E]]
EY
§
º
º:
EAJºRUAUALA
ſ wº, “
=ri ſº
\º
w

2–3–é-R3+-4-4-- \. § –4–4- •y.)
\)) \'l-

INSANITY
*-*-*i-sº
*~~~~~
*** *** ... . . .
AND 5–gº ~ - 2
*
,” *Sº,
ITS TREATMENT.
LECTURES
ON THE
TREATMENT OF INSANITY AND KINDRED
NERWOUS DISEASES.
BY -
SAMUEL WORCESTER, M.D.,
SALEM, MASS.
LECTURER ON INSANITY, NERVous DISEASES AND DERMATOLOGY AT Boston UNIVERSITY SCHOOL
of MEDICINE ; MEMBER OF THE AMERICAN INSTITUTE OF HOMOEoPATHY ; MEMBER of THE
MAss ACHUSETTS HoMOEOPATHIC MEDICAL SOCIETY ; Honor ARY MEMBER of THE
NEW YORK STATE HOMOEOPATHIC MEDICAL SOCIETY ; For MERLY Assist-
ANT PHYSICIAN OF THE BUTLER HOSPITAL FOR THE IN SANE A.T
PROVIDENCE, R. I., ETC., ETC.,
BOERICKE & TAFEL:
NEW YORK : PHILADELPHIA :
145 GRAND STREET. 1011 ARCH STREET.
LoNDoN : HomoeoPATHIC PUBLISHING Co., No. 2 FINSBURY CIRCUs.
1882.

Copyright, Boericke & Tafel, 1881.
TO
SELDEN H. TALCOTT, M. D.,
MEDICAL SUPERINTENDENT OF THE STATE HOMOEOPATHIC ASYLUM FOR THE
INSANE AT MIDDLETown, NEw York, IN APPRECIATION OF HIS
EFFORTS TO EXTEND OUR KNOWLEDGE OF THE
FROPER HOMOEOPATHIC TREATMENT
of THE INSANE;
ALSO,
TO THE STUDENTS
OF THE
BOSTON UNIVERSITY SCHOOL OF MEDICINE,
For WHOM THESE LECTURES werE FIRST PREPARED,
THIS VOLUME IS RESPECTFULLY DEDICATED
IBY
THE AUTHOR.
PREFACE.
The lectures which form the basis of the present
volume were first prepared, and delivered before the
Senior Class of the Boston University School of Medi-
cine, in the winter of 1879–80. They were revised and
again delivered at the session of 1880–81. Frequent
inquiries were made by the students and others for the
best work on insanity, one giving at the same time a
knowledge of homoeopathic therapeutics, but I was
obliged to answer that, with the exception of Jahr's
Mental Diseases, we had no treatise upon that subject;
hence the attempt to supply the want by the publica-
tion of these lectures, imperfect as they are. Additions
and changes have been made, and the book is now
given, not as a complete text-book, but as containing
a fairly correct summary of our present knowledge of
insanity and its homoeopathic treatment.
In the preparation of these lectures, free use has
been made of the extensive material within my reach,
- and several hundred volumes have been consulted.
. As a rule, due credit has been given for all matter ap-
propriated from other writers; except in those portions
comprising the lectures as originally given, where to
some extent the views and even the words of others
Vi PREFACE.
have been used. When the lectures were first compiled
there was no thought of their publication, and the same
care was not taken in this respect, as would otherwise
have been the case.
More weight has been laid upon certain subject and
less upon others, than would have been fitting, had I
the intention of preparing an exhaustive text-book,
such as that of Bucknill and Tuke; I have simply tried
under the form of lectures to present such a book as
would be of practical value to the student and practi-
tioner—one that was concise, and yet extensive enough
to be useful as a work of reference.
It has been said by Grotius, that: “The care of the
human mind is the most noble branch of medicine,”
and if these pages enable anyone to do this work any
more perfectly their purpose will be fully accomplished.
SAMUEL WoRCESTER, M.D.
Salem, Mass., Sept. 5th, 1881.
CONTENTS.
LECTURE I.
Introductory and General Survey of the Subject of Mental Disease, .
LECTURE II.
Definition of Terms. False Beliefs of the Insane, .
LECTURE III.
Early Symptoms of Insanity,
Acts of the Insane, . &
Restraining Apparatus, . *
Artificial Feeding of the Insane,
LECTURE IV.
Causes of Insanity,
LECTURE V.
Classification, .
LECTURE VI.
Idiocy and Imbecility and Dementia,
LECTURE WII.
Melancholia, .
LECTURE VIII.
Melancholia, continued. Indications for the Use of Fourteen Principal
Remedies,
LECTURE IX.
23
47
62
65
68
78
94
100
114
145
167
Mania,
LECTURE X.
Mania Transitoria,
Folie Circulaire,
202
210
viii CONTENTS.
LECTURE XI.
Monomania or Instinctive Insanity, .
LECTURE XII.
Pyromania,
Suicidal Mania, .
Kleptomania,
LECTURE XIII.
Puerperal Insanity,
LECTURE XIV.
Epileptic Insanity,
LECTURE XV.
General Paralysis of the Insane,
LECTURE XVI.
Hysteria,
Hypochondriasis,
LECTURE XVII.
Chorea,
Catalepsy, .
Somnambulism,
LECTURE XVIII.
Moral Insanity and Medical Jurisprudence,
LECTURE XIX.
Non-Restraint in the Treatment of the Insane,
217
236
247
252
257
278
321
367
386
393
403
410
413
440
INSANITY AND ITS TREATMENT.
LECTURE I.
Introductory and General Survey of the Subject of
Mental Disease.
Ladies and gentlemen of the Boston University School of
Medicine:—There is said to be always a strong inclination in
the mind of the specialist to magnify the importance of the
particular subject toward which his studies are directed, and
in which his thoughts are bound up. If, however, I remind
you of the many thousands who fill our asylums; and the
thousands at large in Our midst, whose mental disturbance
only becomes a matter of public knowledge after the commis-
sion of some open act of violence and crime; of the frequency
with which questions as to the testamentary or business ca-
pacity of the individual may involve wide spread and serious
results to person and property; if we consider these things it
would seem difficult to magnify the importance of our subject,
especially when we remember that an ability on the part of
the physician to detect and appreciate at their just value, the
early symptoms of mental derangement, and to apply the
proper remedy, would, in very many cases, result in a rapid
cure, if not in preventing the full development of the disease.
But while I fully recognize the importance of the topics we
are to study together, I bear in mind that my lectures form
only a small part of your course of study, and the varied char-
acter of your future professional life. I think, therefore, that I
shall best fulfil my duty, by as far as possible keeping clear of
1 (9)
10 INSANITY AND ITS TREATMENT.
º
the realm of metaphysics, and giving you a clear idea of what
insanity is, the various forms under which it presents itself,
their frequency, causes, dangers and treatment; so that when
you go out into your chosen field of labor, you may not feel
entirely at a loss or ignorant as to what course to pursue when
called to see a patient who is insane.
What is insanity? Strange to say, it is difficult to give such
an answer to this question as will satisfy the accurate critic;
an answer that will include all forms and varieties of mental
derangement, and at the same time exclude diseases not prop-
erly coming under this head.
Dr. Conolly, while admitting the difficulties which attend
any attempt to define insanity, has offered the following, which
will be found to include a large number of cases. “Insanity
is an impairment of one or more of the faculties of the mind,
accompanied with, or inducing a defect of the comparing
faculty.” f
Dr. Andrew Combe says: “It is a prolonged departure, and
without any adequate external cause, from the state of feeling
and modes of thinking usual to the individual when in health,
that is the true feature of disease of the mind,” and again,_
“there is a morbid action in one, in several, or in the whole of
the cerebral organs; and, as its necessary consequence, func-
tional derangement in One, in several, or in the whole of those
mental faculties which those organs subserve.”
Dr. Bucknill, who is one of the best English authorities, and
co-editor of a standard work on Psychological Medicine, re-
gards insanity “as a condition of the mind in which a false
action of conception of judgment, a defective power of the will
or an uncontrollable violence of the emotions and instincts,
have separately or conjointly been produced by disease.”
Prof. W. A. Hammond, late Surg. Gen. U. S. Army, says:
“Insanity is a manifestation of disease of the brain, character-
ized by a general or partial derangement of one or more facul-
ties of the mind, and, in which, while consciousness is not abol-
ished, mental freedom is prevented, weakened or destroyed.”
The late Judge Edmonds of New York, in his Select Cases,
Vol. I, defines a same man as one
INTRODUCTORY AND GENERAL SURVEY. 11
“1. Whose senses bear truthful evidence.
“2. Whose understanding is capable of receiving that evi-
dence.
“3. Whose reason can draw proper conclusions from the
truthful evidence thus received.
“4. Whose will can guide the thought thus obtained.
“5. Whose moral sense can tell the right and wrong grow-
ing out of that thought. *
“6. And whose act can, at his own pleasure, be in conformity
with the action of all those qualities; all these unite to con-
stitute Sanity; the absence of any one of them makes insanity.”
Professor Maudsley says: “Whatever opinion may be held
concerning the essential nature of mind and its independence
of matter, it is admitted on all sides that its manifestations
take place through the nervous system, and are affected by
the condition of the nervous parts which minister to them.
If these are healthy, they are sound; if these are diseased, they
are unsound. Insanity is, in fact, disorder of brain, produc-
ing disorder of mind; or, to define its nature in greater de-
tail, it is a disorder of the Supreme nerve centres of the brain,
the Special organs of mind, producing derangement of thought,
feeling and action, together or separately, of such degree or
kind as to incapacitate the individual for the relations of life.”
Dr. Prosper Despine, of Marseilles, France, expresses him-
self thus in his work De la Folie: “Madness consists in an
involuntary moral blindness of the mind as to the false, ab-
surd, immoral and irrational ideas, and the irrational per-
verted propensities inspired by the passions. A blindness
caused by the absence of the rational sentiments; the only ones
capable of enlightening the mind as to the true character of
these ideas and desires; that is to say, an absence of the moral
consciousness. It seems that this definition clearly points out
the nature of instinctive insanity, a form of mental alienation
which specially merits the name of insanity; a form in which
the instinctive or moral faculties are alone affected, the intel-
lectual remaining untouched. The other forms, such as
mania, paralytic insanity, dementia, idiocy and stupor, seem
to form a class of a wholly different nature, for which the
term, mental alienation serves as the best definition possible.”
12 INSANITY AND ITS TREATMENT.
I shall hardly venture on a definition, but the position taken
in these lectures will be that insanity is a disease of the brain,
a morbid physical state, and not a disease of the mind; but
only, so far as the mind is concerned, a disturbance of its
manifestations. It is undoubtedly true that in the past and in
the present there are insanities caused by spiritual and moral
disturbances and disorders. But in all such cases we have
the accompanying physical symptoms, and it is upon and
through the physical organism that we as physicians must
operate. This theory assumes the existence of a soul or spirit
independent of bodily conditions, so far as death and disease
are concerned, but, so far as this life is concerned, dwelling in
a natural earthly body through the mediation of an inner
spiritual body, which gives form and life to the former; for
St. Paul truly says, “There is a natural body and there is a
spiritual body.” It assumes the brain to be the instrument of
the mind, the physical instrument of mental action. It as-
sumes as a precedent fact and cause of insanity that a morbid
physical change must occur in the brain or its investing mem-
branes; or that there must be a functional disturbance as of
the circulation.
Says Winslow : “Can we conceive a more preposterous no-
tion than that sanctioned by high authority, which inculcates
that the spiritual principle admits of being disturbed, de-
luded, depressed, exaggerated, perverted, exalted, independ-
ently of any bodily disease, or modification of nervous mat-
ter?” and he adds, “is it necessary that I should in this ad-
vanced age of the Science of physiology stop to argue the ques-
tion, whether the brain is or is not the material organ of the
mind 2’’
We can subscribe to the doctrine, that with each display of
mental power, there are correlative changes in the material
substratum (if we choose so to designate the brain), and, with-
out subscribing to the doctrine that mind is the product of
matter under any condition of change, may assert that every
manifest phenomenon of mind is the result or the accompani-
ment to our senses, “of some change, molecular, chemical or
vital, in the nervous elements of the brain.” Man has two
INTRODUCTORY AND GENERAL SURVEY. 13
faculties, a will and an understanding, and together these con-
stitute the mind. The will and understanding are not spir-
itual abstractions, but real substantial forms, even though not
visible to the eye nor the microscope, any more than many
other things which really exist. The human understanding has
its seat in the cerebrum, and thence come the thoughts; the hu-
man will is in the cerebellum, whence come the affections,
passions and desires. Man thinks and wills sanely or in-
Sanely, according as the parts of the brain are in a state of in-
tegrity or not; consequently, he is rational and moral accord-
ing to his mind's organic structure. This is only making the
brain, what has long been admitted and what science seems
fully to demonstrate, the material organ of the mind; a ma-
terial medium through which it impresses itself upon matter,
and through which it communicates with other minds.
In an address upon Biology, delivered before the British
Association, at Sheffield, England, August 20, 1879, the presi-
dent, Dr. Allman, remarked as follows: “When we say that
life is a property of protoplasm, we assert as much as we are
justified in doing. * * * * When a thought passes
through the mind, it is associated (as we have now abund-
ant reason for believing) with some change in the proto-
plasm of the cerebral cells. Are we, therefore, justified in re-
garding thought as a property of the protoplasm of those cells,
in the sense in which we regard muscular contractions as a
property of the protoplasm of muscle? Or is it really a prop-
erty residing in something far different, but which may yet
need for its manifestation the activity of cerebral protoplasm?
The chasm between unconscious life and thought is deep and
impassible, and no transitional phenomena can be found by
which, as by a bridge, we may span it over; for, even from
irritability, to which, on a superficial view, consciousness may
seem related, it is as absolutely distinct as it is from any of
the Ordinary phenomena of matter.”
Holding these views, we may agree with Dr. C. H. Hughes
in admitting that just as a good liver Secretes good bile, pro-
vided the conditions of the blood are favorable, a good candle
gives good light, and good coal a good fire, provided the two
14 INSANITY AND ITS TREATMENT.
latter have a good supply of oxygenated air, and the primary
conditions to the development of light and heat; so does a
good brain, all other conditions being favorable, give the
manifestations of a good mind; without agreeing with Dr. W.
A. Hammond, that “when the brain is quiescent there is no
mind;” and without regarding the mind as nothing more
than “the result of cerebral action,” as does Tyndall; “granted
that a definite thought and a definite molecular change in the
brain occur simultaneously, we do not possess the intellectual
organ, nor apparently any rudiments of the organ which
would enable us to pass by a process of reasoning from the
One phenomenon to the other, they appear together but we do
not know why.” We admit the invariable connection be-
tween brain-power and the power of mental manifestation;
but the brain is still in our view the servant of the mind,
though the latter is influenced by the states of the former, in
the manifestations it makes to the world. The brain serves
the mind, and yet the mind is dependent upon the brain, just
as the master is in a sense, the servant of his servants, and de-
pendent upon them.
We may regard mind, as manifested to us, as so closely
blended with matter in the form of brain-cells, that we cannot
tell where one ends and the other begins,—cannot draw a line
of demarcation. We may consider a living material organism
as essential to the manifestations of the mind; and the differ-
ent manifestations or expressions of mind in health and in
disease as dependent upon the physical condition of that or-
ganism, just as the will-power is dependent upon the healthy
state of the organs which it controls for its expression or mani-
festation.
We would also fully agree with Prof. Maudsley in the re-
mark, “To call mind a function of the brain, might lead to
much misapprehension, if it be thereby supposed that the
brain is the only organ which is concerned in the function of
mind. There is not an organ in the body which is not in in-
timate relation with the brain by means of its paths of ner-
vous communication; which has not, so to speak, a special
correspondence with it through internuncial fibres, and which
INTRODUCTORY AND GENERAL SURVEY. 15
me
does not therefore, affect more or less plainly and specially its
function as an organ of mind. It is not merely that a pal-
pitating heart may cause anxiety and apprehension, or a dis-
ordered liver gloomy feelings, but there are good reasons to
believe that each organ has its specific influence on the consti-
tution and function of mind. So close is the physiological
sympathy of parts in the commonwealth of the body, that it is
necessary in the physiological study of mind to regard it as a
function of the whole organism, as comprehending the whole
bodily life.”—(Responsibility in Mental Disease, p. 17.)
We see then that the term diseased mind is merely a con-
venient mode of saying that the mind in its manifestations to
our perceptions is altered, just as the light of the Sun is ob-
scured to our sense of vision by the clouds. The emotions
and manifestations of mind to the individual and to those
about him are changed by the obscuration and destruction of
his senses.
Again using the language of Maudsley, “We recognize how
entirely the integrity of the mental functions depends upon
the bodily organization,” and as physicians we cannot afford
to lose sight of the physical aspects of mental states, if we
would truly comprehend the nature of mental disease. “We
must recognize the existence of an intelligent mental force,
linked in harmonious association and essential relations with
other forces, but leading and constraining them, and led and
constrained by them in its manifestations.”
What I would especially impress upon your minds is that
insanity is one of the neuroses, always an actual disease of the
brain. Dr. Amariah Brigham, for many years Superintendent
of the Asylum at Utica, N.Y., says: “The phrase derangement
of the mind conveys an erroneous idea, for such derangement
is only a symptom of disease in the head, and is not the pri-
mary affection. The immaterial and immortal mind is, in
itself, surely incapable of disease, decay, and derangement;
but, being allied to a material organ upon which it is entirely
dependent for its manifestations upon earth, these manifesta-
tions are suspended or disordered when this organ is diseased.”
Again, Griesinger says: “Insanity being a disease, and that
16 INSANITY AND ITS TREATMENT.
disease being an affection of the brain, a disease which also
causes death, it can only be studied in a proper manner from
the medical point of view.” And Dr. Blandford says: “Un-
soundness of mind is but another term for disorder of the
human brain, or rather of that portion of nerve matter which
has for its function the manifestation of mind.”
It is evident that in order to properly understand the dis-
ordered workings of the mind, we must study it in health.
The physician necessarily becomes a student of mental philo-
sophy. He has to deal with mental phenomena in all forms
of disease. In cases of indigestion and constipation he has
often to deal with quality of depression, which he may after-
wards recognize in a more marked degree, as the developing,
central impression; clouding the judgment, and disturbing
the emotional life, and heralding an attack of melancholia or
hypochondria. Later, he finds this quality of depression be-
coming a defined, concrete, painful Sentiment, occupying the
entire thought, and ultimately developing into delusion and
the patient is insane. So in other forms of insanity; the
normal habits of thought, the ordinary play of feeling, will
be found to have undergone an unsteadiness under physically
disordered states, which may or may not have been brought
to the attention of the physician, before the final outbreak in
Open insanity.
I cannot do better at this point than repeat the words used
by Dr. John P. Gray in a lecture before the medical class at
Bellevue College. He says: “Insanity is not a strange, mys-
terious, incomprehensible condition of mind. It introduces
nothing new. It is only a heightening, a lessening, or a per-
version, more or less complete, of the natural qualities and
characteristics of the individual; a changed state of the mental
operations due to physical disorder within the cranium. That
this disturbance of feelings and of the mental operations is
often painfully appreciated by the patient is a significant fact.
Indeed the majority of persons who become insane, detect the
earlier indications and are frequently able to give the preced-
ing and concomitant bodily troubles. And it is not uncom-
mon for persons to seek admission to an asylum themselves,
INTRODUCTORY AND GENERAL SURVEY. 17
not simply under vague apprehensions of insanity, but under
a recognition of bodily and mental disturbance, in which they
are conscious, to use a common phrase, that “they are not
themselves, and are out of their mind.” He also says: “I
wish here to state that I have never carefully examined an
insane person who did not present physical marks of the dis-
order, and I have never seen a post-morten) of the brain of an
insane person, however recent or mild the attack, where the
microscope failed to reveal lesions of structure.”
It is also true that in an asylum we meet with nothing new,
we find the same ideas, the same errors, the same passions, the
same misfortunes; it is the same world; but in such a house
the traits are stronger, the colors more vivid, the shades more
marked, the effects more startling, because man is there seen
in all his nakedness, because he does not discriminate his
thoughts, because he does not conceal his defects, because he
lends not to his passions the charm which seduces, nor to his
vices the appearances which deceive.
I have dwelt thus long on this part of my subject, so as to
bring your minds fully to recognize the one central idea of
disease; to urge you to look upon it as physicians, to bring to
your aid your knowledge of anatomy and physiology in study-
ing this subject, so that under clinical study you may more
easily apply the principles of pathology and common sense
in your investigations.
In all times various opinions have been held regarding the
connection between the soul and the body, and the most
widely differing hypotheses have been put forth on this point;
this is still the case, especially in Germany; where the opinions
of the spiritualistic school, first set forth by Stahl, and supported
by Heinroth and Ideler, still contend for supremacy with the
views of the materialistic or somatic school, of which Jacobi is
the most able and noted champion. The psychical School dis-
regarded or denied the influence of the body on the mind, and
considered all the phenomena of insanity only as abnormal
activity of the mind. On the other hand if the existence of
the mind were denied, all spiritual activities were stamped as
expressions of the life of the brain, or crowded together in a
18 INSANITY AND ITS TREATMENT.
labyrinth of incomprehensible and complicated reflex phe-
nomena; and upon this conception, a mere machine or autom-
aton was made out of the human body.
According to my convictions we must clearly separate the
functions of the brain, which have different results according
to their different purposes, and according to the condition of
the active cells, from a higher principle, namely, an indepen-
dently operating mind, which, as was before intimated, is in
the most intimate way connected with those cells, and receives
impressions through them, but which again can act inde-
pendently upon them; and, by this arbitrary acting is dis-
tinguished from all other powers of nature.
This absolute will acts nowhere but in the brain, and in this
alone is our consciousness rooted. Some writers speak of an
unconscious will in the spinal cord, but the words themselves
seem to involve a contradiction. If a nerve or the spinal cord
be divided, automatic or reflex movements may occur in the
separated parts, but not spontaneous or voluntary. We feel
indeed that the seat of our consciousness is in the head alone,
and the body really finds itself outside the ego; that we act on
the body as on an apparatus in which our mind does not dwell.
Dr. Garth Wilkinson divides the nervous system into an
animal and an automatic; the latter is a mere machine; the
former in its two-fold aspect is a nerve animal with senses.
The cells in the brain develop an activity which communi-
cates itself to the mind, be it as perception of a sensitive im-
pression, be it—and this is the principal thing—as image or
idea, as reproduction of a previous perception. Thus we stand
in the closest connection with that cell-activity. For as it may
communicate itself to our mind, so on the other hand may our
mind act on the cells in the cortical layer; we are in a posi-
tion to set the cells in activity and thus call up a dormant
image, a memory or a recollection. Yet the functions belong-
ing to the cells, must not be confounded with the ego; the or-
ganic power acting in them finds itself dependent upon their
composition, and they are accessible to other stimuli than our
will. If the cells are irritated in the way of inflammation as in
insanity, or through abnormal conditions of the blood as in
INTRODUCTORY AND GENERAL SURVEY. 19
fever, then the images appear involuntarily, and we are de-
lirious.
Prof. Van der Kolck says: “Could any one, indeed, contend
that the violent spasms of an epileptic attack exhibit abnormal
action of the mind? The organic power acts here for itself;
therefore, not according to the will; it is not identical with
our higher principle, but rather subservient to it. If through
an attack of cerebral hemorrhage the implements on which
our will acts become affected, then paralysis occurs, that is to
say the capability for movement is lost, but not the will for
their execution, from which it may be concluded that the
activity of the brain is not the same thing as the mind or
higher principle. Surely no one would maintain that by
means of drugs or electricity, through which anaesthesia or
paresis would be removed, the lost activity of the perception
or the lost will would again be restored to the mind. Only
the instruments with which our mind works are brought
again to their normal state. In this relation between the
higher individuality and the functions of the brain, we have
the connection between mind and body, by means of which
both act interchangeably on one another. But the connection
is so intimate a one, that every increase of energy of the brain,
every alteration or exhaustion of it soon reacts on the mind;
in the one case, raising and straining, in the other, depressing
and blunting.”
This involuntary influence of the body in general, and of
the brain in particular, displays itself under special circum-
stances in a more or less decided manner; indeed, even ex-
hibits itself in peculiarities in the dispositions and character
of different individuals. It is the cause why, in our actions,
So often something involuntary, a certain blind impulse, is in
operation.
The occurrence of the voluntary and the involuntary in
our actions is one of the most difficult problems. The most
Satisfactory explanations are offered to us by the accurate in-
vestigation of diseased conditions, where the activities occurr-
ing belong to the involuntary, and, according to the differ-
ent degrees of their manifestation, can be most readily dis-
tinguished.
20 INSANITY AND ITS TREATMENT.
We should remember that the brain-cells, those namely in
the anterior part of the hemispheres, not only aid us to achieve
ideas, but also to recall the presence of earlier received im-
pressions; which impressions are sometimes involuntarily
communicated to our mind; or at times through our mind
are again increased in liveliness and activity. The faculty of
imagination belongs therefore to that mental power which
stands in the closest consociation with the functions of the
brain. “If these cortical cells are in activity, it depends
entirely on the degree of excitement, whether the involuntary
has the upper hand as in delirium; or whether the mind gov-
erns and arranges the images and ideas, and voluntarily pro-
duces through quiet ruling, bold creations of fancy, such as
we admire in the plastic works of a Powers, in the “Jerusalem
Delivered” of a Tasso, or in Beethoven’s masterly compositions.
These cells of the cortical substance thus mediate as connec-
tion between body and mind. If, on the one hand, through
these cells involuntary images are called forth, as in sleeping
or dreaming, so on the other hand, we are able to act upon
them and set them in operation, so that this or that image
arises for us, which at a previous time had been laid down
there by sensitive impressions and stored up.”—(Pathology
and Therapeutics of Mental Diseases. J. L. C. Schröder Van
der Kolck.)
The cortical, or ideational cells, as Maudsley calls them, first
receive the impressions through the perception cells of the sen-
Sory apparatus, and, while the impression in the perception
cell soon vanishes, it remains stored up and slumbering in the
ideational cells of the cortex. These latter form the store-
house and magazine for the treasures of our memory; if they
have once reacted on an impression, and have thus become
Set in activity, then they appear changed in state and form,
So as to retain this impression, and henceforth are capable of
responding in the same way to a mental stimulus from within,
as formerly to a sensory stimulus from without.
This effect of sensory impressions on the cortex of the brain
must be clearly distinguished from the impressions themselves.
Borrowing an illustration from Van der Kolck, let us imagine
INTRODUCTORY AND GENERAL SURVEY. 21
a blind man who feels a triangle. He first finds one angle,
and then passing the finger over the object, he finds also the
other two angles. These impressions are conveyed to the per-
ception cells of feeling, and thence are delivered to the cells in
the cortex of the brain, where the different impressions are by
the mind combined into a whole, so that the triangle is per-
ceived. Such a course of events can be possible only by the
impression here not being obliterated as quickly as in the
perception cells. If the impression remained a long time in
the latter, the observation of the first angle would coincide
with that of the second and third; and the perception of the
three different angles, and their combination in the brain
cortex into one body, namely, into a triangle, would be im-
possible. Here the isolated impressions are first combined,
here also we discern whether different simultaneous in pres-
sions coming through several organs of sense proceed from one
object or from several.
All this is higher action of the mind, and the cells which
retain and elaborate the impressions as images and ideas
stand in relation to it as indispensable means.
Observation and the progress of modern physiology all tend
to show that the workings of the mind act upon the body, not
merely in exceptional cases, but constantly; that is to say, that
the ideas, emotions, thoughts, passions and actions are invar-
iably followed by certain organic changes in the brain. Hence
the efficacy of moral causes in producing insanity.
From the foregoing considerations it seems evident that in
our spiritual activities, an involuntary action of the body (the
organic function of the brain cells included), and the volun-
tary action of the mind meet together, and in and on one
another, and thus complex thoughts, thoughts and ideas are
Originated.
Dr. Garth Wilkinson says: “I know of nothing that ex-
presses so physiologically the case between the automatic and
the other parts of this system as the ratio between the living
creatures and the wheels in Ezekiel. “And the living crea-
tures went, the wheels went by them; and when the living
creatures were lifted up from the earth, the wheels were lifted
22 INSANITY AND ITS TREATMENT.
up. Whithersoever the spirit was to go, they went, thither
was their spirit to go; and the wheels were lifted up over
against them, for the spirit of the living creature was in the
wheels. When those went, these went; and when those were
lifted up from the earth, the wheels were lifted up over against
them for the spirit of the living creature was in the wheels.”
As regards the different kinds of action of the cortical cells,
it seems to be acknowledged by most physiologists, that the
convolutions lying under the frontal bone, or the fore-brain,
are concerned more in the higher, spiritual faculties: the un-
derstanding and the function of ideas; while the posterior
convolutions and especially those of the cerebellum are more
involved in manifestations of the emotions, affections and
passions.
Schröder van der Kolck says, although anatomical evidence
of its truth is wanting: “Through the anterior lobes of the
brain rather the plastic visual impressions are received;
through the posterior lobes rather the perceptions of hearing
and feeling. Through the posterior cells the mind receives a
peculiar perception and disposition by means of its faculty of
delineation, and indeed with the help of the anterior brain
lobes it gives to this perception form and body.”
In support of this view that the different lobes of the brain
have different kinds of work to perform, Van der Kolck, who
was for a long time Professor at Utrecht, says, that in insanity
proper he has always found the anterior lobes of the brain
suffering; while in the melancholic and those who have con-
demned themselves, with or without religious admixture, he
has found the upper and posterior parts of the lobes diseased;
and, that in the latter cases the understanding showed no
trace of disturbance, inasmuch as the individual judged cor-
rectly and disputed acutely. The pathological affection then
limits itself to the upper and hinder parts of the lobes, and in
the foreparts nothing abnormal is seen in regard to color,
firmness and connection with the pia mater. In those who
had finished with dementia, the anterior parts of the lobes
were never found intact; they were always adherent to the
pia mater, and this could not be removed without injury to
the brain cortex.
FALSE BELIEFS OF THE INSANE. 23
LECTURE II.
Definition of Terms. False Beliefs of the Insane.
Before entering upon the study of the various forms of in-
sanity, it will be well for us to obtain a clear understanding
of the meaning and proper use of certain terms in constant
use when speaking of the insane. These terms you must
comprehend if called upon to give opinions respecting the
mental condition and legal responsibility of parties who have
made wills or contracts; or who have committed offenses
against person or property; or in cases where it is proposed to
appoint guardians over the persons and estates of those sus-
pected of insanity, or commit them to the custody of an asylum.
All this you will find of great importance if ever brought into
courts of law, as well as when you are seeking to understand
the workings of the insane mind.
These terms are hallucination, illusion, delusion, impulse, lucid
interval and delirium. I mean to do more than call your at-
tention to the bare definition of these words, and to try to
give you an idea of the pathological states in which they are
found, so that you may be able to differentiate insanity from
other diseases of the brain, and from other disordered states
of the nervous system.
Let us first briefly consider the various false beliefs of the
insane, and then give a more particular study to a few of the
most important.
IHallucination is variously defined by authors and is used in
a wide sense; but in a restricted and medical sense, it is a false
perception of the senses. The person sees, hears, smells or
feels that which has no existence. Despine says, that halluci-
nation consists in the perception of a sensorial impression,
produced, not as is usual, by the action of the external world
upon the sensory nerves in the organs of sense, the eyes, ears,
skin, etc., but by stimulation of those nerve tracts from within.
Hallucination then, is not a simple product of the imagina-
24 INSANITY AND ITS TREATMENT.
tion; it does not bring up an object as in a dream or an ob-
jective memory; the sensorial impression is as real as when
caused by an external stimulus. The hallucinated individual
sees the object with his eyes as if it really existed. He hears
the voices as well as if they really spoke; and there is noth-
ing so far as his senses are concerned which can cause him to
distinguish the sensorial impression thus produced from one
caused by an outward object. The knowledge that he has of
the phenomena, the reasoning that demonstrates the impossi-
bility of the presence of the perceived objects, the testimony
of others denying their existence, can alone give him the cer-
tainty that they do not really exist. The hallucinated pa-
tient thinks that he sees in the blackest darkness, or hears a
voice through any number of thick walls, whereas his seeing
or hearing is entirely subjective, taking place altogether within
his own head, without any excitation conveyed to his organs
from the outer world; when in fact he would hear and see
just the same were he deaf or blind; for example: Mr. T., a
highly educated and refined gentleman was a patient in the
hospital where I was a medical officer. Being fond of bil-
liards we often indulged in a game for recreation; but more
than once while we would be playing in perfect silence, he
would glance up at me suspiciously, and in a few moments
throw down his cue, leaving the game unfinished, and with-
out a word, retire to his room, and from choice remain there
in seclusion two or three days. While playing it would seem
to him as though he was suddenly assailed by voices insult-
ing him with all manner of vile language, and accusing him
of all sorts of crimes.
An Illusion is an error of perception, the person transforms
a real object or sound into something else. There is in this
case something to See and something to hear, but that which
the patient thinks he sees is not the real thing but something
else. He sees a chariot in the sky, when every other person
sees only a cloud; he hears a voice when others hear the
noise of a carriage, the sighing of the wind or a distant foot-
fall.
A Delusion is, in a general sense, a false idea; of the falsity
FALSE BELIEFS OF THE INSANE. 25
of which he cannot be persuaded, either by his own knowl-
edge and experience, by the evidence of his senses or by the
demonstrations and declarations of others. A man thinks
that he is dead, that he has a fire in his inside, etc., and no
amount of proof convinces him to the contrary. In a medi-
cal sense it is a false belief, and mainly, as it appears in in-
Sane persons, a misinterpretation of the appearance, the man-
ner, the speech and the acts of those about them, or their con-
ditions and circumstances.
These three terms are often used as if synonymous. They
do interlace with each other. However, if you bear in mind
as Dr. J. P. Gray says, that hallucinations and illusions are
Only associated with the special senses and bodily sensations;
and that hallucination is wholly error, that what the patient
maintains that he sees, hears, smells or feels, is utterly without
foundation; and that illusion is a deception as to the identity
or real character of the object; that the patient simply trans-
forms a given object into something else; and that delusion
applies only to ideas, you will establish in your own mind a
sufficiently clear distinction. To put the matter in the plainest
possible form, hallucination is a lie told by the senses out and
out; illusion is a deceptive view of any existing fact or thing
by the senses; and delusion is a belief by the mind of that
which has no foundation, and, as we often see delusion in
insanity, an untrue interpretation of that which does take
place.
As was said before, insanity introduces nothing new. These
terms as must be evident to you, describe conditions of the
mind and sense, constantly found disconnected with insanity.
All these states of mind and sense are acknowledged to be
compatible with reason, with entire freedom from insanity,
though perhaps not with perfect health. As examples of this
we may refer to the voices heard and appearances seen by Dr.
Samuel Johnson, Nicolai the bookseller of Berlin, and others.
In a lecture before the students of Columbia College upon
hallucinations consistent with reason, Dr. John Ordronaux
said: In those individuals who habitually overtask the brain,
we shall find manifestations of that form of hallucination
2
26 INSANITY AND ITS TREATMENT.
which is the offspring of intensified and protracted thought.
It is the true hallucinatio stadiosa, and the period at which it
develops itself will depend upon certain physical causes not
necessary to mention here. Let it suffice to say that these
hallucinations are generally produced by inability to sleep
soundly, and this tendency to insomnolence once established,
readily passes into that of coma vigilans, a state productive of
exquisite irritability. When the brain is long robbed of sleep
it loses both the knowledge of and the ability to sleep. During
this condition of vigil it reacts upon the stomach, and this
again upon the brain, so that we now have two foci whence
nervous irritability can be radiated and interchanged. The
famous Lawrence Sterne was once in this condition for several
months, and Martin Luther, as the result of his protracted
mental labors, was often visited by an hallucination that the
Prince of Darkness stood before him, and on one occasion went
so far as to throw his inkstand at him. Dr. Johnson too,
whose mighty intellect could endure a superhuman amount
of labor, was nevertheless the victim of hallucinations, and
one of the most superstitions men of his time. Rare Ben
Johnson was also similarly visited, and Andral the great
anatomist was pursued by the image of a child which he had
most critically dissected. &
In these instances the false perceptions were corrected by
the understanding, they did not believe in them and were not
insane. But we also find a firm belief in hallucinations and
illusions to be perfectly consistent with sanity, as for example
that of the Emperor Napoleon in his star, as related by Gen-
eral Rapp; and the appearance of the radiant child to Lord
Castlereagh, and other similar instances. In all these cases
we find the belief caused by superstitious education, or a belief
in such appearances as not only consistent with religion, but
as a sort of divine revelation. Belief was held in their truth,
but the persons were not insane. As a noted author has said:
“Some individuals do not rectify their hallucinations; they
believe in the reality of the perceived sensations, but, at the
same time, they explain them as Supernatural causes, the in-
terference of a higher power. On other points their conduct
FALSE BELIEFS OF THE INSANE. 27
is perfectly sensible. In our opinion there is no more mad-
ness with these than with the others. The belief in the super-
natural is in the depths of the heart. Their point of view
being different, they form a different judgment of the impres-
sions which they receive; they deduce different consequences.
In order that madness be real, confirmed, that it be alienation,
it is requisite, in order to be true to the etymology of the word,
that the intellectual portion of the consciousness, or that be-
longing to the affections, be injured, that the individual be
master neither of his will nor of his judgment.” (A. de Chambé,
Analysis of Stafkowski’s work on Hallucinations.)
You may say what hallucinations, illusions and delusions
are we to consider, and why take any into account? In all
those cases referred to as being consistent with sanity, the
appearances were recognized as being outside of their ordinary
experience. A portion referred them to some departure from
a normal state of health, and regretted and deplored their ex-
istence. Others accepted them as real, but did so in conse-
quence of religious training or the ordinary belief of the time,
and regarded them as messengers sent to warn, instruct and
guide them; as indeed we must acknowledge may have been
the case many times, if we believe in the truths of divine rev-
elations, and that God’s care for his children did not cease
with the end of the Jewish dispensation.
We will now consider the hallucinations, illusions and delu-
sions not included in the previous classes, but occurring in
the insane; all these are due to recognized disorders of the
brain and nervous system. In many cases you will find these
three forms of false belief existing in the same persons, or you
may meet but one or two of them.
I do not wish to be understood as teaching that these phe-
nomena are to be referred to the organs of special sense.
Whilst hallucinations and illusions are of the order of sensory
phenomena they are as to their origin cerebral in character,
as are delusions. Hallucinations and illusions of sight and
hearing in insanity have their origin in the brain as a part of
the disturbance of mental operations, and the external senses
have nothing to do with them. Doubtless there are insane
28 INSANITY AND ITS TREATMENT.
persons who have true hallucinations from disease of the
organs of hearing and sight; or of touch, from disease of the
terminations of the peripheral nerves, but they are mostly
general and ill-defined in their character, and are similar to
the phenomena common to diseases of those organs.
In speaking of the hallucinations of the insane, Dr. John
P. Gray, Superintendent of the Utica asylum, says, that the
history of cases shows:
1. That in these cases there is, as a rule, no disease of the
organs of special sense.
2. Hallucinations disappear with the decline of the delu-
sions, if recovery take place.
3. Hallucinations take on the character of the prevailing
delusions or false line of thought.
4. Hallucinations disappear in dementia or failure of men-
tal activity, but remain in chronic mania, with activity of
mind and fixed delusion.
5. Entirely blind and deaf persons have hallucinations of
sight and hearing when insane.
6. Hallucinations of sight are frequent and prominent in
the dark as well as in the light.
7. In the acute stages of insanity, hallucinations and illu-
sions are present, and rapidly change with the constantly
changing false ideas, revealing their mental or cerebral origin.
8. The hallucinations of the insane are not simply vague
sounds, or words or lights, or ghostly shadows flitting about.
They are compound, varied; often consist in seeing and talk-
ing with people in long conversations; and often like a rev-
erie intensified and prolonged.
The diagnosis of hallucination is generally simple, but you
will not always find it easy to distinguish between it and de-
lusion. In some cases your task will be difficult, when the
patient refuses or is unable to speak, or when his explanations
are confused or incoherent. Certain delusions may develop
Quite different hallucinations in one person than in another,
You will find entirely different hallucinations in persons
who are highly educated, and whose range of thought is great,
from what you will see in the ignorant and illiterate. This is
FAILSE BELIEFS OF THE INSANE. 29
easily understood when we remember the important part
played by the memory and the imagination in the achieve-
ment of ideas, which occurs as the result of education and
habits of thought, and is an additional argument for the cere-
bral origin of hallucinations in the insane.
The phenomena of hallucination being psycho-sensorial, let
us study the part taken by the internal nerves of sense on the
one side and the mind on the other. This analytical study is
necessary in order to gain an exact idea of hallucination and
to satisfactorily explain its mechanism. Many theories have
been advanced, and among them those views lately advanced
by Dr. Ritti, in a work entitled, “Théorie physiologique de
l'hallucination,” are well worthy of attention and study, being
based upon some noteworthy researches of Dr. J. Luys, at La
Salpêtrière. But I propose placing before you the views of
Dr. Prosper Despine, as unfolded in his valuable work entitled,
“Psychologie Naturelle,” as they are the most satisfactory to
my mind of any yet advanced.
1. The role played by the organs of sense; and by an organ
of sense in this connection we understand not only the exter-
nal apparatus which contains the peripheral terminations of
the special nerve, but this nerve throughout its entire ex-
tent up to its termination in the nervous centre of mental and
automatic perception, whether this be or be not in the optic
thalami as taught by Luys. For the production of the phe-
nomenon it is not even necessary that the whole nerve should
remain; a part of the nerve, however small, if in communica-
tion with the nervous centre of perception, is sufficient; thus
hallucinations are possible after the destruction of the ex-
ternal organs of sense, and also part of its special nerve. The
final ramifications of this nerve, which lose themselves in
the white brain substance, in order to terminate in the gray
cortex, the organs of mental perception, are alone required.
Frequently, indeed, the irritation giving rise to the halluci-
nation has its origin in this part of the nerve; then the mind
by force of habit, ascribes to the organ of sense even when it
no longer exists, the impression felt by the nerve, regardless
of the portion of its course that may be irritated. It is in ac-
30 INSANITY AND ITS TREATMENT.
cordance with this law of projection, that after amputation,
the patient refers to his absent foot, in which he has long suf-
fered pain, the twinges which he still feels in the nerve trunks
of the leg. Esquirol speaks of a man who for thirty-eight
years had hallucinations of sight; after death the optic nerves
were found atrophied through their whole extent.
Ordinary sensation being caused by a transmission to the
brain, and consequently to the mind; not of a quality or state
of an external object, but of the quality or state of a sensory
nerve; a quality or state determined by an external cause, it
follows that if one of these nerves is stimulated by an internal
cause in the same manner as by an external, it will produce
in the brain a sensorial impression similar to that caused by
stimulation from without. Every stimulation of the nerves
of sense produces in the brain an impression holding a defi-
Inite relation with the functions of that particular nerve, and
a similar perception by the mind. Thus the stimulation of
the optic nerve produces a light; one sees a thousand stars or
a globe of fire; stimulation of the auditory nerve produces a
sound; that of the olfactory an odor, etc. The circumstances
then requisite to the sensory act of the hallucination reside
in the irritation, by an internal stimulus, of the sensory nerve
at Some point in its continuity, and not, as is usually the case,
by the external world through the organs of sense.
Among other proofs that all excitation of the nerves of sense
produces a perception in specific relation to their special func-
tion we may cite the following. When the nerves remain im-
pressed for a short time after the cessation of the external ex-
citing cause, they continue to transmit to the brain the same
sensory impressions so long as the stimulation lasts. For a
short time after looking at the sun, everything seems sur-
rounded by fire, and it is the same on shutting the eyes. If
we gaze intently for a few moments at a very bright white ob-
ject resting upon a black background, we continue to see it
after turning away almost as well as if it were before our eyes
If the acoustic nerve be exposed for a long time to the noise
of a steam engine, the vibrations in the nerve continue for
Some time after the cause has ceased.
FALSE BELIEFS OF THE INSANE. 31
This active intervention of the sensory nerves is not hypo-
thetical, we have irrefutable proofs that the nerves of sense
are affected, excited, in hallucinations, just as they are at other
times by external stimuli. Thus persons have hallucinations
of one eye only, others of one ear, etc. Moreau speaks of an
insane woman who heard imaginary voices with the right ear
only. Marcel Douat speaks of a woman who saw ghosts and
tombstones with the left eye only, etc. According to Ritti, all
these facts are easily explained by the physiological theory
developed by him. He thinks that these unilateral hallucina-
tions are due to functional disturbances of certain parts of the
optic thalami of one side only. But the most convincing proof
is to be found in the experiment proposed by Dr. Brewster
and repeated many times with the same result. It is well
known that if we derange by the pressure of the finger the
parallelism of the two eyes, the objects before our eyes will
appear double. Now if the experiment be tried with the man
suffering from hallucinations of sight, he will see double the
objects which do not exist at all. If the optic nerves were not
affected, as they are in normal vision; if the hallucinations
were only a mental phenomenon, as Esquirol believed, it must
be evident to you that disturbing the axes of the two eyes
would not produce such an effect.
An excellent illustration of hallucination and sensorial
phenomena occurring in himself is related by S. Van der
Kolck as follows: “The operation of the sympathetic, derived
from the colon, which exhibits a peculiar tendency to reflex
action on the brain, I have had an opportunity of perceiving
on myself. In consequence of a powerful mental exertion and
fatiguing work with the addition of a cold, I was attacked with
a remittent fever, after, quite contrary to my habit, I had pre-
viously suffered for some days from constipated bowels, with a
feeling of fulness in the abdomen. After two days duration of
the fever, hallucinations and phantasms appeared to me; on
shutting my eyes I always saw a number of people about me,
and at the same time I had complete consciousness, as I was
convinced it was only hallucination. Three days and nights
these appearances continued with increasing intensity. In
32 INSANITY AND ITS TREATMENT.
sleep I dreamed constantly, and after waking I only needed
to close my eyes in order to see the people who continually
changed. At last I had a clyster, through which a large
amount of highly fetid matter was evacuated, and in a mo-
ment all the appearances vanished, so that I felt myself re-
stored.” He adds: “On account of the feverish heat, I used
cold applications to the head, and these had immediately the
effect of making the surrounding persons and their clothes
pale; their movements also became slower; for there played
about me the image of a landscape, filled with a number of
men, and at last I believed that I saw around me only dull
gray and white statues. As I had full consciousness, I repeated
this experiment several times with the same results. With the
cessation of the cold applications the movement and colors of
the images again returned. I even altered the experiment a
few times by making the application only on the right or on
the left side of the head; then only the pictures on the side
corresponding to the cold applications became pale, and the
other half of the group of images retained their former live-
liness.”
2. We will consider the role played by the mind. Hal-
lucination being both a sensory and psychical phenomenon,
we will attempt to study the part taken by the mind in its
production. This participates in two ways. First, by furnish-
ing by the memory or imagination the objects represented.
The object generally has some relation to the sentiments felt
by the individual. He who is a prey to fear will experience
terrifying hallucinations, the man dominated by religious feel-
ings will have hallucinations connected with the mystic and
Supernatural ideas of his mind. Still as the imagination has
its singular freaks, producing, without known cause, strange,
ridiculous and eccentric ideas, having no connection with or
resemblance to the habitual thoughts, such, for example, as
come to us in dreaming, so also it can furnish to the halluci-
nations similar strange objects for its perception, this peculiar-
ity ought not then to surprise us more in one case than the
other. The queerness of the ideas at times present in the hal-
lucinations even of the Sane is very remarkable. “A man,”
FALSE BELIEFS OF THE INSANE. 33
writes Gratiolet, “applied himself so diligently to some pro-
found research, that his imagination was kindled, his intellect
solved the problem; but in the midst of his labor he hears fre-
quent and confused voices around him, reviling and insulting.
A religious man gives himself up to God in prayer, all the
forces of his will are directed toward the things of heaven, and
yet he thinks he hears around him devils reviling, and words
of contempt and ridicule. How shall we explain this? That
a hermit, lost in toils of solitude and fastings, overcome by
hunger and continence, should hear voices tempting him to
eat, or the voices of women alluring him, is not strange; there
may be reasons for this in the organic stimulation, the crav-
ings of the flesh momentarily regain their sway as all can un-
derstand. But from what particular organs proceed these
bitter railleries, these reproaches, and persecutions without
cause, which shake the faith of the noblest minds, and cause
the most cultured reason to tremble in the balance?”
After furnishing the object of the hallucination through the
medium of the imagination or the memory, the mind enters a
second time into the phenomena, by perceiving this object
after it has béen materialized, projected, personified, so to
speak, by means of the stimulation of the nerves of sense by
some internal cause.
Understanding the respective parts taken by the mind and
the sensory nerves, we can now perceive the manner in which
the hallucinations are produced. This hallucination generally
coincides with a cerebral excitation, either pathological as in
the insane, or physiological as with deep thinkers; this exci-
tation may extend to the nerves of sense terminating in their
organ; but when these nerves are stimulated, then results,
according to the nerve impressed, a light, a sound, an im-
pression of touch, an odor, a taste, the only ways in which
these nerves manifest their activity. How now do these sen-
sory impressions take a form, a body? How do they give the
representation of an object, and how is this object drawn in
the imagination? The cerebral excitement which produces
all these phantoms and pictures being the agent whereby the
nerves of sense are stimulated, and it being the custom of each
34 INSANITY AND ITS TREATMENT.
stimulated nerve to transmit the representation of an object in
a material form, it follows that the nerve, before transmitting
a Sensible object to the mind, will take that object into the
actual thought through the medium of the brain. The person
will then really perceive with his eyes an object furnished by
his mind; he will see sensibly, so to speak, the products of his
imagination; he will hear his thoughts articulated in words,
as clearly and in the same way as if they came from without.
Then by force of habit, the mind refers to the external world,
the perceived sensations, and assigns in that external world, a
place to those objects, such as seems suited to their character;
these different phases succeed each other so rapidly as to seem
almost simultaneous.
It is here interesting to note that hallucinations of sight
never occur to those born blind, but do occur to those in whom
the external visual organs have been destroyed; another evi-
dence in favor of the cerebral origin of this phenomenon.
This activity of the nerves of sense, produced by the excita-
tion of the brain, being the cause of the sensorial phenomena
of hallucination, it may be asked, Why does not all brain ex-
citement act upon some one of the nerves and give rise to hal-
lucination? The fact is, that this kind of stimulation is ab-
normal, pathological; for, as you know, the natural course of
the current in sensory nerves is towards and not from, the
brain. A current following this latter course in a sensory
nerve is as unnatural and abnormal as are the anti-peristaltic
contractions of the stomach. Thus we see that in order that a
cerebral stimulus may extend outwards through a sensory
nerve, a peculiar abnormal condition of the organism is re-
quired. If the tendency toward such a condition is natur-
ally great, hallucinations are produced by trifling causes;
and the excitement of the brain caused by ordinary intense
thought, or religious reverie will at times suffice. Such is
especially apt to be the case with children, and, as you will
find, when they are very feverish, they are quite apt to see
and hear the creations of their imagination projected out-
ward in a sensible form.
The automatic nerve centres, receiving, as do the cerebral
FAILSE BELIEFS OF THE INSANE. 35
hemispheres, the terminal expansions from the nerves of sense,
may also, like the hemispheres, transmit a nerve current out-
wardly; thus we see how the automatic part of our system can
take part in the hallucinations. It explains excellently well
"Such cases as that of the monk who, in a state of somnambu-
lism, approached the bed from which his abbot had hastily
risen as he entered the room. The monk passed his hand
over the bed as if to satisfy himself of the presence of his pro-
posed victim ; and them raising a long knife plunged it deeply
several times into the place where he felt the abbot's body
lying.
In order to make as clear as possible the mechanism of hal-
lucination and of normal perception, I will reproduce the dia-
gram given by Dr. Despine, from whose work much of the
foregoing explanation is translated.
MECHANISM OF NorMAL PERCEPTION.
Organ of Sense and its Nerve.
1 * B. © gº
The external world. A. ****, *.*.*, C. The brain, the organ of perception.
In normal sensation, the exterior object A, sends an im-
pression to the organ of sense at B; this impression is trans-
mitted from the special nerve of sense to the cerebrum C,
where the mind enters as a factor, judges of and appreciates
it, and then by the law of projection refers it to its proper
place and relations in the external world.
MECHANISM OF HALLUCINATION.
Organ of Sense and its Nerve.
1 * B.
2
The brain the organ of perception. C. *... }–)- A. The external world.
Here the mental activity giving rise to ideas and images
in the brain transmits a stimulus to the sensory nerve B, some-
where in its course, contrary to the usual laws governing
nerve.currents. This cerebral stimulus produces an activity
of the sensory nerve exactly the same as if caused by an im-
pression from without; this is now returned from the sensory
36 INSANITY AND ITS TREATMENT.
nerve to the perception cells, and is consequently considered
and judged of by the mind, not as a mental image, but as a
real object. Finally by habit, the mind refers to a suitable
place in the outward world—this materialized image.
In general mental excitement you will meet with halluci-
nations, but less frequently than with illusions; they are apt
to appear among the first symptoms, and also at the last as
the excitement subsides. Although frequently present dur-
ing the height of the maniacal paroxysm, they are so mingled
with the illusions, delusions, restlessness of body, and géneral
incoherence of thought and speech, that it is almost impossi-
ble to distinguish them from the other false beliefs. The ad-
missions of the patient cannot always be relied upon to prove
the existence of illusion or hallucination. But they may often
be detected by certain expressions of the face, and certain atti-
tudes and gestures; sometimes, for example, the constant rest-
lessness of the eyes gleaming anxiously from side to side, in-
dicate that he is seeking to see some person or object pictured
in his brain.
When hallucinations are present in cases of mania, we may
have what some writers call sensorial or intuitive mania. The
delirium is as in other cases, except that there may be a pre-
dominance of some one of its characteristics; but there is the
usual incoherence of ideas owing to the inability of the mind
to exercise its usual power of analysis and judgment. The
presence of hallucination in general mania tends greatly to
increase the incoherence. Patients of this sort seem lost in a
perfect labyrinth, and their actions bear testimony to the in-
tensity of their sufferings.
Such are the features of hallucination as found in the dif-
ferent forms of insanity. They may be fixed and well-defined,
or rapid, incoherent and changeable. They may be distinct
and clear, and even seem to add dignity and character to the
mental processes, or they may be vague, hazy and testify to the
decay of the mind. Then too the degree of culture and the de-
velopments of the intellectual faculties, especially of the imagi-
nation, with the insane, makes a great difference, not in the fun-
damental character of the mental phenomena, but in the variety
FALSE BELIEFS OF THE INSANE. 37
and abundance of its images and the degree of its intensity.
“With those who have only a limited education, and have
passed their lives at hard manual labor, the hallucinations
generally consist of a limited number of perceptions, and bear-
ing some relation to their surroundings in life; whilst those
who have a liberal education, and whose minds are well stored
with the fruits of travel, and a knowledge of art, literature and
Science, will present hallucinations whose images may interest
and instruct.”
In all patients alike there is an inability to see that these
beliefs are false. They see it when they recover, see it without
the demonstration which failed to convince them when they
were insane. As Dr. Blandford says: “Nothing can be more
certain than this, that during the insane state the brain cannot
act as a whole, cannot by means of one part correct the ideas
which arise in another. The ideas are the concomitants of
strange and altered feelings which have a real existence, and
until the latter pass away they are not to be removed by ar-
gument or demonstration. Sometimes during an apparent
state of clearness you may flatter yourself that you have suc-
ceeded in convincing the patient of the falsity of his ideas, or
at least shaken his belief in its truth, but at your next visit
you will find that you have just the same state of affairs to
deal with; you will be surprised also to see the acute reasoning
displayed by your patients, so that you will find it difficult to
avoid giving an apparent assent to the delusions. When the
feeling subsides—the feeling of depression, or the excitement
and elation which causes the grand and exalted fancies of
Some—the ideas in the majority of cases vanish also, especially
if no long time has elapsed. The patient is said to have lost
his delusions, and their gradual disappearance, or occasional
reappearance coincides with the restoration of the general
health and strength, of sleep, digestion, uterine and other
functions. But it sometimes happens that the delusions re-
main after the feelings have gone, and we behold in the patient
a confirmed monomaniac. The ideas which were at first the
explanation to the patient of his altered sensations are stored
up as facts of experience in a deranged brain, which never
3S INSANITY AND ITS TREATMENT,
recovers from the injury it has received, and never resumes its
entire working power; remaining permanently unable by
means of one part to correct the false notions of another; it
remains forever the dream that arose in its half waking state.”
(Lectures on Insanity by Dr. G. F. Blandford.)
The delusions met with among the insane may be arranged
in comparatively a small number of classes. All are connected
in some way with self, the self-hood of the patient; all are
supposed to indicate some change that has taken place with
regard to himself. This change must be for the better or the
worse; a change affecting his worldly or his spiritual interests;
his bodily condition or his surroundings; a change which has
already happened, is happening, or is about to happen at some
future time. The extravagance of the idea will depend on the
amount of brain disorder, and we may often see this marked
out by the delusions as it rises to its climax, and then falls
again.
The delusions presented by a patient who believes that
things are amiss with him may be connected with his worldly
or his spiritual interests. In the extreme melancholic condi-
tion which accompanies excessive depression and prostration
of nerve force, there will probably be delusions on both these
points. The patient is ruined and a beggar; and he has also
committed the unpardonable sin and is doomed to eternal
perdition. This by the way is a very common delusion. What
now do we learn from these delusions? They show that there
is a condition of melancholia, and they warn us to be on our
guard against any tendency to suicide. “Thinking that he is
doomed, and that life is insupportable; incapable of reflection
and impelled by the ever present horror of his position he
attempts suicide, and unless extreme caution is used he will
succeed.” We are taught also that the patient will try and
escape, either that he may commit suicide, or may wander
over the earth to escape the evils and dangers that encompass
him at home. It matters not whether the delusions have
reference to the past, the present or the future; he may be in
a state of profound remorse for imaginary crimes, or he may
shrink in terror from the torments which are to come upon
him unjustly hereafter, the result is the same.
FAILSE BELIEFS OF THE INSAN E. 39
Others labor under a feeling that very much is amiss with
them; yet the feelings may not be those of depression and
melancholy, but rather of alarm and restless anxiety, or anger
and fury. So far as the delusions are concerned, it is evidently
optional whether we call such persons melancholic or mania-
cal; but the general deportment and feeling of many of them
is far from being melancholic, and is unquestionably mania-
cal; while others may be ranged with equal propriety under
either of the two classes. Their delusions resemble those of
the melancholic class. They imagine that some evil is going
to befall them ; they do not, however, think that they have
deserved it, but that they are unjustly treated; that wicked
persons are conspiring to ruin them or their family, to blast
their character or to kill them. Following out the train of
thought likely to result in such cases, you will see that such a
patient would be very dangerous to those about him. In order
to escape, he may set the house on fire; may try to escape by
force or violence; or he may conceive the idea that those
around him are about to do him some harm, and murder them
in supposed self-defence. A large number of the homicides
committed by the insane are done in fear and panic, especially
those by persons suddenly aroused from sleep. Murders are
committed by those who imagine that their victim has accused
them of foul and unnatural crimes, and who suffer from hallu-
cinations in which they actually hear a voice repeating all
sorts of slanderous words, or as in the case of Freeman at
Pocasset, they hear voices commanding them to kill. Again
a man imagines that his food is poisoned; his clothes or bed-
ding infected; the room or furniture tainted and filthy; and
all these fancies make him refuse to eat, and also very danger-
ous and violent. Generally speaking when such delusions re-
main without improvement for a year or two, the patient will
remain insane through life.
A number of delusions are presented by those who fancy
that the changes they feel are all for the better. In their bodily
or spiritual state, or worldly position or fortune they are much
better off than before. All these are said to be suffering from
mania with ºxaltation or ambition, the manie ambitiewse or
40 INSANITY AND ITS TREATMENT.
Tmegalomanie of the French writers; but among them are num-
bered the victims of that most fatal of all the forms of insanity,
viz., general paralysis. When a man between thirty and fifty-
five years of age is full of delusions that he is of great strength,
rank and wealth, we may suspect that he has general paralysis,
and as will be shown in another place, the result is always
fatal. Often, however, these exalted, ambitious ideas make
their appearance in men and women who are not paralytics,
and in such cases, unless the duration of the disease has been
a long one, we may render a hopeful prognosis. In fact, when
there is no paralysis nor hallucination, and the attack recent,
the prognosis is favorable. Here there is but little danger of
injury to self or others. They may be dangerous at times,
however, if we attempt to control them too closely, or insult
their idea of what is due to their dignity or position.
Insane persons will and act, in all those things that are
prompted by the ruling passion, with surprising tenacity, be-
cause no opposing forces arise in the mind. Thus an insane
man can dissimulate and conceal his delusions and false ideas
with much more cunning than the same man, for all his ener-
gies are directed toward that end ; and it is only by closely
observing the person and throwing him off his guard that his
true thoughts can at times be learned.
DEFINITION OF IMPULSE.-The next term to which I would
call your attention is Impulse, and with the exception of the
phrase Moral Insanity, there is no term in connection with the
subject of insanity which has caused more discussion and dif-
ference of opinion; a fact which lawyers have not been slow
to recognize and take advantage of in courts of law.
Dr. John P. Gray of Utica, who takes an extreme stand at
one side of the question, says: “The term impulse expresses
no condition of insanity, and characterizes no true phenomena
of the disease. It is one of those makeshifts coined to meet
cases ill-examined, and has mainly been used to screen crimi-
mals from the just punishment of the law. It has done more
to bring the profession into just contempt than any other term
of speculative expertism which has obtained foothold under
the guise and protection of science. This terºh, while it was
DEFINITION OF TERMS. 41
only applied as a qualifying word to describe certain acts of
the insane, which were suddenly executed, and apparently
without premeditation, did no harm. Here it had the same
meaning as when applied to acts of the sane. The word was
used as qualifying a mental state during an act, such as im-
pulsive suicide, impulsive homicide. By transposition it is
suicidal impulse, homicidal impulse. The transposition is easy
and simple, but mark how it changes the sense. Now, it de-
clares, not that these acts were apparently unpremeditated and
sudden, but that in the mind there was suddenly generated a
murderous impulse, an irresistible power, which, without the
intervention of reason, or any intellectual act or motive, sud-
denly impels to the physical acts of suicide or murder. One
step more, and a murder is ‘impulsive insanity.’ What could
be more absurd, unphilosophical, and illogical than such a
conjectural condition of mind and body ? Impulsive insanity!
Why one might as well talk of impulsive diarrhoea or hydro-
phobia, yet it is a grave thing, because it is unfortunately in-
stalled in the vocabulary of both law and medicine.”
Says Dr. Bucknill: “It would be well, if the term insane
impulse could at once be banished from medico-legal dis-
cussions, the adjective in common use, uncontrollable, is also
liable to serious objection.”
On the other hand Prof. Maudsley says: “It will be a hard
matter for those who have not lived among the insane and so
become familiar with their ways and feelings to be persuaded,
if, without such experience they ever can, that a man may be
mad, and yet free from delusion, and exhibit no marked de-
rangement of intelligence. Nevertheless it is a fact that in a
certain state of mental disease a morbid impulse may take
such despotic possession of the patient as to drive him, in spite
of reason and against his will, to a desperate act of suicide or
homicide; like the demoniac of old into whom the unclean
spirit entered, he is possessed by a power which forces him to
a deed of which he has the utmost dread and horror.” And
he adds: “This impulse is truly a convulsive idea from a mor-
bid condition of nerve element, and is strictly comparable with
an epileptic convulsion.”
3
42 INSANITY AND ITS TREATMENT.
In his work, entitled Responsibility in Mental Disease, Prof.
Maudsley further says, p. 150: “By the almost unanimous
testimony of those who have made insanity a practical study,
it is agreed that instances of irresistible homicidal impulse do
occur, that this is a positive fact of observation, be the ex-
planation of it what it may. The medical psychologist who
studies mental function by the physiological method, who
judges of the functions of the supreme nerve centres in man by
aid of the generalizations which he has formed regarding their
functions in animals, where they have not attained so great a
development, and by aid also of the generalizations which he
has formed concerning the functions of the lower nerve cen-
tres in man, does not experience the same difficulty in realiz-
ing the probable state of mind in impulsive insanity.”
Placing insanity in the same category as a nervous disease
with chorea, which has not inaptly been called an insanity of
the muscles, he perceives that, just as a deranged state of the
motor centres destroys co-ordination of movement and occa-
sions spasmodic or convulsive muscular action, so a deranged
state of the mind centres destroys the healthy co-ordination of
ideas, and occasions a spasmodic or convulsive mental action.
In the one case the man is unable to perform his movements
correctly, in the other case he is unable to perform his ideas
correctly; in both cases they play him evil tricks against his
will, though within his consciousness.
Griesinger speaks of instances where individuals hitherto
supposed to be perfectly Sane, and in the full possession of
their senses, “are suddenly and without any assignable cause
seized with the most anxious and painful emotions, and with
an homicidal impulse as strange to themselves as to others.”
And in illustration of this proposition he gives three examples
from the experience of others, but none from his own. He
also says: “We cannot speak of the absence of delirium in
these cases when there is a morbid impulse to commit acts
of violence.” “That the murderous ideas are, in themselves,
delirious ideas, just as in furious mania and in all violent
emotion as in rage.” He believes that the morbid dispo-
sition gives rise to the vague and disturbed ideas, opinions
DEFINITION OF TERMS. 4.
3
and conclusions. In fact this state is, in its mental uncertainty
and incoherence, quite like the more demonstrative states of
incoherence in mania.
Griesinger also makes this significant comment: “If we
consider more closely to which maniacal states, the designa-
tion mania sine delirio can be applied, we recognize the funda-
mental fact, that in no case of mania is the conscious thought,
the intelligence, perfectly free from any disorder. Even in
the very slightest degrees of mania, the intelligence partici-
pates in the general exaltation, and though it be only to the
extent of increased liveliness and rapidity of thought; gen-
erally, however, there is incoherence. In all attacks of fury,
clear, calm, healthy thought is impossible.” (Mental Diseases.)
Prof. William A. Hammond would surely not be accused of
favoring any fanciful distinctions in insanity; and yet in a
paper upon the case of Daniel McFarland, read before the
New York Medico-Legal Society, July, 1870, he says: “The
brain may be so disordered that insanity is manifested only as
regards the will. 1. There are no false conceptions of the
intellect and no emotional disturbances, but solely an inability
to exert the full will-power, either affirmatively or negatively.
2. Many instances of morbid impulse are uncomplicated cases
of volitional insanity, in which an idea, suddenly flashing
across the mind, is immediately carried out by the individual,
although his intellect and his emotions are strongly exerted
against it. Thus a person who previously has not exhibited
any very obvious symptoms of mental derangement, though
careful inquiry will invariably show that slight evidences of
cerebral disease have been present for some days, instanta-
neously feels a morbid impulse to commit a murder, or perpe-
trate some other criminal act. The many species of what is
called ‘moral insanity, may properly be classed together under
the head of ‘volitional insanity,’ of such are kleptomania, dip-
Somania, pyromania, etc.”
In some cases there is a true irresistible impulse as a conse-
Juence of the pathological conditions of the brain. Thus a
patient spoken of by Dr. Bonfanti, of Milan, a subject of mel-
ancholia, with an aversion to food, had from time to time
44 INSANITY AND ITS TREATMENT.
paroxysms of rage, during which he would throw himself
upon the floor, striking out violently with his fists and feet,
and spitting at those around him. This man recovered, and
remembered perfectly his mental state during the paroxysms.
He desired he said to act differently, but he could not. He
was unable to conquer the impulse forcing him to act thus.
The real question is not, whether the emotions occasioning
the overt act are beyond the power of the individual to control,
but whether they are the result of disease. This is the sum
of the whole matter. If certain acts and ideas are traceable
to cerebral disease they have a pathological origin and are
excusable; but if not, the individual is responsible in law and
morals, and is not insane, no matter what he may have done,
or what opinions he may have uttered; without respect to
whether man is considered to be a spiritual being, or a physio-
logical machine. But this matter will again be spoken of
when we come to consider the subject of moral and volitional
insanity.
Lucid interval is another term of which I must briefly speak.
Dr. John P. Gray says, “This term is chiefly employed and has
its principal significance in jurisprudence, particularly with
wills and contracts, but occasionally with regard to crimes.
You will have to determine whether patients, who have un-
questionably been insane, and who have had guardians
placed over their persons and estates, have really recovered, or
whether certain rational speech and conduct amount to what
may be called a lucid interval. So, also, you will be called on
to draw the same line in behalf of persons acknowledged to
have been insane, and who have for a time manifested no
irrational conversation and habits, and are desirous of execut-
ing a deed, making a sale, or entering into Some legal con-
tract. In such cases you need to appreciate the term lucid
interval. In ordinary disease we use the term intermission or
remission to express temporary suspension or abatement of
symptoms. We know that the disease still exists, and expect
its phenomena to reappear. In insanity there are also appar-
ent intermissions and remissions; and a lucid interval is a
condition, not of entire freedom from disease, but a degree of
IDFFINITION OF TERMS. 45
clearness of mind which for a time holds the true manifesta-
tions in abeyance. If you are called upon to answer this
question, it is safer to first make your own definition as being
an abatement or non-manifestation of symptoms, and if this is
not sufficient, then express only an opinion as to the rational
or irrational conduct, manner or speech of the individual as he
then appears—remembering that rational and sane are not
convertible terms. The term same is a positive state of mental
Soundness; rational is applied also to particular acts or mani-
festations, to the seeming or apparently rational or reasonable
condition of mind as casually observed in the speech and con-
duct. An insane man may appear rational, but he cannot
be called sane.” (Lecture to the Students at Bellevue Medical
College.)
The presence of a delusion is not at all necessary to consti-
tute a person insane, even in the narrowest sense of the word.
In many cases no special delusion is present, or at least there
is none exhibited; but the sentiments, disposition and conduct
are altered in a morbid manner, and, owing to a morbid state
of the brain, the individual is so influenced that the faculty of
judgment is obscured, the intelligence formally involved, and
the spirit held in bondage. Such an individual can be ra-
tional, that is he can speak on ordinary subjects without mak-
ing great mistakes; he can distinguish right from wrong;
directs his actions with a proper use of means and proper re-
flection; shows by his conduct that he knows a criminal act,
and seeks to avoid punishment therefor; he can, at least for a
time, so conduct himself that nothing striking is observable,
and yet his disposition may be so entirely altered, his whole
affective sentiments so disturbed, that an essentially different
relation of the personality to himself (the ego), and to the world
is formed, and the irritation of sentiment can, at any moment,
appear in impassioned perverted acts and desires. “This is
especially noticeable in the early stage of mental disease, in
moderate cases of melancholia, in the slightest cases of mania,
and very frequently in the early stage of paralytic dementia.
The last term to which I shall at present call your attention
is Delirium. This word is generally used to describe three
kinds of sensorial disturbances:
46 INSANITY AND ITS TREATMENT.
1. That met with in the insane. 2. That accompanying
many acute disorders, especially those of an inflammatory and
feverish character. 3. That caused by the use of toxic sub-
stances, such as alcohol, opium, hashish and the like.
In speaking of the insane, the word delirium is used to de-
note any departure from the normal line of thought, action or
speech. This may arise suddenly, but as a rule it comes on
gradually, giving premonitory signs of warning. The person
becomes irritable, and his character and disposition changed;
there are eccentricities in his conduct; his will is vacillating;
we notice also perversions in his moral sense and disturbances
in his intellect. In all such cases there is delirium, or as the
word itself may be rendered, the patient is wandering, is out of
the road.
This disturbance may be mild or severe; it may be confined
to one or a few of the faculties and form a partial delirium; or
it may extend to all, causing a general delirium. It is very
often partial, as in mild cases of melancholia or monomania,
and if extensive, does not affect all the faculties with equal
power; hence the maniac, even in the acute stage of the dis-
Order, is to a certain extent capable of thinking and acting
properly,
EARLY SYMPTOMS OF INSANITY. 47
LECTURE III.
Early Symptoms of Insanity. Acts of the Insane. Re-
straining Apparatus. Artificial Feeding
of the Insane,
As has been indicated elsewhere, the cause of all insanity,
and indeed of all disease, is to be found in the neglect or in-
fraction of the established laws of physical, mental or spiritual
health. It may originate from the physical side of man's na-
ture, as from some form of ill-health in which the nutrition
of the brain is affected; or from the mental side where exces-
sive brain action produces the same result; or it may even
come from a higher source still—from a disorderly use of the
spiritual intelligences and loves; but in every case bodily dis-
ease is the result. In the ambition to acquire riches, power,
prominence in politics, art, literature or science, the plainest
laws of our physical and mental well-being are constantly vio-
lated. The claim of the body, especially the brain, for repose,
for sleep, or even for nourishment to repair the waste of ordi-
nary or excessive activity is disregarded, and the vain hope is
fostered that an escape from the penalty of our actions is not
only possible but certain. The folly of this course has been
plainly pointed out by a recent writer in the following words:
“This marvellously constituted brain, men may ignore it, de-
spise it, degrade it, defile it, but they do it at their peril; and
let them remember that whether the result is or is not actual
madness, they will pay the penalty sooner or later in some
form or other; they will not be permitted to escape the conse-
quences of the infraction of the laws on which its integrity
hangs.”
In judging of insanity it is important to have clearly in mind
what it really is; what changes it produces in the mental and
moral status of the individual. “No diseases present such an
infinite variety of light and shade belonging to their own na-
ture, or to their intermixture with other maladies, or to the in-
fluence of temperament, of individual peculiarities of habit, or
48 INSANITY AND ITS TREATMENT.
of Social position; and therefore, the diagnosis of no other
class of diseases taxes nearly so much the ingenuity and the
patience of the physician. The diagnosis of almost all other
diseases depends principally upon weighing the evidence af-
forded by physical signs and symptoms; upon evidence ad-
dressed to the senses; but in mental disease, it is, for the most
part, dependent upon evidence which is cognizable by the
intellect alone, and upon data which the senses furnish to us
only at Second hand.” (Bucknill & Tuke, Manual of Psych.
Med.)
Insanity is shown by a change in the disposition, sentiments,
desires, habits, conduct or opinions, induced by, and founded
upon, disordered states of the brain. Thus the investigation
of these states, and the recognition of these changed conditions
is specially important to the general practitioner, as upon
him rests the responsibility of the diagnosis, and the treat-
ment of the disease in its initiatory stages. He is also called
upon to decide as to the necessity for hospital care.
In making a diagnosis of a case of suspected insanity, it is
not enough to study a few of the more prominent symptoms,
or even one or two forms of mental alienation, but we must
study all the accompanying circumstances. We must seek
out and inquire into all the peculiarities, both mental and
physical of the patient; the causes, near and remote, which
may have contributed to the outbreak, and to the disturb-
ance of his intellectual powers. In other words, we must take
into account the whole individual, mentally and physically,
together with his surroundings, and compare him with the
same individual in a state of health.
Other diseases than insanity may produce mental disturb-
ance, or as Griesinger says: “One may be melancholy from
eight or ten different cerebral disorders, and demented from
twenty.” You will learn, too, that no arbitrary line separates
insanity from sanity, for between these two, as between health
and disease, we find numberless varying shades and degrees,
and meet many cases where the most experienced alienist
must doubt and hesitate, and give an opinion with reserve.
The existence of such cases (such as graduate between reason
EARLY SYMPTOMS OF INSANITY. 49
and mental disease) is, as Sir Henry Holland observes, but a
part of that law of continuity which pervades so generally
every part of the creation.
A person may be led to commit the most unreasonable acts
under the influence of ignorance, credulity, prejudice and
superstition; and also when blinded and deprived of moral
sense by certain violent emotions, such as love, hatred, anger,
vengeance, jealousy and religious fanaticism; and in many
such cases it is difficult to decide whether insanity does or
does not exist. Neither the belief in an absurd, fixed, irrational
or false idea is sufficient to constitute a man insane. Indeed,
on the one hand we continually find same persons dominated
by a multitude of false and absurd ideas; and on the other, we
meet, both in the written and spoken words of the insane,
most rational, consistent and logical thoughts and ideas. In-
sanity has no one marked characteristic; it cannot be diagnosed
by a single erroneous idea, nor an isolated act of extravagance,
crime or folly; far from this, it is a pathological whole, which
acknowledges special causes, and which has its multiple symp-
toms, a well-known course, varieties and periods.
Dr. Prosper Despine says: “The conditions necessary for the
existence of insanity are two; it requires, first, one or more
absurd, irrational, false or immoral ideas; or exaggerated,
strange and perverted affections and desires inspired by pas-
sion. But neither these irrational ideas, nor perverted cravings,
nor the passions prompting them are insanity, but only its
result. Insanity itself is the Second condition, viz.: the moral
blindness of the mind in respect to the irrational nature of
these ideas and loves; an involuntary blindness due to the fact
that the passions inspiring the thoughts and desires wholly
Occupy the mind, so that the rational sentiments, which alone
can enlighten in regard to the true nature of things, are not
present in the mind; in a word, there is a loss of moral con-
Sciousness in respect to the true relation of objects.” (De la
Folie, p. 275.)
The early symptoms of insanity assume an importance, as
they mark the period when treatment may avail in averting
a threatened attack. The pathological processes in the brain
50 INSANITY AND ITS TREATMENT.
which produce insanity are preceded by certain changes in the
physical system and mental states of the individual, which, if
understood and appreciated, may often be arrested by proper
hygienic and therapeutic measures. It however generally
happens, from various reasons, that the advice of a physician
is not sought until the disease is fully developed.
Contrary to the general opinion, insanity never breaks out
Suddenly. Doubtless a sudden shock of terror, grief or joy, or
any strong and violent emotion, may, in a few hours, be fol-
lowed by an explosion of acute mania or melancholia; but, in
nearly every case, the careful observer may notice for weeks or
months before the outbreak a steadily increasing change, an
instability in the patient's thoughts and feelings.
“Those around him remark something unusual in his tastes,
inclinations, habits, character and ability to apply himself.
Where he was once lively and communicative, he is now mo-
rose, Sad, and shuns society; carefulness and prudence have
given place to wastefulness and Ostentation; modesty and
chastity to all the indulgences of licentiousness and debauch-
ery; and confidence to suspicion and jealousy. The wife re-
gards her husband and children with indifference, and the
merchant neglects his business.” (Georget, Dict. de Med.)
One of the earliest symptoms to attract our attention is the
occurrence of bad DREAMS. Many patients, before becoming
completely insane, have frightful dreams, and appear as if they
were conscious of being on the eve of losing their reason. They
often express this dread, and manifest great anxiety. They
start up out of sleep, and complain of horrible apparitions.
Pinel observes, “Ecstatic visions during the night often form
the prelude to paroxysms of maniacal devotion. It is also by
enchanting dreams, and a supposed apparition of a beloved
object, that insanity from love breaks out with fury after
longer or shorter intervals of reason and tranquility.”
The mental activity during sleep which constitutes dream-
ing is so common in the experience of most people as not to
be considered important as an indication of disease, but
dreams especially of a frightful character, as of being tortured
or murdered, of dying or of the grave, occurring in persons
EARLY SYMPTOMS OF INSANITY. 51
unaccustomed to dreaming, and without a definite exciting
cause, are often symptomatic of disorder of the brain and of
the nervous system, and have long been recognized by medi-
cal writers as worthy of consideration, but too much neglected
in practice. “Such symptoms in medical psychology,” says
Tuke, “are like the delicate clouds in the sky in meteorology;
they indicate to the practiced observer the coming storm.”
Dr. Buckmill says: “Want of refreshing sleep we believe to
be the true origin of insanity, dependent upon moral causes.
Very frequently, when strong emotion tends to the production
of insanity, it causes, in the first instance, complete loss of
sleep. In many cases, however, the power of sleeping is not
lost, but the quality, so to say, of the function is perverted,
the sleep being so distracted by agonizing dreams, that the
patient awakens jaded rather than refreshed. We have known
several instances in which patients becoming convalescent
from attacks of acute mania, have distinctly and positively re-
ferred to frightful dreams as the cause of their malady; and
it is probable that a certain quality of sleep, in which dreams
excite terror and other depressing emotions more forcibly
than waking events are likely to do, is not less adverse than
complete insomnia to the nutritive regeneration of that por-
tion of the brain on whose action those emotions depend. In
such a condition it is highly probable that the very portions
of the brain which most need a state of rest are, even during
the sleeping quiescence of other portions, more wastefully en-
gaged in the activity of their functions than they could be in
the waking state. The main-spring of insanity is emotion of
all kinds. This, stimulated by phantasy, and emancipated
from the control of judgment, during harassed sleep, may be
more profoundly moved than at any other time. In this man-
ner, a patient, some one or other of whose emotions has been
profoundly affected, may continue to be sleepless, so far as the
activity of the particular emotion is concerned, although he
may by no means be the subject of general insomnolence.”
(Manual of Psych. Med., p. 423.)
SLEEPLESSNEss–Of still more importance and greater fre-
quency is impairment of the function of sleep. Stress is laid
52 INSANITY AND ITS TREATMENT.
upon this fact where the causes of insanity are spoken of.
There is no symptom, when viewed in relation to the health of
the brain and mind, that requires more careful and unremit-
ting attention than that of insomnia or sleeplessness. It is
One of the most constant accompaniments of insanity. The
brain cannot be in a healthy condition whilst a state of sleep-
lessness exists. Sound, continuous, unbroken, regular and
uninterrupted sleep is essential to the preservation of mental
and bodily health.
“We cannot too zealously guard against, or too anxiously
watch for the first approaches of this characteristic symptom
of incipient brain and mental disorder. Persons predisposed
to attacks of cerebral and mental disease ought never to per-
mit a condition of sleeplessness, or even a state of disturbed
and broken rest, to continue for many consecutive nights,
without seriously considering the state of their health. In the
premonitory stage of some forms of acute insanity, the patient
is in a constant condition of sleeplessness by night and rest-
lessness by day. His repose at first is broken and disturbed.
He slumbers lightly, having only snatches of sleep. If asleep,
the slightest noise or ruffle of the bed-clothes awakens him ;
and when suddenly aroused, he looks like a person whose eyes
had never been closed. This is a characteristic and significant
symptom of the insomnia of incipient insanity.” (Winslow on
the Brain and Mind.)
This condition may vary from a simple state of wakefulness
to one of persistent insomnia, and may result from exceptional
causes—the accidents of life rather than the daily habits. Such
are an additional and unusual amount of labor, unexpectedly
thrown upon the individual, from which he cannot escape; or
it may be the overpowering influence of some emotion, as from
the illness or loss of a friend, or the worry that comes from the
sudden destruction of ones hopes or prospects in life. In one
female patient the state of sleeplessness arose from a severe
shock which she had received, consequent upon finding her
husband, in the middle of the night, dead by her side, he hav-
ing retired to bed apparently in excellent health. Again there
may be no mental or physical cause apparent, sufficient to ac-
EARLY SYMPTOMS OF INSANITY. 53
count for the disturbance of sleep, but this seems to be the
earliest of a series of conditions which may gradually culmi-
nate in open insanity.
Persons actively engaged in literary pursuits, whose occupa-
tions absorb a large amount of nervous energy are subject to
conditions of insomnia, and instances are known where this
would continue for weeks. Boerhaave is recorded not to have
closed his eyes in sleep for a period of six weeks, in conse-
quence of his brain having been overwrought by intense
thought on a profound subject of study; and a case is pub-
lished of a deranged person who was not known to close his
eyes in sleep for the period of three months. It is difficult to
form an idea of the tenacity of sleeplessness in the incipient
periods of insanity; complete sleep among the insane is seldom
observed, except in confirmed dementia, and in melancholy
with stupor; even in convalescence, patients will often com-
plain of inability to sleep.
“The pathological condition of the brain may account for
this condition of sleeplessness, but in many cases the insomnia
seems to arise from a complete absorption, abstraction, concen-
tration of the thoughts and pre-occupation of the mind, in
some terrible and fearful form of illusion, or frightful type of
hallucination. Under these circumstances the patient is afraid
to close his eyes, from an intense fear of falling a prey to the
horrible phantasms created by his morbid imagination, and
which he imagines follow him in all his movements. The
patient so afflicted declares he will not sleep, and resolutely
repudiates and perseveringly ignores all disposition to slum-
ber. On many occasions he absolutely refuses to go to bed, or
to place himself in a recumbent position. He will battle with
his attendant if he attempts to confine him to bed. He insists
on remaining in the chair, or standing in an erect position all
night, and often determinately walks about the room when
those near him are wrapt in profound repose. The hallucina-
tions appear to be most exquisitely and acutely vivid when
the patient is placed in a recumbent position, on account, it is
conceived, of the mechanical facilities thus afforded for the
blood gravitating rapidly to the head.” (Winslow on the
Brain and Mind.)
54 INSANITY AND ITS TREATMENT.
We often find disturbances of other functions, and the fol-
lowing combination of symptoms, when not otherwise fully
explained, should receive attention as indicating the danger
which threatens. There is indigestion and loss of appetite;
with pain, eructations, flatulence, heart-burn, and offensive
breath. The circulation is disturbed, the heart beating ir-
regularly, or with diminished force, and the pulse is increased
or lowered in frequency. There are flashes of heat, alternat-
ing with chilliness and coldness of the extremities. The skin
is harsh and dry; the bowels constipated; there is usually loss
of flesh which may extend to emaciation, and the whole organ-
ism sympathizes in the general depression.
There is another array of symptoms, in part the opposite of
that described, which also frequently precedes an attack of in-
Sanity, especially when it is rapid in its access. The heart's
action is increased in force, the pulse is full and strong, the
face flushed, the eyes injected and the temperature slightly
elevated. The appetite may be unaffected, or even ravenous,
but there is usually loss of flesh. In this condition there is
marked increase in the activity of the vital functions, mani-
fested more especially in the circulatory system. This combi-
nation of symptoms may furnish a warning of approaching
disorder of the brain, usually of a congestive or hyperaemic
character. It is however, so frequently found in the early
stages of febrile disease, that its real significance as an indica-
tion of insanity may easily be overlooked or misinterpreted.
HEADACHE.-Disturbances of sensation not only occur as
premonitory symptoms, but often continue as serious symp-
toms of insanity throughout its course. Among the most
frequent of these is headache. This is usually described as a
dull, aching sensation; but sometimes as a sharp, acute pain.
It is often accompanied by a feeling as if a band was drawn
tightly about the head, or as if the hat were to small; or again,
there is a sense of pressure as if the brain were too large for
the skull. Some complain of a throbbing of the arteries;
others of a singing or roaring in the ears or of the noise of
falling water. In other cases there is a feeling of excessive
heat, or of a crackling, hissing Sound, like that made by fry-
EARLY SYMPTOMS OF INSANITY. 55
ing fat. These last sensations are more often referred to the
vertex, and occur in the nervous and excitable, especially in
women. Romberg says that with the exception of atrophy,
none of the diseases of the brain occur unaccompanied with
headache. Moreau, describing carefully the different sensa-
tions, speaks especially of the heaviness of the head; of its
being painful and feeling as if Screwed in a vice; a vague in-
describable pain was felt in the frontal and occipital regions;
and one patient felt as if a double current of warm and cold
water was flowing through his brain, which filled the cranial
cavity almost to bursting. Others feel nervous shocks similar
to those of electricity. The pain in the head is located most
frequently in the frontal and temporal regions, and next in
order in the occipital, and is produced by disturbances in the
circulation of blood in the meninges. These abnormal feel-
ings are frequently the cause of the sleeplessness.
PECULLARITIES OF SPEECH.-In some cases of insanity the
tone of voice and peculiarities of speech will attract our atten-
tion. Given to man for the purpose of expressing his thoughts
and affections, it may disclose the character and degree of the
mental disturbance of him who is deprived of reason. Some
persons will speak Snappishly, sharply and quickly; this is
especially the case in incipient mania; while in the fully
developed attack, the words and phrases flow from the lips
without sequence or order, but with an astonishing volubility.
The voice, at first shrill and piercing, soon becomes hoarse and
harsh from its constant exercise. Morel refers to a case in
which the patient was subject to dangerous periodical attacks
of violent homicidal delirium. His relations always knew
when the maniacal crisis was about to occur from a singular
alteration that took place in his voice. It had at these periods
a bell-like sound. He spoke in what is designated by French
pathologists, “Voix de Polichinelle,” or Punch's voice.
In acute melancholia the voice assumes a grave and solemn,
or even a querulous tone; and when there is associated a con-
dition of stupor, the voice is low, feeble and as if muffled;
the words being uttered with the same slowness and hesitation
that marks all the other actions.
56 INSANITY AND ITS TREATMENT.
The characteristic speech of general paralysis will be noticed
more particularly in the chapter devoted to that form of in-
Sanity. Guislain makes the following observations about the
morbid vocal phenomena associated with insanity:—he says:
“The speech is altered from the natural tone and style; the
articulation becomes embarassed. It is not so distinct as usual,
or it is clipped, or hurried, or weak, or too emphatic, or prosy,
or drawling. Some words are cut short like a drunken man's,
or single words are repeated hastily, or a syllable of a word is
repeated, or there is a difficulty in uttering certain letters, such
as tºs and r's, or words requiring an emphasis, or when several
consonants come together. At times the patient stammers and
seems to be at fault in finding the proper word, expletive, epi-
thet or phrase, which in health he was both apt and fluent in
using; or it may be that instead of being cautious and steadied
in his speech, he is all of a sudden voluble, redundent, and pro-
fusely garrulous. But at other times the speech is perfectly
natural in utterance, and rational in what is said, and yet the
patient is deeply attainted with insanity all the time. There
shall not be a single unreasonable or ill-spoken word uttered.
But at the same time there is a retired, reserved manner, a
slinking out of sight, a refusal to speak to an old friend, or
answer the queries of the physician.”
In some cases of insanity all power of speech seems for a
considerable time to be lost. Insane patients have been
known to continue for years without uttering a vocal sound.
This does not arise from any paralysis of the organs of speech,
but it is owing to the mind being intensely absorbed or pre-
occupied in the contemplation of predominant insane ideas.
Dr. Forbes Winslow speaks of a man who was for fifty-two
years insane and had not spoken for thirty years. When per-
severingly questioned he would give a kind of grunt and run
away. About fifteen days before his death, this patient re-
covered the use of his speech, and answered perfectly well all
questions put to him.
APPETITE AND DIGESTION.—Disturbances of digestion are
generally present, especially at the beginning of an attack.
This is so often the case that Pinel said that the seat of insan-
EARLY SYMPTOM'S OF INSANITY. 57
ity should always be sought for in the region of the stomach,
and that the disease spread from there as a centre.
During the first part of an acute attack of mania, food will
often be refused from an inability on the part of the patient to
fix the attention long enough to eat; or if food is taken it will
be by snatches and without thought; digestion will take place
imperfectly; the tongue will be furred, and the bowels consti-
pated. At a later period the appetite will be good, and food
easily digested; the assimilative process going on rapidly to
compensate for the increased waste of tissue.
The melancholic digests food slowly; he eats but little and
requires urging; either from the depressing influence of his
false conceptions and fears, or from the general inertia per-
vading his whole being. It is among such patients that we
find persistent refusal to eat, and are forced to use artificial
alimentation.
In dementia and general paralysis, where all intellectual
force is lost, the digestive functions seem to survive untouched,
and the patient seems reduced to the animal level; the appe-
tite is excessive and is not fastidious either as to the quality
or quantity of the food taken.
Constipation is a very common symptom in all forms of
insanity, but especially in melancholia and general paralysis.
It seems due to a torpor of the liver; to a want of contractility
in the intestinal walls, and a decrease in the secretions.
It is considered an unfavorable symptom if the patient
gains in flesh without a corresponding improvement in the
mental disturbance.
MoTOR DISTURBANCES.–Muscular restlessness is often pres-
ent, and may be manifested either in localized movements of
the extremities, or in the more general movements of the
whole body. These movements with the maniacs are usually
without order or purpose; such patients feel an irresistible
need of changing position, of running, leaping, turning Somer-
saults and the like. This mobility may vary from slight
twitching of the muscles to the most incessant and extravagant
motions. At the same time the mental confusion and disorder
is equally pictured out by the gestures and physiognomy.
4
58 INSANITY AND IT& TREATMENT.
Tears are mingled with smiles; songs with oaths, and the
muscles of the face, especially those of the mouth, are twitched
convulsively. The hands or feet may be kept almost con-
stantly occupied during the waking hours in the repetition
of certain movements, while the abstraction of the individual
gives them the appearance of being unconsciously or automat-
ically performed. Again the person may move restlessly
about without any apparent purpose or design, and without
being able to assign any cause further than a sense of uneasi-
ness or discomfort. Indeed in many of the acute cases of
insanity, it only requires that we should see the attitude,
gestures and movements of the patient, to enable us to diag-
nose the particular variety before us.
In melancholia an opposite condition exists, in which there
is not only a disinclination to muscular movements, but action,
both mental and physical, is performed, if at all, by a strong
effort and the direct exercise of the will. The loss of control
over muscular movements, indicated in these conditions and
that shown, though in less degree, in the irregular twitching
or jerking of the muscles of the tongue and of those about the
mouth, are often important aids in diagnosis.
MENTAL CHANGES.—With these changes in the physical
system, and preceding the full outbreak of the disease there
are necessarily associated disturbances of the mental states.
The earliest are to be found on the side of the emotions. These
may be slight, amounting only to an exaggeration of the ordi-
nary mental feelings; or they may be more marked and the
inclination to tears or laughter may be yielded to in spite of
all effort. This disturbance of the emotions frequently takes
the form of depression. There may be loss of spirits or a
shading off from the natural cheerfulness of disposition,
noticeable to friends and at first fully appreciated by the pa-
tient himself. Often he complains of being very ill, that he
is losing his senses, and asserts that his mind is not his own;
When rallied a smile may for a moment light up the counte-
nance and dispel the gloom, but a relapse soon follows. We
find, too, an acute morbid sensibility, physical and mental, to-
gether with a difficulty of fixing and concentrating the atten-
EARLY SYMPTOMS OF INSANITY. 59
tion; investigation will often show that long before any
mental disease was apparent, they were subject to fits of apa-
thy, had been in the habit of sitting for hours together in a
state of moody abstraction, or deep study, and this too, at a
time when they were neglecting important duties.
There are forebodings of some indefinite, indefinable evil
impending from which no way of escape lies open. Then
commences an introspection; all the thoughts are turned in-
ward; all the acts of life are subject to a review and scrutiny
more severe than by the most unfriendly tribunal. The judg-
ment rendered is always adverse and self-convicting.
“Upon analyzing the patient's antecedents still more closely,
it will perhaps also be found that, for a long period, there has
existed much irregularity and absurdity of thought, eccen-
tricity and singularity of conduct. He has been considered
as an oddity in his family, being rarely seen in the domestic
circle. When his friends and relations are engaged in social
union and converse, he retires quietly to his own room, where
he is discovered abstracted, brooding and uttering nonsense to
himself. At other times he is forward and obstreperous, loud
and vociferous, wild, ungovernable and untrainable. On
these occasions the eyes exhibit a bright, brilliant aspect, and
the physiognomy is lighted up by an unnatural degree of in-
telligence. At other times, the patient is restless, abstracted,
and moody during the day, and at night slumbers and sleeps
uneasily, often, when awaking, complaining of headache,
mental confusion or vertigo. During his sleep, he is occasion-
ally subject to slight attacks of muscular convulsion, Somnam-
bulism, and temporary illusions of the senses. He is liable
to frightful and distressing dreams. All these symptoms are
often indicative of the commencement of organic disease of
the brain, as well as alienation of the mind.
“In the early period of insanity the most material elements
of character undergo strange tranformations. A person natu-
rally remarkable for his caution and circumspection becomes
reckless, extravagant and prodigal. If noted for his precise-
ness he exhibits great carelessness and negligence. If gay
and communicative, he is sullen and morose. If previously
60 INS ANITY AND ITS TREATMENT.
meat and particular in his dress, he becomes slovenly, dirty
and indifferent to his attire. If timid, he is brave, resolute,
Overbearing and presumptuous. If kind, affectionate and gen-
tle, he is rude, austere, irritable and insulting in his intercourse
and communications with others. If benevolent, he becomes
parsimonious and miserly, hoarding up with the greatest care
the smallest sums of money, sometimes under the insane ap-
prehension that he will eventually be obliged to go to the
workhouse. If, when in health, the patient is known for his
attention to his religious duties, he is, when insanity is casting
its dark shadow over his mind, sadly neglectful of them, not
paying even decent respect to the ordinances of religion. The
man of business, who never, when well, was found absent from
his counting-house, or known to neglect his vocation, now
shows great indifference to his affairs, and refuses to converse
about them.” (Dr. Forbes Winslow, Brain and Mind, p. 101.)
In the direction of this general depression, and partaking of
its character, is the development of scruples of conscience.
These may refer to the performance of duty toward God or
toward man. They sometimes lead to an unhappy zeal in
the observance of religious rites and ceremonies, and to self-
accusations of intentional wrong, if not of criminal action, in
the simplest affairs of life. This occurs alike to those of the
most exemplary lives, and of undoubted Christian faith, and
to the wicked and depraved. It is not a matter of surprise
that when this condition is not recognized as dependent upon
disease of the physical organism, the spiritual aid of the min-
ister should be invoked, rather than the more material aid of
the physician; or that insanity should be considered as a dis-
ease of the spiritual nature. Dr. H. Tuke says upon this point:
“Sudden and extraordinary scruples should also excite our at-
tention and concern, indicating as they frequently do, latent
brain mischief, and a twist in the emotions which, although
seemingly leaning to virtue's side, may nevertheless be pure
delusions, simulating conscientious duty, and leading the mis-
guided fancy into courses of action which, if the brain fog is
ever dispelled by the sun of returning health, are remembered
with bitter but unavailing regret.”
EAELY SYMPTOMS OF INSANITY. 61
Another indication of commencing insanity may be mani-
fested in a change of conduct, in the direction of an unnatural
indecision of purpose. “The clothing to be worn, or the food
to be eaten, or any of the minor affairs of every-day life, which
are ordinarily decided without a thought or question, then
become subjects of serious consideration, and are magnified to
a degree out of all proportion to their significance.” Whatever
course may finally be decided upon is soon given up for
another, which in time makes room for some new line of con-
duct. The vacillation and uncertainty thus exhibited may be
in strong contrast to the ordinary stability of purpose and
character.
A change in disposition without sufficient rational cause
may have the same significance. The naturally amiable and
gentle may become irritable, morose and fault-finding. This
change is manifested first toward the members of the family
and intimate associates, and is concealed from ordinary or
casual acquaintances. It however gradually gains more com-
plete control and affects all the relations of life.
Unfounded suspicions and jealousies, in the beginning vague
and shadowy, give rise to a belief in the existence of a general
spirit of opposition to the plans and purposes in which he is
interested. At first they are concealed or reluctantly expressed,
and easily removed by appeals to reason. Eventually they
become attached to individuals, and being more fixed in the
mind, often take the form of hatred and opposition to the most
loved relatives and friends.
Insanity often manifests itself in a morbid exaggeration, a
diseased eaccess, of normal healthy mental conditions. Upon
this point all writers lay much emphasis, and Dr. Winslow
says: “The naturally timid and reserved man shuns society,
isolating himself altogether from the companionship of his
family and friends. The bold man is boisterous, presuming
and noisy. The courageous, officious and talkative. The
strictly conscientious person exhibits an unhealthy exaltation
of conscience respecting his moral, social and religious duties,
and, when insane or becoming so, will manifest the acutest
misery, at the notion of thinking or doing anything, in the
62 INSANITY AND ITS TREATMENT.
remotest degree, at variance with his strict and literal inter-
pretation of Holy Writ.”
An unnatural buoyancy of feeling or levity of manner, in
contrast to former habit and disposition, sometimes indicates
the departure from mental health. Other early changes may
also show increased mental activity which takes the form of
exaggeration or exaltation. Such symptoms are serious, and
especially so when alternating with periods of depression. Re-
garding the diagnostic value of this state of increased mental
activity, Dr. Tuke says: “It is most important to remember
that exuberant spirits, mental exhilaration, loquacity, when
unusual to the individual, are fully as serious indications as
the opposite state of mind.”
Acts of the Insane.
Dr. Blandford says that as the discovery of certain delusions
leads us to inquire whether the individual has done, or at-
tempted to do certain things, so the acts in turn will help us
to discover the delusions. Many acts which, taken by them-
selves, would not prove insanity are, when explained or justi-
fied according to the insane ideas of the individual, valuable
evidence of his state of mind. But not half of the insane acts
of a person laboring under general mania are really the off-
spring of his delusions; they represent the overflow of insane
energy, and are often, so far as we can judge, motiveless and
aimless—the mere convulsive expressions of disordered nerve
centres. Even the acts which are the offspring of delusion are
not such as are the logical outcome of it, or such as are
adapted to the attainment of the delusive aim; they are the
results of insane reasonings from insane premises, or of im-
pulses which spring up in minds without being connected
with the existing delusions.
It is a common though erroneous idea that the acts of the
insane are without premeditation, so that the plea of insanity
is received with distrust, when it is shown that a crime has
been planned and carried out with judgment and caution.
Although, as a rule, the acts committed by the insane are un-
ACTS OF THE INSANE. 63
premeditated, we meet with a large number of cases in which
premeditation is clearly shown, and yet no doubt can exist
as to the insanity.
It is quite common to find insane persons stripping stark
naked, and in this condition they will run out of the house,
regardless of the weather; summer or winter, rain or shine,
day or night, and the restraining influences of decency seem
totally absent from their minds. “Putting aside all the cases
where patients have gotten rid of their clothes in a struggle,
we find that they strip themselves from a desire to destroy
everything within reach, or from a wish to get rid of the feel-
ing of heat or restraint due to the clothing.” They may also be
actuated by delusion, thinking the clothing filthy or poisoned,
or may ruin it from malice and mischief. One case was that
of an organist with delusions of persecution; being troubled
with an eczema which was worse at night; he believed that his
enemies had persuaded the officers to medicate his sheets and
clothing, and he complained most bitterly. I remember one
young man, an epileptic, whose insanity took a religious form,
so that he was very fond of reading the Bible and repeating
its teachings to those around him. One day he made his ap-
pearance in the gallery or ward of the hospital in a complete
state of nakedness, and told the Supervisor that he had been
told from above to lay aside his clothes and white robes would
be furnished him, and thereafter his name was to be “Frank,
angel.” A few hours afterwards this state of exaltation ended
in an epileptic fit.
In acute delirium, acute mania and melancholia, it is usual
to find patients stripping off their clothes and tearing them to
shreds. Sometimes they will refuse to assign any reason for
such conduct, and it seems to be merely the result of a spirit
of destructiveness, or of the high state of nervous excitement;
a state, such as we see in anger, requiring that the mental ex-
citement shall vent its force in some external act.
Imbeciles, idiots and the chronic insane will strip themselves,
destroy their clothing, smash windows, and befoul their beds
and rooms from mere wantonness. Or as one young woman
told me, because she could not help it; she knew it was Wrong,
64 INSANITY AND ITS TREATMENT.
but she felt driven to do these things. In some cases there
will be a return of such paroxysms with each menstrual period.
For mild cases the use of a “muff,” or “camisole” may suc-
ceed in checking this propensity, but in most instances the
proverbial insane will, and insane cunning, will manage to
pick even these strong garments with tooth and nail, and the
Only Safeguard is close attendance of one or two persons.
The propensity to remain naked is frequent, and is due to
several causes: it is generally found in connection with hallu-
cinations of Smell, or of sensation; also as a result of delusion.
“A young lady may desire to live in the primitive simplicity
of Paradise; or she may think her body invisible and wish to
remove the gross envelopes which would render this corporeal
translucency of no avail; or, clothing may be thrown off and
destroyed out of mere mischief and destructiveness; or, the
sensibility of the skin may be greatly enhanced, and the
warmth and friction of clothing may cause much annoyance.”
(Bucknill.)
Indecent exposure of the person and masturbation are fre-
quently met with, both with the sane and insane. They are
not infrequent symptoms in the early stages of epileptic in-
Sanity, general paralysis, and in those cases which are passing
from chronic mania into dementia; we also find such condi-
tions attending the mental disturbance consequent to cerebral
haemorrhage. In these last cases the patient will seem almost
entirely unconscious of the exposure.
A great deal is said in stories and novels about the extrav-
agancies of dress and general appearance in which the insane
indulge; and excellent delineations of these may be found in
the works of Shakespeare and Sir Walter Scott.
The clothing and hair; the condition of the face and hands;
the various articles worn as ornaments; the habits, speech,
methods of eating and drinking; all these may attract our at-
tention in a thousand different ways. The man who is insane
may stuff his pockets with pebbles, sticks, bits of paper or
leaves, and regard them as very precious. His eating and
drinking may attract our notice. He may eat voraciously or
very little, or refrain entirely from food. “He may eat only
RESTRAINING APPARATUS. 65
*
such food as eggs, from fear of being poisoned; or only the
food cooked by himself; or he may require others to taste every-
thing before he partakes of it. He may eat filth of all kinds;
in fact, there is nothing too nasty to be carried to the mouth
by the insane in all stages of the disease. Such acts are pre-
sumptive evidence of derangement of mind, generally of acute
mania or dementia. Absolute refusal to take food would also
warrant us in presuming that a person was not in his right
mind.”
Restraining Apparatus.
It may be well to devote a portion of this chapter to ex-
plaining and describing the various kinds of mechanical re-
straint in more common use in hospitals for the insane. Some
of its forms, with such modifications as the case requires, will
at times be of Service to you in private practice. I shall con-
sider the vexed question of restraint or no restraint in another
place.
Restraint implies first: the confinement of one or both
hands so as to prevent their use to inflict injuries or abuse on
themselves or others; or the destruction of furniture or cloth-
ing; or the denuding or exposure of the person. Second, con-
finement in a sitting position in an ordinary chair or settee,
or in bed in a horizontal position.
Seclusion signifies that on account of noise, destructiveness
or violence, it is found necessary to place the patient in a
room alone. This room may at times be padded to prevent
the patient from injuring himself; and it may be darkened
for the sake of its quieting influence.
The first method of confinement is effected by the following
means: 1. By a camisole, or waist, laced up the back, with
endless sleeves, attached in front or behind as the case may
require, to a loop on the waist. This article is made of strong
washable material, such as heavy cotton-cloth or bed-ticking.
The hands are entirely free within the sleeve, and the health-
ful action of the muscles of the arms, shoulders, chest, etc., is
not interfered with.
66 INSANITY AND ITS TREATMENT.
At the State Homoeopathic Hospital for the Insane at Mid-
dletown, New York, a new camisole for use in summer has
been devised by Dr. N. E. Paine, late Assistant Physician.
“It consists of a jacket made of heavy twine, with large meshes
Something like a fish-net; the cords, however, are fastened at
the points of intersection by being wrapped and tied with soft
thread, thus avoiding the knots that would be occasioned were
the fabric wrought after the manner of netting. The sleeves
are made of light but strong canvas and of sufficient length.
This jacket forms a useful means of restraint, and is much
cooler for the patients than the one in ordinary use.”
A second means of restraining the hands is by the use of
simple padded leather wristlets, moving on a belt about the
waist.
Thirdly, by a leather muff and wristlets, which is an addi-
tion to the second mode of a leathern shield covering the
hands. This method is resorted to when the others fail to
restrain. These three modes of restraint are used in cases of
suicidal disposition, when it is so persistent and determined
that watchfulness will not insure the necessary safety. When
there is determined and persistent disposition to self-mutilation
or exposure, or denuding of the person and self-abuse, as well
as when there is great destructiveness or violence towards
others.
Lately at the Homoeopathic Asylum, a pair of restraint
breeches have also been devised for the benefit of masturbators.
These are also made of canvas, fitting snugly to the body and
limbs, secured around the waist with a strap running through
a continuous loop, and fastened in the rear by a lock-buckle.
In front is a block-tin, semi-cylindrical receptacle for the parts
to be protected. This is strongly riveted to the canvas pants.
The apparatus was first made for and used upon male patients.
Subsequently, however, a similar apparatus was gotten up for
females, and both have proved quite effectual for the purpose
designed. Dr. S. H. Talcott says that in several cases marked
improvement has followed the application and steady use of
these protective breeches. They at least prevent a continued
series of excitements, and consequent exhaustion to the nervous
RESTRAINING APPARATUS. 67
system; and thereby afford appropriate remedies a favorable
opportunity to act.
Confinement to a seat is effected by passing a leather strap
about the waist and attaching it behind to a chair or settee.
This is resorted to in controlling cases of great restlessness or
high excitement, with a view of husbanding the general
strength and promoting calmness. Many cases, especially in
the acute stages of mania, if left to themselves, would soon
exhaust their vital powers by excessive muscular action.
Confinement in bed in a horizontal position is effected by
two methods: first, by an apparatus known as a bed-strap,
consisting of a leather cushion about eighteen inches wide
and twenty inches long, with three straps at the top, one about
the middle of it, and two at the bottom. The central top strap
is fastened to the head of the bed, and the two bottom ones to
the foot; the patient is then placed on the cushion, the middle
strap is passed about his waist, the two straps at the top passed
forward diagonally across the breast and buckled to the waist-
strap, thus confining the body of the patient to the cushion.
Two bights move on rings on the straps attached to the foot of
the bed. These bights are buckled around the ankles with a
strap attaching them to the foot of the bed, to regulate and in
a manner restrain the motion of the feet. This instrument of
restraint is more formidable in description than in fact. It is
simply an apparatus confining the patient to the bed, allowing
Some motion, such as drawing up the feet, turning on the
side, etc.
The other method is a covered bed or crib. I have never
used this myself, but many asylum superintendents prefer it
to the bed-strap. This bed is constructed like an ordinary
child's crib, with the addition of a slat cover. This arrange-
ment does not interfere with the movements of the patient in
rolling from one side to the other, or moving the limbs in any
way. It merely prevents the patient from sitting up or getting
out of bed. As the sides and top are open, the air circulates
as freely about the body of the patient as in an ordinary bed.
“Restraint in a horizontal position is used in cases of exhaust-
ion, when the physical health of the patient demands that he -
68 INSANITY AND ITS TREATMENT.
be kept in bed. The medical thought involved will be readily
appreciated. Sick people ordinarily lie in bed under the
advice and direction of the physician, but the same class when
insane will not always do so, and these arrangements are to
effect this end.”
The above description of the instruments used in restraint
is largely taken from the Report of the State Asylum at Utica,
New York, for 1863, by Dr. John P. Gray.
Artificial Feeding of the Insane.
Among the most troublesome circumstances that you will
meet, either in asylums or general practice, are those cases
when the patients for a longer or shorter time persistently re-
fuse to take food, and where, in consequence, recourse must be
had to artificial feeding. When we consider the large number
of patients who, habitually or otherwise, in one or the other
stages of insanity, refuse food, the aggravation of the disease,
the obstacles created to the administration of remedies, and
the danger to strength and life produced by such a cause, it is
a matter of surprise that so little attention has been paid by
the general practitioner to the evils of abstinence and the
measures to be taken for its relief.
Some years ago it was estimated that one-ninth of the insane
refuse food. Whether we accept this estimate as true, or con-
sider it to be exaggerated, there is no doubt that the cases of
melancholia combined with abstinence are now more numer-
ous than formerly; and even the tendency to refuse food,
whether associated with delusion or despair, fury or abstrac-
tion, is more generally met with.
Refusal to take food is not a symptom confined to the sub-
jects of any one form of mental disorder, but by far the greater
proportion are the acutely melancholic, in whom the nervous
system is so depressed and lowered, that the natural craving
for food is altogether absent; those in whom the mind is so
pre-occupied with the thought of its miserable condition, that
the feeling of hunger is entirely in abeyance and unheeded in
the presence of a more severe, though it may be groundless,
Source of uneasiness and anxiety.
AIRTIFICIAL FEEDING OF THE INSANE. 69
Deliriums, more or less fanciful and absurd, are frequently
associated with refusal of food; and, though in many cases,
they arise from abnormal sensations, the result of simple dys-
pepsia, or more grave disorders, and thus are, as it were, the
secondary, but not the less important cause of abstinence; in
others they have no foundation in digestive derangements,
and are the sole and primary cause. For example, one man
abstains because he has no money to pay for what is offered
him ; another, because he does not work and consequently
does not deserve it; a third asserts that he has been dead for
years and has no further need of food; a fourth affirms that
everything set before him is poisoned, and prefers to suffer the
pangs of hunger rather than give his enemies the satisfaction
of ending his days; while a fifth is in a constant state of alarm
and terror, and paces the room from end to end, exclaiming
that the last day is at hand and the world is to be burned up;
in a case of puerperal melancholia, recently under my care,
the patient thought it wrong to gratify her appetite, as it
would draw her attention from the affairs of religion, so she
obstinately refused food, and I was obliged to feed her by force
on three successive days.
