Mental Pathology and Therapeutics

BOOK THIRD. FUHMS OF MENTAL DlSEAtJE. (part 4)

§ 136. 3. Anomalies of sensorial function and of movement. — Hallucinations of sight, of hearing, of smell, and of cutaneous sensibiHty, are sometimes observed in mania, and not unfrequently they cause aggravation of the symptoms. Generally, however, they

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are of but little importance ; they also speedily disappear 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 freqnent : 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 superhcial similarities.

There is also sometimes observed an exaggerated sensibility to impressions 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 continual impulse to contractions of many muscles. The move- ments 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 counte- nance 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, &c.). 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 mastered by a single attendant, and the appearance of increased bodily power 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 for a very long time, to make use of their muscular power, and to an extent which far surpasses their capability during health. Such individuals frequently pass whole weeks, and even months, almost without sleep, a prey to the most violent fury ; and the possibility of such enormous muscular exertion appears only explicable by the assumption that, owing to an ab- normal 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 ca])able of any fatigue, while at the same time the great emaciation, and the exhaustion which succeeds the attack, unmistakeably demonstrate that the organism cannot bear those exertions with impunity.

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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 frequently the first commencement of general paralysis shows itself during a moderate attack of mania bv the uncertain move- ments of the tongue.

Amongst the other symptoms of mania, trouble J sUep is very common — in many cases persistent complete sleeplessness. Again, too much ougiit not to be expected from a calm sleep during the course of ihe disease, as the most violent exacerbations occasionally ensue after the quietest nigiits, and, on tlie other hand, even convalescents frequently continue for a long time to complain of sleeplessness.

Anomalies of sensation of the most various forms may present themselves in mania — headache, vertigo, heat, aura-like sensations arising from the chest, abnormal cutaneous sensations, pains in the limbs real or apparent (owing to indifference), insensibility to heat or cold ; actual anesthesia is much less fre- quent than was formerly supposed (§ 50).

In many cases there is observed an enormous increase of the appetite ; ami 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 regulated by the degree of expenditure of muscular force. Not unfrequenlly, however, the demand for nutriment is not at all heeded, the patient quite neg- lecting 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 entirely absent. It is manifested by obscene language and writings, in movements of the hands, exposing the person, onanism, &c. On the whole, it appears to occur more frequently in female patients. Irregularity and suppression of the menses exist in the great majority of cases : their re-establish- ment has often no effect upon the mental state, often it has an aggravating influence; at other times it appears coiucidently with recovery.

Changes in the organs of circulation and digestion are not always present. Although it is of great importance, when such derangements exist, that they should be minutely investigated, in order to establish the indications of treat- ment 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 arc indistinct during great excitement, and become again clear when calm sets in.

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It is not uncommon to see considerable, sometimes very great cerebral con- gestion, redness of the face and heat of tlie head. It is only exceptionally that the countenance is pale ; sometimes it presents a cyanotic hue j 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 geueral paralysis that the temperature 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 melan- cholia. 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 in- numerable varieties of these accessory symptoms, the result of former or existing disease of other organs, and which need not always necessarily be closely con- nected with the insanity.

§ 137. As to the invasion and course of mania, it is observed sometimes as a pure and independent form of mental disease^ as we have hitherto considered it — as a stage of development in the succes- sive series of mental disorders ; sometimes transient attacks of mania, or more correctly 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 occasionally appear during the course of paralysis.

In epileptics, also, it is not uncommon to observe attacks of mania which are often characterised by a high degree of bhnd fury and ferocity. Sometimes they immediately follow the epileptic attack, as

' Neumann (' Psychiatrie,' p. 74) remarks that these attacks of fury increase in presence of others, while in simple mania the patient generally becomes quieter ou the entrance of the physician or attendant.

19

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if tlie excitation to the tumultuous motory movt-meiits 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 hccmorrhage (as in childbed, racnorrhagia, frequent bleedings), states of exhaustion after typhus fever, or after rapidly advancing tuberculosis or prolonged excesses, may in many cases be recognised as proximate or predisposing causes. The acute meningitis 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 course of mania there is usually an alternation of remissions 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 intermediate 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 which take place in other chronic morbid states which accompany the 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) alternation of exaltation and depression {folie ciradaire of the Prcuch 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, &c. — periodical mania, a grave form, a real psychical epilepsy which shares the unfavorable prognosis with ordinary epilepsy which has become habitual.

Milliner (' Psvchiatr. Corresp,-Bl.' 1857, No. 17) communicates an interesting case where an individual of limited intellectual capacity, with insufficiency and murmur 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, aud 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 mcdico-legal point of view, it is, of course, quite

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the same whether the state of mania duriug 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 paroxysms of mania constituted a sort of resolution and compensa- tion for the former state of mental pain, in the same way as we see in epilepsy and hysteria many disagreeable and painful sensations which precede the attack disappear with it. Maniacal attacks Avhich are mild and moderated 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 feehug of fatigue and of hunger which, combined with the patient's absorption in his delirium, renders him httle liable to subjective impressions.

Maniacs may recover suddenly, or this favorable result may be gradually arrived at after progressive diminution of the symptoms. The excitement ceases, the lucid intervals become more frequent and longer, the behaviour becomes gradually more orderly ; the patient agahi inquires concerning this or that person, experiences emnd 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, diarrhoea, skin diseases, furunculi, &c. "We ourselves have in certain cases observed such so-called critical appearances ; generally, 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 without foundation. The most trustworthy symptom of recovery is the return of the former desires and pursuits of the patient, and of his uuimpassioned behaviour and acknowledgment that he is really ill. We have on several occasions seen the observa- tion 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 with exuberant joy of Ins

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complete recovery. Even those who are completely cured are always predisposed in a high degree to a return of the disease.

In individual cases, our ojnnion concerning ihe curahilltij 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 persistent convulsions or paralysis in the extremities, of the facial nerve, or of the pupils, are equally unfavorable. These symptoms, at least wiicn they are not quite transitory — occurring, for example, in consequence of temporary but violent cerebral congestion,^ — appear to indicate a permanent extension of the morbid process to the parts situated at the base or in the centre of the brain. Indeed, the cerebral hypersemias which are so frec[ucnt in mania may occa- sion the development of exudations and their fiu'ther transforma- tions. The more the disease is prolonged, the less it is interrupted by lucid intervals and remissions ; and the more intense the hyperremia, the more these exudations are to be feared. The great majority of recoveries from mania take place within a year from the commence- ment of the disease : nevertheless, cases occur where recovery 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 recrard to the curabiHtv of the disease, no more than violent liysterical attacks are of evil omen in the prognosis of hysteria. According 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 ansemia, hydrsemic or scor- butic states, &c. — requires no further explanation. Not unfrequently, convalescents 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

* Sec llie cliapter 011 " Pathological Auatomy."

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weakness — into one of the various forms of dementin, with or without intervals of agitation.

In mania, death may result from the cerebral affection itself, in consequence of violent hypersemia of the brain, or more rarely of apopletic extravasations. Frequently the patients die in a state of exhaustion, with the symptoms of collapse (as frequently occurs in epilep^), in consequence of acute or chronic disease in other organs, as pneumonia, pleurisy, carbuncle, violent intestinal catarrh, phthisis, &c. Accidents, such as leaping from a window, &c., are, in this form of insanity, not unfrequently the cause of death.

Example XXXII. — Simple mania, with sexual excitement ami cleptomania ; recovery. — Gottfried Demons, aet. 22, of delicate constitution. During child- hood he had been frequently affected with eruptions of the scalp : his cha- racter is peculiar, and his intellect weak. His maternal grandmother had been insane for seven years, and he, at the age of nineteen, fell into a state of melancholy, which, under the use of remedies, disappeared in three months. At twenty-one, he suffered for some time from obstinate constipation and vomiting. In May, 181 1, 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 complained 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 inco- herent talk (large doses of tartar emetic and purgatives). During the fifteen days which followed, 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 chattered 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 were ob- served 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 surrounded 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 paroxysms 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 ex- traordinary confusion ; he talked nonsense the 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 brut?l gluttony, &c. The nights were generally calm ; the pulse and the temperature of the body con-

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tiuued almost unvnial (extract of belladonna for four weeks ; then tincture of digitalis from the bcgiuuing of October to the end of December). Under the influence of the latter remedy, the pulse fell sometimes to 50. In the carotids it was fuller and more tense than formerly. Tiic ))aticut had, from time to time, a tendency to epistaxis. On the other hand, it was then observed tliat 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 the end of October he was somewhat less confused in judgment; but the emotional perversion had rather augmented, and he exhibited a manifest disposition to steal — an inclination which had never been observed in him while in health. From time to time he still suf- fered some paroxysms 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 M'ay. By the end of February, he could answer correctly all simple questions. The attacks of maniacal ex- citement 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. 8:.)

ExAirPLE XXXIII. — Moral causes : mania tcith tendency to derision, vi/m- phomania {pntrif/o imdendi). Recovery. — Catherine J — , set. 39, without any hereditary tendency to insanity, enjoying good health, exhibited, while quite a young girl, deeply religious fefclings, and 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 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 iiusband, the marriage which she had contracted with him was nothing but a concubinage, and that the phantom had come to reproach her with the crime, as well as with 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 conscien- tiously the titles of the property, and the means by which her husband had gained his fortune. She obtained in that 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 her 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 (he same point. She saw and heard nothing, save the profound restlessness which tormented her within.

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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 lier friends at Riedelheim. When she arrived, she gave herself up to a per- fect 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 applications, clusters, &c.)-

I was then called in. When I entered her room with one of her neighboura — 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 laugjiter. Her neighbour 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 tlie 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 niean- ng, except that she was enraged. She seemed a satyr. 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 some- thing ; again she would make rapid and violent 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 counte- nance 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 connection came, they were biting sarcasms. She named her guardian Monsieur Robespierre, and she added, "In German, that means M. the valet of the executioner." After a few coherent thoughts, there came all at once an uninterrupted flow of words completely devoid of sense ; altiiough 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 higli degree ; rubbing the genital organs; swearing at her unsatisfied desires; asking for men, &c. &e. All this formed an assemblage of symptoms which could not be mistaken.

T subjected the patient to prolonged walks along unfrequented roads; and

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when she had a violent attaek 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/«ror nteriniis returned, the patient believing that she saw in every man au 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 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 au 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 reprimand was enough to cause her to conduct herself becomingly. As in the case of children, it was necessary 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 interval 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 itchiug 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 * Zeitschrift,' 1820, p. 709.)

ExAMi'LE XXXIV. — Two attacks of mania, each after strong impressions of smell during confinement and nursing; a third attack after a premature birth. Recovery. — K, — , a:;t. 34, was admitted to the asylum on the loth November, 1813. She is of soft temperament, but very sprightly ; tall ; hair of chestnut colour ; eyes large and brown. At sixteen, menstruation set in without diffi- culty ; at twenty-four, E, — was married.

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 attaek was characterised by mania with fury, and lasted only two months. It ceased suddenly after a sudden fright. Since this first attack, this woman has continued very susceptible. Every spring she was subject to exaltation un- accompanied by delirium, which was dispelled by the use of antispasmodics.

In her thirtieth 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 imme- diately excited delirium, which increased during five days, and was succeeded by mania with fury. On the 4th of August, 1809, she was admitted to the Sal- p6triere. Very marked abatement ; E. — 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

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mania ; stoppage of menstruation ; abdomen swollen. Returned to the asylum (he patient becomes quiet on the approach of winter. In December, the courses are re-established, and E. — leaves the asylum June, 1811.

In her thirty-fourth year, ist November, 1813, premature birth at two months ; haemorrhage. From the second day, great talkativeness. 3rd 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 recognises the fact that she is in the asylum.

On the 1 6th November, the courses cease. The patient sees her liusband with evident interest ; she is sad, but her answers are accurate. On the 28th, fever; gastric oppression; copious ejection. Since that time her ideas are connected ; E. — is calm, and engages in work ; gradual return to reason.

On the 2ist 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 attempls 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 comes on. Immediately when he has the presentiment, he earnestly asks to be tied up and bound with chains, lest he commit some crime. " When it takes me," he says, " I must kill — I must strangle, were it only an infant." 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 the fit, he retains the consciousness of his own existence, and knows perfectly that in committing murder he is guUty 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 j 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 represented by authors would be of no special interest. They are arranged, as we have already 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, &c.), partly according to the various causes of the disease (mania puerperalis, parturientium, potatorum, &c.). As to the latter form, delirmm tremens, in all cases in which it is well

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marked, it consists in a generally moderate degree of mania, which s likewise almost always preceded by a short stage of melancholia, and with which there are ordinarily, at the same time, present some degree of stuj)or, trembling of the limbs, persistent sleeplessness, and copious perspiration. Frequently a state of anxiety is present during the whole maniacal period, and keeps up the excitement ; very frequently there are also hallucinations of sight of the most varied description, which in the great majority of cases consist of phantasms of animals, mice, horses, birds, &c. : the delirium also turns upon various other illusions and phantasms of a predominantly sad and anxious nature.

AVe shall not liere enter into details regarding cklirium tremens. It is not usually classed amongst mental diseases, and owing lo its short duration is not often met with in asylums. Nevertheless, the institutions of large towns arc constantly liable to receive a number more or less considerable of these cases ; their statistics arc on that account, as compared with other asylums, essentially modilled (much more favorable.) Of 322 delirium tremens patients admitted into the ]31oomingdale 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 nymphomaniacal states, i.e. those of increased sexual e.^citemcnt in the female sex, do not always manifest themselves by an open expression of the sexual 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, &c. We fre- quently observe iu 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, 'Psychiatric,' 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 (particulai'ly Brierre) have described under the title of aciite delir'mm (delire aigu), appear to merit being distinguished as a special form of mania, and to demand further investigation. These cases are characterised by the rapidity of their outbreak ; by furious delirium with incessant incohe- rent, senseless chattering, but with the dominant expression of anxiety, and, frequently, ideas of being poisoned; by vertigo, awkward trembling movements, as if tlie patient were half intoxicated; frequently, slight muscular contractions, sleeplessness, paleness of the countenance, dry tongue, rapid exhaustion. According to Brierre, these states are

STATES OF MENTAL EXALTATION. 299

often accompanied by fever ; they last from a period of from several davs to six or eight weeks, they often terminate fatally through sudden collapse ; after death, hypersemia of the cerebral membranes, or nothing at all, is found.

Crnveilhier and Abercromby have already described such cases. See Brierre • Uuion Medicale/ 1849, and 'Memoires de rAcademie de Medecine,' torn, xi' Luther Bell/Amer. Journal of Insanity,' 1849; Jensen,' Zeitschrift f. Psychiatrie/ xi, 1854, p. 616.

§ 139. The frequent states of hicomiihtely develojied mania are of great practical importance ; in the majority of cases they represent the first stage of exaltation v/hich 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 considered as a special form of insanity with the 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 definite series of objects ; and this is manifested as an uncommon and inconstant 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, &c. ; all they see or which happens to them they would have and possess, and very often they thereby spend large sums in a very short time. Ordinarily, they are very vain, show a desire to be considered great and to excite admiration; theii- demeanour is confident and arrogant : the humour generally changes rapidly from joy and frolick to depression, and again to violent out- breaks of anger, the latter especially when their actions are opposed and their pride hurt. Some show a tendency to cunning and intrigue — others a desire to steal, to drunkenness, erotic tendencies, expansive 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 delusio7i of being some other illustrious person ; they have merely a tendency to estimate to the utmost their faculties and powers — their wealth, their physical strength, health, or figure. The higli estimate

300 STATES OP MENTAL EXALTATION.

which the patient has of himself frequently extends to all that belongs to him, and the mere fact of anything being in his posses- sion is perfectly sufficient to endow it with extraordinary quahties.

In this description, given from actual observation, and which agrees with that of Jessen,^ there will be recognised a state of moderate exaltation, which, when the explosion of the effort takes place towards the exterior, becomes mania ; when the increase is more internal, aTid 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 morbid tendencies by reasons which still lie within the bounds of possibility, and do not yet appear to be decidedly the result of insanity — the more easily will the morbid nature of his state be overlooked and confounded with the result of the normal tendencies of a capricious and original individual. He then falls under the category olfolle raisonnante, of which this con- stitutes 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 recovery, or pass into a state of mental weakness in which the domi- nant joyous self-satisfied and self- contented humour becomes fixed, and manifests itself in silly, foolish acts and desires — laughing, dancing, &c. ; in childish play, in the collection of worthless things, upon which, however, he places an extraordinary value, &c. Tor this form of mania it will be most convenient to keep by the name of moria.

The following case offers 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-

* Art. "Moria," 'Berl. Encycl. Worterbucb,' Bd. xxiv, p. 127.

STATES OF MENTAL EXALTATION. 301

tinually busy, and engaged from morning to night, without rest, in the hardest field-work. He had a great opinion of liimself, 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 sufi"ering in the least from that circumstance 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 intoxicatiou. Never, during these moments, did he, to say the truth, suffer from any profound intel- lectual derangement; but several times 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 rapidly 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.

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 that the patient had since his childhood iudidged 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 inclina- tion ; but after having struggled in vain for some time, he ended by yielding, and soon after, 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 keeping him for at least several months from his shameful habit. (Jacobi, 'Die Hauptformen der Seelenstorungen,' i, 1844, No. I.)

§ 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 deduced from his observations, that the impulses and violent actions in mania are ?iot ahoays founded upon perversion of

302 STATES Ol' MENTAL EXALTATION.

the ideas — we are of opinion now-a-days that originally this is alto- gether not the case — so confusing was it to give the same designa- tion 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 demeanour, 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 possi- bility, i.e., folic raisonnante. 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 con- sequence 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 designa- tion mania sine delirio can be applied, we recognise the fundamental fact that in no single case of mania is the conscious thought, the intelligence, perfectly 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 livehness and rapidity of thought ; generally, 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 possi- bility of temporary remissions and intermissions ; '' 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 external 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 conclusions, 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

' 'Bcrl. Eiicycl. Wuiterbucli,' xxii, p. 420.

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we have described in the foregoing paragraph, which, however, are generally merely the forerunners of the commencement of violent mania. For these, for /olie 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 a psychological 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.

lu a court of law the morbid nature of these states is most easily demou- strated in cases where the disorder has come ou within a short time, or returns at intervals, 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 be- come habitual and passed into fixed peculiarity of character. It should con- stantly 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 characterised by affirmative expansive emotions, accompanied by persistent over-estimation of self, and the extravagant Hxed delirious conceptions which proceed therefrom.

It is this form which Heinroth has described in great part under the name of Ecstasis jiaronoica, and which Jessen has designated Schwdrmarei (and in part Aberwitz, 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 cf 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 pecu- liar, namely, the early invasion of symptoms of mental weakness.

' In several parts of his work upon Mania, for csamj)!c. in the i8th and 19th illustrative cases.

304 STATES OF MENTAL EXALTATION.

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 arc all grouped together round a common centre, viz. the exaggerated idea which the patient has of himself. This is psychically grounded. Inasmuch as the power of voli- tion, which during the melancholic stage was weakened or entirely suppressed, has not only returned, but is actually exalted (externally in the form of increased actinty) — 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 great 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 indignation any expression to tlie contrary — but he frequently declares that he never in his life felt so well and so happy. The exalted self-consciousness manifests itself as an elevated frame of mind, as a joyful disposition, sometimes with the \asionary enjoyment of sublime sensations ; it is further manifested in great self-confidence, in presumptuous, auda- cious, proud, and superciHous behaviour, in which the i)atient displays sometimes a superficial self-satisfied afit'ected bearing, some- times a more deeply seated haughtiness and pride, and a desire to magnify himself in every possible way. This affirmative 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 angry; he seeks to justify his actions and ideas, and will permit nothing to approach liim which might encroach upon his elevated frame of mind.

The increased power of volition is manifested in the necessity for increased eccentric activity, especially, however, in numerous ex- travagant 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 difference from — the demeanour of the maniac. For, as in

STATES OF MENTAL EXALTATION. 305

mania, so iu monomaiiiaj the primary aucl principal desire is that of manifestation of power ; but in mania this necessity of an emo- tional explosion immediately produces muscular movements (some- times tumultuous) in which it relieves itself. Hence the instinc- tive 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 ^nll, the more the current towards the exterior 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.

Tuis difference is seen most distinctly when, as is very often observed, cer- tain groups of sensations and obscure ideas appear with especial vivacity and urge themselves towards the exterior as instincts ; for example, the sexua passion. The maniac with 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, &c.

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 cliaracter, 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. — Here, also, there is first of all observable 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 delhious ideas exclusively predominate, and, without interchange with others, determine the actions.

Another anomaly of the intelligence consists in an inward increase, an exaggeration, of the ideas in regard to their subject, which shows itself by a tendency always to employ grand, high-sounding words,

* See further on a case of this kind.

30

306 STATES OJb' MENTAL EXALTATION.

the most brilliant images, the liighest poi^sible numbers (thousands, millions, &c.) ; and inasmuch as those overdrawn ideas pass into acts, they explain the numerous eccentric plans of such patients. These naturally vary very much, accordmg to the former circum- stances of life, employment, and degree of education of the patient. The artizan magnifies his employment to the utmost ; the soldier dreams of large armies, enters upon campaigns and makes con- quests; another seeks to solve impossible mechanical problems, such as perpetual motion ; others discover new means of locomotion by land and sea, new railways, or steamboat enterprises to command all the seas of the world ; or, again, he projects impracticable journeys, or immense architectural plans (castles, towns, kc.) en- tirely occupy his mind. Others busy themselves within the sphere of ideas ; conceive comprehensive scientific thoughts, great humane and religious aims, &c. : beheve themselves to be apostles, benefactors of the whole family of mankind, bearers of universal happiness and peace. Sec. ; 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 exaggera- tion.

Most intimately connected with these ideas, and, like them, pro- ceeding from increased self-consciousness and over-estimation of the individual powers, there arise, further, false ideas and opinions relating to the special e(/o audits connection with the external world. In these cases we frequently meet with the idea of being some distinguished person : a superhuman power of possessing inexhaustible resources, of occupying a high position, of aristocratic descent, &c. To this class belong those patients, so numerous in asylums, who believe that they are generals, jS'apoleons, milhonnau'es, reformers of the world, gods and heroes ; the many female patients who are beloved by kings, those who believe that they hold frequent and intimate converse with the Deity, &c. 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 aUemjjfs at ex^jh nation.

These false ideas have originally a significance such as the following : the idea of being Napoleon, for example, fundnnicntally means that the patient feels him-

STATES OF MENTAL EXALTATION. 307

self powerful, believes himself capable of dolug great things, of accomplishing al 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 completely 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, as this exalted frame of mind continues to provoke attempts at explanation, we can with instruction observe the progress of this exaggera- tion in the delirious ideas. A patient, for example, who had formerly been a common soldier, manifests at first merely the idea of being an ofiicer ; 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.

It would, however, be a very great error to suppose that the patient is conscious of this explanation, as such — that he calmly 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 overjoyed, 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 e(/o, and will even deny the testimony of his senses.

Not uufrequently, when these states have attained to a considerable development, 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 greatness merely with the view of deceiving himself and others, with reference to the already perceptible urgent and increasing weakness of dementia — of colicealing, 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, where the mental processes remain active, that certain of these delirious conceptions become completely fixed. Certain stedfast, con- nected circles of ideas then incessantly urge themselves into the foreground of the consciousness, govern all the thoughts, and are expressed in words and deeds. Trom this cause it may seem as if there were merely a partial destruction of the intelligence, while in reality the essential elements of thought — normal self-consciousness, and a correct appreciation of the special individuality and its relation to the world — are utterly perverted and destroyed.

Of these fixed ideas, which to him possess the bighest ciegree of subjective

308 STATES OF MENTAL EXALTATION.

reality, the patient caunot be divested either by demonstration or by evidence. It is only at the commencement that remissions occasionally occur, during which the patient may admit for a short time the error of his delusion, when reasons or extenial evidence are laid before him ; while at the same time he cannot inwardly convince himself of the falsity of his ideas.

§ 142. Anomalies of fhe Semorial 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 arc in mania. In the latter they are soon forgotten ; but here they persist, foster, and essentially strengthen the delirious conceptions. The patient, for exam])le, sees an angel bringing to him a message from heaven ; hears voices commanding him to commit certain deeds, or communicating unin- telligible nonsense, which he believes to be some divine mystery ; worthless objects appear precious, kc.

The movement? of the monomaniac do not, on the whole, present the external excitement and tumultuous violence wliicb 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 movements is here also very frequently the first premoni- tory 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 demeanour. Some dress fantastically ; others, especially females, with extraordinary elegance ; others, again^ are totally neglectful of their toilette, forgetting every- thing 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 dbminant delirious ideas, they make various arrangements for the carrying out of their desires : letters, requisitions, and proclamations are issued ; large purchases are made, and pohte announcements prepared; they bestow orders and titles with a Hberal hand, they prepare laborious statis- tics and compKcated plans for the reorganisation of the world, kc. Some patients appear perfectly calm ; their conversation and conduct indicates an exalted tranquil joy, a sort of inward raptui'ous revelry

STATES OF MENTAL EXALTATION. 309

of feeling. With this there are generally associated ideas of close and mystical connection with the Deity, Messianic ideas, &c., com- bined with hallucinations — which they carefully conceal — of the appearance of angels, heavenly voices, Szc. This is the weak senti- mental form of monomania, which is observed principally in onanists ; but this visionary happiness may also be interrupted by violent outbreaks of anger when their wishes are opposed, accom- panied by threats of Di^ine displeasure, and solemn prophecies of dreadful punishments which are certain to follow. In women similar states of inward rapture occur, having for their object sexual sensations and imaginary 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 as Theomania, Erotomania, &c.

The other symptoms, although here also the cerebral disease may be accompanied by the most numerous and varied disorders of the general health, present nothing peculiar, and are very similar to those observed in mania. At the commencement, when the attack is acute, a feverish condition, frequently exists ; afterwards, sleeplessness, constipation, and sometimes cerebral con- gestion.

§ 143. The form of monomania is developed, like mania, gene- rally 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 certain dehrious conceptions become fixed, the patient enters into an essentially different state; and this condition, that of confirmed monomania, is, for the reasons already stated, to be considered a much more serious affection than mania. The more calm the external behaviour 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 peculiarities which favour the rapid penetration and falsifying of the er/o by these fixed ideas, the less is a return to health to be looked for.

During the course of these states there occur 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 occupation of the mind by the delirium : complete intermissions only take place when the disease is still vacillating between mania and monomania.

310 STATKS OF MENTAL KXALTATIOX.

The patieut may recover. Then it seems to him as if a veil had suddenly fallen 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 ; stUl 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 the whole, they are recognised by him as false. A completely fixed exalted delusion, when it has continued for more than half a year, is not easily got rid of ; never- theless, cases sometimes occur where the monomania gradually disappears after it has lasted for several years : when this occurs, other morbid processes are generally developed. All symjitoms of commencing mental weakness — loss of memory, recurrence of inco- herence, kc. — indicate that the patient is becoming incurable,

AYhen 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 terminatioii 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, expansion of all the mental processes, volition especially becomino- easier and more free. At first the ideas succeed each other more rapidly, the imagination becomes more brilhant, the languafre abounds in striking and surprising inflexions, thoughts arise as if spontaneously, conversation proceeds more easily, and muscular action is more energetic : to this corresponds usually the jovfui frame of mind, the psychical pleasure and power. Afterwards the drunken man throws off all restraint ; the objects of the precipitate

STATES OF MENTAL EXALTATION. 311

and rapidly succeeding perceptions are immediately^ and 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 ap- proaching to insolence; he is a braggart; he is generous and prodigal, because he appears to himself to be richer than he really is. fre- quently, certain desires and tendencies appear with especial force and recklessness ; for example, the desire to speak in verse, to con- verse in a foreign language (especially in Latin), to sing, to scream, to quarrel, &:c. He is very irritable, and, like the monomaniac, nothing offends liim more than to be told that he is drunk. The humour may change with or without 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 impression 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. Xow, 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 adynamic condition of the nervous system in typhus fever, or general paralysis with dementia.

The phenomena in insanity pursue, on the whole, the same course, but proceed more slowly. Trom a preliminary state of exaltation of the sensations and emotions, of the intelligence and of the will, the insane man gradually, as the cerebral disease progresses, falls into a condition of mental weakness, with loss of command over the faculty of speech and all voluntary movements.

Example XXXVII. — Cerehral congestion; melancholy; monomania lermi- ■tutting in dementia. — O — , au ofiBcer, enjoying habitual good healtii, and a strong constitution, had in his youth indulged in a multitude of excesses, which had not been followed by any appreciable bad consequence. He was irritable.

312 STATES OF MENTAL EXALTATION.

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 tlien 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 experienced frequent attacks of vertigo and confusion, and could only with great difQculty perform the duties of his office. His pulse was full and slow ; his belly distended ; his countenance flushed. He had violent headaches and lumbar pains ; had a constant feeling of tiredness ; micturition was painful, and the bowels constipated. 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, &c. 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 agitation 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 already 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 happiness was at the highest pitch, and lie 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 pupils were somewhat contracted ; the haemorrhoidal vessels were swoUen; he had pains iu 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 considerable fortune, and was of lofty station ; he believed himself endowed with supernatural power, &c. Every minute he distributes the largest sums of money, one hundred and twenty millions of louis-d'or; afterwai'ds 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 lie said that he found himself in the midst of several hundreds of Venuses. He wished to increase all the rooms of the asylum by means of gas, and 1o give them considerable 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 regiments in the air by millions of balloons, <S:c. Ten mouths after his admission, the attacks of vertigo returned, and by degrees

BOOK THIRD. FUHMS OF MENTAL DlSEAtJE. (part 5)

STATES OF MENTAL EXALTATION. 313

symptoms of general paralysis with increasing dementia developed themselves apoplectiform attacks; death. (Jacobi, ' Beobachtungen,' &c., i, 1830, p. 372.)

Example XXXYIII. — Monomania terminativg in dementia. — J. U — , aet. 44, formerly an officer, manifested already for a lengthened period a certain hasti- ness in his acts and movements. He was restless and irritable. 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 fan- tastic manner, and read a book of very fine type by the light of a large lamp, and with a powerful magnifying glass. In spring, symptoms of emotional ex- citement 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, and spent the entire day in designing and colouring landscapes, as children of five or si.x years do, and showed thera to everybody as chefs-d'oeuvre.

In a few days he was admitted into Siegburg. The pupils were contracted. He had, at the 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 epi- leptic attack, followed by great excitement ; palpitation of the heart; oppres- sion ; the subcutaneous 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 excrement. 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 was appointed ambassador, &c.

Gradually he became more calm ; the pulse slower ; the temperature of the body normal. An abscess formed 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 be- trothed 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, &c.

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 con- tinued 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

314 STATKR or MEN'TAI, EXALTATTOX.

newspaper containing the account of his uomiuatiou. At tlie same time, lie charged liis friend to buy for. him a new house at 75,000 florins, &c.

After many alternations of calm and rationality, with new manifestations of monomania, the patient, under the employment of digitalis, bleeding, &c., re- mained for six mouths 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. (Jacol)i, 'Bcobachtungen,' ic., i, 1^30, p. 295.)

Example XXXIX. — Melancholia ; an act 0/ violence in consequetice ofmelan- cJiolic delirious conceptions ; a/lenrards monomania. — M. A — , fct. 30, of a very lively disposition ; very gay ; bad always had liis own will from the earliest years. lie is sensitive to any lack of respect shown in company, and has the ambition to pass for a person of high importance. lie likes violent exercise, such as the chase and fencing, lie 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, ^f. 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 stromrf'r at tiio time of puberty.

A — , after having fatigued himself with reading, is seized 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, lie dreads all who approaeli him, except his parents, who are condemned to snffer the same fate with him- self. He believes he sees and hears people armed with poignards and air-guns, which have been distributed 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 ear. Sometimes he 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 conscious that be 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 — fired 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 more sane and calm ; he eats, although always possessed by fears.

He was now put under my charge. The countenance of the patient is extremely changeful and animated ; his bearing proud and haughty. During the first days he refuses every kind of food. He will not have his beard trimmed.

STATES OF MENTAL EXALTATION. 315

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, Csesar. 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 con- founded with insanity. A — writes to all the men who occupy the highest positions, even to the king himself. Every moment be expects orders to set him at liberty. He threatens me with all the weight of his authority, the mo- ment he shall be at liberty. Meanwhile he asks for an advocate aud 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 need- ful that he should bathe or have a blister applied, it can only be done by a great show of force. Many times the patient 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 hy 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 impression 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 encouutered 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 t/iat meant. There was, nevertheless, a disorder aud de- rangement ; 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 never having read, seen, or experienced any similar circumstance. On ap- proaching a little town which lay on our route, aud having seen several women, they caused me the same trouble and the same illusions as those whom 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 accompanied me everywhere, I left the inn liurriedly, telliug the innkeeper at the same time that I thought he had a hand in it, and I entered the carriage again. Tliere, fixing my attention, as far as

310 STATES OF MKNTAl, EXALTATION.

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 Riba- deneyra, 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 figlit, but against spiritual powers as well, could not escape me, and, arguing from that, I recognised no other cause of my trouble and illu- sions except the possession of a demon, and I resolved in consequence to make war against him by fasting, prayer, and exorcism

"My activity having been changed into warlike fury, the image and remem- brance of those warriors whose history and character had most strongly im- pressed mc in my childhood presented themselves to me. Tlien, 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 Achilles, and of Henry IV; and with the first, to whom I likened myself so far as to believe that I possessed his appearance, his name, and to he himself, I conquered at Arbela ; I laid siege to Tyre, and carried its ram- parts by assault. While I represented the character of Alexander, the image of the Tyrians whom the conqueror caused to be suspended on crosses along tlic bank of the sea came to my imagination. Seized with indignation and with horror at that spectacle, I detested the character of the Macedonian hero, and I no longer desired to be that monster ; but, fixbg 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 armour; I assumed his voice and courage ; I addressed to the Trojans words of insult and defiance. Then driving before mc, 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 which were dim and badly defined, passing rapidly from the character of Achilles to that of Pyrrhus, or rather, confounding the person of the father with that of the son, and strongly impressed by the picture 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!'

"!^^y parents, who knew nothing of what ailed me, followed the course of binding my body and shackling my hands. Good God ! what sufi'erings I en- dured ! What a resolution was accomplished all at once in my imagination ! Fallen from the high degree of fortune to which I had raised myself — down- cast, 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 assailed by the most fearful images. I thought I saw Ancient Rome rising from beneath its ruins, opening its tombs, and pre- senting to my eyes the skeletons of the most famous warriors invested in armour, the shape, the variety, the antiquity, and the rust of which constituted a horrible sight. That spectacle impressed my imagination so strongly, that I

STATES OF MENTAL EXALTATION. 317

remained for a long time without being able to fix my attention on any objec 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 odour 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 thought 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, favoured that illusion, perhaps caused it to spring up. I imputed this frightful treatment to the inhumanity which I fancied to have been exhibited towards the person of Hector. Nevertheless, a moment after- wards, 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 o inhumanity, I disavowed and abhorred the cruelty of Achilles, and passing immediately to feelings of the teuderest pity and compassion, 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.

"Tlie feeling of these gentle passions brought me back to peace and tranquillity, which induced ray 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 burst its bonds, and enjoyed with me the charms and advantages of liberty. 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, architecture, geometry, &c. 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 partitions 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, ima- gined 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 approached me ; I unfolded their character with astonishing sagacity, and, un- influenced 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 1 was possessed by tiie 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, Tragmens,' &c., Paris, 1834, p. 282.)

318 STATES Oir" MENTAL EXALTATION.

ExAMPtK XLI. — Attach of mononutida, of the nature of exafjijetation of the ■<exual instinct ; rational self-defence of the patient. {Folic raisonnanle, with 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. lie addressed to Madame Bonaparte, to a Madlle. Bcauharnais, and to a multitude of ducliesses, prin- cesses, and ladies at court, letters written in a style of revolting obscenity, which he named heroic poems. Ilis manner of conversation was otherwise slumped with such calmness, and had such an appearance of reason, that people hesitated several limes to call him mad. Nevertheless, the reality of his in- sanity 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 irreproachable 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 officer, 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-Elysecs, on the side of the Place Louis XV. As for myself, at that instant I was more than a hundred paces ofT. " 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 1 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. Nolwithstand- iug, he summoned the officer to arrest 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 government; all the more, that the loyalty of my well-known character ought always to deliver me from any kind of plot formed against me."

This assurance, adds Marc, seems to result either from a real forgelfulness 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,' &c., von Ideler, i, p. 33.)

CHAPTER III.

CHAPTER III. THE STATES OF MENTAL WEAKNESS.

§ 145. Under this section are compreliended a series of morbid states of mind wliicli, although presenting great differences in their details, collectively form a natural group. They aU closely resemble each other in the cii'cumstancethat (with a few exceptions to be after- wards mentioned) 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 aUied 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 constitutes in itself the funda- mental anomaly, the emotions being suppressed or enturely 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 reproduction of ideas (loss of memory) and their healthy association — it may proceed 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, bluntness of 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 per- sistence 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, stiU 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 thai partial (lemenf la ought to be comprehended under tlie states of mental weakness.

320 STATES OF MENTAL WEAKNESS.

In these states we no longer recognise the changeabiHty of the forms which we have hitherto been considering, nor that activity of the morbid process in which the play of active, healthy mental function, mental elaboration and combination, is so plainly recog- nisable (particularly 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 hallucinations not depending on the emo- tions and on an extension, constantly more penetrating, of former delirious ideas relating to the entire sphere of perception. All these morbid states (again \nth a few exceptions), when not cut short by death, are very chronic in their course, and generally are capable only of one kind of change or modification — namely, increase of the mental weakness. Nevertheless, they often remain quite stationary for long series of years ; they no longer admit of complete recovery.

My having, in the first edition of this work, classed partial dementia with the slates 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 delirious conceptions which have become as it were stereotyped, a decided dimiuution of the moral powers, a mental decrepitude, a wreck after the sub- sided storm. There exists, it is true, between this terminal point and tlie primary stages, in many patients a long period of transition, in which there still plays around several groups of delirious conceptions remaining over from these primary stages, an active menial process. In this the dehrium becomes in part modified quite involuntarily, in part elaborated and systematised (§ 44). When this is completely finished, tlie 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 pheno- mena, and which are numerously represented in every asylum, are, in regard to classification, a source of embarrassment to the beginner. Ke may, without hesi- tation, keep to the principal classes which have been here established, but must consider that sometimes a long period of observation is necessary to determine in a given case how much is still activity and progress, and how much is fimplj/ residue. Neumann ('Lehrb. d. Psychiatrie,' 1859, p. 70) calls what we desig- nate dementia, " recovery with defect." How far " recover/' may be spoken of, or rather cannot be spoken of, is clear. As to tlie " defect," 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 de- mentia we distinguish two divisions — the one with incoherence of the ideas, but with considerable, although merely superficial.

