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 LIBRARY 
 
 OF THK 
 
 University of California. 
 
 GIFT OF 
 
 Class 
 
MENTAL PATHOLOGY 
 
 AND 
 
 THERAPEUTICS 
 
 BY 
 
 W. GRIESINGER, M.D., 
 
 PROFESSOR OF CLINICAL MEDICINE AND OF MENTAL SCIENCE IN THE UNIVERSITY 
 OF BERLIN ; HONORARY MEMBER OF THE MEDICO-PSYCHOLOGICAL ASSO- 
 CIATION ; MEMBRE ASSOCIE ETRANGER DE LA SOCIETE MKDICO- 
 PSYCHOLOGIQUE DE PARIS; ETC., ETC. 
 
 TRANSLATED FROM THE GERMAN (SECOND EDITION) 
 
 BY 
 
 C. LOCKHART ROBERTSON, M.D. Caktab., 
 
 MEDICAI. SUPKRINTKNDENT OP THE SUSSEX LUNATIC ASYLUM HATWARD's HEATH ; 
 
 AND 
 
 JAMES RUTHERFORD, M.D. Edin.- 
 
 NEW YORK 
 WILLIAM WOOD & COMPANY 
 
 1882 
 
BIOL-Lia. 
 
 Copyright by 
 WILLIAM WOOD & COMPANY. 
 
 1882. 
 
 STEAM PRESS OP 
 
 H. O. A. Industrial School, 
 187 & 189 E. 76th St., New York. 
 
N^OTE BY THE TRANSLATORS. 
 
 We have endeavored, in the following translation of the second 
 edition of Professor Griesinger's standard work on 'Mental Pathology and 
 Therapeutics,' to give the English reader an accurate and literal rendering 
 of the German text. In thus adhering to the literal meaning of the 
 author, we have followed the example of the learned translator of the 
 French edition' of this work, with which we have throughout carefully 
 compared our own readings. If possible, the French translation renders 
 Professor Griesinger's German medico-metaphysics (not easily understood 
 even in German) more literally than we have done. It was soon evident 
 to us that any attempts at a more liberal rendering of these difficulties 
 would only farther obscure — possibly contravene — the author's meaning. 
 
 Pkofessoe Griesinger is essentially the representative and the ac- 
 knowledged leader of the modern German school of Medical Psychology. 
 As such, his work must be an object of deep interest to every student in 
 
 Mental Science. 
 
 C. L. E. 
 
 J. E. 
 June 1, 1867. 
 
 ' ' Traite des Maladies Mentales, pathologie et therapeutique, par le Docteur 
 W. Griesinger, etc. etc. Traduit de I'Allemand (2e edition) sous les yeux de 
 I'Aiiteur, par le Docteur Doumic, Medecin de la Maison centrale de Poissy.' Paris, 
 
 1865, pp. 587. 
 
 210798 
 
PREFACE TO THE SEOO:ND EDITIOjST. 
 
 I AM happy to be able at last to place in the hands of the profession 
 the long-delayed second edition of this work. It is not entirely a new 
 work, many chapters remain entirely unaltered; many others, however, 
 have undergone correction and remodelling, and, in particular, great ad- 
 I ditions have been made, which I hope may be considered as adding to the 
 value of the work. Fewest changes have been necessary in the descrip- 
 : tion of the special forms of insanity: melancholia, mania, dementia, etc., 
 i have indeed remained the same since 1815. Most alterations and addi- 
 \ tions occur in the parts relating to etiology, pathological anatomy, the 
 anatomy of the brain, the psychological introduction, the complications 
 of insanity, and treatment. An entirely new section on the general diag- 
 nosis of mental disease has been added, and also a section on idiocy and 
 cretinism. This subject is entirely omitted in the first edition. Since 
 the date of its publication I have had occasion and opportunity more im- 
 ' mediately to employ myself with these states through my connection 
 ! with the idiot asylum of Mariaberg, which was under my direction during 
 the latter period of my residence in Wiirtemberg. The number of illus- 
 I trative cases have been increased by the addition of several interesting 
 i examples: in many of the more important chapters the princii^al litera- 
 ture is given to the reader who desires further information; finally, I 
 have, as often as opportunity occurred, sought to elucidate the medico- 
 legal aspect of psychiatry from the stand-point of the doctrines contained 
 in this work, and, as occasion offered, expressed my views shortly but 
 distinctly concerning much that is related to the present state of medical 
 psychology. In this I had solely the interests of science aud the profit 
 of the reader in view, totally regardless of the censure or applause of this 
 or of that school. 
 
 As, to my great joy, the first edition of this work won many friends 
 to the study of our interesting science, I hope that the second also Aviil 
 contribute to the extension of psychological knowledge, and, in particu- 
 lar, of correct views upon the subject. In the Universities our specialty 
 is still far too much ignored, and clinical instruction especially is as yet 
 nowhere conducted and acknowledged in a degree corresponding to the 
 
VI PREFACE TO THE SECOND EDITION. 
 
 importance of the subject. I liave done my j^art. In Tubingen, for up- 
 wards of ten years, I regularly delivered lectures upon medical jisychology, 
 in conjunction with my principal subject, and, as often as opportunity 
 offered, admitted cases of mental disease into my clinique, making them, 
 like any other disease, the subjects of clinical instruction and discussion. 
 The advantage of this is so apparent that I live in the hope that very 
 soon the establishment of regular psychological cliniques will become 
 general. It is through these that the proper idea, the purely medical, 
 of mental disease, conjoined, however, with a knowledge of the morbid 
 mental symptoms, can first receive that general extension, so very desir- 
 able, whereby mere asylum managers can no longer call themselves med- 
 ical psychologists, whereby that fantastical bombast, sounding of the 
 spiritual world, which is still sometimes apparent in psychological litera- 
 ture, will soon give way to temperate, clear, medical observation. 
 
 Several of the most recent writers on insanity have been so well 
 pleased with the first edition of my book that they have assumed into 
 their writings not only the ideas and doctrines, the arrangement and ex- 
 ample scontained in it, but have even taken, without restraint, as their 
 own, simple excerpts of whole sections. I quietly permitted this to oc- 
 cur, but now it would, of course, be disagreeable to me if any one were 
 to think that it was I who, in this edition, had borrowed from those 
 authors. I would therefore beg of the reader, wherever doctrines, pages, 
 and even chapters, occur similar, or nearly similar, to what they may 
 shortly before have read in books or journals, simply to compare them 
 with the first edition of this Avork which appeared in 1845. 
 
 G. 
 
CONTENTS. 
 
 BOOK FIRST — GEI^EEAL. 
 
 CHAPTER I. 
 On the Seat of Mental Diseases and the Blethod of their Study 
 
 CHAPTER II. 
 Preliminary Anatomical Observations . . . 
 
 CHAPTER III. 
 Preliminary Physio- pathological Observations on Mental Phenomena 
 
 CHAPTER IV. 
 
 Tlie Elementary Disorders in INIental Disease . 
 
 I. The Elementary Intellectual Disorders 
 
 A. Anomalies of Sentiment 
 
 B. Anomalies of Thought 
 
 a. Formal Deviations 
 
 b. Perversions of Thought — Delirioiis Ideas 
 
 c. Anomalies of the Will 
 
 II. The Elementary Disorders of Sensation 
 
 III. The Elementary Disorders of Movement 
 
 CHAPTER V. 
 
 On Insanity in General 
 
 I. The Analogies of Insanity 
 
 II. The General Diagnosis of Mental Disease 
 
 PAGE 
 1 
 
 17 
 
 43 
 43 
 45 
 47 
 47 
 50 
 53 
 55 
 73 
 
 75 
 
 75 
 80 
 
 / 
 
 BOOK SECOI^D. 
 
 THE CAUSE AND MODE OF ORIGIN OF MENTAL DISEASE. 
 
 CHAPTER I. 
 The Causes of Insanity ...... 
 
 CHAPTER II. 
 
 The Predisposing Causes of Mental Disease .... 
 
 I. General Predisposing Causes .... 
 
 II. Special Predisposing Causes . . • • 
 
 89 
 
 94 
 94 
 
 106 
 
 CHAPTER in. 
 
 The Causes of Insanity (continued) 
 
 I. Mode of Action of Causes 
 
 II. Psychical Causes 
 
 III. Mixed Causes 
 
 IV. Physical Causes 
 
 114 
 114 
 115 
 119 
 122 
 
Vlll 
 
 CONTENTS. 
 
 BOOK THIED. 
 
 FORMS OF MENTAL DISEASE. 
 
 CHAPTER I. PAGE 
 
 States of Mental Depression — Melancholia .... 146 
 
 I. Hypochondriasis ...... 147 
 
 II. Melancholia in a more Limited Sense . • .156 
 
 III. Melancholia with Stupor . . . . .172 
 
 IV. Melancholia with Destructive Tendencies . . .176 
 
 A. Melancholia with Suicidal Tendencies . . . 177 
 
 B. Melancholia with Destructive and Murderous Tendencies , 183 
 V. Melancholia with Persistent Excitement of the Will . . 190 
 
 CHAPTER II. j 
 
 States of Mental Exaltation . . . . . .192 
 
 I. Mania . . . . . . .195 
 
 II. Monomania ...... 2V6 
 
 CHAPTER HI. 
 
 The States of Mental Weakness . . . ^ ^ . .225 
 
 I. Chronic Mania (Die Verriicktheit ; La Folie svstematisee) . 228 
 
 II. Dementia . . . " . . .240 
 
 III. Apathetic Dementia ..... 242 
 
 IV. Idiocy and Cretinism . . , • . 244 
 
 A. Idiocy in general ..... 245 
 
 B. Endemic Cretinism ..... 253 
 
 CHAPTER IV. 
 On several Important Complications of Insanity . i • 277 
 
 BOOK rOUBTH. 
 
 THE PATHOLOGICAL ANATOMY OF MENTAL DISEASE. 
 
 CHAPTER I. 
 
 Pathological Anatomy of the Brain and its Membranes 
 
 290 
 
 A. The Cranium .... 
 
 294 
 
 B. The Arachnoid .... 
 
 296 
 
 C. The Pia Mater and Surface of the Brain . 
 
 298 
 
 D. The Cerebral Substance . . • 
 
 300 
 
 E. The Ventricles and Internal Parts . • 
 
 303 
 
 I. Acute Insanitj^ . . . . « 
 
 306 
 
 II. Chronic Insanity ..... 
 
 306 
 
 III. Paralytic Dementia .... 
 
 307 
 
 CHAPTER II. 
 
 
 The Pathological Anatomy of other Organs . . • 
 
 309 
 
 BOOK FIFTH. 
 
 
 THE PROGNOSIS AND TREATMENT OF MENTAL DISEAS 
 
 5E. 
 
 CHAPTER I. 
 
 
 Prognosis ...... 
 
 317 
 
 CHAPTER II. 
 
 
 Therapeutics ....... 
 
 326 
 
 I. General Principles . . . . . 
 
 326 
 
 II. Physical Treatment . . . . . 
 
 333 
 
 III. Moral Treatment ...... 
 
 342 
 
 rV. Various Modifications of Treatment 
 
 351 
 
 V. Lrmatic Asylums ..... 
 
 358 
 
 Indkx ........ 
 
 371 
 
ON 
 
 MENTAL DISEASES. 
 
 BOOK FIEST-GEI^5"EEAL. 
 
 CHAPTER I. 
 
 ON THE SEAT OF MENTAL DISEASES AND THE METHOD 
 
 OF THEIR STUDY. 
 
 § 1. The following treatise has for its object the study of mental 
 disease or insanity, its diagnosis and treatment. Insanity itself, an ano- 
 malous condition of the faculties of knowledge and of will, is only a 
 symptom; our classification of the group of mental diseases proceeds upon 
 the symptomatological method, and by such a method alone can any 
 classification be effected. The first step towards a knowledge of the 
 symptoms is their locality — to which organ do the indications of the 
 disease belong? what organ must necessarily and invariably be diseased 
 where there is madness? The answer to these questions is preliminary to 
 all advancement in the study of mental disease. 
 
 Physiological and pathological facts show us that this organ can only 
 be the brain; we tlierefore primarily, and in every case of mental disease, 
 recognize a morbid action of that organ. 
 
 § 2. Physiology considers mental activity as a special form of organic 
 life; it recognizes in mental energy the function of a particular organ, 
 and attempts to deduce it from the physical organism. Well-known ex- 
 periments prove that if the mental faculties, in the wide sense of the term, 
 are related to the whole nervous system, the seat of intelligence and of vo- 
 lition is in the brain, and confined to certain portions of it. Of course, 
 the spinal cord, as also the ganglionic system of the sympathetic, possess 
 not only functions of transmission, but also central functions of commu- 
 nication, of association, and of excitation (tonicity, reflex action, etc.), 
 but relatively to the higher central functions theirs is merely peripheral. 
 The states of any part of the nervous system, inasmuch as they are trans- 
 mitted to the brain, also furnish matter of mental excitation and Intel-, 
 lectual activity. Impressions can originate from every peripheral nervous 
 ramification which may prompt to motives, and originate obscure or well- 
 defined conceptions and efforts; but it is the brain alone which receives 
 and concentrates these impressions, and which originates the influences 
 
2 THE SEAT OF MENTAL DISEASES 
 
 exerted by them upon series of co-ordinate movements — that is, upon the 
 actions. 
 
 The deeper actions of the understanding and will can no more be de- 
 duced from the organization of the brain than those of sensation. Never- 
 theless, the successive acts of the mental faculties can, in a general 
 manner, be easily referred to the structure of the different parts con- 
 cerned. That portion of the central nervous system within the cranium 
 consists of masses of nerve-substance. These receive the sensitive 
 columns of the spinal marrow, and the central expansions of the higher 
 nerves of sense; from this again the motory columns of the marrow pro- 
 ceed. In accordance Avith this, we see that all impressions occurring 
 centripetally, through the senses, converge in the brain, are perceived, 
 assimilated, and excite the mental faculties, and then give rise to new 
 centrifugal acts, owing to the relation in which sense and mind stand to 
 the actions of the motory system. 
 
 We see that in the animal species the psychical powers are varied, and 
 capable of high development, in proportion to the size, the quality, and 
 the form of the brain; in short, according to the volume of the great 
 hemispheres. So also, in the human race, we observe that great defi- 
 ciency of cerebral development is attended by weakness of the mental 
 faculties, of the intellect and will (in many cases of idiocy); and experi- 
 ence teaches, that in all men these faculties materially alter with the de- 
 gree of development, and tlie changes which the brain presents, at the 
 different stages of life. Even in these changes, these successive steps of 
 gradual progress in maturity and decline, thementalcapacity of the brain 
 runs parallel with all the other organic functions, and thus proves itself 
 liable to the same laws of organic development 
 
 As is well known, it has been already attempted to refer certain phases 
 of mental activity to other parts of the nervous system than the brain : for 
 instance, feeUng has been referred to the nervus sympatheticus. From a 
 psychological point of view, this attempt sprang from the sufficiently refuted 
 assumption of the isolated character of the mental faculties. From the physio- 
 pathological point of view, it stands in opposition to all we can positively declare 
 respecting the functions of the sympathetic nerve. Quite as unfounded, and 
 equally unexpounded, is that doctrine which assumes an immediate co-oper- 
 ation of all parts of the organism, therefore of the bones, glands, etc., with the 
 mental functions, and would, accordingly, deduce insanity immediately from 
 disturbance of these peripheral organs. . , , , 
 
 In recent times, in consequence of very interestmg results furnished by 
 experiment, essentially psychical functions, sensation, and even volition, have 
 been ascribed to the spinal marrow (Pfliiger, Aurbach). Schiff (' Physiol, des 
 Nervensystems,' i., p. 211) has clearly and conclusively elucidated these views, as 
 well from the experimental as from the psychological stand-point. It may readily 
 be admitted that the impressions are produced in the spinal marrow, generally 
 after the same scheme as in the brain ; and it cannot easily be directly refuted, 
 that in the spinal marrow of the frog, sensation, and even pain, still remain after 
 decapitation ; but as regards ivill (in the ordinary sense of the word) it cannot be 
 supposed to be here in question, for the will implies sensations, which have 
 entered the sphere of consciousness, along with the idea of the effort which pro- 
 duces movement, of space, of the limits of body— acts for the accomplishment of 
 which the co-operation of the central sphere of the sense of sight is absolutely 
 necessary. Very recently, Ffiuger's theory, founded upon his experimental 
 data, has also been caUed in question (Goltz, 'Konigsb. Med. Jahrbuch.'ii., 1860, 
 p. 189). 
 
 § 3. Pathology proves as clearly as physiology, that the brain alone 
 can be the seat of normal and abnormal mental action; that the normal 
 state of the mental process depends upon the integrity of this organ; and 
 
AND THEIK METHOD OF STUDY. • 3 
 
 that both together are influenced by the state of the other organs in 
 disease. The invariable and essential symptoms of cerebral diseases may 
 arise from internal causes or external lesions; may proceed from anomalies 
 of sensation and movement, and, in serious diseases, even from mental 
 disturbance (exaltation or depression of the ideality, loss of self -conscious- 
 ness, delirium, etc). Cases of less frequent occurrence, Avhere, with 
 serious disorganization of the brain and loss of brain-substance, no dis- 
 turbance of the mind is apparent, do not invalidate the results of our 
 everyday experience. 
 
 Collections of such cases are to be found, as in Longet (Anat. et Physiol, d. 
 Syst. nerv.,' Paris, 1842, i., p. 670). With reference to most of these and other 
 similar cases with which we are acquainted, different opinions may be held. In 
 almost all, intelligence, in the narrow sense of the word, is alone considered; 
 the circumstances of disposition and will are entirely overlooked; and even to 
 the intelligence but slight tests are applied to prove its integrity, such as the 
 answering of simple medical questions. In none of these observations has the 
 intelligence been tested in its full extent, and in many, particularly in all 
 liospital cases, a comparison of the mental condition after the disease or loss of 
 substance with the earlier state was absolutely impossible. All nicer distinctions, 
 therefore, cannot be considered. Notwithstanding, it must be admitted that 
 there may be disease and loss of brain, and yet no appreciable disturbance of the 
 mental life. Very much depends upon the seat of the disease ; all parts of the 
 brain do not stand in the same close relation to the mental functions ; some stand 
 much more in relation to muscular movement (Pons, Thalami, etc.). Further, 
 with the brain, as with all other bilateral organs, it is highly probable that a 
 compensation is made by the remaining healthy half (see § 15). Lastly, we 
 frequently find limited anatomical lesions in other important organs without any 
 striking functional derangement (chronic gastric ulcer, pleuritic adhesions, 
 tubercle, etc.); and loss of substance (through gangrene) has likewise been 
 observed, as in the lungs or in the bowels, where, after recoveiy, the process of 
 respiration or of digestion proceeded without apparent interruption. Such facts, 
 however, would not readily be admitted in opposition to the tenet, that the lungs 
 are the organs of respiration, and that digestion takes place in the bowels. 
 
 Further and more apposite testimony in favor of our assertion, that 
 the brain is the organ affected in insanity, is furnished by examination of 
 the bodies of the insane after death. In many such examinations, true 
 anatomical changes are found in the brain itself, or in its coverings; and 
 where anatomical changes exist those of the brain are, at least, the only 
 constant. The circumstance that such changes are not always found 
 should not weaken this argument. In those affections of the nervous sys- 
 tem which are chiefly indicated by states of irritation, as neuralgias, 
 cramps, etc., we very frequently find no appreciable anatomical lesion; 
 ind this is still more the case in the conditions of weakness, paralysis, etc. 
 Very many mental diseases belong to the first of these two classes. It is 
 with this class of mental diseases as with a number of other nervous af- 
 fections, as epilepsy, tetanus, etc., whose seat is in the brain or spinal 
 marrow; and although in many cases this cannot be ocularly demonstrated 
 by pathological anatomy, still, on physiological grounds it is universally 
 admitted. 
 
 The majority, however, of the mentally diseased, besides disturbances 
 of the intellect and will, present remarkable anomalies of other functions 
 which doubtless belong also to the brain; above all, hallucinations, ano- 
 malies of sensation, whicli in many cases are felt to be peripheral, but 
 whose origin must necessarily be in the brain, as is irrefutably demon- 
 strated by Esquirol's cases of permanent hallucinations of sight with com- 
 plete blindness from atrophy of the optic nerve. We see, too, that the 
 central excitation of voluntary muscles, which is incontestably a cerebral 
 
4: THE SEAT OF MENTAL DISEASES 
 
 function, is altered in the cases of many who are mentally diseased : some- 
 times it assumes the forms of exalted activity and energy, sometimes of 
 cataleptic rigidity; at others it is seen as that form of paralysis whose 
 rapid progress accompanies the course of a certain form of insanity (de- 
 mentia). Besides, many other anomalies of cerebral function, as lessened 
 sensibility to pain and temperature, sleeplessness, convulsions, cerebral 
 congestion, etc., are observed in the insane more as accessory symptoms; 
 which, however, may serve further to confirm the existence of disease in 
 the brain. 
 
 While, at all events at the time of the first edition of this book, many physi- 
 cians, indeed wliole psychological schools, still require absolute proof of the 
 concluding sentence of § 1, many of the more eminent psychologists long ago 
 came to the same correct conclusion, tliat in every mental disease the brain is. 
 affected, and that this cerebral affection is the proximate cause of the insanity. 
 (See Stiedenroth, ' Psychologie,' ii., p. 278.) 
 
 § 4. While we are forced by facts to refer understanding and will to 
 r the "brain, still, however, nothing can be assumed as to the relation exist- 
 ing between these mental acts and the brain, the relation of soul to 
 material. From an empirical point of view the unity of soul and body 
 is indeed a fact primarily to be maintained, and the a priori investiga- 
 tion of the possibility of soul apart from body, of a bodiless soul, must 
 be entirely dismissed, confining ourselves to abstract considerations of 
 its unity and oneness as distinguished from the endless modifications of 
 matter. But these hypotheses that have been framed to render more 
 conceivable the otherwise inexplicable unity of soul and body, by means 
 of attenuated fluids which mediate between them, " fluids subtle 
 enough to be reckoned spirit," even by the system of pre-established 
 harmony according to which body and soul never act on, but always 
 along with, one another, — these hypotheses are, empirically considered, 
 as difficult to sustain as to refute. How a material physical act in the 
 nerve fibres or cells can be converted into an idea, an act of conscious- 
 ness, is absolutely incomprehensible ; indeed, we are utterly unable even 
 to settle the question of the existence or nature of the media existing 
 between them. All these matters are as yet only probable ; in wliich 
 state of affairs the simplest hypothesis is the best; and certainly the 
 materialistic offers fewer difficulties, obscurities, and contradictions than 
 any other, especially in relation to the origin of thought._ Therefore, 
 leaving out of view those possible but quite unknown mediating events, 
 it is scientifically admissible to connect the faculties of the soul with the 
 body in the same intimate relation as exists between function and organ 
 — to consider the understanding and the will as the function, tlie special 
 energy, of the brain, just as transmission and reflex action are considered 
 the special functions of the nerves and spinal cord, and to consider the 
 soul primarily and pre-eminently as the sum of all cerebral states. 
 
 Definite information regarding v^hat takes place in the soul can neither be 
 afforded by materialism, which would explain all mental acts by the pliysical, 
 nor by spiritualism, which would explain the material by the psychical. And 
 even if we did know all that takes place within the brain when in action—if we 
 could penetrate into all the processes, chemical, electrical, etc., of what use is it? 
 Oscillation and vibration, all that is electrical and mechanical, are still not mental 
 conditions, acts of thought. How they can be transformed to these is, indeed, a 
 problem which shall remain unsolved to the end of time ; and I believe that if 
 to-day an angel from heaven came and explained all to us, our understanding 
 would not even be able to comprehend it. 
 
 What shall now be said of the flat and shallow materialism which would 
 overturn the most general and most valuable facts of human consciousness 
 
AND THEIR METHOD OF STUDY. 5 
 
 because it finds no palpable trace of them in the brain? Empirical perception, 
 in asciibing the phenomena of sensation, intellect, and will to the brain as its 
 function, leaves not only the actual contents of the life of the human soul 
 untouched in all its riches, and, in particular, maintanis energetically the fact of 
 free self-determination; it leaves also, naturally, the metaphysical question, 
 what it may be that enters as soul-substance in this relation of the sensation, 
 understanding, and will, which takes the form of psychical existence, etc. 
 Empiricism must patiently await the time when the questions concerning the 
 connection of the contents of the life of the human soul, with its forms, shall 
 have become physiological instead of metaphysical problems. Meanwhile, would 
 tliey but desist from the pursuit of unanswerable questions, from striving wildly 
 in science, and from accusing each other of heresy by the mixing up of quite 
 heterogeneous questions. Would the followers and fanatics of materialisnr but 
 consider a point wliich appears to me not to have been hitherto sufficiently 
 brought forward in the discussions of these questions. The elementary phenom- 
 ena wiiich occur in the nerve-masses must be in all men always identical, 
 especially if they be considered (as is now believed by many) as essentially elec- 
 trical, necessarily in the highest degree simple, consisting of 4- and — . How "^ 
 could the endless variety of thoughts, feelings, and desires, not only of individual 
 men, but of different ages, proceed from these alone and immediately ? 
 
 Any discussion concerning the materiality or immateriality of the mental 
 processes cannot, therefore, in the present state of our knowledge, be decided; 
 it would fall in part, and already in its first premises, together with the question 
 of the internal changes in the activity of the nervous system. All comparison 
 with the imponderables, which stand in a relation analogous to matter, and 
 appear also as somewhat immaterial, provoke however material changes and 
 modifications, are of but little service. The mental or nervous agent has no real 
 analogue in the whole of the universe; the theory, as Locke has already shown, 
 experiences the same difficulties, whether they allow to think the material, or 
 whether they will comprehend the action of an immateiial agent upon matter. 
 That the functions of the soul, moreover, must alwaj's be accompanied by 
 material acts, no one denies; this relation is very well developed by Stiedenroth 
 (i., p. 53, and a. a O.); only the idea which participates in the organic accompani- 
 ment is to him a real, and known, and — a still more fruitful proposition! — indeed, 
 the more lively the organic accompaniment, the livelier the thought. Some 
 phases of the mental processes are, moreover, evidently more closely associated 
 with so-called physical events (with other acts of the organism) than others; for 
 example, than pure and calm thought. Memory and love, says Aristotle (On the 
 Soul,' i., 4), do not proceed from the soul, but from the association of the soul and 
 the body. Indeed, it is in memory and in love that a direct mixture of organic 
 processes is most evident ; the same may also be said of the imagination. 
 
 § 5. lu accordance with the foregoing statements, the question so 
 frequently and so largely treated of by the earlier psychologists, whether 
 insanity, in the anomalies of the understanding and will, the disease 
 really affects the soul, finds a ready and an affirmative solution. Of 
 course we must not speak of diseases of the soul alone — a pathology not 
 less incorrect speaks of diseases of the vital processes, of the functions — 
 but of disease of the brain, through which every act of the intelligence 
 and the will is deranged. 
 
 § 6. Although, however, every mental disease proceeds from an 
 affection of the bi'ain, every disease of the brain does not, on that account, 
 belong to the class of mental diseases. What kind of brain affection, 
 then, is it with which we hav^e to do in insanity? Anatomically con- 
 sidered, the diseases whose symptoms are called insanity are of all the 
 most diverse, simple irritations without perceptible changes of structure, 
 inflammation of the cortical substance, atrophy, changes of nutrition, 
 anomalies of the circulation within the cranium, intra-meningeal aj)o- 
 plexy, simple hyperaemias of the brain, etc. All these conditions, differing 
 so widely from each other, can originate sym])toms on account of whicli 
 we send the patient to an asylum, and which are described in psycholog- 
 ical works as mental diseases. All attempts strictly to distinguish insau- 
 
6 THE SEAT OF MENTAL DISEASES 
 
 ity from the acute or chronic diseases of the brain, as they are described 
 from the anatomical point of view — for example, meningitis, encepha- 
 litis, etc. — would be an undertaking most futile, for even certain cases of 
 mental disease are really meningitis, encephalitis, etc. The idea of 
 mental diseases being purely symptomatological in great measure accom- 
 panies these anatomical notions, and the objects of both do not admit of 
 their being compared with each other. Only this much can in general 
 be with certainty affirmed, that the brain affections which lie at tlie root 
 of mental diseases are infinitely more frequently diffuse than localized.' 
 
 Cerebral pathology is, even in the present day, to a great extent in 
 the same state which the pathology of the thoracic organs was in before 
 the days of Laennec. Instead of proceeding in every case from the 
 changes of structure of the organ, and being able to deduce in an exact 
 manner the production of the symptoms from the changes in the tissue, it 
 has very often to deal with symptoms of which it can scarcely give an ap- 
 proximation to the seat, and of whose mode of origin it is totally ignorant. 
 It must keep to the external phenomena, and establish the groups of dis- 
 eases according to something common and characteristic in the symptoms 
 altogether independently of their anatomical basis. As with epilepsy, 
 chorea, etc., so also with psychical or mental diseases, under which we 
 include all those affections of the brain in which anomalies, derangements 
 of the understanding and of the will, constitute the most striking 
 symptoms. 
 
 The ordinary diseases of the brain, circumscribed inflammation, abscesses, 
 tumors, tubercular meningitis, etc., are not termed mental diseases, even 
 although in these affections the mental faculties are usually more or less- 
 deranged, because other cerebral symptoms, those of disturbed sensation and 
 movement in general, greatly predominate: a potiori Jit denominatio. 
 
 Exceptionally, however, such patients are also considered as mentally 
 diseased, and are sent into asylums, when, for example, the case assumes from 
 the first the chronic form, when maniacal excitement sets in very early, etc. On 
 the other hand, in mental diseases the sensitive and motory functions of the 
 brain are very commonly also disturbed; but this disturbance is subordinate, — 
 the psychical appear as the leading phenomena. More minute definitions of 
 mental diseases cannot and need not be given here; their general diagnosis will 
 be found in the 2d section, chapter 5th of this book. 
 
 § 7. As insanity is only a complication of symptoms of various morbid 
 states of the brain, the question might be asked, whether its special study 
 apart from that of the other diseases of the brain can be justified, or 
 whether mental pathology should not rather always accompany cerebral 
 pathology? But, although at some more distant period this may perhaps 
 be looked for, any attempt at such a combination would at present be 
 premature and quite impracticable. If the intimate fundamental union 
 which exists between insanity and the other cerebral diseases be only 
 constantly kept in view, — if in the one, as in the other group, the same 
 exact anatomical physiological method be as far as possible pursued, — 
 cerebral pathology will not be retarded, but rather advanced, by the 
 formal specializing and monographical elaboration of these diseases classi- 
 fied according to their symptoms. As psychiatric must assert the posi- 
 tion so lately obtained for it — as a part of cerebral pathology, and as 
 several of its practical phases, asylum economy, its medico-legal bearings, 
 etc., invest it with an extent and character peculiar to itself, which under 
 all circumstances, even when viewed as a part of cerebral pathology, keep 
 
 ' See " The Diagnosis of Brain Diseases," a paper by the author, ' Archiv der 
 Heilkunde,' Leipzig, 1860, part i., p. 51. 
 
AND THEIR METHOD OF STUDY. < 
 
 it distinct, any attempt to obliterate that distinction would at present be 
 still less justifiable. 
 
 The earlier attempts completely to combine the mental diseases, based upon 
 their corresponding anatomical changes, with the cerebral diseases, were proved 
 by their want of success to be premature and impossible (Sc. Pinel, ' Pathologie 
 cerebrale,' Paris, 1844). And just as when, quite recently, one of our most 
 eminent physicians attempted to study a department of mental diseases from a 
 purely anatomical point of view (Calmeil, ' Traite des Maladies inflammatoires 
 du Cerveau,' Paris, 1859, 2 vol.), so this praiseworthy attempt treats, from the 
 nature of the question, only of a part of these conditions. Thus psychiatrie 
 will long remain a special branch of medical science ; its special study also gives 
 to the physician opportunity to acquaint himself, in some degree at least, with 
 the phenomena of mind of which, unfortunately, so little knowledge is in general 
 attained in the ordinary course of medical study. 
 
 § 8. Insanity being a disease/ and that disease being an affection of 
 tlie brain, it can therefore only be studied in a proper manner from the 
 medical point of view. The anatomy, physiology, and pathology of the 
 nervous system, and the whole range of special pathology and thera- 
 peutics, constitute preliminary knowledge most essential to the medical 
 psychologist. All non-medical, more particularly all poetical, and ideal 
 conceptions of insanity are as regards its study of the smallest value. 
 Several poetical representations of madness are excellent in certain points, 
 and evidently drawn from a study of nature (as Ophelia, King Lear, and 
 particularly Don Quixote); but, as the poet has almost entirely evaded 
 the organic causes of these states, looking only to the intellectual side, 
 regarding them as the results of former moral conflicts, and only requires 
 to bring forward that which serves this end, his delineation is at least 
 one-sided. A similar reproach is applicable to the manner in which the 
 moralists consider the subject, and still stronger, on account of the 
 earnestness with which some such attempts appeared. Nothing is more 
 false, nothing is more opposed to everyday observation, than any attempt 
 to transpose the nature of the mental diseases into the territory of mo- 
 rality. Facts speak loud enough, it is true, in favor of a very frequent 
 psychical etiology of these diseases; how can it be otherwise when moral 
 causes are amongst the weightiest, and most frequent, of the other dis- 
 eases of the brain and nervous system. The present state of the under- 
 standing and will is essentially dependent upon, and is indeed to a great 
 extent the necessary result of, the sum of all the previous thoughts and 
 wishes, and, as a consequence, the intellectual life becomes a fruitful 
 scource of the causes of insanity. But whilst the sphere of morality is 
 contained entirely within that of free and conscious thought, the start- 
 ing-points of the anomalous mental processes to which these cerebral 
 diseases give rise belong to quite another territory. It is from obscure 
 perversions of the inner consciousness, that in insanity the states of the 
 mind originally emotional, proceed; and where these have given birth 
 to a perversion of the judgment and inclinations of the patient, he is 
 already in a state where the first condition of all morality, self -conscious- 
 ness, the power of deliberation, of choice, are wanting, and his acts, be 
 they what they may, can no more be the object of a moral appreciation. 
 
 Poetical and rhetorical representations of insanity are not only unnecessary and 
 false theoretically, but even practically they are positively dangerous. Through 
 these the laity are filled with representations of mental diseases which do not in 
 
 ' A disease which also causes death. When a recent writer says, lunatics die 
 as little from insanity as other men from soundness of mind, he tries a wretched 
 antithesis. It is evident that no one dies frona sound health, mental or bodily. 
 
8 THE SEAT OF MENTAL DISEASES. 
 
 the remotest degree resemble nature: if, then, the facts do not correspond with 
 their ideas, they doubt whether mental disease be present. How natural is the 
 astonishment of many persons, when visiting an asylum, to find the inmates so 
 very different from what they expected! Psychological theories, which represent 
 mental diseases as the highest pitcli of the passions, lead many into such errors. 
 Any serious controversy, however, regarding the moral view of mental dis- 
 eases, is nowadays unnecessary. It would be even superfluous to oppose to this 
 doctrine the numerous cases where insanity is produced by causes purely physical 
 — by injury to the head, by narcotics, etc. ; its hereditariness, the family predis- 
 position, often showing itself in other relatives, as a disposition to other severe 
 neuroses, epilepsy, hysteria, etc. ; its various types, which often affect the course 
 of insanity as that of other nervous diseases; its occasionally observed interchange 
 with other diseases, the possibility of rapid cure, its analogy with dreams, etc. 
 The best refutation, however, is the simple examination of the progress of the 
 symptoms of insanity. 
 
PKEUMINABY ANATOMICAL OBSERVATIONS. 9 
 
 CHAPTER 11. 
 PRELIMINARY ANATOMICAL OBSERVATIONS. 
 
 § 9. In a paper' published in the year 1844, I have already called at- 
 tention to the universally demonstrable pathological analogy which exists 
 between the diseases of the brain; also, in as fur as they present by pre- 
 ference anomalous mental symptoms, and the functional disturbances, 
 and deeper organic lesions, of the spinal marrow. This comparison is 
 justified not only by the facts there stated, that both sections of the cen- 
 tral nervous system are liable to the same forms of morbid action, which 
 only show themselves very differently according to the originally given 
 difference of their energies, but it has also its basis in the normal and 
 pathological anatomy, which teaches us to recognize in the brain and 
 spinal cord a single, only artificially divided, whole, and exhibits to us, 
 in both, the same general dispositions, the same elementary tissues, and 
 also the very same pathological changes. 
 
 Presuming that the reader is acquainted with the general anatomy, 
 the divisions of the brain and spinal cord, the structure and diposition 
 of their membranes, we shall here premise only a few remarks upon the 
 structure and connection of the central nervous system, which, further 
 on, will explain certain physio-pathological results, and upon the review 
 of the healthy and morbid state of the brain. 
 
 § 10. The brain and spinal cord form a whole, whose different sections 
 present essentially the same elementary structure, and a common, though 
 constantly progressing, type of organization.'^ 
 
 As the vertebrated structure of the bony envelope of the spinal cord 
 recurs in a more highly developed form in the skull, which is composed 
 of a number of bones, so also the cranial portion of the central nervous 
 system consists of a complicated multiplicity of nerve-masses, which at 
 first sight appear not to have the same general structure as the spinal 
 cord, but in which, nevertheless, in sjiite of many important differences, 
 an analogy with the spinal cord and its immediate envelopes may be 
 recognized. 
 
 The central canal of the spinal cord, which is seen most distinctly in 
 the embryo, but also still perceptibly in the adult, and which is completely 
 inclosed by gray substance, opens at the level of the fossa of the ventricle 
 of Aurantius, closes again at the fourth ventricle, and forms in the in- 
 terior of the cerebrum the third and the lateral ventricles, in which it 
 terminates in the infundibulum. 
 
 The gray substance of the spinal cord is in direct commuuication 
 
 ' ' Archiv f, physiolog. Heilkunde,' iii., 1, p. 69. 
 
 * Compare Arnold, ' Bemerkungen ilber den Ban des Gehirns und Rticken- 
 marks,' Zurich, 1838. Valentine, ' Hirn- und Nervenlehre,' Leipzig, 1841. 
 Foville, ' Anatomie du Systeme nerveux cerebro-spinal,' Paris, 1844. Longet, 
 ' Anat. et Physiol, d. Syst. nerv.,' 1843. Buschke, ' Schadel, Gehirn und Seele,' 
 Jena, 1854. Gratiolet (Leuret), ' Anatomie comparee du Syst. nerveux,' torn, ii., 
 Paris, 1857. 
 
10 PKELIMIKABY ANATOMICAL OBSERVATIONS. 
 
 not only with the sensitive and motory roots of the nerves whicli pass in 
 and out of it, and with its white longitudinal columns, but also wiih the 
 gray substance of the brain. After it has extended into the medulla ob- 
 longata, partly upon the surface, and partly by entering into the corpus 
 iimbriatum of the olivary bodies, and into the corpora restiforniia, it 
 communicates with the corpus rhomboideum of the cerebellum; then in 
 its further passage forwards, with the gray substance of the crura cerebri, 
 the corpora quadrigemina, the optic thalamus, and corpus striatum; and 
 ends, at last, in the infundibulum or in the anterior perforated substance. 
 The continuation, therefore, of the gray substance of the spinal cord into 
 the interior and upon the base of the brain, forms a connected system of 
 gray lines and masses. Another system of gray substance is, however, 
 found in the brain, viz., the cortical substance of the hemispheres, 
 which everywhere covers the surface of the convolutions except in one 
 point — the gyi'us fornicatus. This mass of gray substance communicates 
 directly with the first system in only one point, at the substantia perfo- 
 rata, and this connection is formed through the medium of white fibrous 
 tracts; in the spinal cord itself it has nothing analogous. It forms the 
 point of common termination for the system of the extended columns 
 of the spinal cord, and for the system of fibres which arises within the 
 cranium and does not pass out of it.- 
 
 The cortical gray substance of the great hemispheres presents a strati- 
 fied structure,' and consists of from four to six layers of substance alter- 
 nately opaque and transparent; their difference depends chiefly upon the 
 greater or less quantity of cell elements entering into their composition. 
 The most external layer is in direct connection Avitli the surface of the 
 ventricles. These superficial layers of the cortical substance of the brain 
 present frequently changes, and more seldom disorganization, in the in- 
 sane. The minute structure of this substance is not the same throughout 
 It is composed, fundamentally, of nerve fibres, whicli proceed from the 
 white substance and in entering subdivide until they become very fine ; 
 secondly, of peculiar granules, which are directly connected with the 
 ultimate termination of these fibres; thirdly, of ganglion cells, which are 
 in part direct prolongations of nerve fibres, or continuations of the gran- 
 ules; fourthly, of an apparently homogeneous and structureless molecular 
 mass, which is considered by some as cellular tissue having a purely me- 
 chanical function, that of nerve cement, but which, at least in the corti- 
 cal substance, presents an extremely fine network in which the ultimate 
 terminations of the white nerve fibres and the continuations of the gran- 
 ules are finally lost, a canalicular tissue communicating on all sides, 
 and which seems to conduct to every part, and consequently to render 
 possible the transmission to all parts, of the states of the brain. 
 
 As these elements of the gray substance present in different parts of this 
 apparatus a different arrangement, the inference may be drawn of differences 
 in function. Thus, in some parts, the granules form a special and im- 
 portant layer in the most inferior part of the gray substance (in the corti- 
 cal gray substance of the cerebellum and in Amnion's horn); whilst in 
 
 Baillarger, 'Mem. de I'Acad, de Medecine,' viii., 1840, p. 172. Remak, ' Miil- 
 ler's Archiv,' 1841. 
 
 '^ Compare Gerlach, ' Microscopische Studien,' etc., Erlang., 1858. Hess, ' De 
 Cerebelli Gyrorum Structura,' Dorp., 1858. BerHn, ' Beitrage z. Structurlehre 
 der Grosshiruwiudungen,' Erlang., 1858. C. Kupffer, ' De Cornu Ammonis 
 Structura,' Dorp., 1859. Stephany, ' Beitrage z. Histologie der Rinde des grossen 
 Gehirns,' Dorp., 1860. 
 
PRELIMINARY ANATOMICAL OBSERVATIONS. 11 
 
 the cortical substance of the cerebrum they do not form a special layer, 
 but are more isolated. Thus, the gray substance of the cerebellum contains 
 ciiielly great cells; that of the cerebrum, on the contrary, besides a num- 
 ber of large cells, contains chiefly small ones (Jacobowitch, sensitive cells): 
 besides, tliese cells are sometimes separated, in some places more scat- 
 tered, and in others congregated in special layers. The fine fibres 
 which proceed from the white substance extend in the cerebellum almost 
 exclusively to the most inferior layers of the gray substance; in the cere- 
 bral convolutions they penetrate farther into it, giving ofE fibrous elements 
 to almost all its layers, and they here appear to run horizontally. In 
 some places the axes of the white fibres appear to pass into the pro- 
 longations of the ganglion cells; in other places their ultimate termina- 
 tion appears to be in the granules (cerebellum). In certain parts of the 
 gray substance, as in Ammon's horn, a considerable system of fibres 
 appears to originate in the thick layers of cells which does not proceed 
 farther than to another layer of the same substance where the fibres immedi- 
 ately terminate. Thus the relatively little which we as yet know of the 
 intimate structure of the gray substance permits us to suppose, not only 
 very great differences in the phenmoena of this extremely delicate_ appa- 
 ratus, but also that these phenomena are essentially different in the 
 various parts of the brain. 
 
 § 11. The white substance of the brain is composed of the well- 
 known transparent primitive fibres; in general they are here very fine; 
 they subdivide many times within it, and it appears afterwards penetrate 
 into the gray substance, which contains their ultimate divisions, their 
 points of termination or of origin. That a certain portion of the white 
 substance of the brain is formed by direct continuations of the three 
 columns of the spinal cord of each side, which, however, undergo a 
 complete process of decussation, is beyond doubt: for example, portions 
 of the posterior and lateral columns can be easily traced into the cerebel- 
 lum, portions of the anterior columns into the corpora quadrigemina, 
 the corpus callosum, etc. ; and, according to undisputed researches, 
 it is admitted that continuations of all three columns of the spinal 
 cord enter into each of the great ganglion- like enlargements which 
 constitute the brain. It is evident, however, that these prolongations 
 constitute but a small portion of the bulk of the white substance. New 
 systems of fibres enter into its composition: these are not only the central 
 expansions of the nerves of sense, which on their entrance into the brain 
 substance subdivide, disperse themselves in various directions, and, 
 amongst other things, appear to form a larger membranous expansion 
 in its interior, but also the new systems of fibres furnished by the com- 
 missures, and the so-called investing membrane (Belegungssuhstanz). 
 
 It would be of great importance to know the conditions of mixture 
 and of disposition of each of these systems of fibres, and their relation to 
 the corresponding prolongations of the three columns of the spinal cord. 
 Hitherto the efforts made to elucidate this point have not been fully suc- 
 cessful, but recently an advance has been made in unravelling the different 
 systems of fibres of the white substance of the brain. According to the 
 present state of our knowledge, the following principal systems are found 
 in it. 
 
 (1.) The system of fibres of the corona radiata {Stahkranz). These 
 enter into all the convolutions of the external surface of the hemispheres, 
 especially at the posterior parts, and extend even to the summit of the 
 convolutions. A preponderating relation to the motory functions may be 
 
12 PRELIMINARY ANATOMICAL OBSERVATIONS. 
 
 attributed to this system of fibres. The corona radiata is not simply the 
 prolongation of parts of the medulla oblongata; this is evident from the 
 remarkable size which it presents in man in proportion to that of the me- 
 dulla oblongata. In most of the lower animals the reverse is the case; 
 the corona is relatively smaller than the medulla. 
 
 (2.) The expansion of the corpus callosum. The corpus callosum 
 (like the pons Varolii in the cerebellum) ought to be considered as the 
 analogue, more highly developed, of the anterior commissure of the 
 spinal marrow. It appears to be formed principally by the fibres of the 
 corona, Avhich in passing forward cross here, and pass to the hemisphere 
 of the opposite side; therefore the dependence of each half of the body 
 upon the oppossite hemisphere. The fibres proceeding from the corpus 
 callosum radiate to all the convolutions of the hemispheres, especially, 
 however, to their internal and superior parts. 
 
 (3.) The system of fibres of the anterior commissure; of which a part 
 suddenly terminates in the inferior convolutions of the middle lobe of the 
 brain, another part enters into the posterior lobe, from which it spreads 
 over the whole extent of the superior border of the hemispheres. The 
 anterior commissure appears, therefore, to be in man an apparatus of 
 connection between the two hemispheres in their totality (in many ani- 
 mals rather a connection between the olfactory lobes). The high psychi- 
 cal function which by some has been attributed to this system appears to 
 me to be in the highest degree doubtful; the very considerable size which it 
 ])resents in the Kangaroo (Gratiolet) seems rather to indicate that it has 
 .some connection with the movements of the lower extremities. 
 
 (4.) The expansions of the nerves of sense within the brain, and in 
 particular of the optic nerve. A fan-formed expansion can be distin- 
 guished within the hemispheres passing from the optic tract to the 
 summit of the posterior lobe; other such radiations pass forwards in all 
 the anterior convolutions, the high development of which is characteristic 
 of the human brain. The optic nerve and its roots are in the human 
 species relatively small, but the expansion of the nerve within the brain 
 assumes an extraordinary development. This expansion is not to be con- 
 sidered throughout as a simi)le continuation of the fibres of the nerves 
 itself, but rather as the result of a multiplication of these, or of the addi- 
 tion of a new system of fibres to the optic nerve. This high development 
 of the expansion of the optic nerve appears to constitute an essential 
 characteristic of the human brain, and also of that of the higher apes, 
 and to represent an apparatus devoted to some of the most important 
 mental functions. In nearly all mammiferous animals the impressions of 
 sight appear to excite, to a very great measure in the corpora quadrige- 
 mina to which the comparatively large, in many animals perhaps only 
 root, of the optic nerve proceeds, much more simple and more im- 
 mediate reflex actions; in man, on the contrary, most impressions trans- 
 mitted by the optic nerve appear to experience in that expansion within 
 the cerebrum a further psychical elaboration (by combination with fibres 
 and ganglion masses of other systems), before acting upon the movements. 
 There appears to exist within the cerebellum, and likewise within the 
 cerebrum, an expansion furnished by the auditory nerves; it appears to 
 enter, with the continuation of the fibres of the posterior column of the 
 spinal cord, through the optic tlialami into the hemispheres. 
 
 (5.) Special systems of fibres which pass from one convolution to 
 another, and line the internal aspect of the cortical substance. To these 
 systems the fibres of the gyrus fornicatus appear to belong, which radiate 
 
PKEL.IMINARY ANATOMICAL OBSERVATIONS. 13- 
 
 in all the convolutions of the internal aspect of the hemisplieres; the 
 arciform fibres also constitute commissures between tlie different parts of 
 the same hemisphere. While in the gray substance conduction and com- 
 munication of impressions to all parts is provided for, these fibre systems 
 of the white substance appear to furnish likewise a most complete means 
 of communication between all parts of the hemispheres. 
 
 The prolongations of the posterior columns of the spinal cord, or, at all events, 
 the bundles of fibres in direct communication with them, give off successive 
 portions to the cerebellum, the corpora quadrigemina, the optic tract, and the 
 hemispheres. According to Foville, whose researches inoreover require confirma- 
 tion in many points, there exist within the cerebrum two large groups of fibres, 
 distinct in their mode of disposition but interlaced with one another, one of 
 which is connected to the anterior and lateral columns, the other to the posterior 
 columns. To the latter group, which is much the more important, belong not 
 only the successive enlargements which are fovmd upon the axis of the brain, 
 the corpora quadrigemina, the optic thalami and corpora striata with their gray 
 kernels, but also all the corpus callosum, the septum lucidum, and the fornix 
 with its dependencies, which all surround, in a circular manner, the cone of fibres 
 which proceeds from the anterior and lateral cords, penetrates the gray masses 
 of the thalamus and corpus striatum, as a flattened trunk, and ramifies in the 
 interior of the great hemispheres. According to Foville, the nervous membrane 
 of the surface of the ventricles, and (as that in Amnion's horn is prolonged into 
 the white, most external lamella of the cortical substance) the entire surface of 
 the brain is intimately related to the prolongations of the posterior cord, so 
 that the prolongations and dependencies of the lateral and anterior cords, from 
 their entrance into the thalamus onwards, remain absolutely hidden in the interior 
 of the portions furnished by the posterior cords, and never step out upon the 
 surface itself. A relation would here exist similar to what is seen in the distri- 
 bution of the peripheral nerves, where the cutaneous and mucous surfaces are 
 likewise supplied chieflv by nerves of the posterior columns, while the nerves 
 from the anterior and lateral columns are distributed principally to the subad- 
 jacent muscular layers. 
 
 According to this view the brain, as a whole, would have to be considered as 
 a great ganglionic enlargement, which, like the spinal ganglia, belongs primarily 
 to the prolongations of the posterior cords, but in which the prolongations of the 
 anterior and lateral cords not only enter most intimately into the composition of 
 the ganglia, but even originate in them (the gray cortex). From this point of 
 view the cerebrum would represent then an enormous ganglion resulting from 
 the blending of the optic and olfactory nerves; the cerebellum would represent a 
 similar one resulting from the auditory nerve and fifth pair. This appellation 
 ganglion may be allowed to remain; a more minute definition would lead to the 
 conclusion that both brains form the inner expansions of a central, and partly 
 special, nervous system, in which the immediate prolongation of the columns of 
 the spinal cord are combined most intimately with new masses of gray substance, 
 with new systems of white fibres, in particular the central expansions of the 
 nerves of sense— a circumstance the physiological importance of which is shown 
 by the very great and important part which the central function of the senses 
 plays in almost all our psychical acts. 
 
 § 12. The cerebellum, therefore, contains prolongations of the three 
 columns of the spinal cord in the compact mass of medullary hiyers which 
 forms the kernel of the cerebellum and its immediate envelopes, and this 
 kernel is, according to Foville, surrounded by a membranous expansion 
 of nerve substance which lines tlie internal surface of the cortical sub- 
 stance, and is formed by prolongations of the auditory nerve and of the 
 fifth pair. Both nerves send, besides, prolongations into the layers of 
 fibres of the kernel, which are lined in their interior by the gray fringed 
 membrane of the olives of the cerebellum. 
 
 From the lateral columns of the spinal cord an important contingent goes 
 with the corpus restiforme into the cerebellum; these fibres go principally to its 
 hemispheres, few if any of them go to the middle portion. The fibres of the 
 
14 PRELIMINARY ANATOMICAL OBSERVATIONS. 
 
 pons Varolii also go to the lateral parts. The white substance in the interior of 
 the cerebellar hemispheres, which immediately surround the olives, comes prin- 
 cipally from the processus cerebelli ad corpora quadrigemina, the only point of 
 direct communication between the cerebrum and the cerebellum. The fact of 
 the entrance of a root of the auditory nerve with the corpus restiforme into 
 the kernel of the cerebellum is confirmed by Gratiolet. Guillot (' L' Experience,' 
 II., 1888, p. 497) has published a case of Notencephalie in which the auditory 
 nerve and the fifth pair entered into the vesicles which corresponded to the cere- 
 bellum, the optic and olfactory nerves into the parts which represented the 
 cerebrum. It is certain, however, that the perceptions of sound do not take place 
 in the cerebellmn. The little that can be said regarding the functions of this part 
 of the brain is reduced to this, that it appears to have more to do with the move- 
 ments of the vertebral column and the trunk than with those of the extremities; 
 probably also it presides ver the movements of certain portions of the viscera 
 (the genital organs). For all this many relations of the auditory nerve and the 
 fifth pair have yet to be discovered. The cerebellum appears to have very little 
 to do with the higher mental functions. 
 
 The corpora quadrigemina also are evidently organs of very little im- ■ 
 portance psychically. In man and in the higher animals they are alwaj^s 1 
 smaller in proportion as the hemispheres are larger. They have an evi- " 
 dent relation, and are indispensable, to the sense of sight; principally, 
 however, they constitute the apparatus of the reflex action exerted by the 
 sense of sight upon great combined muscular movements. 
 
 In the cerebrum prolongations of all three columns of the spinal cord 
 are likewise grouped together, so that the anterior and lateral parts radiate 
 towards the exterior, are surrounded by the fore-mentioned ring-like 
 structures, and at last penetrate upwards in the centre of the convolu- 
 tions, into the gray cortical substance (there originate?). The white 
 masses of the hemispheres are not connected with the mass of peripheral 
 nerves, or with the columns of the spinal cord, but with the cortical gray 
 substance; the surface of which, according to Baillarger, has an area of 
 1700 square centimetres,' not in relation to outward sensation and mus- 
 cular movement, but to the intelligence. 
 
 Of these three accessory structures (cerebellum, corpora quadrigemina, and 
 great hemispheres), which are superadded to the cerebral kernel to the spinal 
 marrow in the brain, it is always the last which stands in the most immediate 
 relation to the mind. Unfortunately their functions are of such a nature that 
 they (like those of the cerebellum) escape, to a very great extent, being experi- 
 mented upon. Their very extensive motory function presides rather over the 
 movements of the extremities, especially of the arms, of the tongue, and the 
 countenance, than over the movements of the trunk; the hemispheres are the 
 seat of all consciousness, of all deliberations, and from them seem to proceed all 
 these extremely complicated acts intermediating between the sensorial impres- 
 sions and the abstract psychical phenomena, and, again, between these last and 
 the movements; the limits to which special psychical life may extend, and at 
 which sensation and movement cease, are almost arbitrary. Think of the endless 
 multiplicity of the movements of the tongue in speech, of the elaborate uses of 
 the limbs, especially of the hands, what innumerable intuitions and impulses of 
 movement must here take place, in the central organs, with a rapidity and har- 
 mony which are unequalled. These faculties alone must necessitate a far greater 
 development of the hemispheres in man than in any other animal. We often 
 observe in diseases, in localized injury of the hemispheres, that the media between 
 the word thought and the movement of the tongue, between determination and 
 the use of members, are suppressed; here a great deal appears as paralysis which 
 is certainly due to no direct affection of the motory apparatus, but of psychical 
 function. Think, on the other hand, of the endless multiplicity of phenomena 
 which we can neither name nor demonstrate, which are produced, for example, 
 between the impressions of sight and the absti-act ideas; these phenomena are 
 also produced by causes which lie in the apparata of the hemispheres. This 
 
 ' Average of three brains, ' Annal. Med. Psychol ,' 1853, v., p. 1. 
 
 I 
 
PUBLIMINARY ANATOMICAL OBSEKVATIONS. 15 
 
 transformation of the perceptions being much stronger, more varied, and more 
 developed, in man than in any other animal, it must be admitted that more com- 
 plicated arrangements are required. 
 
 The two nerves of tlie cerebrum, the optic and the olfactory, commu- 
 nicate with the surface of the ventricles, and are connected by the ex- 
 pansions of their roots, witli almost all the fundamental parts of the 
 brain. 
 
 As the blind termination of the ventricles, the infundibulum, pos- 
 sesses at its inferior part a particular appendage, of whose function we 
 are ignorant, the pituitary body, so there exists superiorly, upon the deli- 
 cate blind expansion of the ventricular cavity which forms the inferior sur- 
 face of the corpora quadrigemina, an analogous appendage, the pineal gland. 
 The analogy is still more striking when the configuration of the neigh- 
 boring parts is considered; in the one case we have the mammillary 
 bodies, in the other the corpora quadrigemina, but while one of these, the 
 pituitary body, is only in connection with the gray substance, the other, 
 the pineal gland, communicates only with the white substance. These 
 structures appear to have no connection with the psychical and sensorial 
 functions. 
 
 § 13. In the examination of the brain in the body of one who has been 
 mentally diseased, the state of the cerebral coverings should, in the first place, 
 be minutely investigated. In the skull, one should not only notice those 
 deviations of form which admit of being easily estimated, such as marked 
 obliquity, knotty curvature, convexities and concavities, but should also 
 give the measurements of its various diameters, the thickness and tex- 
 ture of the cranial bones, and the degree of ossification of the sutures; 
 this in young persons being somewhat morbid. It is necessary to observe 
 whether the skull presents on its internal surface any nodes, or sharp osseous 
 projections, to examine the foramina which give passage to the great ves- 
 sels, and also the great veins and arteries themselves, with reference to 
 contraction, dilatation, or degeneration. The degree of repletion of 
 the sinuses, and the condition of the blood they contain, ought to be 
 mentioned. In estimating the amount of blood contained in the mem- 
 branes and in the brain itself it is necessary always to bear in mind the 
 total quantity of blood in the body, as a considerable quantity of blood 
 within the cranium in great general jDlethora is of much less significance 
 than in opposite anaemic conditions. In the healthy brain the pia mater 
 and arachnoid are thin and translucent; there is, it is true, a degree of 
 opacity along the line of the longitudinal sinus, and great veins which is 
 of no signification in adults or old persons; in youth, however, it is impor- 
 tant, as it marks the previous existence of prolonged hypersemia. The 
 same may be said of the Pacchionian bodies, and this is also true with 
 regard to the amount of serum within the cranial cavity, it being also more 
 considerable in old men. When the brain is healthy, and freshly taken 
 from the skull, the membranes are easily detached from the surface with- 
 out bringing with them portions of the cerebral substance, except, per- 
 haps, small and separate flakes. The contrary is the case when the 
 brain is diseased. The convolutions should lie close to one another, and 
 their surface should be smooth and uniform: an unequal rough pitted 
 surface is characteristic of atrophy of some of the convolutions, Avhich 
 is likewise of less significance in old age. In a healthy brain the whole of 
 the gray substance should contrast strongly with the white substance; the 
 inner layer of the cortical gray substance ought to be a little clearer 
 than the more external layers. The white substance ought to be firmer 
 
16 ' PRELIMINARY ANATOMICAL OBSERVATIONS. 
 
 than the gray; some parts, as the pons Varolii and the medulla ohlongata,, 
 are of firmer consistence than the mass of the white substance. More- 
 over, the consisteuce of the brain ought to be uniform over all, and 
 partial indurations and softenings are of greater significance than the 
 degree of consistence, the hardness or softness, of the brain as a whole.' 
 
 1 The weights of the brain have not the great value whicli was formerly 
 attached to them : the more important points upon this subject will be considered 
 in the Fourth Book. 
 
PKELIMINARY PHYSIO PATHOLOGICAL OBSKEVATIONS. 17 
 
 CHAPTER III. 
 
 PRELIMINARY PHYSIO-PATHOLOGICAL OBSERVATIONS 
 ON MENTAL PHENOMENA. 
 
 § 14. The function of the spinal marrow is to conduct impressions 
 to, and impulses of movement from, the brain. Besides, and this is its 
 principal function, it produces the more simi)le reflex acts, the transfor- 
 mation, still })retty direct, of sensations into movements. It is the gray 
 substance whicli is the seat of the mediatory functions between this 
 double centripetal and centrifugal current; reflex action constitutes one 
 of its specific functions. But the gray substance also conducts from and 
 to the brain. Towards the brain it conducts certain qualities of sensa- 
 tion which could not be conducted by the posterior column, which 
 evidently also originate in the gray substance itself, and constitute a sort 
 of "psychical "modification and transformation of the centripetal impres- 
 sions. Inversely, the impulses of movement from the brain do not 
 appear as yet to possess all the qualities necessary to isolated muscular 
 contractions. It appears to be in the gray substance that these impulses 
 are first elaborated and arranged in a proper manner. 
 
 All the impressions transmitted through the spinal cord, and those 
 proceeding from the nerves of special sense, sight, hearing, etc., are col- 
 lected in the brain. There, without being confounded the one with the 
 other, tliey meet, are combined, associated, brought into the most mani- 
 fold relations and combinations, and awaken within the brain other new, 
 but purely subjective, internal images. All these images leave behind 
 traces or remains, of which the combination produces again certain gene- 
 ral results (Abstractions), and, quite involuntary, in the moment even of 
 their production, they are already logically elaborated, collected, and 
 associated in judgments, conclusions, etc. All these phenomena are evi- 
 dently intimately related to the activity of the sensorial sphere of the 
 brain. But the brain is also an immense reflex apparatus, in which all 
 these states of sensorial excitation, of which this organ is almost constantly 
 the seat, are transformed into impulses of movement. Here also, to a cer- 
 tain degree, simple immediate reflex actions from sensory excitations to 
 muscular contractions take place; generally, however, they are of a 
 very complex nature, as starts from fright, harmonious movements, and the 
 like. Much more characteristic of the brain, however, are the reflex actions 
 from those already elaborated results of very many sensorial acts, modified 
 by opposing influences, and which have become more or less abstract. 
 They are followed, on the motory side, by reflex actions which do not 
 manifest themselves in immediate muscular contractions, but tend rather, 
 only to the excitations and to the most general ideas or consequent mus- 
 cular movements of the greatest complexity and variety (actions). 
 
 All these functions ought also, by analogy, to be attributed princi- 
 pally to the gray substance of the brain, and in particular to the cortical 
 gray substance of the hemispheres; the great extent of whose surface 
 5? 
 
18 PRELIMINARY PHYSIO-PATHOLOGICAL OBSERVATIONS. 
 
 constitutes one of the chief characteristics of the human brain,, which is 
 very often found altered in mental disease, and has been long declared by 
 many to be the seat of the "intellect" and of the "will." The intellect 
 is, it is true, a result of many and very complicated acts, to which, also, the 
 process of transmission is indispensable; but this even, and indeed in the 
 most complicated manner, ought also to be attributed to the gray substance. 
 Between the perceptions and the ideas which they originate as between 
 volition and the resulting acts there are many intermediate conditions; 
 these will have to be sought for principally in the white system of fibres, 
 and here, as has been already remarked, it is impossible to fix the limit 
 where what is specially psychical begins. 
 
 The walls of the ventricles appear, moreover, to be of considerable importance 
 in regard to mental function; this appears to be shown by observation, where 
 there is a large accumulation (especially if rapid) of cerebro- spinal fluid, and 
 where its constitution is altered with superficial maceration of the ventricular 
 walls; in those cases there is always deep dementia, a state of stupor, etc.: 
 several pathological anatomical observations upon the insane also show this. If 
 ■we can, on this account, limit the mental processes principally, but not exclu- 
 sively, to the cerebral gray substance, it appears on the other hand very probable 
 that all the free surfaces of the brain, the cortical gray substance, as well as the 
 ventricular walls, are especially related to the mental processes; that their healthy 
 action depends upon the integrity of this free surface of the brain and that it is 
 principally disturbances in it which give rise to the symptoms of insanity. On 
 the other hand, where disorganizations occur somewhat deeper in the cerebral 
 substance, disturbances of movement are seldom absent; and they generally 
 accompany the mental derangement when the lesion extends from the surf ace of 
 the ventricle, or the cortical substance, deeper into the interior of the brain. 
 Limited inflammations in the white substance (without pressure on the brain) 
 never give rise to great disturbances of the higher mental faculties; occasionally 
 they cause no disturbance at all, as if the semi-oval centre had no function. It 
 appears to be chiefly a medium of transmission, but transmission may take place 
 by several ways, and so be enabled to avoid the injured part. 
 
 § 15. The central nervous system, which expands itself in the hemi- 
 spheres, is double and symmetrical, like the peripheral nervous system. 
 We do not, however, think double with our two hemispheres any more than 
 we see double with our two eyes. In explanation of the unity of the 
 thoughts, as well as of the impressions of sense, we must look to the mid- 
 dle simple parts of the brain, the commissures. It is certain, however, 
 that injuries and disorganizations affecting both halves of the brain, even 
 when they are relatively unimportant, give rise to much more serious and 
 more general symptoms, especially of a psychical kind, than diseases lim- 
 ited to one side. Therefore, when anatomical changes are found in the 
 brain in mental disease, these changes, although often unimportant in 
 themselves, almost always affect both sides, and a wide extent of struc- 
 ture (Hyperaemias, Atrophy, etc.). 
 
 ' Cases have been recorded in which, with very considerable atrophy of one of 
 the great hemispheres, the mental faculties have remained intact. One hemi- 
 sphere, therefore, may suffice for the performance of the mental functions; yet 
 it has been observed, that in these cases the mind is very easily fatigued. It 
 seems that in such circumstances the activity developed by the one hemisphere 
 
 ^ can go on only for a short time with a certain energy, as if in health a continual 
 interchange of function between both, or a distribution of the mental activity 
 over the two hemispheres, took place. 
 
 The opinions of Wigan (' Duality of Mind,' London, 1844), who assumes a 
 complete duality of the mind in the two cerebral hemispheres; the conjecture of 
 Holland (' On the Brain as a double organ, Chapters on Mental Physiology,' 2d 
 Ed., London, 1858, p. 179), that many mental disorders, especially the states of 
 mental disunity and internal contradiction, depend upon a disharmony m the 
 functions of both hemispheres; and lastly, the recent attempt of FoUet to refer 
 
PKELIMINAEV PHYSIO-PATHOLOGICAL OBSERVATIONS. 19 
 
 mental aberrations to " disturbance in the equilibrium of the innervation of the 
 two hemispheres," are wanting in sufficient proof. 
 
 In a single case of quite recent disease melancholia, with ideas of persecution, 
 attempts at suicitle (a brother being insane), we have heard the patient, who 
 could still give a good account of his state, say that he felt very well; that he 
 was deranged only on one side, the right side of the head. Analogous cases have 
 been published. Friedreich, ' Allgem. Pathologic der psychischen Krankheiten.' 
 Erlangen. 1839, p. 61; and Demme,' Ueber ungleiche Grosse beider Gehirnhalf ten. ' 
 Wurzburg, 1831, p. 78. We are not disposed to attach much importance to these 
 facts. 
 
 § 16. The psychical life of man, as of other animals, commences in 
 the organs of sense, and the constant current as which we perceive it, 
 passes out again into the organs of movement. The transformation of 
 the sensitive excitation to the motor is the foundation of the scheme of 
 reflex action, with or without sensitive perception. In the lower animals 
 and in children, simple forms of this psychical taking in and giving out 
 can be observed in different degrees of development. Here we see, 
 little modified and influenced by clear and energetic perceptions, changes 
 of the sensitive impressions into motory excitation in the impulses to 
 lively movements in the immediate saying and acting according to the 
 momentary impressions of sense. Between these two fundamental acts 7 
 of the psychical life something else is interposed, excited by the sensa- 
 tion, a third element, which presents, it is true, some analogy to the sen- 
 sation, and is in the closest connection with it, but is not really it. It , 
 forms, as it were, an accessory sphere which treads midway between sen- \J 
 satiou and motory impulse, and, as it gi'ows, acquires richness and extent; 
 it becomes gradually a powerful, and in itself a complex centre which 
 rules in many relations sensation and movement, and within which moves 
 the whole mental life of the man. This sphere is that of the intelli- 
 gence. 
 
 All mental acts take place within the intelligence. This is the special 
 seat of thought, and all the various mental acts Avhich were formerly 
 designated separated faculties (imagination, will, emotions, etc.) are only 
 different relations of the understanding with sensation and movement, 
 or the result of the conflicts of ideas with themselves. 
 
 What is, properly speaking, intelligence, what occurs within the brain 
 when one thinks, nobody knows, but the forms of its procedure are 
 accessible to observation, and the locality where it performs is not un- 
 known. All seems to indicate that it, at all events proper, clear, evident, 
 thought, is referable to the cerebrum. And, moreover, it may with rea- 
 son be said, that thought is an act most closely related to, and is even to 
 be reckoned amongst, the inner sensorial functions. There appears to 
 occur in perception essentially, on the one side, a subjective (generally 
 very weak, languid) excitation of the sensory centres, and on the other 
 side, a combination of several, and many of these excitations into a gen- 
 eral image (Abstracts), and moreover, one can put to flight each of those 
 impressions from which the whole has resulted. 
 
 In the wider sense of the term (in the sense which, for example, the word is 
 used by Herbert) every intellectual act, active or passive, and naturally also sen- 
 sation, is a perception. Sensation is a perception which has arisen in the brain 
 through immediate transmission of an excitation that has acted upon a centripetal 
 fibre. A great number of other perceptions are not immediately provoked by 
 irritation of the sensitive nerves, but are produced internally by the functions of 
 the brain which are independent of all sensorial excitation. They are also inti- 
 mately dependent upon the traces which former sensorial impressions have left 
 in the brain, and with the inward phenomena of the sensation. 
 
20 PRELIMINARY PHYSIO PATHOLOGICAL OBSERVATIONS. 
 
 We speak of the "perceptions " sometimes only as of things known, that is to 
 say, which are actually presented to the mind with a certain degree of force and 
 clearness: sometimes also we speak of them as absent (apparently concerned in 
 the memory, but, in fact, existing rather in the state of dispositions). There is 
 in intelligence an actual, though to us an unconscious life and movement; we 
 recognize it, however, by its results, which often suddenly make their appearance 
 from some unexpected source. A constant activity reigns over this almost, if 
 not wholly, darkened sphere, which is much greater and more characteristic for 
 the individuality than the relatively small number of impressions which pass into 
 the state of consciousness. A number of physical irritations, of impressions 
 from the interior of the organism, strike at first, and even so to speak exclusively, 
 this sphere, and, quite unconsciously to us, act upon it, and modify the occur- 
 rences which take place within it. The occurrences, the movements which are 
 produced within this sphere, contribute greatly towards the regulation of the 
 character; the direction of our tastes, the guidance of our sympathies and anti- 
 pathies. 
 
 Great and rapid changes in the ideas are occasionally (though very rarely) 
 accompanied by perceptible occurrences in the head, by a feeling as if something 
 opened or shut itself, as if a slight jerk were received, like the gathering and 
 scattering of clouds. Guislain, ' Legons Orales,' II., page 178, and Trelat, ' Annal. 
 Med. Psychol ,' 1856, VIII., p. 175, mention such cases; and a case is also known 
 to myself in which I am certain that no deception took place. It is not, of course, 
 to be thought that, in these cases, changes m the cerebral processes are felt; it 
 appears rather to be events which take place in the membranes, changes in the 
 amount of blood they contain, perhaps in the distribution of the cerebro-spihal 
 fluid, or the like. 
 
 § 17. We have been led to consider the whole brain as two ganglia 
 upon the nerves of sense, in which the central expansions of these unite 
 with new nerve substance. In accordance with this, we find, in the ana- 
 lysis of the intelligence, that the constant, simultaneous, and reciprocal 
 action of the mental activity with the central sensorial activity is of 
 primary importance. Not only is the intelligence constantly awakened, 
 excited) and entertained by the sensorial impressions, not only does the 
 reverse very often occur, the sensorial function being laid claim to and 
 excited by the intelligence (hallucinations, illusions, delusions, etc. ), but all 
 our perception, if it be only somewhat clear, ought constantly to be 
 accompanied by some degree of sensorial activity, by feeble and vague 
 sensorial images. The plainest and clearest perception is that which 
 occurs with the aid of the sense of sight, in which visual images essen- 
 tially enter, whence also the supposition is most probable that it belongs 
 to the ganglion of the optic nerve, to the brain ; in the intelligence of 
 animals, where the olfactory nerve forms very extensive expansions upon 
 the ventricular walls, the perceptions of smell may indeed play a very 
 important part. On the contrary, the ideas resulting from pure sensa- 
 tions of sound (for example, the musical idea) are very vague, undecided, 
 and very difficult to express; and it is very remarkable that for the ex- 
 pression of this idea — which consists simply of joint impressions from 
 many analogous objects, wherein the concrete element is effaced, and for 
 which, therefore, it can never give a sufficient, adequate institution, 
 especially for the purpose of intelligible perception— we have no other 
 means at our disposal than again sonorous images, namely words. 
 
 Speech is a process much too complicated to admit of its being referred to any 
 particular part of the brain. Some parts on its lower portion, the surface of the 
 fourth ventricle, the olivary bodies, which are in man more fully developed than 
 in any other animal, may indeed be closely related to the expression of the 
 thoughts and to articulation; at all events, however, there are other parts of the 
 brain, and particularly the anterior portion of the hemispheres, which are very 
 important in speech. 
 
 It is principally in pathological cases, where the words fail although the cor- 
 
PEELIMINAEY PHYSIO-PATHOLOGICAL OBSERVATIONS. 21 
 
 t 
 
 responding thoughts are present, or where continually words quite different 
 from those meant are pronounced, that •we see how much must co-operate in the 
 wonderful mechanism of speech. This kind of affection does not occur most fre- 
 quently in mental disease, it occurs chiefly in diseases of the character of localized 
 inflammations, in the sensorial centre, or more particularly in the hemispheres. 
 We shall afterwards refer to the changes which occur in speech in mental diseases. 
 The true psychological nature of words is very frequently not properly recog- 
 nized. Words are conventional images of sounds, signs for already very y[ 
 generalized forms; by themselves they give no concrete ideas, but only the exci- 
 tation to such, to a number of ideas only to a small extent developed, only frag- 
 mentarily entering into the state of consciousness, and tiae details of which vary 
 in each individual. Thus it is that different individuals attach different ideas to 
 words; this is why it is difficult to give the correct and exact definition of the 
 ideas which invoke the words, and to determine the question, which is to be 
 understood by the words, and their possible combinations. The excitation, 
 often so uncertain, of ideas which disappear again before their complete develop- 
 ment, and are replaced with new ideas, also incompletely developed, incurs the 
 danger of superficiality and abstractness, of the want of sensitive concrete 
 thought, to one who is accustomed to keep simply to words. Without doubt, 
 all the higher mental functions are bound in an intimate manner to speech; 
 animals are mute, speech is a property peculiar to the soul of man. There are, 
 however, moments of our existence when our inner life seems for once to be 
 elevated above the form of words, when things unspeakable, inexpressible, 
 unheard by human ear, rise as from a suddenly opened depth, and upon after 
 reflection, perhaps it seems to us as if all which we know, or may yet attain, 
 could never be a realization of what our innermost thoughts had conceived in a 
 single such moment. Then one comprehends for the first time what is meant 
 by ' despising the word.' Such circumstances which by their nature are accom- 
 panied by very strong, even overflowing, feelings, are probably more frequent 
 in the various states of mental disease than in health. 
 
 § 18. A closer comparison of the mental processes within the sphere 
 of the intelligence, with those depending on the emotions, reveals to us 
 many important analogies, and also some differences, which are worthy 
 of consideration as rendering more simple the study of insanity. 
 
 1. In the first place, it ought to bo remembered that there exists a 
 similarity in the general conditions of irritation and irritability in per- 
 ception and in sensation. In both there is perfect rest only in the deepest 
 sleep; ordinary rest, which appears for example in the sense of sight as 
 darkness, in the understanding as vacancy, is still function, there is con- 
 sciousness of the dark field of vision, of the void in the sphere of percep- 
 tion. But the proper affection of the subject, that which in the sensation 
 is color, sound, smell, etc., is always the reality, that is, the perception 
 of which we are conscious. As there are, in seeing, hearing, etc., many 
 degrees of strength and clearness, so also,* in this knowledge of the per- 
 ception, there are varieties of strength and clearness. 
 
 2. For the development and normal progress of the perception, as 
 well as of the seiisation, a steady, moderate, and adequate excitation from 
 without is necessary. In the functions of sense, this excitation is pro- 
 duced by actual external irritation, and that which happens in the 
 sensitive nervous system is, in the so-called eccentric phenomena, again 
 referred, transported, projected, to the place of the accustomed peripheral 
 excitation. The perception, on the other hand, never receives the irrita- 
 tions by means of which it is excited, and which are indispensable to its 
 constant function, directly from the outer world, but always through the 
 medium of sensation. There is then presented in the perception a simi- 
 lar eccentric phenomenon, a projection similar to what takes place in 
 sensation, not towards the peripheral surface or the outside of the organ- 
 ism — we are conscious of perception rather as of an occurrence within our 
 head — but within the same sphere from which the irritation ordinarily 
 
22 PBELTMINAEY PHYSlO-PATHOLOGlCAL OBSERVATIONS. 
 
 proceeds, within that of sensation. This eccentric projection of percep- 
 tions appears to be that wliich necessitates a constant entrance of sensitive 
 images into them. Through it, there is effected in the central organ of 
 sense that feeble weak hallucination which accompanies all perception, 
 and from it there is procured that sensitive appreciation of color, form, 
 and sound, so indispensable to its clearness and vivacity, and wliich 
 nature has meted out to each of us in such different proportions. _ It is 
 the basis of all the psychical phenomena which are assigned to the imagi- 
 nation, and especially of tliose in which we have no more a feeble and 
 vague impression, but one in the highest degree clear, closely resembling 
 the objective perceptions of sense, and, like them, fully awakened by the 
 outward activity of the organs of sense — namely, the hallucinations pro- 
 per. Here the perceptions act in such a manner upon the central sensory 
 apparatus, that in it something takes place which ordinarily is produced 
 only upon their external irritation; namely, an act of sensation. 
 
 3. An excess of irritation has in both spheres the same consequences. 
 An intense and sudden impression of light, a very loud sound or strong 
 smell (as that of ammonia), gives a powerful and violent sensation, 
 together with a sudden shock of the sense. Its immediate paralysis may 
 be the result. This has been frequently observed in the senses of sight 
 and hearing, in the cutaneous sensibility, and, in a rare case related by 
 Graves, it has also been observed in the sense of smell. Should, however, 
 the sense not be quite paralyzed it remains, for a time at least, less sus- 
 ceptible to all weaker impressions, and the incited impression continues 
 for a long time after the cause is removed (continued apjiearance of the 
 object in the eye after one has been blinded by looking at the sun, of a 
 report of a cannon in the ear, etc.). It is the same with the perception. 
 In man, a prodigious mass of perceptions of a certain kind are suddenly 
 incited by a very strong impression, and here also the shock in its first 
 strength may cause even paralysis of the organ (cases of sadden death 
 beginning at the brain from violent mental influences); but if not, the 
 complex mass of perceptions which has been provoked will, at all events 
 for a long time, have the sole control of our consciousness, and the sus- 
 ceptibility will remain, for a considerable time, notably impaired in regard 
 to all other perceptions. In this manner, agitating events may lay waste 
 and impoverish the mind. 
 
 § 19. 4. Perception and sensorial function (and here again the rela- 
 tions are most evident in the sense of sight) cannot continue for an un- 
 limited time in quite the same state; they appear to be soon fatigued by ar 
 continuation of the same action, and therefore a certain change is always 
 necessary. Where no motive to such a change is presented from without, 
 a new sensation or perception, purely subjective, will be called forth from 
 the original perception. The simplest phenomenon of this nature, with- 
 in the sphere of sensibility, is that of the so-called complementary colors, 
 and subjective contrast colors (the appearance of blue when we look at 
 an orange color, of violet when we look at green, etc.). In perception 
 something analogous occurs, in it this process proceeds according to the 
 fundamentally obscure relations of contrast and similarity. When a per- 
 ception has lasted for a certain time it calls up anotlier, similar to, or 
 contrasting with, itself, that is to say, there may be produced a series of 
 perceptions, either altogether new, or such as can be retraced to the first 
 perception, which continues to predominate. 
 
 This occurs very frequently, for example, in those cases where, in the midst 
 of sad ideas excited by an external cause, others of a completely opposite nature 
 
PRELIMINARY PHYSIO- PATHOLOGICAL OBSERVATIONS. 23 
 
 very humorous, suddenly arise. The ideas call forth each other, as well accord- 
 ing to the sense they contain, as according to the analogy of the sensorial images 
 entering into them (images of vision, of sound, words); the last is sometimes 
 seen in mental disease, especially in mania, in the most striking manner, where 
 the patient finds and pronounces with great rapidity long series of similarly 
 sounding words which are unconnected in meaning, or at least connected only 
 by the niost incoherent sense. 
 
 In other senses than that of sight, especially in cutaneous sensation, and par- 
 ticularly in pathological conditions, we see that a sensation, for example, a pain 
 in a certain part, may excite an analogous sensation (titillation, pain, etc.) in 
 another part, and that these have always a tendency to accompany the primary 
 sensation. 
 
 In so far as through the so-called association of ideas no new percep- 
 tions are originated, but only some are awakened and reproduced out of 
 the store of perceptions which were formerly present, this process is called 
 the memory. The more intimate proceedings of this process of repro- 
 duction are obscure, and quite incomprehensible; old ideas suddenly arise 
 without any origin being discoverable in the ideas that have been present, 
 even as those reproductions of sensorial images, which Henle described 
 under the title of the memory in the senses, reappear suddenly, and with- 
 out motive, in the field of vision. 
 
 It is upon this central reprodviction of the perception that all the more 
 delicate mental processes of combination depend, and therefore the intelligence 
 is very much affected by anything which, to any extent, impairs the memory. 
 In many mental diseases, particularly in dementia, the impossibility of judging 
 correctly, and of forming right conclusions, is owing to the destruction of 
 memory. Ideas are more easily retained and reproduced according to the degree 
 of strength and of force with which they at first entered, and to the healthiness 
 and activity of the brain. Any disease of the brain may impair or destroy the 
 memory; consequently the state of the memory, in many of the insane, indicates 
 the severity of their malady. Even slight changes in the cerebral states, as, for 
 example, the eflEects of alcohol, can considerably advance or retard the reproduc- 
 tion of ideas, break up associations of ideas which were formerly familiar, and 
 recall old and forgotten combinations. There are few phases of mental activity 
 upon which the effects of direct physical influences are so evident as upon the 
 memory. Nevertheless, one must not take too material a. view of the matter. 
 The examples of quite partial loss of memory, so frequently the result of wounds 
 or diseases of the brain, in which one might infer the loss of the apparatus 
 devoted to a particular class of ideas, appear in reality to be more general in their 
 effects than might at first be supposed. Here there appears to exist a general, 
 though moderate, diminution of the reproductive power whereby those which 
 are least connected with the individuality are the ideas most liable to be for- 
 gotten. (Gratiolet.) 
 
 In all the functions of the central organs, even of the spinal cord, there is 
 memory, as well in reflex actions as in sensorial images, words, and ideas. To 
 habit, in this reproduction of acts and ideas, which becomes always more facile 
 and mechanical, stands opposed inspiration, in which series of new ideas are 
 produced. 
 
 § 20. 5. In the next place, the circumstance is conclusive that in 
 the organ of perception, as in that of sensation, the energy special to 
 them can be put in i)lay not only by their normal external irritants, but 
 also by internal irritation, which differs from perception and sensation 
 itself; in particular it is excited by morbid irritation. Inflammation of 
 the choroid is followed by irritation of the retina, which is shown by the 
 apparition of subjective sensations of light, of various colored luminous 
 globes, flashes of light, etc.; likewise all irritation applied to a sensi- 
 tive nerve or to its centre can call forth subjective sensations of sound, 
 smell, taste, cold, burning, formication, etc. In the same manner irri- 
 tation of the brain, through internal organic irritation, manifests itself 
 
24: PRELIMINARY PHYSIO -PATHOLOGICAL OBSERVATIONS. 
 
 in new morbid phenomena of perception. As inflammation of the vascu- 
 lar membrane of the eye causes abnormal sensations of light, so disease of 
 the vascular membrane of the brain, of the pia mater which so completely 
 invests its free surface and even penetrates into it, hypersemias and exu- 
 dation on this membrane, beget also anomalies of perception (delirium), 
 new states of the mind proceeding outwards from within (agitations, 
 emotions, etc.), which, naturally, occurs to a still higher degree in 
 diseases of the brain-substance itself. Besides, it is not only these serious 
 and palpable diseases which cause such anomalies of perception. It is 
 evident that the cerebral irritation may also originate through the com- 
 munication of nerve-state from distant internal organs, as the heart, the 
 intestines, the genital organs. That the nerves of the abdominal viscera 
 are intimately related to the cerebrum and cerebellum has been experi- 
 mentally proved; and as, even Avithin the physiological limits of health, the 
 states of the abdominal viscera have an evident influence upon the frame 
 of mind as a whole, and upon the entrance of certain kinds of ideas, so 
 morbid irritation of the nerves which have their source in these organs 
 will frequently induce morbid states of the mind wliich sometimes again 
 disappear upon removal of the peripheral irritation, although, at other 
 times, when once originated, they preseiwe an independent and perma- 
 nent existence. 
 
 It may be here mentioned that in health, as in disease, such organic irrita- 
 tions do not usually excite at the commencement new ideas clear and definite, 
 but, in tlie first place, they cause those vague, indeterminate modifications of 
 the intelligence which are designated emotions. In particular, the rapidity in 
 the succession of the ideas, and the manner in which they intermingle are mod- 
 ified by these impressions from the orgahism, which identifies itself with the 
 changes of the feelings and tlioughts ' something like the flywheel which pro- 
 longs the received movement, sometimes like an inert burden which impedes it 
 or renders it impossible.' Lotze has very correctly pointed out this relation 
 which exists between the organs and the thoughts. "The ulterior development 
 of the organism," says he, "acts upon the soul much less by the formation of 
 definite ideas than by causing certain fixed natural inclinations or certain pecu- 
 liarities of the movement of the thoughts, which, as inexpressible first proposi- 
 tions, form the basis of the views and conclusions of life. The sensations from 
 the organs of the body, individually feeble and vague, in their sum, however, 
 powerful and effective, act upon the soul; and this direction of the mind, in 
 itself aimless, can, however, be the cause which guides the remaining powers of 
 the spirit over a circle of adequate and determined ideas." Out of these frames 
 of mmd, particular determinate ideas may even be developed when aided by cer- 
 tain circumstances. 
 
 We shall find the same in insanity; we will see that nearly the whole 
 patliology of mental disease consists in mental perversions originating from 
 internal organic causes; and these perversions, in turn, give rise to insane ideas 
 conformable to the new mental disposition, and over which the most various 
 circumstances exert an influence. 
 
 § 21. 6. Perception, like sensation, can be accompanied by pain or 
 pleasure; in this respect they present a very great analogy, which is all 
 the nnn-e worthy of remark as mental pain is a fundamental element in 
 insanity. 
 
 In sensation, as well as in 2>erception, the nature of pain and pleasure is 
 a kind of vague obscure opinion, on the one hand concerning the elevation, 
 on the other concerning the limitation and degradation, of the /. This 
 opinion can be connected with a single sensation or perception, which 
 will then be felt as painful: there are, however, also in sensation, as in 
 perception, many more general, more vague states of discomfort where 
 that obscuro opinion is not related to any single sensation or perception, 
 
PBELIMINAKY PHYSIO-PATHOLOGICAL OBSERVATIONS. 25 
 
 but rather to sensation or perception as a whole. To these belong the states 
 of general uneasiness, of bodily ifialaise without localized pain, and in 
 perception, the feeling of oppression, of lowness of spirits without ade- 
 quate cause, which moreover, when long continued, develop in turn par- 
 ticular, really painful, ideas. 
 
 Mental pain may be occasioned by all that disturbs the normal course 
 and combination of the ideas which represent the / (§ 28), and which 
 therefore limit its freedom. An excess of mental excitation, which awakes 
 a disordered pressure of new ideas, as also a deficiency of excitation 
 (ennui, indifference), can awaken disagreeable feelings; so, in the nerves 
 of sense, pain can originate as well through violent irritations and 
 tumultuous impressions as from the abstraction of the customary excitant 
 (cold, hunger). 
 
 It has been shown in a very interesting manner through the effects of the 
 inhalation of chloroform, that the transmission of the tactile sensibility can be 
 maintained, while the sensation of pain is annulled; and Schiff (Physiologie, i.) 
 has recently shown that in the spinal cord the white posterior columns possess 
 the property of conducting tactile impressions, and that pain can be transmitted 
 only by the gray substance. Evidently, therefore, pain originates in the gray 
 substance. It is by no means improbable that also in the organs of the i^er- 
 ception the phenomena of transmission are not connected immediately and 
 necessarily ■with the phenomena which produce mental pain, and that the latter 
 can originate directly through the special irritation of certain constituent parts 
 of the cerebral tissue. 
 
 It would depend very much upon the nature of the individual, 
 whether the derangement of the normal course of the ideas would be so 
 felt as to originate mental pain. ^ delicate versatile mental organization 
 can feel great annoyance at a circumstance which would not at all disturb 
 a more sluggish intellect; one, for example, which could not comprehend 
 the reasons of a fact nor solve a problem. Very much, however, will 
 depend upon the state of irritation in which the organs of perception are 
 at the moment, whether or not the idea will be accompanied by pain. 
 The same circumstance can produce at different times very different im- 
 pressions; for example, if it happens after one has partaken of wine, on 
 return from the opera, or, if shortly before, something disagreeable has 
 taken place. As a nerve which is in a state of neuralgic irritation does 
 not react upon external contact as in the normal state, and pain is awak- 
 ened by the slightest impression, so there are states of the brain in which 
 every mental irritation awakes a mental pain and where all thought is 
 painful. But the actual state of irritation of the brain is a product of all 
 the former states of irritation in connection witli the irritation now act- 
 ing. Where frequent and profound states of mental ])uin have been 
 experienced, whether on account of an original predisposition to such, or 
 mental impressions of an adverse kind, there is gradually formed a gene- 
 ral painful state of the feelings which is sometimes persisteiit and some- 
 times transient; to the unfortunate all seems sorrowful, and he who experi- 
 ences many reverses falls easily into a state of permanent sadness and 
 misanthropy. We shall see that very frequently insanity begins with 
 conditions such as occasion the patient to receive from everything pain- 
 ful impressions, and that this frame of mind is in many instances the 
 result of disagreeable events. There is here revealed to us an important 
 mental predisposing cause of insanity in that susceptibility to impression, 
 that tendency to easy and rapid changes of mind, in which, through 
 every mental impression, those obscure opinions concerning special men- 
 tal acts are awakened, and in which, by degrees, almost every idea is 
 
26 PRELIMINARY PHYSIO-PATHOLOGICAL OBSERVATIONS. 
 
 converted into a mental disposition wlierein the objective impressions are 
 considerably wealcened, and a hypochondriacal subjectiveness and egotism 
 is easily indnced. 
 
 Then mental, like physical pain, has this peculiarity, that it always 
 presses prominently into the foreground of the consciousness and permits 
 little else to enter it; indeed, as the highest degrees of physical pain 
 cause external anaesthesia, its highest modes are accompanied by complete 
 mental insusceptibility to the normal excitants. The pupil of the 
 mental eye contracts, and the sharp, fixed, mental pain is the only object 
 with which it is occupied, and of which we are conscious; as in hyperaes- 
 thesia of the sense of sight, the eye withdraws itself from the excitation 
 of light, at other times agreeable, and seeks the darkness, so the patient 
 who is afflicted with mental pain avoids mental intercourse with the 
 external world because all contact is painful to him, and abjectly indiffer- 
 ent to all around him, he becomes more and more concentrated in him- 
 self. Mental pain has still other important consequences. On account 
 even of this concentration, all other perception becomes dull and slug- 
 gish; ingenious in his own torment and constantly occupied with his pain, 
 the patient becomes unconscious of the things that used formerly to inter- 
 est him; they are momentarily forgotten, and when recalled to memory, 
 the impossibility of now taking his accustomed part in them becomes to 
 him a new source of grief. As every mental impression is disagreeable, 
 there is developed a general disposition of indifference and digust, and 
 benevolence and love give place to the dark impulses of suspicion and 
 hatred. Again, the law of causality, which is innate in the human soul, 
 urges him to search for the causes — which originate only from Avithin — 
 of the mental pain: these are sought for in the external world, because 
 man is accustomed to receive thence the incitements to his mental states: 
 as these causes, however, do not really exist in the external world, there- 
 fore the ideas, opinions, and conclusions Avliich the patient forms are false 
 — they are delirious. This searching for causes of the mental perversion, 
 these attempts at explanation, Ave shall afterwards recognize as the princi- 
 pal source of the delirium of insanity, and we shall see that in this 
 searching after causes there is presented to the mind of the patient not 
 only ideas in the narrow sense of the word, but also, through the influ- 
 ence of the imagination and of the central excitation of the sensorial ac- 
 tivity through the perception, many various hallucinations and illusions 
 by which he attempts to explain his state. 
 
 Sensitive pain always impairs the tonicity and movement of the 
 muscles. Sometimes the patient carefully avoids all movement, and in- 
 stinctively rests the afEected part ; sometimes the movement is really 
 rendered difficult, there is partial paralysis ; or sometimes there are mor- 
 bid movements, contractions, and convulsive tremblings. The mental life- 
 has also its motory side (see next §), and this is affected by mental pain 
 in a similar manner. Sometimes volition is chiefly impaired and para- 
 lyzed, the patient is purposeless and inactive, in the same manner as 
 sensitive pain is so frequently accompanied by a state of profound enfee- 
 blement of the central organs : sometimes, on the contrary, it adheres 
 tenaciously to a single object — a condition Avhicli may be interruiited by 
 rapid, although not energetic, mental movement ; sometimes the pain 
 excites outbreaks of violent and aimless (convulsive) effort, such as is not 
 proportionate to its duration. As, however, in the so-called muscular 
 sensibility, the central organ is conscious of the condition of the motory 
 nervous system, so also we are conscious of these states of the motory side 
 
PRELIMINARY PHYSIO-PATHOLOGICAL OBSERVATIONS. 2T 
 
 of the mental life; this morbid mental languor, this absence of will, this 
 one-sided adherence, and this convulsive jerking of the efforts are again 
 perceived by the patient as a kind of motory 2)ain, Avhich increases still 
 further his present painful condition. 
 
 TJie states of mental pain, anxiety, fright, sorrow, grief, etc., whether brought 
 about by internal or external causes, have the same effects upon the rest of the 
 organism as physical pain. Sleep disappears; nutrition is impaired; emaciation 
 and general exhaustion result. Mental pain alternates sometimes with neuralgias, 
 accompanied by so-called spinal irritation; at other times it originates these neu- 
 ralgias; in particular, the existence of that epigastric pain (muscular pain) so 
 frequent in spmal irritation is often observed. At other times it is complicated 
 with pliysical anesthesia of various degrees (diminished sensibility to tempera- 
 ture and to bodily pain, excited by an external cause). 
 
 The states of mental pleasure give entirely opposite results; the thoughtful 
 reader may be allowed to pursue for himself their analogies with the nature and 
 the results of the agreeable physical sensations (see also the chapter on Mono- 
 mania in Book III., and various articles by the author in 'Med. Vierteljahrs- 
 schrift,' 1843 and 1844). 
 
 § 22. As the special function of the brain, perception, is most inti- 
 mately related to sensorial activity, so also there exists between the acts 
 of the motory nervous system, which has its origin in the same organ, . 
 and the perception, a very direct connection. This relation is very ana- 
 logous to that which exists between perception and sensation. 
 
 As we have seen that the sensorial perceptions leave after them feeble 
 and faded vestiges, Aviiich become a constituent part of our ideas (§ 18), 
 it is the same with the impulses of movement ; they leave behind, in the 
 muscular activity, faded designs which mix with our ideas as perceptions 
 of movement. There is an intermediate sphere between the pure percej)- 
 tion and the nervous excitation which gives rise to immediate muscular 
 contraction — a s^ihere for which there exists no characteristic expression, 
 which however, contains the impulses to the series of single muscular 
 movements already co-ordinated in great groups and formed beforehand in 
 our mind. Here the appropriate impulses of movement are transmitted to 
 many muscles, which, in relation to single muscles, constitute compre- 
 hensive wholes, but which, in relation to our special actions, only again 
 represent fragments, and are combined ])artly according to a pre-estab- 
 lished harmony, partly according to the order given by practice and custom. 
 This very complicated mechanism, whose seat, according to physiological 
 experiment and the facts presented by pathological anatomy, is to be 
 sought in the various points of passage of the continuations of the ante- 
 rior columns and the pyramidal columns of the spinal cord, through tlie 
 gray substance, first in the pons Varolii, then in the cerebellum and in 
 the brain, is set in motion, on the one hand, by the mass of sensorial 
 irritation which meets it at all these points. It presides then over those 
 instinctive movements and actions which are quite independent of the 
 intelligence, or which depend on it only in different degrees, and thereby 
 come under its furthering or restraining influence. On the other hand, 
 however, the general forms of these great impulses of movement and 
 their ideal reproductions so mix themselves with our mental processes, 
 that they enter into the single perception as essential constituents. 
 Thereby, however, the idea itself assumes a motory direction tending to 
 muscular movement, and thus becomes effort. 
 
 The mind never excites our voluntary movements in the sense of invoking 
 single muscles to contraction; it is unconscious of these muscles, knowing only 
 the internal images impressed by previous sets of movements, which, when once 
 
28 PKELIMINARY PHYSIO-PATHOLOGICAL OBSERVATIONS. 
 
 they have become free impulses of movement, set the muscles in motion, with- 
 out further mental effort, in great and regularly co-ordinated groups (walking, 
 writing, etc.). In the more limited localized brain diseases, those of the pons 
 Varolii, the cerebellum, tlie optic thalami, the corpora striata, etc., we see usually 
 derangements of this mechanism, suspension of its connection with the percep- 
 tion, where complicated movements, excited by the irritation of the disease, are 
 sometimes involuntarily performed (walking forwards, moving round and 
 round); sometimes, owing to the mechanical separation of the brain substance, 
 the influence of the perceptions can no longer reach this mechanism (for exam- 
 ple, paralysis of one-half of the body, owing to the extravasation into the corpora 
 striata). Sometimes, also, complications of these two causes occur, and, indeed, 
 within quite limited spheres of movement; e. g., that of the organ of speech, so 
 that the patient cannot pronounce the words which he thinks, or, on the con- 
 trary, expresses words which he has not thought. 
 
 § 23. The mixing of tlie intuitions of movement with our perception 
 is the intermediate process tlirough wliich every manifestation of our 
 intellectual life must pass. But tliat there dwells in the psychical life 
 within us an overruling tendency to express itself, to exhibit itself in 
 motions and acts, depends upon tliis general fundamental fact which 
 meets us everywhere in the nervous system — namely, that peripheral 
 excitations transform themselves in the central organs into motory im- 
 pulses. At different stages of the psychical life we observe that different 
 consequences result from this arrangement. In the spinal cord, centripe- 
 tal impressions not yet received into consciousness excite irregular, or only 
 partially regular, movements of muscles, separate or in groups (the most 
 simple reflex actions). All the organs of sense are accompanied by mus- 
 cular apparatus, which, when excited by the state of the nerve of sense, 
 become the seat of involuntary but suitable reflex actions which accom- 
 pany and aid the sensitive perception. Also, that greater mechanism 
 which contains within itself the impulses of movement to entire series of 
 muscular contractions suitably combined, and to which the movements 
 of the Avholo body are ultimately related, is set in action by the sensorial 
 impressions according to the simple plan of reflex action ; sometimes it 
 acts harmoniously, at others irregularly, as when it is the result of a violent 
 sensorial impression. Movements of the former kind are in part evoked 
 by sensitive impressions from without, as may be observed in the rhyth- 
 mical movements of the body resulting from musical impressions, or in 
 the rapid so-called instinctive acts consequent on strong sensorial impres- 
 sions (turning aside, etc.). Sometimes, however, the causes of the sen- 
 sorial impressions, which occasion the action, exist within the body. The 
 impressions from the whole organism, especially, however, from the 
 viscera, the intestines, tlie genital organs, etc., under the form of sen- 
 suous requirements, give the impulse to action sometimes moderate, 
 sometimes impetuous ; in animals they rule uncontrolled, they constitute 
 the principal element of their psychical existence, they impel them to 
 long journeys, and govern all their great series of movements. In man, 
 the immediate transition of these sensations to movement is subject in a 
 higher degree to the influence of the understanding, and through it duty 
 and morality intervene to control and govern the sensuous desires. But 
 there are cases where these lose their power. In the insane, in whom the 
 influence of the understanding over the instincts is enfeebled, and more- 
 over the sensu ous impulses perhaps strengthened, we often see, for example, 
 the appetite for food or the sexual instinct showing itself with the most 
 open regardlessness. Many sad examples (of shipwreck, etc.) have shown 
 that hunger, carried to the highest degree, defiantly overleaps the barriers 
 "which ethical and aesthetical exhortatign op])Ose to it; and also, without 
 
PRELIMINARY PHYSIO-PATHOLOGICAL OBSERVATIONS. 2& 
 
 recurring to such extreme cases, it is a true maxim that, even amongst 
 men of civilized life, hunger and love are the strongest motives which 
 direct their actions. 
 
 In animals, the immediate reflex actions of the spinal cord in the brain are 
 much stronger than in man. All their perceptions have the tendency to be 
 immediately transformed to movements; pure calm perception seems unknown 
 to them; their whole psychical life is connected with effort towards external 
 objects. In man, the more tliis impulse to movement is governed by thought, 
 the more the mind is capable of pure reflection, the less this impulsion transforms 
 itself immediately in movement, the stronger and more developed seems to be 
 his intellectual life. 
 
 The impulse, the necessity to muscular movement, to action, in consequence 
 of such sensitive impulsions as proceed from the organism, is called (sensuous) 
 instinct. The simplest and the most easily understood are the nutrient and 
 the sexual instincts ; the special instincts which belong to many animals 
 are quite obscure, and their origin totally uninvestigated. Still, at least in 
 man, it is not always the sensations proper which form the foundation of 
 the instincts, but also obscure movements connected with them, and even 
 awakened by them, in the perception; movements that are designated in 
 part as feelings, which, however, may fail to form distinct representations, 
 of their object. 
 
 All instincts in man belong essentially to the brain, and not to the peripheral 
 nervous system. The point of origin of a given sensation may lie in the most 
 distant part of the organism, but nowhere else can it affect the mechanism by 
 means of which complicated movements are realized, nowhere else can these 
 obscure perceptions be united than in the brain. By means of both, however, 
 these sensations are transformed into instincts. 
 
 One speaks also of the mental instincts, intellectual, accumulative, family 
 iuptinct, the love of children, etc. There is here also implied the necessity to 
 certain acts, stirred up by certain groups of ideas become persistent; ideas, 
 however, which do not proceed from one another as single definite perceptions, 
 but necessitate action conjointly, with the obscure abstraction of simple sen- 
 sation. 
 
 § 24. In the appetites and instincts, wherever they are not at once 
 gratified, certain masses of ideas relative to the end to be attained strug- 
 gle against the opposing circumstances, and the relations of tension 
 between the ideas are thereby materially altered. In this way the in- 
 stincts easily excite emotions more or less strong, continuous, or transient 
 (§ 30); and in that the instincts, and the feelings awakened by them, 
 mino-le with the perception, this already assumes an element of move- 
 ment impelling towards outward objects, and receives something warm, 
 sensuous: bv this union there are produced quite new states of mind. 
 
 The relations of the intercourse of the sexes offer a good example of this. 
 The aesthetic pleasure in the society of an individual of the ojjposite sex,. 
 or the sensible conviction of their excellency, is first awakened through 
 the mingling of sexual feelings and emotions with the states of mind which 
 are in tlie whole termed love, and which with the extinction of the sexual 
 feelings also ceases. 
 
 There is nothing inconsistent in seeking to discover in certain parts 
 of the brain the seat of the sensual instincts. It must be in those parts 
 where certain nerves of sensati(ui and their central expansions— for exam- 
 ple, the vagus, the nerve of the sexual organs — meet with the motory 
 apparatus. But hitherto it has not been proved, nor is the supposition 
 probable, that these parts are situated upon the superior surface of the 
 brain. 
 
 In insanity, not only do the nutrient and sexual instincts very often show 
 themselves in an uncontrolled manner, but also new instincts appear, and 
 frequently of such a nature as did not belong to the former life of the individual. 
 
30 PRELIMINARY PHYSIO-PATHOLOGICAL OBSERVATIONS. 
 
 persistent inclinations to certain acts — as, for example, the continual collection 
 of all sorts of trifles (feathers, rags, paper, etc.); which reminds us of the 
 instincts of collection, etc., proper to certain animals, and whose psychical 
 origin is equally peculiar and undiscovered. In general, tlie acts of the insane, 
 where the disease is manifested chiefly by external actions, as in mania, assume 
 what Jacobi has strikingly called an instinctiform character; and it is remark- 
 able that frequently the physiognomical expression corresponds thereto, expres- 
 sively calling to mind the appearance and demeanor of certain species of 
 animals. 
 
 § 25. Ill the instincts there are no single, clear, and definite ideas; 
 but there are no sensations and feelings which excite the impulses of 
 movement, and whereby the action of the motory nervous system is 
 directed towards the groups of muscles. If, however, the known and 
 definite ideas, by being united to the impulses of movement, exercise an 
 influence u2:)on the muscular movements, this is called Will. 
 
 This is at least the simplest case, and the ground-work of the will. Here the 
 impulses of movement proceed no longer from sensitive irritation, but from 
 motives; that is to say, from complex ideas present to the consciousness, although 
 in only a slight degree, the motive still resembles the irritation (see Schopen- 
 hauer, ' Grundprobleme der Ethik,' p. 41). Essentially it is the same process as 
 that of reflex action. 
 
 Already in my first work upon psychological matters (' Archiv f . physiolog. 
 Heilkunde,' ii., 1843, p. 76), I have represented the motory side of the mental life 
 as a gradual succession of events following the same principle, from the simplest 
 reflex action to the most known act of the will, and have therewith first 
 shown this fundamental fact of all psychical life. Amongst philosophers, we 
 will find essentially the same opinion m a thinker who certainly does not assign 
 to the will a lower place (Schopenhauer, ' Ueber den Willen in der Natur,' and 
 'Grundprobleme der Ethik'). I have been very happy also to find the same 
 general idea in the very valuable work upon Nerve physiology, by Schiff (Lehr- 
 buch der Physiologie). I have there also called attention to the fact, that 
 in insanity much depends upon derangements in the normal psychical reflex 
 action, without the entire higher mental life requiring to be involved in the 
 disease. Guislain ('Legons Orales,' ii., 1, p. 169j agrees with me upon this 
 point. 
 
 Those intuitions of movement associate themselves to the evident 
 sensitive perception; but also into the perception, which consists solely 
 in abstract general impressions which are indicated by words (the intel- 
 ligible perception, § 17), images of movements can also enter. These, 
 however, are then only equally obscure general impressions from large mas- 
 ses of intuitions of movement, which still are not generally separated, but 
 are contained therein bundled together; in order to the realization of the 
 intelligible perception, this aggregation of intuitions must go out in a 
 number of single images of movements, previously undetermined. 
 
 It holds good in every case of abstract desire, as in the wish to be virtuous, to 
 be successful in examinations, etc. ; that is, would realize his idea of vhtue, of 
 examination. Wherever this is a real wish, and no mere thought, there is asso- 
 ciated with the idea an obscure mass of still unformed intuitions of movement, 
 which, in the realization, must resolve themselves into a complicated smgle 
 desire. The determination to the object develops itself in the determination 
 to the effectual means, and this finally resolves itself into numberless single 
 efforts. 
 
 The ideas transform themselves into effort and will under the impulse 
 of an internal force, in which we recognize, even in the innermost sphere 
 of the life of tlie soul, the fundamental law of reflex action. We 
 micst will. In the healthy mind it urges and impels the individual to 
 express his ideas, to realize them in actions, and thereby to rid himself 
 of them. If this has taken place, the soul feels disburdened and freed; 
 
PRELIMINARY PHYSIO-PATHOLOGICAL OBSERVATIONS. 31 
 
 by the act it relieved itself of the ideas, and thus its equilibrium is again 
 established. This is a remarkable fundamental fact of mental life winch 
 the inward experience of each man must know. It shows itself in the 
 artist whose mind for years is restlessly occuj^ied with the burden of his 
 yet uncreated fancy, to whom the complete and successful work is still 
 vague and unknown, even as in those unfortunate men who, contemplat- 
 ing the perpetration of some hazardous misdeed, are subjected to the 
 most tormenting inward struggles, which, however, disappear after the 
 performance of the act, and are succeeded by rest. 
 
 There is also a memory of the effort and of the will (§ 19), a reproduction of 
 the intuitions of movement, which, under certain conditions, reunite with the 
 ideas. Amongst different men there exists great difference in the ease and 
 energy with which the intuitions of movement succeed in their aims, apathy to 
 complete absence of will. 
 
 All effort, the instinct and the will, form the centrifugal motory aspect of the 
 activity of the soul. The special constitution of this phase of the soul-life con- 
 stitutes, in a great measure, that which is called the individual character. These 
 facts present a close analogy to what takes place in the musculo-motor nervous 
 system, while pure conception has far more in common with the phenomena in 
 the nerves of sense. We find, therefore, in effort the same categories which, as 
 general expressions, represent certain states of muscular movemement — fatigue 
 and paralysis of movement (weakness and paralysis of the will), tonic convulsion 
 (continued and determined effort in one direction with immovability in all 
 others), convulsive movement (instincts let loose by disease, covetousness, 
 morbid restlessness, forming of projects and desire of action). It is worthy 
 of consideration, that frequently in mental disease, this motoxy side of the soul- 
 life and the musculo-motory function are both altered in the same morbid 
 manner. Thus, there occurs absence of will, together with general subparalysis 
 of movement, a morbid exaggei-ation of the will, with increased muscular 
 activity (for example, in maniacal conditions); at other times, the disease 
 passes quickly from the one sphere to the other, as in an attack of epileptic 
 convulsions, followed immediately by a psychical convulsive state, a violent fit 
 of mania. Weakness of the spinal cord is also frequently accompanied by weak- 
 ness of will, despondency, and absence of mental energy. 
 
 § 26. But as the sensations and feelings are the more easily converted 
 into instincts in proj^ortion to their strength, so Will is developed out of 
 the single perceptions the more easily according to the strength and per- 
 sistence with which they enforce themselves. On this account the strong- 
 est ideas, at the end of their transition, pass forcibly in actions. It is a 
 fortunate provision, however, in mental life that every perception does 
 not attain to this degree of strength. Then, according to the laws of the 
 association of ideas, there arise tiie contrasting perceptions (§ 19); they 
 draw after them further perceptions related to them, and there arises in 
 consciousness a conflict. The whole mass of ideas which represents the 
 /(§ 28) comes into exercise, and gives the final decision according as it 
 impedes or favors that first idea. This opposition in consciousnes, which in 
 the end is decided by the /, is the fact of the liberty of the individual. 
 
 The assumption of absolute liberty, as well as the results that flow from 
 it, is erroneous. The liberty of an individual is always relative, and difl'er- 
 ent men are free in different degrees. Originally the individual is in no 
 respects free; he becomes so, first, by being possessed of a mass of well 
 ordered and easily-evoked perceptions, out of which there is formed a 
 strong kernel, the /. There are two general conditions necessary to the free- 
 dom of human action. In the first place, an unobstructed association 
 of ideas whereby, around the ideas presented, which are transformed 
 into will, other ideas originating may be gathered, and may be opposed 
 to the former. In the second place, a sufficiently strong / (§ 28), that 
 
32 PRELIMI^'aUlY PHYSIO-PATHOLOGICAL OBSEKVATION8. 
 
 can give the decision by its mass of ideas, strengthening one set of the- 
 opposing perceptions, and tliereby relatively weakening the other. With 
 those weak in perceptions and mentally dull, freedom is to a great extent 
 absorbed in the dreamlike monotony of custom. _ The man of weak 
 mind is less free, since the living association is absent from his 
 perception, and opposing ideas are not, or only very slowly, awakened. A 
 child is less free as his perception is active, since no strong / has as 
 yet been formed, that could send a powerful, firmly combined mass of 
 perceptions into the conflict. 
 
 In a medico-legal aspect, it is very important for the physician to have clear 
 views upon the nature of human hberty, so much obscured by abstract modes of 
 treating the subject. The contents of this paragraph are mainly devoted to this, 
 purpose. Liberty, therefore, consists essentially in an influencing and transfor- 
 mation of the (occasional) will : in (occasional) masses of ideas pressing into re- 
 flection by the aid of other ideas, and especially by the entire mass of combined 
 ideas belonging to tlie I; in the control which the I exercises over the tendencies 
 actually existing ; therefore in the possibility of self-command. The more com- 
 pact and united the / is in itself, the more decided is the character ; on that 
 account the more decidedly does each one call into exercise, by his affirmation or 
 negation, the ideas which are already floating in the mind. So is the saying to 
 be understood, that "true liberty consists in limitation,"— namely, by means of 
 the /. Where this limitation fails, the ideas that occasionally spring up, often 
 depending only on the sensitive excitations present at the moment, or only pass- 
 ing desultorily (capricious), press unhindered towards the motory side, and enforce 
 their accomplishment. By the most varied bodily influences, however, this 
 limiting power of the I may be restricted, diminished, or quite abolished. 
 
 When an individual makes moral motives the rule of conduct in his actions, 
 this can only be done inasmuch as by frequent reproduction and practice he 
 unites the masses of perceptions which are referable to his moral law with all his 
 ideas, so that they, with every strong motion of the thoughts, accompany them 
 into consciousness. They form tlien an essential constituent element of the 
 measure of perception of his I; and if a conflict arise in the consciousness, they 
 not only immediately step forward, but they also over all the contents of the /, 
 upon the whole, have the advantage. In the immoral man, on the other hand, 
 the egotistical and malignant thoughts have graiUially so rooted themselves that 
 they alwavs are ready to step forward, and the I is occupied by that whose chief 
 mass is, upon the whole, to the bad side. Of course it is not supposed that such 
 an individual on this accounb acts wickedly in every case ; in him also the associa- 
 tion of ideas is an active principle, and, inasmuch as it suggests to his mmd the 
 contrasts of his evil thoughts, half-smothered emotions, half -erased images, and 
 the remembrance of better days, with the good advices received in youth, step 
 into consciousness, and a violent conflict may result. In the end, indeed, the / 
 favors the wicked side ; were it to favor the good, the man would not be immoral; 
 still, he is a man whom certainly it would be unsafe to trust too much, altho\igh 
 in this case he may have overcome his evil desires. The strength of the opposing- 
 moral motive can, however, never beforehand be estimated. There is no man 
 absolutely bad ; benevolent inclinations may sometimes have the predominance, 
 in no human being are they totally suppressed, and the histoiy of criminals shows 
 how often that httle store of youthful recollections, the remembrance of an old 
 saying or verse of a song, forcing itself into tlie train of thouglit, calls up the 
 suppressed moral perceptions, and therewith the impression of the good is con- 
 firmed. If there existed an individual such as old Cenci in Shelley's drama, the 
 wicked conclusion could with him, indeed, each time be predicted as a result to 
 which he was irresistibly impelled : but there is no such individual, and no one 
 who is mentaUy healthy is compelled to acts of villany. 
 
 § 27. The normal reciprocal action of the perception, whereby, 
 through the ideas actually in the mind, other contrasting, or in general 
 limiting, ideas are awakened, whereby all proceeds with moderate strength 
 and rapidity, so that, in general, a conflict can arise in consciousness, so 
 that thought and reflection, and therewith a survey of past and future, 
 are possible, is best designated as the state of Reflection. One easily per- 
 ceives how this is an essential condition of all liberty. 
 
PRELIMINARY PHYSIOPATHOLOGICAL OBSERVATIONS. 33 
 
 Now there are many states where this reflection is weakened or de- 
 stroyed. This appears to a greater or less extent, first, in the emotions 
 (§ 30), which are still considered physiological states; then, in almost all 
 patiiological states of the brain. Alcoholic intoxication, sympathetic cere- 
 bral irritations, most of the deeper organic diseases of the cerebral sub- 
 stance — in short all the diseases of the brain with which we have here to 
 do as mental diseases — disturb the free exercise of the perception, and 
 thereby limit, or completely destroy, the reflecting power. They effect 
 this in many ways; sometimes certain desires and instincts, through 
 disease of the brain, are directly increased to excessive intensity (sexiial 
 instinct, destructiveness), and are transformed into will and actions Avith- 
 out any other ideas being able to control them; sometimes all perception 
 proceeds with such rapidity, that, in the confusion of ideas, there is no 
 one so powerful or lasting as even to originate an actual conflict in the 
 consciousness. Frequently we see both these conditions in the maniacal 
 states, where, in the latter case indicated, the slightest excitation from 
 without often decides the nature of the actions. Sometimes the percep- 
 tion is so sluggish, and the /so weak, that from this source the conditions 
 of an internal conflict are wanting; forexample, in dementia. Sometimes, 
 in consequence of cerebral affection, certain false connections of ideas, 
 erroneous conclusions, become so persistent, and so interweave themselves 
 with the whole mass* of ideas of the /, that their contrasts are completely 
 effaced from the soul, and they therefore press themselves into all con- 
 clusions; and the /, falsified through these fixed ideas, is now forced 
 always to decide according to their sense: this is the case in monomania, 
 also in many maniacal and melancholic states. The determination and 
 the deed often follow in these cases with great placidity, and with ap- 
 parently sufficient deliberation and choice of means; notwithstanding the 
 inward reflection is v/anting, because the false opinions' have acquired the 
 strength of irresistiDie motives, and the patient cannot rid himself entirely 
 of them. 
 
 In the above we have merely given a few examples, and not enumerated all 
 the states in which the reflection is suppressed in insanity. Much in the mechan- 
 ism of the mind is as yet entirely unknown ; in many states of insanity, of intoxi- 
 cation, etc., entire great series of perceptions, the sense of duty, a3sthetic ideas, 
 etc., appear to have disappeared altogether or temporarily, without other masses 
 of ideas, by which the former were banished, being allowed to establish them- 
 selves. 
 
 In all mental diseases the power of reflection suffers first, and therewith the 
 liberty. Naturally, this loss of liberty is not the essential manifestation of the 
 morbid process, but only a result of the most varied mental disorders abstractly 
 expressed in order to be understood ; at no time can it have the significance of 
 a diagnostic sign. The reflection also suffers in the insane in very difi'erent 
 degrees. There are conditions which cannot be distinguished from the class of 
 mental diseases without an unnatural separation of things analogous ; for 
 example, the initiatory stage of many states of profound nielauchoha, which 
 frequently is much prolonged and in which there still exists in the patient a cer- 
 tain caimcity of reflection. Mental disease and comj^lete absence of liberty are 
 therefore not the same ; a medical opinion upon such states ought not to embrace 
 in a general manner the abstract ideas, which ought to be thoroughly distin- 
 guished from each other, of either mental disease or health, of liberty or non- 
 liberty, but it must trace physiologically the concrete phenomena, the psychical 
 events, even to their source, analyze their connection, and estimate their results. 
 But in order to do this, special education in this subject is indispensable, which' 
 unfortunately, is possessed by few. ' * 
 
 This would be the proper place to consider the question of imputation and 
 responsibility : a full investigation of this subject does not, however, lie within 
 the sphere of this work ; the leading principles of its study are laid down in the 
 3 
 
34 PRELIMINARY PHYSIO-PATHOLOGICAL OBSERVATIOXS. 
 
 preceding paragraphs. A few remarks might nevertheless be submitted. When 
 the question of responsibility is raised, it has always hitherto been a customary 
 concession by the medical jurist to answer it. From the nature of the question, 
 however, the physician is not obliged to give any opinion upon these wholly 
 juridical matters, but only to furnish the judge or the jury, who decides these 
 questions, with the facts, fully digested, relative to the case. Tlie physician can 
 also, it it be his interest, refuse to answer the question of responsibility ; and I 
 myself have, in a celebrated case (Process Fahrner, Rottweiler Schwurgericht, 
 December, 1858), declared that if the question of responsibility were put to me, I 
 would not answer it, as being extra medical. It was accordingly not put. What 
 other question may then be legitimately proposed to the physicians ? Evidently, 
 in most cases, questions like the following : — Whether disease exists which dis- 
 turbs the mental activity generally, and specially suspends liberty of will ; or, as 
 degrees must here be admitted, whether to a greater or less extent it has limited 
 it, or could have done so. By answering this question the physicians keep within 
 their own sphere, and it contains all the essentials that can be learned from them. 
 For the physician who is a competent judge, it is impossible in the present state 
 of science to give a definite answer to this question, and therefore he should 
 declare it, and without respect to consequences. He has no other interest than 
 that of truth, and thereby should not intermeddle with matters which do not 
 belong to his ofiice, and for which he is not responsible : for example, whether 
 the law should punish those who are evidently to some extent insane, or what 
 degree of punishment should be inflicted upon the accused. The judges (or jury) 
 are not bound by the opinion of the medical man, which is but one element 
 among others to aid them in coming to a decision. It would be fearful if the 
 medical evidence, often so bad and so contradictory, had a decisive influence 
 upon the issue of a criminal process. It were "well that physicians could see that 
 hereby the influence of their science is limited ; the more strictly they keep to 
 their own sphere, into which none can follow them, the greater will be their 
 influence. The author speaks from forensic experience. 
 
 § 28. In the course of our lives, in consequence of the progressive 
 combination of the perceptions, there are formed great masses of ideas 
 which constantly become more associated. Their peculiarity in individuals 
 does not depend merely upon the special contents of the single perceptions 
 excited by sensitive impressions and outward events, but also by their 
 habitual relations to the instincts and will, and by the jDersistent restrict- 
 ing or extending influences which arise out of the whole organism: even 
 the child comes to receiye from his, as yet comparatively simple, mass of 
 ideas, a general impression, then, as soon as the material is sufficiently 
 developed and strengthened, he begins to employ an abstract impression, 
 the /. 
 
 The / is an abstraction in which traces of all former separate sensa- 
 tions, thoughts, and desires are contained, as it were, bundled together, 
 and which, in the progress of the mental processes, supplies itself with 
 new material; but this assimilation of the new ideas with the pre-existing 
 / does not happen at once — it grows and strengthens very gi'adually, and 
 that which is not yet assimilated appears as an opposition to the / as 
 a thou. Gradually it confines itself no longer to a single complexity of 
 ideas and desires which represents the /, but there are found several such 
 masses of ideas united, organized, and strengthened; two (and not only 
 two) souls then dwell within the man, and this changes or is divided 
 according to the predominance of the one or of the other mass of ideas, 
 both of which may now rei^resent the /. Out of this, internal contra- 
 diction and strife may result; and such actually occurs within every 
 thinking mind. In happy harmonious natures this conflict is sjDontaneous- 
 ly and rapidly brought to an end, since in all these various complex percep- 
 tions, there is developed, in common, several general, in all recurring, 
 fundamental intuitions, still obscure, and which cannot be easily expressed, 
 whereby there is given to all the spheres of the thought and will a har- 
 
PRELIMINARY PHYSIO-PATHOLOGICAL OBSERVATIONS. 35 
 
 monizing fundamental direction. Faith on the one hand and empiricism 
 on the other may serve as examjiles of such various fundamental directions. 
 It is the highest object of self-education not only to acquire such general 
 and solid fundamental directions, but to elevate them gradually as much 
 as possible by thought into consciousness, and so, in the firm possession 
 of such, to attain to the elaborated first propositions of all thought and 
 will adequate to the particular individual nature. 
 
 At different times our /presents different characters, according to age, various 
 duties of life, occurrences, momentary excitations of this or that mass of ideas, 
 which at the time represents the /, being more developed than others and occupy- 
 ing the foreground. " We are another and still the same." My / as physician, 
 my I as a scholar, my sensuous /, my moral /, etc.,— that is the groups of per- 
 ceptions, instincts, and directions of the will which are expressed by these words 
 —can come into opposition with each other, and repel each other, at different 
 times. Not only must inconsistency and disorder of the understanding and will 
 result, but also — on account of the continued limiting influence of the others — 
 complete want of energy in each of these features of the / would ensue, did not 
 some of these more obscure or apparent fundamental directions return to all of 
 these spheres. 
 
 One of the most evident, and in relation to mental diseases most instructive, 
 examples of an entirely physiological renewal and transformation of the I is 
 afforded by the mental events which occur during the period of puberty. With 
 the awakening of activity in a hitherto dormant part, and with the complete 
 organic revolution which then takes place in a comparatively short time, great 
 masses of new sensations, instincts, obscure or more definite pei'ceptions and 
 impulses, come into consciousness. These gradually pervade the whole sphere of 
 perception, and become constituent permanent parts of the I. Thereby it is 
 thorouglily altered and renewed, and the sentiment of self undergoes a radical 
 change. But, indeed, until this assimilation is completed, this penetration and 
 transition of the old /can scarcely take place without much pressure on the con- 
 sciousness and tumultuous agitation ; that is, not without great emotion. This 
 period of life is therefore especially the time for emotions arising from within, 
 without being excited by external influences. 
 
 § 29. It is not without a purpose that we have selected this example 
 which illustrates insanity by many analogies. In it also there is usually 
 developed, with the commencement of the cerebral disease, masses of new 
 sensations, instincts, and perceptions, proceeding from within outwards, 
 which were hitherto, at least in their present form, unknown to the indi- 
 vidual; for example, sensations of great anxiety with which there is com- 
 bined the idea of persecution. At first these stand opposed to the old / in 
 the character of a foreign thou often exciting amazement and fear. Fre- 
 quently their forcible entrance into the whole sphere of perception is felt 
 as if it were the possession of the old / by an obscure and irresistible 
 power, and the fact of such forcible possession is expressed by phantastic 
 images. But this duplicity, this conflict of the old / against the new 
 inadequate groups of ideas, is always accompanied by painful opposing 
 sensations, by emotional states, and by violent emotions. Herein, in great 
 measure, lies the foundation of the fact taught us by experience, that the 
 first stages of the great majority of mental diseases consist in predominat- 
 ing affections of the sentiments, generally of a painful kind. 
 
 If tlie immediate cause of the new and abnormal state of the percep- 
 tion — the cerebral affection — be not removed, it becomes fixed and per- 
 sistent, and because connections are gradually formed throughout with 
 the groups of perceptions of the old 7, and since frequently other masses 
 of perceptions more capable of resistance are completely destroyed and 
 effaced through the cerebral disease, the resistance of the old I, the 
 struggle in consciousness, ceases by degrees and the motions are allayed. 
 
36 PRELIMINARY PHYSIO-PATHOI.OGICAL OBSERVATIONS. 
 
 But now, through these connections, through that introduction of abnor- 
 mal elements of perception and will, the /itself is falsified, and has quite 
 changed its nature. Then the patient can again be calm, and his thoughts 
 sometimes formally correct ; but these abnormal erroneous ideas push 
 tliemselves into every part of it as irresistible premises; because they 
 have over all formed connections, the patient has become in no respect 
 what he formerly was, but quite another man — his / has become new 
 and false. At other times it appears that several new groups of ideas, 
 having little coherence amongst themselves, are formed, each of which 
 may represent the /, and thus the unity of the individual may be quite 
 lost (many demented monomaniacs). In so far as in these conditions all 
 emotion has ceased, we may rightly designate them simply false thought 
 — diseases of the understanding. 
 
 In the preceding remarks we have expressed in few words the ordinary course 
 of events in insanity from its commencement to its termination in incurable 
 dementia. What has been said does not, of course, appty to every case ; for 
 example, not to the dementia ensuing immediately after wounds of the head ; 
 and also, where the morbid phenomena, on tlie wliole, follow this course, there 
 are presented many intermediate cases and deviations. In particular, through the 
 deeper and further progress of an organic brain disease — for example, that chronic 
 inflammation of the cortical substance which ends in atroph}' — the course is so 
 curtailed, that dementia ensues so rapidly as not to admit of the formation of a 
 new I; or recovery or death takes place before this can happen. We shall recur 
 to this subject in the third book (on the varieties of insanity). 
 
 We may also here call attention to the great influence which the state of the 
 former (old) I must have in these conditions. A weak I will be sooner subdued 
 by the new abnormal perception than a strong one. A slow imperceptible pene- 
 tration of the old groups of ideas by the new will certainly cause much less 
 emotion ; but, inasmuch as it offers to the /less opposition, the latter is the more 
 readily subdued and absorbed. The duration of the disease is of all circumstances 
 the most important. The new groups of perceptions are dangerous to the 1 in 
 proportion as their contents are related to the old ; their imion will then be easier, 
 but the combination of the two states, contrasted with the earlier, will be propor- 
 tinately less striking. All these statements are fully confirmed by everyday 
 experience. 
 
 In the state of health, the various groups of id3as which can represent the / 
 find a fundamental element of unity, above all, in the complexus of ideas of the 
 body proper. And if, in the course of life, this physical sensation of self is in 
 various ways subject to change (disease, age, etc.), so does the joint perception of 
 the same body serve as a point of union for the remaining preceptions, and as a 
 centre from which the motory acts jjroceed. But there are abnormal conditions, 
 particularly in mental disease, in which the general bodily feeling quickly and 
 sensibly changes, so that hereby this fundamental sensuous element of the old / 
 undergoes a total transformation. Then for the first time does the patient lose 
 his former personality ; this he no more recognizes as his distinguishing feature 
 — then for the first time the patient considers himself a difi'erent person than he 
 actually is. It is very essential to distinguibh this from those changes which the 
 /undergoes through simple occupation by new ideas and aims, produced by the 
 disease of the brain, without essential change in the physical sensation of self. 
 
 § 30. A simple difference in the perception, familiar to all, consists 
 in this — that it sometimes proceeds quietly as calm imagination or 
 thought, while at others it is accompanied by great disturbance, by a 
 general state of mental disquietude. In the first case, the masses of 
 perceptions which represent the / act towards the thought which is 
 present in the consciousness as quiet onlookers, as in being perceived 
 they are only feebly and slowly changed by it, and when obscure 
 opinions thereby result relating to the demands or limitation of the 
 / (pleasure or displeasure), these also are of but slight intensity. In 
 the second case, any striking occurrence in the consciousness, as a mass 
 
PKELIMINABY PHYSIO-PATHOLOGICAL OBSERVATIONS. 37 
 
 of perceptions suddenly presented, or a sudden urgent desire, enters with 
 violence. By these occurrences, separate groups of perceptions are 
 promptly evoked, which bring others along with them; whilst others are 
 rapidly, but not without opposition, repelled, and the / must neces- 
 sarily be affected by them pleasurably or painfully according as they pro- 
 mote or impede it. 
 
 Those obscure opinions, psychical pleasure or pain (§ 21), constitute the founda- 
 tion of our moral sentiments, Tlie sentiments' are completely bound to the 
 ideas, and by tliem exclusively we are made aware of the relations of tension and 
 movement in certain perceptions, of the degree of free movement, and of pro- 
 moting or impeding influences within them, and of the nature of their reciprocal 
 action. The perceptions themselves whose relations of movement are thus made 
 known to us may be perfectly clear and strong, but they may also be very obscure 
 and their contents not easily distinguishable. Frequently, and especially in 
 physical influences on the disposition, we are unable certainly to distinguish the 
 cause of the feeling, of pleasure or pain. Sentiments such as have no definite 
 object presented, and such as are of a depressed irritated nature, often call forth 
 merely a change in the bodily states. Sickness usually changes completely our 
 mode of feeling ; it modifies not only the contents of our ideas, but also their 
 relations of tension and movement. Conversely, strong feelings, when they pro- 
 ceed from the perceptions, are usually accompanied by marked changes in the 
 dormant masses of bodily sensation. Thus many powerful feelings are half cor- 
 poreal and half mental (anxiety, fright, etc.;. 
 
 Emotion may accompany calm thought : scientific thought can, for example, 
 w^hen the allied ideas meet in a favorable manner, be accompanied by a sense of 
 pleasure, by the feeling of success. But the emotions are much more lively when, 
 through a sudden change occurring within the consciousness, the masses of ideas 
 belonging to the / fall into violent oscillation, and the / thereby suffers an abrupt 
 or restless change. These affections of the / are called the emotions : in the first 
 case they are joyful, in the second of a sad nature. In all the sentiments, 
 emotions occur as essential constituents, although every sentiment does not 
 occasion emotion. There are sentiments, more lasting and stable, which have no 
 emotion, as the sentiments of self, country, family.'^ The sentiment of the /can 
 proceed even to instantaneous suppression ; one becomes " out of himself." 
 
 As in the emotions, only the relations of tension and movement in certain 
 masses of perceptions, and the manner in which the I is excited by these events, 
 come into consciousness ; so they have no definite existence that can be expressed 
 in words, but they call forth desires, and are in turn evoked by them. The senti- 
 ments, since they consist of rapid changes in the relations of tension and move- 
 ment in the perceptions, are naturally always bound to the emotions. 
 
 Music excites in many individuals intense emotion, and affords a very good 
 example of the half bodily, half mental, states of this kind. Here, certain changes 
 in the sensations of sound act immediately, and principally (almost unconsciously 
 to the individual) upon the internal impulses of movement for great extended 
 muscular actions (cadence, rhythm, melody), but so feebly that usually no move- 
 ment is produced. This constant cliange in the internal impulses of movement 
 (ideas of movement), with its tensions and relaxations, produces nothing but 
 sentiments, and indeed of an aimless kind ; it presents something inexpressible 
 and highly superficial, without at all enriching the mind with clear perceptions 
 or ideas. Nevertheless, this excitation of the sentiments need not on this account 
 be either worthless or indifferent to the soul ; it can contain much that is fitted 
 to soothe, impel, or excite the present disposition, and thus, indirectly, expand or 
 contract the soul itself. 
 
 The dispositio7i to which these events are attributed as movements 
 (emotions) bears an essential relation to the motory side of the soul-life, 
 to the instincts and the will. Not only are instincts and impulses of the 
 will awakened by all emotional states in order to oppose the limitation or 
 advance the promotion, but also observation shows that the production 
 
 ' Stiedenroth, ' Psychologie,' ii., p. 2 ff.; Volkmann, ' Psychologie,' p. 301 ff. 
 2 Herbart, 'Lehrbuch.' 1816, p. 54. Drobisch, ' Empirische Psychologie,' 
 1842, p. 20.5. 
 
38 PRELIMINARY PHYSIO-PATHOLOGICAL OBSERVATIONS. 
 
 of the affections proceeds more easily from the motory side of the soul-lif& 
 than from simple pure thought. 
 
 Restrained or expanded effort affects the J much more than the same condi- 
 tions in pure perception, and tlie most sudden and violent agitations result from 
 the sudden arrest of efforts in progress. When, for example, our calm scientific 
 thought is impeded by an unexpected extei-nal hindrance, we may indeed be 
 annoyed; but when our will is opposed, when the execution of plans designed 
 and determined by the / is hindered, this excites much more violent emotions — 
 anger, disappointment, etc. We frequently observe that thwarted plans and 
 determinations of the will — for example, an occupation enforced while all the 
 inclinations of the individual are directed towards engagements of quite a different 
 nature—become the causes of lasting emotions, and of insanity thereby developed. 
 We know the case of a man who became insane because he was forced to be a 
 butcher, while he desired to become an ecclesiastic. Examples of this kind are 
 to be found in all asylums. 
 
 § 31. The question, what projDerly sjoeaking the affections and the 
 sentiments are, and what position they hold in the mental life, is of great 
 importance to the understanding of insanity (which so frequently, and for 
 so long a time, consists principally of a disorder of the affections). Our 
 perception and effort are always subject to progressive change; we only, 
 however, speak of a sentiment, when the mass of perceptions which repre- 
 sents the / is subjected to a violent shock and brought into collision, 
 which (§ 30) never can occur without emotion. In this disturbance of 
 the tranquillity of the mind, there is no further agitation than that of the 
 wonted calm which our /maintains towards the perceptions j^resent, than 
 of the manner in which, above all, the multifarious masses of perceptions 
 and efforts which we feel within us behave towards each other. This 
 usual tranquillity is not, however, absolute quiet or inactivity, but is the 
 result of regulated moderate activity, which simultaneously represents 
 the acquired amount of mental power and the ordinary direction of the 
 mental life; it may be called the mental tone.'' 
 
 The tonicity of the spinal cord, which is evinced in the muscles, in the cellular 
 tissue, etc., as a moderate habitual degree of contraction, and on the side of 
 sensation as a moderate degree of sensitivity and irritability, is the product, not 
 of a single sensation or movement, but of the sum of the sensations and imi3ulses 
 of movement which is lost in the unity and generality of a moderate irritability. 
 It depends upon a moderate amount of excitation, which is the combined result 
 of the separate central nerve-acts. This moderate degree of apparent quiet is not 
 broken or destroyed as a whole by every sensation and movement, but it becomes 
 so by all sudden and strong sensations and movements (exhaustion, pain, etc.). 
 In both domains the tonicity is naturally sometimes more unsettled and variable 
 than at others ; indeed, according to the state of the organ, the slightest irrita- 
 tion can at times excite fatigue, pain, or convulsions; even a fly upon the w^all 
 can be a source of annoyance. It is not the customary view, and it would be too 
 vague, although quite correct, to consider tetanus convulsions, etc. , as changes 
 in tonicity (one-sided increase, interruption, etc.); undoubtedly also it suffers 
 from the disturbance present. Likewise in the parallel mental states (mental 
 pain, mental convulsions) the disturbance of the sentiments is the most striking; 
 and it is, in general, in this sense that we speak of the disorder of the emotions 
 and of their priority in insanity. 
 
 We call the man iinpressible, whose / is easily moved, and in whom,, 
 accordingly, agreeable or disagreeable feelings — sympathy, compassion, 
 benevolence, aversion, etc. — are readily excited. Agreeable as is this, 
 characteristic, yet this danger follows, that the sentiments willingly 
 attach themselves to these obscure excitations, so that they do not suc- 
 
 ' Compare the author's essay, ' Aufsatz iiber psych. Reflexactionen,' loc. cit., 
 p. 95. 
 
PRELIMINAKY PHYSIO-PATHOLOGICAL OBSERVATIONS. 39 
 
 ceed each other in a clear train of thought, and that the habit of clear 
 thinking is lost, and the individual governed by mere sentiment, of whose 
 influence he cannot divest himself, but thereby orders his actions and 
 frames his life. This is the impressible character in the bad sense. He 
 is called unimpressible, whose / is not easily affected by pleasure or pain, 
 either on account of great weakness and dulness of all the mental powers 
 (apathetic, very phlegmatic men), or because, upon contact of the /with 
 the perception present, there is simultaneously produced distinct opinions 
 in clear ideas instead of obscure sentiments (intelligent men). The man 
 is strong-minded, in whom there is developed a firm tone of mind, who is 
 not immediately moved by every mental excitation; he, indeed, feels events 
 as agreeable or disagreeable, and they are accompanied by obscure opinions 
 relating to the promotion or hindrance of the /; but the /itself, however, 
 is not so easily shaken ; he is not easily subject to general mental dis- 
 quietude, to anger and ill-humor, and in joy and pain moderation is 
 maintained. There is, on the other hand, weakoiess of mind, where re- 
 actions of the /, extended, but wanting in energy, are easily evoked; 
 nearly every perception excites a sentiment; joy and sadness succeed each 
 other with the utmost ease, and emotions become necessary to mental life: 
 the diminished sensibility then frequently demands new and strong irri- 
 tation, as finding pleasure in shocking and fearful events, and the /is at 
 rest only in times of exhaustion and sleej). 
 
 It is easy to recognize the identity of the last -mentioned case with what, in 
 the sensitive niotory sphere, is called irritable weakness, and is considered the 
 most important disposition and fundamental state in many nervous diseases (for 
 example, the spinal neuroses). This state is well called weakness, since with the 
 single and one-sided increase of excitability there is accompanied an absolute 
 diminution of power in the functions. In convulsions, the voluntary muscular 
 movement is weak; in constant emotion, the thought and the will are ^veak and 
 languid. These states are not only very frequently combined with each other, as 
 in the tendency to emotion and the increased tendency to convulsions in many 
 hysterical persons, but they also very often originate simultaneously in both 
 spheres from the same causes, have in their course the same consequences, and 
 the principles of their treatment are throughout analogous. 
 
 § 32. Upon the nature, method, and facility with which the / is af- 
 fected in the form of emotions and sentiments, depends certainly a con- 
 siderable part of the modes of reaction, and therewith the individual 
 peculiarities of men. In so far as the peculiar modes of the individual 
 lie in the inner world of the disposition, and this is not opposed by the 
 versatility of the mental states, the peculiar manner in which this change 
 proceeds is the characteristic; it is this which gives the fundamental com- 
 plexion and tone to our disposition. The disposition is a certain mode 
 of behavior of the /, the fixed steadfast kernel of our individuality, Avith 
 which the results of our whole mental history are associated. This may, 
 indeed, be shaken in the emotions, but not impaired or destroyed ; what else 
 can be affected in the emotions than that group of ideas, the I? The / 
 can be detached, and completely destroyed, in serious disorganizations of 
 the brain (in dementia); it may succumb, and a new one arise in its place 
 (monomania); but even this is only the case (§ 29) when the emotions 
 which necessarily accompany the lesion and destruction of the old /have 
 been completely pacified. 
 
 The nature and the manner in which the mass of ideas representing 
 the /Ts affected by what passes within the consciousness, or presses into 
 it, determines the nature and manner of the self-sensation. Moderate 
 and lasting changes of consciousness are, again, the foundation of the 
 
40 PRELIMINARY PHYSIO-PATHOLOGICAL OBSERVATIONS. 
 
 various modifications of the dispositions; when they take place suddenly 
 and energetically, and are accompanied by considerable disturbance of 
 the mental equilibrium, they constitute the foundation of the mental 
 affections. The objects of consciousness can only be of a twofold nature, 
 pleasurable or painful; the one, when the groups of perceptions of the /, 
 the interest of our inner life, are favored and advanced, through the 
 events in consciousness, in their free course, their adequate relations, and 
 especially in their transition into efforts; the other, when hereby they are 
 repressed, subverted, and limited. From the slightest changes in the 
 disposition up to the most violent emotion, only two kinds are possible: 
 either a state of furtherance and expansion of the /, which affords pleasure, 
 therefore it is in harmony with the new occurrences in consciousness, and 
 seeks to retain them; or a state of limitation and depression, where the 
 group of perceptions of the /, in their flow and transition into effort, are 
 impeded and repressed, sometimes take to flight, sometimes perseveringly 
 strive to enter; here the /is in negative relation to a new perceptions. 
 Accordingly, all the dispositions and emotions divide themselves info two 
 gi'eat classes — the expansive (and at the same time affirmative), and the 
 depressing (and at the same time negative, accompanied by abhorrence). 
 To the one belong joy, gladness, pleasure, frolic, hope, humor, merriment, 
 etc. ; to the other, anger, malice, dejection, sadness, sorrow, shame, fear, 
 horror, etc. 
 
 This relation is the basis of the classification of those states of insanity where 
 affections of the disposition predominate, therefore of the primary forms of 
 mental diseases (§ 29;. "We meet with two principal classes: in the one, the cliief 
 disturbance consists in depressive negative dispositions and emotions — all melan- 
 cholic conditions; in the other, they consist in expansive affirmative emotions — 
 monomania. We have not yet spoken of anger: it occupies an intermediate 
 place between the two kinds of emotions, viewed in relation to its causes, it 
 belongs rather to the first, in that it implies an invasion of the I; but there fol- 
 lows a violent reaction, a lively expansion and explosion of the perception and 
 effort, by which this hostile impression is overcome, and the equilibrium again 
 established. The conditions, however, wliich are understood by the term mania 
 are, according to their psychological nature, intimately related to anger, and 
 nosologically their proper place is between melancholia and monomania. 
 
 § 33. An important circumstance, which clearly distinguishes the 
 emotions from calm thought, is this — that in the former other organic pro- 
 cesses besides the celebral are always involved. The heart's action, the 
 respiration, the digestion — the secretions of the skin, the liver, and the 
 kidneys — are altered in the emotions. In anger, the facial veins congest; 
 occasionally it seems as if violent emotion would suffocate. Fright and 
 horror quickly excite watery secretions; in grief, tlie respiration is pro- 
 longed and superficial, and must, therefore, be occasionally broken by 
 deep gasps and sighs. It is thus that the emotions and emotional states, 
 originally by excitation of the nervous system coming from the brain, give 
 rise to abnormal physical states. Emotion, wdien transitory, and occur- 
 rino- in a previously healthy organism, is speedily calmed; where, however, 
 bodily disease is already present, and where the causes are long continued 
 (for example, prolonged sadness), there gradually arise many complicated 
 disorders of the organic mechanism, which the simple cessation of the 
 emotion cannot as "quickly terminate; and these disorders can noAV, by 
 means of new secondary irritation of the brain, not only maintain and 
 increase the existing emotion, but also orginate new conditions of a sim- 
 ilar nature. 
 
 For, it is a fact taught us by experience, that when the mental func- 
 
PRELIMINARY PHYSIO-PATHOLOGICAL OBSERVATIONS. 4:1 
 
 tion of the brain is influenced by the organic processes (respiration, diges- 
 tion, etc.), this does not immediately tiSect the sphere of clear percep- 
 tion; it does not thereby follow that we receive new thoughts,, but rather 
 that there originate, in the first place, within us obscure modifications of 
 self-consciousness and disposition, feelings of furtherance and limitation 
 of our mental function, and thereby an essential element of emotional 
 states is forced upon us (§ 20). 
 
 Examples of this are met with in many diseases. We very often see that in 
 those afflicted with heart disease anxiety appears, and that in diseases of the 
 intestines, in changes in the blood resulting from icterus, sullen, anxious, irri- 
 table moods, sluggishness of thought, general disharmony, etc., are observed. 
 The feeling of corporeal well-being or of bodily illness generally exercises a great 
 influence upon the frame of mind, whether it be glad and cheerful, or depressed 
 and sad; should external causes capable of exciting an emotion now influence us, 
 very much depends upon these existing, habitual or transient, cerebral states 
 which are excited by the bodily conditions, whether the emotion will be constant. 
 In an individual already irritated by bodily disease, an emotion excited by any 
 external cause becomes sooner fixed, and is more lasting in its effects, than when 
 it originates in a man who enjoys the best ijhysical health and joyful disposition. 
 
 These relations constitute some of the most important fundamental elements 
 of the pathology of insanity. They are the key to a knowledge of the predispo- 
 sition to mental diseases resulting from the most diverse bodily diseases, and of 
 the mode of action of psychical causes. The latter very seldom (see 2d book) 
 produce insanity directly; they do so much more frequently secondarily through 
 the interposition of other disorders; for example, in this manner — that through 
 long-continued grief the nutrition greatly suffers, and this primarily exerts an 
 influence upon the brain and thereby upon the psychical processes. 
 
 § 34. In the emotions calm deliberation is impossible. The / itself, 
 having fallen into a vacillating and disturbed condition, does not possess 
 the composure necessary to consider the facts present in consciousness 
 with sufficient concentration and attention. That state in which this 
 consideration is possible, and actually takes place, is called the reason. 
 In order to this consideration, and therefore also to deliberation, there is 
 requisite a reciprocal definitencss of the perceptions, leisure and delay, 
 composure and reflection. The contrastuig perceptions (§ 2G) must be 
 capable of becoming effective, and requisite calm must be afforded to the 
 /. Neither of these occur in mental disease. Through the cerebral 
 affection, dispositions and instincts are produced which become points of 
 origin of emotions. If out of these, again, false opinions arise, they can- 
 not be rectified, and the patient cannot see his error; at first, because the 
 persistent emotions do not permit the calm necessary to allow the con- 
 trasting perceptions sufficiently to develop themselves, and the longer it 
 continues the more doits results, the false judgments, become fortified and 
 consolidated; later, however, because tliose false judgments have become 
 integral fundamental parts of all the groups of ideas of the /. 
 
 In every fully developed mental disease it is therefore impossible for the 
 patient to recognize the falseness of the morbid perceptions. This fact is con- 
 founded to a very great extent with loss of reflection, spoken of in § 27. But by 
 that even the insane have also lost their reason, and on the ground so well stated 
 by Herbart, that " their thoughts do not admit of being disturbed in their special 
 course by means of external or internal opposition." Also in health, all kinds of 
 caprices, false opinions, foolish thoughts, pass through the brain; but one can, 
 if he be not actually in a state of emotion, calmly accept or reject them. 
 
 § 35. Kecovery from insanity ordinarily takes place only in the primary 
 period, which, however, often continues for a series of years, during 
 which it principally depends on emotional states. Inasmuch as through 
 removal of the disease of the brain, or of its more remote organic causes, 
 
42 PRELIMINARY PHYSIO-PATHOLOGICAL OBSERVATIONS. 
 
 the morbid dispositions and emotions disappear, the false judgments 
 which were bused upon it must likewise disappear, and the group of per- 
 ceptions of the, now no longer shaken, / enter immediately into their old 
 direction. Should, however, the organic causes of the cerebral disease 
 not have been removed until the false opinions have entered into mani- 
 fold combinations with the groups of perceptions of the /, the patient 
 may certainly recover; but his recovery will be a longer and much more 
 gradual psychological process, until, through strengthening of the former 
 normal direction of the thoughts, the connections which the false opinions 
 had contracted with the /, gradually loosen, and eventually are entirely dis- 
 solved. Many convalescents do not recover completely until they return 
 to their homes and to their former relations of life, employments, etc. 
 When, however, the old / is vitiated, corrupted, and falsified on all sides 
 by the morbid false ideas — when, besides, the group of perceptions of the 
 former /is so completely repressed (forgotten), that, without any trace 
 of emotion, the patient has exclianged his whole personality, and has 
 scarcely any remembrance of it, then recovery is next to impossible, and 
 only occurs in rare cases through excitation of violent emotions, and 
 thereby through a kind of mechanical training (as attempted, for exam- 
 ple, by Leuret '), continuously to repel tlie appearances of the insanity. 
 Naturally, this can only be attempted where the brain has not as yet sus- 
 tained any deep organic lesion: where this is present, as in many of these 
 states, especially in secondary dementia, all hope of recovery is past. 
 
 1 Du Traitement moral de la Folie,' Paris, 1840. 
 
THE ELEMEKTAKY DISORDERS IN MENTAL DISEASE. 43^ 
 
 CHAPTER IV. 
 
 THE ELEMENTARY DISORDERS IN MENTAL DISEASE. 
 
 § 36. Previous to the consideration of those complex groups of 
 symptoms which constitute the special forms of mental disease, there 
 are some general relations which require to be briefly noticed; especially 
 the separate elementary disturbances which_ are always found, dift'erently 
 grouped together, in the various forms of insanity (melancholia, mania, 
 etc.). In those cerebral afEections which come under consideration as. 
 mental diseases, there are, as in all others, only three essentially distinct 
 groups — namely, sensitive, motory, and mental (perceptive) anomalies. 
 Thus, according to this threefold division, we have to consider succes- 
 sively each of the three leading groups of elementary disturbances — intel- 
 lectual insanity, emotional insanity, and insanity of movement. 
 
 Of all these states, the mental disorders are certainly the most striking, the 
 most characteristic, and those upon which the diagnosis is based;' but we must not 
 consider that the sensitive and motory morbid processes are only accessories. 
 The anomalies of sensibility play an important part in insanity; disorders of what 
 we call the imagination (§ 18) extend over a great part of its sphere; and the 
 anomalies of movement which at first sight seem quite foreign to insanity, form, 
 as we shall afterwards see, some of the most weighty points of anatomical diag- 
 nosis and of prognosis. 
 
 SECTiO]sr I. — The Elementary Intellectual Disorders.'' 
 
 § 37. The essential characteristic of insanity, that which distin- 
 guishes it as a morbid state, consists chiefly in the fact that certain states 
 of the brain — certain dispositions, feelings, emotions, opinions, determi- 
 nations — proceed from within outwards, owing to disease of the organ of the 
 mind; while, in the healthy state, our emotions, opinions, determinations, 
 originate only upon sufficient external motives, and on that account also 
 stand in a certain harmonious relation to the external world. No one 
 wonders if any one who had sustained a great loss is sad, if another to whom 
 an earnest wish has been fulfilled manifests exuberant joy; but we rightly 
 consider it as a morbid symptom when an individual without any exter- 
 nal motive is depre:sed with sadness or elated with joy, or even, where 
 some external cause has been given, the individual is immoderately or for 
 too long a time affected by it, as when a trifling occurrence excites an 
 individual to violent rage which he is unable for a long time to restrain. 
 
 According to the same fundamental principle, we judge of all events in the 
 nervous system. Fatigue after a long march is normal; persistent weariness alter 
 sufficient rest is morbid. A shivering sensation experienced when the air is cliili 
 is normal, the sensation of cold when the external temperature is high is morbid. 
 
 ' In considering the mental anomalies, it is necessary to allude to much in the 
 previous section which will not be again repeated. For the elucidation of certain 
 points which are therefore but cursorily mentioned, the reader may refer to 
 §§ 18-35; there is much, however, which cannot be properly explained till we 
 come to describe the various forms of insanity. 
 
 2 For the paragraphs immediately following see Zeller's 'Remarks upon 
 Guislain's Phrenopathie. ' Stuttg., 1838. 
 
44 THE ELEMENTAKY DISOEDEES IN MENTAL DISEASE. 
 
 Numbness of the leg from pressure upon the nerves is certainly slightly morbid, 
 but it is normal when compared with persistent numbness due to an internal 
 cause, as disease of the spinal cord. .So, too, the condition is morbid when a 
 slight cause excites disproportionately violent reaction -if walking a few steps 
 causes fatigue, or when a gentle breeze excites shivering. In these respects, 
 however, the limits of disease and health are by no means clearly defined, since 
 there are many states of this description, especially such as are transient, that 
 are not ordinarily considered as diseases. A glass of wine can elevate our spirits 
 "without external cause for joy. Here, by means of the alcoholic, a cerebral 
 state, an expansive disposition, is induced from within outwards; a weak analogy 
 to insanity, which, however, no one has designated a disease, as it quickly passes 
 off without any durable effect. 
 
 Very much depends iTpon the duration and intensity of the phenom- 
 ena, whether we consider tlie mental state as morbid. Every one knows 
 from personal experience, that occasionally there may originate in us, 
 without outward motive, dispositions lively or sad, tender or bitter — 
 states of mind whicli arise out of slight changes in the organic processes, 
 and only recognizable by careful attention. These dispositions are not 
 morbid when moderate and of short duration, and thoroughly subject to 
 the control of the mass of perceptions of the /; Ij^it they are morbid when 
 they constantly and in every matter intrude themselves on the individual, 
 when they can no longer be removed by outward mental excitation, and 
 when, instead of being controlled by the group of perceptions of the /, 
 they affect us tumultuously and excite a lasting state of painful internal 
 disquietude. As with such dispositions, so also' is it with single distinct 
 perceptions. A strange or foolish thought may pass through the mind of 
 the most rational man; if only it does not lodge there, but is by a power- 
 ful /soon again forced out of consciousness, no one can call this morbid. 
 In insanity, however, such dispositions, such thoughts, are persistent; 
 they, owing to the duration and strength of the cerebral affection, be- 
 come persistently and deeply impressed upon the mind. 
 
 § 38. In order to a correct understanding of insanity, we must our- 
 selves endeavor to tliink with the insane. From the mental states which 
 are sdll within the limits of health, and therefore within our own expe- 
 rience, Ave may form some conception of what takes place within the dis- 
 eased mind. Tlie phenomena of dreaming, the state of the emotions, 
 mental fatigue, etc. — especially, however, the above-mentioned moderate 
 changes of disposition which in health arise spontaneously out of slight 
 physical disorders — are for this purpose especially instructive. For, ob- 
 servation shows that these phenomena, on the one hand, of anger, of 
 inclination to rage, of discontent, rancour, and, on the other, of joy, 
 gaiety, frolic, are frequently, and with unwonted persistence and inten- 
 sity, found to be marked elementary phenomena of insanity; conse- 
 quently, many of the conditions of healthy life are met with in insanity, 
 and are by the comparison considerably elucidated. 
 
 But we find other psychological anomalies in the insane to which 
 there is nothing analogous in the state of health, and for this reason we 
 are unable fully to comprehend them. Thus, we cannot form any clear 
 conception of what is meant when we hear insane persons complain that 
 their thoughts are entirely made for them by others, or that they are ab- 
 stracted from them, or when we see how, with particular words and 
 gestures, they associate some very mysterious sense, and attribute a secret 
 importance to them. The deepest mental fatigue cannot even afford any 
 analogy approaching the destruction of thought occurring in dementia; 
 scarcely even can the peculiar states of sleep and dreaming convey any 
 
THE ELEMENTARY DISORDERS IN MENTAL DISEASE, 4:5 
 
 * 
 
 adequate idea of it. Whoever has experienced the delirium of fever may, 
 therefore, form some notion of wliat takes place in mental disease. 
 
 In the following paragraphs, in speaking of the individual morbid states of 
 disposition, thought, and effort, we will always refer to the corresponding physi- 
 ological states. This threefold division of mental disturbances is merely conven- 
 tional to render their study more simple; their more intimate relations will be 
 understood from paragraphs 25-34. 
 
 A. Anomalies of Sentiment. 
 
 § 39. Observation shows that the great majority of mental diseases 
 are first manifested, not by senseless discourse or extreme acts, but by 
 morbid changes of disposition, anomalies of the self-sensation and the 
 sentiments, and consequent emotional states. And, indeed, the earliest 
 stages of insanity generally consist in an aimless feeling of ill-humor, 
 discomfort, oppression, and anxiety, owing to the fact that the new 
 groups of ideas and instincts resulting from the cerebral affection are 
 usually at first exceedingly obscure. On this account, the disturbance 
 of the normal process of thought and will, and the new mental states 
 obtruding on the /, are first felt simply as vague modifications of the 
 sentiment and disposition. The diminished power and energy of the /, 
 the contraction of its sphere of ideas, produces an indefinite state of 
 mental pain, and, from its vagueness, great irritation of the feelings. 
 The new morbid perceptions and instincts produce divisions of the mind, 
 a feeling of division of the personality, and of imminent annihilation of 
 tlie /. The mental pain discovers itself in some of the familiar forms of 
 agitation, anxiety, sadness, and entails all of the forementioned (§ 21) 
 consequences of a radically changed reaction towards the external world, 
 and of a disturbance in the motory function of the mind. Perversions 
 of the natural feelings, aversion and hate towards those formerly loved, 
 outward insensibility, or a morbid fondness clinging to a single object, 
 but without the depth and tenderness of the normal sensation, and sub- 
 ject to rapid and capricious changes, are here ordinary appearances. 
 The increased sensibility involves everything, because, indeed, it is 
 painfully affected by everytiiing, and, from the mournful complexion 
 that pervades all his views and opinions, the individual puts an 
 evil interpretation upon everything present, and discovers in the future 
 nothing but evil. Distrust and susi)icion are engendered by the feeling 
 of diminished power of resistance, and are constantly excited by bodily 
 feelings of anxiety. Everything appears strange to him, because he acts 
 strangely towards every mental impression, because he himself feels al- 
 tered, and he feels a strong inclination to ascribe his condition sometimes 
 to the direct influence of the outer world — to believe that he is ])ursued, 
 influenced, charmed, governed by secret influences — and at others to 
 refer to his former life for the causes, and to accuse himself of a variety 
 of serious crimes, depravities, and misdeeds, of which his present posi- 
 tion is the necessary consequence. 
 
 Here the most varied modifications of those fundamental states are to be ob- 
 served; sometimes an entire absorption of the individual in self, sometimes total 
 despair, frequently malevolence; occasionally sympathetic tenderness, persistent 
 self-torture; sometimes continual dissatisfaction with the external world; some- 
 times weariness of life and calm determination to commit suicide; sometimes 
 dread of death, of the pains of hell, etc. Frequently the patient is conscious of 
 the commencement of insanity, occasionally he seeks advice, and we have known 
 patients in the preliminary stages voluntarily conaing from great distances to the 
 asylum. 
 
46 THE ELEMENTARY DISORDERS IN MENTAL DISEASE. 
 
 The above-named states are the foundation of the various forms of melancholy, 
 although they present themselves also in other forms (as in chronic mania). In 
 the majority of cases the patients feel great disquiet, even misfortune, which may 
 probably have originated the old appellation of ?/iorosita^es applied to all who were 
 mentally diseased. The analogues in healthy life corresponding to these states 
 are, all depressed dispositions and emotions, discouragement, immoderate irrita- 
 bility — habitually bitter, discontented, and self-vexatious frames of mind — as are 
 occasionally observed in highly intellectual minds (J. J. Rousseau); groundless 
 jealousy, anger, fear, irritability, etc. 
 
 § 40. The morbid states of emotion with a disposition to gaiety, cheer- 
 fulness, frolic, with increased mental and bodily activity, are closely 
 analogous to the expansive emotions, and they are both followed by es- 
 sentially the same immediate consequences. There is, even in health, a 
 possibility of being ''joy-mad;" a state in which, not only the feeling of 
 present happiness expands all the powers of the soul, but the dreams of 
 the future seem to be realized, and in which men and things come nearer 
 to us — in which we could allow every man to share our fortune, and 
 could, as it were, embrace the world. Even in these states it can attain 
 to a certain degree of disorder and incoherence of the ideas, and it always 
 shows that the excitation is not deep when the fortunate one can quickly 
 regain all his faculties. Also in health there is usually combined with 
 these feelings an impulse to external movement, restlessness, talkative- 
 ness, and business. These states are similarly exhibited when they origi- 
 iiate morbidly, from within outwards; they generally form the fundamen- 
 tal states of monomania, and are present, although in a much weaker 
 degree, in chronic mania and dementia. In accordance with what we 
 have ourselves observed, we must coincide with the view of Guislain, that 
 joyous insanity almost invariably makes its first appearance as succeeding 
 states of depression that have passed off. On this account it seems also 
 to depend upon a mental disease more deeply seated than the latter-men- 
 tioned state. It seems often as if, upon a change in the state of the 
 brain, the previous oppression weighing upon the soul were suddenly re- 
 moved, and as if, as a symptom of still deeper destruction, the feeling of 
 great mental freedom, the happy hopeful disposition could arise. A re- 
 mote analogy taken from the sensito-motory nervous system presents 
 itself in the fact (Purkinje) that when the extremities are weighed down 
 for some time by attached weights, immediately after their removal there 
 is experienced an unusual sense of lightness of movement. 
 
 Besides, there are presented a number of other morbid dispositions and emo- 
 tions, odd capriciousness, inclinations, and aversions, sensuous and ideal love, 
 coquetry, etc. , too numerous to be individually stated. 
 
 With the appearance of these various anomalies of sentiment, commonly, 
 the relation of the individual to the outer world, his whole character, his desires 
 and tastes, are totally changed. The amiable man becomes fierce, the parsimo- 
 nious prodigal, the moral licentious, the modest proud and insolent. The 
 changes of the character are generally the most striking symptoms in the early 
 stages of Insanity ; and generally the insanity itself, in these cases of slow 
 gradual origin, appears simply as an excessive development of the natural dis- 
 position or peculiarity of the individual. Therefore, frona the peculiarities in 
 the sentiments of the patient, it is only with the greatest caution that we should 
 venture to express on opinion as to his former character. Extreme viciousness 
 and malevolence can, for example, during the duration of the malady, con- 
 tinue for years in men of at other times kind and benevolent natures, and on 
 recovery the old dispositions may be quickly revived, and no trace left of the dis- 
 ease. 
 
