A N D T H EI R

H O M GI O PATH I C T REAT M ENT

FO R T H E S T U D E N T A N D
P RA C T I T I O N ER O F
M E D I C I NE

BY

W I LL I A M O R R I S B U T LE R A M M
M ,
. . . . D .

Fo r m l y Fi t A
er rs i ta t P h y i i a
ss s h M idd l t w
n S ta t H ms c n to t e e o n e o oe

o p hi
at H p i ta l f h I a P f
c os or t f M et l Di ns ne : ro e sso r o en a se a se s

N w Y k H m m p h i C ll g
e or o d Fl w
o at H pi t l C
c o e e an o er os a ; on

l i g A li
su t n i t M idd l t w S t a t H m p t h i H p i t a l
en s e o n e o oeo a c os

l g i t C m b- la d S t t H
.

f h I
or t e N n sa n e ; e u ro o u er n r ee os

i a I t i t t i H m p thy ;
s .
.

pi tal M m b ; A m e er er c n ns u e o o oeo a

E P id t H m m p h i M d i a l S i t y
x- re s en o o at c e c oc e

f h S tat f N w Y k
o t e e o e or

BO ERI C K E RUN YON

N E W YO R K
1 9 10
 C OPY R I G H T
B Y

B O E RI C K E R UN YO N
1 91 0
 P R E FA C E

T he l a c k in our s c hoo l of a w ork o n M e nt a l D i seases

, ,

based upo n t he l a t es t c l ass i c a ti o n n ow adop t ed in n ear ly

a ll o f t he bes t H osp it a l s for the I n sa n e i s t he ex c use for
,

prese ntin g t h i s book to t he pub l ic .

Wh i l e n u m erous c l ass i c a t i o n s have bee n fra m ed by

d i ff ere nt w r it ers n o o n e has so c o m p l e t e ly ll ed t he
,

publ ic n eed as t ha t b y K raepe l in w h ic h w e have fo ll ow

,

ed f or severa l y ears in our l e ct ures to t he s t ude nt s of

t he N ew York H om oeopa t h ic C o ll e ge a n d Fl o w er H os
p it a l
.

Fo r ease of refere nc e w e have int rodu c ed m a r g in a l

,

n o t es to t he m a in t ex t t h in k in g t he y w ou l d be appre
,

c i ated a s t i m e savers b v t he c ro w ded s tude nt a n d bus y

-

pra ct iti o n er .

A bs t ruse d i s c uss i o n s o f u n p rove n t heor i es o f e t i o l o gy

a n d pa t ho l ogy have bee n care f ul l v avo i ded I t has bee n
.

t he a i m to prese nt a c l ear w ord p ict ure o f t he m e nt a l d i s

-

eases l i ab l e to be e nc ou nt ered in da i ly pra ctic e T he .

m ed ic a l t rea t m e n t g i ve n i s pure ly H om oeopa th ic t he i n

,

d i ca ti on s for re m ed i es be in g t hose w h ic h w e h ave per

son al l y repea t ed ly ver i ed dur in g m a n y y ears o f pr ac

t ic e in ever y for m o f m e nt a l d i sease .

A l l o f t he m os t va l uab l e re c e nt w orks have bee n

d ra w n upon for t he l a tes t a cc ep ted v i e w s o f P sy chi atr v ,
vi PR EFAC E

a n d w e g ra t efu lly a c k n o w l ed ge our in deb t ed n ess t o t he i r

au t hors W e are espe ci a lly in debt ed t o t ha t re n o w n ed
.

a l i e ni s t K raepe l in a n d h i s t ra n s l a t or D e f en d or f w ho
, , , ,

has re n dered su c h g rea t pub l ic serv ic e b y t ra n s m ittin g

h i s i deas t o the A m er ic a n profess i o n .

\V e a l so des i re t o t ha n k D r M aur ic e C A sh l e y . .
,

S uper int e n de nt O f the M i dd l e t o w n St a t e H o me opa t h ic

H osp it a l for t he I n sa n e for h i s g rea t k in d n ess in a ll o w
,

in g us t o se c ure pho t og raph s o f the d i f f ere nt var i e t i es O f

m e nt a l d i sease at h i s in s t it u ti o n a n d t o D rs \V ood m an , .

a n d B re w s t er f or t he i r he l p in se l e ctin g t he c ases a n d
,

se c ur in g t he pho t og raph s W e are a l so in deb t ed t o t hese.

g e n tl e m e n for t he d i ff ere nt ty pes O f w r it in g prese nt ed

in t he book A l l O f t he i ll us t ra t i o n s are fro m or i g in a l
.

pho t og raphs t ake n espe ci a lly f or t h i s boo k a n d n ever

, ,

before pub l i shed T ha n ks a re a l so hereb y t e n dered to

.

D r A m os JG i ve n s O f t he G i ve n s S a nit ar i u m a t St a m
. .
,

ford C o nn e ctic u t for sa m p l es o f ha n d w r itin g a n d to

, , ,

M rs El i z abe t h S pau l d in g f o r va l uab l e a i d in p roof

.

read in g .

I f t h i s w ork sha ll a i d t he g e n era l pra ct iti o n er a n d s t u

de n t i n ob t a inin g a fu ll er k n o w l ed ge o f th i s m os t d i f c u l t
c l ass o f d i seases w e sha ll fee l t ha t our l abor has n ot
,

bee n in va in .

W I LL I A M M O RR I S B U T L E R M D ,
. .

M a y 9 19 10 ,
.

5 07 C l int o n A ve n ue ,

i rook l y n ,
N ew York C it y .
 I LLU S T R A T I O N S

A
F C IN G P A GE

Pl t
a e I C r ti W ith M rk d Sti gm t of D g r ti o
e n a e a a e en e a n 24

Pl t
a e 2 . G rou p D g r t M l S how i g C r i l A om l i
e en e a e a es, n an a n a es 25

Pl t
a e 3 . Fm le D g r t S h ow i g F c i l A y m m t
a e e en e a e, n a a s e rv an d

A om l i of E
n a es ar 30
B r d d W om
ea e an 3t
PA GE

C of P u r p r l
ase e e a or m of E xh au ti v P yc ho i
F s e s s s 1 00

D m ti P r co
e en a ae x W it h M ark d M t al e en 2 10

M u cu l r T i o
s a en s n i C at at o i c S t u p or
n n 216

M u cul ar T i o
s en s n i C at t o i c S t u p or
n a n 22 2

L tt r W r itt
e e by en a Ca of D m ti a P ra c ox
se e en e 2 26

C of D m ti
a se e en a P r a c ox W it h M ark d C t t o i c
e e a a n T en

228

G rou p W it h M rk d C t at o i c T i o a e a n en s n 2 34

G rou p of F m al P ar ti c e e e s 2 50

S mp l
a of H d w r iti g From D i c t ti o of Thr C a
es an n a n ee ses

of D m ti P r lyti c e en a a a a

P r ti c W r iti g
a e n

F m l I vo l u ti o al M l c ho l i c
e a e n n e an

I vo l u ti o al M l
n c ho l i C h r c t r i ti c Fac i l E x p r i o
n e an a a a e s a ess n .

D p r d T y p of M i c D p r i v I a it y
e esse e an e ess e ns n

D p r d T y p of M i c D p r i I
e e sse e it y H y po
an e e ss ve n san

c ho n d r i acal

Dp e d T y p of M
r e sse ic D pr iv I e an e ess e n san it y
D p r d T y p of M i c D p r i v I
e es se e an e e ss e n san ity
M i c T y p of M i c D p r i v I
an e it y an e e ss e n san

P r o i c \V it h M rk d D l u i o of P
a an a a e e s ns r cuti o
e se n

C t to i c T i o C
a a n f E pi l pti c I
en s n a se O e ns n a it y

G rou p of D m t d E pi l pti c e en e e s
 C O NT ENT S

C H A PT ER I
P AG E
D e n i ti on C l a ssi ca ti o n an d P t ho l o gy
a of I it y E x
n sa n am n a i ti o n

an d C om m it m t of I D i ti en n san e . e n on B ro w r B e an n s e itr
A d r w C o m b L g l I
n e it y D dC l i ti T h
e e a n san e ne a ss ca on s .

Zi h A g o ti i K r p l i P t h l o gy E m i
e en s n ti o f th ae e n a o xa na n O e

I N
n san e w York S t t uL e L w P ti t W ho S houl d a e n ac v a a en s

B C o m m itt d
e e

C H A P T ER II

ET I O LO G Y

I n h r t P r d i p o iti o Sti g m t of R g rati o A t om i c al

e en e s s n a a e en e n na

n a
C ra i l A o l i F c i l A y m m t ry D form iti of th
m n a es a a s e e es e

Pal at A o m l i of th T t h To gu
e n a es d L ip E y
Ee ee n e an s e ar
Li m b G it l i Sk i s en a a -
P h y i o l og i c l Sti gm t A om l i n s a a a n a es

of M o t or Fu c ti o S ory Fu c ti o S p c hG it o U r i r y
.

n n ens n n ee en -
na

Fu c ti o In ti c t or A pp tit
ns ns P yc h i c S ti g m t a C h g
n e e . s a an e

bl
a M t al I t bi l it yEg o ti m A b c of M r l S
en e ss en ns a s sen e o a en se .

I ans ne
D i t h i C au a
H r d it y Law
es s f H
r d ity P
se s e e s O e e re

t al I u
na n
S h c k D ru k
en ce D i t D ur i g P r g cy
o n en n ess e n e n an

I m p rf c t Nu t r iti o Tr u m ti m O v r t x ti o of th U
e e n a a s e a a n e n

d v l o p d P h y i c l P o w r F i l ur t o E r ly L r
e e e s a S lf e s a e a ea n e -
co n

t ro l D i ipati o a d E c i v S xu l I d u lg c E x c iti g
ss n n x es s e e a n en e n

C u a St r i
se s Tox i c A g t B d i l D i a
a ns C r iti c l en s o v se se a

P r i o d S hoc k
e s s 24

C H A P T ER I I I
S YM Y P T O M A T O LO G

s e s D o ee
D i or d r f S l p i or d r of Nu t r iti o S c r ti o C h g i s e s n e e ns an es n

th e e
Ar t r i T ro p h i c C h g Fr g i l it y f th Bo
es D rm an es a o e n es e

g phyo P l
ra
T m p r t ur S ory S m pt o m D l u i o
n se e e a e en s y s e s ns
E x p i v D p r iv an s I ll u i S i gh t H r i gO r g i c
e e e ss e . s ons ea n an

S
en sa m
ti o S l l T t M u c u l r Sns H l lu i
e ti as e s a en se a c i a
'
on s
x CO N TE N TS

r i gS i g h tT t
PA G E
H ea n S m ll G it l S F l i
as eg Touc h e en a en se ee n

I m p u l P se i o t S i p l St r o t y py N gati i m D i t urb
m
ass n a e, e e e e v s s

an e c of P o w r of A tt ti I d a I m p r ti v Fi
e d en on . e s e a e xe

Au t oc h t ho ou D i ord r of th W i ll D i or d r i th Em
n s s e s e s e s n e o

D i or d r of M m or yJu d gm t R ac ti o
.

ti o al S p h r
n e e s e s e en e ns

. .

I m pu l P se m
ass n a e,
i o t S i p l St r ot y p y N g ti v i m D i t urb e e e e a s s

a n ces of E x p r i o Sp c h H d w r iti g C o d u c t
e ss n . ee . an n n 51

C H A P T ER I V
NF T N PS YC S ES I EC IO H O

e e e
F v r D l i r i u m E ti o l o gy P t ho l o g i c l A t om y S ym pt o m t o l o gy a a na a

P rog o i Tr t m t I f c ti o D l i r i T yp ho i dSm ll po
n s s ea en . n e n e a, a -
x

M l r i A c u t C hor I u
a a a H y d ro p ho bi Tr t m t
e ea n en z a, a. ea en .

P o t I f c ti o P yc ho P ro g o i Tr t m t K k
s -
n e n s ses n s s ea en . o r sa o
'

Di E ti o l o gy
sease P t hol o gy Sy m pt om to l ogy P r g o i. a . a . o n s s

D i g o i Tr t m t
a n s s . ea en 78

C H A P T ER V
A T N PSY C S ES EX H US IO H O

C o ll p D l i r i u m T h A c u t D l i r i u m D l i r i um G r v P h o
a se e e e e . e a e ren

ma i B ll Di E ti o l o gy P t ho l o g i c l A t m y Sy m p
'

n a. e s sease , . a a na o ,

tom t l gy P ro g a o oi Tr t m t A c u t C o fu i l I
, n o s s. it y ea en . e n s ona n san

(A m ti ) H all u c i t or y I
en a it y H ll uc i at or y C o fu i o
- na n san , a n n s n

P r oi D i o c i ti v (Zi h ) Eti o l ogy Sy m pt om t o l g

a an a. ss a e e en , . a o y .