“Individuals will partake of certain meals, or certain quali-
ties of food only, at particular times, or by stealing; will take
portions of each meal, but never a full meal; will take a small
portion of whatever is presented to themselves or to others;
will prefer fluids to solids or vice versa; the servants allow-
ance but not their own.”
But when the digestive disturbance is the primary cause of
the abstinence, the delirium generally has reference to the un-
easiness and pains experienced; one fancies that his throat is
closed up, and therefore he cannot swallow; another says that it
is absolutely impossible for him to take anything, and that he
already has more than he can contain, though he may have
been fasting for days; while another fancies that there are
serpents in his stomach, which can only be gotten rid of by
starving. In many of the latter class, the most insignificant
feelings are magnified and dwelt upon, and their importance
exaggerated to an extent greater even than among hypochon-
70 INSANITY AND ITS TREATMENT.
driacs; but when the delirium has reference to the patient's
Sensations, there is reason to suspect the existence of some
organic or functional derangement of the digestive apparatus.
“In some cases, abstinence from food may depend entirely
upon organic disease of one or other of the Organs more im-
mediately concerned in the process of digestion, as for exam-
ple, the stomach or liver, without the existence of delirium;
and, in such cases this symptom may be ascribed to a wrong
cause, owing to the mental state of the patient, and food be
forced upon him, which, if his mind were not affected, would
not be so earnestly insisted upon. But these diseases, though
their diagnosis is often extremely difficult, from the inability
of the patient to communicate his subjective symptoms, can
never be long overlooked, if the objective are duly attended
to; and even when such diseases are present it is necessary to
administer sufficient nourishment and suitable medicine, so as
to prolong life as far as possible.”
Some from utter stupidity and helplessness are unable to
feed themselves, or even Swallow what is placed in the mouth;
such are those laboring under melancholia with stupor, and
some of the cases of acute dementia; while others offer a
strong and determined resistence to being fed. Occasionally
an acutely maniacal patient requires to be fed with the stomach
pump, in order to ward off the great prostration and exhaust-
ion which are sure to follow after the violence of the mania
has subsided, and which are best met by a liberal supply of
food administered during the attack. From whatever cause
food is refused and life thereby endangered from inanition,
the stomach pump must be used, but not before all ordinary
means for inducing the patient to partake voluntarily have
been tried in vain. Its employment is not to be long delayed
when necessary; nor, on the other hand should it be resorted
to too hastily, and lead us to dispense with the tact and pa-
tience which both attendants and physician should use.—“If
a patient refuses food from Some unimportant reason or from
pure obstinacy, and if it is considered that one application of
it will succeed in correcting this perversity for the future, then
it should be employed; but sending food directly into the
ARTIFICIAL FEEDING OF THE INSANE. 71
stomach without its undergoing the natural process of masti-
cation, or at least passing through the cavity of the mouth,
where it is mixed with saliva, and prepared for its further di-
gestion in the stomach, is a proceeding which the extremity
of the case alone renders necessary and justifies. No doubt,
food in the stomach for sometime after it has entered it stimu-
lates a flow of saliva, which is swallowed, and is made avail-
able for the purpose of digestion; but this only to a limited
extent makes up for the ordinary and thorough mastication of
solid food, and its due mixture with the Secretions from the
salivary glands of the mouth.”
One of the most characteristic symptoms of long abstinence
from food is a peculiar and disagreeable odor of the breath.
This is so peculiar, and so different from the ordinary offensive
breath of dyspeptics that it can readily be recognized by any
one who has met it a few times. It is as characteristic as the
smell from small-pox, diphtheria or measles, and arises from
the altered state of the Secretions of the stomach and mouth.
“The mouth becomes clammy, the teeth become foul, and in
the worst cases are covered with Sordes; the tongue is coated
with a thick white fur of old epithelium, little saliva enters
the mouth, and what does so escapes by the lips. The offensive-
ness soon disappears in most cases, if a regular and sufficient
amount of nourishment is administered, without the aid of
medicine at all,—a circumstance which shows that it mainly
arises from the want of food, and the consequent state of the
mouth and the body generally, in which the wasting.process
far outstrips and exceeds the renewing.”
When we have tried persuasion, coaxing, bribes and threats
even, but all in vain, our first resort is of course to the spoon,
and to the various small feeding-jugs sold at all china stores;
and we will attempt to make our patient swallow by compress-
ing the nose, and we may in simple cases succeed; in other
cases we will fail and be obliged to deliver the food directly
into the stomach, either through the nose or the mouth; and
fhe question arises: How soon shall I attempt this? How long
is it safe to allow the patient to abstain from food?
Dr. Luther Bell, former Superintendent of the McLean Asy-
72 INSANITY AND ITS TREATMENT.
lum, at Somerville, Mass., said: “In those cases of mere will,
where the patient absolutely refuses, with the calculation that
he will compel his release by endangering his life, when the
health and deposition of fat are average, perhaps it would be
a safe general rule to allow three days, that is seventy-two
hours, to elapse before any force be used.” But his opinion
seems to have been somewhat influenced by the presence or
absence of the brown crust upon the tongue, the sordes on the
teeth, the chapped lips, the blush on the mucous membrane,
and especially the fetid breath. Dr. Tuke limits the delay to
from three to four days. Dr. Bucknill says that the feeding
should be resorted to early, and Dr. Gray of the Utica Asylum
prescribes feeding after the refusal of one meal in the weak
and three meals in robust patients.
Dr. W. A. Browne, consulting physician to the Crichton In-
stitution, and ex-Commissioner of Lunacy for Scotland, says
that in his own practice he never waited for the appearance of
any critical signs, but feeds artificially after the expiration of
forty-eight hours—in other words, when six meals have been
positively or pertinaciously refused. This calculation was not
arbitrary, but the result of his experience: first, that after this
period, whether abstinence were voluntary or involuntary,
emaciation and debility increased with great rapidity; second,
that digestion and assimilation were tardily and imperfectly
performed; third, that mental weakness increases to a degree
of temporary dementia, and that in proportion to this enfeeble-
ment the moral impressions generally produced by the prepa-
rations for and the process of feeding, were in a great measure
lost, or impaired. When great debility existed, this step was
taken even earlier. Nor should we be swayed from our pur-
pose by those cunning concessions and evasions which the
insane essay when they take a portion of a meal, pick, dally,
dawdle over what is presented; when they appear to masticate,
but do not swallow; when they deceive; distribute the food to
others, to pets, destroy or conceal it, even having recourse to
indecent practices in order to defeat us. These subterfuges
are numberless, and, if successful, may reduce the quantity
taken so low, that life and strength and intelligence may all
AIRTIFICIAL FEEDING OF THE INSANE. 73
be ebbing imperceptibly during the delay, and in some cases
gangrene of the lung may set in. You should be on your
guard against those patients who, by rumination, can partly
disgorge the contents of the stomach; and Dr. Browne reports
the case of a gentleman transferred to his care, pale, skeletonic
and exhausted, from a well-conducted home, where his anx-
ious friends saw him take abundant meals, but at last discov-
ered that the inefficacy of these was explained by the patient
retiring to the water closet, tickling the fauces, and by this
means rejecting all that he had swallowed,
Having determined upon compulsory feeding, the next step
is to select the safest, best and most irresistible means to
accomplish our purpose. The naso-pharyngeal tube has lately
been recommended, because it enables the operator to escape
all the obstacles offered by lips, spasmodically closed jaws,
raising of the tongue, etc. The use of this tube was first urged
by Dr. Harrington Tuke, and is now generally adopted in
France, but it has some weighty objections, principally due to
the stiffness of the tube. Great irritation is occasionally the
result of passing any pipe through the nostrils, and then from
the narrowness of the tube and its orifices very thin fluids only
can be given. Again Esquirol, Leuret, Trelat, Voisin and
others state that its use gives rise to grievous disasters, such as
the infliction of wounds in the Soft palate, hemorrhage, entrance
of the glottis, pumping of fluids into the air passages, and per-
foration of the oesophagus. Voisin also accuses it of causing
abrasion, ulceration and fracture of the turbinated bones,
penetration of the larynx, and as being useless when there is
narrowness, deformity or disease of the nares. It is fair to
state, however, that Griesinger expresses a decided preference
for the naso-Cesophageal sound, founded upon its use for twenty
years, during which no accident occurred; and at a late con-
gress of Paris physicians the majority of the debaters favored
the use of this tube.
Many of the objections to the use of a naso-Oesophageal tube
are removed by the plan first advocated, so far as I am aware,
by Dr. N. E. Paine, late assistant physician at the Homoeopathic
Asylum for the Insane, at Middletown, N. Y. He says: “A soft
5
74 INSANITY AND ITS TREATMENT.
rubber Nelaton catheter is taken. The great difference between
it, adapting itself so readily to any curve, and the old-fashioned
stiff catheters of Tuke, that remained “fixed against the cervical
vertebræ,’ is apparent to everyone. This is now passed through
the nose into the stomach, after having been oiled or dipped
into the liquid to be given. The nozzle of a Davidson syringe,
filled with fluid instead of air, is then inserted into the project-
ing end of the tube, and the food is pumped directly into the
stomach.” And again he says: “Its advantages are that the
introduction causes no pain; there is no struggling to Weary
the patient; all the food enters the stomach and none is thrown
about the room; respiration proceeds regularly and even con-
versation may continue without hindrance. The objections to
it are those against the much used stomach-tube; while, over
that instrument, from the non-necessity of forcing open tightly
clenched jaws, and because of the inability of the patient to
prevent its passage, it holds a deserved supremacy.”
My own experience, both in asylum and private practice,
has been exclusively with the stomach-tube, and I have thus
far met with no difficulty or seen any ill results. I believe
that a similar practice exists in nearly all the British and
American asylums; while the naso-oesophageal tube is used
mainly in France.
Dr. Browne says: “For forty years I have tried, or seen tried,
the various methods mentioned, and have no hesitation in Say-
ing that the syringe and elastic tube, introduced by the mouth,
when proper precautions are taken, is the more safe, more suc-
cessful, and more easily applied than any other apparatus.”
There are different ways of using the stomach-tube, and I
shall follow the descriptions given by Dr. Blandford in his
work on Insanity, and by Dr. Browne in one of the West Rid-
ing Reports, as a thorough knowledge of the details will make
the operation an easy and Safe one for you.
At St. Luke's Hospital the patient is seated in an arm-chair,
and restrained in that position by means of sheets, which ren-
der him incapable of any sudden movement, by being passed
around the body and legs and then drawn through the arms
and legs of the chair. In cases where there is not much resist-
ARTIFICIAL FEEDING OF THE INSANE. 75
ance offered, this position is, perhaps, preferable to any other,
its chief advantage being that there is then little risk of chok-
ing, should there be regurgitation of the food while the stom-
ach-pump is being used, as what fluid is returned readily
passes out of the mouth, and the patient can again breathe
freely; but if the patient is very strong and makes a vigorous
resistance, it is almost impossible to hold him quiet in a chair
by any means; which, however, can easily be done if he is
placed in a recumbent position upon a bed, and held by a
sufficient number of assistants, and that without any risk of
bruising or inflicting any injury. The great advantage of
having the patient completely overpowered is, that there is
then no struggling or resistance; and the abdominal muscles
being thus set at rest, there is much less chance of vomiting;
whereas, if there is much struggling, the breath is held in,
the diaphragm and abdominal muscles are in a state of ten-
sion, and what is forced into the stomach by the pump, is as
speedily rejected.
The patient being in position on the back and held by at-
tendants, aided by sheets or rugs thrown over the body, and
upon the edges of which they can kneel; the mouth has to be
opened by Some kind of gag. The gag most frequently em-
ployed is the one with which the ordinary stomach-pump case
is furnished, and consists of a straight piece of wood with a
hole in the centre of it, through which the tube is passed.
One objection to this gag is, that it is often very difficult,
almost impossible, to insert it in the mouth; and another is,
that the tube has to be passed, so to speak, in the dark. It is
pushed through the hole in the gag into the back part of the
mouth, and as very little inclination can be given to it, it
must be steadily thrust on, until it finds its way into the
Oesophagus, after being bent against the posterior wall of the
pharynx, a proceeding which is apt to excite retching and
contraction of the pharynx, and so render the passage of the
tube still more difficult. When obtainable, it is best to use
one of the varieties of the expanding screw-keys. These in-
struments are light and strong, and the screw should be toler-
ably quick in its action, not for the purpose of forcing open
76 INSANITY AND ITS TREATMENT.
rapidly jaws that are firmly clenched, but for the purpose of
quickly taking advantage of any voluntary separation on the
part of the patient. An instrument of this kind is easily ap-
plied, as it can be inserted wherever there is an open space be-
tween the teeth, and the mouth is then readily opened by
turning the screw, no matter with what determination it is
shut. A short time ago, I made use of a simple wedge-shaped
piece of hard wood, and it answered excellently well, although
a little more difficult of introduction; it may be inserted flat-
ways as a wedge, and then watching your opportunity, you
may turn it on the side and have ample room; care should
be taken to insert it well back between the jaws, or the efforts
of the tongue may push it out again. In all cases great care
should be exercised in opening the mouth, that the patient’s
teeth are not broken off, as might happen if too much or too
sudden force were used. All this care must be taken by you
or your assistants, for the patient will be totally regardless of
results in offering all possible resistance.
When the mouth has been opened, the key or wedge should
be entrusted to an assistant, whose only duty should be to
hold it in place; and there is no difficulty in doing this so
long as the head is kept perfectly steady. In this way the
greatest freedom is afforded in passing the tube, and the left
forefinger may be inserted into the mouth to give the tube the
proper curve, and guide it over the root of the tongue, should
there be any difficulty in passing it; this ought, however, to
be seldom the case, as the passage of the tube is as easily
effected as that of the male catheter.
The main points to be attended to in passing the instru-
ment are, that it should be moved slowly and inclined towards
one or other of the pillars of the arch of the palate; that spe-
cial caution should be observed as the cardiac orifice of the
stomach is approached; that a candle should be held at the
upper extremity in order to see whether air escape or not,
that we may be sure not to have entered the air passages; that
the tube should not be withdrawn until it be quite emptied,
and should be quickly drawn out when supposed to be in the
vicinity of the glottis, placing the finger upon the external
orifice which has been detached from the syringe, as by the
ARTIFICIAL FEEDING OF THE INSANE. 77
escape of a portion of ths contents at this time into that open-
ing, accidents have taken place, especially in debilitated and
paralytic patients.
The calibre of the tube will depend somewhat on the size
of the pump used. Too large a one is of no advantage, and
is objectionable on account of its inflexibility and the diffi-
culty with which it adapts itself to the curved passages through
which it has to pass, though it may be the safest in careless
hands as it cannot enter the larynx or produce laceration so
easily. I prefer a medium sized tube, a little larger than a
large bougie, having a slightly enlarged or bell-shaped ex-
tremity, and two good sized openings on the side near the end.
In passing the tube, there is sometimes a little pressure needed
to make it enter the Oesophagus, on account of its having to
follow a slightly obtuse curve, and coming in contact with the
bodies of the vertebrae, which become prominent if the head
is held too far back.
Instead of using a pump, or metal syringe, a Davidson's
Syringe may be used to good advantage; in any case being
careful that your tube is free from air; and injecting the food
slowly, watching to see that it is not thrown back by the side
of your tube.
The frequency with which your patient will need to be fed,
and the amount of food used will of course vary according to
circumstances; in most cases twice a day will suffice, using at
each meal a pint or SO of beef-tea, Soup, gruel, egg and milk,
etc., but the kind of diet given will, of course, vary.
Cases are on record where life has been sustained eleven
years by artificial feeding, and I would urge its use, not mere-
ly in cases of voluntary fasting, or when the trachea and
Oesophagus have been wounded, but when there is any impedi-
ment to the act of swallowing of whatever kind.
I have spoken at length upon this point, for it may happen
to some one of you, to have your medical career made or mar-
red, by your ability or failure to feed an insane or other patient.
Few things will have so great an influence in favor of a young
physician as his ability to successfuly deal with such cases as
these, and few things are more overlooked in the teachings of
the schools.
78 INSANITY AND ITS TREATMENT.
LECTURE IV.
Causes of Insanity.
The causes of insanity, as enumerated by authors, are so
general and vague as to make it a difficult matter to settle in
the mind what they really are. The uncertainty springs
from the fact that, in the great majority of cases, there is a
concurrence of conditions, not one single effective cause. All
the conditions which conspire to the production of an effect
are alike causes, alike agents, and therefore all the conditions
whether they are in the individual or in the circumstances in
which he is placed, must alike be regarded as causes. “A
complete biographical account of the individual, not neglect-
ing the consideration of his hereditary antecedents would
alone suffice to set forth distinctly the causation of his insani-
ty. If all the circumstances, external and internal, were duly
scanned and weighed, it would be found that there is no acci-
dent in madness. The disease, whatever form it might take,
by whatever complex concurrence of conditions, or by how
many successive links of causation it might be generated,
would be traceable as the inevitable consequence of certain
antecedents, as plainly as the explosion of gunpowder may be
traced to its causes.” The germs of insanity are sometimes
latent in the foundations of the character and the final out-
break of a long train of antecedent preparations.
It is common to treat of the causes of insanity as being moral
and physical, though it is not possible to discriminate in all
cases. When, for example, hereditary taint exists, and is the
cause of some defect or peculiarity of character, which ulti-
mately results in insanity, one person might describe the
cause as moral, while another would class it as physical. In
reality every moral cause operates by means of the physical
changes which it produces; and, in the great majority of cases
in which the cause has been pronounced moral, there have
been some things in the physical constitution by the co-opera-
tion of which the result has been produced.
CAUSES OF INSANITY. 79
As a predisposing or exciting cause of disease, constitutional
defects or instability of elements stands pre-eminent. “If we
See a flat, narrow chest in a large organism, and find that this
individual is subject to cough on slight atmospheric changes,
we are apt to inquire whether his ancestors died of consump-
tion, and find the inquiry usually answered in the affirmative.
In this instance we have natural infirmity and instability of
lung element, and they lead us to recognize a tubercular di-
athesis and prognosticate consumption under unfavorable cir-
cumstances of life. And, as we know, the poorly-housed and
poorly-fed of this class of people almost always die of tubercu-
lar disease.” The pulmonary Imanifestations of the diathesis
are here obvious; not so, however, if they shall have mainly
involved the nervous system. The mental state, the propensi-
ties and tendencies, the cerebral premonitions which herald a
threatening attack of insanity in individuals tainted with a
diathesis, whether inherited or acquired, at any age of life, are
subjects still open to research.
The doctrine of heredity of nervous tissue rests upon the
same foundation of natural infirmity and instability of nerve
element. In regard to insanity this question of heredity is of
the highest possible in portance. Prof. Maudsley says: “The
insane neurosis which the child inherits in consequence of its
parent's insanity, is as surely a defect of physical nature as is
the epileptic neurosis to which it is closely allied. Past all
question, it is the most important element in insanity.” He
further says: “We have not to deal with disease of a meta-
physical entity, which the method of inductive inquiry cannot
reach, nor the resources of the medical art touch, but with dis-
ease of the nervous system, disclosing itself by physical and
mental symptoms. Mental disorders are neither more nor
less than nervous disorders in which the mental symptoms
predominate, and their entire separation from other nervous
diseases has been a sad hindrance to progress.” “It is quite
true, that when we have referred all the cases of insanity that
we can to bodily causes, and grouped them according to their
characteristic bodily and mental features, there will remain
cases which we cannot refer to any recognizable bodily cause,
80 INSANITY AND ITS TREATMENT.
and connect with any bodily disease, and which we must be
content to designate as idiopathic. The explanation of these
cases we shall probably discover ultimately in the influence of
the hereditary neurosis and in the peculiarities of individual
temperament.” But in accepting this explanation we must,
while admitting the probability of hereditary neurosis, not lose
sight of the fact that insanity itself is a special nervous dis-
order, and may in many individual cases originate in Some
still unknown morbid process in the brain tissue. It is also
evident that we are constantly discovering new structural
degenerations of brain tissue, which throw more and more
light on causation, and constantly narrows down the class of
idiopathic cases.
Speaking on the subject of physical causation, Prof. Mauds-
ley uses the following emphatic language: “I am tempted
sometimes to think that no person goes mad, Save from palpa-
ble physical causes, who does not show more or less plainly by
lmis gait, manner, gesture, habits of thought, feeling and action,
that he is predestined to go insane;” and again he says: “It
cannot be in the normal order of events that a healthy organ-
ism should be unable to bear the ordinary mental trials, much
less a natural physiological function, such as the evolution of
puberty, the puerperal state or the climacteric change.” When,
therefore, the strain of grief or one of those physiological con-
ditions becomes the occasion of an outburst of insanity, we
must look for the root of the evil in some natural infirmity or
instability of nerve element.
It will not do to say that excessive grief, which is a compar-
ative expression as between individuals, because grief influ-
ences the physical organization normally, will therefore induce
a diseased condition of that organism. Grief may be excessive,
intense, prolonged, and yet the person remain sane; and so of
the other passions. Can grief cause a mental change, inde-
pendent of bodily change, and thus under its stress can the
mind be overthrown? While the bodily functions are health-
fully performed, and the brain properly nourished, and due
rest is secured, can any degree of grief cause insanity? Is it
not only when the grief is so absorbing as to withdraw atten-
CAUSES OF INSANITY. 81
tion from the due care of the body, and the brain is conse-
quently ill-nourished and ill-rested, that insanity supervenes?
Only when the moral cause has induced that degree of func-
tional activity and exhaustion, the necessary effect of which is
to transform the physiological action into a pathological state,
does insanity ensue, and then through the medium of struct-
ural change. The factor introduced, therefore, is disordered
function or disease of the brain. So of jealousy, excitement
in business, politics or religion. These are in one sense moral
causes, but as moral influences alone they are insufficient to
induce insanity. As remarked by Dr. Amariah Brigham, they
must first induce physical disease. Or, in the words of Gries-
inger, the moral cause is potent “when it has, become fixed
through the mediation of abnormal functional phenomena.”
Whatever may be the remote or inciting cause of insanity,
however strongly circumstances may tend to harass, weary
and depress the mind, insanity will result only as a conse-
quence of a disordered state of the brain. We may enumerate a
wide range of what are denominated predisposing causes, such
as heredity, sex, age, nativity, education, social position, loss
of friends, property or position, anger, disappointment in love,
etc., and yet when we have done all this, we have only shown
that in connection with the history of insane persons, we have
found facts and circumstances which are also of common Oc-
currence in the lives of those who are not insane. For this .
reason Some psychologists are disposed to deny the force of
these agencies as predisposing forces. It is a pertinent ques-
tion, what value should we give to them; and what relation do
they sustain as elements of causation in producing insanity?
As Dr. Maudsley well says: “Not until we apply ourselves
earnestly to an exact observation and discrimination of the
mental and bodily conditions, which cooperate in the causation
and are manifested in the symptoms of the manifold varieties
of insanity, shall we render more precise and satisfactory our
knowledge of its causes, its treatment and its classification.”
“How unscientific it appears,” he continues, “when we reflect, to
enumerate as is commonly done, sex and age among its pre-
disposing causes. No one goes mad because he or she happens
82 INSANITY AND ITS TREATMENT.
to be a man or a woman, but because to each sex, and at a
certain age, there occur special physiological changes, which
are apt to run into pathological effects in persons predisposed
to nervous disorders. How often it happens that a moral
cause of insanity is sought and falsely found in a state of
mind, such as jealousy or grief, which is really but an early
symptom of the disease.”
Griesinger in speaking of the emotional influence in the
Causation of insanity says: “It may be direct or indirect. In
the first case, the emotions, particularly the passed off psychi-
cal phenomena, are the immediate originators of the mental
disease, inasmuch as they produce a state of intense irritation
of the brain which now continues.” “More frequently, how-
ever, the insanity originates indirectly through the medium
of a pathological process from the psychical cause, inasmuch
as they, in the first place, bring about further deviation from
the normal organic processes in other parts, from which the
cerebral disease proceeds as a secondary result.”
If we consider the fact previously spoken of, that the emo-
tions ordinarily disturb sympathetically, the functions of the
Organs of respiration, circulation, digestion, and of blood for-
mation, we will understand how these, when long continued
and violent, must cause slight disorders of these functions;
and those individuals are most easily affected in whom—
Owing to congenital or acquired disposition—emotions are
most easily excited. Very frequently the cerebral disease
commences when, after long oscillation, some serious patholog-
ical change has gradually arisen in some other organ, and it
is easily comprehensible that those consequences of the emo-
tions are most frequent and dangerous in the period of life in
which the organism is subjected to the greatest expenditure of
force in order to its proper development and further growth,
and in which it is generally most capable of disease, viz., at
the period of puberty, during child-birth and the climacteric.
As to the manner in which the predisposing moral causes
influence the physical system, Griesinger says: “It is by no
means rare, after some untoward event which immediately
caused disturbance of the cerebral processes, to see the indi-
CAUSES OF INSANITY. 83
vidual become again mentally quiet; but he begins to feel ill,
to suffer in various other organs, and it is only after years of
constantly increasing deterioration of the constitution, Owing
to the development of anaemia or other chronic disease, that
mental disease is established.” He says that under such cir-
cumstances, emaciation, indigestion, sleeplessness, palpitation,
cough, cerebral congestion, nervousness and hypochondria,
neuralgias, menstrual irregularities, and various anomalies of
sensibility supervene. Tuberculosis, and heart diseases are
now awakened or rapidly aggravated, and out of these patho-
logical mediators between first causes and ultimate results,
mental diseases proper are finally established.
A nervous child should be placed in a strong minded fam-
ily,–that is, with those who have the will under complete con-
trol, never allowing themselves to be betrayed into doubt or
vacillation. The melancholy should consort with the cheer-
ful, the unduly hilarious with the more sober minded and
sedate; the wandering and vacant should be won to interest
by comparatively sensational modes of placing things before
them; their perceptive and reflective faculties being alike en-
couraged. These principles are worth considering, to neglect
them is to repudiate the basis of a sound psychology; to study
them is, or should be, the power to prevent evil. In a large
number of persons the hereditary law is so overpowering and
imperious that there seems no alternative but to yield to its
behests. “Multitudes of human beings,” says Maudsley, “come
into the world weighted with a destiny against which they
have neither the will nor the power to contend; they are the
step-children of nature, and groan under the worst of all
tyrannies, the tyranny of a bad organization.”
Now when this bad organization involves what Dr. Anstie
termed the active or dormant hereditary neurosis; and what
we call the insane temperament, the future of its subjects can-
not be very bright and cheering. There is about them a want
of uniformity; their cranial development is not always satis-
factory; the features are irregular, one part of the face being
bright and expressive, and another part being very much the
reverse. They are given to facial twitchings, an occasional
84 INSANITY AND ITS TREATMENT.
Squint, convulsive movements of the limbs; all the movements
are ungainly and lack that muscular co-ordination which is
the life of symmetry. In early life they may have stuttered,
or had occasional fits, and it is somewhat singular that they
may have been unusually stupid or unusually precocious. By
only these partitions are the two states represented by the two
terms great wit and madness separated. Those who are
affected with any form of neurosis are easily thrown off their
equilibrium, eager, excitable, impetuous; they are constantly
On the qui vive. They jump and dance rather than walk
through life. The puberty of such persons is premature; the
Sexual appetite strong, and they are given to habits of self-
abuse. “Happily the power of propagation is not equal to
the intensity of their passion, and there is a tendency in all
faulty organizations to die out and become extinct.” I need
hardly tell you that marriages with such should in every way
be discouraged. It is a dreadful calamity, this repetition of
the insane or neurotic temperament.
“It is equally singular and instructive as bearing on the as-
Serted league between a high order of intellect and the neu-
rotic temperament, that the fecundity of both should be de-
fective. England has no Shakespeare, no Milton, no Bacon,
no Byron, no Pope, no Newton. Italy has no Dante, no Pe-
trarch, no Ariosto, no Alfieri. Germany has no Heine, no
Goethe, no Schiller. France no Montaigne, no Descartes, no
Voltaire, no Lamartine. There is no descendant known of
Calvin, Luther or John Knox.”
“Authors,” says Dr. Maudsley, “are not agreed as to the
proportion of cases of insanity in which positive hereditary
taint is detectable; some, like Moreau, putting it as high as
nine-tenths, others as low as one-tenth. The most careful re-
searches fix the proportion as not lower than one-fourth if not
as high as one-half; and there can be no doubt that the tend-
ency is to increase the proportion as investigation becomes
more exact and searching.” (Reynolds Syst. of Medicine.)
“Another fact of observation is that the offspring of persons
who have suffered from some nervous disease, frequently in-
herit a liability to the attacks of some other nervous disease
CAUSES OF INSANITY. 85
than that which has given them their neurotic heritage;
there is a kinship between nervous diseases by virtue of which
it comes to pass that they undergo transformation through
generations. The two diseases most closely related in this
way are insanity and epilepsy; the descendants of an epilep-
tic parent being almost, if not quite, as apt to become insane
as to become epileptic, and one or other of the descendants of
an insane parent not infrequently suffering &om epilepsy.”
(Responsibility in Mental Disease.)
Since the direct cause of insanity is some morbid affection
of the nervous system, some instability of nerve element, and
as every part of the organism is transmissible, we see that
heredity of mental diseases must be the rule. Convulsions in
the ancestors may be hysteria, or epilepsy, or insanity in the
descendants. A case is cited where hyperaesthesia in the
father branched out in the grand-children into the various
forms of monomania, mania, hypochondria, hysteria, epilepsy,
convulsions and spasms.
Piorry says: “A goldsmith who had been cured of a first
attack of insanity, caused by the revolution of 1789, took poi-
son; later, his eldest daughter was seized with an attack of
mania, passing into dementia. One of her brothers stabbed
himself in the stomach with a knife. A second brother gave
himself up to drunkenness, and ended his career by dying in
the streets. A third, owing to domestic annoyances, refused
all food, and died of anaemia. Another daughter, a woman
of most capricious temper, married, and had a son and daugh-
ter; the former died insane and epileptic; the latter lost her
mind during her lying-in, became hypochondriac, and wished
to starve herself to death. Two children of this same woman
died of brain fever, and a third would never take the breast.”
(De l'Hérédité dans les Maladies, p. 169.)
This hereditary disposition may appear at the same period
of life in successive generations. Prosper Lucas relates the
case of a noble family at Hamburg, all of whose Scions, distin-
guished through four generations for great military talents,
went mad at the age of forty; there remained but one member,
a soldier like his father, and he was, by decree of the Senate,
86 INSANITY AND ITS TREATMENT.
forbidden to marry; the critical period came, and he also went
mad. Esquirol says that in one family the father, son and
grandson committed suicide at about the age of fifty. One
family came under my own observation where the father and
Son committed suicide at about the fiftieth year, and the grand-
Son made two attempts, and may have succeeded since I lost
sight of the case.
In considering this question of heredity we must remember
that a certain number of insane persons will necessarily have
insane ancestors, without there being a necessary connection, in
the way of transmission between the ancestor and the insane
descendant.
M. Baillarger has made some important investigations to
decide whether the father or the mother were more apt to
transmit this hereditary influence, with the following results.
“1. The insanity of the mother, as regards transmission, is
more serious than that of the father; not only because the
mother's disorder is more frequently hereditary, but also be-
cause she transmits it to a greater number of children.
“2. The transmission of the mother's insanity is more to
be feared with respect to the girls than the boys; that of the
father, on the contrary, is more dangerous as regards the boys
than the girls.
“3. The transmission of the mother's insanity is scarcely
more to be feared, as regards the boys, than that of the father;
it is, on the contrary, twice as dangerous to the daughters.”
The first and second of these propositions are confirmed by
the late Dr. A. Brigham, and apparently endorsed by Bucknill
and Tuke. &
Dr. Leubuscher, of Berlin, points out that the lower forms
of mental disease, as imbecility or silliness, and various forms
of depression, appear in a remarkable degree, to be of an he-
reditary nature; and, also, that the outbreak of an hereditary
predisposition to insanity is especially connected with such
processes as those of puberty, childbirth, and the climacteric
period.
The exciting causes of insanity, so far as we are able to de-
termine, are physical; that is, no moral or intellectual opera-
CAUSES OF INSANITY. 87
tions of the mind induce insanity apart from a physical lesion.
From a circulatory disturbance in the supply of blood to the
brain, induced through irregular or excessive use of the organ,
or under mental emotions, there may be initiated temporary
or even permanent cerebral disease, whereas it is equally true,
that from an altered condition of the fluids not yet adequately
understood and determined, and which may have been super-
induced during peculiar natural periods, as lactation, gesta-
tion, menstruation, etc., in Some distant organ, such as the
uterus, kidneys, lungs, we may have like results.
Doubtless the most frequent physical cause is intemperance.
Considering the unreliability of statistics, it is not easy to
measure with accuracy the extent of this evil as a cause of
insanity. But it is the testimony of all alienists that its vic-
tims are filling our asylums. Yet it is to be noticed that even
there an element of great uncertainty is introduced. A re-
nowned French psychologist, Moreau, says: “Drunkenness is
regarded as one of the most frequent causes of insanity. But
it is equally certain that drunkenness, or rather the taste for
drink, is as often, and even more frequently, a first symptom, -
the effect therefore, and not the cause of disease.” And this
taste, he affirms, has been hereditarily transmitted from the
parents to the offspring, just as the same features, and color of
hair and complexion.—“I receive patients daily at the Bicêtre,”
he writes, “in whom I can trace back the origin of the malady
to nothing else but the habitual intoxication of their parents.”
Esquirol also long since gave utterance to the same idea when
he said, “If the abuse of alcoholic liquors is an effect of men-
tal depravity, of educational vices, and the force of bad exam-
ple, men sometimes give way to it by reason of a morbid
impulse, which they have not the power of resisting.”
Another French psychologist, Dr. Morel, also observes, “It
is not necessary to create a monomania of which the chief
characteristic is an irresistible tendency to fermented liquors.
That tendency is most frequently only a symptom of a prin-
cipal disease, especially when it is suddenly developed in
persons who previously had given no evidence of such a pro-
pensity.”
88 INSANITY AND ITS TREATMENT.
The late Dr. Anstie, who made alcoholism a special study,
is clearly of the opinion that of all depressing agencies it has
the most decided power to impress the nervous centres of a
progenitor with a neurotic type, which will necessarily be
transmitted under various forms and with increasing fatality
to his descendants.
Morel relates the history of one family which may be cited
here as a typical example of the course of degeneration pro-
ceeding unchecked, as follows:
First generation: — Immorality; Alcoholic excess; Brutal
degredation.
Second generation: — Hereditary drunkenness; Maniacal
attacks; General paralysis.
Third generation:-Sobriety; Hypochondria; Melancholia;
Systematic mania; Homicidal tendencies.
Fourth generation: Feeble intelligence; Stupidity; First
attack of mania at sixteen. Transition to complete idiocy and
probable extinction of the family.
Dr. H. Dagonet, while placing intemperance at the head of
the physical causes of insanity, and devoting in his text-book
a whole chapter to its special features, says, that it is especially
true in the colder countries, as Sweden, Great Britain, Russia
and North Germany where it seems to enter as a factor in One
third of the cases; and in France it seems that the past few
years have witnessed a steady increase in the proportion of
cases caused wholly or in part by the use of intoxicating
liquors, especially brandy and absinthe.
Loss of Sleep. In the chapter upon Hallucinations, allusion
was made to the ill effects produced upon the brain by the
loss of sleep, and, when a predisposition to insanity exists, it
proves a frequent and powerful exciting cause. Persons thus
unfortunately constituted should be very careful not to allow
their duties or their pleasures to interfere with this needful
restorative process, which is indispensable to their perfect
safety. The records of our asylums show that in a large pro-
portion of cases the disease was attributable chiefly to this
cause which a little prudence could have prevented.
Dr. Isaac Ray says, in his little work on Mental Hygiene,
CAUSES OF INSANITY. 89
“One of its most common effects is a degree of nervous irrita-
bility and peevishness, which even the happiest self-discipline
can scarcely control. That buoyancy of the feelings, that
cheerful, hopeful trusting temper, that springs far more from
organic conditions than from mature and definite convictions,
give way to a spirit of dissatisfaction and dejection, while the
even demeanor, the measured activity, are replaced either by
a lassitude that renders any exertion painful, or an impatience
and restlessness not very conducive to happiness. Upon the
intellectual powers the mischief is still more serious. They
not only lose that healthy activity which combines and regu-
lates their movements in the happiest manner, but they are
no longer capable of efforts once perfectly easy. The concep-
tions cease to be clear and well-defined, the power of endur-
ance is weakened, inward conceptions are confounded with
outward impressions, and illusory images obtrude themselves
unbidden upon the mind. This kind of disturbance may pass
Sooner or later into actual insanity, and many a noble spirit
has been utterly prostrated by habitual loss of rest.”
Loss of sleep is also one of the earliest symptoms, and one
of the most frequent, in all the different forms of insanity, but
especially acute mania and melancholia.
Probably to the unprofessional mind the habit of Self-abuse
or masturbation would at once suggest itself as a fruitful cause
of insanity, as is indeed the case. All alienist physicians bear
evidence to the power and prevalence of the pernicious habit.
No vice can be more easily initiated, none can be eradicated
with greater difficulty. It is, however, true that a great differ-
ence of opinion exists among authors as to the frequency with
which this habit should be considered a cause or an effect of
insanity; a difference of opinion due in part to the difficulty
of obtaining trustworthy evidence from the patient or his
friends.
It is very remarkable, but it is very true, that the indul-
gence of the sexual passion through unsexual means is very
frequently associated, in both sexes, with certain neurotic
temperaments given to the display of precocious piety and the
manifestation of religious ecstasy and gloom. “I could not
6
90 INSANITY AND ITS TREATMENT.
Say,” says Morel, “how frequently I have seen this pernicious
habit existing in youths educated with the most pious senti-
ments, generally, however, endowed with a timid and retiring
disposition.” Speaking of this sexual neurosis in women,
Guislain says that it finds its constant cure in “marriage and
asafoetida.” &
Cranial injuries, whether at birth or later, have not received
the attention that their importance as a cause of mental dis-
ease seems to demand. Dr. J. Crichton Browne has, however,
published two important papers upon this subject in the
West Riding Lunatic Asylum Reports. He shows clearly
that cranial injuries may hold an etiological relation to every
species of mental defect and disease, and that the full history
of their effects upon mental health would be co-extensive with
that of insanity. From a slight peculiarity of temper up to
fierce madness; from the deprivation of a single sense up to
the denudation of almost every faculty there is no phase of
derangement which may not have a blow on the head as its
starting point. The forms of mental disease, which concussion
and blows on the head were most active in producing, and
their effects most readily traced were: 1. Idiocy; 2. Recurrent
Mania; 3. Dementia; 4. Dementia with Epilepsy; 5. Senile
Den.entia; and 6. Mania a Potu. From April 1st, 1870 to
April 1st, 1872, there were admitted forty-two patients into
the West Riding Asylum, in whom the influence of cranial
injuries, in the production of mental derangement was clearly
set forth.
Sun-stroke, fever, insufficient and even excessive nutrition, epi-
lepsy and child-bearing may also cause insanity. The two
last causes are so important that the special kinds of insanity
caused by them will call for extended notice elsewhere.
Affections of the uterus and its appendages afford notable
examples of a sympathetic action upon the brain, and not un-
frequently play an important part in the production of cer-
tain kinds of insanity, especially melancholia. Dr. Maudsley
says: “Perhaps the best opportunity of studying the early
stages in the genesis of melancholia is afforded by the mental
depression that commonly accompanies certain uterine dis-
CAUSES OF INSANITY. 91
eases. On the other hand there is equally striking evidence
of this intimate sympathy of parts, in the fact that morbid
states of organs favoring a certain mental disposition may un-
questionably be in turn caused by the latter.”
Few conditions exercise so profound and widespread an in-
fluence upon the physical organism and mental health of
Women as does the climacteric, and hence it is reasonable to
Suppose that the symptoms of insanity originating under such
circumstances should present a certain amount of uniformity,
and this is so far the case that we find “climacteric insanity”
appearing in many of the classifications.
Dr. Skae gives as pathognomonic, a group of symptoms
characterized by “a monomania of fear, despondency, remorse
and hopelessness, passing occasionally into dementia;” and Dr.
Maudsley says of the same time of life: “When positive insan-
ity breaks out it usually takes the form of profound melan-
cholia, with vague delusions of an extreme character.”
Sometimes, finally, insanity results from a single lesion, but
more generally it is the culmination of a series of morbid
changes. The person may have no special or well marked
disease, but is in general ill-health, is run down in tone, and,
reaching a certain point the brain gives way, and he is in-
Sane. Now this point is by no means a uniform one. Each
individual has a standard of health and also a constitutional
status, both as to the resisting power and recuperative energy.
What will induce insanity in one will not in another. Causa-
tion can never, therefore, reach scientific exactness, except as
the condition is fully developed in each case. Or, as Dr.
Blandford says: “Men and women become insane because it is
in their nature and constitution to develop insanity.”
SEx. It is difficult to decide whether one sex or the other
be more inclined to insanity. It is not sufficient to take into
account the relative number of the two sexes admitted into
an asylum, nor even to compare the admissions with the pro-
portion of the sexes in the general population; we must also
make allowances for the modifying influences of life, as found
in different parts of the country.
“The disorders of menstruation, pregnancy and childbirth
9 3
INSANITY AND ITS TREATMENT.
are undoubtedly circumstances which frequently become causes
of insanity; but there are also in the male sex, a series of cir-
cumstances special to it, such as the more frequent drunken-
ness, mental exertion, the struggle of ambition, the emotions
and exhaustions which necessarily accompany an active life.
These circumstances certainly counterbalance the special in-
fluence of the sexual process on the origin of insanity.”
(Griesinger.)
From an examination of 71,000 cases Esquirol was led to
think that females were rather more apt than males to be
affected with insanity; but further study of the subject led
Dr. Jarvis, of Dorchester, to an opposite conclusion.
Bucknill and Tuke say, in their Manual of Psychological
Medicine, “On the whole, while it is clearly proved that, in
general, fewer women become insane than men, it is difficult
to establish that the female sex is intrinsically less susceptible
to the causes of insanity than the male, since the former is less
exposed to those causes than the latter.”
The whole number of “registered lunatics, idiots and persons
of unsound mind” in England and Wales on the 1st of January,
1879, is given as 69,885; male, 31,683; female, 38,202. The
Commissioners in Lunacy in their Report to the Lord Chan-
cellor remark in regard to the relative statistics of the two
sexes: “The result obtained by distinguishing the sexes in
these tables confirm the opinion already generally entertained
that, as compared with the population, insanity, congenital
and acquired, is somewhat more frequent among males than
females. The extent to which it appears to be more curable
among females and the degree in which it is more fatal among
males is also shown. It will be seen that, although the rate of
recovery is higher among females than males, the mortality is
so much greater among the latter than the former, that the fe-
males largely preponderate over the males in the total number
under care.”
AGE.-Setting aside cases of idiocy and imbecility, we sel-
dom meet with insanity during childhood; occasional excep-
tions are on record, however, especially in private practice,
where children of eleven, twelve and thirteen years of age
CAUSES OF INSANITY. 93
have been attacked by mania. Insanity seems most frequent
from twenty to forty; after the fiftieth year it is much more
rare and gives place to other organic affections of the nerve
centres which produce a more or less marked enfeeblement of
the intellect.
Age seems to exercise an influence in deciding the form
which the insanity will assume. Between the ages of twenty
and thirty mania is frequent with both sexes; later we find
general paralysis among men; and both melancholia and ma-
nia among women. At the climacteric melancholia is the
more common among women, as is indeed the case with men
at a corresponding period when the full activities of life begin
to flag. At fifty or sixty all the forms of insanity show a strong
tendency to be complicated with dementia.
The following table was compiled by Dr. John Merson, one
of the Assist. Med. Officers to the West Riding Lunatic Asylum,
and published in volume six of the Medical Reports.
TABLE.
Showing the relative frequency of insanity at different ages
in 1054 cases, and the proportion of insane cases to the entire
female population.
* NUMBER OF ENTIRE FEMALE
A.G.E. INSANE ºrs. popur,Arros.T. PROPORTION:
Under 15 years, 13 211,446
15 and under 20 years, 55 — 59,960 1 in 1090
20 4 “ 25 - 88 55,659 1 “ 633
25 “ “ 30 “ 130 50,401 1 “ 388
30 “ “ 35 “ 135 43,653 1 “ 323
35 “ “ 40 “ 127 37,311 1 “ 294
40 “ “ 45 “ 124 33,388 1 “ 268
45 “ “ 50 “ 111 28,341 1 “ 255
50 “ “ 55 “ 98 23,982 1 “ 244
55 “ “ 60 “ 56 17,968 1 “ 321
60 “ “ 65 “ 49 14,599 1 “ 298
65 “ “ 70 “ 36 10,217 1 “ 284
70 “ “ 80 “ 27 10,150 1 “ 376
80 “ “ 85 “ 5 1,511 1 “ 303
“This table shows that the period of fifteen years from
twenty-five to forty is the most productive of insanity; but
when we take the proportion of the cases of insanity to the
94 INSANITY AND ITS TREATMENT.
whole female population of the same age, we find the tendency
to insanity increases with age up to about the fifty-fifth year,
when it suddenly diminishes, and further, that the period of
fifteen years, from forty to fifty-five, though it does not furnish
the highest actual number of cases, gives the highest ratio to
the number of persons of that age living, and is therefore more
prone to insanity than any other period of life.”
LECTURE W.
Classification,
Before proceeding to consider any of the special forms of in-
sanity, it will be well to suggest some classification under
which we may arrange with something approaching to sim-
plicity the different varieties of disease which come under the
care of the alienist. Upon examining and comparing the
different text-books you will be surprised and puzzled by
the number of classifications presented, some of them very
simple, others complex and burdensome in their arrangement.
Scarcely a writer but has prepared a new noSology of his own,
and each seems more embarrassing than its predecessor. The
fact that more than fifty different systems of classification have
been devised, is sufficient proof of the dissatisfaction felt, and
of the difficulties encountered in making a real improvement.
In 1863 Dr. Skae, of Edinburgh, proposed and sketched out
an arrangement in groups of the varieties of mental derange-
ment, under the title of “A Rational and Practical Classifica-
tion of Insanity.” “My proposition,” he says, “is this: that
we ought to classify all the varieties of insanity, to use a bo-
tanical term, in their natural orders or families; or, to use a
phrase more familiar to the physician’s ear, that we should
group them in accordance with the natural history of each.”
His schema he puts forth not as complete, “but as one which
CLASSIFICATION. 95
may, by combined efforts, culminate in a better, a more def-
inite, and, at least, a more practical method than the one in
present use.” This classification is perhaps the most generally
adopted of any at the present time, and receives the endorse-
ment of Dr. Blandford in his standard work on insanity; but
in my description I shall make use of the comments given by
Dr. Maudsley in his Physiology and Pathology of Mind, p. 420.
“The first natural group is idiocy, including imbecility under
all its various forms and degrees. To this class must be re-
ferred a large number of cases of moral idiocy and imbecility,
many of which are mixed up in the present system of classifi-
cation as monomaniacs of various sorts, e.g., cases of instinc-
tive cruelty, destructiveness and theft. ‘Many of our most
noted kleptomaniacs have had that tendency from childhood,
and have been moral imbeciles.’ He would refer all those cases
of insanity which are but the development and aggravation of
a congenital moral perversion, or want of balance, to the class
of congenital moral imbeciles.
“The second natural group is that of epileptics. As a disease
of childhood, epilepsy arrests the development of the brain,
and is associated with idiocy and imbecility. Afterwards it is
associated with maniacal paroxysms, monomania, dementia
or total fatuity.
“The third natural family is that of the masturbators. It is
characterized by a series of symptoms easily recognized—the
peculiar imbecility and sly manner of the youthful victim;
the suspicion and fear, and suicidal impulses, and palpitations,
and scared look, and feeble body of the old offender, passing,
gradually into dementia and fatuity.
“The fourth group is formed of the insanity occurring at the
period of pubescence, and apparently dependent upon the
changes affecting the circulation and nervous system by the
development of puberty.
“Satyriasis and nymphomania constitute the next two groups.
“The seventh group is that of hysterical mania—certainly a
well-marked natural order.
“Closely allied to the last group is that of sympathetic mania,
connected with a memorrhoea or dysmemorrhoea, commonly assum-
96 INSANITY AND ITS TREATMENT.
ing a recurrent or periodic form, frequently with maniacal
attacks, and not unfrequently passing into chronic mania or
dementia.
“Sexual mania includes a form of insanity occasionally met
with both in the male and female sex, but more frequently in
the latter, developed immediately after marriage, and con-
nected with the effect produced on the nervous system by
sexual intercourse. It usually presents itself in the form of
acute dementia.
“The insanity of pregnancy, puerperal mania, and the insanity
of lactation form three distinct groups.
“Climacteric insanity, occurring at the change of life, mani-
fests itself as a monomania of fear, despondency, remorse,
hopelessness, passing occasionally into dementia.
“Another group consists of cases of insanity associated with
ovarian or uterine disease, and of which one of the most com-
mon symptoms is sexual hallucination.
“The next natural order is senile insanity, beginning occa-
sionally as mania or melancholia, but more frequently during
its whole course presenting the features of dementia.
“Phthisical mania is a form of insanity which Dr. Skae
believes to present characteristic features.
“The insanity following blows on the head, traumatic mania,
and that following Sunstroke present their distinctive charac-
teristics.
“Syphilitic mania is a distinct form associated with syphilis.
“Delirium tremens and its allied disease dipsomania.
“General paralysis of the insane.
“Metastatic mania includes all those cases following the sud-
den suppression of an accustomed discharge or eruption, etc.
“The cases which remain and cannot be referred to any of
these groups, Dr. Skae would class under the general term of
idiopathic insanity, divisible into two varieties, Sthenic and
asthenic; sthenic, combined with distinct symptoms of vascular
action—occurring in persons of robust health and brought on
most commonly by causes exciting the passions and emotions;
asthenic, when combined with symptoms of anaemia, emaciation,
feeble pulse, etc., and brought on by such causes as exhaustion,
want of sleep, grief, anxiety, starvation, fever.
CLASSIFICATION. 97
These are Dr. Skae's twenty-five natural orders or families,
each of them to be considered as a separate disease, of which
mental derangement is the most prominent feature—“a dis-
ease,” he says, “presenting a certain variety and kind of men-
tal symptoms, varying in different cases, and at different times
in the same case, but still varying within certain limits only,
So as to give to each variety its own special psychological
character, sufficiently marked and peculiar to make out a
distinct physiognomy for each group.”
You see how elaborate all this is, and for purposes of scien-
tific discussion and accurate arrangement it answers excel-
lently well, but I cannot help agreeing with the sentiments of
Dr. Sheppard, Superintendent of the immense Asylum at
Colney Hatch, near London, who says: “This sort of thing
looks very learned on paper, but to my way of thinking it is
very preposterous and pedantic, for, as Dr. Sankey of the
Hanwell Asylum has pointed out in his lectures, it exalts
varieties into species, and multiplies simple conditions, which
are alike in progress, into complicated conditions, merely be-
cause there is a difference in their causation.”
Dr. Maudsley speaks as follows, and his remarks apply
equally well to all of these elaborate classifications. He says:
“It is obviously a classification of which it is more easy to
sketch the outline than to fill up the details, and which looks
better in outline and promise than probably it ever would do
in actual accomplishment. The objections against it which
Suggest themselves, are, first, that the picture of the charac-
teristic features of each group or family appear to be over-
drawn; that in practice we do not find them so well defined
as they are represented to be; that the physiognomy of the
mental derangement of each of the groups does not really
present characteristic features, or a special psychological
character; that one of the special causes, which is made the
basis of a natural order, may really produce quite different
kinds of mental derangement according to the particular tem-
perament or idiosyncracy of the individual, or according to
Some other circumstance of which we know little or nothing.
And this brings us to the second objection, that under the
9S INSANITY AND ITS TREATMENT.
term idiopathic. Dr. Skae lets in all the vagueness, and all
the defects of the old classification; for beneath the mysteri-
ous word, there is no knowledge hidden, there is no definite
cause, nor definite course, nor definite termination for the
manifold varieties of insanity included under it; nor are there
any characteristic features distinguishing the varieties of idio-
pathic insanity from some of the forms of insanity included
under the other so-called natural groups or families. In fact,
the proposed classification so far as it carries out its method,
applies only to cases of insanity caused by, or associated with,
certain bodily disease, other than the brain disorder, whereas
many cases of insanity are examples of brain disorder only;
other bodily derangements if present being incidental coin-
cidences or consequences.”
A more simple arrangement is that generally adopted in
Germany, being a modification of that proposed by Esquirol.
It is as follows:
First. Conditions of Depression.
1. Hypochondria. 2. Melancholia.
Second. Conditions of Exaltation.
1. Acute Mania. 2. Monomania.
Third. Conditions of Mental Weakness.
1. Craziness or Incoherence. 2. Dementia or Fatuity.
3. Idiocy or Cretinism.
Fourth. Dementia Paralytica or General Paralysis of the
Insane.
Dr. Henry Maudsley divides insanity, according to the men-
tal symptoms, as follows:
I. Affective or Pathetic Insanity.
1. Maniacal Perversion of the Affective Life, Mania
sine delirio.
2. Melancholic Depression without Delusion, Simple
Melancholia.
3. Moral alienation proper. Approaching this, but not
reaching the degree of positive insanity, is the
Insane Temperament.
II. Ideational Insanity.
1. General.
CLASSIFICATION. 99
a. Mania }.
b. Melancholia J Chronic.
2. Partial.
a. Monomania.
b. Melancholia.
i., U. Primary.
3. Dementia ſ Secondary.
4. General Paralysis.
5. Idiocy and Imbecility.
For the purpose of these lectures I shall make use mainly of
Dr. Isaac Ray's classification. It is similar to that of Pinel,
and also the one used by Dr. Sheppard, Lecturer upon Insanity
at King's College, London. The forms of insanity may be
divided into two grand divisions founded on two very differ-
ent conditions of the brain; the first being a want of its ordi-
nary development, and the second some lesion of its structure
subsequent to its development. We thus have:
First. Defective development of the faculties.
a. Idiocy Both of these may arise from congeni-
b. Imbecility J tal defects, or result from an obstacle to
the development of the faculty, Supervening in in-
fancy. Cretinism is also included in this class.
Second. Lesion of the faculties subsequent to their de-
velopment.
a. Mania } Characterized by unnatural exalta-
b. Melancholia J tion or depression of the faculties, and
may be chiefly confined to either the intellectual or
affective powers, or affect both; and these may be
generally or partially deranged. This class includes
the various Monomanias, Epileptic, Puerperal,
Moral and Recurrent Insanity.
Third. Dementia, depending on a more or less complete
enfeeblement of the faculties, and may be consecutive to injury
of the brain, to mania, or to some other disease.
Fourth. General Paralysis of the Insane.
Dr. Maudsley says: “With the exception of the form called
General Paralysis, the received classification is founded on the
recognition of a few of the most prominent mental symptoms
tº e
o • e°e :: • fe s:
• * e e º e * * * *
100 INSANITY AND ITS TREATMENT.
only—is purely psychological. It amounts simply to this:
When a person is excited and raves more or less incoherently,
he has acute mania; when, after subsiding into a more quiet
state, he continues to have delusions and to be incoherent, he
has chronic mania; when he exhibits insane delusions on one
subject, or in regard to certain trains of thought, and talks
sensibly in other respects, he is said to have monomania;
When he is gloomy, wretched and fancies himself ruined or
damned, he has melancholia; and, when his memory is im-
paired, his intelligence enfeebled or extinct, he is said to be
suffering from dementia.” (Responsibility in Mental Disease.)
LECTURE WI.
Idiocy, Imbecility and Dementia.
The term idiot is applied to that class of persons of feeble
intellect who have never had a normal amount of intelligence,
or whose intellectual development was arrested soon after
birth; this is usually associated with some cranial malforma-
tion and defective moral sense.
The degree and extent of idiocy may vary greatly. It may
range from a complete absence of intelligence (amentia) to the
slight deviations from intellectual health, only to be dis-
Cerned by close observation, and classed by some authors
among the instinctive monomanias.
Idiots may be persons of fair bodily development and de-
generate in brain only. The condition of mind is one in
which the reflective, and all or a part of the affective powers
are either entirely wanting, or are manifested to only a slight
degree. The idiot, in some cases, may hardly seem to rise to
the level of the more intelligent brutes, and his movements be
limited to the necessities of automatic life; or he may be ca-
pable of performing some useful service, of exercising some
©
© •ee
IDIOCY, IMBECILITY AND DEMENTIA. 101
talent, or of displaying to a slight degree the moral sentiments.
In the condition called idiocy we are not dealing with what
may strictly be called disease, but with defective or imperfect
development, whilst imbecility contrasts with idiocy in that
the brain development may be complete, and yet the material
of the brain so wanting in normal constituents that mental
perfection is impossible. Idiocy does not necessarily imply a
less amount of intellectual power than imbecility, though it is
usually less. Both conditions are congenital, and as a rule
the mental defect is rather to be measured by a standard of
degree than considered as absolute; for the subjects of abso-
lute idiocy or imbecility seldom long survive their birth.
Esquirol was the first to clearly define the term, and restrict
it to a congenital defect. He says: “Idiocy is not a disease,
but a condition in which the intellectual faculties are never
manifested, or have never been developed sufficiently, to en-
able the idiot to acquire such an amount of knowledge as per-
sons of his own age and placed in similar circumstances with
himself, are capable of receiving. Idiocy commences with
life, or at that age which precedes the development of the
affective and intellectual faculties, which are from the first,
what they are doomed to be during the whole period of ex-
istence.” Again he says: “Dementia and idiocy differ essen-
tially; otherwise the principles of every classification are
wrong. A man in a state of dementia is deprived of advant-
ages which he formerly enjoyed, he was a rich man who has
become poor. The idiot, on the contrary, has always been in
a state of want and misery.”
Griesinger says: “It is beyond doubt that the weakness of
the intellect, and therewith the arrest of the psychical develop-
ment, depends upon a cerebral anomaly. This fact is, in
general, much more capable of being directly proved and
demonstrated than in other mental diseases. In many cases
of idiocy there may be observed considerable pathological
changes in the brain or its membranes, on an average much
more so than in mental disease in the restricted sense, and
we can, in general, say, supported by the great majority of
cases, that the deficient mental development is the direct
102 INSANITY AND ITS TREATMENT.
result of deficient cerebral development in childhood, and that
it is in proportion to it. Nevertheless, evident and palpable
changes in the brain or its membranes are not always found
in idiocy, and we are impelled, by numerous facts, to the as-
sumption that there are also idiotic states where the weakness of
perception does not depend upon organic changes, but origin-
ally upon a simple functional anomaly of the brain. To this
class many cases ought to be referred, where frequent epilep-
tic attacks in very early life, or where onanism, commenced at
a very early period, have induced an early exhaustion of the
cerebral functions; others, when, long general illness in a
child, with impairment of the nutrition of all the organs, in-
cluded the brain, and therefore the due performance of its
functions; further, cases where the mental development re-
mains stationary from want of any external mental impulse,
from extreme neglect and inattention, association with other
dements, unfavorable outward relations, etc.; finally, certain
cases where the mental development does not progress, because
in weakly children there exists such an excessive degree of
emotional irritability, of timidity and fear, that a state of
passionate excitement is awakened by every attempt of mental
influence, even by any lively sensorial impression, so that
development of the normal process of perception is rendered
impossible. Although few of the latter cases originally belong
to the idiotic states, still they have the same practically im-
portant result — arrest of mental development. But these
cases of merely functional cerebral disorder, which at the
commencement constitute a more apparent dementia, form a
very small minority compared with the cases where the psy-
chical disorder is the result of organic changes in the brain.”
(Mental Diseases, p. 348.)
Some authors speak of a congenital and an acquired idiocy;
others of idiocy and imbecility; but Griesinger thinks it un-
wise to multiply these divisions, and makes two classes of
idiocy; the first comprising the more marked cases where in-
telligence is almost wanting, and the second including the
lighter cases of intellectual weakness.
Esquirol divided the feeble minded into two classes, imbeciles
IDIOCY, IMBECILITY AND DEMENTIA. 103
and idiots. With the first, the physical organization is more
or less perfect; the intellect and sensory organs fairly devel-
oped; and the affections, passions, desires, ideas and memory
present to a limited degree. They think, feel and talk and
are capable of being educated. In the second class the organ-
ization is incomplete; the senses are obtuse; and the faculties
of attention and memory are almost wanting.
He further bases his division upon the power of speech they
possess. In the first degree of imbecility it is free and easy, in
the second more difficult and the vocabulary limited. In the
first degree of idiocy, properly so called, the idiot uses merely
words and short phrases; idiots of the second degree articulate
only in monosyllables or certain cries; finally in the third
degree of idiocy there is neither speech nor phrases, words nor
monosyllables.
Dr. Maudsley speaks of imbecility and idiocy, and defines
them thus: “Imbecility is simply weakness of mind owing to
defective mental development, and may be of every degree of
deficiency, moral and intellectual; on the one hand passing
by imperceptible gradations into idiocy, and on the other
hand passing insensibly into ordinary intelligence. There
are some imbeciles in whom a general deficiency of intelli-
gence is accompanied by a singular development of it in a
special direction; they manifest for instance a surprising
memory for details, such as dates, names, numbers, the exact
particulars of distant events, which they recall and recount
with the greatest ease and accuracy, or display certain re-
markable mechanical aptitudes, or exhibit a degree of cun-
ning which might seem inconsistent with their general mental
feebleness.
“Idiocy is a defect of mind which is either congenital or
due to causes operating during the first few years of life, before
there has been a development of the mental faculties, and may
exist in different degrees; the person affected with it may have
the power of articulate speech and manifest a limited degree
of intelligence, or he may be utterly destitute of any semblance
of intelligence and of the power of speech, being little more
than a vegetating organism.” (Responsibility, etc., p. 65.)
104 INSANITY AND ITS TREATMENT.
H. Dagonet makes the following four divisions: 1. Simple-
mindedness; 2. Imbecility; 3. Idiocy; 4. Automatism.
The physical character of idiocy varies according to the
degree in which the cerebro-spinal system is involved. In the
lower forms of idiocy the functions of organic or vegetable life
are ill-performed; the idiot is below the plant; nutrition is
imperfect and the power of reproduction zero. He would
perish but for the assistance of others.
The functions of animal life are likewise to a greater or less
extent impaired; he may be scarcely alive to external impres-
sions, or possess the power of executing spontaneous acts. In
the lowest type he may be blind, deaf and dumb; the dejec-
tions are involuntary; he is indeed nothing more than a
living dead man.
The senses of the imbecile may be fairly well developed,
though it is difficult for him to fix his attention upon anything
requiring prolonged effort; with the idiot, however, the senses
are imperfect. The hearing is generally defective, but it is
often difficult to tell whether we have to do with deafness or
want of attention. Sight is often poor in consequence of a
want of symmetry between the eyes, and amblyopia is common.
Although not completely insensible to pain, sensibility is
greatly diminished.
No particular physical marks can be given as absolutely
inseparable from idiocy or imbecility, although after infancy
the physical organization never fails to give notice of its pres-
ence. In rare cases the head presents no deviation from the
normal shape and size, but generally it is too large or too
small. Dr. Ray says: “The senses of idiots are more or less
imperfect or entirely wanting. Some are blind, others deaf or
mute. Some speak with difficulty, others tolerably well.
Their movements are awkward and constrained; they walk
badly, easily falling down, and are constantly dropping things.
They are afflicted with rickets, scrofula, epilepsy and paralysis,
their whole physical economy indicating a depraved and de-
fective constitution.”
It is common to see idiots with small sized heads, and such
have received the title microcephalous in contradistinction to
IDIOCY, IMBECILITY AND DEMENTIA. 105
those called macrocephalous or having large heads. These lat-
ter should generally be classed with imbeciles rather than
idiots. The true typical idiot's head measures on an average
only about thirteen inches in circumference, whilst an ordina-
rily developed head will measure from twenty to twenty-four
inches or even more. In shape the idiot's head is often im-
perfect and deformed, the deformity appearing most marked
in the frontal and occipital development.
The head of the imbecile is usually fully formed, though
you often see considerable contortions and variations in its
shape; sometimes the two sides of the face are different, but
more generally you see distortion of the cranial bones. The
most marked features of distortion are, however, to be found
about the mouth and oral cavity.
Some remarkably large brains have been found amongst
imbeciles. One in particular, weighed by Dr. Levinge, when
at the Hants County Asylum, was 70% oz. = 1998 grams in
weight. This is one of the heaviest brains on record. It oc-
curred in a patient thirty years of age, and a congenital in-
becile. Its consistence was normal, and there was no evidence
of sclerosis. The cerebrum alone weighed 1786 grams or 63
ounces, and the cerebellum, pons and medulla 212.6 grams or
7%. Ounces.
The patient who was 5 ft., 8 in. in height, died of phthisis.
The dimensions of the head were: whole circumference, 24%
inches; arch, ant. post., 15% inches; transverse, 12% inches.
The degraded condition of the idiot is very clearly seen in
the vacant stare, and the foolish and expressionless counte-
nance; in the thick, everted lips, the slavering mouth, the irreg-
ular and decayed teeth, the gums often swollen, the frequent
strabismus, the ill-formed, generally large ears, and the ab-
sence or defect of one or more of the senses. They cannot eat
without help, and it may be necessary to introduce the food
far back in the mouth, in order to excite reflex swallowing.
Others eat without urging, and will put into the mouth any-
thing that comes in the way—bits of earth, stones, sticks, cloth,
straw, and even excrement. The bodily movements are un-
certain and without precision; his staggering walk is very
7 e
106 INSANITY AND ITS TREATMENT.
striking, yet it seems as though he must be in motion; if he is
on his feet, and even if seated, he often has a difficulty in bal-
ancing himself. There is a general want of symmetry; the
limbs are frequently contracted or paralyzed; the fingers long,
slender and deformed; the grasp of the hand feeble or power-
less; while the extremities are often cold and bluish from im-
perfect circulation. Many are blind, deaf and dumb, or they
may make their wants known by some harsh and in articulate
sounds; they are rickety, scrofulous, paralyzed, choreic and
epileptic. The worst cases lead a purely vegetable life and, as
a rule, die young.
Between idiocy of so pronounced a type and simple imbecil-
ity, we find all possible grades of physical and mental develop-
ment. Idiots of this middle grade have at their disposal a
limited stock of words or even phrases, and they may articu-
late distinctly. They eat properly and exercise a choice in
matters of diet, rejecting those articles they dislike. They re-
cognize friends and acquaintances, and show gratitude to those
doing them a kindness. The range of their intellectual power
seems limited, they can originate nothing, but seem possessed
to a certain extent, of the faculty of imitation; thus an idiot
seeing a man cut a pig's throat, soon after cut the throat of a
child, and then displayed great pleasure in telling what he
had done. Owing, too, to this imitative faculty some idiots
can play passably well on the piano, or engage in some easy
mechanical work, but they can design or invent nothing. The
sexual instinct is strong, and idiots are given to masturbation
and seem destitute of any sense of shame. They are easily
excited to anger and subject to fits of blind rage.
Imbecility may be considered as a weakness of mind, con-
sequent upon an unhealthy condition of brain, commencing
whilst the foetus is in utero; and though the mind may be-
come partially developed, yet it is feeble and abortive.
Georget speaks of imbeciles as those who “are conscious of
sensations, have memory, can judge of the simple acts of life,
can work at the rough occupations which require little dis-
cernment; they employ, in order to express themselves, a
language composed of those expressions which are most essen-
tial to their ordinary wants.”
IDIOCY, IMBECILITY AND DEMENTIA, 107
Imbecility, like idiocy, is manifested in different degrees.
In the lower forms, “imbeciles produce nothing; and all their
movements, both intellectual and moral, are aroused only by
impulses from without. They do not think or act except
through others; their will is without energy. They will and
do not. They cannot follow a conversation, still less a dis-
cussion. They regard as serious, things the most gay; and
laugh at those most sad. Does something interest them, their
eyes are fixed, but they do not see; they hear, but do not com-
prehend; although they affect to have both seen and under-
stood. They reply correctly, but you must not ask them too
many questions, nor require from them responses which de-
mand reflection or are contrary to their habits.” (Esquirol.
Maladies Mentales.)
The imbecile often exhibits some degree of cunning, and in
him you sometimes find that the animal characteristics, as
they are called, are more than ordinarily developed. In par-
ticular, you may observe his ravenous appetite for food, which
frequently resembles that of the brutes. Many are, however,
capable of learning, and are quite apt in acquiring a facility
in using tools, and applying them in simple mechanical trades
and manufactures. It is even possible to teach some of them
who have never spoken, to speak, when the want of the faculty
of speech is dependent upon malformation of the mouth. They
know those about them, are affectionate to their friends, but
easily put in a rage.
All the mental faculties, both moral and intellectual, may
be partially developed, or as Esquirol puts it, sensations, ideas,
memory, as well as the affections, passions, and even inclina-
tions may exist though only in a slight and limited degree.
Thus imbeciles may be able to think a little, and to judge of
the simple acts of life, according to the degree of change, and
the conditions of development of their brains. Some even
display considerable shrewdness, and are constantly indulging
in jokes; they pass for half-witted people, whose droll behav-
ior and ready repartees create amusement. From this class
the court-fools were drawn. As a rule they are able to take
care of themselves but are wanting in moral control, nor do
108 INSANITY AND ITS TREATMENT.
they distinguish between right and wrong; they understand
that an act is forbidden but they cannot understand the rea-
son. Thus they will commit any criminal act to which they
may be prompted and feel no emotions of remorse or regret;
they may even be affectionate to their friends, and yet be
homicidal and may murder those with whom they are con-
stantly associated, and commit the act with a sort of Satisfac-
tion and glee. They will at times relate their deed openly
without any appreciation of its enormity and show no sign of
remorse; or they may use a great deal of cunning in conceal-
ing their deed from fear of punishment. Others are given
to thieving and acts of incendiarism, so that as a class they
may be considered as dangerous to society, for they are so
wanting in moral sense, that they are apt to glide impercepti-
bly into the ranks of criminals.
Prof. Maudsley says: “There are children of a defective
mental capacity not reaching the degree of idiocy, or even of
positive imbecility whom it is very difficult to know what to
do with sometimes. They are dull, stupid, appear careless,
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 im-
practicable. Their inability to learn looks very much like
stupidity and obstinacy, when it is really the result of disease,
and marks a certain degree of imbecility.
“There is another class of boys who cause great trouble and
anxiety to their parents and to all 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 skill which could never be
acquired; they display no trace of affection for their parents,
or of feeling for others; the only care which they evince is to
contrive the means of indulging their passions and vicious
propensities. Intellectually, they are certainly defective also,
for they usually read no better when they are sixteen years
old than a healthy child of six years of age would do; and
yet they are very acute in deception and in gratifying the
desires of their vicious natures. Passionate, selfish, cruel, and
IDIOCY, IMBECILITY AND DEMENTIA. 109
Sometimes violent, they are intolerable at home; and if they
are sent to school they are sure to be expelled. Where they
belong to the lower classes, they find their way to prison many
times; when they belong to the better classes, there is nothing
for it but to seek out some firm and judicious person who, for
Suitable remuneration, will take care of them, keep them out
of mischief, and, while checking their vicious propensities,
will try to discover and foster any better tendencies which
they may have in them.” (Phys. and Path. of Mind.) *sº
Although imbeciles and idiots are legally considered as of
unsound mind, they are not mad in the ordinary sense. But
both idiots and imbeciles are specially liable to the various
forms of insanity, particularly mania and melancholia. Nor
is this to be wondered at; their brains are already imperfect
and predisposed to abnormal action and they merely want an
excitant to throw the little mind they have off its balance.
Contrary to what one would naturally suppose the first step
towards improving their state lies in association; experience
shows that the cases associated together under proper care
never get worse; and the general rule is that the companion-
ship of each other is so congenial, that if any case does not
improve under its influence, such case is exceptional, and that
exceptional cases are very rare.
Dr. Dickson, of St. Luke's Hospital, London, says: “These
patients must be associated together, at home, or amongst
those only who are of ordinary mind; they do not feel an in-
fluence of sympathy, but when several imbeciles or idiots are
together, they seem to sympathize with and compassionate
one another. They next require good feeding and nourish-
ment; they must then be taught, and the teaching requires
judgment, study and experience, and must be modified to suit
each particular case. These patients have to be weaned from
bad habits, and trained to observe the decencies and necessities
of Social comfort; they may then be in a condition to appre-
ciate and profit by more intellectual culture.”
Dr. Maxwell, lately the Superintendent of the Earlswood
Asylum for Idiots, writing of the idiotic cases which had been
admitted under his care, observes: “I think they have all im-
110 INSANITY AND ITS TREATMENT.
proved more or less. Kind treatment, good diet and attention
will improve the most hopeless cases. Many that come in
dirty and irritable, not only become cleanly, but get to speak
intelligently, to dress themselves properly, and to make them-
selves useful.”
Dementia.
All cases of insanity when very long continued have a ten-
dency to pass into a condition of, I might almost say, absence
of mind, called dementia. In this state, the disorder of ideas,
affections and actions is characterized by feebleness, and by
the abolition, more or less marked, of all the sensitive, intel-
lectual and voluntary faculties. This condition, however, must
not be confounded with imbecility or idiocy. In these latter
neither the understanding nor the senses have been properly
developed. He who is in a state of dementia has lost these
faculties to a great extent.
Bucknill says, in regarding a number of patients in a state
of dementia, it is convenient to divide these as follows:
1. Those who, whether previously well or insane, are gradu-
ally passing into a decidedly demented condition. Some con-
fusion of thought, a perplexed rather than a stupid expression,
and a failing memory, are the most obvious symptoms. Such
patients are not incoherent, or are only occasionally so. They
are sometimes conscious of their condition, and carefully avoid
committing themselves. They can read and write, but in re-
gard to the latter it will be found that after composing a few
sentences correctly, they express themselves confusedly and
spell incorrectly. This is a condition of partial or incipient
dementia.
2. Those who are so far advanced that they cannot tell their
names. Many of this class are dirty in their habits. Their
time is mainly spent in listlessness, or muttering to them-
selves, twirling their fingers about in all directions, now catch-
ing up something from the ground with which they play un-
til some fresh fancy seizes them; or scraping together bits of
paper, sticks, strings, stones, etc. We here have complete or
confirmed dementia.
DEMENTIA. 111
3. Those cases which are intermediate between the two.
The only form of chronic dementia with which the general
practitioner will have much to do is that of old age, or senile
dementia, this is a condition to which old age has a tendency
and is not infrequently observed in men who have long been
engaged in active business life, soon after they have relin-
quished their business or profession and laid out plans for en-
joying ease and pleasure the rest of their lives. A fact which
is often observed is, that the brain, in common with all the
other tissues, wastes with age, and dementia as the result of a
wasted brain is not at all surprising; the only wonder is that
more old people do not become demented, when we take into
consideration the high pressure living, and wear and tear of
the present day.
The main features of senile dementia are loss of memory,
restlessness and irritability; or they may be marked by pla-
cidity and amiability. It would seem as if the real feelings of
the mind had full sway. If the habitual emotions have been
evil, the state of dementia will be marked by anger easily
aroused, by fretfulness or a discontented selfishness. In per-
sons of really evil disposition, the mental decay of old age is
characterized by a hideous display of malignant feeling. The
proverb says that very old women are either angels or devils.
Acute dementia.-That enfeeblement of the intellectual, emo-
tional and voluntary powers which constitutes dementia, and
which occurs most frequently as the sequel of other forms of
mental disease may occur also as a primary disorder. De-
mentia thus primary is also called acute and apathetic, this
last term in allusion to the complete torpor of feeling by which
it is marked, and is the same state described by some French
writers as stupidité.
It attacks both sexes, but females by preference. It is es-
sentially a disease of youth, being rarely seen in persons be-
yond thirty years of age, and it seems to be dependent in Some
instances upon the exhausting influences operating at a period
of rapid growth. Children whose powers are over-taxed at a
time when the process of development is going on, and when
nutrition has not only to repair tissue waste, but form new
112 INSANITY AND ITS TREATMENT.
tissue, often fall into a state resembling idiocy, in which they
are dull, sullen and oppressed.
Under various conditions of life, where new impressions
and ideas are not supplied, and where a tedious routine is in-
evitable, failure of mental power must occur. This is especi-
ally so during the period of mental evolution, when the grow-
ing mind is greedy for nourishment suited to its wants. Child-
ren who are sent at an early age into the mills and factories,
when brick wall and clanging machinery surround them; and
their work requires the incessantly repeated muscular move-
ments, often pass into a state of acute dementia.
Acute diseases which occasion much exhaustion have some-
times acute dementia among their sequellae. After severe at-
tacks of typhoid fever there is frequently a certain amount of
fatuity exhibited in childishness of manner, loss of memory
and complete moral inertia.
This fatuity, which is accompanied by great bodily pros-
tration, and which may proceed from changes in the intra-
cranial circulation, or from an anaemic, atrophical, or imper-
fectly nourished state of the brain, is oftenest seen in those
cases in which there has been much delirium during the fever.
It sometimes has its origin in malaria. There can be no
question that it is often brought on by masturbation, as anae-
mia, loss of strength and nervous exhaustion, result from the
practice, and after these come forgetfulness, heaviness and
listlessness, which grow and grow until fatuity is attained.
Acute dementia either steals over the patient by gradual,
and at first almost imperceptible, encroachments, or it is
ushered in by an attack of excitement. But however intro-
duced, when once fairly established, it is manifested by a
greater or less suspension of the mental activities. The in-
ward weakness is also expressed outwardly in modifications
of physiognomy, gait and conduct. The countenance wears
a perplexed or vacant expression. The attitude betokens
lethargy or irresolution. The voice loses its accustomed tone
and becomes low and drawling, and the limbs perform their
duties with an effort. The patient is silent and self-absorbed.
If spoken to gives no heed to what is said. If roused, he may,
DEMENTIA. 113
after a pause, answer a few questions correctly, but when the
conversation is pushed further, it is found that his ideas are
mixed, and that he cannot collect or arrange them. His
memory is bad, his command of language poor. The patient
will slowly repeat any question that is asked of him, and if
the sentence be a long one, he will repeat the three or four
words which close it. He does not attempt to answer the
Question, he simply echoes it.
When the dementia is of a severe type, the mental state is
one of profound stupidity. Comprehension is lost, memory is
a blank, the sentiments are lifeless, the will is palsied. Organic
existence alone remains.
Of the bodily symptoms those connected with the circulation
are the most prominent. They consist in feeble action of the
heart, small pulse, and passive hyperaemia of the extremities.
The hands and feet are cold and have a bluish-red color; this
is very striking and is often accompanied with swelling. They
are in fact affected with real chilblains even in summer. The
same bluish-red look is also seen in the nose, ears and cheeks,
giving rise to a chilled, livid and pinched look. In females
there is generally amenorrhoea and rarely leucorrhoea.
When placed under favorable surroundings as regards food,
air, light, warmth and exercise, these cases not infrequently
recover. The same class of remedies will be called for as in
melancholia.
114 INSANITY AND ITS TREATMENT.
LECTURE WII.
Melancholia.
I shall begin my description of the special forms of mental
disease with that known as Melancholia, because almost every
case of mental exaltation is preceded by some degree of de-
pression, although in many cases this is transient and may
pass unnoticed. The primary symptoms of all cases of insanity
are connected with the emotions, and alterations in these
emotions are the earliest phenomena to be observed.
The term melancholia is derived from two Greek words
which signify black bile, and had its origin in the belief that
the liver was the seat of the soul, and of the intellectual opera-
tions; and it was supposed that the particular condition which
we call melancholy was consequent upon a secretion of black
bile. Although this idea has passed away, although a secre-
tion of black bile is not a cause of the mental state known as
melancholia, still nearly every form of disorder of the liver is
accompanied by more or less mental depression.
Esquirol, whose writings you will find still regarded as high
authority, suggested the term lypemania, from lupeo to cause
sadness, and mania, madness, as a substitute for melancholia,
but the latter term had become too well fixed in popular use
to be easily abandoned. Nor does melancholia partake of the
nature of mania, in the sense in which the latter term is gen-
erally used, and we shall find that melancholia as a rule pre-
sents features of depression, and mania those of excitement or
exaltation.
Melancholia may precede, succeed, or alternate with mania;
or there may be mixed cases, or cases in which excitement
and uncontrolled impulse appear in the midst of the depression.
We may define melancholia to be a state of mental depres-
sion which engrosses the faculty of attention and paralyzes the
faculty of reasoning, and permits actions which are impulsive
and beyond the control of the will. It is characterized by
MELANCHOLIA. 115
delirium of a sad character, and by mental depression, some-
times extending to stupor.
Melancholia may be acute or chronic; the invasion of the
disease is usually gradual, but sometimes sudden; and we find
in this form of disease what we constantly notice in various
physical disorders, viz., that each case is marked by some
peculiarity of its own, in the same way that every human
face differs from another.
Sir Benj. Brodie writes: “On some occasions I have labored
under depression of spirit, having what I may call an abstract
feeling of melancholy, there being no external cause to which
it can be attributed, and it being at the same time, so far as I
can judge, not connected with any derangement of any one of
the animal functions.” Although no derangement of the ani-
mal functions could be detected by him, there was probably
in his case, and there is in all similar cases, some error in the
system, some slight malassimilation, Some failure in the or-
gans of nutrition, which, acting on the brain through the cir-
culation, caused the slight degree of melancholia, for although
we have not yet been able to connect special changes of the
blood with special disturbances of nervous function, we know
that the nervous centres are exquisitely sensitive to the slight-
est modification of this fluid. This condition, though com-
monly transient, is nevertheless a state of melancholy of a
slight degree, and, when it becomes habitual, really constitutes
a state of mental disease.
Griesinger makes special mention of such cases as follows:
“Such a condition, but wholly of a chronic character, of an
habitual depression of spirits and ill-humor, with a tendency
to a constant love of contradicting, arguing, Suspecting, etc., is
not infrequently met with in conjunction with apparent health,
especially among females, and is very seldom recognized as a
morbid condition, although it may readily be distinguished
by the following characteristics: By being traced to a distinct
attack of indisposition; by undergoing distinct remissions;
and by a consciousness of the change on the part of the pa-
tient, but with inability to resist it.” He further says: “The
fundamental affection in all these forms of disease consists in
116 INSANITY AND ITS TREATMENT.
the morbid influence of a painful depressing negative affec-
tion,-in a mentally painful state. This state may at the out-
set, in the simplest and most primitive form of melancholia,
continue in the form of a vague feeling of oppression, anxiety,
depression and gloom; generally, however, this vague obscure
feeling of annoyance passes into a single concrete, painful per-
ception; then arise thoughts and opinions in harmony with
the actual disposition of mind, and without external motive:
a Veritable delirium, revolving constantly upon some torment-
ing and painful subject, while at the same time the intellect
presents some anomalous forms, is restrained in the exercise
of its freedom, becomes slow and sluggish, and the thoughts
monotonous and vacant.”
The following will describe an ordinary case of melancholia.
A person of previously cheerful temper, either suddenly, from
Some obvious, or gradually, from no appreciable cause, mani-
fests a change in his habits and demeanor. He is indifferent
to what is going on about him and has a general feeling of
lassitude and depression; he shuns his neighbors and family
and takes no pleasure in the society which he has heretofore
enjoyed. His natural sleep is disturbed, and he awakes in the
morning unrefreshed, burdened with the oppressive thoughts
of another day, and with a growing incapacity for pleasure
and work. His taciturnity is accompanied by emotional dis-
turbances. He bursts into tears, and appears to be lost in a
gloomy reverie from which he is aroused only to tell you that
his mind is going, that there is no remedy, that his soul is lost,
that he has no hope, that his wife and family are against him,
or that they are starving. He may have a good balance at
the bank, but he will not believe it, and no favorable calcula-
tions and demonstrations will make him do so. His credit is
gone, he is absolutely penniless. All the acts, he says, of his
life should have been different. He has thrown away chances,
neglected opportunities, and done deeds, which in their terri-
ble influence are not to be cancelled. The future has no hope,
the past no consolation, they are alike dark and clouded. It
is useless to attempt to reason with persons in this state; self-
feeling is so intensified and exaggerated that you cannot divest
MELANCHOLIA. 117
them of its painful and absorbing reality. You may tell the
religious melancholic that there is hope and comfort for all,
and assure him of the same by Scripture passages with which
he is already familiar, and which were once balm to his
wounded spirit, but it will not do, there is comfort and hope
for all except himself. With this state of things involving so
completely, though not exclusively, the affective life you may
have hallucinations of sight and hearing. Delusions you per-
ceive already exist, and a very common one is, that food can
be of no service; that life can be equally sustained or death
met, without it. Or there may be a suspicion that the food is
poisoned, and under either state of things there is often great
difficulty in getting the patient to take food, or it may be per-
sistently refused altogether. More alarming even than the
delusions are the hallucinations. Voices whisper or loudly
dictate; they may be struggled against for awhile and success-
fully resisted, but at length, perhaps, they are overpowering.
Homicidal and suicidal impulses overthrow the power of the
will, and arr act of violence follows.
Dr. John Conolly records the case of a lady who lost her
only son, who was her idol, by a sudden and most unex-
pected death. He dropped down dead in the midst of appar-
ent health. This shock stunned and overwhelmed the unfor-
tunate parent, and for a long time grief alone occupied her.
In a few weeks her state became that of deep melancholia, in
which she never, in any way, alluded to her bereavement, but
was ever reproaching herself as sinful, unworthy to live, and
deserving of eternal condemnation. She became insensible
to all ordinary occurrences and affections, indifferent to her
family, inactive and silent, and attempted suicide.
Dr. Dickson reports the following typical case, in his work
on Medicine in Relation to Mind, page 180.
“E. B., a young lady aet. twenty-five, a member of a most
united and well brought up family, was admitted into St.
Luke's Hospital while I had charge of that establishment. At
the time of her admission she said that she was lost to all hu-
man feeling, that she knew the reason why her friends had
brought her to the hospital, viz., because she had attempted to
118 INSANITY AND ITS TREATMENT.
commit suicide by taking laudanum; but she told me that
she had so frightened herself that she had resolved not to at-
tempt to do so again. Conversing with her on ordinary sub-
jects she spoke remarkably well. Her information was very
good, and the ordinary observer might have failed to discover
any insanity in her. She had for some time before been cap-
tious as regarded her food, but when she saw that another pa-
tient in the ward was fed like a baby, she said she would
make an effort to take her food, rather than be similarly
treated, and she said she hoped she should never come into
the same state as that patient. She was exceedingly neat and
cleanly in her habits and dress, and employed herself gener-
ally with needle-work, and for several days her state seemed
to improve. She then asked for writing-paper, and to my Sur-
prise exhibited a very much more marked departure from her
normal condition than I expected. When in health she used
to write a very clear hand, and her orthography was good, but
the letter she attempted to write in the asylum occupied her
the whole day, and when brought to me was on a quarter of
a sheet of paper, was covered with blots, was in a small, almost
illegible hand, and crossed; it was very badly spelt and full
only of her moaning and complaining that she had sold her-
self to the devil. The next day she was very much more de-
pressed and asked not to go out in the streets, as she had done
on almost every previous day. On several occasions she asked
for writing-paper and every letter was in exactly the same
strain as the one I have mentioned, and after each she seemed
more depressed than before.
“From time to time whenever I made occasion to converse
with her upon general subjects, I found her information quite
as good as when she was admitted, and her mind clear, and
her power of attention in conversation for a short time very
good. In fact her conversation was generally coherent; but
she always reverted before long to her own wickedness, and
to her belief that she had sold herself to the devil; that she
had sinned against the Holy Ghost; that she could never be
forgiven, and that in fact she had no Soul, so that it was agony
for her body to be alive; reasoning with her on the subject
MELANCHOLIA. 119
was quite out of the question; both calm grave reasoning, and
jocose and satirical interpretation were powerless to shake her
fixed ideas, though naturally she had a most keen sense of the
ridiculous. She continued much in the same condition as
when admitted for about a fortnight, when one day she put a
table-knife into her pocket at dinner time, the discovery of
which fanned into a flame the smouldering embers that had
racked this poor girl's brain for weeks and weeks. She stated
that she had intended to stab herself in the night, and that
she was greatly distressed that her purpose had been detected
and baulked. All through the night she was screaming and
crying, and declared that her room was full of devils; the
next night she packed her bedding into a heap, and tried to
get up at the window, and stated that she wished to have one
more view of the London gas lights before she died, and she
told me that she had hoped that she would have been able to
get her head between the partitions of the iron window frame,
and so have succeeded in hanging herself; this, I am happy
to say, she found impossible. For days and nights she was
continuously restless, sometimes crying, sometimes screaming,
sometimes lying underneath the bedstead, sometimes she turned
her feet on her pillow and her head the reverse way in the
bed, declaring that she was loathsome and full of devils, and
that her room was full of devils, and that she herself was up-
side down.
“She refused food, saying it was a shame to waste it on her,
and it became necessary to feed her. She also became dirty
in her habits, and her condition of distress and agony of mind
were the most appalling that could be witnessed. The acute
attack ran a course of a few weeks only, and she died ex-
hausted; the post-mortem examination presented one general
appearance, viz., that of Wasting.
“The patient had a remarkable history. Insanity had
shown itself in her family for four generations. At the time
she became affected, one of her sisters was in an asylum suffer-
ing from acute mania; and I learned from my patient that the
interviews which she, from time to time, had with her sister at
first impressed her most profoundly with the awfulness of in-
120 INSANITY AND ITS TREATMENT.
Sanity, but that since she herself had become affected the
dreadfulness of the idea had disappeared. She told me that
her own attack was very insidious and commenced with a sim-
ple feeling of depression. She afterwards turned her attention
to religion, and, by degrees, she came to assume the idea that
she was wicked, an idea which became exaggerated to the un-
bounded imaginings I have described.”
Through the kindness of Dr. S. H. Talcott, the details of
several cases have been furnished from the case-book of the
Homoeopathic Hospital at Middletown, and they will give a
better picture of the daily changes and progress of a case of
melancholia, than would a condensed and running narrative.
CASE 1.-‘Mrs. J. P., aet. 35; has two children, the youngest
aged nine months; has no insane relatives. Fifteen years ago
was insane and recovered; the present attack began four
weeks ago, she then commenced to talk incessantly, this con-
tinued a few days, since then talks incoherently at times,
laughs and cries without cause; her physical condition is poor
and weak; pulse 80.
“Apr. 3d, 1879–Admitted last night, much fatigued by her
journey. Slept an hour and a half. Pulse 88; temp. 99.8.
Has headache mostly in occipital region; talks incessantly,–
“Tell me the story,” “Give me the papers,” “They know.”
Breathing is labored and husky, with long inspiration, fol-
lowed by short expiration. Pupils slightly dilated. Com-
plained of chilliness during the night; is thirsty and tongue
coated. B. Natr. mur.
“Apr. 4th.-Pulse 76, temp. 97.5. Tongue coated white on
edges, red through centre and at tip. Breathing natural, and
says she feels better than yesterday. Slept four hours. Wants
petting, and is restless at times.
“Apr. 7th.-Pulse 80, temp. 98.9. Slept well, is quiet, pleas-
ant, and looks better. Wishes that she had a pile of singing
books, so that she could start off. Incoherent talk. Hungry.
“Apr. 8th.-Is inclined to cry. Tongue coated on edges;
thirsty. Head feels tired, and she slept little. Pulse 76.
“Apr. 15th-During the past week has been mischievous,
hysterical, and full of delusions. To-day the pulse is 74 and
MELANCHOLIA. 121
weak. Had a pain in head during the night, and has had
pressure in back of head for some time; the pupils are dilated,
and she cries, laughs and sings.
“Apr. 24th.-Has had frequent desire to urinate, passing
but little at a time; now complains of pain under left shoulder
and through lung. Better mentally.
“May 28th.-Improving in mental and bodily strength.
“June 10th.-Inclined to be lachrymose. Tired feeling in
head.
“July 7th.-Talks and acts rationally, and on July 29th she
was discharged recovered. .
CASE 2.—“Mrs. S. A. T., age 43, married; has three children,
the youngest being 16 years old; no insanity in the family;
first attack, duration eight months; menstruation regular;
admitted June 9th, 1879, laboring under melancholia.
“HISTORY.-Always of a quick, violent, emotional tempera-
ment, and very devoted to her children; when business cares
and reverses came upon her husband she felt them intensely
for the sake of her children, but bore the pain in silence. Her
first symptom was want of sleep and consequent nervousness;
next followed talkativeness and fixed ideas. About this time
a short illness of a daughter, the death of a sister and of a
dear friend contributed to unhinge her mind yet more. Now
appeared fixed and mistaken views of commonplace things,
erroneous impressions, great restlessness and increased in-
somnia, dissatisfaction with some of her family, and inability
to adapt herself to circumstances.
“June 11th-Trifles disturb her and everything seems a
burden to her, and she feels worried all the time. When quiet
she gets along pretty well, but anything out of the usual
routine disturbs her greatly. Has a dull pressure through the
head, and sensation as of a tight band; also a tired and con-
fused feeling. Bad taste in mouth; constipation; menstruation
irregular. B. Merc. Sol.
“June 13th.-She feels worse on awakening in morning, and
after she has slept well. Appetite poor. Toward night she has
a dull pain in the forehead.
“June 17th.-Mental condition much as before. A vaginal
8
122 INSANITY AND ITS TREATMENT.
examination shows the uterus to be somewhat prolapsed, the
cervix enlarged, especially anteriorly; and the OS elongated
laterally with three small polypi projecting from it, causing
no pain or inconvenience to patient. Menstruation recurs at
intervals varying from three to six or eight weeks, and causes
much suffering. The cervical canal seems filled with a glairy
albuminous discharge. Merc. Sol. continued.
“June 21st.—Complains of feeling heavy, stupid and de-
pressed, but is better able to throw it off than before.
“July 1st.—Awakes more cheerful in the morning, and
seems generally better.
“July 5th.-Not as well; has a dull heavy sensation in head,
cannot look constantly at anything as her eyes hurt her. Also
a feeling of depression and lassitude.
“July 29th.-Seems mentally well. Examination with
speculum shows that the polypi have not decreased in size,
but appear larger and more irregular; local applications of
Sanguinaria powder were ordered.
“Aug. 15th.-Examination showed the polypi decreased in
size and the patient was discharged on the 17th. Recovered.”
CASE 3.−“Female; married; mother of six children; Catho-
lic; native of Ireland; thirty-four years of age; two sisters and
a brother insane; admitted June 1st, 1874.
Patient is of a cross, nervous temperament. A year ago fell
and struck her cheek against a chair. Drank hard for six or
seven years; then stopped until a week before last Lent, since
which she has grown worse. Three months ago commenced to
think and say that others were slandering her, and neglected
her work and family. Has made several attempts at suicide,
once by taking a mixture for softening horses' hoofs; once
with white lead; again injured herself with an axe, and has
tried to drown herself.
“June 2d.—Quiet and depressed; slept poorly; says she
wishes to die as she has neglected her husband and children,
and no longer has a home; complains of pain in head, in-
creased by stooping, and dizziness; eats well; Aurum”. 3d.—
Slept better; ate no breakfast; worried and depressed. 5th-
Brighter every way; sewed, and swept the hall; considerable
MELANCHOLIA, 123
pain in head and chest, which was injured by her husband
beating her, six years ago. 8th.—Constipated for last four days;
Nux wom.” every two hours; Sulphur” at night. 10th.-No
stool; ordered an injection. On account of white lead which
she had taken some weeks before, gave Alum.*. 12th.-Much
better; thinks she will get well; bowels moved; eats, sleeps
and works; menstruating. 13th.-Constrictive sensation
through chest; pain in back and hips; worse when still, re-
lieved by motion; Soreness over bowels; head better, cheerful,
and desires to hire out when she gets well; better out-of-doors
in air; worse in warm room and at night; Pulsat.”. 15th.--
Better; no stool since she stopped taking Alum.*, although
she has had three injections; Alum.*. 17th.-Had a natural
stool; relieved of all her pains; had a good visit with her
husband. 20th.-Seems mentally well, but weak in body;
taken home against our wish and judgment. 29th.-Readmit-
ted yesterday; brought by her husband, who says that after
two or three days she became moody, stood in middle of floor,
and talked to herself; depressed, but not as much as before;
Alum.*. 30th.-Very despondent; took off her clothes yester-
day in the hall; very weak; eats poorly; given beef tea.
“July 1st.—Would not take food or medicine, without being
forced. 3d.-Much excited; takes her clothes off repeatedly;
sent to third ward; restless; talks a great deal about her
family dying and being in want; Says her husband is dead,
and she wishes to lie beside him; Hyosc.0, 4th.-Very bad
last night; would not stay in bed; kicked the door; con-
stantly removed her clothing; says her father is starving, her
husband dying, etc.; put in sleeves; Aurum”. 10th.--Some-
what stronger; would not sleep in bed; cribbed and slept;
much depressed; has a very offensive-smelling, yellowish,
thick leucorrhoea, also constipated; Sepia”. 11th.-Slept in
crib; leucorrhoea diminished; still constipated ; ordered in-
jection. 13th-Leucorrhoea diminished and not as offensive;
stronger though still depressed. 28th–Stronger; little leucor-
rhoea; anxious to see her husband; has to be fed.
“Aug. 3d.-Leucorrhoea entirely checked; eats at table;
still somewhat depressed; Sepia". 4th.-Hears husband's
424 INSANITY AND ITS TREATMENT.
voice in building, and cannot be convinced that he is not
here. 7th.-Slight reappearance of leucorrhoea; otherwise
same. 9th.-Much depressed; less leucorrhoea; Sepia”. 10th.
—No leucorrhoea, complains of her head; much depressed;
wishes she was dead; thinks her husband is dead, or in the
building; Aurum”. 14th.-A little leucorrhoea, but less fetid;
still thinks she hears her husband down stairs. 7th.-Visited
by her husband yesterday, without injury to her; still thinks
she hears him ; wishes to die. 27th.—Same; has not men-
struated since she came back; Graphit.”. 28th.-No better;
Sulphur”.
“Sept. 1st.—Changed to Arg. nitr.”.
“Oct. 2d.—Anxious to go home, so as to get money to pay
tus for the release of her husband. 23d.—Detected this morn-
ing in an attempt to hang herself; much depressed; Aurum
met.ºr. 24th.-Still suicidally inclined; says she will yet
succeed.
“Nov. 10th-No better; bowels constipated; Alum.*. 14th-
Threatens suicide; Aurum met.*. 21st.—Does not sleep; much
more excited each day about going home, and always thinks
her husband is down stairs, and tries to get down; Bellad.6.
23d.—Slept better; still excited, but less so; pulse about 100.
“Dec. 5th.-Much better; sews all day; cries less; sleeps;
still thinks her husband is down stairs, but the delusion makes
less impression upon her; Bellad.".
“Jan. 2d.—Improving; anxious to get home; cries less;
helps in the ward; sleeps better; Bellad.*. 4th.-Says if her
husband will come and see her, and bring her a warm dress,
she will believe he is in New York. 11th.-Had a visit from
Ther husband yesterday; seems free from all delusions; anxious
to go home. 16th-Last night became nervous from overwork
sewing, and sleepless; quieted to sleep by Bellad.". 21st.—Did
not sleep any; no pain; feels and appears well; bruised feel-
ing of hips and back; bowels regular; Aurum”. 22d.—Slept
better; still some bruised sore feeling. 31st.—Discharged
cured; under treatment eight months.”
“It is noteworthy,” says Maudsley, “in some of these cases,
how sudden and complete may be the change from the deep-
MELANCHOLIA. 125
est anguish and despair to a state of perfect calm and sanity.
Thus one of my patients, who suffered from acute melancholy,
who usually wandered about moaning grievously, or sat weep-
ing profusely, and who had made several attempts against 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. Next morning, however, she hal
entirely relapsed, and it was some months before she entirely
recovered.” Again, 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 cases are of interest in
regard to the pathology of the disease, as they would seem to
show that there is no serious organic disease so far, that the
condition of nerve element is a polar modification which may
soon pass away, not unlike, perhaps, the electrotonic state that
may be artificially produced in nerves.
All writers on insanity, whatever theories of mental action
they may hold, are driven by observation of cases to describe
certain varieties of the two great primary divisions of melan-
cholia and mania, namely a melancholia simplex or melancholia.
without delusion, and a mania Sine delirio. These are truly
very important varieties, because it is in them, especially in
the mania Sine delirio, that dangerous impulses to homicide or
suicide or other destructive acts, are apt to arise.
Melancholy without delusion, is also called lypémanie raison-
mante, mélancolie moral and Gemiithskrankheit.
This condition is a disturbed state of the moral feelings,
not, however, necessarily marked by delirious conceptions; in
many instances it is difficult to detect the least intellectual
disorder, strictly speaking, no hallucination or delusion, but
there are always perversions or changes in the emotions.
“I meet every day,” observes Guislain, “with melancholics
who do not exhibit any disorder in their ideas, or lesion of the
judgment.” “Melancholia is exclusively an exaggeration of
the affective sentiments; it is, in all the force of its signifi-
cation, a Gemüthskrankheit, in the sense in which the word is
employed by German psychologists. It is a pathological
126 INSANITY AND ITS TREATMENT.
emotion, a sadness, a chagrin, a fear or dread, and nothing
more. It is not a condition which sensibly weakens the con-
ceptive faculties.” (Leçons Orales, vol. 1, p. 112.)
Absorbed in profound melancholy, these persons remain in
careless indolence, and become slovenly and even indecent in
their manners and dress; they seem deprived of all power to
undertake any thing new; are heedless and apathetic; they
are at once without will, power and energy, and have the con-
sciousness of this lack; they may also bitterly deplore their
condition and reason about it with great clearness, expressing
a desire to be in a more natural frame of mind and body.
Moreover they oppose a passive resistance to all advice and
counsel, and show great dread and dislike to changes and
novelty of every kind, resisting all care and attention shown
to them. Although such persons show traits of moral de-
pression without marked lesion of intellect, yet close exami-
nation will reveal some peculiarities of thought which really
serve as a basis and outline for delirious ideas, as for instance
erroneous impressions and conclusions upon many points, and
an inability to rate things at their true value. Thus they find
in their surroundings a continual source of chagrin and grief.
Dr. Bucknill says: “Simple melancholy, then, as is so em-
phatically laid down by these writers, may exist in association
with normal action of the intellectual functions, and is, there-
fore, fairly illustrative of what Prichard called moral insanity.”
Dr. Prichard himself expressly says: “The term which I
have adopted as designating this disease (moral insanity)
must not be limited in its use to cases which are character-
ized merely by preternatural excitement of the temper and
spirits. There are many other disordered states of the mind,
which come under the same general division. In fact, the
varieties of moral insanity are, perhaps, as numerous as the
modifications of feeling or passions in the human mind. The
most frequent forms, however, of the disease are those which
are characterized by the kind of excitement already described,
or by the opposite State of melancholy dejection.” And again,
the same writer observes, “A considerable proportion among
the most striking instances of moral insanity are those in
MELANCHOLIA. 127
which a tendency to gloom or sorrow is the predominant feature.
When this habitude of mind is natural to the individual and
comparatively slight, it does not constitute madness. But
there is a degree of this affection which certainly constitutes
disease of mind, and that disease exists without any illusion
impressed upon the understanding. The faculty of reason is
not manifestly impaired, but a constant feeling of gloom and
sadness clouds all the prospects of life. The individual,
though surrounded by all the comforts of existence, and even
(exclusively of his disease) suffering under no internal source
of disquiet, at peace with himself, with his own conscience,
with his God, yet becomes sorrowful and desponding. All
things, present and future, are, to his view, involved in dreary
and hopeless gloom.” (Treatise on Insanity, p. 18.)
Although in many of the cases of simple melancholia the
condition is merely one of mental depression, more or less
profound or extensive, there may also be such strong emo-
tional disturbance as to induce the most irrational conduct
and even criminal acts. Here it is necessary to guard against
the mistake of supposing delusion to be necessarily the cause
of this delirium. “In cases of simple melancholia there may
be no delusion; the patient's feeling of external objects and
events may be perverted, so that he is conscious of being
strangely and unnaturally changed; impressions which should
be agreeable or indifferent are painful; he feels himself
strangely isolated, and cannot take any interest in his affairs;
he is profoundly miserable and shuns society, perhaps lying
in bed all day. All this while he may be quite conscious of
his unnatural state, and may strive to conceal it from his
friends. Suddenly, it may be, an idea springs up in his mind
that he is lost forever, or that he must commit suicide, or that
he has committed murder and is about to be hanged; the vast
and formless feeling of profound misery has taken form as a
concrete idea—in other words, has become condensed into a
definite delusion, this now being the expression of it. The
delusion is not the cause of the feeling of misery, but is
engendered of it, is precipitated, as it were, in a mind Satu-
rated with the feeling of inexpressible woe; and it takes differ-
128 INSANITY AND ITS TRE, ATMENT.
ent forms according to the degree of the patient's culture, and
the Social, political and religious ideas prevailing, or the par-
ticular epoch. In some cases it is striking to see how dispro-
portionate the delusion is to the extreme mental anguish, the
patient assigning the most ridiculously inadequate cause for
his gloom ; one man under my care, whose suffering was very
great, said that it was because he had drunk a glass of beer
which he ought not to have done; and another man was, as
he thought, lost forever because he had muttered a curse
when he ought to have uttered a prayer.
“With him who believes that he is doomed to infinite and
eternal misery, it is not the delusion, but the affective disorder,
that is the fundamental fact; there cannot be in the finite
mind an adequate or definite idea of the infinite or the eter-
nal ; and the insane delusion of eternal damnation is but the
vague and futile attempt to express an unutterable real suffer-
ing. In all these cases of melancholia the deep sense of in-
dividual restriction which exists, the wretched feeling of the
oppression of self, is interpreted as due to some external
agency; and as the existence of any passion notably intensi-
fies an idea that is congruous with it, the delusion ultimately
attains great vividness. The essential nature of the delusion
will depend upon the special nature of the passion in which
the individual’s self-feeling is engaged, but the particular form
which it assumes will depend greatly upon the education and
upon the circumstances of life in which he has been placed.
Thus the vain and ambitious man who has had a religious
training, will assume a character in accordance with his senti-
ments, and will deem himself a prophet favored of heaven, or
aven Jesus Christ; the politician will be a prime minister or
some great political character; the man of Science will have
solved the problem of perpetual motion, or will be the victim
of complicated and ingenious persecution by means of elec-
tricity.” (Maudsley's Physiology and Pathology of Mind, p. 374.)
Esquirol thought that he could have written the history of
the French revolution from the character of the insanity which
accompanied its different phases. *
Aside from the somewhat rare instances where some violent
MELANCHOLIA. 129
moral shock causes a sudden attack, the causes of melancholy
act, as a rule, slowly and prepare gradually for the explosion.
These causes are prolonged sorrows, and incessant moral con-
flicts which shake the nervous system and hold it in a perpetual
state of tension and fatigue; thus it is that among the causes
giving rise to puerperal melancholia we assign a very promi-
nent place to the griefs and annoyances induced by a state of
pregnancy. *
The more prominent physical causes are those which would
produce debility, such as fatigue, privation, poverty, insufficient
food, loss of blood, as well as those febrile conditions which
profoundly weaken the system. This special influence exerted
by depressing physical influence upon the development of mel-
ancholia deserves to be kept in mind on account of the con-
nection which seems to exist between the character of the
causes and the character of the disease.
Of all the so-called mental diseases melancholia is the form
most frequently found in connection with some lesion or dis-
turbance of the abdominal viscera, especially the liver and
uterus. M. Azam investigated the histories of seven cases of
melancholia with suicidal tendencies; of one case of simple
melancholia with dangerous tendencies and of one case of
hystero-mania. There were granulations of the neck of the
uterus in five cases; there was anteversion of the uterus with
congestion of its neck and ulceration of the inferior lip in one
case; in three cases there were fungous and fibrous growths of
the uterus; and in one case there was painful engorgement
with leucorrhoea. Schröder Van der Kolk relates the case of a
woman profoundly melancholic, who at the same time suffered
from prolapsus uteri, and in whom the melancholy used to
disappear directly the uterus was replaced.
In the Section upon the causes of insanity, allusion was made
to the influence of the climacteric period in producing insanity,
among those who are predisposed, and Dr. Maudsley says:
“When positive insanity breaks out at this period of life it
usually has the form of profound melancholia with vague
delusions of an extreme character, as that the world is in
flames, that it is turned upside down, that everything is
130 INSANITY AND ITS TREATMENT.
changed, or that some very dreadful but undefined calamity
has happened or is about to happen. The countenance has
the expression of vague terror and apprehension. In some
cases short and transient paroxysms break the melancholy
gloom. These usually occur at the menstrual period and may
continue to do so for some time after the function has ceased.”
Such a condition no doubt is very common in connection
with insanity at the change of life, but there seems to be
another class of symptoms almost equally common, consisting
in the early stages of the disease of perversion of the affections,
distrust and vague suspicions of relatives and friends and
developing into a later stage of well marked delusions of sus-
picion and persecution. Not long since a lady was under my
care who resided with a married daughter, her own husband
being at home in the West. Generally she was very fond of
the Society of her daughter and her family, but at regular
intervals of four or five weeks she would seclude herself in her
room, be very quiet, and almost dislike the very sight of her
son-in-law, of whom at other times she was very fond. At
such times too she would have a strong impulse to throw her-
self from the window, especially upon bright moonlight nights.
She endured this condition of things for months in silence,
until at last fearing lest she might harm Some one of the
family or herself she called upon me for help, and under the
use of Cimicifuga and Aurum she was thoroughly cured.
Prof. Maudsley says that both these groups of symptoms
seem to be highly characteristic of insanity, connected with
the climacteric condition, but he does not think that an ob-
server, unacquainted with the age and history of the patient,
would be warranted in pronouncing a case presenting such a
group of symptoms to be one of climacteric insanity. To be
of diagnostic value the symptoms must be taken in connection
with the early history and development of the disease, which
in most cases observe a pretty uniform course.
Before any attention has been called to the mental condition,
the patient has, in the great majority of cases, been for some
time more or less out of health; anaemia and debility in some
form being generally present. Probably she is reduced by
MELANCHOLIA. 131
previous severe menorrhagia, although the occurrence of this
condition in connection with the menopause does not seem to
predispose specially to an attack of insanity. In other cases,
though menstruation has not entirely ceased, it has been for
some months scanty, irregular and painful. In most cases,
however, the menstrual flow has entirely ceased, sometimes
before mental symptoms are developed, but in the interval the
patient has never been restored to her former good health.
She continues to suffer from various anomalous sensations,
faintness and sinking, headache, palpitations, epigastric pains,
and feelings of general debility, with flushings and perspira-
tions. At this time there often appears a craving for stimu-
lants, and not infrequently habits of intemperance are devel-
oped. So far the, condition of the patient is one common
enough in women at this period and occasions no remark.
Even at this stage, however, the patient herself is often con-
scious of some mental defect, forgetting where she puts things,
and not being able to get on with her work as before. She
may have a vague feeling of something being wrong, though
not sufficiently intense to prompt her to do anything obnoxious
to others or injurious to herself. At the same time she is irri-
table and restless, anxious about trifles, and unusually suscep-
tible to the influence of all stimuli. Occasionally she experi-
ences a strong impulse to certain acts, often of a suicidal or
homicidal nature.
In some cases depression is an early symptom, and the pa-
tient may confess that she feels tired of her life, and has enter-
tained thoughts of suicide. More generally, however, attention
is first called to her mental condition by some marked change
in her character and conduct, such as neglect of her house-
hold duties, or an amount of fussiness in the performance of
them quite foreign to her usual disposition. In one case, for
instance, a woman noted for regularity in habits and economy
in the management of her household affairs took to getting
up at irregular hours in the night for the Ostensible purpose
of getting through her domestic duties, with which, however,
she never made any progress. Another, whose former life had
been marked by devotion to the interests of her husband and
132 INSANITY AND ITS TREATMENT.
family, and whose delight was found in making home pleas-
ant to them, became neglectful of home, and spent most of her
time in going about from house to house, collecting and retail-
ing all the gossip of the neighborhood.
With such changes in the habits and character there is al-
ways more or less marked depression, and often an inclination
to suicide. The patient manifests great restlessness, extreme
nervous irritability, and it may be, distrust, and vague sus-
picions of those around her. She has a sense of dissatisfaction
with everything she does, and, though always busy, “can never
get through with her work.” Later as the disease progresses,
the depression deepens into profound melancholia marked by
a condition of fearfulness and apprehension of some impend-
ing calamity, with vague delusions of a gloomy character. In
other cases, the distrust and suspicion of others manifested at
an early period, become the most prominent symptoms and
develop into well marked delusions of persecution, under the
influence of which the patient may become violent and
abusive.