STATES OF MENTAL WEAKNESS. 321

activity of perception^ generally -with a slight degree of outward agitation (demence agitee) ; the other with extreme sluggishness of perception, even to complete abolition of it, and with external apa- thetic 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 hisaniiy, may of course arise primarily — that is, without having been preceded by another form of mental disease, or other cerebral disease of a dif- ferent nature, as in the case of the mental weakness of advanced life or premature decrepitude, primary ati'ophy of the brain, intra- cranial tumours^ &c. As to the cases described by many authors as acute, curable, primary dementia, the great majority of them cer- tainly 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. Xevertheless, it cannot be doubted that there exist intermediate states between melancholic stupor and actual dementia, and also decided cases of primary, acute, and curable de- mentia ; in proof of which we shall cite an interesting example of a case in which the dementia was ])robably owing to oedema of the brain from pressure on the cervical veins.

Example XLII. — State of dementia of several weeks' duration, and without sithsequent recollection of it, cattsed by an attempt at strangulation. — A prisoner, ret. 23, strong and liealtliy, liauged himself. Ahnost immediately after the cutting down of the body, it showed signs of life ; consciousness returned. The patient gave, apparently quite cahnly and sensibly, the history of his life and liis motive for the deed (weariness of life). On the following day he was tran- quil 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 contractions of the facial muscles; he w^ent about and ate •without e.xpressing 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 strugrde in his mind between the resolve and the fulfilment of the deed, and the

Co

sensations in the moment of hanging — lingi'i.^ tif the curs and stars in the eyes.

21

322 STATES OF MENTAL WEAKNESS.

From this time to the hour of his awakinjj in the asylum, all recollection of his personal existence was wanting; even the animation after the hanginij and the temporary possession of consciousness 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 tiie general health rapidly became re-established. (Meding, in Siebenhaar, ' Magazin fiir die Staatsarzneikunde,' i, 1842.)

But far more frequently acquired dementia. ov\^'ma.ies conseculivel^, that is, after the symptoms of another severe cerebral disease (epilepsy, acute meningitis, typhoid cerebral affections, &c.), and especially when 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 is not unfrequently preceded by a period of exaltation — a short maniacal stage, characterised by great psychical irritability, a newly awakened tendency to activity, reapjjearance of the sexual desires (wishing to marry. Sec), 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, especially from violent mania, there not unfrequently occurs a condition of profound mental weakness : this state bears the same relation to true dementia that great and long- continued fatigue does to actual paralysis.

It is not at all unusual, although hitherto it has been very little attended to, to observe a mental state characterised by moderate weakness occasionally ensue after apparent recovery from other forms, and to remain persistent. In individuals who have recovered in this way, 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 dehcate moral and esthetic 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 hfe, all consideration or desire of them, are foreign to them. These persons might be regarded as perfectly sane —

STATES OF MENTAL WEAKNESS. 323

siuce there are many individuals who are all along of this disposition — if we had not been acquainted with their former life, and if, in many cases, in the physiognomy and whole demeanour, a marked change to idiotic, even animal-like expressions, was not recognised. They are further capable of simple mechanical employments, in the performance of which they show care and intelligence ; for themselves hey desire nothing more than suffices to satisfy simple material wants. Should such individuals be permitted to leave the asylum and return to ordinary life, they run a great risk of new 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 higher 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 superficial 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 afi'ord material for superficial fantasy, and the unmasked and unrestrained manifestation of the disposition actually present (laughing, jumping, seeping) 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 kindness or severity be kept at light mechanical employments, and by methodical regulation and care kept from manifesting the in- coherence 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 majority 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 some- what approaching to the rich opportunities afforded to us of studying them ! The individual varieties are here still greater than in the forms we have already considered ; they can neither be enumerated nor described. "We must rest satisfied with stating and describing several principal types.

324 bTATESJ OF MENTAL WEAKNESS.

Skction I. — Chi'unic Mania {Die Verri/ckt/ieii ; La Folic

si/stematisee) .

§ 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 byEsquirol, but employed by him in an essentially different sense, especially adapted to 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 obser- vation.

Anomalies of Self-consciousness, the Desires and the Will. — The transition 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, oscillating for several years : a chronic state of modified melanchoha or maniacal excitement, however, often remains long persistent ; after a time this also disappears, leaving behind it certain delirious conceptions. 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 acti\ity. Gradually there is re-established an entire or partial external equilibrium, as with the disappearance of the morbid emotions the mind becomes calm.

But this is no longer the equilibrium of the former healthy life. Gradually 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

STATES OF MENTAL WEAKNESS. 325

mauifested where the general melancholia and the maniacal exalta- tion have now entirelij disappeared, consists essentially in dulness and weakness of all psychical reaction — in an absence of senti- ment^ indifference, and diminished energy of the will. None of these patients are any longer capable of the 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 disagree- able or agreeable excitement, or they will quickly turn from the subject as from some unwelcome disturbance, or they may not react at all. Only on one point can the psychical tone still be readily ascertained and altered — can emotions and reactions of tlie will be rapidly called forth : if we touch upon the fixed idea, if we oppose his statements by arguments or his projects 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 re&ctlon, 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 principal though by no means the only examples of this condition are to be found amongst drunkards who have become insane (see § 41).

The emotional dulness of the chronic mania is very characteristically mani- fested in his relations to the asylum. The individuals are, almost without ex- ception, 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 ruhng disposition is, indeed, on the whole, one which corresponds to the delirious idea, although in a weaker degree; and in the higher grades of par- tial 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, &c. The psychical reaction on all excitation other than that which is directly in connection with the delusion is generally very feeble, because, on the one hand, perception, 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

326 STATKS OF MENTAL WEAKNESS.

frequently many masses of ideas which belong to the former life of the patient are now completely dissipated, forgotten, or no longer recognised by him as his own. It is the same circumstance which in the sphere of the intelligence does not permit the patient to recognise 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 pos- sibihty 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 formerly rendered it impossible for him to recognise 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 course, is owing to the circumstance that no counterpoise, no inward opposition 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 recognising the delusion as such, and the general indifference and diminished psychical reaction, may both be founded upon the same psychical defects.

It is the same with the emotions and the will. So long as slight melancholia and emotional excitement remain, volition presents the general character of these states; and there are then ob- served, sometimes, a one-sided persistence in a single negative direc- tion (for example, a continual tendency deliberately to destroy inanimate objects — to tear the clothes, pieces of paper, &c.), 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 weakness; 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 Rome, and continued to read his course of lectures in the College ; or they can pursue easy manual occupations : 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, &c., gradually become less energetic and more suj)erficial ; while in the most confirmed states there only remains the most feeble emplovment — the amusing themselves with pebbles, rags, paper, kc.

STATES OF iMENTAL WEAKNESS, 327

All sorts of capricious desires, sucli 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, smg, 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 malicious acts, making peculiar gestures, &c. These desires have often a peculiar, mysteri- ous significance to the patient, or they proceed from certain frames of mind connected with the delusion ; at other times they are purely automatic, the patient himself knows no cause for them, and is angry when Cjuestioned regarding them, in the same way as healthy persons are irritated when asked the reason of peculiar habits, such as chewing the nails or making unnecessary movements with the hands, &c.

§ 149. Amongst the anomalies of tJtought in chronic mania, we meet, in the first place, with a formal change — namely, a sometimes moderate, sometimes increased degree of weakness of thought, gene- rally accompanied by loss (forgetfulness) of great series of ideas which formerly belonged to the individual in health. Eor these reasons, no clear apprehension, no healthy mental conception is now possible to the patient. Some may, indeed, carry on a pretty rational conversa- tion, but generally it consists merely of current phrases ; so soon as actual abstract thought is required, they show their incapacity to grasp the subject. Real acuteness never exists in chronic mania, unless, indeed, the occasional curious combinations of thought which, occurring abruptly and unexpectedly, 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 which 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 per- ception becomes actual incoherence — a casual rising of images and thoughts without sense or coherence, only loosely connected by the

328 RTATKS OF :\[ENTAL WKAKNKSS.

unity of tlie fixed ideas : with this chronic mania passes into dementia.

We liavc ahrady seen, in a former chapter, how the separate delirious conceptions arise in melancholia and mania, and their subject-matter is there indicated. They always relate to the special persoiuditv of tlie ])atient, to his position in the world or iclntion to the Deit\, MlthoiiLrh their >ubicct-niattcr pre^Mits f'ss(M\ti;il (hflVr- ences.

Sometimes they arc 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 per- petual motion, the mother of nature, one who has penetrated all mysteries and knows the elements of all things. Sec.

Or the delirious conce])tions relate to some affliction, to domina- tion by external things. The patients believe that they are persecuted, surrounded 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, &c. Or they cherish lixed delirious conceptions regarding their own body; they arc dead ; their bones are made of glass, of butter ; they harbour strange things in their body, &:c.

From the dilVerent characters of these ideas wc are enabled to distinguish chronic mania Avith active, exalted (§ 131) delirium, from the same with passive, depressed dehrium.

The more limited the circle of these delirious conceptions, the more do they appear, on superlicial consideration, to be simple and even inconsiderable errors of judgment. But how much do such errors, even in the most favorable case, differ from those mistakes which in the sane proceed from deficient knowledge ! A long series of psy- chical 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 bv an act of will, nor rid himself of them bv arirument: and in order to the existence of the delirium in this mild form, not only must that long series of emotional states in which it grew have run their course, but there must also remain behind a deficieucv of thousrht to ensure 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

STATES OF MENTAL WEAKNESS. 3:29

limited to one subject, as on this — that he always, by preference, expresses 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 senti- ments extends not only to the neighbouring sphere of self-con- sciousness, where it disturbs the proper estimate 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 de- lirium ; 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. AYhere, 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 freciuently to a comprehensive and sometimes carefully concealed system of delusions, in which all the relations of human intercourse, all moral considerations — indeed, the whole internal and external organisation of the universe — are mysteriously expressed. Sometimes ordinary language is not sufficient to express his thoughts, and he invents, at least to express the delirious ideas, a totally different language, which he declares to be the primitive language, tlie language of heaven, &:c. ; and the more the sensorial impressions are obscured by hallucinations, and the inward views become in- distinct 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 behaviour 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 melan- cholia) ; 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

330 STATES OF MENTAL WEAKNESS.

speak of it as of a third person, aud often only vague recoUectious of it pene- trate 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 aud melancholic conditions, and comprehended under the name of chronic mania. New investigations may throw further light on this sub- ject.

Tlie following examples will still further aid in giving a correct idea of this form,

§ 150. Hallticinations and ilhis'ions of all the organs of sen.'^e are in no form of insanity so frequent as in chronic mania, and in many cases they nourish and maintain the delirium. Frequently the patient converses 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 distortion. 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 constantlv, or move their hands and feet in a monotonous manner ; others preserve an ecstatic stillness, in order to listen to their hallucinations ; others walk up and down incessantly in a favorite place, hke 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 disturb- ance ; others constantly employ themselves in collecting trifles of every description — rags, pebbles, shells, ko,. — to which they attribute great value; while others, again, decorate themselves fantastically with everything they can lay their hands on.

Generallv, 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 experience goes to show that complete recovery is impossible ; but by the communications of Leuret it is placed beyond doubt that, by energetic methodical treatment, some of these patients can be made

STATES OF MENTAL WEAKNESS. 331

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 them- selves, they become more and more engrossed in their delirious con- ceptions ; these gradually extend to wider ranges of thought, and the patients finally fall into complete or apathetic dementia.

Example XLIII. — Chronic mania and monomania. — 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, occu- pying himself with nothing. lie laughed and mocked at everything with great haughtiness ; and if any one happened to ask him anything, he replied witli great assurance, and with a perfectly self-satisfied air, because — aud 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 power came out in all his acts and move- ments. A consummate actor would have had difBculty in expressing the mag- nificence and disdain manifested by this young man, simply clad in a blouse and seated on a wooden bos. The fact is, that never had man profounder convic- tion 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 wlierein 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 alcoholic 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; I am a capital player at billiards, an extra- ordinary expert horseman ; lately, I got on horseback in the circus, and I dis- tanced 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 my house — I want to have a little amusement. Tlie man you have given me here, and whom you call a keeper, pleases me ; he also saw me get ou horseback in tlie

33.2 STATES OF MENTAL WEAKNESS.

circus," &c. 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 nie 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 every- body."

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 backward, saying, " Who are you ?" M. S — : " I am a colonel of His Imperial Majesty of Russia, and adjutant -general." M. H — : " It is not un- pleasant 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 organisation of the naval and military forces of Russia." M. S — .asto- nished at the unheard-of arrogance of his interlocutor, looked about iiim quite embarrassed, while M. H — looked at him with all possible dignity of manner, and, filled with the consciousness of his vast superiority, he said to him, " Have you still some other accomplishments 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 admir- able . . . ." Then M. H — , throwing himself back and assuming a still grander air, while he shot at iiim as disdainful a look as possible, " Vile bateleur"

said he, "miserable , wortliy of being in a madhouse !" and he withdrew

haugiitily. 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 in 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. 1 wish I could, tell this gentleman that I did not get on horseback with the groom of the circus. Take me, I pray you, immediately to him." I replied, " 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 mat- ter," I replied, " and we shall talk about it afterwards ; but, at present, you have for ever 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 development. M. H — always shunned him, never spoke to him, and treated him with pro- found contempt. M. S — was always ashamed in his presence, as if he remem- bered 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

STATES OF MENTAL WEAKNESS. 333

which he experienced in presence of M. H — . AYheu he was completely cured, 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 the 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,' &c., 1843, p. 22.)

Example XLIV. — Chronic mania of many years' standing : habits capricious, but intimately connected icith the leading delusion. — The woman B — was, when she came under my observation, about 65 years of age. So far as known, she had been an inmate of asylums since she was sixteen. lu her deportment she constantly showed traces of superior training. I could never learn whether she had any relations still living ; nobody visited her, and I had no other means of information. Her once fair and luxuriant hair was now nearly grey ; her fore- head wrinkled, her deeply-set blue eyes were very moveable, and when excited they actually sparkled ; her gait was generally slow, and she moved without definite direction — always as if looking for something, and in semicircles. She never greeted any one, nor acknowledged a salutation ; it was only rarely that she, when saluted by any one not known to her, would look up, minutely exa- mine the individual, then rapidly withdraw her eyes and occasionally murmur a few incomprehensible words. At other times she replied to all communica- tions 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 from long custom joined in the ordinary household arrangements. She often wrote letters, which con- sisted entirely of capital letters ; they were always written on large sheets of paper, and addressed to the most powerful mouarchs in the world and their wives. She always accepted a few sheets of large paper and some pens with marks of gratitude, 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 occa- sions, and perhaps intentionally, disturbed her in her employments. If the name and designation of such persons were unknown to her, she would give a description of them, according to their clothing and habits, so true that the persons meant could be easily recognised, in order that the high monarchs might commit no mistake. If any one were doomed by her to be burned in

331. STATES OF MENTAL WEAKNESS.

one of these letters, she repeated to him his judgment each time siie saw or spoke to him : pardon need no more be expected. This patient was, as al- ready mentioned, an accumulator of uncommon perseverance. Only on very cold and rainy days did siie desist from collecting, but wiien the sun shone during tiie hours of recreation in the garden she was most active. Quite ob- sorbed in her work, she collected small coloured stones, dead brilliant beetles, flie-s, certain small leaves, twigs, coloured fealhcrs, rags, bright pieces of glass, &c. If she had made a large collection, 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 resist- ance if hindered, she would attempt to withdraw herself from the next walking party, in order that she might, when possible, be alone in her room. In this solitude 1 found opportunity to observe her unnoticed, 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 time in profound con- templation; siie then tied these gaudy articles, fastened with green, yellow, red, and while threads, between the iron bars outside the window, so that they remained suspended in rows. When this bright array was finished, she opened the door opposite the window, which caused a draught. Wlien, owing to this, the slightly fastened leaves, feathers, rags, &c. commenced to flutter, the old woman would look with joy expressed in iier 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 neighbours from the garden, and rapidly and care- fully, disturbing nothing, pack up all ; and when those who shared her apart- ment entered, no trace uf them would be observed. As I, during my repeated observations, approached (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 wiihdrew, and was afterwards several times enabled to witness the same scene, although I had already been doomed to be burned in her letters.

I directed that this unfortunate woman should not be annoyed during hei hours of recreation ; for no one has a right, without some good motive, to break upon the happiness of his neighbour. Accordingly, this old woman en- joyed in peace her small measure of happiness until her death, wliich occurred a few years afterwards. She was more than lifty years in asylums ; her insanity had never been cured, but had often been aggravated by her quarrelsome neigh- bours.— (Sinogowitz, 'Die Geistesstorungen,' Berl., 1843, p. 35.)

Example XLV. — Chronic mania with the character of depression; hallucinations 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 trembling, 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 still near her, and she continued to look at nic. 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,

STATES OF MENTAL WEAKNESS. 335

and soon again the movemeuts of her features indicated agitation of mind. I walked a hundred paces wiliiout 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, without 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 continued 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 Salpe- triere, 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 Lave never engaged in the lottery; that I will go everywhere with honour; 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 I sir, I have never been unfaithful to him. If monsieur want to answer me ?"

" What difference 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 speak. . . . 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 you 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 is come ; I made a crown, and I said, ' If I 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."— (Siuogowitz, ' Die Geistesstorungen,' Berlin, 1843, P- 35-)

Example XL VI. — Chronic mania; loss of personal identiti/ ; hallucinations of all the senses. — An invalid, of the division of Pariset, set. 56, enjoying, to all ap. pearance, good health, has lost, since 1827, the consciousness of her personality, and believes herself to be quite another woman than she was formerly. That

336 STATES OF MENTAL WEAKNESS.

belief seems to be united to a cliange wliicli lias taken place in her way of feeling, and especially to bailucinalions, various, and manifold, and continual. She never speaks of herself except in the third person, and employing this phrase — " the person of me."

Provided one does not come loo near ber, and does not touch her bed, ber cbair, or ber garments, nor anything that belongs to her, one succeeds easily in conversing witb 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 enougb to tell me."

" The person of me lias not a name ; she desires you not to write it."

" I would like mucb 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 what took place. The person of me bas lost her name ; she gave it up on entering the Salpulricre."

" AViiat is your age?"

" The person of me lias no age."

" But that Catberine X of what of wbora you spoke, how old was slie ?"

"I don't know. She was born in 1779, of Mary and James , living at

, and was captured at Paris, &c."

" If you are not tbe person of whom you speak, you are pcrbaps two persons in one r"

"No! tbe person of me docs not know that which was born in 1779 It is perhaps that lady you saw downstairs."

"Are your parents still alive P"

" The person of me is alone, and much alone ; s-hc has 110 relations, and never bad any."

" And the relations of the person whom you formerly named ?"

"Folks say tbey are still alive; they called 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? lour 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 un- known ; she has no recollection of tbe 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 bad several children." (Jlinutely relates the circumstances of her former life, but always stops at the year 1827. j

" What have you done and what has happened to you since you became that person ?"

" The person of mc lives in the asylum at . They make, and sliil make,

physical and metaphysical experiments with her. This work w.is 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 bold ot."

" How are they clad ?"'

" lu blouses."

STATES OF MENTAL WEAKNESS. 337

"What lauguage do they speak ?"

"French. If they spoke iu any other language, the person of me could not understand them."

" Is it actually certain that you see them ?"

" Quite certain ; the person of me sees them, but metaphysically, in in- visibility, not materially ; else they would not be invisible."

"Do you sometimes experience odours ?"

" A feminine composition, invisible, has sent bad odours to me."

" Do you sometimes feel the invisible in your body ?"

*' 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," &c.

"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 aU events, the most of them." — (Leuret, Tragmens Psychol.,' p. 121.)

Example XLVII. — Chronic mania with the character of exaltation. — A woman at present in the Salpetriere believed herself to be at the same time, God, Jesus 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 iu 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 thus offend me; God cannot descend from his throne to avenge me."

" Do not excite yourself ; you are God, are vou'not ?"

"Yes."

" Are you here of your own accord ?"

" No ; I was on a pilgrimage, when I was waylaid, and brought into this hospital."

22

338 STATES or MENTAL WEAKNESS.

" Why, then, did jou allow it, if you were God ?"

" I could not prevent it ; it is not for me to go against the authorities. Tlie slate procurator would not let mc 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, 'Eragmens Psychologiques,' 1834, p. 323.

Example XLVIII. — Si/stemaUcaliy developed and dramatised delusions oj bodily and mental influences. Ilallucinatiotis of all the senses, especially of the cutaneous sensibility ; 2}0ssibiHti/ of completely concealing the delusion. — Haslam narrates, in his small work, ' Illustrations of Madness,' London, 18 10, the history of a man, named Matthews, who, iuthe year 1797, inconsequence 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 considering himself the subject of experiments made by certain persons — some- times the emperor of the world. In 1809, his relatives, who were opposed to his residence in Bethleliem, proposed that he should be dismissed, and requested Drs. Clutterbuck and Birkett to inquire more minutely into his mental con- dition. These gentlemen, after having visited the patient four times, certified on soul and conscience that Matthews was //* a state of perfect mental health. A new commission of eight physicians was now appointed, who, after a long examination, granted a certificate, also ou oath, that the man teas in a high degree insane.

Aud indeed he was. He cherished the delusion, in its details highly elabo- rated and dramatised, that a band of wicked men acted upon him in a great many ways by ■magnetic currents from an apartment in the vicinity of the town- wall. He heard aud 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 : he is from sixty-four to sixty-five years of age; his thoughts are constantly directed towards wicked objects ; no one ever saw him laugh. The second is called Jack the School- master, 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-coloured coat and knee-breeches ; he constantly employs 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 con- stantly sits grinning. The first woman is called Augusta : thirty-six years old, of medium height, aud characterised by the sharpness of her features. She dresses in black, like a country shopkeeper's wife, and wears her hair unpow- dered. 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-woman, because she always wears cotton gloves, and indeed, as Sir Aichy dryly remarks, to keep people from seeing that she has the itch.

( The influences which these imaginary individuals exert upon the patient, by means of a complicated maciiine which he can minutely describe, are of a very various nature. The patient describes a number of these various torments (hallucinations) in his own terms, thus : Obstruction of the fluids— ». knotting together of the fibres of the root of the

STATES OF MENTAL WEAKNESS. 339

tongue, whereby speech is brought to a standstill. Cutting off of the soul from the feelings — au expansion of the magnetic current from the root of the nose to the under surface of the brain, as if a veil were spread ov'er it, so that the feelings of the heart are disconnected from the operations of the mind. Bragon- flging — as boys fly a paper dragon, so these rascals, by means of their art, cause any special 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 M'hole 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 hound doicn — a fettering of judgment in reviewing one's thoughts. Burstivg of bombshells — one of the most frightful modes of being influenced. The vital fluid present in the brain and in the nerves, the vapour 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 sufferings 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, &c. &c.

During sleep, Matthews is tormented by dreams. These rascals have many various kinds of 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, &.c.

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 vapour of vitriol and aqua fortis, of nightshade and hellebore ; the excrement of dogs, human gas, croton oil, vapour of arsenic, &c. [See the detailed communications of the patient, and his description of the machine, in Nasse, ' Zeitschrift fiir Psychia- tric,' A, 1818, i.]

Many cases found described in original MSS. or in pamplilets, some of them published by the patients themselves, belong to the same category as this case : for example, " Cry of Distress of one who is poisoned by Magnetism/ Stuttg., 1853; ^^^^ ^^® ^^^^ described by Kieser as " Melancholia diimonomania occulta^^ (' Zeitschrift fiir Psychiatrie/ x, 1853, p. 423), of externally concealed mental dis- order of forty years' duration, with the delusion of being the continual object of demoniacal experiments, and with domhiant hallucinations of hearing. — Anomahes of sensation m the most varied parts of the body, which in these cases are so fantastically elaborated, occasionally occur in the state of health. These condi- tions are in general far too little studied ; they are generally thrown into the general class of hypochondrias, and I thmk I shall again

340 STATES or MENTAL WEAKNESS.

refer to them elsewhere. A patient of thi.>* kind, in my practice, and about fifty years of age, has for many years experienced, ahnost uninterruptedly, the sensation of a constant " heaving and lifting " in his whole body. A young man, twenty-one years of age, w/iose father had been insane, has a sensation, which has been constantly increasing since his fourt<?enth year, as if head and face were covered with threads, and some one was continually pulling at them, always preferring the head ; lancinating pains in the knees and shin-bones, &c. These j)aticnts do not think of ascribing their malady to others ; but their abnprmal sensations would, should mental disease set in, immediately afford rich material for such imputations.

Section II. — Dementia,

§ 151. Under the states of mental weakness without the striking predominance of a single dehrious idea, we comprehend under the name of dementia — as distinguished from apathetic dementia — those in which tlie patients still manifest a certain degree of external vivacity and activity 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 manifested, !^^ost characteristic are the mumerous cases which in their external symptoms present an apparent simi- larity to mania : this similarity, however, can only be external and superficial.

In all these cases the fundamental disorder consists in a general weakness of the mental faculties. In the sphere of the emotions this is manifested 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 neither 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 reactions towards the ex- ternal world (laughing and amusing themselves in the midst of the saddest events, &c.). The dominant disposition of mind presents

STATES OF MENTAL WEAKNESS. 341

endless varieties. Some of these patients constantly manifest 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 without any cause, and are expressed in a manner altogether foolish and childish. "With the complete indif- ference and absence of all actual desires which characterise the patients, we sometimes see manifested disorderly mental movements and aimless extravagant impulses whose meaning the patient him- self cannot understand, and the reaction of the will, where this still exists, has throughout the character of transitormess and in- constancy.

§ 152. "While in the sphere of the emotions all tends towards feeble- ness, 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 re- production 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 con- nected with 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 general 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 com- bining them into a distinct judgment. From this there results, on the one hand, the impossibihty of all abstraction, and, on the other, an external incoherence in the associated images and ideas which

342 STATES OF MENTAL WEAKNESS.

proceed from accidental impressions of sense, or according to the merely external connection 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 ])ainfully feeling their own inability to direct themselves aright amidst these broken remains of psychical life.

Special fixed ideas, true delirious conceptions, are never produced anew in dementia ; those which formerly existed become with the increasing 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 excitement 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 ideas of their own greatness and large possessions (thousands of millions, diamonds, worlds, &:c.). 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 normally ; the patients see, hear, &c., correctly ; but the elaboration and transformation of the sensorial impressions into adequate ideas in the brain no longer proceeds properly, or — and, indeed, ordinarily — hallucinations exist M'hich, along with the ideas, share the cha- racter of incoherence, 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, ges- ticulating with the hands and making odd automatic movements.

STATES OF MENTAL WEAKNESS. 343

Their demeanour 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 loath- some things. Very many of these patients who have been long confined in the asylum are addicted to onanism, and we may fre- quently gather from their conversation indications of considerable disorder of the sexual functions — a circumstance which ought to receive immediate and farther 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. Remissions occur in such a manner that quieter and somewhat more rational 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.

ExAMFLE XLIX. — Transition of monomania into complete dementia. — Julia bad but one idea, and tbat 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, My 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 one has stolen both my gold and my jewels,"

" Who took them from you ?"

" Ask your own thoughts -. I am not the cuirassier woman — T 'am tlie Almighty."

311 STATES OF MENTAL WEAKNESS.

" Since wlien 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 reniembranee of the past, and very little of the present. She is only capable of the simplest acts — making her bed, putting on her clothes, eating 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, &c. (Leuret, 'Fragmens 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 occur- rence 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 always 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 elaborated, 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 patients even in the most favorable cases can employ only a few current, very hmited, and little applicable expressions ; more frequently the few words that remain arc only automatically re- peated, or the words themselves are not entire, but are merely ejaculations of accustomed sounds. This very high degree of dulness 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 rather 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

STATES OF MENTAL WEAKNESS. 345

— swaying to and fro of the body, rubbing the hands, murmuring, making unmeaning noises, Szc. The gestures are lifeless — the countenance is relaxed or amazed, or apparently attentive 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 particular persons ; of the sense of shame, of childish pleasure in mischief, of anxiety (hiding themselves), &c. In their better moments, there come back to them reminiscences of former hfe, 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 unfor- tunates, whose silent, inexplicable gestures often, unconsciously to themselves, reveal a melancholy past.

Serious disorders of the 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 patient 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, &c. 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, gangrene of the lung, tuberculosis, intestinal catarrh. Some die from want of proper care, owing to retention of urine or of fsecal accumulations, or in consequence of accidents, burns, choking by taking too large mouthfuls of food, &c.

Senile dementia, too, terminates ia the way we have just described, as also many analogous conditions sometimes observed in the prime of life, and pro- ceeding from 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 excessive mental and bodily exertion and irritation. It is often very

316 STATES OP MENTAL WEAKNESS.

difiBcuU to distinguish the commencement of these conditions from mental ex- haustion 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 conclusion can be arrived 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 along time preceded an attack of apoplexy or of encephalitis, generally depend upon disease of the cerebral arteries,

Section IV. — Idiocy and Cretinism.

§ 155. By the term idiocy, we are to understand those condi- tions in which a state of mental weakness lias existed from birth or from early infancy, and in which the jjsyc/iica I develojiment 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 cor- responding to their age and social position.

TThilc psychologists are generally agreed as to this definition of idiocy, they are, on the other hand, farfrom 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 plnjsical 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 : never- theless, 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, but especially in mountainous districts, as a widely spread disease depending upon local causes. The prototype of this form is alpine cretinism, and may be desig- nated by the term cretinism in the restricted sense of the word. It will be afterwards described. This form is always endemic ; oc- casional 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, \st, the more severe cases of

STATES OF MENTAL WEAKNESS. 347

intellectual nullity — dementia^ fatuity; and, ^ncl, the less severe cases of simple mental weakness — weakness of mind, imbecility. In cretins the degree of intellectual disorder (viewed general!}/) 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 inter- mediate degrees into the state of health without any distinguishmg 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 Wieu/ i860, 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 edu- cation and instruction."

In sporadic idiocy, the physical conformation may be 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 de- velopment is generally involved, in particular it is often far behind the age of the patient ; the forms, especially of the liead and face, are incomplete and far from beautiful ; but in sporadic cases we never find those well-marked and pe- culiar defects in the physical conformation which, owing to the extensive anomalies found in several organs (for example, in the thyroid gland), may be considered 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 it found in Zillner an original and well-informed advocate.

A. Miocy in general.

§ 156. The essential character of all idiotic states is weahiess of the intellect, as the fundamental faculty of the mind ; a weakness which in many cases may be recognised in all the phases of the mental life equally, while 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 circumstance that the Aveakness of perception is itself the fundamental disorder, idiocy is entirely dis-

348 STATES OF MENTAL WEAKNESS.

tinguislicd from the psychical imperfections dependent upon de- ficiency of the senses, such as deaf-dumbness. From the cir- cumstance that this weakness comes on at an early period of life, and that therefore the psychical development is annulled, or at least much retarded, it is distinguished from dementia developed during the subsequent years of life when, as is indeed very often the case, the 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 bevond doubt that the weakness of the intellect, and there- with the arrest of the psychical development, depends upon a cerebral anomaly. This fact is, in general, much more capable of being directly proved and demonstrated than in other mental diseases. In many cases of idiocy there may be observed consider- able 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 dcGcient mental development is the direct result of deficient cerebral development in childhood, and that it is in proportion to it. Nevertheless, evident and palpable changes in the brain or its membranes are not always found in idiocy, and we are impelled, by numerous facts, to the assumption that there are also idiotic states whore the weakness of perception does not depend u})on 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, com- menced at a very early period, have induced 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 stationary from want of any external mental impulse — from extreme neglect and inattention, association with other dements, unfavorable outward relations, &c. ; finally, certain cases where the mental development does not pro- gress, 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 intluence, even by any hvely sensorial impression, so that development of tlie normal process of perception is rendered impossible. Al- though few of the latter cases originally belong to the idiotic states.

STATES OF MENTAL WEAKNESS. 349

still tliev have the same practically important result — arrest of mental development. But these cases of merely functional cerebral disorder, which at the commencement constitute a more apjjarent 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, those cases which now and then occur of great dulness or absence of emotion, existing from early infancy, and which are manifested in a precocious perversity of the desires, often as rudeness, wickedness, savageness, &c., do not belong to idiocy, although they are in a certain sense psychical defects, and are sometimes spoken of as cases of moral idiocy, stunting of the sentiments, &c. 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 the various cerebral diseases which form the organic basis of idiotic states correspond in many relations 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 famiHes where epilepsy, mental diseases, paralytic affections, deaf-dumbness, are frequent, idiocy is also obsen'ed to be common. Frequently it occurs as a mere partial phenomenon, as an individual manifestation of a general deteriora- tion 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 other form of degeneration ; indeed, in certain cases this may be recognised 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, &:c. 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 the various children, the state of health of the parent may sometimes increase, sometimes consider-

350 STATES OF MENTAL WEAKNESS.

ably diminish, tlie influence of the constant (tending to degeneration) causes.

The shallow doctrine which has recently been promulgated, that mental disease, drunkenness, &c., of the parents, does not so much influence the germ as it favours the development of the idiocy — that, under such relations, the care and education of the children must necessarily be neglected — can easily be refuted by the results of observation of idiocy in the higher and even the highest ranks of life. This hypercritical questioning the hereditarincss of idiocy can, generally, only lead from the way of truth (see §§ 92 93), and its hereditarincss may be accepted in the same wide sense as that of other mental diseases (§92). In a case which came under my observation, the father of a highly idiotic child sui'- fered from violent periodic headaches, during which he sometimes quite lost his senses : the brother of the father was likewise disposed to frequent headaelies (see § 92). In another case which I observed, the father of an idiotic boy lived in a habitual 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 foetal period. During this period various errors of development and diseases of the brain and its membranes may occur, to which some- times external injuries may give the impulse, for which, however, much more frequently, no direct mechanical cause can be discovered. Great antemia 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 eff'ect.

Far more frequently, however, those diseases which lead to idiocy (also those which are hereditary) do not commence till after birth, from then till within the third or fourth year ; in exceptional cases, till the 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 nutritient 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 wliich compress the head ; the nse of opiates ; injuries and shocks to the head, and other injurious influences of a Uke nature ;^ other

' See Kostl, 'Der endemisehe Cretinismus,' &c., 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 upon ignorance of the

parents or guardians, or upon popular opinions.

STATES OF MENTAL WEAKNESS. 351

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 affections. The influence of early commencing epilepsy, or irritation of the sexual organs at an early age and its consequences, and, finally, the influence of total mental neglect and association mth other idiotic children, is likewise not to be lightly estimated.

Finally, there are a series of powerful local causes, peculiar to certain locahties, which we at present must consider to be miasmatic in then* nature : with the progress of science, however, we may be yet able to analyse the individual circumstances. These causes lie at the foundation of endemic cretinism, and will be afterwards con- sidered 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 analogous action ; the long-con- tinued residence of young children in such chambers is therefore especially injurious. The '^ cretinism of large towns,^-" amongst the inhabitants of low-lying, overcrowded, badly ventilated, cold houses, is certainly to be in part attributed to miasmatic causes — together with a number of other co-operating influences. Miasmatic causes act more upon the origin of diseases of the cranial bones than upon affections of the brain itself or of its membranes ; they act partly upon the foetus, partly upon the child after birth.

§ J 58. "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 loliat 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, &c., with the different kinds of mental defects. TTe 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 anatomical diagnosis during life.

' Erlenmeier has recently published the case of an idiotic child, where the cranium presented numerous exostoses, and wlio recovered under the influence of iodide of potassium. The case of Guislain (' Lep. or.' ii, p. Q)^)., 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 ciuestion of the influence of syphilis.

352 STATES OF MENTAL WEAKNESS.

Nevertheless, we soon become convinced that, with our present material, certain by no means unimportant results in these direc- tions may be arrived at (see § i66), but the principal part of the work cannot at present be undertaken. In a great number of the cases now under consideration, the psychological analysis is so defec- tive ; 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. Tor the practical anatomical diagnosis, however, we must depend more on the results afforded by direct examination of tlie head, on the etiology and on certain raotory 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 development , 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 par- ticular, 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 may be 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 fundamental process, is, as far as possible, to be maintained. In the following enumeration of the anomalies which, according to experience, are presented in idiocy, we shall endeavour, as far as possible, to carry out this distinction.

§ 159. Of these anomalies, /JOirr/y of the brain, in its various modifications, takes the lead. Abnormal smallness of the entire brain (generally well pronounced in the convolutions), with micro- cephalus, is to be regarded as an arrest of development, of which the source is sometimes in the brain itself, and sometimes in the cranium.

' We expect to receive information on these points from the idiot institutions, just as correct ideas regarding mental disease were first received from the asjlums.

STATES OP MENTAL WEAKNESS. 353

The latter appears to be the more common, and it is principally the premature ossification of the entire cranium which confines the brain and prevents its normal expansion. Very early occlusion of the fontanelles (which is sometimes even complete at birth), prema- ture 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 cerebral development is greater according as the compensation which occurs through the expansion of other parts is less. In the other, less immerous class of microcephalics, all the cranial sutures remain, even to adult life (whereby the cranium may be either well proportioned 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 simply small — a miniature brain, without other anomaly or defect, and properly proportioned in all its parts : more frequently, there also exist other changes, particularly scleroses, hydrocephalus, unequal size of the hemispheres, or other form of dis-symmetry.

In many raicroceplialics the brain is even smaller than might be presumed from the external aspect of the cranium, owing to tlie occasional enormous thickness of the bones of the skull, and to the occasional existence of a considerable amount of hydrocephalus.

Baillarger ('Acad, de Med.,' 29 Jul., 1856) has reported cases in which the fontanelles were, even at bbth, 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 rare. 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 years of age, had been epileptic 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 inclined 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 which had belonged to an idiotic woman, twenty-one years of age (weight of the brain, 36 loth — about 18 ounces — the left hemisphere 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, pos- teriorly 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

23

35^! SiA'iES Uh" MENTAL WEAKNESS.

a female Aztec child (§ 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 eight mouth.

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.