Di g i Tr t m t
a nos s . ea en 98

C H A P T ER V I
N L EN IA E
'
RA S T H

E ti l o gy
o Sy m pt m ti l gy
,
P t ho g i o a o ,
a en e s s, Die ren t i al Di g o i a n s s,

C our P rog o i T r t m t
se, n s s, ea en 1 20

CH A PT ER V I I
I N TO I C A T IO N P S Y C O E S X H S

A lc oh l i c I o i ti A ut C hro i c G r l Sym pt o m of A lco

n san es c c n . en e a s

ho l i m Cl i i c l A p c t O f A lc oho l i m A lc ho l i c P h
s n a s e s s . o svc o s es
 C ON T E N T S xi
PA G E
n
M el an c ho l i a M a i a A lc oho l i c P r P yc ho a an
o i a Kor sako

s s

i
s s
A lc oho l i c P ud o P r i A lc oho l i c P ro g i v D
se -
a es s . re ss e e

m ti A lc oho l i c E pi l pti c I
en a it yA c u t A lcoho l i c I
e it y n san e n san

Cl i i c l Form (D l i r i u
n a m Tr m
) S y pt o
m
e m
t o l o gy P e en s a a

th l gy
o o T ea en
r t m t A lcoho l i c M l c ho l i Sym pt om t o l ogy e an a a

o
A lc ho l i c M i Sym pt om to l ogy P rog o i P t ho l o gy
an a a . n s s a

A lcoho l i c P r i Sy m pt om t o l ogy P rog o i T r t m t

a an o a . a . n s s ea en .

A lcoho l i c P u d o P r i S ym pt om t o l o gy A lc oho l i c D
se -
a es s a e

m ti en S ym p t o m at o l o gy
a P rog i A lcoho l i c E pi l p y n os s e s

Sy m pt o m t o l o gy P ro g o i
a n s s 1 63

C H A P T ER V I I I
NT C T N P S YC S S CO N T I N E
I O XI A IO H O E U D

M or p h i i m C u
n s D ru g aS y m pt
se so m D p r i v ti o S y m pt o m s e a n s

P rog o i D i g o i Tr t m t
n s s a n C oc i i m Sy m pt om
s s ea en . a n s s
n
P rog o i D i g o i T r t m t M t l S y m pt o m P ro
s s a n s s ea en . en a s

du d ce
by B rom i d Q u i i
I o d ofor m L d C h l or l
es n ne ea a

C h l rofor m Et h rB l l d
o S l i cyl i c A c i dH y o y m i
e e o on n a a A sc a ne

C r b a D i x i d A tip y r i Sy m p t t l gy D i ag o i
on o e n ne O I na o o I
n s s

Tr t m t ea en 1 89

C H A PT ER I X
E N T I A P RA C DE M E O K .

e . ti o l ogy P t ho l ogy Sym pt o m t o l gy

a H b p hr i Sy m pt m
a o . e e en a o a

o l
t ogy o n s s .

P r g o i C t t o i Sy m pt o m t o l ogy Cour P ro g
a a n a a se

n o i P r o i d or
s s . F
a an m I
c oh r t T y p Sy t m ti d T y p
s n e en e s e a ze e

S y pt o
m m a
t o l ogy C our D i g o i P ro g o i T r t m t
se a n s s n s s ea en .

O cu l r S ig d S y m pt o m D m o t r at d b y D
'

a n s an l d s e ns e rs . v son an

Cl rk
a

C H A PT ER X
E N T I A PA R A YT I C A
DEM L

I I i sto rv S m D i ti
v n on v s E ti o l o gy P r d i p o i g C u E x
e n on -
e s s n a ses

c iti g C u
n a P ro d rom l S t t Sym pt om t o l ogy Fi r t S t g
se s . a a e a . s a e

of th E te b l i h
s ad D i s e S y m pt o m t o l o gy
sea seS co d St g a . e n a e

S y m pt o m at o l o gy .

Th i r S t g S ym pt om t o l ogy G l l o pi g
d a e a . a n
x CO N TE N TS

PA G E
F C i rc u l r T y p D p r d Form Spi l G r l P r
or m a e . e esse na en e a a e

i
s s D m . t d F m
or Juv l G r l P r i R m i i o
e en e en a en e a a es s . e ss ns

Dur ti o P t ho l o g i c l A t om y P rog i D i g o i
a n a a na no s s a n s s

T r tm t ea en 248

C H A P T ER X I
O RG A N C ENTI A I DEM

Sy p h i l iti c D m ti P r g r si v D m ti a \V it h P r ly i
e en a oD es e e en a a s s . e

m ti en \V i th ut P r ly i
a P o t A p op l c ti c d Em b o l i c D
o a a s s . s -
e an e

m ti
en Throm bo ti c D m ti D m ti From D i m i t d
a . e en a . e en a sse na e

S cl ro i D m ti Fro m B r i T u m or
e s s . e en a a n s 29 2

C H A PT ER X I I
N O JJ NA PS Y C S E S I V I TIO L H O

M l ch l i
e an E o
ti l o gy P t ho l og i c l
a A t o m ySy m pt om t o l ogy
o a a . na a

C our D i g o i T r t m t S i l D m ti Sy m pt m
se a n s s ea en . en e e en a o a

t l gy OP t ho l og i c l A t om yT tm t
o a a na rea en 300

C H A PT ER X I I I
M A N I C E PR E SS I E I NS A N I T Y D V

T y p M i cD p r d M i x d D iti Eti l ogySym pt om

es an e esse e . e n on o

t l
a o o
gy M i c T y p D i v i d t o H yp o i M i D
. d I an m e e n an a an a e

ns m
l i r i o M i H y p o i Sy pto m t o l ogy C our M i
m
an a .
an a a se . an a

Sy m pt o m t o l o gy C our
D l i r i ou M i Sy m pt om t o l o gy
a se . e s an a a

C our T r t m t D p r i v St t D i v i d d I t o S i m p l
se ea en . e ess e a es e n e

R t r d ti o D l u i o l Form S t u p orou D p r i o S i m p l
e a a n, e s na . s e e ss n. e

R t r d ti o Sy m pt om t o l o gyC our
e a a n D l u i o l Form a se . e s na

S y m pt o m t o l o gy S t u p orou a
D p r i o Sy m pt m t o l ogy
. s e e ss n o a

C our T r tm t se Mi x d T p D i v i d d I t o I r c ibl M i
ea en . e y es e n as e an a,

D p r i v Ex c i t m t U p ro d u cti v M i M i c St p r
e es s e e en . n e an a . an u o .

D p r i o \V it h Fl i gh t of I d
e ess n D pr i W it h Fl i ght of eas . e e ss on

Id d Em
ea s o ti o l anE l ti I r c ib l M i Sy m pt m
na a on . as e an a o a

t l gyo o D pr .

i v E x c it m t Sy m pt om t o l gy U p rod u c ti v
e e ss e e en a o . n e

\l .
Sy m pt m t l gy
an i a o
M i c St u p or Sy m pt om t o l ogy
a o o . an a .

D p r i o \V it h Fl i gh t of I d Sy m pt om t o l gy D p
e e ss n eas a o . e res

i o \V i th Fl i gh t of I d
s n

d E m ti l l tiE S m pt m eas an o on a a on v o
 C O N T EN T S x ii i
PA G E
atol ogy P r i od i c I
. eiti D i v i d d I t oR c urr t M i
n sa n es e n e en an a,

R curr t M l c ho l i A l t r ti g I
e en e an it y C i rc u l r I
a, it y e na n n san , a n san ,

I rr g u l r Form
e a
R c urr t M i Sym p t o m at o l o gy R
s . e en an a . e

c urr t M l c ho l i Sy m pt om t l ogy C i r c u l r I
en e an a it y a o . a n san

S y m pt o m t o l o gy I
a rr g u l r For m Di g o i
. e a s a n s s 32o

C H A P T ER X I V
PA R A N O I A
i v P r o i S t g P ro d ro m l P
.

D e n i ti o C hro i c P ro g r
n n ess e a an a . a es a er

sec ut or y E p iv P u d o D m t d Sy m pt om t o l o gy
x an s e . se -
e en e a .

K t Eb i g
ra -
Cl n i ti
'

s P r oi O r i gi
ass
ri P r oica on a an a . na a a an a

T r d i v a S u b d i i d d I t o P ar o i S i m p l
a v e P r o i H ll u
n an a ex , a an a a

i t i a W it h Mi or V r i ti
c n a or ,
of P r o i P
n ut i R a e es a an a e rec or a e

l i gi o E ro ti c
sa d S u p r b S y m pt o m t o l o gyQ u ru l ou I
a an e a a e s n

san m
it y Sy pt om at o l ogy P t ho l ogy P rog o i Tr t m t a n s s ea en 386

C H A PT ER X V
P I E PT I C I N S A N I T Y E L

P r p rox y m l S t g P r m o it or y St g P ox y m l St g P o t
e a s a a e, e n a e, ar s a a e s

P rox y m l P r i od I t r P rox y m l S t t M d i co L g l R
a s a e . n e -
a s a a e, e - e a e

l ti o hi p
a M l i g r i g P rog o i Tr at m t
ns s, a n e n , n s s e en

C H A PT ER X V I
T M N
ER E M ENTIA
I A L D

A gi t t
a ed orF mS m
y pt om a t o l ogy P i For m Sym pt om t o l og
. a ss v e a y

T r tm t
ea en 43 1

C H A PT E R X VI I
G E N ER A L T R E A T M E N T
H om e T r t m t M t ho d A d v t g
ea en e C D m d i g C om m it an a es . a se s e an n

m t R t T r t m t Tu b F d i g D i t S urg i c l O p r
en . es ea en . e ee n e , a e a

ti ons .

H y d ro t h r p y H o t T ub B t h H o t P c k C o l d P c k
e a a , a , a ,

D ou c h Sp r N d l B t h
e ay , ee e a s 43 7

C H A P T ER X V I I I
M E I CA L TR EAT M E N T
D

D r
ep essed S t t a es R em e di esM i c St t R
. an a es em ed es i 4 59
M ENT A L D I S E A S ES
A ND T H EI R

H O M CE O P A T H I C T R E A T M ENT

C H A P T ER I

D E FI N I T I O N , C LA S S I FI C A T I O N , P A T H O LO G Y
EX A M I N A T I O N , A ND C O M M I T
M E N T O F I NS A N E

I n c o mm e ncin g t he c o n s i dera t i o n O f a n y sub

j ec t it i s c us t o m ar y to de n e it l ay in g do w n,i t s
l i m it s a n d c o nci se ly s t a tin g it s spe ci a l a n d esse n
ti a l fea t ures T ha t t he fra m in g O f a r i g i d d e n i
.

m f ra m m
g
t i o n o f I n sa n i t y I S a d l f cul t I f n ot I m possI bl e d e n i ti on
t ask i s de m o n s t ra t ed b y t he d i verse de ni ti o n s f l
'

o n sa m ty
,

w h ic h have bee n prese nt ed by d i ff ere nt w r it ers

upo n the subj e ct No r i s th i s t o be w o n dered a t
.

w he n w e c o n s i der t he var i e t y O f m a ni fes t a t i o n s

O f m e nt a l aberra ti on t he n um ber O f fa c u l t i es i n
,

vo l ved a n d t he d i ff ere nt de g rees O f dev i a t i o n

,

fro m t he n or m a l T he e m in e nt En gl i sh j ur i s t
.
,

Lord J us tic e Bl a c kbur n o nc e sa i d w h i l e g i v in g

, ,

ev i de nc e be fore a comm i tee O f t he H ouse O f

C o m m o n s : I have read ever y de nit i o n w h ic h I
"
 2 M EN T AL D I SE A SES

c ou l d m ee t w it h a n d n ever w as sa t i s ed w it h on e
O f t he m , a n d have e n deavored in va in to m ake
o n e sa t i s fa ct or y to my se l f I ver i l y b e l i eve t ha t
.

i t i s n o t in hu m a n po w er t o d o it

Wh i l e t he
.

fra m in g O f a r i g i d ly c orre ct m ed ic a l de n iti o n

m a y be i m poss i b l e y e t a perso n appea r in g as a
,

m ed ic a l w itn ess m a y be requ i red to de n e i n

sa n it y a n d on e O f the fo ll o w in g de n iti o n s w i ll
,

B rower (37
' fa i r ly m ee t t he l e ga l requ i re m e nt s : I n san i tv i s
B a n m stei 5
'

a m ore or l ess per m a n e nt d i sease o r dera n ge m e nt .

d ef/5n ztzon
' '

O f the bra in produ cin g d i sordered a ct i o n O f t he

,

m in d in su c h a w ay as to pu t t he subj e ct in a con
d iti o n var y in g fro m h i s n orm a l se l f a n d out o f
re l a ti o n w it h h i s e n v i ro n m e n t in suc h a w ay as
to re n der h i m da n g erous o r i nc o n ve ni e n t to h i m

se l f O r o t hers (B ro w er B a nni s t er ) -
I n sa n .

it y i s a pro l o n ged depar t ure w it hou t a n ade q ua t e

,

ex t er n a l c ause from t he s t a t es o f fee l in g a n d

,

d q n li io n m odes o f t h in k in g usua l to the in d i v i dua l w he n

in hea l t h T h i s i s t he t rue fea t ure o f d i sorder
.

in m in d (A n dre w C o m be ) .