As has been stated, melancholia may begin suddenly. In
Some cases a sudden shock or fright may induce a condition
of melancholy with stupor; the mélancholie avec Stupeur of the
French; but we usually may detect some premonitory symp-
toms. Sometimes this may be a fixed idea of a sad nature,
which once implanted in the mind slowly gains ground and
finishes by invading the intellect and lending to all its thoughts
a uniform cast of Sorrow. At other times there may be a con-
fused mass of incongruous delirious ideas accompanied by
great restlessness; at the end of a few days of this premonitory
stage, the melancholia defines itself clearly by the generaliza-
tion and more pronounced character of the false conceptions.
We sometimes meet with extreme cases of melancholia,
which, from the absolute manner in which the mental and
physical powers seem to be annihilated, may easily be mis-
taken for cases of acute dementia. These cases have received
much attention under the name of Stupidité and melancholy
with stupor from the prominent symptom. Griesinger says,
“this form is not only of the highest theoretical importance
MELANCHOLIA. 133
on account of the well-marked mental symptoms, and of the
very characteristic anatomical lesions in the brain which exist
in some cases, but on account of its being so often and So
easily confounded with dementia, which may lead to serious
errors both as regards prognosis and treatment.
“Really the patients in the higher degree of these states pre-
sent to appearance the very picture of dementia. They are
perfectly dumb, completely passive, they only move when
compelled by some strong external motive; their whole bear-
ing is that of stupidity; the expression is that of profound
mental oppression, of a veritable annihilation; but the glance
of such patients does not indicate the nullity proper to de-
ments—it expresses a painful emotion, sadness, anxiety or
concentrated astonishment. In the more advanced degrees
there generally exists anaesthesia, sometimes partial and some-
times general, of the surface of the skin, and a condition of
the higher organs of sense whereby the impressions of sight
and hearing are rendered quite indistinct and confused, and
frequently so perceived as if they came from a distance.
“The voluntary muscles appear at times to be perfectly
rigid and on the stretch, sometimes benumbed; it is not un-
common to find such patients in a cataleptic condition, and
many of the observations concerning so-called catalepsy be-
long in reality entirely to this form. The mobility of the
members under the control of the will is always very much
diminished, occasionally almost suppressed. There is a con-
dition like that of restraint of all the motory functions of the
brain.
“In such circumstances the patients have in a majority of
cases lost all consciousness of time and place, as well as the
appreciation of their bodily necessities; consequently they are
in the highest degree unclean, require to be fed, to be clothed,
to be put to bed, etc.”
This stupor sometimes arises suddenly after some violent
and intense emotion or shock; in such cases it is not, as a rule,
of long duration, and seems to have been caused by an in-
stantaneous paralysis of nerve-force; it may also occur as a
paroxysm in ordinary cases of melancholia, and after attacks
of epilepsy, of mania, or even alternate with this last.
134 INSANITY AND ITS TREATMENT.
A case of this sort came under my observation a short
time ago, in which the cataleptic condition was very clearly
marked.
Mrs. U., aet. 30, having had four children in about six years,
was attacked about six months after her last confinement by
puerperal mania which gradually passed into melancholia.
Owing in part to unfavorable surroundings which could not
be controlled, and in part to strong hereditary predisposition
she has never fully recovered. Her melancholia has had a
well-marked religious cast; she thinking that she cannot be
saved, and that she is more wicked and worthless than anyone
else in the world. I have not the time to give all the details
of the case but will come down to the present time. About
the middle of August, 1880, her husband informed me that
she was not quite as well as she had been, and I made several
visits trying to persuade her that it was right for her to take
Some enjoyment in life and try to be more happy. The Essex
Institute was to make an excursion to the mountains and into
Canada, and the husband, who was much worn by the mental
strain of the past year, desired to be of the party, and was
anxious to take his wife, hoping that the change of scene and
air would do her good; she however refused to go, but con-
sented to have him take the trip, though reluctant to have
him away from her. The party went on Wednesday, August
18th, and on the following Sunday, I called and found Mrs. U.
much as usual, though perhaps a little more depressed; still,
she was surrounded with her children and playing with them.
Her mother and aunt were staying in the house during the
husband’s absence. They told me that Mrs. U. had refused to
go to ride, because she had not been alone with them before. One
of her peculiarities being a strong repugnance to doing any-
thing, eating anything, or wearing anything, for the first time
since her illness began a year ago. I, too, tried to induce her
to go to ride but in vain.
Early Tuesday morning, about half past three, I was sent
for, as she was said to be in a trance, and I reached the house
about four. She was in the habit of sleeping in a front room,
and the nursery where her children slept opened from it.
MELANCHOLIA. 135
Monday night her mother urged to be allowed to sleep with
her, but she refused, saying that she had not been in the habit
of so doing, and that if her husband had wished it, he would
have said something about it, and that if she needed anything
in the night, she would call. About two o'clock in the morn-
ing the mother and aunt were awakened by one of the child-
ren crying, and, going into the nursery, found Mrs. U. stand-
ing in her night dress in the middle of the floor; there was a
look about her face as if she were peering into vacancy, and
an expression as if listening with horror to some dreadful
news, and she were waiting to hear more; her finger was
raised in the attitude of bidding one hush and listen. All
the efforts on the part of her relatives failed to gain any notice
or recognition, and they sent for me. On my arrival two
hours later her position was literally unchanged; once only it
seemed for a moment as though she would fall, but she quickly
resumed her position.
I found her in the position above described; limbs rigid
and features fixed. All appeals to her feelings or her reason
elicited no response, it was like speaking to a statue. I sat
down and waited for developments; and here let me say that
in dealing with most cases of insanity nothing is to be gained
by haste or yielding to the impulse to be doing something.
The mother now put in an appearance, and clinging to the
patient tried to get her to bed, using tears, entreaties and
threats, but all in vain; finally she tried pulling, when sud-
denly the patient gave her a sound box on the ear, and at
once resumed her former attitude and stolid and anxious gaze.
About six o'clock I placed an arm-chair behind her and drew
her back into it, but she kept her legs almost straight, and
now folded her arms across her breast. All attempts to induce
her to swallow were useless, as she kept her mouth tightly
closed. From time to time I placed her leg, arm, or finger in
a constrained and awkward position, using Some force to over-
come the resistance of her muscles, but the limb would remain
in the awkward position until I again moved it. She in the
meantime took no notice of anything; but once in awhile she
would look at us with an expression of unutterable horror and
136 INSANITY AND ITS TREATMENT.
grief. This state of things continued at 8.30, when I left the
house. In the evening I found that she had to a limited ex-
tent emerged from her condition, but remained speechless and
refused to take food. That evening, Wednesday, she slept
from 10.45 to 12.30, when she arose and went down to the
front door and attempted to go out with nothing on but her
night-dress; she was easily prevented, however. Thursday
her condition seemed more like intense melancholia, but there
was still great rigidity of all the muscles. The temperature
was a little below the normal point, pulse natural. The pa-
tient was menstruating at the time of the attack, although
only two weeks had elapsed since her last period. The hus-
band returned from his trip on Thursday evening, and on
Friday she seemed to have emerged from her cataleptic con-
dition, and to be in a state of deep melancholy. She was then
removed to a hospital and has somewhat improved.
Griesinger says: “In what condition is the intellectual life
of the sufferer during the course of this disease? On this sub-
ject certain patients have, after their recovery, given us the
most remarkable information. So far from experiencing
that total psychical void which is proper to dementia, the
mind in the great majority of instances retains its normal
activity. But the patient, owing to this abnormal condition
of the sensorial perception, unconscious of what goes on
around him, lives in an imaginary world. So far as he is
concerned, all reality has disappeared, all around him is
transformed and effaced. An intense internal anxiety consti-
tutes the fundamental state which torments him almost to
suffocation, and from this proceed ideas of being threatened
every moment with misfortunes; as, houses going to fall upon
him, of the world coming to an end, of total annihilation of
everything, as well as certain delusions of having committed
some frightful crime, of depravity, etc.
“The sufferer is unable to exert his will, and therefore feels
the impossibility of freeing himself from the terrors which
threaten him on all sides. Very frequently he cannot after-
wards tell why he was incapable of the least exercise of will,
why he could not reply, why he could not cry out. Esquirol
MELANCHOI,IA. 137
has, however, acquainted us with the interesting declaration
of a patient after his recovery, ‘This want of activity was due
to the fact that my sensations were too feeble to call forth an
exercise of will.’ But this absence of will is most evidently
manifested in the utter passiveness, inactivity, and immobility
of the patients; as well also by the intercurrent fits of intense
activity which sometimes occur, in the same way as many pa-
tients may have now and then a short moment of conscious-
ness and obtain a glimpse of the actual world.
“Very often this external insensibility, this suppression of
the effort, and the exclusive sad delirium, are accompanied by
hallucinations and illusions of the same nature. The patient
hears voices which seem to reproach him, to insult him, and
to threaten him with death; or a confused noise of bells, trump-
ets and cannons, etc., in a word, the entire subjective change
which is produced in his sensorial perceptions, and the conse-
quent transformation in all impressions causes all external ob-
jects which he still perceives to appear only in the forms and
figures colored by the predominating sentiment.
Dr. Bucknill says that these cases of melancholia, resem-
bling profound acute dementia, may be distinguished from
the latter malady—First, by the expression of the counte-
nance, which, in melancholy is contracted, and marked by an
intense though an immovable expression; and, in dementia
is relaxed and expressionless. Secondly, in abstracted melan-
choly the patient resists being moved, sleeps badly, and often
refuses food; in dementia, he complies with the wishes of the
attendants, has a good appetite and sleeps well. Thirdly, in
abstracted melancholy the bodily functions are more seriously
affected than in dementia; the body is emaciated, the com-
plexion sallow, the skin harsh, and the secretions generally
deranged; whereas in dementia the body often retains its
plumpness, and the secretions are little altered from a healthy
standard. Fourthly, after recovery the patient who has been
affected with abstracted melancholy is found to have retained
his consciousness through the whole period of his disease;
when recovery takes place from primary dementia, the past is
found to have left no traces in the memory.
9
138 INSANITY AND ITS TREATMENT.
There is the same difference between melancholia with
stupor, and dementia, as between temporary diminution in the
Sensory nerves of sensibility to external impressions, with pain
and new abnormal sensations on the one hand, and complete
and persistent anaesthesia on the other. “But as the two con-
ditions may depend on the same cause, and while it is not rare
to see these two states succeed each other, and rapidly trans-
form the one into the other, so also this form of melancholia,
as melancholic stupidity, may, when it lasts for a lengthened
period, become transformed into actual persistent weakness of
the intellectual faculties, with cessation of the painful emo-
tions, into dementia, into conditions, therefore, where the in-
tellectual activity is not merely restrained, but actually per-
sistently and most profoundly destroyed.”
The following case is reported by Dr. S. H. Talcott in the
Homoeopathic Times of Dec., 1880:
“J. N., female, single, aet. 30, admitted to New York State
Homoeopathic Asylum for the Insane, June 2d, 1880. Her
medical certificate of commitment states: ‘She sits in her chair
with her mouth wide open, her eyes fixed on vacancy, while
the muscles of her face spasmodically twitch. Sometimes she
tightly closes her teeth and lips, refusing to take food or drink,
imagining it is poisoned. She refuses to speak, sometimes
screams wildly and is violent.
“We also notice that her hands are tightly clenched, that
she resists every attempt to move her arms, and at times she
seems to be intensely frightened at some imaginary object.
“On June 3d, the day following her admission, the patient
had to be restrained in bed on account of her extreme restless-
ness. Had slept none the night before; very thirsty; restless
and uneasy; hands hot; inclined to keep them constantly
clenched; much twitching of extremities; pulse 84. Ordered
the patient to have Zincum.
“On the 4th, the patient's temperature was 99.6° and pulse
.90. Slept none; very weak; lies in bed with mouth open;
tongue swollen, and does not seem able to protrude it; can
scarcely speak, and does not seem inclined to talk. Urine re-
...tained, and a catheter used to remove a large quantity of water.
MELANCHOLIA. 139
On account of the stupid condition, with swollen tongue, puffy
appearance about the eyes, and retention of urine, we gave the
patient Apis.
“June 5th there was no improvement. The temperature
had risen to 102.2°, while the pulse was running at 116. Had
to be catheterized ; also was fed beef tea and milk with the
Soft rubber nasal tube.
“From June 5th to June 14th the patient was given Ver. vir.,
Gelsem., and two or three other remedies, as apparently indi-
cated, hoping thereby to reduce the constantly rising tempera-
ture, but with no avail. On the morning of the 14th the ther-
mometer in patient's axilla recorded 106.5°; the pulse was
146, and respirations 52 per minute. All other indications
were those of speedy collapse. At this juncture we prescribed
Baptisia, five drops of the mother tincture in half a glass of
water, a teaspoonful of the solution to be given every half
hour. In the afternoon an enema was given for relief of the
constipation, and a considerable amount of feces was dis-
charged. At 9.15 in the evening the temperature was 105.8°,
pulse 140 and respirations 46, showing a slight change for the
better. On the morning of the 15th, the temperature was
104.7°, pulse 120, respirations much less rapid, and the skin
was not so intensely hot as on the day before. Still, the pa-
tient had slept none during the night, and the bowels re-
mained bloated and tympanitic. On the 16th the patient's
temperature was 104°; on the 17th, 103.3°; on the 18th,
102.2°; on the 19th, 100.4°. During these days the bowels
were moved with enemata as necessary, and the Baptisia was
continued at lengthening intervals as improvement warranted.
“It is well to state here that the patient had totally neglected
herself for over two weeks previous to admission, and when
action of the bowels was established the movements were abso-
lutely enormous. After an immense discharge the tempera-
ture would be lowered a degree or two for a few hours, but
would soon rise again unless the Baptis. was given steadily.
At one time this remedy was discontinued for Arsen., for a few
hours, on account of symptoms apparently demanding the
latter drug, but we were forced to return to Baptis, in order to
140 INSANITY AND ITS TREATMENT.
keep the temperature within bounds. On the night of June
17th the patient slept five hours; on the 18th seven hours at
night, and three hours during the following forenoon; on the
19th slept sufficiently, and from this time until recovery she
was no more troubled with wakefulness.
“On the 18th of June the patient began to talk with some
degree of coherency, although manifestly still under a mental
cloud. In reply to a question as to how she felt, she replied:
“I feel better, but I don’t know what I am.’
“June 22d, she “wished she was dead.’
“June 25th, the patient talked sensibly and acted much
better in every respect.
“During the remainder of June and through the months of
July and August, this patient grew stronger and brighter in
body and mind, developing new powers from day to day, the
temperature and pulse became normal, the tongue became clear
and regained its natural moisture, the appetite improved, and
the patient began to sit up and amuse herself with light fancy
work. º
“The group of remedies most likely to be used in cases where
the temperature is greatly elevated, consists of the following,
viz.: Acon., Bapt., Gelsem. and Ver. vir. The intense mental
excitement of Acon. and the great physical restlessness of Ver.
vir. would exclude a consideration of their use in such a case
as we have described, particularly when fully developed.
Neither of these drugs, in the proving, produces such a deep
mental fog as that which existed in the aforementioned pa-
tient. Gelsem. has a condition of stupidity simulating the
Bapt. case, but the remedy is usually effective only in the
early stages of disease, and before there are marked changes of
the vital fluids, or degenerations of muscular and other tissues.
Of all these fever remedies, therefore, Bapt. is the only one
that corresponds, in almost every particular, to the fully de-
veloped disease, known as melancholia with stupor. I mean,
of course, those victims of the disease whose symptoms and
conditions are similar to the one of which we have treated.
“CASE II.-M. H., widow; has insane relations, her father
and a sister having suffered from insanity; age 53; date of
MELANCHOLIA. 141
first attack, 1871; was admitted to the asylum for the second
time, December 29th, 1879. This case had suffered from
mania, which assumed a chronic form. Having improved
materially during her former visit to the asylum she was dis-
charged, and for several years remained quietly at home, caus- .
ing no trouble. About three weeks previous to readmission
this patient had endeavored to commit suicide by jumping
into a cistern. She was rescued, and confined to prevent a
repetition of the act. After her reception it was found that
she was weak, emaciated, sleepless, yet apparently stupid and
refusing to speak. All the vital functions were lowered, and
she presented the appearance of a person in the midst of a
slow fever. Her pulse was 120. The breath very offensive,
tongue heavily coated, having a tendency to crack, and with
a dark brown appearance. Patient was given Baptisia tinct.
in water. Within ten days a decided change for the better
was observed. The tongue cleared, the pulse subsided to 80,
the patient seemed brighter, and she began to sit up a few
minutes each day, although still very weak. After about three
weeks careful treatment the patient became more talkative,
but mentally was much agitated. She frequently exclaimed:
‘I am in all sorts of trouble and cannot get out.’ Baptisia
was continued in rising potencies until the fullest possible
effects were obtained, after which Opium, China, and Apis
were given as indicated. After three months treatment this
patient was able to walk about and attend chapel services, a
progress which can only be realized by those cognizant of the
hitherto abject prostration of all the forces both mental and
physical. In four months from inception of treatment, the
patient was bright, cheerful, free from delusions, and better in
all respects than previously for years.
“CASE III.--We now present a case treated with Bellad., and
with equally brilliant results:
E. W. W., admitted June 6th, 1878, act. 50, married; form of
attack, melancholia with stupor; assigned cause of insanity,
overwork. Patient came in a stupid condition; head hot,
tongue bright red, with elevated papillae. Had passed no
water in twenty-four hours; had taken no nourishment for
142 INSANITY AND ITS TREATMENT.
Several days and was much prostrated. The woman was
catheterized and given Bellad. Although utterly refusing to
speak and appearing as if in a semi-comatose state, she, never-
theless, was extremely restless and constantly threw her arms
and legs about in a manner as vague and uncertain as the
fans of a dilapidated windmill. On the day following admis-
sion the patient's temperature was 102.2° and the pulse 104.
There was considerable muscular twitching, and the thumbs
of both hands were flexed into palms and grasped by the
fingers. There was a collection of sordes on the teeth and the
mouth appeared hot and dry. Occasionally the patient mut-
tered about fire.
“June 8th. Temperature 101.2°, pulse 96; slept three hours.
Less muscular twitching; less heat in the head; eyes more natu-
ral; manifestations of intense fear less observable. Passed
water twice during the day; took nourishment fairly, and in
every way appeared better. The prescription of Belladonna
was continued.
“June 9th. Slept four and one-half hours last night; pa-
tient continued to improve.
“June 13th. A steady gain is noted during the past four
days, and from last date the sick one slept sufficiently.
“It is well to remark here that previous to admission the
patient had been treated with massive doses of chloral hydrate,
the effects of which were to partially stupefy, not to produce
natural sleep. By the use of Bellad., and no other remedy,
the result, in a very few days, was a full amount of natural
sleep. More than this, under chloral hydrate, the patient
rapidly grew worse; under Bellad., she with equal rapidity,
took up the march toward the happy goal of perfect health,
and on the tenth of August she was discharged fully recov-
ered.
“CASE 4.—J. B., male, aet. 16, admitted to the asylum May 1st,
1877. Physical condition on entrance was that of extreme ex-
haustion. Mentally the patient was utterly depressed and stu-
pid. The causes of mental and physical derangement were
masturbation and abstinence from necessary food. The pa-
tient's pupils were largely dilated; extremities cold and blue;
MELANCHOLIA. 143
pulse 60 and weak. Face flushed; eyes staring steadily at one
point; complete apathy—says nothing. Urine dark red and
scanty, ; was catheterized, and relieved of about one pint of
water. Nothing has been eaten by the patient for four days.
Prescription, Digitalis.
“May 26.-Slept well last night; symptoms the same.
“May 3d.-Slept all night; urinated in bed. .
“May 4th.-Asked for milk; the first words spoken by the
patient since his arrival.
“May 6th.-Begins to eat well, and now feeds himself. Pu-
pils still dilated.
“May 7th.-Answers questions with ‘yes’ or ‘no,' is pleas-
ant and smiling; got out of bed for the first time; pulse 80.
“May 8th.-Pupils dilated, but respond easily to light. Pa-
tient weak and suffering from seminal losses; pulse fuller and
stronger.
“May 9th.-Walks around the room ; seems stronger, and
physically is improving; mind still very sluggish. During
the remainder of the month of May, the patient continued to
gain both mentally and physically, although at times slightly
depressed and inclined to suicide. -
“The months of June, July and August were passed with-
out unusual episode by this case, except that he experienced
an occasional epileptic fit, to which malady he had before been
subject. The patient was also addicted to masturbation. For
epilepsy and the effects of sexual excess he was subsequently
treated, but all traces of melancholia with stupor passed away
before the vigorous march of Digitalis.
“The recapitulated symptoms which led to the use of this
drug are slow pulse (the prime and principal symptom), pu-
pils dilated, and eyes suffused with tears (the latter quite.
marked), clammy skin of a purplish cast, and utter inertia of
the mental faculties.”
Dr. Talcott also gives the following valuable hints as to the
special treatment of this form of melancholia:
“The patient suffering from melancholia with stupor should.
be placed in a recumbent position in bed, and kept there:
He should no more be allowed to sit up, or stand, or walk
144 INSANITY AND ITS TREATMENT.
around, than a patient who is passing through a course of
continued fever. Constant and patient watching and nursing
are imperatively necessary. Careful attention must be paid
to the condition of bladder and bowels, and these should be
evacuated of their contents by artificial means at regular
intervals, otherwise serious dangers would spring from over
distention of the former or impaction of the latter. .
“Frequent bathing with alcohol and water is highly bene-
ficial, as by this means the skin is kept clean and free from
noxious emanations, while at the same time the temperature
of the patient is thereby moderated.
“Beef tea and milk should be administered from three to six
times per day, as the weakness of the patient may demand.
If unable or unwilling to swallow nourishment, it may easily
be injected with a soft rubber nasal tube, by means of a
Davidson's syringe; medicines, and an occasional draught of
fresh water may be given in the same way.
“The remedies most frequently demanded by the observable
symptoms of melancholia with stupor are Baptis., Bellad.,
Digit., Apis, Gelsem, Opium, Ver. alb., and Oleand.; China and
Arsen. may also be of service during convalescence.
“We have noticed in one case a marked change for the
better after the use of Oleander. The symptoms on which the
drug was prescribed were: Absent-mindedness and slowness
of perception, utter indolence and aversion to do anything;
would not dress nor eat; could not bear the slightest handling,
and became greatly enraged if touched by anyone; breathing
oppressed and heavy; head hanging down constantly, itching
of the scalp with a constant tendency to scratch the head;
rumbling and flatulence of bowels, with hard difficult stool;
urine brown although passed in fair quantities.” Under the
influence of Oleand. the patient began to talk, and appeared
quite pleasant, although for weeks previous to its use he had
obstinately refused to say a word, or to act in the slightest
degree like a sentient being. From utter apathy he awakened
to new life, and began to eat, drink, and be merry like ordinary
mortals.”
MELANCHOLIA. 145
LECTURE WIII.
Melancholia Continued. Indications for the Use of
Fourteen Principal Remedies.
In melancholia we have two classes of symptoms to study,
the physical and mental.
The delirious ideas of the melancholic present great simi-
larity in all cases, and differ more in degree than in kind;
the patient believes himself lost, ruined, dishonored; he ac-
cuses himself of imaginary crimes, and considers the most
trifling acts of his life as unpardonable faults; he thinks that
he has brought dishonor upon himself and family, and has
become an object of contempt and scorn to all around him.
He is condemned and sent to prison, and the people surround-
ing him are jailors and his house a prison; thus he lives in
the midst of a most overwhelming anxiety; he feels keenly all
the moral anguish of the situation created by his delirium,
and sees everywhere signs of Scorn, threats of death, and a
gloomy outlook for the future.
Illusions and hallucinations are added to the delirium and
give rise to paroxysms of dread and suspicion of everything
and every one. The patients hear voices accusing and in-
sulting; see threatening images; feel strange Sensations, and
their actions as well as their thoughts strongly bear the
imprint of their deep intellectual disturbance. Thus it is
that they refuse food, because being ruined they cannot pay
for it, or because they believe it to be poisoned, or because they
are wicked and ought not to accept anything of God’s bounty
to mankind. Some wish to die from hunger in order to es-
cape some ignominious punishment, others in order to relieve
their families from the disgrace of their presence. Such per-
sons will make every effort to commit suicide and require con-
stant watching.
A marked feature of the mental state of these melancholics,
beside the peculiar and special form of their delirious concep-
146 INSANITY AND ITS TREATMENT.
tions, is the monotony and passiveness of their delirium; the
imagination has to a singular degree lost its activity. Instead
of discussing their false ideas, instead of trying to sustain
them by ingenious and varied reasoning, as do the so-called
monomaniacs, these patients, borne down by the weight of
their ideas, simply repeat the same words and the same ideas.
If you attempt to convince them, or demonstrate the falsity of
their fears, they do not argue, and instead of arousing them-
selves respond only by negatives to all your efforts of logic.
At a more advanced stage, the delirium not only revolves in
a narrow circle of thought, but the ideas become incoherent
and confused in equal ratio as the intellectual depression be-
comes more marked. This chain of symptoms is easily un-
derstood if we think of the oppressive influence that sadness
and grief have upon the intellectual powers, even in the nor-
mal condition of health.
With this delirium there are often associated hypochondria-
cal ideas, which lend it yet more weight. The patient be-
lieves that his digestive canal is closed up; that the bowels
are prolapsed at the rectum; and they are unable to urinate.
The thoughts dwell on the functions of this or that organ,
and find new fuel for delirium in their fears about the physi-
cal condition of the viscera. Some feel that this or that part
of the body is changed or destroyed, or that the sex has been
changed; that they have lost an arm or a leg; that the head
of an animal has been substituted for their own. With others,
again, the ideas are still more connected with the delirium,
and in the midst of their intellectual disturbance they think
that their bodies are decomposed and give forth a vile odor,
hence they flee the society of others and even attempt suicide.
Finally it may happen that the delirium pushed to its extreme
limit produces so profound a feeling of abasement and anni-
hilation that they think they are dead. You may see them
lying motionless on the back, mute, eyes closed, replying nei-
ther by word or gesture to the questions of those about them,
refusing to eat, and perhaps repeating in a low voice and at
long interval that they are dead.
Beside the delirious conceptions which, in spite of their
MELANCHOLIA. 147
number and variety, present such uniform characteristics, we
find with melancholics an assemblage of modifications in the
organic functions which may be summed up in the word de-
pression. These changes, difficult to perceive and define when
the depression is slight, but clearly marked when the depres-
sion is profound, may extend even to stupor or stupidity. But
whatever their degree, the changes produced, although varying
in intensity, are always identical with themselves, and indicate
a uniform cause acting upon the whole body.
The description given by Esquirol of the patient's physical
condition is as follows:– “In person, the melancholic is lean
and slender; his hair is black, and the hue of his countenance
pale and sallow; the surface over the cheek-bones is sometimes
flushed, and the skin brown, blackish, dry and scaly; whilst
the nose is of a deep red color; the physiognomy is fixed and
changeless, but the muscles of the face are in a state of con-
vulsive tension, and express sadness, fear and terror; the eyes
are motionless, and either directed towards the earth or some
distant point, and the look is askance, uneasy and suspicious.”
Among the common physical symptoms are a quickened or
a slow, compressible pulse; an unnaturally red, or perhaps
extremely foul and coated tongue, constipation, dryness of the
hair and skin, sleeplessness, and the “peculiar odor” so com-
mon with insane persons. This group of symptoms often
gives rise to the opinion that one has to deal with some kind
of a continued fever complicated with delirium, as in typhoid.
After a longer or shorter time, however, these accessory symp-
toms subside, and the persistence of the delirium as well as
the nature of the false belief leaves no doubt as to the nature
of the disease.
In women the uterine functions are often disturbed, and
are suspended in the large majority of cases. In men, the re-
productive instinct is usually in abeyance.
Frequently there is pain in the head, epigastric uneasiness,
and a fluttering or burning sensation. This is especially no-
ticeable in cases of hypochondriacal melancholia, where the
apprehensions are generally limited to the patient's own bodi-
ly infirmities, upon which he at all times loves to dilate.
148 INSANITY AND ITS TREATMENT.
Loss of sleep and disturbed dreams will frequently claim
Our attention at an early stage. In some cases the dread of
falling asleep is intensely agonizing, from the anticipation of
dreaming, and awaking with horrible sensations.
Changes in the countenance will attract our notice. The
pinched contracted features express anxiety and suffering, the
brows are knit, the eyes cast to the earth, the figure motionless
and insensible, indicating a profound concentration of thought;
in the melancholy with stupor this immobility of feature be-
comes So great that it seems as though a mask were worn.
The mouth is half open, the lower lip hangs down, the nos-
trils are covered with dust and dirt, and the expression is
stolid and foolish, in a word the appearance is similar to that
of one with typhoid.
The attitude equally denotes great dejection; the move-
ments are slow and undecided; short steps are taken in walk-
ing, the feet are scarcely raised from the ground, and it is
necessary to urge the person in order to have him dress or
undress. If the depression increases they remain motionless,
the head bent upon the chest, the arms extended inertly along
the body, the knees half bent, and they scarcely seem able to
sustain their own weight. In other cases “the melancholy
induces a still more passive attitude; the arms hang loose at
the side, the hands are open, and the muscular system is re-
laxed altogether; at other times, grief intensifies the action of
the muscles; the patient's arms are rigidly flexed; the hands
clasped and pressed against his chest, or he wrings them in all
the bitterness of despair.”
In melancholia with stupor, the inspirations instead of being
full and regular, and accompanied by a regular rising of the
chest-walls and a clear vesicular murmur, lose their physiolog-
ical character. The thorax is hardly raised, and the vesicular
murmur is so weakened as to be hardly perceptible. In some
cases six or seven weak inspirations are followed by one stronger
one. In others the inspiration is jerky as if it were composed
of a number of secondary ones.
The inspirations not only lose their fulness, but become
much too slow for the number of pulse-beats. In a state of
MELANCHOLIA. 149
health there exists a certain proportion between the number of
pulsations and inspirations. If we examine the Stupid melan-
cholic, we find that the number of respirations is relatively
less than it should be, and consequently the blood is imper-
fectly oxygenated and the usual evil results follow.
“In melancholia the digestive functions are disturbed, the
appetite is poor, and the amount of food taken is small. The
patient eats slowly and requires constant urging; digestion
takes place slowly and assimilation is defective. Constipation
is generally complained of; this is due to the small quantity
of food taken, to the diminished secretions from the alimentary
canal, and to the weakened contractable power of the intestines.
This condition should be guarded against, for it is capable of
producing serious disturbances of the nervous system, halluci-
nation, etc.
“Melancholics complain,” observes Dr. Conolly, “when any
distinct complaint is made, of uneasy sensations in the epigas-
trium, in the left hypochondrium, or other parts of the abdo-
men; of a feeling of fluttering, drawing, gnawing, or tearing.
They even refer a sense of terror to the epigastrium, accompa-
nying a feeling of having done wrong, without knowing what.
These sensations sometimes alternate with uneasiness referred
to the forehead and occiput, or to the portion of the head
corresponding with the superior and lateral boundaries of the
occipital bone.”
For my notes upon the medical treatment of this as well as
the other forms of insanity I am largely indebted to the kind-
ness of Dr. Selden H. Talcott, Superintendent of the State
Homoeopathic Hospital for the Insane at Middletown, New
York, who has furnished me with some of the results obtained
at that institution.
Melancholia and mania, alternating as they do so frequently
in Some patients, often require similar remedies. It is not
the name of a disease nor, indeed, the supposed pathological
condition, which must always be a matter of uncertainty, but
the array and totality of the symptoms that indicates the
choice of a drug. Still for purposes of convenience we some-
times group under the name of a disease, certain drugs most
often of service in the cure of that disease.
150 INSANITY AND ITS TREATMENT.
Digitalis rises to prominence in this connection, not so much
by reason of the fame it has acquired in “the books,” but on
account of the effects following its use when homoeopathically
indicated. It is mostly of use when the patient is in a dull
lethargic condition; the pupils are dilated to their widest, yet
all sensibility to light or to touch seems lost; the pulse is full,
regular, or but slightly intermittent and very slow. The slow
pulse is the grand characteristic, and upon this indication
Digitalis may be given with much assurance that relief will
follow speedily, if relief be possible. We notice that the Digi-
talis patient, when rallying from his melancholic stupor, often
moans a good deal, and his eyes are all afloat in tears. Relief,
however, speedily follows the bursting of the lachrymal
fountains.
It has long been supposed and advocated that Aurum met.
was the princely remedy for suicidal melancholia. But the
experience at Middletown does not fully sustain this idea.
Dr. Talcott says: “Aurum has often been prescribed in such
cases, but usually without good results. Another remedy
which we have tried repeatedly has generally hit the case
most happily; and that remedy is Arsenicum. My mind has
been exercised in solving the mystery of Arsen.'s happy effect
in cases of suicidal tendency, while the much vaunted Aurum
has repeatedly failed. Our conclusion is this, the patients
whom Arsenicum has relieved have been those whose physi-
cal condition would warrant the administration of that drug.
They have been much emaciated; with wretched appetites; a
dry, red tongue; shrivelled skin; haggard and anxious in ap-
pearance, and evidently great bodily sufferers. It would
seem as if the mental unrest of these patients was due, in the
main, to physical disease, and consequent exhaustion, and
their desire to commit suicide is evidently for the purpose of
putting an end to their temporal distresses. On the other
hand the suicidal patients whom Aurum has seemed to benefit
are usually in fair health, physically; but have experienced
some unfortunate disaster of the affections, or have had trouble
with friends; they fancy they have been slighted, persecuted
and wronged, and out of revenge or disgust for the irksome
MELANCHOLIA. 151
trials of life seek an untimely end by their own hands. But
each drug has its own individual sphere beyond which it be-
comes a useless agent.” You will probably find in private
practice, as I have, that Aurum is more generally called for
than Dr. Talcott's remarks would indicate; but the Aurum
patient frequently escapes being sent to the hospital. I have
found Aurum very useful in cases of suicidal melancholy in
connection with the climacteric, especially when there is great
dislike to seeing men, and desire to be alone; also great irrita-
bility; all the symptoms aggravated at the full of the moon.
I remember one patient with the above symptoms who in-
variably at the period of full moon was strongly impelled to
throw herself out of the chamber window. Aurum completely
cured the case. Actea rac. or Cimicifuga should be kept in
mind in suicidal melancholy.
Aurum has as characteristics:
Disgust for life; suicidal tendency.
Melancholy: he imagines he is unfit for this world, and
longs for death, which he contemplates with delight.
Great anguish, increasing unto self-destruction, with spas-
modic contraction of abdomen.
Peevish and violent, the least contradiction excites his
wrath.
Religious mania; prays all the time.
Very apprehensive and fearful; a mere noise at the door
makes one afraid.
Loss of confidence in oneself.
When we see a patient suffering with melancholia, who is
constantly moaning and muttering to herself, walks all the
time, looking down; is disinclined to talk, and angry, if any
one speaks to her; tries to get away from her friends, if they
seek to comfort her: sleepless at night and uneasy during the
day, Chamomilla may be given with satisfactory results.
Natr. mur. affords relief to patients given to much cry-
ing, their continuous weeping being of the open kind, while
the grief of the Ignatia patient is more passive and concealed.
Natrum also has :
Difficulty of thinking; absence of mind; weakness of mem-
152 INSANITY AND ITS TREATMENT.
ory, and will-power; fondness for dwelling on unpleasant
trifles; is joyless, indifferent and taciturn.
Schüssler gives us for Natr. mur. : Sadness, with beating of
heart; avoids company, being too easily vexed; hates people
who had offended him ; wrathful; much disposed to weep;
hasty; shuns labor; sparing of words; much excited; and
after it numbness of limbs.
Bayes describes well the passive hypochondriasis of this
drug, when he says: “There is a sort of hopeless despairing feel-
ing about the future, accompanied by dryness of the mouth,
irritable mucous membrane, often with sore tongue and slight
ulceration, and almost invariably chronic constipation with
hard stools.”
Hering gives us: weariness in the head; vertigo, as if a cold
wind were blowing through the head; debility and emaciation.
The Pulsatilla case has the general appearance of the person
requiring that remedy: she weeps easily, but smiles through
her tears, and is readily pacified for the time being, but as
quickly relapses into the depths of sorrow when the words of
comfort cease.
The Cactus patient is sad and hypochondriacal, and has
frequent palpitations of the heart, with a corresponding pal-
pitation, so to speak, in the top of the head. Thuja will
benefit those patients who have a tenacious hold on One idea,
and indulge in the strangest and most unnatural fancies.
Such cases are quarrelsome and talkative, or very reticent;
won’t speak to nor look at a person, and manifest great dis-
gust if spoken to by others. Thuja also has the following im-
portant mental symptoms, some of which are frequently pres-
ent. The patient cannot think, talks slowly, as if hunting
for words, and uses the wrong words.
Fixed but mistaken ideas; as if a strange person was at his
side; as if soul and body were separated; as if made of glass;
as if a living animal were in the abdomen.
Extremely scrupulous about the least trifles.
Cannot bear to be approached or spoken to (like Chamom.).
Lilium tigr. and Sepia find important place in the treatment
of depressed and irritable females. The troubles of such cases
MELANCHOI,IA. 153
originate largely in the mal-performance of duty on the part
of the generative organs. Both Lilium and Sepia are full of
apprehensions, and manifest much anxiety for their own wel-
fare. In the Sepia case, however, there is likely to be found
more striking and serious changes of the uterine organs; while
the Lilium case presents either functional disturbances, or very
recent and comparatively superficial organic lesions. Lilium
is more applicable to acute cases of melancholia where the
uterus and ovaries are involved in moderate or subacute in-
flammation, and when the patient apprehends the presence of
a fatal disease, which does not in reality exist. The Lilium
patient is sensitive, hyperaesthetical, tending often to hysteria.
She quite readily and speedily recovers, much to her own sur-
prise, as well as that of her friends, who have been made to
feel by the patient that her case was hopeless. The Sepia
patient is sad, despairing, sometimes suicidal, and greatly
averse to work or exercise. There is, however, oftentimes, a
good reason for such a patient's depression, for too frequently
she is the victim of profound organic lesions which can, at
best, be cured only by long, patient and persistent endeavor.
The Lilium patient is more demonstrative and excitable than
is the Sepia case.
The following cases will illustrate the sphere of Arsen. alb.
in melancholia.
CASE 1.--Melancholy in an old lady, nearly seventy years
old, who had lost all love of life, and sat brooding for hours in
a corner; had no appetite; her tongue was heavily coated:
stool once in seven or eight days; entire sleeplessness. All
this came on after a scaly itchy eruption upon the head and
behind the ears had disappeared. Arsen. alb. high, brought
the eruption back and cured the case.
CASE 2.-Mr. B., artist, aet. 43. In ten years has had four
attacks, and during the last one was in an asylum five months.
Thinks himself guilty of every imaginable crime; worse at
night, with palpitation of heart; fears to be left alone, yet
must be kept in his room by force, despair of getting well,
cured by Arsen.”, a dose each evening.
Dr. Whiting, of Danvers, reports the case of a man who
10
154 INSANITY AND ITS TREATMENT.
“fears he will be impelled to destroy his life; with asthma,
so that he has to leave his bed from midnight until morning.
Arsen. One dose cured the case.”
Argent. nitr. is a remedy which is very important, especially
in cases with a taint of epilepsy; you will be led to study it
by the following symptoms:
Loss of memory; cannot find the right word, hence falters
in speech (similar to Thuja).
Dulness of the head, tendency to fall sideways.
Thinks about killing himself.
Indisposed to work; reserved; taciturn; easily frightened,
or angered.
Cimicifuga or Act. rac. is a remedy which has not as yet been
extensively used in melancholia, but when you meet patients,
especially at the climacteric period, who are desirous of being
alone, and dislike to talk; who like to sit by themselves and
weep, and declare that they will go crazy, you will find Cimi-
cif. a capital remedy. I alluded to it at another part of the
lecture as being of use in suicidal melancholy, and I have for
such cases given the lower dilutions such as the 2d or 3d dec.
Of course Ignatia will at once occur to the minds of you all
as being preeminently a remedy for melancholy. The follow-
ing case illustrates its action: “Melancholy after deep mortifi-
cation; heaviness of the head; very great weakness of the
memory; forgets everything except dreams; hardness of hear-
ing; sees everything as if through a fog; sits quietly, always
with a vacant gaze; thinking of the mortification endured
prevents him from going to sleep as early as usual; restless
sleep; starts during sleep from much dreaming; pain in the left
hypochondria, increased by pressure and continuous walking.
Loses his hair, face colorless, hollow; voice low and trembling
with distortion of the muscles of the face; does not like to
talk; no desire to eat or drink; appetite is very soon satisfied.
Always feels cold, especially in the evening. Very weak,
staggering walk; walks carefully. Increased stool and urine.
Ignatia cured. *
Ailments arising from grief, mortification, bad news, dis-
appointed love or jealousy often require Ignatia.
INDICATIONS OF REMEDIES. 155
Pulsatilla.-The following group of symptoms call for Pulsat.:
After mortification, sad, gloomy and weary of life. Often
pain in the forehead, earthy face, dark rings around the eyes;
bitter, sapid taste in the mouth; dislikes meat and bread; nau-
sea, with pain in stomach; occasionally bitter slimy vomiting;
frequent profuse nose-bleed; stitches in the side with cough-
ing, with frothy, bloody expectoration. Palpitation of the
heart; labored breathing, hard scanty stools; frequent cutting
pains in the bowels; heaviness of the legs; limbs feel bruised;
anxious dreams; thinks of drowning with great pleasure; is
sad; bursts into tears; dissatisfied with everything; easily en-
raged; reticent; very easily frightened; anxious, and weary
of life.
Indications for the use of Fourteen Remedies in the
Treatment of Insanity.
The following indications for a few of our most commonly
indicated remedies have been collated by William M. Butler,
M. D., First Assistant Physician of the State Homoeopathic
Asylum for the Insane, at Middletown, N. Y.
These indications are such as have been found reliable in
the treatment of the insane at that institution.
ACONITE.
Mind-Great fear of approaching death, of darkness, and
being alone; constant excessive anxiety; confusion of mind,
weakness of memory, unsteadiness of ideas, and disinclina-
tion for mental labor; variable humor, at one time gay, at
another sad; irascibility and fretfulness.
Head.—General heat of head, with a Sensation of fulness
and severe pain, especially in frontal region; face red and
swollen, or alternately red and pale; mouth dry and parched.
Sleep. —Sleeplessness or sleep disturbed by unpleasant
dreams.
Accompaniments—Oversensitive to noise, smells and light;
constant excessive thirst and loss of appetite; dysuria, or fre-
quent urination, urine hot and dark colored; oppression of
156 INSANITY AND ITS TREATMENT.
chest with difficult respiration; hot skin and full, rapid pulse,
often muscular pain and Soreness, with general tired feeling.
This remedy is chiefly useful in acute cases, where the
disease has been caused by over-heating, or some violent emo-
tion, as great fright, joy, or anger, and when, with the mental
symptoms, we find an exalted condition of the general circu-
lation.
. ARSENICUM.
Mind.--Excessive anguish, with irresistible desire to commit
suicide; great fear of sudden death, ghosts and thieves; hallu-
cinations of sight and hearing; hears voices, sees demons,
rats, mice, bugs and worms, from which he attempts to escape
by hiding; indisposition to mental or bodily work; ill-humor,
with great sensitiveness to insult, and disinclination to look
at anyone or answer questions; great mental anxiety and rest-
lessness. *
Head.—Great heaviness and weight, with a feeling of stupe-
faction in head, accompanied by a humming in ears; worse
in-doors; better in the open air; severe pains in the face and
head, especially in the left side; worse in the evening and at
night; relieved by warmth; face pale, yellow, cachectic, or
covered with a cold sweat, and expressive of intense mental
agony; great dryness of mouth and tongue.
Sleep.–Sleeplessness or fitful disturbed sleep; worse after
midnight, with disinclination to remain in bed.
Accompaniments.-Violent thirst with loss of appetite, and
burning pains in stomach and bowels, with inclination to
vomit; black, acrid, putrid stools, burning at the anus like
fire; involuntary micturition; suppression or scanty discharge,
burning during emission; oppression of the chest with diffi-
cult breathing and palpitation of the heart, especially when
lying down at night; excessive restlessness, with quick, weak,
irregular pulse, and general condition of exhaustion and pros-
tration.
Arsen., is one of our most valued remedies, and is especially
indicated where the insanity has been produced by, causes
which have greatly exhausted and debilitated the patient's
general condition, as from anxiety, overwork, loss of sleep, and
INDICATIONS OF REMEDIES. 157
a diseased condition of the mucous membranes generally, and
particularly of the stomach, thus preventing the proper di-
gestion and assimilation of food.
BELLADONNA.
Mind.--Furious delirium with great rage, biting, striking,
Spitting and tearing everything within reach; fear of dogs,
wolves, giants, fire, and horrid monsters filling the room;
foolish and obscene talking, laughing, dancing and gesticu-
lating; mirthfulness, with singing and laughing, or depres-
Sion with moaning, groaning and fear of immediate death;
anxiety, anguish, trembling and constant restlessness; cerebral
exaltation, or confusion of mind with loss of memory; stupid-
ity and loss of consciousness; excessive nervous excitability
of all the senses.
Head.-Intense digging, jerking pain, especially through the
forehead and temples, with vertigo, pressure, great heat and
violent throbbing of all the cerebral vessels; eyes congested,
swollen and protruded, pupils dilated, face extremely red and
Swollen, pains aggravated by stooping, noise, motion, mental
exertion, moving the eyes, shocks and open air; relieved by
rest, lying down, pressure and bending the head backward;
dryness of nose, mouth, tongue and throat, interfering with
Speech and deglutition; everything seems red, double, upside-
down or crooked.
Sleep.-Sleeplessness, or sleep disturbed by anxious, fright-
ful dreams, or frequent startings as in affright; drowsiness
with inability to fall asleep.
ACC0mpaniments.-Excessive thirst or aversion to all liquids;
pulse full, quick and much increased in force and frequency,
with red skin and increased temperature; excessive tender-
ness of the abdomen, which cannot bear the slightest touch;
violent pressing and urging towards the Sexual organs as
though everything would fall out there; worse on sitting bent
and walking, better on standing and sitting erect; menses too
soon, profuse, bright-red or thick, dark-colored and offensive;
badly smelling hemorrhage from the uterus.
In two forms of insanity Bellad. has proven itself preemi-
158 INSANITY AND ITS TREATMENT.
nently curative. Acute mania attended with great excite-
ment, violence and destructiveness, and accompanied by the
characteristic cerebral congestion, and in melancholia, where
the mind is extremely dull, stupid and slow to act, with great
heat of head, dilated pupils, congestion of the eyes, full pulse
and persistent sleeplessness. In the former chass of cases we
have found the 30th potency most effectual, while in the lat-
ter, frequently repeated doses of the 1st potency, or even the
tincture, have been necessary to achieve the desired result.
CALCAREA CARBONICA.
Mind.—Despondent and melanchobic; great anxiety and ap-
prehension of some misfortune or impending evil, as sickness,
insanity or immediate death; irritability and peevishness;
unsteadiness of ideas; anxious, then cheerful and pleased; kind
and calm, then angry and vehement, hopeful, then despond-
ing; weakness of memory with dulness and confusion of
mind.
Head.-Constant feeling of fulness in the head; pressure in
forehead extending down into nose; sticking pain in left side
of head, relieved by closing the eyes; coldness in and on the
head; ringing and roaring in ears; offensive Smell in nose;
white-coated tongue, with offensive or sour taste in mouth;
face pale, eyes deep-seated and surrounded by dark rings.
Sleep.–Sleepiness during day with difficulty of getting
asleep at night; sleep disturbed by dreams of dogs, fires, corpses
and death.
Accompaniments.-Ravenous hunger or loss of appetite; ab-
domen much distended ; oppression of chest with shortness of
breath and palpitation on going up the slightest ascent; gland-
ular swellings; menstruation too early ; leucorrhoea like milk;
great exhaustion, with loss of power on walking, and inability
to go up stairs; feet and hands cold ; night-sweat, and sweat
during day on slightest exertion; especially indicated in cases
of melancholia, in women of scrofulous diathesis and leuco-
phlegmatic temperament.
DIGITALIS.
Mind,-Great anxiety; depression and dread of the future,
INDICATIONS OF REMEDIES, 159
with sadness and weeping; worse about 6 P.M., and aggra-
wated by music; morose, irritable and gloomy; weakness of
memory; mind dull, stupid and confused.
Head.—Heavy and confused as if full; throbbing headache
in forehead or at bottom of the orbits; pupils dilated, red, yel-
low, green, black and white colors before the eyes; hissing and
roaring in the ears; face pale and sickly.
Sleep.-Sleep uneasy and unrefreshing; troubled by frequent
waking.
Accompaniments.-General appearance of weakness and ex-
haustion; appetite poor; respiration irregular and difficult;
pulse slow and weak, or slow and full, often intermitting with
sensation at times as if the heart stopped beating, accompanied
by great anxiety, faintness, sinking at the stomach, and gen-
eral coldness of skin and extremities.
This drug, although little known as a remedy in mental
disorder, is, in reality, of the greatest importance. It's chief
indication is a slow pulse. Whenever a case is found of men-
tal disease of whatever form, presenting this symptom, attended
by a general appearance of exhaustion and debility, a prompt
and satisfactory improvement is sure to follow the exhibition
of Digitalis.
H YOSCY AMU.S.
Mind.-Insensibility and loss of consciousness; does not recog-
nize those about him; great mental excitement with constant
foolish talking, laughing and singing, or rage with attempts to
strike and bite; sexual excitement with inclination to remove
the clothing and go about naked; obscene talking; jealousy;
great apprehensiveness; fear when alone, with fear of being
poisoned or bitten by animals.
Head.—Constricting stupefying headache in the upper part
of forehead; eyes red, wild, sparkling with dilated pupils; Ob-
jects look red or too large; face red and flushed or pale;
twitching of muscles of face.
Sleep.–Very deep sleep or sleeplessness.
Accompaniments.-Dryness of mouth, tongue and throat, with
difficulty of swallowing; micturition frequent and scanty, or
160 INSANITY AND ITS TREATMENT.
retention of urine, or involuntary urination; increased sexual
desire; general muscular twitching and jerking.
This remedy is most efficacious in mania of hysterical fe-
males, characterized by excessive talkativeness and inclination
to laugh and sing; or puerperal mania with sexual excite-
ment; in cases refusing to eat from fear of poison it seldom
fails to remove the delusion. Although frequently effectual
in reducing the sexual excitement of patients inclined to ex-
pose themselves, it seldom proves beneficial in masturbation,
and time spent in waiting for its action in such cases is simply
wasted.
LACHESIS.
Mind-Depression with a tendency to look constantly upon
the dark side; nightly fear of disease—death, robbers; mistrust
and suspicion with fear of being poisoned; peevish, irritable
and quarrelsome, with a disposition to find fault with others;
great mental activity with excessive loquacity, wandering con-
stantly from One subject to another, or confusion of mind;
weakness of memory and difficulty in listening to others
Head.—Pressure in the orbits with sensation of drawing from
the eyes to the Occiput; unilateral headache creeping gradually
toward the left side until it makes a complete circuit of the
head; unilateral, temporal pain—blue vision preceding head-
ache; worse after sleep; dimness of vision with black flicker-
ing before the eyes.
Sleep.–Wide awake, restless, and talkative at night, or rest-
less sleep with aggravation of symptoms on awaking.
Accompaniments.-Dryness of throat, sensitiveness of larynx
and throat; the slightest constriction from clothing producing
cough and a sensation of Suffocation ; great physical and men-
tal exhaustion, especially in morning.
Laches., although not as frequently demanded as many other
remedies, is, at times, useful in melancholic, hysterical females
near the climacteric, or in mania attended by excessive talk-
ativeness.'
LILIUM TIGRINUM
Mind-Depression of spirits; constant inclination to weep,
with fearfulness and apprehension of suffering from Some ter-
INDICATIONS OF REMEDIES. 161
rible internal disease already seated; fears of becoming insane;
Suicidal thoughts; irritable and impatient with an inclination
to profanity and obscurity; constant hurried feeling as of im-
perative duties, and utter inability to perform them, with
sexual excitement; disinclination to mental or bodily work
from inability to apply the mind steadily to any object.
Head.—Intense pain in both eyes extending backward into
head with dimness of sight; shooting pains in right temple,
passing to left; intense, blinding frontal headache from five to
seven o’clock P. M., then changing to occiput and extending
down neck, or pressing frontal pain with heat.
Sleep.–Sleeplessness or restless sleep.
Accompaniments.-Increased sexual desire; great bearing down
in uterine region with a sensation as if the whole pelvic con-
tents would issue through the vagina, if not prevented by up-
ward pressure of the hand on the vulva; severe pain in the left
ovary, running down ; thin, brown, acrid leucorrhoea; con-
stant pressure on rectum and bladder, causing frequent desire
to go to stool; frequent urination followed by Smarting and
burning in the urethra; sharp, sudden pain in the left chest ;
with sensation as if the heart was grasped, interrupting the
heart's action and respiration.
This remedy has no superior in hysteria with uterine dis-
placements, and marked ovarian irritation, complicated by
frequent neuralgic attacks of the left ovary.
NUX VOMICA.
Mind.—Obstinate, cross, irritable, ugly and quarrelsome; vio-
lent upon the least contradiction ; extraordinary anxiety and
restlessness; oversensitive to noise, music, singing, talking,
strong odors or light; obstinately taciturn, hypochondriacal,
inability for mental work.
Head.--Dull, pressive pain in forehead and above the eyes, as
if one had not slept enough; headache in the forehead as if the
eyes would be pressed out; headache worse after eating, fol-
lowed by violent stitches in left temple, with nausea and Sour
vomiting, disappearing in evening after lying down; sensation
as if the head were larger than the body; tongue coated white;
bitter or sour taste in morning, with offensive breath.
162 INSANITY AND ITS TREATMENT.
Sleep.-Sleepiness early in evening; wakefulness in the
middle of the night, followed by troubled sleep until late in
the morning; arising reluctantly, tired and unrefreshed.
ACC0mpaniments.-Ravenous hunger or loss of appetite; press-
ure in the stomach with constant nausea, and cutting pains
in abdomen, worse in the morning and after eating; constipa-
tion with much tenesmus, and frequent ineffectual attempts
at stool; retention of urine or dysuria; muscular twitching
and trembling; sensation of ants crawling upon the skin;
general increased sensibility.
This is one of the few remedies brought into constant use in
the treatment of insanity; it is especially adapted to individu-
als of sedentary habits; long subject to mental strain, and
“high-livers” suffering from chronic weakness of the digestive
Organs.
PLATINA.
Mind,-Arrogant and proud; everything and every person
seems small and inferior; patronizes or treats with contempt
all about her; considers none her equal, physically or mental-
ly; changeable, one day joyous, the next sad ; lachrymose,
fretful, morose and tired of life, but with great dread of death,
which she believes near at hand; peevish, anxious, sensitive,
excitable, absent-minded and forgetful.
Head.-Cramp-like, drawing constriction in the head from
time to time, especially about the forehead, commencing slight,
increasing until violent and ending slight; tense, numb sen-
sation in the zygomata and mastoid processes, as if the head
were screwed together; numb pain on top of vertex, as if a
heavy weight were lying on it; crawling-like formication on
the right temple, and down the lower jaw, with a feeling of
coldness in it; sensation in tongue as if burned.
Sleep.–Sleep disturbed by dreams.
Accompaniments.-Empty eructations, constipation and pres-
sure in lower abdomen; menses too early and profuse; blood
dark and clotted, with great sensitiveness of genitals; in-
creased sexual desire in females; numbness, coldness and
crawling sensation in different parts of the body.
Although not having as wide a sphere of action, or being as
INDICATIONS OF REMEDIES. 163
often indicated as many other remedies, Platina is still of great
importance in diseases of the brain. It is especially indicated
as an intercurrent remedy in hysterical females, afflicted with
melancholia, or possessed of delusions of greatness and grand-
eur occuring in connection with its characteristic menstrual
derangements.
SEPI.A.
Mind,-Nervous; sensitive to the least noise; sadness; wor-
rying about her health and the future, with frequent attacks
of weeping, worse in evening and in open air; fits of involun-
tary laughter or weeping; dread of being alone; very irrita-
ble; indifference towards those she loves best; indisposition
for mental work, with weak memory and difficulty in expres-
sing her ideas; indolent mood.
Head.—Pain shooting from forehead to vertex and both sides
of the face; drawing, tearing pains, sometimes stitches as of
needles in right side of head; severe pains in left temple, or
occasional dalting pains from left eye over left side of head
towards the occiput; worse in evening, better after meals; in-
tense frontal headache; pressive pain in vertex; yellowness
of whites of eyes; fiery sparks and black spots before the eyes;
yellow spots on the face and yellow saddle across the upper
part of the nose and cheeks.
Sleep.–Restless sleep, disturbed by anxious dreams, awaking
in a fright.
Accompaniments.-Weak, empty, gone feeling in stomach ;
frequent desire to urinate; urine thick, slimy, very offensive,
with yellowish or red sediment; prolapsus uteri, with great
bearing-down pains, as if all the pelvic contents would issue
through the vulva; dull, heavy pain in ovaries; profuse yel-
lowish or white, acrid, offensive leucorrhoea; tired pain in
small of the back, with great weariness, exhaustion and pros-
tration.
This remedy is chiefly indicated in the treatment of women
whose insanity has been caused by uterine displacements, and
whose general constitution has been sapped by a long stand-
ing debilitating leucorrhoea. Although not usually rapid in
164 INSANITY AND ITS TREATMENT.
its action, it is almost certain to restore to health the diseased
sexual organs, and with this restoration sound mental health
returns. f
STRAMONIUM.
Mind.—Fearful delusions of men, ghosts, dogs, cats, rabbits,
bugs and flies springing up around him, with violent en-
deavors to escape; worse in dark and when alone; imagines
that he has been killed, roasted, and is being eaten; that he
is very tall and large, surrounding objects seeming to him too
Small; hallucinations of hearing, music, dancing and voices;
mania, with constant incoherent talking, screaming, laughing
or crying; merry exaltation with pride and affectation, or
furious, almost uncontrollable, rage and violence, with desper-
ate attempts to bite, strike and injure those around; melan-
cholia, with crying, fear of death, and despair of salvation;
stupor and inability to recognize friends.
Head.—Sensation of lightness in head, headache in both
temples, shooting to occiput, with thirst; sticking, stabbing
pain in right temple; beating headache, particularly in ver-
tex, with fainting fits; headache on waking in morning; face
red and swollen, eyes wild and staring, pupils dilated and in-
sensible to light; lips tremulous; tongue immovable or pro-
truded with difficulty; inability to swallow, or swallowing
with difficulty.
Sleep.–Drowsiness, with deep, heavy sleep; sleeplessness or
sleep disturbed by frightful dreams.
ACC0mpaniments.--Suppression, retention or involuntary pas-
Sage of urine; increased sexual desire; trembling or convulsive
twitching of limbs; oversensitiveness to noise.
The therapeutic sphere of Stramon., from its symptomatol-
ogy and the writings of various authors, we suppose to be in
acute mania, characterized by more intense excitement than
Hyosc. or Bellad., and with less cerebral congestion. From
the wonderful curative effects assigned to it, we had expected
to achieve some marked results, but thus far we have been
doomed to disappointment. After many trials, with apparently
clear indications for its use, we are forced to admit that we
have seen but few positive results from this drug.
INDICATIONS OF REMEDIES. 165
SULPHUR.
Mind–Melancholia, with disposition to weep, wishes to die,
but fears for her salvation; inclined to dwell upon religious
things; apprehensive of future misfortune; variable mood,
one moment crying, the next laughing; indisposition to men-
tal or physical labor, with slowness of mind and body; great
absence of mind and forgetfulness; peevish and irritable;
dresses herself in rags and imagines that she is beautifully
clothed.
Head.—Constant heat in top of head; shooting pains in fore-
head and temples from within outward; worse from eating or
stooping, better when pressing the head and when moving;
pressing, dull pain in vertex and sinciput rousing from sleep
early in morning, ceasing before noon.
Sleep.-Drowsiness during day and wakefulness at night;
unrefreshing sleep, disturbed by frightful dreams.
ACC0mpaniments.-Faint, weak sensation in stomach about
11 A.M.; much thirst with little appetite; constipation with
hemorrhoids, or tendency to early morning diarrhoea; burn-
ing in vagina; menses too early and profuse and lasting too
long, with flushes of heat and weak, faint spells; feet cold Or.
burning in soles of feet; skin covered with pimples, burning
and itching, easily ulcerating after scratching; sensation of
insects crawling on skin of face, with itching increased by
heat of bed; sensation of something running from chest to
throat, causing a feeling of choking in throat; frequent general
flashes of heat, with faintness.
Sulphur is exceedingly useful as an intercurrent remedy in
many chronic cases where the psoric element predominates.
It is also frequently useful as a developer, bringing out symp-
toms at first hidden and unapparent, or reviving the sus-
pended action of an indicated drug, causing the patient to go
on to a rapid recovery. It seldom effects a cure unaided by
other drugs.
VERATRUM ALBUM.
Mind.-Melancholia, with anxiety, as if she had committed
an evil deed; sadness, despondency and grief, with involun-
166 INSANITY AND ITS TREATMENT.
tary weeping and despair of her salvation; fearful and appre-
hensive of misfortune; mind dull and stupid with obstinate
taciturnity; delusions, of being a prince, a hunter; of being
deaf and blind, pregnant and in labor; violence, with incli-
nation to tear and cut everything; much lascivious and profane
talk; noisy; wants to escape; can scarcely be held.
Head.-Paroxysms of pain in various parts of the head;
frontal headache with nausea, vomiting and fever; pressive
pain in the top of head; cold spot on vertex; face pale; eyes
fixed and sunken, with blue or green circles around them;
nose cold and pointed; cold sweat on face and forehead.
Sleep-Sleeplessness or sleep disturbed by bad dreams.
ACC0mpaniments. – Great thirst for cold drinks; ravenous
hunger or loss of appetite; frequent inclination to nausea and
vomiting; constipation or exhaustive diarrhoea; excessive
Weakness and sudden sinking of strength; skin blue and cold;
pulse frequent small and weak, often intermittent, at times
almost imperceptible; defective circulation with general ap-
pearance of lowered vitality.
This remedy has a wide range of action in mental disease.
Its reputed efficaciousness in puerperal mania we have not
had sufficient opportunity of verifying, but its effects in mania
and melancholia with stupor have been most gratifying. It
is especially efficacious in the apparently most hopeless cases,
where the patient sits in a stupid manner, with the head bent
forward, taking no apparent notice of anything, answering in
monosyllables, or not at all; often eating nothing, unless fed;
skin cold and blue; pulse weak and intermitting. With the
foregoing symptoms we have occasional fainting spells, with
temporary unconsciousness and suspension of the heart's
action. Under the influence of Veratr. the depressed vital
powers are soon revived, and the patient advances to a com-
plete recovery. After a seeming recovery, the patient is liable
to a relapse, if the medicine is too soon discontinued, but when
once the cure is fully accomplished it remains permanent.
MANIA. 167
LECTURE IX.
Mania.
The condition of mental disturbance which goes by the
name of mania is almost always consecutive to a more or less
marked degree of melancholia. The transition may be gradual
or rapid, well defined or uncertain, and it is often difficult to
say at what particular moment one state ends and the other
begins. The opinion is becoming prevalent that melancholia
and mania are simply different stages of one disease.
Griesinger quotes Guislain as follows in speaking of melan-
cholia: “These transitions and transpositions are not made
suddenly; the patients pass from one to another by innumer-
able intermediate degrees, which present so to speak, all the
states of admixture in a thousand different ways. Hence one
must conclude that all these groups of symptoms, out of which
one has striven to make several diseases, form different degrees
of the self-same morbid state, and that which proves it is, that
in an accession of mania which manifests itself in a melan-
cholic patient, one observes in succession the greater part of
the phenomena indicated.”
Neumann in his work discards melancholia from his classi-
fication of diseases on the following ground: “It is unscientific,”
he says, “to talk of one morbid action complicating another,
or that the concrete case is due to other than a single morbid
process; for instance to call the pericarditis of rheumatism a
complication or a metastasis of a morbid process, and not a
single morbid phenomenon resulting from the original and
single process is unscientific. Therefore to speak of a case of
insanity commencing by one species of mental disease, devel-
oping itself into a second and finally terminating by becoming
a third is simply absurd.” Hence we should simply consider
these as all stages of one and the same disease, and further-
more, besides the difficulty of separating one stage from the
other, there are many cases which by some physicians would
168 INSANITY AND ITS TREATMENT.
be designated melancholia, and by others mania, while in
Some cases the two forms alternate.
We first present a case reported by Dr. Sankey, which shows
how mania and melancholia may blend in the same person.
CASE: A young woman left her place telling her parents
she was going to be married. She went, however, to cohabit
with a man, and shortly afterward became melancholy and
went to her father who took her in; she would then, he re-
ported, sit and cry for hours. She had been at home a month,
when she broke a window; said that the devil and witches
came to tempt her, and to get her into hell. She also attacked
her parents. She was taken to a hospital, and the following is
the patient's condition while there as given by the medical
officer: She is generally taciturn, or answers with an hysteric
laugh. This morning she seized the nurse by the hair, and
said she “could read her, she was a devil, and she would dash
her brains out.” On admission the expression of the counte-
nance was vacant and dull. She was indisposed to speak; she
was rude in her conduct and in her mode of answering, and
she struck one or two of the patients.
Thus an ordinary attack of insanity, beginning with perhaps
only a trace of melancholia, may terminate by becoming a case
of mania; or may continue partly melancholia, but mixed
with maniacal symptoms; or the case may throughout exhibit
depression and terminate in chronic mental disease with some
permanent mental defect, such as a fixed delusion, an altera-
tion or eccentricity of habit, and pass into mental imbecility.
In this chapter we will consider those cases in which the
depression of spirits is quite transient, and the opposite condi-
tion or elation of mind is the predominating feature, which
assemblage of symptoms makes up what is usually known as
mania.
The word mania is derived from the Greek flatwomat, to be fu-
rious; but other writers refer it to the word pºv, the moon,
whence the Greek, maniac, moonstruck, and the Latin, lunatic.
The symptoms of maniacal insanity are connected with the
emotions, the intellect and the motor functions. The emotions
are, as already stated, painfully affected in the premonitory or
MANIA. 169
melancholic stage of mania; this depression is of variable
duration. Occasionally there are cases, as Esquirol has ob-
served, in which persons “sink into a deep stupor, appearing
to be deprived of every thought and idea. They do not move,
but remain where they are placed, and require dressing and
feeding. The features of the face are contracted, and the eyes
red and glistening. Suddenly, mania bursts forth in all the
strength of its delirium and agitation.”
At other times this period of incubation is scarcely observed
by the patient's friends, or, at all events, it is not voluntarily
acknowledged by them when questioned as to the onset of the
attack. It escapes their notice for several reasons. In the
first place, the melancholic cloud that passes over the patient's
mind does not materially differ from the natural depression of
spirits in sane minds; and second, in the first stage of all cases
of mental disease, the intellect proper, the reason, judgment,
etc., remain comparatively unimpaired, so that the friends
see no sign of mental disease, until some very striking out-
break of violence or departure from rational conduct ensues;
then this very outbreak at once eclipses all foregone impres-
sions, so that on examining a case you have to inquire closely
as to the first or premonitory symptoms, especially as in many
cases, the melancholic stage will have passed ere medical aid
is sought and you see the patient.
Esquirol and Bucknill assert that what is ordinarily under-
stood as fury is not identical with mania. “If maniacs are
more frequently furious than other insane persons, it must be
attributed to their temperament, their extreme susceptibility,
and the exaltation of all their faculties; circumstances which
render them exceedingly impressible, and consequently very
irritable and choleric.” “All that can be said is, that one or
more of the passions is almost always exalted in mania, and
that a furious condition, although not constituting an essen-
tial symptom, is very generally present in the acute form. It
is essentially a disorder of the impulses or propensities; al-
though in the vast majority of instances the purely intellectual
functions are more or less disturbed.”
With respect to the emotional symptoms, there is often a
11
170 INSANITY AND ITS TREATMENT.
strange mixture of hilarity, depression, excitement and grief;
the instinctive feelings and sense of propriety and of personal
cleanliness are impaired or lost; the patient appears at times
indifferent to the most disgusting objects; some become filthy
in the extreme, pass their feces in the bed, or room, and be-
smear themselves from head to foot, and this seems almost a
characteristic of the disease it is so common. They will eat
dirt, filth, and the most disgusting substances; they are to-
tally unmindful of decency, not apparently with any lewd in-
tent, but from an apparent loss of the normal feelings on this
subject. And it would seem that the more refined and deli-
cate the women were when sane, so much the deeper do they
sink in vileness and obscenity of speech and conduct when
insane.
The delirium in mania has much of the character of frolic
and boisterous excitement; there is not in the acute stage the
scowling of the resentful madman, but rather a violence of
muscular, motor irritability. Maniacal patients are not neces-
sarily irascible; they run, jump, throw themselves down, beat
their heads against the wall, break or jump through doors
and windows, shout, scream and swear, whistle and sing, and
consequently are almost always hoarse; they tear off their
clothes, and go about in a condition of disorder, their shoes
off, stockings down and hair dishevelled.
As a rule such patients retain a remembrance of what
transpires during such attacks, except when they are consecu-
tive to, and form part of, an epileptic paroxysm, in which case
the acts of violence seem accomplished in a blind and auto-
matic fashion. g
Incoherence is one of the most notable symptoms in mania,
and it may be present to a varying extent. The ideas chase
and follow each other rapidly and in great disorder. The
maniac may answer a question correctly, but in a moment
will ramble again from the point, and speech is so rapid and
rambling that it is often very difficult to ascertain the pres-
ence of delusion. They cannot be made to attend long to
the questions asked. We have to deal with an over-excitable
state of the mind rather than one of intellectual weakness;
MANIA, 171
an impossibility of ruling and moderating the rush of ideas
coursing through the brain. These mental manifestations
seem less the result of true delusion, than of delirium or a
state of general excitement. The ideas follow each other in
too quick succession; you will not be struck by their elo-
quence or depth of thought, the expressions are more like a
confused medley, and seem uncontrolled and uncontrollable.
It is true, as Dr. Dickson says, that “the lesion of attention
is not necessarily attended with a loss. The maniac in his
raving often seems to pay no attention, and yet is observant
of everything, and will, after the excitement has passed away,
repeat all that has been said in his presence. The popular
notion that a maniac is incapable of understanding what is
Said to him, or that he is incapable of giving a rational an-
swer, is not in accordance with fact; neither is it a fact, as is
popularly supposed, that he is a dangerous being, who can only
be restrained by bars and bonds and locks.”
Delusions are frequently, but not always met with ; halluci-
nations and illusions are more frequent than in any other
form of insanity, and those affecting the senses of sight and
hearing are the most common. “In acute mania, patients
See the Deity, angels and devils; hear music and voices, and
have a hundred hallucinations of the same sort, far more fre-
quently than in other forms of insanity.”
Headache is not often complained of in the acute stage, and
there is seldom, as a rule, any appearance of paralysis, stra-
bismus or convulsion. The pupils usually are equal, but may
be contracted, or less frequently, dilated; there is photopho-
bia and intolerance of noise in some cases.
Sleeplessness is a prominent symptom in acute mania; this
may be very persistent, the patient seeming to go without
sleep for weeks at a time; and in Some cases you will meet
with increased excitement and boisterousness at night. In
Some cases instead of complete wakefulness we may have
troubled sleep, together with unpleasant and wearisome
dreams. Too much ought not to be expected from a calm
sleep during the course of the disease, as the most violent ex-
acerbations occasionally ensue after the quietest nights, and,
172 INSANITY AND ITS TREATMENT.
on the other hand, even convalescents frequently continue for
a long time to complain of sleeplessness. This sleeplessness
is one of the most difficult symptoms for the feigner to suc-
cessfully imitate, as the violence of his physical efforts must
soon produce exhaustion, and the would-be-insane man rests
and sleeps.
Maudsley says: “Considering the great and continued agi-
tation, mental and bodily, and the loss of sleep in acute in-
sanity, the bodily functions are very little affected. In the
early stage, when there is, perhaps, some febrile disturbance,
the pulse may be a little quicker, but it is afterwards scarcely
accelerated. The temperature of the body is slightly, if at
all, increased in ordinary cases; but in cases of a typhoid
type, when there is sleeplessness, restlessness, gradual wast-
ing, and when the tendency is to death from gradual exhaus-
tion, it may be raised from three to five degrees above the
natural standard. When the temperature rises notably in a
case of insanity, we may then justly suspect an attack of some
other disease, or a tendency to fatal exhaustion; in either
case the prognosis is serious.”
In some cases the facial expression gives us a clue to the
form of derangement, as well as the class of mental thought.
In many instances the physiognomical expressions seem simi-
lar to those in the Sane only intensified, again, there may be
an incongruity between the expression of the different parts
of the face, or there may be a ceaseless and apparently motive-
less play of feature. In melancholia the face indexes the de-
pressed emotions of the mind pretty accurately; while in
mania the extravagance of ideas, the mixture of grief, grati-
tude and resentment alternate and change so quickly that
there is no one fixed characteristic expression. “In dementia
all expression has disappeared, the vacant stare and the
meaningless lineaments indicating the loss of thought and
desire, while in the face of the general paralytic,+the trem-
bling lips, the drooping brows, the features expressive of a
mixed state of imbecility and excitement, the eyes with pupils
of unequal size, together afford to the experienced alienist,
unquestionable testimony of the existence of the most hopeless
of maladies.”
MANIA. 173
The acute form of mania generally terminates in from three
to six months; but many cases run on from one to two or
three years and then recover. When the disease has passed
its third month and the melancholic symptoms have set in,
the access of a maniacal paroxysm is considered favorable
rather than otherwise.
When the case progresses favorably, the symptoms disappear
gradually, there is a return to a more natural expression of
the face, and an inclination to more orderly habits in dress
and conduct. Often at the same time the patient gains in
flesh, and he begins to acknowledge his past insane condition.
It is generally considered unfavorable if the patient's bodily
health and strength improve without a corresponding gain in
mental health. In all cases gradual improvement will afford
stronger ground for hoping that the recovery will be per-
manent, than if the change occurs rapidly or in a few days,
especially if the attack has first lasted some little time.
The profound change in all faculties of the mind in mania
can commence by an acute paroxysm, which is the least dan-
gerous form, and the most easily cured; or it may take a
chronic course from the beginning.
Esquirol, whose masterly descriptions are still taken as
models, gives the following description of the mental phenom-
ena in acute mania: “What a change,” says he, “has taken
place in that man, who only this morning submitted to his
calculations the laws regulating the universe; who, by his wise
combinations, opened to his country new sources of prosperity;
who, by his genius, enriched the arts with so many master-
pieces; who, in the generosity of his heart, breathed only good
will to all his fellow men. Suddenly, regardless of all that
surrounds him, ignoring himself even, this same man lives
but in mental chaos. His distempered and threatening words
betray the trouble of his mind, his actions are mischievous, he
wishes to overthrow all, to destroy all; he is at war with all
the world, and now hates what he had lately loved. To so
deplorable a condition, if he does not recover, there succeeds a
calm a thousand times more grievous. The maniac falls into
a condition of apathetic thoughtlessness; there is no more
174 INSANITY AND ITS TREATMENT,
strife of mind, no more threatenings, all memory is lost, all
has become confused and gone in dementia, the true tomb of
the human mind; the unfortunate man becomes an object of
pity and disgust to his fellows, who in his deplorable condition
no longer recognize him as a man, since its distinguishing
feature ‘reason’ is lost; he drags out a stupid existence the rest
of his natural life, without desires, or regrets until released by
death.”
His intellectual faculties have been struck powerless; his
mind has not even power to create and follow out a delirious
idea; he cannot bind together his thoughts sufficiently to rea-
son and hardly even to imagine. Sometimes acute mania
manifests itself by the following changes in the mental facul-
ties. The cerebral excitement is shown on the instinctive side
by an ambitious, generous delirium, by impatience, by anger
and petulance about trifles, and even without cause. On the
reflective side it is shown by an unaccustomed activity of
thought, producing brief, incomplete, disconnected ideas; wild
and whirling words; various projects begun and abandoned;
by a confusion of incoherent ideas having no possible relation
one to the other; and finally, by a craving for movement and
a nervous restlessness, putting into motion the whole muscular
system, preventing the patient from remaining still; this state
of things would indicate an excitement in the automatic nerv-
ous centres equal to that existing in the brain.
Similar disturbances in the two orders of mental faculties are
also to be observed in the chronic mania. I will again
quote the words of Esquirol, who says: “Chronic mania is a
chronic cerebral affection, usually without fever, characterized
by disturbance and exaltation of the sensibility, of the intellect
and of the will. Maniacs are remarkable by reason of their
hallucinations and illusions; by the strange and vicious jux-
taposition of their ideas which occur without any logical
sequence, but with extreme rapidity. They are remarkable for
their errors of judgment, the change in their affections, and
the impetuous violence of their temper. This class of persons
have a very great nervous excitement, their delirium is gen-
eral, all the intellectual faculties are overturned or exalted,
MANIA. 175
anything which attracts their attention, either moral or physi-
cal, excites them and becomes a centre for their delirious ideas.
In melancholia and monomania, the symptoms are the expres-
sion of the perversion or disturbance of the emotions or affec-
tive faculties, while in mania they are symptomatic and signifi-
cant of the overthrow of the intellectual powers.”
In a course of lectures delivered before King's College, Lon-
don, Dr. Sheppard, one of the Medical Superintendents of the
great asylum at Colney Hatch, relates a case from his private
practice which is so typical and interesting that I transcribe it
entire. He says: “I was sent for one morning to see a young
lady, who was described to me as excessively violent and un-
manageable, and I was requested to visit her immediately.
She was a handsome, well-made brunette, nineteen years of
age, and had always enjoyed good health until attacked by
scarlet fever, from which she had recently recovered. She was
happy in her domestic relations, and was engaged to be mar-
ried to a gentleman who was in the house at the time of my
visit. There was no insanity in the family. Two days pre-
viously this damsel had suddenly and without any obvious
cause displayed a petulance and irritability towards her father
and mother, and absolute rudeness and indifference to her
betrothed. She was heard to talk in the bed-room that night,
long after the family had gone to rest, and in the morning it
was pretty obvious from her appearance that she had had no
sleep. Her countenance was flushed, she was in a state of con-
siderable excitement, and she refused to leave her room. Med-
ical assistance was sent for, and two local practitioners were
charged with the responsibility of her treatment. But she
would not be treated, she refused to take their medicine or
their advice, and she spat in their faces when they went near
her. As night approached she became more excited, and she
would allow no one to approach her. They had a terrible
night with her, she tore up and down the room in her night
dress, smashed everything she could lay her hands on, spat at
everybody, made use of the most disgusting language, exposed
her person, and threw out her arms as though to clutch imagi-
nary objects. She took a singular dislike to one of the medical
176 INSANITY AND ITS TREATMENT.
gentlemen, and he really became quite frightened at her and
left the house. It was on the morning of the next day that I
saw her. I shall never forget the look of utter dismay and
bewilderment upon the countenances of everybody as I en-
tered the house. They were baffled in all their attempts to
meet the emergencies of the case, and even the medical man
was on his beam-ends. As I ascended the staircase I heard
vehement declarations and shouts, associated with as obscene
language as the nastiest mind could desire. The bed-room was
strewn with different articles; one of the windows had several
panes broken; a glass which was fastened to the wall over the
mantle-piece was also broken; the whole place was a Babel of
confusion. Wild and flushed, the central figure, this young,
mad, and imperious lady, with dishevelled hair, torn night-
dress, and exposed bosom, sat up in the middle of the bed.
“Who are you ?” she screamed, drawing herself up with a
threatening aspect, “Leave my room instantly, how daré you
come into my bed-room?” I approached her and endeavored
to take her hand; but, spitting at me, she sprang out of bed
on the opposite side to that on which I stood, and threatened
to burn down the house if I did not leave. Fierce as a lioness
at bay, she stood there, with dilated nostrils and heaving
breast, the incarnation of ungovernable passion. The friends
around were anxiously watching me to know what I was
about to do and how I was going to free them from
their terrible bondage. “That will do,” I said, “let us go
down stairs again,” and the patient, without speaking an-
other word, kept her piercing eyes upon me until I had
retreated. When we reached the dining-room, all looked
very much astonished, and were evidently thinking I was
as much baffled as themselves, But I had seen all I
wanted to see upstairs; a glance, and the history narrated to
me on my way to the house, had told me what the case was,
and what was needed, My continued presence in the bed-
room could only be a source of increased irritation to the
patient, and the Sooner I left her therefore, the better, in order
to organize my plans and arrangements. First I selected an-
other bed-room, and completely dismantled it of all furniture,
MANIA. 177
except the bedstead itself, which had no canopy or hangings.
A bath-room was close by, and I turned on the cold water, and
threw a sheet into it, and sent for all the blankets that could
be found. I laid a mackintosh upon the mattress, and over
that, after wringing"it out, I spread the sheet which had been
immersed in the bath. My proposal was to pack the young
lady. Returning to her bed-room, with my medical colleague,
one of her brothers, a nurse, and three female servants, we
seized and carried her forcibly, and with great difficulty on to
the bed where the wet sheet was spread out for us. After
much labor, we managed to straighten her limbs, and get the
sheet thoroughly round her, followed by about ten or twelve
blankets; we then placed a pillow under her head and a wet
towel on her forehead. For half an hour I never worked
harder in my life. But there she lay at last powerless and
baffled. It was a great triumph and she knew it, and the
sense of defeat helped to tame her and tone her down to com-
parative calm. Now in a case of this kind the wet sheet
serves a double purpose. It is a powerful depressor and Sudo-
rific, and it is at the same time a very legitimate means of
restraint. It lowers the abnormal elevation of temperature, it
converts a dry and harsh skin into a moist one, and it places
your patient in a position to submit to further processes. It
relieves everyone; it gives you breathing time, and enables
you to look about and to plan. It should be mentioned that
the room had one window with shutters, which we nearly
closed, for darkness is a material aid in quieting maniacal
fury. In about five minutes after our patient had been
packed she asked for water, and it was given to her iced; she
gulped it down eagerly, but refused to take anything with it,
and in ten minutes afterward she was sleeping calmly. As a
rule it is not desirable to keep a person in a wet sheet more
than an hour or an hour and a half, but in this case I felt
justified in doing so. At the end of two hours I awoke and
unpacked our patient. She steamed again as we unwrapped
the ponderous coverings, and I then instructed the females
about her to carry her in the adjoining bath-room, and there
place her in an open bath which I had prepared at a tem-
178 INSANITY AND ITS TREATMENT.
perature of 75°. She was quite passive under it, and after
being rubbed dry with rough towels, she was carried back to
the room last used, where, in a clean night-dress and clean
sheets, she lay down quietly in charge of the nurse and one
female servant. It was now about three P.M. She refused
nourishment and immediately fell asleep again, not waking
until eight o'clock. She then took a glass of pale ale, some
milk and beef-tea with two eggs beaten into it, and seemed as
calm as she had ever been in her life, and remained so. She
had no bad symptoms afterward. In three months she was
married. She has borne children, and the puerperal state has
been free from all complications.”
“Miss M., aet. 16, after suffering several weeks with melan-
cholia, suddenly developed acute mania. After some allo-
pathic treatment she had paroxysms of frenzy. Eyes red,
protruding and ghastly; hair dishevelled and wild demeanor;
talking and singing alternately; hands, feet and head alter-
nately hot and cold; tongue much coated; bowels constipated,
and appetite capricious. Gelsem. in drop doses every hour,
cured in less than three weeks.” (Dr. C. P. Hart. A. H. Observer.
September 1873.)
Dr. Bullard gives the following well reported case: “Woman
aet. 24; unmarried. Three years ago, after apparent perfect
health, was taken suddenly with violent pains through her
breast like knife thrusts; followed after a few days by a raging
fever, during which she commenced imagining all sorts of
queer things. In two weeks the fever left her, but not the
imaginings. Great fear was now prominent; afraid to eat, to
sleep, and of everything; became greatly emaciated, was re-
duced from one hundred and forty pounds to ninety. Her
bodily health began to improve, but she now became very
violent, breaking everything she could lay her hands upon.
She would bite and pinch, would swear and use the most in-
decent language; would laugh in a peculiar maniacal manner,
the laugh ending in a half howl. Her eyes had a never ceas-
ing rolling motion, and her face that look of stealthy cunning
of the insane. Would sometimes stop in the middle of some
mad freak, and would say with a scream, “I know I am doing
MANIA. 179
wrong, I can’t help it, etc.,” and perhaps in a few minutes
would be more violent than ever. Had menstruated at twelve,
and had been regular up to the time of her sickness; had al-
ways been modest and retiring in disposition and a great stu-
dent. There was no inherited taint of insanity. When I
first saw her she was very reticent, and upon my approach re-
tired; had not menstruated for eleven months; bowels were
constipated and she was passing but little water; very restless
at night, seemed to be always awake; appetite varied; no
thirst; had been less violent of late and very moody. Com-
plained of no pain but was weaker than usual. B. Nux wom.
in water. One week afterward she wanted to sleep all the
time, and in fact it was difficult to arouse her from her stupor.
For this and because her body was covered with a cold clammy
Sweat, and she was troubled with an offensive diarrhoea, I
gave her Secale. Two days afterwards she had a profuse dis-
charge from the womb of thick black putrid substance, look-
ing like disintegrated liver, and very offensive. The bloated
abdomen had assumed its natural size, and she awoke from
her stupor appearing better than for a year. She continued
to improve rapidly, and the symptoms changing somewhat,
received Hyoscyamus and became entirely cured.”
The following case of subacute mania, with delusion with-
out violence, is from the records of the Homoeopathic Hospital
at Middletown, N. Y.
“CASE-T. E., male; married; aet. 33; blacksmith by occu-
pation; admitted August 26th, 1878. This was his first attack,
beginning nine months ago; he had worked day and night
Over a patent, and began to have delusions that people were
after him, and he had threatened to shoot them in self-defence.
“August 27th.-Pulse 84, and very weak. Patient very
anaemic and white. Speaks in a hoarse whisper. Has infil-
trated apices of both lungs, and slight mitral insufficiency.
Also chronic inflammation and ulceration of larynx and vocal
cords. Says that he had very bad whooping-cough in the
summer. B. Lycopodium.
“August 28th.-While talking about his family cried some,
and lamented his inability to support them. Mentally has no
180 INSANITY AND ITS TREATMENT.
bad symptoms. Was ordered milk diet, and to be out doors
as much as possible.
“During the month of September he was troubled with
dyspnoea, night-sweats and neuralgia, but gradually improved
So that by October 24th he was out daily on parole.
“November 26th, his delusions had entirely disappeared,
and he seemed stronger both bodily and mentally and was
discharged cured.”
The following case of subacute mania will serve to show the
relations existing between uterine disease and mental derange-
nment.
“Mrs. R., aet. 45, married at sixteen; five children; having
been in ill health for some time came under my care in the
hospital for subacute mania. She was under the delusion that
she was bewitched, and had killed some witches. Said her womb
was turned upside down and inside out. Was menorrhagic,
pale, feeble and anaemic. She believed herself constantly
pregnant with twins, and insisted that they were spirited away
from time to time. It was necessary to restrain her to prevent
self-abuse, to which habit she was addicted. Had incontinence
of urine. During the period of her residence here, her delu-
sions were at all times the same, and were referred to the
generative organs. Previous to admission she had been treated
for prolapsus uteri, but there was no suspicion of any cancerous
disease. The disease slowly progressed, and after a residence
of eighteen months she died. Upon post-mortem examination,
beside other grave lesions, the os and cervix uteri were found
nearly destroyed by scirrhus, and a portion of the body was in
a softened state.”
Not unfrequently you will meet with cases where all the
delusions will be referred to the stomach and digestive organs,
and the patient will declare that the sufferings he experiences
are penalties inflicted by God for the violation of some spiritual
law, while a post-mortem examination will show inflammation,
Scirrhus or some other disease.
Leaving at one side mania transitoria, in some exceptional
cases recovery from mania may be rapid, as shown in the
following case reported by Dr. W. H. De Witt of the asylum
at Longview, Ohio.
MANIA. 181
“Mrs. K., admitted May 5th, 1875; native of Germany; aged
38 years; married; occupation housekeeping; second attack;
duration two months; length of previous attack unknown.
“Patient has not been addicted to the use of alcoholic stimu-
lants; she has not received any injury to her head, and has
not been subject to epilepsy. The disease is supposed by friends
to be hereditary.
“Medical certificate states that the patient had both delusions
and hallucinations, described as follows, thinks that some one
is about to kill her, or that she must kill some one to atone for
sins she has committed. Hears imaginary voices talking
about her.
“On admission she presented the following symptoms: Was
much emaciated, anaemic and extremely feeble, had an ex-
tremely haggard look; temperature about normal; circula-
tion feeble; pulse small and frequent ; tongue dry and covered
with dark coating; breath very offensive. Her conversation
was variable, at times for a few moments she would converse
with a certain degree of rationality. This apparent rationality
was, however, soon succeeded by disconnected incoherences
and delusionary utterances; she imagined that she was to be
tortured or killed by those around her, and seemed impressed
with the belief that she must kill others to atone for sins; she
was exceedingly restless, never violent and noisy. Patient
slept but little the night following her admission; took but
little nourishment, believed the food to be poisoned, continued
incoherent and delusionary, and exhibited some suicidal ten-
dencies. On the third day after she began to show marked
evidences of returning reason, and conversed with a good deal
of earnestness and rationality; her improvement from this
time forward was remarkably rapid. Ten days from the date
of admission she exhibited no indications whatever of mutual
derangement. Her general health had also improved; she
was discharged on the 27th of the month as cured; I have
every reason to believe she is doing well.”
The three following cases of mania are reported from the
case-book of the Homoeopathic Asylum at Middletown. The
literature of the homoeopathic treatment of the insane is so
182 INSANITY AND ITS TREATMENT.
limited, that I feel that no apology is needed for laying before
you anything and everything which may aid us in selecting
the true remedy in a case of insanity.
CASE 1.-Female; nineteen years of age; single; Methodist;
academic education; admitted April 19th, 1875, in a very ex-
cited condition, having slept only four and one-half hours in
four nights.
20th.-Much excited; head hot; pupils dilated; talks in-
collerently on all sorts of topics; last night would not eat; was
sleeved, fed, and received Bellad."; slept nine hours; this morn-
ing looks much better; has passed water; still has to be fed ;
Bellad."; 21st.—Slept between eight and nine hours; drank
two glasses of egg-nog voluntarily ; pulse strong and full; face
flushed; pupils dilated ; urinated this morning; no stool since
admission; out of restraint, but in bed; talks more rationally;
looks refreshed.
22d.—Slept about six hours; wet the bed; pulse one hun-
dred and twenty, and not so full or strong; head hot; pain in
forehead; temporal arteries throb; pupils dilated; no stool;
less restless and noisy; talks quietly and pleasantly; sleeved.
23d.—Slept well; looks better and stronger; pulse full; pupils
less dilated; tongue dry and red; has not urinated since yes-
terday; urine then red, thick and scanty; still constipated;
less excited; talking quietly and incoherently all the time;
still has to be restrained. 24th.-Slept well; less arterial ex-
citement; had quite a quantity of water removed yesterday,
and has not passed any since; no stool; obstinate,_Objected
to eating, and was fed by force; Nux wom.”. 26th.-Slept
five hours; quiet; up and dressed; out of restraint; no stool;
no water since yesterday; pulse good, much stronger; some
pain in forehead; Nux vom.".
27th.-Slept well; urinated twice yesterday; bowels moved
after an injection; has not urinated to-day; quiet and pleas-
ant; went to table for breakfast; Nux wom.”. 28th.-Slept
well; natural stool; urinated twice yesterday; stronger; pulse
good; goes to the table. May 3d.-Slept fairly; at chapel
yesterday; to-day writing a letter home, an unintelligible
scrawl. 5th–Slept well; excited yesterday by another pa-
MANIA. 183
tient; wrote a letter, which was a great improvement on her
former in chirography, but not more coherent. 13th.-Slept
five hours; full of mischief; talking about law-suits; talks
much to herself. 15th.-Headache all yesterday and to-day;
tongue fiery-red; thirsty; eats well; urine Scanty, and passed
with difficulty; Nux wom.". 16th-Slept poorly; at the
dance last night; less headache to-day; Nux vom.". 18th-
Menstruating; slept well; complains of pain in shoulder;
Quiet; pleasant; not excited ; Sulphur". 28th.-Quite wild;
pupils dilated ; no headache; tied in a chair; Bellad.".
29th. Looks much better; quieter; slept well; Bellad.".
June 9th.-Wrote a letter to her aunt, two-thirds of which
was perfectly sane. 14th-Doing well; removed to first hall.
19th.-Menstruating regularly ; some headache; head hot ;
pulse full and quick; pupils dilated; Bellad.". 25th.-Feels
tired and weak; eyes slightly congested; some pain in shoulder;
rather dejected ; Phosph. ac.".
July 3d.--Wrote two letters, one somewhat mixed, the other
sensible; not much life or energy; Phosph. ac.". 20th.—Com-
plains of pain in head at times, and a feeling of sleepiness all
the time; seems stronger; Phosph. ac.". 26th.-IIead aches
and is hot; slept poorly; Bellad.*. 27th.-In bed; near the
time of menses; much uterine pain and backache; pulse
full. August 26.-Less pain; menses have stopped ; pulse
full and bounding; Acon.”. 3d.—Occasional twinges of pain,
not as rational as yesterday; Acon.0. 4th.-Still womb-pain
when she moves; pupils dilated; head hot, with little pain;
appetite poor; Bellad.". 9th.-Much better, but physically
weak; Phosph. ac.”. 16th.-Pleasant; appetite poor; home-
sick, but mentally well. 30th.-Discharged cured ; having
been four months under treatment.
CASE 2.-Female, aet. 25, native of Ireland; house-maid;
Catholic; common school education; admitted August 28th,
1875. Patient is naturally amiable and cheerful; about a
year ago became homesick and nervous, and returned to Ire-
land; remained only a short time, and is said to have there
shown some signs of insanity. About two weeks before her
admission was thrown from a wagon, and hurt her head. A
184 INSANITY AND ITS TREATMENT.
few days after became depressed about the pecuniary and
general welfare of her brother, whom she had, a short time
before, induced to come to America. From this time her
symptoms continued to increase in severity until she was
brought to the asylum.
Aug. 29th.-Brought in last evening, in a quiet state, about
6 o'clock; at night insisted that she was dying and wanted
a candle; went to sleep early, and slept until 11 P.M., then
awoke in a frenzy of fright and rage; was sleeved but tore
them off and continued noisy until near morning; then slept
about ten hours; ate a good breakfast; pulse 100, and strong;
tongue dry; pupils contracted; says she has been very thirsty;
Acon.". In afternoon fell asleep, but awoke at 3, and at
9 o'clock in same sort of rage as last night; Bellad.", to be
given at time of paroxysms. 30th.-Slept well; pulse 104;
appetite good; looks better. 31st.—Slept well last night, and
two hours to-day; pulse 100, and good; quieter; not excited;
last night head less hot; tongue dry; very thirsty in morn-
ing; says her head does not ache; Acon.".
Sept. 2d.—Excited yesterday; jacketed; slept well; inclined
to be irritable; pulse less rapid; eats poorly; talks much about
her brothers and her family. 3d.-Slept well; excited at
times; stamps around; seems to have some religious delu-
sions; pulse 120; talks to herself. 4th.-Slept well, but ugly
this morning; attacked every one she met; tried to bite;
sleeved; Bellad.". 5th.-Commenced to flow very profusely
last night; flow, bright red; Nux vom. 0. 6th.-Slept well;
flowing less; Nux wom.0. 9th.-Menses have ceased; pain
in back part of head; slept poorly; Cimicif.”. 11th-Less
excited; pulse weak; sleeps and feels better; China b. 15th–
Mind much better; says she is only weak, and sometimes gets
afraid. 20th.-Seems nearly well; stronger; pulse nearly
normal; talks rationally, no excited paroxysm for some time;
still has a burning sensation of the head; China b. 22d.—
Had a visit from her brother yesterday, and is no worse for
it; pulse better. 24th.-Daily gaining in strength; head sore
in occipital region; Arnica". 25th.—Quiet; complains still of
soreness of occiput; sent to first ward; Arnica". Oct. 10th–
Discharged cured; under treatment six weeks.
MANIA. 185
CASE 3.—Female; American ; married ; aet. 18; admitted
January 23d, 1875.
Said to have been taken insane a few days before her admis-
sion, ten days after marriage. 25th.-Slept very well in crib
two nights past; inclined to be lively, talks to herself a great
deal; commenced menstruating yesterday, flowing profusely;
pulse quick, rapid, not very full; feels weak; Sulphur'. 26th.
—Would not eat, was fed; flowing less. 27th.-Slept poorly;
walked the floor most of the night; looks better this morning;
anxious to get away; hoarse from cold caught before she
came; Bellad.". 28th.-Looks and acts better; quieter, at
work on tatting; menses over; says she has had headache a
long time. 30th.-Eats and sleeps; noisy; singing; Bellad.".
February 3d.—Quiet; says noise hurts her head; says trou-
ble made her crazy. 5th.-Did not sleep first at night, but
did afterwards; headache when she stoops. 6th.-Did not
sleep well after being down to dance; Bellad.”. 8th.-Wild
last night; cribbed; wanted to hide and be in the dark; got
down on the floor and covered herself with a chair; afraid
some one will get her; slept only about two hours, singing
and shouting all night; Bellad.". 9th.-Slept none; shouted
and cried; covered up her head and called for Charlie all
night; Arsen.". had no effect; would not eat, and was fed; pale;
tongue coated; breath bad. 10th.-Slept well; tore up skirts;
sleeved; wants to go out sleigh-riding; wild and incoherent
talk; head hot; inclined to cry; Bellad.". 12th.-Slept well;
sleeved, as she would take off her clothes; breath bad; men-
struating; had menses only three weeks ago; Hyosc.". 13th.
—Only slept an hour; tears her clothes; sleeved; pale; weak;
talks constantly about Charlie; put abed; restless; crying;
sick at stomach and thirsty; Arsen.”. 14th.-Did not urinate
from yesterday morning until night; then passed a large
quantity; slept about five hours; this morning stronger; pulse
100 and stronger; Arsen.'. Slept well, noisy, cries, laughs and
strips off clothes; passage from bowels; pulse quick, not very
strong; Hyosc.". 16th.-Slept well; very thirsty; pale, but
quieter; at times noisy and talks incoherently; Arsen.”. 17th.
—Better in every respect. 20th.-Still better; complains of
12
186 INSANITY AND ITS TREATMENT.
pain in her side, worse when moving; tongue slightly coated;
very thirsty; drinks a great deal; Bryon.". 22d.—Slept well;
this morning wild; pulse quick, 100; seems weak; breath very
offensive; discharge from bowels very offensive; singing and
shouting; Arsen.”. 23d.—Slept poorly; pulse weak, 116; pale,
but less so than a few days ago; restless; thirsty and craves
sours; Arsen.'. 24th.--Does not sleep more than three hours
at night; took off all her clothes two or three times yester-
day; pulse quick, but fuller; Hyosc.". 27th.-Decidedly bet-
ter, quieter and pleasanter.
March 4th.-Slept yesterday afternoon, and poorly last
night; fretful; walks the hall and cries. 5th.-Went to ride
last evening; slept well; has laughing and crying spells, the
latter especially when doctors are in the ward; menstruating.
6th.-Slept well; kept taking off her clothes; menstruating
freely; Hyosc.”. 8th.-Slept; ceased menstruating; makes less
trouble about her clothes; quiet; less restless; Hyosc.". 11th.
—IIas constant desire to wet her head; quieter; pulse not
strong; Arsen.”. 22d.-Sleeps quieter; pale; pulse weak and
quick; says she does not feel well; Arsen.”. 26th.-Improv-
ing.
April 10th.-Menses commenced; headache; quiet and
pleasant. 12th.-Menses scanty; not excited. 13th.-Menses
regulated ; not as cheerful as usual; crying spells this morn-
ing. 14th-Better. 20th.-Pain in knee, better when still:
noise hurts her head; Bryon.". 21st.—Sent to first ward; eats
and sleeps well. 24th.--About same; dizzy at times; Bryon.”.
26th.-Very feverish yesterday; slept well; head hot and
aches; breath offensive ; in bed ; Bellad.". 28th.-Better.
30th.-Rather weak; anxious to go home; head aches a little;
('alc. carb.”.
May 1st.—Feels better; no headache; stronger. 7th.-Com-
plains of being hot and then cold; head aches badly; worse
in morning; Calc. carb.”. 26th.-Improving; complains of
heat at times, and then pulse is considerably accelerated;
Sulphur'.
June 3d.—Looks pale and weak; headache coming on in
morning about ten o'clock; feels as if she would fall over;
MANIA. 187
Calc. carb.”. 16th.-Improved; paroled. 19th.-In bed; men-
struating; head hot and aches; pulse quick; skin hot; pupils
dilated; Bellad.". 21st.—Breath very offensive; in the morn-
ing mouth tastes badly; tongue coated yellow at the base;
sleeps poorly; constipated; appetite poor; Nux wom.0.
July 1st.—Improving ; wants to go home. 6th.-Seems
well. 17th.-Discharged cured. Under treatment four months
and twenty-five days.
Two cases of mania are reported in the Medical Counselor:
Case I.-A single woman at the climacteric began to im-
agine she had committed some great crime, and that the
authorities were in pursuit of her; and that her neighbors
are persecuting her; and that the devil is after her, and that
he comes up into her room through the floor. Sleep is poor
and unrefreshing—filled with tiresome dreams; she is dizzy,
her gait is unsteady and she is constipated. Zinc. ozyd. was
prescribed, one-sixth of a grain every four hours. At the ex-
piration of one week these troublesome symptoms had dis-
appeared.
Case II.—A man, thirty-six years of age, had been insane
for several months. “He thinks that he is lying in the grave,
pleads, prays, demands that he be killed. Laughs as if some
one was tickling him. Wants everybody to kiss him ; accuses
his wife of faithlessness. He scolds, strikes about him in a
rage, cannot be held by his watchers. He thinks his watchers
are dogs, and barks to make himself understood by them.
He thinks the house is surrounded by wagons full of geese
and people, who make obscene gestures at him, which make
him rave.” He was cured in a few days by Stramon.”.
“Chronic mania,” says Buckmill, in one of those vivid de-
scriptions that give a peculiar charm and value to his writings,
“represents the rudderless and shattered state of the vessel
after the tornado of raving madness has passed by. The wreck
is left in every variety of condition, sometimes with sail enough
to keep her head to wind; sometimes she lies upon the water,
a log in the helpless state of consecutive dementia. In some
of the milder forms of chronic mania, however, the wreck of
humanity may have passed through the tornado and come out
188 INSANITY AND ITS TREATMENT.
of it hopelessly damaged, and yet not so utterly scathed and
broken as are many other goodly vessels that have encountered
the same tropical hurricane of passion; they have lost helm
and compass, and must drift henceforth in circular voyages
without port or purpose, but they are not entirely lost to
treason, nor are they threatened with speedy engulfment.”
In them the acute attack of insanity with which their men-
tal troubles commenced has ended in disorder rather than
enfeeblement of intellect. Their perceptive faculties may be
as lively as ever. They may notice all that takes place around
them. They apprehend whatever is said to them, and reply
with more than ordinary celerity. Their memories have a
strong grasp on the past, except that portion of it which was
covered by the primary stage of their mental malady, and
they are quick to recognize, classify and name the persons and
objects that are brought before them. Their acquirements have
not gone from them. They can read, write and cipher nearly
as well as they ever did, but they are incapable of continuing
any exercise of the kind for many moments consecutively.
No distinct nor superficial signs of mental decay are to be
detected in them, and yet they are as much incapacitated as if
they were demented. They have lost control over their mental
processes and cannot pursue any train of thought. Their
minds are in some respects more active than they were in
health, and a copious flow of ideas passes through them; but
the activity is morbid, and the ideas are incongruous and
apparently disconnected. Then the gift of reticence is want-
ing. They cannot think silently, or with only faint external
indications of the current of thought within; but they must
babble out all their delirious conceptions, or at least as much of
them as articulation at its quickest is capable of keeping pace
with. Their conversation is more incoherent than their ideas,
probably because thought distances expression, and because
utterances can only be given to Snatches here and there of the
fancies that course through the brain.
The excitement of certain areas of the brain causes a large
development of nervous energy, which expands itself in pro-
ducing an equivalent amount of new thoughts and emotions
MANIA. 189
in unusual arrangements, and which overflows also in motor
currents discharged through various classes of muscles, and
notably through the vocal apparatus. Thus chronic maniacs
are in a state of perpetual mental and bodily restlessness.
They talk to themselves, they chatter throughout the night,
they dance, clap their hands, gesticulate, indulge in shouts of
laughter, or tear their clothing to pieces. The length of time.
during which they can continue to discharge nervous energy
uninterruptedly in this excessive and almost convulsive man-
ner is truly wonderful.
These chronic maniacs in many cases are permitted to re-
main at home, and come and go at pleasure. They are
generally considered harmless, and it is from their number
that come the authors of so many of the crimes of which we
read almost daily, and whose details resemble each other so
much. A sudden murder committed under the most revolting
or heart-rending circumstances, and the account almost always
ends, “the author of the crime, though insane, was considered
harmless and inoffensive.”
Not less remarkable than the length of time during which
unintermitting excitement can be kept up in chronic mania,
is the smallness of the effect which the long sustained and
severe exertion, and the protracted sleeplessness exert upon the
bodily health. Exhaustion is rare in chronic mania, neither
the body nor the brain seem to suffer much from the strain
imposed upon it. When life is cut short during the course of
chronic excitement by any intercurrent disease, the brain is
seen to be of almost normal appearance. Whatever changes
in it may be revealed by microscopic investigation, none are
perceptible to the unaided eye. The membranes are not
thickened; the arachnoid is not opaque, nor is the pia mater
adherent to the gray matter beneath. The convolutions are
not wasted, nor is their gray matter thin and pale on the one
hand, nor swollen and red on the other.
In those grave cases of chronic mania that merge into con-
secutive dementia, impairment of physical health of course
often occurs. As the ideas become more and more fragmen-
tary, and as the whole powers of mind are wrecked, bodily
190 INSANITY AND ITS TREATMENT.
decrepitude sets in. But in other cases in which the mania is
not of the severest type, and in which fatuity only gradually
sets in, little or no physical weakening will be noticed.
Whether it be that chronic maniacs are tickled by the in-
congruity and unaccountableness of their own ideas, or that
they have a sense of exuberant joyfulness, or that they are
merely manifesting the excitement of some cerebral centres
of movement, it might be difficult to determine; but certain
it is that they laugh inordinately, and that there are gener-
ally smiles of some kind on their faces. The corners of the
mouth are drawn somewhat backwards and upwards, the
upper lip is shortened, while the bright and sparkling eyes
are moved rapidly about, or look furtively out from beneath
the eyebrows. Of all expressions this is the most character-
istic of chronic mania, especially when it is associated with
negligence in dress or peculiar attitudes.
Of course there is no one expression that is constant in this
ever changing malady. Grief, rage, scorn and terror may be
signalized by the features in rapid alternation, but the expres-
sion described is undoubtedly that which is the most frequent
and characteristic. To that expression there is not infre-
Quently added an element of surprise or astonishment.
As has been said, chronic maniacs are almost always rest-
less, and indulge in numerous unmeaning and curious move-
ments. Some of them attitudinize, others deal destruction to
the clothing and furniture around them; others again are per-
petually running from place to place. Some of them collect
useless articles, such as pebbles and leaves; and others again
bedizen themselves with any cast-off finery that they can lay
hands upon. *
Of late the value of the ophthalmoscope in investigating
cases of brain disease is beginnning to be known; but the
results attained can only be briefly referred to here.
The investigations of Clifford Albutt, in England, and of
Dr. Noyes, in this country, would show:
1. That symptomatic changes in the eye are to be found in
a large proportion of the cases of mania.
2. That if cases known to be functional only, or incorrectly
MANIA. 191
mamed (such as erotomania, transient mania, hysteria, etc.),
be omitted, the proportion of cases presenting permanent
change in or near the optic disks is still larger.
3. That both in mania depending on organic causes, and in
functional mania, the back of the eye, if observed within a
few days after a paroxysm, presents a vascular suffusion, or
pinkness; a pinkness So great after severe paroxysms as to
obscure the disk. No exudation is seen in these cases, unless
there exist some permanent mischief.
4. That during the paroxysm, on the contrary, the disk is
anaemic, perhaps from spasms of the vessels.
5. That the permanent changes in the disk are due either
to stasis from obstruction to the intracranial circulation, with
consecutive atrophy, or to softening, ending in simple white
atrophy, or they may present changes of a mixed character.
The following case of chronic mania was reported by Dr.
R. A. Phalan, Prof. of Materia Medica in the Homoeopathic
College of Missouri, and is taken from the Homoeopathic Cow-
rier of January 1881.
“Miss P., 19 years of age, was sunstruck in the summer of
1864, from which time till the 17th day of July, 1868, she had
been insane. After repeated efforts of medical men had failed
to restore her to health, she was sent to the State Lunatic
Asylum in the Spring of 1865, and kept under treatment and
discipline thereof, during a full term, at the expiration of
which she was returned to her father's home without any
amendment whatever in her condition.
“At the close of another year, seeing that she was getting
worse and becoming unmanageable, she was sent back to the
asylum, and kept there during the course of a second term,
and again returned to her father's house as incurable.
“What the symptoms that characterized her case during all
this time were we did not learn, except in a general way, not
essential to be mentioned here; but she continued in her pe.
culiar state until the 17th day of July, when she came under
my treatment.
“The condition expressive of her derangement, and for
which we prescribed, was the following, viz: Unsteadiness of
192 INSANITY AND ITS TREATMENT.
purpose, with almost constant tendency to move some part of
the body; indisposition to converse, especially with, but mak-
ing determined answers to strangers; and an occasional ex-
hibition of silly laughing during her agreeable intervals.
When her wishes to go into the streets met with the opposition
of her parents, she flew into a rage, and used all the force at
her command to carry out her determination. She would cut
with a knife if it came in her way, and when she got out she
walked hastily on her way, singing and dancing, and laughing
and waving her hands. These circumstances were observed
to be much aggravated in the afternoon and evenings, and es-
pecially at the approach of, and during the first day of, the
menstrual period; particularly the eyes when in anger, the
pupils of which seemed to be more than ordinarily dilated
most of the time, the menses being premature, dark, clotted
and scanty. º
“These indications taken in conjunction with the very char-
acteristic original cause, whereby they were generated, and as
consequence of which they continued to exist, marked defin-
itely the course to be pursued. What was there left us to do
in so important a case? Nothing, but as a true Hahnemannian
to carefully individualize in selecting the proper remedy, and
having found it, to administer it in the smallest quantity
capable of curing the case. Now which of the two remedies
Bellad. and Hyosc. covers the case the most perfectly? Both
have laughing, singing, furious actions, rage, attempts to strike,
and aggravation of symptoms in the afternoon and evening,
and before and during menstruation, in common; we must
individualize further.
“With Bellad., however, and not with Hyosc., do we find
the dislike to conversation, the constant disposition to move
Some part of the body, especially the hands; the condition of
the eyes; the majority of the symptoms connected with the
menstrual appearance, and to the cause of the disease; it stands
in the very highest order as a remedial agent. Bellad. was
therefore the remedy, and accordingly, we, on the 17th of July,
1868, gave the patient one dose thereof, in the 4000th potency,
(Lentz's preparation), with the usual allowance of Sac. lac. for
one week, and departed.
MANIA. 193
“On the afternoon of July the 19th, the lady's father in-
formed me that she had been unusually excited the previous
evening and during that day, and thought the medicine might
be too strong. This was an aggravation. July 24th.-Found
the patient unusually quiet, had been so for three or four days,
was more communicative, and general appearance favorable.
Sac. lac. furnished for one week. July 27th.-Her father called
to see me, and informed me that she was ‘getting along finely,’
was making herself generally useful about the house without
being asked, and evinced no desire to leave home on any ac-
count. July 31st.—Patient wonderfully improved, almost
natural in her conduct, no excitement or restlessness, conversed
with apparent ease; parents delighted, but feared a return of
her difficulties at approach of menstruation, a natural fear
which was shared in even by ourself. Sac. lac. for one week.