 § 41. The anomalies of emotion which have been hitherto described 
 are to be regarded essentially as appearances of abnormal emotional irri- 
 
THE ELEMENTARY DISORDERS IN MENTAL DISEASE. 47 
 
 tability. There are also, however, abnormal states of dulness, and even 
 of total loss of emotion. Here either the occasional perceptions are no 
 longer connected with the changes in the relation of tension of the quiet 
 masses of perceptions of the / which occur in the healthy state — there is 
 little or no disturbance of the emotions generally — or it may be that 
 these events occur indeed, but they are no longer known to the indi- 
 yidual, and therefore have no existence to him. To all that formerly 
 interested him he is now equally indifferent, and he is no longer capable 
 of being much affected by any new sentiment; participation and interest, 
 pain and pleasure, love and hate, cease. Apathy and indifference to 
 everything beyond the satisfaction of his sensuous requirements succeed. 
 Intelligence can thereby be tolerably maintained, but generally a greater 
 or less degree of dementia is apparent. 
 
 Perversion of the affections is a state of considerable importance in a medico- 
 legal point of view, and one which is frequently difficult to distinguish. It 
 appears as a morbid state acquired principally by onanists and drunkards, and is 
 recognized to be a disease, especially where it originates rapidly. It forms an 
 essential clement in veiy many states of chronic mania (see Book III.), where 
 commonly all interests are extinguished excepting such as relate to certain insane 
 ideas and to the individual himself ; indeed, there are cases where the perversion 
 of the affections and the apathy appear as the chief elements. In a remarkable 
 medico-legal case which was decided by the opinion of the author (Seitz), the 
 crime — the murder of three of his own children— proceeded directly from this 
 anomalous state of the affections. And, indeed, in crimes of this kind, where the 
 patients are quite rational, the physician cannot be too careful to discover condi- 
 tions of this nature. 
 
 B. Anomalies of Thought. 
 
 § 43. Within the sphere of distinct perception, of opinion, and con- 
 clusion, we can readily distinguish two varieties of abnormal states. 
 First, there is an abnormal relation of perception in the abstract; sec- 
 ondly, abnormal views in relation to its (false) objects. These states are 
 intimately related, inasmuch as certain formal modifications, for example, 
 too rapid succession of the ideas, extreme slowness in the course of 
 thought, or disorder of the feelings which necessarily accompany them, 
 excite or promote certain morbid ideas; for example, the moderate 
 excitation of perception, where the combinations proceed with increased 
 facility, is frequently accompanied by false judgments, which result from 
 the feeling of mental liberty and mental well-being. 
 
 a. Formal Deviations. 
 
 Extreme sluggishness of thought depends either on suppression aris- 
 ing from violent mental pain, which entirely occupies the mind and per- 
 mits nothing else to approach it, or on real weakness, especially loss of 
 memory. In both cases, however different they may be as to their 
 internal causes, there is observed poverty and sameness of thought, the 
 train of thought appears to stand still; single words, modes of expression, 
 movements, repeated for hours, show the continued presence of the same 
 perceptions. _ There is often observed a hesitation of the speech, great 
 uncertainty in the connection of the thoughts, and timidity in judging. 
 This condition is found principally in melancholia and in dementia. 
 
 This insufficient interchange of the perceptions is a very important element 
 in many mental diseases. The patient can no more thoroughly divest himself of 
 certain perceptions, he is no longer free, he is continually exposed to their tor- 
 menting influences and impulses; he feels how, gradually, in spite of his opposi- 
 tion, his I, the oneness of his person, is being snatched from him. Similar states 
 
48 THE ELEMENTARY DI80KDERS IN MENTAL DISEASE. 
 
 may be observed even in dreaming; many repugnant ideas by their constant 
 recurrence induce a state of despondency. As will be found on minute consid- 
 eration, sleeplessness often arises from the continued influence of a group of 
 ideas; whenever these disperse sleep returns. 
 
 An increased joroduction and accelerated flow of the thoughts in some 
 degree facilitates mental combinations; therefore we sometimes observe 
 individuals who at other times are even intellectually dull become acute 
 and witty, especially in the happy expression of raillery against indi- 
 viduals present, versification, etc. On that account we hear little 
 wisdom from the insane. Then, even in these states where abundant 
 material is offered to the cultivated imagination, generally disorder and 
 incoherence very soon appear. Particularly wlien great numbers of per- 
 ceptions originate in the brain, and their course is accelerated, are they 
 succeeded by long series of ideas; and frequently long-forgotten images 
 and events, words, songs, and so forth, are renewed with the freshness of 
 first impressions; but, inasmuch as the perceptions so rapidly succeed 
 each other, that tliey cannot enter into the necessary combinations, and 
 inasmuch as the multiplicity of thoughts is attended by corresponding 
 changes in the sentiments, the only result is extreme agitation and 
 tumult of ideas. All is hurried along in the most confused succession, 
 and it is a chance if here and there in this turmoil tlie elements of a. 
 quaint idea meet together which is in the least more rational than what 
 surrounds it. 
 
 The latter states appear principally in mania. There is often appar- 
 ently great mental vivacity, especially at their commencement, and we 
 have known cases where it was the invariable symptom of an approaching 
 attack when the patient became witty. 
 
 Incoherence of the ideas does not, however, solely originate in this way, 
 namely, through over-fulness of the consciousness. There is also incoherence 
 of thought anil speech corresponding to projections of the thoughts and of the 
 emotions, as anger, and still another which proceeds from complete abolition and 
 deep destruction of the mental processes. The psychological mechanism of this 
 last condition is still very obscure in its details, it appears that the incoherence 
 frequently depends on the fact that the perceptions are called forth, not only 
 according to their (similar or contrasting) contents, but especially according to 
 external similarity of sound in the words. Perhaps deficient reciprocal action of 
 the two halves of the brain may have some influence in producing incoherence. 
 Incoherence is frequent at the commencement of mental diseases, where there ia 
 violent disturbance of the emotions, and here it is no more an evil indication than 
 it is in the delirium of fever cr in dreams. On the otlier hand, tlie incoherence 
 which first appears after a long continuance of melancholia and mania, or at the 
 commencement of chronic insanity, is significant of a transition to the incurable 
 forms of dementia. 
 
 Two marked examples of temporary incoherence from transient disturbance of 
 the brain in otherwise healthy persons, with a clear description of the progress 
 of the symptoms, by Spalding and Gadike, maybe seen in Jessen, "Versuch 
 einer wissenschaftlichen Begriindung," etc., 1855, p. 180. 
 
 To the morbid states of tli ought described in this paragraph there are found 
 many psychological analogies, partly in the determined persistence with which 
 disagreeable ideas often follow us, in intimidation of the judgment by an adverse 
 occurrence, also in so-called sulkiness and in confusion of the ideas owing to 
 fright. To the second series in loquaciousness without ideas, in the internal con- 
 fusion which originates from abundant simultaneous reception of ideas which 
 have no common characteristic or leading direction, or in the incoherence of 
 images in dreams. 
 
 *&"- 
 
 § 43. Memory in particular is very variously affected in mental dis- 
 ease. Sometimes it is unimpaired as regards the events of the former 
 life as well as the occurrences during the disease. In the preceding 
 
THE ELEMENTARY DISORDERS IN MENTAL DISEASE. 49 
 
 paragraph we have spoken of its morbid increase. It is more frequent, 
 however, to observe enfeeblement of the memory in various modes. 
 Dementia in particular is characterized by feebleness of sucli a kind that 
 events happening at the present time are quickly, even instantaneously, 
 forgotten, Avhile there is distinct recollection of events that took place in 
 former periods of life, which may even be the subject of tolerably well- 
 ordered conversation. At other times the contents of the previous life 
 are either (seldom) completely effaced from the tablets of the memory, or 
 (more frequently) are so far removed that they become so vague and so 
 strange to the individual, that they can scarely be recognized as events in 
 his own histoi'y. Here the actual individual existence is dated from the 
 commencement of the disease, and the entire former life is either attrib- 
 uted to a strange personality or at least to a former quite different state, 
 to an imaginary life. This estrangement, this complete falling away of 
 the former /, depends, not only upon weakness of memory, but ordi- 
 narily it is produced and rendered persistent by special sensitive anoma- 
 lies; but the disappearance of whole masses of former perceptions is 
 especially favorable to the consequent internal production of such a 
 delirium.' 
 
 An individual who has recovered from insanity generally remembers 
 what occurred to him during his disease, and can often narrate with re- 
 markable truth and precision the most trifling incidents in the outer 
 world and the minute details of his motives and sentiments during the 
 disease. He can often interpret every glance, word, and change of 
 expression of his visitor — circumstances which suggest an incidental 
 caution to those who have to do with the insane, to be constantly on 
 their guard as to how they conduct themselves, to be just and mild, if 
 indeed such an exhortation be required! This kind of intelligence is 
 especially observable in those who have recovered from melancholia and 
 moderate states of mania, less frequently after monomania, of which the 
 patient generally retains very confused ideas. The statement of one who 
 has recovered, that he has no knowledge of anything that occurred 
 during his disease, is to be received with caution, since the patient often 
 conceals what he clearly remembers through deceit. 
 
 With the anomalies of form wliich have been described there are frequently 
 connected changes in speech and the modes of expression. Many are dumb 
 owing to a cessation of perception, or even where numerous perceptions are 
 present, because no reflex action occurs in the apparatus of speech. Others speak 
 incessantly, their narratives are endless, or, without communicating anything 
 precise to a listener, the continuous reiiex action in the organs of speech pro- 
 ceeds as incessant prattle (logomania proper, generally with incoherence). Fre- 
 quently it is rather the formation of sentences and the mode of expression that is 
 altered; they are more fluent or interrupted, disconnected, affected, etc. In 
 other cases, which are the most interesting, there appear in the language of the 
 insane newly formed words, and old ones are employed with new significations; 
 in short, the patient forms for himself a new language. It would appear that 
 occasionally ordinary language is not sufficient to express completely new and 
 strange contents of sensation and perception, and therefore new words are 
 formed, or that in the abnormal cerebral state the conventional images of sound 
 (words) directly stir up and allude to other perceptions (see § 17), or that fre- 
 quently the hallucinations of hearing immediately necessitate the formation of 
 new combinations of syllables, which are then retained and held fast (in dream- 
 ing also there is thus formed new words). All these changes appear most highly 
 developed in chronic mania, more transiently in mania. 
 
 The altered modes of expression, under certain conditions, present to the 
 practised physician direct points of diagnosis; those who feign insanity imitate 
 
 ' Examples are found in g 49 and in " Dementia." 
 
50 THE ELEMEKTAKy DISOKDERS IN MENTAI. J)ISEASE. 
 
 tliese states very clumsily. See Snell, 'Zeitschrift fiir Psychiatrie,' 1853, ix., p. 
 11; W. Nasse, ibid., 1853, x., p. 525; Martini, ibid.. 1856, xiii., p. 605;^ Brosius, 
 ibid., 1857, xiv., p. 37: Blandet, "Du Delire phonetique," ' Gazette Med.,' 1845, 
 No. 27. 
 
 Z». Perversions of Thought — Delirious Ideas. 
 
 § 44. Mental disease does not necessarily imply the existence of 
 delirious perceptions. Marked changes in the character and in the 
 sentiments, morbid dispositions and emotions, blunting of the senti- 
 ments, total or partial relaxation of the mental powers, can exist without 
 truly insane ideas, as acute and chronic morbid states of the mind. A num- 
 ber of such cases may be comprehended under the class of moral insanity 
 ( Gemiithsioahnsinn). But experience teaches that, in the great majority 
 of cases, the mental derangement does not cease here, that special insane 
 ideas are developed, and that these false opinions which can no longer be 
 regulated are accompanied by true delirium, the mental affection, wliich 
 at the commencement was only an insanity of the feelings and emotions, 
 becomes also insanity of the intellect. The pressure of _ the morbid un- 
 easiness tends rapidly to incorrect percei)tion and interpretation of 
 objective relations, but, at first, only of such as relate to the patient 
 himself or to his immediate surroundings. The false contents of the 
 thoughts, i. e., which are not in harmony with the external world and 
 with the events of the former life, at first generally happen in such a 
 way that the patient attempts to account for his dispositions and morbid 
 emotions by the law of causality (§ 23, 39). The most varied external 
 causes and events, and the innumerable recollections of his individual 
 existence, afford abundant material for this attempt at explanation, and 
 circumstances, education, and the views of life, have here the most 
 decided influence. For example, the same disposition which excites in 
 the superstitious mmd the idea of witchcraft may in another suggest the 
 idea of being pursued by freemasons, of invasion through secret magnetic 
 influences, etc. All hallucinations have a special influence, as well on 
 the formation of such insane ideas as on their special objects; they are 
 so frequent, present materials for explanation so lively, obtrusive, and 
 often so constant, that in our experience we must find them to be a 
 common source of insane ideas; thus, the subject of an hallucination of 
 sight who sees fiery appearances believes himself in hell, another with an 
 hallucination of smell thinks he is surrounded on all sides by dead 
 bodies, the effluvia of which he believes he smells, and thereon founds 
 further conclusions, etc. 
 
 As to their contents, two leading differences are particularly to be 
 ©beerved in insane conceptions — first, joyous, sublime, brilliant ideas; 
 secondly, sombre, sad, and painful thoughts. The former arise from the 
 expansive emotions and from cheerful joyous hallucinations, the latter 
 from depressed states of the disposition, and gloomy ill-boding hallucina- 
 tions, as language of abuse and mockery which the patient is always 
 hearing, diabolical grimaces which he sees, etc. 
 
 The false ideas and conclusions, which are attempts at explanation 
 and vindications of the actual disposition in its effects, are spontaneously 
 developed in the diseased mind according to the law of causality; on the 
 part of the individual the explanations do not imply reflection, still less 
 are such conclusions formed by the tedious form of syllogism. _ At first, 
 the delirious conceptions are fleeting; the / perceives them, it may be 
 terrified by them, acknowledge their absurdity, and yet feel quite 
 
THE ELEMENTARY DISORDERS IN MENTAL DISEASE. 51 
 
 unable to rid itself of them, and struggles with them; gradually, by con- 
 tinued repetition, they gain more body and form, repel opposing ideas, 
 and form connections with similar masses of perceptions of the /; then 
 they become constituent parts of it, and the patient cannot divest him- 
 self of them, or only in some degree by exchange with similar false 
 perceptions. The excited, lively, and happy insane ideas are naturally, 
 received by the / much more easily and completely; it yields to them 
 after a short resistance, and then it occasionally gives itself over to the 
 insane perceptions, half-conscious imagination in a world of happy 
 dreams arises. 
 
 All false ideas, however, are not to be considered as thus explicable; 
 many originate with the fortuitous abruptness of hallucinations, or of 
 those peculiar quaint thoughts which often spontaneously intrude on 
 the healthy mind during its most earnest employment. They often 
 originate simply from phantasms of sense, dreams, owing to ex- 
 ternal circumstances; their persistence depends on the present dispo- 
 sition of the patient, and whether in the present perceptions any 
 material for connection is found. We will find, on careful attention, 
 that many such ideas in the insane are related to hallucinations, which, 
 however, do not clearly show themselves. 
 
 In the early stages of insanity, when the disorder of the emotions is still the 
 principal element, innumerable strange perceptions begin to pass through the 
 mind of the patient; interweaving themselves with the ordinary circle of his 
 thoughts, he can neither free himself of tliem nor assimilate them. At first 
 fleeting and changeable, they gradually gain body and form, but still the emo- 
 tional excitement is the foundation on which they stand or fall. The disturbance 
 of the emotions gradually diminishes, and therewith do certain leading insane 
 perceptions become proportionately fast rooted ; gradually the entire mental life 
 circles round them and assumes their character, that is, the incoherence becomes 
 systematic. This, too, is still a period of mental activity; the transformation of 
 the whole internal life still proceeds, partly with the actual consent of the I, with 
 the co-operation of reason. When this process, which is always slow, is at last 
 completed, then the stationary period follows, in which the insane ideas, now 
 become fixed, exist merely as remains of former active processes. 
 
 We should speak of fixed ideas only where the false opinions have become 
 radically and permanently fixed, as in chronic insanity. In melancholia, mania, 
 and monomania, they frequently change. All the false opinions of the insane 
 have tlie characteristic that they are related to the subject itself, or at least have 
 been formed out of false ideas relating to him; they are thereby distinguished in 
 a great degree, if not fully, from the errors of the healthy mind in reference to 
 objective relations. Thus, an insane man may believe that all Jews are damned, 
 but merely because he considers himself injui-ed by them or because he has dic- 
 tated this punishment; he may believe in the existence of a bridge from the 
 earth to the moon, but only that he himself might walk upon it, or that its con- 
 fitruction may afford a proof of his creative power. Nearly all fixed ideas are, 
 when reduced to their fundamental elements, expressions of a frustration or 
 gratification of what specially relates to the emotions, therefore their separate 
 consideration, as if they were the chief points in insanity, always tends to a one- 
 sided and narrow view, and the knowledge, as well as the medical treatment of 
 them, can, in individual cases, rest only upon the view of the mental states lying 
 at their foundation. 
 
 The insane ideas of the mentally diseased are distinguished from the erroneous 
 ' views of the healthy, not only by the circumstance of their relation to the 
 diseased subject himself, but also by numerous other essential characteristics. 
 They are always connected with a disturbance of the whole mental process, 
 (emotions, incoherence, etc.), whether it be that they arise therefrom (generally 
 in the preliminary stages) or that they involve such disturbance. Often they 
 are directly opposed to the former views held by the individual; he cannot get 
 rid of them at will; they resist "against the testimony of sense and under- 
 standing," adjustment, and correction, and therefore stand in a quite different 
 relation to the emotions and the will; they depend upon a disturbance of the 
 
52 THE KLEMENTAKY DISORDERS IN MENTAL DISEASE. 
 
 brain which frequently shows itself in other morbid nervous symptoms (disorder 
 of the sleep, hallucinations, paralytic appearances, etc.). We can easily see from 
 this how unreasonable and fundamentally false it is to consider the errors, " the 
 delusion" of by-gone ages, as the belief in witchcraft, enchantments, etc., as at 
 all analogous to mental disease. 
 
 On the special form of the delirium, there is still another circumstance 
 which exercises great influence, and which hitherto has not received 
 sufficient attention, namely, that the nature of the delirium is often 
 determined by the series of perceptions which last actively engaged the 
 patient's attention immediately before the outbreak of the_ insanity. 
 Consequently, if these are constantly dwelt upon by the patient, it is 
 often erroneously supposed that they have been the cause of the insanity, 
 while, on the contrary, they may have been completely or to a great 
 extent fortuitous. 
 
 In the year 1848, when all the world was engrossed in politics, it was believed 
 that in many cases politics had been the cause of insanity. Flemming ( ' Psy- 
 chosen,' p. 158) brought forward two examples where the patient had attended 
 the hunt shortly before the outbreak of the insanity, and the delirious concep- 
 tions for a long time referred to the incidents of the hunt; another had just been 
 reading an account of a journey to the Himalayas, and that formed the central 
 point of the delusions. The same is observed in acute delirium. In a case known 
 to me, where the last healthy employment of a typhus patient was reading the 
 account in the newspapers of the war then raging in the Crimea, the delirium 
 of the fever for several weeks was confined to the subject of that event. 
 
 § 45. Whether the patient is affected by only a few or by very many 
 false opinions, whether his delirium is partial or general, is to_ be con- 
 sidered in estimating his condition, and is at least of some diagnostic 
 value, as the first case is observed more generally in melancholia and 
 monomania, the latter in mania. But it is wrong to base a distinction 
 of forms on the fact of the insanity being partial or general. EspeciaUy 
 would it be fundamentally false to believe in the existence of states in 
 which the patient has but one single, limited, fixed idea, while in all 
 other respects his ideas are quite healthy. We shall afterwards see that 
 even where this appearance can earliest arise, namely, in the form of 
 chronic insanity, there is always present a deep inward destruction of 
 the mental unity. So, then, the one-sidedness of the delusions^ ordinarily 
 depends, not so much on the patient's having only one fixed idea as on 
 the fact that the same idea is constantly repeated by him in preference 
 to any other. Finally, these relations are subject to frequent change. 
 The same patient, in the same form of insanity, can not only change his 
 ideas from one day to another, but he can also to-day renounce false 
 opinions upon many points, while, perhaps, the day before he was de- 
 luded only on one accustomed favorite idea. 
 
 The establishment of a class, monomania (in opposition to mania), which 
 related less to the existing of a single fixed idea than to the one-sided dominion 
 of a particular impulse (monomania of murder, of theft, etc.), by setting aside 
 the most important relations, namely, the fundamental mental state, has united 
 wliatis outwardly distinct and separated what is internally united; it is not, 
 therefore, to be approved of. 
 
 Originally established by Esquirol, and always of more importance forensi- 
 callv than pathologically, this doctrine, even in the land of its birth, has fallen 
 into a state of complete neglect. Bariod (' Etudes critiques sur les Monomanies,' 
 Paris, 1852), Morel, Falret (' Archives Gen.,' 1854, Aout), and in part also Brierre 
 and Delasiauve, have declared themselves generally against it; more recently, 
 however, the latter has candidly modified his views ('Des Pseudomonomanies, 
 ou Folies partielles diffuses,' Paris, 1859). Scarcely any French psychologist now 
 maintains it in its complete original sense. The discussion m the Societe Medicr>- 
 
THE ELEMENTARY DISORDERS IN MENTAL DISEASE. 53 
 
 psychologique may be consulted on this subject: it, however does not offer much 
 real information. 
 
 The partial delirium, the government by a single delusion which becomes the 
 centre of all thought, bears many analogies to the exclusive dominion of some 
 particular class of ideas in health, or to the tenacious attachment to a favorite 
 theory which to the subject of it is an element of his very existence, or to the 
 domination of certain passions, as love, jealousy, pride, desire for pleasure, 
 avarice, etc. These, in their higher grades, when they expel everything else 
 from the mind, are equally destructive to the mental life, and many even in their 
 expression, as in external distraction resulting from internal concentration, 
 affectation, pleasure in outward pomp, present numerous resemblances to the 
 corresponding forms of insanity. 
 
 (\ Anomalies of the Will. 
 
 § 46. Volition also presents in the insane many serious deviations 
 from ordinary states of health, as well in those internal spheres where 
 distinct perception is transformed into conscious effort as in those where 
 indistinct, though not on that account less forcible, effort (impulse) is 
 excited through sensitive impressions and obscure emotions. 
 
 In the first place stand opposed as extremes a total absence of volition 
 and with an increased, even unlimited, power of will. Weakness of will 
 may proceed from inability to form conclusions, arising from sluggish- 
 ness of perception or the want of an /sufficiently powerful to determine 
 volition from an undefined perception, or it may depend on the influence 
 of deficient reflex action on the perceptions. These states manifest them- 
 selves in a hopeless apathy, or in extreme hesitation, irresolution, incapa- 
 city to call up the accustomed impulses of the will, for example, to 
 ordinary employments, and are very frequent in the first, melancholic, 
 stages of insanity. On the other hand, absence of volition (in demen- 
 tia) originates from the absence of clear perceptions in general ; with 
 loss of thought, volition also ceases. 
 
 Increase of will takes the form of inordinate desire, a thirst for action, 
 a passion for forming plans, attempts to realize all thought in effort, 
 ruling peculiarity, powerful desire towards certain objects similar to the 
 strong directions of the will consequent on the passions. It shows itself 
 either as the frequent result of a weakened will, or it is really founded upon 
 a feeling of increased bodily and mental power, very great vigor, and 
 morbidly increased feeling of self. The last frequently appears in the 
 form of so-called monomania. 
 
 In general, however, the morbid emotions bring along with them their 
 corresponding states of effort, and these are the more clear and distinct, 
 the morbid volitions are more special, in proportion to the distinctiveness 
 with which the insane perceptions have been formed out of emotions or 
 hallucinations. 
 
 As the reflex activity of the spinal cord may be morbidly excited Ijy 
 means of certain influences (as strychnia), or on the contrary diminished, 
 it is the same with the brain. An example of general diminution of the 
 cerebral reflex activity which is found in various acute diseases (very 
 often in typhus), and in nearly the same form in many melancholic and 
 demented states, and in the so-called ecstasies, is presented to us in the 
 condition called stupor. Of partial diminutions there are numerous 
 examples, but at present they are difficult to define and to point out. 
 The clearest cases of increased reflex action are to be found in many con- 
 ditions of excitement. It is possible that such increase may depend on 
 a state of the brain in which the diffusion of the impression (to another 
 
54 THE ifiLEMENTARY DISOKDERS IN MENTAL DI&EASE. 
 
 place) is hindered or prevented. In the spinal cord we see that when 
 the transmission of the central apparatus is interrupted by a transverse 
 section, the reflex acts become stronger in the i)art below the point of 
 section. 
 
 Absence of will {ahulie) is discussed by Leubuscher in the ' Zeitschrift 
 fiir Psychiatric,' iv., 1847, p. 562. 
 
 § 47. Of all the morbid desires, the violent impulse to muscular 
 activity, to bodily movement, is particularly to be noticed, as it is seen, 
 especially in states of mania, as a constant necessity to restless motion 
 hither and thither, beating about, screaming, etc., a state which fre- 
 quently involves the injury and destruction of what is within reach of 
 the patient, without his having any definite purpose in doing so. The 
 patient seeks and finds relief from his inward pressure and the burden of 
 his feelings by throwing them outwards (§ 25) ; those states in which 
 violent feelings of anxiety or certain shocking ideas urge the patients to 
 take to the commission of certain definite misdeeds come under the same 
 category. This impulse towards a definite end, towards some decision 
 of his painful condition, may become so violent as to induce the patient 
 to the perpetration of deeds which in other states he would resolutely 
 shun, owing to the feeling that thus alone can deliverance and rest be 
 found. Therefore, if we closely examine, as we ought, according to their 
 motives, the several known cases in which the insane have manifested 
 their disease by dangerous and lawless acts (murder, suicide, incendiar- 
 ism, robbery), we will thereby discover the great differences that exist 
 between their respective fundamental causes. We immediately feel how 
 unsatisfactory it is to arrange such cases according to the nature of the 
 acts committed, or according to a special impulse to murder, incendiarism, 
 suicide, etc., or to consider them as "pure diseases of the will" (mono- 
 mania in the sense of lesion of one of the faculties of the mind, of the will), 
 and that it is necessary to judge of them individually according to the fun- 
 damental morbid states of the mind from which they proceed. Therefore, 
 the several impulses of this kind recur as motives sometimes melancholic, 
 sometimes maniacal, sometimes partially demented, and we shall have 
 again to refer to them in the special consideration of these forms of insan- 
 ity. 
 
 In such tendencies to devise mischief, to tear the clothing, to destroy the 
 furniture, to conceal things of value, to steal, etc., as also in many other strange 
 actions of a harmless nature (as always undressing), the patients are sometimes 
 prompted only by a general necessity to destruction, in order to free themselves 
 of their ill-humor, to vent their rage, sometimes by distinct motives, and only in 
 the most rare cases should these acts be considered as purely automatic. Either 
 hallucinations enjoin them to such acts or the effort by a violent daring deed to 
 procure rest from internal anxiety or delirious conceptions proper. Zeller 
 (' Bemerkungen zu Guislain,' p. 490) records a number of such cases, with the 
 motives given by the patients. "One of our patients beat out all the windows 
 within his reach with the greatest quietness and composure to procure glass for 
 the filling up of mouse-holes, another that he might be able to coin crown thalers 
 to his heart's desire. Another deliberately tore all his shirts to pieces in order to 
 collect lint for the military hospitals; another took down the stove to light his 
 pipe, and then leisurely replaced it. Another broke the chairs into pieces, and, 
 in answer to my question why he acted so foolishly, he replied while quietly pro- 
 ceeding with his work, and witliout looking up, ' Philosophy must conquer 
 aesthetics.' " Nevertheless, in such cases we must not place too implicit confi- 
 dence in the patient's account of his motives; they are often extremely reserved 
 in giving their real motives; and many such cases remind ixs of the scene in 
 Shakespeare where Falstaff when in a dilemma always answered " in starched 
 linen" {in Steijieinen)'i? 
 
THE ELEMENTARV DIS0KDEB8 IN MENTAL DISEASE. 55 
 
 Whether, and to what extent, certain directions of the will and im- 
 pulses in the insane, particularly such as lead to criminal acts, are 
 irresistible, is a question which can scarcely ever be answered with 
 certainty. Few of the acts of the insane have the character of forced, 
 purely automatic movements; in mania also, according to the testimony 
 of individuals who have recovered, many of the wild desires could often 
 be restrained; the criminal deeds of the insane are not generally instinc- 
 tive. The loss of free will (or, if we choose, irresponsibility), therefore, 
 seldom depends on the fact of inability to have abstained from the act 
 committed, or that the normal conditions of volition have been completely 
 suspended. The causes of this loss of free will chiefly depend on quite a 
 different cause, they depend on violent excitation of the emotions, or on 
 incoherence, on false reasoning proceeding from delirious conceptions, 
 hallucinations, etc., and on the circumstances mentioned in § 27. 
 
 In the criminal acts of the insane tlie circumstances worthy of minute investi- 
 gation are whether the patient manifested a similar tendency (as to steal) even 
 in health, which is only now showing itself when the power of the reflection is 
 suspended, or whether the desire first arose with the insanity, and disappeared 
 on recovery; whether it really proceeded from morbid emotions and insane 
 ideas. See Jakobi, 'On Cleptomania,' in Jacobi and Nasse's ' Zeitschrif t,' 1837, 
 1 Heft, p. 179; Hoffmann, "On Cleptomania," ' Giinsburg Zeitschr.,' 1, p. 299. 
 
 To the manifestation of such desire, to the free disclosure of tendencies which 
 are generally concealed, to certain morbid impulses may be referred much of the 
 peculiarity which distinguishes the conduct of the insane. Each has its analogy 
 in healthy life, partly in those peculiar habits and caprices which are occasionally 
 observed as curious appendages to great and energetic intellects (which form 
 the materials of many anecdotes relating to learned men), partly in the directions 
 of the will and the modes of action of the passions and emotions. These in detail 
 afford materials for numerous comparisons, and we find in the poets who dwell 
 much on the emotional states numerous analogies by way of example. Thus, 
 when the melancholic has the impulse to leave his home, and roam in the open 
 air because it appears too confined for him, and because he expects alleviation 
 from his state of internal pain by outward disquiet and change, so the same 
 appears in cases of real mental pain, where the sufferer spends his life in the open 
 air, or even in distant lands, in the world, in order to recover internal calm by 
 outward disquiet and restlessness. Eichendorff has well expressed this disposi- 
 tion in one of his well-known songs. 
 
 Section II. — The Elementary Disorders of 8ensatio7i. 
 
 § 48. Previous to the consideration of anomalies of sensation — so 
 important in insanity — we shall consider the various modes in which 
 the general feeling of illness is manifested. In the majority of cases of 
 mental disease this feeling of illness is altogether absent; generally, there- 
 fore, the patients do not feel ill, and often protest against medical treat- 
 ment. Indeed, in not a few cases of serious mental disease there is, 
 instead of a feeling of illness, a sense of extreme well-being, of increased 
 bodily power and vigor. Such patients (maniacs) are often angry and 
 irritated when any doubt is expressed as to their perfect health, and 
 voluntarily refer to their excellent appetite — morbidly increased — to prove 
 it. This absence of the feeling of illness is observed in a number of brain 
 affections, sometimes after injuries of the head, and very commonly in 
 -acute meningitis and the affections of the brain in typhus fever. At the 
 height of the disease, when interrogated, the patient generally answers 
 that he is quite well, occasionally even he assures us that we are much 
 deceived by considering him as ill, while, when the danger is past and 
 the symptoms alleviated, there enters a strong feeling of illness, of deei) 
 
56 THE ELEMENTARY DISORDERS IN MENTAL DISEASE. 
 
 depression and fatigue. This feeling, then, is generally present in con- 
 valescence from these forms of insanity. 
 
 There are, on the other hand, other states of insanity where the feel- 
 ing of illness is not only present, but seems, in relation to the objective 
 symptoms, to be immediately increased. The patient is thereby deceived 
 as to the objective facts of his state of bodily feeling and indulges in false 
 ideas of serious special disease. There is thus formed a disproportionately 
 strong or persistent feeling of illness, a fundamental element of the hyi^o- 
 chondriacal state, and it is characteristic of these that they generally are 
 not confined to general impressions of bodily discomfort, but, as the atten- 
 tion is directed to the individual organs, disagreeable feelings are awakened 
 in each of them. The same condition of the nervous centres is found 
 in an acute manner in the early stages of most severe fevers, but then 
 there is no time for the attention to become fixed, and the feeling of 
 illness is soon justified by severe objective symptoms. 
 
 § 49. There are, besides, numerous other anomalies of the general sen- 
 sibility. In the first place, those extensive modifications of the sensation 
 of self which ordinarily accompany serious aflEection of the mind (§ 43], 
 and which establish the idea of transformation of the person. The 
 patients renounce their former personality, and consider themselves 
 sometimes animals (wolves, oxen, etc.), sometimes historical individuals 
 (N^apoleon). Sometimes the whole body is considered dead, or as not 
 really theirs, or as composed entirely of inanimate substances, as wood, 
 glass, wax, butter, etc. At other times the body is merely felt to be ex- 
 traordinarily heavy, or to have acquired a very great circumference, etc. 
 
 On the other hand, these anomalies of the general sensation are some- 
 times local, confined to certain parts of the organism. The patient 
 supposes that certain of his members are wanting, or that they are not 
 connected to his body in the way they used to be. For example, ke 
 thinks that he no longer has a head, that one of his arms or legs is petri- 
 fied or made of glass. Or he feels as if a certain part were uncommonly 
 large, and the nose in particular is, in many cases, the object of this 
 illusion. 
 
 There are, besides, observed in the insane, as more transient states, 
 sensations familiar to many healthy persons in dreaming, of flying high 
 in the air, of being precipitated from a height, or of general giddiness. 
 Sometimes a veritable aura is felt before an attack, as it is before an epi- 
 leptic seizure. 
 
 The seat and the more immediate cause of these anomalies of the gen- 
 eral sensation are difficult to understand. In several cases, indeed, they 
 depend — for example, the feeling of absence of a part of the body — on 
 evident ana3sthesia, or more frequently an analgesia of the organ. At 
 other times, however, the peripheral sensibility of the cutaneous surface^ 
 and perhaps even the sensibility to pain, is fully maintained, and obscure 
 modificatians of the muscular sensibility, Avhich likewise appear to play 
 an important part in ordinary dreaming, may be the original disorder 
 which the explanatory reflection lays hold of to form delirious concep- 
 tions. The transformation into animals appears to be much more related 
 to the mind in its origin, and the basis of this false idea may depend on 
 the appearance and iniiuence of certain instincts peculiar to certain 
 species of animals, as the cruelty and ferocity of the wolf. But here also 
 a marked deviation from the normal general sensation is always necessary 
 to the full development of the ideal metamorphosis. 
 
 Leuret (' Fragm. Psychol, sur la Folie,' Paris, 1834, p. 101) has made an 
 
THE ELEMENTARY DISORDERS IN MENTAL DISEASE. 57 
 
 interesting collection of several old examples of the so-called Lycauthropia, and 
 several cases of more recent date of insane persons wandering in the woods and 
 carrying off, and even kilhng, children, frona a fierce instinct to murder. Wier 
 narrates an example of a man from Padua who, in the year 1541, believed him- 
 self transformed into a wolf, and, on the open plain, attacked and slaughtered 
 those whom he met. " I am really a wolf." said he, " and the reason why my 
 skin is not hairy like that of a wolf is that it is reversed and the hairs are inside." 
 To convince himself of this he made incisions in his body, and cut his legs and 
 arms, so that he died of the wounds. 
 
 Examples of insane persons considering themselves dead, and not recognizing 
 tlieir body as their own, are numerous. Esquirol mentions that, in a woman 
 who believed that the devil had carried away her body, the surface of the skin 
 was completely insensible. This was also the case in the following example from 
 Foville. A soldier considered that he had been dead since the battle of Auster- 
 litz, in which he was severely wounded. When any one asked how he was he 
 answered, " You ask how father Lambert is, but father Lambert is no more, he 
 was carried off by a cannon ball at Austerlitz. That which you now see is not 
 him, but merely a clumsy machine made to resemble him; pray make another." 
 When he spoke of himself he never said 7, but always it. The skin is insensible, 
 and, several times, attacks of various kinds of immobility and insensibility have 
 occurred. 
 
 A young epileptic, who had also numerous hallucinations of smell and of 
 taste, sometimes felt his whole body of such an extraordinary weight that lie 
 could scarcely stand upright, at other times of such lightness that it seemed as if 
 he rose from the floor and flew; besides, his body and his limbs seemed to him 
 so enormously enlarged that it was impossible for him to pass through a door.' 
 
 To such states there are also analogues in acute diseases. A medical friend 
 has frequently told me that he, in even slight febrile affections, has always the 
 sensation of remarkable enlargement of the limbs. 
 
 A convalescent from fever believed that he was really two persons, one of 
 whom lay in bed while the other walked about. Although he had little or no 
 appetite,"yet he ate a great deal, because he had to nourish two bodies (Leuret, 
 loc. cit., p. 95). 
 
 Patients with paralysis of sensation of one half of the body have sometimes 
 the idea that another person, or even a corpse, lies beside them in bed (Bouilland, 
 ' Traite de FEucephalite,' Paris, 1825, p. 6-1). Such false opinions belong to the so- 
 called illusions, soon to be considered; further examples will be given in § 61. 
 
 The sensation of flying in dreams appears to be due to acceleration of the 
 inspiratory movements, and that of being drawn from a height to their becoming 
 slower (Gratiolet); corresponding images are associated with these. 
 
 All considerable alterations of the common sensation are always amongst the 
 most important elements of mental disease. When this general basis of the 
 bodily sensations is falsified, corresponding false ideas are formed with extreme 
 facility. These anomalies are always to be specially investigated, as they 
 occasionally furnish indications for therapeutical treatment. 
 
 § 50. The angesthesias of the insane have to be considered more in 
 detail. Diminution or complete suppression of tlie sensibility of the 
 skin to impressions of temperature and of pain is by no means frequent, 
 still less is it general in insanity. We find, on the contrary, in some 
 instances an excess of sensibility to pain (Esquirol relates such a case), 
 and it is remarked that in asylums in winter the patients, with very few 
 exceptions, constantly seek the warmth. Nevertheless, cases of tran- 
 sient and persistent cutaneous anaesthesia (as already shown in the forego- 
 ing §), and of analgesia, are sometimes seen, particularly in states of 
 melancholia and dementia, and confined to more local limits, is also fre- 
 quent in hysteria. A careful investigation of the cutaneous sensibility 
 in the various parts of the body should always be made. 
 
 Rochoux (Sitting of the Academic deMedecine, 22dDec., 1840) communicated 
 a case of accident which occurred through want of sensation in the patient. A 
 patient in Bicetre, while no one was in the room, laid his head on the red-hot iron 
 
 1 Bottex, ' Essay on Hallucinations,' Lyons, 1856, pp. 58-61. 
 
58 THE ELEMENTARY DISORDERS IN MENTAL DISEASE. 
 
 of the Stove; and put his arm into the midst of the fire. The strong smell first 
 drew the people near; the patient was quite unconcerned and throughout gave 
 no sign of pain, though the arm was burned to the bone. 
 
 In the 'Zeitschrift fiir Psychiatrie,' xi.. 1854, p. 717, there is an example of 
 voluntary self-burning by a melancholic patient. He was quite happy, although 
 legs, thigh, and nates were burned, so that even the bones were charred. A 
 patient in Bedlam, mentioned by Morison, laid the back of his head upon the 
 fire till the greater part of the cerebral coverings were burned; he, however, 
 recovered. Michea ('Gaz. Hebdom.,' 1856) cites a number of cases in which 
 melancholies sufl:ered mutilation without pain (analgesia), and it is interesting 
 that this state often exists also in Delirium traumaticum (nervosum), so that the 
 patients tear off the bandages, and use most regardlessly the broken limbs (Dupuy- 
 tren, Klose). 
 
 Snell (' Zeitschrift fiir Psychiatric,' x., 1853, p. 213), in 180 patients, found the 
 skin quite angesthetic in 18 (?), and in there was analgesia; the anaesthesia in 
 states of excitation and depression was present always in cases presenting little 
 hope of recovery. A very remarkable case is communicated by Renaudin 
 (Moreau, 'Psychologic Morb.,' p. 313), of a boy who had hitherto conducted him- 
 self perfectly well, and all at once exhibited the worst desires and most reprehen- 
 sive behavior. He was not entirely insane, but the whole cutaneous surface 
 became sensationless. This state was intermittent, and when it went off the patient 
 became again quite orderly and obedient. Simultaneously with the anaesthesia 
 the worst desires, even desire to murder, returned. In general paralysis, too, 
 there is sometimes present an evident diminution of the cutaneous sensibility. 
 Diminution of the sense of smell may be assumed in those patients who would 
 amuse themselves with their excrements. All these anaesthesias must have a 
 central basis. 
 
 We sometimes hear the insane, especially melancholies, complain of 
 ■quite a different kind of anaesthesia, which is more related to the intellect- 
 ual, most inward, act in sensation. "I see, I hear, I feel," say they, 
 "but the subject does not reach me; I cannot receive the sensation; it 
 seems to me as if there were a wall between me and the external world," 
 etc. In such patients there is sometimes a diminution of the peripheral 
 cutaneous sensibility, so that the subjects appear to them somewhat 
 indistinct, as if rough, woolly; but this, when constantly present, does 
 not explain the phenomenon. These modifications in the perception of 
 sensations rather recall to us the changes which, in general, our mind 
 undergoes in regard to the sensitive world, partly in the various ages of 
 life, partly in the emotional and impassioned states. In the years of 
 childhood we feel the world of sensitive appearances nearer to us, we live 
 immediately with and in it, an intimate bond of a living dependence 
 unites us to it. As the reflection becomes matured this bond becomes 
 relaxed, the interest cools, things appear otherwise, and we become 
 more strange to the outer world, although at the same time we know it 
 better. Joy and the expansive emotions generally draw us again to 
 the external world ; everything creates anew a lively impression, and 
 under the ready influence of sensuous impressions' joy exercises an im- 
 mediate and reinvigorating influence. The opposite is the case with 
 the painful emotions ; the external world, animate or inanimate, ap- 
 pears to have become suddenly cold and strange ; it seems also as if 
 the objects of our affection no longer belonged to us, and, as nothing 
 can now excite in us a lively impression, we become estranged to ex- 
 ternal objects, and more and more concentrated in ourselves (isolation). 
 An analogy may be seen between these latter states and the complaints 
 of the melancholies, as their intensity, their duration, and their want of 
 
 ' •• "Warum doch glanzt um uns das All 't 
 Jeglichem Staub sein Herz erschlossen !" 
 
THE ELEMENT AKV DISORDEKS IN MENTAL DISEASE. 59 
 
 mentiil motive, urge the patient openly to complain of such changes in 
 his power of receiving impressions. 
 
 Further examples of these conditions will be found in the chapter on melan- 
 choly. In another point of view they are also analogous to the faintness of sen- 
 soi'ial impression during sleep. 
 
 § 51. In Ecstasy, together with much diminished, or almost, or com- 
 pletely suppressed, external sensations, there exists a strong internal con- 
 centration on certain feelings, circles of ideas, images, etc., with great 
 elevation and tension of the entire mental activity. This state is mani- 
 fested by a very highly emotional expression of the countenance, in which 
 there is depicted astonishment, rapture, pain, according to the nature of 
 the emotions. It is generally accompanied by complete loss of speech, 
 immobility of the limbs, and often by a cataleptic state of the muscles. 
 The patients appear to be quite absorbed in their emotions, they generally 
 refuse nourishment, and particularly does volition appear to be entirely 
 prostrate. These states are not very frequent; they sometimes come on 
 primarily after a violent shock, in hysterical insanity, in onanists, also in 
 epileptics, and, now and then, in alternation with violent attacks of mania. 
 Fasting, causes of weakness of any kind, want of sleep, appear to favor 
 their origin. In the religious ecstasies of bygone times, of which we 
 have reliable information, these causes appear also to have played an 
 important part. 
 
 The diminished external sensibility combined with immobility of the body, 
 sometimes even with abolition of hearing, cause this condition closely to resemble 
 sleep; nevertheless, it is truly a state of wakefulness, with complete concentra- 
 tion on certain powerful domineering circles of ideas or sensations. 
 
 § 52. But the most general and most important sensitive anomalies in 
 states of mental disease are the hallucinations and illusions. By halluci- 
 nations Ave understand subjective sensorial images, which, however, are 
 projected outwards, and thereby become, apparently, objects and reali- 
 ties. By an illusion is meant the false interpretation of an external 
 object. It is an hallucination when I see human forms while in reality 
 no man is near, or hear a voice which has not spoken; it is an illusion 
 when I take a bright cloud in the heavens for a fiery chariot, or when 
 I believe that I see an old friend when a stranger walks into the room. 
 In hallucination there is no external objects, it is a false sensation; an 
 illusion is a false construction, a transformation of a j)eripheral sensa- 
 tion. 
 
 The motive to this sensation does not necessarily require to exist in 
 the external world, it may also be within the special organism, therefore, 
 the false interpretations to which peripheral pains (neuralgic, rheumatic) 
 are subject are considered illusions, as the idea of being pregnant, which 
 proceeds from unusual abdominal sensations, or that case mentioned by 
 Esquirol, in which a patient had pain in the knee, and kept striking it 
 with the fist, calling out, '"Wait, you rascal, you shall not escape me ! " 
 
 The distinction between hallucinations and illusions was made by Esquirol. 
 It ought to be maintained, although it cannot be adhered to with perfect exact- 
 ness. In the senses of taste and cutaneous sensation especially the distinction is 
 often impossible. In the other senses, too, the view of illusions as false judg- 
 ments is, in many cases, too limited. They are, in the majority of cases, actual 
 transformations of impressions transmitted by the organs of sense, wlien, for 
 example, a portrait on the wall appears to roll its eyes and walk out of the frame, 
 or when the visage of an old woman appears to be young and beautiful. Here 
 internal images are substituted for real perceptions; it is a mixture of halluci- 
 
60 THE ELEMENTARY DISORDERS IN MENTAL DISEASE. 
 
 nation and real sensorial perception; the latter becomes thereby transformed 
 in the sense of the dominant ideas and frames of mind. We can also express 
 the relation between them so; the hallucinations are either quite complete 
 when they provide the entire object, or they are incomplete (illusions) when 
 to a real external object other qualities wliich it does not possess are attributed 
 (Gratiolet). 
 
 The literature of sensorial deUrium is very rich. Esquirol, several articles in 
 ' Dictionnaire des Sciences Medicales,' and ' Traite de I'Alienation.' Bayle, 
 " Mem. sur les Hallucinations," ' Revue Medic.,' January, 1835. Miiller, ' Ueber 
 phantastische Gesichtserscheinungen,' Coblenz, 1826. Lelut, " De la Folie Sen- 
 soriale," ' Gazette Med.,' 1833. Bird, " Thatsachliche Bemerkungen iiber Sinnes- 
 tituschungen," ' Friedreich's Magazin,' Heft 17, 1831. Dietz, "Ueber die Quelle 
 der Sinnestauschungen," ibid., Heft 111 1832. Leuret, 'Fragments psycholo- 
 giques,' Paris, 1834. Bottex, ' Sur les Hallucinations,' Lyon, 1836. Marc, ' Geis- 
 teskrankheiten,' ti-anslated by Ideler, i., 1843. Hagen, 'Die Sinnestauschungen,' 
 Leipzig, 1837. Baillarger, in ' Arch. Gener.,' 1842-43. Patterson, 'Anal. Med. 
 Psycholog.,' Mars, 1844. Likewise the writings of Arnold, Reil, Haslan, Hoff- 
 bauer, Neumann, Friedreicli, Jessen, Archambault in Elhs's 'Traite,' p. 180, seqq., 
 etc., Sinogowitz, 'Die Geistesstorungen,' Berlin, 1843. Michea, 'Du Delire des 
 Sensations,' Paris, 1846. Baillarger, " des Hallucinations," ' Mem. de I'Acad. de 
 Med., tomexii., Paris, 1846. Brierre, 'Des Hallucinations,' Paris, 1847 (2d edi- 
 tion, 1853). Leubuscher, ' Ueber die Entstehung der Sinnestauschungen,' 
 Berlin, 1852. 
 
 § 53. Hallucinations may occur in all the senses — in the senses of 
 sight, hearing, smell, taste, and cutaneous sensibility. In individuals 
 sometimes this, sometimes that, frequently several, occasionally all, these 
 various sensorial functions are affected at the same time ; the hallucina- 
 tions are real sensations, not mere fancy. The patient really, and not 
 merely thinks that he hears, sees, and smells ; and should we meet the 
 sensorial delirium with arguments of reason, we generally receive answers 
 as Leuret did from one of his patients ('' Fragments,' p. 203) : — " I hear 
 voices because I hear them — how they originate I know not, but to me they 
 are as distinct as your own voice ; if I admit the reality of your words, 
 you must also allow me to believe in the reality of those voices, as to me 
 both are equally appreciable." Thus, in the opinion of the subject of 
 the hallucination his subjective sensitive perceptions have commonly the 
 same reality as the objective perceptions presented by the external world, 
 and to this very circumstance is in a great measure due the importance 
 and danger of the phenomena. We are accustomed to trust our senses, 
 to consider that as most true which we ourselves see or touch ; he in 
 whom false sensorial j^erceptions are substituted for those which are true, 
 and the material of his ideas and their combination thereby falsified, 
 enters a new sphere of appearances and of falsehood. He cannot distin- 
 guish them from the objective reality, according to which he regulates 
 his thoughts and acts, and in general it cannot be forced on him by the 
 opinion of a stranger ; he is compelled to follow the decej^tion, because 
 to him it has the force of sensorial conviction; and not only are the most 
 crazy and stupid ideas awakened and maintained in him, but very often 
 the most dangerous misdeeds result from the hallucinations. 
 
 The subject of hallucinations may,. at any moment, be incited by voices or 
 visions to inflict violence on himself or others; for example, to murder in conse- 
 quence of having had a command from God to deeds of vengeance for abusive 
 language which he has heard, etc. The majority also of the crimes committed 
 by the insane depend on hallucinations, a circumstance which, from the great 
 frequency of hallucinations, is not to be wondered at. According to Esquirol,. 
 80 in every 100 patients have hallucinations; Falrrt (' Leg. Clin, de Med. Ment.,' 
 Paris, 1854, page 151) gives, of course, a much lower proportion — about a third 
 of the number of the patients. 
 
THE ELEMENTARY DISORDERS IN MENTAL DISEASE. 61 
 
 § 54. Subjective sensorial function is in itself not extraordinary; 
 sensation originating through internal irritation, without external cause, 
 is rather an everyday occurrence ; our inner world of sense is ever active ; 
 indeed, all, even abstract, thouglit is accompanied by an inward hearing 
 and seeing as an evident essential element of normal mental life. But 
 the sensations which thus originate are generally very weak, and this is 
 wh'^-^ distinguishes them from the external perceptions ; indeed, during 
 sleep, when the sensations originating internally cannot be compared 
 with jieripheral impressions, they often assume for us the strength and 
 the character of external sensations, also during waking they may by 
 degrees become stronger and more active, and at last resemble reality. 
 These constitute the pathological states of irritation t'^ the nervous 
 system. 
 
 Physiology shows that the nerves of special sense react towards all 
 irritation according to their own inherent energy. The compressed or 
 ■congested retina gives light, the irritated auditory nerve sensations of 
 sound, etc. Shall we, therefore, consider hallucinations as tlie simple 
 results of irritation of the peripheral exj^ansions of the corresponding 
 nerve? This is impossible, in the first place, and principally because 
 hallucinations c?.n exist where there is suspension of the perii^heral 
 sensorial function ;' and, secondly, because, according to all known fact, 
 by direct irritation of these nerves — for example, tlie retina — there can 
 be produced flashes of liglit, globes of fire, colored images, etc., but no 
 definite complex forms (mei^.. houses, trees, etc.); in the ear a humming 
 noise, high or low sounds, but no formed words or tunes. For the latter, 
 something more is needed, namely, the co-operation of the perception, 
 from which alone such forms, retained from former impressions or pro- 
 duced anew, can come. This jDrojection of the perception, by which the 
 corresponding sensorial images enter our mind, this penetration of the 
 internal sensorial function into the perception by which the latter receives 
 the appearance of the sensation, we have learned (§ 18) to consider as 
 the function of the imagination; but while, as a rule, these acts are 
 such that in the field of vision only ideal outlines and forms arise, conse- 
 quently only weakened faded images arc conserved, so here in pass- 
 ing through numerous transitions of strength and vivacity, the percej)- 
 tion awakens strong sensorial function, so that only the things imagined 
 
 ' The observations of Esquirol upon this point deserve to be fully commu- 
 nicated. " I once had vinder my care an old merchant, who, after a very active 
 life, was seized with black cataract in his forty -fourth year. Some years after- 
 wards he became insane r he was very agitated, spoke loudly with persons whom 
 he thought he saw and heai'd. He saw the most wonderful things, and was 
 often quite enchanted with his visions. There was in Salpetriere a Jewess, aged 
 thirty-eight, who was blind and a maniac. Nevertheless, she saw the strangest 
 things. She died suddenly. I found on examination of the body the optic nerves 
 atrophied in their ivhole course. Certainly, in this case, transmission of impressions 
 was impossible. It is the same with the deaf who think they hear persons speak. 
 We have at present in Salpetriere two women absolutely deaf, who have no other 
 false ideas than those of hearing various persons, with whom they dispute night 
 and day; they often become even furious." (Esquirol, ' Maladies Mentales,' vol. 
 i., page 195). More recent cases of hallucinations of sight with atrophy and de- 
 generation of the optic nerve have been published by Johnson (' Med.-Chirurg. 
 Reviev/,' 1836); Romberg, ' Nervenkrankheiten,' 3d edition, p. 138); Bergman 
 (Gottinger ' Naturforscherversammlung,' 1854; ' Psychiatr. Corresp.-bl.,' i., No. 
 8, Beil); Leubuscher, 1. c, p. 33. Calmeil and Foville have also observed such 
 cases. Tlie report of the Vienna Asylum ("Wien, 1858, p. 46) contains two cases 
 where, in blindness of one eye through atrophy of the globe, the same hallucina- 
 tions affected the diseased as the healthy eye. 
 
62 THE ELEMENTAKY DISORDERS IN MENTAL DISEASE. 
 
 are really clear and colored, articulate and melodious. The seat of all 
 these acts, the seat of the imagination, is not the retina nor the ramifi- 
 cations of the auditory nerve ; it is within the brain, and doubtless it is 
 the central expansion of the nerves of sense ; therefore, in accordance 
 with important observations, Ave must consider hallucinations as intra- 
 cerebral phenomena. 
 
 But this does not exhaust the question; there are many other facts — 
 all specially evident in hallucinations of sight — which indicate that the 
 peripheral expansions of the nerves of sense, when intact, are concerned 
 in sensorial delirium; on the one hand, morbid action in the eye, involv- 
 ing the retina, appears to originate the production of hallucinations (or 
 rather illusions, Avliich in this case, however, cannot be distinctly sepa- 
 rated from hallucinations). This is especially seen in cases where, with 
 opacity of the transparent media of the eye, hallucinations of sight exist.' 
 and where it would appear that the imagination seizes upon those indis- 
 tinct, dissolving, cloudy images, which the retina receives as material 
 belonging to it to transform them into imaginary combinations. On the 
 other hand, however, those cases, by no means rare, where hallucinations 
 of sight can be made to disappear by covering the eyes, show that the 
 intact retina can take a certain part in the production of these phenom- 
 ena; sometimes even where the axes of vision are not parallel, hallucina- 
 tions are seen double — at all events, there are cases where hallucinations 
 exist only on one side. Michea mentions such cases ; I myself have 
 observed a case where hallucinations of hearing continued during the 
 whole duration of the insanity, and were only of the left side. In the 
 cases communicated by Kieser ('Zeitschrift fiir Psychiatric,' x., 1853), of 
 hallucinations of hearing of many years' standing, the majority were of 
 the right side; sometimes opposite phantasms of different senses, such as 
 hallucinations of sight of the right side, with hallucinations of hearing 
 of the left side, are seen. 
 
 Cases where the hallucinations of sight ceased on covering the eyes are known 
 in considerable number. A young man saw ai-ound him ail the personages of 
 the court; he threw himself at the feet of that one whom he considered the king; 
 I allowed the eyes to be bound for two days, and his delirium ceased. When the 
 bandages were taken away it commenced anew. (Esquirol.) Reil (' Rhapsodies ') 
 relates, "A young lady who saw apparitions and monsters fell into delirium 
 with convulsions. Her maid, in order to maintain her in the upright position, 
 laid Iier hand upon the eyes of the patient, who at once called out, ' I 
 am healed! ' This was repeated next day by the physician with the same result." 
 (Esquirol.) 
 
 " D — , set. 75, mentally healthy, came home one day terrified by a thousand 
 visions which followed him. Wherever he looked, the objects changed them- 
 selves into frightful images; sometimes monstrous spiders which grasped at him 
 in order to suck his blood, sometimes soldiers with halberds, etc. Venesection 
 was performed on the foot; still the hallucinations remained, and he could not 
 sleep. A bandage was laid over the eyes, and they at once ceased, and returned 
 as soon as the bandage was removed until the patient continued its use without 
 interruption for a night and part of a day. He now saw the phantasms only at 
 long intervals, and after a few days they totally disappeared. Since then, the 
 man has remained healthy." (' Bulletin de Therapeutique,' 1842.) The visions of 
 Nicolai also disappeared on shutting the eyes.''' 
 
 ' See the well-known case related by Bonnet (Essai Analytic sur I'Ame,' chap. 
 23), of a person who had both eyes operated on for cataract, and could only dis- 
 tinguish objects with the right eye. He had the most lively hallucinations of 
 sight without believing In their reality. In the case of a patient whom I saw in 
 Tiibingen there was cataract in both eyes, and his insanity was characterized 
 almost entirely by the most manifold hallucinations of sight. 
 
 '■^ See also ' Leuret,' loc. cit., p. 147. 
 
 1 
 
THE ELEMENTARY BISORDEKS IN MENTAL DISEASE. 63 
 
 These cases, which are the opposite of hallucinations in the blind, may be 
 regarded as illusions; whereby, however, our physiological knowledge of them is 
 not much advanced. Thej- may be viewed as a centrally provoked simultaneous 
 hallucination of the retina surface according to a scheme given by the imagina- 
 tion; this view has, indeed, its difficulties, but it is also supported by the fact 
 that surrounding objects are often seen through the phantasms of sight as 
 through a veil. 
 
 That it is perceptions which give form and body to the sensorial functions is 
 especially shown by the circumstance that certain observei"s can voluntarily call 
 forth hallucinations, that is, that detinite and lively ideas, previously existing in 
 the state of consciousness, first excited the sensorial functions. An individual 
 who had hallucinations of hearing remarked that he could himself call forth the 
 words which the voices subsequently spoke, and this aided, him in recognizing 
 them as deceptions (Holland, ' Chapter on Mental Physiol.,' 2d ed., p. 52). The 
 communications of Sandras are also very remarkable (' Ann. Med. Psych.,' vii., 
 1855, p. 542) regarding special hallucinations in a disease where the special 
 thoughts and requirements were heard as voices. The voice answered to mental 
 questions of the patients as a third person, but always replied in the sense of his 
 wishes. Intelligent patients also often tell us that at tirst tliey are spoken to 
 ideally, "mentally;" it is not till a later period that the voices really become 
 audible. 
 
 Certain observers have questioned the idea of the imagination being the cause 
 of hallucinations, by calling attention to the difference which exists between 
 them and the simple fancies ( Leuret, Hagen). This objection fails, inasmuch as 
 we (§ 8) consider the phenomenon of the imagination as being one of the func- 
 tions of the internal sensorial appai'atus, but differing from the otliers in strength 
 (see Miiller, loc. cit.y i., 5). 
 
 Doubtless there is still a great difference between an hallucination and that 
 internal excitation of the imagination which, for example, the artist has in the 
 conception of his work of art; the hallucinations are considered as externally 
 real — they are in the eye, in the ear. It may be asked, is this difference there- 
 fore specific, or is it only an affair of degrees ? In the first place, there would 
 be in the hallucination the co-operation of a special act, which is wanting in the 
 so-called excitation of the imagination. I consider the assumption of simple 
 difference in degrees as the correct one. We see from the exact description of 
 their hallucinations, which the insane give us, that they may range from the 
 most faded and shadowy appearances even to the greatest sensuous vivacity, and 
 it is not so very unusual for artistic excitation of the imagination to proceed to 
 sensuous appearances, although they may be light and pale. 
 
 I have seen an interesting transformation of that obscure, pale, internal hal- 
 lucination, which accompanies perception in ordinary states into hallucinations 
 with real objective distinctness, in a patient who was extraordinarily rich in 
 visions, and delighted in them. He often spoke of them, saying that many of his 
 appearances existed only m outline, without color; others as obscure, cloudy 
 images; and others as lively colored images, fully corresponding to actual external 
 objects. 
 
 Lelut also (loc. cit.) very correctly calls hallucinations complete transforma- 
 tions of thought into external sensorial impressions; and the anwer is very 
 Bignificant which a melancholic gave to Esquirol, who spoke to him regarding 
 the falseness of his hallucinations of hearing. " During conversation, he said 
 tome, 'Do you think sometimes?' ' Without doubt,' said I. 'Very well; you 
 think quite quietly, and I — I think aloud.'" 
 
 An intelligent patient whom I have previously mentioned (a medical student), 
 who had throughout hallucinations of the left side during a violent attack of in- 
 sanity, had the impression that the voices did not come from the immediate 
 neighborhood; he had estimated them at a distance of several minutes. He also 
 made the remarkable declaration that he could by his belly exercise voluntarily 
 an influence on the hallucinations of hearing. On closer investigation, it was seen 
 that he meant the respiratory function of the abdominal muscles, and that it was by 
 means of the respiration that he exercised the influence. On holding the breath 
 the voices were often changed — appeared to come from a point nearer or more dis- 
 tant. We know that in expiration the cerebro-spinal fluid rises from the spinal 
 canal into the cavities of the brain and subarachnoid space (owing to the filling of 
 the numerous venous plexuses of the canal of the spinal marrow), and that it again 
 subsides during inspiration. 
 
64: THE ELEMENTARY DISORDERS IK MENTAL DISEASE. 
 
 § 55. The different behavior of an individnal in regard to his halhi- 
 cinations may depend, in part, on slight differences of a certain kind, in 
 the strength and clearness of the false perceptions, compared with 
 objective sensorial impressions. Far more inflnence, however, is ex- 
 erted in this respect by the state of tlie cerebral functions generally, in 
 so far as they permit a greater or less degree of reflection, and by the de- 
 gree of education and the former views of life of the patient. 
 
 Hallucinations are not entirely confined to states of mental disease. 
 It is well known that in dreams — to which we shall again refer — inebria- 
 tion, vertigo, and analogous states, phantasms of sight are produced. 
 But even exclusive of these states, hallucinations are not uncommon ir 
 persons not insane. The well-known case of Nicolai, the fact befort 
 quoted from Bonnet, several of the cases mentioned by Patterson, all re- 
 ligious visions, etc., are examples of this. Nothing would be more erro- 
 neous than to consider a man to be mentally diseased because he had 
 hallucinations. The most extended experience shows rather that such 
 phenomena occur in the lives of very distinguished and highly intellectual 
 men, of the most different dispositions and various casts of mind, but es- 
 pecially in those of warm and powerful imagination. Tasso, who in 
 presence of Manco carried on a long conversation with his protecting 
 spirit — Goethe's well-known (blue-gray) vision, and his ideal flowers with 
 their curious buds — Sir Walter vScott's apparition, in which his dead 
 friend Byron stood before him in the folds of a curtain— Jean Paul, who 
 saw the head of a little girl looking down from the window' — Benvenuto 
 Cellini's vision of the sun — may serve as an example from the life of 
 artists. Spinoza,'^ Pascal,' had hallucinations; Van Helmontsawhis own 
 soul in the form of a light Avith a human coutenance; Andral* tells tluit 
 he himself had an hallucination of sight, and Leuret that he has experi- 
 enced a phantasm of hearing.^ Indeed, judging from what we have 
 heard and observed on this sul)ject, hallucinations doubtless occur also in 
 men of very average minds, not as rare, but us frequently overlooked phe- 
 nomena.^ 
 
 The man who is mentally healthy either views such hallucinations 
 with calmness and consideration, because he recognizes them as origi- 
 nating subjectively (Nicolai and others), or he believes in their reality, 
 either because his reflection does not possess the premises necessary to 
 judge of these phenomena, because superstition, sluggishness of thought, 
 love of the marvellous, obscure and restrict their correct interpretation; 
 or because certain dispositions, passions, and emotions (fear, anger, joy, 
 etc.), susjiend reflection and calm consideration; or even because they 
 are borne out by hallucinations of several senses, of sight, of hearing, of 
 cutaneous sensibility, and thus the means of rectifying one of the errors 
 is itself falsified. 
 
 Hallucinations alone, even when considered true, are not sufficient to 
 constitute insanity. For this there must also exist a general profound 
 perversion of mind or fully developed insane ideas. In order, however, 
 
 ' Jean Paul, ' Glimpses into the Dream-world. ' 
 
 '^ Spinoza, Epistle XXX. to Peter Balling. 
 
 ^ Ever after a dangerous fall from the bridge of Neuilly Pascal saw an abyss 
 before him. 
 
 ■* ' Special Pathology.' 
 
 ^ ' Fragments Psycholog.,' p. 135. 
 
 * For further examples of hallucinations in healthy persons, see Lahr, ' Irresein,' 
 p. 32. 
 
THE ELKMENTAKY DISORDERS IN MENTAL DISEASE. 65 
 
 to consider hallucinatious as true, it is necessary that, thanks to them, 
 the whole of the healthy sensorial ])erceptions be perverted; and there- 
 fore, hallucinations, when considered as true, are, of course, a very near 
 step to insanity, and especially where a morbid perversion already exists. 
 In the still moderate commencing stages of insanity the hallucinations 
 tix and root themselves so easily that very often they are then considered 
 as causes of the entire disease. According to our o^nnion, it is only in 
 rare cases that we can assign to them this jiosition. We believe, rather, 
 that hallucinations must be considered as symptoms of already existing, 
 although perhaps still moderate, irritation of the brain. At all events, 
 however, the fact is correct, that they very often appear in the first 
 period of insanity, and that with the appearance of hallucinations, with 
 the falsifying of the external world, the patient frequently first begins 
 really to become delirious. 
 
 In mental disease hallucinations are almost invariably considered as 
 realities. Still, in occasional cases, especially at the commencement, 
 the patient admits their morbid nature. Sometimes, indeed, we hear the 
 patients declare that they know very well that it is no ordinary hearing 
 or seeing, it is a mental hearing* — some one "composes to him in his 
 head," etc., or he complains bitterly that the malice of strangers, the 
 , medicines which he has taken, etc., have caused such wicked appearances, 
 and he expresses in his own peculiar way the idea that he is governed ly 
 something in his mind which is opposed and perfectly foreign to his /. 
 The most remarkable cases, however, are those in which the patient 
 knows and can give tlie subjective origin of his hallucinations, and yet con- 
 siders them as realities. Sometimes they say that the voices proceed from 
 within their head." At other times, and very frequently, it seems to the 
 patient as if the voices proceed from the epigastrium, and as if he were 
 spoken to from there — true, not in the ordinary manner, but in quite a 
 new way.' In all such statements much depends on the patient's capabil- 
 ity of self -observation and of describing his mental state. 
 
 In mental disease hallucinations are generally at first circumstances of 
 great attention, and very harassing and troublesome to the patient. 
 After a time, from habit, they become less engrossing, but they often at- 
 tain such a degree of independence that they remain isolated after the dis- 
 ease has run its course, and may impede the complete return to mental 
 health; owing to the hallucinations, also, such patients avoid all inter- 
 course with the world, and therefore fall into a state of mental poverty.* 
 
 We shall here mention a few examples of hallucinations occurring in individ- 
 uals not insane. 
 
 Mr. H — one day was reading Commine's ' History of Burgundy.' Looking 
 towards the window he saw a skull lying on a chair ; he thought of calling out 
 to inquire who had put it there, but he first went towards it in order to examine 
 it. As he put out his hand to grasp it it disappeared. He was terrified almost to 
 fainting. Fourteen days afterwards he again saw in a lecture-room in the College 
 at Edinburgh a skull lying on the desk, and said to his neighbor, " What will the 
 
 ' Also Shakespeare makes Hamlet reply to Horatio's question where he saw 
 the ghost, ' In my mind's eye, Horatio.' 
 
 ^ " C'est un travail qrn se fait dans ma tete," Leuret, loc. cit., p. 162. I too 
 have seen such a case. The patient heard several men speaking together in his 
 head ; he sometimes also thought that a whole tableful of persons sat at meat 
 somewhere in the neighborhood of his cardiac region. 
 
 2 Leuret, loc. cit., p. 177. In another case (Lafargue, ' Gaz. Med.,' 1841, p. 
 713) the hallucinations of hearing came from the neighborhood of the heart. 
 
 * See Neumann, ' Psychiatrie,' p. 119. 
 
 5 ..„ , 
 
66 THE ELEMENTARY DISORDERS IN MENTAL DISEASE. 
 
 professor do with a skull to-day ? " Another time Mr. H— was present at the 
 post-mortem examination of a friend. Three months after, when going to bed, 
 he found an invitation to the funeral of the mother of his friend lying on the 
 table. Scarcely had he put out the light when he felt himself seized by the arm 
 below the shoulder, and it pressed strongly against his side. He sought to free 
 himself, and cried, " Let go my arm ;" he then heard distinctly a voice, " Be not 
 afraid." He immediately answered, " Allow me to strike a light." The arm was 
 then set free. H — rose, but felt violent vertigo and great weakness. When he 
 had lighted a lamp he saw the countenance of his friend at the door, but it was 
 indistinct, as if a veil were over it. As Mr. H — approached, the figure withdrew; 
 he followed it down the steps to the outer door, where he fell in a fainting fit. 
 He was afterwards seized with violent pain over the eyebrows, fever, and sleep- 
 lessness. 
 
 A Southerner in the prime of life and in perfect health paid a visit one day to 
 a neighbor. As he was entering the door there passed before him the figure of a 
 woman clothed in white, and immediately a second, then a third. He stretched 
 out his hand to seize the last, and it disappeared. Shortly after, the man was 
 walking through a park in which he saw several asses grazing ; he wished to pat 
 one of them on the back, and was much surprised when he found that he could 
 feel nothing ; they still remained before his eyes, and he several times in vain 
 repeated the attempt to touch them. 
 
 The following case affords a striking example of numerous hallucinations and 
 illusions in a lunatic, and shows how false ideas originate from them (Bergmann, 
 ''Remarks of a Person, who had been Insane, on his Morbid Mental State," 
 TYiedrich's ' Archiv fiir Psychologic,' 1834, i., p. 15). 
 
 " Once there was a storm, but such a storm as I have never seen before nor 
 since. The clouds appeared to me to be waves of the sea elevated into the air, 
 where they fought with each other, while an enemy's fleet commenced a mortal 
 combat with the inhabitants ; this was the decisive moment for the salvation of 
 Holland, which appeared to me to be already completely lost. I heard no thun- 
 der, saw no lightning, but saw the flashes of cannon and heard their loud reports 
 rapidly succeeding each other. Afterwards, on emptying my linen and clothes 
 out of my box, I saw an extraordinary quantity, and also a table-cover which had 
 been left behind at C — . As, on another day, many things were wanting which I 
 believed I had in my hands, I thought they must have been stolen. One evening 
 I lay in bed, following with my eyes the maid servant, whom I supposed to be a 
 ghost ; then the tallow of the candle began to run very fast ; I saw the tallow, 
 however, run, not from the candle, but from a hole in the wall, and, indeed, in 
 such quantity as to resemble a constant stream. I then declared, with a scream, 
 that I would be suffocated. Hereupon I fell into the delusion that the air was 
 poisoned, and from that moment I constantly felt a sweetish disagreeable odor, 
 which I tasted in all food, and formed the opinion that the beef brought to me 
 was human flesh. The buildings which I could see from my room appeared to 
 be a small clay pipe, which evidently projected above out of the chimney, and 
 therefore engendered in me the frightful idea that this pipe was the only place by 
 which air could enter. Therefore all who entered were supposed by me to be 
 doomed to suffocation." 
 
 § 56. In the consideration of the more immediate circumstances 
 under which hallucinations appear, the following causes are especially to 
 be kept in view. 
 
 (1) Local disease of an organ of sense may become the source of sen- 
 sorial delirium; therefore it is always necessary minutely to examine the 
 patient in this respect. 
 
 (2) All states of deep exhaustion, whether of mind or of body, appear 
 to favor the development of hallucinations. As, in former times, the 
 strong asceticism from religious motives was a cause of numerous halluci- 
 nations, so at the present time we very frequently see the sensorial delir- 
 ium coming on after inanition, prolonged fasting, or other exhausting 
 cause, great mental fatigue, etc. This is particularly favored by one- 
 sided mental concentration, by superstitious ideas when fervently main- 
 tained (Benvenuto Cellini, many devils and religious visions). 
 
 (3) The morbid emotional states from which insanity so frequently 
 
THE ELEMENTARY DISORDERS IN MENTAL DISEASE. 67 
 
 originates evoke hallucinations and illusions in the same manner as the 
 analogous states in health, fear, fright, etc., obscure the sensorial per- 
 cei^tion and awaken new and false sensorial images. 
 
 (4) Outward calm and stillness favor hallucinations, and the produc- 
 tion of hallucinations between sleeping and waking is a circumstance of 
 special importance. Their aj^pearauce under such circumstances in 
 health is well known, and, in particular, J. Miiller's description of these 
 events from personal experience is frequently referred to by physiologists. * 
 Observation shows that also in the mentally diseased they very often origin- 
 ate during sleep, and especially that their first commencement often 
 dates from the time of sleep. ° If they have lasted for a considerable time 
 under these circumstances in the commencing periods of insanity, they 
 often become persistent, appearing also when the patient is fully awake, 
 and exciting false ideas. In certain rare cases, however, an attack of 
 mania has been seen, even on the first day, to succeed hallucinations 
 appearing between sleei^ing and waking. As, however, even the simple 
 closing of the eyes occasionally suffices to call forth hallucinations in those 
 who are disposed to them (Goethe and J. Miiller say this of themselves^), 
 so it has been found that also in the insane simple closing of the 
 eyelids causes hallucinations to appear (Bailiarger, loc. cit. ). Those 
 cases spoken of in § 53, where the phantasms of sight disappeared on 
 closing the eyes, again remind us of the great variety which exists in the 
 complex phenomena of the hallucinations. 
 
 The cases are by no means rare where at the commencement of the insanity 
 the patients made light of, or resisted, the rising and as yet fleeting insane ideas ; 
 wrlien tliey turned them over in their mind, and perhaps affirmed or perhaps 
 rejected them. Some night, when the hglit is put out, when in the still of night 
 all is externally calm to the ear, the first hallucinations, the voices, appear which 
 confirm the insane ideas, and these thereby receive the force of sensorial con- 
 viction. 
 
 (5) Certain poisons and substances used in medicine can very effect- 
 ually call forth hallucinations, especially the preparations of hemp, bella- 
 donna, stramonium, etc. 
 
 Although these are instructive, as they show that phenomena can in part be 
 called forth at will and be made subjects of experiment, yet they have no special 
 relation to the hallucinations of the insane, and it is sufficient merely to have 
 mentioned them. 
 
 § 57. The forms of the various hallucinations depend, as a rule, upon 
 the present disposition of mind and direction of the thoughts.^ This 
 also, to a great extent, decides whether they be gay or sad; and sensorial 
 delirium is rarely altogether independent in its nature. The melancholic 
 frequently hears language of reproach or menace, or voices which call on 
 him to perform some atrocious act; in mania, the hallucinations sanction 
 the excited state of mind. In short, the ruling emotion (fear, jealousy, 
 joy, etc.) determines the form of the phantasms. This circumstance is 
 important in a prognostic point of view. Observation shows that hallu- 
 
 ' See Miiller, ' Phantastische Gesichtserscheinungen ;' Blumroder, ' Ueber Ein- 
 schlafen ;' Traum ; Schlaf, in Friedrich's ' Magazin,' 1830, iii., p. 87. 
 ^Bailiarger, 'Archives Gener.,' 1842, p. 354. 
 3 Miiller, loc. cit., p. 21-27. 
 
 ^ Shakespeare makes Macbeth say, when he would seize the dagger — 
 
 " There's no such thing ; 
 It is the bloody business which informs 
 Thus to mine eyes." 
 
68 THE ELEMENTAKY DISORDERS IN MENTAL DISEASE. 
 
 cinations depending in tliis way on a certain morbid emotional state, can 
 again disappear on removal of that state; while independent hallucina- 
 tions — not connected with emotional states — seldom admit of real cure, 
 and generally enter as essential elements into the state of chronic mania. 
 
 In states of great weakness, after long pain, before death, etc., 
 joyous brilliant hallucinations are often observed. Various other organic 
 conditions— irritation of the genital organs, want of food, etc. — deter- 
 mine in other ways the content of the sensorial delirium which now pre- 
 sents adequate images, voices, etc. 
 
 The remarkable similarity which exists between certain hallucinations 
 produced by certain similar causes in well known. Thus, appearances of 
 animals, mice, rats, birds, etc., are very common in delirium tremens. 
 We might be inclined to consider such as phantastic transformations of 
 musccB volitantes, were it not that, according to our observation, large 
 animals— sometimes in great herds— are also frequently seen; horses, 
 dogs, ''a million of cattle," etc. The illusions, too, Avhich result from 
 taking stramonium, belladonna, and especially Indian hemp, are some- 
 what specific. 
 
 Hallucinations of a religious kind are very common. The thinker 
 recognizes the religious element of his being in the images presented by 
 his imagination; and this, the highest sentiment of the human mind, he 
 takes pleasure in confirming by self-drawn images. In the mentally dis- 
 eased, voices from heaven, sometimes demanding human sacrifice, some- 
 times denouncing divine messages to the poor monomaniac, are very fre- 
 quent. Their contents vary according to the degree of education; and 
 much depends on whether the individual was formerly most engrossed 
 with the Apocalypse, with the Urania of Tiedge, with Byron's angels, or 
 with modern mediums. In general, a belief in the reality of such morbid 
 visions is not a characteristic of this age; yet, even in our day (1816), a 
 monomaniac was recognized as inspired, not only by the masses, but was 
 even considered by an archbishop, and by a minister of police, as an 
 ambassador from God, and as such was consulted by a king (Louis XVIII. > 
 on matters of state. 
 
 See the history of the peasant Martin, by Leuret (loc, cit., p. 171). While 
 engaged in manuring his field, a figure appeared before him, and summoned him 
 to warn the king of threatened danger to his person, and conspiracy against the 
 state. After the affair had created a great excitement in Paris, Pinel declared 
 that Martin was suffering under intermittent mania with hallucinations; he was 
 therefore taken to Charenton; but there also he found disciples, and even amongst 
 
 the physicians ! , „ , „ . ^. j -n • 
 
 In the following paragraphs, further examples of hallucmations and illusions 
 in the insane are given according to their idiosyncrasies. ' 
 
 § 58. Hallucmations of sight. —Accovding to Gratiolet, there may be 
 distinguished the following leading varieties in hallucinations of sight: — 
 (1) Such as appear in darkness by night, on shutting the eyes, or in the 
 blind: they are generally bright, even fiery, but somewhat pale; the forms 
 are very frequently those of birds, hideous faces, etc., and they have a 
 tendency to move to and fro. (2) Those seen in dim light or in the twi- 
 light are frequently white figures which appear to take a position in the 
 room at an appreciable distance, and do not move to and fro. (3) Those 
 seen by daylight; they appear generally as perfect realities. This, how- 
 ever, I cannot corroborate: from many descriptions of hallucinations, I 
 assume that they are also frequently indistinct and shadow-like^ 
 
 > See also the writings of Esquirol, Hagen, Leuret, Sinogowitz. 
 
THE ELEMENTARY DISOKDEKS IN MENTAL DISEASE. 69 
 
 Very often the patients see masses of fire and of liglit; and, according 
 to circumstances, according to the direction abeady given to the thoughts, 
 these appearances are yariously interpreted. One believes that he is in 
 heaven, and sees the majesty of G-od in all its glory; another believes 
 himself encompassed by the flames of hell. A young woman at the period 
 of menstruation, saw (really) her parental home on fire; immediately she 
 became furious, would throw herself into the fire, knew no person, and 
 believed that she herself was on fire. Brought into the hospital, she filled 
 the air with the perpetual cries of ''Fire!" She thought that she suf- 
 fered the pain of the flames, and that her parents were abandoned to 
 them. She was constantly a prey to delirium and fury, and cried per- 
 petually, "See how everything burns! all the engines in the town cannot 
 put out the fire — it must destroy us all!" She died in four weeks, and 
 "Fire! fire! " whei'e her last words. ^ 
 
 Another had a great number of visions. The Son of God frequently 
 appeared to him: he sees him borne upon clouds, surrounded by angels, 
 and holding a cross in his hand. He entrusts to him his commands, but 
 not by words, but by signs, which appear in the air. The patient delin- 
 eates the forms which he sees in the air; they are sometimes geometrical 
 figures, sometimes those of animals or of household materials, flowers or 
 musical instruments; sometimes they are curious figures to which nothing 
 is similar, etc. (Esquirol. ) 
 
 Another writes, " I have seen God the Father several times. He had 
 the graciousness to speak to me; He entered into several hells, where He 
 slew several monstrous beasts, and had them buried in holes, from which 
 one, I believe, gave false oracles. I several times saw John the Baptist 
 in heaven, in a chariot with seven horses," etc.^ 
 
 A gentleman who had hypochondriacal melancholia continually went 
 about striking the furniture of the room with his cane, and the faster he 
 went the more he struck. I afterwards learned that he mistook the shad- 
 ows of the furniture on the floor, and his own shadow, for rats. There- 
 fore, the faster he went, the more persuaded was he that the rats were 
 increasing in number. (Ibid., p. 129.) 
 
 The seat of hallucinations of sight muet be the internal expansion of the optic 
 nerves. Anatomical observations have yet to be made on this point; in dissec- 
 tions, the thalainal surfaces, the corpora quadrigemina and their neighborhood, 
 also the centrum ovale, should be carefully examined. In a case reported by 
 Bright (' Guy's Hospital Reports,' 1837) of a patient, who, after two apoplectic 
 attacks, had hallucinations of sight, there "was found an inflamed spot, half an 
 inch in size, in the corpus geniculatuni, penetrating to the surface of the brain. 
 
 §59. Hallucinations of hearing. — Hallucinations of hearing are not 
 quite so common as those of sight. They are most general in melancholia 
 and chronic mania, in which they are occasionally the cause of an attack 
 of mania. They are generally indications of a more serious, less curable, 
 affection of the brain, and are often latent until certain false ideas have 
 become fully fixed. They have been with special frequency observed in 
 connection with the diseases of the abdomen and genital organs. The 
 anatomical signification of this fact would, if it were known, perhaps ad- 
 vance our knowledge on this point (connection with the cerebellum). 
 The voices appear to come sometimes from a distance, sometimes from the 
 neighborhood; sometimes from the earth, the walls, the furniture, or even 
 
 ' Sinogowitz, loc. cit., p. 258. 
 
 ■^ Esquirol, loc. cit., p. 100-102. See also a patient's description of his visions 
 communicated by Hirsch in Nasse's ' Zeitschrift fiir Anthropol.,' 1852, Heft 1. 
 
70 THE ELEMENTARY DISOKDEKS IN MENTAL DISEASE. 
 
 from the patient's own body. Sometimes they continue so persistently 
 that the patients fall into a state of desperation. Those who have hallu- 
 cinations of hearing have also more nonsensical ideas than generally result 
 from the other phantasms, and they often exhibit the most peculiar and 
 grotesque demeanor. They reply to the voices by friendly or threatening 
 gestures or words. They often become suddenly quiet and attentive in 
 order to listen, and then commit the oddest and most dangerous acts 
 which the voices have recommended. 
 
 A young man had not spoken a word for six months after an attack of furious 
 mania, nor performed any vohmtary act. One day he seized a full bottle and 
 threw it at the head of the waiter. He remained immovable and quiet, and after 
 several months he recovered. I asked him why he had thrown the bottle. 
 " Because I," said he, " heard a voice which said to me, ' Kill somebody, and you 
 shall be delivered;' I did not kill the man; therefore, my lot could not be altered, 
 and I remained quiet and immovable. Moreover, the same voice repeated with- 
 out ceasing, 'Move and you will be dead.' This warning was the cause of my 
 immobility." (Esquirol.) See also the well-known case of the French prefect, 
 by the same observer. 
 
 A patient (communication by Kieser, * Zeitschrift fiir Psychiatric,' x., 1853, p. 
 436) describes his hallucinations and illusions of hearing in the following terms: 
 — " It is as surprising as frightful, and to me degrading, what acoustic practice 
 and experiments— and without reason— have been made with my ear and my 
 body for nearly twenty years! I had the shocking conviction that not only with- 
 out my will, but even without my knowledge, sounds and articulate words of the 
 most various kinds proceeded from my ears as the disgraceful band wished it. 
 And such sounds and words! During six months of the year 1815, they consisted 
 almost entirely of invectives against me and those belonging to me; one and the 
 same word often resounded for two or three hours without interruption! Then 
 there would often be heard a long-continued discourse regarding me, generally 
 containing abuse; the voices of persons well known to me were often imitated. 
 These discourses rarely contained anything that was true, more frequently they 
 contained the blackest hes and calumnies concerning myself and others. Fre- 
 quently it would be made to appear that it was I who said all that. These con- 
 tinuous prolonged sounds were often heard quite near to me ; frequently, however, 
 they seemed to be produced half or even a whole mile off. They are likewise 
 thrown and violently ejected from my body: the greatest noise and clatter is 
 heard around me, especially if I enter a house or go into a village or town, there- 
 fore, I have for several years lived almost like a hermit. At the same time, my 
 ears almost constantly resound, and often so strongly that the noise may be heard 
 at a considerable distance. Every single tree when I approach becomes— even m 
 calm weather— a source of murmurs and sounds resembhng words and speaking; 
 the carts and carriages crack and sound in an extraordinaiy manner, and relate 
 anecdotes; the horses' hoofs do the same; the swine grunt names and stories; the 
 dogs bark abuse and reproaches, the cocks and hens, and even the geese and 
 turkeys, cackle names, words, and sentences. The smith causes his hammer 
 and bellows to sound words, phrases, and often entire anecdotes, and thinks he 
 does this with my consent and will. AU who come near me tell with their feet, 
 without their will, the most curious, droll, and nonsensical things which happen 
 to me and to those around me. This is especially the case in going upstairs. ^^ Even 
 the pen with which I write produces articulate tones, words, and phrases." 
 
 At other times the patients hear celestial harmony, music of the 
 spheres, concerts; frequently accusations, loose speech, and indecent lan- 
 guage. Of this female patients often bitterly complain. In illusions oi 
 hearing, sounds present are transformed in the sense of the ruling dis- 
 position or false idea: for example, a noise upon the steps will be ascribed 
 to officers of the law coming to imprison the patient, etc. ' 
 
 There is a particular kind of hallucination of hearing to which it is 
 difficult to give a name, viz., those internal voices without sound, mere 
 
 > In Schiller's ' Erwartung,' simple hallucinations of hearing in health are so 
 described that they may be taken as examples. 
 
THE ELEIVIENTARY DISORDERS IN MENTAL DISEASE. 71 
 
 lively ideas, which appear to the patient as speaking and answering. 
 They are described by certain of the insane as spiritual, as "the voice of 
 the soul," etc. {mental hallucination of Baillarger). There are all possi- 
 ble varieties of them, even to the loudest cry of voices. 
 
 The point of origin of these morbid phenomena of hearing must be referred, 
 in part, to the fourth ventricle and its neighborhood; but the pathological 
 anatomical grounds for such an hypothesis are scanty. ' In certain cases, phan- 
 tasms of hearing could be stopped by stuffing the external auditory meatus. At 
 other times they have been found in the deaf. 
 
 § 60. Sense of smell. — Hallucinations of smell are not so common as 
 of the senses we have just considered: they appear also to belong chiefly 
 to the early stages of insanity. Schlr<,ger^ found, amongst 600 patients, 
 27 cases in which bad smells were complained of, which sometimes caused 
 ideas of poisoning, with refusal of food, owing to the idea that the intes- 
 tines were putrefying. In the great majority of these cases, however, the 
 bad smells were objective, excited from without, and not true hallucina- 
 tions; only about five cases could be considered as such. In almost every 
 case it is disagi-eeable odors which the patients perceive: the smell of sul- 
 phur, of carbonic oxide, of carrion, etc. The idea of living in a poisoned 
 atmosphere, surrounded by dead bodies, etc. , is a frequent result of these 
 hallucinations. Leuret (loc. cit., p. 198) relates the case of a woman who 
 ascribed the bad smell which she felt to the effluvia arising from mur- 
 dered bodies in the vaults of Salpetriere: smells presented externally were 
 well distinguished, and she was quite normally affected by them. We 
 have seen a parallel case in a young man. 
 
 Sinogowitz narrates the following interesting example of an insanity 
 which depended to a great extent on illusions of smell. 
 
 K — , formerly lively and sociable, became gradually, for about a year, medita- 
 tive, taciturn, irritable, and solitary; he often used secret remedies, and always 
 showed distrust of those by vs^hom he was surrounded. At last he openly declared, 
 " I feel myself very unwell; I have within me a putrefying mass which destroys 
 my inwards; my neighbors therefore treat me with mockery and contempt, and 
 avoid coming near me because I emit a pestilential odoi*." He led a solitary and 
 sorrowful life; his delirium became always more confirmed, and he accounted 
 for his disease by infection from glanders. He removed to a strange town, and 
 took a walk to see whether those whom he met would also avoid him on account 
 of the bad smell. As, by chance, a passer-by put his pocket-handkerchief to his 
 nose, and at the same time looked at him, K — violently attacked him, called him 
 a hard-hearted mocker, an uncharitable despiser of men, and gave him a box on 
 the ear. He was then recognized to be insane; it was found that he was insensi- 
 ble to external odors; he declared that he felt only his own smell, which resembled 
 that of horse's urine, and complained also of a corresponding taste in his mouth. 
 The patient then gave himself to onanism; he soon began to complain of con- 
 stant dull pain in the head, to grow lean, and at last fell into dementia. 
 
 In a patient who had strong hallucinations of smell, a fungus of the dura 
 mater as large as a hazel-nut was found in the cribriform process, and surrounded 
 by the olfactory nerves ('Vienna Asylum report,' 1858, p. 266). 
 
 In another patient, who had been constantly followed for more than six 
 months by a smell of dead bodies, there was found an abscess of the corpus callo- 
 sum (Cabanis, quoted by Morel. 'Traite des Maladies mentales,' p 331). The 
 island of Reil might, according to certain facts in the minute anatomy of the 
 brain, be considered an olfactory centre. 
 
 Hallucinations of taste. — In this sense real hallucinations cannot be 
 
 ^ Foville says that he has found adhesions of the surface of the cerebellum to 
 the membranes. But there appears to be also a prolongation of the auditory 
 nerves into the great hemispheres. 
 
 ^ 'Zeitschrift der k. k. Gesellschaft zu Wien,' 1858, 19, 20. 
 
72 THE ELEMENTARY DISORDERS tN MENTAL DISEASE. 
 
 distinguished from illusions, false interpretation of real objective impres- 
 sions (from furred tongue, state of the saliva, etc.)- Here, too, there are 
 commonly disagreeable sensations of taste of which thejiatients complain: 
 they say that everything has a bad taste, metallic, sharp, rotten, sandy, 
 earthy, etc. ; and found on this the idea of poisoning, hate towards their 
 neighbors, and frequently refusal of food — always so important on ac- 
 count of its speedy and injurious influence on the organism. The cases 
 in which the insane have agreeable sensations of taste — suppose that they 
 eat delicacies — are very rare. 
 
 Esquirol mentions such cases, the single case brought forward by Leuret 
 (p. 197) can scarcely be considered an example of this. 
 
 § 61. In the skin, and in the viscera, hallucinations and illusions can- 
 not be distinguished from each other ; or rather the phenomena which 
 constitute them, so far as they do not depend on anassthesia (§ 49), are in 
 every case to be considered as illusions, because the specific anomaly 
 consists in the false interpretation of certain sensations observed in 
 health or in various states of disease. The commencement of these illu- 
 sions consists in certain painful sensations being merely phantastically 
 compared by the patient to analogous phenomena. Therefore hypochon- 
 driacs, at first, say only that it seems to them as if serpents crawled in 
 their skin, as if there were frogs in their belly, as if a bird chirped with- 
 in their chest, or, as we once heard a patient say, a young dog lapped 
 water in their head. But, by prolongation of the sensations, the influ- 
 ence of unfavorable external circumstances, and increasing internal dis- 
 harmony, owing to which the patient soon begins to consider the matter 
 more earnestly, the comparison, at first imaginary, becomes a fully de- 
 veloped delirium: then, from abnormal cutaneous sensations or morbid 
 muscular action, there originate fixed ideas, in which those sensations are 
 seriously attributed either to internal phantastic causes (spiders, crickets, 
 and other animals in the body, demoniacal possession of certain organs), 
 or to outward influences of a prejudicial kind (magnetism, physical ex- 
 periments). Thus, the idea of being stabbed or flogged, of the arms 
 being bound or made fast, is seen to originate from certain pains in the 
 skin; and from abnormal abdominal sensations, the idea that the devil, the 
 last judgment, crucifixion,' is taking place within the belly of the patient. 
 Any part of the body may become the point of origin of such insane 
 ideas. A young man told me he had felt the devil, rough and bristly, 
 seize him by the neck (globus hystericus?); another, mentioned tiy Sinogo- 
 witz, stufled his nose at night because venomous worms crawled into it. 
 A woman, spoken of by Bergmann, saw in her breast a circular fiery body 
 turning constantly round. 
 
 The sexual illusions merit special consideration, as, from normal and 
 abnormal sexual sensations, there is frequently developed in men the idea 
 that they are urged by others to onanism; in women, the idea of preg- 
 nancy, of their accouchement always being imminent — of sexual inter- 
 course with some imaginary lover, with the devil, etc. ; and as those 
 sensations constitute a frequent source of sexual insanity which may 
 show itself in the form of sentimentality, or of nymphomania. 
 
 ^ A patient of Esquirol's had this delusion. " I can scarcely bear it," he said 
 occasionally : ' ' when will there be lasting peace in the Church ? " A patient in 
 Winnenthal cried continuously, for months, " Desist, and let me go! " He some- 
 times believed that he was tormented by something within Ixis body, sometimes 
 that he was stmck with the horns of imaginary oxen. 
 
THE ELEMENTARY DISOKDERS IN MENTAL DISEASE. 73 
 
 Hallucinations and illusions of several senses combined are very 
 common, and the literature of this subject (Hagen, Escjuirol, Leuret, 
 Bottex) is rich in examples in which simultaneous false perceptions of all 
 the senses formed the most important and most striking phenomena of 
 the insanity. In a practical point of view, it cannot be too much insisted 
 on that these false perceptions of the senses be sufficiently investigated, 
 that they are often results of organic processes which may be allayed, 
 and that attention be paid to these in considering the plan of treatment. 
 In relation to this, we might recommend — a point hitherto quite over- 
 looked in hallucinations of the three superior senses — attention to the 
 state of their accessory nerves, the fifth pair: in several cases, hallucina- 
 tions of hearing and of sight appeared to us to have been awakened by 
 neuralgic affections of these nerves. 
 
 I saw, now many years ago, a remarkable case which began with hallucina- 
 tions of several senses. A man was returning one moonlight night from a pedes- 
 trian excursion by which he was somewhat fatigued. All at once it seemed to 
 him as if he saw a great animal like a dragon rolling i^-self in a ditch filled witli 
 water by the roadside. He became exceedingly af raia, and at the same time f e] t 
 himself painfully grasped on the right shoulder by the animal; nevertheless, he 
 could, as he said, free himself by running. Immediately after, he fell into a 
 disease which was soon discovered to be a pleural exudation of the right side, 
 filling the whole of that side of the chest. He died in a few months, and I was 
 present at the examination of the body. 
 
 SECTioiir III. — The Elementarij Disorders of Moveinent. 
 
 § 62. We observe, in most of the insane, slight inconsiderable dis- 
 orders of muscular movement; changes in the tone of voice; slowness or 
 excessive rapidity of the contraction of the muscles, etc. It is not rare 
 to see also a certain degree of general tightness and rigidity, or of relax- 
 ation of the muscles ; the latter principally in states of weakness. 
 Difficulty of movement of the whole body, including the organs of 
 speech, perhaps even statue-like cataleptic rigidity, is proper, in particu- 
 lar, to the so-called ecstatic states (see § 51), in which the external 
 sensorial activity is at the same time more or less suspended (generally 
 with coexisting hallucinations), and the patient is plunged either in 
 inexpressible mystical joy, in ecstasies, or in a state of violent painful 
 emotion. Such muscular rigidity, moderate and of short duration, may 
 be present in the slightest, most curable, forms of insanity, and does not 
 render the prognosis less hopeful ; yet, in certain cases, the patients 
 have become demented (Guislain). Of far greater significance are, on the 
 one hand, the local contractions interrupted at times by paralysis, and on 
 the other, the partial or general convulsive states. The persistent 
 automatic grimacing, strabismus originating during the disease— immod- 
 erate contraction, dilatation, and irregularity of the pupils — painful con- 
 vulsions of the muscles of the neck — those confused convulsive move- 
 ments of the extremities which cause the patient often to walk irregularly, 
 or to progress in short leaps — are all phenomena of serious signification, 
 and their continuance usually indicates a transition to the state of in- 
 curability. A constant trembling, grinding of the teeth, chorea-like 
 symptoms in adult lunatics, automatic circular movements, walking 
 backwards, are likewise, at least in the majority of cases, symptoms of 
 the development of serious organic disease of the brain: although, in 
 accordance with certain observations of subsequent recovery in similar 
 cases, we must admit the possibility of the production of the phenomena 
 from simple nervous irritation, or from temporary palpable disease. The 
 
74: THE ELEMENTARY DISOKDERS IN MENTAL DISEASE. 
 
 gravest, and, alas! but too frequent, anomalies of movement in the 
 insane, are, however, the epileptic and general paralytic states, to which 
 we shall, owing to their great importance, devote a special chapter (see 
 the Complications of Insanity.) 
 
 In cases of obstinate taciturnity, which sometimes continues for several — 
 certain cases for ten years, and even longer — we must, first of all, discover 
 whether the patient ivill not speak (simple morbid peculiarity) or cannot speak 
 (chronic cataleptic states, profound melancholia, stupor, dementia). The strength 
 and tone of the voice correspond in general to the ruling disposition of mind. 
 
 In the insane there is sometimes observed a convulsive rolling of the eyeball 
 (nystagmus). This phenomenon appeai-s to belong to the period of transition from 
 the acute into the chronic states, and is therefore of unfavorable prognosis. 
 Modifications in the mobility of the iris are more common. Inequality of the 
 pupils is seen most frequently in paralytic dementia, more seldom in simple cases 
 of mania or melancholia: and hei-e also it is most common in chronic, slowly 
 progressing, and hopeless cases. In certain cases the inequality appears for the 
 first time during convalescence. Great contraction of the pupils in mania is, 
 according to experience, of unfavorable prognosis, and I'enders probable the com- 
 mencement of paralytic dementia. In insanity, as in many other affections of 
 the brain and nerves, it cannot in every case be ascertained whether the abnormal 
 state of the pupils depends on convulsion or paralysis ; but the latter, from the 
 symptoms, appears generally to be the more probable. See Merier, ' Gazette des 
 Hopitaux,' 1853, 19 Aout ; Seifert, 'Zeitschrift fiir Psychiatric,' x., 1853, p. 544 ; 
 Richarz, ibid., xv., 1858, p. 21. 
 
ON INSANITY IN GENERAL. . 75 
 
 CHAPTER V. 
 ON INSANITY IN GENERAL. 
 
 Section I. — The Analogies of Insanity. 
 
 § 63. What may be said on insanity in general, its course, its mode 
 of termination, etc. , can only be drawn from the study of its single forms, 
 owing to the extraordinary diversities which they present. Still, our 
 general knowledge of mental diseases is considerably increased by consider- 
 ing their analogy to certain kindred states, especially to dreams and to 
 the delirium of fever. ' 
 
 The simple testimony, so frequently given by those who have recov- 
 ered, that the whole period of their disease now appears to them as a 
 dream — sometimes a happy, but more frequently a painful and gloomy 
 one; and further, that during insanity, in certain cases, the impression 
 left by their former healthy life was also like a bygone dream — might 
 lead us to the great similarity of insanity to states of dreaming. 
 
 It is true that in the insane the principal signs of sleep are absent — 
 the closing of the external senses, the suppression of consciousness of the 
 outer world, and of the influence of the will upon the muscles — all of 
 which we regard as essential to dreaming. But, on the one hand, it is 
 known that we dream the more readily the less profound our sleep is, 
 and that there are states of sleep where an influence similar, indeed 
 almost akin, to a waking state is exerted on the muscles (speaking dur- 
 ing sleep, sleeping of the postilion while riding, somnambulism). On 
 the other hand, the whole circle of such sensorial acts as do not originate 
 through external excitation of the senses, and which nevertheless may 
 exert such power (which acts exert such influence in mental diseases), 
 can be considered as related to dreaming in the wider sense. Finally, 
 there are in the insane states of sensation and of motion, — dulness of sen- 
 sorial impressions, which no longer aflect (§ 50) the individual as they 
 formerly did — that weakening of the influence of the will upon the mus- 
 cles which is manifested in great slowness of movement, and even, at 
 times, in cataleptic persistence of positions enforced (§ 62), — which, in 
 connection with the coexistent obscurity of consciousness, vividly reminds 
 us of what takes place when sleep comes on. 
 
 Indeed, the analogy of insanity to dreaming, especially to dreams occurring 
 in the half-waking state, must be admitted. In children, we occasionally see, 
 especially when under slight disease, that they, while sleeping, still speak; for 
 example, they understand the mother, they answer her, they open their eyes and 
 recognize her, but nevertheless they dream on, and in particular they cannot 
 withdraw themselves from uneasy dreamy ideas. Even the intermediate con- 
 ditions of sleep and waking, which succeed each other in endless gradations, 
 
 ' The analogy of insanity to the emotional states of health has already been 
 spoken of ; the similarity of many states of mental disease to intoxication will be 
 afterwards mentioned (under Mania and General Paralysis). 
 
76 OK INSANITY IN GENERAL. 
 
 strongly favor the appearance of illusions and hallucinations (§ 56), and which 
 are distinguished by an irregular activity of the imagination and by incoherence 
 of the intelligence. They are preceded by a state of sleepiness, the individual 
 being dull, torpid, and taciturn; the senses become blunt, the impressions of 
 sight fail, sounds appear distant, his consciousness is dull, answers are delayed, 
 he forgets himself and speaks incoherently. These are often observed in the 
 commencement of insanity. In the first place, sensitive and motory reaction 
 towards the external world becomes feeble; and secondly, a world of phantasms 
 and confused ideas appears, in which the patient loses liimself. This gradual 
 lulling of the understanding and will, wliich constitutes healthy sleep, is denied 
 the insane man, owing to the pei-sistent (painful) emotions; and we often observe 
 also, in the commencing period of the disease, in spite of the apparent sleepy 
 tiredness, actual sleeplessness. 
 
 Bichat says, " Le sommeil general est I'ensemble des sommeils particuliers;" 
 indeed, each sense and each phase of mental life may be at the same time awake 
 in different degrees, the one more than the other. In somnambulists certain 
 faculties are very active, and dreams set in action may, if of short duration, be 
 considered as somnambulism; if of longer continuance, as mental disorder. 
 
 § 64. The dream, like insanity, receives its essential color, its certain 
 iundamental tone, from the governing disposition; Avhicli may be deter- 
 mined as well by the mental occurrences of waking life, as by changes of 
 the organic states during sleep; in which, especially, all congestive states, 
 and all morbid impressions from the digestive organs, and abdominal 
 organs in general, have a very great influence. The ruling sentiments 
 of pleasure and pain call for their corresponding images, in which objects 
 without form in themselves, become sensuous clothed forms, the reality of 
 the actual impression is delusive, and what enters from without, through 
 the senses, meets in the dreamer, as in the insane man, a centre, pre- 
 occupied and filled with the given disposition, and becomes perverted 
 and construed in the sense of the ruling sentiments and ideas. On the 
 other hand, however, the same twofoldness of the personality and the 
 .same emotions ensue when groups of ideas and sentiments of unaccus- 
 tomed hostile intent stand opposed to the/, and the dream, like insanity, 
 is busy to transfer to the external world and to dramatize subjective 
 images (hallucinations) of all the senses. 
 
 In dreaming, this occurs particularly with bodily sensations, in the elaboration 
 of which there is great exaggeration and they have a powerful effect upon the 
 imagination. A confined position in bed, pressure on the arm or the breast, 
 becomes cause of sensations of being put in chains, of danger, of precipices, of 
 threatened execution, etc. ; a draught of air coming on us excites ideas of being 
 at sea, and the other circumstances connected with it; warmth of the feet causes 
 us to dream of fatiguing marches, or of climbing a burning mountain; a slight 
 prick evokes ideas of drawn swords; bodily feelings of anxiety from oppressed 
 respiration may excite the idea of a monster setting on us, or dramatic represen- 
 tations of great crimes being committed, against all of which, however, our 
 natural I, to which no such thoughts belong, strongly protests. All these closely 
 resemble the waking dreams of the melancholic, and in both conditions the 
 individual cannot recognize these false representations as such for want of reflec- 
 tion, owing to repression of the I or even partial overthrow of it, and because 
 rectification through the senses is impossible, in the one case through their dul- 
 ness, and in the other through their false images (hallucinations). Heerman 
 narrates that when asleep, having colic pains, he dreamed that his belly was 
 opened and that a preparation was made of his sympathetic nerve. _ We have 
 brought forward examples (§ 61) of similar interpretations of abnormal sensations 
 by the insane when awake. 
 
 The dreamer, like the insane, accepts all, even the most adventurous and 
 foolish, representations as possibilities without particular astonishment, and the 
 veriest absurdity becomes the most unquestionable truth, if the naasses of percep- 
 tions which can rectify it remain dormant. An individual may dream of having 
 solved a scientific problem, and is filled with joy at his fortunate success; he 
 awakes and discovers that it is an ordinary false thought. Thus, there are insane 
 
ON INSANITY IN GENERAL. 77 
 
 persons who suddenly discover perpetual motion, or a mechanicnl idea which, 
 must change the whole surface of the earth, and similar tilings: they circ filled 
 with ecstasy at such discoveries; what they demonstrate, hov'over, ic to ue folly, 
 and they, after removery, cannot understand why they could not at once see 
 through such great errors. 
 
 § 65. Agreeable, ravishing, heavenly dreams are very rare in health r 
 they are most frequent in states of deep bodily or mental exhaustion, and 
 Ave often observe at such times tliat the ideas suppressed during waking 
 come forth strongly in dreams. To the individual who is distressed by 
 bodily and mental troubles, the dream realizes what reality has refused — 
 happiness and fortune. The starving Trenck, during his imprisonment, 
 often dreamed of rich repasts; the beggar dreams that he is wealthy, the 
 person who has lost by death some dear friend fondly dreams of the most 
 ultimate and lasting reunion. So also in mental disease, from the dark 
 background of morbid painful emotion, by sinking into a still deeper 
 state of dreaming, the repressed contending ideas and sentiments — bright 
 ideas of fortune, greatness, eminence, riches, etc., stand out — and, as 
 soon as this happens, through a change in the state of the brain, but 
 without recovery, the pressure of the painful sensations is removed, the 
 former mental misery changes voluntarily to the mirth of the maniac. 
 Thus we see clearly how supposed possession and imaginary realization of 
 good things and wishes, the denial or destruction of which furnished a 
 moral cause of the disease, constitute commonly the chief subjects of the 
 delirium of insanity; for example, she who has lost a darling child raves 
 of a mother's joy, he who has suffered loss of fortune imagines himself 
 rich, the disappointed maiden is hajjpy in the thought that she is tenderly 
 loved by a faithful lover. 
 
 A number of other phenomena of dreaming present an evident analogy ta 
 insanity. Thus, sometimes in insanity, as in dreams, all idea of time is wanting;, 
 minutes seem hours, as in a dream we live years in a quarter of an hour, and 
 events which would take months to occur in reality, appear to the insane man 
 to pass in the shortest space of time. In both states, muscular sensations — inter- 
 preted as flying, being precipitated, etc. — and illusions play a most iniportant 
 part, and the latter serve, in particular, to express certain situations evoked by a 
 governing fundamental disposition and cori-esponding to it, while the masses of 
 perceptions of the I, which could bring order into this chaos, are partly obliterated 
 or destroyed, partly lie in painful opposition to the new contents of the mental 
 life, or are violently carried by this in certain definite directions. 
 
 Those rarer cases are very interesting where intermitting insanity takes the- 
 place of normal sleep, and thereby seems to stand midway between dreaming and 
 somnambulism. Guislain (' Die Phrenopathieen,' translated by Wunderlich, p. 80) 
 relates such a case, and considers generally that there exists a certain analogy 
 between mental disease and states of dreaming. Those cases also are of the same 
 nature in which a state of waking dream suddenly interrupts the ordinary state 
 of waking, which after its cessation again assumes its ordinary course. A lady 
 was subject to such paroxysms: suddenly in the midst of a conrersation she 
 would stop and commence to speak of something else; after a certain time, she 
 would again resume the conversation at the sentence and word at which she had 
 bi'oken off, and be quite unconscious of the interruption. A lady from New York 
 suddenly became delirious while working some intricate embroidery; she 
 remained ill for seven years, and as suddenly recovered. She immediately 
 resumed her work with the same composure as if she had only been an hour 
 absent from it (Prichard, ' Annal. Medicopsychol.,' i., 1843, p. 336). 
 
 When the seeds of mental disease are actually present, agitating dreams may 
 hasten its outbreak; sometimes the subject of the future delirium is clearly 
 exhibited in them. Results of the existing cerebral in-itation, they act destruc- 
 tively on the emotions, and their after-effects continue dominant during the 
 waking state. 
 
 § 66. Many states of insanity specially resemble the so-called magnetic 
 
78 ON INSANITY IN GENERAL. 
 
 sleep which is observed in chronic nervous diseases, particularly in states 
 of serious constitutional disturbance. The extraordinary feeling of well- 
 being in its higher grades, those indescribable sensations which seem to 
 belong to another sphere, are here exhibited in the great satisfaction and 
 contentment seen in many maniacal states, and in those feelings of exqui- 
 site happiness experienced by many of the insane which really cannot be 
 described, and for which they themselves choose the image of the divine. 
 The new expressions which certain somnambulists suppose to be the com- 
 mon language of the region of the spirits — that tendency to busy them- 
 selves mystically with the construction of the universe, and, above all, 
 with the highest problems of human thought, and that affectation of fine 
 language in those without education, are all to be found, alike combined, 
 in many chronic maniacs; and in certain cases the greater freedom of the 
 organs of movement in the latter state constitutes the chief distinction. 
 
 It appears also that magnetic exaltation, like maniacal agitation, is frequently 
 developed from anterior states of pain, and that there then results antagonistic 
 dominion, on the one hand, of the bodily and mental affection during waking, 
 and on the other, according to our observation, of obscure states of dreaming 
 accompanied by nightmare, which constitute the first period of the magnetic state. 
 The further confirmation of the latter conditions would be very important for 
 the analogy in the course of both series of morbid states. In the somnambulists, 
 also, their knowledge— according to all experience so very worthless -is generally 
 communicated through the medium of hallucinations (of sight and hearing). 
 Most of the analogies mentioned in the preceding paragraphs with the other 
 states of dreaming serve also for the magnetic states; and, particularly, reminis- 
 cences of magnetic dreams are not so rare as is generally supposed. 
 
 Although the different states of insanity do not in the same degree possess the 
 character of dreams— although this attaches most to certain primary forms, 
 especially to melanchoha with stupor, in which, indeed, intercourse with the 
 external word is extremely limited, and impressions are phantastically trans- 
 formed, and also to certain states of mania; although, on the contrary, other 
 particvdarly secondary, forms, such as partial dementia, present all the signs of 
 complete waking, in which at times the patient renounces his whole former iife 
 or has quite forgotten it — where he lives, externally in the false world of his 
 hallucinations, and internally in the reveries of his false ideas:— whether such 
 waking, indeed, is not more analogous to certain magnetic states which partially 
 conceal our day-hf e, than to that waking which we know by experience to be 
 the healthy state. 
 
 The analogy of mental disease to dreams has in recent times been treated ot 
 by several authors, especially by Moreau, ' Annal. Med. Psych.,' 1855, p. 11, ff.; 
 ibid., p. 361; Maury, ibid., 1853, v., p. 40-4; Holland, 'Chapters on Mental Phy- 
 siology,' 2d edition. 
 
 § 67. As, however, insanity presents a similarity sometimes superficial, 
 sometimes profound, sometimes qualitative to the various states of dream- 
 ing; so the psychical process by means of which the individual, when the 
 cerebral disease is removed, returns to healthy life, presents various modi- 
 fications. Sometimes recovery resembles simple waking; when the indi- 
 vidual astonished seeks, as it were, to know himself, the masses of ideas 
 belonging to the disease soon disappear, and the old /returns uninjured 
 and unimpaired to its former place. At other times, the already united 
 connections loose themselves with greater difficulty, and as the old / 
 is but slowly strengthened, recovery consists again of a painful struggle, 
 in which the individual awakened frequently requires the instruction 
 and advice of another will to strengthen his. Not unfrequently, even 
 then all the traces of the morbid state do not disappear, and the patient 
 for a long time retains, as vestiges of the past, certain ties, oddities, 
 aberrations, and perversions. From this point it may frequently be ob- 
 served that the patient undergoes a decided change of character. 
 
ON INSANITY IN GENERAL. 79 
 
 It is inadmissible to refer those processes to the moral sphere, to which they as 
 little belong as the process which characterizes the commencement of the disease; 
 but it is certain that, for a convalescent who has been formerly unsteady, proper 
 moral training is necessary, and that very often the physician may produce a new 
 effect on the patient by such instruction as is generally given to the young. 
 
 Those cases are very interesting where, shortly before death, the men- 
 tal health completely returns or becomes decidedly improved. This 
 occurs most frequently in mania,' seldom in melancholia, and almost 
 never in the secondary forms — chronic mania and dementia. In those 
 cases where serious anatomical changes have already taken place in the 
 brain, and the morbid perceptions have completely pervaded and destroyed 
 the /, the fundamental requisites of return to normal thought seem to be 
 wanting. The length of time required for this cannot be estimated. 
 
 Brierre de Boismont- mentions the case of a gardener who, in his twenty- 
 second year, after receiving a violent fright from a person dressed like a bear, at 
 a masked ball, became insane, and for fifty-two j'ears did not speak a word, but 
 appeared, with growls and moving to-and-fro of the body, to imitate that species 
 of animal. Some weeks before his death, when diarrhoea and oedema had set in, 
 he began to speak; his intelligence showed itself to be, indeed, very limited, but 
 the connection of his thoughts was correct and orderly. 
 
 In cases where the cerebral symptoms originate secondarily, and are main- 
 tained by disease in other organs, and still depend on simple nervous irritation 
 or on slight hyperasmia, such mental improvement before death may even be 
 expected; this is easily explained, and is in many ways analogous to the cessa- 
 tion of certain pains before death. Certain exceedingly rare cases have also been 
 seen where even dements (paralytic) some time before death recovered a great 
 part of their lost recollections, and exhibited a certain correctness of judgment. 
 Such, it is true, is still far from being a state of reason. Hoffmann correctly 
 remarks, that this " rationality " which reappears shortly before death is in most 
 cases merely a re-establishing of an equilibrium between diminished powers, the 
 past, the future, and the most important relations of life still remaining in 
 obscurity. 
 
 Such mental improvement before death is not always coincident with marked 
 aggravation of the bodily symptoms; cases have occurred where the patients 
 were considered cured, and then rapidly carried off by sudden death. It is very 
 rare to see insanity assume a more serious form shortly before death, still, in 
 mania, an access of fury sometimes comes on which does not cease tiU death 
 occurs. 
 
 § 68. The acute delirium of fever, from which insanity is in no way 
 specifically distinct, likewise consists of active dreams during waking or 
 half- waking. Although generally the delirium of fever is more a state 
 of simple incoherence than of mental aberration, still we observe fre- 
 quently that in these dreams the various hallucinations and false ideas 
 are only expressions of a governing fundamental disposition, sometimes 
 fixed, sometimes changing, and are thus connected through the unity of 
 the ruling sentiments; and also that the specid subject of each of the 
 imaginary images and false ideas is generally decided by accidental cir- 
 cumstances (psychical wants, the paper on the wall, old recollections). 
 In the delirium of fever also, we can often arrive at the same fundamen- 
 tal psychical differences according to which the division of mental diseases 
 into single principal forms is based. Thus there is a melancholia, a 
 mania, partial dementia (restricted to single insane ideas without much 
 emotion), and dementia in febrile delirium. There are also certain pre- 
 
 1 In the Quaker Asylum at York, in 33 cases of death from mania this occurred 
 8 times, and in 45 from melancholia 8 times (Julius, ' Contributions to British 
 Mental Medicine,' p. 255). The three examples brought forward by Parchappe 
 were also cases of mania. 
 
 2 ' Gazette des Hopitaux,' 1844, No. 54. 
 
80 ON INSANITY IN GENEBAL. 
 
 disposing constitutional causes of slight delirium as of mental disease, such, 
 as previous weakness, hereditary influences, etc. 
 
 Although, in general, acute delirium differs essentially from insanity 
 in its shorter duration, the absence of premonitory symptoms, and its 
 sudden outbreak, its symptomatic character, the presence a high degree 
 of fever — although, in acute delirium, owing to its short duration, that 
 psychologically organized transformation of the personality observed in 
 so many mental diseases is never present, still, both kinds of disorders, 
 as regards their nature — nervous irritation, hypersemia or inflammation of 
 the brain, probably_ of its surfaces — and causes — sympathetic irritation of 
 other organs, emotions, anaemio states, abuse of alcohol, etc. — are identi- 
 cal; there are manias which are transitory and of short duration, there is 
 a kind of insanity which is accompanied by fever, and not unfrequently, 
 the cerebral affection has, even in mental disease, a symptomatic signifi- 
 cation. So we may correctly designate the psychical disturbance in 
 insanity as a generally chronic delirium, and we have no groun^ds for 
 agreeing with Georget and Burrows in their views as to the specific 
 difference between the delirium of fever and mental disease. 
 
 See Georget, 'Ueber die Verriicktheit,' translated by Heinroth, Leipzig, 1821, 
 p. 127 ; Burrows, ' Commentai-ies on Insanity,' London, 1828 ; Jacobi, ' Beobach- 
 tungen iiber die mit Irresein verbundenen Krankheiten ;' Elberfeld, 1830 ; Moreau,. 
 ' Annal. Med. Psychol.,' vii., 1855, p. 20, and Bousquet's review of Moreau's work, 
 ibid., p. 448 ; Fee, 'Bull, de I'Acad. Imp. de Med.,' vol. xx., 1855, p. 1213. 
 
 Sectiq]!^ II. — The General Diagnosis of Mental Disease. 
 
 § 69. The question whether an individual be insane may be put in 
 two different senses. It may be asked whether in him the general men- 
 tal disturbance is the result of disease ? or it may be demanded — in evi- 
 dently present and established morbid psychical disturbance — whether 
 this belongs to one of those cerebral affections which are usually called 
 "mental diseases," or whether the disorder does not perhaps depend on 
 some other disease, as meningitis, typhus, intoxication, etc. ? The latter 
 question is purely medical, the former is more frequently medico-legal. 
 
 When the mental faculties in a man are in a state of morbid distur- 
 bance, this may in some cases be easily and by any layman distinguished; 
 in many other cases the decision on this point is very difficult, and 
 requires prolonged observation and intelligent acquaintance with the 
 science of mental disease. I have had submitted to me opinions of special 
 medical psychologists, who, after six months' observation of a patient in 
 their asylum, could not come to a decision whether they should declare 
 him insane or not; and older and recent cases have been published (Eeiner 
 Stockhausen) on which the opinions based upon long observation, insti- 
 tuted adlioc, of eminent psychologists have been quite contradictory: the 
 reading of these is very instructive. We see, likewise, how very inadmis- 
 sible, in many cases, is the demand frequently made on the medical jurist 
 (by the jury) that he, after one or two short examinations of the prisoner, 
 should give his opinion, when, sometimes, the time allowed is insufficient 
 to enable him to acquire a full knowledge of the subject of investigation. 
 
 The difficulty of this question depends on the fact that perversities 
 of feeling and effort, false ideas and opinions, and even delusions of the 
 senses — all, as we have seen, essential elements of mental diseases — are 
 also produced in other than morbid states, and can exist together with 
 wholly undisturbed mental health ; further, that when such psychical 
 anomalies do not at all exist, their prominent symptoms may be design- 
 
ON INSANITY IN GENERAL. 81 
 
 edly imitated ; or, when they do exist, these may be concealed ; finally, on 
 the fact that there are many cases where the disease is partially developed, 
 and with but incompletely marked signs, which constitute the chief cri- 
 teria from which an individual is to be pronounced insane. 
 
 § 70. (1) The chief point is invariably this — that, in the great majority 
 of cases, there appears with the mental disease a change in the mental 
 disposition of the patient in his sentiments, desires, habits, conduct, and 
 opinions. He is no more the same ; his former / becomes changed, he 
 becomes estranged to himself (alienated) (see § 5). In order to prove 
 that this change has taken place in the patient, it is necessary that his 
 former habits and character should be made known to the physician, 
 even though solely from the communication of others. The contrast is 
 then often very striking — the temperate man gives himself to drunken- 
 ness, the frivolous pores over the Bible, the bashful becomes impudent, 
 the moral obscene, etc. This change in the mode of thought, in the affec- 
 tions and actions, is more evident the more rapidly it occurs, and more 
 difficult to prove when it comes on gradually in the course of years. 
 Cases of the latter kind are, if the insanity be limited to a slight degree, 
 often very difficult to distinguish from eccentricity, immorality, capri- 
 ciousness, or false views of life. In certain cases, which however are not 
 common, no marked change can be distinguished, but rather a stronger 
 development and increase of prominent peculiarities of character ; and 
 when, in such cases, the mental disturbance comes on slowly and grad- 
 ually, it is difficult satisfactorily to prove insanity : this is seen in many 
 cases_ of gradually increasing morbid desire for law-suits, in slowly in- 
 creasing sensuality and ill-temper. This change is also wanting in con- 
 genital cases, and such as have existed from early youth; also in individ- 
 uals who have been all along eccentric, peculiar, or mentally weak ; and 
 in these cases, when moderate in degree, it is often extremely difficult to 
 diagnose the presence of disease (this difficulty is also felt when called 
 on to distinguish between a slight degree of mental weakness or dementia 
 and stupidity), while peculiarities acquired, and changes of the normal 
 individuality still going on, are generally more easy to determine. From 
 all this we learn that comparison with the former ways of the individual 
 must always be a principal element in the consideration of these ques- 
 tions. 
 
 We must therefore make ourselves acquainted with the antecedents, the his- 
 tory, of the individual. Unfortunately, we are not always assisted in this by the 
 friends and relatives of the patient, but frequently left ignorant, through their 
 silence, of the most essental circumstances ; we often learn more indirectly. 
 Likewise, in the short-lived transitory insanity, as frequently presented in epilep- 
 tics, in drunkards, and sometimes, without special cause, in those predisposed, 
 the total change of the personality during the attack is an important point ; but] 
 indeed, the life of an individual may be such externally that the greatest contrast 
 to his acts is seen during the "attack," while a knowledge of his inner life mio-ht 
 show the cause of the emotion, in the disposition naturally strongest, though 
 perhaps more or less externally concealed, from which these acts emanated. We 
 must, therefore, be very cautious with regard to transitoiy insanity, which is 
 quite familiar to many medical jurists (see Devergie, ' Oii finit la Raison? ou com- 
 mence la Folie? ' " Memoires de I'Acad. de Med.," vol. xxiii., 1859), and generally 
 can be recognized even where the attack presents a dreamlike character, and 
 where, ordinarily, the change of the personality is most complete. We should in 
 all such cases note well the presence or absence of any premonitory symptoms ; 
 complete absence of such is suspicious. 
 
 § 71. (2) Should the consequent change in the habits of the patient 
 or the suspected exaggeration of certain nluises of his individuality have 
 6 ^ 
 
82 ON INSANITY IN GENBRAi. 
 
 occurred under circumstances which, according to experience, may be 
 viewed as causes of insanity, or if the individual has been so situated as 
 to be exposed to important exciting causes, we can, with still greater con- 
 fidence, pronounce his state to be one of mental disease. Hereditary 
 predisposition, nervous constitution, injuries to the head, dissipation, 
 hysteria, epilepsy, may be mentioned as examples of the most important 
 predisposing causes ; while disappointment, fright, acute disease, the 
 puerperal state, are amongst the most frequent exciting causes : the causes 
 will be more closely considered in the following book. But, here also, 
 there is great difficulty in proving and judging of the facts. The judg- 
 ment is particularly difficult in those cases where there are circumstan- 
 ces which are, indeed, important causes of insanity, which in themselves 
 might be considered as symptoms of mental derangement, but which are 
 also very often presented as appearances of immoral desires, and have, 
 without anything morbid, a demoralizing and degrading influence on 
 the character, sentiments, and intelligence. Thus, a dissolute life, and 
 particularly the abuse of alcoholics. Whether the perversity, the blunt- 
 ing of the feelings, and the habitual ill-humor of the drunkard in their 
 moderate degrees should be considered as morbid mental states, is occa- 
 sionally a question which can scarcely be satisfactorily solved. In the 
 higher degrees insanity may always be admitted. In the same way, 
 judgment may occasionally be difficult in cases where very powerful 
 mental causes, motives to violent emotions, have existed, and where 
 mental excitation or depression, with all their consequences, have ensued 
 as natural results of that motive : for example, very great depression 
 emotional after the loss of a fortune or the death of a friend, prolonged 
 excitement after disease. The essential difference between a melancho- 
 lic from mental causes and a person affected with sadness in a healthy 
 way by the same cause is, that, in the latter case reaction takes place on 
 removal of these causes or on the entrance of opposite conditions, while 
 the melancholic cannot rid himself of his morbid grief, and his state con- 
 tinues, at least for a time, even after removal of the external motive : 
 this distinction, however, can scarcely be employed as a practical diagnos- 
 tic basis. The judgment is, as a rule, more easily arrived at when no 
 such external occasional causes of the suspected state, of the consequent 
 change in the habits of the patient, can be discovered — when, therefore, 
 this change cannot be considered as healthy reaction from external events, 
 and when, on the contrary, there exist prepared or predisposing causes, 
 such as hereditary predisposition. Here we discover one of the most 
 essential elements of insanity, viz., abnormal reaction from internal causes, 
 from an abnormal mental etate. If an individual has, on a former occa- 
 sion, suffered from what was unquestionably an attack of insanity, this 
 is of the greatest importance, for we know that a disposition to subse- 
 quent attacks is thereby founded. 
 
 If it were possible, taking into consideration the etiological and path- 
 ogenetic circumstances spoken of in the second book, to demonstrate the 
 development of mental disease purely objectively, and apart from will, a 
 very essential part of the problem would be solved. 
 
 § 72. (3) The symptoms of mental diseases consist only to a small 
 extent of definite, isolated, and unmistakable morbid appearances, ar.d 
 never in any case of directly palpable and physical signs. They depend 
 essentially on the interpretation of the mental acts by an observer ac- 
 quainted with disorders of the mental functions and their modes of expres- 
 sion. Two individuals may say and do the same thing; for example. 
 
ON INSANITY IN GENERAL. 83 
 
 they may express their belief in witchcraft, or the fear of being eternally 
 lost; the intelligent observer would declare the one to be healthy and the 
 other to be insane. This judgment is come to by a consideration of all 
 the accompanying circumstances, and from a knowledge gained by expe- 
 rience of the various forms of insanity and their accompanying phenom- 
 ena: the idea of being eternally lost is a notion entertained so frequently 
 by melancholies, that it must at once awaken the suspicion of melan- 
 cholia, and we may at once proceed to investigate whether the founda- 
 tion of this idea is really that which is seen in melancholia and the delir- 
 ious conceptions which accompany it. 
 
 Should the condition of the jjatient and the collective essential indi- 
 vidual symptoms correspond to the image of one of the principal forms 
 of insanity (to which all classifications must in the end return as they are 
 really founded on nature), mania, melancholia, chronic mania or de- 
 mentia, with the certain diagnosis of this form, of course insanity is 
 also established. But, on the other hand, we cannot, as has been already 
 seen, because the case does not completely coincide with one or other of 
 these principal forms, come to the conclusion that no mental disorder is 
 present. These principal forms have been established by carefully select- 
 ing the most characteristic states and connecting them into typical classes. 
 There are, however, many intermediate conditions, mixed forms, imper- 
 fectly marked states, which do not exactly correspond to these classes. 
 Generally it is not difficult to find out, at least, the general character, 
 whether the state be one of exaltation, depression, or weakness: neverthe- 
 less, in certain cases, such as morbid dulness of sentiment, mania for law- 
 suit, etc., this general character even is not definitely marked. 
 
 The presence of a delusion is not at all necessary to constitute an 
 individual insane, even in the narrowest sense of the term (in contradis- 
 tinction to simple disturbance of the affective sentiments). In many 
 cases no special delusion is present, or, at least, there is none exhibited, 
 but the sentiments, dispositions, and conduct are altered in a morbid 
 manner; and owing to a morbid state of the brain, the individual is 
 influenced so that the healthy faculty of judgment is obscured, the intel- 
 ligence formally involved, and the spirit held in bond. Such an indi- 
 vidual can be "rational," that is, can speak without making great mis- 
 takes on ordinary objective subjects; he can distinguish right from wrong 
 — direct his actions with a proper use of means, with apparent reflection; 
 proves by his conduct that he knows a criminal act, and seeks to avoid 
 the punishment thereof, etc. ; he can, at least for a time, so conduct him- 
 Belf 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 (his former /) 
 and to the world is formed, and the irritation of sentiment can, at any 
 moment, appear in impassioned perverted acts and desires. This is 
 particularly observed in the primary stages of mental disease, and in many 
 moderate cases of melancholia, in the slightest degrees of mania {folie 
 raiso7inante — see further on), and, very frequently, in the early stage of 
 paralytic dementia. 
 
 In criminal cases, the act committed can of itself often give essential 
 aid in answering the question whether the individual is mentally diseased, 
 as, even in the act, there often lies a leading symj^tom of the insanity — 
 indeed, the only ground for the assertion that insanity exists. (I may 
 here note the many instances of murder of their own children. ) In the 
 great majority of cases, however, this is inadmissible and quite impossible; 
 
84 ON INSANITY IN GENERAL. 
 
 we must rather, in order to prove insanity, and that the origin of the 
 deed proceeded from mental disease, endeavor to establish before, exclu- 
 sively and quite independently of the deed itself, the marks of insanity 
 according to origin, symptoms, and course. The opposite course, that 
 of making the deed itself the distinctive mark of an abnormal mental 
 state, has led to the doctrine of instinctive insanity (homicidal mania, 
 cleptomania, etc.), alike dangerous to science and to practice, and has 
 only served to bring the medical opinion, very properly, to bear upon the 
 judges. 
 
 But, finally, are there not cases in which, in criminal deeds, a mor- 
 bid mental state exists and has influence, and yet i)resents no external 
 manifestation? I believe it possible. Who would dare to trust himself 
 to separate his mental mechanism as one would lay open the leaves 
 of a book? Who would dare to deny the possibility of active 
 organic influences of a morbid nature, not externally noticeable, when 
 disturbed and disordered at the moment of action, turning the scales 
 towards crime? In this sense I was compelled to express myself at the 
 bar in the case of a murderer who suffered from well-constituted vertigo 
 epileptica. I was constrained to say that, neither before, nor at, nor 
 after the deed, did we find certain signs of mental disturbance, yet, not- 
 withstanding, it was possible that this disease allowed influences to act 
 on the phenomena of volition, which obscured reflection and weakened 
 the freedom of will, without, however, manifesting themselves by any 
 external symptoms. 
 
 § 73. (4) Symptoms of bodily disease ascertained by the 6tate of the 
 pulse, the digestion, the secretions, etc., cannot naturally, in any case, 
 betaken as proofs of mental disease; the diagnosis depends essentially and 
 exclusively on the mental symptoms. Nevertheless those symptoms of 
 diseases in other parts may be of great value. From them we are enabled 
 to answer the question, Is the individual in a state of general ill-health? 
 If, from these symptoms, this can be said with certainty — if, on the one 
 hand, a striking mental change is observed, or very suspicious behavior, 
 and, on the other, a general morbid state of the organism be present — it 
 becomes highly probable that both series of phenomena are related to 
 €ach other, i. e., that the mental change is itself morbid. As, however, 
 insanity depends essentially on an affection of the brain, there are none 
 of all the psychical symptoms, not in the narrow sense, of greater signifi- 
 cance than certain phenomena of disturbed (irritated, depressed, etc.) 
 cerebral function. Therefore, anomahes of the central sensorial function, 
 hallucinations, etc., are of such extraordinary value, and violent head- 
 aches, sleeplessness, fainting, anaesthesia, changes in the pupils, all con- 
 comitant convulsions and paralyses are also of such great importance, in 
 the diagnosis of insanity. If these symptoms can be traced to an affec- 
 tion of the brain, and if we can, by these, prove that at all events a cere- 
 laral affection is present, it is clear that in few cases we can doubt that the 
 suspected psychical symptoms depend also upon the cerebral affection; at 
 least the opposite can seldom or never be shown. On the other hand, 
 the non-appearance of such further symptoms, and the absence of all 
 physical disorder (of the pulse, digestion, etc.), can never be takenas 
 proof of the absence of a mental disease {i. e. a cerebral affection of which 
 the actual symptoms are exclusively psychical); we frequently meet with 
 cases of undoubted mental disease, especially chronic cases, in which the 
 bodily functions remain unimpaired. 
 
 § 74. (5) From the physiognomy, gestures, words, and actions of an 
 
ON INSANITY IN GENERAL. 85 
 
 individual, we learn the essential symptoms, those of the mental state. 
 But there are cases where the external signs mislead, as tlue insanity is 
 sometimes simulated, or — but not so frequently — feigned. When dis- 
 simulation is suspected, the following circumstances should esijecially be 
 considered. The simulator, if he does not possess special psychiatrical 
 knowledge, very seldom succeeds in correctly feigning the symptoms of 
 any one form of mental disease. He generally mixes the appearances of 
 several forms with each other, so that an unnatural representation of 
 disease is offered. Moreover, he usually overdoes the phenomena of men- 
 tal disturbance. He believes that all must be reversed; instead of giviug 
 expression to delirious conceptions, he talks absurdly, and conducts him- 
 self as if, in insanity, the greater part of the intelligence and of the mem- 
 ory must be disturbed; acts as if he could no longer count, read, write, 
 or tell his name, etc. The simulator is careful, and very often shows 
 great uncertainty in regard to how he can best play the fool; he exi^resses 
 and withholds what would be of advantage or disadvantage to him. He 
 presents few or no general (bodily) morbid symptoms; he requires far 
 more rest and sleep than many patients, and is incapable of continuous 
 muscular exertion (as maniacal excitement continuing for weeks without 
 interruption). Therefore, the quiet forms of insanity are more easily 
 simulated than the very agitated; the easiest mode of deception is to 
 feign imbecility. It may be difficult also to give an opinion in cases 
 Avliere vague delirium with the character of weakness is simulated. Fre- 
 ({uently, observation where it is unremarked by the patient, and even sur- 
 prising him sometimes, leads to our object; but this we do not require to 
 notice further. It is not necessary in this work that we should enter 
 into the subject minutely. It is, however, important to observe that 
 even the existence of simulation is by no means a certain evidence of 
 mental health; the insane themselves frequently simulate: indeed, there 
 is a kind of morbid pleasure connected with this simulating which may 
 be compared to the analogous disposition noticed in hysteria, but must 
 not be identified with it. We may also be brought to the opinion that 
 the individual simulates morbid mental symptoms, but that he is neverthe- 
 less mentally deranged, only in a way different from what he simulates: in 
 such a case, naturally, other signs of insanity must be present. 
 
 Should we suspect that insanity which really exists is feigned by the 
 patient, who is conscious of the disorder, which may be affected particu- 
 larly in the preliminary stages, or even occasionally with fixed melancholic 
 delirious conceptions, when the general disharmony of sentiment has 
 again subsided (H. Hoffmann), a continuous careful observation of him 
 when he thinks he is unnoticed is a most important means of ascertain- 
 ing the truth: it should be particularly observed how he passes the night; 
 opportunities should be given him to express himself upon various themes, 
 when he may occasionally betray himself; his writings, in which insanity 
 often appears more strikingly than in conversation, are specially to be 
 looked at. 
 
 That is not dissimultation when an insane man denies that he is ill— energeti- 
 cally protests against the suspicion of his being insane. A very adroit simulator 
 could also imitate this denial : ordinarily this would appear to him too hazardous; 
 he would show an opposite demeanor, he would readily declare liimself ill, and 
 especially mentally ill. 
 
 § 75. (6) But, simulation excluded, and all that we have hitherto said 
 carefully considered, still, in many eases, the (juestion whether an indi- 
 vidual be insane cannot with certainty be solved. The question, Whether 
 
86 ON INSANITY IN GENERAL. 
 
 mentally diseased or not? is by no means a correct one. There are no 
 well-marked boundaries between health and disease in general; there is 
 in mental as in other pathology, an intermediate territory of disorder 
 which is not yet fully developed disease, and where the individual still ex- 
 hibits many of the characteristics of health. Is not this the case with the 
 simplest bodily troubles? Where is the exact point at which we pronounce 
 a man blind ? Only where there is absolutely no appearance of light? Or, 
 who is dumb? Who is dropsical? The individual who has the slightest 
 trace of oedema? If not, where does the limit of dropsy commence? When 
 there are extremes, all are agreed. When the degrees are slight, we 
 may even argue whether these signs may be taken into consideration in 
 the case. 
 
 In mental medicine, however, many medico-legal cases fall within this 
 category; for exam23le, of deeds done in passion by persons habitually 
 moody, and those of weak intellect — of habitual moderate excitement, or 
 of perverseness with temporary distraction, of drunkenness, hysteria, etc. ; 
 cases of which it must ordinarily be said that the individuals are not in 
 a healthy mental state, but the marks of definite mental disease cannot 
 be clearly discovered; therefore, it is more probable than certain that 
 their actions are regulated, or at least greatly influenced, by morbid 
 organic causes. In the mode in which these actions are expressed there 
 is, indeed, no marked line of distinction between eccentricity, passion, 
 perversity of desire, dulness of sentiment, and mental disease; there is no 
 constant sign from which we can tell Avhether those states result entirely 
 from organic disease (morbid), or only partially from such, or whether 
 they exist without organic influence, as original traits of character, or as 
 the hereditary results of the psychical individuality. All existing phe- 
 noma of cerebral disorder, hallucinations, paralysis, etc., and all physical 
 morbid appearances, are here of special value. 
 
 We must bear in mind that in very many cases there are few distinct, clear, 
 and perfectly demonstrable signs of mental diseases or health — that the general 
 and collective impression of tlie patient and his acts much more determines the 
 opinion. On such a collective impression, however, only the man who thoroughly 
 understands the question, an intelligent physician, ought to proceed. A subjec- 
 tive view of a case by one man, who at the moment cannot clearly show on what 
 individual grounds he forms his conclusion, may be highly valuable — by another 
 man quite wortliless. We must not therefore believe that every physician to an 
 asylum is capable of so judging. 
 
 § 7G. It is now evident that the question whether an individual be 
 mentally diseased can only be decided by a careful personal examination; 
 nevertheless, very recently, and in some cases perhaps still, the physician 
 is expected to state his opinion merely from a description of the actions. 
 After becoming acquainted with the chief facts of the case, we at once 
 proceed to a personal examination of the patient. Not unfref^uent- 
 ly, the very state of what immediately surrounds him shows, to the 
 experienced eye, in the most unmistakable manner how matters stand: 
 the apartment is fantasically decorated, the clothing is odd, disorderly, 
 torn; there are marks of neglect, of dirty habits, freakislmess, all of 
 which were before foreign to tiie individual. In the next place — with- 
 out showing the patient that any particular attention is directed to 
 him — his physiognomy, his bearing, his conduct, are to be observed, es- 
 pecially in so far as they are expressions of certain dispositions: the 
 countenance in the really insane is frequently strikingly altered, or irreg- 
 ularly distorted, clearly expressing certain passions aud emotions; the 
 voice may, ])articularly in melancholies, be often takeu as a true expres- 
 
ON INSANITY IN GENERAL. 87 
 
 sion of the ruling disposition. Conversation with the patient must, as 
 far as possible, be carried naturally and calmly; sympathy should be 
 shown, we shoud seek to rouse his attention and gain his confidence. In 
 general, it is best to commence with questions regarding the bodily sensa- 
 tion, certain requirements or wishes, etc. ; then to proceed to the former 
 life of the individual, the history of whicli we allow him to relate in an 
 unconstrained manner; hereby we seek to understand his story, views 
 of life, interests, hopes, and plans, in order to receive from these, in 
 connection with that communicated by others, a collective picture of 
 his former individuality. We inquire into his present disposition, his 
 given intelligence, his conduct (especially according to the point of view 
 in the preceding chapter and third book). In how far these have be- 
 come altered in his present state, what has occasioned these changes — 
 whether they are to be considered as really morbid, whether any criminal 
 deed might result from the morbid disposition or mental condition — be- 
 come now objects of our judgment; we may conclude by a minute inves- 
 tigation of the general physical state, and an examination of the several 
 organs, the lungs, the heart, the arteries (so very important), the organs 
 of digestion, the secretions, etc. All signs of paralysis, faltering in 
 speech, dissimilarity of the pupils, etc., are particularly to be noted. 
 The primary stage of paralytic dementia frequently appears in the form 
 of folie raisonnante, of perverted activity with relatively little disturbance 
 of the intellectual faculties, which leads the patient to commit illegal acts, 
 especially to steal. The patient must continue under observation until a 
 definite conclusion can be arrived at, or until it becomes evident to us 
 that no decision can at present be come to, and that any further exami- 
 nation would elicit nothing essentially new. 
 
 § 77. The other question, whether an individual whose psychical 
 functions are disturbed suffers from a so-called mental disease in the nar- 
 row sense of the term (§ 6), or from some other cerebral disturbance or 
 disease, cannot, in many cases, be definitively solved, because various 
 kinds of cerebral affections may appear as mental diseases (§ 6). But 
 gross errors can and must be avoided; and above all, we must endeavor 
 to establish a diagnosis, in some degree special, of the cerebral affection. 
 The most frequent mistakes are made in intoxication, in typhus fever, 
 and in acute meningitis. 
 
 Intoxication is generally very easily distinguished by the smell of the 
 breath after the abuse of alcoholics, from the imperfect utterance which 
 never appears at the outset of mental disease, and from the rapidly en- 
 suing drowsiness and desire to sleep. It has, however, been occasionally 
 observed that a fit of drunkenness has occasioned the acute commencement 
 of insanity (but in every case predisposed from other causes), and, 
 further, that there are certain specially predisposed individuals who, even 
 after a moderate indulgence in the use of spirits, fall into a state of ex- 
 citement which has more the character of mania than of drunkenness. 
 
 Typhus fever, in its first periods, occasionally appears under the form 
 of a maniacal attack with great excitement, attempting to get out at the 
 window, etc., and cerebral congestion, or even under the form of melan- 
 cholia with stupor; or as a more vague delirium, in which the patient 
 may walk about for a certain time. In all mental disorders coming on 
 unexpectedly in young persons, we should keep in view the probabilty 
 of typhus fever, more especially when it is epidemic. First of all, we 
 note the feverishness (especially the increased temperature as shown by 
 the thermometer), the nightly exacerbations — the full, weak pulse — the 
 
88 ON INSANITY IN GENERAL. 
 
 splenic enlargement, the roseola, the meteorismus, the yellow flocculent 
 stools. 
 
 Not long ago, a young man was brought to me at the hospital as mentally dis- 
 eased ; he had for several days shown symptoms of bewilderment, and on the 
 previous night had left his room by the Avindow and proceeded to his office at a 
 distance. The great uncertainty of gait, complete incoherence, hesitation in 
 speech, marked inequality of the pupils, permitted, in the absence of other history, 
 the assumption of quickly developing mental disease with paralysis ; the hot dry 
 skin, and frequent, full, compressible pulse, awakened in me, at the same time, 
 the suspicion of fever. As soon as the patient was laid in bed, the diagnosis could 
 with certainty be established : the course of the disease was serious, but ended 
 in recovery. It is a well known fact that, at one time, a German psychologist who 
 was ill of typhus fever was sent to an asylum as insane by one of his colleagues. 
 
 Acute meningitis with strong inflammation at the convexity is mani- 
 fested by violent headache, vomiting, ordinary delirious excitement, con- 
 vulsive appearances, changes in the pu})ils ; it is always accompanied 
 by high fever — the patient is compelled to keep in bed. This disease is, 
 on the whole, rare, and its course is rapid; in the majority of cases there 
 is rapid sinking of the vital powers; decreasing pulse, coma, and destruc- 
 tion of all the mental faculties. Basilar meningitis and tlie tubercular 
 affections of the membranes present essentially the same symptoms, but 
 a somewhat more protracted and irregular course. As a rule, tuberculosis 
 of the lungs may be discovered; where this does not exist, the diagnosis 
 from the first form is, in adults, uncertain. From what has been said, 
 it is certainly but seldom that these forms can be confounded with 
 mental disease ; still, there are cases of somewhat protracted moderate 
 tubercular basilar meningitis which may again improve, and which pre- 
 sent the appearances of mania (but with convulsion, contraction of the 
 cervical muscles, etc.), and now and then, recent and rapidly fatal cases 
 are actually brought to asylums as cases of mania. From this diagnostic 
 question, that disease which according to the older pathology was desig- 
 nated meningitis is to be quite excluded; for the so-called chronic men- 
 ingitis there are no completely satisfactory diagnostic signs. 
 
 When, however, these great mistakes are excluded, when it is clearly 
 established that the patient is mentally diseased, then commences a new 
 series of diagnostic questions; namely, which state of the brain may, in 
 this concrete case, lie at the foundation of the mental disorder (§ 6). 
 In this, the same fundamental principles of diagnosis hold good as in all 
 other affections of the brain. An evident disease within the cranium is, 
 if any paralytic appearances are manifested, probably unilateral; states of 
 congestion are arrived at by their well-known signs (heat, redness, etc.). 
 In the immense majority of cases no definite anatomical diagnosis can 
 be established, but the general (and very important) symptomatic phy- 
 siological diagnosis, whether the symptoms represent more a state of 
 active irritation, or of torpor, or of exhaustion of the cerebral functions; 
 this is to be determined, not by the psychical symptoms alone, but by all 
 the appearances collectively. Now we come to the concluding series of 
 questions — viz., whether the existing cerebral disturbance is primary and 
 idiopathic, or secondary and sympathetic (from disease of other organs, 
 from changes in the blood, etc.); in a word, the question of pathogenesis, 
 the solution of which is to be sought from the present symptoms in con- 
 nection with the etiology and history of origin of the disease (see the 
 following book). 
 
THE CAUSES OF INSANITY. 89 
 
 BOOK seco:n"d. 
 
 THE CAUSE AND MODE OF ORIGIN OF MENTAL DISEASE. 
 
 CHAPTER I. 
 THE CAUSES OF INSANITY. 
 
 § 78. Under the head of Causes in mental as in general pathology 
 are nnderstood all the different classes of circumstances to which may 
 be ascribed an iniiuence on the development of the disease, although 
 their mode of connection may be variously exhibited. The causes com- 
 prehend, on the one hand, the external circumstances (nationality, 
 climate, season of the year) under the influence of which insanity is 
 generally, with more or less frequency, observed; on the other hand, they 
 signify certain external injuries (sunstroke, wounds of the head) of 
 Avhich insanity is frequently a consequence; finally, they comprehend 
 certain internal states dependent of the organism itself (hereditary dis- 
 jjosition, previous disease, or other general disturbance of the organic 
 mechanism, such as disease of the lungs, the genital organs, etc. ) which 
 we know by experience have an influence in the development of insanity. 
 In very many of these circumstances the intimate connection between 
 them and the influences ascribed to them, the mode in which from them 
 the mental disease is developed, is scarcely ever or not at all evident. 
 The conclusion post Jioc ergo proijter hoc dej)ends, therefore, only on a 
 simply empirical (statistical) knowledge of the fact that these particular 
 circumstances (for example, hereditary disposition) very frequently coin- 
 cide with, or precede, the commencement of the insanity. In other of 
 these so-called causes, their mode of action, the manner in which, in 
 consequence in them, the disease is established, can be comprehended. 
 But the province of etiology in the narrow sense is only to enumerate 
 empirically the known circumstances of causation; it belongs to patho- 
 geny to explain the physiological connection between cause and effect, to 
 show the particular mechanical act by means of which insanity is induced 
 through a given circumstance (for example, excessive depressing emotion, 
 heart-disease, etc.), a task towards which we have hitherto done little 
 more than prepare the way. 
 
 § 79. Etiology, and especially pathogeny, are of the utmost import- 
 ance in the j^ractice of mental medicine. If, then, the old saying sublata 
 causa tollitur effectus is no longer sanctioned in this, as in general' medi- 
 cine, in fully developed and confirmed disease, and if, likewise, the 
 removal of many remote causes is beyond the power of the physician,. 
 
90 THE CAUSES OF INSANITY. 
 
 still we frequently see, especially in commencing insanity, that by removal 
 of certain of the many ordinary co-operating causes, the disease may be 
 successfully combated, and especially all the various periods of transition 
 in the disease, all those organic disorders which pathogeny points out as 
 intermediate between the external causes and the develojjed cerebral 
 disease which is their final result, present rich opportunities for medical 
 treatment. Further, even the theory of insanity cannot be understood 
 without a full knowledge of its causes and of its mode of progress in indi- 
 vidual cases: therefore, the etiological questions are the most important 
 iu tlie whole range of mental therapeutics. 
 
 In concrete cases, we deduce the etiological circumstances from the 
 history of the case; and this is always to be collected with the greatest 
 care and strict attention to. the minute details. It is here necessary, in 
 the first place, to guard against the great mistakes of assuming, without 
 satisfactory evidence, the conjectures of those who have hitherto sur- 
 rounded the patient regarding the origin of the disease, or, as happens 
 so often, of considering as real causes even decided symptoms of the 
 commencing insanity, or only the last accidental circumstance which 
 caused its evident outbreak. We ought not, however, as a rule, to be 
 satisfied merely with the striking bodily or mental circumstances which 
 immediately preceded insanity, but must assume a position from which 
 the present morbid state can appear as the ultimate result of all the pre- 
 ceding circumstances of life. The inquiry into the history of the case 
 ought to embrace the whole of the bodily and mental antecedents of the 
 individual. It must commence ab ovo, indeed from former generations — 
 family predisposition — and minutely trace the bodily development, habit- 
 ual state of health, the nature of the diseases to which the patient is 
 subject, and of those which he has already had. Likewise, as regards 
 the mental sphere, we must faithfully and intelligently comprehend the 
 relation of the predispositions and congenital peculiarities of disposition, 
 the degree of education, and the governing inclinations of the individual 
 — his mode of life and views of the world, his outward position and 
 the nature of his thoughts; thus endeavoring to gain a full picture of the 
 history of the individuality. Only in this way is an insight into the 
 true history of these diseases possible; only thus can we succeed in grasp- 
 ing at their beginnings those fine threads which have ultimately en- 
 twined themselves into delirious conceptions; only thus can we, in many 
 cases where insanity appears suddenly and apparently without motive, 
 recognize the far-back commencement of the preparation for the disease, 
 and the almost mathematical necessity of its occurrence. All this is of 
 the highest importance in a system of treatment which gathers from the 
 history of the case indications, sometimes for the amelioration of invet- 
 erate chronic morbid processes, at others for the removal of certain psy- 
 chical causes, and which requires a profound knowledge of the character 
 of the individual to enable us to employ all his inherent resources in 
 support of our active treatment. 
 
 The opinions of those about the patient regarding the etiology of the disease 
 are more frequently erroneous than correct, and almost always are at least one- 
 sided. By laymen, and even by physicians, symptoms of commencing and occa- 
 sionally of already confirmed insanity are frequently regarded as causes. In the 
 commencement of the mental disease, a strong desire for alcoholics, or strong 
 sexual irritation leading to excesses or to onanism, can, for example, appear as 
 sj'mptoms ; the already existing emotional excitement may occasion indiscreet 
 connections, rash speculations, religious vexations and discussions, and the error 
 is often committed of ascribing the disease to drunkenness, unfortunate love, an 
 
THK CAUSES OF INSANITY. 91 
 
 unlucky venture, religion, etc., etc. So, also, it very often happens that insanity is 
 considered by the friends of the patient or by an experienced physician as of 
 recent origin, which, on closer investigation, shows itself to be of many years' 
 standing and already deeply rooted. Pinel himself relates the case of a patient 
 who was said to have been nine months insane, while in fact the disease had 
 existed for hfteen years. 
 
 The German psychologists claim the merit of having always understood the 
 etiology and pathogeny of insanity more thoroughly and correctly, and of having 
 more successfully elaborated it, than the French school. While the latter, partly 
 even in recent times (Moreau de Jonnes, Brierre, Parchappe), still adhere to 
 abstract tables of physical and moral causes, in which drunkenness, epilepsy, 
 ambition, prostitution, politics, loss of fortune, etc., are ranged as being of equal 
 importance, the German psychologists (Heinroth and Ideler from the psychical 
 side — Bergmann, Flemming, Jacobi, Jessen, Nasse, Zeller, etc., partly with 
 greater regard to bodily causes) have for long insisted on investigating the causes 
 in each individual case ; and it has been more the plan with us most carefully to 
 consider all the circumstances, in their various connections, which can influence 
 the development of the morbid state. 
 
 § 80. A closer investigation of the etiology of insanity soon shows 
 that, in the great majority of eases, it was not a single specific cause under 
 the influence of which the disease was finally established, but a compli- 
 cation of several, sometimes numerous, causes both predisposing and 
 exciting. Very often the germs of the disease are laid in those early 
 periods of life from which the commencement of the formation of cliarac- 
 ter dates. It grows by education and external influences, or in spite of 
 these, and it is but seldom that the abnormal psychical irritability attains 
 either gradually or through scarcely noticeable intermediate stages to an 
 evident disorder of mental function. More frequently there are a gi-eater 
 number of psychical impressions and bodily disorders, by the successive 
 influences or unfavorable combinations of wliich the disease is developed. 
 It is then not to be ascribed to any one of these circumstances, but to 
 them as a whole. Thus, for example, we see in the concrete cases, long- 
 continued drunkenness and violent emotion, hereditary disposition, domes- 
 tic unquiet, and heart disease — childbirth and violent anger or shock — 
 disappointed love and commencing tuberculosis; in short, we generally 
 see several injurious influences acting on the organism, or states of disease 
 already present — and often more numerous and more complicated than 
 these examples — appear as causes of insanity. 
 
 The difficulty lies in the proper appreciation of the influence which each one 
 of these circumstances has on the production of the disease. We must here 
 endeavor by every means to keep the mind unbiassed by this or that theory, and 
 from one-sided preference of one or of certain series of causes ; for example, the 
 somatic or the mental. The judgment ought only to be guided by a minute 
 investigation of the facts of the case ; where empirical data as to the cause are in 
 any case wanting, they ought not to be supplied by conjectures, and tlie importance 
 of the single circumstances present is to enable us to conform to the principles of 
 a rational pathology. 
 
 An influence of causation can naturally be attributed with most certainty to 
 those circumstances w^hose mode of action can be clearly traced, and whose 
 effects therefore may be considered as physiological necessities ; or, where this 
 is not the case, to those whose influence is established by reliable statistics. A 
 slight gastric affection, haemorrhoids, or a transient cutaneous eruption, cannot, 
 for example, be considered as causes, because no statistics warrant the opinion, 
 no visible connection exists between these affections and insanity either as to 
 their gravity or nature. On the contrary, disease of the heart or of the arteries 
 are manifestly important etiological circumstances, as they can affect the circula- 
 tion within the cranium. Depressing emotions would appear to be such, though 
 little is known I'egarding their mode of action, because they — as statistics incon- 
 testably show — very frequently precede the coming on of insanity. The possi- 
 l)ility of mental disease originating from the irritation produced by intestinal 
 
92 THE CAUSES OF INSANITY. 
 
 worms (taenia) can scarcely be entirely rejected, as we occasionally see other 
 serious cerebral diseases (epilepsy) originate from them. We should always bear 
 in mind that anything, to be a cause, must really precede the presumed effect : 
 we should not, for example, when serious disorder of the digestive organs appears 
 simultaneously with the commencement of insanity, conclude that chronic disease 
 of the abdomen is the cause of the insanity. In some cases all etiological data 
 utterly fail, and the insanity originates gradually, like many other chronic dis- 
 eases, from influences wholly unknown. Nothing is more erroneous than here 
 to suppose an imaginary bodily cause, and to allow such a supposition to influence 
 our mode of treatment, as, even in the present day, is so often done, especially by 
 the votaries of the so-called somatic school. 
 
 § 81. After extensive observation and comparison, we find that the 
 etiology of insanity is in general none other than that of any other cere- 
 bral or nervous disease. In particular, the etiology of epilepsy and of the 
 states of chronic irritation of the spinal cord offer instructive analogies as 
 Avell in regard to predisposing as to the more immediate causes. Ex- 
 cluding the predisposition circumstances (period of life, hereditary pre- 
 disposition, certain errors in education), we find that in all these diseases 
 two distinct modes of origin may be recognized : in the first place, an ori- 
 gin (idiopathic) from influences working directly on the brain — shock, 
 injury, excessive fatigue and exhaustion of the brain and entire nervous 
 system, alcoholics, narcotics, excessive mental irritation through emotion, 
 and the like; in the second place, an origin (symptomatic) resulting from 
 other further morbid changes in the organism through which the func- 
 tion of the brain becomes affected. These different morbid states now 
 appear to act upon the brain principally in three different ways: in the 
 first place, by generating or favoring anomalies in the circulation (hyper- 
 emia, angemia) within the cranium (diseases of the heart and arteries); 
 in the second place, by nervous irritation of the brain, which we can 
 scarcely otherwise account for than by communication and transmission 
 of peripheral irritation of certain nerves to the central organ, occurring 
 to a certain extent in a reflex manner (injury of a peripheral nerve, influ- 
 ence of the sexual organs, etc. ) ; in the third place, by deficient nutrition 
 and excitation of the brain in consequence of dyscrasia (general anemia, 
 etc.). 
 
 On this account, the distinction between an idiopathic and symptomatic origin 
 of insanity cannot in the concrete cases be fully carried out. It is here just as in 
 epilepsy, in which it has been frequently attempted. This is explained by the 
 fact that, on the one hand, in general many injurious influences are at work 
 which act in different ways ; and, on the other hand, that certain etiological cir- 
 cumstances, especially the all-important pressing emotions, not only in different 
 cases, but also simultaneously in the same individual, may affect the brain either 
 primarily, or secondarily and indirectly, in consequence of chronic affection 
 of other organs and general destruction of the constitution. 
 
 In so far, however, as it can be established and proved, this distinction is very 
 valuable. It agrees in part with the distinction between mental disease resulting 
 from anatomical changes within the cranial cavity, and those existing without 
 any palpable disease of the brain or its membranes. In the latter states the 
 insanity is frequently transient, dependent on morbid conditions of other organs, 
 and a purely functional disorder (for example, the hysterical insanity from 
 anaemia or disease of the genital organs) : in the first group, again, the cerebral 
 disease is more fixed and more independent ; for example, paralytic dementia, 
 the chronic mental weakness of drunkards, etc. 
 
 In the following remarks on the various classes of etiological circum- 
 stances, their mode of action will be minutely considered. In their 
 enumeration we shall adhere to the customary division into predisposing 
 circumstances and special causes (not altogether correctly exciting or 
 
THE CAUSES OF INSANITY. 93 
 
 occasional causes), which, notwithstanding certain of the influences to be 
 mentioned (for example, disorders of menstruation, psychical influences), 
 can act sometimes as predisposing, sometimes as exciting causes. In this 
 arrangement, which at present is the most convenient, any departure from 
 scientific exactness may be compensated for by a careful analysis of indi- 
 vidual cases. 
 
 !£ SS- 
 
94r THE CAUSES OF INSANITY. 
 
 CHAPTER II. 
 THE PREDISPOSING CAUSES OF MENTAL DISEASE. 
 
 § 82. If we consider the extreme frequency of all the injurious influ- 
 ences which have been enumerated as causes of mental disease, and the 
 comparative variety of their direct orgin from these causes, we are of 
 necessity led to the assumption that certain preparatory circumstances 
 are requisite in order that, in individual cases, disease generally, and in 
 particular this disease, may arise — that a certain susceptibility and pre- 
 disposition to such diseases must advance to meet the sometimes slight 
 exciting causes. Indeed, in the present state of science, we are neces- 
 sitated to admit this assumption in most diseases of the nervous system. 
 The cases of injury are innumerable, and it is only seldom that tetanus 
 succeeds them. Numbers of children suffer from worms, and few only 
 fall into convulsions; many individuals live under conditions Avhich are 
 acknowledged to exert a powerful influence on the development of men- 
 tal diseases, and only a few of them really become insane. Should we at- 
 tempt to explain these neuroses, which cannot be more definitely accounted 
 for by the assumption of a special disposition of the nervous system, it 
 may appear, indeed, that we are but using empty words concerning an 
 unknown subject; but sometimes a more minute investigation permits u& 
 here to penetrate into the more intimate relations of this disposition. 
 We, know, for example, that in warm countries tetanus more frequently 
 suceeds injury than in our climate, that this complication is favored by a 
 cold caught at the time of the accident, or by mental irritation and the 
 like. The same may be said of insanity. We know by experience that 
 there are series of circumstances which have a preparing and favoring 
 influence on its origin. The study of the predisposing causes of mental 
 diseases embraces, on the one hand, the consideration of those more dis- 
 tant relations which mjluence whole communities, and can only be shown 
 by statistics, their mode of action on individuals being quite uninvestig- 
 at)le, — viz., nationality, climate, season of the year, sex, age, difference 
 of social position, and the estimation of their influence on the origm of 
 these diseases: on the other hand, together with these general relations, 
 we have also to analyze the individual predisposition congenital and 
 acquired, such as hereditary disposition, education, constitution, pecu- 
 liarities of character, bad habits, etc. Doubtless, the predisposing circum- 
 stances are more important, stronger, and act more frequently in the pro- 
 duction of insanity than the occasional causes. He who has a strong 
 individual predisposition, especially if of a certain definite kind, is endan- 
 gered by the slightest occasional causes; while the man in whom this is 
 entirely absent can be exposed to the most serious conflicts with perfect 
 safety to his mental health. 
 
