accompanied with suicidal impulse,
and in not a few cases there starts up out of the morbid gloom
a strong impulse to kill her child—an impulse which, notwith-
standing the horror which it causes her in the first instance, is
not unlikely to be carried into effect if the child be not taken
from her care. Nor is there anything special to be said of the
melancholia which, occurring at a later period after parturition,
has been described as the Insanity of Lactation. It is preceded
by symptoms of cerebral exhaustion and general prostration—
headache, ringing in the ears, dimness of vision, flashes of light
before the eyes, and a general feeling of weariness and debility;
and it appears mostly to be due to the bodily exhaustion pro-
duced by suckling, in conjunction often with depressing moral
influences. In most cases there is good reason to anticipate
a timely recovery if suitable measures be taken to restore the
IX.] CLINICAL GROUPS OF MENTAL DISEASE. 469

bodily strength by putting a stop to the debilitating drain and
by giving good nourishment, and to revive the mental tone by
removing the patient from depressing influences and giving her
the benefit of rest of brain and change of scene.

Climacteric Insanity.

This is the name given to the mental disorder which befalls
in women at the so-called change of life. During this crisis of
their lives they commonly suffer more or less from various ano-
malous feelings of bodily distress, and from some depression or
discomfort of mind—symptoms that bear witness to the disturb-
ance of the circulation and of the nerve functions; and some of
them go through much suffering before their constitutions are
adjusted to the new conditions of life. It is the time too when
the age of pleasing is past, the desire of man being no longer
to them ; wherefore if the life has been one of empty vanity and
habitual self-indulgence, and the wish to be an object of desire
and flattering attention remains, the unwelcome proof of their
decline is a trial which they do not bear well. Thus mental and
bodily causes may work together to produce a morbid depression
of mind. An insane jealousy, having its root in the apprehen-
sion of the extinction of the power to provoke desire, sometimes
shows itself in an extremely exacting form, in unfounded suspi-
cions of a husband, in gross accusations of unchastity, in much
violence of passion and conduct; and a habitually indulged pro-
pensity to alcoholic stimulants, which may have been taken in
the first instance to relieve the feelings of mental depression
and bodily sinking, makes more frantic the paroxysms of jealous
fury. This sort of insane jealousy is certainly not special to the
climacteric period; it may be met with before that change in
women who have lived the sort of life of self-indulgence to
evoke and foster it; but it is most likely to break out or to be
greatly exaggerated then. The gratification of a selfish passion
is like the gratification of a liking for stimulants ; the appetite
grows by what it feeds on, and the doses necessary to produce
the pleasing effects must be progressively increased, until in
the end such a state of moral and physical deterioration is
470 PATHOLOGY OF MIND. [cHap.

produced that the largest doses only avail to palliate a distress
which is declared to be unendurable without them.

When the mental disturbance incident to the climacteric
change goes on to unquestionable insanity—and there is almost
always a hereditary predisposition when it does—the disease
has the melancholic form. In many cases a vast and over-
whelming apprehension of some great but undefined impending
calamity is exhibited in a terror-stricken countenance, in con-
stant agitation of behaviour, in frequent ejaculations of distress ;
the patient is sure that something dreadful is going to happen,
but cannot in the least explain what it is she fears. Or there
may be such vague delusions as that the whole world is in
flames or is turned upside down, that everything in it is changed,
neither person nor thing remaining the same, that her memory
and other faculties are gone, that her soul is doomed to ever-
lasting torment in hell, She is many times curiously conscious
of her state, so much so that while holding firmly to her de-
lusions she perhaps admits herself to be a proper subject of
medical care, and declares that she ought to be sent to an
asylum in order to prevent her from doing harm to herself or
to others, at the same time that she expresses a great horror of
such a procedure, and protests that it will drive her out of her
mind entirely and that she never can be restored to her former
state of comfort whatever be done. “It is all in vain; you
don’t believe what I tell you; but I know something unspeak-
ably dreadful will happen to me—oh dear, oh dear!” is the
wearisome burden of her exclamations. Suicidal feelings are
sometimes very strong, and persistent refusal of food may
necessitate forcible feeding. As many as half of these cases
may be expected to get well if properly treated, but not always
quickly; the disease is apt to last for a considerable time in
some of them before recovery takes place.

Some authors suppose that there is a critical period in men be-
tween fifty and sixty years of age, corresponding to the climacteric
change in women, and that they also suffer sometimes from a
climacteric insanity. It is certain that there is no such abrupt
and marked physiological change in men as is natural to women,
but it is not improbable that a similar constitutional change takes
i] CLINICAL GROUPS OF MENTAL DISEASH, 471

place in a more gradual way and is spread over a longer period.
Whena man has made self-gratification the sole or main interest
of his life, and in pursuit thereof has indulged the sexual passion
to excess, and when he finds his interests gone by the extinction
of desire, he is without aim or pleasure in his self-indulgent
life, and may well fall, if he is of a decided nervous tempera-
ment and has a predisposition to mental disease, into a morbid
melancholy. In such event the melancholy is sometimes of an
extremely hypochondriacal nature: he complains of anomalous
pains in all parts of the body which he describes as causing him
the greatest agony; of the absence of all appetite for food,
although he eats very well; of habitual sleeplessness, which
others do not observe; of inability to exert himself to take
exercise, and of the frightful suffering which he endures after-
wards if he forces himself to do so, notwithstanding that he may
plainly enjoy the exercise at the time, always however without
admitting that he does so; he protests that he cannot remember,
cannot read, cannot employ his mind in any way, although his
faculties show themselves as acute as ever they were when he
can be lured to exercise them, or when he exercises them
on his own account, as he does more frequently than he pre-
tends; and he is continually uttering his fears that he will
go out of his mind, and begging to be told candidly whether
he will or not. Whatever be the subject of conversation
started he brings it round to himself, and is never wearied
of relating the story of his torturing sensations and assuring
his listener what agony he endures every moment of his life.
Call his attention to an ache or a pain which he has not, and
next day he will have it. Although he may be gifted with
a mind of superior powers in some respects, and is clearly
conscious of his state and earnestly anxious to be delivered
from it, he cannot get out of himself and interest himself in
anything but his sufferings: his morbid self is the one thing
alone which he cares to talk about. When, after the long detail
of them, he has received all the encouragement and assurance
that can be given him, he begins again telling the same story
and asking the same questions, just as if nothing had been
said. His afflictions are assuredly genuine, however much they

21
472 PATHOLOGY OF MIND. [cHaP.

may have the air of being magnified and systematically nursed ;
they are so unceasing that he oftentimes thinks and speaks
of suicide, and so insupportable sometimes that he makes a
desperate attempt at suicide in one of his paroxysms of distress.
I knew one gentleman suffering in this way who on one occa-
sion threw himself over the bannisters of the stairs from the
second floor of his house into the hall, injuring himself seriously,
and on another occasion thrust into his abdomen a knife which
he had concealed. Both attempts were unsuccessful.

I do not wish to describe this sort of extreme hypochon-
driacal melancholia as exclusively climacteric, since it may
certainly occur at an earlier period of life, especially where
sexual pleasure and power have been exhausted prematurely
by excesses, but it is perhaps most often met with in con-
nection with that constitutional change. I am apt to think
that in many cases of the kind there is a commencing de-
generation of the coats of the arteries, of an atheromatous
nature, whereby the proper nutrition of the brain is hindered,
and that this degeneration is a more potent cause of the mental
depression than the sexual change. As the sufferer pours out
his tale of woe, one notices perhaps a twisted artery with rigid
coats winding over one or the other of his temples, and feels that
if that outward and visible sign of decay of structure is a mark
of the state of the small arteries within the brain, there -is
little hope that he will be delivered from the gloom which en-
velopes him. However, the arterial degeneration is certainly
not observed in all cases.

Senile Insanity.

It is in this form of insanity that we are most likely to find
atheromatous cerebral arteries, which, if they are not directly
the cause, are at any rate the mark, of a real decay of brain.
Miliary aneurisms, which have been described in at least one
cease, are strong proof of arterial degeneration. Shrunken con-
volutions, and serous effusion under the arachnoid to fill up
the void made by the decay and absorption of nerve-elements,
result from, and bear witness to, the defective nutrition. With
1x. ] CLINICAL GROUPS OF MENTAL DISEASE, 473

the decay of brain goes a corresponding decay of mind, the
symptoms of which are characteristic. They may be described
as the exaggeration of the natural decline of mental faculties
which often accompanies the bodily decline of old age.

The symptom which attracts first and most notice is an impair-
ment of memory, particularly in respect of recent events; these
are perceived correctly at the time, but are not retained; although
they may have appeared to arouse proper interest when they
happened, they are clean gone from the mind in a day or two,
or in an hour or two, or in extreme cases the moment after-
wards, while long-past incidents are talked of as if they were
affairs of yesterday. The memory is long-sighted, so to speak,
seeing not what is close at hand, but seeing fairly well what is
distant. This persistence of past memories with the loss of
recent ones is the cause of a striking want of congruity between
the habitual thoughts and the actual circumstances of daily
life, and gives to the patient’s conduct an air of greater imbecility
than it actually warrants. If his attention be actively roused by
some stimulus and the facts be put quietly and clearly before him
he may apprehend them correctly and even pass a sound judg-
ment upon them, notwithstanding that he may not, if questioned
a few days or some hours afterwards, be able to give a good account
of what he said or did, and may incontinently babble of some-
thing which took place twenty years before. The next step in
the course of his brain-decay is an impairment of the power of
‘perception, in consequence of which he fails to apprehend cor-
rectly what occurs and to recognise familiar persons and places:
he mistakes trains of ideas belonging to the past for present
perceptions, talks as if he were now in a place where he has
not been for years, and supposes a person whom he sees for the
first time to be some one whom he knew years ago. Not recog-
nising one whom he had formerly known quite well, he will
inquire of him after his own health as if he were making the
inquiry of another person; he will express his surprise that
somebody who has been dead for a long time does not come to
see him ; will ask the same question over and over again within
a few minutes, forgetting instantly on each occasion that it has
been asked and answered. There are considerable variations in
474 PATHOLOGY OF MIND. [cirar.

his mental capacity at different times according to variations in
his bodily health ; he may remember an incident one day which
he had clean forgotten the day before, or mistake the identity
of a person to-day whom he will perhaps recognise to-morrow,

As decay proceeds it effaces more and more the lines of
mental function; memory and perception are nearly extinct ;
the patient knows not those who are constantly about him, and
forgets instantly whatever happens. His brain can neither
receive nor register impressions. Its past registrations, which
persist after recent ones have been effaced, are disorganised, so
that he jumbles together persons and events in the most con-
fused way, his talk is fragmentary and incoherent rambling, and
his conduct has no relation to his external conditions. He gets
up in the middle of the night, insisting that it is day, or goes
to bed at midday believing that it is night; imagines that he is
occupied in work which he has not touched for many years, or
wonders why he is not so occupied, and blames angrily those
whom he supposes to be hindering him from setting to work;
seems perhaps to understand a very simple question when it is
slowly and plainly put to him, so as to give time for the sound
of each word to reach his apprehension, and begins a reply
which, his attention breaking down after the first word or so,
‘becomes utterly confused and meaningless ; or he cannot compre-
hend in the least what is said to him, and says something that
is altogether irrelevant and incoherent. In many cases there
are morbid suspicions or actual delusions that he is being
robbed or maltreated, or that some great injury is to be done to
him, and the paroxysms of noisy excitement which occur in
consequence are a great trouble to those who have the care of
him. His social feelings are involved with his intelligence in
the common “ruin of oblivion ;” all the feeling which he shows
being anger at the supposed injuries done him, or an outburst
of the tears of dotage from time to time. Oftentimes his habits
are uncleanly. At last he dies, the machinery of his organism
completely worn out.

It is interesting to compare these symptoms of mental decay
with the symptoms of failing mind that are natural to the
decline of old age. Then the sharpness of the senses is blunted,
Ix.] CLINICAL GROUPS OF MENTAL DISEASE. 475

especially those of sight and hearing, and when the old person
appears to hear what is said it sometimes takes an appreciable
interval of time before the sensation of sound reaches the
chamber of apprehension. Responsive vibrations are less easily
excited and more slowly conducted. The energy and suppleness
of mind and body are likewise lessened; he is more circumspect
and cautious, more dull in apprehension, more slow in ideas, more
measured in his language and in his movements; his memory
fails him and his judgment is impaired, being slow and _hesitat-
ing. Hence there is an appearance of greater prudence and
wisdom than are really possessed, since people are apt to mistake
the slowness of judgment and gravity of manner for sagacious
deliberation. However good in counsel, the old man is bad in
execution where decision and vigour are required, His interest
in current events wanes, he cannot assimilate new experience,
which therefore makes only a fleeting impression upon him, and
he shrinks from new enterprises; being truly in a state of
gradual dissolution, it is natural that he does not take an active
part in a process of evolution; he lauds the past, concerning
which he has the memories of interest and policies and achieve-
ments, finds no such giants living nowadays as when he was in
his prime, and wonders what the world is coming to with its
revolutionary changes. Moreover there is the beginning of that
decline of the moral faculties which reaches extinction in senile
dementia ; peevishness and quarrelsomeness, avarice, excessive
vanity, obstinate self-opinion, dictatorial self-will, loss of moral
enthusiasm and moral courage, cynicism and misanthropy are
modes in which the moral decline shows itself. When one con-
templates the daily suffering which -the old man lagging surer-
fluous on the stage inflicts sometimes upon those who are under
his sway and forecasts the amount of good which his obstructive
self-opinion prevents being done, it needs a moment’s reflection
to check the upspringing regret that his disappearance from the
scene must be left to the slow operation of natural decay. How
often does the vain and suspicious victim of senility take up an
unreasoning prejudice or dislike, rising perhaps to an insane
animosity, against some honest relative or former friend, or
an excessive and not less unreasoning liking, amounting to
£76 TATHOLOGY OF MIND. [ wap.

infatuation, for some adventurer, relative or not, who flatters his
foibles'' Here then we have the initial stages of the lines of
mental degeneracy which end in the phenomena of senile de-
mentia—failure of memory ending in its extinction; dulnoss
of apprehension ending in loss of power of perception; wane of
interest in what is going on ending in incapacity to appreciate
the surroundings ; slowness of ideas and hesitation of judgment
ending in incoherence and fatuity; decay of moral feeling ending
in drivelling suspicions and tears of dotage.

Although senile dementia usually comes on by a gradual
decay, as I have described it, in some cases it is ushered in
by a period of mental excitement which gives the patient. a
transient and fictitious appearance of energy and. capacity.
He shows great mental exaltation and self-confidence, transacts
business in a sanguine and reckless way that is quite the oppo-
site of his ordinary sober and prudent ways, broaches projects
or launches into speculations of a transparently foolish character
which he cannot be persuaded are not excellent, indulges freely
in alcohol, associates with low company, and visits or goes about
openly with women of loose character, although hitherto a grave
and reverend senior; impatient of advice or opposition, he
repudiates social ties and resents all attempts at interference or
control, is irritated and angry with his family who try to check
his follies, and occasions them no little perplexity and distress
by his doings.. When the excitement expires, as it sometimes
does suddenly, he falls into a state of dementia.

There is another form of senile insanity which I have ob-
served particularly in old women, and which I take leave to
describe as senile melancholia. They are acutely depressed and
show extreme distress at whatever is proposed, wander up and
down their room or the house in restless agitation, cannot be
persuaded that they are not ruined and soon to be turned
destitute into the strects, or that some other dreadful calamity is
not impending over them and their relations, repeat the same
exclamations of grief, or keep up a continual moaning, varied
only by wild shrieks or yells of acuter anguish. Frequently
they refuse food frantically, thinking it to be drugged or
poisoned, or declaring it to be filth or carrion, or even the flesh
1x.] CLINICAL GROUPS OF MENTAL DISEASE. 477

of their relations, or protesting that they cannot swallow it.
They are remarkably quick in perception and exact in memory,
notwithstanding their delirium, being much more conscious of
what is going on about them than they seem to be; are extremely
suspicious, passionate, and wilful withal, striking, scratching, or
pinching their attendants, whose needful services they resist;
use perhaps such bad language as it is a surprise they should
ever have known—language which is sometimes very obscene,
and accompanied with indecent, dirty, or grossly immodest acts.
What one notices specially in these cases is the extraordinary
moral perversion that is mixed up with the depression, giving
the appearance of extreme wilfulness to their behaviour, the
gross extravagance of the horrid ideas which come into their
minds and force themselves out into their speech—surprising
themselves suddenly perhaps in the first instance and causing
them to shriek out in a panic of distress—the sexual excitement
manifest in the ideas and acts, and withal the singular clearness
of their understanding when the mind can be lifted for a
moment out of its morbid groove. In some the excitement
rises to such a height that they do not sleep, cannot be got to
take necessary nourishment, and die at last from exhaustion; in
others it subsides, and the disease continues in a more chronic
form. In no case is the forecast favourable.

This concludes what I have to say concerning the features of
the varieties of mental disorder that occur in connection with
processes of bodily development and of bodily decline—Evolu-
tional and Dissolutional forms cf derangement, as any one may
call them who thinks to throw light upon’ obscure phenomena
by giving them big but undefined names written with initial
capital letters.

LPhihisical Insanity.

Under this name Dr. Clouston has proposed to group a class
of cases in which insanity and phthisis make their appearance
nearly at the same time in the patient, and the features of the
former malady are somewhat modified in consequence. I ques-
tion, however, whether the peculiar neurotic temperament which
is so often met with in phthisical persons has not much more to
478 PATHOLOGY OF MIND. (crap.

do with the features of the mental malady than any deposit of
tubercle, especially as it is acknowledged that phthisical insanity,
so called, may befall in persons of the phthisical diathesis who
have no symptoms of local tubercular deposit.

Without doubt many phthisical persons exhibit features of
character in some respects peculiar. They are quick, irritable,
fanciful, and changeable, eager in project and. impatient of
opposing delays, very idealistic, but unstable of purpose, bril-
liant in flashes, but wanting in breadth and calm depth of
thought, and in methodical and steady perseverance; quick in
insight and intense in energy, they see the project of the hour
and press for its realisation as the one important thing in the
world, and in a short time perhaps are engaged with as eager
interest and abandonment in some other project; there is some-
thing fitful in their projects, in their energy, in their moods, in
their displays of imagination—a sort of hectic in their thoughts,
feelings, and actions. As the end of life’s fitful fever is neared,
the whims and wanderings of the mind merge into a transitory
delirium, and the fancies become almost delusions. Very notable
too is the singular hopefulness which is shown in the disease
even to the last, notwithstanding that the continuity of the
sanguine feeling is often interrupted by passing intervals of
despondency; day after day the patient speaks hopefully of
himself as better, although he presents plainly every token of
the steady progress of his disease, and when within the very
shadow of death may discuss a change of life, and project what
he will do in years that will never come to him.

The insanity which occurs in connection with phthisis cannot
be said to have very distinctive symptoms. It may have the
form of mania, of melancholia, or of monomania, and it is the
general course of the disease rather than any special feature of
it which has attracted notice. The acute stage, when there is
one, whether it be maniacal or melancholic, is of very short
duration, and does not run on into the ordinary chronic malady,
nor into distinct dementia, but lapses quietly into an irritable,
excitable, moody, and suspicious state without any fixed delusion,
which is a sort of mixture of subacute mania and dementia.
The suspiciousness is thought to be the feature which is most
1x.] CLINICAL GROUPS OF MENTAL DISEASE. 279

constant, and the most characteristic by itself; indeed Dr.
Clouston believes that nearly all cases of pure monomania of
suspicion will be found to be phthisical. When there is no
acute stage at the beginning, the derangement comes on in an
insidious way, showing itself by irritability, waywardness, and
eaprice, with progressive weakening of intellect, but without
any marked excitement or depression. Later on the increasing
irritability may pass into brief attacks of excitement with im-
pulsive acts that have a demented character, and later still the
symptoms of dementia increase. But the appearance and con-
duct of these patients are calculated to suggest the notion of a
greater dementia than actually exists; they will make from
time to time fitful displays of intelligence of which they might
well be thought incapable, and in them there happens more
often than in other patients a momentary revival of intelligence
before death. The oncoming of insanity seldom benefits the
phthisis: in a few cases certainly it is followed by the arrest of
tke phthisis and the disappearance of its symptoms; in more
cases the mania and the phthisis seem to take turn and turn
about, the one being active while the other is in comparative
abeyance; but in most cases the phthisical symptoms are only
masked by the mental symptoms, the disease going steadily on
the while. The prognosis is bad in phthisical insanity ; in the
few instances in which recovery takes place it is where there is
no actual deposit of tubercle, or where the deposit has only just
taken place.

It is beyond doubt that we do meet- with cases of mental
derangement presenting the features just described as phthisical,
but I should be loath to affirm on the one hand that we do not
meet with similar mental features where there is no suspicion of
phthisis and no known predisposition to it, and on the other
hand that they will be met with in all cases of insanity com-
plicated with phthisis. It is probable that we have to do
essentially with a peculiar neurotic temperament, which under-
goes actual derangement in partial consequence of the enfeebled
nutrition of tuberculosis, and I doubt not that if we had the
same temperament acted upon by some other cause of de-
teriorated nutrition to produce mental derangement it would
£80 PATHOLOGY OF MIND. [cuar.

present the same features; indeed we get something very like
them sometimes in the insanity of the thin artistic temperament,
and in the insanity caused by self-abuse in conjunction with a
certain neurotic temperament. Still if the features described
are most often observed in connection with phthisis, it will be
convenient to gather the cases into a separate clinical group
provisionally, and to call them by a name which marks their
most constantly observed relation.

Syphilitie Insanity.

It is customary nowadays to speak of a group of cases by this
name, the practical justification of the custom being that their
pathology, their causation, and their proper treatment are at once
indicated thereby. If what cures the syphilis will cure the
insanity it would be a pedantic conceit to reject so useful a
grouping simply because it was not scientific enough. Let it
be admitted that there is no symptom which is characteristic of
this sort of insanity, and will enable us to distinguish it on all
Gecasions, as it must in candour be, it may still be maintained
that when we look to the entire course of the disease, observing
how the symptoms begin, their character, how they are asso-
ciated with and succeed one another, and how they end, there is
good reason to warrant an empirical grouping of the cases, apart
from the help in diagnosis which we get from the history and
from the old signs of syphilis.

The order of events in a case of syphilitic insanity I conceive
to be of this kind: the patient has suffered from constitutional
syphilis, and is much distressed by deep-seated headaches, which
are increased by movement and are worse at night; the scalp is
perhaps tender when pressed, and the headache even increased
thereby. He is deeply dejected, destitute of energy, incapable
of undertaking his work, in a state of great alarm about himself,
and extremely sensitive to noises and to sudden impressions of
any kind. The nights bring no refreshing rest, but rather an
aggravation of his sufferings; he is sleepless, not from pain in
the head only, but even when he has not pain enough to prevent
sleep; or if he does sleep, it is in short snatches from which he
rx.] CLINICAL GROUFS OF MENTAL DISEASE, 481

awakes sometimes in a state of trembling alarm, hardly knowing
whether he has slept, or even where or what he is, so that he
almost dreads to fall into such unconsciousness again. There is
the greatest prostration without fever; loss of appetite, with
vomiting sometimes but without gastric disorder, is marked ; rapid
emaciation takes place, and the pulse is irreoular and often slow.

The. eyes should now be examined by the opthalmoscope in
order to see whether there be optic neuritis; if there is, then
the presence of a syphilitic product in the brain is very prob-
able; it is practically certain, according te Dr. H. Jackson, if
the neuritis existed before the illness became acute. Next some
signs of sensory or motor disorder are likely to show themselves
—to wit, paralysis of sensation or of motion in eyelid, muscles
of eye, face, or other part of the body—since the paralysis may
implicate a single nerve, or be hemiplegic, or be more or less
completely general—blindness, giddiness, and difficulty of mus-
cular co-ordination, spasms, and even epileptiform convulsions
eventually. Up to this point we may consider the disease to be
in its first stage, and the sufferer may recover after a time with-
out any further bad symptoms. But if he gets worse he begins
to lose his memory, and the other faculties of his mind undergo
serious impairment; there is an increasing stupidity, which
passes soon into deep dementia. Outbursts of mania and of
melancholia interrupt the steady mental decline in some in-
stances, and it is not very uncommon for it to be accompanied
by symptoms of progressive muscular paralysis so like those of |
general paralysis of the insane that the one disease may easily
be mistaken for the other. The mistake is particularly likely to
be made when besides the mental weakness there are delusions
of grandeur, as is sometimes the case. Epileptiform and apo-
plectiform attacks usually occur in the later stages, and there is
little hope of recovery when they do; there is barely a hope
warranted when the patient has become profoundly demented.
Still the exceptional occurrence of a quick and an unlooked-for
recovery now and then in what seemed the worst condition of
things may preclude absolute despair. The syphilitic product
(gumma) in the brain to which the symptoms are due is more
likely to be absorbed than a tumour of another kind.
182 PATIIOLOGY OF MIND. [cuar.

We have no reason to suppose that the syphilitic gumma acts
differently from what any other tumour or morbid deposit in its
position, and increasing at the same rate, would do, and every
reason to suppose that the symptoms which it causes, so far as
they are special, are characteristic of cerebral tumour, not of
syphilitic tumour in particular. It probably either acts as a
centre of irritation, exciting the neighbouring parts of the brain
to morbid activity—delirium and convulsions; or it encroaches
steadily upon them, occasioning destruction of function—de-
mentia, coma, and paralysis; or it appears sometimes to produce
a thickening of the coats of the small cerebral arteries, by the
deposit of plasma in them, and so to lead to the production of
thrombosis, which will then act just as thrombosis in the same
position but otherwise caused would do. In considering the
pathological meaning of the symptoms it must of course be
borne in mind that a destruction of a part of the brain may not
only cause directly the positive symptoms due to loss of its
function, but may be the indirect cause of abnormal activity in
another part by withdrawing the controlling or inhibiting in-
fluence which one member of the intimate physiological union
exercises upon another.

The diagnosis will rest mainly upon a previous history of
syphilitic symptoms, and upon the marks they may have left
behind them ; upon the occurrence of the disease at an age when
a similar nervous derangement from other causes is unusual;
upon the absence of any other discoverable cause of disease;
upon the irregular character and the disorderly association and
sequence of the various symptoms, mental and bodily; and upon
the successful results of specific treatment. Albeit then the
syphilitic deposit produces no specific nervous symptoms, there

is usually something in the general course of syphilitic insanity ---

which is not quite what is observed in the cases of other cerebral
tumours, and is calculated to raise a suspicion of its nature.

In one who has suffered from a previous attack of mental
derangement, or who has inherited a strong predisposition there-
to, it has happened that an outbreak of acute mania has taken
place at the same time as the secondary symptoms of syphilis
have made their appearance. But there is nothing special ahout
1x.] CLINICAL GROUPS OF MENTAL DISEASE. 483

the mania in such event; it is merely that a brain strongly pre-
disposed to derangement has been overthrown by a particular
constitutional disturbance, as it might be overthrown by another
disturbance. In like manner when mania occurs after syphilitic
epilepsy, as it does sometimes, there is nothing special in its
symptoms. It has been alleged that in such cases the mania
most often follows those epileptic paroxysms in which loss of
consciousness occurs not at the commencement of the attack,
but as a later event—in which, therefore, the mischief pre-
sumably does not begin in the supreme cerebral centres,

Alcoholic Insanity.

It is a fixed popular opinion, but a popular error, that when a
person’s mind gives way in consequence of alcoholic intemperance
he must have delirium tremens. Without doubt he may have
delirium tremens, but on the other hand he may have a genuine
acute mania that has no character of delirium tremens about
it. Persons who have been previously insane, or who have
suffered an injury to the head which produced severe symptoms
at the time, or who have had a sunstroke, or who have inherited
a strong predisposition to insanity, or who are epileptic—persons
in fact who have a natural or acquired undue irritability and
instability of brain—are liable to have their irritable and
unstable brains upset by slight alcoholic excesses and to do
very strange and eccentric things in consequence, or even to
compromise themselves by some act of impulsive violence:
perhaps they give themselves up to the police as the perpetrators
of an undiscovered murder which has made a great sensation; or
commit some indecent offence which brings them into a police
court; or inflict serious injury upon some one against whom they
have conceived an unfounded suspicion, only realising the
gravity of what they have done when they come to themsclves
after the effects of the alcoholic disturbance have passed off.
The little self-control which they have, owing to inherent weak-
ness of brain, is easily abolished, the co-ordination of its func-
tions overthrown, and with it that consciousness of personal
identity and responsibility which is its highest expression.
484 PATHOLOGY OF MIND. [ciaP.

After a prolonged alcoholic debauch the mental derangement
may take the form of acute mania—the true mania a potw so-
called—which is usually of a noisy and destructive character, but
differs not in essential features from mania due to other causes.
In some instances the derangement is melancholic, but I am
inclined to think that melancholia a potu, as it might be called,
is most likely to occur in persons whose health has been im-
paired by long continued excesses and insufficient nourishment,
and who are obliged to forego their drinking without getting
better nourishment.