“August 7th.-Still gaining in every respect, very quiet and
orderly, patient sewing when we reached the house. Placebo
for another week. August 14th.—Menstruation present one
day too soon; and much to the gratification of all, accompanied
by no aggravating circumstances, excepting that she appeared
more reserved in her manner. Placebo continued.
“July 22d.-Was informed that menstruation passed off
almost naturally ; was much more profuse and not dark and
clotted as formerly. Patient gained much in strength and
certainly in appearance. Sac. lac. for one week. At the end
of two weeks more, viz: on the 5th of September, it was almost
impossible to notice the difference between her actions and
those of other people; she was then attending church and
visiting her friends as naturally as she ever did in her life,
and nothing of her old difficulties remained to be discovered,
except in the impression amongst her friends and relatives
that she was once insane. In six months from the time we
began the treatment, we surrendered the young lady to her
father and mother in a perfect state of health. I saw the
lady as late as the 11th of October, when she continued per-
fectly well and wonderfully improved in general appearance,
and, as late as the 14th of November, her father told us “he
could see no end to her improvement.’”
194 INSANITY AND ITS TREATMENT.
All writers emphasize the importance of early treatment,
especially in cases of acute mania, as thereby the attack may
often be cut short. Many cases, even when noisy and vio-
lent, can be treated more satisfactorily at home than in a hos-
pital, provided that proper attendance and accommodation
can be furnished.
Great care should be taken to keep the patient as quiet and
free from excitement as possible. During paroxysms of ex-
citement he should be kept in a room apart from the family,
and the same precautions taken to guard against light and
noise as in a case of brain fever.
Much stress is given, especially by French medical writers
to the use of baths, both cold and warm, in the treatment of
insanity.
The use of prolonged warm baths was introduced by Brierre
de Boismont, and they are now generally adopted. The pa-
tient's body is plunged into a warm bath and remains
there for six, eight or ten hours, and if thought best, cold effu-
sions are made to the head at the same time. Warm baths
should be used with caution if the patient is weak and ca-
chectic, or if there is any tendency to lung trouble, and they
are of most benefit in cases of acute mania, marked by a high
degree of excitement and delirium. Care should always be
observed lest syncope occur, or too great prostration.
The use of cold baths is more limited, and should be con-
fined to the young, strong and robust. Their use also should
always be followed by sufficient friction to produce a healthy
reaction of the skin.
In many cases much trouble is caused from the filthy habits
of the insane, and Dr. R. Lawson recommends the following
treatment; he says: “Special attention was called to this
matter from an accumulation of patients with extreme de-
mentia, associated with general paralysis, softening of the
brain and senile dementia.
“The principle seems mechanical but effectual, and patients
became clean in many cases at once, and would go to stool,
when before they would pass their feces involuntarily; and it
also causes bed Sores to be almost unknown.
MANIA. 195
R. Acid Tannici, grs. 120.
Adipis Benzoat, grs. 80.
Cera alb, grs. 20.
Ol. Theobromae, grs. 140. Fºt. Suppositories.
“Dissolve the oil of Theobromae with the wax over a water
bath, then add the tannic acid and lard, previously mixed in
a mortar. Pour the mixture while fluid into suitable moulds,
capable of holding 30 grains each.”
Medical Treatment.—We come now to the medical treatment,
and, as in my lecture upon melancholia, I must again ac-
knowledge my indebtedness to Dr. Talcott, of the Middle-
town Asylum, for the results of his experience among the
large number of patients under his care. He says the reme-
dies used at the asylum are those whose effects upon the
healthy were “proved” many years ago, and the verification
of whose symptoms, in a curative sphere, has been demon-
strated at the bedside of the sick repeatedly and satisfactorily.
In other words, “old remedies,” like “old friends,” have been
our main reliance. A few of the new remedies have been
used, and in some instances with gratifying success. Drugs
whose primary effects are largely manifested by their action
upon the circulatory apparatus, the heart and its vessels, have
most frequently proven themselves effectual in modifying the
symptoms and promoting the recovery of those suffering with
mania. Hence we find Aconite and Veratrum viride playing
an important part in the early stages of this disease, which is
marked by such an unnatural and exalted excitement.
The distinguishing features between Acon. and Ver. vir. are
these: In Acon. there is a fitful mood, changing from one
thing to another, now full of mirth, and in a few moments
disposed to weep, and great mental ama'iety; in Ver. vir., exces-
sive physical unrest. The Acon. patient is fearful of the
future, and terribly apprehensive of approaching death, pre-
dicting the day he is to die; the Ver. vir. patient is depressed,
but comparatively careless of the future. The Acon. face is
flushed bright red, or is pale, with moderate congestion;
Ver. vir. has intense cerebral congestion, with a face flushed
to a purple hue, and hot; or it is cold, with a pale bluish cast.
196 IN SANITY AND ITS TREATMENT.
The Acon. case has great thirst, and gulps water eagerly; the
Ver. Vir. case has a dry, hot mouth which feels scalded, but
the thirst is moderate. The muscles of the Acon. patient are
tense, and the whole mental and physical conditions are
those of an instrument strung to the highest pitch; the
Ver. Vir, patient is relaxed and restless, has nausea, retches
and vomits profusely, has muscular twitchings, and constantly
changes his position. In short the Acon. patient has mental
anxiety with physical tension; while the Ver. vir. patient has
a lower grade of mental unrest with physical relaxation.
Treading closely upon the heels of Acon. and Ver. vir., and,
in fact, contesting strongly for the palm of superiority are
Bellad. and Hyosc. Probably no remedy in the Materia Med-
ica possesses a wider range of action, or greater powers for
removing abnormal conditions of the brain than Bellad. Its
symptoms are clear, well defined, unmistakable; its action
sharp, vigorous and profound. It is the powerful supplement-
ary ally of Acon. in removing the last vestiges of cerebral
congestion, and beyond this it subdues like magic, the subtler
processes of inflammation. The following are a few of its
characteristic symptoms.
She attempts to bite and strike her attendants; breaks into
fits of laughter, and gnashes her teeth.
Head hot, the face red, the look wild and fierce.
Inclination to bite those about one, and to tear everything
to pieces.
She tears her night-dress and bed-clothes.
Furious delirium.
Fury; she pulled at the hair of the by-standers.
Much fury (with burning heat of the body, and open, star-
ing, immovable eyes), that she had to be held constantly lest
she should attack some one, and when thus held, that she could
not move, she spat continually at those around.
His face was livid; his eyes injected and protruding, the
pupils strongly dilated; the carotids pulsating violently; a
full, hard and frequent pulse, with inability to swallow.
When put into bed, he sprang out again in delirium; talked
continually, laughed out, and exhibited complete loss of con-
Sciousness; did not know his own parents.
MANIA. 197
A marked and happy effect will follow the use of Bellad. in
cases, when, in addition to the flushed face, dilated pupils and
throbbing arteries, we have a mental condition which mani-
fests itself by the most positive ebullitions of rage and fury;
and when the patient tosses in vague spasmodic restlessness;
attempts to bite, strike, tear clothes, strip herself naked, and
make outrageous exhibitions of her person. While in this
state, Bellad. patients are exceedingly fickle and constantly
changing; now dancing, singing, laughing, and now violent
with intolerable rage. The speedy disappearance of such a
grave and serious train of symptoms after Bellad. is adminis-
tered proclaims its unmistakable power. The magic workings
of this protean drug are also manifested in the relief of symp-
toms directly opposite to the foregoing. When you have a
patient whose face is flushed to an intense reddish-purple hue,
pupils widely dilated, eyes having a fixed stony stare and
utterly insensible to light; heavy, almost sterterous breathing;
stupid, dozed condition of the mind so that he cannot be
roused to speak; inclined to remain quiet, but with occasional
muttering, incoherent delirium; marked rigidity or steady
tension of all the muscles, then you may give Bellad. in the
confident expectation of reaping good results. The excitable
Bellad. patient requires a minimum dose of the drug, while
the stupid one is affected most readily and favorably by re-
peated doses of the 1st cent. or 1st dec. dilution.
Hyoscyamus gives us mania, with lasciviousness and occa-
sional mutterings; singing of amorous and obscene songs;
and uncovering of the whole body.
Delirium, without consciousness; does not know anybody;
has no wants (except thirst), with closed eyes; talks of business;
fears of being poisoned or sold; scolds and raves.
Unconscious, with aversion to light and company.
Jealousy, with rage and delirium.
Inability to think, thoughts cannot be controlled.
Sees persons who are not, and have not been, present.
Thinks he is in the wrong place.
Insane passion for work.
Indistinct muttering loguacity.
198 INSANITY AND ITS TREATMENT.
Abuses those about him.
Cannot bear to be talked to.
Makes irrelevant answers.
The Hyosc. patient is very excitable, but much less frenzied
than the Bellad. patient; is very talkative, mostly jolly and
good natured, but occasionally has savage outbursts; is in-
clined to be destructive and obscene, with a tendency to expose
the person. Hyosc. is perhaps more often indicated as a rem-
edy for female patients than Bellad., the latter being frequently
indicated for the male insane.
Dr. R. Lawson, Assistant Medical Officer of the West Riding
Asylum, of Yorkshire, England, in speaking of Hyosc., says:
“Its use in mania with delusions of suspicion, and in simple
and recurrent mania, also in mania associated with logorrhoea,
or incessant incoherent talking, and in insane conditions char-
acterized as a prominent feature by constant and apparently
involuntary, or at least incontrollable destructiveness is often
followed by happy results.
“There is one condition associated with mania, and not in-
frequently with senile dementia with excitement, which is
most annoying, the propensity to the tearing of wearing ap-
parel, blankets, etc. When appearing as a symptom of chronic
mania it is frequently wilful, and is effectually put a stop to
by single large doses of Hyosc. Case: The patient either in
wanton mischief, or in retaliation for some imagined slight, or
necessary exercise of discipline, either tears blankets in shreds,
or strips his clothing in pieces. Three-quarters of a grain of
Hyoscyamine invariably put a stop to his excitement, and he
will remain quiet for a month or six weeks.”
Again he says: “Hyosc. has great value in the treatment
of cases in which aggressive and destructive excitement is the
leading symptom of insanity; in cases of chronic mania with
special delusions of suspicion, mania of a subacute or recur-
rent form, and simple mania characterized from the first more
by agitation than excitement, and due to the existence of ob-
scure delusions and hallucinations. Also useful in the ex-
citement and epileptic seizures of general paralysis. But the
most striking results are in cases of wanton and wilful de-
struction.”
MANIA. 199
Following these remedies in the treament of mania come
Canthar., Laches., Nux wom., Rhus tox., Sulphur, Thuja and
Ver. alb.
The Canthar. patient has mental exhibitions somewhat
similar to Bellad. and Hyosc., i. e., frenzied paroxysms of rage
of an exalted type, with biting, Screaming, crying, tearing and
howling or barking like a dog. This rage is renewed by the
sight of dazzling, bright objects, by touching the larynx, and
when trying to drink water. As an invariable accompani-
ment there is great excitement of the sexual organs. In this
latter respect Canthar. resembles Hyosc. and Ver. alb., but
these latter drugs commingle the psychical with the physical,
the Hyosc. patient displaying lively fancies in connection with
erotic desires, and the Ver. alb. patient uniting religious senti-
ment with lustful tendencies; but the Canthar. patient is
strictly and solely the victim of lechery for its own sake, a
result of the intense erethism of the sexual organs, impelling
him to seek immediate physical gratification. Such patients
are inordinate masturbators of an acute type. Proper restraint
and the administration of Canthar, often affords prompt and
happy relief, both from the sexual excitement and the par-
oxysm of mania. Very scanty urine, and frequent micturi-
tion are characteristic of the Canthar. patient.
Cicuta vir. is a remedy you will do well to keep in mind, it
has: weeping, moaning and howling; doing all kinds of gro-
tesque and foolish things.
Opium may be indicated both in melancholia and mania,
and in spite of its abuse by old School physicians is called for
by the following symptoms:
Delirious talking; eyes wide open ; face red; puffed up.
Dulness of the senses and at intervals Sopor, with Snoring;
sees animals; affrighted expression of face.
Unconscious; eyes glassy, half open; face pale; deep coma.
Imagines parts of the body very large.
Thinks she is not at home.
Illusions and frightful fancies.
Loquacious delirium, with open eyes and red face, furious
delirium.
200 INSANITY AND ITS TREATMENT.
When your patient has gone hours without sleep, and it
seems an impossibility for him to close his eyes, you will be
able to give a good refreshing sleep ofttimes, by putting a few
drops of Opium in half a glass of water, and giving teaspoon-
ful doses of the solution every half-hour or hour ; in other
cases, however, you will find it necessary to produce sleep at all
hazards in order to prevent nervous exhaustion, and be forced
to use chloral in doses of from fifteen grains upwards.
Stramon. has its own peculiar marks especially in relation
to the hallucinations. “a
The patient has a mania for light and company, cannot
bear to be alone.
Has strange and absurd ideas; thinks herself tall, double
or lying crosswise, one half of body cut off.
Thinks he converses with spirits, and prays fervently.
Hallucinations which terrify the patient; sees ghosts; hears
voices; sees strangers, or imagines animals to be running
around or jumping at him.
Talks all the time, sings and makes verses.
Coma, spasms; unconsciousness; jaw hangs; hands and feet
twitch; eyes roll; pupils dilated; grasping of hands towards
nose, ears, etc.; difficult to swallow liquids.
For loguacity, Lachesis is a most valuable remedy.
Nux wom. is useful in cases that are cross, irritable, ugly and
obstinate. Rhus tox. and Hyosc. relieve the belief of having
been poisoned, the former remedy being particularly adapted
to low typhoid conditions. Sulphur is useful as an intercur-
rent, and also for fantastic mania, when the patient is inclined
to deck herself with gaudy color, or puts on old rags of bright
hue and fancies them the most elegant decorations. Sulphur
seldom achieves a cure by itself, but sometimes seconds with
vigor the efforts of other drugs.
Ver. alb. is a remedy whose sphere of usefulness compre-
hends both profound prostration of the physical forces and a
most shattered condition of the intellectual forces. The fame
of this drug extends over a period of more than three thous-
and years. It is related that about the year 1500 before Christ,
a certain Melampus is said to have cured the daughters of
MANIA. 201
Proetus, King of the Argives, who, in consequence of remaining
unmarried were seized with an amorous fever, and affected by
a wandering mania. They were cured chiefly by means of
Ver. alb. given in the milk of goats. Dr. Talcott says that at
the asylum they have verified the homoeopathicity of Veratr.
in amorous fever and in wandering mania, particularly when
these symptoms of peculiar excitement are followed by great
mental depression, and tendency to collapse. The Veratr, pa-
tient combines the wildest vagaries of the religious enthusiast,
the amorous frenzies of the nymphomaniac, and the execrative
passions of the infuriated demon. The patient soon passes
from this exalted and frenzied condition into one of deepest
melancholia; abjectly despairs of salvation, imbecile taciturni-
ty and complete taciturnity both of body and mind. The ex-
tremities become cold and blue, the heart's action weak and
irregular; the respiration hurried; and all the objective symp-
toms are those of utter collapse. With such a picture before
us we can scarcely hesitate in the choice of a remedy, and
Veratr. is the one selected.
Many, if not most, of the cases of mental disease reported in
our journals as cured under the use of this or that drug, are
extremly unreliable; owing to the careless manner in which
they are reported, and also to a lack of knowledge on the part
of the reporter of the natural progress and etiology of the
disease. As a guide to aid you in choosing the appropriate
drug either in a case of insanity, or any case when the mental
symptoms are prominent I know of no work so valuable as Vol.
1, of Analytical Therapeutics by Dr. Hering, a work which
should be in the library of every physician who desires to pre-
scribe carefully and accurately for mental symptoms.
13
202 INSANITY AND ITS TREATMENT.
LECTURE X.
Mania Transitoria.-Folie Circulaire.
Mania Transitoria.
Mania transitoria is a form of mental disorder which Sud-
denly appears in persons previously sound, or not supposed to
be unsound in mind; it has a short duration and suddenly
disappears. e
Castelnau calls this “La Folie Instantanée, temporaire, passa-
gère;” a mania instantaneous, transitory, fleeting, temporary;
a mental disorder which breaks out suddenly, like the sudden
loss of sense in some physical disease, and the subject is urged
in a moment to automatic acts which could not have been
foreseen. The first act of the mania may be homicide, and the
disease may pursue its course under the continued or inter-
mittent form, but when the act of violence or homicide is the
only maniacal manifestation, it is instantaneous, temporary or
transitory insanity according to Henke, Marc and Cazauvielh.
He says: “I could show by facts, already so numerous, re-
corded in the works of physicians devoted to the study of in-
sanity, and the observation of the insane, the existence of a
mental malady which society has the greatest interest to know,
in order to prevent consequences dangerous to the community,
and the person affected. We could cite a great number of facts
sufficient to show that the various kinds of insanity, as of all
the diseases of the organism, can establish themselves in a
manner either progressive or sudden, and have a progress slow
or rapid; continued, intermittent or temporary.”
Dr. A. Devergie says in an essay read before the Imperial
Academy of France: “There is another mode of alienation to
which they give the name of Transitory Insanity, that is to
. Say, without preceding apparent symptoms, without cause
near or remote, appreciable to the world, bursting out as sud-
denly (brusquement) as a clap of thunder, and ceasing com-
pletely with a criminal act.
MANIA TRANSITORIA. 203
“No motive for the act, either in ungoverned passions, or in
acquired ideas; previous character and manner without re-
proach; absence of hallucination; the explosion of mania
manifesting itself in acts of violence or crime, and the imme-
diate return of reason after this act is accomplished; these in
my opinion are the characters of temporary insanity.”
He qualifies the above a little by adding the following im-
portant statement: “Nevertheless the word transitory, perfectly
just for the world, in the sense that the mania was fleeting
(passagère), although the act was of the most criminal nature,
does not seem sufficiently exact for the physician. The per-
sons of this description should not be considered as sound in
mind when the idea of crime suddenly rises within them, and
becomes the ruling thought, irresistible, stronger than them-
selves, stronger than their own will. The antecedents of their
families, hereditary taint, divers acts of social life, perverted
tendencies and tastes, tendencies to silence and abstraction,
thoughts of suicide for years existing in many; have been the
forerunners of the sudden outbursts of irresistible criminal
mania.”
Dr. Otto Schwartzer says, in a little work on Transitory
Mania, published in 1880: “It presents itself as a peracute
physical affection, arising suddenly under phenomena of a
violent, active cerebral hyperaemia, in the form of a wild and
blind, spontaneous maniacal excitement or fury, with entire
absence of consciousness. It is of short duration, lasting
from a few to, in rare instances, twelve hours, and terminates
in a deep and sound sleep, whereupon there ensues speedy
recuperation of all normal mental faculties, associated with a
complete amnesia of that which has happened during the
access.” The author gives the history of fourteen interesting
cases, of which we translate the following:
“CASE 12.-N. H., doctor and state official, aet. 35, married,
and for a number of years an intimate friend of the author,
came during a summer month to the capital in order to settle
some difficulties which had arisen between himself and his
superiors in office. He had been accused of neglect of his
duties, and only after many inconveniences had finally suc-
204 INSANITY AND ITS TREATMENT.
ceeded in purging himself of the charges brought against
him. At all times somewhat self-conceited and proud of his
services rendered the government, he asked as a compensa-
tion for the injury thus done to him to be promoted to a
higher position. In spite of a communication from a high
official that nothing of that kind could be realized, and
against the wishes of his friends, he continued to petition.
One forenoon, after a renewed visit at court, where he was
told that in his case a very unfavorable report would be sent
in by the referee, he left the court-house in a state of great
excitement. On his way home, in one of the most frequented
streets of the city, he suddenly broke down. Picked up by
passers-by, he roared some incoherent and threatening words,
beat violently every one who tried to approach him, knocked
out a number of show-windows, and was only with great
difficulty secured and transferred to a hospital. Here this
access of excessive furor continued for some hours; all at-
tempts at medical interference proved impossible on account
of his high degree of motor excitation, until suddenly he fell
into a deep sleep, which lasted ten hours. On Waking, he was
psychically perfectly normal; he was quiet and cheerful, and
showed complete amnesia of all that had happened in the
interval. When the facts were related to him, he felt dis-
tressed to the utmost, and he himself diagnosed the access
very clearly as one of transitory mania. He remained vol-
untarily for several days in the hospital, without showing,
however, physically or psychically, anything abnormal. N. H.
is of strong plethoric habit, and since leaving the University
has frequently suffered from severe congestions, in consequence
of excessive labor and late hours. Aside from this, he was a
model of health, and of a sanguine and cheerful tempera-
ment. No case of neuro or psycho-pathic affections had ever
before occurred in his family, several members of which
ranked among high civil and military officials. N. H. re-
turned home immediately after the accident, where he at
once resumed his official duties with usual energy, though
under unpleasant circumstances, without, however, experi-
encing, in the course of several years, a similar attack.”
MANIA TRANSITORIA. 205
Dervergie quotes the case of a young man, aet. 19, the son of
a merchant at Bordeaux. He had been most regular and ex-
emplary in all his previous life, an affectionate brother, duti-
ful son, faithful to his employer, a banker, and the heir of an
immense fortune; but he was the child of insane parentage, and
had a step-mother for whom he had an intense aversion.
“There was a dinner party at his father's house which
passed without unusual incident. At the time of the dessert,
Julius, the youth, left the table, and went to the hall to warm
himself; the fire was not burning; he went to his chamber
and took his gun and straw-hat to walk in the fields as he
was accustomed to do. Then the thought of suicide, which
had troubled him for a month, suddenly presented itself and
as suddenly changed to the thought of killing his step-mother.
He threw down the gun, went to his brother's chamber, took
two pistols which had been loaded three months, leaving his
own pistols that he had loaded the evening before. He went
to the dining-room where his step-mother was sitting at the
table with his father, and discharged one of the pistols into
her temple. He was rational immediately afterwards.”
Devergie says: “If the act which young Julius committed
was one of mania, it was in him a passage, sudden and rapid,
from reason to insanity, and a return, as rapid, from insanity
to reason. This then is a very exact example of that species
of mania which is called temporary.”
Drs. Gintrac and Delafosse, of Bordeaux, Calmeil, Tardieu
and Devergie gave, as their opinions, that Julius at the mo-
ment of this action had not the possession of his freedom of
will, and he was fully acquitted of the charge of crime. (Ann.
Hyg. et. Med. Leg. XI, 2d Series.)
A few years ago much interest was excited by the trial of
McFarland for shooting Richardson. The defense set up was
temporary insanity, and Dr. Wm. A. Hammond testified as
an expert for the defense. In 1870, he read a detailed “opin-
ion” before the New York Medico-Legal Society, in which he
said:
“There is a form of insanity which, in its culminating act,
is extremely temporary in its character, and which, in all its
206 INSANITY AND ITS TREATMENT.
manifestations from beginning to end, is of short duration.
This species of mental aberration is well known to all physi-
cians and medical jurists who have studied the subject of in-
sanity. By authors it has been variously designated as tran-
sitory mania, temporary insanity and morbid impulse. It
may be exhibited in the perceptional, emotional or volitional
form, or as general mania, and its exciting causes are nu-
II) 62.I’OllS.
“Transitory mania may be defined as a form of insanity in
which the individual, with or without the exhibition of pre-
vious notable symptoms, and with or without obvious exciting
cause, suddenly loses the control of his will, during which
period of non-control he commonly perpetrates a criminal act,
and then as suddenly recovers more or less completely his
power of volition.
“Attentive examination will always reveal the existence of
symptoms precursory to the outbreak which constitutes the
culminating act, though they may be so slight as to escape
superficial examination. The hypothesis, therefore, that a
person may be perfectly sane one moment, insane the next,
and then again perfectly sane in a moment, is contrary to all
the experience of psychological medicine.”
Maudsley says: “A transitory mania, accompanied by homi-
cidal and other destructive impulses may be produced by a
sufficient exciting cause in a person who has a distinct insane
neurosis, just as epileptic convulsions or mania may be pro-
duced when the epileptic neurosis exists. They are really
cases of acute general mania, only they are of much shorter
duration than acute general mania commonly is.
“While conceding unhesitatingly the occurrence of an acute
attack of transitory mania on the occasion of a sufficient ex-
citing cause, where there was an epileptic neurosis or an
insane neurosis, or where there had been an injury to the
head which had affected the mind at the time or afterwards,
or when a previous attack of insanity had left behind it a
tendency to the recurrence of the disease, I certainly hold that
we ought to regard with extreme suspicion the allegation of
transitory mania in excuse for crime, when none of these con-
ditions were present.
MANIA TRANSITORIA, 207
“It must be acknowledged that most symptoms of derange-
ment in addition to the morbid impulse, either antecedent to or
concomitant with it, will be discovered if a careful examination
be made, such symptoms as previously marked melancholic
depression, morbid suspicion or actual delusions. It will be
found that many of the suicides and homicides done by insane
persons, are done by persons laboring under commencing
melancholia, before the disease has developed into the stage of
intellectual derangement; though overwhelmed with a vague
fear of distress, dejected, sleepless and feeling themselves over-
laden with the heavy burden of their miserable lives; they
manifest no actual delusion, and are not thought by their
friends or medical attendants ill enough to be placed under
control.”
There are two important conditions which are precedent
to an outbreak of insane homicidal impulse. These are the
insane neurosis and the epileptic neurosis, in both of which the
tendency is toward convulsive action. It is in strict accord-
ance with the view taken of homicidal impulse as a convulsive
idea springing from a morbid condition of nerve element and
comparable with a convulsive movement, that it should most
often occur where there is hereditary predisposition to insani-
ty; it may be that in some cases there is not, but there can be
no doubt that in the majority of cases there is, such a neuro-
pathic state. It is in accordance again with experience that
when this neurosis exists; and when the circumstances of life,
or physiological and pathological conditions put a great stress
upon the nervous organization, an outbreak of homicidal im-
pulse should in some instances be the first overt evidence of
insanity.
Among such physiological and pathological conditions we
reckon the development of puberty, with the revolution which
takes place then in the mental and bodily economy; preg-
nancy and the puerperal state; the change of life; irregulari-
ties of function in woman; the effects of excessive drinking
and of other injurious vice. Not one of these conditions but
has occasioned an outburst of insanity in persons predisposed
to the disease; not one of these conditions furthermore, but
208 INSANITY AND ITS TREATMENT.
has, as the recorded cases show, occasioned an outbreak of
homicidal insanity.”
Although epilepsy, marked or not, will be found to be at
the bottom of most cases of mania transitoria, it must be ad-
mitted that there are some cases in which there is no evidence
of epilepsy in any of its forms to be found ; but it may well
be doubted whether a distinct insane neurosis is not always
present in these cases. With such a constitutional predisposi-
tion, a genuine attack of acute insanity, lasting for a few
hours only, or for a few days, may break out on the occasion
of a suitable exciting cause, and, during the paroxysm, homi-
cidal or other violence may be perpetrated. After child-birth
it sometimes happens to women, or even in some rare cases at
the menstrual period. The effect of alcoholic intemperance
upon a person strongly predisposed to insanity, or upon one
whom a former attack has left predisposed to a second, is,
sometimes, a short but acute mania of violent character, with
perhaps vivid hallucinations and destructive tendencies, and
a like effect may be produced by powerful moral causes, sexual
excitement, and the other recognized causes of insanity.
Says Dr. Hammond : “The symptoms indicative of an ap-
proaching attack of temporary insanity are chiefly those of
cerebral congestion, though it will be found upon thorough
examination that other organs beside the brain are more or
less deranged in their functions. Thus the appetite is lessened,
or altogether abolished, the bowels are torpid, the kidneys fail
to eliminate the normal quantity of urine, the heart becomes
irregular in its action, and beats with increased frequency, L
a certain sign of a weak and excited nervous system, and the
skin is either bathed in perspiration or harsh and dry.
“The initial symptoms of cerebral congestion can always,
even when slight, be detected by a physician accustomed to
the study of the diseases of the nervous system. Among the
most prominent, and in its effects the most exhausting, is wake-
fulness. It indicates an increased flow of blood to the brain,
and in turn reacts upon this organ, and still further deranges
its normal functions. The effect therefore becomes a cause.
“With the wakefulness there is generally combined great
MANIA TRANSITORIA. 209
mental and physical irritability. He may likewise have illu-
sions, hallucinations and delusions, and when he does toward
morning obtain a little sleep, he is disturbed with frightful
dreams which prevent his being refreshed.”
Even in healthy persons or in persons of plethoric habit,
this determination of blood may occasion transient delirium,
with various signs of encephalic disturbance, such as extreme
sensibility to light and sound, restlessness, pain in the head
and visual hallucinations; a flood of distorted ideas flows
through the mind, and overpowers it; bewilderment and in-
coherence follow, and for the time being the patient is to all
intents and purposes maniacal.
In addition to other evidences of mental and physical dis-
order, the face is flushed, the eyes suffused, the carotid and
temporal arteries beat with increased force; vertigo is com-
plained of and the pupils are contracted.
Such a condition may exist for weeks or months and then
pass away, or terminate in apoplexy, epileptiform convulsions,
inflammation of the brain, or an attack of transitory mania.
Dr. McIntosh, of the Murray Royal Institution at Perth, in
Scotland, says: “Ordinarily friends around do not dream of
mental derangement, and even one examination by a physi-
cian may not always lead the patient to betray his defect, un-
less very skilfully handled; yet, in no long time, a desperate
or disgraceful act may startle all alike by its impetuous Sud-
denness and dangerous nature.
“For instance, it is related that a gentleman of high attain-
ments and character, while in the apparent enjoyment of ex-
cellent health and spirits, had a dinner party of his friends;
there was no one present so agreeable and attractive in con-
versation and manners as himself, but in the middle of the
festivity he arose, and politely apologized for absenting him-
self for a moment, retired to an adjoining room, and cut his
throat to the vertebrae at the very time his friends were drink-
ing his health.”
The acts performed during temporary insanity, in their
more obvious aspects, and when viewed isolatedly, resemble
those done in the heat of passion. But they are so only as re-
210 INSANITY AND ITS TREATMENT.
gards the acts themselves. Thus a person entering a room at the
very moment when one man was in the act of shooting another,
would be unable to tell whether the homicide was done in the
heat of passion, or under the influence of temporary in-
sanity. The act, therefore, can teach us nothing. We must
look to the circumstances and to the antecedents of the perpe-
trator for the state of facts which are to enlighten us as to the
state of mind of the actor. Now the conditions of temporary
insanity are so well marked that there can be no difficulty On
that score. Suffice it to say that the act which marks the
height of the paroxysm is always preceded by symptoms of men-
tal aberration; while acts done in the heat of passion are not
thus foreshadowed.
In cases of temporary insanity, after-evidences are nearly
always present, and remain for days, weeks or even months
and years. These symptoms are in general those of cerebral
congestion.
Folie Circulaire,
The French have described under the name Folie à dou-
ble forme, or Folie Circulaire, a special form of mental disturb-
ance marked by two regular periods, one of exaltation, ma-
nia, and the other of depression, melancholia, both of which
together go to make up a paroxysm, just as the chill, fever
and sweat constitute an attack of intermittent fever. Each
attack may be separated by a lucid interval, or they may fol-
low each other continuously. In 1845, Griesinger, noticing
this class of cases, said: “It is not rare to see the whole dis-
ease consist in a cycle of the periods alternating very regu-
larly. Other observers as well as myself have seen cases in
which a state of melancholy occurring in the winter, is re-
placed by mania in the spring, and again transformed into
melancholy in the autumn. The condition of mania alter-
nates regularly with that of melancholy, and sometimes these
attacks regularly occur at certain seasons of the year. Falret
was the first to apply the name folie circulaire, because the ex-
istence of this class of the insane rolls in a fixed circle of dis-
FOLIE CIRCULAIRE, 211
eased states which are constantly reproduced, and are only
separated by short intervals of reason.” Baillarger noticed
that in many cases a lucid interval did not occur between the
states of mania and melancholy; that the association of the
two formed the full attack, and that the intermission when it
occurred, did so only after the evolution of this double period,
hence the name folie à double forme. Although I have used
the terms mania and melancholy, the two states whose suc-
cession forms the folie circulaire are, strictly speaking, neither
mania nor melancholia as they usually appear. In the first
state there is not the incoherence of ideas as in mania, but a
simple delirious excitement, that is to say, an extreme activity
of the mental faculties, attended with great restlessness and a
lack of order in all the actions. In the second, there is no re-
stricted lesion of the intellect with predominance of certain
well-defined delirious ideas as in ordinary melancholia; but a
physical and mental depression, at times carried almost to
the complete suspension of the intellectual and affective facul-
ties. This period of depression is longer than that of excite-
ment, and it is remarkable that while mania and melancholia
taken separately are the most curable forms of mental dis-
ease, they are the most intractable when occurring together as
folie circulaire. Falret, who long had charge of La Sälpetrière
says, that he never saw complete recovery take place, or even
lasting improvement. As it has been my lot to meet several
cases in private practice as well as in asylum life, I judge that
you may meet with the same, and shall therefore spend more
time upon this variety than I would if it was more fully de-
scribed in our English text-books.
As was said before, folie circulaire is characterized by the
successive and regular evolution of a state of mania, of melan-
cholia, and a more or less prolonged lucid interval. It varies
in Severity and duration as to its whole, and as to each of its
periods, both with different persons and in successive attacks
in the same person. In some cases the circle is described in
a few weeks, in others it requires months or even years. But
whether the march be slow or rapid, the essential features of
the disease remain unchanged either in generals or in particu-
212 INSANITY AND ITS TREATMENT.
lars. Thus we class it as a well defined variety, having a
right to a name of its own, as it presents a group of physical,
intellectual and moral symptoms always the same at a given
time, and succeeding each other in a given order. It has per-
haps a juster claim than either melancholia or mania to be
considered a distinct variety of insanity, for it is not based
upon the single characteristic of excitement or depression,
but upon the junction of these states succeeding each other in
a fixed order, capable of being foreseen and not changeable.
A marked feature in folié circulaire, as in epileptic insanity, is
the similarity of the different attacks occurring in the same
person. This is true not only of the principal but also of the
lesser symptoms; not only as to the excitement and depression,
but as to the particular ideas and emotions as well as the phy-
sical symptoms. In some cases this is carried so far as to re-
produce exactly the same symptoms at the same period of
each attack.
In describing a case we will commence with the maniacal
stage. In general this stage is characterized by a simple ex-
altation of the intellect and the sentiments, such as we ex-
perience when the mind is active and everything seems easy,
and when nature appears under her most smiling aspect. The
patient presents only an increased activity of the mind, but to
the careful observer it seems as though some change were im-
pending by little alterations in his actions, his manner and his
Sentiments. This gradually increases, and in a short time the
exuberance of thought is excessive, and the sentiments are
changed. Evidences of hatred and dislike are shown toward
those who were but lately very dear, and tokens of love and
friendship toward those who were bitter foes. The movements
are rapid and incessant. In this state the patient, if left to
himself, will displace and overturn his furniture, keeps chang-
ing his room, and disarranges his garden and grounds. He
is full of tricks and malicious, playing all manner of practical
jokes, and is full of projects which he carries out at once; he
composes music, writes in prose and verse, and this prodigious
activity of spirits which overflow at all points is the same at
night as by day. The person feels in perfect health, often in-
FOLIE CIRCUILAIRE. 213
deed, ailments previously existing are suspended during this
stage of exhilaration; the appetite is increased, all the organic
functions seem to have increased activity, and despite the ab-
sence of sleep, the person endures happily and without fatigue
the constant restlessness, and the excesses he commits. The
face is flushed, the eyes bright and sparkling, the features are
mobile and the senses are acute. This excitement remains
about the same through the whole period without reaching the
extreme and wide spread disturbance of the sentiments and
ideas found in ordinary mania. Still there are some cases in
which the stage of excitement consists of a true attack of mania
with grave and well defined illusions and hallucinations; but
it is more common to find cases where the mild delirium above
portrayed seems interrupted by a spell of maniacal excitement
or even intellectual weakness, especially if the patient is ad-
vanced in years; but the general course of the delirium is of a
mild type.
After a time of varying length, we see this excitement di-
minish as gradually as it arose. As it ceases we find a con-
dition that is hard to define or describe; it seems to partake
of excitement half finished and depression just begun. Is
this a true lucid interval? It would seem not, and yet there
are cases where it would be difficult to say that the person
was not in his right mind; but a very careful examination
will show that he seems rational only in contrast with his
previous condition. Such seem able to control their ideas for
a time, and even to conceal some of the wandering thoughts
remaining in the mind, induced by the past delirium, or
those which commence to intrude as forerunners of the state
to follow. In order to judge properly of their condition we
must notice their omissions to do, as well as their actions.
We see that they do not act or speak as freely as do persons
perfectly sane, and such negative points are quite important.
Still there are cases, rare indeed, where no trace of confusion
can be found, and the person seems in full possession of his
faculties; but in any case this state is of short duration, and
always much shorter than the lucid interval following the
period of depression.
214 INSANITY AND ITS TREATMENT.
The stage of depression generally begins slowly, especially
in those cases which require much time to complete the cir-
cuit, but there are cases where it sets in abruptly. When it
comes on, how changed is the scene! and the more we ob-
serve, the more we wonder at the change so short a time has
wrought. The audacity and enterprise of mind have given
place to Sadness, discouragement and inertia; the patient dis-
trusts himself, thinks himself incapable of accomplishing any-
thing, becomes avaricious, irresolute, timid and yielding. Im-
agination is quiescent, and the intellectual efforts are wanting
in dash or vigor, often indeed a prey to the most sombre
thoughts; they bitterly regret the resolutions taken at other
times, seek to retrace their steps, and feel only disgust and in-
difference for all that lately aroused their enthusiasm.
At the beginning of this stage of depression, the patient,
instead of running after others to overwhelm them with a
torrent of words; instead of tormenting and playing tricks
upon those around, and giving himself up to pleasure, holds
himself aloof and speaks but seldom. Sometimes he acts as
though ashamed of the state that has just passed, and which
he remembers more or less perfectly. Others display great
humiliation. Gradually all these symptoms are intensified,
the patient remains quiet and alone. So much as he was
imperious and exacting in the period of excitement, so much
now is he humble in the time of depression, and at times this
humility goes so far as to induce a refusal of even needed care
and attention, on the ground that he is not worthy. This
abasement becomes daily more pronounced, until in extreme
cases, there comes a time when the patient seems almost trans-
formed into a statue. The instinct of self-preservation is so
weakened that the individual no longer seeks food, or even
accepts it when offered, unless strongly urged. The current
of ideas is also affected, but seldom reaches a complete suspen-
sion of the intellect. The emotions are weakened, he neither
manifests likes nor dislikes, but yields to any external influ-
ence. All spontaneity of action is lost, frequently it is neces-
sary to lead the patient from place to place; to dress and un-
dress him, or at least to give him the start in doing these
things.
FOLIE CIRCULAIRE. 215
The physical symptoms are as follows: The face is pale, the
features drawn down, indicating weakness rather than anxiety;
the eyes are dry, the lids about half opened, and all the senses
seem half asleep. He seems to have a feeling of general
malaise, and all his motor powers are in a torpid state. The
appetite is poor and he eats slowly; digestion is imperfect and
the act of defecation painful. Sleep is more natural than
during the excited stage, but it is neither regular nor peaceful.
Such is a brief picture of the stage of depression, which might
be spoken of as the base of a condition of melancholia, without
its relief, without its prominent delirious ideas. Still as we
have shown, in some cases these are not entirely absent and
we find ideas of humility, of ruin, of poisoning and self-wick-
edness.
The stage of depression is generally longer than that of ex-
citement, and it is long when the latter is also. There are
times, however, especially at the onset of the disease, when the
two periods seem about equal. This period after arriving at
its height, remains stationary a short time and then gradually
decreases to pass into what is known as a lucid interval.
Gradually the patient seems to come to himself; to awaken
to his relation to others; he comes out of his state of phy-
sical and mental torpor, he speaks more freely and returns to
his usual habits, although he retains a certain sluggishness in
his speech and actions. Ere long he appears to be in perfect
health, although close scrutiny detects in most cases a certain
lowering of the level of the intelligence. The state of de-
pression has not wholly passed, although to the Superficial ob-
server there appears a state of perfect health. In fact, the
more care and experience we bring to bear in our judgment
as to this transition stage, the more we shorten the duration
of the lucid interval, the more difficult is it to say that the
patient has perfectly recovered his reason. Still the lucid
interval does exist. It is usually shorter than either of the
other periods, but its length varies according to whether the
cycle covers a long or a short term; in the first case it too
may be quite long.
The same remarks that we made about the end of the stage
216 INSANITY AND ITS TREATMENT.
of melancholy, will apply equally to the lucid interval. The
keen observer already sees the impending excitement, when
the inexperienced still sees perfect reason. The symptoms of
the approaching excitement now appear and a new cycle of
disease begins, unfolding itself with the same features and the
same ending. Thus the life of this class of the insane seems
to move on in a regular circle. We have here sketched only
the outlines of this form of mental disease, which to our mind
merits a more careful study, but I think that you can gain
from my description a fair idea of the principal symptoms.
As I intimated before, this form of insanity has not been
noticed as it deserves; generally the observer, in forming his
diagnosis, contents himself with noting the condition of the
patient as it exists at a given time, instead of reviewing the
whole course of the disorder. Hence we are apt to class our
patients as maniacal or melancholic according as we see them
at the time. Then many times the physician is not able to
watch the patient long enough to enable him to form a correct
judgment. In other cases the severity of the attack is not
great enough that the person be secluded, or the services of a
physician secured, but he merely gets the name of being
“strange.” The parents and relatives are very reluctant to
acknowledge the insanity of the individual and resort to all
kinds of evasions to hide it. Thus the period of depression
is to them a time of mental lassitude and discouragement
which they ascribe to the most trivial causes, the person re-
mains at home, saying and doing little to attract attention.
During the excited period, the parents deceive themselves in
other ways; part of the time the person seems slightly ex-
hilarated, and the family pride themselves upon his gaiety,
brilliancy and wit. If he presents alteration of sentiment
and commits improper and malicious acts, he is peculiar, odd,
changeable, hard to live with, but it is seldom that the word
insane is ventured upon.
Folie circulaire occurs more frequently in women than men,
and is very apt to be hereditary. The prognosis is unfavor-
able so far as recovery is concerned; the most we can hope for
is to shorten and lighten the paroxysms, and lengthen the
MONOMANIA OR INSTINCTIVE INSANITY. 217
lucid interval. A knowledge of this form of mental disease
will often be of service in a medico-legal point of view. For
if a person affected by this form of insanity commits some of
fence against the law, the physician who is cognizant of the
existence of folie circulaire and understands its peculiar feat-
ures can distinctly show its presence; and at any stage in its
progress can point out its course, and the result will justify his
prognosis. He may thus protect innocent, because diseased,
persons from unjust punishment, and further the cause of
justice, as well as of humanity.
LECTURE XI.
Monomania or Instinctive Insanity.
The term monomania applied by Esquirol to the different
instinctive insanities in which the intellectual faculties remain
comparatively unaffected is entirely wanting in fitness; for in
this form of mental disease the delirium does not always fix
upon a single idea, nor a single set of ideas, and it may even
change its form. The term then should be discarded in favor
of that of “instinctive insanity,” as more accurately expressing
the psychical element specially affected.
If in instinctive insanity the imagination produces false,
absurd and ridiculous ideas, it is because, according to the
mental law which acts equally in the abnormal as in the
normal activities of the mind, it exercises itself conformably
to the strange or perverse passions which are produced by the
disease and hold it in an impassioned state.
In this form of insanity the memory is unimpaired; the
attention can be well sustained, and the patient is guilty of no
gross fault in reasoning; he gives to things their right names,
and, as a rule, their proper relations; a point very often over-
looked by those trying to feign insanity, as they are apt to
apply the wrong names to objects and to give senseless answers.
14
218 INSANITY AND ITS TREATMENT.
The will of the monomaniac at times manifests a tremend-
ous energy. When the passion ruling him imperiously de-
mands to be satisfied, he will seek that satisfaction with un-
parallelled tenacity; with the proverbial “will of a madman.”
The absence of all instinctive opposition to his powerful and
unvarying desire is the cause of this perseverance and energy
of will. Here, his will is only the active power of an impas-
sioned desire, and not of his deliberate free will or judgment;
this will or impulse does not partake of any freedom, it is
determined by the nature of the desire alone.
As a rule the homicidal monomaniac will kill with the
greatest Sang-froid, with the greatest calmness, without giving
any warning of the crime to be committed. The suicidal
monomaniac will make all his needed preparations with equal
coolness even when they require much time, as did those of a
Frenchman near Naples, who spent three or four years in
secretly making a guillotine, and who committed suicide the
day it was finished. All these instinctive insanities are serious
in their nature, because the cerebral disturbances giving rise
to these abnormal passions are generally deep-seated and per-
sistent.
This absence of all instinctive opposition to the ruling
desire, renders the patient not only very tenacious in his ideas
and wishes, but also exceedingly intolerant and reckless. If
this person reasons and forms conclusions leading to errors,
absurdities and immorality, it is because he is inspired and
directed by this controlling passion. If he judges after a pro-
cess of reasoning, he is still controlled by his passions for they
furnish the premises on which his arguments are based. If
he judges by instinct, it is again his passions which control
his instinct. The falsity, absurdity and immorality of these
judgments does not come from a lesion of the intellectual
faculties, since they are logically drawn from the premises
furnished, but they are due to the fact that these premises are
derived from the perverted state of the passions ruling the
mind. The reasoning powers are so far untouched, that upon
all other subjects the monomaniac can imagine, think, reason,
judge and act, conformably to the dictates of reason, basing
himself upon true premises.
MONOMANIA OR INSTINCTIVE INSANITY. 219
“As an argument against the existence of partial insanity
use has been made of the asserted unity of the intellect. The
intellect being a whole, it is said, it cannot be partly sound and
partly unsound. But this objection falls to the ground before
the fact that the origin and seat of these partial insanities lies
in the instinctive elements of the mind, and not in the intel-
lectual faculties, and that these latter become involved only as
a consequence of the former.
“Morever when they speak of the intellect as being one
they confound it with the mind which indeed is one. The
intellect is made up of three distinct faculties, viz: perception,
memory and the power of reflection. Again as has been in-
timated above, the seat of this class of insanities is in the in-
stinctive faculties of the mind and, as is well known, we have
here faculties of the most conflicting nature, such as moral
and immoral desires, perverted and eccentric wishes and pas-
sions of every kind and nature, good and bad, both in health
and disease, and any one of these may become the seat and
Source of a diseased or disordered condition of the mind, and
thence of the brain.” (Despine; de la Folie.)
The patient reasons so well about his false ideas, that in
hearing him talk we may easily forget that we are dealing with
a madman, and we try to overcome his delusions by sound
arguments, such as we could use toward a man of Sane mind
whom we thought in error. Despine relates a case of an in-
sane woman who experienced pains in the bowels after each
meal, and imagined that some One poisoned her food. She
reasoned so well upon every other subject, and even upon her
fixed idea, her premises being granted, that several times he
endeavored to overcome her error, by piling up proof upon
proof, forgetting that he was arguing with a person whose
brain was diseased. One day, after listening quietly and with-
out interruption she said to him, “You may be right, but I feel
that it is as I tell you, and nothing in the world can take away
that feeling or convince me to the contrary.” The words that
this woman used to show her belief were remarkably apt and
expressive, she did not say I think, or I know, but I feel; she
invoked no intellectual or material evidence, but the testimony
220 INSANITY AND ITS TREATMENT.
of her instincts, of her feelings, the most convincing of all
witnesses to the mind. Nothing will dissipate her delusion so
long as a cerebral trouble imposes upon her mind the feelings
of distrust and fear giving rise to this erroneous belief. It has
already persisted four years, and, as her disease is incurable,
the belief will never cease until all her mental faculties are
destroyed by dementia.
It is said with truth that an insane man is an unfortunate,
who knows not himself. No one is so strenuous as to his
sanity as is the insane, no one cries more persistently, “I have
a perfectly sound mind.” When a man, upon the border line
of insanity, perceives that he has become the prey of certain
passions and emotions which disturb his mind and control his
thoughts, he is not yet fully insane, but he has a suspicion or
fear lest he may become so. Such cases are common. But
when he does become insane such fears no longer trouble him,
and he deems himself rational.
An insane man who has committed a crime will deny his
insanity when brought into court, and judge and jury are apt
to take him at his word. Physicians as a rule are unwilling
to acknowledge the presence of insanity, unless they can also
detect some well marked pathological change. But that such
cases can occur is shown by the fact that old age often pro-
duces cerebral weakness, which, without being pathological,
is accompanied by the Ordinary physical symptoms of in-
sanity; together with disorders of the instinctive faculties,
such cases end in Senile dementia.
We will now consider instinctive insanity under the three
forms described by Esquirol and accepted by Dr. Ray.
1. Partial lesion of the intellect.
2. Affective mania.
We shall see that these two forms have a common origin in
one or many perverted or exaggerated instinctive elements,
placing the patient in an impassioned state.
The second of these two forms is especially dangerous, since
it is impulsive in its nature. The passion for killing for the
sake of killing; of robbing for the sake of robbery; of arson
for the sake of arson, are in fact passions which never arise in
MONOMANIA OR INSTINCTIVE INSANITY. 221
the healthy well-ordered brain; but only when the brain is
diseased or under the domination of some immoral influence.
And in such conditions we find an entire moral blindness of
the mind toward the wrong and evil nature of the acts com-
mitted, and hence no sense of remorse; since no sentiments of
a moral duty and conscience arises to conflict with them.
3. The third, which he calls lesion of the will or impulsive
insanity, consists in perverse desires, imperious, irresistible
even, which do not place him in this impassioned state, nor
bind him as to the morality of his acts. Then we see this
form presenting the singular mingling of sanity and insanity;
not upon different points, as in the first two forms of instinc-
tive mania, but upon the same point. This impulsive in-
sanity consists wholly in abnormal, perverse, irresistible im-
pulses, and is the one to which the term moral, should be con-
fined.
Partial Intellectual Mania.-This form of monomania mani-
fests itself by one or many delirious ideas created by the im-
agination under the influence of a ruling passion; a passion
which has been awakened in the mind by the pathological ac-
tivity of the brain. These ideas are generally remarkable for
their absurdity and exaggeration, sometimes for their per-
versity, and always by their falsity. These ideas, more than
any others, occupy the mind of the patient, and he, feeling by
the passion which controls that they are undoubted truths, be-
comes perfectly unconscious of, and blinded to, their true na-
ture.
These delirious ideas, so varied and grotesque, originating
from the passions, may vary according to the nature of the
feeling prompting them. Two opposite classes of feelings cor-
responding to the conditions of the brain may give rise to
these delirious ideas. Cheerful, expansive, ambitious, gener-
ous, proud emotions; passions marked by exaltation of mind,
correspond to an overactive condition of the diseased brain.
Passions marked by Sadness, moral weakness, discouragement,
distrust, fear, inactivity and indecision, all correspond to a
lessening in activity, a want of normal power in the brain.
But these latter emotions, without losing their character of de-
222 , INSANITY AND ITS TREATMENT.
pression, also have periods of activity; and the form of in-
sanity to which they give rise is called melancholia. If this
prostration in the cerebral action is excessive, it gives rise to
intellectual and moral stupor, the so-called melancholy with
stupor. That these two opposite mental conditions are ac-
companied by opposite physical conditions of the brain may
be reasonably supposed; for excessive physical restlessness
always accompanies the delirium of excitement, and great
prostration the depressed passions.
“In monomania proper, and in melancholia,” says Mauds-
ley, “we have a partial ideational insanity, with fixed delusion
upon one subject, or a few subjects, apart from which the pa-
tient reasons tolerably correctly. Psychologically speaking
the existence of a delusion indicates fundamental disorder of
mental action,-radical insanity, secondly, the delusion reacts
injuriously upon other mental phenomena, interfering Sec-
ondly with correct ratiocination, or due co-ordination of func-
tion, and predisposing to convulsive mental phenomena; and,
thirdly, while it cannot be subordinated to reflection, the in-
dividual may, at any moment, be subordinated to it, and act
under its instigation.”
The following are some of the more common delirious ideas.
The expansive, vain, ambitious sentiments produce ideas of
grandeur, power, riches and of generosity. He fancies that
his coffers are filled with gold; he leaves his ordinary occupa-
tion to engage in wild, irrational speculations, in whose success
he firmly believes; he claims to rule the stars and the clouds,
he threatens rain or a drought, he calls himself prince, or some
illustrious man of ancient or modern times, king, pope, and
God himself, and so far as possible he plays the character he
assumes. Under the influence of strong emotions of distrust,
fear and sadness, he believes himself persecuted, followed by
the police, persecuted by secret societies, and the inquisition;
pursued by implacable enemies; ruined or dishonored; he
sees a trap in the most trifling incident, a threat in the most
natural expression. He hears things constantly, and is always
trembling, he doubts everything and everyone. One person
thinks his limbs are glass and dares not move for fear of
MONOMAN1A OR INSTINCTIVE INSANITY. 223
breaking them; another dares not urinate lest he flood the
country. The pains that they experience in the different
parts of the body, become a basis for their false ideas.
He may think that his bowels are obstructed, and all
his viscera destroyed, that he has no stomach, he cannot
swallow, nor go to stool; his food is poisoned so that
he refuses to eat and drink, and his fear and distrust are so
great that he will die from hunger and thirst for fear of being
poisoned. Another, if the general sensitiveness of the skin is
increased, thinks that his nourishment passes through its
pores; that he is eaten by animals and devils. If deceived
by hallucinations of smell, or disagreeably impressed by the
unpleasant exhalations of their bodies, they think they are
becoming corrupt. You will notice that some of these same
false ideas were present both in ordinary cases of mania and
melancholia; but in melancholia, beside these special ideas,
we find general sadness and depression; fear, distrust and dis-
couragement coloring all the thoughts. Melancholics are the
most unhappy people in the world, and merit all our sym-
pathy and pity; they suffer just as much as if there was a
real cause. The insane person who thinks himself con-
demned to death, suffers as much as the criminal awaiting
the hour of execution. Under the influence of the sad feel-
ings which control them, the insane fancy all kind of dangers
and horrors, and they are in a measure held absorbed in these
ideas by the hallucinations that often accompany them. I do
not say, however, that the hallucinations render these ideas
more tenacious, for when the cerebral trouble is cured, the
hallucinations are counted at their true value. It is not
always easy to refer a delirious idea to the emotion prompt-
ing it; but the important thing for the psychologist to keep in
mind, is, that the source of the delirious ideas of the insane is
in the instinctive elements which control his mind and direct
his thoughts, and also that the nature of their ideas depends
upon the nature of the passions arising in the brain.
The reasoning faculty is unaltered. The monomaniac rea-
sons as formerly; from the premises which he accepts he
draws his conclusions as rationally as if Sane, Upon all
224 INSANITY AND ITS TREATMENT.
which concerns his ruling passion he takes as a base, for pre-
mises, the false, absurd and perverted ideas prompted and in-
spired by that passion. With such a basis, the conclusions
and judgments must be equally irrational and absurd; but
since his mind is entirely controlled by this passion, no idea
can arise of sufficient weight to oppose or correct the errone-
ous ones, and the faculty of comparison being lost he cannot
judge aright. Thus the conclusions reached by the insane
are in necessary sequence to their premises. The judgments
are false, absurd and irrational from premises of the same
nature; but they are true, just and moral when they are de-
rived from right premises; and thus we see how a person can
be under the influence of partial insanity.
Says Despine (Psychologie Naturelle): “In an attack of mania
a man strips off his clothes in public, crying out that he is
father Adam, and has no need of clothing. To what elements
shall we refer these ideas? Doubtless to an unbounded pride
which led him to suppose himself a celebrated person, and he
chose that person who chanced to be present to his mind at
the moment when this feeling demanded to be personified, to
be fixed in some outward form. Then starting from the idea
that he is Adam, he concludes that he ought to wear no
clothes since Adam wore none. In such a case the saliant
points really teach little, while the pride, the very foundation,
scarcely appears.”
Some very interesting examples of the tenacity with which
the monomaniac will cling to his delusions, and the manner
in which every occurrence is made to contribute to the ruling
or dominant passion of the mind will now be given.
These cases were reported by Drs. Drouet and Foville, at a
meeting of the Medico-Psychological Society at Paris, in 1872.
Says Dr. Drouet: “During the siege of Paris by the Prussians,
I was sent with 550 patients from the asylum at Ville-Evrard
to that at Vauclose. Everything around us vividly portrayed
the scenes of war, and if the patients had been sane they
would have taken an active part in the disastrous events
which succeeded each other so rapidly. But they remained
passive and indifferent. Strange to say, in spite of the inces-
MONOMANIA OR INSTINCTIVE INSANITY. 225
sant roaring of cannon, and the other signs of war, Some of
the patients insisted that there was no war, and that we were
making use of ridiculous pretexts in order to keep them shut
up. Some of the patients escaping were driven back by the
Prussians, and even then were scarcely convinced of the real-
ity of the blockade.”
Dr. Foville reported that a similar state of mind existed
among his patients at Charenton. The situation of this hos-
pital was such as to overlook a large extent of country, and
here, for months, the most vivid and realistic scenes of war
were daily witnessed, embracing all the engagements on the
southern side of Paris. Three forts, many redoubts and num-
erous batteries were constantly giving proof of their existence
to the eye and ear.
The combats of Ville-juif, Choisy, Rond-Pompadour, Cré-
tail, and Montmédy took place in full view; the whole country
was filled with soldiers, and the coming and going of artillery,
infantry and ambulances. A few of the inmates watched the
progress of events with a fair degree of interest, but the num-
ber was very small.
“As a rule the patients remained completely indifferent to
all that was taking place so near them; their impressionability
was too much deadened, or they were too much absorbed in the inner
contemplation of their delirium to take any interest in the outside
world or its events. Others, and these excited my great surprise,
were in a state to notice all these occurrences, but they never
recognized their true nature, nor believed in the reality of the
war. They saw and heard everything, but interpreting it all
in the light of their delirious conceptions, denied their reality
and believed that it was all done to deceive them.
“The explanations varied in different cases. Mr. X. told
us each day that this pretended war was only a comedy, whose
successive scenes had been prearranged between the French
and Prussian governments. The proof was that all the arms,
muskets and cannons were only charged with powder. All
that was told him as to the wounded and dead was pure in-
vention. If by chance a ball had been fired it was by acci-
dent, or through the treachery of some evil disposed person.
226 INSANITY AND ITS TREATMENT.
All those around might be deceived by the comedy, but it was
useless to try to fool him, for he knew too much.”
The blindness of mind in this case was very remarkable.
According to the ruling passion directing his thoughts two
nations had conspired to deceive one individual, and for this
purpose had brought together in mock battle thousands of
men and spent enormous sums.
“Another patient who read all the papers and appeared to
follow all the events with intelligence affirmed that he was not
foolish enough to believe all the accounts he read, nor accept
as real the noise of the artillery.
“During the second siege, and the terrible cannonade of the
last days of the fighting in the streets of Paris, he preserved
the same attitude. Even to-day he assures me that he was
never the dupe of what he was told; he knows that Paris was
never really besieged; that all the noise he heard was made
by some fools who fired the cannon to amuse themselves, but
whose real motive was to drive him, Prince Emile, to extremi-
ties, and to have a pretext for causing him to starve, by re-
ducing more and more the supply of food for the whole insti-
tution.
A still more remarkable case is that of Z., a captain in the
Imperial Guard who labored under delusions of persecution
with hallucination, and was admitted into the asylum at Char-
enton only a few weeks before the breaking out of the war.
“One would naturally suppose,” says Dr. Foville, “that his
profession, his having many friends in the army, and his com-
parative clearness of mind, which in many respects was per-
fect, would have caused him to be interested in the military
events, and that he would have followed the various reverses
of the war with an intense interest. But the opposite was true.
He constantly denied the most evident facts. The succession
of disasters, the investment of Paris, the capitulation of Metz,
when his regiment and comrades were made prisoners, the
fights around Paris, which took place before his eyes, the
bombardment from the forts, which he constantly heard, the in-
surrection in Paris and its deplorable results, and the formation
of a second army, all was to him as if it had never happened.
MONOMANIA OR INSTINCTIVE INSANITY. 227
He never ceased to believe that the empire was at peace, and
the emperor at the Tuileries; that all means of communica-
tion were open, and that it was due to our making common
cause with his persecutors that no letters were received from
or sent to his friends; also that all the cannonading round the
house was made by some of the officers of his regiment, whom
he mamed, for the purpose of tormenting him. When he read
the papers containing an account of all these military events
he would insist that they were copies printed especially for
the purpose of deceiving him; and he persisted in this belief
even when he was handed his five or six different journals all
of the same date relating the same facts; and he insisted that
the Imperial Guard was still at Versailles, the empire at peace,
and Metz not captured.”
We have said that these delirious ideas are the offspring of
the imagination. But what is the imagination? It is the
faculty of forming ideas under the guidance of the instinctive
elements of our being, by means of previously acquired knowl-
edge. The results furnished by this knowledge are the
more readily accepted by the mind for the formation of delir-
ious ideas, the more closely they are related to the ruling pas-
sion. The patient possessed with fear, soon creates some vivid
fixed idea upon which that emotion can rest. The most in-
significant objects serve as a focus upon which the passion
can ultimate itself. A hastily spoken word, a blade of grass,
a pain, a sudden encounter, a memory, an event impressing
the mind, political, religious, scientific, social and other ideas,
the whim of the moment, in fact anything and everything, is
seized by the imagination to give form and expression to the
passion; no difficulties nor impossibilities will stand in the
way of its adaptation to the diseased emotion; and this is
equally true with regard to the insane and the man in anger.
For example: A man becoming insane had some little pim-
ples of acne on his face. Under the influence of the dread
and distrust which were his ruling passions, these scarcely
perceptible pimples became the focus of his delirious ideas.
He thought himself hideously disfigured, and constantly
viewed himself in a hand-mirror which he carried with him.
228 INSANITY AND ITS TREATMENT.
He said that he was an object of disgust to the family, and he
wished to leave home and remain in a hospital until cured of
what seemed to him a serious disease. Sometimes the in-
Sanity developed in the advanced years of life, is only an ex-
aggeration of the eccentric, erratic traits of character natural
to the individual; such was the case with the celebrated J. J.
Rousseau, whose melancholy terminated in suicide. M’me de
Stael says of him: “His mind was slow but ardent. He had
no sudden impulses, but all his thoughts grew by reflection.
He would at times become enamored of a woman merely by
thinking about her while absent. Sometimes he would leave
you on more than friendly terms, but if, perchance, you had
Said a word that could displease him, he would recall it, ex-
aggerate it, think and brood over it for days, finishing by get-
ting angry with you.”
In order to give you an idea of the influence of the feelings
upon the nature of the thoughts created by the imagination,
I will quote from a letter written by a hypochondriac. “If I
decide to ride horseback, I see myself falling from the horse
and bruised on the rocks; the idea of a sea-voyage always leads
to that of ship-wreck. In the country the fear of snakes con-
stantly pursues me, it even seems that they are in my bed. No
matter how secure my chamber may be, I cannot go to bed
without making a thorough search for serpents, and I scarcely
dare to sleep. I have this same dread in the city. Sometimes
I figure to myself that an assassin is concealed under the bed,
and the least noise awakens me with fright, so that I never
would consent to sleep in a house alone. I always have pres-
ent to my imagination the objects, persons and even the
places of which I hear mention. If I am told of the death of
Some one, I immediately see it all; I see the coffin placed in
the hearse, and lowered into the grave. Often indeed I see
myself dead, and assist at my own funeral. Would you believe
that for ten years, I have never gone to bed without thinking
of death; frequently I have been sure of dying in the night.”
The following case shows how the delirious ideas of the
monomaniac may change, not only by some modification in
the nature of his ruling passion, but by some trifling incident,
the passion remaining the same.
MONOMANIA OR INSTINCTIVE INSANITY. 229
“A man with a somewhat extended knowledge of anatomy
and physiology, pretended for some years that his brain was
the seat of a hyperaemia, for whose relief he thought a very
active and heroic treatment was needed. He dieted most
rigorously, bathed frequently and employed blood-letting.
These hypochondriacal ideas so disturbed his peace of mind,
that he constantly changed his place of abode, to escape the
dangers his health constantly encountered. In the hope of
quieting this restlessness, his father told him that this frequent
change of residence had attracted the attention of the police.
From that time thoughts of the police took possession of him.
He dares not remain anywhere, for fear of arrest, he believes
himself constantly watched, and uses all his efforts to escape
the detectives.” To the fear of being sick, has succeeded that
of being arrested. The monomania remains the same; the
form of the idea alone has changed; and the new idea has
only been adopted because it accords perfectly with the ruling
sentiment of fear and suspicion.
When the intellectual monomania comes on slowly it begins
in general with some ficed idea. Given an individual, weak
and nervous; endowed with an acute sensibility, and some day
a word, an emotion, a fright, a joy may leave a profound im-
pression. The thoughts arising in this manner lay hold on the
mind, besiege it, and control its conceptions. For a time the
individual may fully appreciate the absurdity, foolishness, or
criminality of the idea; he seeks to overcome it; fights against
it, and remains months and even years in a state of moral
anguish; while his free will is not entirely gone, so far as his
acts are concerned; at least, if his thoughts and conduct are
influenced there is not clear delirium. In such cases it is
difficult for the observer to define, and easy for the individual
to pass, the limit between reason and insanity.
Van Swieten narrates a curious instance of this fixed idea.
“A man having heard that many persons bitten by a mad
dog were in turn attacked with hydrophobia in spite of copi-
ous blood-letting, conceived the idea, that if the surgeons used
the same lancet in other cases, they in turn would become in-
oculated with the virus, and then communicate the poison to
230 INSANITY AND ITS TREATMENT.
others. To save himself from so great a misfortune he re-
Solved in future never to allow any one to touch him, and in
spite of his love for his wife and children, he did not even ex-
cept them.”
Taking for granted this fixed idea as being absolutely true,
it serves as a point of departure; a point on which all the
ideas and actions depend; and the mind follows out its con-
clusions even to delirium. The actions, too, are not slow to
conform to the diseased conceptions, they also become extrav-
agant and absurd. Limited at first to one idea, or train of
ideas, the insanity grows step by step, occupying each day
new ground, and finishing by encroaching upon all the
thoughts and acts.
Such is the mode of development of the monomanias. If
the partial delirium is once organized and arranged, it holds
on with an immovable tenacity; the patient interprets every
word and action, even the most trifling, in the light of his
false beliefs. If we try to argue with him, to convince him of
his error, it is in vain that we bring the clearest proofs. He
argues, resists, and entrenches himself behind his convictions
with an unshaken obstinacy. If we do make him confess that
his enemies are imaginary, that the one he suspects is really
his friend, that the invention claiming his attention is im-
practicable, we perhaps think him cured, as we receive his
most solemn avowals, but an hour afterward the same doubts,
beliefs, and convictions reappear. Far from curing these
monomaniacs, such discussions only excite them, make them
seek new arguments to strengthen their position, and settle
them more firmly than ever in their error. It is only with
the convalescents who begin to doubt and hesitate that argu-
ment can be of any use.
The following case is of especial interest, as it is such as you
are liable to meet any day in general practice; it was reported
by Dr. Despine in his work De la Folie.
“M. X., merchant, aged 35, Sanguine and bilious tempera
ment, presented himself in my office, and said, ‘Doctor, I have
a very singular disorder. At times I am possessed by extra-
ordinary ideas for which I cannot account. I have a child
MONOMANIA OR INSTINCTIVE INSANITY. 231
eight years old whom I love dearly, and yet at times I detest
it. I also experience the same disgust toward my wife. If
any one contradicts or even speaks to me, it puts me in a rage,
and I break out against my father-in-law and my mother-in-
law who are most excellent people. These thoughts, after
lasting a few days will suddenly disappear. Then I experi-
ence the most vivid chagrin for what has passed, and ask par-
don for the insults and abuse that I have offered.
“‘Moreover I have during the past few years persistently
solicited my sister-in-law, and afterwards when my lustful
thoughts have left me, I would deplore my conduct and ex-
press my sincere regret. I cannot account for this passion, for
my wife is far preferable to her sister. Also it has many times
happened that I would become enamored of old women, ugly
and disgusting. I would constantly think about them and
they would seem to be the handsomest women in the world.
In the intervals when I recovered my senses, I recognized the
absurdity of such behavior, and, wishing to cure myself at
any price, I thought the most successful way would be to seek
out and enjoy the society of the most beautiful of the demi-
monde, and I spared no expense; but in the company of those
women I was as cold as ice, and they inspired me only with
disgust.
“‘When my evil thoughts were present they would pursue
me even in my dreams, in which I would talk out loud, so
that my wife learned what I was doing, and experienced great
grief and distress of mind. In fact I do not know but what
it is insanity. Still I have an excellent memory. I do a
business of $100,000 per year, and keep my own books; and I
make no mistakes in business, even when most fully under
the influence of my worst thoughts. My affairs are prosper-
ous, and although I am making money I am one of the most
unfortunate of men.’ .i.
“His physical condition showed that he was subject to obsti-
nate constipation, and when his dark thoughts came on he
had pain in his head, an indefinable but painful sensation in
the chest, a load at the epigastrium, and a stricture at the
throat. Under the influence of repeated laxatives and a tem-
232 INSANITY AND ITS TREATMENT.
perate diet, together with frequent and prolonged baths, these
physical disturbances were corrected, and for the past two
years his normal mental phenomena have not made their
appearance.”
Dr. Despine also relates the following curious case of affect-
ive monomania: “At the hospital at Jenno, in Italy, there
was an epileptic, æt. 47, who, after having had several mania-
cal attacks, was seized with a violent passion and desire for eat-
ing human flesh. One day he tore with his teeth the whole
cheek of a child. Escaping from the asylum he went to his
own home, and found his little girl, aet. 2, asleep. He threw
himself upon her, and devoured the buttocks, the chest and
thighs, and the unfortunate child lingered two days. Next
the epileptic attacked his wife, who resisted with all her
strength. Then the man laid hold of a child, aet. 5, which
his wife had in her arms, but after a hard struggle the
child was saved. The epileptic was seized, bound and carried
to prison, and thence back to the asylum.”
The symptomatology of monolmania varies greatly accord-
ing to the extent to which the mind is under the control of
the delirious ideas. Some persons filled with dread of being
poisoned, with scruples of a religious nature, and fear of im-
aginary enemies, can, in the presence of strangers, conceal
their false conceptions and mingle in the world, which notices
in them only eccentric and original ways, without suspecting
the strange ideas which serve as motives to their peculiarities.
When closely watched and questioned, these persons will avow
and discuss their false ideas, and then give full rein to their
delirium; but conversing on different matters, they reason with
judgment, and often seem to have perfect intellectual Sound-
IleSS.
With others the symptoms are more marked; the periods of
quiet alternate with paroxysms coming on under the influence
of some strong emotions, exposure to heat or cold, menstrua-
tion, and even without any appreciable cause. During these
paroxysms the delirium extends itself, becomes general, and
loses its character as a partial delirium; this phase of the mal-
ady together with its essentially progressive character, has
MONOMANIA OR INSTINCTIVE INSANITY. 233
been much insisted upon by those writers who deny the exist-
ence of monomania; but they neglect to note that this state
of things is only transient; that during the periods of remis-
sion, these accessory delirious ideas disappear to leave clear
and distinct the conceptions and delusions which first gave
the malady its distinctive stamp; it is like a river which at
times may overflow its banks but always finishes by returning
to its own bed and course.
These periods of excitement in monomania are not as a rule
dangerous, and only require quieting measures and an in-
creased watchfulness. They may however assume a more
grave aspect, and offer all the signs of acute mania; and at
times it happens that new delusions developed during this
paroxysm of delirium may remain after the paroxysm has
ceased; the monomania then becomes more extensive and also
presents a more unfavorable prognosis.
Some have thought that this general delirium which at
times springs up in cases of monomania, may exercise a favor-
able influence upon the latter; that delirium having in-
flicted such a general shock and overtürning to the intellectual
powers, will, in its departure, bear with it the previous isolated
delusions. With this view some physicians have sought to
produce such a state of things, but seldom with the success
desired.
In general terms the prognosis of monomania is more un-
favorable than that of either mania or melancholia, and this
is a little surprising, for it would seem that a delirium affecting
only parts of the intellect, would be more favorable than one
invading the whole; when, however, the monomania is recent,
of slight extent, and has not yet had time to affect our actions;
when it has arisen suddenly, and is not the result of a train
of thought extending over months, it is curable; the cure,
however, takes place slowly and gradually; and as in other
forms of insanity the patient may have a relapse.
When the monomania is not curable, it is prolonged in-
definitely, with alternate periods of calm and excitement; the
ideas preserve with varying shades, the same character as at
the beginning of the malady, though at length they lose some
15
234 INSANITY AND ITS TRfATMENT,
of their activity, They become less numerous, less fruitful
and consistent; the patient speaks of nothing new, he employs
the same terms and moves in the same routine; as Falret says,
“his delirium has become stereotyped.” There is already a de-
gree of intellectual weakening. As to dementia proper it
supervenes only after a long time and is never complete. We
may see patients of twenty years standing who preserve a re-
markable vigor of mind, as if the constant exercise of a cer-
tain portion of the brain faculties had retarded any weaken-
ing of the intelligence.
How are we to distinguish monomania from mania and from
melancholia? In mania there is a general state of excitement,
manifested not only by a general incoherent delirium, but
also by an overactivity of all the organic functions. Melan-
cholia is characterized by an entirely opposite condition of
things; by a depression and mental stupor affecting the whole
system. Every motion, gesture, and word of the patient,
speaks of these two conditions, exhilaration or depression. In
monomania the case is different, the patient is neither excited
or depressed, he apparently lives like the rest of the world;
preserves a normal degree of activity, and seldom betrays by
his looks any of his false beliefs. A man may have a fixed
idea of a melancholy nature, for example, that he is ruined.
If, holding this false belief, he shapes all his actions in accord
therewith, he may yet go and come, and transact his business
as usual, but he is a victim of monomania. If, again, this
false idea extends itself, affects the whole intellect, and leads
to depression, inactivity and stupor, we have a case of melan-
cholia.
This is the diagnostic sign which first attracts the attention
of the observer. On more closely examining the patient, we
learn that his delirium, beyond certain well defined limits,
does not impede his intellectual workings. He is neither in-
coherent like the maniac, whose ideas are numerous, rapid and
uncertain; nor confused like the melancholic, who restricts
himself to monotonous, vague and burdensome thoughts. Far
from this, the delirious ideas in monomania are logical and
perfectly systematic in their arrangement; everything is order-
MONOMANIA OR INSTINCTIVE INSANITY. 235
ly and coherent, and we soon see that there is no general dis-
turbance exalting or obscuring our mental operations.
The question of diagnosis being settled in a given case, we
have next to inquire as to the extent or limit of this delirium;
and here we must be on our guard against the deceptive results
of a careless examination. One patient will talk only of him-
self and his troubles; another, especially when hallucinations
are present, holds himself aloof from the physician, conceals
his delusions, and only allows them to escape him by accident
or from skilful cross questioning. Such patients have set
phrases which do not deceive the skilled alienist. Their accu-
sations are vague and always of one kind. They are tormented,
persecuted, followed. A phrase of this sort will soon open the
way for you to lay bare the whole extent of the delusions.
A full enumeration of the various intellectual monomanias
would be impossible; they are so numerous and varied that
we meet with no two cases exactly alike. The delirious con-
ceptions bear as a rule the imprint of the surroundings in
which the patient has lived, and the manners and customs of
sóciety. In olden times they believed themselves persecuted
with the wrath of the gods; in the middle ages the belief in
sorcery, witchcraft, and diabolical possession gave to their de-
lusions a character of their own. In our day, the new forms
of government, the watchfulness exercised over all citizens;
the new and wonderful discoveries in physics and chemistry
have given rise to the belief in persecution by the police and
detectives, and that one is a victim to the mysterious tortures
of electricity and magnetism.
In the lectures upon Epileptic and Moral Insanity your
attention will be called to those cases of monomania charac-
terized by homicidal impulses, and in our next lecture we will
consider those varieties called respectively Pyromania, Suici-
dal Mania, and Kleptomania.
Time does not permit us to give a detailed study to each of
the many varieties of monomania to which special names have
been given.
236 INSANITY AND ITS TREATMENT.
LECTURE XII.
Pyromania, Suicidal Mania, Kleptomania.
Pyromania.
Pyromania or the monomania for burning, consists in an
instinctive desire, or an irresistible impulse to commit arson,
to set something on fire. But you will please bear in mind
that it is to set fire without any adequate motive, and not for
purposes of revenge. We must here draw a clear line of dis-
tinction between those suffering from pyromania, and those
maniacs or imbeciles, who, to satisfy their vengeance, or pro-
cure means of escape, will set fire to the house of a neighbor,
or even to the asylum in which they dwell. The true pyro-
maniac obeys an impulse, a command; he burns the house of
his friend and neighbor, and even his own, as readily as that
of an enemy. Maniacs and the demented; imbeciles and
idiots only set fire incidentally or at the instigation of others.
Pyromania, like the other forms of insanity, springs from
various causes, such as age, Sex, approach of puberty, the in-
fluence of heredity, difficult menstruation, nostalgia, etc.
As I think that a well told typical case will give you a better
idea of pyromania than any description of my own, I will
translate a case given by Le Grand Du Saulle in his work en-
titled, “La Folie devant les Tribunaux,” p. 463.
“Mary Anne B., aged 40, laundress, is a robust woman, with
reddish hair and complexion. Of a nervous sanguine tem-
perament, she has always enjoyed excellent health except that
the menstrual flow has been scanty. Mary has usually been
bled twice a year; if she neglected this precaution she has
headache, ringing in the ears, and flashes of light before the
eyes. Her father was an epileptic and her mother was called
strange and original. Mary has been married for six years to
an excellent man of steady habits.
“In the year 1850, many fires occurred within a short time
PYROMANIA. 237
in the village where Mary lived, and among others her house
was burned. The suspicions of the authorities being aroused
by some peculiarities of conduct, Mary was arrested. The
judge examining her was surprised by her calm impassibility,
her serenity of mind, and especially by her great frankness.
She would have been severely dealt with, had not the magis-
trate in the midst of her avowals, perceived symptoms of hal-
lucination. Desirous of further information as to her mental
condition, he called in the aid of a medical expert, who de-
cided, after a careful examination, that she ought to be sent
to an asylum for detention and further observation. On her
arrival at the asylum she showed no signs of excitement or
depression of mind; answered rationally all the questions
asked, asked for some work to do; and ate and slept well. A
few days after her admission, Dr. Du Saulle had a long inter-
view with her, the substance of which is as follows: }
Q.—Do you know where you are?
A.—Yes, at the Petit Maison.
Q.—Why are you here?
A.—Probably because I set fires in my village; but what of
that? I was almost forced to it, and beside it pleased me so
much.
Q.—What forced you to it?
A.—Reasons which concern me alone.
Q.—What were these reasons?
A.—First, my own gratification.
Q.—What gratification would you feel in setting a fire?
A.—I should get rid of my shadow. (Cauchemar.)
Q.—What do you mean by your shadow 7
A.—My shadow is a kind of phantom, a black spectre, a
black shade, which I often see to my right or left; in front or
behind; it follows me, torments me, and lays hold on my
IlêI’VéS.
Q.—Does your shadow talk?
A.—Usually not, but one day it insulted me, but I rebuked
it so effectually that it has not opened its mouth since.
Q.—Is it to rid yourself of your shadow that you set fires?
A.—Yes; because it goes away as soon as I approach a fire,
238 INSANITY AND ITS TREATMENT.
or go near a stove, in my laundry, or when I wash clothes by
the river side in the hot sun.
Q.—For how long a time has this shadow followed you?
A.—Ever since the house of father F. was struck by light-
ning and burned. It was at night; I heard the noise, arose,
saw the flames and was terribly frightened; in a short time
that feeling passed away, and as soon as the fire was out, I
wished to see it again.
Q.—Had you your courses at the time?
A.—Yes, they had commenced the evening before, but were
suddenly stopped, and did not re-appear until thirty-nine days
afterwards.
Q.—How soon after the fire did you notice the appearance
of this shadow 2
A.—I think it was the next day. The black mass fright-
ened me. I would have given the world to get rid of it, but
no matter where I went, that shadow followed me. All at
once I noticed that a fire made it disappear.
Q.—Before remarking this, had you not already made up
your mind to set fire?
A.—Yes and no; a multitude of thoughts were in my head;
I cannot explain to you how I felt; but perhaps I might have
thought of setting fires.
Q.—Then you persisted more decidedly in your incipient
resolution, when you discovered that fire caused your shadow
to disappear 2
A.—Yes, certainly.
Q.—When did you set a fire for the first time?
A—Fifteen days after the burning of Father F.'s house. I
could not control myself. I went to the house of Mrs. D. in
her absence, and I lit a fire under a chair, near her bed. I
then went home and was very uneasy until I learned from
the neighbors, and the noises outdoor, that Mrs. D.'s house
was on fire. Then I felt as if cured. I went into her cham-
ber which was transformed into a vast furnace, and saved
many of the articles of furniture belonging to poor Mrs. D. I
then went into the street for some fresh air, as I felt stifled.
Q.—At that moment did you feel no remorse of conscience?
PYROMANIA. 239
A.—No, but I was not perfectly at my ease, and I think that
if any one had spoken to me, I could not have answered. I
should have been as one drunk.
Q.—Had you any motive for choosing Mrs. D. 7
A.—It happened to her as to any one; I had no spite against
her, no particular choice.
Q.—Did any one in the village suspect you of being the
author of these fires 2
A.—That may have been the case, the world is so corrupt.
Q.—Did you not set fire to your own house 2
A.—Yes, and lost everything.
(IHere Mary appeared to be much moved, and wept for some
moments.)
Q.—What reasons impelled you to burn your house?
A.—It was, I hardly know what, a necessity, a craving to
See a fire; a fire is so beautiful. I was in ecstasy when I saw
the flames flashing out from the old roofs of thatch. It was
so beautiful that even the good God could not be more so !
(Here she threw herself suddenly upon her knees and raised
her eyes to heaven.)
Q.—And your shadow, what became of it?
A.—It was scorched, melted down, burned to ashes, and
spread all around the odors of roasted meat. *
Q.—Have you sometimes thought Óf the state of poverty
into which your husband was thrown by the burning of your
house and furniture?
A.—Yes, and in a whisper I called myself huzzy. . It was
certainly very wrong; I did wrong toward my husband who
is a good man, and whom I love, and besides, I had the fool-
1shness to burn all my effects.
Q.—Did you not save the most valuable of your things?
A.—I forgot everything and all were lost.
Q.—Was your house insured?
A.—It seems that it was.
Q–Did you expect that the insurance company would pay
you enough to make up for your loss on the furniture and
house?
A.—I never troubled myself about it at all; my husband
240 INSANITY AND ITS TREATMENT.
arranged it in some way; but it seems that we were insured.
I did not look so far ahead as that.
Q.—Was your furniture insured?
A.—I do not know, and I do not know whether furniture
can be insured like a house.
Q.—Where did you go after your house was burned?
A.—To my sister-in-law.
Q.—And your husband?
A.—I believe he went somewhere in the village. I have
not seen him since, poor man.
Q.—While your sister-in-law received you so hospitably did
you not try to set fire to her house?
A.—Yes, twice; but it did not burn.
Q.—Did you expect to escape detection always?
A.—I have never reflected about the results of my Conduct;
they might put me in prison, condemn me, or put me to
death ; I know it well enough; but my blood would lie upon
the heads of my executioners, for such as you see me, I am not
wicked. &
Q.—Do you fulfil with zeal your religious duties?
A.—Yes, but I no longer dared go to confession, for I would
have been obliged to tell everything to the priest, and he
might not have understood my reasons; he probably would
have repulsed me as a wicked woman; me, who am innocent
of evil. I am like the men who are drunk, they keep calling
for liquor, and when I have once seen a fire it gives me a de-
sire to burn everything. They have put me in this asylum,
but I am no more crazy than you are. To put me in an asy-
lum ! me, who was so happy and free from cares before all
this; but God is more powerful than you, and he will deliver
me. This person who showed much intelligence in her ex-
amination quickly recovered, but having a relapse Some time
after, committed suicide.
The monomania for burning is produced by such varied
causes, and presents itself under circumstances so dissimilar,
that it is convenient to consider it under the heads of com-
plete and incomplete pyromania.
As was said before, it is not rare to meet with different in-
PYROMANIA. 241
same patients who attempt to set fire to the asylum in which
they dwell, prompted by different motives, but generally per-
haps by the hope of escaping in the confusion; such cases are
familiar to the officers of every asylum, and Esquirol relates
Some interesting cases in his classic work.
A young man while taking a trip on horseback during the
hot months, had his head affected so as to become slightly
delirious, when the bystanders approached he thought that he
had fallen into the hands of robbers; he set fire to the house
where he had been hospitably received, in order to escape from
what he thought to be a den of robbers.
Schlegel relates the case of a woman affected by religious
melancholy who attempted suicide by setting fire to her bed.
She had shown no disturbance of the intellect except religious
exaltation and a disgust of life.
Sometimes we find that intense home-sickness, or an im-
passioned condition will lead children, and persons of rather
feeble intellect to set fire, and such cases come under the head
of incomplete pyromania; as a rule they do not feel the irre-
sistible impulse. It generally occurs with young children, or
children in servitude who strongly desire to go to their own
homes, being harshly treated by their masters. This nostal-
gia produces in them a state of sadness akin to melancholia,
accompanied by feelings of anxiety, tears, loss of sleep and of
flesh.
A young boy aged fourteen, having been punished, set fire
to his master's house, that he might return to his parents.
A girl fifteen years old, while suffering from home-sickness,
or nostalgia, made two incendiary attempts in order that she
might be able to leave the service of her employers. She
stated that from the moment she entered their service she was
unceasingly beset by the desire of burning buildings. It
seemed as if a shade that was constantly before her impelled
her to acts of incendiarism. It appeared that she had long
suffered violent pains in her head, and had never menstruated.
A young girl, aet. 12, had her intellect somewhat weakened
by a brain fever, and soon afterwards took service with a
farmer near London. While there she set fire to a bed, and
242 INSANITY AND ITS TREATMENT.
then went and told the family what she had done, and the
fire was quickly stopped. This child made the following
answers to the magistrate examining her: “I did not intend
any harm, I only wanted to see if I brought a lighted candle
near the bed curtain it would set it afire. I was curious to
See the flame, for I thought it would be finer than a coal fire,
or the wood fire in the fire-place. I had no hatred toward
my master, I was well treated by him; I did not think it was
Wrong to burn a poor, miserable bed, when he is rich enough
to buy another. I did not reflect that I was committing a
crime in setting fire to the property of another; I only
wanted to see a bonfire; if I had know that I should be
hanged for making a bonfire, I should not have made it.”
A young wheelwright's apprentice, act. 18, living in the
country, set sixteen fires in the space of four months. He
always carried with him a sponge and thread covered with
sulphur, and though he would steal to procure means to
Satisfy his appetite and pleasures, he never robbed the houses
that he fired. He had no revengeful motives, but when the
flames burst out, he felt happy; this joy was increased by the
sound of the bells, the lamentations, the cries and despair of
the people; so much so that as soon as the bells began to ring
he was forced to quit work, his mind and his body were so
excited.
Incomplete pyromania, caused by nostalgia, development of
puberty, menstrual irregularities, etc., may sometimes be com-
plicated with kleptomania, or a desire to steal; the following
is a typical case: º
“Catharine Lambert, aet. 15%, with menstrual irregularities,
went from the country to Paris with her aunt, who was a ser-
vant. Catharine has always been good-tempered, affectionate
and obedient to her parents. A few weeks after arriving in
Paris, her aunt frequently remarked that she had lost her
cheerfulness, and would weep without giving any reasons.
One day she came into the house all in tears, saying that she
had seen some one of her village friends riding by, and had
not been able to speak to her. She spent the day in tears.
Soon after her arrival many articles were missed from the
PYROMANIA. 243
house, in spite of a most constant watch. One evening, after
the family had gone out, Catharine remained shut up in her
room for awhile, then went out in her turn, and soon re-
turned; but in a few moments she came down and asked the
porter to help her open the door, as some one had been tam-
pering with the lock. The porter went upstairs, opened the
door, and entering found the room filled with smoke, which
came from a closet filled with clothes and linen; the chairs
and furniture were all in confusion, and clothing was strewn
all over the floor. A woman's bonnet was found in a pail of
water in the kitchen; and in the cistern were found many of
the things that had disappeared, and among them some
articles of jewelry. On examining a secretary containing gold
and bank notes, it was found that they had not been dis-
turbed. Catharine at once confessed that she was the author
of all this mischief.”
Complete pyromania includes all acts of incendiarism due
to an irresistible impulse to set fires, to an impairment of the
will power, or to delirious conceptions with hallucination.
The case of Mary B. which I related at length is an example
of this sort. Gall reports the case of Maria Franc who was exe-
cuted for house burning. “She was a peasant of little educa-
tion, and, in consequence of an unhappy marriage, had aban-
doned herself to habits of intemperance. In this state a fire
occurred in which she had no share. From the moment she
witnessed this fearful sight, she felt a desire to fire houses,
which, whenever she had drunk a few copper's worth of spirits,
was converted into an irresistible impulse. She could give no
other reason, nor show any other motive for firing so many
houses, than this impulse which drove her to it. Notwith-
standing the fear, the terror and the repentance she felt in
every instance, she went and did it afresh. In other respects
her mind seemed sane. Within five years she fired twelve
houses, and was executed on the thirteenth attempt.”
A peasant girl, named Kalinovska, seventeen years of age,
while returning from a dance, where she had got quite heated,
was suddenly seized with a desire to burn a building. She
struggled with the desire for three days, when she yielded, and
244 INSANITY AND ITS TREATMENT.
she declared that on seeing the flames burst out she experi-
enced a joy such as she had never felt before.
Unlike the other criminal monomanias, pyromania is due,
not to a rarely curable and profound cerebral disturbance, but
to a transient, though active, neuropathic condition. This
condition is usually found in persons between the ages of ten
and twenty-five years. Sometimes it exists alone, sometimes
in complications with other disturbances of the nervous sys-
tem, such as those which induce hysteria and epilepsy.
This neuropathic condition can be produced by a kind of
moral contagion in very impressionable persons. Reading
detailed and graphic accounts of fires, or witnessing them, can
cause this impulse. We find, too, that those who are subject
to this neurosis have a very excitable, susceptible brain and
are apt to be noted for their violence and strangeness of char-
acter. Oftentimes they are peculiar and malicious, perhaps
hysterical and epileptic,+or even said by their neighbors to
be a little odd and lacking in sound sense.
Some who commit arson under the influence of this morbid
influence do not manifest any signs of excitement whatever,
they will commit the act calmly and tranquilly. There is no
excitement of mind, because the passion or impulse felt is pow-
erful enough at any given moment to stifle all the opposing
moral sentiments which might arise. This is shown by the
pleasure and joy felt by such persons on seeing the flames
burst forth, and the absence of regret and remorse before and
during the act. The general distress does not affect them;
they neither call for aid nor seek to arrest the flames; but the
sight of the glowing flames gives them joy and rapture. As a
rule they do not experience any remorse after the deed, except
as they may pretend repentance from fear of punishment; in
Some cases, however, the sight of the flames does awaken
thoughts of the harm done, and they experience real regret,
not that they have done wrong, but that they have unavoid-
ably caused suffering and injury to others.
Dr. Ray says, in his Medical Jurisprudence of Insanity, “that
the evolution of the sexual functions is very often attended by
more or less constitutional disturbance, especially in the female
PYROMANIA. 245
sex, is now a well-established physiological truth. The shock
seems to be felt chiefly by the nervous system, which ex-
periences almost every form of irritation, varying in severity
from the slightest hysteric symptoms to tetanus, St. Vitus'-dance
and epilepsy. And when we bear in mind also, that general ma-
nia is sometimes produced by this great physiological change,
it cannot be deemed an extraordinary fact that partial mania,
exciting to acts of incendiarism or murder should be one of
its effects. Still we would not be understood as favoring the
opinion that every youth between the age of twelve and fifteen,
guilty of incendiarism, is a subject of pyromania. The
general principle of the power in question to produce this dis-
order is not alone sufficient. It is necessary to trace the con-
nection between them in the particular case; and unless this
can be done, we have no right to claim the benefit of the
general truth.” To aid us in such inquiry we may avail our-
selves of the guiding principles laid down by Marc, in his
memoir upon this subject. 1st. To prove the existence of
pyromania, produced by the sexual evolution, the age should
correspond with that of puberty, which is between twelve and
fifteen. Sometimes, however, it may occur, especially in
females, as early as the tenth or eleventh year, and, therefore,
if the symptoms are well marked, we have a right to attribute
them to this cause.
2. There should be present symptoms of irregular develop-
ment; of marked critical movements, by means of which
nature seeks to complete the evolution. These general signs
are, either a rapid increase of stature, or a less growth and
Sexual development than is common at the age of the individ-
ual; an unusual lassitude and sense of weight and pain in
the limbs; glandular swellings; cutaneous eruptions, etc.
3. If, within a short time of the incendiary act, there are
symptoms of development in the sexual organs, such as efforts
of menstruation in girls, they deserve the greatest attention.
They will strongly confirm the conclusion that might be
drawn from the other symptoms, that the work of evolution
disturbed the functions of the brain. Any irregularity what-
ever of the menstrual discharge is a fact of the greatest im-
246 INSANITY AND ITS TREATMENT.
portance in determining the mental condition of incendiary
girls.
4. Symptoms of disturbance in the circulatory system, such
as irregularity of the pulse, determination of blood to the
head, pains in the head, vertigo, stupor, a sense of oppression
and distress in the chest, are indicative in young subjects of
an arrest or disturbance of the development of the sexual
functions, and therefore require attention.
5. For the same reason, symptoms of disturbance in the
nervous system, such as trembling, involuntary motions of the
muscles, spasms, and convulsions of every kind, even to epi-
lepsy, are no less worthy of attention.
6. Even in the absence of all other symptoms, derangement
of the intellectual or moral powers would be strong proof, in
these cases, of the existence of pyromania. Of the two, the
latter is far the more common, and is indicated by a change
in the moral character. The patient is sometimes irascible,
quarrelsome; at others, Sad, silent, and weeping without the
slightest motive. He seems to be buried in a profound revery,
and suddenly starts up in a fright, cries out in his sleep, etc.
These symptoms may have disappeared and reappeared, or
degenerated at last into intellectual mania.
7. The absence of positive symptoms of mental disorder, as
well as the presence of those which appear to show that the
reason is sound, is not incompatible with the loss of mental
liberty. The words of Marc, on this point, should be quoted
in full: “Even when, previously to the incendiary act, they
have shown no evident trace of mental alienation, and been
capable of attending to their customary duties; when on their
examinations, they have answered pertinently to questions
addressed to them; when they have avowed that they were
influenced by a desire of revenge, we cannot conclude with
certainty, that they were in possession of all their moral liber-
ty, and that, consequently, they should incur the full penalty
of the crime. These unfortunates may be governed by a sin-
gle fixed idea, not discovered till after the execution of the
criminal act. Pyromania resulting from a pathological cause
may increase in severity, as this cause itself is aggravated and
SUICIDAL MANIA. 247
Suddenly may be converted into an irresistible propensity, im-
mediately followed by its gratification.”
Commenting upon the above, Dr. Ray, remarks: “If the
above considerations are carefully pondered by the medical
jurist, he will be in little danger of mistake, in determining
the question whether or not the incendiary act is excited by a
pathological condition of the nervous system, incident to the
evolution of the sexual functions. If it be decided in the
affirmative, the acquittal of the accused should follow as a
matter of course, though it might not square with the tech-
nical definitions of insanity, and the usual subtleties respect-
ing moral liberty and the freedom of the will. In the north
of Germany, where pyromania in young subjects is remark-
ably frequent, the court is generally governed by the opinions
of the medical experts, and thus the accused escapes the
ignominious fate which is almost inevitable wherever the
spirit of the English common law prevails.”
Suicidal Mania.
There is a strong, though unfounded, conviction in the
average mind that suicide is always the result of insanity,
but, as Bucknill says, the act of self-destruction may originate
in different, and even opposite conditions of the mind.
In Wharton and Stillé's Medical Jurisprudence it is held that
the propensity to self-destruction may co-exist with sanity;
that we are not warranted in coming to the conclusion that
suicide is always the symptoms or result of insanity; that
there is no insanity present when the feeling of disgust with
life is in exact relation with the circumstances; when evident
moral causes exist which sufficiently account for the act; that
when a man of delicate feeling puts an end to his existence,
that he may not survive the loss of his honor or of some highly
valued possession which forms an intimate part of his intel-
lectual being, and when a man prefers death to a miserable,
contemptible life, full of mental and physical ills, although
morality may, indeed, call him to account for the deed, yet
there exists no ground for us to consider him necessarily
insane. *
248 INSANITY AND ITS TREATMENT.
The insane man may attempt self-destruction under several
different conditions.
1st. He may be under the influence of a violent attack of
mania, which leads him equally to kill himself or others.
2nd. Suicide may be attempted under the influence of a
delirious idea; from delusions, hallucinations, etc. He may
throw himself from a window in obedience to some fancied
supernatural command, and in the belief that he will be held
Suspended in the air. A man believes that he can only gain
admittance into heaven by self-immolation; another distinctly
hears a voice commanding him to destroy himself; while
another sees a form which leads him on to the brink of a river
or a precipice.
3d. Suicide may result from melancholia. The sad, fearful
and depressing emotions in this form of insanity may give
rise to a profound distaste for life; or there may be a condition
of mental misery from which the person seeks to escape; and
this morbid condition of the emotions brings about an im-
passioned state in which the moral sentiments are stified and
rendered nugatory.
4th. There are cases in which the instinct of self-preservation
is diseased, being as it were reversed in its operation. There
is here a blind, unreasoning, irresistible impulse to commit
suicide,-a true suicidal monomania. Here the person is led
to commit suicide from the sole desire to die, without being
prompted by any other motive, such as fear, anguish or dis-
tress of mind. This passionate desire governs his whole be-
ing, and no other thought or desire can change it. This com-
plete absence of any opposing emotion, this absence of any
moral conflict, explains why such suicides may occur with an
appearance of calmness and deliberation.
This last form alone deserves the name of suicidal mono-
mania; and Dr. Bucknill says: “Several well-marked examples
have come under our observation, and we have recently been
informed of a case in which the patient was attacked by a
strong impulse to commit suicide, and, at his own urgent
request, was confined in a lunatic asylum, where he has not
manifested the slightest aberration of intellect. Two or three
SUICIDAL MANIA. 249
years previously, he was injured by lightning; shortly after
which he was decidedly insane, but recovered.”
M. Debreyne has recorded the following: The patient who
was opulent, stated that he was perfectly happy, and free from
any cause of suffering, with the exception of one circumstance
that tormented him. This was the desire, thought, or violent
temptation, to cut his throat whenever he shaved himself. He
felt as if he should derive, from the commission of the act, .
indescribable pleasure, and he was often obliged to throw the
razor away.
The following case of attempted suicide is of special inter-
est, since we can learn the thoughts which passed in the man's
mind during the whole attack. It is translated from Prosper
Despine's work, “De la Folie,” p. 340:
Mr. X., merchant, intelligent and industrious, having a
large family, which he had carefully brought up, lost large
sums in his operations at the stock exchange. Naturally
lively, he did not seem depressed by his losses.
Some time after this he left his house at eight o'clock one
morning, agreeing to meet his wife and daughter at nine, to
make some purchases. At quarter after nine, while awaiting
them at his office door, he was suddenly and without motive
seized with a sudden and intense disgust for life, which en-
tirely possessed his mind. Said he to himself: “It is very
foolish to be always at work and take so much trouble, it is
better to end it at once.” “When this fit of disgust seized
me,” he told me later, “no sentiment arose to oppose it. I was
so wrapped up in the idea of suicide, that if any one had pro-
posed some business affair in which I could have made one
hundred thousand francs, I should have refused it, in order
to follow my new thought. No sooner had this idea laid hold
upon me, than I started to put it in execution. While going
home, I Saw, in the distance, my wife and daughter going to
the rendezvous. At sight of them, the only thought coming
to my mind was how to avoid them that I might not be pre-
vented or delayed in carrying out my design. Arrived at
home I shut myself up in my chamber and wrote a letter to
my eldest son, telling him what I was about to do, and then
16
250 INSANITY AND ITS TREATMENT.
made some additional testamentary dispositions of property.
Then taking two bottles, one containing sulphuric acid and
the other laudanum, I mixed them in a glass, thinking the
two would act more surely than one, and I swallowed the
mixture without a single fear or regret.” Upon the doctors
arrival, they found him suffering torments and vomiting
copiously, but the two poisons had partly diluted each other,
and some coffee and milk taken at breakfast had acted some-
what as an antidote, so that his stomach had emptied itself
after repeated vomitings. After months of suffering he en-
tirely recovered his physical and mental health. “After hav-
ing swallowed the poison,” said he, “I only came to myself
after the frightful sufferings and the sight of my children.
Then I asked myself how it was ever possible for me to com-
mit such a crime. At that moment I would have given all I
had in the world to undo the deed. You may be sure that
man is sometimes exposed to irresistible impulses which would
seem incredible to me had I not felt them.” This word irre-
sistible, however, was wrongly used, says Despine, since he
avowed that there was no struggle whatever in his conscience,
and no conflict between a desire to do right and a desire to do
wrong. He was asked whether, in case the thought of killing
his wife or his children had come into his mind in the same way,
he would have committed the crime, he answered: “I have no
doubt of it, for everything impelled me to it, and nothing restrained
me.” In such a case as this it is not the violence of the passion
that produces the result, but it is the absence of all rational
instinctive opposition. tº
The following case is reported by Prof. Maudsley: “A married
lady, aged thirty-one, who had only one child a few months
old, was for months afflicted with a strong and persistent sui-
cidal 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 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 frightful impulse, and often
SUICIDAL MANIA. 251
wept bitterly, deploring the great grief and trouble which she
caused to her friends. She was quite rational, even in her
great horror and reprobation of the morbid propensity; and
all the fault that could possibly be found with her intellect
was, that it was enlisted in the service of her morbid impulse.
She had as complete a knowledge of the character of her in-
Sane acts as any indifferent bystander could have, but she
was completely powerless to resist them. Nevertheless her
attempts at suicide were unceasing. 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 pre-
contrived 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 endeavored 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. Sometimes 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. Watchfulness was somewhat relaxed, when
One night she suddenly slipped out of a door which had care-
lessly been left unlocked, climbed a high garden wall with
surprising agility, and ran off to a reservoir 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 regained her cheerful-
ness and her love of life. Her family was saturated with in-
sanity.
It is notable how strongly hereditary this suicidal insanity
often is, and how desperate are its manifestations under such
circumstances, even when there are no other signs of mental
disease.
252 INSANITY AND ITS TREATMENT.
Kleptomania.
We not unfrequently meet with cases of insanity marked
by an irresistible propensity to steal, accompanied or not by
intellectual disturbance.
“There are persons,” says Dr. Rush, “who are moral to the
highest degree as to certain duties, but who, nevertheless, live
under the influence of some one vice. In one instance, a
woman was exemplary in her obedience to every command of
the moral law, except one,—she could not refrain from steal-
ing. What made this vice more remarkable was, that she
was in easy circumstances, and not addicted to extravagance
in anything. Such was the propensity to this vice, that when
she could lay her hands on nothing more valuable, she would
often at the table of a friend fill her pockets secretly with
bread. She both confessed and lamented her crime.”
Bucknill and Tuke say that: “Theft may be committed by
the insane, either in consequence of certain delusions, or of
Some motive, as revenge, or as the result of what appears to
be some instinctive impulse; lastly, the mind may be so per-
verted by disease, that under circumstances of powerful temp-
tation, theft may be committed, which would not have been the
case, had the individual been free from any mental affection. The
fact of external motive does not, therefore, remove the possi-
bility of insanity, although, doubtless, those cases which are
motiveless are much more easily credited.”
This condition, as Marc observes, is, doubtless, very singular
and inexplicable, as are so many other of the intellectual and
physical phenomena of life; but it is not the less real on that
account, as is proved by numerous examples. Besides, the
existence of facts of this description is now generally admitted
by medical men, and even by lawyers, who have devoted any
attention to mental diseases.
Dr. Ray says: “It would be difficult to prove directly that
this propensity, continuing perhaps through a whole life, and
in a state of apparently perfect health, is, notwithstanding, a
consequence of diseased or abnormal action in the brain; but
the presumptive evidence in favor of this explanation is cer-
tainly strong.
RLEPTOMANIA. 253
“1. It is very often observed in abnormal conformations
of the head, and accompanied by an imbecile condition of the
understanding. 2. This propensity to steal is not infrequently
observed in undoubted mania. 3. It has been known to fol-
low disease or injuries of the brain, and therefore to be de-
pendent on morbid action. 4. This propensity is sometimes
followed by general mania, and thus constitutes a premoni-
tory Symptom. 5. It seems sometimes to be the result of a
sudden and temporary confusion of mind, like that of mania.
6. This condition may be produced by certain physiological
changes in the animal economy, as, for instance, pregnancy.
7. This propensity is often the precursor of general paralysis,
and where it occurs in persons whose antecedents were cal-
culated to provoke this disease, the fact should be carefully
considered in forming a diagnosis of the case.”
The following account given by Dr. Julius Steinau, and
quoted by Bucknill and Tuke, shows excellently well the he-
reditary tendency so frequently met with in monomania:
“When I was a boy, there lived in my native town an old
man, named P , who was such an inveterate thief, that
he went in the whole place by that name. People, speaking
of him, used no other appellation but that of the thief, and
everybody knew then who was meant. Children and com-
mon people were accustomed to call him by that name, even
in his presence, as if they knew no other name belonging to
him ; and he bore it, to a certain degree, with a sort of good-
naturedness.
“A Son of this P-, named Charles, afterwards lived in B–,
He was respectably married, and carried on a profitable trade,
which supported him handsomely. Still, he could not help
Committing many robberies, quite without any necessity, and
merely from an irresistible inclination. He was several times
arrested and punished. The consequence was, that he lost
his credit and reputation, by which he was at last actually
ruined.
“A Son of this Charles, in my native town, lived in the same
house where I resided. In his early youth, before he was
able to distinguish between good and evil, the disposition to
254 INSANITY AND ITS TREATMENT.
stealing, and the ingenuity of an expert thief, began already
to develop themselves in him. When about three years old, he
stole all kinds of eatables within his reach ; although he al-
ways had plenty to eat, and only needed to ask for whatever
he wished. He, therefore, was unable to eat all he had taken;
nevertheless, he took it and distributed it among his play-fel-
lows. When playing with them, some of their playthings
often disappeared in a moment, and he contrived to conceal
them for days, and often for weeks, with a slyness and Sagacity
remarkable for his age. When about five years of age, he
began to steal copper coins; at the age of six years, when he
began to know something of the value of money, he looked
out for silver pieces, and, in his eighth year, he only con-
tented himself with larger coins, and he proved himself to be,
on public promenades, an expert pick-pocket.”
A similar case is that of Madame M., a widow, in good cir-
cumstances, who was sentenced to thirteen months imprison-
ment, and a fine of five dollars, for stealing from one of the
stores. This person alleged, in defence, that she was ill, and
that she was irresistibly impelled to take the articles against
her will. “I knew that I was doing wrong,” said she, “but
the impulse was stronger than I, and I could not control my-
self.” An examination was made into her condition, and she
was acquitted.
“This woman was of nervous sanguine temperament, and
her antecedents were well marked. Her mother was eccentric,
and had an irresistible craving for alcoholic liquors, from the
use of which she could not be kept either by counsel of her
friends, or the téachings of religion, and she finally lost her
mind. An aunt became insane when twenty years old; and
an uncle blew his brains out as a result of some idle brawl.
“Madame M., had convulsions in childhood, and has since
that time shown great impressionability, not being able to en-
dure the slightest opposition; and being subject to frequent
unpleasant dreams and the nightmare. At puberty, menstru-
ation was established with difficulty, and was accompanied
with headache, pains in the limbs, eccentricities of character,
and depraved tastes. The first menstrual period was marked
ECLEPTOMANIA. 255
by a nervous attack, with loss of consciousness. In all other
respects she was a woman of most refined tastes and ex-
emplary character.
“November 21st, after a restless and sleepless night, she
complained of headache, thirst, abdominal heat, constipation,
restlessness of the limbs, and was obsessed with a desire to
steal something. She rose at seven in the morning, and went
to a shop where she was accustomed to trade, and saw upon
the counter, amongst a pile of goods, a piece of alpaca worth
about nine dollars. At first she struggled against the impulse
to steal it, appreciating the wickedness of the act; the wish to
possess it so ruled her as to conquer her reason, and her power
of resistance. Pale and trembling, she experiences a violent
pain in her head, and, yielding to the impulse, hides the goods
under her shawl.” (Dagomet, p. 316.)
This person was led to steal, as was Glena.del and others to
kill, without power to resist the impulse, although its wicked-
ness was fully felt. Such obsession, when without any motive,
can only be explained as a result of insanity, or demoniac
possession, which, however, in Some cases may be synonymous
terms.
Friedreich gives the case of a pregnant woman who, other-
wise perfectly honest and respectable, suddenly conceived a
violent longing for some apples from a particular orchard, two
or three miles distant. Notwithstanding the entreaties of her
parents and husband not to risk her character and health, and
their promises to procure the apples for her in the morning,
she started off in company with her husband, at nine o'clock
of a cold September night, and was detected by the owner in
the act of stealing the apples. She was tried and convicted of
theft, but subsequently a medical commission was appointed
by the Supreme Court to examine and report upon her case.
Their inquiries resulted in the opinion that she was not
morally free, and consequently not legally responsible, while
under the influence of those desires peculiar to pregnancy.
Dr. Isaac Ray says: “We are not prepared to go to the length
of referring all the instances of this propensity thus manifested
to the influence of disease, but they cannot all be attributed
256 INSANITY AND ITS TREATMENT.
to faults of education, to evil example, or to innate depravity,
without doing violence to the testimony of every day's experi-
ence. It may be difficult no doubt, in many cases, to distin-
guish them in respect to their physical or moral origin, but
the distinction is no less real on that account; the same prin-
ciples are to guide us that regulate our decision in questions
touching any other form of insanity; and if common sense
and professional intelligence preside over our deliberations,
the final judgment will not often be wrong. Where the pro-
pensity to steal is manifested in a person whose moral char-
acter has previously been irreproachable, and whose social
position and pecuniary means render indulgence in this vice
peculiarly degrading and unnecessary, his plea of having com-
mitted the larceny while deprived, in a measure of his moral
liberty, deserves to be respectfully considered. If the object
stolen is of trifling value, or incapable of being turned to any
purpose of use or ornament; if the offence have been pre-
ceded by others of a similar kind; and especially if, in addi-
tion to those circumstances, the individual be a woman in a
State of pregnancy, there can scarcely be a doubt that the plea
should be admitted. We must not overlook the fact, however,
that objects which are utterly valueless to some men are ex-
ceedingly prized by others; and it is a lamentable truth that
Some persons, in their eagerness to get possession of certain
objects that gratify a favorite passion or taste, seem to lose
sight all at once of the ordinary distinctions of meum and
tewm. (Ray, op. cit. p. 245.)
Pluſ ERPERAL INSANITY. 257
LECTURE XIII.
Puerperal Insanity.
During the periods of pregnancy, child-bed and lactation,
women are liable to intellectual and emotional disturbances of
a marked character, which in some cases amount to real in-
sanity. While these disturbances resemble in very many
respects those noticed in other forms of insanity, there are
certain peculiarities which justify usin considering them apart
under the name of puerperal insanity. The term implies that
the mental and physical changes peculiar to the puerperal
state form a marked and constant factor in such cases; and it
should be stated here, that in the present lecture the word
“puerperal” is not used in its narrow sense, but covers the
whole period from conception to the weaning of the child;
for, during the whole of this period, the woman being more
nervous, and more sensitive to morbid impressions, is kept
in a condition holding close relations with the reproductive
functions, which thus constitute a true prolonged puerperal
State.
The special character of puerperal insanity is due to the
co-existence of an organic or functional change in the uterus
or its appendages. If we examine into the ordinary forms
of insanity, we know that in many cases it is difficult or im-
possible to decide upon the exciting moral or physical cause,
or the accompanying changes of bodily structure. But we
shall find the case otherwise in puerperal insanity.