 SECTioisr I. — General Predisposing Causes, 
 
 § 83. 1. Nationality. — The idea of nationality includes a number of 
 the most varied relations — the climate, the fertility of the soil, the prin- 
 
THE CAUSES OF INSANITY. 95 
 
 cipal employments of the inhabitants, the dominant religious creed, the 
 degree of civilization, the public morality, the previous lot of the people, 
 the form of government, etc. These all co-operate to form certain 
 national peculiarities which are propagated as persistent types from father 
 to son; but as all these circumstances act only when combined and asso- 
 ciated, it is impossible to accord to each of them individually its influence 
 on the origin of insanity — it is only statistically that the reports concern- 
 ing the frequency or rarity of insanity in the various countries can be 
 compared, and even this leads to little satisfactory results. Of scarcely 
 any country in the world do we possess quite trustworthy statistics. 
 Where more exact reports are presented, they are often rendered compara- 
 tively useless, owing to their not being collected according to the same 
 method, and especially — a great source of diiference of numbers — owing 
 to the mixing of two states which ought naturally to be separated — insan- 
 ity proper, and idiocy and cretinism. Of many districts our knowledge 
 is limited to an average calculation of the number of the insane in asy- 
 lums, so various in different countries. The unsatisfactoriness of this is 
 self-evident. There is still another possible source of considerable mis- 
 take which cannot be completely elucidated, namely, the probably differ- 
 ent duration of life amongst the insane in different countries (where life 
 is more prolonged, the number appears greater). It will be well, there- 
 fore, to accept the following statement with great reservation. ' 
 
 § 84. For the countries of Germany there are many statistics pre- 
 pared at different times, and differing much in value. We shall only 
 mention a few of the most interesting. 
 
 In the Rhenish provinces of Prussia, the number of the insane in 
 relation to that of the community was, in the year 1838, 1 in 1027; more 
 recently Jacobi estimated it at 1 in 666. In Westphalia, in 1836, 1 in 
 1590; or, inclusive of idiots, 1 in 846. In Silesia, in 1833, 1 in 1160; in 
 1853 there were in this province 3147 insane, of whom 969 were idiots, 
 either congenital or from early infancy. In the province of Saxony, in 
 1836, 1 in 968. In Old Pomerania, in 1847, 1 in 931. 
 
 For Austria we have very meagre statistics. In 1849 there were, in 
 the twelve kingdoms comprising the empire, with 33,643,000 inhabitants, 
 6254 insane in asylums (in eight of these kingdoms there were, at that 
 time no asylums). In Moravia and Austrian Silesia there were, in 1857, 
 1740 insane, of which, however, 1375 had congenital mental disorders; so 
 that (excluding these) there were only 7.8 insane to every 10,000 inhab- 
 itants. 
 
 More trustworthy results are afforded by the recent calculations made 
 in several of the smaller German States. In Wiirtemberg, where in 1833 
 there was 1 case of mental disease (exclusive of idiots) to 1500 inhabitants, 
 in 1853 there were 1917 insane and 3740 congenital idiots; of the first 
 there was 1 to 943 inhabitants. In Hanover a calculation made in 1836 
 gave as a result 3084 insane (1 to 590 inhabitants). In Baden there 
 Avere, in 1850, on the whole, about 3000 insane including cretins, or 1 to 
 454 inhabitants. In the Palatinate of Bavaria (according to Dick), in 
 1856, there were 418 insane (1 in 1374 inhabitants) and 563 idiots (1 in 
 1030 inhabitants). In the Bavarian district of Upper Franconia (accord- 
 ing to Stahl), there were, in 1850-53, about 450 insane (1 in 1046 in- 
 
 ' The following are gathered from the best sources up to 1859. Frequently, 
 however, I have been obliged to limit myself entirely to older statistics, owing 
 to the want of reliable reports of more recent date. Quotations have only been, 
 made use of in certain special cases. 
 
96 THE CAUSES OF INSANITY. 
 
 habitants). In Oldenburg there was, in 1845, 1 insane (including idiots) 
 in 636 inhabitants. In Brunswick (including idiots), 1 in 539 inhabi- 
 tants. In the Duchies of Anhalt, in 1849, nearly 1 in 450 inhabitants. 
 In Nassau, in 1840, 1 in 607— in 1856, 1 in 378 inhabitants. The chief 
 differences in these figures do not certainly depend on differences of the 
 actual number of the insane, but rather on the varying frequency of 
 idiocy and cretinism, and especially on the fact that the calculations were 
 based on different principles and made in various ways. At all events, 
 these recent calculations give the general results that the average num- 
 ber formerly assumed as well for Germany as for the other countries of 
 Central Europe, of about 1 insane in 1000 inhabitants, is much too low; 
 that it should (including idiots) rather be taken at 1 in 500 inhabitants. 
 The lunatic asylums of all Germany contained, in 1852, 11,663 patients 
 <Lahr). 
 
 In France the old statistics calculate 1 insane in 1900, or, according 
 to the probably more correct valuation of Pierquin and Brierre, 1 in 1000: 
 a more recent calculation (1853) gives 1 in 800 (795 inhabitants). In Bel- 
 gium the proportion stood, in 1835, at 1.33 to 1000. Guislain considered 
 this number far too small; but as he repeated them in the * Lemons ora- 
 les,' 1853, it would appear that up to that date no new calculation had been 
 made. Moreover, the number of the insane varies very much in differ- 
 •ent provinces. In Eastern Flanders the proportion is 1.73; in Western 
 Flanders, 1.33. In Luxembourg, only 0.51 to 1000 inhabitants. In 
 Ghent there is 1 insane in. 303; in the province, 1 in 1473 inhabitants 
 (Guislain, 1853): in 1853 the total number of the insane amounted to 
 about 5500. In Holland there were found, in 1850, 3056 mentally diseased 
 (1 to 1000 inhabitants). Schroder van der Kolk considers this estimate 
 too small, and that 1 in 800 would be more correct. 
 
 In England, Scotland, and Ireland, there were, in 1847, 41,810 pa- 
 tients in asylums. The proportion of the insane to the population has 
 been estimated by Pierquin at 1 in 783; by Hitch, for Wales alone, at 
 1 in 500; by Tuke, 1858, for England and Wales (including idiots), 
 1 in 300. In Scotland, in 1855 (including idiots) the proportion was 1 in 
 390. In Ireland, 1 in 569. 
 
 For Denmark (exclusive of the Duchies and the Colonies) it was calcu- 
 lated that in 1847 there where 1761 insane, and 1995 idiots and cretins. 
 In the Faroe Islands there was 1 insane in 114 inhabitants: almost one 
 third of these, however, were cretins. In Norway, in 1835, there was 1 
 insane in 334 inhabitants; in 1845, 1 in 309 — in 1855, 1 in 239 inhabit- 
 ants. Amongst the insane, numbering 6340, there were, however, 4911 
 cases of mental weakness, of which almost two-thirds were congenital. 
 
 Kegarding Italy and Spain no comprehensive or reliable statistics are 
 known to me. 
 
 As to the countries of the East, no correct valuation can as yet be 
 made. There are, however, a few exceptions: for example, Malta, where 
 in 1836 there was 1 case in 7-800 inhabitants, and the Greek population 
 of Smyrna, where there was 1 in 1000 (Horeau). This is not without 
 interest, as it shows that in spite of the great difference of climate, we 
 find in these places, where European civilization predominates, the same 
 proportion of insane as is found at the same period in European countries. 
 It is generally supposed that the number of those afflicted with mental 
 disease is smaller in the East than in civilized Europe: I will not deny 
 this, but I have convinced myself than in the towns a great many insane 
 persons appear as beggars, fanatics, etc. ; Cairo abounds in such semi- or 
 
THE CAUSES OF INSANITY. 97 
 
 often wholly-demented individuals, and he who would form his opinion 
 from the small number of insane in the asylum at Boulak, near Cairo, 
 would very much deceive himself. In general, the remarks of travellers 
 in half or uncivilized countries concerning the frequency of insanity are 
 entirely worthless. ' 
 
 For the United States of America the number of the insane in the State 
 of New York, in 1825, amounted to 1 in 7-800; in Massachusetts, in 
 1854 (including idiots), to 1 in 302. In 1849 it was calculated that in 
 the Union there was 1 insane in 500 inhabitants: more recent reports, 
 however, give a much higher proportion. According to Brigham, of 
 Boston, the proportion of the insane is in North America almost three 
 times as great as in England — a consequence of the immense commercial, 
 political, and religious excitement.'' In the States of La Plata, mental 
 disease is very frequent (Saurel). In the East Indies it is not rare, but 
 not so frequent as in Europe (Wise, physician to a lunatic asylum in 
 Bengal). 
 
 § 85. From the discrepancy and insufficiency of these statistics, it is 
 •evident that we are deficient in the very first elements necessary to the 
 solution of the much-discussed and ambiguous question, whether the •pro- 
 gress of civilization has increased the number of these diseases. We 
 possess no trustworthy statistics from uncivilized countries to compare 
 with those of civilized, nor have we from by-gone centuries any informa- 
 tion to enable us to make a comparison with present conditions; and even 
 if we had such statistics, they would not enable us to j^enetrate entirely 
 this complex question. The question of the influence of modern civiliza- 
 tion ought rather to resolve itself into a series of isolated problems, such 
 as the influence of the increasing growth of the population in large towns, 
 the influence of the manufacturing industries peculiar to many country 
 places, the influence of the diffusion of education, the press, etc. Hither- 
 to it may be considered possible that the constantly increasing number 
 •of the insane which is almost universally remarked is only a23parent, and 
 that it is owing to the increase of the population, the great attention now 
 paid to mental diseases, the more exact methods employed to ascertain 
 their existence, and to the circumstance that all improvements in asylum 
 matters lengthen the period of life amongst the inmates, thereby causing 
 the admissions greatly to exceed the number of deaths, and the patients 
 •consequently accumulate. It is, I say, possible that it may be so, but 
 very improbable; and I would rather coincide with the opinion of most 
 medical psjxhologists, that the increase of insanity in recent times is real, 
 and quite in accordance with the relations of modern society, in wliich 
 certain causes, according to experience, exerting a great influence, which 
 cannot however be quite expressed in figures, have become stronger and 
 more extended. The progress of industry, art, and science necessitates 
 & general increase of the cerebral functions; the constantly increasing de- 
 jjarture from simple modes of life, and extension of the more refined 
 mental and physical enjoyments, bring with them desires and emotions 
 formerly unknown. The general possession of a liberal education awak- 
 ens in the minds of many a feeling of ambition which few only can 
 gratify, and which brings to the majority but bitter deception. Indus- 
 
 ' It may be left to the reader to judge of the value of the statement of Dr. 
 Butler, who spent twenty-five years among the Cherokee Indians, that during 
 that period he had never seen a well-marked case of insanity. — Bucknill and 
 Tuke, ' Psychological Medicine,' London, 1858, p. 46. 
 
 - Holland, ' Chapters on Mental Physiology,' p. 77. 
 
98 THE CAUSES OF INSANITY. 
 
 trial, political, and social agitations work destructively on individuals, as 
 they do on the masses; all live faster — a feverish pursuit of gain and 
 pleasure, and great discussions upon political and social questions, keep 
 the world in constant commotion. We may say, with Guislain, tliat the 
 present state of society in Europe and America keeps up a general half- 
 intoxicating state of cerebral irritation which is far removed from a 
 natural and healthy condition, and must predispose to mental disorder: 
 thus many become insane. The demoralizing influence of large towns— 
 in Paris it is estimated that there are 63,000 individuals who maintain 
 themselves by dishonest means and at the cost of society, in London there 
 are thousands of children already devoted to crime and prostitution — the 
 greater frequency of celibacy, the altered relations of religion, may be con- 
 sidered as co-operating circumstances: but, on the other hand, we should 
 not forget tliat the greater diffusion of knowledge and of comfort, and bet- 
 ter hygienic conditions, oppose these injurious influences; that drunken- 
 ness probably everywhere, but certainly in those countries, such as Eng- 
 land, where it used to be considered one of the most powerful causes, is 
 supposed to be steadily decreasing; that the community in civilized coun- 
 tries has opened up to it in asylums means and ways of recovery which 
 were unknown to former generations and to uncivilized countries. These 
 circumstances ought to compensate, at least to a certain extent, for any 
 injurious influence of the spread of civilization. 
 
 It has been said that the numbers of the insane in England have increased 
 ninefold within the last twenty years.' Naturally, neither the population nor 
 the civilization has increased in this proportion. We can speak of instances of 
 much smaller increase: for example, in Wiirtemberg, in twenty-one years, the 
 number of the insane have increased from 1 in 1500 to 1 in 943. It is, however, 
 in general, quite inadmissible always to at once ascribe that which distinguishes 
 the present generation from the former to the " progress of civilization." 
 According to this theory, one should also attribute the increasing improvements 
 in the murderous weapons used in warfare to our higher state of civilization! 
 The above-mentioned diminution of drunkenness is a mark of real civilization 
 which indeed deserves the name: this does not engender disease, but prolongs 
 life, and conserves the power and the health of generations. 
 
 Large towns very evidently furnish more insane than country districts; but 
 whether manufacturing or agricultural pursuits have a marked influence on the 
 frequency of insanity — whether commercial nations, as sijch, in this respect 
 acquire an unenviable notoriety— whether Catholicism or Protestantism favors 
 insanity, and many similar questions, must for the present remain unanswered 
 for want of material, and owing to the unavoidable complexity of the influencmg 
 circumstances. It would be useless to rush forward with arguments in favor of 
 or against the statistics, and to attempt to solve inexplicable questions. 
 
 It is a remarkable fact, that great political agitations appear to have less mflu- 
 «nce on the frequency of mental diseases than might at first be supposed. 
 Esquirol remarked this at the time of the first French revolution. Accordmg to 
 many French and German physicians (excepting Brierre), the revolutionary move- 
 ment of 1830, and especially of 1848, gave rise to little or no mcrease m the num- 
 ber of cases of insanity. To the laity the influence of the revolutions appeared 
 very considerable, because in these times politics formed the subject of the 
 delirium in many patients: this, as we have seen, is a purely accidental and 
 superficial relation. 
 
 § 86, 2. Sex.— The question whether the one sex be more disposed 
 to insanity than the other cannot be definitely answered, owing to the 
 want of sufficient statistics. On this subject there is an abundant litera- 
 ture containing many statistics, but we have no guarantee for their 
 correctness; in particular, all statistics framed from asylum reports are 
 
 1 Bucknill and Tuke, ' Psychol. Med.,' p. 32. 
 
THE CAUSES OF INSANITY. 99 
 
 insiiflficient and apt to mislead. From the very nature of things, espe- 
 cially before the recent improvements in asylnm mutters, female patients 
 constituted the minority amongst the inmates of the asylum; their fami- 
 lies have more hesitation in parting with them, and, besides, they are 
 more easily attended and restrained at home than men: indeed, the 
 older statistics of Fuchs,' prejjared according to the numbers in a 
 great many asylums, show a relation of 100 men to 75 women. France 
 and the Netherlands formed, however, an exception; the number of fe- 
 males in these countries being greater than that of males. In more recent 
 times the German asylums also appear to contain considerably more males 
 than females: for example, the asylum of Siegburg^ has in 18 years re- 
 ceived 900 males and 566 females, and that of Winnenthal,' in 10 years, 
 396 males and 251 females; while the French establishment St. Yon 
 admitted in the 8 years from 1835 to 1843 exactly the same number of 
 men as of Avomen. ^ 
 
 From all these statistics, however, it does not follow that insanity is 
 really more frequent in the one than in the other sex. The statistics of 
 Esquirol, which included 70,000 patients of all countries, but not on that 
 account founded on a more secure basis, showed a slight majority in favor 
 of the female sex. For England, Norway, Denmark, Rusia, and North 
 America — also for the Prussian provinces of Westphalia and Saxony, and 
 for the Southern departments of France — the statistics have as yet shown 
 more men than women; while, on the other hand, in the northern pro- 
 vinces of France, and in the Netherlands, the number of females is the 
 greater. Likewise the older and the new statistics (1832 and 1853) for 
 Wiirtemberg, for the Palatinate of Bavaria, and for Holland, show an 
 excess of females. All these reports seem to require confirmation; they 
 do not admit of a general conclusion, but show that in different localities 
 different relations exist in this respect. 
 
 It would be equally inadmissible to attempt to draw a priori conclusions from 
 the frequency and significance of several causes special to the female sex. Tlie 
 disorders of menstruation, pregnancy, childbirth, are undoubtedly circumstances 
 which frequently become causes of insanity ; but there are also in the male sex a 
 series of circumstances special to it, such as the more frequent drunkenness, 
 mental exertion, the struggle of ambition, the emotions and exhaustions which 
 necessarily accompany an active life. The circumstances certainly counter- 
 balance the special influence of the sexual process on the origin of insanity. In 
 women we frequently find that the more simple forms of mental disease may be 
 more easily concealed, and admit of the patients being kept at home; while the 
 same forms coming on in man render impossible the continuation of their calling 
 and the maintenance of their social position. 
 
 As to the influence of marriage or of celibacy, all accounts ^ agree m 
 this, that insanity is more frequent amongst unmarried men, and that 
 amongst women more married persons become affected — a fact which can 
 only be ex})lained by the earlier marriage of the female sex. Of widowed 
 persons there are more belonging to the female sex; this may be owing to 
 their helpless and unprotected condition in such circumstances. Certain 
 statistics, as those of Ehenish Bavaria for 1856, show a large proportion 
 of widows. Zeller, too, very properly remarks in regard to the influence 
 
 ' Prepared in the year 1833; loc. cit., p. 96. 
 
 " Jacobi, ' Die Hauptformen der Seelenstorungen, ' i., 1844, p. 573. 
 ^ Zeller, ' Report on the Efficacy of the Hospital for the Insane at Winnen- 
 thal;' " Journal fiir Psychiatric von Damerow und Roller," 1844, i., 1, p. 73. 
 " Parchappe, ' Annal. Med. Psych.,' 1843, ii., p. 867. 
 ' Fuchs, loc. cit., p. 103; Kostlin, loc. cit.. i^ 9. 
 
100 THE CAUSES OF INSANITY. 
 
 of married life, that if, indeed, celibacy appears to present more occasion 
 to mental disorder, still, in not a few cases, the marriage connection and 
 the misfortunes resulting from it have been the chief causes of the dis- 
 ease. 
 
 § 87. 3. Age. — No period of life assures absolute immunity from 
 mental disease, but all statistics agree in this, that ceitaiii periods 
 particularly and very markedly predispose to it. 
 
 During childhood (before puberty) insanity is not frequent, but almost 
 all forms of it occur. 
 
 Those most generally observed are the various kinds of mental weak- 
 ness, from deficient mental development to the most profound dementia: 
 this will be completely discussed in the third book (Idiocy). 
 
 Next in order of frequency come the maniacal conditions in their 
 various degrees and modes of appearance. Sometimes they appear as 
 persistent or even habitual moderate irritability of character: the child is 
 passionately obstinate, quarrelsome, malignant, and even inclined to 
 immorality; it is a kind of moral insanity, or folie raisonnante, entirely 
 corresponding to that of adults (see further on), and may very easily be 
 taken for simple wickedness of disposition. Sometimes it is a state also 
 persistent, but more intense: there is greater restlessness, a constant aim- 
 less roving, confusion of the intelligence, perversion of the emotions, with 
 excitement, which (with the greater impairment of the mental develop- 
 ment) sometimes passes into profound mental weakness. It is impossible 
 definitely to distinguish this from the versatile form of infantile dementia: 
 these children cannot keep quiet even for a moment; tliey talk incessantly 
 and incoherently, pay no attention, canstantly wander about, laugli, cry, 
 etc.; a form in which, according to Seguin,' with suitable treatment the 
 prognosis is not altogether unfavorable. Sometimes there are longer or 
 shorter attacks of really developed mania. 
 
 Romberg (' Deutsche Klinik,' 1851. p. 178) has seen the case of a child 6 years 
 of age attacked by a blind instinct t(i destroy, whereby it dashed everything to 
 pieces, rushed along tlie street with a knife in its hand, and could scarcely be held 
 in restraint (subsequent recovery). Indeed, we occasionally observe in still 
 younger children (of from 3 to 4 years of age) attacks of crying, of wild refracto- 
 riness, striking, biting, desire to destroy, which last only for a time, and ought to 
 be regarded as true mania. These sometimes alternate with epileptic attacks, 
 with chorea, with stupor, with ecstatic cataleptic states (in which the patients 
 remain for hours or even for days as if quite absorbed, with open eyes, fixed 
 countenance, and peculiar position, sometimes suddenly breaking out in loud 
 cries, etc.), as if there existed here the most manifold intermediate states between 
 epileptic, choreic, somnambulistic, and mentally diseased states. In ordinary 
 chorea, mental disorders are by no means rare; they are sometimes of a slight 
 nature, such as weeping or laughing without motive, obstinacy, temper, forget- 
 fulness, hallucinations: sometimes, on the contrary, there is an increasing state 
 of general mental excitation which passes into maniacal delirium; this, in the 
 height of the excitement, may terminate in death, but it may also end in recovery 
 or in chronic insanity. (Marci, " De L'etat mental dans la Choree;" 'Mem. de. 
 I'Acad. de Med.,' xxiv., 1, 1860, p. 1.) 
 
 Tlie melancholic forms in all their varieties are also observed, tliougli 
 much less freciuently, in the years of childhood. If carefully looked for, 
 hypochondria will often be found in children, especially where the 
 parents manifest excessive care of the health of the child. Such children 
 exaggerate their slightest ailments, attentively dwell upon them, and 
 gradually lose all interest in others, just as is seen in the hypochondriasis 
 
 ' ' Traitement moral, Hygiene et Education des Idiots,' Paris, 1846, p. 95. 
 
THE CAUSES OF INSANITY. 101 
 
 of adults. The children see that because they are unwell, all their whims 
 are gratified, and half designedly magnify their ills. Simple melancholic 
 states also present themselves, whose foundation is a general feeling of 
 anxiety; and the increase that has been remarked in recent times of cases 
 of suicide in the years of childhood (see Book III., chapter iv.) ought 
 also, to a very great extent, to have its source in the existence of a melan- 
 cholic disposition. The form of demonomania is also sometimes observed. 
 Monomania, on the other hand, is uncommonly rare, if it exists at all, in 
 the years of childhood. No persistent ego is as yet formed in which there 
 could occur a lasting radical change; the mobility of this age does not 
 allow single insane ideas to become persistent and systematized, as at a 
 late period; but, on the other hand, the various primary mental diseases 
 having the character of irritation, when of a certain duration, lead almost 
 certainly to a state of general confusion and dementia: the latter states, 
 as the intelligence of the child is not yet confirmed, rapidly produce 
 arrest of development, when in adults they would rather have caused 
 monomania. 
 
 It is a general essential characteristic of the mental disorders of child- 
 hood that they limit further mental development. We are then, in th^e 
 concrete cases, often in doubt as to whether the states of irritation pre- 
 ceding dementia, esiJecially the exalted forms, acted thus limitingly, per- 
 haps destructively, or whether they were the expression of the stage of a 
 cerebral disease which for a long time had tended to persistent change of 
 structure and degeneration, and only at the commencement gave for a 
 short time symptoms of irritation. Hallucinations and fixed delirious 
 ideas are much rarer in children than in adults; the irritative forms 
 alfect almost exclusively the sphere of the sentiments and instincts. 
 
 As to the more intimate foundation of mental diseases in childhood, 
 they appear to depend in part on an original irritability of the brain 
 (often hereditary), or produced and maintained by injudicious treatment 
 (intimidation, ill-treatment of mind, intellectual over-exertion, dissi})a- 
 tion), partly on deeper organic disease originating spontaneously, or after 
 injuries of the head (especially those cases which lead rapidly to demen- 
 tia); they often proceed from sympathetic irritation of the brain trans- 
 mitted from the genital organs (onanism, approach and entrance of 
 puberty). Again, chloro-anajmic states from various causes, rapid growth, 
 previous acute diseases (typhus, measles, etc. ) are often circumstances of 
 causation. Also after recovery such patients are much disposed to 
 relapse; their mental health continues in danger during the whole of 
 their lives, or they occasionally become, without being actually insane, 
 owing to an unfavorable change in their whole character, useless for the 
 world. 
 
 Thumam enumerates, from statistics of 21,333 cases of insanity, 8 cases of chil- 
 dren under 10 years of age. Haslam, Perfect, Esquirol, Spurzheim, Guislain, 
 Zeller, and myself have observed children who suffered under well-marked mania, 
 at the ages of 6, 7, 9, 10, 12, 13 years. Foville (art. " Alienation," ' Diet. d. Med..' 
 i., p. 516) relates two cases of this kind. Jordens communicates (' Huf eland's 
 Journal,' vol. iv., p. 224) the remarkable case of a boy who, in consequence of an 
 accident in wliich some small pieces of glass penetrated into the soles of his feet, 
 became maniacal, and continued so till their removal. Pignoceo (' Osserv. suUe 
 Alien, ment.,' Palermo, 1841, p. 34) mentions a case of mania observed by him in 
 a boy 8 years of age. Morel ('Traite des Maladies mentales,' Paris, 1860, p. 101) 
 mentions the case of a girl, 11 years of age, who had attacks of fury, and at- 
 tempted to murder her mother and sister. Stf)ltz ('Med. Ja>kfTiT7re"f?'Oesterr. 
 Staats,' Marz, 1844, p. 257) narrates a very interesting case^if inaiiia in a child 7 
 years of age (with loss of speech and serious degeneration /t the anterior cer.ebrax 
 
102 THE CAUSES OF INSANITY. 
 
 lobes). In the several institutions recently erected for the reception of children 
 of weak intellect, there are generally found also more or less special cases of 
 mental disease. In the institution at Mariaberg, in Wurtemberg, I have found 
 especially the slighter states of mania (versatile form of mental weakness) repre- 
 sented : we shall enter more ininutely into this subject in the chapter on Idiocy. 
 I have recently seen a case of mania connected with epilepsy in a child of 5 years: 
 a, case of morbid anxietv and hallucinations, following epilepsy, in a very small 
 girl 14 years old; and a case of mental disorder after typhus fever in a boy 10 
 
 years old. » , ., , j. ■■ 
 
 Further contributions to the study of the mental diseases of chddren are found 
 in West, ' Journal der Kinderkrankheiten,' 1854, xii., 7, 8, p. 1; Rosch, ' Beob. iiber 
 den Cretinismus,' ii., 1851, p. 81; Delasiauve, 'Ann. Med. Psych.,' vu., 1855, p. 
 527; Paulmier, ' Sur les Aif. mentales des Enfants,' These, Pans; Brierre, 'Acad, 
 d. Sciences,' 7 Juin, 1858. 
 
 § 88. Mental diseases are more frequent between the ages of 16 and 
 25 than in tlie years of childhood; the great majority, however, of all 
 cases occur during the period of highest maturity— in the time of the 
 corporeal reproduction and mental activity, of marriage and of business, 
 between the ages of 25 and 50. But here even the reports before us are 
 not sufficiently satisfactorily to enable us definitely to determine this 
 question, inasmuch as the greater number of the calculations ' are based 
 upon the ages of the patients when admitted into the asylum, with which 
 naturally the age of the actual commencement of the disease does not 
 necessarily correspond, or inasmuch as only the number of insane gener- 
 ally of a certain age at present in a country is mentioned, without at the 
 same time giving the total number of individuals of that age in the 
 country.' Were we allowed to take as a standard very carefully prepared 
 statistics of a proportionately small number of patients,' it would be seen 
 that the most frequent age of the commencement of insanity is between 
 20 and 30 years, the next between 30 and 40, and that already between 
 40 and 50 the proportion is remarkably diminished. For the male sex, 
 Zeller * gives the period of from 20 to 30, and for the female of from 30 to 
 40, as that at which insanity most frequently commences, and explains the 
 difference by the fact that in the latter period the bloom of youth begins 
 to fade, and with this the hopes of a fortunate life begin to disappear: 
 this, he thinks, accounts for the greater number of the attacks. The 
 great number of attacks Avhich, according to observation and also to 
 Parchappe's calculations, occur in women of from 40 to 50 years of age, 
 may be connected with the phenomena of involution. Above 50 years 
 of ao-e, insanity is still more frequent in the female sex. In general, from 
 this^age onwards the predisposition begins to decline; but, nevertheless, 
 there continues even to the last limits of human life a certain inclination 
 to mental disease, and this at middle life is not greatly diminished: 
 indeed, more exact statistics might show that senile dementia exists 
 to such an extent as to show a large proportion for the last years of life. 
 
 Moreover, senile dementia is by no means the sole form of insanity occurring 
 in these years. Esquirol saw two women, the one eighty, the other eighty-four 
 years old, recover from mania. Burrows mentions a case of melancholia and 
 suicide in a person aged eighty-four. I myself have treated a recent case of 
 
 ' See Fuchs, loc. cit., p. 97; Quetelet, p. 443. 
 
 2 For example, Kostlin, loc. cit., p. 8; Ruer, p. 9; and many other statistics. 
 
 3 Zeller, "Second Report on the Efficacy of the Hospital for the Insane at 
 Winnenthal," ' Medic. Correspondenzblatt,' 1840, p. 143, 
 
 ■* 'Journal fiir Psychiatric,' i , 1, p. 18. In the Vienna Asylum, on the con- 
 trary, the maximum period seems to be in men between 30 and 40, and m women 
 between 20 and 30 (' Report.' Vienna, 1858). 
 
THE CAUSES OF INSANITY. 103 
 
 melancholia in a person eighty years of age, and could narrate many other cases 
 of the same kind. 
 
 § 89. 4. The question whether .social position exerts an essential 
 influence on the origin of mental disease cannot, as Fuchs very properly 
 observes, be determined by calculations based on the number of admis- 
 sions into public asylums, as, naturally, far more patients from the 
 lower classes enter these institutions. The only authority on this subject 
 which we can quote, and which is known to us, is Junius,'' who states 
 that in England and Wales there are 8500 poor, and only from 1300 to 
 1300 wealthy persons in public and private asylums. If we consider that 
 there are far more poor than rich, we can easily conclude that the two 
 classes are about equally subject to insanity; nevertheless, it is ordinarily 
 assumed tbat in the better classes of society, or rather in the wealthy, 
 mental diseases are not so frequent as in the poor. It even appears that 
 the circumstances which act on the one side through greater direct exci- 
 tation of the cerebral functions, are on the other compensated by hunger, 
 poverty, and drunkenness; while the powerful passions, as love, ambition, 
 jealousy, etc., are alike frequent and originally as powerful in all cases; 
 but where there is least intellectual culture they are most insupportable 
 and act most destructively. 
 
 As to a special predisposition which results from certain trades and employ- 
 ments, there is almost nothing to add to the foregoing remarks, viz., that proba- 
 bly those classes who lead a fatiguing and oppressed life of hard manual labor 
 are more frequently attacked by this, as indeed by every other disease, than those 
 who are engaged in the less exhausting mental labor, or who do no work at all. 
 Should, therefore, a marked preponderance exist in certain kinds of employments 
 — for example, in sailors, day laborers, peasants, etc., or amongst merchants, 
 officials, officers, etc. — we must first compare the relative numbers engaged 
 in such professions to the general population; and even then we would not 
 be warranted in concluding that it is the profession, as such, which causes the 
 disposition. Certain callings do not of necessity give rise to certain classes 
 of injurious influences, but they may present more opportunities which the 
 individual may voluntarily resist: for" example, butlers and sailors are, from 
 habits of drunkenness, very frequently the subjects of delirium tremens. The 
 assertion of Ferrus, that those professions furnish the greatest number of insane 
 which involve the least amount of bodily exertion, has not been confirmed 
 by any trustworthy statistics. 
 
 § 90. Certain vocations appear to enjoy a remarkable immunity, 
 while in others the disposition to mental disease is considerably in- 
 creased. Professional beggars, according to Guislain,^ do not become 
 insane. He ascribes this to the indifference of these jieople. Female 
 prostitutes in large towns are often attacked by mental disease: misery, 
 destitution, drunkenness, violent passions, syphilitic contagion, etc., 
 ordinarily act together in these cases. The number of cases of insanity 
 occurring amongst young female teachers and governesses is, at all events 
 in England, very great: Bedlam received in 10 years (1846-55) 110 such 
 young Avomen. Here adverse fortune, want of rest, excessive mental 
 exertion, and a disagreeable life may be the chief causes. 
 
 Imprisonment brings into simultaneous action many influences which 
 are dangerous to mental health — remorse, longings, concentration on one 
 small circle of ideas; sometimes insufficient nourishment and impure air, 
 want of exercise, etc. Indeed, in all houses of correction, the number of 
 
 ' Fuchs, loc. cit., p. 106. 
 - ' Beitrage zur britt. Irrenheilkunde,' p. 8. 
 
 3 'Legons orales,' ii., p. 22. Joret ('Mem. de I'Acad. de Med.,' xiv., p. 34G) 
 shows that, on the other hand, female beggars very frequently become insane. 
 
104 THE CAUSES OF INSANITY. 
 
 cases of mental disease is relatively greater than in the free population of 
 tlie same age; but the majority of these cases should certainly not be 
 entirely ascribed to the imprisonment — very commonly the individuals are 
 already very strongly predisjiosed, and frequently the disease is even more 
 than half developed before he is put into prison, inasmuch as during 
 his previous life the criminal has been exposed to the influence of all the 
 causes of insanity. The question still remains unsolved, and probably in 
 the present state of our knowledge it cannot be solved. What is the influ- 
 ence of the various new systems of punishment on the mental healtli of 
 the criminal? It appears certain that the strict solitary confinement, 
 applied indiscriminately, augments the number of mental affections; 
 that many individuals cannot stand it, and that especially irritable and 
 already half-deranged individuals by it become easily affected with hallu- 
 cinations, excitement, and insanity; and then frequently, immediately 
 on being transferred to the common prison, they rapidly recover. It 
 appears also that women and uneducated persons do not well bear 
 solitary confinement. Where, however, all regulations are framed en- 
 tirely with a view to the bodily and mental health of the criminals — 
 where the period of solitary confinement not being too prolonged, suffi- 
 cient open-air exercise is secured, and where the feelings and ideas of tlie 
 criminals are suitably excited and perhaps elevated — where, at the same 
 time, attention is given to symptoms of moral perversion of the senti- 
 ments; and the first signs of commencing mental disorder are constantly 
 and carefully watched, and the individuality of the prisoner as far as 
 possible considered, the danger to the mental health should not here be 
 very considerable. 
 
 Experience has shown, particularly at Lausanne (Verdeil, 1842) and in Tus- 
 cany, that strict solitary confinement is considerably more prejudicial to mental 
 health than general imprisonment. On the other hand, the excellently conducted 
 system of solitary imprisonment employed at Bnichsal does not, according to the 
 report of Fiisslin, show any injurious influence on the mental health of the pris- 
 oners. Also, in the model prison of Pentonville (London), according to Parrish,^ 
 only 13 cases of insanity occur amongst every 1000 prisoners. Solitary confine- 
 ment, however, does not extend there for longer than eighteen months. Solitary 
 confinement particularly disposes to hallucinations of hearing; this appears 
 to result from the patients soliloquizing and believing that they hear others 
 speaking. 
 
 From the very interesting communications of Delbriick, it would appear that 
 mental disease amongst criminals is more frequent in those who have committed 
 crimes from passionate motives than in those who have committed crimes against 
 property. It is most frequent after murder and mortal injury than after rape 
 and arson. Amongst criminals, two chief categories of delirium may be distin- 
 guished: — 1st, cases where a solitary great crime, such as murder, with its conse-, 
 quences, has subsequently produced a mental disorder: 2d, where habitual crim- 
 inals become insane, owing to predisposition and the effects of time. In the first 
 case, the single criminal act is evidently the essential cause of the insanity; it 
 determines the form of the disease and the subject of the delirium. In the 
 second case, the entire habits of life and the customs of the prison give a peculiar 
 impi'ess to the disease. Insanity is generally developed during the first years 
 of imprisonment in solitary confinement in those already distinctly predisposed; 
 it often shows itself even in the first months. In the delirious conceptions, the 
 attempt to palliate the crime or entirely to deny it is often seen, or to picture to 
 themselves a speedy deliverance. Mention of the crime usually evokes, in those 
 of the first category, passionate excitement or anxiety, with increase of the 
 delirious expressions. Refusing to work, excesses, refractoriness are naturally 
 of daily occurrence amongst these insane prisoners. 
 
 Ferrus (1850) attempted to adapt the various systems of punishment to the 
 different classes of criminals. He divides these into three categories: — 1st. Intel- 
 ligent, energetic, and totally corrupt individuals — unimprovable scoundrels. 2d. 
 
THE CAUSES OF INSANITY. 105 
 
 Such as possess a moderate degree of intelligence, a little developed sense of duty 
 — who are indifferent to good and evil, and regardless of shame and disgrace — who 
 have no opposition to bestow to their evil inclinations. 3d. Particularly dull in- 
 dividuals, who cannot estimate tlie significance of their deeds, and often even the 
 cause of their imprisonment. Those of the first category should , throughout, be 
 subjected to solitary confinement; those of the second require rather " Auburn's 
 System," with quiet and solitarj^ confinement during the night; those of the third 
 cannot at all bear solitary confinement. The application of such a classification 
 must be very difficult in practice. 
 
 On this subject, seeWlirth 'Die neuesten Fortschritte des Gefangnisswesens,' 
 Wien, 1844; Lelut, 'De I'Emprisonnement cellulaire, etc.;' Moreau, Christophe, 
 ' Annal. Med. Psychol.,' 1843, vol. ii. ; Joret, "De la Folie dans la regime peniten- 
 tiaire," ' Mem. de I'Acad. de Med.,' xiv., 1849, p. 319 (contains many interesting 
 remarks upon female prisoners and their insanity and facts concerning the "silent 
 system"); FeiTus, ' Des Prisonniers, de FEmprisonnement, etc.,' Paris, 1850; Fiiss- 
 lin, 'Die Einzelhaft,' etc., Heidelberg, 1855; Delbriick, 'Zeitschr. f. Psychiatric,' 
 1854, xi., p. 57; xiv., p. 375; Pietra Santa, 'Acad, de Medecine,' 23 Januar and 
 17 April, 1855; Scholz, 'Zeitschr. der k. k. Gesells. der Aerzte zu Wien,' 1856, xii., 
 p. 635; the reports of Mittermaier in ' Archiv desCriminalrechts.' 
 
 § 91. 5. We now mention the question so often and so variously 
 discussed, of tJie influence of the seasons of the year in originating 
 insanity, merely to call attention once more to the fallaciousness of many 
 statistical reports. From the circumstance that, according to Esquirol's 
 tables, most admissions into several asylums took place during the 
 summer months (May to July), fewer were admitted during spring and 
 autumn, and fewest in winter, it has been concluded that insanity 
 originates most frequently in summer. This is a very erroneous conclu- 
 sion; for what asylum is so fortunate as to procure a majority of its cases 
 within two or even three months from the commencement of the disease?' 
 There exists no constant relation between the commencement of insanity 
 and the admission into an asylum, and we are at perfect liberty to frame 
 conjectures as to when these cases admitted in summer really had their 
 commencement, whether the greater difficulty of travelling in winter has 
 any effect on the admissions, etc. Statisticians speak also of the influ- 
 ence of the seasons of the year on the single forms of insanity. Esquirol 
 has asserted, and Jacobi has proved the fact in 181 cases, that in winter 
 the attacks of mania are most seldom — that they are more frequent in 
 summer, and especially in spring. 
 
 With regard to the influence of the moon, if not on the origin, at 
 least in aggravating and modifying insanity in its course. This influence 
 is denied by the great majority of medical psychologists, and that path- 
 ology is derided which, for example, would ascribe the periodical return 
 of the attacks of mania to the influence of the stars, because they coincide 
 with certain regular changes in the heavens. Because of this the influence 
 of the moon's light upon the insane should not be denied, for even in 
 healthy persons the light of the moon can peculiarly affect the course of 
 the thoughts, giving rise, for example, to ardent and elegiac ideas readily 
 disposing to sentimental poetry. In the insane, who are more powerfully 
 and differently affected than the healthy by various sensible impressions, 
 this may, with the absence of sleep, the view of the full and brilliant 
 moon, the uncertain light, the fleeting shadows of the clouds, combined 
 with the stillness of the night, or the confused murmurs which then float 
 through the asylum, indeed, create still greater impressions, more violent 
 
 ' Winnenthal, an institution solely devoted to curable cases, received in 6 
 years 133 cases of 6 months' standing, and 150 of even longer durartion. Zeller 
 'Medic. Correspondenzblatt,' Juli, 1840, p. 143. 
 
106 THE CAUSES OF INSANITY. 
 
 emotions, yarious hallucinations, etc. Esquirol prevented the agitation 
 which was regularly remarked in several patients at the time of the full 
 moon by hanging curtains on the windows. ' 
 
 Section II. — Special Predisposing Causes. 
 
 § 92. 1. Hereditary Predisposition. — Statistical investigations 
 strengthen very remarkably the opinion generally held by physicians and 
 the laity, that in the greater number of cases of insanity a hereditary 
 predisposition lies at the bottom of the malady; and I believe that we 
 might, without hesitation, affirm that there is really no circumstance 
 more powerful than this. Doubts have recently been raised as to whether 
 hereditary predisposition plays a more important part in insanity than in 
 any other disease, or whether it is merely most sought for in that disease, 
 and therefore most frequently found. ^ It is quite possible that further 
 advances may show that hereditary predisposition exercises quite as great 
 an influence in many other diseases, especially when more positive data 
 are once obtained concerning the transformation and transmission of 
 pathological states. At present, we can claim for tuberculosis alone an 
 influence of hereditary circumstances in some degree equal to that ex- 
 hibited by mental diseases. 
 
 In details, however, the reports differ very considerably, both accord- 
 ing to the experiences of the observer, and according to the rank of the 
 individuals examined and the locality in which the investigation took 
 place. 
 
 The enormous proportion given by Burrows (hereditary predisposition 
 in fths of the cases), or the estimate of Moreau, that in j\ihs of the cases 
 hereditary influences have been at work, are proved by no reliable statis- 
 tics. In the following paragra])hs, we have united the results of a great 
 number of reports of German, French, and English asylums. 
 
 Jacobi, in 230 cases (of mania) found hereditary predisposition pres- 
 ent in only about |th; Bergmann (1838), whose investigations were limited 
 to the statistics of one year, detected direct hereditary predisposition in 
 ^th, direct and indirect together in Jd, of the cases. Hagen, in 187 
 cases, found family disposition in -^d, direct hereditary disposition (father 
 and mother mentally diseased) in ^th-i-th. Flemming found it, at 
 Sachsenberg, in the proportion of over |th; Damerow, at Halle, in 773 
 admissions, found it in ^th. Martini, in Leubus, had in twenty-five years 
 amongst the higher ranks nearly -^d (x^o-tlis), amongst the middle and 
 laboring classes somewhat over ^th, "officially constituted hereditary 
 cases." At Colditz, amongst 77 admissions, fths of the cases were proved 
 to be directly hereditary. Hereditary predisposition appears, on the con- 
 trary, to exist to a remarkably small extent in the lunatic asylum of 
 Vienna (1853-5G). 
 
 In Bicetre and the Salpetriere, hereditary predisposition was, accord- 
 ing to an old compilation (8272 cases), present only in tV*!^5 in the 
 Marseilles asylum, Lautard proved it in only about yV^^^- Esquirol found 
 it in the poor in more than ^th, in the rich in about fths; Parchappe, in 
 somewhere over ^th; Guislain, in over ith; Brierre, in almost half; Da- 
 gonet, in Stephansfeld (in three statistics together), in about ^th of the 
 
 cases. 
 
 Webster (1848) found at Bedlam, in 1798 patients, hereditary 
 
 ' Loc. cit , p. 568. 
 
 * Neumann, ' Psychiatrie,' 1859, p. 141. 
 
THE CAUSES OF INSANITY. 107 
 
 predisposition in almost ^d oftener in females; Skae, in Edinburgh 
 (1851-52), in 248 admissions, a little over ^d. In a large number from 
 English and Irish asylums, collected by Jarvis (1850), it was found, in 
 44,717 men, only in ^V^h; in 43,091 women, only in ^\d. At Blooming- 
 dale Asylum (New York), from 1841-9, among 1841 patients,there were 118 
 men whose fathers had been mentally diseased, and 83 who had some 
 other relative insane; 89 women whose .fathers had been insane, and 67 
 who had other relatives insane (together ^th). 
 
 Bini, in Florence, found hereditary predisposition present in about ^ 
 of the cases. It will be remarked that very large statistics (Bicetre, 
 Jarvis), which probably could only be made with material less carefully 
 gathered, give a very small proportion; while those from less extensive but 
 well-investigated spheres of observation prove it to be much more frequent. 
 
 The still considerable differences presented by these figures might depend on 
 the predominance of certain circumstances, which, being very important, ought 
 to be more closely considered . 
 
 (1) Congenital disposition to insanity is more frequent where marriages always 
 take place amongst a limited circle of families, or even in the same families. On 
 the other hand, the transmission is diminished by constant crossing with strange 
 blood. The first circumstance is very evident amongst the aristocracy of certain 
 countries, also in the Jewish population; and it is especially striking among the 
 English Quakers. In the Asylum at York, which is destined to this religious sect, 
 direct hereditary predisposition can be traced in one-third of the patients, indirect 
 (mental disease in other relatives) in another sixth; therefore, both together, in 
 one-half of the cases. > Progressive uninterrupted transmission leads finally to the 
 special degenerative forms (Morel)— to imbecility and idiocy, and with the dimin- 
 ished capability of propagation of individuals of the latter kind, the race gradu- 
 ally becomes extinct.'^ 
 
 (2) There exist further considerable differences in the statistics, inasmuch as 
 sometimes only the cases where the parents or grandparents have been insane are 
 included, while at others the assumption of family predisposition is made wher- 
 ever insanity is present in any near relative (uncles— blood relatives— cousins). 
 The latter appears to be the more correct view, when we consider that almost 
 always, besides hereditary disposition, still further causes are required for the 
 outbreak of insanity; that, therefore, the present disposition may remain dormant 
 from want of such further causes in the nearest relatives. That the disposition 
 exists, however, can be plainly proven by the insanity of other relatives. 
 
 (3) We do well not to conceive of a family predisposition to mental diseases 
 as limited to these alone, but rather to consider it as a disposition to serious cere- 
 bral and nervous diseases generally. It is not at all rare to see in a family certain 
 members suffering from insanity,' others from epilepsy, severe spinal irritation, 
 hysteria, neuralgia, etc. Rush,-^ for examples, relates the case of a mechanic 
 who had two attacks of insanity— the latter of which ended his life. All his six 
 children suffered from headache, but none presented the least trace of insanity. 
 In this and similar cases, which are by no means rare, the disposition appears to 
 be able to manifest itself in various forms, and occasionally even we see through 
 several generations pathological states of the nervous system whicli at first grad- 
 ually increase, and end by passing into insanity proper. 
 
 (4) An original anomalous disposition is also not to be denied in those cases 
 where one or both parents, although not suffering under insanity, present a 
 striking eccentricity or extravagance of character, and a morbid exaltation of the 
 passions, which strongly approach to insanity; in those cases also where several 
 instances of suicide have occurred in near relatives. For suicide, in many cases 
 a symptom of developed serious mental disease, is in many others at least the 
 evidence of a weariness of life resulting from a morbid state of the organism, 
 and which is to be numbered amongst the primary foi-ms of insanity, melan- 
 
 ' Julius, 'Beitr. z. britt. Irrenheilkunde.'p. 281. 
 
 ^ Morel, " Des Caracteres de I'Heredite dans les Maladies nerveuses," ' Archives 
 generales de Med.,' 1859, September. 
 
 3 'Med. Unters. iiber d. Seelenkrankh.,' translated by Konig, Leipzig, 1835, 
 p. 36. 
 
108 THE CAUSES OF INSANITY. 
 
 cholia; and experience has frequently shown that the inclination to suicide^ 
 which often comes on in all the members of a family at the same age, communi- 
 cates itself by hereditary descent. We will also easily comprehend how that 
 weakness of character and excessive passionateness by which this hereditary 
 tendency is so frequently shown, may, by the co-operation of unfavorable circum- 
 stances on individuals so affected, beget criminal actions. In like manner, we 
 occasionally see in certain families insanity, suicide, crime, the result of the 
 intimate connection of certain dispositions of character combined with each other, 
 alternating in a deeply deplorable manner. 
 
 Lautard (Oppenheim, 'Zeitschrift,' vol. xxi., p. 16) relates the following 
 case: A husband and his wife, the former 42, the latter 36 years of age, became 
 insane and committed suicide, the one by strangulation, the other by drowning. 
 They left behind them three children. The eldest daughter poisoned herself at 
 the age of 24, after having lived for a long time in prostitution. The son, accused 
 of assassination, strangled himself at the age of 21. The j^oungest daughter, in 
 the sixth month of pregnancy, threw herself from a roof. She left behind her a 
 son, who, altliough very young, had been several times in prison, and at last went 
 on an adventure to Egypt. 
 
 Miss M — , of Ortava, set. 30, of an old noble Spanish family, never contami- 
 nated by any misalliance, became insane. The disease presented the form of 
 periodical changes of melancholia and mania, with a tendency to suicide. Her 
 gi-andfather committed suicide in his fiftieth year. Of his three sous, two spon- 
 taneously ended their lives in the years of their youth from being crossed in love. 
 The third, the father of Miss M — , showed such oddities and whims that he was 
 considered almost insane. His son (the only brother of the young lady), when 20 
 years of age, threw himself into the sea, because he doubted the fidelity of his 
 lady-love. His sister, although living in the most favorable relations of life, 
 showed so sad a disposition that her friends prophesied for her the same fate.' 
 
 But sometimes also we find in those families where individual members suffer 
 from insanity, others of remarkably superior intelligence with or without eccen- 
 tricities. I could name two such examples from among the great scientific 
 celebrities of our own time. It is not improbable that great excitability of the 
 cerebral processes, and even those mental peculiarities which in certain individ- 
 uals run into extravagance and eccentricity, may in otliars, under favorable 
 external circumstances and perfect physical health, appear in the form of increased 
 activity and energy of intellect, and originality of thought. Moreau (' Psycholo- 
 gic morbide,' Paris, 1859) has recently brought forward this question and pressed 
 it beyond its limits. 
 
 The entire assumption that hereditary disposition generally plays an important 
 part in the etiology of insanity has been attacked as incorrect by Schlager 
 ('Zeitschrift der k. k. Gesells. der Aerzte zu Wien,' 1860, Nos. 34, 35). He very 
 properly calls attention to the inconsiderate manner in which occasionally the 
 hereditary predisposition is proved by physicians. He confines himself to the 
 most limited signification of the word hereditariness, and only admits such cases 
 as hereditary where before or at the time of procreation one of tlie parents was 
 mentally diseased. According to this principle, he found hereditary predisposi- 
 tion present in only four per cent of the cases. That this critic overshoots the 
 mark at once becomes evident, if we substitute the question of family disposition 
 for that of hereditary predisposition. In page 94 of the ' Wiener Bericht ' 
 (Vienna, 1858) there are also found sufficient grounds for the small number of 
 hereditary cases admitted into the asylum there. 
 
 § 93. Esquirol assumed, and Baillarger" has proved by the statistics 
 of 453 cases, that insanity is more frequently transmitted (indeed, about 
 one-third oftener) from the mother than from the father to the children. 
 He found, at the same time, that when the mother Avas insane more of 
 the children became so, and that the transmission of insanity to sons is 
 as frequently from the mother as from the father: on the contrary, in the 
 case of daughters the disposition to insanity is inherited twice as fre- 
 quently from the mother as from the father. It follows from this, that 
 
 » ' Anal. Med. Psychol.,' Mai, 1844, p. 389. 
 
 * " Rech. statist, sur I'Heredite de la Fohe," ' Annal. Med. Psvcn.,' Mai. 1844, 
 p. 330. 
 
THE CAUSES OF INSANITY. 109 
 
 through insanity of the mother the children generally are more endan- 
 gered than through insanity of the father, and also that it is more espe- 
 cially the children of the female sex who inherit this unfavorable dispo- 
 sition. 
 
 Moreover, experience shows that children who are born before the 
 period of manifestation of the mental disease are less frequently attacked 
 than those born after the parents have become insane. Occasionally, 
 therefore, cases also present themselves where the children become 
 aifected before the parents, because a number of causes favorable to the 
 outbreak have acted on them, while the parents, more fortunate, resist to 
 a gi'eater age these further influences. 
 
 Sometimes hereditary mental disorders present essentially the same 
 character in parents and children, and occasionally also in a whole line 
 of brothers and sisters, appearing at the same age and terminating in the 
 same manner — as for example, by suicide. Frequently, however, this is 
 not the case; the psychical disorder manifests itself in different ways, 
 partly dependent on external circumstances. Morel, who has recently 
 investigated this subject in a comprehensive and judicious manner,* men- 
 tions the following as the leading modes of manifestation of hereditary 
 mental disorder: (1) Such as appear rather in the form of extreme exag- 
 geration of the nervous temperament of the parents. (2) Those in which 
 the disorder principally shows itself in evil desires, eccentricities, per- 
 verseness of every kind, the intelligence being well preserved, the disease 
 showing itself far more by senseless actions than by insane thoughts and 
 speech. (3) Those in which there already exists an increasing limitation 
 of the intellectual activity, mental dulness and weakness: very commonly, 
 also, it is with great difficulty that the individuals affected can direct 
 their energies to useful and moral ends. Frequently there is found in 
 these cases all sorts of evil inclinations, and occasionally even smallness 
 of the skull and sterility. (4) Lastly — Dementia proper, from imbecility 
 to the highest degree of idiocy and cretinism: these individuals have 
 often rudimentary genital organs, are deaf and dumb, clubfooted, etc. 
 All these various pathological states are (according to Morel) branches of 
 the same trunk in certain families. The disposition may disappear by 
 constantly renewing the blood by marriage with perfectly healthy fami- 
 lies; it is increased and developed to the most degenerate forms by 
 further intermarriages, by drunkenness of fathers, etc. In this state- 
 ment there is a great deal of truth: every physician who directs his at- 
 tention to this subject will discover numerous examples of it, not only in 
 the asylums, but far more frequently in ordinary life, which cannot well 
 be definitely demonstrated by statistics. The deterioration of a whole 
 race, as well as the special degeneration of a particular patient, generally 
 occurs gradually and progressively. For a long time the hereditary in- 
 fluence can be found only in certain members of a family; besides, others 
 often render themselves conspicuous by their uncommon mental powers, 
 and the really degenerate character of the disease may not as yet mani- 
 fest itself in those who are attacked. It appears, nevertheless, that hered- 
 itary influences may be highly and quickly increased by drunkenness, 
 by disease, and, in short, by various intercurrent disorders of the parents 
 a,t the time of procreation; perhaps also by certain external influences. 
 
 ' 'Traite des Degeuerescences de FEspece humaine,' Paris, 1853; 'Traite des 
 Maladies mentales,' Paris, 1860, p. 513; and the above-mentioned work in the 
 Archives, 1859. 
 
110 THE CAUSES OF INSANITY. 
 
 especially of an endemic nature. Thus the severe forms may originate 
 at once, and several or all the children 2:)rocreated under such circum- 
 stances may suffer. 
 
 Of the general diagnostic characters of hereditary mental disease the 
 following may (according to Morel) be considered the chief: — This kind 
 of insanity generally breaks out suddenly from insignificant external 
 causes: it shows itself often in marked emotional insanity, the intelli- 
 gence remaining relatively intact; there are considerable remissions and 
 exacerbations. _ Strong hallucinations and paralytic dementia are some- 
 what rare; while, on the other hand, there exists a strong tendency to 
 delirious_ conceptions. Although still in a condition of relative health, 
 such individuals render themselves remarkable by their great emotional 
 excitement, and, therefore, their greater dependence on the influence of 
 the external world; frequently, by all kinds of originalities and eccen- 
 tricities; and occasionally, along with intellectual and emotional perver- 
 sions, we find them endowed with certain one-sided extraordinary gifts 
 or accomplishments. 
 
 § 94. 2. Education. — The direction which the understanding and 
 will of an individual receives in childhood exercises a decided influence 
 on his whole future life. The moral and intellectual influence of the 
 parents upon the child is, therefore, to be mentioned next to liereditary 
 influence as of the utmost importance. With Ideler, we are of opinion 
 that there are cases of so-called hereditary insanity which can be traced^ 
 not so much to the transmission of organic disposition as to a subsequent 
 psychical continuation of peculiarities of character, inasmuch as certain 
 eccentricities, odd and peculiar views and maxims, have been presented 
 to the child for imitation. Influences of this nature are, from the first, 
 decidedly adverse to the development of a healthy soul-life in harmony 
 with the external world. Thus, in the same manner as hysteria is trans- 
 mitted from the mother to the daughter, so are psychical perversions; 
 transmittecl to their children from insane or silly parents, and passion- 
 ateness and evil inclinations are impressed upon the youthful mind. To 
 this circumstance, not unf requently, also, may be traced the fact that fam- 
 ily life is often disordered, and thereby the co-operation of those favor- 
 able circumstances so necessary to the harmonious development of the in- 
 fantile character is disturbed. 
 
 Amongst the special errors of education may be mentioned, in the 
 first instance, premature mental exertion. This, with the undue preco- 
 city of the various mental processes thereby necessitated, proportionately 
 retards and hinders physical development; the brain is overwrought, and 
 the germs of future weakness and disease are surely laid. Still more 
 serious, however, are perverse and unfavorable influences on the sensa- 
 tion and will of the child. There are cases, for example, where, by 
 undue severity, by the cold and repulsive demeanor of parents towards 
 children — by protracted grief, humiliation, or harshness of sentiment — 
 the development of naturally benevolent dispositions is hindered, and the 
 gentler feelings stifled. Thereby there is thus early implanted in the 
 individual a painful opposition to the external world. This is especially 
 apparent in certain strong benevolent natures, whose warm and generous 
 inclinations instinctively seek a return of affectionate sympathy, by the 
 absence whereof they are necessitated to take refuge in an imaginary 
 world, and so a pernicious imaginative tendency is awakened and nour- 
 ished. Finally, still more destructive to the child is that over-indulgence 
 on the part of parents, which curbs not the wayward development of 
 
THE CAUSES OF INSANITY. Ill 
 
 every desire and inclination, which incapacitates the child for enduring 
 suffering or pain, which renders him incapable of self-control or resigna- 
 tion, and develops, not a strong and hardy nature, but a weak, soft 
 character which cannot stand the test; for sooner or later the rude en- 
 counter of life must be met, and, unable to support himself under the 
 fierce assault, he falls a victim to all the agitating emotions and health- 
 disturbing influences of violent passion. 
 
 See, in the following book, the case mentioned by Pinel (" Traite de I'Aliena- 
 tion mentale,'" p. 159). 
 
 § 95. 3. Mental and jjhijsical constitution. — Our decision as to the 
 physical constitution is generally founded on certain striking anatomical 
 differences amongst individuals," especially in relation to the development 
 of the muscular system. We must renounce the attempt to discover any 
 predisposition to mental diseases in such differences; for daily observa- 
 tion shows that the weak and the muscular, and likewise dry and moist 
 constitutions, are liable to the attack of insanity in nearly equal propor- 
 tions. On the other hand, there is another constitution, sometimes con- 
 genital, sometimes acquired, which we cannot recognize anatomically, 
 but which physiology permits us to appreciate, which materially predis- 
 poses to mental disease. It is the so-called nervous constitution— that 
 relation of the central organ which we may generally define as a dispro- 
 portion between reaction and irritation. This state may be confined, to 
 certain parts of the central nervous system; for example, in the spinal 
 cord or in the brain. Very frequently it is observed equally in all nerv- 
 ous acts. In the sensory nervous system, hypergesthesias of various kinds 
 are observed; great sensibility to impressions of temperature; spontaneous 
 changes in the sensation of heat and cold: but especially the presence of 
 numerous sympathetic sensations, and great disposition to pain. The 
 motory nervous acts are characterized by the withdrawal of all force, the 
 individual being easily exhausted; by a disposition to sudden extensive, 
 but only slightly, energetic movements; by increased tendency to convul- 
 sions. In the mental sphere we observe, corresponding to the analogous 
 states of sensation and motion, great mental sensibility— susceptibility ta 
 mental pain, and to that condition in which every thought becomes an 
 emotion. Hence the rapid alternations in self-consciousness and volition, 
 leading on the one side to weakness and inconsistency of will, and on the 
 other want of energy, with abrupt and changeable jDlans. _ The intellect 
 at the same time often presents the same condition. This is seen in those 
 who, even in childhood, are very irritable. The intellect is dispropor- 
 tionately developed, and constantly presents something unstable. In the 
 case of lively imaginative minds which, however, are deficient m depth 
 and endurance, incapable of continuous exertion, because they address 
 themselves seriously to no single vocation — in the case of those imagina- 
 tive second-rate but quaint musicians and poets, or those misguided uni- 
 versal geniuses, who, with a certain vivacity and variety of thought, never 
 can find composure or repose for any arduous work — should such indi- 
 viduals in the long run fall into insanity, we find in all such cases a 
 confirmation of the doctrine, that only he who has had a correct under- 
 standing can lose it, while, indeed, a really sound development and 
 cultivation of the intellect is in no respect favorable, but, on the con- 
 trary, is decidedly unfavorable to the approach of insanity. 
 
 In the mental r-phere. the more immediate consequences, the external modes 
 of appearance, of too great irritability, of the irritable weakjiei^s (see p. 39), are 
 
112 THE CAUSES OF INSANITY. 
 
 very various. Many of these appearances, however, may primarily be traced to 
 a great tendency to mental pain, "Where there exists a very extensive sphere of 
 agitation, the mental equilibrium is more easily disturbed, the ego more easily 
 affected; from whence chiefly results the greater susceptibility of those individu- 
 als who behave sometimes impatiently, are excited, intolerant of contradiction, 
 aggressive — at other times, evading all mental impressions, they reservedly con- 
 centrate their thoughts upon themselves. Such individuals, incapable of satisfy- 
 ing their emotional cravings by external actions, dwell in the realms of imagina- 
 tion. To them the world appears common, and they fancy themselves too good 
 and too noble for its pursuits. Thus are produced various modes of manifesta- 
 tion of the same fundamental state, which nevertheless agree generally in this — 
 that the disproportion which exists between the reaction and the impression 
 appears in the higher degrees as extravagance and excess. The result is, that the 
 individual, with his whims and unusual modes of reaction, steps out of the ordi- 
 nary beaten path of humanity, and passes in the world as an original, singular 
 man. Such individuals sometimes exhibit a painful degree of scrupulousness 
 and trifling pedantry (frequently this is associated with mechanical talent). At 
 other times they are remarkable for frivolity, irregularity, uncertainty of thought 
 and action — sometimes for their coolness and apathy, or even for their eccentric 
 ardor, irresolution, or audacity. They exhibit striking peculiarities — at one time 
 lowness of spirits, at another time enthusiam; but they are always changeable, 
 always violent. The mode of reaction differs in such cases from that of the aver- 
 age of mankind, and therefore seems freakish. In those passionate, eccentric, 
 often inwardly discordant and disunited natures, bodily disorder of every descrip- 
 tion may become truly dangerous. They often bring to rapid development the 
 ■existing latent germ of mental disease. 
 
 § 96. These mental dispositions are undoubtedly congenital and 
 inherited; they are, so to speak, not nnfrequently the media of the hered- 
 itary predisposition to insanity, and are early evinced in the mental life 
 of the child by peculiar directions of taste, uncommon sensibility, vola- 
 tility of the inclinations, and little disposition for study; so that sncli 
 individuals are frequently, from the very first, objects of solicitude and 
 grief to their parents and teachers, while they are occasionally the objects 
 of injudicious wonder. Many of our observations, based on the confes- 
 sions of patients and convalescents, coincide with the statements of 
 Foderi,' that in the subjects of such dispositions there is frequently a 
 premature development of the sexual passion, and consequent spontane- 
 ously developed onanism, together with early haemon-hoidal disease (the 
 latter probably in consequence of the irritation of the genital organs). 
 
 Although it may be doubted whether such circumstances act as causes of 
 those psychical peculiarities, it is nevertheles worthy of careful consideration that 
 even in cases where there is no such congenital disposition, we very f requentlj- 
 find the same psychical anomalies developed in later years in consequence of 
 structural disease of the genital organs.- It need scarcely be stated here that 
 hysteria, which presents that condition of the nervous process chiefly in the 
 spinal, but frequently also in the cerebral system, often arises from disorder of 
 the sexual processes. 
 
 Other diseases, especially all considerable losses of fluids, and the 
 states of anaemia and exhaustion resulting therefrom, are often recogniz- 
 able as causes of the acquired nervous constitution. It appears at other 
 times that local hypersesthesia, prolonged irritation of any particulai' 
 nerve, ^ may produce such chronic states of irritation of the central 
 organs — as in acute tetanus. In the central organs themselves there may 
 
 1 ' Essai medico-legal sur les diverses especes de Folie, etc' Strasb., 1883. 
 
 ^ Compare the 115 cases of Lallemand (' Des Pertes semmales,' Paris, 1836- 
 42). It is astonishing how. almost without exception, these patients present a 
 change of their psychical condition in the direction I have here indicated. 
 
 ^ Lotze, ' Allgem. Pathologic.' 
 
THE CAUSES OF INSANITY. 113 
 
 also exist localized inflammations, and caiases of the disease which evade 
 anatomical demonstration, but from which we may approximately ascer- 
 tain the seat, perhaps, througli the sensibility of certain parts of the 
 spine, headache (affection of the flfth pair of nerves), etc. 
 
 In like manner, those depressing mental impressions, shock, grief, 
 etc., which are so frequently met with as causes of the nervous constitu- 
 tion, act by provoking a violent irritation, instantaneous or persistent, of 
 a more or less considerable portion of the brain — if, indeed, they have 
 not already (see § 99) indirectly produced a secondary cerebral affection. 
 
 The cases are proportionately rare, but cannot be questioned, wliere 
 such mental anomalies, after being developed, pass slowly and gradually 
 without further appreciable injurious influence into actual insanity. 
 Much more commonly the nervous constitution is but a predisposing cir- 
 cumstance, besides which something else is necessary — a real cause, either 
 a physical disease or a moral influence — in order that the simple disposi- 
 tion may become actual disorder — that the moderate mental aberration 
 may pass into profound insanity, may become an actual cerebral disease. 
 
 After what has been said in the two preceding paragraphs, we may dispense 
 with the further discussion of the so-called temperaments in so far as they dis- 
 pose to mental diseases. In common with many esteemed investigators (Gall, 
 Georget, Lotze, etc.), we cannot accord any real importance to those four classes 
 of temperaments taken from the ancient humeral pathology — a division which 
 can scarcely be adhered to, as it has never been empirically proved and is of lit- 
 tle practical use. 
 
 Besides the circumstances wliich have been spoken of, there are still a number 
 of serious chronic diseases whicli ought to be considered as bodily predisposing 
 causes. As has been already remarked, mental diseases originate under the 
 influence of several unfavorable co-operating causes, that, in certain cases, such 
 a cerebral disease may appear under the influence of cei'tain given circumstances 
 which may be traced to the previous detei'ioration of the general health incon- 
 sequence of chronic disease in some other organ. We must be careful, however, 
 not to assume the existence of severe chronic general diseases merely fi"om cer- 
 tain slight or obscure symptoms, and in the absence of necessary pathological 
 proof, because such assumptions frequently lead to superfluous and even violent 
 treatment. To enumerate all these diseases would be to repeat the entire special 
 pathology. The most important of them will be considered, and their mode of 
 action in the production of insanity pointed out, in tlie chapter on Physical 
 Causes. At present, we shall merely once more call to mind the intimate relation 
 which exists between the predisposing circumstances and those which, strictly 
 speaking, are circumstances of causation. 
 
 That a formerly existing insanity, though now removed, predisposes to a 
 retuni of the disease, need not be further discussed. Concerning relapse, see the 
 chapter on Px'ognosis. 
 
 8 
 
114 THE CAUSES OF INSANYIY, 
 
 CHAPTER III. 
 THE CAUSES OF INSANITY (CONTINUED). 
 
 Sectiok I. — Mode of Action of Causes. 
 
 § 97. Although in the majority of cases mental diseases are pro- 
 duced by the co-operation of several, it may be of many, unfavorable 
 circumstances, there are, however, ordinarily several amongst these cir- 
 cumstances which appear so especially important and effectual as to merit 
 the designation of special causes; or, in other words, cases of illness 
 present themselves which can only be ascribed to the influence of a sin- 
 gle unfavorable relation. In the discussion of these more intimate 
 causes, we have to consider, on the one hand, certain external injuries; 
 on the other, the adverse influence of health-destroying habits; and, 
 again certain abnormal organic states which can be the immediate cause 
 of such diseases of the brain. It would, indeed, be impossible to state 
 with absolute certainty the mode in which all these causes act; but if, 
 on the one hand, we consider the nature of the causes as they are men- 
 tioned further on, and, on the other, the comparatively little which is 
 known regarding the special lesion of the brain in insanity— moreover, 
 if we compare with these two series of facts which we learn by observa- 
 tion of the patients during the period when the causes act on them, Ave 
 will, with our present knowledge and comprehension, arrive at the fol- 
 lowing conclusions: — In many cases the cerebral affection in insanity is 
 not palpable; it depends either on simple nervous irritation, or on slight 
 changes of nutrition which as yet cannot be more definitely defined. 
 Often, then, the causes of insanity must act in such a manner that even 
 such impalpable cerebral disorders can be proved. In many other cases, 
 insanity is a symptom of cerebral disease, of which we do not yet know 
 the minute anatomical changes of the first stage, but which, at a later 
 period, leads to atrophy of the brain, to chronic hydrocephalus: these 
 must be disorders of nutrition, whose inflammatory nature is at least doubt- 
 ful. In others, however, insanity really depends on fixed inflammatory 
 processes in the cranial cavity, which are known to us as well in the 
 early stages as in their results. Finally, disorders of the circulation 
 within the cranium appear to play an important part in the origin of 
 insanity: in the one case there is anaemia (originating in various ways — 
 see further on); in the other, hypersemia of the brain; and, lastly, kin- 
 dred states which may exist as part appearances and essential elements 
 of inflammatory processes, as well as alone and independent of any inflam- 
 matory state. 
 
 We can in general trace the influence of the causes of insanity on the 
 origin of these various categories of morbid events, but we will be com- 
 pelled to confess that this gives us but a limited view of the special 
 mode of action of the causes generally, and that there are only a few 
 
THE CAUSES OF INSANITY. 115 
 
 of these causes ot which we know with special certainty the mode in 
 whicli they produce sucli changes of the brain as have been enumerated 
 in disease. It is the same here as in other pathology, where, as a rule, 
 the mediators between the causes on the one hand and the effects on the 
 other are always what we know least about. 
 
 I cannot now attribute so much importance to the hypergemias within the 
 cranium, as I did in the first edition of this work; although, since its publication, 
 experienced medical psychologists have assented to the opinion there stated. 
 But neither should the hypersemias be undervalued as pathogenetic circumstan- 
 ces, to which at present there exists too great an inclination in German medicine. 
 It is very evident that, in many cases, active cerebral congestions precede and 
 accompany the pai'oxysms; for example, of mania, of melancholia, of hysteria; 
 these congestions can naturally also present themselves in quite anaemic individ- 
 uals. Hypersemia of the brain, which can scarcely be considered entirely as a 
 post-mortem phenomenon, is an anatomical condition very commonly observed 
 in recent cases of insanity : stagnation, slowness of the circulation, with conse- 
 quent more venous congestion, may result -from diminished cai'diac ,power, 
 from organic changes in the cerebral arteries. Mechanical stasis in the veins 
 not unfrequently shows itself in recent cases of disease, at least in the counten- 
 ance by a general slight cyanotic livid color, dark color of the neighborhood of 
 the eyes and point of the nose, redness, and sometimes even ecchymosis of the 
 conjunctiva, prominence of the veins of the temple, neck, etc. The cause of 
 this congestion of the venous system may be heart-disease, functional weakness 
 of the left heart, in overfulness of the right heart, resulting from prolonged 
 incomplete respiration. The depressing emotions when long-continued, grief or 
 anxiety, may, it appears, in this way cause slowness of the respiration, through 
 which the lesser circulation is retarded, and venous congestion follows. 
 
 In the same manner may be explained the oppression felt at the chest (sighing) 
 and the smallness of the pulse, the tendency of the extremities to become cold, 
 the dark appearance of the countenance, the gray circles round the eyes obsei-ved 
 in individuals so affected. But these emotions have still other and not less 
 important effects, of which impairment of the general nutrition, sleeplessness, 
 and diminution of the blood-forming powers are the chief. 
 
 We do not believe that general simple hypereemia of the brain alone, without 
 the co-operation of other more essential, especially predisposing circumstances, 
 causes mental disease. We must admit, on the other hand, that when these 
 circumstances exist, this condition co-operates to a great extent in the produc- 
 tion of the disease. 
 
 Where well-marked and general plethora exists, the congestive states in the 
 period of their first commencement, or in more transitory mental disorders, 
 may justify the abstraction of blood. A plethoric young man, who had high 
 hopes of obtaining a situation, was taken on probation ; his services, however, 
 were not accepted. He learnt the result at night ; till then he had been quite 
 well and cheerful, but all at once he fell into a state of great depression ; he 
 passed a sleepless night— he could not remain in bed, but spent the greater 
 part of the night sitting at an open window. Slight delirium, in which he 
 imagined he was hunting, set in ; soon violent headache and general illness 
 came on. 
 
 Next morning, the whole head was of a dark-red color and very hot ; the eyes 
 injected, the pulse small, quick, and very irregular; there was also violent head- 
 ache, great agitation, foul tongue, and inclination to vomit. Patient bled to one 
 pound. This was immediately followed by rapid improvement of all the symp- 
 toms ; the patient declared that, after the bleeding, things suddenly ceased to 
 have the heavy and sad appearance which they formerly wore, and that he could 
 profit by advice. In the afternoon, epistaxis spontaneously set in, which was fol- 
 lowed by complete recovery. 
 
 Section II. — Psychical Causes, 
 
 § 98. We have now to discuss in detail the principal immediate causes 
 of mental diseases. They are so numerous — their mode of action, of 
 which often little is known, is so various, that it is impossible to form 
 
116 THE CAUSES OF INSANITY. 
 
 a logical classification of them; therefore we will merely arrange them 
 in groups according to their importance and significance. 
 
 The psychical causes are, in our opinion, the most frequent and the 
 most fertile sources of insanity, as well in regard to preparation as espe- 
 cially and principally the immediate excitation of the disease. We rec- 
 ognize, meanwhile, that this view rests not only on statistics,' but also 
 on the collective impression of many observations; but if we could fully 
 appreciate the psychical causes, which are often concealed in their most 
 important details, this impression would probably be a still stronger one. 
 
 Under psychical causes, we are before all to understand former pas- 
 sionate and emotional states. It is an absolute fact that intellectual 
 exertion, unaccompanied by emotional excitement or other further 
 powerful causes (for example, all kinds of excesses, sleeplessness, arti- 
 ficial excitation by excitants), leads only in the rarest cases to insanity. 
 
 The contrary is undoubtedly the case with the continuous or violent 
 emotions, of which disagreeable^ adverse, or depressive states of emotion 
 merit special attention; while immoderate joy alone has handed over to 
 the asylums very few, if any, patients. Pinel, that model medical 
 psychologist for all times, was so convinced of the truth of this, that the 
 first question which he addressed to a new patient was always, "Have you 
 suffered vexation, grief, or reverse of fortune?'" and nowadays it is quite 
 as rare as it was then to receive a negative answer to this question. In 
 individual cases these painful emotional states may vary very much in 
 their nature and in their causes: sometimes it is sudden anger — shock' or 
 grief excited by injury, loss of fortune, a rude interference witii the mod- 
 esty, a sudden death, etc. ; sometimes it is the result of the slow gnavvings of 
 disappointed ambition on the mind, regret on account of certain unjust 
 actions, domestic affliction, unfortunate love, jealousy, error, forced so- 
 journ in inadequate circumstances, or any other injured sentiment. In 
 every case there are influences which, through intense disturbance of the 
 mass of ideas of the ego, cause a mournful division in consciousness, and 
 we always see the most powerful effects where the wishes and hopes have 
 been for a lon^ time concentrated upon a certain object. Where the 
 individual has made certain things indispensable to his life, and when 
 these are forcibly withdrawn, the passage of the ideas into efforts is cut 
 off, and accordingly a gap in the ego and a violent internal strife results. 
 
 The effect of these emotions in the production of insanity is to be judged of 
 according to the strength of the first shock, according to its longer or shorter 
 duration, but more especially according to the present mental disposition of the 
 patient. Then, again, the degree of violence of the first impression, its more 
 rapid cessation or orolonged reverberation, depends to a great extent on this dis- 
 position. In many cases, the fact that such long and violent states of passion or 
 ill-humor could arise is of itself a sign of this (already spoken of in g 95) psychical 
 
 1 We could quote many statistics in favor of this view, especially the state- 
 ments of Parchappe and Brierre de Boismont, in opposition to the calculations of 
 Moreau ('Comptes rendus,' xvii., 1843, pp. 134, 279). We consider, however, 
 for the reasons stated in § 63-64, that it is impossible to solve this question by 
 statistics alone ; still it may be mentioned that Guislain also (' Legons orales,' 
 ii., 1852, p. 44), found moral causes to exist in 66 out of 100 cases; which quite 
 coincides with the figures given by Guislain— 67, and Hare 66 per cent. 
 
 2 Georget, ' De la Folic,' Paris, 1820, p. 160. 
 
 3 See two examples of insanity caused bv violent shock, by Ellis (' Traite,' etc., 
 trad. p. Archambault, Paris, 1840, pp. 108, 109). Ellis here ascribes the effect to 
 the altered cardiac activity. Guislain found, amongst 100 patients who were 
 admitted in the course of a year, shock or anxiety to be the cause of the insanity 
 in nine instances. 
 
THE CAUSES OF INSANITY. 117 
 
 peculiarity; and it was the special original irritability and passionateness of the 
 individual— tlie already existing disposition to emotions, and to sudden dimming 
 of the consciousness, which from a period dating even from the years of child- 
 hood could often be pointed to as the source of mental sickness, often as the cause 
 of the subsequent habits and actions of the iDatient. This disposition may be 
 manifested by disorderly conduct, idleness, desire for fashionable follies, love of 
 pleasure, and political extravagance; or by religious enthusiasm and asceticism, 
 by misplaced friendship and love; and, finally, by the moral bankruptcy of a life 
 lavished in follies. On the form which the emotion receives from the external 
 causes, very little rarely depends: each I'ace, each position in life, each individual 
 receives liis mental wounds in that sphere which nature and external circum- 
 stances have provided for him; and, moreover, each has a point on which he is 
 most vulnerable, another sphere from which violent shocks most easily proceed: in 
 one it is money, in another the estimation in which he is held by others; in the 
 third, his feelings, his faith, his knowledge, his family, etc. But the emotions 
 and passions are not the only precursors of insanity; the state of exhaustion of 
 the sensibility wdiich they produce is also a very frequent cause. Where there 
 is no strong intelligence to govern the illusions, the mental coldness and want of 
 interest— where everything seems cold and stale, the heart benumbed, the world 
 become emptj- — these mental states very coutmonly end in melancholia, suicide, 
 or profound insanity. 
 
 Although, in general, it is chiefly the long, continuous emotions which have 
 a powerful influence on the production of mental disorders, there are also cases 
 where an attack of insanity, especially of mania, immediately follows a single 
 outburst of violent anger or rage: such cases, also interesting in a forensical 
 point of view, frequently occur under tlie co-operating influence of spirituous 
 liquors, even when they have been taken in very small quantity. This would 
 not be likely to occur in any but those who are strongly predisposed. 
 
 § 99. The mode of action of these psychical causes is either direct or 
 indirect. 
 
 In the first case, the emotions, particularly the passed-off psychical 
 phenomena, are the immediate originators of the mental disease, inasmuch 
 as they produce a state of intense irritation of the brain, which now con- 
 tinues. 
 
 Thus, for example, fright, which is so dangerous to the female organi- 
 zation, may immediately give rise to an insanity which for years may 
 present the chief character of the physiological effects of fear — that half 
 convulsive, half paralytic state of torpor, of thought, and will.' At other 
 times we see long-continued moderate psychical perversion, persistent 
 anger, grief, anxiety, owing to direct excessive irritation of the brain, 
 gradually increase and pass immediately 'nto the first stage of insanity 
 which very often presents the special character of these kinds of psychical 
 pain. 
 
 Here also (according to the preceding section) it is often difficult to 
 distinguish early mental predisposition from more immediate psychical 
 causes. Those causes may also here be mentioned, in which mental pecu- 
 liarities of long standing, which have for a long time gained for the 
 individual the title of a half-foolish, crotchetty candidate for the mad- 
 house, gradually pass without further appreciable cause into actual in- 
 sanity. 
 
 More frequently, however, the insanity originates indirectly — through 
 the medium of a pathological process — from the psychical causes, inas- 
 much as they, in the first place, bring about further deviations from the 
 normal organic processes in other parts, from which then the cerebral 
 
 ' We may call to mind the similar sudden effect of shock in the production of 
 epileptic attacks. Anger may act quite as suddenly. In these cases a very rapid 
 and intense change in the collective activity of the brain takes place, which 
 appears to act very injuriously upon that organ. 
 
118 THE CAUSES OF LNSANITY, 
 
 disease proceeds as a secondary result. If we consider the fact previously 
 spoken of, that the emotions ordinarily disturb sympathetically the func- 
 tions of the organs of circulation, respiration, digestion, and of blood 
 formation, we will easily understand how these, when long continued or 
 very violent, must cause slight disorders of these functions, and those 
 individuals are most easily affected in whom (owing to congenital or ac- 
 quired disposition) emotions are most easily excited. 
 
 Very frequently the cerebral disease only commences when, after long 
 oscillations, some serious pathological change has gradually arisen in some 
 other organ. 
 
 It is by no means rare, for example, after some untoward event which 
 immediately caused disturbance of the cerebral processes, to see the indi- 
 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. These effects are 
 particularly evident in states of continued buc carefully concealed mental 
 pain: those tears which have been long restrained and concealed with 
 smiles or pride, or falsehood, show themselves almost unfailingly in the 
 development of chronic diseases which secondarily give rise to a cerebral 
 affection. We see that under such circumstances the individual soon 
 becomes emaciated, digestion suffers, and the intestinal functions become 
 weak; that sleeplessness, palpitation, cough, all kinds of anomalies of 
 sensibility, cerebral congestion, nervousness and hypochondria, establish 
 themselves. In the female sex, menostosia or irregularity of the periods, 
 angemia, neuralgias, and the group of symptoms of hysteria appear. 
 
 We see that, under the influences of such circumstances, dispositions 
 to disease which had hitherto been dormant — tuberculosis, chronic heart 
 diseases, etc. — are now awakened or rapidly aggravated, and that out of 
 these pathological mediators between first causes and ultimate results, 
 mental diseases proper are finally established. 
 
 A mediator of this description of especial importance and frequency 
 in connection with mental diseases is continned sleepless /less, which often 
 accompanies the depressing emotions, which overexcites the brain, and 
 lowers the nutrition. It presents, therefore, in the preliminary stages of 
 insanity, a symptom which may be often effectually combated by thera- 
 peutic measures. 
 
 Most of the relations spoken of in this section are explicable through the influ- 
 ence of the nervous centres on the whole economy; and it is easily comprehen- 
 sible that these consequences of the emotions are most frequent and most dan- 
 gerous 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 generally is most capable of disease, viz., at the period of puberty, 
 during pregnancy, childbirth, the climacteric period, etc. 
 
 The cause of the depressing emotions, the groups of ideas around which it 
 revolves, exercise frequently (but not always, much more decided in the minority 
 of cases) a deciding influence on the subject of the insane ideas. Thus, after the 
 loss of a loved relative, the delirium will long revolve around those ideas which 
 have relation to this loss— a relation which coincides to a certain extent with 
 that mentioned above. In these cases the boundary betwixt the physiological 
 state of emotion and insanitv is often difficult to trace. At least, it may demand 
 profound consideration; the" latter may appear as the immediate continuation of 
 a physiological state of the established emotion. 
 
 The essential difference between the two, therefore— between melancholia and 
 a gloomy disposition— consists in this, that in the former the patient cannot 
 withdraw himself from his ill-humor, because it has become fixed through the 
 mediation of abnormal organic phenomena: these latter may in certain circum- 
 stances be very important in regard to diagnosis. 
 
THE CAUSES OF INSANITY. 119 
 
 Besides this regulating influence of the cause of the depressing emotions on 
 the subject of the delirium, there are certain definite moral causes, which give 
 (but not always) also a peculiar character to the insanity. Thus, the insanity 
 observed in women after disappointment in love is characterized generally by a 
 deep melancholic depression, occasionally passing into stupor; by a tendency to 
 suicide by hysterical complications, great bodily enervation, frequent termination 
 In tuberculosis. Insanity from fright most commonly presents the character of 
 •sTielancholia with stupor, with or without consequent mania, etc. 
 
 Section III. — Mixed Causes. 
 
 § 100. 1. DrunTcenness stands midway between the psychical and the 
 physical causes ; its effects are very powerful as well as very complex. 
 On the one hand, the action of alcoholic excesses is principally purely 
 physical — in part direct, by causing irritation and changes in the nutri- 
 tion of the brain, by the development of chronic stasis within the cra- 
 nium ; in part indirect, by producing drunkard's scorbutus, fatty degen- 
 eration of the liver, serious gastric diseases ; in short, by complete ruin 
 of the constitution. But, on the other hand, drunkenness produces also 
 important psychical causes — partly in those excitements, noisy quarrels 
 and brawls, which drunkenness so frequently occasions ; partly in the sad 
 mental impressions which its ordinary consequences — domestic discom- 
 fort, ruin in business, withdrawal from the family circle, loss of self-respect 
 — must gradually force home. Finally, as a third cause, it is to be 
 remembered that in many cases the drunkenness is not the cause, but the 
 consequence, of such impressions — domestic sorrow, grief, annoyance, 
 and vexation ; because of which, relief and consolation are sought in 
 dissipation. Under the simultaneous action of two such powerful causes, 
 insanity is generally very rapidly developed. 
 
 That intoxication, when carried to a certain degree, as a dreamy condition 
 with numerous hallucinations and illusions, really resembles insanity, is easily 
 understood. Sometimes we see individuals who, after partaking of a relatively 
 small quantity of spirits, and without being in a state of deep intoxication, but 
 retaining fully their consciousness, present a gi-eat tendency to commit very 
 extravagant, noisy, and foolish acts; a circumstance which may be truly con- 
 sidered as a symptom of predisjwsition to mental disease. Moreover, there occur 
 in drunkards sudden convulsive states which resemble epileptic attacks, and 
 which are sometimes followed by a condition of forgetfulness and tranquil delir- 
 ium, at other times by outbreaks of furious delirium, which has been termed the 
 convulsive form of intoxication. ' 
 
 The habitual drunkard, in whom the habit is already far advanced, presents 
 also, even when he is not in a state of intoxication, many signs which indicate tlie 
 existence of an advancing chronic disease of the brain, and which make him closely 
 resemble the mentally diseased. Indeed, this condition may gradually pass into 
 insanity, and particularly into dementia; and there are constantly found in the 
 brains of habitual drunkards, as in many of the insane, the results of passive 
 congestion — chronic opacities and thickenings of the cerebral membranes. The 
 appetite acquired by habit is so powerful in the drunkard, the ideas which might 
 oppose it are so weak, and the will has become so paralyzed, that he, even though 
 he is aware that he renders himself despised and contemptible, undermines his 
 constitution, disturbs his domestic happiness, ruins his business, and every day 
 postpones the good resolution which he perhaps had made. The craving, the 
 dizziness, the dulness of the senses, the muscular feebleness, the stomach com- 
 plaints from which he suffers, are, each time he partakes, alleviated for the 
 moment, and it may, perhaps, be partly owing to the fact that these disorders 
 require each day to be remedied that drunkenness is often so inveterate. 
 
 Serious mental disorders may commence in drunkards in various ways. 
 
 ' See Marc, ' Die Geisteskrankheiten,' ii., p. 431; Drake, in Nasse's ' Zeitschrift 
 fiir Anthropologic,' 1824, p. 224. 
 
120 THE CAUSES OF INSANITY. 
 
 Delirium tremens attacks habitual drunkards, and sometimes also indivi- 
 duals who are in the habit of drinking, but who very seldom become 
 intoxicated. Occasionally it comes on suddenly ; generally it is preceded 
 by sleej)lessness, or by disturbed sleep from confused dreams. Emotions, 
 pains, acute diseases (especially pneumonia), haemorrhages, weakening 
 influences of any kind, sudden suspension of all alcoholic drinks, fre- 
 quently determine the commencement. Its characteristic symptoms are 
 sleeplessness, tremor, tendency to perspire, hallucinations ; the mental 
 state is generally that of great restlessness and agitation, chiefly depend- 
 ing on the hallucinations — therefore in certain cirewmstances the patient 
 may become dangerous to those surrounding him. 
 
 Of all the various forms of chronic insanity, drunkenness especially 
 appears to possess much in common with general paralysis. Besides, 
 incompletely developed forms, which in a medico-legal point of view are 
 often very difficult to judge of, are very common. These slight chronic 
 mental anomalies observed in the drunkard are manifested by very appa- 
 rent mental dulness, loss of the sense of duty, and in general of all the 
 higher sentiments ; conscience and the sense of truth are blunted ; the 
 intellect is generally enfeebled, especially the memory : frequently slight 
 or well-marked hallucinations also exist. Numerous other anomalies of 
 the nervous system also present themselves — tremors of the hands and 
 of the tongue, deadening of the sense of sight iind o"f touch, debility of 
 the genital organs ; the patient has formication and cram])s in the limbs, 
 giddiness, sometimes epileptic attacks of greater or less severity ; sooner 
 or later marasmus and dropsy may set in, with the usual local affections 
 (gastric disease, emphysema, cirrhosis of the liver, Bright's disease, etc.). 
 The children of drunkards very frequently die early from convulsions ; 
 many of them are idiots, imbeciles, or microcephalic ; or in later life 
 they present the same disposition to drunkenness, insanity, and crime. 
 
 We cannot state generally to what extent drunkenness acts in the 
 production of the mental diseases ordinarily met with in asylums ; the 
 various nations present in this respect very great differences, and the 
 statistics which we possess can be only to a slight extent compared, because 
 delirium tremens is sometimes included, sometimes not. Amongst 747 
 cases, Halloran found drunkenness given as a cause in more than \i\\. 
 Prichard and Esquirol ascribe the half of the attacks in England to 
 this cause. In 1848, Webster, in Bedlam (704 cases), found this to be a 
 cause in only ^th-^tli of the cases ; Morrison, in Bedlam (1428 cases), 
 in scarcely -^th, and amongst these there are certainly included several 
 cases of delirium tremens. It is generally known that in later times the 
 abuse of spirits in England has very much diminished, and this cause 
 has proj)ortionately decreased in the etiological lists of the asylums. I 
 have been assured by very competent authorities in England, that this 
 gratifying result is to be attributed, not to temperance societies, but to 
 the influence of the corn laws. At the present time drunkenness nowhere 
 appears to be such a powerful cause of mental disease as in America. 
 Rush gives this as the cause in^-d of the cases in the hospitals of Penn- 
 sylvania, and later statistics of certain American asylums show even a 
 larger proportion. From Germany we have important statistics by Jacobi ; 
 Bergmann (for Hanover, -^-th) ; Dagonet (1856), for Stephansfeld, gives 
 ■|^th-4th of the cases as the average. 
 
 Drunkenness is naturally a more important and frequent cause of insanity in 
 men than in women; still there also occur amongst females, not only of the lower 
 class — amongst prostitutes — where, without doubt, this drunken mania is very 
 
THE CAUSES OF INSANITY. 121 
 
 frequent — but also in the higher classes, amongst hysterical females, particularly 
 during the climacteric period, examples of drunkenness and resulting insanity. 
 Sutton mentions a case where, in a lady, delirium tremens resulted from the 
 excessive use of tinctv^re of lavender for sleeplessness. 
 
 Dipsomania, properly so called, or periodic intermittent dninkenness, should 
 not be considered as a cause, but rather a symptom, of periodic insanity. Several 
 cases have been observed — and I myself know of such — in which from time to 
 time, simultaneously with other nervous symptoms, headache, great prostration, 
 sleeplessness, nausea, gnawing sensation in the epigastric region, mental perver- 
 sion, general discomfort, and a certain degree of melancholy sets in, which, after 
 a time, is succeeded by restlessness; the patient begins to frequent the tavern, 
 and generally drinks hard for several days continuously. The drunkenness in 
 these cases generally attains the proportions of an actual maniacal attack, from 
 which the patient emerges sometimes quickly, sometimes slowly, in a state of 
 deep depression, and often retains for a long time a strong aversion to spirits. 
 Generally these attacks are repeated. In their diagnosis we have to inquire par- 
 ticularly whether or not the attack has been preceded by a stage of melancholia, 
 whether there be any hereditaiy predisposition, and whether the ordinary habits 
 of the patient be those of sobriety, or, on the contrary, he exhibits an inclination 
 to drunkenness. In the latter case it is very problematical whether the attack 
 of dipsomania be the result of disease.' 
 
 In America, and also in England, cases enter the asylums in which the abuse 
 of opmm seems to have been the cause of the insanity; such cases present also 
 the general appearances of chronic opium-poisoning. Tobacco, wlien indulged 
 in to excess, and in some cases even its moderate use, may considerably affect the 
 functions of the entire nervous sj^stem. Although there seem to be no facts 
 which might lead us to suppose that tobacco alone can become a cause of insanity, 
 still it cannot be denied that in many individuals with weak and disturbed mental 
 functions it may co-operate to this end. The cerebral affection which is produced 
 by ch ronic lead-poisoning presents sometimes many analogies to delirium tremens, 
 particularly as in both cases there is observed an excited muttering delirium with 
 tremor; but in lead-poisoning the excitement passes frequently into stupor: 
 besides, there are often cramps and paralysis: tlie prior existence of lead-colic 
 and the gray line rovmd the gums may assist in forming the diagnosis. Moreau 
 (Annal. Med. Psychol., vii., 1855, i). 639) narrates a case of stupor alternating 
 with maniacal excitement after the extensive use of a pomade which contained 
 a great quantity of lead. The disease commenced after the pomade had been used 
 for fourteen days. In this case there was also colic and the gray coloration of 
 the gums. 
 
 § 101. 2. A complex action like that of drunkenness, influencing at 
 the same time the mental and bodily health, results in a life spent in 
 disquietude and tumult, in carelessness and dissoluteness ; we may also 
 add, misery and privation, which are very important, and frequently the 
 only appreciable causes. How often do we find in the antecedents of the 
 insane, an irregular life, disturbed by adventures, changing impulses, 
 and peculiar complication, full of varying fortunes, hardships, misery, 
 and excess — full of incidents such as must afford fertile sources of con- 
 flicts with the world, of mental excitement and deep disappointment ! 
 How often do we see jnivation and poverty which lead to mental pain 
 and despondency, in which the individual can no more surmount the 
 misery of his position, can no longer resist his misery, and falls into 
 melancholy, suicide, or profound insanity ! But there are other influ- 
 ences than those which are directly mental : the bad nourishment, hun- 
 ger, cold, fatigue, and over-exertion, which must necessarily accompany 
 such misery, are important physical causes. In all disorderly and irreg- 
 ular lives, Avhether voluntary or compulsory (as fatigues of military life, 
 in war, et,c.), we ordinarily meet these two kinds of injurious influences 
 together. 
 
 ' See Briihl-Cramer, 'Ueber die Trunksucht,' etc., 1819; Hohnbaum, " Ueber 
 die psych. Behandlung der Trunkstichtigen," Nasse's 'Zeitschrift fiir psych. 
 Aerzte,' 1820; Marc-Ideler, ii., 1, c; Huss- ' Alcoholismus Chronicus.' 
 
122 THE CAUSES OF INSANITY. 
 
 3. Sexual excesses have a similar dou1)le injurious influence, in conse- 
 quence of the mental excitement which is frequently associated therewith, 
 and owing to the physical exhaustion which results. The same may be 
 said of onanism, which is likewise an important and frequent cause 
 of insanity, as of all other physical and moral degradation. Besides the 
 emission of semen, and the direct action of the often permanent irrita- 
 tion of the genital organs on the spinal cord and the brain, onanism cer- 
 tainly has a still more injurious action on the mental state and a more 
 direct influence in the production of insanity. That constant struggle 
 against a desire which is even overpowering, and to which the individual 
 always in the end succumbs — that hidden strife betwixt shame, repent- 
 ance, good intentions, and irritation, which imperiously impels to the act, 
 we consider, after not a little acquaintance with onanists, to be by far 
 more important than the primary, direct physical effect. The share 
 which each mode of action exerts cannot be distinguished in individual 
 cases; but, generally speaking, the effect of onanism seems to be greater 
 in proportion to the earliness of the age at which the constitution is in- 
 jured and the patient becomes markedly anaemic, the degree in which it 
 is accompanied by those painful emotions, and in which it becomes the 
 cause of local disease of the genital organs (see § 108). When these three 
 influences fail, masturbation is seldom followed by serious consequences. 
 
 Ellis (' Traite de rAlienation,' p. 133) ascribes the majority of all the cases 
 treated in public asylums to onanism. Others, as Guislain and Parchappe, in 
 their etiological tables, attribute to this cause but a small proportion. Compare 
 the treatise on the relations of self-abuse as a cause of insanity in Jacobl and 
 Nasse (' Zeitschrift,' i., 1835, p. 205). Ellinger (■ Zeitschrift fiir Psychiatrie,' ii., 
 1845, p. 22) considers, from careful observation in Winnenthal, that onanism is a 
 co-operating influence in one-fifth of the cases. See Nasse, ibid., 1849, p. 869; 
 Claude, ' Revue Medicale,' 1849, Mai, p. 252. 
 
 In this series of causes we must carefully avoid confusion. It is not at all 
 rare to see at the commencement of insanity (or rather at the stage of transition 
 of a moderate degree of melancholia into mania) the patient exhibits an increased 
 sexual instinct which may lead to onanism or to frequenting bad houses. In this 
 we recognize, not a cause, but a symptom of mental disease. In many cases 
 where the sexual excesses really at the time appear to be causes of the insanity, they 
 are only the immediate consequences of a morbid irritation, of an excitation of 
 long standing of certain portions of the nervous system. In particular, onanism 
 spontaneously commencing in early life, long before puberty, may almost with 
 absolute certainty be ascribed to morbid irritation of the genital organs, which 
 coincides with the entire nervous constitution and with a predisposition to mental 
 disease. 
 
 The mental disorders which originate under the influence of onanism have no 
 constant specific character, but they in the majority of cases betray themselves 
 by profound dulness of sentiment and mental exhaustion, by hallucinations of 
 hearing, by a religious character of the delirium, by a rapid transition to demen- 
 tia, and consequent frequent incurability. 
 
 Section IV. — Physical Cmcses. 
 
 § 102. As we do not consider it possible that (see §§ 79 and 98) the 
 question whether insanity originates more frequently from psychical or 
 from somatic causes can be solved by statistics alone, any discussion of 
 the statistics relating to this subject, from the days of Pinel to the pres- 
 ent time, may be dispensed with, in that the reader in regard to the 
 investigations on this subject is referred to the old discussion jvhich has 
 been carried on between Moreau de Jonnes on the one hand, and Par- 
 chappe and Brierre on the other,' with the remembrance that all such 
 
 ' ' Comptes rendus de I'Academie des Sciences,' xvii., 1843. 
 
THE CAUSES OF INSANITY. 123 
 
 tables afford results inadmissible and unreal, according as the individual 
 titles are vague and abstract, ' and idiocy less carefully separated from the 
 other mental diseases/ It is evident that in many cases insanity may 
 originate from purely physical causes; that, on the other hand, under 
 tlieir co-operation, psychical causes lead more rapidly and more markedly 
 to the production of mental disease. A hereditary or acquired disposi- 
 tion may frequently, though not invariably, be made out; it often mani- 
 fests itself, besides the symptoms we have already mentioned, by the easy 
 origin of delirium in acute diseases, even though of but slight intensity. 
 In such individuals, in different degrees, any serious bodily disease may, 
 through secondary affection of the brain, become a cause of insanity: on 
 the other hand, however, somatic causes do not only act in this way by 
 exciting disease in those already predisposed, but by them dispositions 
 are originated which afterwards, under the influence of moral causes, 
 pass into insanity. 
 
 These physical causes consist partly in conditions which, although 
 still physiological, expose the patient more to disease (as childbed), partly 
 in already developed acute, or to a greater extent in chronic diseases {e. g., 
 tuberculosis) — partly in certain external injuries {e. g., injury of the 
 head). In their enumeration we shall commence with those which act 
 directly on the nervous system. 
 
 § 103. 1. Insanity originating from other nervons diseases. — Most 
 diseases of the brain, even althougli they do not at first present the 
 characters of mental diseases, may in their further course become such. 
 Acute meningitis can only, when it has become chronic — that is, through 
 the metamorphoses, and the other results of the exudation — be immedi- 
 ately recognized as a mental disease. The various affections of the brain 
 which may give rise to epilejjsy are sometimes connected from the first 
 Avith decided mental disturbance — intermitting attacks of the former may 
 even precede the intermittent convulsions — sometimes it is only after the 
 epilepsy has existed for a long time that those morbid processes can 
 become the originators of mental disease' (either because the affection — e. 
 g., chronic inflammation— originally situated in the interior of the brain, 
 extends to the surface, or through consecutive atrophy of the brain, etc.). 
 It is the same witli apoplexy: it can, besides the paralysis, be followed by 
 an insanity (almost always in the form of dementia — sometimes, however, 
 of mania) which is sometimes primary, existing from the commencement 
 — sometimes secondary, owing to those degenerations which apoplexy 
 gives rise to within the brain. Sometimes the mental disorder is very 
 limited, affecting only certain series of ideas: it may, however, extend to 
 general and profound mental weakness. 
 
 All severe injuries to the head are acknowledged to be of great import- 
 ance in the production of insanity, whether they consist of fracture of 
 the skull, extravasation of blood, loss of cerebral substance, or simple 
 concussion. While in the most severe of these cases the resulting men- 
 tal disturbance (dementia, dementia with mania, etc.) generally appears 
 at once or on recovery from the injury, in other cases it does not appear 
 till much later — one, two, six, or even ten years after the accident. In 
 the majority of these cases there may be small residuous purulent patches 
 
 1 Moreau has, for example, a quite incomprehensible and vague title, " Irrita- 
 tion excessive," with a large number to it. 
 
 ^ The same author brings forward iodicy with an enormous number, as one of 
 the physical causes of mental disease. 
 
 ^ See, further on, the special description of epilepsy as a complication. 
 
124: THE CAUSES OF INSANITY. 
 
 wliicli long remain withoiit any injurious consequence, or small apo- 
 plectic cysts, chronic processes in tlie dura mater, etc., around which 
 there arises, later, without any cause, a gradually extending inflamma- 
 tion of the delicate membranes or of the cerebral substance. In other 
 cases there is slowly formed an exostosis, a tumor, or chronic caries of 
 the skull, from which hyperremias and exudative processes proceed. 
 Occasionally, however, nothing of this sort can be perceived; it appears 
 that in certain cases concussion may, without there being any anatomical 
 lesion, be followed by such results within tlie brain that it remains for 
 years after very suscejotible to disease, so that after the slightest exciting 
 cause (for example, a moral cause) insanity is produced. 
 
 It frequently happens that on minute inquiry the physician learns from the 
 relatives of tiie patient of former circumstances of this kind which had been 
 almost forgotten — a severe kick from a horse, a fall or blow on the head which 
 was followed by insensibility.' Sometimes the friend now remembers for the 
 first time, that since the accident a certain change has taken place in the character 
 of the patient — that he had become fretful, irritable, perverse, etc. This cliange, 
 however, has been little heeded, and had not even been recognized in its true 
 significance — as a precursor of insanity — when the disease -broke out. 
 
 We quote the following from the interesting work of Schlager, " On the 
 Mental Disorders which result from Concussii^n of the Brain" ('Zeitschrift der 
 k. k. Gesells. der Aerzte zu Wien,' xiii., 1857, p. 454): — Amongst 500 patients the 
 author discovered 49 (43 males and 7 females) in wliom the development of the 
 mental disorder stood in direct relation to the consequences of previous concussion 
 of the brain. In 21 cases, the injury was followed immediately by loss of con- 
 sciousness; in 16, by simple mental confusion, wandering of the thoughts; in 12, 
 by dull pain in the head. In 19 cases the mental disease commenced within the 
 first year after the accident, but in the great majority not until the lapse of a 
 much longer time; in 4, after upwards of ten years. Generally, the individuals 
 manifested from the time of the injnry a tendency to cerebral congestion after 
 the use of even a small amount of spirits, after mental excitement; also in several 
 cases ocular hyper^sthesiee (subjective impressions of light and of color, photo- 
 phobia), often amblyopia. In 15 cases, there appeared shortly before and during 
 the existence of the cerebral disorder black specks, which exercised a deciding 
 influence on the character of the delirium. Very often also the patients experi- 
 enced ringing and noises in the ears: in 18 cases there was dulness of hearing; in 
 3, abnormal subjective perceptions of smell, changes in the pupils. Very often 
 the character and disposition changed: in 20 cases great irascibility, an angry 
 passionate manner even to the most violent outbursts of temper was remarked — 
 less frequently over-estimation of self, prodigality, restlessness, disquietude; in 
 14 cases there were attempts at suicide, frequently weakness of memory, confu- 
 sion. The prognosis was almost always unfavorable. Seven of the cases ended 
 in general paralysis, 10 cases came to post-moilem examination. In these there 
 were found occasionally osseous cicatrices, adherent dura mater, opacity and 
 serous infiltration of the delicate membranes, more or less hydrocephalus chroni- 
 cus, granulations on the lining membrane of the ventricles; in one case a cerebral 
 induration, witli atrophy of the brain and clironic inflammation of the delicate 
 membranes. Injury of the cranial bones renders the probability of consequent 
 psychical disturbance much greater than simple injury of the soft parts. Very 
 interesting examples of insanity consequent upon injuries to the head may be 
 found in the ' Report of the Vienna Asylum ' (1858, p. 47). 
 
 To those cases which result from diseases of the bones in consequence of 
 
 injury may be added insanity from caries of the skull owing to internal causes, 
 
 especially from caries of the temporal bone, internal otitis with its results, 
 
 thrombosis, meningitis, etc. Jacobi'^ has observed 7 cases of the latter kind; they 
 
 . never admit of recovery, and but seldom of improvement. In the asylum at 
 
 ' In a similar manner, we frequently see also severe spinal neuroses appear for 
 the first time long after the accident. Jakubowsky (' Chorea St. Viti traumaticae 
 exemplum,' Krakau, 1838, Gratulationschrift) relates a case of St. Vitus' dance 
 of this kind which appeared several months after the receipt of a kick on the back 
 from a horse; subsequent recovery. 
 
 " ' Die Hauptformen,' etc., p. 663. 
 
THE CAUSES OF IK8ANITY. 125 
 
 New York, 7 cases occurred in a single year in which mental disease originated 
 from diseases of the internal ear fHanbury Smith, ' Annal. Med. Psychol.,' 1854, 
 vi., p. 450). Cases have been observed in which a violent attack of mania ensued 
 on cessation of a purulent discharge from the ear, and ceased, or at least con- 
 siderably diminished, on the return of the discharge (L. Meyer, ' Deutsche Klinik,' 
 1855, No. 6). 
 
 Along "with injuries to the head we may also mention insolation as a cause, 
 though not of frequent occurrence, of insanity. This acts, perhaps, by causing 
 great cerebral hyperemia (and oedema?); perhaps the insanity is due to exces- 
 sive nervous irritation of the brain caused by pi'olonged exposure to the rays of 
 a burning sun. Ellis' mentions two cases of insanity caused by insolation: one 
 of them ended in recovery, the other in dementia. 
 
 Those cases in which insanity originates after (and, without doubt, in 
 consequence of) a relatively insignificant injury of a jieri/pheral nerve 
 (above all, wounds of the soft tissues), or disease of a nerve of sense 
 commencing at the periphery — for example, peripheral deafness — are of 
 very great pathological interest. Thus we have seen an attack of pro- 
 found melancholia occur in a hysterical woman after a slight injury of 
 the eye caused by a splinter of wood; insanity has also been observed 
 (Herzog) to occur after the operation for strabismus.^ Foville^ mentions 
 numerous cases of superficial disease of the cerebellum in the insane in 
 consequence of peripheral disorders of the fifth and auditory nerves; to 
 this pathogenic category belongs also the case already quoted from Jor- 
 dens,"" of a boy who became maniacal through a small piece of glass pene- 
 trating the sole of his foot, and continued so until the glass was removed. 
 It is very probable, too, that the cases mentioned by Zeller,^ of insanity 
 consecutive to simi^le external wounds of the head, may also be ranged 
 under this head.'' Inasmuch as these cases vividly remind us of the 
 delirium nervosum observed after and sometimes during operations, this 
 cerebral affection may be compared to that affection of the spinal cord 
 which determines traumatic tetanus; but with this difference — that the 
 spinal cord and the brain always react according to their own peculiar 
 energv. 
 
 In the next place, we may here mention various other powerful or 
 long-continued nervous irritations from the periphery of the organism. 
 As an example of the first series, we may mention that remarkable case 
 recorded by Esquirol, of mania occurring after a strong impression of 
 smell; of the second series, perhaps, e. g., the irritation ])rodaced Avithin 
 the bowels by ta?nia and other entozoa, or even of pruritus chronicus. 
 Very severe pain may also call forth an attack of insanity in an individ- 
 ual who is predisposed. The 'Report of the Vienna Asylum' (1858, \). 
 60) contains a case of this kind, in consequence of severe pain resulting 
 from inflammation of one of the tendinous sheaths in the palm of the 
 hand. 
 
 § 104. Formerly existing spinal neuroses, whether manifested in 
 states of developed hysteria, or merely in limited convulsive or neuralgic 
 affections, may become important causes of insanity. Here it seems that 
 mental disorders may originate as well from a gradual extension over 
 more considerable portions of the nerve centres — and this is very fre- 
 
 ' • Traite de I'Alienation,' etc., par Archambault, 1840, p. 81. 
 - Oppenheim"s ' Zeitschrift,' xxi., 1842, p. 101. From the 'St. Petersburg 
 Transactions,' where I, alas! could not read the case in the original. 
 " ' Note an die Academie, I'lnstitut,' Jan., 1843. 
 ^ ' Hufeland's Journal,' vol. iv., p. 244. 
 ^ ' Zeitschrift fiir Psychiatrie,' i., 1, p. 49. 
 '' See moreover the case mentioned by Hirsch (' Spinaineurosen,' p. 131). 
 
126 THE CAUSES OF INSANITY. 
 
 quently the case with hysterical persons — as from a rapid transition from 
 one part of the nervous system to another: in the latter case the insanity 
 may frequently, and even periodically, alternate with other nervous 
 affections. Thus Brodie' narrates the case of a lady who for a year suf- 
 fered from permanent convulsion of the sterno-mastoid muscle; suddenly 
 tlie convulsive state ceased, and she fell into melancholia. The melan- 
 cholia lasted for a year, when her mental health returned ; but the muscu- 
 lar convulsion returned also, and continued for several years. In another 
 case, also reported by Brodie, a neuralgic state of the vertebral column 
 alternated with true insanity. 
 
 Concei'ning Hysteria proper. This general affection of the nervous 
 system is manifested sometimes more in one, sometimes more in another 
 part of the nervous apparatus: only very seldom, however, do the mental 
 faculties remain entirely free from all disturbance. In the ordinary 
 slight cases which cannot as yet be considered as mental diseases, Ave see, 
 sometimes together with marked motory-sensitive anomalies, sometimes 
 without them, as a predominating affection, the peculiar hysterical dis- 
 position, viz., immoderate sensitiveness, especially to the slightest re- 
 proach — tendency to refer everything to themselves; great irritability, 
 great change of disposition on the least or even from no external motive 
 (humors, caprices), and not the slightest reason can be given for the 
 change they often exhibit tender sympathy for other female individuals, 
 peculiar eccentricities, very lively intellects (in young girls, pleasure in 
 learning, etc.). This general state comprises many peculiarities of char- 
 acter, often of quite another kind, as tendency to deception and prevari- 
 cation, to all kinds of misdemeanors. Jealousy, malice, etc. 
 
 Serious hysterical mental disorders are manifested principally in two 
 different forms. In the first place as acute attacks of delirium and ex- 
 citement even to developed mania. These are developed sometimes from 
 ordinary hysterical convulsive attacks, which, however, may be very 
 slight; sometimes they appear to occur instead of these convulsive attacks, 
 which are then entirely absent (as occurs in epilepsy). Such maniacal 
 attacks are sometimes observed in very young girls, and manifest them- 
 selves by vociferation, singing, cursing, aimless wandering; occasionally 
 by more formal delirium, attempts at suicide, nymphomaniacal excite- 
 ment, occasionally by delirium of a religious or demoniacal character; or 
 there are attacks of all kinds of noisy and perverse, but still coherent, 
 actions. In either case they retain but slight remembrance of what took 
 place during tlie disorder.^ 
 
 The chronic form of hysterical insanity may show itself in the form 
 of melancholia or mania. It commences sometimes as a slow gradual in- 
 crease of the habitual hysterical disposition; the symptoms gradually 
 appear more persistent and more intense, the patient becomes more and 
 more incapable of self-control; sometimes it commences acutely under 
 the influence of mental emotion or menstrual derangement, weakness 
 owing to various acute diseases — after a few slight, perhaps incomplete, 
 hysterical attacks. At first, moderate, but easily noticed, changes of 
 character are observed; greater seriousness, egotism, great care of the 
 health is manifested — indecision and absence of will, impatience, violence, 
 tendency to anger. The patients always grow lean, ansemic, occasionally 
 
 ' ' Lectures on certain Local Nervous Affections,' London, 1837, p. 8. 
 -See L. Meyer, "Ueber acute todliche Hysterie," Virchow's ' Archiv,' ix., 
 1856, p. 98. 
 
THE CAUSES OF INSANITY. 127 
 
 quite marasmatic; they suffer from constipation, from disorders of diges- 
 tion and menstruation; occasionally the more serious chronic forms of 
 melancholia and mania are developed; temporary exacerbations frequently 
 occur with marked cerebral congestion, swelling of the upper lip, violent 
 headache, or sym})toms of diarrhoea. The symptoms almost always 
 become aggravated at the menstrual period. An erotic element may fre- 
 quently be recognized in the disposition and delirium of these patients; 
 in many instances it is very slightly marked, and not unfrequently it is 
 altogether absent. Ecstatic states are occasionally presented in the 
 higher grades; hysterical insanity passes more frequently into dementia 
 than one might at first believe. 
 
 The diagnosis of hysterical insanity is principally based upon former 
 peculiarities of character, present or past existence of globus hystericus, 
 meteorismus, convulsive attacks, local anaesthesias and hyperaesthesias, 
 symptoms of paralysis. Very frequently we find in these individuals a 
 well-marked hereditary disposition to nervous diseases, chlorotic appear- 
 ances, disorders of menstruation (which, however, often disappear with- 
 out any improvement of the hysteria), and — of the greatest importance 
 in regard to prognosis and treatment — local diseases of the genital 
 organs. Some cases may doubtless be attributable to non-satisfaction of 
 the sexual aj^petite; but this is, as a rule, much overrated, as the exist- 
 ence of hysteria in girls who have not reached the age of puberty, its 
 great frequency amongst married women — the frequent injurious influ- 
 ence of marriage, pregnancy, and childbirth, and the frequency of the 
 affection amongst prostitutes, shows. 
 
 Fully developed hysteria occurs also, although more rarely, in young men 
 (besides many other cases, I have recently observed such a one with distinct 
 globus and convulsions in a young married, very anaemic man, whose wife was 
 pregnant). I do not know, however, whether hysterical insanity has ever been 
 observed in men. 
 
 § 105. 2. Acute fehrile diseases of different kinds occasionally give 
 rise to an outbreak of insanity; the disorders which they occasion within 
 the organism seem to be the only causes of the insanity. Typhus fever, 
 intermittent fever, cholera, the acute exanthemata, pneumonia, and acute 
 rheumatism, are the diseases in which it occurs most frequently. In re- 
 gard to the latter, the facts are as yet little known and studied: we shall 
 here give this remarkable cause of mental disorders the consideration 
 which it deserves. 
 
 After tyi^hus fever, and as well after a slight as after a severe at- 
 tack, it is not at all rare to see a slight degree of mental disorder which 
 may be placed in the same category with the slight affections of other 
 parts of the nervous system — incomplete ansesthesias, transient paralyses 
 of the extremities, etc. The patient, now quite free from fever, or even 
 become convalescent, retains either some fragments of his former delirium, 
 or he exhibits, independently of this, all kinds of perversities — erroneous 
 ideas on various subjects, sometimes even in regard to himself; also hallu- 
 cinations, with nervous exhaustion and weakness, without profound ex- 
 citation of sentiment. This form of mental disturbance, this species of 
 fragmentary delirium, admits of an altogether favorable prognosis, and 
 almost always disappears rapidly when the nutrition is improved and the 
 strength increased, even though, as sometimes occurs, a certain degree 
 of maniacal excitement be associated with it. But there are also much 
 more severe cases of true chronic insanity which commence during con- 
 valescence from typhus fever, or can at least be traced to this and to its 
 
128 THE CAUSES OF INSANITY. 
 
 slow commencement. Melancholia, wliicli gradually increases; occasion- 
 ally it is accompanied with stupor — sometimes with ideas of poisoning, 
 refusal of food, early intermixture of symptoms of mental weakness, and 
 transition to mania and profound dementia; — such is the ordinary course 
 of these cases in which recovery of the cerebral functions does not take 
 place, which perhaps depend on permanent disturbances of nutrition of 
 the brain; but, at all events, the prognosis is, according to experience, 
 always unfavorable. 
 
 Those who have written upon typhus fever— for example, Chomel, Louis (ii., 
 p 33, 2d ed.), Simon (' Journal des Connais. Med.-Chir..' Aoiit. 1844, p. 53), Sau- 
 vet (' Annal. Med. Psychol.,' 1845, vi., p. 223), Leudet (ibid., 1850, p. 148), Thore 
 (ibid., p. 596). Sclilager ('Oesterr. Zeitschrift fiir prakt. Heilk.,' 1857, 33-35). 
 Tiingel (' Clinische Mittheilungen,' Hamburg, 1860, p. 18)— have communicated 
 cases of this description. Jacobi, in one-eighth of his cases of mania, ascribes 
 the disease to the consequences of typhus fever: it appears to me very doubtful, 
 however, whether this has always been true typhus. Schlager found amongst 
 500 mentally diseased, 22 cases \vhich could be traced to typhus fever. I cannot 
 indorse the opinion that the foundation of these cases is to be sought in the 
 hypertemia of the brain which remains after typhus fever; all point rather to 
 states of aneemia and exhaustion, occasionally even with remnants of the fever. 
 In exceptional cases, these diseases may be caused by the presence of sanguine- 
 ous clots in the sinus of the dura mater, perhaps by meningitis or by acute atrophy 
 of the brain. 
 
 The relation of certain cases of mental disease to intermittent fever 
 has been observed since tlie days of Sydenham. Here, too, a very differ- 
 ent relation of the two affections to each other is to be distinguished. In 
 the one, perhaps the smallest, series of cases, we see that in localities 
 where intermittent fever is endemic, certain individuals are attacked, 
 instead of ordinary ague, by an intermittent cerebral affection which 
 manifests itself in regular (tertian, quartan) attacks of insanity (so-called 
 intermittens larvata). There are here generally certain signs of the stages 
 of the attack — yawning, rigors, heat — to be observed, and it is the hot 
 stage especially Vhich is most frequently complicated with cerebral con- 
 gestion to such an extent as to produce mania. It is, therefore, not an 
 existing intermittent fever, but the endemic cause of the fever, which is 
 the cause of the insanity. The periodic nature of the attacks, and espe- 
 cially great increase of temperature during the attack, together with the 
 endemic character of the fever, are the principal diagnostic signs. 
 
 Example I.— A young man had five attacks of mental disorder, one every 
 other day. The attack commenced, after very slight rigors, with an indescribable 
 feeling of pain in the cardiac region, and palpitation, which rapidly increased to 
 a state of extreme anxiety. This formed the commencement of the delirium, 
 out of which the patient emerged bathed in perspiration, after a deep sleep. He 
 soon recovered under the treatment for intermittent fever. (Flemming, ' Psy- 
 
 chosen,' p. 87.) , . „ 
 
 Example II. — A strong laborer, set. 30, who had never had mtermittent fever, 
 but wiio lived in one of the many fever districts which surround Siegburg, was 
 suddenly seized with mania: he considered himself to be Christ and those around 
 him to be witches; he abused his master, etc. The head was hot; the eyes red 
 and rolling wildly; the tongue Avhite; epigastrium distended; the pulse somewhat 
 rapid, not feverish; the feet cold. On the application of ice to the shaven scalp, 
 etc., the patient became calm, and during the two following days seemed to be 
 mentally healthy. On the fourth day, exactly at the same hour, the same scene 
 was repeated (sal ammoniac, extr. trifol., and tartar emetic). A third attack 
 occurred in the quartan type, but milder, shorter in duration, and succeeded by 
 sweating: after this, the 'symptoms disappeared under the use of quinine. In 
 spite of the continued vise "of quinine, there occurred after five weeks a fourth 
 attack of this periodic insanity, which however, like a subsequent one, whicli was 
 the last, finally gave way under felie administration of bark and quinine. (Focke, 
 ' Zeitschrift fiir Psychiatric,' v., p. 376.) 
 
THE CAUSES OF INSANITY. 129 
 
 At other times, after an ordinary intermittent fever has lasted for a 
 certain time, there appear, instead of the paroxysms of heat and cold — as 
 if through a leap of the affection — intermitting paroxysms of insanity 
 (violent attacks of mania with delirium, also impulsive suicide during the 
 fit) : these states often, with disappearance of decided periodicity, assume 
 the remittent and continuous type, and pass into chronic mental diseases. 
 Finally, there is a third mode of origin which is the most frequent of all: 
 the insanity occurs as a disease consequent upon intermittent fever which 
 has disappeared either in the early stage of convalescence, or not until 
 several months after the cessation of the ague. It is especially after very 
 protracted and severe (especially quartan) fevers that disorders remain 
 which may produce insanity. 
 
 The mental disease frequently continues as a uniform persistent 
 chronic affection, and the symptoms of the intermittent fever are no 
 longer observed. Or traces of the fever may still be present; the spleen 
 and liver are enlarged, cachexias exist, and irregular paroxysms of ague 
 appear from time to time (during the mental disease). In cases of the 
 latter kind especially, the insanity frequently ceases, sooner or later, with 
 the return of an acute series of a severe attacks of intermittent fever, but 
 by the use of quinine the collective intermittent disease may be removed. 
 In the origin of all cases belonging to the third category, it is certain 
 that, on the one hand, the cachectic-ansemic state which the intermittent 
 fever leaves behind it, and, on the other, the melangemia and the deposit 
 of granular pigment in the cerebral vessels must play an important part 
 (on this subject see my paper on infectious diseases, Virchow's ' Patho- 
 logie,' ii.) as the later can also very probably call forth severe acute cere- 
 bral affections (coma, apoplectiform attacks, etc. ) which are sometimes 
 observed in intermittent fever {occasional cases belonging to the first and 
 second category). Still, post-mortem examinations occur in which no 
 pigmentation of the brain can be discovered. ^ 
 
 Jacobi has reported three cases in which attacks of ague occurred instead of 
 insanity (chronic) which existed, and with those the disease ceased (a so-called 
 critical phase of intermittent fever). 
 
 Koster obsei-\'ed that in 24 cases of insanity in Siegburg who took intermit- 
 tent fever, 7 recovered, 7 were improved, and in 10 no change resulted: amongst 
 the latter, however, there were many chx-onic and incurable cases. Amongst the 
 former there were also several in whom the prognosis had been considered 
 unfavorable. Gaye, in the Schleswig Asylum, observed in three years 56 cases 
 of intermittent fever in insane patients, " but only exceptionally have favorable 
 results occuiTed." 
 
 See Sebastian, " Bemerkungen iiber die Melancholie und Manieals Nachkrank- 
 heiten der Wechselfieber," 'Hufeland's Journal,' 1823, Ivi., p. 3; Mongellaz, 
 'Monographic des Irritations Intermittentes,' Paris, 1839, i., p. 638; Lippich, 
 " Beitrage zur Psychiatrie," ' OesteiT. Jahrbiicher,' Juni, 1842, p. 282; BaUlarger, 
 "Sur la Folic a la suite des fie^^•es intermittentes," ' Annal. Med. Psjxhol.,' 1843, 
 ii., p. 372; Focke, " Ueber typisches Irresein," ' Zeitschr. f. Psych.'' v., 1828, -p. 
 375; Koster, ' Diss.,' Bonn, 1848; ' Bericht der Wiener Irrenanstalt (Wien, 1858), 
 p. 51. 
 
 Acute mental disorders occasionally occur also after cholera (asiatica). 
 Sometimes it is transient delirium, absence of mind, perverted instincts; 
 sometimes paroxysms of mania, generally of short duration (several days 
 to several weeks), which terminate in exhaustion and sleep; occasionally, 
 also, melancholia of somewhat longer duration, with insane ideas, and, 
 
 1 Hoffmann ('Giinsberg Zeitschr.,' iv., p. 365). The insanity had originated 
 after intermittent fever. The autopsy showed atrophy of the brain; "cortical 
 layer pale, paler than the central gray masses." 
 9 
 
130 THE CAUSES OF INSANITY. 
 
 more or less, with appearance of mental weakness. The prognosis is 
 generally favorable, and most of these cases do not find their way into 
 the asylums; sometimes the individuals, already weakened by the pre- 
 vious serious disease, die during an attack of mania; occasionally, also, 
 they pass into the incurable forms. 
 
 See Fischer, ' Prager Vierteljahrschrift,' vol. xxxii., 1851, p. 85; Delasiauve, 
 ' Annal. Med. Psychol.,' 1849, Seme Ser., vol. i.; Neumann. ' Lehrb. d. Psychia- 
 tric,' 1859, p. 164. 
 
 Those cases of insanity are very interesting which appear during the 
 course of pneumonia (generally acute mania). In these cases the insan- 
 ity is rarely developed at the commencement or at the height of the 
 disease, but more frequently at the time when the fever ceases, or even 
 not until convalescence sets in : these cases are by no means to be con- 
 founded with the ordinary delirium which so frequently accompanies the 
 more severe cases; they are generally of short duration, but tend to pass 
 into chronic insanity, so that such patients ought at once to be placed in 
 an asylum. It is not unfrequently slight and limited pneumonias which 
 are followed by mental disease; hereditary predisposition or previous 
 habits of drunkenness may frequently be recognized as predisposing cir- 
 cumstances. The mental disturbance sometimes passes off so rapidly 
 that the existence of a palpable cerebral disease is very improbable and is 
 most likely dependent upon acute anaemia of the brain. In other rare 
 cases, the mental affection lasts for a longer time; it approaches dementia, 
 and is associated with certain paralytic appearances in the muscles. It is 
 probable, therefore, that there may be in these cases sanguineous clots 
 in the sinuses, encephalitis or localized meningitis which may gradually 
 disappear, sometimes completely, sometimes incompletely. 
 
 Cases of mental disease consecutive to pneumonia may be found in Jacobi 
 (29th example of mania). Thore (' Annal. Med. Psychol.,' Mai, 1844, p. 389, and 
 ibid., 1850, ii., p. 586) has several very interesting cases. One of these patients 
 had two successive attacks of pneumonia, each of which was followed by mental 
 disorder. Another case is mentioned by Snell, of mania after pneumonia in a 
 child of nine years (• Zeitschr. f. Psych.,' xiii., 1856, p. 540). Two of these rare 
 cases came imder my observation in the clinique at Tubingen, both in the same 
 winter, and another recently at Zurich; two of them belonged to the first, the 
 case in Tiibingen to the second, of the above-mentioned categories. 
 
 Example III. — Pneumonia ; transient mental disorder on the cessation of the 
 fever. — C. G— , set. 21, vigorous and robust, was, on the 26th of February, 1859, 
 suddenly seized with a severe rigor, bleeding at the nose and giddiness. He was 
 admitted into my clinical ward on February 28th. On examination, there was 
 found pneumonia of a portion of the right lower lobe, and severe typhus- 
 like symptoms with prostration; there was a good deal of quiet delirium; respi- 
 ration 39-40; pulse 100-104; temperature 40.3 "-41.0° C. On the third day of the 
 disease, herpes labialis appeared, which did not develop properly. On the 
 fourth, the temperature sank from 40.3° in the morning to 39.2° in the even- 
 ing, pulse 92; the patient became more delirious and absent. On the fifth day, 
 the physical signs indicated complete retrogression of the local process; the tem- 
 perature is in the morning 38.1°, and in the evening 38.2° C; pulse 66-72, some- 
 times intermittent. The countenance is pale; the patient is quite without sense 
 — knows not where he is, does not recollect the simplest events, talks constantly 
 and dehriously, and towards night becomes very restless and unnily (morphia). 
 After passing a very restless night, he next morning had a long and quiet sleep: 
 the face was pale, slightly convulsed; respiration slow, irregular; pulse 60-66; 
 temperature 37° C. From this time the patient continued free from fever; the 
 delirium, ringing in the ears, and vertigo continued for two days longer, after 
 which they disappeared; the pulse still presented great irregularity, and from the 
 eighth to the tenth day of the disease fell to 56-48. On the thirteenth day, 
 resolution of the pneumonia was complete, tl>e mental state was quite normal. — 
 This case is not to be considered one of febrile delirium; the mental disorder was 
 
THE CAUSES OF INSANITY. 131* 
 
 quite a different affection from the preliminary delirium, and did not appear till 
 the fever began to cease,' the temperature to diminish, and pulse to become slow 
 and intermittent (the only medicine used was nitre). The case which recently 
 came under my observation in Zurich was very similar to this: the following is, 
 however, very different. 
 
 Example IV. — Pneumonia, mania, slight hemiplegia, consecutive mental weak- 
 ness. — J. H — , aet. 24, a laborer, was admitted into my clinique on the 21st of 
 January, 1859. The father of the patient died in his fifty-second year from a 
 chronic chest affection, with dropsy. His mother was alive when the patient 
 entered the hospital, but during his residence there she committed suicide. I^ — 
 had, on the whole, always enjoyed good health; five or six years ago he was sud- 
 denly seized with weakness and loss of consciousness, together with stiffness of 
 the limbs: this, however, disappeared in an hour. He had not been intemperate. 
 Three years ago he fell from a tree, but after lying for a short time unconscious 
 he rapidly recovered. At midday, on the 16th January, the patient was suddenly 
 seized with pneumonia; he was bled. Had not been delirious at home, but on 
 the day before his admission he showed symptoms of derangement; during the 
 night of the 20th-21st he spoke in a more lively manner than usual, and on the 
 morning of the 21st, while being conveyed to the hospital, he commenced to be 
 delirious; he screamed in the vehicle, and his excitement increased as he 
 approached the town. On his entrance into the clinique, he was quite void of 
 sense, looked perplexedly about, stretched his arms rigidly before him; his hands 
 clenched; he gave no answers, or if he did they were quite incoherent. After a 
 few hours he partially recovered his senses, and could, for the first time, be 
 minutely examined. His face was more flushed than during the delirium; pulse 
 76, full; the left pupil more dilated than the right, and the left side of the face 
 seemed slightly paralyzed. A physical investigation resulted in the discovery of 
 pneumonia of moderate extent of the right lower lobe, without complete dulness; 
 other organs normal, urine free from albumen or bile, temperature 38.4 (marked 
 remission of the fever on the fifth day of the pneumonia). On the following day, 
 the temperature had increased from 39.7 in the morning to 40.7 in the evening; 
 marked crepitation in the right lung; the pneumonia has not extended. The 
 pulse was in the morning 82, in the evening 108; respiration 36-44. The patient 
 is in a state of constant violent agitation, continually asks for something or other, 
 is irritable, refuses everything, and very rarely gives a correct answer. In the 
 evening his state passed into complete mania, so that he had to be put into the 
 strait- jacket and into a cell; on this being done, he showed great acuteness of 
 the senses. 
 
 On the morning of the 23d, the temperature had again fallen to 38, and in 
 the evening to 37.8; the percussion note was somewhat clearer; the crepitation 
 diminished; pulse 80-100. The patient was still delirious, but not so restless; 
 frequently gave correct answers, slept occasionally and appeared very tired. 
 But on the following day, while the pneumonia had completely disappeared, the 
 patient exhibited total confusion and absence of mind; during nearly the whole 
 of the night he ran about, drawing off and on his shirt; gives no answers, or if 
 he does they are quite incoherent. The temperature could not, in these circum- 
 stances, be taken. The pulse was slow, 68; the patient appeared pale and col- 
 lapsed; the left pupil still more dilated than the right; the left side of the face 
 slightly paralyzed; no trace of paralysis of the extremities (the most probable 
 supposition would be encephalitic inflammation owing to thrombosis of the 
 sinus). On the morning of the 26th, after the patient had spent almost the whole 
 night standing, great oedema of the lower extremities up to the middle of the 
 thigh was found (thrombosis of the crural veins); the temperature was not so high; 
 pulse 124; the cardiac impulse strong and full. Tlae patient sees, hears, and 
 feels; but he seems as if the sensorial impressions were not elaborated; he con- 
 stantly looks around him with an astonished impression, and is quite without 
 intelligence (Infusum Sennae; a blister). 
 
 During the next eight days, the temperature — with moderate variations — 
 gradually sank to the normal standard, the oedema of the lower extremities dis- 
 appeared, now and then perspirations occurred, the pulse remained between 64 
 and 80. The local symptoms of the pneumonia had quite disappeared. The men- 
 tal disorder continued, but varied in intensity. Sometimes the patient was so 
 
 ' Metzger (Henle und Pfeufer, ' Zeitschrift,' 1858, iv., p. 220) has also commu- 
 nicated four instances of transient mania in pneumonia, which, Jiowever, appear 
 to have commenced at the height of the disease and of the fever, and therefore 
 have quite a different signification. 
 
132 THE CAUSES OF INSANITY. 
 
 Stupid and confused, that he seemed to have entirely lost his senses; sometimes 
 he seemed to understand better what was said to him, and to express himself a 
 little more connectedly; sometimes he was more excited, would escape, etc. 
 Now and then he had hallucinations — saw figures, heard firing, etc. His appear- 
 ance was that of one who had a serious cerebral disease : the eye was fixed and 
 injected; the left eyeball was somewhat more prominent than the right, and 
 turned slightly inwards; the mydriasis was much diminished; the tongue for 
 several days inclined a little to the right. Gradually the patient commenced to 
 walk about; but he always staggered, and, without any symptoms of paralysis of 
 the extremities, it was remarked that he allowed the whole of the left side to 
 hang somewhat. The patient remained in the clinique until the 10th May, 1859. 
 He was at this time entirely without feverishness. His mental state was at first 
 that of profound, and afterwards that of declining dementia. At first he was 
 quite stupid, quite incapable of deliberation; he spoke none at all, or as if he were 
 in a dream, and generally about nothing but eating; at the same time he appeared 
 to be in great anxiety. By slow degrees his mental state commenced to improve; 
 he became cleanly in his habits; on some days he gave correct and on others very 
 incorrect answers. His behavior continued to be very childish, yet it gradually 
 became more cheerful. The symptoms of weakness of the left side improved 
 quite as slowly and incompletely as those of the mental disorder; even at the 
 date of the patient's dismissal, the left pupil was slightly dilated, the tongue 
 inclined slightly towards the left side, and when walking the left side of the body 
 ■was still a little dependent. He often complained of tiredness and of frontal 
 headache; occasionally also epistaxis occurred. It was a very remarkable cir- 
 cumstance that, on the cessation of the fever, polyuria set in and continued for 
 several weeks; the pale urine, the quantity of which sometimes amounted to 
 4000 C.C.M. in the twenty-four hours, had a specific gravity of 1006 to 1008. 
 The ordinary sugar-test afforded a negative result. A minute examination in 
 the chemical laboratory showed that it also contained no phosphates. The 
 patient sometimes complained of slight pains in the region of the kidneys. This 
 diuresis disappeared during the last week of his residence in the hospital, when 
 also the nutrition became quite normal, and the patient quite well. On his dis- 
 missal on the 10th May, he understood all that was said to him, and could express 
 himself quite correctly, though with a little hesitation, on most subjects. He 
 called about f ovuteen days afterwards, and there was no alteration in his mental 
 state. 
 
 Acute rheumatism, like pneumonia, causes the development of 
 mental disease but very rarely, and we shall have to conceive of the rela- 
 tion which exists between the insanity and the acute disease as somewhat 
 different from that just spoken of. It appears, namely, that these 
 mental disorders ought not to be considered as sequelce or accidents of 
 convalescence, but that they are only a protracted form of that cerebral 
 affection appearing in various forms, and in its acute development often 
 so very dangerous, which frequently appears in acute rheumatism, either 
 simple, or complicated with cardiac inflammations, which leaves behind 
 it no definite anatomical changes, and therefore is most conveniently 
 designated rheumatic cerebral disorder. The acute cerebral symptoms 
 consist here sometimes in acute delirium and maniacal excitement, which 
 may terminate in death or soon disappear (in other, still more serious 
 cases, the symptoms are chiefly those of coma). Sometimes — and these 
 are the cases which now occupy us — under the influence of accessory 
 causes, we see prolonged melancholia with stupor, mania, mental weakness, 
 etc., occur — in short, the development of actual mental disease in various 
 protracted forms, sometimes associated with cliorea-like attacks. In these 
 as in the acute cerebral forms of rheumatism, we frequently see the 
 articular affection diminish or even disappear with the appearance of the 
 mental disturbance, and occasionally there is an alternate improvement 
 of the one and aggravation of the other, sometimes even a decided 
 retrogression of the latter on the reappearance of the former. ' 
 
 * See the author's paper " On the Protracted Form of the Rheumatic Cerebral 
 Disorder;" ' Archiv der Heilkuude,' i., 3, 1860, p. 235. 
 
THE CAUSES OF INSANITY. 133 
 
 Example V. — Commencement of insanity during acute rheumatism, with 
 disappearance of the articular affection; mental improvement icith return of the 
 disease in the joints; fluctuating state; recovery in about three months. — E. D — , 
 set. 50, a very poor unmarried woman, was on the 10th of March, 1857, admitted 
 into the clinique at Tiibiugen. The following was learned concerning her: — 
 Twenty years ago, after her second confinement she became insane; she, how- 
 ever, recovered after three months, and since then she has given birth to another 
 child without any consequent disorder. For the last ten years she had been in 
 the continuous enjoyment of good health. About four or five weeks ago she 
 suddenly became ill: at first she complained much of toothache; she became 
 feverish, and many of the joints of the upper and lower extremities became 
 swollen and painful — acute rheumatism had set in. About ten days after its 
 first appearance the articular afl'ection disappeared rather suddenly, and at the 
 same time the patient became mentally deranged. She was delirious, understood 
 nothing, attacked those about her; was sometimes very quiet, at others very 
 loquacious; ran about crying all night; searched out all her effects, and threw 
 them about; in short, she behaved in all respects like an insane person. She 
 slept and ate very little, drank a great deal, and occasionally i-eplied in answer to 
 questions put to her that every part of her body was jDainful. 
 
 On admission, the patient, who was very strong for her age, appeared pale: 
 she was perfectly free from fever; had no cardiac affection, nor pain in any of 
 the joints. She was in a state of well-marked melancholia with stupor (melan- 
 cholia attonita); her look was shy and anxious; she was quite concentrated in 
 herself, and evidently in a state of prolonged dreaming; she spoke very little, 
 and quite confusedly. She continued in this state for two days after her admis- 
 sion. On the second day (12th March) she became more restless, and spoke con- 
 tmuously during the whole of the night. In the morning she spoke generally in 
 rhyme : for example, ' ' God knows what I try for, He sees what I cry for, and 
 He hears my prayer — shall I see Him there?" etc. During the visit, she broke 
 into an outburst of anger, accused those present of having taken her children; 
 she had to be confined in a refractory cell. 
 
 On the 14th March, oedema of the lower extremities set in; the patient was 
 free from fever; the pulse calm; bowels constipated; urine free from albumen. 
 During the day she was much quieter, she had numerous hallucinations of a 
 gloomy character; during the night she again became excited. During the fol- 
 lowing days the oedema of the feet increased, and appeared also in the hands; on 
 the 19th there appeared, together with the oedema, redness and swelling of the 
 finger-joints, which were very sensitive to pressure (only shown by gestures); 
 the right ankle-joint was also very painful on pressure. Percussion and auscul- 
 tation of the heart and organs of respiration showed not the slightest change; 
 pulse 84, full; skin dry and warm; appetite moderate; bowels regular. The 
 patient lay in bed, was quiet; on being questioned, she generally made no reply 
 — at most occasionally, and slowly, yes or no; the physiognomical expression 
 was that of indifference and apathy; now and then she searched the wall around 
 her bed, and seems quite in a dream (Nitre 3 ij.). On the following day the pain 
 and swelling of the joints had again almost disappeared; she again became much 
 more restless, very talkative, said that her children were outside and ought to be 
 beheaded, etc. From this date, 20th March, the patient continued in a state 
 which it would be needless to describe day by day. The rheumatic articular 
 affection never attained to any great intensity, but there was frequently a 
 moderate degree of swelling and of pain in certain joints of the fingers and feet; 
 she often complained of pain in the limbs and joints, and of stiffness of the whole 
 body. She was consequently almost always confined to bed, but free from fever; 
 there was never any cardiac disorder; the urine continued non-albuminous; 
 appetite and sleep slowly returned (Colchicum and Opium). Therewith the 
 patient, with numerous interruptions of restlessness, confusion, and loquacity, 
 became gradually more calm and more reasonable, to manifest a more lively dis- 
 position, and by-and-by commenced to do a little work. She had not the slightest 
 recollection of the first period of her residence in the hospital. By the middle of 
 April the patient could be considered as quite recovered in mind; for some time 
 after, however, she complained of frequent startings, giddiness, and ringing in 
 the eai"s; and traces of pain and swelling remained in some of the joints until the 
 beginning of May. These were dispelled by the judicious use of baths, and on 
 the 12th May the patient was dismissed cured. 
 
 Example VI. — A delicate lady, 30 and odd years of age, who had hitherto 
 enjoyed good health, was somewhat debilitated by her last confinement, and had 
 
134 THE CAUSES OF INSANITY. 
 
 a tedious recovery, owing to an attack of articular rheumatism. Modified hydro- 
 pathic treatment was employed — cold fomentation of the affected parts. The 
 pain and sweUing rapidly disappeared, and the limbs became free and movable. 
 But immediately she began to complain of drawing pains along the spine, rest- 
 lessness and stretching, straining, occasionally jerking movements in the extremi- 
 ties. At the same time there appeared in a few days a state of mental depression, 
 which rapidly increased, and assumed the form of apathy, and finally of com- 
 plete insensibility. The patient was now confined to bed; felt disinclined to 
 move, to dress herself, and even to eat; she was mute and indifferent to all but 
 very strong impressions; in a short time she presented the characteristic appear- 
 ance of melancholia attonita. The whole expression seemed less to betray men- 
 tal pain than complete indifference (even to ordinary personal cleanliness), 
 together with an aversion to all kinds of excitement, which was manifested by 
 strong expressions of displeasure (throwing, striking, etc.). The disease termi- 
 nated favorably; the patient recovered under the influence of baths containing 
 malt and salt, an issue in the neck, flying blisters applied to the spine, aconite 
 with guaiacum, and afterwards see-bathing. — (Flemming, ' Psychosen,' p. 88.) 
 
 Mental disease has also been observed, though very rarely, to origi- 
 nate rapidly after small-pox, measles, and erysipelas — indeed, even after 
 the acute anginas. These resemble the cases occurring after typhus 
 fever and pneumonia. In all these cases, hypersemia of the brain, and 
 occasionally also thrombosis of the sinuses, may play an important part. 
 
 § 106. 3. Chronic constitutional diseases very frequently cause the 
 develoijment of insanity. Of these, we may place in the first series all 
 states of weakness and of anasmia resulting from great loss of blood (in 
 childbirth, for example), from continued hunger and misery, from self- 
 inflicted fasting (religious asceticism of former times), after too jDrolonged 
 nursing; finally, in consequence of the most various general and local 
 maladies which impair digestion, blood-formation, and nutrition. Anae- 
 mia likewise plays a very important part in the production of a number 
 of other neuroses; and we see that, even within the limits of physiology, 
 a bodily condition in which the nutrition is lowered renders more easy a 
 state of irritation in the functions of the nervous system, more or less 
 disturbance of sleep, etc. Of all purely physical causes, I might almost 
 attribute to these very variously modified anaemic states the greatest weight 
 in the production of insanity. This view is confirmed by the fact that, 
 in the great majority of cases, a nutrient and restorative treatment is 
 followed by the best results, while an antiphlogistic system of treatment 
 aggravates the disease. It is evident tliat the older physicians held the 
 same idea when they spoke of the "asthenic nature" of a great many 
 mental diseases. 
 
 The cases of insanity consecutive to acute diseases belong, as formerly 
 remarked, in a great measure to this category, likewise many cases of hysterical 
 mental disease; the peculiarities and caprices of very chlorotic individuals 
 become frequently gradually developed to actual mental disorder. Moreover, it 
 is quite uncertain whether, in all these cases, anemia of the brain is to be con- 
 sidered as the immediate determinate cause of the insanity; general anaemia may 
 be accompanied by transient and even persistent states of congestion of the brain, 
 and the first is very frequently seen in states of nervous and mental exaltation. 
 
 Constitutional syphilis does not readily lead to insanity otherwise 
 than through palpable diseases of nutrition of the skull, of the brain and 
 of its membranes : in this relation, however, it merits very serious con- 
 sideration. These diseases are periostitis with slight inflammation of the 
 dura mater and delicate membranes, severe chronic meningitis and 
 encephalitis ; actual exostoses of the basis cranii have also been found in 
 general paralysis. Headaches of long standing with nightly exacerbation, 
 affection of the nasal bones, superficial tophi on the skull, and the well- 
 
THE CAUSES OF INSAJfirY. 135 
 
 known symptoms of constitutional syphilis in other parts of the body, 
 render the diagnosis comparatively simple. 
 
 See the article by the author, " Diagnost. Bemerkungen iiber Himkrankliei- 
 ten" (' Archiv der Heilk.,' 1860, i.), in which a rare case of true syphilitic menin- 
 gitis with dementia is communicated. Recently the opinion has been advanced, 
 that all the cases of general paralysis of the insane are to be ascribed to syphilis 
 —a very improbable assumption, which, however, may do good by causing in 
 future more attention to be paid to this important etiological circumstance. 
 
 Tulercular constitutional disease appears likewise to be sometimes the 
 cause of the development of insanity.' Isolated cases, considered as 
 cases of mental disease, even come into asylums in which mental disorder 
 (not generally, however, without more or less coexisting motory affec- 
 tion, sometimes also vomiting, etc.) has been caused by tubercular depo- 
 sits_ within the cranium, tubercular meningitis or tuberculosis of the 
 brain-substance itself, or even by slight basilar meningitis of a somewhat 
 protracted type.^ Cases of recent mental disease presenting indications 
 - of contraction of the chest, in which, on examination, pulmonary tuber- 
 culosis is discovered, or even only the probable remains of formerly 
 existing tubercles, deserve in this respect the most careful consideration. 
 All these cases terminate fatally within a short time. Ordinarily, how- 
 ever, tuberculosis and insanity stand in another relation to each other, 
 and the insanity appears in its ordinary chronic forms. Sometimes 
 mental disorders appear at the commencement or during the early stages 
 of phthisis pulmonalis, which is frequently not discovered. Even later, 
 concealed from the less attentive observer by the symptoms of the mental 
 disease, it is hardly even recognized by the increasing marasmus and 
 hectic fever. And of especial interest are the cases in which, with symp- 
 toms of cerebral congestion, melancholia or mania occurs in individuals 
 who as yet present no certain symptoms of pulmonary tuberculosis ; but 
 after the mental disorder has existed for a short time, distinct symptoms 
 of phthisis may be recognized with which the intellect becomes more free 
 and clearer, and the morbid mental symptoms improve or altogether 
 disappear. Generally, in these cases in which the insanity has been cured, 
 the tuberculosis runs a rapid and fatal course : nevertheless, even here a 
 complete arrest (cure) of the tubercular process sometimes takes place. ^ 
 The rationale of the production of mehtal disease in such cases cannot 
 well be explained. The explanations by ''crasis" are very properly 
 abandoned. In other cases, also, the insanity appears, for the first time 
 during the later stages of confirmed phthisis, in the form of melancholia, 
 or more frequently as maniacal attacks ; occasionally these make their 
 first appearance shortly before death. In the more chronic cases of this 
 kind it generally happens that the leading symptoms of the phthisis, the 
 cough, expectoration, etc., disappear on the outbreak of the mental 
 disease, and even the nutrition slightly improves. 
 
 It has not been proved that the insanity which is accompanied by or 
 developed from tuberculosis presents any peculiar character. Jacob! 
 ascribes to it a certain capriciousness, a whimsical fluctuation between 
 extremes. Neumann* states that, from the commencement, depression, 
 
 1 We shall afterwards speak, in the fourth book, of the occurrence of tuber- 
 culosis in asylums in those already insane. , 
 •^ L. Meyer, ' Zeitschrift fiir Psychiatric,' xv., 1858, p. 713. 
 3 Wiener Bericht ' (Wien, 1858), p. 55. 
 ■* 'Psychiatrie,'p. 162. 
 
136 THE CAUSES OF INSANITY. 
 
 self-absorption, great irritability and discontent, morosity and tendency 
 to swear, are present, and that at a later period a more gentle disposition 
 is developed : but these characteristics are by no means constant. In 
 diagnosis, the physical signs, in connection with any hereditary disposi- 
 tion, the history, etc., can alone be employed. 
 
 In a case which came under my observation, the serious cerebral affection 
 with prominent mental symptoms, in an individual in the last stage of phthisis, 
 depended on a large coagulum in the sinus (see ' Diagnost. Bemerkungen liber 
 Hirnkrankheiten,' p. 84). The clu-onic insanity which is developed in the way 
 which we have described in phthisical persons, without palpable disease of the 
 brain, appears rather to be in connection with the general constitutional disease, 
 which produces, in persons predisposed, great nervous irritability, perhaps also 
 with disorders of the circulation within the cranium. 
 
 Pellagrous insanity also, which is met with especially in Northern 
 Italy, and, according to recent observers, also in certain parts of France 
 (Kennes, Angers, etc.), appears to depend upon a constitutional disease 
 the special cause of which is still unknown, but which is manifested 
 particularly by an erythematous exanthema, chronic diarrhoea, anaemia, 
 and marasmus. 
 
 It is perhaps allowable to doubt the specific nature of pellagra; but I think it 
 right, after the merely passing view of it which I obtained in the asylums of 
 Northern Italy, to abstain from any discussion on this subject. Pellagrous 
 insanity, according to Clerici (1855), consists chiefly in a, "vague, incoherent 
 delirium, accompanied by stupor, loss of memory, and by loquacity without 
 special disorder of intelligence or violent excitement;" the melancholic state 
 which predominates for a long time always passes gi-adually into a state of torpor 
 of all the mental powers, with muscular weakness which greatly resembles 
 general paralysis. 
 
 Concerning the origin of mental disorders from the special influence of gout, 
 nothing positive can be said. Cholcemia appears to have a great influence on the 
 disposition, and we sometimes see acute icterus gravis accompanied by violent 
 delirium without any cerebral change. Concerning the influence of cholaemic 
 states on the production of chronic insanity, no definite observations are on 
 record. 
 
 § 107. 4. Among the chronic local disorders of the various organs, a 
 certain influence must always be attributed to diseases of the heart, 
 although this circumstance does not seem to act with any special fre- 
 quency. In the older psychological literature, the influence of cardiac 
 disease is evidently very much over-estimated (Nasse, 1818, and others). 
 Observation shows that in the German asylums there are not many indi- 
 viduals with the ordinary heart affections, such as those, for example, 
 which are produced in acute rheumatism. Certain exceptions are, indeed, 
 more apparent than real. In the interesting reports by Voppel, of the 
 autopsies in the asylum at Colditz,' for example, heart diseases appear in 
 rather high proportion ; but amongst these there were a great number 
 of aged patients who had been long resident in the asylum, and even 
 slight changes are there minutely noted. It may be that many, even of 
 the most severe, of these heart affections were of long standing, and were 
 connected with the production of the insanity : for the great majority, 
 however, it may certainly be assumed that they were developed during 
 the existence of the insanity. 
 
 ^ In one of these reports, of 75 post-mortem examinations, 13 cases (16 per 
 cent), in another (' Zeitschrift fiir Psychiatrie,' 1855, xii., p. 392), slight affections 
 of the valves occurred in |, marked cardiac disease in 3V of the cases; a third 
 report (Giinsburg, 'Zeitschrift,' vii., 1856, p. 179) showed also a considerable 
 number. 
 
THE CAUSES OF INSANITY. 137 
 
 The same remarks apply to the statements of Tyermann, who, in Cohiey 
 Hatch, found cardiac or valvular disease in } of the female patients. Slight 
 emotional irritability is, it is true, peculiar to many persons affected with heart 
 disease; but we should not therefore conclude that these diseases have a greater 
 influence on the development of insanity than actual obsei'vation demonstrates. 
 The diagnosis of heart diseases in the insane during life is rendered more dilScult 
 (and the statistics more uncertain) by the fact that, in states of exaltation, cardiac 
 murmurs, especially of the aortic valves, are very frequent without any valvular 
 deficiency (' Wiener Bericht,' 1858, p. 58). Concerning the frequency of diseases 
 of the heart, see also tliQ statistics given in the Fourth Book. 
 
 Diseases of the arteries in tlie form of the so-called arteritis chronica 
 (fatty degeneration, atheroma, calcareous deposit, etc., etc.) exert a much 
 greater influence; and part of the action, too, which is attributed to 
 heart diseases ought to be referred to the arterial degeneration which so 
 frequently accompanies them. This degeneration causes disorders of the 
 circulation of the most various kinds — local ansemia from increasing 
 diminution of the calibre of the arteries, encephalitic inflammation, and, 
 as it ajjpears, various changes of nutrition of the cerebral substance, not 
 yet known in detail. Finally, general marasmus, and the early old age 
 which often results from a high degree of atheroma of all the arteries of 
 the body, may contribute in a high degree to the development of men- 
 tal disorders. Atheroma is frequently met with in the cerebral arteries 
 of the insane; and even when the larger vessels present no marked alter- 
 ation, the minute branches ijiay be profoundly degenerate. Therefore, 
 statistics of the diseases of the arteries of the brain cannot be given. 
 
 Amongst pulmonary affections, a certain pathogenetic influence may 
 perhaps be attributed to empliysema. It has seemed to me in certain 
 cases, that the feeling of anxiety and melancholia were connected 
 with the oppression which this affection of the lungs and its develop- 
 ment can cause: nevertheless, with the enormous frequency of emjihy- 
 sema, this influence, which so rarely shows itself, cannot be highly esti- 
 mated; and even here it is possible that the emphysema was but a partial 
 symptom of a general marasmus, which was really the important cause 
 of the origin of the insanity. 
 
 In regard to diseases of the abdomen, it cannot be disputed that they 
 may give rise to insanity; but the vague diagnosis of the older physicians 
 — disorders of the abdominal nerves, stases in the portal system, infarc- 
 tus, hgemorrhoidal derangements, etc. — generally represented as of pri- 
 mary importance, do not at all assist us. We ought rather to guard against 
 inferring, without cause, from moderate disorders of digestion and of 
 the bowels, from the sensations produced by the intestinal contents re- 
 maining too long in the colon, the dark color of the faeces, etc., the 
 existence of pathological states of which a positive pathology knows noth- 
 ing. We do not deny that diseases of the liver may impede the circula- 
 tion, and that also those slight derangements of digestion may sometimes 
 form the media by which especially the injurious influences of the moral 
 causes react secondarily upon the brain; and we can admit with Brous- 
 sais, as well as the German followers of the infarctus theory, that disor- 
 ders of the bowels,' especially catarrh, maybe, in certain cases, the origin- 
 
 ' Willis narrates the remarkable case of a young lady whose health had been 
 undermined by prolonged and severe grief. After having partaken of some very 
 indigestible pastry, she was suddenly seized with a burning sensation in the 
 cardiac region; she thought that the upper part of her body was in flames, and 
 ran into the street. She had the idea that she was very wicked, and would be 
 dragged into hell. These ideas always returned when she felt the sensation of 
 burning. Jacobi, loc. cit., p. 667. 
 
138 THE CAUSES OF INSANITY. 
 
 afcing causes of cerebral disease, and therefore the objects of treatment. 
 Only it is necessary, on the one hand, to insist upon a minute separation 
 of those intestinal disorders which appear as consequences of an already 
 existing cerebral disease, and those which are really causes, on the other 
 hand, and principally to urge a precise anatomical knowledge and diag- 
 nosis of these chronic diseases. All the various organic diseases of tlie 
 liver, spleen, pancreas, large and small intestine, ought not promiscu- 
 ously to be ranked amongst bilious diseases; we must remember that as 
 long as a minute anatomical diagnosis is not made in each individual case, 
 we have no certain basis on which to found our opinion as to etiology or 
 treatment, and we must not attribute too much significance to the more 
 palpable but slight disorders of the intestinal canal (hgemorrhoids, for 
 example), which only cause the other more important circumstances to 
 be overlooked. In regard to tlie theory of cases where changes in the 
 abdominal organs have been found in the insane after death, we must 
 refer to the abundant, especially the older literature on this subject (for 
 example, the work of Buzorini, and the series of dissertations composed 
 at Bonn by Nasse's pupils); again calling to mind the fact that the sim- 
 ple coincidence of these diseases, without any knowledge of the ratio7iale 
 of their reciprocal action, is not sufficient to enable them to be considered 
 as causes of the insanity. 
 
 Copro-psychiatrie [the secretions of the insane], which has been developed as 
 a peculiar bud from the stem of the "Somatic School," has— partly, indeed, 
 through the first edition of this book — gone out of fashion: it may, nevertheless, 
 perhaps still have some admirers amongst the stragglers of the diagnostic system. 
 
 The accounts of cases in which mental diseases were caused by intes- 
 tinal ivorms (especially taenia), and cured on their removal, would be very 
 interesting and practically useful, if they could only bear a closer inves- 
 tigation. Many of these cases ajjpear very doubtful, others seem rather 
 to refer to a nervous excitement maintained by anaemia than to actual 
 insanity; in these cases, after removal of the parasites, the nutrition was 
 imj^roved and the functions of the nervous system restored. 
 
 The case communicated by Morel, ' Etudes cliniques,' i. , p. 293, may be viewed 
 in this light. — Esquirol has observed two cases. Other cases have been communi- 
 cated by Girardin, Ferrus(' Academic de Medecine,' September 23d, 1834), Wood 
 {'Lancet,' January, 1851), and others. — Even congenital dementia is said to have 
 been cured by the expulsion of worms ! 
 
 Diseases of the kidneys and the anomalies with which we are as yet 
 acquainted of the urinary secretion do not appear to be of great import- 
 ance in the etiology of mental diseases. Some cases may be mentioned' 
 in which the insanity probably had some connection with an affec- 
 tion of the kidneys; but these cases must be very rare, and it is impos- 
 sible to give any particulars regarding them. No one would rank the 
 cerebral symptoms in Bright's disease amongst the mental diseases: 
 Bright's disease, to which any etiological relation to insanity could be 
 attributed, is very rare in the insane, although the slighter forms of renal 
 disease, so often present in those suffering from marasmus, etc., are as 
 frequent in asylums (in general paralysis, wasting diseases, etc.) as else- 
 where. 
 
 Neumann has related a case of insanity which originated along with diabetes 
 {' Psychiatric,' p. 163). In Addison's disease there is generally great depression 
 of sentiment, but no case of actual mental disease is known to me. 
 
 ' Royer, ' Malad. des Reins,' i., 1839, p. 523; Friedreich, ' Allgemeine Patholo- 
 gic,' etc., p. 402. 
 
THE CAUSES OF INSANITY. 139 
 
 It is, at all events, very problematic whether shin diseases have any 
 pathogenetic influence on mental disorders. We have nowadays become 
 very sceptical about the older reports of insanity originating from the 
 rapid healing of exanthems or ulcers of the skin. General paralysis some- 
 times commences with erysipelas of the scalp, but it is very doubtful 
 whether the exanthem has any connection with the cerebral disease which 
 succeeds it. 
 
 § 108. 5. On the contrary, certain diseases of the genital organs, 
 and the pathological influences generally which arise from them, have in 
 both sexes an important influence. During the period of sexual develop- 
 ment, particularly where there are morbid states of these organs, insan- 
 ity frequently arises which still presents the principal characters of the 
 mental disorders of childhood. There frequently occur in these cases 
 complications with epilepsy, or chorea, or states of somnambulism — cap- 
 ricious melancholy, or attacks of mania with suspicion. 
 
 Cases occur, but only exceptionally, where non-satisfaction of the 
 sexual functions and continence ought to be considered as the chief causes 
 of the insanity. A certain co-operation of this circumstance is, however, 
 especially in the female sex, not unfrequent, and it may be this which 
 gives a certain definite color to develop insanity, inasmuch as the long- 
 repressed desire now readily shows itself as amorous and sexual delirium, 
 sometimes ideal, sometimes unconcealed. 
 
 In the male sex, all those disorders of the sexual functions which are 
 designated involuntary seminal emissions, pollutio diurna, etc., are of 
 great importance. These anomalies, in which evidently the loss of the 
 seminal fluid is in but few cases the main point, frequently depend, as 
 Lallemand has shown, on local diseases of the urethral mucous membrane, 
 the seminal vesicles, etc. ; in other cases the disorder proceeds rather from 
 the nervous system : ordinarily, they are preceded for a long time by in- 
 creased sexual irritability (excessive pollutions), which is less a cause than 
 a symptom of the already existing irritation. Once developed, these 
 anomalies manifest themselves by considerable decrease of the sexual feel- 
 ings, diminution of erection, impotence, combined with all possible kinds 
 of sensitive and mental perversions, which sometimes represent actual 
 hysteria, sometimes profound hyi:)Ochondriasis. 
 
 I, many years ago, prompted by the writings of Lallemand.' directed my 
 attention to this point in a number of insane male patients — a delicate investiga- 
 tion, as the patients are generally very ciuming in this respect, and their state- 
 ments are not to be depended on : moreover, great caution is necessary, in order 
 not to direct their attention too much to this subject. In only one case could I 
 succeed in proving microscopically the fact of decided pollutio dim-na at defeca- 
 tion ; but I certainly convinced myself that, in a much greater number of cases 
 than I had supposed, a diminution of the sexual sensations and desires, generally 
 very appreciable to the patient, and sometimes also actual impotence, had for a 
 long time preceded the development of the insanity. In such cases it can very 
 rarely be ascertained with certainty whether these symptoms were the conse- 
 quences of the anterior sexual excesses and abuses, or of the depressing emotions 
 which had also acted as causes of the insanity — whether they were actually the 
 first symptoms of the melancholic stage, or depended upon local diseases of the 
 genital organs. In two instances where the latter decidedly appeared to be the 
 
 ' ' Des Pertes seminales :' see reports of cases, and ' Resume,' iii., p. 127-200. 
 Lallemand's statements and opinions on these points have met with much oppo- 
 sition, and in truth they present many weak points. But that which now con- 
 cerns us, viz., the fact that many hypochondriacal and melancholic states are in 
 connection with local disorders of the male genital organs, he has well succeeded 
 in proving. 
 
14:0 THE CAUSES OF INSANITY. 
 
 case, I had recourse to the treatment recommended by Lallemand, viz., cauteri- 
 zation of the prostatic portion of the urethra — in the one case without any 
 appreciable influence on the disease, in the other the operation removed various 
 disagreeable sensations in the genital organs of which the patient complained' 
 (sensations of constant currents of heat, etc.), but did not produce any rapid 
 favorable influence on the insanity. 
 