I n a ge n era l w ay in sa nit y m a y be de n ed as a
,

c ha n ge fro m t he in d i v i dua l s n or m a l m e nt a l con

'

Al ed i ca l I n

sa n il y p ro
d iti o n as t he resu l t of d i sease o f the bra in o r
,

or d er o f n ervous s y s t e m H e nc e it i s appare nt th a t w ha t
. ,

the m i nd m a y be sa n it y in on e perso n m av be in sa nit y in

ca m m! by
d is s
ea e
a n o t her For in s t a nc e a n u n educ a ted super sti
.
, .

ti ous n e g ro m a y express a be l i e f in fe ti sh w or
sh i p o r w itc h c raf t a n d vet be per f ectl v sa n e bu t ,
 D E FI N I T I O N 3

if a c u l t i va t ed c oll e ge professor shou l d c l a i m t ha t

a b it of sk in o r c l o t h w as t he d w e ll in g p l a c e O f a n

om ni po t e nt sp i r it possess in g po w er to ha r m h i s

e n e m i es or be n e t h i s fr i e n ds o n e w ou l d i mm e ,

d i ately suspe ct t ha t he w as sq er i n g f ro m so m e
for m O f in sa nit y T e m porar y d i sorder of t he
.

fa c u l ti es m a y resu l t from the in h i b iti o n O f a l c o

hol op i u m c o c a in e or ha sh i sh w h ic h w i ll d i sap
, . , ,

p ear as soo n as t he e ff e c t o f t he dru g passes

a w a y T h i s w ou l d n ot be in sa nit y al t hough t he
.
,

t e m porar y svm p tom s m i gh t be t he sa m e T he .

c h i e f c hara ct er i s tic s O f m ed ic a l in sa n it y m av .

t herefore be des c r i bed as a pro l o n ged d i sorder

,

o f the m in d c aused b y d i sease .

T he l e ga l v i e w O f in sa n i ty d i ff ers som e w ha t
fro m t he m ed ic a l .

P eter son s
I n sa nit y in l aw i s de n ed b y P e t erso n d e m ti o :

'

( C hur c h P e t erso n N ervous a n d M e n ta l D i s of n a/

-
,

I n sa n ity
eases p 6 44 ) as fo ll o w s :
,
.

1 .A c r i m in a l i s in sa n e i f he does a n a ct t he
n a t ure a n d qua l i ty of w h ic h he does n o t k n o w or ,

i f k n o w in g t he n a t ure a n d qua l it y O f h i s a ct he
. ,

does n ot k n o w w he t her it i s r i gh t o r w ro n g .

2 .A t es t a t or i s in sa n e i f h i s m in d m e m or y , ,

"
or un ders t a n d in g i s u n soun d .

3 .I n a l u n a c y in qu i s iti o n t he subj e ct O f t he
in qu i r y i s in sa n e i f he i s inc apab l e o f m a n a g i n g zsl zc of ' '

"
h i m se l f a n d h i s a a i rs
f f .
L e g a l l n

sa m ty lack '

T he c ha ra ct er i s tic o f l ega l in sa n it y i s l a c k o f ,

r e spon si b i l i tv . ri b{I i /y
 4 M E N T AL D I SE A SES

C LA SS I P I CA T I O N
l ar ge n u m ber of c l ass i c a ti o n s O f in sa ni t y
A -

have bee n m ade n ear ly ever y w r i t er prese n t in g

,

a c l ass i c a ti o n O f h i s ow n T he fo ll o w in g ar e .

som e o f t he m os t prom in e n t :

A I I C AT I O N
C L SS F O F TH . Z IEH EN .

s y c hoses w it hout int e ll i ge nc e defe ct

l . P .

SS A Si m p l e ps y c hoses : on ly o n e c h i e f phase
. .

1 A ff e ct i ve ps y c hoses : c h i e f s ym p t o m s i n
.

t he e m o t i o n a l sphere .

( )
a M a ni a .

b
( ) M e l a nc ho l i a .

( )
c N euras t he ni a .

2 I nt e ll e ct ua l phy choses : ch i ef s ym p t om s in
.

t he re g i o n O f t he int e ll e ct .

a
( ) St up i d it y .

b
( ) P ara n o i a .

a
( ) P ara n o i a s i m p l ex .

b
( ) P ara n o i a ha ll u cin a
t o ni a .

( )
c D e l i r i ous ( Idee n

euchti ge ) for m .

St uporous for m .

( )e I nc ohere nt for m .

c
( ) I n sa nit y o f xed i deas .

C om b in ed ps y c hoses w it h severa l phases ,

.

2 D efe ct ps y c hoses
. .

A C o n ge nit a l m e nt a l w eak n ess

. .

a
( ) Id i o c y .

(b ) I m be ci l it y .

(c ) D eb i l it y .
 CLA S S I FI CA T I O N 5

B . A c q u i red m e nt a l w eak n ess or de m e nti a .

a
( ) D e m e nt i a para ly tic a .

b
( ) S e ni l e de m e nt i a .

c
( ) S e c o n dar y de m e n t i a af t er
fu nct i o n a l ps y c hoses .

S e c on dar y de m e n t i a w it h l oc a l
bra in d i sease (s y ph i l i s c ere
b r i cl e ) .

e
( ) Ep i l ep tic de m e nt i a .

f
( ) A l c oho l ic de m e nti a .

C LA S S I FI CA T I ON O F A G O ST I N I ( 1 898 )
A g ostzrzz s
'

G r oup 1 .

c ti o l d i
Fu n M i
I
a . na s an a .

or r of g r
de s e n e al M l l li I
e an c i o i ti c n sa n es .

m t bol i m
e a s .
ICo f i o l I
n us i ti na n sa n es .

LS t u p orou I i ti s n sa n es .

0 .I t ox i c ti o
n
A cut D n
a ns or

a c u t i f c ti o
e n e ns .
e e n a!

c S u b c t or P r l y ti c D m ti
a u e a a e en a
P l l grou I i t y
. .

c h r i c i t xi c
on n o a e a s n sa n .

t i o fro m u t o S y p hi l i ti c I
ns a i ty n sa n .

M e n tal or h t ro t o x i c M yx d m t ou I
e e -
i ty e e a s n sa n
g t or b y p A l c oh l i c I
.

ea se in no r a e n s, s i ty
e o n sa n .

ma l y l d e- l

i l poi
c n or S t r i I
so n s i ty a u n ne n sa n .

v e l o ed I n
p dr g u s . C rb i c I i ty a on n sa n
M or p h i i c I
.

d i v i d ua l s . i ty n n sa n .

LC i i I i ty o ca n c n sa n .

d F mR g
. ro i eS i l D m ti
re ss v e en e e en a
or D g r t v
.

e en e a i e
C r b l ch g
e e ra S c o d ry D m
an es ti . e n a e en a .

e .F m ro D i f fu H m i p l gi c D m se ti e e e en a .

or L l C r b l D m ti fr m D i ff S l
oc a e e ra e en a o u se c e
Di se ase . ro i s s

fro m C r b r
.

l
D m ti e e n a e e al
Co m p r i t e ss o n , e c .
 M E N T AL D S I E A SE S

G r oup I I .

Id i o y c
Im b ci l i ty
e .

E d m i c Cr ti i m
n e e n s
l P r
.

P re c o c i o u s
'
ty pe s O i gi
r na oi a an a
r r t or
.

i gI
.

A R i ty
l EM p ir ld Ii c P i t y o i
e s s e aso n n n san
i ti o
.

D e v a ns o a n sa n .

of th P y e s L so a ra n a
c hi c F l
.

ac u
t i i th
es n e P r i T rd i v
a an o a a e
D g e te n e ra e l L t ty p
a e es . P r i od i c I i t y
e n sa n .

C t to i
a a n a.

G r oup I I I .

P yc1 o
s 1 ses

co ct n ne ed H y ste ri c I i ty n sa n .

wi th N eu E p i l p ti c I
e i ty n sa n .

r op t h i c a H yp h oc d i I
on it y r ac n sa n .

C on sti tu N u e th i c I
ras it y
en n sa n .

ti on .

K RAE P EL I N S CLA SS I FI CA T I O N

K rue/56 1i ) : s F v r D l i ri u m
e e e .

I fn ti
e c D lir o n e
i m u
P y cho C h r c
.

I f c ti o
n e n s se s a a
P y ch o
s se s. t i ti
e r f th
s c o e

P o t F b ri l
s - P e e e
i d of I f c t i ou
r o n e s

l Di se ase .

Col l p D l i ri u m
a se e .

Ex h u ti o a s n A c u t Co fu i l
e n s o na

P y cho
s se s . I i t y (A m
n sa n en

ti l a .

A c q ui re d
C h ro i c N rv u
n e o s
N e u rasth e
E x h u ti oa s n .

n ia .

A c t I t oxi c ti o
u e n a n

C h r i c I t ox i c
on n a

I t ox i c ti o
n a n ti o n

P y c ho
s se s A c u t A l c o h o l i c I t ox i c
e n a
A l coho l i m ti o
.

s . n .

C h r i c A l co h l i m
on o s .
 C LA S S I FI CA T I ON 7

De l i ri u m Tr m e ens
A l co ho l i c D l u i l I i ty
e s on a n s an

Al coh ol i c P r i
.

a an o a
Al coh l i c P ud op r i
.

o se a es s.

A c u t M or p hi
i
e ne
I t i c t i o n ox a n .

M orp hi i m n s
C h ro i c M orp hi n ne

L I t ox i c ti o n a n .

A c u t Co c i I t ox i c ti o e a ne n a n .

Co c i i m
a n s C h o i c Co c m I t
. t r n a n o x tca i o n .

Co c D l u lI i tyai n e si o n a n sa n .

T hy ro ig e M t D i t urb c of M y d a
e n al s an e xe en
ou P
.

n s s y
ch o se s . Cr ti i m
e n s .

H b ph r i
D emen t ia
e e

C t t o i c F rm
en a .

P r c ox
e .
a a
P oi d Form
a ra n
n o
s
.

D m e t d Form
en e .

D em e n ti a Exp i Form
an s v e
P
.

a ra l y ti c a . A gi t t d F m
a e or .

D pre d F m
e sse or .

O rg i c an D i ff L io
u se es ns
L c li d L i o
.

D em e n ti a . o a ze es ns .

I l tl
M l e an c h ol i a .

il D lu i l I it y
n
gs
y g
l gz l s s
P
S
re -se n
eni l D m ti e e
e e
en
s on a
a .
n sa n .

H y p om i an a .

M i l St t
a n aca M i a es . an a .

D l i ri u M i e o s an a .

M ic
an D e
f S i m p l R t rd t i e e a a on .

pr i ve I R t r d ti o w i th D l u i o
w St t i
e ss n e a a n e s ns
D p
i ty d H l l uci ti o
e re ss e a es '

sa n . an a na ns .

L S t u p orou Co d i t i o s n ns .

M d St t
M i l S tu pb an aca r.

S t u p rou M i
I XC a es
o s an a .

Pr a an o i a .

G e n e ra l E p i l p ti c I
e n sa n it y .

Ne uro se s. H y t ri c l I
s e a n sa n i ty .

T ra um tic N
a en ro se s .
 8 M EN T AL D I SEA SES
C o n s titu Co g i t l N u th i
n en a e ras en a .

ti o n a l Com p u l i I i ty
ch o p a
P sy
t h i c
j I mp u l i v I i ty
s
s ve

e n sa n
n sa n
.
.

St ta es .
L C t y S xu l I ti c t
o n ra r e a ns n s .

D e f e ti v e c I m b c i l i ty
I
e .

M e n al D e t
v e l o pm e n t .
LI d i o c y .