It is a matter for surprise that so little is to be found in
homoeopathic literature concerning this form of mental dis-
order; and both Drs. Guernsey and Ludlam leave it un-
noticed, at least in the earlier editions of their works, the only
ones I possess. Although somewhat rare, it may occur at any-
time in the practice of any physician. “It may occur during
gestation, soon after labor, or not until several weeks or even
months after its completion. Two periods have been noticed
258 INSANITY AND ITS TREATMENT.
as peculiarly susceptible to its invasion, the one, before the
system has completely recovered from the shock of parturi-
tion; the other, during lactation. It cannot be affirmed of any
woman that she is exempt from it during her child-bearing
period. It is not confined to any rank of life, or to constitu-
tional peculiarities. Those of robust frame and obtuse sensi-
bilities are numbered among its victims; it most frequently
occurs, however, in feeble, nervous, excitable women, of hyster-
ical constitution, and especially among those of strong sexual
instincts.”
The insanity of puerperal women appears under the two
great types of mania and melancholia, though even dementia
is seen at times. Mania, however, is undoubtedly the most
frequent form of mental alienation. The frequency of this
form of disease is variously stated, but out of 13,748 deliveries,
26 women were affected by it immediately after delivery; a ratio
of 1 to 528; if, however, we include the cases occurring during
pregnancy and lactation, the ratio would be much larger.
The statistics of the Pennsylvania Hospital for the Insane
show that ten per cent. of their female patients are such from
puerperal causes; and the late Sir James Y. Simpson gives
the same proportion. At the State Lunatic Asylum at Utica,
New York, out of 4716 insane women admitted within thirty-
two years, puerperal conditions were assigned as cause in 584
C8,SéS.
Mania, when affecting puerperal and pregnant women, is
one of the most curable forms of insanity, while melancholia
is somewhat less so. Perhaps no other form or complication
of mental disease furnishes so large a proportion of recoveries
as a result of prompt treatment; hence the Supreme import-
ance of the ordinary obstetric attendant recognizing the earliest
symptoms and being able to treat with promptness those fore-
warnings that almost always occur.
The painful character of the delusions, and the scrupulous
care with which the persons affected have to be guarded in
consequence of suicidal and homicidal impulses, in many cases
will compel an early separation or seclusion from friends; and,
should not the premonitory symptoms yield to treatment al-
PUERPERAL INSANITY. 259
most immediately, the most humane plan is to have the pa-
tient removed to fresh scenes and, if necessary, purer air, with
a special attendant, or, to recommend removal to an asylum.
Too much stress cannot be laid on the importance of taking
prompt measures in these cases. All authorities speak very
decidedly upon this point, and anyone at all conversant with
the insomnia accompanied by restlessness, irritability of man-
ner, foul tongue, and the other signs that usher in an attack of
puerperal insanity, is aware of the beneficial and in most cases
curative effect resulting from the right treatment promptly
applied.
If you read the various text-books upon nervous diseases,
you will be struck with the emphasis which even the ancient
writers laid upon the intimate relation and sympathy exist-
ing between the uterus and the other viscera, especially the
brain. “There,” said Hippocrates, referring to the uterus, “is
the starting point of a thousand ills.”
Pregnancy, as well as menstruation, is one of those physio-
logical processes which may easily become pathological, and
predispose one to morbid states by reason of the susceptible
and disordered condition in which so many women find them-
Selves at such a time. With healthy women, accustomed to
healthful work and proper ways of living, the changes pro-
duced by pregnancy are scarcely noticeable; but for those,
especially the dwellers in cities, whose nervous system has
been vitiated by bad air and irregular habits; by improper
food and constant excitement; by the various cares and trials
of married life, so often entered upon heedlessly and without
a thought of its duties and responsibilities; and especially by
the mental emotions of chagrin and ill-humor, consequent
On the too common aversion to having children; in all such
Cases pregnancy may become a serious matter, impressing the
whole organism most profoundly, and arousing thoughts and
feelings which otherwise would have remained latent.
Pregnancy produces, in those specially disposed, various
phenomena of the nervous system which at once attract the
notice of the physician. Whether we explain this on the
grounds of a sympathetic influence radiating from the uterus,
260 INSANITY AND ITS TREATMENT.
or by the changes in the composition in the blood, it is never-
theless true that this condition presents certain symptoms
impossible to mistake. Pregnancy forms, like menstruation,
first and second dentition, lactation, traumatic injuries, and
convalescence from severe illness, one of those physiological
states in which the nervous system acquires an excessive
mobility and susceptibility; and we see in pregnant women,
all sorts of physical symptoms never manifested in health,
such as cramp, vertigo, vomiting, syncope, etc. There are
also disorders of the intellect which, though briefly alluded
to by most authors, have for us a peculiar interest. These dis-
turbances are of two kinds. The one, marked by simple
changes in the moral feelings and emotions that do not take
away the freedom of the will, but do give a peculiar cast to
all the actions, looks and words. The other makes up a clear
case of insanity. These two conditions are quite different so
far as legal questions are concerned, but in reality they are
different degrees of the same condition; for we occasionally
meet cases which it is difficult to assign clearly to either class.
The emotional disturbances caused by pregnancy consist at
times in an unnatural excitement of the intellectual faculties,
but more commonly in marked discouragement and melan-
choly.
The causes of puerperal insanity may be divided into pre-
disposing and provinate, or those which render the person sus-
ceptible to the disease, and those which actually occasion it.
The disease occurs under such a variety of circumstances,
and in such various conditions of the system, both physical
and mental, that it is often difficult to arrive at any satisfact-
Ory conclusion as to the real cause. The first attack some-
times occurs in women who have previously borne several
children, passing through the periods of gestation, parturition
and nursing without the slightest observable manifestation of
mental disorder; while primiparae who have been the subjects
of puerperal insanity have subsequently borne children with
complete immunity from the disease. Statistics show that
about one-half of all the cases occur in women who have an
inherited predisposition to insanity.
PUERPERAL INSANITY. 261
Among the causes, beside the hereditary predisposition just
referred to, and the insane temperament, one or the other of
which underlie nearly every case of insanity of whatsoever
kind, we may give a front place, especially with primipara,
to the profound and wide-spread changes which marriage
itself produces in both the physical and mental life of woman;
her home, surroundings, occupations, modes of life, compan-
ions, all are different. If pregnancy now sets in with the
physical discomforts accompanying its onset we will find rest-
lessness and sadness. Pregnancy is not to all women a wel-
come event. We all know how unwelcome such a condition
is in many, very many, families, converting peace and happi-
ness into discord and sorrow.
It would be useless for me to recount the many and varied
motives assigned by our American women for their dislike to
child-bearing; but all of them operate powerfully in the
female mind when the unwelcome event occurs, so much So
that the question would seem a pertinent one; why do they
get married at all ? Others again may experience chagrin
lest they be detected in a fault, while yet another, having al-
ready passed the middle age and being the mother of grown
up children, may experience a sense of disgrace at an un-
looked for pregnancy, which may warp all the feelings of the
mind and extend into a condition of true melancholia. A
case of this kind came lately under my notice, when both the
lady and her husband believed and reported that all the
peculiar symptoms were caused by the climacteric, and the
chagrin which was felt on learning the true condition of affairs
came near resulting seriously.
On the other hand it is true that we meet cases where the
fact of pregnancy is greeted with joy, and yet, owing to the
mental constitution, the physical disturbance produces in-
sanity. But generally these persons are cast down and dis-
couraged, they cease to enjoy their former pleasures and re-
main idle and listless, saying that they are unable to apply
themselves to any work. If they are primiparae, the unknown
trials through which they are to pass fill them with dread; if
they have borne children, the remembrance of their past suf-
262 INSANITY AND ITS TREATMENT.
ferings gives them anxiety for the future; they are sure that
they cannot survive the dangers of confinement, and this idea
becoming more and more fixed serves as a centre around
which all their melancholy thoughts turn. At the same time
they worry about the expected child which they are sure will
be hideous or deformed. To these intellectual disturbances are
added physical ones; digestion is slow and difficult, and as a
result we meet with constipation, diarrhoea and headache.
The least emotion brings on troubles of respiration and of cir-
culation, and the sleep is painful and disturbed by dreams.
Others may present an increased liveliness and gaiety, or be
fretful and irascible.
These morbid feelings are due, in great measure, to the phys-
ical changes that the system has undergone. At first, while
the uterus has increased but little in volume, we may ascribe
them to a sympathetic influence in the nervous centres; later,
as the uterus gains in weight and volume, it produces a sensa-
tion of fatigue and languor; it compresses the iliac vessels, im-
pedes the return of venous blood to the heart, and produces at
the periphery a congested condition shown by the bluish color
of the arms and legs, and also by varicose veins of those parts.
There is also headache, with heaviness and drowsiness, owing
to slower cerebral circulation. Still later the uterus rises
higher in the pelvic basin, and pushes up the diaphragm, im-
peding the thoracic expansion and the oxygenation of the
blood, producing a state of respiratory distress which reacts
upon the emotional states and produces fear, restlessness and
unhappiness.
Thus these physical causes added to the morbid tendency
may produce quite serious departures from mental and phys-
ical health, which indeed may be removed by delivery, or
may increase to a state of real insanity. It is by no means
always easy to mark the limits which divide insanity from the
warped moral dispositions which so strongly influence preg-
nant women as to partially deprive them of their moral free-
dom. Between this involuntary excitement which gives to
the intellectual workings an abnormal but depraved activity,
between this tendency to sadness, this depression of mind
PUERPERAL INSANITY. 263
which acts upon the whole system, and mania or melancholia,
there exist an infinite variety of shades and degrees, and it is
the province of the physician to distinguish them.
It is well to keep one fact in mind, viz: that the tendency
to sadness, and all the changes in character and intellect,
which are met with at the beginning of an ordinary preg-
nancy become less and less marked toward the close of that
period, especially after the sixth or seventh month; while in
those cases complicated with insanity, the mental disturbance
is apt to increase at that time, “In such cases the majority
of the attacks occur at those periods of utero-gestation which
are generally considered critical, viz: the third, fifth and
seventh months. This form of puerperal insanity is the most
favorable, and may be considered along with another variety
which is transient, and which occurs during parturition. Some
few women suffer from a passing form of alienation when the
pains are most acute, either when the OS uteri is at full stretch,
or when the head is emerging from the vagina. This form
can hardly be classed as a separate one, nor placed correctly
under any other, as it is more properly speaking a delirium of
agony, ceasing as soon as the intense pain which causes the de-
lirium has passed away.”
We find then that among the causes of the insanity of preg-
nancy we must first place heredity, previous attacks of insanity,
anaemia, painful and prolonged moral conditions, and ill-
health. Perhaps it is met most frequently in those cases
where the mind is disturbed from a sense of shame and dis-
grace for their condition.
When a woman has been insane during one pregnancy, we
must fear its return at a subsequent pregnancy; but we meet
with curious examples where insanity occurs only at each al-
ternate pregnancy; or again some women are insane when
pregnant with a male child only, and others with a female.
Melancholia is the form generally met with in connection
with pregnancy. Our prognosis should be guarded ; in rare
cases recovery takes place before delivery ; but in most instan-
ces at the time of confinement or soon after; while in other
cases parturition seems to exercise no influence whatever, SO
264 INSANITY AND ITS TREATMENT.
that in forming our opinion, we must consider rather the his-
tory of the patient, her age, constitution, habits, etc., than the
doubtful influence of parturition, and consider the latter as a
disturbing element possessing nothing of certainty in its
action.
We come now to the cases arising at the time of labor, cases
which may strictly be called “puerperal.” These are the most
frequent and occur during the first month after delivery. Most
of the cases of this variety arise during the first fortnight,
and although the prognosis is not as favorable as during preg-
nancy, yet the recoveries are numerous and take place in much
less time than the average duration of other kinds of insanity.
We are now met with the question, has the puerperal con-
dition, strictly so-called, any predisposing influence toward
insanity? We know that the puerperal state is the climax of
various physiological processes, and that during the lying-in
period women are disposed to pyaemia, and to infection from
the putrid matters which bathe the wounded and lacerated
parts; and we also find a condition of weakness similar to the
nervous shock following the more severe surgical operations.
After the expulsion of the child there remains an exten-
sive suppurating surface which exposes the patient to all
the dangers of purulent infection. Later we find the lochial
and lacteal secretions established for a longer or shorter time,
and these processes even in the most healthy organisms are
attended with nervous and other disturbances which may well
serve as a starting point for nervous or mental disease.
The most important predisposing cause in this as in the
other forms is of course heredity or the insane temperament. It
does not require that there shall have been well developed in-
Sanity in the parents, there may have been any one of the
neuroses such as hysteria, epilepsy, paralysis, etc. Anaemia is
a strong predisposing cause, and it may be constitutional or
consecutive to hemorrhage or prolonged lactation. Previous
attacks of insanity of any kind give, as might be expected, a
strong tendency to the disorder; some may have apparently
recovered, and the puerperal state has merely aroused the pre-
disposition which had been slumbering for a time; but unlike
PUERPERAL INSANITY. 265
other forms of insanity, the later attacks of puerperal insanity
are as curable, or nearly so, as the earlier; it often happens
however that a person may suffer from an attack at each con-
finement and recover, and later, at the climacteric, when the
nervous system again undergoes a shock, a hopeless condition
of insanity may set in.
As was intimated in speaking of the insanity of pregnancy,
the various moral emotions and excitements which the woman
experiences may have a powerful effect in bringing on the
attack; or, in brief, any prolonged influence that may disturb
the system, whether by acting directly upon the body, or in-
directly through the mind, may give rise to puerperal insanity.
Albuminuria is thrust upon us by Sir Jas. Simpson as a
probable predisposing cause, he claiming to have found it in
eight out of ten cases of puerperal insanity at the commence-
ment of the disease; but other authorities do not agree with
him in this.
Cases of mania are met with in women who have borne
children so rapidly as to induce a weakened state of the
system, and thus predispose to the disease, as for instance
when a woman bears children four times within five years.
Among the physical causes may be classed difficult labor,
injuries from violent delivery, or from forcible removal of an
adherent placenta, eclampsia, great loss of blood, a disordered
state of the digestive system, the nervous shock attending par-
turition, etc.
If we have reason to fear the occurrence of the disease in
any case, we should exercise a wise interference, and should
point out the dangers of too frequent pregnancy, and pro-
longed lactation, and we should also strive to place our patient
in as favorable a moral and physical condition as possible.
In the few weeks directly following parturition mania is the
form of insanity most frequently met with. It may be de-
veloped in the first few days after confinement, especially at
the time of the milk-fever, or the return of the menses. The
features of puerperal mania are, as a whole, very similar in
their general outlines to those met with in other forms of mania.
It generally begins gradually, but at times suddenly. The
17
266 INSANITY AND ITS TREATMENT.
woman is sad, morose, or perhaps excited; her manners and
habits are changed; she manifests extravagant affection for her
family and child, or the most intense aversion; she becomes lo-
quacious and talks incessantly, weeping and laughing without
cause. The Senses become more active and acute; the least
noise causes disturbance.
These symptoms are similar to those we may observe in
many susceptible women at the time of the milk-fever. But
in these as a rule the symptoms soon disappear, while if the
patient is of the insane temperament, or is under unfavorable
conditions, they may increase and the patient is insane. The
attack is usually preceded by insomnia, irritability and unrest.
The general demeanor of the patient is unusual. She is anx-
ious, troubled and agitated. Her movements are hurried, eyes
restless, and the expression of the face is that of anxiety and
distrust; she is impatient and fault-finding in a marked de-
gree; anger is easily excited, and vacillation of purpose is
evident in the contradictory orders frequently given. The
patient is pale, the features pinched, pulse small, irritable and
usually accelerated in proportion to the excitement; the tem-
perature of the body is below the normal standard, and the
skin often clammy; there is great debility, yet she is blatantly
noisy; she stares wildly at imaginary objects, and instead of
answering a question she repeats it, or she talks incoherently,
uttering her words with great rapidity. She picks at the bed-
clothes; grasps at anything or any one around her; curses
and swears, sings, laughs, prays and yells; objects to being
confined in bed, complains of being watched and tries to es-
cape. Occasionally obscene language and lascivious actions
are indulged in to an extent that excites our amazement. All
considerations of decency and propriety are cast aside, and the
most filthy and profane language is poured forth with aston-
ishing volubility. Masturbation is sometimes noticed, but
probably more from a wish to allay irritation than a desire to
excite it. The obscenity of word and manner often continues
until convalescence is well advanced. She imagines that some
calamity has befallen her husband, or that her babe is dead or
has been stolen; and if brought to her she says it is not hers,
FUERPERAL INSANITY, 267
refuses to nurse it and even attempts to kill it if left within
her reach. Sometimes she is impressed with the idea that
her husband is unfaithful, and has conspired with others to
poison her. Confidence and affection give place to suspicion
and hatred. She may think herself dead and in hell, sur-
rounded by flames of fire, and consider those around her to be
devils in the guise of men and women. Again, she will mani-
fest great anxiety with regard to herself, fears that she will
die; thinks that she has been poisoned; that she is flooding
to death, that her blood has turned to water, etc.; or, on the
other hand, she may manifest an absolute indifference to
everything. Suicide is often attempted by violently throwing
herself on the floor, attempting to jump from a window,
strangling herself with a handkerchief or the bed-clothes, or
stabbing suddenly with some sharp instrument, as the scissors
or a knife; this is generally the result of an impulse, and
without method or premeditation. She refuses to eat, and it
often becomes necessary to use force, the tongue is coated;
and the head aches, this latter is usually described as being of
a throbbing, bursting character; or else a sharp, cutting pain;
the bowels are generally constipated, the Secretion of urine
diminished and the lochia suppressed.
This description of course applies only to the more severe
cases, but in the more mild the symptoms present the same
general characteristics, differing only in degree.
These cases are generally curable, and you may usually
hope for recovery within six months. As one author has
said, “the question is not will she recover, but how soon will
she recover.” Some patients, however, die from the exhaust-
ion attending the maniacal excitement, or from some inter-
current disease, such as consumption; or the hereditary taint
may be so strong, or the surrounding influences so unfavora-
ble, that reason cannot be restored. In some cases acute
delirium may set in and complicate the case, especially when
the attack sets in soon after delivery; or we may have ery-
sipelas, phlebitis, or a slow, nervous fever, as further compli-
cations.
The following record, from the case-book of the Homoe-
26S INSANITY AND ITS TREATMENT.
opathic Asylum at Middletown, will give a good idea of the
course of a case of puerperal mania:
“K. D. T., admitted October 26th, 1878; female; aet. 23;
married; has one child, four weeks old; the present attack of
insanity, the first, has lasted three weeks. Pupils slightly
dilated; pulse 80 to 90, and irregular; respiration 20.
“The first indication of any mental disturbance was noticed
about one week after confinement, when she was possessed
of an inordinate desire to talk, and indulged in a great many
wild remarks about herself, her baby and her surroundings.
She now imagines herself to be a queen, or that she is beauti-
ful, or that she is the wife of another than her husband, but
manifests no fixed delusion. Pulse 84; temperature 98.6°;
disinclined to stay in bed, and wants to walk constantly;
talks and sings constantly; mind wanders, and is easily
moved to laughter. B. Hyosc.
“Oct. 27th.--Temperature normal; pulse 74; pupils dilated;
tongue slightly cracked. Slept some yesterday afternoon, and
two hours last night; constant rambling talk; much thirst.
“Oct. 28th.--Temperature normal; pulse 80; tongue streaked
with white; pupils slightly dilated; bowels constipated;
thirsty. Is very talkative about yellow-fever, etc., and says
she does not want to live. Has had three hours sleep, but
was tied into bed to keep her off her feet. An examination
with the speculum showed the uterus partially retroverted;
os uteri gaping, very red and granulated; also a copious,
white, creamy leucorrhoea. Small quantity of milk in breasts.
“Oct. 29th.--Temperature 100.4; pulse 78. Reported as
having slept mone, but says she slept between the visits of the
night-watch, and some during the evening. Stayed in bed
without restraint. More quiet; pupils less dilated; tongue
less coated; no pain. Hears heavenly music all the time.
Has been resurrected from the dead. º
“Oct. 30th.-Pulse 78; would not let her temperature be
taken. Pupils more dilated; talkative and anxious to get
away. Says this is a house of prostitution; that she has been
given Belladonna and the clothes smell of it. Will be dead
this week if kept here. Bowels constipated; tongue streaked;
slept poorly.
PUERPERAL INSANITY. 269
“Oct. 31st.—Temperature 99.3; pulse 72. Talking constant-
ly, wandering from one subject to another; two hours sleep;
says she could not sleep as she was afraid. Pupils less dilated;
head not as hot; cheeks less flushed.
“Nov. 1st.—Temperature and pulse as before; says she slept
at times during the night, but thinks she will die to-night; is
not inclined to take nourishment this morning. Is good-
natured, talking, laughing and crying. Tongue coated white.
Religious delusions.
“Nov. 2d.—Temp. 99.3; pulse 72. Thinks the superintend-
ent is her husband; says she has taken smut-rye and Bella-
donna in everything she has eaten; talks about fallen women,
masonic lodges, etc., wandering from one subject to another.
Thinks the house is full of men at night who try to insult
her, and would outrage her, if she did not keep awake. Had
four hours sleep.
“Nov. 4th.--Temp. 98.6; pulse 88. Thinks it is the last of
the world, and that “she smells dead bodies around her.’ Has
three buttons on her dress which she says are the stars in
the east. Says that Belladonna was given to her last night.
Is inclined to cry, and worries about saving those around her.
Is troublesome about taking medicine, and the pupils are
dilated. Talks incessantly, ‘I am Mary, the mother of Jesus.
I had a baby last night and will have to have another to-
night. I want to be a Roman Catholic apostolic priest. I
hear the heavenly music.’
“Nov. 7th.--Temp. 100; pulse 84. Slept one hour. Con-
tinues talkative, ‘I am here as Peter; see myself in a thousand
shapes.’ Hears music; wants air and company. B. Stra-
monium.
“Nov. 12th.--Temp. 99.3; pulse 84. Mischievous yesterday,
and threw things out of the window; this morning broke
dishes and top of a bureau. Looks worn.
“Nov. 14th.-Pulse 76. Eats well, and says the steak she
had for breakfast was venison. Good-natured, singing, laugh-
ing and mischievous. B. Hyosc. *
“Nov. 18th.--Temp. 98.6; pulse 78. No sleep; ate no break-
fast; is quiet and depressed; says “they gave me urine to drink
last night.’
270 INSANITY AND ITS TREATMENT.
“Nov. 19th.--Temp. 98; pulse 84. Afraid to eat; says she
has been poisoned too much.
“Dec. 10th.-Is worried about going to heaven, and not
trusting enough in her Savior. Pupils dilated. Bowels con-
stipated.
“Dec. 12th.-Says she don’t want to live any longer. Head
hot, and mental depression. Had to be fed with tube yester-
day and again this morning. B. Bellad.
“Dec. 16th.-Pulse 96. Complains of a pain in the fore-
head, and pressure and weight in the head. Thinks her life
has been a failure. Broke her dishes last night, and had to
be fed with a tube this morning.
“Dec. 19th.-Pulse 90. Throat sore, and painful on swal-
lowing. Tongue coated white; breath offensive; feet cold.
Has much feeling of religious depression, but promises to eat.
B. Merc. proto-iod.
“Dec. 23rd.—Pulse 72. Head heavy, but no pain; is will-
ing to eat. Had a visit from her brother yesterday and seems
much more cheerful to-day.
“Dec. 29th.-Pulse 66. Slept three hours last night; her
head feels dull, and she is homesick.
“Jan. 3rd, 1879–Pleasant and quiet. Has few delusions,
and is less influenced by them.
“Jan. 16th.--Talks.rationally and is sent home on parole.
“Feb. 17th.-Discharged recovered.”
The next form that we meet is that of lactation, and the
most frequent cause is heredity. Another cause is anaemia,
due to the exhaustion produced by too prolonged suckling of
the child, reducing the woman to a state almost identical with
that seen in those who have lost large quantities of blood.
There may also be some blood-poisoning, caused by a failure
of the kidneys to properly eliminate effete matters from the
system.
In the Insanity of Lactation the mental condition is either
that of mania or melancholy, or an alternation of the two
conditions. Melancholy is the more frequent. The mania is
violent, but evanescent, and is not associated with the ob-
Scenity so prominent in puerperal insanity proper, otherwise
PUERPERAL INSANITY. 271
it is similar to the mania described. The melancholy is char-
acterized by great depression of mind, the face is pale and
the expression dejected. The pulse varies but little from the
normal standard, while the temperature of the body is usu-
ally rather below that of health; all the secretions are dimin-
ished; the tongue presents an unhealthy appearance; the di-
gestion is impaired and the bowels constipated. She will
Sometimes sit for hours, silent and motionless, indifferent to
everything that is going on around her. She never asks for
anything, makes any inquiry, or expresses any desire. She
will speak when spoken to, and will generally comply with
the requests of her attendant, partake of her food when offered
to her, but as a rule only sparingly, and sometimes not at all.
In the worst cases the ordinary calls of nature are disregarded,
unless she is reminded of them. She is wakeful, despondent
and apprehensive. Her mind dwells upon some particular
subject, usually of a religious character. She accuses herself
of being vile and sinful, and expresses great fear and anxiety
in regard to her future state. It is remarked by some au-
thors that in cases of puerperal melancholia, any violence
contemplated by the patient is against herself, while in acute
puerperal mania the propensity of the patient is to do injury
to others.
Dr. Forbès Winslow has called attention to the stage of in-
cubation, and it is during this variable period that treatment
is of most value. But beside this period of incubation there
is also a period, after the cessation of the maniacal ravings,
and in the midst of the state of melancholy, of dementia of
varying severity. In some cases this is so marked that it be-
comes a question in the physician's mind, whether the patient
will ever regain her intellect, and he may be sufficiently im-
pressed with the gravity or prolongation of this demented con-
dition to give a hopeless prognosis of the case. The recover-
ies are so numerous, even after a long period of apathy, that
great caution should be observed in the opinion given as to
the ultimate recovery of the patient.
Prognosis. There are three ways in which puerperal in-
sanity may terminate.
272 INSANITY AND ITS TREATMENT.
1. In the restoration to reason.
2. In permanent insanity.
3. In death. t
The ultimate restoration to a state of sanity may be reason-
ably expected in a large majority of cases. A favorable prog-
nosis, however, depends upon the absence of complications.
In making up our mind we should keep in mind the recipro-
cal influence of the body upon the mind and vice versa. The
mental phenomena may sometimes be but the simple ex-
ponents of organic or functional disease of some distant part
of the body. It is a well known fact that the mental functions
of the brain may be deranged by the sympathetic influence of
some distant diseased organ. A rapid and inflammatory state
of the pulse is unfavorable, as it indicates inflammation of
Some internal organ, the usual symptoms of which are marked
by the mental condition. The latency of the symptoms of
acute and chronic affections amongst the insane is well known
to alienist physicians, and is one of the great difficulties with
which they have to contend. The mental symptoms may even
be so prominent as to completely mask the bodily disease to
which they are due, while the bodily health of the patient
may appear but little impaired. Dr. Tuke says, “phthisis may
exist for years undetected, were it hot for the stethoscope, with-
out cough, sweats, emaciation, or hectic, till the disease is very
far advanced. Tuberculosis of other organs may run its course
without any indication of its presence. Caries and necrosis
kill without pain, most extensive abscesses collect without
causing inconvenience.” In the insane, reflex action is im-
paired. The chronic maniac may die of phthisis, bronchitis
or even pleurisy, without cough or pain, however extensive
the disturbance may be. These facts apply equally to the sub-
jects of puerperal insanity. Peritonitis, bronchitis, pelvic
cellulitis, and inflammation of vital organs, may exist with-
out a discoverable symptom, if we except an inflammatory
pulse, and even this is sometimes absent.
When the attack is ushered in soon after delivery, with a
rapid pulse and furious mania, the life of the patient is in
great danger. It may be laid down as a general principle
PUERPERAL INSANITY. 273
that the longer the interval between delivery and the onset of
the disease, the more favorable the prognosis, but the less
favorable to complete restoration to reason. According to
Gooch, “mania is more dangerous to life, L-melancholia to
reason.”
Females who have previously had attacks of insanity, are
liable to another at any succeeding pregnancy.
Dr. Crichton Browne, who has had a large experience, is of
opinion that the swarthy complexioned, and dark haired wom-
en, when affected with this disease, are much longer before
they recover, and also that the after period of dementia is
much more prolonged in them than in the fair-haired.
.The duration of the disease is uncertain. In some cases it
may last but a few days, and in others months or even two or
three years will elapse and recovery then take place. A ma-
jority, however, recover in from six months to a year.
Treatment. It is quite evident that no general plan of treat-
ment will suit every case, inasmuch as each one has an indi-
viduality of its own. The state of the general health should
be rigidly inquired into, and any deviation from the normal
standard rectified as far as possible. Diet, baths, ventilation
and out-door exercise (if the physical condition of the patient
will allow), should be insisted upon and carried out under the
*guidance of the physician. The warm bath is a useful remedy,
both in regard to its diaphoretic qualities, and on account of a
special calming effect it seems to have upon the patient. The
patient should be surrounded with every possible comfort and
convenience, and provided with a female attendant (two will
be needed, if the case is likely to be protracted, so that one or
the other may constantly be on duty), accustomed to the charge
of the insane, and who has tact and firmness in controlling the
patient. No one should be allowed in the sick-room whose
presence seems to have even the slightest irritating effect upon
her, and this rule should be enforced even if it excludes the
husband and other near relatives. The patient should not be
left for a moment alone, or with one physically unable to con-
trol her in any effect at escape or self violence. Every thing
that can be used as instruments of violence, such as knives,
274 INSANITY AND ITS TREATMENT.
Scissors, razors, etc., should never be left within her reach;
cords, handkerchief, or articles of dress by which strangula-
tion might be effected should not be allowed her under any
pretence whatever. It the patient is very violent and un-
manageable it will be better to confine her in a strait-jacket
than to restrain her by physical force, which will always
excite more or less resistance on her part.
Therapeutics. There are two or three agents employed by
the old School whose use you will do well to bear in mind,
both for your patient's sake, and because you will not want
to see your patient pass into another physician's hands. The
first of these is Chloral Hydrate. There are some cases when
your patient in spite of your best efforts will not close her eyes
for several days and nights in succession. Her nature demands
sleep; her friends demand it for her; you will have tried your
indicated remedy and yet no sleep. In such cases the Hydrate
of Chloral is a valuable remedy. It may be given in doses of
20 or 30 grains at night, but care should be taken that the
condition of the patient after taking it, is, as regards the sur-
roundings, that of absolute quiet. The continued use of this
drug is attended by many dangers, and although very useful
When given in single doses, yet it may prove a most dangerous
remedy when continued for any length of time.
Bromide of Potassium is one of the most valuable remedies •
used, especially in the true puerperal mania occurring within
the month of parturition. Its action is prompt in this form
of insanity, in which the principal topic of the rambling talk
is connected either directly or indirectly with the generative
functions, the remedy seems to have great power in control-
ing the lewd discourse, and erotic desires. Ten grain doses
may be given at bed-time or twice per day, dissolved in water.
The remedies from the homoeopathic Materia Medica, to
which I have called your attention as useful in the other forms
of insanity, will not fail you in this, if used according to the
proper indications. We do not prescribe for a name, but for
the whole condition of the patient, but in those cases when
the mental symptoms are the prominent ones, we are guided
in the choice of our remedy by mental symptoms. I will give
PUERPERAL INSANITY. 275
a brief résumé of the leading indications and then speak of
three or four remedies concerning which I have thus far said
but little.
When fear of approaching death is a prominent symptom,
especially when accompanied by an inflammatory state of the
pulse: Acon. She imagines herself a criminal: Bellad., Cup-
rum, Mercur. Fixed ideas: Ignat., Silic. Despair of her sal-
vation: Ignat., Laches., Pulsat., Sulphur. Apprehends want and
means of support: Bryon., Calc. carb., Nua, vom. She has vi-
sions of ghosts and demons: Arsen., Bellad., Ouprum, Opium,
Platina. When haunted by visions of rats and mice: Arsen.
and Calc. carb. When by vermin and worms: Cimicif., Nua.
vom. When she imagines herself surrounded by dead bodies,
or sees pins everywhere: Silic. Fear of being poisoned: Hyosc.
and Rhus tow. Objects appear large to her, everything is
magnified: Hyosc. and Cann. ind. Objects appear Smaller:
Platina. She swears and scolds: Amac., Lycop. She tries to
escape: Bellad., Stramon. When shameless, immodest, strips
off her clothes: Hyosc., Phosphor., Stramon. and Veratr. alb.
If lascivious: Bellad., Stramon., Veratr. alb. When she desires
to be alone: Calc. carb., Cuprum and Ignat. When she dreads
being left alone: Cimicif., Lycop., Phosphor., Stramon. She
desires company, but does not want to be talked to: Gelsem.
If imperious, commanding that this and that be done: Cuprum,
Lycop., Sulphur. If sly, tricky and malicious: Laches., Nua.
vom. If she sings, warbles and whistles: Bellad., Crocus, Stra-
mom. When given to censure and rebuke: Arsen., Capsic.,
Helonias, Veratr. alb. If she weeps: Bellad., Ignat, Kali brom.,
Natr. mur., Pulsat., Platina, Sepia, Sulphur. If she is devotional
and prays a good deal: Aurum, Pulsat., Bellad., Hyosc., Stramom.
and Veratr. For melancholy of a religious nature: Arnica,
Aurum, Cuprum, Kali brom., Laches., Lycop., Pulsat., Silic.,
Staphis., Sulphur, Veratr. alb. For suicidal melancholy: Arsen.,
Aurum, Helleb., Hepar S. c., Nua, vom., Pulsat., Secale, Veratr. alb.
For silent melancholy: Arnica, Cactus, Coccul, Conium, Helleb.,
Igmat., Lycop., Nua, vom., Phosph. ac., Petrol, Pulsat., Silic.,
Stramon.
Anacardium is a remedy which, although not frequently
276 INSANITY AND ITS TREATMENT.
called for, is very valuable in some cases. It has great weak-
ness of memory, and forgetfulness.
Imagines she hears voices of persons far away.
Feels as though she had two wills, one commanding to do
what the other forbids. Unsociability; aversion to work or
to Society. At times almost a demented condition.
Very irritable, passionate and contradictory.
Does all sorts of foolish things in a clumsy way, almost as if
under the influence of liquor.
Gelsemium is one of my favorite remedies; and in my
hands it occupies a place between Aconite and Bellad. It has
cataleptic immobility, with dilated pupils, closed eyes, but
conscious.
Desires to be let alone; irritable, sensitive.
Loquacity, brilliant eyes, shooting through temples.
Depression of spirits, and anxiety or solicitude about the
present. Fear of death. -
Mental exertions cause a sense of helplessness from brain-
weakness; inability to attend to anything requiring thought.
Attack brought on from bad news.
Generally feeling of fulness in the head; throbbing of carot-
ids, etc. Head feels heavy, and symptoms of hyperaemia.
Heat at base of brain.
Gelsem. is useful both during the maniacal and melancholic
stages, and is a valuable remedy.
Conium mac., is a remedy which will occasionally be of use,
especially when in connection with the melancholia there is
Some uterine or ovarian trouble. Its mental symptoms are:
Extreme want of memory.
Dulness; difficulty in understanding what she reads or
what is said.
Aversion to man, and yet averse to being alone.
Indifference to everything.
Hypochondriacal depression.
Easily disturbed by trifles, and moved to tears.
Morose mood.
Headache and vertigo. Buzzing and roaring sounds in the
€8,I’S.
PUERPERAL INSANITY. 277
Hepar sulphur. The last remedy to which I will call your
attention is Hepar sulphur.
The effects of Hepar upon the sensorium is of a very de-
pressing character, causing most frightful anguish and fearful-
ness, as of perishing in consequence of this condition, which
may not be at all serious; particularly during the evening
hours, and before midnight; the sadness is so great that one
meditates suicide. When walking alone in the open air one
feels greatly discouraged and ill-humored, is reminded of all
the disagreeable thoughts and occurrences of a life-time, and
is apprehensive upon no reasonable ground about one's own
family and some impending misfortune. The memory is ex-
ceedingly weak, frequently allowing the use of wrong terms,
and this condition is found to exist, especially when one is
in an irritable frame of mind. Frightful visions make their
appearance while in a conscious state in bed in the morning,
and after rising an exceedingly irritable condition remains,
accompanied by mental depression. The over-Sensitiveness and
irritability, even to hasty speaking, are characteristic.
You will see that Hepar presents a good picture of the stage
of incubation, so to speak, of the melancholia of pregnancy
and of lactation.
Few things will be more difficult for you than the proper
management of a case of puerperal insanity, for every one will
be ready to interfere with plans and suggestions, but if you
keep firm and carry the case to a successful conclusion it will
aid you much in your medical career.
278 INSANITY AND ITS TREATMENT.
LECTURE XIV.
Epileptic Insanity.
One of the most important of the so-called varieties of in-
sanity, especially in a medico-legal point of view, is that
where the mental disease is complicated with epilepsy. For
if you can demonstrate to proof that a criminal act was com-
mitted under the influence of the epileptic paroxysm, the ac-
cused will not be held responsible for the act; while Jules
Falret, one of the ablest observers and writers on the subject,
goes so far as to say that all epileptics are irresponsible beings.
The insanity associated with epilepsy usually, though not
always, takes the form of mania. Pathologically, this form
of insanity does not form a complete class by itself, but it is
convenient to consider it by itself in these lectures.
As you doubtless know, the paroxysmal recurrence of epi-
lepsy forms one of its chief pathognomonic features, and the
main elements of the existence of the disease are, uncon-
sciousness, muscular convulsion and mental disturbance. The
occurrence of these three fundamental phenomena does not
appear with unvarying distinctness, inasmuch as one or more
of them may acquire such a prominence as to impart a spe-
cific character to the epileptic paroxysm. No one of these
isolated symptoms would, however, suffice to prove epilepsy,
any more than one single mad act would prove insanity.
Nevertheless, in every case, unconsciousness displays itself
conspicuously, in Some instances assuming such an absolute
prominence as to constitute almost the whole epileptic fit.
According to Dr. Reynolds, author of a standard work on
epilepsy, the memory and mental powers become affected in
but a small proportion of the cases of epilepsy. He says that:
1. Epilepsy does not necessarily involve any mental change.
2. That considerable intellectual impairment exists in some
cases, but that it is the exception, not the rule.
3. That women suffer more frequently and more severely
than men.
EPILEPTIC INSANITY. 279
4. That the commonest failure is loss of memory, and that
this, if regarded in all degrees, is more common than integ-
rity of that faculty.
5. That apprehension is more often found preserved than
injured.
6. That ulterior mental changes are rare.
7. That depression of spirits and timidity are common in
the male sex, but not in the female; that excitability of
temper was found in both.
Dr. Marcé, physician to the Bicêtre at Paris, says, on the
contrary, that perfect integrity of the intellect and emotions
in epileptics is of exceedingly rare occurrence, and it is use-
less to cite the history of a few great men, such as Caesar,
Mahomet, Petrarch and Napoleon, who are alleged to have
been epileptics, against the testimony offered by daily experi-
€I) Cé.
Dr. Althaus says, in his late work on Nervous Diseases,
“Even where there is no epileptic vertigo and automatic
action of the lower nervous centres, the mental condition of
epileptics is almost always peculiar. They are not really in-
Sane, but eccentric, suspicious, ill-tempered, quarrelsome, fault-
finding, fretful and difficult to get along with. They seem to
expand only with those who are similarly affected, but are
otherwise shy, peevish, gloomy and exclusive. Their intellect
is below the average, and their memory impaired, more espe-
cially after attacks. Their judgment is often incorrect, and
they are generally unhappy.”
We see here very clearly the insane temperament so strongly
insisted upon by Prof. Maudsley, and would naturally expect,
as is the case, that epilepsy very frequently superinduces in-
Sanity. Dr. M. G. Echeverria says, that during a period of
thirteen years he analyzed and recorded the history of 532
cases of epilepsy, 267 of which were of manifest epileptic in-
sanity. In these 267 cases, insanity, paralysis or epilepsy was
noticed among the ancestors of 83; intemperance in the par-
ents of 50, and phthisis among the ancestors of 83; and in 18
of these last cases there were consumptive brothers in the
family. This would lend strength to the opinion advanced
280 INSANITY AND ITS TREATMENT.
by Schroeder Van der Kolk, that insanity may appear trans-
formed from one generation to another into epilepsy or phthi-
sis or vice versa.
Dr. Maudsley says in the Journal of Mental Science, October,
1872: “In addition to entire absence or perversion of moral
sense, without feelings of remorse, which experience of habit-
ual criminals brings prominently out; other important facts
which we learn from an investigation of their family histo-
ries are, that a considerable proportion of them are weak-
minded or epileptic, or become insane, or that they spring
from families in which insanity, epilepsy or some other neu-
rosis exists; and that the diseases from which they suffer, and
from which they die, are chiefly tubercular diseases and dis-
eases of the nervous system. Crime, is not then, always a sim-
ple affair of yielding to an evil impulse or a vicious passion,
which might be checked were ordinary control exercised ; it
is clearly sometimes the result of a neurosis which has close
relations of nature and descent to other neuroses, especially
the epileptic and the insane neuroses; and this neurosis is the
physical result of physiological law of production and evolu-
tion.”
Dr. Jules Falret says: “Whenever we meet with isolated
acts of violence, outrage to persons, homicide, suicide, arson,
which nothing Seems to have instigated; and when, upon at-
tentive examination and thorough inquiry, we find a loss of
memory after the perpetration of the act, with a periodicity
in the recurrence of the same act, and a brief duration, we
may diagnose larval epilepsy.” (Annal. Med. Psyc., January,
1873.)
An analysis of the cases presented by Dr. Echeverria, shows
that hereditary predisposition, intemperance, ill-health and
injuries to the head, are the principal causes which combine
with the epileptic condition and produce insanity. Dr. Rey-
nolds states that hereditary taint is not essential to the pro-
duction of mental failure in epilepsy, and, after analyzing
thirty-four cases, says: “The numbers represented in the
above table are too small to establish any doctrine with re-
gard to the degrees of mental failure, and their relation to he-
EPILEPTIC INSANITY. 281
reditary taint; but they are amply sufficient to prove that
there is no necessary dependence of the one upon the other.”
The much fuller statistics of Dr. Echeverria contradict the
above statement, for out of 135 patients in whom the heredi-
tary taint was known and confessed, 83 displayed insanity, and
the 52 remaining showed some peculiarity in their character,
or a manifest weakness of mind with defective memory; con-
sequently it is very consistent with reason to believe that there
must be a dependence between hereditary taint and mental
failure, although the presence of the latter does not necessarily
involve the existence of the former, which is not an abso-
lutely essential condition of mental failure, since it may arise
from other etiological elements.
Epileptic insanity may display itself like all other varieties
of insanity in an intermittent, a remittent and a continued
form. The intermittent form is characterized by periodical
attacks, breaking out with intervals of variable regularity.
In the remittent form, there is no complete recovery of in-
tellectual soundness between the paroxysms or maniacal exac-
erbations; and lastly in the continuous form, the mental
trouble exhibits a permanent character, not essentially modi-
fied by the recurrence of the fits.
Epilepsy may be defined as a chronic disease of which the
characteristic symptom is a sudden loss or trouble of con-
sciousness occurring occasionally. This affection of conscious-
ness is sometimes accompanied by evident spasms of muscles,
and sometimes occurs without obvious spasm.
Dr. J. Hughlings Jackson says that there are three varieties
or rather degrees of epilepsy as thus defined; and they are
called (a) vertigo, (b) le petit mal, (c) le grand mal. “Not only
is there affection of consciousness in each of these, but it is, I
repeat, the first, or nearly the first thing in the paroxysm;
this must be borne in mind. There are three other things
about epilepsy to be kept vividly in mind.
“1. That there occur all degrees of obscuration of conscious-
ness, not loss only, in cases of epilepsy. From temporary con-
fusion of thoughts (which is defect of consciousness) to deepest
coma there are all gradations. In fact the patient who is sub-
18
282 INSANITY AND ITS TREATMENT.
ject to genuine epileptic attacks may have had abortive seiz-
ures without any affection of consciousness before he ever had
a full attack; for example he may have had paroxysmal epi-
gastric Sensations only.
“2. That there are all degrees of severity of epileptic par-
oxysms, from giddiness attended by trivial confusion of thought,
to a full violent seizure with universal convulsion and deep
COIſla.
“3. And, most important, that cases of epilepsy in which
there are the slightest attacks are the worst for the mind. We
must not forget this for two reasons: (a) the importance of
these attacks is unfortunately often underrated because they
are slight; (b) the attack being slight and transitory it is lia-
ble to be overlooked, and attention may be paid to its sequelae,
that is, to the patient's grotesque actions, raving, etc. These
may in a woman be erroneously attributed to hysteria, and in
a savage man to criminal intent. The gravity of these cases
is not because the paroxysms are slight, but because the ‘dis-
charging lesion’ in cases in which such slight fits occur, is of
the highest and most intellectual nervous arrangements (sub-
strata of consciousness).” (West Riding Reports, Vol. 5.)
Dr. Jules Falret divides the mental maladies of epileptics
into three classes.
1. Those in which the mental disturbance manifests itself
in the intervals of the epilepsy and may be independent of it.
2. Those in which the mental disorder occurs as a tem-
porary phenomenon, and either precedes, accompanies or fol-
lows the epilepsy.
3. Those in which the mental symptoms occur in paroxysms
of greater or less duration, either directly with or indepen-
dently of the vertiginous or convulsive phenomena.
Dr. Dickson, Lecturer on Mental Diseases at Guy's Hospital,
London, prefers to condense these three divisions into two ;
1. That in which the epilepsy and the insanity are more or
less independent of one another.
2. That in which they are so associated as to be more or less
dependent upon one another.
The first class of cases is very common in asylums. The
EPILEPTIC INSANITY. 283
constant and habitual state of the patients is insanity, from
which they appear never to be entirely free; their epilepsy re-
curring at greater or less intervals, and seemingly independent
of their insanity. Sometimes the patients drop down, pass
through one or more fits, and recover without any apparent
alteration in their mental condition; sometimes they exhibit
an increase in their habitual excitement, but the tendency of
all these cases is downward and toward absolute and complete.
dementia. *
In some cases the epileptic fit is a mere dizziness or vertigo,
and in some cases the giddiness even, is not apparent to the
observer, and all that is observable is the transient mental dis-
turbance. Sometimes in incipient cases the disturbance will
be shown in perverted speech. A case is reported by Forbes
Winslow of a lady who, at times, in attempting to repeat the
Lord's prayer, gave utterance to “Our Father which art in
Hell,” instead of “Our Father which art in Heaven.” This
tendency caused her great mental agony.
Dr. Beddoes knew a gentleman who, previously to an attack
of epilepsy, misplaced his words in a singular manner. For
example he would say, “Everbody feels very languid this wet
weather—I mean this hot weather,” or, “Come who will sit
down to supper? here is only cold meat and pudding, LI mean
pie.” Dr. Dickson says that he too has occasionally met with
cases where the patient so misused words, as to say hot for cold,
wet for dry, and sometimes he has seen very clearly marked
cases of temporary aphasia.
At times the conduct of epileptics undergoes strange vicissi-
tudes; in a very short time passing from gay to grave, and
from grave to gay. They may become, without apparent cause,
peewish, desponding, sad or depressed; or they may become
irritable, magnify little worries into annoyances of great
moment, engage in rash and hazardous undertakings incom-
patible with sound judgment; or lend themselves to quarrels
or to violence, which have no seeming origin, and which are
inexplicable unless the epilepsy be recognized. Again, they
may suffer from confusion of ideas and loss of memory; or
their memory was never so powerful or their intellect so bril-
liant.
284 INSANITY AND ITS TREATMENT.
“Remarkable intellectual activity has sometimes signalized,”
says Morel, “the commencement of epilepsy among the young.
A wonderful aptitude to conceive things quickly, to examine
them under their most brilliant and poetical aspects, has been
exhibited by many of them. History has transmitted to us
the names of several great men who have been epileptics; but
these have been the victims of the most tyrannical passions.
The full and entire preservation of the faculties of epileptics,
the possibility of applying them in a Gontinuous manner to
the execution of designs remarkable for their grandeur and
continuity, are in fact excessively rare.
“The first change remarked in the character of epileptics
threatened with insanity, is the very great irritability, which
takes place without, and even at, the least contradiction, under
the most varied, and sometimes most compromising forms.
Hypochondriasis and hysteria have an undeniable action in
the delirium which begins to systematize itself in the minds
of the patients. Preoccupations on the subject of their health,
unjust complaints, recriminations without foundation, de-
cided venereal tendencies, are facts which awake the just
solicitude of families.” (Traité des Maladies Mentales. p. 696.)
Prof. Trousseau says in one of his lectures: “If there have
been epileptics who, in spite of more or less frequent attacks,
have retained to the end of even a pretty long career, not only
the perfections of their reason, but also the full force of their
intellect, and like those men of genius whose names history
has handed down to us, preserved that superior intelligence,
instances of this kind are too exceptional to invalidate the
general law.
Maudsley further remarks: “It is not so clearly understood
that the mental derangement so occurring may have the form
of profound disturbance with homicidal propensity, without
manifest intellectual derangement.” He also points out the
frequency of such phenomena in children who afterwards be-
come insane. He says children three and four years old are
sometimes seized with sudden fits of shrieking, desperate stub-
bornness, or furious rage, in which they bite, tear, and destroy
what they can lay hand upon, these may occur periodically,
EPILEPTIC INSANITY. 285
and may either pass in a few moments into developed epilepsy,
or alternate with epileptiform attacks, representing a vicarious
epilepsy.
In this connection it is convenient to note that the epilep-
sies of which the “discharging lesions” are seated in the high-
est nervous arrangements are those which occur in asylums
in connection with insanity. Clinically speaking, asylum
cases are most often those in which the paroxysms begin by
loss of consciousness, which is equivalent to the anatomico-
physiological statement, that the discharge begins in the high-
est nervous centres; or we may say that these cases gen-
erally begin without a warning. Dr. Crichton Browne says,
that in asylum practice, an aura is of rare occurrence in epilepsy.
He says that using the term aura in its widest sense to include
all prodromata, all symptoms, psychical, sensory or motor,
which immediately precede a paroxysm, an aura is rare in a
lunatic hospital. He says, however, that the absence of an
aura may be owing to the fact that the patients are often far
advanced in the disease when admitted; and again, it may
not be recognized by the patients, because their feelings and
intelligence are blunted. But in cases which occur in hos-
pitals, there is sometimes an aura, but loss of consciousness
soon follows; loss of consciousness is almost the first thing.
Then the warnings are of a particular kind. They are fre-
quently vertigo, epigastric uneasiness, or a general creeping,
tingling or thrilling of the skin. Dr. Browne says, that
“when auras are present they are almost invariably general
in character, and consist in indescribable feelings in the head
or abdomen, spreading thence over the body, or in this uni-
versal creeping, tingling and thrilling of the skin.
Foville remarks that “a peculiar sensation, it may be of
cold, pain, heat or itching, is developed suddenly in a toe, a
finger, a limb, in the belly or the back, and from the point
where it originates, mounts gradually to the head. When it
arrives there the patient falls (as if struck) and the convul-
sions break forth at once.”
“On the eve of a fit,” says Dr. Radcliffe, “confirmed epi-
leptics are noticed to sit or move about in a moping and list-
2S6 INSANITY AND ITS TREATMENT.
less manner; to complain of chills and shiverings, or of faint-
ness and sickness. Occasionally there is headache, dazzling
of the eyes, singing in the ears, and other excitement of sen-
sation; slight flushing of the face, dilatation of the pupils, and
extreme irritability of temper.”
Again, the very cases in which the intellect is most rapidly
affected are those in which there are very slight attacks be-
ginning with, or apparently constituted solely by, loss of con-
sciousness, le vertige épileptique and le petit mal, of the French
writers.
“The greatest injury to the intellect is not inflicted by the
most frightful and frequent convulsions, nor when the mature
and muscular man struggles like a chain-bound Hercules.
Absence of mind, momentary obliviousness, vertiginous feel-
ings, a pause, a stoppage or an intermission in consciousness,
such as has been described as the petit 'mal, as surely and
swiftly produce enfeeblement.” (Dr. W. A. Browne, Journal
of Mental Science, October 1865.)
“On a remarqué que l'absence, malgré Sa légèreté apparente,
est la forme la plus redoubtable au point de Vue de l'altération
des facultés intellectuelles.” (Jaccoud, Pathologie Interne, p.
394.)
Whatever marked the stage of excitation during the con-
tinuance of the disturbance, is as a rule forgotten when the
brain recovers itself. Sometimes there is a memory of what
has passed, a memory vague and dream-like, usually very
painful and depressing; or a feeling as though something had
occurred, but a something they cannot account for or recall.
Falret commenting upon the actions and other phenomena
presented by patients in this somnambulistic state, says: “No
one can form any accurate notion of the irascible feeling
which suddenly seizes the epileptic and urges him to strike
and to smash everything near him.
During these transient attacks of fury he is dangerous to
those about him as well as to himself, and the attention of
medical men cannot be too earnestly drawn to these conditions
of instinctive and blind violence, which all authors have
pointed out as frequent results of epileptic fits.
EPILEPTIC INSANITY. 287
In order to gain a clear idea of this peculiar epileptic char-
acter let us see what Le Grand de Saulle says of it in his
work “La Folie devant les Tribunawa”.-“The character of the
epileptic is made up of contradictions; nothing can equal the
frequency, rapidity and marked contrast of its changes. The
same person whose crabbed disposition, ill-natured and obsti-
nate, just now attracted your attention suddenly becomes sub-
missive, flattering, obsequious and fawning. The versatility
of the mental manifestations in epileptics is such that at our
morning visit to our patient we find him affable, gay, demon-
strative, enthusiastic; he is proud of his actions, and boasts of
the resources of his mind, and the qualities of his heart; he
speaks with lavish praise of his wife, his children and his
friends; and is so blinded as to his real condition, as to enum-
erate a quantity of extravagant projects to which he means
to devote himself as soon as he is well enough to go out. A
few hours later, if you revisit him, this same man will be sad-
ly crouching in a corner; he weeps and is in the depths of
despair. Approach him and make kindly inquiries, and he
will return a look of suffering and of shame; he will speak to
you of the dreadful results of his disease, of the forced seclu-
sion in which he is doubtless condemned to remain as long as
he lives; of his strong desire to be cured, and the bitterness
with which his life is filled.” (p. 268.)
Violence and perversity are not all that characterize the
epileptic; there is also the impassioned state produced by the
emotions which he experiences. These emotions excited by the
disease often become so vivid that they control the whole
mind, and stifle all manifestations of the moral Sentiments
which might oppose them, and which the person would feel
were he in his normal state. Thus we see one of these epilep-
tics in the impassioned state, at times controlled by violence
and anger, sometimes by ambitious and haughty passions,
and at others by shame and discouragement. Under the in-
fluence of the emotions imposed by disease, and of the im-
passioned state produced thereby, deliriums arise, and strong
desires which make of him an insane man. The abnormal
excitement of his nervous system, together with the nerves of
288 INSANITY AND ITS TREATMENT.
^
sense, is especially favorable to the production of hallucina-
tions, as we shall see later.
In his valuable memoir on the “Mental State of Epileptics,”
Dr. Jules Falret draws a distinction between the intellectual
grand mal, and the intellectual petit mal, indicating these by a
close relation between the physical and psychical manifesta-
tions of the disease. The intellectual grand mal corresponds,
according to Falret, with the incoherent and violent state com-
monly described as furious mania. The intellectual petit 'mal
may continue from several hours to several days, constituting
an intermediate condition between the irregularities of charac-
ter which attend the fits, and the highest disturbances of the
furious maniacal seizures. This state is mainly disclosed by
a great confusion of mind, accompanied with instinctive in-
stantaneous impulse and acts of violence. No sooner has the
stupor of the epileptic fit subsided, then the patient laboring
under this particular kind of delirium, becomes sullen and
deeply dejected, with great confusion of mind, and irritability
against everything surrounding him. The patient feels an
utter inability to collect or fix his thoughts and to master his
will, which is variably displayed according to the social posi-
tion of the individual. Epileptics have no energy or desire
(during the paroxysm), to overcome these feelings, and, seized
by a vague anxiety, or hallucination, or an involuntary dread,
they leave their homes to wander aimlessly about.
In the midst of this confusion of mind they recall to their
memory painful past impressions, which spontaneously spring
up in their imagination, always the same at every new access;
and it is during this terrible condition that such epileptics
give themselves up to acts of violence, in the most sudden in-
stantaneous manner, thus committing homicide, Suicide, arson,
or any other criminal deed, and giving vent to their rage,
blindly striking repeated blows at their victims and fearfully
mangling them. After the fit of violence a crisis may take
place, the patient either returns to himself, in a sort of in-
stantaneous manner, regaining his consciousness and render-
ing an imperfect account of his misdeed; or, on the contrary,
he tries to escape, running away in a bewildered state of great
EPILEPTIC INSANITY. 289
agitation. In some cases, however, there will be present both
motive and premeditation; the insane epileptic may commit
the criminal act deliberately, and yet be under the influence
of morbid emotions and of delusive ideas.
Dr. Maudsley says: “There are no special features so dis-
tinctly marking an epileptic homicide as to enable us to iden-
tify it on every occasion; but those which will commonly be
observed are an absence of intelligible motive, an absence of
premeditation, great determination and ferocity in the execu-
tion, much more violence than necessary being used, an ab-
sence of secrecy in the execution or of concealment afterwards,
a great indifference and absence of remorse, and an incomplete
and fragmentary remembrance of all the circumstances, if not
a complete forgetfulness of them.” (Responsibility in Mental
Disease, p. 245.)
In these cases, the very confused recollection, if not the com-
plete oblivion of what has happened, is almost always a strik-
ing essential symptom of the mental state, so much resembling
the awakening from a dreadful dream. -
. This paralyzed condition of the brain which occurs during
the convulsive attack, may continue for some time afterwards.
If the nervous centres, then in a state of activity, are not over-
excited, they do not produce this attack of rage, but merely
the ordinary features of an attack of somnambulism. Drs.
Darwin, Pritchard and Maudsley have pointed out the affinity
between epilepsy and somnambulism. This also has been well
pointed out by Falret, who says: “There are certain incomplete
attacks of epilepsy, which hold an intermediate place between
the simple vertigo and the full paroxysm, and which occur
while the patient appears perfectly conscious of everything
about him. Such persons pronounce words, or commit acts
which would make one doubt the real epileptic nature of the
attack and would lead us to ascribe to them a freedom of will
and moral sense to which they can lay no claim. This singu-
lar mental condition, in many respects resembles ordinary
Somnambulism, and other neuroses besides epilepsy.” A re-
markable phenomenon, which frequently occurs in these in-
complete attacks of epilepsy, or in the interval between two com-
29() INSANITY AND ITS TREATMENT.
plete attacks should be noticed in this place, though examples
will be given later. The patient seems to have come to him-
Self, enters into conversation with those around, and performs
certain acts apparently dictated by the will. Then the epilep-
tic attack recommences, and when the patient again emerges
from its influence, he has no remembrance of the words or acts
of the interval between the two paroxysms. Such are the
principal traits of the two conditions delineated by Falret,
and as a rule actually exhibited by the epileptic insane.
Dr. Echeverria says that although the description here given
is true as a whole, yet the ingenious distinction between the
intellectual grand mal, and the intellectual petit mal, and their
respective relations to the corresponding physical conditions of
epilepsy, involve a connection which is far from being con-
stant. The most fearful fits of rage and frenzy he ever wit-
nessed were superinduced after attacks of simple petit mal,
and he says that fits of furious mania have too repeatedly
fallen under his observation to regard the phenomena as of
exceptional occurrence. We find also, after successive fits of
grand mal, or of petit mal, or of both together, a state of harm-
less insanity, with the highest degree of melancholia with
stupor, without the violent reactions which, as set forth by
Falret, should, in the intellectual grand mal, exclusively follow
the physical grand mal. In other instances, the epileptic,
without any dejection or stupidity, talks and acts coherently,
in an apparently rational manner, but actually without any
appreciation of his outward relations; and this change may
supervene in connection with diurnal or nocturnal fits, or
throughout the paroxysms of cerebral or larvated epilepsy.
All these various manifestations, not corresponding to any of
the two intellectual varieties proposed by Falret, necessarily
shake the foundation of his absolute division.
According to Van der Kolk, Kussmaul, Brown-Sequard and
others, the pathology of epilepsy has its starting point in the
medulla oblongata. The two essential phenomena are loss of
consciousness and convulsions, and these being the states or
conditions produced, the question arises, What is the imme-
diate exciting cause?
EPII,EPTIC INSANITY. 291
Dr. Reynolds argues that loss of consciousness is a simple
negative condition, and that the convulsion is due to irrita-
tion at the medulla, or upper part of the spinal axis, and is
the modification of a normal function, and not the effect of a
structural change, since the organ shows a complete structural
integrity in the interval between the fits. He considers, there-
fore, that the convulsion is a simple excess of normal action.
“The nature of the morbid change is,” he writes, “an exag-
geration in degree of the functional activity of the medulla
oblongata, and upper part of spinal axis,” and he considers
that augmented activity in the nutritive processes is the prime
and essential factor in epilepsy. The seizure or excess of
action, however, he believes may be brought on by lesions of
the adjacent or other tissue.
Dr. Sankey, Lecturer on Mental Diseases, at University
College, London, thinks that in cases of epileptic mania there
is an extension of this morbid activity to the rest of the cere-
bral organs, and a certain persistence of it in those parts
presiding over motility; for, not only is the patient convulsed,
but for a period anterior and subsequent to the fit, there is
generally exhibited great restlessness and irritability of the
motor faculties.
Dr. Echeverria looks upon epileptic insanity as one of the
manifestations of the spasmodic neurosis, recognizing its
essential and primary source, not in the fits, but in the very
etiological elements of the disease. The various fits are noth-
ing else but paroxysmal manifestations, which may accompany
each other in a close sequence, or exist entirely by themselves;
separate, though nevertheless depending upon one common
etiology. We do not know why under certain circumstances
we have to contend with fits of petit 'mal, in others with fits of
grand mal, and in others again with nocturnal attacks; neither
can we better explain why the counterpart of these convulsive
paroxysms should be characterized by purely cerebral symptoms
unattended by any spasmodic phenomena. Morever, Falret posi-
tively asserts that there is but one form of epileptic insanity,
in which the delirium and convulsions are not two distinct
maladies, but two diverse manifestations of the same morbid
292 INSANITY AND ITS TREATMENT.
state, which may exist separately or simultaneously, or within
short intervals of each other.
Marcé says that in the immense majority of cases the attack
of rage is consecutive to the fit. The delirium arises imme-
diately after the period of stupor, that is to say sometimes a
quarter of an hour, sometimes many hours or even some days
after the convulsion. In some exceptional cases the delirium
precedes the convulsion which thus seems to serve as a crisis.
The paroxysm of mania, may then have a duration of some
hours or days. At times the fit abruptly ends the period of
delirium, and at others, the latter disappears slowly and grad-
ually. Finally there are a few rare cases when the fit has been
both preceded and followed by delirium. Falret reports one
case in which the convulsion was preceded by melancholy and
followed by mania. For all these reasons, instead of attempt-
ing to establish an immediate relation of cause to effect—
which could only be proved with difficulty,+between the in-
tellectual and physical paroxysms, I have thought it safer to
adopt the usual division, and to consider unconsciousness and
the excessive reflex susceptibility as the chief characteristics of
epileptic insanity, capable of breaking out, either alone, or
coupled with any other form of the epileptic malady.
I cannot leave this topic, however, without quoting the
views of Dr. J. Hughlings Jackson, and I do so the more
readily, since it is only of late that the important mental
changes connected with epilepsy are receiving the attention
they deserve.
Dr. Jackson says: “It is convenient to have one name for
all kinds of doings after epileptic fits, from slight vagaries up
to homicidal actions. They have one common character;
they are automatic; they are done unconsciously, and the
agent is irresponsible. Hence I use the word mental automat-
ism. I say mental, as the doings are probably external signs
of crude mental states—external signs of ‘epileptic dreams.’
“I have spoken of mental automatism as occurring after
the paroxysm, but I must mention that according to some, I
believe most, alienist physicians that degree of it which is
called epileptic mania, although it usually occurs after a fit,
EPILEPTIC INSANITY. 293
does not always do so. It sometimes replaces a fit. A patient
who is subject to ordinary epileptic attacks may, on this hy-
pothesis have, as it were, instead, a paroxysm of mania. It has
been said that the patient who is subject to attacks in which
there is convulsion of muscles, may at another time have an
attack in which there is ‘convulsion of ideas' and correspond-
ing excess of external action (mania). I used to adopt the
theory of masked epilepsy. But I do not now think it possi-
ble that a nervous discharge at all comparable in degree to
that which causes convulsion would cause even such carica-
tures of normal action as occur either in epileptic mania or
in slight cases of mental automatism. I now think another
hypothesis is preferable. I think it is probable that there is a
transitory epileptic paroxysm in every case of mental autom-
atism occurring in epileptics before their mental automatism
sets in. I am fully aware, and freely admit, that occasionally
no signs of a prior fit are discoverable. The patient who at
other times has ordinary convulsive seizures may become sud-
denly maniacal, although even when under observation he
presented no physical change to indicate a paroxysm before
the raving begins. To acknowledge this fully let me give an
example. A very intelligent medical man came up to town
with an epileptic patient of Inine. He afterwards told me
that the patient became suddenly, without any premonitory
symptom to indicate an epileptic paroxysm, very much ex-
cited, struggling more or less violently with his attendants for
twenty minutes. I believe there is in such cases, during the
paroxysm, an internal discharge too slight to cause obvious
external effects, but strong enough to put out of use for a time
more or less of the highest nervous centres. For medico-legal
purposes it may, however, be assumed either that mental au-
tomatism always occurs after, or that in some cases it replaces
an epileptic seizure.” (Temporary Mental Disorders after Epi-
leptic Paroxysms. West Riding Reports, Vol. 5.)
Dr. Thorne Thorne of London has published in St. Bartholo-
mew's Hospital Reports, 1870, a valuable case, especially note-
worthy from the peculiar mental symptoms which in a meas-
ure replaced the ordinary convulsive attack.
294 INSANITY AND ITS TREATMENT.
“H. S., a coach builder, ast. 36, and of temperate habits,
had, fourteen years previous to the present history, been ex-
posed to the sun's rays for some time, and suffered from Some
pain in the head for three weeks afterwards. After a rheu-
matic illness three years subsequently, the pain returned, and
he had never been free from it for any time since; he had, too,
occasional attacks of dimness of sight and trembling. He
married and became the father of several children. Nine or
ten years after his partial sun-stroke he had several well
marked epileptic fits, and they continued increasing in fre-
quency until he had one on an average every third week. Up
to this time in the clinical history we have nothing but a well
marked case of epilepsy; about this time a train of morbid
mental phenomena appeared. Whilst in hospital for slight
bronchitis, he is reported to have become “strange in manner,’
and to have had some delusions. One night he suddenly
jumped out of bed, rushed wildly to the door of the ward,
which he quickly opened, and then fell to the ground, on his
back. He was picked up, and carried to his bed; he seemed
to retain consciousness, but gave no explanation of his con-
duct. During his stay in the hospital, which was about a
month, he was liable to these attacks, that is, spells of mental
excitement, associated with delusions, and followed by periods
of depression. In the intervals he was cheerful, his manner
was calm, and he was always ready to make himself useful.
Before his admission into the hospital he had never had any
mental symptoms, but during the next two years they fre-
quently recurred in a very marked form. He had occasionally
suffered from spells of mental depression, but these gradually
were transformed into paroxysms of acute mental excitement.
In these attacks he becomes suddenly wild, his intellect is con-
fused, and he will snatch up a knife, and declare aloud that
he is going to kill his children, rushing after them into the
closets, etc., where, terror-stricken, they may hide. After his
wife has removed everything with which he might do himself
and others harm, and locked up with him trying to pacify
him, more than once it has required all her strength and tact
to hinder him from throwing himself out of the window. After
EPILEPTIC INSANITY. 295
remaining in this state for several hours, and sometimes for
an entire night, he will gradually get quiet and go to sleep.
On awaking he has but a dim recollection that he has in any
way been ailing, and none whatever of what he has done or said
during the attack. These attacks are preceded by the same
warning symptoms as his regular epileptic fits; viz: a sensa-
tion of cold and trembling.
“It is also stated that this man subsequently became a sub-
ject of kleptomania. On one occasion he was arrested for
stealing his fellow-workmen's tools which had been found in
his possession. He most emphatically asserted that he had
not taken the articles. His well-known honesty and previous
history favored the notion that the theft had been done during
an access of epileptic vertigo. On medical evidence to that
effect being given, the charge was withdrawn and he was re-
leased. The medical officer of the prison, who examined him,
however, was unable to state that he could at that time find
any indications of mental unsoundness; although, having
heard of his former attacks, he said that he could not doubt
that such indications had from time to time manifested them-
selves. This man is unquestionably liable during an access
of his disorder to commit some serious criminal act. It will
be remembered that his first impulsive act was to rush madly,
and apparently without purpose to the door of the ward of
the hospital, and he might just as well have made a motive-
less, murderous attack upon a fellow-patient.”
At a meeting of the New York Medico-Legal Society, May,
17th, 1871. Dr. Meredith Clymer reported the following case;
“About a year ago I was consulted by a middle aged gentle-
man, who told me of his troubles as follows: Without warning
or immediate provocation, he would suddenly have the most
horrible homicidal impulse toward certain persons, who, either
really, or at the moment he imagined, had injured, or slighted
or offended him. In his room, or in the street, or crossing a
public square, the fit instantly seized him, and fancying the Sup-
posed evil-doer before him, he would strike at him with some
murderous fantastic weapon, stabbing him in the neck, or
breast, or belly, with a sharp instrument, or giving a blow on
296 INSANITY AND ITS TREATMENT.
the head with a blunt one, the act being accompanied with the
most violent, reproachful language. He said, he was not
aware that in the street, or when any one was present, the
gesture or speech were more than subjective; but, if alone, he
knew that he spoke aloud, and suited the words to the action.
The fit over, he always felt very much exhausted, with more
or less loss of power, particularly recently, of the left extrem-
ities. Although occasionally in the company of some of the
menaced persons, he had never felt at such times any disposi-
tion to harm them, or to behave towards them in any way
that showed the feelings he at periods involuntarily ex-
perienced regurding them; but he was tormented by the
apprehension that the time might come when he would be
attacked whilst in their presence, and thus commit some hor-
rible crime. He was a man of high moral tone and Christian
training and practice, irritable, subject to temper-fits from
childhood, but naturally of an amiable and generous disposi-
tion. He was greatly disturbed at his infirmity, had for some
time concealed it, and at last, dreading the possible conse-
quences sought advice. He said that he had more than once
decided to go voluntarily to an asylum, but was withheld from
the fear of exposure, and injury to his prospects and family.
Although he had had many vexations from pecuniary losses
and general bad luck, he was usually cheerful. He had no
headache, and his general health was excellent. After one of
these spells his left arm would grow weary and his left leg
weighted, along with some numbness and tingling in the
parts; these sensations would soon pass off. He had had neu-
ralgic attacks occasionally for years, but they had become
lighter and rarer. He never had suffered from epileptic fits,
or, as he thought, anything like them; nor had any of his
family. One day he asked me to prescribe something for
a sore tongue, and on examination I found evidence of its
having been bitten, which led me to believe that he was sub-
ject to nocturnal attacks; and, on being questioned, he admitted
that often before falling asleep, he had remarked that his jaw
snapped, and sometimes his limbs jerked. I looked upon
these phenomena apparently so insignificant, as really the key
to the psychical troubles.”
EPILEPTIC INSANITY. 297
In some cases of epileptic insanity, the profound stupidity
or the state of pseudo-catalepsy into which the patient is sunk,
prevents the reaction of the reflex susceptibility, which un-
derlies the generation of impulsive acts; but I find no case
on record where the existence of unconsciousness was not
clearly manifest. We quote from Dr. Dickson’s “Medicine in
Relation to Mind,” a case of this sort. He says: “I saw a gen-
tleman the other day, of whom I learned that on two occa-
sions he had suddenly risen from the dinner table, walked to
a corner of the room, made water, and then returned to his
seat, quite unconscious of what he had done. On another oc-
casion he lost his way completely in the neighborhood where
he lived, and was $o utterly unable to give any account of
himself that he was taken into custody by the police, and
kept in their charge until his friends were found. On a
third occasion his right arm was found to have become par-
alyzed during the night; the paralysis was very transient and
soon passed away, but it pointed to an origin like epilepsy,
and I learned that the patient was subject to attacks of vio-
lence and excitement of which he remembered nothing when
the paroxysm had passed. His friends had never seen him
in a convulsive fit, and therefore doubted the epileptic char-
acter of his malady. I, however, had no doubt of it, and my
opinion is supported by the fact that the gentleman is be-
coming gradually, but certainly, progressively demented.”
You may remember a somewhat similar case mentioned by
Trousseau in his lectures. The patient, a French judge, got up
from his seat one day whilst the court was sitting, muttered
some unintelligible words, went to the council room, and re-
turned in a few moments, unconscious of having left his seat.
When his colleagues asked him where he had been, he an-
swered them that he did not recollect having moved from his
place. Shortly afterwards he got up in the same manner, and
the usher was told to follow him, and he was seen to enter the
council room, make water in a corner, and then again return
into the court, but he was altogether ignorant of what he had
done.
We may have epileptic attacks where the mental disturb-
19
298 INSANITY AND ITS TREATMENT.
ance is pushed to a state of delirium ; unconsciousness then
becomes obvious in the stupor, which Delasiauve has pointed
out as the characteristic accompaniment of epileptic delirium.
As you would naturally suppose, epileptic insanity usually as-
sumes the form of mania. It begins suddenly, and in a very
short time reaches a high degree of excitement and violence,
after having been preceded or not, for a few hours, by Sad-
ness, irritability, or some physical ailment, such as headache,
vomiting, alteration of the voice, or some slight convulsive
movement of the face and limbs. This excitement once
started is never held within moderate bounds. The patients,
a prey to blind rage, break everything upon which they lay
hands; they tear, strike, bite and yell; they dash their heads
against the wall, and attack with rage anyone who approaches,
and, for the time, more nearly resemble wild beasts than hu-
man beings. Thus they are justly considered as the most ter-
rible and most to be dreaded of all lunatics. Overmastered
by ideas of terror, pursued by hallucinations of sight and
hearing; they see and hear around them armed assassins who
seek to kill them; they perceive flames and circles of fire, and
their visions impress them deeply with sentiments of confu-
sion and terror. Then it is, that, driven by an irresistible
impulse, they seize the first weapon near to hand, and strik-
ing right and left vent their anger and fury upon the ani-
mate or inanimate objects which they may meet in their
course. Dr. Sankey says, that while he was at Hanwell, an
epileptic male patient, while digging in the fields, was seized
with his paroxysm, and rushed blindly upon an inoffensive
patient near, and cut him down with the blade of the spade,
inflicting frightful injury, and killing him on the spot.
Some other characteristics enable us to distinguish epileptic
from ordinary uncomplicated mania; for instance it is said
that all the paroxysms in the same patient present an absolute
resemblance, not simply as a whole, but in all its details.
When one has carefully observed the different phases of one
paroxysm of epileptic mania, he will be surprised to see that
particular patient express the same ideas, in the same words;
commit the same acts; experience, in a word, the same physi-
EPILEPTIC INSANITY. 299
cal and moral phenomena at each subsequent paroxysm. It
is also worthy of note, that in spite of the disorder and vio-
lence of the acts; the words spoken by the epileptic insane are
less incoherent than those of other maniacs. They compre-
hend better the questions asked them, and are more apt to
notice things about them.
The following cases will serve to illustrate the peculiar ten-
dency to violence and passion.
A Swabian peasant, aged twenty-seven years, whose parents
did not enjoy the best health, had been epileptic from his
eighth to his twenty-fifth year. But the character of his
disease then underwent a change; in place of epileptic con-
vulsions, the man found himself with an irresistible impulse
to commit murder. He felt the approach of the homicidal
paroxysm for several hours, and sometimes for a day, before it
came on, and then earnestly begged to be bound, lest he
should commit a crime. “When it seizes me” he said, “I
must kill some one, were it only an infant.” His mother and
father, whom he loved dearly, were the first victims of these
fits: “Mother,” he cried in a loud voice, “save yourself, or I
must strangle you.” Before the attack he was greatly exhaust-
ed, had slight convulsive movements in the limbs, and was
overpowered with a feeling of sleep, without being able to go
to sleep. During the paroxysm which lasted one or two days,
he retained consciousness, and knew perfectly that if he com-
mitted murder he would be guilty of a crime; and when he
was put under restraint, he made contortions and fearful
grimaces, sometimes singing and sometimes speaking in
rhyme. When it was over, he cried, “Unloose me. Alas! I
have suffered greatly; but I am well out of it, since I have
killed no one.” (Esquirol.)
A man, aged fifty-five, sober and industrious, had suffered
from an attack of cerebral hemorrhage a year ago, and re-
mained hemiplegic. His intelligence was sound and he fol-
lowed his usual occupation. But his character was changed;
he felt weary of life; he had become morose and irritable; and
he complained that at times the blood rose to his head, when
vertigo, noises in the ears, and flashes before the eyes, occurred.
300 INSANITY AND ITS TREATMENT.
These attacks became periodic. During them his heart beat
violently, his eyes were injected, the face flushed, the fingers
of paralysed side contracted, the arteries of neck throbbed; he
was unspeakably dejected, wept, said he was lost, and became
furious, throwing himself upon his wife and children, and
during the very transitory delirium, had several times at-
tempted suicide. (Morel.)
The paroxysms of epileptic mania are never of long dura-
tion. Marcé says that it is rarely that they continue more
than a few days. Echeverria says, and this is very important
for us to remember for medico-legal reasons: “Let me notice
distinctly, that epileptic mania very seldom lasts less than two
or three hours, and I have never met with one instance of
shorter duration.” The patient suddenly becomes calm, and
in a few hours resumes his accustomed state without any well-
marked period of transition; he frequently presents, by the
timidity of his acts, his distrustful and anxious mind, a most
striking contrast with his late scenes of violence.
Some present a short intermediate period of physical and
intellectual torpor, from which they emerge as from a dream,
preserving only a vague and confused remembrance of the
events occurring during the paroxysms. Nothing similar to
this, you will observe, takes place during an ordinary attack
of mania, even when it lasts some weeks or months. In or-
dinary mania, the patient preserves with extraordinary tenac-
ity the remembrance of those things occurring even when he
was most excited.
The description just given is that of epileptic mania as it oc-
curs in close connection with the fits, and such as you will rec-
ognize in practice at once, and easily refer to them; but we
have another form, the “larvated epilepsy” of Morel, the inter-
mittent form of Echeverria; allusion to which has already been
made. This generally accompanies the fits, it has often a sub-
sequent occurrence, though it not rarely heralds them ; in
some instances the fit breaks out as though it were an inter-
current phenomena of epileptic insanity, and in yet other in-
stances it may go on even to its most dreadful stages without
any fit being seen or suspected.
EPILEPTIC INSANITY. 301
I will now translate what Morel says about Epilepsia lar-
valis. He founds the name upon the periodic recurrence of
the violence, which he considers to be in fact a kind of epi-
leptic seizure, and he uses the word larvalis, to signify that the
true convulsions of the disease remain in a larval condition,
in a chrysalis state. At page 480 of his Treatise on Mental Dis-
eases, he writes: “I have remarked for some considerable time
a certain class of patients in whom the accession of the excite-
ment, which was like, and was in reality, a state of mania in
the most rigorous acceptation of the term, alternated with
periods of remission, so perfect and prolonged, that there could
be no room for doubt in my mind that this patient had com-
pletely recovered. And it has been only after being painfully
and repeatedly deceived on this point that I have been obliged
to give a more special attention to the cause and development
of the disease in this class of patients. That which struck me
more especially has been the sudden invasion of the morbid
phenomena after remissions which have varied in duration
from several months to intervals of years. The friends whom
I have carefully questioned, have not been able to particularize
any premonitory symptom or warning of the attack. On the
eve of the paroxysm the patients neglect their ordinary occu-
pations, but make no complaints. There is to be observed
only an increased activity in their movements and a peculiar
excitability; the patient then breaks out suddenly in the same
manner that characterized their former paroxysms, in extra-
ordinary acts of violence; in exhibitions of the most danger-
ous propensities and irresistible impulses, so that I have had
to sincerely regret that I have ever authorized the discharge of
these patients, so deplorable have been the circumstances at-
tending their relapse.” “On readmission, these patients,” Dr.
Morel goes on to say, “after a period of excitement equal in
duration to that of their former attack, suddenly return to
their former quiescent condition exactly as before, presenting
the same evidences of recovery as those which led me to dis-
charge them from the asylum. My experience,” he adds,
“however, has made me more prudent, and the exhibition of
a phenomenon which had existed in a larval condition, has
302 INSANITY AND ITS TREATMENT.
allowed me to place these cases in the class to which in reality
they belong. These patients have presented a close resem-
blance to epileptics in the character of their ideas and actions,
but to such an extent only as to leave me up to a certain time
in doubt as to the true nature of the disease. It has occurred
to me since to witness several patients whose attacks had all
the character of the relapse, the intermittence and periodicity
that I have described, and who have subsequently been the
subject of well-marked epileptic seizures.”
Dr. Sankey calls attention in his lectures to the similarity of
this description to that of the cases commonly known as recur-
rent insanity, in which the patient after a comparatively sane
and quiet period, suddenly breaks out into violence, or exhibits
as suddenly some extraordinary or insane act, the act differing
in different cases; in some being that of homicide, and he
gives the following case under his care at Hanwell.
CASE.-E. S., was taken up at Chelsea by a policeman for
creating a disturbance. She got into a physician’s carriage
which was standing at a patient's house, and vociferated to the
coachman to drive on. She could only with great difficulty
be dislodged from the vehicle; she resisted violently, and was
taken to the station and thence to the work-house; and, after
making a great disturbance there, was sent to prison. In pris-
on she disobeyed the rules, and was several times punished.
At last she was sent to the asylum. On admission she behaved
well for awhile, then began to encroach by making extravagant
demands for indulgences, and, if refused, she broke windows,
and threatened and attacked several of the female officers.
She broke and destroyed with great dexterity her rooms, how-
ever strongly secured. At times she would go a whole week
without eating. Her violence when it commenced lasted
several days, and for several days afterwards she remained
quiet, then began again to be mischievous and to plot. She
was at times neat and tidy in her person; at times filthy and
disgusting. She had no attack of epilepsy while under my
observation, during about eight months. It was a case which,
from the intellectual integrity and apparent wilful perversity,
would be considered by many, and indeed was by several, to
EPILEPTIC INSANITY. 303
be merely a moral delinquency. The history of the case was,
however, that up to the age of twenty she was a hardworking,
industrious retiring person, her sister said, “the reverse of
what she had become.” About the age of twenty she lost her
mother somewhat suddenly, and became melancholic and out
of her mind, and was sent to an asylum in Ireland. She was
there some time and had several epileptic fits while there, and
continued to have fits regularly for some time afterwards. The
fits, in fact, had only left her shortly before she was taken in-
sane again. The nature of this case would have been very
obscure without the history of the attack; and, indeed, it is
very doubtful whether popular diagnosis would have been in
her favor, had her unruly acts brought her before a public
tribunal. The patient had been repeatedly punished while in
prison, without effecting any improvement in her conduct.”
(Lectures on Mental Diseases.)
Dr. Sankey says that this class of cases resemble those
quoted by Morel, in the termination by distinct epileptic seiz-
ures, and they resemble in everything but the epileptic seiz-
ures, the cases which Dr. Sankey with others have called
recurrent mania. They resemble that form: 1. In the re-
currence of distinct attacks of violence, at more or less regular
intervals. 2. In the violence of the paroxysmal outbreak.
3. In the somewhat rapid cessation of the symptoms, and
return to comparative lucid condition. 4. In the very slight
permanent injury to the intellect. 5. In the irritability of
disposition present in the intervals, and frequently exhibited
by accusations of unfairness or injustice towards themselves.
6. The positive denial of having acted improperly; in self-
justification, and in strenuous denial of ever having been
insane. The whole of the phenomena viewed together to his
mind brings these cases of larval epilepsy and cases of recur-
rent mania into close pathological proximity; there seems to
be some approximation indeed between the two pathological
conditions, especially in the phenomena of periodicity.
The great danger from epileptics originates from their
morbid impulses more than from their intellectual derange-
ments. The abnormal increase of their reflex faculty makes
304 INSANITY AND ITS TREATMENT.
them act without reflection, and it is from this source that
most of their misdeeds flow. They react involuntarily to
every physical or moral incitation. Their ideas are derived
from feelings exaggerated by the hyperaesthetic condition into
which they are carried, and which must therefore necessarily
expose them to irresistible acts. These acts are, then, always
sudden and instantaneous, for any ordinary feeling or im-
pression perceived by a brain so deeply upset in its functional
activity is beyond the control of the will, and gives rise to
perverted ideas, automatically developed. It is necessary,
however, to say that such instantaneous, impulsive acts are
quite distinct from the condition of transitory mania, during
which they arise, and with which they should not be con-
founded. Morel, indeed, emphatically declares that there is
no such thing as instantaneous insanity, but instantaneous
evil acts in relation to the effects of some kind of mental dis-
order displayed by the parents of the culprit. Echeverria
says that he goes a step further, and, without simply confining
their source to heredity, fastens such instantaneous acts to
Some unsuspected form of epilepsy, when, by tracing back the
history of the individual, we discover indications of the epi-
leptic disease in its hidden varieties, such as nocturmal fits, or
simply vertigo. These considerations place mania tramsitoria on
the only sound and evident grounds on which it can be estab-
lished, without lending ourselves to the prevalent misuse of it
which has been made to exculpate criminals. The fact is
further more important, to account for the extreme suscep-
tibility of epileptics and their evil propensities, where insan-
ity has not been fully developed. It is readily recognized that
many of the reported cases of mania transitoria prove to be, upon
closer investigation, those of unsuspected epilepsy or epileptic
insanity. It is also worthy of remark that the greater the
excitement and incoherence, the less liable will the epileptic
maniac be to commit an assault or acts of violence, which are
usually the offspring of the hallucinations and perverted feel-
ings, underlying the apparently inoffensive and quieter-look-
ing forms of epileptic insanity.
On the subject of vertigo or nocturnal epilepsy, and the ju-
EPILEPTIC INSANITY. 305
dicial errors to which these doubtful cases lead, Dumesnil, the
celebrated French jurist, writes: “I have treated a great many
epileptics who exhibited their attacks at long intervals, ex-
periencing thereafter an irresistible impulse to strike other
persons, to steal, to commit arson, etc., but who returned after-
ward to their natural state, without displaying any indication
whatever beyond their antecedents to account for their evil
inclinations. How easy it is to err in such instances if we
solely judge from present actions without resting on any safer
data.”
“A young lad who had committed several thefts was recent-
ly transferred from the prison of Bicêtre to Quatre-Mares; he
managed to escape thirty-six hours after admission, when he
seemed hardly recovered from a fit, and was arrested the very
next day near Louviers for burglary. Nothing in the answers
of this man betrayed the disease in question. However, the
imperial attorney, without discontinuing proceedings, kept
him under close guard, and when the information was received
from the prefecture, he immediately became convinced of the
frequency of his fits, their attending intellectual derangement,
and the complete mental recovery intervening between them,
therefore the return of the patient to the asylum was at once
ordered.”
There are other cases still more perplexing, viz., those in
which the convulsive accident is only evidenced by a slight
vertigo, that may pass unnoticed for a long time, although,
nevertheless, attended by the most strange and dangerous im-
pulses. Dumesnil gives some very curious observations of
this kind, upon which point there is a lack of scientific docu-
ments. “A Soldier, a subject to more or less frequent out-
bursts of passion, was brought before a court-martial on a
charge of having gravely insulted his superior officer. A
medical investigation was instituted, and thereupon the
arraigned soldier was transferred to an insane hospital, when
it was ascertained that he was subject to mild attacks of
periodical mania. Long afterwards I had occasion to Satisfy
myself that each one of these attacks was preceded during the
night by a slight nervous fit. This condition had passed
306 INSANITY AND ITS TREATMENT.
ignored by the patient himself, by those who for several years
had kept close to him, and by those who attended him.
“At the present time three of my patients at Quatre-Mares
have only been considered epileptic for eighteen months, after
having spent several years at Saint Yon without this dreadful
complication having been suspected. These insane patients
are the most dangerous, their fury breaks out suddenly and is
almost always directed against some person, most frequently
terminating in the quickest manner, and recurring at such dis-
tant intervals that one might think it a complete recovery after
a simple attack of mania.
“I would take pains to affirm that there is now no patient
at the institution under my direction, whose insanity is not
intimately associated with slight nocturnal attacks, which up
to the present time have escaped our attention and may be-
come recognized at any moment after a stronger attack or a
fit of vertigo in the daytime, as happened with the patient
above alluded to.
“A man arraigned for larceny, and recently admitted into
the hospital, whose physignomy had struck me, and whose
delirium exhibited very similar characteristics was discovered
a few days ago as having epileptic fits during his sleep. At
present this man evinces no sign of insanity, and does not
recollect the larceny he committed, or the circumstances con-
nected with it.”
I will also cite a case from Morel, as it is such a one as you
will be very apt to meet in your practice, and also such a one
as generally excites but little sympathy from the apparent
absence of moral sense. A young man condemned to five
years imprisonment by a Court of Assizes, for having without
provocation inflicted a nearly fatal blow on one of his best
friends, was subject to epileptic fits during his sleep. Morel
had the opportunity of verifying the fact at the prison where
this young man was incarcerated. This unfortunate sprung
from a family among whose ancestors were epileptics, lunatics,
and others that died of cerebral hemorrhage. He had no dis-
tinct recollection of the act for which he had been tried, nor
did he show the least grief; and such an apparent insensibil-
EPILEPTIC INSANITY. 307
ity, the result of his disease, helped in no small degree to con-
demn him. Morel further remarks, that on repeated occasions
the young man had struck his friends without provocation,
and that he had exhibited dulness and hypochondria.
You probably have noticed that in all these cases stress has
been laid upon the unconsciousness, which is one of the chief
characteristics of epileptic insanity, but in nearly all the
English and American text-books on the jurisprudence of in-
sanity this point has been almost entirely ignored. Even in
Dr. Ray's work it is merely said, “such loss of consciousness
is not so far removed from the psychical impairment ordi-
narily attributed to epilepsy as to render its occurrence impos-
sible.” This statement was made after remarking that Win-
nemore (tried for the murder of Dorcas Magilton), and others
committed homicide in a state of unconsciouness not imme-
diately connected with a fit; but as Dr. Ray himself says,
“Winnemore stated that he once rowed about in a boat on the
river for several hours, without being conscious of the fact,
having been told of it by those who saw him.”
We occasionally read of persons wandering from home for
days at a time, and when they return or are found, they are
unable to give any account of where they have been. The
following case from Dr. Echeverria is a good example: “A
young man fell from the top of a ladder, fifteen feet high, and
became epileptic thereafter. He would while in conversa-
tion, stop suddenly, drop his head and look as if dead, but
would regain consciousness in a few seconds, entirely unaware
of his condition. One evening, after one of the attacks, he
went into the street, took a horse and buggy which he found
in front of a house, rode over a mile and a half to his father's
grave, pulled the flowers from the bushes planted over it, and
brought them home to his mother whom he invited to take a
ride. Being asked where he procured the horse and buggy,
he answered that he found them in the street. His mother
desired him to go forthwith to a livery stable and there leave
the horse and wagon, that they might be returned to their
owner. He started to do so, but left the horse and buggy for
keeping at a livery stable, as his own. When discovered by
:
:
Q
.
:
:
308 INSANITY AND ITS TREATMENT.
the owner the transaction was looked upon as larceny, thereby
causing great annoyance and mortification to the family.
The boy, however, could never account for his conduct, and
completely forgot every circumstance connected with it. On
another more recent occasion, he left home after the attack,
and, while wandering through New York, came across a ship-
ping agent, who engaged him to go as a sailor on board an
English vessel starting for London. The agreement was
signed, and, after leaving almost all his pay and some of his
personal effects, he started for England. The captain dis-
covered from the start that he was no sailor, and, finding him
very flighty, exempted him from going to the top of the masts
and assigned to him very light duties. A few days after his
departure, on coming out from this state of epileptic insanity,
he expressed great surprise at finding himself on board a ves-
Sel bound for London, and completely ignorant how he came
to be there. The mother discovered through the police the
departure of her son, and took the necessary steps to have
him brought back. He has similar attacks of insanity after
nocturnal paroxysms, or fits of petit 'mal, but is very rational
and gentle in the periods intervening between the paroxysms,
during which he is very mischievous, inclined to be con-
stantly running and wandering about, and prone to acts of
violence.”
You are doubtless aware that in many cases of epilepsy, the
paroxysm is preceded by a peculiar sensation, varying in its
nature with different persons, called an aura. Allusion to
this was made at an early point in this lecture.
This epileptic aura may not only vary in its nature, but
may involve the intellectual, sensory or motor faculties, or ex-
clusively the vascular and secretory systems. Without at-
tempting to describe those varieties with which you are famil-
iar, I will give here only the characteristics of the mental aura,
scarcely described by our American writers. Falret says: “Just
as different bodily derangements may precede the epilepsy by
a few moments or a few hours; for example several kinds of
indisposition, headache, vomiting, pains of various sorts, or
else the sensory or muscular symptoms to which the generic
#
g
•.
g
:
:
:
EPILEPTIC INSANITY. 309
term of epileptic aura has been applied; so also the convulsive
attacks of epilepsy may be preceded either immediately or at
a greater or less distance, by different disorders of mind and
temper. Thus, it happens that certain epileptics become sad,
peevish, irritable, quarrelsome, often for several hours before
the fits. Others again complain of slowness of conception,
failure of memory, obtuseness of ideas, or a kind of hebetude,
or physical or moral prostration which to those used to their
society, or to themselves, are sure presages of an approaching
fit. Others, lastly, display for several hours before the epilep-
tic attack an unusual gaiety, an exaggerated sense of physical
and moral well-being, an unbounded confidence in their own
strength, and sometimes even a state of restlessness and loqua-
city which may be pushed on to maniacal excitement, or to
violent outbursts of passion. Apart from these precursory
symptoms, which may come on at a variable time previous to
an epileptic seizure there are other more immediate intel-
lectual prodromata, a sort of intellectual aura, which only pre-
cedes the convulsive paroxysm by a few minutes, and consti-
tutes in a certain measure the first symptoms thereof. We
see, for example, some epileptics in whom the same idea, the
same recollection, or the same hallucination, springs up spon-
taneously at the moment of the invasion of the fit, and in-
variably precedes its appearance. The patient sees flames,
fiery circles, red or purple objects, a ghost or a phantom; he
hears the sound of bells, or a determined voice always utter-
ing the same word, or lastly he may perceive the smell of
some peculiar substance. These ideas and recollections, or
these false sensations which are excessively variable as to in-
dividuals, ordinarily reproduce themselves with singular uni-
formity in the same individual in each successive attack. It
is further a curious fact that, very often, this recollection, this
idea, or this image is the reproduction of an idea or a sensa-
tion which provoked the first fit in the patient. Many, in fact,
who have become epileptic after strong mental exertion or in-
tense terror, behold again in spirit or before their eyes, on each
succeeding seizure, the painful or the dreadful scene which
first produced their complaint.”
310 INSANITY AND ITS TREATMENT.
I have used the description given by Falret in his work on
the “Mental State of Epileptics,” because it would be impossible
for me to render so precise and clear an account of the intel-
lectual aura, as is given by him.
The psychical phenomena attending the paroxysm, and
peculiar to it, though not of constant occurrence, deserve the
most attentive consideration, since their sudden intervention
may render epileptics, not otherwise insane, extremely danger-
ous and liable to commit suicide or murderous acts of violence
for which they could not be held responsible. Echeverria
reports the following: “A gentleman subject to fits of grand
mal, every five or six weeks, manifests for a day or two before,
the most extraordinary ill-temper and sensitiveness, with a
sad expression of countenance, and assaults and insults the
bystanders without provocation. These propensities and per-
iods of unnatural excitement are displayed before, but never
after, the paroxysms; and, as this breaks out, he always sees
with the left eye a hideous black and human figure, which
slowly magnifies as it approaches him. His head perspires
freely after the attack and no perceptible difference has been
detected with the ophthalmoscope between the right and left
optic nerve. This patient, during one of these premonitory
stages, assaulted his attendant with a chair; and gave him a
blow on the head, which left him senseless, because the attend-
ant asked him how he was feeling. Then he ran to his sister
in a frantic condition, told her that he had killed the attend-
ant, and dropped in a fit. This epileptic is perfectly rational
at other times, when he can render a circumstantial account
of his distressing feelings. During the temporary disorder of
action preceding the fits, his eyes and cheeks become flushed,
and he has to be kept in seclusion.”
You will notice that in many of the cases mentioned in this
lecture, there were hallucinations of the various senses; and
the statistics of 267 cases of epileptic insanity show hallucina-
tions in 86 per cent., while about 30 per cent. displayed dis-
turbance of general sensibility, such as anaesthesia, hyper-
aesthesia and numbness.
Brierre de Boismont, one of the highest authorities on this
EPILEPTIC INSANITY. 311
subject of hallucination and illusion, disapproves of the man-
ner in which those who have discussed the legal responsibility
of epileptics have so thoroughly ignored the relation between
the hallucination and epilepsy, in considering only the epi-
leptic shock which simply impairs the will. He says: “Some-
times the fantastic figures address the epileptic in words, they
insult him or command him to do something. It is probable
that many crimes committed by these unfortunate beings, and
for which some have been severely punished, were but the re-
sult of hallucinations of sight and hearing.”
The physiognomy of a patient with cerebral epilepsy bears
in a high degree the heavy, lost look and unmistakable stamp
with which epilepsy brands its victims. The bloated and livid
appearance, with the slight quivering of the face, the tremor
of the limbs, and the moral perversion that springs out of the
malady and leads to shameless vicious habits or intemperance,
account for the frequent arrest and punishment as drunkards
of individuals suffering at the time from cerebral epilepsy.
I have not the time to discuss the prevalence of religious
and erotic ideas among the epileptic insane; but can only say
that as regards their peculiar salacity, Onanism is one of the
early symptoms in nearly every case, instead of its cause;
such indulgence does of course aggravate the fits, and when a
neurotic hereditary tendency exists, acts of Onanism often pre-
cede the onset of epilepsy.
In the American Journal of Insanity, of January, 1881, Dr.
M. G. Echeverria thus speaks of feigned epilepsy. “Attentive
examination of the pupils of an epileptic after seizures of petit
mal or grand mal, discloses an alternate dilatation and contrac-
tion of the iris, persisting for over a minute after the patient's
return to consciousness. This epileptic pupil is also conspicu-
ous during the paroxysms of mania, at those moments when
the patient suddenly becomes stupefied for a few seconds, star-
ing with eyes wide open and fixed; it again betrays the du-
bious forms of psychical epilepsy and above all furnishes,
even to those most inexperienced with the malady, a sure
means of differentiating in a ready and easy way, true from
feigned attacks. Again, if we cover with a handkerchief or
312 INSANITY AND ITS TREATMENT.
towel the nostrils and mouth of an epileptic at the moment
that he is seized with a fit, this continues without change,
because the obstacle thus put to breathing does not materially
interfere with the asphyxia characteristic of the initial stage
of the convulsive paroxysm, dependent upon tonic contrac-
tion of the thoracic muscles. This process, on the contrary, at
once determines in the simulator, a besoin de respirer, with in-
evitable suffocation and struggles, which discloses the best
studied imposture. It happens, however, with certain cases
and mainly in incomplete seizures, that the impediment to
respiration quickly suspends them, but then a phenomenon
impossible to simulate always takes place; this phenomenon
is the convulsive contraction and dilatation of the iris or the
epileptic pupil, which as already stated may recur for more
than a minute before it entirely disappears, and which be-
comes very remarkable when the eye is exposed to a bright
light.”
I have not the time to dwell on the medico-legal bearings
of epileptic insanity, nor is it necessary for me to dwell upon
the legal points raised in such cases as I have cited. My idea
of responsibility is clearly defined in these lucid words of Dr.
Buckmill: “Responsibility rests upon power, not upon knowl-
edge, still less upon feeling. A man is responsible to do that
which he can do, not that which he feels or knows it is right to
do. If a man is reduced under thraldom to passion by dis-
ease of the brain, he loses moral freedom and responsibility,
although his knowledge of right and wrong may remain in-
tact.” Having arrived at this conviction in reference to re-
sponsibility, and bearing in mind the reflex nature of the phy-
sical and mental phenomena connected with epilepsy, and our
inability to avoid the effects of reflex action, it follows as a
matter of course, that I should regard epileptics irresponsible
for any criminal act they might commit under the influence
of a paroxysm.
Dr. Ray says: “It has always been a question in legal medi-
cine, within what period, before or after a fit, can an epileptic
claim immunity for a criminal offense? In cases of this kind,
bearing in mind the cases that have been recorded, are we
EPILEPTIC INSANITY. 313
able to fix upon such a period? Is there any time when the
epileptic can be considered as clearly free from the pathologi-
cal effects of the disease? Can he ever commit a crime with-
out being entitled to excuse? At any rate, the criminal acts
of epileptics should ever be regarded by the expert with great
distrust, and receive the most exhaustive investigation. I
think he is bound to accept the single alternative, either that
the patient has entirely recovered beyond the reach of the epi-
leptic disease, or that he is in some degree of probability, still
suffering from it. He is clearly entitled to every doubt.”
(American Journal of Insanity, Oct., 1870.)
The punishment of these epileptics may be legitimate under
the statutory laws, though nothing less than inhuman, since it
deems a man accountable for being visited with the most
dreadful disease, the consequences of which he has no power
to avoid or overcome.
Your teachers of Materia Medica and of Clinical Medicine
have of course indicated to you at length, the remedies gener-
ally called for in cases of epilepsy; and holding the view that
epilepsy differs from epileptic insanity more in degree than in
kind, I need only call your attention to the remedies pointed
out by your other teachers.
There are, however, a few remedies of which I may speak
briefly.
Cupr. met. This remedy has rendered me good service in
cases of epileptic mania, and is called for by the following
symptoms:
He says words not intended; tendency toward apoplexy.
Afraid of every one who approaches him; shrinking away
and trying to escape.
Unconquerable sadness; constant restlessness as if some
misfortune were approaching him; fears he will lose his
I’éâSOIl.
Incoherent delirious talk.
Attacks with Savage malice, with proud bearing, and at
times interrupted by clonic spasms.
Mania with biting; trying to tear things in pieces.
20
314 INSANITY AND ITS TREATMENT.
Frequent headache, and tendency of the head to fall for-
wards.
Nuſc vomica and Ignatia are remedies frequently required;
the former when there is great irritability; maliciousness and
anger, and vertigo at the time of the attack and the patient is
apt to fall forward. The aura also is apt to begin at the epi-
gastrium.
Ignatia should be thought of when the attacks are brought
on from the shock of some mental anxiety and grief.
Sulphur is a remedy that will act well in those cases where
there is some scrofulous taint; there will usually be some
strong religious feelings present, and the patient is puffed up
with a sense of his own importance. It is said that the Sul-
phur patient is apt to fall, to the left side; I cannot say that I
have confirmed this symptom, but we know that some patients
always fall on one side, and others on the other; some on the
back and others on the face, and we know that our remedies
give us in their proving similar peculiar symptoms. Epilepsy
has often been called the opprobrium of medicine from the
difficulty we meet in treating it; and if we can receive help
from any source it is our duty to avail ourselves of it no
matter if the symptoms seem trivial. There is always some
cause for every symptom observed in every patient, and for
every symptom in the drug pathogenesis, and he will do his
work most successfully, who reads both clearly, and adapts
the one to the other. e
Argent. nit is a remedy that I am fond of using; not in the
massive doses of the old school, which barely stop short of
discoloring the skin, but in the usual doses of the homoeo-
pathic triturations. In my treatment of epilepsy, I generally
use, at first, the lower triturations and gradually work up
to the 6th, 12th, and 30th centesimal dilutions. Both Argent.
met. and Argent. nit. are very valuable remedies; the latter I
have alluded to elsewhere as being serviceable in melancholia.
It has among its symptoms: disposition to fall sideways, with
great dizziness. The patient is low spirited, easily discouraged
and frightened.
The Argentum met. patient is more irascible, especially after
EPILEPTIC INSANITY. 315
the attack, when he will have blind fits of rage. He is very
restless and uneasy, going from place to place. The epileptic
attacks are more apt to occur on entering a room from the
open air; before midnight, and while slumbering in bed.
Bromide of potassium is a remedy you of course have heard
recommended in epilepsy, and, though it does not cure many
cases, it does keep away and diminish the frequency of the
epileptic paroxysm, and as a consequence quiets the mental
disturbance. But in order to do this, in order even to use it as
a direct sedative, it is not needful nor safe to use the massive
doses recommended by Dr. W. A. Hammond; doses of ten or
fifteen grains will answer every purpose.
During the maniacal attacks, Belladonna, Hyoscyamus,
Gelsemium, Ignatia and Stramonium will do good service
when administered according to the indications for those
remedies as pointed out in the chapter upon Mania; but too
often you will find that all your efforts avail only to palliate
and not to cure.
The remainder of this Lecture is mainly taken from a paper
by Dr. Samuel Lilienthal entitled “Epilepsia larvata,” published
in the Transactions of the N. Y. Hom. Med. Soc., 1878. His
remarks upon the therapeutics of epilepsy are equally valuable
in the present connection.
All allopathic authorities agree that Bromine and its salts
are the palliatives, par excellence, in epilepsy, and Le Grand
du Saulle affirms that the continued use of this drug will keep
in check somatic as well as psychical epilepsy, though it will
lead finally to dementia. There is no doubt that the Bromide
exerts in time a lasting influence upon the intellectual facul-
ties, but there is less harm done by it than by frequently
repeated epileptic fits.
Our school is too apt to condemn the use of bromide of
potassium in epilepsy, just as it does with quinine or cal-
omel, instead of investigating closely whether the very cures
made with them do not rest on our great law, Similia Simili-
bus Curantur.
Hughes (Pharmaco-dynamics, 202) confesses that his own de-
cision is against the bromidal treatment of epilepsy, save when
316 INSANITY AND ITS TREATMENT.
from their frequency the attacks are threatening life or reason,
and when careful homoeopathic medication has failed; but we
may find in the phenomena of bromism indications for the
use of this drug according to the law of similars. Hale
(Therapeutics, 84) finds it indicated when the attacks are at-
tended or caused by an unmistakable congestion of the brain.
Falret (Annales Med. Psychol., 1871) uses the bromide in in-
veterate cases which obstinately withstood other modes of treat-
ment, and has found it to act favorably in those cases where
the fits appear in full force, but at longer intervals; less bene-
ficial in so-called lighter cases, consisting only of vertigo, of a
momentary loss of consciousness, or where mental troubles com-
plicated the case. In mania epileptica the mania may cease, though
the epileptic fits may continue for awhile.
Hale mentions as the most prominent, unvarying symptoms
of the brain and mind caused by this drug :
1. Profound melancholic delusions, either a religious depres-
sion or a feeling of moral deficiency.
2. Loss of memory; absent mindedness; he forgets how to
talk; slowness of ideas.
3. Delusions of conspiracies against him.
4. Illusions.
5. Amnesic aphasia; he could pronounce any word he was
told to, but could not speak otherwise.
Allen (Mat. Med., Vol. V., p. 265) gives us many symptoms
which form a characteristic picture of psychic epilepsy. Thus
we see that the sense of buoyancy, comfort and relief follow-
ing its use, is a curative effect, which accompanies its exhibi-
tion for symptoms of mental depression, because it will rouse
the sluggish mind to act more normally. Hence Le Grand
du Saulle was right in recommending it for the mental
trouble, even though it does not cure the organic disease,
whatever that may be, in the brain. In recent cases it cer-
tainly holds out good prospects, especially as we find in the
disease and in the drug, vertigo with confusion of the head;
giddiness accompanied with actual stupor; hollow, fixed eyes;
hallucinations of sound and sight, with or without mania,
precede cerebral indifference, apathy and palsy; wearied,
EPILEPTIC INSANITY. 317
anxious look (after a few days); the expression of hebetude
becomes that of imbecility, and then that of idiocy (after
toxic doses); great muscular debility.
How much of the praise due this salt belongs to the brom-
ine and how much to the potassium it is hard to decide. Dr.
W. A. Hammond uses the bromides of potassium, of sodium
and of calcium, indiscriminately.
Some authorities recommend nitrite of amyl as a good
remedy in epilepsy, be it psychic or somatic, and it may act
beneficially when there is an aura epileptica, and by its timely
use may prevent the attack. English and American authori-
ties agree in recognizing that the inhalation of this agent
arrests or anticipates the attacks in cases of epilepsy when
an aura is present, but that it exercises very little influence on
the disease itself.
We come now to more familiar ground in studying the
action of Belladonna and Atropine. Let us study Hering's
Analytical Therapeutics page 247, where he advises Bella-
donna for the following symptoms: Gradual loss of conscious-
ness; starts at trifles and gets irritable; vexation; after emo-
tions, after exertion of mind; smiling before attack; anxiety
in præcordia during attack; timid feeling; Screaming, laugh-
ing, singing, weeping; tries to escape; wanders about; restless-
ness and anxiety toward evening; bites himself, tears his clothes,
with mania and furor; stupor and weak memory.
Hoyne (Clinical Therapeutics, p.40) recommends Belladonna
in epilepsy, when the convulsions commence in the arm ; pre-
vious to the attack, congestion to the head, headache and
throbbing in the temples. During the intervals, anxiety;
fear of imaginary things; peevishness; vertigo, when at rest
or in motion; burning and dryness of the eyes; red, hot face;
restless sleep with twitching and jerking. Though Bella-
donna may not cure the case, it is at any rate good as a pallia-
tive in averting or removing the maniacal attack.
Atropia gives us the same restlessness and wandering mood
in an aggravated form, as it becomes at last a desire to fight;
but the movements are unsteady and the gait staggering;
morbid sensitiveness to sounds and objects, followed by anaes-
318 INSANITY AND ITS TREATMENT.
thesia; clonic and tonic spasms; frightful phantasies; spectral
illusions; now and then he seems to have almost a conscious-
ness of what transpires about him, so that he returns an
answer when addressed; mentally very sad, depressed, in con-
stant anxiety and restlessness; fearful of misfortune, or angry;
inclined to be alone; unconscious and very irritable; incoherent
quarreling; slowness of intelligence; loss of memory; uncon-
Sciousness and coma, dizzy confusion of the head; pains in
base of skull; frequent micturition.
Stramon. is the very opposite of Bellad., for, whereas in the
latter the patient shuns the light, fears noises and is sensitive
in the highest degree; the Stramon. patient fears darkness and
hates to be alone; he acts like a coward, as we see him tremb-
ling and shaking; in his religious mania he shows exaggerated
and ridiculous scruples of conscience, and his imagination is
full of frightful hallucinations; he sees ghosts and hears voices
back of his ears; he fears death and prays fervently; epilepsy
from fright, attacks sudden, with screams, afterwards drowsy;
gives warning of approach by premonitory symptoms; con-
vulsions, especially opisthotonic, from bright, dazzling objects,
water or touch; vertigo with reeling, as if drunk; very sensi-
tive to noises which startle him; hot and red face, with cold
hands and feet. We must not expect too much from remedies
of this class. They cover all the symptoms of the case at the
present moment, and give great relief; but probably for the
eradication of the neurotic dyscrasia, if possible, our anti-
psorics take the lead.
Hering considers Hyosc. another palliative, especially where
grief, homesickness, love-pangs, jealousy, are the cause of the
attack, during which the patient laughs or Screams. If I
should give a picture of a Hyosc. patient, I would consider
him the egotistic fool; hence madness, as if possessed by the
devil; ungovernable passion and restlessness of the body; full
of visionary phantoms; a great mental vivacity with laugh-
ing, dancing, Screaming, singing obscene songs; incoherent
talking; complete loss of consciousness; vertigo, with un-
steady tottering gait, amounting even to faintness; wild, spark-
ling eyes; illusions of sight and of hearing; convulsions, with
EPILEPTIC INSANITY. 319
frothing at the mouth, he falls suddenly to the ground; is
unconscious, with cries and convulsions. There is a great deal
of hysteria in the symptoms of henbane.