The symptoms of delirium tremens are tolerably characteristic,
and I need only recount them briefly here. Premonitory of its
outbreak are feelings of lowness of’ spirits and debility, nausea
and vomiting in the mornings, loss of appetite, little sleep, and
that little disturbed by frightful dreams. The person dreads to
face his work, is anxious about his affairs, agitated by the least
unusual occurrence, oppressed by gloomy forebodings, and is
described as excessively nervous; bis hands shake on occasion
of the least mental agitation, and his tongue is tremulous and
coated with a soft whitish fur. Upon these symptoms follow
mental excitement and delirium, the delirium being generally
characterised by great agitation and alarm; there are hallucina-
tions and illusions, the patient seeing rats and mice running
about the room, snakes crawling over the bed, or having terror-
striking visions of threatening objects. His restlessness is
extreme and he gets no sleep. He talks almost incessantly, but
says little that is sensible. His hands, which are in constant
tremulous motion, he moves over the bed-clothes as if seeking
for something, or thrusts out as if to push back the vermin that
he sees invading his bed. The pulse, which is quickened, is
small and compressible at the wrist, but full and throbbing in
the carotid arteries, the heart’s action violent, and the breathing
panting and irregular. In general he is manageable, though
restless, but sometimes he is violent and hard to be controlled;
and he may even jump out of the window, if not prevented, either
in pursuit of phantoms whom he imagines to threaten him or
in his terrified efforts to escape from them. After three or
four days of this delirious horror he falls into a sound sleep and
1X.] CLINICAL GROUPS OF MENTAL DISEASE. 485

recovers, if the issue be favourable, or sinks into a low muttering
delirium and dies, if the issue be unfavourable. When the
attack is over there is great mental and bodily feebleness in all
cases, and in a few cases the mind is found to be not quite clear ;
it is more or less confused, troubled with morbid suspicions, and
perhaps with hallucinations of hearing, and prone to suicidal
impulses. This occasional after-effect is most likely to be-
seen where there was a predisposition to mental derangement,
and most likely to be got rid of by abundant exercise in the
open air, entire change of scene, and variety of occupation and
amusement. If the hallucinations of hearing persist notwith-
standing these measures, doubts of complete mental restoration
gather and thicken,

Delirium tremens might be described justly as an acute
alcoholism, since there is also a chronic alcoholism which is
characterised by the slow and gradual development of similar
symptoms—in truth, a chronic delirium tremens which is called
the insanity of alcoholism. Premonitory of it are the same
sleeplessness, the same motor restlessness, the same nausea and
want of appetite that go before delirium tremens. Instead, how-
ever, of the rapidly rising excitement, the changing hallucina-
tions and delirious incoherence then following, there is great
mental disquietude with morbid suspicions or actual delusions of
wrongs intended or done against him, of wilful provocations
and persecutions by neighbours, of thieves about his premises,
of unfaithfulness on the part of his wife and the like; sus-
picions which are frequently attended with such hallucinations
of hearing, of sight, of tactile sensation, as threatening voices
heard, insulting gestures or mysterious signs seen, electric
agencies felt, In this state a violent tempered man, resolved to
be even with the scoundrels whom he declares to be persecuting
him, sometimes does sad deeds of violence. Recovery usually
takes place if the patient is resolutely prevented from getting
alcohol. His hallucinations disappear first in the daytime,
being as bad as ever perhaps during the night; then they are
less vivid at night, being most marked in the stage between.
sleep and waking; next they are no more than bad dreams cr
nightmares, and at last they go entirely. The order of their
486 PATHOLOGY OF MIND, [ctap.

disappearance is the opposite of their order of occurrence.
Unfortunately the recovery seldom lasts; inasmuch as the
patient goes back to his indulgence as soon as he can, the
chances are that he has other attacks, and that in the end his
mind is permanently impaired. His memory is so damaged
perhaps at last that it has no more hold of recent impressions
than that of one who suffers from senile dementia; his under-
standing is enfeebled and even childish; his moral sense is
blunted or destroyed, so that he loses all feeling of moral
responsibility, and becomes cunning, cowardly, untruthful, and
untrustworthy ; and his will is so deteriorated that he has not
the least control over himself in respect of indulgence in drink.
Muscular unsteadiness and trembling go with these signs of
increasing mental debility, and there is oftentimes sensory dul-
ness or actual sensory and motor paralysis of the limbs; on
which account he cannot hold firmly with them, perhaps
dropping helplessly what he takes into his hand, or lies in bed
because he cannot use his legs to walk. At the same time one
cannot help feeling sometimes that he could grasp better and
make more use of his legs if he would exercise more will. In
some cases there are epileptiform convulsions from time to time—
perhaps many in succession—which are accompanied with much
albumen in the urine. This condition of mental impairment
may be brought about gradually by a steadily continued course
of excessive drinking in some persons, and especially in women,
without any of the hallucinations and delusions of persecutions
that go before it in other cases. Ata later and worse stage the
patient is completely demented, his mind being thoroughly dis-
organised ; he utters the most incoherent nonsense in a whining
tone, and has the most extravagant hallucinations and delusions
—as, for example, that the most extraordinary scenes occur in
his room, that knives and broken glass are coming out of his
flesh, that insects are crawling between his flesh and skin, that
people cut up his body, carry him away at night, and the like.
The mental deterioration is so great that he resembles not a
little in mental symptoms a person who is in the last stage of
senile dementia.

The insanity produced by alcohol is instructive, for it exhibits
Ix.] CLINICAL GROUPS OF MENTAL DIS#ASE, 487

in more rapid sequence a train of symptoms very like those of
ordinary idiopathic insanity, so-called, and exhibits them in a
case where we can clearly trace the operation of a physical
cause. We know of a certainty that the alcohol is absorbed into
the blood, that it is carried by it to the brain, and that it acts
there directly upon the nervous tissue, from which indeed it may
be extracted again when it has been taken in quantity. Its first
effect is to stimulate the tissue and cause increase of activity,
but in the end it produces degeneration of tissue and destruc-
tion of function. Let it be noted too that it acts equally
perniciously upon the different nervous centres, motor, vaso-
motor, sensory, and ideational, the collective symptoms of this
impartial action giving its peculiar physiognomy to alcoholic
insanity.

Dipsomania is a well-marked form of mental degradation, if
not of actual mental derangement, which shows itself in a fierce
morbid craving for alcoholic stimulants and is greatly aggravated
by indulgence. Had alcohol never been tasted by the individual
the desire would probably have slumbered, but once indulgence
has awakened the desire, it flames quickly into an uncontrollable
craving. The outbreaks are commonly paroxysmal—at longer
intervals of a year or so, or at shorter intervals of two or three
months, or even more often still in bad cases. The victim of
this drink-craving does not, like the ordinary drunkard, get
drunk in company, and then become sober, remaining so until
the next early and convenient opportunity of getting drunk
again, but he goes on drinking recklessly day after day, often
in secret, when he has broken out into a debauch, and does
nothing else but drink until he can take no food, suffers from
persistent vomiting, and is compelled to stop because his stomach
rejects instantly whatever he swallows. One is forced to recog-
nise disease rather than vice in the spectacle when one takes
note of the many instances in which men and women of good
means, in high social position, and having perhaps superior
intellectual endowments, abandon themselves from time to time
without restraint to orgies of pure drunkenness, notwithstanding
the most solemn resolutions to abstain which they may have
made when they were sober and in their right minds; reckless
488 PATHOLOGY OF MIND, [cuap. 1x

of consequences, defiant of all social proprieties, to the ruin of
themselves and their families, consorting during their, paroxysms
with the lowest of the low, and sinking to the meanest shifts
and the basest degradation in order to obtain the means of
gratifying the craving. When the paroxysm is over they are sad
and penitent, dilapidated and wretched, bitterly self-reproachful
and full of good resolves, and return to their social sphere to
perform their duties with regularity and propriety until the next
outburst takes place. In their sane intervals of sobriety these
persons oftentimes evince no unusual inclination to stimulants,
and are perhaps exceedingly moderate in what they take; yet
when the craving comes upon them, as it seems to do with
gathered force after a period of sobriety, they yield unrestrained
submission to it, and go through the same miserable experience
as before. Their moral nature is thoroughly perverted while the
paroxysm is on them; they are given over to deceit and lying
and cannot in the least be depended upon, and the wife may
evince violent dislike of the husband, or the husband a hatred
of his wife.

The malady calls to mind recurrent mania and epilepsy—
first of all, by its common periodic character; secondly by
the profound change of moral character with which it is
accompanied; thirdly, by the exact repetition which one
paroxysm is of another in its mode of onset, in its features and
in its course; and lastly, by the permanent deterioration of
mind which it produces in the end when it goes on unchecked.
And it commonly does go on without effectual check, since the
restraint necessary to do any good cannot be legally enforced.
It is true that the persons may be persuaded sometimes to place
themselves voluntarily under control, and that they will submit
to it so long as they are in their sane moods and do not there-
fore need it, but the chances are that they evade or repudiate it
when the craving comes upon them and restraint is truly needed.
The condition is undoubtedly oftentimes hereditary, or the out-
come of a neurotic temperament, some ancestors or relatives
having suffered either in the same way or from some other
nervous disorder,
CHAPTER X.
THE MORBID ANATOMY OF MENTAL DERANGEMENT.

BEFORE going on to describe the morbid cerebral changes which
have been met with in mental disease some preliminary con-
siderations of a general character will not be amiss, the less so
as one is compelled to begin with the acknowledgment that
there may be no morbid appearances at all. This absence of
discoverable physical changes where marked mental disorder
has existed necessarily renders a chapter on morbid anatomy the
' most barren chapter in a book on mental pathology. A patient
dies raving mad, and yet the examination after death shall not
pethaps disclose the reason why he was mad or even why he
died. To conclude thence, however, that nerve element does not
subserve mental function, or is not affected when function is
affected, is to make a hasty and unwarranted inference. At
present we know nothing whatever of the intimate molecular
constitution of nerve element and of the mode of its functional
action, and it is beyond doubt that important molecular and
chemical changes may take place in those inner recesses to which
our senses have not gained access. The cerebral nerve-cells
are minute laboratories—chemical and physiological—in which
not only are the most complex chemical processes in the world
carried on unceasingly, but vital processes also which, material-
ising experiences in structure, condition or determine their inti-
mate constitution. And yet all these processes are hidden from
our present means of observation. Where the subtilty of nature
so far exceeds the subtilty of human investigation, to conclude
from the non-appearance of change to the non-existence thereof
490 PATHOLOGY OF MIND, [cHaP.

would be just as if the blind man were to maintain that there
were no colours, or the deaf man to assert that there was no sound.
Justly then may we with Pinel rather doubt the sufficiency of our
senses than believe that mental disorder can exist without any
physical disorder in the brain, and rest in the certitude that in
the fulness of time a means will be discovered to penetrate the
yet inscrutable recesses of nerve life, and to make known the
physical conditions of its functional manifestations. That it is
now a region of uncertainties and obscurities may be taken as
promise that it is the destined field of future discoveries.

There are many facts to prove that serious modifications in
the constitution of nerve element take place without any other
evidence of them than we infer from correlative changes of
energy. After severe and prolonged mental exertion there
ensues exhaustion, which may be so great that the brain is
utterly incapacitated from further function; a large increase of
phosphates in the urine bears witness to the disintegration of
nerve; the individual is, so far as power of active life is con-
cerned, almost a nonenity; and yet neither microscopist nor
morbid anatomist would succeed in discovering any difference
between the nerve substance of his brain and the nerve
substance of the brain of one who, after due rest and nutrition,
was prepared for a day of vigorous activity. The sudden shock
of a powerful emotion has produced instantaneous death, just as
a stroke of lightning has, and perhaps in the same way; but
neither in the one case nor in the other may there be any detect-
able morbid change. If the electric fish is persistently irritated
so as to be made to give forth shock after shock, the excessive
expenditure of energy leaves it utterly exhausted, and it can
give no more shocks until its powers have been restored by rest
and nutrition; its nervous centres have plainly undergone a
considerable modification, though we know not the nature of it.
Instead of arterial blood send through the brain blood heavily
charged with carbonic acid, and the victim of the experiment
must inevitably die; but no one can describe the secret change
that has been produced in the composition of the nerve element.
Without killing a person outright, it is possible, by causing
him to breathe a mixture of one part of air and three parts of
x.J MORBID ANATOMY OF MENTAL DERANGEMENT. 491

carbonic acid, to render him as insensible to pain as if he had
inhaled chloroform; but it is the gross result only that is
recognisable by our senses. In this regard, however, the experi-
ments of Lister on the early stages of inflammation are of some
interest ; for he showed that carbonic acid produced a direct
sedative effect upon the elements of the tissue, paralysing for the
time their vital energies ; the effect being transient, and the tissue
recovering its energy after a considerable time. The experiment
brings us to the individual elements of the tissue, but no farther ;
it tells us nothing of the more intimate changes that take place
in them. It is obvious that the difference may be the difference
between life and death, and yet there may be no appreciable
physical or chemical change.

As regards morbid appearances in cases of insanity, there can
be no question that the instances in which they are not found
become less frequent as investigation becomes more searching
and efficient ; and those who are best capable of judging, and
best fitted by acquirements to give an opinion, are those who are
most certain of the invariable existence of organic change.
When a morbid poison acts on the body with its greatest inten-
sity there are fewer traces of organic alteration of structure met
with than in cases where the poison has been, milder and has
acted more slowly; and so likewise organic change of nerve
element in insanity, appreciable by the imperfect means of
investigation which we yet possess, may justly be expected only
when the degeneration has been going on for a long time. In
truth I might not unfitly speak of the morbid changes as
(@) ascopic or intramolecular, they being matters of faith, not
of observation ; (6) microscopic, that is, such as are disclosed by
the microscope ; and (¢) macroscopic, or changes that are visible
by the naked eye.

The many careful and important researches into the physiology
of nerve which have now been carried on for several years have
made it more easy to conceive the existence of undetectable
organic changes, albeit they have not revealed their nature.
They have been of real service, moreover, in freeing the con-
sideration of the supreme nervous functions from those vague
metaphysical conceptions which the notion of mind as an
492 PATHOLOGY OF MIND. [orar,

exalted spiritual entity and of brain as its humble instrument
have reflected upon them, and in making them fit subjects of
scientific inquiry by bringing them into the category of organic
processes. With the perfecting of present and the discovery of
new means of minute investigation, it is probable we may have
in time to come an evolution of knowledge of nerve-function
not unlike that increased knowledge of the heavens which
followed the invention of the telescope.

One of the first things that has been made clear thus far is
that time is as essential an element in the intestine motions of
nerves as it is in the motions of the heavenly bodies. A definite
interval is necessary for the propagation of a stimulus from
the peripheric ending of a nerve to its central ending in the
brain ; and when the stimulus has reached the brain, there is an
appreciable interval, about one-tenth of a second, before the will
can transmit the message to the nerves of the muscle so as to
produce motion. This time-rate of conduction varies in different
persons and at different periods in the same person, according
to the degree of attention; if the attention be slight, the period
is longer and less regular, but if the attention be active, then
the period is very regular. But whether the attention be great
or little, a certain time must elapse from the moment of irrita-
tion of a sensory nerve to the resulting contraction of muscle;
and a message from the great toe to the brain will take an
appreciably longer time than a message from the ear or face,
There is a considerable delay in crossing the spinal cord by the
stimulation in a simple reflex action ; according to an experiment
by Helmholtz, more than twelve times the time required for the
transmission of a stimulation through the sensory and motor
nerves is required to cross the spinal cord. The time-rate of
propagation, again, is greatly dependent upon the temperature of
a nerve; cold very much diminishes it, so that the speed may
be ten times less in a cold than in a normal nerve; and in a
cold-blooded animal, like the frog, the rate is only about 80 feet
in a second, while in man itis about 180 feet in the second.
Haller first proposed to measure this speed of nervous action,
and made a calculation of it in man which was not very far
from the truth; but after him no one seems to have attempted
x.] MORBID ANATOMY OF MENTAL DERANGEMENT. 493

the task, and Miiller even pronounced it impossible, because the
time seemed to him infinitely little and unmeasurable. In ex-
periments on frogs poisoned with opium or nux vomica, he could
not perceive the slightest interval of time between the stimulus
applied and the resulting muscular contraction. However, the
rate of conduction by nerve has now been found to be not only
measurable, but comparatively moderate—not to be compared
with the infinitely more rapid: motion of electricity and light,
less even than the rate at which sound travels, about the same
as that of an eagle’s flight, and only a little quicker than the
speed. of a racehorse or of a locomotive. Instead of nervous
action being due to the instantaneous passage of some imponder-
able or psychical principle, conduction by a nerve depends upon
a modification of its molecular constitution, for the production
of which acertain time is essentially requisite.

The attempts which have been made to ascertain the time
required by the brain for a volition have shown clearly that it
also is a measurable period, and that it differs according as the
person is prepared beforehand or not for what he has to volun-
tarily respond to: thus, for example, Jaager found that when he
received an electric shock on one side, knowing beforehand that
the shock was to be on that side, the interval between it and the
answering signal given by him was about -29,th of a second; but
if he did not know beforehand on which side the shock was to
be, then the interval between shock and respondent signal was
about =2,th of a second, that is to say, a difference of 35th of
a second. There can be no question that there is a considerable
variation in the time in which the same mental functions are
performed by different individuals, in consequence of original
constitutional differences, and by the same individual at differ-
ent times, owing to transitory conditions of the psychical
centres. No one who has done intellectual work but knows the
vast difference in the rapidity, ease, and success of it according
to good or ill moods. ‘ There is,” says Locke, “a kind of rest-
iveness in almost every one’s mind. Sometimes, without per-
ceiving the cause, it will boggle and stand still, and one cannot
get it a step forward; and at another time it will press forward,
and there is no holding it in.” The oppression of mental
494 PATHOLOGY OF MIND. [culap.

suffering is notably attended with great sluggishness of thought,
the train of ideas seeming to ‘stand still, and even perception
being dull and imperfect. In some forms of mental disease this
defective association is well marked, whilst in others a certain
sort of association is wonderfully quickened, so that ideas
follow one another with extraordinary rapidity, or like-sounding
words are strung together in the most incoherent rhymes. In
many cases of affection of the brain, as in recovery from
apoplectic seizure and in senile decay, a considerable time must
elapse between a question asked of the patient and his reply:
there is, so to speak, a deafness of the mind, which both per-
ceives and reacts more slowly than is natural The time-rate
of the function is probably the measure of the molecular activity
which is the condition of it.

But there are other physiological discoveries which may help
eventually to build up some conception of the physical condi-
tions of mental activity. The researches of Matteucci and Du
Bois Reymond into the electrical relations of nerve have shown
that there are currents of electricity engendered in nerve, as in
other animal structures, which are constantly circulating in it.
When the nerve going to a muscle is transmitting to it the
stimulus to contract, there is a diminution of the nerve’s proper
current, and the needle of a galvanometer connected with it ex-
hibits a negative variation. In like manner sensation has been
proved to be accompanied by a negative variation of the nerve-
current. Matteucci supposed that there was a rapid succession
of electric discharges from nerve and muscle during activity,
and although that supposition has not been confirmed, there
can be no doubt that the negative variation of the needle of the

1 “ Every one must have noticed the slowness, as well as difficulty, with
which the tongue is put out, the eyelids raised, or words uttered by patients
in a semi-comatose state. It seems as if a certain time were needed,
either for concentration or transmission of nervous power, before the
intended action can be begun; while so much labour is necessary in pur-
suing it, that I have repeatedly observed perspiration breaking ovt from
the contiuued effort to raise a palsied arm, and an exhaustion to follow,
such as might ensue in health upon violent muscular exercise of the whole
body. How striking the contrast here to that instant and free effort by
which action is evolved almost simultaneously toall sense with the external:
impression producing it, though various mental and bodily operations
actually intervene.” —Sir H, Holland. Chapters on Mental Physiology.
x.J MORBID ANATOMY OF MENTAL DERANGEMENT. 495

galvanometer marks a decrease in the electromotive force of the
nerve, and that this decrease is in some way “intimately related
to that molecular change in the interior of the nerve which
when it reaches the muscle will produce contraction, or when
it reaches the brain will be received as sensation.” It is to be
borne in mind that every minute particle of nerve acts according
to the same law as the whole nerve ; the current, therefore, which
a piece of nerve produces in a circuit of which it forms part is
to be considered only as a derived portion of incomparably more
intense currents circulating in the interior of the nerve around
its ultimate particles. There is thus certain evidence, not only
of electro-motor properties of nerve, but of a modification of
these during functional activity: such modification again testi-
fying to an intimate change in the polar molecules of the nerve.

The results prove clearly enough that nervous functions are
not to be embraced in any metaphysical conception, nor dismissed
as inexplicable. Conduction by nerve is a measurable process
of molecular movement ; the proper electrical current of nerve
is diminished during its excitation, and its intimate molecular
constitution modified ; and there seem to be reasons to suppose
that its excitation is in close relations with those chemical oxi-
dation changes which are known to take place in it during
activity, rendering its reaction acid, and giving rise to similar
products of retrograde metamorphosis to those which are pro-
duced by muscular activity. A complete and adequate theory
of nerve-function must take into account, and account for, all
these phenomena. But it is difficult to see how any physico-
chemical theory will ever embrace all the phenomena of nervous
function. Certainly life is a great deal more than physics or
chemistry, or than physics and chemistry, as physics and chem-
istry are known to us at present; in the functions of the nervous
centres there are such vital acts of assimilation of experiences
and their structuralisation by nutrition as no physics and chem-
istry that we yet know of can in the least approach unto. But
while no person in his senses will pretend to set forth a physico-
chemical theory of the mood of a lover, of the imagination of a
philosopher, of the delusion of a monomaniac, it is not a whit lesg

unwarrantable to fly incontinently to the conclusion that such
22
496 PATHOLOGY OF MIND. [cHar.

mental phenomena are independent of physical organisation ; it
does not follow that they have not a material basis because they
are not physical and chemical ; and it is bey ond doubt that they
are as essentially dependent upon nerve-structure as the move-
ment of a limb is upon its muscles, whether any more spiritual
than it or not. How is it that those persons who look down with
scorn and contempt on the doctrine of materialism from their
high intellectual and moral platform have not hitherto invented a
spermatozoic soul to have and account for those wonderful latent
potentialities which, albeit the spermatozoon plainly has them,
they are unable in the least to detect in its material substance ?

When we consider that one molecule of nerve-element is pro
bably more complex in constitution than the entire solar system,
and that we have not access to the observation of its intricate
intestine movements, so far from its being surprising that there
are no visible morbid appearances in some cases of insanity, the
wonder is that they should have been expected. If a distinct
sensation of smell is caused by zzg4a00 gt. of oil of resin, as has
been calculated, and even by a still smaller quantity of musk, it is
surely no little inconsistent to look with the naked eye for the
physical condition of psychical disorder and to talk of a patho-
logical classification of mental disorders. The microscope must
be used in order to observe the spermatozoon and ovum—uminute
and almost homogeneous substances to look at—which never-
theless contain in some mysterious fashion those multitudinous
qualities of parents and ancestors that are subsequently deve-
loped in the mental and bodily characters of the offspring or,
lying dormant in them, are transmitted through their sperma-
tozoa or ova to another generation. Whosoever is clever enough
to discover and describe the physical basis of the multitudinous
qualities that are latent in the spermatozoon may perhaps suc-
ceed in discovering and describing the physical basis of a mo-
nomaniac’s morbid suspicion, and of the warped thought of a
person predisposed hereditarily to insanity.

The foregoing considerations explanatory of the absence of
detectable morbid changes in some cases of insanity are entirely
borne out by our experience of such severe nervous diseases as
epilepsy, tetanus, hydrophobia, and neuralgia. Not the least
x] MORBID ANATOMY OF MENTAL DERANGEMENT. 497

change after death in any one of these instances may be found
to account for the furious storm of symptoms during life, not
even when the disease has been the direct cause of death. And
just as it is certain that epilepsy or tetanus or neuralgia may
be caused by an eccentric irritation, and be therefore a reflex or
sympathetic disorder, so it is certain that in some cases an attack
of mental derangement, being provoked and kept up by disease
elsewhere than in the brain, is also essentially reflex or sympa-
thetic. When a deep melancholia disappears almost instantly
after the putting right of a prolapsed uterus it is obviously
right to look upon the mental disorder as reflex ; and in such
case we certainly should not expect to find, had we the oppor-
tunity to examine, morbid appearances in the brain. But this
sympathetic melancholia may be quite as severe in its symptoms
as melancholia otherwise caused: why then think it strange if
there are no morbid appearances in the latter case?

In this connection it is important to bear in mind that the
reflex transmission may take place along different channels—
not from sensation to motion only, but also from sensation to
sensation, from motion to sensation, from motion to motion, and
from sensation or motion to nutrition, A molecular change in
the interior of a nerve being set up by the primary irritation,
whatever and wherever that be, is carried: to any part with
which it is in connection by continuity of nerve-structure;
when the molecular agitation reaches a motor centre it is reflex
movement or reflex paralysis; when it reaches a sensory centre it
is reflex or sympathetic sensation ; when it reaches the supreme
ideational centres it may occasion reflex disorder of thought,
feeling, and will; when it reaches the interior of a gland it
may modify the intimate processes of secretion, and so cause
a reflex derangement of secretion ; and when it reaches a part
which is not sensitive, which does not’ contract, which does not
think, feel, or will, which does not secrete, it may still give rise
to a perversion of nutrition or a so-called trophic derangement.
Let me give examples: When severe pain is felt along the spine
after a fit of sudden and violent coughing, when the throat
_ tickles after speaking for a long time, when facial neuralgia is
increased by muscular exertion, the reflex is from motion to
498 PATHOLOGY OF MIND. (crap.

sensation; when pain in the knee is felt in discase of the hip-
joint, when facial neuralgia is caused by toothache, when the
pain of a toothache is felt’in the opposite tooth to that which
is carious, the reflex is from sensation to sensation ;. when the
muscles of a paralysed limb in a hemiplegic patient contract
during some emotional or voluntary act in which the corre-
sponding muscles of the opposite limb take part, it is from
motion to motion; when the suppuration of a gland in the
neck is kept up by a carious tooth, disappearing soon after the
tooth is extracted, the reflex effect is shown in nutritive dis-
order. But in truth the various symptoms of the protean
disease, hysteria, furnish examples of all these varieties of reflex
action, if we look upon them, as for the most part perhaps we
may, as mainly the effects of the operation of the reproductive
organs upon a somewhat unstable nervous system: we meet
with deranged thought, moral perversion, impaired will, abnor-
mal sensations of all sorts, spasms or convulsions, vaso-motor
irregularities and disordered secretion and nutrition in different
cases, and often enough in the same case. Let it be noted as
probable that the reflex action may be both directly through
nerve upon the elements of the tissue or indirectly through the
vaso-motor system.

There remains yet another matter to be taken into account in
explanation of the absence of discoverable morbid changes in
insanity, before passing from the subject—namely, the local dis-
turbances of circulation, which, present during life, may have
disappeared after death. I am inclined to think that most
writers on insanity have laid too great stress upon the vascular
changes in the brain and its membranes which are undoubtedly
frequently met with in connection with insanity, in so far as they
have looked upon them as primary agents in initiating and keep-
ing up mental disorder ; in most cases they might more justly
have set them down as effects of prolonged mental disturbance.

The truth is that the first step in insanity probably is, as it is
in inflammation, a direct change in the individual elements of
the tissue, the change in the blood-vessels being secondary. Take,
for illustration, the early steps of inflammation: by the obser-
vations of Professor Lister it has been made evident that in the
x.} MORBID ANATOMY OF MENTAL DERANGEMENT. 499

case of mechanical or chemical injury to some part the elements
of the tissue are directly injured; they are brought to a lower
state of life, and their functional activity is impaired; as a con-
sequence of the injury the elements are brought nearer to the
condition of ordinary non-living matter, the blood-vessels dilate,
and the corpuscles of the blood exhibit a tendency to stick to-
gether in the neighbourhood of the damaged part, just as they
do when brought into contact with ordinary matter after being
withdrawn from the body. The dilatation of the vessels is pro-
duced indirectly through the nervous system. Observation of
the effects of irritants upon the pigment-cells of the frog’s skin
confirmed these views in an instructive way: Mr. Lister found
that when irritants were applied in such a mild form as to cause
little or no derangement of the blood, they did nevertheless pro-
duce a certain degree of loss of power in the elements of the
part to which they were applied ; for there took place a diffusion
of the pigment in the cells, which he declares to be “ the visible
evidence of diminished functional activity accompanying, if not
preceding, the earliest approaches to inflammatory congestion,”
and corresponding with arterial dilatation. Experiments with
carbonic acid proved that it had a powerful sedative effect upon
the tissues themselves, paralysing their vital energies so a3 to
give rise to intense inflammatory congestion, which, however,
was transient; even in amputated limbs, in which there was of
course no circulation, the tissues recovered after its action, so
that, as the restoration of the action of cilia separated from the
body might indicate, the “ tissues possess, independently of the
central organ of the nervous system or of the circulation, or even
of the presence of blood within the vessels, an intrinsic power
of recovery from irritation, when it has not been carried beyond
a certain point.”1 From which researches it appears that the
earliest condition of inflammation is some damage to the ele-
ments of the tissues and a more or less complete suspension
of their functional activity, whatever be the cause; and it is
evident also that the walls of the blood-vessels are more or less
deprived of their vital endowments when inflammation is set

1 “On the Early Stages of Inflainmation,” by J. Lister, F.R.S. Philo-
sophical Transactions, vol. xxxi. 1858.
590 PATHOLOGY OF MIND. (cmap,

up, as they then allow fibrine to pass readily through, though
they repel it in health. These experimental results have con-
firmed the opinions of those philosophical pathologists who
gave due weight to such phenomena as the immediate effects
of mechanical and chemical injury of a part, the growth of
blood-vessels in the primordial development of parts, and the
increased action of one kidney and the sequent increased afflux
of blood when the other is destroyed or rendered incompetent.

Bearing well in mind these observations respecting the in-
trinsic action of the tissues, it is not difficult to perceive how
damage to the nerve elements of the brain, however caused—
whether from overwork or emotional anxiety, or some poison in
the blood, or sympathetic irritation, or direct injury—may im-
mediately manifest itself in disordered function: the nerve
element is brought to a lower state of life, and exhibits its de-
viation from the normal state by a disturbance of function.
And as in inflammation a dilatation of the blood-vessels, a de-
termination of blood, and an adhesion of its corpuscles follow
the local mischief, so here a disturbance of the circulation follows,
and in its turn becomes the cause of further mischief. One may
perceive also how it is that, when there is an innate feebleness
of nerve element in consequence of hereditary taint, insanity is
produced by causes that would have no such baneful effect upon
a soundly constituted brain; for the weak element is more easily
brought to a lower state of life, and is then of course less able
to contend with the vascular troubles that gather round it and
overwhelm it.