T he c l ass i c a t i o n w h ic h w e sha ll prese nt i s the

fo ll o w in g w h ic h i s a s l i gh t m od i c a t i o n
, of
K raepe l in s

.

u tlzor s
C LA SS I FI C A T I O N
A

r D l i i um Fe v e e r .

ti on d ig/z! I f ti o n ec I f c ti
n D l i r i u m n e on e
P y cho 1
P y c h o C h c t r i t i c of th Po t F b ri l
.
, 6
s se s s se s a ra e s e s - e e
P
. .

L r i d of I f c ti o u D i
tion o
e o n e s se ase s
f
.

K ra epelin s E x h u ti
Co l l ap D l i i u m se e r .

P y cho
a
A c u t Co fu i
s on
l I it e
y (A m t in) s ona n sa n en a .

s
N r th i
se s .

e u as en a .

I O r d i ry D r k na un e n n e ss .

A c ut A lc o hol i c I i t y (D l i r i u m Tr m )
e n sa n e e ens .

C h ro i c A l c o h o l i c I it yn n sa n .

I tox i c ti o
n a n M l c hol i e an a
P ych
.

s ose s M i an a
A lc o h o l i c P r
. .

oi a an a
A lc h l i c P y c h P ycho i
.

K

o k w
o s o o rsa o s s s s

A lc h l i c P u d o p r i
.

L se s o o se - a es s
A l c o h o l i c P ro g r
. .

iv D e ss e e

m ti en a .

A l coh l i c E pi l pt i c I o e n sa n

L i t y .

M or p hi i m n s .

C c i im o a n s .

B ro m i m s
I d f rm i m
.

o o o s .

Q u i i i m
n ne s
Pl u m bi m
.

s .

H b ph r i e e en a
D m
.

ggg C t t o i c Form
e a
a a n
P
.

i d Form
co x
a ra n o s .

D m t d Form e en e .

D m ti
e E xp
en a i v Form ans e
P r l y ti c A gi t t d F m
.

a a a . a e or .

L D p r d Form e e sse .

O rg i c D I D i f fu d L i o
an e se es ns .

m ti enI Loc l i d L i o
as . a ze es ns .
 P A T H O L OG Y 9

I u ti
n vo l o n al M el an ch l i
o a
P y cho
.

s se s . Se n i l e D e m en ti a .

H y po m a n i a .

M i c
an a a l S t t
a es . M an a i .

I Del i i r ou
s M an i a
.

M anic D e
pr
S t m p1e D e e s si n o
i ve 1 m
re ss

g i ty D e p re ssw e S t t a es . u
D e l s i o n al D e p re sst o n
.

o w th t u p r
.

u
De pr
e ssi n i S o .

L M ix ed S t t
a es .

P ara n oi a .

G e n e ral Ne uro se s (E p i l p ti c I
e n sa n i ty ) .

r
T e m i n al D e m e n i a t .

P A T H O L OG Y
I n de nin g in sa n it y as a d i sease O f t he bra in it s
pa t ho l ogy i s exp ressed I n o t her w ords i n san i tv .
,

i s a ph y s ic a l d i sease a n d a ll m e nt a l a be rra ti o n s ,

are c aused b v so m e org a nic o r fu nct i o n a l d i sease

o f the bra in or n ervous s y s t e m Eit her t he c e ll s .
,

bers or b l ood vesse l s O f t he bra in have be c o m e

,

d i seased or so m e c ha n ge has o cc urred in t he N em 'aus

S rstom
qua nt it y or q ual i tv O f t he b l oo d b y w h ic h it i s
n our i shed M a n y O f t he d i sorde red c o n d i t i o n s
.

o f t he bra in are un d oub ted l v o w in g to c ha n g es in

I 71g r ra i t I :

t he b l ood it se l f e i ther t h rou gh a l t era t i o n s O f it s

,

ph y s i o l og ic a l in g red i e nt s or b v the int rodu ct i o n ,

of so m e t ox ic e l e m e nt fro m w i t hou t or w i th in , ,

t he s y s t e m .

U po n t h i s t heor y o f it s phv si cal bas i s i s foun d

ed a ll m oder n a n d e n l i gh t e n ed m e thod s O f t rea t
 10 M EN T AL D I SEA SES

P hy s ica l m e nt of in sa n i t y T o c ure in sa n it y o n e m us t r e
.

Ba s is0/
s t ore al l d i seased c o n d iti o n s O f bra in a n d bod y ;
T r r a tm en t as o n ly in a sou n d bod y c a n a sa n e m in d ex i s t .

B e fore e nt er in g upo n a m in u t e s t ud y o f i n
sa nit y as a d i sease l e t us c o n s i der t he bes t
, ,

m e t hod O f exa m inin g a pa ti e n t suspe ct ed of i n

sa nit y.

E X A M I N AT I O N O FTH E I N SA N E
T he in sa n e prese nt ed for exa m in a ti o n m a y be
. ,

ti on 7 7: r re d i v i ded int o t h ree g roups : the rs t w here t he ,

G r oups o f m e nt a l c o n d iti o n i s appare nt to the u n sk i ll ed oh

I n sa n e
server ; the s econd w here it i s eas i ly re c ogn i z ed
.

b y t he ord in ar y pra ct it i o n er ; the th i rd where a ,

d i a gn os i s de m a n ds t he h i ghes t sk i ll O f t he ex
p e r i en ced a l i e ni s t .

I n t he exa m in a ti o n O f a pa ti e nt it i s w el l to
fo ll o w so m e xed l in e o f in qu i r y From som e .

m e m ber O f t he fa m i ly as c o m p l e t e a hi stor v O f
,

the c ase as i s poss i b l e shou l d be O b t a in ed em b r ac ,

in g a ll fa ct s c a l c u l a t ed to t h ro w an v l i gh t upo n
t he n a t ure o r c ause o f t h e d i seas e T he pre g .

n a nc y a n d par t ur it i on O f t he m o t her the ex i s t ,

e nc e O f m en tal n ervous t uber c u l ous or c a nc e r

, , .

ous d i sease in a n y o f t he a nc es t ors t he hab it s o f ,

t he pare nt s as re gards a l c oho l i s m o r d ru gs l i ke

, , ,

P a ti mzl m orph in e or c o c a in e t he a ge a t w h ic h t he pa t i e nt
'

s
,

H i stor l '

c o mm e nc ed to w a l k a n d speak t he d i sorder s o f ,

i n f an cv a n d c h i l dhood t he ten d en cv t o w ard

,
 E X A M I NA T I O N 11

febr i l e d i sease or c o n vu l s i o n s shou l d be in q u i red

, ,

int o A s m u c h kn o w l ed ge as poss i b l e shou l d be

.

Ob t a in ed as t o t he c h ara ct er t e m pera m e nt a n d , ,

hab it s O f t he pa ti e nt dur in g c h i l dhood a n d a t

,

t he per i od O f puber t y t he s t re n g t h O f t he severa l

,

in s tinct s a n d sexua l re l a t i o n s as m as t urba t i o n ,

a n d ex c esses i ll ici t or in m arr i age a n d as to

, ,

prese nt or prev i ous ve n erea l d i sease I n qu i r i es .

shou l d a l so be m ade as to t he hab it s O f t he pa ti e nt ,

as regard s a l c oho l m orph in e c oc a in e or t oba cc o

, , , ,

or t he o cc urre nc e O f a n y sho c k in j ur y severe i ll , ,

n ess or prev i ous a tt a c k O f in sa nit y A m in u t e

,
.

h i s t or y O f t he prese nt a tt a c k shou l d be Ob t a in ed
fro m t he t i m e t he rs t c ha n ge I n t he pa t i e nt s d i s

pos it i on hab it s a n d m a nn er w as n o t ic ed T he
, ,
.

h i s t or y g i ve n m us t be c are fu lly c o n s i dered t ha t ,

t he pa t i e nt s int eres t s m a y n ot be prej ud ic ed b y

t he exa gg era ti o n or m ini m i z in g O f t he fa ct s p re

se nt ed b y fr i e n ds des i rou s fro m in t eres t ed m o
,

ti v es to prove in sa nit y or c o nc ea l it
,
.

T he perso n a l exa m in a ti o n shou l d e m bra c e a ll s

P er on a l
t he or ga n s O f t he bod y t he hear t l u n g s ab d om i
, , ,
i
E x am na
ti on
n a l v i s c era a n d pe l v ic or ga n s t he c o n d iti o n o f
, ,

t he re exes a n d t he se n sa t i o n s T he ge n era l ap .

p e a r an c e O f t he pa ti e nt shou l d be c arefu lly n o t ed ,

t he express i o n O f t he fa c e as in d ic a ti ve O f exa l t a
ti o n depress i o n or a du ll in g O f t he m e nt a l f acul
, ,

ti es T he shape a n d s i z e O f t he head a n d t he ap
.

p e a r a n c e o f t he e y e s shou l d be O bserved a n d ,
 12 M E N T AL D I SEA SES

sear c h m ade for an y O f t he s t i g ma t a O f de ge n era

t i o n A n y t re m u l ous n ess O f t he t on gue or l i ps or
.

d i s t urba nc e O f t he spee c h dra w l in g s c a nnin g or , ,

e l i s i o n O f s yll ab l es shou l d re c e i ve a tt e nt i o n
,
.

Le tt ers a n d ha n d w r it in g shoul d be s t ud i ed as ,

t hese O f t e n revea l in sa n it y c o nc ea l ed in c o n versa

ti o n T he pa t i e nt s m a nn er o f dress in g g a it

.
, ,

ge n era l m us c u l ar m ove m e nt s a n d the appear ,

a nc e O f h i s apar t m e nt s m a y a l so revea l m u c h re
gard in g h i s m e nt a l s t a t e .

M en ta l I n t he m e nt a l sphere t he a tt e nt i o n m e m or y
, , ,

E x am i na j ud gm e nt a n d ge n era l m e nt a l a ct i o n shou l d be
,

t es t ed b y c arefu l ques t i o nin g T he prese nc e or .

abse nc e O f de l us i o n s ha ll u cin a ti o n s a n d i ll us i o n s
, ,

O f s i gh t hear in g t as t e
,
s m e ll a n d t ou c h shoul d
, , ,

be as c er t a in ed T he k n o w l ed ge O f t he pa t i e nt as
.

to h i s m e nt a l c o n d it i o n h i s p rese nt l o c a ti o n a n d
,

surrou n d in g s shou l d a l so be t he subj e ct O f i n

,

q u i r v .

G rea l C a re I n m a n y c ases t he m e nt a l s t a t e c a n be asce r

N eeded i n tai n ed a lm os t b y a gl a nc e : in o t hers a pro l o n ged

, ,

Leg a l C a ses
a n d c arefu l s t ud y w i l l be requ i red O f t e n n ecessi ,

t a tin g repea t ed exa m in a t i o n s I n m ed ic o l e g a l .

-

c ases t he g rea t es t c are i s de m a n ded fro m t he f re

que nt a tt e m p t s o f c r i m in a l s to es c ape pu ni sh m e nt
b y fe i gn in g in sa n it y The form s usua lly c hose n
.

are som e t y pe o f m a ni a m e l a nc ho l i a de m e nt i a
, , ,

or ep i l eps y bu t t he pa r t assu m ed i s usua l ly over

,

don e a n d c a n ord in ar i ly be read i ly de t e ct ed b y

 C O M M I T M EN T 13

O ne versed in in sa ni t y B efore g i v in g a de ci s i ve
.

Op ini o n severa l exa m in a t i o n s shoul d be m ade to

, ,

avo i d a n y poss i b l e m i s t ake .