Ill idiots the brain is frequently diminished in volume in certain partSj or it may even present certain defects. The following are the principal varieties: — Sometimes the cerebral hemispheres are imperfectly developed in certain pio-rts, most frequently in the anterior lohes (when the antero-posterior diameter of the cranium — as frequently happens — is diminished^ the cerebral hemispheres are necessarily shortened, but this is generally most strikingly mani- fested in the anterior lobes), w^hen there is often remarkable stunting of the olfactory bulbs, sometimes also of the posterior lobes, when the cerebellum is not so completely covered as usual or not com- pletely covered by the cerebrum ; those parts which are insufficiently developed may present few but moderately developed convolutions, or they may be very small, as if atrophied, or as if they remained at an early childish stage.^ Inequalitj/ of the two halves of the brain, particularly of the cerebral hemispheres, must not be attributed to hypertrophy of the 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, apoplectic, or other processes, of which palpable traces may sometimes subsequently be found (brown or yellow spots, small deficiencies in the cerebral substance, Src). In this respect all degrees exist, from the slightest shortening to the state where a whole hemisphere has almost totally disappeared, and is transformed into a meshwork filled with serum ; even in moderate degrees, the sub- stance of the lesser hemispheres is often changed, coriaceous, compact (sclerosity), the lateral ventricles dilated, the choroid plexus thick- ened, &c. The dis-symmetry frequently extends to the cerebel-

1 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, ex- hibited 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.

STATES or MENTAL AVEAKNESS. 355

!um, 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 atrophy is some- times on the same side as the atrophied cerebral lobe, sometimes on the opposite 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 airophy of the medulla oblongata and inequality and asym- metry of many parts of the base of the brain in idiots. These, how- ever, will appear more important in proportion as the osseous basis cranii is, through recent investigations,- recognised 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 fibreus. of Foville, coming from the corpus restiforme) was much more pronounced, sepa- rated 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 uugleiche Grosse beider Hernhalften,' Wurzburg, 1831, there are many analogous examples of inequality of the two halves of the pons Varolii, of the two sides of the spiual cord, and of the two olivary bodies. The same condition has been observed by Valentin in an idiotic child from Abeudberg : anomalies also in the pyramidal and olivary bodies were seen in a case by the Sardinian Com- mission on Cretinism (' Rapport,' &c., 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, &c. Cases of spina bifida together with hydrocephalus have also beeu observed.

Heschl ^ has described, under the name of porencejphaliis, those cerebral defects in which a large portion of the convolutions and

* See Virchow, 'Entwicklung des Schadelgrundes,' BerliOj 1857, ?• ^'4- ■ 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 me- dulla oblongata, and the fourth ventricle, may originate through spheno-basilar synostosis.

3 Prager, ' Vierteljahrschrift,' Bd. Ixi, 1859, p. 59. A self-observed and three other cases.

356 STATES OF MENTAL WEAKNESS.

ccutrum 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 ])ia mater; sometimes the corresponding part of the cranium projects outwards.

PorencepbaUis does not appear to be produced by actual arrest of develop- ment of the affected part of the brain, but rather by an intra-uterinc disease which at a very early period destroys the part. In nearly every case of this kind there is idiocy, with 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 one side of the skull, the existence of this lesion may be pre- sumed (Hesehl). Tiingel (' Clin. Mittheil.,' Hamburg, i860, 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 mentioned numerous, more localised, cerebral defects, deficiency or extraordinary smallness of the most varied structures of the orscan: indeed, there is scarcely any portion of the brain which has not been found either altogether absent or quite rudimentary in these crea- tures. Thus, there are examples of absence of the entire cere- bellum •} of deficiency of the pineal gland ;~ of defects of the fornix (Xiepce in several of his autopsies) ; of a rudimentary condition of one or of both olivary bodies, peduncles, corpora mamillaria, thalamus and corpus striatum ; of atrophy of the optic commissure, deficiency of the auditory nerves (Valentin) ; finally, of absence or rudimentary state of the corpus collosum : 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 ano- malies were presented by the brain. To these belong — ist, the case of Bianehi (1748, quoted by Forg) : 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. 2nd, the case of

' 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 pituitary gland was absent ; in its place were two concretions, hard like stones. Tlic subject had been weak-minded from birth, and died at the age of twenty-nine.

STATES OF MENTAL WEAKNESS. 357

Forg ('Die Bedeutung desBalkens,' &c., Miincheu, 1855 : girl, seveuteen 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 foruicatus, only a rudiment exists ; the island of Reil is considerably atrophied ; th>j convolutions are abnormally grouped, many of them entirely absent ; the lobes of the cerebellum are unsymmetrical ; hydrocephalus. 3rd, the case of Chatto ('London Medical Gazette,' vol. i, 1845) '• f^^^i^d 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 which hang in front from each hemisphere ; hydrocephalus. Finally, several of the nine autopsies of cases of endemic cretinism by Niepce ('Traite du Goitre,' &c., 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 other 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 pecu- liarity, 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 fornix were absent. Case of Mitchell Henry ('Med.-Chir. Transact.,' vol. xxxi, 1848, p. 239: a boy, aged fifteen, gentle, but slow to learn, dull, sleepy, much disturbed when rapidly spoken to ; the brain normal ; the corpus callosum represented by a horizontal band of fibres, i| inch broad ; the septum and middle anterior part of the fornix absent. Case mentioned in the Report of the Vienna Asylum for 1858 : a man, aged twenty-five, in his twentieth year became epi- leptic in consequence of a fright, and since then has gradually fallen into dementia ; the corpus callosum absent, the anterior commissure incomplete ; hydrocephalus.

§ 160. To the anatomical lesions most frequently met with in the brains of idiots belongs chronic hjdrocepTialus, congenital or com- mencing in early youths 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 hydroce- phalus seems to constitute the primary and chief disease ; this may be assumed in those cases especially where the ossification of the

358 STATES or MENTAL WEAKNESS.

cranium takes place slowly, where the bones of the head remain thin, Avhere 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 second- ary ; 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 complication of various malformations of the brain. A convincing example of this is afforded by the unilateral hydrocephalus in atrophy of one side of the brain. In all these cases the cranium may be of the ordinary circumference, or even (and very often), as we have abeady 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 performing its function.

Rare but very interesting malformations of the head are caused by partial hydrocephalus, by great dilatation of the lateral ventricles in only one part (for example, the inferior coruu). Should this occur at a period when tiie skull still consists in part of the membranous elements of the cranial bones, symme- trical protrusions are formed, in consequence of the eccentric pressure exercised on the corresponding portion of the brain, sac-like prominences on the skull. See Willigk, Prager, ' Vierteljahrschr.,' Bd. 1, 1855, p. 30; Lambl, sec § 161. A very remarkable and very rare fact which has been observed by Valentin and Nicpce is the presence of a fifth ventricle within the olives of the cere- bellum (ventric ciliaris, normal in the brain of birds). In the first case (from Abendberg) the ventricle was from i to i^ inch long. Those idiots with considerable hydrocephalic enlargement of the cranium generally re- main 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 body and pleasant features. The causes of these differences would form an interesting subject of study.

lEncephalitic proccBses of variable extent, sometimes localised, some- times more diffused and terminating in different ways, but especially in sclerosis and atrophy 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 difficult to distinguish, and it is prin- cipally through cicatrices or other thickenings, through pigmenta- tion, iHrc, tliat the atrophied parts (sometimes a whole hemisphere)

STATES Of MENTAL WEAKNESS. 359

can be distiuguislied from structures siraply arrested in tlieir develop- ment. In these cases the idiocy is very frequently accompanied by a unilateral motory affection (paresis, contraction), and sometimes by epilepsy. The diffused hypeiirojiJiie of the connective tissue of the brain -^vhich may, generally speaking, be referred to chronic ence- phalitis, and which is often found in paralytic dementia, has been proved by certain "well-marked examples to occur in idiocy.

Isambertbas communicated ("Soc. de Biologic," 'Compt. rend. etMem.,'ii, 2, 1856, p. 9) an interesting case of tliiskind whicb was examined microscojjically by Eobin : it occurred in an idiotic child, two years of age : the ventricular walls, the great ganglia, the pons and peduncles were solid and hard ; their tissue was elastic like caoutchouc, the nerve-tubes in the white substance were almost completely 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 re- covered, but the intellectual development remained at a standstill ; speaking and walking, which it had recently commenced, become diflacult, 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 ossification (inflammatory) of the sutures of the cranium or with the general development of the iufantUe brain, and very frequently leave behind serous efi'usions, or a disposition to the gradual development of hydroce- phalus. Or they are states of encephalitis, which, after the passing off of the acute stage (with swelling of the brain, &c.), involve or suspend further deve- lopment in the affected parts, and may often be recognised long after in their results at the autopsy. These processes may be assumed, above all, in cases where one side of the body is a little less developed than the other, where con- vulsions, pai-alyses. contractions, kc. 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 Cerveau,' Par., i859,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 cf 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 articulate 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 colour externally, internally of a dull white colour ; the left middle

360 STATES OF MENTAL WEAKNESS.

and anterior lobes were also smaller than ordinary ; the right posterior lobe was likewise a little diminislied and slightly sclerotic ; the optici were indurated. The sclerosis and atrophy of the brain were evidently the results of an ence- phalitic process consecutive to measles.

Hypertropliy of the brain occurs much less frequently in idiots than do the various alterations which we have enumerated ; it is im- possible to distinguish it during life from hydrocephalus distending the cranium, as in both cases the head is large and the ossification imperfect, and — which is interesting in many ways — the base of the cranium is not extended, but rather shortened, or it presents 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 1305 grammes (or more than the adult average) ; and another case of a child (' Gaz. hebdomadaire,' 1859, No. 6, p. 93) in whom the body weighed forty-six pounds, and the brain 1160 grammes. Bricquet, Delasiauve have recently reported analogous cases.

A remarkable appearance, and one which has hitherto received very little attention, is the unusual abundance of grey substance (in the ordinary localities) which has been remarked by various ob- servers (Stahl, R()sch, Niepce — seventh and ninth autopsies) in the brains of certain idiots, the amount of the grey substance being greater than that of the w^hite. Occasionally, new formations of grey substance are found in ])arts where in the normal state it does not exist (Virchow found this in an epileptic idiot — I once saw it in an epileptic, of Avhose mental condition there was no information), finally, the reports of several autopsies mention the interesting fact of hypertrophy of the pituitary body (Xiepce, Bergmann). We may here very properly doubt whether these were cases of true hy- pertrophy, 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 (Xiepce's second autopsy) .

§ 161. We noAv pass from the anomalies of the brain itself to the consideration of those of the cranium. These occur very fre- quently, 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

STATES or MENTAL WEAKNESS. 361

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 tliis subject. 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 auy pathological museum. See Malacarne, in P. Frank, * Delectus Opusc. Med.,' vol, vi, lie. 1789, p. 241 ; Ackermann, ' Ueber die Cretiuen/ &c., Gotha, 1790; J. and E. Wenzel, 'Ueber den Cretinismus,' Wien, 1802; Stahl, 'Neue Beitrage,' &c., Erlangen, 1848, 2nd edition, 1851 ; "Cliuische Studien," &c., ' Zeitschr. f. Psychiatric,' xi, 1854, p. 545; ibid., xvi, 1859,'p. ^ ; Virchow, ' Wiirzb. Verhandl.,' 1851, 1852, 1855, 1856, and ' Gesam- melte Abhandl.," Frankfurt, 1856, p. 891; ' Untersuchuugen iiber die Ent- wickelung des Schiidelgrundes,' Berk, 1857 ; "Ueber Knochenwachsthum und Schadelformen," Yirchow's 'Archiv.,'xiii, 1858, p. 323 ; Luca, 'Zur Arehitectur desMenschenschadels,'Fraukf., 1857 ; Gratiolet, "Mem. sur la Microcephalie," 'Journal de Physiol.,' ix, Jan. i860; Lambl, ' Aus dcm Franz-Joseph-Kinder- spitale,' &c., Prag, 1861.

We shall not occupy ourselves with those alterations of the cra- nium which are at present of little interest in connection with idiocy, such as the frequent partial aiienuations , and the still more frequent, generally much less general, th'ichen'mgs 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 persistence, even to adult life,^ of the fontanelles and such-like : but the principal object of our study is the consideration of those deviations in the development and growth of the cranium wliich impart to it abnormahties in form. We must here consider, especially — ist, anomalies of the arch^ and, 2nd, 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 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, &c. Many cases of simple microcephalus belong to this form of anomaly; perhaps, also, many unilateral stenoses of the cranium, owing to closure of the sutures with

^ Stahl (' Neue Beitr.') found this in a man Dfty years of age.

362 STATES OF MENTAL WEAKNESS.

inequality in' size of the two cerebral hemispheres : in this case the ossification of the sutures is not the cause of the malformation, but appears rather to constitute the last stage of the changes. In these limitations from an internal cause, from the contents of the cranium owing to irregular development of the brain there are frequently formed a number of closed sutures — a circumstance of great import- ance in the determination of these relations : there result from this, 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 devia- tions in form of the cranial arch are primary and independent of its contents — of the development of the brain. These depend, especially, upon mterruidhm of the groioih of the bones ; and this, again, often appears to be o^ving to simple deficiency and incompleteness in the 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 morbid, appa- rently inflammatory, process in the sutures, the process by wliich the normal growth of the cranial bones proceeds, and which termi- nates in occlusion of the sutures. Thus, in whatever way a suture is prematurely ossified, the cranium becomes narrowed at that point, because the growth of the bones, which takes place at the suture, is arrested, and, of course, always in a direction perpendicular to the suture. This limiting of one part may, when it is considerable, extend its influence far beyond the part : thus, for example, very early synostosis of the arch of the cranium also afi"ects 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 w-here it meets least resistance, because there the sutures are more distended by the growing brain, and consequently present more points of ossification, and perhaps there is a tendency even to exuberant growth. These so-called compensations correct the contractions in the cranial ca\nty, 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

STATES OF MENTAL WEAKNESS. 363

appear principally to depend upon an active growth of the brain, andj consequently, in these changes in form we have not solely to do with purely mechanical relations, but with a far more intimate nutritive relation connected with the condition, with the power or weakness of the general physical nutrition. In all considerable ossifications of the sutures, the compensations are seldom sufficient for the complete development 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 forma- tion of the so-called encephal'dic 'protuberances (Lambl) — protuberances on the skull, especially in the neighbourhood of the sutures and fontanelles. These always 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 tlie formation of greater or smaller deficiencies in the osseous cranium.

The deformities produced by these stenoses may be referred to several 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 microce^hahs : if the base of the cranium becomes also ossified, or should no compensation be formed there, tlie entire cranium, though small, is properly proportioned; but the growth of the brain is also uniformly and most profoundly dis- turbed. Should^ on the contrary, a great compensation be made by the ossification of the basis crauii being rendered unusually slow, and consequently a much greater expansion of it rendered possible, there appears to originate from this a special type of physiognomical and physical development, and also of intellectual life, which we shall afterwards describe more minutely under the name of the Aztec iype. Merely partial occlusion of the sutures of the arch of the cranium determines the following principal forms : — Too narrots crania {i. e., when the transverse diameter is shortened) are caused principally by early ossification of the sagittal suture ; more rarely, and rather with contraction of the frontal than the parietal region, by ossification of the spherno-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, considerably 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

36 A STATES OF MENTAL WEAKNESS.

the occiput. Too short crania are caused, behind, by ossification of the lambdoidal suture (the highest degree of absence of the pos- terior portion of the cranium causes the rare ape-Hke form of the so-called mask), and here compensation often takes place by development of the region 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 low crania are caused by ossification of the wings of the sphenoid with the frontal bone and squamous portion of the temporal bone. Finally, the unsym- metrical obliquely narrowed crania are caused by unilateral ossifica- tion, anteriorly through ossification of one half of the coronal suture, 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 the development of the corresponding portions of the brain : for example, unilateral stenoses are apt to cause shortening of one of the cerebral hemispheres, &c. 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, moreover, that dis-sjmmetry (and deformity generally) may be caused not only by partial stenoses, but also by local expansion ; namely, by the immoderate development of ossa Wormiana : in particular, a special form of elongated cranium appears to be produced by the plentiful formation of Wormian bones.' According to Lambl (1. c, p. 26), scolioses of the cranium originate also in rickety children through displacement, owing to softness of the bones and long continuance of the sutures : finally, there also appears to be sco- lioses 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 this kind upon the development of the bones of the base of the cranium are, as yet, almost unknown, and all the changes which occur in this part of the cranium, when not compensatory or consecutive to changes in the arch of the cranium,- are in the present state of science to be considered as

' Virchow, ' Gesammelte Abhandlungen,' p. 902.

'■^ 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 crauium.

STATES OF MENTAL WEAKNESS, 365

primary and independent 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 depend upon the persistence of the cartilages ; and the premature ossification of these cartilaginous surfaces arrests the longitudinal development of the bones which enter into the formation of the base of the cranium, which must, of course, produce shortening of the base. More rarely, the ossifica- tion of the cartilaginous disc between the primitive anterior and posterior portions of the sphenoid bone produces 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 fifteenth 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 short- ening 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 intra- uterine life ; namely, a great curvature upwards of the base of the cra- nium, a small angle at the point of union between the sphenoid and the basilar portion, a steep clivus : further, this shortening causes malformation of the face (cretin physiognomy), which is character- ised 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 pro- minent (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 lessen- ing of the great wings, and of the central cavity comiected with them. There is thus produced through this — together with a probable unfavorable influence upon the development of the pons Varolii and medulla oblongata from the abnormally formed clivus — arrest of development of the anterior and middle parts of the brain. Actual microcephalus may now exist ; more frequently this is not the case, and there are produced various compensations, which, however, are not complete, probably on account of the deficient development of tlie brain. These compensations are produced partly by growth of the cranium upwards (conical heads), partly by elongation of the arch

366 STATES OF MENTAL WEAKNESS.

of the cranium with persistence of the frontal suture, or, finally, by moderate dilatation of the superior and posterior parts of the head.

The tribasilar sinostosis forms the anatomical foundation, and, as it appears, the sole point of origin of one special form of cretinism which is specially repre- sented in Alpine cretinism. Several of the older observers had already arrived at tlie perfectly correct conclusion that the fundamental lesion in this form is in the base of the cranium, and had very nearly come to the correct idea upon the subject. Ackermann said (1790), 1. c, p. 33, "It is solely on the lower part of the basis cranii that the abnormal change exists -which essentially constitutes cretinism;" and in page 119 he says, "it is this slight altera- tion 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 fundamental changes chiefly involve the base of the cranium," &c. : 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 neg- lected in the subsequent investigations regarding cretinism. Stahl revived it (1848). The actual state of matters in this fundamental deformity of the basis cranii was, however, for the first time clearly elucidated by the investigations of Virchow. This observer has also shown that complete synostosis of the two parts of the sphenoid bone and the basilar portion may even occur during fcctal life, in which case the newly born child will present in 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 (as also in certain healthy persons) the sphenoid and the basilar portion not yet ossified after the age of twenty (Niepce, 1. c, ii, p. 118, 6th section;^ Stahl, 'Neue Beitrage,' p. 70; 'Ztschr. f. Psysch.,' Bd. xvi, p. 368). The basilai- synostosis gives rise to a special but very frequent form of cretinism, possessing the pecuhar physiognomical expression, and — to which the small size of body, the frequent complete dwarfishness, points — the cartilaginous epiphyses of the long bones of the extremities seem also to experience a similar arrest of develop- ment 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 iu many microcephals, to the afi'ection of the brain, but to a constitutional malady

' It is worthy of remark, that in these cases the penetrating body was greatly hypertrophied, and contained a cavity in the centre ; while in Virchow's case of a newly born cretin with complete synostosis, the pituitary body was yery small — almost atrophied.

STATES OF MENTAL WEAKNESS. 367

to'Uh premature ossification of the cartilages — to an affection wliicli ia many re- spects is diametrically opposed to rickets. Trae rickets has never been observed to pass into cretinism ; a circumstance of great importance in the treatment of these conditions.

The types of cerebral abnormalities wliicli correspond to the various deformities of the cranium which have been described are as yet very incompletely 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 phenomena are very different in their nature; they cannot be referred to one type, nor to a single fundamental process. "We must also carefully guard against recognising in the special nature of an anomaly which is presented to us — for example, in hydrocephalus, or in a deficiency in the commissural system of the brain, — the immediate anatomical cause of the psychical disorder in question — of the idiocy. This anomaly, or this defect, may perhaps have no influence in regard to the special ])sychical disorder, and the latter depends upon the mode in which the existing, apparently quite normal, 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 what the elements are which gradually contri- bute 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 influence upon the development of the functions of the brain wliich relate to sensation and movement, may withdraw what is essential to the development 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 foetal diseases, synostoses, &c.) ; in regard to the cases of deficient development,

368 STATES OF MENTAL WEAKNESS.

there is a circumstauce which seems to me to deserve more considera- tion than has yet been accorded to it, namely, that of abnormal narrowness of the cerebral arteries, -which may be either a primary defect in development, or the result of an abnormal state of the bones M'ith contraction of the foramina (contraction of the carotid canal from abnormal state of the sphenoid bone ?).

This contraction of the arteries was very prominent in the anterior Sylvian fissure and on the basilar portion in several of Kiepce's cases; in three cases of endemic cretinism, also, the vertebral and basilar arteries were very small. (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 arteries, will not less compensation be required ?

§. 163. As all the various diseases of the brain and its mem- branes which occur during intra-uterinc 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 anomahes 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 dis- turbed. Here, therefore, we must content ourselves with a general consideration of the disorders of the mind.

Anomalies of percejHion. — In severe cases, the sensorial impres- sions 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 sen- sorial 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 Avhich render them a part of our inner consciousness ; 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. AVe observe, also, loss of the powers of atten- tion and reflection ; they have no memory, no mental spontaneity : in

STATES OF MENTAL WEAKNESS. 369

extreme cases we can discover no germ of individuality which might be compared to the healthy ego; no trace of a mental personahty.

These defects in concrete cases are uot only manifested in various ways, but the phenomena themselves may also be altogether different : in the one, that 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, &c. 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 dream, are completely strange to all that goes on around them, and show no other spontaneous sign of life than devouring the food which is placed in their mouths. The animal perceives the external world ; it is complete in its special organisation; it is capable of expressing its impres- sions, its sensations and desires, with the means of gratifying them. In this respect these poor idiots stand far below the healthy brute, but without on that account — which very curiously is possessed even by them as a leading charac- teristic— 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 pene- trates 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 recognise their attendants, the prepara- tions for meals, &c. ; they feel a desire for muscular motion, which is per- formed in the most uniform manner ;i gradually acquire a mechanical knowledge of certain words, orders, &c., which they execute 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 recognised 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 conclusion that in cer- tain idiots there is more received into the mind and there elaborated 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 com-

1 I know a boy, fourteen years of age, a little microcephalic but otherwise well formed, who,"every day all day long, pushes out and in a drawer, and rattles two keys.

2 See Niepce, ' Comptes rendus,' 37, 1853, Ko. 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 uot the slightest attention.

24

370 STATES or MENTAL WEAKNESS.

plete 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. But that prompt, involuntary blending of the ideas, by Avhich 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 in- vestigation, 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 capa- bility 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 ac- complish several mental processes at the same time or in rapid suc- cession is impossible : therefore, the understanding is in general slower, the judgment uncertain and diffident ; the sphere of compre- hension 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 performing that sort of work which exercises the imitative rather than the initiative faculties.

The remarkable one-sided aptitudes and talents occasionally dis- played in the shghter degrees of idiocy are rather of a semi-con-

STATES OF MENTAL WEAKNESS. 371

scious iustinctive 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 cor- rect and evident manifestation — mechanical, musical, arithmetical talent, memory for words, signs, &c. TTe never find these special aptitudes in cases of idiocy occurring accidentally, occurring in once healthy children in consequence of cerebral disease in early youth, but only where the disease is hereditary or endemic.

In the beautiful asylum for idiots at Earlswood^ 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 liad in particular no icka of numbers. We frequently see persons in profound idiocy execute (purely mechanical) curious works of design and painting. Morel ('Etudes Clin.,' i, p. 49) cites the remarkable case of a speechless idiot who had a special gift of playing on the drum ; his grandfather had been drum-major and his father drummer in a regiment, his brother had always had a desire (which, however, was not grati- fied) to become a drummer. The remarkable 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 well cared for, with whom persons have taken some trouble, whose minds have been properly directed, behave very dififerently from those whose education has been neglected, and wiiose minds have been excited, although the cerebral disease may have been quite as severe. We observe also that, in the cretin districts, those who roam about, who go about the villages begging, &c., 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 -consciousness, 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 excitations 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, &c.), are entirely connected with bodily sensations, or they appear to originate immediately, entirely without 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 respect

372 STATES OF MENTAL WEAKNESS.

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, oil the other hand, those who, with absolute want of intellect, constantly exhibit a joyful and gay dis- position,— who, with always — about nothing — laughing features and good-humoured eyes, bear the expression of good-nature and com- placency. In profound idiocy the efforts and determinations are j)rincipally set in motion by the instincts, above all by the instinct for food ; most of these acts have the character of half-conscious retlex actions ; certain simple ideas which have become persistent — for example, pleasure in playing with httle strips of paper, &c. — can again excite vohtion. 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 effo, or at all events merely a trace of it, and in many cases — but not belonging to the most degraded class — we arc frequently led, on observing their instinctive acts, to ask ourselves. Is there anything 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, grunting noises, &c. ; those a little higher in the scale move their hands and lips in a certain manner, or weep till some food is given them ; they " tcanf to be fed. In the lowest forms we also occasionally see rapid changes of humour, occur- ring without external motive ; for example, at one time the expression of fear, of wish to go away, or sudden aversion to an accustomed amusement, or they become angry at it : this anger is often very violently expressed by scratching, throwing the arms about, biting, &c., even to actual mania. Those capricious emotions observed in certain individuals are quite inexplicable, as, for example, the appearance of all the signs of joyful excitement whenever they see a piece of paper, or the manifestation of the most tender regard towards some particular child, while they appear to take no notice of anything else; a good-humouied idiot, when taken ill, commencing to scold himself, to knock his head against the wall, &c.

In the slighter cases, inconsistency and dulness of the emotions, and weakness of will, are also general characteristics : the disposition, therefore, very much depends upon the sun-oundings, and the treat- ment 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 malicious ; in some there habitually exists a melancholic or more excited frame of mind. In the localities where

STATES OF MENTAL WEAKNESS. 373

cretinism is cudemic, we seldom observe anv agreeable traits of character in these idiots. The higher degrees are characterised 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^' (Maffei), are still incapable of any real affection, or even attachment, or, indeed, of any human feehng ; they are rude egotists, whose desire for idleness can only be overcome by force, or by tlie prospect of enjoyment.

§ 165. The anomalies in the senses and in the movements ob- served in a great number of idiots are extremely important. In severe cases these, especially the latter, are always present, although in very ditferent degrees ; 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, how- ever, it is very difficult to distinguish whether actual deafness exists, or only complete want of attention. SmeU 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 impres- sions of smell, and likewise of taste, so that they put the most unclean things into their mouths — eat nettles, excrement, kc. Others exhibit a special aversion towards certain kinds of food, as beef, and will eat only milk and bread, and such like. The cuta- neous 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 unfrcquently resemble chorea. But the most serious of all are the epileptiform convulsions, which constitute an extremely fatal complication, and one which is very unfavorable in a prognostic

374 STATES OF MENTAL WEAKNESS.

point of view, and extremely frequent in severe cases. Frequently, the acute cerebral affections (§ ^6^) 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 generally a symptom of the disease of the central nervous apparatus, which determines the deficient mental development, and then appears simultaneously with or not till long after the commencement of the idiocy (sometimes 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 disease, and the mental weakness the result of the violent commo- tion and exhaustion of the cerebral functions caused by the frequent attacks, just as we occasionally see in adults, especially after the first rapidly repeated epileptic attacks, extreme dulness and general derangement of all the mental functions, which lasts for several days.^ The contractions are more frequently partial — of the toes, of the sterno-mastoid muscles, spasmodic club-foot, &c. ; sometimes they are more general, as, for example, of the knee-joint, so that the heel is kept firmly pressed against the nates. Paralytic conditions are much more frequent. Many of the most degraded idiots can neither stand nor walk ; the lower extremities are relaxed, stiff, or atrophied, owing to which slight convulsive movements often take place in them. Frequently, there is a condition of muscular weakness with prema- ture fatty atrophy; the limbs remain small, have a purple hue, and are always cold, as has been observed in the so-called " paralysis of children'"' (Heine). From this there are all possible kinds of transi- tions to more partial forms of paralysis, paralytic club-foot, &c. 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, i860) . In the slighter cases of idiocy — in the semi- cretins, for example — we frequently observe not only the

' I have already expressed this opinion in the ' Twelfth Annual Report of the Asylum at Mariabere,' Tubingen, 1859. Siiould we succeed by very early and appropriate treatment in removing tiie epilepsy, we may aLo hope to improve the idiocy : very soon, however, these cases become incurable wiien the epi- leptic 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.

STATES OF MENTAL WEAKNESS. 375

general feebleness of body, 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 muscles, or of a complete half of the body.

It is interesting to observe the automatic movements, and the entire outward demeanour, particularly in the severe cases. In these feeble and, often, so peculiar manifestations of a perfectly stunted intelhgence, there exists something which provokes us to problematic conjecture; but who can determine what shall be the answer ? In many of these cliildren, 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, frequently clap their hands, beat violently against the wall, puff and blow with their mouths, &c. A very peculiar circumstance which is sometimes observed, is the rapid carrying of the hand to one of the eyelids, whereby the eye becomes rubbed, compressed, or even displaced (will they see double ?) . The expression of countenance and whole bearing of these degraded idiot childi'en manifest complete nullity of the intelligence, with unprovoked alternations of superficial emotions (laughing and weeping), movements hke 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 regitlar. 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 the moderate cases of idiocy, the sexual functions also present great dif- ferences ; but, as a rule, they are more generally diminished than increased. Conception, it is true, sometimes occurs amongst semi- cretins ; but aU that has been said regarding the exaggerated sexual instincts of idiots is false, and only based upon the shameless demeanour 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.

376 STATES OF MENTAL WEAKNESS.

§ 1 65. 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 us in the midst of the very 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 opatJieiic (dull, torpid), and the excited (versa- tile, agitated). The profound idiots of the first category have frequently an awkward, clumsy, and disproportioned body, and repul- sive, old-looking features; the dulness of their movements, their passivencss — their stupid, monotonous,uiiexcitable demeanour — 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, want 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 appearance. They are restless in their movements, quick, irritable, rapidly change their impressions ; but they are extremely absent, and in the higher grades 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 behaviour is often so excitable and turbulent, moving the body, jumping about, gesticulating, laughing, weeping, crying, all day long, that it actually appears to pass into mania (see p. 146). 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 tori)idity.

Besides these two principal groups, we find ourselves constrained, on glau- cing 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 development may remain at the lowest grade, or have advanced to various degrees ; they are generally moderately versatile, but sometimes apathetic, with hfeless, rather auto- matic movements, sometimes with weakness of the lower extremities. These cases

STATES OF MENTAL WEAKNESS. 377

are not only always sporadic and extremely rare, but they seem to be the result of altogether accidental cerebral affections, occurring in previously healthy and well-developed children without any hereditary disposition, without any degene- rative element, without miasmatic influences, &c. In these cases the physical development proceeds properly, in spite of the cerebral affection.

2nd. 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 all the peculiarities of that age, without considerable deformity or degeneration. These cases are diametrically opposite to the other remariiable 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 com- pare them with those arrests of development which, in atrophy of one of the cerebral hemispheres, involves the opposite half of the body, but here, where both hemispheres 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, fet. 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 remamed stationary.

Baillarger presented before the Academy of Medicine (26th May, 1857) a young woman, aet. 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 denti- tion commenced when she was eighteen, and at twenty-seven was not com- pleted. 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 (enfans 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 hearing. 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

378 STATES OF MENTAL WEAKNESS.

of improTement through the memory and imitative faculties, but ouly make progress wheu tliey arc 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 epi- leptic, 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 Ihey are actually dwarQsh, with round forms, slow easy movements, an expression of great benevolence and good-humour : these little fellows have sometimes some- thing extremely droll and humorous in their manners and actions ; they, how- ever, though extremely goodnatured, 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, cruelly, theft, drunkenness, &c., 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 arc by no means identical with the evil desires wliich are developed in children through the example of their seniors.

3rd. The sinosto-basilar form ; crednism in the proper sense of tlie term. The extreme degrees of this form arc 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 cretinism. Generally, the head is disproportionately large ; the features old-looking; the body small, thick-set, and often childlike ; the lips thick, the eyelids puffv, the uose large and deeply impressed at its base ; the body is often swollen and |)uffy- looking, owing to hypertrophe 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 aitger. In opposition to the theory that these states are actual monstrosities (Rosch, Virchow), we can always show that the malady frequently does not com- mence 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 ; the i)ase 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 cai)rieious, little capable of attention, and of weak intellect, although

' Very good examples of this form were some years ago exhibited as the reputed remnant of the extinct American Aztec people; thcre.'"ore the uanie.

STATES OF MENTAL WEAKNESS. 379

many of them can speak correctly. The very interesting investigation of Graiiolet (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 sliglitly 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 brain of these microcephals may present fewer convolutions than that of the ourangoutang 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 cor- responding to the compensatory dilatation of the basis cranii (see § i6i), cor- responds to the peculiar anomaly of the functions which constitutes a direct opposition to that presented by the form with diminution 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-like form ;" and the small, low or short liead, aquiline nose, and lively moveable eyes, strongly remind us of the physiognomy of birds.

5th. Certain idiots, in their physiognomy, habits, and demeanour, resemble in a still more specific manner certain sj^ecies of animals. Some strongly resemble apes (well-marked microcephalus), others forcibly remind us of swine. The following case observed by Piuel 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 be, ma tante., whereby she showed her attachment to her nurse : she also, like a sheep, laid her head on the abdomen of her nurse ; when fight- ing with other children, she butted them as a sheep does ; when wisiiing to fall asleep, she curled herself up 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 charac- teristic fundamental disorders. The opposite types — synosto-basilar and Aztec — are especially worthy of further anatomical investigation.

§ 167. As to the course of the various 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 disappeared at birth ; in which case all mental processes are from the commencement very feeble, speech is not developed, &c., 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

380 STATES OF MENTAL WEAKNESS.

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 becomes dominant. It is especially in hydrocephalic children 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 apathy become more profound and persistent. Epi- leptic convulsions exercise in every case a prejudicial influence upon the psychical 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, kc). But even should this not be the case, still many idiots die during childhood : this may be because many injurious influences 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 cretinism is endemic, where examples may be met with of cretins of sixty and seventy years of age. The reader need scarcely be reminded how much depends, in all such questions, upon the external relations, care, kc.

§ 1 68. Improvement takes place in many cases of idiocy. It is rarelv 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 consists merely of a more free and more regular emplovment of the existing fragments or remnants of intelligence, be thev greater or less; and this result can only be attained very ffraduallv, in the course of many years. The first condition necessarv to all improvement is tlie complete cessation of the cerebral disease which occasioned the idiocy.

Bv cure of idiocy, must be understood the complete removal of the cerebral disease which hinders the mental development ; a process wherebv cultivation of the intellect by education and instruction would be rendered possible. Recover}- in this sense can only be considered jaouible in certain cases, viz., when the cerebral afiection 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

STATES OF MENTAL WEAKNESS. 381

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 entirely mn their course before the idiocy is recognised. Then we hive to deal with residues and consecutive states ; and these offer the greatest resistance to spontaneous or artificial recovery, inas- much 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 majority 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 seK-directiou 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 individuals themselves, as weU as to their relatives, and the ex- istence 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 of 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. TTe may also refer to Kem, ' Zeitschrift f. Psvchiatrie,' xii, 1855, p. 521; Damerow, ibid., xv, 1858, p. 499; Goggenbiih], (together with many other -works') 'Zeitschrift der k.k. Ges. der Aerzte iu Wieu," i860, Xo, 6.

B. Endemic Creiinum.

The following works, besides those mentioned in § 161, are the most im- portant on the subject of Cretinism in the strict sense of the term : — rodere, 'Essai sur le Goitre et le Crelinisme,' Turin, 1792; Ipbofen, 'Der Cretinis- nius,' Dresden, 1817: Maffei und Eoscb, 'ruters. iiber Cretinismus,' 2 Bde., Erlacgen, 1844: Mejer-Ahrens, 'Hasers Archir,' 1S45, p. 360; Prager, • Yierteljahrschrift,-" Bd. xlii, 1854, p. 99; Behrend, 'Journal fur Xinderkrank- heiten,' 1846, Juli; 'Rapport de la Commission creee, par S. M. le Roi de Sardaigne,' etc., Turin, 1S48 (indispensable for the study of cretinism) ; Ferras, 'Acad, de Medecine,' lolh and 31st December, 1S51, and Discussion; Roscb, ' Beobacht. uber den Cretinisraus,' Tubingen, 1S50-1S52 ; Niepce, ' Tr. du Goitre

382 STATES or MENTAL WEAKNESS.

et du Cretinisme,' 2 Bdc, Paris, 1851, 1852 ; Billet, 'Ann. Med. Psycbol.,' 1854, PP- 339. 362, 530; 1855, p. 41; ^lorel, ibid., p. 342; West, 'Journal f. Kiiidcikranklieilen,' 1854, xii, 7, 8; Kostl. ' Dcr endemische Cretinismus/ etc., Wicn, 1855; Fabre, ' Traite du Goitre et du Cretinisme,' Par., 1857; Morel, 'Traite des Degcncrcscences,' etc.. Par., 1857, and bis two later works ('Cliniqtie,' 1852, and 'Traite,' i860); Erlenmeyer, 'Archiv der D. Gesell- schaft f. Psychiatric,' i, 1858, pp. 13, 97 ; Tlieile, ' Ueber Cretinismus ;' Schmidt's •Jahrb.,' i860, No. 7; Zilluer, "Ueber Idiotic," in 'Nova Acta Caesar. Ac. Leop.-Car.,' xix, i860.

§ 169. The distinction between sporadic and endemic idiocy depends, in the first pUicc, upon a simply quantitative relation, the greater or lesser frequency of the affection in a given population. ]^ul in this distinction there are contained still other legitimate differences in quality. The causes Mhich render idiocy so frequent in a particular locality are generally (not unexceptionally) peculiar; indeed, sometimes specific (miasmatic), and excite peculiar diseases which 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 disease of the thyroid gland. There are also certain qualitative differences be- tween endemic and sporadic idiocy which cannot be disputed, in- asmuch 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 aud sporadic idiocy. They dwell in the midst of a population who bear generally a trace (more or less evident) of cretinism, aud they are not ia 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 intel- lectual 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 cerebral defect), but certainly these arc, iu the first place, to be distinguished from the principal prevailing diseases which lie at the foundation of the endemic cretinism. And it may, moreover,

STATES or MENTAL WEAKInESS. 383

be asked — special observations do not appear ever to have been made on this point — whether these acciilental diseases, in a generally infected population, do not assume the form of the prevailing degeneration. In England idiocy is not rare — in many parts it may even be said to be frequent — but those un- sightly deformities (Alpine form) are never seen : there is, therefore, a gi"eat difference between frequent idiocy and "cretinism." Yirchow also says, ende- mic idiocy is not cretinism ; he, however, considers the difference to be alto- gether etiological : that which originates from conditions of the soil, of the locality, is cretinism ; that which results from social conditions is idiocy. Un- fortunately, he does not tell us how we may certainly distinguish all which originates from territorial and all which arises from social conditions. Besides, what may not be comprehended under the term " social conditions " ?