When a dog is poisoned with strychnia, there are perhaps no
appreciable morbid appearances in the animal’s body; but if
any are found they are congestion of the spinal cord, aneuris-
mal dilatation of the capillaries, and perhaps small effusions of
blood in the grey matter. Now the congestion or effusion of
blood in such case is plainly a secondary result of the intensely
morbid activity of the nerve elements upon which the strychnia
directly acts. Here, in fact, is the abstract and brief chronicle
of what may be presumed to happen in some cases of insanity.
Transfer the convulsive action from the spinal nerve-cells to

1 General Pathology, by J. Simen, F.R.S.
x.] MORBID ANATOMY OF MENTAL DERANGEMENT. = 501

the cortical cells of the hemispheres, the result is an acute
and violent mania, in which the furious morbid action of the
‘directly poisoned nervous centres initiates an acute determina-
tion of blood. Let the disease become chronic, the congestion of
the blood-vessels will become chronic also. The common prac-
tice has been to discover the pathological cause of the insanity
in the congestion, in spite of the patent observation that it was
not the way of congestion, otherwise caused, to give rise to in-

sanity. In what is described as Mania transitoria, an individual
falls with great suddenness perhaps into a violent fury, in which
he evinces dangerous, destructive, and even homicidal tenden-
cies: his face ie flushed, his head hot, and there is plainly an
active determination of blood to the brain. After a short time
the attack subsides, and the man is himself again, scarcely
conscious of what has happened to him, There is not good
reason to look upon the rush of blood as the active agent in
the production of the fury; but there is good reason to look
upon it as secondary to the violent and degenerate action of the
nerve-centres ; in truth, the attack is a sort of epilepsy of the
cerebral centres, and the congestion presumably takes place much
as it takes place in the spinal cord poisoned by strychnia. To
the formation of correct views of the pathology of insanity it
is very necessary that this possible order of events should be
distinctly realised.

At the same time it is important not to overlook or underrate
the fact that extraneous disturbances of the circulation, quanti-
tative or qualitative, may be the direct cause of disorder of the
cerebral centres, Whatever interferes with the regular supply
of the proper material to be assimilated by them, and the regular
removal of the waste products of function—whether a disturbed
blood supply or a vitiated blood—so far predisposes to disease,
and will do so especially where there is any innate disposition
to morbid action or any prostration, otherwise caused, of nerve
element. In his Lumleian Lectures the late Dr. Todd insisted
much upon what Andral had pointed out—namely, that an
anemic condition js favourable to the production of delirium
and of coma.

That congestion or inflammation of the brain will produce
502 PATHOLOGY OF MIND. [cu ar,

serious disturbance of its functions is known to every one; but
it is well worth considering how rarely congestion of the brain
originating in causes outside itself gives rise to delirium or in-
sanity, and how often congestion of the brain has been found after
death in cases where there was no symptom of mental derange-
ment during life. It is because of a diminution in the functional
power of the nerve element itself, because this has been brought
to a stage nearer to the condition of non-living matter, that the
adherence of the blood-corpuscles and the stagnation of the blood
take place. In such circumstances we may understand how
little fitted the nervous element is to contend with the difli-
culties that are gathered around it: it is weak, and it is con-
sequently miserable; evils cluster around it, and threaten to
quench its life; it has more difficult work to do, and yet it is
less able to do it; it responds, therefore, as weakness always
does, with a convulsive or delirious energy, and, if circumstances
continue unfavourable, its activity is extinguished. May we not,
then, perceive. how it is that the abstraction of blood by some
means from the labouring part has been beneficial in certain
cases? The aim is to put the suffering part as nearly as pos-
sible in that condition in which it is during natural sleep—in a
condition of rest; and the recovering power which, as we have
seen, is inherent in the elements of living tissue, is then under
the most propitious conditions for restoring the natural state of
things.t

Morbid Appearances in the Brain and Membranes.—The
morbid changes in the brain that are discovered by the micro-
scope or otherwise certainly do not admit of being described
so definitely as to throw any light upon the pathology of the
different forms of mental derangement; they do not in the

1 Morel mentions the case of a man, aged fifty-five, who was hemiplegic
after cerebral hemorrhage. His intelligence was sound, but he was
morose and irritable, and weary of life. Periodically, however, he was
subject to attacks in which he complained of blood rising to the head; his
heart beat violently ; the fingers of the paralysed side contracted ; he was
unspeakably dejected at first, saying that he was lost; then became furious,
threw himself on his wife or children, and several times attempted suicide.
Blood-letting and cold to the head produced immediate calm.— Traité des
Maladies Mentales p. 138.
x.] MORBID ANATOMY OF MENTAL DERANGEMENT. 503

least tell us, for example, why the disease is melancholic in one
case, maniacal in another, monomaniacal in a third. Some
writers deny that the post-mortem appearances in the insane
throw any light on the nature of the disease; and the belief
affords a comfortable excuse for shirking laborious and tedious
investigation,, Schroeder van der Kolk, however, held a differ-
ent opinion :—* More than thirty years’ experience,” he says, “ has
led me to an entirely opposite opinion, and I do not remember
to have performed, during the last twenty-five years, the dis-
section of an insane person who did not afford a satisfactory
explanation of the phenomena observed during life. On many
occasions, I was able accurately to foretell what we should
find.”1 It must be confessed that no other person of authority
has expressed or felt a like certitude.

The broad result of pathological observation is, that the
morbid changes that are most constantly met with after insanity
are such as affect the surface of the brain and the membranes
immediately covering it. Of these changes certainly those in
the layers of the cortical substance are the essential. The
evidence of more or less inflammation of the membranes, and
especially a milky opacity of the arachnoid, common in the
insane, is also common enough in the bodies of those who have
not died insane. Certain observations of Schroeder van der
Kolk enable us to perceive how this may happen. In the first
place, he has remarked that adjacent parts which are of differ-
ent. structure are not.readily attacked by inflammation in equal
degree—it does not spread from like to unlike tissue by any
easy infection or sympathy as it does from element to element
of the same kind of tissue : the intercostal muscles, for example,
are almost unaffected: when acute costal pleurisy exists; the
muscular wall of the intestine is scarcely affected in: peritonitis ;
and the heart substance remains sound, in spite of acute peri-
carditis and effusion into the pericardium. So is it with the
pia mater and the brain substance which it closely envelopes:
congestion, inflammation, and effusion may take place in it while
the. brain. itself:is not implicated, and exudation between the

- ae the Minute Structure and Functions of the Medulla Oblongata,
pe 4 1, Se R
504 PATIOLOGY OF MIND. [ CHAP.

arachnoid and pia mater will accordingly be found after death
when there has been not the least mental derangement during
life. In the second place, he directs particular attention to the
distribution of vessels in the pia mater: while most of the
arteries pass down from it into the substance of the brain and
are there distributed to the grey matter in a most plenteous
network, the blood being brought back to the membrane by a
corresponding series of veins, there are in addition direct chan-
nels of communication between the arteries and veins in the pia
mater itself. In that anatomical arrangement there is obviously
a provision by which temporary disturbance of the circulation
may leave the cortical layers of the brain unaffected, the storm
passing over them; the direct communications are overflow
channels, as it were, for the surplus blood. But for such pro-
vision it would be a wonder that any one escaped serious
mental disturbance, considering the frequent changes in the
cerebral circulation to which every one is subject and the ex-
treme delicacy of nerve element. As it is, vascular disturbance
seldom remains entirely without effect; ‘although the hemi-
spheres are not themselves sensitive to pain, they manifest their
sensibility to the abnormal blood-supply by a feeling of unusual
irritability and a proneness to excitement and passion ; and this
is a condition of things which, as every one’s experience teaches,
is not so uncommon, but which usually soon passes away with
the physical cause of it.

There is no question that the mind suffers when the inflam-
matory action in the membranes does seriously implicate the
adjacent cortical layers; for, without claiming the delirium of
acute meningitis in proof, the morbid appearances sometimes
found after acute insanity afford sufficient evidence. As might
be expected, the appearances of acute hyperemia are most
marked after death from acute delirious mania. In the case
mentioned in a former chapter,? the pia mater was strongly in-
jected, the arachnoid was clouded like glass that has been
breathed upon, and streaked with a delicate milky opacity along
the lines of the vessels, there was a bulging at the sulci by a

1 Die Pathclogie und Therapie der psychischen Krankheiten.
2 Page 406,
x.J MORBID ANATOMY OF MENTAL DERANGEMENT. 505

clear serous fluid beneath it, and numerous red spots were
visible in the white substance of the brain when it was cut
into. In France much attention has been given to the morbid
conditions of acute maniacal excitement or maniacal delirium ;
they are described as those of acute hypereemia—namely, great
injection of the pia mater with spots of ecchymosis, more or
less discoloration and softening of the cortical layers—the dis-
coloration being in red streaks or stains with spots of extra-
vasated blood, and the softening being of a violet or ‘pink hue—
and increase of the puncta vasculosa of the white substance,
Dr. Ringrose Atkins has recently described the morbid appear-
ances observed by him in a case of acute insanity which ended
fatally within a week, both lungs of the patient being found
studded with miliary tubercles throughout their entire substance,
The pia mater was much injected and there were numerous
minute extravasations of blood, some globular and others strati-
form in appearance, between the pia mater and brain substance
both on the surface of the convolutions and between them
where the pia mater dipped down into the sulci; some of the
extravasations were visible with the naked eye, others with a
low power of the microscope. There were none in the brain
substance itself? Here then the weakened walls of-the over-
full vessels had given way and the blood had escaped in
numerous minute extravasations. As patients do not often die
suddenly in the acute stage of insanity, opportunities are not
given to examine whether this pathological condition is often
met with; but it is certainly not invariably met with when they
do die in the acute stage, and is more likely to be found after
death during the delirium of fever than in ordinary systematised
mania. If we call to mind what has already been said of the
relation of nerve element to the blood-supply, it will be easy
to understand how this may happen, as also how, when hy-
pelzemia is met with, it ought perhaps to be regarded, not as
direct cause of the mental disorder, but, if not as effect of it,
in the light of a concomitant effect of a common cause. With
due regard to this possible relation, it niay be justly said that
the visible morbid appearances of acute insanity are those of

1 Journal of Mental Science, 1875,
506 PATHOLOGY OF MIND. [cuap.

acute hyperemia of the brain. There are no appreciable differ-
ences between the morbid conditions of acute mania and acute
melancholia: in the latter it more frequently happens that
anatomical lesions are absent; and when they are present, they
have been said to mark less hyperemia than exists in acute
mania, and to be attended with more or less serous exudation.
The cases of chronic insanity in which all anatomical lesions
are wanting are rare, albeit they do occur: the longer the
insanity has lasted, the more evident they usually are. In
most instances there is a thickening and milky opacity of the
arachnoid; and many of the more advanced cases exhibit
a degree of atrophy of the brain, especially of the convolu-
tions, effusion of serum into the sub-arachnoid space to fill
the void made by the shrunken brain, discoloration of the
cortical substance, and some hardening of the white substance.
The pia mater is oftentimes more or Jess firmly and generally
adherent to the surface of the brain, so that it cannot be stripped
off without tearing the latter; and a finely granular condition
of the ependyma of the ventricles, with its frequent adherence
to the parts beneath, would seem to bear witness to a previous
sub-inflammatory condition: granulations of the arachnoid, care-
fully described by Meyer, have probably a like interpretation.
Of the granulations of the ependyma of the ventricles, which
were noticed: by Bayle in general paralysis, but are certainly
not peculiar to it, as they have been asserted to be, Dr. Lockhart
Clarke says: “They consist of globular aggregations of the
ordinary epithelial cells, which, in a natural or healthy state,
are arranged side by side, and form a smooth or level surface on
the floor of the ventricle. The tissue immediately subjacent,
and which consists of exceedingly fine fibres proceeding from
the tapering ends of the epithelial cells, and running in various
directions, was more abundant than usual; and—as might be
expected from the homologous relation of this part to that
which surrounds the spinal canal—it was interspersed with
corpora amylacea, but certainly not to a corresponding extent.” !
Although the adhesion of the pia mater to the surface of the
brain is most frequent in general paralysis, it is met with in
1 Beale’s Archives of Mcdicine, vol. iii.
x.] MORBID ANATOMY OF MENTAL DERANGEMENT. 507

other forms of chronic insanity, particularly in dementia following
epilepsy and alcoholism.

General paralysis is the one’ form of mental disease in which,
if death has not taken place early in jts course, we may be sure
of finding morbid changes. These are great cedema of the
membranes, opacity and thickening of arachnoid in various
degrees, adhesion of the pia mater to the surface of the brain,
larger or smaller portions of which are torn away with it when
it is removed, greyish-red local softening or discoloration of the
cortical layers, and superficial induration thereof, owing to an
increase of the connective tissue and a destruction of the proper
nervous elements. More or less atrophy of the whole brain,
and particularly of the convolutions, is common, and is accom-
panied with greater firmness of its substance, enlargement of
the ventricles, and serous effusion into them. Diffuse pachymen-
ingitis and considerable effusions of blood into the membranes or
into the new formed layers of exudations, as described by
Virchow and Rokitansky, are not unfrequent ; these effusions be-
ing no doubt the cause of the apoplectiform attacks which occur
in the later stages of the disease. The degeneration of the nerve-
substance from the increase of connective tissue has been
observed by Rokitansky and others to extend sometimes even to
the spinal cord; but Westphal has more recently expressed a
doubt whether an increase of connective tissue has been satis-
factorily demonstrated in the grey and white substance of the
brain, although he has no doubt of its occurrence in the posterior
columns of the spinal cord. The morbid changes described are
certainly more evident in general paralysis than in any other
form of insanity, but they do not occur with uniform constancy,
nor are they of uniform character ; in some cases the meningitis
being most marked, in others the atrophy of the brain, and in
others the induration thereof. Dr. Sankey has made a careful
comparison of the morbid appearances observed by him in
fifteen cases of yeneral paralysis with those observed in fifteen
cases of chronic insanity of other. forms. The greatest differ-
ence was in the frequency of effusion beneath the arachnoid,
which was found in eleven of the fifteen cases of general
paralysis, and in only three of the other cases. Adhesion of
508 PATHOLOGY OF MIND. [cHar.

the pia mater to the grey matter occurred in eight of the
general paralytics, and in only one of the others. The convolu-
tions were abnormally open and wide apart in nine of the cases
of general paralysis, and in three of the other cases; in eight of
the former, again, there was a dark discoloration of the grey
matter, which was met with in only three of the. latter; the
layers of the grey matter were indistinctly marked in ten cases
of general paralysis, and in six of the other cases.’ Plainly
there are no morbid appearances characteristic of general
paralysis, although morbid changes are more marked and more
constant in it. Dr. Mickle has recently attempted to group
cases of general paralysis into varieties according tothe differ-
ences in the character and situation of the morbid changes
which he has found in the brain, and to indicate the clinical
features which he has observed to belong to these pathological
varieties. In this way he has provisionally sketched the patho-
logical and clinical characters of five special groups.”

Schroeder van der Kolk has given a detailed description of
several cases of what is commonly considered a very rare
affection, but which he thought by no means so uncommon—
namely, a diffuse inflammation of the dura mater or an idio-
pathic pachymeningitis. It was, he thought, often overlooked,
and considered to be rheumatic headache. The symptoms were
intolerable headache, delirium, sometimes calmer delusion, and
coma; and after death the dura mater was found to be ex-
tensively inflamed, and more or jess adherent to one or both
hemispheres ; the inflammation had in some cases extended to
the brain, which was found to be softened. According to his
experience, this affection, where neither syphilis nor injury
could be assumed as cause, was not rare. A remarkable cir-
cumstance in regard to it which he took notice of was, that
regular intermissions occurred in its course, the patient having
considerable intervals of apparent health.

On the authority of so eminent an observer this idiopathic

- ‘On the Pathology of General Paresis,” Journal of Ilental Science,
4, a

? “Varieties of General Paralysis of the Insane.” Journal of Mental
Science, April, 1878.
x] MORBID ANATOMY OF MENTAL DERANGEMENT. 509

inflammation of the membranes may be admitted, but it must
be confessed that the morbid appearances described by him are
very like those which have since been described as almost
pathognomonic of syphilis. A diffuse fibrinous exudation of
low form, gluing the membranes to the brain substance beneath,
has been held to be a characteristic feature of syphilitic de-
mentia. Instead of being diffused the exudation is sometimes
circumscribed, so as to have the form of a tumour; and it may
then press into the brain-substance, causing softening im-
mediately around it. Or, again, the gum-like exudation, or
syphiloma, as it is called, may take place as a diffuse infiltration
or as a tumour within the substance of the brain, the mem-
branes being unaffected. Such is the morbid product which
recent researches have assigned to syphilis; and, according to
Virchow, it consists at the outset, like the substance of granu-
lations, of an exuberant growth of connective tissue, its
further development taking place in two directions: (1) either
the formation of cells predominates, and then the intercellular
substance is soft, jelly-like, mucous, or fluid, the whole mass
remaining jelly-like and coherent, or undergoing purulent de-
generation ; (2) or the formation of cells is léss prolific, and the
intercellular substance increases, so that the fibres preponderate ;
the cells are spindle-shaped or stellate, like the cells of con-
nective tissue, or round like granulation cells. Ultimately
yellow patches of fatty degeneration appear in it. There cer-
tainly is no character whereby this exudation can be dis-
tinguished as a specific product, and every pathologist admits
the difficulty of distinguishing it from tubercle. In some in-
stances the arteries of the brain are surrounded and infiltrated
with this gummatous deposit, their walls being much thickened
and their channels narrowed, or actually closed in the smaller
vessels The starting-point of its formation has been supposed
by Virchow to be the nuclei of the connective tissue and its
equivalents; the proper elements of the organ undergoing
atrophy as the result of the hypertrophy of the connective

‘1 Cases are described in Journal of Mental Science, vol. xx. p. 852; also
vol. xxii. p 615.
510 PATHOLOGY OF MIND. [ouae.

tissue The form of mental disorder with which this syphiloma
is associated in its extreme stage is, as might be expected, an
extreme paralytic dementia.

Such are the morbid appearances that have been seen by
the naked eye in cases of mental derangement. Obviously
those that are found in acute disease indicate a process which
is of the nature of acute hyperemia or actual inflamma-
tion, and their effect will be to interfere seriously with the
nutrition and function of the nerve-elements of the brain.
Whether they and the maniacal symptoms stand to one
another in the direct relation of cause and effect or not—and
their non-essential concomitance in mania weighs heavily
against the theory of such a precise relationship—they both
witness to the loss of the natural vital equilibrium and to the
display of degenerate vital activity: in the one case we have
the marks of that resolution of higher into lower vitality
which we agree to call inflammation, in the other we have the
symptoms of that resolution of higher into lower mind which
we agree to call mania. Let the disorder be much prolonged
and become chronic and irreparable, the observed morbid
changes still tell the same tale: a thickening of the walls of
the blood-vessels, an increase of the connective tissue, and an
atrophy of the proper nerve-elements bear witness to vital
degeneration as emphatically as does the mental incoherence.
In the difference of histological dignity between a nerve-cell
and a connective tissue corpuscle is there not a gap as great as
that between sound mental activity and dementia?

Microscopic examinations of the brain after insanity have
added something to our knowledge of its pathology by disclosing
morbid changes in the blood-vessels, in the neurovlia or so-
called connective tissue, and in the nerve elements themselves.
Still there is far from being agreement among different
observers concerning what they find; moreover there is no little
reason to think that in many instances the appearances which
have been described as morbid were produced artificially

1 Virchow’s Archiv, vol. xv. p.217. “Das Syphilom, oder die consti-

tutionell-syphilitische Neubildung,” von E. Wagner, Archiv der Heil.
leunde, 1863, a
x] MORBID ANATOMY OF MENTAL DERANGEMENT. 611

by the treatment to which the brain-substance had been sub-
jected in order to fit it for minute examination. Most pains
have been given to the microscopic examination of the brain in
general paralysis, and it is in it that the most definite morbid
changes have been met with. Recent observers have described
masses of cells adhering to the vascular walls and more or less
filling the perivascular spaces. They resemble, and appear to
he, colourless blood-corpuscles, single red blood-corpuscles being
seen here and there among them; and at a later period there
are regular small extravasations in all stages of pigmentary
degeneration. The vessels themselves are filled and crowded
with blood-corpuscles. A pretty constant result has been to
discover an exuberant production of connective tissue in long-
standing insanity, and especially in-general paralysis. The homo-
geneous matrix of what is supposed to be connective tissue lying
between and supporting the nerve elements of the brain, and
continuous with the ependyma of the ventricles, appears to be
prone, in certain circumstances, to undergo an undue increase, to
the detriment of the higher elements of the part. The researches
of Rokitansky and Wedl into the morbid changes in general
paralysis have also made known a more or less diseased state of
the capillaries of the cortical substance of the brain. There is
a certain tortuosity of the capillaries apparent in almost every
case, this being in some cases only a simple curve or twist, in
others amounting to a more complex twisting, and even to little
knots of varicose vessels. Round the capillaries and small
arteries and veins there is often a hyaline deposit of what is
supposed to be embryonic connective tissue, beset with oblong
nuclei; this afterwards becomes more and more fibrous, so that
the vessel may look like a piece of connective tissue in which
granules of fat or calcareous matter are occasionally seen. It is
thought that this growth of connective tissue may hove its
starting-point, not only from the nuclei of the walls of the blood-
vessels, but also from the proper nuclei of the brain-substance.
As a consequence of its exuberant increase, the nerve elements
as well as the delicate capillaries are injured or destroyed; “in
the grey substance the ganglionic cells appear inflated, their
continuations are undoubtedly torn, and the nerve-tubes pene-
512 PATHOLOGY OF MIND, [cHap.

trating the grey substance are destroyed.” Rokitansky believes
that it is not to be looked upon as an inflammatory process,
and it certainly is not so in the common acceptation of the
meaning of inflammation, albeit it plainly bears witness to a
deterioration of nutrition very like that which accompanies and
marks a chronic sub-inflammatory derangement.

In respect of this sheath round the small arteries and capil-
laries it must be borne in mind that, as Lockhart Clarke and Mr.
Robin have pointed out, in every healthy brain a great number
of the capillaries and small arteries are surrounded by secondary
sheaths precisely similar in all essential particulars to those
which have been considered as morbid products in general
paralysis! The difference is that the sheaths are often less
delicate in general paralysis, thicker, more conspicuous, and fre-
quently darker than in the healthy brain ; sometimes, especially
when the vessels are convoluted, they appear as fusiform dilata-
tions along their course. Moreover, while in the healthy brain
granules of hamatoidin are commonly scanty, and frequently
absent altogether, they often abound in general paralysis,
scattered in some places, collected into groups in others. In con-
nection with the hypertrophied tissue are amyloid corpuscles,
colloid corpuscles, calcareous and fatty granules—all being pro-
ducts of a retrograde metamorphosis, if the colloid and amyloid
bodies be not, as some suppose, fragments of broken-up nerve.
There are, as I apprehend the matter, two ways in which retro-
grade products are formed: first, there is a mal-nutrition, or a
retrograde nutritive process, whereby the vitality not being at the
height necessary to the production of the proper elements, there
are engendered from the germinal nuclei elements of a lower kind
—connective tissue instead of nerve; and, secondly, there is a
retrograde-metamorphosis of the formed elements of the parts.

An elaborate examination by Dr. E. Rindfleisch of the morbid
changes in the brain and spinal cord of a patient who died from
tabes dorsalis, and in different parts of whose brain there were
numerous patches exhibiting different degrees of grey degenera-

1 “On the Morbid Anatomy of the Nervous Centres in General Paralysis
of the Insane,” by J. Lockhart Clarke, F.R.S, Lancet, September 1st,
1866.
X.] MORBID ANATOMY OF MENTAL DERANGEMENT, 513

tion from a greyish pulp to sclerosis has in the main confirmed
Rokitansky’s observations. His results are of special interest
here in relation to those varieties of general paralysis which
begin with or are associated with symptoms of tabes dorsalis.
The process of degeneration seemed to begin in the vessels, as
their walls were enormously thickened by a number of cells and
nuclei, and their diameter was increased. This first stage he
considered to be the result of long-enduring hyperemia. The
neuroglia or hyaline connective tissue next undergoes change,
fibres being formed in the amorphous basis substance; the nerve
fibres then suffer atrophy, lose their medulla, and appear to con-
sist of axis cylinder and sheath, or of axis cylinder only. As
they disappear, the connective tissue increases; numerous
single nuclei appear in it, as also groups of nuclei, which seem
to proceed from the division of a single nucleus. Round these
groups a certain quantity of finely granular substance collects,
so that cell-like bodies are formed, resembling the four-nucleated
bodies described in marrow by Kolliker and Robin. The fibres
of the connective tissue are formed out of the basis substance,
Rindfleisch believes, but are probably developed in organic rela-
tion to the nuclei. Ata still later stage retrogressive metamor--
phosis sets in: molecules of fat appear in the ganglionic cells,
according to Virchow, and as they increase form granular
bodies ; Rokitansky, however, thinks these bodies proceed from
the fragments of the medulla of the nerve fibres. So also is it
in Rindfleisch’s opinion with the amyloid corpuscles that are
found: the nucleated cells of the connective tissue go through
the amyloid degeneration ; and he has watched every stage of
the transition from the normal cell to the amyloid corpuscle.
When by fatty degeneration the greater number of nerve-cells
have been converted into a detritus capable of being absorbed,
the fine elastic fibres contract, get closer and closer together,
and remain as the constituent tissue of the cicatrix, which
sometimes causes considerable deformity; whole sections of
nerve substance having been replaced by a relatively small
quantity of an unyielding, compact, dry tissue. There are then
three principal stages in this degenerative process :—(1) a
change in the vessels, whereby there must be a great hindrance
514 PATHOLOGY OF MIND, [cuar,

to regular nutrition ; (2) atrophy of nerve element, either in con-
sequence of the interference with its nutrition (Rindfleisch), or
from the growth of connective tissue (Rokitansky) ; and (3) the
subsequent metamorphosis of the connective tissue.*

Wassilief has described the results of a microscopical exami-
nation of the brain of a young woman who died from hydro-
phobia? Some of the nerve-cells of the medulla appeared
muddy, their contours dimmed, and their nuclei obscured. In
the interstitial tissue of the brain were a number of round
bodies of the size of the white blood corpuscles, and supposed
to be exudated white blood corpuscles which were most
numerous in the vicinity of the perivascular spaces. The blood-
vessels were strongly dilated and were filled with blood cor-
puseles, In the perivascular spaces, especially in the cortex of
the hemispheres, was a slightly shining, strongly refracting
hyaloid substance, which was very striking; it was sometimes
collected round the vessel so as to form an irregular ring
and perceptibly to narrow it. In other parts of the brain the
perivascular spaces were more or less dilated.

A careful microscopical examination of the brains of three
idiots has been made by Wedl. The changes which he observed
were such as are usually met with in atrophy of the cortical
layers, In the pia mater. and the convolutions there was local
obliteration of capillaries, these sometimes having the appearance
of a dirty yellowish band of connective tissue which, like other
connective tissue, swelled up and lost its wavy lines in acetic
acid. Other thickenings in the capillaries of the cortical layers
he described as colloid : these were knotty swellings in their
course that were unaffected by acetic acid. Atheromatous de-
generation of arteries, veins, and capillaries was more or less
marked in all the cases. In one instance the small arteries and
veins and the capillaries exhibited furinel-like dilatations, owing
to a proliferation of nuclei that lay nestled in them ; and a trans-
parent basis substance containing many oval nuclei surrounded
the capillaries for some distance. In all three cases there was

} “Histologisches Detail zu der grauen Degeneration von Gehimn u.

Riickenmark,” von Dr. E. Rindfleisch. Virchow’s Archiv, B. vi,
2 Centralblatt f. d. med. Wissensch. No, 36, September, 1876.

.
x.] MORBID ANATOMY OF MENTAL DERANGEMENT. 515

a metamorphosis of the contents of the ganglionic nerve-cells,
the noticeable change being a condensation of the contents
with disappearance of the nuclei—a condition which called to
mind the colloid degeneration of the ganglionic cells of the
retina.! It has been recently stated that the commissural fibres
which should unite neighbouring convolutions have been found
absent in the brains of some idiots, the “fibres of association ”
(Meynert) which unite distant convolutions being present only ;
and this defect has been supposed to be the reason of the
defective intelligence.”

It appears, then, that the vital degeneration which shows itself
in an increase of connective tissue, with atrophy and destruc-
tion of nerve element, so far from being peculiar to general
paralysis, is of common occurrence in insanity of long standing.
There can be little doubt that the morbid product which is
thought to be the result of syphilitic disease is of like nature;
and Billroth found a peculiar gelatinous degeneration of the
cortex of the cerebellum, which he met with in one insane
person, to consist of soft connective tissue. This proliferation
of connective tissue with destruction of the nerve elements has
at any rate been now observed and described in dementia fol-
lowing continued insanity, in general paralysis, in syphilitic
dementia, in tabes dorsalis, and in congenital idiocy. No wonder,
then, that the clinical features of paralytic dementia, general
paralysis, syphilitic dementia, and alcoholic dementia are some-
times so very like that they cannot be distinguished symptoma-
tically. The so-called hypertrophy of the brain which is met
with sometimes in large-headed imbeciles, and especially in
epileptic imbeciles, and which is apt to be hastily mistaken for
hydrocephalus, is really due to an increase of the connective
tissue, and not of the nerve-cells and fibres, since they, with the
capillaries, undergo atrophy. ‘The convolutions of the brain are
flattened, and its substance is hardened, and, when cut into,
presents a clean, pale, glistening, and elastic surface. <A similar

1 “ Histologische Untersuchungen itiber Hirntheile drier Salzburger
Idioten,” von Dr. ©. Wedl. Zeitschrift der K. K. Gesellschaft der Aerzte
in Wien, 1863. : ;

® Researches on Idiocy. Dr. Mierzejewski, Journal of Mental Science,
January, 1879.
516 PATHOLOGY OF MIND. [cuap

induration may occur without any hypertrophy ; it is said to be
a distinct result of long-continued lead-poisoning ; and M. Brunet
has described a hypertrophy of the brain without induration, but
due to an increase of the connective tissue.?