We w i ll n ow c o n s i der t he requ i re m e nt s f or a
l ega l c omm it m e nt t o a hosp it a l f or t he in sa n e in S ta te La w
a s to C om
t he St a t e O f N ew York as t he y are re c orded in
,
m i tm en t of
C hap 54 5 La w s of 1 89 6 A r t 3 S e ct i o n s 60
.
, ,
.
, , the I n sa n e
"
6 1 6 2 6 3 a n d 64
, , ,
A perso n a l l e ged to be i n
.

sa n e a n d w ho i s n o t in c o n n e m e n t o n a c r i m in a l
,

c har ge m a y be c omm itt ed to a n d c o n n ed in a n

,

in s tit u ti o n for t he c us t od y a n d t rea t m e nt O f t he

in sa n e upo n a n order m ade by a J ud ge O f a C our t
O f Re c ord O f t he C it y or C ou nt y or a J us tic e O f .

t he S upre m e C our t O f t he j ud ici a l d i s t r ict in ,

w h ic h t he a ll e ged in sa n e perso n res i des or m a y ,

be adj ud g in g su c h person to be in sa n e upo n a

, ,

c er ti c a t e O f l u n a c y m ade b v tw o qua l i ed m ed i
c a l exa m in ers i n l u n a c y a cc o m pa ni ed b y a ver i
,

ed pe tit i o n t here for or upo n su c h c er t i c a t e a n d

,

pe titi o n a n d a f t er hear in g t o de t er m in e su c h
,

ques ti o n as prov i ded in th i s ar t ic l e T he c o m .

m i ss i o n sha l l pres c r i be a n d fur ni sh bl a n ks for

su c h c er t i c a t es a n d pe t it i o n s w h ic h sha l l be
,

m ade o n l y upo n suc h b l a n ks A n in sa n e person .

sha ll be c o mm itt ed o n ly to a St a t e hosp it a l a ,

du ly l ic e n sed in s t it u ti o n f or t he in sa n e or t he ,

M atteaw an St a t e H osp it a l or to t he c are a n d ,

c us t od y o f a re l a ti ve o r c o mm it tee as hereaf t er
prov i ded N O i d i o t sha ll be c omm it ted to or con
.
 14 M EN T AL D I S EA S ES

n ed in a St a te hosp it a l B u t auv ep i l ep tic or

.

feeb l e m in ded perso n be c o m in g i n sa n e m a y be

-

c omm it t ed as a n in sa n e perso n to a S t a t e hosp it a l

for c us t od y a n d t rea t m e nt t here in .

Exam na i T he c er t i c a t e O f l u n a c y m us t sho w t ha t su c h
i
t on by T wo
perso n i s in sa n e a n d m us t be m ade b y tw o repu t
P hy c a n si i s
ab l e ph y s ici a n s g radua t es O f a n inc orpora t ed
,

Yel l rs i n m ed ic a l C o ll e ge w ho have bee n in t he a ct ua l pra o

,
P r o eti ee

ua l ed
t ic e O f t he i r profess i o n a t l eas t three y ears a n d
Q i
,

by C om m i s have l ed w it h t he C omm i ss i o n er a c er ti ed c op y
si on of
o f t he c er t i c a t e o f a J ud ge O f a C our t O f re c ord
L u n a cy
Sho w in g su c h qua l i c a t i o n s in a cc orda nc e w it h

form s pres c r i bed b y t he C omm i ss i o n er S uc h .

ph y s ici a n s sha ll j o int l y m ake a n a l exa m in a ti o n

O f t he perso n a ll e g ed to be in sa n e w it h in t e n

da y s n ex t be fore g ra nt in g O f t he order T he .

da t e o f t he c er ti c a t e o f l u n a c y sha ll be t he da t e
O f su c h j o int exa m in a ti o n S u c h c er ti c a te o f
.

l u n a c y sha ll be in the for m pres c r i bed b v t he C om

m i ss i o n er a n d sha ll c ont a in the fa ct s a n d ci r c u m
s t a nc es upo n w h ic h t he j ud gm e nt O f the ph y s i
ci an s i s based a n d sho w t ha t the c o n d it i o n o f t he
,

P hy si ei a a s
perso n exa m in ed i s su c h as to requ i re c are a n d
m 2! st n ot be t rea t m e nt in a n in s tit u ti o n f or t he c a re c us t od y
,

con n ected
a n d t rea t m e nt O f t he in sa n e
i
w th i n sti
.

i t
tu t on o N e it her su c h perso n s sha l l be a re l a t i ve o f
w hi h i t is
c t he perso n app ly in g f o r t he order O f t he perso n
r o ) 0
ed
p / to
a ll e ged to be in sa n e o r a m a n a ger super int e n d
com m it , ,

p i
a t er: t e nt propr i e t or O f c er st oc kho l der or h ave a n y
, , , ,
 CO M M I T M E N T 15

pec un i a r v interest di rectly or indirectly or be an ,

attend i ng physician in the institution to w h ich it

is propose d to commit such person .

A ny person w ith w hom an alleged insane per
son may reside or at w hose house he may be or ,

the father o r mother husband or w i fe brother

, ,

or sister or the ch ild o f any such person and an y

, ,

overseer of the poor o f the to w n a n d super i n ,

tendent o f the poor o f the C ounty in w hich any

such person may be m ay apply f or such order b v ,

presenting a veri ed petition containing a state l

ch ti on

'

ment o f the fact s upon w hich the allegat ion o f

insanity is based and beca use of w h ich the appl i
cation f or the order i s made S uch petit ion shal l
.

be accompanied by the cert i cate of lunacy of the

medical examiners as prescribed in the preceding
section N otice of such appl ication shall be serv
.
P er son a l
Serv i ce on
ed personall y at l east one day be fore makin g P a l i en ! B e
such appl i catl on upon the person allege d to b e
,

a m {n a ti on
insane and i f made b y an overseer or super
,

i n ten d en t o f the poor al so upon the husban d or

,

w i fe father o r mother o r next o f kin o f such

, ,

allege d ins ane person i f there be an v such kno w n

,

to be residing w ith in the C ounty and i f not upon

, ,

the person w ith w hom such al leged insane person

may reside or at w hose house he may be The
,
.
j dgu
e m ay
D i spen se
j u d ge to w hom the appl ication is to be ma d e mav
d ispense w ith such personal service or may di rect P r son a :
e

substitute d service to be made upon some person S e r v i ce

 16 M EN T AL D I SEA S ES

to be designated b y h im He shall state in a cer

.

ti c ate to be attached to the petition h is reason

for di spensing w ith personal service of such n o

tice and i f substituted service is directe d the
,

name o f the person to be served there w ith .

The Judge to w hom such application is mad e
m ay i f n o demand is made f or a hearing in b e
,

hal f o f the alleged insane person proceed forth

,

w ith to determine the q uest ion of insanity and i f ,

sat is ed that the al leged person is in sane mav

immediately i ssue an order for the commitment
of such person to an institution for the custod y
and t reatment o f the insa n e I f ho w ever it ap
.
, ,

l 213a :1 6 may pears that such insane person is harmless and h i s

be ca red relatives or a co m mittee of his per son are w ill ing
f or O ut
and able to properly care for him at some pl ac e ,

other than such institution upon their w ritte n

,

co n sent the Judge may order that he be placed in

the care and custody of such rel at ives or such
committee S uch Judge may in his di scretion
.
, ,

requi re other proo fs in addit ion to the pet it ion

and certi cate o f the medical examiners .

Upon the demand o f any relative or near

friend in behal f o f s uch alleged insane person the ,

Judge shal l or he may upon his ow n motion issu e ,

an order di recting the hearing o f such appl icat ion

be fore him at a time not more th an ve days
from the date of such order w hich shall he serv
,

ed upon the parties interested in the application

 C O M M I T M EN T
p

1/

and upon such other persons as the Judge in h is

discret ion may name U pon such day or upon .
,

such other day to w h ich the proceeding shall be

,

regu larly adjourned he shall hear the testimony

,

introduced by the part ies and examine the alleged

insane person i f deemed advisable in or out o f ,

court and render a decision in w riting as to such

,

person s insanit y I f it be determined that such

.

person is insane the J ud ge shall forth w ith i ssue

,

h i s order committing him to an instit u tion for the

custody and t reatment of the insane or make ,

such other order as is provided i n th is sect ion I f .

such Judge cannot hear the appl ication he may in

his o w n order di rect ing the hearing name some ,

re feree w ho shal l hear the test imony and re

, H ca r i n b
g y
port the same forth w ith w ith hi s opinion t here ,

on to such Judge w ho shall i f satis ed w ith such

, ,

report render h is decision accordingly I f the

, .

commitment be made to a S tate Hospital the or d er

shall be accompanied by a w ritten statement o f
the Judge as to the nancial con d ition o f the i n
sane person and o f the persons legally l iable f or
,

h is maintenance as far as can be ascertained .

The superinten d ent of such S tate Hospital shall

be immediately noti ed of such commitmen t and ,

he shall at once make provi sion s f o r the t rans

, ,

fer o f such insane person to s uch hospital .

The petition o f the appl icant the certi cate ,

in lunac y o f the m e d ical examiners the order .

 18 M EN T AL D I SEA SES

directing a further hearing as provided in th is

section i f one be issued and the decision of the
, ,

j udge or referee an d the order o f commitment

,

shall be presented at the time o f the commitment

to the superintendent or person in charge o f the

inst itution to w h ich the insane person is com

m i tted and verbatim copies shall be for w arded
,

by such superintendent or person in charge and

led in the o f ce of the S tate C ommissioner in
'

lunacy The relative or committee to w hose

.
, ,

care and custody any insane person i s committed

shall forth w ith le the petition cert i cate an d
order in the o f ce o f the clerk of the C ounty
,

w here such order is made and t ransmit a cert i ed ,

copy of such papers to the C ommi ssioner in

lunacy and procure and retain another such cer ~

ti ed copy .

The superintendent or person in charge o f
any institution for the care and t reatment o f the
p anhu

nuk n t mw /
insane may refuse to receive any person upon an y
g
such order i f the papers required to be presented
,

a hk n t
shall n ot comply w ith the provisions o f th is sec
t ion or i f in his j udgment such person is not
, , ,

in sane w ith in the meaning o f this statute or i f , ,

received such person mav be di scharged by the

,

commi ssion N o person shall be admitted to an y

.

such institution under such order a f ter the ex

p i r at i o n o f ve davs from and inclusive o f the
date thereof .
 CO M M I T M E NT 19

I f a person ordered to be committed pursuant ,

to this chapter or any friend in h is behal f is

, , ,

d issatis ed w ith the nal or d er of a Judge or

Justice committing him he mav w ith in ten days
, ,

a fter the making o f such order appeal there from ,

A ppm ! to
to a J u stice o f the S upreme C ourt other than the

Justice making the order w ho shall cause a j ury

,

to be summone d as in case of proceedings for the S uprem e

C ou rt a n d
appointment of a committee f o r an insane person ,

and shall t ry the quest ion o f such insanity in the by j u ry

same manner as in proceedings f or the appoin t

ment o f a committee Be fore such appeal shall
.

be heard such person sh all make a deposit or give

,

a bond to be approved by a Just ice o f the S upreme Bon d f or

,

f
o
C ourt f or the payment of the co sts o f appeal i f
, , A pp ea l

the order of commitment i s sustained I f the ver .

dict o f the j u rv be that such person i s insane the ,

j ust ice shall certi f y that fact and make an order

o f commitment as upon the original hearing .

S uch order shal l be presented at the time of the

, b l ot/20d a n d
commitment of such in sane person to the super C on di ti on s
,

f pp
o A m !
i n ten d en t or person in charge of the inst i tu t ion
to w hich the insane person is committed and a ,

cop y thereof shall be for w arded to the commis

sion by such superintendent or person in charge
and led in the o f ce thereo f P roceedings under
.

the order shall not he stayed pending an appeal

there from except upon an order o f a Justice o f
,

the S upreme C ourt an d made upon a notice and

,
 20 M E N T AL D I SEA SES

a fter a hearing w ith provisions ma d e therein f or

,

such temporary care and treatment of the alleged

insane person as may be deemed necessary .

I f a Judge shal l re fuse to grant an appl ication
f o r an order of comm itment o f an insane person ,

proved to be dangerous to himsel f or others i f at ,

large he Shall state his reasons f or such re f usal

,

in w riting and any person aggrieved thereby

,

may appeal there from in the same manner and

under the same condition s as from an order o f
commitment .

The costs necessarily incurred in determining
the quest ion of the insanity of a poor or indi gent
person and in securing hi s admission into a S tate
hospital and the expense of providing proper
clothing for such person in accordance w ith the
.

'
rules and regulations adopt ed b v the C ommis
osi s
sion shall be a charge upon the to w n cit y or
, ,

T ow n county Securing the commitment S uch costs

.

C i!1 or S hall incl ude the fees allo w ed by the J udge or Jus
'

0 1 r i ng
t ice ordering the commitment to the medical
C om m i ! examiners I f the person sought to be commit
.

mm ! ted is n ot a poor or indigent person the costs of ,

the proceedings to determine his insanity and to

secure hi s commitment as provided in th i s article
, .

shall be a charge upon his e state or shall be p aid

,

by the persons legal ly l iable for hi s maintenance .

I f in such proceedings the alleged insane person

,

is determined not to be insane the Judge or Jus

,
 CO M M I T M E N T 21

tice may in his discretion charge the costs of the

, ,

proceedings to the person making the appl ication

f or an order o f commitment and j udgm ent may ,

be entered f or the amount thereo f and en forced

by execution against such person .

W e see from the foregoing t hat a commitment

to be legal must meet the follo w ing requi rement s
of l aw :

1 . petitionA .

2 .P ersonal service .
m en t: f
o

3 .Ex amination by tw o qual i ed examiners in m i l m on t

lunacy .