 Lisle (' Academic de Med.,' Mars, 1851, and in a subsequent work) has published 
 a number of observations in which mental disease appeared to originate from 
 spermatorrhoea. The insanity was specially characterized by the following 
 appearances :— all kinds of chronic peculiar and irregularly manifested bodily 
 troubles, melancholic perversion, tendency to suicide ; feebleness of the intelli- 
 gence, and especially of the emotions and will ; great indecision, etc. : further, 
 remarkable sensibility, distrust, tendency to consider himself mocked by every 
 one. The microscope alone can confirm the diagnosis, and all treatment is useless 
 so long as the spermatorrhoea continues ; when it ceases, the mental disease gen- 
 erally rapidly disappears. 
 
 In the female sex, menstruation and all its disorders exercise great 
 influence on the development and course of mental diseases. The most 
 simple, but at the same time the most rare, cases are those where, in per- 
 sons who have been hitherto healthy, there occurs, after sudden cessation 
 or suppression of the menses, acute violent hyperaemia of the brain, and 
 immediately therewith an outbreak of mental disorder, generally mania 
 with active cerebral congestion. More frequently, indeed, the cessation 
 of the menses precedes the insanity, but does not stand in so direct a re- 
 lation to it; it is rather to be considered as a result of the persistent 
 emotional depression, as a co-symptom of an existing anoemic state, of 
 other chronic disease, or of a generally depraved state of the constitution: 
 all which conditions are themselves more important causes than the me- 
 tastasis. On the other hand, menorrhagia resulting from antemia and 
 general lowering of the nutrition may be a cause of insanity as well as of 
 any other neurosis. Frequently, however, irregularities of menstruation 
 first appear with the commencement of the mental disease, in the same 
 manner as they may occur in any other chronic disease; and we may also 
 frequently observe during recovery from insanity that it does not follow 
 upon the return of the menses, but the reverse— the return of the menses 
 follows upon the already accomplished cure of the mental disease. When 
 menstruation continues during the mental disease, as it often does with- 
 out the least derangement, it is not unusual to observe, with each return 
 of the period, increased excitement, general increase of the mental 
 disorder. In rare instances, insanity simply periodic, lasting during the 
 menstrual period with complete lucid intervals of several weeks' duration, 
 has been observed. 
 
 The period of the first appearance of the menses often brings with it, together 
 with headache and all sorts of nervous affections, disturbances of the feelings and 
 emotions which may proceed to delirium and to mania. Still more frequently 
 the latter occurs, or other forms of insanity appear (as melancholia w-ith stupor, 
 suicide), in cases where menstruation is for a long time morbidly retarded, or 
 even has not appeared ; some cases of the kind pass in incurable insanity or 
 dementia. It is well known that most females are very sensitive, very peevish 
 and nervous, at the menstrual periods. All causes of disease, especially moral 
 causes, act more powerfully at these times; and in many persons who enjoy 
 perfect health during the intervals, there may be observed, during the periods, a 
 perversion of sentiment bordering on disease, sadness, hypochondria, or capricious- 
 ness. In many of the insane, the mental disease becomes increased in these times, 
 
 1 Cooper, in his Lectures, mentions a case in which a large number of prostatic 
 calculi were removed by means of operation. These calculi did not only cause 
 pain, but a continuous emotional excitement bordering on insanity. 
 
THE CAUSES OF INSANITY. 141 
 
 sometimes to mania, sometimes to nymphomaniacal forms accompanied by cere- 
 bral congestion, and suicidal patients require to be carefully watched. These 
 should be considered as cases of nervous irritation of the brain proceeding from 
 the genital organs ; if the loss of blood has been profuse, the irritation will be the 
 more increased. The connection between the menstrual disorder and the insanity 
 appears to be most intimate in those cases of suppression of the menses which we 
 mentioned first of all. Here, too, recovery takes place with the return or regu- 
 lation of menstruation, and here alone is appropriate emmenagogue treatment 
 indicated and necessary : to this category alone belong also those rare cases in 
 which recovery from the insanity occurs immediately after the return of the 
 menses. Dysmenorrhoea is ordinarily accompanied by those nervous affections 
 which are understood by the name hysteria ; these are often principally cerebral. 
 The period of the cessation of the menses often exercises a very favorable, even 
 occasionally a curative, influence on the existing mental disease : more frequently, 
 however, it exerts an unfavorable influence, so that the hitherto more variable 
 and irritable forms become fixed, and pass into chronic mania and dementia. 
 Those cases also which make their first appearance at this time of life, often 
 melancholia, are generally of an unfavorable character. 
 
 The influence of menstruation is treated of in two excellent recent papers : 
 Brierre, ' Annales Med. Psychol.,' 1851, iii., p. 574, and Schlager, ' Zeitschrift fi'ir 
 Psychiatrie,' xv., 1858, p. 457 (this paper may also be found in the Report of the 
 Vienna Asylum, Wien, 1858, p. 140). 
 
 The local diseases of the uterus, ovaries, and vagina (ovarian cysts, 
 displacements of the uterus, uterine catarrh, ulcers of the cervix, etc.) 
 are generally followed in the first place by well-marked hysteria, which 
 then may gradually pass into insanity. This insanity often presents dis- 
 tinct traces of its origin in its general hysterical character, or in certain 
 morbid conceptions (for example, the idea of pregnancy). 
 
 Whether it be the case or not, the possibility of the existence of such local 
 disease in female patients ought always to be kept in view, and on the least sus- 
 picion a minute examination should be made. It is certainly of great detriment 
 to the patients that there exists at the present time amongst asylum physicians a 
 truly childish delicacy in regard to vaginal examinations and the use of the 
 speculum. In Germany, France, and England, I have found the same delicacy ; 
 they seem afraid of exciting the patients, of awakening or increasing certain 
 delirious ideas, just as long ago. for similar reasons, they were afraid to auscul- 
 tate : such subordinate consideration ought not to be regarded when it interferes 
 with what is the only means of arriving at a correct diagnosis, and therefore a 
 proper system of treatment. The light which we gain by the speculum, and 
 which so frequently elucidates hysteria, can alone clear up much in connection 
 with that insanity which is so closely aUied to hysteria ! I have myself observed 
 in private practice certain very successful cases of recovery from hysterical 
 insanity by means of local treatment of the genital organs, after all other means 
 had failed. Brosius (' Med. Centralzeitung,' 1858, 27) relates two cases of recovery 
 from simple acute melancholia in consequence of local treatment of diseases of 
 the genital organs. Flemming (' Psychosen,' p. 194) saw two cases in which pro- 
 lapsus uteri accompanied by frequent haemorrhages gave rise to attacks of rage 
 and maniacal excitement, which ceased when the prolapsus was permanently 
 retained by means of a pessary ; in one case the untimely removal of the pessary 
 was followed by a return of the mental disorder. Concerning uterine displace- 
 ments as causes of insanity, see the remarks of L. Meyer, Virchow's ' Archiv,' 
 ix., p. 108. 
 
 § 109. But of all the influences which arise from the female sexual 
 system, pregnancy, and still more the imerperal state and lactation, are 
 the most important. Of these, pregnancy is most rarely followed by de- 
 veloped insanity in the form of profound melancholia or mania; more 
 frequently it causes merely a state of moderate depression, which is some- 
 times evidently the first stage of subsequent puerperal mania. The 
 direct moral influences, especially the various emotions, which accompany 
 a first pregnancy, may be of great importance in those previously disposed 
 
14:2 THE CAUSES OF INSANITY. 
 
 to insanity. An influence not less great ought in other cases to be as- 
 cribed to the states of congestion and of anasmia which are so frequently 
 developed during pregnancy. 
 
 Slight mental disorders, hysterical humors, irresistible longings, foolish 
 jealousy, and kleptomania, are during pregnancy more frequent than fully devel- 
 oped insanity. Cases occur in which the mental disorder appears in a certain 
 form in each pregnancy ; on the contrary, cases — I myself know of one, and 
 Guislain (' Legons oraleo,' ii., p. 275) mentions one— in which an existing slight or 
 severe mental affection disappeared during each pregnancy, so that the individuals 
 were in possession of their reason only when they were pregnant. We may assume 
 that in such cases the cerebral disease is sympathetic, dependent upon some 
 (slight) probably mechanical affection of the generative organs, which— and with 
 it the evil influence which it exercises on the cerebral functions — always dis- 
 appears when conception takes place. Insanity may also commence during the 
 first months of pregnancy, more frequently it makes its first appearance in the 
 latter months ; it occasionally disappears with the delivery, or it may be not till 
 a later period, till the return of the menses, but we cannot calculate with certainty 
 on this being the case— it may also continue and become incurable. When one 
 who is already insane becomes pregnant, it is only very expectionally that it 
 exerts a favorable influence on the insanity ; and this can only be expected in 
 recent cases, and such as depend on diseases of the generative organs themselves. 
 Sometimes the existing insanity ceases with conception, but returns after de- 
 liver5\ Most commonly the mental disease is only rendered worse, and incura- 
 bility accelerated. See Marce, ' De la Folie des Femmes enceintes,' etc., PariS; 
 1858. 
 
 Even during delivery, and from that time during the whole course of 
 the puerperal state, severe mental disorders may arise, the comprehension 
 of which under the term puerperal insanity, according to the form of the 
 insanity, does not seem to be very correct, as they have in regard to symp- 
 toms both something altogether distinct from ordinary insanity, and 
 amongst themselves possess many peculiarities in common: still, in re- 
 lation to the peculiar circumstances of the origin, the term is quite justi- 
 fiable. In a practical point of view, a minute separation of these cases is 
 always necessary. 
 
 During the act of delivery, there occasionally occur states of great ex- 
 citement and mania"; indeed, it has even been observed that with each pain 
 there occurred a violent outbreak of fury. The pain, the very great 
 general nervous excitement, and the evident congestive states, lie at the 
 foundation of these disorders; tliey occasionally manifest themselves in 
 great enmity towards the child (sometimes killing it), do not continue 
 for longer than a few hours or a day, and are very important in a medico- 
 legal point of view. 
 
 Amongst the mental disorders which appear subsequently to, but 
 generally within fourteen days after delivery, the one may be considered 
 as the symptomatic delirium of other serious puerperal diseases^— endome- 
 tritis, phlebitis and pygemia, consecutive endocarditis (PKiwisch), etc.; 
 cases in which the cerebral affection ought to be ascribed partly to the inju- 
 rious effect of the purulent infiltration, partly to the evident cerebral con- 
 gestion — in Avhich the mental disorder shares the (critical) prognosis of the 
 principal disease, in general it persists or ceases with it; in certain cases, 
 however, it may continue for a long time after recovery from the puer- 
 peral fever. 
 
 In another series of cases, on the contrary, insanity is developed with- 
 out the existence of any other serious puerperal disease; a cerebral 
 disease which, independent from the commencement, is either in the 
 form of melancholy, especially of raptus melancholicus, or, especially if a 
 
THE CAUSES OF INSANITY. 143 
 
 state of mental depression has existed during pregnancy, or one of excite- 
 ment, and frequently of nymphomaniacal delirium. These are, above 
 all, the cases Avhich afterwards pass into persistent insanity — of, however, 
 on the whole, not unfavorable prognosis. They appear particularly in 
 individuals already predisposed under the influence of all kinds of de- 
 termining causes, of which the depressing emotions,* on the one hand, 
 and anaemia, owing to great hasmorrhage during delivery, operations, etc., 
 on the other, are evidently the most important. 
 
 The first symptoms of the mental disorder in cases of the latter kind appear 
 sometimes very soon after the birth of the child, or on the third or fifth day with 
 the milk fever; most frequently, at all events, in the first, then in the second 
 week — at latest four weeks after delivery. Great loss of blood, likewise emotions, 
 are often the exciting cause; hereditary pi-edisposition, great nervous irritability, 
 great emotional susceptibility during pregnancy, from important predisposing 
 circumstances (Reid in Bedlam— 1848— found in 111 cases of puerperal insanity, 
 hereditary predisposition in 45). The most frequent forms are maniacal excite- 
 ment, then melancholia (frequently attonita). 
 
 Amongst 131 cases in Bedlam (Webster), tendency to suicide existed in 41 (31 
 per cent); in mania the prognosis is more favorable than in melancholia. On the 
 whole the prognosis of puerperal insanity is very properly considered as relatively 
 favorable ; still, the curability of this form is frequently over-estimated : in Bed- 
 lam, of 181 cases, 81 were cured (41.83 per cent), while during a space of twenty 
 years in the same asylum the proportion of recoveries from insanity in general 
 was 53.67 per cent (Webster). Recovery occurs most frequently within the first 
 three months ; sometimes we see, under the symptoms of puerperal rnania, an 
 already existing tuberculosis proceed with great rapidity after childbirth, and 
 terminate in death. Simpson ( 1853) thought it probable that the use of chloroform 
 m obstetric practice might prove a prophylactic against puerperal insanity. Not 
 only has this assumption not been confirmed, but cases have occurred in which 
 the use of chloroform appeared to determine the outbreak of the mental disease 
 (Webster). 
 
 See Esquirol, ' Maladies Mentales,' i., cap. 5 ; Schneider, ' Ueber Mama lactea," 
 inNasse's ' Zeitschrift fiir Anthrop.,' 1823. p. 163; Neumann, 'Krankheiten des 
 Vorstellungsvermogens,' 1822, cap. 14 ; Kiwisch v. Rotterau. ' Die Krankheiten 
 der W6chnerinnen,'ii., 1841. p. 228; Helm, 'Monographic der Puerperalkrank- 
 heiten,' 1840, §§ 28, 46, 53, 75 ; Sinogowitz, ' Die Geistesstorungen,' 1843, § 25 ; 
 Leubuscher,' ' Verhandl. der Gesells. fur Geburtshiilfe,' Berlin, 1846, p. 94; 
 Macdonald, ' American Journal of Insanity,' iv., 1847, p. 113 ; Webster, 'Journal 
 of Psychological Medicine,' 1849 ; Ideler, " Die Vesania puerperalis," ' Charite 
 Annalen,' ii., 1, 1851, p. 122; Weill, 'Consid. sur la Folie puerperale,' Diss., 
 Strasb., 1851 ; Marce, ' Traite de la Folic des Femmes enceintes,' Paris, 1858. 
 
 Finally, as to the influence of ladatmi, it is well known that weaken- 
 ing of the constitution through prolonged nursing is a cause of all possi- 
 ble forms of severe neuroses; and it is especially severe or persistent emo- 
 tionsv moral predispositions, etc., which give rise to this form of cerebral 
 affection — puerperal insanity. 
 
 From this enumeration of the causes of insanity, the general doctrine 
 may have been deduced that everything which lowers the nutrition, all 
 true states of weakness, and further that all circumstances which over- 
 excite the nervous system, which favor congestion of the nervous centres 
 —in short, all which has as a result the development and fixing of the 
 nervous constitution, may become causes of insanity. We shall again 
 revert to this subject when we come to speak of the treatment of mental 
 diseases. 
 
 "See Esquirol, i., pp. 141, 142. 
 
144 rOKMS OF MENTAL DISEASE. 
 
 BOOK THIED. 
 
 FOEMS OF MENTAL DISEASE. 
 
 § 110. A CLASSIFICATION of mental diseases according to their nature 
 — that is, according to the anatomical changes of the brain which lie at 
 their foundation — is, at the present time, impossible (§ 6). But, as the 
 whole classification of mental diseases is merely a symptomatological one, 
 so that we recognize the different /orms of insanity only by their present- 
 ing different groups of symptoms, instead of the anatomical principle of 
 division, we must adopt the functional, the physiological; and this is — as 
 the disorders of the understanding and will are the principal and the most 
 striking — also a psychological basis. Insanity is, therefore, to be divided 
 according to the form and nature of the psychical anomalies. But 
 whilst it is the aim of clinical instruction to render conspicuous and to 
 analyze the multiplicity of mental disorders in the concrete, nosology 
 must content itself with establishing fewer principal groups of mental 
 disorders, fewer fundamental ahiormal states, which result from the 
 agreement of a great number of cases in certain characteristic signs, and 
 to which, therefore, all the varieties of individual cases may be referred. 
 It is these fundamental conditions and their symptoms that we have here 
 principally to describe; and although all the varieties which they may 
 present and their reciprocal transformations must indeed be considered, 
 our limits do not permit us to enter into exhaustive details. Even that 
 fusion of normal and abnormal mental appearances on which the varieties, 
 intermediate states, and transitions depend, constitutes one of the most 
 interesting objects of clinical study. It cannot, however, be minutely 
 followed in the short expositions of a text-book. 
 
 The analysis of observations leads to the conclusion that there are two 
 grand groups or fundamental states of mental anomalies, which represent 
 the two most essential varieties of insanity. In the one, the insanity 
 consists in the morbid production, governing, and persistence of emotions 
 and emotional states, under the influence of which the whole mental life 
 suffers according to their nature and form. In the other, the insanity 
 consists in disorders of the intellect and will, which do not (any longer) 
 proceed from a ruling emotional state, but exhibit, without profound 
 emotional excitement, an itidependejit, tranquil, false mode of fJwught 
 and of will (usually with the predominant character of mental weakness). 
 Observation shows, further, that in the great majority of cases, those 
 conditions which form the first leading group precede those of the 
 second group; that the latter generally appear only as consequences 
 
FORMS OF MENTA.L DISEASE. • 145 
 
 and terminations of the first, when the cerebral affection has not been 
 cured. There is, moreover, again presented within the first group, in a 
 great proportion of cases, a certain definite succession of the various 
 forms of emotional states, whence there results a method of viewing in- 
 sanity which recognizes in the different /orm.s% different stages of one 
 morbid process; which may, indeed, be modified, interrupted, or trans- 
 formed by the most varied intercurrent pathological circumstances, but 
 which, on the whole, pursues a constantly progressive course, which may 
 proceed even to complete destruction of the mental life. By means of 
 this knowledge, most distinctly expressed by Zeller, it is now possible, 
 from the nature of the symptoms, to approach much more closely to the 
 problem (which ouglit always to occupy the foreground) of an anatomico- 
 pathological knowledge and diagnosis of mental diseases. 
 
 Pathological anatomy shows us, even at present, that in the first group, 
 or in the first stages of insanity, it is rare to find important organic altera- 
 tions, or such as are not capable of complete removal; whilst in the 
 second group, or in the terminal stages, very often there exist palpable 
 organic changes which are incapable of cure — particularly atrophy of the 
 brain more or less extensive, with oedema of the membranes, and chronic 
 hydrocephalus. We may say, then, that those cerebral lesions which 
 give rise to the first stages of insanity — lesions which are certainly not 
 always of an identical nature, and which we, as yet, cannot generally 
 characterize anatomically — have this in common, that they terminate in 
 very many cases in those characteristic consecutive changes in the brain 
 which we have spoken of as a stage of permanent anatomical lesions. 
 
 Consequently, the simple symptomatological, the psychologico-analy- 
 tical method, and the anatomical manner "of investigation, come all to 
 the same practically important conclusion, that insanity is a curable dis- 
 ease only so long as it is confined to the first group of primitive (emo- 
 tional) mental disorders, and that it becomes incurable with the develop- 
 ment of the secondary lesions which constitute the second group. That 
 first series includes the forms of melancholy, mania, and monomania; 
 the second, the forms of chronic mania and dementia. 
 
 ' "Zeit. Bericht, etc.;" ' Med. Correspondenzbl.,' Juli, 1840. 
 10 
 
146 BTAXEB OF MENTAL DEPRESSION. 
 
 CHAPTER I. 
 STATES OF MENTAL DEPRESSION— MELANCHOLIA. 
 
 § 111. The fundamental affection in all these forms of disease con- 
 sists in the morbid (§ 37) influence of a painful depressing negative affec- 
 tion — in a mentally painful state. This state may, at the outset, in the 
 simplest and the most primitive form of melancholia, continue in the 
 form of a vague feeling of ojipression, anxiety, dejection, and gloom; 
 generally, however, this obscure vague feeling of annoyance passes into 
 a single, concrete, painful perception; there arise thoughts and opinions 
 in harmony with the actual disposition of mind, and without external 
 motive (false ideas) — a veritable delirium, revolving constantly upon some 
 tormenting and painful subject, while at the same time the intellect pre- 
 sents some anomalous forms, is restrained in the exercise of its freedom,^ 
 becomes slow and sluggish, and the thoughts monotonous and vacant. 
 The normal reaction towards the external world is either weakened and 
 blunted (mental anaesthesia, indifference even to actual stupor), or 
 exaggerated in such a manner that all mental impressions are painful 
 (mental hyperaesthesia) ; and very often tliese two forms are found 
 in the same patient alternating with each other. Many disorders of the 
 emotion and of the will are moreover associated with this. Their varie- 
 ties form a basis for the distinction of the several principal forms of 
 melancholia. Sometimes volition is directly diminished and weakened, 
 at other times it is convulsively restricted (absence of energy and of will); 
 at others there appear certain desires and impulses of will to which mate- 
 rial and object are afforded by the morbid mind; or, lastly, a high degree 
 of moral pain excites various impulses of an aimless convulsive character, 
 which manifest themselves in extreme restlessness, the continuance and 
 increase of which cause these forms of melancholia to assume a different 
 character, and to pass into quite another variety of that of mania. 
 
 In employing the term " states of mental depression," we do not wish to be 
 understood as implying that the nature of these states or conditions consists in 
 inaction and weakness, or in the suppression of the mental or cerebral phenomena 
 which accompany them. We have much more cause to assume that very violent 
 states of irritation of the brain and excitation in the mental processes are here 
 very often the cause ; but the general result of these (mental and cerebral) pro- 
 cesses is depression or a painful state of mind. It is sufficient to recall the analogy 
 to physical pain, and to those who imagine that they make things better by sub- 
 stituting "cerebral torpor" and "cerebral irritation" for "depression" and 
 " exaltation," it may fairly enough be objected that in melancholia there is also 
 a state of irritation. 
 
 Observation shows that the immense majority of mental diseases com- 
 mence with a state of profound emotional perversion, of a depressing and 
 sorrowful character. Guislain was the first to elucidate this highly inter- 
 esting fact, and make it at all serviceable. Of its general correctness 
 there is no doubt, and we can have no hesitation in speaking of the " sfn- 
 dium melancholicum" as the initiatory period of mental disease. Of 
 
STATES OF MENTAL DEPRESSION. 147 
 
 course there are exceptions.' Thus, in senile dementia, in periodic 
 mania, in meningitis, in the mental diseases consecutive to typhus fever, 
 l)neumonia, cholera, sun-stroke, etc., the outbreak of mania is generally 
 observed without being preceded by melancholia; but the cases are much 
 more frequent in which this stadium melancholicum only appears to be 
 absent because it was less intense, and was not then recognized as a stage 
 of mental disease. 
 
 The " stadium melancholicum" which precedes insanity is by some physicians 
 designated as the period of incubation, or "prodromal stadium ;" and, in their 
 opinion, the outbreak of the disease dates only from the time wlien the patient is 
 no longer able to control his actions. This limitation is to a certain extent arbi- 
 traiy, but the circumstance that the stage of incubation has almost always a 
 depressive character is interesting and of great importance. 
 
 The melancholia which precedes insanity sometimes appears exter- 
 nally as the direct continuation of some painful emotion dependent upon 
 some objective cause (moral causes of insanity), e. g., grief, jealousy; and 
 it is distinguished from the mental pain experienced by healthy persons 
 by its excessive degree, by its more than ordinary protraction, by its 
 becoming more and more independent of external influences, and by the 
 other accessory affections which accompany it (see further on). In other 
 cases the melancholia originates without any moral cause, though most 
 frequently there are such, but it does not originate as their direct con- 
 tinuation, but only shows itself after these affections have wrought con- 
 siderable disturbances in the functions and nutrition of the nervous sys- 
 tem, or have undermined the entire constitution. , . ^ 
 
 Section I. — Hypochondriasis. 
 
 § 112. The hypochondriacal states represent the niiildest, most mod- 
 erate form of insanity, and have many peculiarities which essentially 
 distinguish them from the other forms of melancholia. _ While they, of 
 course, share with the others the generic character of dejection, sadness, 
 depression of mind, diminution of the activity of the will, and of a delir- 
 ium which corresponds to this mental disposition, they yet differ from 
 them in this characteristic manner — that in these states the emotional 
 depression proceeds from a strong feeling of bodily illness which con- 
 stantly keeps the attention of the patient concentrated upon itself; 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^upou unfounded and curious ideas regard- 
 ing the nature, the form, and the danger of this his disease. This feel- 
 ing of bodily illness is sometimes general and vague, sometimes it resolves 
 itself into particular anomalous and disconnected sensations. It often 
 depends on irritation of the nervous centres arising from peripheral dis- 
 ease — often very obscure and concealed — of the viscera. It is also fre- 
 quently provoked centrally under the direct influence of moral causes — 
 e. g., reading medical books, frequent contact with hypochondriacs. 
 
 These morbid sensations are always increased through the direction 
 of the attention to them; and when the disease has attained a certain de- 
 
 ' Guislain himself knew of such exceptions (' Leg. orales.' ii., p. 162) ; and he 
 compares them to cases of intermittent fever, where the cold, hot, and sweating 
 stages did not follow precisely the usual course. 
 
148 STATES OF MENTAL DEPRESSION. 
 
 gree of development, such may, through direction of the attention to this 
 or that organ, be awakened, dispkced, 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 usually unimpaired; 
 the abnormal sensations and ideas are logically connected throughout: 
 and justified by reasons which are still within the bounds of possibility. 
 And just because of this absence of actual derangement of the under- 
 standing, hypochondria appears to be essentially afolie raisonminte me- 
 lanchoUque, the antithesis of which — the ordinary so-called monomania- 
 ^Blfolie raisonnante — we shall in find the states of mental exaltation. 
 
 We recommend the thinking and intelligent reader to verify for himself the 
 analogy which results from the comparison of these two forms of the morbid 
 states and feelings. Hypochondria reaUy finds no other suitable place in nosology 
 than among mental diseases, among which Sauvages and CuUen have long ago 
 ranged it, and since then Pinel, Georget, and Falret. It is also the natural con- 
 sequence of the symptomatology of the affection. It is a perversion of sentiment 
 which may go to the slightest or the most extreme degrees without essentially 
 changing the character. The hypochondriac, it is true, may reason correctly- 
 setting out from false premises ; but this does not in the least invalidate the fact 
 that hypochondria is a mental affection, any more than that because hypochondria 
 often accompanies or complicates various chronic diseases seated in different 
 organs, it ought on that account to be identified or confounded with these dis- 
 eases. 
 
 § 113. Symptojns. — The disposition of the patient begins to change 
 without any assignable cause. He becomes dejected, peevish, suspicious, 
 exhibiting more extreme sensibility and a disposition to connect every- 
 thing with himself. Everything wearies him, and he is very easily fa- 
 tigued. At the commencement, this state experiences many remissions; 
 and the paroxysms assume the form of an irritable, restless, and distrust- 
 ful disposition, or of a mental apathy, which may go so far as to pro- 
 duce weariness of life, or anxiety which may proceed to despair and loss 
 of self-control. An undefined yet vivid feeling of illness torments and 
 annoys the patient in an obscure sort of manner. All the parts of the 
 sensory nervous system may be the seat of morbid sensations, often very 
 painful (formication, heat and cold, crawling about of a foreign body — 
 as if his head would burst — as if he were empty, dead, pierced, torn in 
 pieces, etc.). And the higher senses also often present an exaggerated 
 sensibility or great bluntness, and actual hallucinations. All these 
 anomalous sensations urge themselves vividly into the consciousness, 
 awaken and maintain an idea which relates to the disease in all its va- 
 rious possible forms and means of cure. All sensations are watched, and 
 seriously commented upon and analyzed in the sense of the ruling gloomy 
 and anxious frame of mind. From these the patient concludes that he 
 is the subject of very serious and dangerous diseases; and often he ex- 
 presses his fears with an exaggeration of which he himself is half aware, 
 and in the most graphic and ludicrous language. The patient who ex- 
 hibits only the most insignificant symptoms of disease, speaks of apo- 
 plexy—asserts that he is half dead, that his heart is dried up or petrified, 
 his nerves are burning coals, his blood is boiling oil, etc. He willingly 
 allows that he is the subject of serious disorders, or of entire new diseases 
 which have never before existed, because the gravity and danger of the 
 disease is in proportion to the intensity of the feeling which annoys him. 
 Whenever the morbid sensations change their situation and nature, the 
 ideas regarding the seat and the nature of the disease also change, and 
 
STATES OF MENTAL DEPKESSION. 149 
 
 the patient believes himself to be successively attacked with all the dis- 
 eases whose pathology he knows. So much do these ideas constitute a 
 true delirium, so false and purely imaginary are they, and so little do the 
 sensations Avhich serve as their basis seem to be connected with them, 
 that they may be regarded essentially as mere attempts at explanation. 
 
 We therefore find here exactly the same origm— the same objective ground- 
 lessness and subjective foundation of the delirious conceptions as in the other 
 forms of melancholia and more advanced insanity. Take from the hypochon- 
 driac his morbid sensations, and he will no longer be afflicted with his imaginary 
 diseases ; cause the feelings which agitate and torment the melancholiac in another 
 way to disappear, and no longer will he believe himself to be pursued by his 
 enemies, etc. In melancholia the abnormal feelings which precede the delirium 
 are as r6al, and. at least at the commencement, the same unstableness, the same 
 abrupt change in the delirious perceptions prevails as in hypochondria. 
 
 § 114. The hypochondriac, constantly preoccupied with his afflictions, 
 seeks by every possible means to penetrate them. He often feels his 
 pulse, examines his tongue and his excretions, and frequently discovers 
 in these investigations causes for fear or hope, which he sometimes, 
 though the details may be very disgusting, takes a sort of pleasure in 
 communicating to everybody. The great desire to be cured induces him 
 frequently to change his physician and his treatment. He seeks for in- 
 struction' by reading medical books, and often changes his opinion re- 
 garding the nature of his malady, inasmuch as he applies to his own 
 case all which he reads or hears of. The mere mention of a disease is 
 sufficient to start the notion that he himself labors under it ; and, influ- 
 enced by this idea, he now discovers in the corresponding organs phenom- 
 ena which he had never before experienced.' 
 
 But not always is it the fear simply of ordinary bodily diseases which 
 occupies the attention of the hypochondriac, and is the object of his 
 anxiety. Frequently the mental" element in his malady does not escape 
 his notice, and the complete change of his personality, the possession of 
 morbid sensations and ideas, especially, however, a certain anomaly (al- 
 ready noticed § 50), particularly in the mental sphere, in the sensorial 
 sensations, whereby these, although perceived as formerly, no longer pro- 
 duce the same impressions, frequently form the great subject of his com- 
 plaint. 
 
 This last and very remarkable state, which the patients themselves have much 
 difficulty in describing, which we also have ourselves observed in several cases as 
 the predominant and most lasting symptom, is as well as possible described m the 
 following letter of one of Esquirol's patients : 
 
 " I still continue to suffer constantly ; I have not a moment of comfort, and 
 no human sensations. Surrounded by all that can render life happy and agree- 
 able, still to me the faculty of enjoyment and of sensation is wanting— both have 
 become physical impossibilities. In everything, even in the most tender caresses 
 of my children, I find only bitterness. I cover them with kisses, but there is 
 something between their lips and mine ; and this horrid something is between me 
 and all the enjoyments of life. My existence is incomplete. The functions and 
 acts of ordinary life, it is true, still remain to me ; but in every one of them there 
 is something wanting— to wit, the sensation which is proper to them, and the 
 pleasure which follows them. . . . Each of my senses, each part of my iwoper 
 self, is as it were separated from me and can no longer afford me any sensation; 
 this impossibility seems to depend upon avoid wliichl/fieZ in the front of my 
 head, and to he due to the diminution of the sensibility over the ivhole surface of 
 my body, for it seems to me that I never actually reach the objects which I touch. 
 
 ' One cannot help being struck Mnth the remarkable similarity between this 
 process and the production of hallucinations in general. 
 
150 STATES OF MENTAL DEPRESSION. 
 
 . . . I feel ivell enough the changes of temperature on viy skin, but I no longer 
 experience the internal feeling of the air when I breathe . . . viy eyes see and 
 my spirit perceives, but the sensation of that tohich I see is completely wanting," 
 etc. 
 
 The psychical changes, too, which occur in the sphere of the will, are, 
 in the majority of instances, very striking. The patients become de- 
 jected, thonghtfnl, indecisive; in the higher grades volition is altogether 
 absent. "I wish that I could be more determined, that I could per- 
 severe longer; but to do this depends no longer upon myself. I feel that 
 if I could will, I might rescue myself from this desperate situation, but I 
 am obliged to yield to my painful sensations. I feel myself incapable of 
 everything, and the smallest obstacle appears to me insurmountable," 
 etc. These are expressions which may frequently be heard in the higher 
 degress of hypochondria, as well as in all other forms of melancholia.' 
 In tlie more advanced stage of tliis disease, the intellect also suffers not 
 only in the manner of which we have been speaking, but the constant 
 direction of the thoughts to the special state, and the means which might 
 possibly aid him impart likewise to the perception a certain monotony, 
 and in consequence of this ruling preoccupation of the consciousness, 
 everything that does not fall within this circle of ideas is without the 
 slightest interest, of perfect indifference, and is very speedily effaced 
 from the memory. Hence it is that such patients are often in the high- 
 est degree absent and forgetful. They are very loquacious upon the one 
 subject of their affection, but are little inclined to speak on any other 
 theme; and those are never severe cases of hypochondria where the pa- 
 tient is still amiable and can be an interesting companion. But the in- 
 telligence and acumen which the patient often displays in fine combina- 
 tions upon his favorite theme may still remain intact as also in regard 
 to objective relations. It is only in the most extreme grades of hypo- 
 chondria tliat any actual diminution in the intelligence is observed in a 
 form of dull and morose dementia which renders the sufferer almost in- 
 capable of any intellectual exertion. 
 
 In the aggregate of these mental disorders which collectively have the char- 
 acter of depression, hypochondria shows itself as a form of melancholia. Although 
 in general, on account of the peculiar nature of these delirious conceptions, and 
 of the much greater command which the patient has over himself, hypochondria 
 may be regarded as to a certain extent specific, yet that ruling tendency which 
 the patient has to connect and to compare everything with himself, the limita- 
 tion of the perception to the special 7— this morbid egotism is an essential 
 characteristic corresponding to the concentration in self of the melancholic states 
 in general, and occasionally, at the commencement of the melancholic perversion, 
 it is more by chance that the body and not external objects becomes the object of 
 the morbid mode of thought. The higher degrees of hypochondria, too, gradu- 
 ally pass, partly through increase of the feeling of anxiety, partly through the 
 fixing of certain attempts at explanation, not only into true melancholia, but even 
 comphcated with delusions (ideas of being surrounded by an invisible agency, of 
 being the victim of evil machinations, influenced by magnetism, etc.). That 
 considerable degree of self-control also which hypochondriacs still possess, often 
 disappears during each exacerbation. Could the physicians only observe these 
 paroxysms as freely as they can at any time in severe cases in asylums, all doubts 
 concerning the mentally morbid nature of hypochondriasis would very soon 
 disappear. 
 
 8 115. Besides these mental disorders and anomalies of the sensations 
 
 ' See a capital example of absence of volition in hypochondria by Leuret, 
 
 ' Fragmens,' p. 383. 
 
STATES OF MENTAL DEPRESSION. 151 
 
 which we have mentioned, there may occur in almost all hypochondriacs 
 innumerable morbid symptoms in all the various organs, and that old 
 comparison of hypochondria to a chronic derangement involving the 
 whole nervous system with fever, as the most general acute stage of the 
 disease (Hoffmann), is by no means a bad one. Thus, for instance, very 
 frequently the digestion suffers, the tongue is loaded, the appetite is 
 immoderate or diminished, the bowels are constipated, and digestion is 
 accompanied by a considerable development of gas, whereby tension is 
 produced in the hypochondriac regions, pushing up of the diaphragm and 
 causing a feeling of oppression. Such persons are frequently afflicted 
 with haemorrhoids, abdominal pulsations, palpitations of the heart, cere- 
 bral congestion, headaches, disturbed sleep ; very often they have an 
 abundant mucous expectoration from the larynx and throat. In many 
 cases it is impossible to decide whether and to what degree these very 
 variable symptoms are due to such primary disorders of the viscera under 
 the influence of which the hypocliondria 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 accessible organs. 
 Not unfrequently we see, during the course of the mental disease, some 
 visceral affection gradually make its appearance which, in its obscure 
 commencement, may be etiologically connected to the hypochondria. 
 
 It is evident that hypochondria may arise in two different ways. In 
 the first place, as a secondary cerebro-spinal irritation, in consequence of 
 internal, but of course often slight, diseases (of the intestinal canal, of 
 the liver, of the genital organs, perhaps also of the kidneys), which give 
 rise more to a feeling of general discomfort than to localized pains. These 
 are specially, on the one hand, the slighter mechanical obstructions to the 
 passage of the intestinal contents, flatulence, and in particular gastro- 
 intestinal catarrhs, which very often give rise to hypochondria in sensi- 
 tive individuals, and that too often of a most aggravated form ; and, 
 on the other hand, affections of the sexual and nervous system consequent 
 on onanism, gonorrhoea, and venereal excesses ; and, finally, all dyscra- 
 siae. It is principally to these three series of affections that the physician 
 ought to direct his attention. 
 
 In the second place, however, hypochondria may undoubtedly also 
 arise from direct moral causes, inasmuch as through external circum- 
 stances the ideas may be so constantly directed to the state of the general 
 health, or of one particular organ, as to induce morbid sensations. This 
 is particularly observed in those who read medical books, who are fre- 
 <^uently in the company of hypochondriacs, or during the time of an epi- 
 demic, as of cholera, etc. Such cases are, therefore, less severe and rare 
 in comparison to those which are produced by indirect moral causes, 
 such as depressing emotions, excessive mental exertion, etc. These 
 generate derangements of digestion, of the circulation, of the nutrition, 
 etc., which become the sources of the feeling of illness. 
 
 Hypochondriacal states are sometimes observed in the years of child- 
 hood, and more frequently at the age of puberty. They are extraordi- 
 narily frequent in young people, and more rare in advanced age. They 
 are more common in men than in women ; however, it is by no means 
 rare to meet with most characteristic and complete cases in the latter sex. 
 The course is in general very slow, and it sometimes presents remissions. 
 I have seen some cases where the hypochondria appeared like an inter- 
 mittent mania at almost regular periods, with intervals of several years. 
 
152 STATES OF MENTAL DEPRESSION. 
 
 Another time I observed in a severe case (female sex) an almost complete 
 remission take place after severe spontaneous diarrhcea, combined with 
 lancinating pains in the vertebral column. 
 
 During the very chronic course of hypochondria, the nutrition and 
 appearance of the patient may often continue good for a long time ; but 
 when an organic affection of some of the viscera becomes developed, the 
 })atient enters into a stage generally prolonged of physical languor, with 
 emaciation, discoloration of the skin, great weakness, etc., wherewith 
 occasionally the hypochondriacal frame of mind begins to disappear. 
 Sometimes also symptoms of apoplexy, of paralysis, develop themselves ; 
 or the insanity may gradually assume another form, particularly that of 
 partial dementia with depression. 
 
 Eecovery is not unfrequently obtained by moral treatment, but alsa 
 by removal of all physical causes ; the hypochondriacal symptoms have 
 also been observed to disappear with the accession of a fit of gout or of 
 intermittent fever. 
 
 Examj^les of simple and complicated cases of hypochondria of various 
 modes of origin, appearance, and termination. 
 
 Example VII. — Simplest case of hypochondria, cured hy moral treatment. — 
 Mademoiselle H — , set. 2\, naturally of a very strong constitution, regular in her 
 menstrual periods, though the flow was somewhat scanty, and presenting no 
 other deviation from perfect health than a continual and habitual constipation, 
 suddenly lost her usual cheerfulness and completely secluded herself. In vain, 
 for a whole year, was she Implored to explain this sudden change. At last the 
 patient admitted her physician to her confidence, and vowed to him with great 
 bashfulness the cause of her misery. She complained that she felt a continued 
 pain in her right hip, a feeling of uneasiness there, upon which all her thoughts 
 were concentrated. Having examined this region, the physician was unable to 
 discover anything that would account for this sensation of which the patient 
 complained; when she all at once burst into a fit of weeping, and declared that 
 she would very soon die, and that she felt convinced her bowels were about to 
 escape from her half -open abdominal parietes. The physician was careful not to 
 impugn this foolish notion altogether, but informed his patient that the muscular 
 covering of the abdomen was sometimes somewhat weak in this region, as in her 
 case, and that to remedy this weakness it was only necessary to wear a bandage 
 round the part. The young lady adopted his advice, and with the use of the 
 girdle all these uneasy feelings completely disappeared; and, what is also worthy 
 of remark, the constipation which had so long and so obstinately persisted also 
 left her. (' Bulletin de Therapeutique,' 1842, p. 201.) 
 
 Example VIII. — Nervoufi temperament; hepatitis; hypochondria; death. — Mr. 
 M — was of a nervous excitable temperament; good-natured, sprightly, and en- 
 dowed Avith a vivid imagination, he devoted his utmost energies to his business. 
 He married at the age of thirty-one. Up to this time, everything had gone on 
 prosperously and happily with him. Though he endured suffering with the 
 utmost courage and magnanimity, yet the smallest trifles annoyed him, and he 
 could not rid his thoughts of them. 
 
 One year after marriage, he was attacked with a very severe and acute hepatitis. 
 The liver projected four fingers' breadth below the false ribs. (Eighteen leeches 
 ad anum.) The inflammation subsided, but with the return of the liver to its 
 natural size, the irritability of the patient increased; a mere nothing made him 
 impatient, and everything was a perpetual source of pain and annoyance to him. 
 The most gloomy apprehensions as to the nature of his liver complaint were 
 awakened in him. He began to think of obstruction and cancer, and looked for- 
 ward to a future of pain. In spite of this, his cure was complete; only there 
 remained a greatly increased nervous sensibility, a tendency to exaggerate 
 everything, and his temper became extremely variable. 
 
 At one time he was gay and cheerful, as formerly ; and at another, choleric 
 and fiery, without any perceptible cause. Changes of temperature had a marked 
 influence on him. In his iiioments of bad humor, he suffered pain in all parts of 
 his body, according as his attention was directed to them. But he complained 
 almost constantly of a pain in his right hypochondrium, which he ascribed to 
 
STATES OF MENTAL DEPRESSION. 153 
 
 his liver. His digestion was often faulty, and he had distinct epigastric pulsa- 
 tion. He now believed himself attacked by a fatal gastritis. A tickling in the 
 throat, with a slight dry cough, or the expectoration of some mucus, then 
 awakened in him the idea that he was consumptive. He took to reading 
 medical books, and imagined himself to be the subject of every disease he read 
 of. At the same time, he occasionally came to the conviction that all his sus- 
 picions were groundless, and he often had entire months of resj)ite from his 
 affliciion. 
 
 In the year 1831, the patient was attacked by a very serious fcA^er which 
 affected the mucous tissues, accompanied by great nervous irritation and violent 
 pains in the right shoulder. No sooner was he cured of this, than he complained 
 of greater pains, which recurred more frequently than ever. For this, a course 
 of mineral waters and travelling was prescribed. But any amelioration was con- 
 stantly broken in upon by new suiferings and new fears, which very soon 
 reduced him to a perfect skeleton. 
 
 Some time after this, pains in the lumbar regions, a burning sensation in the 
 urethra and bladder, suggested to him the idea of catarrh of the bladder, or of 
 stone; and, in fact, he did pass some gravelly particles. From this time forward, 
 his phantasy left him no longer at rest. Incessantly occupied with his sufferings, 
 which were much exaggerated by the attention paid them, and by the careful 
 manner in which they were analyzed, his temper became more and more irrita- 
 ble, and he scarcely ever had one moment's peace. Sometimes he gave himself up 
 to a sort of rage and despair, but more often he sank into a state of gloomy 
 depression, in which he fancied that his end was at hand, and that he was to be 
 cut off by one of the five maladies by which he was in turn afflicted. Thus he 
 became, latterly, in the highest degree eccentric and phantastic. Nothing pleased 
 him, everything was hateful to him. The most assiduous attentions were 
 ungratefully received by him, and he would weep over the misfortune that placed 
 him in such circumstances. Then he would ask his wife's pardon for all his 
 injustice to her, and again would take it into his head that she no longer loved 
 him; and this thought became a new source of disti'ess. 
 
 He now retired from business. By constantly pondering over his afflictions, 
 he increased still more the nervous irritability which gave rise to them. He con- 
 sulted all the physicians that were suggested to him, and the desire to become 
 well urged him to follow their prescriptions most eagerly. He soon discovered 
 the inefficiency of their remedies, which only inflicted upon him renewed pain. 
 The disappointment of his hopes tended to incite his delusive imagination, to 
 increase his nervous excitement and undermine his strength. In 1834, he was 
 again attacked with a fever, which attached itself principally to the mucous tis- 
 sues, during which his temper was almost unbearable. He, however, rallied, but 
 without any alleviation of his nervous sufferings. Perpetually tormented with 
 his peculiar phantasies, he tot)k it seriously into his head that he was a martyr to 
 stone in the bladder, and nothing would persuade him to the contrary. He per- 
 sisted in this belief, and set off to visit a celebrated lithotritist in Paris. The 
 examinations which he there underwent so irritated the urethral canal and the 
 bladder, that at the end of a few days the patient died. No autopsy was made. 
 (Brachet, ' De I'Hypochondrie,' Paris, 1844, p. 29.) 
 
 Example IX. — Weakejied constitution and melancliolia from vioral causes; 
 
 recovery through satisfaction of a passion. — Madame , get. 26, of great mental 
 
 and physical sensibility, was the mother of three children. Her health was good, 
 until the persevering attentions of a visiting acquaintance completely gained her 
 affections. Filled with ideas of her duty, she resisted the seducing influence, and 
 kept the secret of a violent passion buried in her heart. This constraint gradually 
 affected her health: she began to suffer from palpitation, sensation of fulness at 
 the chest, and indescribable morbid symptoms. The appetite failed, the gastric 
 region felt painful, and stitches were felt in the side. To these actual sensations 
 were associated the most peculiar and sad ideas concerning her health. She 
 believed sometimes that she suffered from aneurism, sometimes from cancer of 
 the stomach, sometimes and most frequently from consumption. Indeed, a feel- 
 ing of tenseness, cough and abundant expectoration, feverishness and nocturnal 
 perspirations, had established themselves. The doctor suspected phthisis, and 
 sent the patient to the South of Europe. On her journey she consulted me. I 
 found her mental condition much affected, and her imagination seriously involved. 
 Her sufferings were, according to her own testimony, actually fearful; sharp, red- 
 hot irons were forced through her flesh, the fliires of which wei-e torn as if by 
 pincers. She did not, hower, complain much of the pulmonary organs. After 
 
154 STATES OF MENTAL DEPRESSION. 
 
 six months' residence in the South of France, she was neither bodily nor mentally 
 improved. The pulmonary affection seemed not to have extended, but her 
 imagination was far more disordered ; she exhibited a greater tendency to view 
 every tiling in its worst light; and on her return to Paris her state became still 
 worse. There she again saw the object of her passion, succumbed, abandoned 
 her husband and family, and fled with her seducer. 
 
 Six months afterwards I saw her again. I could scarely recognize her. 
 Beauty, freshness, and fulness were in the place of a condition bordering on 
 marasmus. There was no longer cough, expectoration, palpitation, gastric affec- 
 tion, pain, or any disease. The gratification of her passion had re-established 
 her health and dissipated the dark ideas of hypochondriasis. (Brachet, ' De 
 I'Hypochondrie,' p. 69.) 
 
 • Example X. — Hypochondriasis produced by a moral cause and nourished by 
 
 superstition; recovery by moral means. — A. M , an active and laborious but 
 
 very simple woman, injured her arm through a fall. A bone setter who was con- 
 sulted declared "the veins of the arm were too much disordered for him to cure 
 her completely." She now sought the aid of a physician; but as the arm still re- 
 mained uncured, she came to the conclusion that a vein in her arm might have 
 been broken, and that, owing to want of the vein, she would never again be able 
 to veork with it. 
 
 This sad idea constantly pursued her; she, in the most unhappy frame of mind, 
 complained to her friends of her fate. Some one advised her to lay the leg of a 
 frog on the spot where the vein was injured, and throw it afterwards into the 
 river. Wlien she had done this, she felt from that moment the roar of the water 
 in her head. Her sad and melancholy disposition had now reached the highest 
 degree; she believed that all her sufferings were a punishment from God, because 
 she had not prayed sufiiciently when she was a child, and reflected on her father for 
 not having more strictly enforced this duty. In order, however, to make amends 
 for her fault, she prayed day and night. 
 
 Her son, who was twenty -three years of age, a reader of religious books and of 
 irreproachable character, nursed and humored his mother with such diligence, 
 that his friends, anxious regarding the state of his health, sought to divert him 
 by bringing him into lively society. He was very bashful; and a lively girl hav- 
 ing grasped his arm with some force in order to make him sit down, he felt the 
 arm painful. When he got home, the mother's sorrowful complaints led him to 
 think that the same thing had happened to himself, and that he also had had a 
 vein broken. Next morning the pain was actually much more severe, and the 
 young man believed that he was less able to use his arm. He became every day 
 worse; he ceased to work, and felt assured that a vein was wanting; and by-and- 
 by it seemed to him impossible to use the arm in the least. The whole employ- 
 ment of mother and son consisted now in praying. 
 
 By constantly brooding over his state, the latter commenced to think that, 
 owing to the connection between the veins of both arms, the otlier would also 
 suffer — in a moment he became unable to move tho other arm, and in the course 
 of a year he fell into such a state of apathy that he had to be dressed and 
 undressed, as well as fed. In the case of the mother also, the melancholia and 
 the religious ideas inci-eased; she thought, as often as she lighted the fire, that 
 she lighted the flames of hell, etc., and her misery became so great that she 
 attempted to commit suicide. The son could only be weaned from the idea of 
 starving himself through the exhortations of a clergyman. 
 
 I found both individuals engaged in their only employment, viz., praying. 
 The young man held both arms straight downwards, with hands and fingers ex- 
 tended. He complained that he could not give me his hand, because there was a 
 vein wanting in his arm. He came nearer to me, and, after a minute investiga- 
 tion, I said to him that of course a vein was wanting, giving him at the same 
 time a positive assurance that I would help him. 
 
 I now ran my fingers up and down the arm in the direction indicated, and 
 stopping suddenly at the long nail of the thumb, hurriedly cut off the end of the 
 nail, together with a piece of the flesh, so that it bled. I tlien rubbed the arm 
 strongly with both hands, and exclaimed with a loud voice, "With God's help it 
 has succeeded — the vein is now there!" In order to convince him that the vein 
 really existed, he was shown the flowing blood, and he was immediately compelled 
 to make certain movements. 
 
 But, as the mother remonstrated that the recovery of her son was not yet 
 possible, because he still bore the mark of daiiniation (namely, black dirt upon the 
 <;hest), this was imine<liately rubbed off and liis skin cleansed. The son now, after 
 
STATES OF MENTAL DEPRESSION. 155 
 
 some religious exhortation, shook hands with the bystanders, put off and on his 
 clothes, and on the following day commenced to work by thrashing some corn. 
 The mother, too, convinced of the actual recovery of her son, again resumed her 
 diligent habits, and both are now bodily and mentally well. (Berlyn, in Nasse, 
 'Zeitschr. f. Psych. Aerzte,' ii., 1819.) 
 
 Example XI. — Heart disease, hypochondriasis, several feigned operations 
 xvithout decided result; feverish state; recovery, relapse.— Lucy M— , a3t. 50, with 
 no hereditary disposition to insanity, was chlorotic at 14, married at 22 (two 
 abortions and eight ordinary births). During her second pregnancy, she was 
 seized with violent headache, with vertigo and delirium, which ceased at her 
 confinement. For the last twenty months she has not menstruated. In Decem- 
 ber, 1839, she was seized with a general feeling of ill-being, with pains in the 
 gastric region, beatings in the whole body, and nervous attacks. During her 
 residence in the hospital, the patient suddenly remembered of having drunk out 
 of a well in which there were three spiders. From that moment she felt convinced 
 that she had swallowed them, and fell into the most violent agitation, owing 
 to which she was on the 11th February, 1840, removed to the lunatic asylum at 
 Tours. 
 
 She complained of formication and smarting over all her body; stitches and 
 beating at the breast, stomach, abdomen, and limbs; ringing of the ears, sleepless- 
 ness, vertigo, and peculiar dreams. The course of her thoughts was regular, and 
 her answers correct; but so soon as she referred to the subject of her delirium, 
 she became agitated, and spoke not only of spiders which inwardly pained her, 
 but of demons, serpents, and beasts of all descriptions which gnawed at her. 
 There was slight hypertrophy of the heart, and a bruit with the first sound; the 
 pulse was hard (calming remedies, digitahs). Constant restlessness, and doubts 
 concerning the possibility of recovery (gamboge). In the stools excited by this 
 remedy, three spiders were secretly placed, which the patient was allowed to dis- 
 cover; but she at once replied, "These are the old ones; they have left their young 
 behind— I feel them in my bowels." The same contrivance was twice repeated; 
 but the patient felt certain that the spiders multiplied tremendously, and were 
 now in her body from head to foot. Every attempt to convince her of the error 
 of her idea was met with threats and abuse. 
 
 It was now proposed to her to have an operation performed, through which 
 all the spiders must certainly be removed. She received the proposal with joy, 
 longed for the hour of the operation, and spoke of her recovery with hope and 
 confidence. The operation was performed with great solemnity, in presence of 
 several physicians, in order to make an impression on the imagination of the 
 patient. It consisted in a slight incision of the skin of the back, and several 
 spiders which were held in readiness were allowed to run about the bed, she 
 believing that they were taken from her body. She said that she felt their 
 removal distinctly, and rejoiced at the result. These small incisions were fre- 
 quently repeated in all parts of her body. At this time she took intermittent 
 fever (quinine, antispasmodics), was always excited, felt insupportable pain over 
 the whole body, and constantly begged for new operations. Once she attempted 
 to tlirow herself from the window, but without doing herself any injury; at 
 another time she attempted to strangle herself. Finally, it was declared to her 
 that now there were no more spiders in her body; and to convince her of this, 
 two new incisions were made, the oesophageal sound used, and purgatives 
 administered. On September 9th, she still attributed certain physiological 
 phenomena to the presence of the spiders— the rising and falling of the larynx, 
 the arterial pulse, etc. She was, however, soon convinced that these appear- 
 ances were present in all men. There now appeared a feverish state, with bead- 
 ache and ringing of the ears; and on the 18th September, all the symptoms had 
 disappeared. 
 
 The patient now became completely quiet, happy, and thankful, and was 
 employed in the kitchen. The news of the death of her husband, which was 
 rashly told her, vexed her very much, but in no way disturbed her mental health. 
 During the next winter, however, which was very severe, living in the most 
 indigent circumstances, and struggling against cold and hunger, she suffered a 
 relapse, accompanied with violent palpitation, agitation, mania, and attempt at 
 suicide. The patient was no longer treated according to her false ideas, but 
 gradually recovered under simple nutrient treatment, affusions, baths, narcotic 
 and aperient medicines. (Charcellay, ' Annales Med. Psychol.,' ii., 1843, p. 485.) 
 
156 STATES OF MENTAL DEPRESSION. 
 
 Sectioj^ II. — MelmichoUa in a more Limited Sense. 
 
 § 116. Anomalies of self -consciousness, of the desires, and the will. 
 — In many cases, after a period of longer or shorter duration, a state of 
 vague mental and bodily discomfort, often with hypochondriacal perver- 
 sion, depression, and restlessness, sometimes with the dread of becoming 
 insane, passes off, a state of mental pain becomes always more dominant 
 and persistent, but is increased by every external mental impression. This 
 is the essential mental disorder in melancholia, and, so far as the patient 
 himself is concerned, the mental pain consists in a profound feeling of 
 ill-being, of inability to do anything, of suppression of the physical 
 powers, of depression and sadness, and of total abasement of self -con- 
 sciousness. So soon as this condition of the sensorium attains a certain 
 stage, the most important and wide-spread consequences, as regards the 
 demeanor of the patient, result. 
 
 The disposition assumes an entirely negative character (that of abhor- 
 rence or repulsion). All impressions, even the slightest and formerly 
 most agreeable, excite pain. The patient can no longer rejoice in any- 
 thing, not even the most pleasing. Everything affects him uncomfort- 
 ably, and in all that happens around him he finds new sources of pain. 
 Everything has become repulsive to him; he has become irritable and 
 angry. Every trifle puts him out of temper. The result is, either per- 
 petual expressions of discontent, or — and this is more common — he 
 endeavors to escape from all outward mental impressions, by withdrawing 
 himself from the society of men, and, completely idle and unemployed, 
 seeking solitude. This general feeling of aversion and indifference is 
 often expressed by a dislike towards those by whom he is surrounded, his 
 family, friends, and relatives, which often merges into absolute hatred — 
 by a complete and unhappy change in his character. 
 
 We may sometimes observe in individuals apparently healthy (partic- 
 ularly among females) a similar though much more chronic state of 
 habitual perversion of sentiment, accompanied by a capricious and morose 
 disposition, with a tendency to contradiction and ill-nature. Neverthe- 
 less, it is very rarely that this is regarded as a morbid state, even although 
 it differs widely from similar evil dispositions which we see sometimes 
 displayed in those who are perfectly healthy, — through its frequent origin 
 from palpable diseases, through its frequent remissions, which are explic- 
 able by no well-grounded mental motive, and through the fact that at 
 times the patient feels himself constrained to yield to the evil disposition 
 in direct opposition to the dictates of his conscience and his will, and 
 although he is perfectly aware that such conduct is most unwarrantable. 
 
 In simple melancholia we frequently find a condition of the sensorium 
 precisely analogous to that which we have described under the head of 
 Hypochondria, in which the objects of the outer world, although they 
 come into consciousness through the medium of the senses, and are in- 
 deed properly understood and recognized, still they produce an impression 
 utterly different from what they were wont to do, of which the intelligent 
 and educated sufferers can alone give a true description. ''It appears to 
 me," says such a melancholic, "that everything around me is precisely 
 as it used to be, although there must have been changes. Everything 
 around me wears the old aspect, everything appears as it was, and yet 
 there must have been great cluinges.''etc. This confounding by the 
 
STATES OF MENTAL DEPRESSION. 157 
 
 patient of the subjective cliango of exterior things, and then objective 
 change, is the commencement of tliat dreamy state, in which, when it 
 has attained to a tolerably high degree, it appears to the patient as if the 
 real world had actually and completely vanished, — that it has sunk, dis- 
 appeared, or is dead, and all that now remains to hini is an imaginary 
 Avorld, in tlie midst of which he is perpetually tormented by finding that 
 he has still to live. 
 
 At 'he jeginning of this state the patient is perfectly cognizant of the 
 change vhich has taken place in his moral nature, in all his feelings and 
 affections. Sometimes he seeks to hide it, and the inquiries concerning 
 the cause of his peculiar behavior weary and annoy him. He feels that his 
 former enjoyment in everything that was honorable and estimable is fast 
 passing into indifference and actual repugnance. He even complains 
 himself that his sensations are no longer natural, that they are perverted, 
 and vhen his evil genius constrains him to regard the worst side of the 
 world, a new source of pain and sorrow is presented to him, viz., that he 
 can rejoice about nothing, and must oppose everything. The unwonted 
 impressions from the outer world excite his astonishment, grief, and 
 fear. He feels himself excluded from his former intercourse with society; 
 and this feeling of isolation, this exceptional position in which he finds 
 himself, favors, on the one hand, the limitation of all ideas concerning 
 the relation in which he stands to the world, and the relation of external 
 objects to himself. On the other hand, there proceeds from this feeling 
 of isolation, distrust, anxiety, and fear of all possible evils — sometimes a 
 feeling of hatred and revenge towards the world, but more often a power- 
 less, helpless withdrawal from society and concentration in himself. 
 
 That which weighs most heavily upon the mind of the patient at the 
 commencement of his trouble, is that feeling of change which has taken 
 place in his own personality, that vagueness and obscurity arising from 
 this undefined feeling of annoyance. Yet at this stage he is sometimes 
 perfectly aware that his fears are absurd, and that those uneasy thoughts 
 which force themselves upon him are utterly false; and he is even con- 
 scious of his own actual state. But then, he perceives that it is impossi- 
 ble for him to feel, to think, to act otherwise than he does, — that he 
 cannot resist, and how useless every effort at resistance is; then he 
 receives from his overcoming of the Ego (§ 22) the idea of being ruled, of 
 being irresistibly abandoned to some foreign influence, to which, after- 
 wards, ideas of being governed by evil powers, of secret direction of the 
 thoughts, of demoniacal possession, etc., correspond. 
 
 The limitation of the will, which is one of the fundamental disorders 
 of melancholia, is manifested by inactivity, cessation of all employment, 
 constant doubt and irresolution, incapacity of decision, and abscence of 
 will. In the higher degrees, it shows itself in actual torpidity and dul- 
 ness of feeling, inasmuch as impressions are no longer followed by a 
 reaction of the will; in the more moderate degrees, as slowness, monotony, 
 hesitation in movement and action, feeling of incapacity for the slightest 
 mental exertion, lying in bed, etc. 
 
 Frequently there are sensations of intense anxiety, which often appear 
 to spring from the epigastric and cardiac regions, and to mount upwards. 
 " Here," say many of these patients, pointing totheepigastiium — ''here 
 it remains like a stone: would that I could get rid of it!" These feelings 
 of anxiety sometimes increase to such an extent as to be almost unbear- 
 able; thus driving the patient into a state of despair, whicli generally 
 passes into an attack of mania. Moreover, these states manifest them- 
 
158 STATES OF MENTAL DEPKESSION. 
 
 selves externally in many various forms, accordino- to the former disposi- 
 tion of the patient, the moral causes, and accomiuiaying physical anoma- 
 lies, etc. ; at times, with the outward signs of grief and care, or as silent 
 melancholy, as self-concentration, or a dull, passionless, reserved bearing; 
 sometimes as loud self-accusation, with weeping, wringing of the hands, 
 and great restlessness; sometimes as morbid peculiarity and intractable 
 obstinacy; or, finally, as a tendency to lay violent hands on self. 
 
 There are some melancholies who are always discontented, and whom 
 nothing pleases; others to whom everything is alike indilferent, because 
 their attention is completely absorbed in the contemplation of their own 
 misfortune; and others who maintain that for them ''everything is too 
 good, and they cannot understand how it is that people do not despise 
 such miserable creatures as they are." 
 
 All these varieties in the disposition of melancholies are at the com- 
 mencement generally unaccountable, and do not depend on certain defi- 
 nite delirious conceptions; tlierefore it is that the patient himself is also, 
 at this stage, perfectly incapable of giving any statement which might 
 account for his present condition. ''I am afraid," says such a patient; 
 and if asked Avhy, he can only reply, *' I don't know, but I am afraid " 
 (Esquirol). Hence, we are constrained to come to the conclusion — which 
 indeed, observation has led us to, and serves only every day to confirm — 
 that exhortations, solicitude, and argument have not the slightest effect 
 iipon this state of depression, engendered by some cerebral lesion; and that 
 the ideas which conduce to the development of this state must have an 
 internal, subjective origin, and therefore a character of irrefutability, so 
 that they render the patient wholly impervious to anything like argu- 
 ment, and at best only permit him to exchange one mournful train of 
 ideas for another. 
 
 § 117. Anomalies of the mtellect. — The painful concentration of the 
 mind represses the vivacity and the natural course of the thoughts. A 
 few ideas occupy the mind of the patient, and all that he gives utterance 
 to is a few monotonous complaints regarding himself, and of the sad change 
 which has come over him. Or, he continually reverts to certain events 
 which happened about the commencement of his illness, etc. All desire 
 for intellectual intercourse with his friends is generally very much dimin- 
 ished. The patient often sits perfectly mute, or at best speaks timidly, 
 with hesitation, in a low tone, frequently interrupting himself. One 
 melancholic who was under my charge preserved an inviolable silence for 
 several years, and it was only from his physiognomy that we learned his 
 ruling disposition, for it expressed most unequivocally intense anxiety and 
 sadness, while at times he would weep and wring his hands. In other 
 cases the patient bewails himself, heaves deep sighs, and is engaged in 
 prayers and supplications, but always on the same subject; yet, in spite 
 of the extraordinary monotony of his intellectual life, he never becomes 
 a prey to ennui. 
 
 Together with these formal disorders, there now appear false ideas 
 and judgments, corresponding to the actual disposition of the patient. 
 Thus, for example, he feels that he is in a state of anxiety of mind exactly 
 similar to that which a criminal is likely to experience after the perpe- 
 tration of some misdeed, and so he believes that he, too, has committed 
 some crime; and from this predominating idea he cannot rid himself. 
 But as in the review of his life he is unable to recall what this crime is, 
 he fixes upon some insignificant event, when he has committed some tri- 
 vial fault, some petty carelessness (or perhaps he may not even be guilty 
 
STATES OF MENTAL DEPRESSION. ] 59' 
 
 of that), and this unfortunate occurrence beconies the subject of bis de- 
 lirium. In it he discovers the cause of bis present misfortunes, and his 
 fears for the future. Sometimes he feels himself the prey of some unde- 
 fined torment, and imagines himself encompassed with enemies. Soon 
 he actually considers himself persecuted, surrounded by foes, the subject 
 of mysterious plots, and watched by spies; and as he connects everything 
 with himself, the most insignificant matter tends to nourish his delirium. 
 
 Again, the patient who formerly cherished religious ideas feels how 
 profoundly he has changed in regard to this train of thought; how this 
 state of anxiety and uneasiness renders him totally incapable of reflection; 
 how, consequently, he is unable any longer to pray, or at his devotions 
 he is assailed by unhappy negative ideas. He feels that the church and 
 all other external objects give rise in him merely to painful impressions. 
 Thus he seems, in his exceptionable position, like a castaway whom God 
 has given up and abandoned to the devil and to eternal damnation. 
 Soon he comes actually to believe that he has indeed committed grave 
 faults, innumerable sins, and that he has entirely neglected his duties, 
 etc. Hence we see that it often depends upon chance, upon which par- 
 ticular thoughts or ideas the patient attaches so much importance that 
 they recur to him as fixed or partially fixed delusions. 
 
 All these melancholic insane ideas have one essential character, that 
 of passive suffering, of being controlled, and overpowered. But we can 
 readily discern how very various must be the special subjects of these 
 ideas, according to the amount of education and the character of each 
 individual, their antecedent history, and the impressions which have been 
 accidentally made. The same feeling of loss of self-control, of being given 
 over to foreign and peculiar sensations and ideas, which awaken in tlic .- 
 credulous peasant the idea of being bewitched, may in the better educated 
 call forth the idea tluit some one is acting upon him by means of electri- 
 city, magnetism, or chemistry. To the one it seems as if he has lost all 
 his most cherished goods, his children, his relations, and his fortune. 
 This he firmly believes, and fears that nothing now remains for him and 
 his family but to die of starvation. Another imagines that he has become . 
 bankrupt, that his business has gone from him, that he is mixed up in 
 the most serious and criminal offences, and ceases not to bewail that he 
 has reduced his family to the most abject poverty and beggary. At 
 other times it seems to the patient, when he feels the ciiange which has 
 occurred in his whole mode of sensation, and experiences the impos- 
 sibility of maintaining his ordinary share of worldly duties and employ- 
 ments — imagines that he can no longer be a man — that he is gradually 
 becoming like one of the lower animals, or that he is even already trans- 
 formed into a beast. As the change in the patient's views of life and 
 morals in general usually gives to the insanity a certain color and expres- 
 sion, so long as the natural sensations continue the same, and the general 
 relations of love of family, interest, friendship (emotions which in all 
 times most actively bear on the human heart) remain, so also the deli- 
 rium of the melancholic presents various phases at different epochs. 
 The fundamental disorders of the self-sensation are, however, always the 
 same, whether the melancholic believes, as in the days of old, that Atlas, 
 becoming fatigued with his burden, may at any moment let the arch of 
 heaven drop; or whether he imagines, as in the middle ages, that he 
 is under the power of sorcerers, ghosts, and witches; or, as in our times, 
 that he is sought after by the police, or tliat he is engaged in the most 
 disastrous speculations, etc. 
 
160 STATES OF MENTAL DEPRESSION. 
 
 As to the manner in which this delirium is brought about, we have 
 already several times pointed this out. The patient experiences a feel- 
 ing of sadness. At first these fits of sadness are only produced under the 
 influence of vexatious causes; but the law of causality demands even here 
 .some motive, some cause for this, and before the patient has had time to 
 inquire into the rationale of it, there arise as answers all sorts of mourn- 
 ful thoughts, dark presentiments and apprehensions, over which he broods 
 and ponders until certain ideas have become strong and persistent enough 
 to be, at least for the time, fixed. Thus these delirious conceptions again 
 possess the essential character of aiienipts at explanatioii of the special 
 state. 
 
 At the commencement, and in many cases even during the entire course of 
 the melancholia, there may be no delirium, properly so-called. The patients may 
 be able quite correctly to realize their own condition and the things of the exter- 
 nal world; to analyze their sensations with precision, and anxiously desire to free 
 themselves from them, but to do this is absolutely beyond their power. 
 
 A mongst the most marked cases of melancholia, there is one most important 
 distinction to be made, viz., whether the patients appear to be, as it were, in a 
 profound dream, or whether all their transactions with the outer world are car- 
 ried on as if they were quite awake. Cases of tlie first class ordinarily assume a 
 more acute character, and more nearly approach that form known as " melan- 
 cholia with stupor," the prognosis of which is much more favorable than that of 
 those which fall under the second head, which usually develop themselves slowly, 
 and are much more chronic in their course. The first class of cases may termi- 
 nate very speedily, as if the patient had suddenly wakened up; the latter never 
 do this. 
 
 § 118. Anomalies in the sensibility and movement frequently accom- 
 pany these mental disturbances. These are at times indicated (as already 
 mentioned, § 49) by sensations of emptiness in the head, of deadness in 
 the head, or of some other member, or even of the whole body; some- 
 times by these annoying sensations experienced over the whole surface of 
 the skin, and suggest to the sufferer the idea that some one is electrifying 
 him; or, finally, by hyperaesthesia of the sight and hearing (trembling, 
 starting at the slightest noise — perhaps a fundamental cause of the so- 
 called panphobia). 
 
 The special insanity of the senses, the hallucinations and illusions, have 
 quite the character and impress of painful emotional perversion. The 
 patient sees the preparations for his punishment — he hears the messengers 
 of justice who have come to seize him — he perceives himself surrounded 
 by the flames of hell — precipices appear to open under his very_ feet — 
 spirits come to annonnce to him that he is about to judged — he is pur- 
 sued by voices Avliich address him in the most abusive and niocking 
 language, etc. A young melancholic who was under my observation, one 
 day saw the head of a pig staring at her as she looked into the mirror; 
 and for long after she continued to fancy that she herself had been trans- 
 formed into such an animal. Hallucinations are most common and 
 most varied in that very serious form of melancholia, in which the patient 
 continually broods over his own misfortune, and is wholly wrapt up in it; 
 and wliere there is a partial suppression of consciousness of what is going 
 on in the external world (see under the head "Melancholia with Stu- 
 por "). We often meet with hallucinations of taste and smell, the for- 
 mer particularly, when the patient, perceiving a metallic taste in all he eats, 
 has the idea thus suggested to him that some one is endeavoring to poisou 
 him, or that a charm has been wrought upon his food. The subjective 
 
STATES OF MENTAL DEPRESSION. 161 
 
 Tinpleasant odors lead him to imagine that he is surrounded by dead bod- 
 ies, or that he himself is in a state of putrefaction, etc. 
 
 With the appearance and increase of the hallucinations, the patient 
 commences to act entirely according to imaginary relations, and conse- 
 quently becomes more and more estranged from the world. These hallu- 
 cinations often serve as the object of new explanations, and the most 
 gloomy and absurd ideas of worlds of spirits, of machines below the earth, 
 which exert their influence upon these unfortunates, etc., take their ori- 
 gin in these perversions of the senses which often only manifest them- 
 selves long after the commencement of the disease, or which may even 
 never give any outward sign of their presence. 
 
 The movements of the melancholic bear the impress of the ruling pain- 
 ful emotions. Generally they are languid, feeble, or constrained. The 
 patient gladly rests in bed, or keeps the whole day to one corner, where 
 he sits without taking the sliglitest notice of anything that is going on 
 around him. Often he sits absolutely motionless, as immovably fixed as 
 a statue. In such cases the limbs are perfectly stiff, and offer consi- 
 derable resistance to any attempts to give them another position; or else, 
 on the other hand, they are abnormally flexible and mobile, and often 
 retain the position in which they have been placed (cataleptic states). 
 The muscles of the face are sometimes the seat of a permanent contrac- 
 tion, the features are fixed, the eyebrows wrinkled, the angles of the 
 mouth drawn down. All this, joined to the generally grayish livid tint 
 -of the skin, gives to these melancholies almost invariably the appearance 
 of great age. The eyes are always cast downwards, or, on the other 
 hand, widely open, and fixed with the expression of suffering, of painful 
 tension, or of astonishment. 
 
 An essentially different deportment is presented by movements in 
 that form of melancholia where the inner disquietude is also expressed 
 by physical restlessness (melancholia agitans), in which there usually is 
 a confused tumult of thought. In essentials, however, these are cer- 
 tainly very monotonous and of small variety ; and it is through this 
 paucity of ideas, this want of fertility, that this state differs from mania.' 
 At other times, the patient keeps up a perpetual motion, often breaks 
 out into fits of weeping, and constantly wrings his hands. Not unfre- 
 quently, hemanifests a great desire to wander about at liberty, to make 
 long excursions, and to visit his friends and relations (melancholia erra- 
 bunda). Often while walking he wrings his hands, or, becoming violently 
 agitated, throws his arms into all manner of wild contortions. We may 
 quite correctly recognize in these two different modes of appearance of 
 the morbid mental pain, the analogues to the painful emotions of the 
 healthy : on the one hand, to the immobility consequent on shock or 
 fright ; on the other hand, to the physical restlessness and agitatation 
 (running about in the open air, etc.) observed in these in this frame of 
 mind. 
 
 Hie deviations from the normal standard of physical health are valueless for 
 the purpose of diagnosis of insanity in general, or of any one form of mental dis- 
 ease, but are of the highest importance so far as regards its etiology and treat- 
 ment. These deviations are by no means constant, and do not always present the 
 same relation to insanity. Sometimes they are merely the symptoms of some 
 malady which may have been in existence for a considerable time previously, 
 but wliich at the same time may have contributed somewhat to the production of 
 
 ' See Richarz, 'Zeitschr. f. Psychiatrie,'xv., 1858, p. 28. 
 11 J , , ,y 
 
162 BTATES OF MENTAL DEPBESSION. 
 
 cerebral disease {e. g. , arterial affections). Sometimes they are accidental com- 
 plications; at other times they form the symptoms — and these latter are by far 
 the most important — of the cerebral disease itself. To these latter belong par- 
 ticularly — 
 
 1st. The absence or diminution of sleep, so that the patient either remains quite 
 sleepless or feels so little refreshed by his sleep that he affirms that he has not 
 slept (this being, in fact, a prolonged internal wakefulness with drowsiness of the 
 sensorial functions). He often has disagreeable dreams, and frequently halluci- 
 nations occur at the moment of awakening. 
 
 2d. Painful sensations in the head; c. g., heat, pressure, weight, vertigo, a 
 feehng of emptiness, of water, etc.. in the skuU; a light-headedness like that of 
 drunkenness; noises in the ears; sensations similar to that of an aura; slight con- 
 vulsions of the muscles; wandering pains in different parts of the body — the chest, 
 vertebral column, epigastrium, etc., insensibility of some portions of the skin; 
 feelings as if this or that member no longer belonged to him, and a marked dimi- 
 nution of the sexual desires. Such are some of the principal symptoms which 
 indicate that some change has taken place in the action of the nervous centres. 
 These sensations often present the most marked correspondence to the mental 
 affection. For example, a young woman suffering from melancholia, aged thirty- 
 two, whom I Iiad an opportunity of observing in the year 1857, complained much 
 of neuralgic pains in the right side of the forehead, the right supra-orbital nerve 
 being peculiarly sensitive. Every day she had an attack, which began by a sort 
 of darting above the right eye, and then the whole head was immediately attacked. 
 in the same way; the tendency to melancholy increased rapidly, and the patient 
 became completely confused. 
 
 3d. Very often the digestive function is disordered, and, as in nearly all cases 
 of cerebral disease, constipation is present. This fact may lead to certain errors 
 in the etiology, the assumption of hypothetical stoppages or infarctus. while 
 every-day experience teaches us how easily derangements in the intestinal canal 
 are brought about in otherwise healthy individuals ^vhen any painful event 
 occurs. Occasionally, of course, especially at the commencement, we do find 
 some unmistakable signs of a gastro-intestinal catanh. Oftener, however, we 
 merely find the tongue loaded, and an abnormal appetite present — either much 
 decreased or (and this is more common) increased, and that to such an extent as 
 to suggest the idea that the sensation of satiety is utterly lost. The surprising 
 gluttony of some patients often forms a singular contrast, almost grotesque, to 
 their state of profound sadness. Thus we may see them hastily gorging huge 
 pieces of cake, and at the same time loudly bewailing their numerous sins, and 
 grieviog over the loss of their soul's salvation, or over temporal misfortunes. 
 The sensation of weight at the epigastrium which we have observed to be com- 
 plained of by a large number of such patients, appears to arise from the diaphragm 
 or the abdominal muscles. Beyond this we are as yet unable to go with our 
 explanation. This is to be regretted, because it often appears to maintain the 
 feelings of anxiety, and we might, by controlling it, essentially ameliorate the 
 condition of the patient. Thus, in the case of a young woman whom I saw in 
 1857, and who, after severe tartar-emetic treatment (for pneumonia), suffered for 
 a long time from symptoms of chronic ulcus ventriculi. The frequent fits of 
 acute melancholia, with tliis feeling of anxiety, accompanied by palpitation, 
 maintained a certain relation to overfulness of the stomach, errors in diet, indi- 
 gestion, etc. TJie refusal to take food, which is frequently observ3d in the case 
 of melancholies, and which, when long persisted in, becomes a troublesome com- 
 plication on account of the forced alimentation and consequent defective nourish- 
 ment, often arises from the fear which these unfortunates entertain of being 
 poisoned, or from various abnormal sensations which they experience in their 
 rtomach; as if their intestines were closed up, or there were no room for mora 
 bod; or as if appetite had completely left them. At other times they refuse to 
 >at, because they wish to die of hunger, or because tliey believe that by thus 
 starving themselves they can expiate their sins: or because of hallucinations, 
 such as the hearing of voices which command them not to eat, etc. These ideas 
 seem sometimes to be suggested and kept up by serious affections of the intestmal 
 mucous membrane, and particularly by an acute catarrh, extending over a great 
 portion of the intestinal tract. But this refusal of food is also not unfrequentlj', 
 as Guislain has judiciously observed (' Legons orales,' p. 265) only another form 
 of displaying their obstinacy — just as they refuse to speak. Or, lastly, it may be 
 the result simply of imitation. The immediate results of this prolonged absti- 
 
STATES OF MENTAL DEPKESSION. 163 
 
 nence are rapid emaciation, dryness of the skin, slowness of respiration, slugreish- 
 ness of the bowels, deficiency of urine. 
 
 4th The nutrition of the body frequently suffers. The patients become thin; 
 the skm loses its moistness and fresh appearance; it becomes pale, withers ami 
 dries up. In the normal state we do at times observe an analogous condition of 
 the skin as tlie result of harassing and sorrowful emotions; yet it has been most 
 justly remarked that the perversion of the feelings in melancholies never pro- 
 duces so profound an effect upon the constitution as severe and protracted emo- 
 tions certainly do in those who are in perfect health. This has been accounted 
 for by the fact that the majority of melancholies eat more and digest their food 
 much better than persons in health do when under the influence of profound sor- 
 row. But, on the otlier hand, when such patients nuist be fed by force, as when 
 they refuse their food, they sink rapidly into acute marasmus, often associated 
 with severe and fatal local maladies, e. g., lobular pneumonia, gangrene of the 
 lungs, etc. 
 
 5th. The respiration is frequently prolonged, incomplete, and difficult. The 
 patient is oppressed, and seeks to obtain air by means of deep sighs. Palpitations 
 of the heart are by no means uncommon, and often it is from this organ that 
 those sensations of anxiety proceed. We have already spoken of affections of the 
 cu-culation, and of their importance so far as regards the development and main- 
 tenance of cerebral disease, Tlie state of the pulse is extremely variable; it 
 is often very small and slow. The feet and hands are often constantly cold, par- 
 ticularly in those who never move about, when they may present a cyanotic or 
 leaden hue. 
 
 6th. Derangements of the menstrual function. Absence and irregularity are 
 very frequent. In some cases, with the re-establishment of the menses we see 
 the mental affection completely disappear; while in others it produces no effect 
 whatever, and even at times tends greatly to aggravate the disease (see § 108). 
 
 7th. Anomalies in the urinary secretion may be much more frequent than is 
 generally supposed. Unfortunately, any reliable researches on this important 
 subject are still wanting. The secretion of tears, in spite of the state of mental 
 sorrow under which the patient constantly labors, is very rarely increased. 
 
 Chronic affections of the viscera very often develop themselves during the 
 course of melancholia, as tubercles of the lungs, affections of the skin, chronic 
 intestinal catarrh, etc. These affections sometimes remain latent for a very long 
 time. When death results, it is generally in consequence of one of these diseases. 
 It is by no means rare to see a fatal issue when the patients refuse their food; and 
 in melancholia with stupor, death, independent of this circumstance, sometimes 
 supervenes in the midst of an access of the symptoms by an aggravation of the 
 cerebral torpor and paralysis, and sometimes at the autopsy in such cases consid- 
 erable oedema is found. 
 
 § 119. TJie Course of the simple forms of melancholia is often very 
 acute : thus, for example, in those cases where a very short period of 
 painful perversion of the feelings, accompanied with profound anxiety, 
 precedes the development of mania, particularly of intermittent mania! 
 Usually, however, the course of melancholia is chronic, with remissions j 
 more rarely with complete intermissions, of variable duration. I, have 
 once seen, in a woman attacked with intense melancholia (ideas of com- 
 plete loss of fortune, of forced starvation, etc. ), a complete lucid interval 
 of scarcely a quarter of an hour's duration supervening without any 
 issignable cause, and terminating quite as suddenly. Naturally, the 
 temissions are of more frequent occurrence at the commencement of the 
 jQelancholia, and also on the approach of convalescence. 
 
 Transformations into mania, and the passage from this again into 
 melancholia, are phenomena by no means rare. Sometimes the disease 
 represents a cycle of these two forms, which often regularly alternate with 
 each other— "la folic circulaire," which the French alienists have recently 
 been discussing. Other observers, including myself, have seen cases 
 where regularly at one particular season— for example, in winter— a pro- 
 found melancholia has superverned, which in spring passes into mania, 
 which again in autumn gradually gives way to melancholia. 
 
 r 
 
164 STATES OF MENTAL DEPRESSION. 
 
 The name " folie circulaire" was employed for the first time by Falret (1851), 
 who has most correctly brought before the world the extreme gravity of this 
 form of mental alienation. Baillarger (' Ann. Med. Psych.' 1854, vi., p. 369) took 
 much trouble to explain that in " folie circulaire" there are not two different 
 attacks — one of melancholia, another of mania — but that both are mei'ely two 
 different stages of one and the same attack; chieflj' because of the fact that 
 between the melancholia and the mania there is no complete remission. This 
 author gives to this affection the name of "la folie a double forme." In some 
 cases there has been observed, and this too during a continuance of several years, 
 a regular alternation, lasting for a day or for several days, between melancholia 
 and mania. 
 
 A very moderate degree of melancholia with considerable remissions 
 may persist for many years. Snch patients very rarely come into asylums, 
 or at least only during an exacerbation or an intercurrent attack of mania. 
 They may generally be maintained in their ordinary rehitions, and are 
 torments to those who surround them, and objects of the most varied 
 mistaken speculation on the part both of pliysicians and of the laity. 
 
 The persistent foi-m of melancholia, when of moderate intensity and 
 properly treated, lasts usually from six months to a year. Judging from 
 a considerable number of observations, we may almost regard it as certain 
 that acute intercurrent diseases, as well as newly developed chronic ones, 
 frequently exert a favorable mfluence upon tlie melancholia, as it usually 
 desists with their api)earance. To the former chiss (acute) belong, for 
 example, salivation, the development of an exanthem, intermittent fever ; 
 and to the latter pulmonary tubercle. At all events, however, we must 
 not look upon these facts as having the significance of crises in the old 
 sense of the term, since certain neuroses (such as spinal affections, 
 violent toothache, etc.) certainly do moderate, and sometimes even cause, 
 tlie disappearance of the cerebral disease.' 
 
 But what is certainly as frequent as the disappearance of the melan- 
 cholia on the accession of other diseases, is its persistence, or even its 
 increase; or the insanity may, with the cessation of the melancholia, 
 merely assume another form. Thus, for example, we have seen a young 
 man who for years had been afflicted with profound melancholia with 
 only slight remissions, in whom, upon the appearance of a severe catarrh, 
 accompanied by haemoptysis (the first symptoms of pulmonary tuber- 
 culosis, which rapidly progressed) and acute pain along the entire length 
 of the spinal column, the melancholia yielded to a gaiety, equally mor- 
 bid, and a restless cheerfulness. Such cases are far from rare. 
 
 Convalescence generally takes place gradually, with successive dimi- 
 nution of the symptoms, and of always more prolonged periods of calm; 
 return of former desires and peculiarities; frequently with simultaneous 
 improvement of the bodily health. 
 
 We have already seen that melancholia not unfrequently passes into 
 one of the forms of mania; but further, simple melancholia, or melan- 
 cholia Avith stupor, may also terminate by leaving the patient in a state 
 of intellectual weakness, a more or less exaggerated state of veritable 
 dementia. This is probably owing to the development of organic altera- 
 tions within the cranium. Although the patient may have regained his 
 physical vigor, yet the physiognomy wears an expression of heaviness and 
 stupidity. The sadness may have gradually disappeared, but the intel- 
 lectual faculties have lost their energy. Not unfrequently, there are also 
 developed states of more or less profound partial dementia, where the 
 
 ' See the cases of Brodie, already quoted alx)ve. 
 
I 
 
 I 
 
 STATES OF MENTAL DEPRESSION. 165 
 
 patient has some fixed delirious conceptions, particulurly certain halluci- 
 nations, through which he is led to believe that people desire to poison 
 liim, that he is the subject of various plots, or that he is constantly- 
 electrified, etc.; in which case the patient is almost always incurable. 
 Such patients, laboring under this partial dementia, states of mental 
 weakness, with the remains of melancholia (and mania) and hallucina- 
 tions, generally with numerous exacerbations, in the form of one or otlier 
 of the primitive states (apathy alternating with turbulence, a modified 
 sadness with a gaiety equally superficial, etc. ), constitute by far the ma- 
 jor portion of the chronic cases met with in asylums. We shall enter 
 more into detail on this subject when we come to consider partial demen- 
 tia and dementia. At first the condition frequently continues for a long 
 time stationary in the form of melancholia, varied only with slight 
 changes for the better, only again to relapse. At this period it is ex- 
 tremely difficult to say anything with certainty as to the curability of 
 such patients; but when this state of melancholic apathy continues for 
 three or four years consecutively without remission, recovery is extremely 
 rare. 
 
 Examples of simple forms of melancholia terminating in recovery: 
 
 Example XII. — Hypochondria, profound melancholia, intermittent fever; 
 recovery. — N. N — , a parish miuister, get. 43, of strong constitution, was in 
 August, 1825, received into the asylum at Siegburg, he having been taken ill 
 in March of that year. The chief symptoms had hitherto consisted in an expres- 
 sion of great anxiety and restlessness; amazed, sceptical glance: pale counten- 
 ance; short reapiratiou, and small and rapid pulse. He accused himself of hav- 
 ing spent a disgraceful life, and of serious misdemeanoi's. In some lucid moments, 
 liowever, he could correctly appreciate his condition (bleeding, blisters, nitre, 
 emetics, and use of feriiiginous water). 
 
 On admission, his glance was timid and unsteady; the expression that of 
 anxiety and doubt; the abdomen distended; the bowels constipated, and skin of 
 an earthy hue. The patient declared tliat he was torn, crushed, and hewn 
 to pieces (cream of tartar with sulphur, light mental employment). 
 
 In September, the patient became gi-adually quieter, and showed less inclina- 
 tion to complain of his sorrowful feelings. Soon he complained of weai'iness and 
 headache, and there now appeared attacks of intermittent fever of the tertian 
 type. On each feverish day he continued in the belief, until the sweating stage 
 came on, that he would immediately die, repeating this continually, with the 
 most intense expression of anxiety in his countenance and gestures. When it was 
 represented to him that he had said and believed the same thing on the preceding 
 fever-day, he replied, "It is quite different to-day; to day I must die." After- 
 wards the feverish attacks occurred daily, and the fear of death became less 
 intense. At last they spontaneously ceased, and with them disappeared also the 
 accusations, which had now become less violent than formerly, but were still fre- 
 quently repeated, which the patient made against himself of having committed 
 unpardonable crimes, and the presentiment of temporal and eternal punishment 
 which therefore awaited him. Only a certain degree of hypochondriacal self- 
 torment and excessive anxiety regarding the state of his physical health 
 remained, for a short time, behind. The pulse became regular; the oedema of 
 the legs (which came on during the last attack of intermittent fever) and the 
 earthy hue of the skin both disappeared. 
 
 He voluntarily and cheerfully engaged in some intellectual labor, became 
 happy and lively, and in January, 1826, left the asylum completely cured. 
 
 The following statements regarding the origin of his disease were written by 
 the patient after his recovery: " From my youth there existed in me a hypochon- 
 driacal state. Even before I entered the university I believed that I had con- 
 sumption, and the assurances of the physicians to the contrary were fruitless. 
 Many disagreeable events inspired me with di.strast towards men. and in 1820, 
 when I was condemned to inactivity on account of disease of the eyes, my ordi- 
 nary occupation consisted in thinking, the ideas being often very sad, and such 
 as could not fail to exert on me an unfavorable influence. In the year 1822 a fire 
 took place, and a thorough wetting, which I there received, when just convales- 
 
166 STATES OF ]VrENTAL DEPRESSION. 
 
 cent from an illness of several weeks' duration, made a most unfavorable im^ 
 pression on me. From that time the stools became less frequent, and diflficulty 
 of hearing set in. In 1824, I was oppressed with work, and very low-spirited; I 
 ceased to take exercise; household cares weighed heavily upon me, and I lost a 
 newly -born child. From that time forth I lost all cheerfulness and pleasure in 
 work. After preaching, I felt fatigued and exhausted; anxiety and sad ideas 
 came over me; my sleep was scanty and tormented by horrible dreams, after 
 which a violent shiver ran through all my members. Nevertheless, I considered 
 myself healthier than formerly; the dulness of hearing, pains in the limbs and 
 flatulence, from which I had hitherto suffered, became less troublesome, and I 
 had no disagreeable sensations after meals. It did not occur to me, therefore, to 
 seek the cause of my sad condition in my own body, but rather in my entire life, 
 which appeared to me to have been one great crime. This idea did not originate 
 gradually, l)ut entered, if I remember rightly, my mind all at once like a dream. 
 Thus I explain my entire state. This occurred in perfect clearness of thought, 
 confidence in others and in myself. The entire human race seemed to rise 
 up against me, to throw me from their midst with the most shocking torments, 
 and I myself was my greatest enemy. I acknowledged to my wife that I had 
 committed the most fearful crime that had ever been perpetrated, and would be 
 torn in pieces by my parishioners as soon as they became aware of it. Tlie per- 
 formance of my duties became impossible to me, and my anxiety constantly 
 increased. The leading members of my congregation gave me the best assur- 
 ances and propositions, but still I considered that all was lost; and one day when 
 I fainted at a meeting, I believed that I had done so willingly. I thought that 
 the noise of the stove was the beating of drums, and believed that soldiers were 
 coming to carry me off. Afterwards, it seemed as if a scaffold stood before me, 
 on which I should be torn in little pieces, and the fear of execution constantly 
 pursued me. The things around me appeared more beautiful and brilliant than 
 usual; all men seemed wiser and more clever; I considered myself in the deepest 
 depths, and no longer capable of performing anything. I sometimes, only for a 
 moment, believed that I nevertheless might still be delivered: and this feeling 
 was generally followed by great sadness. I cannot better describe my state, 
 towards the termination of the disease, than that of one who has awakened from 
 a profound dream, and cannot immediately convince himself that it has been a 
 dream." 
 
 (Much abridged from Jacobi, ' Beobachtungen iiber die Pathologie und Thera- 
 pie der mit Irresein verbundenen Krankheiten,' i., Elberfeld, 1830, p. 141.) 
 
 Example XIII. — Melancholia; recovery with the return of the menstrual dis- 
 chaige. — A young woman, set. 19 (whose mother had committed suicide during 
 an attack of profound melancholia), healthy and of joyful disposition, had men- 
 struated regularly since she was fifteen years of age, and from her sixteenth 
 year had suffered from leucorrhoea. Afterwards her feelings were affected by a 
 love affair which was not favorable in the circumstances, and by other events; 
 and she suddenly became ill in August, 1825. She presented a slight degree 
 of imbecility; frequently laughed without occasion: made all kinds of merry hits, 
 and was incoherent in her speech and actions. Her glance, expression, and 
 movements were lively and hasty; the belly distended, the bowels constipated, 
 menstruation scanty. In the course of a few months there appeared a complete 
 remission of the mental symptoms, but in six weeks the insanity appeared anew 
 under a different form. 
 
 The patient seemed a prey to melancholic anxiety, either sat dumb and 
 motionless and lost in thought, or weeped and sighed, occasionally exclaiming, 
 "What a misfortune! what have I done?" She refused food; her appearance 
 became altered; her former freshness was changed into an earthy hue; she 
 became wrinkled, and her strength left her. The beUy was hard and distended; 
 the stools were small and dry; the menses disappeared; the leucorrhoea continued. 
 After a time her appetite returned; she went to a trough containmg hen's meat, 
 or sought elsewhere raw and dirty food, which she secretly devoured. She soon 
 gained a little strength and bulk. 'but had a bloated and livid appearance. After 
 the mental disorder had continued for eight months without medical aid, the girl 
 was admitted in August, 1826, into the asylum at Siegburg. Excepting a some- 
 what scrofulous habit and the long-existing leucorrhoea, no symptom of bodily 
 disease could be observed. Her movements were without energy, her carriage 
 drooping, and she wept continuously all day long, and, indeed, drew such deep 
 sighs and made such lamentations, that it seemed as if every moment she met 
 with something terrible. She generally slept quietly during the night; she re- 
 
STATES OF MENTAL DEPRESSION. 167 
 
 quired to be somewhat pressed to take her food. The mental disorder in the 
 patient was now manifested principally by the exclusive governing mental dis- 
 position which ruled all her thoughts and paralyzed her will, without any other 
 mental confusion or any definite morbid direction of the desires being evinced. 
 The disordered digestion, the distention and hardness of the abdomen, together 
 with the amenorrhoea and fluor albus, appeared to afford the most important 
 therapeutic indications (mild and regulated diet, baths, occupation). A conva- 
 lescent attended to the patient with motherly care, gained her confidence, and 
 was of great benefit to her. 
 
 Towards the end of September the menses began to appear, but the abdomen 
 continued distended and hard. The patient gradually became calmer, wept less, 
 and ate voluntarily. In three weeks, the menses returned; the belly lost its hard- 
 ness; the bowels became regular; the wrinkles disappeared from her face, and the 
 expression became more cheerful. After the menses had again returned, on the 
 10th of November, her sorrow and tears left her. Employment was her only 
 pleasure; the fluor albus gradually disappeared; her health became gradually 
 more confirmed, and in April, 1827, she was dismissed cured. (Jacobi, loc. 
 cit., p. 198.) 
 
 Example XIV. — Melancholia, with tendency to suicide and hallucinations; 
 suspected nocturnal j)ollutions. Recovery in consequence of cauterizatio7i of the 
 urethra. — Emil G — , set. 23, showed formerly high mental attainments, and at the 
 age of twenty-one became an advocate. His figure was bent, the body lean, the 
 muscles soft, the skin colorless, the countenance void of expression, the eyes dull 
 and turned towards the ground; the voice weak, behavior timid, and the lower 
 extremities in constant motion. Although he spoke little and awkwardly, yet he 
 made the following clear statement in writing regarding his condition: — 
 
 After the patient had been addicted to onanism from his twelfth year, there 
 appeared at the age of nineteen a change in his character. At first there was a 
 gradual mental loathing at everything, a profound general ennui. Hitherto he 
 had seen only the bright side of life, but now everything was viewed from the 
 dark side, and soon the idea of suicide entered his mind. In a year after this the 
 idea left him, and he then considered himself the object of scorn by others. He 
 thought that everybody laughed at his appearance and his manners, and he 
 several times heard, as well in tbe streets as in the house amongst his relations 
 and friends, reproaches directed against him. At last he believed that aU the 
 world insulted him; if any one coughed, sneezed, laughed, put his hand to his 
 mouth, or a pocket-handkerchief before his face, it made on him the most painful 
 impression— sometimes angry emotions, sometimes deep depression and an invol- 
 untary flow of tears. He was indifferent to everything, and always engrossed 
 with his ideas; besought solitude, and society was painful to him. He owned 
 that he may have had hallucinations, but felt convinced that his ideas were not 
 without foundation; that his countenance was somewhat strange; that persons 
 could read in it his fears, and the thoughts which tormented him. 
 
 He now experienced a weight in his head, a sort of pressure on the brain; he 
 was weak, passionless, sleepy, and dull. Every movement fatigued liim, and 
 yet he had the constant desire to change his position. He felt that he had 
 become old; for the last few months his depression had been increasing; for the 
 past jive years nothing had made on him a cheerful impression, everything had 
 oppressed and annoyed him; he was anxious, bashful, perplexed, incapable of 
 acting or of speaking: "The Spirit of life has withdrawn itself from me." 
 
 For the past nine months, the patient had completely renounced the j^ractice 
 of onanism, and yet his condition became every day worse. 
 
 He had inveterate constipation; complete absence of erections and sexual 
 desires; about one to two pollutions in a month. The urine always contained 
 a copious flocculent sediment, like a thick decoction of barley, and decomposed 
 rapidly. After each stool, a viscid fluid, like thick gum, appeared at the orifice 
 of the urethra. The urine was voided frequently; tliere was irritability of 
 the seminal ducts, testicles, and particularly of the urethral mucous membrane, 
 and redness of the urethral orifice. Cauterization of the neck of the bladder and 
 prostatic part of the urethra was resorted to. This was followed by a gradual 
 improvement, which was furthered by continuous tepid baths. Complete recov- 
 ery and re-establishment of the sexual function resulted. — Lallemand, 'Des 
 Pertes seminales,' i., p. 357. 
 
 k 
 
168 STATKS OF MENTAL DEPKESSION. 
 
 § 130. The modes of expression of the mental pain experienced in 
 melancholia are so diverse and so multifarious, that, founding upon these 
 principal d\&erences, certai7i forms and varieties of melancholia have 
 been constituted. 
 
 In so far as the difference extends merely to the form and subject of 
 the delirium; which often agree with the most salient causes of the men- 
 tal affection, tlie classification of sucli varieties is of minor importance. 
 According to tliis view, we have to note the following chief sub-forms: 
 
 1st. Melancliolia religiosa is the name given to that form of melan- 
 cholia in which the delirium centres chieily upon religious ideas, the 
 patient's principal delusions being that he has committed fearful sins, the 
 terror of being punished by hell, and that he is a castaway, etc. It is 
 frequently owing entirely to external accidental influences that the inter- 
 nal feeling of anxiety is exhibited, as anxiety on account of sin; or that 
 the patient, in his mournful perversion, seeks the consolations of religion, 
 which here indeed have not the expected influence, but frequently only 
 result in increasing the anxiety. In such cases we must beware of con- 
 founding the effect with the cause. If it can scarcely be denied that 
 the constant calling forth of such ideas of contrition, and fears of the 
 punishment of hell, and particularly that gloomy and ascetic manner of 
 viewing the affairs of this world, do paralyze the energy of the soul, favor 
 the ascendency of mournful thoughts, and promote in weak minds a state 
 of moral distraction and sad emotion which may thus most essentially 
 contribute to the development of melancholia, still, in the vast majority 
 of cases, those religious delusions of the melancholic are to be regarded 
 as symptoms merely of an already existing disease, and not as the causes 
 of the affection. 
 
 This form of religious melancholia must be carefully distinguished from that 
 other form of insanity, in which the predominating delusions are also religious, 
 but assume a gay, audacious, and exalted form — where the patients imagine that 
 that they are either God himself, or are most intimately related to God, the 
 angels, and heaven. This form differs widely and entirely, in a psychological 
 point of view, from melancholia, and we shall speak of it when we come to con- 
 sider the foi'ms of exaltation in detail. 
 
 The symptoms are also similar in that interesting form of melancho- 
 lia in which the sentiment of being governed and overcome manifests 
 itself in the idea of demoniacal possession, the so-called demono-melan- 
 cholia, which is met with in all countries (in France, particularly, it is 
 by no means rare'), and of which recently, in our own country, ignorance 
 and the grossest superstition have used to the worst ends. 
 
 In this form, this foreign evil power by which the patient imagines 
 himself to be governed assumes different demoniacal shapes, according 
 to the prevailing superstitions and beliefs of the epoch and country 
 (devils, witches, etc.), to which, as he may probably at the same time 
 experience some abnormal sensations in different parts of his body, a 
 very limited seat is assigned by the patient, — sometimes one half of his 
 body — sometimes his head, his back, or his chest, etc. It is not uncom- 
 mon to see, along with this, convulsion of the voluntary muscles, con- 
 
 ' M. Macario," Etudes cliniquessurlaDemonomanie," ' Annal. Med. Psychol..' 
 i., 1843, p. 400: Esquirol, translated by Bernhard. i., p. 280. See also on this 
 subject — Calmeil. ' De la Folie.' Paris, 1845, i., p. 85; Albers, 'Archiv. f. Physiol. 
 Heilk.,' xiii., 1Hj4, p. 234; Portal. 'Mem. sur plusieurs Maladies.' ii., p. 110? 
 Moreau, ' Du Hachich,' etc., pp 336, 354; Baiilarger, 'Annal. Med. Psychol.,' vi,,. 
 p. 152; Schiitzenberger, ib., viii., p. 261. 
 
STATES OF MENTAL DEPKESSION. IC^ 
 
 tractions of the larynx whicli alter the voice in a striking manner, 
 anaesthesia of different important organs, hallucinations of sight and 
 hearing. This delirium is at times accompanied with intermittent 
 paroxysms of violent convulsions, evidently analogous to epileptic, or 
 still more frequently to hysterical attacks, which are separated by inter- 
 vals of perfect lucidity. 
 
 That form of melancholia in whicli the predominant delusion is that the sub- 
 ject of it is possessed by some demon, appears chiefly in females (almost always 
 hysterical women) and in children. The most easy explanation of this physio- 
 logical phenomenon is found in those by no means rare cases where the trains 
 of thought are always accompanied by a feeling of inward contradiction, which 
 quite involuntarily attaches itself to them, the result of which is ii fatal division 
 or separation in the personality. In the more developed cases, this circle of 
 ideas, which constantly accompanies and arrays itself in opposition to the actual 
 thought, asserts a perfectly independent existence; it sets in motion the mechan- 
 ism of speech, exhibits and clothes itself in words, and appears to have no 
 connection with the (ordinary) ego of the individual. Of this train of ideas 
 which acts independently on the organs of speech, the individual giving utterance 
 to them has no consciousness before he hears them; the ego does not perceive 
 them; they spring from a region of the soul which is in obscurity so far as the 
 ego is concerned; they appear to the individual to be utterly foreign, and are felt 
 as intruders exercising a constraint upon his thoughts. Hence uneducated persons 
 see in these thouglits the presence of a strange being. In some cases we find in 
 the extravagant discourse of these women or children a vein of poetry or irony 
 iitterly at variance with the opinions which they formerly most dearly prized; 
 but usually the demon is a very dull and trivial fellow. 
 
 Since the publication of the first edition of this work, I have had the oppor- 
 tunity of studying several cases of demonomania in various stages, of which I 
 shall here give tivo interesting examples. 
 
 Example XV. — Attacks of mental disorder, occurring every two or three days, 
 X>resenting particularly the character of ideas of opposition. — M. S — , a peasant, 
 aet. 54, had, when twenty -two years of age, every night for three mouths, an 
 attack of violent nightmare and hallucinations of hearing. At the age of thirty, 
 she gave birth to a child; the menses never reappeared, and severe hasmorrhoidal 
 disease of the rectum developed itself. The appearance of the patient is good, 
 and, on tactile examination, nothing more than slight anteflexion of the uterus is 
 found. Wlien she was between thirty and forty years of age, there gradually 
 appeared a disease occurring in paroxysms, and wiiich became more and more 
 fixed. The attacks occurred every two or three days, and in the interval the 
 patient was perfectly well. They commenced with pains in the head, loins, and 
 neck; palpitation, anxiety, great exhaustion; occasionally symptoms of globus and 
 hysterical convulsions. She was obliged to lie in bed, became completely apa- 
 thetic, could no longer connect her thoughts, and there was manifested, as a 
 mental anomaly, an internal contradiction against her own thoughts and con- 
 clusions a constant immediate opposition against all which she thought and did. 
 An inward "voice," which she, however, did not hear in her ear, opposed 
 everything which she herself would do (for example, even against the mere lying 
 in bed, which her condition renders necessary), especially, however, against all 
 elevation of the sentiments — praying, etc. The voice is always wicked when the 
 patient would do good, and sometimes calls to her, but without being heard 
 externally, "Take a knife and kill yourself!" The patient, who is a clever 
 woman, says on this subject, that she almost believes that a strange being, a 
 demon, is within her, so certain is she that it is not herself who does this. I 
 took the patient into the clinique at Tiibingen, and there had frequent oppor- 
 tunities of observing the attacks. During them she seemed much heated, con- 
 gested, had an obscure and confused expression, was not feverish (temperature 
 normal). The attack lasted from twenty-four to forty-eight hours. On one 
 occasion at the commencement, when the head was much congested, venesection 
 to a small amount was performed, which only temporarily relieved her. Th& 
 hsemorrhoidal affection was much improved by the use of an electuary of pepper, 
 but the attacks continue without change. (Original observation.) 
 
 Example XVI. — Chronic demonomayiia. — C. S — , an unmarried peasant, aet. 
 48. voluntarily presented herself at the clinique, because she was possessed by 
 spirits. Her father became a little strange as he advanced in years; her sister 
 
170 STATES OF MENTAL DEPRESSION. 
 
 and sister's son are insane. The patient had a child at the age of nineteen; she 
 nursed it for three years, and fell into a state of anaemia, with extended pains of 
 the limbs, and sometimes convulsions. For a long time she had convulsive 
 movements of the mouth. Three years after the first appearance of the disease 
 (about thirteen years ago), "the speaking out of her " commenced. From that 
 moment, all kind of thoughts or vt^ords were expressed unintentionally by the 
 patient, and sometim?s with a voice different from her usual. At first it seems 
 to have been not so much opposing, as quite indifferent and even reasonable 
 remarks, which accompanied the thoughts and language of the patient: for 
 example, " it " said, " Go to the doctor," " Go to the priest," or " Tlius, thus you 
 must do it," etc. Gradually these indifferent remarks were succeeded by other more 
 negative, and at present the voice sometimes simply confirms what is said by the 
 patient, at others it derides and mocks it: for example, when the patient says 
 anything which is right, the voice says after her, "You, that is a lie; you, that 
 you must keep to yourself." The tone of the voice in this sjieaking of "the 
 spirit" is always somewhat (sometimes entirely) diffei-ent from the ordinary 
 voice of the patient, and she looks upon the fact of her having another voice as a 
 leading proof of the reality of the spirit. "The spirit" often commences to 
 speak with a deep bass voice, then passes to a pitch lower or higher than the 
 ordinary tone of the patient; occasionally it passes into a shai'p, shrill ciy, which 
 is followed by a short ironical laugh, I have myself often observed this. Besides 
 those words spoken by " the spirit," the patient heard inwardly, and almost in- 
 cessantly, a great number of spirits speaking. Sometimes she had actual 
 hallucinations of hearing, but never of sight. Praying rendered the state which 
 we have described still worse; it increased the restlessness. In church, however, 
 she could, from awe of tlie congregation and clergyman, restrain the voice of the 
 spirit; she could also read aloud from the prayer-book without being disturbed. 
 Sometimes her discourse had a slight taint of nymphomania; she said that the 
 spirits caused her to have obscene thoughts, and to express them: she had pruritus 
 pudendi. The ^latient never knows, until it is spoken, what the spirit would say. 
 Sometimes tlie power of speech is altogether denied her for a certain time. In all 
 the phenomena which we have described, the greatest and invariable uniformity 
 prevailed, and her condition, which for a long time had been fixed and stationary, 
 continued the same during the short period during which she was under treat- 
 ment. (Original observation.) 
 
 Example XVII. — Convulsive attacks, icitli ideas of possession and plurality 
 cf tlie personality, of short duration, in a child.'' — Margaret B — , aet. 11, of lively 
 disposition, but a godly, pious child, was on the 19th January, 1829, without 
 having been previously ill, seized with convulsive attacks, which continued with 
 few and short intermissions for two days. The child remained unconscious so 
 long as the convulsive attacks continued. She rolled her eyes, made grimaces, 
 and performed all kinds of curious movements with her arms. On Monday, the 
 31st January, she assumed a deep bass voice, and kept repeating the words, " I 
 pray earnestly for you!" When the girl came to her senses, she felt tired and 
 exhausted. She was perfectly unconscious of what had passed, and merely said 
 that she had been dreaming. On the evening of the 22d January, another com- 
 menced to speak in a tone distinctly different fi-om the forementioned bass voice. 
 This voice sjioke almost without intermission as long as the crisis lasted, that is, 
 for half hours, hours, and even longer ; and was only occasionally interrupted by 
 the bass voice, which still repeated the forementioned words. In a moment this 
 voice would represent a person different from that of the patient, and perfectly 
 distinct from her, speaking of her always objectively and in the third person. 
 There was no confusion or incoherence in the words of the voice, but great con- 
 sistency was shown in answering all the questions logically, or in skilfully evading 
 them. But that which principally distinguished these sayings was their moral, 
 or rather their immoral, character. They expressed pride, arrogance, mockery, 
 or hatred of truth, of God and of Christ, The voice would say, " I am the Son 
 of God, the Saviour of the world — you must adore me," and immediately afterwards 
 rail against everything holy — blaspheme against God, against Clirist, and against 
 the Bible ; express a violent dislike towards all who follow what is good ; give 
 "vent to the most violent maledictions, a thousand times repeated, and furiously 
 rage on perceiving any one engaged in prayer, or merely folding their hands. All 
 
 ' We give the case as narrated by the patient in order to show the artlessness 
 of the story. See also ■what is said further on regarding the psychical condition 
 during an epileptic attack. 
 
STATES OF MENTAL DEPKESSION. 171 
 
 this might be considered as symptoms of a foreign influence, even although the 
 voice had not, as it did, betrayed the name of the speaker, calling it a devil. 
 Whenever this demon wislied to speak, the countenance of the girl immediately 
 and very strikingly changed, and each time presented a truly demoniacal expres- 
 sion, which called to mind the scene in the ' Messiade,' of the devil oflfering Jesus 
 a stone. 
 
 On the forenoon of the 26th January, at 11 o'clock, the very hour which, ac- 
 cording to her testimony, she had been told by an angel several days before would 
 be the hour of her delivery, these attacks ceased. The last thing which was heard 
 was a voice from the mouth of the patient, which said, "Depart, thou unclean 
 spu-it, from this child I— knowest thou not that this child is my well-beloved ? " 
 Then she came to consciousness. 
 
 On the 31st January, the same condition returned with the same symptoms. 
 But gradually several new voices appeared, until the number had increased to 
 six, differing from each other partly in their tone, partly in their language and 
 subject; therefore each seemed to be a voice of a special personality, and was 
 considered as such by the voice which had been already so often heard. At this 
 period, the violence of tiie fury, blasphemy, and curses reached their highest 
 degree; and the lucid intervals, during which the patient had no recollection of 
 what had occun-ed in the paroxysm, but quietly and piously read and prayed, 
 were less frequent and shorter in duration. 
 
 On the 9th Febiniary , which, like the 31st January, had been announced to her 
 as a day of delivery, this most lamentable trouble came to an end, and, as on the 
 former date, after there had proceeded from the mouth of the patient the words, 
 " Depart, thou unclean spirit ! " " This is a sign of the last time ! " the girl awoke 
 and since then has continued well. (Kerner, 'Geschichten Besessener,' Stutte., 
 1834, p. 104.) 
 
 § 121. 2. It is not uncommon to meet with melancholies who imagine 
 that they have entirely lost their personality, and that they are changed. 
 
 Melancholia metamoiyhosis. — We have already adverted to those ideas 
 which depend npon general and partial dys- or anaesthesias; as where the 
 patient imagines that he is dead, that his limbs are made of wood, etc. ; 
 and also to those delirious ideas, proceeding from hallucinations, of being 
 transformed into some unsightly beast. But of much more interest, as 
 well in. a psychological as in a pathological point of view, are those cases 
 in which the sufferer believes that he has changed his sex, men imagining 
 themselves to be women, and vice versa. This delusion, it is true, is by 
 no means confined specifically to melancholies, but it may be developed 
 during the course of this disease, and appears in many cases to be con- 
 nected with a disease of the genital organs, in which the sexual sensa- 
 tions disappear. 
 
 Thus, Lallemand speaks of a patient who imagined himself to be a woman, and 
 wrote letters to an imagined lover. The autopsy discovered enlargement and 
 induration of the prostate gland, abscesses, also obliteration of the ductus ejacu- 
 latorii, with dilatation of the vesiculas seminales and of the vas deferens. (' Dea 
 Pertes seminales,' i., p. 64.) 
 
 M. Leuret also records some facts concerning individuals who imagined that 
 they had changed their sex. In general, such cases are rare ; it is more common 
 to find in the French asylums, e. g., the Salpetriere, the delusion that the other 
 female patients are changed into men. 
 
 § 122. 3. Another variety of melancholia is that form which is 
 characterized by a longing for one's native land, and by the predominance 
 of those ideas which refer to a return to one's home — Home-sickness. 
 An analogous affection is sometimes developed in prisoners by want 
 of employment and frequently also by the co-operating influence of bad 
 nourishment, damp cells, and onanism. Nostalgic melancholia is som- 
 times accompanied by symptoms of congestion of the head, and even 
 of cerebral inflammation (Larrey) ; in this form, too, the same kind of 
 hallucinations appear (visions of home scenes, etc.). Not unfrequently, 
 
172 STATES OF MENTAL DEPRESSION. 
 
 we see indivichials affected with a greater or less degree of nostalgia 
 commit acts of violence (for example, the murder of young children, 
 incendiarism, etc., by servants). Those acts proceed more frequently 
 from evidently selfish motives, as from the desire to escape from a forced 
 and painful position, thati from the impulse, which also comes involun- 
 tarily in the melancholic, to procure a certain degree of solace through 
 the perpetration of some frightful deed. 
 
 Naturally, home-sickness is not always a mental disease : this is of impc^rtance 
 in a medico-legal point of view. In itself it is a mournful disposition of spirit 
 suggested by external circumstances. It becomes insanity vs^hen this disposition 
 so strongly impregnates all the faculties of tlie mind as utterly to exclude the 
 entrance of any other senf^iment, and when it is accompanied by delirious con- 
 ceptions and hallucinations; a state in which physical derangements— e:. g., loss 
 of appetite, emaciation, etc. — are seldom absent. In short, home-sickness ought 
 inforo to be regarded as a mental af/ection only when it presents the usual signs 
 of insanity. The want of reflection which :s the most important point in concrete 
 cases, ought not to be admitted when ihe individual is perfectly competent to 
 engage in his usual avocatior:: and perform his duties, ac is the case with many of 
 those young incendiaries aiflicted wiMi home-sickness. 
 
 It is of more importance to distinguish various form of melancholia 
 according to the difereni relation of ^lie emotional nature ; of the will 
 and of the actions." Thuc the conditions which we have just beon con- 
 sidering may present important modifications in tw- > different and, in 
 some degree, opposite ways. On tiie one hand, they may proceed to a 
 state of still deeper selfyconcentration with complete loss of will, or more 
 usually with convulsive tenacious effort. On the other hand, in these 
 states, new desires and new movements of the will may appear, corre- 
 sponding to the general negative disposition, which either manifest tiiem- 
 selves only in one isolated act of violence, or in a continual outward 
 restlessness and excitement ; when the melancholia passes into the form 
 of mania. 
 
 According to this view, we may consider, as the principal forms of 
 melancholia, the following : 
 
 1st. Melancholia where the subject of it is lost in self-co7iteniplation. 
 Melanclwlia with stupor (usually described by the French writers Georget, 
 Etoc-Demazy, Baillarger, etc., by the not very appropriate name of 
 ''stupidite," though properly understood by the latter according to its 
 nature'). 
 
 2d. Melancholia with manifestation of negative destructive tenden- 
 cies, particularhj with certain acts of violence sometimes directed against 
 self (the so-called suicidal mania), sometimes against other persons and 
 inanimate objects (homicidal mania, and monomania of destruction so 
 far as these cases are connected with melancholia). 
 
 3d. Mela7icholia accompanied by persistent excitement of the will, in 
 the stage of transition into mania. 
 
 *a^ 
 
 Section III. — Melancholia With Stupor. 
 
 % 123. That form of melancholia in which is represented the highest 
 degree of self-absorption under the outward form of stupe)r, is not only of 
 the highest theoretical importance on account of the well-marked mental 
 
 ' Baillarger, " De FEtat designe chez les Alienes sous le nom de Stupidite ;"■ 
 'AnnalMed. Psychol.,' i., 1843, pp. 76 and 256. A later article by the same 
 physician (' Annal. Med. Psychol.,' 1853, v., p. 251) bears the title, " De la Melan- 
 cholie avec Stupeur." Guislain included this condition in part under " Ecstasy. 
 
STATES OF MENTAL DEPRESSION. 3 73 
 
 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 
 readily confounded with dementia, which may lead to serious errors both 
 as regards 2:)rognosi3 and treatment. 
 
 Eeally the patients in the higher degree of these states present to 
 appearance the very picture of dementia. They are perfectly dumb, 
 completely passive, they only move when compelled by some strong ex- 
 ternal motive; their whole bearing is that of stupidity; the expression is 
 that of general profound mental oppression, of a veritable annihilation; 
 but the glance of such patients does not indicate the nullity proper to 
 dements — it expresses a painful emotion, sadness, anxiety, or concentrated 
 astonishment. In the more advanced degrees there generally exists an- 
 aesthesia, sometimes partial' and sometimes general, of the surface of the 
 skin, and a condition of the higher organs of sense whereby the impres- 
 sions of sight and of hearing are rendered quite indistinct and confused, 
 and frequently so perceived as if they came from a distance; perhaps in 
 some cases there is an increase of that cerebral paresis of sensation of 
 which we have already spoken several times (§ 50, § 114). 
 
 The voluntary muscles appear at times to be perfectly rigid and on 
 the stretch, sometimes benumbed; it is not uncommon to find such pa- 
 tients in a cataleptic condition; and many of the observations concerning 
 so-called catalepsy belong in i-eality entirely to this form. The mobility 
 of the members under the control of tlie will is always very much di- 
 minished, occasionally almost suppressed. There is a condition like that 
 of restraint of all the motory functions of the brain. 
 
 In such circumstances, the patients have in the 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 un- 
 clean — require to be fed, to be clothed, to be put to bed, etc. Usu- 
 ally they then emaciate rapidly, marasmus speedily comes on, and death 
 is by no means uncommon in this form of melancholia. 
 
 In what condition is the intellectual life of the sufferer during 
 the course of this disease? On this subject 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 per- 
 ception, 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 effaced and transformed. An intense internal anxiety constitutes 
 the fundamental state which torments him almost to suffocation, and 
 from this proceed ideas of being threatened every moment with mis- 
 fortunes; 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 im- 
 possibility of freeing himself from the terrors which threaten him on all 
 sides. Very frequently he cannot afterwards tell why he was incapable 
 of the least exercise of will, why he could not reply, why he could not 
 cry out. Esquirol'^ has, however, acquainted us with the interesting de- 
 claration of a patient after his recovery. "This want of activity was 
 
 » Sc. Pinel, ' Traite de Pathol. Cerebrale,' Paris, 1844, p. 250. 
 ' 'Geisteskrankheiten.' von Bernhardt, ii., p. 125. 
 
17Jr STATES OF MENTAL DEPRESSION. 
 
 due to the fact that my sensations were too feeble to call forth an exer- 
 cise of will." But this absence of will is most evidently manifested in 
 in the utter passiveness, inactivity, and immobility of tlie patients; as 
 well also by the intercurrent fits of intense activity which sometimes 
 occur, in the same way as many patients may have now and then a 
 sliort moment of consciousness, and obtain a glimjjse 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 re- 
 proach him, to insult him, and to threaten him with death; or a confused 
 noise of bells, trumpets and cannons, etc. He sees witches, funeral pro- 
 cessions, subterranean vaults, volcanic craters, which appear to yawn at 
 his very feet. He sees, also, the most cherished of his relations martyred, 
 etc. He fancies himself in a desert, in hell, chained to the galleys; in one 
 word, the entire subjective change which is produced in his sensorial per- 
 ceptions, and the consequent transformation in all impressions, causes all 
 external objects which he still perceives to appear only in the forms and 
 figures colored by the predominating sentiment (see examples) — a state 
 which is also characterized by a considerable degree of confusion of 
 ideas. 
 
 In many ways this condition presents the greatest similarity to a state 
 of half-sleep or dream. The production of emotions of ideas and thoughts 
 of a mournful and painful description find an exact analogue in the ap- 
 pearance of peculiar new and disagreeable sensations (formication, prick- 
 ing, cold) in the deadened sensory nerves; and we shall see that this 
 comparison is only the more true because in a large proportion of these 
 cases we are able to prove the existence of an evident pressure upon the 
 brain. The patients themselves, when they again commence to become 
 more lively, to feed themselves, and to do a little work — in short, to con- 
 valesce — are as astounded as if they were just waking up, and often ask 
 where they are, and only gradually recover themselves. They then com- 
 pare their actual state to a dreadful dream, and their convalescence to an 
 awakening therefiom. 
 
 § 124. Still, there is not always present during the course of this form 
 of melancholia such a multiplicity of painful sensations, ideas, and im- 
 ages as have been mentioned. In many cases it is rather a half-sleeping 
 state, without distinct dreams or lively hallucinations — a state of self- 
 absorption, of estrangement from the outer world, in which little else is 
 perceived than the feeling of profound internal disturbance and absence 
 of will; where the intellectual faculties, it is true, seem to be in a state of 
 abeyance, but yet the patient retains the consciousness of his condition. 
 Perhaps, indeed, it may be because the patient cannot give a good ac- 
 count of his state, or at best can only feebly recall it, that psychical ano- 
 malies so striking m themselves are so little known. 
 
 This, too, may serve to explain why several distinguished observers 
 (Esquirol, Georget, Ellis') have considered these conditions to be de- 
 mentia, and the fact propounded by M. Etoc-Demazy (1833), and most 
 erroneously generalized by Sc. Pinel (1840, 1844), that in certain of these 
 patients a cerebral oedema, and consequently compression of the brain, 
 is by no means unfavorable to this view of the matter. But, in the first 
 place, this cerebral oedema is by no means constant; and further, the de- 
 
 ' Ellis, 'Traite, etc., par Archambault,' Paris, 1840, p. 199. 
 
STATES OF MENTAL DEPRESSION. 175 
 
 clarations made by patients after their recovery are of themselves sufficient 
 most unequivocally to clear up the difference between this form of mel- 
 ancholia and dementia. There is the same difference between melan- 
 cholia 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 anes- 
 thesia on the other. But as the two conditions may depend on the same 
 cause (compression), and while it is not rare to see these two states suc- 
 ceed each other, and rapidly transformed 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 weak- 
 ness of the intellectual faculties, with cessation of the painful emotions, 
 into dementia, — into conditions, therefore, where the intellectual activity 
 is not merely restrained, but actually persistently and most profoundly 
 destroyed. 
 
 That which outwardly distinguishes these two states over and above 
 the expression of the countenance, and particularly of the aspect of the 
 patient, is, first, in many cases the primary and very rapid development 
 of this melancholia with stupor, and further, the almost universal emaci- 
 ation, the sallow complexion, the irregularity of the secretions, the Avant 
 of sleep, the great opposition to passive movements, the refusal to take 
 food, and the attempts to commit suicide — phenomena which are never 
 met with in dementia. 
 
 When melancholia with stupor does not pass into dementia, it is 
 rarely prolonged beyond a few months; many sufferers from it recover, 
 and recover generally quickly as if awaking from a dream. Drastics and 
 vesicatories seem in many cases to be of the utmost service. Death 
 sometimes supervenes as the consequence of an augmentation of the ap- 
 pearances of cerebral compression (very slow pulse, etc.); sometimes, also, 
 as the termination of a gradually increasing marasmus, depending upon 
 intense intestinal catarrh or pulmonary phthisis. I once saw a case of 
 suicide in this form of melancholia. 
 
 Melancholia with stupor is sometimes developed as a primary affec- 
 tion, especially in the case of young female patients, as the consequence 
 of a profound mental shock: sometimes, also, it makes its appearance 
 after attacks of epilepsy, of mania, or it may even alternate with the 
 latter. 
 
 Example XVIII. — Melancholia with stupor conseciitixie to remittent fever ; 
 recovery. — A. B — , set. 25, a government official, was admitted into Charenton on 
 the 12th August, 1833. At the age of fifteen he had an attack of insanity, and 
 another at the age of twenty-two ; the first lasted for six weeks, the latter for 
 fourteen days. B — had been for six weeks ill with intermittent fever, and sud- 
 denly, without any appreciable cause, the insanity appeared after several days' 
 suffering from violent headache. The symptoms were those of cerebral inflamma- 
 tion ; convulsions occurred several times in three weeks, and on more than one 
 occasion the patient attempted suicide. On admission, the countenance was pale; 
 the eyes fi:xed, widely open, and directed to the ground : his physiognomy was 
 expressionless and dull. B — remained the whole day sitting in the same place, 
 and appeared quite strange to all around him. To questions which had to be 
 several times repeated and spoken in a loud voice, he replied in monosyllables 
 slowly and softly pronounced. In walking, he supported himself on the wall, or 
 on other persons, and proceeded very slowly : he offered resistance when taken to 
 the bath. Memory appeared to be completely suspended ; he required to be fed, 
 and was very dirty in his habits. The cutaneous sensibility was dull, the sleep 
 prolonged, and the appetite great. Esquirol prescribed a blister to the nucha. 
 B — complained of the pain, and immediately began to improve. His replies 
 became longer and more loudly spoken ; he declared that he could not develop 
 
176 STATES OF MENTAL DEPRESSION. 
 
 his ideas, something prevented him. The physiognomical expression and dirty 
 habits still continued. Sometimes he burst into loud laughter when he caught a 
 glimpse of a patient clothed in a linen blouse. By the 15th of October the im- 
 provement was very evident; he was cleanly, and had begun to play on the piano. 
 In December his former lively expression returned, and his intellect appeared 
 completely developed. B — compared the state in which he had been for the past 
 three months to a prolonged dream. All around him seemed changed : he 
 believed in a kind of genex-al desolation ; the earth trembled and moved under his 
 feet ; he seemed every moment in danger of stepping into an abyss. He held bj-^ 
 those who were near him, in order to prevent them from stepping into the chasms 
 which appeared to him like the mouths of volcanoes. He imagined that the bath- 
 room was hell, and tliat the baths were boats. Tlie blister he believed was the 
 brand of a galley-slave, and that he thereby was forever dishonored. The persons 
 who surrounded him he took for resuscitated dead. He saw his brother in the 
 midst of torments ; he heard the cry for help of his relations, and each scream 
 was to him like the thrust of a poignard. The crack of firearms was heard on all 
 sides, and the bullets penetrated his body ^vithout doing him any injury. His 
 mind was all chaos, confusion, delirium. He could not distinguish night from 
 day, and the months seemed years. He blamed himself for all his ailments, and 
 therefore sought to commit suicide. The more he suffered, the more contented 
 was he, for he believed that his troubles were the just punishment of his crimes. 
 At the commencement of his recover^-, a letter which he received from his brother 
 assisted greatly in bringing him to a correct view of his position. (Baillarger, 
 loc. cit.) 
 
 Example XIX. — Intermiitent vielancholy during the menstrual peHods ; con- 
 tinued melancholia tcith stupor. Recovery. — Mrs. M , set. 44, was admitted into 
 the Salpetriere on the 24th October, 1842. During the menstrual period, the pa- 
 tient made several attempts at suicide ; her reason rapidly returned, and by the 
 beginning of November she was completely well ; she was dismissed, but on the 
 25th November the delirium set in anew, and she was brought back to the hos- 
 pital. During menstruation she made a new attempt at suicide. The patient is 
 calm, listless, and sad ; the countenance stupid, and the glance unsteady. Her 
 answers are short and slowly pronounced ; she is unable to collect her thoughts. 
 to remember the days or the months ; in short, to have a clear idea regarding 
 anything. Her head is heavy and weary. She is sad without knowing why; she 
 believes that she has committed many sinful deeds, but does not know what they 
 are. All around her seems changed. She has ringing of the ears and hallucina- 
 tions of hearing ; when she falls asleep, she sees shadows and figures ; suddenly 
 she awakes from fright. The bowels are constipated, the appetite good ; pulse 
 100, skin cool. Laxatives, encouragement to do some work, forced promenades, 
 society, and baths, were prescribed and followed by improvement. 
 
 On the 27th December the menses returned, without attempts at suicide or 
 aggravation of her condition. After their cessation the improvement was very 
 rapid ; slie voluntarily engaged in household work, and became communicative. 
 
 On the 6th January her reason had completely returned, and she communi- 
 cated the following : 
 
 During the delirium it seemed to her as if she \vere surrounded by fire, which 
 burned her, but she did not feel the pain ; she smelt abominable odors, and her 
 food had no taste. The nights appeared twice as long as ordinary. She heard 
 voices around her, but could not distinguish the words. At first she thought that 
 she was in prison, and took the patients (female) for disguised men. In the 
 morning she saw the objects around her more distinctly than in the evening. 
 Just at the commencement, she felt persuaded that she was about to be thrown 
 into a kettle full of boiling water, and thought that she heard persons putting the 
 coal on the fire. The reason why she attempted to commit suicide was that 
 everything around her was transformed, and that she herself was the cause of it. 
 She thought that she was to blame for all the hardsliips and complaints of the 
 patients around her, and that therefore it was better that she should die. (Bail- 
 larger, loc. cit.) 
 
 Section" IV. — Melancholia with Destructive Tendencies. 
 
 § 125. In melancholia this emotional state of uneasiness, of anxiety, 
 and especially of mental suffering, gives rise to certain im])ulses and 
 directions of the Avill which are manifested in external actions, which 
 
STATES OF MENTAL DEPRESSION. 177 
 
 always assume a negative, gloomy, hostile and destructive character. 
 The negative ideas and feelings which here pass into effort, the acts which 
 are the result of them, may be directed either against the individual him- 
 self, against other persons, or finally against inanimate objects; and 
 according to the difference of the outward act, these cases have been 
 described as different monomanias (monomania of murder, suicide, arson, 
 etc.). 
 
 A. Melancholia luith suicidal tendencies. — The pathological and etio- 
 logical history of suicide does not appertain entirely to the province of 
 mental medicine; in fact, whatever certain scientific authorities' may 
 assert, we are not warranted in coming to the conclusion that suicide is 
 always a symptom or a result of insanity. There is no insanity present 
 where the feeling of disgust with life is in exact relation to the actual 
 circumstances; where evident moral causes exist which sufficiently account 
 for the act (§ 37); where the resolution has been deliberately made, and 
 might have been abandoned had the circumstances changed; and in 
 which we discover no other symptom of mental derangement. When a 
 man of very delicate feelings puts an end to his existence, that he may not 
 survive the loss of his honor, or of some other highly valued possession 
 which forms an intimate part of his intellectual being — when a man pre- 
 fers death to a miserable, contemptible life, full of mental and physical 
 ills, — morality, indeed, may call him to account for the deed, but there 
 exists no ground on which we can consider him insane; the abhorrence 
 of life and the idea of self-annihilation correspond to the intensity of the 
 painful impressions which bear upon the individual, and it is after delib- 
 erate reflection that the act is resolved upon and perpetrated. But the 
 cases which come under this category are the rarest; more frequently 
 the tendency to commit suicide depends either upon fully developed 
 melancholia, with all its usual symptoms, or (and this is more frequent) 
 on a state closely bordering upon melanchola of moderate but, at the 
 same time, general painful perversion of the feelings. The apparently 
 deliberate and cold-blooded act of suicide can, when considered ;;er se, 
 no more prove the non-existence of insanity than any other deliberate act 
 committed in mental disease. The disposition to originate those states of 
 mental suffering which most generally coincide with exhaustion, coldness, 
 and deadening of the reaction of the feelings, is precisely the same as the 
 disposition to mental diseases. When these have once appeared, they 
 become fixed, and rule the individual the more easily according as a feeble 
 ego offers only slight resistance to them (p. 51); they therefore frequently 
 appear as essential result of a previously weak character. They are, how- 
 ever, essentially distinguished from the abhorrence of life which is the 
 result of certain explicable moral causes, by their internal origin (§ 37), 
 by the want of sufficient moral causes to account for the act; frequently 
 by their evident appearance in consequence of some physical disease, by 
 jiresenting periodic exacerbations without any moral cause; and finally, 
 
 ' Esquirol (loc. cit., p. 183). " I believe that I have proved that an individual 
 will only put an end to his life when he is delirious, and that suicides are 
 mentally diseased." Falret, ' De I'Hypoch. et du Suicide, ' 1833, p. 137. Esquirol, 
 moreover, expresses himself less absolutely in other parts of his work. Bourdin 
 (' Bull, de la Soc. Med. Prat, de Paris,' 1845, No. 41, p. 38) has attempted in an 
 elaborate essay to prove the theory that every suicide is a monomaniac. Brierre 
 has recently opposed the opinion of the universally morbid nature of suicide, etc. , 
 by the interesting collection of the last writings of very many suicides, and 
 called attention to the ordinary clearness and deliberateness which these writings 
 showed. 
 
 12 
 
178 STATES OF MENTAL DEPRESSION. 
 
 by being sometimes undoubtedly hereditary. When the whole psychical 
 life is governed by this perversion of the feelings, there arise no limiting 
 or restricting ideas and impulses to resist the thought,' be it spontaneous 
 or suggested, of self-destruction; or these ideas and impulses soon become 
 worn out and exhausted, owing to the existence of those which constantly, 
 and with the persevering obstinacy of all other melancholic dispositions 
 of this kind, urge themselves upon the ego. Indeed, the more insignifi- 
 cant the outward motives to the deed, the more likely are we to find in 
 the antecedent history of the individual, causes, or even certain symp- 
 toms, of incipient insanity; and the more barbarous and the more extra- 
 ordinary the means employed for the perpetration of the deed,* the more 
 are we warranted in considering it to be a result of some morbid perver- 
 sion of the faculties. 
 
 Sometimes we see in persons hitherto healthy a suicidal impulse sud- 
 denly developed, as a form of raptus melancholicus, with obscuring of 
 the consciousness and all the signs of great exaltation. (Example XX.) 
 Thus in the case recorded by Forbes Winslow, a lady in whom no one 
 had ever remarked anything extraordinary, suddenly during dinner sprang 
 up and attempted to throw herself over the window; she was prevented 
 accomplishing her purpose, and forthwith there was developed an attack of 
 mania. If the suicide has been successful, it would have represented a 
 case of very problematical raptus occurring in a healthy person. In 
 many of those cases in which the individual suddenly resolves to put an 
 end to his existence, and immediately puts his purpose into execution, 
 and where we have failed to recognize the existence of any characteristic 
 delirium, if we attentively examine the facts, we shall probably find that 
 for a long time past the individual has been plunged in the most pro- 
 found hypochondria; that he has constantly been dwelling upon the state 
 of his health; that he has frequently complained of being unable to com- 
 mand his thoughts and will as formerly; that he has been annoyed with 
 a general weakness, accompanied by vague systems of bodily discomfort, 
 particularly with derangement of the digestive functions. The weariness 
 of life is generally more chronic, which shows itself as spleen owing to 
 weakness of the constitution from hard drinking — that general exhaus- 
 tion and desolution of mind which arises from various causes, and among 
 others from immorality, onanism, and venereal excesses; sometimes it 
 almost appears as if some slight deviations in the development of the sex- 
 ual organs might give rise not only to those longing hypochondriac states 
 of mind which we often enough see at the period of puberty, but might 
 also, in some individuals, awaken suicidal impulses. 
 
 Cases of suicide occur at all ages of life, even among mere children. 
 We have already seen (§ 92) that it is frequently hereditary, and that it 
 may alternate with other forms of insanity in different generations. It 
 is about three times more frequent among males than females. The most 
 recent and reliable statistics would seem to indicate that it is increasing 
 in frequency at a most astounding and, so to speak, progressive rate. In 
 Berlin, Caspar has demonstrated the correctness of this statement. In 
 France, the statistics of the minister of justice show, during a period of 
 ten years, from 1827 to 1837, the astonishing increase of about one fourth;* 
 from 1838 to 1852, the increase still continued; in 1838 and 1839, there 
 
 ' Imitation of suicide. 
 
 ^ See the shocking case of starvation in ' Hufeland's Journal,' 1819; the case of 
 Matthieu Lovat, who crucified himself, etc. 
 
 3 Dufan, ' Traite de Statistique,' Paris, 1840, p. 298. 
 
STATES OF MENTAL DEPRESSION. 179 
 
 occurred one case of suicide in every 12,489 inhabitants; and in 1852, one 
 in every 9340 (Lisle): in 1827 the proportion was only as 1 to every 20,660 
 inhabitants; and in 1836 it stood as 1 to every 14,338. It is well known 
 that suicide is often propagated by imitation; examples of this kind are 
 numerous, from the case of the maidens of Mileta, of whom Plutarch 
 Avrote, to that of the well-known example in the Invalides in Paris, and 
 others of still more recent date. In all times, too, cases have not been 
 wanting where two individals of different sex have together committed 
 suicide, and those in which the person put an end to his existence after 
 having committed some act of violence. 
 
 It is not our intention to enter into details regarding the causes and social sig- 
 nificance of suicide, or to enumerate tlie statistics of different countries in regard 
 to it. As to the latter, and the hundreds of documents which are brought 
 forward to prove, what we have already admitted, viz. the enormous increase in 
 the numljer of cases of suicide in our time, their authority is of precisely the 
 same value as that of the statement regarding the great increase of insanity 
 (g 85). The older statistics were both inaccurate and defective, and it is just 
 possible that the increase which it has been attempted to establish may only be 
 apparent; the later statistics being much more exact and complete. Thus, as I 
 have mentioned in the first edition of this work, M. Archambault assured us in 
 1843, that so far at least as France was concerned, this increase in the number of 
 suicides was not an actual fact ('Ann. Med. Psych.,' i., p. 147), and that the dif- 
 ference was entirely due to the much greater care and exactitude with which the 
 statistics were drawn up. This is possible, just as it is in regard to insanity in 
 general (§ 85), but not at all probable; it must be admitted that there is an actual 
 increase in the number of suicides, but the rate of progression is not so great as 
 has been mentioned. 
 
 Solomon ('Welches sind die Ursachen,' etc., Bromberg, 1861) has, moreover, 
 pubhshed some extremely interesting statistical tables, from which it comes out 
 that the number of suicides in Belgium from 1846 to 1855, in Sweden, and even in 
 Paris, so far from increasing in a constant uniform progression, is maintained 
 within certain, not very extended limits. In the central European countries, it 
 is reckoned that at tlie present day there occurs, on an average, one suicide in 
 every 12 or 15,000 inhabitants: in the East, suicide was and still is rare. At least 
 one -fifth, perhaps one-fourth, of those who commit suicide are drunkards. In 
 France, the greater part adopt drowning as the means of ending their existence; 
 while in England and Germany, hanging is the favorite method. One very 
 mournful fact connected with this subject is the suicide of children. In England, 
 during the space of five years, from 1852 to 1856, out of 5415 cases of suicide, 33 
 were committed by children under the age of ten yeai-s (Buckle). Durand-Fardel 
 ('Ann. Med. Psych.,' 1855) has collected twenty-six cases of suicide by persons 
 varying in age from five to fourteen years. The motives which usually lead to 
 this mournful end are, as a rule, pitiable as compared with those in adults; fear 
 of punishment, etc. Thus, a boy, aged nine years, killed himself because he had 
 lost a bird; another, aged eleven years, whose case Schlager describes, from dis- 
 appointed love; another, aged five, threw himself into the water because his 
 mother maltreated him. It is a fact that death does not inspire children with the 
 same fear as it does in the majority of adults, and the weak ego is easily over- 
 come by the idea of the thing. Further, in such children there has often, for a 
 long time, been observed something anomalous, a certain perversion of the 
 feelings; as, for example, cruelty to animals (for examples, see Forbes Winslow, 
 "Obscure Diseases of the Mind and Brain," London, 1859, p. 186), 
 
 § 126. We must carefully distinguish (with Guislain'), among the 
 actually insane, those cases in which the suicidal impulse is the most 
 essential symptom of the malady, the chief disease, from those in which 
 it appears, merely as an epiphenomenon, during the course of some other 
 form of mental affection. The majority of insane persons in whom this 
 suicidal impulse manifests itself suffer from some well-pronounced form 
 
 ' ' Lemons orales,' i., p. 244. 
 
180 . STATJiS OF MENTAL DEPRESSION 
 
 of melancliolia. But the psychological motive which gives rise to this 
 impulse is far from being uniform. Often it is an insupportable excess 
 of a general nndefined feeling of anxiety which leads the patient to seek 
 relief in suicide; at other times he gives way to this impulse, because he 
 feels that all his feelings have become disagreeable and frightful, and his 
 mind subject to dreary and wicked ideas; in desperation concerning this 
 perpetual yoke, he considers himself unworthy longer to live, and imag- 
 ines his whole life is evil, abandoned, and impious. Or there arise dismal 
 ideas of general non-existence; the sufferer imagines that the whole world 
 is annihilated, and that consequently he too must put an end to his ex- 
 istence. But that which is perhaps the most frequent occurrence is the 
 presence of hallucinations, in which the profound uneasiness of the feel- 
 ings, and the still more dismal ideas of self-destruction, take a sensible 
 form, and are presented to the mind of the patient with all the force and 
 reality of objective perceptions (voices which say, ''Slay thyself ! Slay 
 thyself !" or hallucinations of vision conveying the direct commands of 
 the Deity). Such impulses come in melancholies often very suddenly 
 and transiently (lasting some hours or days) ; sometimes there appears 
 with the accomplishment of the deed, even though unsuccesful, an actual 
 relief and remission, just as in other cases we observe, after some injury 
 or act of violence has been perpetrated on another person by one of 
 unsound mind, that the feeling of profound oppression which weighed 
 so heavily on the patient is thereby removed, and perfect calm is restored. 
 Many melancholies artfully seize an opportune moment to put into exe- 
 cution the resolution long ago taken, but till now concealed ; at other 
 times they openly, one might almost say shamelessly, avow their purpose 
 to commit suicide, and diligently await for weeks and months an oppor- 
 tunity of satisfying this impulse by every possible means, and even before 
 the very eyes of their attendants. 
 
 Schlager (Prager ' Vierteljahrsschr.,' Bd, 64, 1859, p. 1) observed that in 1000 
 cases of insanity, 91 who either committed suicide, or made the attempt to do so, 
 almost all were melanchohcs. In these cases the most important predisposing 
 causes were, cerebral congestions, profound exhaustion caused by previous dis- 
 ease, disappointed love, drunkenness conjoined with mental excitement (here we 
 often see a suicidal impulse suddenly develop itself, and if the commission of the 
 deed be prevented, the patient retains no recollection of what has taken place); in 
 one solitary case fear was the determining cause. Exhaustion of the constitution, 
 anaemia, a chronic cerebral hypera^mia, dysmenorrhoea, chlorosis, the climacteric 
 period, and diseases of the heart, were also observed to have considerable influ- 
 ence in producing this state of mind. The mode of death which these individuals 
 chiefly selected was hanging. 
 
 But it is not only in melancholia that we observe this suicidal ten- 
 dency ; we meet with it also in other forms of mental disease. It then 
 depends, not so much on abhorrence of life, as upon all kinds of delirious 
 conceptions, in the more restricted sense of the term; the idea, for 
 example, of martyrdom for the benefit of mankind, of being about to 
 enter paradise, which is presented to their eyes in splendid visions, etc. 
 Further, there occasionally appear, in persons suffering under partial 
 dementia, intercurrent attacks of suicidal impulse, from most intense 
 abhorrence of life, as a form of melancholic or maniacal raptus. In the 
 asylum at Winnenthal, there was, for many years, a mentally weak and 
 partially demented patient (ideas of being the Emperor of China, etc ), who 
 from time to time was suddenly (with considerable cerebral congestion) 
 seized with the most intense disgust of life, and it was only by being con- 
 tinually kept under restraint that he was prevented from putting into 
 
STATES OF MENTAL DEPRESSION. 181 
 
 execution his determination to commit suicide. These attacks lasted for 
 live or six days, and then completely disappeared ; on each occasion the 
 withdrawal of some blood from the head seemed essentially to aid in cut- 
 ting short and diminishing the strength of the fit. Those cases in which 
 the insane kill themselves unintentionally and without wishing to die are 
 to be distinguished from cases of suicide ; — when, for example, a maniac 
 in the midst of his delirium mistakes the window for the door, and insists 
 upon making his exit by that means, or when he leaps out at the window 
 in obedience to the command of the Almighty, whose voice he hears say- 
 ing, '* Gro to the window, and thou shalt fly as doth a bird ;"* or when a 
 monomaniac believes that he is commissioned to convert mankind, and in 
 order to convince people that he is really sent from God, and therefore 
 invulnerable, throws himself from a bridge and is drowned;' — these are 
 not cases of suicide, for here the patients had no desire to kill themselves. 
 Closely allied to such cases of morbid self-destruction, and falling under 
 the same category, are those examples of self-mutilation, generally the 
 result of melancholia or delirious ideas, in which the patients cut off their 
 fingers, tear out their eyes, cut off their testicles, etc. At times we are 
 warranted in coming to the conclusion that there is in these parts a 
 considerable diminution of the sensibility. 
 
 Cases also occur in which persons actually insane simulate attempts at suicide; 
 it does not, however, follow that the mental disease is simulated. Morel, ' Ann. 
 Med. Psychol.,' vi., 1854, p. 84, mentions a case of this description. 
 
 Example XX. — Sudden appearance of attempts at suicide ivith obscuring of the 
 consciousness and loss of alt recollection — A lady still alive, and now (1821) 43 
 years of age, had hitherto lived in comfortable circumstances, and, excepting 
 occasional hysteric headaches and dj'smenorrhcea, in the constant enjoyment of 
 good health. Up to the year 1804, she had never met with a misfortune. Her 
 husband loved her tenderly; her children, whom she herself had partly nursed, 
 were strong and healthy, and her circumstances easy. On the 24th July of this 
 year, however, after she had suffered for several days before from her ordinary 
 headache, but which by this time had disappeared,'she was sitting, at half -past three 
 o'clock after noon, in her own house, apparently well pleased and engaged in knit- 
 ting. Suddenly, and without the least provocation, she sprung up and called out, 
 ' ' I must drown myself — I must drown myself ! " whereupon she ran straight to the 
 moat which surrounded the town, and threw herself into it. She was immedi- 
 ately taken out of the water and carried, apparently dead, to her home. A doctor 
 was rapidly summoned, and he speedily restored animation. She, however, re- 
 mained mute, and stared with widely open eyes fixedly on one spot, paying no 
 attention to the events which passed around her. I saw her for the first time on 
 the evening of the 27th of July. She had, it is tiiie, during the time which had 
 intervened since the attack, calmly submitted to all that was done to her, and 
 even swallowed some medicine; but she had not spoken, nor partaken of food or 
 drink — she had not slept, nor shown interest in anything. When I saw her late 
 at night, she was lying in bed, and sighed continually. When I spoke to her, she 
 started and pronounced my name. A candle was brought, and when she saw me 
 she exclaimed, "My God! where am I, and what has happened to me?" and 
 commenced to weep violently. I soon calmed her. After she had recognized 
 and spoken to her husband, and inquired about her children, she fell asleep and 
 rested undisturbed till morning. 
 
 On awaking, she at once cheerfully inquired about all that had happened, and 
 was astonished to hear of her attempt to drown herself, and of the danger into 
 which she had thereby fallen. On my appearance next morning, she laughingly 
 asked what I actually thought and had said of her, and was anxious to know how 
 she could have come to the foolish idea of drowning herself without being con- 
 scious of the occurrence or knowing any cause for it. Since then she has had 
 several children, and many things have occurred to disturb her equanimity, but 
 she has never had any such extravagant ideas. With the exception of occasional 
 
 ' Leuret, 'Fragments,' p. 290. 
 
 2 Falret, ' Hypoc. et Suic," p. 139. 
 
182 STATES OF MENTAL DEPRESSION. 
 
 hysterical attacks and dysmenorrhoea, she has always continued healthy, cheer- 
 ful, and gay. (Mende, in Henke, ' Zeitschrift fiir die Staatsarzneikunde,' 1821.) 
 
 Example XXI. — Tendency to suicide caused by concealed hallvAiinations. — A 
 young man of large fortune had been addicted to onanism, but nevertheless con- 
 tinued to enjoy pretty good health. He had no other cause of annoyance than the 
 remembrance of the Revolution, the principles of which he disapproved of, and 
 had even on several occasions attempted to commit suicide by shooting himself 
 with a pistol, and would use no other means. He remained for two years under 
 my care, during which time he did not speak one word of nonsense; he was 
 cheerful, amiable, well-informed, and jometimes said to me, "Give me a pistol !" 
 — "Why would you kill yourself ? " — " Because all seems tiresome." It was not 
 till after the lapse of two years tliat he informed me that for a long time he had been 
 subject to hallucinations of hearing and of sight. He believed that he was fol- 
 lowed by policemen, whom he constpjitly heard and saw, even between the walls 
 of his apartment, which he believed were double, and consisted of two movable 
 partitions, so that one could hear and see all which he said or did. (Esquirol, 
 'Maladies Mentales,' i., p. 555.) 
 
 Example "KXll. — Vague impulse to commit suicide caused by a violent fright 
 during a state of bodily weakness. — N — , a tailor, set. 31, had fallen into a state of 
 great exhaustion in consequence of onanism, and had afterwards to submit to 
 repeated courses of treatment by mercury. On the outbreak of cholera in the 
 year 1831, he was so terrified by the report that the patients were drawn from 
 their dwellings with tongs, and otherwise roughly handled, that he fell into a 
 swoon and believed that he was seized with cholera. At first he could not work 
 during the day, nor sleep at night, and the idea that he also must subject himself 
 to treatment so frightful set him quite beside himself. He even spent the night 
 with friends for fear of being carried off to a cholera hospital. When at work, 
 his limbs trembled from anxiety: this he considered to be a premonition of chol- 
 era, having heard that fright predisposed to it. His appetite left him, and besides 
 he was afraid to eat too much, as too much food and many kinds of it seemed 
 hurtful to him; indeed, he weakened his digestion through abstinence. Being 
 perpetually tormented by fears, he slept little, and dreamed a great deal of deaths 
 and funerals. During the day he could not venture out, for fear of the disease 
 and of the police. This torment threw him into a state of mind so irritable, that 
 the sight of cattle going to the slaughter-house disturbed him very much, because 
 he represented to himself how the knife would be plunged into then* throats. At 
 last, when he had somewhat recovered from this anxiety, he one day heard a sliot 
 go off; whereupon he became very much afraid, because he thought that some 
 one had committed suicide. On the same evening he learned that a person in the 
 neighborhood had cut his throat. His terror was now so great that he could not 
 sleep at night, because he kept constantly considering how the suicide had com- 
 mitted the deed — what part of his body had he wounded? In vain he attempted 
 to banish these thoughts, which were continually arising anew on the slightest 
 occasion; forexample, by a headless figure in the Royal Museum, which represented 
 in his eyes a beheaded individual. If a knife lay before him, it seemed to him as 
 if he must cut his throat, in spite of his horror of it and his love of life. When a 
 knife was put into his hand, he trembled and threw it from him, or laid it under 
 his plate that he might not see it. He constantly ':hought of violent modes of 
 death: if he saw a rope, the idea of haiiging immediately entered his mind; if he 
 crossed a bridge, he felt as if he must jump into ':he water — therefore he never 
 walked near the edge, but rapidly ran across in the centre of the bridge, in order 
 not to be impelled to throw himself over against his will, if he stood at a window, 
 he felt impelled to jump through it, and therefore retreated in terror. Knives 
 and pistols were presented to him, that he might become accustomed to handle 
 them; but he could not command himself for fear„ After this terror had long 
 pursued him, and had at last attained to its highest degree, he voluntarily sought 
 admission into the Charite. Here even this condition lasted for a considerable 
 length of time, but at last complete recovery took place under the employment 
 of continuous bodily exercise and the use of baths. (Marc, translated by Ideler, 
 i.,p. 196.) 
 
 Example XXIII. — Suicide caused by anxiety and hallucinations. — A former 
 soldier, set. 38, received fracture of both legs, which were accordingly amputated. 
 He became dull, and was seized with an attack of mania. He heard voices which 
 continually insulted him, persecuted him, and threatened to shoot him. These 
 were followed by answers which he directed to the voices. The state of hallur i- 
 nations and anxiety lasted for tuu months, in spite of all possible remedies. Tu(» 
 
STATES OF MENTAL DEPRESSION. 183 
 
 patient became always more absorbed in his false sensations ; he persistently 
 refused food in order to tvithdraw himself from these torments^-the voices demand 
 that he should eat no more. He had to be fed by force ; the more feeble he 
 became, the stronger the voices seemed to become : at last he died from exhaus- 
 tion. (So. Pinel, 'Pathol. Cerebr.,' Par., 1844, p. 212.) 
 
 Example XXIV. — I have at present under treatment a young girl who has pro- 
 lapsus of the uterus, caused by a violent blow on the os sacrum. Since the acci- 
 dent she suddenly becomes very low-spirited, and suffers from a most peculiar 
 perversion of ideas, and a tendency to suicide whenever, from any exertion, the 
 neck of the uterus presents itself at the orifice of the vagina or passes through it. 
 This remarkable anomaly is prevented by the employment of a pessary. (Guis- 
 lain, ' Plirenopathies,' 1838, p. 282.) 
 
 B. — Melancholia ivith Destructive and Murderous Tendencies. 
 
 § 127. Directly and immediately connected with the suicidal impulse, 
 is the morbid tendency to injure and destroy other persons or inanimate 
 objects. Not only do these tendencies frequently occur together — not 
 only have these acts of violence towards others, inasmuch as they are 
 often perpetrated upon those most loved and cherished by the patient, fun- 
 damentally the same essential character as the tendency to self-injury 
 and self-mutilation — but, in general, both depend upon the same funda- 
 mental state of morbid negative emotion, and in both there may be also 
 observed certain differences in the immediate morbid cause. 
 
 As to the psychical motives which give rise to these acts of violence 
 in persons already laboring under melancholia, these impulses would 
 seem to be due, in part at least, to an actual delirium of the intelligence 
 or of the sensorial perception. To this class belong those cases in which 
 the patients imagine that they are persecuted, or generally injured by 
 others,' — where they attribute to certain persons insulting and injurious 
 expressions which they hear of their hallucinations of hearing, and con- 
 sequently actually commit deeds of vengeance upon them. To these are 
 very closely associated those violent deeds which are suggested under the 
 idea, evidently melancholic, that everything in this world is bad, that 
 everything is abandoned and lost; that, for example, the innocent chil- 
 dren may be best delivered from the misery of this world by an early (vio- 
 lent) death; or the patient, without the slightest ground for any such 
 fear, imagines that there is now left to him no possible means of existence, 
 and that soon he will perish of hunger and misery, etc. These ideas, more 
 or less obscure, not unfrequently discover themselves in hallucinations, 
 in which the patient is directly commanded to kill, it may be children or 
 wife; and falling under nearly the same category, are those hallucinations 
 of hearing which partake of religious fanaticism (voice of God or of 
 angels), in which the patient hears the command to go and follow the 
 example of Abraham, and such like. Such acts spring from vague ideas 
 of the necessity of sacrificing some person, other than but closely con- 
 nected with the patient, an expiation of some terrible but imaginary 
 crime; while in other cases the patient, regarding himself as a felon shun- 
 ned by all, commits some dreadful deed in order to draw down upon 
 himself the well-deserved punishment of death. 
 
 In regard to a great many of these cases, including those which be- 
 long to the following paragraph, there is a most important and charac- 
 
 ' Thus, for example, the cases which have several times occurred of patients 
 attempting to murder their physicians. See Marc, translated by Ideler, ii., p. 'J. 
 We would refer generally to the rich collection of cases contained in this work to 
 illustrate this chapter. 
 
184 STATES OF MENTAL DEPKESSION. 
 
 teristic circumstauce which we have ah-eady adverted to in speaking of 
 suicide, viz., the freeing of the patient from his painful emotions and 
 frightful thoughts by the fact that the deed committed has become ob- 
 jective to him; the ease and calm wliich the patie.nt gains by the mani- 
 festation of his disposition, by the accomplishment of the deed — a cir- 
 cumstance which gives to these acts what has been termed a critical 
 significance. In the following very simple cases, there may be recog- 
 nized various modifications of such mental disburdening; something sim- 
 ilar is frequently observed after the actual accomplishment of deeds of 
 murder depending on melancholic motives. 
 
 Example XXV. — A case of melancholia presented a character which is not 
 uncommon, and which in its higher degrees, and when it has attained its full 
 development, represents a form of "moral insanity." The patient, a married 
 lady, aged 45, fell into a state of profound melancholia, with constant anxiety. 
 She declared that whenever she heard or read of a crime, she felt an intense 
 desire to commit the same crime, but at the same time she also felt a very great 
 terror of its accomplishment. It was impossible for her to recount all the terrible 
 things which passed through her mind. She added that every act of violence, 
 whether in word or deed, which she perpetrated on her children or those around 
 her, afforded her considerable relief, and that she had now the greatest difficulty 
 in controlling herself. 
 
 The patient recovered under the employment of dilute acids, tincture of 
 opium, digitalis, infusion of quassia, and laxatives. (Guy, "King's College 
 Annual Reports," 1841 ; 'Lond. Med. Gaz.,' Sept., 1842.) 
 
 Example XXVI. — A patient who suffered from fissure of the anus and sperma- 
 torrhoea, with transitory cerebral congestion, gradually fell into melancholia. He 
 abominated suicide, but an evil genius seemed constantly to urge him to it. The 
 sight of anything with a sharp point, or of firearms, caused him to tremble, and 
 awakened in him an impulse to kill himself, from which he could only free him- 
 self by exciting violent pain ; for example, by severely pinching some part of his 
 body. He rudely repelled the kind ofiices of his friends. He detested what was 
 bad, but felt himself involuntarily impelled to commit evil deeds: thus he expe- 
 rienced pleasure in tormenting a lady whom he loved very much, and then seeing 
 her weep. (Lallemaud, ' Des Pertes seminales,' i., p. 251.) 
 
 § 128. We frequently see in subjects who, up to that moment, have 
 been in the actual, or at least apparent, enjoyment of perfect health, 
 just as in some of those cases in which there is developed a suicidal ten- 
 dency (No. XX.), attacks of most violent anxiety with obscuring of con- 
 sciousness suddenly show themselves; accompanied with frightful hallu- 
 cinations, during which the patient, in the blindness of his fury, seeks to 
 massacre and slay all who come in his way. These cases, which, judged 
 by their symptoms, appertain more, it is true, to mania, but which, in 
 their psychological relations, represent violent fits of melancholic anxiety, 
 and especially morbid negative emotions, possess, in their want of any 
 actual moral cause, a great analogy to those sudden fits of profound 
 anxiety and severe mental suffering which have sometimes been witnessed 
 as precursors of ^^iV^'^^^'c attacks.' 
 
 Almost as obscure, in so far as the motives which dictate them are con- 
 cerned, and yet of the greatest importance in a medico-legal point of view, 
 are those cases where individuals hitherto perfectly sane and in the full 
 posession of their intellects, are suddenly, and without any assignable 
 cause, seized with the most anxious and painful emotions, and with a 
 homicidal impulse as inexplicable to themselves as to others. In such 
 cases there are two categories into which they must be carefully arranged 
 and distmguished. 
 
 ^ See the chapter on epilepsy. 
 
STATES OF MENTAL DEPRESSION. 185 
 
 Under the first fall those cases in which those homicidal impulses, 
 suddenly and without external motive, arise in persons Avho have been 
 hitherto of a lively, joyous, and loving disposition, and incessantly in- 
 trude themselves upon their thoughts. Most generally, there arises a 
 profound and mournful division of the consciousness, an internal strug- 
 gle and storm of the most painful nature with these new and fearful 
 ideas, against which the whole former contents of the / resist with all 
 their power, which of course varies in different individuals. Frequently, 
 during the combat, the individual is only able to prevent the total dis- 
 comfiture and defeat of the / by retiring from the struggle and betaking 
 himself to a solitary neighborhood, where the impulse which thus be- 
 sets him no longer finds an object. Then, after a certain time, these 
 thoughts may again disappear as quickly as they sprang into existence, 
 and the individual is again as he used to be. He scarcely knows how he 
 fell into this painful, terrible dream, and with a feeling of intense relief 
 he breathes again with the knowledge that it has terminated so happily. 
 At other times, hoAvever — and fortunately this is rarer — the / is compelled 
 to succumb, and the unfortunate one perpetrates the deed, and that too 
 without affording him any advantage, with the certain prospect of a life 
 of shame and misery — indeed, with tlie certain expectation of the dis- 
 graceful death which the last penalty of the law inflicts. This, however, 
 appears to him as a relief, and an actual benefit, as compared with the 
 perpetual anxiety and tormenting struggle in his soul, which he feels he 
 must end at any cost. 
 
 Example XXVII. — M. R — , a distinguished chemist and amiable poet, of a 
 character naturally pliable and sociable, came to place himself as a patient in one 
 of the inlBrmaries situated in the Faubourg Saint- Antoine. Tormented with a 
 homicidal impulse, he would often prostrate himself before the altar, and 
 implore the Deity to deliver him from this atrocious pro^jensity, the origin of 
 which he never could understand. When he found that his will was entirely 
 under the control of this impulse, he would run to the head of the establishment 
 and cause him to tie his two thumbs together with a ribbon. This fragile band 
 sufficed to calm the unfortunate R — , who, however, ended by attempting to 
 kill one of his keepers, and he thereafter died in a violent fit of rage. R — had 
 left behind him a collection of letters, in which he attempted to describe his inter- 
 nal sensations. They proved that this desire to kill some one was wholly unac- 
 countable, and arose without any reason whatever, and that it was purely 
 instinctive. These very interesting letters, which I had read in great part, fell 
 into the hands of Dr. Gall, and have unfortunately been lost. (Marc, translated 
 by Ideler, i., p. 169.) 
 