Dr. Howden has recently described the morbid changes which
he found in a case of senile dementia in which death took place
from coma. The brain was wasted, much serous fluid effused
into the meshes of the pia mater, the ventricles were distended
with fluid, and the vessels at the base of the brain atheromatous.
The brain-cells of the grey matter were clouded with fuscous
granules which almost always obscured the nucleus, but the
granular deposit was evidently outside the cell-wall. Many of
the cells had a shrunken and misshapen appearance ; there were
many amyloid and hyaline bodies in the outer layers of the
cortex ; and the minute vessels in the grey matter were almost
universally coated with granular matter. There were also twist-
ings and well-marked aneurismal dilatations of the vessels of
the pia mater, in all parts of which were found miliary aneurisms,
such as have been observed in the neighbourhood of a cerebral
clot, varying in form from a slight bulging to a round swelling,
and the walls of the vessels had a granular look. The aneurisms
were most numerous neara thin layer of semi-fluid blood and a
small dark clot.?

We have no definite and complete descriptions—nothing more
than vague intimations—of the morbid changes that take place
in the cells of the convolutions, albeit we feel sure that import-
ant changes do take place in them, and have the testimony of
many observers as to their shrunken, misshapen, and abnormal
look in such states of extreme mental disorganisation as dementia
following long-continued derangement, senile dementia, and
congenital idiocy. Some years ago a German observer, Dr.
Tigges, described an increase of nuclei in the ganglionic cells in

1 Annales Médico-Psychologiques, 1874. He gives many references to
French papers treating of hypertrophy of the brain. In the Journal of
Anatomy and Physiology for May, 1873, is a description of the brain of a
hydrocephalic epileptic idiot, the right lobe of whose brain was several
ounces heavier than the left ; its greater weight being due to an increase
of the neuroglia,

2 Journal of Mental Science, vol. xx. p. 587,
X.] MORBID ANATOMY OF MENTAL DERANGEMENT 617

acute insanity, and declared that the numerous scattered nuclei,
usually thought to belong to the connective tissue, had really
escaped from the cells through rupture of their walls at a later
stage of their inflammatory degeneration ; but I am not. aware
that these observations have been confirmed Dr. Meschede
has described the morbid changes of the first stage of general
paralysis as being inflammatory in character, and the later
changes as those of fatty and pigmentary degeneration of the
ganglionic cells.?

Pigmentary degeneration has been met with in the ganglionic
cells of the brain in senile atrophy, in dementia, and in ad-
vanced general paralysis. Schroeder van der Kolk found the
cells of the medulla spinalis and oblongata to be darker. and
more opaque in old age; and in one case of dementia after
mania, where there was partial paralysis of the tongue, the
gapglionic cells forming the nuclei of the hypoglossal nerves
were in a state of blackish-brown degeneration, so that he at
first mistook them for little points of blood. On more careful
examination, however, they were seen to be degenerated gang-
lionic cells, filled with granular dark brown pigment. Dr.
Lockhart Clarke has observed similar structural changes in
general paralysis. “These changes,” he says, “consist of an
increase in the number of the contained pigment-granules,
which in some instances completely fill the cell. In other in-
stances, the cell loses its sharp contour and looks like an
irregular heap of particles ready to fall asunder.” In regard to
this form of degeneration, certain pigmentary changes that have
been described in the retina are not without interest. In what
is called Retinitis pigmentosa there are found scattered over the
fundus oculi irregular figures of deep black colour, consisting
of pigment apparently in the substance of the retina. A point
of interest with regard to these cases is, that they occur in the
same family and are accompanied by general imperfection of
development. Grife observed this degeneration to be often-
times of hereditary occurrence, and Liebreich has pointed out
that many subjects of the defect are the offspring of marriages
of consanguinity. More or less imperfection of the mental

1 Leitschrift fir Psychiatrie, B. xx. 2 Virchow’s Archiv, 1865,
518 PATHOLOGY OF MIND, [cHap.

faculties and arrested development of the sexual organs usually
co-exist ; and the concurrence of mutism and cretinism with
Retinitis pigmentosa is occasional. Pigmentary degeneration
may be regarded as a no'less certain retrograde morbid change
in the brain than it is in the retina. .

Granules of earthy matter are common enough in connection
with the hypertrophied connective tissue of long-continued
and extreme insanity. But a few cases have also been men-
tioned in which a so-called calcification of some of the gang-
lionic cells of the brain has been met with. Erlenmeyer found
the commissure of the optic nerves hardened by a deposit of
calcareous matter in the brain of a monomaniac who had died
with epileptiform convulsions. It had been first deposited
about the small arteries and in the connective tissue; and the
cells had afterwards been occupied and made opaque by fine
granules of what appeared to be phosphate of lime. Forster,
in his Atlas of Pathological Anatomy, describes calcified cells
found in the grey substance of the lumbar enlargement of the
spinal cord of a boy whose lower extremities were paralysed.
Heschl met with what hé calls an ossification of cells in the
brain of a patient, aged twenty-six, who had died melancholic :
they were in the compact substance surrounding a small heemor-
rhaghic cavity in the cortical part of the right cerebral hemi-
sphere. Hydrochloric acid dissolved the granular contents, and
left the cells with a pale outline in view. Dr. Wilks believes
certain bodies which he found in the brain of a general paralytic,
in whom the small arteries were calcified, to have been gang-
lionic cells that had undergone calcareous degeneration.2? Some
persons may find an interest in reflecting that a similar degene-
ration takes place on a microscopic scale to that which the
whole organism must undergo at last: as the body is formed out
of the dust of the earth by an upward transformation of matter
and force, so by a retrograde metamorphosis of matter and corre-
lative resolution of force does it, in parts and as a whole, return
to the earth whereof it is made.

Such, then, are the morbid changes which have been observed

1 Schmidt's Jarbiich, 1863.
2 Journal of Mental Science, 1864,
x.J MORBID ANATOMY OF MENTAL DERANGEMENT, 519

and described in the bodies of insane persons. Obviously those
which have been made known by the microscope—the changes
in the blood-vessels, the increase of connective tissue, the de-
generation of nerve-cells—are entirely consistent with those
which are visible to the naked eye, in setting forth a story of
vital degeneration that is of degradation from a higher to a lower
life. And notwithstanding the admission that morbid changes
cannot be detected in every case of insanity, and all that such
an admission implies, still the lesson to be derived from the
study of the changes which are seen is a certitude of the essen-
tial dependence of mental function on physical structure and a
strong faith in the existence of unseen changes where none can
yet be seen, As by the invention of a suitable sense-sharpening
instrument we have gone below macroscopic into microscepic
anatomy, so may we hope that the time will come when those
who come after us shall by the invention of new instruments of
research go yet deeper into the discovery of the hidden changes
which I have called ascopic.

Morbid Conditions of other Organs.— Perhaps the most frequent
local diseases met with in the insane, and the most frequently
fatal, are diseases of the respiratory organs. Many who are ina
low, deteriorated constitutional state, especially the demented
paralytics, succumb to a diffuse pneumonia of low type. The
usual symptoms of the disease, however, are rarely marked, being
masked by the madness; there is seldom any cough, expectora-
tion, or pain; no complaint is made; there may be little or no
dyspnoea ; and the only ground of diagnosis lies in the physical
signs. Gangrene of the lung was observed by Guislain almost
exclusively amongst the melancholics who had refused nourish-
tent and died of exhaustion, and in as many as nine such cases
out of thirteen; but it has been found since his time that the
disease is not limited to those who refuse food, although most
frequent amongst them. In the Vienna Asylum there were, out
of 602 post-mortem examinations made in three years, fifteen
cases of gangrene of the lung. Pain, cough, dyspncea, and fever
are often entirely absent ; there is prostration, and the extremities
are cold; the complexion is dusky red or cyanotic; the odour
of the sputa and breath becomes intolerably offensive; extreme

23
520 PATHOLOGY OF MIND. [clar,

weakness is increased by diarrhoea, and death follows within a
period varying from ten days to three weeks.

Almost every writer on insanity has called attention to the fre-
quency of phthisis pulmonalis among the insane, although there
is far from being agreement as to the proportion of cases in
which it occurs. A careful comparison of the statistics of several
asylums by Von Hagen showed that on an average about one-
fourth of the deaths were attributed to phthisis ; but this pro-
portion is really about the same as that for the sane population
above fourteen years of age. Out of 1,082 deaths which occurred
in the Royal Edinburgh Asylum from the year 1842 to 1861,
phthisis was the assigned cause of death in 315, or in nearly
one-third (Dr. Clouston). In eight of the American asylums
the deaths from consumption were, according to Dr. Workman,
27 per cent. of the whole number of deaths. Dr. Clouston has
however proved by the examination of a series of carefully
made post-mortem examinations that phthisis was the assigned
cause of death in only 73 of 136 men, and in 97 of 146 women,
in whose bodies tubercular deposit was actually found—that is,
in little more than half of those in whom tubercle really existed.
His conclusion is, that not only is phthisis a more frequently
assigned cause of death amongst the insane than amongst the
sane, but that tubercular deposition is about twice as frequent
in the bodies of the former as in those of the latter. But there
is reason to think that the association of the diseases is not
essential, but accidental; that it is due to the conditions in
which the insane, congregated in great numbers in large asylums,
live, not to any special power which insanity has to provoke
phthisis, or phthisis to provoke insanity.

Observers, agreed as to the frequency of the occurrence of
disease of heart in the insane, differ much as to the proportion
of cases in which they are found: Esquirol found them in one-
fifteenth of his melancholic patients, Webster in one-eighth, Bayle
in one-sixth, Calmeil and Thore in nearly one-third. The obser-
vations of late years tend to lessen the exaggerated proportion
commonly assumed; out of 602 post-mortem examinations in
the Vienna Asylum, affections of the heart were met with in
about one-eighth of the cases; and in some of these the discase
x.] MORBID ANATOMY OF MENTAL DERANGEMENT. 521

was very slight. All such statistics are of small value. Until
we have a more accurate comparison with the ‘statistics of heart
disease in the sane population than has yet been made, it must
remain a conjecture whether it is even more common in insane
than in sane people.

There is nothing special to be said concerning diseases of the
abdominal organs in the insane. A more or less inflammatory
state of the intestinal mucous membrane is at the bottom of that
colliquative diarrhoea which at last carries off many feeble
patients, mostly those suffering from paralytic dementia, but
now and then even some who are maniacal or melancholic. A
changed position of the colon, the transverse portion of it lying
in the hypogastric region or in the pelvis, was taken particular
notice of by Esquirol, but is not now thought to be of any real
importance or to have any special ‘siouliieanve,

All sorts of disorders of one or more of the abdominal organs
have been met with in particular cases, but not one in any con-
stant relation to a particular form of insanity. Rokitansky
noticed a considerable increase and induration of the cceliac axis
in a case of hypochondriasis with great wasting. Cancer of
the stomach, liver, or of some other part has been discovered in
cases where there existed during life a delusion with regard to
some animal or man being present in the belly; in one notable
case, described by Esquirol, where delusions of this sort were
most extravagant, there was chronic peritonitis which had glued
together the intestines. Diseases of the sexual organs are, as
already pointed out, of some importance in the causation of in-
sanity. In the female, prolapsus of the uterus, fibrous tumour
of the uterus, ovarian cyst, &c., may in some few cases impart
to the insanity a sexual character, or become the occasions of
special delusions; but in other cases of like disease there is
no sort of connection traceable between the character of the
insanity and the particular disease. However, if there be no
such special relation, we shall do well to remember that, by
reason of the consensus of parts, the intimate connection and
interaction between one organ and another as parts of an organic
whole, disorder of any organ—dissentient where all should be
consentient—may still conspire with other predisposing or ex-
citing causes to provoke an attack of mental derangement.
CHAPTER XI.
THE TREATMENT OF MENTAL DISORDERS.

In no other disease are the difficulties of treatment so great as
they are in mental disease. The intrinsic difficulties appertaiu-
ing to the nature of obscure disease are increased and multiplied
by the social prejudices concerning it; by the frequent conceal-
ments and misrepresentations on the part of friends, who may
often be reckoned on to mislead rather than enlighten the physi-
cian ; by the necessity of removing the patient—probably against
his will—from the care of his relations to other care more suited
to his malady ; by the unsatisfactory character and position of
the institutions for the reception of insane persons ; and, in some
measure also, by the necessary stringency of lunacy legislation.
In face of such difficulties one may sympathise with Casaubon
when he says, ‘“‘ Let others admire witches and magicians as
much as they will, who by their art can bring them their lost
precious things and jewels: I honour and admire a good physi-
cian much more who can (as God’s instrument), by the knowledge
of nature, bring a man to his right wits again when he has lost
them.” ?

The cruelties formerly inflicted upon insane persons no doubt
originated partly in the distrust and fear which their disease
occasioned and were kept alive, after they were quite out of
harmony with the moral feeling of the day, by a neglect spring-
ing from the desire to hide madness as a disgrace ; but they were
in part legacies from the superstition which looked upon the

1 On Enthusiasm,
cu. X1.] THE TREATMENT OF MENTAL DISORDERS. 423

insane as possessed by evil spirits which it was necessary to
expel by the severest penal discipline when prayers had proved
unavailing. The ancient Egyptians and Greeks used humane
and rational methods of treatment ; it was only after the Christian
doctrine of possession by devils had taken hold of the minds of
men that the worst sort of treatment of which history gives
account came into force. However it came about, the end was
that to be the victim of the most pitiable of diseases became a
treason not for undergoing the most patient and considerate
medical treatment, but for being subjected to the harshest rhea-'
sures and to an imprisonment which was too often lifelong.
To shut the madman from gaze, and, if possible, from memory—
to be rid of his offending presence at any cost—that was the one
thing to be done, and fit implements were not wanting, as they
never have been when wrong was to be done, to execute what
was wished.

The great and beneficent reform which was conceived and ini-
tiated by Pinel in France and carried out in this country by
Conolly and others, had to encounter a strong phalanx of obstruc-
tive prejudices, selfish indifference, and interested opposition. But
it triumphed, and for many years the revolution in the treatment
of the insane has been quoted as one of the proud reforms of the
century. Still there lingers a deep distrust of lunatic asylums
in the public mind, and it gets angry expression from time to
time in vague accusations. The distrust is partly a relic of the
memory of their past evil management; it is partly the result of
the clamour of insane persons at large who have been at one
time in confinement, as they believe, unjustly ; it arises in greater
degree out of a vigilant and active jealousy of any interference
with personal liberty; and it is most of all due to the fact that
many asylum; belong to private proprietors whose interest may
be supposed to be to get and to keep as many patients as they
can, rather than to cure and discharge them. Granting full weight
to these suspicions, there is still reason for congratulating our-
selves on the vast reform which has been accomplished, when we
contrast the worst complaints made now with the accusations
that were justly made some years ago. A Committee of the
House of Commons was lately appointed at the instigation of
524 PATHOLOGY OF MIND. [cHaP.

those who were dissatisfied with the state of the Lunacy Laws,
in order to examine whether the facilities were unduly great for
consigning people to asylums, and not duly great for obtaining
their discharge from them. The Committee made a painstaking
inquiry which extended over several months, taking a great deal
of evidence, including the evidence of those who believed that
they had been improperly confined as lunatics ; the result being
that they did not discover a single instance of a sane person
having been confined as insane, and.made a report which con-
tained only a few not very important recommendations. When
this report is compared with reports made by two former Com-
mittees of the House of Commons it plainly shows how great is
the progress which has been made.

So long as insane persons cannot themselves perceive that they
are out of their minds, there will be some who, having improved
so far as to be discharged from confinement in asylums, without
being quite recovered, will make loud complaints against the
injustice of laws of which they consider themselves to have been
victims. Nothing short of the abolition of restraint of every
kind in insanity could prevent the recurrence from time to time
of outcries of that sort. And that isa freedom which the most
thoroughgoing advocate of the liberty of the subject would not
claim for them. In the interests of society antisocial beings
must be so guarded as to prevent them from doing serious harm
to others who may be brought in contact with them or may be
dependent upon them, In their cwn true interests, too, as well
as in the interests of their families and of society, it would seem
right that morbid varieties of the race should be brought back,
if possible, to healthy minds. They are placed in confinement
therefore not only because they are dangerous to themselves or
to others, but in order that they may have the medical treatment
which, not recking themselves that they are ill, they will not
seek or will not accept—in fact, as the statutory terms ‘express
it, as “fit and proper persons to be detained under care and
treatment,”

-The grave and anxious question in a particular case is
whether an asylum is necessary or not. The accepted notions
regarding insanity not many years ago were—first, that the
xi] THE TREATMENT OF MENTAL DISORDERS. 525

best means to promote the recovery of a person who was
labouring under it was to send him to an asylum; and,
secondly, that so long as he was insane there was no better
place for him than the asylum. These opinions had been urged
so persistently, and held so long, that they had become a habit
of thought which was deemed by some to have the authority of
a law of nature. Opinion has now, however, changed so much
that the question which first occurs to the mind is whether it
is possible to treat the patient successfully out of an asylum.
The decision as to what should be done is often most difficult,
since social, pecuniary, and legal considerations come in to
complicate the medical question, and most medical men would
willingly be rid of the responsibility which it entails. At one
time, perhaps, they find the friends absolutely refuse to adopt
asylum-treatment when, in their judgment, it is desirable or
urgently necessary ; at another time they find them urgent to
have the patient removed to an asylum, and as eager, if he
leaves it with bitter feelings of resentment after his recovery, to
disclaim all responsibility for what was done, and to throw the
blame of it on the medical adviser. A prudent man, having
eased his conscience by the candid expression of his opinion,
will scrupulously avoid officious pressure, and decline all respon-
sibility which is not a just part of his medical function. In a
great many cases the question is settled at once by the pecu-
niary means of the person: if it is necessary to remove him
from home, he must go to an asylum, because he cannot afford
the heavy cost of treatment in a private house. The expenses
of a suitable house or lodgings, of skilled attendance, and of
medical treatment, amount to a sum which those only who are
well off pecuniarily would be justified in incurring for the
lenoth of time that might be necessary; and these may be
obtained in an asylum at one-third the cost of providing them
specially for himself. Then again some cases are manifestly
unsuited for private treatment. If the patient is in a state of
furious mania, if he is desperately suicidal, or dangerous to
others by reason of delusions which are likely to lead him into
acts of violence, if he persistently refuses food and requires to
be fed by force, if he is impatient of restraint and violently
526 PATHOLOGY OF MIND. [cHaP.

rebels against it or shows a persistent resolve to elude it, an
asylum is the fittest place for him. When the mental derange-
ment is caused by epilepsy, the sullen suspicions and blind fury
which are common features of the disease render it unsafe to
keep the patient at home. On the other hand, it is not well to
send a young person who is suffering from mental disorder which
is of a hysterical character, or occurs in connection with puberty,
or is the result of self-abuse, to an asylum; he is likely to be
injured by the surroundings and to sink to their level.

In choosing an asylum it will be a question for those who
are able to pay for suitable care whether it should be a public
or a private asylum. Many persons entertain an easily occurring
and deeply rooted suspicion that it is not the interest of a pro-
prietor of a private asylum to cure his patients, and that, there-
fore, he will not adopt the best measures to cure them. But

that is obviously a kind of suspicion which might reach very ....

far indeed: it might be suspected that it is not the interest of
any medical man to cure his patient quickly; not the interest
of a lawyer to expedite his client’s business ; not the interest. of
any one to do with good speed what will bring him a greater
immediate profit if he makes it a long business. The asylum-
proprietor, like other people, will find his true interest in the
long run to be in doing best the service which he professes to
do. Itis a better founded objection to private lunatic asylums
that it is not right that a private speculator should have 'the
power which he has to detain in confinement persons who are
deprived of their liberty against their wills, albeit for their
good. The principle of the objection is:‘thoroughly sound and
cannot be gainsaid, but the answer to the particular objection is
that practically the proprietor has not anything like the power
which those who make it think he has. The stringent legis-
lative enactments under which he conducts his business, the
numerous official returns which he is compelled to make, the
minute regulations which he must submit to on pain of losing
his licence, and the jealous inspection from time to time of his
house by the Commissioners in Lunacy and by the magistrates,
to whom each patient has the right and the opportunity to
appeal, reduces an authority which looks despotic to a mockery
XL] THE TREATMENT OF MENTAL DISORDERS. 527

of power that is essentially more like slavery. He is rather in
the position of a person who has unlimited responsibility with
very limited power.

The force of these objections put aside, it may be admitted
that a sensible advantage accrues from the strong personal
interest which the proprietor of an asylum has in its good
management and success: when his livelihood or his profit
depends upon the reputation which it has he is not likely to
neglect it. His business is to please his patrons, and if he
fails to do that his establishment will suffer. A well-managed
private asylum is sometimes a more comfortable residence
than a public asylum for the same reason that a well-conducted
proprietary hotel is more comfortable than a large joint-stock
hotel conducted by a paid manager—that is because of the
strong personal interest which the proprietor has init. In
a public asylum everything depends upon the character, the
zeal, and the skill of the superintendent. If he has the requisite
qualities for his post, if he has genuine interest in his work
and is content to devote himself to it with single-minded
energy, and if he is well supported by a body of intelligent
governors, then there will be good management and efficient
treatment; but if he is indifferent or negligent, or has other
interests to engage him, or is not well qualified by character
and attainments for his onerous and anxious post, or is not in
harmony with his governing body, then abuses soon creep in;
and they cause a vast amount of suffering in a large establish-
ment before they grow to such a pitch as to attract proper
notice from a body of governors who, having only a corporate
responsibility, have only a corporate anxiety, and know little
about the real working of the establishment. A public asylum
must have fallen into a very bad state of disorder before a super-
intendent is actually dismissed for incompetence, and during the
course of its decline, while servants are negligent and needful
supervision wanting where it should be present at every turn,
the patients may suffer much neglect and ill treatment.

The discipline of a large asylum certainly counts for a great
deal in some cases, but it has this great disadvantage—that the
patient’s individuality is little thought of; he becomes one of a
528 PATHOLOGY OF MIND. (crap.

crowd, the majority of whom are not expected to recover, and
his moral treatment is little more than the routine of the esta-
blishment and the despotism of an attendant. In pursuing a
proper individual treatment of insanity it is necessary to pene-
trate the individual character, in order to influence it benefici-
ally by moral means, and to investigate carefully the concurrence
of conditions which have issued in disease, in order to obviate
them. But in a large asylum containing two or three hundred
patients or more, where there are two medical men who go
round the establishment once or twice a day, inspecting the
patients generally as they inspect the baths and the beds.and
exchanging a few words with one and another of them, they are
not so many individuals, each having a particular character and
a particular bodily disposition with which the medical officer is
intimately acquainted, but so many residents who might almost
be called, as the residents in a large hotel are, by numbers
instead of names. For this reason it is sometimes the best
treatment to remove a patient from an asylum to the care of
some private person who will dévote himself to’ his care with
a strong personal interest; he may then recover, perhaps, not-
withstanding that there seemed no likelihood of his recovery
in the asylum.

One advantage, however, a public asylum has, which is un-
doubtedly a very great one: it is that the patient cannot assert,
nor his friends suspect, that the authorities have a pecuniary
interest in detaining him. That puts him at once in a frame
of mind more favourable to treatment, and gives the phy-
siclan a vantage ground of independence which the pro-
prietor of the private asylum cannot have. Moreover, the
feeling extends through the whole ‘of the establishment and
affects its general tone; attendants experience it and are not
so much tempted to intrigue with the patient or meddlesome
friends against the wishes of its head, or—what is a greater
danger in private ‘asylums—conspire with the proprietor to con-
ceal any wrong-dving, and to hoodwink the friends of patients
and the inspecting authorities. Some patients certainly are
influenced beneficially by the spirit of a public asylum and
conform to its rules who would resent bitterly or actively rebel
XL] THE TREATMENT OF MENTAL DISORDERS. 529

against the orders of a private proprietor, whom they considered
to keep them. in confinement for their own profit. No one
who knows the difference between the tone of feeling in a
public and in a private school will have any difficulty in appre-
ciating what I mean.

The consequences of the difficult and harassing position which
the proprietor of a private asylum occupies are not beneficial to
his character: the suspicions to which he is liable from his
patients and their friends, the jealous inspection to which he is
subject, the rooted popular distrust of his functions, the dreary
aud thankless nature of his duties, and the ever urgent sense of
responsibility without a corresponding sense of power, have a
demoralising effect upon him; and he runs no small danger of
sinking into a state of mind in which his sole aim is to make
large profits, looking to them as the one compensation for all
the humiliations and anxieties which he has to undergo. When
the treatment of an insane person is thus considered merely as
an object of commercial profit, it is clear that matters are very
wrong arid that grave evils must ensue. Moreover, medical men
of the best type will certainly not be found to take or to keep
such a position: a fact which goes far to be a practical condem-
nation of private asylums, seeing that wheré the dangers of the
position are such as to require the highest qualities of mind,
these will never be obtained.

It is hopeless to expect such perfection of arrangements
either in public or private asylums as will get rid of all com-
plaints, since mental disease is so exceptional in the trouble and
anxiety which it occasions, in the danger which it sometimes
involves, and in the conditions of treatment which it requires;
but one may probably look forward to an extension of the
system of public asylums and to a contraction of the system of
private asylums according as social feeling with respect to it
becomes healthier. The entire abolition of the latter by legisla-
tion would not be a wise measure now, nor perhaps at any time.
Certainly it will not put an end to recurring outbursts of clamour
in newspapers, since these have been louder in America,
where the public asylum system is in vogue, than in this
country. There will always be some patients moreover who are
530 . PATHOLOGY OF MIND. (cuar,

extremely ill fitted to face the life of a public asylum, and upon
whom the associations and the system would have an injurious
effect ; and great abuses would be sure to ensue if there were no
way of placing any recent cases of mental disorder under proper
care and treatment except by sending the sufferer at once into
a public asylum, or placing him, as a single patient, in a private
house under the care of attendants and unskilled supervisors.
Meanwhile, in making choice of an asylum in the present state
of things, the two principal considerations to be had in mind and
duly weighed are—first, the character of the patient and the
form which his malady takes; and secondly, the reputation
and character of the asylum. It would be foolish to carry a
prejudice for or against a particular system so far as to reject
what was the best measure in the particular circumstances. If
the friends of a patient have known some one who has been
treated kindly and successfully in a particular private asylum,
they will do well to act upon that recommendation ; if they
have a particular public asylum strongly recommended to them
by some one who is qualified to speak confidently, then they
will do well to be ‘guided by the experienced advice.

When it is not actually necessary to send the patient to an
asylum, it is still often necessary to remove him from his own
home, where he has been accustomed to exercise authority and
to exact attention, and where, in his much changed state, there
are necessarily ever-recurring occasions of irritation and con-
tention. It is impossible to allow a madman to do everything
he wishes, by yielding submission to all his changing fancies,
delusive projects, and perverted feelings, and the least opposi-
tion from those whose compliance he looks for as a matter of
course, is likely to produce an outbreak of excitement. If he
is melancholic, and mistrusts those whom he most loved when
he was himself, or grieves that he has lost all his affection for
them, their presence is a constant irritation of his mental sore ;
if he exacts their sympathy by continually talking about his
sufferings, and they yield it in full measure, his disease is
really fostered thereby ; if he has delusions that he is ruined,
he is driven frantic by the sight of the necessary expenditure.
An entire change of surrowndings will sometimes of itself
x1] THE TREATMENT OF MENTAL DISORDERS. 551

initiate recovery; it takes him from the midst of the cir-
cumstances in which his derangement has been developed and
gets rid of a thousand occasions of irritation and of aggrava-
tion. elatives endowed with a similar neurotic temperament
usually constitute the worst surroundings. If the separation
from them and the experience of his new surroundings pro-
duces a mental shock and is a real grief, that will be no great
harm; it is better that he should sorrow with a real cause
of sorrow than brood continually over an imaginary grief;
and his genuine affliction may haply become the initiation
‘of another than the train of fixed morbid thought. It is com-
mon enough to hear the friends of a person whose mind is
showing plain signs of disorder declare earnestly that they are
sure it would drive him quite mad, so sensitive as he is, to send
him from home and to place him under the control of strangers,
and that they cannot consent to it. They are mistaken for the
most part; and the result of their over-anxious apprehensions
and their reluctance to do what is right, but painful to their
feelings, is to let pass the important opportunity of proper treat-
ment at that early period of the disease when there is always
the best hope, and sometimes the only hope, of effecting a cure.
It is not in the least an exaggeration to say that many insane
persons have owed their life-long affliction to the jealous
sympathies, without knowledge, of those to whom they were
most dear.

Travelling from place to place with a suitable companion and
attendant may be justly reconimended in the early stages of
melancholic derangement, but not at the beginning of an attack
of acute mania. Moreover, the travelling should certainly not
be out of the country at the outset of any form of decided
mental derangement ; for until the physician can form a fore-
cast of the course which the disease is likely to take—can
satisfy himself, at any rate, that it is not likely to become acute
—he should not permit the patient to go out of reach of the
measures that may be required urgently for his safety or his
proper care. Great and grievous mistakes are sometimes made
in this respect by those who ought to know better than advise
2 person to be sent abroad to travel who is sickening for an
532 PATHOLOGY OF MIND. [cHar.

acute attack of insanity, or who, not knowing better, ought
certainly to know better than advise at all concerning what they
do not understand. The results of such ignorant mistakes are
sometimes calamitous—an attack of acute mania perhaps in a
foreign city, where those in charge, ignorant of the laws, cus-
toms, and perhaps language of the country, know not what to
do or where to turn for help, and are put to the greatest straits
and to the most cruel anxieties; or perhaps an act of suicide on
the Alps, which appears in the newspapers as an accidental death
from a perilous attempt to gather the Alpine flower edelweiss,
When an attack of acute insanity has passed off and the mental
atmosphere does not clear, but there remains some disorder of
feeling and thought which raises an apprehension that the
disease will become chronic, then an opportune change of scene
may be of vital importance and make all the difference between
a final recovery and permanent illness. This is the critical time
when removal from an asylum is sometimes the salvation of
reason. Nay, removal only from one asylum to another, when
the patient makes no progress, but appears to be sinking into a
chronic groove, has sometimes a singularly beneficial effect. It
is not af course necessary that the person who leaves an asylum
be sent abroad; he may go to the seaside, or take a walking
tour through Scotland or Wales, or tramp from the Land’s End
to Edinburgh and back. Should his means allow it he may go
with a suitable companion and efficient attendant to Norway,
or to America, or even make a voyage to Australia. I have
seen good results from all these measures in different instances.
Where the patient is not fit to go to Australia in a passenger-
ship, or it is not desirable for other reasons he should do so, I
have sent him, accompanied by a medical man and an attendant,
in a sailing barque which took no other passengers. Although
there is no accommodation for passengers in such a vessel, good
arrangements may be made by appropriating the captain’s cabin,
which he will give up for a suitable consideration.