4 .Judical order o f commitment by a Judge

of a C ourt of R ecord .

5 .S tateme n t o f nancial condition of a

pa tien t .

Blank forms o f commitment may be Obtained

from the hospital to w h ich the pat ient i s to be
sent or from the O f ce o f the C ommission in
,

L unacy or from the oi ce o f the C ommi ssioner

,

of C harities .

A ll to w n city or county authorities be fore

, ,

sending a patient to a hospital must see that said

pat ient is in a state of bodily cleanl iness and pro ,

v i d ed w ith n ew clothing th roughout inc l udin g ,

shoes and hat Bet w een the month s of N ovem

.

ber and A pril both inclusive there shall be pro

, ,

v i d ed in addition to the foregoing a suitabl e

, ,

sha w l or cloak for female patient s and a suitabl e

3
 22 M E N T AL D I SEA SES

overcoat for male pat ients al so gloves or ,

mittens .

l V/zen
/
The last subj ect w hich w e shall di scuss in this
st un / [d a

P a ti en t be
connection is the question \V hen Should w e com ,

C om m i ti ati mit a patient to an insane hospital

to a n I n sa n e In determining thi s question w e shall consider
1
. The nancial condit ion of the patient .

2
. The form o f the disease .

3
. The age o f the patient .

4 The patient s physical condition

'

. .

W hen the family is suf cientl y w ealthy t o

secure S ki l led medical service and to surround
the pat ient w ith enough t rained nurses to prevent
h is harming himsel f or others an v case w hat , ,

ever the type O f the disease may be treated at ,

home When ho w ever this cannot be done he

.
, , ,

should invariably be sent to a hospital .

U sual ly suicidal cases and a l w ays cases o f

homicidal mania paranoia an d paresi s should be
, ,

committed It is al w ays un w ise to t reat sui

.

c i d al patients at home as the oppor tui ti es for

,

the accompl ishment of their one purpose in l i fe

are too great f or the phv si ci an to take the respon
si b i l i ty. P aranoiacs are the most dangerous O f
all the insane and should invariably be under
rest raint .

In the rst stages i f closely w atched the pa

, ,

r et i c may remain at home but in the later stages ,

he w i l l be much better off in any w el l equipped -

insane hospital .
 C O M M I T M EN T 23

Children and age d people shoul d i f possible be

, ,

kept at home Y oung men and w omen shoul d

.

al so be given the bene t o f home t reatment i f i t

,

can be accompl ished as vou w ill thus prevent the

.

stigma o f a conne ment in an as y lum from

blackeni n g their fu ture l i fe w hen they have
recovered .

A n y pat ient su ff ering from an y form of insan

i tv w h ich produces great physical w eakness l ike ,

an v of the exhaust ive ps y choses should never be

,

sent to an i n stitution until the ph y sical po w ers

are su ffi ciently restored for the patient to bea r
the j ourney w ith sa f etv VI an v cases of thi s
. .

class w hich might recover at home under proper,

ca re die from the exhaust ion caused by thei r

.

t ransportation to the hospital .

Imbeciles and harmless cases o f dementia al s o

shoul d be kept at home .
 C H A P T ER I I .

E TI O L O G Y .

I n I zcrc n W hatever the immediate exciting cause m ay

P rca i sposi
'

be the pre d ominan t factor in the production o f

,
ti on
insanity is an inherent predisposit ion Hence .

exc iting causes ine ff ect ive in sound individual s ,

m ay in those cases from thei r excessive vul ne r

,

ability prove disast rous

,
.

S tzjem a ta W hat a rc the bodil y and mental marks o f thi s

of D eg e n er
insane diathesis ?
M uch stud v has been given o f
a ti on
late vear s to these de generates and as a resul t
,

many characterist ic an atom i cal p h y s i ol ogi cal

, ,

and p s y chi cal stig mata have been revealed .

A mong the most common and important anatom

ical stigmata are certain

CRA N I AL A N O M AL I ES

C r a n i al A side from the de formities o f the head w hich ,

A n om a/i cs are congenital others are produced in early l i fe

,

by rachitis and hydrocephalus in later l i f e b v

,

tumors and exostoses : w hile at all periods the

, ,

shape o f the S kull is menace d by external inj uries .

The fol lo w ing are some o f the commoner d e s

i gn ati on s o f w ell kno w n cranial de formit ies :
-
CR E TI N
'
ITH M A R K ED S T M ATA
I G O F D E G KN E R A T I O N
 E I T O L O GY 25

C I I EM O C E P H A LU S OR FLA T H EA DE D N ES S C b cm occp/z

This is cha r actei z ed bv a atness of the top of

the head .

O R N A RRO W H EA DED N ESS

LI P T O C EP H A LU S

al u s
This i s caused by an early synostosis o f the
frontal and s phenoid bones .

M A C RO C EP I I A LU S I p
a cr occ l z

M acrocephalus i s a large head usually attrib

u tab l e to h y drocephalus .

M I CR O C E P H ALU S
M icrocephalus i s a smal l head due to con gen i
tal at roph y of the brain or rarel y to pre m ature, , .

s v n o sto s i s o f sutures .

T EEPL E S H A P ED S K U LL
O X YC EP I I A LI S O R S
'
-

al a s
This i s produced b v s y nostosi s o f the parietal
w ith occipital an d temporal bones w ith com pen
sator y development in the region O f the bre gm a .

P LA G I O C EP I I A LL S () R

O B L I Q U E DE F OR M I T Y O F T H E
a /n s
H EA D

This is due to unilateral s y nostosis o f the

frontal bone w ith one o f the parietal bo nes .

S C A I I I O C EP H A LI S
'

. TH E TO P O F TH E H E AD
K EEL S H A P ED
I S -
/
ccb/za / n s

Thi s is caused either b y too earl y union o f the

sagittal suture or b v the development o f both
parietal bones from o n e center .
 26 M E N T AL D I S EA sES

T R I G O N O C EP H ALU S
The trigonocephalus characterized by a very ,

narro w forehead and great w idth beh ind i s ,

caused b v a premature u n ion O f the frontal

suture .

D O LI C H O C EP H A LU S S K U LL
T he d ol i chocephal u s skull is Of unusual le n gth .

B RAC H Y C EP H A LI C S K ULL
co p/ ml u s
The brachycephalic skull is characterized b y
its unusual breadth .

The cranial deformities can be summed up as

at heads abnormally large heads small he ads
, , .

steeple shaped Obl i q ue keel shaped heads w ith

-
, .
-
.

narro w foreheads and great w idth be hind long ,

heads and broad heads .

F AC I AL A S Y M M ET RY
A sy n: m ot;
y
O ther physical stigmata appear in the Shape of

the face the j a w s being too proj ect ing too

, ,

st raight or too receding Ine q ual it y of the tw o

,
.

sides o f the face may al so occur w ith too great ,

1 1/ f
a / or m ca

or une q ual prominence of the m a l ar bones an d
asymmetry O f the orbit s .

S tigmata o f the nasal bo nes are al so f r eq ue n tl v

encountered such as de formities of the nasal
,

septum deect ion hypert rophy and at rophy O f

, , ,

the turbinate bones de formit ies of the maxill ar y

,
 E I T O LOGY 27

sinus hypertrophy of the mucous membrane and

,

N a sal
polypi Deect ion of the external nose is a D ef or m i ti es
.

very common stigm a O f degeneracy Not on l v .

is the sept um involved but al so the outer plates

,

o f the nasal cavity So unstable are the bones

.

of the face in their development that it is n ot an ,

uncommon thing for the nasal process O f the

upper j aw on on e side to be much more developed
than the other N ot only is the nasal septum
.

involved but also the bones O f the face as w ell

, , D cf or m i ti cs
of ti l e Fa ce
producing a fullness on the long S ide o f the face .

Deection o f the septum to the left may en ti rel v

obliterate the le ft nasal cavity In some cases .

the nose i s deected to the right or le ft side I n .

some degenerates the face looks as though the

tw o halves w ere made separately and j oined

together one hal f higher than the other
,

( Talbot )
A mong the most important o f the stigmata o f
degeneration are :

D EFO R M I T I ES O F T H E PALA T E q or m i ti cs

S even varieties of the pathologica l palates

have been discovered These are : .

1. P alate w ith Goth ic arch .

G ol i nk a rd :

2. P alate w ith horseshoe arch .

H orses/1 0c

3. The dome shaped palate -

.

4. The at roo fed palate

-
.

H at -r o
of ed
5.

The h ip roofed palate .
 28 M E N T AL DI SE A SES
A sy n: m et 6 . The asy mmet rical pal ate .

r i ca l

T om s pa l 7 . The torus palat inus .

al i n a s The seven varieties named are to be regarded
merely as types Each type w il l be found to pre
.

se n t variations and combination s w ith other

forms Thus the Gothic arch may have a l ow or
.

h igh pitch and be shor t o r long The dome .

sh aped palate may be h igh or l ow may be com ,

b i n ed w ith asymmetr y or torus The presenc e .

o f a torus in the Goth ic variety is l ia b le to dest roy

the purely Goth ic form and may cause it to ,

resemble the at roo fed palate U nder the head

-
.

ing O f at roo fed palate are incl uded all such pal
-

ates as are n earl y horizontal in outline as w ell as ,

those w ith incl ined roo f S ides b ut attened gable .

In the hip roofed pal ate w e have the s l opin g

-

S ides as usual but al so a marked pitch o f the pal

,

ate roo f in front and beh ind : occasionally one ,

may meet w ith a palate o f this kind w ith SO

remarkable a pitch from before back w ard that i t
i s almost l ike a Gothic roof turned about SO that ,

the gable runs t ransversel y .

The torus palatinus is a proj ecting ridge or

ell ing along the palat ine sut u re someti m es i n ,

its w hole l ength sometimes in onl y a port ion o f

,

its course It varies considerabl y in its course

.

and shape It mav be w e d ge shaped narro w

.
-
,

broad very prominent or irregular
,
P eterson ) . .
 E I T O L OG Y 29

T AL A N O M AL I ES
D EN D en tal
A n om a l i es
M acrodont i sm m I crO d on tl sm prot rud i ng m i s
, , ,

shapen ed mispl aced and striated teeth are found

,

among the dental anomal ies .

A N O M AL I ES O F T H E T O N G U E A N D L I P S A n om al i es

o T
f , g
on ue
The tongue m ay be too l arge or too small o r , ,
and U P S

present asvm m et ry o f the tw o hal ves or b i d i ty

of the point U ndue s w el ling and pu i n ess o f
.

t he lips is al so n otew o r thv .

ANO M AL I ES O F T H E E YE A n om al i es

The eve sti gmata are ex ceed i n gl v important .

P eterson has grouped them into tw o classes as .

fol lo w s
A N A T O M I C AL H YS I O L O G I C AL
P

Flecks on the iris . Bl indne ss .

C hromat ic as y mmet r y M yopia .

o f the iri s . Hypermet ropia .

N arro w palpebral S A stigm atism .

sures . Dal tonism .

A lbinism . Hemeralopia .

C onge n ital cataracts . C oncent ric l imitation

P igmentar y retinitis . o f the vi sual el d .

1\I i c roph thal m o s

'

. N ysta gmus .

M uscul ar i n suf c ien c v .

Wh ile on e o r tw o o f these condit ions may not

constitute posit ive proo f of degenerac y stil l the y ,

are signi c ant in con n ection w ith other abnorm al

states N o examinatio n o f a su spected de gener
.
 3O M E N T AL D I SEA sEs

are shoul d be considered complete until the eye

has be en care f ul l v examined .

n om a l i cs A N O M AL I ES O F T H E EA R

N o de f ormities have been more care ful l y

studied and none take higher rank as stigmata
,

of degeneration than those that pertain to the

,

ear .

E special study o f this subj ect has been ma d e

by M orel S tahl \V i l d erm uth B inder and
, , , ,

S ch w albe and w e ch i e v are i n debted to them

,

for the best description o f these conditions .

These deformities are numerous and o f various

kinds Not only the form and structure of the
.

ear s but their mode O f implan tation may di ff er

,

so radical ly from the normal as to enable the

observer at a glance to recognize that the pos
, ,

se sso r belongs to this class o f human u n f o r

tun ates .

T w enty tw o v arieties o f d e formit ies have been
discovered .

The ears mav be abnormall y implanted They .

may proj ect too far or l ie too cl osel v be p l ace d ,

to o h igh or too l o w stand too f a r for w ar d or l ie

,

too far back w ard o n the head The ears mav be .

excessively large or too small or o f u gl y Shape

, , .

abnormall y long or unusuall y short ,

Great .

var i at i ons I n the lobule m av occur the lobule mav ,

be en l arged adherent or mi ssing O ne ear mav

, , .
FE M A LE D EC -E N ER A T E S H N FA C A L A S Y M M E T R Y
O \V I G I
A ND AN O M A L ES F T H E E A R
I O
 T O LOG Y
E I . 31

di ff er in Shape from its fello w or be placed at a

di ff erent angle upon the head and so on to the ,

end of the chapter .