§ 170. Eegarding the j^ropaffation of idiocy as an endemic disease we have here 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, authorised to recognise in both the effects 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 the bones generally) than in others (simple affection of the thyroid gland). Thus it is that the great majority of cretins have a large goitre, which is sometimes congenital and sometimes developed after birth, and which in general assumes 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 mountain chains and their connections — in Europe the Alps, in Asia the Himalayas, 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, as 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 the cantons of Yalais, Grison, Uri, Yaud, Argow, &c. ; 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

^ In the work of A. Hirsch, 'Handb. der histor. geogr. Pathologic' (i, 2, Erlangen, i860, p. 394^ an excellent epitome of all that is as yet known on the subject may be found.

381 STATES OF MENTAL WEAKNESS.

the valley of the Ehine, in the neighbourhood of Strasburg (above all, in plains which are often inundated) ; tlffe island of Mederworth (which is frequently inundated), then lower and middle Eranconia, inany parts of "VYiirtembcrg and the Grand Duchy of Baden. These are the localities which, at the present time, are known as the chief centres of endemic idiocy, accompanied 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 striking in his district, and in this respect everything which could possibly be brought forward has been discussed : sometimes a certain height above the level of the sea (not more than Irom 2 — 3000 feet), deep damp valleys, stagnation of the an, frequent inundations with marshiness of the ground ; sometimes high tfinperature, great and sudden changes of temperature ; sometimes deficiency of hght and of the sun's rays ; sometimes the formation 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, &c. All these various circumstances 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, &c.) exist, and that in many places every one of these influences may be met with, without either goitre or cretinism being prevalent.

We ought not, however, to push this objection too far. We cannot deny the certain influence of marsh-miasm on the production of intermittent fever, because this disease sometimes occurs in localities where there are 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 the more remote causes of the production of definite immediate causes of cretinism.

STATES OV MENTAL WEAKNESS. 385

the latter are produced by combinatioiis of circumstances in 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 constantly^ 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 famihes. Likewise, there are a number of mountainous districts with deep valleys where there is no trace of goitre or cretmism, and cretinism often occurs in level districts and in very open valleys.

In my opmion, 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 tbe majority of them.

Concerning the more immediate and true causes of cretinism, however, to which the circumstances which 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 drmking-water, act feebly upon the mass of the population, and strongly upon a few, who then experience the full effects of the poison. The malady is now considered as an infectious disease, as 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 intermittent fever.

1 111 the work of Georgens and Deinbardt, ' Die Heilpadagogik, etc./ Leip. zio-, 1861, p. 201, we find, "Endemic idiocy is prevalent only iu places wMcA are behind in civilisation." This is not correct. The two villages in the neighbourhood of Tiibingen where cretinism is endemic, are no more behind in civilisation than 100 other villages which are free from it.

25

386 STATES OY MENTAL WEAKNESS.

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 prevalent, they have in recent times much diminished (like inter- mittent fever) under the influence of better regulation of the courses of rivers, the draining of marshy ground, and generally improved hygienic arrangements : in many places, indeed, they have completely disappeared. (Such diminution has been remarked, for example, by Tourdes in the neighbourhood 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 : the same may be said of many other places.)! A profound 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 increased in modern times.

According to the view bere adopted, and in recent times pretty generally accepted, endemic goitre and cretinism are, to a certain extent, specific diseases generated by a specific toxic cause of a miasmatic nature. I cannot oppose this view, which has much in its favour, and can show that many recent attempts to explain the production of these endemic diseases by a multitude 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 form : that consequently, 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 disease of the bones gene- rally, 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 ossification might be caused by miasmatic poison.

The great influence of humidity in the causation of cretinism is demonstrated by a number of facts both general 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

' Toder^ remarked, moreover, in 1 792, that the amount of goitre and cretin- ism had considerably diminished within a certain number of years.

STATES OF MENTAL WEAKNESS. 387

seen to diuiinish rapidly iu consequence of the better regulation of the courses of rivers. But even in regard to these facts, examples of totally different experiences are not wantin^r. 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 example) 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 tliyroideal en- largement sometimes 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 Salzburg 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, &c. — circumstances which demonstrate the existence of an inti- mate 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 diminution of the goitre in an idiot, by operation or other treatment, the mental state improved,'^ I can accord no great im- portance.

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 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 frequently iu the northern Alps) ; they are, on the contrary, very frequent upon dolomite, clay slate, &c., 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 neighbourhood 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 iu the drinking water is the essential cause of goitre and cretinism, has been com- pletely refuted. 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 neighbourhood of Strasburg,

* L. c, p. 229. Examples of epidemic goitre may also be found in Hirsch, 1. c, p. 452.

2 Arthaud, 'Gazette Med.,' 1855, p. 428; Fabre, 1. c, p. 240.

' 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).

388 STATES 0¥ MENTAL WEAKNESS.

raaguesia was found in the water of certain districts wliere goitre and cretinism are not more frequent than in others where tlie water is free from magnesia (Tourdes). The theory which attributes cretinism to the presence of calca- reous salts in the water requires no further refutation.

The statements of Chatin regarding the presence of iodine in the air, water, and food, and upon the absence of iodine in the goitre and cretin districis, 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 impure reagents. See Fabre, 'Traite,' p. 83; De Luca, ' Comptes rendus,' vol. xlix, p. 170; vol. Ivii, 1858; Cloez, ' L'lustitut,' 1857, Juin.

§ 171. That the local causes^ whatever they may be, are alone sufficient to produce fully developed cretinism, is demonstrated by the frequently occurring circumstance, that families entirely free from any special predisposition, that parents who hitherto had always healthy children, had children complete cretins soon after taking up their residence in the locality. If the statement of Niepcc be correct,- tliat the foundlings of Grenoble and Marseilles — districts where cretinism is unknown — become goitrous and cretins when given out to nurse in the infected villages of Is^re 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 (MafTei), 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 hereditary. The child of a male or female cretin, begotten and reared beyond 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 cannot be individually and separately distinguished : when a child comes into the world a complete cretin,

1 See especially the communication to the Academy of Sciences, January i6th, 1854, in which he described the journey during which he made those investigations 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. 492. The statement has been contradicted.

STATES OF MENTAL WEAKNESS. 389

we do not know whether a powerful miasmatic influeuce acted upon the foetus, or whether it is to hereditary influences that the cretinism is due. It is the same with the many children in the cretin districts who are born apparently healthy, but in from three to six months present evident symptoms of the affection : we cannot tell Avhether it is to hereditary influences, or to the endemic cause which now acts upon them for the first time, or to both circum- stances 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 between a man who is in a moderate degree a cretin, and a woman who is per- perfectly healthy, are frequently beautiful and healthy ; frequently they are pro- found cretins, semi-cretins, epileptics, deaf and dumb. In general, cretinism is transmitted more by the father than by the mother (Guggenbiihl, Erlen- meyer). The crossing of races causes the predisposition to disappear 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 diminished thereby. Here the favorable influence of crossing of races is neu- tralised by a very powerful endemic cause. In a locality where the endemic cause was not so strong, 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 cretinism is endemic, result from mismanagement of children, and the whole 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 en- demic. 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 favorable 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 extended to idiocy in general. In fully confirmed cretinism, change of locality and all other treatment is generally ineffectual ; improvement may occasionally take place.

§ 172. In the localities where -cretinism is endemic, there is not.

390 STATES OF MENTAL WEAKNESS.

as we have already remarked (p. 372), 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 Mell of the cranial arch as of the cranial base, which we have already described (§ 161). The most common 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 modifications in the various localities in which it occurs : for example, the cretins in Salzburg are in general a little different from those in Switzerland. The synosto-basilar form which we have described (§ 166) as the cretin type in the strict sense, with large head, small unsightly thick body, broad stump nose with its root impressed, sad features, wrinkled, partly hyper- trophied skin (also accompanied by the most extreme dementia), is nowhere frequent in its most extreme degrees, as the extreme examples of all the forms are in general rare ; but a great number of cases present an approximation to this, and it is this which gives to the majority of cretins in all localities where it is endemic a common striking family likeness. ]\Ioreover, in localities where the endemic influence is strong, the whole population are affected by it. Besides cretins, half-cretins and goitrous ])ersons, there are a number of weakminded, stunted, ill-proportioned individuals, many deaf and dumb — many who stammer, are hard of hearing, squint, &c. ; a o-eneral vein of physical degeneration and mental dulness runs through the whole population ; and even those who are considered healthy and clever, are, as a rule, ugly, stunted, and lazy: they are a narrow-minded race, whose want of inteUigence is by no means com- pensated 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 the 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

' 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 (' Wiirtemb. Med. Corresp. Blatt,' 1839, No. 28). The Stuttgart Cabinet of Natural History contains a very interesting cranium of onn of these children, described in the same journal.

STATES or MENTAL WEAKNESS. 391

neck thick and short; they cry very little^ and sleep almost con- stantly. But at about the third or fourth month, sometimes not untn the fifth or eighth month, the symptoms of the malady com- mence 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 sometimes even cannot walk : the expression of mental nullity is also very marked ; the morbid process has run its course.^ Up to the period 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 condition 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 immediately commences; from puberty onwards little change occui's in the bodily or mental con- dition.

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 head and body, rolling of the eyes, &c.). 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 Com- mission. It does not lie within the province of this work to enter into minute details on this subject.

1 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 endemic, admit of great doubt whether they ought to be considered as cases of endemic 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.

CHAPTER IV.

CHAPTER IV. ON SEVERAL IMPORTANT COMPLICATIONS OF INSANITY.

§ 173. The various forms of mental disease which have been described, especially those mentioned in the second and third chapters, are sometimes accompanied by serious disorders, in par- ticular by certain severe affections of the motory nervous system, which — although intimately 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 speciality, that they may be regarded as complications 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, there- fore, which are known to special pathology, may occur in the insane. Here, however, we have to do only with the study of those compli- cations which are directly connected \^'ith 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 in- sanity. 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 pre- dominant psychical symptoms with other groups of symptoms which in the great majority of mental diseases are altogether absent.

IMPORTANT COMPLICATIONS OF INSANITY. 393

§ 174. Of these disorders, the so-called general {hicomjilete) paralysis, on 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, &c.) belongs the credit of having first minutely observed this affec- tion ; 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, 1822 . further — 'Maladies du Cerveau/ 1826, and ' Annales Med. Psychol.,' 1855, vii, p, 409 ; Delaye, 'Cons, sur une espece de Paralysie,' etc., Paris, 1824; Calnieil, ' De la Para- lysie,' etc., Paris, 1826; Duchek, Prager's ' Vierteljahrsschrift,' Bd. xxix, 1851, p. I ; Hoffmann, 'Giinsburgs Zeitschr.,' Bd. i-viii, 1850-58; Baillarger, nume- rous minor papers in 'Ann. Med. Psych.,' 1852-59; J. Palret, 'Rech. sur la Folie paralytique,' Par., 1853, and 'Archives Gen.,' 1858, ii, p. 200; Joffe, • Zeitschr. der k.k. Ges. der Aerzte zu Wien,' xiii, 1857, p. 675 ; L. Meyer, ' Annal. des Charite-Krankeidiauses,' viii, 2, 1858, p. 44 ; Erlenmeyer, 'Die Ge- hirn-Atrophie der Erwachsenen,' 3rd edition, 1857 ; Austin, ' A Practical Ac- count of General Paralysis,' Lond., 1859 ; Parchappe, ' De la Polie paralytique,' Paris, 1859.

Tiiis 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 symp- toms. The mental symptoms either appear simultaneously with the disorder of movement — or, most frequently — they precede for a certain time the manifestation of the motory symptoms, or — much more rarely — the paralytic appearances were observed for a short time before the development of the insanity.

Since the publication of the first edition of this work, the question whe- ther 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 op- position to the few who answer this question in the affirmative (' Requin, Sanze, and to a certain degree 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 tcith mental derangement (for example, paralysis owing to apoplexy, tumours of the braiu, &c.) ; indeed, that by no means does every general and progressive state of muscular weakness, in part proceeding to para- lysis, in the insane or mentally weak belong to this special form (thus the muscular weakness which accompanies senile dementia, or chronic alcoholismus, or the

39-i IMPORTANT COMPLICATIONS OF INSANITY.

progressive spinal paralysis wliich sometimes accidentally complicates insanity). In this special form, the progressive muscular weakness and the insanity pro- ceed 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, folic paralytique).

The first symptoms which usher in this cerebral affection are very often psychical, 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 commencement 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, Bail- larger 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 accessory. Hoffmann states the number of these cases at i8 per cent, of his observations ; and it is of course possible that the first, slight muscular disorders are, in many cases, for a time overlooked by those who surround the patient, and that accordingly the paralysis preceded, or perhaps occurred simultaneously with the mental disease, in a greater number of cases than was formerly sup- posed. 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 articulate 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, diminished faciUty 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 con- sidered as lost. Then, although these patients have all the appear- ance of robust health, and cannot sufficiently extol their own feeling of well-being, there gradually becomes developed a series of the most various symptoms. At the same time that the speech becomes difficult, more frequently not until some time after, a change in the gait of the patient 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 be at all uneven, — for example, when going over a step. Still, they take pleasure in walking about a great deal ; some of them even ex- perience a constant desire for restless change of scene : they take long walks, and, to the inexperienced eye, nothing striking is pre-

IMPORTANT COMPLICATIONS OF INSANITY. 395

sented so long as they keep upon level ground. Tlie arms remain for a long time unimpaired. Gradually, however, while the pro- nunciation of words becomes constantly more indistinct, so that we 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 himself 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, &c., gradually become impossible. When rechning, 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 comparative freedom of movement.

The muscular affection appears to be even at the commencement very ex- tended, indeed almost general, although at the same time very feeble : it is manifested first of all in those organs whose movements require 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, particularly in the formation of labial sounds (Duchek) ; and also, apart from speech, we frequently remark slight convulsive movements in the mus- cles about the mouth. In the upper extremities we remark at the commence- ment, yet without any actual weakness, a slight tremor, which renders the movements irregular, awkward, and constrained. In the lower extremities it is at first less tremulousness 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 naore 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 (ist edition, p. 286). Since then this point has been many times con- firmed : see especially J. Falret, 'Archiv,' 1. c, p. 202; Duchenne, " De I'Ataxie 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 (Neu- mann) : still this does not suffice to explain all the phenomena — for example, the trembling of the muscles of the face.

396 IMPORTANT COMPLICATIONS OF INSANITY.

Afterwards au 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 respira- tory muscles become paralysed. It is only in exceptional cases that we ob- serve greater weakness in one half of the body, an inclination of the tongue to one side, obliquity of countenance : these exceptional cases appear to depend upon considerable atrophy of one half of the brain, or upon unilateral hsemato- mata in the dura mater.

The contradilily of the muscles under the influence of elect) ieity is, as in other forms of cerebral paralysis, always normal (in condistinction to peripheral and many spinal paralyses). Tliis, however, is of very little diagnostic value, as it is also observed in a number of other paralyses (hysterical paralysis, paralysis resulting from a tumour of the brain, &c.). Duchenne, who established this fact in 1850, has published the further results of his experiments in ' Traite de I'Electris, loc.,' Par., 1855, and especially in his " Memoire sur I'Ataxie loco- motrice" ('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 mobility 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 com- mencement ; 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 to the last without 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 patient, for example, cannot distinguish wiue from water. Pain does not exist, but at the commencement the patient some- times complains of headache, with a sensation of weight and confu- sion in the head, and a slight degree of vertigo. The cutaneous sensibility occasionally presents a remarkable peculiarity. Vrhile it in all cases appears at the commencement to become blunted, and afterwards in certain cases almost abohshed (so that the patients can endure severe pinching without experiencing pain), there occasionally occur transitory states of extreme hypersesthesia of the cutaneous surface, in which the slightest touch excites the most extended reflex movements, convulsions of all the voluntary muscles — conditions 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

IMPORTANT COMPLICATIONS OF INSANITY. 397

cutaneous hypersesthesia during the hours immediately succeeding an attack of convulsions.

Not unfrequently^ we observe in these patients, under the symp- toms of violent cerebral congestion, sudden attacks of loss of con- sciousness, 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 observed 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, aud 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 later 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 oi the disease the ps^c/iical disorders do not always present the same character. It is rarely that a melancholic stage does not exist. This is sometimes simply depres- sive, sometimes strongly hypochondriacal in its character. The first disorders of movement are very rarely manifested in the melancholic stage; nevertheless, cases do occur, as Calmed (1. c, p. 328) has observed, and in such cases the patients may retain for a long time the melancholic nature of the delirium, so that the depression passes almost immediately into dementia. The change in the character and entire nature of the patient is very variously exhibited at the com- mencement 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 start- ling, occurring in patients who still move freely, in society, pursue their avocations, &c. : these may give rise to medico-legal questions which are often very difficult to settle — especially violations of pro- perty (sometimes proceeding from the idea that the objects in

398 IMPOllTANT COMPLICATIONS OF INSANITY.

question really belong to them ; frequently, also, from a momentary irresistible impulse to gratify a desire) ; rude, immodest acts, and the like.

Whatever the commencement may be, in ordinary cases there always arrives a period characterised 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 Ave have described when speaking of monomania ; namely, such as relate to exaltation of the person, to grandeur, which, on account of their frequent connec- tion with general paralysis, are correctly considered of great prog- nostic 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 recognised as mentally diseased by the initiated. Soon they allow themselves greater freedom, become more and more restless ; manifest in everything their satisfied, exalted frame of mind; spend lavishly and make magnificent presents; recount imaginary histories, in which they frequently contradict themselves ; 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 — imbearable. Should the patients be admitted at this period into an asylum, they generally, under isolation and appropriate diet, rapidly become somewhat more calm ; but usually this is of only short duration, and in the great majority of cases there are now developed the specially characteristic ideas of greatness, in which all that relates to the person of the patient assumes in his eyes colossal dimensions, and is expressed by him in the- most superlative language and highest 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 hmited ; incoherence soon becomes (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 incapable of resistance, and is entirely taken posses- sion of and subdued by them. Their will is weak ; they appear vio- lent, but are pliable as children, easily subdued, and they are also somewhat mobile and lachrymose in their nature.

IMPORTANT COMPLICATIONS OF INSANITY. 399

The weakness of the mental faculties becomes more and more pro- found in proportion 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, &c. From this time the dementia progresses step by step with the paralysis : still, in certain patients the course of the disease is varied, sometimes by increased restlessness — sometimes even by attacks of mania, vociferation, and desire to destroy. Certain patients continue for a long time to manifest, but without any actual sense of what they say, those extravagant ideas of possession of provinces, riches, worlds, milhons, &c., variously modi- fied accordmg to the degree of education. The one i possesses milhons of billions — all the world belongs to him, all things were made by him, &c. Another has built the most splendid castle, bought all Italy, plundered Asia, destroyed the bridge from the earth to the moon, transferred the Chinese to Paris, is himself 800 feet high, &c. 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, &c.

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 manifested rather as a general lively, happy, self-contented manner, than in many exalted ideas, or where the latter are at least comparatively unassuming b their character ; for example, in women, simply the conviction that they have a great many fine dresses at home, &c. Sometimes the dementia forms the base and the background of all the psychical phenomena, and also soon mani- fests 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 dis- appear : 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 the patient requires not only to be fed, but the food must often be pushed backwards in the mouth.

^ See Bayle, 'Maladies du Cerveau,' Paris, 1826, pages 71, 210, 502.

400 IMPORTANT COMPLICATIONS Ol' INSANITY.

The appetite, the digestion, and nutrition are at the commence- ment, and during a considerable period of the course of the disease, well maintained : the patients then eat well, and even greedily ; their appearance is often good, and they frequently have a tendency to become fat : a remarkable 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 advanced period that the patients become emaciated; gangrenous spots appear in various parts of the skin, especially 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, accompanied by profuse diarrhoea and ulceration of the intestines ; at other times it is connected with general tuberculosis. Some also die of pneumonia, particularly of lobular pneumonia, con- secutive to chronic bronchial catarrh ; others from accident, &:c.

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 in- crease of temperature, and that the maniacal stages are in particular intimately connected with this febrile increase of temperature. This is, more- over, sometimes very inconsiderable (Meyer's 17th observation, p. 167), and it seems to me still problematical whether 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 paralytic in every 15 insane in men, and in women i 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;' Hoflfmann found 18 paralytic women to 138 men ; in Leubus there were, in about 2700 cases, 1*376 per cent, males, and only 3'i6 per

' L. c, p. 371. ' L. c, p. 403.

* 'Diet, de Med. et de Chir. Prat./ art. " Alienation," p. 505.

IMPORTANT COMPLICATIONS OF INSANITY. 401

cent, females ; in Prague, to 6^ men there were 6 women ; in Stephansfeld, from 1835 to 1853, -^tli of the males and only ^^th of the females suffered from general paralysis ; Bazire/ in Bordeaux, had 62 general paralytics amongst 996 females, &:c. The causes of this difference between the sexes are obscure : it may, with some show of reason, be assumed that the more frequent excesses in spirituous liquors and in venery amongst men predispose the braui to such affections ; perhaps strong cigars and strong coffee have a share in this : nevertheless, cases occur in which the disease sets iu after the most regular life, where 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 (TT. .lessen) — existed.

This disease almost never occurs before the a^e of twentv : it is most frequent about the age of forty. It is most frequent amongst the educated classes - — amongst military officers, merchants, govern - uient 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 agitations, 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 Prance) as in the north.

General paralysis is nowhere more common than in France, or, at least, iu the asylums of Paris. According to Bayle (1855), ^^^ proportion of paralytics is I in 4. (Baillarger, on the other hand, gives for Bicetre and Salpetrierc together the proportion of i in 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, 1 851) more frequent than in Prague (Duchek). The very large proportion which Bini gives for the asylum at Florence is remarkable (about iS 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 consider- able diminution in the number of paralytics ('Lef. or.,' ii, p. 104), while else- where 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.

1 'Ann. iJed. 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'oo.

26

402 IMPORTANT COMI'LICATIONS OF INSANITY.

§ 178. The duration of general paralysis varies from several months to about three years : exceptional cases^ indeed, occur, in which the disease lasts for a longer period, even for ten years (Brierre, Trelat) ; still, not without long periods of intermission. When nursed in their families, 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 accele- rated by the congestive attacks of which we have spoken ; frequently also we see the patient become daily worse without any appreciable cause.

Several examples of recovery, or at least of long- continued con- siderable improvement — never without urgent danger of relapse — have been pubhshed. Calmeil has observed two and Bayle six cases of this kind : Hemming, Snell, Ferrus, Baillarger, have also communicated several cases of recovery. The immense majority of the patients, however, die within the given time. On the other hand, it is less rare to observe transitory improvements, and some- times even complete intermissions; but, unfortunately, these are only of short duration.

On the wliole, this affection is essentially progressive iu its character ; but, iu general, this progression is rather irregular than constant, and sometimes even jerking in its character. Remissions of all the symptoms, psychical as well as motory, are not unfrequent ; they may even proceed to a condition iu wliich the patient no longer manifests any trace of delirium, returns to his employ- ment, aud only a slight hesitation in speech and a certain degree of mental and emotional weakness is perceptible to the initiated. These marked re- missions 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 iu a medico-legal point of view may be very important : as a rule, the ordinarily recognised signs of insanity are altogether absent in these cases. Trequently these marked intermissions are suddenly cut short by a congestive attack, with which the patient is again plunged into his former state, and usually tho 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 Pathological Anatomy), we discover that the alterations which lie at the foundatio]! 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.

IMPORTANT COMPLICATIONS OF INSANITY. 408

Ordinary apoplexy — irritation of the brain^ owing to extravasation of blood — never gives rise to this form of paralysis ; on the con- trary, during the attacks of cerebral congestion and loss of conscious- uesSj more or less considerable effusion 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 vegetations 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 incom- plete character of the paralysis — its progressive nature ; upon the convulsive character of the early symptoms of the disease — its com- mencement v.'ith trembling of the tongue and of the lips ; upon the special character of the mental derangement, particulai'ly the ideas of greatness and the rapidly ensuing mental weakness ; upon the irregular course. It is by regarding these symptoms that we in general soon succeed in distinguishing this affection from paralysis due to cerebral haemorrhage, embolism, encephalitis, tumours 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 drunkenness, mentioned by me in the first edition of this work (p, 246), has since then been more minutely described by Lasegue ('Arch, G^n.,' 1853, i, p. 49) and by Bayle ('Ann. Med. Psych.,' 1855, vii, p. 423). The former calls attention to the fact that there are cases in M'hich the diagnosis between this paralysis and alcoholismus is not very easy -. the course of the disease, however, will always La these cases soon lead to a correct conclusion.

§ 179. As the second important complication of insanity may be mentioned ejrj'ilejjsij. The numerous points of contact and transition of the motory convulsive forms comprehended under this name, to the more profound derangements of the psychical functions, are

t04 IMPORTANT COMPLICATIONS OF INSANITY.

iiiauifested 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 — immediately 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 expres- sion of fixed terrified astonishment which he so frequently manifests might awaken the idea that he is suffering extreme mental pain. There are, however, many epileptic conditions in which we may recognise, during the attack, the existence of a psychical disorder. Thus we may frequently observe attacks sometimes preceding and sometimes alternating with intermittent convulsions, which consist principally in a psychical anomaly, 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 repeatedly murmurs the word last spoken; when he recovers, he perceives his mental absence, and sometimes attempts to conceal it, or continues his conversation, 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 depres- sion, 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 recollec- tion of these.^

1 ' Cyclopsedia of Pract. Med.,' vol. ii, art. " Epilepsy," by Cheyne. See also the case where phantasies were remembered after the epileptic attack, in Nasse, 'Zeitschrift fur Anthropologic,' 1825, i, p. 190. The dissertation on Epilepsy bv Dr. C. F. Horing, Tiibiingen, 1859, contains many observations of this kind.

IMPORTANT COMPLICATIONS OF INSANITY. 405

Immediately after the attack,, the psychical fmictious are often very seriously disturbed. Sometimes the patient speaks incohe- rently for a long time, as if he were in dementiaj and the intellect does not recover its former state for several days. Still more important, however, are those paroxysms of mania immediately followins: the convulsive attacks, which manifest themselves bv such a degree of blind fury and violence, such wild gesticulation, as scarcely ever occurs 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, par- ticularly 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 condi- tion 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 description, 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 appreciate 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 question 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 ; 1 2 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 weak in memory or had exalted ideas. Sixty (only -i-th) were free from intellectual derangement ; but nearly all of these were irri- table, peculiar, and easily enraged. The latter trait of character — a dominant, suspicious, discontented, misanthropic perversion of senti- ment, sometimes even actual melancholia with suicidal tendency — is observed in a great many epileptics. This may, in great degree,

' ' Maladies Meutales,' vol. i.

406 IMPORTANT COMPLICATIONS OF INSANITY.

originate from the sense of their sad and exceptional position, from the gradual perception of the moral death to which their malady condemns them.

The most important persistent psychical disorder to which epi- leptics are subject is dementia. As a rule, it makes its appearance earlier according to the frequency of the attacks. jMemory fails ; perception becomes dull ; the imagination loses its brilliancy ; its genuineness and fervour; and the emotions become withered. The physiognomy and deportment change — the patient becomes thick-lipped, coarse in his features and repulsive in ]\is appearance. As the attacks become weaker and less frequent, the mental facul- ties may regain their power, but, owing to the rarity of radical cure in epilepsy, the majority of these patients finally fall into dementia.

Tlio existence of these intermittent convulsive forms in the insane is, therefore, of very great importance in regard to the prognosis. Dementia with epilepsy may be considered as perfectly incurable ; and in other forms of insanity complicated with epilepsy, recovery is altogether exceptional. Some asylums, therefore, which are ex- clusively 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 wealcness. Muscular paralysis occasionally occurs iu 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, 'Psychoseu,' p. 118; liaushalter, * Dii Delire epileptiquc,' Diss., Strasb., 1853; Weyers, ibid., 1857; Cossy, *Rech. sur le Deiire aigue des Epileptiques,' Paris, 1854.

§ 180. Many other morlicl a.ppearances hi 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 backwards or in a circle, and the like ; sometimes chronic convulsions restricted to certain muscles, — for example, con- stant convulsive nodding of the head, convulsive lifting of the leg when walking, &c. ; sometimes contractions of certain groups of muscles (of the extremities, strabismus), with or without paralysis succeeding.

IMPORTANT COMPLICATIONS OF INSANITY. 407

We have already spoken of these (§ 62), and of their unfavorable prognostic signidcance.

Of quite as serious significance are those vague neuralgias — hitherto too little considered — which are observed in all parts of the organism as fleeting pains, and, not uufrequently^ at the period of transition of the disease to an incurable state of weakness. The fact of their frequency under such circumstances warrants us in consider- ing 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 f eh rile symptoms which so frequently ac- company the first appearance of the insanity may be mentioned as a common complication, and one intimately connected with the disease of the brain. Eigors, heat, exhaustion, pains in the limbs, thirst, foul tongue ; disordered appetite, bowels, and urinary secretion ; epi- gastric tenderness, dryness of the skin, rapid emaciation — occur very frequently at the period when the symptoms of the cerebral disease begin to be manifested. Generally 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 ex- ceptions^— 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 tlie foul tongue, loss of appetite, and constipa- tion are regarded as symptoms of some serious abdominal disease ■which is now termed the cause of the insanity. In such cases, an unbiassed 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.

1 See § 62.

BOOK FOURTH. THE PATHOLOGICAL ANATOMY OF MENTAL DISEASE.

BOOK FOURTH.

THE PATHOLOGICAL ANATOMY OF MENTAL DISEASE.

§ i8i. Whoever attends not merely to the symptoms of disease, but also to the abnormal organic conditions from Avhich these symp- toms 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, If 'hat are the special diseases the symptoms of which we have previously become acquahited with either by themselves individually, or in combination 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 arc 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 discovered after death first originated, and to employ them for tlie preservation and treatment of living patients ; we have also to consider whether a careful examination of patho- logical and anatomical facts will not assist us in forming conclusions of a still more comprehensive nature, and whether definite funda- mental 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 whole physiology and pathology of the brain. If we do not deceive ourselves, this department of our subject has not been without such results.

CHAPTER I. pathological axatomy of the brain and its

CHAPTER I.

pathological axatomy of the brain and its

:meaibraxes.

§ 182. The anatomical changes which indicate insanity, that is, which produce psychical anomalies daring 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-con- stituted 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 wliich 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 confirmation of this fact, as for the discovery of anatomical lesions. For although in all cases of insanity we must assume a pathological aifection 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 treatment.

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 careful observers, these cases always constitute the minority. We must estimate their numbers, not by the statements of those phy- sicians who, though perhaps excellent administrators or theorists, have had no opportunity 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. "\Ye must consider how easily many very

410 PATHOLOGICAL ANATOMY OF THE BRAIN.

minute but, nevertheless, important 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 acknowledge 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 in- vestigation of previously known facts, have tended greatly to promote the pathological 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 theoretical apphcation and the conclusions derivable from them, be received with favour. 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 occasionally exist without any anatomical changes in the lungs, therefore in pneumonia these symptoms might not be the results of this pulmonary affection; because convulsions, spasms, paralyses, sometimes exist without organic change in the spinal cord, therefore, in cases of inflammation of the spinal cord, the convulsions, spasms, paralyses, &c., 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 recognise in every such anomaly the particular disorder from which the individual psychical anomaly directly springs. A knowledge of the intimate connection between 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 insane, what thej are, what appearances they bear, and how their form in general is related to the appearance of the mental affection as a whole.

The gross misconceptions held by the older excKisively psychological or theo-

o

PATHOLOGICAL ANATOMY OF THE BRAIN. 411

retical school regarding tbe entire anatomical view of mental diseases, require in the present state of science no further refutation. Now, errors and one- sided viev.'s within the pathological anatomical school are rather to be guarded against. It does not by any means follow that tlie alterations which we dis- cover in the cranium are the immediate causes of definite psychical anomalies, of this or of that form of delirium, or that the individual s!/?np(oms of the mental derangement are the direcl result of the anatomical lesion. Certain attempts in this direction, among others those of an eminent German psy- chologist, are entirely misdirected, and will for a long time prove fruitless. The already discovered alterations can, as yet, only demonstrate that the braiu generally, or, still more indefinite, that the cranial contents are diseased, and in what manner ; hut hojo a psychical disorder, 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 the same alteration, cannot yet be explained with any degree of certainty. 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, &c. : 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, &c. — in short, present after death a morbid change of long standing which, perhaps, 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 anatomi- cal knowledge and experience. The anatomical view does not consist in the belief that every mental disorder r,im{ 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 observed in any form of mental disease ! — the anatomical method consists iu investigating 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 during life, to arrive at com= prehensive anatomical views in regard to these cerebral affections. This doc- trine is maintained in the first edition of this work, though not so explicitly stated.

Another misunderstanding, which we at present need scarcely do more thau mention, is this — that the pathological lesions iu the insane are merely results of the mental disease. In this quibble a sort of last refuge is sought from the pathological 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 resuK of the idiocy.

Authentic reports of autopsies in which the condition of the brain is stated to be normal are principally those of cases of uncom- plicated recent insanity, in the forms of melancholia and mania; and, as a rule, anatomical changes are frequent in proportion to the duration of the mental disease, according as it presented symptoms

s

412 PATHOLOGICAL ANATOMY OF THE BRAIN.

of mental weakness, particularly of profound dementia^ and, finally, according as it was complicated with paralysis. Still, cases pre- senting considerable acute anatomical changes occur as recent cases of primary insanity (for example, the mania of acute meningitis) ; and, again, many reports of autopsies of cases which correspond to chronic cases of dementia and advanced imbecihty show an entire absence of any anatomical anomaly. Indeed, even of the most severe mental affection known, paralytic dementia — in which also, generally 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 processes and of the motory acts may occur without 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, there- fore, many of these cases ought to be viewed as affording only apparently negative post-mortem results.

The following figures may be cited as examples of the great differences which exist among observers iu regard to the number of diseased and healthy brains met with amongst the insane. The renowned Pinel in 261 autopsies found only 68, Esquirol in 277 only 77, cases in which there were changes in the brain (Sc. Pinel, 'Eecherches sur les Causes physiques,' etc., Paris, 1826, p. 9); Chiarugi in 100 cases found changes to exist in 95, Parchappe in 160 cases of uncomplicated mental disease in 152 (" Traite dc la Folic;" 'Docum. necrose.,' Paris, i84i,pp. 46, 141); "Webster in 72 cases (*Med.-Cliir. Transactions,' vol. xxvi, 1843, and ' Annal. Med. Psych.,' Mai, 1844, p. 445) found lesions within the cranial cavity in allQi them; Lelutin 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 Yaleur des Alterations de I'Encephale,' Par., 1836, pp. 6^, 76). In the Vienna Asylum, in 171 autopsies, absolutely 710 abnormality was dis- covered 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. Pischer, 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..

PATHOLOGICAL AM ATOMY OV THE BRAIN. 413

tetanus. Wallis (•DeTetano Disquis. Arithmeticse,' Diss., Hal.,' 1837, p. 24) found, iu a collectiou of 38 autopsies of persons who died of tetanus, evidences of inflammation of the nerve-cells (with softening induration and pigmentation) in 14 cases; other 11 cases presented inflammation without degeneration (hyper- aeniia) ; the remaining 13 presented notliing abnormal in the central organs.

§ 183. According to recent investigations, it may be considered a well-establislied fact that the majority of post-mortem examinations of the insane show anatomical changes to exist within the cranium. But is there ever any speciiic alteration in insanity ? If by this we mean a change which everywhere, where generally an abnormal cerebral condition exists, must invariably and iu the same manner be present, then this question must not only be answered in the negative, but considered as a jji'iori false. A simple pathological reasoning must prove to us that the pathological psychical symp- toms, differing so widely amongst themselves, which are compre- hended under the forms of melancholia, mania, dementia, &c,, cannot possibly always have the same alteration of the organ for their foundation. It has never even been considered possible that, iu 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 auomaKes of self-consciousness, intellect, and will are not only caimhle of being excited, but musthe excited, by very various diseases of the organ in question. On the other hand, if we reverse the question of the speciahty of the anatomical lesion, the question becomes, — Are there not anatomical changes with whose existence it is always necessary that a marked disturbance of the mental faculties, a mental disease, should exist ? This must be answered in the affirma- tive. Indeed, there are certain structural diseases of the brain which always cause considerable anomalies in the mental functions, even insanity. A diffuse inflammation of the grey substance, ex- tending over a number of convolutions, has never been observed without profound mental 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 alteration of the ventricular surface of any extent were never observed without psychical disturb- ance, particularly mental weakness. Generally speaking, 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 external

414 PATHOLOGICAL ANATOiMi' OF THE BRAIN.

surface, than the circumscribed localised diseases, Avhich are found in the insane ; in particular, a comparison of the facts lying before us appears decidedly to support the view, that the most important and most constant clianges in the insane consist in diffuse diseases of the external layers of the cortical substance — that is, of the siufaces of the Irain and of the memhranes covering them ; and it would be equally justiiiable, in many cases of insanity which corre- spond to palpable changes in the brain, to consider that the chief and essential disease is that of the periiihery of the brain. Many facts also could speak in favour of an essential participation of the ven- tricular surfaces ; but this point is as yet not so well established. Of the various sections of the cortical grey substance of the convolu- tions, we find the morbid change most frequent in the anterior and middle (superior) portions of the great hemispheres ; many surgical observations agree with this where, in loss of substance from injury of the anterior and superior portions of the hemispheres, there most constantly resulted aberration and weakness of the mental faculties.

In the sequel we sliall first describe the anatomical changes of the brain and its membranes which are met with in insanity. We shall describe them in- dividually, according to an anatomical arrangement as they appear in recent rcsearclies, and then we shall, hy way of summary, investigate what conditions of the organs in the cranium most frequently correspond to tlie various forms of insanity. The older pathological anatomical researclies of Bonet and Mor- gagni, and the results of Haller's historical studies, are collected by Arnold (' Observations,'. &c., 1788); the works also of Meckel, Chiarugi, Burdach, Greding, and Portal ou^lit specially to be consulted. Parchappe (' Recherclies sur I'Eiicephale,' 2me Memoire, 1838) has collected the most important of the older and more recent observations, es))ecially those of his own countrymen. We may aUo consult Dulir, 'De vitiis qute apud Amentes/ etc., Diss., Bonn, 1840; Giintz, 'DeAnat. Pathol. Cerebri Vesanorum,' Lips., 1853; Webster, 'Med.-Cliir. Transactions,' 1849, vol. xxxii, p. 115; H. pisclier,' 'Path. Anat. Befunde,' etc., Lucern, 1854; Pollet, 'Ann. Med. Psych.,' Oct.,' 1857. P- 477 ; "Voi)pe!, several valuable papers in ' Gunsburg Zfschr.,' 1856^ vii, p. 161; Zeitschrift, fiir Psychiatrie,' xiv, 1857, p. 175; 'Archiv der Ges. fiir Psych iatrie,'i, 1858, p. 49; Otto, ibid., i, ii, p. 64; ' Wiener Bericht' (Wien, 1858), in many parts; Calmeil, ' Des Maladies inflamm. du Cerveau,' 2 vols., Par., 1859.