Igmat. has also grief as its characteristic, but it is tears wept
inwardly; the patient is full of compassion for himself, and
loves to brood over his misfortunes, be they real or imaginary;
hence, fixed ideas; quiet, earnest melancholy; tender mood,
with very clear consciousness; hurry of mind; wants to do
everything rapidly; transient obscuration of the head; vertigo,
with a feeling of swaying too and fro; zig-zag flickering before
the eyes; noise is intolerable; jerking and twitching in various
parts of the body; convulsions. Hahnemann has taught that
Ignat. will only be indicated for a first attack of epilepsy
brought on by some disagreeable emotion, and which assumes
a threatening aspect on account of the length of time it lasts;
but in chronic epilepsy Ignat. affords no permanent relief, any
more than it is capable of doing so in other chronic diseases.
OEnanthe crocata ought to become one of our grandest rem-
edies in latent as well as in fully developed epilepsy; and
provings ought to be made with the higher potencies, as the
symptoms so far gathered are mostly from toxic cases. Hale
gives us: Disturbances of intellect, mad and furious as if
drunk; sudden and complete loss of consciousness; madness with
convulsions; he remembered nothing that had befallen him
during his illness, nor what caused the sickness; violent ver-
tigo, with falling and convulsions; coma after the convulsions;
Sudden convulsions, trismus, biting of the tongue, followed by wr-
consciousness and oblivion of the circumstances.
Agar. musc. gives us a true likeness of frenzied intoxication.
The patient is furious and can hardly be restrained; he is fear-
less, menacing and mischievous; forming bold and revengeful
projects; raging delirium alternating with religious excite-
ment; increase of strength; sad mood and anxiety; confusion
of mind; imbecility; sudden vertigo during the day; convul-
sions; most violent tonic and clonic spasms; jactitation of the
muscles all over the body.
Hughes brings forward Hydrocyanic acid as the remedy in
epilepsy. Allen gives us the following hints: Sudden loss of
320 INSANITY AND ITS TREATMENT.
consciousness and sensation; confusion of the head; vertigo
and obscuration of sight ; wild looking and bloated counte-
nance; appeared like a man suffering from excess of drink;
involuntary excretion of urine; noisy and agitated breathing;
gurgling noise in the throat; general convulsions with loss of
consciousness; the muscles of the face undergoing great distor-
tion; her limbs becoming spasmodically extended and her
head drawn down on her shoulders, followed by great weak-
ness and lassitude. This is certainly as good a picture of an
epileptic fit as we find in any pathological work, but still it
may only suit those cases where the epilepsy is a pure neurosis,
not based on any dyscrasia.
It is hardly to be wondered that an epileptic patient, suffer-
ing continually from the dread of an attack, should withdraw
himself as much as possible from the outside world, and, brood-
ing over his affliction, become melancholic. No other remedy
leaves so decidedly this picture as Calc. carb. Here we read:
Great anxiety and palpitation; frightened apprehensive mood
as if some misfortune were about to happen to him, which he
could in no way overcome; she feared that people would ob-
serve her confusion of mind; hence despondency, fretfulness,
and irritability; obstinate, depressed mood; great weakness of
memory; loss of consciousness with illusions; vertigo on Sud-
denly turning the head; transient vertigo, mostly when sit-
ting, less when standing, and still less when walking; convul-
sions; epilepsy; before the attack, sense of something running
in the arm, or from pit of stomach down through the abdomen
into the feet, caused by fright or by protracted intermittent
suppression of chronic eruption, worse during Solstice and full
moon; nocturnal enuresis; in sleep he often chews and then
swallows; screaming at night, with restless sleep, a stupid-like
sleep from which he could not be awakened.
Kafka recommends Hepar sulph., for nocturnal epilepsy, in-
asmuch as we find among its symptoms: OverSensitiveness
and irritability; sad mood for many hours; depressed, sad,
apprehensive; fretful and obstinate; the slightest thing made
him break out into the greatest violence; he could have killed
some one without hesitation; great weakness of memory while
GENERAL PARALYSIS OF THE INSANE. 321
©
peewish; frequent short attacks of unconsciousness when walk-
ing in the open air; head confused; vertigo; enuresis nocturma;
weariness in the morning after waking; dreams of danger,
fright and anxiety.
Hering, in his Analytical Therapeutics, gives us the case of a
man insane on religion, who had frequent attacks of epilepsy
from childhood. Psorim., in water, improved the mental con-
dition and epilepsy.
Zincum has been already used by the old School for convul-
sions and hystero-epilepsy. Recently the bromide of zinc has
gained an enviable reputation in the treatment of nervous dis-
orders, especially of children and women, and it is now-a-days
considered an anti-spasmodic of great power.
LECTURE XW.
General Paralysis of the Insane.
There is no form of disease complicated with insanity which
is more ominous and presents less hope of recovery, than that
known as General Paralysis of the Insane. We are now tol-
erably well acquainted with its history, symptoms, and in-
variably fatal termination, but are still ignorant of its reme-
dial therapeutics, and for the most part its pathology remains
obscure.
The names applied to it have been, Paralytic Insanity or
Paralytic Dementia; General Incomplete or General Progres-
sive Paralysis; Allgemeine progressive paralyse der Irren;
Paralysie générale des aliénés; and finally, General Paralysis
of the Insane, shortened to General Paralysis by English, and
to General Paresis by a few American writers.
Mickle defines General Paralysis as “a disease of the ner-
vous system, especially of the brain, marked clinically by (1),
certain general disorders of motility, viz: ataxy and finally
322 INSANITY AND ITS TREATMENT.
paresis, usually following a certain order and course of de-
velopment, and especially obvious in the apparatus of speech
and of locomotion; also, but in less degree, by (2) sensory dis-
Order or defect, and marked also, by (3) mental symptoms,
which invariably tend to dementia, but in the earlier stages
often consist in part of exaltation of feeling, or even expan-
sive delirium. Fourthly, it is evidenced by certain organic
changes in the encephalon and its tunics, often in the spinal
cord and its membranes also, and, as some say, in certain sym-
pathetic ganglia as well.
Most of the cases received into the hospitals for the insane
are in the more advanced stages and prove rapidly fatal. It
will be useful for you as general practitioners to acquaint
yourselves with the signs by which the disease may be recog-
nized in its earlier stages, that the patient may be warned of
his danger before entering upon a period in which he can
have little or no hope of recovery, or even of many years of
life.
That this knowledge is needed is shown by Dr. A. E. Mac-
donald, the superintendent of the New York City Asylum for
the Insane, who says, that “an examination of the certificates
sent to the asylum by gentlemen in private practice shows
that they recognized the true character of the disease in but
three cases out of thirty-five in which they had made affidavits.
Physicians connected with public institutions made a some-
what better showing, detecting the form of insanity in thir-
teen instances out of thirty-five.”
“The diseased condition to which we apply the name gen-
eral paralysis, is characterized by an association of mental
and physical symptoms, of which progression is the promi-
nent quality. A case fulfilling the requirements of its desig-
nation will be marked by progressive incomplete paralysis of
the muscles extending gradually over those of the entire body;
and by a mental failure, marked by extravagant delusions,
progressive also, both in the degree of their grandeur, and in
the variety of the subjects which they embrace.”
Exceptions have been taken to the term general paralysis,
as not being scientifically correct, for there is no real palsy,
GENERAL PARALYSIS OF THE INSANE. 323
but only a progressive impairment of the power of motion;
and many writers, both in this country and in Europe, think
that the term paresis better expresses the progressive nature
of the disease.
At the International Congress of Mental Medicine held in
Paris, in Aug. 1878, Dr. Jules Falret, Physician to the Bi-
cètre, speaking of this disease said, that since the time when
general paralysis was first noticed, that is since 1822, its
history has passed through many successive stages. At first
it was studied among the insane alone, and was then con-
sidered as a mere complication or termination of mental dis-
ease. In fact, the work of Calmeil, published in 1826, was
entitled, “General incomplete paralysis as noticed among the
insane.”
Bayle, it is true, had given to the disease, in 1822, the name
of chronic meningitis, and, separating it from the other forms
of mental disease, considered it as a special affection.
At a later period two opinions were current among physi-
cians; one school believing that there were two varieties of
general paralysis, one with, and the other without, delirium ;
another held that such a distinction could only be made in
the earlier stages of the disorder, and that all cases of general
paralysis finished in insanity, or paralytic dementia. Thus
general progressive paralysis came to be regarded as a disease
special and distinct; differing from insanity, properly so
called; and holding an intermediate place between the ordi-
nary cerebral affections and the various forms of mental
alienation.
, Dr. G. Mackenzie Bacon thus writes on its nosological posi-
tion, he says: “General paralysis has some peculiarities in its
history and symptoms which may serve to distinguish it from
other forms of disease, as follows: It is not hereditary. It
occurs but seldom among women. Certain mental changes
are always associated with it, and generally precede the para-
lytic symptoms. In most cases epileptiform attacks affecting
one side, or one limb and half the face occur during the
Second stage. A curious amelioration takes place after a cer-
tain period when brought early under proper treatment. The
324 INSANITY AND ITS TREATMENT.
optimism, the often furious character of the mania, the de-
structive tendencies, and the mixture of elation and confusion
of mind producing the most ludicrous contradictions, are such
as are not seen in other forms of brain disease.” He also says:
“These phases occur so constantly, and in so many instances,
that I do not see how to doubt that there is such a disease,
whatever its name, and that it differs from others in which
patients fade away gradually and die paralyzed; it seems to
me that the history, symptoms and pathology point to a dis-
ease different from any other, and that the symptoms above
alluded to almost suffice to answer the question, what is meant
by the term general paralysis?”
According to Dr. Lemaëstre, general paralysis, although a
pathological entity, may put on all the forms of insanity:
1st.—The maniacal form, the most common. In this form
the paralytic symptoms are associated with that group of pecu-
liar mental symptoms so frequently met with; which latter
may range from simple content with self, to the most pro-
nounced delirium of grandeur and riches and excessive mus-
cular activity.
2d.—The melancholic form, with its hypochondriacal or
melancholic depression extending even to the most obstinate
attempts at suicide, persistent refusal of food, and extreme
physical inertia; a marked contrast to the preceding form.
3d.—The epileptic form. I do not refer to the symptoms of
cerebral congestion with convulsive paroxysms such as we
often notice in the course of general paralysis, especially in
the maniacal form, but to those instances where the attack is
ushered in by epileptic paroxysms, which form almost the only
symptoms for some time, after which the disease runs its
usual course.
4th.-General paralysis without delirium, analogous to those
cases of insanity called sine delirio, in which delirium is
almost entirely wanting.
5th.-General paralysis complicated with hemiplegia or
paraplegia; and with or without ataxy.
6th.-General paralysis progressing rapidly with typhoid
symptoms, also called acute delirium.
GENERAL PARALYSIS OF THE INSANE. 325
7th.-General paralysis of a slow progressive character, es-
pecially susceptible to more or less prolonged remissions.
8th.-Dementia paralytica a double forme.
The symptoms of general paralysis are psychical and motor,
and it is a somewhat important though disputed question
which of the two appear first. Most observers think that the
cases begin by some unusual and undue irritability of mind,
others believe that the motor disturbance is first. Dr. J. Crich-
ton Browne says: “The psychical appear first in order of time.
Soon after the psychical symptoms have declared themselves,
the motor symptoms appear, and, Subsequently they advance
together, though often at very different rates and in very
varied combinations.”
Dr. John P. Gray, Superintendent of the Utica Asylum, holds
the opposite view, saying: “I believe that the paresis precedes
the insanity, the latter is the result of the morbid changes. I
have observed paretics when there was no 'insanity, no delu-
sions, only that impairment or enfeeblement which is often
noticed in the later stages of chronic meningitis and softening.
In one case now in the asylum the symptoms of paresis long
preceded insanity, and the latter did not develop until nearly
two years after.”
Although my own experience with the disease is somewhat
limited, I have not as yet seen a case where the motor disturb-
ance preceded the mental; though I have seen cases where
they seemed to arise simultaneously, but in deciding this point
it is well to bear in mind the following remark of Prof. Mauds-
ley: “Before asserting in a particular case that there is no
evidence of paralysis, it will be well to observe the patient
when emotionally excited, or after a sleepless night, when there
may be exhibited a tremulousness of speech which is not at
all visible when he is perfectly calm and collected.”
The mental and physical symptoms are thus classed by Dr.
J. Crichton Browne.
MENTAL SYMPTOMs.
1. General restlessness and unsteadiness of mind with im-
pairment of attention; alternating with apathy and drowsi-
IléSS.
326 INSANITY AND ITS TREATMENT.
2. A change in disposition and temper, and a general loss
of Self-restraint; at first as regards trivial social observances,
and then as regards general conduct.
3. Impairment of the reflective powers, so that there is no
logical and systematic development of thought.
4. General exaltation of thought, with a profusion of re-
membered images and ideas, and numerous extravagant ideas.
5. Failure of memory and forgetfulness, at first of words and
then of events.
6. Delirious conceptions, and the transformation of desires
into beliefs, these being generally connected with personal
greatness and power.
7. Hallucinations of the senses, in which remembered sense
impressions are so vivid and intense as to spread to the pe-
riphery.
8. Maniacal restlessness and excitement, in which present
impulses and feelings instantly pass over into action.
9. Increased mental weakness, with the incoherent and frag-
mentary repetition of the false ideas previously entertained.
10. Failure of the senses, with more marked impairment of
memory.
11. Complete fatuity, passing into coma and death.
MOTOR SYMPTOMS.
1. Persistent contraction of the occipito-frontalis muscle, and
Some dilatation of the pupils, causing the eyes to be widely
opened, and the forehead wrinkled, thus giving an expression
of surprised attention to the face.
2. Persistent contraction and frequent tremors of the zygo-
matic muscles, giving a pleased and benevolent expression to
the countenance.
3. Slight general muscular restlessness and unsteadiness.
4. Impairment of the power of executing fine and detailed
movements, so that manipulative skill is lost while move-
ments en masse are still well performed.
5. Fibrillar tremors of the tongue, and some loss of control
over its movements, so that it is protruded with difficulty; is
rolled about when protruded, and is suddenly withdrawn.
GENERAL PARALYSIS OF THE INSANE. 327
6. Twitchings of the nostrils and upper lip with frequent
tremor of the latter.
7. Impairment of articulation which is thick and wanting
in distinctness.
8. An alteration in the voice, as well as thickness and hes-
itancy in speech.
9. Loss of control over the combined movements of the
hand and wrist, so that the handwriting greatly deteriorates.
10. Changes in the pupils, which at first are irregularly con-
tracted, and then become irregularly dilated.
11. An alteration in gait, which becomes unsteady, the more
complex movements of the thigh, leg and foot, and the balanc-
ing of the pelvis on the hip-joints being performed with diffi-
culty.
12. General muscular agitation and restlessness.
13. Gradual loss of power in the muscles of the face, tongue,
neck and limbs.
14. Spasmodic contraction of the masseter muscles, causing
grinding of the teeth.
15. Convulsive seizures, most marked on one side of the
body, followed by transitory hemiplegia.
16. Loss of control over the sphincters.
17. Complete prostration of muscular strength and helpless-
ness, speechlessness and difficult deglutition.
18. Contraction of muscles of the limbs, and paralysis of
the muscles of respiration.
Dr. Mickle in his late work on General Paralysis says:
“Sometimes three, sometimes four stages are described. The
division into four stages is that of 1st, a stage of mental alter-
ation; 2d, a stage of decided mental alienation, often with
active mental symptoms; 3d, a stage of chronic mental dis-
order or failure, during part of which there is generally a re-
mission of at least the active mental symptoms of the preced-
ing stage and, 4th, the stage in which mental weakness has
advanced through confirmed dementia towards amentia, and
in which also the primary ataxy and subsequent paresis have
given place to a general complete helplessness with impaired
sensibility, and in which, therefore, there is virtually a com-
328 INSANITY AND ITS TREATMENT.
plete prostration of the mental and motor powers and, we may
add, of the nutritive also.
The patient attacked with general paralysis is usually a
man of middle age, of active and vigorous habits, actively en-
gaged in business or the pursuit of pleasure; given very prob-
ably to high living, but preserving among his associates the
reputation of being a keen and shrewd business man. Sud-
denly and without any apparent cause a change may be seen
in his habits and demeanor; or there may be a period of
melancholy and depression, with moroseness and irritability
lasting for a variable length of time, and very possibly passing
unnoticed; then the man is seen to be flighty. He neglects
his business, or shows a speculative tendency and a reckless-
ness that are new to him; he makes useless purchases or con-
tracts, and bargains that must necessarily be disadvantageous
to him; he takes little notice of his family, displays great
restlessness and anxiety, and is disposed to wander about; he
gives frequent contradictory orders, and is very angry if not
obeyed at once; he becomes careless in his dress and personal
appearance, and neglects all habits of order and neatness; his
mind is filled with the most visionary projects, and he has
boundless ideas of his own wealth and importance. In his
personal life, if he has been correct before, he now becomes
dissipated and fast; if he has been self-indulgent, he seeks
new and graver dissipations.
With it all there is an air of self-esteem, of physical and
mental well-being, a tendency to “loudness” of manners and
dress; to Ostentatious display coupled with unusual and un-
necessary generosity. The prevailing tone is one of good
humor, the desire is to have a good time, and to share it with
as many others as possible. A little further progress in this
direction and we find open indecencies of conduct, petty
thefts, violence towards those who have refused to join in
the proposed good time; and with all, a decided failure of
memory covering actions and events of very recent occurrence.
In the meantime physical symptoms have become apparent,
detected at first, if at all, only by those familiar with the disease,
but gradually forcing themselves upon the attention of ordi-
nary observers.
GENERAL PARALYSIS OF THE INSANE. 329
This stage is thus epitomized by Dr. Sankey. He says:
“The following may serve as a summary of the mental symp-
toms, the occurrence of which should direct our attention to
the first indications of motor paralysis.
“1. The various actions, showing the conditions of the mind,
as a disposition to wander from home; to rid himself of cloth-
ing; the commission of petty thefts; disposition to extrava-
gance; neglect of duties; general restlessness, shown by driv-
ing about, or going from place to place, or even by an inordi-
nate amount of letter writing.
“2. The ideas expressed; as notions of great personal im-
portance, great connections, possession of wealth, acquisition
of honors, or by utopian schemes, and
“3. The alteration in the feelings or moral affections, espe-
cially a change from religion to profanity.”
I have alluded to the boundless ideas of his own wealth and
importance; but these are not such as we meet in melancholia
or monomania, for these latter preserve at least the appearance
of plausibility, while the exaggerated ideas of the general
paralytic are utterly inconsistent with each other. A melan-
cholic may think himself a lord or a duke; or that his legs
are made of glass, but his speech and conduct will bear some
relation to his fancied condition; a paretic, however, will be
emperor, king, pope and Creator all at once; he can build a
city in a day, or defeat an army single handed. No person
can be named, of any note in the world, but the paretic has
been instrumental in his attainment of fame and position; he
is also possessor of countless millions which he dispenses with
a lavish hand; he confers numberless titles of nobility and
there is no favor however extravagant or absurd which he is
unwilling or unable to grant. Being very forgetful, his delu-
sions are not of a fixed character, but change from day to day,
though always retaining their general tone of grandeur and
ambition.
Dr. Mickle says: “Under the heading of prodromes are often
placed symptoms and signs that really aid to constitute the
first period of general paralysis. Yet in certain cases some of
these so long antedate the affection that they may be viewed
21
330 INSANITY AND ITS TREATMENT.
as prodromal. To these, and to others, reference is now made,
and they are of the most varied kind.
“Some embarrassment of speech is occasionally the very
first sign noticed, and Dr. Austin speaks of extreme contrac-
tion of the pupils, and of a fixed or unsymmetrical condition
of the pupils as being prodromal.
“Sometimes the prodromata consist of seizures of cerebral
congestion, or of mere palpitation, flushing and heat of the
face and head, with aural tinnitus, or of convulsive seizures
of an obscure nature, also of severe headaches and obstinate
neuralgias.
“Also we have mental prodromata. If the purely intel-
lectual powers are involved there is a species of inattention.
Repeatedly may the patient evince the same particular forget-
fulness or blunder; or the conducting of duty or of business
may become irregular, fitful or ill-judged. There may be an
expansive, busy, speculative frame of mind; a restless, fitful,
yet energetic, application to business, with perhaps some loss
of the usual foresight and acumen; a rashness of action and
a brusqueness of manner, and a forced and noisy laugh, with
unnatural loudness of conversation. To these warnings may
be added that of the danger signal, insomnia.
“Or the patient may be depressed, dull, worried about
trifles, yet angry if opposed; or full of vague fears and hypo-
chondriacal fancies; and, indeed, languor, ennui, and melan-
choly have been viewed by Some as the most frequent pro-
dromes. º
“Or, again, with forgetfulness and inattention to duties,
there may be progressive mental confusion and stupidity, with
or without drowsiness and heaviness of head. Memory fails,
especially for recent events, and recent mental acquisitions,
and the power of attention progressively lessens.”
Baillarger speaks of a loss of the sexual instinct and desire,
and, on the other hand, there may be sexual excess.
Brierre de Boismont draws special attention to perversion
of the moral and affective faculties in the prodromal period of
general paralysis. Even several years beforehand there may
be unwonted acts of indelicacy, impropriety or debauchery,
GENERAL PARALYSIS OF THE INSANE. 331
and with these there may be a placid apathy and an utter
indolence. He also states that great irritability may occur
two or three years before the outbreak, or menace of Suicide,
or failure of the usual determination of character, as well as
the failure of memory, or of the clearness or precision of
judgment already referred to.
Dr. Blandford says: “You are to recollect that general para-
lysis is to be suspected, if we hear a lunatic boasting of his
grandeur, strength and riches, especially if his delusions on
this point are altogether wild and beyond the bounds of pos-
sibility. No proof of the absurdity of his ideas suffices to con-
vince him for a moment. For instance, the patient claims to
be heavier than the world, and no one can lift him; we invite
him to lie down, and lift him with care, but he explains our
success by the buoyancy of the angels that are in him.”
Having spoken of some of the leading mental symptoms
found in this disorder, let us now consider some of the physi-
cal changes which are equally characteristic.
Dr. J. Crichton Browne says: “The earliest physical symp-
tom is a trembling at the corners of the mouth, and at the
outer corners of the eyes. Constant tremulous agitation of the
palpebral and great zygomatic muscles is pathognomonic of
the earlier stages of general paralysis. The countenance has
a pleased and benevolent expression. As the disease advances,
other muscles become involved, but, until complete fatuity is
reached, the prevailing expression is that of feeble beneve-
lence.”
The prominent feature of these changes is a loss of cūordi-
nating power in the voluntary muscles progressing steadily
toward their complete paralysis. This is recognized as affect-
ing those most delicate in function first. Our attention will
be called to a slight hesitancy in speech; and, looking at the
lips and protruded tongue, we shall find in the former a slight
tremor, with an inability to keep them firmly closed, and in
the latter a convulsive trembling, with an inclination to return
by a sudden involuntary jerk into the mouth. This is often
evident long before any difficulty can be observed in the
movement of the limbs. This peculiar articulation is described
332 INSANITY AND ITS TREATMENT.
by Calmeil as an effort in speaking; the patient uttering his
words tardily, and with a sort of mumbling and stammering
like that of a person intoxicated; a halting at certain words,
and a slurring over of others, but if he is desired to put out his
tongue, he does it without any perceptible deviation. He feels,
however, that something is amiss with his speech, and en-
deavors to right it, enunciating his words slowly and carefully;
and, for a time succeeding, but soon lapsing again and mak-
ing especially bad work of it when vowel sounds are few, and
those syllables frequent which have k, l, m, n, r, and e in them.
This is due to the fact that the hypoglossal is involved in the
progressing paralysis. The appearance of the whole face alters
too; it has a greasy, flabby look, and the facial folds are re-
laxed, perhaps unequally, and in time obliterated. The
mouth is drawn down at the corners spasmodically, owing to
partial paralysis of the facial nerve; the head is moved or
nodded by an effort to extricate a particular labial; and,
while speaking, the lips, especially the upper one, will be seen
to twitch or be affected with an undulatory or quivering mo-
tion, and the chin purses slightly. This peculiar impediment
in the speech is one of the most characteristic of the physical
symptoms, and, in connection with the exalted ideas, is con-
clusive evidence of the presence of the disease.
Quite distinctive also is the appearance of the eye, giving
changes so constant and so uniform, that they furnish one of
our most reliable aids to diagnosis. At first there is contrac-
tion of the pupils, but later there is dilatation, usually un-
equal; and in this inequality lies the value of the evidence.
Often added to the inequality, there is also irregularity of the
pupil, from the edge of the iris being folded in, and there
may be ptosis. Irresponsiveness to light on the part of the
pupil is characteristic in nearly all paretic cases. “The pa-
tient is unable to control in full the motion of the eye, owing
to failure on the part of the motor oculi. There is a certain
restlessness and unsteadiness in moving the eye, which, to the
careful observer, is quite discernible.”
In this early stage maniacal excitement may mask the
motor signs, although in the later stages similar maniacal ex-
GENERAL PARALYSIS OF THE INSANE. 333
citement often only serves to heighten the manifest impair-
ment of speech.
Dr. Mickle also observes, of this earlier stage, that “usually
the gait is still fairly free, but in other cases it is somewhat
awkward, the steps are long and slightly irregular, and may be
attended with awkwardness. A decidedly tabic gait may be
observed, though this is exceptional. Trembling movments
in the limbs, varying in degree and frequency, also attest the
ataxia. Now the gait, whether in this or other stages of gen-
eral paralysis, varies with the relative proportions of ataxy
and paresis present. I say ataxy and paresis, for although the
latter is perhaps not absolutely essential, as is the former, yet
is it almost invariably present. When the special ataay of
the affection is relatively prominent, the gait is more or less
jerky, irregular, the steps are long, the limbs thrown forward,
the movements apt to be hurried, and made with unnecessary
efforts, the lines of march swerving and crooked. On the
other hand, when paresis relatively predominates, the gait is
slow, heavy and unsteady, and the widely separated feet
readily trip at any inequality or obstacle on the ground. In
advanced cases an unsafe tottering follows upon any attempt
to turn. This slow and helpless gait, together with the
bended, stooping frame, imprint an aspect of premature
senility.”
As the disease progresses, derangement of the motor powers
becomes more prominent. The muscles themselves are not
affected, nor is there much loss of strength, except in the
latest stage; but we find great loss in the co-ordinating power,
especially in the lower limbs, but in the upper also, though in
a less degree. This is shown in the imperfect attempts at Sew-
ing, playing the piano, writing, or in any other operation
requiring manual dexterity. If the elbow is bent and the
fingers extended, they cannot be held steadily, but their tips
will tremble and jerk convulsively. Hence the handwriting
is altered and becomes scratchy and irregular; some letters
are larger than others, and the lines upon the paper are not
followed. The mental change makes itself apparent in the
composition of the letters, so that their perusal will doubly
334 INSANITY AND ITS TREATMENT.
indicate the condition of the writer. The change will be
similar to that noticed in the speech—a tendency to omit .
words or parts of sentences, to mingle topics together, and
especially to repeat phrases, and to reassert some prominent
idea, until the meaning becomes unintelligible, and this inco-
herence progresses with the disease.
In the lower limbs, as has been intimated, the want of co-
ordinating power produces changes of gait. This is peculiar,
but like the other characteristic symptoms of the diseases, viz.
the impaired articulation and the exalted ideas, is said not to
be invariably present. There is at first a little difficulty in
getting started promptly and easily; a little tendency to make
a wider circle around corners, and a decided difficulty in
changing direction quickly and avoiding collisions. As these
difficulties progress the gait becomes yet more abnormal.
There is a tremulous unsteady step, the patient separates his
feet and stretches his hands as if afraid of toppling over, and
he either drags his feet after him as in the ordinary forms of
paralysis, or brings his feet down with a rap as in locomotor
ataxy. As these troubles increase it becomes altogether too
much of a tax upon his attention to keep his equilibrium, and
to make progress, to permit of his turning it at the same to
anything else; and, if he be addressed, he will stop and steady
himself upon his legs before answering, even if his questioner
is walking with him.
Dr. Sankey thus describes the gait: “The paretic patient
walks as if he had to direct the whole of his muscles by
distinct efforts, and as though he had lost the whole of his
acquired automatic movements. He walks therefore, without
looking to the right or left; and often there is an appearance
or expression of having to poise his head carefully, or to keep
his own centre of gravity carefully balanced. At the same
time there is an evident absence of elasticity or spring in the
step; the foot is placed flat upon the ground; the legs are kept
somewhat apart as though to increase the base of support for
the superincumbent weight, and the patient has a straddling
gait; there is no balancing or throwing the centre on one or
the other limb.”
GENERAL PARALYSIS OF THE INSANE. 335
Long before this extreme muscular disturbance has been
reached, the delusions of which I have spoken will be fully de-
veloped. They are, like delusions of all kinds, primarily con-
nected with the patient personally; if extended to others it
must be secondarily; as for instance, because a patient imag-
/ines himself to hold a certain rank, he must extend his imagi-
nation to recognize some other and inferior rank in those
around him. When he is placed in an asylum, it becomes at
once a palace or a country residence, and those around him
are courtiers or servants. In some cases the delusions are said
to be of a sad and depressing character, but this is not usual.
Naturally the exalted delusions have reference, first, to the
patient's person, his health, and powers of endurance and ac-
tions; thus he always thinks himself robust and hearty. His
answer to your inquiry as to his condition is always a positive
assertion of his well being, although he may stagger at every
step, and this continues long after his advancing disease has
deprived him of the strength to leave his bed, and almost of
the power to articulate at all; and the phrase, “first rate,” with
which he answers inquiries after his health, is of itself almost
sufficient proof of the presence of the disease.
Constant hopefulness is another characteristic symptom.
Although confined in an asylum, he is generally contented,
but at times complains that he is shut up through a conspir-
acy of enemies interested in his detention. He displays great
anxiety to see his friends on important business and writes
frequent letters. His anxiety about the non-arrival of friends,
relatives or letters is easily allayed, and he consents as a par-
ticular favor to the doctor, to postpone his departure until
“to-morrow,” but, his memory possessing no cumulative force,
the same process is daily repeated, and the to-morrow never
CODO €S.
As a sequel to belief in his vigorous health, comes an equally
decided estimate of his bodily powers and prowess; he is the
greatest pugilist, pedestrian, oarsman, ever known. “He will
spend hours in training himself for a boat race; totter up and
down the ward in the firm belief that he is walking a thou-
sand miles in a thousand hours, and give you an earnest in-
336 INSANITY AND ITS TREATMENT.
vitation to test his skill as a boxer.” But his powers and
skill are not confined to mere animal superiority,+mentally
he is the most brilliant of men. There is no language with
which he is unfamiliar; no branch of study in which he is
not proficient; no philosophical experiment which he has not
successfully undertaken; no discovery which is not his own.
And the legitimate rewards of such perfection of body and
mind have not failed to follow him; renown, wealth, honors,
are his without measure or number; he is not king of a sin-
gle country but emperor of the whole world; he is not as rich
as some one else, but richer than every one else put together.
One patient under my care had invented a new needle-gun,
and was under contract with Louis Napoleon, single-handed,
to compel the Prussians to give up the Rhine provinces.
Delusions of this extent are not reached all at once. Some-
times they come with the progression which is so marked in
the other features of the disease.
You will observe more tolerance of the delusions of others,
even amounting to a belief in them, among paretics, than in
the insane of other classes. “Ordinarily an insane man will
recognize wherein his neighbor is deficient in sense, while
strenuously maintaining his own soundness, but a paretic's
delusions are extensive enough to embrace all mankind.
When one of them has given a summary of his wealth, the
others, if appealed to, will often endorse his statements, but
always adding that wealthy as he is, they are still more so.”
Prominent differences between the delusions of the general
paretic and those of the sufferer from some other form of in-
Sanity, are seen in their greater extravagance, their want of
permanency, and in the absence of sequence and co-ordina-
tion.
The characteristic differences between the delusions of am-
bition and grandeur manifested by the general paralytic and
those found in ordinary “ambitious mania,” the “Megalo-
manie” of the French writers are thus described by Dr.
Drouet in “Les Annales Medico-Psychologiques.” “Ambitious
mania, properly so-called, that is to say the chronic form of
mania marked by a systematized ambition may, as a rule, be
GENERAL PARALYSIS OF THE INSANE. 337
easily distinguished from general paralysis. While in this
latter we find a childish contentment, incoherent and incon-
sistent ideas of greatness, progressive and rapid signs of intel-
lectual decay, and characteristic disturbances of motion, we
find nothing similar in ambitious mania. These patients
logically follow out their false conceptions, and often display,
to account for their surroundings, much Sound and shrewd
reasonings based upon their false premises. Their delirium is
not as general nor changeable as the general paretic's, the lat-
ter of whom can say the most contradictory things in a short
time, but it presents a remarkable fixity and steadfastness of
ideas. There is no motor disturbance, and if dementia sets in,
it is at a later period, as in other cases of mania.”
Most delusions in the maniac and melancholic are as to
things which might possibly exist or occur. They are com-
paratively fixed and persistent, and starting from false prem-
ises, they have thereafter a natural and logical connection.
But the delusions of the paretic are absurd and impossible,
they vary constantly, and they are utterly contradictory and
incompatible. The former too, will maintain the truth of
their delusions with keenness and shrewdness of argument,
and will endeavor to explain differences, and reconcile them
with facts. But the paretic does not detect incongruities and
will not argue, but simply re-assert.
During all this time the patient is generally possessed of a
keen appetite and sleeps soundly, and it is not uncommon for
him to gain considerably in weight. The mental change in-
creases, sometimes bringing the patient into a condition of
complete. dementia, but more frequently preserving the more
active character, of which these delusions give evidence, until
the end.
There is often in the second stage of the disease a paroxysm
of maniacal violence of varying duration, which is followed by
a marked amelioration of all the symptoms, both mental and
physical; this remission is so evident that the friends of the
patient are often deluded by the hope that he may entirely
recover; this improvement is, however, temporary, and the
patient soon relapses into the third stage, that of fatuity.
338 INSANITY AND ITS TREATMENT.
Jules Falret says: “Formerly all writers believed that the
disease once begun, progressed steadily without interruption till
death. But to-day we know that anywhere in its course re-
missions may arise of varying duration, and that these remis-
sions not only make a notable difference in the degree of
intensity of the symptoms, but may even be so well marked
as to simulate recovery. Baillarger, for example, is led by the
existence of these remissions to believe that the disease must
be curable. These remissions may last for months, or even in
specially favorable cases for years, and are of great importance,
especially in a medico-legal point of view.”
As the disease progresses, paresis of the excito-motor system
becomes more marked, and the patient can hardly walk alone,
falls against the furniture, or crawls about the floor, picking
up splinters or bits of paper. He also loses control over the
sphincter muscles and becºmes filthy.
The appetite is very voracious, and the paralytic will cram
great masses of food into his mouth, but owing to loss of exci-
tability in the muscles of deglutition, even soft food is swal-
lowed with difficulty, and becomes impacted in the pharynx
or larynx, causing frequent and sometimes fatal choking.
Grinding of the teeth may be noticed, and there is a glutinous
Secretion in the corners of the eyes. The mental condition
rapidly deteriorates, memory is almost entirely destroyed, and
the patient requires the same care as in advanced dementia.
Physically these changes progress until death is reached by
simple exhaustion, due to the increasing muscular paralysis,
unless it occur sooner, as it often does, from intercurrent dis-
eases, pulmonary especially, or from the convulsive seizures
which are another characteristic of the disease, and which will
now be spoken of
A large proportion of those suffering from general paralysis
are, during some one or more of the stages of its progress, at-
tacked by fits simulating epilepsy, occurring at intervals, and
leaving behind them only slight and transient disturbances
of the intellect, and so similar to the ordinary attacks of epi-
lepsy that even experienced physicians are often deceived. A
remarkable case of this sort was that of the Count Chorinsky
GENERAL PARALYSIS OF THE INSANE. 339
in Germany, concerning whom, Dr. Morel, of Saint-Yon, gave
an opinion before the court at Munich, which although con-
tradicted by the German physicians, was confirmed by the re-
sult. He considered him as an insane man suffering with
epilepsia larvalis, and, further observation as well as the autopsy
showed that the patient having first presented the symptoms
of that species of epilepsy, afterwards traversed the successive
stages of a marked case of general paralysis.
The late Dr. Skae thus writes: “These epileptiform or con-
gestive attacks vary much in frequency and degree in different
cases. In some they are very frequent, occurring every three
or four weeks; in others they are very rare, occurring only
once or twice in the whole course of the malady. In some
cases they are very slight, the patient complains of pains in
the head and confusion of ideas; his face becomes very red
and congested; he looks stupid, and perhaps cries without any
cause, and, after a few hours in bed, he recovers his usual
composure. In other cases, with more or less congestion of
the countenance and confusion of thought, there is temporary
loss of speech, lasting only a few minutes, or passing off after
an hour's sleep. In the more completely developed attacks of
this affection there is a total loss of consciousness, with con-
vulsive twitchings of the face and limbs, varying from one or
two slight attacks to repeated and vary violent convulsions
lasting for hours, and accompanied with great venous conges-
tion of the scalp and face. These epileptiform attacks are very
characteristic, and have been regarded by some writers as
essential features, and diagnostic only of this disease.”
Dr. Harrington Tuke and some others deny that general
paralysis ever runs its whole course without producing these
epileptiform attacks; but my experience leads me to take ex-
ception to this view. In cases under my care, such attacks
have as a rule been met with, but I have observed at least one
case, from the beginning to the end, without noticing the
slightest evidence of them. In some patients death may
result as a consequence of these attacks, but in hospital prac-
tice they readily yield for the time to the action of remedies.
The fits are undoubtedly owing to wasting of the brain sub-
stance, and are, with some, the first proof of the disease.
340 INSANITY AND ITS TREATMENT.
For diagnostic purposes it is important to distinguish be-
tween these epileptiform attacks, and the fits caused by true
epilepsy complicated with paralysis, or even simple mono-
mania. The distinguishing points are thus given by Dr. H.
Tuke: “The tongue is seldom wounded in paralytic insanity,
and the tendency to sleep, after an epileptic fit, is very differ-
ent from the entire stupor which follows the fit of general
paralysis. The convulsions, too, in epilepsy are more univer-
sal, affecting the whole body.”
Epileptic attacks may occur for years without seriously
damaging the intellectual faculties, but in a patient who is
affected with fits in combination with general paralysis, each
Seizure is, as a rule, followed by an exacerbation of the mental
derangement, which, from the first, is out of proportion to the
disorganization indicated by the fits alone. The difference in
the mental symptoms is also well marked, and is thus clearly
and graphically described by Delasiauve in the Journal of
Mental Medicine: “The epileptic paretic seldom exhibits the
moral inconsistency and vague ambitious delirium so fre-
quently displayed by ordinary paretics; indeed, he does not
let his faculties ramble; his judgment is slow and confused,
his memory weak and obscure, the expression of his ideas
dull and laborious, like the articulation of his speech; but,
nevertheless, preserving throughout sufficient conception to
accomplish the ordinary acts of his life, and being not insane
in the ordinary acceptation of the word. What prevails with
him is the inability to act; an intellectual confusion, rather
than the incoherence or rambling of thought. No matter
how deep the deterioration, the cases of general paresis due to
epilepsy display always such an identical physiognomy that
it is impossible to mistake them for those acknowledging some
other source.”
During the past few years the history of general paralysis
has entered upon a new phase. Up to that time the endeavor
had always been made to group many widely different condi-
tions under the comprehensive but vague term of general
paralysis. Now, however, there is a disposition to recognize
the fact that clinical experience shows many varieties, all, per-
GENERAL PARALYSIS OF THE INSANE. 341
haps, having the same general pathological condition as a
basis.
In the classification of Dr. Lemaestre before alluded to, we
find first mentioned the maniacal form, which seems to de-
serve more than a passing mention. When general paralysis
presents itself under the maniacal form, with violent excite-
ment, mixed and contradictory ideas of grandeur and import-
ance, excessive disorder in act and slight impediment in
speech, we may call it an attack of congestive mania. It often
happens that after six or eight months the excessive excite-
ment decreases and gives way to an almost complete return of
reason. Those persons who may have presented all the char-
acteristic signs of the first stage of general paralysis, realize
that they have been delirious, abandon their false conceptions
and return, to all appearance, to reason. Most of them, it is
true, give signs of intellectual weakening in spite of the Cessa-
tion of the delirium, but many are able to resume to a great
extent the use of their intellectual faculties. Having in mind
such cases as these, M. Baillarger divides general paralysis
into two classes. 1. Those of congestive mania, susceptible of
cure, but having a general tendency to pass into well devel- .
oped general paralysis; and 2. Paralytic dementia always in-
curable and progressing steadily and regularly toward more
and more marked dementia and death.
Referring to the first of these two classes, Dr. Jules Falret
says: “These patients resemble in many points the general
paralytics of our asylums, and differ from them in others.
They also resemble those persons affected with successive cere-
bral congestions of softening of the brain. They experience
during many years light and congestive attacks of short dura-
tion, leaving behind hesitancy of speech, symptoms of incom-
plete paralysis, and a more or less well marked impairment
of intellect, but in many instances without well marked delir-
ium; and they can survive thus many years, slowly advanc-
ing toward simple dementia, without presenting some other
of the symptoms so generally met with in our asylum cases.”
Another form which it is well to mention in a description
of general paralysis, is the melancholic variety. Not only is
342 INSANITY AND ITS TREATMENT.
melancholia observed as a first stage in the ordinary or ex-
pansive form of general paralysis, but it may occur anywhere
in the course of the disease. Baillarger was the first to call
attention in a special manner to this point.
This melancholia consists not only in ideas of being ruined,
poisoned and persecuted, but in special delirious conceptions
that Baillarger calls hypochondriacal, and can, perhaps, be
more precisely indicated by saying that they bear some rela-
tion to changes in self. Such patients believe, for example,
that they are dead, or have lost their personality, or that por-
tions of their body have been changed; they have no mouth
or intestines; the head is of wood, the jaw of iron and the
limbs of lead. This point is to-day well established, and this
special condition may arise at any period in the course of the
disease, and even in some cases the states of depression and
expansive ambition may alternate in a regular manner.
Almost always the melancholy delirium in general paraly-
sis is coincident with lesions of nutrition, and with subacute
attacks. It would seem then that the chronic meningitis
which is present in this affection takes on for the time a sub-
acute form which manifests itself in the general health.
These patients rapidly grow thin and almost cachectic.
They often refuse food, not only from their mistaken ideas
of being poisoned, or their belief that they have no mouth
or stomach, but also from the generally disordered state of
nutrition which gives them an absolute disgust for all nourish-
ment, an unconquerable and instinctive aversion for all food,
especially meat, similar to that met with in the cachectic states
of cancer or diabetes.
We also meet with an increased bodily temperature and
slowness of pulse as in the meningitis of children or adults,
together with a higher temperature of the top of the head than
of the other parts of the body. There is also a great increase
in the flow of urine, without sugar, but with an excess of urea.
In such cases the refusal to take food may be very persistent,
requiring the use of the feeding tube and in some extreme
cases death may ensue. On the other hand after a few months
have elapsed a change, for the better may take place, the
GENERAL PARALYSIS OF THE INSANE. 343
patient regain strength and flesh, and even give rise to hopes
of recovery.
Cases of general paralysis without delirium, are said to
occur occasionally in ordinary hospital and private practice.
For many years these patients who present all the physical
symptoms of progressive and incomplete general paralysis
seem to be free from delirium. If their intellect is below par,
as is common, it is not very noticeable, and the paralytic phe-
nomena are much more prominent. These latter are even
more marked than in most of our asylum cases; there is the
usual hesitancy in speech, trembling of the limbs, difficulty in
walking and prehension, unequal dilatation of the pupils, etc.
These persons may live for many years in ordinary hospitals,
without being sent to an insane asylum, if indeed they are
sent at all. They become demented only after a long time and
differ in many respects from the general paralytics in our
asylums; but at the same time there are enough points of re-
semblance to make us refer them to the same pathological con-
ditions as a cause. *
The variety of general paralysis known as “double forme”
has been almost unnoticed until now; indeed I find very little
said about it in any of the standard works, I shall therefore
call your attention to the description given by Dr. Lemaestre
at the International Medical Congress held in Paris, in 1878,
he says:
“General Paralysis à double forme presents features pecu-
liar to itself, viz.: the passage from one form to the other with-
out any remission or interval between. The two forms are
different as to symptoms, though the disease remains the
S8.II) 62.
“In the ordinary maniacal form of paralytic dementia, we
Sometimes observe, after a paroxysm of excitement, perhaps
violent and prolonged, a condition of moral depression to-
gether with muscular prostration, sometimes very marked.
“This period of depression lasts for a varying period, and
afterwards there may occur a fresh remission in the mental
symptoms and even a limited improvement in the paralysis.
“In the paralysis à double forme, however, no such remis-
344 INSANITY AND ITS TREATMENT.
Sion takes place, and the two stages pass rapidly and directly
the one into the other.
“Case.—Mr. D., banker, bachelor, aged 33 years, has led a
very active life, equally divided between pleasure and intel-
lectual work. He states that he has had syphilis, of which
none of the ordinary symptoms remain, and was salivated by
mercury.
“About a year ago the initiatory symptoms of general
paralysis appeared, such as frequent headaches, change in
habits and character, irritability; less refined appearance,
greater freedom of speech, handwriting less distinct, forget-
fulness of hours and dates, finally hazardous speculations lead-
ing him to bankruptcy.
“After several voyages, vainly undertaken in the hope
of staying the progress of the disease, he entered two hos-
pitals, and finally brought up at St. Everard, on November
11th, 1877.
“His appearance was as follows: On the physical side, a
slight hesitancy of speech, with trembling of the hands; on
the mental side, a certain degree of weakness of memory
with no expansive ideas, but no perceptible delirium.
“This satisfactory condition lasted about a month, and he
seemed so well that the subject of discharging him was under
consideration.
“Early in December, Mr. D. ceased to be in this expansive
condition; he became sad, taciturn, ate little, walked very
little and spoke scarcely at all. December 6th, he complained
of pain at the stomach, refused food and took to his bed.
The next day, on visiting him, we found gastric disturbance,
together with constipation and retention of urine. Under
the influence of purgatives these symptoms were relieved, but
he made no efforts to rise.
“He remained cast down, depressed, spoke in a doleful
voice, did not eat nor rise, and allowed the catheter to be used
every day, saying that he had no power to urinate.
“The persistency of these ideas soon revealed the existence
of a true delirium of depression with hypochondriacal ideas.
This delirium and depression increased each day. We forced
GENERAL PARALYSIS OF THE INSANE. 345
him to rise and to eat, or to accomplish the acts of excretion,
but he resisted; or rather, he would not take the initiative
nor yield to threats. He remained sitting the whole day,
cast down and doing nothing; he spoke but little, and
then in a low voice, and only to complain. He received even
his visitors, even his dearest friends, with indifference. At
the same time the idea ruled him that he had all sorts of
diseases. Sometimes it was his urethra or his rectum which
was so closed up that he could neither urinate nor go to stool.
One day he would have a hernia; another the shoulders
were higher than the head; at times he could not speak,
. could not walk; one eye was larger than the other, and
he had pains all through his body.
“At the time this change in his condition occurred, his
eyes, which had previously been alike, became unequally
dilated, the left pupil being perceptibly larger. His speech,
too, became embarrassed, and his limbs feeble; he lost flesh
and required the use of tonics. One day he accidentally
received a blow in the left eye from another patient, from the
effects of which he recovered slowly, and producing a slight
drooping of the lid lasting a month.
“This state of depression lasted until early in March, about
three months. Then a change was noticed, both physically
and intellectually. He ate better and took more exercise; no
longer complained of unusual diseases, nor of pain in his
legs. Soon his voice became louder, and he became loqua-
cious and boisterous, and gesticulated much in speaking;
his speech was disturbed and his countenance animated;
he became importunate; found fault with his food as insuffi-
cient, and began to write a great deal.
“March 24th, at our visit, he surprises us with a glowing
account of his wonderful skill upon the cornet à piston, and
boasted of having played a solo upon that instrument before
thirty crossed and mitred bishops, at the same time he handed
us a letter, in which, recounting his genealogy, he tells of one
of his ancestors, a friend of Robespierre, who saved at the
scaffold, eighty peasants condemned to death by the revolu-
tionary tribunal.
22
346 INSANITY AND ITS TREATMENT.
“It cannot be doubted that a great change has taken place
in his condition. These symptoms becoming more marked
each day, soon reached the usual height, and the word millions
so often on the lips of the general paralytic, do not fail to
appear.
“Mr. D., writes letters to all the distinguished men in Eu-
rope; he is to be councillor-general, deputy for Paris, minister
of finance, in short he displays all the characteristics of le
delire des grandeurs.
“March 26th.-He became so violent that he had to be re-
moved to another ward, and restrained by a camisole.
“March 29th.-He had a peculiar attack and fell; this
attack, of short duration and without convulsive movements,
was to be attributed to a state of syncope, produced by his
excessive excitement. His general health grew worse, he re-
mained seated, the left pupil dilated, the voice unintelligible,
the throat dry, and the lips fuliginous and covered with a
dark coating.
“Gradually his excitement decreased; he rose up, and the
camisole was removed; he ate better again, but he remained
feeble, his limbs trembled and he walked in an ataxic manner.
“April 10th-His condition continued to improve. His ex-
citement is great at times, and his expansive delirium con-
tinues; his speech is more intelligible, but he continues to
speak of his millions, of which he gives away many.
“To-day, July 1st, 1880.-He remains quiet and a little
depressed, and it would not be surprising at any moment to
again see him relapse into the melancholic and hypochondri-
acal state as at first.”
Although general paralysis, like other forms of insanity,
seeks its victims in all ranks of society, we find that certain
classes and persons of certain age display a greater predisposi-
tion than others. According to Dr. Sankey the liability
occurs in the following order:
1. Males of the lower classes. 2. Males of the upper classes.
3. Females of the lower classes. 4. Females of the upper
classes, and he adds this significant remark: “This order of
sequence may be also considered that of the subjugation of
GENERAL PARALYSIS OF THE INSANE. 347
the animal passions in the different classes,” and Calmeil tells
us that males are attacked more frequently than females in
the proportion of fifty to fifteen. As a rule the disease makes
its appearance in persons of from thirty-five to fifty years, but
there is a case on record where the patient was a girl of seven-
teen. g
The causation of the disease is a subject upon which different
opinions are held, and no one opinion is sustained by con-
vincing arguments. At one time one cause was thought to be
the potent one; at another time, another. Only one thing can
be assumed as settled, and that is, that heredity must be looked
upon as the great predisposing cause in this, as in other varie-
ties of insanity, but, as Althaus says, whether the disease itself
is hereditary remains an open question.
Of one hundred and nine patients, regarding whose ancestry
fairly complete particulars could be obtained by Dr. Macdonald,
thirty-nine revealed a history of insanity in one or other of
the branches; thirty of other nervous diseases; twenty-two of
intemperance in parents, and in fifteen cases the record was
unfavorable regarding both branches.
In turn, prolonged intellectual efforts, intemperance, and
venereal excesses have been cited as the distinct determining
agent in the production of the disease. But the fact that it
attacks men of all grades of mind, and, chiefly indeed, those
of a how order of intelligence and education, negatives the
first proposition; and the occasional occurrence of the disease
in persons of perfectly correct habits, and addicted to no
vicious indulgence, shows that such excesses, though actual,
cannot be the essential causes; and, “in speaking of excess it
should be kept in mind, that we are dealing with an unfixed
and uncertain quantity, for what would be moderation in one,
is excess in another.” Dr. Sankey, who had charge of the
women's department of the great asylum at Hanwell, says
that in going through the notes of his cases of paresis, it is
remarkable how many of them had led irregular lives, and,
especially, had been guilty of sexual impropriety of some
sort. But this is not always the history, often it is of loose
habits, suddenly assumed, shortly before the supposed incep-
348 INSANITY AND ITS TREATMENT.
tion of the disease, and, contrasting with a former life of
steadiness and propriety of conduct. Then the question
arises (as it has arisen regarding most of the assigned causes
of insanity, and to the ultimate exclusion of many of them,
and especially of the so-called moral causes), whether the
alleged cause is really a cause at all, and not rather an effect;
whether, in other words, the insanity did not precede the
drunkenness or other excess, and lead to it, and not the
TeVeTSé.
Change of character is the prominent symptom of other
forms of commencing insanity, and there is scarcely sufficient
ground for assigning it another function or significance in
this.
Dr. Macdonald says: “One hundred and sixteen out of one
hundred and fifty-five patients give a history of habitual in-
temperance, while all but ten of the remainder claim (or their
friends claim for them), the designation of moderate drinkers;
the word moderate, if the truth were known, being probably
a very mild and insufficient indication of the real amount of
customary indulgence.” But we must remember that the
patients coming under his care were drawn from the class
which commonly uses alcoholic liquor in excess.
At one time syphilis was asserted to be the cause of the
brain changes finding expression through the symptoms of
paresis, but, though probably an occasional cause, it is certain-
ly not the only one, and the attempt to assign to it a role, or
even a special importance has ceased.
All that it is Safe to assume then regarding the causes of
general paralysis, in the present state of our knowledge, and
pending the progress of pathological study, is, that in common
with the other forms of insanity, it finds its subjects mainly
among those in whom there is an hereditary tendency towards
nervous disease, and that So far as immediate causes are con-
cerned, while the disease undoubtedly attacks a few who
have no such vices, and many in whom the relation of such
vices to the disease—whether that of cause or effect—is not
determined; yet the fact that in a conspicuous number of
cases attacked there is a history of profligate and vicious in-
GENERAL PARALYSIS OF THE INSANE. 349
dulgence justifies the belief that such indulgences are opera-
tive as the most frequent, if not the sole determining in-
fluence.
As has been intimated, a characteristic of the disease is its
Selection of the male sex as its subjects, in a very large propor-
tion of cases. Indeed, early in its history, writers upon the
subject were inclined to regard it as only attacking men, but
in course of time undoubted cases occurring in women came
to be recognized and recorded, and now we know that it is a
disease to which women, in common with men, are liable,
although in a much inferior degree. There seems to be a
very marked difference in this respect in different localities;
in some places the number of women attacked bearing a much
larger proportion to the whole number than in others. Thus
in England twenty-five per cent. of the deaths from general
paralysis during a given period were women.
These facts have a bearing upon the question of causation.
That the disease is relatively rare in the sex which is less
given to alcoholic intemperance, and upon whose economy ex-
cessive sexual indulgence has less effect, is a point in favor of
the potency of these irregularities in its determination. Fur-
ther weight is given by the greater prevalence of the disease
in countries and districts, and among classes, where the use of
spirituous liquors among women is more common; and still
further from the fact, that the investigation of the former con-
dition of the females attacked reveals a history of dissolute
practices, and frequently of professional prostitution.
Prognosis.—There seems to be no reasonable ground for
anticipating any result but death, when once the presence of
the disease is unmistakable. The few cures that have been
from time to time reported are at best doubtful; either their
history admits the suspicion that the diagnosis was incorrect,
or the short period during which they were kept under ob-
servation after discharge, renders it probable that the apparent
restoration to health was simply a remission in the disease,
and not a recovery from it. I have never seen or known of a
case of real recovery, and have seen returned to the hospital,
cases in which recovery had been claimed by others. These
350 INSANITY AND ITS TREATMENT.
remissions, which are frequently seen in the course of the dis-
ease, are very apt to give rise to false hopes and false beliefs in
recovery. To an unskilled eye, every trace of the disease
Seems to have disappeared, and, although in most cases, one
accustomed to their observation will find some slight traces
remaining, -a slight inequality in the pupils, a trembling of
the lips, or difficulty in articulation,-there are some cases
where even these signs are absent. But relaxation of the
regularity and discipline of asylum life, and especially any
endeavor to resume former pursuits will inevitably rekindle
the disease and a relapse will speedily follow. So that if our
diagnosis be positive, there is no good reason why our prog-
nosis should be less positive; and, though the prophecy of
death may appear for a time to have been an erroneous one,
the patient who has so markedly improved, will soon again
relapse and confirm the verdict.
As regards the duration of the disease, either the opinion of
observers has been modified of late years, or else it is not so
rapidly fatal as in times past; probably both are true. For-
merly it was spoken of as terminating usually in a very few
months, and three years was assigned as its utmost limit in
rare cases. Now three years is named as the average duration,
and many cases are recognized as having lasted more than
twice that length of time, and facts go to show that it may
last ten, twelve, or even fifteen years. This is partly to be ac-
counted for by the greater length of premonitory or prodromic
periods which have been so much more thoroughly studied,
and it is partly to be explained by the special nature of the
disease. Thus many of the later observers say that the dura-
tion of general paralysis is very much greater when it attacks
those who have well-marked hereditary taint, or whose an-
cestors have suffered from the various mental and nervous
diseases, than when it attacks those without such predis-
position.
Dr. Crichton Browne says in vol. 5 of the West Riding
Reports: “It is most satisfactory to observe that the average
time of residence of general paralytics in the West Riding
Asylum is more than three and one-half months longer than
GENERAL PAIRALYSIS OF THE INSANE. 351
what is stated by Drs. Bucknill and Tuke to be the generally
estimated total duration of the disease.”
Death from uncomplicated paresis comes in one of two ways,
either gradually through the extension of the paralysis to the
respiratory muscles and the exhaustion attending the disease,
or suddenly by one of the epileptiform convulsions. The first
is much the more common mode of death. Pulmonary com-
plications are not infrequently a cause of death.
Dr. Talcott says truly that the treatment of paresis should
be both hygienic and medical. While we are unable with our
present knowledge to expect a cure, we may at least prolong
and render endurable an otherwise wretched existence; and
perhaps succeed in giving months of comparative comfort and
ease. Each case of general paralysis, like every other case of
disease, has of course its own individuality, yet there is in all
cases a remarkable uniformity of both objective and subjective
symptoms.
Thus far alcohol, pure and simple, is the most thoroughly
indicated according to the symptoms, and most efficacious in.
effecting relief. A weak and tottering gait, limp and uncertain,
movements of the entire body, tremulousness of lips and
tongue, thickness and hesitancy of speech, uncertain expres-
sion of the eyes, together with transcendent notions of wealth
and power, are all characteristic of the paretic patient, and
find their most perfect counterpart in the actions, words and
thoughts of him who makes a proving of alcohol.
Dr. Talcott says that under the action of small but appreci-
able doses of alcohol several of his patients have experienced
marked temporary amelioration of their symptoms; but the
medicine has not charmed away the malady, nor hindered for
any great length of time its onward march.
Again he says: “We have used Cannab. ind, as our patients
have manifested the strange vagaries, or experienced the mar-
velous visions of the Hashish eater; we have tried Coca, when
the sense of strength has outstripped the actual physical pow-
ers; we have administered in varying potencies Act. rac.,
Arsen., Bellad., Cupr, met., Hyosc., Ignat., Nux wom., PhOS-
phor., Digit., Calc, phosph., Phosphide of zinc, Conium, Anacar.,
352 INSANITY AND ITS TREATMENT.
Stramon., Sulphur, Ver, alb., and Ver. vir., when any of these
were called for by proper indications, but while our remedies
have apparently produced beneficial results, yet the El Dorado
of our hopes, the perfection of a cure remains unreached. The
treatment of paresis by homoeopathic medication has been too
imperfect and brief to be either discouraging, or conclusive or
satisfactory.”
Dr. Samuel Lilienthal says in an article published in the
Transactions of the New York Homoeopathic Medical Society,
1878:
“The therapeutics of progressive paralysis is just as rich in
means as poor in success. Still we cannot get our clue from
asylums, where patients are too often received in late stages;
and statistics would show far better results if the patients were
admitted early in well managed institutes provided with large
gardens. In such a good asylum the patient gets mental and
somatic rest, a condition sine qua non for a cure. Here the
patient must enjoy fresh air as much as possible, and his diet
must be plentiful and nourishing. Wine in moderate quanti-
ties is easily borne during meals, but tobacco must be strictly
forbidden. During the initial stage transient benefit can be
expected from galvanism to the medulla oblongata and upper
part of the spinal cord; also iodide of potassium and cool
sponging are advisable. All heroic treatment is certainly in-
jurious, as hydropathic treatment, all mercurials, or abstraction
of blood. Calabar bean is praised by George Thompson and
J. Crichton Browne. especially when palsy has advanced, but
it failed in other hands. During the intercurrent states of
excitation, prolonged tepid baths, keeping the head cool at the
same time, do good service. Sometimes morphium and chloral
may be nessary for quieting the patient. The patient must be
frequently reminded to attend to the calls of nature, especially
during the dementia; and the utmost cleanliness must be en-
forced, but this can only be done by patient and intelligent
nurses.”
“Sheppard (Lectures on Madness, p. 160) recommends, during
the early paroxysms of excitement, tincture of digitalis,
whose exhibition may be disguised by putting it in the
GENERAL PARALYSIS OF THE INSANE. 353
patient's beer at dinner and supper. In some cases chloral
is also very useful. The wet sheet is also a very valuable
adjuvant in the summer time during the initiatory period of
this malady. The heat of the skin is sometimes abnormally
high, with great excitement and destructive tendencies. All
such cases are admirably suited to be under asylum discipline
and management.
“Jahr, in his Mental Diseases, gives us any quantity of
remedies, but we doubt whether many of them would be of
benefit in the treatment of this disastrous disease. We turn
with far more confidence to Kafka (Hom. Therapie, II, p. 152)
where he says: Vertigo, in the prodromal stage, deserves our
close attention. We would think of Nua, vomica, two doses
daily, where the sensation prevails as if the patient were in-
toxicated—as if everything turned in a circle—with nausea,
vomiting, dyspepsia, constipation or hard stool; the gait
clumsy and dragging. Should Nux v. fail, we will find in
Natrum mur. the same complex of symptoms. Phosphorus is
indicated for that vertigo showing itself in walking, stooping,
turning the head, closing the eyes, with the sensation as if he
would fall to one side, ameliorated by standing still or lying
down; with dulness and stupefaction of the head, sleepiness,
and frequent falling asleep in daytime, weakness of memory
and of the lower extremities, especially where the atrophy is
caused by excessive venery and onanism.
“Rhus toacicodendron has vertigo from previous senility in
consequence of bodily over-exertion, especially during walk-
ing, standing and sitting, with the sensation as if they
would fall forward or to the right side. They walk about as
if they were drunk, and feel better when lying down. There
is a sensation of drunkenness and stupefaction in the head,
with weakness of memory, languid run of ideas, and heavi-
ness in speaking. º
“For pride of rank or riches we have good remedies in
Platina and Veratrum, the former, especially, where the patient
is proud, full of self-esteem, and looks down upon everybody
as his inferior; the latter gives us the purse-proud patient,
who lavishes his imaginary wealth on everything and every-
354 INSANITY AND ITS TREATMENT.
body. Where the disease has fully set in, and the manie de
grandeur continues, we may still expect some good results
from Stramonium. Where the patient suffers emphysema
simultaneously with the symptoms of the disease, Phosphorus
might be indicated.
“According to the authorities already cited, we may be al-
lowed to consider dementia paralytica a tabes cerebralis; and as
this disease is so frequently combined with tabes seu atrophia
dorsalis, it may be worth while to study the remedies applica-
ble to the latter. Kafka divides also into three stages, ex-
actly corresponding to those of atrophia cerebralis, viz., that of
Sexual excitement, that of debility and that of paralysis.
Here also a cure is only possible during the stage of excite-
ment, and the prognosis becomes steadily more doubtful the
more the disease has progressed towards paralysis. For too
frequent seminal losses, he recommends Phosph., Nux wom.,
Calc. carb., Agaric, Staphisagria. For bodily over-exertion,
Rhus, Arnica, Arsen., Coccul, Sulph. At the same time a
strengthening diet is recommended, sojourn in the country,
cold sponging of the back, hydropathy, sea-bathing, chalyb-
eate waters, and induction-electricity. In cases of paralysis,
Plumbum, Cuprum, Arsen., Phosph., Secale, Strychnine, may
be tried, although at this stage not much benefit can be
expected.
“Baehr (Therapie, 1, 133) also hopes beneficent results from
early treatment. Hints for Mercurius are found in all phases
of paraplegia extremitatum, of the bladder and rectum, with a
decided tendency to twitching and shocks; severe pain in the
spine, increased by motion; restlessness; anaesthesia of the
skin. Secale also gives us the characteristic twitchings and
shocks, painful contractions, even tetanic symptoms, perfect
paralysis, sometimes with increased irritability, decubitus etc.
Rhus toz. corresponds to the third stage, just as Veratrum
does to the second stage. Plumbum combines the symptoms
of tabes cerebralis and spinalis. Sulphur is an important remedy
even at a late stage, when the disease comes to a standstill
(the long intermissions of these diseases are well known), and
where it is worth while to act upon these obsolete exudations,
GENERAL PARALYSIS OF TEIE INSANE. 355
and thus, perhaps, improve the paralysis, Silicea, Causticum,
Aluminium met. deserve to be mentioned, for where we can-
not cure, we might thus procure a temporary amelioration.
“Ruddock (Text-book, 407) considers general paralysis of the
insane essentially a chronic meningitis, the chief symptoms of
which are gradual and complete loss of both mental and phy-
sical powers. Of remedies he only mentions Stramon., Veratr.,
Zincum.
“Hering, in his Analytical Therapeutics, gives us some hints
to prescribe successfully for this insidious disease. Thus,
under complaints after mental over-study; Lachesis, for talk-
ative mania, speaks in choice phrases; jumping from one ob-
ject to another; or exalted language; corrects herself by sub-
stituting another word. Hyosc., for hyperaesthesia of sight,
with thirst and mania; melancholy; unwilling to talk; weak-
ness, with exaltation now and then. Stramom., pupils immov-
able, unconscious and moving hands and feet. Cuprum,
Hyosc, Stramon., Veratr., Vip, tor., unsteady and melancholic,
with mania. Bellad., contracted pupils, pulse and skin nor-
mal, deranged mind. In fact, we feel that the treatment of
insanity is now greatly facilitated by the study of this work,
and there is hardly a case where we cannot find the correspond-
ing remedy.”
It may not be out of place to mention the treatment of the
excitement of general paralysis by repeated large doses of
hyoscyamine, given on successive nights, as practiced in some
asylums, and, it is claimed, with good results.
Case.—A. B., admitted August 27th, 1876. For a whole
month he was exceedingly excited and restless, and had only
short Snatches of sleep. In the intervals he was employed in
tossing about, rearranging and tearing his bed-clothes, and
in Smearing the walls and swabbing the flow with his excre-
tions. After three repetitions of three-quarter grain doses of
hyoscyamine on alternate nights his excitement was completely
removed. He also became clean in his habits, has since re-
mained well, and has been transferred to a ward where he may
have the privilege of enjoying, for a time at least, such advan-
tages as would have been impossible had his degraded habits
356 INSANITY AND ITS TREATMENT.
remained unchecked. This condition continued for four
months when the report was made.
Mickle says: “A patient threatened with general paralysis,
one who has shown symptoms of the prodromic period, the
period of mental alteration not yet amounting to decided
mental alienation, should be at once freed, as far as possible,
from the conditions under which symptoms of so sadly pro-
phetic a nature have arisen. A perfectly regular life, early
hours, moderate and regular bodily exercise, a total disuse of
alcohol in any form, and of tobacco; the use of bathing and
friction of the skin, the application of cold to the head when
it becomes unduly heated, while the feet are kept warm, and if
necessary, mustard, or hot pediluvia are used.
“Every source of mental worry, anxiety, annoyance, fear,
chagrin, should be scrupulously avoided at almost any cost.
All intellectual labor should cease, and just such an amount
of reading, of conversation, and of thought, should be under-
taken as will afford the most gentle of intellectual and emo-
tional exercise. The society should be that of the patient's
family or intimates. In a word, the patient must go out of
his ordinary life, must retire from his duties, labors, contrarie-
ties, turmoils and ambitions, and in repose seek a renewal of
nervous tone, and of power of resistance to hostile influences.”
Dr. S. H. Talcott says: “Hygienically the paretic needs the
most scrupulous and kindly care. During the stage of excite-
ment he should be watched over and handled with all the
caution attendant upon the nursing of a patient suffering
with acute mania. After passing into the chronic stage his
strength and physical health may be long preserved by abund-
ant out-door exercise. By placing the patient at work he is
relieved of his overcharge of activity without feeling the chaf-
ings of close confinement. The air and sunlight contribute
to his happiness and well-being; the labors of the day divert
his thoughts at the time and promote his tendency to sleep at
night. His appetite is kept up, and his powers of digestion
remain longer unimpaired than when idle. These labors of
the paretic can only be begun after the excited stage is past;
as during that period his attention can hardly be attracted to
GENERAL PARALYSIS OF THE INSANE. 357
anything of an ordinary worldly nature. Work should of
course be imposed only when the patient is sufficiently strong
to endure it, and it should be continued only So long as it pro-
duces evidently beneficial results. In his labors the patient
should be protected from the hot sun, as this almost always
brings a return of the unnatural excitement.”
In regard to the treatment of confirmed general paralysis
Dr. Mickle speaks as follows:
“For the most part the means suggested in the treatment of
the prodromic period will still conduce to amelioration. In so
malignantly fatal a disease, general management and nursing
hold the chief place in the nursing.
“Most general paralytics should be removed from home for
a time, either to an asylum, or to some house of which part
can be set aside for their use. To retain them at their own
homes, where they may squander their means, are most dicta-
torial, fly into furious passion if not obeyed, and where every-
thing rouses their desire to alter, sell, or destroy, is to promote
angry and disturbing Scenes, most prejudicial to the patients,
and most painful to those about them.
Tact and gentleness are very necessary in their manage-
ment. By tact, gentleness and bonhomie, many of them can
be kept in good humor; or, at least, those angry outbursts
which, too often, follow the slightest crossing or thwarting,
may be avoided as far as possible. In the early stages peace
and mental rest should be sought by every means, but too
often are unattainable, and when furious paroxysms of de-
structiveness or violence occur, a judicious isolation or seclu-
sion may prove beneficial. In the early stages, also, and espe-
cially in the forms characterized clinically by much mental
excitement, by expansive delirium, or by so-called congestive
tendencies, the nourishment should be light, easily digestible,
limited, and absolutely free from alcohol. This limitation of
diet is far from being always easy to carry into effect, inasmuch
as the patient's appetite is usually large, nay, often voracious,
although when this is more apparent than real—the patient
eating over-plentifully through inattention, it may be pre-
vented by judicious management. In such cases, also, the ex-
358 cº) -
INSANITY AND ITS TREATMENT.
cretory organs, and especially the bowels, should be kept in
free action by the usual dietetic and other means. As far as
possible the patient should live in the open air, and take a
moderate amount of exercise.
With the advancing progress of the disease the diet may be
made more generous, and in the third and fourth periods may,
with advantage, be extremely liberal.
When the patient becomes unable to walk by himself with
Safety, he must have the assistance of attendants in taking
regular daily open air exercise; at a later period he may re-
cline in an easy chair, sitting on air cushions; and thence,
either by a gradual decline, or after convulsive or paralytic
attacks, he must sink yet a step lower in the scale and pass his
days on a water-bed, but usually, for a short time only. Bed-
Sores tend to form, pulmonary affections and diarrhoea afflict
his feeble and now attenuated frame; the excrements all pass
involuntarily beneath him, and, as a rule, the end is not far.
Hence, in the later stages, the paramount importance, next to
good feeding, of perfect cleanliness and of the prevention of
bed-sores. These are only attainable by the most constant
and scrupulous care in the instant removal of all excreta, the
use of “railway ” urinals, where possible, and of a water-bed,
frequent changes of position, and the employment of Some
hardening application on the parts exposed to pressure.
Dr. Talcott says, that these bed-sores are best treated by the
method proposed by Dr. Brown-Sequard. Two poultices are
alternately applied—the one of pounded ice, the other a very
warm bread or linseed poultice. The pounded ice, contained
in a bladder, is applied for eight or ten minutes; the warm
poultice for from one to four hours.
Dr. Mickle says, if the sores are acute: “Apply a solution of
carbolic acid, or of potassium permanganate, and over it a lin-
Seed poultice; cut away sloughs as soon as they are loosened,
syringe out regularly, frequently, and thoroughly, with the
carbolic, permanganate, thymol or chloralum lotions, then
dress with the same, or with a solution of boracic acid, or with
powdered zinc oxide.”
Pathology.—Most of the writers upon general paralysis con-
GENERAL PARALYSIS OF THE INSANE. 359
sider that the essential changes of the disease are inflamma-
tory in their nature.
Dr. Talcott says: “There exists during the progress of par-
esis a slow but continuous inflammation of the cortical sub-
stance of the brain and its meninges.”
In 1826, Bayle asserted that it “is the effect of irritation or
inflammation of the cortical gray substance of the cerebrum,
which directly disorders the functions of the brain. This irri-
tation, or this inflammation, is in its turn the direct result of
a chronic inflammation of the Soft meninges, which com-
mences at their cerebral surface.”
Calmeil attributed the symptoms to chronic diffuse peri-
encephalitis, and Ludwig Meyer also supports the inflam-
matory view; he believes that the inflammatory action starts
from the walls of the capillary vessels of the gray cortex.
Hitzig, Voisin, Clouston, Westphal, Erlenmeyer and Crich-
ton Browne, all lend the weight of their authority to this
view, only differing perhaps as to its starting point and ex-
tent.
Baillarger describes two orders of lesions as marking differ-
ent cases in general paralysis. 1. The inflammatory, those
due to peripheral meningo-encephalitis; and 2, those depen-
dent upon hydrocephalic or serous effusion, with atrophy
or softening of the brain.
Dr. Talcott says: “We prefer the expression “meningo-peri-
encephalitis with atrophy, as the one which will most complete-
ly cover the whole pathological condition. The pia mater is al-
ways found adherent to the brain surfaces in spots upon the up-
per parts of the convolution, and when peeled off takes with it
small portions of the cortical substance. These adhesions are
found upon the anterior and middle lobes. The brain always
atrophies under the influence of paresis, and the tissues be-
come more or less sclerotic. Effusion to a moderate degree
usually occurs. So it does also in senile dementia, but in the
latter case it is a process of years duration and a result of old
age, while the atrophy and effusion of paresis may occur in a
few months, and in the prime of life. Inflammation of the
arteries exists to a considerable extent, and occasionally athe-
360 INSANITY AND ITS TREATMENT.
romatous deposits are found. The dura mater is often thick-
ened, sometimes to the extent of half an inch, and is some-
what discolored, and darker than usual. There is generally
an oedema of the membranes of the brain, with a more or less
opacity of the arachnoid. In addition to the pathological con-
dition of the brain, there is found a decided atrophy of the
great sciatic nerve, which may account for the gradual loss of
power in the limbs, the tottering, uncertain and shuffling
gait.
“This atrophy of nerve tissue which apparently begins in
the great nerve-centres steadily proceeds to involve the entire
nervous system. Closely associated with the manifest weak-
ness in walking is a tremulousness of the lips and tongue,
hesitancy and thickness of speech, and a flat, masked appear-
ance of the face, all of which latter are due to the wasting
away and loss of power of the facial, tri-facial and glosso-phar-
yngeal nerves.”
A second class of authors consider general paralysis to be
primarily and principally a degeneration.
L. V. Marcé thinks it due to chronic congestion with exu-
dation.
Bucknill speaks of general paralysis as being “essentially a
disease of nutrition affecting the whole nervous system. It
consists in some vice of nutrition whose nature is yet un-
known, but whose extent embraces the whole of the nervous
system, and is by no means limited to the encephalic centres.
The morbid processes in the brain are not encephalic.”
Bonnet, Poincaré and Blandford agree in the main with
this view, while Dr. J. Luys believes the morbid process to be
a true, diffuse, interstitial sclerosis of the neuroglia of the ner-
VOuS CentreS.
Dr. C. J. Mickle says: “In the vast majority of cases the
cerebral cortex is primarily affected, the meninges usually be-
ing more or less involved almost simultaneously.
“The morbid process is primarily set up by excessive, irregu-
lar, protracted activity and overstrain, of a larger or smaller
number of the active functioning elements of the cerebral cor-
tex, which subserve the higher faculties of the organism. It
GENERAL PARALYSIS OF THE INSAN.E. 361.
is usually admitted that these active functioning elements are
the so-called ganglionic nerve-cells of the cortex. Of the most
potent and frequent causes of general paralysis each, in its
own way, brings about the primary step to which we refer,
namely, the excessive, irregular, protracted activity or over-
strain of a larger or smaller number of the nerve-cells.
“Partly in consequence of the different modes of action of
the several causes, partly owing to the varieties in habits, work
and circumstances of the patients, producing habitual relative
over-activity, activity or disuse, of this or that part of the
brain, and, hence, relative higher development in the one
case, and relative feebleness of action and simplicity of inter-
communication in the other; and partly owing to hereditary
and to diathetic causes, and, possibly, temperament as well;
it comes about that the cortical regions or centres most se-
verely affected, vary as we have said, in different cases.
“Over-activity of this kind and over-strain, induce contem-
poraneous hyperaemia of the part, and this hyperaemia tends
to keep in action its own causes. From frequent repetition of
this condition the normal tonus of the arterioles is gradually
lost, and not only in the cortex, but in the overlying meninges
also. Hereby is prepared the way for sudden and protracted
meningeal and cerebral hyperaemias, which embarrass the
brain circulation and brain nutrition in a more or less pro-
tracted manner, and leave behind them more or less perma-
ment effects or traces.
“In consequence of this there is distention of the vessels,
circulatory impediment, irritative over-growth of the connec-
tive nuclei of the walls of the vessels, and probably, also, of
the neuroglia, while others of the nuclei and cellules often
termed embryoplastic, or their materials, are, perhaps, di-
rectly effused. Other changes occur in both, also, as a result
of the lowered standard of the local processes of nutrition.
Moreover, out-wandering of white blood-corpuscles, and escape
or extravasation of red blood-corpuscles, may further choke
the parts. There is a constant tendency to diffusion of all
the morbid processes, and among the macroscopic changes are
a thickening opacity, and Oedema of the Superjacent meninges.”
23
362 INSANITY AND ITS TREATMENT.
The mental symptoms unmistakably point to the primary
involvement of the frontal lobes, which have been fixed upon
by Ferrier as the centres of attention, and of the reflective and
intellectual faculties, and where, as we shall see, adhesions are
numerous and constant in general paralysis.
“In general paralysis,” says Westphal, “the mental disturb-
ance is from the first based on the foundation of mental weak-
ness.”
The order in which the motor symptoms present themselves
corresponds pretty closely with the order in which, according
to Ferrier, the motor centres are arranged in the cerebrum
from before backwards. Of course there are great varieties in
the order in which these motor symptoms appear, and in the
manner in which they are combined. In some cases one or
more of them are never seen, and in other cases they succeed
each other most irregularly, but, as a rule, they come in the
order indicated, and are manifested through the muscles of
the face, tongue, larynx, hand, arm, foot and leg in succession.
The centres for the muscles of all these parts are all placed in
the posterior third of the frontal, and in the parietal lobe, and
in a region where adhesions are always abundant in general
paralysis. Each motor centre affected by the morbid proces-
ses of general paralysis would, at first, during the hyperaemic
and inflammatory stage, be irritated and stimulated to a pro-
fuse reproduction of motor ideas, and to incontinent dis-
charges; and would, finally, during the degenerative stage, be
broken down, and have its functional activity abolished.
The sensory centres seem, on the whole, to be more fre-
quently exempt than the other parts of the cerebrum from
morbid change. There is one of them, however, the angular
gyrus or pli courbe, the sight centre according to Ferrier, on
which adhesions are often seen. Now hallucinations of vision
are the most frequent of all hallucinations in general par-
alysis.
I shall devote the rest of this lecture to a description of the
appearances of the brain as given by Dr. J. Crichton Browne
in Vol. 6 of the West Riding Reports. He says:
Let us suppose that the brain of a patient who has died of
GENERAL PARALYSIS OF THE INSANE. 363
general paralysis has been removed from the skull, and that
in this case there are no arachnoid cysts or other adventitious
conditions. What first strikes us is an abnormality in the
shape and consistency of the brain. It is somewhat attenuated
in the frontal region, and it lies upon the board as if it were
flattened and collapsed. It lacks the rounded contour and
plumpness of the healthy brain; and has an uneven outline
and lateral bulgings, obviously due to the softness of its text-
ure, which renders it unable to preserve its proper form, when
deprived of the support of the cranial walls. And not only
is the brain softened, but it is atrophied, and there is an
obvious decrease in the volume of the entire cerebral mass. In
no form of mental disease, except in the dementia of brain
wasting, is atrophy of the brain so advanced as in general
paralysis, which is all the more remarkable, as death happens
in general paralysis in that decade of life in which the maxi-
mum weight of the brain is attained.
The next observation that occurs to us is that the arachnoid
is greatly thickened, and that it has in many places lost its
transparency and become white and opaque. Along the mar-
gins of the great median cleft, where the Pacchionian granu-
lations are unusually numerous and large, it has become a
tough, glistening membrane, and over the frontal and parietal,
lobes it is in many places cloudy or opalescent. Over the
occipital lobes the arachnoid retains its natural aspect, but
over the temporo-sphenoidal lobes and cerebellum, scattered
patches of whitish opacity are generally to be noticed. Wher-
ever situated, the opaque patches are but seen over the sulci
and not on the summits of the gyri. Directing our attention
next to the pia mater, we notice that it, as well as the arach-
noid, is remarkably thickened. Instead of being thin and
delicate, it is coarse and tenacious, and has a swollen and
Somewhat gelatinous appearance, owing to infiltration of its
meshes with serous fluid. It is not, however, pale and watery,
as in brain wasting, but is irregularly hyperaemic, presenting
amidst its Oedematous expanse reticulations of dilated vessels,
and with more or less injection. The distribution of the
morbid changes in the pia mater corresponds with that of
364 INSANITY AND ITS TREATMENT.
those in the arachnoid. They do not extend on to the occipital
lobe, and are most marked over the frontal and parietal lobes.
As regards the great arteries of the brain, we are struck by
their freedom from atheromatous deposit and calcareous de-
generation. *
Looking next at the convolutions, as seen without disturb-
ing the membranes, a glance suffices to show that they are
much atrophied, the wasting being most advanced in the
frontal and parietal lobes, present to some extent in the upper
part of the temporo-sphenoidal lobes, but invisible in the
occipital lobes or orbital lobules. To compensate for the
wasting there is much oedematous effusion, which is diffused
throughout the meshes of the pia mater; and collected in some
places in hollows and channels, when the wasting is very far
advanced. The wasting of general paralysis seems to differ
from that of senile, simple and consecutive dementia, in that
it is nearly as well marked in the parietal as in the frontal
lobes, and to agree with it in that it does not invade the occip-
ital lobes.
But there are other appearances that are very characteristic
of the disease. The skull is generally thickened, but not of
very dense consistence, its inner surface having a reddish-
blue tinge, owing to the presence of blood in the diploé.
Sometimes the skull is decidedly soft, and in those cases the
thickening is considerable. The dura mater, which is thick-
ened, is adherent to the skull; most so in the frontal region,
but the adhesions are not of that strong and intimate char-
acter so often noticed in senile dementia.
If the dissection of the brain is now proceeded with, the
thickening of the pia mater is again impressed upon the
observer when it has to be torn through. It is then found to
be in some places intimately united with the gray matter of
the convolutions. Instead of coming away from the frontal
and parietal lobes, as a loose and well-worn glove does from
the hand, it is glued to the surface of certain gyri, and if it is
forcibly torn away it removes some tissue, and leaves a rough
eroded surface beneath.
The superficial layers of the cortical substances are, in fact,
GENERAL PARALYSIS OF THE INSANE. 365
torn away with the pia mater, and may be seen adhering to
its inner aspect. The points or areas of adhesion may be few
or numerous, large or small, distinct or confluent, but they are
invariably confined to the summits of the gyri, and do not
spread down their sides nor occur at the bottom of the sulci.
Where the pia mater has been stripped from a region of the
cerebrum in which the adhesions are abundant, the denuded
and abraded convolutions look just as if they had been gnawed
or eaten away by a caterpillar. The surface of the convolu-
tions, when not implicated in the adhesions is generally
smooth and normal.
On slicing the brain, a general deterioration in its quality
is at once recognized: The gray matter has a shallow and
faded appearance, and is traversed by vessels that are coarse
and prominent, and in Some places it has a violet or vinous
tinge. It is undoubtedly softened and watery, as is also the
medullary substance, which is of a dirty, grayish white color,
and presents an excessive number of coarse vascular points,
and a varying number of blotches of vinous staining. The
ventricles, which are abnormally capacious, contain an exces-
sive amount of serous fluid ; the choroid plexuses are Oedema-
tous, and the ependyma is often granular. The basal ganglia
are all more or less atrophied, and the cerebral nerves, as a
rule, have a preternaturally white and glistening aspect.
But the one appearance in general paralysis which is very
constant and very characteristic is the adhesion of the pia
mater to the cortical substance. Since the frequency of these
adhesions was first recognized, I have given them a large
amount of attention and have come to these conclusions: 1st,
that they constitute the most constant pathological change in
general paralysis; 2d, that they explain the essential nature of
the morbid process in the disease; 3d, that they will also,
when minutely studied, explain its symptoms and progress.
A headache in the second stage of the disease is sometimes
so severe as to induce the patient to beat his head, to knock it
against the wall, or to rub the scalp until it is denuded of
hair; this headache is seated in the frontal or parietal region,
and is accompanied by giddiness and a sense of fulness and
pressure within the skull.
366 INSANITY AND ITS TREATMENT.
I have now endeavored to show, that these adhesions are
caused by a chronic adhesive inflammatory process, spring-
ing out of excessive functional irritation, and proceeding to
disintegration of the cerebral gray matter; and, that they,
generally speaking represent the course and distribution of the
morbid processes in which the disease essentially consists.
There are in general paralysis, invariably, certain motor
symptoms involving in different degrees and in various orders
of succession the muscles of the face, tongue, hand, arm, leg,
etc. There are in the human brain certain areas which by ar-
guments from homology as well as by clinical facts, can be
proved to be centres of representation of the movements of the
face, tongue, hand, arm, leg, etc. Do adhesions cover over
these areas in cases of death from general paralysis? Yes,
almost invariably; a fact which in itself gives plausibility to
the claims advanced for these adhesions to be regarded as reli-
able vestigia of the diseased action.
Jurisprudence.—The victims of general paralysis are very
likely to come before the courts, and, as might be expected
from the nature of their delusions, the act of which they are
generally accused is some form of theft. Deeds of violence are
more rarely committed by them; they are ordinarily good
humored and indisposed to quarrel; and if they do attack
others it is because their power has not been deferred to, or
their rights not respected. Petty thefts are the most common
offences calling for the determination of the medico-legal rela-
tions of general paretics, and they are committed by the
patient under the delusion that what is taken is his own prop-
erty; that his exalted position gives him the right to help
himself to the property of others, or else that he has ample
wealth and will pay at any time for the article appropriated.
In yet other cases arrests for intoxication, disorderly conduct,
or indecent exposure of the person, first bring the paretic
under suspicion of insanity, and lead to the recognition of its
existence and his seclusion. The boisterous behavior and the
indecencies of conduct are frequent and direct outgrowths from
the mental disturbance; and the intoxication may be real, or
merely the interpretation given to the symptoms of insanity
by the policemen making the arrest.
HYSTERIA- 367
LECTURE XVI
Hysteria, Hypochondriasis.
Hysteria.
Thus far we have confined our attention to those diseases
which are specially called mental, but there are also a few,
very important, which are sometimes classed as nervous and
sometimes as mental, because the mental disturbances are
more or less prominent, but not generally to such an extent
as to constitute insanity. Of these diseases we propose now to
consider hysteria, hypochondria, catalepsy, chorea and Som-
nambulism.
Undoubtedly these topics will be presented to you by the pro-
fessors of pathology, clinical medicine, and diseases of women,
from the standpoint of their respective chairs, but these dis-
eases are so protean in their character that it will be well to
consider them from the mental standpoint as well, keeping
constantly in mind that for us the word mental disease does
not mean disease of the mind, but a disturbance in its mani-
festation.
Hysteria is a disease which has been known from the very
earliest times of civilization, and was so called by the phy-
sicians of Ancient Greece, who believed it to arise from the
freaks of a dissatisfied and ill-tempered uterus. Plato and his
followers believed the organ to be an animal endowed with
spontaneous sensation and motion, lodged in another being
and ardently desirous of procreating children. If it remained
sterile long after puberty it became indignant at its unnatural
condition, travelled through the whole system, arrested respira-
tion and threw the body into extreme danger, until it became
pregnant, whereby its wrath was appeased, and it behaved
well ever afterwards.
The multiform symptoms which are included under the
term hysteria may, without exception, be recognized as the
368 INSANITY AND ITS TREATMENT.
consequences of a functional disturbance of the nervous sys-
tem. The disease, therefore, belongs to the class of the neuro-
ses, and to those neuroses to which, in the absence of a suffi-
cient knowledge of their anatomical basis, the term functional
must be applied. Hysteria is further to be described as a
general neurosis, for its symptoms allow one to infer a partic-
ipation of the most various portions of the nervous system—
certainly of the brain and spinal cord, and, with much prob-
ability, of the peripheral, and particularly also of the sym-
pathetic nervous system.
The most constant symptoms of hysteria are those which
show a condition of increased irritability to physical and psy-
chical stimuli. A peculiar mental behavior is partly an im-
mediate consequence of this abnormal irritability, and is in
part the expression of greater disturbances of brain power.
Romberg, the celebrated German pathologist, first called at-
tention to the fact that reflex excitability is largely increased
in hysteria, but he did not lay sufficient stress upon the emo-
tional character of the disease.
And yet it is this emotional character which seems to ex-
plain, not only the infinite variety of symptoms, but also the
causation and progress of hysteria. As regards the symptoms,
we find that their multitude and apparent incongruity have
perplexed and bewildered those observers who were without
this clue. Sydenham said that the forms of Proteus and the
colors of the chameleon were not more various than the divers
aspects under which hysteria presented itself.
Again, all the symptoms, such as convulsive attacks, faint-
ing fits, pain, cough, globus hystericus, difficulty of deglu-
tion, vomiting, borborygmi, asthma, hiccough, palpitation of the
heart, tenesmus of the bladder, general and partial loss of power,
coma, catalepsy and delusion, all flow from the same source,
and may be classified as functional spasm and paralysis,
anaesthesia and hyperaesthesia, resulting from a painful im-
pression, whether mental or physical, acting upon the emo-
tional portion of the encephalon. Finally, there occur, as
symptoms of an apparently altogether different nature, those
of altered power of Secretion and excretion; yet these, too,
HYSTERIA. 369
may undoubtedly be recognized as dependent upon an influ-
ence of the nervous system.
Being guided by this fundamental principle, we find the
transition from physiological to pathological manifestations
natural and easy. All symptoms of hysteria have their pro-
totype in those vital actions by which grief, terror, disap-
pointment, aud other painful emotions and affections, are
manifested under ordinary circumstances, and which become
signs of hysteria as soon as they attain a certain degree of
intensity.
Efforts have been made to show that hysteria was more
general among persons of certain ranks in Society, or of cer-
tain physical constitution, but all such attempts have proved
futile. Nor has the intellect anything to do with it, for some
hysterical women are very clever, and others are the reverse.
It is rather the mental constitution, which, together with
heredity, exercises an all-powerful influence, or, as Maudsley
would say, it is the hereditary influence of the nervous or in-
Sane temperament.
One thing is certain, that there exists in some persons a
much greater readiness to take on the disease, upon the appli-
cation of the exciting cause, than in others; for in these indi-
viduals there pre-exists a peculiar condition of the nervous
system, “for which,” says Dr. Alison, “we have no more pre-
cise or definite expression than nervous irritability, or mobility;
a condition which is more common in women and children
than in men, and more common in all persons when in a
state of weakness than when in the full enjoyment of mus-
cular strength; in women, particularly, more common about
the menstrual periods, and immediately after delivery, than
at other times; more common also in those in whom the
monthly discharge is habitually excessive, or altered, as in
leucorrhoea; or suddenly suppressed. In this condition of
mobility, both sensations and emotions are intensely felt, and
their agency on the body is greater and more lasting than
usual. In persons of this moveable temperament, spasmodic
complaints are easily excited, and the tendency to their re-
currence is increased by each repetition of them.
370 INSANITY AND ITS TREATMENT.
Women whose sensibility is blunt, never become hysterical;
while those who are readily accessible to impressions coming
from without, who feel acutely and are liable to strong emo-
tions are certain to become hysterical if made to suffer mental
agony or prolonged physical pain. This high degree of sensi-
bility is not confined to any particular rank of society but may
be found as well among the lower as the higher classes. As
emotion and anxiety on the one hand, and highly impression-
able women on the other, are found in all quarters of the globe,
hysteria is not confined to any climate or country. But there
is no doubt that the circumstance whether women live in town
or the country has considerable influence in the production of
the disease. Although hysteria does occur in the country yet
it is far more frequent in large towns and cities, where every-
thing tends to weaken and wear upon the nervous system; and
where the struggles of life, and consequently painful emotions,
are more intense than elsewhere.
The persons suffering from hysteria are of the class above
described. They are generally young women, in whom the
process of menstruation is in some way or other disordered;
and who naturally are of a feeble constitution, or have been
weakened by disease, or by their habits of life.
So long as the uterus was believed to be the sole, or even the
main factor in the disease, it was necessary to deny its occur-
rence in men; but Briquet states that of 1000 cases of hysteria,
fifty occurred in men; and all authors state that it does occur
in males as well as females, though much more rarely, if they
are highly sensitive and subject to painful emotions. Although
it is true that the different physiological and pathological pro-
cesses in the female reproductive system have an unmistak-
able influence in its production, yet this influence merely in-
dicates one of the different ways by which similar functional
disturbance of the nervous system may be caused.
The common idea is that hysteria does not occur in child-
hood and advanced ages, but statistics show the contrary. Out
of 820 well marked cases, 71 were of patients under 10 years,
and 28 over the age of 45. During childhood the female
sexual organs are in a state of perfect rest, and do not give
HYSTERIA. 371
rise to sufferings; but nervous sensibility is high and reason
still undeveloped; so that if painful emotions be frequently
repeated or be unusually powerful, we have all the needed
conditions for the development of hysteria. Between 15 and
20 years of age, hysteria is most frequent, in consequence of
the radical change which the nervous system undergoes at
that period. Within those years, girls begin as it were a new
existence; they enter upon the world with its passions and
excitements; and if painful emotions be frequently and power-
fully experienced, hysteria is the inevitable result, provided
the system is predisposed to it. After 20 and 25, the disease
is more rarely developed, a circumstance which cannot be ex-
plained by the uterine theory; for at no other age are the
female sexual organs subject to more considerable disturbance.
We find however that as age advances hysteria becomes less
frequent because the mind has become more settled, and less
liable to be disturbed by sudden impressions and emotions.
Some of you have probably read of the Dancing Mania,
and the Convulsionists of Saint Medard, together with other
epidemics of hysteria in the middle ages. Similar attacks on
a smaller scale are not infrequently met with in young ladies’
boarding schools, factories, etc., at the present day, and show
the extent to which the imitative faculty takes part in pro-
ducing hysteria.
Hysteria is almost always a chronic disease, which up to a
certain point is developed in a somewhat regular way but be-
yond that the symptoms show themselves in the most confused
alternation and succession; we can only enumerate them one
after another, and point out their relation and frequency. But
never absent are the peculiar psychical alterations, to which
particular disturbances of sensibility and motion stand in the
closest relation. Around these the remaining symptoms group
themselves, according to the intensity and general prevalence
of the disease.
At first the complexion becomes pale and sallow, the skin
dry and hard, the patient generally loses flesh and complains
of headache. The appetite is fanciful and feeble, some pa-
tients having a great aversion to anything but water, acids,
372 INSANITY AND ITS TREATMENT.
confectionery or even chalk and slate pencils. They generally
have cold hands and feet and are subject to.chilblains; biliary
Secretion is tardy and constipation habitual. Many hysterical
Women only go to stool once or twice per week, and in excep-
tional cases constipation may last even for a fortnight or three
weeks. There is generally a large accumulation of gas in the
intestines, giving rise to colic or belching. Pain in the epi-
gastrium, which is very tender to touch, is much complained
of, and is worse after emotion or walking, but not after meals.
There is almost always pain at the level of the middle part of
the false ribs on the left side, which the patient generally de-
scribes as pain in the heart, and which the physician is apt to
consider as inflammation. Pain at the left side of the spine,
near the transverse processes of the vertebrae, is also a very
constant symptom. Abdominal pulsation is frequent, and
menstruation generally troublesome. The blood also is often
impoverished, the pulse being quiet, small and feeble. There
is always great nervous excitability in these patients. The
Smallest contrarieties of daily life, which have scarcely any
effect on other people are sufficient to upset them. A trifling
variation in the day's temperature, a shower of rain, a change
in plan, or any disappointment is enough to make them
miserable.
The mental condition of these patients thus becomes after
a time considerably perverted. They feel depressed and low
spirited; they find it difficult to fix their attention on any sub-
ject; they cannot read a serious book; their conversation be-
comes disconnected, their judgment incorrect, their character
capricious and irritable. They become extravagantly fond of
sensational novels, of balls, concerts and theatres and neglect
the graver duties of life.
One of the most frequent forms of spasm is the well known
“globus hystericus.” Ziemssen says that this symptom is only
absent in a few of the hysterical, but in individual cases is
very variable in its character and in the frequency of its re-
currence. Patients usually have the sensation as if a foreign
body, generally of the shape of a ball, passed upward from the
stomach or some part of the digestive canal, and remained im-
FIYSTERIA. 373
pacted in the region of the throat. The ball frequently arises
in this part, without changing its position further. After con-
tinuing for a time, the feeling gradually becomes less marked,
or suddenly vanishes. The ball seems to flatten. Sometimes,
instead of this sensation, only that of a tightening in the
throat exists, similar to that which so easily develops itself in
the healthy from emotions of anxiety or fear. Some patients
do not feel the movement of a ball, but of some other differ-
ently shaped body, such as a kernel, a bean, or of some animal
Creeping about in the throat. Not rarely the sensation of
Something present is so distinct that patients think they can
pull it out of the throat with their fingers. The entire phenom-
enon is apparently caused by peristaltic contractions of the
Oesophagus passing upward, and partly by a circular tighten-
ing of the pharyngeal muscles. It is almost always present as
a forerunner of a so called “fit of the hysterics.” It occasion-
ally also takes place in a reflex manner, and may occur in
Some patients while eating; occasionally particular kinds of
food produce the lump, and now solid and at other times liquid
food can most easily be taken. The globus occurs not only in
the throat, but also in the abdomen, as the sensation of a body
rising from the region of the symphysis toward the stomach.
Some will declare that they distinctly feel the womb pass up-
ward to the stomach, and then arrive at the throat, a declara-
tion which forms a basis for the oldest theory of hysteria. We
meet also with spasmodic strictures of other parts of the body,
causing retention or emission of urine, singultus, vomiting, etc.
One of the peculiar features of hysteria is what may be
termed its paroxysms or convulsive attacks. Such attacks
Sometimes take place without a demonstrable cause; in other
cases they are the result of over-excitement of the most varied
description, occurring after painful emotions, ill-treatment,
terror, fright or some shock. The consciousness of being un-
der observation, and the desire to attract attention may cause
an increase or exaggeration of this, as of all other hysterical
symptoms. In many patients an increased tendency is shown
at the menstrual periods. There are two forms of this attack.
The first of these has a general resemblance to an epileptic fit.
374 INSANITY AND ITS TREATMENT.
The trunk and limbs of the patient are agitated with strong
convulsive movements; she struggles violently, like a person
contending; rises into a sitting position, and then throws her-
self back again; forcibly retracts and extends her legs, while
her body is twisted from side to side; and so powerful are
these muscular contortions that frequently it is all three or
four strong persons can do to restrain a slight girl and pre-
vent her from injuring herself or others. The head is gener-
ally thrown backwards, and the throat projects; the face is
flushed; the eyelids are closed and tremulous; the nostrils
distended; the jaws often firmly shut, but usually there is no
distortion of the countenance; the cheeks are at rest, unless
when, as often happens, the patient is uttering screams and ex-
clamations. If the hands are left at liberty, she will often
strike her head repeatedly and quickly, or carry her fingers
to her throat as if to remove some oppression there; or she
will sometimes tear her hair, or rend her clothes, or attempt
to bite those around her. With all this, her breathing is deep,
laboring and irregular, and the heart palpitates. After a short
time this violent agitation is calmed; but the patient lies
panting and trembling, and starting at the slightest noise or the
gentlest touch; or sometimes she remains motionless during
the remission, with a fixed eye, till all at once the convulsive
movements are renewed, and this alternation of spasm and
quiet will go on for a space of time that varies considerably
in different cases; and the whole attack frequently terminates
in an explosion of tears and sobs and convulsive laughter.
“There is a variety of this form of hysterical paroxysm, in
which the patient sinks down suddenly insensible and without
convulsions; with slow and interrupted breathing, a turgid
neck and flushed cheeks; and she recovers from that condi-
tion depressed in spirits, fatigued and crying.
In the form above described the symptoms strongly indi-
cate functional disturbance of the nervous system, but in
another form the symptoms are referable to the abdominal
and other viscera.
“The patient experiences a sense of uneasiness in some part
of the abdomen, frequently towards the left flank; a ball ap-
HYSTERIA. 375
pears to roll about, and to rise first to the situation of the
stomach, and then to the throat, where the patient feels a
choking sensation; the act of swallowing is frequently re-
peated; the abdomen becomes distended with wind, loud
rumblings and sudden eructations take place; there is much
palpitation of the heart; the patient is sad and sorrowful and
prone to shed tears.” As has been intimated before, after the
paroxysms, these patients usually void a large quantity of
limpid pale urine, looking almost like water; and this is
sometimes expelled during the fit.”
The convulsive attacks described above, are often confounded
with epileptic seizures, and it is important to understand the
points of difference.
“Hysterical attacks occur almost always after painful emo-
tions, ill-treatment, terror, fright or some other great mental
or physical shock, while epileptic attacks come on without
any appreciable cause. The starting point of the hysterical
attack is generally the epigastrium, while the epileptic attack
occurs either without any warning, or with an aura of a differ-
ent kind, which mostly starts from the limbs. In the hysteri-
cal attack the loss of consciousness is preceded by globus and
a feeling of Suffocation; in the epileptic it is sudden. The
epileptic patient falls down as if struck by lightning, no matter
where he may be; the hysterical patient has almost always
time to find a suitable and comfortable place in which to fall.
The epileptic convulsion is a sort of tetanus which does not
resemble physiological movements, and scarcely ever lasts
more than five or ten minutes; the hysterical convulsions
always mimic physiological movements, and last from fifteen
minutes upwards. At the end of the epileptic attack the
patient falls at once into a deep coma, or he recovers con-
sciousness at once, and feels shaken and exhausted; at the
end of the hysterical attack there is generally an attack of
crying and sobbing. Finally we observe that after the hys-
terical attack, urine of a peculiar character is passed, which is
not usually the case after the epileptic. The chief peculiarity
of this urine is its great abundance, amounting to a pint or
more at a time. This urine is clear and colorless; almost
376 INSANITY AND ITS TREATMENT.
inodorous and tasteless; it has a specific gravity of about 1000,
and consists of scarcely anything but urinary water. The
cause of the large increase of the water is a spasm of the
capillary vessels of the skin, which contain less blood than
usual, and therefore send additional work to the kidneys.
This spasmodic condition may also in some cases cause profuse
perspiration, as in a case I will relate later. An important
sign is also that the epileptic generally dislikes to speak of his
attack or discuss his condition, but the hysterical patient has
no such objection. Keeping in mind these points, you ought
to have no difficulty in determining the character of the at-
tack. During the convulsive paroxysm the patients are often
seized with a delirium which has been compared to that
caused by the use of chloroform. The patient is always rest-
less, noisy and sometimes, though rarely, incoherent. The
delirium has relation generally to places where, or persons
with whom, the patient thinks herself to be; it is like a wak-
ing dream.
If we are called to see a patient during a fit, and have no
knowledge whatever of the history of the case, the following
points laid down by Dr. Watson will enable you to decide be-
yond mistake. He says: “In the epileptic paroxysm the face
is usually livid, and foam which is frothy with air, or red with
blood, escapes from the patient's mouth. These are symptoms
which we do not see in fits of hysteria. In epilepsy again
the convulsive movements are commonly more marked on one
side of the body than the other, and the same movements are
rapidly repeated; there is a strangling rattle in the breathing,
while in hysteria the forcible flexion and extension of the
limbs, and the contortions of the trunk, are more sudden, and,
as it were, capricious; the respiration is deep, sighing, mixed
with cries and sobs, and often with laughter. But, perhaps,
the convulsive motions differ most in the face. The epileptic
expression is usually frightful; the eyelids half open, the eye-
balls rolling, the mouth drawn to one side, the teeth grind-
ing, the gums exposed by the retraction of the lips, the tongue
protruded and bleeding, the complexion leaden; while in hys-
teria the cheeks are red, but at rest; the eyelids are closed and
FIYSTERIA. 377
trembling; if you raise the upper one you will see the eye
fixed, perhaps, but it is bright and very different from that
of the epileptic, which, if it be not rolling, is dull, projecting
and the pupil usually dilated.”
You will also have to be on your guard not to confound
heart disease with heart symptoms caused by hysteria. “The
cardiac affections which you will most frequently find simu-
lated are valvular lesions, dropsy, and alleged displacement of
the heart. Dr. Ludlam tells us that “when they do exist, the
symptoms of valvular disease of the heart in hysterical sub-
jects are almost invariably associated with chloro-anaemia.
The blood is impoverished. The rhythm of the heart's action
is disturbed, and there is a fluttering and praecordial oppres-
sion, palpitation and an exaggerated impulse against the
thoracic parietes. In chronic cases there may be dropsy of
the feet and of the face.
“Physical exploration will enable you to decide between
real and spurious lesions of the valves. (In bona fide disease
of the valves, either the first or the second sound of the heart
is impaired in its quality, or its place is supplied by an ab-
normal murmur. If the first of these is implicated or super-
seded, we know that the auriculo-ventricular valves are dis-
eased; if the second sound is changed, that the semi-lunar
valves are the seat of the difficulty. In hysterical affections
which counterfeit this form of endo-cardial lesion both the
cardiac sounds are normal. With the first sound of the
heart, however, we note the soft bellows-murmur of anaemia.)
“Women who are supposed to have dropsy of the heart
sometimes complain of great difficulty of breathing after ex-
ercise, of Orthopnoea, of Cramping-cutting pains in the cardiac
region, of stifling Sensations, of a stoppage of the heart's ac-
tion, or of a feeling as if it had suddenly turned topsy-turvy,
of gurgling, and even as if the heart were pulsating in a col-
lection of water; and yet all these symptoms may be found to
represent a spurious affection.
“Then, too, it is not uncommon for a hysterical patient to
complain that her heart is displaced. And this may annoy
her exceedingly. The mal-location may appear to her to be
24
378 INSANITY AND ITS TREATMENT.
either transient or permanent. Emotional influences “bring
her heart into her mouth.” She suffers from violent palpita-
tion and sometimes from abnormal pulsations in different
parts of the body. Her general appearance is healthy, her
habit is plethoric, and her looks belie her sensations. The
anaemic murmur is sometimes so distinctly heard by such a
patient as to induce the belief that her heart is actually dis-
located.” I think you will find the majority of such patients
to be inveterate tea drinkers, or even tea drunkards.
Partial or complete loss of muscular power is of frequent
manifestation in hysteria and invades by preference the left
side of the body. Hysterical hemiplegia is by no means rare,
and occurs either suddenly, after painful emotions and hysteri-
cal attacks, or it creeps on slowly and unawares. It differs
from hemiplegia due to cerebral disease from the following
points. There is no distortion of the face nor a deviation of
the tongue from the median line. The paralysis is scarcely
ever complete, and in the large majority of cases more severe
in the leg than in the arm. Moreover it is subject to consider-
able and sudden variations under the influence of emotions or
treatment. A woman with hysterical hemiplegia may, under
the influence of great excitement, get out of bed and walk
several miles, and then after the excitement has subsided
relapse into complete immobility. But no such thing is pos-
sible in a case of hemiplegia from intracranial disease. More-
over, in the hysterical affection there is generally great weak-
ness of sight, loss of hearing and senses of taste of the same
side, and partial or complete anaesthesia of the skin; but no
rigidity of the muscles. If an interrupted electric current is
applied to the muscles, they contract well enough, but the pa-
tients do not feel the passage of the current unless it be one of
great power. It is only in cases of very long standing that
the electric contractility of the muscles appears diminished.
Hysterical hemiplegia is often accompanied by retention of
urine, pain in the head, and numbness. Sometimes there are
sensations as of pins and needles in the paralyzed parts; and
at the commencement there may be febrile symptoms, with
sleeplessness and great disturbance of the digestive function.
HYSTERIA. 379
Hysteria paraplegia is sometimes confounded with paraple-
gia from myelitis, and other diseases of the cord. Such a
mistake should be carefully guarded against. The following
are some of the chief points of difference: The commence-
ment of hysterical paraplegia is always accompanied by
severe headache, showing the part played by the brain.
Moreover there is neither tremor during rest, nor spasms in
walking. The lower limbs, too, are feeble; the knees give
way under the body, and the feet drag on the ground. The
patient is generally able to move the legs well enough when
in bed, and may even get out of bed with ease, but after
taking a few steps the limbs give way, the gait becomes totter-
ing and the patient falls. Concomitant symptoms are anaes-
thesia of the skin and muscles of the lower extremities,
tympanites, constipation, dysmenorrhoea and retention of
urine.
By far the most common form of hysterical paralysis is
that which affects the vocal cords and the muscles of the
larynx, and is known as hysterical aphonia. It almost always
appears suddenly, after Some violent emotion, or after taking
cold; and it may last only an hour or two, or be protracted
for years. I have found this form of hysteria to frequently
affect women during the climacteric, and Lachesis is the
remedy that has done me the best service. It is not difficult
to distinguish this kind of aphonia from that due to laryn-
gitis or other structural diseases of the larynx, such as indura-
tion, thickening, etc., for an examination with the laryngo-
Scope will reveal a normal condition of affairs; in such cases
there is a total absence of any structural lesion, the vocal
cords being merely flaccid and incapable of movement. In
order, however, to assist in making the diagnosis, especially in
those cases where the use of the laryngoscope may be difficult .
or impossible, I will point out the points of difference be-
tween hysterial aphonia and aphonia from laryngitis, as
given by Dr. R. Ludlam:
380
INSANITY AND ITS TREATMENT.
APEIONIA FROM LARYINGITIS.
1. Febrile disorder; a quick pulse.
2. The loss of voice is sudden and
complete in proportion to the extent
and violence of the inflammation. The
aphonia disappears slowly, and is apt
to become chronic.
3. There is more or less cough and
expectoration, which are paroxysmal,
and vary in character in different
stages of the disease.
4. The inspiration is noisy, harsh
and stridulous. At an early period it
may be croupal, but later it is less
labored and softer.
5. The dyspnoea is attended by an
anxious expression of countenance.
She may have fits of suffocation.
6. There is complaint of angina.
The fauces and uvula are congested
and inflamed, with tickling, raw or
burning sensations, which extend into
the larynx and trachea.
7. Pains referred to the pomum
Adami. The pains are sticking and
lancinating in character.
8. The anterior surface of the neck
is sore and tender to the touch, and
she will not permit one to handle it
roughly.
9. In the acute form the aphonia
generally results from taking cold.
10. Has no necessary connection
with spinal irritation.
BIYSTERICAL APPIONIA.
1. Absence of fever; pulse normal.
2. The aphonia comes and goes
abruptly, and without leaving any
local lesion or sequel behind it. The
relief is sudden and perfect.
3. Cough is rare in this form of the
disease. There is no characteristic
expectoration.
4. The inspiration is heaving, sigh-
ing and spasmodic, the ràle being
moist and softened in its tone.
5. The features are calm and inex-
pressive. She is more liable to syn-
cope than suffocation.
6. There is a complete absence of
faucial and tracheal inflammation and
suffering.
7. There is no complaint in or
about the larynx.
8. Globus hystericus with clutching
at the throat. She tears away the
clothing from about the neck.
9. Never results from this cause
unless it has first given rise to some
menstrual or uterine disorder, upon
which the aphonia is secondary.
10. Generally accompanied by symp-
toms of spinal irritation, and by ten-
derness upon pressure on some of the
cervical and dorsal vertebrae.
Such cases of hysterical aphonia are generally relieved at
once by the application of galvanism.
You will find hysterical affections of the joints to be very
common. Sir Benj. Brodie, the distinguished English sur-
geon, said that among the higher classes of society, at least
four-fifths of the female patients who are commonly supposed
to labor under diseases of the joints, labor under hysteria and
HYSTERIA. 381
nothing else. In very many cases the true state of things can
only be discovered by placing the patient under the effect of
ether. I have known surgeons of national reputation to be
deceived in such patients, and counsel even amputation of a
limb; and later seen the same patient cured by faith in the
powers of a so-called “magnetic physician.” And I may say
here, that the harvest field for the so-called miraculous cures
of these traveling charlatans is found among those persons
laboring under the different forms of hysteria.