Whatever the v ariety of the mal formation it ,

dist inctly brands it s possessor reveal ing the l ow ,

ered qual ity Of h is brain and is positive proof ,

of his dangerous inheritance w h ich is a constant ,

menace to h is mental l i fe .

A N O M AL I ES O F TH E LI MBS A nom al i es

e
O ther inherited anomal ies may appear as , I i n: bs
.

supe rn um a ry ngers or toes or missing nger s ,

or toes or anomalous brevit y of the digits

,
as ,

compared w ith the rel ative port ions o f norma l

digits fusion Of the ngers or toes fusion of the
, ,

extremities excessive length o f the arms as com

, ,

pared w ith the legs O r the rest o f the b od v or ,

absence of parts O f the limbs producing excess ,

ive Shortening or excessive volume o f the l imbs

or digit s These anomal ies occur less f req uen tl v
.

than many previously mentioned but w hen pres , ,

ent are essential ly degenerative indices In the

,
.

same category may be cla ssed d w ar sm or giant

ism in fantile characteristics in an adult m ascu
, ,

l ine pecul iarities i n females and fem inine trait s .

in males .

A N O M AL I ES O F T H E G E N I T AL I A
4 n om a l i es
Frequent degenerat ive st igmata may appear in
both the male and female genital ia mani fested in , G en i ta ti a
 32 M E N T AL D I SE A SES

excessive or diminished gro w th and various

mal formations .

A n om al i es A N O M AL I ES O F TH E S KI N
f
o the S i nk
The degenerate may al so present numerous
abnormal ities of the skin and hairy s y stem .

B ea r d ca
This i s Often seen in the excessive gro w th o f
l Vom en hair on the chin and breast in w omen or in com ,

pl e te or part ial discolorat ion O f the hair M ore .

or less marked cases o f th is kind can be seen in

an v i n sane hospital w hile numerous exaggerated
,

examples are presented to the publ ic by enter

prising Sho w men as A lbinos and bearde d .

w omen .

A n om a l i es A N O M AL I ES O F A PP ET I T E
f
o A pp eti te
A mong al l degenerates anomal ies o f appetite
are found rendering them especially l iable to the
,

format ion o f the drink or drug habit or of both ,

a tes Li a bl e h abit s : and w hen these habit s are forme d re f or

, ,
to For m
Dr i n k or mation is practically impossible .

O ne of these un fortunates w hom I ha d under

H a bi t
m y care a short time since beside being a ,

drunkard had at di ff erent times taken in exces s

, , ,

morph ine cocaine and hydrate O f chloral A n

, , .

other degenerate in w hose t rial f o r the murder

,

o f h is w i fe I w a s cal led and w ho i s n o w servin g

,

a l i fe sentence beside being one of the w orst

.

cigarette ends took morphine cocaine an d

, . ,
 E I T O L O GY 33

n it ro glycerine and w hile under the inuence o f

-
, ,

some or all o f these poisons committed the crime ,

for w hich he is n ow undergoing punishment .

The follo w ing are the most important o f the

physiological stigmata as given by P eterson

( C hurch and P eterson N ervous and M ental ,

Diseases p , .

P H Y S I O L O GI C A L S TI G M A T A
A N O M AL I ES O F MO T O R FU N C T I O N A n om a l i es

f
o V otor
Retardat ion of learning to w alk .
z

F un cti on
Tics .

Tremors .

Epilepsy .

N y stagm tts .

A N O M AL I ES SE N SO RY FU N C T I O N
A n om a l i es
Dea f mutism
-
.

f
o S ensory
N euralgia .
Fu n cti on

M i graine .

H y per esthesi a .

A nesthesia .

Bl indness .

M yopia .

H y perm etropi a .

A stigmat ism .

Dal tonism .

Hemeralopia .

C oncent ric l imitat ion o f the visual eld .

4
 34 M E N T AL D I SE A SES

nom a l i es A N O M AL I ES O F S P EE C H
M utism .

De fective speech .

S tammering .

S tuttering .

AN O M AL I ES O F G EN I T O U R I NAR Y -
U CT I ON
F N

nom a l i es
S exual i rritabil ity .

Impotence .

S teril ity .

U rinary incont inence .

nom a l i es
A N O M AL I ES O F I N ST I N C T O R AP P ET I T E
I n sti n ct
U ncont rollable appet ite (food l iquor drugs ) .
, ,

M erycism .

I m i n i sb ed
'

Dimini shed resi stance against external i n u

si sta n ee
en ces and diseases .

Di sea se
R etardat ion o f puberty .

P S Y C H I C S TI G M A T A
W ith the bodily t raits have j ust been w h ich w e
con sidering a person w ith a st rongly marked
,

insane neurosi s p resents certain peculiarities of

though t feel ing and conduct W ithout being i n
, ,
.

sane he is l ikely to be regarded as st ran ge queer

, , ,

and unl ike other persons He is incl ined to look .

at th ings di ff erently from other people an d think

en 0 /
about them under novel rel ations M an v men o f .

n i us genius have possessed these pecul iar st ig mata ,

 ET I O LOG Y 35

among w hom may be named C hatterton De ,

Q uincey C
,
o w per Turner S helley
,
Tasso L amb
, , , ,

a n d Goldsmith In some musical and m athem at

.

ical prodigies l ike the negro Bl ind T om and the

, , ,

l ightning calculator Zerah C olburn
,
these ,

stigmata have appe a red in exaggerated form ; f or

w h ile on e possessed marvelous musical and the ,

other w onder ful mathemat ical talent neither o f , ,

them w as capable of improvement by ordinary

educational methods and outside of h i s individ
ual talent w as l ittle above imbeciles in regard to
the ordinary a ff airs of l i fe .

A marked characteri st ic o f neurotics i s thei r

changeableness and l ack O f mental poise E ither .

a bl en ess
unduly el ated or dep ressed they are incl ined to ,

do things di ff erently from the rest o f the w orld .

E xceedingly emot ional and excitable they are ,

e asily upset by any great moral shock or by the ,

st rain of continued anxiety Governed by i m .

pul se rather than by j udgment they are incl ined ,

to w himsical and purposeless act s L acking in .

sel f cont rol they are Often subj ect to violent ts

-
,

o f passion .

Hyperesthetic and exceedingly sensitive to

pain they are subj ect to mental disturbances
,
t/zeti c {V en

from sl igh t physical disorders Hence any .

tn rba n ce
great physical change in the sv stem such as is ,

caused b y the advent o f puberty by the puerperal .

state or the menopause i s l iable to disturb t hei r

, ,

m ental stabil ity .

 36 M E N T AL D I SE A sES

goti sm A nother characteristic fre q uently Observed is

an over w eening egotism C onsidering them .

selves very superior to their associates they ,

look upon them selves as the great center about

w hich everything and everybody revo l ves Ex .

ceed i n gl y j ealous they are al w ays misinterpret

,

ing the motives o f thei r companions an d detect

ing mal iciousness in the most innocent actions .

E ver d w ell ing upon imaginary S l i ght s it i s but a ,

short step from their ordina ry mental S tate to ,

paranoia w ith it s compl icated net o f plot s and

conspi racies Driven by their imagin ings in to a
.

l i fe o f sol itude and sel f broodin g they easi l v cre ,

ate an impassable gul f bet w een themsel ves and

the rest o f the w orld .

A nother group of neurotics seem to be born

or a l

me w ith an enti re absence Of moral sense W hile .

thi s is usually conj oined w ith general mental

w eakness it may occur in persons w ith acute
,

intellects N o cl ass O f cases cause more

.

t rouble O ccurring as they frequently do in the

.

best famil ies it is often di fcul t to decide w ha t

,

i s b est to do w ith them E xcee d ingly cunning .

an d c ra fty utterl y obl ivious of the ri ghts o f

,

others they cause n o end of t rouble in the f am

,

i l i es to w h ich they be long C rimes o f ev er v .

character may be committed by them al to gether ,

m ot iveless w hich from the nature o f thei r su r

, ,

roundings vou are forced to ascribe to mental

,
 T I OL O GY
E 37

w eakness ; yet y ou may b e unable to commit the '

patient to any in sane hospital or i f y ou are able , ,

to d o S O he i s often returned to you and imme

,

d i atel y recommences h is o l d l i fe O f th i s class .

are many of the inmates of our prisons and re

f orm a to r i es .

M r Thompson for m erly surgeon to the G en
.
,
P ron e to
eral P rison of S cotland has gone so far as to , M en tal
express h is conviction that the principal business D i sease

o f prison surgeons must al w av s be w ith mental

de fect s or disease ; that the diseases and causes

o f death among prisoners are ch ie y o f the ner

vous system and in ne that the t reatment o f

, , ,

crime is a branch of psychology He holds that .

the re is among criminal s a distinct and incurable

crim inal cl ass marked by pecul iar l ow physical
,

and mental characteristics ; that crime i s heredi

tar v in the fami l ies of criminal s belonging to th i s
class ; and that thi s hereditary crime i s a di sorder
of mind having close relations o f nature and de
scent to epilepsy dipsomania insanity and other
, , ,

for m s of degeneracy S uch criminal s are real l y

.

morbid variet ies and often exhibit marks o f phys

ical degeneration spinal deformit ies stammer
, ,

ing imper fect organs of speech club foot C le ft

, , ,

palate hare l ip dea fness epilepsy and scro fula
, , , ,
.

Having studied the general ph v si cal and psy C a u ses 0]

chical characteristics Of the insane diathesis the , I n sa n e
D i a tlzesi s
primal cause o f insanity let us consider w hat are ,
38 M E N T AL D I SE A SES

i ts causes W hat are the inuences l ikely to pro

.

duce th is w eakness of the brain structure render ,

ing it l iable to fall at the fi rst w ind of adversity ?

First and foremost among the causes should be
placed heredity including prenata l in uences
,

the diet of the mother and drugs taken during

pregnancy and the shocks to w h ich she has b een
subj ected during th is period .

In determining the ful l extent o f thi s in uence

w e must n ot be content w ith simply ascertainin g
the e x i stence or n on existence o f psychoses in the
-

ancestors A care ful search must be made f or

.

any O f the heredi tary equivalents : epilepsy ,

chorea hysteria neurasthenia som nambul ism

, , , ,

migra ine and organic diseases of the central ner

vous system criminal tendencies eccen tricities of
, ,

character drunkenness ; as any of these appear

, ,

m g in the ancestor may produce an unstable ner

,

vous system in the descendant A ll stati stics on .

this subj ect are on ly app roximately corr ect for it ,

exceedingly d i i cul t al w ays to Obtain the t ruth

as to the existence o f any family w eakness M uch .

attention has been given to the subj ect o f hered

ity but no one has more closely studied it s prob
,

lems or be tter formulated its l a w s in relat ion to

in sanity than M ercier in his S anity and Insan

ity . He assert s that besides the importance
,

o f di rect t ransmission o f an unstabl e nervous sys

tem there i s another l aw Of heredity w hich

,
 E I T O L O GY 39

is know n as the l aw o f sanguinity T w o parents La w f

.

may be per fectl y stable and have normal organ

isms and yet produce o ff spring w ith unstable and
,

abnormal nervous constitutions because o f the ,

unsuitabil ity O f the sexual elements of the parents

to each other . The per fect organization o f the Perf ect 0r

progeny is the result Of three factors the qual ity g a n i z a ti on

of the germ (w h ich brings matter ) the q ual ity ,

of the sperm (w hich brings force ) and the suit ,

abil ity O f the one to the other .

The la w s of heredity as they relate to insanity
f t/1 e O
may be briey summarized as follow s : o ne

to M e O ther
1 The child tends to inherit every att ribute
.

of both parent s .

2 C ont radictory att rib utes can not be i n her

.

i ted from both parent s .

3 The ch ild may inherit the att ributes o f

.

either parent solely .

.4 I t may inherit the qual ities Of one parent

in some respect s and O f the other in other
respect s .

5 I t may inherit the father s att ributes for

.

one period o f existence and the mother s for

another .

.6 S ome att ributes have the qual i ty of pre

potency or the tendency to push aside or over L a ws of
H eredi ty
rule other attributes .

.7 A tt ributes w h ich are similar in both pa

rents tend to become prepotent giving rise to ,

convergent or cumulat ive heredity .

40 M E N T AL DI SE A SES

8 A tt ributes may be t ran smitted in l atent

.

form from on e generat ion to a n other to reappear ,

in a th ird o r fourth or still more remote gener a

t ion a phenomenon termed reversion
.