A. The Cranium,

§ 184. The iniiuence of an abnormal conformation of the cranium IS naturally most considerable upon the brain when the process of

PATHOLOGICAL ANATOMY OF THE BRAIN. 416

developineut is still progressing ; this point has been already suf- ficiently noticed (§ i6i). 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 degrees, in which for a long time no special deviation from normal function is apparent, likewise prove a predisposing cause of those affections 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, Stahl, Seifert, kc.) distinctly state 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 par- ticularly the too short crania ; in short, the various forms of asym- metry and malformation, especially those produced by premature ossification of the sutures, or unilateral or partial contraction of the cranial cavity, and, less frequently, microcephalus, owing to mode- rate hydrops ventriculorum dating from early infancy. It cannot be said of any one of these malformations that it is especially unfavor- able ; all seem to exert a certain predisposing influence, unless they are rectified by compensations (§ i6i). The opinion that cranial deformities may be especially t/ie t/iedia of the hereditariness of mental disease (Stahl, Voppel) is as yet stUl hypothetical; an hypo- thesis, however, deserving the utmost attention and careful research. A special form of abnormahty of the cranium is produced by an artificial deformity, to which roville in particular has directed atten- tion.^ In several provinces of Prance, especially Normandy 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 elongated, 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 proportion of insane in his native province (Gascogne), and by the statistics of the local asylums. Regarding the thickness and texture of the cranial hones, almost every observer has noticed the frequency of anomalies of the cranium in this respect. Greding found — concurring with more recent observers — in ii6 autopsies, 167 instances of thickening, 38 of ' roviile, 'Auatomie clu Systeme Nerveux,' etc.j I, Par., 1844.

116 PATHOLOGICAL ANATOMY OF THE BRAIN.

abnormal thinness, of these bones. This increase in bulk, hyper- ostosis of the cranium, is either associated with too great abundance of diploetic substance, or, more frequently, with great thickness, sclerosity, of the bone. It is the final product of an acute increase of nutrition, from tune to time repeated; or it may be of a chronic and, to a certain extent, inflammatory process, which produces a suc- cessive series of new osseous layers. As the hyperostosis takes place at the cost of the intracranial space, and of the foramina and (issures througli which the blood-vessels pass to and from the brain, it is frequently the cause of disorders of the circulation within the cranium, partial or general hypergemia or anfcmia ; generally speak- ing, 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 nnfrequently constitutes the sole (of which no explanation has as yet been given) anomaly. Depressions resulting from former injuries, traumatic and syphilitic exostoses, are also frequently met with ; partial hyperostoses, of the kind previously 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 inflicted.

In many other cases among the insane, as also in epileptics, bony formations upon the internal surface of the cranium, in the form of needles and stalactites — sometimes, also, small exostoses, and osseous tumours and plates, external and internal, on the cranium — indicate an extinct localised inflammatory process, the products of wliicli here remain in an ossified form ; and the abnormal adhesions of the dura mater to the internal 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, according 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 cranial sutures to be an important predisposing cause of melancholia and suicide. At the present time these synostoses are considered primarily as

PATIIO],OGICAL ANATOxMY OF THE BRAIN. 417

causes of deformities of the craaium and of contractioa of the cranial cavity — and it is certaiulj established, according to investigations of recent times, that to the latter a certain predisposing influence upon the origin of mental diseases is to be ascribed. See Virchow, 'Gesamm. Abhandl.,' p. 937, u. a. a. 0. ; Stahl, 'Ztschr. f. Psych.,' xi, 1854, p. 545; xii, 1855, p. 559; xvi, 1859, p. i ; Seifert, ibid., xi, 1854, p. 198; Krause, '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, that in the insane there is frequently found a contraction (generally of one side only) of tliu jugular foramen, appears to have no special value, as inequalities of tiiat kind are frequent in health : Hoffmann, however, declares (Giinsb., ' Zeitschr.,' iii, p. 132) that, in reality, differences in size of the foramina jugularia are more frequently met with in the insane than in the healthy. Finckelnburg has recently given the account of an interesting case of insanity arising from acute [luerperal osteomalacia of ihe cranium ('Ztschr. f. Psych.,' xviii, 2, two cases).

Amongst those remarks upon the external parts of the brain^ we have to include the conditiou of t//e great vessels icWdn the cnui'ium. lligidity with atheroma or ossification of the larger arteries has been observed, in various degrees, in numerous autopsies of persons who have been insane. 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 vsx the capillary arteries too small for investigation; in these there is also frequently observed narrowing of the calibre, owing to the development of con- nective tissue in the arterial walls, fatty degeneration, Src. ; here and there, also, small (microscopic) aneurismal or more general dilata- tions. We may assume tlie existence of such states in the living in pro])ortion 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 companion in arms, Monge, and in the celebrated Pourcroy, who botii died melancholic). In the case of a child twelve years of age who committed suicide, there was foinid calcification of the cerebral arteries (Miiller, 'Oestr. Med. Jahrb.,' 1844, Juli, p. 44). Thrombosis of the cerebral sinuses, occasionally discovered in the bodies of the insane (see 11. Fischer, 1. c, p. 8), has been hitherto observed only as a final process in connection with pytemia and the

' ' Zeitsc'.irift fur Psychiatric,' i.x, 1852, p. 124.

27

418 TATIIOLOGICAL ANATOMY OF THE BRAIN.

like : accordingly, there is every reason to believe that the processes associated with this thrombosis, when more clironic in their course, also play a part in the jR-oduction of mental disease; this was, perhaps, the case iu a case of throm- bosis mentioned in the Vienna Report (1858, p. 191). See p. 190.

B. The Arachnoid.

§ 185. One of the most frequent anatomical changes in mental disease is opacifi/, thickening, and hi/jocrtrojjhe 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 serious lesions, after paralytic dementia. It may generally be considered as the result of former chronic hypersemia and inflamma- tory stasis ; it accordingly occurs together with increase of the Pacchionian granulations — which depends on analogous processes — under all circumstances where habitual cerebral congestion existed during life, as in the case of drunkards, 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 handj 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 complete agglutina- tion of all these membranous layers, Tine granulations of the external surface of the arachnoid, sunilar to those of the ependyma ventriculorum, are, according to L. Meyer, frequently observed along witli other important changes — thickening of the skull, opacity and thickening of the delicate membranes, atrophy of the brain, &c.

Ilj/percemia of the arachnoid, especially in tlie 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 Yirchow as pacchy- meningitis interna, and which is accompanied by the formation of firm pseudo-membranes, or thin, delicate, almost gelatinous struc- tures, interspersed with sanguineous spots and an acute growth of cellular tissue.^ With regard to the contents of the arachnoid

^ These changes, which were formerly described, especially by French ob- servers (Calmcil, Bayle, Prus, Aubauel, &c.) as " pseudo-membraues of the

PATHOLOGICAL ANATOMY OF THE BRAIN. 419

cavity, there is frequently found in it an increased quantity of serous fluid, which is sometimes the result of habitual hypersemia and a varicose state of the blood-vessels, sometimes of secondary atrophy of the brain. It is always accompanied by thickening of the mem- branes and infiltration of the pia mater.

Of special importance, however, are the frequent and spontaneous lisemorrhages into the sac of the arachnoid^(heematomata) which have been noticed by all observers, particularly in paralytic dementia, but not unfrcquently 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 con- sciousness (see § 178). Their diagnosis daring life is, however, uncertain ; because, on the one hand, when slight they pass oft' with- out giving rise to any symptoms; and, on the other hand, their symptoms — those of compression — may readily 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 floating cyst under the dura mater, firmly adherent to the membrane previously described, 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 (Kokitansky). 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 atrophy of the affected hemisphere, with contraction of the ventricles, in- creased consistency of the cerebral substance, and mechanical hyperaemia and infiltration of the meninges. The organised walls of the sac appear to be ca- pable 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 be- liind Ihem, at first rust-brown, then yellow, and afterwards almost quite colour- less lamellae of coagulated fibrine. When observed -while still recent, they consist of a meshworkof reddish fibres, sometimes as thin as those of a spider's web, and mixed with small accumulations of blood-corpuscles ; afterwards they

arachnoid," 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 (pacchy meningitis).

420 rATllOLOGICAL ANATOMY 01' THE BRAIN.

become pale. WhcD lliey consist of several layers, it is probable tbat they have originated from several successive extravasatious, the most reccut of whicli reveals the hacmorrhagic nature of the whole. When tlie quantity is small, and after undergoing transformation, these extravasations of blood finally constitute a simple expansion upon the internal aspect of the dura mater, which may be easily overlooked or erroneously considered to be an inflammatory exudation.

In consequence of tiie work of Virchow (' Wilrzb. Verhaudlungen,' 1857, ii, p. 134), which moreover was preceded by J. HofTmanii's (Giinsburg, 'Ztschr.,' iv, 1853, p. 176) assumption that in these haemorrhages we have essentially to do with hiumorrhagic 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 meshe.s of the product of previous pacchymenin- gitis (pseudo-membranes, newly formed cellular tissue), the blood comes from the newly-formed vessels of the latter, and therefore these htemorrhagcs gene- rally presuppose the exiitence of a former inflammatory process. Tiiese pro- cesses cannot be considered as primary fundamental disorders iu insanity (al- though in exceptional cases this may occur ; see ' Wiener Bericht,' 1858, p. 49 — 51); they occur much more frequently in the course of already existing mental disease : the larger hajmatomala which compress the brain may, how- ever, considerably aggravate the symptoms of mental weakness.

IJreniorrhage occurring beneath the arachnoid is quite a different and much more rare process ; it bus no special significance in mental disease (being gene- rally traumatic, or consecutive in general hfcmorrhagic diathesis, &c.). Here the haemorrhage is from the pia mater, in which ecchymotic patches are ob- served ; the l)lood may extend with the cerebro-spinal fluid into the ventricles and vertebral canal.

c. The Pia mater and Surface of the Brain.

§ 186. The pathological conditions of the pia matter and of the surface of the brain are so intimately connected, that it is necessary to consider them simultaneously.

Hi/peramia of the pia mater (and also, in a greater or less degree, of the contiguous cerebral surface) is frequently met with in autopsis 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, there- fore, a certain connection with the morbid state is to be ascribed. We must here distinguish the following two principal cases : —

PATHOLOGICAL ANATOMY OF THE BRATX. 421

A bigli degree of hyperacmia 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 intense, uniform injection of the smallest vessels with small stellate ecchy- raoses ; this may be so intense, that, having regard to the final symptoms of the disease, to it may be attributed the fatal issue (apoplexia vascularis) : there is frequently connected 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 tliis hypereemia 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 fre- quently very marked, of cerebral congestion. The mechanism of its production is, at present — as of '' active " hyperremia in general — unknown. In the cortical grey substance, this hyperemia fre- quently presents itself as a red coloration 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 commence- ment there is, at the same time, increase in volume and in consistence of the cortical substance. This hypersemia may easily pass into actual inflammation.

A very different, 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 oedema of the delicate mem- branes. This form is altogether chronic in its course, and is fre- quently associated with a greater or lesser degree of atrophy of the brain {" ex vacuo^^) ; but it may also be produced by heart-disease, pulmonary affections — perhaps functional disturbances in tlie circula- tory and respiratory functions, contraction of the foramina, &rc. ; in short, from mechanical causes which impede the venous return. The significance of these hypersemias, especially of that originating ex vacuo, is naturally not very great : the mechanical venous stases, on the contrary, always exert, in individuals predisposed, a certain influence upon the development and form of the disease.

Ekker ('De Cereb. et Med. Spin. Syst. Vas.,' Traject., 1853) Las made com- parative microscopic measurements of the smaller blood-vessels and capillaries

422 PATHOLOGICAL ANATOMY OF THE BRAIN.

of the cortical substance in mania, in dementia, and in liealth, and finds tliat in mania they are considerably dilated, llamaer found this to be the case with regard to the pia mater.

Anamia of the pia mater and cortical substance^ which is some- times met with in acute and chronic conditions as remarkable pallor of the cranial contents, merits, under certain circumstances (deduced from the clinical observations of tlie case), great consideration. It may be a co-symptom of general anfcmia. The great influence wliich 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 anomahes, is well known ; and it is also admitted that all sorts of symptoms of irritation or of torpidity of the central organs may originate from this source alone. We cannot speak so positively regarding the cause and symptoms of ana?raia limited to the brain : contraction of the small arteries through atheromatous processes may occasionally be assumed as the cause of special anaemia. "We must always consider that there is connected Mith this an insufficient and abnormal nutrition of the brain. When the anicmic 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 hypergemia ex vacuo^ and from mechanical causes, we observe chronic opacity and serous infiltration — cedema of the pia mater. This ccdema is extremely frequent, espe- cially after chronic 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, axlema of the- brain, coloration of the cortical grcv substance, rigidity of the arteries, &c., — in short, with states of ma- rasmus of the brain, — and appears to be of much less significauce in the origin and form of the psychical anomalies than the marasmus itself.

§ 187. Injlammal'ioti proper of the pia mater produces sometimes merely a more or less rapid thickening of the membranes, together with adhesion of these to each other. In the cortical i^rev sub- stance, however, the ordinary result of inflammation in the nervous tissue is softening, sometimes the secondary transformations of the softened tissue, and in both together the important adhesion of the pia mater to the surface of the hrain. These consequences of

PATHOLOGICAL ANATOMY OF THE BRAIN. 423

meningo-cerebritis are ordinary conditions in the latter periods of certain forms of iusanit3^

Recent conditions of this kind rarely occur after states of depres- sion, more frequently after acute mania (see § i86). Thus we frequently fuid, after sudden death in acute mania, intense hyper • semia of the cortical substance, particularly of its middle layers, with (inflammatory) wine or violet-coloured softening or sponginess of the tissue, which, if the patient continues to live, undergoes a still more ])rofound alteration — viz., hardening and atrophy of the tissue, — dementia being the result.

These inflammatory softenings of the grey substance are some- times very difficult to recognise, 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 ob- servers have found the various layers of the grey cortex separately diseased: Sc. Pinel, redness of the middle layer in mania; Bail- larger, redness of the inner aspect of the four internal layers, or of the three grey strata.^ j\Iost 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, 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 chronic insanity, particularly in the secondary states of weakness, in the mental disorders of the drunkard and epileptic, still it is by far most frequent in paralytic dementia, and constitutes one of the most important organic elements of this affection. Calmeil found it to be the most frequent 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

' " "Reclierclies sur la Couclie corticale," etc., ' Mem. de I'Acad. de Medeciue,' 1840, p. 172.

■ L. c, p. 249.

2 ' Wiener Bericlit,,' 1858, p. 237. This slatemeiit is worth mentioning, as opposed to the opinioa that chronic meningitis (often with intlammatiou of tlie

424 PATHOLOGICAL ANATOMY OF THE BUATN.

nerve-tissue, afterwards pass into a state of atropliy and induration. It is always the most superficial layer which first becomes atrophied and indurated, and as a callous, thickened membrane, adheres to the likewise dense and tendinous pia mater ; the atrophied 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 ofi" as a coherent, somewhat consistent membrane, leaving beliind 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 origmally arises from softening; the atrophy of the cortical substance througli this kind of shrivelling — analogous to tlie shrivelling of other parts after inflammation (cicatrical tissue) — may be so considerable as to reduce it to an extremely thin layer, and it may even seem to have com- pletely disappeared.

jUI these disorders in which, according to the microscopic investi- gations of Rokitansky and other observers, increase of cellular tissue in the grey substance is the principal result of the inflamma- tion, are, as we have before remarked, associated with dementia, and in particular with paralytic dementia.

D. The Cerebral Substance.

§ 1 88. Volume and consistence of the brain. — In certain cases we find in insanity, as well as in epilepsy, hypertrophe of the brain. In such cases, the skullcap, after having been removed, cannot be re- placed ; the membranes are thin and dry, the ventricles small, and the convolutions flattened. Sc. PineP states that he has several times met with conditions of this kind after paralytic dementia — increase of the cerebral substance, with atrophy of the cortical grey substance ; a statement which, as yet, stands so isolated that little

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 tlie publication of his first work, returned to the opinion which he then held, viz., that this was the case ; Duchek and L. Meyer suppose menin- gitis to be the principal cause of the maniacal excitement in paralytic mono- mania. » ' Path. C6rebr.,' p. 369.

PATHOLOGICAL ANATOMY OF THE BR.MX. 425

value can be attached to it. The acute, dry swelling of the cerebral substance, which frequently occurs as an important epiphenomcnou at the termination of many other cerebral diseases (softening, tumours, S:c.), is associated with anfcmia of the brain and its mem- branes, and in the present state of our knowledge may be regarded as a peculiar acute hyper trophe, 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 brain — 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 fun- damental 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 inflam- mation, of prolonged hypersemia, or of compression owiug 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 unfrequently the atrophy takes place unequally, so that their surface, especially in the anterior portion of the hemispheres, is uneven. The grey substance, in particular, is considerably reduced in volume, and of a brown or wine colour, sometimes more incompact than in health, but more frequently it is hard and shrivelled. The white substance is often of a dirty-white colour, very tough, and crumples up when cut ; occasionally 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 cel- lular tissue presents that special increase discovered by Eokitansky : 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 de- stroyed, shrivelled, 6cc. The vacant space in the cranium is occupied partly by hypertrophe of the bones, partly by thickening of the mem- branes, 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 ventri- cles, which become filled with fluid. The vacuum sometimes even

426 PATHOLOGICAL ANATOMY OF THE BKAIN.

gives rise to sanguineous efl'usions — certain apoplexies of the arach- noid may be due to this cause.

Tliese general or circumscribed atropines are frequently observed as the fundamental lesion in secondary dementia, after former states of exaltation, after repeated attacks of delirium tremens, kc. In 122 cases of chronic insanity observed by Parcliappe,^ there was a nota- ble diminution 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 arc not, however, constant in this affection, and the degree of the dementia is not always in pro- portion to that of the atrophy.

The induration, sclerosis of the cerebral substance, is essentially an increase of cellular tissue — the formation of true connective tissue, and more or less atrophy. In the highest degrees, the medullary substance is of the consistence of a hard-boiled egii, and when cut is as resistant as a piece of caoutchouc; the colour is generally dirty- white, blue, grey, without sanguineous points ; and the libration is, notwithstanding the great hardness of the brain, indistinct. There are sometimes observed in it traces of former apoplexies, with cavities llllod with serum, which when cut through resemble the holes in a cheese. This induration corresponds entirely to the various forms of dementia.

Here, with atropliy of the brain, would be the place to consider tlip results obtained by weighing the brain. J priori, we might imngine that the weight would best show the diminutiou iu volume. Two circumstances, however, ren- der the estimation of results arrived at in this way very difEcult: on the one liand, the weight of the brain varies considerably, even in healthy individuals ; and on the otlier 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 (sec 11. AVagner, ' Nachr. v. d. G. A. Universitiit zu Gottingcn,' i860, No. 7, Ko. 16). The general results at which Parehappe arrived (1. c, p. 142, and ' Comptes rcudus,' 31 Juill., 1848) appears to nie to be the most practical, namely, that an average moderate dimi- nutiou of weight takes place in insanity generally, and particularly in chronic cuses; he even considers it proved that there is a gradual diminution iu the weight of the brain corresponding to the progressing diminution of the intelli- gence. Further, the more recent investigations (Skae, 'Med.-Chir. Review,'

^ L. c, p. 140.

- And this in a patient afferted for the third time. Ohs. 22, pp. 19, 50.

o

PATHOLOGICAL ANATOMY OF THE BRAIN. 427

Jan., 1853; Sankey, 'Journal of Psychol. Med.,' 1855. p. 573; Buckuill, 'Brit, and For. Review,' Jau., 1857) regardiug the uiode of determining the specific gravity in certaia abnormal states appear to be of interest : the older iuvesti- gatious in this direction (Meckel, 1764 Leuret and Mitivie, 1832) 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 iu the brain" (increase of connective tissue?); and it is indeed possible that the two other observers include many brains of this de- scription. According to Buckuill, 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 diminu- tion in volume. But the methods hitherto employed in determining the spe- cific gravity of the brain are so unsatisfactory, that even these statements cannot be considered conclusive ; they rather show the necessity of more perfect modes of investigation.

§ 189. Amoimt of blood in the Lmin. — General liypenemia of the entire brain is sometimes observed in recent cases of insanity ; in its liighest degree (turgescence of the entire brain, dark-red colour of the cortical substance, strong injection of the pia mater and arach- noid, 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 hjperpemia limited to the pia mater and cortical substance of the convex surface of the brain. ^Yhen the disease has lasted for a long time, and especially iciihin the atrophied brain, the amount of blood is generally diminished. We have already spoken of the mode of production of cerebral hypersemia. 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 colour, and may give rise to exudations and inflammatory softenings.

The various observations regardiug the frequency of apoplexy in the insane do not all correspond. Esquirol, Georget, Guislain, Jacobi, and T. Hoffmann seldom met with it ; Webster, on the contrary, found effusion of blood into the brain 13 times iu 72 autopsies 3^ I have seen it occur in acute mania. It is at least cer- tain that traces of former small apoplectic clots are by no means

' 'Med.-Cliir. Transactions,' vol. xxvi, 1843, P- 4i3- I'^ his recent work (i85o) he states that in sixty-seven post-mortem examinations of patients in Bethlehem he found extravasation of blood in fifteen.

428 PATTTOLOGTOAL ANATOMY OF TIIK BRAIX.

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 neigh- bouring tissue, which it entails.

Amouni of serum in the braiw (oedema of the brain). — Special attention has been directed to oedema of the brain by the work of Etoc-Demazy.i According to his opinions, which arc also in part advocated by Sc. Pinel, we are led to consider acute oedema of the brain as essential in melancholia with stupor and immobility (§ 123), and as the fundamental cause of this entire group of symptoms. This statement, however, has not been confirmed : oedema 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 affection of the brain. In mental, as in other diseases, we find slight oedema of the brain under the most various circumstances : in its higher degrees it is sometimes observed after states of exaltation and of depression, but especially after paralytic dementia ; in general, it is associated with anaemia and more or less atrophy of the brain.

E. The Ventricles and Internal Parts.

§ 190. Dilatation of the ventricles (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 (/. e., it may have origi- nated in these conditions, even in states of depression or exaltation of sentiment), but more particularly after protracted states of weak- ness, and, above all, after paralytic dementia (together with oedema of the pia mater, the cerebral substance, increase of cellular tissue in the latter, osteophytes, &c.) : 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 paralysing the mental faculties through the pressure which it exerts) ; in general it

' 'De la Stupiditc consideree chez les Ali^n^s,' Paris, 1833 (ten cases and four autopsies).

PATHOLOGICAL ANATOMY 01' THL l3KAlN. 429

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 anomalies; and the latter con- sidered them — but incorrectly — to be the special pathological lesions in chronic dementia. They may be regarded as results of slight inflammation of the ependyma, and as such have a certain thougli very inconsiderable pathological interest.

In chronic hydrocephalus we generally find the ependyma ventri- cularum 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.2

The presence of so-called hydatids of tlie vascular plexus is too common to be considered an essential alteration j 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 headaciie (Nasse, ' Zeitschrift f. Au- thropologie,' 1823, i'» P- 5°^) 5 Bergmaun discovered a formation of pretty large crystals cf 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 induratiou is some- times associated with dilatation of the ventricles in atrophy of the brain (para- lytic dementia).

Regarding the 'pineal rjland (see also Grediug, ' Yermischte Schriften,' Al- tenburg, 1781, p. 180), Bergmanu has already shown, in his earlier works (Nasse's ' Zeitschrift f. Anthropol.,' 1825, i, p. 173 ; Holscher's ' Annalen,' 1. c, pp. 510, 523, 529, &c.), that in autopsies of the insane we frequently find con- siderable tumefaction and luxurious growth of the vascular plexus around the gland, in part together with an almost general hypertrophe of its pia mater, a border of granulations, an adhesion of the pineal gland to the vascular plexus on the lower aspect of the corpus callosum, and the like. Subsequently (' Zeit- schrift f. Psychiatric,' 1844, 1. c.) this observer declares, in numerous publica- tions, the abnormal tumefaction of the vascular plexus, displacement and adhe- sion of the pineal gland, to be one of the most constant alterations in chronic partial dementia : this opinion, however, does not appear to me to be at all founded on fact.

1 ' Ztschr. f. Psychiatric,' 1844, No. 2.

'' Tor example, Macquet, 'Anna!. Med. Psych.,' Mai, 1844, p. 464.

430 PATHOLOGICAL ANATOMY OF THE BRAIN.

The pUuitary gland also presents in insanity as well as in epilepsy, oeca- sional examples of pathological cliangc. Amclung (Nassc, 'Zcitselir. f. Anthro- pologic,' 1824, p. 352) found it transformed into tiiin purulent matter, after monomania with fixed ideas and suicidal tendencies ; F. Arnold (' Bemerkungen iiber den Eau des Hirns und Ruckenmarkes,' 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, a'dema meiiingum et cerebri, and exostosis basis cranii — hypertrophy of the gland ; its posterior lobe was transformed into a soft tumour of a greyish-rcJ colour, almost as large as a walnut, and filled with a creamy fluid ; the sella turcica was considerably atro- phied (' Wiener iknicht,' 1K58, p. 189).

The cerebellum has as yet received comparatively little consideration ; never- theless, Bergmaun's observations regarding the ventricular surfaces — granula- tion in the fourth ventricle, &c.— refer also in great part to the cerebellum ; and I'oville states that he has frequently met with adhesions of the pia mater to its surface along with a certain constancy of the symptoms during life. Besides, there are also many descriptions of rare diseases of the cerebellum in paralytic dementia by Arnold, Stolz (' Oestreich. Jahrbuciier,' Marz, 1844. p. 268), Lelut ('Annul. Med. Psychol.,' Mai, 1844, p. 462), kc.

§ 191. In reviewing these anatomical changes in the brain, it mav perhaps surprise us tliat no mention lias been made of the eerious degenerations whicli result from the ])roduetion of pseudo-plastic formations within the organ (cancer, tumours, u])on the basis cranii, tubercles, parasites, &c.). In reality these affections are rarely met with in asylums for the insane. It is not that they do not produce serious psychical anomalies — in the latter stages of tliesc cases states of mental weakness, and sometimes even profound dementia,* are usually present, and at the commencement they are frequently ac- companied by a melanchohc disposition or by maniacal excitement. These, however, are not in general the most striking symptoms ; the commencement is rather characterised by " apoplectic symptoms," - especially severe motory disorders (convulsions, paralyses, &c.) ; 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, &c., are merely accessory symptoms — therefore (p. 9) the afi'ection is not classed amongst mental diseases, and the patient is not sent into an asylum. In tliis relation and its immediate consequences hes the simple ex])lanation of the apparent

^ In the last stages of tumonrs, encephalitis, abscess of the brain, &c., there is frequently such profound dementia as is not even seen in the lowest grade of idiocy. These patients occasionally behave as animals do after the abstraction of the hemispheres.

- See ' Diagnost., Bemerkungen,' &c., by the Author, !. c.

PATHOLOGICAL ANATOMY OF THE BRAIN. 431

anomaly brought so prominently forwaixl by the opponents of the, pathological anatomical mode of consideration, viu., that very slight anatomical changes of the brain produce an effect (insanity) which the most serious and most profound alterations do not. Xeverthe- less, profound alterations of the cerebral substances are constantly and frequently found after death in the insane.

I again refer to the cases of Stoitz and Lelut, to a case cited by Romberg (Xasse, ' Zeitschr. f. Authropologie,' 1823, iii, p. 195), where, alter mania without paralysis, four " hydatids" were found penetrating several lines into the cortical substance, together witli 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 who, after headache and excitement, fell into dementia, there was found a fibroid tumour the size of an egg in the centre of the brain, involving the septum, fornix, &c. (' Wiener Bericht,' p. 190) ; the point of a penknife surrounded 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 en- cephalitis (ibid., p. 212) ; chronic tuberculosis of the brain with mental disease of one year's standing (Finkelnburg, Yirchow's 'Archiv,' sx, 1861, p. 524); finally, the numerous cases of cysticercus of the brain regarding which the following works may be consulted : — 'Med.-Chir. Transact.,' vol. xxvii, 1844, p. 12; Giinsburg, 'Zeitschr.,' i, p. 62; ii, p. 274; Virchow's ' Archiv,' ii, p. 84; ' Correspondenzblatt filr Psychiatric,' 1858, 8; 'Zeitschrift fiir Psy- chiatrie,' 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. H6pit.,' i860, 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 liis famous career (1835)^ viz., that pathological anatomy 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 excluding rare and more isolated observations, we shall attempt, in the following paragraph, to com- pare 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 :

432 pathol(jgical anaiumy of the bhain.

1st, Acute recent cases of melancholia and mania; and. Chronic cases of protracted, exhausting melancholia and mania, partial de- mentia and dementia ; 3rd, Paralytic dementia.

1. Acute Ih-'hih'iIi/.

§ 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 imtrition which are as yet unknown.

(2.) AVhen palpable disorders exist, they consist chieliy in anoemia, with more or less serous intiltration, or (more frequently) in hy])er- lemia of the entire brain, and particularly in simple aud ecchymotic liyperaimia of the delicate membranes and cortical grey substance. These hypera3mias appear sometimes to produce, and at other times merely to accompany, other morbid processes of nutrition wMch lead to further consequences.

(3.) This hyperremia 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 hypersemia 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, neverthe- less, not entirely identical.

(5.) In melancholia the brain appears perfectly healthy more frequently than in mania ;^ when an anatomical lesion exists, it does not consist in hypergeraia so frequently as in mania, but rather in aniemia with greater consistence of the cerebral substance, or with more or less serous iufiitration.

(6.) Mania presents more rarely tlian melancholia no lesion or simple hyperismia. The hypersemia is more profomid and more intense (sometimes attahiing to an erysipelatous liue of the entire grey cortex), and it more frequently proceeds to inflammation and softening, which affects the cortical substance in only certain layers, sometimes the middle, sometimes the external layers. The rapid

* Besides many observers whom we have already mentioned, Bertoliiii aud Bottex agree in this ; likewise most of the more recent observers ; see Vienna Report, p. 198.

PATHULOGlCAJi ANATOMY OF THE BRAIN. 43S

occurrence of extended softening of this kind frequently corresponds to a state of profound dementia which precedes death. The intense hyperpemias whicli accompany or produce the softening ajjpear partly <o determine the violent maniacal excitement. ^Frequently also, when the mania is of long standing, there is found pigmentation of the cortical grey substance.

II. Chronic Insanity.

(i.) Cases in which no anatomical lesion is found are here rarely observed ; the same may be said of simple hypersemias ; 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 con- volutions; chronic hydrocephalus, effusions into the subarachnoid space, pigmentation of the cortical substance, extended and profound sclerosis of the brain.

(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, hypera3mia ceases; when it does exist, it is of the nature of hyperemia ex vacuo ; sometimes the more or less atrophied brain is anaemic and oedematous. 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 difl'erence, anatomically, as between 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.)

r28

i31 rATHOLUGlCAL AxXATUMY 01' THE BRAIN.

III. Paralytic Btuientia.

(i.) 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 know that in such cases the microscope reveals important anatomical changes.

(2.) The changes most frequently observed in general paralysis are great oedema of the membranes, adhesion of the pia mater to the cerebral surface, greyish red softeniug, or coloration; and partial, superficial induration of the cortical substance, \\ith increase oi' 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, &:c. The increase of cellular tissue and development of true connective tissue occurs frequently 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) j 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 varieties. 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) j 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 con- clusions : —

(«.) 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.

(^.) In the majority of cases this is not the case ; it depends upon l)alpablc diseases which are generally distinct in proportion to the

PATHOLOGICAL ANATOMY OF THE BRAIN. 435

duration of the iusauity. These consist partly in hjpersemia and inflammatory 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, termhiate in incurable destruction and atrophy of the cerebral substance — a lesion to which the group of symptoms of dementia corresponds.

(c.) Frequently, however, it is non-inflammatory changes in nutrition, recognised 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 unin- vestigated. To these processes we may give the name of atrophic irritailon of the brain.

{(I.) Our knowledge of symptoms is not yet so far advanced as to enable us to state with certainty whether, in a given case of insanity, anatomical changes exist, and where they are situated ; but the facts which we observe enable us to speak with as much con- fidence as we can in any other diseases of the nervous system.

(e.) The most important circumstance in regard to anatomical diagnosis and to prognosis is the existence or non-existence of severe motory disorders, in particular of general progressive paralysis.

CHAPTEll II. THE PATHOLOGICAL ANATOMY OF OTHER ORGANS.

§ 193. In describing the pathological changes whicli take place in other organs, we shall restrict ourselves to those which are practically most important, or theoretically most interesting — in the hrst place, in so far as they are amongst the most fretjuent 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 essen- tially 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 discovered, 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 ])sychical significance of the viscera was framed. Such theories, although every day refuted by observation, 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 con- sidered as supplementary to what has already been said regarding etiology.

Of general or Hood diseases, those most frequently met with in the insane, especially in females, are the ancem'ic states (see § 106). In spite of the most careful nourishment, profound anremia with a waxy hue of the entire skin aud a general pufFed-up appearance is sometimes seen during the course of the cerebral affection which lies at the foundation of general paralysis. Thore (1849) found in these patients, even although suffering from pneumonia, a serous con- dition of the blood, the clots being without consistence. Many inmates of asylums for the insane, ])arMlvtics, dements, &c., die from

PATHOLOGICAL ANATOMY OF OTHER ORGANS. 437

anaemia and marasmus without any serious local affections, except, perhaps, a slight degree of atheroma of tlie arteries being dis- covered.

Typlius fever is rarely met with in the hisanc; nevertheless it sometimes occurs in an epidemic form, as, for example, in the asylum at Sclileswig (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 institutions devoted to chronic cases (for example, SalpiUriere) . The remarkable immunity which several asylums enjoyed from epi- demics of cholera (for example, Bethlehem in 1833, 1848, and 1849) does not at all depend upon the insane being less predisposed to its attack. The disease seldom exercises a beneficial influence upon the insanity ; it more frequently exercises an unfavorable effect both on the bodily and mental condition (marasmus) .

Dpentery is very common ; epidemics of it have been occasionally observed (for example, by Stoltz).- The mortality is generally con- siderable. In the epidemic just referred to, the disease had no appre- ciable effect upon the mental disturbance ; even periodic attacks of mania were neither interrupted nor prevented.

Regarding intermiilent fever, see p. 188.

Cancer appears to be rare amongst tlie insane, In tlie Vienna Asjium, only six cases were met with in 384 autopsies.

§ 194. Amongst the local affections frequently met with in in- .sanity, we may mention, in the first place, that much-discussed affection of the external ear usually described under the name of hsematoma of the ear (sethamatoma, also erysipelas of the external ear). The skin of the concha becomes swollen, smooth and tense, and indistinct fluctuation may be felt ; the entire ear becomes pain- ful, hot, and red. If cut into, there is observed a cavity filled with half-clotted, half-fluid blood, which rapidly fills again after being- emptied. Sometimes the cavity empties itself by spontaneous rupture. Upon closer examination, the tumour is seen to consist of an extravasation of blood under the perichondrium, which is thereby

' ' Ztscbr. fiir Psychiatrie,' ix, 1852, p. 173. " 'Psych. Corr.-Bl.,' 1857, No. 3.

438 PATHOLOGICAL ANATOMY OF OTHER ORGANS.

se])aratcd from the cartilage. In a few weeks the redness and swell- ing usually abate ; there remains more or less thickening of the afTocted 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 Ihis disease is still the subject of discussion, and there already exists an abundant literature on the subject — more so, indeed, than the question is worth. AYhile 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 hremor- rhngic inflammation of the cartilage analogous to ha^morrhagic ])achymcningitis j others, as connected with cerebral congestion), another class declares that it is solely caused by external circum- stances,— by injuries, sometimes by knocking the head against the bedposts — at other times, and particularly, by the pulling and tugging which the car 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 affection is almost solely confmcd 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 afl'ection 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 tlie ophtlialmoscope, changes in the eyes of the insane, and that these diseases are sometimes per- manent, sometimes transitory — coming and going with the paroxysms (the hitter consisting of hyperemia of the internal parts of the eye). These facts, though not sufficiently minute, are very interesting, and merit further inves- tigation.

§ 195. Amongst the other organic alterations met with in the insane, those of ilie thoracic organs are, on account of their great clinical importance and frequently fatal termination, the most important.

I. Abnormalities of the organs of resjnration. — The most im- l)ortant of these are pneumonia, pulmonary gangrene, and phthisis. A large proportion of the insane die of pneumonia, especially those with weak and deteriorated constitutions, and, in particular, many

' Gunsb., ' Ztschr.,' vi, p. 250.

- 'Ztschr. f. Psych.,' xvii, 18(^0, 2.

PATHOLOGICAL ANATOMY OF OTHER ORGANS. 1'39

general paralytics. Calmeil foimd pueumouia to be the cause of death in one fifth ; Aubauel and Thore, in one seventh ; in Sachseu- berg it was the cause of death in one ninths, and in the Schles^Aig Asylum (Gaye^) in one sixth, of the fatal cases. As in hospitals for old men, so in asylums for the insane, there occur, especially iu the winter months, many sudden deaths from this cause. These patients do not show, during life, the ordinary series of symptoms of pneumonia. Eigors are seldom observed; likewise cough, expecto- ration, and pain : dyspnoea, on the contrary, is usually observed in a greater or less degree : the only symptom which renders our dia- gnosis 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 thera- peutic measures are quite as ineffectual as in the pneumonia of aged persons. In an anatomical point of view, these cases present nothing peculiar. Lobular imeumonia is very frequent, especially in cases where the patients presented during life the symptoms of great exhaustion j 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 au'-passages (food, &c.).

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 hianition : in such patients, however, it was very frequent (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 consideT'ed the impoverishment of the blood — a species of scorbutic state — to \)t the primary condition and special cause of the gan- grene : 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 diminution of the general sensibility — indifference to cold, heat, and

^ 'Ztscbr. f. Psycli.,' x, 1853, p. 569.