There are some cases of commencing mental derangement
which do well by being sent toa hydropathic establishment ;
for they get thus entire change of scene, rest from work which
they are unfit to do, some kind of society, regulated diet and
KL] THE TREATMENT OF MENTAL DISORDERS. 533

exercise under medical supervision, and, if needful, the benefit or
the distraction of going through a series of baths daily. Others
who are too unwell for that treatment may be sent to reside in
the houses of medical men, many of whom now in different
parts of the country are willing to receive single patients into
their houses ; there, however, they must be properly certified
as persons of unsound mind, and all the statutory regulations
concerning them strictly complied with, since it is an offence
against the lunacy laws for any one to take charge of an insane
person for profit without complying with those regulations. Care
must be used in the selection of a proper dwelling, since there
are unfortunately not a few persons anxious to have a resident
patient whose minds are more set upon the payment which they
desire to get than upon the responsibility which they incur to give
habitual attention to their charge and to endure patiently the
burden or the annoyance which he is apt to be to the family.
Tf he is banished to a room of his own and left all day to the
company of an attendant, he would be better off in a well-
conducted asylum. It is indeed a great difficulty to ensure
suitable provision and skilful treatment in a private house, and
the physician is sometimes driven in despair of having things
‘done properly to recommend the patient’s removal to an asylum,
when it would not have been necessary otherwise. With the
proper persons about the patient there is hardly a case of
insanity which might not be treated successfully in a private
house ; with unfit persons about him the simplest case becomes
worse and worse. An asylum is proper if the malady is of such a
character as to render it difficult to let him go out into the streets
and roads and so have the regular exercise which ought to be
enforced. There are some patients again who do not do well in
ptivate houses because they make themselves too much felt, and
themselves feel that they are the main object of concern in all
the arrangements; their perverted morbid feelings experience
gratification—unconsciously to themselves—in the commotion
which they raise, and are fostered thereby, and they wilfully
display caprices that gratify their morbid self-feeling rather
than desire or attempt to restrain them; they are likely to do
far better in an asylum where they are units in a number
534 PATHOLOGY OF MIND. (omar.

and parts of a system, where their morbid moods and: perverse
doings excite not much notice nor any alarm, and where they
feel the steadily pressing discipline of the establishment as a re-
straint which there is neither gain nor gratification in rebelling
against, as there is against the control of individuals.

The practice which was so common at one time of placing
insane patients in cottages under the control of attendants is to
be condemned except as a temporary expedient: persons of the
class of attendants in the charge of a patient should be under
the supervision of some one of higher social position who may
also be a fit companion for him, Some asylum- keepers, quick:
to make profit out of the weaknesses of the friends of patients
who evince a natural anxiety to avoid the stigma of an asylum,
take cottages in the neighbourhood of their asylum or on the
edge of its grounds, and persuade the friends that the patient
will have in one of them the advantage of their constant super-
vision without being in the asylum. The truth is in such cases
that the proprietor sees the patient once or ‘twice a-day at times
when the attendants know well to expect the visit, and that for
the rest of the day he may be grossly neglected or ill used, or if
not ill used actually, he is left to an enforced and unfit associa-
tion with vulgar-minded persons who talk for the most part of ;
betting, horse-racing, their low debaucheries, and the like, and
who in the worst cases convert the place into a brothel. No
friends should consent to have their relative placed in a cottage
of this sort who is not so well as to be able to take care of and
amuse himself, unless there is a lady or gentleman living in the
house whose duty it is to superintend the attendants and to
associate with the patient. And it would not be amiss if the
Commissioners in Lunacy were to bestow some pains to inquire
closely into the particulars of the actual life from morning to
night of the patient who is placed in a cottage of this kind and,
if need be, to make strong representations to the friends, who:
are perhaps being grossly duped by the advantage taken of an
amiable sentiment.

It is unquestionably of the first importance that early treat-
ment should be adopted in any case of insanity, as the pro-
bability of recovery is immensely increased thereby. The
x1] THE TREATMENT OF MENTAL DISORDERS. 535

statistics of all asylums are at one in proving that the more
recent the outbreak the better is the chance of recovery; the
expectation whereof indeed is about four to one when efficient
treatment has been put in force within three months from the
commencement of the disease, but hardly as much as one to
four when it has lasted twelve months. Were the first obscure
threatenings of mental disease duly appreciated and right action
promptly taken, there is reason to think that many cascs might
be cut short at the outset; but the difficulty is to bring the
patient and his friends to recognise the gravity of the crisis, or,
if they are brought to see it, to induce him to submit to what is
necessary. The consequence is that the disease goes on until
the habit of a definite morbid action is fixed in the mental
organisation, which cannot then be eradicated quickly by
vigorous and energetic measures of any kind, but must be
undermined slowly by a patient course of systematic treatment.
And this also should be borne in mind, in order to check feel-
ings of undue impatience, that the natural duration of mental
disease is much longer than that of most other diseases: where
in them time is counted by hours and days, it must be counted
in it by weeks and months.

Furthermore it must be confessed that recovery after mental
disease is not worth so much as recovery after some other diseases,
since there is considerable risk of arelapse at some time or other.
On this subject we can have no more weighty authority than the
late Dr. Thurnam, who came to the broad conclusion that while a
proportion of 40 per cent. of recoveries, calculated on the yearly
admissions into asylums, was to be regarded as low, and a pro-
portion exceeding 45 per cent. as high, the liability to a recurrence
of the disease after recovery from a first attack could not be esti-
mated at less than 50 per cent., or as one in two cases discharged
recovered. Onthe whole then it may be said that of ten persons
who fall insane five recover, and five die sooner or later without
recovering. Of the five who recover not more than two remain
well for the rest of their lives ; the others have subsequent attacks,
after long intervals of sanity it may be, during which at least
two of them die. The apprehension then which is commonly
shown of persons who have once been insane, as if they might
536 PATHOLOGY OF MIND. [cHaP.

at any moment relapse into their malady, is in some measure
just. In the first place, the susceptibilities and peculiarities of
character which issued in the first attack remain the same—
the personality is unchanged; and, in the second place, there is
in addition the acquired aptitude which has been left behind by
the previous derangement.

When putting in force measures to place an insane person
under restraint it is desirable to avoid practising deception, if it
be possible : what is done should be done openly, and explained
and enforced as necessary and unavoidable. Itis certainly most
objectionable to entrap him into an asylum on some’ pretext
which he discovers to be false so soon as he gets there ; but it is
still worse to employ fraud to get the medical certificates, as
asylum-keepers often did in times past and some do still, and
then to leave him to be removed to the asylum by attendants
without ever explaining to him what his position is and what is
to be done with him. Insane persons frequently turn out to be
much more amenable to reason than might be expected when
they are approached openly and dealt with frankly and in a
straightforward manner. But when they are grossly deceived
the natural suspicion of the disease is strengthened; they
cannot have that confidence in those who have been parties to
the fraud which they ought to have if a good moral influence is
to be exercised upon them, and they are likely to cherish a bitter
feeling of resentment afterwards.

Suitable conditions of treatment having been arranged, the
aim must be to turn the patient from the absorption of his
self-brooding or his self-exaltation to wholesome relations with
matters outside himself—to engage him by degrees in some work
or interest, it matters not however trivial at first, which shall
take his attention from his morbid self. If he is induced to do
like other people, he will be helped in the best way to feel and
think like them. The great principle to be acted upon in order
to recover from insanity is that which should be acted upon by
a person in order to prevent himself from becoming insane—
namely, not to distinguish himself from other persons as in any
respect extraordinary nor to dissociate himself from their in-
terests and doings. Now it is really more easy for an insane
x1.] TUE TREATMENT OF MENTAL DISORDERS. 537

person to do some simple work or to foster some simple interest
when the surroundings have been entirely changed than when
he is solicited to do so in the midst of the surroundings and
interests of his former life, since it seems to him almost a
mockery to press him to do trifles when he is in face of real
duties to which he is unequal, and when perhaps a great part of
his avowed distress is because he cannot perform them. The
success of attempts to engage his attention on matters outside
himself will depend greatly upon the knowledge, tact, and
patience of those who make them. Good and kindly feeling
and natural tact require to be supplemented by some special
experience. Those who in an eager anxiety to encourage the
patient make much of his initiatory and perhaps half-ashamed
attempts and call attention to them ostentatiously, instead of
accepting them tacitly and making them the steps of a further
advance, drive him back into his morbid self and cause him to
abandon them. If it can be brought about, steady employment
will do more than anything else to promote recovery: for the
insane, as for the sane, action is the best cure of suffering. The
natural apprehensions of harm to the patient from the depress-
ing influences of association in an asylum with other persons
similarly afflicted are generally exaggerated; in his changed
state he will more easily begin to do something among those
whose condition he recognises as no better or as worse than his
own than among those whom he has, been accustomed to
meet when he was so different from what he now feels himself to
be. When he can be brought to take some intelligent notice of
them, if it be only to combat the opinions of another patient,
and to think less of himself, he has made the first step towards
recovery. Strange as it may seem, insane surroundings are
sometimes a positive relief and benefit to the deranged mind.
When there is a fixed delusion in the mind it is not of the
least use to argue against it, for it will not be uprooted by the
most logical reasoning ; on the contrary, it will be likely to hold
the firmer the more it is directly combatted. By engaging the
mind in other thoughts as much as possible, and so substituting
a healthy energy for the morbid energy, the force of the delusion
will abate by degrees and finally die out. Besides, by denying
538 PATHOLOGY OF MIND. [cHap.

bluntly the reality of what seems so very real to the patient, one
hurts his self-love and angers him, and he loses that confidence in
one’s good feeling which it is most important he should have.
For this reason also it is a mistake to treat his delusions with
contemptuous ridicule. But, although it is vain to argue
against a delusion, it is proper to avoid assent to it: by a calm
expression of dissent, or by a quiet show of incredulity, or by
a little good-tempered banter, the patient should be left under
no mistake as to the opinion which other people have of it. A
word of contradiction in season will sometimes have a good
effect of shaking his confidence in his delusion, or at any rate of
making him ashamed to talk of it, which is the first step to-
wards feeling a doubt of it. Baillarger tells a story which
shows well how little force proof has against an insane delusion.
When M. Trélat was intrusted provisionally with the manage-
ment of the Bicétre, he had under his charge a patient who
believed that he had discovered perpetual motion. After
having argued vainly against the delusion, the idea occurred to
Trélat that perhaps the great authority of Arago would have
the good effect of convincing the patient of his error. Arago,
after having had the assurance given him that insanity was not
a contagious malady, consented to combat the delusion of the
lunatic, who was accordingly introduced into his study when
Humboldt happened to be paying him a visit. Hardly had the
patient heard from Arago the firm and convincing disproof of
his error than he was confounded and shed tears, deploring the
loss of his illusion. The desired end seemed to be attained, but
they had not gone more than twenty paces from the observatory
on their return when the patient, addressing Trélat, said, “It is
all one; M. Arago deceives himself; I am in the right.” It is
common enough for the friends of an insane patient who labours
under the delusion that he is doomed to eternal damnation to
employ the services of a clergyman in order to dissipate it by
argument, and in one case which came under my care the aid
of an eminent bishop had been invoked in vain. Those who
fondly hope to overthrow an insane delusion by argument would
do well to consider how little the most illogical convictions of
sane persons are touched by the plainest demonstration of theiy
XL] THE TREATMENT OF MENTAL DISORDERS. 539

unsoundness, and how easy some of them find it to hold
contentedly side by side in their minds two logically
incompatible opinions. They do not sincerely believe that
Jonah was swallowed by a whale and lived three days and
nights in its inside, but they would be dreadfully shocked if
they were charged with doubting the truth of the miracle.
They admit, when pressed with quiet argument, that the leaders
of their political party have done everything which they should
not have done and left undone everything which they should
have done in a great crisis, and at the same time when they get
amongst their kind they shout and yell in sincere and exulting
admiration of the profound statesmanship shown on that and
- all occasions by these same leaders.

Beliefs rest for the most part on foundations which arguments
cannot reach—on feelings, habits, prejudices, the bias of interests
and of wishes and of fears, and they change without reason
when the substratum of feeling in which they are rooted
changes. All history shows that revolutions of popular belief
have not taken place gradually in consequence of the assaults of
reason, but suddenly from no immediate help of reason, in con-
sequence of a certain change of sentiment that has been insen-
sibly brought about: the multitude which is shouting acclam-
mations at its hero one day is howling execrations at him on
another day, and could give no intelligent reason either for its
adoration or its hatred, or for the change from the one to the
other. The effect of mental infection, when enthusiasm is
inflamed, is to cause multitudes to think and howl together, as
jackals hunt, in packs. It is as with the spread of a conflagra-
tion; the heat of the burning part raises the adjacent parts to
a temperature at which they easily catch fire, and so one earnest
fool makes many fools.

The way to get rid of an insane delusion is to change the
feeling in which it is rooted—to disarm his suspicion if the
patient is suspicious, to raise his spirits if he is depressed, to
appease his anger if he is offended, to abate his conceit if he is
proudly exalted ; in that way the particular delusion is deprived
of the sap which nourishes it. It is of the greatest importance,
therefore, to have about him persons whose dispositions and
540 PATHOLOGY OF MIND. [cHap.

dealings with him are adapted to attract his confidence, and to
avoid the irritation, the collisions, and the aggravation of the
disease which are produced by uncongenial attendance. <A
female nurse will sometimes do more with a male patient than
the best male attendant; he will not resist her violently as
he would a man, and will perhaps yield to her persuasion more
readily and with less feeling of humiliation. Certainly a good
deal more use might be discreetly made of women as nurses
of male insane patients than is done at present. As regards
attendants generally it is certain that a patient will sometimes
begin to improve immediately under the care of one person when
he or she has been getting worse and worse under the care of
another. Here, indeed, lies the real difficulty in the treat-
ment of insanity—namely, to obtain as attendants persons
who are fitted for so anxious, trying, and responsible an
employment. It is nota question of money only, for money
cannot buy the gentleness, the firmness, the patience under
infinite irritation, the willingness to do without sign of re-
luctance or disgust the most disagreeable offices, the self-re-
straint that is almost more than human, which are the ideal
qualities of a good attendant. The easy recommendation to
obtain for the work the services of persons of a superior class
to that from which attendants are usually procured, by making
higher payments, is liable to the objection that superior persons
who have not failed in more congenial positions from faults of
character will not undertake the anxious, dreary, and disagree-
able work. Stillit is probable that great improvement might
be made in the management of asylums by appointing several
persons of a higher class as superintendents over the ordinary
attendants, whose duty it would be to live amongst the patients
as attendants do. Meanwhile there is clearly a great work for
brethren of the cross and sisters of mercy who wish to live lives
of the most self-sacrificing devotion. If there be a danger of
these people showing an indiscreet religious zeal and doing harm
thereby, let those who are fired by the enthusiasm of humanity
institute a brotherhood of humanity which shall show to the
world of what self-sacrifice men are capable who are inspired only
by a simple love of their kind and a desire to do it good. They
XL] THE TREATMENT OF MENTAL DISORDERS. 541

may expect to do more in that practical way to propagate the
religion of humanity which they profess than by any number
of meetings together to worship the Great Being of Humanity,
or by multitudes of impassioned articles in magazines,

Medical Treatinent.

The special medical treatment of mental disease lies within a
small compass. No physic in the world can touch an insane
vanity or suspicion, or pluck from the memory a rooted sorrow,
or raze out the written troubles of the brain. If that is to be
done, it must be done by the gradual operation of sound moral
hygiene and the healing effects of time. We must be content
to recognise the fact that in a great many cases it will not be
done ; and that we may do without feeling that medical art is
thereby reproached with a culpable incompetence. There are
some persons who have been begotten and conccived in an
insane spirit, bred in an insane moral atmosphere, and have
thought, felt, and acted in an insane way all their lives; these
people will remain lunatics as long as they live, will die
lunatics, and, unless they have been made new creatures mean-
while, will rise lunatic spirits at the day of judgment.

In determining what medical treatment to use in a particular
case the important thing is to look to the general bodily con-
dition of the patient, and to treat that, if it needs treatment—
to do in fact exactly what would be done were there no mental
malady. If the person be gross and overfed, the physician must
prescribe active exercise and moderate and clean living; if he
be of a gouty diathesis, he must attack the latent gout; if
epileptic, the epilepsy ; if phthisical, the phthisis; if syphilitic,
the syphilis; if aneemic, the iron-wanting blood. There will
be a better hope of doing good to the mental disorder when he
can lay hold of some positive constitutional disorder to work
upon, than when he finds no fault in the bodily health. Let
him first take heed then to the removal of those bodily con-
ditions which appear to have acted as causes, partial or entire,
’ of the mental derangement, and to the general improvement of
nutrition, That being his first duty, it is plain that no one is
542 PATHOLOGY OF MIND. (cHaP.

fitted to practise as a specialist in mental diseases who has not
a sound knowledge of disease generally.

It will be proper next to inquire closely concerhing any mor-
bid sensations which may be felt in one part or another of the
body ; eftentimes these spring from some real bodily disorder
and help to sustain the delusion or other derangement of mind;
wherefore the removal of their cause may do good to the mind,
Bodily disease is not easily detected, and is apt to be overlooked
in the insane, since they, like animals, make no complaint in
many instances, and the usual symptoms are masked by the
mental malady; wherefore it is necessary to pay particular
attention to all physical signs of disease. Phthisis, for example,
will probably be discovered in that way only, since there may be
no cough, no expectoration, even when it is far advanced ; and
there is no doubt that many cases of unrecognised phthisis are
received into asylums. If we bear well in mind the various
modes of the pathological causation of insanity which were pre-
viously set forth, we shall perceive the necessity of making a
careful and exact examination of the entire bodily functions in
every case, aud of applying our medical measures to put right
what is wrong in them. To go through an examination of the
possible bodily derangements would be to recapitulate what has
been already said.

Going on then to the discussion of particular means of treat-
ment, I shall say a few words about general blood-letting, which
was at one time a fashionable measure in the treatment of
mental as of other disease. It is not used now even in the
most acute and seemingly sthenic forms of insanity. The con-
viction is that it is not merely useless, but positively pernicious:
convulsion of mind is not strength of mind, and is not to be
radically benefited by draining off the life that is in the blood;
for although violent symptoms may be lessened temporarily by
blood-letting, they soon return and call as loudly again for
blood-letting, and with each loss of blood the risk is increased
of the disease becoming chronic and ending in permanent de-
mentia. A local abstraction of blood by means of leeches to
the temples or of cupping on the back of the neck is not open
to the same objection ; it should not be done, if it is done, with
x1] THE TREATMENT OF MENTAL DISORDERS. “643

the object of abating the excitement by lowering: the general
strength, but in order to withdraw blood from the overfull
vessels, and of so yielding relief and rest to the suffering nerve-
element. ° If that can be accomplished one may consider that
it is to follow in the path of nature, which lessens the quantity
of the blood in the brain during sleep. Practically, however,
local blood-letting in insanity is but little more used nowadays
than general blood-letting.

Baths of different kinds have been more largely used abroad
in the treatment of insanity than in this country, where, on the
whole, their value is not sufficiently appreciated. A prolonged
warm bath will sometimes do more to allay excitement and to
procure beneficial sleep in acute insanity than any narcotic; and
its good effect will be increased by the application of cold to the
head while the patient lies in it, either by means of a douche-
pipe, or by watering the head from a hand shower-bath or a
common garden watering-can, or by sponging the head and face
with cold water. There can be no doubt of the good effects of
a tepid bath to allay cerebral excitement. Our knowledge of
the sympathy of organs has taught us how we can ‘produce
indirectly a change in the state of one organ which is directly
inaccessible to us by producing an appropriate change in another
which is directly accessible to us; and we may operate in this
way upon the brain by means of baths, either to exalt indirectly
its activity, as when we stimulate the peripheral nerves by
cold baths and vigorous friction of the skin, or to lessen iri-
tation of it, by the soothing and relaxing application of tepid
baths to the consensual skin. Such a simple measure as spong-
ing the forehead and face with cold water, especially if it be
accompanied by the soothing words of a congenial attendant,
will sometimes produce an effect which seems out of all propor-
tion to its simplicity. The warm bath may be continued for
half an hour, or even longer, but its effect should be watched ;
and its prolonged use is to be avoided where the pulse is very
feeble and where there is anything like commencing paralysis.
In France it has been used for eight or ten hours at a time, and,
it is said, with good results; and Leidesdorf, of Vienna, has
used for three or four hours at a time, with marked tranquil-

24
544 PATHOLOGY OF MIND. [cnar.

lising effect, a bath, constructed by Hebra, in which patients
can be kept night and day at a definite temperature. The cold.
bath has also been used abroad for long periods at a time.
Professor Albers published the notes of some cases of excited
melancholia, with dirty habits, destructive tendencies, and sleep-
lessness, in which much good was done by a prolonged use of
the cold bath. The patients were placed for one or two hours,
according to circumstances, in water of the temperature of 54°
Fahr.; the effect was to lower the temperature of the body
several degrees, to bring down the pulse until it was scarcely
perceptible, to subdue excitement, and to procure some hours
of sleep when they were afterwards put to bed. This is a
dangerous practice, which cannot be recommended; the risks
of it are out of all proportion to the good which is ever
obtained; and some cases have been recorded in which such a
prolonged use of the cold bath undoubtedly produced the tran-
quillity of death.

The regular use of the cold shower-bath for half a minute or
a minute at a time, with subsequent brisk rubbing of the skin,
is to be commended in the melancholia of youug and vigorous
subjects, in whom reaction takes. place fully afterwards, but it
should be avoided in aged persons and in those who have a
feeble circulation or show any symptoms of paralysis. In acute
mania, where there is a great deal of noisy excitement and
turbulent energy, the shower-bath is sometimes used systemati-
cally with advantage; and in these cases it may be given for
a longer period than in melancholia—that is to say, for one or
two minutes, but never for more than three minutes at a time.
Some writers recommend its employment as decidedly bene-
ficial in cases in which, after the acute symptoms of mental
disease have subsided, the patient seems to be about to lapse
into depression or dementia instead of going on gradually to
recovery. It is a remedy which is always more fitted for use in
young persons than in those who are advancing in age or are
aged.

The Turkish bath has been extravagantly praised by some of
those who have employed it in the treatment of mental disease, »
It is affirmed to be particularly useful in cases of melancholia.
XL] THE TREATMENT OF MENTAL DISURDERS. 545

I am unable to speak of its merits from personal experience,
but can well believe that the occasional but not too frequent
use of it, with its elaborate shampooing of the body, might be
of service in some cases of mania and melancholia in which the
skin is dry and harsh and its secretion disordered.

Packing in the wet sheet after the hydropathic fashion was
strongly recommended, and largely employed, by Dr. Lockhar*
Robertson, formerly superintendent of the Sussex County Asy
lum. Without doubt it is a valuable measure in some cases of
acute excitement. The wet sheet has an indirect soothing action
upon the brain by its direct soothing action upon the skin, so
that the patient goes to sleep in it sometimes when nothing more
is done; moreover, by keeping a restless and excited person
perforce quiet, it assists a sedative draught to take effect which
would have been useless had he been running about the room.
On one occasion I was called in haste to see a young woman
who had been attacked suddenly with acute hysterical mania, to
the great consternation of the household and to the despair of her
medical attendant, who could not induce her to swallow anything.
She had torn her nightdress into shreds, was quite incoherent, and
was tossing about on her bed ceaselessly. She was immediately
packed in the wet sheet, her face bathed with cold water, and a
cloth dipped in cold water applied to the head; when this had been
done she swallowed without difficulty a drachm of the tincture
of henbane, and soon went to sleep. In the morning she was
free from excitement but confused in mind, and ina few days had
quite recovered. On another occasion I was summoned into the
country to see a lady who was labouring under acute puerperal
mania. The excitement had steadily increased for some days,
and she had not slept despite many sedative doses. I found her
in bed, excited and utterly incoherent, with one leg tied to each
bedpost, and with her body also tied down to the bed. Her
lips and tongue were dry, her voice was hoarse with shouting,
and she refused all food and drink which was put to her lips.
She was straightway released from her bonds and packed in
the wet sheet, her face and forehead and mouth being sponged
gently with cold water. After a while a mixture of milk and
soda-water was put to her lips, which she drank rather greedily,
546 PATHOLOGY OF MIND, (crrar.

and then a dose of the tincture of henbane was given. She fell
asleep, began to mend from that time, and in three week+
was restored to health. These examples of exceptionally suc-
zessful results serve to show the value of the wet-pack, for
there is no doubt that the good was done by it and not by the
henbane. Had that drug been given without the patient having
been previously packed and put in the attitude of repose, it
would most probably have been without effect. The wet sheet
should not be used for more than three hours at a time, anil
should be changed at the end of an hour and a half: its true
purpose is medical treatment, not mechanical restraint,
Counter-irritation applied to the shaven scalp or to the back
of the neck was much used formerly, but has now tacitly fallen
out of use. Schroeder van der Kolk, however, had considerable
faith in it, believing that he got good results from the application
of strong tartar emetic ointment or of a blister to the shaven
scalp; and Dr. Bucknill has thought it useful to rub croton oil
into the scalp at the critical stage when acute is passing into
chronic insanity, and also in chronic melancholy with’ delusion.
In one ease I witnessed a remarkable temporary effect follow the
application of a blister to the nape of the neck. A young lady
who had been for several months in a state of melancholic stupor
or of silent dementia, never having spoken a word, woke up from
her stupor the day after the blister had been applied and talked
quite rationally; on the following day, however, she was much
excited, and inclined to be violent, and then subsided again into
her mute stupor. The experiment was repeated on another
occasion with a similar result, save that her exeitement and
violence were much greater than on the first occasion, The
sudden effect in this case might seem to indicate a powerful
therapeutic agent, but I cannot say that I have seen any positive
lasting benefit from the use of blisters or setons in the ‘treat-
ment of mental disease. It is a question, perhaps, whether a
greater effect might not be produced if the counter-irritation
were applied in a stronger and more active fashion than is ever
done in this country. One knows how the convulsions of epi-
lepsy may be inhibited in. even long-standing cases of the
disease by the suppurating effects of severe local injury: a
XL] THE TREATMENT OF MENTAL DISORDERS. 547

completely demented epileptic, who had two or three fits regu-
larly every day, fell on the fire in one of them and burnt the
back of his hand and forearm severely; extensive sloughing
and suppuration followed; while this was going on he never
had a fit, and his mind even grew much brighter; but as soon as
healing of the suppurating surface began the fits came back and
eventually were as strong and frequent as ever. Another epi-
leptic of the same class suffered a rupture of the urethra behind
a Stricture which had been overlooked; in consequence of the
extravasation of urine which took place there was extensive
sloughing of the cellular tissue and skin of the perinaum and
of the lower part of the abdomen; during this time there
were no fits, but they returned when the wounds healed.
Placing these facts side by side with what we know of the
inhibitory effects of certain local and general diseases upon
mental disorder, we may perhaps entertain a hope that in time
to come more may be done than is done in the way of treat-
ment, by the invention of some means of prolonged and active
counter-irritation or inhibition.t

After derangements of digestion and secretion have been duly
attended to and put right, the dzet of the insane should be good
—plain, but abundant. In melancholia and in asthenic mania
the symptoms plainly call for as much nourishment as can be
taken and digested ; and even in so-called sthenic mania, where
there is much noisy excitement and turbulent conduct, there is
enough present strain upon the vital powers, and enough risk of
vital depression after the fury of the storm is overpast, to make
it unwise to withhold liberal nourishment. The good or bad
issue of an attack of the most acute mania will depend some-
times on whether sufficient food has been taken or not during
its course: if it has, the excitement may continue for a long

1 Several cases have been placed on record in which epilepsy following
injury to the head has been ameliorated, or cured—even when complicated
with mental derangement—by trephining the skull at the seat of injury.
When the injury to the head has not caused a fracture of the skull, or even
a wound of the scalp, it has sometimes caused inflammation or thickening
of the bone and epilepsy. In these cases also the removal of the bone by
the trephine has sometimes cured the epilepsy. De la Trépanuation dans

Ll Epilepsie par Traumatismes der Crdne, par le Dr. M. G. Echeverria, 1878.
See also case described at page 227.
548 PATHOLOGY OF MIND. (cmar.

time, and when it is over the patient still recover favourably ;
if not, he may sink from exhaustion in the midst of unabated
excitement, or lapse into dementia when it subsides. It is
necessary to bear in mind, both in acute insanity and in chronic
melancholia, that the digestive powers are likely to be weak-
ened—in the one case by the withdrawal of power from them
by the maniacal expenditure of vital energy, and in the other
by the general depression of the vital energies—and to take care
therefore that the food which is given is suitable, and is given in
such form as is most easy of digestion. There is no wisdom in
giving quantities of solid and ill-cooked food two or three times
a day to a patient who, if he takes it, perhaps swallows it
hurriedly without masticating it properly: it should be given
at more frequent intervals, in smaller quantities, and in the most
nutritious forms. Let the melancholic, for example, have a diet
of this sort—a tumbler full of milk early in the morning, a not
too heavy breakfast in due course, a cup full of beef tea or soup
about eleven o’clock, oysters or a small quantity of meat at
luncheon between one and two in the day, a dinner of not more
than two courses about six o’clock, and a little milk or arrow-
root or beef-tea before going to bed. If he goes to sleep for the
first part of the night and wakes about two or three in the
morning, unable to go to sleep again, as some melancholics do,
a tea-cupful of beef-tea or milk, or a small quantity of other
light nourishment taken then, will often enable him to get some
more sleep.