 Example XXVIII,— Catherine Olhaver, the third surviving cliild of poor 
 parents, was born in the year 1788, but, in consequence of her mother having been 
 seized with a very severe fever, she was weaned when only six weeks old. The 
 first symptoms of her mothers illness, before any decided signs of her true dis- 
 ease manifested themselves, were shown in the desire to kill her child. To 
 accomplish this fearful plan, she opened one side of her feather coverlet, in order 
 to put the child therein, with the double purpose of suffocating and at the same 
 concealing it. Her intention was discovered in time to prevent her putting it 
 into execution, and immediately thereafter she was seized with the most violent 
 feverish symptoms, which lasted for several weeks. After her recovery, this 
 woman had not the slightest recollection of what had occurred, and devoted her- 
 self with all a mother's tenderness to the care of her child. She is still living, and 
 has never again had a similar attack. 
 
 In spite of the poverty of her parents, Catherine grew up perfectly healthy, 
 though she was frequently troubled with worms. The menses appeared late in 
 life, but further than this there was no irregularity. She became with child, and 
 on the 21st of January, 1821, she was happily and with ease delivered of a healthy 
 boy, whom she herself began to nurse. Soon after her delivery, she fell into a 
 violent rage, and was attacked thereafter with a fit of epilepsy. This attack, 
 however, Avas not again repeated. When her child was six weeks old, she took 
 
186 STATES OF MENTAL DEPRESSION. 
 
 a situation as wet-nurse ; and she conducted herself in this capacity with propri- 
 ety, showing lierself of a quiet, cheerful disposition. She lavished the most 
 tender care upon her charge, whose thriving condition gave evidence enough of 
 the attentions bestowed on it by the nurse. At the end of other six weeks, she 
 was again seized with a violent fit of anger on hearing of the death of her own 
 child, the loss of which she attributed to the carelessness of the person who was 
 rearing it. Acute as these impressions at first were, they became speedily effaced, 
 and she only lavished her maternal cares with greater assiduity upon her nurs- 
 ling. At the end of the thirty -second week after her accouchement, the menses 
 again made their appearance, preceded by a slight illness ; and about the fourth 
 week thereafter the same thing occurred. From this time, the nursing of the 
 chUd was evidently too much for her strength. She became pale and emaciated; 
 the child also began to ail, being first seized with intermittent fever, and then 
 with a nervous cough. 
 
 On Friday and Saturday, the 20th and 21st of October, the nurse was seized 
 with colic, which, more or less severe, lasted until the Sunday, though consider- 
 ably modified. At the same time she experienced a certain agitation in her 
 stomach, and anxiety ; but this did not last for any time. On Sunday evening, 
 when in the room alone with the two youngest children, the thought suddenly 
 flashed across her mind, on seeing a knife on the table, that she must kill the 
 nursling, who was then lying in her lap, by cutting her throat with the knife. 
 She stated that at this moment she felt a peculiar movement in her belly, like a 
 gurgling, as she expressed it, and gusts of heat towards the head ; and she heard, 
 as it were, a voice commanding her to slay the child. The very thought of this 
 made her shudder ; so she quickly laid the child upon the bed, snatched up the 
 knife, and flew with it to the kitchen, where she threw it from her, and entreated 
 the cook to go with her, and not to leave her, because she was beset with evil 
 thoughts. The cook answered her that she could not then leave her work, and 
 thereafter she required to go out ; so Catherine again returned to the children. 
 Still the thought constantly presented itself ; and in order to drive it away, she 
 fell to singing aloud, dancing with the children i"Ound and round the room until 
 bedtime. When the cook had again returned home, the nurse begged her to 
 remain with the children, and she would occupy her place. This request the 
 cook refused, and having departed, Catherine went to bed, slept but little, and 
 suddenly awoke with the ii'resistible desire to murder the cliUd, whose crib stood 
 beside her bed. Happily, at this moment the door opened, and her mistress 
 arrived. This somewhat calmed the girl, because she knew that the mother of 
 the child and her sister-in-law slept in the same room. Still she slept but little, 
 and was very restless the whole night, when, about three o'clock, the murderous 
 impulse was so strong, that she sprang out of bed and ran to wake all those who 
 were present. She now complained that she felt very unwell, and was beset 
 with unholy thoughts, without stating the nature of them. At the same time, 
 she spoke to herself as if she were delirious ; suddenly she cried out aloud, ' ' O God, 
 what horrible, what frightful thoughts!" Soon again, "But this is ridiculous, 
 abominable, terrific ! " Then she asked with anxiety about the child, whether it 
 was really beside its mother, and then spoke to him in an aflfectionate and tender 
 manner ; and after she had taken some chamomile tea, she became more quiet, 
 and slept till about six o'clock next morning. The day following, she was quite 
 fatigued and overcome, and was constantly attacked with the same paroxysms. 
 She remained perfectly dumb and self-absorbed, with a fixed and frequently 
 ferocious look, and face of unwonted color, and, contrary to her usual habit, took 
 no notice of the child. Finally, about five o'clock in the afternoon, after having 
 three times taken the prescribed draught, she experienced more calmness and 
 relief. Only once after this, during the night between Monday and Tuesday, did 
 this murderous thought again obtrude itself ; whereupon she leaped from her 
 bed, and drank of the potion from which she had formerly obtained relief. 
 Since then she has remained free from all simOar attacks. On Thursday, she, 
 with many tears, related what had occurred to her. 
 
 This attack did not come on synchronously with the return of the menses, and 
 not the slightest cause can be assigned for it. The medicines employed were 
 potio Riveri, emetics, and valerian, etc. The child died in November, and the 
 nurse held it in her arms during the last moments of its life, ■wearing at the same 
 time the quiet expression of the profoundest pain; and when it finally died, she 
 fell into a state of the gi-eatest despair, which, however, soon passed away, and 
 gave place to a more calm sorrow. (Mende, in Henke, ' Zeitschrift fiir die 
 iitaatsarzneikunde,' 1801.) 
 
STATES OF MENTAL DEPRESSION. 187 
 
 Example XXIX. — The wife of a shoemaker paid me a visit one day to ask 
 advice about a complaint concerning which she was in despair. She presented 
 all the appearance of sound bodily and mental health, but she was constantly 
 beset with thoughts tempting her to kill her four children, whom, as she said, 
 she loved better than herself. She was afraid lest she should do some evil deed'; 
 she was in despair, and felt inclined to throw herself over the window. In such 
 moments she felt an almost irresistible impulse to some such perfectly unaccount- 
 able act, and in consequence of which she was seized with a general trembhn"-. 
 Towards other children she felt no such evil disposition, only from her own she 
 must flee and be in perpetual fear of them, and carefully hide all instruments 
 which might possibly fall into her hands. She kept constantly running up and 
 down stairs, in order that by the very motion and fatigue she might drive these 
 notions out of her head. This homicidal tendency lasted for about three months, 
 and then with the return of the menses suddenly disappeared of itself. (Georgeti 
 'Discussion Medico-legale sur la Folie,' 1826.) 
 
 Another very characteristic case may be found mentioned in Gratiolet's 
 *Anat. comp. du Syst. Nerv.,' p. 578; and also in Guislain's 'Lemons orales,' 
 t. i., p. 234 and 240; Ellinger, ' Zeitschrift fur Psychiatrie,' 1854, xi., p. 466. 
 
 As to these sanguinary impulses, the production of ideas according 
 to the law of contrast (§ 19) is, it is true,' almost the only point of con- 
 nection between them and the normal phenomena of mental life; altliough 
 there exists a very great difference between the simple fact, that in the 
 fortunate, ideas of want and misery may easily arise — in the lover, ideas 
 of faithlessness — and in him who stands on the brink of a precipice, 
 ideas of a headlong plunge may be suggested, and the actual fulfilment 
 of those ideas which lead to actions, and continually and persistently 
 urge towards their outward expression. 
 
 Somewhat more distinct in their psychological motives are those cases 
 which come under the second category, in which such impulses originate 
 in those who have been long overwhelmed with grief, concentrated in 
 self, and have become actual misanthropes. The more an individual 
 gives himself over to habitual morbid brooding upon his own condition, 
 with a negative disposition of the feelings, the more does he retire upon 
 himself, and withdraw from that interchange of friendly and benevolent 
 sentiments which knit man to man; and gradually he arrives at that 
 point where he feels himself excluded from all intercourse with his fel- 
 lows, and all that interests maiikind at large. In such cases we often 
 see develoi:)ed a feeling of bitter animosity towards the world, which be- 
 comes to such individuals perfectly hateful, gloomy, and fearful; and 
 there frequently arise impulses to commit these indeterminate acts, by 
 which the individual thinks to repay the world, in some splendid crime, 
 for all these griefs and imaginary evils, as well as all those painful im- 
 pressions, the cause of which he is ever seeking, not in himself, but in 
 the outer world. At times, the persons who are most frequently with 
 the patient draw upon themselves his most intense hatred, and become 
 the victims of these impulses which the patient suddenly discovers. 
 More frequently, however, it is neutral persons whom he attacks, as if 
 the feeling of hostility which animates him recognized in them represen- 
 tatives of a race which he detests. Frequently it is the innocent play of 
 a child which irritates him, or the beauty of a woman which incites in 
 him this murderous disposition. 
 
 The well-known case of Henrietta Cornier appeared for a long time to belong 
 to this category (Marc, ii., p. 48, 41). But Bonnet (' De la Monomanie du Meur- 
 tre,' Bordeaux, 1852) tells us that the girl Cornier informed her prison compan- 
 ions that it was to avenge herself on her lover, with whom she had been living in 
 
 ' See Ideler's notes to the fourth and ninth sections of Marc's work. 
 
188 STATES OF MENTAL DEPBESSION. 
 
 the most intimate relations, that she slew her child, after having long premedi- 
 tated the crime. Examples of similar tendencies in children are not wanting 
 (Marc, i., p. 66; Esquirol, ii., p. 61; and in the work of Lallemand, iii., p. 185, 
 186). In many of these cases we are able to establisli the existence of different 
 disturbances of the general health, to which, from experience, we are bound to 
 attribute a certain influence in the production of cerebral disease, or even of the 
 actual symptoms of this affection, e. g., persistent or transitory congestion of the 
 head, menstrual derangements, onanism, diseases of the genital organs, sensations 
 of anxiety proceeding from the cardiac region, weakness of vision, general feelitjg 
 of illness, weakness, constipation, etc. We have not here to do with the consid- 
 eration of these facts, in a medico-legal point of view. We are aware that such 
 estimation is based purely upon scientific grounds, resulting from the most mi- 
 nute research into the psychological and organic causes which have given rise to 
 these tendencies. It is contemptible to see how often science is constrained, as a 
 last remedy, to have recourse to the theory of those morbid impulses, to justify 
 crimes, and seldom (to use an expression of Ideler's) ought medical reports to 
 resemble those Italian churches where every bandit finds a safe asylum; but in 
 such cases medicine must assert her rights, and never ought she, when opposed 
 to popular opinion and prevailing ideas, which rest on no surer ground than an 
 imperfect acquaintance with mental disease, to throw down the arms which 
 science has put into her hands. But neither, on the other hand, should she, 
 when unable to give a determinate opinion on scientific grounds, seek to establish 
 one on any other basis. 
 
 A perfectly distinct group of cases, which in a medico-legal point of view it is 
 extremely difficult to classify, is that which consists of those who kill their own 
 children. Many of those individuals are drunkards, or persons demoralized by 
 other causes, and consequently often attacked with insanity. Usually they de- 
 clare that they kill their children to deliver them from the miseries of this world; 
 a motive which, in many cases, is not in itself so wholly unreasonable. Often, 
 after having committed a murder, these persons make an attempt to commit 
 suicide — or rather they intend to do so, but are too faint-hearted to carry it out. 
 In a good number of cases the act partakes really of the character of self -mutila- 
 tion, and as it were of suicide, through the murder of another; as when the im- 
 fortunate father who tenderly loves his child seeks, in killing him, to slay him- 
 self. 
 
 The pyschological problems in these cases (we shall return to them again m 
 another place) are usually but little cleared up by any declarations which the in- 
 dividuals themselves may make, who in general belong to the uneducated class, 
 and can give no account whatever of their state of mind. In legal medicine, 
 we ought to adhere most strictly to the course of events, to the remarkable 
 changes which may have taken place anteriorly in the moral individuality of 
 the person; to inquire if he has ever been subject to hallucinations, and into his 
 condition both before and after the act. In the case to which we have referred 
 above (Seitz, § 41) tliis most incredible fact came out, viz., that the individual, 
 after having slain his three children, washed his hands, threw himself upon the 
 grass, and went to sleep for two hours. He was perfectly incapable of experi- 
 encing the least remorse for his conduct. Hence we must come to the conclusion 
 that in such cases the acts of the individual are, at least, of as much importance 
 as his words in helping us to arrive at a just appreciation of his mental condition. 
 Another class of cases consists of those where the individual commits crimes 
 in order to die upon the scaffold. They prefer that mode of death to suicide, 
 because they have not the courage to kill themselves, or because they consider 
 that suicide is too gross a sin, and that they could not confess before death, etc. 
 There is scarcely one of those individuals in this class whom we could consider 
 as in the full enjoyment of reason. M. Brierre de Boismont has brought together 
 six cases of this description ('Ann. Med. Psych.,' 1851, iii., p. 626). 
 
 § 129. Closely related to those impulses which have just been exam- 
 ined, stand those morbid inclinations which we see also discovered by 
 melancholies, which impel them to the destruction of inanimate objects, 
 and which may be directed against anything oi"%verything that surrounds 
 the patient. Thus, there are some who have a constant desire to tear 
 their clothes and beds, to make cliariyie of them, etc. Most interesting, 
 however, are those cases in which the deed consists of fire-raising, which 
 
STATES OF MENTAL DEPRESSION. 189 
 
 has been erected into a special monomania, and described under the 
 name of Pyromania — a classification purely artificial, but which possesses 
 at least the advantage of previously settling the object of discussion.' 
 
 If from the observations whicli have been published upon this subject 
 we exclude all those cases where egotistical motives'' have evidently 
 guided the hand of the incendiary, there still remains a certain number 
 in which this crime of arson has been committed by patients laboring 
 under a well-marked melancholia (particularly of nostalgia passing into 
 mania) — a state which is often accompanied by important derangements 
 in the general health, and frequently in the sexual organs. The morbid 
 impulse develops itself precisely in the same manner as does the homi- 
 cidal impulse which we have just been studying. The feeling of mental 
 anxiety and the general disturbance which arises from the morbid condi- 
 tion of the faculties do not, as has been said (Masius), impel the 
 individual to seek to stifle this anxiety by the sight of a great flame, but 
 merely to relieve by an outward act, however negative and destructive m 
 character, the profound discord and uneasiness which rules within, and 
 thereby to obtain peace and tranquillity. The particular direction which 
 this morbid impulse takes, viz., incendiarism, may arise from the fact 
 that to those persons in whom this tendency has been most accurately 
 observed — namely, young people, particularly young maid-servants — fire, 
 with which they in the performance of their duties have much to 
 do, is always ready at hand, and presents itself as the readiest means by 
 which they can satisfy the morbid craving which torments them — a 
 means which is easily employed ; and which requires neither great energy 
 of action nor violent determination to make use of. 
 
 Away, then, with the term Pyromania, and let there be a careful investigation 
 in every case into the individual psychological peculiarities which lie at the 
 bottom and give rise to this impulse. The grand question in foro, in aU such 
 cases, must ever be to ascertain whether there existed a state of disease which 
 limited, or could have limited, the liberty of the individual. Sometimes the 
 symptoms of undoubted mental disease can be clearly distinguished — a dominant 
 feeling of anxiety, hallucinations, states of hysterical exaltation; in other cases, 
 the actual existence of a nervous disease (epilepsy or chorea) renders probable 
 the assumption that the accused has been subject to some passing mental aber- 
 ration. We should not forget that usually very little is wanted to interfere with 
 the liberty of action in such persons (>5 36); they are, for the most part, young, 
 childish, or half-childish, often morally and intellectually weak, silly, and ca- 
 pricious individuals. The incendiary act often appears to be utterly without any 
 motive, — the feeble ego having opposed no resistance to the thought of the deed 
 w^hich suddenly sprang up. 
 
 Of course, there are also cases where the insane set fire to buildings under the 
 impulse of motives very different. Jonathan Martin, who burned the Cathedral of 
 York, was not a melancholic, but was evidently laboring under chronic partial 
 dementia, and it was in consequence of his hallucinations that he sought "to 
 purge the house of the Lord of the unworthy priests " who dwelt in it. To in- 
 clude this case under the title of '-Pyromania" (e. g., Pinel, 'Path. Cerebr.,' p. 
 328) is the necessary but evil result of a superficial classification. 
 
 Example XXX. — Melancholia with a quiet destructive inqndse. — Marie Z — , 
 aged about 30 years, of an eccentric character, became mentally affected after the 
 occurrence of some family annoyances. She believed herself lost, and condemned 
 to the punishments of hell. After having attempted to commit suicide, slie came 
 into our asylum with a blue mark in the neck, and bearing the traces of the cord 
 
 ' See the copious Gerraan literature on this subject by Osiander, Henke, 
 Meckel, Masius, Flemming, Mayer, Hettich, etc., and recently Willers-Jesseu. 
 
 ^ Sometimes revenge, sometimes boyish delight in mischief — sometianes, and 
 indeed most frequently, the opinion that by destroying the house they might 
 put an end to an impatiently borne period of service and return home. 
 
190 STATES OF MENTAL DEPRESSION. 
 
 with which she had sought to strangle herself. After her admission, she aban- 
 doned herself to the utmost despair; from morning till night she remained seated 
 upon her bed, her head concealed in her hands, and replied to questions only in 
 monosyllables. Sometimes she discoursed at length upon the frightful punish- 
 ment which was awaiting her. One day she begged for a pair of scissors, and 
 deliberately proceeded to riddle a mattress and her hood with a mass of llitte 
 holes, and this without the slightest trace of bitterness or anger; and she told me 
 very naively that she was urged to do so by an irresistible impulse. She com- 
 pletely recovered at the end of two years. (Guislain, ' Phrenopathies.') 
 
 Section V. — Melancholia ivith Persistent Excitement of the Will. 
 
 In the last two sections we have studied those conditions in which the 
 morbid state of the faculties manifests itself by a tendency to destruction. 
 Now, the more the motive power of the soul is excited by mental pain, 
 and the more general extended and persistent the manner in Avhich this 
 is done, and the more vague and permanent the excitement, the less are 
 we inclined to regard this condition as one of melancholia, and the nearer 
 does it approach to the form of mania. It is useless and impossible to 
 describe here all those intermediate forms through which this transition 
 from melancholia passes into maniacal excitement; we shall exhibit in 
 the following section the most pronounced form of this state. 
 
 But it is of importance to know that there are certain conditions in 
 which the negative disposition of the faculties and permanent excitement 
 of the will are kept within moderate bounds, and present a very chronic 
 course; conditions which exhibit themselves rather m an habitual eccen- 
 tricity of character, and which are nearly allied to those of slight and 
 chronic melancholia, to which we have already referred, and of which 
 they represent the active form. Some of these cases are described by 
 authors as cases of mental insanity, tnatiia sine delirio, folic raisonnantCy 
 moral insanity (Prichard). These conditions are congenital or acquired; 
 they are characterized by a feeling of discontent and bitterness, which is 
 either constant or roused on the slightest provocation; by a perpetual 
 negative demeanor towards the external world, the impressions of which 
 always are, or very easily become, painful in their nature; and by a con- 
 stant reaction of the will, in the sense of the contrary choleric disposi- 
 tion. Generally this condition is not recognized as a morbid one, or it is 
 only after a long time that we come to look upon these individuals as 
 actually invalids. They well know how to justify by logical arguments 
 their wayward and unreasonable behavior, and how to dissimulate until 
 there arrives a moment when this state suddenly passes into an access of 
 mania, which serves to tear the veil from the eyes of their friends and 
 reveal them in their true character. 
 
 Example XXXl.— Habitual perversion of the feelings, with impulsive fits of 
 anger, without any derangement of the intellect. — An only son, brought up under 
 the eyes of a weak and indulgent mother, early acquired the habit of yielding to 
 all his caprices, and to all the impulses of a restless and ardent temperament. 
 With years the impetuosity of his desires only augmented, and the fortune which 
 was lavishly supplied at his request seemed to level every obstacle which stood in 
 the way of his supreme will. If he met with any serious difficulty, he became 
 exasperated and much enraged; he attacked with boldness, and sought to rule 
 everything by force, and was perpetually quarrelling and fighting. If he was 
 angry with any beast— a dog, a sheep, or a horse, it mattered not which— he im- 
 mediately made an end of it. When in company? or a guest at any fete, he 
 usually got into a rage and then fell to fighting. On the other hand, full of rea- 
 son when he was quiet, and master of a large estate, he conducted his affairs with 
 the greatest good sense and uprightness, fulfilled his duties to society, and made 
 himself known by his liberality to the poor. Hitherto his unfortunate propensity 
 
STATES OF MENTAL DEPRESSION. 191 
 
 for getting into quarrels had only brought him bruises, actions at law, and pecu- 
 niary fines; but one notorious case put an end to his acts of violence, for one day 
 he got into a rage at a woman who was abiising him, and threw her into a spring. 
 The affair came before the court, and on the testimony of a crowd of witnesses, 
 who deposed to the intemperateness of his fits of anger, he was sentenced to be 
 confined in the asylum of Bicetre. (Pinel, ' Traite de I'Alienation,' p. 159.) 
 
192 STATES OF MENTAL EXALTATION. 
 
 CHAPTER 11. 
 STATES OF MENTAL EXALTATION. 
 
 Mania. 
 
 § 130. While the pure and simple forms of melancholia represent 
 conditions of depression of the self-sensation and self-confidence, of con- 
 centration upon some painful emotion, of morbid self-concentration, and, 
 in the highest degrees, of even incapacity for making the slightest exertion, 
 we have seen that, in the forms last considered, the emotional disposition 
 is always more and more accompanied by morbid impulses to manifesta- 
 tions of volition. The possibility of exhibiting the emotion by actions, 
 and of thereby obtaining relief, shows that the affective sphere of the 
 mind and the will have become more free; indeed, the stronger and more 
 persistent these impulses are, and the more extended and independent 
 this aspiration to freedom becomes, the more there result states ot persis- 
 tent excitement and exaltation of luill, with which also there is easily 
 united an increase of the self-sensatio?i and of self-confidence. Such con- 
 ditions, which have been appropriately designated (Jessen), in opposition 
 to melancholia, morbid states in which the patients are 07it of themselves, 
 are comprised under the name of mania; and under this head there are 
 included two different forms, which, while they are intimately connected 
 with each other, and not unfrequently pass into each other, occur still 
 more frequently as states or forms fragmentarily mixed together, viz. 
 matiia and monomania (sensu strictiori). 
 
 The fundamental affection in the maniacal states consists chiefly in a 
 derangement of the motory side of the soul-life, the effort, and of such a 
 nature, that the latter having become free, unrestrained, and considerably 
 increased, the individual consequently feels impelled to give some out- 
 ward manifestation of his powers. From this tendency to an exaggerated 
 psychical movement from within outwards, from this augmented energy 
 and more extended range of the efforts, from this extravagance of the 
 will, which constitute the centre-point of maniacal derangement, spring, 
 as from a common source, those two forms which in their nature and 
 mode of manifestation are sometimes so essentially distinct. On the one 
 hand, this necessity for the manifestation of the increased mental activity 
 may manifest itself directly, being propagated by a continuous impulse 
 to the organs of motion, and there exploding, as it were; whence there 
 ensues a state of great physical restlessness, the patient keeping his mus- 
 cles in constant play (speech, gestures, movements of the body generally), 
 and perpetually speaking, shouting, weeping, dancing, leaping, storming, 
 etc. ; and thus is constituted the form generally called mania. 
 
 Or, on the other hand, the direct result of this more free development 
 of volition may be the development of inordinate vanity, increased self- 
 sensation, and consequently a constant over-estimation of self; and as at- 
 tempts at explanation of this disposition, delirious conceptions arise which 
 now become dominant over the mind, and take the increased activity of 
 
STATES OF MENTAL EXALTATION. 193 
 
 the will into their service. The patient has now no longer to do with mere 
 general manifestation of energy; but this excitation of the motory side of 
 the soul-life is transformed into extravagant volition in the form of parti- 
 cular delirious conceptions, for the most part with much greater outward 
 calm. As soon as such a condition, accompanied by delirious conceptions 
 arising from inordinate self-conceit, has in any degree become fixed, there 
 is founded a state of mental derangement infinitely more serious than that 
 of simple mania. In short, while in the latter form the patient is freed 
 from his exaggerated impulses by their outward manifestation, and again, 
 as we shall soon show in the pure form of mania, the whole disease is 
 •confined to a relatively external sphere of the mental life without pro- 
 foundly involving the individuality, it is the essential characteristic of 
 this second form of mania, which we designate monomania, that delirious 
 conceptions, false ideas, which arise from over-estimation of self, and 
 therefore relate only to the special self of the patient, appear, which im- 
 mediately involve the ego itself, and therefore the innermost part of the 
 individuality becomes alienated and falsified. 
 
 § 131. But if these two forms in their extreme degrees are so utterly 
 distinct as mutually to exclude the possibility of mistaking the one for 
 the other, still observation shows that in mania itself such delirious ideas 
 of self-importance are by no means unfrequent, which certainly ought 
 not to be regarded in an ontological sense as '' fragments of monomania," 
 as phenomena of quite another affection which in this case present them- 
 selves in a very simple form, but as the result of the primary mental con- 
 dition. Thus it is self-evident that, in the direct evolution of the morbid 
 impulse of will in muscular movements, this arrogant disposition must 
 very frequently give rise to this condition of overweening self-estimation, 
 and consequently how readily the patient may come to acquire delirious 
 conceptions; and one can see any day in watching maniacs how sometimes 
 such grand ideas are barely visible, while in others they are developed 
 with the greatest clearness. Fortunately, however, there exists in these 
 most advanced cases of mania a something which prevents these ideas 
 from becoming fixed. They share in the tumult and precipitancy which 
 agitate the motory sphere of the soul-life; they become so confused in 
 their hurry, and pursue each other so rapidly, that they have no time to 
 become fixed or to dwell in the mind. On the other hand, where this 
 rajiid succession of ideas does not exist, and where this state of exaltation 
 and these delirious conceptions penetrate the ego so deejjly and in such a 
 manner as actually to form an essential and constituent part of it, and to 
 become not only a subjective reality to the patient, but the ruling princi- 
 ple of his whole psychical life, this state is called monomania. 
 
 The distinction between mania and monomania, as we have observed 
 it in the most marked and characteristic cases, consists chiefly in the 
 different direction which the original lesion takes, in the different manner 
 in which the intellect is morbidly changed, and the way in which the ego 
 is affected. In mania, the exaggerated impulse of the will immediately 
 passes outwards as a tendency to muscular movement; in monomania it is 
 simply an internal eccentricity of will, whereby the internal feeling of 
 greater liberty of action is transformed by a reactionary process into 
 exalted false ideas, and where this feeling, when it manifests itself, is no 
 longer confined to simjile movements and relief through these move- 
 ments, but tends rather towards the realization of certain plans which 
 proceed from those false ideas. This error in the ideas consists in fixed 
 delirious conceptions in regard to the special individual itv springing from 
 13 
 
194 STATES OF MENTAL EXALTATION. 
 
 this OYer-estimatioii of self; while in mania, the derangement of the in- 
 tellect consists chiefly in a delirious confusion of ideas in consequence of 
 the precipitous haste with which all the mental processes are conducted. 
 Finally, we shall have to consider a third state of mental exaltation, 
 more apparent than real, which is never found except in monomania, and 
 Avhich consists in this — that the anomaly of the psychical self -sensation, 
 tliis overweening disposition whicii has originally given origin to all those 
 false conceptions by which the patient seeks to explain his state, disap- 
 pears more or less completely; but the false conceptions themselves, the 
 exalted ideas which the individual entertains of his own merits, let loose 
 from the foundation on which they were erected, persist, and as constantly 
 present errors of judgment, completely govern the whole intellectual 
 life of the patient. We shall describe this third condition under the title 
 of Partial Dementia with Exaltati07i, in the third section of this book. 
 
 In mania, as in melancholia, there exists an important difference between the 
 cases, in regard to whether the patients are in a simply superficial or in a pro- 
 found dreamy state, whether their relations with the outer world are clear, or are 
 hazy, confused, and obscure. Upon this depends in great part the degree of re- 
 collection of their state which the patients possess after their recovery. 
 
 § 132. We have more than once had occasion to remark that, in the 
 majority of cases, melancholic states precede the maniacal, and that the 
 latter is engendered by the former. In the more chronic cases we often 
 have the opportunity of following the whole course of the disease, and of 
 seeing in melancholies the mental suffering and anxiety increase from day 
 to day, at first manifesting itself merely by extreme restlessness, but grad- 
 ually passing into complete mania. In such cases it is undoubtedly the 
 state of mental suffering which induces this convulsive condition — a phe- 
 nomenon which may appropriately enough be compared on the one hand 
 to those convulsions which are brought on by some particularly severe bod- 
 ily suffering, and at other times to those involuntary muscular contrac- 
 tions which take place as a sort of instinctive reaction against any acute 
 pain (as setting the teeth, clenching the fist, etc.). 
 
 We are not to suppose that, therefore, the nature of mania consists 
 merely in the unregulated and uncurbed manifestation of the negative 
 disposition found in melancholiii. For, though often enough this disposi- 
 tion breaks through all barriers, and displays itself in certain acts of con- 
 vulsive fury or of destruction — conditions which we have already described 
 under the title of raptus melancholicus; and although, often enough, 
 during the Avhole course of the maniacal affection, the melancholia appears 
 behind it as- a shady background, and there are even times when it ad- 
 vances to the foreground and may again become dominant; still the mania,, 
 when once the mo'tory exaltation has been set free, however short the fit 
 may be, becomes entirely independent of the preceding melancholia, and 
 bursts forth without the necessity of being excited anew by melancholic 
 emotions: indeed, the disposition frequently undergoes a total change, 
 the patient becoming joyful, merry, and overforward. 
 
 At the same time, those deeds of destruction, the savage attempts and 
 ferocious acts committed by maniacs, are far from being always due to a 
 "^true negative disposition of mind, or to even a momentary hostile inten- 
 tion; much more frequently the acts of these patients are the result of a. 
 blind impulse to action, of a necessity to change the external world 
 according to their will. In acts of destruction this desire finds its sim- 
 plest fulfilment, because this is so much easier than to create anything — 
 for this demands a certain amount of reflection and of care, of Avhich 
 
STATES OF MENTAL EXALTATION. 195 
 
 maniacs are wholly incapable. The desire longs to be promptly satisfied, 
 and convnlsively hastens, so to speak, to manifest itself without heeding 
 the more slow influence of more orderly thoughts: as he must give vent 
 to his desire in a visible manner, he proceeds at once to the work of de- 
 molition; and that which we might be inclined to regard as the object of 
 the deed, is, in fact, merely the termination of his activity. We see 
 something analogous to this in the child who destroys his toy in the 
 endeavor to satisfy that necessity that he discovers of making it to suit 
 his idea, or in schoolboys who wrestle with each other in order to satisfy 
 the longing they experience to exhibit their strength. In the same way, 
 maniacs often demolish and destroy things amidst shouts of laughter and 
 in the greatest good-humor. But there exists a complete and marked 
 difference between the actions in mania and the deeds of the melancholic 
 in the form of monomania, an affection Avhich in its internal causes is so 
 closely connected to mania. The monomaniac more frequently desires 
 actually to create something, and, indeed, to execute some prodigious work, 
 and to bring it to the light of day; and he may even bring to bear upon 
 this some amount of reflection, because, in his case, the mental processes 
 do not proceed with the haste, restlessness, and confusion present in 
 mania; but there is time afforded for the impulse which the patient feels 
 to expend liis force, to be governed by some fixed great and regulated, 
 but naturally false idea, according to which he is impelled to work. 
 
 When mania, particularly that form accompanied with furious delirium, has 
 proceeded out of melancholia in the manner we have already indicated, we never 
 dream of attributing to the person so affected any premeditated mental act; in 
 fact, it is out of the question to think of looking for any psychological progress 
 regulated by the faculties in an individual laboring under such an affection. 
 That mental act which he apparently performs is rather a modification or change 
 in his morbid disposition, which goes on without any intervention on his part, 
 and is explicable on the ground that some change has taken place in the nature 
 and form of his cerebral affection. So long as this process is confined to a simple 
 change of disposition, the lesion is limited to a sphere relatively exterior or peri- 
 pheral to the mental faculties, and frequently the patient has then a consciousness 
 of his condition, of that mental anomaly which weighs upon him, which 
 oppresses the ego, which seems to exact something of him, and which he cannot 
 resist; and with this consciousness he, at the same time, protests against the im- 
 minence of the disease. 
 
 When mania does break out, it is by no means always determined by a pas- 
 sionate or emotional (melancholic) shock. Apart from those cases of mania caused 
 by acute meningitis, we see in other forms of deUrium — as, for example, of 
 typhus fever — the same outward restlessness, the voluntary acts and impulsive 
 movements, the result at one time of the profound anxiety which torments the 
 patient, or at another provoked by hallucinations, while again they may come 
 on without any appreciable cause, as if this motory impulse commenced spontan- 
 eously to show itself with the more profound destruction of the mental faculties. 
 
 A similar state of matters prevails in certain cases of chronic mania. For 
 observation has distinctly shown than when the brain has once been the seat of a 
 lesion partaking of the nature of mental pain, there remains a condition in the 
 highest degree predisposing to mania. Mania succeeds melancholia — such is the 
 rule; there are cases even where long after recovery from melancholia a second 
 attack of insanity has come on, but this time assuming the form of mania.' 
 
 Section I. — Mania. 
 
 § 133. As we have already remarked, it is rare that mania shows itself 
 ■without having been preceded by certain symptoms of some other mental 
 affection. In the majority of cases, for some time previous, the desires, 
 
 'As, for example, the ninth case of Jacobi ('Hauptformen,' etc.). Zeller and 
 myself have observed similar cases. 
 
196 STATES OF MENTAL EXALTATION. 
 
 the feelings, and habits of the patient have become entirely changed 
 and generally a tone of melancholy seems to pervade them. This ante- 
 cedent stadium melancholium, which may be of a very gentle and tran- 
 sient nature, is what has been termed the period of incubation of mania. 
 The melancholic gradually becomes very restless, nothing pleases him; 
 he is perjDetually wandering about ; he strays amongst the fields, or 
 makes excursions to see friends and relatives, frequently to far-distant 
 places, with the vague expectation of obtaining relief. He gives evidence 
 of his distressing delirium, when such exists, by talking in a loud voice, 
 and by his loquaciousness; his voice is stronger on such occasions than 
 usual, and he is generally more active. In particular, his appetite is 
 actually voracious; he frequently comjjlains of disagreeable sensations in 
 the epigastric region, of a feeling of oppression which extremely annoys 
 and torments him. Persons who have once had an attack of mania fre- 
 quently themselves say that they are going to have a relapse, and beg that 
 they may be watched and removed from their usual neighborhood. Fre- 
 quently such persons exhibit a great desire for spirituous liquors; and as 
 they yield to the desire usually in an immoderate degree, it seems as if 
 they would by the alcoholic stimulus perpetuate and increase their state 
 of excitement, wliich unfortunately they too often succeed in doing. 
 With the increased muscular activity and impulse to exhibit it in actions^ 
 new ideas and new sensations arise, which at first plunge the patient into 
 a state of astonishment and fear, but speedily end by gaining the com- 
 I^lete mastery. At the commencement he could conceal this state of 
 mind, but soon these new ideas and sensations slip out and display them- 
 selves in words and deeds. 
 
 Simultaneously with these psychical symptoms, there are usually pres- 
 ent in this first stage certain signs of derangement of the digestive func- 
 tions, of the circulation, and of nutrition. At first, there is a feeling of 
 illness, great prostration; pain in the head, teeth, and abdomen; sleep- 
 lessness, agitating dreams, hallucinations of the senses, vertigo; redness, 
 or, on the contrary, paleness of the countenance, emaciation, and a yel- 
 lowish tint of the skin; enormous appetite, foul tongue, and constipa- 
 tion; palpitation, frequent pulse, and a generally febrile state; suppres- 
 sion of the menses, and, not unfrequently, exaggeration of the sexual 
 desires. The form of the visage becomes changed; there is often slight 
 general trembling of the whole body; the sensation of heat and cold, and 
 of bodily pain, is weakened. When the mania is fully pronounced, the 
 feeling of illness disappears, and the patient expresses himself as quite 
 well. 
 
 We shall now proceed to examine more minutely this form of insanity 
 in its fully developed state; but before proceeding we must remark in 
 passing, that in consequence of the multiplicity and infinite variety of 
 symptoms of this form of mental disease, it will be necessary to divide 
 them into groups of phenomena, which, of course, will not all be found in 
 each individual case. 
 
 134. 1. Anomalies of the disposition, of the desires, and of the will. — 
 The fundamental disorder in mania, the irritation upon the motory side 
 of the soul-life, exhibits itself, first of all, in this sphere, as a high degree 
 of mental excitement, with restless, impetuous, and violent desires and 
 actions. The desire for ceaseless action and movement, the necessity of 
 immediately exhibiting in action all that passes within the mind, impels 
 him sometimes merely to harmless movements, as in dancing, speaking, 
 singing, shrieking, laughing, weeping, etc.; sometimes to restless, ob- 
 
STATES OF MENTAL EXALTATION. 197 
 
 jectless employment, which would attempt, according to the caprice of 
 the moment, suddenly and impatiently to alter everything around, some- 
 times to destroy everything animate or inanimate — a tendency which may 
 increase to outbreaks of the blindest fury and rage. But while this vio- 
 lent and unbridled impulse attacks all objects, rushes against every im- 
 pediment, and, totally regardless of consequences, shows itself in eccentric 
 and aimless actions, we nevertheless find in many of these patients a cer- 
 tain cowardice when they are energetically and decidedly resisted, or, 
 more correctly, a state of anxiety still remaining from the primary period 
 of the disease, and which appears not only to have originated the mania, 
 but also to maintain it. In such individuals Ave can discover no reason- 
 able act, no deed deduced from any rational train of thought, no care either 
 for their own or their family's existence, no possibility of being guided by 
 any rational principle; indifference towards all which does not directly 
 touch upon the point on which they are peculiarly sensitive; entire want 
 of interest in anything going on around; loss of all sense of decency, 
 modesty, and propriety. 
 
 The concrete mental acts which show themselves with such violence 
 consist either simply in certain rapidly changing dispositions, or in cer- 
 tain sentiments which have become fixed, and obscure groups of ideas 
 which manifest themselves in some particular determinate impulse. 
 Thus it is, that in consequence of a morbid exaggeration of the sexual 
 sensations, frequently arising from local cause, as pruritus pudendi or 
 ovarian disease, we see women exhibiting a morbid lasciviousness which 
 they display in the most shameless manner, and seek to gratify by the 
 most brutal means. The desire of possession may show itself as a per- 
 sistent propensity to collect and accumulate everything, or as a moi-bid 
 propensity to steal. The pleasure in loud speaking, in the rhythmical 
 form of conversation, in noise-making, in spirituous drinks, in satisfying 
 their appetite, iu shedding blood, etc. , may show itself in those violent 
 and boisterious ways, and there result fixed or transitory conditions which, 
 according to the predominance of this or that particular desire, are known 
 under the name of nymphomania, kleptomania, logomania, poiemata- 
 mania, dipsomania, edodomania, homicidal mania, etc. 
 
 Quite as various are the general anomalies of the self-sensation, the 
 morbid dispositions which show themselves in the exalted actions of the 
 patient. At times they exhibit a sorrowful, anxious, sour, angry, defiant 
 or savage disposition; they discover a great pleasure in damaging things 
 and doing mischief, and are exacting, evil-disposed, and malicious. 
 Sometimes, again, their -disposition is — and this is quite as common as 
 the foregoing — cheerful, gay, merry, and frivolous; the morbid notion 
 which they have of their own self-importance displays itself in a bound- 
 less hilarity, in a feeling of liberty and good fortune; they experience a 
 general contentment with everything, and are disposed to be on good 
 terms with mankind at large. 
 
 These different dispositions, excitement and prostration, overflowing 
 contentment and the utter want of it, alternate frequently: it is very 
 common to see maniacs pass suddenly and without any apparent cause 
 from joy to sorrow, from defiance to shrinking cowardice, from in- 
 difference in violent reaction to furious rage, from greedy covetoitsness 
 to contentment, from anxiety to blind confidence and temerity; and but 
 rarely does an external moral excitement succeed in producing, even for 
 but a short time, the slightest degree of calm and repose in this state of 
 perpetually changing versatility. 
 
 I 
 
198 STATES OF MENTAL EXALTATION. 
 
 Sometimes, particularly at the commencement of the disease, the pa- 
 tient himself complains of this necessity to commit violent deeds, and it 
 may be possible in such a case, by reasoning with him, or by some strong 
 mental impression, temporarily to restrain him, and to bring him again 
 to a momentary state of reason; in other cases it seems as if the patient, 
 in a state of semi-consciousness of his condition, gave himself up to the 
 exaltation when it has once begun, and gave tlie reins to the thoughts 
 whicli beset him; it seems as if he wished, when his will has thus got loose 
 and is no longer restrained, to revenge himself for that painful restraint 
 to which he has been subjected during the melancholic stadium of his 
 disease. 
 
 Jacobi has very properly called our attention to the wholly impulsive or instinc- 
 tive character of the maniac's acts. That which determines these is no true act of 
 volition — that is, the transformation of a dominant idea into action, with a cer- 
 tain consciousness of the object to be attained, and of the means necessary to 
 bring it about— and as little is it a state of profound passion which stirs the patient 
 into action; but the ever-running, noisy wheel of unrestrained mental movement 
 busies itself merely with the sensations, the vague oscillations of thought to 
 which men have given the name of feelings, the superficial emotions, the num- 
 berless momentary and accidental sensual excitements— these it is which alone 
 have any influence upon him, and to which he seeks to give expression. At first 
 the patient may be able to control this internal tumult, and, what is sufficiently 
 remarkable, we may see individuals who, when chided for their impropriety of 
 behavior, calmly reply, not without a certain air of irony, that everything is 
 allowed to thera since they are fools. The furious delirium of the maniac ap- 
 proaches in form to the passion of anger, but it does not spring from the same 
 motives regarded from a moral point of view; it is not the result of impressions 
 made upon the mind of ideas, of thoughts; it may spring up quite spontaneously, 
 or, on the other hand, it may be determined by impressions accidentally produced 
 upon the organs of sense, as by the light of the moon penetrating into a room 
 through a window— by a noise, a color, the sight of a person or thing which has 
 no earthly connection with the patient: any of these may be sulficient to pro- 
 voke it. . 1 . • 1 , T 1 
 
 Scarcely is it necessary to remark here, that because an mdividual displays 
 certain desires or dispositions during the course of his mania, we are warranted 
 in concluding that he may exhibit in his normal states similar propensities or 
 mental dispositions. For although we may sometimes see certain moral pecuhar- 
 ities which the individual habitually presents in health reproduced in his manner of 
 conducting himself and in his actions during his disease (e. g., eccentricity, capri- 
 ciousness, etc.), yet certain it is that the character becomes entirely changed: the 
 joyous man becomes gloomy, the serious man gay, the virtuous man obscene, 
 the sober man a drunkard, etc. Sometimes, it is true, certain propensities display 
 themselves for the first time, the very existence of which we had not even before 
 suspected, and of which we believed him totally ignorant; as, for example, when 
 an apparently modest girl utters obscene language which she could not possibly 
 have learnt for the first time during her insanity. 
 
 There are less intense cases of mania, when the patient, displaying certain pro- 
 pensities, gives himself up to them in a manner wholly regardless of propriety, 
 but which still present veiy transient derangement of the intellect, where one is 
 almost inclined to believe that the patient voluntarily indulges his evil desires 
 (kleptomania, nymphomania, dipsomania). However, what shows that this is 
 truly a morbid atfection, is the involuntary nature of these acts; the patient often 
 complains that he cannot resist the desire; and further, these acts have some- 
 thino- instinctive in the manner in which they show themselves: they come on in 
 fits with lucid intervals, they are frequently accompanied by other symptoms of 
 derangement of the general health, and tliey frequently come on after a preced- 
 ing stage of depression. Often enough, too, this state passes rapidly into one of 
 complete and unequivocal mania. 
 
 § 135. 2. Anomalies of the intellect.— The first and most important 
 change which the intellect undergoes in mania, consists in irritability 
 and quantitative exaltation analogous to that of the disposition and the 
 
STATES OF MENTAL EXALTATION. 199 
 
 will— in a more rapid flow of ideas. In its moet moderate degrees this 
 relation appears as an exaggeration of the normal faculty of thought. 
 The increased development and rapid succession of ideas call forth a 
 crowd of long-forgotten remembrances in new and vivid forms — there 
 is an exaltation of memory which, in some cases, presents the pecu- 
 liarity that the maniac is able, during the disease, to recite correctly 
 long pieces of poetry, which, before he was affected, and after his recovery, 
 he was incapable of doing. At times, also, they give utterance to 
 thoughts, combinations of ideas and opinions, to which in a state of 
 health they never could lay claim; frequently, according to the humor of 
 the moment, or stimulated by external circumstances, they draw curious 
 comparisons, ' exhibit a spirit of the most biting sarcasm, express them- 
 selves with extraordinary eloquence, and hazard, with great assurance, 
 the most daring opinions formed from an acute observation of the rela- 
 tive circumstances. 
 
 Such occurs, however, in only the minority of cases. Generally, from 
 the commencement, or at least very soon, the quantitative increase and 
 exaltation of thought are so great, that there results a restless and con- 
 .stant succession of isolated ideas which have no intimate relation with 
 each other, being merely connected by accidental external incidents, and 
 as they pass through the consciousness with great rapidity, and constantly 
 change their combinations, are very transitory and superficial, or of a very 
 fragmentary character. These ideas, which, owing to the extreme rapid- 
 ity with which they succeed each other, are very imperfectly developed, 
 bear the impress of the emotion which at the time governs the patient, 
 and are sometimes lively, supercilious, and extravagant; at others, gloomy 
 and menacing. They are in part provoked and their contents determined 
 by the impressions which the patient receives through the senses; and 
 these impressions themselves are often falsified by hallucinations and illu- 
 sions, or, as in many cases of delirium, imperfectly and erroneously 
 perceived, owing to the impression being only partly received and con- 
 sidered. On the other hand, there is presented to the perception, from 
 the inward, and in details incomprehensible, instinctive action of the 
 association of ideas, a countless number of images, words, figures, phra- 
 ses, which are often isolated and disconnected, often incessantly and 
 separately repeated in cries or singing, or at times collected together into 
 sentences, phrases, and speeches which the patient utters with the ex- 
 pression of the emotion dominant at the time. In certain cases, the 
 musical element of speech appears as a tendency to rhythmical expressions, 
 to assonance and rhyme: the patient then speaks always in verses,^ 
 which, indeed, contain very little poetry, being merely made up of sim- 
 ilarly sounding sentences and words. This has been termed " rliyming 
 delirium." 
 
 The principal modification or anomaly of the intelligence in confirmed 
 
 1 We have, for example, observed a patient who cOuld strikingly delineate any 
 slight resemblance to animals in the physiognomies of those ai'ound hina. 
 -' Two examples of this : 
 
 " Und es ist des Himmels Pflicht, 
 Dass man Gott ins Herze sicht. 
 
 So komm in den Garten. 
 Ei lass mich nicht warten. 
 Der Wein schmeckt mir bitter. 
 Schon naht des Gewitter," etc. 
 Bergmann, * Nasse's Zeitschr.,' 1833, ii., p. 419 ; Jacobi, ' Hauptformen,' p. 540. 
 
200 STATES OF MENTAL EXALTATION. 
 
 mania is, then, an incoherence of ideas which is the inevitable conse- 
 quence of the precipitation with which all the psychical phenomena are 
 executed, of the impossibility of the complete development of any single 
 perception, of the rapid emotional changes, and of the fantastic forms 
 in whicli their imagination clothes the impressions derived from the or- 
 gans of sense. Fixed or persistent delirious conceptions are not proper 
 to this condition, neither are they the result of a passionate imagina- 
 tion which the patient, while yet in good health, may have exhibited; 
 although often enough they may seem to warrant us in coming to this 
 conclusion; as, for example, when a maniac often manifests traces 
 of former mental impressions, we may be led to believe that he is incess- 
 antly occupied Avith certain mental causes which have led to his insanity. 
 Here, also, the possibility of a rapid change in the ideas, and the super- 
 ficial character of the entire alienation show that we have not to do with 
 persistent dominant ideas, such as are peculiar to states of profound 
 emotion. 
 
 But this is not to say that temporary delirious conceptions and false 
 ideas cannot be present in mania. On the contrary, they are very fre- 
 quent. Sometimes they consist in series of false opinions regarding the 
 external world, such as must necessarily result from the confused ideas 
 which, half developed, urge themselves into consciousness, and, in their 
 rapid course, often resemble fragments of abandoned ideas and false sen- 
 sorial impressions. Sometimes, however, delirious conceptions are i^resent 
 which have a much more important signification: here, also, they have 
 again essentially the significance of attempts at explanation of the morbid 
 disposition, and therefore relate only to the special ego. A haughty, 
 audacious, cheerful, gay, elevated frame of mind — the feeling of freedom 
 of action and exuberance of thought — call forth, according to the law of 
 causality, ideas of greatness, possession, riches, great moral or intellectual 
 power, etc., to which under such circumstances alone there is given alike 
 freedom of thought and volition. The exaggerated idea of freedom and 
 power must, however, have a foundation; there must be something in the 
 ego which corresponds to it; the ego must for the moment become another; 
 and this change can only be expressed by an image, Avhich any momen- 
 tary thought may create. The patient may call himself Napoleon, the 
 Messiah, God; in short any great person. He may believe that he is in- 
 timately acquainted with all the sciences, or offer to those around him all 
 the treasures of the world. He may also select characters which are quite 
 nonsensical: for example, he may say in the same breath, '' I am Napo- 
 leon," "I am this chair," ''I am you," etc. In such a case, he either 
 feels that he cannot fully express that which he actually desires to do, 
 and tries to make up for this by an accumulation of images; or he at- 
 tempts thus vaguely to establish a great omnipresence, to show that he is 
 in everything, which, indeed, is in accordance with his exalted frame of 
 mind. 
 
 But — and this distinguishes these incoherently combined desultory 
 delirious ideas from those of the following form (monomania) — none of 
 those remain fixed. Every temporary excitation brings with it new 
 images and ideas which dispel the old; the disposition itself is changeable; 
 and as each frame of mind passes off, no explanation is necessary — the 
 delirious conceptions have no time to develop and fix themselves by at- 
 tracting other similar ideas. The patient, it is true, frequently gives ex- 
 pression to these ideas in a loud and noisy way, but never in a tone of deep 
 conviction; indeed, he may even laugh at them. Those cases present a 
 
STATES OF MENTAL EXALTATION. 201 
 
 certain relation to children playing a comedy: they enter entirely into the 
 spirit of the play, and actually at the moment consider themselves heroes, 
 but at the same time know that they are not seriously considered such by 
 the spectators. 
 
 It is worthy of special consideration, that in many cases of mania, the intellect 
 — exclusive of the disorders we have just mentioned — seems to be very slightly 
 involved, and that no actual weakness or diminution of it is apparent. Fre- 
 quently, in spite of great incoherence of ideas, tne remembrance of the past 
 is not only perfectly true, but in many cases all that happened during the 
 period of the disease is even well remembered. Not unfrequently, the patient 
 may, by an appeal to his recollection, be for the moment withdrawn from the 
 whirl of ideas, and enabled to answer questions concerning his former life cor- 
 rectly, and even to narrate bygone incidents. Frequently, he understands so well 
 all that passes around him, and has so much control over himself, that a friendly 
 word, a threat, or a joke, or even an appearance of confidence in him, may cause 
 him to become calm for the moment. The perversions of the judgment, when 
 they do not actually consist of the forementioned attempts at explanation of the 
 disposition, depend inerely upon suppression, as if from want of time suflficiently 
 to connect the transient, fleeting, incoherent ideas ; sometimes, also, from the 
 predominance of certain series of perceptions which appear to the patient as 
 definite facts. Thus mania, viewed in the double light of a morbid anomaly of 
 the perception and of the will, presents the same general character of an affection 
 of the mind more superficial than profound ; and this is demonstrated, above all, 
 by the possibility of the sudden appearance of a lucid interval, and even of rapid 
 and complete recovery after the disease has lasted for years — of recovery in which 
 the patient, although his mind is much fatigued, may still be in the complete 
 possession of the former range of his intelligence, and in every way the same 
 mentally as he was before. Frequently, also, he can give an exact account of his 
 state during the disease ; and we frequently hear such individuals give vent to 
 expressions like the following statement made by a patient of Jacobi's : "It is 
 actually terrible when the thoughts so run into one another in one's head." 
 
 § 136. 3. Anomalies of sensorial function and of movement. — Hallu- 
 cinations of sight, of hearing, of smell, and of cutaneous sensibility, are 
 sometimes observed in mania, and not unfrequently they cause aggrava- 
 tion of the symptoms. Generally, however, they are of but little imj)or- 
 tance; they also speedily disajipear in the giddy haste of the mental 
 processes, and the patient cannot give them any prolonged attention. 
 Illusions of the senses, false interpretations of sensorial perceptions, are 
 much more frequent: the patient, for example, takes a stranger for an 
 old acquaintance, or when he hears any noise thinks that some one is 
 calling to him. False judgments in this case, as in the delirium of 
 fever, ordinarily depend upon non-consideration of certain parts of the 
 sensorial impressions, and paying great attention to others, and upon 
 superficial similarities. 
 
 There is also sometimes observed an exaggerated sensibility to impres- 
 sions of sight and of hearing. Sometimes, also, there is dilatation or 
 contraction of the pupils. 
 
 As to the organs of movement, there generally exists in mania a con- 
 tinual impulse to contractions of many muscles. The movements of the 
 body, and especially those of the organs of speech, participate in the 
 state of psychical exaltation. They are active, rapid, energetic, inasmuch 
 as the speech, cries, gesticulations, and actions of the patient all tend to 
 outward manifestation; his countenance and expression are lively, intense, 
 and peculiar. Much has been said of the extraordinary strength, of the 
 actual increase of muscular power in mania (Esquirol, Pinel, Ideler, etc.). 
 In the vast majority of cases there is no such increase of strength; the 
 patient, so far from being stronger than in health, can be easily nuistered 
 by a single attendant, and the appearance of increased bodily power 
 
202 STATES OF MENTAL EXALTATION. 
 
 generally arises merely from the regardlessness with which the patient 
 executes muscular movements during the maniacal attack. On the other 
 hand, it is correct and very remarkable that the patients can continue, 
 often /or a very long time, to make use of their muscular power, and to 
 an extent which far surpasses their capability during health. Such indi- 
 viduals frequently pass whole weeks, and even months, almost without 
 sleep, a j^rey to the most violent fury; and the possibility of such enor- 
 mous muscular exertion appears only explicable by the assumption that, 
 owing to an abnormal state of the muscular sensibility, the patient has 
 no feeling of fatigue. We see, in fact, maniacs in whom the nutrition is 
 very much lowered, thinking and declaring that they are very strong, and 
 believing themselves capable of any fatigue, while at the same time the 
 great emaciation, and the exhaustion which succeeds the attack, unmis- 
 takably demonstrate that the organism cannot bear those exertions with 
 impunity. 
 
 Sometimes, also, actual convulsions are observed in the organs of 
 movement — grinding of the teeth, twitches of the countenance, or more 
 extended convulsions, the latter occurring sometimes during waking, 
 sometimes during transitory fainting-fits and ecstatic states. Partial 
 paralyses are much more rare in mania; on the other hand, very fre- 
 quently the first commencement of general paralysis shows itself during a 
 moderate attack of mania by the uncertain movements of the tongue. 
 
 Amongst the other symptoms of mania, troubled uleep is very common — in 
 many cases persistent complete sleeplessness. Again, too much ought not to be 
 expected from a calm sleep during the course of the disease, as the most violent 
 exacerbations occasionally ensue after the quietest nights, and, on the other hand, 
 even convalescents frequently continue for a long time to complain of sleepless- 
 ness. 
 
 Anomalies of sensation of the most various forms may present themselves in 
 mania — lieadache, vertigo, heat, aura-like sensations arising from the chest, ab- 
 normal cutaneous sensations, pains in the Umbs real or apparent (owing to indif- 
 ference), insensibiUty to heat or cold ; actual anaesthesia is much less frequent 
 than was formerly supposed (§ 50). 
 
 Ill many cases there is observed an enormous increase of the appetite ; and 
 this is frequently directed to uneatable and indigestible things. Absence of the 
 feeling of satiety appears to be the cause of this voracity, as it is in no way regu- 
 lated by the degree of expenditure of muscular force. Not unfrequently, how- 
 -ever, the demand for nutriment is not at all heeded, the patient quite neglecting 
 to eat. That desire to eat their own excrements, which sometimes exists, seems 
 to indicate profound perversity of taste and complete absence of the sentiment of 
 disgust. 
 
 An increase of the sexual instinct forms, in many cases, the centre-point of the 
 morbid ideas and efforts ; in other cases it is only accessory and moderate, often 
 it is entirelj' absent. It is manifested by obscene language and writings, in 
 movements of the hands, exposing the person, onanism, etc. On the whole, it 
 appears to occur more frequently in female patients. Irregularity and suppres- 
 sion of the menses exist in the great majority of cases : their re-establishment has 
 often no effect upon the mental state, often it has an aggravating influence ; at 
 other times it appears coincidently with recovery. 
 
 Changes in the organs of circulation and digestion are not alwaj's present. 
 Although it is of great importance, when such derangements exist, that they 
 should be minutely investigated, in order to establish the indications of treatment 
 in individual cases, yet they are of little importance in the diagnosis of the mania 
 itself. Then the pulse is sometimes of normal frequency and fulness ; it is seldom 
 slower, more frequently a little faster than usual, and rather small and full. 
 Nervous palpitation and the ordinary signs of chronic organic heart-disease are 
 here, as in mental disease generally, of only ordinary frequency. According to 
 observations made in the asylum at Vienna, the heart-sounds are indistinct during 
 great excitement, and become again clear when calm sets in. It is not uncommon 
 to see considerable, sometimes very great cerebral congestion, redness of the face 
 
STATES OF MENTAL EXALTATION. 203 
 
 and heat of the head. It is only exceptionally that the countenance is pale ; 
 sometimes it presents a cyanotic hue ; the eyes are sometimes injected. 
 
 In the vast majority of cases there is no fever present. The temperature of 
 the body, as determined by the thermometer, is normal or somewhat diminished; 
 it is only during the maniacal excitement of progressive general paralysis that 
 the Ufemperature of the body is said to be increased. (L. Meyer, ' Charite-Annalen, ' 
 viii., 2.) 
 
 The tongue is often furred, and the salivary secretion increased ; the patient 
 seldom complains of thirst, except where it is caused by an immoderate desire for 
 alcoholic liquors. Frequently the bowels are irregular and constipated, as is 
 usually the case in cerebral diseases generally. 
 
 The majority of maniacs appear emaciated, notwithstanding their increased 
 appetite. Owing to this and to the tension of the countenance, they appear older 
 than they actually are. The diminution of the nutrition is very frequently due 
 to former morbid states— anaemia, febrile diseases, or even to the melancholia. 
 Without doubt, however, the emaciation may also be owing to the increased 
 evolution of force and want of sleep in mania. In some cases, also, it is the result 
 of tuberculosis or of some other serious disease. ; There are innumerable varieties 
 of these accessory symptoms, the result of former or existing disease of other 
 organs, and which need not always necessarily be closely connected with the 
 insanity. 
 
 § 137. As to the invasion and course of mania, it is observed some- 
 times as a pure and independent form of mental disease, as we have 
 hitherto considered it — as a stage of development in the successive series 
 of mental disorders ; sometimes transient attacks of mania, or more cor- 
 rectly of fury, occur in individuals who are already subjects of profound 
 mental disease, especially in all the various forms of mental weakness. 
 These attacks are frequently owing to external causes; for example, to 
 anger : frequently also they are caused by hallucinations.' Here, the 
 characters of the chronic affections, in particular the weakness of the 
 intellect, are always combined with the symptoms of the acute attacks. 
 These paroxysms are connected with those convulsive states which occa- 
 sionally appear during the course of paralysis. 
 
 In epileptics, also, it is not uncommon to observe attacks of mania 
 which are often characterized by a high degree of blind fury and ferocity. 
 Sometimes they immediately follow the epileptic attack, as if the excita- 
 tion to the tumultuous motory movements were simply transferred to other 
 parts of the brain. 
 
 Anaemic states appear to predispose more to the outbreak of mania 
 than states of plethora. Profuse haemorrhage (as in childbed, menor- 
 rhagia, frequent bleedings), states of exhaustion after typhus fever, or 
 after rapidly advancing tuberculosis or prolonged excesses, may in many 
 cases be recognized as proximate or predisposing causes. The acute menin- 
 gitis of adults is frequently accompanied by a delirium which resembles 
 mania in every respect ; and occasionally there is afterwards developed 
 from this disease a more chronic form of mania. 
 
 During the cottrse of mania there is usually an alternation of reniissions 
 and exacerbations, and it is not unusual to see even complete remissions. 
 Thus, cases have been observed in which the patients during entire 
 months were only maniacal on alternate days, with completely free inter- 
 mediate days — a mode of cerebral affection in every way analogous to 
 other rhythmical neuroses. Very often an exacerbation occurs during 
 the menstrual period, at other times violent paroxysms and remissions 
 occur without any appreciable cause, perhaps in consequence of changes 
 
 • Neumann (' Psychiatrie,' p. 74) remarks that these attacks of fury increase in 
 presence of others, while in simple mania the patient generally becomes quieter 
 on the entrance of the physician or attendant. 
 
204 STATES OF MENTAL EXALTATION. 
 
 which take place in other chronic morbid states which accompany tlie 
 mania ; in particular, we sometimes see complete free lucid intervals set 
 in quite suddenly and unexpectedly. 
 
 Melancholia often alternates with attacks of mania ; occasionally 
 there is a regular (for example, at certain seasons of the year) alterna- 
 tion of exaltation and depression {folie circulaire of the French writers). 
 In these cases the melancholic stage is generally somewhat more prolonged 
 than the maniacal, which consists rather in a state of general excitement 
 and restlessness than in actual mania. At other times we see attacks of 
 mania occur after regular or irregular lucid intervals every one, two, three 
 years, etc. — iKriodkal mania, a grave form, a real psychical epilepsy 
 which shares the unfavorable prognosis with ordinary epilepsy which has 
 become habitual. 
 
 Mildner ('Psychiatr. Corresp. Bl ,' 1857, No. 17) communicates an interesting 
 case where an individual of limited intellectual capacity, with insufficiency and 
 naurmur at the aortic valves, in consequence of a violent shock fell into an attack 
 of mania which lasted for only an hour and a half, and returned twice or thrice 
 in the year. The very transitory maniacal attacks (mania transitoria of very 
 short duration, occurring in the course of apparently perfect health) may be all 
 the more readily compared with attacks of epilepsy, as sometimes even the latter 
 end in mania. In a medico-legal point of view, it is, of course, quite the same 
 whether the state of mania during which the crime was committed was of long 
 or of short duration. It is of great importance to know that undoubtedly such 
 quite transient attacks actually occur. 
 
 The single paroxysms of mania last sometimes only a few hours, 
 sometimes entire months ; frequently there is observed after the first few 
 weeks a considerable remission. Sometimes it appears as if the parox- 
 ysms of mania constituted a sort of resolution and compensation for the 
 former state of mental pain, in the same Avay as we see in epilepsy and 
 hysteria many disagreeable and painful sensations which precede the 
 attack disappear with it. Maniacal attacks which are mild and moder- 
 ated by remissions may last for many years. 
 
 It is a well-known fact, that very often during the course of mania 
 the symptoms of other serious diseases are arrested in' a remarkable 
 manner; in particular, the patients seldom or never complain of pain; in 
 phthisis they cough very little, and can speak and cry vociferously. This 
 is not to be considered as an actual arrest of such organic diseases; on 
 the contrary, they continue their course of destruction of the organ, as 
 is shown by the objective symptoms; but an anomaly of sensation similar 
 to the absence of the feeling of fatigue and of hunger which, combined 
 with the patient's absorption in this delirium, renders him little liable to 
 subjective impressions. 
 
 Maniacs may recover suddenly, or this favorable result may be gradu- 
 ally arrived at after progressive diminution of the symptoms. The 
 excitement ceases, the lucid intervals become more frequent and longer, 
 the behavior becomes gradually more orderly; the patient again inquires 
 concerning this or that person, experiences ennui and tries to recover 
 himself. Sometimes, also, we observe that the cessation of the mania is 
 coincident with the appearance of some other disease; for example, 
 intermittent fever, diarhoea, skin diseases, furunculi, etc. We ourselves 
 have in certain cases observed such so-called critical appearances; gener- 
 ally, however, they are absent; and the statement of Esquirol, that no 
 recovery is to be considered permanent which is not accompanied by a 
 well-marked crisis, appears to us to be entirely Avithout foundation. The 
 most trustworthy symptom of recovery is the return of the former 
 
STATES OF MENTAX, EXALTATION. 205 
 
 desires and pursuits of the patient, and of his unimpassioned behavior 
 a.nd acknowledgment that he is really ill. We have on several occasions 
 seen the observation made by Jessen very strikingly confirmed, that a 
 relapse is especially to be guarded against in cases where the (apparently 
 calm) patient feels remarkably well, and speaks wdth exuberant joy of his 
 complete recovery. Even those who are completely cured are always 
 l^redisposed in a high degree to a return of the disease. 
 
 In individual cases, our ojnnion concerning the curability of the dis- 
 ease is regulated principally by the symptoms which the patient presents 
 of more or less presumable organic disease of the brain. Those cases 
 may be considered absolutely incurable in which symptoms, however 
 slight, of general paralysis are present (see § 4) ; all symptoms of jjersist- 
 ent convulsions or paralysis in the extremities, of the facial nerve, or of 
 the pupils, are equally unfavorable. These symptoms, at least when 
 they are not quite transitory — occurring, for example, in consequence of 
 temporary but violent cerebral congestion,' — appear to indicate a perma- 
 nent extension of the morbid process to the parts situated at the base or 
 in the centre of the brain. Indeed, the cerebral hypertemias which are 
 so frequent in mania may occasion the development of exudations and 
 their further transformations. The more the disease is prolonged, the 
 less it is interrupted by lucid intervals and remissions; and tlie more 
 intense the hyperaemia, the more these exudations are to be feared. The 
 great majority of recoveries from mania take place within a year from 
 the commencement of the disease: nevertheless, cases occur where recov- 
 ery takes place after the disease has continued for six or seven years, 
 generally with radical constitutional changes in the organism of the 
 patient. Great violence and fury in the attacks are in no way unfavor- 
 able in regard to the curability of the disease, no more than violent 
 hysterical attacks are of evil omen in the prognosis of hysteria. Accord- 
 ing to all the observations which have hitherto been made, the periodic 
 intermittent form of mania must in general be considered incurable. 
 
 The fact that in many cases the prognosis depends much less upon 
 the cerebral disease than upon the presence of other local or general 
 affections — for example, phthisis, great anaemia, hydraemic or scorbutic 
 states, etc. — requires no further explanation. Not unfrequently, conva- 
 lescents from mania fall into a condition of profound bodily and mental 
 weakness, which at first cannot with certainty be distinguished from 
 transition into dementia; sometimes the disease terminates with a short 
 stage of melancholia. 
 
 When the patient does not recover, the mania may, with the greatest 
 outward calm, be transformed into the form of monomania, or may 
 degenerate into one of the chronic secondary states of mental weakness 
 — into one of the various forms of dementia, with or without intervals 
 of agitation. 
 
 In mania, death may result from the cerebral affection itself, in con- 
 sequence of violent hyperaemia of the brain, or more rarely of apoplectic 
 extravations. Frequently the patients die in a state of exhaustion, with 
 the symptoms of collapse (as frequently occurs in epilepsy), in conse- 
 quence of acute or chronic disease in other organs, as pneumonia, pleurisy, 
 carbuncle, violent intestinal catarrh, phthisis, etc. Accidents, such as 
 leaping from a window, etc., are, in this form of insanity, not unfre- 
 quently the cause of death. 
 
 See the chapter on " Pathological Anatomy." 
 
206 8TATES OF MENTAL EXALTATION. 
 
 Example XXXII. — Simple mania, ivith sexual excitem,ent and cleptomania ; 
 recovery. — Gottfried Demons, aet. 22, of delicate constitution. During childhood 
 he liad been been frequently affected with eruptions of the scalp : his character 
 is peculiar, and his intellect weak. His maternal grandmother had been insane 
 for seven years, and he, at tlie age of nineteen, fell into a state of melancholy, 
 which, imder the use of remedies, disappeared in three months. At twenty-one, 
 he suffered for some time from obstinate constipation and vomiting. In May, 
 1811, on reading the narrative of a traveller, he felt himself deeply affected by the 
 hardships which that individual had had to endure. The following day he com- 
 plained of being ill at ease, and an emetic was administered to him. Two days 
 after, the patient was seized by an attack of persistent fury and incoherent talk 
 (large doses of tartar emetic and purgatives). During the fifteen days which fol- 
 lowed, he had, at different times, lucid intervals of several hours' duration, but 
 they were always succeeded by an attack of fury. Nevertheless, these attacks 
 gradually diminished in intensity ; towards the middle of June they became more 
 rare, and the patient chatted continually from morning to evening. During the 
 night, however, he enjoyed several hours of calm sleep. The pulse was tranquil ; 
 the countenance worn ; the appetite increased ; the bowels constipated. At times 
 some slight convulsive movements '"ere observed in the limbs. 
 
 A month after the commencement of the illness, the patient was taken to 
 Siegburg. During the first ten days which followed his admission, he remained 
 in a state of constant delirium and incoherency, and exhibited a tendency to 
 commit acts of violence on those who suiTounded him. Nevertheless, it was 
 generally during the day that he had his attacks of fury, and during the night he 
 had generally several hours of calm slumber. Although during the paroxyms he 
 indulged constantly in violent movements, the pulse never rose above from 70 to 
 80. The temperature of the body was almost normal ; the tongue was clean and 
 moist ; the patient spat often ; the stools were costive. Towards the end of July, 
 the intensity of the maniacal attacks diminished, although the invalid was always 
 a prey to a certain state of excitement and extraordinaiy confusion ; he talked 
 nonsense tlie whole day, but his ideas had not the least connection, and no trace 
 of a dominant idea could be found in his talk. He was still dirty, and attacked 
 his food with brutal gluttony, etc. The nights were generally calm ; the pulse 
 and the temperature of the body continued almost normal (extract of belladonna 
 for four weeks ; then tincture of digitalis from the beginning of October to the 
 end of December). Under the influence of the latter remedy, the pulse fell some- 
 times to 50. In the carotids it was fuller and more tense than formerly. The 
 patient had, from time to time, a tendency to epistaxis. On the other hand, it 
 was tlien observed that he had an excitement of the genital organs which had 
 not been before observed. He attacked all the maid-servants whom he saw, and 
 indulged in onanism without shame. Otherwise, from a psychical point of view 
 his state had changed very little, except that from th3 end of October he was 
 somewhat less confused in judgment ; but the emotional perversion had rather 
 augmented, and he exliibited a manifest disposition to steal — an inclination which 
 had never been observed in him while in health. From time to time he still 
 suffered some paroxyms of maniacal excitement, which again necessitated the 
 use of the strait-jacket to prevent him from committing acts of violence. 
 
 At the commencement of January, the use of these remedies was stopped. 
 Every two days the patient received a douche of twenty buckets of cold water 
 poured on the head ; and every week three leeches were applied to the nostril. 
 He now improved in a surprising way. By the end of February, he could answer 
 correctly aU simple questions. The attacks of maniacal excitement completely 
 disappeared, as well as the disposition to steal and the venereal tendencies. After 
 a short time his intellect was restored ; his conduct became regular. He quitted 
 the asylum in July, after having spent a year in it. (Jacobi, ' Die Hauptformen,' 
 i., 1844, p. 81). 
 
 Example XXXIII.— ilforaZ causes ; mania unth tendency to derision, nym- 
 phomania {prurigo pudendi). Recovery. — Catherine J — , a?t. i>9, without any 
 hereditary tendency to insanity, enjoying good health, exhibited, while quite a 
 young girl, deeply rehgious feelings, at the same time a very amorous disposition. 
 She married one of her near relatives, after having had a child by him. After a 
 year and a half she lost her husband. He was very rich, and had often lent 
 money, taking securities for it upon property, which forthwith he caused to be 
 sold and bought in. He was, accordingly, universally hated ; and it used to be 
 said, after his death, that on several occasions he had been seen, during the night, 
 in the form of a phantom of fire, passing over the lands which he had thus 
 
STATES OF MENTAL EXALTATION. 207 
 
 bought. Catherine was greatly alarmed by this report, to which she was ready 
 to give credence. She fell at first into a state of agitation and anxiety, brooding 
 over a thought which had troubled her before, namely, that by reason of her near 
 relationship to her husband, the marriage which she had contracted with him 
 was nothing but a concubinage, and that the phantom nad come to reproach her 
 with the crime, as well as witli the property which her husband had acquired by 
 his forced sales. She then conceived the idea of restoring these possessions to 
 their former owners ; she examined conscientiously the titles of the property, and 
 the means by which her husband had gained his fortune. She obtained in tliat 
 way the proof that, as far as she was concerned, the property had been legally 
 acquired : but that gave her not the least tranquillity; the apparition of lier husband 
 under the form of a spectre of fire was always present to her mind. She remained 
 calm, silent, and cold before company; her eyes remained fixed on the same 
 point. She saw and heard nothing, save the profound restlessness which tor- 
 mented her within. This state of things continued for about two months, when 
 she became agitated, unable to remain at home, coming and going to and fro. 
 Then she set out to go to her friends at Riedelheim. When she arrived, she gave 
 herself up to a perfect extravagance of politeness and of compliments, expressing 
 herself with extraordinary elegance ; then, on the following night, she began to 
 cry out " Fire !" came in in extreme terror, and tore her garments (bloodletting, 
 cold application, clysters, etc.). 
 
 I was then called in. When I entered her room with one of her neighbors — a 
 man of dry manners and very little given to compliment, who had a long nose, — 
 she advanced towards me in a friendly way, asked how I did, and made me a 
 profound bow. Then she turned several times on her left foot and burst into 
 laughter. Her neighbor observed to her that it was unbecoming to behave in 
 that fashion before the doctor. ' ' Idiot ! " she answered, ' ' ask the doctor to help 
 you to comprehend; you might reach it with your long nose." She then began to 
 cry out, and to call him names, and wished to bite him. He got out of the way. 
 She then leapt with great adroitness on the couch, and from that on the foot of 
 the bed, where she began to dance like a rope-dancer. She sang, wept, and 
 laughed by turns. She never ceased to talk foolishly, flashing out ideas quite 
 incoherent and without connection, and which were without meaning, except 
 that she was enraged. She seemed a satyi". At the door there was an opening 
 through which she could see into the street. Upon all who passed in front she 
 made wicked, although partially true, observations, relative to the bad side of 
 their character, or to ridiculous incidents in their lives. At times she ran from 
 one corner of the room to another, as if she were scared by something; again she 
 would make violent and rapid movements of the right arm, as if she struggled 
 with a spectre; but she never had a moment's rest. The face was pale, but when 
 the patient was furious it became red. The veins of the brow became swollen 
 like a quill; the eyes injected; the lips red; the countenance menacing; all the 
 muscles tense. She tore her dress; knocked on the window, and scraped the 
 walls. She had an enormous appetite, and ate voraciously the food that was 
 given to her. She made water and went to stool without concerning herself 
 whether any one was near. 
 
 By night she slept for only a few hours; immediately when the rays of the sun 
 appeared she was again agitated. Her menstruation was regular; at the time of 
 her courses the paroxysms were most intense. Whenever ideas having any con- 
 nection came, they were biting sarcasms. She named her guardian Monsieur 
 Robespierre, and she added, "In German, that means M. the valet of the execu- 
 tioner." After a few coherent thoughts, there came all at once an uninterrupted 
 flow of words completely devoid of sense; although sometimes amid this confused 
 nonsense there might be distinguished some ideas relating to maternal love. 
 
 She continued in this condition during several months; then I was again asked 
 to visit her. I found her in the following state:— Except sight and hearing, the 
 other senses were gone. She was nymphomaniac in a high degree; rubbing the 
 genital organs, swearing at her unsatisfied desires; asking for men, etc., etc. All 
 this formed an assemblage of symptoms which could not be mistaken. 
 
 I subjected the patient to prolonged walks along unfrequented roads; and 
 when she had a violent attack of fury, I gave her 50 drops of the distilled water 
 of bitter almonds concentrated. The fury ceased immediately. The patient sank 
 down on a mattress which was beside her. and remained calm. But at the end 
 of two hours the /wror wferwrns returned, the patient believing that she saw in 
 every man an old lover (distilled water of almonds, 50 to 150 drops, three times a 
 day). The sense of touch and of taste seemed to return somewhat; the patient 
 
208 STATES OF MENTAL EXALTATION. 
 
 talked a little, although very vaguely, of her children, but she always thought 
 she saw her lovers around her. The attacks of mania became shorter and more 
 rare; the patient obtained a little more sleep, and remained also more calm in bed. 
 We could already suggest to her the memory of certain important circumstances in 
 her life. When she took to raillery, that generally betokened the near approach 
 of an attack of fury; and when her raillery became refined and intellectual we 
 might count on the certain approach of an attack. She did not any longer tear 
 her dress, but, on the contrary, she liked to attire herself neatly; she no longer 
 spoiled articles except at rare intervals, and the least repremand was enough to 
 cause her to conduct herself becomingly. As in the case of children, it was neces- 
 sary to resume her education at the first elements, and to lead her progressively 
 to a higher stage. But the attacks of furious delirium did not yet altogether cease. 
 In the mterval of the occasions when she took her medicine (water of bitter 
 almonds), and ordinarily two hours after having taken it, she was seized by an 
 attack of fury and an immoderate desire of coition. Fifteen days after each 
 menstrual period, little bleedings of ten ounces were taken from her. From that 
 time the attacks of delirium became rarer, and the patient began to complain of 
 itching and heat in the genital organs. Then gradually the patient was induced 
 to work. Good example and good counsel led her back to religions convictions, 
 and she was at length cured after a year's illness. (Velten in Nasse's 'Zeit- 
 schrift,' 1820, p. 709.) 
 
 Example XXXIV.— Two attacks of mania, each after strong impressions of 
 smell during confinement and nursing; a third attack after a premature birth. 
 Recovery. — R— , set. 34, was admitted to the asylum on the 10th November, 1813. 
 She is of soft temperament, but very sprightly; tall; hair of chestnut color; eyes 
 large and brown. At sixteen, menstruation set in without difficulty ; at twenty- 
 four, R — was manied. 
 
 In her twenty-sixth year, three days after her first confinement, a lady perfumed 
 with musk came to see her. Immediately she became delirious; nevertheless, 
 she continued to suckle her infant, which died at three years of age. This first 
 attack was characterized by mania with fury, and lasted only two months. It 
 ceased suddenly after a sudden fright. Since this first attack, thi^ woman has 
 continued very susceptible. Every spring she was subject to exaltation unaccom- 
 panied by delii-ium, which was dispelled by the use of antispasmodics. 
 
 In her tliirtieth year, while R — weaned her infant at the age of one year, she 
 went to the shop of a man where there was painting. The smell immediately 
 excited delirium, which increased during five days, and was succeeded by inania 
 with fury. On the fourth of August, 1809, she was admitted to the Salpetriere. 
 Very marked abatement; R — is calm, and seems in possession of her reason. Her 
 husband solicits her dismissal, and obtains it on the 12th October following. 
 From the second day after her dismissal, return of delirium, of mania; stoppage of 
 menstruation; abdomen swollen. Returned to the asylum the patient becomes 
 quiet on the approach of winter. In December, the courses are re-established, 
 and R — leaves the asylum June, 1811. 
 
 In her thirty-fourth year, 1st November, 1813, premature birth at two months; 
 haemoiThage. From the second day, great talkativeness. 3d November, mania, 
 fury'; the patient is taken to the asylum. On her arrival, her eyes are haggard; 
 her face pale; look abashed; general raving; mania, fury. Three days after, she 
 is calm, and recognizes the fact that she is in the asylum. 
 
 On the 16th November, the courses cease. The patient sees her husband with 
 evident interest; she is sad, but her answeres are accurate. On the 28th, fever; 
 gastric oppression; copious ejection. Since that time her ideas are connected; R— 
 is calm, and engages in work; gradual return to reason. 
 
 On the 21st December, R— leaves the asylum quite sane; although the courses 
 are not perfectly re-established. (Esquirol, translated by Bernhardt, i., 1838, p. 
 152.) 
 
 Example XXXV.— Paroxysms of fury, accompanied by attempts at murder, 
 coming in the place of epileptic attacks.— A peasant, born at Krumbach in Swabia. 
 whose parents did not enjoy the best health, set. 27, and unmarried, was subject 
 from his eighth year to epileptic attacks. Two years ago, his disease changed its 
 character without any one being able to account for it; and in place of epileptic 
 attacks, the man found himself seized by an irresistible disposition to commit 
 murder. He feels the approach of the fit several hours, and sometimes a day, 
 before it conies on. Immediately when he has the presentiment, he earnestly 
 asks to be tied up and boimd with chains, lest he commit some crime. " When 
 it takes me," he says, "I must kill— I must strangle, were it only an infant." 
 
STATES OF MENTAL EXALTATION. 209 
 
 His mother and father, whom, for all that, he loves dearly, were the first victims 
 of these fits: " Mother," cried he, in a loud tone, " save yourself or I must strangle 
 you." 
 
 Before the fit, he complains of being overpowered by sleep, and yet without 
 being able to sleep. He feels himself greatly exhausted, and experiences slight 
 convulsive movements in the limbs. During tlie fit, he retains the consciousness 
 of his own existence, and knows pei'fectly that in committing murder he is guilty 
 of a crime. When he has been placed beyond the reach of doing harm, he makes 
 contortions and frightful grimaces, sometimes singing, and sometimes speaking 
 in verse. The fit lasts from one to two days. When it is over, he cries, " Unloose 
 me. Alas ! I have suffered greatly ; but I have got out of it well, since I have 
 killed no one." (Esquirol, von Bernhardt, ii., p. 371.) 
 
 § 138. More minutely to describe the various forms of mania repre- 
 sented by authors would be of no special interest. They are arranged, as 
 we have ali'eady indicated in a former paragraph, partly according to the 
 various tendencies and desires which manifest themselves in a prominent 
 manner (nymphomania, mania saltans, furor poeticus, etc.), partly 
 according to the various causes of the disease (mania puerperalis, parturi- 
 entium, potatorum, etc.). As to the latter form, delirium tremens, in all 
 cases in which it is well marked, it consists in a generally moderate degree 
 of mania, which is likewise almost always preceded by a short stage of 
 melancholia, and with which there are ordinarily, at the same time, 
 present some degree of stupor, trembling of the limbs, persistent sleep- 
 lessness, and copious perspiration. Frequently a state of anxiety is pres- 
 ent during the whole maniacal period, and keeps up the excitement; very 
 frequently there ar^ also hallucinations of sight of the most varied de- 
 scription, which in the great majority of cases consist of phantasms of 
 animals, mice, horses, birds, etc. : the delirium also turns upon various 
 other illusions and phantasms of a predominantly sad and anxious 
 nature. 
 
 We shall not here enter into details regarding deliriuvi tremens. It is not 
 usually classed amongst mental diseases, and owing to its short duration is not 
 often met with in asylums. Nevertheless, the institutions of large towns are 
 constantly liable to receive a number more or less considerable of these cases; their 
 statistics are on that accoimt, as compared with other asylums, essentially modi- 
 fied (much more favorable). Of 322 delirium tremens patients admitted into the 
 Bloomingdale Asylum at New York, 20 died, 286 recovered, and 16 were still 
 under treatment: the fatal issue occurred generally within the first week. (P. 
 Earle.) 
 
 The nymjihomaniaeal states, ^. e. those of increased sexual excitement in the 
 female sex. do not always manif3st themselves by an open expression of the sex- 
 ual excitation; more frequently they assume a milder form, such as flirting, love 
 of dress, freedom of conversation and a certain familiarity with the physician, 
 much talking about marriage, little equivocations, etc. We frequently observe 
 in women affected with this form of mania, a constant desire to wash the body, 
 to comb the hair, to destroy their clothes, to spit at people, to scold the female 
 attendants, to suspect other women in a sexual respect. (See Neumann, ' Psy- 
 chiatrie,' p. 79.) These states often last for a long time. Finally, mania with the 
 character of nymphomania sometimes assumes the form of an acute affection, 
 leading rapidly to exhaustion and death: in these cases there is generally acute 
 inflammation of the internal organs of generation. (L. Meyer, Virchow's ' Archiv,' 
 ix., 1856, p. 98.) 
 
 Those cases which several French observers (particularly Brierre) have 
 described under the title of acute delirium (delire aigu), appear to merit 
 being distinguished as a special form of mania, and to demand further 
 investigation. These cases are characterized by the rapidity of their out- 
 break; by furious delirium with incessant incoherent, senseless chattering, 
 but with the dominant expression of anxiety, and, frequently, ideas of 
 14 
 
210 STATES OF MENTAL EXALTATION. 
 
 being poisoned; by vertigo, awkard trembling movements, as if the patient 
 were half intoxicated; frequently, slight muscular contractions, sleepless- 
 ness, paleness of the countenance, dry tongue, rapid exhaustion. Accord- 
 ing to Bierre, these states are often accompanied by fever; they last from 
 a period of from several days to six or eight weeks, they often terminate 
 fatally through sudden collapse; after death, hypertemia of the cerebral 
 membranes, or nothing at all, is found. 
 
 Cruveilheir and Abercroniby have already described such cases. See Brierre, 
 'Union Medicale,' 1849, and ' Memoires de 1' Academic de Medecine,' torn. xi. ; 
 Luther Bell, ' Amer. Journal of Insanity,' 1849 ; Jensen, ' Zeitschrift f. Psychia- 
 trie,' xi., 1854, p. 616. 
 
 § 139, The frequent states of incompletely developed mania are of great 
 practical importance; in the majority of cases they represent the first 
 stage of exaltation which precedes the outbreak of mania or of monomania, 
 or a period of remission between two maniacal attacks, or even a stage of 
 termination of mania. Occasionally, however, this state continues for a 
 long time in the same manner, and it may then very properly be con- 
 sidered as a special form of insanity with tlie character of exaltation. We 
 have already in part made mention of this state as a relatively mild mode 
 of expression of certain desires and instincts, while the patient still shows 
 no striking disorder of the intelligence. Frequently, however, there is. 
 also observed a general increase of volition not concentrated upon a defi- 
 nite series of objects; and this is manifested as an uncommon and incon- 
 stant activity and restlessness, as an ardent desire always to begin 
 something new, as a necessity to alter and remodel the external world 
 according to eccentric projects. Such patients have always something to 
 do — speculations to enter into, to buy or to sell, to present, to build, etc. ;, 
 all they see or which happens to them they would have and possess, and 
 very often they thereby spend large sums in a very sliort time. Ordi- 
 narily, they are very vain, show a desire to be considered great and to 
 excite admiration; their demeanor is confident and arrogant: the humor 
 generally changes rapidly from joy and frolick to depression, and again 
 to violent outbreaks of anger, the latter especially when their actions are- 
 opposed and their pride hurt. Some show a tendency to cunning and in- 
 trigue — others a desire to steal, to drunkenness, erotic tendencies, expan- 
 sive religious ideas. The patients generally talk a great deal, loud and 
 rapidly, but without special delirium; their discourse shows that they 
 have an exaggerated idea of self, but without the delusion of being some 
 other illustrious person; they have merely a tendency to estimate to the 
 utmost their faculties and powers — their wealth, then- physical strength, 
 health, or figure. The high estimate which the patient has of himself 
 frequently extends to all that belongs to him, and the mere fact of any- 
 thing being in his possession is perfectly sufficient to endow it with 
 extraordinary qualities. 
 
 In this description, given from actual observation, and which agrees 
 with that of Jessen,' there will be recognized a state of moderate exalta- 
 tion, which, when the explosion of the effort takes place towards the ex- 
 terior, becomes mania; when the increase is more internal, and fixed 
 delirious conceptions are developed, becomes monomania. The further 
 his condition is from one of these evident characteristic forms — that is, 
 the less the patient is delirious, the more is he in a state to justify his. 
 
 ^Art. "Moria," ' Berl. Encycl. Worterbuch,' Bd. xxiv., p. 127. 
 
STATES OF MENTAL EXALTATION. 211 
 
 morbid tendencies by reasons which still lie within the bounds of possi- 
 bility, and do not yet appear to be decidedly the result of insanity— the 
 more easily will tlie morbid nature of his state be overlooked and con- 
 founded with the result of the normal tendencies of a capricious and 
 original individual. He then falls under the category oifolie raisonnante, 
 of which this constitutes the maniacal form. 
 
 Should the affection remain at the stage of development which we 
 have described, it may either terminate (after a short duration) in re- 
 covery, or pass into a state of mental weakness m which the dominant 
 joyous self-satisfied and self-contented humor becomes fixed, and mani- 
 fests itself in silly, foolish acts and desires— laughing, dancing, etc. ; in 
 childish play, in the collection of worthless things, upon which, however, 
 he places an extraordinary value, etc. For this form of mania it will be 
 most convenient to keep by the name of moria. 
 
 The foUowing case oflEers an example of this kind of moderate, uncomplicated, 
 and paroxysmal exaltation, not progressing to fully developed mania or to mono- 
 mania. 
 
 Example XXXVI.— Johann Reiberg, set. 37, vigorous, without hereditary 
 tendency to insanity, living in good circumstances as an agriculturist. At the 
 age of twenty, he had for the first time an attack of insanity which lasted for six 
 weeks ; since that time he had seven similar attacks, returning at intervals of 
 one, two, or three years. 
 
 On each occasion the disease followed a course like this :— he was at first, for 
 some time, dull and downcast ; then there succeeded an always increasing ex- 
 citement, but which, even in. its most intense paroxysms, consisted of a simple 
 exaggeration of the ordinary dispositions of the individual. His love of horses, 
 dogs, and the chase became stronger than ever, and he displayed extraordinary 
 activity in agricultural operations. He was then extremely enterprising ; con- 
 tinually busy, and engaged from morning to night, without rest, in the hardest 
 field-work. He had a great opinion of himself, and easily became enraged. His 
 judgment was somewhat feebler on these occasions. At the same time, he was 
 distant in manner ; shunned the members of his family, and in their presence 
 was cold and impolite. During these fits he spent the night generally without 
 sleep, without his activity suffering in the least from that cucumstance on the 
 following day. The appetite increased ; and although when not suffering from 
 these fits he was temperate as respects the use of alcoholic liquors, he had then 
 a great tendency to drink without going the length of intoxication. Never, 
 during these moments, did he, to say the truth, suffer from any profound mtel- 
 lectual derangement ; but several tunes he betrayed passing conceptions bordering 
 on insanity. In all the fits, insanity did not betray itself except by a general 
 excitement of all the mental faculties, and by the instinctive character, so to 
 speak, of those acts by which he manifested his will and his desires. In the 
 course of from four to five weeks this state attained its maximum, and the ex- 
 citement then rapidlv disappeared ; but the restoration to his normal character 
 was not effected until after the intervention of a period of dejection similar to 
 that which marked the commencement of the attack, and which lasted for several 
 
 days. . , , . . , J 
 
 The patient himself, while the attacks lasted, was conscious of his state, and 
 when they were over was abashed and ashamed. Several times he showed the 
 desire, if the attacks were renewed, to place himself under medical treatment at 
 Siegburg At length, when he was violently seized another time, he was con- 
 ducted to the asylum, in September, 1829. His attack had by that time nearly 
 reached its height, and soon began to decrease and to give place to the ordinary 
 period of dejection. The patient then returned to his normal condition. 
 
 What were the causes which from time to time induced this irritable condition 
 of the brain and entire nervous system, which sometimes attained an extra- 
 ordinary degree of intensity ? It is difficult to explain. But it was found tliat 
 the patient had since his childhood indulged in habits of onanism, to which he 
 yielded himself up very frequently. Continually tormented by remorse, he formed 
 the resolution of no longer abandoning himself to his unhappy inclination ; but 
 after having struggled in vain for some time, he ended by yielding, and soon after, 
 
212 STATES OF MENTAL EXALTATION. 
 
 following the exhaustion of the brain and of the nervous system, there came the 
 period of maniacal excitement which we have described. 
 
 The treatment consisted in a moderate diet ; tepid baths, with cold shower- 
 baths ; moral influence and compulsory expedients to restrain him from onanism. 
 These were successful in keepmg him for at least several months from his shame- 
 ful habit. (Jacobi, ' Die Hauptformen der Seelenstorungen,' i., 1844, No. 1.) 
 
 § 140. Before concluding the consideration of this subject, it may be 
 well to say a few words regarding the so-called mania sine delirio, a 
 pathological variety established by Pinel — we may say — to the detriment 
 of science; for so true and so serviceable was the remark which Pinel de- 
 duced from his observations, that the impulses and violent actions in 
 mania are not always founded upon perversion of the ideas — we are of 
 opinion nowadays that originally this is altogether not the case — so con- 
 fusing Avas it to give the same designation to two different morbid mental 
 states; namely, on the one hand, to actual periodic attacks of fury with very 
 little delirium, and, on the other hand and principally, to those moderate 
 states of mental exaltation referred to in the former paragraph, in which 
 the patients perform foolish actions and show perversity of demeanor, but 
 are also in a position to justify and to explain their conduct by a course 
 of coherent reasoning which still lies within the bounds of possibility, i. 
 e.,foUe raisonnate. The disciples of Pinel have even ranged other states 
 under the same title; for example, that condition which we have described 
 as a moderate degree of melancholia with violence, and, more than this, 
 even outbreaks of violence in consequence of hitherto concealed fixed 
 ideas: for the latter there is not even the appearance of reason. 
 
 If we consider more closely to which maniacal states the designation 
 mania sine delirio can be applied, we recognize the fundamental fact that 
 in no single case of mania is the conscious thought, the intelligence, per- 
 fectly free from any disorder. Even in the very slightest degrees of 
 mania the intelligence participates in the general exaltation, though it be 
 only to the extent of increased livelmess and rapidity of thought; gene- 
 rally, however, there is incoherence. In all attacks of fury, clear, calm, 
 healthy thought is quite impossible. It is true that maniacs can 
 occasionally, by means of exhortation, be brought for a short time to 
 their senses, and be enabled to give correct answers; but this only shows 
 as Jessen' remarked, the possibility of temporary remissions and intermis- 
 sions; " the patient is not delirious when he speaks sensibly, and he does 
 not speak sensibly in those moments in which he is delirious." Neither 
 can we speak of the absence of delirium in those cases, which we have 
 described, where there is a morbid impulse to commit acts of violence. 
 Then those murderous ideas which are not at all in accordance with ex- 
 ternal moral causes, but awakened by a morbid disposition, are already in 
 themselves delirious ideas, just as in furious mania, and in all violent 
 emotion — for example, rage — there arise new ideas, opinions, and conclu- 
 sions, corresponding to the morbid disposition. 
 
 Those states in which there is least confusion of ideas and delirious 
 perceptions, in which there is the greatest amount of logical coherence in 
 thought, are the slight states of exaltation which we have described in 
 the foregoing paragraph, which, however, are generally merely the fore- 
 runners of the commencement of violent mania. For these, for folie 
 raisonnante, we might, as Pinel in part did, use the name mania sine 
 delirio; but, as in concrete cases it is of little practical advantage to range 
 cases under consideration under certain names, but of far more to obtain 
 
 ' ' Berl. Encycl. Worterbuch,' xxii , p. 420. 
 
STATES OF MENTAL EXALTATION. 213 
 
 a jjsychological appreciation of the fundamental morbid psychical state, 
 the circumstances which have caused its development and its consequences, 
 it is, at all events, more advisable to allow those obscure names which 
 provoke the curiosity of lawyers and other laymen to fall completely into 
 disuse. 
 
 In a court of law the morbid nature of these states is most easily demonstrated 
 in cases where the disorder has come on tvithin a short time, or returns at inter- 
 vals, and therefore admits of comparison with the state of health in the same 
 individual; also in cases where there are concomitant nervous or other bodily 
 symptoms. It is, on the contrary, difficult to prove that a certain state is morbid 
 when it has been slow and gradual in its development, when it has become habit- 
 ual and passed into fixed peculiarity of character. It should constantly be borne 
 in mind that an individual may talk "quite rationally," and at the same time 
 show by his acts and by his conduct (and even by what he does not do) that he is 
 mentally deranged. 
 
 Section II. — Monomania. 
 
 § 141. Under the term monomania are comprehended those states of 
 exaltation which are characterized by affirmative expansive emotions, ac- 
 companied by persistent over-estimation of self, and the extravagant 
 fixed delirious conceptions which proceed therefrom. 
 
 It is this form which Heinroth has described in great part under the name of 
 Ecstasis paronoica, and which Jessen has designated Schivdrmerei (and in part 
 Aherwitz, craziness). Our form only corresponds in part with those states de- 
 scribed by Jacobi as monomania, as the latter also included melancholia with 
 delirious conceptions.' The majority of the French medical psychologists call 
 these states monomania (acute) of ambition, of pride, of vanity; also (according 
 to Rush) amenomania. These conditions are, it is true, specially observed in 
 many of the cases which terminate in dementia and paralysis; but it would be very 
 erroneous to suppose that monomania is always the first stage of this form — it 
 frequently terminates in recovery without any paralytic appearances, and the 
 " monomaniacal " delirium of paralytics has moreover something peculiar, namely, 
 the early invasion of symptoms of mental weakness. 
 
 We refer the reader, in the first place, to what has been said concerning the 
 states of exaltation in general, and also to paragraph 135, and may now proceed 
 to a short description and explanation of the morbid phenomena in monomania. 
 
 Anomalies of Self -consciousness, the Desires and the Will. — In this 
 form of insanity these are all grouped together round a common centre, viz. 
 the exaggerated idea which the patient has of himself. This is psychic- 
 ally grounded. Inasmuch as the power of volition, which during the 
 melancholic stage was weakened or entirely suppressed, has not only re- 
 turned, but is actually exalted (externally in the form of increased 
 activity) — inasmuch as, at the same time, this freedom of impulse to 
 action is accompanied by great freedom of thought and an abundant 
 flow of ideas — there results a feeling of great self-satisfaction; the patient 
 rejoices over his gi-eat mental (and bodily) well-being; he feels himself 
 richer and more free; every exertion has become easy to him; therefore 
 he considers himself to be not only perfectly healthy — and rejects with in- 
 dignation any expression to the contrary — but he frequently declares that 
 he never in his life felt so well and so happy. The exalted self-conscious- 
 ness manifests itself as an elevated frame of mind, as a joyful disposition, 
 sometimes with the visionary enjoyment of sublime sensations; it is 
 further manifested in great self-confidence, in presumptuous, audacious, 
 proud, and supercilious behavior, in which the patient displays sometimes 
 
 ' In several parts of his work upon Mania, for example, in the 18th and 19th 
 illustrative cases. 
 
21i STATES OF MENTAL. EXALTATION. 
 
 a superficial self-satisfied aflfected bearing, sometimes a more deeply seated 
 haughtiness and pride, and a desire to magnify himself in every possible 
 way. This afiirmative disposition is persistent, it does not alternate with 
 other dispositions without external motive, as is the case in mania. It 
 may, of course, be momentarily interrupted by external circumstances. 
 The patient becomes irritable and violent; and if any one expresses a doubt 
 as to the accuracy of his assertions, or opposes by remonstrance or force 
 the execution of his extravagant acts, he at once becomes impatient and 
 angi-y ; he seeks to justify his actions and ideas, and will permit nothing to 
 approach him which might encroach upon his elevated frame of mind. 
 
 The increased power of volition is manifested in the necessity for in- 
 creased eccentric activity, especially, however, in numerous extravagant 
 plans and projects, the accomplishment of which appears quite possible 
 and easy to the patient, who believes himself capable of anything. In 
 this he presents a great similarity to — yet with a marked diflierence from 
 — the demeanor of the maniac. For, as in mania, so in monomania, the 
 primary and principal desire is that of manifestation of power; but in 
 mania this necessity of an emotional explosion immediately produces 
 muscular movements (sometimes tumultuous) in which it relieves itself. 
 Hence the instinctive character, but outwardly exalted, of these states. 
 The more, on the contrary, that co-ordinated series of morbid ideas and 
 opinions act upon the exalted will, the more the current towards the ex- 
 terior is set in motion, not merely by an obscure tumultuous necessity, 
 but by conscious thoughts — the more, therefore, that some sort of plan 
 presides over the morbid will, the further is the condition removed from 
 mania and drawn towards monomania. 
 
 This difference is seen most distinctly when, as is very often observed, certain 
 groups of sensations and obscure ideas appear with especial vivacity and urge 
 themselves towards the exterior as instincts; for example, the sexual passion. 
 The maniac vs^itli simple exaltation of the sexual instinct seeks to gratify his 
 desire in the most direct manner; he attacks every female who comes in his way; 
 and the nymphomaniac makes obscene advances to every visitor. In monomania, 
 on the contrary, the exalted sexual instinct, before it passes into action, is guided 
 by new ideas and opinions (of a morbidly exalted kind) which occupy the mind: 
 the patient will then only gratify his desires in the sense of his over-estimate of 
 self and of certain delirious ideas; he only pays his addresses' to princesses and 
 illustrious ladies; the female patients have imaginary love adventures with princes 
 and kings, etc. i . , 
 
 Thus the excitement of the monomaniac does not pass so immediately towards 
 the exterior; effort is accompanied by clear conscious thoughts and opinions, loses 
 thereby the instinctive character, and becomes actual morbid volition. With far 
 greater, sometimes with perfect outward calm, there is a more profound internal 
 loss of reason than in mania, because consequences soon result from the general 
 exaltation which set aside the essential conditions of healthy mental action. 
 
 Anomalies of the Intelligence.— B.eve, also, there is first of all obser- 
 vable a purely formal increase in the vivacity and rapidity of thought, 
 which is manifested in exuberance of ideas — owing to which the patient 
 inwardly rejoices — in lively conversation, and in frequent change of the 
 object towards which the morbid volition is directed. But, ordinarily, 
 this occurs only at the commencement; afterwards a few delirious ideas 
 exclusively predominate, and, without interchange with others, deter- 
 mine the actions. 
 
 Another anomaly of the intelligence consists in an inward increase, 
 an exaggeration, of the ideas in regard to their subject, which shows it- 
 
 1 See further on a case of this kind. 
 
STATES OF MENTAL EXALTATION. 21S 
 
 self by a tendency always to employ grand, high-sounding words, the most 
 brilliant images, the highest possible numbers (thousands, millions, etc.); 
 and inasmuch as those overdrawn ideas pass into acts, they explain the 
 numerous eccentric plans of such patients. These naturally vary very 
 much, according to the former circumstances of life, employment, and 
 degree of education of the patient. The artisan magnifies his employ- 
 ment to the utmost; the soldier dreams of large armies, enters upon cam- 
 paigns and makes conquests: another seeks to solve impossible mechan- 
 ical problems, such as perpetual motion; others discover new means of 
 locomotion by land and sea, new railways, or steamboat enterprises to com- 
 mand all the seas of the world; or, again, he projects impracticable jour- 
 neys, or immense architectual plans (castles, towns, etc.) entirely occupy 
 his mind. Others busy themselves within the sphere of ideas; conceive 
 comprehensive scientific thoughts, great humane and rehgious aims, etc. ; 
 believe themselves to be apostles, benefactors of the whole family of man- 
 kind, bearers of universal happiness and peace, etc.; all in accordance 
 with the accidental external influences or the former practical tendencies 
 or speculative aims of the patient. These ideas, however, are invariably 
 distinguished, in the first place, by the feature of activity (in opposition 
 to the ideas in melancholia, where the patient believes he is governed and 
 tormented by external influences), and, in the second place, by their 
 fantastic exaggeration. 
 
 Most intimately connected with these ideas, and, like them, proceeding 
 from increased self-consciousness and over-estimation of the individual 
 powers, there arise, further, false ideas and opinions relating to the spe- 
 '^ ci.al ego and its connection with the external world. In these cases we fre- 
 quently meet with the idea of being some distinguished person: a super- 
 human power of possessing inexhaustible resources, of occupying a high 
 position, of aristocratic descent, etc. To this class belong those patients, 
 so numerous in asylums, who believe that they are generals. Napoleons, 
 millionnaires, reformers of the world, gods and heroes; the many female 
 patients who are beloved by kings, those who believe that they hold fre- 
 quent and intimate converse with the Deity, etc. But all such belong to 
 this class only in so far as, and so long as, these ideas depend upon an 
 actually existing increased consciousness of self, to which they again 
 stand in the relation of attempts at explanation. 
 
 These false ideas have originally a significance such as the following: the idea 
 of being Napoleon, for example, fundamentally means that the patient feels him- 
 self powerful, believes himself capable of doing great things, of accomplishing all 
 things by his great mental and physical powers to a degree of which he had never 
 before even dreamed, and could only be possible to one of the few great men of 
 history. 
 
 Afterwards this affirmative disposition often becomes weaker, and even com- 
 pletely disappears, when the delirium alone remains. The more the elevated 
 frame of mind, which was originally attempted to be explained by the delirium, 
 disappears, the more does the still existing delirium degenerate into mere words, 
 to which the patient no longer attaches any real significance, and the more does 
 he pass into another condition, that of dementia with the character of exalta- 
 tion. 
 
 So long, however, at this exalted frame of mind continues to provoke attempts 
 at explanation, we can with instruction observe the progress of this exaggeration 
 in the delirious ideas. A patient, for example, who had formerly been a common 
 soldier, manifests at first merely the idea of being an officer; in a few days he is a 
 general, and soon the leading warrior of the day: and should this not suffice— 
 should these words not be strong enough to express the power, the freedom, and 
 the delight which he feels within him, he becomes Lord of the universe, the 
 Messiah, the Saviour, God; in short, he uses the highest and strongest expressions 
 of which he is aware to denote his imaginary greatness. 
 
216 STATES OF MENTAL EXALTATION. 
 
 It would, however, be a very great error to suppose that the patient is con- 
 scious of this explanation, as such — that he calnily considers what may be the 
 cause of his frame of mind. This is not the case: the ideas called forth by the 
 frame of mind arise suddenly, as in a dream, and while he, at first perhaps over- 
 joyed, shocked, timid, or frightened by them, may be able to suppress them, yet 
 they soon intrude themselves upon him so fixedly and so perseveringly, that he 
 can no longer doubt their reality; for them he renounces all his former views and 
 ideas, surrenders his old ego, and will even deny the testimony of his senses. 
 
 Not unfrequently, when these states have attained to a considerable develop- 
 ment, weakness of the mental processes ensues (consisting at first generally in. 
 loss of memory and confusion of ideas). The patient, however, does not cease to 
 imagine things, particularly in regard to his exalted feeling of satisfaction: but it 
 appears, often, as if he were affecting arrogance and gi-eatness merely with the 
 xiew of deceiving himself and others, with reference to the already perceptible 
 urgent and increasing weakness of dementia — of concealing, by a kind of morbid 
 pride, a commencing void and emptiness — but of course with no direct intention. 
 While, then, gradually this disorder of the intelligence becomes a confused mass 
 of grand words and figures, it soon occurs, wliere the mental processes remain 
 active, that certain of these delirious conceptions become completely fixed. 
 Certain steadfast, connected circles of ideas then incessantly urge themselves into 
 the foreground of the consciousness, govern all the thoughts, and are expressed 
 in words and deeds. From this cause it may seem as if there were merely a par- 
 tial destruction of the intelligence, while in reality the essential elements of 
 thought — normal self -consciousness, and a correct appreciation of the special in- 
 dividuaUty and its relation to the world — are utterly perverted and destroyed. 
 
 Of these fixed ideas, w^hich to him possesss the highest degree of subjective 
 reality, the patient cannot be divested either by demonstration or by evidence. 
 It is only at the commencement that remissions occasionally occur, dxiring which 
 the patient may admit for a short time the error of his delusion, when reasons or 
 external evidence are laid before him; while at the same time he cannot inwardly 
 convince himseK of the falsity of his ideas. 
 
 § 142. Anomalies of the Sensorial Functions, the Movements and the 
 Conduct. — Hallucinations and illusions corresponding to the dominant 
 disposition are frequently present, and are much more serious in their 
 consequences than they are in mania. In the latter they are soon for- 
 gotten; but here they persist, foster, and essentially strengthen the deli- 
 rious conceptions. The patient, for example, sees an angel bringing to 
 him a message from heaven; hears voices commanding him to commit 
 certain deeds, or communicating unintelligible nonsense, which he believes 
 to be some divine mystery; worthless objects appear precious, etc. 
 
 The movements of the monomaniac do not, on the whole, present the 
 external excitement and tumultuous violence Avhich appear in simple 
 mania; they are generally more calm, and any excitement is usually the 
 result of some external motive. An uncertainty in the muscular move- 
 ments is here also very frequently the first premonitory symptom of a 
 fatal termination — of the commencement of general paralysis. 
 
 The outward appearance and conduct of these patients is in accordance 
 with those anomalies which we have described. One displays the gestures 
 of pride and of power; another appears as a theatrical hero, full of high- 
 sounding words; while others are very polite, affected, gracious and 
 affable in their demeanor. Some dress fantastically; others, especially 
 females, with extraordinary elegance; others, again, are totally neglectful 
 of their toilette, forgetting everything in the contemplation of extravagant 
 plans. These patients delight in giving orders, and are impatient to 
 know that their commands are promptly executed; they are covetous, 
 generous, and profligate. According to the nature of the dominant 
 delirious ideas, they make various arrangements for the carrying out of 
 their desires: letters, requisitions, and proclamations are issued; large 
 purchases are made, and polite announcements prepared; they bestow 
 
STATES OF ilENTAL EXALTATION. 21 7 
 
 orders and titles ■with a liberal hand, they prepare laborious statistics and 
 complicated plans for the reorganization of the world, etc. Some patients 
 appear perfectly calm: their conversation and conduct indicates an exalted 
 tranquil joy, a sort of inward rapturous revelry of feeling. With this 
 there are generally associated ideas of close and mystical connection with 
 the Deity, Messianic ideas, etc., combined with 'hallucinations — which 
 they carefully conceal — of the appearance of angels, heavenly voices, etc. 
 This is the weak sentimental form of monomania, which is observed princi- 
 pally in onanists; but this visionary happiness may also be interrupted by 
 violent outbreaks of anger when their wishes are opposed, accompanied by 
 threats of Divine displeasure, and solemn prophecies of dreadful pimish- 
 ments which are certain to follow. In women similar states of inward 
 rapture occur, having for their object sexual sensations and imac^inary 
 love affairs: they also are accompanied by numerous but well-concealed 
 hallucinations. 
 
 According to the predominance of certain fixed ideas, or efforts dependent, 
 upon delirious conceptions, special forms of monomania have been distinguished 
 and called by such names a^ Theomania. Erotomania, etc. 
 
 Tlie other symptoms, although here also the cerebral disease may be accom- 
 panied by the most numerous and varied disorders of the general health, present 
 nothing peculiar, and are veiy similar to those observed in miinia. At the com- 
 mencement, when the attack is acute, a feverish condition frequentlv exists; 
 afterwards, sleeplessness, constipation, and sometimes cerebral congestion. 
 
 § 143. The form of monomania is dcTeloped, like mania, generally after 
 a stage of melancholy has passed off. At first the state of exaltation may 
 rest for a long time indeterminate between the two forms. When cer- 
 tain delirious conceptions become fixed, the patient enters into an essen- 
 tially different state: and this condition, that of confirmed mouomania. 
 is, for the reasons already stated, to be considered a much more serious 
 affection than mania. The more calm the external behavior of the 
 patient gradually becomes — the more the alternation of the false ideas 
 recedes, and only a few particular but fixed ideas remain — the more 
 there existed in the former individuality of the patient certain peculiari- 
 ties which favor the rapid penetration and falsifying of the ego bv these 
 fixed ideas, the less is a return to health to be looked for. 
 
 During the course of these states there recur remissions which are 
 more apparent than real: they have more the nature of an external 
 quieting than of an internal cessation, and are only a calmer occupa- 
 tion of the mind by the delirium: complete intermissions only take 
 place when the disease is still vacillating between mania and mouomania. 
 
 The patient may recover. Then it seems to him as if a veil liad 
 suddenly fiillen from his eyes: he awakes as if from a dream, and cannot 
 understand why simple reasoning in relation to his delusion, which is 
 now quite clear to him, could make no impression upon him during the 
 disease. He is now accessible to reason; still it is often necessary to aid 
 his comprehension by explanations and palpable evidence in order to 
 completely counteract the delirious ideas which still occasionally arise, 
 although, upon tlio whole, they are recognized by him as false. "A com- 
 pletely fixed exalted delusion, Avheii it has continued for more than half 
 a year, is not easily got rid of; nevertheless, cases sometimes occur 
 where the monomania gradually disappears after it has lasted for several 
 years: when this occurs, other morbid jnvcesses are generally developed. 
 All symptoms of commencing mental weakness — loss of memory, recur- 
 rence of incoherence, etc., indicate that the patient is becoming incurable. 
 
218 STATES OF MENTAL EXALTATION". 
 
 When he does not recover, he never continues during the whole of 
 his future life in the state of high emotional exaltation which is proper 
 to this form of insanity. The affirmative disposition, the elevated frame 
 of mind disappear, and its products, the fixed delirious conceptions, 
 alone remain; external calm returns, and the general health improves; or 
 the patient, owing to the development of serious anatomical lesions 
 within the cranium, gradually falls into a state of profound dementia. 
 
 § 144. It is very interesting to observe the close analogy that exists 
 in essentials between the symptoms and modes of termination of the 
 maniacal forms and those of alcoholic intoxication. This analogy is 
 sometimes observed even in the premonitory symptoms. There are 
 drunkards on whom wine has, first of all, the effect of rendering them 
 quiet, thoughtful, and self-concentrated, presenting an analogy to the 
 preliminary melancholic period. 
 
 The essential action, however, of alcoholic drinks is excitation, expan- 
 sion of all the mental processess, volition especially becoming easier and 
 more free. At first the ideas succeed each other more rapidly, the imag- 
 ination becomes more brilliant, the language abounds in striking and 
 surprising inflections, thoughts arise as if spontaneously, conversation 
 proceeds more easily, and muscular action is more energetic: to this cor- 
 responds usually the joyful frame of mind, the psychical pleasure and 
 power. Afterwards the drunken man throws off all restraint; the objects 
 of the precipitate and rapidly succeeding preceptions are immediately, 
 a,nd without reflection, thrown outwards in words and actions; thoughts 
 formerly kept concealed escape from him involuntarily, or he takes 
 pleasure in giving expression to ideas of his own self-importance; he 
 manifests fearlessness, courage, a. degree of self-confidence frequently 
 approaching to insolence; he is a braggard; he is generous and prodigal, 
 because he appears to himself to be richer than he really is. Frequently 
 certain desires and tendencies appear with especial force and reckless- 
 ness; for example, the desire to speak in verse, to converse in a foreign 
 language (especially in Latin), to sing, to scream, to quarrel, etc. He is 
 Tery irritable, and, like the monomaniac, nothing offends him more 
 than to be told that he is drunk. The humor may change with or with- 
 out external motive; occasionally sad ideas involuntarily arise in his 
 mind, and he begins to weep bitterly; sometimes he becomes tender and 
 sentimental; sometimes the impulse to increased evolution of force 
 urges him to senseless dangerous acts, to strike all around him, and he 
 becomes slightly delirious. While in this state, a strong mental impres- 
 sion has sometimes such an effect upon him that he immediately becomes 
 sensible, and the intoxication is suddenly cut short. 
 
 Afterwards still greater incoherence ensues. The drunkard has his 
 hallucinations and illusions; he mechanically repeats what he has already 
 said, his memory fails, and he becomes quite incapable of calling forth 
 new series of ideas; in short, he falls into a state of dementia. Now 
 presenting a striking analogy to the commencement of general paralysis, the 
 speech falters, the movements of the tongue are irregular, the voluntary 
 muscles lose their energy, the legs are no longer able to carry the body, 
 and the individual falls into a state of powerlessness resembling the ady- 
 namic condition of the nervous system in typhus fever, or general par- 
 alysis with dementia. 
 
 The phenomena in insanity pursue, on the whole, the same course, 
 but proceed more slowly. From a preliminary state of exaltation of the 
 sensations and emotions, of the intelligence and of the will, the insane 
 
STATES OF MENTAL EXALTATION". 219 
 
 man gradually, as tlie cerebral disease progresses, falls into a condition 
 of mental weakness, with loss of command over the faculty of speech and 
 all voluntary movements. 
 
 EXA.MPLE XXXVII. — Cerebral congestion; melancholy; tnononiania terminating 
 in dementia. — O— , an officer, enjoying habitual good health, and a strong consti- 
 tution, had in his youth indulged in a multitude of excesses, which had not been 
 followed by any appreciable bad consequence. He was irritable, violent, flighty, 
 and so unstable in his talk, that often, in telling a story, he would pass from one 
 to another without finishing any. For a long time he lived carelessly in that 
 fashion; and then dark, hypochondriacal ideas gradually took possession of him. 
 He suffered from constipation and internal haemorrhoids. He was always dejected, 
 and nothing could distract him. In a fall which he had from his horse, he 
 received a severe contusion on the head and on the leg, and was obliged for three 
 months to maintain a horizontal position. The congestion of the head, combined 
 with the haemorrhoidal affection, now increased to such a degree, that he experi- 
 enced frequent attacks of vertigo and confusion, and could only with great diffi- 
 culty perform the duties of his office, His pulse was full and slow; his belly dis- 
 tended; his countenance flushed. He had violent headaches and lumbar pains; 
 had a constant feeling of tiredness; micturition was painful, and the bowels con- 
 stipated. At the same time, he was in a constant state of mental anxiety. He 
 often clasped his hands, as if he were the victim of the most profound despair. 
 He refused at times to eat or drink, and constantly dreaded that for his neglect of 
 military duty and for his crimes (purely imaginary) he would be degraded and 
 prosecuted criminally, etc. At the end of two months he felt improved, and in 
 two months more was completely restored. 
 
 But when his physician saw him again in the commencement of November, he 
 found him in an agitated condition, occupying a well-furnished apartment. He 
 observed in him at the same time an extraordinary flow of language, and great 
 ao-itation of the whole body. Already on the following morning the monomaniac 
 exaltation had reached a Very considerable height. He got ready to visit the 
 daughter of a superior officer, whom he was but slightly acquainted with, and 
 whose hand he was about to ask. He had ah-eady bought a carriage and horse for 
 the purpose of making a long journey with this lady through Europe. He declared 
 himself to be of noble blood, and announced that his promotion was to be very 
 rapid. His happmess was at the highest pitch, and he wished to share it with the 
 whole world. Checked in his desires, he fell into a fit of frenzy. 
 
 Towards the end of November he entered Siegburg. The pupds were somewhat 
 contracted; the haemorrhoidal vessels were swollen; he had pains in the joints; 
 there was a determination of blood to the head; the pulse was rapid. He was very 
 Irritable, and easily became enraged. He imagined that he possessed a consider- 
 able fortune, and was of lofty station; he believed himself endowed with super- 
 natural power, etc. Every minute he distributes the largest sums of money, one 
 hundred and twenty millions of louis-d'or; afterwards he says that he is God the 
 Father; but if any one asked who his father was, he replied that he was a judge 
 in the court of exchequer; and it was in vain that one tried to show him that what 
 he said was absurd and impossible. At another time he said that he had been in 
 heaven, and that he saw an exceedingly beautiful Venus; the following day he said 
 that he found himself in the midst of several hundreds of Venuses. He wished to 
 increase aU the rooms of the asylum by means of gas, and to give them consider- 
 able proportions. He wished to increase men in size, and to make them giants. 
 He wished to raise the dead; and especially he wished to transport thousands of 
 reo-iments in the air by millions of balloons, etc. Ten months after his admission, 
 the attacks of vertigo retmned, and by degrees symptoms of general paralysis 
 with increasing dementia developed themselves; apoplectiform attacks; death. 
 (Jacobi. 'Beobachtungen,'etc., i., 1830, p. 372.) 
 
 Example XXXVIII. — Monomania terminating in dementia.— 3. U — , aet, 44, 
 formerly an officer, manifested ali-eady for a lengthened period a certain hasti- 
 ness in his acts and movements. He was restless and imtable. In the winter of 
 1824, even when he still punctually attended to his business, he began to seclude 
 himself more in his chamber, which he had adorned in a somewhat fantastic 
 manner, and read a book of very fine type by the light of a large lamp, and with 
 a powerful jnagnifying glass. In spring, symptoms of emotional excitement 
 were already manifest. In July, there appeared ideas of the possession of an 
 immense fortune and of an elevated position. Soon he believed himself to be the 
 Prince of Neuchatel; and at the same time he thought himself a great painter, 
 
220 STATES OF MENTAL EXALTATION. 
 
 and spent the entire day in designing and coloring landscapes, as children of five 
 or six years do, and showed them to everybody as chefs-d'oeuvre. 
 
 In a few days he was admitted into Siegburg. The pupils were contracted. 
 He had, at tlie root of the nose, a deep scar, the result of a wound which he had 
 received at the age of twenty-five by falling from a carriage. His speech was 
 hesitating and fast. He had several stools per day. The pulse was soft between 
 95 and 100. Trembling in the limbs; in the evening a kind of epileptic attack, 
 followed by great excitement; palpitation of the heart; oppression; the subcu- 
 taneous veins were greatly swollen (bloodletting). 
 
 The following morning he was calm, very happy, walking continually from 
 one side to the other. Later, great agitation. The patient washed his head with 
 his urine, saying, by way of excuse, that it was the fashion of the Hottentots, 
 Often he requested some one to get ready his carriage and saddle his horse, and 
 beat his keeper because he refused to obey him. Sometimes he cried and shouted 
 when hindered from indulging in his insane practices. The countenance was 
 pale; the look fixed; the head hot and flushed. He slept a little at night (baths, 
 tartar emetic, bleeding, seclusion, moderate diet, tincture of digitalis; later, 
 leeches and calomel). Sometimes the patient rubbed his head with his excre- 
 ment. He collected pebbles, to which he attached great value, saying that they 
 were diamonds. He said that he was going to Mexico with a great retinue, 
 because he Avas appointed ambassador, etc. 
 
 Gradually he became more calm, the pulse slower, the temperature of the body 
 normal. An abscess found on the hip, which soon healed. He asked why he 
 had been brought to Siegburg, and could not recollect any circumstance either of 
 his journey or of his admission. He said that his daughter, eighteen years of age, 
 was to marry the son of the first banker in the country; and when he was made 
 to confess that his daughter was only four years of age and her betrothed five, he 
 did not seem greatly surprised at it. He wrote home that his wife, his brother- 
 in-law and the relations of his wife had been carried off to hell by the devil; that 
 God had offered him a high position in London; that he had forwarded his watch 
 and his uniform to Mexico, etc. 
 
 Afterwards he began to say that he was the Prince of Neuchatel, and that he 
 was about to have conferred upon him the order of the Holy Spirit. When I 
 tried to show him the absurdity of his remarks, he took no heed and continued 
 his talk. He one day secretly wrote to his agent, begging him to say if it were 
 not true that he was Prince of Neuchatel, and to forward to him the newspaper 
 containing the account of his nomination. At the same time, he charged his 
 friend to buy for him a new house at 75,000 florins, etc. 
 
 After many alternations of calm and rationality, with new manifestations of 
 monomania, the patient, under the employment of digitalis, bleeding, etc., re- 
 mained for six months without showing any appreciable symptoms of insanity. 
 But soon he fell into a state of intellectual weakness and confusion of thought, 
 and eight days after his dismissal he was brought back again, and the malady 
 assumed the very same character as formerly. He was afterwards removed to 
 an institution for chronic cases. (Jacobi, ' Beobachtungen, ' etc., i., 1830, p. 295.) 
 
 EXAJVIPLE XXXIX.— Melancholia; an act of violence in consequence of melan- 
 cholic delirious conceptions; aftenvards monomania.— M.. A— , eet. 30, of a very 
 lively disposition; very gay; had always had his own will from the earliest years. 
 He is sensitive to any lack of respect shown in company, and has the ambition to 
 pass for a person of high importance. He likes violent exercise, such as the chase 
 and fencing. He is vexed when he cannot exhibit a great show. From his birth 
 to his fifteenth year he was subject to convulsions. At six years, he had a sharp 
 inflammation of the brain, which was cured at the end of ten days; at twelve, he 
 had inguinal hernia; later, he had inflammation of the throat with delirium. 
 During his infancy he was often exposed to alarming incidents, living at that 
 time in midst of the events of La Vendee. Since that time M. A— never ceased 
 to be subject to panics of fear. Arbitrary and violent acts exercised towards him 
 in time of trouble contributed to fortify his tendency to alarm. Nevertheless, his 
 constitution got stronger at the time of puberty. 
 
 A—, after having fatigued himself with reading, isseized by a love of study, and 
 is convinced that an attempt is about to be made upon his life. Already he feels the 
 terrible effects of poison. He dreads all who approach him, except his parents, 
 who are condemned to suffer the same fate with himself. He beUeves he sees 
 and hears people armed with poignards and air-guns, which have been distri- 
 buted for the purpose of killing him. If he walks in the garden, he comes back 
 immediately, saying that he heard a bullet whistle past his eai". Sometimes he 
 
STATES OF MENTAL EXALTATION. 221 
 
 indulges in excessive laughter, and, when asked why, he answers that he hears 
 sounds out of which he makes words that excite his laughter. He would fain 
 persuade those around that they hear the same sounds as he does. He is con- 
 scious that he is reckoned mad; he hears every instant some one crying near him, 
 " Madman! madman! " He often asks his parents whether his eyes are not fixed 
 or haggard. Often, after a meal, he raves and feels himself oppressed. While in 
 an inn at D — , a barber who came to shave him bent down to gather something. 
 Without any previous altercation, A — tired a pistol at him and fractured his arm. 
 Everything seemed to show that he mistook the unfortunate man for an assassin. 
 After that fit of madness, A — remained five days without drinking, eating, or 
 going to bed. After this, he recovered his sleep. A — is naore sane and calm; he 
 eats, although always possessed by fears. 
 
 He was now put under my charge. The countenance of the patient is ex- 
 tremely changeful and animated; his bearing proud and haughty. During the 
 first days he I'efuses every kind of food. He will not have his beard trimmed. 
 He does not sleep. The bowels, in spite of tepid baths, continued for some length 
 of time, remain constipated. 
 
 A — pretends to be the first man of genius in the world, and attempts are made 
 on his life through fear that he may become Lord of the universe. He is Apollo, 
 Cassar. In virtue of his twofold title, he expects and requires all the world to 
 obey him. He is ashamed that the loftiest reason should be so confounded with 
 insanity. A — writes to all the men who occupy the highest positions, even to the 
 king himself. Every moment he expects orders to set him at liberty. He 
 threatens me with all the weight of his authority, the moment he shall be at 
 liberty. Meanwhile he asks for an advocate and a sheriff's officer. He alone is 
 master; no one has any authority over him. He answers disdainfully questions 
 addressed to him; very often he does not deign to answer at all. 
 
 It is quite impossible to persuade this patient that he is the sport of his own 
 disordered fancy, and that his condition demands medical treatment. People 
 wish, he says, to turn his head with their remedies; but it is of no use, they will 
 not succeed. Gentleness and persuasion are powerless. When it is needful that 
 he should bathe or have a blister applied, it can only be done by a great show of 
 force. Many times thei^atient is calm; he talks well, is amiable, plays at several 
 sports, and manifests no symptoms of insanity; the functions of the organism 
 present no disorder. (Esquirol, ' Geisteskrankheiten,' von Bernhardt, ii., p. 8.) 
 
 Example XL. — Description given by a monomaniac of his condition. (Exalted 
 emotions of various kinds excite varying ideas of illustrious personalities.) — A 
 poor clergyman, whom the too rigorous observance of his vows had rendered 
 insane, related his history in the following manner: — " Having gone to a house 
 where I was called on some work of benevolence, at the entrance of the chamber 
 into which I was introduced, in glancing towards two women, they made an im- 
 pression upon my sight and imagination so lively, that they seemed to me to have 
 been illumined as if they had been electrified. Ignorant of the cause of so singular 
 a phenomenon, I attributed it to satanic agency, and left. When I had got out 
 of the house and away from the objects which had so strongly affected me, I 
 became calm; but during the day, having encountered other women, I had the 
 same distraction and the same illusion. The following day, being on a journey, 
 it seemed to me several times that the carriage in which I was seated was about 
 to be overturned, which caused me to cry to the people in charge of it to hold it 
 up. But the false alarms causing them to laugh, I knew too well what that 
 meant. There was, nevertheless, a disorder and derangement; but my error lay 
 in attributing this derangement to external objects, whereas it was in the organs, 
 and in the confusion of sense occasioned by my having never read, seen, or 
 experienced any similar circumstance. On approaching a little town which lay 
 on our route, and having seen several women, they caused me the same trouble 
 and the same illusions as those wliom I had seen in the town. Arrived at the 
 inn, I had dinner. The bread and wine, as well as everything around, seemed 
 confused and about to be overturned. Then, persuaded that a satanic power ac- 
 companied me everywhere, I left the inn hurriedly, telling the innkeeper at the 
 same time that I thought he had a hand in it, and I entered the carriage again. 
 There, fixing my attention, as far as the agitation of fancy and feeling would 
 allow, on my adventures of the previous evening and of to-day, I was confirmed 
 in the opinion by the fables of Ribadeneyra, which represent the hermits as 
 continually besieged by demons. The words of St. Paul, where he says that it is 
 not only against flesh and blood that we have to fight, but agr.ijst spiritual 
 powers as well, could not escape me, and, arguing from that, I recognized no 
 
222 STATES OF MENTAL EXALTATION. 
 
 other cause of my trouble and illusions except the possession of a demon, and I 
 resolved in consequence to make war against him by fasting, prayer, and exor- 
 cism. . . . 
 
 " My activity having been changed into warlike fuiy, the image and remem- 
 brance of those warriors whose history and character had most strongly 
 impressed me in my childhood presented themselves to me. Then, my imagina- 
 tion transporting me into all the combats and assaults of which I had read the 
 history , I wished to represent these various characters. I tried those of Alex- 
 ander, of Acliilles, and of Henry IV.; and with the first, to wliom I likened 
 myself so far as to believe that I possessed his appearance, his name, and to be 
 himself, I conquered at Arbela; I laid siege to Tyre, and carried its ramparts by as- 
 sault. While I represented the character of Alexander, the image of the Tyrians 
 whom the conqueror caused to be suspended on crosses along the bank of the sea 
 came to my imagination. Seized with indignation and horror at that spectacle, I 
 detested the character of the Macedonian hero, and I no longer desired to be that 
 monster: but fixing my attention upon the sad victims of his cruelty, I entered 
 into the feelings of the unfortunate men, and was as sad because of them as if they 
 had been beside me. During a second attack of warlike fury, it took my fancy to 
 assume the character of Achilles. I fancied myself binding on his armor; I 
 assumed his voice and courage; I addressed to the Trojans words of insult and 
 defiance. Then driving before me, overthrowing and putting to flight the 
 battalions, as it seemed to me, I found myself, of a sudden, at the gates of the 
 palace of Priam. Then, by the confusion and wandering of an imagination 
 which produced images, the characters of wliich were dim and badly defined, 
 passing rapidly from the character of Achilles to that of Pyrrhus, or rather, con- 
 founding the person of the father with that of the son, and strongly impressed 
 by the pictvire which Virgil makes of the latter, believing myself to be the hero, 
 I got hold of the four pillars of my bed, and I threw them vigorously against the 
 door of my room, which I dragged from its hinges and carried to a distance of 
 four paces off. Transported with joy, excited by the shock and by the crash, I 
 shouted, ' Troy is fallen! the palace of Priam is no more! ' 
 
 " My parents, who knew nothing of what ailed me, followed the course of 
 binding my body and shackling my hands. Good God! what sufferings I en- 
 dured! What a resolution was accomplished all at once in my imagination! 
 Fallen from the liigh degree of fortune to which I had raised myself — downcast, 
 overwhelmed — I looked upon my chains and my prison with horror and trembling, 
 and I felt a burden of the most terrible despair. Having fallen asleep, my 
 imagination was aasailed by the most fearful images. I thought I saw Ancient 
 Rome rising from beneath its ruins, opening its tombs, and presenting to my 
 eyes the skeletons of tlie most famous warriors invested in armor, the shape, the 
 variety, the antiquity, and the rust of which constituted a horrible sight. That 
 spectacle impressed my imagination so strongly, that I remained for a long time 
 without being able to fix my attention to any object or piece of iron without 
 extreme horror, which, passing into my very senses, affected my sense of smell 
 with a sort of stench of iron and brass — a disagreeable odor which troubled me 
 for many days. After that, my imagination got the better of me, and, causing 
 me to traverse the heaps of ruin, which appeared to crumble under my feet and 
 to threaten my head, it led me to the gates of the temple of the god of war. I 
 thouglit I saw these gates open, and heard them grind upon their hinges with a 
 horrible noise. I saw the god in midst of his temple, and, by a cruel trick of 
 imagination, I believed myself a monster dripping with blood and carnage, and 
 laden with chains. The state I was in, bound and in irons, favored that iflusion, 
 perhaps caused it to spring up. I imputed this frightful treatment to the in- 
 humanity which I fancied to have been exhibited towards the person of Hector. 
 Nevertheless, a moment afterwards, by a return of that reflective power of which 
 I seemed so little capable, sounding my feelings and finding them completely 
 opposed to this feature of inhumanity, I disavowed and abhorred the cruelty of 
 Achilles, and passing immediately to feelings of the tenderest pity and compas- 
 sion, I deplored the fate of the Trojan hero. I cried, or believed myself to cry, 
 ' Oh! Hector! dear Hector! why may I not collect thy scattered limbs, to bathe 
 them, to warm them with my tears, and to restore them to life! ' As I spoke 
 these words, I shed, in reality, a flood of tears. 
 
 " The feeling of these gentle passions brought me back to peace and tranquil- 
 lity, which induced my parents to restore me to liberty. I found nothing so deli- 
 cious as these first moments. It seemed to me that all nature, formerly a captive, 
 had bursts its bonds, and enjoyed with me the charms and advantages of liberty. 
 
STATES OF MENTAL, EXALTATION. 223 
 
 I took the character of a peaceful king; I fancied that I fostered and exercised in 
 my imaginary dominion all the arts, all the sciences — painting, sculpture, archi- 
 tecture, geometry, etc. I drew, I made plans of apartments, which greatly 
 amused me: I had so correct an eye, and so firm a hand, that, without any other 
 instruments than were at hand, I traced images on the ground or on the parti- 
 tions of my room with extraordinary accuracy. My parents and other simple 
 people, surprised at seeing me express in such a happy way several features of 
 talent which they knew I never before exhibited, imagined there was something 
 supernatural in it. 
 
 ' ' The disposition which possessed me gave to my senses a quietness, and to my 
 intelligence a penetration, and to my soul a grandeur and an elevation, which 
 made me an extraordinary man. I seemed to read the heart of people who ap- 
 proached me; I unfolded their character with astonishing sagacity, and, uninflu- 
 enced by any consideration, I described it with justice and precision. This gave 
 occasion to a priest, who came to see me sometimes in my illness, to tell my 
 parents quite seriously that I was possessed by the spirit of Pytho, the same that 
 St. Paul drove from the spirit of a girl, and mention of which is made in the Acts 
 of the Apostles. 
 
 " It may, perhaps, surprise people that I have been able to remember so many 
 things and circumstances: but my imagination was so active, that every object 
 impressed itself there, or rather engraved itself in characters of fire; and many 
 things which formerly only touched it slightly when I was in health, have since 
 that time become much more actual." (Leuret, ' Fragmens,' etc., Paris, 1834, p. 
 282.) 
 
 Example XLI. — Attacks of monomia, of the nature of exaggeration of the 
 sexual instinct ; rational self-defence of the patient. {Folic raisonnante, ivith a 
 monomaniacal tinge.) — A certain D — was arrested several times in Paris, and 
 placed on eight different occasions in an asylum, and always for the same reason. 
 He wrote to ladies in the highest society obscene letters; placed himself in their 
 path, or called at their houses. He addressed to Madame Bonaparte, to a Madlle. 
 Beauharnais, and to a multitude of duchesses, princesses, and ladies at court, 
 letters written in a style of revolting obscenity, which he named heroic poems. 
 His manner of conversation was otherwise stamped with such calmness, and had 
 such an appearance of reason, that people hesitated several times to call him mad. 
 Nevertheless, the reality of his insanity was established in a report made by Marc, 
 Esquirol, and Ferrus. Here is the requisition which he wrote one day to obtain 
 his liberty : 
 
 "Five weeks ago I was arbitrarily arrested, and I am still detained in the 
 prison de la Force, in spite of a scandalous violation of right towards an honor- 
 able man, well known by his loyalty and imperturbable reason, and for his irre- 
 proachable conduct in all respects. I was walking on the Tuesday alone, between 
 two and three o'clock, in the Champs-Elysees, when, by a singular fatality, 
 
 Madame came walking herself — a circumstance which almost never happens, 
 
 I believe. She was accompanied only by an equerry, an oflScer, and a lady. 
 Hardly had I seen her than I held myself at a respectful distance in the cross- 
 walks of the great avenue where she was. Thus I was always at a distance of 
 more than fifty paces during her promenade, which lasted about a quarter of an 
 hour, although the public did not seem at all to importune her in surrounding her 
 during her walk, or in gathering round her carriage, when she mounted at the 
 extremity of the Champs-Elysees, on the side of the Place Louis XV. As for 
 myself, at that instant I was more than a hundred paces off. 
 
 ' ' How greatly was I astonished to see the first equerry forbear getting into the 
 carriage to come to me with the officer — to me, who was alone, solitary, and far 
 from help ! I could not believe that it was to lay wait for me on the public road. 
 Nevertheless, it was so. He accosted me, and holding in his hand a paper which 
 resembled a letter still sealed, he accused me of having sent it, at the moment, and 
 
 in the crowd formed before the carriage of Madame , adding that that letter 
 
 was libellous, and signed by my hand. I answered that I did not know what he 
 meant, and that I took M. the officer to witness that I had not been in the group, 
 and that I had never sent any letter or paper, as he affirmed. Then I told him 
 that I considered him a slanderer. Notwithstanding, he summoned the officer to 
 aiTest me. He at first refused, and it was only after a dispute that he yielded to 
 his solicitations. I believed I ought not to resist so arbitrary and scandalous an 
 arrest, and made it a duty to submit with confidence to the -loyalty of govern- 
 ment; all the more, that the loyalty of my well-known character ought always to 
 deliver me from any kind of plot formed against me." 
 
22-i STATES OF MENTAL EXALTATION. 
 
 This assurance, adds Marc, seems to result either from a real forgetfulness of 
 the attacks of delirium which cause M. D— to take pen in hand by inflaming his 
 amatory enthusiasm, or from a system of denial which he regards as useful to his 
 interests. (Marc, "Die Geisteskrankheiten,' etc., von Ideler, i., p. 23.) 
 
STATES OF MENTAL WEAKNESS. 225 
 
 CHAPTER III. 
 
 THE STATES OF MENTAL WEAKNESS. 
 
 § 145, Under this section are comprehended a series of morbid states 
 of mind which, although presenting great differences in their details, 
 collectively form a natural group. They all closely resemble each other 
 in the circumstance that (with a few exceptions to be afterwards men- 
 tioned) they do not constitute primary, but consecutive forms of insanity, 
 — that they continue as remnants and residues of the forms which we 
 have already been considering when these are not cured. Further they 
 are allied in this, that the fundamental mental affection no longer depends 
 in them, as in melancholia and mania, upon ruling emotions which 
 secondarily involve the intellect, but the disorder of the intelligence con- 
 stitutes in itself the fundamental anomaly, the emotions being suppressed 
 or entirely wanting (§ 29). This disorder of the intelligence either 
 presents the decided character of weakness, which in dementia proper is 
 manifested in the sluggishness of thought, the want of normal reproduc- 
 tion of ideas (loss of memory) and their healthy association — it may pro- 
 ceed to total abolition of all the mental faculties, with which there is also 
 combined weakness of the emotions and will, want of energy or com- 
 plete loss of volition, and dulness of the emotions, bluntnessof the moral 
 nature arising from the absence or superficiality of reactionary power, — 
 or the mental weakness is in a measure concealed by the predominance of 
 certain delirious conceptions, whose obstinate persistence is significant of 
 all that remains of mental power, and behind which all consciousness is 
 but an empty void. Out of this vacancy no ideas can any longer arise 
 which might counteract and overthrow the delusion; although the patient 
 is no longer governed by a dominant sentiment, still the delirium remains 
 persistent, owing to vacuity of thought, which ordinarily does not merely 
 affect the limited sphere of the fixed delirious conceptions, but is only 
 the partial appearance of a general diminution and destruction of all the 
 mental processes. Thus we consider that partial dementia ought to be 
 comprehended under the states of mental weakness. 
 
 In these states we no longer recognize the changeability of the forms 
 which we have hitherto been considering, nor that activity of the morbid 
 process in whicli the play of active, healthy mental function, mental 
 elaboration and combination, is so plainly recognizable (i)articularly 
 according to the law of causality). Here the false ideas, in so far as they 
 are not taken over from a former period, depend in great part rather on 
 incoherence and weakness of thought, or on partial dementia, upon hallu- 
 cinations not depending on tlie emotions and on an extension, constantly 
 more penetrating, of former delirious ideas relating to the entire sphere 
 of perception. All these morbid states (again with a few exceptions), 
 when not cut short by death, are very chronic in their course, and gener- 
 ally are capable only of one kind of change or modification — namely, in- 
 cr ease of the mental weakness. Nevertheless, they often remain quite sta- 
 
226 STATES OF MENTAL WEAKNESS. 
 
 tionary for long series of years ; they no longer admit of complete recov- 
 ery. 
 
 My having, in the first edition of this work, classed partial dementia with the 
 states of mental weakness, has caused a great deal of controversy. But, in fact, 
 it can be placed nowhere else. In complete dementia we have, along with deli- 
 rious conceptions which have become as it were stereotyped, a decided diminution 
 of the moral powers, a mental decrepitude, a wreck after the subsided storrn. 
 There exists, it is true, between this terminal point and the primary stages, in 
 many patients a long period of transition, in which there still plays around several 
 groups of deUrious conceptions remaining over from these primary stages, an 
 active mental process. In this the delirium becomes in part modified quite in- 
 voluntarily, in part elaborated and systematized (§ 44). When this is completely 
 finished, the quite stationary period commences, in which the delirium consists 
 only in a repetition of the fixed residuary ideas. Those states of transition which 
 still permit a certain change of the morbid mental phenomena, and which are 
 numerously represented in every asylum, are, in regard to classification, a source 
 of embarrassment to the beginner. He may, without hesitation, keep to the 
 principal classes which have been here established, but must consider that some- 
 times a long period of observation is necessary to determine in a given case how 
 much is still activity and progress, and how much is simply residue. Neumann 
 (' Lehrb. d. Psychiatric,' 1859, p. 70) calls what we designate dementia, " recovery 
 with defect." How far ' ' recovery " may be spoken of, or rather cannot be spoken 
 of, is clear. As to the "de/ec<,"it essentially expresses the same view which 
 prompted me to class dementia amongst the states of mental weakness. 
 
 § 146. The states of mental weakness comprehend two great groups — 
 Chronic Mania and Dementia. In regard to the first, we refer the reader 
 to the description farther on. In the form of dementia we distinguish 
 two divisions — the one with incoherence of the ideas, but with consider- 
 able, although merely superficial, activity of perception, generally with a 
 slight degree of outward agitation (demence agitee); the other with ex- 
 treme sluggishness of perception, even to complete abolition of it, and 
 with external apathetic calm (demence apathique). In this division we 
 only consider that form of dementia which is acquired — that, namely, 
 which occurs in individuals who have been formerly mentally healthy. 
 We shall devote a special chapter to that form which is congenital, or 
 which arises in the early years of childhood — the various degrees of 
 idiocy. 
 
 This acquired dementia, considered as a special form of insanity, may 
 of course arise primarily— that is, without having been preceded by 
 another form of mental disease, or other cerebral disease of a different 
 nature, as in the case of the mental weakness of advanced life or prema- 
 ture decrepitude, primary atrophy of the brain, intracranial tumors, etc. 
 As to the cases described by many authors as acute, curable, primary de- 
 mentia, the great majority of them certainly belong to melancholia with 
 stupor, in the description of which we have already called attention to the 
 readiness with which it may be confounded with actual mental weakness, 
 and to the distinctive signs of both forms. Nevertheless, it cannot be 
 doubted that there exist intermediate states between melancholic stupor 
 and actual dementia, and also decided cases of primary, acute, and cur- 
 able dementia; in proof of which we shall cite an interesting example of a 
 case in which the dementia was probably owing to ojdema of the brain 
 from pressure on the cervical veins. 
 
 Example ^lAl.— State of dementia of several weeks' duration, and without 
 subsequent recollection of it, caused by an attempt at straiigulation.—A. prisoner, 
 set. 25, strongand healthy, hanged himself. Almost immediately after thecuttmg 
 down of the body, it showed signs of life; consciousness returned. The patient 
 gave, apparently quite calmly and sensibly, the history of his life and his motive 
 
STATES OF XENTAL, WEAKNESS. 227 
 
 for the deed (weariness of life). On the following day he was tranquil and spoke 
 little; on the third day he spoke none. The countenance was fixed, the eyes 
 rolling and injected ; the temporal and masseter muscles and those of the eyes were 
 convulsed; the face immovable and lifeless, like that of a statue. No sensorial 
 impressions appeared to be perceived, but a very loud sound caused slight con- 
 tractions of the facial muscles; he went about and ate without expressing desire 
 or sensation. After three weeks had elapsed, the patient was taken to an asylum ; 
 and after a few more weeks he awakened. He remembered perfectly well the 
 time and the circumstances which had preceded the hanging until the onset of 
 loss of consciousness, and described the violent struggle in his mind between the 
 resolve and the fulfilment of the deed, and the sensations in the moment of hang- 
 ing — ringing of the ears and stars in the eyes. From this time to the hour of liis 
 awaking in the asylum, all recollection of his personal existence was wanting; 
 even the animation after the hanging and the temporary possession of conscious- 
 ness were quite unknown to him. The second awaking took place suddenly: one 
 day, in the court, the idea of the buildings around was awakened in him, and this 
 called forth remembrances of other similar objects. From that hour the mental 
 functions and the general health rapidly became re-established. (Meding, iu Sie- 
 benhaar, ' Magazin fiir die Staatsarzneikunde,' i, 1842.) 
 
 But far more frequently acquired dementia originates consecutively, 
 that is, after the symptoms of another severe cerebral disease (epilepsy, 
 acute meningitis, typhoid cerebral affections, etc.), and especially wlien 
 other forms of insanity have preceded it. It constitutes then the sad end 
 of all mental diseases which remain uncured — melancholia, mania, and 
 monomania. What is very remarkable, senile dementia even isnotunfre- 
 quently preceded by a period of exaltation — a short maniacal stage, 
 characterized by great psychical irritability, a newly awakened tendency 
 to activity, reappearance of the sexual desires (wishing to marry, etc.), 
 and a craving for alcoholic drinks: this is then followed either by rapid 
 psychical collapse, or short periods of exaltation alternate several times 
 with the increasing mental weakness. During convalescence also, espe- 
 cially from violent mania, there not unfrequently occurs a condition of 
 profound mental weakness: this state bears the same relation to true de- 
 mentia that great and long-continued fatigue does to actual paralysis. 
 
 It is not at all unusual, although hitherto it has been very little at- 
 tended to, to observe a mental state characterized by moderate weakness 
 occasionally ensue after apparent recovery from other forms, and to re- 
 main persistent. In individuals who have recovered in this wa}, the 
 sentiments regain their former calm; they can also again think and 
 judge in a formally correct manner — the memory is little or not at all 
 disturbed — their conversation is quite coherent and rational. But they 
 are no longer the same persons; it seems as if their mental individuality 
 had been deprived of its best and most valuable qualities, the more deli- 
 cate moral and aesthetic sentiments, interest in the higher mental aims of 
 life, which form the beauty and the nobleness of human nature. Their 
 thoughts and efforts move henceforth within a limited circle, in the 
 sphere of the immediate wants and requirements; and while they conduct 
 themselves rationally, perhaps with a degree of activity in this circle, all 
 the spiritual and ideal concerns of life, all consideration or desire of 
 them, are foreign to them. These persons might be regarded as perfectly 
 sane — since there are many individuals who are all along of this dis- 
 position — if we had not been acquainted with their former life, and if, in 
 many cases, in the physiognomy and whole demeanor, a marked change 
 to idiotic, even animal-like expressions, was not recognized. They are 
 further capable of simple meclianical employments, in the performance 
 of which tliey show care and intelligence; for themselves they desire 
 nothing more than suffices to satisfy simple material wants. Should such 
 
228 STATES OF MENTAL WEAKNESS. 
 
 individuals be permitted to leave the asylum and return to ordinary life, 
 they run a great risk of nevv and severe attacks of insanity, or of gradually 
 passing into confirmed mental weakness. In the asylum they often for 
 years enjoy a life of relative health, calm, and useful employment. 
 
 Such states may be regarded as the mildest forms of dementia. In 
 all liigher degrees the patient ceases to present any appearances of 
 convalescence, and the increasing mental dulness is not restricted to the 
 finer and more delicate faculties. Sometimes the whole mental life 
 again assumes the character it had in childhood, in which most strikingly 
 the capacity of abstract thought is lost; in many forms, again, a 
 certain superfical and incoherent activity and mobility of thought still 
 remains. The absence of all serious thought — because comparatively 
 few and limited masses of ideas are present — the pleasure in trifles and 
 toys which afford material for superficial fantasy, and the unmasked and 
 unrestrained manifestation of the disposition actually present (laughing, 
 jumping, weeping) observed in many of these states, cause them closely 
 to resemble the state of childhood. Many of these patients also have to 
 be treated and guided like helpless children; they may, however, by kind- 
 ness or severity be kept at light mechanical employments, and by meth- 
 odical regulation and care kept from manifesting the incoherence and 
 confusion of their ideas, and often for a long time preserved from more 
 profound mental decay. 
 
 These cases of chronic mania and dementia constitute the vast major- 
 ity of the insane, and institutions devoted to chronic cases are almost 
 •exclusively inhabited by them. It would be well if our psychological 
 knowledge of these states were only in a degree somewhat approaching 
 to the rich opportunities afforded to us of studying them! The individ- 
 ual varieties are here still greater than in the forms Ave have already con- 
 sidered ; they can neither be enumerated nor described. We must rest 
 satisfied with stating and describing several principal types. 
 
 Section I. — Chronic Mania {Die Verrilchtheit; La Folie 
 
 systematisee). 
 
 § 147. Under this term are comprehended those secondary states of 
 insanity in which, although the original morbid state of the sentiments 
 has considerably diminished or even entirely disappeared, the individual 
 does not recover, but remains affected in such a manner that the delirium 
 is now most strikingly exhibited in certain fixed delirious conceptions 
 which are cherished with especial preference and constantly repeated — 
 always, therefore, a secondary disease developed out of melancholia or 
 mania. We consider the term monomania (§ 45) introduced by Esquirol, 
 but employed by him in an essentially different sense, especially adapted 
 designate these states, provided it could always be restricted to a special 
 form of mental disease. The study of the psychical phenomena in these 
 patients seems to us to have been hitherto much neglected, and the true 
 nature of the disease to have been observed and falsified by anecdotal 
 conceptions. We shall attempt to describe what we have learned from 
 actual observation. 
 
 Anomalies of Self -consciousness, the Desires and the Will. — The trans- 
 ition of melancholia and mania with delirious conceptions to these 
 states always takes place gradually. The state of negative or affirmative 
 emotion resulting from these conditions often disappears very slowly, os- 
 cillating for several years: a chronic state of modified melancholia or 
 
STATES OF MENTAL WEAKNESS. 229 
 
 maniacal excitement, howeyer, often remains long persistent; after a 
 time this also disappears, leaving behind it certain delirious concep- 
 tions. According as the emotional excitement becomes weaker, apparent 
 reflection gradually returns; in place of incoherence of thought, mental 
 tension or convulsive shock and suppressed volition, there again enters a 
 more regular flow of psychical activity. Gradually there is re-estab- 
 lished an entire or partial external equilibrium, as with the disapperance 
 of the morbid emotions the mind becomes calm. 
 
 But this is no longer the equilibrium of the former healthy life. Grad- 
 ually a new intermediate state of the psychical tonicity, new emotions 
 and a new character are developed: the patients are not now what they 
 formerly were; with the addition of one or two erroneous opinions or a few 
 delirious conceptions, they are thoroughly changed. This radical change, 
 which is naturally most distinctly manifested where the general melan- 
 cholia and the maniacal exaltation have now entirelij disappeared, con- 
 sists essentially in dulness and weakness of all psychical reaction — in an 
 absence of sentiment, indifference, and diminished energy of the will. 
 None of these patients are any longer capable of tl>e same interest in the 
 external world, the same love and the same hate, as formerly. Friends 
 and relatives may die, that which was formerly most dear to them may 
 go to wreck, the most joyful event may happen in their family — tliey 
 will experience at most only a very superficial disagreeable or agreeable 
 excitement, or they will quickly turn from the subject as from some un- 
 welcome disturbance, or they may not react at all. Only on one point 
 can the psychical tone still be readily ascertained and altered — can emo- 
 tions and reactions of the will be rapidly called forth: if we touch upon 
 the fixed idea, if we oppose his statements by arguments or his pro- 
 jects by force, the patient will immediately become angry and violent: if 
 we encourage the delusion, he will at once rejoice. 
 
 In certain cases which may become the subjects of medico-legal inquiry, the 
 total dulness of sentiment and "thereby perverted reaction, forms one of the most 
 prominent elements of these .conditions; they present a species of quite chronic 
 fixed moral insanity, which might be designated emotional insanity. The prin- 
 cipal though by no means the only examples of this condition are to be found 
 amongst drunkards who have become insane (see § 41). 
 
 Tlie emotional dulness of the chronic maniac is very characteristically mani- 
 fested in his relations to the asylum. The individuals are, almost without excep- 
 tion, quite contented with their lot: they never form plots (which, owing to their 
 number, they could easily do), a single attendant leads them like a flock of sheep; 
 should one of them suffer punishment or be removed, the circumstance does not 
 at all affect the others. 
 
 § 148. Emotional states, therefore, are still possible, but only one 
 group of ideas is able to provoke them. The ruling disposition is, in- 
 deed, on the whole, one which corresponds to the delirious idea, although 
 in a weaker degree; and in the higher grades of partial dementia there 
 often prevails so entire an indifference, that, without any trace of emotion, 
 the patient incessantly declares himself to be the ruler of the world, the 
 possessor of all in heaven and earth, God himself, etc. The psychical re- 
 react'on on all excitation other than that which is directly in connection 
 with the delusion is generally very feeble, because, on the one hand, per- 
 ception, in so far as it is not related to the delusion, has considerably 
 lost its energy and become blunted; and, on the other hand, because fre- 
 quently many masses of ideas which belong to the former life of the pa- 
 tient are now completely dissipated, forgotten, or no longer recognized 
 by him as his own. It is the same circumstance which in the sphere of 
 
230 STATES OF MENTAL WEAKNESS. 
 
 the intelligence does not permit the patient to recognize the folly of his 
 delusion. The relations are not like those of ordinary life, where a leading 
 idea, an impelling thought, temporarily obscures and suppresses the 
 other ideas. In health there is always the possibility of the contrasting 
 ideas, doubt and hesitation, arising. But in chronic mania, although 
 the patient is no longer in the state of emotional excitement which for- 
 merly rendered it impossible for him to recognize the error of his ideas — 
 although he, indeed, sometimes reasons with formal correctness upon 
 certain points — yet he is no longer capable of doubting the possibility of 
 his delusion. That the fixed ideas cannot meet any disturbance in their 
 fourse, is owing to tlie circumstance that no counterpoise, no inward op- 
 position resists'them; and this appears to depend quite as much upon a 
 general weakening of the former intelligence, as upon the disappearance 
 of certain series of healthy ideas. Thus, the cause of the impossibility 
 of recognizing the delusion as such, and the general indifference and di- 
 minished psychical reaction, may both be founded upon the same psychi- 
 cal defects. 
 
 It is the same with the emotions and the will. So long as slight mel- 
 ancholia and emotional excitement remain, volition presents the general 
 character of these states; and there are then observed, sometimes a one- 
 sided persistence in a single negative direction (for example, a continual 
 tendency deliberately to destroy inanimate objects — to tear the clothes, 
 pieces of paper, etc.), sometimes a restless energy in the direction of the 
 delirious conceptions, sometimes transient maniacal attacks. Afterwards, 
 however, there also appears in the volition a mediate or higher degree 
 of general Aveakness; some can continue the mechanical employments to 
 which they were formerly accustomed, as, for example, Professor Titel, 
 who believed himself to be the Emperor of Kome, and continued to read 
 his course of lectures in the College; or they can pursue easy manual oc- 
 cupations: but there is no longer that desire for healthy activity, and 
 even the acts corresponding to the delirious idea, as the writing of letters, 
 issuing of proclamations, etc., gradually become less energetic and more 
 superficial; while in the most confirmed states there only remains the 
 most feeble employment — the amusing themselves with pebbles, rags, 
 paper, etc. 
 
 All sorts of capricious desires, such as are also observed in the forms 
 we have already studied, are particularly frequent in chronic mania, and 
 become fixed habits. Some constantly seek to work amongst water, 
 others would be always pulling off their boots, others manifest a special 
 preference for certain places and corners where they may always be 
 found: some will not speak; others scream, sing, declaim, or continually 
 employ themselves in daubing the walls; some rejoice in decorating 
 themselves with straw, rags, and trifles; others take delight in allowing 
 their nails to grow long; while others again are always perpetrating mali- 
 cious acts, making peculiar gestures, etc. These desires have often a 
 peculiar, mysterious significance to the patient, or they proceed from cer- 
 tain frames of mind connected with the delusion; at other times tliey are 
 purely automatic, the patient himself knows no cause for theui, and is 
 angry Avhen questioned regarding them, in the same Avay as healthy per- 
 sons are irritated when asked the reason of peculiar habits, such as 
 chewing the nails or making unnecessary movements with the hands, 
 
 etc. 
 
 § 149. Amongst the anomalies of thought in chronic mania, we meet, 
 in the first jilace, with a formal change — namely, a sometimes moderate, 
 
STATES OF MENTAL WEAKNESS. 231 
 
 sometimes increased degree of weakness of thought, generally accompanied 
 by loss (forgetfulness) of great series of ideas which formerly belonged to 
 the individual in health. For these reasons, no clear apprehension, no 
 healthy mental conception is now possible to the patient. Some may, 
 indeed, carry on a pretty rational conversation, but generally it consists 
 merely of current phrases; so soon as actual abstract thought is required, 
 they show their incapacity to gi-asp the subject. Eeal acuteness never 
 exists in chronic mania, unless, indeed, the occasional curious combina- 
 tions of thought which, occurring abruptly and unex2)ectedly, and seem 
 now and then somewhat surprising, be considered as such. Generally, 
 the patient cannot fix in his mind, even in a slight degree, any idea 
 winch is not closely connected with the dominant delusion; he deviates 
 from the subject, and generally reverts, in writing even more than in 
 speaking, to that circle of ideas which to him is alone actual and real. 
 In the more advanced degrees, this weakness of perception becomes actual 
 incoherence — a casual rising of images and thoughts without sense or 
 coherence, only loosely connected by the unity of the fixed ideas: with 
 this chronic mania passes into dementia. 
 
 We have already seen, in a former chajDter, how the separate delirious 
 conceptions arise in melancholia and mania, and their subject-matter is 
 there indicated. They always relate to the special personality of the 
 patient, to his position in the world or relation to the Deity, although 
 their subject-matter presents essential differences. 
 
 Sometimes they are exalted maniacal ideas of an active kind, relating 
 to elevation of the subject and his domination over external things — God, 
 one of the Holy Trinity, state reformers, kings, learned men, prophets, 
 ambassadors from God, discoverers of perpetual motion, the mother of 
 nature, one who has penetrated all mysteries and knows the elements of 
 all things, etc. 
 
 Or the delirious conceptions relate to some affliction, to domination 
 by external things. The patients believe that they are persecuted, sur- 
 rounded by spies, tormented by secret enemies who employ electricity 
 against them, tormented by freemasons, possessed of a devil, eternally 
 damned, robbed of their most valued treasures, etc. Or they cherish 
 fixed delirious conceptions regarding their own body; they are dead; 
 their bones are made of glass, of butter; they harbor strange things in 
 their body, etc. 
 
 From the different characters of these ideas we are enabled to distin- 
 guish chronic mania with active, exalted (§ 131) delirium, from the same 
 with passive, depressed delirium. 
 
 The more limited the circle of these delirious conceptions, tlie more 
 do they appear, on superficial consideration, to be simple and even incon- 
 siderable errors of judgment. Buc how much do such errors, even in 
 the most favorable case, differ from those mistakes which in the same 
 proceed from deficient knowledge! A long series of psychical disorders 
 must precede them; they are inwardly developed from states of emotion. 
 The whole personality of the patient is identified with them; he can neither 
 cast them from him by an act of will, nor rid himself of them by argu- 
 ment; and in order to the existence of the delirium in this mild form, 
 not only must that long series of emotional states m which it grew have 
 run their course, but there must also remain behind a deficiency of thought 
 to insure its existence. 
 
 Above all, however, the partial delirium of dementia depends not so 
 much on the circumstance that the false ideas of the patient are limited 
 
232 STATES OF MENTAL WEAKNESS. 
 
 to one subject, as on this — that he always, by preference, exjn'esses one 
 sole and leading false idea which constantly pursues him. His morbid 
 thought is much more extended : the delirium which has been developed 
 in the practical sphere of the affective sentiments extends not only to the 
 neighboring sphere of self-consciousnes, where it disturbs the proper esti- 
 mate of the special personality and its relation to the world, but it also 
 identifies itself with all the theoretical ideas of the patient and gradually 
 falsifies all his thoughts. Then he involuntarily refers everything to the 
 delirium; in its light everything is viewed; and thus he cannot fail, in the 
 most favorable cases (for example, in simple hypochondriacal delirium), 
 to have false notions and views of life which were formerly quite foreign 
 to him. Where, however, there exist more serious false ideas concerning 
 the special personality, all the patient's views in regard to the external 
 world are totally perverted; he judges everything from a false position 
 and from wrong premises; and where there is most form and logical order, 
 the insanity proceeds frequently to a comprehensive and sometimes care- 
 fully concealed system of delusions, in which all the relations of human 
 intercourse, all moral considerations — indeed, the whole internal and ex- 
 ternal organization of the universe — are mysteriously expressed. Some- 
 times ordinary language is not sufficient to express his thoughts, and he 
 invents, at least to express the delirious ideas, atotally different language, 
 which he declares to be the primitive language, the language of heaven, 
 etc. ; and the more the sensorial impressions are obscured by hallucina- 
 tions, and the inward views become indistinct and displaced by confusion 
 and weakness, the more do these states pass into the form of dementia. 
 
 The origin of these prominent delirious conceptions can always be traced to a 
 stage of melancholia or mania, and often to special occurrences during these 
 stages. Should the fixed idea consist in the delusion of being some illustrious 
 personage, their behavior when opposed by the arguments of reason is very 
 remarkable. Generally the patients can still give an account of their former 
 life, sometimes they even admit that they have been insane (certainly, however, 
 only from hearsay, and they then understand by it only the form of melancholia); 
 often they narrate the more minute circumstances of their change (especially 
 hallucinations), but generally they do so very indistinctly. They remark that in 
 conversation persons oppose their fixed ideas, and generally they quietly, though 
 unwillingly keep silence on the subject. Should actual arguments be brought 
 to bear against them, they begin to scold and become violent, and the aggressor 
 has generally lost their confidence for a long time. To some of these patients 
 their former true personality appears dead ; they speak of it as ot a third person, and 
 often only vague recollections of it penetrate the obscurity in which the old ego 
 is involved. 
 