^ "Mumoire sur la Gangrene des Poumons cliez les Aliunes," ' Gaz. Medic.,' 1S36, and iu the * Phrenopatlnes.'

440 PATHOLOGICAL ANATOMY OF OTHER ORGANS.

paiu ; who could stare for a long time at the sun, Sec. ]Yeithcr 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 ordinarily accompanied by violent symptoms. The gangrene is sometimes limited, sometimes diffuse ; in seven out of nine of Cluislain's cases, it was the left lung which was affected : in none of the cases was there gastritis present, which certain authors say always exists in certain individuals who refuse their food.

Since the publication of Guislain's work, gangrene of the lungs has been studied in the insane by Terrus, Calmcil, "Webster, Thore, &c. ; from the German asylums 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 i*6 per cent, of the other autopsies, in the Pathological Institute) were observed : of these, twelve were melan- cholies ; the others suffered from dementia, e})ilepsy, mania. Eefusal of food and bad nutriment were the principal causes ; on one occa- sion it occurred in a patient who had a tendency to eat his fteces. In the Yienna Asylum, in three years (1853 ^0 ^^55)) gangrene of the lungs was discovered fifteen times in 602 autopsies, and of these five were consecutive to refusal of food.

The observations which have hitherto been made incontestably prove that the disease is not confined to those cases in which food is refused in melancholia, although in these it is especially frequent. That in these cases the abstinence and the inanition are actually the cause of the malady, is shown by the fact that it also occurs in cases of stricture of the ccsophagus, and that in persons also who are pro- foundly weakened by inanition, gangrene is observed in other parts — in the cheeks, the genital organs, &c. ; 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

• Prager, ' Vierteljabrsclirift,' Bd. xiii, 1847, p. i. ' * Charite-Auualen,' v, 3, p. 154.

PATHOLOGICAL ANATOMY OP OTIlETx ORGANS. 441

generally the following : — After a period during wliicli 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 odour; the physical signs are those of pneumonic solidification, pleuritic exudation, of a cavity — sometimes of pneumo-thorax and haemo- ptysis : extreme emaciation and weakness, diarrhoea, &c., set in, and death from ansemia, pyaemia, pneumo-thorax, or profuse haemor- rhage ensues, in from ten days to three weeks. In profound melancholia and dementia, the symptoms are sometimes very insig- nificant.

Example L. — Melancholia after mental impressions ; refusal of food ; death ; gangrene of the lungs. — During our last political agitation, a lady, iet. 54, ol" 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 viofent 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 iu exhortation by her family ; a thousand questions were asked, all sorts of food was 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 off 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 Eebruary, 1831. I recognised her refusal of food in the colour 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 colour ; the cheeks, point of the nose, and lobes of the ears were bro\vn ; the pupils were dilated, and the white of the eyes was glistening and of a blue 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 recognised in the iris.

It was only with great 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 emaciation made fearful progress ; the countenance became brown, the lips somewhat livid ; and soon the hands and feet, especially at the phalanges, became perfectly cyanotic. The patient always strenuously resisted being fed ; she became motionless, and soon an ecstatic condition was added to the symp- toms 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 resist- ance, we had recourse to the swuig chair, but without success.

Her breath had an insupportable odour ; the sputa were brown, streaked

442 PATHOLOGICAL ANATOMY OF OTHER ORGANS.

with briglit red; in a few days the expectoratiou becaiue copious, notaclually purulent, but sanious. The countenance had so fallen, that the patient seemed lobe of great age. She gradually became weaker; occasionally she took a little food, and during the last few days took anything that was offered to 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 l)l;iek bile, and the spleen and mesenteric vessels contained blood so very dark ill colour as to conQrm me in what has been said regarding this condition by the celebrated Tlaller.

As I, after opening the thorax, was lifting up the left lung, my finger pene- trated its substance ; and such an insupportable odour 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 colour, interspersed 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 gangrenous limb, permeated the pulmonary tissue ; here and there a few puru- lent particles were seen. On scraping with the scalpel, the blade became covered with a brown, viscous, 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 riglit lung was healthy. (Guislain, " Memoire sur la Gangrene dcs Poumous chez les Alicncs," 'Gazette Mt'dicale,' 1836, p. 341.)

The frequency of phthisis puhnonalis in tlie 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, &c.).

Esquirol considered that more than a third of his melancholies were phthisical ; Calmeil found tuberculosis in ^ ths, Webster in |th, Sc. Pinel in -,',th of their autopsies ; in Vienna it was met with in more than Vrd (in a total of 602 autopsies made in the three years 1853 to 1855) ; in Prague, in 1842 and 1843, in more than -|ths (Fischel) ; in Eberbach, in 4-th ; in the asylum for chronic cases at Colditz, in -f^ths (Voppel) ; in Palermo, in thirteen years, in 192 cases of death, in almost -jth (Piguocco) ; in Hanwell, in four years, amongst the female patients, in not quite -ith ; in Bethlehem, in six years, 1842 — 1848, in -^th ; in certain asylums — for example, in Bicetre — its rarity is remarkable (There, 1. c). The general statistics made by Ilagen^ for a great many asylums show

' ' Ztsclir. f. Psychiafrio,' vii, 1850, p. 257.

PATHOLOGICAL ANATOMY OF OTHER ORGANS, 443

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 particular to Vienna and Prague ; but for the rural population this estimate is for most locali- ties far too high, so that we must still assume that phthisis is more frequent amongst those who inhabit 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 im])rovement of the one always coincides with aggravation of the other. Still, this inter- change 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 § io6).

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 oedema 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, S:c. Hypostatic hyperemia of the lungs is also frequent in those who have lain for a long time in the same position, &c. These various affections present nothing peculiar in the insane ; they are worthy of mention principally on account of the attention which their diagnosis demands durmg life.

II. Affections of the heart. — Xasse," from statistics gathered from the older works on the subject, concluded that heart-diseases were frequent and of great importance in the insane. Subsequent

' Jacobi aud Xasse, ' Ztschr.,' i, p. 677. - ' Zeitschr. f. Psych. Aerzte,' 1818, i, i.

-444 TATIIOLOGICAL ANATOMY 01-' OTllEJl ORGAN'S.

observers differ much in their ojjinions regarding their frequency (Esquirol met with affections of the heart in only one fifteenth of his melanchoHcs, AVebster in one eighth, Bayle in one sixth, Cal- meil and Thore^ in almost one third). The newest and most rehable statistics show only a very average frequency. In the A'ienna 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 i)ost-mortem exami- nations of insane women. According to these figures, wc may assume that the ordinary affections of the heart are rather rare than frequent in the insane. Dilatation and incrustation of the aorta occur more frequently (for example, in about one sixth of the 6oi cases examined in the Vienna Asylum), which is naturally, in many cases, connected with other affections of the heart and with sclerosis of the cerebral arteries.

§ 196. AhnormaUties in the aMom'inal organs. — Amongst the acute organic diseases to which the insane succumb, acute intestinal catarrh occupies a prominent position. It appears in the ordinary manner, as injection with secretion of mucus, kc, or with follicular ulceration, or as 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 colli- quative diarrhceas whose appearance in exhausted and weak indi- viduals is very properly considered as ominous ; the maceration in the ileum may exist without diarrhoea. Many general paralytics, and not a few melancholies and maniacs, are carried off by these diseases. Their causes are obscure ; in many asylums the im- moderate use of purgatives may contribute to their frequency. Their diagnosis is difficult ; loss of appetite, meteorism, rapid fail-

' See tlie writings of Esquirol and the forementioned work of Tliore.

- 'Vienna Report,' p. 204. Certain recent alterations originating sliortly before deatli are not included : I also thought it necessary to exclude fourteen cases of mere thickening of the valves. Amongst the cases of insuflBciencj, there are many very slight changes in the aortic valves, and many cases of simple hypertrophy.

^ ' Ann. M^d. Psych.,' vi, 1854, p. 659. For the frequency of heart-disease in the reports of Voppel, see the above, p, 200.

rATHOLUGlCAL ANATOMY OF OTHER ORGANS. 445

ing of the strength^ and diarrhoea 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 narroiolng of the lurfje 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 iii every pathological theatre. Occasionally there may be a certain degree of contraction of the intestine in consequence of prolonged catarrh.

Bisplacement of the colon, which Esquirol, and afterwards Berg- mann and others, considered to be an important and frequent ano- maly, is likewise altogether immaterial. Most frequently it is caused by the transverse 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; Eokitansky (ii, p. 871) observed " considerable increase in volume of the central abdominal ganglia in a case of eminent hypochondriasis, together with general tabes ;" anomahes 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 delirious ideas (a patient of EsquiroFs declared that Pontius Pilate, all the persons mentioned in the Bible, and a council of popes, were in his belly; another, that there were several devils there) ; foreign bodies in the intestinal canal, such as cherry-stones, which in some cases are swallowed in large quantities — an entire spoon that has been swallowed, &:c. : organic diseases of the liver ; intestinal entozoa (sometimes these are found in unusual localities) •} diseases of the

' Hayner (Nasse, ' Zeitschr. f. Psjch. Aerzte,' 1818, Heft 4) narrates the case of a patient who believed that he was going to die of starvation, and con- stantly complained of something living in his stomach and which rose to his throat. After death, seven lurabrical worms were found in the gall-ducts of the liver, one sticking half in the ductus cholcdochus and half in the duodenum,

446 TATHOLOGICAL ANATOMY 01-' OTHER ORGANS.

ineseutei'ic glauds (Bonet 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 exceed- ingly rare amongst the insane as a primary affection, but the slighter forms which accompany the various marasmatic states are naturally common. 1 Finally, the diseases of the male and female genital organs (prolapsus, hypertrophies, malignant polypoid degenerations, &c.) may be mentioned as important anomalies. The latter (fibroid tumours of the uterus, infarctus, ovarian cysts, &c.) rarely give to the delirium the character of sexual excitement ; they rather occasion a liystcrical disposition which may be important in regard to the origin of the entire mental disturbance. The older as well as the more recent psychological literature abounds in cases of this de- scription,- 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.

and from thirty to thirty-six in the duodeuum itself. In another case of sudden mania, a lumbrical worm was found in the ductus choledochus, and several others in tlie duodenum.

1 Eischcl, in Prague, had only 3 cases of Bright's disease amongst 2400 patients ; the Vienna licport 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 Insanity,' Ulm, 1824.

BOOK FIVTR.

THE PROGNOSIS AND TREATMENT OF MENTAL DISEASE.

CHAPTER I.

PROGNOSIS.

§ 197. The prognosis iu mental disease involves two separate questions. In the first place, Does the existing disease endanger life ? and in the second place, If life he continued, lohetheVi and to what extent, may recovery from the mental derangement he Jwjied 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, &c. (which are to be estimated according to established principles), than upon the presence of the cerebral affection. Amongst the purely cerebral afi'ections, the most rapidly fatal are those serious degenerations of the brain ^Yith the symptoms of general paralysis (see above), because they, as a rule, prove fatal iu from one to three years, and very often in even a much shorter period. Of unfavorable prognosis are likewise extensive and in- tense hypertemias of the brain, which occasionally, at a certain stage, lay the foundation of mania, but more frequently come on paroxysmally during the course of that disease ; they may rapidly advance to acute softening of the cortical substance, or may prove almost immediately fatal by causing serous effusions, extravasation of blood, &c. CEdema 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 melan-

448 I'KOGNOSIS.

clioliiv and inaninj than in those conditions of chronic irritation or more gradual, but incurable, changes of structure in the brain which give rise to clironic forms, to monomania, to melancholia Avith 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 difference.

The mortality is always greater in those establishments destined specially 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 disease, 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 different countries and in various institu- tions. 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 mor- tality was 6 — 9 per cent. ; St. Yon, a general asylum, over 7 per cent. ; "VYiunenthal, almost solely devoted to curable cases, in the twenty years from 1834 to 1854, 1 1 — 12 per cent. ; Siegburg, in the four years from 1846 to 1850, 10 — 11 percent.; Sachsenburg, in the ten years from 7840 to 1849, 16 — 17 per cent.; Hanwell, 12 per cent.; Lenbus (for curable cases), in twenty-four years, 16 ])er cent. (]\lortini) ; 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 differences presented by these superficial quota- tions. Hitchman (1850) came to the conclusion (from the statistics of Hanwell) that the normal ratio of mortality is tripled iij mental disease.

§ T98. The decision on the second (jucstion in our progno.>i?

PROGNOSIS. 449

viz. the curahility of the inmnity when life is not endangered, is to be determined 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 agreeing with each other in their various particulars (for example, the incurability of secondary dementia, the influence of the duration of the disease upon the prognosis, kc). It must, however, be borne in mmd that many statistics regarding curability are not to be implicitly trusted ; the word ciired not being universally employed in precisely the same sense, and no statistics can bring to view all the complicated cir- cumstances which in concrete cases determine the decision as to the curability of the malady.

A primary consideration, and indeed the most important as re- gards the question of curability, is the form of the iiisanity and the period of the disease. Thus we consider as quite incurable every form of secondary dementia (with which, however, we must not con- found melancholia with stupor, nor the temporary profound suspen- sion of the faculties frequently observed after mania). Chronic mania is scarcely more susceptible of radical cure; occasionally, how- ever, it admits of considerable improvement, 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 hallucinations. In the last case, also, the fixity of the ideas depends upon total perversion of the psy- chical individuality, which renders it impossible for the patient to throw off the idea that continually follows him, to distinguish his former self 'mid the confusion of his whole manner of contemplation ; in a word, to become himself again. Any real improvement, there- fore, (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 obser- vations (which correspond exactly with those of Flemming) go to prove 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 psy- chologists (Jessen, Ideler, Falret, Terrus, Haslam, Eush, &c.) de- clare that mania, especially manie agitee, is, generally speakinir, the

i>9

450

PROGNOSIS.

most curable form of insanity, it may be that they come to that conclusion from the results of practice in asylums, into which sim- ple 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 in the order of curabihty. For, very natu- rally, in even the slighter cases of mania, the aid of the asylum is sought, owing to the condition of exaltation ; while many cases of moderate inelanchoHa 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 freciuently a rapid interchange of both takes place, forming a continual vacillation between exaltation and de- pression.

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 ihan manie agitee. In melancholia, too, the appearance of halluci- nations is decidedly unfavorable ; those especially which refer the malady to external agencies (to other persons, to witchcraft, &c.) are remarkably persistent, and introduce 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 delu- sions (Zeller).

In thus forming a prognosis upon the form of the disease, the most important consideration is always the determining whether the mental disease 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 in- dications, 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, which degeneration often takes place after years of alternating ame- lioration and relapse. On the one hand, the cessation of all dis- turbances of the physical state, especially with increasing emhonpoint, and on the other, all permanent anomalies of motion and of sensa-

PROGNOSIS. 451

tion (convulsions, cliauges in the state of the pupils ; loss of smell, of taste; eating of fEeces, fixing the eyes upon the sun, obstinate' wandering muscular pams, &c.), are to be viewed as decidedly un- favorable symptoms, and such signs as the following : the absence of a return to normal tastes, to healthy inclination for employment— the constant leanmg towards unbounded whimsical exaggeration, unaccompanied by exaltation of the sentiments— increased incoherence of ideas, stupidity of countenance, &c., 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 unportance 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 the first six months of the disease, amounted to 68 per cent.; after two years' illness, 18 per cent.; and, after a duration of four and a half years, only 1 1 per cent. : in the Eetreat, of admissions within the first three months, 80 per cent.; from three to twelve months, 46 per cent. Jessen's re- coveries 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, 13 per cent. : in Leubus, of admissions within the first half-year, 64-16 per cent. ; withhi 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 pro- portion of recoveries may be estimated at 70 per cent. (EUinger) ; and Esquirol estimates that after three years' duration of the disease only one in thirty of the cases recover. The hope, therefore, of complete recovery becomes dim, if no appreciable step towards im- provement takes place within a year. Examples, however, are not unfrequent of recoveries after six, ten, ox even twenty years' illness, as may be occasionally observed in institutions devoted especially to chronic cases. This occurs more frequently amongst females, in whom a favorable influence is sometimes exerted at the climacteric period.

Eegarding 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 paroxysms, are decidedly unfavorable. It generally happens, that

452 PROGNOSIS.

with patients who fall iuto 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 disease generally (but not always) denotes that it will be slow in its course and difficult 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 standing. Irregular alternations and violent displays are always more favorable than a prolonged continuance of the same symptoms : for instance, a constant state of maniacal excitement, a permanent and, at the same time, moderate gaiefe, constant voraciousness, prolonged re- fusal of food, &c. Nymphomania, 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 favor- able symptom, inasmuch as a period of melancholy frequently precedes recovery, or, at least, sadness of humour is followed by a lucid interval : so, also, in every case the return of proper senti- ments, of former desires and favorite pursuits (work, music, kc), of memory, of desire to see relatives, kc, are to be regarded in a favorable light. Numerous hallucinations coexistent with a state of calm are unfavorable. A perfect state of physical health (re- garding which we can only speak after a minute and thorough examination of all the organs) in long-standing mental derange- ment is, and very properly too, regarded as an inauspicious circum- stance. On the other hand, the return of former bodily ailments, which had disappeared during the disease (as toothache, headache, oedema, hccmorrhage, &c.), is occasionally, though by no means frequently, observed to coexist with decided improvement in the mental state — sometimes, indeed with rapid recovery. All remis- sions, and all intermissions and lucid intervals, becoming gradually longer in duration, are naturally favorable. But the best pro- gnostic sign of all, is a knowledge on the part of the patient of the

PROGNOSIS. 453

internal trouble — the feeling of illness, and a reaction of the former self against the state now recognised as a morbid one : nevertheless, as Jacobi justl}' 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 favor- ably, 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 general 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. TTith regard to cases of hereditary insanity, there is a preconceived and all but universal opinion that the prognosis is absolutely hopeless ; hence the frequent 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, &c. — 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 capriciousness, their originahty 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

454 PROGNOSIS.

between hope and doubt ended by disappointment, after intense passion causing mental devastation. These deep wounds do not heal without loss of cerebral substance ; they are often followed by com- plete 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, &c.

The primary idiopathic affections of the brain are, generally speak- ing, much more serious than the secondary and sympathetic. Mental diseases following upon injury to the head, acute meningitis, sangui- neous apoplexy, 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, ansemia, acute congestion of the brain, indigestion, menstrual and many other derangements of the sexual organs, are amongst the physical states which contribute to the development of mental diseases of more favorable prognosis. In insanity resulting from inveterate drunken- ness, 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 extraordinary 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 existing local disease successfully treated. Eecovery, on the other hand, is impossible where monomania has set in, and par- ticularly where the patient has hallucinations referring to personal intimacy of the most debased kind with the supernatural, together with a tendency to masturbation. Hysterical insanity, acute in its outbreak and with violent agitation, is of better prognosis than when it is passive, characterised 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 curabiUty, 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 efi'ective 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 hfe is rendered impossible in the midst of whicli

PROGNOSIS. 455

the mental malady arose, and from whence it constantly derives new vigour, no false illusions need be built regarding the possibility of cure; nothing can here be expected from nature, whose efforts are thus rendered ineffectual.

§ 20I. A consideration of the chances of recovery in insanity affords, upon the whole, very gratifying results. From the statistics of institutions 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 shght feebleness of intellect, continues irritable in temper, has occasional tics, or is possessed of certain eccentricities, which, however, permit him to take part in the simpler 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-regulated institutions, such as Winnenthal.

It is evident that by such improvement is to be understood, not only a state of outward calm, but an essential alteration compre- hending 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 reaHty 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 P.), whereof there were 445 recoveries (260 M., 185 1\) — equal to 31 per cent. Sieg- burg, from I st 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. Prom Sonnenstein, during the five years 1846-51, there were dismissed recovered 33 per cent, of those admitted. These

456 PROGNOSIS.

results correspond in a remarkable manner with one another; and when Plemming 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 I cannot at all endorse his statement regarding the (yiLrahilitij of insanity.

§ 202. The mere disappearance of the more striking symptoms, the cessation of the fury and the delirium, cannot be regarded as certam signs of complete return to mental health. The patient may become quiet to all appearance, and learn to conceal many false notions which arc nevertheless inwardly cherished by him ; and this jnay even coincide with a striking improvement in the state of general health. The most important symptoms of really returning sanity are rather the distinct appreciation 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 point of view. Witli 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 com- menced with perverted dispositions and emotional states, so it is this phase of psychical life that is specially to be looked to in its dis- appearance. "When at length the intelligence appears unimpaired, but where abnormal aversions still exist towards certain individuals, or a vague state of sullen anger and passion, or perhaps merely a state of psychical exaltation, is retained, which renders the patient very irritable ; so long as the patient cannot bear any reference to his former malady, and solicitously shuns everything that may recall it — where, m a word, anything strange is still obsers^able in his feel- ings, demeanour, speech, physiognomy or glance — we cannot say that full recovery has taken place. The foundation of recovery is rather a perfect quietness of mind ; the individual who is radically cured speaks freely of his malady to those aroimd, 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

PROGNOSIS. 457

his dismissal from the asylum, without trying to hasten it, entirely to the discretion of the physician.

Those recoveries which take place gradually, with steadily pro- gressing consciousness of the internal malady, are, generally speaking, more lasting 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, &c.), which had evidently exerted an influence upon the development of the mental disease, remain unhealed. In such cases, the verdict of full recovery from the insanity need not be delayed till the restoration 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 certain diu-ation of the psychical feehng of wellbeiug is required to distin- guish permanent recovery from mere lucid interval — ^just as we would not pronounce a case of epilepsy to be cured after months even of freedom from the attacks, but first wait for a longer period the full confii-mation 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 (lessen, C. G. jSTeumann, 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, &c., and that, to a certain ex- tent, a favorable interpretation is dae to those events when they occur coincidently with mental improvement. These phenomena appear, however, more frequently as results than as causes of the recovery ; very often they are wholly accidental occurrences, and the fact of their frequent complete absence would of itself suflBciently refute the opinion of Esquirol.

§ 203. The proportion of the permanent recoveries must be esti- mated by the number of relapses. Jacobi estimates that of 100 recoveries about 25 are readmitted. Parchappe gives 164 relapses in 498 recoveries. Parr, for the English county asylums, gives 1200 relapses in 5486 recoveries (more than one-fourth). Julius, for the York Retreat, makes the official statement of 3 1 relapses to

458 PROGNOSIS,

TOO 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 practice: this number is also given for the asylums of Holland (Schroder van der Kolk). Bui 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.

Kelapses 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 disappearance of the disease, and the greater susceptibihtv to physical aihnents mIucIi must exist after so serious a maladv. Too early dismissal from the asylum is likewise a fre(juent cause. To the first of these causes is also probably due the fact that rcla])srs are somewhat more frequent in the female sex (Schroder van der Kolk and l^irchappc). It should be remembered, too, liow rare complete and lasting recoveries arc in most chronic diseases, and how difficult it is to remove certain constitutional causes which may frequently have existed from earliest infancy, whose constant action has, as a consocjuence, a succession of diseases following the same pathological direction. It is not to \hv powcrlessness of our art, nor to a certain predestinated incurability of these forms of disease, 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, [u 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 cer- tainty predict a relapse ; the drunkard especially is each time dis- missed from the asylum only with the unsatisfactory prospect of soon seeing him again. Upon the whole, however, the prospects of re- covery in insanity are much 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 tlian in the various form of epilepsy.

CHAPTEE II. THERAPEUTICS.

Section I. — General Pnncijdes.

§ 204. The treatment of mental diseases has, in a very abundant measure, experienced the power of theoretical hypotheses, and the alternating influence of one-sided systems. The old humoral pathology taught, and till very recently, the elimination of black bile; the excitation theory sought, and still seeks, the increase or diminution of the action of the exciting powers ; and the followers of the theory of localised inflammation profess, although in opposition to every- day experience, 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 moralising ideas that were held by bigots regarding the treatment of insanity. One great principle, how- ever, pervades the whole system of modern psychiatric — the great principle of humanity in the treatment of the insane, in contradis- tinction to that former barbarism which sometimes persecuted the mentally afflicted with trials for sorcery and death at the stake; sometimes, and this in the most favorable cases, cast them into dun- geons, to be associated with criminals, where, beyond the influence of the medical art, and dej)rived of all human aid, they were con- signed to the realms of despotic cruelty and brutality. Certainly, it was that forced acknowledgment of insanity to be a disease — next to this, however, and mainly, it was that philanthropy which vindicated the claims of the insane from the standpoint of the common rights of liumanity — that first achieved their recognition as human beings by society, towards whom protection and help was due ; that they more and more became 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 labours 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

460 TllEHAPF.rTICS.

of dispute, and if wo, as physicians, allow our practice to be governed by it, we do that wliich tends more than anything, on account of its empirical results, towards arriving at our first and only aim — the recovery of the patient ; results regarding whose incompar- able superiority to the experiences of former times no further proof is necessary. It is not the glitter of an abstract principle of philan- thropy, however, that must guide us; it is practical utihty — the results of suitably directed treatment at the bedside of the patient, or in tlie 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 physician, or is most agreeable to the feelings of the patient, hut thut xoh'ick forks a cure. Psychiatric then should )iever degenerate from the 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 medicaments — baths, &:c. ; while, at the same time, everyday experience has shown that almost no recovery can be perfected without psychical remedies (which may only consist of work, discipline, &:c.). In spite, however, of the practical utility of this method, theoretical hypotheses have rendered it difficult for science to recognise the results of experience — the call for an unde- layed combination of mental and physical remedies in mcjital 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-powders, and perverted witticisms with clyster-tubes ? The votaries of physical 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, &c. ; and, as generally happens in such cases, science.

THEKAPEUTICS. 461

whicli 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 thera- peutics 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 import- ance of the principal plan of treatment, only a subordinate and meager 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 efiectually, directly, and imme- diately by the evocation of frames of mind, emotions, and thoughts, as by diminishing the quantity of blood within the cranium, or by modifying the nutrition of the brain, as, for example, by narcotics and excitants. The fact that medicines proved empirically to be efl'ectual have been employed in insanity, as in other diseases of the brain, requires no vindication ; the frequent 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 processes : we have, therefore, a very powerful means of successfully modifying indirect disturbances of the somatic state (of the circulation, the digestion, &c.) in the direct provocation of certain states of mind. It is true that serious disorganisations of the brain (as imbecility with paraly- sis) render (of course) all moral influences impossible ; but we know that insanity, at its commencement, consists very frequently of mere functional derangement, and that anatomical changes, if slight, do not render the success of moral treatment altogether impossible, pro- vided that 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 skillful use of appropriate means renders possible a certain development of the understanding. From this point of view, the treatment of insanity appears to be eminently personal ; it is simultaneously 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.

462 THERAPEUTICS.

§ 306. If the treatment of mental diseases (especially tlie physical) agrees in a great measure with the principles and practice of ordi- nary therapeutics, so also can we, with the greatest possible clear- ness and cogency, prove that several special claims are due to our department in every rational method of medical treatment. No- where is the desideratum strictly to keep in view the individual of greater importance than in the treatment of insanity ; nowhere is the constant consciousness more necessary 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 bear- ings, 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 indi- viduality 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 acci- dent excepted), that in no case should active treatment be com- menced 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 133 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 explamed 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 specially noted — the necessity of vigorous interposition on our part to prevent its assuming the chronic type ; interference at the earliest possible period, at the very commencement of the malady, and even before its full development is necessary : what has aheady 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. TTe must remember 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 beginning to make their a])pearancc. AVe nmst seek carefully to oppose each

THERAPEUTICS. 463

Bjmptoui of the malady, and every indication of tiie delirious thoughts ; and by a continuous and minute observation and strict superintendence 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, pro- perly speaking, due to direct medicinal interference, is seen from the similarity of statistics furnished by various asylums where the methods of treatment are essentially different (see page 466). It has been now long admitted that mental diseases are not to be cui-ed by any special method of treatment; a conclusion based 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 disease proceed spontaneously to recovery, ^vithout much positive interference, 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 physician (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 (§ 103- 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 everything that might excite nervous irritation, whether tlu:ough direct super-excitation of the brain, or disordered general nutrition and physical frame, or through ex- haustion of any kind, must be rectified. The removal of psychical causes consists mainly in the sini[)le prevention of their further

464 THERAPEUTICS.

effects, and in the temporary withdrawal of the patient from their influence. This, in general, can be done only by 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 deleterious influence of these circum- stances, 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 condition of carefully regulating the rest and activity of the brain (see following section), a key to the knowledge of the w^hole system of mental therapeutics. The prophylaxis of mental disease is seldom the subject of medical consultation. By its means insanity could doubtless be to some extent diminished, as marj-iages might be prevented betwixt members of a family who were manifestly predisposed to mental disease. With reference 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 much as possible encouraged. Everything tending to predominance of the imagination — physical weakness and effeminacy of disposition, or early sexual development — must be withdrawn. Care must be taken that, to the utmost possible extent, the external affairs of life are simple and methodical, continuous states of passion avoided, and habits of subordination instilled into the child. These, as has been justly remarked by Flemming, are not intended as mere abstract rules of good behaviour 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 organisation, and therefore upon a sound state of physical health and careful, unremitting attention to the removal of all diseases which have a tendency towards chronicity. The means em})loyed towards arriving at this result, being chiefly hygienic, must necessarily vary in each individual case.

§ 208. In mental diseases, as in all other derangements of the organism, a duly regulated measure of repose and actiAity 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 accustomed irritation, and still more of all stronger

THERAPEUTICS. 465

or positively injurious influences. The patient instinctively seeks this rest; he withdraws himself from every cheerful expression, from all bustle, fatiguing conversatioUj 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 uoisy amusements especially, the patient can receive now only painful impressions ; it is still more injurious to ply him with impressive exhortations, queries, and admonitions. The mental activity to which he was accustomed is now a source of irritation; and only retreat from the accustomed sphere of life, solitude, and perfect rest of the brain, can act bene- ficially upon those on whose minds everything produces too great agitation. This object may be attained, according to the require- ments of the case and its outAvard circumstances, through removal to retired and peaceful, and at 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 melanchoha, at its commencement and cHmax. 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 stillness would be injm-ious, and where a new impetus in the normal dii'ectiou is necessary to the psychical life to secure it against cessation and decline. In those alreadv 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 fii'st awakened — aye, energetically 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 iu 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, &c., 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.

30

466 THERAPEUTICS.

It appears once more that the general principles of treatment in insanity correspond in a remarkable manner with the means which experience 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 chronic nervous diseases, on the other hand (for example, conditions of muscular weakness), we pay no heed to the sensation of weakness felt by the patient ; Ave know tliat 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 innervation will again be ushered in and established. Brodie has repeatedly called attention to this point in the treatment of neuralgic and subparalytic conditions of the extremities.

§ 209. A very extended experience has shown that the above- mentioned requisites (§§ 207, 208) can, for the most part, only be complied with by totally changing the occupations of the patient, by entirely removing him from his usual neighbourhood, and by ex- posing him to the influence of new and perfectly different impres- sions.

In rare cases only is a simple change of residence, or a sojoui'u in some quiet and agreeable part of the country, at all useful. More prolonged 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 the excitement, and the most serious, perplexing, and dan- gerous scenes which have occurred 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 traveUing, or by change of abode, escape either from him- self 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 lunatic asylum, is, in the majority of instances, the treatment which is most prominently indicated. It is above all things neces- sary for the safety of the patient himself; for nowhere else, in ordi- nary circumstances, is he safe from the obtrusiveness and injudicious, though often well-meant, hiterference of his friends ; and nowhere

THERAPEUTICS. 467

else does he meet with that indulgeut forbearance which springs from a clear miderstandiug of his case. The relatives of the patient generally regard his ever-increasing ill-humour as a fault which he miffht readily overcome if he chose, and meet it with all kinds of admonitions, instead of with ordinary cheerfulness and appeals to his reason ; if, indeed, they do not look upon it as a case of obstinate 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, un- pleasant 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 convalescent to his home peculiarly difficult. Particularly in families where a disposition to the malady has already manifested itself, a careful and complete separation is natu- rally 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 asylum, 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 una- menable 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 ; whilst, uideed, in the majority of cases the first period of their residence in such an insti- tution 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 mis- fortunes 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 behaviour is concealed from over-ofiicious eyes, where the necessary surveillance is unobtrusively accorded him, and where he has usually a far greater amount of

468 THERAPEUTICS.

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 controlled by the example of the other ])atients, 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 resistance 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 depend 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, &:c., can be constantly and satisfactorily carried on. In this manner the patient becomes conscious of an intelligent, gentle, and constant superintendence, from which he gathers confi- dence 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.

§ 2IO. 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 overwhelming experience, been established as a fundamental principle, not only in psychiatric, but is daily becoming more and more recognised 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 influence on the future career of the patient as a citizen.

THERAPEUTICS. 469

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 unmistakeable 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, 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 unfa- vorably 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 wT-eks, seem to necessitate removal to an asylum, so long as it remains of a mild character and with a shght disposition 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 will studi- ously 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 illusions, and becomes disturbed by trouble- some hallucinations ; or if the case degenerates into one of hopeless stupidity or apathetic indiff'erence — removal to an asylum must no longer be delayed. However, the indication depends, in many cases, less upon the form and kind of the disease than upon the circum- stances 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 perfectly 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

470 THERAPEL'TIOS.

more deeply affected by intercourse with other lunatics, springs from the gi'ossest ignorance of the subject. In every well-ordered insti- tution 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 hopeless cases, which could not fail to exercise a deleterious influence upon him. Those patients who come into contact with one another, though on the best of terms, are at the same time profoundly indifl'ercnt about each other, each one being almost wholly occupied with himself. Many remark the insanity of others, and become cognisant of their own state by observing that a similar treatment is adopted towards them; and it exerts the most bene- ficial 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 sub- mission to all over them, and, from the recoveries and dismissals taking place around them, to become tranquil, and encourage the liope that they too will some day be dismissed.

Section IT. — Physical Treatment.

§ 211. The reflection that many of these patients recover spon- taneously under a system of treatment in favour of which nothing more can be said than that it is not positively injurious, will guard us against vulgar therapeutic illusions. The idea of some specific against insanity as a whole, or against its various forms, mania, melancholy, &:c., is counterbalanced by the reflection how widely difierent the diseases which give rise to the symptoms of insanity are in relation to the anatomical state of the brain and to the pathogenic. The prunary object of somatic treatment is the pro- gressing morbid state which led to the development of the cerebral disease, with special regard to the organs of circulation and respi- ration ; to the condition of the blood, of the secretions, of the gastro-intestinal 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

THERAPEUTICS. 471

diagnosis of bodily disease is often rendered verj 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, pnemnonia. Therefore ought the objective diagnosis to be the more carefully practised. "Where no rational indications in a pathogenetic point of view present themselves, the present state of the brain is exclusively the object of somatic treat- ment ; and according to the probability or certainty of cerebral irri- tation— hypersemia — or inflannnation, the treatment ought to be immediately directed against these conditions 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 tolerance is only apparent, since the patient con- ceals many adverse effects as nausea, in the storm of the delirium they are not observed, or by a peculiarity of his disease the patient endures them without complaint, while the action upon the organs in no case fails ; for example, erosion of the gastric mucous mem- brane by large doses of tartar-emetic : only in a few cases are uncommonly large doses of certain medicines, particularly purgatives and narcotics, given. In this respect there is great difference among individuals, and the effect cannot be reckoned beforehand ; therefore 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 tlian in long- protracted states of insanity. These latter cases, wbere 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 indications, it is advantageous to give medicines to the patient, but consisting only of indif- ferent substances, merely to show him that he is really considered ill, to sustain 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 hypochondriacs, &c. 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.

172 THERAPEUTICS.

§ 212. The use of bleeding, to which physicians have been led partly and principally by theories of inflammation, partly by the results of pathological anatomy — partly by the symptoms of the diseases, which are often violent — has in recent times been consider- ably restricted, and all are agi'ecd that the necessity for venesection s not to be inferred from dehrium, or any of its forms, even the most active, excited, and furious.

A state of generally diminished nutrition and anrcmia, not only after loss of blood and other canses 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 out- break of mania. In the states of extreme excitement which accom. pany acute meningitis, and in decided general plethora, it is more justifiable ; but even here venesection is generally quite superfluous : decided and rapid results are specially seen only in those sudden and violent states of congestion which sometimes 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 possible to spare the blood of their patients. Formerly, in Bethlehem all the patients were bled several times during tiie 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, de- clared 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 liber die Seelen Krankheiten,' translation by Konig, Leipzig, 1825, p. 149);

' Resumes of this subject are given by Friedreich, in Friedreich and Blu- roder's 'Blatter fiir Psychiatric ;' J. Nasse, in Jacobi and Nasse's ' Zeitscbrift/ i, p. 216 ; Smith, " On'the Bad Effects of General Bloodletting," &c., ' Lancet,' August, 1846; Pliny Earle, ' Americal Journal of Insanity,' April, 1852 (very comprehensive).

THERAPEUTICS. 473

Haslam, Foville, aud others, frequently employed it iu a moderate degree. It is remarkable that out of 200 patients upon whom Haslam performed venesection iu 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 present in delirium resulting from anfemia (il. Hall) : moderate cerebral congestion (warm head, redness of the eyes, &c.) does not at all indicate a necessity for venesection, as it is frequently the result of impaired general 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 cerebral congestions Ave 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 : some- times its long-continued application at regular intervals is attended 'with a favorable result. Simple hypersemias alone yield to these means ; that the true chronic meningitic and encephalitic processes can no more be removed through bleeding than other chronic in- flammations, will not surprise us if we consider the previous processes which there take place. Cupping-glasses should be applied to the shaven scalp or to the nape of the neck ; leeches should, where pos- sible, be applied in the neighbourhood of emissaries — behind the ear to the Schneiderian membrane, the veins of which communicate with the longitudinal sinus, &c. In women it may be sometimes neces- sary to apply the leeches 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.

PATHOLOGICAL ANATOMY OF OTHER ORGANS, 443 (part 2)

§ 213. In the treatment of hyperaemia of the brain, cold is extensively and advantageously employed, but not in the form of the ordinary cold plunge-baths, to which 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 later times Jacobi, have decidedly expressed themselves against the fruitlessness of this mode of treatment. \Te have our- selves seen cases where the douche was several times employed, and always followed by a visible aggravation of the symptoms : it is only in cases of melancholic stupor that it may occasionally be employed with advantage. The strong shower-bath should scarcely be employed as a means of cure, but rather as a means of punish-

474 THERAPEUTICS.

ment auxiliary to moral treatment; to this end it should only be continued for a short time, and, if neceseary, repeated during the day.