Stimulants, if necessary, should always be given in modera-
tion. If a patient is taking food well and his pulse is fairly
good they are not necessary at all; but if he has been accus-
tomed to take wine or beer, he may usually take two or three
classes of wine or beer in the day with his meals. The acute
maniac, however, who is taking food well is in most cases better
without any stimulant, and if he wants to drink he can drink
nothing better than a mixture of soda or seltzer water and
milk. In some cases of melancholia and of mania which has
passed its meridian a glass of stout or a little mulled claret
or a little sherry and water just before going to bed is found
very useful. If adequate nourishment be not taken, and if
x1] THE TREATMENT OF MENTAL DISORDERS. 549

the pulse begins to flutter and flag, then stimulants may be
more largely used, their use being regulated by careful observa-
tion of their effects: to “pour in wine and brandy” indiscri-
minately, as is sometimes done, is to my mind no better than the
conduct of the man who, affecting to imitate the example of the
Good Samaritan, poured oil into his enemy’s wounds—but it
was oul of vitriol, A judicious use of wine or other stimulant
when an attack of insanity is threatening will sometimes do a
great deal to help to ward it off: at that period when a person
becomes unduly anxious, irritable, apprehensive, and loses his
sleep night after night under the pressure of family-troubles or
business-worries, he may be much benefited by taking some
stimulant with his food ; but it must be combined with other
measures of relief, for if he relies upon it alone he will be
tempted to increase the quantity taken, and his last state will
be worse than the first.

Active purgation, once so much favoured, is now quite
eschewed, in the treatment of insanity. The ancients used
hellebore largely for the purpose, in order to purge away the
black bile which they supposed to cause the malady; whence
the recommendation to a person whose wits were astray—aviget
Anticyram, that being the place where the hellebore flourished.
Still one finds a much too active inclination in some instances
to make the. bowels act by means of purgatives: doses of
calomel or cathartic pills are given every two or three days to
stimulate the depressed abdominal energies of the melancholic ;
and even the patient who is taking little or no food will run the
risk of getting his purge if his bowels, which have nothing in
them to act upon, do not act. Itis a pity that those who run
in this groove of irrational treatment do not try the effect of a
strong mercurial purge upon themselves from time to time, and
take notice how many days are required after it for the bowels
. to recover from the irritation which they have had and to act
naturally. Active exercise, abundance of suitable food, and
perhaps cod-liver oil are the best means of obtaining a regular
action of the bowels in some cases of melancholia, When a
purgative is needed, as it certainly may be at the commence~-
ment of treatment and from time to time in melancholia, the
550 PATHOLOGY OF MIND. [ouar.

most simple is the least harmful and therefore the best. Two or
three grains of the extract of aloes, combined or not with small
doses of the extracts of belladonna and of nux vomica, or a
compound rhubarb pill, or a little castor oil, will usually answer
the purpose; indeed a moderate dose of the last will often suc-
ceed when stronger purgatives fail, and it has the advantage
that it is not necessary to increase the dose when it has to be
given again. A wine-glassful of the Hungarian aperient water
(Hunyadi Janos) taken the first thing in the morning seldom
fails to operate satisfactorily, and is perhaps the most useful laxa-
tive in melancholia. A tumblerful of simple cold water early
in the morning sometimes answers the purpose. Nothing is said
in medical books of what may be done mechanically by a
person to provoke or assist an action of his bowels; but there
is no doubt that by rubbing and kneading the abdomen and
loins, alternately with three or four blows on them, and by a few
sharp taps over the coccyx, repeated now and then at the time
of the usual action of the bowels, they can, either by direct
shock or in a reflex way, be stimulated to act when they would
not otherwise do so.

I come now to the consideration of the propriety of the free
use of so-called sedatives in insanity. It is a practice which is
almost universal among medical men, when they have to do
with a case of mental disease, to prescribe sedatives in order to
subdue excitement and to procure sleep, and the consulting
physician meets in consequence from time to time with disas-
trous effects from the reckless use of large and often-repeated
doses of chloral hydrate. Opinion is yet divided as to the value
of this and other sedatives, and while one physician at the
head of a large asylum denounces them earnestly, another who
has had as large a field of practice cannot speak too well of
them.

Some years ago J took occasion to put the question plainly
whether it was a rational and proper thing to stifle mental ex-
citement by means of sedatives,’ and to suggest that it should
be considered seriously whether the putting the nerve-cells of

1 In a presidential address on Insanity and iis Treatment to the Medico-
Psychological Association. Journal of Mental Science, October, 1871,
xu] THE TREATMENT OF MENTAL DISORDERS. 551

the patient’s brain into chemical restraint, so to speak, did
really benefit them. The answer to this sceptical inquiry, on
the part of the advocates of sedatives, has been more confident,
I think, than well considered. It amounts really to this—that
it must be a benefit to get sleep where there is sleeplessness, and
that it is certainly proper to extinguish a fire which is burning
down a house. But it is not considered, not even suspected
apparently, that natural sleep and narcotic-enforced sleep may
be two different conditions and ought not perhaps to be spoken
of, without more discrimination, by the common name of sleep.
A patient can be made unconscious by chloral hydrate undoubt-
edly, just'as he can by the administration of chloroform, but
what is wanting is the knowledge that in either of these or
similar artificial states the same sort of repair and restoration
of nerve-element takes place which takes place in natural sleep.
Exact information with respect to that point may be set down
as entirely wanting: the chloral-produced state looks like sleep,
and all the rest has been assumed. The second reason, if
reason it'can be called which is an analogical will-o’-the-wisp,
namely, that it is proper to pub out a fire, might be fairly met
by the question whether it is clear that the sedative, albeit it
dulls the flame in the first instance, is not in the end fuel to it.
Does the patient wake up any better from his enforced sleep,
or is he not usually wound up thereby to a greater excite-
ment when he comes out of it? Moreover, is the period of
excitement really shortened in the long run and recovery pro-
moted, or is it lengthened and the lapse into chronic insanity
favoured by the frequent use of the sleep-compelling drug ?
These are the weighty questions which require to be considered
and answered by more numerous and careful observations than
have yet been made,

There is yet another argument in favour of the use of sedatives
which, as it has something of a scientific semblance, it will be
proper to mention. It is based upon our knowledge of the phy-
siological antidotal effect which one poison has to another—
belladonna to opium, for example, chloral hydrate to strychnia
Seeing that a poisonous dose of strychnia, which, given by
itself, would of a certainty quickly kill an animal in tetanic
‘552 PATHOLOGY OF MIND, [cu ar.

convulsions, may be given to it without fatal results wheu a
full dose of chloral hydrate is given at the same time, is it not
probable that chloral hydrate has a like good effect in suppress-
ing the convulsive fury of a deranged mind? Here, again, it
is to be feared that the analogy goes on one foot. Any animal
will recover from a dose of strychnia if it can be kept alive until
the poison is excreted from the body, which begins to happen
soon after it is taken: if the spinal cord, therefore, upon which
the poison acts, can be rendered less sensible to its action while
it is in the body, there is nothing more to be feared when the
poison has been eliminated. But that is not soin mania. The
cases are few, if any, in which we have reason to suppose that
the excitement is owing to the direct action of a poison intro-
duced from without or bred in the body, which the body is
hastening to get rid of by its excretions, and the physiological
action of which the sedative counteracts whilst it is in it. More-
over, such a largely used sedative us opium positively hinders
excretion by its secretion-checking action.

The truth is that the only valid appeal in this matter is to
experience. If that has proved the benefit of sedatives in the
treatment of mania we must accept the fact, although we cannot
yet discover the theory of their action, just as we are compelled
for the present to be content to know that quinine cures ague
without knowing how it cures it. Unhappily experience speaks
with directly contradictory voices: one physician of an asylum,
after full trial of the hydrate of chloral, endorses the description
of it as “ erystallised hell;” another considers it the most useful
drug we have in the treatment of insanity: one physician
declares most confidently that the one form of insanity in which
opium or chloral is unquestionably pernicious is acute delirious
mania; another physician boasts that he has never lost a case
of acute delirious mania since he has freely used chloral hydrate
in the treatment of it. Such are the contradietory voices of
experience. One requires to know the character of the experi-
menter in order to decide which voice to trust; albeit one may
feel pretty sure in a question of the action of a medieal drug,
that he who is least heroic in his use of it, and least confident
in his opinion of its powers, will be most likely, in virtue of his
x1] THE TREATMENT OF MENTAL DISORDERS. 553

mental temperament, to have observed accurately and to have
inferred soundly.

‘Perhaps some confusion and contradiction have been caused by
the failure to keep in mind the different aims with which seda-
tives are used. A large and ordinary use of them in some asylums
is for the purpose of stifling excitement and producing quiet, the
nurses being supplied night after night, and in the day also
sometimes, with draughts of chloral hydrate or of other seda-
tives, to be administered to certain patients who are excited,
noisy, or sleepless. They are used, in fact, as mechanical
restraints have been unwisely used—namely, to keep a tur-
bulent patient quiet. But it does not follow, if they fulfil that
aim, that they at the same time fulfil the aim of promoting
recovery ; on the contrary, it is conceivable that they may have
the quieting effect wished for and yet not really promote recovery.
That may well require another treatment. And yet so little is
this considered that one frequently hears the long-continued
use of some sedative lauded with naive exultation, and with-
out a word being said, or apparently without a thought -being
given, as to whether patients recovered better, or recovered at
all, by taking it. “ Where the methodical use. of morphia
injections is practised,” says an enthusiastic writer in a recent
number of a German periodical, “the restraints and costly
divisions of asylums for violent cases, with their cells, may
be banished.” That is to say, chemical restraint of the cells
of the sick brain may be made to supersede entirely the
mechunical restraint of the body. The successful argument
against mechanical restraint was, that although it kept the
patient’s body quiet, it really aggravated his malady: the
question now which should be considered is, whether chemical
restraint does permanent good, or whether by diminishing
excitement at the ultimate cost of mental power it “makcs
a solitude and calls it peace.”

Undoubtedly the great majority of the inmates of every large
asylum are persons who never will recover, be the medical treat-
ment what it may. Those who drug the troublesome ones into
stupor cannot therefore be justly charged with jeopardising their

1 Dr, Wolf, Archiv fiir Psychiatrie u. Nervenkrankheiten, B, ii. § 601,
554 PATHOLOGY OF MIND. (citar.
recovery; but itis not so clear that they are free from the
charge of practising recklessly a system of treatment which
the experience of the best-conducted asylums proves to be
unnecessary, if not actually pernicious. There cannot be such
differences between asylums as to make invaluable in one what
is baneful in another. Dr. Clouston was at the pains to conduct
a series of researches into the effects of the continued use of
frequent doses of opium upon patients in the Cumberland
Asylum, and he found the result to be—that the opium soon
lost its effect; that all the patients lost weight while taking
it; that their average temperature fell; that the pulse was
lowered; and that in all cases, to use his words, “it inter-
fered with the proper nutrition of the body and pushed it one
step further downhill in the direction of death.” If such
be the effects of opium, what may be expected of the long con-
tinued use of chloral, seeing that it is certainly more injurious
to the nutrition of the body, and particularly of the brain, than
opium? ‘The habitually chloral-dosed patients in an asylum
raay be recognised for the most part, I believe, by their miserable
appearance. Be that as it may, the regular use of chloral, or
any other sedative, in order to produce a stuporous quiet, is
not yet proved to be any more scientific than it would be to
place the patients in suitably constructed chambers and to
render them insensible, as might be done, by supplying the
chambers with a calculated mixture of air and carbonic acid.

As regards the use of sedatives for the purpose of aiding to
bring ahout recovery in acute insanity, my experience is that
while their occasional use may be necessary and beneficial, their
repeated use day after day and night after night is unques-
tionably injurious—promoting death or dementia. And I am
not sure whether they ever produce a beneficial sleep except in
cases in which, with a little patience, sleep would have been
obtained without them, Certainly in any case they should be
looked upon as adjuncts of treatment, not as the backbone of it.
Opium, which was formerly much used, has been ousted from
its place by the hydrate of chloral; nevertheless I believe it to
be a more useful and less dangerous drug. I have found it of
more service when an attack of insanity from moral canses
x1] THE TREATMENT OF MENTAL DISORDERS, 555

seems to threaten than when it has burst out: at the beginning
of the mental depression and apprehension, when the patient is
nervous, depressed, fearful, and cannot sleep, a dose of opium
each night for two or three nights will procure sleep and some-
times do great good; and in other cases small stimulant doses
of morphia two or three times a-day appear to be of real use.
I certainly think that I have seen an imminent attack of insanity
warded off and tranquillity of mind restored by this sort of
treatment. But there are two things to be borne in mind with
regard to opium: first, that there are some persons whom it
does not suit at all, and it is impossible to say, before trying it,
whether it will suit or not; and, secondly, that it is always far
more useful in old than in young persons. In acute mania and
in melancholia agitans, I have never seen the least good, and I
have often seen the greatest harm, done by the frequent use of
opinm. It is possible to get a fitful sleep of an hour or two, in
most cases, if large enough doses be given, but the patient
wakes up more excited and incoherent, and if the medicine be
continued he is far more likely to sink from exhaustion during
the storm,’ or into dementia after it. The important point is to
take care that he gets sufficient food during the paroxysm; but
the effect of the opium is to check his secretions, to lessen: any
appetite he may have for food, and to produce a dry, brown
tongue, which goes before a fatal collapse. If there be any
kidney disease the use of opium is still more prejudicial. It is
always more likely to do good in the forms of sub-acute and
asthenic mania in elderly persons than in any form of acute and
sthenic mania; and it is not of the least use in acute delirious
mania, in recurrent mania, in epileptic mania, and in the attacks
of mania that occur in the course of general paralysis. In any
case in which it is given I should be disposed to lay down the

~practical rule that if one or two full doses do not procure sleep
and manifest relief, its use should not be continued.

The effects of steadily increased doses of opium two or three
times a day have been much praised in melancholia. Certainly
it does not appear ever to do the harm in melancholia which it
does in mania, but it is obvious that a careful discrimination
should be made of the cases in which this free use of it is
556 PATHOLOGY OF MIND. [cHar.

adopted. If there were a gross habit of body with defective
secretion and excretion, or if the melancholia owned a gouty
origin, it would not be a rational treatment, whereas it might
be of service in the melancholia which was produced by poor
nutrition and depressing moral causes, and especially in the
melancholia of advanced age. The wise physician will treat
his patient, not an abstract melancholic entity. My experi-
ence of this heroic opium-treatment does not warrant me to
speak confident'y in its favour; and my preference is for the
use of small and repeated doses of morphia in those cases of
melancholia in asthenic and aged persons in which alone I am
tempted to continue the use of the drug.

The hypodermic injection of morphia may be had recourse to
when there is a refusal to take medicine, and the drug operates
in this way more certainly, quickly, and effectually than when
taken by the mouth. Not more than one-fourth of a grain should
be injected in the first instance, the quantity being increased
afterwards, if necessary. I have not seen more positive good
done by hypodermic injections than when the drug was taken
by the mouth; certainly it will not quench the fury of
acute mania, or of acute melancholia, nor does it seem to be
a desirable practice to commence in chronic insanity; and I
have more than once seen successive injections of morphia,
administered for the purpose of subduing excitement, followed
suddenly by fatal collapse or coma.

Of chloral hydrate, as frequently used, I entertain a bad
opinion, and I much fear that its discovery has been thus far, not
a good, but an evil, to the human race. <A single dose, or an
occasional dose-from time to time, at the commencement or in
the course of mental disorder, as a palliative, may certainly be
useful, but its habitual use is pernicious. This is a case which
is not very uncommon : a person finds himself becoming nervous,
apprehensive, sleepless, and unable to face the cares and re-
sponsibilities of his business; he nerves himself for his work
by taking some stimulant from time to time in the day, and he
evades the horrors of a sleepless night by taking a dose of
chloral when he goes to bed; this practice is continued from

- day to day and week to week with no other effect than to make
x1] THE TREATMENT OF MENTAL DISORDERS. 557

matters gradually worse; and the end perhaps is, if better
counsels prevail not, that he commits suicide or breaks down
into actual insanity. When that which may be used fitly as a
temporary help—whether it be stimulant or narcotic—is resorted
to as an abiding stay, the result cannot fail to be disastrous.
When chloral is given in acute insanity in order to enforce sleep
it succeeds in most cases, if the dose given be large enough, but
I have never observed that the patient was any better for the
sleep so obtained; on the contrary, my experience is that he is
oftentimes more excited and insane when he wakes, and that the
attack in the end lasts longer than when no chloral is given.
The worst cases of insanity which I have seen have been cases
in which large and repeated doses of chloral had been given
for some time. The most violent case of puerperal mania was
one in which forty grains had been given three times a day for
three or four weeks; and in this case the patient began to mend
a few days after the chloral had been entirely stopped, and
eventually recovered. Had it been continued I have not the
least doubt that the lady would have died or become demented.+
On another occasion I was summoned in haste to see a young,
strong, and handsome woman who, suffering from puerperal
mania after the birth of her first child, had been given dose after
dose of chloral for two days in order to subdue excitement and
produce quiet; and certainly it had had its effect, for she was
dying from syncope when I saw her, and died two hours after-
wards. It is one of.three cases in which I have known repeated
large doses of chloral to cause death suddenly by fatal syncope:
a possible danger which should never be lost sight of when large

1 Ag an illustration of the persistence with which chloral is sometimes
given, in spite of evidence of the want of any benefit, and indeed of the
positive harm done by it, I may mention a case of acute hysterical mania
which I was asked to see once. Full doses of chloral had been given
twice a day for weeks, and a larger dose at night. But the excitement had
not been abated in the least, and the mental state was worse ; moreover,
matters had reached the pass that it was impossible to get the young lady
to take it by the mouth. The daily doses had perforce, therefore, been
abandoned, and the nightly dose was administered by the rectum. But as
there was great struggling, and much difficulty in doing it, the patient
was every night rendered insensible by chloroform and the dose then
injected. The treatment was discontinued for a few days but recurred to
afterwards, I believe, and eventually the patient died.
558 PATHOLOGY OF MIND. [cuapP.

doses are freely given. Like opium, its benefits are more mani-
fest, and the harm which it does is less, in melancholia than in
active mania; but here also its use should be occasional rather
than habitual—a help for the time until other and more per-
manent measures of relief can be adopted. Dr. Clouston and
others have spoken favourably of the virtues of chloral, when
given to epileptics, in warding off post-epileptic mania.

In cases of great excitement, maniacal or melancholic, in
which opium and chloral are to be eschewed, full doses of
digitalis will sometimes produce good tranquillising effects.
Digitalis was indeed much esteemed by old writers on insanity,
and has now been restored to favour after having fallen into
disuse for some time. Under its use the excitement may abate,
and the pulse, falling in frequency, may, by repeating the dose,
be kept for some time at a standard below the average. The
effects are certainly excellent as a rule, and marvellous some-
times, in the maniacal outbreaks which take place in the course
of general paralysis. Two cautions seem to be prudent in the
employment of it: first, to begin with a dose of about half a
drachm of the tincture rather than with doses of one drachm or
two drachms, until experience has been obtained of its effects
upon the pulse; and, secondly, not to continue the frequent use
of large doses without carefully watching the effects, Formerly
it was supposed to be a cumulative drug, that is to say, to ac-
cumulate in the system when given in moderate doses until it
suddenly produced dangerous or even fatal effects, and albeit
that opinion of its effects is not now entertained generally,
death has sometimes taken place rather suddenly after repeated
large doses of digitalis. It would certainly appear that although
a patient who has taken large doses may be safe while lying
down, he runs some risk of fatal collapse if he starts up suddenly
or runs about in an excited manner.

Hyoscyamus is a useful sedative in cases of insanity, but it
rnust be given in doses of a drachm or of two drachms of the
tincture. Like digitalis, and also chloral, it acts better when
combined with bromide of potassium than when given alone.
It will oftentimes fail to produce any marked effect, but I have
never seen any ill effect other than loss of appetite and sickness
xi] THE TREATMENT OF MENTAL DISORDERS, 559

from its continued use. Its alkaloid, hyoscyamine, has been
recently employed, having been recommended by Dr. Lawson
after a series of experiments at the West Riding Asylum. It
is a very powerful drug, producing, in small doses of J; or sy of
a grain, similar poisonous symptoms to those which are produced
by unlimited quantities of the tincture of hyoscyamus—namely,
loss of power in the limbs ending in paralysis shown by stag-
gering gait and ultimate inability to stand, mental torpor and
rambling delirium, extreme dryness of the throat rendering
swallowing difficult or impossible, and great dilatation of the
pupils. Twelve hours must elapse before these effects pass
away, and two or three days in some cases before the patient
recovers entirely from the mind-prostrating after-effects. On
account of the great dryness of throat and the loss of appetite
which it produces it cannot safely be given in any form of
asthenic mania, in which it is important that the patient should
not cease to take food; its use must be limited to cases of noisy
and turbulent mania in which there is vigour enough to spare
and no risk of fatal exhaustion from the mental and physical
prostration. But it is not alleged that it promotes recovery in
these cases; all that is claimed for it is that it renders such
patients much quieter. Indeed, they evince oftentimes a
singular dislike and dread of it, being much frightened by the
remembrance of the effects which it produced upon them.
Dr. Savage has tried the alkaloid recently at Bethlehem Hospital
in some cases of violent mania and in a case of melancholia,
and his experience is that it has done no good, but harm. In
one case of mania the treatment was discontinued after two
months as the patient “was becoming alarmingly thin and
sallow in appearance”; in another case it was discontinued in
consequence of the loss of weight and strength which occurred ;
in the case of melancholia the patient “was rendered worse in
body and no whit better in mind.” The instincts of the patients
sometimes rebelled energetically against it: one of them, when
she saw Dr. Savage, used to become violent and call him a
murderer; another was enraged and struck him, calling him
a “poisoner.” In the case of henbane then, as in the case of
other sedatives, we find that, while its occasional use may be of
560 PATHOLOGY OF MIND. [craP.

service, the more heroic the treatment, the greater is the
harm done.

Conium, a drug the action of which is very like that of
hyoscyamus, has been hotly recommended in the form of the
Succus conit. A dose of one drachm or two drachms is to be
given in the first instance, but it may be increased up to as
much as one or two ounces, three times a day, it is said, and be
advantageously combined with bromide of potassium. That it
lessens the excitement of the paroxysms in some cases of
recurrent mania, failing to do so in others, seems to be pretty
certain, but there is not sufficient evidence that it does per-.
manent good to the deranged mind. Dr. Savage found in some
cases a marked tendency to weak-mindedness follow the use of
the drug, and although this might not have been due to it, he
was impressed with the fact that the more he pressed its use
the more marked was the mental weakness. If this were really
so, there would be no cause for surprise: the Datura stra-
monium, which resembles conium and hyoscyamus in its
physiological action, is used largely for poisonous purposes in
India, and it has been observed that some days elapse before
those who have suffered severely from its effects recover their
memories and mental powers completely. Jor my part I do not
doubt that a patient will certainly recover who is taking repeated
large doses of Sueeus conti, if only the vis medicatrix nature be
strong enough to get the better of the disease and of the
drug.

Dr. Clouston has praised highly a mixture of Cannabis indica
and bromide of potassium as a sedative, and he contrasts the
effects of its repeated use with those which follow the use of
opium, much to the disadvantage of the latter. The excitement
was subdued; the medicine did not lose its effect after nine
months’ use; the appetite was not interfered with; the weight
of the patients increased; and the temperature fell. In fact,
the maximum of good effects and the minimum of ill effects
were obtained by him. What one misses, however, in the record
of these experiments is a ratio of recoveries in proportion to the
virtues of the remedy; it is true that eighty per cent. of the
patients were more or less benefited, but only one recovered,
xI.] THE TREATMENT OF MENTAL DISORDERS. 561

A sceptical inquirer might desire to put the question whether
it had been considered how many recoveries were prevented.

I shall say little of other sedatives, because I have nothing to
add to what I have already said in the foregoing pages. Bromide
of potassium is very largely used in all sorts and conditions of
mental and nervous troubles, and there cannot be a doubt of its
value both when given alone and in combination with one or
other of the before mentioned sedatives. But it would certainly
be well to have set forth more plainly than has been done yet
the exact indications for its administration, since, as matters
are at present, a patient gets bromide of potassium if he is
maniacal or melancholic, if he isin good spirits or in low spirits,
if he is sleepless or sleeps too much, if he has acute pains or
distressing numbness in the head—in fact, in whatsoever tribu-
lation of mind or brain he may be. It appears to produce
specially good effects in cases of hysterical insanity, and when-
ever there is evidence of sexual excitement; and it is certainly”
of the greatest service in recent epilepsy. I have not seen any
benefit from its use in recurrent insanity; nor am I tempted to
employ it in old-established epilepsy with mental complications,
since the present suppression of the fits by it seems to be
followed in some instances after a while by an outburst of fits
and fury which is positively appalling. As a simple and harm-
less means of procuring sleep it is of value; and its efficacy for
this end will be found to be increased sometimes by giving it at
bedtime in a glass of beer or porter. Hydrocyanic acid in large
doses, like every other sedative, has had its eager advocates.
I have not used it in heroic doses, but in ordinary full doses it
has appeared to do good in some cases of mania in which there
was evidence of itritation and excitement of abdominal and
pelvic organs ; acting in that case, perhaps, indirectly as a seda-
tive to the brain by a direct sedative action on parts the activity
of which was working prejudicially upon the brain. Tartar
emetic was at one time much used in asylums for the same
purpose as chloral ig used now, namely, to tranquillise noisy,
excited, and troublesome patients, and it has also been employed
inthe medical treatment of acute mania. In the latter case, if
it be given in a large enough dose it will produce the peace of
562 PATHOLOGY OF MIND, [ctaP.

prostration, but the temporary lull of excitement is followed by
a recurrence of it when the patient recovers from the effects of
the drug, and to go on repeating the doses will be likely to cause
loss of appetite where the necessity of food is urgent, and ulti-
mate injurious depression. On the other hand, strong, turbulent,
restless chronic maniacs, in whom the pulse is regular, the
tongue clean, the bodily health nowise affected—in whom the
body seems to have thoroughly acclimatised itself, so to speak,
to the mania—suffer no harm from full doses of tartar emetic,
if it does them no good.

The foregoing remarks will no doubt appear to some persons
to be inspired by a spirit of exaggerated scepticism with
respect to the value of sedatives in the treatment of insanity,
Let if not be overlooked therefore that they refer not to their
occasional use as adjuvants of other well-considered measures,
but to their repeated use day after day and night after night in
order to abate an excitement which they will not abate, and to
enforce a sleep which, so enforced, does no good. It is foolish
to expect that a person who is suffering from acute mania will
have anything like the quantity of sleep which a sane person
gets, and unwise to try to force him into it by stupefying drugs.
If he does not sleep one night, he will probably sleep fora
part of the next night, and if we wait patiently, taking care
meanwhile to attend to his special constitutional state, and to
provide that he takes abundance of exercise in the open air,
that he gets sufficient food, that he has baths if he will take
them, and that his surroundings are such as are not likely in any
way to irritate his disordered brain and to add to his excite-
ment, we shall happily find that the natural sleep which he
obtains by fitful snatches increases gradually in amount; and
we may be content that a few hours of such natural sleep, even
if obtained only on alternate nights, will be worth more to him
in the end than a whole night of chloral-enforced insensibility.
As regards melancholics, it is to be noted that they oftentimes
sleep more than they think and say they do; and it is well
therefore before trezting them for sleeplessness to have the
evidence of some one who has watched them through the night,
Moreover, if they have been wont to have sedative draughts for
x1] THE TREATMENT OF MENTAL DISORDERS. 568

some time, they will protest that they cannot sleep a wink
without them ; albeit, if the strength of the draught be lessened
without their knowledge, a taste of the drug only being left in
it perhaps, they sleep fairly well. In some cases a small quan-
tity of light nourishment taken in the night when they wake up
from their first sleep and begin to toss about in the mental
agony of a succession of tormenting thoughts, will procure
calm and sleep. For example, an old gentleman with a feeble
heart, suffering from melancholic apprehensions and distress,
always woke after a few hours’ sleepin a wretched state of panic
fear, so that he could not get to sleep again but was obliged to
pace the room in an agony of mind. He was recommended to
take when he awoke a cupful of beef-tea with a little sherry or
brandy in it, and then to lie down again; and the result was
that he got to sleep and soon recovered, afterwards getting
married again, old as he was. To get out of bed and walk up
and down the room a few times, to go through a little gymnastic
exercise, to brush the hair briskly, to sponge the body with
water and to rub it well afterwards with a towel—are expe-
dients which may be had recourse to; instead of tossing about
in bed; they may help a mild sedative to take effect when the
person gets into bed again, if they do not break the spell of
tormenting ideas and enable him to go to sleep without any
sedative. One gentleman who consulted me used to get into
a cold bath, and found that efficacious.

There is no doubt of the value of systematic exercise and
employment in the treatment of mental disease. If one could
persuade or compel a strong and turbulent maniac to plough a
field, or to row several hours a day, or to walk twenty miles a
day for a month, taking plenty of nourishment the while, the
treatment would do him more good than he would get from all
the drugs of the Pharmacopceia. The co-ordinated use of
energy in any sort of systematic employment is an excellent
medicine for the distracted and incoherent mind. Employment
is a thing therefore to be patiently and persistently aimed at,
albeit it may be very difficult to get it done: the maniac is
oftentimes too turbulent and restless to fix his attention for any
length of time; the melancholic too self-indulgent or lacking
564 PATHOLOGY OF MIND. [cHaP.

in energy to make what is to him a painful effort and to per-
severe. In enjoining exercise it will, of course, be necessary to
have attentive regard to the state of the bodily strength and to
any symptoms of bodily disease, and to modify rules accord-
ingly ; in the most acute form of mania, especially in acute
delirious mania, the patient should be kept as quiet as possible,
and treated more as a person suffering from meningitis or from
the delirium of fever would be treated.