 From the foregoing, it will be seen how very numerous the intellectual dis- 
 orders are in those patients, or rather how various are the states consequent 
 upon maniacal and rriclancholic conditions, and comprehended under the name 
 of chronic mania. New investigations may throw further light on this subject. 
 
 The following examples will still further aid in giving a correct idea of this 
 form. 
 
 § 150. Hallucinations and illusions of all the organs of sense are in 
 no form of insanity so frequent as in chronic mania, and in many cases, 
 they nourish and maintain the delirium. Frequently the pati-ent con- 
 verses or quarrels continually with the voices which he hears, and falls 
 into angry excitement; frequently he finds his whole happiness in a 
 pleasing illusion of sight, like the demented mother whose darling long- 
 lost child was represented to her by a broken jug clothed with rags, 
 which she for many years cherished with the greatest tenderness. 
 
 The movements, the appearance, and the conduct of these patients 
 always manifest, even in the mildest forms, a certain perversity and dis- 
 
STATES OF MENTAL WEAKNESS. 233 
 
 tortion. The physiognomy generally appears old and withered, and has 
 an expression of stupidity or of the dominant delirious idea. Nearly all 
 manifest certain peculiarities in their conduct : some gesticulate constantly, 
 or move their hands and feet in a monotonous manner; others jireserve 
 an ecstatic stillness, in order to listen to their hallucinations; others walk 
 up and down incessantly in a favorite place, like animals in a cage, and 
 speak or hum words, rhymes, or melodies. Some always remain in the 
 darkest corners they can find, turn their back to the passer-by and are 
 irritated by every disturbance; others constantly employ themselves in 
 collecting trifles of every description — rags, pebbles, shells, etc. — to which 
 they attribute great value; while others, again, decorate themselves fan- 
 tastically with everything they can lay their hands on. 
 
 Generally, with the. cessation of the melancholic or maniacal state 
 there occurs a marked increase in the size of the body and a state of 
 robust physical health. Every asylum contains patients who live for 
 many years in moderate health and attain a great age. 
 
 Intermissions or remissions never occur in these states, and all experi- 
 ence goes to show that complete recovery is impossible; but by the com- 
 munications of Leuret it is placed beyond doubt that, by energetic 
 methodical treatment, some of these patients can be made "to suppress 
 their delirium and lay aside their peculiar habits to such a degree that they 
 may be rendered capable, to a considerable extent, of pursuing simple 
 avocations. If these patients be left to themselves, they become more 
 and more engrossed in their delirious conceptions; these gradually extend 
 to wider ranges of thought, and the patients finally fall into complete or 
 apathetic dementia. 
 
 Example XLIII. — Chronic mania and inonomania. — In 1824 there was a 
 young man in the lunatic wards of the Charite at Berlin who had been there for 
 about eight years. He was more the object of attention and care than of medical 
 treatment; he walked about the corridors and in the rooms, appearing to take an 
 interest in all that went on around him, but, to speak truly, occupying himself 
 with nothing. He laughed and mocked at everything with great haughtiness; 
 and if any one happened to ask him auytliing, he replied with great assurance, 
 and with a perfectly self-satisfied air, because — and there lay the foundation of 
 his insuperable egotism — he was all, knew all, possessed all, and could do all. No 
 station was higher than his, no knowledge equalled his; his fortune was as great 
 as his knowledge, and proportioned to the station which he believed himself to 
 occupy. This assurance which he had of his greatness, his cleverness, and his 
 l^ower came out in all his acts and movements. A consummate actor would 
 have had difficulty in expressing the magnificence and disdain manifested by this 
 young man, simply clad in a blouse and seated on a wooden box. The fact is, 
 that never had man profounder conviction of his own merits and greatness. 
 According to information given, this unhappy young man, after an examination 
 for which he had worked hard, and in which he had failed, became silent, sad, 
 and fell at length into the state wherein we find him. In reality, it is often in 
 this way we see fixed ideas appearing. The same thing is observable in the case 
 of those who, by unhappy speculations, have fallen into the profoundest misery, 
 and who, exhausted by intellectual work, can no longer engage in them; their 
 intelligence is disturbed, and suddenly they present themselves to their friends 
 destitute and speaking of their wealth. 
 
 By the side of this invalid whose portrait I have rapidly sketched, and who 
 was well known to me, I have set another, lately come to the asylum, and 
 respecting whom I shall say the little I know of him. 
 
 M. S— , aged about 30, in a good position in business which brought him in a 
 great deal, of agreeable temper, but easily excited, addicted during several years 
 to an irregular life, distracted by pleasures, often excited and enfeebled by al- 
 coholic liquors, became demented. A long and uninterrupted series of pleasure 
 of every kind seems to have induced the explosion of an old tendency to madness. 
 To every question addressed to him he replied, " I am a colonel, adjutant-general; 
 
234 STATES OF MENTAL WEAKNESS. 
 
 I am a capital player at billiards, an extraordinarily expert lioreeman; lately, I got 
 on horseback in the circus, and I distanced all others by the skill, strength, art, 
 and marvellous elegance with which I managed the most restive horses. I am 
 very rich; I invite you to come to iny house — I want to have a little amusement. 
 The man you have given me here, and whom you call a keeper, pleases me; he 
 also saw me get on horseback in the circus," etc. I answered him, " To-morrow 
 I will introduce you to a man who is here, who will certainly take an interest in 
 you, and who may be useful to you." M. S — then said to me very quietly, " I 
 shall be very glad; I like to have a great many friends, and I like, too, to be on 
 good terms with everybody." 
 
 M. H — was standing in the corridor, supported on his wooden box, with a look 
 of self-satisfaction, when I brought M. S — to him, saying, " Here Is a gentleman 
 whose acquaintance will perhaps interest you." M. H — approached M. S — , fixed 
 his eyes on him, and having watched him some moments, threw his head back- 
 w^ard, saying, "Who are you?" M. S — : "I am a colonel of His Imperial 
 Majesty of Russia, and adjutant-general." M. H — : " It is not unpleasant for me 
 to make your acquaintance. I shall take a great interest in you out of regard to 
 your position, and you may be quite sure of my patronage, for I am a field- 
 marshal, and during my leisure hours I occupy myself with the organization of 
 the naval and military forces of Russia." M. S — , astonished at the unheard of 
 arrogance of his interlocutor, looked about him quite embarrassed, while M. H — 
 looked at him with all possible dignity of manner, and, tilled with the conscious- 
 ness of his vast superiority, he said to liim, " Have you still some other accom- 
 plishments which I might put to use?" '"Yes, Mr. Marshal," replied M. S — , 
 approaching M. H — with a kind of familiarity; " I am chief of the outriders; I 
 am a horseman of great strength and an admirable . . ." Then M. H — , throw- 
 ing himself back and assuming a still grander air, while he shot at him as 
 
 disdainful a look as possible, " Vile hateleur,"'' said he, " miserable , worthy 
 
 of being in a madhouse! " and he withdrew haughtily. He assumed his ordinary 
 position beside the wooden box, with a crushing look at M. S — , who was greatly 
 frightened. I then led away M. S — , saying to him iu a low voice, " How could 
 you say such things to this gentleman?" M. S — replied, "I never did get on 
 horseback, as I said just now, but I often thought how good it would be to be 
 able to do it. I wish I could tell this gentleman that I did not get on liorseback 
 with the groom of the circus. Take me, I pray you, immediately to him." I re- 
 plied, " You have got yourself into a terrible scrape with him. As you know 
 quite well, you placed yourself in a bad position by saying such things. Don't 
 try it again, for you see the contempt which that ill-advised banter has brought 
 upon you." M. S — : "But I am colonel and adjutant-general all the same." 
 " That is another matter," I replied, " and we shall talk about it afterwards; but, 
 at present, you have forever forfeited the esteem of that man. Take care that 
 the same thing does not happen in the case of other people." The keeper walked 
 with M. S — , and told me afterwards that he had continued to talk with him of 
 that affair. He said to me, that from that moment M. S — ceased to believe 
 himself a groom, but he still believed himself to be a colonel. The patient, who 
 was in that condition during the last four months, was quite cured in the course 
 of several months which followed that meeting in which M. H — had so rudely 
 shaken his insane notions, which were henceforth arrested in their further devel- 
 opment. M. H — always shunned hun, never spoke to him, and treated him with 
 profound contempt. M. S — was always ashamed in his presence, as if he 
 remembered the disdain which M. H^ had manifested towards him at their first 
 interview. It was only when quite cured that he got rid of the embarrassment 
 w^hich he experienced in presence of M. H — . When he was completely ciu'ed, 
 and was about to quit the asylum, M. S — extended his hand to M. H — , for whom, 
 since his restoration, he showed a real attachment; but he received him with the 
 same contempt as formerly, more than ever persuaded of his influence, of his 
 fortune, and of the immense distance which separated them. M. H — remained 
 in tlie asylum — he was incurable; M. S — , on the contrary, owed his recovery, 
 doubtless, to the meeting which he had with him after his arrival in the hospital. 
 (Sinogowitz, ' Die Geistesstorungen,' etc., 1843, p. 22.) 
 
 Example XLIV. — Chronic mania of many years'' standing; habits capricious, 
 but intimately connected with the leading delusion. — The w^oman 13 — was, wlien 
 she came under my observation, about 05 years of age. So far as known, she had 
 been an inmate of asylums since slie was sixteen. In her deiiortment she con- 
 stantly showed traces of superior training. I could never learn whether she had 
 
STATES OF MKNTAL WEAKNESS. 235 
 
 any relations still living; nobody visited her, and I had no other means of infor- 
 mation. Her once fair and luxuriant hair was now nearly gray; her forehead 
 wrinkled, her deeply -set blue eyes were very movable, and when excited they act- 
 ually sparkled; her gait was generally slow, and she moved without definite direc- 
 tion — always as if looking for something, and in semicircles. She never greeted 
 anyone, nor acknowledged a salutation; it was only rarely that slie, when saluted 
 by any one not known to her, would look up, minutely examine the individual, 
 then rapidly withdraw her eyes and occasionally murmur a few incomprehensible 
 words. At other times she replied to all communications which were addressed 
 to her with several severe words of reproach, which generally concluded by her 
 withdrawing from all further communication, and pronouncing this judgment: 
 " He shall be burned.'' If listened to, there would ensue a violent scene highly 
 disturbing to those around her. Therefore, the old incurable patient was left to 
 herself, and no attention paid to her harmless energy. When let alone, she 
 offended no one, carefully avoided all contact, seemed occupied only with very 
 urgent affairs, and froni long custom joined in the ordinary household arrange- 
 ments. She often wrote letters, which consisted entirely of capital letters; they 
 were always written on large sheets of paper, and addressed to the most powerful 
 monarchs in the world and their wives. She always accepted a few sheets of 
 large paper and some pens with marks of gi-atitude, although she never expressed 
 her thanks, and generally rapidly disappeared from the donor. From a number 
 of her letters, I gathered, not without some trouble, the following regarding her 
 ideas: — The old woman believed herself to be a queen, daughter of the sun, and 
 near relative and friend of all monarchs. She hoped to be drawn in a coach of 
 gold, drawn by six horses. Most of the letters were directed to the ruler of the 
 Sublime Porte and his wife. The letters to the monarchs, which she wrote almost 
 regularly three or four times a year (she also wrote to the judges of the earth 
 and to the general executioner of the world), generally contained requests and 
 special demands that those persons might be burned who had on several occasions, 
 and perhaps intentionally, disturbed her in her employments. If the name and 
 designation of such persons were vinknown to her, she would give a description 
 of them, according to their clothing and habits, so true that the persons meant 
 could be easily recognized, in order that the high monarchs might commit no 
 mistake. If any one were doomed by her to be burned in one of these letters, 
 she repeated to him his judgment each time she saw or spoke to liim: pardon 
 need no more be expected. This patient was, as already mentioned, an accu- 
 mulator of uncommon perseverance. Only on very cold and rainy days did 
 she desist from collecting, but wlien the sun shone during the hours of recreation 
 in the garden she was most active. Quite absorbed in her work, she collected 
 small colored stones, dead brilliant beetles, flies, certain small leaves, twigs, 
 colored feathers, rags, bright pieces of glass, etc. If she had made a large collec- 
 tion, when the recreation hour ended she cast radiant glances towards her pocket, 
 and rapidly sought her room in order to conceal her treasure. With a certain 
 cunning, and even with open resistance if hindered, she would attempt to with- 
 draw herself from the next walking party, in order that she might, when possible, 
 be alone in her room. In this solitude I found opportunity to observe her un- 
 noticed, and cannot speak without emotion of what I saw. She opened a window 
 on the sunny side of the apartment, and looked a few moments at the sun; then 
 she drew from all her pockets and from the places of their concealment her 
 treasures, spread them before her on the window, and viewed them for a tune, in 
 profound contemplation; she then tied these gaudy articles, fastened with green, 
 yellow, red, and white threads, between the iron bars outside the window, so that 
 they remained suspended in rows. When this bright array was finished, sheopened 
 the door opposite the window, which caused a draught. When, owing to this, 
 the slightly fastened leaves, feathers, rags, etc., commenced to flutter, the old 
 woman would look with joy expressed in her eyes alternately at them and at the 
 sun, and weep for joy; she noiselessly moved backwards and forwards like to a 
 child delighted with its toys. As the time advanced, she would hear the noise of 
 the approach of her neighbors from the garden, and rapidly and carefully, dis- 
 turbing nothing, pack up all; and when those who shared her apartment entered, 
 no trace of them would be observed. As I, during my repeated observations, ap- 
 proached (she was so engrossed that she did not observe my approach) and quietly 
 stood beside her, she bore my presence without scolding, and. observed me with 
 joy expressed in her eyes. Quietly I withdrew, and was afterwards several 
 times enabled to witness the same scene, although I had already been doomed to 
 be bui'ned in her letters. 
 
236 STATES OF MENTAL WEAKNESS. 
 
 I directed that tliis unfortunate woman should not be annoyed during her 
 hours of recreation; for no one has a right, without some good motive, to break 
 upon the happiness of his neighbor. Accordingly, this old woman enjoyed in 
 peace her small measure of happiness until her death, wliich occurred a few years 
 aftei'wards. She was more than fifty years in asylums; her insanity had never 
 been cui'ed, but had often been aggravated by her quarrelsome neighbors. — 
 (Siuogowitz, ' Die Geistesstorungen,' Berl., 1843, p. 35.) 
 
 Example XLV. — Chronic mania tvith the character of depression; hallucina- 
 tions of hearing. — One day I was accosted at the Salpetriere by a woman I had 
 never before seen. She had a quiet and timid air; she looked at me as if trem- 
 bling, and did not speak. Her dress was simple and decent. I judged her about 
 forty years of age, and afterwards discovered that this was indeed her age. I stood 
 stiU near her, and she continued to look at me. Speedily I saw her face assume 
 an expression successively of anxiety and terror; then she remained calm, and I 
 would have said that she was listening, and soon again the movements of her 
 features indicated agitation of mind. I walked a hundred paces witout saying a 
 word, and without appearing to fix my attention on her. She followed me, and 
 continued her quiet action. I stopped again, and regarded her attentively, with- 
 out seeming to be the least curious. She did not discontinue her quiet conversa- 
 tion, for I saw that she talked with me; and although my impassibility was as 
 great as possible, she heard objections and reproaches to which she hastened to 
 respond. We continue looking at each other in this way for nearly half an hour, 
 when she murmured some words which I did not comprehend. I gave her my 
 note-book, on which she wrote as follows: " Clemence, brought to the Salpetriere, 
 ignorant of all that has passed here, for I have not deserved such a punishment 
 for having merited so little happiness. I swear that I have not stolen from any 
 one; that I have not borrowed from any one all that is in my room — the jewels, 
 the goblets of silver; that I am come with confidence; that I have never engaged 
 in the lottery; that I will go everywhere with honor; that I saw the mill 
 turn. . . ." 
 
 Then she gave me back my note-book, and continued as before. At length 
 she said, " But, sir, why do you not speak out to me? I do not know — nothing 
 at all, sir — when nothing is said. , . . Never have I been in a bad place. I do 
 not know what it is you would say to me. If any one has sent me to sleep by a 
 drug, I don't know what has passed. No ! sir, I have never been unfaithful to 
 him. If monsiem* want to answer me ? " 
 
 "What diff'erence do you find in my answers, according as I move my lips and 
 as I don't move them ? " 
 
 " I find that you express yourself frankly, and I prefer to hear you speak. I 
 hear your thought, and I don't know why. . . . No, sir, I never dipped my hands 
 in blood ; never did I assassinate. Yes, sir, I love him still." 
 
 " How does it happen that you heard my thoughts ?" 
 
 "I think that it is by physic that I heard him s^jeak. . . . Even when there is 
 nobody, I hear talking." 
 
 ' • Are sad things ever said to you ? " 
 
 " I never hear agreeable things. . . . You will see if my conduct will not 
 always be the same.'' 
 
 " When were you married ? " 
 
 " I could not tell j'ou exactly," 
 
 "Do you remember what day, what month; whether it was in winter or 
 in summer ? " 
 
 "No, sir, I have forgotten, by the work which has been laid on me, by the 
 baths and fasting. I believe I am pregnant ; I have, perhaps, serpents, but my 
 husband is not a serpent. I felt myself carried off. The King of France ^s come ; 
 I made a crown, and I said, 'If l' have deserved a crown of thorns, I am quite 
 willing to wear it.' I don't know how I came back to earth, and it appears as if 
 underneath me everything was engulfed.'"— (Sinogowitz, ' Die Geistesstorungen,' 
 Berhn, 1843, p. 35.) 
 
 Example XLVI, — Clironic mania; loss of personal identity; hallucinations 
 of all the senses. — An invalid, of the division of Pariset, aet, 56, eujoymg, to all 
 appearance, good health, has lost, since 183T, the consciousness of her personality, 
 and believes herself to be quite another woman tliun she was formerly. That 
 belief seems to be united to a change which has taken place in her way of feel- 
 ing, and especially to hallucinations, various, and manifold, and continual. She 
 never speaks of herself except in the third person, and employing this phrase — 
 ' ' the person of me. " 
 
STATES OF MENTAL WEAKNESS. 237 
 
 Provided one does not come too near her, and does not touch her bed, her 
 chair, or her garments, nor anytliing that belongs to her, one succeeds easily in 
 conversing with her. She replies kindly and politely, " How are you, madam?" 
 
 " The person of me is not a dame ; call me miss, if you please." 
 
 " I don't know your name ; be kind enough to tell me." 
 
 " The person of me has not a name ; she desires you not to write it." 
 
 " I would like much to know your name, or rather what you were once 
 called." 
 
 ' ' I understand what you mean. It was Catherine X. We mustn't talk further 
 of wliat took place. The person of me has lost her name ; she gave it up on enter- 
 ing the Salpetriere." 
 
 " What is your age ? " 
 
 " The person of me has no age." 
 
 ' ' But that Catherine X. of what of whom you spoke, how old was she ? " 
 
 " I don't know. She was born in 1779, of Mary and James , living at , 
 
 and was captured at Paris, etc." 
 
 " If you are not the person of whom you speak, you are perhaps two persons 
 in one?'' 
 
 " No ! the person of me does not know that which was born in 1779. It is, 
 perhaps, that lady you saw down-stairs." 
 
 " Ai'e your parents still alive ? " 
 
 " The person of me is alone, and much alone : she has no relations, and never 
 had any." 
 
 " And th^ relations of the person whom you formerly named ? " 
 
 " Folks say they are still alive ; they call themselves my father and my mother, 
 and I believed it up to the year 1827. I fulfilled my duty to them up to that 
 period " 
 
 " You are therefore their child ? Your mode of speech shows that you think 
 so." 
 
 "The person of me is no one's child. The origin of the person of me is 
 unknown ; she has no recollection of the past. The woman of whom you speak 
 is, perhaps, she for whom this dress has been made (pointing to her dress) ; she 
 was married, and had several children." (Minutely relates the circumstances of 
 her former life, but always stops at the year 1827.) 
 
 " What have you done, and what has happened to you since you became that 
 person ? " 
 
 ' ' The person of me lives in the asylum at . They make, and still make 
 
 physical and metaphysical experiments with her. This work was unknown to 
 her before 1827. — Here comes a spirit, and mixes its voice with mine. The person 
 of me will not have this, and sends it quietly back." 
 
 ' ' What like are the spirits of whom you speak ? " 
 
 " They are small, and cannot be laid hold of." 
 
 "How are they clad ? " 
 
 "In blouses." 
 
 " What language do they speak?" 
 
 ' ' French. If they spoke in any other language, the person of me could not 
 iinderstand them.' 
 
 "Is it actually certain that you see them?" 
 
 "Quite certain; the person of me sees them, but metaphysically, in invisi- 
 bility, not materially; else they would not be invisible." 
 
 " Do you sometimes experience odors?" 
 
 " A feminine composition, invisible, has sent bad odors to me." 
 
 " Do you sometimes feel the invisible in your body r" 
 
 " The person of me feels it, and is very angry at it ; it has perpetrated all sorts 
 of immodest deeds upon her." 
 
 "Have you a good appetite?" 
 
 " The person of me eats , she has bread and water. The bread is as good as 
 any one could wish ; she desires nothing more," etc. 
 
 " Do you pray sometimes ?" 
 
 " The person of me knew her religion previous to 1827 ; she knows it no more." 
 
 " What do you think of the women who live with you in this room ? " 
 
 " The person of me thinks that they have lost their judgment; at all events, 
 the most of them." — (Leuret, ' Fragments Psychol.,' p. 121.) 
 
 Example XLVII. — Chronic viania unth the character of exaltation. — A woman 
 at present in the Salpetriere believed herself to be at the same time, God, Jesus 
 
238 STATES OF MENTAL WEAKNESS. 
 
 Christ, and the Holy Virgin. Adorned with ribbons, with a bunch of feathers 
 and paper flowers upon her head, she joyfully roamed about the grounds of the 
 hospital. She had told me who her parents were, and related circumstances 
 which she had witnessed in her early years. We had the following conversation 
 together: — 
 
 '*' When did you become God?" 
 
 ' ' Three years after my marriage ; one day I wanted to jump out at the window, , 
 but I felt something restraining me." 
 
 ' ' From whom ? " 
 
 " From God." 
 
 " You are God; it was therefore yourself who restrained you?" 
 
 " Yes. and on another day I went to confession." 
 
 " Then you had not yet become God?" 
 
 " No, I did not then feel that I was." 
 
 " Jesus Christ was a man, and you are a woman. You cannot therefore be 
 Jesus Christ?" 
 
 " Ah ! my dear sir, that is a mystery— I know nothing of that; I am the Virgin 
 Mary." 
 
 " It seems to me that you have no cause to consider yourself God ? " 
 
 " I will punish all those who thvis offend me; God cannot descend from his 
 throne to avenge me." 
 
 " Do not excite yourself; you are God, are you not ? " 
 
 "Yes." 
 
 " Are you here of your own accord ? " 
 
 " No; I was on a pilgrimage, when I was waylaid, and brought into this hos- 
 pital." 
 
 " Why, then, did you allow it, if you were God? " 
 
 " I could not prevent it; it is not for me to go against the authorities. The 
 state procurator would not let me go. We shall have a great war, a civil war. I 
 have written to Louis Philippe, saying that he will be king for two years yet. I 
 have a brother who has four sons, and they are apprentice kings."— <Leuret, 
 ' Fragments Psychologiques,' 1834, p. 323.) 
 
 Example XLYIII.— Systematically developed and dramatized delusions of 
 bodily and mental influences. Hallucination of all the senses, especially of the 
 cutaneous sensibility; possibility of completely concealing the delusion.— B.As\a.m 
 narrates, in his small work, ' Illustrations of Madness,' London, 1810. the history 
 of a man, named Matthews, who, in the year 1797, in consequence of a judicial 
 verdict, was received into the hospital of Bethlehem; in 1798 he was removed to 
 the division for incurables. There he remained for several years, sometimes con- 
 sidering himself the subject of experiments made by certain persons— sometimes 
 the emperor of the world. In 1809, his relatives, who were opposed to his residence 
 in Bethlehem, proposed that he should be dismissed, and requested Drs. Clutter- 
 buck and Birkett to inquire more minutely into his mental condition. These 
 gentlemen, after having visited the patient four times, certified on soul and con- 
 science that Matthews was in a state of perfect mental health. A new commission 
 of eight physicians was now appointed, who, after a long examination, granted a 
 certificate, also on oath, that the man teas in a high degree insane. 
 
 And indeed he was. He cherished the delusion, in its details highly elaborated 
 and dramatized, that a band of wicked men acted upon him m a great many tvays 
 by magnetic currents from an apartment in the vicinity of the town-wall. He 
 heard and saw these persons, and can therefore minutely describe them. There 
 are seven of them, four men and three women. The chief amongst them is one 
 named Bill, also called the King : lie is from sixty-four to sixty-five years ot age; 
 his thoughts are constantly directed towards wicked objects; no one ever saw liiin 
 laugh. The second is called Jack the Schoolmaster, who also calls himself the 
 Registrar, about sixty years old, tall and thin. The third person is Sir Archy, 
 aged fifty-five: wears a dirty-colored coat and knee-breeches; he constantly em- 
 ploys sly sarcastic language, and speaks with a provincial accent. The fourth is 
 called the Middle-man: is fifty-seven years of age; has a hawk like expression, 
 wears a blue coat and a glossy vest, and constantly sits grinning. The first 
 woman is called Augusta: thirty-six years old, of medium height, and character- 
 ized by the sharpness of her features. She dresses in black, like a country sliop- 
 keeper's wife, and wears her hair unpowdered. The second is called Charlotte: 
 she is a ruddy brunette, and very like a French woman. The third woman is very 
 peculiar: she appears to have no Christian name, but the others call her the Glove- 
 
STATES OF MKJSITAL WEAKJSEhS. 285) 
 
 woman, because she always wears cotton gloves, and indeed, as Sir Archy dryly 
 remarks, to keep people from seeing tliat she lias the itch. 
 
 The influences which these imaginary individuals exert upon the patient, by 
 means of a complicated machine which he can minutely describe, are of a very 
 various nature. The patient describes a number of these various torments (hallu- 
 cinations) in his own terms, thus : 
 
 Obstruction of the fluids— a knotting together of the fibres of the root of the 
 tongue, whereby speech is brought to a standstill. Cutting off of the soul from 
 the feelings — an expansion of the magnetic current from the root of the nose to 
 the under surface of the brain, as if a veil were spread over it, so tliat the feelmgs 
 
 of tlie heart are disconnected from the operations of the mind. Dragon-flying 
 
 as boys fly a paper dragon, so these rascals, by means of their art, cause any spe- 
 cial idea which strikes them to arise in the mind, which then moves to and fro 
 for several hours; and should he wish to get rid of the idea thus forced upon him. 
 and call forth some other, he cannot do so; he must devote his whole attention to 
 their idea. He is also, during the whole time, conscious that the idea is foreign 
 to him, and urged upon him from without. Being bound down— a. fettering of 
 judgment in reviewing one's thoughts. Bursting of bomb-shells— one of the most 
 frightful modes of being influenced. The vital fluid present in the brain and in 
 the nerves, the vapor which rises up and down in the blood-vessels, the gas in the 
 stomach and bowels, are in the highest degree rarefied and rendered combustible, 
 which then causes a very painful expansion of the whole body. During the suf- 
 ferings of the unfortunate victim, these rascals let loose a powerful charge of the 
 galvanic battery, which produces a fearful shock and rends the whole body. 
 Fearful cracking is felt within the head, and it is really wonderful how the great 
 shock does not cause immediate death, etc. , etc. 
 
 During sleep, Matthews is tormented by dreams. These rascals have many 
 variouskmdsof curiously formed dolls: when they have looked at these for a 
 certain time continuously, they can throw the image of these figures into his soul 
 during sleep, etc. 
 
 The stuff which these individuals use in their experiments is, according to 
 Matthews, of a very complex and various nature— the seminal fluid of men and 
 of women; the emanations of copper and sulphur; the vapor of vitriol and aqua 
 fortis, of nightshade and hellebore; the excrement of dogs, human gas, croton oil, 
 vapor of arsenic, etc. [See the detailed communications of the patient, and his 
 description of the machine, in Nasse, ' Zeitschrift fur Psychiatric,' A, 1818, i.j 
 
 Many cases fonnd described in original MSS, or in pamphlets, some 
 of them published by tlie patients themselves, belong to tlie same cate- 
 gory as this case: for example, ' Cry of Distress of one who is poisoned 
 by Magnetism,' Stuttg., 1853; also the case described by Kieser as "Melan- 
 cholia daraonomania occulta" (' Zeitschrift fiir Psychiatric,' x., 1853, p. 
 423), of externally concealed mental disorder of forty years' duration, 
 with the delusion of being the continual object of demoniacal experi- 
 ments, and with dominant hallucinations of hearing. — Anomalies of 
 sensation in tlie most varied parts of the body, which in these cases are 
 so fantastically elaborated, occasionally occur in the state of health. 
 These conditions are in general far too little studied; they are generally 
 thrown into the general class of hypochondriacs, audi think I shall ao-ain 
 refer to them elsewhere. A patient of this kind, in my practice, lind 
 about fifty years of age, has for many years experienced, almost uninter- 
 ruptedly, the sensation of a constant "heaving and lifting" in his whole 
 body. A young man, twenty-one years of age, 7vJiose father had been 
 insane, has a sensation, which has been constantly increasing since his 
 fourteenth year, as if h^ad and face were covered with threads, and some 
 one was continually pulling at them, always preferring the head; lanci- 
 nating pains in the knees and shin-bones, etc. These patients do not 
 think of ascribing their malady to others; but their abnormal sensations 
 would, should mental disease set in, immediately afford rich material for 
 such imputations. 
 
240 STATES OF MENTAL WEAKNESS. 
 
 Section" II. — Dementia. 
 
 § 151. Under the states of mental weakness without the striking 
 predominance of a single delirious idea, we comprehend under the name 
 of dementia — as distinguished from apathetic dementia — those in which 
 the patients still manifest a certain degree of external vivacity and activ- 
 ity in conversation as well as in conduct, indicating that there still exists 
 some variety and activity of thought and effort. Here, also, there are 
 very many varieties in the manner in which the mental weakness is mani- 
 fested. Most characteristic are the numerous cases whicli in their exter- 
 nal symptoms present an apparent similarity to mania: this similarity, 
 however, can only be external and superficial. 
 
 In all these cases the fundamental disorder consists in a general weak- 
 ness of the mental faculties. In the sphere of the emotions this is mani- 
 fested in the increasing incapacity of the patients for any profound 
 emotion, with irregular change of quite superficial emotions or persistent, 
 complete indifference. Hate and real love are alike impossible to these 
 patients; privations are little if at all felt by them, and they cannot 
 rejoice at agreeable occurrences. If an occasional turbulent ebullition 
 should also occur, it is neitiier the result of strong thought, nor of an 
 energetic act of emotion or will; indifference quickly returns, and it is 
 this indifference which shows the abnormal state of the emotional reac- 
 tions towards the external world (laughing and amusing themselves in 
 the midst of the saddest events, etc.). The dominant disposition of 
 mind presents endless varieties. Some of these patients constantly mani- 
 fest a lively disposition; they laugh, dance, sing, and show, in their 
 gestures and conversation, pride, self-satisfaction, and the most perfect 
 assurance (Moria — see § 139); others, on the contrary, are in a perpetual 
 state of anxiety — they shed many tears, and present the symptoms of 
 grief and care. Others, again, have a tendency to do mischievous acts, 
 to take pleasure in the misfortunes of others. But these dispositions are 
 neither the result of an external (as in health) nor of an internal (as in 
 mania or melancholia) motive; they are quite superficial, alternate with 
 each other Avithout any cause, and are expressed in a manner altogether 
 foolish and childish. With the complete indifference and absence of all 
 actual desires which characterize the patients, we sometimes see mani- 
 fested disorderly mental movements and aimless extravagant impulses 
 whose meaning the patient himself cannot understand, and the reaction 
 of the will, where this still exists, has throughout the character of tran- 
 sitoriness and inconstancy. 
 
 § 153. While in the sphere of the emotions all tends to wards feebleness, 
 impotency and atony, the same tendency is also observed in even a still 
 higher degree in the sphere of perception: this is in accordance with 
 what has been already said regarding the connection between emotional 
 weakness and weakness of perception. This appears chiefly in the form 
 of loss of memory, and the power of reproduction of the ideas is chiefly 
 affected in this manner — that more recent events, things that occur 
 during the dementia, are almost immediately forgotten, while not 
 unfrequently former ideas connected Avitli events which happened 
 long ago are more easily reproduced: still, many of these patients have 
 utterly forgotten their former life, and even their own name. As all the 
 operations of the mind proceed entirely without energy, no durable 
 impression is retained of what is presented to it: besides, these patients 
 have also lost the power of comparing separate ideas, of deducing a gen- 
 
STATES OF MENTAL WEAKNESS. 241 
 
 eral fact from them, of judging and of concluding, and all thought has 
 degenerated into a disconnected mass of fleeting images and_ words. It 
 is a useless and sterile activity of the intelligence, which indulges_ in 
 unequal, isolated, and incomplete ideas, but is incapable of combining 
 them into a distinct Judgment. From this there results, on the one 
 hand, the impossibility of all abstraction, and, on the other, an external 
 incoherence in the associated images and ideas which proceed from acci- 
 dental impressions of sense, or according to the merely external connec- 
 tion of accidental similarities (for example, similarly sounding_ words). 
 From this, too, there results the want of all logical form, the irregular 
 change of disconnected ideas, the unmeaning parrot-like repetition of 
 words and phrases from custom and according to accidental similarity of 
 sound, incoherent and senseless replies. We often think that in such 
 patients an attempt at memory, at judgment, and at attention may be 
 discovered, which, however, falls powerless and inefficacious; again, we 
 may observe breaks in their sentences in which the intermediate parts 
 which should connect them and form the transition to new ideas are 
 wanting, and we may often receive the impression that these pitiable 
 creatures themselves were tacitly and painfully feeling their own inabil- 
 ity to direct themselves aright amidst these broken remains of psychi- 
 cal life. 
 
 Special fixed ideas, true delirious conceptions, are never produced 
 anew in dementia: those which formerly existed become with the increas- 
 ing weakness less intense, and the patient can as little implicitly rely on 
 them as he can energetically adhere to anything. Still, the reproduction 
 of the ideas which are developed during the period of maniacal excite- 
 ment often continues for a long time, and we again frequently find the 
 extravagances of monomania in the senseless repetition of great numbers, 
 in immense and romantic id^as of their own greatness and large posses- 
 sions (thousands of millions, diamonds, worlds, etc.). These, however, 
 have all become to the patient a mere play of words, and are totally void 
 of thought. 
 
 § 153. The organs of sense may perform their functions quite nor- 
 mally; the patients see, hear, etc., correctly; but the elaboration and 
 transformation of the sensorial impressions into adequate ideas in the 
 brain no longer proceeds properly, or — and, indeed, ordinarily — halluci- 
 nations exist Avhich, along with the ideas, share the character of incohe- 
 rence, want of method, and abruptness. 
 
 The muscular movements are in many cases restricted, owing to 
 commencing or progressing general paralysis. Where this is not the case 
 the corporeal movements are restless and unsteady, yet awkward and little 
 varied, and the attitude is often clumsy and helpless. Sometimes the 
 patients constantly run to and fro as if they were looking for something, 
 or they rove about dancing, hopping, gesticulating with the hands and 
 making odd automatic movements. Their demeanor and movements 
 are either altogether inexpressive, or are expressive only of very weak 
 emotions; and here also are presented many childish and capricious habits, 
 such as collecting rubbish, remaining always in bed, pleasure in toys, and 
 dressing fantastically. Sometimes they manifest a wayward refusal of 
 food, and other symptoms of childish obstinacy; more frequently we 
 observe the love of eating — they frequently swallow the most loathsome 
 things. Very many of these patients who have been long confined in 
 the asylum are addicted to onanism, and we may frequently gather from. 
 16 
 
24:2 STATES OF MENTAL WEAKNESS. 
 
 their conversation indications of considerable disorder of the sexual 
 functions — a circumstance which ought to receive immediate and further 
 investigation. 
 
 The physiognomy is generally old and stupid, the expression vacant, 
 and the countenance obscured by neglect and dirt. The physical health 
 may be good, or the most various chronic or acute diseases may be present; 
 not unfrequently there is a great tendency to become corpulent. 
 
 Complete intermissions never occur during the course of dementia. 
 Eemissions occur in such a manner that quieter and somewhat more_ ra- 
 tional states alternate with the periods of greater turbulence and agitation. 
 The course of these states is always progressive; the mental weakness 
 constantly increases, and is most rapid when the dementia is complicated 
 with general paralysis: otherwise the patient may remain in the same 
 state for periods of several years. Recovery never takes place. 
 
 Example XLIX. — Transition of monomania into complete dementia. — Julia 
 had but one idea, and that was a most extravagant one. She thought she was the 
 Almighty. She indeed spoke also of other things ; but her sayings were without 
 definite aim or connection, and she had almost none of the habits of ordinary 
 life. There is not yet complete loss, but only considerable weakness of all the 
 mental faculties, as may be learned from the following conversation : 
 
 "Madame, what is your name?" 
 
 "I am called, my name. You owe me a field. I am indeed the Almighty. 
 JVly understanding has been curtailed in order to make an apron of it." 
 
 " How old are you ? " 
 
 " I am fourteen years old " (she was at least thirty). 
 
 " How many are forty-five and three ?" 
 
 "That makes forty-eight. Now! some has stolen both my gold and my 
 jew^els." 
 
 " Who took them from you ? " 
 
 "Ask your own thoughts ; I am not the cuirassier woman — I am the Al- 
 mighty." 
 
 " Since when have you been the Almighty ? " . 
 
 " Always, always — I have always been the Almighty." 
 
 " But the Almighty has a beard, and you have none." 
 
 " I beg your pardon, here it is " (pointing to her hair). 
 
 This patient seldom remarks anything, and her attention is never continuous. 
 She has little remembrance of the past, and very little of the present. She is 
 only capable of the simplest acts— making her bed, putting on her clothes, eatmg 
 her food. She knows the name of nobody about her, although she has lived with 
 them for several years. In a moment she passes from laughing to quarrelling, 
 etc. (Leuret, 'Fragments Psych,,' Par., 1834, p. 34.) 
 
 Section III. — Apathetic Dementia. 
 
 § 154. Sometimes, as a mode of termination of the forms we have 
 just been considering, sometimes without the antecedent occurrence of the 
 more noisy and agitated forms of dementia, there occur still deeper and 
 more complete states of paralysis of the psychical functions, in the most 
 extreme degrees of mental decay. 
 
 The inability to comprehend several ideas and to compare them al- 
 ways increases, and instead of the numerous abrupt disconnected ideas seen 
 in the preceding forms, there gradually ensues almost a total absence of 
 images and thoughts. The sensorial impressions are no longer elabo- 
 rated, nothing comes out of them; memory is so completely effaced, that 
 not merely what happens in one moment is forgotten in the next, but all 
 reminiscences of bygone times are almost entirely lost. Language even 
 is to a great extent forgotten, so that the patients even in the most fav- 
 orable cases can employ only a few current, very limited, and little applic- 
 able expressions; more frequently the few words that remain are only au- 
 
STATES OF MENTAL WEAKNESS. 243 
 
 tomatically repeated, or tlie words tliemselves are not entire, but are 
 merely ejaculations of accustomed sounds. This very high degree of dnl- 
 ness of the imagination and loss of the intelligence is accompanied 
 by extreme weakness of the will. The patient can no longer actuate 
 himself to do anything, even by the force of former habits; he must ra- 
 ther passively submit to be directed by some extraneous impulse. He is 
 frequently unable to supply his simplest wants, and requires to be fed; he 
 loses himself every moment in his own room; and his ignorance of danger 
 renders it necessary that others should protect him against accidents. 
 His conduct is uniform, and always the same; sometimes apparently 
 concentrated in self — shy, dull, silent, and inert; sometimes automatic 
 movements are gone through — swaying to and fro of the body, rubbing 
 the hands, murmuring, making unmeaning noises, etc. The gestures 
 are lifeless — the countenance is relaxed or amazed, or apparently atten- 
 tive without motive, and the vacant look and bursts of laughter show 
 that there exist no ideas which the patient can express. Nevertheless, 
 they sometimes express slight symptoms of pleasure or displeasure and 
 traces of emotion; of preference, from custom or with a motive, for par- 
 ticular persons; of the sense of shame, of childish pleasure in mischief, of 
 anxiety (hiding themselves), etc. In their better moments, there 
 come back to tiiem reminiscences of former life, a greater participation 
 and pleasure in the external world, and a lively appreciation of kind 
 treatment; and there is in these lingering traces of self-consciousness and 
 emotion enough to make us respect human nature, even in this its state 
 of deepest degradation — in these unfortunates, whose silent, inexplicable 
 gestures often, unconsciously to themselves, reveal a melancholy past. 
 
 Serious disorders of tlie motory and sensitive functions of the brain 
 very frequently accompany this sad mental state, in particular entire 
 paralysis of movement, and frequently also of sensation, so that the pa- 
 tient can often endure the deepest and most extensive burns without any 
 feeling of pain. The nutrition may remain for a long time unimpaired; 
 the patients remaining corpulent, eating with a voracious appetite, etc. 
 Sleep, too, is often well maintained, being sound and prolonged. 
 
 The only mode of termination of these states is death. The patients 
 sometimes succumb to the apoplectiform attacks which occur during the 
 course of general paralysis, or to serous effusions in the brain, to cerebral 
 atrophy, or to chronic and acute disease in other parts — pneumonia, gan- 
 grene of the lung, tuberculosis, intestinal catarrh. Some die from want 
 of proper care, owing to retention of urine or of fajcal accumulations, or 
 in conseqnence of accidents, burns, choking by taking too Icrge mouth- 
 fuls of food, etc. 
 
 Senile dementia, too, terminates in the way we have just described, as also 
 many analogous conditions sometimes observed in the prime of life, and proceed- 
 ing froni atrophy of the brain with or without arterial degeneration. These 
 lamentable cases of primary, slowly commencing, progressive dementia, often 
 proceeding to complete mental destruction, occur in the prime of life among high 
 and low ; among the former, sometimes in distinguished men, owing to exces- 
 sive mental and bodily exertion and irritation. It is often very difficult to distin- 
 guish the commencement of these conditions fi'oni mental exhaustion and 
 apathy, which may be caused by simple anaemia. Slight numbness of the 
 extremities and symptoms of muscular convulsions may also exist in the latter- 
 mentioned cases. It is frequently not until after long observation that a conclu- 
 sion can be ai-rived at ; the treatment must be nutrient and tonic, all causes of 
 irritation being, of course, removed. Those cases in which a primary state of 
 mental weakness has for a long time preceded an attack of apoplexy or of 
 encephalitis, generally depend upon disease of the cerebral arteries. 
 
244: STATES OF MEJSfTAJL WEAKNESS. 
 
 Sectioi^ IV. — Idiocy and Cretinism. 
 
 § 155. By the term idiocy, we are to understand those conditions in 
 which a state of mental weakness has existed from birth or from early in- 
 fancy, and in which the psycliiad develoiiment has been thereby impeded 
 or 'prevented. Individuals in these circumstances remain to a greater or 
 less extent below the average in intelligence; nor can they_ attain to the 
 degree of education and instruction corresponding to their age and social 
 position. 
 
 While psychologists are generally agreed as to this definition of 
 idiocy, they are, on the other hand, far from being at one as to the signi- 
 ficance which the originally popular expression cretinism should bear in 
 science. Most frequently, however, the term cretinism is applied to a 
 particular species of idiocy, namely, that in which the subject presents a 
 hereditary defect of physical conformation: it is in this sense that we 
 shall here employ the word. This physical defect need not of necessity 
 be always the same — it is not specific: nevertheless, there is one form of 
 it, by far the most frequent and best known, everywhere the same, and 
 apparently characteristic; it occurs in various parts of the world, bnt es- 
 pecially in mountainous districts, as a widely spread disease depending 
 upon local causes. The prototype of this form is alpine cretinism, and 
 may be designated by the term cretinism in the restricted sense of the 
 word. It will be afterwards described. This form is always endemic; 
 occasional cases of sporadic idiocy may, however, be developed, according 
 to the nature of the physical defect. 
 
 In all possible forms of idiocy we can, considered from the stand- 
 point of the intellectual development, distinguish several degrees of the 
 malady. It would be useless to establish many degrees and gradations 
 minutely distinguished from each other; it is better to distinguish, in the 
 first place, simply, 1st, the more severe cases of intellectual nullity — de- 
 mentia, fatuity; and, 2d, the less severe cases of simple mental weakness 
 — weakness of mind, imbecility. In cretins the degree of intellectual 
 disorder (viewed (/e/ie?Y<%) is in direct relation to the physical defect; 
 we therefore generally meet with both relations together; and correctly 
 distinguish cretins and semi-cretins: the latter states imperceptibly pass 
 through many intermediate degrees into the state of health without any 
 distinguishing sign. 
 
 According to what has been said, every cretin is an idiot, but every idiot is not 
 a cretin; idiocy is the more comprehensive term, cretinism is a special kind of it. 
 This acceptation of the term is at the present day, if not general, at all events the 
 most frequently adopted; some signify by the term cretinism, the highest degree 
 of congenital dementia. Opinions such as are expressed in the most recent work 
 of Guggenbiihl (' Zeitschr. der k. k. Ges. der Aerzte zu Wien,' 1860, p. 87) only 
 lead to confusion. "We may consider as mentally weak, and therefore on the 
 road to cretinism, (!) all children who neither at home nor in the school can be 
 made accessible to the ordinary means of education and instruction." 
 
 In sporadic idiocy, the physical conformation maybe perfectly normal; we 
 occasionally even meet with beautiful and well-developed children in a high degree 
 of dementia. As a rule, however, this is not the case: the bodily development is 
 generally involved, in particular it is often far behind the age of the patient; the 
 forms, especially of the head and face, are incomplete and far from beautiful; but 
 in sporadic cases we never find those well-marked and peculiar defects in the phy- 
 sical conformation which, owing to the extensive anomalies found in several organs 
 (for example, in the thyroid gland), may be considei-ed as an affection of the whole 
 constitution. The attempt to compare every qualitative peculiarity of the 
 endemic and non-endemic idiocy appears to me to be at present premature, 
 although i-t found in Ziliner an original and well-informed advocate. 
 
STATES OF MENTAL WEAKNESS. 24:5 
 
 A. Idiocy in general. 
 
 § 156. The essential character of all idiotic states is iveakness of the 
 intellect, as the fundamental faculty of the mind; a weakness which in 
 many cases may be recognized in all the phases of tlie mental life equally, 
 wiiile in others certain psychical processes — for example, the emotions — 
 are still allowed a certain degree of activity, or even certain great series 
 of ideas remain free and capable of a moderate degree of development 
 (special aptitudes, talents displayed by certain idiots). From the circum- 
 stance that the weakness of perception is itself the fundamental disorder, 
 idiocy is entirely distinguished from the psychical imperfections depen- 
 dent upon deficiency of the senses, such as deaf-dumbness. From the 
 circumstance that this weakness comes on at an early period of life, and 
 that therefore the psychical development is annulled, or at least much re- 
 tarded, it is distinguished from dementia developed during the subsequent 
 years of life when, as is indeed very often the case, tlie state of weakness 
 arose after an originally normal mental state, or even — which happens 
 more rarely — was ushered in by a preliminary stage of exaltation. 
 
 It is beyond doubt that the weakness of the intollect,#and therewith 
 the arrest of the psychical development, depends upon a cerebral anomaly. 
 Tliis 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 (§ 159); and we can, in general, say, supported by the 
 great majority of cases, that the deficient mental development is the direct 
 result of deficient cerebral develojjment 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 assumption that there are also idiotic states, where 
 the weakness of perception does not depend upon organic changes, but 
 originally upon a simple functional anomaly of the brain. To this class 
 ought many cases to be referred, where frequent epileptic attacks in very 
 early life, or where onanism, commenced at a very early period, have in- 
 duced an early exhaustion of the cerebral functions; others, where long 
 general illness in a child, with impairment of the nutrition of all the 
 organs, included the brain, and therefore the due performance of its 
 functions; further, cases where the mental development remains station- 
 ary from want of any external mental impulse — from extreme neglect and 
 inattention, associations with other dements, unfavorable outward rela- 
 tions, 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 at mental influence, even by any 
 lively sensorial impression, so that development of the normal j^rocess of 
 perception is rendered impossible. Although few of the latter cases ori- 
 ginally belong to the idiotic states, still they have the same practically 
 important result — arrest of mental development. But these cases of 
 merely functional cerebral disorder, which at the commencement consti- 
 tute a more apparent dementia, form a very small minority compared 
 with the cases where the psychical disorder is the result of organic changes 
 in the brain. 
 
 On the other hand, tliose cases which now and then occur of great dulness or 
 absence of euiotion, existing from early infancy, and which are manifested in a 
 
246 STATES OF MENTAL WEAKNESS. 
 
 precocious perversity of the desires, often as rudeness, wickedness, savageness, 
 etc., do not belong to idiocy, although they are in a certain sense psychical de- 
 fects, and are sometimes spoken of as cases of moral idiocy, stunting of the senti- 
 ments, etc. These states may be associated with good as well as with bad natural 
 talents, and are not necessarily due to arrest of development of the psychical 
 functions. 
 
 § 157. The causes of tlie various cerebral diseases which form the 
 organic basis of idiotic states correspond in many rehitions with the causes 
 of the other psychical diseases (see Book II.): nevertheless, there is here 
 much that is peculiar and special. 
 
 It is evident that, in many cases, powerful causes exist in the parents 
 which influence the developing germ which afterwards becomes an idiot. 
 In families where epilepsy, mental diseases, paralytic affections, deaf- 
 dumbness, are frequent, idiocy is also observed to be common. Frequently 
 it occurs as a mere partial phenomenon, as an individual manifestation of 
 a general deterioration of a race: thus we see in a number of brothers and 
 sisters, one or two idiots, together with others who are small, incompletely 
 developed, ugly, and sterile. These degenerations are principally observed 
 in families where the blood has not been sufficiently renewed; where the 
 marriages have always been with near relatives; also where the parents 
 have been too old or too young, or addicted to drunkenness. _ Sometimes 
 all the children of such marriages bear evident marks of idiocy, or of 
 some otlier form of degeneration; indeed, in certain cases this may be 
 recognized as increasing from the first to the last child, so that, for 
 example, the last or the two last are quite demented — the others stunted 
 in growth, hysterical, nervous, epileptic, deaf-and-dumb, etc. At other 
 times some of the children are perfectly healthy; but this does not render 
 the statement incorrect, that idiocy is a mark of degeneration of race in 
 that family: at the time of conception of tlie various children, the state 
 of health of the parent may sometimes increase, sometimes considerably 
 diminish, the influence of the constant (tending to degeneration) causes. 
 
 The shallow doctrine which has recently been promulgated, that mental 
 disease, drunkenness, etc., of the parents, does not so much influence the germ 
 as it favors of the development of the idiocy— that, under such relations, the care 
 and education of the children must necessarily be neglected— can easily be re- 
 futed by the results of observation of idiocy in the higher and even the highest 
 ranks of life. This hypercritical questioning the hereditariness of idiocy can, 
 generally, only lead from the way of truth (see t^S 9^, 93), and its hereditariness 
 may be accepted in the same wide sense as that of other mental diseases (§ 93). 
 In a case which came under my observation, the father of a highly idiotic child 
 suffered from violent periodic headaches, during which he sometimes quite lost 
 his senses: the brother of the father was likewise disposed to frequent headaches 
 (see § 92). In another case which I observed, the father of an idiotic boy lived in 
 ahaiaitual state of excitement, as if he were always intoxicated: the brother of 
 the father was an idiot. 
 
 Another, but little known, series of causes acts during the fo-tal 
 period. Dul-ing this period various errors of development and diseases 
 of tlie brain and its membranes may occur, to which sometimes external 
 injuries may give the impulse, for which, however, much more frequently, 
 no direct mechanical cause can be discovered. Great anemia of the 
 mother, drunkenness, violent shock and grief during pregnancy, appear 
 not to be without influence. In certain rare cases, injury to the head 
 during childbirth may exert an injurious effect. 
 
 Far more frequently, however, those diseases which lead to idiocy 
 (also those which are hereditary) do not commence until after birth, from 
 then till within the third or fourth year; in exceptional cases, till the 
 
STATES OF MENTAL WEAKNESS. 247 
 
 fifth or even the seventh year. They commence and run sometimes an 
 acute, sometimes an insidious chronic course; they consist in congestive, 
 inflammatory, or other derangement of the nutrient processes, more 
 rarely in sanguineous extravasations in the brain and its. membranes, very 
 frequently in affections of the cranial bones. Bad care and ill-adapted 
 nourishment to very young children; keeping the head too hot; the use 
 of coverings which compress the head; the use of opiates; injuries and 
 shocks to the head, and other injurious influences of a like nature;' other 
 diseases of childhood — as acute exanthemata, weakening of the infantile 
 constitution by various causes, in some cases syphilis" — appear at this 
 period to exert the greatest influence on the origin of those cerebral affec- 
 tions. The influence of early commencing epilepsy, or irritation of the 
 sexual organs at an early age and its consequences, and, finally, the influ- 
 ence of total mental neglect and association with other idiotic children, is 
 likewise not to be lightly estimated. 
 
 Finally, there are a series of powerful local causes, peculiar to certain 
 localities, which we at present must consider to be miasmatic in their 
 nature; with the progress of science, however, we may be yet able to ana- 
 lyze the individual circumstances. These causes lie at the foundation of 
 endemic cretinism, and will be afterwards considered more in detail. But 
 house and chamber miasms, owing to dampness, vitiated or too seldom 
 renewed air, uncleanliness, appear to be capable of exerting quite an ana- 
 logous action; the long-continued residence of young children in such 
 chambers is therefore especially injurious. The ''cretinism of large 
 towns," amongst the inhabitants of low-lying, overcrowded, badly-venti- 
 tilated, cold houses, is certainly to be in part attributed to miasmatic 
 causes — together with a number of other co-operating influences. Mias- 
 matic causes act more upon the origin of diseases of the cranial bones 
 than upon affections of the brain itself or its membranes; they act partly 
 upon the foetus, partly upon the child after birth. 
 
 § 158. We have seen that the great majority of cases of idiocy depend 
 upon palpable anomalies of the brain and its membranes, and have now 
 to determine what these anomalies are. If these were known to us, it 
 would be extremely interesting to compare the various anatomical 
 changes, according to their nature, their seat, etc., with the different 
 kinds of mental defects. We might hope in this way to come nearer to 
 the relations of certain parts of the brain to certain faculties of the mind, 
 and, in a practical point of view, to arrive at the elements of an anatomi- 
 cal diagnosis during life. Nevertheless, we soon become convinced that, 
 with our present material, certain by no means unimportant results in 
 these directions may be arrived at (see § 166), but the principal part of 
 the work cannot at present be undertaken. In a great number of the 
 
 ' See Kostl, ' Der endemische Cretinismus,' etc., Wien, 1855, p. 9. " In the 
 Bruck circuit, forty-eight notable cases of children are known whose idiocy is 
 ascribed to a fall on the head from a height." In this work we find a number of 
 contributions to that part of etiology which depends vipon ignorance of the 
 parents or guardians, or upon popular opinions. 
 
 2 Erlenmeier has recently published the case of an idiotic child, where the 
 cranium presented numerous exostoses, and who recovered under the influence 
 of iodide of potassium. The case of Guislain (• Leg. or.,' ii., p. 98), where a child 
 begotten of a powerful man while undergoing a course of mercury (for syphilis), 
 whose former and subsequent children were perfectly healthy, was idiotic: this 
 case is interesting, although it has no direct bearing upon the question of the in- 
 fluence of syphilis. 
 
248 STATES OF MENTAL WEAKNESS. 
 
 cases now under consideration, tlie psycliological analysis is so defective; 
 the manifestations of mental life, especially in idiotic children who die 
 early, are so exceeding scanty; the changes found in the brain are often 
 , so incorrectly described; especially, however, there so frequently exist 
 several cerebral changes, — that, in a theoretical point of view, we must 
 at present renounce more minute explanations,^ and content ourselves 
 with collecting and, in a measure, arranging the material. For the prac- 
 tical anatomical diagnosis, however, we must depend more on the results 
 afforded by direct examination of the head, on the etiology and on certain 
 motory anomalies, than on the particular form of the mental weakness. 
 
 In general, we do not find the organic cause of idiocy to be a recent 
 and still progressing morbid process in the brain, but either actual arrest 
 of develojmient, or states consecutive to and remnants of former morbid 
 processes: as we have seen, these may have originated during intrauterine 
 life, or after birth from the first to the fifth or sixth year, and in certain 
 cases even later. In particular, we must distinguish between anomalies 
 which originally and primarily involve the brain, and such as in the first 
 place constitute an abnormality of the skull, by which, secondarily, the 
 proper development and form of the brain is involved. We must, of 
 course, remain undecided as to many cases which maybe presented to us; 
 but we may expect that the distinctive signs will become gradually more 
 distinct and more certain: this distinction, as one regarding a funda- 
 mental process, is, as far as possible, to be maintained. In the following 
 enumeration of the anomalies which, according to experience, are pre- 
 sented in idiocy, we shall endeavor, as far as possible, to carry out this 
 distinction. 
 
 § 159. Of these anomalies, ^oyer^?/ of the hrain, in its various modifica- 
 tions, takes the lead. Abnormal smaUness of the entire brain (generally 
 well pronounced in the convolutions), with microcephalus, is to be regarded 
 as an arrest of development, of which the source is sometimes in the 
 brain itself, and sometimes in the cranium. The latter appears to be 
 the more common, and it is principally the jjremature ossification of the 
 entire cranium which confines the brain and prevents its normal expan- 
 sion. Very early occlusion of the fontanelles (which is sometimes even 
 complete at birth), premature ossification of a great many of the sutures 
 of the skull, hinder the rapid growth in the early periods of life which 
 is characteristic of the human brain (in none of the lower animals do the 
 fontanelles remain long open); and this injurious influence on the cere- 
 bral development is greater according as the compensation which occurs 
 through the expansion of other parts is less. In the other, less numerous 
 class of microcephalics, all the cranial sutures remain, even to adult life 
 (whereby the cranium may be either well proi^ortioned or unsymmetrical); 
 and the sources of the defective development of the brain must lie within 
 the organ itself, or the cranium remains small with the brain. The 
 brain itself may in both series of cases be simi:)ly small — a miniature brain, 
 without other anomaly or defect, and properly proportioned in all its 
 parts: more frequently, there also exist other changes, particularly scle- 
 roses, hydrocephalus, unequal size of the hemispheres, or other form of 
 dis-symmetry. 
 
 1 We expect to receive information on these points from the idiot institutions, 
 just as correct ideas regarding mental disease were first received from the 
 asylums. 
 
STATES OF MENTAL WEAKNESS. 249 
 
 In many mici'ocephalics the brain is even smaller than might be presumed 
 from the external aspect of the cranium, owing to the occasional enormous 
 thickness of the bones of the skull, and to the occasional existence of a consider- 
 able amount of hydrocephalus. 
 
 Baillarger ('Acad, de Med.,' 29 Jul., 1856) has reported cases in which the 
 fontanelles were, even at birth, to a great extent ossified. Cruveilhier has seen a 
 case where there was synostosis of all the sutures at the age of eighteen months; 
 cases in which many of the sutures are already ossified at the age of 3-4 are by 
 no means ^are. Also Virchow ('Gesamm. Abhandl.,' Frankf., 1856, p. 905) has 
 described microcephalic skulls in which all the sutures existed. I myself have 
 recently examined the cranium of a girl, aged nineteen, who died at Mariaberg; 
 she presented the appearance of a child of ten or twelve yeai's of age, had been 
 •epileptio and quite idiotic (uninterrupted state of profound dreaminess, complete 
 dumbness, incapacity to walk or to stand). The cranium, which was very small, 
 very short, and incliiied to the right side and forwards, presented all, even the 
 frontal suture, without trace of ossification. Another cranium, sent to me from 
 the asylum at Winterbach, and whicli had belonged to an idiotic woman twenty- 
 one years of age (weight of the brain, 06 loth — about 18 ounces — tlie left hemi- 
 sphere very short), was not so large as the skull of an ordinary child of seven 
 years. It did not, however, present any striking abnormality of form, being only 
 a little unsymmetrical; the frontal suture was completely obliterated, the 
 sagittal suture was incomplete anteriorly, posteriorly quite ossified: the other 
 sutures were well preserved. 
 
 (Concerning a remarkable case of miniature brain which Baillarger and Gra- 
 tiolet examined, see 'Acad, de Med.,' 26 Mai, 1857. The brain was that of a 
 female Aztec child (4$ 166); it was perfectly well formed, and presented no trace 
 ■of hydrocephalus; it was, however, so little developed, that it resembled the 
 brain of a foetus in the seventh or eighth month. 
 
 Under the head of general poverty of the brain, may also be ranged those 
 cases in which the convolutions are remarkably simple, although the volume of 
 the brain is not much below the average; these cases present at least a notable 
 diminution of the cerebral surface. 
 
 In idiots the brain is frequently diminished in vohime in certain parts, 
 or it may even present certain defects. The following are the principal 
 varieties: — Sometimes the cerebral hemispheres are imperfectly developed 
 in certain parts, most frequently in the anterior lobes (when the antero- 
 posterior diameter of the cranium — as frequently haj^pens — is diminished, 
 the cerebral hemispheres are necessarily shortened, but this is generally 
 most strikingly manifested in the anterior lobes), when there is often 
 remarkable stunting of the olfactory bulbs, sometimes also of the pos- 
 terior lobes, when the cerebellum is not so completely covered as usual 
 or not completely covered by the cerebrum; those parts which are insuf- 
 ficiently developed may present few but moderately developed convolu- 
 tions, or they may be very small, as if atrophied, or as if they remained 
 ^t an early childish stage.' Inequality of the ttvo halves of the brain, 
 particularly of the cerebral hemispheres, must not be attributed to hyper- 
 trophy of tlie greater, but to atrophy of the smaller half; and this 
 abnormal smallness may be the result of a deformity of the cranium 
 (unilateral stenosis), or of an original deficiency in the development of 
 the brain, or of arrest and atrophy in consequence of encephalitic, apo- 
 plectic, or other processes, of which palpable traces may sometimes subse- 
 quently be found (brown or yellow spots, small deficiencies in the cerebral 
 substance, etc.). In this respect all degrees exist, from the slightest 
 
 • The latter condition, the apices of the two posterior lobes moderately but 
 symmetrically diminished in volume, I recently observed in an individual, aged 
 twenty-three, who had never been idiotic, but had, on the contrary, exhibited 
 a moderate degree of intelligence and read a great deal. He had never manifested 
 any sexual desire (this came to be inquired into, as he was diabetic). The 
 cerebral hemispheres did not completely cover the cerebellum. 
 
250 STATES OF MENTAL WEAKNESS. 
 
 shortening to the state where a whole hemisphere has almost totally 
 disappeared, and is transformed into ameshwork filled with serum; even 
 in moderate degrees the substance of the lesser hemispheres is often 
 changed, coriaceous, compact (sclerosity), the lateral ventricles dilated, 
 the choroid plexus thickened, etc. The dis-symmetry frequently extends 
 to the cerebellum, pons Varolii, and medulla oblongata; in particular, 
 the cerebellum often participates in it when the atrophy results from 
 shortening of the cranium; and, as it appears, this atrojjhy is sometimes 
 on the same side as the atrophied cerebral lobe, sometimes on the oppo- 
 site side;' there frequently exist atrophy, paresis, convulsions of the 
 opposite half of the body (the condition which has in recent times been 
 described as " unilateral atrophy, "and which is not always associated with 
 idiocy). Little attention has as yet been paid to atropliy of the medulla 
 oblongata and inequality and asymmetry of many j^arts of the base of tlie 
 brain in idiots. These, however, will appear more important in propor- 
 tion as the osseous basis cranii is, through recent investigations," recog- 
 nized as the point of origin of the disorder in very many cases of idiocy. 
 
 In the forementioned microcephalic girl from Mariaberg, I found the follow- 
 ing abnormalities in the pons Varolii and medulla oblongata:— the pyramids were 
 alike on both sides; the left olivary body was somewhat shorter than the right, 
 especially at its inferior part; the left processus cerebelli ad pontem was weaker, 
 smaller, and on its anterior and lateral border as if bent inwards; on the left half 
 of the pons Varolii the oblique band of fibres (ruban fibreux of Foville, coming 
 from the corpus restif orme) was much more pronounced, separated on its lower 
 border from the more horizontal fibres of the pons by a deep groove; in the 
 fourth ventricle the tuber cinereum at the point of the calamus was less developed 
 than the right; the left hemisphere of the cerebellum was a little smaller but 
 somewhat higher than the right. In the work of Demme, 'Ueber ungleiche 
 Grosse beider Hirnhalften,' Wiirzburg, 1831, there ai-e many analogous examples 
 of inequality of the two halves of the pons Varolii, of the two sides of theepinal 
 cord, and the two olivary bodies. The same condition has been observed by 
 Valentin in an idiotic child from Abendberg : anomalies also in the pyramidal and 
 olivary bodies were seen in a case by the Sardinian Commission on Cretinism 
 (' Rapport,' etc., p. 204). The entire spinal cord appears to be atrophied in some 
 cretins (case of Eulenberg and Marfels; Niepce, ninth autopsy); this forms an 
 important subject for further investigation, especially in individuals suffering 
 from paralysis with convulsions, etc. Case of spina bifida together with hydro- 
 cephalus have also been observed. 
 
 HeschP has described, under the name of porencephalus, those cere- 
 bral defects in which a lai-ge portion of the convolutions and centrum 
 semiovale is wanting, in such a manner that a person may look through 
 the aperture straight into the ventricle; this is filled with serum which is 
 contained in a bladder or meshwork of the pia mater; sometimes the cor- 
 responding part of the cranium projects outwards. 
 
 Porencephalus does not appear to be produced by actual arrest of development 
 of the affected part of the brain, but rather by an intrauterine disease which at a 
 verv early period destroys the part. In nearly every case of this kind there is 
 idiocy, ^vith more or less paralysis and contraction of the opposite half of the 
 body ; in cases presenting these symptoms, especially if there be a prominence on 
 
 1 See Virchow, ' Entwicklung des Schadelgrundes,' Berlin, 1857, j). 114. 
 
 2 Virchow has, in his work on the Physiognomy of Cretins, particularly called 
 attention to the fact that slight deviations in form of the pons Varolii, the 
 medulla oblongata, and the fourth ventricle, may originate through spheno- 
 basilar synostosis. 
 
 '<" Prager ' Vierteljahrschrift,' Bd. Ixi., 1859, p. 59. A self -observed and three 
 other cases. 
 
STATES OF MENTAL WEAKNESS. 251 
 
 one side of the skull, the existence of this lesion may be presumed (Heschl). 
 Tilngel ('Clin. Mittheil.,' Hamburg, 1860, p. 65) has recently published an 
 analogous case where the subject, a man forty-seven years of age, had suffered 
 from mental weakness, dementia, but had neither been paralytic nor, strictly 
 speaking, idiotic. 
 
 As further but more rare anomalies met with in idiots, may be men- 
 tioned numerous, more localized, cerebral defects, deficiency or extraordin- 
 ary smallness of the most varied structures of the organ; indeed; there is 
 scarcely any portion of the brain Avhich has not been found either alto- 
 gether absent or quite rudimentary in these creatures. Thus, there are 
 examples of absence of the entire cerebellum;' of deficiency of the pineal 
 gland;' of defects of the fornix (Niepce in several of his autopsies); of a 
 rudimentary condition of one or of both olivary bodies, peduncles, cor- 
 l)ora mamillaria, thalamus and corpus striatum; of atrophy of the optic 
 commissure, deficiency of the auditory nerves (Valentin); finally absence 
 or rudimentary state of the corpus callosum : of this anomaly, about a dozen 
 cases, many of them very interesting, have been pubhshed. 
 
 Some of these cases of deficiency of the corpus callosum were profoundly 
 idiotic; this appeared to be the case only in those where other defects or 
 anomalies were presented by the brain. To these belong— 1st, the case of Bi- 
 anchi (1748, quoted by Forge child of seven years, profoundly idiotic; complete 
 absence of the corpus callosum, both hemispheres and the thalami and corpora 
 striata run together in one mass; there was no pituitary body; there was some 
 trace of the pons Varolii, but none of the pyramids and olivary bodies. 2d, the 
 case of Forg (Die Bedeutung des Balkens,' etc., Miinchen, 1855; girl, seventeen 
 years of age, in the highest degree idiotic, and badly developed physically; the 
 middle free part of the corpus callosum was entirely wanting, likewise the 
 septum, the middle part of the fornix; of the anterior and white commissures 
 of the gyrus fornicatus, only a rudiment exists; the island of Reil is considerably 
 atrophied; the convolutions are abnormally grouped, many of them entirely ab- 
 sent; the lobes of the cerebellum are unsymmetrical; hydrocephalus. 3d, the 
 case of Chatto ('London Medical Gazette,' vol. i., 1845): child of one year, in 
 whom all intellectual manifestations and sensorial perceptions appear to have 
 been entirely wanting; corpus callosum, septum and fornix absent, except two 
 small cords belonging to the corpus callosum, and wnich hang in front from each 
 hemisphere; hydrocephalus. Finally, several of the nine autopsies of cases of 
 endemic cretinism by Niepce (' Traite du Goitre,' etc., Paris, 1851, i., p. 25: ii., p. 
 Ill) present very great thinness or imperfect development of the corpus callosum, 
 along with other deficiencies in the brain. 
 
 On the other hand, there is a series of cases where there is no profound idiocy, 
 but' merely a moderate degree of mental weakness; and sometimes even this does 
 not exist. Case of Reil ('Arch. f. Physiol.,' Bd. ii., 1812, p. 341): a female, aged 
 thirty, demented, but still able to go messages; the middle free part of the corpus 
 callosum, the corpora geniculata, the convolution of the corpus callosum and the 
 septum lucidum were entirely absent; the otber parts of the brain appear to have 
 been normal. Case of Solly ('The Human Brain,' London, 1826, p. 433): a boy, 
 aged seventeen, always mentally weak, but took delight in reading religious 
 books; was benevolent, docile, sleepy, inclined to stumble and fall: besides the 
 want of the corpus callosum, a cyst was found in the brain. Case of Paget 
 ('Med.-Chir. Transact.,' vol. xxix., 1846, p. 55): girl, aged twenty-one, amiable 
 and childish disposition, showed no striking peculiarity, good memory, actions 
 rapid and inconsiderate, speech sharp and abrupt; the corpus callosum was quite 
 rudimentary, being represented by a thin band of horizontal fibres; the septum 
 and middle part of the formix were absent. Case of Mitchell Henry (' Med.-Chir. 
 Transact.,' vol. xxxi., 1848, p. 239): a boy, aged fifteen, gentle, but slow to leain, 
 
 ' The famous case of the idiotic girl, of eleven years of age, 'Anal. Path.,' 
 livr. XV., pi. 5. ,„, , . 
 
 » Schnepff ("Soc. de Biologic," 'Gazette Med..' 1850, p. 894). The brain was 
 otherwise normal; the pituitaiy gland was absent; in its place were two con- 
 cretions, hard like stones. The subject had been weak-minded from birth, and 
 died at the age of twenty -nine. 
 
252 STATES OF MENTAL WEAKNESS. 
 
 dull, sleepy, much disturbed when rapidly spoken to; the brain normal; the cor- 
 pus callosum represented by a horizontal band of fibres, H inch broad; the septum 
 and middle anterior part of the fornix absent. Case mentioned in the Rej)ort of 
 the Vienna Asylum for 1858: a man, a^^ed twenty-five, in his twentieth year be- 
 came epileptic in consequence of a fright, and since then has gradually fallen into 
 dementia; the corpus callosum absent, the anterior commissure incomplete; hy- 
 drocephalus. 
 
 § 160. To the anatomical lesions most frequently met with in the 
 brains of idiots belongs chrojiic liydrocejihalus, congenital or commenc- 
 ing in early youth, and from the most moderate to the highest degrees; 
 it is often accompanied by remarkable thickening of the lining membrane 
 of the ventricles. In many cases, the hydrocephalus seems to constitute 
 the primary and chief disease; this may be assumed in those cases, es- 
 pecially where the ossification of the cranium takes jilace slowly, where 
 the bones of the head remain thin, where there is considerable or even 
 moderate increase of size of the cranium (macrocephalus). In many 
 other cases, again, the increased amount of serum in the cranium of idiots 
 is often secondary; a result of limitation of development, of atrophy of 
 certain parts — in short, of cerebral deficiencies (hydrops ex vacuo), or it 
 is even a more accidental comjilication of various malformations of the 
 brain. A convincing example of this is afforded by the unilateral hydro- 
 cephalus in atrophy of one side of the brain. In all these cases the cra- 
 nium may be of the ordinary circumference, or even (and very often), as 
 we have already seen, considerably less. The volume of the brain may in 
 every case of considerable hydrocephalus be considered to be diminished, 
 and very frequently that portion which remains is less capable of jier- 
 forming its function. 
 
 Rare but \erj interesting malformations of the head are caused by partial hy- 
 drocephalus, by great dilatation of the lateral ventricles in only one part (for 
 •example, the inferior cornu). Should this occur at a period when the skull still 
 consists in part of the membranous elements of the cranial bones, symmetrical 
 protrusions are formed, in consequence of the eccentric pressiu'e exercised on the 
 -corresponding portion of the brain, sac-like prominences on the skull. See Wil- 
 ligk, Prager ' Vierteljahrschr.,' Bd. 1., 1855, p. 30; Lambl, see § 161. A very re- 
 markable and very rare fact which has been observed by Valentin and Niepce is the 
 presence of a fifth ventricle within the olives of the cerebellum (ventric ciliaris, 
 normal in the brain of birds). In the first case (from Abendberg) the ventricle 
 was from 1 to \h inch long. Those idiots with considerable hydrocephalic en- 
 largement of the cranium generally remain small, and their entire development is 
 retrograde, so that, for example, at sixteen years of age they appear like five or 
 six. Still, this is not always and necessarily the case. I myself know of cases 
 where a considerable amount of hydrocephalus coexisted with a well-developed 
 bod}" and pleasant features. The causes of these differences would form an inter- 
 esting subject of study. 
 
 Encejyhalitic 2Jrocesses of variable extent, sometimes localized, some- 
 times more diffused and terminating in different ways, but especially in 
 sclerosis and atrojihy of the affected parts, constitute in many cases of 
 idiocy the principal anatomical lesions. These may occur even during 
 the embryonic stage, during the first months of life, or the period of the 
 first dentition, and sometimes later, up to the fourth or fifth years. In 
 those cases where death does not occur till long after the disease has run its 
 course, it frequently happens that the remains of these processes are diffi- 
 cult to distinguish, and it is principally through cicatrices or other 
 thickenings, through pigmentation, etc., that the atrophied parts (some- 
 times a Avhole hemisphere) can be distinguished from structures simply 
 arrested in their development. In these cases the idiocy is very fre- 
 
STATES OF MENTAL WEAKNESS. 253- 
 
 quently accompanied by a unilateral motory affection (paresis, contrac- 
 tion), and sometimes by epilepsy. The diffused hypertrophy of the 
 connective tissue of the brain whicii may, generally speaking, be referred 
 to chronic encephalitis, and which is often found in paralytic dementia, 
 has been proved by certain well-marked examjDles to occur in idiocy. 
 
 Isambert has coiniaunicated ("See. de Biologie," 'Compt. rend, et Mem.,' ii , 
 2, 1856, p. 9) an interesting case of this kind which was examined microscopical l)r 
 by Robin: it occurred in an idiotic child, two years of age: the ventricular walls, 
 the gi-eat ganglia, the pons and peduncles were solid and hard; their tissue waa 
 elastic like caoutchouc, the nerve tubes in the white substance were almost com- 
 pletely destroyed, and an amorphous granular substance occupied their place: 
 there also existed newly formed fibrous connective tissue. 
 
 In those common cases in which we are told that a hitherto healthy and well- 
 developed child, about the period of dentition, or during the second or third year, 
 suddenly became feverish; was attacked by convulsions ("fits'"), delirium; fell 
 into a slight soporific state, and soon afterwards apparently recovered, but the 
 intellectual development remained at a standstill; speaking and walking, which 
 it had recently commenced, become difficult, but the " fits " remain and gradually 
 pass into epilepsy; — in these common cases there are two processes which we have 
 principally to consider. These are generally either congestive states and slight 
 inflammatory processes in the membranes, which may be connected with ossifi- 
 cation (inflammatory) of the sutures of the cranium or with the general develoi> 
 ment of the infantile brain, and very frequently leave behind serous effusions, or 
 a disposition to the gradual development of hydrocephalus. Or they are states of 
 encephalitis, which, after the passing off of the acute state (with swelling of the 
 brain, etc.), involve or suspend further development in the affected parts, and 
 may often be recognized long after in their results at the autopsy. These pro- 
 cesses may be assumed, above all, in cases where one side of the body is a little 
 less developed than the other, where convulsions, paralyses, contractions, etc., 
 exist, limited to one side of the body. As an example of the most severe form of 
 this kind, I quote the following case from Calmeil ('Malad. inflammat. du Cer- 
 veau,' Par., 1859, ii., p. 411): "A healthy boy, during convalescence from measles, 
 fell into a violent convulsive attack, which was followed by prolonged coma: he 
 came out of this state deaf, dumb, and blind; in fourteen days the sense of 
 hearing returned ; after the lapse of a year he learned to speak a few words, but 
 he continued blind, became epileptic and hemiplegic on the right side. At the 
 age of thirteen he was in a state of profound dementia; at nineteen he could arti- 
 culate a few sounds, but could not feed himself ; his right leg was weak, his arm 
 contracted. He died in his twenty-second year. The right half of the body was 
 thinner and smaller than the left; the cranium small, well formed, very thick; 
 oedema of the pia; the left hemisphere considerably smaller than the right. The 
 left posterior lobe was especially small; its convolutions as thin as the blade of a 
 knife, very firm, of a bright yellow color externally, internally of a dull white 
 color; the left middle and anterior lobes were also smaller than ordinary; the right 
 posterior lobe was likewise a little diminished and shghtly sclerotic; the optici 
 were indurated. The sclerosis and atrophy of the brain were evidently the results 
 of an encephalitic process consecutive to measles. 
 
 Hypertrophy of the brain occurs much less frequently in idiots than 
 do the various alterations which we have enumerated; it is impossible to 
 distinguish it during life from hydrocephalus distending the cranium, as 
 in both cases the head is large and the ossification imperfect, and — 
 whicn is interesting in many ways — the base of the cranium is not ex- 
 tended, but rather shortened, or it pi-esents only normal proportions 
 (Virchow). 
 
 Baillarger (' Acad, de Med.,' 29 Jul., 1856) mentions the case of a child of four 
 years, in whom the brain weighed 1,305 grammes (or more than the adult aver- 
 age); and another case of a child (' Gaz. hebdomadaire,' 1859, No. 6, p. 93) in whom 
 the body weighed forty-six pounds, and the brain 1,160 grammes. Bricquet, 
 Delasiauve have recently reported analogous cases. 
 
 A remarkable appearance, and one which has hitherto received very 
 
254 STATES OF MENTAL WEAKNESS. 
 
 little attention, is the unusiial abundance of gray substance (in the ordi- 
 nary localities) which has been remarked by various observers (Stalil, 
 Eosch, Niepce — seventh and ninth autopsies) in the brains of certain 
 idiots, the amount of the gray substance being greater than that of the 
 white. Occasionally, new formations of gray substance are found in 
 parts where in the normal state it does not exist (Virchow found this in 
 an e^iileptic idiot — I once saw it in an epileptic, of whose mental condi- 
 tion there was no information). Finally, the reports of several antopsies 
 mention the interesting fact of hypertrophy of the pituitary body (Niepce, 
 Bergmann). We may here very properly doubt whether these were cases 
 of true hypertrophy, or of some other morbid change. Niepce's third 
 and sixth autopsies point to the latter: in the one (third) there were two 
 small concretions, in the other (sixth) a cavity in the centre (in other 
 cases, too, of endemic cretinism the pituitary body was very small). 
 Examples have also been met with of extraordinary enlargement of the 
 corpora quadrigemina (Niepce's second autopsy). 
 
 § 161. We now pass from the anomalies of the brain itself to the con- 
 sideration of those of the cranium. These occur very frequently, and in 
 great variety, in idiots. We have already mentioned this circumstance 
 when speaking of the consequences of defective development of the brain 
 (§ 158); in the following summary we shall again have occasion to return 
 in part to this, but the principal subject of consideration is the primary 
 anomalies of the cranium, in the investigation of which such interesting 
 discoveries have recently been made. 
 
 It does not lie within the province of this work to enter into minute details 
 upon this svibject. The reader who is interested in this study is recommended to 
 consult the original works, and in particular to examine a number of the skulls 
 which may be found in any pathological museum. See Malacarne, in P. Frank, 
 ' Delectus Opusc. Med.' vol. vi., lie. 1789, p. 241 ; Ackermann, 'Ueber die Creti- 
 nen ' etc., Gotha, 1790 ; J. and E. Wenzel, ' Ueber den Cretinismus,' Wien, 1802 ; 
 Stahl, 'Neue Beitrage,' etc., Erlangen, 1848, 2d edition, 1851; "Clinische Stu- 
 dien," etc., 'Zeitschr. f. Psychiatrie,' xi., 1854, p. 545; ibid., xvi., 1859, p. 1 ; 
 Virchow, ' Wiirzb. Verhandl.,' 1851, 1852, 1855, 1856, and ' Gesammelte Abhandl.,' 
 Frankfurt, 1856, p. 891 ; " Untersuchungen iiber die Entwickelung des Schadel- 
 grundes," Berl, 1857 ; "Ueber Knochenwachsthum und Schadelformen." Vir- 
 chow's ''Archiv,' xiii., 1858, p. 323: Luca, ' Zur Architectur des Menschen- 
 schiidels,' Frankf., 1857; Gratiolet, "Mem. sur la Microcephalie," 'Journal de 
 Physiol.,' ix., Jan., 1860; Lambl, ' Aus dem Franz-Joseph-Kinderspitale,' etc., 
 Prag, 1861. 
 
 We shall not occupy ourselves with those alterations of the cranium 
 which are at present of little interest in connection with idiocy, such as 
 the frequent partial attenuations, and the still more frequent, generally 
 much less general, thickenings of the cranial bones, which so frequently 
 constitute the sole palpable lesion in epilepsy, and the connection of 
 which with that disease, and also with idiocy, is in many cases quite 
 obscure; nor shall we consider, further, those rare cases of long-persist- 
 ence, even to adult life,' of the fontanelles and such-like: but the prin- 
 cipal object of our study is the consideration of those deviations mthe 
 development and growth of the cranium which impart to it abnormalities 
 in form. We must here consider, especially— 1st, anomalies of the arch, 
 and, 2d, anomalies of the base of the cranium. 
 
 Many irregularities in the development of the arch of the cranium 
 are produced by primary anomalies in the development of the brain: the 
 
 ' Stahl (' Neue Beitr.') found this in a man fifty years of age. 
 
STATES OF MENTAL WEAKNESS. 255 
 
 ossification of the cranial bones remains behind, owing to the retarded 
 growth of the brain; it is kept back owing to the entire brain or certain 
 parts of it remaining small, by the non-symmetrical development of the 
 brain, etc. Many cases of simple microcephalics belong to this form of 
 anomaly; perhaps, also, many unilateral stenoses of the cranium, owing to 
 closure of the sutures witli inequality in size of the two cerebral hemi- 
 spheres: in this case the ossification of the sutures is not the cause of the 
 malformation, but appears ratlier to constitute the last stage of the 
 changes. In tliese limitations from an internal cause, from the contents 
 of the ci'anium owing to irregular development of the brain there are fre- 
 quently formed a number of closed sutures — a circumstance of great im- 
 portance in the determination of these relations: there result from tliis, 
 general microcephalus, or partial or general expansion of the osseous 
 arch of the cranium. 
 
 But, evidently, in by far the greater number of cases the deviations 
 in form of the cranial arch are primary and independent of its contents 
 — of the development of tlie brain. These depend, especially, upon 
 interriiption of the groivth of the lones; and this, again, often ajjpears to 
 be owing to simple deficiency and incompleteness in tlie formation of bone 
 substance, it may be from constitutional causes acting unfavorably on the 
 ■general nutrition; especially, however, and most frequently, it is the 
 result of an idiopathic morl)id, apparently inflammatory, process in the 
 sutures, the process by which the normal growth of the cranial Isones 
 proceeds, and which terminates in occlusion of the sutures. Thus, m 
 whatever way a suture is prematurely ossified, the cranium becomes nar- 
 rowed at that point, because the growth of the bones, wliich takes jilace 
 at the suture, is arrested, and, of course, always in a direction perpen- 
 dicular to the suture. This limiting of one j)art may, wlien it is con- 
 siderable, extend its infiuence far beyond the part: thus, for example, 
 very early synostosis of the arch of the cranium also affects the growth of 
 the basis cranii, shortens or narrows it. 
 
 In many cases, there merely remains a contraction of the skull owing 
 to the arrested growth of the bones, and the cranium is simply deformed. 
 In other cases, however, corresponding dilatations are formed in other 
 parts of the cranium, because the brain grows towards the side where it 
 meets least resistance, because there the sutures are more distended by 
 the growing brain, and consequently present more points of ossification, 
 and i^erhaps there is a tendency even to exuberant growth. These so- 
 called compensations correct the contractions in the cranial cavity, but 
 they very often produce even greater deformity of the skull than was 
 caused by the original contraction. When stenosis is once established, 
 all depends upon these compensations for the normal development of the 
 brain, and, therefore, of the mental faculties. These compensations 
 themselves appear principally to depend upon an active growth of the 
 brain, and, consequently, in these changes in form we have not solely to 
 do with purely mechanical relations, but with a far more intimate nutri- 
 tive relation connected with the condition, with the jiower or weakness 
 of the general physical nutrition. In all considerable ossifications of the 
 sutures, the compensations are seldom sufiicient for the complete develop- 
 ment of the brain, and, therefore, even with them the cavity of the 
 cranium is generally too small. 
 
 A special and rare kind of compensation (incomplete) consists in the formation 
 of the so-called encephalitic protuherances (Lambl) — protuberances on the skull, 
 especially in the neighborhood of the sutures and fontanelles. These always 
 
256 STATES OF MENTAL WEAKNESS. 
 
 appear to be connected with internal hydrocephalus, and are produced by the 
 pressure of the compressed parts of the brain ; they may even proceed to the for- 
 mation of greater or smaller deficiencies in the osseous cranium. 
 
 The deformities produced by these stenoses may be referred to seyeral 
 principal types. When all or nearly all the sutures of the arch of the 
 cranium become closed at a very early stage, there results simple uniform 
 mkvoceplialus: if the base of the cranium becomes also ossified, or should 
 no compensation be formed there, the entire cranium, though small, is 
 properly proportioned; but the growth of the brain is also uniformly and 
 most profoundly disturbed. Should, on the contrary, a great compensa- 
 tion be made by the ossification of the basis cranii being rendered un- 
 usually slow, and consequently a much greater expansion of it rendered 
 possible, there appears to originate from this a special type of physiog- 
 nomical and physical development, and also of intellectual life, which we 
 shall afterwards describe more minutely under the name of the Aztec 
 type. Merely partial occlusion of the sutures of the arch of the cranium 
 determines the following principal forms: — Too narrow crania (i. e., 
 when the transverse diameter is shortened) are caused principally by 
 early ossificartion of the sagittal suture; more rarely, and ratiier with con- 
 traction of the frontal than the parietal region, by ossification of the 
 spheno-frontal suture. Ossification of both sides of the suture between 
 the occipital bone and the mastoid portion of the temporal bone may, as 
 I found in the cranium of a semi-cretin girl of nineteen years, consider- 
 ably diminish the whole inferior part of the cranium, situated between 
 the two mastoid processes, and consequently the space destined for the 
 cerebellum. In these crania, compensation takes place in the antero- 
 posterior diameter, by enlargement of the frontal region and protuberance 
 of the occiput. Too short crania are caused, behind, by ossification of 
 the lambdoidal suture (the highest degree of absence of the posterior 
 portion of the cranium causes the rare ape-like from of the so-called 
 mask), and here compensation often takes place by development of the re- 
 gion of the anterior fontanelle (conical or sugar-loaf heads); in front, the 
 shortening is caused by extended ossification of the frontal with the. 
 parietal bones, the cranium being, at the same time, very low. Other too 
 loiu crania are caused by ossification of the wings of the sphenoid with 
 the frontal bone and squamous portion of the temporal bone. Finally, 
 the unsymmetrical obliquely narrowed crania are caused by unilateral os- 
 sification, anteriorly through ossification of one-half of the coronal su- 
 ture, posteriorly through ossification of one-half of the lambdoidal suture; 
 compensation takes place by increased extension towards the opposite 
 sides. All these stenoses which we have enumerated, as they occur at a. 
 very early period, involve to the development of the corresponding por- 
 tions of the brain: for example, unilateral stenoses are apt to cause short- 
 ening of one of the cerebral hemispheres, etc. These hindrances to the 
 development of the brain are very rarely fully corrected by the so-called 
 compensations, and are seldom without serious consequences. 
 
 It appears, morever, that dis-symmetry (and deformity generally) maybe 
 caused not only by partial stenoses, but also by local expansion ; naniely, by the 
 immoderate development of ossa Wormiana : in particular, a special form ot 
 elongated cranium appears to be produced by the plentiful formation of Wor- 
 mian bones. 1 According to Lambl (1. c, p. 26), scolioses of the cranium origi- 
 nate also in rickety children through displacement, owing to softness ot the 
 bones and long continuance of the sutures : finally, there also appear to be scoli- 
 
 1 Virchow, ' Gesammelte Abhandlungen,' p. 902. 
 
STATES OF MENTAL WEAKNESS. 257 
 
 oses which cannot be referred to any of the causes which we have mentioned, but 
 can only be attributed to an original disproportion in the energy of the growth of 
 the bones at a particular part. 
 
 If the original primary obstacles to the development of the brain have 
 a very great influence upon the development and form of the arch of the 
 cranium, influences of tiiis kind upon tlie development of the bones of 
 the base of the cranium are, as yet, almost unknown, and all the clianges 
 which occur in this part of the cranium, when not compensatory or con- 
 secutive to changes in the arch of the cranium,' are in the present state 
 of science to be considered as primary and indej^eudent anomalies due to 
 disorders in nutrition of the bone and cartilage itself . These changes are 
 almost entirely due to premature ossification of the base. As the growth 
 of the bones in the arch of the cranium depends on the persistence of the 
 sutures, the growth of the bones of the base depends upon the persistence of 
 the cartilages; and the prmiature ossification of these cartilaginous surfaces 
 arrests the longitudinal development of bones which enter into the forma- 
 tion of the base of the cranium, which must, of course, produce shortening 
 of the base. More rarely, the ossification of the cartilaginous disc between 
 the primitive anterior and posterior portions of the sphenoid bone pro- 
 duces this result: this is ordinarily completed at birth, or at least soon after 
 it; it is rather the ossification of the synchondrosis between the sphenoid and 
 the basilar portion, which in the normal state does not occur till the fif- 
 teenth year, and sometimes not till the twentieth year and even later: 
 thus, the base of the cranium has, in the normal state, fully fifteen years 
 to grow in the antero-posterior direction. — This shortening of the base 
 of the cranium by ossification is followed by very serious consequences. 
 Should it occur very early, it imparts to the basis cranii a form which is 
 only normal at the middle of intrauterine life; namely, a great curvature 
 upwards of the base of the cranium, a small angle at the point of union 
 between the sphenoid and tlie basilar portion, a steep clivus: further, 
 this shortening causes malformation of the face (cretin physignomy), 
 which is characterized by prominence of the ridge of the nose (cocked-up 
 nose) ; the roots of the nose are deeply set and very broad, the eyes widely 
 apart, the orbits large but shallow, the cheek-bones high and prominent 
 (Prognathismus). With limitation of the development of the base of the 
 cranium are connected the further results of a shallow and transverse 
 position of the sphenoid bone, and of a consequent lessening of the great 
 wings, and of the central cavity connected with them. There is thus pro- 
 duced through this — together with a probable unfavorable influence upon 
 the development of the pons Varolii and medulla oblongata from the abnor- 
 mally formed clivus — arrest of development of the anterior and middle 
 parts of the brain. Actual microcej)halus may now exist; more frequently 
 this is not the case, and thereareproduced various compensations, which, 
 however, are not complete, probably on account of the deficient develop- 
 ment of the brain. These compensations are produced partly by growth 
 ,of tlie cranium upwards (conical heads), partly by elongation of the arch 
 of the cranium with persistence of the frontal suture, or, finally, by mod- 
 erate dilatation of the superior and posterior parts of the head. 
 
 The tribasilar synostosis forms the anatomical foundation, and, as it appears, 
 the sole point of origin of 07ie special form of cretinism whicli is specially repre- 
 
 ' Thus, for example, may synostosis of the superior cranial sutures, especially 
 of the coronal suture, have a direct influence in shortening the base of the 
 cranium. 
 
 17 
 
258 STATES OF MENTAL AVEAKNESS. 
 
 sented in Alpine cretinism. Several of the older observei-s had ah-eady arrived at 
 the perfectly correct conclusion that the fundamental lesion in this form is in the 
 base of the cranium, and had very nearly come to tlie correct idea upon tlie sub- 
 iect. Ackermann said (1790), I. c, p. 33, '• It is solely on the lower part of- the basis 
 cranii that the abnormal change exists which essentially constitutes cretmism ; " 
 and in page 119 he says, " It is this slight alteration in form of the occipital and 
 sphenoid bones (he chiefly refers to the too horizontal position of the occipital 
 bone) which constitutes cretinism." The Brothers Wenzel express themselves in 
 quite analogous terms, 1. c. pp. 54-59 : "In cretins the surface of the base of the 
 cranium is shortened, as if compressed in the antero-posterior diameter ; the fun- 
 damental changes chiefly involve the base of the cranium," etc. ; and further on, 
 p. 206, "the anomalies of cretinism which sometimes show themselves even in the 
 newly born child, are all of a nature such as might lead us to suppose that there 
 exists a high degree of deformity in the basis cranii." Autenrieth also expresses 
 similar sentiments (quoted by Wenzel, 1. c, p. 218). This part of the inquiry, 
 however, was altogether neglected in the subsequent investigations regarding 
 cretinism. Stahl revived it (1848). The actual state of matters in this funda- 
 mental deformity of the basis cranii was, however, for the flrst tune clearly eluci- 
 dated by the investigations of Virchow. This observer has also shown that com- 
 plete synostosis of the two parts of the sphenoid bone and the basilar portion may 
 even occur during ftetal life, in which case the newly born child will present, m 
 a marked degree, the physiognomical peculiarities of cretinism. It is self-evident 
 that basilar synostosis, with shortening of the base of the cranium, not only does 
 not lie at the foundation of all forms of cretinism (idiocy with physical deformity), 
 but even is not always present in endemic Alpine cretinism. This, however, does 
 not oppose the theory advanced by Virchow— it rather confirms it, owing to the 
 circumstance that we occasionally find in individuals with endemic cretinism (a,s 
 also in certain healthy persons) the sphenoid and the basilar portion not yet ossi- 
 fied after the age of twenty (Niepce, 1. c, ii., p. 118, 6th section ;' Stahl, ' Neue 
 Beitriige,' p. 70 ; ' Zeitschr. f. Psych.,' Bd. xvi., p. 368). The basilar synostosis 
 o-ives rise to a special, but very frequent form of cretinism, possessing the peculiar 
 phvsiognomical expression, and— to which the small size of body, the frequent 
 complete dwarfishness, points— the cartUaginous epiphyses of the long bones of 
 the extremities seem also to experience a similar arrest of development from 
 premature ossification : therefore in these cases we ought not to attribute the 
 stunted growth of the body, as we do in unilateral atrophy or in many niicro- 
 cephals to the affectien of the brain, but to a constitutional malady with prema- 
 ture ossification of the cartilages— to an affection which, in many respects, is 
 diametrically opposed to rickets. True rickets has never been observed to pass 
 into cretinism; a circumstance of great importance in the treatment of these con- 
 ditions. 
 
 The types of cerebral abnormalities which correspond to the various 
 deformities of the cranium which have been described are as yet very in- 
 completely known, and would form an interesting subject of investigation 
 to those who have the opportunity. 
 
 § 162. On reviewing what has been said regarding the anatomical 
 foundations of idiocy and cretinism, we find that in a great number of 
 cases there exist cerebral and cranial anomalies which must necessarily 
 act unfavorably on the development of the brain. The two series of phe- 
 nomena are very different in their nature; they cannot be referred to one 
 type, nor to a single fundamental process. We must also carefully guard 
 a'crainst recognizing in the special nature of an anomaly which is presented 
 to us— for example, in hydrocephalus, or in a deficiency m the commis- 
 sural system of the brain,— the immediate anatomical cause of the 
 i.sychical disorder in question— of the idiocy. This anomaly, or this de- 
 fect, may perhaps have no influence in regard to the special psychical 
 disorder, and the latter depends u pon the mode in which the existing, 
 
 ' It is worthy of remark, that in these cases the penetrating body was greatly 
 hypertropliied, and contained a cavity in the centre : while in Virchow s case ot 
 a newly born cretin with complete synostosis, the pituitarj- body was very smaU— 
 almost atrophied. 
 
STATKS OF MENTAL WEAKNESS. ' 259 
 
 apparently quite uormal, parts perform their functions. But those 
 palpable and evident changes clearly demonstrate, on the one hand, that 
 at all events the brain was diseased or defective; and on the other hand, 
 we must remember wliat the elements are which gradually contribute to 
 the development of the intelligence of the child — that the elaboration of 
 the sensorial impressions and the formation of the internal impulses of 
 movement constitute the special basis of the mental development — that 
 disorders in the function of those parts of the brain which, perhaps, have 
 little to do with the more elevated mental processes, but have great influ- 
 ence upon the development of the functions of the brain which relate to 
 sensation and movement, may withdraw what is essential to the develop- 
 ment of the mind by severing it from the healthy roots through which it 
 is developed from the sensitive faculty. 
 
 Regarding the mechanism by which each of these cerebral changes are 
 produced, we know much which serves to explain their origin (intra- 
 uterine cerebral inflammations, other foital diseases, synostoses, etc.); in 
 regard to the cases of deficient development, there is a circumstance 
 which seems to me to deserve more consideration than has yet been ac- 
 corded to it, namely, that of abnormal narrowness of the cerebral arteries, 
 which may be eitlier a primary defect in development, or the result of an 
 abnormal state of the bones with contraction of the foramina (con- 
 traction of the carotid canal from abnormal state of the sphenoid 
 bone?). 
 
 This contraction of the arteries was very prominent in the anterior SylArian 
 fissure and on the basilar portion in several of Niepce's cases : in tliree cases of 
 endemic cretinism, also, the vertebral and basilar arteries were very sniall. 
 (Report of the Sardinian Commission, p. 204.) I found both carotid canals, but 
 especially that of the right side, very narrow in the cranium of an idiotic girl 
 -with poverty of the brain and inequality of the hemispheres. May not premature 
 thickening of the bones of the basis cranii have this effect ? May not this factor 
 play an important part in compensating for deformities of the base which have 
 been brought about by the pressure of a brain growing with morbid activity ? — 
 and, again, where this growth is rendered less active by narrowing of the arte- 
 ries, will not less compensation be required ? 
 
 § 163. As all the various diseases of the brain and its membranes 
 which occur during intra-uterine life and in childhood agree in this, that 
 they impede the complete development of the brain, therefore all the 
 mental disorders of childhood must have the same result, namely, that of 
 impeding the development of the mind. This disordered development 
 manifests itself in anomalies of all the mental faculties, and these are far 
 from being the same in every case of idiocy: therefore, each case ought to 
 be specially investigated, in order to discover in what manner the mental 
 mechanism is disturbed. Here, therefore, we must content ourselves 
 with a general consideration of the disorders of the mind. 
 
 Anoinalies of percej)tion. — In severe cases, the sensorial impressions 
 produce very few ideas: these are so fleeting and so superficial, that they 
 soon again disappear, and the process of abstraction does not proceed, so 
 that they continue isolated — as entirely or half sensorial ideas. There is 
 likewise a deficiency in the production of ideas, as well as in their — 
 which occurs involuntarily in health — movement and elaboration, — that 
 combination with other ideas which render them a part of our inner con- 
 sciousness; there is no regular subject of thought which might powerfully 
 grasp the new ideas, determine the impulses of will, form opinions — 
 which, in a word, could constitute an ego. We observe, also, loss of the 
 powers of attention and reflection; they have no memory, no mental 
 
260 STATKS OF MENTAL WEAKNESS. 
 
 spontaniety: in extreme cases we can discover no germ of individuality 
 which might be compared to the healthy ego; no trace of a mental person- 
 ality. 
 
 These defects in concrete cases are not only manifested in various ways, but 
 the phenomena themselves may also be altgether different: in the one, tiiat per- 
 haps is destroyed which in another never existed, in the one the sensorial element 
 may be at fault; in the other the abstractive element, etc. There are many idiots 
 in whom we can discover actually no symptoms of mental life — neglected children 
 of nature, completely unconscious of the world and of time, who exist in a state 
 of profound dreain; are completely strange to all tliat goes on around them, and 
 show no other spontaneous «ign of life than devouring the food which is placed 
 in their mouths. The animal perceives the external world; it is complete in its 
 special organization; it is capable of expressing its impressions, its sensations and 
 desires, with the means of gratifying them. In this respect these poor idiots 
 stand far below the healthy brute, but withouton that account — which very curi- 
 ously is possessed even by tliem as a leading characteristic — being deprived of 
 humanity. In many others the clear consciousness of a special personality, 
 thought, and almost the very attempt to speak, even by gestures, are wanting; 
 but a greater degree of perception of the world penetrates their state of dream, 
 and they present at least a commencement towards finding their position in it. 
 An idiot of this kind does not, for example, wait till some one removes the finger 
 which he has just bitten from his mouth, but can accomplish this himself. They 
 recognize their attendants, the preparations for meals, etc. ; they feel a desire for 
 muscular motion, which is performed in the most uniform manner;' gradually 
 acquire a mechanical knowledge of certain words, orders, etc., which they exe- 
 cute automatically (they do this, however, in a manner quite different from that 
 of healthy children, without regarding the speaker or manifesting any expression 
 of countenance). From these types of extreme degradation there are numerous 
 gradual transitions to somewhat better states, in which the external world 
 becomes more and more recognized and elaborated in an elementary fashion. 
 From this a small store of knowledge is accumulated, and the possession of an ego 
 capable of simple functions is rendered possible. It is a remarkable fact that 
 sometimes the excitation of an acute disease - calls forth manifestations of mind 
 and capacities which, in the ordinary state, lie latent. This permits the conclu- 
 sion that in certain idiots there is more received into the mind and there elabo- 
 rated than one might be led to suppose, which, however, cannot be expressed by 
 them, although it leaves its traces behind. 
 
 A leading characteristic of all severe cases of idiocy is the complete 
 absence of speech, so that not even the attempt is ever made, or speech 
 so very imperfect as to be called idiotic dumbness (not dependent upon 
 want of hearing). It depends upon want of ideas, or want of _ reflex 
 action from the perceptive to the motory faculties to the mechanism of 
 speech: the first have nothing to say, the second ''have no desire to 
 speak." The idiot who does not speak, has, likewise, no internal idea of 
 speech, and, therefore, is deficient in the most essential element in the 
 mechanism of abstraction. 
 
 The relations of speech are so interwoven with the whole process of mental 
 development, and so necessary to education and intellectual advancement, that 
 the classification of idiots according to their capability of speaking (generally into 
 three degrees) is one of the best that can be established. 
 
 According as these idiotic states become less profound, more ideas 
 may be formed and combined to simple judgments and conclusions. 
 
 ' I know a boy, fourteen years of age, a little microcephaUc, but otherwise 
 well formed, who, every day all day long, pushes out and in a drawer, and rattles 
 two keys. . ,. , 
 
 ^ See Niepce, ' Comptes rendus,' 37, 1853, No. 16: Case of an idiot who was 
 seized with hydrophobia. Usually he could not articulate more than a few 
 words, and now he spoke fluently about things which happened years ago, and to 
 which he at the time appeared to pay not the slightest attention. 
 
STATES OF MENTAL WEAKNESS. 261 
 
 But that prompt, involuntary blending of the ideas, by wliich the process 
 of abstraction is rendered easy, not a laborious act forced by frequent 
 repetition, is entirely wanting; there is no lively mental reaction, strong 
 impressions are required to excite it: therefore, the indifference and lack 
 of interest in the affairs of the external world manifested by these persons, 
 their perpetual immobility to sensorial impressions, and their extremely 
 limited spontaneity. On closer investigation, they manifest differences 
 in their intelligence which, in many, become actual peculiarities which 
 are not amenable to the ordinary means of education. 
 
 With the growing receptivity dependent upon increasing capability of 
 function of the apparatus of thought in the brain, the conceptions and 
 ideas become more numerous, the speech more perfect, and, in the end, 
 even reading and writing are possible; there is increasing intercourse 
 with the external world. But to accomplish several mental processes at 
 the same time or in rapid succession is impossible: therefore, the under- 
 standing is in general slower, the judgment uncertain and diffident; the 
 sphere of comprehension can only be caught at its borders, and this even 
 under foreign guidance; memory is the only accessible way to education; 
 the individual in a very simple sphere of life is satisfied with moderate 
 demands, rational thought and action, and makes himself useful by per- 
 forming that sort of work which exercises the imitative rather than the 
 initiative faculties. 
 
 The remarkable one-sided aptitudes and talents occasionally displayed 
 in the slighter degrees of idiocy are rather of a semi-conscious instinctive 
 character, and may be compared to the instincts of animals. In these 
 cases, certain series of ideas rapidly and easily develop themselves, and 
 with them appear the means for their correct and evident manifestation 
 — mechanical, musical, arithmetical talent, memory for words, signs, 
 etc. We never find these special aptitudes in cases of idiocy occurring 
 accidentally, occurring in once healthy children in consequence of cere- 
 bral disease in early youth, but only where the disease is hereditary or 
 endemic. 
 
 In the beautiful asylum for idiots at Eai-lswood, near London, I saw a young 
 person who had, quite unaided, built a very pretty and large model of a war-ship; 
 he was of limited mental capacity, and had, in particular, no idea of numhers. 
 We frequently see persons in profound idiocy execute (purely mechanical) curi- 
 ous works of design and painting. Morel (' Etudes Clin.,' i., p. 49) recites the 
 remarkable case of a speechless idiot who had a special gift of playing on the 
 dnim; his grandfather had been drum-major and his father drummer in a regi- 
 ment; his brother had always had a desire (which, however, was not gratified) to 
 become a drummer. The remart;able memory for places also exhibited by 
 certain idiots of low mental capacity is very analogous to these special talents. 
 
 It would not be altogether correct to judge of the severity of the cerebral 
 lesion by the degree of mental weakness; a great deal here depends upon the 
 locality, upon the social medium in which the child lives. Children who have 
 been weU cared for, with whom persons have taken soma trouble, whose minds 
 have been properly directed, behave very differently from those whose education 
 has been neglected, and whose minds have been excited, although the cerebral 
 disease may have been quite as severe. We observe also that, in the cretin dis- 
 tricts, those who roam about, who go about the villages begging, etc., are far 
 more intelligent than those kept constantly in the house. All education is, of 
 course, useless in the very lowest degrees of idiocy. 
 
 § 164. Anomalies of self-consciousnes, the desires, and the will. — In 
 general, the state of these faculties corresponds exactly to the degree of 
 weakness of the intellect: nevertheless, even in severe cases, the naturally 
 existing feelings and dispositions proceeding from the body, with the ex- 
 
262 BTATE8 OF MENTAL WEAKNESS. 
 
 citations proceeding from it toward the emotions and the will, always 
 present a great field of psychical activity. In the most profound cases of 
 idiocy, the joyful and painful emotions (anger, etc.), are entirely con- 
 nected with bodily sensations, or they appear to originate immediately, en- 
 tirely Avithout motive, through obscure changes in the state of the brain 
 and nervous system. The habitual nature of these emotions, which has 
 become persistent, gives to the lowest grades of these a something which 
 may be termed their individual disposition, their character. In this re- 
 spect we may, in severe- cases, establish extreme types: on the one hand, 
 those grim, sometimes truly fearful, almost ferocious, and often wild and 
 fearful idiots; and, on the other hand, those who, with absoluj^e want 
 of intellect, constantly exhibit a joyful and gay disposition,— who, with 
 always— about nothing— laughing features and good-humored eyes, bear 
 the expression of good-nature and complacency. In profound idiocy the 
 efforts and determmations are principally set i-n motion by the instincts, 
 above all by the instinct for food; most of these acts have the character 
 of half-conscious reflex actions; certain simple ideas which have become 
 persistent— for example, pleasure in playing with little strips of paper, 
 etc. — can again excite volition. It is self-evident that the acts of these 
 idiots do not proceed from free choice, not from actual volition; there 
 exists in them no ego, or at all events merely a trace of it, and in many 
 cases— but not belonging to the most degraded class— we are frequently 
 led, on observing their instinctive acts, to ask ourselves, Is there any- 
 thing in them which represents a will? and who or what can will in 
 them ? 
 
 In many idiots of the lowest class, eating is the only thing which seems to 
 move their soul: the most debased manifest this desire by restlessness, gruntmg 
 noises, etc., those a little higher in the scale move their hands and lips ui a cer- 
 tain manner, or weep tin some food is given them; they "wmtr'to be fed. lu 
 the lowest forms we also occasionally see rapid changes of humor, occurrmg 
 without external motive; for example, at one time the expression of fear, or wish 
 to go away, or sudden aversion to an accustomed amusement, or they become 
 an«-ry at it. This anger is often very violently expressed by scratching, throw- 
 ing the arms about, biting, etc , even to actual mania. Those capricious emo- 
 tions observed m certain individuals are quite inexplicable, as, for example, the 
 appearance of all the signs of jovful excitement whenever they see a piece of 
 paper or the manifestation of tlie most tender regard towards some particular 
 child, while they appear to take no notice of anything else; a good-humored idiot, 
 when taken ill, commencing to scold himself, to knock his head against the waU, 
 etc. 
 
 In the slighter cases, inconsistency and dulness of the emotions, and 
 weakness of will, are also general charac^ristics: the disposition, there- 
 fore, very much depends upon the surroundings, and the treatment to 
 which the individual is subjected. Under good treatment, for example, in 
 the idiot asylums, most of these children are good-natured, obedient, 
 happy, and sociable; when maltreated, they become embittered and malici- 
 ous; in some there habitually exists a melancholic or more excited frame 
 of mind. In the localities where cretinism is endemic, we seldom observe 
 any agreeable traits of character in these idiots. The higher degrees are 
 characterized by great dulness of sentiment; they are unsociable amongst 
 themselves and repugnant to each other. The semi-cretins, whose good- 
 nature "has its origin neither in the head nor in the heart, but in the 
 stomach" (MaSei), are still incapable of any real affection, or even at- 
 tachment, or, indeed, of any human feeling; they are rude egotists, 
 whose desire for idleness can only be overcome by force, or by the pros- 
 pect of enjoyment. 
 
STATES OF MENTAL WEAKNESS. 263 
 
 § 165. TJie anomalies m the senses and in the movements observed in 
 a, great number of idiots are extremely important. In severe cases these, 
 especially the latter, are always present, although in very different de- 
 grees; they generally depend immediately upon the morbid state of the 
 central nervous apparatus. As a rule, the sense of sight is the best; and 
 when it is affected, it appears to depend more upon affections of the eye 
 itself, which is affected by amblyopia, than upon the state of the brain : 
 strabismus, in all its degrees, is frequent. Hearing is frequently dull; 
 frequently, however, it is very difficult to distinguish whether actual 
 deafness exists, or only comi^lete want of attention. Smell and taste are 
 generally imperfect (the olfactory bulbs are often imperfectly developed): 
 we seldom see idiots smell things like animals, and rejecting what does 
 not please them; many appear to be alike indifferent to all impressions of 
 smell, and likewise of taste, so that they put the most unclean things 
 into their mouths — eat nettles, excrement, etc. Others exhibit a spe- 
 cial aversion towards certain kinds of food, as beef, and will eat only 
 milk and bread, and such like. The cutaneous sensibility is very dull; 
 in many, very little pain can be excited in the skin, and examples occur 
 of extended actual anaesthesia,. This does not apply to the severe cases: 
 in many semi-idiots, or those in whom development has been simply 
 arrested, sensibility to cold and to. injury does not exist; in these cases 
 the sense of hearing is always weak. 
 
 The anomalies of movement consist in convulsions, contractions, and 
 paralyses. The convulsions are sometimes local — for example, in the 
 toes, in an arm or leg; sometimes more general, when they not unfre- 
 qucntly resemble chorea. But the most serious of all are the epilepti- 
 form convulsions, Avhich constitute an extremely fatal compliction, and 
 one which is very unfavorable in a prognostic point of view, and ex- 
 tremely frequent in severe cases. Frequently, the acute cerebral affec- 
 tions (§ 365) which occur about the period of dentition, or somewhat 
 later, constitute the point of origin of epilepsy, as of idiocy itself; there 
 are cases, always of the most serious description, where the epileptic 
 convulsions are for years daily repeated. Evidently, the epilepsy is gen- 
 erally a symptom of the disease of the central nervous apparatus, which 
 determines the deficient mental development, and then apj)ears simulta- 
 neously with or not till long after the commencement of the idiocy (some- 
 times not till the period of puberty); but certainly there are also cases 
 where a different relation exists between the two series of symptoms — 
 where the epilepsy is entirely to be considered the primary and chief dis- 
 ease, and the mental weakness and the result of the violent commo- 
 tion and exhaustion of the cerebral functions caused by the frequent at- 
 tacks, just as we occasionally see in the adults, especially after the first 
 rapidly repeated epileptic attacks, extreme dulness and general derange- 
 ment of all the mental functions, which lasts for several days.' The con- 
 tractions are more frequently partial — of the toes, of the sterno-mastoid 
 muscles, spasmodic club-foot, etc. ; sometimes they are more general, as, 
 for example, of the knee-joint, so that the heel is kept firmly pressed 
 
 ' I have already expressed this opinion in the ' Twelfth Annual Report of the 
 Asylum at Mariaburg,' Tubingen, 1859. Should we succeed by very early and 
 appropriate treatment in removing the epilepsy, w^e may also hope to improve the 
 idiocy; very soon, however, these cases become incurable when the epileptic 
 attacks continue, and are frequently repeated. I shall communicate the result of 
 my numerous observations of this disease during the last few years in another 
 place. 
 
264 STATES OF MENTAL AVEAKNESS. 
 
 against the nates. Paralytic conditions are much more frequent. Many 
 of the most degraded idiots can neither stand nor walk; the lower ex- 
 tremities are relaxed, stiff, or atrophied, owing to which slight convul- 
 sive movements often take place in them. Frequently, there is a condi- 
 tion of muscular weakness with premature fatty atrophy; the limbs 
 remain small, have a purple hue, and are always cold, as has been observ- 
 ed in the so-called "paralysis of children" (Heine). From this there are 
 all possible kinds of transitions to more partial forms of paralysis, paraly- 
 tic club-foot, etc. Many of these paralyses are in severe cases referable 
 to the cerebral affection itself; others, as it appears, to a coexisting 
 disease (atrophy) of the spinal marrow; the electric contractility is also 
 much diminished (Zuradelli, 1860). In the slighter cases of idiocy — in 
 the semi-cretins, for exaraiile— we frequently observe not only the gene- 
 ral feebleness of bod}^ the uncertainty of gait, the helpless use of the 
 hands, but also many indications of spasmodic and paralytic muscular 
 affections, imperfect development or atrophy of certain groups of mus~ 
 cles, or of a complete half of the body. 
 
 It is interesting to observe the automatic movements, and the entire 
 outward demeanor, particularly in the severe cases. In these feeble 
 and, often, so peculiar manifestations of a perfectly stunted intelligence, 
 there exists something which provokes us to problematic conjecture; but 
 who can determine what shall be the answer? In many of these children, 
 continuous rocking, swinging movements are observed, accompanied by 
 monotonous singing, murmuring tones which form a sort of cadence; 
 others continually shake their head, constantly suck their fingers, fre- 
 quently clap their hands, beat violently against the wall, puff and blow 
 with their mouths, etc. A very peculiar circumstance which is some- 
 times observed, is the rapid carrying of the hand to one of the eyelids, 
 whereby the eye becomes rubbed, compressed, or even disjilaced (will they 
 see double?). The expression of countenance and whole bearing of these 
 degraded idiot children manifest complete nullity of the intelligence, 
 with unprovoked alternations of superficial emotions (laughing and weep- 
 ing), movements like the undulations caused by a gentle breeze upon, 
 the calm sea. 
 
 In many of the most severe cases of idiocy, the sexual functions 
 are entirely absent; the genital organs are frequently small and stunted; 
 the menses are long in appearing, not until after the twentieth year, or 
 perhaps they do not appear at all: nevertheless, cases of extreme idiocy 
 sometimes occur, in which the menses appear at the proper time and 
 continue regular. Pernicious sexual habits are, even in severe cases of 
 idiocy, quite as frequent as they are destructive to what remains of the 
 mental functions. In tlie moderate cases of idiocv, the sexual func- 
 tions also present great differences; but, as a rule, they are more 
 generally diminished than increased. Conception, it is true, sometimes 
 occurs amongst semicretins; but all that has been said regarding the 
 exaggerated sexual instincts of idiots is false, and only based upon the 
 shameless demeanor of certain individuals belonging to the class of semi- 
 cretins. 
 
 A thick, fleshy tongue, which sometimes causes the incisor teeth to 
 protrude — copious salivary secretion — unequal, irregular, and carious 
 teeth, are frequently found in idiots of every degree. 
 
 § 166. Hitherto, in describing the symptomatology of idiocy merely, 
 the most general traits drawn from a great number of cases of all degrees 
 have been depicted; we shall now mention a few more points, to direct 
 
STATES OF MENTAL WEAJKJS'ESS. 265 
 
 ns in the midst of the ver}- various symptoms presented in individual 
 cases. 
 
 In all idiotic states, two fundamental forms may be easily distin- 
 guished, which in their extreme degrees differ widely from each other, 
 but, of course, in many moderate cases are not so distinctly pronounced, 
 viz., the apathetic (dull, torpid), and the excited (versatile, agitated). The 
 profound idiots of the first category have frequently an awkward, clumsy, 
 and disproportioned body, and repulsive, old-looking features;' the dul- 
 ness of their movements, their passiveness — their stupid, monotonous, 
 unexcitahle demeanor — cause them in many cases to appear as if they 
 were in a state resembling sleep; many have a brooding, melancholy look, 
 while others have only the expression of utter indifference, w^ant of 
 thought and of mind. Those of the second category are really much 
 deformed, but generally remain far behind their years; sometimes they 
 are proportionate and even well formed, and of fine but delicate appear- 
 ance. They are restless in their movements, quick, irritable, rapidly 
 change their impressions; but they are extremely absent, and in the higher 
 gi'ades utterly incapable of fixing anything on their mind. It is often 
 astonishing, when we see the happy expression and apparent activity of 
 these children, to find that they are utterly incapable of speech and void 
 of understanding. In many cases the behavior is often so excitable and 
 turbulent, moving tlie body, jumping abottt, gesticulating, laughing, 
 weeping, crying, all day long, that it actually appears to pass into mania 
 (see p. 103). In this, the excited form, extremes are much more rare 
 than in the apathetic form, and the slighter cases are more capable of 
 improvement than the corresponding degrees of torpidity. 
 
 Besides these two principal groups, we find ourselves constrained, on glancing 
 over numerous cases of idiocy, still further to distinguish certain well-marked 
 varieties upon the basis of the external characteristics, and with regard to the 
 mental peculiarities. 
 
 1st. Children perfectly well-proportioned and well-developed for their age, 
 apparently in good health — if no disease exist in other organs — with a pleasant 
 expression of countenance, and, as a rule, microcephalic. The mental develop- 
 ment may remain at the lowest grade, or have advanced to various degrees ; they 
 are generally moderately versatile, but sometimes apathetic, with lifeless, rather 
 automatic movements, sometimes with weakness of the lower extremities. 
 These cases are not only always sporadic and extremely rare, but they seem to be the 
 result o£ altogether accidental cerebral affections, occurring in previously healthy 
 and well-developed children without any hereditary disposition, without any 
 degenerative element, without miasmatic influences, etc. In these cases, the 
 physical development proceeds properly, in spite of the cerebral affection. 
 
 '2d. Children in whom the physical and mental development is simply much 
 retarded. The interesting extreme cases of this kind present a complete arrest 
 of development at an early period of life; for example, at the age of from four 
 to six, with aU the peculiarities of that age, without considerable deformity or 
 degeneration. These cases are diametrically opposite to the other remarkable 
 extreme of an extraordinarily rapid bodily development (where, in certain cases, 
 children of four to five years, and even earlier, have already attained to a con- 
 siderable degree of physical development, and presented the symptoms of 
 puberty). It appears admissible, at least in certain cases of this kind, to compare 
 them with those arrests of development which, in atrophj- of one of the cerebral 
 hemispheres, involves the opposite half of the body, but here, where both hemi- 
 spheres are affected, involves both sides: but these cases would require to be 
 studied anew, of which they are well worthy. 
 
 Dancel (1837 and 1843, ' Acad, des Sciences ') has communicated the case of a 
 young woman, aet. 24, whose development proceeded normally up to the age of 
 three and a half years, when it was suddenly arrested. At the age of eighteen 
 and a half, she was 94 centimetres in height; her mental state was that of a child 
 of three and a half years. At twenty-one, she grew a little and attained the height 
 of 96 centimetres; from that time forth, her condition remained stationary. 
 
266 STATES OF MKJMTAL WKAKNE88. 
 
 Baillarger presented before the Academy of Medicine (26th May, 1857) a young 
 woman, set. 27, who had the intelligence and inclinations of a child of four 
 years: she is about three feet high, the body very fat; the second dentition com- 
 menced when she was eighteen, and at twenty-seven was not completed. 
 Menstruation had not yet set in. 
 
 I know of another remarkable case of this kind, in which, in consequence of 
 a blow on the head during childhood, the development which had till then been 
 normal was completely arrested. 
 
 If, however, the extreme cases of this kind are very rare, the moderate cases 
 are, on the contrary, extremely common. They constitute the numerous class 
 of children stopped in their growth (enfants arrieres), whose peculiarity consists 
 in the circumstance that without special deformity, with no symptoms of cere- 
 bral disease, the whole mental and bodily development proceeds very slowly. 
 Those individuals are all small; their sexual system— with certain exceptions— is 
 late in developing, and sometimes is never developed at all; at the age of twenty 
 they resemble children of ten or twelve years; they may be well-proportioned, 
 but more frequently they present all sorts of defects — distorted countenances, 
 clumsy features, the root of the nose impressed, strabismus, dulness of heaiiug. 
 Mentally they are distinguished from true idiots by the greater capability of 
 development, which only proceeds much more slowly than in other children; 
 they learn to walk, to speak, to write, but at a much later period than in health; 
 they are incapable of occupying themselves with several subjects at the same 
 time, and consequently of making comparisons; they are accessible, and capable 
 of improvement through the memory and imitative faculties, but only make 
 progress when they are assiduously and specially treated, schooled, and in- 
 structed. It is those cases which are proudly exhibited as examples of "re- 
 coveries" in idiot asylums. Should they, at the same time, happen to be epileptic, 
 if they are addicted to onanism, all mental impulse is wanting; they become 
 gradually more degraded, and at last completely idiotic. 
 
 In this very numerous class we again find many, physically and mentally, 
 peculiar types; as, for example, children who remain so small that they are 
 actually dwarfish, with round forms, slow, easy movements, an expression of 
 great benevolence and good-humor; these little fellows have sometimes some- 
 thing extremely droll and humorous in their manners and actions: they, how- 
 ever, though extremely good-natured, have many childish peculiarities, and are 
 only capable of education if carefully treated, have affection for their instructors, 
 and give them no trouble. An extremely dangerous class is formed by those 
 weak-minded children with instinctive (congenital) evil desires to mischief, 
 cruelty, theft, drunkenness, etc., which sometimes nothing can suppress. These 
 individuals, when their intelligence is such as to permit them to remain out of an 
 asylum, afterwards furnish a numerous contingent to our prisons and houses of 
 correction; their state is frequently evidently hereditary, and their habits are by 
 no means identical with the evil desires which are developed in children through 
 the example of their seniors. 
 
 3d. The sinosto-basilar form; cretinism in the proper sense of the term. The 
 extreme degrees of this form are to be found only in the localities where cretinism 
 is endemic, and particularly in the mountainous districts, and even in these 
 countries it appears to be less common than it used to be; even the moderate 
 degrees present the deformity and ugliness characteristic of cretmism. Generally, 
 the head is disproportionately large; the features old-looking; the body small, 
 thick-set, and often cliild-like; the lips thick, the eyelids puffy, the nose large and 
 deeply impressed at its base; the body is often swollen and puffy- looking, owing 
 to hypertrophy of the skin and subcutaneous cellular tissue; usually also goitre is 
 present: in the higher degrees they scarcely resemble human creatures. Their 
 mental life has altogether the character of apathy and torpor; they are deaf and 
 dumb, and sometimes inclined to outbreaks of savage anger. In opposition to 
 the theory that these states are actual monstrosities (Rosch, Virchow), we can 
 always show that the malady frequently does not commence till after birth, and 
 that in its moderate degrees it is capable of some degree of improvement 
 (see § 169). , , 
 
 4th. A form in every respect quite the opposite of the foregoing is that which 
 has been termed the Aztec type.^ These Aztecs are microcephals, whose bodies 
 remain small but well-proportioned, slender, sometimes even elegant in form; 
 
 • Very good examples of this form were some years ago exhibited as the 
 reputed remnant of the extinct American Aztec people: therefore the name. 
 
STATES OF MENTAL WEAKNESS. 267 
 
 the base of the nose is generally high, so that the forehead passes straight into it. 
 These little beings are extremely lively, their movements sprightly and well co- 
 ordinated; they are happy, easily excited, inquisitive, but very capricious, little 
 capable of attention, and of weak intellect, although many of them can speaJc 
 correctly. The very interesting investigation of Gratiolet (three cases, 1. c.) 
 showed a very small cranium, the bones thick, and synostosis of the arch: the 
 basis cranii, on the contrary, was very slightly ossified; the basilar portion 
 almost quite cartilaginous; the petrous portion and ethmoid bone were rather 
 larger than normal; the space for the cerebellum was enormous in all directions. 
 The bram of these microcephals may present fewer convolutions than that of the 
 ourang-outang or chimpanzee; the cerebellum is very large, as is also the spinal 
 cord and medulla oblongata. The organs of sense and their nerves are well- 
 developed; the state of the convolutions shows that the condition existed before 
 birth. The exuberant development of the more spinal portions of the brain, in 
 contradistinction to the hemispheres corresponding to the compensatory dilatation 
 of the basis cranii (see § 161), corresponds to the peculiar anomaly of the functions 
 which constitutes a direct opposition to that presented by the form with diminu- 
 tion of the basis cranii. Here also extreme examples are rare, but in most idiot 
 institutions examples may be found which represent the moderate degrees of this 
 type: I, myself, prefer to call it the "bird-hke form;" and the small, low or 
 short head, aquiline nose, and lively movable eyes, strongly remind us of the 
 physiognomy of birds. 
 
 5th. Certain idiots, in their physiognomy, habits, and demeanor, resemble in 
 a still more specific manner certain species of animals. Some strongly reseml)le 
 apes (well-marked microcephalus), others forcibly remind us of swine. The fol- 
 lowing case observed by Pinel affords another rare example belonging to this 
 category: — An idiotic girl, eleven years of age, resembled, by the form of her 
 head, by her desires and capacities, a sheep. She manifested aversion towards 
 animal food, ate only vegetables and drank nothing but water; her whole speech 
 consisted in he, ma taiite, whereby she showed her attachment to her nurse: 
 she also, like a sheep, laid her head on the abdomen of her nurse; when fightino- 
 with other children, she butted them as a sheep does; when wishing to fall 
 asleep, she curled herself on the floor. Her back, shoulders, and loins were clothed 
 with a kind of soft black hair, one to two inches long, which much resembled 
 wool. 
 
 Further observations in asylums will afford material for the discovery of other 
 types, the arrangement of forms, and, finally, for referring them to characteristic 
 fundamental disorders. The- opposite types — synosto-basUar and Aztec — are 
 specially worthy of further anatomical investigation. 
 
 § 167. As to the course of the yarious cerebral affections which lie at 
 the foundation of the different forms of idiocy, it is self-evident that very- 
 little can be said upon the subject generally. The process which has 
 caused the arrest of development may have already in great part disap- 
 peared at birth; in which case all mental processes are from the com- 
 mencement very feeble, speech is not developed, etc., and they all remain 
 stationary. Or the cerebral disease (which perhaps may be hereditary) 
 does not commence until mental development is actually begun, and it 
 may be either an acute or a chronic insidious affection. The mental 
 development ceases to progress, and even generally recedes; speech is 
 often forgotten, and the expression of stupidity and mental poverty be- 
 comes dominant It is especially in hydrocephalic cliildren that acute 
 attacks of cerebral excitation of greater or less severity, with symptoms 
 of cerebral congestion, are frequently repeated: after each of these the 
 obtusion and apathj^ become more profound and persistent. Epileptic 
 convulsions exercise in every case a prejudical influence upon the psychi- 
 cal symptoms. The cerebral disease in idiots is generally of a nature 
 such as by itself causes death very slowly (for example, high degrees of 
 hydrocephalus, perhaps also of atrophy of the brain), or gives rise to 
 intercurrent fatal processes in the cranial cavity (death by meningitis, 
 acute effusions, etc.). But even should this not be the case, still many 
 
268 STATES OF MENTAL WEAKNESS. 
 
 idiots die during cliildiiood: this may be because many injurious influ- 
 ences act more strongly upon them than upon healthy children, or because 
 their power of resisting disease is less. It is, therefore, rare to see idiots 
 attain a great age; they are most frequently seen in countries where cre- 
 tinism is endemic, where examples may be met with of cretins of sixty 
 or seventy years of age. The reader need scarcely be reminded how much 
 depends, in all such questions, upon the external relations, care, etc. 
 
 § 168. Improvement takes place in many cases of idiocy. It is rarely 
 that, under the influence of a favorable change in the entire physical 
 health, the child becomes lively and studious within a short time, and 
 continues to make rapid progress. More frequently, improvement con- 
 sists merely of a more free and more- regular employment of the existing 
 fragments or remnants of intelligence, be they greater or less; and this 
 result can only be attained very gradually, in the course of many years. 
 The first condition necessary to all improvement is the complete cessation 
 of the cerebral disease which occasioned the idiocy. 
 
 By cure of idiocy, must be understood the complete removal of the 
 cerebral disease which hinders the mental development; a process where- 
 by cultivation of the intellect by education and instruction would be 
 rendered possible. Kecovery in this sense can only be considered possible 
 in certain cases, viz., when the cerebral affection is simply functional 
 (§ 156), or when, at the commencement of a palpable cerebral disease in 
 childhood, the morbid process can still be arrested: in certain chronic 
 processes (for example, due to the influence of syphilis or other chronic 
 constitutional anomaly), this period is sometimes of long duration. 
 
 As a rule, however, the morbid processes have entirely or almost en- 
 tirely run their course before the idiocy is recognized. Then we have to 
 deal with residues and consecutive states; and these offer the greatest re- 
 sistance to spontaneous or artificial recovery, inasmuch as, owing to them, 
 the development of the brain, its normal growth within a given period, is 
 interrupted or impaired. In all these, constituting the immense major- 
 ity of cases, the utmost that can be attained is successful improvement 
 of what remains of the psychical faculties, intellectual, sensitive, and 
 motory; the highest aim of this improvement is a certain capability of 
 self-direction in life, the possession of a few correct moral ideas, and a 
 certain degree of practical usefulness, without, on that account, all traces 
 of the idiotic condition being effaced. Here, therefore, we can only speak 
 of improvement: this, however, may be of extreme advantage to the indi- 
 viduals themselves, as well as to their relatives, and the existence of idiot 
 asylums must be considered an actual necessity. 
 
 From what has been said, it is evident that the treatment of idiocy 
 must consist, on the one hand, of therapeutical (hygienic and medicinal) 
 treatment, and, on the other, of education, not only of the mind, but 
 also, and principally, of the organs of sense and of movement, awakening 
 and developing the faculty of speech, practice in the correct performance 
 the functions of ordinary life. 
 
 By far the best rules on this subject are to be found in Seguin's ' Traitement 
 des Idiots,' Paris, 1846. We may also refer to Kern, ' Zeitschrift f. Psychiatric,' 
 xii., 1855, p. 531; Damerow, ibid., xv., 1858, p. 499; Guggenbiihl (together with 
 many other works), ' Zeitschrift der k. k. Ges. des Aerzte in Wien,' 1860, No. 6. 
 
 B. Endemic Cretinism. 
 
 The following works, besides those mentioned in § 161, are the most important 
 on the subject of Cretinism in the strict sense of the term :— Fodere, ' Essai sur le 
 
STATES OF MENTAL WEAKNESS. 269 
 
 Goitre et le Cretinisme," Turin, 1792; Ipliofen, ' Der Cretinismus,' Dresden, 1817; 
 Mafifei und Rosch, ' Unters. iiber Cretinismus,' 2 Bde., Erlangen, 1844; Meyer- 
 Ahreus, 'Hiisers Archiv,' 1845, p. 360; Prager ' Vierteljahrschrift,' Bd. xlii., 
 1854, p. 99; Behrend, 'Journal fiir Kinderkrankheiten,' 1846, Juli; 'Rapport de 
 la Commission creee par S. M. le Roi de Sardaigne,' etc., Turin, 1848 (indis- 
 pensable for the study of cretinism); Ferrus, ' Acad, de Medecine,' 10th and 31st 
 December, 1851, and Discussion; Rosch, ' Beobacht, tiber den Cretinismus,' 
 Tiibingen, 1850-1852; Niepce, 'Tr. du Goitre et du Cretinisme, 2 Bde., Paris, 
 1851, 1852; Billet, 'Ann. Med. Psychol.,' 1854, pp. 339, 362, 530; 1855, p, 41; Morel, 
 ibid., p. 334; "West, 'Journal f. Kinderkrankheiten,' 1854, xii., 7, 8; Kostl, 'Der 
 endemische Cretinismus,' etc., Wien, 1855; Fabre, 'Traite du Goitre et du 
 Cretinisme,' Par., 1857; Morel, ' Traitedes Degenerescences,' etc., Par., 1857, and 
 his two later works (' Clinique,' 1853, and ' Traite, 1860); Erlenmeyer,' Archiv der 
 D. Gesellschaft f. Psychiatric,' i., 1858, pp. 13, 97; Theile, ' Ueber Cretinismus;' 
 Schmidt's ' Jalirb.,' 1860, No. 7; Zillner, " Ueber Idiotie," in ' Nova Acta Caesar. 
 Ac. Leop.-Ca.,' xix., 1860. 
 
 § 169. The distinction between sporadic and endemic idiocy depends, 
 in the first place, upon a simply quantitative relation, the greater or les- 
 ser frequency of the affection in a given population. But in this distinc- 
 tion there are contained still other legitimate differences in quality. The 
 causes which render idiocy so frequent in a particular locality are gene- 
 rally (not unexceptioually) peculiar; indeed, sometimes specific (mias- 
 • matic), and excite peculiar diseases Avhich lead to idiocy. Sporadic 
 idiocy may be owing to any kind of infantile cerebral disorder; endemic 
 idiocy, likewise, does not always depend upon the same anatomical 
 changes, but rather upon a certain class of changes which in particular 
 primarily affect the skull more than the brain. These latter affections 
 are much more associated with general physical deformity — a deformity 
 which is altogether special to cretins, and associated with the disease of 
 the thyroid gland. There are also certain qualitative differences between 
 endemic and sporadic idiocy which cannot be disputed, inasmuch as the 
 well-marked forms of the cretin districts which are very common, or were 
 so till very recently in those localities, are never met with sporadically 
 in the same form. 
 
 I can readily understand how observers, in those countries where cretinism is 
 endemic, could be led to deny the existence of any distinction between endemic 
 and sporadic idiocy. They dwell in the midst of a population who bear gener- 
 ally a trace (more or less evident) of cretinism, and they are not in a position to 
 observe cases of accidental cerebral disease which may occasion idiocy without 
 any physical deformity, where, as we have already several times remarked, well- 
 developed and beautiful children present the complete intellectual nullity of 
 profound idiocy. As it is very rarely that the well-marked deformity peculiar to 
 profound cretinism occurs sporadically, it is also seldom that we see such sporadic 
 cases occur in the form of endemic idiocy: such cases may, perhaps, occasionally 
 occur in the cretin districts (for example, cases of accidental encephalitis or of cere- 
 bral defect), but certainly tliese are, in the first place, to be distinguished from 
 the principal prevailing diseases which lie at the foundation of the endeniic 
 cretimsm. And it may, moreover, be asked — special observations do not appear 
 ever to have been made on this point — whether these accidental diseases, in a 
 generally infected population, do not assume the form of the ijrevailing degener- 
 ation. In England, idiocy is not rare — in many parts it may even be said to be 
 frequent — but those unsightly deformities (Alpine form) are never seen; there is, 
 therefore, a great difference between frequent idiocy and "cretinism." Virchow 
 also says, endemic idiocy is not cretinism; he, however, considers thedifference 
 to be altogether etiological ; that which originates from conditions of the soil, of 
 the locality, is cretinism; that which results from social conditions is idiocy. 
 Unfortunately, he does not tell us how w^e may certainly distinguish all which 
 originates froni territorial and all which arises from social conditions. Besides, 
 what may not be comprehended under the term ' ' social conditions ? " 
 
 § 170. Regarding the 2Jropagatio?i of idiocy as an endemic disease we 
 
270 STATES OF MENTAL WEAKNESS. 
 
 have here a very little to say. ' In the first place, we have the important 
 fact that endemic cretinism is always accompanied by endemic goitre, and 
 in such a manner that we are, in some degree, authorized to recognize 
 in both tlie eifects of one and the same morbid cause, which only acts 
 more strongly in a certain series of cases, and in some its effects are 
 more widely diffused (affection of the cranial and of tlie bones gene- 
 rally) than in others (simple affection of thyroid gland). Thus it is that 
 the great majority of cretins have a large goitre, which is sometimes con- 
 genital and sometimes developed after birth, and which in general as- 
 sumes a rapid growth about the period of puberty. It is rare, indeed, to 
 find no trace of goitre; even the semi-cretins and a large proportion of 
 the healthy population of these districts are affected by it. The great 
 centres of these two diseases are in all parts of the world the great moun- 
 tain chains and their connections — in Europe the Alps, in Asia the Hima- 
 layas, in America the Cordilleras. The sea-coast is altogether exempt 
 from these maladies; in flat inland countries or in mountainous districts 
 • of the second or third class, they are very unequally distributed, and we 
 cannot, ^s yet, state with certainty the common cause of these differences. 
 
 In Europe the countries in which cretinism is most frequent are. 
 Savoy; many parts of Switzerland, particularly tlie cantons of Valais, 
 Grison, Uri, Vaud, Argow, etc. ; more towards the east, Salzburg, Styria,* 
 Tyrol, Carinthia, Upper Austria: next in order come several regions in 
 the Pyrenees, the mountains of Auvergne, certain parts of the valley of 
 the Rhine, in the neighborhood of Strasburg (above all, in plains wliich 
 are often inundated); the Island of Mederworth (which is frequently in- 
 undated), then lower and middle Franconia, many parts of Wiirtemberg 
 and the grand Duchy of Baden. These are the localities which, at the 
 present time, are known as the chief centres of endemic idiocy, accom- 
 panied by goitre and physical deformity. 
 
 Naturally, attempts have not been wanting to refer the origin of the 
 disease to certain definite relations in the cretin districts. Each observer 
 attached most importance to the circumstances which seemed most strik- 
 ing in his district, and in this respect everything wliich could possibly be 
 brought forward has been discussed : sometimes a certain height above 
 the level of the sea (not more than from 3-3000 feet), deep damp valleys, 
 stagnation of the air, frequent inundations with marshiness of the ground; 
 sometimes high temperature, great and sudden changes of temperature; 
 sometimes deficiency of light and of the sun's rays; sometimes the form- 
 ation of the soil, in so far as the land has a certain configuration, or in 
 so far as certain rocks have a particular chemical composition; sometimes 
 the composition of the water; sometimes want of iodine in the water and 
 in the air; sometimes unfavorable conditions of life — misery, neglect, dirt, 
 want of attention to children, bad nourishment, etc. All these various cir- 
 cumstances have been successively declared to be the sole, or at all events 
 the most important, factors in the production of these diseases. But, on 
 the other hand, it is easy to prove that goitre and cretinism also occur in 
 places where not one of these special influences (for example, deep moist 
 valleys, stagnation of the air, certain rocks, etc. ) exist, and that in many 
 places every one of these influences may be met with, without either goitre 
 or cretinism being prevalent. 
 
 ' In the work of A. Hirsch, ' Handb. der histor. geogr. Pathologie ' (1, 2, 
 Erlangen, 1860, p. 494), an excellent epitome of all that is as yet known on the 
 subject may be found. 
 
STATES OF MENTAL WEAKNESS. 271 
 
 We ought not, however, to push, this objection too far. We can- 
 not deny tlie certain influence of marsh-miasm on the production of in- 
 termittent fever, because this disease sometimes occurs in localities where 
 there ure no marshes, and other localities which are very marshy are free 
 from fever. This only proves that the more immediate and true causes of 
 intermittent fever are generated principally, but not exclusively, in 
 marshy localities, and even in marshy localities of a certain nature. In 
 like manner, all those external relations which have been enumerated are 
 tlie more remote causes of the production of definite immediate causes of 
 cretinism, the latter are produced by combinations of circumstances m 
 which many of the forementioned external conditions may exert their 
 influence without necessarily being always in like manner effectual. 
 Certain of these circumstances also may manifest themselves more con- 
 stantly, and therefore lay claim to greater importance; while others are 
 evidently subordinate and accessory. To the latter, for example, belong 
 those which we have termed unfavorable social conditions.' Misery, 
 dirt, neglect, mismanagement of children, ignorance and superstition, 
 may be found in their greatest degree in many places where there is no 
 trace of cretinism; and in the cretin districts the disease is not rare, even 
 in well-to-do and wealthy families. Likewise, there are a number of 
 mountainous districts with deep valleys where there is no trace of goitre 
 or cretinism, and cretinism often occurs in level districts and in very open 
 valleys. 
 
 In my opinion, humidity of the soil and of the air, owing to water 
 found underground, inundations, many streams, constant mists, are 
 amongst the most important circumstances. I believe also (and the 
 work of Hirsch points to the same conclusion) that the amount of 
 magnesia in the soil (which is not to be confounded with the amount of 
 magnesia in the drinking-water) exerts a certain influence. All the 
 other external conditions which "have been enumerated are each only to 
 be found in certain individual cretin districts, and not in the majority of 
 them. 
 
 Concerning the more immediate and true causes of cretinism, how- 
 ever, to which the circumstances wliich have been mentioned stand only 
 as external causes, we can give no definite information. They are called, 
 in the present state of science, miasm or morbid poison, and compared to 
 the malaria of intermittent fever. These miasms, which, as in the latter 
 disease, may be contained in the air or in the drinking-water, act feebly 
 upon the mass of the population, and strongly upon a few, who then ex- 
 perience the full effects of the poison. The malady is now considered as 
 an infectious disease, as it is a constitutional affection. The limitation of 
 goitre and cretinism to a tract of country, often very small, is favorable 
 to this mode of view, just as it is to the theory of the production of inter- 
 mittent fever. Amongst the many differences which the latter disease 
 presents from cretinism, the fact is especially prominent that cretinism 
 once produced " by miasm" is decidedly capable of being transmitted to 
 the children, probably of more than one generation. 
 
 In many localities where goitre and cretinism were formerly very pre- 
 valent, they have in recent times much diminished (like intermittent 
 
 'In the work of Georgens and Deinhardt, ' Die Heilpadagogik, etc.,' Leipzig, 
 1861, p. 201, we find, " Endemic idiocy is prevalent only in places which are be- 
 hind in civilization." This is not correct. The two villages in the neighborhood 
 of Tiibingen where cretinism is endemic, are no more behind in civilization tlian 
 100 other villages which are free from it. 
 
272 STATES OF MENTAL WEAKNESS. 
 
 fever) under the influence of better regulation of the courses of rivers, 
 the draining of marshy ground, and generally imjjroved hygienic arrange- 
 ments: in many places, indeed, they have completely disappeared. (Such 
 diminution has been remarked, for example, by Tourdes in the neighbor- 
 hood of Strasburg; and, according to Zillner, the number of cretins in 
 Salzburg has diminished to about one-fourth between the year 1780 and 
 the present time: tlie same may be said of many other places.)' A pro- 
 found regeneration of race through immigration and marriages contracted 
 with the strangers — above all, through the greater commercial activity of 
 modern times, perhaps also the greater awakening of the intelligence and 
 activity of the inhabitants through the same cause — may likewise tend 
 to this result. In few places do goitre and cretinism seem to have in- 
 creased in modern times. 
 
 According to the view here adopted, and in recent times pretty generally ac- 
 cepted, endemic goitre and cretinism ai-e, to a certain extent, specific diseases 
 generated by a specific toxic cause of a miasmatic nature. I cannot oppose this 
 view, wliich has much in its favor, and can show that many recent attempts to 
 explain the production of these endemic diseases by amiiltitude of heterogeneous 
 causes have been unsuccessful. Still, we must not place too much confidence 
 upon this mode of viewing the matter, remembering that goitre also often occurs 
 sporadically; that the causes of its production are almost unknown; that endemic 
 goitre presents no distinctive peculiarities from the sporadic for jii: that conse- 
 quently, therefore, we may suppose that unknown causes also operate in endemic 
 goitre; and that the connection between the development of goitre and cranial 
 synostoses, and diseases of the bones generally, which perhaps constitute the 
 chief causes of cretinism, is altogether obscure and problematical — that it is even 
 without pathological analogy to admit that closure of the sutures and ossifications 
 might be caused by miasmatic poison. 
 
 The great influence of humidity in the causation of cretinism is demonstrated 
 by a number of facts both genei-al and special, and, just as in intermittent fever, 
 even local dampness, confined to a house or to a block of houses, may generate 
 the peculiar morbid influence. Like intermittent fever, cretinism has been seen 
 to diminish rapidly in consequence of the better regulation of the courses of 
 rivers. But even in regard to these facts, examples of totally different experi- 
 ences are not wanting. There are, analogous to the mountain fevers, certain dry 
 and arid localities where goitre and cretinism are endemic (Fabre, ' Traite,' 1. c, 
 p. 56); and we have many examples of very humid countries (Holland for exam- 
 ple) where there is no endemic disease. 
 
 In many localities intermittent fever is itself frequently observed side by side 
 with cretinism. Analogous causes (paludal) appear, on the one hand, to generate 
 cretinism, on the other, intermittent fever, splenic enlargement, and cachexia. 
 It is especially remarkable that in those places the thyroideal enlargement some- 
 times occurs acutely, and to a certain degree epidemically, analogous to the acute 
 intermittent processes, as if a (not quite identical with that of intermittent 
 fever) miasmatic poison occasionally acted rapidly and with great intensity upon 
 the population. Thus, according to Zillner.^ there occasionally occur in Salzbm-g 
 acute enlargement of the thyroid gland, acute enlargement of the parotids, of 
 the spleen, and in some instances, of almost the entire lymphatic system, or 
 together with intermittent fever, furuncles, glandular suppurations, etc. — circum- 
 stances which demonstrate the existence of an intimate connection between the 
 production of goitre and the malaria, and besides, in an etiological point of view, 
 between endemic goitre and cretinism. To alleged cases, in which, after dimi- 
 nution of the goitre in an idiot, by operation or by other treatment, the mental 
 state improved, ** I can accord no great importance. 
 
 The very numerous investigations regarding the geological composition of the 
 soil, in the goitre and cretin districts, permit us to assume at all events several 
 
 • Fodere remarked, moreover, in 1793, that the amount of goitre and cretinism 
 had considerably diminished within a certain number of years. 
 
 ^ L. c , p. 229. Examples of epidemic goitre may also be found in Hirsch, 1. c, 
 p. 452. 
 
 3 Arthaud, ' Gazette Med.,' 1855, p. 428; Fabre, 1. c, p. 240. 
 
STATES OF MENTAL WEAKNESS. 273 
 
 extremely interesting facts. Both diseases, especially cretinism, occur very 
 rarely upon pure limestone (Jurassic' limestone also on chalk formations) ; they 
 are very rare also upon granite and gneiss (in Savoy, in certain regions of the 
 Vosges, more Irequently in the northern Alps i; they are, on the contrary, very 
 frequent upon dolomite, clay slate, etc., also (at all events, in Wiirtemberg) upon 
 yellow sandstone. In this country, the localities most infected are those in which 
 the soil is composed of freestone, in the neighborhood of which lie beds of marl 
 intersected by strata of gypsum, from which the population obtain their drinking 
 water. (Sich., ' Wiirtemb. Jahrbiicher,' 1855, 2.) 
 
 The assertion of Grange (1855), that a great amount of magnesia in the drink- 
 ing water is the essential cause of goitre and cretinism, has been completely re- 
 futed. Niepce found in those districts of France in which cretinism is most 
 endemic, that there was not one atom of magnesia in the water: in another 
 locality, where, according to Grange, the goitre almost disappeared when the 
 patients were provided with another kind of water, Niepce found a great deal of 
 magnesia in this new water. In the neighborhood of .Strasburg, magnesia was 
 found in the water of certain districts where goitre and cretinism are not more 
 frequent than in others where the water is free from magnesia (Tourdes). The 
 theory which attributes cretinism to the presence of calcareous salts in the water 
 requires no further refutation. 
 
 Tlie statements of Chatin regarding the presence of iodine in the air, water, 
 and lood, and upon the absence of iodine in the goitre and cretin districts, created 
 a great sensation, although from the first they appeared improbable. They have 
 been questioned and refuted on all sides, and the whole affair appears at best to be 
 explicable by the employment of impm-e reagents. See Fabre, 'Traite,' p. 83; 
 De Luca, 'Comptes rendus,' vol. xlix., p. 170; vol. Ivii., 1858; Cloez, ' L'Institut,' 
 1857, Juin. 
 
 § 171. That the local causes, whatever they may be, are alone suffi- 
 cient to produce fully developed cretinism, is demonstrated by the fre- 
 quently occurring circumstance, that families entirely free from any 
 special predisposition, that parents who hitherto had always healthy 
 cliildren, had children complete cretins soon after taking up their resi- 
 dence in the locality." If the statement of Niepce be correct,' that the 
 foundlings of Grenoble and Marseilles — districts where cretinism is un- 
 known — become goitrous and cretins when given out to nurse in the in- 
 fected villages of Isere and Hautes-Alps, it would prove that the endemic 
 cause may exercise its influence for a certain time after birth; indeed, a 
 healthy child runs the risk of becoming a cretin up to the fourth (Maiiei), 
 and even to the seventh year. It is self-evident that these local causes 
 can only be rendered harmless by removal from the infected locality. 
 
 But there is another important cause of cretinism; cretinism is liere- 
 ditary. The child of a male or female cretin, begotten and reared be- 
 yond the reach of the endemic cause, may be a cretin; and it requires 
 not only removal from the infected district, but also repeated renewal of 
 the blood by marriages into healthy families, to cause cretinism finally to 
 disappear in the second or third generation (Billet) — and even then 
 traces of it may still exist. Amongst the constant population of these 
 districts, the action of the endemic and of the hereditary influences can- 
 not be individually and separately distinguished: when a cliild comes into 
 the world a complete cretin, we do not know whether a powerful mias- 
 matic influence acted upon the fcetus, or whether it is to hereditary influ- 
 
 ' These facts are observed in very different countries. They are especially 
 evident in Wiirtemberg, where, otherwise, cretinism is so general: it is the same 
 in Savoy (' Sardinische Commission,' Billet, Garbiglietti). 
 
 '^ See especially the communication to the Academy of Sciences January 16th, 
 1854, in which he described the journey during which he made those investiga- 
 tions which enabled him ' ' to draw a great line upon the map of Europe which, 
 demonstrated the reciprocity of the dissemination of iodine and of goitre." 
 
 * Niepce, 1. c, p. 493. The statement has been contradicted. 
 
 18 
 
274: STATES OF MENTAL WEAKNESS. 
 
 ences that the cretinism is due. It is the same with the many children 
 in the cretin districts wlio are born apparently healthy, but m from three 
 to six months j^resent evident symptoms of the affection: we cannot tell 
 whether it is to hereditary influences, or to the endemic cause which 
 now acts upon them for the first time, or to both circumstances together, 
 that this is due. I incline to the opinion of the Sardinian Commission 
 (loc. cit., p. 194), who consider hereditary influence to be the most 
 powerful cause. 
 
 Cretins of the highest degrees never have children, because the males are 
 almost always impotent, and the women sterile. The children of a marriage be- 
 tween a man who is in a moderate degree a cretin, and a woman who is perfectly 
 healthy, are frequently beautiful and healthy; frequently they are profound 
 cretins, semi-cretins, epileptics, deaf and dumb. In general, cretinism is trans- 
 mitted more by the father than by the mother (Guggenbiihl, Erlenmeyer). The 
 crossing of races causes the predisposition to disa^jpear only when the individuals 
 are at the same time removed from the infected district. According to Billet (1. 
 c, 1855, p. 45), it has long been the custom in several communes of Maurienne 
 where cretinism is prevalent, for the young men to choose their wives from 
 districts free from goitre and cretinism; but these ■women all become goitrous, 
 they have often cretin children, and cretinism is on the whole not diniinislied 
 thereby. Here the favorable influence of crossing of races is neutralized by a 
 very powerful endemic cause. In a locality where the endemic cause was not so 
 sti'ong, such gradual renewal of the blood would, without doubt, have been 
 followed by favorable results. 
 
 It may be admitted that the many injurious influences which, in localities 
 where cretinisnr is endemic, result from mismanagement of children, and the 
 w^hole mode of life of a profoundly degenerate, indolent cretin population, have a 
 -very prejudicial effect upon the young: these influences, however, have only 
 the significance of accessory causes, which act only where the malady is endemic. 
 Still, it is important that they should be removed; and it is certain that through 
 proper nurture and rational early education of the children, the diseases which 
 lead to idiocy may, at all events, be restrained. 
 
 An arrestment of the disease in endemic cretinism may sometimes be arrived 
 at through change of locality in early childhood, and being placed under favor- 
 able conditions. From experiments which have been made in the mountains on 
 this point, together with the opinion that cretinism is never met with at a greater 
 altitude than 2000 feet above the level of the sea, the peculiar idea has arisen that 
 cretinism may be cured upon high mountains; and the opinion has even been ex- 
 ended to idiocy in general. In fully confirmed cretinism, change of locality and 
 ail other treatment is generally ineffectual; improvement may occasionally take 
 place. 
 
 § 172. In the localities where cretinism is endemic, there is not, as 
 we have already remarked (p. 262), only one sole and always identical 
 type of degeneration, but all those types of cranial and bodily deformities 
 are observed, all those anomalies of form of the cranium, especially the 
 various synostotic forms — synostosis as well of the cranial arch as of the 
 cranial base, which we have already described (§ 161). The most com- 
 mon deformities are the examples of moderate microcephalus, especially 
 the brachycephalic forms in all their modifications.' It is likewise 
 an irrefutable fact that endemic cretinism presents certain modifica- 
 tions in the various localities in which it occurs: for example, the 
 cretins in Salzburg are in general a little different from those in Switzer- 
 land. The synosto-basilar form which we have described (§166) as the 
 cretin type in the strict sense, with large head, small unsightly thick body, 
 
 ' G. Jager has brought forward some interesting facts concerning the occur- 
 rence of a high degree of microcephalus (monkey-heads) in certain families in a 
 cretin village in Wiirtemberg (' Wtirtemb. Med. Corresp. Blatt,' 1839, No. 26). 
 The Stuttgart Cabinet of Natural Histoiy contains a very interesting cranium of 
 one of these children, described in the same journal. 
 
STATES OF MENTAL WEAKNESS. 275 
 
 "broad stump nose with its root impressed, sad features, wrinkled, partly 
 hypertropliied skin (also accompanied by the most extreme dementia), is 
 nowhere frequent in its most extreme degrees, as the extreme examjiles 
 of all the forms are in general rare; but a great number of cases present 
 an approximation to this, and it is this whicli gives to the majority of 
 cretins in all localities where it is endemic a common striking family 
 likeness. Moreover, in localities where the endemic influence is strong, 
 the -whole population are affected by it. Besides cretins, half-cretins 
 and goitrous persons, there are a number of weak-minded, stunted, ill-pro- 
 portioned individuals, many deaf and dumb — many wlio stammer, are 
 hard of hearing, squint, etc. ; a general vein of physical degeneration and 
 mental dulness runs through the whole population; and even those Avho 
 are considered healthy and clever, are, as a rule, ugly, stunted, and lazy: 
 they are a narrow-minded race, whose want of intelligence is by no means 
 compensated by largeness of heart. 
 
 Cretinism may exist at birth in all its essential characteristics, and 
 in a well-marked degree; this, however, occurs very rarely, and, as a 
 rule, the signs in a newly born child are very uncertain or altogether 
 absent. Many of these children, it is true, come into the world with large 
 and somewhat irregularly formed heads, wide fontanelles, and abundance 
 of hair; their features are coarse, the neck thick and short; they cry very 
 little, and sleep almost constantly. But at about the third or fourth 
 month, sometimes not until the fifth or eighth month, the symptoms of 
 the malady commence to show themselves, and gradually become more 
 distinct. These children are very fat, do nothing but eat and sleep; 
 their mouths are constantly open, and the head falls to one side; 
 their countenance is void of expression; they seldom weep, and never 
 laugh: they manifest no curiosity nor attention. Dentition proceeds 
 slowly; the teeth soon decay; the tongue protrudes from the mouth; 
 the child understands nothing until he is about six years of age, and some- 
 times even cannot walk: the expression of mental nullity is also very 
 marked; the morbid process has run its course.' Up to the jaeriod of 
 puberty, the features become coarser, more angular, and older looking; 
 the skin is often dark and rough, the body remains small. In the higher 
 degrees, mental development does not proceed at all, or merely in its 
 simplest form, and even this is perverted; the apathetic, gloomy condi- 
 tion of mind and sentiment preponderates: on the other hand, in the 
 more moderate degrees and slighter cases, somewhat agitated conditions 
 are by no means uncommon — these cases furnish the village clowns. 
 Puberty is late in making its appearance, sometimes not until the 
 twentieth year; childhood has continued till now, and old age immedi- 
 ately commences; from jjuberty onwards little change occurs in the bodily 
 or mental condition. 
 
 Many of the more complete cretins fall frequently, some of them daily, into a 
 state of immobility, of half sleep or suspension of all the physical and mental 
 powers. This state may evidently be considered as analogous to epilepsy or to 
 epileptic vertigo (there also occur at the same time irregular movements of the 
 
 ' Iphofen (ii., p. 216) cites an example of a "cretin" who was healthy and 
 clever up to the age of five; then he became epileptic, these increased, and he 
 gradually became "a cretin." Cases of this kind, even where the affection is en- 
 demic, admit of great doubt whether they ought to be considered as cases of en- 
 demic disease, or of accidental cerebral disease, as in sporadic idiocy. It does not 
 necessarily follow that every case which occurs in the infected locality must be 
 the product of the endemic cause. 
 
276 STATES OF MENTAL WEAKNESS. 
 
 head and body, rolling of the eyes, etc.). In regard to the further physical and 
 mental peculiarities of cretins, I must refer the reader to the many special works 
 upon the subject, especially to the ' Comptes rendus' of the Sardinian Commission. 
 It does not lie within the province of this work to enter into minute details on 
 this subject. 
 
IMPORTANT COMPLICATIONS OF INSANITY. 5377 
 
 CHAPTER lY. 
 ON SEVERAL IMPORTANT COMPLICATIONS OF INSANITY. 
 
 § 173. The various forms of mental disease which have been de- 
 scribed, especially those mentioned in the second and third chapters, are 
 sometimes accompanied by serious disorders, in particular by certain 
 severe affections of the motory nervous system, which — although inti- 
 mately and immediately connected with the disease of the brain from 
 which the insanity also results — present such importance, and, to a certain 
 extent, such a degree of specialty, that they may be regarded as com- 
 plications of the insanity. By these complications, therefore, are not to 
 be understood all the diseases which may affect the insane; these are 
 innumerable; indeed, we scarcely know any disease which is not to be 
 met with along with insanity. The opinion formerly held, that the 
 insane were exempt from epidemic diseases, was completely refuted in the 
 days of Pinel by the spread of malignant typhus fever, which prevailed 
 in the ordinary wards of the hospital, to the division for the insane; and 
 since then, on more than one occasion, outbreaks of cholera have proved 
 the erroneousness of this opinion. All the disorders, therefore, which 
 ;are known to special pathology, may occur in the insane. Here, however, 
 we have to do only with the study of those complications which are 
 directly connected with the insanity — those serious disorders of sensation 
 and movement which, themselves symptoms of profound disease of the 
 brain, constitute a part of the history of the insanity, and are here only 
 formally separated from it in order that we may be enabled to study them 
 more in detail. 
 
 It has been considered incorrect to consider these disorders as complications 
 when they are the result of the same cerebral disease which produces the insanity. 
 How far this is correct, is certainly as well known to the author as to his critics; 
 he does not mean, by complications of insanity, complications of cerebral diseases 
 with other diseases, but complications of the ordinary and predominant psychical 
 symptoms with other groups of symptoms which in the great majority of mental 
 diseases are altogether absent. 
 
 § 174. Of these disorders, tlie so-called general {incomplete) faraly- 
 si^ or. account of its frequency, the peculiarity of its course, and its 
 highly unfavorable prognosis, merits the greatest share of our attention. 
 To the French physicians (Bayle, Calmeil, Delaye, etc.) belongs the credit 
 of having first minutely observed this affection; and it has, to the present 
 time, been a favorite subject of study with the medical psychologists of 
 this country. Several German works, however, have recently contributed 
 greatly to advance our knowledge of this disease. 
 
 Of the abundant literature of general paralysis, the following is the most im- 
 portant:— Bayle, 'Rech. sur les Mai. Ment.,' Paris, 1832: further— ' Maladies du 
 Cerveau,' 1826, and 'Annales Med. Psychol.,' 1855, vii., p. 409; Delaye, 'Cons, sur 
 Tine espece de Paralysie,' etc., Paris, 1824; Calmeil, 'De la Paralysie,' etc., Paris, 
 1826; Duchek, Prager's ' Vierteljahrsschrift,' Bd. xxix., 1851, p. 1; Hoffmann, 
 *Giinsburgs Zeitschr.,' Bd. i-viii., 1850-58; Baillarger, numerous minor papers in 
 ^Ann. Med. Psych.,' 1853-59; J. Falret, 'Rech. sur la Folie paralytique,' Par., 
 
278 IMPORTANT COMPLICATIOJSrS OF INSANITY. 
 
 1853, and 'Archives Gen., 1858, ii., p. 200; Joflfe, 'Zeitschr. der k.k. Ges. der 
 Aerztezu Wien,' xiii., 1857, p. 675; L. Meyer, ' Annal. des Charite-Krankenhauses,* 
 viii., 2, 1858, p. 44; Erlenmeyer, ' Die Geliirn-Atrophie der Erwaclisenen,' 3d 
 edition, 1857; Austin, ' A Practical Account of General Paralysis, Lond., 1859; 
 Parchappe, ' De la Folie paralytique,' Paris, 1859. 
 