We now come to the mental disturbances which are many
and various. We have, first, the changes of the character and
of the intellect resulting in long continued cases of hysteria,
which only stop short of insanity; second, the temporary de-
lirium which arises during the convulsive paroxysm, and of
which I have already spoken; and third, the mania, melan-
cholia, and the partial deliriums which, being developed with
the hysteria, place their special imprint upon that neurosis,
but at the same time are not connected with the convulsive
paroxysm.
When the attacks are infrequent, and the disorder not of
long standing, the hysterical person may appear in brilliant
health. Still, nearly all are nervous and restless; very sus-
ceptible and of a vivid imagination; easily fretted about trifles,
impatient, irascible, obstinate and headstrong. The senses,
too, are very acute; a very strong light, certain Sounds, odors,
variations of temperature, the electricity in the atmosphere—
all affect them strongly; while any serious occupation is ex-
ceedingly irksome and causes headache. Sleep is very rarely
sound and refreshing; often it is disturbed, troubled by pain-
ful dreams and broken by sudden starts. For the most part
they are melancholy in temperament, given up to depressing
thoughts, sometimes even with vague ideas of suicide. Others,
on the contrary, are extremely gay and constantly laughing
at the least trifle, or even without any cause; others again are
given to tears.
We also meet with neuralgias, spasmodic swelling of the
throat, difficulty of breathing, profound inspirations, palpita-
tion, vertigo, stomach disorders and constipation. The men-
382 INSANITY AND ITS TREATMENT.
strual flow is often irregular, or if regular, it is of short dura-
tion and painful, and accompanied with headache, malaise,
and irritability of temper. We should also speak of the tend-
ency of the hysterical person to indulge in hyperbole, and to
invent the most romantic and extravagant stories. Their fierce
and ungovernable desires recoil before nothing; the facility
with which they give themselves up to eccentric acts, and the
erotic ideas which often come to complicate the disease and
become the starting point of new passions.
Beside the usual symptoms found in cases of hysteria or of
mania when existing separately, there are others which appear
characteristic of a combination of the two disorders. Thus
the uneasiness of such patients, whilst not reaching the point
of rage, is yet marked by an incessant need of moving, and
activity; by a strong tendency to break, destroy, and upset
everything within reach. The patients complain of a diffi-
culty of breathing, and in the midst of the periods of restless-
ness have real convulsive paroxysms which greatly aggravate
the intellectual disturbances. In the more calm and peaceful
moments erotic desires, without being constant are frequently
present in a marked degree. Young girls, even the most re-
served and ladylike will experience a passion for their physi-
cian, or the first person they meet; the sound of the voice, or
even of the footsteps of a man will affect them strongly and
throw them into a state of passionate desire ; their thoughts
run upon marriage, their eyes become moist and confused,
their gestures alluring, and they offer a singular contrast of
modesty and boldness; often indeed they go so far as to talk
of husband and children, when they have neither; and even
imagine themselves pregnant and about to be delivered.
Aside from these points hysterical mania presents the same
course and termination as does mania in general. Sometimes
a cure takes place rapidly, but more frequently the case runs
into a chronic state of protean nervousness in which the intel-
lect is more or less disturbed.
General melancholia is not common, but we find a partial
delirium ; with or without hallucination. Some patients have
troubles of taste and smell; are pursued by fears of being
HYSTERIA. 383
poisoned and experience feelings of hatred and revenge to-
ward those around them. Others are tormented by scruples
of conscience; accuse themselves of crimes that they have not
committed, and even attempt suicide. Such conditions are
generally curable.
When hysteria is developed in any place where many im-
pressionable women are gathered together, it easily becomes
epidemic, and the hysterical convulsions, the hallucinations,
ideas of diabolical possession, ecstacy, etc., are easily spread
through crowds by the faculty of imitation, and I should earn-
estly advise you to read the history of some of the epidemics'
of this kind.
The following case is reported by Dr. F. W. Payne: “A pa-
tient who had been under allopathic care was placed in my
hands for treatment. She was lying in an apparently uncon-
scious state, the limbs and jaws rigid; the forearms flexed on
the arms, which were firmly pressed to the side; the eyes
fixed and drawn somewhat to the right; eyeballs slightly sen-
sitive to touch ; a constant succession of tears rolling down
the cheeks, and the beat of the heart very irregular and feeble.
She would occasionally utter a groan or a sigh, and press her
hand forcibly over the region of the heart as if suffering there.
At other times the limbs would become relaxed, and she
would frequently raise herself in bed and gaze vacantly about
the room for a minute, and then, if not restrained, would
throw herself forcibly upon the pillow again, or fling herself
from one side of the bed to the other, which latter, by the way,
is a very common symptom. After twenty-four hours this
form of attack ceased, and she became very busy packing and
folding her bed-clothes, and placing them carefully under her
head, or elsewhere about the bed, at the same time guarding
them with watchful eye, allowing no one to touch or take
them. If this were attempted she would strike with her full
strength. She was frequently talking, laughing loudly, or scold-
ing vehemently; would imagine herself surrounded by many
friends, shaking hands with them and calling them by name.
She asked no questions and returned no answers. During
this time, which lasted four days before relief was given, she
384 INSANITY AND ITS TREATMENT.
took no nourishment voluntarily. After several remedies had
been unavailingly given, the irregularity and feebleness of the
heart's beat drew attention to Hydrocyanic acid”, which was
given with the most favorable result. She had no more
threatenings for four months; then she commenced as before,
but the attack immediately yielded to one dose of Hydrocy-
anic acid”.”
Here is another and lighter case: “A lady about to be mar-
ried became very nervous from overwork and mental anxiety.
She had several hysterical attacks daily, among the symptoms
of which, the following seemed characteristic of the remedy
chosen. First, a twitching of the fingers; this extended into
the hands, arms; and body (down to the diaphragm), and con-
vulsive remittent shaking of the upper part of the body and
of the arms. Gave Cuprum", a dose just before and just after
each paroxysm. That day she had three, the next day one,
and the last a light one, a week later.”
Some medical men are very apt to advise their hysterical
patients to marry, as if marriage were a panacea for all ills,
but this is a mistake; for we know that not only many mar-
ried women are hysterical, but in many cases the malady is
only developed after marriage; and is consequent upon the
unpleasant emotions apt to arise in that state when it is en-
tered upon from the motives and feelings so often prevalent.
We must also remember that an hysterical wife will be apt to
prove to be anything but a source of comfort or happiness to
her husband and any family she may have; that there is great
tendency to miscarriage in hysterical women, that their child-
ren are often stillborn, and that if they live, they are gener-
ally delicate and sickly, and liable to inherit hysteria and
other nervous affections. Marriage acts beneficially in those
cases where the home surroundings of the patient are unfavor-
able, and when in consequence of marriage she is rid of all
trouble, anxiety and painful emotions.
MEDICAL TREATMENT.—In our treatment we should distin-
guish between the hysterical condition and the hysterical fit.
The latter is by far the more easily controlled as you would
Suppose.
E[YSTERIA. 385
Asaf will help in hysteria of young women complaining of
a gone empty feeling in the epigastrium, which is not a pain,
but “it hurts them”; pulsations in the same place, which come
on about eleven o’clock and make them feel faint.
For the nervous condition—general increased sensibility: Ignat.,
Cyprip., Sepia and Stramon.; for heightened sensitiveness: Coccul,
Stramon., Platina, Pulsat., Acon. and Nux wom.; for irrita-
bility and impatience: Gelsem., Sepia, Pulsat., Nux wom., Hyosc.
Variable disposition: Ignat., Pulsat., Stramon., Moschus,
Platina, Sepia.
Constant brooding: Nux wom., Ignat., Sepia.
Constant and excessive dread: Acon., Pulsat., Platina.
Fidgety expectation: Valerian.
Persistent silence, or constant moaning and lamentation:
Nux wom.
BODILY CONDITIONS AND SYMPTOMs.
Constant troublesome sinking at the stomach: Asaf., Cimi-
cif., Gelsem., Hydrast., Ignat.
Shortness of breath and cold feet: Calc. carb.
Oppression of chest: Moschus and Ignat.
Sleeplessness: Cyprip., Gelsem., Ignat., Nux wom.
If we consider the cause so far as ascertainable, we find
fright: Acon.; disappointment and grief: Ignat.; prolonged
watching and nursing: Nux wom., Ignat, Cyprip.; intense or
continual mental strain: Cyprip., Phosphor, Cinchon., Nux
vom.; ovarian or uterine irritation: Cauloph., Cimicif., Bellad.
Bellad. will often be of marked benefit in controlling the
convulsive paroxysm.
I can of course touch only briefly on the indications for the
proper remedy, for as hysteria may simulate any disease under
the sun, you will find that no disease will require a more
searching study of your Materia Medica, but above everything
it is necessary that your patients should be built up by plenty
of good nourishing food to which they often object; and should
be placed in as pleasant a situation as possible, free from care,
anxiety and worry.
386 INSANITY AND ITS TREATMENT.
Hypochondriasis.
Dunglison gives the following definition of hypochondriasis:
“This disease seems to be a species of neurosis, and of mental
alienation, which is observed in persons who in other respects
are of Sound judgment, but who reason erroneously on what-
ever concerns their own health. Hypochondriasis is charac-
terized by disordered digestion, without fever or local lesion ;
flatulence; borborygmi; extreme increase of sensibility; pal-
pitations; illusions of the senses; a succession of morbid feel-
ings, which appear to simulate the greater part of diseases;
exaggerated uneasiness of various kinds; chiefly in what re-
gards the health, etc. The disease almost always appears at
adult age; most commonly in irritable individuals, and in
those exhausted, or rather in those in the habit of being ex-
hausted by mental labor, domestic work, etc.” All of which
reads very much like an account of hysteria as it appears in
women, but there are points of difference.
Much confusion exists in regard to the boundary-line be-
tween what is popularly called hypochondriasis and real
mental disease, and this is due to the way in which the two
diseases run together in real life; in a particular case it is diffi-
cult to tell when one ended and the other began; but properly
speaking the hypochondriacal states represent the mildest,
most moderate forms of insanity, and have peculiarities which
distinguish them from the other forms of melancholia. These
states share in the general characteristics of dejection, sad-
ness, depression of mind, diminished activity of the will, and
of a delirium which corresponds to this mental disposition,
they have these distinctive points of their own; that in these
states the emotional depression proceeds from a strong feeling
of bodily illness which constantly keeps the attention of the
patient concentrated upon himself; that, consequently, the
false opinions relate almost exclusively to the state of health of
the subject, and the delirium turns constantly upon apprehen-
sions of some grave malady; upon unfounded and curious
ideas regarding the nature, the form, and the danger of his
disease. This feeling of bodily illness is sometimes vague
EIYPOCEIONIDRIASIS. 387
and general; sometimes it applies itself to particular parts
and organs. It often depends on irritation of the nervous
centres arising from peripheral disease, often very obscure and
concealed, of the viscera. It is also provoked under the
direct influence of moral causes, such as reading medical
books, meeting other hypochondriacs, etc. Occasionally medi-
cal students will have an attack of hypochondriasis lasting
for months, induced by reading about various diseases, and
then searching for their likeness in himself.
These morbid sensations are always increased through the
direction of the attention to them, and, when the disease has
become fully developed, such sensations may, through the
direction of the attention to this or that organ, be awakened,
displaced, and called forth anew in each organ of the body in
succession. As to the part which the intellect plays in this
disease, it may be said that in spite of this emotional disorder,
and of the false conceptions, the association of ideas is unim-
paired; the abnormal sensations and ideas are logically con-
nected throughout and justified by reasons which are still
within the bounds of possibility.
Many physicians, and people in general, look upon all the
complaints of the hypochondriac as depending upon pure im-
agination and illusive sensations, but this is entirely errone-
ous and mistaken, for the hypochondriac really feels and ex-
periences all the pains, all the disagreeable sensations, in a
word, all the morbid symptoms which he describes, and this
corresponds to an objective reality in the condition of the
organ affected. The mistake in the case of hypochondriacs
does not lie in the physical sensations, but the diagnostic con-
clusions which they draw from these; inasmuch as they
ascribe their sensations to this or that organic disease from
which they suffer. Therefore if any hypochondriac complain
of oppressed breathing; pains in the stomach, or abdomen;
headache or the like, we may presume that these affections
really exist; but should he, therefore, conclude that he is
affected with consumption, cancer of the stomach, heart disease,
or softening of the brain, the error lies in his conclusions, not
in his feelings. Still the disease does not depend on these
388 INSANITY AND ITS TREATMENT.
conclusions, but on an abnormal dread of disease, and an
anzious solicitude about his health; in consequence of which,
the patient greatly over-rates his bodily feelings and sensa-
tions, and immediately dreads from the slightest pain and
the most unimportant functional disturbance, the most serious
results. Hence also the anxious care and minute attention
with which all the patients of this class observe the functions
of the different organs of the body, examine their urine, feces,
expectoration, etc. Almost constantly occupied with the state
of their health, they readily believe themselves afflicted with
every disease of which they hear; and constantly read medi-
cal books; they have a great propensity for acting as their
own physician, and keep dosing with patent medicines. He
often feels his pulse, examines his tongue and frequently finds
in these investigations causes for hope or fear, which he takes
pleasure in relating to those around him. The great desire to
be cured induces frequent changes in his physician, and he
often changes his opinion as to the nature of his disease, as he
applies to his own case all he reads of or hears. Hence the
disposition of the patient undergoes a marked change; he be-
comes dejected, sorrowful, morose, low spirited, fearful, suspi-
cious and uneasy. Everthing wearies him, and he is very
easily fatigued. At the commencement this state experiences
many remissions; and the paroxysms assume the form of an
irritable, restless, and distrustful disposition, or of a mental
apathy which may go so far as to produce a weariness and
disgust of life. An undefined yet vivid feeling of illness tor-
ments and annoys the patient in an obscure manner. All
sensations are watched and seriously commented upon, and
analysed in the sense of the ruling gloomy and anxious frame
of mind, and he often expresses his fears with an exaggeration
of which he himself is half aware, and in the most graphic
and ludicrous manner. The patient who exhibits only the
most insignificant symptoms of disease, speaks of apoplexy,
asserts that he is half dead, that his heart is dried up, or pet-
rified; his nerves are burning coals, etc. Many spend hours
before the glass examining their features, complexion and
appearance of tongue. Others, again, may refrain from all
EIYPOCHONDRIASIS. 389
mental exertion or loud speaking, will not rise from bed, or
eat a morsel for fear of aggravating their condition.
It may, in some cases, be very important to distinguish be-
tween hypochondria and melancholia; for a person suffering
from the former would most likely be hanged were he to
commit murder, while the latter would be sent to an asylum.
Prichard, one of the older writers, thus clearly marks the dis-
tinguishing line; he says “that a hypochondriac is in full
possession of his reason, though his sufferings are not so
dangerous or so severe as he supposes; but if he declares that
his head or his nose has become too large to pass through
a door-way, or displays any other hallucinations, he is a
lunatic; his disorder has changed its nature.” Hypochon-
driacs, however, low-spirited or dejected, also suffer differently
from persons affected with melancholy. The apprehensions
of the former are confined to their own feelings and bodily
health. On other subjects they converse cheerfully, rationally
and justly. But melancholics view all things through a gloomy
medium. They despond on all subjects, and are mentally
miserable, and independently of any severe bodily sufferings.
The affections and sentiments of the hypochondriac, especi-
ally to his former friends and connections, are not in the un-
natural or perverted state observed in all forms of insanity.
Beside the mental peculiarities, we have, as has been stated,
innumerable morbid symptoms of the various organs. Thus,
for instance, the digestion suffers, the tongue is loaded, the
appetite increased or diminished, the bowels are constipated
and digestion is accompanied by great development of gas,
whereby tension is produced in the hypochondriac regions,
pushing up of the diaphragm, and causing a feeling of op-
pression. Such persons are very often afflicted with hemor-
rhoids, abdominal pulsations, palpitations of the heart, cere-
bral congestion and disturbed sleep. In many cases it is
impossible to decide whether, and to what degree, these varia-
ble symptoms are due to such primary disorders of the viscera
under the influence of which the hypochondria has arisen, or
how far they are due to some central cause in the nervous
system. The physician has always to make a most careful
examination of all the suspected organs.
390 INSANITY AND ITS TREATMENT.
It is evident that the disorder may arise in two different
ways—either from some physical cause, or mental, but usually
from a combination of the two.
Hypochondriacal states are extraordinarily frequent in
young people, and more rare in advanced life, and they are
more rare in women than in men, it seeming to be among
men what hysteria is to women; but neither disease confines
its attention to one sex.
The remedies spoken of under the head of melancholia
will come well in play here; but one or two will be of special
value:
1. Nuſc. vom. will occur to the minds of you all as present-
ing a similar picture to the one we have just been describing;
it has: Ill-humor and displeasure, with despair and disgust of
life, or with great wrath or irritability; indolence and repug-
nance to every movement and occupation, with incapability
for mental exertions, and great prostration; inquietude and
solicitude on account of his disease, and constant inclination
to speak of his condition, and to complain of his sufferings.
Dulness of head, and pressive pain, as if a nail were driven
into his head; painfulness of hypochondria and the upper
part of the abdomen; constipation and hemorrhoids.
2. Lycopodium is called for by a marked hypochondriacal
mood, with sorrowfulness and inclination to feel unhappy;
thoughts of death and dread, with anxiousness at the heart;
distention of abdomen, with collection of gas and rumbling.
Tension in hypochondria as from a hoop.
Calc. carb., Cinchon., Natr. carb. and Sulphur will frequently
be called for according to the characteristic symptoms of each.
According to Dr. C. P. Hart, the remedies most frequently
called for will be found in the following list:* Anacard., Arsen.,
Asaf., Aurum, Calcarea, Cannab. ind, China, Cimicif., Conium,
Ignat., Mercur., Natr. mur., Nux wom., Petrol., Platina, Pul-
sat., Sepia, Stannum, Staphis., Sulphur.
“Asafoetida.-Hypochondriasis attended with flatulence, tor-
por of the liver, indigestion, constipation, loose cough and
great depression of Spirits.
* Diseases of the Nervous System, by Chas. P. Hart, M.D.
HYPOCHONDRIASIS. 391
“Aurum.—This remedy is best suited to male subjects, espe-
cially such as have a loathing of life, or a suicidal tendency;
they are extremely melancholy, fearful, taciturn and sullen.
Its sphere also embraces religious melancholy, with vertigo,
anaemia, and vascular and nervous depression.
“Cannabis ind.—Strange illusions concerning one's health ;
great depression of Spirits, amounting to despair, with appre-
hension of approaching death; constantly studying his own
symptoms and theorizing about them; religious melancholy;
depraved appetite, with pain in the stomach, flatulency and
cold extremities.”
Nua, vomica.-According to Baehr, “holds the first rank
among anti-hypochondriac medicines. It corresponds most
completely to all the symptoms of the digestive apparatus, to
their appearance after a meal, to the disposition to gaseous
flatulence and to constipation. Other circumstances of great
moment are: the origin of the hypochondria from sedentary
habit; deficient exercise with rich living and excessive men-
tal exertions; use of stimulants in order to keep awake nights;
moreover the excitability of the temper which induces an
ebullition of anger from the least provocation; continual cloudi-
ness of the head, with more or less prominent signs of cerebral
congestion, more particularly in the case of patients who are
fond of wine and good living.”
Stannum.—Of this remedy Hartmann says: “It frequently
has a marvellous effect in various spasmodic hypochondriac
ailments, which mostly originate in the ganglionic system.
By walking about, the patient is greatly relieved, whereas his
distress returns again in a state of rest, which he would like
very much to indulge, in, owing to his feeling continually
weak and weary, both mentally and physically; this makes
him sad and melancholy, and he often feels so discouraged
that he could almost weep. If with these symptoms are asso-
ciated a stupefying pressing distress in the brain, as if the
skull were in a vice, or other abnormal sensations in the brain,
illusions of hearing, distress in the stomach, with irregular ap-
petite, feeling of emptiness in the abdomen, constipation, ex-
hausting night-sweats, etc., the patient feels in the highest de-
392 INSANITY AND ITS TREATMENT.
gree miserable, and by exaggerating his ailments, renders life
disagreeable to those around him. It is to this kind of hypo-
chondria that Stannum will be found to correspond, and where
it will always be found effective.”
Staphisagria.-This remedy, according to Berjeau, may be
employed when there is hypochondria resulting from mas-
turbation, with great taciturnity; constant uneasiness as to
the state of one's health ; anxious imagination; imaginary
fears; queer notions that expose the patient to the suspicion
of being thought crazy; great deficiency of animal heat, and
tendency to take cold ; or when the memory is weak and con-
fused, and there is giddiness and sleepiness; the eyes are deep
sunken, red and lustreless; the hair falls off; there is gnaw-
ing toothache, and caries of the teeth, which are very brittle ;
a dry cough, aggravated frequently after eating, and indigest-
ion attended with great flatulence, the stools being dry and
lumpy. The urine is of a deep red or yellow color, with
brick-dust sediment; there is continued loss of prostatic fluid,
and the sexual desire is impaired; the penis is relaxed,
with dull and contusive pain in the testicles.
Dr. C. P. Hart says: “This remedy takes high rank in all
cases of hypochondriasis attended with seminal emissions,
weakness of the lower extremities, and great prostration of
mind and body, the result of having led a dissolute life.”
CHOREA. 393
LECTURE XVII.
Chorea. Catalepsy. Somnambulism.
Chorea.
(In the preparation of the following lecture I have drawn
largely from a paper by Dr. J. C. Burgher, of Pittsburgh,
published in the Transactions of the American Institute of Hom.,
in 1877.)
To-day we will consider somewhat briefly a form of nervous
disease which in many respects resembles hysteria and which
like it is characterized by abnormal muscular movements
and, in most cases, a disturbed mental condition. I refer to
Chorea, called also St. John's dance, or St. Vitus' dance; this
latter name being given from the Sicilian Saint Vitus whose
remains were believed to rest in a convent in Westphalia, to
which pilgrims from all parts of the world were attracted in
order to be cured of the dancing mania, such as was so widely
spread as an epidemic in the middle ages.
We understand by chorea, a neurosis, of which the seat may
sometimes be the brain alone, sometimes the entire nervous
system, characterized by incessant twitchings or jerkings of
groups of muscles, which sometimes are spontaneous in their
origin, and sometimes are excited by voluntary impulse,
which occur almost exclusively in the waking state, and are
accompanied by a more or less developed mental disturbance.
It is a very unpleasant disease, but, as a rule, neither painful
nor dangerous, and is not attended with fever. The patient
is neither deprived of consciousness nor volition. The ordi-
nary movements of the body performed under the guidance of
the will are disturbed and made uncertain; the voluntary ac-
tion is arrested and the limbs forced to take another direction,
rendering the movements uncertain and imperfect. All the
voluntary muscles of the body are obnoxious to these irregular
clonic spasms.
25
394 INSANITY AND ITS TREATMENT.
Chorea is essentially a disease of childhood, and though
cases are on record where it has affected new-born children
and even the aged, yet three-fourths of the cases occur between
the periods of the first dentition and puberty. Niemeyer says
that it is most frequently met with between the ages of six
and fifteen. Girls are more subject to it than boys, in the
proportion of nearly three to one; perhaps on account of their
more delicate organization and the preparative changes going
on before menstruation.
The beginning of a simple case of chorea may be as follows:
The patient, a boy of about ten years, who attends School,
becomes irritable, loses his appetite and does not care to go
out and play with his mates. He becomes pale and thin,
and sits by himself. His temper undergoes a marked change;
he becomes morose, irritable, fretful, lazy, forgetful, and com-
plains of headache, dizziness and chilliness. There may also
be palpitation of the heart, loss of appetite and general
restlessness. In a little while some movement of the hand
or fingers, some twitching of the face or dragging of one foot
when he walks attracts the notice of parent or teacher. He
may be punished, with the idea that such movements are the
result of bad habits or viciousness, but instead of doing good
it only increases the trouble. These jerkings and convulsive
movements cease at night, when he rests uneasily and is dis-
turbed by bad dreams. This is generally the condition we
find when summoned to see our patient. What next is the
natural unchecked course of the disease? If neglected it will
not be long before the movements become general; in some
cases the muscular dance is so severe that voluntary move-
ments are utterly impossible and the patient becomes helpless.
He cannot sit, stand or lie down with comfort, and in walking
the feet may drag along as if paralyzed. If he attempts to
stand his knees give way and he drops to the ground; and the
whole body is so plunged, jerked and shaken about that he
cannot even sit still on a chair, and is thrown out of bed when
lying down. He may have to be dressed like a baby, and his
clothes are so much pulled and rubbed about the body that
abrasions of the skin and eczematous eruptions are often pro-
duced.
CHOREA. 395
The vocal cords may be affected, and as a result there is a
certain degree of aphonia, so that the speech is husky and
subdued, though in some cases it is shrill and Squeaky. In-
coordination of the lips and tongue give rise to difficulties in
articulation which are quite distressing, the words being
“snapped ” and cut short.
In most cases, however, voluntary motion is not entirely
abolished, but only impeded. Although the involuntary
motion is incessant, the patient nevertheless succeeds in car-
rying out voluntary movements. It is true that he performs
them in an awkward, clumsy and roundabout way; the move-
ment which is intended is commenced, but is, before it can be
carried out, interrupted by spasms. The patient then begins
to manoeuvre, and succeeds after a time in accomplishing his
purpose; but at other times the effect of the will appears to
intensify the spasm, which from having been limited to the
face and hand may then involve the whole body. A simple
effort on the part of the patient to subdue the spasm, and to
keep his face and limbs quiet, is often sufficient to increase
the violence of the twitches.
The muscles of the face are usually first affected by contor-
tions, thus all kinds of physiognomical expressions are pro-
duced, according as the spasm affects the different muscles,
One after another, and the general impression produced on the
observer is decidedly laughable. The patient first frowns,
then laughs, squints, winks with his eyes, stares, moves his
nose from one side to another, grinds his teeth, puts out his
tongue and as quickly puts it back again, bites the tongue,
lips and inside of the cheek, and grins like a monkey. In
the muscles of the lower jaw the spasm is sometimes so violent
that teeth are broken out by it. Mastication becomes difficult
or impossible, and the first act of deglutition is impeded; the
mouth is distorted and the expression vacant. The speech
may become quite unintelligible. The patient begins a sen-
tence, but cannot finish it, because the tongue is in his way;
sometimes he is only able to pronounce one syllable at a time.
When asked to show the tongue, it is suddenly protruded and
a moment after as suddenly retracted. This sudden protru-
396 INSANITY AND ITS TREATMENT.
sion and withdrawal of the tongue, termed the “choreic
thrust,” is almost characteristic of the disease. He cannot sing
because respiration is jerky and explosive; the air is not prop-
erly husbanded, and although great efforts may be made, there
is no result except great fatigue, from excessive disorder in the
co-ordination of the muscles. Von Ziemssen has seen choreic
movements of the abductors and other muscles of the vocal
cords, and insufficient tension of the latter, by the laryngeal
mirror; and this explains why the voice should be changed in
character, monotonous and lowered in pitch.
In the progress of the complaint, a greater number of
muscles are implicated and the spasmodic action is intensified.
The muscles of the extremities and trunk are involved. The
patient writhes, twists the shoulders, and contorts the body,
the shoulder is drawn up and pushed down again, the arm
jerked about, and the hand and fingers thrown in all direc-
tions. The patient cannot put a cup of tea to his mouth
without a good deal of management, and is apt to spill it all
over himself or his neighbor, he is unable to work, write, play
on musical instruments, or button his clothes. The walk is
unsteady, one foot is rather dragged than lifted, and the
patient moves or sways from side to side, while the unequal
and irregular respiration show that the diaphragm and ab-
dominal muscles are also involved.
Allen McL. Hamilton says that he does not think the
choreic movements are always increased by the effort of the
will to stop them, and has been led to suppose that chorea
might be divided into two varieties, viz., one in which the
movements are increased with the exercise of the will, the
other when they are most violent in a state of rest. He con-
siders the movements of the hands characteristic. He says
there is a prehensile movement of the fingers and a rubbing
of the ball of the thumb and ends of the fingers. There is a
swinging of the arm, and a shrugging of the shoulder, as if the
patient had on large or uncomfortable underclothing. There is
a trivial point which may be of interest, and I mention it be-
cause it is unique. I allude to the habit which such patients
have of rubbing the seam of the trousers leg by the hand
CHOREA. 397
which is affected; for these movements go on where the arm
hangs by the side, and when the attention is not directed to it.
An interesting form of the disease is that known as hemi-
chorea, which is limited to one side of the body. It is most
frequently seated in the left side, which is also as a rule more
severely affected in bi-lateral chorea than the right; the uni-
lateral character is not confined to the extremities, but extends
to the face and the apparatus for articulation and swallowing.
In some cases the nerves of the affected parts are tender to
pressure, and there may be painful sensations arising spon-
taneously; and certain portions of the spine may be unduly
sensitive.
There is generally muscular rest during sleep, but this is by
no means constant. In many cases there is great difficulty in
going to sleep, owing to continuance of the muscular spasm,
and sleep when obtained is not profound, but broken. The
patient moans and grunts, and throws himself about in a rest-
less manner. On awakening in the morning there is at first
muscular rest, but the spasm soon recommences, more es-
pecially on getting up and making an attempt to dress.
Mental disturbances are rarely absent, and become more
developed when the disease lasts a considerable time. In the
lighter cases they are but slightly developed, but in the severer
cases the character seems to change a great deal; good-natured
persons become passionate, the peaceable, quarrelsome; the in-
telligent appear childish and simple. The judgment is per-
verted, and ideation slow; there is indifference and want of
respect to parents and friends; the memory is impaired and
there is great want of attention. Some patients are shy and
timid, all are more or less silly. In some, mania and imbecil-
ity follow after a time. These symptoms are not only observed
toward the end, when they might be ascribed to exhaustion
and anaemia, but are often present at an early period of the
complaint. In connection with the stupid look, and the apish
behavior these signs of depressed intelligence and altered
character, especially when occurring in older children at and
after the period of puberty, are apt to terrify the patient's
family, and the physician is often obliged to reassure them
that idiocy will not result.
39S INSANITY AND ITS TREATMENT.
Differential diagnosis.-‘As a rule chorea is easily distin-
guished from other disorders. It differs from the clonic spasm
of acute cerebral disease by the absence of fever, delirium and
coma; from epilepsy by the absence of unconsciousness, and
the continuous movements, while epilepsy is characterized by
recurring attacks of sudden loss of consciousness and convul-
sions. Hysterical outbursts differ from the spasms of chorea
by their remissions and by the partial unconsciousness of the
patient. Paralysis agitans consists in weakness and tremor,
rather than spasmodic contraction and belongs to the diseases
of later life. Facial spasm differs from the choreic in being
always of equal intensity, and in generally being confined to
one side of the face and to the same group of muscles.
The ea citing causes are frequently such as act upon the emo-
tions, viz.: fright, fear, terror and anxiety, and it occurs par-
ticularly in children who have inherited the nervous temper-
ament from the parents. Hysteria of the mother is most effect-
ive in this respect. Chlorosis, anaemia, dysmenorrhoea and
Scarlet fever often precede the outbreak of chorea, and it would
seem to be sometimes caused by the habit of masturbation. It
is no doubt at times contagious, that is, taken by imitation by
those children whose nervous system is very impressionable.
Dr. Allen McL. Hamilton says: “The disease often follows scar-
latina or other zymotic febriculae, or takes its origin from an
attack of acute rheumatism, most frequently this is the rheu-
matic fever, but even simple rheumatism of the muscles with-
out febrile disturbance and articular affection may give rise to
it. It may also result from over-study, bad air, bad food or
worms. This investigation in regard to its occurrence among
school children showed that over twenty per cent of the young
children in the public schools of New York are affected with
choreic affections of greater or less gravity. These varied
from movement of the hands and twitching of the facial mus-
cles to such as attracted the notice of visitors.” In some cases
the disturbance of the nervous system, which causes the out-
break, is not of a mental but of a reflex nature, owing to some
peripheral irritation spreading to the nervous centres.
The pathology of chorea is yet unsettled; most writers
CHOREA. 399
agree with Drs. Todd and Russell Reynolds in thinking that
the origin of chorea is cerebral and not spinal; but there is
no agreement as to the location. Dr. Reynolds thinking it to
be in the corpora striata, other observers locating it elsewhere.
The embolic theory of the production of chorea has received
the support of such men as Mackenzie and Hughlings Jackson.
Bastian adopts the theory that the emboli consist of masses of
agglomerated white corpuscles, and that the location of the
lesion is in the corpus striatum. Dr. Hamilton says he is in-
clined to accept the embolic theory, not only because the pare-
sis of the limb may precede any muscular movements, but
because lesions in or about the corpora striata, which produce
hemiplegia, may also give rise to choreic movements. We
must bear in mind, however, that in many cases of chorea,
Some very able and expert pathologists have been unable to
find any emboli; and also that in undoubted embolism of the
cerebral arteries there is never any appearance of chorea. Dr.
Dickinson found lately, in seven instances, remarkably uniform
appearances, viz.: hyperamia or distention of all the vessels
of the brain and cord, but more particularly of the small arter-
ies, which was succeeded by effusion of blood with consequent
irritation and injury of the surrounding tissue. The parts of
the brain which were most affected were those between the base
and the floor of the lateral ventricles, in the track of the Sylvian
arteries; the substantia perforata, the corpora striata, and the
beginning of the Sylvian fissures. In none of these instances
was any trace of embolism, such as decolorized fibrine, de-
tached clots, or signs of impaction to be found.
Dr. Althaus says, and his views appear to me the most
reasonable of any with which I am acquainted:
“1. In a large class of cases chorea is owing to that alteration
in the composition of the blood which is associated with rheu-
matic fever (and I would add Scarlatina), and which is known
to affect the nervous centres as well as other organs.
2. In another large class of cases chorea is produced by di-
rect irritation of the nervous system, which is either purely
mental in its nature (fright etc.) or partakes of a reflex char-
acter.
400 INSANITY AND ITS TREATMENT.
3. Endocarditis exists in the large majority of cases of
chorea; and is either pre-choreic, when the rheumatic influence
has to be accused; or post-choreic, when we assume it to be due
to irregularity in the action of the cardiac muscle; but endo-
carditis cannot be considered a cause of chorea.
4. Chorea is owing to hyperaemia of the middle cerebral
artery, and more particularly of the corpora striata. In cases
which end favorably, this hyperaemia does not proceed to rup-
ture of the blood vessels; but in fatal cases effusion of blood,
and consequent injury to the surrounding tissue takes place.
5. A similar condition of the spinal cord, more particularly
in the region of the posterior horns, is generally associated
with the cerebral changes; and when mental symptoms have
been prominent during life, it is probable that the cineritious
substance of the convolutions of the brain has also been in a
state of hyperaemia.
Prognosis.--The prognosis of chorea is generally favorable,
as the disease is rarely fatal except from some complication
Such as dropsical effusion, epilepsy, paralysis or organic dis-
eases of the heart, brain or spinal cord. It is, however, very
apt to become chronic. When the irregular movements are
confined to the muscles of one arm or those of the head, espe-
cially when occurring in the adult, they are rarely cured. The
susceptibility of the nervous system to impressions is less in
the adult than in the child; hence the probability of existing
Organic lesion is greater when the disease occurs in advanced
life, especially if the limited character of the disease implies
a local seat. When occurring during gestation it is liable to
produce abortion or premature delivery.
Treatment.— In speaking of the treatment of this disease,
Von Ziemssen says: “From the most energetic treatment with
frequent blood-letting, and regularly repeated purgations, as
advised by Sydenham, to the most complete therapeutic ni-
hilism, which affirms the uselessness of all remedies on the
ground of the theory of the self-limited nature of the disease,
we find all stages of transition.”
At present the principal remedies in vogue in the old School,
are strychnia, arsenic, iron in its various forms, phosphorus,
CHOREA. 401
cod-liver oil, calabar bean and zinc.; and in a less degree the
bromides, valerian, and asafoetida. It is needless for me to
say that each in turn is found useless and cast aside, simply
because they have no law guiding their choice.
Each case should be individualized and treated by itself; so
far as possible all exciting causes should be removed and care-
fully guarded against. If there are coexisting disorders they
should be met by the carefully selected homoeopathic remedy.
The diet above all things should be regulated with judg-
ment. Plenty of fresh air and sleep are absolutely essential
and should be insisted upon; the child should be at once taken
from school and all brain work forbidden; exercise in the
open air and sea bathing is often of service. In severe cases,
when the patient is being exhausted by constant movements
and loss of sleep, nutritious diet, an occasional sponge bath
with tepid water, exclusion of all company and freedom from
excitement will help us in our cure.
Medical treatment. — Act. rac. or Cimicif. This remedy has
been a favorite one with many physicians, and among them
Drs. Scales, of Woburn, Whittier, of Fitchburg, and Packard, of
South Boston; it has generally been given in the lower di-
lutions. It is said to yield very satisfactory results in cases of
chorea in patients with a rheumatic diathesis, those suffering
from uterine irritation, and in cases resulting from physical
causes. The abnormal movements consist of twitching, jerk-
ing, twisting motions, usually unilateral and confined to the
left side, often attended by pains of a neuralgic or rheumatic
nature; depression of spirits and insomnia.
In a discussion before the Mass. Hom. Med. Soc. some few
years ago, Dr. A. J. French, of Lawrence, spoke more highly of
Nux wom. than any other drug, and Dr. N. R. Morse, of Salem,
said that Nux wom. was the most generally indicated and suc-
cessful remedy in this infirmity. He had cured many cases
with a single dose. His indication for Nux vom. was a twitch-
ing of the jaws and upper extremities. Other symptoms are:
a sensation of numbness in the affected muscles; unsteady
gait; the feet drag ; movements renewed by the least touch,
but relieved by firm steady pressure; impaired appetite; con-
402 INSANITY AND ITS TREATMENT.
stipation; despondency; all the symptoms worse in the early
hours of the morning.
Dr. E. U. Jones, of Taunton, advised Ignatia in cases, in
which the left side was principally affected; it should be
thought of especially when the convulsive twitchings are
brought on by fright, or grief; are worse after eating; better
lying on the back; sighing and sobbing are also charac-
teristic.
Calcarea carb. is useful in the chorea during second denti-
tion, or in leuco-phlegmatic patients; also when the disorder
is brought on from fright or onanism ; there is the usual
twitching of the muscles; trembling of the body; falling
down; great weariness and inability to walk.
Crocus sativa seems well chosen in the following case, which
it cured. A girl, 15 years of age. Immoderate laughter with-
Out apparent cause; inability to walk from fear of falling, and
loss of power in the hands so that she could not use a knife or
fork; also indicated by spasmodic contractions of sets of mus-
cles; jumping, dancing, laughing, whistling; wants to kiss
everybody; epistaxis of dark stringy blood; changeable dis-
position.
Hyoscyamus is a favorite remedy, but not one that I have
often used; Dr. Morse places it next to Nux vom. The move-
ments of the head are from side to side; the arms are thrown
about, he misses what is reached for; the gait is tottering; he
is talkative and easily excited to laughter.
The symptoms calling for Stramonium are exceedingly char-
acteristic—the convulsive movements have the feature of af-
fecting the parts of the body crosswise, as, for instance, the left
arm and right leg, while the other limbs are unaffected; or
the muscles of the head and neck are violently agitated; or
the spasms may involve the whole body, compelling the per-
formance of the most grotesque leaps, motions and gestures;
clasps the hand over the head; full of fears; puts hands to
the genitals; weeps and laughs alternately.
Sulphur may be useful in chronic cases after suppressed
eruptions, or when eruptions characteristic of the remedy are
present; the patient is peevish, irritab and obstinate.
CATALEPSY. 403
Cina or Santonin are called for by decided worm symptoms;
and other remedies as indicated by the symptoms laid down
in the Materia Medica, for I have only spoken of a few.
Jahr speaks highly of Causticum in the so-called chorea
minor, with contortions of the limbs, without any derange-
ment of the mental faculties, especially if the attacks are
caused by some violent emotion and Ignatia had failed to
relieve.
Catalepsy.
Among the various diseases which go to make up the noso-
logical list, there is one, fortunately quite rare, which belongs
to the group of unusual neuroses, and whose imanifestations
are as strange and proteiform as its phases are variable and
unexpected. I refer to catalepsy. The physician who has
never been in attendance upon a cataleptic will always re-
ceive with distrust, the strange accounts given of this dis-
order, so incredible will they seem to him. Here, more
than anywhere else, it is necessary to have seen in order to be-
lieve. Nevertheless the accounts are true.
By catalepsy is understood a quite rare disease, closely
allied to hysteria, paroxysmal in its manifestation, and charac-
terized by a condition of muscular contraction and semi-rigid-
ity, so that the limbs may be placed in awkward and con-
strained positions and remain so for some time. It is attended
by loss of consciousness and cutaneous anaesthesia. Eulenberg
says that “its pathognomonic symptom consists in this, that
the muscles remain in a state of contraction into which they
enter at the beginning of the attack, so that certain positions
of equilibrium are maintained by the limbs without spon-
taneous change, while passive changes of posture, Sometimes
of very singular nature, can be easily made.” The affection
occurs on the one hand as one of the many manifestations of
hysteria, or as a symptom of chronic cerebral disease, such as
insanity, and seems to bear a close resemblance to trance or
Somnambulism.
The attacks of catalepsy occur suddenly as a rule, but at
404 INSANITY AND ITS TREATMENT.
times there are premonitory symptoms such as headache or
Vertigo. Sometimes the patients stop suddenly in the middle
of a sentence or of a motion, as if enchanted, with open mouth
or raised arm as the sudden stiffness seizes the muscle. In
genuine catalepsy this peculiar condition of stiffness, or rather
of extreme muscular tension, extends very rapidly over all
the voluntary muscles, though not always over all in equal
proportion. The affected muscles have a firm feeling, and
offer more or less resistance to passive motion. This resist-
ance gradually ceases, and the muscles, though still con-
tracted and firm, yet yield to passive motion, so that the limb
can be placed in any desired position in which it remains for
Some time without a change. This phenomenon can be seen
much better in the upper than the lower extremities, and in
the small than the large joints, for example in a hand or finger
rather than the elbow or shoulder joint. Much that is reported
in old authorities concerning the wonderful positions of those
possessed may be referred to such cases. But the condition
does not persist as long as some would suppose, in its full in-
tensity; as a rule after some moments there is a diminution of
the stiffness, so that the limbs obey the laws of gravity, and
the arm raised horizontally sinks a little.
The consciousness is frequently entirely lost, but in some
cases a clear knowledge is preserved of everything that tran-
spires.
As a rule the general vital functions undergo no marked
change during the attack. The respiration is of normal fre-
Quency, and the pulse usually shows no alteration in quality.
The following case is reported by Prof. Raue, of Philadel-
phia: Mrs. T., aged twenty-nine, married, of nervous, Sanguine
temperament, gave birth to her first child at “term,” Novem-
ber 12th, 1870, whole labor accomplished in about six hours.
Very soon after she was attacked with severe pain in the left
side of the head, chiefly in the orbital region.
In about four hours she had her soiled clothing removed,
her bed fixed, etc. This fatigued her much, and greatly in-
creased the pain in the eye and head. In about five hours after
this she became entirely blind, and ceased to be conscious of
CATALEPSY. 405
pain. She says she does not know whether she slept or not,
but she is certain she was not fully conscious. Twenty-two
hours after labor she was suddenly seized with a convulsion.
During the next four days she remained unconscious of Sur-
rounding events, according to her after recollection, although
she would do many things, such as handle the baby and let it
nurse, and even talked.
Consciousness returned suddenly like an awakening from
sleep. While in this state of semi-consciousness she says it
appeared as if there was a panorama constantly passing before
her, so that she was excessively wearied by it. After waking,
everything that was of a light color appeared to be covered
with minute black spots about one quarter of an inch apart.
This disordered visual condition lasted for three or four days
and then gradually left her.
Immediately after her return to entire consciousness she be-
came greatly depressed in spirits, unutterably sad, felt that she
would die in despair, etc.;_the whole world was dark, had a
feeling of weight at her heart, felt that she had disgraced her-
self by having a baby, etc.
The presence and conversation of her husband, the nurse,
and others would lighten this feeling a little, but it would re-
turn with full force whenever she awoke from sleep. This
mental condition did not improve for about six weeks. The
bowels were not evacuated for about twelve days after parturi-
tion. When the baby was three weeks old the lochia ceased.
About this time she began to sit up out of bed. Soon after
this, while lying on the lounge one day, she was suddenly
taken with a new sensation at or about the heart. She says it
was indescribable, but fearfully intense. She called out for
help, but did not move or lose consciousness; her face became
of a leaden hue; the saliva thickened, and she had a peculiar
sensation at the root of the tongue. The paroxysm lasted
about two or three minutes, then gradually passed off with a
'sigh, leaving her exhausted and wearied.
This kind of paroxysm became of frequent occurrence, of
greater intensity and longer duration. They came suddenly,
under every circumstance of position, occupation or Sur-
406 INSANITY AND ITS TREATMENT.
rounding. At table, when sitting at her work, when engaged
in social enjoyable amusement, when walking the street, and
when asleep. Sometimes there would be several a day. This
condition lasted until her babe was three months old.
She says it required much mental effort to keep her from
committing suicide, and that she has frequently bitten herself
as a kind of relief from her feeling of desperation. She relates
that on one occasion, one of these “spells” came over her as
she was walking on the street; on seeing a man a feeling came
over her (that she resisted with difficulty) to spring at him
and tear him to pieces.
She felt that she was going insane; but after her child was
three months old, the frequency of these recurrences was lessened,
and they returned, with some degree of periodicity, about the
middle of the month, lasting for a day, during which she would
have several, to be followed by a sense of mental depression
for about three days; occupying in all about the time of a
menstrual epoch. This lasted about six months. Then with-
out any change in the character of the “spells” they began to
come irregularly, and she was led to believe that on the re-
turn of menstruation she would be free from this awful condi-
tion.
Her menses became regular and normal, but the only relief
she experienced from her terrible affliction was a slight abate-
ment in the severity of the paroxysm, which still came on at
irregular intervals and of different degrees of intensity; but
what they lost in intensity they made up in frequency.
At this time her babe is nineteen months old. The dura-
tion of a paroxysm, that is, “the spell” itself and its imme-
diate effects, will pass over in about fifteen minutes, and she
will be quite herself again. They still come on without
regard to surrounding circumstances, when asleep or awake.
Dr. Raue assumed charge of the case when the child was
eighteen months old. Although under a constant dread of in-
sanity, and consequently low-spirited, she never weeps. She
says “the spells,” when they come on, cause a kind of mental
terror at the time; she wants some one near her, but not to
touch her; says she knows everything that goes on about her,
CATALEPSY. 407
but cannot move; and thinks she does not wink, but keeps
her eyes open, and immovably fixed. The spell passes off
with a sigh. She refers the sensation to the praecordia; says
there is a weight of sadness there that is terrible; the feeling
is not pain, but emotional; says she believes she has them
without waking from sleep, for she feels as if she had a ter-
rible dream, without any remembrance of a dream.
On inquiry as to her condition previous to parturition he
learned that she had had considerable swelling of the limbs.
This fact, together with the other fact that the restoration of
the normal functions of the unimpregnated uterus had no per-
ceptible influence upon “the spells,” will enable us to form
some idea as to the location of the seat of the difficulty.
Since the pathological researches of Marshall Hall and
others into the causes of convulsions and kindred affections,
we may regard it as one of the demonstrated facts that puer-
peral effects of this kind have either a centric or an eccentric
Origin. In nearly every case of puerperal nervous affection
we are apt to jump to the conclusion that it depends upon
reflex action, or is of eccentric action. But too much care
cannot be used in making up the diagnosis in any given case.
As in the case under consideration, our prognosis at the onset,
based upon the diagnosis of a reflex cause, would be restora-
tion as soon as the uterus resumed its normal unimpregnated
condition and functions. The sequel disappoints us, our
patient does not recover, our prognosis fails, and our patient
is discouraged, and we are also.
In the above case, Dr. Raue prescribed Coccul. ind, for the
following symptoms: “Anxiety;” “anguish about the heart;”
“anguish of death;” “sudden violent anguish;” “frightful
anguish, seeming like a dream, during sleep;” “stupid feeling
of the head;” “thinking fatigues the head;” “headache, as if
the eyes would be torn out.” All these symptoms were pres-
ent at the commencement of the illness, and the Coccul, in
the thirtieth potency, cured the case in a few months.
The case just related had strong mental and puerperal com-
plications; and I will now give one of a different kind, which
I have translated from the French, and it is very remarkable;
the writer says:
408 INSANITY AND ITS TREATMENT.
“On October 26, 1857, one of our most honored associates at
Paris, Dr. L. Cerise, made a verbal communication to the
Medico-Psychological Society, relative to a man affected with
catalepsy in a very peculiar manner, whom he had seen a few
weeks previous at Rome. I was at the time vividly impressed
with the remarks of Dr. Cerise, although I was far from sus-
pecting that circumstances would one day allow me to see the
Same patient, as afterward happened.
“April 15, 1859, I visited the asylum at Rome, and my first
care was to ask Dr. Guarlandi, physician in chief of the estab-
lishment, to be kind enough to show me, if still alive, the
cataleptic who had been spoken of at the meeting of the
Medico-Psychological Society at Paris. A few moments later
I was introduced into an infirmary, not over neat, where there
was a single bed. I found myself in front of a man, apparently
about forty years of age, bronzed complexion, and face much
emaciated, lying upon his back perfectly motionless; con-
stantly having his eyes three-quarters closed, and breathing
without force and noise. His mouth remained half open and
disclosed his teeth horribly filthy and covered with thick
sordes, and, on carefully watching the patient, it was difficult
to say whether he was awake, or plunged into a kind of half
stupor. I continued my survey, and, uncovering the body,
saw before me a veritable skeleton. The thinness of the poor
man was so hideous that it far exceeded that we sometimes see
in persons in the last stages of consumption or cancer. I
placed my hand upon the epigastric and abdominal regions
in order to see, if I could detect the presence of a tumor, but
all seemed natural and in order. I then took in succession an
arm and a leg; the two arms, or two legs, and communicated
to those limbs various attitudes contrary to all the laws of
gravitation. These positions remained until I changed them
myself. Insensibility of the skin existed in a marked degree,
but this symptom was not as well developed as with some
lypemaniacs.
“I had proceeded thus far with my examination when I in-
Quired for the notes concerning the case; they were only scrib-
bled on a bit of paper, and merely said that the man had fol-
CATALEPSY. 409
lowed the trade of saddler at Rome, that the commencement
of his disease dated back five years, but he had been in the
asylum only three years and a half; that on admission it was
noticed that he was of a robust constitution, and a bilious
lymphatic temperament; without being gross he was mus-
cular, large and fleshy; at entrance he appeared sombre and
taciturn ; and rapidly arrived at a condition where he was al-
most a stranger to the things of the world.
“I inquired about the food furnished the patient, and was
told that it was absolutely impossible to make him take his
share of the common ration, and that he ate only bread, and
very rarely a little beef-broth. The supervisor of the men's
department then confirmed the statements made by Dr. Cerise
to the Society, that the patient was entirely insensible to the
words of the physician, students, chaplain and attendants, and
that to the supervisor of the division alone had been given
the power of making himself heard. He alone was obeyed,
he alone could make him eat. In fact, I made many attempts,
if not to make him talk, at least to draw from him a sound,
but he remained impassible and mute. I procured some
bread and presented it to him, and he preserved the same im-
mobility.
“After many efforts and nearly exhausting my patience, being
very desirous to see the man eat, I asked the attendant to be
kind enough to make him talk in my presence. The attend-
ant called him by name, and he answered by a monosyllabic
and gutteral miauling (mialement). I had the attendant
ask if he was ill, if he was in pain anywhere, if he desired
anything, to see his family, etc., etc. To which he answered
always in about the same words, that he had no pain, that he
asked nothing and wished nothing. I then asked the attend-
ant to give him something to eat. He at once presented to
him a bit of brown bread weighing about five hundred grains.
The patient extended his hand, took the bread, opened his
mouth, bit energetically into the little loaf, chewed and swal-
lowed it.
“But further while he was eating, if any one except the
attendant addressed him, he would stop suddenly and leave
26
410 INSANITY AND ITS TREATMENT.
unfinished the acts of prehension, mastication and deglutition,
until the friendly voice told him to continue and finish.
Scarcely has he resumed his meal at the interrupted point
than he again stops and remains motionless if a stranger ad-
dresses him. The experiment could be continued indefinitely.
“I wished to see him drink, but they objected, saying that the
patient without having the least horror of drinking, had for a
long time drunk almost nothing, and that it was with great
difficulty he could be persuaded to drink a little white wine.
“The calls of nature were thus attended to. Once in every
twenty-four hours he was placed upon a chair, and passed a
very small quantity of urine. Every four, five or six days he
had a passage from the bowels. &
“I noticed with this patient a considerable lowness of tem-
perature. All physiologists indeed have insisted upon this
phenomena in cases of insufficient nutrition. They have even
gone so far as to say that death does not result from hunger
but from cold.
“Dr. Cerise had told us two years before that the patient,
although suffering for a long time, had not grown perceptibly
thinner; but my learned colleague will now learn from the
details that I have given, that fearful inroads have since been
made upon his general health. Moreover the prolonged life
of this man in spite of the unfavorable conditions in which I
found him was truly to me something inexplicable, and I
think that others will share my surprise.”
In that form of melancholia where great apathy and stupor
are present, a condition will often be found strongly simu-
lating catalepsy. An example of this sort coming under my
own observation is given in the lecture upon melancholia.
During these attacks of catalepsy but little can be done in
the way of treatment, and it is necessary to wait and watch.
Somnambulism.
I propose to briefly allude to that phenomenon which is
known as somnambulism, or sleep-walking; it is not a disease
in the strict sense of the word, and it is not spoken of as such
SOMNAMIBULISM. 411
in any medical work with which I am acquainted, but you
will occasionally be consulted by parents who will want to
know what to do with their children who have this habit; and
then it does indicate a nervous temperament which under
favoring circumstances may pass into disease.
Somnambulism means more than merely that one walks in
his sleep ; the acts may be extensive, varied and elaborate.
A man may rise from bed, and, while sound asleep, may walk
down stairs, harness a horse, take a drive, put up his horse on
his return, go back to bed, and in the morning have no recol-
lection of any such actions. He may rise and build a fire and
set the table for breakfast, and go back to bed, all the time be-
ing sound asleep. In fact any kind of automatic act may be
accomplished while in this state, and some even that would
seem to require thought, judgment, and volition.
The phenomena of Somnambulism may become important
to us in a medico-legal point of view, for questions may arise
of how far a person is responsible for criminal acts committed
in this state, or in that kindred transition state between sleep-
ing and waking when everything is liable to seem distorted
and unnatural.
Bernard S., a German, was lying quietly in bed with his
wife; at midnight he waked with a start doubtless under the
influence of some terrifying dream. He perceived standing
in front of him a hideous phantom. Fear, and the darkness
of the night prevented his seeing clearly, so in a trembling
voice he called out twice: “who goes there,” receiving no
answer, and thinking that the figure was advancing toward him,
he is seized with terror, seizes a hatchet which was always at
his bedside and hurls it at the supposed spectre. All this was
done so rapidly that not a moment was given for reflection.
A deep groan and a fall recalled the man to his waking self,
and he found that he had killed his wife. As he was subject
to fits of Somnambulism no punishment followed.
It is not unusual for children, after playing hard all day, or
after a supper of some indigestible food, to get out of bed and
walk in their sleep, especially if they are of nervous dipositions
and temperament.
412 INSANITY AND ITS TREATMENT.
In this state of somnambulism the sense of touch plays a
very important part, and is in a highly sensitive state. It is
this sense which enables a man to walk with safety along the
steep roof of a house, close by the brink of a precipice, and in
so many dangerous places where the same person would at
once grow dizzy and fall if in a waking state. He is entirely
given up to the pictures of his imagination or rather of his
memory, so that his actions are guided by this sense alone.
This it is which enables him to accomplish other remarkable
feats, such as to sit down and compose a letter or a poem, and
write with accuracy and even elegance, also to play upon
musical instruments and do many things which require a
nicety of touch and a skill in manipulation; such things seem
to prove the truth of the saying that the touch is the sum of
all the senses put together; and it is owing to this inherent
instinct which makes us strive to handle an object before our
curiosity in regard to its quality is satisfied.
This condition of nervous excitability sometimes attains
such a height that it goes beyond physiological limits, and its
subjects are affected with hypochondriasis, ecstacy, hysteria
and catalepsy. &
As a rule, the Somnambulist has no knowledge of what trans-
pires in his sleeping state, but there are cases where it is
otherwise.
Dr. Maudsley says, in his work on Responsibility in Mental
Disease: “There is no doubt that some persons may rise from
their beds while asleep, go through a series of complicated ac-
tions and retire to bed again without awaking; in the morn-
ing feeling weary, tired and out of sorts, but remembering
nothing of what they have done, or remembering it only as a
dream. If a crime were done by a person in this condition,
there could be no question of responsibility. But it must be
borne in mind that Somnambulism might easily be pretended,
and assuredly the assertion of its occurrence for the first time
when a crime had been done would be extremely suspicious.
Ft is really, if not itself a kind of nervous disorder, very closely
allied to such nervous disorders as epilepsy, catalepsy and
hysteria; it certainly indicates a decided neurosis; wherefore
MORAL INSANITY AND MEDICAL JURISPRUDENCE. 413
if any one really was subject to it, there could hardly fail to
be evidence of its previous occurrence, or of distinct nervous
troubles.”
The mesmeric sleep is only another form of somnambulism,
but we have not the time to enter now into that subject, or its
kindred topic hypnotism, nor, indeed, is an extended consider-
ation of those nervous disorders called for from us.
LECTURE XVIII.
Moral Insanity and Medical Jurisprudence.
In this the concluding lecture of the course on Insanity, I
propose to take up the subject of Moral Insanity, and also that
of Medical Jurisprudence, both in relation to criminal acts
and testamentary capacity.
It is not my purpose to enter upon the pathology of Moral
Insanity, nor to make more than a brief examination of the
peculiar features which characterize it; but I shall touch more
fully upon those medico-legal questions which constantly arise
from the diverse views of insanity, and specially of emotional
insanity, held by the respective professions of law and medi-
cine.
The plea of insanity is now so frequently urged as a
defense in criminal trials, and in several noted cases has been
so successfully used to defeat justice, that it becomes necessary
for the protection of society to consider the proper means for
checking so great and so growing an evil. At the same time
medical science and medical men are unjustly reproached
with inventing “new forms” of insanity; with shielding out-
bursts of passions and acts of crime under the garb of “im-
pulsive insanity,” and exhibitions of moral depravity as
“moral” insanity, until all medical testimony has come to be
looked upon with the greatest distrust. It must be admitted
414 INSANITY AND ITS TREATMENT.
that medical men have, occasionally, been too ready to express
in the witness-box opinions as to the sanity or insanity of a
prisoner based upon insufficient evidence; yet, we believe, the
confusion and misunderstandings in these cases are mainly
attributable to the unsettled condition of criminal law in its
relations to insanity; the conflict between old judicial decis-
ions taken as precedents, and modern psychological medi-
cine, and the consequently different standpoints from which
physicians and jurists view the matter. Looked at from the
legal standpoint it is easy to comprehend why cases of alleged
impulsive insanity are received with incredulity, while to the
medical mind their existence is beyond doubt.
In this unsatisfactory condition I believe the law to be at
the present time in reference to the question of responsibility
when unsoundness of mind is urged as a defense or pleaded
in bar of punishment. Those qualities of mind, the posses-
sion of which is held to constitute responsibility before the
law, and therefore liability to punishment, are well known by
almost every physician of experience to be possessed to a
greater or less extent by the majority of those whose insanity
is beyond question, and who ought not on any principle of
justice to be held fully accountable for their actions, whatever
the law may say to the contrary.
If this be true, it ceases to be a matter for surprise that con-
flicts of opinion arise between medical witnesses and the legal
counsel in the courts; that such conflicts should be the rule
rather than the exception, and that as a consequence a grave
element of uncertainty should enter into the result of such in-
quiries, especially in capital cases. The fact is that the legal
definitions of insanity in its relation to responsibility as set
forth by the authority of the bench is at variance with the
knowledge and experience of the age, at least of those persons
whose opportunities and experience entitle their opinions to
respect. In spite of this difference of opinion, judges con-
tinue with an almost wearisome iteration to repeat the opin-
ions of their predecessors, and to charge juries as follows:
“Notwithstanding a party accused did an act, which was in
itself criminal, under the influence of insane delusions, with
MORAL INSANITY AND MEDICAL JURISPRUDENCE. 415
a view of redressing or revenging some supposed grievance or
injury, or of producing some public benefit, he is nevertheless
punishable if he knew at the time that he was acting contrary
to the law. That if the accused was conscious that the act
was one which he ought not to do; and if the act at the same
time was contrary to law he is punishable. To establish a
defense on the ground of insanity, it must be clearly proved
that, at the time of committing the act, the party accused was
laboring under such a defect of reason, from disease of the
mind, as not to know the nature and quality of the act he
was doing; or so as not to know that what he was doing was
wrong. That a party laboring under a partial delusion must
be considered in the same situation, as to responsibility, as if
the facts, in respect to which the delusion exists, were true.”
Such is a brief exposition of responsibility in cases of in-
sanity as laid down by the judges; and with a few exceptions
every jury has been thus instructed since the year 1843.
The term “emotional insanity,” as used by most later
writers includes the two forms of “moral” and “impulsive” in-
sanity; and it is commonly one of these forms that gives rise
to the misunderstandings and disputes in criminal practice.
Dr. Pritchard, one of the earliest writers upon this subject,
has defined moral insanity to be “a madness consisting in a
morbid perversion of the natural feelings, affections, inclina-
tions, temper, habits, moral dispositions, and natural impulses,
without any remarkable disorder or defect of the intellect, or
knowing and reasoning faculties, and particularly without
any insane illusions or hallucinations.” Dr. Carpenter the
distinguished English physiologist puts it even more strongly,
saying: “Moral insanity may and frequently does exist with-
out any disorder of the intellectual powers or any delusion
whatever.”
Forbes Winslow says that “the patient manifests no mental
delusion; is not monomaniacal; has no hallucinations; does
not confound fancies with realities, but simply labors under a
morbid state of the feelings and affections, in other words a
diseased volition.”
You will hear of Dr. Isaac Ray, if you ever go into a court
416 INSANITY AND ITS TREATMENT.
where the questions of insanity are under discussion; he says:
“The contrast presented in moral mania between the state of
the intellectual and that of the moral faculties is one of its
most striking features. These patients can reason logically
and acutely upon any subject within their knowledge; and
extol the beauties of virtue; while their conduct is filled with
acts of folly, and at war with every principle of moral pro-
priety. Their moral nature seems to have undergone an entire
revolution. The sentiments of truth, honor, honesty, benevo-
lence, purity, have given place to mendacity, dishonesty, ob-
Scenity and selfishness, and all sense of shame and self control
have disappeared, while the intellect has lost none of its usual
power to argue, convince, please and charm.”
Pinel, who was the first to call especial attention to this form
of insanity, says that in common with Mr. Locke, the Eng-
lish philosopher, and other metaphysicians, he considered
mania inseparable from delirium, and upon investigation he
was surprised to find “many maniacs who at no period gave
evidence of any lesion of the understanding, but who were
under the dominion of instinctive and abstract fury, as if the
affective faculties alone had sustained injury,” and Esquirol,
his successor at the Bicêtre says that “there are insane in
whom it is difficult to discover any trace of delusion, but there
are none in whom the passions and moral affections are not
disordered, perverted or destroyed.”
We see from these quotations that the symptoms resemble
very much, the acts and manifestations of what we are accus-
tomed to call vice; and some persons indeed carry their theo-
ries so far as to consider all vice and sin as insanity; but al-
though it may be difficult to distinguish in all cases between
the two, still there is a difference. As has been truly said,
“Much as the assumption of it is a disease has been reprobated,
there can be no doubt that most of the eminent men who have
studied insanity, and whose authority we habitually accept, are
entirely agreed as to the existence of a form of mental dis-
order, in which, without any hallucination, illusion or delu-
sion, the symptoms are exhibited in a perverted state of those
mental faculties usually called the moral powers, or included
MORAL INSANITY AND MEDICAL JUIRISPRUDENCE. 417
under feeling and volition. As, however, feeling is more fun-
damental than cognition, the intellectual activity cannot be
entirely unaffected, though there may not be any positive de-
lusion; the whole manner of thinking and reasoning is tainted
by the morbid self-feeling through which it is secondarily
affected. The patient 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 concerned, his
real nature touched to the quick, then he displays in his rea-
soning the vicious influence of his morbid feelings, and an
answering perversion of conduct, he cannot truly realize his
relations, and his whole manner of thought, feeling and con-
duct, in regard to himself is more or less false.”
It would follow from this that there are as many varieties of
moral insanity as there are different manifestations of the men-
tal emotions, but for all practical purposes they may be divided
into two classes; one marked by depression and gloom, with
the accompanying feelings of distrust, weariness of life, and the
like; and the other shown by preternatural excitement,
thoughtless and extravagant conduct, and a prevalence of ma-
licious and angry feelings; while the characteristic feature is
extreme irascibility depending on a physical morbid cause.
The cases of moral insanity that are brought into consideration
in the courts belong generally to the latter class, and it is this
which will now claim our attention under the name impulsive
insanity.
Impulsive insanity is said to exist “where the crime itself is
held to be evidence of the insanity, and is accounted for upon
the theory that the person is suddenly and insanely impelled
to commit it.”
In some cases the perverse impulse becomes so over-power-
ing that during the paroxysm the moral sentiments are, for
the time, completely paralyzed, and the person blinded as to
the true character of his thoughts and actions. Esquirol says
(Traité des maladies mentales, Vol. 2, p. 97): “Patients, de-
lirious or not, urged on irresistibly to acts of which they dis-
approve, feel their condition and reason about it as clearly as
would a sane person. Are they not then in a lucid interval, a
418 INSANITY AND ITS TREATMENT.
state of clearness of mind 2 But soon the paroxysm follows.
Anew a prey to their delirium, they are impelled and yield,
but reason no longer guides them. In obeying the perverse
impulse pushing them, they forget the motives which but now
restrained them, they see but the object of their passion, like
the man in a fit of anger, who sees only the object of his
rage.”
Dr. Carpenter says: “It is unquestionable that many crim-
inal actions are committed under the irresistible dominance
of some insane impulse, the individual being at the time per-
fectly aware of the evil nature of those actions, and of his
amenableness to punishment for them.”
Speaking of the two forms together, he states: “There may,
however, be no primary disorder of the intellectual faculties;
and the insanity may essentially consist in a tendency to dis-
ordered emotional excitement, which affects the course of
thought, and consequently of action without disturbing the
reasoning processes in any other way than by supplying wrong
materials to them.”
Though some medical writers refuse to admit the correct-
ness of the definitions given, and a few even deny the proper
existence of these forms of insanity, the denial it seems to us
is based rather upon technical than practical grounds. The
objection they make is, that “the insanity is not confined ex-
clusively to the emotional faculties, contending that the mind
cannot be properly separated into such faculties, as of the
intellect, the emotions and the will, but must be considered
as a whole; and that no one part may be diseased with the
other remaining in a perfectly healthy state.”
While this may, strictly speaking, be true, yet the terms are
useful as specifying forms of insanity that possess certain
prominent and characteristic features; and in this sense they
are permitted by all late writers, or as Prof. Maudsley says:
“Whatever name it may ultimately be thought best to give it,
there can be no doubt of the existence of such a form of
disease.” All admit that there are cases in which the intellect-
ual faculties and the will are but slightly affected if at all,
and where the moral perceptions are palpably disordered; and
MORAT, INSANITY AND MEDICAL JURISPRUDENCE. 419
again, those in which criminal impulses have suddenly and
without any special premonitions occurred and been the occa-
sion of homicide, suicide, etc., without any notable impairment
of the intellectual faculties being apparent.
Prof. Maudsley says: “There is one occasional consequence
of descent from an insane stock, viz., an entire absence of the
moral sense. To those who take the metaphysical view of
mind, it will no doubt seem improbable that absence of moral
sense should ever be a congenital fault of moral organization;
but it may be witnessed even in young children, who, long
before they have known what vice meant, have evinced an
entire absence of moral feeling, with the active display of all
sorts of immoral tendencies, a genuine moral imbecility or in-
Sanity. As there are persons who cannot distinguish certain
colors, having what is called color-blindness, so there are some
who are congenitally deprived of moral sense. There are many
persons who still think moral idiocy or imbecility to be a med-
ical crotchet. A deficiency of moral sense, they would say, is a
characteristic of the criminal nature, which must be met by a
suitable punishment. But when we find young children, long
before they can possibly know what vice or crime means,
addicted to extreme vice, or committing great crimes with an
instinctive facility, and as if from an inherent proneness to
criminal actions; when we ascertain that they are the victims
of an insane inheritance; and when experience punishment it
has no reformatory effect upon them—that they cannot reform
—it is made evident that moral imbecility is a fact, and that
punishment is not the fittest treatment of it. Under the in-
fluence of the mental revolution which takes place at puberty,
moral imbecility is apt to take the more active form of moral
insanity, or of actual mania. Cases of this kind obviously
bring us very near the class of criminals; in fact, when a
person of the lower orders of society suffers in this way he
generally does something which causes him to be sent to prison
without question asked of the propriety of his fate.”
In some cases of impulsive insanity, little or no mental de-
rangement, apart from the morbid idea or impulse has been
noticed, but in most cases it will be found on an intimate
420 INSANITY AND ITS TREATMENT.
knowledge of the patient's feelings and doings that there is
more derangement than appears on the surface. His whole
mental tone is more or less affected, so that his feelings are
blunted or changed, the natural interests of life extinguished,
and his judgments of his relations to others, and of their rela-
tions to him somewhat impaired; he is apt to become suspi-
cious of and hostile to those who have been his nearest friends
and acquaintances, and may finally get delusions concerning
them.
Perhaps it has been in some degree owing to the way in
which this deep perversion of feeling, this affective derange-
ment, has been overlooked, or made of little account, attention
having been attracted exclusively to the morbid idea or act,
that there has been so great an aversion toward the doctrine of
impulsive insanity. And yet its impulsive character is of the
very essence of insanity, for in all forms of the disease parox-
ySms of impulsive violence are common features; without
assignable motives, insane patients suddenly tear their clothes,
break windows, smash crockery, attack other patients, and do
great injury to themselves; they exhibit unaccountable im-
pulses to walk, to run, to set fire to buildings, to steal, to utter
blasphemous or obscene words; wherefore if there be one
thing which a large experience of them teaches, it is how im-
possible it is to foretell the impulses which may suddenly arise
in their minds, and to trust them from hour to hour. The
paroxysmal impulse of homicidal insanity is not singular in its
nature, it is singular only in being the prominent or appar-
ently single symptom of the disease.
Pinel reports the case of a man named X. who at regular
intervals was attacked by paroxysms of rage, beginning with
heat in the abdomen and extending thence to the chest, neck
and face. His countenance was reddened and he felt the arter-
ies throbbing violently. At such times he would be seized
with an irresistible impulse to kill, and he would slay the
first person he met. He enjoyed the full eacercise of his reason
even during the attack. He would answer clearly and rationally
all questions without any incoherence or delirium. He real-
ized the full horror of his situation and reproached himself
MORAL INSANITY AND MEDICAL JURISPRUDENCE. 421
bitterly for his wicked desires. When his paroxysms came on
he would cry to his wife to fly and save herself. At the
asylum he sought to kill his attendant whose kindness he
acknowledged and praised. This inner contest at length led
him to such despair that he attempted to commit suicide in
order to end it.
Calmeil reports the following interesting case where there
was no special delusion nor marked physical symptom.
“Glenadel, having lost his father during infancy, was
brought up by his mother, and during childhood his conduct
was exemplary. At the age of sixteen his character changed,
and he became sombre and taciturn. His mother many times
sought to find the cause of his sadness, but in vain. At length
he told her that he must break his silence and said: “You
are the best of mothers and I love you with all my heart,
nevertheless for some time a constant impulse has prompted
me to kill you. In order to prevent such a dreadful event
happening finally, allow me to enlist as a soldier.” He was
persistent in his resolution, enlisted, and made a good soldier,
but he had a constant inclination to desert that he might go
home and kill his mother. His term having expired, his im-
pulse was as strong as ever, and he re-enlisted. His impulse
still persisted but would now be satisfied with the substitution
of his sister-in-law, and this new passion was as strong as the
other had been. At this time Glena.del made a confidant of
one of his comrades newly arrived from his town. This com-
rade reassured him, telling him that the contemplated crime
was impossible, for his sister-in-law was dead. Overwhelmed
with joy, Glenadel obtained his discharge, and started for
home delighted with thoughts of seeing his mother and friends
once more. But on his arrival he found his sister-in-law
alive, and, uttering a frightful cry, he found his impulse to
kill as strong as ever. He confessed all to his brother, telling
him that he was more dangerous than a wild beast. At his
request his brother bound him with cords, sent for Dr. Cal-
meil and carried him to the asylum. The evening of his ad-
mission he wrote a note to the superintendent saying: “I have
entered your asylum and I will behave as well as in my regi-
422 INSANITY AND ITS TREATMENT.
ment, and I shall be considered cured of my dreadful thoughts.
At times, indeed, I may pretend that it is so, but do not be-
lieve me. I ought not to be allowed to depart under any pre-
text whatever. When I beg to be set at liberty redouble your
watchfulness. I should only use that freedom to commit a
crime at which I shudder.’”
While then the experience of all recent medical writers, with
the prominent exception of Prof. W. A. Hammond, is concur-
rent and conclusive that insanity very frequently exists with-
out delusion, and that very frequently insane persons are able
to discriminate between right and wrong, the jurist remains
trammeled by decisions and precedents that can only recog-
nize insanity when accompanied by delusion, or a deficiency
in the ability to discriminate between right and wrong. Un-
der these circumstances it need not cause surprise to find con-
fusion and mal-administration of justice when medical expert
testimony is brought into court.
To adduce arguments to an experienced alienist, at this day,
to prove that a person may be insane and yet possess the power
of discriminating between right and wrong, would be super-
fluous and a waste of time. In every asylum we may see pa-
tients who are given to tearing up their clothes, and who know
as well as anyone, that what they do is wrong, and they de-
light in doing it because it is wrong. If the old legal test of
right and wrong were strictly applied, probably half the in-
mates of our asylums would have to be released. And so with
impulsive insanity, there are many persons who are perfectly
conscious that their acts are wrong; indeed, who will admit
that they are doing wrong, alleging that they “know it is
wrong but yet cannot resist the impulse driving them to do
it.” Instances are not uncommon where persons have even
voluntarily sought the refuge of asylums, asking to be con-
fined and guarded to prevent their committing crimes, which
they appreciate the wickedness of but feel an irresistible im-
pulse to commit. I remember the case of an idiot named
Jimmy who had paroxysms of being destructive and mis-
chievous, and not infrequently when he felt the attacks com-
ing on, he would ask to be kept restrained as he could not
MORAL INSANITY AND MEDICAL JURISPRUDENCE. 423
help acting badly when the spell took him. Others have
sought the shelter of an asylum to be restrained from commit-
ting crimes at which their moral nature shuddered. Many
interesting and instructive cases of these forms of insanity are
on record, and they prove, beyond the shadow of a doubt, that
insanity does exist without delusion, and when the intellectual
faculties, if not absolutely unimpaired, are yet in such a state
of integrity that the patient is perfectly conscious of the un-
lawfulness of his acts, and of his responsibility for them to
the law.
In neither form of emotional insanity will the test of the
knowledge of right and wrong, avail. Under its application
we must decide all these cases to be not insane; and we find
the same unreliability in the test of delusion.
There are probably but few of us who have not at some
time, in our own persons, experienced impulses to do things
that are unexplainable even to ourselves, and that closely
border upon insane impulse. Where there was no perceptible
motive, nay, where every rational consideration impels to an
opposite course of action, we sometimes feel a prompting to do
something, not a crime, it may be, but simply a folly, that is
only prevented by an active exercise of the reason and of the
will. Now it is easy to suppose a condition in which the
prompting is a little stronger; the corrective or restraining
action of the will feebler, and we have a state in which crime
might readily be committed, and yet it would be difficult to
define it as a condition of insanity. It is of these cases that
Dr. Carpenter speaks when he says: “It is unquestionable that
many criminal actions are committed under the irresistible
dominance of some insane impulse, the individual being at
the time perfectly aware of the evil nature of those actions,
and of his amenableness to punishment for them.” The cases
in which murderers have declared their crimes to have been
committed in the manner here spoken of, and the strongly
corroborative circumstances leave no room for a reasonable
doubt upon this point. That such persons are really insane
seems clear; that they should on this account not be held amen-
able to a certain extent, is not at all 80 clear to our mind:
424 INSANITY AND ITS TREATMENT.
The application of criminal law in cases of supposed, or al-
leged insanity was comparatively easy under the old ruling,
that “insanity could only be admitted to exist when there
was a complete inability to discriminate right and wrong.”
It is so palpably unjust to punish one for an action, who is in-
competent to form or hold opinions of the right and lawful-
ness of his acts, that, to prove insanity with this definition
attached, was to secure an acquittal. The case was similar
with those forms of complete mania and melancholia, where
the whole being was plainly under the control and influence
of the disease, and when all the actions were prompted and
guided by the false beliefs. It was from this and kindred
reasons that it came to be a maxim in law “that an insane
person cannot commit crime,” and this fact came to be well
understood by the insane themselves, e.g., at the time of the
burning of the English cathedral at York by an insane man,
named Martin, the latter was shown to be insane; and one of
the inmates of the asylum there said to another, “they cannot
hang him for he is one of us !”
As our knowledge of insanity has become more settled and
thorough, as we have come to a clearer appreciation of the so-
called partial insanities, and as we are now compelled to admit
that many persons do have a knowledge and discrimination
of right and wrong: at the same time the law not making a
proper advance from its old maxims and decisions, the appli-
cation and enforcement of criminal law becomes involved in
most serious embarrassments. On the one hand, it debars
many, who are unquestionably insane, from the protection
they ought to receive; while on the other, many persons are
technically proven insane, and escape the punishment which
ought justly to be awarded; the law being too limited in its
Scope in the one direction, too broad in its application upon
the other.
The law as it now stands is very unsettled. In England it
seems to declare: “If the accused person at the time of com-
mitting the offence knew right from wrong, and that he was
doing wrong, he must be brought in guilty, whether insane or
not.” This is an advance over the older rulings, which re-
MORAL INSANITY AND MEDICAL JURISPRUDENCE. 425
quired a total and general ignorance of the differences between
right and wrong as essential to an acquittal on the grounds of
insanity (or the existence of delusions to be proven), inas-
much as it requires that the person, at the time of committing
the offence, must know he is doing wrong in that particular act.
Yet this advance is far behind the requirements of right and
justice; as it is now notorious that a great many insane per-
sons know the wrongfulness of their actions, and yet ought
not to be considered responsible, and so we find that “juries
often, and judges occasionally, out of a natural humanity, re-
pudiate this dogma,” and the operation of the law becomes
variable and uncertain.
In the “Great Berkhamstead Case,” in England, D. E. was
charged in March, 1877, before Sir W. P. Brett, for the mur-
der of two of his children. The learned judge is reported to
have charged the jury as follows: “Some explanation must be
given of his not knowing it was a wrongful act. It was not
sufficient that his mind was diseased, but to be so far diseased
as not to know the nature of the act, or not to know that it
was wrong. Now was the mind of the prisoner so diseased
that he thought it was better that his children should die, but
not so far diseased as not to know that in killing them he was
committing an offence against the criminal law of the coun-
try. If the jury could conscientiously say that when the pris-
oner killed the children he did not know that at law it was a
wicked thing to do, or that it was contrary to the criminal
law of the country, they would acquit him on the ground that
he had satisfactorily excused himself; but if, on the other
hand, they found that he did know, however much they might
think his mind diseased, it was their duty to show that he was
guilty of murder.”
At Croyden, in 1875, Lord Justice Brett at another trial
thus spoke: “They must disabuse their minds of the medical
notions as to insanity, for the reason that the medical men
had not met the court upon the ground which they desired
them to do, and that their opinions were founded upon their
own ideas as to what the law of insanity ought to be. Even
at the risk of seeming to sum up against the prisoner, he
27
426 INSANITY AND ITS TREATMENT,
must tell them that it was not enough for them to be satisfied
that the prisoner was insane, but that he was so insane as not
to know what he was doing; or if he did, that he did not
know that he was doing a wrong thing, or that he did not
know he was doing a thing contrary to law.”
In 1874, a bill was introduced into the British House of
Commons—a bill drafted by Sir James Stephens:
“Homicide is not criminal if the person by whom it is com-
mitted is at the time when he commits it prevented by any
disease of the mind.
“(a)—From knowing the nature of the act done by him.
“(b)—From knowing that it is forbidden by law.
“(c)—From knowing that it is morally wrong.
“(d)—From controlling his own conduct.
“But homicide is criminal although the mind of the person
committing it is affected by disease, if such disease does not
in fact produce some one of the facts aforesaid in reference to
the act by which death is caused, or if the inability to control
his conduct is not produced exclusively by such disease. If a
person is proved to have been laboring under any insane de-
lusion at the time when he committed homicide it shall be
presumed, unless the contrary appears, or is proved, that he
did not possess the degree of knowledge or self-control herein-
before specified.”
In an article upon “Responsibility of the Insane” in the
American Journal of Insanity of July, 1881, the editor, Dr. John
P. Gray, says:
“Where the disease of insanity is established, we are ready
to hear either of fixed delusions or general mania, with acts
not directly traceable to definite delusions, of melancholia
with homicidal or suicidal tendencies, with or without the
knowledge of right and wrong, but always without the power
of self-control or self-guidance, which is the most direct effect
of the disease. It was substantially this definition which, as
Chief Justice, Sir Alexander Cockburn wished to introduce
into the Criminal Code drawn up by the Royal Commissioners
in 1878, but without success; the Commissioners preferring to
leave the law as it was, throwing upon the defense the burden
MORAL INSANITY AND MEDICAL JURISPRUDENCE. 427
of proving that the criminal was laboring under such insane
delusions or such mental disease as destroys the capacity to dis-
tinguish between right and wrong, and, moreover, that the delu-
sions, if any, were such as pertained to or contributed to the
perpetration of the crime. Judge Cockburn recognized the
fact that an insane delusion may take away the power of Self-
control, even when the abstract sense of right and wrong is
not lost, although he appears to qualify his position somewhat
when it was proposed to make all delusion a presumption
for the loss of self-control, by saying: ‘the pathology of in-
sanity shows that the mind may be subject to delusions which
do not in any degree affect the moral sense or the will as
regards the power of self-control. The mere existence of
mental delusion ought not to affect the decision as to the power
of self-control, unless the nature of the delusion be such as would
legitimately lead to the inference that the power of self-control
was wanting. The question is one which should be decided
by all the circumstances, independently of any presumption one
way or the other.' We suspect that the last sentence indicates
about the only way in which the loss of self-control in any
particular case can be established, but we are inclined to think
that where the disease of insanity is proven aliunde, as by
previous facts or history, it makes but little difference what
may be the character of the delusions; that when a man has
lost his reasoning power, his power of Self-control and guidance
can hardly remain totally unimpaired. It is for this reason
that the insane man is the most uncertain of all creatures, and
we never know in what direction his insanity may not show
itself, or how far in its influence upon conduct, any particular
delusion may extend.”
In the United States, while the same uncertainty prevails to
some extent, the older rulings and decisions, and the so-called
tests of insanity are often repudiated as fallacious; and the
rulings of our courts, more untrammelled by precedents and
theories, and more open to common sense views, are more in
agreement with the requirements of justice.
In the charge to the jury in the case of Kleim tried for
homicide in New York, in 1845, Judge Edmonds said: “It
428 INSANITY AND ITS TREATMENT.
must be borne in mind that the moral as well as the intellect-
ual faculties, may be so disordered by disease as to deprive the
mind of its controlling power,” and, since that time at least,
the courts have at times, recognized both partial and general
intellectual insanity, as well as partial and total moral in-
sanity, as a ground both of exclusion of conviction for crime,
and as incapacitating for the performance of civil contracts,
especially for making a valid will.
In another quite noted trial, that of Cole for the shooting of
Hiscock at Albany, Judge Hogeboom thus charged the jury.
“An insane impulse leaving the mind incapable of exertion,
holding the individual incapable of exercising his mind, so far
as I have defined it to you, exempts him from responsibility,
and if, under the influence of such a want of mind, the
prisoner commits the act, whether you call it an insane im-
pulse or not, it exempts him from responsibility. Mere im-
pulse, whether you call it irresistible or not, does not excuse if
it be the impulse of excited passion arising from revenge, from
resentment, from intention to do an act which is wrong, or a
crime, and the prisoner is aware of it. Whether he is impelled
to it by peculiarities of temperament, by a nervous disposition,
by excited feelings, or anything of that sort, will not excuse
him from responsibility. But how can we distinguish between
this impulse and the insane impulse?”
In a late case the court instructed the jury that “they should
return a verdict of not guilty, if the killing was the result
of mental disease in the defendant; that neither delusions;
nor knowledge of right and wrong; nor design or cunning
in planning or executing the killing, and in escaping or avoid-
ing detection; nor ability to recognize acquaintance, or to
labor or transact business or manage affairs, is as a matter of
law, a test of mental disease; but that all symptoms, and all
tests of mental disease, are purely matters of fact to be de-
termined by the jury.” We find here, that the jury are in-
structed not to inquire whether the prisoner is insane, accord-
ing to any theory or test of insanity, but to consider all the
circumstances of the case, from a common sense standpoint,
and to give a verdict accordingly. In commenting upon this
MORAT, INSANITY AND MEDICAL JURISPRUDENCE, 429
decision, Dr. Maudsley thinks in the future the question sub-
mitted to the jury will probably be, was the particular act the
offspring or product of mental disease? He evidently holds to
the view that it is impossible, and probably ever will be so, to
give any “test” for insanity, as each case must be examined in
the light of all its surroundings. If insanity is found to exist
in the individual, and if the offense is the result of that insanity
(or the product of mental disease), he must be held irrespon-
sible.
At a Parliamentary Inquiry into the Lunacy Laws of Eng-
land held in 1877, Dr. J. Crichton Browne, one of the Com-
missioners in Lunacy, in answer to the question “Are you of
the opinion that they (lunatics) should be relieved from re-
sponsibility to the laws of the land?” answered, “Certainly
not, except so far as any crime they may commit has been
influenced by their insanity, or is the result of mental dis-
ease.” &
While such decisions and views are vast strides in advance,
we cannot think they are fully up to the requirements of the
present time. Lord Hale, when Lord High Chancellor of
England, said: “We must be careful lest on the one side, there
be a kind of inhumanity towards the defects of human nature;
and on the other side too great an indulgence given to great
crimes,” and the latter seems now to be our greatest danger.
The legal authorities tell us that “setting aside cases of de-
mentia, or loss of mind and intellect, the true test of insanity
is mental delusion. If a person persistently believes supposed
facts, which have no real existence except in his fevered im-
agination and against all evidence and probability, and con-
ducts himself, however logically, upon the assumption of their
existence, he is, so far as they are concerned, under a morbid
delusion, and delusion in that sense is insanity,” (Abbott’s New
York Digest, Vol. 7, 1865.)
“The degree of unsoundness or imbecility of mind, sufficient
to invalidate the acts of the party in some cases, may not suf-
fice in others. But in regard to insanity, where there is no
frenzy or raving madness, the legal and true character of the
disease is delusion,--Or as the physicians express it, illusion or
430 INSANITY AND ITS TREATMENT.
hallucination,-and the insane delusion consists in a belief in
facts which no rational person would believe.” (Greenleaf's
Law of Evidence, Vol. 1, p. 464)
It has been shown clearly that many cases of insanity can
and do exist without any delusion whatever, and this has been
shown and acknowledged by both medical and legal authori-
ties. It follows then that it is impossible to define insanity by
any one or two test symptoms. Each case should be exam-
ined by the jury in itself, and they must be left to judge of the
value of all facts in connection with it. This seems to be the
tendency of our latest American rulings, and it is the more
humane, just and proper course, and a great advance over
the older methods;–better calculated to do justice to the pris-
oner, if not to protect the community. Still we cannot refrain
from hazarding the opinion, that the ends of justice would be
better served, the security of society rendered more certain,
and the rights of individuals more secure, if the laws, both
statute and those ordained by custom and sanctioned by pre-
vious rulings of the courts, exempting insane offenders from
punishment, were all repealed, leaving the jury to determine
the guilt or the innocence of the accused, not on the grounds
of insanity alone, but from all the facts; considering in each
case when insanity is alleged, its value if proven, as an ele-
ment in forming an opinion as to the degree and extent of
punishment to be awarded; and I would have the court call
in the advice of expert testimony to give their help in learning
the true condition of the accused, and the extent to which the
insanity has influenced the actions, instead of as now, having
medical experts retained, as are counsel, to aid one side or
another, than which nothing tends more to bring medical ex-
pert testimony into discredit and disrepute.
No doubt it will seem cruel to many, to advocate the doc-
trine that insane persons should ever be made to suffer punish-
ment for crime. But all modern criminal law is based solely
upon the principle of protection to Society. It recognizes in
its administration nothing of the spirit of vengeance or re-
taliation upon the criminal. It imprisons or it kills, not be-
cause the culprit deserves imprisonment or death. Its penal-
MORAL INSANITY AND MEDICAL JURISPRUDENCE. 431
&T)
ties are never imposed with a view to cause suffering simply
because it is thought merited, and as an atonement for the
crime; if this were the case, the punishment would always be
Severe as the crime were atrocious. But always, its only and
Sole object is to protect the community, either by depriving
the criminal of further opportunity to commit crime; or
through the example it offers, to deter others from the perpe-
tration of similar misdeeds. Laws are passed to protect each
individual in the enjoyment of life, property and his other
rights and privileges; and with punitive provisions, that warn
others not to interfere with those rights; and, when crime is
committed, that is, when the rights of another are invaded,
punishment is enforced to impress the fact, that transgression
is not only forbidden, but will be inevitably followed by un-
pleasant consequences to the transgressor. There is no natural,
inherent right in any government or power to deprive any
man of liberty or life. The power is assumed by common
consent, for the common safety, and is only justified by the
law of self-protection; and it becomes brutality and tyranny
when used beyond these strict requirements. But the great
natural law and right of self-protection is Supreme! It has no
limits in its proper application. If any member of the com-
munity is, either through his own voluntary act, or some com-
bination of unfortunate circumstances, detrimental to the com-
munity; the community must protect itself from him. If it
be through his own voluntary act, as a wilful murder, then a
punishment is inflicted to prevent a repetition of the act by
the same person, or by others. If it be through no fault of his
but a misfortune, as when a homicide is committed in an
attack of mania, then the community protects itself by put-
ting the offender in confinement; but no punishment, as such,
is inflicted, because it could have no good effect, as other
maniacs would not be thereby deterred from homicide, hav-
ing no proper conception of the relation of the punishment to
the crime.
But is it always true that punishment, or the prospect of
punishment would have no good effect as applied to insane
persons? Is it not a notorious fact that constantly, both in
432 INSANITY AND ITS TREATMENT.
and out of asylums, insane patients are governed by fear, and
restrained through dread of punishment, though in hospitals
it goes by the name of restraint and seclusion and discipline?
Having seen that it is not at all uncommon for cases of emo-
tional insanity, men clearly and undoubtedly insane, to be
possessed of the ability to discriminate between right and
wrong, and to have sufficiently clear perceptions of the nature
of crime and its penalties, could not some provision be made
for controlling them through fear of punishment, while at the
same time recognizing their insanity? Both as a matter of
protection to the community and of benefit to themselves,
would it not be wise to apply to many of these cases of moral
and impulsive insanity, the same restraining influence we find
useful for same criminally disposed persons?
As an epidemic inclination for suicide among young women
was checked by a law ordering that the bodies of those so
destroying themselves should be exposed naked to the public
view; so in turn it seems as if murder manias might be greatly
controlled by judicious laws.
An extremely good example of the preventive influence of
a judiciously devised punishment, was afforded by the stop
which was put to the repeated alarms to which Queen Victoria
was subjected, after the real attempt made upon her life by
Edward Oxford. The motive in his case seemed to be nothing
else than morbid vanity, which was gratified by his being
tried for high treason and made an object of public notoriety.
Being found “not guilty on the ground of insanity,” to
which he was proved to have an hereditary predisposition,
and being placed in Bethlehem Hospital as a lunatic, no cor-
rective impression as to punishment was made upon the class
from which he sprung, and the like morbid love of notoriety led
one young fellow after another to threaten the Queen, by pre-
senting pistols and other weapons, sometimes unloaded, when
she appeared in public. In order to protect her from the con-
stant repetition of these outrages, a bill was hurried through
Parliament in the shortest possible time, making the offence of
presenting any firearms at the Queen (even if unloaded) a
disgraceful one, to be punished with whipping, and no more
was heard of such attempts.
MORAT, INSANITY AND MEDICAL JURISPRUDENCE. 433
If then there are cases in which the fear of punishment
acts upon the minds of insane persons, with a wholesome and
restraining influence, it seems as though it were right and
proper that the community should receive the protection
which can be given it by the enforcement of the laws in such
cases, as well as in those where insanity does not exist. If it
be made absolutely certain that punishment will follow Swiftly
upon the steps of those who do injury to the persons or
the property of others, many, having the “insane tempera-
ment,” or laboring under “partial” insanity, will be con-
trolled, and have their powers of resisting insane promptings
strengthened, who might, with a less certain prospect of pun-
ishment before them, give way to their evil impulses.
It is not meant that no distinction should be made between
sane and insane criminals; or that each should be punished
with like severity. Of course there are many cases in which
it would be most cruel and unjust, and would serve no good,
purpose, to inflict any punishment other than that implied in
confinement in an asylum. But any attempted definite legis-
lation to afford protection to this class must fail; just as all
attempts to cover such cases by definite judicial rulings have
failed, because it must always be impossible to give a strict
and accurate definition that shall embrace this class only.
The only way to practically solve the difficulty is to render
all criminals, whether insane or not, equally liable under the
law; leaving the court and jury free to determine the kind
and degree of punishment for each individual case; taking
into consideration all the features of the case; investigating
the facts of the insanity as part of the facts of the case, and
as palliative circumstances only, and guiding to determine
the nature and extent of punishment, whether in an asylum
or elsewhere.
We will occupy the remaining portion of this lecture in
considering the testamentary capacity of the insane. First as
to imbeciles, for idiots of course cannot make a will. Imbe-
ciles of the lowest grade are evidently incapable of making a
will, but those who are called feeble in intellect may be capa-
ble even when under guardianship. For it is evident that
434 INSANITY AND ITS TREATMENT.
the nature and consequences of a will may be sufficiently
understood by many an imbecile who is utterly incapable of
discerning the complicated relations that are involved in the
management of property. For this reason it is said “that if
a man be of a mean understanding, neither of the wise sort
nor of the foolish, but indifferent as it were, betwixt a wise
man and a fool; yea, though he rather incline to the foolish
sort, so that he might worthily be called a dull pate, or a
dunce, such a one is not prohibited to make a will.” Noth-
ing can be more natural than that he should be attached to
those who have rendered him important services, and perhaps
have well-founded claims on his bounty; and if anxious to
leave Some substantial token of his regard, no legal impedi-
ment ought to prevent him from bequeathing them a reasona-
ble portion of his property. The danger anticipated from
Such an exercise of the testamentary capacity is more imagin-
ary than real; for it can hardly be conceived that testa-
mentary dispositions, which turn the descent of property
altogether from its natural channels, to heap it upon a
stranger or a favorite, would not be attended by appearances
of circumvention or fraud that would inevitably destroy their
validity. All that is required to establish the wills of people
of weak understandings is that they should have been capa-
ble of comprehending their nature and effect. But of course .
the slightest appearance of interference, or improper influ-
ence, should be closely scrutinized, and as much less evidence
required to substantiate its existence, as the party is more
likely to have been affected by it.
We now consider cases of partial mania, or melancholia,
Such as are usually regarded as monomanias, and the princi-
ples that guide us here are few and simple. “When a man
suffers under a partial derangement of intellect, and on one
point only, it would be unjust to invalidate acts which were
totally distinct from, and seem uninfluenced by, this so limited
insanity; but if the act done bears a strict and evident refer-
ence to the existing mental delusion, we cannot see why the
law should not also interpose a limited protection, and still
less why courts of equity and probate, which in their ordinary
MORAL INSANITY AND MEDICAL JURISPRUDENCE. 435
Fº
jurisdiction relieve against mistake, should deny their aid in
Such cases. If we have a case where a man conceives an an-
tipathy against his relatives, thinking that they seek his life;
and if under the influence of these delusions he makes a will,
leaving his property to others, the will is null and void. On
the other hand, testamentary dispositions which are founded
on motives that might be supposed to govern a sane mind,
and present on their face no indication of insanity, have not
been disturbed, though the mind were confessedly laboring
under some degree of derangement.”
The Surrogate of Orange County, New York, in the matter
of the last will of J. C. Calhoun, 1870, said: “Monomaniacs
are those persons who are insane upon some one or more sub-
jects, whether it relate to one or more persons or things, and
are apparently sane upon all others. Such persons are com-
petent to make a will, unless the subject of their infirmity is
involved in the making of it. The belief in the existence of
mere illusions or hallucinations, creations purely of the imagi-
nation, such as no Sane man would believe in, is unequivocal
evidence of insanity. The persistent belief of a person in Sup-
posed facts which have really no existence, except in his im-
agination, and who act on such, belief, proves him, so far as
such acts are concerned, to be acting under a morbid delusion.
Such a delusion is partial insanity. When it appears that the
will is the direct offspring of such partial insanity, it must be
regarded as invalid, though the general capacity of the testator
is unimpeached,”
The following opinion was given by Judge Denio, of the
New York Court of Appeals, December, 1865.
“1. The true test of insanity affecting testamentary capacity,
etc., aside from cases of dementia or loss of mind and intellect,
is mental delusion.
“2. A person persistently believing supposed facts, which
have no real existence, against all evidence and probability;
and conducting himself upon the assumption of their exist-
ence, is, so far as such facts are concerned, under an insane
delusion. g
“3. If a testator at the time of making his will is laboring
436 INSANITY AND ITS TREATMENT.
under any such delusion in respect to those who would natu-
rally have been the objects of his testamentary bounty, and
the court can see that the dispository provisions were or might
have been caused by such delusions, such instrument is not to
be deemed his will.” *
Judge Gridley, of the Supreme Court of New York, said:
“A monomaniac, on more than one subject, may make a valid
will, when the provisions of the will are entirely unconnected
with, and of course uninfluenced by, that particular delusion.
But where there is good reason to believe the will is the off-
spring of that particular delusion which has seized his mind
and controls its operation the will is otherwise. A will thus
made, under the influence of a powerful delusion, which has
not only impaired but perverted his judgment and under-
standing in relation to subjects connected with the provisions
of the will, so as to exercise a controlling influence in the dis-
position of his property, is not the will of a testator of sound
mind. His mind is unsound quoad, the very subject on which
it is called to exercise its powers in making the will.”
In England, Sir John Nichol said: “Where there is no di-
rect evidence of the deceased's state of mind at the time of the
act done, recourse must be had to the usual mode of ascer-
taining it in such cases, which is looking at the act itself. The
agent is to be inferred rational or the contrary, in such cases,
from the character broadly taken of his act. Testamentary
dispositions that conflict with the natural distributions of
property, and the known and expressed intentions of the tes-
tator, are to be held as sufficient evidence of unsound mind.
(Addams' Ecclesiastical Reports.)
In the case of Dew v. Clark (Addams' Reports), the existence
of monomania is recognized on the ground of delusion, and
its operation on the understanding in controlling the civil
acts of an individual. The testator Scott had conceived a
violent antipathy against his daughter without any cause,
which was declared to be solely the offspring of delusion, and
his will, which cut her off from all participation in his estate,
was set aside on that ground alone.
It must now be regarded as the settled doctrine of English
MORAL INSANITY AND MEDICAL JURISPRUDENCE. 437
and American courts, that partial insanity may or may not
affect the validity of a will. But it is not so well settled that
a will is necessarily invalidated by the presence of mental disease
possessing a wider range of influence.
In quite a celebrated case, Lord Brougham, Chancellor of
England, said that “there was a manifest disposition to lay
down a rule, that no person laboring under monomania, or
partial insanity can be deemed intestable, unless the kind of
insanity appears on the face of the will. But there was want-
ling the courage to lay down a proposition which would at once
have been rejected, and must have been met with the question:
Could any court admit to probate the will of the man who
Said “I am the Christ,” although that will bore no marks
whatever of an unsound mind, still less of the dreadful delu-
sion under which the party labored.” Undoubtedly, many a
man whose mind is swarming with delusions, and whose in-
Sanity is manifested, in some way or other, every hour of the
day, may make a will perfectly correct and proper in its dis-
positions, and exhibiting no trace of disease, either in its form
or substance. Is such a will to stand? Practically there would
be no difficulty. If the testator had shown, in his discourse or
his conduct, the least flash of reason, his case would be re-
garded as one of monomania, and subject to its rules.
A judge or medical expert is seldom required to decide
questions of more delicacy than those of mental capacity in
old age, when the mind is confessedly laboring under Some
kind or degree of impairment. The standard by which some
witnesses' minds are formed in such cases is so different, and
the pertinacity with which each one clings to his own conclu-
sions—in proportion generally to his ignorance of the subject
—is so strong, that nothing but a clear intellect and a good
judgment will enable one to perform his duty with credit.
Though some of the perceptive powers may preserve their
wonted activity through the whole of the disease, yet it is in
, these that the disorder is first manifested, and that long before
the higher powers of the understanding have materially
suffered. The memory of persons, things, and dates, and
especially of recent impressions is exceedingly treacherous;
438 INSANITY AND ITS TREATMENT.
and so striking is this impairment to those unaccustomed to
look beneath the surface of appearances, that when they find
they are not recognized, though once well enough known;
that past events and actors engaged in them are either for-
gotten, or entangled and confused, and that a certain listless-
ness and absence of mind takes the place of former animation
and attentiveness, they summarily conclude, but often mis-
takenly, that for all business purposes, the patient is utterly
unfit. But we must remember that “he may not have Suf-
ficient strength of memory and vigor of intellect to make and
to digest all the parts of a contract, and yet be competent to
direct the distribution of his property by will”; and again, “a
man may be capable of making a will, and yet incapable of
making a contract, or to manage his estate.”
We are to bear in mind, however, that testamentary dispo-
sitions generally imply an exercise of memory. The mind
must be able to bring up before it scenes and persons connected
with the past as well as the present; for without such ability
persons may be overlooked who would otherwise have held a
prominent place in the will, and transactions forgotten which
might naturally be supposed to have an effect upon its dis-
positions. A will which makes no mention of relatives who
had a natural claim on the bounty of the testator, and in re-
gard to whom he apparently entertained only the kindliest
feelings, creates a suspicion that his memory is at fault, and
unless the fact is satisfactorily explained raises a strong pre-
sumption against the validity of the will. Many old men who
have begun to lose their faculties have a passion for making
wills, and So far as the form is concerned, they are able to do
it correctly, but they are often governed by the whim of the
moment rather than any definite views of the claims which
others may have upon them, and not having them brought to
their notice by any one else, they are liable to overlook them
unintentionally.”
Testamentary dispositions made during the lucid intervals
of mania or febrile delirium are often contested on the ground
of incapacity, especially when there is any suspicion, real or
pretended, of improper influence on the testator's mind. The
MORAL INSANITY AND MEDICAL JUIRISPRUDENCE. 439
law requires that in such instances the occurrence of lucid
intervals should be proved beyond a reasonable doubt, but as
delirium is merely an adventitious symptom, and, not like
mania, the habitual state of the patient, it will be satisfied with
much less proof in the former than in the latter affection.
In these cases it is the practice of the English ecclesiastical
courts, not to confine their attention exclusively to the evi-
dence directly relating to the mental condition of the testator,
but to consider all the circumstances connected with the testa-
mentary act; for the object is not so much to settle the ques-
tion of Soundness or unsoundness in general, as in reference
to that particular act. This principle is, that a person may be
capable of testamentary acts while technically and really un-
Sound; and incapable of doing other acts requiring delibera-
tion or reflection. This principle is particularly applicable in
cases of delirium where the transitions from a state of sense-
less raving to that in which the mind is calm, perfectly ration-
al and conscious of its condition are very rapid, and where in
the lucid interval, the mind, though weak, is clear and un-
clouded by any of those peculiar views and notions which
often characterize the lucid interval in mania. Accordingly,
the testamentary capacity is to be determined, in a great meas-
ure by the nature of the act itself. If it be agreeable to in-
structions or declarations previously expressed when unques-
tionable sound in mind; if it agrees with the general tenor of
his affections; if it be consistent and coherent one part with
another; and if it have been obtained by the exercise of no
improper influence, the will will stand, otherwise not.
440 INSANITY AND ITS TREATMENT.
LECTURE XIX.
Non-Restraint in the Treatment of the Insane.
Non-restraint: “La plus haute expression de ce qu'il est
possible de réaliser dans l’intérêt de l'amelioration intellectu-
elle, physique, et morale des aliénés confiés à nos soins.” (Mo-
Tel. Le Non-Restraint, p. 37.)
One of the most important of the “vexed questions” con-
cerning the treatment of the insane at the present time is
that of the use or non-use of mechanical restraint, and, in
entering upon the consideration of this subject, it may be well
to review briefly some of the leading features in the condition
of the insane at the close of the eighteenth century, and the
change that took place at that time.
Previous to the year 1792, the treatment of the insane was
barbarous and cruel; asylums were managed like prisons, and
were full of ingenious devices for torturing and punishing the
unhappy lunatics who were confined and chained within
their walls; stripes were inflicted daily as proper remedial
treatment, and the patients were regarded and treated as wild
beasts rather than as human beings. At that time two illus-
trious men, Hahnemann and Pinel, showed that the insane
can be ruled by kindness more easily than by severity. The
part taken by Hahnemann is not generally known, even
among his followers, as it was the work of but a short period
of his life, and was overshadowed by the brilliant results of
his investigations in..the field of Materia Medica.
In the year 1792 he was appointed to the charge of an
asylum in Georgenthal, and in 1796 he published an account
of his cure of the Hanoverian minister, Klockenbring. In
this report he advocates gentle treatment of the insane in
these words: “I never allow any insane person to be pun-
ished by blows or other painful corporeal inflictions, since
there can be no punishment where there is no sense of re-
sponsibility; and since such patients cannot be improved, but
NON-RESTRAINT IN THE TREATMENT OF THE INSANE. 441
must be rendered worse, by such treatment.” Dr. Dudgeon
says: “May we not, then, justly claim for Hahnemann the
honor of being the first who advocated and practiced the
moral treatment of insane? At all events, he may divide
the honor with Pinel, for we find that towards the end of the
same year, 1792, Pinel made his first experiment of unchain-
ing the maniacs in the Bicêtre.” (Dudgeon's Lectures on Homoe-
opathy, London, 1845, p. 23.)
The above date has been generally accepted as the one in
which Pinel’s experiment was made, but it appears from a
sketch of his life, written by his nephew, that “his appoint-
ment to the Bicêtre hospital was in the latter end of 1793,
and not in 1792.” Thus his work among the insane began
fully a year later than that of Hahnemann.
When Pinel entered upon his duties at the Bicêtre he was
deeply impressed by the fearful condition of the inmates, and
at last, after much urging, prevailed upon the authorities to
allow the removal of the chains and shackles. The story of
this great deed has been told too many times and is too well
known to need relating here; suffice it to say that the experi-
ment was successful, and order and kindness succeeded to
tumult and harshness.
At the time Pinel was laboring in France, Dr. William
Tuke was establishing the Friends’ Retreat at York, England.
He endeavored to treat the inmates with all kindness and
gentleness, in order that the institution might indeed be a
“place in which the unhappy might find a refuge; a quiet
haven in which the shattered bark might obtain the means of
reparation and of safety.” In this asylum, although restraint
was not entirely abolished, the system of treatment by kind-
ness was inaugurated in England, and the restraints used
were of a mild type.
Little reform was made in other hospitals, except the one at
Lincoln. Here in 1829, Dr. Charlesworth, becoming con-
vinced that the use of mechanical restraint was in many cases
injurious, laid his views before the Board of Visitors; who
ordered, February 16th, “that the Director do keep a journal,
in which he shall make daily entry of every Restraint and
28
442 INSANITY AND ITS TREATMENT.
Severity used in this Institution, specifying the name of the
patient, the nature of the restraint or severity applied, and the
hours at which the same commenced and ended, and that the
said journal be laid before each Weekly Board, and signed by
the Chairman.” A similar rule is now in force in every
asylum in Great Britain. Improvement even in the Lincoln
Asylum was slow, and attended with great difficulties, until, in
1835, Mr. Gardner Hill was appointed house surgeon in con-
nection with Dr. Charlesworth, and in a few years their united
efforts resulted in the entire abandonment of the use of re-
straint. Mr. Hill entered upon his duties with the resolution
of carrying into effect his principle, that “in a properly con-
structed building, with a sufficient number of suitable atten-
dants, restraint is never necessary, never justifiable, and always
injurious in all cases of lunacy whatever.”f
In spite of the reform so successfully carried out at Lincoln,
most of the hospitals continued the use of chains, hand-cuffs,
and restraint chairs. In 1839, Dr. John Conolly succeeded Sir
Charles W. Ellis as Resident Physician to the great Hanwell
Asylum, containing about a thousand patients. Previous to
assuming the direction at Hanwell, he visited Lincoln and
other asylums; at all, except Lincoln, were found strait-waist-
coats, hand-cuffs, leg-locks, and various coarse devices of iron
and leather, including gags and horrible screws to force upon
the mouths of unhappy patients who were unwilling or even
unable to take food. At Hanwell the instruments of restraint
of various kinds amounted to some six hundred.
Dr. Conolly was well versed in the views of Pinel, Tuke,
Charlesworth and Gardner Hill, and was fully convinced that
the application of restraint increased the very evil that it was
intended to relieve; and in his first report says: “The example
of the Lincoln Asylum, in which no patient has been put in
restraint for nearly three years, came also powerfully in aid of
* “Total Abolition of Personal Restraint in the Treatment of the Insane.” A
Lecture by R. Gardner Hill, London, 1839, p. 71.
f Hill on Lunatic Asylums, p. 21.
f A Memoir of John Conolly, M.D. By Sir James Clark, M.D., London, 1869,
p. 38.
NON-RESTRAINT IN THE TREATMENT OF THE INSANE. 443
an attempt to govern the asylum at Hanwell by mental re-
straint rather than by physical.” In 1849 he published his
eleventh and final report, giving a summary of his work at
Hanwell during the ten years of his life there. He says: “I
will only further simply state, that now for ten entire years,
no hand or foot has been fastened in this large asylum by day
or night, for the control of the violent or the despairing; that
no instrument of mechanical restraint has been employed or
even admitted into the wards for any reason whatever; that
no patient has been fastened in a coercion-chair by day, or
fastened to a bedstead at night, and that every patient, however
excited or unmanageable, arriving at the asylum in restraint,
has been immediately set free, and remained so from that
time.”
Urged by the results attained by Dr. Conolly, the treatment
of the insane without restraint, and with but a limited amount
of seclusion, has since been the rule throughout Great Britain;
but Dr. Norton Manning says in his report on lunacy that,
“during the last few years there has been a certain reaction in
the feelings of superintendents on the subject. In quite half
of the asylums visited, although restraint was not practiced,
its advantage in certain cases was distinctly admitted, and it
does not now meet with the all but wholesale condemnation
which was accorded to it a few years ago.”*
In the United States, restraint is used in almost every hos-
pital. The forms generally used are the camisole, wristers,
muff, bed and chair straps, the crib-bed, and seclusion; the
amount of restraint varies according to the discretion of the
Superintendent and officers; but in no hospital does it com-
pare with the amount used in England some forty years ago,
and as a whole the patients are treated with a great degree of
kindness and humanity.
It may seem presumptuous to criticize the treatment advised
by those who have made the care of the insane the work of a
life time; but while I am willing to acknowledge that there
are times when the use of restraint may be necessary, and of
* Report on Lunatic Asylums. By Fred. Norton Manning, M.D., Sydney N.