Amongst modern authors ■who still recommend the douche, Ideler may be especially mentioned (' Ciiarite-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, according to him, arises immediately from the passions !) during the period of remission in mania, in states of general sluggishness and stupor, in certain cases of melancholia and monomania, and also in individuals who have become affected through alcoholic and sexual excesses.

o

The application of 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, Src. ; 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. Inso- lation, wounds of the head, threatening apoplexy with 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 employ- ment and utility are tepid baths in older and especially in recent cases. Besides their cleansing and invigorating effect, they, by uniformly and gently stimulatmg the nerves of the skin, and mode- rating and regulating the respiration and heart's action, appear to exert a remarkably tranquillising influence in these diseases. They arc usually contmued for from thirty minutes to one hour ; in acute cases where there is extreme excitement this period is often in- sufficient, and in such cases the plan recommended by Brierre de Boismont, of leaving the patient in the bath for several hours, a uniform temperature of course being maintained, proves a very valuable means of treatment. This method, however, is not suitable

THERAPEUTICS. 475

in chronic conditions — in aged, weakly cachectic persons, when the pulse is weak — or in epilepsy and commencing paralysis.^ The bath frequently induces the mucli-required sleep. It often seems to pre'/ent hypersemia of the brain from becoming fixed ; and where the patients willingly submit to the remedy, there is scarce any contra-iudication to its use, excepting phthisis, evident anaemia, or general paralysis, whether incipient or confirmed. According to circumstances, sulphur, iron, aromatic plants, &c., may be added. Foot-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 then, facts from all quarters have been elicited proving the injury which it generally inflicts on the mentally dis- eased. Most asylum physicians are in a position to contribute examples of this : Flemming, Erieumeyer, Damerow, Sponholz, &c., have expressed them- selves decidedly upon this point. This violent proceedure seems much to favour the transition to general paralysis. The absurdity of sending patients to cold-water establishments, instead of into lunatic asylums, would be incre- dible 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. Guislaiu has laid down several rather indefinite rules for the ad- ministration of cold baths (from 14 — 17° R-, .5 — 25 minutes ('Lef. or.,' iii, p. 1 15) : he has found them, however, 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 quieting maniacal excitement by means of baths of half an hour's continuance, and of 13'^ E., appears to be very well con- sidered.

§ 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, especially 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 the cranial bones, are certainly useful, especially in certain melancholic forms, and occasionally in protracted transitions of the primary forms into states of weakness

1 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' (! !) continu- ance, with a constant stream of cold water on the head.

476 THERAPEUTICS.

(Jacobi). These also are applied to the skull^ to the neck, and even to more distant parts, and should only be continued till mode- rate suppuration ensues ; they are chiefly useful in a moral aspect, as the continued acute pain, which constantly forces itself on the consciousness, breaks the chain of morbid ideas, and prevents the mind dwelling on them. The seton might be advantageously em- ployed, especially in certain cases of injury to the head. The moxa and cautery, the latter of which was often ineffectually employed in former times in general paralysis, do not possess any permanent advantage, and are not now used. All these grave cutaneous irri- tants 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 power- less conditions gangrene may even ensue — dangers which are far from being counterbalanced by the problematic advantages of these applications.

Tartar-emetic ointment bad gone much out of use, when the account of some happy results gained by Jacobi .igain brouglit it for a time into favour. Tliia author had a part of the top of the head shaved, upon which he painted some of tlie 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 chronic mania and dementia, were improved by this treatment; Guislain and others obtained some good results from it in the same states, and also in melancholy with stupor, and other similar conditions. The employment of such means, which should only be used in desperate cases, is, under all cir- cumstances, wholly to be avoided in mania, in recent cases with great excite- ment, and in very sensitive irritable natures already exhausted by bodily or mental pain.

§ 215. At first sight, much might be expected from the direct influence 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 reme- dies are only serviceable within a limited circle of conditions, in which they are certainly very useful as means of cure, and, besides.

THERAPEUTICS. 477

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 effect, but in doses larger and longer continued — a method which must be admitted to be in advance of modern psychiatric. According to this method, there is given at first about one grain twice a day ; this is gradually increased to 3 — 6 grains twice a day, which is continued for several weeks. By this system, no appear- ances of intoxication are observed, and no unfavorable influence on the nutrition ; regular, indeed rather loose stools, where Ave 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 com- plete recovery. It is in harmony with numerous and concurring experiences, that in recent cases, in youug persons, and especially in women, in states of sadness due to the influence of anaemia, hypo- chondriasis, hysteria, and mental causes often advancing to great disquietude and excitement (active melancholy), such favorable influences should make their appearance, particularly also in many puerperal mental disorders, and in dehrium tremens. In the con- ditions of melancholy with stupor, and, above all, with great passive- ness ; 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, durhig a short existence of the malady, than in asylums.

See H. Engelken, ' Prot. derNaturforscber-Tersamriilung' in Bremen 1844 ;' F. Engelken, ' Zeitscbrift fiir Psychiatrie,' viii, 1851, p. 393; Schubert, ' Med. Yereinszeitung,' 1857, No. 24 ; L. Meyer, 'Ztschr. f. Psycb.,' i860. No. 4; Erlenmeyer, 'Arch. d. d. Ges. f. Psych.,' iii. i, i860, p. 53. Besides, many physicians, Guislain (' Lee. or.,' iii, p. 28), Micbea, Zeller, &c., have expressed themselves 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, digitalis is employed. Although it is primarily indicated by irregularity of the circulation, violent heart's action, great frequency

178 THERAPEUTICS.

of pulse, and by changes of structure in tlie lieart — and then it may be employed in melancholia as well as iu 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 efficiency. Digitalis has the advantage that it can be 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; tbe larger doses, which easily produce vomiting, should be only carefully and gradually administered. States of sexual excitement contra-iiidicate 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 rapid recovery has occurred in several cases of recent active melancliolia. But numerous observations have shown that frequently (although not invariably) a temporary remission of the melancholia and mania, sometimes a complete lucid interval, follows the awaking from the narcotic elTects 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 im- portance to obtain a short interval of calm, and in such cases anaesthesia may be employed : ether clysters (3j to 5J) may also be used to obtain quiet in 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, &c.) .

See Meyer, ' Charite Aunalen,' viii, 2, 1857, p. 69. Morel (1854) employed auEestliesia 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 exaltation, melanchohc anxiety, &:c., 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

TKEUAPJilTlUS. 479

fight, hearing (^loreau, Billed). In the hallucinations of chronic mania and dementia it has no effect, and numerous proofs of its uselessness in other cases may be found. Xevertheless, it appears to be beneficial in cases uhere simultaneously ^nth 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 hyperemia 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 dehrious ideas. Assafoetida has been recommended by Guislaiu in large doses, in hysterical affections of the mind. Certain medicines (Brucin, Hachish, Sec), 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 exceptional 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 iu snuiEng and smoking. The great predilection of many, especially chronic patients, for the irritation of snuff is well known ; and often a snuff goodhumouredly offered to an insane person prevents him breaking out iu 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 equalises the temper. The return of the desire should be watched 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.

§ 21 6. Those medicines which act upon the digestive canal are

1 But with great caution: we have seen, in a case in the Salpetriere, con- siderable emaciation, a state of marasmus, result. More recent experiences, which may be of some efficacy in hallucinations, by Boureau, may be found in the ' Annates Med. Psychol.,' vi, 1854, p. 555.

480 THERAPEUTICS.

the oldest, aud 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 ^ven with advantage in all recent cases associated with cerebral congestion, aud are the chief remedy in acute inflammatory states of the brain. Strong and rapid purgatives (croton oil, &:c.) are suitable in these cases; for a more moderate effect, senna, rhubarb, and the various saline purgatives, are used. The long-continued 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 hypochondrical states they often prove injurious. Drastic cathartics are to be entirely avoided where there is chronic disease of the genital organs, aud 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 dis- order of the gastric digestion ; occasionally, especially in melan- cholia, they are employed chiefly for their mental etfects ; in jjuerpcral mental disorders especially, a ra])id and favorable elfect is sometimes observed (Flemming). The so-called nauscant cure by small doses of tartar-emetic may, perhaps, through its long-continued nauseous impression upon the nervous system, modify the humour and inter- rupt the mental pain by substitution of a disagreeable bodily sensa- tion. In the same way, the maniac may be quieted by the pro- stration 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 efi'ects are, on the other hand, evident. The whole system of the nauseant cure is to be considered a remnant of the barbarous age of therajieutics, and the enormous doses of tartar-emetic (gr. xij — xx) which are employed by some are to be emphatically denounced. The con- sequences of such rough practice are not only the formation of pustules in the mouth and oesophagus, circumscribed gastritis, but rapid paralytic collapse may even result. Anthelmintics arc occa- sionally 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

THERAPEUTICS. 481

employed.^ The experiences of several practitioners warrant us in making further trial of this remedy. It is especially indicated in cases of sexual irritation, as seen at the outbreak of puerperal in- sanity ; in such cases it must be administered in considerable doses. The experiments with musk, phosphorus, arnica, &c., to "vivify^^ the brain, betray, in our opinion, an uncommon degree of ignorance of therapeutics.

Cooling remedies are frequently indicated — as nitre, acid drinks, &c. Bitters and tonics may be 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 mav be advantageouslv administered with it in cases of anaemia with emaciation. Emenagogues are frequently useful, par- ticularly at the commencement of insanity, partly arising from disorders of the menstrual functions : in chronic cases, also, men- struation is to be watched. More frequently, however, it is necessary to apply local treatment to the generative organs, as in uterine catarrh, aflections of the vagina, &c., so frequently the cause of functional disorders of nerve-centres, and so difficult to cure by internal treatment. Cases frequently occur where antisyphilitic treatment is necessary to counteract cerebral disease (p. 197). The employment of electricity without evident reasons for it is to be denounced; local nervous pains may occasionally by this means be successfully treated.

§ 218. Witb reference to diet and noiu'ishment, the fact that insanity often depends upon inflammatory processes within the cranium, might suggest the necessity of antiphlogistic regimen. Nothing would be more hurtful to the patient ; experience shows that these diseases, whether depending on such inflammatory pro- cesses or on simple irritation, are frequently associated with general anaemia and defective nutrition ; that frequently the appetite of the patient is increased ; that spare diet irritates and is positively injurious; that the 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 sufficient food. Of coui'se, the effects must be carefully watched,

' As, for example, Perfect, ' Selected Cases, &c., fron^ Michaelis,' Liepzig, 1789.

31

4S2 THERAPEUTICS.

and the diet regulated accordingly ; in acute meningitis, and in all febrile states, spare diet is prescribed ; in impaired digestion, simple diet, as milk, &c., with those Avho have led a life of dissipation, retirement, and simplicity, are often speedily beneficial. Water and simple beverages must generally be the drinks allowed (p. 490), and should be copiously administered in all recent and acute cases : tea and cofl'ee are forbidden in all acute cases. A common table in the asylum, where admissible, stimulates the appetite and social feeling among the patients, recalling to the memory of the convalescent those customs of society which are the external evidences of healthy sen- sations, and which they have in many cases forgotten.

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 observed, fresh and open air, and, in the less acute cases, abundance of out-door exercise on foot, or sometimes in a carriage. jS'o asylum is complete which has not space sufficient to admit of prolonged out- door exercise for all classes of its inmates — in gardens, airing-courts, &c. 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 nar- cotics. Except where special rest is necessary, the patient should be accustomed to early rising ; idle lying in bed, which, especially with women, so easilv becomes a habit, and leads to considerable enfeeble- ment of the whole muscular system, should not be allowed. It is only in certain cases of acute melancholy, where there is 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 congestion the temperatui'c should be kept low and the head cool.

Personal cleanliness is most important. The methods of attaining this are Avell known, and its object is not only to maintain the health and function of the skin, to prevent the evil effects of prolonged

THERAPEUTICS. 488

decubitus in paralytics^ &c.^ but the feeling of comfort which corre- sponds to external attention to the body is the foundation of mental M'ell-being ; and the habit of external care also promotes internal order and regularity. 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 dis- order and confusion distract the mind, and thns deprive it of self- adjusting power.

Section III. — Moral Treatment.

§ 219. Mental activity, constantly employed on account of its indi- rect action on the organic processes, is also used to call up ideas, images, feelings, and efforts, for the purpose of directly modifying mental anomalies. This is effected only to a shght extent by any positive influence exerted by the physician upon the patient, such as exhorta- tion, encouragement, or even surprises, punishments, looks, &c. ; 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 exciting causes, and a proper regula- tion of the external circumstances, are frequently sufficient, especially if the patient has also the feehng of subjection to a rational and well meant control, and is being gradually habituated to proper outward behaviour.

The more direct moral action, for the purpose of restoring mental health, may again be reduced to two indications, which may be understood 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 dispositions and ideas which repress and conceal the former (healthy) individuality must be uprooted and destroyed ; 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 recaUed and strengthened. If, as we have already hinted, there is some analogy between the 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. Tor in the moral treatment of the insane the creation of new ideas is not

484 THERAPEUTICS.

contemplated, but the re-establishment of the old ; it does not con- template any improvement on the ego to be replaced, the realization of uhich is the great object of education {e. g. to make it moral) ; but the sole object is the replacement of the former healthy ego, whether it may have been distinguished by virtues or obscured by manifold defects. Any attempts at improvement can only be useful after recovery. If the success of education is favoured by pliableness of disposition, so the moral treatment 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 sufiicient, viz. the simple removal of all hurtful influences. Is it, then, wonderful that so many of the insane completely recover in the hands of rough and unskilled persons ?

§ 220. As to the first indication, namely the weakening of the morbid dispositions, feelings, and ideas, the most extended experience shows that we seldom arrive at a favorable result by directly oppos- ing them. The diseased mind, even on account of its morbid state, will not receive remonstrances and advice, much less moral represen- tations ; above all, it will not suffer the procedure ordinarily directed against the bad dispositions of persons in health. This ill-humour proceeds necessarily from disease 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 coloured images which result from it. Much can be done to remove this ill-humour by physical treatment, by rational expective treatment, whereby the feeling may sometimes be got rid of by permitting its outburst as in mania ; sometimes the symptoms may be rejircssed, 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 exhortation, 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, to seek reasons for them, and irritates and exasperates him according to the force and acuteness of his opponent's arguments ; the raillery which always accompanies such reasoning is also injurious to him. The morbid ideas are not to be sulnlued by any kind of proof or evidence. To spread all his wealth

THERAPEUTICS. 485

before a patient who thinks he is ruined, to pull clown the wall in which another fancies his tormenting enemy is hid, would only irri- tate them and call their attention more forcibly to their false ideas : in very favorable cases we may obtain an apparent consent and com- pliance ; most commonly, however, they will only substitute one form of delusion for another of a worse kind. All this will be sufficiently explained by what has been said (p. 71) 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 direct means of evidence, occur in convalescents in whom fragments of the insane ideas still remain after the disappearance of the dis- order, and also in the early stages of insanity, where the rising insane notions confront 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 exhortation 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 aggravates, excites distrust and aversion.

Another means of direct opposition, to be reserved for rare and desperate cases, consists in the forcible repression of every expression of the insane ideas, in a judicious system of attack on every insane word or deed. The chief means of this kind is the douche, while the patient is simultaneously impelled to rational dealings and ex- pressions partly by constraint, especially by the consequent advan- tages of freedom, enjoyments, friendly impressions, &c.- Such open uncompromising attack on the insane ideas in order to obtain violent mental diversion can scarcely be attempted in some cases of chronic mania, where there is a general feeling 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 opportimity to indulge in his insane ideas : suppression of the hallucinations or complete cure, by such means, we hold to be impossible.^ The same

1 An exceptional case of this kind, a very interesting recovery by means of exhortation, may be found in Guislain, ' Lef. 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,' &c.

3 This opinion, expressed in the first edition of this work, has since been confirmed. Many patients whom Leuret considered cured were subsequently taken up by other physicians as still insane, and no one has followed Lcuret's

486 THERAPEUTICS.

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 discovers the intention, or rather deceit ; and if they succeed, they generally effect only an exchange of the insane ideas.

There arc certainly examples of rapid improvement by the excitement of violent passions, of anger, fear, &c., iu mental disease, perhaps most fre- quently 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 every 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 patient, whether it be with the view of temporary soothing, or pos- sibly 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, especially in deep melancholic conditions, since the insane ideas which the patient till then, at least inwardly, op- posed become rapidly confirmed.

Instead of logically arguing against the insane notions or con- firming them by sympathy, in circumstances where a direct expres- sion is required, these will be much better opposed by sim])le con- tradiction, a forbearing reference to the future, when the patient will be astonished at his delusions, an allusion to the past when he con- sidered 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 encouragement, by engaging the mind of the patient in matters that have no reference to the diseased ideas. This mental diversion is a fundamental principle in all psy- chical treatment, but as an active method is more adapted to chronic than to acute conditions ; it is effected in different cases by very various means, which are suited to the case according as they are unresisted, as the aim at cure is concealed from the patient. Of these means the most important is employment of a healthy kind (see p. 501) ; next to this stand all kinds of amusement, entertain- ment, conversation, which, with due regai'd to individual tastes,

mode of treatment. Nevertheless, his publication has done away with many prejudices, and the book is well worthy being read.

THERAPEUTICS. 487

should always be judiciously selected, so that whatever tends to the delusion of the patient may be avoided, and that he may be always engaged as far as possible in a healthy subject of conversation. It is therefore necessary to avoid, not only all reference to the delusion, the circumstances that occasioned disease, but also much direct con- versation on his condition. The patient should be seldom left alone or unemployed; so long as he is employed "with matters uncon- nected 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 strength- ened and invigorated, and preserved from suppression and ruin. This is done by whatever promotes and upholds the ideas and sensa- tions which characterise healthy life, and this is the principle of the rule, to lead the patient 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 various modes of action of individuals, which are regulated by peculiarities in habits, tastes, and culture, and in finding out the sides from which he is susceptible. In women, attention is to be directed to other matters than in 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 musician onlv in the tones of his instrument discover, the whole van^e and unity of his former individuality. Quite as varied are the interests of disposition ; the attempt, however, always proves unsuccessful to interest the patient in anything that has no foundation or support from the thoughts and pursuits of his previous life : to the thought- less, for example, 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 over the e^o, 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 new individuahty. But it is well known,

488 THERAPEUTICS.

how scanty our means are of accomplishing this, how difficult such a restitution is, and how defective and always subject to relapse such cases are. Everything connected with the healthy bygone life — social attachments, the old modes of employment, &c. — serves to strengthen the ego, and the endless modifications of the means to be employed in promoting the healthy sphere of thought (correspondence, visits, S:c.) must be left to the judgment and tact of the phy- sician.

§ 223. Of moral remedies, proper employment of the patient seems to us the most important. In healthy work, the innate desire of expressing and giving vent to its energies finds fullest satis- faction in the objective world ; by constant occupation in forming materials, the thoughts and eflbrts engross the mind and withdraw it from empty longings and illusions of the imagination ; tlie fechng of success again prepares the way for expansive sensations, and there- with self-esteem and confidence return. Therefore, a steady employ- ment of the patient, especially when voluntary, is rightly considered a decided indication of improvement, and is frequently the com- mencement of recovery. Those employments are the best which keep the patient engaged in the open air, as all garden and field labour, which prove of great 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 no£ practicable, household or mechanical modes of employment, chiefly of a hght kind, may be substituted ; and very few patients, and these only in alternation with physical exercise and muscular activity, should be engaged in seden- tary and mental work. In chronic cases, the learning of a new and agreeable trade will somethnes engage the attention in a most bene- ficial 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. AYherever 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 appearance of a manufactory, or regard merely to the pecuniary advantage of the institution, is still more to be avoided, Recovery of improvement of the patient should be the only object of work. Each inmate should be required to do only

THERAPEUTICS. 489

what is suitable 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 disease any enforcement to it must prove injurious: recent cerebral irritation demands perfect rest. This does not, however, imply that all mental excite- ment renders work impossible or injurious. In English asylums, where there is no restraint, 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 treat- ment. 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 engagement of the mental powers. In asylums "the schoor' 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 de- monstrate by philosophy the impracticability of his projects, but to withdraw his attention 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 employment 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 comparatively short time. The subjects of instruction are regulated according to age, sex, and education, and consist of elementary instruction in music, history, &c. 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 remember- ing that 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 oppose the duration of the morbid 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 com- mended as a means of amusement.

Besides, conversations, lectures, walks, games, tea-parties, &c., also serve to engross and amuse the patient. These are to be regu- lated as much as possible to suit the different dispositions.

Guislain has very properly declared himself against those promiscuous

490 TnERAPEUTICS.

dancing parties so common in several English institutions, and which have been imitated in otlier countries. In a great German city the newspapers annually contain the announcement of a brilliant ball at the lunatic asylum, with the insulting intimation that the company was not disorderly.

Visits to the patients should always be under special surveillance, and the simply curious should be altogether excluded. In the early periods, and when the disease is still increasing, visits from the relations are ordinarily hurtful, partly by affording nourishment to the frequent aversion of the patient towards his relations, and recall- ing many irritating thoughts ; partly by hindering the necessary habitude and resignation of the patient 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 com- mencing convalescence, the patient often after a single visit quickly discovers his real condition, the nature of his disease, and his rela- tion to the world.

§ 325. The aid of religion in the treatment of insanity is not to be lightly estimated ; the application of this remedy requires, how- ever, great caution. Eehgious 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 in- struction, or attempt to interest in it any one who has no religion at heart. It would show total ignorance of the nature and circum- stances of these 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 remark- able 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- tormenting misery, a melancholic patient should be subjected to severe penance, or that the timid and fearful 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 cir- cumspection— if only those phases of religion be presented which

THERAPEUTICS. 491

seasonably 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 bene- licialj and we very often see the chaplain's visit, independently of what he says, pro\ing of great advantage to the patients, owing to the necessity of their meeting together for some time.

Several medical psychologists would have the whole treatment of the insane to be specifically Christian. But Jews also require the aid of the alienist and his science, and there is no abstract, only a confessional Christianity. There- fore there would require to be a special protestant, catholic, &c., and again a Jewish, heathen, psychiatric. Possibly even this may be yet desired.

§ 226. External means of restraint are employed with the view of preventing the patient from inflicting injury to himself or others, to prevent that rage 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 against which his own exertions are powerless, to bend his will, and subdue obstinacy and a refractory spirit. The means employed should never be such as in the least to wound the 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 means of restraint still in use ; it allows to the patient little or no use of his arms and hands. In many asylums the constramt-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 were invariably connected with the employment of bodily restraint which, about twenty years ago, origi- nated 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, ^^"^ 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 argu-

^ For an enumeration of these, see Schneider's ' Heilmittillehre gegen psy- chischen Krankheiten,' Tubingen, 1824.

492 THERAPEUTICS.

ment in favour of this system, is its greater humanity and its easier quieting of the patient, who 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 where this method has been adopted the patients have been rendered calmer, more submissive and cheerful, and the recoveries more numerous and permanent. In occasional rare cases of neces- sity, 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 alone is capable, in cer- tain cases, of rendering them submissive to the authority of the physician, and harmless to themselves and others ; that the use of these means allow 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 easily understand how the value 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 pro- ceeded entirely from those who had not practicaUy tested the system of non-restraint, and had never even witnessed it, their force will not appear so great. If we interrogate experience, which is the only proper test, we shaU find that during the last ten years all doubts in reference to it have been removed. The question is now decided entirely in favour of non-restraint. This great reform is now carried out M-ith the most favorable results in every pubhc asylum in England, and the name of Conolly will always be mentioned with that of Pinel, whose work he has completed.

The exact metliod of this system is by many, however, not pro- perly understood. It consists of an entire settiiig aside of all

THERAPEUTICS. 493

mecliauical 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 unjustly 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 restraint and violence is exchanged for a mild system of treatment, which, in the majority of cases, can avert those manifestations ; where this, however, 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 hitlierto indispensable ? we have only to say, that according to indisputable evidence, in the asylums where there is no restraint and, at the same time, good dietetic and therapeutic treatment, the cases which appeared to demand restraint have steadily and remark- ably 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 excitement present itseK, we seek, by means suited to each particular case, to distract the patient's attention from the object of his delirium, to calm and to divert him ; he is removed from the locality where his agitation commenced, and, if necessary, isolated for a short time (two to four hours, often less) in a chamber where he is secure against self-injury, or confined in an enclosed court. In all communication with an excited patient the greatest forbearance and gentleness must be ex- ercised, and everything which 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 organised as to meet its demands; the attendants must be sufficiently numerous, intelligent, active, and good-natured, and all must be under the constant surveillance of a physician who takes great interest in the subject, and is of a patient and benevolent disposition.

In certain rare and exceptional cases (such as sudden protection

» Witli regret I find this opinion, so fundamentally false, even in Neuman, ' Psychiatrie,' p. 86. The ardour with which the author defends the strait- jacket should not have led him to such incorrect expressions.

494 THEIIAPEUTICS.

against a dangerous lunatic, surgical cases, &c.) Conolly himself admits the possibility of the necessity of employing (for as short a time as possible) mechanical restraint : this is totally different from its employment as a means of regular treatment of the insane. In all the cases where formerly force appeared indispensable, even in those with a tendency to suicide, experience has proved the 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 sympathised with the reforms, yet I could not see my way clear to refute the contrary arguments which were advanced. Since then practical experience, from the one 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 looo 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 constraint-chair were in daily use. I have seen with happy astonishment how easily several patients on the point of an outbreak were ren- dered 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 applied. Let us hear no more of impossibility ! In Hanwell, with a population which has gradually increased till now it reaches about looo, for twenty-one years there has not been a hand or foot bound either by night or by day. Colney Ilatch, a very large asylum (1200 patients) was opened in 1849, and never to this day has any means of restraint 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. Isor 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 5-6000 patients in a number of English asylums, Morel found (1. c, p. 55) only three in cells, and in these cases the periods of confinement were short. Compare with this the numbers who are confined in cells — many with strait-jackets, and others actually reconciled to their sojourn through its long continuance — in some of our Continental asylums where non-restraint seems to be regarded as a mere chimera. And let it no more be repeated that such a system is suited only to the English, who submit more easily to control than the patients on the Continent. Before the time of Conolly 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 blameable. No one can say where the use ends aud the abuse begins ; indeed,

TUKRAPEITICS. 495

it would appear that the abuse is unavoidable, and a very experienced physi- cian has said "restraint is synonymous with neglect" (ConoUy).

Let us then pursue with confidence the new system, fearlessly break off the old customs and assume the new responsibilities, ever remembering that the least negligence will re-open the gates to the employment of violence. This is, however, a more difficult task than to amuse the public with pleasing descrip- tions of Christmas presents at asylums where the wretched constraint-chair still flourishes. The example of the perseverance with which the English phy- sicians have carried out the new principles is encouraging, and still more so are the results. Tf 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 Piuel. At all events, let every one keep a register in which each instance of the employment of restraint is entered, with the cause, nature, duration, and effect, and inquire at the end of the year what it has effected for the cure and improvement of the patients, and how far it has justified the confidence reposed in it. TTe 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 literature on this subject, see Coiiolly, ' On the Treatment of the Insane without Mechanical Restraint ;' Dick, * Zeitschr. f. Psych.,' xiv, 1856, p. 353; Morel, ' Le Non-restraint,' Paris, 1861.

Section IV. — Far ions Modijications of Treatment.

§ 227. The means hitherto discussed must be essentially modified on their apphcation, 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 difierences 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, disposition, and mental character. For the last-mentioned particular no general rules can be established. In the treatment of the diff'erent 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 observa- tion of the patient the diagnosis is to be certainly 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 disposition, of certain causes having been at work, &c. Always avoiding any gross error, such as confounding typhus fever with insanity, it is a judi-

496 THERAPEUTICS.

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 probable benefit, can ensue. For at this period the chief treatment is confincfl to avoiding all causes of the disease, and to careful dietary arrangements 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-humour; from all exciting argument, all urgent exhortation or religious discussion. On the other hand, his mental pain, as far as possible, is allayed by distracting 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 arc to be strengthened by moderate and benevolent encouragement. 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 dissimulate; 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 he 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 bane- ful 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 im- pressions of contact with those who are not acquainted with the nature of his malady, and quiet and stillness. The success or non- success of these rules depends very much on the degree of patience and perseverance with which they are carried out, on the external

TUEIIAPEUTICS. 497

coiiditious of the patient, and on those who surround liim j and the aid of an intelligent woman is often valuable. The physician must counteract the 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 witli the danger in which the patient stands, and the necessity of imme- diate interference ; he must not accept any excuse w hen he observes lliat his instructions are not im])licitly 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. All symptoms of acute or chronic disease in other parts (menstruation, heart-disease, diseases of the bowels, &c.) must be carefully watched, and anything that c-ould determine or maintain hyperemia or irritation of the brain must be unremittingly and attentively treated. Although it be true that all treatment "having a specially weakening effect is to be avoided, yet it is in this, the stage of commencement, when the disease is acute, that well-directed bloodletting, if specially indicated, can have the best results.

Treatment by mineral waters at the commencement of insanity, especially by slightly laxative waters, as Marienbad, Kissingen, kc, 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, kc.) ; the excretions maintained, nervous agitation calmed, and, if possible, sleep reinduced (baths, opium, aq. lauro-cerasi, digitalis, kc). Removal to a quiet country residence, together with a simple mode of life, does good in many instances. Moderate exercise, long-con- tinued 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 con- stant rest, should be prescribed according to the case.^

' See Erlenmeyer, "How are Mental Diseases to be treated at iheir com- rnenceiiieut ?" IseuwieJ, 1861 ; Guulz, "How are Mentul Diseases," &c., ' Arch, der GesscUs. f. Psycli.,' iii, 1, i860, p. i.

'6-2

498 THERArEUTlUS.

§ 228. When the commencemeut of the disease is sudden^ and its outbreak violent, we 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 upon 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, complete isolation of the patient, who can no longer mix with the world.

In melancholia, all attempts to repress the mental pain with ques- tions and exhortations should be avoided. The patients should be spoken to as little as possible about their own condition, and not at all regarding the object of their dehrium ; they should not be per- mitted to make many complaints, and a somewhat strict system of treatment, which may occasionally even have the appearance of severity, is often of more service than words of consolation. The stronger patients should rise regularly in the morning, do some work, take a walk, &c. ; those who are weakly, especially females, and patients with weak, irritable action of the heart, and dry, cold skin, may be permitted 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 appear, especially in the agitated form of melancholia, all active repression is objectionable ; it is best treated by regulated exercise in the open air, the use of baths, &c. In these cases, the remedies that are em- ployed in intestinal catarrh, and occasionally emetics, are of service — more frequently the milder laxatives, which may sometimes be combined with bitters. In many cases, digitalis, tonics, quinine, are indicated — exceptionally a little wine; above all, however, opium in large doses (see p. 488). In melancholia with stupor, drastic cathartics, and strong external irritants — vesicatories,tartar-emetic ointment — are often use- ful; 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 extrava- gant undertakings and eccentric demands are met, becomes soon exasperated, can only be tolerated in an asylum, and, above all, can only be treated there. Nothing is more injurious to them than uncontrolled freedom, which constantly increases the malady ; while the rest and ([uietness of the asylum, with its restraining influences.

THERAPEUTICS. 499

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 humour in large protected rooms, or better in the open air. Moreover, the outward excitement 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 new 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 wishes. In occasional cases, indeed, especially if we may presume from former attacks that the'mood will 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 sufficient" mind,[we may say to the patient that he is ill, and call his attention to the anomaly of his acts and pursuits ; where possible, the patient should be exhorted to a proper demeanour, and after a time put to some employment. Such patients should be allowed to drink a great deal — to use baths in the manner described. Leeches and cupping may be employed when necessary ; also digi- talis, coohng medicines, and sliglit aperients ; 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 too much, remembering that outward quiet is not the sole aim of treatment, and that the nutrition is to be maintained as much as possible.

There is no specific treatment for puerperal mania, alilioiigli such has beeu often recommended. Each case must be treated according lo the form it pre- sents. The chief consideration is always whether any other (always feverish) puerperal disturbance be present (see p. 208) : 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

500 TilKllAPtUTICS.

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 considerable anaemia, 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. 302), cold afl\isiou in a tepid bath often does good; a rapid sinking of the nutrition in this form demands particular attention.

It is (liflicult to detme more precisely the rules of troatmeiit iu the degenerate ehroiiie forins of mania and melancholia which pass into dementia. Each case must be individually considered, and the therapeutical and moral treatment cannot be too early commenced. All marked changes in the bodily health arc to be carefully watched, as they sometimes 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 rela- tions, 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 i'orci)ig the patient to healthy acts and desires, has not been justiHed by its results.

In fully developed systematic mania, and iu dementia, treatment is restricted to i)rotectiou 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 benevo- lent treatment, 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, however, state that they have seen benefit result from the use of the actual cautery; others, from methodical and long-continued application of cupping-glasses — dry, or with the abstraction of only a small amount of blood — to the nucha, from strict diet (in some cases milk diet), evacuants, iodide of potassium, the mineral acids, &c. As the disease advances, the utmost clean- liness (but to the total exclusion of baths) is to be seen to ; well- chosen nourishing diet, consisting towards the end of semi-tluid ele- ments ; above all, ])ure air, the patient being as much as possible in the open air ; and, in short, the same attention is required which is necessary in the earliest years of childhood — anything that can pro- long life and make it more supportable.

The treatment of the various states of idiocv, whetiier contrenital

THERVPEUTICS. 501

or occurring in early j'Cars, if recovery (which is extremely rare) or simple improvement be 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 post^iblc 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 necessary is removal of the child beyond reach of the influences (p. ^j6 — 392) of causation (when the causes are miasmatic, removal to another and healthy locality — not neces- sarily 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 jiowers, and to a mild, gradual, and methodical excitation and elevation of his senses and dispositions. Sj)ecial cases (syphilis, rickets, &:c.) require the treatment special to these maladies. Epi- leptic 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, kc. 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 that 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 feehng of bodily well-being and comfort (nutritious food, exercise in the open air, baths, cold sponging, cod-liver oil, iron, &c.) . It is not so much by methodical instruction (lectures, reading, learning. Sec), which has a gently stimulating effect upon the brain, as by illustration, simple employ- ments, 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 ABC, but stumble before every little obstruction that comes in their way ? Agri- cultural employment would be well adapted for most of the lighter cases, but it is very difficult to obtain it. Music exerts a favorable

50.2 THERAPEUTICS.

iulluence upon many ; constant repetition is a means wliereby, 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 bo 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 berc restrict myself to these few aphorisms ; furtlier details will be found in the works mentioned in page 388, and in the writings of Yoisin and Rosch, Erlenmeyer, Georgens and Deinhardt.

§ 229. When hallucinations are present, the organ of sense to which they refer should be minutely examined ; if necessary, the cars can be syringed, and the attempt made to remove any sensorial irritation by means of leeches, derivatives, Datura stramonium, &:c.

Should the patient refuse his food, the mouth is the first place to be carefully examined, as refusal of food is sometimes caused by inflammation of the buccal mucous membrane, cynanche, S:c. If nothing of this kind is discovered, we then attempt to turn the patient from his resolution, 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 proceed, 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 cesophagial sound. AYhen food has been for a long time refused, stimulating fluids, such as wine, should not be given at first, but mild substances, as milk, beef-tea, kc.

PATHOLOGICAL ANATOMY OF OTHER ORGANS, 443 (part 3)

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-lried 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, &c. Many instruments more or less complicated have been devised for artificial feeding; as, Leuret's double cesophagial sound, of slieep-gut ; the instruments of Belliomme (1850), Blanclii, Baillarger, &c. A simple elastic sound introduced througli the nose is the best of all : the patient is held in an oblique position, the liead 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 lukewarm — milk, beef tea, with eggs, thin soup, &c. — and always injected a little at a time, with some fresh water between. Most of those patients ougjit to lie iu bed all day, and be kept warm. Baths are often very beneficial.

THERAPEUTICS. 503

Nutrient eiiemataof preparations of beef and eggs, which have been prepared by digestion witli pepsineand a little 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 melancholia in the Turin Asylum communi- cated by Zelusclii ; 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 simple ])0uring 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, chloroform 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 care- fully 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, &c. ; 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

501 THERAPEUTICS.

than by force, and cases are on record whore by feminine cunning the knife was playfully wrested from the hand of the madman.

A youn^ man who had been tranquil for several months, was suddenly seized witli an attack of mania, lie ran to tlie 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 tlireatened to strike on the head any one who dared to approach. The wife of Superintendent I'ussin loudly called to the people that lliey were preventing the patient from working with her, re- quested liim gently to come near, and showed him how to use the instrument. At this moment the people laid liold of him and took away his weapon. (Reil, frc.)

Several ))atienfs were quarrelling in a garden : one of them seized a knife and threatened to murder his comrades. Lady Ellis arrived, and said to him that she was much surprised to see that a man of his understanding and strengtii could so far forgot 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, &c.)

A very strong, violent patient had found opportunity to possess himself of an iron bar three feet long, and threatened to murder all who came near him. Attendants and patients fled, and he Mas left alone in the gallery, no one daring to approach. After a little while I entered alone : balancing tlie key of the door upon the back of my hand, 1 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. Alihough it appeared to be disagreeable to him to find himself disarmed, he made no attempt to take back his weapon, and a few minutes afterwards ail traces of excitement were gone. (Ellis, ' Traiti',' P- 31 1-)

§ 2 ^o. The period of convalescence still requires much care and supervision. 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 continue 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 threat- ened or actual relapse, may be readmitted into the asylum without trouble or delay.

Should great relaxation and debility come on during convales- cence, it should not be treated by stimulating means ; quietness.

THERAPEUTICS. 505

suitable diet, open-air exercise, and gradual resumption of employ- ment, are to be promoted. The patient is to be alIo^Yed 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 neighbourhood ; all that would excite him should be avoided, or accompanied by judicious encourage- ment. He 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 conso- lations of religion. Counsel as to future modes of life, suitable employment, and to all tliat can protect him from a return of the disease, are now applicable. 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- thinkinsr men !

SFrTTox V. — Liiiinfic J-v/Inms.

§ 231. In former times, the leading object of treatment in mental disease was generally quite unknown. TVith no purpose beyond the preservation of public order, and the aversion of the danger that might arise to the sane from the uncontrolled roaming of such as were mentally deranged, some were confined in hospitals, others in penitentiaries and workhouses, and generally in the most wretched and concealed apartments. 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.

ivOG THEllAl^EUTlCS.

Whoever ouce 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 confined in jjrisons ; in several English institutions, entire rows of them might have been seen in chains ; and even to the present day, in a few remote districts, their apartments arc coarse, stall-like enclosures of the strongest and roughest construction, before which vacant curiosity stands to irritate the madman by a mockery of his curses. [Query, Where? — Transl.]