 This paralysis is never met with in individuals who are mentally 
 healthy; that is, it depends upon a disease of the brain which is always 
 so severe as to number profound insanity amongst its symptoms. The 
 mental symptoms either appear simultaneously with the disorder of move- 
 ment — or most frequently — they precede for a certain time the manifesta- 
 tion of the motory symptoms, or — much more rarel}' — the paralytic ajipear- 
 ances Avere observed for a short time before the development of the in- 
 sanity. 
 
 Since the publication of the first edition of this work, the question whether 
 general paralysis might arise without mental disturbance, in persons mentally 
 healthy, has been much discussed; but the subject has not always been treated 
 with that clearness and experience which is so desirable. In opposition to the few 
 who answer this question in the affirmative ( Requin, "Sanze, and to a certain de- 
 gree Baillarger), it was not difficult to show that the various states of progressive 
 paralysis in the sane are quite different from this special form, and that the latter 
 is also essentially distinct from many other paralytic conditions uiith mental de- 
 rangement (for example, paralysis owing to apoplexy, tumors of the brain, etc.); 
 indeed, that by no means does every general and progressive state of muscular 
 weakness, in part proceeding to paralysis, in the insane or mentally iveak belong 
 to this special form (thus the muscular weakness which accompanies senile de- 
 mentia, or chronic alcoholismus, or the progressive spinal paralysis which some- 
 times accidentally complicates insanity). In this special form, the progressive 
 muscular weakness and the insanity proceed from the same cerebral disease; and 
 the latter differs in many points so distinctly from the cerebral affections which 
 lie at the foundation of the other mental disorders, that it is now established that 
 it ought to be considered as a special form (general paralysis, paralytic dementia, 
 folie paralytique). 
 
 The first symptoms which usher in this cerebral affection are very often psy- 
 chical, or, in other words, the motory disturbance occurs in individuals already 
 mentally deranged. Nevertheless, in these cases the first muscular symptoms 
 usually appear very shortly (within a few months, or even weeks) after the com- 
 mencement of the psychical symptoms. That cases also occur where the first 
 appearances of the paralysis preceded the psychical symptoms, has been already 
 asserted in the first edition of this work. Since then, Baillarger has laid especial 
 stress upon this mode of commencement, and in one of his works has even gone 
 so far as to declare that the paralysis is the primary and leading symptom of the 
 disease, and the insanity more secondary and accessoiy. Hoffmann states the 
 number of these cases at 18 per cent of his observations; and it is of course possi- 
 ble that the first, slight muscidar disorders are, in many cases, for a time over- 
 looked by those who surround the patient, and that accordingly the paralysis pre- 
 ceded, or perhaps occun-ed simultaneously with the mental disease, in a greater 
 number of cases than was formerly supposed. Still, in the present state of science 
 we must assume that in the great majority of cases the psychical derangement 
 precedes the paralysis. 
 
 § 175. The tongue is always the organ whose movements first present 
 irregularity. The patient commences to speak with difficulty, to articu- 
 late somewhat indistinctly, and to stammer. In this the tongue, when 
 protruded, does not incline to one side, but tremulous and occasionally 
 convulsive movements of it are observed. This early symptom, dimin- 
 ished facility of speech, which soon advances to stammering, is of very 
 great importance; whenever this is remarked in an insane person, he may 
 with almost absolute certainty be considered as lost. Then, although 
 these patients have all the appearance of robust health, and cannot suf- 
 ficiently extol their own feeling of well-being, there gradually becomes 
 developed a series of the most various symptoms. At the same time that 
 
IMPORTANT COMPLICATIONS OF INSANITY. 279 
 
 the speech becomes difficult, more frequently noc until some time after,' 
 a change in the gait of tlie j^atient is observed; he does not lift his legs 
 properly, walks stiffly, involuntarily deviates to one side when attempting 
 to walk straight forward, and easily stumbles if the floor he at all uneven, 
 — for example, when going over a step. Still, they take pleasure in 
 walking about a great deal; some of them even experience a constant de 
 sire for restless change of scene: they take long walks, and, to the inex- 
 perienced eye, nothing striking is presented so long as they keep upon 
 level ground. The arms remain for a long time unimpaired. Gradually, 
 however, while the pronunication of words becomes constantly niore in- 
 distinct, so that Ave occasionally have to guess what the patient intends 
 to say; the gait becomes unsteady, like that of a drunken man; the feet 
 are dragged after him; the knees appear as if they would collapse; he 
 must support liimself by the wall, stumbles every moment, and frequently 
 falls. The arms and hands now become somewhat stiff; objects are 
 grasped, as if convulsively, and occasionally suddenly let fall; all the 
 more delicate movements,* such as writing, sewing, playing the piano, 
 etc., gradually become impossible. When reclining, the patient can 
 freely move his legs and arms; but these movements are more slowly and 
 stiffly performed than usual. As the disease progresses, he can no longer 
 maintain himself erect, language is replaced by confused and indefinite 
 sounds, which run into each other; even while sitting or lying he can 
 scarcely move or stretch his legs, but the arms and hands still enjoy com- 
 parative freedom of movement. 
 
 The muscular affection appears to be even at the commencement very extended, 
 indeed almost general, although at the same time very feeble: it is manifested 
 first of all in those organs whose movements required to be most delicate and 
 precise: the principal of these is the tongue, and difficulty in the pronunciation 
 of words is therefore always a leading feature in the picture of this paralysis. 
 Ordinarily, the movements of the lips are also rendered more difficult, particu- 
 larly in the formation of labial sounds (Duchek); and also, apart from speech, we 
 frequently remark slight convulsive movements in the muscles about the mouth. 
 In the upper extremities we remark at the commencement, yet without any act- 
 ual weakness, a shght tremor, which renders the movements irregular, awkward, 
 and constrained. In the lower extremities it is at first lesstremulousness than an 
 involuntary restlessness, a jerking irregular movement of the legs in walking. 
 At this period the gait is rapid; but later, when the patient can no longer walk 
 owing to actual weakness, we may often perceive transient or more persistent 
 stiffness in certain of the muscles of the leg. 
 
 I believe that I was the first to call attention to the fact that this motory 
 disorder is at the commencement not so much paralytic as convulsive in its nature 
 (1st edition, p. 286). Since then this point has been many times confirmed: see 
 especially J. Falret, ' Archiv,' 1. c, p. 202; Duchenne, " De TAtaxie locomotrice, 
 ' Archives,' 1859, p. 62. A great impairment of the muscular sensation, which, 
 for example, enables the healthy person to estimate the degree of resistance and 
 the amount of muscular power expended in the performance of a certain 
 action, appears to play an important part in producing the disorder, and want of 
 co-ordination and precision of the movements (Neumann): still this does not suf- 
 fice to explain all the phenomena— for example, the trembling of the muscles of 
 
 Afterwards an actual state of weakness of the muscles sets in, and this is very 
 general; the body becomes completely bowed down, the arms hang loosely by the 
 side, the head hangs back, the sphincters or detrusory muscles of the urine and 
 intestinal contents become feeble, and, finally, even the respiratory muscles be- 
 come paralyzed. It is only in exceptional cases that we observe greater weakness 
 in one half of the body, an inclination of the tongue to one side, obhquity ot 
 countenance; these exceptional cases appear to depend upon considerable atrophy 
 of one-half of the brain, or upon unilateral hsematomata in the dura mater. 
 
 The contractility of the muscles under the influence of electricity is, as in other 
 forms of cerebral paralysis, always normal (in contradistinction to peripheral and 
 
280 IMPORTANT COMPLICATIONS OF INSANITY. 
 
 many spinal paralyses). This, however, is of very little diagnostic value, as it 
 is also observed in a number of other paralyses (hysterical jjaralysis, paralysis I'e- 
 sulting from a tumor of the brain, etc.). Duchenne, who established this fact 
 in 1850, has published the further results of his eKperiments in ' Traite de I'Elec- 
 tris. loc," Par., 1855, and especially in his " Memoire sur I'Ataxie locomotrice" 
 ('Arch, de Med.,' 1859, p. 68). 
 
 At the commencement the pupils are often regularly contracted; afterwards 
 they again enlarge, but often unequally. Seifert (' Zeitschr. f. Psych.,' x., p. 561) 
 observed, in twenty-five paralytics, seventeen cases of anomaly in the mobiUty of 
 the iris. This irregularity of the pupils, which sometimes exists for years before 
 the outbreak of the malady, is not to be considered as its first commencement; 
 this occurs quite as frequently in individuals who afterwards become attacked 
 with other forms of mental disease. Strabismus, and disorders of movement of 
 the eye generally, scarcely ever occur; sometimes, but in a later stage of the 
 disease, a convulsive rolling of the eyeballs may be observed. 
 
 As to sensibility, the special senses generally remain till the last with- 
 out any striking impairment; when the affection has lasted for a long 
 time, the senses of taste and of smell become less acute, so that the pa- 
 tient, for example, cannot distinguish wine from water. Pain does 
 not exist, but at the commencement the patient sometimes complains 
 of headache, with a sensation of weight and confusion in the head, and a 
 slight degree of yertigo. The cutaneous sensibility occasionally presents a 
 remarkable peculiarity. While it in all cases appears at the commence- 
 ment to become blunted, and afterwards in certain cases almost abolished 
 (so that the patients can endure severe pinching without experiencing 
 pain), there occasionally occur transitory states of extreme hypergesthesia 
 of the cutaneous surface, in which the slightest touch excites the most ex- 
 tended reflex movements, convulsions of all voluntary muscles — condi- 
 tions which present the greatest similarity to the symptoms produced in 
 animals by a poisonous dose of strychnine. In a well-marked case of this 
 kind we were able minutely to observe this cutaneous hyperaesthesia 
 during the hours immediately succeeding an attack of convulsion. 
 
 Not unfrequently, we observe in these patients, under the symptoms 
 of violent cerebral congestion, sudden attacks of loss of consciousness, 
 often accompanied by convulsive attacks resembling those of epilepsy. 
 These, when they have once appeared, are generally repeated at intervals;* 
 the patient may die in them, but generally he soon recovers. After each 
 attack there is usually observed an increase of the paralysis and of the 
 mental dulness; more rarely, contractions of certain ligaments of the 
 forearm, finger, or leg, remain after an attack. 
 
 We must distinguish between the slight attacks of vertigo obsei-ved at the 
 commencement, the congestive attacks which occur in the course of the disease, 
 and are more or less apoplectiform and combined with loss of consciousness, and 
 the epileptiform attacks. In certain rare cases the congestive attacks occur at 
 the very commencement, so that the disease appears to begin with one of them: 
 in cases of this sort, however, slight symptoms have always previously existed. 
 In the latter stages of the disease they are seldom altogether absent ; in the end 
 they occur more frequently, and are of longer duration, sometimes lasting for 
 several days. The epileptiform attacks never make their appearance until the 
 disease is far advanced. 
 
 § 176. At the commencement of the disease the i^sycliical disorders 
 do not always present the same character. It is rarely that a melancholic 
 stage does not exist. This is sometimes simply depressive, sometimes 
 strongly hypochondriacal in its character. The first disorders of move- 
 ment are very rarely manifested in the melancholic stage; nevertheless, 
 eases do occur, as Calmeil (1. c, p. 328) has observed, and in such cases 
 the patients may retain for a long time the melancholic nature of the 
 
IMPORTANT COMPLICATIONS OF INSANITY. 281 
 
 delirium, so that the depression passes almost immediately into dementia. 
 The change in the character and entire nature of the jjatient is very 
 variously exhibited at tlie commencement of the disease. A want of 
 the former> mental activity and energy, a painful anxiety regarding 
 the most trifling circumstances, are frequently the first symptoms 
 observed; amongst the prodromal symptoms we occasionally observe, also, 
 certain perversions of the character and affective sentiments, which are 
 often extremely startling, occurring in patients who still move freely in 
 society, pursue their avocations, etc. : these may give rise to medico-legal 
 questions which are often very difficult to settle — especially violations of 
 property (sometimes proceeding from the idea that the objects in ques- 
 tion really belong to them; frequently, also, from a momentary irresis- 
 tible impulse to gratify a desire); rude, immodest acts, and the like. 
 
 Whatever the commencement may be, in ordinary cases there always 
 arrives a period characterized by a state of general psychical excitement. 
 The first evident symptoms of the motory disorder generally correspond 
 with this — that is, with the vague delirium of mania, or accompanied by 
 those fixed ideas which we have described when speaking of monomania; 
 namely,, such as relate to exaltation of the person, to grandeur, which, 
 on account of their frequent connection with general paralysis, are 
 correctly considered of great prognostic value {monomanie des grandeurs). 
 These patients are active, busy, speak a great deal, are constantly in 
 movement, buy and sell, plan great schemes; their manner is, indeed, 
 odd, peculiar, and extravagant, but they are only recognized as mentally 
 diseased by the initiated. Soon they allow themselves greater freedom, 
 become more and more restless; manifest in everything their satisfied, ex- 
 alted frame of mind; spend lavishly and make magnificent presents; 
 recount imaginary histories, in which they frequently contradict them- 
 selves; now and then they give offence by their habits of drunkenness 
 and gross indecencies: in short, they make themselves — to use Neumann's 
 appropriate expression — unbearable. Should the patients be admitted 
 at this period into an asylum, they generally, under isolation and appro- 
 priate diet, rapidly become somewhat more calm; but usually this is of 
 only short duration, and in the great majority of cases there are now de- 
 veloped the specially characteristic ideas of greatness, in which all that 
 relates to the person of the patient assumes in his eyes colossal dimen- 
 sions, and is expressed by him in the most superlative language and 
 liighest numbers. At the same time, however, the intellect, character, 
 and emotions, all assume the character of weakness. In their delirious 
 ideas they often contradict themselves; they do not persist in them, but 
 soon forget and pass on to others: the circle of the ideas is, in spite of 
 their apparently active production, very limited; incoherence soon be- 
 comes (particularly in writing) marked; and it is in the highest degree 
 remarkable how all things, even the most absurd, are at once accepted as 
 realities without the least internal opposition: the ego becomes quite in- 
 capable of resistance, and is entirely taken possession of and subdued by 
 them. Their will is weak; they appear violent, but are pliable as children, 
 easily subdued, and they are also somewhat mobile and lachrymose in 
 their nature. 
 
 The weakness of the mental faculties becomes more and more pro- 
 found in j)roportion as the paralytic appearances become more marked; 
 the patient loses his memory, the capability of mental association, all 
 sense of duty; he becomes completely indifferent, dirty in his habits, etc. 
 Prom this time the dementia progresses step by step with the paralysis: 
 
282 IMPORTANT COMPLICATIONg" OF INSANITY. 
 
 still, iu certain patients the course of the disease is varied, sometimes hy 
 increased restlessness — sometimes even by attacks of mania, vociferation, 
 and desire to destroy. Certain patients continue for a long time to mani- 
 fest, but without any actual sense of what they say, those extravagant 
 ideas of possession of provinces, riches, worlds, millions, etc., variously 
 modified according to the degree of education. The one' possesses mil- 
 lions of billions — all the world belongs to him, all things were made by 
 him, etc. Another has built the most splendid castle, bought all Italy, 
 plundered Asia, destroyed the bridge from the earth to the moon, trans- 
 ferred the Chinese to Paris, is himself 800 feet high, etc. Others walk 
 100 leagues in a day, write 100 tragedies and 1000 poems in the same 
 space of time — have heads made of diamonds set in gold, horses and 
 palaces made of gold, etc. 
 
 Moreover, the ideas of greatness are not always so completely developed as 
 might be supposed from the descriptions given of individual cases. Exclusive of 
 those rare cases in which the entire mental disorder had for a long time the 
 character of depression, and no special stage of mania ever existed, conditions are 
 also frequently observed where the excited and elevated disposition was mani- 
 fested rather as a general lively, happy, self-contented manner, than iu many 
 exalted ideas, or where the latter are at least comparatively unassuming in their 
 character; for example, in women, simply the conviction that they have a great 
 many fine dresses at home, etc. Sometimes the dementia forms the base and the 
 background of all the psychical phenoinena, and also soon manifests itself in the 
 expressionless countenance and contented residence in the asylum. The gigantic 
 ideas are now expressed, as it were, mechanically, as a remnant of the former 
 activity of the mental processes. 
 
 In the latter periods of this affection these ideas completely disappear : 
 the patient is in the extreme stage of mental decay; he is as little capable 
 of having a complete idea as he is of pronouncing a proper word; he is void 
 of any conception of his whereabouts: even the primary instincts, as the 
 desire for food, disappear, and tbe patient requires not only to be fed, 
 but the food must often be pushed backwards in the mouth. 
 
 The appetite, the digestion, and nutrition are, at the commencement, 
 and during a considerable period of the course of the disease, well main- 
 tained: the patients then eat well, and even greedily; their appearance is 
 often good, and they fvequently have a tendency to become fat: a remark- 
 able dryness of the skin, with considerable separation of the epidermis, 
 were the only circumstances which struck us in certain cases where the 
 cutaneous sensibility was diminished. It is not generally until the ad- 
 vanced period that the patients become emaciated; gangrenous spots ap- 
 pear in various parts of the skin, especiallly of the back; large abscesses 
 form; extensive suppurations and infiltrations of the extremities occur, 
 and the patients sink under hectic fever, which in many cases is connected 
 with pyemia — in others with acute or chronic intestinal catarrh, accom- 
 panied by profuse diarrhoea and ulceration of the intestines; at other 
 times it is connected with general tuberculosis. Some also die of pneu- 
 monia, particularly of lobular pneumonia, consecutive to chronic bronchial 
 catarrh; others from accident, etc. 
 
 The work of L. Meyer (1. c.) renders it very probable that the morbid process 
 in the cranium which lies at the foundation of the paralytic mental derangement, 
 at least in many cases, is itself accompanied by a febrile increase of temperature, 
 and that the maniacal stages are in particular intimately connected with this 
 febrile increase of temperature. This is, moreover, sometimes very inconsiderable 
 (Meyer's 17th observ^ation, p. 167), and it seems to me still problematical whether 
 
 ' See Bayle, ' Maladies du Cerveau,' Paris, 1826, pages 71, 210, 503. 
 
IMPORTANT COMPLICATIONS OF INSANITY. 283 
 
 a distinction between these forms and the other states of psychical exaltation can 
 be founded upon the state of the bodily temperature. Sander (Virchow's ' Archiv, ' 
 XV., p. 160) found the secretion of urea comparatively small, even in patients who 
 took their food well and became emaciated; he accounts for this by diminished 
 assimilation of the nutritive elements. 
 
 § 177. General paralysis of the insane occurs, according to all known 
 experience, much more frequently in men than in women. According to 
 Calmeil, there is one general ])aralytic in every 15 insane in men, and in 
 women 1 in 50;' according to Bayle, in Charenton general paralysis was 
 eight times more frequent amongst the males than amongst the females;^ 
 Foville calculates 31 general paralytics to 334 insane, of whom 22 are 
 males and 9 females;' Hoffmann found 18 paralytic women to 138 men; 
 in Leubus there were, in about 2700 cases, 1.376 per cent males, and 
 only 3.16 per cent females; in Prague, to 03 men there were G women; 
 in Stephansfeld, from 1835 to 1852, ith of the males and only -gJ^th of 
 the females suffered from general paralysis; Bazire", in Bordeaux, had 62 
 general paralytics amongst 996 females, etc. The causes of this difference 
 between the sexes are obscure: it may, with some show of reason, be as- 
 sumed that the more frequent excesses in spirituous liquors and in venery 
 amongst men predispose the brain to such affections; perhaps strong 
 cigars and strong coffee have a share in this: nevertheless, cases occur in 
 which the disease sets in after the most regular life, wliere none of these 
 causes have been at work, and in particular where no traces of former 
 syphilitic disease — a cause which has recently been assigned an important 
 place in the etiology of this affection (W. Jessen) — existed. 
 
 This disease almost never occurs before the age of twenty, it is most 
 frequent about the age of forty. It is most frequent amongst the edu- 
 cated classes^ — amongst military officers, merchants, government officials, 
 and the like; it is also very frequent in. mentally excitable persons — in 
 poets, musicians, learned men, especially if of the sanguine temperament. 
 Excessive mental excitement, and, in a still greater degree, emotional agita- 
 tions, appear to be important factors in its production. Climate, too, 
 appears to exert some influence upon the frequency of general paralysis; 
 it is not so common in many southern countries (for example, in the 
 South of France) as in the north. 
 
 General paralysis is nowhere more common than in France, or, at least, in 
 the asylums of Paris. According to Bayle (1855), the proportion of paralytics is 
 1 in 4." (Baillarger, on the other hand, gives for Bicetre and Salpetriere together 
 the proportion of 1 to 16.) In Vienna the disease is common (in 1855 and 1856 
 about 12 per cent of the admissions, to which afterwards a considerable number 
 would of course be added); in the Tyrol Asylum (Stoltz, 1851) more frequent than 
 in Prague (Duchek). The very large proportion which Bini gives for the asylum 
 at Florence is remarkable (about 18 per cent of the admissions); it is also worthy 
 of note that Guislain, in the few years previous to 1850, remarked, in his sphere 
 of observation in Ghent, a considerable diminution in the number of paralytics 
 ('Leg. or.,' ii., p. 104), while elsewhere it was universally found to be on the 
 increase. It would be interesting to compare all the existing statistics of general 
 paralysis; many errors might thus be corrected, and greater light thrown upon 
 its true causes, which are as yet buried in obscurity. 
 
 § 178. The duration of general paralysis varies from several months 
 
 'L. c.,p. 371. 
 'L. c, p. 403. 
 
 3 ' Diet, de Med. et de Chir. Prat.,' art. " Alienation," p. 505. 
 ^ ' Ann. Med. Psychol.,' vi., 1854, p. 658. 
 
 ^ In Leubus, there were of all the male patients 13.76 affected, but of those in 
 the higher ranks of life 25.00. 
 
284 IMPORTANT COMPLICATIONS OF INSANITY. 
 
 to about three years: exceptional cases, indeed, occur, in which the uiS- 
 ease hasts for a longer period, even for ten years (Brierre, Trelat); still, 
 not without long periods of intermission. When nursed in their fami- 
 lies, these patients live longer than in asylums, as their care in the higher 
 degrees demands the same trouble and attention as that of a young child. 
 The course of the disease is not only interrupted unfavorably to the patient, 
 or accelerated by the congestive attacks of which we have spoken; fre- 
 quently also we see the patient become daily worse without any appreci- 
 able cause. 
 
 Several examples of recovery, or at least of long-continued consider- 
 able improvement — never without urgent danger of relaj)se — have been 
 published. Calmeil has observed two and Bayle six cases of this kind: 
 Flemmiug, Snell, Ferrus, Baillarger, have also communicated several 
 cases of recovery. The immense majority of the patients, however, die 
 within the given time. On the hand, it is less rare to observe transitory 
 improvements, and sometimes even complete intermissions; but unfortu- 
 nately, these are only of short duration. 
 
 On the whole, this affection is essentially progressive in its character; but, in 
 general, this progression is rather irregular than constant, and sometimes even 
 jerking in its character. Remissions of all the symptoms, psycliical as well as 
 motory, are not unfi-equent; they may even proceed to a condition in which the 
 patient no longer manifests any trace of delirium, i-eturns to his employment, 
 and only a slight hesitation in speech and a certain degree of mental and emo- 
 tional weakness is perceptible to the initiated. These marked remissions may 
 last for several weeks, and even for a year or a year and a half; even such slight 
 signs of intellectual weakness do not in the least warrant us to consider the 
 individuals as of sound mind — a fact which in a medico-legal point of view may 
 be very important: as a rule, the ordinarily recognized signs of insanity are alto- 
 gether absent in these cases. Frequently, these marked intermissions are 
 suddenly cut short by a congestive attack, with which the patient is again 
 plunged into his former state, and usually the disease then runs rapidly towards 
 its fatal end. 
 
 From the many careful and interesting investigations concerning the 
 condition of the brain in general paralysis (see the chapter on Pathologi- 
 cal Anatomy), we discover that the alterations which lie at the founda- 
 tion of this disease are not exactly similar in every case. Here also, as 
 in the other diseases of the nervous system, different anatomical changes 
 may give rise to the same groups of symptoms. Ordinary apoplexy — irri- 
 tation of the brain, owing to extravasation of blood — never gives rise 
 to this form of paralysis; on the contrary, during the attacks of cere- 
 bral congestion and loss of consciousness, more or less considerable effu- 
 sion of blood appears to take place into the sac of the arachnoid, which 
 afterwards either becomes encysted or, where the quantity has been small, 
 transformed into a thin, incompact pseudo-membrane, resembling vege- 
 tations upon the internal aspect of the dura mater, covering the convex 
 portion of the hemispheres. 
 
 It is not to be supposed that the congestive apoplectiform attacks always 
 depend upon extravasation of blood into the cavity of the arachnoid (haemato- 
 mata); there are cases with frequently repeated and strong attacks, and no 
 extravasation. Ordinary extravasation of blood into the brain occurs in certain 
 rare cases as a complication ; it never lies at the foundation of general paralysis. 
 
 The diagnosis of paralytic mental disorder is, in the great majority of 
 cases, no difficult task. It is based upon the existence of the symptoms 
 we have been describing; upon the general but incomplete character of 
 the paralysis — its progressive nature; upon the convulsive character of 
 the early symptoms of the disease — its commencement with trembling of 
 
IMPORTANT COMPLICATIONS OF INSANITY. 285 
 
 the tongiie and of the lips; upon the special character of the mental de- 
 rangement, particularly the ideas of greatness and the rapidly ensuing 
 mental weakness; upon the irregular course. It is by regarding these symp- 
 toms that we in general soon succeed in distinguishing this affection 
 from paralysis due to cerebral haemorrhage, embolism, encephalitis, tu- 
 mors of the brain; from hysterical and toxic paralyses; from progressive 
 spinal paralysis, the tremor of old age, progressive muscular atrophy. 
 
 The great analogy which exists between this paralysis and the insanity con- 
 nected with it and di-unkenness, mentioned bj^ me in the first edition of this 
 work (p. 246), has since then been more minutely described by Lasegue (' Arch. 
 Gen.,' 1853, 1., p. 49) and by Bayle ('Ann. Med. Psych.,' 1855, vii., p. 423). The 
 former calls attention to the fact that there are cases in which the diagnosis be- 
 tween this paralysis and alcoholismus is not very easy: the course of the disease^ 
 however, will always in these cases soon lead to a correct conclusion. 
 
 § 179. As the second important complication of insanity may be men- 
 tioned epilepsy. The numerous jjoints of contact and transition of the 
 motory convulsive forms comjjrehended under this name, to the more 
 profound derangements of the psychical functions, are manifested partly 
 in the symptoms which precede, accompany, and follow the attack — 
 partly in the whole course of the disease. 
 
 Striking psychical disturbances sometimes occur hefore the attack. 
 Sometimes a confusion and obscuring of the consciousness resembling 
 drunkenness; sometimes profound sadness — an extremely painful, angry 
 disposition; sometimes violent hallucinations of all the senses — immedi- 
 ately precede the attack. 
 
 During the attack, in fully developed cases, the psychical faculties 
 are completely suspended; at least, the patient cannot remember any 
 psychical act that happened during this time, although the expression 
 of fixed terrified astonishment which he so frequently manifests might 
 awaken the idea that he is suffering extreme mental j^ain. There are, 
 however, many epileptic conditions in which we may recognize, during 
 the attack, the existence of a psychical disorder. Thus we may frequent- 
 ly observe attacks sometimes preceding and sometimes alternating with 
 intermittent convulsions, which consist principally in a psychical anom- 
 aly, either entirely without, or with very limited, disorder of movement 
 (for example, contractions of certain muscles of the face, movements of 
 deglutition, relaxation of the brachial muscles), of which occasionally the 
 patient has some degree of recollection. In many of these patients there 
 is a sudden obscuring or suspension of consciousness as to external objects: 
 the eyes become fixed; the patient, if he had been speaking, sometimes re- 
 peatedly murmurs the word last spoken; when he recovers, he perceives his 
 mental absence, and sometimes attempts to conceal it, or continues his con- 
 versation, commencing at the word at which he stopped. Such patients 
 have subsequently described their state as one of profound mental pain, 
 with great incoherence and depression, as though they were in a painful 
 dream; they had a sensation of anxiety, or as of some terrible misfortune, 
 without knowing any reason for it. Others, after partial or complete 
 loss of consciousness, execute combined movements — series of actions 
 which correspond to a state of dreaming, of varied, but, in general, of a 
 painful and depressive character. Most frequently the patients have no 
 recollection of these.* 
 
 ' 'Cyclopsedia of Pract. Med.,' vol. ii., art. •' Epilepsy," by Cheyne. See also 
 the case where phantasies were remembered after the epileptic attack, in Nasse. 
 
286 IMPORTANT COMPLICATIONS OF INSANITY. 
 
 Immediately after the attack, the psychical functions are often yery 
 seriously disturbed. Sometimes the patient speaks incoherently for a 
 long time, as if he were in dementia, and the intellect does not recover 
 its former state for several days. Still more important, however, are 
 those paroxysms of mania immediately following the convulsive attacks, 
 which manifest themselves by such a degree of blind fury and violence, 
 such wild gesticulation, as scarcely ever occui's in ordinary mania. In 
 other cases, states of profound melancholia, sometimes calm, sometimes 
 agitated, and in the latter case sometimes amounting to actual mania, break 
 out after the attack. In general, all these states rapidly pass off, particu- 
 larly by sleep; sometimes, however, they pass into a condition of stupor, in 
 which the patients, with more or less cerebral congestion and fever, lie 
 completely exhausted and prostrated, and may at last sink, in the course 
 of a few days, or it may be weeks, under a condition presenting indefinite 
 typhoid-like symptoms (with negative post-mortem results). 
 
 Precisely similar intellectual derangements may also occur without 
 having been preceded by convulsive attacks, or, to a certain degree, in 
 their stead. Then these always occur several times in succession, and 
 there is thus originated an intermittent mania of the most serious descrip- 
 tion, alternating with epileptic attacks. 
 
 But a very great number of epileptics are in a state of chronic mental 
 disease even during the intervals between the attacks. In order to appre- 
 ciate to what extent this is the case, we must not confine ourselves to the 
 isolated cases met with in private practice, but we must study the ques- 
 tion in the light of the results furnished by observations conducted in 
 large asylums devoted to such patients. Thus, amongst 385 epileptic 
 women observed by Esquirol,' there were 46 hysterical, of whom many 
 suffered from hypochondria and maniacal attacks; 30 others were maniacs; 
 12 were monomaniacs; 8 were idiots; 145 were dements (of these 16 were 
 constantly so — the others for only a shorter or longer time after the 
 attack); 50 were Aveak in memory or had exalted ideas. Sixty (only |th) 
 were free from intellectual derangement; but nearly all of these were 
 irritable, iieculiar, and easily enraged. The latter trait of character — a 
 dominant, suspicious, discontented, misanthropic perversion of sentiment, 
 sometimes even actual melancholia with suicidal tendency*— is observed 
 in a great many epileptics. This may, in great degree, originate from 
 the sense of their sad and exceptional position, from the gradual percep- 
 tion of the moral death to which their malady condemns them. 
 
 The most important persistent psychical disorder to which epileptics 
 are subject is dementia. As a rule, it makes its appearance earlier 
 according to the frequency of the attacks. Memory fails; perception 
 becomes dull; the imagination loses its brilliancy; its genuineness and fer- 
 vor, and the emotions become withered. The physiognomy and deport- 
 ment change — the patient becomes thick-lipped, coarse in his features 
 and repulsive in his appearance. As the attacks become weaker and less 
 frequent, the mental faculties may regain their power, but, owing to the 
 rarity of radical cure in epilepsy, the majority of these patients finally 
 fall into dementia. 
 
 The existence of these intermittent convulsive forms in the insane is, 
 
 ' Zeitschrift fiir Anthropologie,' 1825, i., p. 190. The dissertation on epilepsy by 
 Dr. C. F. Horing, T bingen, 1859, contains many observations of this kind. 
 ■ 'Maladies Mentales,' vol. i 
 
IMPORTANT COMPLICATIONS OF INSANITY. 287 
 
 therefore, of very great importance in regard to the prognosis. Demen- 
 tia with epilepsy may be considered as perfectly incurable; and in other 
 forms of insanity complicated with epilepsy, recovery is altogether excep- 
 tional. Some asylums, therefore, which are exclusively devoted to curable 
 cases of insanity, shut their gates against all insane persons who are 
 affected with epilepsy. 
 
 The psychical derangements observed in epilepsy are not nearly so peculiar as 
 those in general paralysis; these may assume various forms, which, however, 
 all terminate in states of mental weakness. Muscular paralysis occasionally oc- 
 curs in the epileptic insane, but it does not commence in the tongue and lips, and 
 is very frequently confined to one half of the body; the accompanying delirium 
 is not the same as in general paralysis. For insanity complicated with epilepsy, 
 see the recent works on the latter disease, especially that of Delasiauve (Paris, 
 1854); Flemming, 'Psychosen,' p. 118; Haushalter, ' Du Delire epileptique,' Diss., 
 Strasb., 1853; Weyers, ibid., 1857; Cossy, ' Rech. sur le Delire aigue des Epilep- 
 tiques,' Paris, 1854. 
 
 § 180. Many other morbid appeararices in the motory nervous system 
 may also complicate insanity. Sometimes transitory general convulsive 
 states resembling hysterical attacks, or proceeding from great cerebral 
 congestion or acute meningitis; sometimes chronic general convulsive 
 forms, chorea-like movements, turning round and round, walking back- 
 wards or in a circle, and the like; sometimes chronic convulsions re- 
 stricted to certain muscles, — for example, constant convulsive nodding of 
 the head, convulsive lifting of the leg when walking, etc. ; sometimes con- 
 tractions of certain groups of muscles (of the extremities, strabismus), 
 with or without paralysis succeeding. We have already sj)oken of these 
 (§ 62), and of their unfavorable prognostic significance. 
 
 Of quite as serious significance are those vague neuralgias — hitherto 
 too little considei'ed — which are observed in all parts of the organism as 
 fleeting pains, and, not unfrequently, at the period of transition of the 
 disease to an incurable state of weakness. The fact of their frequency 
 under such cn-cumstances warrants us in considering them as of central 
 origin, and as intimately connected with the insanity, and especially with 
 the persistent organic changes within the cranium, which ordinarily take 
 place at this period. They are often closely connected with those slight 
 cutaneous neuralgias which give rise to ideas of being electrified, and by 
 no means ought these to be discarded under the excuse of "rheumatic 
 pains." 
 
 Finally, the group of febrile symptoms which so frequently accompany 
 the first appearance of the insanity may be mentioned as a common com- 
 I^lication, and one intimately connected with the disease of the brain. 
 Eigors, heat, exhaustion, pains in the limbs, thirst, foul tongue; dis- 
 ordered appetite, bowels, and urinary secretion; epigastric tenderness, 
 dryness of the skin, rapid emaciation — occur very frequently at the period 
 when the symptoms of the cerebral disease begin to be manifested. Gen- 
 erally they disappear spontaneously or under the use of simple remedies 
 in the course of a few weeks, or even days, and the insanity continues its 
 course — with certain exceptions' — without fever. Not unfrequently 
 these states, on account of the still slightly prominent cerebral symptoms, 
 are regarded as gastric, rheumatic, catarrhal fever, which preceded the 
 development of the mental disease, out of which this has "developed" 
 itself from want of a crisis. Or the foul tongue, loss of appetite, and 
 
 » See 8 63. 
 
288 IMPORTANT COMPLICATIONS OF INSANITY. 
 
 constipation are regardea as symptoms of some serious abdominal disease 
 which is now termed the cause of the insanity. In such cases, an unbiased 
 observation and physiological analysis of the symptoms, and their analogy 
 with those of other cerebral diseases, will generally suffice to enable us to 
 avert such errors. 
 
fATHOLUGiUA-L, AJSATOMY Oh >1£JMTAL DISEASE. 289 
 
 BOOK FOUETH. 
 
 THE PATHOLOGICAL ANATOMY OF MENTAL DISEASE. 
 
 § 181. Whoever attends not merely to the symptoms of disease, but 
 also to the abnormal organic conditions from which these symptoms 
 spring, will readily admit that in insanity the observation of post-mortem 
 appearances is a department of psychology of the utmost importance. 
 Here, in pathological anatomy, do we find a full answer to the question, 
 WJiat are the special diseases the symptoms of which we have previously 
 become acquainted with either by themselves individually, or in combi- 
 nation with certain forms of disease? Here, also, is to be found the basis 
 of a true diagnosis — that is, an anatomical diagnosis. To us post-mortem 
 examinations are not mere employments from which we seek, after the 
 death of the patient, to gratify an idle curiosity. We do not consider 
 pathological anatomy in the light of a mere collection of curious facts, 
 as a dry register of observed anomalies. We have not only to consider 
 the presence or absence of such alterations generally, not only to establish 
 their intimate connection with the morbid cause through which that dis- 
 covered after death first originated, and to employ them for the preserva- 
 tion and treatment of living patients; we have also to consider whether 
 a careful examination of pathological and anatomical facts will not assist 
 us in forming conclusions of a still more comprehensive nature, and 
 whether definite fundamental facts cannot be elicited which might throw 
 a clearer light on the intimate nature, on the mode of progression of 
 these diseases, as well as upon the wliole physiology and patliology of the 
 brain. If we do not deceive ourselves, this department of our subject 
 has not been without such results. 
 19 
 
290 PATHOLOGICAL ANATOMY OF THE BRAIN. 
 
 CHAPTEK I. 
 
 PATHOLOGICAL ANATOMY OF THE BRAIN AND ITS MEMBRANES. 
 
 § 182. The anatomical changes which indicate insanity, that is,, 
 which produce psychical anomalies during life, are naturally to be sought 
 for within the cranium — in the brain and its membranes. According to 
 the data which we at present possess, it is a well-constituted fact, that in 
 the bodies of many persons who have been insane no anomalies in these 
 parts are to be found. If we examine the great mass of uncertain records, 
 and except the cases in which the insanity was cured before death, there 
 still remains a number of cases, reported by careful special observers (and 
 which may easily be confirmed in any asylum), where the cranial cavity 
 and its entire contents presented altogether normal relations. 
 
 We ought to be quite as grateful to pathological anatomy for the con- 
 firmation of this fact, as for the discovery of anatomical lesions. For 
 although in all cases of insanity we must assume a pathological affection 
 of the brain, there is thus presented to us by these negative results, on 
 the one hand, the strong analogy of cerebral disorders without anatomical 
 changes to many affections of the spinal and peripheral nerves, in which 
 there is likewise no anatomical lesion of the tissue; and, on the other 
 hand, we thereby obtain trustworthy data for our prognosis and treat- 
 ment. 
 
 But, in order that we may not form false conclusions from the fact 
 that cases exist where no anatomical changes are present, it must be 
 particularly borne in mind that, according to the statistics of recent care- 
 ful observers, these cases always constitute the minority. We must esti- 
 mate their numbers, not by the statements of those physicians who, 
 though perhaps excellent administrators or theorists, have had no oppor- 
 tunity of studying the structure of the brain and its pathological 
 changes — who understand merely how to make a rough section of the 
 brain with scalpel and forceps, and, of course, constantly find nothing.. 
 We must consider how easily many very minute but, nevertheless, impor- 
 tant changes — even exclusive of those which are only microscopically 
 appreciable — may elude mere ordinary attention, and we ought, as a rule, 
 to accept statements regarding the normal or abnormal condition of the 
 brain from those only who, by the whole spirit of their writings, show 
 that they are acquainted with pathological anatomy, that they acknowl- 
 edge this pre-eminently, and that they know what is to be looked for and 
 what is to be esteemed. Besides, in more recent times, the discovery of 
 previously unknown changes, and a more definite anatomical and logical 
 investigation of previously known facts, have tended greatly to promote 
 the patliological anatomy of the brain; and just as we know for certainty 
 that much that is important was overlooked by the older investigators, so 
 may we anticipate still greater results from still more searching and 
 minute investigations in the future. 
 
 Not only should these negative results, however, but even their theo- 
 retical application and the conclusions derivable from them, be received 
 
PATHOLOGICAL ANATOilY OF THE BKAIN. 291 
 
 with favor. We must be careful not to underrate their importance on 
 account of the occasional absence of anatomical changes after death, and 
 to conclude that, for this reason, such anatomical lesions when present 
 may not be the cause of the mental disorder. That would be similar to 
 reasoning of the following nature: because cough and dyspnoea occasion- 
 ally exist witho^^t any anatomical changes in the lungs, therefore in 
 I^neumonia these symptoms might not be the results of this pulmonary 
 affection; because convulsions, spasms, paralyses, sometimes exist with- 
 out organic change in the spinal cord, therefore, in cases of inflammation 
 of the spinal cord, the convulsions, spasms, paralyses, etc., are not the 
 direct results of this inflammation, but it is more probable that they 
 have some other and unknown cause ! Indeed, the mere discovery of any 
 abnormal cerebral condition is only the first step in advance; and we 
 must not rest content with this, or expect to recognize in every such 
 anomaly the particuhir disorder from which the individual psychical 
 anomaly directly springs. A knowledge of the intimate connection be- 
 tween kind of alteration and form of psychical disease has not yet been 
 arrived at. It is, however, of great importance to discover whether in 
 concrete cases palpable indications of disease exist in the crania of the in- 
 sane, what they are, what appearances they bear, and how their form in 
 general is related to the appearances of the mental affection as a whole. 
 
 The gross misconceptions held by the older exclusively psychological or theo- 
 retical school regarding the entire anatomical view of mental diseases, require in 
 the present state of science no further refutation. Now, errors and one-sided views 
 within the pathological anatomical school are rather to be guarded against. It - 
 does not by any means follow that the alterations which we discover in the cra- 
 nium are the immediate causes of definite psychical anomaUes, of this or of that 
 form of delirium, or that the individvul symptoms of the mental derangement are 
 the di7'ect result of the anatomical lesion. Certain attempts in this direction, 
 among others those of an eminent German psychologist, are entirely misdirected; 
 and will for a long time prove fruitless. The already discovered alterations can, 
 as yet, only demonstrate that the brain generally, or, still more indefinite, that 
 the cranial contents are diseased, and in what manner; but how a psychical dis- 
 order, or, to speak more plainly, how this or that particular form, arises from this 
 disease in the case of some particular person, and not in other persons, although 
 affected by tlie same alteration, cannot yet be explained with any degree of cer- 
 tainty. Doubtless, there exist many pathological lesions in the insane which have ; 
 no connection with the mental disease; in particular, the various final processes, ' 
 recent meningitis, softenings, apoplexy, etc. ; these are fatal, and for the most 
 part not accidental complications; and certainly, as these may occur acutely and 
 cause death, so may they in many cases appear earlier, persist, recover partially, 
 etc.— in short, present after death a morbid change of long standing which, per- 
 haps, had very little connection with the symptoms of the mental disorder. To 
 distinguish and to decide on each of these separately is the province of a critic of 
 anatomical knowledge and experience. The anatomical view does not consist in 
 the belief that every mental disorder must correspond to a palpable cerebral lesion 
 —what must we expect to find in the brain of one who dies during sleep? and 
 yet sleep is a change in the psychical functions even more decided than is ob- 
 served in any form of mental disease \—<ihe anatomical method consists in inves- 
 tigating what, according to experience, the post-mortem appearances in the insane 
 are, and then, by comparing these lesions and the processes which lie at their 
 foundation with the symptoms observed durmg life, to arrive at comprehensive 
 anatomical views in regard to these cerebral affections. This doctrine is main- 
 tained in the first edition of tliis work, though not so explicitly stated. 
 
 Another misimderstanding, which we present need scarcely do more than 
 mention, is this— that the pathological lesions in the insdne are merely results of 
 the mental disease. In this quibble a sort of last refuge is sought from the patho- 
 logical anatomical modes of viewing matters; any attempt, however, at earnest 
 inquiry as to how the psychical disorder could have this result has never yet been 
 made. Consequently, a microcephalus or cerebral defect in idiots must in the 
 end also be declared the result of the idiocy. 
 
( 
 
 292 PATHOLOGICAL ANATOMY OF THE BRAIN. 
 
 Authentic reports of autopsies in which the condition of the brain is 
 stated to be normal are principally those of cases of uncomplicated recent 
 insanity, in the forms of melancholia and mania; and, as a rule, anatomi- 
 cal changes are frequent in proportion to the duration of the mental 
 disease, according as it presented symptoms of mental weakness, particu- 
 larly of profound dementia, and, finally, according as it was complicated 
 with paralysis. Still, cases presenting considerable acute anatomical 
 changes occur as recent cases of primary insanity (for example, the mania 
 of acute meningitis); and, again, many reports of autojisies of cases which 
 correspond to chronic cases of dementia and advanced imbecility show an 
 entire absence of any anatomical anomaly. Indeed, even of the most 
 severe mental affection known, paralytic dementia — in which also, gener- 
 ally speaking, by far the greatest and most constant lesions are found — 
 there constantly occur cases where nothing abnormal can be discovered by 
 the methods hitherto in ordinary use. In the present state of science, 
 such cases must be considered either as rare isolated observations, such 
 as occur in many other departments of pathology, and hitherto beyond 
 the reach of theoretical interpretation, or they must be accepted as proofs 
 of the fact that even the most profound weakness of the psychical pro- 
 cesses and of the motory acts may occur Avithout change of texture in 
 the brain — analogous to what is sometimes presented in the spinal cord; 
 or — and this is especially applicable to the last-mentioned case-^^we must, 
 according to a well-founded analogy, assume, that as when the naked eye 
 can observe little or nothing, still the microscope may probably reveal 
 important changes, so from future advances in such methods of research 
 still further results may with confidence be expected; certainly, therefore, 
 many of these cases ought to be viewed as affording only apparently nega- 
 '^ tive post-mortem results. 
 
 ^ The following figures may be cited as examples of the great differences which 
 exist among observers in regard to the number of diseased and healthy brains met 
 with amongst the insane. Tlie renowned Pinel in 261 autopsies found only 68, 
 Esquirol in 277 only 77, cases in which there were changes in the brain (Sc. Pinel, 
 'Recherches sur les Causes physiques,' etc., Paris, 1826, p. 9); Chiarugi in 100 
 cases found changes to exist in 95, Parchappe in 160 cases of uncompUcated men- 
 tal disease in 152("Traite de la Folie;"' Docum. necrose.,' Paris, 1841, pp.46, 
 141); Webster in 72 cases (' Med.-Chir. Transactions,' vol. xxvi., 1843, and ' Annal. 
 Med. Psych.,' Mai, 1844, p. 445) found lesions within the cranial cavity in a?/ of 
 them; Lelut in 20 cases of acute mania found this in only 3, and in chronic mania 
 and dementia in more than one-half of the cases ' Inductions sur la Valeur des Al- 
 terations de I'Encephale,' Par., 1836, pp. 63, 76). In the Vienna Asylum, in 171 
 autopsies, absolutely no abnormality was discovered in only 19 cases (' Wiener 
 Bericht,' 1858, p. 195); in Prague, in 318 cases, no abnormality of the brain or its 
 
 . membranes was discovered in 32 cases (R. Fischer, 1. c, p. 114). It may, perhaps, 
 be interesting to compare with these the anatomical statistics of a severe affection 
 of the spinal marrow, viz., tetanus. Wallis (' De Tetano Disquis. Arithmetica}.' 
 Diss. Hal., 1837, p. 24) found, in a collection of 38 autopsies of persons who died 
 of tetanus, evidences of inflammation of the nerve-cells (with softening, indura- 
 tion, and pigmentation) in 14 cases; other 41 cases presented inflammation without 
 degeneration (hyperaemia); the remaining 13 presented nothing abnormal in the 
 central organs. 
 
 ^ § 183. According to recent investigations, it may be considered a well- 
 ! established fact that the majority of post-mortem examinations of the in- 
 sane show anatomical changes to exist within the cranium. But is there 
 ever any specific alteration in insanity? If by this we mean a change 
 which everywhere, where generally an abnormal cerebral condition exists, 
 must invariably and in the same manner be present, then this question 
 must not only be answered in the negative, but considered as a priori 
 
PATHOLOGICAL ANATOMY OF THE BRAIN. 293 
 
 false. A simple pathological reasoning mnst prove to ns that the patho- 
 logical psychical symptoms, differing so widely amongst themselves which 
 are comprehended under the forms of melancholia, mania, dementia, etc., 
 cannot possibly always have the same alteration of the organ for their 
 foundation. It has never even been considered possible that, in diseases 
 of the spinal cord, the very various symptoms of disordered sensation and 
 movement could always proceed from one and the same anatomical lesion; 
 it must be quite as clear that the various anomalies of self-consciousness, 
 intellect, and will are not only capable of being excited, but must be ex- 
 cited, by very various diseases of the organ in question. On the other 
 hand, if we reverse the question of the specialty of the anatomical lesion"^ 
 the question becomes, — Are there not anatomical changes with whose ex- 
 istence it is always necessary that a marked disturbance of the mental 
 faculties, a mental disease, should exist? This must be answered in the ^ 
 affirmative. Indeed, there are certain structural diseases of the brain 
 which always cause considerable anomalies in the mental functions, even 
 insanity. A aiffused inflammation of the gray substance, extending over 
 a number of convolutions, has never been observed without profound men- 
 tal disturbance, extensive meningitis of the convex surface (in previously 
 robust individuals), considerable acute oedema of the greater hemispheres, 
 rapid bilateral atrophy of the convolutions; a deeply penetrating altera- 
 tion of the ventricular surface of any extent were never observed without 
 psychical disturbance, particularly mental weakness. Generally speak- 
 ing, it is far more the diffuse, the more general diseases, involving a large 
 portion of the cerebral substance, or a great extent of its internal or ex- 
 ternal surface, than the circumscribed localized diseases, which are found 
 in the insane; in particular, a comparison of the facts lying before us ap- 
 pears decidedly to support the view, that the most important and most 
 constant changes in the insane consist in diffuse diseases of the external 
 layers of the cortical substance — that is, of the surfaces of the brain jnd 
 of the membranes covering them; and it would be justifiable, in many 
 cases of insanity which correspond to palpable changes in the brain, to 
 consider that the chief and essential disease is that of the per iphery^ of 
 the brain. Many facts also could speak in favor of an essential participa- 
 tion of the ventricular surfaces; but this point is as yet not so well estab- 
 lished. Of the various sections of the cortical gray substance of the con- 
 volutions, we find the morbid change most frequent in the anterior and 
 middle (superior) portions of the great hemispheres; many surgical obser- 
 vations agree with this where, in loss of substance from injury of the an- 
 terior and superior portions of the hemispheres, there most constantly , 
 resulted aberration and weakness of the mental faculties. '^ 
 
 In the sequel we shall first describe the anatomical changes of the brain and 
 its membranes which are met with in insanity. We shall describe them individu- 
 ally, according to an anatomical arrangement as they appear in recent researches, 
 and then we shall, by way of summary, investigate what conditions of the organs 
 in the cranium most frequently correspond to the various forms of insanity. The 
 older pathological anatomical researches of Bonet and Morgagni, and the results 
 of Haller's historical studies, are collected by Arnold ('Observations,' etc., 1788); 
 the works also of Meckel, Chiarugi, Burdach, Greding, and Portal ought specially 
 to be consulted. Parchappe (' Recherches sur I'Encephale,' 2me Memoire, 1838) 
 has collected the most important of the older and more recent observations, espe- 
 cially those of his own countrymen. We may also consult Duhr, ' De vitiis qu^ 
 apud Amentes,' etc., Diss., Bonn, 1840; Giintz, ' De Anat. Pathol. Cerebri Vesa- 
 nonim,' Lips., 1853; Webster, 'Med.-Chir. Transactions,' 1849, vol. xxxii,, p. 115; 
 R. Fischer, 'Path. Anat. Befunde,' etc.. Lucern, 1854; Follet, 'Ann. Med. Psych.,' 
 Oct., 1857, p. 477; Voppel, several valuable papers in ' Giinsburg Ztschr.,' 1856, 
 
294 PATHOLOGICAL ANATOMY OF THE BKAIN. 
 
 vii., p. 161 
 
 Psychiatrie 
 
 1858), in many parts 
 
 1859. 
 
 A. The Cranium. 
 
 8 184. The influence of an abnormal conformation of the cranium is 
 naturally most considerable upon the brain when the process of develop- 
 ment is still progressing; this point has been already sufficiently noticed 
 (8 161). But it also appears that the same anomalies of the cranium 
 which, in their higher degrees, limit the development of the brain and 
 
 ' psychical faculties, and lead to idiocy, may, in their extremely moderate 
 deo^rees, in which for a long time no special deviation from normal func- 
 tion is apparent, likewise prove a predisposing cause of those aifections 
 of the brain which give rise to the symptoms of insanity. It is true that 
 we find the most various and most irregularly formed crania in individuals 
 who have always been healthy and even in talented and intellectual men. 
 But older (Foville) and more recent observers (W. Krause, Stalil, Seifert, 
 etc. ) distinctly that such irregularities occur in much greater proportion 
 amongst the insane. These consist of the forms already described in the 
 chapter on Idiocy — the too small, too low, and particularly the too short 
 crania; in short, the various forms of asymmetry and malformation, espe- 
 cially those produced by premature ossification of the sutures, or unilate- 
 ral or partial contraction of the cranial cavity, and, less frequently, 
 microcephalus, owing to moderate hydrops ventriculorum dating from 
 
 r early infancy. It cannot be said of any one of these malformations 
 that it IS especially unfavorable; all seem to exert a certain predisposing 
 influence, unless they are rectified by compensations {§ 161). The opin- 
 ion that cranial deformities may be especially the media of the hereditari- 
 ness of mental disease (Stahl, Voppel) is as yet still hypothetical; an 
 hypothesis, however, deserving the utmost attention and careful research. 
 A special form of abnormality of the cranium is produced by an artificial 
 deformity, to which Foville in particular has directed attention.' _ In 
 several provinces of France, especially JSTormandy and Gascogne, it is 
 customary to fasten the head-dresses of newly born children, by means of 
 bandages round the head, whereby their heads readily receive an elon- 
 gated, pointed, cylindrical form. In these districts inflammation of the 
 brain in children, and insanity in adults, is unusually common; a fact 
 which is attested by Esquirol, who often wondered at the large propor- 
 tion of insane in his native province (Gascogne), and by the statistics of 
 the local asylums. Eegarding the thickness and texttire of the cranial 
 
 , hones, almost every observer has noticed the frequency of anomalies of 
 the cranium in this respect. Greding found— concurring with more re- 
 cent observers — in 216 autopsies, 167 instances of thickening, 38 of ab- 
 normal thinness, of these bones. This increase in bulk, hyperostosis of 
 the cranium, is either associated with too great abundance of diploe- 
 tic substance, or, more frequently, with great thickness, sclerosity, of the 
 bone. It is the final product of an acute increase of nutrition, from 
 time to time repeated; or it may be of a chronic and, to a certain extent, 
 inflammatory process, which produces a successive series of new osseous 
 layers. As the hyperostosis takes place at the cost of the intra-cranial 
 space, and of the foramina and fissures through which the blood- 
 vessels pass to and from the brain, it is fr equently the cause of disorders 
 
 1 Foville, ' Anatomie du Systeme Nerveux,' etc., i., Par., 1844. 
 
PATHOLOGICAL ANATOMY OF THE BRAIK. 295 
 
 of tlie circulation within the cranium, partial or general hyperaemia or 
 aufemia; generally speaking, the changes of nutrition in the bones of the 
 cranium cannot be without influence upon the processes of circulation 
 and nutrition in the interior of the cranium. Considerable thickening 
 and sclerosis of the cranium occurs, moreover, especially in dementia and 
 epilepsy; in the latter it, as is well known, not unfrequently constitutes 
 the sole (of which no explanation has as yet been given) anomaly. De- 
 pressions resulting from former injuries, traumatic and syphilitic exos- 
 toses, are also frequently met with; partial hyperostoses, of the kind pre- 
 viously mentioned, may also result from injuries to the head; and their 
 gradual development corresponds with the psychical disturbance which, 
 perhaps, appears for the first time long after the injury has been in- 
 flicted. ^ 
 
 In many other cases among the insane, as also in epileptics, bony for- 
 mations upon the internal surface of the cranium, in the form of needles 
 and stalactites — sometimes, also, small exostoses, and osseous tumors 
 and plates, external and internal, on the cranium — indicate an extinct 
 localized inflammatory process, the products of wliich here remain in an 
 ossified form; and the abnormal adhesions of the dura mater to the in- 
 ternal surface of the skull, sometimes limited, at other times general, 
 frequently met with in the insane, have the same significance. 
 
 In the dura mater, scarcely any change is ever observed other than 
 an occasional thickening, and an excessive tension or great laxity, accord- 
 ing to the volume and consistence of its contents. The pathological 
 changes upon its inner surface are connected with the so-called parietal 
 layer of the arachnoid. 
 
 Larrey (' Clinique,' i., p. 329) has declared premature ossification of the craniall 
 sutures to be an important predisposing cause of melancholia and suicide. At 
 the present time these synostoses are considered primarily as causes of deformi- 
 ties of the cranium and of contraction of the cranial cavity — and it is certainly 
 establishetl, according to investigations of recent times, that to the latter a cer- 
 tain predisposing influence upon the origin of mental diseases is to be ascribed. 
 See Virchow, ' Gesamm. Abhandl.,' p. 937, u. a. a. O. ; Stahl, ' Ztschr. f. Psych.,' 
 xi., 1854, p. 545; xii., 1855, p. 559; xvi., 1859, p, 1; Seifert, ibid., xi., 1854, p. 198; 
 Ki-ause, 'Ztschr. f. ration. Medicin,' 1858, p. 73; Voppel, 'Ztschr, f. Psych.,' xiv., 
 1857, p. 175; and ' Archiv der Ges. fiir Psych.,' i., 2, 1858, p. 49.— The statement 
 of Kasloff, tliat in tlie insane there is frequently found a contraction (generally 
 of one side only) of the jugular foramen, appears to have no special value, as in- 
 equalities of tiiat kind are frequent in health: Hoffmann, however, declares 
 (Giinsb., 'Zeitschr.,' iii., p. 132) that, in reality, differences in size of tlie fora- 
 mina jugularia are more frequently met in the insane than in the healthy. 
 Finckelnburg has recently given the account of an interesting case of insanity 
 arising from acute puerperal osteomalacia of the cranium ('Ztschr. f. Psych.,' 
 xviii., 2, two cases). 
 
 Amongst those remarks upon the external parts of the brain, we have 
 to include the condition of the great vessels within the cranium. Rigid- 
 ity with atheroma or ossification of the larger arteries has been observed, 
 in various degrees, in numerous autopsies of persons who have been in- 
 sane. Comprehensive statistics regarding this occurrence are wanted. 
 Hitchman found, in 94 autopsies of insane females in Hanwell, atheroma 
 of the cerebral arteries in 37.' A similar condition may also be supposed ?> 
 to exist in the capillary arteries too small for investigation; in the sethere 
 is also frequently observed narrowing of the calibre, owing to the develop- 
 ment of connective tissue in the arterial walls, fatty degneration, etc. ; 
 
 ' 'Zeitschrift fiir Psychiatrie,' ix.. 1852, p. 124. 
 
296 PATHOLOGICAL ANATOMY OF THE BRAIN. 
 
 liero and there, also, small (microscopic) aneurismal or more general 
 dilatations. We may assume the existence of such states in tlie living iu 
 proportion as there is rigidity of the external, especially of the temporal 
 arteries; their significance is the greater the earlier the age at which it is 
 observed. The frequent occurrence of atheroma in connection with 
 heart disease, and its disturbing influence on the circulatory process, has 
 already been mentioned. 
 
 Larrey (' Clinique,' p. 330) has also remarked the occurrence of ossification of 
 the arteries as well in home-sickness as in melancholia (for example, in his com- 
 panion in arms, Monge, and in the celebrated Fourcroy, who both died melancho- 
 lic). In the case of a child twelve years of age who committed suicide, there 
 was found calcification of the cerebral arteries (Miiller, 'Oestr. Med. Jahrb.,' 1844, 
 Juli, p. 44). Thrombosis of tlie cerebral sinuses, occasionally discovered in the 
 bodies of the insane (see R. Fischer, 1. c, p. 0), has been hitherto observed only 
 as a final process in connection with pyaemia and the like; accordingly, there is 
 every reason to believe tha'3 the processes associated with this thrombosis, when 
 more chronic in their course, also play a part in the production of mental disease; 
 this was, perhaps, the case in a, case of thrombosis mentioned in the Vienna Re- 
 port (1858, p. 191). See p. 133. 
 
 B. The Arachnoid. 
 
 § 185. One of the most frequent anatomical changes in mental disease 
 is opacity, thicketiirig, and hypertrophy of the arachnoid. There is no 
 form of insanity where, if long continued, this has not been observed; it 
 is especially frequent, in conjunction with other more series lesions, after 
 paralytic dementia. It may generally be considered as the result of 
 former chronic hyperaemia and inflammatory stasis; it accordingly occurs 
 together with increase of the Pacchionion granulations — which depends 
 on analogous processes — under all circumstances where habitual cerebral 
 congestion existed during life, as in the case of drunkr.rds, who, indeed, 
 can rarely be considered as mentally healthy. 
 
 The products of former inflammation of the arachnoid may become 
 ossified, and we frequently find such osseous concretions with rugged 
 rough surfaces on the anterior surface of the brain ; on the other hand, 
 the development of connective tissue gives rise to abnormal adhesions to 
 the pia mater and cerebral cortical substance, and to the dura mater and 
 the skull: sometimes there is a complete agglutination of all these mem- 
 branous layers. Fine granulations of the external surface of the arach- 
 noid , similar to those of the ependyma ventriculorum, are, according to 
 L. Meyer, frequently observed along with other important changes — 
 thickening of the skull, opacity and thickening of the delicate mem- 
 branes, atrophy of the brain, etc. 
 
 Hypermmia of the arachnoid, especially in the form of ecchymosis, 
 frequently occurs as a sign of acute recent morbid processes: the same 
 may be said of the inflammation of the actually existing parietal layer of 
 the arachnoid, described by Virchow as pacchymeningitis interna, and 
 which is accompanied by the formation of firm pseudo-membranes, or 
 thin, delicate, almost gelatinous structures, interspersed with sanguineous 
 spots and an acute growth of cellular tissue.' With regard to the con- 
 tents of the arachnoid cavity, there is frequently found in it an increased 
 quantity of serous fluid, which is sometimes the result of habitual hy- 
 
 ' These changes, which were formerly described, especially by French observ- 
 ers (Calmeil, Bayle, Prus, Aubanel, etc.) as "pseudo-membranes of the arach- 
 noid," were for a long time viewed in Germany more as extravasations of blood 
 and the consequences of this; but Virchow has again pronounced them to be in 
 great part actual products of inflammation (pacchymeningitis). 
 
PATHOLOGICAL ANATOMY OF THE BRAIN. 297 
 
 perremia aiul a varicose state of the blood-vessels, sometimes of secondary 
 atrophy of the brain. It is always accompanied by thickening of the 
 membranes and infiltration of the pia mater. 
 
 Of special importance, however, are the frequent and spontaneous 
 hfemorrhages into the sac of the arachnoid (hgematomata) which have 
 been noticed by all observers, particularly in paralytic dementia, but not 
 unfrequently after other states of weakness, and even after acute or 
 chronic mania. In paralytic dementia, they often seem to occur during 
 the frequent attacks of cerebral congestion with loss of consciousness (see 
 § 178). Their diagnosis during life is, however, uncertain; because, on the 
 one hand, when slight they pass off without giving rise to any symptoms; 
 and, on the other hand, their symptoms— those of compression — may read- 
 ily be mistaken for those of atrophy and of encephalitis; and, further, 
 because compression of the brain may be due to other causes. 
 
 These extravasations of blood almost always occur upon the convex surface of 
 the hemispheres. As they have usually existed for a considerable length of time, 
 they are generally found in a state of transformation, which in certain cases may 
 lead to mistakes regarding their true nature. 
 
 When there is a considerable degree of extravasation, we observe a large float- 
 ing cyst under the dura mater, firmly adherent to the membrane previously de- 
 scribed, and almost free on the side in contact with the visceral layer of the 
 arachnoid. From the borders of the sac there often extends a thin, rust-brown 
 membrane, which finally terminates in a thin expansion (Rokitansky). The sac 
 contains a thick, dark-brown, serous fluid; this becomes clear according to the 
 age of the extravasation. The presence of this cyst causes compression and atro- 
 phy of the affected hemisphere, with contraction of the ventricles, increased con- 
 sistency of the cerebral substance, and mechanical hyperajmia and infiltration of 
 the meninges. The organized walls of the sac appear to be capable of being 
 formed as well by the peripheral layer of the coagulated fibrine as by the 
 fibrinous exudation of an inflammation originating secondarily around the clot. 
 
 It is otherwise when the amount of blood extravasated is inconsiderable. 
 These small extravasations, after absorption of the watery portion, leave behind 
 them at first rust-brown, then yellow, and afterwards almost quite colorless laniel- 
 Ise of coagulated fibrin. When observed while still recent, they consist of a mesh- 
 work of reddish fibres, sometimes as thin as those of a spider's web, and mixed 
 with small accumulations of blood-corpuscles: afterwards they become pale. 
 When they consist of several layers, it is probable that they have originated from 
 several successive extravasations, the most recent of which reveals the hemor- 
 rhagic nature of the whole. When the quantity is small, and after undergoing 
 transformation, these extravasations of blood finally constitute a simple expan- 
 sion upon the mternal aspect of the dura mater, which may be easily overlooked 
 or erroneously considered to be an inflammatory exudation. 
 
 In consequence of the work of Virchow (' Wiirzb. Verhandlungen,' 1857, ii., p. 
 134), which moreover was preceded by J. Hoffmann's (Gilnsburg, 'Ztschr.,' 
 iv,, 1853, p. 176) assumption that in these hemorrhages we have essentially 
 to do with hemorrhagic inflammations, our ideas in regard to these extravasa- 
 tions have been modified, inasmuch as it is now assumed that these ordinarily 
 occur between the layers and meshes of the product of previous pacchymeningi- 
 tis (pseudo-membranes, newly formed cellular tissue), the blood comes from the 
 newly- formed vessels of the latter, and therefore these hemorrhages generally 
 presuppose the existence of a former inflammatory process. These processes can- 
 not be considered as primary fundamental disorders of insanity (although in ex- 
 ceptional cases this may occur; see ' Wiener Bericht,' 1858, pp. 49-51); they occur 
 much more frequently in the course of already existing mental disease: the larger 
 hsematomata which compress the brain may, however, considerably aggravate the 
 symptoms of mental weakness. 
 
 Hemorrhage occurring beneath the arachnoid is quite a different and much more 
 rare process; it has no special significance in mental disease (being generally 
 traumatic, or consecutive in general hemorrhagic diathesis, etc.). Here the hem- 
 orrhage is from the pia mater, in which ecchymotic patches are observed ; the 
 blood may extend with the cerebro-spinal fluid into the ventricles and vertebral 
 canal. 
 
\ 
 
 V 
 
 298 PATHOLOGICAL ANATOMY OF THE BRAIN. 
 
 c. The Pia mater and Surface of the Brain. 
 
 § ] 86. The pathological conditions of the pia mater and of the sur- 
 face of the brain are so intimately connected, that it is necessary to con- 
 sider then simultaneously. 
 y Hypermmia of the pia mater (and also, in a greater or less degree, of 
 ' the contiguous cerebral surface) is frequently met within autopsies of the 
 insane. Its pathological significance has been greatly over-estimated, as 
 in the first edition of this work. Slight injection of the vessels, and 
 many states merely connected with the form of death, have been considered 
 pathological; but, exclusive of these, there are many cases in which, from 
 the changes found after death, increased fulness of the vessels during 
 life is to be assumed, and to this, therefore, a certain connection with 
 the morbid state is to be ascribed. We must here distinguish the follow- 
 ing two principal cases: — 
 
 A high degree of hypersemia of the pia mater and surface of the brain 
 may exist as an acute or sub-acute condition, especially in violent mania, 
 proving rapidly fatal; it appears as a very intejise, uniform injection of 
 the smallest vessels with small stellate ecchymoses;this maybe so intense, 
 that, having regard to the final symptoms of the disease, to it may be at- 
 tributed the fatal issue (apoplexia vascularis): there is frequently con- 
 nected with it a slight red softening of the cortical substance. Such states 
 are observed especially after the violent maniacal excitement of acute 
 delirium (§ 138); and should they not constitute the sole pathological 
 lesion in this form, they at all events play an important part in its produc- 
 tion. The existence of this hyper^emia during life is demonstrated, on 
 the one hand: by the' changes in the cortical substance of the brain, and, 
 on the other hand, by the symptoms, which are fr^^quently very marked, 
 of cerebral congestion. The mechanism of its production is, at present 
 — as of "active" hyperaemia m general — unknown. In the cortical gray 
 substance, this hyperaemia frequently presents itself as a red coloration of 
 of various shades, attaining sometimes, in very acute cases, the dark-red 
 hue of erysipelas (Foville), or as a spotted, variegated, striated coloration, 
 with various dark-red spots (small extravasations of blood). At the com- 
 mencement there is, at the same time, increase in volume and in consist- 
 ence of the cortical substance. This hypersemia may easily pass into 
 actual inflammation. 
 
 A very difierent, and to a certain extent completely opposite, kind of 
 congestion, more connected with the finer and larger veins, is due to a 
 varicose state and abnormal formation of sinuses of these vessels; there is 
 at the same time thickening and a3dema of the delicate membranes. This 
 form is altogether chronic in its course, and is frequently associated with 
 a greater or lesser degree of atrophy of the brain ("ex vacuo"); but it may 
 be also procured by heart-disease, pulmonary affections — perhaps func- 
 tional disturbances in the circulatory and respiratory functions, contrac- 
 tions of foramina, etc. ; in short, from mechanical causes which impede 
 the venous return. The significance of these hyperaemias, especially of 
 that originating ex vacuo, is naturally not very great: the mechanical ve- 
 nous stases, on the contrary, always exert, in individuals predisj^osed, a 
 certain influence upon the development and form of the disease. 
 
 Ekker (' De Cereb. et Med. Spin. Syst. Vas.,' Traject., 1853) has made compar- 
 ative miscroscopic measurements of the smaller blood-vessels and capillaries of 
 the cortical substance in mania, in dementia, and in health, and finds that in 
 niania they are considerably dilated. Ramaer found this to be the case with re- 
 gard to the pia mater. 
 
PATHOLOGICAL ANATOMY OF THE BRALN. 299 
 
 Ancpmia of the pia mater and cortical substance, wliicli is sometimes 
 met with in acute and chronic conditions as remarkable pallor of the 
 cranial contents, merits, under certain circumstance (deduced from the 
 clinical observations of the case), great consideration. It may be a co- 
 symptom of general anaemia. The great influence which this state of the 
 blood exercises, especially in females, and when acute in its origin, upon 
 the development of the most varied nervous and psychical anomalies, is 
 well known; and it is also admitted that all sorts of symptoms of irrita- 
 tion or ot torpidity of the central organs may originate from this source 
 alone. We cannot speak so positively regarding the cause and symptoms 
 of anaemia limited to the brain: contraction of the small arteries through 
 atheromatous processes may occasionally be assumed as the cause of spe- 
 cial anaemia. We must always consider that there is connected with this 
 an insufficient and abnormal nutrition of the brain. When the anaemic 
 state is developed slowly, and its course chronic, it appears principally to 
 give rise to states of intellectual weakness and dementia. 
 
 As the final result of chronic hypersemia ex vacuo, and from mechani- 
 cal causes, we observe chronic opacity and serous infiltration — oedema of 
 the pia mater. This oedema is extremely frequent, especially after chro- 
 nic mental disorders (for example, in the Vienna asylums in more than 
 50 per cent), and principally after the secondary forms with well-marked 
 mental weakness. It frequently occurs, therefore, in connection with 
 atrophy of the brain, chronic hydrocephalus, oedema of the brain, colora- 
 tion of the cortical gray substance, rigidity of the arteries, etc., — in short, 
 with states of marasmvis of the brain, — and appears to be of much less 
 significance in the origin and form of the psychical anomalies than the 
 marasmus itself. 
 
 § 187. Inflammation prope?' of the pia mater produces sometimes 
 merely a more or a less rapid thickening of the membranes, together with 
 adhesion of these to each other. In the cortical gray substance, how- 
 ever, the ordinary result of inflammation in the nervous tissue is soften- 
 ing, sometimes the secondary transformations of the softened tissue, and 
 in both together the important «f//!e5^o/i o/Z/ie pia mater to the surface 
 of the hrain. These consequences of meningo-cerebritis are ordinary 
 conditions in the latter periods of certain forms of insanity. -..^ 
 
 Eecent conditions of this kind rarely occur after states of depression, i 
 more frequently after acute mania (see § 186). Thus we frequently find, 
 after sudden death in acute mania, intense hypera^mia of the cortical 
 substance, particularly of its middle layers, with (inflammatory) wine or 
 violet-colored softening or sponginess of the tissue, which, if the patient 
 continues to live, undergoes a still more profound alteration — viz., hard- 
 ening and atrophy of the tissue, — dementia being the result. 
 
 These inflammatory softenings of the gray substance are sometimes 
 Yery difficult to recognize, when they occur with very little red coloration, 
 where the sole symptom of the inflammation is simple softening of the 
 cerebral substance to a uniform pulp. Many observers have found the 
 various layers of the gray cortex separately diseased: Sc. Pinel, redness of 
 the middle layer in mania; Baillarger, redness of the inner aspect of the 
 four internal layers, or of the three gray strata.' Most frequently the 
 inflammation is of the most superficial layers, combined with that of the 
 pia mater; the membrane adherent to the cortical substance takes with it, 
 
 ' " Recherches sur la Couche corticale."etc., ' Mem. de TAcad. de Medecine,' 
 1840, p. 172. 
 
300 PATHOLOGICAL ANATOMY OF THE BRAIN. 
 
 when detached, the superficial layers which are adherent to it, so that 
 an uneven, bloody, torn surface remains. Although this adhesion 
 and superficial softening, which particularly affects the convolutions 
 of the superior convex and internal contiguous surfaces of the hemi- 
 spheres, or even the Ammonshorn, occurs now and again in simple chro- 
 nic insanity, particularly in the secondary states of weakness, in the 
 mental disorders of the drunkard and epileptic, still it is by far most fre- 
 quent in paralytic dementia, and constitutes one of the most important 
 organic elements of this affection. Calmeil found it to be the most fre- 
 quent and most constant lesion in general paralysis; and Parchappe,' in 
 eighty-six cases, never saw profound and extensive softening of the cortical 
 substance, especially of its middle layer, absent; and the pia mater was 
 adherent to it in all but nine cases: in Vienna, again, this occurred in 
 not quite half of the cases of paralytic dementia.'' These inflammatory 
 softenings, here, as in other nerve-tissue, afterwards pass into a state of 
 atropliy and induration. It is alwa)'s the most superficial layer which 
 first becomes atrophied and indurated, and as a callous, thickened mem- 
 brane, adheres to the likewise dense and tendinous pia mater; the atro- 
 phied tissue soon becomes remarkably pale, and it is always in the most 
 external layer that it is most strongly marked. In the middle layers the 
 softening still continues, and the superficial layers may now be pulled off 
 as a coherent, somewhat consistent membrane, leaving behind an uneven, 
 pulpy surface, like that of a roasted apple when the skin is peeled off. 
 Should the middle layer be only moderately softened, we may be led to 
 the erroneous conclusion that no softening exists, if we do not take 
 the induration into account, remembering that it originally arises from 
 softening; the atrophy of the cortical substance through this kind of 
 shrivelling — analogous to the shrivelling of other parts after inflamma- 
 tion (cicatricial tissue) — may be so considerable as to reduce it to an 
 extremely thin layer, and it may even seem to have completely dis- 
 appeared. 
 
 All these disorders in which, according to the microscopic investiga- 
 tions of Rokitansky and other observers, increase of cellular tissue in the 
 gray substance is the principal result of the inflammation, are, as we 
 have before remarked, associated with dementia, and in particular with 
 paralytic dementia. 
 
 D. Tlie Cerebral Substance. 
 
 § 188. Volume and consistence of the brain. — In certain cases we find 
 in insanity, as well as in epilepsy, hypertrophy of the brain. In such 
 cases, the skullcap, after having been removed, cannot be replaced; the 
 membranes are thin and dry, the ventricles small, and the convolutions 
 flattened. Sc. PineF states that he has several times met with conditions 
 of this kind after paralytic dementia — increase of cerebral substance, 
 with atrophy of the cortical gray substance; a statement which, as yet, 
 
 1 L. c, p. 249. 
 
 ^ ' Wiener Bericht., 1858, p. 237. This statement is worth inentioning, as op- 
 posed to the opinion that chronic meningitis (often with inflammation of the 
 cortical substance) always lies at the foundation of paralytic dementia, or, to use 
 a better expression, of the paralytic mental disorders. Bayle, in 1855, thirty 
 years after the publication of his first work, returned to the opinion which lie 
 then held, viz., that this was the case; Duchek and L. Meyer suppose meningitis 
 to be the principal cause of the maniacal excitement in pai'alytic monomania. 
 
 3 'Path. Cerebr.,'p. 369. 
 
PATHOLOGICAL ANATOMY OF THE BRAIN. 301 
 
 stands so isolated that little value can be attached to it. The acute, dry- 
 swelling of the cerebral substance, which frequently occurs as an im- 
 portant epiphenomenon at the termination of many other cerebral dis- 
 eases (softening, tumors, etc.), is associated with anaemia of the brain 
 and its membranes, and in the present state of our knowledge may be 
 regarded as a peculiar acute hypertrophy, is, from its nature, very rare 
 after mental disturbances, and has no connection whatever with these 
 affections. 
 
 An important lesion, and one which is frequently met with in the 
 insane, is atrophy of the train — sometimes of the convolution, some- 
 times of the entire cerebral mass. It may appear primarily as senile or 
 premature marasmus of the brain; and it is then the fundamental cause 
 of an insanity which, from the first, has the character of mental weakness. 
 Or in the convolutions, especially in the cortical substance, it may be the 
 result of former structural disease, of inflammation, of prolonged 
 hyperaBmia, or of compression, owing to an extravasation or exudation, 
 just as the apex of the lung becomes atrophied when compressed by a 
 false membrane, or the heart under the influence of a strong pericarditic 
 exudation (through compression and destruction of the capillary system) . 
 
 The convolutions are thinner than in the normal state; but not 
 iinfrequently the atrophy takes place unequally, so that their surface, 
 especially in the anterior portion of the hemispheres, is uneven. The 
 gray substance, in particular, is considerably reduced in volume, and of 
 a brown or wine color, sometimes more incompact than in health, but 
 more frequently it is hard and shrivelled. The white substance is often 
 of a dirty-white color, very tough, and crumples up when cut; occasion- 
 ally it presents that porous form, that cribriform aspect, which is seen 
 in the substantia perforata of the normal brain, and which is the result 
 of chronic congestion and dilatation of the cerebral vessels in the 
 atrophied organ (etat crible). Here the cellular tissue presents that 
 special increase discovered by Rokitansky: the originally soft cellular 
 tissue becomes indurated and retracted, and takes the place of the nerve 
 elements which have disappeared; colloid masses, so-called corpora 
 amylacea, occur; the nerve-tubes are destroyed, shrivelled, etc. The 
 vacant space in the cranium is occupied partly by hypertrophy of the bones, 
 partly by thickening of the membranes, especially by oedema of the pia 
 mater, which sometimes lies over an atrophied convolution like a floating 
 sac, or by effusion of fluid into the cavity of the arachnoid; partly also 
 by dilatation of the ventricles, which become filled with fluid. The 
 vacuum sometimes even gives rise to sanguineous effusions — certain 
 apoplexies of the arachnoid may be due to this cause. 
 
 These general or circumscribed atrophies are frequently observed as 
 the fundamental lesion in secondary dementia, after former states of ex- 
 altation, after repeated attacks of delirium tremens, etc. In 122 cases 
 of chronic insanity observed by Parchappe,' there was a notable diminu- 
 tion in the convolutions in more than one-half; in 38 cases of recent 
 insanity, this was observed only once.^ But the states of atrophy of the 
 cortical layer and of the entire brain are especially peculiar to paralytic 
 dementia; they are not, however, constant in this affection, and the 
 degree of the dementia is not always in proportion to that of the atrophy. 
 
 The induration, sclerosis of the cerebral substance, is essentially an 
 
 ' L c, p. 140. 
 
 - And thi.3 in a patient affected for the third time. Obs. 22, pp. 19, 50. 
 
302 PATHOLOGICAL ANATOMY OF THE BRAIN. 
 
 increase of cellular tissue — the formation of true connective tissue, and 
 more or less atrophy. In tlie highest degrees, the medullary substance 
 is of the consistence of a hard-boiled egg, and when cut is as resistant as 
 a piece of caoutchouc; the color is generally dirty- white, blue, gray, 
 Avithout sanguineous points; and the fibration is, notwithstanding the 
 great hardness of the brain, indistinct. There are sometimes observed in it 
 traces of former apoplexies, with cavities filled with serum, which when 
 cut through resemble the holes in a cheese. This induration corre- 
 sponds entirely to the various forms of dementia. 
 
 Here, with atrophy of the brain, would be the place to consider the results 
 obtained by weighing the brain. A priori, we might imagine that the weight 
 would best show the diminution in volume. Two circumstances, however, ren- 
 der the estimation of results arrived at in this way very difficult: on the one 
 hand, the weight of the brain varies considerably, even in healthy individuals; 
 and on the other hand, the specific gravity of the brain in diseases appears 
 occasionally to undergo such deviations that the weighing of the organ must 
 thereby afford less useful results. Generally, however, the entire study of the 
 extraordinary and of the pathological weights of the brain is in a great measure 
 confusing and undeserving of confidence (see R. Wagner, ' Nachr. v. d. G. A. 
 Universitat zu Gottingen,' 1860, No. 7, No. 16). The general results at which 
 Parchappe arrived (1. c, p. 142, and 'Comptes rendus,' 31 Juill., 1848) appears to 
 me to be the most practical, namely, that an average moderate diminution of 
 weight takes place in insanity ganerally, and particularly in chronic cases; 
 he even considers it proved that there is a gradual diminution in the weight 
 of the brain corresponding to the progressing diminution of the intelligence. 
 Further, the more recent investigations (Skae, 'Med.-Chir. Review,' Jan., 1853; 
 Sankey, 'Journal of Psychol. Med.,' 1855, p. 573; Bucknill, 'Brit, and For. 
 Review,' Jan., 1857) regarding the mode of determining the specific gravity in 
 certain abnormal states appear to be of interest: tlie older investigations in this 
 direction (Meckel, 1764, Leuret and Mitivie. 1833) were entirely without result. 
 It must be admitted that discrepancies exist between these new investigations, 
 but they are such as may in part be accounted for. While, for example, Skae 
 and Sankey consider that in general there is an increase in the specific gravity of 
 the brain in insanity, Bucknill found an average lower specific gravity: still he, 
 too, found an increase in " interstitial albuminous deposit in the brain " (increase 
 of connective tissue?); audit is indeed possible that the two other observers 
 include many brains of this description. According to Bucknill, there is also a 
 kind of atrophy of the brain in mental disease which manifests itself solely by 
 diminution of the specific gravity— a kind of fatty degeneration of the cerebral 
 substance without diminution in volume. But the methods hitherto employed 
 in determining the specific gravity of the brain are so unsatisfactory, tliat even 
 these statements cannot be considered conclusive; they rather she w the necessity 
 of more perfect modes of investigation. 
 
 § 189. Amount of blood in the brain. General hypersemia of the 
 entire brain is sometimes observed in recent cases of insanity; in its 
 highest degree (turgescence of the entire brain, dark-red color of the 
 cortical substance, strong injection of the pia mater and arachnoid, rosy 
 hue of certain portions of the white substance), it is sometimes the cause 
 of sudden death in acute mania, after having produced apoplectiform 
 collapse. Altogether it is more rare than hyperaemia limited to the pia 
 mater and cortical substance of the convex surface of the brain. When 
 the disease has lasted for a long time, and especially wiY/^m the atrophied 
 brain, the amount of blood is generally diminished. We have already 
 spoken of the mode of production of cerebral hyperaemia. Very often it 
 is limited to certain parts of the brain; in the white substance its higher 
 degrees appear as variegated spots of a rose, violet, or lilac color, and 
 may give rise to exudations and inflammatory softenings. 
 
 The various observations regarding the frequency of apoplexy in the 
 insane do not all correspond. Esquirol, Georget, Guislain, Jacobi, and 
 
PATHOLOGICAL ANATOMY OF THE BRALN, 303 
 
 F. Hoifmann seldom met with it; Webster, on the contrary, found effu- 
 sion of blood into the brain 13 times in 72 autopsies;' 1 have seen it 
 occur in acute mania. It is at least certain that traces of former small 
 apoplectic clots are by no means rare; sanguineous apoplexy also may be 
 sufficient to produce incurable dementia, by the destruction of cerebral 
 substance, the compression, the subsequent inflammation and induration 
 of neighboring tissue, which it entails. 
 
 Amount of serum in the train (cedema of the brain). — Special atten- 
 tion has been directed to oedema of the brain by the work of Etoc- 
 Demazy.* According to his opinions, which are also in part advocated 
 by Sc. Pinel, we are led to consider acute cedema of the brain as essential 
 in melancholia with stupor and immobility (§ 133), and as the funda- 
 mental cause of this entire group of symptoms. This statement, how- 
 ever, has not been confirmed: cedema of the brain is not at all constant 
 in this affection, and neither in mental nor in general pathology do we 
 know of any group of symptoms which is quite a characteristic of this af- 
 fection of the brain. In mental, as in other diseases, we find slight 
 cedema of the brain under the most various circumstances : in its higher 
 degrees it is sometimes observed after states of exaltation and of de- 
 pression, but especially after paralytic dementia; in general, it is asso- 
 ciated with anaemia and more or less atrophy of the brain. 
 
 E. The Ventricles and Internal Parts. 
 
 § 190. Dilatation of the veiitricles (hydrocephalus chronicus) is 
 frequently found in the insane. It rarely can be considered as having 
 originated in infancy; in the great majority of cases it is developed 
 during the disease, together with diminution of the cerebral mass and 
 more or less disease of the ventricular surface. Most frequently it is 
 merely the necessary result of atrophy of the brain. It is observed, 
 therefore, after all forms of insanity {i. e., it may have originated in 
 these conditions, even in states of depression or exaltation of sentiment), 
 but more particularly after protracted states of weakness, and, above all, 
 after paralytic dementia (together with cedema of the pia mater, the 
 cerebral substance, increase of cellular tissue in the latter, osteophytes, 
 etc. ) : it is also frequent in the insanity of drunkards. In very few 
 cases can it be considered the primary process and fundamental cause of 
 the symptoms {i. e., acts by paralyzing the mental faculties through the 
 pressure which it exerts) ; in general it is to be considered as secondary, 
 consecutive to atrophy of the brain, the latter state being the essential 
 pathological lesion. 
 
 Partial contractions and shortening of the ventricles, and adhesions 
 of their surfaces (particularly in the posterior and inferior cornua), are 
 by no means rare in health, but much more frequent in insanity; Greding, 
 Esquirol, Ferrus, especially Bergmann' (in chronic dementia — adhesion 
 of the posterior cornua, according to his account, in several hundred 
 cases), have observed these anonalies; and the latter considered them — 
 but incorrectly — to be the special pathological lesions in chronic demen- 
 
 ' ' Med.-Chir. Transactions,' vol. xxvi., 1843, p. 413, In his recent work 
 (1850) he states that in sixty-seven post-mortem examinations of patients in 
 Bethlehem he found extravasation of blood in fifteen. 
 
 5 De laStupidite consideree chez les Alienes,' Paris, 1833 (ten cases and four 
 autopsies). 
 
 3 ' Ztschr. f. Psychiatrie,' 1844, No. 2. 
 
304 PATHOLOGICAL ANATOMY OF THE BKAIN. 
 
 tia. They may be regarded as results of sliglit inflammation of the epen- 
 dyma, and as such have a certain though very inconsiderable pathological 
 interest. 
 
 In chronic hydrocephalus we generally find the epeudyma ventricula- 
 rum thickened, covered with granulations, and of a leathery consistence; 
 more rarely the ventricular surface is covered with false membranes or 
 cretaceous plates: the former are- sometimes found in paralytic dementia.' 
 
 The presence of so-called hydatids of the vascular plexus is too common to be 
 considered an essential alteration : Devaux found a free hydatid as large as an 
 acorn in the right lateral ventricle (with ecchymosis of the cerebral surface) after 
 nostalgic melancholia with violent headache (Nasse, ' Zeitschrift f. Anthropolo- 
 gie,' 1823, ii., p. 501); Bergmann discovered a formation of pretty large crystals 
 of double phosphate in both plexus chorioidei, in a case of mania with mental 
 weakness. 
 
 Recent, especially white softenings of the ventricular surfaces occasionally 
 occur as the cause of death in acute cases; their chronic induration is sometimes 
 associated with dilatation of the ventricles in atrophy of the brain (paralytic de- 
 mentia). 
 
 Regarding the pmeaZ gland (see also Greding, ' Vermischte Schrif ten,' Al ten- 
 burg, 1781, p. 18U), Bergmann has already shown, in his earlier works (Nasse's 
 'Zeitschrift f. Anthropol. ,' 1825, i., p. 173; Holscher's 'Annalen,'!. c, pp. 510, 
 5a3, 529, etc.), that in autopsies of the insane we frequently find considerable tume- 
 faction and luxui'ious growth of tiie vascular plexus around the gland, in part to- 
 gether with an almost general hypertrophy of its pia mater, a border of granula- 
 tions, an adhesion of the pineal gland to the vascular plexus on the lower aspect 
 of the corpus caUosum, and the like. Subsequently ('Zeitschrift f. Psychiatrie,' 
 1844, 1. c.) this observer declares, in numerous publications, the abnormal tumefac- 
 tion of the vascular plexus, displacement and adhesion of the pineal gland, to be 
 one of the most constant alterations in chronic partial dementia: this opmion, 
 however, does not appear to me to be at all fotmded on fact. 
 
 The pituitary gland also presents in insanity as well as in epilepsy, occasional 
 examples of pathological change. Amelung (Nasse, ' Zeitschr. f . Anthropologic, ' 
 1824, p. 352) found it transformed into thin purulent matter, after monomania 
 with fixed ideas and suicidal tendencies; F. Arnold ('Bermerkungen iiber den 
 Ban des Hirns und Riickenmai'kes,' p. 203) observed suppuration of its posterior 
 lobule after general paralysis. In a maniac in the Vienna Asylum there was found 
 — together with hydrocephalus chronicus, oedema meningum et cerebri, and exos- 
 tosis basis cranii — hypertrophy of the gland ; its posterior lobe was transformed 
 into a soft tumor of a grayish-red color, almost as large as a walnut, and filled with 
 a creamy fluid; the seUa turcica was considerably atrophied ('Wiener Bericht, 
 1858, p. 189). 
 
 The cei'ebellum has as yet received comparatively little consideration; never 
 theless, Bergmann's observations regarding the ventricular surfaces — granulatioo 
 in the fourth ventricle, etc. — refer also in great part to the cerebellum, and S'o- I 
 ville states that he has frequently met with adhesions in the pia mater to its sui'- 
 face along with a certain constancy of the symptoms during life. Besides, there 
 are also many descriptions of rare diseases of the cerebellum in paralytic demen« 
 tia by Arnold, Stolz (' Oestreich. Jahrbucher,' Marz, 1844, p. 268), Lelut ('Aim6 
 Med. Psychol.,' Mai, 1844, p. 462), etc. 
 
 § 191. In reviewing these anatomical changes in the brain, it may 
 perhaps surprise us that no mention has been made of the serious de- 
 generations which result from the production of pseudo-plastic forma- 
 tions within the organ (cancer, tumors, upon the basis cranii, ^ibercles, 
 parasites, etc.). In reality these affections are rarely met with in asylums 
 for the insane. It is not that they do not produce serious psychical ano- 
 malies — in the latter stages of these cases states of mental weakness, and 
 sometimes even profound dementia,^ are usually jn-esent, and at the com- 
 
 ' For example, Macquet, ' Annal. Med. Psych.,' Mai, 1844, p. 464. 
 
 '^ In the last stages of tumors, encephalitis, abscess of the brain, etc., there is 
 frequently such profound dementia as is not even seen in the lowest grade of 
 idiocy. These pj,tients occasionally behave as animals do after the abstraction or 
 the hemispheres. 
 
PATHOLOGICAL ANATOMY OF THE BKAIN. 305 
 
 mencement they arc frequently accompanied by a melancholic disposition 
 or by maniacal excitement. These, however, are not in general the most 
 striking symptoms; the commencement is rather characterized by "apo- 
 plectic symptoms,'" especially severe motory disorders (convulsions, 
 paralyses, etc.); and these are the more constant according as the morbid 
 process affects the cerebral substance to only a certain depth: the existing 
 psychical disposition, the loss of memory, etc., are merely accessory 
 symptoms — therefore (p. 9) the affection is not classed amongst mental 
 diseases, and the patient is not sent into an asylum. In this relation and 
 its immediate consequences lies the simple explanation of the apparent 
 anomaly brought so prominently forward by the opponents of the patho- 
 logical anatomical mode of consideration, viz., that very slight anatomi- 
 cal changes of the brain produce an effect (insanity) which the most 
 serious and most profound alterations do not. Nevertheless, profound 
 alterations of the cerebral substances are constantly and frequently found 
 after death in the insane. 
 
 I again refer to the cases of Stoltz and Lelut, to a case cited by Romberg (Nasse, 
 'Zeitschrift fur Antliropologie,' 1828, iii., p. 195), where, after mania without par- 
 alysis, four " hydatids " were found penetrating several lines into the cortical 
 substance, together with pseudo-membranes upon the arachnoid, and mentions 
 the following cases by way of example: — In a melancholic in the asylum at 
 Prague, there was found in the right cerebral hemisphere a cancerous nodule as 
 large as a hen's egg, together with opacity and thickening of the membranes and 
 slight chronic hydrocephalus (R. Fischer, 1. c, p. 89); in a patient wlio, after 
 headache and excitement, fell into dementia, there was found a fibroid tu- 
 mor the size of an egg in the centre of the brain, involving the septum, fornix, 
 etc. ('Wiener Bericht,' p. 190); the point of a penknife surirounded by hardened 
 tissue in the cerebral substance after dementia with epilepsy (ibid., p. 191); a 
 sharp osseous concretion in the fourth ventricle, with oedema of the membranes 
 after mania; recent and old tubercle of the brain after dementia and mania 
 (ibid.); tuberculosis of the pia mater with encephalitis (ibid., p. 212); chronic tu- 
 berculosis of the brain with mental disease of one year's standing (Finkelnburg, 
 Virchow's 'Arch.,' xx., 1861, p. 524); finally, the numerous cases of cysticercus 
 of the brain, regarding which the following works maybe consulted:— Med. -Chir. 
 Transact.,' vol. xxvii., 1844, p. 12; Gunsburg, 'Zeitschr.,' i., p. 62; ii., p. 274; 
 Virchow's 'Archiv,' ii., p. 84; ' Correspondenzblatt fur Psychiatrie,' 1858, 8; 
 'Zeitschrift fiir Psychiatrie.' x., 1853, p. 294; xv., pp. 426, 680; xviii., p. 66; R. 
 Fischer, 1854, 1. c, p. 8.: 'Wiener Bericht,' 1858, pp. 190, 207, 268, 308; 'Archives 
 Gener.,' 1859, Mars; 'Gaz. d. Hopit.,' 1860, 22. 
 
 A consideration of the pathological changes which have been described 
 shows that the principle expressed in the statement made by Esquirol 
 towards the end of his famous career (1835), viz., that pathological ana- 
 tomy has done nothing towards establishing the material conditions of 
 insanity,_ no longer holds good; it may even be admitted that from the 
 pathological anatomical stand-point of that time something definite could 
 be said regarding mental diseases. Keeping in view the great and well- 
 constituted results, negative as well as positive, and altogether excludino- 
 rare and more isolated observations, we shall attempt, in the folloAving 
 paragraph, to compare the various states of psychical disease with the 
 anatomical conditions which most frequently correspond to them. With 
 this view, we shall divide the various cases of insanity into three classes: 
 1st, Acute recent cases of melancholia and mania; 2cl, Chronic cases of 
 protracted, exhausting melancholia and mania, partial dementia and de- 
 mentia; 3d, Paralytic dementia. 
 
 ' See ' Diagnost. Bemerkungen,' etc., by the Author, 1. c. 
 20 
 
306 PATHOLOGICAL ANATOMY OF THE BRAIN. 
 
 I. Acute Insanity. 
 
 § 192. (1.) As in a considerable number of cases of acute insanity the 
 brain, on anatomical examination, appears perfectly healthy, it must, in 
 the present state of science, be assumed that the symptoms very often 
 depend upon simple nervous irritation of the brain, or upon disorders of 
 nutrition which are as yet unknown. 
 
 (2.) When palpable disorders exist, they consist chiefly in anaemia, 
 with more or less serous infiltration, or (more frequently) in hyperaemia 
 of the entire brain, and particularly in simple and ecchymotic hyperaemia 
 of the delicate membranes and cortical gray substance. These hypere- 
 mias appear sometimes to produce, and at other times merely to accom- 
 pany, other morbid processes of nutrition which lead to further conse- 
 quences. 
 
 (3.) This hyperaemia is frequently accompanied by thickening and 
 opacity of the membranes, the result of chronic stasis. This_ may, in 
 certain cases, proceed from the same causes as the hyperaemia itself; in 
 others, however, it may be the result. 
 
 (4.) There is no constant distinct anatomical distinction between 
 melancholia and mania: the disorders in both forms are, nevertheless, not 
 entirely identical. 
 
 (5.) In melancholia the brain appears perfectly healthy more fre- 
 quently than in mania;' when an anatomical lesion exists, it does not 
 consist in hyperaemia so frequently as in mania, but rather in anaemia with 
 greater consistence of the cerebral substance, or with more or less serous 
 infiltration. 
 
 (6.) Mania presents more rarely than melancholia no lesion or simple 
 hypersemia. The hyperaemia is more profound and more intense (some- 
 times attaining to an erysipelatous hue of the entire gray cortex), and it 
 more frequently proceeds to inflammation and softening, which affects 
 the cortical substance in only certain layers, sometimes the middle, some- 
 times the external layers. The rapid occurrence of extended softening of 
 this kind frequently corresponds to a state of profound dementia which 
 precedes death. The intense hyperaemias which accompany or produce 
 the softening appear partly to determine the violent maniacal excitement. 
 Frequently also, when the mania is of long standing, there is found pig- 
 mentation of the cortical gray substance. 
 
 II. Clironic Insanity. 
 
 (1.) Cases in which no anatomical lesion is found are here rarely 
 observed; the same may be said of simple hyperaemias; opacity and 
 thickening of the membranes are common (much more so than in acute 
 insanity). 
 
 (2.) Many cases present lesions which are never observed in the 
 former class: namely, atrophy of the brain, particularly of the convolu- 
 tions; chronic hydrocephalus, effusions into the subarachnoid space, 
 pigmentation of the cortical substance, extended and profound sclerosis 
 of the brain. 
 
 ' Besides many observers whom we have already mentioned,. Bertolini and 
 Bottex agree in this; likewise most of the more recent observers: see Vienna 
 Report, p. 198. 
 
PATHOLOGICAL ANATOMY OF THE BRALN. 307 
 
 (3. ) Here, softening is not so frequently met with in the superficial 
 cortical layer as pigmentation, superficial induration and adhesion of the 
 pia mater; all in very various degrees. 
 
 (4.) In these states, but perhaps also in the acute stages, slight 
 superficial inflammations of the ventricular walls must necessarily be of 
 frequent occurrence; the granular condition of the ependyma and the 
 frequent adhesions of the ventricular surfaces demonstrate this. 
 
 (5.) When the disease reaches the chronic stage, hyperasmia ceases; 
 when it does exist, it is of the nature of hyperaemia ex vacuo; some- 
 times the more or less atrophied brain is ansemic and cedematous. All 
 the changes in the brain are less indicative of active processes than of 
 consecutive states and residues of former processes, and of marasmus — 
 corresponding to the character of the symptoms observed during life. 
 
 (6. ) Between partial dementia and dementia there is as little differ- 
 ence, anatomically, as betAvcen melancholia and mania: still, generally 
 speaking, considerable atrophy of the brain corresponds to a condition 
 of profound mental weakness. (The reverse, however, does not hold 
 good.) 
 
 III. Paralytic Dementia. 
 
 (1.) Even here, cases are occasionally met with where no palpable 
 changes exist appreciable to the naked 'eye; but these are rare and of 
 slight significance, as we knoAV that in such cases the microscope reveals 
 important anatomical changes. 
 
 (3.) The changes most frequently observed in general paralysis are 
 great oedema of the membranes, adhesion of the pia mater to the cerebral 
 surface, grayish-red softening, or coloration; and partial, superficial in- 
 duration of the cortical substance, with increase of connective tissue and 
 destruction of the nervous elements. 
 
 (3.) Atrophy of the whole brain, or especially of the convolutions, is 
 very common; together with its further consequences, induration of the 
 cerebral substance, dilatation of the ventricles, etc. The increase of 
 cellular tissue and development of true connective tissue occurs fre- 
 quently in the white substance, either generally diffused or limited to 
 certain portions. 
 
 (4.) Pachymeningitic processes, meningeal apoplexy, degeneration of 
 the cerebral arteries, are common. 
 
 (5. ) The degeneration of the nerve substance, and in particular the 
 increase of connective tissue with destruction of the nervous elements, 
 may extend to the spinal cord (Rokitansky, Joffe, Mildner, Gulliver); an 
 important circumstance in regard to the symptoms observed during life. 
 
 (6.) The anatomical changes in general paralysis are more evident, 
 more characteristic, and more general than in any other form of insanity: 
 still, they are not always identical, but constantly present certain varie- 
 ties. This appears to depend upon the fact, that in some cases one and 
 in other cases another element of the disease is the most prominent (it 
 may be meningitis, or atrophy of the entire brain, or sclerosis of the 
 cortical substance) ; and this may depend upon the more rapid or more 
 acute course of the disease. 
 
 From what has been said, we arrive at the following general conclu- 
 sions: — 
 
 [a.) Insanity, whether acute or chronic, may be the result of simple 
 abnormal excitation or nutrition of the brain, without the existence of 
 any palpable change. 
 
308 PATHOLOGICAL ANATOMY OF THE BRAIN. 
 
 {b.) In the majority of cases this is not the case; it depends upon 
 palpable diseases which are generally distinct in proportion to the dura- 
 tion of the insanity. These consist partly in hyperemia and inflamma- 
 tory processes, which, as a rule, are first observed in the pia mater and 
 cortical substance, penetrate to various depths of the cerebral substance, 
 and, if not arrested, terminate in incurable destruction and atrophy of 
 the cerebral substance — a lesion to which the group of symptoms of de- 
 mentia corresponds. 
 
 (c.) Frequently, however, it is non-inflammatory changes in nutrition, 
 recognized only in their final results — viz., marasmus of the brain — which 
 correspond to the serious secondary forms. The initiatory periods and 
 stages of development of these nutrient changes, which correspond to the 
 primary forms, as yet are uninvestigated. To these processes we may 
 give the name of atrophic irritation of the brain. 
 
 (d.) Our knowledge of symptoms'is not yet so far advanced as to en- 
 able us to state with certainty whether, in a given case of insanity, ana- 
 tomical changes exist, and where they are situated; but the facts which 
 we observe enable us to speak with as much confidence as we can in any 
 other diseases of the nervous system. 
 
 {e. ) The most important circumstance in regard to anatomical diag- 
 nosis and to prognosis is the existence or non-existence of severe motory 
 disorders, in particulai' of general progressive paralysis. 
 
PATHOLOGICAL ANATOMY OF OTHKK ORGANS. 309 
 
 CHAPTER 11. 
 THE PATHOLOGICAL ANATOMY OF OTHER ORGANS. 
 
 § 193. In describing the pathological changes which take place in 
 other organs, we shall restrict ourselves to those which are practically 
 most important, or theoretically most interesting — in the first place, in 
 so far as they are amongst the most frequent causes of death in the 
 insane, and in general possess great clinical interest; and, in the second 
 place, in so far as they occur with a certain degree of regularity in those 
 cerebral diseases, or even have essentially a pathological connection with 
 them. All these changes are of the utmost importance to the physician; 
 and numerous fallacies have been introduced into the theory of insanity 
 by the narrow views which have been held regarding them. Thus, if in 
 an insane person disease of the spleen or cirrhosis of the liver was discov- 
 ered, the conclusion was at once arrived at that diseases of this kind only 
 were to be considered as physical conditions of insanity; examples were 
 collected on all sides, and a theory of the psychical significance of the 
 viscera was framed. Such theories, although every day refuted by obser- 
 vation, and at the present time generally abandoned, still occasionally 
 give rise to misconceptions. It is now beyond doubt that the insane 
 may die of any disease, whether acute or chronic, which affects other 
 persons; and the following remarks may be considered as supiDlementary 
 to what has already been said regarding etiology. 
 
 Of general or blood diseases, those most frequently met with in the 
 insane, especially in females, are the anmmic states (see § 106). In spite 
 of the most careful nourishment, profound anaemia with a waxy hue of 
 the entire skin and a general puffed-up appearance is sometimes s>Qep. 
 during the course of the cerebral affection which lies at the foundation of 
 general paralysis. There (1849) found in these patients, even although 
 suffering from pneumonia, a serous condition of the blood, the clots being 
 without consistence. Many inmates of asylums for the insane, paralytics, 
 dements, etc., die from anaemia and marasmus without any serious local 
 affections, except, perhaps, a slight degree of atheroma of the arteries 
 being discovered. 
 
 Typhus fever is rarely met with in the insane ; nevertheless, it some- 
 times occurs in an epidemic form, as, for example, in the asylum at 
 Schleswig (Gaye).' Sometimes the fever exercises a persistent beneficial 
 influence upon the insanity (in Schleswig this was observed four times in 
 forty-nine cases, two being of mania and two of melancholia). 
 
 Cholera makes more or less considerable ravages in asylums. It is 
 sometimes very fatal amongst the old and infirm inhabitants of institu- 
 tions devoted to chronic cases (for example, Salpetriere). The remark- 
 able immunity which several asylums enjoyed from epidemics of cholera 
 (for example, Bethlehem in 1832, 1848, and 1849) does not at all depend 
 upon the insane being less predisj^osed to its attack. The disease seldom 
 
 Ztschr. fur Psychiatrie,' ix., 1852, p. 173. 
 
310 PATHOLOGICAL ANATOMY OF OTHER ORGANS. 
 
 exercises a beneficial influence upon the insanity; it more frequently 
 exercises an unfavorable effect both on the bodily and mental condition 
 (marasmus). 
 
 Dysentery is very common; epidemics of it have been occasionally 
 observed (for example, by Stoltz).' The mortality is generally consider- 
 able. In the epidemic just referred to, the disease had no appreciable 
 effect upon the mental disturbance ; even periodic attacks of mania were 
 neither interrupted nor prevented. 
 
 Regarding intermittent fever, see p. 132. 
 
 Cancer appears to be rare amongst the insane. In the Vienna Asylum, only 
 six cases were met with in 384 autopsies. 
 
 § 194. Amongst the local affections frequently met with in insanity, 
 we may mention, in the first place, that much-discussed affection of the 
 external ear usually described under the name of haematoma of the ear 
 (gethilmatoma, also erysipelas of the external ear). The skin of the con- 
 cha becomes swollen, smooth, and tense, and indistinct fluctuation may 
 be felt ; the entire ear becomes painful, hot, and red. If cut into, there 
 is observed a cavity filled with half-clotted, half-fluid blood, which rap- 
 idly fills again after being emptied. Sometimes the cavity empties itself 
 by spontaneous rupture. Upon closer examination, the tumor is seen to 
 consist of an extravasation of blood under the perichondrium, which is 
 thereby separated from the cartilage. In a few weeks, the redness and 
 swelling usually abate; there remains more or less thickening of the 
 affected part — according to some, owing to the formation of new layers of 
 cartilage — which is afterwards followed by shrivelling and persistent 
 deformity of the concha auris. The mode of origin of this disease is 
 still the subject of discussion, and there already exists an abundant lite- 
 rature on the subject — more so, indeed, than the question is worth. 
 While one class of observers consider it to be a process of spontaneous 
 origin more or less connected with the changes within the cranium (for 
 example, Hoffmann,'' a hgemorrhagic inflammation of the cartilage, anal- 
 ogous to haemorrhagic pachymeningitis; others, as connected with cere- 
 bral congestion), another class declares that it is solely caused by external 
 circumstances, — by injuries, sometimes by knocking the head against the 
 bedposts— at other times, and particularly, by the pulling and tugging 
 which the ear undergoes by cruel and barbarous attendants. This view 
 of a purely accidental and traumatic origin, which has been in recent 
 times advocated especially by Gudden,' is the most probable. The affec- 
 tion is almost solely confined to male patients (by male attendants) and 
 to asylums. It occurs more frequently in the left ear (suits the right 
 hand^of the attendant); it is rapid in its origin; the impression of the 
 finger-nails is sometimes observed; and the affection can, by care on the 
 part of the attendants, be made entirely to disappear in well-regulated 
 asylums; 
 
 Ludwig states that he has often observed, by means of the ophthalmoscope, 
 changes in the eyes of the insane, and that these diseases are sometimes perma- 
 nent, sometimes transitory— coming and going with the paroxysms (the latter 
 consisting of hyperemia of the internal parts of the eye). These facts, though 
 not sufiSciently minute, are very interesting, and merit further investigation. 
 
 1 ' Psych. Corr.-Bl., 1857, No. 3. 
 
 2 Giinsb., 'Ztschr.,' vi., p. 250. 
 
 3 'Ztschr. f. Psych.,' xvii., 1860, 2. 
 
PATHOLOGICAL ANATOMY OF OTHER ORGANS. 311 
 
 § 195. Amongst the other organic alterations met with in the insane, 
 those of tJie thoracic organs are, on account of their great clinical import- 
 ance and frequently fatal termination, the most important. 
 
 I. Ai7iormalities of the organs of res2nration. — The most important of 
 these are pneumonia, pulmonary gangrene, and phthisis. A large pro- 
 jiortion of the insane die of pneumonia, especially those with weak and 
 deteriorated constitutions, and, in particular, many general paralytics. 
 Calmeil found pneumonia to he the cause of death in one-fifth; Aubanel 
 and Thore, in one-seventh. In Sachsenberg, it was the cause of death in 
 one-ninth, and in the Schleswig Asylum (Gaye),' in one-sixth of the fatal 
 cases. As in hospitals for old men, so in asylums for the insane, there 
 occur, especially in the winter months, many sudden deaths from this 
 cause. These patients do not show during life the ordinary series of 
 symptoms of pneumonia. Rigors are seldom observed; likewise cough, 
 expectoration, and pain. Dyspnoea, on the contrary, is usually observed 
 in a greater or less degree. The only symptom which renders our diag- 
 nosis certain is naturally the presence of the physical signs. In every case, 
 therefore, where a patient shows symptoms of illness (loss of appetite, 
 thirst, foul tongue, and increased frequency of pulse), the thoracic organs 
 ought to be minutely examined. The course of pneumonia, especially in 
 paralytics, is generally rapid, and therapeutic measures are quite as inef- 
 fectual as in the pneumonia of aged persons. In an anatomical point of 
 view, these cases present nothing peculiar. Loiular pneumonia is very 
 frequent, especially in cases where the patients presented during life the 
 symptoms of great exhaustion; in paralytics, it may frequently originate 
 through the accumulation of the bronchial secretion in the finer bronchial 
 tubes, and through the impaction of foreign substances in the air- 
 passages (food, etc). 
 
 Gangrene of the lungs, which has sometimes been observed suddenly 
 to become frequent in prisons, has been well known and appreciated in 
 the insane since the days of Guislain.^ This author observed gangrene 
 of the lungs to occur almost exclusively in patients who had refused their 
 food and died of inanition: in such patients, however, it was very fre- 
 quent (nine times in thirteen deaths of this description). In these 
 patients, of whom several had lived for from twenty to sixty days on 
 nothing but water, Guislain considered the impoverishment of the blood 
 — a species of scorbutic state — to be the primary condition and special 
 cause of the gangrene: a dark-red, brown-red, and, finally, cyanotic hue 
 of the cheeks, was, in his estimation, an important symptom during life. 
 It generally occurred in patients who had manifested symptoms of dimi- 
 nution of the general sensibility — indifference to cold, heat, and pain; 
 who could stare for a long time at the sun, etc. Neither pain, cough, 
 dyspnoea, nor fever existed; the pulse was generally slower than usual — 
 other observers (Thore) found it accelerated — and the temperature of the 
 skin was very low. In persons not insane, gangrene of the lungs is ordi- 
 narily accompanied by violent symptoms. The gangi'ene is sometimes 
 limited, sometimes diffuse. In seven out of nine of Guislain's cases, it 
 was the left lung which was affected: in none of the cases was there gas- 
 tritis present, which certain authors say always exists in certain individ- 
 uals who refuse their food. 
 
 1 'Ztschr. f. Psych.,' x., 1853, p. 569. 
 
 ' "Memoiresur la Gangrene des Poumons chez les Alienes," 'Gaz. Medic.,' 
 1836, and in the 'Phrenopathies.' 
 
312 PATHOLOGICAL ANATOMY OF OTHER ORGANS. 
 
 Since the publication of Guislain's work, gangrene of the kings has 
 been studied in the insane by Ferrus, Calmeil, Webster, Thore, etc. ; from 
 the German asyhims there have recently issued many valuable works 
 (especially that of Fischel)' and useful individual facts. In the Prague 
 Asylum, in six years, twenty-five cases (in 7.4 per cent of the deaths, in 
 only 1.6 per cent of the other autopsies, in the Pathological Institute) 
 were observed: of these, twelve were melancholies; the others suffered 
 from dementia, epilepsy, mania. Refusal of food and bad nutriment 
 were the principal causes; on one occasion it occurred in a patient who 
 had a tendency to eat his faeces. In the Vienna Asylum, in three years 
 (1853 to 1855), gangrene of the lungs was discovered fifteen times in 60:^ 
 autopsies, and of these five were consecutive to refusal of food. 
 
 The observations w 3h have hitherto been made incontestably prove 
 that the disease is no confined to those cases in which food is refused 
 in melancholia, althou^ in these it is especially frequent. That in these 
 cases the abstinence an the inanition are actually the cause of the mal- 
 ady is shown by the fac that it also occurs in cases of stricture of the 
 oesophagus, and that ii persons also who are profoundly weakened by 
 inanition, gangrene is observed in other parts — in the cheeks, the genital 
 organs, etc. ; all the circumstances render Meyer's theory," that gangrene 
 of the lungs arises directly from the penetration of particles of food into 
 the air-passages during the forced alimentation of individuals who refuse 
 their food, less probable. In certain cases, also, gangrene of the lungs is 
 evidently the result of general septic infection, originating, for example, 
 from a bedsore. 
 
 In states of inanition, the symptoms (according to Fischel) are gener- 
 ally the following: — After a period during which the patient has become 
 rapidly emaciated, fever, cough, and accelerated respiration set in; the 
 patient presents the symptoms of catarrh, with pain and oppression in 
 breathing, great muscular weakness, coldness of the extremities, pallor of 
 the skin, and deep-red or cyanotic hue of the cheeks. Soon the breath 
 and the sputa assume a gangrenous odor; the physical signs are those of 
 pneumonic solidification, pleuritic exudation, of a cavity — sometimes of 
 pneumo-thorax and haBmoptysis: extreme emaciation and weakness, 
 diarrhoea, etc., set in, and death from anemia, pyasmia, pneumo-thorax, 
 or profuse hemorrhage ensues, in from ten days to three weeks. In pro- 
 found melancholia and dementia, the symptoms are sometimes very 
 insignificant. 
 
 Example L. — Melancholia after mental impressions ; refusal of food ; death ; 
 gangrene of the lungs. — During our last political agitation, a lady, set. 54, of 
 sensitive disposition, and who had hitherto led a very quiet life, was violently 
 affected by the sight of several armed men fighting under her window. The 
 violent shock was rapidly followed by a state of mental confusion, and several 
 days passed before it was noticed that she took no food. Three, five, nine days 
 were passed in exhortation by her family; a thousand questions were asked, 
 all sorts of food were offered to her, but nothing could overcome her aversion to 
 eat. A physician was called, and applied fifteen leeches to the epigastrium. 
 The great falling ofl: in her appearance, the emaciation, the melancholia, which 
 constantly became more profound, awakened the anxiety of her family, and she 
 was admitted into our asylum on the 4th Febi-uary, 1831. I recognized her 
 refusal of food in the color of her countenance: on putting some questions, I 
 learned that Madame B — had, for the last four weeks, taken nothing but a few 
 basins of milk-soup and some weak beef-tea. The face was of a dark-red color; 
 cheeks, point of the nose, and lobes of the ears were brown; the pupils were 
 
 1 Prager ' Vierteljahrschrift.' Bd. xiii., 1847, p. 1. 
 ^ ' Charite-Aimalen,' v., 3, p. 154. 
 
PATHOLOGICAL ANATOMY OF OTHER ORGANS. 313 
 
 dilated, and the white of tlie eyes was ghstening and of a bhie shade; the hair, 
 which, according to the testimony of her relatives, was usually smooth, had been 
 for some days extremely dry, and had assumed a hue which could also be 
 recognized in the iris. 
 
 It was only with gi-eat trouble that she could be persuaded to take a few 
 spoonfuls of beef-tea; the patient, who was very strong, struggled violently with 
 the attendants, so that the melancholia actually passed into mania. The emaci- 
 ation made fearful progress; the countenance became brown, the lips somewhat 
 livid; and soon the hands and feet, especially at the phalanges, became iierfectly 
 cyanotic. The patient always strenuously resisted being fed; she became motien- 
 less, and soon an ecstatic condition was added to the symptoms of melancholia. 
 It was with difficulty that she could from time to time be forced to take a cup of 
 milk or soup; and in order to overcome her resistance, we had recourse to the 
 swing chair, but without success. 
 
 Her breath had an insupportable odor; the sputa were brown, streaked with 
 bright red; in a few days the expectoration became cojiious, not actually puru- 
 lent, but sanious. The countenance had so fallen, that the patient seemed to be 
 of great age. She gradually became weaker; occasionally she took a little food, 
 and during the last few days took anything that was offered her. 
 
 On examination of the body, the brain and its membranes appeared normal. 
 The contents of the abdomen presented no trace of inflammation, the stomach 
 was not injected nor at all drawn together. The gall-bladder was full of very 
 black bile, and the spleen and mesenteric vessels contained blood so very dark in 
 color as to confirm me in what has been said regarding this condition by the cel- 
 ebrated Haller. 
 
 As I, after opening the thorax, was lifting up the left lung, my finger pene- 
 trated its substance; and such an insupportable odor arose from the rent, that I 
 was obliged to stop my investigation for a little. The posterior aspect of the 
 superior lobe of the extracted lung was of a black color, interspei'sed with green 
 and brown spots. An incision made into this part showed that the tissue was 
 very easily torn, A bloody, black, stinking liquid, like the fluid in a gangreous 
 limb, permeated the pulmonary tissue; here and there a few purulent particles 
 were seen. On scraping with the scapel, the blade became covered with a brown, 
 Aiscous, putrid mass; bright-red stripes penetrated the tissue in all directions; 
 internally, the decomposition extended similarly into the lung. The entire 
 gangrenous portion was about the size of a flattened ball, five inches in diameter. 
 The bronchi were filled with a red, frothy, foetid fluid; the right lun^ was 
 healthy. (Guislain, " Memoire sur la Gangrene des Poumons ches les AUenes," 
 ' Gazette Medicale,' 1836, p. 341.) 
 
 The frequency of phthsis pulmonalis in the insane has been 
 acknowledged by observers from the days of Lorry to the present time. 
 We have, however, no definite statistical proof that this disease is 
 actually more frequent amongst the insane in asylums than among 
 persons living under similar conditions (in institutions, etc.). 
 
 Esquirol considered that more than a third of his melancholies were 
 phthisical; Calmeil found tuberculosis in fths, Webster _ in |th, Sc. 
 Pinel in |-th of their autopsies; in Vienna it was met Avith in more than 
 |d (in a total of 602 autopsies made in the three years 1853 to 1855) ; in 
 Prague, in 1843 and 1843, in more than fths (Fischel); in Eberbach, in 
 -^th; in the asylum for chronic cases at Colditz, in y^^ths (Voppel); in 
 Palermo, in thirteen years, in 192 cases of death, in almost f (Pignocco); 
 in Han well, in four years, amongst the female patients, in not quite -^th; 
 in Bethlehem, in six years, 1842-1848, in |th; in certain asylums — ^for 
 example, in Bicetre — its rarity is remarkable (Thore, 1. c). The gen- 
 eral statistics made by Hagen' for a great many asylums sliow that in 
 asylums generally a little more than one-fourth of the deaths are due to 
 phthisis, and that this proportion is almost the same as for the general 
 population above fourteen years of age. This may be true in regard to 
 large towns, and in particuhir to Vienna and Prague; but for tlie rural 
 
 ' ' Ztschr. f. Psychiatrie,' vii., 1850, p. 257. 
 
314 PATHOLOGICAL ANATOMY OF OTHER ORGANS. 
 
 population this estimate is for most localities far too high, so that we 
 must still assume that phthisis is more frequent amongstthose who in- 
 habit large institutions (not asylums merely) than amongst the general 
 population. It is not merely on account of its mortality that phthisis is 
 important in insanity; it is certainly also of great pathogenetic value, 
 owing to which it may stand in various relations to the insanity. 
 
 Tuberculosis is developed principally in the primary forms, and its 
 course sometimes presents many deviations from the ordinary symptoms; 
 in particular, there is occasionally observed a striking interchange in the 
 intensity of the symptoms of the pulmonary and of the cerebral affection, 
 so that apparent improvement of the one always coincides with aggi-ava- 
 tion of the other. Still, this interchange is not only very inconstant, 
 but it is also merely apparent; the subjective symptoms of the pulmonary 
 affection disappear in profound mental disorder, while the objective, 
 physical signs show that the process continues its ravages. Frequent 
 examination of the patient is therefore necessary. 
 
 The statement that the delirium of the phthisical insane has a certain 
 specific character is equally incorrect (see § 106). 
 
 All the various diseases of the respiratory organs are met with in 
 insanity. After long-continued violent screaming and excitement, acute 
 catarrh of the larynx and osdema of the glottis may ensue. Pleurisy has 
 been observed by Sc. Pinel 7 times in 135, by Thore 8 times in 76, in 
 the Vienna Asylum 89 times in 431 autopsies; pulmonary apoplexy was 
 observed by Jessen' on 6 occasions, etc. Hypostatic hyperjBmia of the 
 lungs is also frequent in those who have lain for a long time in the same 
 position, etc. These various affections present nothing peculiar in the 
 insane; they are worthy of mention principally on account of the atten- 
 tion which their diagnosis demands during life. 
 
 II. Affections of the heart. Nasse,'' from statistics gathered from the 
 older works on the subject, concluded that heart-diseases were frequent 
 and of great importance in the insane. Subsequent observers differ 
 much in their opinions regarding their frequency (Esquirol met with 
 affections of the heart in only one-fifteenth of his melancholies, Webster 
 in one-eighth, Bayle in one-sixth, Calmeil and Thore' in almost one-third). 
 The newest and most reliable statistics show only a very average fre- 
 quency. In the Vienna Asylum, in 602 autopsies, affections of the 
 heart were met with in about one-eighth;^ still, a large proportion of 
 these belong to the class which is of more importance in regard to the 
 completeness of the report than in a clinical sense. Bazin^ (in Bordeaux) 
 found only three cases of organic heart-disease in 343 post-mortem 
 examinations of insane women. According to these figures, we may 
 assume that the ordinary affections of the heart are rather rare than fre- 
 quent in the insane. Dilatation and incrustation of the aorta occur 
 more frequently (for example, in about one-sixth of the 602 cases 
 examined in the Vienna Asylum), which is naturally, in many cases, 
 
 ' Jacobi and Nasse, 'Ztschr.,' i., p. 677. 
 
 2 'Zeitschr. f. Psych. Aerzte,' 1818, i., 1. 
 
 ^ See the writings of Esquirol and the f orementioned work of Thore. 
 
 ■* ' Vienna Report, ' p. 204. Certain recent alterations originating shortly before 
 death are not included: I also thought it necessary to exclude fourteen cases of 
 mere thickening of the valves. Amongst the cases of insufficiency, there are many 
 very slight changes in the aortic valves, and many cases of simple hypertrophy. 
 
 ^ ' Ann. Med. Psych.,' vi., 1854, p. 659. For the frequency of heart-disease in 
 the reports of Voppel, see the above, p. 200. 
 
PATHOLOGICAL ANATOMY OF OTHER ORGANS. 315 
 
 connected with other affections of the heart and with sclerosis of the 
 cerebral arteries. 
 
 § 196. Ahnormalities in the abdominal organs. — Amongst the acute 
 organic diseases to which the insane snccumb, acute intestinal catarrh 
 occupies a prominent position. It appears in the ordinary manner, as 
 injection with secretion of mucus, etc., or with follicular ulceration, or 
 us an exudative process with relaxation, maceration, and extensive 
 softening of the mucous membrane, which may be stripped off in the 
 form of a pulpy bloody substance (especially in the ileum). These 
 catarrhs are the fundamental cause of the colliquative diarrhoeas whose 
 appearance in exhausted and weak individuals is very properly considered 
 as ominous; the maceration in the ileum may exist without diarrhoeL 
 Many general paralytics, and not a few melancholies and maniacs, are 
 carried off by these diseases. Their causes are obscure; in many asylums 
 the immoderate use of purgatives may contribute to their frequency. 
 Their diagnosis is difficult; loss of appetite, meteorism, rapid failing of 
 the strengtli, and diarrhcea are always the most constant symptoms. The 
 frequency of their occurrence renders careful examination of the stools 
 necessary in all cases of suspicion. 
 
 The older observers attached much importance to a narroivmg of the 
 large intestine, which they considered to be very frequent: these cases, 
 however, presented nothing morbid, but merely a drawing together of 
 the large intestine — a condition frequently met with in every pathologi- 
 cal theatre. Occasionally there may be a certain degree of contraction 
 of the intestine in consequence of prolonged catarrh. 
 
 Displacement of the colon, which Esquirol, and afterwards Bergmann 
 and others, considered to be an important and frequent anomaly, is like- 
 wise altogether immaterial. Most frequently it is caused by the trans- 
 verse colon in its middle portion or in its* left half descending into the 
 hypogastric region, behind the symphysis, or even into the pelvis, and 
 then rising perpendicularly towards the spleen. 
 
 There are several other disorders of the abdominal organs which may 
 be mentioned, such. as hypertrophy of the ganglionic nerves, which has 
 been observed in certain cases; Rokitansky (ii., p. 871) observed "con- 
 siderable increase in volume of the central abdominal ganglia in a case of 
 eminent hypochondriasis, together with general tabes;" anomalies of the 
 intestines; prolapsus of the rectum, which Bergmann has often seen in 
 dements affected with constipation; cancer of the stomach (rare— Esquirol 
 observed a case of it in a woman who believed that she had a beast in her 
 stomach); old peritoneal adhesions, folds and adhesions of the bowel, in 
 which cases the flatulence and other obscure painful sensations may give 
 rise to peculiar dehrious ideas (a patient of Esquirol's declared that Pon- 
 tius Pilate, all the persons mentioned in the Bible, and a council of 
 popes, Avere in his belly; another, that there were several devils there); 
 foreign bodies in the intestinal canal, such as cherry-stones, which m 
 some cases are swallowed in large quantities — an entire spoon that has 
 been swallowed, etc.; organic diseases of the liver; intestinal entozoa 
 (sometimes these are found in unusual localities);' d iseases of the mesen- 
 
 1 Hayner (Nasse, ' Zeitschr. f . Psych. Aerzte, 1818, Heft 4) narrates the case 
 of a patient who believed that he was going to die of starvation, and constantly 
 complained of something living in his stomach, and which rose to his throat. 
 After death, seven lumbrical worms were found in the gall-ducts of the liver, one 
 sticking half in the ductus choledochus and half in the duodenum, and from 
 thirty to thirty-six in the duodenum itself. In another case of sudden mania, a 
 lumbrical worm was found in the ductus choledochus, and several others in the 
 duodenum. 
 
316 PATHOLOGICAL ANATOMY OF OTHER ORGANS. 
 
 teric glands (Boiiet found in an insane man who believed that he had three 
 frogs in his belly, three " scirrhous" glands in the exact spot where the 
 sensation was felt). Bright's disease is exceedingly rare amongst the in- 
 sane as a primary affection, but the slighter forms which accompany the 
 various marasmatic states are naturally common.' Finally, the diseases 
 of the male and female genital organs (prolapsus, hypertrophies, malig- 
 nant polypoid degenerations, etc.) may be mentioned as important ano- 
 malies. The latter (fibroid tumors of the uterus, infarctus, ovarian cysts, 
 etc.) rarely give to the delirium the character of sexual excitement; they 
 rather occasion a hysterical disposition which may be important in regard 
 to the origin of the entire mental disturbance. The older as well as the 
 rilore recent psychological literature abounds in cases of this description,* 
 although they are not always related with the necessary minuteness and 
 pathological accuracy: besides their theoretical interest, they, above all, 
 show the necessity of a minute examination of all the organs accessible to 
 our means of diagnosis. 
 
 ^ Fischel, in Prague, had only 3 cases of Bright's disease amongst 2,40C 
 patients; the Vienna Report gives 23 cases to 602 autopsies, of which, however, 
 several were of phthisical persons. 
 
 - See, for example, the work of Burzorini, ' On the Physical Conditions of In- 
 sanity,' Ulm, 1824. 
 
PBOGKOslS. 
 
 317 
 
 BOOK FIFTH. 
 
 THE PROGNOSIS AND TEEATMENT OF :yiENTAL DISEASE. 
 
 CHAPTER I. 
 PROGNOSIS. 
 
 § 197. The prognosis in mental disease involves two separate ques- 
 tions. In the first place, Does the existing disease endanger life 9 and in 
 the second place, If life he continued, lohether, and to what extent, may 
 recovery from the mental derangement he hoped for? 
 
 The reply to the first of these questions often depends more upon the 
 presence of serious disease in other parts, as tuberculosis, heart-disease, 
 etc. (which are to be estimated according to established principles) than 
 upon the presence of the cerebral affection . Amongst the purely cerebral 
 affections, the most rapidly fatal are those serious degenerations of the 
 brain with the symptoms of general paralysis (see above), because they, 
 as a rule, prove fatal in from one to three years, and very often in even a 
 much shorter period. Of unfavorable prognosis are likewise extensive 
 and intense hypersemias of the brain, which occasionally, at a certain 
 stage, lay the foundation of mania, but more frequently come on parox- 
 ysmally during the course of that disease; they may rapidly advance to 
 acute softening of the cortical substance, or may prove almost immedi- 
 ately fatal by causing serous effusions, extravasations of blood, etc. 
 CBdema of the brain, especially if it comes on acutely, might be a cause 
 of death, and the refusal of food seen in certain forms of melancholia, if 
 long continued, become one of the events dangerous to life. As a rule, 
 there is a much greater tendency to death within the earlier periods, 
 during the acute stages of melancholia and mania, than in those condi- 
 tions of chronic irritation or more gradual, but incurable, changes of 
 structure in the brain which give rise to chronic forms, to monomania, 
 to melancholia with the character of mental weakness, or to imbecility. 
 These thoroughly chronic forms allow of not only a long duration of life, 
 but very frequently there is noticed at an early stage of the disease a re- 
 markable improvement in the state of health of the patients, who gain 
 flesh and weight. Every asylum contains amongst its old inmates many 
 such examples. 
 
 A comparison of the death-rate in asylums for the insane, to be of any 
 value, requires a minute inquiry into the various causes of their differ- 
 ence. 
 
 The mortality is always greater in those establishments destined spe- 
 cially for recent cases than in asylums proper; for the majority of deaths 
 amongst the insane occur within the first twelve to eighteen months of 
 the malady. This is explained by the fact that the recent and acute 
 cerebral affection may be merely a complication of serious physical dis- 
 
318 PROGNOSIS, 
 
 ease, and by the frequent occurrence of mania or of general paralysis in 
 the early stages. The comparative frequency of this latter complication 
 tends more than any other circumstance to modify the statistics in dif- 
 ferent countries and in various institutions. It is this also which causes 
 in general a greater (earlier) mortality amongst males than females. In 
 Bethlehem, where no case of more than a year's standing and no 
 epileptic or paralytic is admitted, and where no case is detained longer 
 than a year, the mortality was 6-9 per cent; St. Yon, a general asy- 
 lum, over 7 per cent; Winnenthal, almost solely devoted to curable 
 cases, in the twenty years from 1834 to 1854, 11-13 per cent; 
 Siegburg, in the foiir years from 1846 to 1850, 10-11 per cent; Sachsen- 
 burg, in the ten years from 1840 to 1849, 16-17 per cent; Han well, 12 
 per cent; Lenbus (for curable cases), in twenty-four years, 16 per cent 
 (Mortini); the English poorhouses, 27 per cent; the Antiquaille, in 
 Lyons, 30 per cent. It would be not only irksome, but impracticable, to 
 consider here the various circumstances which cause the remarkable dif- 
 ferences presented by these superficial quotations. Hitchman (1850) 
 came to the conclusion (from the statistics of Hanwell) that the normal 
 ratio of mortality is trij)led in mental disease. 
 
 § 198. The decision on the second question m our prognosis, viz., 
 the curability of the insanity when life is not endatigej'ed, is to be deter- 
 mined by the consideration of a great number of special circumstances, 
 and requires a much more intimate knowledge of mental disease. Here, 
 also, the statistics of the various institutions for the insane afford us 
 much valuable information, inasmuch as they exhibit a series of the 
 results of experience, and agi'eeing with each other in their various par- 
 ticulars (for example, the incurability of secondary dementia, the influ- 
 ence of the duration of the disease upon the prognosis, etc.). It must, 
 however, be borne in mind that many statistics regarding curability are 
 not to be implicitly trusted; the word cured not being universally em- 
 ployed in precisely the same sense, and no statistics can bring to view all 
 the complicated circumstances which in concrete cases determine the 
 decision as to the curability of the malady. 
 
 A primary consideration, and indeed the most important as regards 
 the question of curability, is the /brw of the insanity and the period of 
 the disease. Thus we consider as quite incurable every form of secondary 
 dementia (with which, however, we must not confound melancholia with 
 stupor, nor the temporary profound suspension of the faculties frequently 
 observed after mania). Chronic mania is scarcely more susceptible of 
 radical cure; occasionally, however, it admits of considerable improve- 
 ment, because the falseness or errors of judgment may extend over a 
 large circle of ideas, or may, on the contrary, be confined to a few hallu- 
 cinations. In the last case, also, the fixity of the ideas depends upon total 
 perversion of the psychical individuality, which renders it impossible for 
 the patient to throw off the idea that continually follows him, to distin- 
 guish his former self mid the confusion of his whole manner of contem- 
 plation; in a word, to become himself again. Any real improvement, 
 therefore (which can only be shown in the concealing of his delusions, in 
 his becoming accustomed to orderly habits and deportment, and to a, at 
 all events, mechanical sense of duty), can only be obtained after long- 
 continued, and in many cases most energetic treatment. Even then, 
 however, the result is very uncertain. 
 
 Amongst the primary forms of melancholia and mania, my observa- 
 tions (which correspond exactly with those of Flemming) go to prove 
 
PROGNOSIS. 319 
 
 that it is the former in its really primary stage which is the more easy of 
 cure. If, on the other hand, many other medical psychologists (Jessen, 
 Ideler, Falret, Ferrus, Haslam, Rush, etc.) dechire that mania, especially 
 manie agitee, is, generally speaking, the most curable form of insanity, 
 it may be that they come to that conclusion from the results of practice 
 in asylums, into which simple cases of melancholy seldom find their way, 
 but more frequently difficult cases and those of long standing, and which 
 therefore, of course, come after mania m the order of curability. For, 
 Yery naturally, in even tlie slighter cases of mania, the aid of the asylum 
 is souglit, owing to the condition of exaltation; while many cases of 
 moderate melancholia are, when taken in time, successfully treated at 
 home. As for chronic and protracted cases of melancholia and mania, 
 however, it is difficult to distinguish any difference in the prognosis; 
 indeed, more frequently a rapid interchange of both takes place, forming 
 a continual vacillation between exaltation and depression. 
 
 Amongst the primary forms, a short stage of melancholia is more 
 favorable than a long one; a state of vague, objectless emotion, be it sad 
 or cheerful, and vague general delirium, is always more favorable than the 
 appearance and continuance of fixed ideas. It is on this account that 
 monomanie exaltee is far less susceptible of cure than manie agitee. In 
 melancholia, too, the appearauce of hallucinations is decidedly unfavor- 
 able; those especially which refer the malady to external agencies (to 
 other persons, to witchcraft, etc.) are remarkably persistent, and intro- 
 duce at a later period a condition of dementia; when, on the other hand, 
 the patient attributes the cause of his condition to something within 
 himself (for example, to imaginary vomiting), he is much sooner disposed 
 to quit his delusions (Zeller). 
 
 In thus forming a prognosis upon the form of the disease, the most 
 important consideration is always the determining whether the mental dis- 
 ease is still active and in progress, or whether it is only the remains of an 
 exhausted and extinct pathological process. Seeing that mania represents 
 the acme of all stages and of all forms, it may be given as a practical rule, 
 that if a period of mania be succeeded by a complete and prolonged calm, 
 but without really favorable indications, the patient is in the greatest 
 danger of incurability. The prognosis, moreover, is especially difficult 
 at that stage when the primary forms degenerate into chronic mania and 
 mental weakness, whicli degeneration often takes place after years of 
 alternating amelioration and relapse. On the one hand, the cessation of 
 all disturbances of the physical state, especially with increasing embon- 
 point, and on the other, all permanent anomalies of motion and of sensa- 
 tion (convulsions, changes in the state of the pupils; loss of smell, of 
 taste; eating of faeces, fixing the eyes upon tlie sun, obstinate wandering 
 muscular pains, etc.) are to be viewed as decidedly unfavorable symptoms, 
 and such signs as the following: the absence of a return to normal tastes, 
 to healthy inclination for employment — the constant leaning towards un- 
 bounded whimsical exaggeration, unaccompanied by exaltation of the 
 sentiments — increased incoherence of ideas, stupidity of countenance, 
 etc., indicate, from the psychical side, continuance or further progress 
 of the disease. 
 
 § 199. The duration of the disease is, as all experience has shown, of 
 greater importance as regards the prognosis in this than in any other 
 malady. In reference to this point, various statistics may present slightly 
 different results, but the principle admits of no exception. Thus, in 
 Winnenthal, the number discharged recovered, of those admitted within 
 
320 PROGNOSIS. 
 
 the first six months of the disease, amoiinted to G8 per cent; after two 
 years' illness, 18 per cent; and, after a duration of four and a half years, 
 only 11 per cent: in the Retreat, of admissions within the first three 
 months, 80 per cent; from three to twelve months, 46 per cent. Jessen's 
 recoveries in recent cases {i. e., those of not more than a year's standing 
 before admission) amounted to 66 per cent; in cases of longer standing, 
 12 per cent: in Leubus, of admissions within the first half year, 64.16 
 per cent; within the first year, 34.26 per cent; after a year's illness, 20 
 per cent. In cases which come under proper treatment within the earlier 
 months of the disease, the proportion of recoveries may be estimated at 
 70 per cent (Elliuger); and Esquirol estimates that after three years' 
 duration of the disease only one in thirty of the cases recover. The 
 liope, therefore, of complete recovery becomes dim, if no appreciable 
 step towards improvement takes place within a year. Examples, how- 
 ever, are not unfrequent of recoveries after six, ten, or even twenty 
 years' illness, as may be occasionally observed in institutions devoted 
 esjoecially to chronic cases. This occurs more frequently amongst females, 
 in whom a favorable influence is sometimes exerted at the climacteric 
 period. 
 
 Regarding the prognostic signs to be drawn from the course of the 
 disease and the manner in which the symptoms are grouped, periodic 
 attacks, with the lucid intervals longer in duration than the i)aroxysms, 
 are decidedly unfavorable. It generally happens, that with patients who 
 fall into insanity, and at the earlier period of the disease have an attack 
 once a year, or once in three years, or even once in seven years, the 
 attacks, as time advances, become longer and more serious, the lucid 
 intervals shorter, and with each new attack the prognosis becomes more 
 unfavorable. In continued cases, a gradual slow development of the dis- 
 ease generally (but not always) denotes that it will be slow in its course 
 and diiScult of cure; while a sudden commencement is, as a rule, more 
 favorable. On the other hand, however, recoveries which take place 
 gradually and slowly are generally more permanent than the rapid cures, 
 which are seldom lasting, especially if the malady has been of long stand- 
 ing. Irregular alternations and violent displays are always more favor- 
 able than a prolonged continuance of the same symptoms: for instance, 
 a constant state of maniacal excitement, a permanent and, at the same 
 time, modenite gaiefS, constant voraciousness, prolonged refusal of food, 
 etc. Xymphomania, with its various modifications, is, in young persons, 
 of rather favorable prognosis; but when it appears later in life, at the 
 climacteric period, it rarely admits of cure. The various conditions 
 arising from sexual super-excitation in men of advanced years are equally 
 grave in a prognostic point of view; they generally proceed to dementia. 
 The return of a period of depression in mania (as, for example, much 
 weeping) is a favorable symptom, inasmuch as a period of melancholy 
 frequently precedes recovery, or, at least, sadnes of humor is followed by 
 a lucid interval: so, also, in every case the return of proper sentiments, 
 of former desires and favorable pursuits (work, music, etc.), of memory, 
 of desire to see relatives, etc., are to be regarded in a favorable light. 
 Numerous hallucinations coexistent with a state of calm are unfavorable. 
 A perfect state of physical health (regarding which we can only speak after 
 a minute and thorough examination of all tlie organs) in long-standing 
 mental derangement is, and very properly too, regarded as an inauspi- 
 cious circumstance. On the other hand, the return of former bodily 
 ailments, which had disappeared during the disease (as toothache, head- 
 
PKOGNOS18. 321 
 
 ache, oedema, hgemorrliage, etc.), is occasionally, though by no means 
 frequently, observed to coexist with decided improvement in the mental 
 state — sometimes, indeed, with rapid recovery. All remissions, and all 
 intermissions and lucid intervals, becoming gradually longer in duration, 
 are naturally favorable. But the best prognostic sign of all, is a knowl- 
 edge on the part of the patient of the internal trouble — the feeling of 
 illness, and a reaction of the former self against the state now recognized 
 as a morbid one: nevertheless, as Jacobi justly observes, '' the power may 
 fail to carry through this reaction, and the temporary glimmer of self- 
 consciousness be again extinguished." 
 
 § 200. The causes, exciting or predisposing, of the mental disease 
 have also a prognostic value. It cannot be disputed that insanity at an 
 early age is more frequently cured than when it occurs in advanced years. 
 Still, cases of recent insanity occurring in individuals of fifty or sixty years 
 of age frequently turn out favorably, and senile imbecility is the only 
 malady which presents absolutely no hope of recovery. The generally 
 admitted fact, that insanity is more easy of cure when it occurs in women, 
 is doubtless chiefly owing to the less frequent occurrence in them of gene- 
 ral paralysis. Jessen (and his observations have been confirmed by several 
 others) obtained better results, especially in cases of long standing, 
 amongst females. It would therefore appear that in the opposite sex a 
 •state of incurability sets in, on an average, at an earlier date. AVitli 
 regard to cases of hereditary insanity, there is a preconceived and all but 
 universal opinion that the prognosis is absolutely hopeless; hence the fre- 
 quent neglect of the necessary therapeutic measures. But the numbers 
 of such cases that have been successfully treated are sufficient to establish 
 the fact that hereditary taint does not constitute a case incurable; still 
 the chances of recovery are but slight, and even when it has taken place 
 there is great danger of relapse. As to whether patients from the upper 
 ranks of society, of good education (as has been asserted), present greater 
 chances of cure than those from the lower classes — whether recoveries are 
 of rare occurrence amongst Jews, etc. — are subjects upon which I must 
 confess my inability to give a definite opinion. The natural disposition, 
 acquired peculiarities of character, the degree of strength of mind, the 
 ease or difficulty with which the patient yields to the malady or to the 
 curative influences, are points of the greatest value in prognosis. Diseases 
 which have been gradual in their development, occurring in persons who 
 have been remarkable from youth upwards for their excessive capricious- 
 ness, their originality of taste and eccentricity of character, are serious 
 in every point of view. Equally unfavorable are cases originating after 
 long and painful emotions, years of vexation, prolonged suspense between 
 hope and doubt ended by disappointment, after intense passion causing 
 mental devastation. These deep wounds do not heal without loss of cere- 
 bral substance; they are often followed by complete derangement of the 
 mental constitution, and in such cases the chances of recovery are far less 
 than in those resulting from a sudden mental shock — a fright, etc. 
 
 The primary idiopathic affections of the brain are, generally speaking, 
 much more serious than the secondary and sympathetic. Mental diseases 
 following upon injury to the head, acute meningitis, sanguineous apo- 
 plexy, and long-standing epilepsy, especially the two latter, are almost 
 absolutely incurable (still there are exceptions); and the same may be 
 said of those which have made their appearance after typhus fever and 
 become chronic. On the other hand, anaemia, acute congestion of the 
 brain, indigestion, menstrual and many other derangements of the sexual 
 21 
 
322 TKOGKOSIS. 
 
 organs, are amongst the physical states which contribute to the develop- 
 ment of mental diseases of more favorable prognosis. In insanity result- 
 ing from inveterate drunkenness, the prognosis is most unfavorable; it 
 early assumes the character of mental weakness. Where it originates 
 from more moderate intemperance, the case may be considered curable, 
 but there is an extraordinay tendency to relapse. Onanists, and those 
 exhausted by sexual excesses, are not to be considered incurable so long 
 as the cause can be removed, the general health improved, and any exist- 
 ing local disease successfully treated. Eecovery, -on the other hand, is 
 impossible where monomania has set in, and particularly where the patient 
 has hallucinations referring to personal intimacy of the most debased kind 
 with the supernatural, together with a tendency to masturbation. Hys- 
 terical insanity, acute in its outbreak and with violent agitation, is of 
 better prognosis than when it is passive, characterized by depression, and 
 slow in its course. Of all the forms of insanity, puerperal mania is that 
 in which the prognosis is most favorable. In asylum practice this form 
 stands high in the ratio of curability, although the majority of such cases 
 do not enter these institutions, but are successfully treated at home. 
 
 The external circumstances and relations of life of the patient greatly 
 influence the prognosis. Where effective treatment is limited by poverty 
 or other untoward circumstance, where the obstinacy or prejudice of 
 relatives prevents timely interference, or where removal from those scenes' 
 of life is rendered impossible in the midst of which the mental malady 
 arose, and from whence it constantly derives new vigor, no false illusions 
 need be built regarding the possibility of cure; nothing can here be 
 expected from nature, whose efforts are thus rendered ineffectual. 
 
 § 201. A consideration of the chances of recovery in insanity affords, 
 upon the whole, very gratifying results. From the statistics of institu- 
 tions for the insane, it appears that recent mental disease allows of a far 
 better prognosis than most other chronic affections of the brain. If we 
 understand, however, the word ''recovered'' to signify, as it ought, the 
 total disappearance of the mental disease — the complete return of the 
 former capacity of intellect, of the whole earlier force of character, it 
 must, of course, be but seldom that such a result can be expected. Cases 
 are by far more numerous where, indeed, the leading symptoms of the 
 insanity disappear, but the individual retains a slight feebleness of intel- 
 lect, continues irritable in temper, has occasional tics, or is possessed of 
 certain eccentricities, which, however, permit him to take part in the 
 simple avocations of life, and, it may be, to return to his former pursuits. 
 Hence a distinction ought to be made in successfully treated cases between 
 recovered and improved, as has long been the practice in many well-regu- 
 lated institutions, such as Winncnthal. 
 
 It is evident that by such improvement is to be understood, not only a 
 state of outward calm, but an essential alteration comprehending the 
 complete arrest of the further progress of the disease. It would, for 
 example, be wholly inadmissible to declare that a maniac whose disease 
 had gradually verged into dementia, and who was now, as a consequence, 
 quiet and inoffensive, and could even be kept in private circumstances, 
 was on that account improved. Such a case has, on the contrary, become 
 in reality aggravated, and can only be dismissed from the asylum as no 
 longer curable. 
 
 It may be here permitted to give a few quotations from the statistics 
 of the asylums of Germany. Winnenthal had in twenty years (1834-54) 
 1424 admissions (888 M., 536 F.), whereof (here were 445 recoveries: 
 
PROGNOSIS. 323 
 
 (260 M., 185 F.) — equal to 31 per cent. Siegburg, from 1st October, 
 1846, to 31st December, 1850, 872 patients, 277 recoveries — equal to 31 
 per cent. Sachsenburg, in ten years (1840-49), 695 admissions, with 213 
 recoveries — equal to 30-31 per cent. From Sonnenstein, during the five 
 years 1846-51, there were dismissed recovered 33 per cent of those 
 admitted. These results correspond in a remarkable manner with one 
 another; and when Fleming says ('Ztschr. f. Psych.,' xv., 1858, p. 8) — 
 "It is, at the present time, satisfactorily demonstrated that with respect 
 to mental diseases no statistics exist whereon conclusions may be founded 
 regarding the curability of these diseases, or the efficacy of the remedial 
 means employed," — I quite agree with him in the latter point, but lean- 
 not at all indorse his statement regarding the curability of insanity. 
 
 § 202. The mere disappearance of the more striking symptoms, the 
 cessation of the fury and the delirium, cannot be regarded as certain signs 
 of complete return of mental health. The patient may become quiet to 
 all appearance, and learn to conceal many false notions which are never- 
 theless inwardly cherished by him; and this may even coincide with a 
 striking improvement in the state of general health. The most impor- 
 tant symptoms of really returning sanity are rather the distinct appre- 
 ciation of the mental disease by the patient, the discernment of the 
 abnormality of the former state, the parting with all its accompanying 
 delusions, and the impartial estimation of the present position from every 
 poinb of view. With these must be associated, a return to former 
 tastes and to normal habits, of the instinct for vital activity, of interest 
 in the former affairs of life, of that affection towards family and friends 
 so often changed to hatred during the disease. Just as the insanity 
 commenced with perverted dispositions and emotional states, so it is this 
 phase of psycliical life that is specially to be looked to in its disappear- 
 ance. When at length the intelligence appears unimpaired, but where 
 abnormal aversions still exist toward certain individuals, or a vague state 
 of sullen anger and passion, or perhaps merely a state of psychical exal- 
 tation, is retained, which renders the patient very irritable; so long as 
 the patient cannot bear any reference to his former malady, and solici- 
 tously shuns everything tliat may recall it — where, in a word, anything 
 strange it still observable in his feelings, demeanor, speech, physiognomy 
 or glance — we cannot say that full recovery has taken place. The foun- 
 dation of recovery is rather a perfect quietness of mind; the individual 
 who is radically cured speaks freely of his malady to those around, and 
 especially to the physician, as of something which has now become quite 
 foreign to him. He expresses almost always thankfulness and confidence, 
 but never boisterous joy, at his recovery, and leaves the date of his dis- 
 missal from the asylum, without trying to hasten it, entirely to the dis- 
 cretion of the physician. 
 
 Those recoveries which take place gradually, with steadily progressing 
 consciousness of the. internal malady, are, generally speaking, more last- 
 ing than rapid and sudden improvements, even though they may appear 
 quite as complete. On the one hand, there may exist from the psychical 
 aspect the most favorable signs of complete recovery; while, on the other 
 hand, physical diseases (such as tuberculosis, diseases of the genital 
 organs, etc.), which had evidently exerted an influence upon the devel- 
 opment of the mental disease, remain unhealed. In such cases, the ver- 
 dict of full recovery from the insanity need not be delayed till the re- 
 storation of bodily health; but, at the same time, the great danger of new 
 and repeated mental disease must be kept in view. In all these cases, a 
 
324; PROGNOSIS. 
 
 certain duration of the psychical feeling of wellbeing is required to dis- 
 tinguish permanent recovery from mere lucid interval — just as we would 
 not pronounce a case of epilepsy to be cured after months even of free- 
 dom from the attacks, but first wait for a longer period the full confirm- 
 ation of our favorable opinion. 
 
 Some observers (Esquirol) were disposed to consider only those cases 
 of recovery as sufficiently certain which were accompanied by a well- 
 marked crisis; others (Jessen, C. G. Neumann, and ourselves) have, 
 upon the whole, very seldom observed such crises. We do not deny that 
 those constitutional changes which must frequently accompany recovery 
 from such a serious disease may occasionally be announced by increased 
 quantity or altered quality of the excretions, by the appearance of skin 
 eruptions, etc., and that, to a certain extent, a favorable interpretation is 
 due to those events when they occur coincidently with mental improve- 
 ment. These phenomena appear, however, more frequently as results 
 than as causes of the recovery; very often they are wholly accidental oc- 
 currences, and the fact of their frequent comjilete absence would of itself 
 sufficiently refute the opinion of Esquirol. 
 
 § 203. The proportion of the permanent recoveries must be estimated 
 by the number of relapses. Jacobi estimates that, of 100 recoveries, about 
 25 are readmitted. Parchappe gives 164 relapses in 498 recoveries. 
 Farr, for the English county asylums, gives 1200 relapses in 5486 recov- 
 eries (more than one-fourth). Julius, for the York Eetreat, makes the 
 official statement of 31 relapses to 100 recoveries; he, however, considers 
 the actual proportion to be much higher. Damerow had in Halle 14 per 
 cent. Guislain estimates 19 per cent as the proportion in asylum prac- 
 tice: this number is also given for the asylums of Holland (Schroder van 
 der Kolk). But all the cases of relapse do not again enter the asylum to 
 be treated; we must, therefore, accept a higher number, from 20 to 25 
 per cent, as the proportion of the once recovered who again become 
 insane. 
 
 Eelapses occur by far most frequently during the first and second 
 years after recovery. This is easily accounted for by the state of exalted 
 psychical irritability, which often continues for some time after the dis- 
 appearance of the disease, and the greater susceptibility to physical ail- 
 ments which must exist after so serious a malady. Too early dismissal 
 from the asylum is likewise a frequent cause. To the first of these 
 causes is also probably due the fact that relapses are somewhat more fre- 
 quent in the female sex (Schroder van der Kolk and Parchappe). It 
 should be remembered, too, how rare complete and lasting recoveries are 
 in most chronic diseases, and how difficult it is to remove certain consti- 
 tutional causes which may frequently have existed from earliest infancy, 
 whose constant action has, as a consequence, a succession of diseases fol- 
 lowing the same pathological direction. It is not to the powerlessness of 
 our art, nor to a certain predestinated incurability of these forms of dis- 
 ease, that we ascribe relapses in those who, on their dismissal from the 
 asylum, return to the most deplorable conditions of life, or to the full 
 influence of those health-destroying causes which were to blame for their 
 first attack. In the case of individuals who, on recovery, return to habits 
 of drunkenness, to misery, to over-fatiguing employments, to the causes 
 of violent agitations and emotions, we can almost with certainty predict 
 a relapse; the drunkard, especially, is each time dismissed from the asy- 
 lum only with the unsatisfactory prospect of soon seeing him again. 
 Upon the whole, however, the prospects of recovery in insanity are much 
 
PROGNOSIS. 325 
 
 brighter than is generally supposed by medical men and the public. At 
 all events, we may confidently assert that the prognosis in recent acute 
 insanity is very much more favorable than in most other diseases of the 
 brain, especially than in the various forms of epilepsy. 
 
326 THEiiAPEUTICS. 
 
 CHAPTEE II. 
 THERAPEUTICS. 
 
 Section I. — General Principles. 
 
 § 204. The treatment of mental diseases has, in a very abundant 
 measure, experienced the power of theoretical hypotheses, and the alter- 
 nating influence of one-sided systems. The old humoral pathology 
 taught, and till very recently, the elimination of black bile; the excita- 
 tion theory sought, and still seeks, the increase or diminution of the 
 action of the exciting powers; and the followers of the theory of local- 
 ized inflammation profess, although in opposition to every-day experi- 
 ence, the ordinary antiphlogistic method as the basis of their treatment. 
 Mental medicine had, more than this, an addition of its own to contend 
 with in the moralizing ideas that were held by bigots regarding the 
 treatment of insanity. One great principle, however, pervades the whole 
 system of modern psychiatry — the great principle of humanity in the 
 treatment of the insane, in contradistinction to that former barbarism 
 which sometimes persecuted the mentally afflicted Avith trials for sorcery 
 and death at the stake; sometimes, and this in the most favorable cases, 
 cast them into dungeons, to be associated with criminals, where, beyond 
 the influence of the medical art, and, deprived of all human aid, they 
 were consigned to the realms of despotic cruelty and brutality. Cer- 
 tainly, it was that forced acknowledgment of insanity to be a disease — 
 next to this, however, and mainly, it was that philanthropy which vindi- 
 cated the claims of the insane from the stand-point of the common rights 
 of humanity — that first achieved their recognition as human beings by 
 society, towards whom protection and help was due; that they more and 
 more become the objects of earnest guardianship by the State, and 
 of earnest scientific research, whose aim is their cure. The retrospect of 
 former times, and, above all, of the labors of Pinel, must be pleasing and 
 elevating to the minds of all of us. That great principle of humanity is 
 now placed beyond all possibility of dispute, and if we, as physicians, 
 allow our practice to be governed by it, we do that which tends more 
 than anything, on account of its emj^irical results, towards arriving at our 
 first and only aim — the recovery of the patient; results regarding whose 
 incomparable superiority to the experiences of former times no further 
 proof is necessary. It is not the glitter of an abstract principle of phil- 
 anthropy, however, that must guide us; it is practical utility — the 
 results of suitably directed treatment at the bedside of the patient, or in 
 the cell of the maniac. For this reason, also, we must acknowledge 
 these humanitarian principles as rules of treatment only in so far as they 
 further our aim; we must remember that that treatment is not always the 
 most humane which best accords with the particular sentiments of the phy- 
 sician, or is most agreeable to the feelings of the patient, but that which 
 worhs a cure. Psychiatry, then, should never degenerate from the 
 
THERAPEUTICS. 327 
 
 gravity of a practical science into a system of sentimentality, such as even 
 laymen could scarcely be found to defend. 
 
 § 205. In the first place, it has so come about, from the fact of 
 results arrived at through experience, that both the psychical and somatic 
 methods of treatment are equally entitled to a precisely similar amount of 
 our attention. Both modes of acting upon the patient have always 
 instinctively been combined, and the most narrow-minded moralistic 
 theory cannot possibly dispute the efficacy of properly directed medica- 
 ments — baths, etc.; while, at the same time, everyday experience has 
 shown that almost no recovery can be perfected without psychical reme- 
 dies (which may only consist of work, discipline, etc). In spite, how- 
 ever of the practical utility of this method, theoretical hypotheses have 
 rendered it difficult for science to recognize the results of experience — 
 the call for an undelayed combination of mental and physical remedies in 
 mental disease on the ground of its necessity. Can deviations of the 
 power of thought, it has been ironically demanded, be corrected by the 
 thinning of an atrabilious blood or by the solution of stagnant fluids in 
 the portal system? Shall mental pain be combated with sneezing-pow- 
 ders, and perverted witticisms with clyster-tubes? The votaries of phy- 
 sical treatment, on the other hand, urge the influence of the bodily 
 states upon that of the mind; they appeal to the cases in which — ay, 
 quite evidently — insanity has been cured by digitalis, camphor, etc. ; and, 
 as generally happens in such cases, science, which aims above all things 
 at unity and consistency of principle, satisfies in the end both parties, by 
 the eclectic admission that in individual urgent cases either the one or 
 the other system of therapeutics must become secondary or assisting 
 treatment to the other or chief plan of treatment. So, with the one 
 party, psychical, with the other somatic, treatment plays, in comparison 
 to the importance of the principal plan of treatment, only a subordinate 
 and meagre part. But to understand the necessary equal right of both 
 methods, it may be remembered, in the first place, that all psychical acts, 
 normal or abnormal, are cerebral phenomena, and that cerebral activity 
 may be modified quite as effectually, directly, and immediately by the 
 evocation of frames of mind, emotions, and thoughts, as by diminishing 
 the quantity of blood within tlie cranium, or by modifying the nutrition 
 of the brain, as, for example, by narcotics and excitants. The fact that 
 medicines proved empirically to be effectual have been employed in insan- 
 ity, as in other diseases of the brain, requires no vindication; the fre- 
 quent success of psychical treatment, too, in cases where palpable organic 
 lesions had influenced the development of the mental disease, is 
 explained by the influence which the brain exerts upon other organic pro- 
 cesses: we have, therefore, a very powerful means of successfully modify- 
 ing indirect disturbances of the somatic state (of the circulation, the diges- 
 tion, etc.) in the direct provocation of certain states of mind. It is true 
 that serious disorganizations of the brain (as imbecility with paralysis) 
 render (of course) all moral influences impossible; but we know that 
 insanity, at its commencement, consists very frequently of mere func- 
 tional derangement, and that anatomical changes, if slight, do not ren- 
 der the success of moral treatment altogether impossible, provided tliat 
 the organs are capable of accommodation to a certain extent to their 
 respective functions; and the success which in recent times has attended 
 many attempts, even in idiocy, and where the brain was defective, 
 demonstrates that the skilful use of appropriate means renders possible 
 a certain development of the understanding. From this point of view, 
 
328 THERAPEUTICS. 
 
 the treatment of insanity appears to be eminently personal; it is simul- 
 taneously directed to the physical and mental nature of the individual, 
 and when, in the following chapters, we speak in detail of the psychical 
 and somatic as distinct modes of treatment, the fact of their intimate 
 relation to one another cannot but be very evident. 
 
 § 206. If the treatment of mental diseases (especially the physical) 
 agrees in a great measure with the principles and practice of ordinary 
 therapeutics, so also can we, with the greatest possible clearness and 
 cogency, prove that several special claims are due to our department in 
 every rational method of medical treatment. Nowhere is the desideratum 
 strictly to keep in view the individual of greater importance than in the 
 treatment of insanity; nowhei'e is the constant consciousness more neces- 
 sary that it is not a disease, but an individual patient — that it is not 
 mania, but an individual who has become maniacal — that is the object of 
 our treatment. Each individual case should be specially investigated in 
 all its bearings, which constantly vary, and all the means of anatomical 
 diagnosis and pathological research ought to be brought to bear upon its 
 elucidation; in fact, a penetration into the psychical individuality of the 
 patient is here demanded, which is scarcely ever necessary in ordinary 
 medical practice. Hence follows, on the one hand, the practical rule 
 (urgent measures in cases of sudden accident excepted), that in no case 
 should active treatment be commenced without previous careful inquiry 
 into the previous history of the patient and the origin of the disease, and 
 towards which all those special requisites have not been fulfilled which have 
 been already spoken of in page 94 as constituting the first duties of the 
 physician in the treatment of mental disease. It follows, therefore, that 
 there is a degree of variety in the practical treatment of the insane which 
 cannot be explained in detail in a treatise such as this, and of which we 
 can only lay down and specify the general principles of treatment. 
 