The general medical treatment in mental disease must be
based upon the most careful appreciation of the bodily state.
If there is reason to believe that it is of syphilitic origin, iodide
of potassium should be given freely, and, if necessary, some
preparation of mercury. Small doses of the chloride of mercury
in decoction of cinchona answer very well. It is remarkable
how rapid and complete sometimes is the change for the
better which follows the administration of antisyphilitic remedies
to a patient whose demented symptoms seemed to portend
certainly an incurable insanity. The one hope for an obscure
case which, presenting most of the features of commencing
general paralysis, as syphilitic insanity sometimes does, cannot
be diagnosed with certainty, is that it is of syphilitic origin,
since, if it be, there is a fair chance that recovery will take
place under specific treatment. If there be a suppression of
the menses, as there often is, it must be borne in mind that the
insanity most frequently causes the suppression, not the sup-
pression the insanity. No good therefore will’ be done by
active measures to provoke menstruation in such cases; on the
contrary, if such measures are successful and the menses are
regular without an accompanying change for the better taking
place in the mind, the prognosis becomes more gloomy. But if
they return naturally as the mind shows definite signs of
amendment, then there is good hope that mind and body will
go on together to complete recovery. Sometimes, however, they
remain obstinately suppressed after decided improvement or
complete restoration of mind. In that case I have found
nothing more useful than an ounce of a mixture containing
equal parts of Mistura Ferri Co. and Decoct. Aloes Co., taken
early every morning. Or a pill containing aloes and iron
XL] THE TREATMENT OF MENTAL DISORDERS. 565

may be given every night. In some very obstinate cases Dr.
Savage has found the tincture of hellebore in doses of from
half a drachm to a drachm two or three times a day to be very
successful, Obviously in a case in which the menstrual sup-
pression and the mental disease appear to be common effects
of a low state of the general health or of an enfeebling bodily
disease, the proper treatment will be to treat the constitutional
state: to strengthen the weak body will be to do the best for
the functional irregularity.

In many cases of melancholia and in some cases of asthenic
mania cod-liver oil is most useful, and it may be proper to
give iron and quinine also. Among tonics, however, I have
found small doses of arsenic alone, or in combination with
small doses of strychnia, to be of the greatest service. I have
more faith in arsenic, indeed, than in phosphorus, which many
persons now employ largely in cases of nervous depression. In
the treatment of general paralysis, physostigma, the active prin-
ciple of the calabar bean, has been employed by Dr. Crichton
Browne, at the West-Riding Asylum, with alleged results
which, having regard to the generally accepted notion of the
incurable nature of the disease, must be accounted extraordi-
narily successful. Other experimenters have not yet had the
successes which he has had from its use, and further observa-
tions are required in order to settle what its actual value is.
It may be given when given in doses of twenty drops of a
Tincture or of from jy to i of a grain of the Extract.

Let it not be forgotten that a cheerful and hopeful mood of
mind is a most valuable remedy against disease of all sorts, and
that if the physician can infuse that into the patient he will
often do him more good than by all infusions of drugs.
Charms, amulets, ceremonies, and the like, which have prevailed
amongst all nations in all ages, have without doubt been truly
- helpful in curing disease, having owed their efficacy to the
faith and hope which they inspired. Hope inspires the organic
elements of the body with energy; despair infects them with
feebleness. If a person is convinced he will die of a disease
from which he is suffering, and abandons himself to despair,
he will die when there was not death.in the disease; if he is
566 PATHOLOGY OF MIND. (cuaP, XI.

convinced that he will not die, and looks forward buoyantly to
recovery, he will hold death successfully at defiance even when
its victory seems assured. In like manner recovery from
chronic disease will take place when the organic functions feel
the animation of a hopeful spirit, whereas the disease may
continue or even increase if they are oppressed with the weight
of despondency. He is commonly the best physician who
inspires the most faith in his patient.

In conclusion—and it may well be the last word concerning
treatment—the physician cannot too constantly and sincerely
bear in mind that the body is not a mechanism the parts where-
of work independently of one another and may be adjusted to
their special purposes without relation to the purpose of the

whole, but a living organism, each part of which calls the

furthest brother, and no part of which can suffer or be glad
without the whole suffering or being glad with it, the humblest
element working in the whole and the whole in the humblest
element. Keeping this just conception ever in mind, he shall
not miss the practical lesson of it: namely, that he should
strive always to bring the inspiration of a healthy tone of mind
to bear upon the disorders of the body, and should not ever
neglect to observe and to put right the meanest bodily disorder
in his efforts to restore health to the disordered mind. Let him
pass reverently through a holy—z.e. healthy—temple of the
body to the inner sanctuary of a holy temple of mind,
INDEX.
INDEX.

A.

ABDOMEN, disease of, as cause of in-
sanity, 211, 212, 238, 521.

Abstraction, the state of mental, 55.

Aconite, poisonous effects of, 36, 368.

Action, in the formation of character,
161.

Age, its influence in heredity, 119,
120; decay of old, 120, 475 ; its in-
fluence in insanity, 167, 168, 238,

Agoraphobia, 319, 431.

Ague, as cause of insanity, 200.

Albers, Professor, on the use of a pro-
longed cold bath, 544.

Alcohol, the effects of, 194, 195, 398.

Alcoholism, acute, 484; chronic, 485,

Alternation, of sanity and insanity,
412; of mania and melancholia,
352, 394, 412. |

Ambition, the vanity of, 159, 160; a
contemptible social, 170; disap-
pointed, 222,

Amenorrhcea, treatment of, 564, 565.

Amentia, 326.

Amyloid bodies, 512, 513.

Ancestors, latent qualities of, 90.

Aneurisms, miliary, 472, 516.

Animals, mesmeric experiments on,
54; acute perceptions of, 69; man’s
community of nature with, 116,
117; insanity of, 260, 261.

Antisocial beings, 100 —105, 115, 524.

Apoplexy, predisposing to insanity,
110, 111 ; in old age, 120.

Appetites, perverted, 427.

Arago, his attempt to overthrow an in-
sane delusion, 538.

Areteus, 206.

Aristocracy, the, insanity among, 170.

Aristotle, on the melancholy of great
men, 245.

Armenians, the, 151.

Arsenic, in melancholia, 565,

Arteries, atheroma of, 472.

Ascaris lumbricoides, unusual symp-
toms caused by, 208.

Ascetic, the religious, 243.

a the influence of confident,

6.

Asthma, its neurotic relations, 107,

108.

Asylums, the propriety of treatment
in, 525; public and: private, 526—
630.

Atavism, 93.

Atheroma, 472.

Atkins, Dr. Ringrose, on the morbid
appearances in acute mania, 505.

Atmosphere, effects of states of, 48,
49. ; 8

Attendants on the insane, 534, 540.

Aura epileptica, the, 447.

Australian, the native, inferior brain
of, 89...

Automatism, of ideas and feelings, 69;
of action, 74, 228.

Aveyron, the savage of, 178,

Azam, on the mental effects of uterine
disease, 208.

B.
Baur, von, 176.
Baillarger, on delirium following
dreaming, 40, 41; on arrest of
570

growth in idiocy, 180; on an at-
tempt to overthrow an insane delu-
sion, 538. :

Baths, in the treatment of insanity,
548—545,

Bayle, on the resemblance between
drunkenness and general paralysis,
443.

Belief, enforced, 56 ; influence of tem-
perament on, 65; influence of faith
on, 79; real and professed, 134; in
the supernatural, 187 ; the ordinary
foundations of, 539.

ae hallucinations caused by,
875.

Billroth, on a gelatinous degeneration
of the cerebellum, 515.

Blake, William, his hallucinations,
268.

Blood, the, effects of quality of, upon
dreams, 41; the circulation of, in
idiocy, 480; the influence of, upon
mind, 188—205 ; the effects of viti-
ated, 194; poverty of, 198.

Blood-letting, in the treatment of in-
sanity, 542. :

Blumenbach, on the state of the brain
during sleep, 3.

Body, the, arrested growth of, in
idiocy, 180, 181.

Bohemia, Agnes of, 35.

Bowels, state of, in melancholia, 378.

Braid, Mr., his hypnotic experiments,
387, 38, 53.

Brain, the—state of, during sleep, 3;
during dreaming, 4; effects of pres-
sure on, 8, 9; the unconscicus action
of, 15—17 ; syphilis of, 109, 110,
235, 506 ; cancer of, 109, 110, 234;
inferior type of, 175; the microce-
phalic, 176; arrested development
of, 177—180; the influence of blood
upon, 188—205 ; congestion of, 189,
502; anemia of, 191, 198, 501;
irritation of, 192; organic disease
of, 217; excessive function of, 219 ;
injuries of, 226, 227; tumour of,
231 ; abscess of, 231, 235; cysticer-
cus of, 234, 235; loss of substance
of, 235 ; an excess of serum in ven-
tricles of, 289 ; disordered circulation
in, 498—502; morbid changes in,
502—519; hyperemia of, 510; the
so-called hypertrophy of, 515.

Brown, Dr. Crichton, on the insanity
of early life, 276; on the calabar
bean in general paralysis, 565.

INDEX.

Brunet, on hypertrophy of the brain,
516

Bucknill, Dr. J. C., on counter-irrita-
tion in the treatment of insanity,
546,

Buddha, self-sacrifice of, 140.

Burdach, 94,

Burrows, Dr., on different pulses in the
carotid arteries, 190 ; on sympathetic
mania, 207; on the transformation
of nervous diseases, 230, on homi-
cidal impulse in epilepsy, 339,

Bushman, the, brain of, 175,

Cc,

CaBanis, on the senses in somnam-
bulism, 62.

Calabar bean, the, in the treatment of
general paralysis, 565.

Cameron, Commander,
across Africa, 128,

Capillaries, diseased, 511; the second-
ary sheaths of, 512.

Carbonic acid, effects of inhalation of,
189, 490.

Carotid arteries, the, the pulses in,
190 ; the effect of tying, 192.

Casaubon, 522.

Cases, notes of, illustrating causation
of insanity, 249—255.'

Catalepsy, 56, 73.

Celibacy, an effect of, 136.

Cerebellum, the, the lamine of, 176;
gelatinous degeneration of, 515.

Cerebral circulation, the, during sleep,
3; during dreaming, 39—48 ; partial
irregularities of, 193; disordered,
498—502.

Character, the moral development of,
154, 155, 161; effects of sectarianism
on, 150 ; the formation of a strong,
aes 161, 163; differentiations of,

Childhood, the dreams of, 47 ; the in-
sanity of, 256—295 ; the nightmare
of, 263; incoherence of, 265: falla-
cious memory of, 265; the imagina-
tion of, 269 ; suicide of, 279,

Children, of deficient intellect, 283,

China, insanity in, 131.

Chloral, the hydrate of, in the treat-
a of insanity, 552—554, 556—

Chorea, 108, 269 ; as cause of insanity,

his journey
INDEX,

Church of England, the, 148.

Church of Rome, the, 136, 144.

Civilisation, its effects on the increase
of insanity, 127—135 ; the pursuits
of modern, 133.

Clarke, Dr. Lockhart, on granulations
of the ventricles, 506; on the
secondary sheaths of the capillarics,
512; on pigmentary degeneration of
nerve-cells, 517.

Classification, the, of insanity, 296,
297, 326—3829, 439.

Climacteric change, the, 168, 469.

Clouston, Dr., on phthisis and in-
sanity, 112, 520; on opium in the
treatment of insanity, 554; on can-
nabis indica, 560.

Coleridge, S. T,, on dream-images, 24;
on nightmare, 29; on fancy and
imagination, 269.

Coleridge, Hartley, phantasms of, 268,

Colloid corpuscles, 512.

Colon, the, a displacement of, 521.

en social, 157; religious,
157.

Conception, slowness of, 494.

Confessional, the effects of, 144.

Conium, the juice of, in the treatment
of insanity, 560.

Conjuror, the, his tricks, 77.

Connective tissue, the, of brain, in-
erease of, 511, 515.

Consanguinity, marriages of, 95, 120—
126,

Conscience, loss of, in dreaming, 11;
exaggerated sensibility of, 1438;
among savages, 129; a sanitary,
155; a completely developed, 156;
varieties of social, 161. 3

Consciousness, a peculiar phenomenon
of, 28; @ probable law of, 58; a
state of abnormal, 75—77.

Consensus, the physiological, 521.

Conservatism, the, of savages, 129.

Constitution, how to change a, 123.

Convolutions, cerebral, simplicity of,
175, 178; the layers of, 183.

Convulsions, infantile, 257; co-ordi-
nate, 259,

Cooper, Sir Astley, on the effects of
tying the carotid arteries, 192.

Corpora amylacea, 512.

Corpus callosum, the, absence of, 178.

Cottages, the insane in, 534.

Counter-irritation, in the treatment of
insanity, 546.

Cousins, intermarriage of, 123, 124.

571

Cox, Dr. Mason, on the radial and
carotid pulses, 190,

Craziness, 827, 427.

ee 103—105 ; unscientifie view of,

Criminals, classes of, 104.

Cynicism, 99.

Cysticercus, 217.

Czermak, mesmerie experiments on
animals, 54.

D.

Daconet, on homicidal impulse, 337.

Damnation, delusion of eternal, 146,
361, 385.

Dancing mania, 73,

Darwin, Dr. Erasmus, on the dreams
of a deaf person, 22; on the trans-
ne of nervous diseases, 218,

Darwin, Charles, on the cross-fertili-
sation of plants, 122,

Darwin, George, on marriages of con-
sanguinity, 120.

Datura stramonium, poisonous effects
of, 268, 414.

Deat-mutism, 125.

Death, Christian and Pagan views of,
145; cause of, in melancholia, 394,
395 ; cause of, in mania, 414, 415;
cause of, in general paralysis, 442,
fet caused by chloral hydrate,

Deception, deliberate, 64, 775 self-
deceiving, 64, 78, 149; of the in-
sane, 536, %

Degeneracy, human, 104, 105, 113—
117, 290—295 ; theroid, 293 ; bodily
signs of, 322,

DE Eanes the process of, 294,

95.

Délire aigué, 405, 406.

Delirium, of cerebral hyperemia, 39 ;
of cerebral anemia, 39; acute, 405,
406; of fever, 204; sympathetic,
208 ; of tumour and abscess of the
brain, 232; tremens, 484, 485.

Delirium tremens, its rareness among
eee 128 ; acute, 484; chronic,

85.

Delusion, insane, 486; the mode of
development of, 202, 205, 211, 225,
240, 258, 360; the growth of, 203 ;
the removal of, 208, 240, 530; the
infection of, 309; of persecution,
889; of suspicion, 390; of gran-
572

deur, 489 ; the uselessness of argu-
ment against, 537.

Dementia, 326; senile, 168, 473—
476, 516; temporary recovery from,
during fever, 190 ; symptomatology
of, 425—431; acute, 429, 430; of
gencral paralysis, 441; of epilepsy,
448 ; of insanity of self-abuse,, 459 ;
alcoholic, 486; morbid changes in,
515, 516.

Despair, the depressing effects of, 565.

Development, stages of embryonic,
116.

Diabetes, in insane families, 113.

Diaboleptics, 71.

Dialectical Society, the, 80.

Diet, the, in insanity, 547, 548.

Differentiations, of constitution, 122,
123, 126, 306.

Digitalis, in the treatment of insanity,

Dipsomania, 107, 108, 487, 488.

Disease, foreboded by dreams, 42;
caused by ideas, 68: the causation
of, 85; not a morbid entity, 172;
metastasis of, 201; inhibition of,
201, 210; functional and organic,
218 ; ascopic changes in, 491; mi-
eroscopic changes in, 491; macro-
scopic changes in, 491.

Dissent, religious, 148.

Dogs, hallucinations in, 261.

Dreaming, 7—49; time of, 9; resem-
blance of, to insanity, 9, 10, 24, 30;
volition in, 10, 11; personal identity
in, 11; absence of surprise in, 12;
the images of, 13, 24; the charac-
teristic features of, 14; the imagin-
ation in, 15; achievements in, 18;
the dramatic power in, 18 ; memory
in, 18—21; the causes and condi-
tions of, 21—48; by a deaf person,
22; Coleridge on the images of, 24; an
interpretation of, 26 ; impressions on
senses in, 28—30, 58; the experi-
mental production of, 28, 29; or-
ganic impressions in, 29—35 ; effects
of visceral organs upon, 38, 34; the
effects of muscular sensibility upon,
35—39 ; of falling, 37; of flight,
38 ; effects of cerebral circulation on,
89—48 ; vivid, 39; followed by de-
lirium, 41; the effects of quality of
blood upon, 41; foreboding disease,
42; effects of nervous exhaustion
upon, 44, 46; in old age, 46; in
childhood, 47, 48; effects of atmo-

INDEX.

spheric states upon, 48, 49 ; the me-
dical significance of, 49.
Durham, A., on the brain during sleep,

3. ,
Durand Fardel, on suicide by children,
279.

E.

Ear, the malformation of, 822; the
asylum or insane, 384,

Eccentricity, 100, 297, 298.

Echeverria, Dr. M. G., on the use of
the trephine in epilepsy, 547.

Eclipse, the race-horse, 121.

Ecstasy, 70; the phenomena of, 71;
holy and demoniacal, 71 ; memory
in, 73 ; trances of, 144; insane, 459.

Education, limits of power of, 89 ; and
insanity, 152—164; the true basis
of, 153; the ideal of, 160, 163; the
bad system of female, 163.

Egotism, 100—102.

Electricity, in nerves, 494.

Emotion, wise and unwise cultivation
of, 141—144 ; the wear and tear of,
169, 170, 219 ; the physical basis of,
222.

Employment, of the insane, 537, 563.

Energy, kinds of, 411.

Enthusiasm, bodily effects of, 72, 73 ;
kindling of, 157; prophetic, 446 ;
infection of, 539.

Environment, the, adaptation to, 85,
98, 99, 173; the influence of the
social, 160, 161.

Epidemics, moral, 158.

Epilepsy, automatic action in, 74—77 ;
a peculiar case of, 75 ; resemblance
to somnambulism, 76; predisposing
to insanity, 107, 108; a cause
of idiocy, 179; a cause of insanity,
228, 273; furious mania of, 261;
masked, 274; homicidal impulse in,
3838—341 ; moral insanity in, 353;
a suggestion of mental, 365; hallu-
cinations of, 445, 446 ; the religious
feeling in, 445; monomania of, 445.

Erotomania, 344.

Esquirol, on hereditary transmission,
117 ; on menstruation and insanity,

197 ; on sympathetic delirium, 208 ;- - - -

on abdominal disease in insanity, 212;
on loss of sensibility of skin, 215;
on phases of insanity, 289 ; cases of
insanity in children, 283, 284; on
the marks of an insane heredity,
INDEX.

320; his classification of mental
diseases, 827 ; on moral alienation,
328 ; monomanie raisonnante, 355;
a case of auditory hallucinations,
374 ; on convalescence from insanity,
404; on lypemania, 416; on three
forms of monomania, 416; on dis-
placement of the colon, 521.
Etiology, of insanity, 88—174.
Eunuchs, the moral character of, 454.
Evangelicalism, 149.
Evolution, the aim of, 98—100.
Experience, influence on dreams, 21—
27 ; reversions to ancestral, 27,

F.

Facuttics, mental, superior natural,
188, 189; the right cultivation of,
188,

Faith, power of, 79, 566; real and
professed, 134.

Family, an insane, 309 ; sympathetic
feeling of, 306, 311.

Faria, the Abbé, his mode of mes-
merism, 54.

Fatuity, 327, 429.

Features, peculiarities of, 821; in in-
sanity, 403 ; in acute mania, 409.
Feeding, the necessity of forcible, 409,
Feeling, insanity of, 328, 329; dege-
neration of social, 100—105, 347;

the religious, in epilepsy, 445.

Feigning, of disease, 324.

Fetish, the belief in a, 1838—140, 149.

Fever, its effects on mental derange-
ment, 190; a cause of mental: de-
rangement, 201; the delirium of,
204 ; failure of memory after, 414.

Folie circulaire, 352, 412,

Food, refusal of, in melancholia, 379;
in mania, 409.

Foville, Dr, A., on the general impair.
ment of mind in monomania, 423,

Frenzy, the prophetic, 397, 446.

Function, excess of, 219; structurali-
sation of, 223, 489.

G.

GALEN, 206,

Galton, F., on hereditary genius, 96,
118.

General paralysis, 225; disorders of

573

organic sensibilities in, 369; symp-
tomatology of, 432—444 ; causes of,
433—435; varieties of, 441; the
course of, 442, 443; cause of death
in, 443; morbid changes in, 507,
511, 512, 517.

Genius, non-inheritance of, 96; Mr.
Galton on hereditary, 95, 118.

Ghosts, visions of, 25.

God, the belief in, 140, 141.

Goethe, 299, 301, 304.

Goltz, experiment on frog, 194.

Gout, as cause of insanity, 111, 197 ;
occurrence of, 120.

Governesses, their supposed liability to
insanity, 169.

Gratiolet, 125, 126.

Gravitation, the law of, 156, 173.

Gregory, Dr., on hallucination preced-
ing epilepsy, 447.

Griesinger, on ayuy as cause of in-
sanity, 200; on rheumatic insanity,
201; on sympathetic insanity, 207 ;
on the mental effects of pregnancy,
209; on anomalies of sensibility,
216 ; acase of cataleptoid insanity,
275 ; homicidal epileptic mania, 340;
intermissions in melancholia, 366.

Guislain, 209 ; on mania generated by
intemperance, 182; a case of mania
from caries of nose, 276.

Gummata, syphilitic, 200, 481, 482,
5

H.

Hanir, the formation of, 86, 224; the
tyranny of, 303.

Hematoidin, granules of, 512,

Hematoma auris, 384.

Hair, the, in melancholia, 378; in
mania, 409.

Hallucinations, of movements, 35, 36,
78, 79, 215, 899; sympathetic, 207;
sexual, 211; in dogs, 261; in in-
fants, 268; in children, 267; their
modes of production, 266, 267, 372
—376; in melancholia, 8371—877 ;
in mania, 399; in epilepsy, 445—
447; in the insanity of self-abuse,
459 ; in delirium tremens, 484; in
chronic alcoholism, 485.

Hamilton, Sir W., on perception by
somnambulists, 62.

Haslam, case of insanity in a young
child, 282 ; a case of moral insanity,
286,
574

Hearing, hallucinations of, 371—376.

Heart, the, sleep of, 1; exhaustion of,
2; intermittence of, 378; diseases
of, in the insane, 520,

Heberden, 210.

Hellebore, 549 ; in amenorrhcea, 565.

Helmholtz, on the time-rate of conduc-
tion of nerves, 492.

Tlerbert, George, quotation from, 212.

Heredity, 87—106 ; law of reproduction
in, 88—91 ; law of variation in, 91--
93, 97 ; morbid, 106—120, 186, 291,
337, 3388—343, 350; statistics of
morbid, 106, 107, 117; degrees of
morbid, 107 ; the influence of sex in,
117; the influence of age in, 119,
120; in deaf-mutism, 125; the
marks of morbid, 320—323,

Heschl, on ossification of nerve-cells,
518.

Hippocrates, 128, 191, 206.

Hobbes, on association of ideas, 18.

Holland, Sir H., a case of auditory
‘hallucination, 372; on slowness of
conception and volition, 494. |

Homicide, during somnambulism, 81 ;
in insanity, 332—335, 365, 389-393 ;
behaviour after, 343, 392 ; in demen-
tia, 428; in epilepsy, 447.

Hope, the inspiring etfects of, 565.

House of Commons, the, Committees
of, 523, 524.

Tlowden, Dr., on the religious senti-
ment in epileptics, 445; on the
morbid changes in senile dementia,
516.

Howe, Dr., on intemperance as a cause
of idiocy, 181.

Hoy, Dr., on the effects of pressure on
the brain, 8, 9.

Humanisation, the progress of, 102,
174,

Humor, 99.

Hales John, on organic sympathies,
211,

Hydrocyanic acid, in the treatment of
insanity, 561.

Hydropathic houses, 532,

Hydrophobia, morbid
514, 2

Hyoscyamus, in the treatment of in-
sanity, 558.

Hypnotism, 50—61; surgical opera-
tions in, 52; conduct during, 52;
isolation of ideas in, 57 ; memory in,
57; after effects of, 59, 60; physical
causes of, 60, y

changes in,

INDEX.

Hypochondriasis, 107, 120; of great
men, 245; of melancholia, 370, 471.

Hypocrisy, unconscious, 149, 150, 308.

Hysteria, 107, 108, 324 ; as cause of
insanity, 228; mental, 323, 461;
reflex action in, 498.

I,

Ipzas, the association of, 13, 15 ; their
inverse relation to moyemeuts, 32 ;
isolation of, 57; effects of precon-
ceived, 67 ; disease-producing, 68 ;
organisation of, 265; abnormal ex-
citation of, 359; greatly elated,
439,

Idiocy, the brain in, 176—180; tho
causes of, 181, 182.

Idiosyncrasy, 214, 236.

Idiots, sterility of, 95; the braing of,
176—180; on morbid changes in the
brains of, 514, 515.

Innagination, the, in dreaming, 15, 21;
in reverie, 15; in childhood, 269:
one-sided, 303.

Imbecility, intellectual, 288,
moral, 289—-291, 318, 344, 350,

Imposture, deliberate, 64, 773  self-
deceiving, 67, 78.

Impulses, morbid, 76 ; homicidal, 279,
333, 338—846, 362, 459; suicidal,
279, 332, 338, 362, 389, 459; to
steal, 290; to vice and crime, 290;
ridiculous morbid, 312—317, 844,
355 ;.predisposing conditions of, 337.

Individuality, the foundation of, 88 ;
J. S. Mill on, 298,

Infant, first perceptions of, 257; in-
sanity of an, 258; hallucinations in
the, 263.

Infection, mental, 158; putrid, 199.

an, the early stages of, 491,

Inhibition, cerebral phenomena of, 55 ;
suspension of, 402, 411; vasomotor,
198 ; of one disease by another, 201,
210, 230. ;

Insanity, causation of, 83—255 ; etio-
logical causation of, 88—174 ; path-
ological causation of, 175—286 ; co-
operation of causes, 84; physical and
moral causes of, 85; generation of
predisposition to, 95, 97, 102, 124,
134; neutralisation of a predispo-
sition to, 97, 164; the fundamental
meaning of, 98—100; its: affinities

344;
INDEX.

to crime, 1083—105; scrofula and,
111, gout and, 111; phthisis and,
112; diabetes and, 113; hereditary
transmission of, 117—120; inter-
marriages as cause of, 120—126;
civilisation and, 127—135 ; statis-
tics of, 131, 165; religion as cause
of, 135—152 ; education and, 152—
164; tlie scientific view of, 158;
moral causes of, 159; influence of
sex on, 164—167 ; influence of age
on, 167 ; influence of occupation on,
168 ; a proof of weakness, 173; re-
covery during fever in, 190 ; of oxa-
luria, 199; pellagrous, 199; inter-
mittent, 200 ; post-febrile, 201, 204;
sympathetic, 207, 208 ; of pregnancy,
209; puerperal, 209, 466—469 ; cli-
macteric, 210, 469—472; uterine
and ovarian, 211; phthisical, 213,
477—480 ; the moral causes of, 220
225; from injury to brain, 227;
hysterical, 228, 463—466 ; epileptic,
228, 261, 273—276, 444449;
moral, 229, 285 —288 344 —
355 ; cause of special forms of, 236
240; common quality of, 240; the
medical and legal views of, 246, 247;
of early life, 256 —295; sensorial,
260—265 ; choreic, 263—265, 270
—272 ; cataleptoid, 272, 273 ; affec-
tive, 277—292, 329—353 , instinc-
tive, 280—285, 330—344 ; the symp-
tomatology of, 296 ; the infection of,
309—311 ; the classification of, 296,
326—329 ; characters of hereditary,
350, 419, 420 ; of pubescence, 449—
452; of self-abuse, 452---463 ; amen-
orrheeal, 465 ; hypochondriacal, 471;
senile, 472--477 ; syphilitic, 480—
483, 564 ; alcoholic, 483—-488 ; mor-
bid changes in, 502—521 ; the moral
and medical treatment of, 522—566.
insensibility, from drowning, 8 ; from
injury to the head, 8, 9; during
mental abstraction and excitement,
55, 73; during religious exaltation,
72, 73; in catalepsy, 74; from liga-
ture of the carotid arteries, 192; from
inhalation of carbonic acid, 189.

Insolation, effects of, 227.

Inspiration, 303. :

Instincts, 259 ; insanity of, 280--285,
293; of self-conservation, 281; of
propagation, 283.

Intellect, the, developed out of sensa-
tion and motion, 17.

575

Intemperance, a cause of idiocy, 181,
182 ; mania caused by, 182; convul-
sions caused by, 182.

Interbreeding, the effects of, 95, 120—
126. ;

Intermittence, of cerebral symptoms,
232—235 ; of melancholia, 866 ; of
mania, 411; of general paralysis,
442,

Intervals, Incid, 411.

Introspection, evils of, 143,

Irving, Edward, insanity of, 416,

Israel, a proverb in, 88.°

J.

Jackson, Dr. Hughlings, on syphilitic
neuritis, 481.

Jeffrey, Lord, his mental wanderings
before death, 46, 47.

Jesus Christ, the delusion of being,
418, 424,

Jews, the, 151,

K,

Kisciirnr, mesmeric experiments, 54.

Kiss, the holy, 144,

Kleptomania, 290, 344.