S. W., 1865. By Authority, p. 116.
444 INSANITY AND ITS TREATMENT.
benefit to the patient, I also contend that the use of restraint,
as it now prevails in our hospitals, is excessive and injurious
to the patient. I know, too, that patients have spent the largest
portion of their asylum life, secluded (i.e. locked in), in their
own room; one patient of whom I had knowledge, during a
residence of over two years, only left his room when it was de-
sired to clear out the rubbish which had accumulated there.
It is by no means rare for a violent, or so-called dangerous, or
noisy patient to spend weeks restrained by the camisole, muff
or wristers by day, and a suitably prepared room at night. If
an attendant desire to leave his gallery for a time, insuffi-
ciently guarded, he simply makes matters safe and quiet by
applying restraint or seclusion to any noisy or excitable pa-
tient. Similar examples might be given to almost any extent,
but it seems as though they should not occur, and that the
constant aim should be to avoid restraint as much as possible.
It is a rule in every asylum that restraint or seclusion shall
never be applied except by order of one of the medical offi-
cers, and if through some emergency the rule should be neg-
lected, the fact is to be immediately reported. Practically, in
many hospitals, this rule is a dead letter, and the application
of restraint is left too much to the wishes and discretion of
the subordinate officers and attendants. As a necessary con-
sequence the object kept in view at all times and under all
circumstances, is not the greatest amount of comfort to the
patient, and his recovery, but the quiet and orderly govern-
ment of the hospital, and, in a less degree, the convenience of
the employes. This is not due to any intention on the part of
the officers of the hospital, but is one of the fruits of the pres-
ent system of asylum management.
It is not my purpose to discuss the question of whether, as
is supposed by many, abuses occur in hospitals, but only to
speak of such treatment as receives the indorsement of Super-
intendents as being right and proper. Among the methods
of restraint or discipline in use in some hospitals there is one
called “bathing,” a process thus described by one who was sub-
jected to it: “The patient's hands and feet are tied, and some-
times a gag is inserted in the mouth. He is then placed on
NON-RESTRAINT IN THE TREATMENT OF THE INSANE. 445
the bottom of a bath-tub upon his back, his face directly un-
der the faucet, through which the water is let into the tub.
The faucet is then opened, and the water rushing through
falls directly on and into the patient's face, filling his nostrils
and mouth, producing all the sensation of Suffocation by
drowning.” This evidence was given before a legislative com-
mittee of investigation, and the attendant who inflicted this
bathing, testified that he did so by order of the superintend-
ent, in order to induce the patient to confess committing some
slight misdemeanor of which his innocence was afterwards
proved. “Ducking” is another recognized use of the bath in
many asylums in cases of patients, male or female, of filthy
habits.
Among the late writers on insanity no one is more justly
eminent than Dr. Henry Maudsley, who gives his views as
follows: “There can be no greater fallacy than that of Sup-
posing what is called a moderate use of mechanical restraint,
to be consistent with a general plan of treatment in other re-
spects humane and beneficial. It must be dispensed with
altogether, or deterioration will ensue in the patient, and all
kinds of neglect and tyranny will be engendered by degrees,
until restraints become the usual substitutes for forbearance
and watchful attention. It is necessary that the abolition of
restraint should be absolute to be efficient; the principle of
the non-restraint system will admit of no compromise. I do
not hesitate to express a strong personal conviction that the
use of mechanical restraints in any asylum, public or private,
is an indication of a badly managed institution, and that its
use in the treatment of private cases is unnecessary and preju-
dicial.”
The advocates of restraint in its milder forms claim that in
abandoning its use there would be a great increase of Seclu-
sion, which would prove fully as objectionable; but Dr. Man-
ning says in his Report, p. 121: “In all the arguments used
for restraint by American physicians, the evils of seclusion are
pointed out; but there is, as a rule, more seclusion notwith-
standing the restraint in American than in English asylums.”
When the true advocate of non-restraint uses seclusion, he
446 INSANITY AND ITS TREATMENT.
practices it as did Dr. Conolly, at Hanwell, with whom it was
simply the removal from a gallery to a quiet room; from
noise and excitement to tranquility. In extreme cases the
room was padded and partially darkened. All cases of seclu-
sion, if of only half an hour's duration, were reported to the
medical officer and a record kept.
If our superintendents were required to keep for inspection
by proper officers an accurate record of every instance of re-
straint, seclusion or use of the bath, is it probable that they
would consider it necessary to use them as often as is now the
case?
Dr. Conolly says in his Eleventh Report: “The temporary
Seclusion of patients—that salutary exclusion of causes of ex-
citement from an already irritated brain—is found to be but
seldom necessary except for a few hours, and as an actual
remedy which the soundest principles of medicine would re-
cognize in every disease of excitement.”
In Scotland, in 1855, an objectionable amount of seclusion
had followed the abolition of restraint. Patients were locked
up in darkened rooms for days, weeks and even months. Now,
however, such a state of affairs is never seen; and in Some
asylums seclusion is virtually abolished except for medical
reasons.”f
Dr. John P. Gray says: “Do what we may, there will always
be dangerous lunatics, there will be those who want to kill
themselves, mutilate themselves, who will tear off their cloth-
ing, indulge in fecal self-defilement, and strike their associ-
ates or keepers. If kind words sufficed to calm them, do you
suppose recourse would be had to restraint? Kind words,
however, only produce this effect in the books; and even in
that corner of Paradise Lost called Gheel, when a patient
becomes disturbed he is restrained—he is chained.”
The advantages claimed for a proper use of mechanical re-
straint, are thus set forth by the distinguished alienist, M.
* Memoir of Dr. Conolly, p. 34.
† Letter from Sir James Coxe, Commissioner in Lunacy for Scotland, to Sir
James Clark, quoted in Memoir.
NoN-RESTRAINT IN THE TREATMENT OF THE INSANE. 447
Christian, in a paper read before the Medico-Psychological
Society of Paris,* October 25, 1880.
“Suppose, for instance, that in a medical or surgical Service
a patient—and the case is one of frequent occurrence—who is
the victim of fever and delirium, should get out of bed in the
night, disturb his associates and put the whole ward in dis-
order, do you believe that one would hesitate to fix him in
bed, or, if necessary, apply a camisole 2 Indeed, families
themselves, be their social status what it may, have no such
scruples. When one of their members, under the visitation of
disease, becomes boisterous, violent, and dangerous, he is ren-
dered incapable of self-injury by restraint-and with what
gentleness this is applied, you may gather from the condition
of the unfortunates who are brought to us covered with con-
tusions and abrasions, and having on their ankles and wrists
the visible traces of the cords with which they have been
bound. Observe that in all these cases it is the safety of the
entourage, the interest of the patient himself which demands
the restraint. The mad man must be prevented from injur-
ing himself and others, and here we have a motive before
which every other consideration must yield.”
Then alluding to the claim made by English Superinten-
dents that no restraint whatever was needed, he says: “From
the day on which Conolly applies his reform, all excitement
disappears in his asylum ; patients the least amenable to dis-
cipline, obey the gentle and firm voice of the physician as if
by a charm; the attendants are all intelligent, faithful, of a
patience capable of every trial. So true, indeed, was all this,
that in order to ensure sleep, all that was necessary in the case
of even the most excited patients, was to have them swallow a
large glass of fresh water at bed-time ! Gentlemen, when I
read these things, written in good faith by a conscientious
physician worthy of all respect, I bow my head in admiration.
I am struck with the fact that in a latitude differing so slightly
from ours, there are lunatics so entirely different from those
which I have had occasion to observe; that among those Eng-
* Annales Médico-Psychologiques, November, 1880.
448 INSANITY AND ITS TREATMENT,
lish people, who do not exactly shine by reason of their gentle-
ness and mansuetude, there suddenly appears on the scene a
corps of attendants, so gentle, so patient, so long-suffering.
But having admired, I examine and interrogate; and I learn
that in all these asylums, so easy of management, a few auxil-
iary means are nevertheless necessary. It may be a padded
cell in which the patient can be abandoned to himself with-
out fear of self-injury; gloves like those used by boxers and
fencers, which they apply to prevent him from injuring him-
self or others; or garments of a thick substantial fabric, but-
toned behind, and used to preclude their removal or destruc-
tion; or, again, they may envelop him in a sheet; finally and
especially; it is surveillance, a surveillance exercised every
instant by two, four, or it may be six of these model attend-
ants, who delicately seize the patient in their robust arms
whenever he becomes too ºboisterous, and, without struggle,
without violence, have him glide into the padded cell. And
these are not the only means; the lavish use of narcotics, such
as opium, morphia and chloral, forms an essential part of non-
restraint.
“Quite recently the German Psychiatrical Society put this
question on the order of the day. It was discussed at great
length, a committee was appointed to examine it in all in its
bearings, and each member related what his individual ex-
perience had been. “I know no alienist,” said Laehr, ‘who
accepts non-restraint in an absolute manner. Nor is there
any who voluntarily accepts means of restraint and applies
them systematically.’ The case could not be better stated, and
I venture to say that in France we are nearly all of the same
opinion. We avoid restraint as much as possible, but when it
is imposed on us by force of circumstances, it is our duty to
apply it, for we have to protect the madman against himself,
and ourselves against him. I use the camisole, but I use
it as seldom as possible, and on an average I have never
had two per cent. of patients on whom it was applied. I say
emphatically that when the camisole is well made, when it is
cut from a soft and flexible material, when it is sufficiently
ample, when, finally, it is only used on the physician's order,
NON-RESTRAINT IN THE TREATMENT OF THE INSANE. 449
and under his control, then not only does it not hamper the
patient's movements, but it enables him to move about at
liberty, and, if need be, he may be afforded sufficiently free
motion of the arms and hands. If, in viewing the question
from its sentimental aspect, you deplore the insult offered to
manly dignity by camisoling a fellow-creature, let me ask if
this manly dignity is not otherwise compromised by the fact
of patients covering themselves with ordure, denuding and
mutilating themselves, and striking those who surround them?
I may say that for me the camisole possessess one immense
advantage—it prevents struggling between the patient and his
keepers.”
Among American superintendents, no one stands higher
than Dr. T. S. Kirkbride, and in his views he represents the
ideas held by the most eminent and successful of his associ-
ates. In his report for 1852, he refers to the subject of re-
straint in the following terms: “No point connected with the
treatment of the insane is more conclusively established than
that every such institution may be conducted without any
mechanical restraint whatever; whether it is expedient to do
so under all circumstances is not so well settled. To dispense
with restraining apparatus entirely, requires that a hospital
should be so constructed as to give all the benefits of the
most perfect classification; that it should always have a full
force of tried attendants and abundant means of exercise and
occupation in the open air.” The amount of restraint used
in the hospital under charge of Dr. Kirkbride is perhaps less
than in any other American hospital; owing perhaps in part
to the fact that a large majority of his patients are drawn
from the wealthier classes of society, and whose friends are
able and willing to pay for every comfort and convenience.
Elsewhere the doctor says: “The use of mechanical means
of restraint, and the protracted seclusion of patients in their
rooms, ought both always to be regarded as evils of no trifling
magnitude, and to abate which as far as possible no effort
should be left untried. Besides leading patients into bad
habits, the frequent use of the means referred to in a ward,
induces attendants and others to look upon them as a common
450 INSANITY AND ITS TREATMENT.
resource in cases of difficulty and danger, to regard them as
their grand reliance in every emergency, and to forget the
great power of other measures that are entirely unobjection-
able—the value of tact and kindness and sympathy in con-
trolling the violence and dangerous propensities of the in-
Sane. Objectionable as I deem the use of restraining appar-
atus in a hospital for the insane, it cannot be too strongly
insisted on that it is no advance to substitute the frequent
and long-continued seclusion of the patients.””
Dr. H. P. Stearns, in his report of the Hartford Retreat for
the year 1877, on page 27, uses the following language:
“They (waistcoat, wristlet, camisole, manacles, muffs, etc.)
are eminently unscientific, and should be dispensed with as far
as possible. It has been my aim to earnestly and carefully
study each case coming under my observation with this in
view, and I am happy to be able to report that we have suc-
ceeded in passing the year without the use of any of these
means of mechanical restraint.”
The reasonable advocates of non-restraint do not deny that
cases may occur when the use of restraint may be of service
and even necessary. They insist, however, that it should not
be resorted to except in a case of clear necessity, and that its
use shall only be ordered by the medical officer after personal
inquiry, as he would order any other remedial agent.
I have now, ladies and gentlemen, traversed with you the
field of mental diseases, and tried to give you as clear an idea
as possible of their fundamental principles, their symptoms,
treatment and jurisprudence. As you are aware it is a sub-
ject in which I have been deeply interested for more than
fourteen years, and in preparing and delivering these lectures,
I have been engaged upon a labor of love; and if they aid any
one of you in restoring health to the diseased mind I shall feel
amply repaid for my work.
* Insanity and Insane Asylums. Report of E. T. Wilkins, M.D., Commissioner
in Lunacy for the State of California, p. 106.
IND E X.
A
Aconite, 140; general indications for,
155; in mania, 183, 184, 195, 196,
275; in hysteria, 385.
Actaea racemosa, 151; in melancholia,
154; in mania, 184; in general
paralysis, 351; in hysteria, 385;
in hypochondriasis, 390; in chorea,
401.
Activity of intellect in epileptics, 282.
Acts of the insane, 62 et seq.
Affective monomania, 220; case of 232.
Agaricus musc., in epilepsy, 319; in
general paralysis, 354.
Age in relation to insanity, 92; to hys-
teria, 370; to chorea, 394.
Albuminuria, as a cause of puerperal
insanity, 265.
Alcohol, the use of, in general paralysis,
351
Alison, Dr., on hysteria, 369.
Allen, Dr. T. F., on use of bromide of
potash in epilepsy, 316.
Allman, Dr., address on biology, 13.
Althaus, Dr. Julius, on mental condi-
tion of epileptics, 27.9; on pathol-
ogy and causes of chorea, 379.
Aluminium, use of, 123, 124; in gen-
eral paralysis, 354.
Amyl nitrite, in epilepsy, 317.
Anacardium, indications for, in puer-
peral insanity, 275,276; in general
pºlysis, 351; in hypochondriasis,
90.
Anaemia, as a factor in puerperal in-
sanity, 264.
Anstie, Dr., on hereditary neurosis, 83;
relations of alcoholism to insanity,
Aphonia, laryngeal and hysterical, 380.
Apis mel, in melancholia, 139,141, 144.
Apparatus of restraint,description of, 65.
Appetite and digestion, general dis-
turbances of, 56.
Argentum met., in epilepsy, 314.
Argentum nit., 124; in melancholia,
154; in epilepsy, 314.
Arnica, 184, 275; in general paralysis,
354.
Arsenicum alb., 139, 144; in melan-
cholia, 150, 153, 154; in mania,
185, 186; general indications for,
156, 275; in general paralysis, 351,
354; in hypochondriasis, 390.
Artificial feeding of the insane, 68 et seq.
Asafoetida, in hysteria, 385; in hypo-
chondriasis, 390.
Ataxic gait in general paralysis, 333.
Atropine, use of, in epilepsy, 317.
Attitude of dejection in melancholia,
148.
Aura in epileptic insanity, 285; intel-
lectual or emotional disturbances
as a substitute for, 285, 308.
Aurum, in melancholia, 123,124; with
..climacteric, 130, 150, 275; in hy-
pochondriasis, 390, 391.
Austin, Dr., on prodroma in general
paralysis, 330.
B
Bacon, Dr. G. M., on noSology of gen-
eral paralysis, 323.
Baehr, Dr., treatment of general paraly-
sis, 354; of hypochondriasis, 391.
Baillarger, on hereditary influence, 86;
folie circulaire, 211; sexual in-
stinct in general paralysis, 330;
varieties of general paralysis, 341;
melancholic form of general pa-
ralysis, 342; pathology of general
paralysis, 359.
Baptisia, in melancholia with stupor,
139, 140, 141, 144.
Bastian, Dr. C., on pathology of chorea,
399.
Baths, use of, in mania, 177; tepid, in
jºral paralysis, 352; abuse of,
Bayle, on pathology of general paraly-
sis, 359.
Beddoes, Dr., on disturbance of speech
in epilepsy, 282.
452
INDEX.
Bed-sores, in general paralysis, 358.
Bed-strap, description of 67.
Bell, Dr. Luther, when to feed the in-
Sane, 72.
Belladonna, in melancholia, 124; with
stupor, 141, 142, 144; general in-
dications for, 157; in mania, 182,
183, 184, 185, 186, 187, 192, 196,
197, 198; in puerperal insanity, 270,
275; in epilepsy, 315, 317; in gen-
eral paralysis, 351, 355; in hys-
teria, 385.
Berjeau, on treatment of hypochondria-
sis, 392.
Blandford, Dr. G. F., false beliefs of
the insane, 37; acts of the insane,
62; causes of insanity, 91; ex-
alted ideas in general paralysis,
331; pathology of general paraly-
sis, 360.
Bonnet, on pathology of general paraly-
sis, 360.
Brain, as an organ of the mind, 12.
Brain-cells, function of 20, 22.
Brºs. peculiar, in melancholia,
8.
Breeches, restraint, for masturbators,
66.
Brett, Sir W. P., on responsibility of
the insane, 425, 426. e
Brewster, on hallucination, 31.
Brierre de Boismont, hallucination in
epilepsy, 310; on mental prodro-
mata in general paralysis, 330.
Brigham, Dr. A., insanity a physical
disease, 15.
Briquet, relation of sex to hysteria, 370.
Brodie, Sir Benj., on melancholia, 115;
§ hysterical affections of the joints,
80.
Bromide of potassium, in puerperal in-
sanity, 274; in epilepsy, 315.
Brougham, Lord Chancellor, on testa-
mentary capacity in partial insan-
ity, 437.
Brown, Dr. J. Crichton, cranial injur-
ies as a cause of insanity, 90; on
puerperal insanity, 273; on the
aura of epileptic insanity, 285; the
earliest symptoms of general paral-
ysis, 325, 326, 327, 331; duration
of general paralysis, 350; pathol-
ogy of general paralysis, 359; mec-
roscopic appearances in general
paralysis, 362; on responsibility
of the insane, 429.
Brown, Dr. W. A., on artificial feed-
ing, 72; intellectual weakness
from epilepsy, 286.
Brown-Sequard, on pathology of epi-
lepsy, 290.
Bryonia, 186, 275.
Bucknill, Dr. J. C., definition of insan-
ity, 10; on insane impulse, 41;
early symptoms of insanity, 47;
dreaming as a warning symptom,
51; sex as a factor in insanity, 92;
on dementia, 110; on simple mel-
ancholia, 123; on melancholia
with stupor, 137; chronic mania,
187; homicidal mania, 247, 248;
on kleptomania, 252; responsibil-
ity of epileptics, 312; pathology of
general paralysis, 360.
Bullard, Dr., case of mania, 178.
Burgher, Dr. J. C., on chorea, 393.
Butler, Dr. W. M., indications for the
use of fourteen principal remedies,
155.
C.
Cactus grand., in melancholia, 152,
275.
Calcarea carb., general indications for,
158; 156, 157, 275; in epilepsy,
320; in general paralysis, 354; in
hysteria, 385; in hypochondriasis,
390; in chorea, 402.
Calcarea phosph., 351.
Calmeil, on mania transitoria, 205; on
pathology of general paralysis, 359;
case of impulsive insanity, 421.
Camisole, use of, 65.
Cannabis ind., 275, 351; in hypochon-
driasis, 390, 391.
Cantharis, in mania, 199.
Capsicum, 275.
Carpenter, Dr. W., on moral insanity,
415; on insane impulse, 418, 423.
Castelnau, on mania transitoria, 202.
Catalepsy, definition of, 403: symptoms
of, 404; cases of, 404–408.
Caulophyllum, in hysteria, 385.
Causation, of insanity, 78–94; of mel-
ancholia, 128; of mania transito-
ria, 208; physical, of puerperal in-
sanity, 262; of general paralysis,
347.
Causticum, in general paralysis, 355;
in chorea, 403.
Cerebral congestion, symptoms of, in
mania transitoria, 208.
Chamomilla, in melancholia, 151.
Changes, in ideas, in monomania, 229;
in conduct of epileptics, 282, 284,
287; in mental state, 58; in char-
acter, 59.
INDEX.
453
Charlesworth, Dr., reform in asylum
management, 441.
Child-bearing, as a cause of insanity,
90; mental and physical changes,
incident to, as a cause of puerperal
insanity, 261; aversion to, of Amer-
ican women, 261; frequent, as a
cause of puerperal insanity, 265.
Child-birth, as a cause of mania transi-
toria, 208; the insanity of, 264.
Chloral hydrate, the use of, 142; in
puerperal insanity, 274; in general
paralysis, 353.
Chorea, definition of, as a neurosis, 393;
description of, 394; facial expres-
sion in, 395; choreic thrust, 396;
hemi-chorea, 397; mental symp-
toms, 397; differential diagnosis,
398; causes, 398; pathology, 399;
prognosis, 400; hygienic treatment,
400; medical treatment, 401.
Christian, Dr., on the use of restraint,
447.
Cicuta virosa, 199.
Cimicifuga, its use in climacteric mel-
ancholia, 130, 150, 154; in mania,
184, 275, 351; in hysteria, 385;
in hypochondriasis, 390; in cho-
rea, 401.
Cina, use in chorea, 403.
Cinchona, 141, 144, 184; in hysteria,
385; in hyphondriasis, 390.
Circular insanity, see Folie Circulaire,
p. 210.
Classification of insanity, 94, et seq.
Climacteric, the, as a cause of insanity,
91; with melancholia, 129.
Clothing, stripping off of, 63; destroy-
ing, 63; fantastic, 64.
Clouston, Dr. T. S., on pathology of
general paralysis, 359.
Clymer, Dr. Meredith, case of mental
epilepsy, 295.
Coca, 351.
Cocculus, 275, 352; in hysteria, 385;
in catalepsy, 407.
Cockburn, Chief Justice, on responsi-
bility of the insane, 427.
Combe, Dr. Andrew, definition of in-
sanity, 10.
Complications of puerperal insanity,
272.
Conduct of epileptics, 282.
Conflict between medical and legal
views of insanity, 414.
Congestion, cerebral symptoms of in
mania transitoria, 208.
consive mania in general paralysis,
Conium mac., its use in puerperal in-
Sanity, 275,276; in general paraly-
sis, 351; in hypochondriasis, 390.
Conolly, Dr. John, definition of insanity,
10; case of religious melancholia,
117; on digestive disturbances in
melancholia, 149; on asylum re-
form, 442, 446.
comºtion. scruples, devolopment of,
Constipated habits of insane, 57.
Countenance, appearance of the, in mel-
ancholia, 148; in mania, 172; in
epileptic insanity, 311; in general
paralysis, 331.
Coxe, Sir Jas., on asylum mismanage-
ment, 446.
Cranial injuries a cause of insanity, 90.
Crib-bed, use and description of, 67.
Crocus sat., 275; in chorea, 402.
Cuprum, 275; in epilepsy, 313; in gen-
eral paralysis, 351, 354, 355; in
hysteria, 384.
Curability of puerperal insanity, 258,
265.
Cypripedium, in hysteria, 385.
D
Dagonet, Dr. H., intemperance as a
cause of insanity, 88; on idiocy
and imbecility, 104; case of klep-
tomania, 254.
Debreyne, Dr., on suicidal mania, 249.
Definitions of insanity, 10.
Delafosse, on mania transitoria, 205.
Delasiauve, on epileptic delirium, 298;
mental symptoms of general par-
sº complicated with epilepsy,
0.
Delirium, definition of, 46; in melan-
cholia, 145; in mania, 170; with-
out, a form of general paralysis, 343.
Delusion, definition of 24; varieties,
38; in melancholia, 128, 145; in
mania, 171; in partial intellectual
mania, 222; character of, modified
by habits of life, 235; exalted, in
general paralysis, 335; tolerance
of, in others, 336; as a test in insan-
ity, 422.
Dementia, 110; senile, 111; acute, 111 ;
physical symptoms of 113; treat-
ment of 113.
Demº udge, on testamentary capacity,
8).
Depressed condition in melancholia,
147.
454
INDEX.
Despine, Dr. Prosper, definition of in-
Sanity, 11; mechanism of halluci-
nation, 29 et seq; conditions ne-
cessary for the existence of insanity,
49; unity of the intellect, 219; on
delusion, 224; case of partial in-
tellectual mania, 230; affective
monomania, 232; case of suicidal
mania, 249.
Devergie, Dr. A., on mania transitoria,
202; case of 205.
De Witt, Dr. W. H., case of mania, 180.
Diagnosis, differential, between acts done
in anger and those under the influ-
ence of mania transitoria, 209; of
monomania, 234; of pyromania,
245.
Dickenson, Dr., the pathology of chorea,
3
Dickson, Dr. J. T., on education of im-
beciles, 109; case of melancholia,
117; incoherence in mania, 171;
the varieties of epileptic insanity,
282; disturbances of speech in epi-
lepsy, 282; unconsciousness in epi-
lepsy, 297.
Digestion, disturbances of, 56; in mel-
ancholia, 149.
Digitalis, in melancholia, 143, 144, 150;
general indications for use of, 158;
in general paralysis, 351, 352.
Double forme, variety of general par-
alysis, 343.
Dreams, an early symptom of insanity,
50; in melancholia, 148.
Drouet, Dr., on tenacity of ideas in
monomania, 224; distinction be-
tween general paralysis and ambi-
tious mania, 336.
Dumesnil, on nocturnal epilepsy, 305;
epileptic vertigo, 305.
Dunglison, Dr., definition of hypochon-
driasis, 386.
Duration of mania, 173.
E
Early treatment, importance of, 194.
Ecclesiastical law and testamentary
capacity, 439.
Echeverria, Dr. M. G., relations of
epilepsy to other neurosis, 279;
heredity and epileptic insanity,
281; mental state of epileptics;
grand and petit mal, 290; pathology
of epilepsy, 291; duration of epi-
leptic paroxysm, 300; automatic
habits of epileptics, 307; nocturnal
epilepsy, 304; mental disturbances,
310; feigned epilepsy, 311.
Edmonds, Judge, definition of insanity,
10; on responsibility, 427.
Education of idiots and imbeciles, 109.
Emotional insanity, see Impulsive In-
sanity, 415.
Endocarditis, in chorea, 400.
Epilepsia larvalis, description of 301;
case of 302; similar to recurrent
insanity, 303; cases of 304, 305,
306.
Epilepsy, as a cause of insanity, 90; a
cause of mania transitoria, 208; re-
lations to somnambulism, 289; pa-
thological centre of 290; pathol-
ogy of 291; automatic nature of
acts in, 292; cases of mental epi-
lepsy, 293, 295; with kleptomania,
295; unconsciousness in, 297;
symptoms of maniacal paroxysm
in, 298; feigned, 311.
Epileptic insanity, features of, 278; re-
lation to other neuroses, 279, 280;
larval epilepsy, 280; causes, 280;
how displayed, 281; definition of,
281; change of conduct in, 282;
intellectual activity in, 282;
changes in character, 284, 287;
vicarious paroxysm, 284; aura in,
285; violence of fury, 286; intel;
lectual grand and petit mal, 288;
homicidal tendency in, 289; dura-
tion of paroxysm, 300; state of un-
consciousness, 307; state of semi-
somnambulism, 307; physical and
mental aura in, 308; hallucina-
tions, 310; responsibility, 312;
medical treatment, 313.
Epileptiform fits in general paralysis,
338.
Erlenmeyer, on pathology of general
paralysis, 359.
Esquirol, on hereditary transmission,
86; on sex as a factor in insanity,
92; classification, 98; on idiocy,
101, 103; on imbecility, 103; phy-
sical condition in melancholia, 147;
description of acute mania, 173; of
chronic mania, 174; case of pyro-
mania, 241; case of epileptic ma-
nia, 299; on emotional insanity,
416; on impulsive insanity, 417.
Eulenberg, definition of catalepsy, 403.
Exaggeration of usual methods of
thought, 61.
Excitement, absence of, in pyromania,
Exciting causes, physical, of insanity,87.
INDEX.
455
&
Excito-motor disturbances, in general
paralysis, 338.
Exhilaration of spirits, in insanity, 62;
in mania, 170.
Exposure, indecent, 64.
Eyes, peculiar appearances of, in gen-
eral paralysis, 332; changes in, as
shown by the ophthalmoscope, 190.
F.
Facial expression, in acute mania, 172;
in chronic mania, 190; in epilepsy;
311; in general paralysis, 331; in
chorea, 395.
Falret, Dr. Jules, on folie circulaire,
210; responsibility of epileptics,
278; larval epilepsy, 280; varie-
ties of epilepsy, 282; violence of
epileptic rage, 286, 292; mental
state of epileptics, 288 ; relations
between epilepsy and somnambu-
lism, 289; mental aura, 308; the
use of bromide of potash in epi-
lepsy, 316; history of general pa-
ralysis, 323; congestive maniacal
form of general paralysis, 341; re-
missions in general paralysis, 338.
Feeding the insane, 68 et seq.
Feigned epilepsy, 311.
Ferrier, Dr. David, on cerebral func-
tion, 362.
Fever, a cause of insanity, 90.
Filthy habits in the insane, 63; treat-
ment of, 194.
Fixed idea, in monomania, 229.
Flesh, gain of, as a symptom, 57.
Food, abstinence from, 69; causes of,
69; results from, 71; in puerperal
insanity, 269.
Folie circulaire or Folie à double forme,
210; description of, 212; stage of
excitement, 213; stage of remission,
213; stage of depression, 213; phy-
sical symptoms, 215; sex as a factor
in, 216; prognosis of, 216; juris-
prudence of, 217.
Foville, Dr., on tenacity of ideas in
monomania, 224, 226; aura in epi-
leptic insanity, 285.
French, Dr. A. J., 401.
Frequency of puerperal insanity 258.
Friedreich, case of kleptomania, 255.
G.
Gait, ataxic, in general paralysis, 333.
Galvanism, in general paralysis, 352.
Gelsemium, 139, 140, 144; in mania,
178; in puerperal insanity, 275,
276; in epilepsy, 315; in hysteria,
385.
Georget, early symptoms of insanity,
50; on imbecility, 106.
General Paralysis of the Insane, defini-
tion of, 321; importance of recog-
nizing the early signs, 322; history
of, 323; nosology of 324; varieties
of, 324; order of development of
symptoms, 325; mental symptoms,
325; motor symptoms, 326; stages
of, 327; changes of disposition in,
328; delusions of 329; prodromata,
330; symptoms of, 330, 331; ataxic
gait, 333; delusions in, 334; toler-
ance of the delusions of others,
336; diagnosis from ambitious ma-
nia, 336; character of delusions,
337; remissions in, 337; physical
changes, 338; epileptiform fits in,
338; mental condition produced
by epileptic fits, 340; maniacal or
congestive form, 341; melancholic
form, 342; without delirium, 342;
double forme, 343; sex as a factor
in, 346; causes of, 347; prognosis,
349; duration of 350; causes of
death, 351; treatment of 351; hy-
gienic treatment of, 356; bed-sores
in, 358; pathology, 359; patho-
logical anatomy, 362; jurispru-
dence of, 366.
General Paresis, see General Paralysis.
Gintrac, Dr., on mania transitoria, 205.
Globus hystericus, 372.
Gooch, Dr., on puerperal insanity, 273.
Grand mal, le, 288.
Graphites, 124.
Gratiolet, on hallucinations, 33.
Gray, Dr. John P., views on insanity,
16; definition of hallucination, etc.,
25; causes of hallucination, 26; on
impulse, 40; on lucid intervals, 44;
apparatus for restraint, 68; early
symptoms in general paralysis,
325; responsibility of the insane,
426; on non-restraint, 446.
Greenleaf, on delusion as a test of in-
sanity, 429.
Gridley, Judge, on testamentary capa-
city in monomania, 436.
Griesinger, insanity as a disease, 15;
insane impulse, 42; causes of in-
sanity, 81, 82, 83; sex as a factor
in insanity, 92; idiocy and imbe-
cility, 101; depression of mind in
456
INDEX.
melancholia, 115; sudden mental
changes in insanity, 125; melan-
cholia with stupor, 136; melancho-
lia, 167; folié circulaire, 210.
Guislain, on speech of the insane, 56;
on masturbation among the insane,
89; melancholia without delusion,
125; melancholia, 167.
H.
Hahnemann, the first advocate of asy-
lum reform, 440. ſº
Hale, Dr. E. M., on bromide of potas-
sium in epilepsy, 316.
Hale, Lord Justice, on responsibility of
the insane, 429.
Hallucination, definition of 23; con-
sistent with sanity, 25; of the in-
sane, 27; mechanism of, 29, 35;
in melancholia, 145; in mania,
171; in epilepsy, 310.
Hamilton, Dr. Allen McLean, on cho-
rea, 396, 398; pathology of 399.
Hammond, Dr. Wm. A., definition of
insanity, 10; views on mind, 14;
insane impulse,43; mania transito-
ria, 205; symptoms of mania trans-
itoria, 208; the use of the bro-
mides in epilepsy, 317; insanity
without delirium, 422.
Hart, Dr. C. P., on Gelsemium in ma-
nia, 178; medical treatment of
hypochondria, 390, 391.
Hartmann, Dr., treatment of hypochon-
driasis, 391.
Head, size of, in idiots, 105; in imbe-
ciles, 105.
Headache, an early symptom of insan-
ity, 54; in melancholia, 148; in
mania, 171.
Heart disease, simulation of, in hyste-
ria, 378.
Helleborus, 275.
Helonias, 275.
Hemi-chorea, 397.
Hemiplegia, hysterical, 378.
Hepar. S. c., in puerperal insanity, 275,
276; in nocturnal epilepsy, 320.
Heredity, as a cause of insanity, 78, 84
et seq.; with puerperal insanity,
260, 264; and epileptic insanity,
280; and general paralysis, 347.
Hering, Dr. C., on Belladonna in epi-
lepsy, 317; on treatment of general
paralysis, 355.
Hillº; Gardner, on asylum reform,
2.
| Hitzig, on the pathology of general pa-
ralysis, 359.
Hogeboom, Judge, on responsibility
and insane impulse, 428.
Home-sickness and pyromania, 241.
Hoyne, Dr. T. S., on Belladonna in epi-
lepsy, 317.
Hughes, Dr. C. H., views on insanity,
13
Hughes, Dr. R., on bromide of potas-
sium in epilepsy, 315.
Hydrastis, in hysteria, 385.
Hydrocyanic acid, in epilepsy, 319; in
hysteria, 384.
Hyoscyamine, for excitement of general
paralysis, 355.
Hyoscyamus, in melancholia, 123; gen-
eral indications for, 159; in mania,
179, 185, 186, 192, 196, 197, 198,
199, 200; in puerperal mania, 268,
269, 275; in epilepsy, 315, 318; in
general paralysis, 351, 355; in
hysteria, 385; in chorea, 402.
Hypochondriacal ideas in melancholia,
146
Hypochondriasis, mental state in, 228;
definition of, 386; as a mental dis-
ease, 386; description of 387;
morbid dread of disease in, 388 ;
diagnosis from melancholia, 388;
physical symptoms of 390; treat-
ment, 390.
Hysteria, nature of 367; susceptibility
to, 369; sex and age as factors in,
370; epidemic nature of 371;
mental and physical symptoms,
371; globus hystericus, 372; par-
oxysms of 373; visceral parox-
ysms, 374; diagnosis between hys-
terical and epileptic fits, 375; sim-
ulation of heart-diseases, 377; false
motor paralyses, 378; hysterical
paraplegia, 379; aphonia, 379; af.
fections of the joints, 381; mental
disturbances, 381; influence of mar-
riage upon, 384; medical treat-
ment, 384.
I.
Idea, change of, in monomania, 229;
fixed idea in intellectual monoma-
nia, 229.
Idiocy, 100 et seq.; cerebral develop-
ment in, 101; definition of, 103.
Idiots, education of 109.
Ignatia, in melancholia, 151,154, 275;
in epilepsy, 314, 319; in general
INDEX.
457
paralysis, 351; in hysteria, 385;
in hypochondriasis, 390; in cho-
rea, 402. g
Ill-health, as a cause of insanity, 91; in
epileptic insanity, 280.
Illusion, definition of 24, 27; in melan-
cholia, 145; in mania, 175.
Imagination, want of, in melancholia,
145; in monomania, 217; work-
ings of, 227.
Imbeciles, weakness of moral sense,
108; education of 109; testament-
ary capacity of, 433.
Imbecility, 100 et seq.; definition of,
103; mental power in, 107; de-
grees of, 107; moral, 108.
Imitation, as an influence in pyromania,
244
Imitative faculty in hysteria, 375.
Impassioned condition in monomania,
218.
Impulse, definition of, 40.
Impulsive insanity, 221, 417; responsi-
bility in, 428.
Inception, gradual, of insanity, 50.
Incoherence in mania, 170.
Incubation, period of, in puerperal in-
sanity, 271.
Indecision of purpose, 61.
Influence of imagination in producing
fixed idea, 227, 229.
Injuries, cranial, a cause of insanity, 90;
of epilepsy, 280.
Insane persons deny their insanity, 220.
Insane temperament, 83; and mania
transitoria, 208; as a cause of pu-
erperal insanity, 260.
Insanity, definitions of, 10; as a plea
against punishment, 424.
mºve insanity, see Monomania,
217.
Intellectual, activity in epileptics, 282;
aura, 308
Intellectual mania, partial, 221.
Intellect, unity of the, 219.
Intemperance, a cause of insanity, 87;
cause of general paralysis, 347;
cause of epileptic insanity, 280;
cause of mania transitoria, 208.
Intervals, lucid, 44.
J.
Jaccoud, intellectual deterioration in
epilepsy, 280.
Jackson, Dr. J. Hughlings, on varieties
of epilepsy, 281; on automatic na-
ture of epileptic actions, 292; the
pathology of chorea, 399.
29 .**
Jahr, Dr. J. H. G., 403.
Joints, hysterical affections of the, 381.
Jones, Dr. E. U., 402.
Jurisprudence, Medical, of general pa-
ralysis, 366; of Somnambulism,
412; general observations upon,
413; in criminal cases, 422 et seq.;
examples of English law, 424; of
American law, 427.
Jury, to decide as to responsibility, 430.
FC.
Kafka, on Hepar sulph., for nocturnal
epilepsy, 320; treatment of general
paralysis, 353.
Kali brom., 275; see also bromide of
potassium.
Kinship, of nervous disorders, 85.
Kirkbride, Dr. Thos. S., views on re-
straint, 449.
Kleptomania, associated with pyroma-
nia, 242; description of 252; men-
tal and physical concomitants of,
253; cases of 253 et seq.; with
pregnancy, 255; with epilepsy,
295; jurisprudence of 256.
Knowledge of right and wrong, as a test
of insanity, 422, 424.
Kussmaul, pathology of epilepsy, 290.
L.
Lachesis, general indications for, 160;
in mania, 200, 275; in general
paralysis, 355.
Lactation, the insanity of 270 et seq.
Larvated epilepsy, description of 301;
see epilepsia larvalis.
Laryngeal and hysterical aphonia, 380.
Lawson, Dr. R., on Hyoscyamus in
mania, 198.
Le Grand du Saulle, case of pyromania,
236; character of the epileptic in-
sane, 287.
Le Maëstre, Dr., on varieties of general
paralysis, 324; general paralysis à
double forme, 343. *
Leubuscher, Dr., hereditary influence,
86
Lilienthal, Dr. S., medical treatment of
epilepsy, 315; medical treatment
of general paralysis, 352.
Lilium tigrinum, in melancholia, 153;
general indications for, 160.
Lucas, Dr. Prosper, on hereditary
transmission, 85.
458
INDEX.
Lucid intervals, definition of 44, and
testamentary capacity, 438.
Ludlam, Dr. R., on simulated heart
disease in hysteria, 377; diagnosis
between hysterical and laryngeal
aphonia, 380.
Luys, Dr. J., the pathology of general
paralysis, 360.
Lycopodium, 179, 275; in hypochon-
driasis, 390.
Lypemania, 114; see melancholia.
M.
Macdonald, Dr. A. E., on importance
of recognizing the early signs of
general paralysis, 321.
MacFarland shooting Richardson, case
of 205.
McIntosh, Dr., on mania transitoria,209.
Maºis. Dr., pathology of chorea,
9.
Macrocephalous idiots, 105.
Mania, 167; definition of 168; symp-
toms of 168; duration, 173; de-
scription of acute, 173; of chronic,
174, 187; tendency to violent acts
in, 189.
Mania, partial intellectual, 221.
Mania, suicidal, see Suicidal Mania.
Mania transitoria, 202; symptoms of,
203; cases of 203, 205; described
by Dr. Hammond, 206; premon-
itory symptoms, 206, 207, 208;
predisposing influences, 207; due
to larval epilepsy, 304.
Maniacal paroxysms in epilepsy, 298.
Manning, Dr. Norton, on asylum man-
agement, 443, 445.
Marc, on pyromania, 244, 246; on klep-
tomania, 252.
Marcé, Dr., on mental integrity in epi-
leptic insanity, 279; on epileptic
rage, 292; duration of epileptic
paroxysm, 300; pathology of gen-
eral paralysis, 360.
Masturbation, as a cause of insanity, 89.
Maudsley, Dr. Henry, definition of in-
sanity, 11; on brain and mental
function, 14; insane impulse, 41,
42; hereditary predisposition, 79;
physical causation, 80; climacteric
insanity, 91; remarks on Dr. Skaës
classification, 95, 97; classification,
98; idiocy and imbecility, 103;
moral imbecility in the young,
108; sudden mental changes in
insanity, 124; melancholia without

delusion, 127; on climacteric mel-
ancholia, 130; symptoms of mania,
172; on transitory mania, 206; on
fixed delusion, 222; case of suicidal
mania, 250; epileptic tempera-
ment, 280; on vicarious epileptic
attacks, 284; diagnosis of epileptic
homicide, 289; earliest symptoms
in general paralysis, 325; respon-
sibility of somnambulists, 412; re-
sponsibility in moral insanity, 418;
absence of moral sense,418; on re-
sponsibility, 429; the use of re-
straint, 445.
Maxwell, Dr., on treatment of idiots,
109.
Mechanism, of normal perception, 35;
of hallucination, 35.
Medical jurisprudence, general observ-
ations on, 413.
Megalomania, how distinguished from
general paralysis, 336.
Melancholia, 114 et seq.; definition,
114; description of 115; divisions
of, 120; without delusion, 125;
causes of, 128; delusious in, 128;
its connection with uterine dis-
order, 129; connection with cli-
macteric, 130; with stupor, 132;
case of, 134; diagnosis from acute
dementia, 137; hygienic treatment,
143; mental symptoms, 145; phy-
sical symptoms, 147; medical
treatment, 150 et seq.; diagnosis
from hypochondriasis, 388; mel-
ancholic form of general paralysis,
342; testamentary capacity, 434.
Memory, state of the, in monomania,
217; required in making a will,
438.
Mental changes, 58; symptoms of mel-
ancholia, 145; of mania, 174; im-
pairment in epilepsy, 278, 285,
286; epilepsy, case of 293, 295;
condition in epileptic general para-
lysis, 340.
Mercurius proto-iod., 270.
Mercurius Sol, in melancholia, 121,
275; in general paralysis, 354; in
hypochondriasis, 390.
Merson, Dr. John, on age as a factor in
insanity, 93.
Meyer, Ludwig, on pathology of gen-
eral paralysis, 359.
Mickle, Dr. Julius, a definition of gen-
eral paralysis, 321; stages of gen-
eral paralysis, 327; on prodromata
of general paralysis, 329; ataxic gait
in general paralysis, 333; on hygi-
*-
INDEX.
459
enic treatment of general paraly-
sis, 356, 357.
Microcephalous idiots, 104.
Mind, the part taken by the, in hallu-
cinations, 32.
Mind and body, connection between, 12,
14, 17
Monomania or Instinctive Insanity,
217; the term monomania incor-
rect, 217; state of memory in, 218;
state of the will, 218; futility of
argument in, 219; forms of, 220;
delusions, 222; reasoning faculty
in, 223; tenacity of ideas, 224, 230;
change of ideas, 229; formation of
delusion, 228, 229; cases of, 224,
225, 226, 230, 232; mental symp-
toms of 232; influence of general
excitement upon, 235; prognosis
of, 223; diagnosis of 234; testa-
mentary capacity in, 434, 436.
Moral and Physical Causes of Insanity,
78 et seq.
Moral Insanity, 413; as a source of
conflict between law and medicine,
414; responsibility in, 415; defi-
nition of, 415; difference from
vice, 416; varieties of, 417; im-
pulsive insanity, 417 et seq.; cases
of, 420 et seq.; jurisprudence of,
430 et seq.
Moral Sense, absence of 419.
Moreau, on headache in insanity, 55;
on intemperance as a cause of in-
sanity, 87.
Morel, on intemperance as a cause of
insanity, 87, 88; on masturbation
and insanity, 90; on epileptic in-
sanity, 284; on intellectual activ-
ity of epileptics, 282; a case of epi-
leptic mania, 299; description of
epilepsia larvalis, 301, 306; on in-
stantaneous insanity, 304.
Morbid impulse of epileptics, 303.
Morse, Dr. N. R., treatment of chorea,
401, 402.
Moschus, in hysteria, 385.
Motor derangement in general paral-
ysis, 326, 333.
Motor disturbances in general, 57.
Motº, paralysis, simulated in hysteria,
378.
Motives prompting incendiarism, 241.
Muff º wristlets, description and use
of, 66.
Muscular restlessness, 57.
N.
Naked, the propensity to go, 63.
Naso-oesophageal tube, dangers of 73;
advantage of 74.
Natrum carb., in hypochondriasis, 390,
391.
Natrum mur., in melancholia, 120, 151,
152, 275; in general paralysis,
353; in hypochondriasis, 390.
Necessity of seclusion in puerperal in-
sanity, 259.
Neumann, on classification, 167.
Neuroses, the insane and epileptic, as
predisposing influences in mania
transitoria, 207.
Nichol, Sir John, on testamentary ca-
pacity, 436.
Nitrite of amyl, in epilepsy, 317.
Nocturnal fits, 304; case of 205.
Non-restraint, 440 et seq.
Nostalgia and pyromania, 241.
Nutrition, disordered, a cause of in-
sanity, 90.
Nux vomica, 123; general indications
for, 161; in mania, 179, 184, 182,
187, 200, 275; in epilepsy, 314; in
general paralysis, 351, 353, 354; in
hysteria, 385; in hypochondriasis,
390, 391; in chorea, 401.
O.
CEnanthe crocata, in epilepsy, 319.
Old age and testamentary capacity, 437.
Oleander, in melancholia with stupor,
144
ophthalmoscopic appearances, in insan-
ity, 190.
Opium, 141, 144; in mania, 199, 200,
275.
Ordronaux, Dr. John, production of
hallucinations, 25.
P.
Packard, Dr., 401.
Paralytic Dementia or Insanity, see
General Paralysis, 321.
Paraplegia, hysterical, 379.
Partial insanities, 424.
Partial intellectual monomania, 220,
221.
Payne, Dr. F. W., case of hysteria, 383.
Petit mal, le, 288.
Petroleum, 275; in hypochondriasis,
390.
460
INDEX.
Phalan, Prof. R. A., a case of chronic
mania, 191.
Phosphide of zinc, in general paralysis,
351.
Phosphoric acid, in mania, 183, 275.
Phosphorus, 275; in general paralysis,
351, 353, 354; in hysteria, 385.
Physical causes, of insanity, 78; of pu-
erperal insanity, 262.
Physical condition of idiots, 105.
Physical symptoms, in melancholia 147.
Pinel, on dreams in early stage of in-
sanity, 50; on disturbed digestion
in insanity, 56; on emotional in-
sanity, 416; case of impulsive in-
sanity, 420; work of asylum re-
form, 441.
Piorry, hereditary nature of insanity, 85.
Platina, general indications for, 162,275;
in general paralysis, 353; in hys-
teria, 385; in hypochondriasis, 390.
Plea of insanity as a defense in criminal
cases, 413.
Plumbum, the use of, in general paraly-
sis, 354.
Poincaré, on pathology of general pa-
ralysis, 359.
Potassium bromide, in puerperal in-
sanity, 274; in epilepsy, 315.
Pregnancy, as a depressing factor, 259;
mental and physical disturbances
produced by, 259; insanity of, 259.
Premeditation no proof of sanity, 62.
Premonitory stage, in mania, 169; in
mania transitoria, 206.
Prevention of criminal acts by the in-
Sane, 432.
Prichard, Dr., on melancholia without
delusion, 126; on moral insanity,
415.
Psorinum, in epilepsy, 321.
Puerperal insanity, definition of the
term, 257; special changes in, 257;
periods of special liability to, 258;
frequency of, 258; curability of,
258, 265; need of seclusion in, 258;
influence of pregnancy, 259; causes
of, 260, 261, 262, 264; danger of
recurrence, 263; at confinement,
264; relation of puerperal condi-
tion to, 264; maniacal form of,
265; symptoms of, 266; prognosis,
267, 272; cases of, 268 et seq.; dur-
ing period of lactation, 270; forms
of 271; complications of 272;
treatment of 273.
Pulsatilla, in melancholia, 123, 152,
154, 275; in hysteria, 385; in hy-
pochondriasis, 390.
Punishment for the insane, 430, 432;
influence of, in preventing crime,
432.
Pyromania, definition of 236; causes'
of 236; cases, 236 et seq.; motives
giving rise to, 241; in young peo-
ple, 241; complicated with klepto-
mania, 242; complete, 243; incom-
plete, 242; curability of 244; ab-
sence of excitement in, 244; evo-
lution of the sexual function as
a factor in production of 244.
R.
Radcliffe, Dr., on intellectual aura, 285.
Raue, Dr. C. G., case of catalepsy, 405.
Ray, Dr. Isaac, sleeplessness and insan-
ity, 89; on classification, 99; on
idiocy and imbecility, 104; on py-
romania, 244, 246; on kleptoma-
nia, 252; on its jurisprudence, 255;
on unconsciousness in epilepsy,
307; on responsibility of epileptics,
312; on existence of moral insan-
ity, 416.
Reasoning, correctness of, in monoma-
nia, 219; faculties of, 223.
Recurrence of puerperal insanity, 263.
Recurrent insanity, similar to epilepsia
larvalis, 302, 303.
Religious melancholia, 116.
Remissions in general paralysis, 337.
Remorse, absence of, in pyromania,
Responsibility in insanity, 414,423,424
et seq.; a question for the jury,
430; principles for deciding, 431.
Restraint, apparatus of, 65; use of, 440;
abuse of, 444; see also Non-Re-
straint.
Reynolds, Dr. Russel, on mental changes
in epilepsy, 278; on hereditary and
epileptic insanity, 280; the pathol-
ogy of epilepsy, 291; pathology of
chorea, 399.
Rhus tox, use of, in mania; 200, 275;
in general paralysis, 353, 354.
Richardson, the shooting of, by Mac-
Farland, 205.
Right and wrong, a knowledge of, as a
test of insanity, 422, 424.
Ritti, Dr., on hallucination, 29, 31.
Romberg, on headache in insanity, 55;
on hysteria, 368.
Rousseau, J. J., case of, 228.
Ruddock, Dr., on general paralysis, 355.
Rush, Dr., on kleptomania, 252.
INDEX.
461
Sanguinaria, 122.
Sankey, Dr. W. H. O., a case of mania,
168; on pathology of epilepsy, 291;
violence of epileptic rage, 298;
similarity of epilepsia larvalis to
recurrent insanity, 302, 303; on
early stages of general paralysis,
328; ataxic gait in general paraly-
sis, 334.
Santonin, in chorea, 403.
Scales, Dr. T. S., 401.
Schlegel, a case of pyromania, 241.
Schwartzer, Dr. Otto, on transitory ma-
nia, 203.
Secale cornutum, in mania, 179, 275;
in general paralysis, 354.
Seclusion, use of, 65; abuses of 443.
Self-absorption in hysteria, 387.
Sense, part played by the nerves of, in
hallucination, 29.
Sepia, in melancholia, 123, 153; gen-
eral indications for the use of, 163,
275; in hysteria, 385; in hypo-
chondriasis, 390.
Sex, as a factor in imisanity, 91; in re-
lation to general paralysis, 346; to
hysteria, 370; to chorea, 394.
Sexual excess, as a cause of general
paralysis, 348, 349; the remedies
for its results, 354.
Sexual function, evolution of, as a
cause of pyromania, 244.
Sheppard, Dr. Edgar, on classification,
97; a case of mania, 175; on treat-
ment of general paralysis, 352; on
the use of Strychnia in general
paralysis, 354.
Silicea, 275; use of in general paraly-
sis, 355.
Skaë, Dr., on classification, 94; on cli-
macteric insanity, 91; on epilepti-
form attacks in general paralys.s,
339.
Sleeplessness, as a symptom of insan-
ity, 51; as a cause of insanity, 88;
in mania, 171. A
Somnambulism, state of, in epilepsy,
307; description of, 410, 411; case
of 411; condition of senses in, 412;
unconsciousness in, 412; responsi-
bility in, 412.
Speech, peculiarities of, among the in-
sane, 55; among idiots and imbe-
ciles, 103; in general paralysis,
331.
St. Vitus' dance, see chorea, 313.
Stael, Madame de, on case of J. J.
Rousseau, 228.
Stannum, use of, in hypochondriasis,
391.
Staphisagria, 275; in general paraly-
sis, 354; in hypochondriasis, 390,
391.
Stearms, Dr. H. P., on the use of re-
straint, 450.
Steinan, Dr. Julius, case of kleptoma-
nia, 253.
Stephens, Justice, on responsibility of
the insane, 426.
Stomach-pump, use of, in feeding the
insane, 74.
Stramonium, general indications for
the use of 164; in mania, 187,200;
in puerperal mania, 269, 275; in
epilepsy, 315, 318; in general para-
lysis, 352, 354, 355; in hysteria,
385; in hypochondriasis, 390; in
chorea, 402.
Suicidal mania, 247; suicide not in-
consistent with sanity, 247; mo-
tives leading to, 248; cases of 249,
250; hereditary nature of, 251.
Suicidal melancholia, treatment,of, 150.
Suicidal tendency in puerperal mania,
267.
Sulphur, 123, 124; in melancholia,
148; general indications for use
of 165; in mania, 183, 185, 186,
200, 275; in epilepsy, 314; in
general paralysis, 352, 354; in hy-
pochondriasis, 390; in chorea,
402.
Sun-stroke, as a cause of insanity, 90.
Sydenham, on hysteria, 368.
Symptoms of insanity, 47.
Syphilis, as a cause of general paraly-
sis, 348.
T.
Talcott, Dr. S. H., cases of melancholia,
120; of melancholia with stupor,
138; medical treatment of melan-
cholia, 149; treatment of mania,
195; cases of mania, 179, 181;
medical treatment of general par-
alysis, 351, hygienic treatment of,
356, pathology of 359.
Tardieu, on mania transitoria, 205.
Temperament, the insane, 83.
Temporary insanity, character of 203;
definition, 206; symptoms of 206,
207, 208.
Tenacity, of will in monomania, 218; of
ideas, 224, 230.
1-#62
INDEX.
Testamentary capacity in the insane,
433; of imbeciles, 434; in partial
insanity, 434.
Thorne, Dr., on mental epilepsy, 293.
Todd, Dr., on pathology of chorea, 399.
Transitory, the term inexact as applied
to mania, 203.
Transitory mania, see Mania transitoria.
Trousseau on mental deterioration of
epileptics, 284; on unconsciousness
in epilepsy, 297.
Tuke, Dr. H., on development of scru-
ples of conscience, 60; exaltation
of spirits, 62; on epileptiform at-
tacks in general paralysis, 339;
diagnosis of 340.
Tuke, Dr. Wm., on asylum reform, 441.
D.
Unconsciousness, in epileptic insanity,
278, 297, 307.
Unity, of the intellect, 219; of the mind,
219.
Uterine disorders, as a cause of insanity,
90; their relation to melancholia,
129; to mania, 180; to puerperal
insanity, 259.
V.
Valerian, in hysteria, 385.
Van der Kolk, on connection between
mind and body, 19; on action of
brain cells, 22; on hallucination,
31; on interchangeability of neu-
roses, 280; pathology of epilepsy,
290.
Van Swieten, on fixed idea in intellec-
tual monomania, 229.
Vipera torv, in melancholia, 355.
Veratrum alb., 144; general indications
for, 165; in mania, 199, 200, 275;
in general paralysis, 352, 353, 355.
Veratrum viride, 139, 140, 195, 196; in
general paralysis, 352.
Vertigo, epileptic, 304; cases of 305.
Voice, alterations in, 55.
Voisin, on pathology of general paraly-
sis, 359.
W.
Water, the use of cold, in acute mania,
177.
Watson, Dr. Thos., diagnosis between
epileptic and hysteric fits, 376.
Well-being, the sense of, in general
paralysis, 335.
Westphal, on pathology of general par-
alysis, 359.
Wharton and Stillé, on suicidal mania,
247.
Whittier, Dr. D. B., 401.
Will, strength of the, in monomania,
218
Wilkinson, Dr. J. Garth, on the nervous
system, 18; relation between auto-
matic and voluntary nervous sys-
tem, 21.
Winslow, Dr. Forbes, on brain as an
organ of mińd, 12; on sleepless-
ness as a forerunner of insanity, 52,
53; on loss of speech in insanity,
56; on changes in character, 59;
on moral insanity, 415; on the
period of incubation in puerperal
insanity, 275; on the disturbances
of speech in epilepsy, 282.
Words, wrong use of, in epilepsy, 282.
Wristlets, padded, the use of, 66.
Z.
Zincum met, in melancholia, 138; in
melancholia with stupor, 138; in
general paralysis, 355.
Zincum bromide, in epilepsy, 321.
Zincum oxide, in mania, 187.
Ziemssen, on globus hystericus, 372; on
chorea, 396; on treatment of chorea,
400.
EOEFICLXE & TAFEL’S
*Hom(POpathic Publications:-
ALLEN, DR. T. F. The Encyclopedia of Pure Materia Medica;
a Record of the Positive Effects of Drugs upon the Healthy
Human Organism. With contributions from Dr. Richard Hughes,
of England; Dr. C. Hering, of Philadelphia; Dr. Carroll Dunham, of
New York; Dr. Adolph Lippe, of Philadelphia, and others. Ten vol-
umes. Price, bound in cloth, $60.oo; in half morocco or sheep, $70 oo
This is the most complete and extensive work on Materia Medica ever
attempted in the history of medicine—a work to which the homoeopathic
practitioner may turn with the certainty of finding the whole pathogenetic
record of any remedy ever used in homoeopathy, the record of which being
published either in book form or in journals. The volumes average about
640 pages each.
ALLEN, DR. T. F. A General Symptom Register of the Homoe-
opathic Materia Medica. By TIMOTHY F. ALLEN, M.D., Author of
the Encyclopedia of Pure Materia Medica. 1340 pages in one large
volume. Price, in cloth, $12.oo; in sheep or half morocco, $14 oo
This Index to the Encyclopedia of Materia Medica is at the same time
the best arranged and most complete Repertory ever attempted. Its inge-
nious selection and arrangement of different kinds of type greatly facilitate
its use.
ANGELL, DR. H. C. A Treatise on Diseases of the Eye ; for
the Use of Students and Practitioners. By HENRY C. ANGELL,
M.D., Professor of Ophthalmology in the Boston University School of
Medicine, etc., etc. Sixth edition, enlarged and illustrated. 12mo.
Cloth, tº cº sº * º * > * & de . $3 Oo
The sixth edition of this standard work has just been issued from the press, and shows
that the whole work has been thoroughly revised and brought up to the latest dates in oph-
thalmology. Exquisite clear photographic illustrations have been added, and an exposition
given of the dioptric or metric system, as applied to lenses for spectacles.
BAEHR, DR. B. The Science of Therapeutics according to the
Principles of Homoeopathy. Translated and enriched with nu-
merous additions from Kafka and other sources, by C. J. HEMPEL,
M.D. Two volumes. I 387 pages, g * * } tº • $9 oo
. . . . “In short Dr. Baehr has presented us with the results of his observations at
the bedside rather than of his researches in the study. It is this which renders his work
valuable, and which at the same time accounts for his occasional imperfections. We know
2 BOERICKE & TAFEL's
of no work of the kind in homoeopathic literature where the suggestions for the choice of
medicines are given in a fresher or clearer manner, or in one better calculated to interest
and inform the practitioner. We have only to add that the two volumes are highly credit-
able to the publishers The type is good, the paper good, and the binding excellent.”—
MONTHLY HomoeoPATHIC REview.
BELL, D.R. JAMES B. The Homoeopathic Therapeutics of
Diarrhoea, Dysentery, Cholera, Cholera Morbus, Cholera
Infantum, and all other loose evacuations of the bowels.
Second edition by DRs. BELL and LAIRD. 275 pages. 12mo.
Cloth, o e © . $ I 5 o
This little book had a very large sale, and but few physicians' offices will be found with-
out it The work was, without exception, very highly commended by the homoeopathic press.
BERJEAU, J. P.H. The Homoeopathic Treatment of Syphilis,
Gonorrhoea, Spermatorrhoea, and Urinary Diseases. Revised,
with numerous additions, by J. H. P. FROST, M.D. 256 pages. 12mo.
Cloth, & dº wº g * ſº g wº te . $ I 50
“This work is unmistakably the production of a practical man. It is short, pithy, and
contains a vast deal of sound, practical instruction. The diseases are briefly described; the
directions for treatment are succinct and summary. It is a book which might with profit
be consulted by all practitioners of homoeopathy.”—NORTH AMERICAN JOURNAL.
BREYFOGLE, DR. W. L. Epitome of Homoeopathic Medi-
cines. 383 pages, tº & e tº tº * wº . $ I 25
Interleaved with writing paper. Half morocco, . ſº . $2 25
We quote from the author’s preface:
“It has been my aim, throughout, to arrange in as concise form as possible, the leading
symptoms of all well-established provings. To accomplish this, I have compared Lippe's
Mat. Med. ; the Symptomen-Codex; Jahr's Epitome; Boenninghausen's Therapeutic Pocket-
Book, and Hale's New Remedies.”
BRYANT, DR. J. A Pocket Manual, or Repertory of Homoeo-
pathic Medicine, Alphabetically and Nosologically arranged, which
may be used as the Physicians' Wade-mecum, the Travellers' Medical
Companion, or the Family Physician. Third edition. 352 pages.
18mo. Cloth, . e g º tº e e ſº . $I 5o
BUTLER, DR. JOHN. Electricity in Surgery. Pp. 112. Cloth,
$I. oo.
These few pages are intended as a practical guide for the use of the specialist and general
practitioner, and aim at showing the necessity of attaining accuracy of detail in all electro-
surgical operations.
The scope of the work precludes the possibility of more than cursory allusion to clinical
cases, but is based almost entirely upon the author's own personal experience, and is for the
most part composed of articles written from time to time for different periodicals, revised
and condensed.
BUTLER, Dr. JOHN. A Text-Book of Electro-Therapeutics
and Electro-Surgery, for the Use of Students and General
Practitioners. By JoHN BUTLER, M.D., L.R.C.P.E., L.R.C.S.I.,
etc. Second edition, revised and enlarged. 350 pages. 8vo. Cloth,
$3 Oo
“Butler's work gives with exceptional thoroughness all details of the latest researches on
Electricity, which powerful agent has a great future, and rightly demands our most earnest
consideration. But Homoeopathia especially must hail with delight the advent from out the
ranks of her apostles of a writer of John Butler's ability. His book will also find a large
circle of non-homoeopathic readers, since it does not conflict with the tenets of any thera-
peutic sect, and particular care has been bestowed on the technical part of electro-therapeia.”
—HOMCEOPATISCHE RUNDSCHAU.
3
HOMOEOPATHIC PUBLICATIONS.
DAKE, DR. W.M. C. Pathology and Treatment of Diphtheria.
By WM. C. DAKE, M.D., of Nashville, Tenn. 55 pages. 8vo. Pa-
Der, . e & º ſº * • & © . 5o Cts.
This interesting monograph was enlarged from a paper read at the Third
Annual Meeting of the Homoeopathic Society of Tennessee, held at Mem-
phis, September 19, 1877.
It gives a report of one hundred and seventy-six cases treated during a
period of eleven months. It well repays a careful perusal.
DUNHAM, CARROLL, A.M., M.D. Homoeopathy the Science
of Therapeutics. A collection of papers elucidating and illustrating
the principles of homoeopathy. 529 pages. 8vo. Cloth, . $3 Oo
Half morocco, e e e tº & i.e e tº . $4 Oo
“After reading this work no one will attempt to justify the practice of alternation of
remedies. It is simply the lazy man’s expedient to escape close thinking or to cover his
ignorance. The one remedy alone can be accurate and scientific; a second or third only
complicates and spoils the case, and will inevitably ruin a good reputation. But to come to
more practical matters, more than one-half of this volume is devoted to a careful analysis of
various drug-provings. It teaches us Materia Medica after a new fashion, so that a fool can
understand, not only the full measure of usefulness, but also the limitations which surround
the drug. . . . We ought to give an illustration of his method of analysis, but space
forbids. We can only urge the thoughtful and studious to obtain the book, which they will
esteem as second only to the Organon in its philosophy and learning.”—THE AMERICAN
HoMCEOPATHIST.
DUNHAM, CARROLL, A.M., M.D. Lectures on Materia Med-
ica. 858 pages. 8vo. Cloth, . tº © * e . $5 Oo
Half morocco, & tº e * º º tº g - $6 oo
. . . “Vol. I is adorned with a most perfect likeness of Dr. Dunham, upon which
stranger and friend will gaze with pleasure. To one skilled in the science of physiognomy
there will be seen the unmistakable impress of the great soul that looked so long and stead-
fastly out of its fair windows. But our readers will be chiefly concerned with the contents
of these two books. They are even better than their embellishments. They are chiefly
such lectures on Materia Medica as Dr. Dunham alone knew how to write. They are pre-
ceded quite naturally by introductory lectures, which he was accustomed to deliver to his
classes on general therapeutics, on rules which should guide us in studying drugs, and on
the therapeutic law. At the close of Vol. II we have several papers of great interest, but
the most important fact of all is that we have here over fifty of our leading remedies pre-
sented in a method which belonged peculiarly to the author, as one of the most successful
teachers our school has yet produced. . . . Blessed will be the library they adorn, and
wise the man or woman into whose mind their light shall shine.”—CINCINNATI MEDICAL
ADVANCE.
EATON, D.R. MORTON. M., on the Medical and Surgical Dis-
eases of Women, with their Homoeopathic Treatment. Fully illus-
trated. Pp. 781. 8vo. Sheep, . * * e e . $6 5o
This work is received with great favor by the profession, and is com-
mended by the homoeopathic press as being the best and most complete
work on the subject hitherto issued.
“This is a large, handsome volume of 782 pages, beautifully printed on good paper,
and strongly bound in leather. The illustrations are numerous and good and well bring
out the anatomical relationship of the parts, and put the various dislocations before the mind
very clearly indeed; in fact, almost too clearly, for he who learns thus, and then tries to
carry his knowledge into practice, will feel rather disappointed at the less obliging disposi-
tion of nature herself. Drawings of almost all the principal instruments are given, and the
whole subject brought down to date. There is an air about this work that commends it
very much to our judgment for the use of the student, and of the general practitioner, and
4 BOERICKE & TAFEL's
hence, we believe, it is destined to become thc class-book in homoeopathic colleges for many
years to come. There is a healthy absence of the scissors and paste business. The author
holds the candle of his own experience, and thus affords a reliable aid to the gynaecological
path-finder in all his freshness and inexperience.”—From the HOMOEOPATHIC WORLD for
January, 1881. .
EGGERT, DR. W. The Homoeopathic Therapeutics of Uterine
and Vaginal Discharges. 543 pages. 8vo. Half morocco, $3 5o
The author brought here together in an admirable and comprehensive
arrangement everything published to date on the subject in the whole homoe-
opathic literature, besides embodying his own abundant personal experience.
The contents, divided into eight parts, are arranged as follows:
Part I. Treats on Menstruation and Dysmemorrhaea; Part II. Memor-
zhagia; Part III. A memorrhaea ; Part IV. Abortion and Miscarriage; Part
V. Metrorrhagia, Part VI. Fluor albus, Part VII. Zochia ; and Part
VIII. General Concomitants. No work as complete as this, on the subject,
was ever before attempted, and we feel assured that it will meet with great
favor by the profession.
“The book is a counterpart of Bell on Diarrhoea, and Dunham on Whooping cough.
Synthetics, Diagnosis and Pathology are left out as not coming within the scope of the work.
The author in his preface says: Remedies and their symptoms are left out, and the symp-
toms and their remedies have received sole attention—that is what the busy practitioner
wants. The work is one of the essentials in a library.”—AMERICAN OBSERVER.
“A most exhaustive treatise, admirably arranged, covering all that is known of thera-
peutics in this important department.”—HOMCEOPATHIC TIMES. r
GUERNSEY, DR. H. N. The Application of the Principles
and Practice of Homoeopathy to Obstetrics and the Dis-
orders Peculiar to Women and Young Children. By HENRY
N. GUERNSEy, M.D., Professor of Obstetrics and Diseases of Women
and Children in the Homoeopathic Medical College of Pennsylvania,
etc., etc. With numerous Illustrations. Third edition, revised, en-
larged, and greatly improved. Ioo.4 pages. 8vo. Half morocco, $8 oo
This standard work, with the numerous improvements and additions, is the most com-
plete and comprehensive work on the subject in the English language. Of the previous
editions, almost four thousand copies are in the hands of the profession, and of this third
edition a goodly number have already been taken up. There are few other professional
works that can boast of a like popularity, and with all new improvements and experiences
diligently collected and faithfully incorporated into each successive edition, this favorite
work will retain its hold on the high esteem it is held in by the profession, for years to come.
It is superfluous to add that it was and is used from its first appearance as a text-book at the
homoeopathic colleges.
GUERNSEY, DR. E. Homoeopathic Domestic Practice. With
Full Descriptions of the Dose to each single Case. Containing also
Chapters on Anatomy, Physiology, Hygiene, and an abridged Materia
Medica. Tenth enlarged, revised, and improved edition. 653 pages.
Half leather, o e sº e tº * > e & • $2 50
GUERNSEY, DR. W. E. The Traveller's Medical Repertory
and Family Adviser for the Homoeopathic Treatment of
Acute Diseases. 36 pages. Cloth, ſº sº ſº ... 3o Cts.
This little work has been arranged with a view to represent in as compact a manner as
possible all the diseases—or rather disorders—which the non-professional would attempt to
HOMOEOPATHIC PUBLICATIONS. 5
~~
prescribe for, it being intended only for the treatment of simple or acute diseases, or to allay
the suffering in maladies of a more serious nature until a homoeopathic practitioner can be
Summoned.
HAHNEMANN, DR. S. The Lesser Writings of. Collected and
Translated by R. E. DUDGEON, M.D. With a Preface and Notes by E.
MARcy, M.D. With a Steel Engraving of Hahnemann from the statue
of Steinhauser. 784 pages. Half bound, o ſº g . $3 oo
This valuable work contains a large number of Essays, of great interest to laymen as
well as medical men, upon Diet, the Prevention of Diseases, Ventilation of Dwellings, etc.
As many of these papers were written before the discovery of the homoeopathic theory of
cure, the reader will be enabled to peruse in this volume the ideas of a gigantic Intellect
when directed to subjects of general and practical interest.
HAHNEMANN, DR. S. Organon of the Art of Healing. By
SAMUEL HAHNEMANN. “Aude Sapere.” Fifth American edition, trans-
lated from the Fifth German edition, by C. WESSELHCEFT, M.D. 244
pages. 8vo. Cloth, . © © e e © . $I 75
This fifth edition of “Hahnemann Organon” has a history. So many
complaints were made again and again of the incorrectness and cumbersome
style of former and existing editions to the publishers, that, yielding to the
pressure, they promised to destroy the plates of the fourth edition, and to
bring out an entire re-translation in 1876, the Centennial year. After due
consideration, and on the warm recommendation of Dr. Constantine Hering
and others, the task of making this re-translation was confided to Dr. C.
Wesselhoeft, and the result of years of labor is now before the profession,
who will be best able themselves to judge how well he succeeded in acquit-
ting himself of the difficult task. - -
“To insure a correct rendition of the text of the author, they (the publishers) selected as
his translator Dr. Conrad Wesselhoeft of Boston, an educated physician in every respect,
and from his youth up perfectly familiar with the English and German languages. than
whom no better selection could have been made.” “That he has made, as he himself de-
clares, ‘an entirely new and independent translation of the whole work,’ a careful compari-
Son of the various paragraphs, notes, etc., with those contained in previous editions, gives
abundant evidence; and while he has, so far as was possible, adhered strictly to the letter of
Hahnemann's text, he has at the same time given a pleasantly flowing rendition that avoids
the harshness of a strictly literal translation.”—HAHNEMANNIAN MONTHLY.
HALE, DR. E. M. Lectures on Diseases of the Heart. In Three
Parts. Part I. Functional Disorders of the Heart. Part II. Inflamma-
tory Affections of the Heart. Part III. Organic Diseases of the Heart.
Second enlarged edition. 248 pages. Cloth, e * . $I 75
HALE, DR. E. M. Materia Medica and Special Therapeutics
of the New Remedies. Fifth edition, revised and enlarged. In
• two Volumes.
Vol. I. Special Symptomatology. With new Botanical and Pharmaco-
logical Notes and Appendix. 1882. 746 pages. Cloth, . . $5 od
Half morocco, . . . º tº te gº gº . 6 oo
Vol. II. Special Therapeutics. With Illustrative Clinical Cases.
900 pages. Cloth, . ge e tº e sº tº * . $5 Oo
Half morocco, º ſº tº ſº * ſº * > ſº . $6 oo
6 BOERICKE & TAFEL's
“Dr. Hale's work on ‘New Remedies’ is one both well known and much appreciated
on this side of the Atlantic. For many medicines of considerable value we are indebted to
his researches. In the present edition the symptoms produced by the drug investigated and
those which they have been observed to cure, are separated from the clinical observations,
by which the former have been confirmed. That this volume contains a very large amount
of invaluable information is incontestable, and that every effort has been made to secure
both fulness of detail and accuracy of statement, is apparent throughout. For these reasons
we can confidently commend Dr. Hale's fourth edition of his well-known work on the ‘New
Remedies’ to our homoeopathic colleagues.”—MONTHLY HOMOEOPATHIC REVIEW.
“We do not hesitate to say that by these publications Dr. Hale rendered an inestimable
service to homoeopathy, and thereby to the art of medicine. “The school of Hahnemann in
every country owes him hearty thanks for all this; and allopathy is beginning to share our
gain.” The author is given credit for having in this fourth edition corrected the mistake
for which the third one had been taxed rather severely, by restoring in Vol. II the ‘special
therapeutics,’ instead of the ‘characteristics’ of the third edition.”—BRITISH JOURNAL OF
HOMOEOPATHY. tº -
HALE, DR. E. M. The Medical, Surgical, and Hygienic Treat-
ment of Diseases of Women, especially those causing Ster-
ility, the Disorders and Accidents of Pregnancy, and Pain-
ful and Difficult Labor. By Edwin M. HALE, M.D., Professor of
Materia Medica and Therapeutics in the Chicago Homoeopathic College,
etc., etc. Second enlarged edition. 378 pages. 8vo. Cloth, $2 5o
“This new work embodies the observations and experience of the author during twenty-
five years of active and extensive practice, and is designed to supplement rather than Šuper-
cede kindred works. The arrangement of the subjects treated is methodical and convenient;
the introduction containing an article inserted by permission of Dr. Jackson, of Chicago, the
author upon the ovular and ovulation theory of menstruation, which contains all the obser-
vations of practical importance known on this subject to date. The diseases causing sterility
are fully described, and the medical, surgical and hygienic treatment pointed out. The
more generally employed medicines are enumerated, but their special or specific indications
are unfortunately omitted. The general practitioner will find a great many valuable things
for his daily rounds, and cannot afford to do without the book. The great reputation and
ability of the author are sufficient to recommend the work, and to guarantee an appreciative
reception and large sale.”—HAHNEMANNIAN MONTHLY.
HART, DR. C. P. Diseases of the Nervous System. Being a
Treatise on Spasmodic, Paralytic, Neuralgic and Mental Affections.
For the use of Students and Practitioners of Medicine. By CHAs. Por-
TER HART, M.D., Honorary Member of the College of Physicians and
Surgeons of Michigan, etc., etc., etc. Pp. 409. 8vo. Cloth, $3 oo
“This work supplies a need keenly felt in our school—a work which will be useful
alike to the general practitioner and specialist; containing, as it does, not only a condensed
compilation of the views of the best authorities on the subject treated, but also the author's
own clinical experience; to which is appended the appropriate homoeopathic treatment of
each disease. It is written in an easy, flowing style, at the same time there is no waste of
words. * * * * * We consider the work a highly valuable one, bearing the evidence
of hard work, considerable research and experience.”—MEDICO-CHIRURGICAL QUARTERLY.
“We feel proud that in Hart’s “Diseases of the Nervous System' we have a work up to
date, a work which we need not feel ashamed to put in the hands of the neurologist or
alienist for critical examination, a work for which we predict a rapid sale.”—NORTH AMER-
ICAN JOURNAL OF HOMOEOPATHY. •
HELMUTH, DR. w. T. A system of Surgery. Illustrated with
568 Engravings on Wood. By WM. ToD HELMUTH, M.D. Fourth edi-
tion. Iooo pages. Sheep, . e {º & ſº e . $8 5o
This edition of Dr. Helmuth's great work is already in appearance a great improve-
ment over the old edition, it being well printed on fine paper, and well bound. By in-
creasing the size of the page, decreasing the size of type, and setting up solid, fully one-half
more printed matter is given than in the previous edition, albeit there are over 200 pages
HOMOEOPATHIC PUBLICATIONS. 7
less; and while the old edition, bound in sheep, was sold at $11.5o by its publishers, this
improved third edition is now furnished at $3 less, or for $8.50. The author brought the
work fully up to date, and for an enumeration of some of the more important improvements,
we cannot do better than to refer to Dr. Helmuth's own Preface.
HEMPEL, D.R. C. J., and D.R. J. BEAKLEY. Homoeopathic
Theory and Practice. With the Homoeopathic Treatment of Surgi-
cal Diseases, designed for Students and Practitioners of Medicine, and
as a Guide for an intelligent public generally. Fourth edition. I Ioo
pages, . e Ç G tº tº tº © g º . $3 OO
HERING, DR. C. Condensed Materia Medica. Second edition.
More condensed, revised, enlarged, and improved, º . $7 Oo
In February, 1877, we were able to announce the completion of Hering's Condensed
Materia Medica. The work, as was to be expected, was bought up with avidity by the pro-
fession and already in the fall of 1878 the author set to work perfecting a second and im-
proved edition. By still more condensing many of the remedies, a number of new ones
could be added without much increasing the size and the price of the work. This new
edition is now ready for the profession, and will be the standard work par excellence for the
practitioner's daily reference.
HEINIGKE, DR. CARL. Pathogenetic Outlines of Homoeo-
pathic Drugs. Translated from the German by EMIL TIETZE, M.D.,
of Philadelphia. 576 pages. 8vo. Cloth, . e e • $3 5o
This work, but shortly issued, is already meeting with a large sale and an appreciative
reception. It differs from most works of its class in these respects:
I. That the symptomatic outlines of the various drugs are based exclusively upon the
‘pathogenetic” results of provings.
2. That the anatomico-physiological arrangement of the symptoms renders easier the
understanding and survey of the provings.
3. That the pathogenetic pictures drawn of most of the drugs, gives the reader a clearer
idea and a more exact impression of the action of the various remedies.
Each remedy is introduced with a brief account of its preparation, duration of action
and antidotes.
HOLCOMBE, DR. W. H. Yellow Fever and its Homoeopathic
Treatment, º e º º © © º & . Io CtS.
HOLCOMBE, DR. W. H. What is Homoeopathy P A new ex-
position of a great truth. 28 pages. 8vo. Paper cover. Per dozen,
$1.25, º G * & • wº e g ſº . I5 CtS.
“Prove all things, hold fast that which is good.”—St. PAUL.
HOLCOMBE, DR. W. H. How I became a Homoeopath. 28
pages. 8vo. Paper cover. Per dozen, $1.25, . tº . I 5 CtS.
HOLCOMBE, DR. W. H. Special Report of the Homoeopathic
Yellow Fever Commission, ordered by the American Institute of
Homoeopathy for presentation to Congress. 32 pages. 8vo. Paper.
Per hundred, $4.oo, . ge is e ſº tº tº . 5 cts.
This Report, written in Dr. Holcombe's masterly manner, is one of the best campaign
documents for homoeopathy. The statistics must convince the most skeptical, and every
homoeopathic practitioner should feel in duty bound to aid in securing its widest possible
circulation. *
HOMCEOPATHIC POULTRY PHYSICIAN (Poultry Veteri-
narian); or, Plain Directions for the Homoeopathic Treatment of the
8 BoERICKE & TAFEL's
most Common Ailments of Fowls, Ducks, Geese, Turkeys and Pigeons,
based on the author's large experience, and compiled from the most re-
liable sources, by Dr. Fr. Schröter. Translated from the German. , 84
pages. I2mo. Cloth, ſº g © ſº © e . 5o CtS.
We imported hundreds of copies of this work in the original German for our customers,
and as it gave good satisfaction, we thought it advisable to give it an English dress, so as to
make it available to the public generally. The little work sells very fast, and our readers
will doubtless often have an opportunity to draw the attention of their patrons to it.
HOMCEOPATHIC COOKERY, Second edition. With Additions
by the Lady of an American Homoeopathic Physician. Designed chiefly
for the Use of such Persons as are under Homoeopathic Treatment. I 76
pages, e ſº & © tº e . . . e . 5o CtS.
HULL’S JAHR. A New Manual of Homoeopathic Practice.
Edited, with Annotations and Additions, by F. G. SNELLING, M.D.
Sixth American edition. With an Appendix of the New Remedies, by
C. J. HEMPEL, M.D. 2 volumes. 2076 pages, . © . $9 Oo
The first volume, containing the symptomatology, gives the complete pathogenesis of
two hundred and eighty-seven remedies, besides, a large number of new remedies are added
by Dr. Hempel, in the appendix. The second volume contains an admirably arranged Re-
pertory. Each chapter is accompanied by copious clinical remarks and the concomitant
symptoms of the chief remedies for the malady treated of, thus imparting a mass of informa-
tion, rendering the work indispensable to every student and practitioner of medicine.
JAHR, DR. G. H. G. Therapeutic Guide; the most Important Re-
sults of more than Forty Years' Practice. With Personal Observations
regarding the truly reliable and practically verified Curative Indications
in actual cases of disease. Translated, with Notes and New Remedies,
by C. J. HEMPEL, M.D. 546 pages, . e {º º . . $3 Oo
“With this characteristically long title, the veteran and indefatigable Jahr gives us
another volume of homoeopathics. Besides the explanation of its purport contained in the
title itself, the author’s preface still further sets forth its distinctive aim. It is intended, he
says, as a “guide to beginners, where I only indicate the most important and decisive points
for the selection of a remedy, and where I do not offer anything but what my own individual
experience, during a practice of forty years, has enabled me to verify as absolutely decisive
in choosing the proper remedy. The reader will easily comprehend that, in carrying out
this plan, I had rigidly to exclude all cases concerning which I had no experience of my
own to offer. . . . . We are bound to say that the book itself is agreeable, chatty, and
full of practical observation. It may be read straight through with interest, and referred to
in the treatment of particular cases with advantage.”—BRITISH JOURNAL OF HOMOEOPATHY.
JAHR, DR. G. H. G. The Homoeopathic Treatment of Dis-
eases of Females and Infants at the Breast. Translated from
the French by C. J. HEMPEL, M.D. 422 pages. Half leather, $2 oo
This work deserves the most careful attention on the part of homoeopathic practitioners.
The diseases to which the female organism is subject are described with the most minute
correctness, and the treatment is likewise indicated with a care that would seem to defy
criticism. No one can fail to study this work but with profit and pleasure.
INDEX to the first eighteen volumes of the North American Journal of
Homoeopathy. Paper, . wº tº & gº * e . $2 oo
JONES, DR. SAMUEL A. The Grounds of Homoeopathic
Faith. Three Lectures, delivered at the request of Matriculates of the
Department of Medicine and Surgery (Old School) of the University of
HOMOEOPATHIC PUBLICATIONS. 9
Michigan. By SAMUEL A. Jones, M.D., Professor of Materia Medica,
Therapeutics, and Experimental Pathogenesy in the Homoeopathic
Medical College of the University of Michigan, etc., etc. 92 pages.
12mo. Cloth. Per dozen, $3.oo; per hundred, $20.oo, . 30 cts.
Lecture first is on THE LAw OF SIMILARs; Its CLAIM TO BE A SCIENCE IN THAT IT
ENABLES PERVERSION. Lecture second, THE SINGLE REMEDY A NECESSITY OF SCIENCE.
Lecture third, THE MINIMUM DOSE AN INEVITABLE SEQUENCE. A fourth Lecture, on THE
DYNAMIZATION THEORY, was to have finished the course, but was prevented by the approach
of final examinations, the preparation for which left no time for hearing evening lectures.
The LECTUREs are issued in a convenient size for the coat-pocket; and as an earnest testi-
mony to the truth, we believe they will find their way into many a homoeopathic household.
JOHNSON, DR. I. D. Therapeutic Key; or, Practical Guide for
the Homoeopathic Treatment of Acute Diseases. Tenth edition. 347
pages. Bound in linen, tº º tº g * e . $ I 75
Bound in flexible cover, g e © tº * e . $2 25
This has been one of the best selling works on our shelves; more copies being in circu-
lation of this than of any two other professional works put together. It is safe to say that
there are but few homoeopathic practitioners in this country but have one or more copies of
this little remembrancer in their possession.
JOHNSON, D.R. I. D. A Guide to Homoeopathic Practice. De-
signed for the use of Families and Private Individuals. 494 pages.
Cloth, . te o tº * te e & tº tº . $2 oo
This is the latest work on Domestic Practice issued, and the well and favorably known
author has surpassed himself. In his book fifty-six remedies are introduced for internal ap-
plication, and four for external use. The work consists of two parts. Part I is subdivided
into seventeen chapters, each being devoted to a special part of the body, or to a peculiar
class of disease. Part II contains a short and concise Materia Medica, i. e., gives the
symptoms peculiar to each remedy. The whole is carefully written with a view of avoiding
technical terms as much as possible, thus insuring its comprehension by any person of ordi-
nary intelligence. A complete set of remedies in vials holding over fifty doses each, is fur-
nished for $7, or in vials holding over one hundred doses each for $10, or book and case
complete for $9 or $12 respectively. Address orders to Boericke & Tafel's Pharmacies at
New York, Philadelphia, Baltimore, Chicago, New Orleans, or San Francisco.
JOSLIN, DR. B. F. Principles of Homoeopathy. In a Series of
Lectures. 185 pages. I2mo. Cloth, we º tº . 6o cts.
KREUSSLER, DR. E. The Homoeopathic Treatment of Acute
and Chronic Diseases. Translated from the German, with Im-
portant Additions and Revisions, by C. J. HEMPEL, M.D. 190
pages, e tº e • {º * & * g . 6o cts.
The author is a practitioner of great experience and acknowledged talent. This work
is distinguished by concise brevity and lucid simplicity in the description of the various
diseases that usually come under the observation of physicians, and the remedies for the
various symptoms are carefully indicated. Dr. Hempel has interspersed it with a number
of highly useful and interesting notes, which cannot fail to enhance the value of this work
to American physicians.
LAURIE and McCLATCHEY. The Homoeopathic Domestic
Medicine. By Joseph LAURIE, M.D. Ninth American, from the
Twenty-first English edition. Edited and Revised, with Numerous and
Important Additions, and the Introduction of the New Remedies. By
R. J. McCLATCHEY, M.D. Io.44 pages. 8vo. Half morocco, $5 od
“We do not hesitate to indorse the claims made by the publishers, that this is the most
complete, clear, and comprehensive treatise on the domestic homoeopathic treatment of dis-
4 º'
10 BOERICKE & TAFEL's
eases extant. This handsome volume of nearly eleven hundred pages is divided into six
parts. PART ONE is introductory, and is almost faultless. It gives the most complete and
exact directions for the maintenance of health, and of the method of investigating the con-
dition of the sick, and of discriminating between different diseases. It is written in the
most lucid style and is above all things wonderfully free from technicalities. PART Two
treats of symptoms character, distinctions, and treatment of general diseases, together with
a chapter on casualties. PART THREE takes up diseases peculiar to women. PART FOUR
is devoted to the disorders of infancy and childhood. PART FIVE gives the characteristic
symptoms of the medicines referred to in the body of the work, while PART six introduces
the repertory.”—HAHNEx:ANNIAN MONTHLY.
‘ Of the usefulness of this work in cases where no educated homoeopathic physician is
within reach, there can be no question. There is no doubt that domestic homoeopathy has
done much to make the science known; it has also saved lives in emergencies. The prac-
tice has never been so well presented to the public as in this excellent volume.”—NEW
ENG. MED. GAZETTE. -
A complete set of remedies of one hundred and four vials, containing over fifty doses
each, is furnished for $12, put up in an elegant mahogany case. A similar set in vials con-
taining over one hundred doses each, is furnished for $18. or book and case complete for
$17 or $23 respectively. Address orders to Boericke & Tafel's Pharmacies at New York,
Philadelphia, Baltimore, Chicago, New Orleans, or San Francisco.
LILIENTHAL, DR. S. Homoeopathic Therapeutics. By S.
LILIENTHAL, M.D., Editor of North American Journal of Homoeo-
pathy, Professor of Clinical Medicine and Psychology in the New York
Homoeopathic Medical College, and Professor of Theory and Practice
in the New York College Hospital for Women, etc. Second edition.
8vo, . tº { } e te e e º e { } . $5 Oo
Half morocco, tº e º tº te º tº e . $6 oo
“Certainly no one in our ranks is so well qualified for this work as he who has done it,
and in considering the work done, we must have a true conception of the proper sphere of
such a work. For the fresh graduate, this book will be invaluable, and to all such we un-
hesitatingly and very earnestly commend it. To the older one, who says he has no use for
this book, we have nothing to say. He is a good one to avoid when well, and to dread
when ill. We also hope that he is severely an unicum.”—PROF. SAM. A. JonBS IN AMERI-
CAN HOMOEOPATHIST.
“ . . . It is an extraordinary useful book, and those who add it to their library
will never feel regret, for we are not saying too much in pronouncing it the BEST work ON
THERAPEUTICs in homoeopathic (or any other) literature. With this under one elbow, and
Hering's or Allen's MATERIA MEDICA under the other, the careful homoeopathic practitioner
can refute Niemayer's too confident assertion, ‘I declare it idle to hope for a time when a
medical prescription should be the simple resultant of known quantities.” Doctor, by all
means buy Lilienthal’s HOMOEOPATHIC THERAPEUTICS. It contains a mine of wealth.”—
PROF. CHAs. GATCHEL IN IBID.
LUTZE, DR. A. Manual of Homoeopathic Theory and Prac-
tice. Designied for the use of Physicians and Families.
Translated from the German, with additions by C. J. HEMPEL, M.D.
From the sixtieth thousand of the German edition. 750 pages. 8vo.
Half leather, © ſº tº te tº & Q e ... $2 5o
This work, from the pen of the late Dr. Lutze, has the largest circulation of any homoeo-
pathic work in Germany, no less than sixty thousand copies having been sold. The intro-
duction, occupying over fifty pages, contains the question of dose, and rules for examining
the patient, and diet; the next sixty pages contain a condensed pathogenesis of the remedies
treated of in the work; the description and treatment of diseases occupy four hundred and
eighteen pages, and the whole concludes with one hundred and seventy-three pages of reper-
tory and a copious index, thus forming a concise and complete work on theory and practice.
MALAN, H. Family Guide to the Administration of Homoeo-
pathic Remedies. II 2 pages. 32mo. Cloth, º . 3o CtS.
HOMOEOPATHIC PUBLICATIONS. 11
MANUAL OF HOMOEOPATHIC VETERINARY PRAC-
TICE. Designed for all kinds of Domestic Animals and Fowls, pre-
scribing their proper treatment when injured or diseased, and their par-
ticular care and general management in health. Second and enlarged
edition. 684 pages. 8vo. Half morocco, o ſº . $5 Oo
“In order to rightly estimate the value and comprehensiveness of this great work, the
reader should compare it, as we have done, with the best of those already before the public.
In size, fulness and practical value it is head and shoulders above the very best of them,
while in many most important disorders it is far superior to them altogether, containing, as
it does, recent forms of disease of which they make no mention.”—HAHNEMANNIAN
MONTHLY. - -
MARSDEN, DR. J. H. Handbook of Practical Midwifery, with
full instructions for the Homoeopathic Treatment of the
Diseases of Pregnancy, and the Accidents and Diseases in-
cident to Labor and the Puerperal State. By J. H. MARSDEN,
A.M., M.D. 315 pages. Cloth, * e e º ... $2 25
“It is seldom we have perused a text-book with such entire satisfaction as this. The
author has certainly succeeded in his design of furnishing the student and young practitioner,
within as narrow limits as possible, all necessary instruction in practical midwifery. The
work shows on every page extended research and thorough practical knowledge. The style
is clear, the array of facts unique, and the deductions judicious and practical. We are par-
ticularly pleased with his discussion on the management of labor, and the management of
mother and child immediately after the birth, but much is left open to the common-sense
and practical judgment of the attendant in peculiar and individual cases.”—HOMCEOPATHIC
TIMES.
MOHR, DR. CHARLES. The Incompatible Remedies of the
Homoeopathic Materia Medica. By CHARLEs MoHR, M.D., Lec-
turer on Homoeopathic Pharmaceutics, Hahnemann Medical College,
Philadelphia. (A paper read before the Homoeopathic Medical Society
of the County of Philadelphia.) Pamphlet, in cover, . . Io CtS.
This is an interesting paper, which will well repay perusal and study. It gives a list of
fifty-seven remedies and their incompatibles, diligently collated from the best-known sources.
MORGAN, DR. W. The Text-book for Domestic Practice,
being plain and concise directions for the Administration of Homoeo-
pathic Medicines in Simple Ailments. 191 pages. 32mo. Cloth, 5o cts.
This is a concise and short treatise on the most common ailments, printed in convenient
size for the pocket; a veritable traveller's companion.
- A complete set of thirty remedies, in vials holding over fifty doses each, is furnished for
$4.50, in stout mahogany case; or same set in vials holding over one hundred doses each,
for $6.50; or book and case complete for $5 or $7 respectively. Address orders to Boericke
& Tafel's Pharmacies, New York, Philadelphia, Baltimore, Chicago, New Orleans, or San
Francisco.
MURE, DR. B. Materia Medica; or, Provings of the Principal Ani-
mal and Vegetable Poisons of the Brazilian Empire, and their Applica-
tion in the Treatment of Diseases. Translated from the French, and
arranged according to Hahnemann's Method, by C. J. HEMPEL, M.D.
220 pages. I 2 mo. Cloth, . e e tº e * . § I oo
This volume, from the pen of the celebrated Dr. Mure, of Rio Janeiro, contains the
pathogenesis of thirty-two remedies, a number of which have been used in general practice
ever since the appearance of the work. A faithful wood-cut of the plant or animal treated
of accompanies each pathogenesis.
12 BOERICKE & TAFEL's
NEIDHARD, DR. C. On the Universality of the Homoeopathic
Law of Cure, . º wº gº * > * G g . 3O CtS.
NEW PROVINGS of Cistus Canadensis, Cobaltum, Zingiber and Mer-
curius Proto-Iodatus. 96 pages. Paper, . § wº . 75 CtS.
NORTH AMERICAN JOURNAL OF HOMOEOPATHY. Pub-
lished quarterly on the first days of August, November, February and
May. Edited by S. LILIENTHAL, M.D. Vol. X, New Series, com-
menced in August, 1879. Subscription price per volume, in advance,
$4 Oo
Complete sets of the first twenty-seven volumes, in half morocco bind-
ing, including Index to the first eighteen volumes, e . $90 oo
Index to the first eighteen volumes, . te © gº . $2 oo
OEHME, DR. F. G. Therapeutics of Diphtheritis. A Compila-
tion and Critical Review of the German and American Homoeopathic
Literature. Second enlarged edition. 84 pages. Cloth, . 60 cts.
“This pamphlet contains, the best compilation of reliable testimony relative to diph-
theria that has appeared from the pen of any member of our school.”—OHIO MEDICAL AND
SURGICAL REPORTER.
“Although he claims nothing more for his book than that it is a compilation, with
* critical reviews,’ he has done his work so well and thoroughly as to merit all praise.”—
HAHNEMANNIAN MONTHLY.
“Dr. Oehme’s little book will be worth many times its price to any one who has to treat
this terrible disease.”—BRITISH JOURNAL OF HOMCEOPATHY.
“It is the best monograph we have yet seen on diphtheria.”—CINCINNATI MEDICAL
ADVANCE.
PETERS, DR. J. C. A Complete Treatise on Headaches and
Diseases of the Head. I. The Nature and Treatment of Head-
aches. II. The Nature and Treatment of Apoplexy. III. The Nature
and Treatment of Mental Derangement. IV. The Nature and Treat-
ment of Irritation, Congestion, and Inflammation of the Brain and
its Membranes. Based on Th. J. Rückert's Clinical Experiences in
Homoeopathy. 586 pages. Half leather, . e tº . $2 5o
PETERS, DR. J. C. A Treatise on Apoplexy. With an Appendix
on Softening of the Brain and Paralysis. Based on Th. J. Rückert's
Clinical Experiences in Homoeopathy. 164 pages. 8vo. Cloth, $1 oo
PETERS, DR. J. C. The Diseases of Females and Married
Females. Second edition. Two parts in one volume. 356 pages.
Cloth, . © te e e º & tº e tº • $I 5o
PETERS, DR. J. C. A Treatise on the Principal Diseases of
the Eyes. Based on Th. J. Rückert's Clinical Experiences in Ho-
moeopathy. 291 pages. 8vo. Cloth, . e & e . $I 5o
PETERS, DR. J. C. A Treatise on the Inflammatory and Or-
ganic Diseases of the Brain. Based on Th. J. Rückert's Clinical
Experiences in Homoeopathy. I56 pages. 8vo. Cloth, . $1 oo
HOMOEOPATHIC PUBLICATIONS. 13
PETERS, DR. J. C. A Treatise on Nervous Derangement and
Mental Disorders. Based on Th. J. Rückert's Clinical Experiences
in Homoeopathy. Io.4 pages. 8vo. Cloth, º e . $I oo
PHYSICIAN'S VISITING LIST AND POCKET REPER-
TORY, THE HOMCEOPATHIC. By Robert FAULKNER, M.D.
Second edition, . ſº tº • ſº ge tº e . $2 oo
“Dr. Faulkner's Visiting List is well adapted to render the details of daily work more .
perfectly recorded than any book prepared for the same purpose with which we have hitherto
met. It commences with Almanacs for 1877 and 1878; then follow an obstetric calendar;
a list of Poisons and their Antidotes; an account of Marshall Hall’s ready method in AS-
phyxia; a Repertory of between sixty and seventy pages; pages marked for general memo-
randa; Vaccination Records; Record of Deaths; Nurses; Friends and others; Obstetric
Record, which is especially complete; and finally, pages ruled to keep notes of daily visits,
and also spaces marked for name of the medicine ordered on each day. The plan devised
is so simple, so efficient, and so clear, that we illustrate it on a scale just half the size of the
original (here follows illustration). The list is not divided into special months, but its use
may be as easily commenced in the middle of the year as at the beginning. We heartily
recommend Faulkner's List to our colleagues who may be now making preparations for the
duties of 1878.”—MONTHLY HomoeopathIC REVIEW, LONDON.
RAUE, DR. C. G. Special Pathology and Diagnosis, with
Therapeutic Hints. Io'ſ 2 pages. 8vo. Half morocco. Second
edition, gº º t . tº e © e º . $7 oo
This standard work is used as a textbook in all our colleges, and is found in almost every
physician’s library. An especially commendable feature is that it contains the application
of nearly all the NEw REMEDIES contained in Dr. Hale's work on Materia Medica.
REIL, DR. A. ACONITE, Monograph on, its Therapeutic and
Physiological Effects, together with its Uses and Accurate
Statements, derived from the various Sources of Medical
Literature. By A. REIL, M.D. Translated from the German by
H. B. Millard, M.D. Prize essay. 168 pages, . e . . 68 cts.
“This Monograph, probably the best which has ever been published upon the subject,
has been translated and given to the public in English, by Dr. Millard, of New York.
Apart from the intrinsic value of the work, which is well-known to all medical German
scholars, the translation of it has been completed in the most thorough and painstaking way;
and all the Latin and Greek quotations have been carefully rendered into English. The
book itself is a work of great merit, thoroughly exhausting the whole range of the subject.
To obtain a thorough view of the spirit of the action of the drug, we can recommend no
better work.”—NORTH AMERICAN Jou RNAL.
RUDDOCK, DR. Principles, Practice, and Progress of Homoe-
Opathy. 5 cts. ; per hundred, $3 ; per thousand, º . $25 od
RUSH, DR. JOHN. Veterinary Surgeon. The Handbook to Vet-
erinary Homoeopathy; or, the Homoeopathic Treatment of Horses,
Cattle, Sheep, Dogs, and Swine. From the London edition. With
numerous additions from the Seventh German edition of Dr. F. E.
Gunther's “Homoeopathic Veterinary.” Translated by J. F. SHEEK,
M.D. 150 pages. 18mo. Cloth, º e e e . 5o CtS.
SCHAEFER, J. C. New Manual of Homoeopathic Veterinary
Medicine. An easy and comprehensive arrangement of Diseases,
adapted to the use of every owner of Domestic Animals, and especially
designed for the Farmer living out of the reach of medical advice, and
showing him the way of treating his sick Horses, Cattle, Sheep, Swine,
14 BOERICKE & TAFEL's
and Dogs, in the most simple, expeditious, safe, and cheap manner.
Translated from the German, with numerous Additions from other
Veterinary Manuals, by C. J. HEMPEL, M.D. 321 pages. 8vo.
Cloth, . * & º tº {- wº tº . $2 oo
SCHWABE, DR. WILLMAR. Pharmacopoeia Homoeopathica
Polyglottica. Second edition. Cloth, de tº & . $3 Oo
SHARP’S TRACTS ON HOMCEOPATHY, each, . . 5 CtS.
Per hundred, e wº º e tº ſº & e . $3 Oo
No. 1. What is Homoeopathy P No. 7. The Principles of Homoeopathy.
No. 2. The Defence of Homoeopathy. No. 8. Controversy on 6 &
No. 3. The Truth of & & No. 9. Remedies of & &
No. 4. The small Doses of “ No. Io. Provings of & 6
No. 5. The Difficulties of & & No. 1 1. Single Medicines of “
No. 6. Advantages of & 6 No. 12. Common-sense of & &
SHARP’S TRACTS. Complete set of Twelve Numbers, . 5o Cts.
Bound, tº º e tº e . 75 CtS.
SMALL, DR. A. E. Manual of Homoeopathic Practice, for the
use of Families and Private Individuals. Fifteenth enlarged edition.
831 pages. 8vo. Half leather, . c wº ſº tº . $2 5o
SMALL, DR. A. E. Manual of Homoeopathic Practice. Trans-
lated into German by C. J. HEMPEL, M.D. Eleventh edition. 643
pages. 8vo. Cloth, . e e * e p ę . $2 5o
SMALL, DR. A. E. Diseases of the Nervous System, to which
is added a Treatise on the Diseases of the Skin, by Dr. C. E. Tooth-
AKER. 216 pages. 8vo. Cloth, e wº tº © . $1 oo
This treatise is from the pen of the distinguished author of the well-known and highly
popular work entitled, “Small's Domestic Practice.” It contains an elaborate description of
the diseases of the nervous system, together with a full statement of the remedies which have
been used with beneficial effect in the treatment of these disorders.
STAPF, DR. E. Additions to the Materia Medica Pura. Trans-
lated by C. J. HEMPEL, M.D. 292 pages. 8vo. Cloth, . $ I 5o
This work is an indispensable appendix to Hahnemann's Materia Medica Pura. Every
remedy is accompanied with extensive and most interesting clinical remarks, and a variety of
cases illustrative of its therapeutical uses. -
VERDI, DR. T. S. Maternity; a Popular Treatise for Young
Wives and Mothers. By TULLIO SUzzARA VERDI, A.M., M.D., of
Washington, D. C. 450 pages. I2mo. Cloth, . te . $2 oo
“No one needs instruction more than a young mother, and the directions given by Dr.
Verdi in this work are such as I should take great pleasure in recommending to all the young
mothers, and some of the old ones, in the range of my practice.”—GEORGE E. SHIPMAN,
M.D., Chicago, Ill.
“Dr. Verdi's book is replete with useful suggestions for wives and mothers, and his
medical instructions for home use accord with the maxims of my best experience in prac-
tice.”—John F. GRAY, M.D., New York City.
VERDI, DR. T. S. Mothers and Daughters; Practical Studies for
the Conservation of the Health of Girls. By TULLIo SUzzARA VERDI,
A.M., M.D. 287 pages. 12mo. Cloth, . gº . $ I 50
HOMOEOPATHIC PUBLICATIONS. 15
“The people, and especially the women, need enlightening on many points connected
with their physical life, and the time is fast approaching when it will no longer be thought
singular or ‘Yankeeish’ that a woman should be instructed in regard to her sexuality, its or-
gans and their functions. . . . Dr. Verdi is doing a good work in writing such books,
and we trust he will continue in the course he has adopted of educating the mother and
daughters. The book is handsomely presented. It is printed with good type on fine paper,
and is meatly and substantially bound.”—HAHNEMANNIAN MONTHLY.
VON TAGEN. Biliary Calculi, Perineorrhaphy, Hospital Gan-
grene, and its Kindred Diseases. 154 pages. 8vo. Cloth, $1 25
“Von Tagen was an Industrious worker, a close observer, an able writer. The essays
before us bear the marks of this. They are written in an easy, flowing, graceful style, and
are full of valuable suggestions. While the essay on perineorrhaphy is mainly of interest to
the Surgeon, the other essays concern the general practitioner. They are exhaustive and
abound in good things. The author is especially emphatic in recommending the use of bro-
mine in the treatment of hospital gangrene, and furnishes striking clinical evidence in sup-
port of his recommendation. -
“The book forms a neat volume of 150 pages, and is well worthy of careful study.”—
MEDICAL COUNSELOR.
WILLIAMSON, D.R. W. Diseases of Females and Children,
and their Homoeopathic Treatment. Third enlarged edition.
256 pages. I 2mo. Cloth, . e tº © tº º . $ 1 OO
This work contains a short treatise on the homoeopathic treatment of the diseases of fe-
males and children, the conduct to be observed during pregnancy, labor, and confinement,
and directions for the management of new-born infants.
WINSLOW, D.R. W. H. The Human Ear and Its Diseases.
A Practical Treatise upon the Examination, Recognition, and Treat-
ment of Affections of the Ear and Associate Parts, Prepared for the In-
struction of Students and the Guidance of Physicians. By W. H. WIN-
SLOW, M.D., Ph.D., Oculist and Aurist to the Pittsburg Homoeopathic
Hospital, etc., etc., with one hundred and thirty-eight illustrations.
Boericke & Tafel: New York and Philadelphia. Pp. 526. 8vo.
Cloth, . . º e e e º e º e . $4 50
& & We hail with pleasure the advent of this work. There is perhaps no branch
in the science of medicine in which there has been so little advance as in that of otology.
Our author has treated his subject very systematically, giving first the anatomy, then the
physiology, as at present understood, methods of examination, morbid changes and injuries,
and finally the therapeutics. This last is of especial value to us, as our provings are singu-
larly deficient in reference to symptoms of the ear. . . . This book is a move in the
right direction, and we earnestly hope it will prove a stimulus ſor other specialists of our
school.”—NEW ENGLAND MEDICAL GAZETTE.
• * Moreover, he has literally crammed the work with thoughts and suggestions
of a practical kind, such as could only be the outgrowth of a large personal experience and
long-continued habits of close and careful observation. . . . The work is thoroughly
practical throughout; theories are left iu the background, and the hard facts of the business
of the otologist are portrayed with a distinctness and force which characterize all the writings
of this author.—HAHNEMANNIAN MONTHLY.
66
WORCESTER, DR. S. Repertory to the Modalities. In their
Relations to Temperature, Air, Water, Winds, Weather and
Seasons. Based mainly upon Hering's Condensed Materia Medica,
with additions from Allen, Lippe, and Hale. Compiled and arranged
by SAMUEL WoRCESTER, M.D., Salem, Mass., Lecturer on Insanity and
its Jurisprudence at Boston University School of Medicine, etc., etc.
188o. I 60 pages. I2mo. Cloth, $º & º e • $1 25
16 BOERICKE & TAFEL's HOMOEOPATHIC PUBLICATIONS.
“This “Repertory to the Modalities’ is indeed a most useful undertaking, and will,
without question, be a material aid to rapid and sound prescribing where there are promi-
nent modalities. The first chapter treats of the sun and its effects, both beneficial and hurt-
ful, and 'we see at a glance that Strontium carb., Anacardium, Conium mac., and Kali bich.
are likely to be useful to patients who like basking in the sun. No doubt many of these
modalities are more or less fanciſul; still a great many of them are real and of vast clinical
range.
“The book is nicely printed on good paper, and strongly bound. It contains only 160
pages. We predict that it will meet with a steady, long-continued sale, and in the course of
time be found on the tables of most of those careful and conscientious prescribers who admit
the philosophical value of (for instance) lunar aggravations, effects of thunder-storms, etc.
And who, being without the priggishness of mere brute science, does not?”—HOMCEO-
PATHIC WORLD.
WORCESTER, DR. S. Insanity and Its Treatment. Lectures
on the Treatment of Insanity and Kindred Nervous Diseases. By
SAMUEL WORCESTER, M.D., Salem, Mass. Lecturer on Insanity, Ner-
vous Diseases and Dermatology, at Boston University School of Medi-
cine, etc., etc., . Q g gº * º iº ſº . $3 5o
Dr. Worcester was for a number of years assistant physician of the Butler
Hospital for the Insane, at Providence, R. I., and was appointed shortly
after as Lecturer on Insanity and Nervous Diseases to the Boston University
School of Medicine. The work, comprising nearly five hundred pages, will
be welcomed by every homoeopathic practitioner, for every physician is called
upon sooner or later to undertake the treatment of cases of insanity among
his patrons' families, inasmuch as very many are loth to deliver any afflicted
member to a public institution without having first exhausted all means within
their power to effect a cure, and the family physician naturally is the first to
be put in charge of the case. It is, therefore, of paramount importance that
every homoeopathic practitioner's library should contain such an indispensa-
ble work.
“The basis of Dr. Worcester’s work was a course of lectures delivered before the senior
students of the Boston University School of Medicine. As now presented with some altera-
tions and additions, it makes a very excellent text-book for students and practitioners. Dr.
Worcester has drawn very largely upon standard authorities and his own experience, which
has not been small. In the direction of homoeopathic treatment, he has received valuable
assistance from Drs. Talcott and Butler, of the New York State Insane Asylum. It is not,
nor does it pretend to be, an exhaustive work; but as a well-digested summary of our present
knowledge of insanity, we feel sure that it will give satisfaction. We cordially recommend
it.”—NEW ENGLAND MEDICAL GAZETTE. -
JUST ISSUED. W.
THE AMERICAN HOMOEOPATHIC PHARMACOPOEIA.
Compiled and Published by Boericke & Tafel. Pp. 523, 8vo. Cloth, $3.50.
No physician, busy or otherwise, can afford to neglect a correct knowledge of the forms
and preparations of his armament against disease. This knowledge is as necessary in con-
trolling legitimate operations on part of the pharmacist, as in preparing remedies individually.
In point of general information and especially of minute and unmistakable directions, the
work stands alone among the recent publications on this subject. Special attention is given
to synonyms in the body of the book, besides being fully represented in a large and copious
index.
• , ; ** * „Ť
��
±----
§§§§y→*… ?
·Ží №--
-* （&
. . .' N \， . . ~~) .
* } ***, *）?, - ***
~ && ！ :}}}''. ; &
..ſº tº
§§§
* - e. -
... t ??

§§§§
§§§ ¶ （×） și șºſ§§§§§§§§
ſae：§§§ſae§§
！！！！！
ſae
§3ºaț¢）.
S?
§*... º
§***
gº º
º
º
º
،----
ſae·
-ſae
ſaeºrges;
¿?
Q：
**¿.
&（3）
§¶√∞
ſae
¿
*§§§
·§§§§
ſae
sae.№
§§
ſaeºſ:
¿