 There is one point in the treatment of insanity which requires to be 
 sjjecially noted — the necessity of vigorous interposition on our part to 
 prevent its assuming the chronic type; interference at the earliest possi- 
 ble period, at the very commencement of the malady, and even before its 
 full development is necessary: what has already been said under the head 
 of prognosis (§ 199) will have sufficed to establish this point. But, on 
 the other hand, after it is fully developed, nothing is more to be avoided 
 than impatience and over-officiousness in treatment. We must remem- 
 ber that the ordinary course of mental diseases, even in favorable cases, 
 is slow; we have to reckon by months and by years; we must wait, and 
 learn to take advantage of favorable periods, which are often late in be- 
 ginning to make their appearance. We must seek carefully to oppose 
 each sym^Dtom of the malady, and every indication of the delirious 
 thoughts; and by a continuous and minute observation and strict superin- 
 tendence of the patient, we can, in many cases, anticipate a favorable 
 issue without the use of active measures. 
 
 In mental, as in many other diseases, the simple expective and dietetic 
 treatment — which is so far removed from meriting the absurd reproach of 
 the do-nothing — is in many cases, though not in all, far in advance of 
 the employment of very active and often-changed remedies. To how 
 small an extent their recovery is, properly speaking, due to direct medi- 
 cinal interference, is seen from the similarity of statistics furnished by 
 various asylums where the methods of treatment are essentially different 
 (see page 331). It has been now long admitted that mental diseases are 
 not to be cured by any special method of treatment; a conclusion based 
 
THERAPEUTICS. 329 
 
 on the fact that in the two sections of the Bicetre, where then directly 
 opposite methods were followed, the results as to recovery were exactly 
 similar. 
 
 § 207. Indeed, observation shows that very many cases of recent dis- 
 ease proceed spontaneously to recovery, without much positive interfer- 
 ence, through a treatment limited to the warding off of all injurious 
 influences. In relation to this, the causal indication next presents itself; 
 the removal, so far as we can, of those causes by whose united influence 
 the disease has arisen. And if the etiology, as it may, exhibits here 
 many important points the removal of which is not within the province 
 of the pnysician (compare the second book), still, to dissolve that mutual 
 connection out of which the disease has arisen, it is often sufficient to do 
 away with some of these injurious influences, whether concurrent physical 
 diseases, or unfavorable psychical states. We should, therefore, in the first 
 place, always try to discover means and ways to withdraw the patient from 
 those influences to which his disease is traceable. The means are various 
 enough; the removal of physical causes (§ 102-109) does not differ from 
 the treatment ordinary in these conditions: special attention must be paid 
 to all that might cause a determination of blood to the head; so also every- 
 tliing that might excite nervous irritation, whether through direct super- 
 excitation of the brain, or disordered general nutrition and physical frame, 
 or through exhaustion of any kind, must be rectified. The removal of 
 psychical causes consists mainly in the simple prevention of their further 
 effects, and in the temporary withdrawal of the patient from their influ- 
 ence. This, in general, can be done only hj a complete change of his 
 external condition through separation from his former domestic relations, 
 more particularly if he continually finds in them new sources of emotion 
 and vexation; where, too, the patient is altogether unaware of the delete- 
 rious influence of these circumstances, he must be withdrawn, at any 
 price, from the continuous repetition of the impressions which engendered 
 the disease. This, to a great extent, coincides with the important condi- 
 tion of carefully regulating the rest and activity of the brain (see following 
 section), a key to the knowledge of the whole system of mental therapeu- 
 tics. 
 
 The prophylaxis of mental disease is seldom the subject of medical 
 consultation. By its means insanity could doubtless be to some extent 
 diminished, as marriages might be prevented betwixt members of a 
 family who were manifestly predisposed to mental disease. "With refer- 
 ence to individual prophylaxis, much depends upon a well-regulated 
 system of mental and physical diet. During the period of early education, 
 all stimulus of the mental faculties must be avoided, and the development 
 of the physical powers as mucli as possible encouraged. Everything tend- 
 ing to predominance of the imagination — physical weakness and effemi- 
 nacy of disposition, or early sexual development — must be withdrawn. 
 Care must be taken that, to the utmost possible extent, the external 
 uffairs of life are simple and methodical, continuous states of passion 
 avoided, and habits of subordination instilled into the child. These, as 
 lias been justly remarked by Flemming, are not intended as mere abstract 
 rules of good behavior which are of but little weight when the mind is 
 deeply agitated by stormy passions; the power of resisting sorrow and 
 emotion depends most of all upon a vigorous and powerful organization, 
 and therefore upon a sound state of physical health and careful, unre- 
 mitting attention to the removal of all diseases which have a tendency 
 towards chronicity. The means employed towards arriving at this re- 
 
330 THERAPEUTICS. 
 
 suit, being chiefly hygienic, must necessarily vary in each individual 
 case. 
 
 § 208. In mental diseases, as in all other derangements of the organ- 
 ism, a duly regulated measure of repose and activity is amongst the most 
 important'means of treatment. In every case, if acute and recent, the 
 primary indication is absolute rest of the brain, the suppression of all ac- 
 customed irritation, and still more of all stronger or positively injurious 
 influences. The patient instinctively seeks this rest; he withdraws him- 
 self from every cheerful expression, from all bustle, fatiguing conversa- 
 tion, and everything that would be painful to him; he seeks solitude. 
 So, when an individual falls into melancholia, all attempts to resist^ it 
 by external distraction are useless or injurious. From loud and noisy 
 amusements especially, the patient can receive now only painful impres- 
 sions; it is still more injurious to ply him with impressive exliortations, 
 queries, and admonitions. The mental activity to which he was accus- 
 tomed is now a source of irritation; and only retreat from the accustomed 
 sphere of life, solitude, and perfect rest of the brain, can act beneficially 
 upon those on whose minds everything produces too great agitation. This 
 object may be attained, according to the requirements of the case and its 
 outward circumstances, through removal to retired and peaceful, and afc 
 the same time agreeable and pleasant associations; or through the strictest 
 seclusion, and sometimes even through prevention of all impressions of 
 sound and light; the latter especially in conditions of recent exaltation, 
 and sometimes in melancholia, at its commencement and climax. As, 
 however, in most diseases, a period ensues, after the termination of the 
 acute stage, in which the organ gradually resumes its function, and can 
 only regain its normal power through a return of well-directed activity; 
 so here, too, there are periods where a further prolongation of deep still- 
 ness would be injurious, and where a new impetus in the normal direc- 
 tion is necessary to tlie psychical life to secure it against cessation and de- 
 chne. In those already convalescent, this requisite appears of its own 
 accord; but in very many cases, at the termination of the acute stage, 
 and on entry of a state of quiet, it must be first awakened — aye, energeti- 
 cally aroused. From custom, the patient often continues to struggle 
 against this healthy mental excitation, and still more against healthful 
 self-exertion; while he nevertheless, chiefly through the resumption and 
 practice of his power, can regain his former strength and healthy tendency, 
 and many do not recover while energetic interference was neglected in 
 this often short and always invaluable period. Thus, while with some 
 such this object can be effected through agreeable sensuous impressions, 
 visiting, re-entrance into society, light employments, etc., with others 
 something like compulsion is often needful to rouse them from their 
 mental torpor, and the whole range of mental therapeutics is, in such 
 cases, especially to be employed. 
 
 It appears once more that the general principles of treatnient in in- 
 sanity correspond in a remarkable manner with the means which experi- 
 ence has shown to be useful in other nervous affections. In all states of 
 acute irritation of any portion of the nervous system, we permit the 
 strictest observance of that quiet which is instinctively sought by the 
 patient. In many clironic nervous diseases, on tlie other hand (for ex- 
 ample, conditions of muscular weakness), we pay no heed to the sensation 
 of weakness felt by the patient; we know that it is rather by combating 
 this sensation, so that he has frequently, at the commencement, to be 
 half compelled to resume muscular action and exertion, that the normal 
 
THERAPEUTICS. 331 
 
 innervation will again be ushered in and established. Brodie has repeat- 
 edly called attention to this point in the treatment of neuralgic and sub- 
 paralytic conditions of the extremities. 
 
 § 209. A very extended experience has shown that the above-men- 
 tioned requisites (§§ 207, 208) can, for the most part, only be comi)lied 
 with by totally changing the occupations of the patient, by entirely re- 
 moving him from his usual neighborhood, and by exposing him to the 
 influence of new and perfectly different impressions. 
 
 In rare cases only is a simple change of residence, or a sojourn in 
 some quiet and agreeable part of the country, at all useful. More pro- 
 longed travelling, which in the milder cases of hypochondria is often of 
 the greatest advantage, although, generally speaking, only attainable by 
 the more wealthy, is in all severer and more confirmed cases of insanity 
 wholly inadmissible. It tends usually only to increase tbe excitement, 
 and the most serious, perplexing, and dangerous scenes which have oc- 
 curred in our experience, have been those in which mania has come on 
 after such "pleasure tours;" and justly does it recall to one's memory 
 the old saying, that a man cannot, by travelling, or by change of abode, 
 escape either from himself or from the vexatious burden of his own 
 thoughts. 
 
 On the other hand, the removal of a patient thus situated into a place 
 specially set apart for the reception of such cases, viz., into a good luna- 
 tic asylum, is, in the majority of instances, the treatment which is most 
 prominently indicated. It is above all things necessary for the safety of 
 the patient himself ; for iiowbere else, in ordinary circumstances, is he 
 safe from the obtrusiveness and injudicious, though often well-meant, in- 
 terference of his friends; and nowhere else does he meet with that indul- 
 gent forbearance which springs from a clear understanding of his case. 
 The relatives of the patient generally regard his ever-increasing ill-humor 
 as a fault which he might readily overcome if he chose, and meet it with 
 all kinds of admonitions, instead of with ordinary cbeerfulness and ap- 
 peals to his reason; if, indeed, they do not look upon it as a case of obsti- 
 nate dissimulation, and punish him accordingly with harshness and 
 severity. None of them understand the patient; indulgence and severity 
 are indiscriminately and wrongfully employed: consequently, distrust 
 arises in his mind, and, as the result of this treatment, unpleasant scenes 
 and struggles occur, which not only irritate the patient to the highest 
 degree, but, by the recollection of them, render the return of the con- 
 valescent to his home peculiarly difficult. Particularly in famihes where 
 a disposition to the malady has already manifested itself, a careful and 
 complete separation is naturally the first step to be adopted; but even 
 -where this does not exist, aversion and enmity to his nearest relatives are 
 often excited in the mind of the patient by the injudicious treatment to 
 which he is subjected by them, and on this account the most complete 
 isolation is demanded. By this means, too, the whole current of his ideas 
 is suddenly interrupted and diverted into a new channel, and the ten- 
 dency to the ever-increasing irritability of temper is successfully resisted 
 by the different impressions and emotions to which he is exposed. How 
 beneficial in these circumstances is the removal of the patient to an asy- 
 lum, is shown by the fact that the mere idea of it is often sufficient to 
 interrupt the progress of the disease; so that, in a few cases which have 
 been till then in the highest degree unamenable to treatment, not only 
 does perfect quiet ensue, but even the most decided improvement begins 
 to manifest itself from the very moment of their reception into the asylum; 
 
332 THEKAPKUTICS. 
 
 whilst, indeed, in the majority of cases the first period of their residence 
 in such an institution is marked by a notable remission of the symptoms. 
 Here alone, viz., in the asylum, does the patient, who is no longer able 
 to take his part in the business of life, find everything that his misfor- 
 tunes require : a physician well acquainted with the treatment of cases 
 similar to his own ; skilful attendants who, as well as all about him, know 
 how to treat him suitably to the circumstances of his case ; an asylum 
 where his eccentric behavior is concealed from over-officious eyes, where 
 the necessary surveillance is unobtrusively accorded him, and where he 
 has usually a far greater amount of freedom than he could possibly have 
 under any other circumstances. Here he can weep or give vent to his 
 rage by himself, if necessary; but generally speaking, his restless habits, 
 and the noisy expression of his maniacal impulses, are materially con- 
 trolled by the example of the other patients, and by the ruling spirit^ of 
 peace and order ; he is brought of his own accord into the quiet routine 
 of the house, and little more direct coercion is necessary to overcome any 
 opposition that may arise than the singular feeling of utter powerlessness 
 to resist the overwhelming authority that prevails over everything. Here 
 he meets with forbearance and attention, with common sense and words 
 of kindness; he feels that, in conformity with the circumstances of his 
 case, he is treated as an actual invalid; and he also observes that here re- 
 sistance is utterly useless, and soon learns to submit to the injunctions 
 of his medical attendant, and notices that his whole style of treatment, 
 and the amount of liberty and enjoyment accorded to him, entirely de- 
 pend upon his condition, and the degree of self-command exercised by 
 him. He finds here the essential helps to self-government; he learns again 
 to take an interest in things; while, simultaneously with this care for his 
 mental improvement, a bodily treatment, by means of a regulated diet, 
 baths, exercise in the open air, medicine, etc., can be constantly and sat- 
 isfactorily carried on. In this manner the patient becomes conscious of 
 an intelligent, gentle, and constant superintendence, from which he 
 gathers confidence and hope; and the sight of the other patients, already 
 well and fast convalescing, awakens in his mind the hope that his own 
 health will also be re-established, and when the natural longing for 
 return to his home again springs up, generally speaking, the patient 
 leaves it with entire confidence to the discretion of the physician to fix 
 the date of his dismissal. 
 
 § 210. Most convalescents bless the day of their entrance into the 
 asylum, and the advantage of removal to such an institution, first most 
 urgently insisted on by Esquirol, has since then, as the result of an over- 
 whelming experience, been established as a fundamental principle, not 
 only in psychiatry, but is daily becoming more and more recognized as 
 such by the great bulk of medical men generally, as well as by the laity 
 themselves. But this removal, which, on the one hand, when certain 
 indications manifest themselves, cannot be too soon effected, cannot fail, 
 on the other hand, to exercise a very important infiuence on the future 
 career of the patient as a citizen, and is a step which always demands the 
 gravest consideration. The first and most urgent indication for this 
 procedure is that condition of the patient where he may be dangerous 
 either to himself or to others, or may cause any great disturbance; the 
 outbreak of mania, or unmistakable signs of its approach are manifested; 
 a tendency to commit suicide, the prevention of which in private can 
 never with certainty be relied upon; and refusal of food, such as cannot 
 be easily overcome. Moreover, all cases of mania, many of monomania. 
 
» 
 THERAPEUTICS. 333 
 
 and many unruly dements are proper subjects for a lunatic asylum; and 
 the harmless dement, in the early stage of his malady, in which there is 
 often some graver mischief lurking, finds there, at the earliest possible 
 period, his disease correctly diagnosed and properly treated. Secondary 
 apathetic and paralytic dementia, on the other hand, are fit subjects for 
 treatment in private, in any place where careful attention can be secured. 
 The determination, when removal to an asylum is really indicated, is 
 only occasionally difficult in melancholia: what we observed with regard 
 to the adoption of this measure in hypochondriasis, inclines us to look 
 upon it rather unfavorably than otherwise at first sight; there we saw 
 that not till the patient has become wholly incapable of self-control does 
 this step appear to be at all called for. So, likewise, simple melancholia 
 does not, during the first few weeks, seem to necessitate removal to an 
 asylum, so long as it remains of a mild character and with a slight dispo- 
 sition towards improvement; probably, change of scene or an excursion 
 to the country may prove sufficient, provided that the patient is there 
 surrounded by judicious attendants who Avill studiously enforce all the 
 directions of the physician. But, on the other hand, if the melancholia 
 has continued for some months unchanged, and rather increasing than 
 otherwise; and if the patient become from time to time subject to illu- 
 'sions, and becomes disturbed by troublesome hallucinations; or if the case 
 degenerates into one of hopeless stupidity or apathetic indifference — re- 
 moval to an as3"lum must no longer be delayed. However, tlie indication 
 depends, in many cases, less upon the form and kind of the disease than 
 ufton the circumstances and character of the patient. It is always the 
 more necessary according as it is less possible for the patient to have paid 
 him at home all the attention he needs; for the less 2)erfectly the measures 
 necessary for treatment can be carried out, the more does the patient 
 seem disposed resolutely to resist them. 
 
 The prejudice that the reason of the patient will only become more 
 deeply affected by intercouse with other lunatics, springs from the gross- 
 est ignorance of the subject. In every well-ordered institution there is 
 a proper separation of the inmates, so that each individual associates only 
 with a few whose company is suitable; the new patient never has, for 
 example, any intercourse with the bad and liopeless cases, which could 
 not fail to exercise a deleterious influence upon him. Those patients 
 who come in contact with one another, though on the best of terms, are 
 at the same time profoundly indifferent about each other, each one being 
 almost wholly occupied with himself. Many remark the insanity of 
 others, and become cognizant of their own state by observing that a simi- 
 lar course of treatment is adopted towards them; and it exerts the most 
 beneficial influence upon the new patients, to be led spontaneously, 
 through the example of those around them, to conform to the order and 
 routine of the establishment, and to learn from the others submission to all 
 over them, and, from the recoveries and dismissals taking place around 
 them, to become tranquil, and encourage the hope that they too will some 
 day be dismissed. 
 
 SECTiOif II. — Physical Treatment. 
 
 § 211. The reflection that many of these patients recover spontane- 
 ousiv under a system of treatment in favor of which nothing more can 
 be said than that it is not positively injurious, will guard us against vul- 
 gar therapeutic illusions. The idea of some specific against insanity as 
 a whole, or against its various forms, mania, melancholy, etc., is coun- 
 
334 THEKAPEUTICS. 
 
 terbalanced by the reflection how widely different the diseases which give 
 rise to the symptoms of insanity are in relation to the anatomical state of 
 the brain and to the pathogeny. The primary object of somatic treatment 
 is the progressing morbid state which led to the development of the cere- 
 bral disease, with special regard to the organs of circulation and respira- 
 tion; to the condition of the blood, of the secretions, of the gastro-intes- 
 tinal mucous membrane, and to the organs of generation. The treatment 
 of the anomalies here observed presents no peculiarity. The admission 
 of such disorders without sufficient foundation, but only suggested by 
 theoretical supposition to strengthen a particular hypothesis, must, on 
 the one hand, be carefully guarded against. On the other hand, it is 
 to be remembered that in insanity the diagnosis of bodily disease is often 
 rendered very difficult, inasmuch as many patients do not at all, or very 
 inadequately, express their sensations; and because, in virtue of the brain 
 affection, many symptoms — especially subjective — which we otherwise find 
 are absent, as in phthisis, pneumonia. Therefore ought the objective diag- 
 nosis to be more carefully practised. Where no rational indications in a 
 pathogenetic point of view present tiiemselves, the present state of the 
 brain is exclusively the object of somatic treatment; and according to the 
 Drobability or certainty of cerebral irritation — hyperaemia — or inflamma- 
 tion, the treatment ought to be immediately directed against these con- 
 iitions precisely as under other circumstances. 
 
 In the use of medicines, the prevalent opinion that the insane always 
 require considerably larger doses is frequently hurtful to the patient. In 
 many cases, no ground for this opinion exists; in others, the greater toler- 
 ance is only apparent, since the patient conceals many adverse effects, as 
 nausea, in the storm of the delirium they are not observed, or by a peculiar- 
 ity of his disease the patient endures them without complaint, wliile the 
 action upon the organs in no case fails; for example, erosion of the gas- 
 tric mucous membrane by large doses of tartar -emetic: only in a few 
 cases are uncommonly large doses of certain medicines, particularly pur- 
 gatives and narcotics, given. In this respect there is great difference 
 among individuals, and the effect cannot be reckoned beforehand; there- 
 fore moderate doses must in all cases be first tried, from which (of course, 
 sometimes rapidly) a transition to stronger ones may be made. 
 
 In general, special somatic treatment is more needful in recent than in long- 
 protracted states of insanity. These latter cases, where so frequently the bodily 
 health is not disturbed, give, therefore, no decided indications for the use of medi- 
 cines, nor has their empirical employment by way of trial shown itself in the 
 least degree beneficial. Still, there are cases where, even without rational indi- 
 cation, it is advantageous to give medicines to the patient, but consisting only of 
 indifferent substances, merely to show him that he is really considered ill, to sus- 
 tain hope, and to remind him of a steady medical supervision. Here medicines 
 act as moral remedies, as in the case of very distrustful patients who look upon 
 the asylum as a state prison, a place for criminals and the like — of hypochondri- 
 acs, etc. Under the subject of bodily treatment we shall not speak of all the 
 means which might be indicated, but only of those which, with direct reference 
 to the brain-disease, show themselves to be decidedly useful, or such as from the 
 nature of the symptoms would be specially indicated. 
 
 § 212. The use of bleeding, to which physicians have been led partly 
 and principally by theories of inflammation, partly by the results of path- 
 ological anatomy — partly by the symptoms of the diseases, which are 
 often violent — has in recent times been considerably restricted, and all 
 are agreed that the necessity for venesection is not to be inferred from 
 delirium, or any of its forms, even the most active, excited, and furious. 
 
THERAPEUTICS. 335 
 
 A state of generally diminished nutrition and anaemia, not only after 
 loss of blood and other causes of physical weakness, but quite as frequently 
 after prolonged states of mental pain, belong very often to the etiological 
 conditions of insanity, and especially of mania. These cases, and next to 
 them such as arise from habitual intemperance, naturally contra-indicate 
 any abstraction of blood. 
 
 If, however, bleeding be employed in such cases, there usually follows 
 an aggravation of all the symptoms: its practice, therefore, in individuals 
 hitherto melancholy, very frequently causes an outbreak of mania. In 
 the states of extreme excitement which accompany acute meningitis, and 
 in decided general plethora, it is more justifiable; but even here venesec- 
 tion is generally quite superfluous: decided and rapid results are specially 
 seen only in those sudden and violent states of congestion which some- 
 times appear along with the symptoms of mental disorders after strong 
 sudden emotions, with stormy, irregular heart-action, and symptoms of 
 overfulness of the lesser circulation. 
 
 Venesection was formerly the subject of various opinions and numerous dis- 
 cussions;' the conviction is now general that in most cases it is not only useless, 
 but injurious, and that seldom it is of real utility; and we cannot too earnestly 
 exhort those practitioners whose chief care is devoted to the insane, as far as pos- 
 sible to spare the blood of their patients. Formerly, in Bethlehem all the patients 
 were bled several times during the summer; and the most abused, most extensive, 
 use of this remedy was known in France during the last century as ' ' traitement 
 de I'Hotel-Dieu." Willis, Chiarugi, but especially Pinel, declared themselves 
 strongly against the abusive use of bleeding; Hill, Esquirol, Burrows, and most 
 of the German physicians, agreed with them. The chief advocate of profuse 
 bleeding, especially in mania, was Rush (' Untersuchungen iiber die Seelen-Krank- 
 heiten,' translation by Konig, Leipzig, 1825, p. 149); Haslam, Foville, and others, 
 frequently employed it in a moderate degree. It is remarkable that out of 206 
 patients upon whom Haslam performed venesection in Bethlehem, the blood of 6 
 only showed a crust (Rush, 1. c, p. 150). Several indications for venesection, 
 which are only partially true, have been laid down, such as youth, recentness of 
 attack, strong pulsation of the arteries of the head — which, however is also pres- 
 ent in delirium resulting from anaemia (M. Hall): moderate cerebral congestion 
 (warm head, redness of the eyes, etc.) does not at all indicate a necessity for vene- 
 section, as it is frequently the result of impaired genei'al nutrition. 
 
 Local bleeding by means of cupping-glasses and leeches is much more 
 generally employed than venesection. In acute meningitis its effect is 
 more certain and more immediate in relieving the brain; in intense cere- 
 bral congestions we frequently see it exercising a very favorable and rapid 
 influence upon the mental disease; and if the effect is seldom permanent, 
 the remedy can easily be repeated: sometimes its long-continued application 
 at regular intervals is attended with a favorable result. Simple hyperae- 
 mias alone yield to these means; that the true chronic meningitic and en- 
 cephalitic processes can no more be removed through bleeding than other 
 chronic inflammations, will not suprise us if we consider the previous pro- 
 cesses which there take place. Cupping-glasses should be applied to the 
 shaven scalp or to the nape of the neck; leeches should, where possible, be 
 applied in the neighborhood of emissaries — behind the ear, to the Schnei- 
 derian membrane, the veins of which communicate with the longitudinal 
 sinus, etc. In women it may be sometimes necessary to apply the leeches 
 
 ' Resumes of this subject are given by Friedreich, in Friedreich and Bluroder's 
 ' Blatter fiir Psychiatrie;' J. Nasse, in Jacobi's and Nasse's ' Zeitschrift,' i., p. 216; 
 Smith, 'On the Bad Effects of General Bloodletting," etc., ' Lancet,' August, 
 1846; Pliny Earle, ' American Journal of Insanity,' April 1852 (very comprehen- 
 sive). 
 
336 THERAPEUTICS. 
 
 to the genital organs; abstraction of blood from the anus in the treatment 
 of congestion of the head is an uncertain and sometimes even prejudicial 
 measure. 
 
 § 213.* In the treatment of hyperemia of the brain, cold is extensively 
 and advantageously employed, but not in the form of the ordinary cold 
 plunge-baths, to wliich the practitioner so readily recurs to quiet recent 
 cases of mania, but which frequently only increase the fury and even 
 augment the cerebral congestion, Zeller, and in latter times Jacobi, 
 have decidedly expressed themselves against the fruitlessness of this 
 mode of treatment. We have ourselves seen cases where the douche was 
 several times employed, and always followed by a visible aggravations of 
 the symptoms: it is only in cases of melancholic stupor that it may oc- 
 casionally be employed with advantage. The strong shower-bath should 
 scarcely be employed as a means of cure, but rather as a means of punish- 
 ment auxiliary to moral treatment; to this end it should only be contin- 
 ued for a short time, and, if necessary, repeated during the day. 
 
 Amongst modern authors who still recommend the douche, Ideler may be es- 
 pecially mentioned (Charite-Annalen, i., 4, 1850, p. 692). Besides he applies it 
 more frequently to the spine than to the head (from the neck to the haunches); 
 this he has found exceedingly useful in idiopathic insanity (which, accoi'ding to 
 him, arises immediately from the passions!) during the period of remission in 
 mania, in states of general sluggishness and stupor, in certain cases in melancholia 
 and monomania, and also in individuals who have become affected through alco- 
 holic and sexual excesses. 
 
 The application of the ice to the head, or of cold compresses, which 
 the patient himself often earnestly desires, is also useful in many states 
 of excitement where the head is hot, the carotid arteries pulsate strongly, 
 etc. ; and the application of cold to the head during a tepid bath, either 
 in the form of a compress or as a shower gently falling from a moderate 
 height, is particularly beneficial. The great calm which often succeeds, 
 and the marked feeling of ease experienced by the patient, may indicate 
 the advantage of employing it even several times a day to allay agitation 
 as often as it appears. Insolation, wounds of the head, threatening 
 apoplexy Avith symptoms of congestion, render the application of cold to 
 the head especially urgent. 
 
 On the other hand, baths of the most varied description are now 
 much more extensively employed, and their judicious use is followed by 
 the greatest advantage in the disorders of the brain which are the causes of 
 insanity. Occasionally, especially in young persons of the female sex and 
 in hysterical patients, the use of cold baths, and if possible of river baths, 
 is indicated: of more general employment and utility are tepid baths in 
 older and especially in recent cases. Besides their cleansing and invigorat- 
 ing effect, they, by uniformly and gently stimulating the nerves of the 
 skin, and moderating and regulating the respiration and heart's action, 
 appear to exert a remarkably tranquillizing influence in these diseases. 
 They are usually continued for from thirty minutes to one hour; in 
 acute cases where there is extreme excitement this period is often insuffi- 
 cient, and in such cases the plan recommended by Brierre de Boismont, 
 of leaving the patient in the bath for several hours, a uniform temper- 
 ature of course being maintained, proves a very valuable means of treat- 
 ment. This method, however, is not suitable in chronic conditions — in 
 agedj weakly cachectic persons, when the pulse is weak — or in epilepsy 
 
THERAPEUTICS. 337 
 
 and commencing pcaralysis. ' The bath frequently induces the much-re- 
 quired sleep. It often seems to prevent hyperaemia of the brain from be- 
 coming fixed; and where the patients willingly submit to the remedy, 
 there is scarce any contra-indication to its use, excepting phthisis, evi- 
 dent ana3mia, or general paralysis, whether incipient or confirmed. Ac- 
 cording to circumstances, sulphur, iron, aromatic plants, etc., may be 
 added. Footh-baths, in certain cases, assist in relieving the head. 
 
 In the first edition of this work, I have already expressed my opinion of the 
 treatment in hydropathic institutions. Since tlien, facts from all quarters have 
 been elicited proving tlie injury which it generally iniiicts on the mentally dis- 
 eased. Most asylum physicians are in a position to contribute examples of this: 
 Flemming, Erlenmeyer, Damerow, Sponholz, etc., have expressed tliemselves 
 decidedly upon this point. This violent procedure seems much to favor the 
 transition to general ))aralysis. The absurdity of sending i)atients to cold-water 
 establishments, instead of into lunatic asylums, would be incredible were it not 
 of daily occurrence, still, it is evident that, in certain cases, the occasional use of 
 wet compresses, cold sitz-baths, and, above all, cold washing followed by dry 
 friction, can, under special indications, be beneficially employed. Guislain has 
 laid down several rather indefinite rules for the administration of cold baths 
 (from 14-17 R., 5-25 nnnutes; 'Leg. or.,' iii., p. 115): he has found them, how- 
 ever, of more general service in cases of upwards of six months' standing, than 
 in quite recent cases. Jacobi's practice (' Ztschr. f. Psych.,' xi., p. 379) of quietmg 
 maniacal excitement by means of baths of half an hour's continuance, and of 13° 
 R. , appears to be very well considei-ed. 
 
 § 214. The cutaneous irritants and the so-called derivatives are often 
 applied to improper parts. Blisters are, in ordinary cases, useless: placed 
 upon the head, they frequently increase the irritation; in melancholic 
 stupor, again, they seem occasionally to be used with advantage, espe- 
 cially when placed upon the neck. The ointments and plasters of tartar- 
 emetic, which are used by some in the most extravagant manner, even to 
 necrosis of tlio cranial bones, arc certainly useful, especially in certain 
 melancholic forms, and occasionally in protracted transitions of the 
 primary forms into states of weakness (Jacobi). These also are applied 
 to the skull, to the neck, and even to more distant parts, and should 
 only be continued till moderate suppuration ensues; they are chiefiy use- 
 ful in a moral aspect, as the continued acute pain, which constantly 
 forces itself on the consciousnees, breaks the chain of morbid ideas, and 
 prevents tlie mind dwelling on them. The seton might be advanta- 
 geously employed, especially in certain cases of injury to Ihe head. The 
 moxa and cautery, the latter of which was often ineffectually employed 
 in former times in general paralysis, do not possess any permanent ad- 
 vantage, and are not now used. All these grave cutaneous irritants are not 
 only quite unserviceable in cases of acute excitement, but also in cases of 
 deep dementia, where the irritated surface is often subjected to violent 
 rubbing and to the action of cold: serious erysipelatous inflammations 
 may hereby result, and in certain powerless conditions gangrene may 
 even ensue — dangers which are far from being counterbalanced by the 
 problematic advantages of these applications. 
 
 Tartar-emetic ointment had gone much out of use, when the account of some 
 happy results gained by Jacobi again brought it for a time into favor. This 
 author had a part of the top of the head shaved, upon which he painted some of 
 
 ' See Brierre, 'Mem. de I'Acad. de Med.,' 1847. He allowed maniacs to remain 
 in a warm bath, sometimes for from six to ten hours, with cold applied to the 
 head; but from three to four hours will always be found sufficient. Pinel's nephew 
 has given, in cases of mania, baths of several days' (!!) continuance, with a con- 
 stant stream of cold water on the head. 
 23 
 
338 THERAFEUTICS. 
 
 the ointment with a brush until the inflammation and swelling spread over all 
 the head, and the skin upon the place of application sloughed and was brought 
 away with poultices ( !) : during this time the patient was allowed only water, 
 soup, milk, and white bread. Several chronic cases, in the stage of transition to 
 clironic mania and dementia, were improved by this treatment; Guislain and 
 others obtained some good results from it in the same states, and also in melan- 
 choly with stupor, and other similar conditions. The employment of such means, 
 which should only be used in desperate cases, is, under all circumstances, wholly 
 to be avoided in mania, in recent cases with great excitement, and in very sensi- 
 tive irritable natures already exhausted by bodily or mental pain. 
 
 § 215. At first sight, mucli might be expected from the direct influ- 
 ence of narcotics upon the functions of the brain. The cases, however, 
 in which these remedies can be advantageously employed will be much 
 reduced if we consider how frequently insanity is the gradually matured 
 and deep-rooted result of combined influences, that it often depends 
 upon anatomical changes, and that even the most powerful narcotics, 
 with some notable exceptions, are suited rather for temporary use. 
 Observation also shows that these remedies are only serviceable within a 
 limited circle of conditions, in which they are certainly very useful as 
 means of cure, and, besides, they are of essential service in diminishing 
 and suppressing certain symptoms. 
 
 Among all remedies of this kind, opium is pre-eminent for its 
 narcotic effects, and also as that from which in other respects we can 
 anticipate the most powerful results; not, however, as it was formerly 
 used, in small and squandered doses, which had little or no permanent 
 effeftt, but in doses larger and longer continued— a method which must 
 be admitted to be in advance of modern psychiatry. According to this 
 method, there is given at first about one grain twice a day; this is grad- 
 ually increased to 3-6 grains twice a day, which is continued for several 
 weeks. By this system, no appearances of intoxication are observed, 
 and no unfavorable influence on the nutrition; regular, indeed rather 
 loose stools, where we employ larger doses; there is never profuse sleep, 
 but, in cases adapted for this treatment, rather improvement in the 
 symptoms of cerebral irritation, increasing quietness of the patients, 
 lessening of the hallucinations, disappearance of the feelings of anxiety 
 and of the insane notions accompanying them, and sometimes rapid and 
 complete recovery. It is in harmony with numerous and concurring 
 experiences, that in recent cases, in young persons, and especially in 
 women, in states of sadness due to the influence of anasmia, hypo- 
 chondriasis, hysteria, and mental causes often advancing to great dis- 
 quietude and excitement (active melancholy), such favorable influences 
 should make their appearance, particularly also in many puerperal 
 mental disorders, and in deliritim tremens. In the conditions of melan- 
 choly with stupor, and, above all, with great passiveness; in mania 
 proper, in the lively excitement of monomania — this method seems to 
 effect nothing: it follows, therefore, that the cases for its use occur more 
 frequently in private practice, during a short existence of the malady, 
 than in asylums. 
 
 SeeH Engelken, ' Prot. der Naturforscher-Versammlung in Bremen, 1844;' 
 F Engelken, ' Zeitschrift fiir Psychiatric,' viii., 1851, p. 393; Schubert, 'Med. 
 Vereinszeitung,' 1857, No. 24; L. Meyer, ' Ztschr. f. Psych.,' 1860, No. 4; Erlen- 
 meyer, ' Arch. d. d. Ges. f. Psych.,' iii., 1, 1860, p. 53. Besides, many physicians, 
 Guislain (' Leo. or.,' iii., p. 28), Michea, ZeUer, etc., have expressed theniselves 
 favorably upon the system of large doses. Morphia appears to be less serviceable 
 than opium; Guislain alone ascribes to it better effects. 
 
 Likewise in states of excitement, but especially of a maniacal kind. 
 
THERAPEUTICS. 339 
 
 « 
 
 digitalis is employed. Although it is primarily indicated by irregularity 
 of the circulation, yiolent heart's action, great frequency of pulse, and 
 by changes of structure in the heart — and then it may be employed in 
 melancholia as well as in mania — nevertheless the empirical use of this 
 medicine is often Justified by its success, even in cases where there is no 
 disturbance of the cardiac etficiency. Digitalis has the advantage that it 
 can 1)6 given for a long time continuously, and may in certain cases be 
 advantageously combined with other diuretics; moderate doseS are at 
 first employed; the acceleration of the pulse occasionally observed during 
 the early periods of its use passes speedily into abatement, and in certain 
 cases it is advantageous to keep the pulse for some time under the 
 normal frequency by doses of the medicine adapted to each case; the 
 larger doses, which easily produce vomiting, should be only carefully 
 and gradually administered. States of sexual excitement contra-indicate 
 the use of digitalis, which, like other diuretics, appears to increase the 
 excitement, and sometimes is what first calls it forth. 
 
 High expectations were formed of ether and chloroform when 
 ansesthesia was first discovered; and certainly complete and raj)id recov- 
 ery has occurred in several cases of recent active melancholia. But 
 numerous observations have shown that frequently (although not in- 
 variably) a temjiorary remission of the melancholia and mania, some- 
 times a complete lucid interval, follows the awaking from the narcotic 
 effects of chloroform; soon afterwards, however, the morbid symptoms 
 return, and with each inhalation the remissions gradually shorten till 
 they can no longer be obtained. Certainly, there are cases, as in violent 
 puerperal mania, where it is of the utmost importance to obtain a short 
 interval of calm, and in such cases angesthesia may be employed: ether 
 clysters (3j. to 3 j.) may also be used to obtain quiet m states of nervous 
 excitement. But often it does not exert this soothing effect, sometimes 
 it seems rather to increase the agitation. In all cases the utmost care 
 should be observed in its administration (proper entrance of air, etc.). 
 
 See Meyer, ' Charite Annalen,' viii., 2, 1857, p. 69. Morel (1854) employed 
 ansesthesia to discover malingering, but without effect. 
 
 Hydrocyanic acid (Aqua Lauro-cerasi, Aqua Amygdal. Amar.) is 
 occasionally useful as an accessory medicine in states of moderate exalta- 
 tion, melancholic anxiety, etc., in the early stages. Its sedative effect 
 appears to us to be more effectual in females. The use of Datura 
 Stramonium, which was long ago much employed, has been recently 
 revived with some success, especially in hallucinations of sight, hearing 
 (Moreau, Billod). In the hallucinations of chronic mania and dementia 
 it has no effect, and numerous proofs of its uselessness in other cases may 
 be found. Nevertheless, it appears to be beneficial in cases wliero si- 
 multaneously with the outbreak of insanity the hallucinations of hearing, 
 which on account of their immediate psychical effects are so unfavorable, 
 constitute the chief symptoms. It must then be administered in large, 
 even intoxicating, doses.' Belladonna, which is now little used, can 
 also be tried in predominant hallucinations of the above two senses. 
 There are no established indications for the employment of these 
 remedies, both of them seem contra-indicated when there is hyperaemia 
 
 ' But with great caution: we have seen, in a case in the Salpetriere, consider- 
 able emaciation, a state of marasmus, result. More recent experiences, which 
 may be of some eflacacy in hallucinations, by Boureau, may be found in the 
 'Annales Med. Psychol.,' vi., 1854, p. 555. 
 
34:0 THERAPEUTICS, 
 
 of the brain. Quinine is useful in regularly intermitting forms, and can 
 also be advantageously used to counteract certain neuralgic states which 
 are often evidently productive of delirious ideas. Assafoetida has been 
 recommended by Gruislain in large doses, in hysterical affections of the 
 mind. Certain medicines (Brucin, Hachish, etc.), which hitherto 
 have been little used, promise by careful experiment to become valuable 
 adjuncts to mental therapeutics. 
 
 Alcoholics are to be wholly condemned in the treatment of the insane 
 in general, particularly in recent cases; during convalescence, they are 
 only to be administered with the utmost caution. It is only in ex- 
 ceptional cases, as in those of former drunkards who have fallen into a 
 state of deep mental weakness with serous infiltration of the extremities, 
 that the use of strong wine may be useful. 
 
 Tobacco is much used by the insane, but only in snuffing and smoking. The 
 great predilection of many, especially chronic patients, for the irritation of snuff 
 is well known; and often a snuff good-humoredly offered to an insane person 
 prevents him breaking out in a storm of invectives, brings him to himself and 
 calms him. Strong snuff is occasionally administered to produce a sanguineous 
 secretion from the Schneiderian membrane. The smoking of tobacco by those 
 who have been accustomed to it, aids the easy flow of the ideas and equalizes the 
 temper. The return of the desire should be Avatched and encouraged; for even 
 such habits, unimportant in themselves, may assist the mind to resume its 
 former thoughts, and to follow its former courses. In the commencement of 
 paralysis, all use of tobacco should be forbidden. 
 
 § 216. Those medicines which act upon the digestive canal are the 
 oldest, and still those that are most frequently used. Besides their 
 evident indication in constipation — which is common in these diseases, 
 and very often better obviated by dietetic means and mild clysters than 
 by medicines — they are also given with advantage in all recent cases asso- 
 ciated with cerebral congestion, and are the chief remedy in acute 
 inflammatory states of the brain. Strong and rapid purgatives (croton 
 oil, etc.) are suitable in these cases; for a more moderate effect, senna, 
 rhubarb, and the various saline purgatives, are used. The long-con- 
 tinued employment of mild laxatives (the various salts of potash and 
 soda, or, better still, the aperient soda mineral waters) often proves 
 useful in chronic cases, even where there is no constipation. We must 
 not expect from the use of these means a great curative action, and in 
 hypochondriacal state they often prove injurious. Drastic cathartics are 
 to be entirely avoided where there is chronic disease of the genital 
 organs, and the long-continued use of any strong purgative may become 
 the cause of serious intestinal catarrh. 
 
 Emetics are sometimes employed in the treatment of evident disorder 
 of the gastric digestion; occasionally, especially in melancholia, they are 
 employed chiefly for their mental effects; in puerperal mental disorders 
 especially, a rapid and favorable effect is sometimes observed (Flemming). 
 The so-called nauseant cure by small doses of tartar-emetic may, per- 
 haps, through its long-continued nauseous impression upon the nervous 
 system, modify the humor and interrupt the mental pain by substitution 
 of a disagreeable bodily sensation. In the same way, the maniac may be 
 quieted by the prostration which is consequent on the medicine; but any 
 real advantage is but seldom obtained: while there are no decided 
 reasons for the continuance of these palliative means, their injurious 
 effects are, on the other hand, evident. The whole system of the nauseant 
 cure is to be considered a remnant of the barbarous age of therapeutics, 
 and the enormous doses of tartar-emetic (gr. xij.-xx.) Avhich are em- 
 
THERAPEUTIUo. \ 341 
 
 ployed by some are to be emphutically denounced. The consequences of 
 such rough j)]actice are not only the formation of pustules in the mouth 
 and oesopliagus, circumscribed gastritis, but rapid paralytic collapse may 
 even result. Anthelmintics are occasionally useful, especially in the 
 mental disorders of children. 
 
 § 217. Of the class of excitants which have a special action on the 
 nervous system, camphor has for a long time been much employed.' 
 The experiences of several practitioners warrant us in making further 
 trial of this remedy. It is especially indicated in cases of sexual irrita- 
 tion, as seen at the outbreak of puerperal insanity; in such cases it must 
 be administered in considerable doses. The experiments with musk, 
 phosphorus, arnica, etc., to "vivify" the brain, betray, in our oioinion, 
 an uncommon degree of ignorance of therapeutics. 
 
 Cooling remedies are frequently indicated — as nitre, acid drinks, etc. 
 Bitters and tonics may bo necessary in cases of long-disordered digestion 
 and in anaemia. Iron is especially useful in many cases, and is very 
 beneficial in many nervous hysterical disorders of females; cod-liver oil 
 may be advantageously administered with it in cases of angemia with 
 emaciation. Emmenagogues are frequently useful, particularly at the 
 commencement of insanity, partly arising from disorders of tlie menstrual 
 functions: in chronic cases, also, menstruation is to be Avatched. More 
 frequently, however, it is necessary to apply local treatment to the gene- 
 rative organs, as in uterine catarrh, aifections of the vagina, etc., so 
 frequently the cause of functional disorders of nerve-centres, and so diffi- 
 cult to cure by internal treatment. Cases frequently occur where anti- 
 sphilitic treatment is necessary to counteract cerebral disease (p. 138). 
 The emioloyment of electricity without evident reasons for it is to be de- 
 nofincect; local nervous pains may occasionally by this means l^e success- 
 fully treated. 
 
 § 218. With reference to diet and nourishment, the fact that insanity 
 often depends upon inflammatory processes within the cranium, might 
 suggest the necessity of antiphlogistic regimen. Notliing would be more 
 hurtful to the patient; experience shows that these diseases, whether de- 
 pending on such inflammatory processes or on simple irritation, are fre- 
 quently associated with general anaemia and defective nutrition; that 
 frequently the appetite of the patient isincreased; that spare diet irritates 
 and is positively injurious; that tlie frequent increased expenditure of 
 muscular force demands correspondingly increased nourishment; that 
 the general state of the patient is most improved by stimulating diet, and 
 that refreshing sleep, and the feeling of well-being, are induced by suffi- 
 cient food. Of course, the effects must be carefully watched, and the 
 diet regulated accordingly; in acute meningitis, and in all febrile states, 
 spare diet is prescribed; in impaired digestion, simple diet, as niilk, etc., 
 with those who have led a life of dissipation, retirement, and simplicity, 
 are often speedily beneficial. Water and simple beverages must gene- 
 rally be the drinks allowed (p. 348), and should be copiously administered 
 in all recent and acute cases: tea and coffee are forbidden in all acute 
 cases. A common table in the asylum, where admissible, stimulates the 
 appetite and social feeling amonglhc patients, recalling to the memory 
 of the convalescent those customs of society which are the external evi- 
 dences of healthy sensations, and which they have in many cases forgot- 
 ten. 
 
 1 As, for example, Perfect, ' Selected Cases, etc., from Michaelis,' Leipzig, 
 
 J 789 
 
342 THEKAPEUTICS. 
 
 In all cases of insanity, whether recent or of long standing, next to- 
 diet, the proper regulation of rest and activity is most necessary to be ob- 
 served, fresh and open air, and, in the less acute cases, abundance of out- 
 door exercise on foot, or sometimes in a carriage. No asylum is complete 
 which has not space sufficient to admit of prolonged outdoor exercise for 
 all classes of its inmates — in gardens, airing-courts, etc. In many chronic 
 cases it is highly beneficial to prescribe gymnastic exercises and cheerful 
 games which necessitate exercise, where, in the harmless excitement of the 
 game, the patient for a time forgets self and the thoughts which harass 
 him. Sleep should be the result of work, of exercise in the open air, of 
 fatigue; it may also be promoted by baths, by quiet and stillness, seldom 
 by narcotics. Except where special rest is necessary, the patient should 
 be accustomed to early rising; idle lying in bed, which, especially with 
 women, so easily becomes a habit, and leads to considerable enfeeblement 
 of the whole muscular system, should not be allowed. It is only in cer- 
 tain cases of acute melancholy, where there is a general enfeeblement of 
 the vital powers, that long rest in bed is beneficial and necessary. 
 
 As to temperature, we need only repeat that the insane are not, as 
 was formerly supposed, insensible to warmth and cold. In winter the 
 apartments should be heated, and patients who are inclined always to sit 
 still or stand motionless, and whose extremities are often cold, should be 
 the objects of special care. Where there is tendency to cerebral conges- 
 tion the temperature should be kept low and the head cool. 
 
 Personal cleanliness is most important. The methods of attaining^ 
 this are well known, and its object is not only to maintain the health and 
 function of the skin, to prevent the evil effects of prolonged decubitus in 
 paralytics, etc., but the feeling of comfort which corresponds to external 
 attention to the body is the foundation of mental well-being; and the 
 habit of external care also promotes internal order and regukirity. In 
 the same way all dietetic measures, when systematically employed, act 
 beneficially on the patient. They are therefore a powerful aid to moral 
 treatment, while all outward disorder and confusion distract the mind,, 
 and thus dem-ive it of self-adjusting power. 
 
 Sectiok III. — Moral Treatment. 
 
 § 219. Mental activity, constantly employed on account of its indirect 
 action on the organic processes, is also used to call up ideas, images, feel- 
 ings, and efforts, for the purpose of directly modifying mental anomalies. 
 This is effected only to a slight extent by any positive influence exerted by 
 the physician upon the patient, such as exhortation, encouragement, or 
 even surprises, punishments, looks, etc.; much is gained by negative 
 measures. Often even the gait of the patient is such as to admit the 
 hope of a rapid spontaneous cure; in such a case the removal of all ex- 
 citing causes, and a proper regulation of the external circumstances, are- 
 frequently sufficient, especially if the patient has also the feeling of sub- 
 jection to a rational and well-meant control, and is being gradually habi- 
 tuated to proper outward behavior. 
 
 The more direct moral action, for the purpose of restoring mental 
 health, may again be reduced to two indications, which may be under- 
 stood quite as well from a profound theoretical acquaintance with insanity, 
 as from the practical knowledge of a successful system of treatment. In 
 the first place, the morbid disi)ositions and ideas which repress and con- 
 ceal the former (healthy) individuality must be uprooted and destroyed; 
 
THERAPEUTICS. 343 
 
 in the second place, the old ego, which in insanity for a long time is not 
 lost, but only superficially repressed, or hidden in a storm of emotion, 
 behind which it remains for a long time capable and ready to re-establish 
 itself, must, as far as possible, be recalled and strengthened. If, as Ave 
 have already hinted, there is some analogy between tlie moral treatment 
 of the insane and the art of education, in the aim proposed and the means 
 employed, they present, however, essential differences in the latter respect. 
 For in the moral treatment of the insane the creation of new ideas is not 
 contemplated, but the re-establishment of the old; it does not contem- 
 plate any improvement on the ego to be replaced, the realization of which 
 is the great object of education {e.g. to make it moral); l)ut the sole ob- 
 ject is the replacement of the former healthy ego, whether it may have 
 been distinguished by virtues or obscured by manifold defects. Any at- 
 tempts at improvement can only be useful after recovery. If the success 
 of education is favored by i^liableness of disposition, so the moral treat- 
 ment of insanity is most successful where the ego, already formed, fixed, 
 and only temporarily repressed, for a long time waits the opportunity to 
 resume its former place, and sometimes even struggles with all its powers 
 against the disease. Hence, it results that very often merely negative 
 moral treatment is sufficient, viz. the simple removal of all hurtful influ- 
 ences. Is it, then, wonderful that so many of the insane completely 
 recover in the hands of rough and unskilled jiersons? 
 
 § 220. As to the first indication, namely the weakening of the mor- 
 bid dispositions, feelings, and ideas, the most extended experience shows 
 that we seldom arrive at a favorable result by directly opposing them. 
 The diseased mind, even on account of its morbid state, will not receive 
 remonstrances and advice, much less moral representations; above all, it 
 will not suffer the procedure ordinarily directed against the bad disiwsi- 
 tions of persons in health. This ill-humor proceeds necessarily from dis- 
 ease of the brain, and the patient can no more divest himself of it by an 
 act of will, than the subject of irritation of the retina can escape the 
 colored images which result from it. Much can be done to remove this 
 ill-humor by physical treatment, by rational expective treatment, where- 
 by the feeling may sometimes be got rid of by permitting its outburst as 
 in mania; sometimes the symptoms may be repressed, but their diversion 
 by moral means, which is soon to be spoken of, is always the principal 
 object. Quite as useless and even more injurious than"such simple ex- 
 hortation, is any attempt directly to overcome the delusive ideas of the 
 patient by logical reasoning. All direct, especially passionate, discussion 
 generally augments the delusion by instigating the patient to justify his 
 views, seek reasons for them, and irritates and exasperates him according 
 to the force and acuteness of his opponent's arguments; the raillery 
 whicli always accompanies such reasoning is also injurious to him. The 
 morbid ideas are not to be subdued by any kind of proof or evidence. To 
 spread all his wealth before a patient who thinks he is ruined, to pull 
 down the wall in which another fancies his tormenting enemey is hid, 
 would only irritate them and call their attention more forcibly to their 
 false ideas: in very favorable cases we may obtain an apparent consent and 
 compliance; most commonly, however, they will only substitute one form 
 of delusion for another of a worse kind. All this Avill be sufficiently ex- 
 plained by what has been said (p. 50) upon the manner in which insane 
 ideas originate from dispositions becoming fixed; only by the removal of 
 these is the insanity to be thoroughly uprooted. 
 
 Occasional exceptions to the general rule not to attack insanity by 
 
34:4 THEKAPEOTICS. 
 
 direct means of evidence, occur in convalescents in whom fragments of 
 the insane ideas still remain after the disappearance of the disorder, and 
 also in the early stages of insanity, where the rising insane notions con- 
 front the patient still as vague images, and where the ego still opposing 
 the disease can find help from the external view of the true state of 
 affairs.' But, even in these cases little can be expected from much ex- 
 hortation and attempts at conviction; it is preferable to intimate the real 
 condition as if by accident, and thus to let the patient think that he has 
 arrived at the conclusion by himself, all controversy tires and aggi-a- 
 vates, excites distrust and aversion. 
 
 Another means of direct opposition, to be reserved for rare and des- 
 perate cases, consists in tlie forcible repression of every expression of the 
 insane ideas, in a judicious system of attack on every insane woz-d or 
 deed. The chief means of this kind is the douche, while the patient is 
 simultaneously impelled to rational dealings and expressions partly by 
 constraint, especially by the consequent advantages of freedom, enjoy- 
 ments, friendly impressions, etc.^ Such open uncompromising attack on 
 the insane ideas in order to obtain violent mental diversion can scarcely 
 be attempted in feome cases of chronic mania, where there is a general feel- 
 ing of well-being and an absence of all other disturbances; it is quite as 
 fatiguing to the physician as to the patient, who should never have an 
 opportunity to indulge in his insane ideas: suppression of the hallucina- 
 tions or complete cure, by such means, we hold to be impossible.^ The 
 same may be said of the various and ingenious artifices and modes of sur- 
 prise which have been employed to convince the patient of the falseness 
 of his ideas: when they fail they actually injure the patient; he discov- 
 ers the intention, or rather deceit; and if they succeed, they generally 
 effect only an exchange of the insane ideas. 
 
 There are certainly examples of raj)icl improvement by the excitement of vio- 
 lent passions, of anger, fear, etc. , in mental disease, perhaps most frequently in 
 hypochondriasis. But apart from the circumstance that complete recovery does 
 not result, such a system of treatment is extremely hazardous, and we may safely 
 assume that for eveiy case of improvement ten are made worse, many of which 
 will proceed rapidly to a state of incurability. 
 
 § 221. If possible, still more reprehensible than direct opposition is 
 the so-called method of assent, sympathy with the delusion of the pa- 
 tient, whether it be with the view of temporary soothing, or possibly to 
 employ what is conceded by the patient as a new means of removing his 
 delusions. Such assent will only confirm the patient in his delusions; 
 he may afterwards appeal to it; and from such a system of treatment, 
 pursued with the best intentions, we often see the saddest results, espe- 
 cially in deep melancholic conditions, since the insane ideas which the 
 patient till then, at least inwardly, opposed become rapidly confirmed. 
 
 Instead of logically arguing against the insane notions or confirming 
 them by sympathy, in circumstances where a direct expression is required, 
 these will be much better opposed by simple contradiction, a forbearing 
 
 ' An exceptional case of this kind, a very interesting recovery by means of ex- 
 hortation, may be found in Guislain, 'Leg. or.,' iii., p. 222. 
 
 - See Leuret, ' Du Traitement moral de la Folie,' Paris, 1840, and the later 
 works of his followers; on the other hand, Blanche, ' De I'Etat actuel,' etc. 
 
 ^ This opinion, expressed in the fii-st edition of this work, has since been con- 
 firmed. ]\Iany patients whom Leuret considered cured were subsequently taken 
 up by other physicians as still insane, and no one has followed Leuret's mode of 
 treatment. Nevertheless, his publication has done away with many prejudices, 
 and the book is well worthy being read. 
 
THERAPEUTICS. - 34:5 
 
 reference to the future, when the patient will be astonished at his delu- 
 sions, an allusion to the past when he considered such things impossible. 
 It is better, and generally more applicable, to leave the delusion as much 
 as possible untouched, and thereby to weaken it by want of encourage- 
 ment, by engaging tlie mind of the patient m matters that have no ref- 
 erence to the diseased ideas. This mental diversion is a fundamental 
 principle in all psychical treatment, but as an active method is more 
 adapted to chronic than to acute conditions; it is effected in different 
 cases hy very various means, which are suited to the case according as 
 they are unresisted, as the aim of cure is concealed from the patient. 
 Of these means, the most important is employment of a healthy kind 
 (see p. 3.35); next to this stand all kinds of amusement, entertainment, 
 conversation, which, with due regard to individual tastes, should always 
 be judiciously selected, so that whatever tends to the delusion of the pa- 
 tient may be avoided, and that he may be always engaged as far as possi- 
 ble in a healthy subject of conversation. It is therefore necessary to 
 avoid, not only all reference to the delusion, the circumstances that occa- 
 sioned the disease, l)ut also much direct conversation on his condition. 
 The patient should be seldom left alone or unemployed; so long as he 
 is employed with matters unconnected with his malady, he is in a great 
 measure free from it, and by abstracting his attention from the insane 
 ideas, they are most readily weakened and dispersed. 
 
 § 222. Thereby, what is healthy in the patient will be strengthened 
 and invigorated, and jn-cservcd from suppression and ruin. This is done 
 by whatever promotes and upholds the ideas and sensations which char- 
 acterize healthy life, and this is the iirinciple of the rule, to lead the pa- 
 tient solely, or at all events, pre-eminently, in the direction of his former 
 special interests. Again, it must be kept in mind that the same thing 
 is not equally adapted to every patient. Here practical knowledge of 
 mankind on the part of the physician must be exercised in discovering 
 the character by the different modes of action of individuals, Avhich are 
 regulated by peculiarities in habits, tastes, and culture, and in finding- 
 out the sides from which he is suscejitible. In women, attention is to be 
 directed to other matters than m men; in some cases all healthy thought 
 and action is inseparably connected with their ordinary employments and 
 calling in life; the mechanic can often find only in his work, the musi- 
 cian only in the tones of his instrument discover, the whole range and 
 unity of his former individuality. Quite as varied are the interests of 
 disposition; the attempt, however, always proves unsuccessful to inter- 
 est the patient in anything that has no foundation or support from the 
 thoughts and pursuits of his previous life: to the thoughtless, for exam- 
 ple, religious exhortation during his disease would be as useless as to 
 force one who has no sense of harmony to engage himself with music. 
 But the principle of carefully maintaining and strengthening the whole 
 former personality is to be departed from where defects of character, by 
 long control of the ego, have evidently tended to the formation of the 
 disease. In cases which occasionally appear, where the insanity is the 
 last result of a life of dissipation and folly, no recovery can be expected 
 except by a complete change, the commencement of a wQvr individuality. 
 But it is well known, how scanty our means are of accomplishing this, 
 how difficult such a restitution is, and how defective and ahvays suljject 
 to relapse such cases are. Everything connected with the healthy bygone 
 life — social attachments, the old modes of employment, etc. — serves to 
 strengthen the ego, and the endless modifications of the means to be em- 
 
346 THERAPEUTICS. 
 
 ployed in promoting the healtliy sphere of tlioiiglit (correspondence,, 
 visits, etc.) must be left to the judgment and tact of the physician. 
 
 § 223. Of moral remedies, proper employment of the patient seems 
 to us the most important. In healthy work, the innate desire of express- 
 ing and giving vent to its energies finds fullest satisfaction in the 
 objective world ; by constant occupation in forming materials, the 
 thoughts and efforts engross the mind and withdraw it from empty long- 
 ings and illusions of the imaginations; the feeling of success again pre- 
 pares the way for expansive sensations, and therewith self-esteem and 
 confidence return. Therefore, a steady employment of the patient, espe- 
 cially when voluntary, is rightly considered a decided indication of 
 improvement, and is frequently the commencement of recovery. Those 
 employments are the best whicli keep the patient engaged in tlie open 
 air, as all garden and field labor, which prove of gi'eat advantage not 
 only to the lower ranks who have been accustomed to daily toil, but also 
 to the educated classes, owing to the peaceful and soothing influences of 
 immediate intercourse with nature. Where this is not practicable, 
 household or mechanical modes of employment, chiefly of a light kind, 
 may be substituted; and very few patients, and these only in alternation 
 with physical exercise and muscular activity, should be engaged in 
 sedentary and mental work. In chronic cases, the learning of a new and 
 agreeable trade Avill sometimes engage the attention in a most beneficial 
 way. Indigent patients should receive a small remuneration for their 
 work during recovery; this has often proved a seasonable protection 
 against want: the exertions of the affluent are devoted to the institution 
 and the poorer inmates. Wherever his state of health will admit of it, 
 the patient should work methodically. And while the patients are to be 
 restrained from unsettled trials of all possible employments, every appear- 
 ance of a manufactory, or regard merely to the i")ecuniary advantage of the 
 institution, is still more to be avoided. Eecovery or improvement of the 
 patient should be the only object of work. Each inmate should be re- 
 quired to do only what is suitaljle to him, and only at the proper period, 
 and indolence alone is to be strictly prohibited. 
 
 Work is evidently not adapted to acute states; in the exalted stage of the dis- 
 ease an}- enforcement to it must prove injurious: recent cerebral irritation de- 
 mands perfect rest. This does not, however, imply that all mental excitement 
 renders work impossible or injurious. In English asylums, where there is no re- 
 straint, many excited vociferous patients are put to work, for example, at the 
 washing-tub. who, in many German asylums, would be confined in cells; and it is 
 remarkable that they become sooner calm by the first method of treatment. But 
 ■work is decidedly more advantageous in the quieter, especially protracted, states 
 of insanity, in the period of transition to the secondary forms and in these forms 
 themselves, and during convalescence where the desire for work is spontaneous. 
 
 § 224. Closely related to physical employment stands a healthy en- 
 gagement of the mental powers. In asylums "the school" is a means 
 for this purpose suited to many of the patients. This is not intended to 
 combat the insane ideas of the patient, or to demonstrate by philoso- 
 phy the impracticability of his projects, but to withdraw his atten- 
 tion from the morbid ideas to matters which are interesting and useful. 
 It is a useful means of awakening the mind and of imparting the elements 
 of mental culture to patients who were previously ignorant. Like all em- 
 ployment which excites the brain, it ought never to be permitted in the 
 acute stages, and in all other Cases it should be continued only for a com- 
 paratively short time. The subjects of instruction are regulated according 
 to age, sex, and education, and consist of elementary instruction in music, 
 
THERAPEUTICS. 34T 
 
 history, etc. It may be combined with recitation, and can with advantage 
 be conducted on the principle of mutual instruction; the more educated 
 patients assisting the uneducated, always remembering tliat teacher and 
 method must be made attractive to the patient. Too much has frequently 
 been anticipated from the influence of music; the sentiments provoked 
 by it are too transient to oj^pose the duration of the moi'bid disposition^ 
 and it has no influence beyond other means of distraction, except when 
 it is the decided choice of the patient. The practice of part-singing in 
 asylums is to be commended as a means of amusement. 
 
 Besides, conversations, lectures, Avalks, games, tea-parties, etc., also 
 serve to engross and amuse the patient. These are to be regulated as 
 much as possible to suit the diflierent dispositions. 
 
 Guislain lias very properly declared himself against those promiscuous dancing 
 parties so common in several English institutions, and which have been imitated 
 in other countries. In a great German city the newspapers annually contain the 
 announcement of a brilliant ball at the lunatic asylum, with the insulting inti- 
 mation that the company was not disordei'ly. 
 
 Visits to the patients should always be under special surveillance, and 
 the simply curious siiould be altogether excluded. In the early periods, 
 and when the disease is still increasing, visits from the relations are ordi- 
 narily hurtful, partly by affording nourishment to the frequent aversion 
 of the patient towards his relations, and recalling many irritating 
 thoughts; partly by hindering the necessary habitude and resignation of 
 the jDatient to his residence in the asylum, and exciting longings for 
 home. On the contrary, when the patient is calm, and healthy desires 
 are again awakened, visits contribute much towards his improvement and 
 strength. In commencing convalescence, the patient often after a single 
 visit quickly discovers his real condition, the nature of his disease, and 
 his relation to the Avorld. 
 
 § 225. The aid of religion in the treatment of insanity is not to be 
 lightly estimated; the application of this remedy requires, however, great 
 caution. Keligious instruction should not be withheld from any patient 
 who desires and requires it; it would, however, oppose the first principles 
 of mental treatment to enforce such instruction, or attempt to interest in 
 it any one who has no religion at heart. It would show total ignorance 
 of the nature and circumstances of tbose diseases to aim at direct recovery 
 by reforming or converting the patient by religious instruction. All such 
 means should only aim at imparting quietude, trust, and hope — to direct 
 attention from the morbid representations to an earnest and remarkable 
 theme — to revive the modes of thought and sensation of his healthy state. 
 How far such ends should be attempted by these means can only be 
 judged by the physician. He will never comply with the cruel-and useless 
 request, that, in addition to his self-tormentmg misery, a melancholic 
 patient should be subjected to severe penance, or that the timid and fear- 
 ful be threatened with the torments of hell. Melancholies and maniacs, 
 unless all excitement of this kind has ceased to influence them, confirmed 
 maniacs, gladly seize all such representations to nourish their delirium. 
 Should, however, the religious influence be exerted with the necessary 
 circumspection — if only those phases of religion be presented which sea- 
 sonably appeal to the feelings, and if the chaplain be judicious enough 
 to have in view the single aim of the patient's recovery — regular religious 
 services according to both creeds is highly beneficial, and we very often 
 see the chaplain's visit, indejiendently of what he says, proving of great 
 advantage to the patients, owing to the necessity of their meeting together 
 for some time. 
 
3i8 THERAPEUTICS. 
 
 Several medical psychologists would have the whole treatment of the insane to 
 be speciticaliy Christian. But Jews also require tlie aid of the alienist and his 
 science, and there is no abstract, only a confessional Christianity. Therefore 
 there would require to be a special Protestant, CathoUc, etc., and again a Jewish, 
 heathen, psychiatrie. Possibly even this may be yet desired. 
 
 § 226. External means of restraint are employed with the view of pre- 
 venting the patient from inflicting injury to himself or others, to prevent 
 that vdire and fury, especially such manifestations of his insane desires as 
 would afford them new nourishment, and thereby to aid his self-control. 
 Besides, they should serve to make him sensible of an external force 
 ao-ainst which his own exertions are powerless, to bend liis will, and sub- 
 due obstinacy and a refractory spirit. The means employed should 
 never be such as in the least to wound tlie self-esteem of the patient; they 
 should never be suggestive of a house of correction (as chains and blows), 
 neither should they shock the imagination, as did those great apparatus 
 which were used till very recently in many places.' At the present day, 
 the strait-jacket (which is of linen) is the principal moans of restraint 
 still in use; it allows to the patient little or no use of his arms and hands. 
 In many asylums the constraint-chair is still used— an arm-chair in which 
 the patient* is confined; straps also to fasten him down in bed. 
 
 It was abuses which formerly Avere invariably connected with the em- 
 ployment of bodily restraint which, about twenty years ago, originated 
 in England the opposite system, the total banishment of all means of 
 mechanical restraint from the treatment of insanity. This method known 
 as the system of non-restraint, first (1838) tried by Gardiner Hill in the 
 Lincoln Asylum, was fully developed by Conolly in Hanwell in 1839, and 
 within the last ten years has been adopted in nearly all English asylums. 
 Its advantages have been as much praised as they have been disputed. 
 The principal argument in favor of tliis system, is its greater humanity 
 and its easier quieting of the patient, Avho is often rendered more irritable 
 by mechanical coercion. It has been affirmed that the patient is thus more- 
 habituated to self-observation and control, that he is raised in his own 
 esteem, and that by it arbitrary violence on the part of the attendants is 
 rendered impossible. It is alleged that in those asylums Avhere this 
 method has been adopted the patients have been rendered calmer, more 
 submissive and clieerful, and the recoveries more numerous and perma- 
 nent. In occasional rare cases of necessity, the use of mechanical means 
 is nevertheless conceded (Conolly). 
 
 On the other hand, it is argued that it is an excess of philanthropy to 
 consider it an act of inhumanity to confine a lunatic with the strait- 
 jacket; that mechanical restraint aloue is capable, in certain cases, of 
 rendering them submissive to the authority of the physician, and harm- 
 less to themselves and others; that the use of these means allows the 
 patient himself more freedom, especially to move in the open air; that 
 without them a disproportionately large staff of attendants is necessary; 
 that a personal control is more irritating than mechanical means; that 
 some patients, when they feel a paroxysm of madness coming on, even 
 desire mechanical restraint, especially, however, in occasional cases of 
 suicidal tendency (there being no other means of control); and lastly, 
 that the seclusion which is employed in the system of non-restraint is 
 equally mechanical coercion under a different but not improved form. 
 
 In taking a retrospect of these arguments for and against, we can 
 
 ' For an enumeration of these, see Schneider's ' Heilmittellehre gegen psychi- 
 sche Krankheiten,' Tubingen, 1824. 
 
THEEAPKUTIC8. 349" 
 
 easily understand how the yalne of the system of non-restraint was so 
 long questioned, and how the arguments against it appeared to keep the 
 ascendancy. But if we consider that these objections proceeded entirely 
 from those who had not practically tested the system of non-restraint, 
 and had never even ^witnessed it, their force will not aiypear so great. If 
 Ave interrogate experience, which is the only proper test, we shall find 
 that during the last ten years all doubts in reference to it have been re- 
 moved. The question is now decided entirely in favor of non-restraint. 
 This great reform is now carried out with the most favorable results in 
 every ])ublic asylum in England, and the name of Conolly will always be 
 mentioned with that of Pinel, whose work he has completed. 
 
 The exact method of this system is by many, however, not properly 
 understood. It consists of an entire setting aside of all mechanical means 
 of restraint, and the substitution of other means of quieting and watching 
 the patient. The new system is therefore a positive treatment, not a 
 mere leaving of the patient to himself; still less, as has recently been un< 
 justly asserted, is it the supplying the place of mechanical restraint by 
 coercion, by seclusion, or restraint by the hands of attendants.' The 
 system of repressing the manifestations of the disease by mechanical re- 
 straint and violence is exchanged for a mild system of treatment, which, 
 in the majority of cases, can avert those manifestations; where this, how. 
 ever, does not succeed, some other means, conciliatory or simply quieting, 
 is devised to meet the case. If, then, it should be asked what in these 
 asylums is put in the place of mechanical restraint, which was hitherto 
 indispensable? we have only to say, that according to indisputable evi- 
 dence, in thcasylums where there is no restraint and, at the same time, 
 good dietetic and therapeutic treatment, the cases which appeared to de- 
 mand restraint have steadily and remarkably diminished; that there are 
 rarely seen any of those cases of continued and violent mania which are 
 still treated in many places by means of prolonged seclusion, the use of 
 the strait-jacket, or the constraint-chair. Should, however, violent ex- 
 citement present itself, Ave seek, by means suited to each particular case, 
 to distract the patient's attention from the object of his delirium, to calm 
 and to diA'ert him; he is removed from the locality where his agitation 
 commenced, and, if necessary, isolated for a short time (tAvo to four 
 hours, often less) in a chamber Avhere he is secure against self-injury, or 
 confined in an inclosed court. In all communication Avith an excited 
 patient the greatest forbearance and gentleness must be exercised, and 
 everything Avhich has the least appearance of violence, or could in any 
 way irritate him, ought to be avoided. This system, which is so much 
 to be preferred to the old mode of coercion still practised in many places, 
 can naturally only be carried out in an institution so organized as to 
 meet its demands; the attendants must be sufficiently numerous, intelli- 
 gent, actiA'e, and good-natured, and all must be under the constant sur- 
 veillance of a physician Avho takes great interest in the subject, and is of 
 a patient and benevolent disposition. 
 
 In certain rare and exceptional cases (such as sudden protection 
 against a dangerous lunatic, surgical cases, etc.) Conolly himself admits 
 tiie possibility of the necessity of employing (for as short a time as possi- 
 ble) mechanical restraint: this is totally different from its employment as 
 a means of regular treatment of the insane. In all the cases Avhere for- 
 
 ' With regret I find this opinion, so fundamentally false, even in Neuman, 
 Psychiatrie,' p. 86. The ardor with which the author defends the strait-jacket 
 should not have led him to such incorrect expressions. 
 
350 THERAPEUTICS. 
 
 merly force appeared indispensable, even in those with a tendency to 
 suicide, experience has proved tlio entire abolition of all such means, and 
 their substitution by milder measures which act upon the disposition of 
 the patient, to be in every way more suitable. 
 
 Up to the time of the publication of the first edition of this work, I allowed 
 myself, influenced by the adverse opinions of the German psychologists, to oppose 
 the system of non-restraint; although at heart I sympathized with the reforms, 
 yet r could not see my way clear to refute the contrary arguments which were 
 advanced. Since then practical experience, from the cne end of England to the 
 other, has done so. I have seen the new system carried out in several of the large 
 English institutions, and have been convinced. Indeed, in one of the institutions 
 containing about 1,000 patients, I saw a bloody nose and heard the crash of broken 
 glass, but I have remarked the same in asylums where the strait-jacket and con- 
 straint-chair were in daily use. I have seen with happy astonishment how easily 
 several patients on the point of an outbreak were rendered speedily calm through 
 a kind of psychical diversion, who to a certainty, in the majority of Continental 
 institutions, would at once have had means of restraint api^lied. Let us hear no 
 more of impossibility! In Hanwell, with a population which has gradually in- 
 creased till now it reaches about 1,000, for twenty-one years there has not been a 
 hand or foot bound either by night or by day. Colney Hatch, a very large asylum 
 (1,200 patients) was opened in 1849, and never to this day has any means of re- 
 straint been employed; Bedlam and St. Luke's which are specially devoted to 
 acute cases, have, to the great benefit of these institutions, long ago embraced the 
 system of non-restraint, and not one of the asylums in which the new system has 
 been introduced has reverted to the old treatment. Nor let it be said that in the 
 system of non-restraint confinement in a cell is "also restraint," a substitute for 
 the strait- jacket. Amongst 5-6,000 patients in a number of English asylums, 
 Morel found (1. c, p. 55) only three in cells, and in these cases the periods of con- 
 finement were short. Compare with this the numbers who are confined in cells — 
 many with strait-jackets, and othei's actually reconciled to their sojourn through 
 its long continuance — in some of our Continental asylums wheVe non-restraint 
 seems to be regarded as a mere chimera. And let it no more be repeated that 
 sucli a system is suited only to the English, who submit more easily to control 
 than the patients on the Continent. Before the time of ConoUy it was believed 
 in England also that it was impossible to treat the insane without powerful means 
 of restraint; even as recently as 1843, in Bedlam and St. Luke's the patients were, 
 owing to their presumed ferocity, fastened in rows to the walls. Neither let it be 
 said that the use of means of restraint is good, and that only the abuse is blame- 
 able. No one can say where the use ends and the abuse begins; indeed, it would 
 appear- that the abuse is unavoidable, and a very experienced physician has said 
 "restraint is synonymous with neglect " (ConoUy). 
 
 Let us then i)ursue with confidence the new system, fearlessly break off the 
 old customs and assume the new responsibilities, ever remembering that the least 
 negligence wiU re-open the gates to the employment of violence. This is, how- 
 ever, a more difficult task than to amuse the public with pleasing descriptions of 
 Christmas presents at asylums where the wretched constraint-chair still flourishes. 
 The example of the perseverance with which the English physicians have carried 
 out the new principles is encouraging, and still more so are the results. If we 
 quietly begin to inquire how many patients have been really benefited by means 
 of restraint, we will be led to ask ourselves whether the arguments against non- 
 restraint are not the same which, seventy years ago, were advanced against the 
 first removal of the coarse and barbarous fetters by Pinel. At all events, let 
 every one keep a register in which each instance of the employment of restraint 
 is entered, with the cavise, nature, duration, and effect, and inquire at the end of 
 the year what it has effected for the cvire and improvement of the patients, and 
 how far it has justified the confidence reposed in it. We doubt not that ere long, 
 in every new institution, with the very foundation-stone the assurance will be 
 laid, that for all time coming the system of restraint is excluded. For the litera- 
 ture on this subject, see Conolly, ' On the Treatment of the Insane without 
 Mechanical Restraint;' Dick, 'Zeitschr. f. Psych.,' xiv., 1856, p. 353; Morel. ' Le 
 Non-restraint,' Paris, 1861. 
 
THERAPEUTICS. 351 
 
 Section IV. — Various Modifications of Treatment. 
 
 § 227. The means hitherto discussed must be essentially modified on 
 their application, according to the particular form of insanity, from 
 which the patient suffers; the mental and physical treatment have again 
 to be modified as well by differences of individuality as by differences of 
 form, by the presence of other bodily diseases which may be the same in 
 all forms, and especially according to the differences of social status, dis- 
 position, and mental character. For the last-mentioned particular no 
 general rules can be established. In the treatment of the different stages 
 of insanity, and particularly at the commencement, the necessity of 
 prompt and early interference must again be insisted on. First, by a 
 careful and minute observation of the patient the diagnosis is to be cer- 
 tainly established. Where the first indications are moderate, it may 
 happen that only a probable diagnosis can be made, which, however, can 
 be further supported by evidence of the existence of hereditary disposi- 
 tion, of certain causes having been at work, etc. Always avoiding any 
 gross error, such as confounding typhus fever with insanity, it is a judi- 
 cious course for the patient where there is strong presumption of it to 
 treat him as if he were insane, as from this course no injury, but proba- 
 ble benefit, can ensue. For at this period the chief treatment is con- 
 fined to avoiding all causes of the disease, and to careful dietary arrange- 
 ments suited to his case. 
 
 It is here that physical treatment is most extensively employed: as to 
 moral treatment, the patient is to be guarded against too eagerly engaging 
 himself with adverse circumstances, which increase his ill-humor; from 
 all exciting argument, all urgent exhortation or religious discussion. 
 On the other hand, his mental pain, as far as possible, is allayed by dis- 
 tracting his attention by other subjects, by directing it to the sphere of 
 his accustomed duties, or to mild, cheering external influences: and his 
 sinking hopes are to be strengthened by moderate and benevolent en- 
 couragement. The patient should not be allowed to discover that any 
 doubt is entertained regarding his mental health, that he is directly 
 observed; nor should he be urgently questioned regarding the reasons of 
 his change, which would cause him to be distrustful and inclined to dis- 
 simulate; he should be as little as possible left alone. It is sometimes, 
 however, advantageous to observe him when he thinks himself alone and 
 unnoticed, as then lie often gives way to soliloquy and gesticulation. 
 Wherever the general health permits, he should not be altogether idle — 
 a suitable employment should be chosen for him; but all mental exertion 
 is to be entirely avoided, and frequently the first step in treatment is the 
 entire cessation of the previous occupation. 
 
 The patient should in every instance be withdrawn from the baneful 
 influences which have hitherto been at work, and conducted to others 
 which are new and beneficial. In order to arrive at this, a total change 
 of all the external relations is frequently necessary; very beneficial results 
 are often obtained by change of scene, short excursions, if possible, on 
 foot, and, if the circumstances permit, a residence at some carefully 
 selected watering-place — never in great cities, where the brain and senses 
 of the patient may be excited. All exciting amusements — the theatre, 
 music parties, and the various "pleasures" that one might be tempted to 
 permit — can only do injury. The patient, above all, requires prevention 
 of violent impressions of contact with those who are not acquainted with 
 the nature of his malady, and quiet and stilhiess. The success or uon- 
 
352 THERAPEUTICS. 
 
 success of these rules depends very much on the degree of patience and 
 perseverance with wliicli they are carried out, on tlie external conditions 
 of the patient, and on those who surround him; and the aid of an intelli- 
 gent woman is often valuable. The physician must counteract tlie error, 
 so frequently committed by relations, of considering the mental anomaly 
 as if it depended upon waywardness and dissimulation; he must kindly 
 yet decidedly acquaint them with the danger in which the patient stands, 
 and the necessity of immediate interference; he must not accept auy 
 excuse when he observes that his instructions are not implicitly attended 
 to. 
 
 Moreover, a regulated diet, exclusion of all alcoholics, abundant out- 
 door exercise, refreshing sleep, and a healthy maintenance of all the 
 secretions, must be seen to. AH symptoms of acute or chronic disease in 
 other parts (menstruation, heart-disease, diseases of the bowels, etc.) 
 must be carefully watched, and anything that could determine or main- 
 tain hypera^mia or irritation of the brain must be unremittingly and 
 attentively treated. Although it bo true that all treatment having a 
 specially weakening effect is to bo avoided, yet it is in this, the stage of 
 commencement, when the disease is acute, that well-directed blood- 
 letting, if si^ecially indicated, can have the best results. 
 
 Treatment by mineral waters at the commencement of insanity, 
 especially by slightly laxative waters, as Marienbad, Kissmgen, etc., is, 
 to say the least, useless. Systematic hydropathic treatment is generally 
 still more injurious; tepid thermal baths, if the change be in other 
 respects beneficial, may have a calmative effect upon certain patients. 
 The nutrition must be improved, in some cases, directly, by means of 
 stimulating nourishment — iron, cod-liver oil, or by a lighter diet, as 
 milk; in others, indirectly, by improvement of the digestion and sleep. 
 All states of congestion must be opposed (cold applications, sinapisms, 
 cooling remedies, leeches, etc.); the excretions maintained, nervous 
 agitation calmed, and, if possible, sleep reinduced (baths, opium, aq. 
 lauro-cerasi, digitalis, etc.). Removal to a quiet country residence, 
 together Avitli a simple mode of life, does good in many instances. 
 Moderate exercise, long-continued rest of the body (so that the greater 
 part of the day is spent in bed — the remainder, if possible, quietly in the 
 open air), or constant rest, should be jjrescribed according to the case.' 
 
 § 2:28. When the commencement of the disease is sudden, and its 
 outbreak violent, wo should not, merely to calm for a time the most 
 striking symptoms, be induced to adopt thoughtlessly the use of means 
 which might exert an injurious influence iTpon the subsequent course of 
 the disease (for example, profuse bleeding, tartar emetic in large doses). 
 In such cases there should only be added to the treatment previously 
 mentioned, comjilete isolation of the patient, who can no longer mix 
 with the world. 
 
 In melancholia, all attempts to repress the mental pain Avith questions 
 and exhortations should be avoided. The patients should be spoken to 
 as little as i>ossible about their own condition, and not at all regarding 
 the object of their delirium; they should not be permitted to make many 
 complaints, and a somewhat strict system of treatment, which may oc- 
 casionally even have the appearance of severity, is often of more service 
 
 ' See Erlenmeyer, " How are Mental Diseases to be treated at their com- 
 mencement?" Neuwied, 1861; Guntz, "How are Mental Diseases," etc., 'Arch. 
 derGesells. f. Psych.,' iii., 1, 1860, p. 1. 
 
THEKAPEUTICS. 353 
 
 than words of consolation. The stronger patients should rise regularly 
 in the morning, do some work, take a walk, etc. ; those who are weakly, 
 especially females, and patients Avith weak, irritable action of heart, and 
 dry, cold skin, may be jiermitted to lie long in bed; their harmless 
 wishes are to be attentively fulfilled, every healthy feeling encouraged, 
 and only what is morbid resisted. When great anxiety and restlessness 
 apiDcar, especially in the agitated form of melancholia, all active repres- 
 sion is objectionable; it is best treated by regulated exercise in the open 
 air, the use of baths, etc. In these cases, the remedies that are employed 
 in intestinal catarrh, and occasionally emetics, are of service — more fre- 
 quently the milder laxatives, which may sometimes be combined with 
 bitters. In many cases, digitalis, tonics, quinine, are indicated — excep- 
 tionally a little wine; above all, however, opium in large doses (see p. 
 346). In melancholia with stupor, drastic cathartics, and strong 
 external irritants — vesicatories, tartar-emetic ointment — are often useful; 
 the bodily strength is to be improved by means of good nourishment. 
 
 In mania, the removal of the patient from former scenes is always 
 indispensable. The maniac who has forgotten all ideas of order and of 
 healthy life, and who may become very dangerous, and the monomaniac 
 who, through the opposition with which his extravagant undertakings 
 and eccentric demands are met, becomes soon exasperated, can only be 
 tolerated in an asylum, and, above all, can only be treated there. 
 Kothing is more injurious to them than uncontrolled freedom, which 
 constantly increases the malady; while the rest and quietness of the 
 asylum, Avith its restraining influences, have in many an immediate 
 beneficial effect. Even there, unruly patients generally require to be 
 isolated, it may be for only a short time. Some require complete rest 
 and quietness — in rare cases the withdrawal of light; many are soonest 
 rendered quiet by being allowed free vent to their humor in large pro- 
 tected rooms, or better in the open air. Moreover, the outward excite- 
 ment should not be immediately opposed by means of restraint, and 
 quite as little by exhortations and counsels. It is best to allow such 
 patients to speak and to cry unheeded; and the outbreaks of temper should 
 only, when of a dangerous nature, or where they might originate ncAV 
 internal excitation, be restricted by mental diversion or isolation, which 
 should be carried out promptly, without any talking or struggling. 
 Everything not positively injurious may be granted to the patients; but 
 we should not give in to extravagant demands, and not show ourselves 
 too indulgent to the morbid Avishes. In occasional cases, indeed, es- 
 pecially if we may presume from former attacks that the mood Avill only 
 last for a short time, it is often better to satisfy even unnecessary 
 demands. Uproarious, disobedient patients, even though highly refined, 
 must be subdued at any price; indulgence only increases their demands, 
 and awakens the idea that they can impose upon the physician. Where 
 there seems to be suflBciont mind, we may say to the patient that he is ill, 
 and call his attention to the anomaly of his acts and pursuits; Avhere 
 possible, the patient should be exhorted to a proper demeanor, and after 
 a time put to some emjiloyment. Such patients should be allowed to 
 drink a great deal — to use baths in the manner described. Leeches and 
 cupping maybe employed when necessary; also digitalis, cooling medi- 
 cines, and slight ai^erients; very seldom (except in delirium tremens) 
 should narcotics be given. Cutaneous irritants seldom do good in acute 
 cases. In general, it is necessary in these cases to guard against doing 
 23 
 
354: THERAPEUTICS. 
 
 too mucb, remembering that outward quiet is not the sole aim of treat- 
 ment, and that the nutrition is to be maintained as much as possible. 
 
 There is no specific treatment for puerperal mania, although such has been 
 often recommended. Each case must be treated according to the form it presents. 
 The chief consideration is always whether any other (always feverish) puerperal 
 disturbance be present (see p. 145): if so, it is the principal object of treatment; if 
 not, if the cerebral affection does not depend upon other disease, then all violent 
 measures, especially bloodletting, cathartics, cutaneous irritants, are, as a rule, 
 wholly to be avoided, and, on the contrary, nourishing diet, keeping the bowels 
 gently open, and quieting the excitement by means of baths and opium, are, in 
 the majority of cases, the chief means of treatment. In cases where there is con- 
 siderable anasmia, small quantities of alcohol may be advantageously given; in 
 other cases, digitalis, camphor, and quinine are useful. The same remarks apply 
 to the treatment of hysterical mania. Where there is acute delirium (see p. 212), 
 cold affusion in a tepid bath often does good; a rapid sinking of the nutrition in 
 this form demands particular attention. 
 
 It is difficult to define more precisely the rules of treatment in the de- 
 generate chronic forms of mania and melancholia which pass into 
 dementia. Each case must be individually considered and the therapeu- 
 tical and moral treatment cannot be too early commenced. All marked 
 changes in the bodily health are to be carefully watched, as they some- 
 times favorably modify the insanity. The great point, however, is to re- 
 excite the spontaneity of the patient. This may be sometimes brought 
 about by a complete change of the external relations, as removal to 
 another asylum, or temporary discharge by way of trial. ^ That system of 
 treatment which attempts to bring about this result by violent repression 
 of all morbid manifestations, and forcing the patient to healthy acts and 
 desires, has not been justified by its results. 
 
 In fully developed systematic mania, and in dementia, treatment is 
 restricted to protection of the patient, by work, strict discipline, order, 
 and cleanliness, from deeper mental and bodily degradation, and to 
 rendering his existence as comfortable as possible by benevolent treat- 
 ment, and by allowing him all the enjoyments he may desire, and which 
 his state permits us to accord. 
 
 For paralytic dementia there is no therapeutical treatment. Several 
 observers, hoAvever, state that they have seen benefit result from the use 
 of the actual cautery; others, from methodical and long-continued appli- 
 cation of cupping-glasses — dry, or with the abstraction of only a small 
 amount of blood — to the nvicha, from strict diet (in some cases milk 
 diet), evacuants, iodide of potassium, the mineral acids, etc. ^ As the dis- 
 ease advances, the utmost cleanliness (but to the total exclusion of baths) 
 is to be seen to; well-chosen nourishing diet, consisting towards the end 
 of semifluid elements; above all, pure air, the patient being as much as 
 possible in the open air; and, in short, the same attention is required 
 which is necessary in tlie earliest years of childhood — anything that can 
 prolong life and make it more supportable. 
 
 The treatment of the various states of idiocy, whether congenital or 
 occurring in early years, if recovery (which is extremely rare) or simple 
 improvement he aimed at, must be commenced in the years of childhood. 
 Adult idiots and cretins can only be subjects of care and protection. To 
 arrive at real results, the treatment must be begun at the earliest possible 
 age. By active and proper means commenced during the second or 
 third years of life, there is reason to believe that results may be obtained 
 • such as we have at present no idea of. At this age, the first step neces- 
 sary is removal of the child beyond reach of the influences (p. 251-276) 
 
THERAPEUTICS. 355 
 
 of causation (when the causes are miasmatic, removal to another and 
 healthy locality — not necessarily to a high mountain); and, in the second 
 place, to see to the proper regulation of the rearing of the child, the 
 strengthening of his physical powers, and to a mild, gradual, and 
 methodical excitation and elevation of his senses and dispositions. Spe- 
 cial cases (syphilis, rickets, etc.) require the treatment special to these 
 maladies. Epileptic conditions are, if possible, to be treated according 
 to their causes, or, secondly, by atropine (in the epilepsy of children this 
 often produces most rapid results), oxide of zinc, etc. But, in the 
 majority of cases, the treatment, especially that of the asylums, is not 
 commenced until a much later period — at an age when the object would 
 rather be to render the stunted remains of the mental faculties capable 
 of performing their function, than to attempt to cure or even improve 
 the morbid state of the brain. The object, therefore, is more tliat of 
 education. In this, experience teaches that even at a more advanced age 
 (from five to ten years) the education depends altogether upon a healthy 
 development of the body. We should, therefore, with all our energy try 
 to strengthen the constitution, improve the nutrition, institute a feeling 
 of bodily well-being and comfort (nutritious food, exercise in the open 
 air, baths, cold sponging, cod-liver oil, iron, etc.). It is not so much by 
 methodical instruction (lectures, reading, learning, etc.), which has a 
 gently stimulating effect upon the brain, as by illustration, simple em- 
 ployments, the relating of interesting narratives which awaken the atten- 
 tion — by well-regulated practical exercise and games, which render the 
 sensorial impressions more correct — that the formation of proper though 
 simple ideas is to be promoted. Of what use is it to bring up learned 
 idiots who know the whole ABO, but stumble before every little 
 obstruction that comes in their way? Agricultual employment would be 
 well adapted for most of the lighter cases, but it is very difficult to obtain 
 it. Music exerts a favorable influence upon many; constant repetition is a 
 means whereby, even in the most serious cases, improvement of certain 
 phases of the mental life is occasionally obtained; but with these children 
 all discipline and punishment is worse than useless — any improvement is 
 only to be obtained by kind and benevolent treatment. The sociability 
 of the asylum is very beneficial and improving for most of the more 
 slightly affected children, 
 
 I must here restrict myself to these few aphorisms; further details will be 
 found in the works mentioned in page 273, and in the writings of Voisin and 
 Eosch, Erlenmeyer, Georgens and Deii3iardt. 
 
 § 229. When hallucinations are present, the organ of sense to which 
 they refer should be minutely examined; if necessary, the ears can be 
 syringed, and the attempt made to remove any sensorial irritation by 
 means of leeches, derivatives, Daturia stramonium, etc. 
 
 Should the patient refuse his food, the mouth is the first place to be 
 carefully examined, as refusal of food is sometimes caused by inflamma- 
 tion of the buccal mucous membrane, cynanche, etc. If nothing of this 
 kind is discovered, we then attempt to turn the patient from his resolu- 
 tion, not by argument, but by placing before him choice food when he is 
 alone and silently taking it away again, or by putting him where he may 
 see others eat. Should this not be speedily successful, we quietly pro- 
 ceed, after a short exhortation, to the use of artificial alimentation, by 
 forcing him to swallow food while holding his nose, or, should he still 
 resist, by employing the (esophageal sound. When food has been for a 
 
356 THERAPEUTICS. 
 
 loug time refused, stimulating fluids, such as wine, should not be given 
 at first, but mild substances, as milk, beef-tea, etc. 
 
 Since the publication of the first edition of this work, numerous experiences 
 of the treatment of refusal of food have been communicated; they all revert to 
 the long-tried mode of artificial alimentation. It is strongly to be recommended 
 that no time be wasted with the employment of all sorts of medicaments (even 
 the preparations of copper have been recommended!), douches, etc. Many 
 instruments more or less complicated have been devised for artificial feeding; as 
 Leuret's double oesophageal sound, of sheep-gut; the instruments of Belhomme 
 (1850), Blanchi, Baillarger, etc. A simple elastic sound introduced through the 
 nose is the best of all: the patient is held in an oblique position, the head fixed 
 and a little bent upon the chest while the sound is being introduced. Fluids are 
 injected through the sound; they ought previously to be strained, always luke- 
 warm—milk, beef-tea with eggs, thin soup, etc.— and always injected a little at 
 a time, with some fresh water between. Most of those patients ought to lie in 
 bed all day, and be kept warm. Baths are often very beneficial. Nutrient ene- 
 mata of preparations of beef and eggs, which have been prepared by digestion 
 with pepsin and a httle salt, or only of strong beef-tea, may frequently be used. 
 Cases of prolonged alimentation by the sound are recorded (two years and fifty 
 days) in a case of melanchoha in the Turin Asylum communicated by Zeluschi; 
 Bell narrates a case in an American asylum of two years' nourishment. Should 
 we not be able at once to introduce the sound, the object may be gained by sim- 
 ple pouring through the nose; injecting is not necessary. A peculiar method has 
 been tried in the asylum at Vienna— that of opening the mouth by electricity, a 
 method which allows feeding with solid food. In very excited patients, chloro- 
 form may be tried, and food given while the patient is under its influence. 
 
 The habit of masturbation is very difficult radically to suppress: and 
 besides, recovery scarcely ever takes place during its continuance. 
 Mechanical contrivances rarely succeed in their object: this is better 
 attained by minute surveillance of the patients, who should never be left 
 alone; by work or walking, even to fatigue — light diet, cold bathing, a 
 hard bed, and, in some cases, by the utmost strictness. The causes of 
 the habit may require to be treated by therapeutical means; ascarides are 
 to be kept in view; the iodides, from which some good results have been 
 obtained, may be given where the sexual irritation is produced by chronic 
 irritation or inflammation of the urethra; lupuline in considerable doses 
 (gr. iv. three times a day) and bromide of potassium may sometimes be 
 employed. 
 
 Those patients who have a tendency to suicide require to be carefully 
 watched. The inclination can rarely be subdued by medicinal treatment, 
 and usually our means are limited to constant personal surveillance, the 
 removal of all implements, cords, etc.; and our attention ought to be 
 the more unremitting if the patient exhibits much cunning. Such patients 
 often accomplish their object in a single unguarded moment— indeed, in 
 the very presence of attendants; for example, by strangulation in bed. 
 Experience has shown that mechanical means of restraint will not in the 
 least diminish the tendency to suicide, even though it should succeed in 
 rendering its accomplishment impossible for a time; but sometimes it 
 does not even succeed in this. I myself have seen a patient who strangled 
 himself when wearing a strait-jacket. 
 
 Before dangerous, and especially armed patients, we ought to show 
 undisturbed self-possession; there is frequently a concealed feeling of 
 anxiety behind the furious agitation, and the remains of a knowledge of 
 right from wrong which comes to the aid of the courageous. They are 
 generally more easily disarmed by artifice tiian by force, and cases are on 
 record where by feminine cunning the knife was playfully wrested from 
 the hand of the madman. 
 
THERAPEUTICS. 357 
 
 A young man who had been tranquil for several months, was suddenly seized 
 with an attack of mania. He ran to the kitchen and took away an instrument used 
 for chopping vegetables. He resisted those persons who wished to lay hold of 
 him, sprang upon a table and threatened to strike on the head any one who dared 
 to approach. The wife of Superintendent Pussin loudly called to the people that 
 they were preventing the patient from working with her, requested him gently 
 to come near, and showed him how to use the instrument. At this moment the 
 people laid hold of him and took away his weapon. (Reil, etc.) 
 
 Several patients were quarreling in a garden: one of them seized a knife and 
 threatened to murder his comrades. Lady ElUs arrived, and said to him that she 
 was much surprised to see that a man of his understanding and strength could so 
 far forget himself as to quarrel with a patient, and one who was known to have 
 been mad for years. These words flattered his self-esteem. " You are right," he 
 replied, "I will pay no more attention to these men," and became immediately 
 calm. (Ellis, etc.) 
 
 A very strong, violent patient had found opportunity to possess himself of au 
 iron bar three feet long, and threatened to murder all who came near him. Atten- 
 dants and patients fled, and he was left alone in the gallery, no one daring to 
 approach. After a little while I entered alone: balancing the key of the door upon 
 the back of my hand, I advanced very slowly towards him, attentively observing 
 what excited his attention. He came up to me, and asked me what I was doing. 
 I replied that I was trying to balance the key, and added that he could not do the 
 same with the iron bar. He tried it in vain, stretched out his hand and placed 
 the bar of iron upon it; I then took it quietly from him without any further notice. 
 Although it appeared to be disagreeable to him to find himself disarmed, he made 
 no attempt to take back his weapon, and a few minates afterwards all traces of 
 excitement were gone. (Ellis, 'Traite,' p. 311.) 
 
 § 230. The period of convalescence still requires much care and super- 
 vision. The convalescent remains often for a long time in a very weak 
 and irritable state of mind. The last traces of the false ideas are often 
 long in commencing to disappear, and it is frequently necessary to con- 
 tinue the physical treatment for a long time. The patient should not, 
 therefore, be allowed to leave the asylum till the mental and bodily health 
 is as far as possible consolidated, generally not earlier than several months 
 after the first symptoms of recovery; and the discharge should, as is now 
 the practice in many public asylums, be at first always provisional, so that 
 the patient, on threatened or actual relapse, may be readmitted into the 
 asylum without trouble or delay. 
 
 Should great relaxation and debility come on during convalescence, 
 it should not be treated by stimulating means; quietness, suitable diet, 
 open air exercise, and gradual resumption of employment, are to be pro- 
 moted. The patient is to bo allowed greater liberty and intercourse with 
 the world according as the desire and the capacities for it increase. He 
 should be habituated to a suitable occupation, and placed in a pleasant 
 neighborhood; all that would excite him should be avoided, or accom- 
 panied by judicious encouragement. lie should be distinctly told of his 
 malady. Courage and self-confidence should be raised within him, 
 through the exercise of his faculties, the example of others, and also 
 through the consolations of religion. Counsel as to future modes of life, 
 suitable employment, and to all that can protect him from a return of 
 the disease, are now apj^licable. In certain cases, amusement, travel, or 
 residence at a watering place might prove beneficial; in others, a speedy 
 return to the narrow sphere of their calling and their family circle is the 
 only means by which recovery can be completed. Many go from the 
 asylum to their homes more reasonable than they ever were before: would 
 it were but possible to keep those thankful and joyful, and frequently 
 mentally strengthened (recovered), patients from the influences of adverse 
 circumstances — the coldness of those by whom they are surrounded, and 
 even from the raillery of low-thinking men! 
 
358 THEKAFEUTICS. 
 
 SECTioisr V. — Lunatic Asylums. 
 
 § 231. In former times, the leading object of treatment in mental 
 disease was generally quite unknown. With no purpose beyond the pre- 
 servation of public order, and the aversion of the danger that might arise 
 to the sane from the uncontrolled roaming of such as were mentally de- 
 ranged, some were confined in hospitals, others in penitentiaries and 
 workhouses, and generally in the most wretched and concealed apart- 
 ments. To treat them as patients was a thing unthought of; the great 
 aim was to render them harmless (a method adopted from a mistaken 
 notion of their excessive bodily strength). This was effected by the 
 roughest measures: the poor, unfortunate creatures, often oppressed with 
 chains, pined away, behind massive beams and iron bars, in wretchedness 
 and filth; in the sufferance of tortures and lashes such as it was their lot 
 to endure, the remaining traces of humanity could not but disappear. 
 Whoever once crossed the threshold of an asylum was considered lost. 
 This was the fate of the insane in many places until very recently. Even 
 so lately as 1833-34 in some provincial towns of France they were con- 
 fined in prisons; in several English institutions, entire rows of them 
 might have been seen m chains; and even to the present day, in a few 
 remote districts, their apartments are coarse, stall-like inclosures of the 
 strongest and roughest construction, before which vacant curiosity stands 
 to irritate the madman by a mockery of his curses. [Query, Where? — 
 Tkansl.] 
 
 In the middle of last century was erected the first institution whose 
 avowed object was the cure of insanity — St. Luke's in London, long the 
 only example of active humane feeling for the insane. This was followed 
 by the erection of an asylum at York for the reception of Quakers who 
 w"ere mentally diseased. Upon the Continent, Pinel was the first who 
 resolved to interest himself in the condition of the insane. Impelled by 
 the great humanitarian idea of his time, he began his efforts even during 
 the troublous times of the Eevolution. At first, not without danger to 
 his own life, he devised, before the very gates of Paris, in Bicetre, his 
 great and happy reforms by freeing the insane from their fetters.' Pinel'.s 
 endeavors were an example, and gave the impulse to a complete renova- 
 tion of the treatment of insanity. The merit of this reform in Germany 
 belongs pre-eminently to Langermann, about the beginning of the present 
 century. The revolution in opinions upon this subject was even then so 
 marked, the acknowledgment of the curability and incurability of insanity 
 
 1 Pinel, in directing his efforts with all his attention to the amelioration of the 
 condition of the insane, first devoted them to those who had been confined at the 
 instigation of the pubUc authorities. In consequence of this interference, he was 
 stigmatized as a moderate and an aristocrat — names which at that time were al- 
 most synonymous with sentence of death. Undeterred by this, he presented 
 himself before the Town Council of Paris, and with renewed energy solicited 
 them to sanction his reform. " Citizen," said Couthon to him, " I shall meet j^ou 
 to-morrow at Bicetre, and woe betide you if you have deceived us, and if under 
 the names of fools you have concealed the enemies of the people! " Accordingly, 
 Couthon made his appearance; but the cries and howls of the madmen when he 
 at first attempted to interrogate some of them were too much for him, and he 
 said to Pinel, " O citizen, art thou thyself a fool, that thou wouldst liberate such 
 animals? Do with them wliat thou wilt, but I am much afraid that thou wilt be- 
 come the victim of thy rashness." Nevertheless, the same day Pinel began his task 
 and struck off the chains from a number of patients. See the narrative taken 
 from Pinel's own diary, and published by his son, ' Memoires de I'Acad. Roy. de 
 Medecine,' tome v., Par., 1836. 
 
THEKAPEUTICS. 
 
 359 
 
 was then so widespread, that he was at once enabled practically and ener- 
 getically to insist on the erection of special institutions for the cure of 
 insanity; and on their complete separation from establishments devoted 
 to incurables. The first German hospital in which the new theory was 
 carried out and practically accomplished was the Sonnenstein, in Saxony, 
 under the superintendence of Pienitz; side by side with which stand, as 
 asylums for incurables, first, Waldheim, and, latterly, Colditz. _ These 
 first successful essays in asylum concerns were gradually followed in Ger- 
 many either by the new erection or complete re-modelling of the public 
 asylums in Schlcswig (1820), Sieburg (1825), Heidelberg (1826), Prague 
 (1826), Hildesheim (1827), Leubus in Silesia (1830), Hall in Tyrol (1830), 
 Sachsenberg in Mecklenburg-Schwerin (1830), Winnenthal and Zweifal- 
 ten in Wiirtemburg (1834), Marsberg in Westphalia (1835), Illenau in 
 Baden (1842), Halle (1844), Erlangen (1846), Eichenberg in Nassau 
 (1849). Many smaller or less known also followed the example, and are 
 still doing so. The erection of new and well-organized asylums is thus 
 constantly progi-essing, and even these places that were hitherto delaying 
 as long as possible, appear at last to have made a beginning towards the 
 fulfilment of a requirement demanded of all civilized countries. Among 
 those which have been erected within the last ten years in Germany, and 
 are particularly worthy of mention, are those at Vienna (1853), Werneck 
 in Frankonia (1855), Klingenmunster in the Pfalz (1858), Miinich (1859). 
 
 With the erection of such efficient institutions, the therapeutics of 
 insanity have in most countries, within the last forty years, made the 
 most extraordinary progress. Thus, in Germany, where theoretical 
 psychology was almost entirely devoted to the discussion of abstruse 
 questions (whether insanity is the result of sinfulness? whether in insanity 
 the body or the soul is diseased? etc.), practical efforts have almost in a 
 single season been made the chief regulators of asylum practice, and that 
 with the best results; and in this matter, Jacobi's exertions to introduce 
 the Ensjlish practice into Germany have had an unprecedented and most 
 beneficial effect. The literary treatment of these practical questions soon 
 became in the highest degree irksome, in consequence of the extraordi- 
 nary pedantry with Avhicli all the minutiaa of the asylum were canvassed, 
 as if these were primary questions. Thus, the interest was in a great 
 measure diverted from really weighty points in psychology in order to 
 settle these comparative trifles. Much, however, can be excused at this 
 time, owing to the novelty of the subject; and we must always thankfully 
 acknowledge the exertions by which, in so short a time, results so remark- 
 able were effected. Even this paltry, insipid devotion to trifles appears 
 to do good, in spite of the bombast with which they have been recently 
 asserted and oracularly promulgated. Notwithstanding, in Germany, 
 till within a short time ago, there was, and even yet there is, much re- 
 maining to be done. In proof of this I shall only cite one example. An 
 account of an excursion by Willing in tlie year 1856 contains the follow- 
 ing ('Ztschr. f. Psych.,' xiii., p. 84):—" In the noisy patients are 
 
 confined in cells; the cells for the men and women adjoin one another, 
 and only through a grating can a patient be communicated with. The 
 quiet patients employ themselves, the men and women associating to- 
 gether. " 
 
 § 232. From the commencement of the reforms, the conviction 
 gained root, especially in Germany, that the first condition of success in 
 treatment was the separation of the curable from the incurable insane. 
 Indeed, the mixing of the recent cases with incurables, with epileptics 
 
360 THERAPEUTICS. 
 
 and cretins, proved perfectly ruinous: the rery sight of these creatures, 
 so demoralized, exerted an influence upon the former in the highest de- 
 gree injurious. Besides, the two classes of insane require for their treat- 
 ment and protection arrangements differing in many particulars, and, 
 naturally, the space of the asylum would by such mingling become so 
 much occupied with incurables, that it could no longer receive recent 
 aud curable cases. Whilst in certain foreign asylums — as, for example, 
 Salpetriere — different departments of the same institution have for a long 
 time been set apart, the one for cases requiring active treatment, and the 
 other for such as had become quite chronic; in Germany, and occasion- 
 ally in England, another principle has been adopted — the erection of 
 special institutions, quite separate, for curable cases and for incurables 
 (Sonnenstein, Siegburg, Leubus, Winnenthal, etc.). Various reasons led 
 to this arrangement of special hospitals for treatment and asylums for 
 incurables. It was the wish to bring into practice the new attempts at 
 reform in asylum concerns, which were associated with much expense, at 
 first only for those of the insane who were considered curable; new asy- 
 lums were therefore built for those, while the old institutions, which had 
 been found quite inefficient for the carrying out of attempts at cure, 
 were, with a few alterations, converted into asylums for incurables. It 
 was soon understood that the organization of asylums for incurables 
 must, in many points, be essentially different from hospitals for the 
 treatment of recent cases, inasmuch as we have to consider that in the 
 former case nearly all have to remain during their entire subsequent 
 lives, while in the latter their residence is but temporary; and, further, it 
 was a decisive blow to strong wide-spread prejudice when, long before 
 public acknowledgment of the curability of insanity, special hospitals were 
 erected where an average proportion of rapid recoveries were effected. 
 
 There was every reason to be satisfied with the general result of this 
 system where the number of inmates m the institution for treatment and 
 in the asylum for chronic cases were suitably proportioned, where each 
 enjoyed an equal amount of the fostering care of the State, and where 
 there existed for both a certain unity in the higher superintendence. So 
 far as we are aware, it was not on account of any deficiency in this sys- 
 ■ tern in relation to the treatment and guardianship of the insane which 
 led, at a later date, to its expediency being called in question, and the 
 curable and the incurable being again united under one roof. External 
 motives, the results of theoretical advocacy and numerous practical at- 
 tempts appear to us to have effected this reunion. 
 
 § 233. When, about twenty years ago, it began to be considered a 
 requisite that asylums should be new and specially erected institutions, 
 in many countries men hesitated at a prospect so expensive as the erection 
 of several large establishments, with their complicated arrangements and 
 increased medical superintendence. They could not, however, return to 
 the former system of mingling all the insane, the alienists insisting on 
 the complete separation of the curables from the incurables. So the plan 
 was formed, and in several cases carried out, of constructing two separate 
 establishments, each complete in itself, but situated within the same 
 grounds, under the same medical superintendence, and having in com- 
 mon many economical arrangements (chapel, storehouses, kitchen, baths, 
 etc.). Thus the great so-called "relativ verbundenen" asylum system is 
 not, as they would have us believe in Berlin, the project of Hegel's logic, 
 though certainly he was a strong advocate of it, and that in a manner 
 worthy of consideration. 
 
THERAPEUTICS. 361 
 
 It might be said in favor of this system, that where new buildings 
 have to be erected, it is less costly, because, as remarked above, many 
 buildings and arrangements being common, one set only is required for 
 both institutions; many patients being united under one management, 
 fewer officials are required; and as such an asylum can sooner maintain 
 itself by the produce of its own labor — which is chiefly from the inmates 
 of the incurable institution — it is less expensive to the State. As further 
 reasons for such union, it has been urged that the boundary between 
 curability and incurability is in the highest degree fluctuating and 
 uncertain; that in "relativ verbundenen" institutions the patient is 
 observed by the same physician in every stage of his disease to its termi- 
 nation; that the admission of patients, not being delayed by discussion 
 about the proper institution — which must depend upon the prognosis — is 
 facilitated; that such institutions admit of an easy survey of the whole 
 number of lunatics in a land or in a province; that the inmates of an 
 asylum for incurables can, when necessary, be very easily remitted to the 
 hospital for treatment; whereas, in the other system, the transference of 
 patients from a curable to a chronic asylum is a process not only dilatory 
 and expensive, but also very hard and disheartening to the patient and 
 his friends, and a return to the hospital upon the reappearance of favor- 
 able symptoms is then almost impossible. 
 
 But, on the other hand, it may be argued that the chronic asylum 
 should not be a place whose portal bears the inscription "Lasciate ogni 
 speranza." Though solely fitted up for the reception of old chronic 
 cases, yet the means of recovery ought still to be present in the person of 
 the physician, and in the external relations of the patient, which occasion- 
 ally, though not frequently, afford returning hopes of recovery. Indeed, 
 in the chronic asylum sometimes patients do recover,' and that without 
 casting any slur upon the institution for treatment, which, in the trans- 
 ference of such a patient, would only say that nothing more can there be 
 done, but that, however, other and quite new relations might still prove 
 beneficial to him. Zeller, for instance, lays great stress upon the fact 
 that removal to another institution* proves to many patients of no small 
 value, and adduces as important arguments against the union of the 
 institution for cure with that for mere guardianship, the want of efficient 
 superintendence and of treatment of individual cases Avhere there are so 
 many patients under the care of one physician; the overloading of the 
 medical superintendents with a mass of official business of no service to 
 the patients; the great confusion which must result from a system so 
 complicated and requiring so many assistants; the danger of the physi- 
 cians neglecting the incurables, owing to the greater attraction offered by 
 the curable cases, they being so much richer in results; finally, the evil 
 influence which the sight of so many lost and hopeless lunatics — nay, 
 even the very knowledge of the proximity of so many who are incurable 
 — has upon the recently admitted cases. 
 
 The system of relatively connected ('^relativ verbundenen") recent 
 
 ' According to Focke, the recoveries in incurable asylums are at the rate of from 
 3 to 6 per cent. In Pforzheim there recovered from secondary dementia from 4 
 to 6 per cent. 
 
 ^ See the interesting communication by Trelat regarding the transference of a 
 great number of insane from the overcrowded asylums of Paris to several, in 
 many cases far-distant, provincial institutions, ' Annal. Med. Psychol.,' tome iv., 
 1844, pp. 230, 366. The advantage of transference to another institution has 
 recently been learned in England; 'Ztschr. f. Psych.,' xv., 1858, pp. 114, 147. 
 
562 THERAPEUTICS. 
 
 and chronic asylums, as advanced by Damerow, lias been fully and prac- 
 tically carried out only in a very few places (Illenau and Halle); and in 
 these, indeed, the separation of the hospital from the asylum has always 
 been more fanciful than real, and may nowadays be regarded as com- 
 pletely abandoned. In this system there is, at all events, one other 
 institution required, to which, out of the relatively connected ("relativ 
 yerbundenen") chronic asylum — if this is not to become of stupendous 
 proportions — a regular draft can again take place of all such as are abso- 
 lutely hopeless, those afflicted with other diseases — in short, the Avorst of 
 the incurables (idiots, epileptics, etc., etc.). But if only a certain num- 
 ber of incurables, and selected from amongst the best of that class { i. e. , the 
 quiet, and those still capable of leading a rational life) remain in the 
 '•'relativ verbundenen" cure institution, there will not be required for 
 these a perfectly distinct set of buildings, and a special chronic asylum 
 relatively connected with the hospital for treatment. These incurables 
 may, almost without harm, dwell amongst the recent and curable cases; 
 nay, many alienists recognize in the presence of a stock of such long- 
 disciplined incurable inmates a beneficial and essentially curative element 
 for the newly admitted patients. So that recently, in a new asylum 
 which would have presented unusual advantages for a ''relativ verbun- 
 denen" cure and chronic institution, this system has been foregone,' and 
 in the more lately built asylums in Germany, and in plans for such, the 
 system of mingling the incurable (of the better sort) with the curable has 
 been again adopted (as is moreover also the case in by far the greater 
 number of asylums both in England and France). 
 
 But that is not to say that we have reverted to the old system of mix- 
 ing all the insane indiscriminately together; but the principle of division, 
 founded upon curability — a principle Avhich was founded upon motives 
 the most earnest— and which, at least in Germany, has long served as a 
 guide for the variety of institution, has been abandoned. It appears to 
 me that in the special cure institutions, that nucleus of patients habitu- 
 ated to an asylum, which appears so desirable, forms everywhere of itself, 
 in spite of the destination of the cure institution, and entirely without 
 the connivance of the physician; for it is well known that nothing is 
 more difficult to maintain'in a pure hospital than a regular and prompt 
 dismissal of all the incurable patients, and always a numberof these in- 
 sane remain through entire years, even although their insanity is known 
 to be incurable. Whether, then, is it better to erect asylums which shall 
 receive curable lunatics mingled with a certain select number of incura- 
 bles, or such as are destined entirely for curable (recent) cases, and from 
 which all who become incurable are again ejected? This is a question 
 which cannot be answered in a general way. The solution of this, like 
 so many practical questions regarding asylum concerns, depends very 
 much upon the population of the country, upon the number of lunatics 
 already in asylums, upon the possibility of making use of the existing 
 buildings, upon the pecuniary resources at one's disposal, upon the spe- 
 cial aims which it is intended to combine with their erection {e. g., clini- 
 cal instructions), and most of all depends, in the end, upon the style of 
 execution, and the spirit which is imparted to the whole by those charged 
 with the direction of such matters. At all events, it seems to me as 
 
 1 Gudden, ' Ztschr. f. Psych.,' xvi., 1859, p. 628. 
 
THERAPEUTICS. 363 
 
 premature completely to renounce the system of special cure institutions.' 
 If, liowever, we accept this system of two relatively connected lunatic 
 asylums, the chronic asylum must be capable of containing at least three 
 times the number of inmates of the other (3-400 : 100). The chronic 
 asylum can and must be large; the cure institution must be able promptly 
 to dismiss all recognized as incurable. When these conditions are fulfilled, 
 when the cure institution contains such patients only as are undergoing 
 active treatment, then their number ought never to exceed one hundred; 
 for even with this number it is almost impossible for one physician to 
 examine minutely into, and actively to treat, each individual case. 
 
 Whatever system be adopted for the regulation of asylum matters in 
 a country, the special guardianship of the State ought, at all events, 
 only to be extended to a certain portion of the insane. The overcrowd- 
 ing, of which all lunatic asylums at present complain, the pressure upon 
 them, and which is always bringing discredit upon the calculations upon 
 which they are constructed, must somewhere find a limit. This is 
 possible. In the first place it is, of course, necessary that those calcula- 
 tions be correct (based upon an exact calculation of the number of insane 
 in a country, and it can be assumed that, at the utmost, half of them 
 require the care of an asylum), but in that case there should be received 
 into the chronic asylum only the dangerous patients, or the incurables 
 who cannot be taken care of in families or in parishes (not, however, the 
 absolutely inoffensive or simply troublesome), and no concession ought to 
 be made to families and parishes for supporting the harmless incurables; 
 it is their duty to take care of them, and the State ought to see that this 
 duty be both satisfactorily and humanely performed. It is self-evident 
 that the State asylums for incurables ought only to be made use of by 
 the poor. As to the curable patients, it is the duty of the State to see 
 that the necessitous are treated as such in the asylums devoted to the 
 purpose of treatment; but whether it should also see to those of the 
 insane who, by their own private means, are able to enjoy all the de- 
 sirable advantages found in good private asylums, is still an open 
 question. Were this question answered in the negative, a great 
 simplification and reduction would take place in all that concerns public 
 asylums, and in all large countries the erection of pauper asylums of very 
 simple organization, for treatment and for care, would certainly be a 
 great advantage. But, of course, in the present condition of affairs, it is 
 not yet possible to effect a conversion of all the public lunatic asylums 
 into pauper lunatic asylums. 
 
 § 234. If we proceed now to examine the general requisites for a 
 public lunatic asylum, we may place in the foremost rank facility of 
 access to the patients, and the capability of constantly receiving fresh 
 cases. We shall attain these objects partly by regulations of the medical 
 23olice, and partly by dispensing with all useless and time-wasting 
 
 ' Roller ('Ztschr. f. Psychol.,' x., p. 397) at that time considered the question 
 regarding the best system for quite distinct, in the sense of • " relativ verbun- 
 denen," cure and chronic asylums, and imagines that no man would now think 
 of erecting completely separated asylums for recent cases. According to a new 
 order of lunatic-asylum arrangements, it was no longer proposed to erect in the 
 province of Silesia a "relativ verbundenen" institution, but to hare one cure- 
 institution where patients should undergo treatment for a certain fixed period 
 (one year), two cure-institutions where patients should reside for an indefinite 
 time, and one chronic institution (ibid., 1855, p. 438). In 1858 there was a prize 
 offered in Germany for the best plan of a lunatic asylum for purely recent cases 
 <Heilanstalt) capable of containing from 150 to 300 patients. 
 
364: THERAPEUTICS. 
 
 formalities, by diminishing the cost of maintenance or gratuitously sup- 
 porting patients of the poorer classes, and by inspiring the public with 
 confidence in asylums generally; and further, as a result from this, in all 
 large countries the asylums would be more distributed in different 
 districts. Asylums, too, ought to recommend themselves by their 
 excellent organization and by the spirit which pervades them; and not 
 only ought this organization, and this spirit, to be in conformity with 
 the ideas of humanity in our own epoch, but they must also be — and this 
 is truly a fundamental requisite — out-and-out medical. 
 
 Every asylum is nothing more than an hospital for those affected 
 with disease of the brain. All of them, and especially those whose object 
 is the cure of the patients, must all throughout present the character of 
 an hospital, not of a reformatory, a manufactory, or a prison. It may 
 be here stated, at the same time, that everything in connection with the 
 asylum must be under medical superintendence, that its management must 
 be in the hands of the chief physician, who should have, with a certain 
 freedom from restriction, command of all extraneous aids for the benefit 
 of the whole institution; but the physician to an asylum must be a 
 thorough physician, and not simply a manager, who, though possessing a 
 knowledge of medicine to some extent, is yet at every examination of his 
 patients obliged to call in the assistance of a regular practitioner. 
 
 The peculiarity of the diseases treated in an asylum require the 
 physician to have at command, not only all the usual medical appliances 
 (pharmaceutic baths, etc.), but, in addition to these, every arrange- 
 ment tending to prevent patients inflicting injury on themselves or 
 others, and to have them always amenable to medical treatment. In the 
 same w^ay must be provided whatever else is necessary to their main- 
 tenance, exercise in the open air, labor, recreation, and amusement. 
 Thus, institutions of this kind must be furnished not only with a staff of 
 servants for superintending and waiting upon patients, and extent of 
 accommodation necessary for individuals who require isolation (in 
 addition to the ordinary means of restraint), but it must also be furnished 
 with plots of ground for the employment of the patients in field labor, 
 gardens and pleasure grounds for walking, materials for working, and 
 every possible means of amusement. 
 
 A requisite even more essential in the arrangement of an asylum is 
 the appropriate separation of patients from one another; in the first place 
 according to sex (this is usually done by apportioning them to separate 
 wings of the establishment); then according to the form of madness, yet 
 not strictly according to nosological classification, but rather by the 
 symptoms of the malady {i. e., whether quiet or more turbulent); and 
 lastly, among the quietly disposed who Jive together according to their 
 station in life and their intellectual cultivation (of course in the case of 
 the secluded such distinctions are needless). For the purpose of thus 
 separating the patients, the nosological form cannot be accepted as a rule, 
 especially because the cases usually present such mixed forms and so mul- 
 tifarious transitions; because it would even be dangerous in some cases 
 (e. g ., in jjatients with suicidal tendencies) to permit them to live together 
 and to have much intercourse; and lastly, because the aj^parently quiet 
 melancholic maniacs and dements could not, as proved by iiniversal expe- 
 rience, well live together w'ithout an equal amount of trouble and preju- 
 dicial results ensuing: the dements, especially the paralytics, must be 
 entirely separated and confined to apartments expressly devoted to them. 
 In the separation of patients according to their outward demeanor, one 
 
THERAPEUTICS. 365 
 
 must be cautious, in so doing, not to carry it to such an extent as to 
 subdivide the service too much, and thereby augment the requisite 
 amount of superintendence. From four to five divisions are needed, both 
 on the male and female sides: one for individuals who must be secluded 
 {e. g., the dehrious, noisy, and most unruly), though this, of course, 
 should be limited to the shortest possible time, a second (especially in the 
 chronic asylum) for the paralytic, epileptic, and arrant idiots; two for 
 quiet patients (one for those of the higher class, another for those in the 
 humbler stations of life); fifth, divisions or detached dwellings for con- 
 valescent or other patients for whom it may be considered beneficial for a 
 longer time to live more retired, and in perfect quiet. In many institu- 
 tions yet another division is kept for the bedridden, and a perfectly 
 detached building for convalescents. This last has proved not so expe- 
 dient. 
 
 In several institutions situated in large towns, a division is reserved 
 for insane persons who have committed some crime. In Bicetre there is 
 a division for this purpose, but it is of a dirty menagery-like character. 
 Dundrum in Dublin is a well-conducted institution, especially set apart 
 for the reception of such individuals, and capable of accommodating 
 iibout a hundred j^atients. In Konigsberg, also, there is an institution of 
 this description, and in America several have lately been opened. The 
 greater number of insane criminals would, however, as Delbriick has 
 l^ointed out, be much better if left in a penitentiary than removed to an 
 asylum. 
 
 The chief literature on the subject of lunatic asylums may be here re- 
 ferred to: Zeller, 'Art. Irrenanstalten in Ersch und Griiber's Encyclo- 
 ])adie;' Damerow, 'Ueber die relative Verbindung der Irren-Heil- und 
 Pflegeanstalten,' Leipzig, 1840; Parchai^pe, ' Des Principes a suivre,' etc., 
 Paris, 1853; Guislain, ' Le9. oral.,' iii. 
 
 § 235. In different countries Avhere the subject of insanity has re- 
 ceived attention, it has been attempted to meet these requirements by 
 widely different architectural arrangements. While the English institu- 
 tions in general present a most imposing appearance by their massive and 
 elegant exterior, possess the greatest completeness in the interior as re- 
 gards convenience of space and all domestic arrangements (as heating, 
 lighting, cleaning, working arrangements, etc.), and, combined Avith 
 great comfort, a certain regularity of routine that corresponds well with 
 the almost mechanical nature of the superintendence and treatment, the 
 French asylums, on the other hand, are constructed on quite a different 
 principle, especially those formed on Esquirol's plans. They consist of a 
 series of square houses, widely apart, of merely a ground-floor containing 
 a number of single cells or rooms, a common conversation-room, work- 
 room, etc., with a colonnade around, and inclosed in the centre a plot of 
 grass. Several parallel rows of such single-storied squares are connected 
 together by those colonnades, including the storehouses, work-room, 
 chapel, bathing-houses, etc. This mass of distinct buildings, which oc- 
 cupies an immense area, is not only more costly to erect, but renders the 
 oversight more difficult, and affords fewer facilities of visiting the more 
 distant parts of the institution and of general superintendence. 
 
 On this account, up to the period when, by the introduction of labor 
 and instruction, quite different principles were followed in the construc- 
 tion and arrangement of French asylums, these institutions were dis- 
 tinguished by a want of restraint, the uncontrolled roaming about, and 
 unruly character of the patients. In the construction of the most modern 
 
36G THERAPEUTICS. 
 
 institutions in France, the ideas of Esquirol seem to liave been consider- 
 ably deviated from. 
 
 In Germany there has been an attempt to combine the good qualities 
 of both systems,' although, upon the whole, the German institutions ap- 
 jn-oach nearer in their construction to the English asylums than to those 
 formed on the plans of Esquirol. The newer institutions are usually so 
 arranged, that in one, or several, central buildings of two or three stories 
 in height, the common rooms, the office, the chapel, the kitchen, the 
 washing-houses, the store-rooms, the rooms of the officials, are all to- 
 gether. From each side of these one, or, in " relativ yerbundenen " insti- 
 tutions, two double-storied wide wings extend, either in direct communi- 
 cation or detached. In these are the different divisions for convalescents, 
 boarders, quiet patients of middle and lower rank in life, together with 
 attendants' accommodation, baths, etc. As a completion to the whole, 
 are small, single-storied buildings, as far as possible removed from the 
 centre, which contain the cells for unruly patients, especially those re- 
 quiring isolation. Each division of the house must have its own garden 
 and pleasure-grounds for its inmates; all the stairs, windows, and doors 
 must be seen to, that they are not only of sufficient strength, but also 
 that they are of the simplest possible mechanism, and a sufficient 
 guarantee for the security of the patients; the internal fittings of the 
 dwelling and sleeping apartments in the division for the noisy and 
 maniacal must be of the simplest description; it must also be immovable, 
 and in the other parts of the institution simpler or more elegant, accord- 
 ing to the station and requirements of the patients. 
 
 A leading principle in the erection and whole internal arrangements, 
 Avhicli has certainly been too often overlooked, is that all the household 
 arrangements of an asylum should, so far as is consistent with its peculiar 
 design, resemble those of a large private dwelling-house — that they should 
 differ as little as possible from the houses and furnishings of the sane. 
 On this princii)le all plans are objectionable which, b}^ attractive peculi- 
 arities of architecture, such as steeples, turrets, etc., insinuate, even by 
 their external appearance, that they are intended for some peculiar pur- 
 pose. All prison-like cells on the one hand, and on the other all undue 
 magnificence in lofty halls, colonnades, etc., must, on the same principle, 
 be avoided. It should throughout have the appearance of a medical in- 
 stitution, whose express aim is the restoration of health; it should convey 
 the idea of ease, comfort, stability; it should also be cheerful and pleasant, 
 with a scrupulous regard to cleanliness, which in such institutions should 
 be always assiduously and perseveringly insisted on. 
 
 The institution must, moreover, be situated in a healthy locality, and, 
 where it is possible, in a neighborhood rich in natural beauties. It may 
 be well to have it in the vicinity of a small town, where the necessary 
 provisions may be had, and intercourse conveniently maintained with the 
 inhabitants. It is needful also to have asylums in proximity to large 
 cities. Institutions so situated have the advantage of a constant supply 
 of new cases. Under no circumstances, however, should an asylum be 
 built within the precincts of a city. It should be surrounded by a piece 
 of ground, its own property, inclosed all round by a wall. It is of great 
 
 ' Holland has, in its distinguished Meer-en-Berg, produced a model institution 
 by combining in a certain degree the advantages of all the systems: specially as 
 in that country Schroeder van der Kolk has directed all the matters connected 
 with the insane in such a pattern manner. 
 
THERAPEUTICS. 
 
 367 
 
 advantage to have the ground-floor raised above the level of the soil. 
 Where practicable, it should be built near a flowing stream, in order that 
 the bathing and washing establishments may possess an abundant supjily 
 of fresh water, and for the purpose of out-of-door bathing. The grounds 
 should be extensive and agreeable, with gymnasium, skittle-gi-ound, play- 
 ground, etc. 
 
 Where there are special chronic asylums (Pflegeanstalten), much 
 larger workrooms will be required, in which the patients — especially 
 during the winter season — may employ themselves, and where many 
 things necessary for the institution may be made. Asylums of this kind 
 must also have the usual divisions for the unruly, the quiet, the well- 
 conducted of all grades; however, they may be much sirnpler, and it is 
 expedient to erect a greater number of single-storied dwellings on account 
 of the large number of dirty patients and of paralytics. 
 
 Of institutions for the reception of idiots, a twofold division can also 
 be made: of those whose object is the cure or improvement of the inmates, 
 and of those devoted merely to their confinement. Since the undertak- 
 ing of Gruggenbiihl on the Abendberg (1841) these first have attracted 
 great interest, and in them numerous experiments have been made, but, 
 from the very nature of the case, their benefits can extend only to 
 children, and thus they partake more of the nature of training institu- 
 tions than of hospitals. Ferrus Sequin and Voisin during the last thirty 
 years have given a great impulse to the efforts for the training and cure 
 of idiots; and even so early as 1835 a clergyman of Wiirtemberg (Halden- 
 wang in Wildberg) had a small institution erected for the training of idi- 
 otic children. After the plan of that at Abendberg, the following insti- 
 tutions were founded: that at Mariaberg (founded by Rosch, 1847), 
 Winterbach (likewise in Wiirtemburg, 1852), Ecksbergm Bavaria (1852), 
 Hubertusburg in Saxony (a Government institution, 1852), two in Berlin 
 (one in Liesing near Vienna, one in Bendorf in Coblenz), one large idiot 
 school in the Hague (1855), and many still smaller or less known houses;, 
 but all of these are far surpassed by the magnificent institution of Earls- 
 wood, in the vicinity of London (1857). 
 
 It does not fall within the province of this book to treat in detail how 
 such institutions should be furnished and organized so as to accomplish 
 their special ends (p. 364); but, in general, that may very easily be de- 
 duced from the propositions already laid down when discussing the treat- 
 ment of idiots. Concerning the more modern idiot asylums, see Theile 
 (loc. cit., p. 105). 
 
 § 236. At the head of the per&onnel of the lunatic asylum, subject to 
 the directing authorities of the State, stands the superintending jihysi- 
 cian, by whose character, as a man and as a scholar, the pervading influ- 
 ence in the institution in a great measure depends. Side by side with 
 the grand essential of a thorough acquaintance with medicine (and, in 
 institutions specially devoted to the cure of insanity, a particular knowl- 
 edge of nervous pathology), there is required in the head physician, and 
 justly expected of him, a rare combination of moral excellencies — benev- 
 olence, great patience, self-command, freedom from prejudice, a knowl- 
 edge of men gained by actual experience of the world, conversational 
 powers, a decided liking for his own special vocation; for this alone will 
 enable him to overcome its manifold toils and discouragements. Assist- 
 ant pliysicians are also needed to aid the director in the treatment of the 
 patients, the keeping of the journals and correspondence, in post-mortem 
 examinations, in the major surgical operations, etc. In most asylums, a 
 
368 THERAPEUTICS. 
 
 clergyman is appointed, wliose duty is to conduct divine worship, regu- 
 larly to visit the sick, and promote recovery by religious remedies. It 
 has been already remarked (p. 357) that in few cases ought such mea- 
 sures to be adopted, and that all such visits should be made under the 
 supervision of the physician, and only by his permission. It would be 
 an egregious error to put into the hands of the laity any degree of liberty, 
 however limited, in the treatment of the insane. Their views in such 
 matters must necessarily be very one-sided. Justly, therefore, have some 
 of the most illustrious physicians (e. g., ISTasse, Jessen, and some others) 
 sought to curtail more than ever the assistance in psychological thera- 
 peutics formerly rendered by clergymen. Frequently, also, we find a 
 teacher appointed who, without any pretensions to the exercise of such 
 psychological means of cure, is employed to instruct the jDatients, and 
 thereby promote their intellectual culture and amusement. 
 
 Two head attendants, a male and a female, should take charge of the 
 lower staff of servants. Only persons of considerable bodily strength 
 should be engaged as attendants; they should also be intelligent and 
 good-natured: but persons in every respect what could be desired are sel- 
 dom to be found. Each attendant is generally intrusted with from six 
 to ten patients, but some patients require the entire services of an attend- 
 ant. In many institutions, these attendants are selected from the 
 brotherhood or sisterhood of some religious order, a proceeding which, 
 on the whole, has more objections than recommendations. Besides 
 these, there are in asylums, as in every other institution, officers spe- 
 cially connected with the economical department. 
 
 § 237. In order thac the arrangements in connection with an asylum, 
 necessarily always so complicated m consequence of the great number of 
 persons and requisites employed, may go on with order and without con- 
 fusion, there must be a written set of rules for the guidance of the offi- 
 cials; the precise duties of each servant should be definitely and briefly 
 stated, all their duties punctually arranged, and the method of each pre- 
 scribed. These rules, judiciously framed, should become the habit of 
 the institution, and the director of the establishment should be himself 
 an example of order, and thereby exert a wholesome influence on all that 
 are under him. The discipline of an asylum should be stringent, and 
 not, under the specious appearance of benevolence, conducted on the 
 laisser-aUer principle; punctuality in the division of time, the strictest 
 order, and the faithful discharge of duty, must all be attended to. All 
 its operations should be so conducted that every one, whether healthy or 
 insane, who visits or resides in the establishment, may be impressed with 
 the idea that it is conducted on rational principles; a sense of tranquil- 
 lity and ease should pervade the whole, and the desire for activity on the 
 j)art of the patients, which precedes and accompanies every case of recov- 
 ery, should be quietly and moderately indulged. As we strive to divert 
 the mind from the feeling of restraint by planting trees and shrubs 
 round the walls that inclose the grounds of the institution, familiar 
 intercourse should not be too strictly prohibited among the patients. 
 We have seen much benefit result from a certain amount of social inter- 
 course, in which the ordinary forms of general society were observed. 
 Indeed, everything that would estrange the patients from the habits of 
 the Avorld should be steadily avoided. To counteract such a tendency, 
 general amusements, social gatherings, and walks are of great service. 
 By degrees the patients should be thus introduced to the society of the 
 sane. It has been sliown above that from such a system of humane lib- 
 
THERAPEUTICS. 369 
 
 eral treatment, mucn more satisfactory results will flow than there 
 would from a stricter method. Every gloomy, ascetic, barrack-like 
 spirit should be avoided, and the great object of treatment should be, not 
 only to diffuse a spirit of cheerfulness and reflection, but also to elicit 
 and encourage it on the part of the patient. 
 
 § 238. Previous to the admission of a patient into a public asylum, a 
 special medical report must be prepared, indicating the present state of 
 his cusease, its origin, and development. Many of the particulars on 
 these subjects have generally to be furnished by his friends. Their 
 statements should contain an Tinreserved disclosure of everything 
 important in the previous history of the patient, since these are "of the 
 utmost importance to the physician. The medical report should deal 
 with all questions that bear on the duration of the malady; all etiological 
 questions, as to its hereditariness, bodily and mental dispositions, 
 previous diseases — especially of the nervous system. It must particularly 
 recount all the symptoms of its gradual or suddo.^ outbreak, and the 
 present state of the morbid phenomena, whether the patient has pre- 
 viously shoAvn any outrageous symptoms — details which are of essential 
 service to the physician who has any pretensions to a comprehensive 
 acquaintance with insanity. When once it is determined to remove him 
 to an asylum, the patient should be informed of the resolution; if he 
 obstinately refuses to go, it is much better to convey him by force' than 
 to lure him in by artifice {e. g., by telling him he is going on a pleasure 
 excursion). Such a plan exasperates him to an intense degree, and pre- 
 vents for a long time that confidence in the institution which is so 
 essential to his welfare. 
 
 The admission of individual patients into Government asylums, 
 unless in urgent cases, depends very much on the approval of the 
 Government authorities, which in turn* is regulated by the opinion of 
 the directing physician. In order to facilitate the admission of new 
 cases, the forms of procedure should be as simple and expeditious as 
 possible. The dismissal of patients chiefly depends upon the order of 
 the director. At first it should invariably be provisional or experimental. 
 Thus, on the first indications of relapse, it will be easy to bring the 
 patient back to the asylum. During this temporary dismissal, the 
 patient's private physician should furnish an occasional report of the 
 state of his health. Should the convalescence continue during a 
 sufficient period, varying from at least one to two years, the patient may 
 then, for the first time, be permitted to quit all connection with the 
 asylum. Free societies in aid of needy convalescents have, in many 
 places, been attended with most happy results. 
 
 § 239. In addition to public asylums we have to speak also of private 
 institutions. _ This latter class in a great measure supplies the deficiency 
 that is felt in • countries where the interests of the insane receive no 
 attention from Government, or where the Government asylums are 
 inadequate to the accommodation of all lunatics. Their chief use, how- 
 ever, is for patients belonging to the wealthier and the aristocratic 
 classes of society, who would not be satisfied with the ordinary public 
 asylums. Their importance has in later times greatly inci-eased, and is 
 daily becoming greater. The State should place these institutions in the 
 charge of scientific physicians; they ought never to be committed to the 
 care of laymen, surgeons, and such like; and the directors should be 
 
 ' No restraint is the universal rule nowadays in well-regulated asylums. 
 
370 
 
 THERAPEUTICS. 
 
 required to furnish sufficient evidence of tlieir ability to treat insanity, 
 namely, a sufficient a-cquaintance with that special branch of study and a 
 complete knowledge of its practice. Such abuses and scandals as have 
 occurred in some English private institutions should be rendered quite 
 impossible in all cases, although cases of a similar kind have never even 
 been suspected in Germany. 
 
 Another plan than that of asylums has been followed in some places 
 for the maintenance and employment of the insane. A colony of insane 
 has been formed in the remarkable Belgian village of Gheel, in which, 
 for several hundreds of years past, lunatics have lived together with the 
 inhabitants, and even resided in their families. In former times, people 
 frequently resorted thither to supplicate the aid of Dymphne, the patron 
 saint of the insane, although people are seldom in the habit now of con- 
 sulting her oracle. Repeated attempts have recently been made to establish 
 some degree of regularity and system among this settlement of lunatics. 
 Out of a population of about 9,000, it has from 900 to 1,000 inhabitants 
 who are insane. In the year 1850, it was sought to establish an admin- 
 istration for regulating the habits of the people and to introduce some 
 reforms. But, according to Parigot,' these attempts generally met with 
 little success. The lunatics enjoy an amount of pleasure and freedom 
 which could never be permitted them in an asylum. All wlio are 
 capable of it share in the mechanical or agricultural em2)loyments of the 
 sane. The treatment in the main is very mild, and restraint is never 
 made use of without previously consulting a physician. Suicide is rare, 
 and the general physical health so good, that in 1838 two of the patients 
 reached upwards of 100 years of age. Owing to the peculiar situation of 
 Gheel, escape by the patients is difficult; it is enclosed by moors, and is 
 several leagues distant from other villages. With all its advantages it 
 has undoubted drawbacks, and there has recently been published such an 
 amount of literature of a polemical kind, furnished by critics and visitors 
 of Gheel, that, although the majority are in favor of this lunatic-colony, 
 they are obliged to admit it has serious defects. But the experiment at 
 Gheel has proved^ that the greater number of insane do not require the 
 confinement of an asylum; that many of them can safely be trusted with 
 more liberty than these institutions allow; and that association in the 
 family life is very beneficial to many insane patients. Tlie case of Gheel 
 has suggested the question whether similar colonies might not be estab- 
 lished in other places, and the evils resulting from the overcrowding of 
 lunatic asylums thereby removed. In England and Germany, an exact 
 imitation of Gheel has been recommended; it was recently proposed to 
 assemble a number of lunatics within a village in the immediate vicinity 
 of a Government asylum, so that it might maintain a certain relation to 
 them. The difficulties in the way of adopting this plan, which have been 
 collected and clearly set down by W. Jessen,^ have not yet been 
 surmounted. Still, however, I continue in the belief that the day will 
 come when the means and method will be discovered by which the 
 problem of a lunatic colony, and thus the question of the care and treat- 
 ment of all classes of the insane, will be finally solved. 
 
 1 ' Journ. de Med. de Bruxelles,' 1859, p. 464. 
 
 "^ Roller, 'Ztschr. fur Psych.,' xv., 1858, p. 420. 
 
 3 Deutsche Clinik, 1858, * Ztschr. f. Psych.,' xvi., p. 42. 
 
INDEX. 
 
 371 
 
 I ]^ D E X 
 
 Abdominal disease causing insanity, 
 . 137 
 Abdominal organs, affections of, in the 
 
 insane, 315 
 Age, influence of, on insanity, 100 
 Alcohol, effects of, compared with 
 
 mania, 218 
 
 — in treatment of insanity, 340 
 Anaesthesia in insanity, 57 
 Anger, impulsive fits of. 190 
 Anxiety a cause of insanity, 116 
 Apoplexy and insanity, 123 
 Appetite, increase of, in mania, 203 
 Arachnoid, alterations in, in insanitv, 
 
 296 
 Arteries, disease of, a cause of insanity, 
 137 
 
 — of brain, condition of, in insanit}-, 
 295 
 
 Asylums, advantages of, 331 
 
 — authorities on, 365 
 
 — for idiots, 367 
 
 — history of, 358 
 
 — statistics of recoveries in, 361 
 Aura in insanity, 56 
 
 Aztec type of idiocy, 266 
 
 Baillarger, case of melancholia, 175 
 Baths in insanity. 337 
 Bergmann, case of insanity, 65 
 Berlyn, a case of hypochondriasis, 154 
 Bierre, use of baths in insanity, 337 
 Blood diseases in the insane, 309 
 Boismont, case of insanity after fright, 
 
 Brachet, case of hypochondriasis, 153 
 Brain and membranes, pathology of, in 
 insanity, 290 
 
 — anterior commissure of, 12 
 
 V — condition of, in general paralysis, 
 
 — cortical substance of, function of, 17 
 v^ — deficiency of parts of, 251 
 
 — gray substance of, anatomy of, 9 
 V — gray substance of, in idiots, 254 
 
 «^ — hypertrophy of connective tissue of, 
 253 
 
 — method of examining, in disease, 15 
 '" — smallness of, in idiocy, 248 
 
 V — substance, changes in, in insanity, 
 301 ^ 
 
 — unequal development of, 249 
 
 295 - 
 hypochondriasis, 
 
 309 
 
 Brain, white substance of, anatomy of. 
 
 Bright, case of hallucinations, 69 
 
 Camphor in insanity, 341 
 Cerebellum, anatomy of, 13 
 
 — changes in, in insanity, 304 • 
 Cerebral centres, changes in, in insan- 
 ity, 303 
 
 — substance, changes in, in insanity, 
 300 
 
 — vessels in insanity, 
 Charcellay, case of 
 
 155 
 Cholera in the insane, 
 
 — insanity after, 129 
 Civilization, progress of, and insanity, 
 
 97 
 Cleptomania, 206 
 Cold in treatment of insanity, 336 
 Conolly on treatment of the insane, 348 
 Corpora quadrigemina in relation to 
 
 sight, 14 
 Corpus callosum, absence of, 251 
 
 — callosum, cerebral expansion of, 12 
 Cranium, alterations in, in insanity, 294 
 
 — alterations in, in idiocy, 253 
 Cretinism a form of idiocy, 244, 2'66 
 
 — absence of iodine a cause of, 273 
 
 — atrophy of spinal cord in, 250 
 
 — endemic, 268 
 
 — hereditary, 273 
 
 — humidity a cause of, 272 
 
 — nature of soil a cause of, 272 
 
 — nature of water a cause of, 273 
 Crisis in insanity, 324 
 
 Deafness, peripheral, followed by in- 
 sanity, 125 
 DeUrium, acute, form of mania, 209 
 
 — in insanity, 50 
 
 — of fever analogous to insanity 79 
 
 — rhyming, 199 
 
 — sensorial, 59 
 
 — tremens, symptoms of, 209 
 Delusions not necessary to insanity. 83 
 Dementia, 226 
 
 — apathetic, 242 
 
 — cases of, 218, 220, 226, 242 
 
 — defined, 240 
 
 — paralytic, changes in, 307 
 
 — partial, with exaltation, 194 
 
 — with epilepsy, 286 
 
 y 
 
372 
 
 INDEX. 
 
 Demonomania, cases of, 169 
 
 V Diagnosis of mental disease, 80 
 Digitalis in mania, 339 
 Dreaming, insanity analogous to, 76 
 Dreams, sensation of flying in, 57 
 Drunkenness a cause of insanity, 119 
 Dumbness, idiotic, 260 
 Dysentery in the insane, 310 
 
 *^ Earle, statistics of insanity, 209 
 Ecstasy in insanity, 59 
 Education, influence of, on insanity, 
 
 110 
 Electricity, influence of, in general 
 
 paralysis, 279 
 Ellis, cases of insanity, 357 
 
 — on onanism as a cause of insanity, 
 
 100 
 
 Emotional irritability, 46 
 
 Emotions, analysis of, 37 
 
 Emphysema a cause of insanity, 137 
 .Epilepsy a complication of insanity, 
 
 285 
 ^ — and insanitj', 123 
 
 — replaced by luania, 208 
 Erlenmeier, a case of idiocy, 247 
 
 V Esquu'ol, atrophy of optjc nerves with 
 
 hallucinations, 61 
 
 — case of attempted suicide, 182 
 
 — case of hallucination, 70 
 
 — case of mania, 208 
 
 — case of monomania, 220 
 
 — removal of hallucinations by cover- 
 ing the eyes, 02 
 
 — on removal of the insane to asvlums, 
 332 
 
 — suicides mentally diseased, 177 
 
 Exaltation, states of mental, 193 
 Falret on folie circulaire, 163 
 Ferrus, treatment of ci'iminals, 104 
 ^' Fevers causing insanity, 127 
 Flemniing, cases of insanity, 52, 128, 
 134 
 
 — on use of emetics in insanity, 340 
 Focke, case of insanity, 128 
 
 — statistics of recoveries in asylums, 
 361 
 
 Foville, structure of brain, 13 
 Fright a cause of insanity, 116 
 
 v/ Genital organs, disease of, a cause erf 
 insanity, 139 
 
 Georget, insanity witn homicidal ten- 
 dency, 187 
 
 Gheel, colony of insane at, 370 
 
 Goitre, see Cretinism, 268 
 
 Gratiolet on auditory root, 14 
 
 — on hallucinations of sight, 68 
 
 — on sensation of flying in dreams, 57 
 Guillot on auditory root, 14 
 Guislain, analogy between dreaming 
 
 and insanity, 77 
 
 — case of idiocy, 247 
 
 — case of insanity (recovery), 344 
 
 — case of melancholia, 183, 189, 312 
 
 Guislain on dancing parties in insanity, 
 
 347 
 Guy, case of melancholia with desire to 
 
 murder, 184 
 
 Hasmatoma of the ear, 310 
 Hallucinations in chronic mania, 232 
 
 — in insanity, 56-72 
 
 — in sane persons, 65 
 
 — of sight with atrophy of optic nerves, 
 61 
 
 Head, injuries to, and insanity, 123 
 Hearing^ hallucinations of. 69 
 
 — hallucinations of, in a case of mania, 
 236 
 
 Heart, affections of, in the insane, 314 
 
 — affections of, a cause of insanity, 136 
 Henle, memoiy in the senses, 23 
 
 \ Hereditary insanity, 106 
 Heschl on porencephalus, 250 
 Holland, duality of mind, 18 
 Home sickness, form of melancholia, 
 171 
 
 \ Hydrocephalus a cause of idiocy, 252 
 
 — chronicus in the insane, 303 
 Hydrocyanic acid in mania, 339 
 Hyclropathy in insanity, 337 
 
 ''■ Hypertemia of brain a cause of insanity, 
 115 
 Hypochondriasis, 147 
 
 — cases of, 152, 155 
 
 — mode of origin, 151 
 
 — symptoms of, 148 
 Hysteria, 126 
 
 Ideas, incoherence of, 199 
 
 Idiocy, anomalies of cranium in, 254 
 
 — anomalies of desires, etc.. in, 261 
 
 — anomalies of senses in, 259-263 
 
 — apathetic, 265 
 
 — causes of. 246 
 
 — course of. 267 
 
 — dumbness in, 260 
 
 — excited, 265 
 
 — gray substance of brain in, 254 
 
 — hypei-trophy of brain in, 253 
 
 — meaning of term, 244 
 
 — varieties of, 265 
 Idiots, asylums for, 367 
 
 — classecl according to speech, 260 
 Illusions and hallucinations distinct, 59 
 Impressible explained, 38 
 Imprisonment, influence of, on insan- 
 
 ity, 104 
 Incoherence of ideas in mania, 200 
 
 — temporary, in health, 48 
 
 Insane, affections of the abdominal 
 organs in the, 315 
 
 — affections of the heart in the, 314 
 
 — blood diseases in the, 309 
 
 — cholera in the, 309 
 
 — colony of, at Gheel, 370 
 
 — criminal acts of the, on, 54 
 
 — dysentery in the, 310 
 
 — haematoma of the ear in the, 310 
 
 — physical treatment of tlie, 333 
 
 — removal of the, to asylums, 331 
 
INDEX. 
 
 373 
 
 Insane, respiratory diseases in the, 311 
 
 — statistics of mortality of tlie, 317 
 
 — typhus fever in the. 309 
 Insanity, see Melancholia, etc, 
 
 — acute, changes in, 306 
 
 — after cholera, 129 
 
 — after strong smell, 125 
 
 — analogies of, 75 
 
 — and civilization, 97 
 
 — and intoxication, 87 
 
 — and tjq^hus fever, 87 
 
 — aura m, 56 
 
 — blood diseases in, 309 
 
 — cases of, 54. 56, 57, 60, 62, 68, 70, 71, 
 73, 77, 79, 128, 130, 133, 149, 152, 165, 
 160, 175, 181, 184, 185, 187, 189, 190. 
 204, 206, 211, 219, 226, 233, 242, 312, 
 344, 357 
 
 — causes of, 89 
 
 — changes in arachnoid in, 296 
 
 — changes in cerebral centres in, 303 
 
 — changes in cerebral substance in, 
 300 
 
 — changes in cranium in, 294 
 
 — changes in great vessels of brain in, 
 295 
 
 — changes in pia-mater in, 298 
 
 — chronic, changes in. 306 
 
 — complications of, 277 
 
 — complicated with epilepsy, 285 
 
 — compulsory feeding in, 355 
 
 — delusions not necessary to, 83 
 
 — emphysema a cause of, 137 
 --.■(umsof, 144, 299 
 
 — feigned, 85 
 
 — following peripheral irritation, 125 
 
 — from abdominal disease, 137 
 
 — from disease of genital organs, 139 
 
 — from drunkenness, 119 
 
 — from fever, 127 
 
 — from heart disease, 136 
 
 — from intestinal worms, 138 
 
 — from other nervous diseases, 123 
 
 — from pregnancy, etc., 141 
 
 — general diagnosis of, 80 
 
 — general paralysis in, 278 
 
 — hereditary predisposition to, 106 
 
 — hyperaemia of brain a cause of, 115 
 
 — hysterical, 126 
 
 — in course of pneumonia, 130 
 
 — in different sexes, 98 
 
 — influence of age on, 100 
 
 — influence of education on, 110 
 
 — influence of imprisonment on, 103 
 
 — influence of marriage on, 99 
 
 — influence of moon on, 105 
 
 — influence of seasons on, 105 
 
 — influence of social position on, 103 
 
 — mental constitution a cause of, 111 
 
 — method of examining brain in, 15 
 
 — of the intellect, 50 
 
 — opium a cause of, 121 
 
 — pellagrous, 136 
 
 — periodic, 129 
 
 — physical causes of, 122 
 
 — prognosis and treatment of, 317 
 
 Insanity, psychical causes of, 115 
 
 — sexual excess a cause of, 122 
 
 — sketch of course of, 36 
 
 — statistics of, in different nations, 95 
 
 — suicide, attempts at, in, 181 
 
 — therapeutics of. 326 
 
 — tobacco a cause of, 121 
 
 — venesection in, 334 
 
 — with apoplexy, 123 
 
 — with chronic diseases, 134 
 
 — with disease of arteries, 137 
 
 — with epilepsy, 123 
 
 — with injury to head. 123 
 
 — with rheumatism, 132 
 
 — with syphilis, 134 
 
 — with tendency to murder, 183 
 
 — with tuberculosis, 135 
 Intellect, weakness of, in idiocy, 245 
 Intermittent fever followed by insanity, 
 
 128 
 Intoxication a cause of insanity. 119 
 
 — and mania compared, 218 
 
 — diagnosed from insanity, 87 
 Iodine, absence of, a cause of cretin- 
 ism, 273 
 
 Jacobi, ague in place of insanity, 129 
 
 — cases of mania, 206, 211 
 
 — case of monomania, 219 
 
 — case of recovery from melancholia, 
 165 
 
 — on cleptomania, 55 
 
 — on mania, 198 
 
 — on use of cold in insanity, 336 
 
 — on use of tartar emetic ointment in 
 mania, 337 
 
 Jessen on colonies of insane, 370 
 
 Kerner, case of insanity, 170 
 Kidneys, disease of, a cause of insanity, 
 
 138 
 Kieser, case of hallucination, 70 
 
 Lactation a cause of insanity, 143 
 Lallemand, melancholia with desire to 
 murder, 184 
 
 — recovery from melancholia, 167 
 
 — sexual functions in insanity, 139 
 Langermann, reform in treatment of in- 
 sane, 358 
 
 Lautard, case of hereditary transmis- 
 sion of insanity, 108 
 
 Lead-poisoning, influence of, on brain, 
 121 
 
 Lelut on hallucinations, 63 
 
 Leuret, case of chronic mania, 236 
 
 — case of deinentia, 242 
 
 — case of monomania, 221 
 
 — cases of lyranthropia, 56 
 
 — on suppression of hallucinations, etc., 
 
 344 
 Longet, cases of insanity, 3 
 Lung diseases in the insane, 311 
 Lycanthropia, 56 
 
374 
 
 INDEX. 
 
 Magnesia in water a cause of cretinism, 
 
 273 
 Mania and intoxication compared, 218 
 
 — anomalies of disposition, etc., in, 196 
 
 — anomalies of intellect in, 198 
 
 — anomalies of senses and movement 
 in, 201 
 
 — cases of, 206-209 
 
 — chronic, 226 
 
 — chronic, anomalies of desires, etc., 
 in, 228 
 
 — chronic, anomalies of the senses in, 
 232 
 
 — chronic, anomalies of thought in, 230 
 
 — chronic, cases of, 233-239 
 
 — chronic, defined, 228 
 
 — incoherence of ideas in. 200 
 
 — incomplete, cases of. 211 
 
 — incomplete, symptoms, 210 
 
 — invasion and course of, 210 
 
 — period of incubation of, 196 
 
 — periodical, 204 
 
 — prognosis of, 205 
 
 — sudden recovery in, 204 
 
 — two forms of, 192 
 
 — without delirium, 212 
 
 Marc, case of attempted suicide, 182 
 
 — case of insanity, 185 
 
 — • case of monomania, 223 
 Marriage, influence of. on insanity, 99 
 Masturbation a cause of insanity, 122 
 Meding, case of dementia, 226 
 Medulla oblongata, inequality of, 250 
 Melancholia, 146 
 
 — cases of, 219, 220, 312 
 
 — cases of (recovery), 165-167 
 
 — changes in, 306 
 
 — course of, 163 
 
 — metamorphosis, 171 
 — • religiosa, 168 
 
 — religiosa, cases of, 169 
 — -simple, 156 
 
 — symptoms of, 156, 163 
 
 — with destructive tendencies, 176 
 
 — with persistent excitement, 190 
 — ■ with stupor, 172 
 
 — ■ with tendency to murder, 183 
 Memory, affections of, 48 
 
 — process of, 23 
 
 Mende, a case of attempted suicide, 181 
 
 — melancholia, with attempt to mur- 
 der, 185 
 
 Meningitis, symptoms of, 88 
 Menstruation, influence of, on sanity, 
 
 140 
 Mental constitution causa of insanity, 
 
 111 
 
 — disease, forms of, 144 
 
 — disease, pathology of, 289 
 
 — disease, prognosis and treatment of, 
 317 
 
 — disorders in idiocy, 259 
 
 — exaltation, states of, 192 
 
 — processes, observations on, 17 
 
 — weakness, states of, 225 
 Michea, cases of melancholia, 58 
 
 Microcephalism, 248 
 Microcephalics, cases, 248 
 Mildner, case of transitory mania, 204 
 Moon, influence of, on insanity, 105 
 Monomania, anomalies, of desires, etc., 
 in, 213 
 
 — anomalies of intelligence, 214 
 
 — anomalies of senses, etc. , in, 216 
 
 — bad term, 52 
 
 — cases of, 219, 223, 233 * 
 
 — defined, 213 
 
 — distinguished from mania, 192 
 
 — form of chronic mania, 228 
 
 — passing into dementia, 242 
 Moral treatment of the insane, 342 
 Morel, case of simulated suicide, 181 
 Morphia, in mania, 338 
 
 Mortality of the insane, statistics of, 317 
 Movement, anomalies of, in idiocy, 263 
 
 — anomalies of, in mania, 201 
 
 — anomalies of, in monomania, 216 
 
 — disorders of, 73 
 
 Miiller on hallucinations. 67 
 
 Murderous impulse with melancholia, 
 183 
 
 Muscular activity, tendency to, in in- 
 sanity, 54 
 
 Narcotics in mania, 338 
 Nerve, auditory, cerebral expansion of, 
 12 
 
 — olfactory, cerebral expansion of, 15 
 
 — optic, cerebral expansion of, 12 
 Neuman on use of Straight-jacket in 
 
 mania, 349 
 Neuroses followed by insanity, 125 
 Niepce, a case of hydrophobia in an, 
 
 idiot, 260 
 Nymphomania, 206 
 Nystagmus in insanity, 74 
 
 Opium a cause of insanity, 121 
 Ovaries, disease of. a cause of insanity, 
 141 
 
 Pain causing insanity, 126 
 
 — mental, 25 
 
 Paralysis, general, with insanity, 277 
 
 Pathology of mental disease, 289 
 
 Pellagrous insanity, 136 
 
 Perfect, use of camphor in insanity, 
 341 
 
 Peripheral irritation followed by in- 
 sanity, 125 
 
 Personality, renunciation of, 56 
 
 Pia-mater, alterations in, in insanity, 
 298 
 
 Pineal gland, affections of, in insanity, 
 304 
 
 Pinel, case of immoderate anger, 190 
 
 — case of suicide, 182 
 
 — on use of restraint in insanity, 349 
 
 — reform in treatment of the insane, 
 358 
 
 Pituitary gland in insanity, 304 
 Pneumonia, insanity in course of, 130 
 
INDEX. 
 
 375 
 
 Porencephalus, 250 
 Pregnancy a cause of insanity, 141 
 Prognosis of insanity 317 
 Psychical causes of insanity, 115 
 Puerperal condition a cause of insanity, 
 
 141 
 Pupils, state of, in general paralysis, 
 
 280 
 
 — great contraction of, unfavorable, 
 74 
 
 Pyromania, 189 
 
 Reason, analysis of process of, 41 
 
 Recovery, statistics of, in Germany, 332 
 
 Reflection, analysis of, 32 
 
 ReU, case of insanity, 357 
 
 Religion an aid in treatment of the 
 
 insane, 347 
 Renaudin, case of anaesthesia, 58 
 Restraint in treatment of insanity, 348 
 Rheumatism a cause of insanity, 132 
 Rochoux, a case of anaesthesia in a 
 
 maniac, 57 
 Romberg, case of mania, 100 
 
 Salomon, statistics of suicides in Bel- 
 gium, 179 
 Scliiff , functions of spinal marrow, 2 
 Schlager on concussion as a cause of 
 insanity, 124 
 
 — suicide among melancholies, 180 
 Seasons, influence of, on insanity, 105 
 Sensation, anomalies of, in mania, 202 
 
 — disorders of, 55 
 
 Senses, anomalies of, in chronic mania, 
 232 k 
 
 — anomalies of, in idiocy, 259, 263 
 
 — anomalies of, in mania, 201 
 
 — anomalies of, in monomania, 216 
 
 — hallucinations, etc., of several, com- 
 bined, 73 
 
 Sentiment, anomalies of, 45 
 Sexes, insanity in different, 98 
 Sexual excesses a cause of insanity, 122 
 
 — instinct, increase of, in mania, 202 
 Shock a cause of insanity, 116 
 Sight, hallucinations of, 68 
 Sinogowitz, a case of chronic mania. 
 
 233 
 
 — case of illusions of smell, 71 
 Sleep, troubled, in mania, 202 
 Smell, hallucinations of, 71 
 
 — impression of, followed by mania, 
 125, 208 
 
 Snell on anaesthesia in insanity, 58 
 Speech, absence of, in idiocy, 260 
 Spinal cord, atrophy of, in cretinism, 
 250 
 
 — cord, cerebral prolongations, 13 
 
 — cord, functions of, 17 
 
 — neuroses followed by insanity 125 
 
 Statistics of age of the insane, 101 
 
 — of drunkenness as a cause of insan- 
 ity, 120 
 
 — of nationalitj^ of insanity, 95 
 
 — of sex as a cause of insanity, 98 
 — of social position of the insane, 103 
 Stiedenorth, brain affected in insanity. 
 
 Strangulation, attempt at, followed by 
 
 dementia, 226 
 Suicidal tendencies with melancholia, 
 
 177 
 Suicide, simulated, in insanity (cases), 
 
 181 
 Syphilis a cause of insanity, 134 
 
 Tartar emetic ointment in mania, 337 
 Taste, hallucinations of, 71 
 Temperature in cases of mania with 
 pneumonia, 130 
 
 — in general paralysis, 282 
 Therapeutics of insanity, 326 
 Thought, anomalies of, 47, 230 
 Thurnam, statistics of insanity, 101 
 Tobacco, influence of, on sanity, 121 
 
 — in insanity, 340 
 
 Tongue, paralysis of, in insanity, 278 
 Treatment modified according to case, 
 351 
 
 — physical, of the insane, 333 
 Tuberculosis a cause of insanity, 135 
 Tyerman, autopsies at Colney Hatch, 
 
 137 
 Typhus fever diagnosed from insanity, 
 87 
 
 — fever in the insane, 309 
 
 — followed by insanity, 127 
 
 Uterus, disease of, a cause of insanity, 
 141 
 
 Velten, case of mania, 207 
 
 Venesection in insanity, 334 
 
 Ventricles of brain, changes in, in in- 
 sanity, 303 
 
 Voppel, accounts of autopsies in Colditz 
 Asylum, 136 
 
 Wigan on quality of mind, 18 
 Will, analysis of the, 30 
 
 — anomalies of the, 53 
 Willis, case of insanity, 137 
 Winslow, case of attempted suicide, 
 
 178 
 Worms, intestinal, a cause of insanity, 
 138 
 
 Zeller on cases of mania, 54 
 
 — on Guislain's Phrenopathie, 48 
 
 — use of cold in insanity, 336 
 
10 
 
 6 
 
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