Kolk, Schroeder Van der, on phthisis
and insanity, 112; on sympathetic
insanity, 207, 208; on the morbid
changes in insanity, £03, on acute
pachymeningitis, 508 ; on pigment-
ary degeneration of nerve-cells, 517;
on counter-irritation in the treatment
of insanity, 546.

L.

LACTATION, insanity of, 209, 468.

Lallemand, on the mental effects of*
spermatorrheea, 338.

Lamb, Charles, on the sanity of true
genius, 301.

Larrey, Baron, case of morbid sym-
pathy, 207.

Lateau, Louise, 71.

Laughter, convulsive, 259, 264.

Laurent, on sympathetic delirium, 208.

Law, the reign of, 135, 138, 189, 146,
256; physical and moral, 157; the
infraction of, 157.

Lawson, Dr., on hyoscyamine in the
treatment of insanity, 559.
576

Lead palsy, 196.

Lebert, Prof., on abscess of the brain,
231.

Lee, Anne, the visions of, 446.

Leidesdorf, Dr., on a prolonged bath,
543,

Leucocythemia, 199.

Liebreich, on retinitis pigmentosa, 517.

Life, the change of, 168, 469.

Lister, on the early stages of inflam-
mation, 491, 499.

Locke, John, on the moral effects of
the love of riches, 161 ; on the right
use of natural faculties, 188 ; on the
reasoning of a lunatic, 422; on the
time-rate of mental functions, 493.

Love, the holy kiss of, 144; ecstasies
of, 144,

Lucas, Dr. Prosper, 94.

Lung, the, gangrene of, 395, 519.

Luther, his interview with the devil,
24,

Lypemania, 326, 416.

M.

Macnan, on the production of hallu-
cinations in dogs, 261.

Mahomet, the visions of 446.

Mandeville, on instinctive acts, 259.

Mania, 326 ; gouty, 197 ; intermittent,
200; rheumatic, 201 ; post-febrile,
204 ; sympathetic, 208 ; transitoria,
229, 274, 413. 501; epileptic, 340
444-449 ; moral, 352 ; sine delirio,
355; hysterical, 461; symptoma-
tology of acute, 395—415; precur-
sory symptoms of, 395, 396; hallu-
cinations in, 399 ; different types of,
405 ; acute delirious, 405, 406, 505 ;
state of memory in, 407 ; the tempe-
rature in, 408 ; course of, 411—415 ;
periodic or recurrent, 412 ; chronic,
415 ; of pubescence, 450 ; puerperal,
467; senile, 476; phthisical, 478,
479 ; morbid changes in acute, 505 ;
morbid changes in chronic, 506; a
potu, 484 ; sleep in, 562.

Marriage, unwise recommendation of,
457, 463.

Materialism, 496.

Melancholia, 326 ; symptomatology of,
256 —395 ; uterine, 208, 497 ; alter-
nation of, with mania, 352, 394, 412;

antecedent symptoms of, 356, 357 ;_

simple, 358 ; panic in, 365, 392 ; in-

INDEX.

termissions of, 366, 393; attonita,
857, 880; hypochrondriacal, 370,
471; hallucinations in, 371—3877 ;
acute or agitans, 382 ; suicide in, 384
—889 ; homicide in, 389—393; the
course of, 393—-395 ; of pubescence,
451; puerperal, 468; climacteric,
470; senile, 476 ; a potu, 484 ; sym-
pathetic, 497; the morbid changes
in acute, 506 ; sleep in, 562, 563.

Menstruation, irregularities of, 197,210;
in melancholia, 378 ; in mania, 409 ;
insanity caused by, 465 ; treatment
of, 564, 565.

Meschede, Dr., on the morbid changes
in general paralysis, 517,

Metastasis, 201, 218.

Meyer, Dr. Ludwig, on mania transi-
toria, 274. .

Mickle, Dr. J., on varieties of general
paralysis, 508.

Mierzejewski, Dr., on idiocy, 515,

Mill, J. 8, on individuality, 298,

Milton, 252.

Monomania, 217, 326; symptoma-
tology of, 415—425; predisposing
causes of, 419; the course of, 420;
general mental impairment in, 421—
424 ; epileptic, 445 ; phthisical, 479.

Monomanie, affective, 355, 416; in-
stinctive, 416 ; intellectuelle, 416.

Moreau, a case of moral insanity, 287;
on the physical condition of genius,
301.

Morphia, the hypodermic injection of,
556.

Morrison, Sir A., on insanity in chil-
dren, 259, 260.

N.

Nature, the laws of, 185, 153; the
sympathetic study of, 141; the creed
of, 142,

Nerve-cells, cerebral, morbid changes
in, 516—518; pigmentary degene-
ration of, 517 ; calcification of, 518,

Nervous centres, different constitution
of, 195.

Nervous exhaustion, 490.

Nervous system, the mimicry by, 68,

Nervous structure, hidden defects of,
183, 185, 490; materialisation of
function in, 185, 489.

Nervous diseases, predisposing to in-
sanity, 107, 108; hybrid varieties
INDEX.

of, 107; functional and organic,
109, 110; the transformation of,
218, 229, 230.

Neuralgia, 107; reflex, 206 ; forebod-
ing general paralysis, 438.

Neuritis, syphilitic, 481.

Neuroglia, the increase of, 511.

Neurosis, spasmodica, 58, 186, 297 ;
the criminal, 103; the epileptic,
108, 337 ; the insane, 103, 186, 297,
337; transformation of, 107, 108 ;
the outcomes of, 113.

Nicolai, his hallucinations, 375.

Nightmare, the, 29, 32; in children,
48, 263 ; a waking, 380.

Nutrition, states of deteriorated, 171 ;
depression of, in melancholia, 378 ;
state of, in general paralysis, 433.

QO.

ObsERvVaTION, insufficient, 66, 67 ; in-
fluence of faith on, 79, 80.

Odic force, Baron Reichenbach’s, 53.

Old age, the dreams of, 46, 47; the
decay of, 120, 168, 475.

Opium, the sleep of, 5; relief pro-
duced by, 220; in the treatment of
insanity, 554—556.

Optimism, 386. ~

Organism, the, the sleep—-needs of, 1,
2; the physiological unity of, 11, 12,
869, 566; relation to environment,
85 ; the social, 99, 160; the tyranny

of, 849 ; dependence of moral feeling -

on, 354, .
Organic impressions, 29—35.
Originality, 299, 300.
Othematoma, 384.
Over-population, 171.
Oxaluria, symptoms of, 199,

Pp.

PAcHYMENINGITIS, in genera] paralysis,
507 ; acute, 508.

Pack, the wet, 541—545.

Pain, varieties of, 403.

Palate, the saddle-shaped, 179.

Panic, melancholic, 365, 392.

Panphobia, 238, 361.

Paralysis, general, 225, 432 — 434;
syphilitic, 481 ; alcoholic, 486.

Passions, the, 159; the depressing,
222; the elated, 224, 419; the best
sort of, 244,

377

Pauperism and insanity, 133.

Pellagrous insanity, 199.

Perception, acute, 68, 69; education
of, in infant, 257 ; compound nature
of, 376 ; by somnambulists, 62.

Persecution, some effects of, 136, 137 ;
delusions of, 374, 389, 394.

Personal identity, in dreaming, 11, 12.

Pessimism, 386.

Philanthropist, the selfishness of, 242,
248.

Phosphates, increase of, in urine, 490.

Phosphuria, 199.

Phthisis, as cause of insanity, 112,
213 ; and insanity, 479, 520.

Pick, Dr. A., on a peculiar state of
consciousness, 28,

Pinel, on mania sine delirio, 355 ; on
the primary seat of mania, 399; on
morbid changes in insanity, 490;
his reform in the treatment of in
sanity, 523.

Plants, the cross-fertilisation of, 122.

Pneumonia, 519.

Poe, Edgar Allan, 301.

Poisons, the specific effects of, 195,
200,

Potassium, bromide of, its use in epi-
lepsy, 448 ; its use in insanity, 558,
560, 561.

Poverty, the fear of, 385.

Prayer, the effects of, 138.

Predestination, origin of doctrine of,
91.

Pregnancy, the mental effects of, 209 ;
insanity of, 209, - 467.

Prichard, Dr., a case of moral insanity,
285; on moral insanity, 346,

Priesthood, a, useful functions of, 148,
149.

Prognosis, the, in melancholia, 393;
in mania, 412; in monomania, 420;
in general paralysis, 442 ; in epileptic
insanity, 448; in insanity of self-
abuse, 460; in hysterical insanity,
465; in puerperal insanity, 468 ;
in climacteric insanity, 470; in
phthisical insanity, 479 ; in syphilitic
insanity, 564.

Progress, the foundation of, 137,

Pubescence, the insanity of, 449—452,

Pulse, the differences of, in different
arteries, 190; in melancholia, 193,
878 ; in primary -disease of brain,
193.

Punishment, natural, 135, 153 ; eter-
nal, 141,
578

Pupils, the inequality of, 436.

Purgation, the abuse of, in insanity,
549,

Pursuits, effects of, upon character,
134, 135,

Pyromania, 344.

Q.
Quincy, Dr, 301.

R.

RacrnorssEs, barrenness of mares, 121.

Reason, contradictions of, 139.

Recovery, signs of, in melancholia, 393;
period of, 394; in mania, 412, 413;
in monomania, 420; in general par-
alysis, 442,

Reflex action, morbid, 205—218, 497,
498,

Reichenbach, Baron, on odie force, 53;
on perception by somnambulists, 62
—64; his sensitives, 319.

Relapse, the threatenings of, 414.

Religion, influence of, on the causation
of insanity, 185—152; the Chris-
tian, 146 ; the Roman Catholic, 148;
the true function and actual effect
of, 151.

Responsibility, in mental disease, 246
—248.

Restraint, chemical and mechanical,
553.

Retina, the, colloid degeneration of,
515; pigmentary degeneration of,

a

Reversions, to ancestral experiences,
27, 34; to animal instincts, 116.
Reymond, Du Bois, on electrical cur-

Tents in nerves, 494.

Rheumatism, the occurrence of, 120;
a cause of insanity, 201.

Riches, the love of, 161, 168.

Richter, Jean Paul, 26.

Rindfleisch, Dr. E., on the morbid
changes in tabes dorsalis, 512.

Ritualists, confession among, 144,

Robertson, Dr. Lockart, on packing in
the wet sheet, 545...

Robin, on the secondary sheaths of
small arteries, 512.

Rokitansky, on diffuse pachymeningitis,
507 ; on diseased capillaries in gene-
ral paralysis, 511; on the increase
of the neuroglia, 512, 514; case

INDEX.

of induration of the caliac azis,
421, :

Rome, the Church of, -persecution by,
136 ; confession in, 144.

8.

Saints, the communion of, 157.

Sander, Dr. Julius, on absence of the
corpus callosum, 178.

Sankey, Dr., on the morbid changes in
general paralysis, 507.

Savage, Dr., on hyoscyamine, 559 ; on
conium in the treatment of in-
sanity, 560; on hellebore in amen-
orrhea, 565.

Savages, insanity among, 127—131 ;
239; thesenses in, 130; the moral
sense in, 129, 130 ; the conservatism
of, 129.

Schamans, the Siberian, 446.

Schlager, Professor, on injuries of tho
head, 226.

Schwarzenthal, Dr. A., a case of ab-
scess of the brain, 235.

Sclerosis, the morbid changes of, 513.

Scrofula, as cause of insanity, 111.

Séances, spiritualistic, 63.

Secretion, derangement of, in melan-
cholia, 378; in mania, 403.

Sects, evil effects of, 149.

Sedatives, the use of and abuse of, in
insanity, 550—558, 562.

Self-abuse, effects of, 225, 338; in-
sanity of, 225, 276, 280, 452—463,
Self-control, in melancholia, 367: in
mania, 398, 400 ; morbid impairment

of, 391 ; in monomania, 417, 418.

Self-consciousness, in acute mania, 404.

Self-feeling, exaggerated development
of, 240—245 ; the good side of, 244;
intense family, 306; exaltation of,
395, 402, 439.

Self-knowledge, a means of, 119.

Self-love, wounds of, 222.

Self-renunciation, the lesson of, 160,
163,

Self-sacrifice, a good work of, 540,

Self-torture, 311—317,

Senility, 475.

Senses, the degrees of sleep of, 5; im-
pressions on, in sleep, 20—380, 58;
conditions of, in hypnotism, 52, 58 ;
in somnambulism, 60-62 ; in savages,
130; the vital, 215.

Sensibility--muscular, 35--39 ; anom
INDEX,

alies of, 216 ; in melancholia, 367—
877 ; disorders of organic, 369 ; loss
of, in dementia, 427; loss of, in
dementia, 427; loss of, in general
paralysis, 487, :

Sensitives, Reichenbach’s so-called, 53,
63, 64, 319.

Sex, in heredity, 117, 118 ; in insanity,
164—167,

Sexual excesses, effects of, 225, 338 ; as
cause of general paralysis, 483, 434.

Shakspeare, 80, 84, 141, 301, :

Shakers, the, 144, 157.

Shock, fatal effects of moral, 490.

Shuttleworth, Dr., on the brain of an
imbecile, 176.

Siamese twins, the, mental sympathies
of, 70; the quarrels of, 87.

Sight, hallucinations of, 376,

Sin, the unpardonable, 358, 360.

Single patients, 533.

Skae, Dr. D., the insanity of preg-
nancy, 209; ovarian insanity, 211 ;
insanity from injury to the head,
227 ; homicidal insanity, 334, 340;
sexual, 430; a clinical classification
of insanity, 4382; general paralysis,
435, 440 ; amenorrheeal insanity, 465.

Skae, Dr. Holland, a case of insanity
from injury to the head, 227.

Skin, the loss of sensibility of, 215;
in the insanity of children, 264, 271,
287 ; in melancholia, 368 ; in mania,
409.

Skull, the, premature ossification of,
178 ; a successful trephining of, 227,
448, 547, :

Sleep, 1—49; purpose of, 1; causes
and conditions of, 2—5 ; effects of de-
privation of, 2; condition of brain
during, 3; varying states of, 4, 5;
narcotic, 5; effects of expectation
and habit on, 6, 7; whether ever
dreamless, 7, 8; methods of: pro-
curing,.40, 563 ; talking in, 48; the
hypnotic, 50—6U; induction and
phenomena of so-called mesmeric,
51, 52: in melancholia, 378, 379,
562; in mania, 410, 562.

Smell, hallucinations of, 376, 377.

Somnambulism, 60—68 : state of senses
in, 60—62; state of memory in, 61;
skilful feats in, 61; the muscular
sense in, 62; the miraculous percep-
tions in, 63 ; its kinship to epilepsy,
76, 82; homicide during, 81.

Soul, delusion of lost, 361.

579

Spermatorrhcea, mental effects of, 338.

Spinoza, 140,

Spiritualism, 77—80 ; report on, 80.

Square, a, inability to cross, 319.

Starvation, the delirium of, 198.

Statistics, of a predisposition to in-
sanity, 106, 107; function of, 109:
of insanity, 181,

Stigmata, 71, 324, 461.

Stigmatic, the Belgian, 71.

Stimulants, the use of, in insanity, 548.

Strychnia, 200, 500 ; the excretion of,
552 :

Suicide, 107, 108; in children, 279;
in insanity, 332, 866; in melan-
cholia, 384—389 ; arguments against,
387; reason of, 887; hereditary,
889; in hypochondriacal melan-
cholia, 472,

Supernatural, the, belief in, 187—142.

Superstition, a scientific, 154.

Suspicion, morbid, 101, 242, 307 ; de-
lusions of, 390.:

Sympathy, mental, 69, 70, 155; with
nature, 141; the infection of, 157 ;
pathological, 205—218 ; physiologi-
cal, 111, 112, 566; morbid family,
306.

Syncope, the effect of moral shock,
490 ; caused by chloral hydrate, 557.

Synergy, 155.

Synthesis, 155.

Syphilis, effects of, 200 ; and insanity,
480, 564,

Syphiloma, 509.

Swedenborg, insanity of, 417}; pro-
bable epilepsy of, 446,

T.

TABES DORSALIS, 435, 512.

Tartar emetic, in the treatment of in-
sanity, 561, 562.

Taste, halucinations of, 376.

Temperament, an unstable, 56, 65, 80,
186, 297325 ; influence of, on be-
lief, 65, 80 ; influence of, on obser-
vation, 67 ; the phthisical,-112, 478,
479; a cause of emotional anxiety,
170; the action of alcohol on, 195;
the sensitive, 213 ; need of study of,
236 ; tubercular, 267 ; varieties of an
insane, 305—321 ; the egoistic, 305;
the suspicious, 307; the self-tov-
menting, 311; the impulsive, 312;
the miserly, 317; tbe morally de-
580

fective, 318 ; bodily features of an
insane, 320, 821; the melancholy,
385, 386.

Temperature, the, in mania, 408; in
general paralysis, 442, 443.

Tendencies, the fostering of bad, 162.

Tennyson, Alfred, 26.

Theoleptics, 71.

Theresa, St., 71,72, 144.

Thurnam, Dr., on the relative liability
of men and women to insanity, 166 ;
on the prognosis in, 535.

Time, in nervous and mental functions,
492—494, s
Tissues, the, intrinsic action of, 498,

500.

Tone, the mental, 202, 211, 220, 277,
830.

Torture, insensibility to, 72.

Trance, 70.

Travelling, the recommendation of,
534, 535.

Treatment, the, of insanity, 522—566 ;
the importance of early, 531, 534,
535 ; in private houses, 533.

Trephine, the, successful use of, in in-
sanity, 227; and in epilepsy, 448, 547.

Trousseau, on morbid impulses after
epilepsy, 341.

Tubercle, meningeal, 267; in the insane,

5,

Tuke, Mr. Samuel, on the effects of fever
upon mental derangement, 191.

Tuke, Dr., J. B., on puerperal insanity,
210.

Tumour, of brain, 230, 231 ; diagnosis
of, 233. :

Twins, mental sympathies of, 70; dif-
ferent dispositions of, 87 ; insanity in,
310.

U.

UNDERSTANDING, an insincerity of,
188, 139, 145. 147; arrest of deve-
lopment, of, 149.

Urine, the, in melancholia, 378 ; and in
mania, 410. :

Uterus, mental effects of discase of,
208, 497.

Vv.

VACILLATION, morbid, 311.

INDEX.

Varieties, degenerate or morbid, 292,
293.

Velpeau, surgical operations by, on
hypnotics, 52.

Vertigo, nature of, 36; in crossing a
square, 319.

Virchow, on diffuse pachymeningitis,
507; on syphiloma, 509.

Volition, time-rate of, 493; slowness
of, 494,

Voltaire, on the effects of magic words,
67.

Ww.

Warinc, causes of, 1, 2; successive
phases of, 5.

Wanderings, of persons with delusions
of persecution, 374.

Wassilief, on morbid changes in hy-
drophobia, 514. -

Weber, Dr. H., on the temperature in
post-febrile mania, 408.

Wedl, on diseased capillaries in gene-
ral paralysis, 511 ; on morbid changes
in idiocy, 514.

West, Dr., case of insanity in a child,
273. ‘

Westphal, Prof., on the increase of con-
nective tissue in general paralysis,
507. :

Whytt, Dr. Robert, on pathological
sympathy, 206; case of insanity in
a boy, 264.

Wild men, 178.

Will, the, during dreaming, 10; the
strengthening of, 188, 163 ; the free-
dom of, 156, 187 ; enervation of, 324;
degrees of, 325.

Wilks, Dr., on calcified nerve-cells,
518.

ies Dr., on the elation of mania,
897.

Women, the education of, 163; the
predominance of the aflective life in,
163, 450; the rareness of general
paralysis in, 434 ; thechange of life
in, 168, 469.

Woorara poison, the, 200.

Worms, intestinal, a cause of insanity
in children, 276,
 

 

 

 

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“Mr. Darwin’s latest study of plant-life shows no abatement of his power of
work or his habits of fresh and original observation. We have learned to expect
from him at intervals, never much prolonged, the results of special research in some
by pak or other subordinated to the main course of the biological system associated
with his name; and it has been an unfailing source of interest to see the central
ideas of the evolution and the continuity of life developed in detail through a series
of special treatises, each wellnigh exhaustive of the materials available for its sub-
ject.”—Saturday Review.

A Physical Treatise on Electricity and Magnetism.

By J. E. H. Gorpvon, B. A., Assistant Secretary of the British Association.
With about two hundred full-page and other Illustrations. Two vols., 8vo.
Cloth, $7.00.

“We welcome most heartily Mr. Gordon’s valuable contribution to the experi-
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every investigator and every teacher who goes beyond the merest rudiments must
needs equip Ties There is certainly no book in English—we think there is
none in any other language—which covers quite the same ground. It records the
most recent advances in the experimental treatment of electrical problems, it de-
scribes with minute carefulness the instruments and methods in use in physical
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scale.”—London Times. ;

New York: D, APPLETON & CO., 1, 3, & 5 Bond Street.

 
HEALTH PRIMERS.

EDITED BY

J. LANGDON DOWN, M.D.,
HENRY POWER, M. B., F. R.
J. MORTIMER-GRANVILLE,
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HOUGH it is of the greatest importance that books upon health should be in
the highest degree trustworthy, it is notorious that most of the cheap and
popular kind are mere crude compilations of incompetent persons, and are often
misleading and injurious. Impressed by these considerations, several eminent
medical and scientific men of London have combined to prepare a series of HratTH
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to be brief, simple, and elementary in statement, filled with substantial and useful
information suitable for the guidance of grown-up people. Each primer will be
written by a gentleman specially competent to treat his subject, while the critical
supervision of the books is in the hands of a committee who will act as editors.
As these little books are produced by English authors, they are naturally based
very much upon English experience, but it matters little whence illustrations upon
such subjects are drawn, because the essential conditions of avoiding disease and
preserving health are to a great degree everywhere the same.

VOLUMES OF THE SERIES.

Exercise and Training. (Illas- (| The Heart and its Functions.

trated.) The Head.
Alcohol: Its Use and Abuse. Clothing and Dress.
The House and its Surround- | Water.

ings.

Premature Death: Its Promo-
tion or Prevention.

Personal Appearances in Health
and Disease. (Illustrated.)

Baths and Bathing.

The Skin and its Troubles.
Fatigue and Pain.

The Ear and Hearing.

The Eye and Vision.

Temperature in Health and
Disease.

In square 16mo volumes, cloth, price, 40 cents each,

 

For sale by all booksellers.

Any volume mailed, post-paid, to any

address in the United States, on receipt of price.
D. APPLETON & CO., Pusiisuers,

New Yorr.
LE ae,

AND

HOW TO PROMOTE IT.

By RICHARD McSHERRY, M. D.,

Professor of Principles and Practice of Medicine, University of Maryland; Member of
American Medical Association; President of Baltimore Academy of Med cine.

Extract from Preface,

“Hygiene, public and private, has become, of late years, one of the most im-
portant elements of modern civilization. It is a subject in which all mankind has
an interest, even if it be, as it too often is, an unconscious interest,

“The present work is addressed to the general reader, no matter what his pur-
suit, and the language is such as any physician may use in conversation with an
intelligent patient ; it is therefore as free as such a work can be made from scien-
tific technicalities.

“Tt is offered as a contribution to a great cause, and the writer trusts that it
will have some influence in promoting the health, happiness, and welfare of all
who way honor it with a careful perusal. The principles advocated have been,
to a great extent, put in practice in the personal experience of the writer in
various parts of the world, and under many vicissitudes, and he has found them
to be not vague theories, but practical truths of the greatest importance.”

CONTENTS.

PART I—INTRODUCTORY REMARKS.
Hygiene the Better Part of Medicine—The Four Divisions of Human Life: The First
Quarter, or the First Score of Years. The Young Man; the Young Woman. The
Man; the Woman. The Declining or Old Man.

PART IL—HYGIENICS IN SOME DETAIL.

Race, Temperaments, and Idiosyncrasies.—Inheritance.—Habit.—Constitution.—The Air
we Breathe.—Sewers and Cesspools.—Ozone.—Malaria.—Animal Emanations.—De-
vitalized House-Air.—Water.—Clothing.—Exercise or Work.—Influence of Occupation
upon Longevity.—Limit to Labor.—The Food of Man.—Accessory Food.—Manner of
Eating.—Tea and Coftee.—Alcohol.—Use and Abuse.—Ardent Spirits —Wines.—Malt-
Liquors.—Tobacco.—Chewing and Smoking should be forbidden in Schoo].—Report
of Naval Surgeons.

One volume, 12mo0. Cloth. Price, $1.25.

D. APPLETON & CO., Pusuisuers, 1, 3, & 5 Bonn Srrzet, New Yor.
Treatise on Chemistry,

BY

H. E. ROSCOE, F.R.S., and
Cc. SCHORLEMMER, F.R.S.,

Professors of Chemistry in Owens College, Manchester.

ILLUSTRATED.

NOW READY.

Votume J—THE NON-METALLIC ELEMENTS. 8vo.
Cloth. $5.00. Containing a Portrait of Dat-
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“Tt has been the aim of the authors, in writing their present treatise,
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the present transition state of the science will permit.

‘“‘Special attention has been paid to the accurate
description of the more important processes in tech-«
mical chemistry, and to the careful representation of
the most approved forms of apparatus employed.

“VWiuch attention has likewise been given to the
representation of apparatus adopted for lecture-room
experiment, and the numerous new illustrations res
quired for this purpose have all been taken from
photographs of apparatus actually in use.°?—LZziract from
Preface.

The above will be sent by mail, post-paid, to any address in the United States,
upon receipt of price.

D. APPLETON & CO., Publishers, New York.
APPLETONS’

SCHOOL READERS,

CONSISTING OF FIVE BOOKS.

BY

WM. T. HARRIS, LL.D, A.J. RICKOFF, A.M, MARK BAILEY, A. M.,

Superintendent of Schools, Superintendent of Instruction, Instructor in Elocution,
St. Louis, Mo. Cleveland, O. Yale College.

Appletons’ First Reader....Child’s Quarto, 90 pages.
Appletons’ Second Reader............ 12mo, 142 =‘
Appletons’ Third Reader,............12mo, 214 ‘
Appletons’ Fourth Reader...........l2mo, 248 =‘
Appletons’ Fifth Reader..............12mo, 471 *

CHIEF MERITS.

These Readers, while avoiding extremes and one-sided tendencies, combine
into one harmonious whole the several results desirable to be attained in a series
of school reading-books. , These include good pictorial illustrations, a combination
of the word and phonic methods, careful grading, drill on the peculiar combina-
tions of letters that represent -vowel-sounds,’ correct spelling, exercises well ar-
ranged for the pupil’s preparation by himself (so that he shall learn the great
lessons of self-help, self-dependence, the habit of application), exercises that de-
velop a practical command of correct forms of expression, good literary taste,
close critical power of thought, and ability to interpret the entire meaning’of the
language of others.

THE AUTHORS.

The high rank which the authors have attained in the educational field and
their long and successful experience in practical school-work especially fit them
for the preparation of text-books that will embody all the best elements of modern
educative ideas. In the schools of St. Louis and Cleveland, over which two of
them have long presided, the subject of reading has received more than usual
attention, and with results that have established for them a wide reputation for
superior elocutionary: discipline and accomplishments. Feeling the need of a
series of reading-books harmonizing in all respects with the modes of instruction
growing out of their long tentative work,.they have carefully prepared these vol-
umes in the belief that the special features enumerated will commend them to
practical teachers everywhere.

Of Professor Bailey, Instructor in Elocution in Yale College, it is needless to
speak, for he is known throughout the Union as being without a peer in his pro-
fession. His methods make natural, not mechanical readers,

D, APPLETON & CO., Publishers, 1,3, & 5 Bond St., New York,
PRIMERS

IN SCIENCE, HISTORY, AND LITERATURE.

18mo. ....

Flexible cloth, 45 cents each.

 

I.—Edited by Professors HUXLEY, ROSCOE, and BALFOUR STEWART.

SCIENCE PRIMERS.
Introductory........ ..T. H. Hoxuey. | Astronomy............ J. N. Lockyer,
Chemistry.............. H. E. Roscor, | Botany................ J. D. Hooxer.
Physies........... Batrour Srewarz. | Logie.................. W. S. Jevons.
Physical Geography........ A. Gerxiz. | Inventional Geometry. .W. G. Srexcer.
Geology. ...... Sel aeateace cite A. Gergre. | Pianoforte.........FRANKLIN TayLor.
Physiology......... Saeritucds M. Foster. | Pelitieal Economy...... W.S. Jevons.

IL.—kKdited by J. R. GREEN, M. A., Examiner. in the School of Modern History
at Oxford.

ETISTORYT PRIMERS.

GreGlOs4). is vane ewan ews C.A.Fyrre. | Oid Greck Life....... J. P. Mawarry.
Rome............ .....M. Creienron. | Roman Antiquities... .. A. 8. WIzxrns.
Enrope.............. E. A. Freeman. | Geography............ GEorGE GROVE.

Ti.—Edited by J. R. GREEN, M. A.
LITERATURE PRIMERS.

English Grammar......... R. Morris. | Studies in Bryant.......... J. ALDEN.
English Literature. ..Srorrorp Brooks. | Greek Literature......... R. C. Juss.
Philology.................. J. Pets. | English Grammar Exercises. .R. Morris.
Classical Geography.......M1.F. Tozer. | Homer............ W. E. Guapstone.
Shakespeare............. E. Downen. | English Composition....... J. NicHOoL.

(Others in preparation.)

The object of these primers is to convey information in such a manner as to
make it both intelligible and interesting to very young pupils, and so to discipline
their minds as to incline them to more systematic after-studies. In the Science
Series some simple experiments have been devised, leading up to the chief truths
of each science. By this means the pupil’s interest is excited, and the memory is
impressed so as to retain without difficulty the facts brought under observation.
The woodcuts which illustrate these primers serve the same purpose, embellishing
and explaining the text at the same time.

D. APPLETON & CO., Publishers,
1, 8, & 5 Bonn Srreetr, New York.
 

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