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 were mentally diseased. Upon the Continent, Pincl 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 devolution. At first, not without danger to his own life, he devised, before the very gates of Paris, in Bicetre, his great and ha])py reforms by freeing the insane from their fetters.^ Piiiel's endeavours were an example, and gave the impulse to a complete renovation 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 sub- ject was even then so marked, the acknowledgment of the curabihty

' Pinel, ifl directing Iiis efforts with all his attentiou to the amelioration of the coudil.ion of the insane, first devoted tlicm to those who had been confined at the instigation of the public authorities. In consequence of this interference, he was stigmatised as a moderate and an aristocrat — names whicii at that time were almost synonymous with sentence of death. Undeterred by this, lie pre- sented himself before the Town Council of Paris, and with renewed energy solicited them to sanction his reform. " Citizen," said CoutJion to him, " I shall meet you 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, Coulhon 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 Pincl, "O citizen, art thou tliyself a fool, that tiiou wouldbt liberate such animals? Do with them what thou wilt, but I am much afraid that thou wilt become tiie victim of thy rashness." Nevertheless, the ^ame day Pinel began his task and struck off the chains from a number of patients. See the narrative taken from Pincl's own diary, and published by his son, 'Mt-moires de I'Acad. Roy. de M^decine,' tome v. Par., 1836.

THERAPEUTICS. 507

and incurability of insanity was tlien so ■\Yicle-s])read; that lie was at once enabled practically and energetically to insist on the erection of special institutions for tlie 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 prac- tically 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 Germany either by the new erection or complete re-modelling of the public asylums in Schleswig (1820), Sieburg (1825), Heidelberg (1826), Prague (1826), Hildesheim (1827), Leubus in Silesia (1830), Hall in Tyrol (1830), Sachsenberg in Mecklenberg- Schwerin (1830), Winnenthal and Zweifalten in Wiirtemburg (]834), 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 doina: so. The erection of new and well-organised asylums is thus constantly progressing, 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 civilised countries. Among those which have been erected within the last ten years in Germany, and are ])articularly worthy of mention, are those at Yienna (1853), Werneck in Frankonia (1855), Klina'eumiinster in the Pfalz (1858), Milnich

(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 theo- retical 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 ? &c.), 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 English 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 extraordinary pedantry with which all the minutiae of the asylum were canvassed, as if these were primary questions. Thus, the interest was in a great

508 TPIERAPKUTICS.

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 remarkable 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 remaining to be done. In proof of this I shall oidy cite one example. An account of an excursion by Willing in the year 1 856 contains the following {' Ztschr. f. P«?ych.*'

xiii, p. 84) : — " In the noisy patients arc 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 together.""

§ 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 and cretins, proved perfectly ruinous ; the very sight of these creatures, so demoralised, exerted an influence upon the former ill the highest degree injurious. Besides, the two classes of insane require for their treatment and protection arrangements difl'ering 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 and curable cases. Whilst in certain foreign asylums — as, for example, Salpetriere— difl'erent 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 occasionally in England, another principle has been adopted— the erection of special institu- tions, quite separate, for curable cases and for incurables (Sonnen- stein, Siegburg, Leubus, TTinnenthal, &c.). 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 asylums 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

THERAPEUTICS. 509

asylums for incurables. It was soon understood that the organisation of asylums for incurables must, in many points, be essentially dif- ferent 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 resi- dence is but temporary ; and, further, it was a decisive blow to strong wide-spread prejudice M-hen, long before public acknowledg- ment 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 in the institution for treat- ment and in the asylum for chronic cases were suitably proportioned, M'here 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 system 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 attempts 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 institu- tions, in many countries men hesitated at a prospect so expensive as the erection of several large establishments, wath their comi)licated 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 tlie 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 common many economical arrange- ments (chapel, storehouses, kitchen, baths, t^c.) . Thus the great so- called " relativ verbundenen" asylum system is not, as they would have us believe in Berlin, the project of HegeFs logic, though cer- tainly he was a strong advocate of it, and that in a manner worthy of consideration.

It might be said in favour of this system, that where new build- ings have to be erected, it is less costly, because, as remarked above,

010 THERAPEUTICS.

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 labour — which is chiefly from the inmates of the incurable institution — it is less expen- sive 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 verbun- denen^' institutions the patient is observed by the same physician in every stage of his disease to its termination ; 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 ea.sy survey of the whole number of lunatics in a land or in a province ; that the inmates of an asylum for in- curables 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 favorable symptoms is then almost impossible.

But, on the other hand, it rnay be argued that the chronic asylum sliould not be a place whose portal bears the inscription "Lasciatc ogni speranza/' Though solely fitted up for the recep- tion of old chronic cases, vet the means of rccoverv outtht still to be present in the person of the physician, and in the external relations of the patient, which occasionally, though not frequently, afl'ord returning hopes of recovery. Indeed, in the chronic asylum some- times patients do recover,^ and that without casting any slur upon the institution for treatment, which, in the transference 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

' According to Focke, the recoveries iu curable asvlums are at the rate of from 3 to 6 per cent. Iu Pforzheim there recovered from secondary dementia from 4 to 6 nor cent.

' See the interesting communication by Treliit regarding the transference of a great number of insane from tlie overcrowded asylums of Paris to several, iu many cases far-distaut, provincial institutions, ' Annal. Med. P^ycllol ,' tome iv, 1S44, pp. 230, T^dd. Tiic advantage of transference to another iiistitutiou has recently been learned iu England ; ' Ztschr. f. Psych.,' xv, 185^', pp. 114, 147.

THERAPEUTICS. 511

patients of no small value, and adduces as important arguments against the union of the institution for cure with that fur mere guardianship, the want of efficient superintendence and of treatment of individual cases where 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 physicians neglect- ing 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 and chronic asylums, as advanced by Damerow, has been fully and practically carried out only in a very few places (lUenau and Halle) ; and in these, indeed, the separation of the hospital from the asylum has always been more fanciful than real, and may now-a-days be regarded as completely abandoned. In this system there is, at all events, one other institution required to which, out of the relatively connected ("relativ verbundeneu^') chronic asylum — if this is not to become of stupendous proportions — a regular draft can again take place of all such as are absolutely hopeless, those afflicted with other diseases — in short, the worst of the incurables (idiots, epileptics, (fcc. &c.) . But if only a certain number of incurables, and selected from amongst the best of that class (/. 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 buildiugs, and a special chronic asylum relatively connected with the hospital for treatment. These in- curables may, almost without harm, dwell amongst the recent and curable cases; nay, many alienists recognise 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 verbundenen" cure and chronic institu- tion, 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 ^ Gudden/Ztsclir. f. Psycli./ xvi, 1859, p. 6jS.

512 THtRAPELTlCS.

adopted (as is moreover also the case in by far the greater uumber of as}hims both in England and France).

Hut that is not to say that we have reverted to the old system of mixing all the insane indiscriminately together; but the principle of division, founded upon curability — a principle which 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 ajjpears to me that in the special cure institutions, that nucleus of patients habituated 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 physi- cian ; for it is well known that nothing is more difficult to maintain in a jjure hospital than a regular and prompt dismissal of all the incurable patients, and always a number of these insane remain through entire years, even although their insanity is known to be incurable. AVhether, then, is it belter to erect asylums which shall receive curable lunatics mingled with a certain select number of incurables, 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 re- sources at one's disposal, upon the special aims which it is intended to combine with their erection [e.g., clinical 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 premature com- pletely to renounce the system of special cure institutions.^ If,

* Roller (' Ztsclir. f. Psych., x, p. 397) at that time considered the question regarding the best sjslem for quite distinct, i?. tlie sense of "relativ verbun- denen," cure and cliionic asylums, and imagines tiiat no man would now think of erecting completely separated asylums for recent cases. Accord- ing to a new order of lunatic-asylum arrangements, it was no longer pro- posed to erect in the province of Silesia a "relativ verlundeneu" institution, but to have one cure-iustitution 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 ofTered iu Germany for the best plan of a luualic asylum for purely recent cases (Ileilanstall) capable of containing from i.;;o tu 200 patients.

THERAPEUTICS. 513

however, we accept this system of two relatively connected Innatic asylnms, 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 recognised 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 mdividual case.

Whatever system be adopted for the regulation of asylum matters in a country, the special guardianship of the State ouo-bt, at all events, only to be extended to a certain portion of the insane. The overcrowd- ing, of which all lunatic asylums at present complam, the pressure upon them, and which is always bringing discredit upon the calcu- ations upon which they were constructed, must somewhere find a imit. This is possible. In the first place it is, of course, necessarv that those calculations be correct (based upon an exact calculation ot 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 i.i tiiat case there should be received into the chronic asylum onlv the dangerous patients, or the incurables who cannot be taken care ot 111 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 tlie State to see that the necessitous are treated as such in the asvlums devoted to the purpose of treatment ; but whether it should afso see to those of the insane who, by their own private means, are able to enjoy all the desirable advantages found in good private asylums, i'. stiU an open question. Were this question answered in the ne-a- tive, a great simplification and reduction would take place in all that concerns public asjlums, and in all large countries the erection of - pauper asylums of very simple organisation, 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 con- version of all the public lunatic asylums into pauper lunatic asvlums.

33

514 THERAPEUTICS.

§ 234. If we proceed now to examine the general reqtiiisUes for a })ublic lunatic asylum, we may place in the foremost rank facililj/ of access to the patients, and the capability of constantly receiving fresh cases. AYe shall attain these objects partly by regulations of the medical police, and partly by dispensing with all useless and time-wasting formalities, by diminishing the cost of maintenance or gratuitously supporting patients of the poorer classes, and by in- spii'ing the pubhc with coniidence in asylums generally ; and further, as a result from this, in all large countries the asylums would be more distributed in difl'erent districts. Asylums, too, ought to recommend themselves by their excellent organisation and by the spirit which pervades them ; and not only ought this organisation, and this spirit, to be in conformity with the ideas of humanity in our own epoch, but they must also be — and tliis is truly a funda- mental requisite — out-and-out meiVical.

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 ctire 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 superin- tendence, that its management must be in the hands of the chief physician, who should have, with a certain freedom from restriction, conmiand of all extraneous aids for the benefit of the whole insti- tution; 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 ])ractitioner.

The peculiarity of the diseases treated in an asylum requires the physician to have at command, not only all the usual medical appli- ances (pharmaceutic baths, &c.), but, in addition to these, every arrangement tending to prevent patients inflicting injury on them- selves or others, and to have them alwavs amenable to medical treatment. In the same way must be provided whatever else is necessary to their maintenance, exercise in the open air, labour, recreation, and amusement. Tims, institutions of this kind must be furnished not only with a staff of servants for superintending and waiting upon the 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 vith plots of

THERAPEUTICS. 515

grouud for the employment of the patients hi field labour, 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 classi- fication, but rather by the symptoms of the malady {i. e. whether quiet or more turbulent) ; and lastly, among the c[uietly disposed who live together accordmg to their station in life and their intellectual cultivation (of course in the case of the secluded such distinctions are needless). Por 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 multifarious transi- tions ; because it would even be dangerous in some cases {e. g. in patients with suicidal tendencies) to permit them to live together and to have much intercourse ; and lastly, because the apparently quiet melancholic maniacs and dements , could not, as proved by universal experience, well live together without an equal amount of trouble and prejudicial 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 then" outward demeanour, one must be cautious, ia 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 delirious, 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 dwell- ings for convalescent or other patients for whom it may be con- sidered beneficial for a longer time to live more retired, and in per- fect quiet. In many institutions yet another division is kept for the bedridden, and a perfectly detached building for convalescents. This last has proved not so expedient.

In several institutions situated in large towns, a division is re- served for insane persons who have committed some crime. In

516 THERAPEUTICS.

Bicetre there is a divisiou 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 about a hundred patients. 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 Dclbriick has pointed 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 referred to : ZcUcr, ' Art. Irrenanstaltcn in Ersch und Gruber's En- cyclopiidie / Damerow, ' Ueber die relative Vcrbindung dcr Irrcn- Hcil- und Pflcgcanstalten,' Leipzig, 1 840; Parchappe, 'Des Principes a suivre,' etc., Paris, 1853; Guislain, 'Le?. oral.,' iii.

§ 235. In different countries where the subject of insanity has received attention, it has been attempted to meet these requirements by widely different architectural arrangements. "While the English institutions in general present a most imposing appearance by their massive and elegant exterior, possess the greatest completeness in the interior as regards convenience of space and all domestic ar- rangements (as heating, lighting, cleaning, working arrangements, &c.), and, combined with great comfort, a certain regularity of routine that corresponds well with the almost mechanical nature of the superintendence and treatment, the Trench 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 sin^rle cells or rooms, a common conversation-room, work-room, kc, with a colonnade around, and enclosed 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, &c. This mass of distinct buildings, which occupies 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 labour and instruction, quite different principles were followed in the construction and arrangement of French asylums, these insti- tutions were distinguished by a want of restraint, the uncontrolled

THERAPEUTICS. 517

roaming aboutj and uui'uly character of the patients. In the con- struction of the most modern institutions in France, the ideas of Esquirol seem to have been considerably deviated from.

In Germany there has been an attempt to combine the good quaHties of both systems,^ although, upon the whole, the German institutions approach 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 together. Erom each side of these one, or, in^relativ verbundenen'^ institutions, two double-storied side wings extend, either in direct communication or detached. In these are the different divisions for convalescents, boarders, quiet patients of middle and lower rank in life, together with attendants^ accommo- dation, baths, &c. As a completion to the whole, are small, single- storied buildings, as far as possible removed from the centre, wliich contain the cells for unruly patients, especially those requiring 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, according to the station and requirements of the patients.

A leading principle in the erection and whole internal arrange- ments, which 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 dweUing- house — that they should differ as little as possible from the houses and furnisliings of the sane. On this principle all plans are objectionable which, by attractive peculiarities^of architecture, such as steeples, tur- rets, &c., insinuate, even by their external appearance, that they are

1 Holland has, in its distinguished Meer-en-Berg, produced a model institu- tion by combining in a certain degree the advantages of all the systems : spe- cially as in that country Schroeder van der Kolk has directed all the matters connected with_the insane in such a pattern manner.

518 THERAPErTICS.

intended for some peculiar purpose. All prison-like cells on the one hand, and on the other all undue magnificence in lofty halls, colon- nades, kc, must, on the same principle, be avoided. It should through- out have the appearance of a medical institution, 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 pcrseveringly insisted on.

The institution must, moreover, be situated in a healthy locality, and, where it is possible, in a neighbourhood 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 main- tained with the inhabitants. It is needful also to have asvlums in proximity to large cities. Institutions so situated have the advan- tage 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, enclosed all round by a wall. It is of great 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 supply of fresh water, and for the purpose of out-of-door bathing. The gi-ounds should be extensive and agreeable, with gymnasium, skittle- ground, playground, &c.

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 simpler, 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 undertaking of Guggenbiihl on the Abendberg {1841) these fu'st have attracted great interest, and in them numerous ex- ]ieriments have been made, but, from the very nature of the case, their benefits can extend only to children, and thus ihcy partake

THERAPEUTICS. 519

more of tlie nature of training institutions than of hospitals. Ferrus Sequin and Yoisin during the last thhty 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 (Haldemvangin Wild- berg) had a small institution erected for the trainmg of idiotic children. After tlie plan of that at Abendberg, the following in- stitutions were founded : that at j\lariaberg (founded by Eosch, 1847), AYinterbach (likewise in Wurtemburg, 1853), Ecksberg in Bavaria (1852), Hubertusburg in Saxony (a Government insti- tution, 1852), two in Berlin (one in Liesing near Vienna, one in Bendorf in Coblenz), one large idiot school in the Hague (185^), and many still smaller or less known houses j but all of these are far surpassed by the magnificent institution of Earlswood, 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 organised so as to accomplish their special ends (p. 515) ; but, in general, that may very easily be deduced from the propositions already laid down when discussing the treatment of idiots. Concerning the more modern idiot asylums, see Theile (loc. cit., p. 105).

§ 236. At the head of the personnel of the lunatic asylum, sub- ject to the directing authorities of the State, stands the superintend- ing physician, by whose character, as a man and as a scholar, the pervading influence 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 knowledge of nervous pathology), there is required in the head physician, and justly expected of him, a rare combination of moral excellencies — benevolence, great patience, self- command, freedom from prejudice, a knowledge of men gained by actual experience of the world, conversational powers, a decided hking for his own special vocation; for this alone will enable him to overcome its manifold toils and discouragements. Assistant-phy- sicians 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, &c. In most asylums a clergyman is appointed, whose duty is to conduct Divine worship, regularly to visit tlie sick, and promote recovery by religious remedies. It has been already remarked (p. 504) that

520 THERArEUTICS.

in few cases ought such measures 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 neces- sarily be very onesided. Justly, therefore, have some of the most illustrious physicians [e.g. Nasse, Jesseu, 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 patients, and thereby promote their intellectual culture and amuse- ment.

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 seldom to be found. Each attendant is generally intrusted with from six to ten patients, but some patients require the entire services of an attendant. In manv institutions these attendants are selected from the brotherhood or sisterhood of some religious order, a proceeding which, on the whole, has more ob- jections than recommendations. ]3csides these, there are in asylums, as in every other institution, officers specially connected with the economical department.

§ 237. In order that the arrangements in connection with an asylum, necessarily always so complicated in consequence of the great number of persons and requisites employed, may go on with order and without confusion, there must be a written set of rules for the guidance of the officials ; the precise duties of each servant should be definitely and briefly stated, all their duties punctually arranged, and the method of each prescribed. 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.

THERAPEUTICS. 521

All its operations sliould be so conducted that every one, whether healtliy 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 tranquillity and ease should pervade the whole, and the desire for activity on the part of the patients, which precedes and accompanies every case of recovery, 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 enclose 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 intercourse, in which the ordinary forms of general society were observed. Indeed, everything that would estrange the patients from the habits of the world should be steadily avoided. To counteract such a tendency, general amusements, social gatherings and walks, are of great service. By degrees the patients should thus be introduced to the society of the sane. It has been shown above, that from such a system of humane liberal treatment, much more satisfactorv results will flow than there would from a stricter method. Every gloomy, ascetic, barrack-like spirit should be avoided, and the great object of treat- ment should be, not only to diffuse a spirit of cheerfuhiess 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 disease, its origin, and development. Many of the particulars on these subjects have generally to be furnished by his friends. Their statements should contain an unreserved dis- closure 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 heredi- tariness, bodily and mental dispositions, previous diseases — especially of the nervous system. It must particularly recount all the symp- toms of its gradual or sudden outbreak, and the present state of the morbid phenomena, whether the patient has previously shown 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

523 THERAPEUTICS.

asylum, tlie patient should be informed of the resolution ; if he obsthiately refuses to go, it is much better to convey him by force^ than to lure him in by artifice {e. y, by telling him he is going on a pleasure excursion). Such a plan exasperates him to an intense degree, and prevents for a long time that confidence in the insti- tution 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 con- valescence continue during a sufficient period, varying from at least one to two years, the patient may then, for the first time, be per- mitted 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 deficieucy that is felt in countries where the interests of the insane receive no attention from Government, or where tlie Government asy- lums are inadequate to the accoimnodation of all lunatics. Their chief use, howev^er,is for patients belonging to the wealthier and the aristo- cratic classes of society, who woidd not be satisfied with the ordinary public asylums. Their importance has in later times greatly increased, 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 Required to furnish sufficient evidence of their abihty to treat insanity, namely, a sufficient acquaint- ance ■with that special branch of study and a complete knowledge of its practice. Such abuses and scandals as have occurred in some

^ No restraint is the universal rule no\v-a-days in well-regulated asjlums.

THERAPEUTICS. 523

English private institutions sliould 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 hi the remarkable Bekian villaffe of Gheel, in whichj for several hundreds of years past, lunatics have lived together ^vith 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, al- though people are seldom in the habit now of consulting her oracle. Eepeated attempts have recently been made to establish some degree of regularity and system among this settlement of lunatics. Out of a population of about 9000, it has from 900 to 1000 inhabitants who are insane. In the year 1850 it was sought to establish an administration 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 wliicli could never be permitted them hi an asylum. All who are capable of it share in the mechanical or agricultural employ- ments of the sane. The treatment in the main is very mild, and restraint is never made use of without previously consulting a phy- sician. 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. A\'itli 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 favour 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. The case of Gheel has suggested tlie question whether similar colonies might not be established in other places, and the e^ils resulting from the overcrowding of

' ' Journ. de Med. de Bruxelles,' 1859, p. 464. - Roller, 'Zlsclir. filr Psych./ xv, 1858, p. 420.

524 THERAPEUTICS.

lunatic asylums thereby removed. In England and Germany an exact imitation of Ghcel has been recommended ; it was recently proposed to assemble a number of lunatics ^yithin a village in the immediate vicinity of a Government asylum, so that it might main- tain a certain relation to them. The difficulties in the way of adopting this plan, Avhich have been collected and clearly set down by AV. 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 treatment of all classes of the insane, will be finally solved.

1 (

Deutsche Cliuik,' 1858, 'Ztsclir. f. Psych.,' xvi, p. 42.

INDEX.

Abdominal disease causing insanity, 196 Abdominal organs, aft'ections of, in the

insane, 444 Age, influence of, on insanity, 141 Alcohol, effects of, compared with mania,

310

— in treatment of insanity, 479 Anaesthesia in insanity, 81 Anger, impulsive fits of, 272 Anxiety a cause of insanity, 1G5 Apoplexy and insanity, 175 Appetite, increase of, in mania, 288 Arachnoid, alterations in, in insanity, 418 Arteries, disease of, a cause of insanity,

195

— of brain, condition of, in insanity, 417 Asylums, advantages of, 466

— authorities on, 516

— for idiots, 519

— history of, 506

— statistics of recoveries in, 510 Aura in insanit_v, 79

Aztec type of idiocy, 378

Baillarger, case of melancholia, 251 Baths in insanity, 475 Bergmann, case of insanity, 93 Berlyn, case of hypochondriasis, 221 Bierre, use of baths in insanity, 475 Blood diseases in the insane, 436 Boismont, case of insanity after fright,

112 Brachet, case of hypochondriasis, 219 Brain and membranes, pathology of, in

insanity, 409 Brain, anterior commissure of, 16

— condition of, in general paralysis, 402

— cortical substance of, function of, 24

— deficiency of parts of, 356

— grey substance of, anatomy of, 13

— grey substance of, in idiots, 3G0

— hypertrophy of connective tissue of, 359

— method of examining, in disease, 21

Brain, smallness of, in idiocy, 352

— substance, changes in, in insanity, 426

— unequal development of, 354

— Avhite substance of, anatomy of, 15 Bright, case of hallucinations, 93

Camphor in insanity, 481 Cerebellum, anatomy of, 19

— changes in, in insanity, 430 Cerebral centres, changes in, in insanity,

428

— substance, changes in, in insanity, 424

— vessels in insanity, 417 Charcellay, case of hypochondriasis, 221 Cholera in the insane, 437

— insanity after, 184

Civilisation, progress of, and insanity,

138 Cleptomania, 293 Cold in treatment of insanity, 473 Conolly on treatment of the insane, 491 Corpora quadrigemina in relation to

sight, 19 Corpus callosum, absence of, 356

— callosum, cerebral expansion of, 16 Cranium, alterations in, in insanity, 414

— alterations in, in idiocy, 360 Cretinism a form of idiocy, 346, 378

— absence of iodine a cause of, 388

— atrophy of spinal cord in, 355

— endemic, 381

— hereditary, 388

— humidity a cause of, 386

— nature of soil a cause of, 387

— nature of water a cause of, 387 Crisis in insanity, 457

Deafness, peripheral, followed by insanity,

178 Delirium, acute, form of mania, 298

— in insanity, 70

— of fever analogous to insanity, 112

— rhyming, 284

— sensorial, 84

526

INDEX.

Deliriura tremens, symptoms of, 297 Delusions not necessary to insanity, 118 Dementia, 320

— apathetic, 344

— cases of, 311, 313,321, 343

— defined, 340

— paralytic, changes in, 434

— partial, with exaltation, 276

— witli epilepsy, lOG Demonoraania, cases of, 242 Diagnosis of mental disease, 113 Digitalis in mania, 477 Dreaming, insanity analogous to, 107 Dreams, sensation of flying in, 81 Drunkenness a cause of insanity, 109 Dumbness, idiotic, 370 Dysentery in the insane, 437

Earle, statistics of insanity, 298 Ecstacy in insanity, 83 Education, influence of, on insanity, 156 Electricity, influence of, in general para- lysis, 396 Ellis, cases of insanity, 504

— on onanism as a cause of insanity, 1 74 Emotional irrital)ility, 65

Emotions, analysis of, 52 Emphysema a cause of insanity, 195 Epilepsy a complication of insanity, 403

— and insanity, 175

— replaced by mania, 297 Erlenmeier, case of idiocy, 351 Esquirol, atrophy of optic nerves with

hallucinations, 86

— case of attempted suicide, 260

— case of hallucination, 99

— cases of mania, 297

— case of monomania, 314

— removal of hallucinations by covering the eyes, 83

— on removal of the insane to asylums, 468

— suicides mentally diseased, 253 Exaltation, states of mental, 273

Falret on folia circulaire, 234 Ferrus, treatment of criminals, 149 Fevers causing insanity, 181 Fleming, cases of insanity, 73, 183, 191

— on use of emetics in insanity, 480 Focke, case of insanity, 183

— statistics of recoveries in asvlums, 510

Foville, structure of brain, 18 Fright a cause of insanity, 165

Genital organs, disease of, a cause of in- sanity, 198

Georget, insanity with homicidal ten- dency, 207 Gheel, colony of insane at, 523 Goitre, see Cretinism, 381 Gratiolet on auditory root, 19

— on hallucinations of sight, 97

— on sensation of flying in dreams, 81 Guillot on auditory root, 19

Guislain, analogy between dreaming and insanity, 109

— case of idiocy, 351

— case of insanity (recovery), 485

— case of melancholia, 261, 271, 441

— on dancing parties in insanity, 490 Guy, case of melancholia with desire to

murder, 263

Ilaematoma of the ear, 437 Hallucinations in chronic mania, 330

— in insanity, 80-103

— in sane persons, 93

— of sight with atrophy of optic nerves, 86

Head, injuries to, and insanity, 176 Hearing, hallucinations of, 98

— hallucinations of, in a case of mania, 334

Heart, affections of, in the insane, 443

— affections of, a cause of insanity, 194 Ileule, memory in the senses, 32 Hereditary insanity, 150

Ilerschl on porencephalus, 355

Holland, duality of mind, 25

Home sickness, form of melancholia,

245 Hydrocephalus a cause of idiocy, 357

— chronicus in the insane, 428 Hydrocyanic acid in mania, 478 Hydropathy in insanity, 475 Hvperaemia of brain a cause of insanity,

'lG3 Hypochondriasis, 210

— cases of, 217-222

— mode of origin of, 216

— symptoms of, 212 Hysteria, 179

Ideas, incoherence of, 284

Idiocy, anomalies of cranium in, 360

— anomalies of desires, &c., in, 371

— anomalies of senses in, 368, 373

— apathetic, 376

— causes of, 349

— course of, 379

— dumbness in, 370

— excited, 376

— grey substance of brain in, 360

— hypertrophy of brain in, 360

— meaning of terra, 346

INDEX,

527

Irliocy, varieties of, 377 Idiots, asylums for, 519

— classed according to speech, 370 Illusions and hallucinations distinct, 84 Impressihle explained, 54 Imprisonment, influence of, on insanity,

147 Incoherence of ideas in mania, 284

— temporary, in health, 68

Insane, affections of the abdominal organs in the, 444

— affections of the heart in the, 443

— blood diseases in the, 436

— cholera in the, 437

— colony of, at Gheel, 523

— criminal acts of the, on, 77

— dysentery in the, 437

— hsematoma of the ear in the, 437

— physical treatment of the, 470

— removal of the, to asylums, 466

— respiratory diseases in the, 438

— statistics of mortality of the, 448

— typhus fever in the, 437 Insanity, see Melancholia, &c.

— acute, changes in, 432

— after cholera, 184

— after strong smell, 178

— analogies of, 106

— and civilisation, 138

— and intoxication, 124

— and typhus fever, 124

— aura in, 79

— blood diseases in, 436

— cases of, 77, 80, 81, 86, 88, 96, 99, 101, 103, 109, 112, 183, 185, 189, 214, 217, 236, 242, 251, 259, 263, 265, 268, 271, 272, 290, 293, 300, 311, 321, 331, 313, 441, 485, 504

— causes of, 127

— changes in arachnoid in, 418

— changes in cerebral centres in, 428

— changes in cerebral substance in, 424

— changes in cranium in, 414

— changes in great vessels of brain in, 417

— changes in pia-mater in, 420

— chronic, changes in, 433

— complications of, 392

— complicated wtih epilepsy, 403

— compulsory feeding in, 499

— delusions not necessary to, 118

— emphysema a cause of, 195

— forms' of, 206, 423

— feigned, 120

— follovFing peripheral irritation, 178

— from abdominal disease, 196

— from disease of genital organs, 198

— from drunkenness, 169

— from fever, 181

— from heart disease, 194

Insanity from intestinal worms, 197

— from otiier nervous diseases, 1 75

— from pregnancy, &c., 202

— general diagnosis of, 113

— general paralysis in, 394

— hereditary predisposition to, 150

— hypera3inia of brain a cause of, 163

— hysterical, 179

— in course of pneumonia, 185

— in different sexes, 140

— influence of age on, 141

— influence of education on, 156

— influence of imprisonment on, 147

— influence of marriage on, 141

— influence of moon on, 150

— influence of seasons on, 149

— influence of social position on, 146

— mental constitution a cause of, 158

— method of examining brain in, 21

— of the intellect, 70

— opium a cause of, 172

— pellagrous, 194

— periodic, 183

— physical causes of, 1 74

— prognosis and treatment of, 447

— psychical causes of, 164

— sexual excess a cause of, 173

— sketch of course of, 50

— statistics of, in different nations, 135

— suicide, attempts at, in, 259

— therapeutics of, 459

— tobacco a cause of, 172

— venesection in, 472

— with apoplexy, 175

— with chronic diseases, 191

— with disease of arteries, 195

— with epilepsy, 175

— with injury to head, 176

— with rheumatism, 188

— with syphilis, 192

— with tendency to murder, 261

— with tuberculosis, 192 Intellect, weakness of, in idiocy, 347 Intermittent fever followed by insanity,

182 Intoxication a cause of insanity, 169

— and mania compared, 310

— diagnosed from insanity, 124 Iodine, absence of, a cause of cretinism,

388

Jacobi, ague in place of insanity, 184

— cases of mania, 294, 301

— case of monomania, 311

— case of recovery from melancholia, 237

— on cleptomania, 77

— on mania, 282

— use of cold in insanity, 473

— on use of tartar emetic ointment in mania, 476

528

INDEX.

Jessen on colonies of insane, 524

Kerner, case of insanity, 244

Kidneys, disease of, a cause of insanity,

197 Kieser, case of hallucinations, 99

Lactation a cause of insanity, 204 Lallemand, melancholia with desire to murder, 2G3

— recovery from melancholia, 239

— sexual functions in insanity, 199 Laugermann, reform in treatment of in- sane, 506

Lautard, case of hereditary transmission

of insanity, 153 Lead-poisoning,influence of, on brain, 1 72 Lelut on hallucinalions, 89 Leuret, case of chronic mania, 335

— case of dementia, 343

— case of monomania, 315

— cases of lycanthropia, 80

— on suppression of hallucinations, &c., 485

Louget, cases of insanity, 3 Lung diseases in the insane, 438 Lycanthropia, 80

Magnesia in water a cause of cretinism,

387 Mania and intoxication compared, 310

— anomalies of disposition, &c., in, 280

— anomalies of intellect in, 283

— anomalies of senses and movement in, 286

— cases of, 293-297

— chronic, 320

— chronic, anomalies of desires, &c., in, 324

— chronic, anomalies of the senses in, 330

— chronic, anomalies of thought in, 327

— chronic, cases of, 331-339

— chronic, detined, 321

— incoherence of ideas in, 284

— incomplete, cases of, 300

— incomplete, symptoms, 299

— invasion and course of, 289

— period of incubation of, 279

— periodical, 290

— prognosis of, 292

— sudden recovery in, 291

— two forms of, 273

— without delirium, 301

Marc, case of attempted suicide, 261

— case of insanity, 265

— case of monomania, 318 Marriage, influence of, on insanity, 141 Masturbation a cause of insanity, 173 Meding, case of dementia, 322

Medulla oblongata, inequality of, 355 Melancholia, 209

— cases of, 311, 314, 441

— cases of (recovery), 236-240

— changes in, 432

— course of, 234

— metamorphosis, 245

— religiosa, 240

— religiosa, cases of, 242

— simple, 223

— symptoms of, 223-233

— with destructive tendencies, 252

— with persistent excitement, 271

— with stupor, 247

— with tendency to murder, 261 Memory, a(Tectioris of, 68

— process of, 32

Mende, case of attempted suicide, 260

— melancholia, with attempt to murder, 265

Meningitis, symptoms of, 125 Menstruation, influence of, on sanity,

200 Mental constitution cause of insanitv,

158

— disease, forms of, 206

— disease, pathology of, 408

— disease, prognosis and treatment of, 447

— disorders in idiocy, 368

— exaltation, states of, 273

— processes, observations on, 23

— weakness, states of, 319 Michea, cases of melancliolia, 82 Microcephalism, 353 MicrocephaHcs, cases, 353 Miidner, case of transitory mania, 290 Moon, influence of, on insanity, 150 Morel, case of simulated suicide, 259 floral treatment of the insane, 483 Monomania, anomalies of desires, &.C.,

in, 304

— anomalies of intelligence in, 305

— anomalies of senses, &c., in, 308

— bad term, 74

— cases of, 311-318,331

— defined, 303

— distinguished from mania, 274

— form of chronic mania, 324

— passing into dementia, 343 Morphia, in mania, 4 77

Mortality of the insane, statistics of, 448 Movement, anomalies of, in idiocy, 373

— anomalies of, in mania, 287

— anomalies of, in monomania, 308

— disorders of, 104 Mullcr on hallucinations, 94 ^lurderous impulse with melancholia, 261 Muscular activity, tendency to, in in- sanity, 76

INDEX.

529

Narcotics in mania, 476 I

Nerve, auditorv, cerel)ral expansion of,

17 ' I

— olfactory, cerebral expansion of, 20

— optic, cerebral expansion of, 1 7 Neuman on use of strait-jacket in mania,

493 Neuroses followed by insanity, 179 Niepce, case of hydrophobia in an idiot,

369 Nymphomania, 294 Nystagmus in insanity, 105

Opium a cause of insanity, 172 Ovaries, disease of, a cause of insanity, 201

Pain causing insanity, 179

— mental, 35

Paralysis, general, with insanity, 393 Pathology of mental disease, 408 Pellagrous insanity, 194 Perfect, use of camphor in insanity, 481 Peripheral irritation followed bv insanity,

178 Personality, renunciation of, 79 Pia-mater, alterations in, in insanity, 420 Pineal gland, affections of, in insanity,

429 Pinel, case of immoderate anger, 272

— case of suicide, 261

— on use of restraint in insanity, 492

— reform in treatment of the insane, 506 Pituitary gland in insanity, 430 Pneumonia, insanity in course of, 185 Porencephalus, 355

Pregnancy a cause of insanity, 202 Prognosis of insanity, 447 Psychical causes of insanity, 164 Puerperal condition a cause of insanity,

202 Pupils, state of, in general paralysis, 396

— great contraction of unfavorable, 105 Pyromania, 270

Reason, analysis of process of, 58 Recovery, statistics of, in Germany, 455 Reflection, analysis of, 46 Eeil, case of insanity, 504 Religion an aid in treatment of the in- sane, 490 Renandin, case of antesthesia, 82 Restraint in treatment of insanity, 491 Rheumatism a cause of insanity, 188 Rochoux, case of anaesthesia in a maniac,

81 Romberg, case of mania, 142

Salomon, statistics of suicides in Belgium, 256

Schiff, functions of spinal marrow, 3 Schlager on concussion as a cause of in- sanity, 177

— suicide among melancholies, 258 Seasons, influence of, on insanity, 149 Sensation, anomalies of, in mania, 288

— disorders of, 78

Senses, anomalies of, in chronic mania, 330

— anomalies of, in idiocy, 368, 373

— anomalies of, in mania, 286

— anomalies of, in monomania, 308

— hallucinations, &c., of several, com- bined, 103

Sentiment, anomalies of, 63

Sexes, insanity in different, 140

Sexual excesses a cause of insanity, 173

— instinct, increase of, in mania, 288 Shock a cause of insanity, 165 Sight, hallucinations of, 97 Sinogowitz, case of chronic mania, 331

— case of illusions of smell, 101 Sleep, troubled, in mania, 288 Snell, hallucinations of, 100

— impression of, followed bv mania, 1 78, 296

Snell on anaesthesia in insanity, 82 Speech, absence of, in idiocy, 370 Spinal cord, atrophy of, in cretinism, 355

— cord, cerebral prolongations of, 18

— cord, functions of, 23

— neuroses followed by insanity, 179 Statistics of age of the insane, 144

— of drunkenness as a cause of insanity, 171

— of nationality of insanity, 135

— of sex as a cause of insanity, 140

— of social position of the insane, 146 Stiedenroth, brain affected in insanity, 5 Strangulation, attempt at, followed by

dementia, 321 Suicidal tendencies with melancholia,

252 Suicide, simulated, in insanity (cases),

259 Syphilis a cause of insanity, 192

Tartar emetic ointment in mania, 476 Taste, hallucinations of, 101 Temperature in cases of mania with pneumonia, 186

— in general paralysis, 400 Therapeutics of insanity, 459 Thought, anomalies of, 66, 327 Thurman, statistics of insanity. 144 Tobacco, influence of, on sanity, 172

— in insanity, 479

Tongue, paralysis of, in insanity, 394 Treatment nodiucd according to case, 495

— phvsical, of the insane, 470

34

530

INDEX.

Tuberculosis a cause of insanity, 192 Tverman, autopsies at Colney Hatch,

'195 Tvphus fever diagnosed from insanity,

'124

— fever in the insane, 437

— followed by insanity, 181

Uterus, disease of, a cause of insanity, 201

Velten, case of mania, 296 Venesection in insanity, 472 Ventricles of brain, changes in, in in- sanity, 428

Voppel, accounts of autopsies in Colditz Asylum, 194

Wigan on duality of mind, 25 Will, analysis of the, 42

— anomalies of the, 74 Willis, case of insanity, 196 Winslow, case of attempted suicide, 254 Worms, intestinal, a cause of insanity,

197

Zeller on cases of mania, 77

— on Guislain's Phrenopathie, 60

— use of cold in insanity, 473

THE END,

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G7213 1867

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Griesinger, V.ilhelm

Mental pathology and therapeutics

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