9 A ttributes tend to appear in the progeny

.

about the same t ime of li fe at w hich they becam e

mani fest in the parent s .

1 0 A ttributes o f the father tend to be i n her

.

i ted by the sons and o f the mother by the

d aughters .
_

A study o f these la w s w ill furnis h an ex pl an
at ion o f many puzzles o f psychopath ic heredity ;
w hy f o r instance on e child o f a neurot ic paren t
, ,

m av be a ff ected and another escape and again ,

w hy mental w eakness appears in the progen y O f

healthy parents There i s al so a variation I n the
.

degree o f hereditary taint originated by the sev

eral heritable equivalents The heritage o f epi .

lepsy chronic al cohol ism and paranoia for

, , ,

instance is much more serious than that of si m

,

ple neurasthenia eccen tr i c i tv o f character an d

, ,

puerperal psvcho si s The greater the number o f

.

membe rs and branches of a family a f icted the ,

st ronger the taint ; w hen the degree of heredi

tary taint is marked the psychosi s w h ich may
develop tends to be mo d i ed from the or d i n a r v
types of such psychoses and th is deviation is
termed hereditary degenerat ive modi cation or ,

in S hort hereditary degenerac y w hile the i n
,
 T O L O GY
E I 41

sanit y evolved is designated a degenerative psy

c hO S I S . The particular degenerative psychoses
a r e such forms as idiocy imbecil it y feeble
, ,

mindedness periodical and ci rcular insanity hys

, ,

ter i cal insanity ,

acute S imple paranoia poly ,

m orphic insanity etc ,

A polymorphic course is
.

p a r t i cu l a r l v characterist ic of psych ic degeneracy ,

so that sometimes a p er fect chain O f ps y chopathic

c onditions and psychoses w il l be mani fested

throughout the l i fe Of the degenerate (P eter .

son )
.

\V e nd here al so the explanation for the exist

m i n ded
ence of so many w eak m in d ed sons of eminent
-

men The fathers having exhausted their force

.
,

in their great mental e ff ort s have l ittle le ft to ,

cont ribute to the children w hom they create .

A nother poten t factor o f heredity in th is con P ren a tal

n ecti o n is that o f prenatal inuence A lthough
.
I n uen ce

the fact o f maternal impressions has been dis

p u te d by some , it s inuence has been markedly
s ho w n by too man y undenia b le instances to
remain in doubt S pitzka w ho approached
.
,

maternal impressions from an actively sce ptical

standpoint had his S kepticism shaken b y speci
,

men s (preserved in the B rit ish M useum ) o f

ne w l y hatched chicks all O f u hi ch had a curved
-
,

be ak l ike a parrot and the toes set back as in that

bird A ccording to the report o f the cura to r
. ,

the hen s in the farm y ard w here the se m o n st ro s i

42 M E N T AL DI SE A SES

ties w ere
hatched had been frightened by a par
,

rot w h ich having escaped utte r ed among them

, , ,

some t ime be fore the eggs w ere laid and greatly

fri ghtened those from which the ma l formed
chicks w ere received S ince then so many i n .
,

stances have come into this author s experience

t hat he has become a thorough believer in the

marked inuence of maternal imp ressions He .

assert s that he has never seen an idiot ic or m al

formed child or one a ffl icted w ith morbid i m
pul ses derived from healthy parents free from ,

hereditary taint in w hich a maternal impression

,

could not be t raced .

O ne Of the most remarkable illust rations Of

prenatal inuence appeared in a young l ady w ho
w as a patient in the M iddleto w n Hospital w h ile
I w as connected w ith that i n s titution This .

lady an imbecile w as the daughter o f a man w ho

, ,

died leaving his family t w enty mil l ions Of dollars

, ,

w hich he had gained in the mael st rom o f Wal l

S treet \V eakm i n d ed from birth utterl y i g nor
.
,

an t o f wall S tree t and it s method s thi s gi rl ,

w oul d sit by the hour and w rite orders for stock .

This father s mind w as so ful l of W all S treet and

its methods at the instant that she w as begotten

that its stamp w as indel ibly made upon her mind
for l i fe H ere w e have n ot only an instance o f
.

prenatal impression but an illust ration o f the

,

l aw of heredity w hich declares that a c ertain

,
 E I T O LO GY 43

amount of healthy force must exist in the pater

nal sperm for the procreation o f a normal child .

Innumerabl e instances o f cerebral de fect and C e7 ebr al

arrested developme n t in the o ff spring have been D ef ect i n
O spr i ng
sho w n by various authors as the e ff ect o f pro
C a used by
, ,

found grie f or mental or physical shock acting G r i ef or

on the mother O f ninet y tw o children born in
.
-

S b ock A et
Paris during the great siege of 1 8 70 7 1 sixty -
,
i ng on the
four had mental or physical anomal ies and the r e M ot/zer
maining t w enty eigh t w ere w eakly t w enty one
-
,
-

w ere intellectu al ly de fective and eight sho w ed,

moral or emotional in sanity A fter the great .

C hicago re in 1 8 7 1 and a fter the nancia l crisis

,

in the U nited S tates in 1 8 7 3 and the nancial ,

crisi s in B erlin in 1 8 7 5 to 1 8 8 0 simi l ar de fects ,

w ere sho w n to have been produced in numbe rs of

children begotten during those t rying times .

The bane ful e ff ects upon the o ff spring of D r u n ken

drunkenness in the parent s has long been recog n ess i n the
P a r en ts
n i z ed .
Q u aint ol d Burton ,
in h is A natomy o f

M elancholy says i f a drunken man gets a chi l d
, ,

it w ill never l ikely have a good brain N ot .

less emphatic is the predict ion o f M ichelet : \V oe
unto the children of darkness the S ons of drunk ,

en n ess w ho w ere nine month s be fore their birth

an outrage on thei r mothers . A nd again H e ,

w ho is bo rn o f a nocturnal orgy o f the very f or

g e t f ul n e ss o f l ov e ,o f a p r o f an a t i on O f the beloved

on e w il l drag out a sad and t roubled l i fe
, No t .
 44 M E N T AL D I SE A SES

less dire fu l are the e ff ects produced upon the

brains of childre n born of parent s addicted to
N a rcoti c
the Opium habit N arcot ic habits in the an ces
.

tors produce descendants i n w hom the normal

A n cestors
checks on excessive nervous act ion are removed
so that paranoiacs periodical lunatics epilept ics
, , ,

hysterics congenital criminal s congenital pau

, ,

pers or other degenerates resul t Th is is espe

, .

c i al l y emphasized i f the maternal ancestor i s the

t ransgressor .

I mproper
Improper maternal diet during pregn ancy may
D i et do incalcul able harm to the fe tus Thi s w as .

D u r i ng
P reg n a n cy
exce l lently il lust rated in the results of the fruit

diet formerly advised by certain vegetarians .

Here the ch ild ren became as E l ise B er w ig has ,

recentl y sho w n rickety i rritabl e peevish l iab l e

, , , ,

to convul sions moral ly pecul iar and other w ise

,

de fect ive in cont rast w ith children born o f the

sa m e parents not con ned to fruit diet d urin g
pre gnancy .

The insane diathesi s can be ac q ui red as w ell as

inherited The fol lo w ing are some O f the most
.

I n sa n e
D i a #2esi s
potent causes :
A cq n i red
'
1
. Imper fect nut rition .

.

2 Traumat ism blo w s or fal l s upon the head .

3 O vertaxation o f the undeveloped ph y sical

.

po w ers .

4 Failure to earl y learn sel f cont ro l

.
-
.

5 Dissipat ion and excessive sexual i n d ul

.

gence .
 T O L O GY
E I 45

TOO great st ress cannot be l aid upon the dan

N utr i ti on
gers to the brain from imper fect nutrition .

When you recall to mind the anatomical st ruct

ure of the brain w ith its compl icated arrange
ment o f cell s and bres re q uiring one sixth of -

the blo od o f the body f o r its n ur i shm en t you w il l

,

rea d ily understand how disastrous must be any

lo w ering o f the qual ity Of th is vital uid A ny .

organ improperly nouri shed must soon fail in

function and improper funct ioning O f an organ
,

w il l promptly produce structural change .

Improper feeding o f y oung children may do I mproper

incalculable harm E xcessive q uant ities Of
Y
.

f
o ou ng
s w eet s rich cake pastries early use Of co ff ee and
, , , C hi l dren
tea not only fail to supply needed nourish m ent
,

but create a demand for arti cial stimulants ; an

irritabil ity of the brain and nervous system is
thus early produced w h ich mani fests it sel f in
,

numerous functional nervous disorders I m .

properly strengthened and developed the brain ,

is unable to perform it s normal functions and the

stress o f li fe s burdens renders the victim an easv

prey to some Of the n umerous forms of insani t y

A nother potent a gency in the production of
the insane diathesis is t raumatism Blo w s or.

fall s upon the head o f a ch ild SO sl ight in their ti sm

,

immediate e ff ect s as to be fo rg otten may set up

,

a slo w in ammatory action that may so disturb

the funct ion s o f the b rain cell s as to enti rely
46 M E N T AL DI SE A SES

change the di sposition o f the ch ild and at last ,

produce structural changes that in later l i fe m ay

culminate in incurable insanity U ndoubtedly .

many cases the etiology Of w h ich is put do w n as

unkno w n i f all the circum stances o f early l i fe
,

could be ascertained w ould come under thi s ,

classi cation The fol lo w ing case from my p ri

.

vate case book is an apt illust ration o f this class

-

O f cases :

M rs A W ido w 4 5 years o f age mother o f

. .
,

tw o children came under my care in N ovember

, ,

1 888
. M other died of cancer Father w hen 70 .

years o f age a fter a most active and success ful

,

business l i fe as merchant and manufacturer lost ,

h i s mind and during the two last years of hi s l i fe

w as unable to do anything W hen a ch ild n ine .

years o f age the pat ient in atte m pting to sl ide

, ,

do w n a bannister lost her balance and fel l dow n

,

tw o stories st riking her head upon a marble oor

,
.

A severe scalp w ound w as in icted requi ring ,

several stitches P at ient w as picked up uncon

.

scious but soon recovered and sho w ed n o imme

,

diate e ff ect from the accident A s a child w as .

,

v ery impetuous hasty and incl i n ed to have her

, ,

o w n w ay During her entire l i fe has been sub

.

j ec t to ext reme t s o f passion and has done man y ,

st range th ings w hich have been a subj ec t o f

,

comment and have greatly mort i ed her friends .

W hen th irt y v e years O f age married and has

-
,
 T O L O GY
E I 47

since borne ch ildren the rst of w hom w as ,

d eformed and did n ot l ive Five years ago .

,

a fter birth o f child w as v er v nervous but a fter

, , ,

short stay at C l i fton S pr ings recovered Four ,

.

years ago w as depressed f or three w eeks In

,
.

S eptember had an attack of laryngit is and

,

b ronch itis w hich lasted th ree w eeks N ov 2d . .

commenced to be positively insane and has been

gro w ing w orse ever since H as not S lept more .

than four hours in tw o w eeks I s ver y nois y .

,

violent and full o f a variety o f delusions A fter

, .

tw o years Of t reatment patien t re gained almos ,

t

completel y her mental po w ers w hen a fter a f ew , ,

d ays illness she di ed Of fatty d e en e r ati on O f

'
' "

the heart A n autopsy made sixteen hours a fter

.

death revealed a fatt y de generat ion of the heart

and kidneys and the follo w ing condition O f c ra
nium and contents : C ranium : V ertical plate o f
frontal bone much th ickened and it s inner surface
studded w ith bony protuberances or tuberosit ies ,

(eight in number ) enc roaching on the brain sur

,

face evidently Of long standing and the resul t

,

of an inj ury B rain : S ur face pale Fronta l

. .

lobe s o f the cerebrum dented by bony proj ections

from frontal bone other w ise the brain appeared
,

normal H ad n o post mortem been made in this

.
-

case no al ienist w oul d have att ributed the disease

to the e ff ect s Of a fall thi rty six years be fore -
.

\V i thout a di ssenting voice heredit y w ould have ,

 48 M E N T AL D I SE A S ES

been assigned as the cause yet there is no reaso n

,

for bel ieving in the l ight o f w hat w e n ow kno w

, ,

that the father s mental trouble had any inuence

w hatever upon t hi s patient A fall thi rty S i x

.
-

years be fore (almost forgotten by the family )

had set up a S lo w inammatory action in the inner
table o f the vertical plate O f the frontal bone ,

resul ting in eigh t bony protuberances w h ich by , ,

their pressure upon the brain w arped the w hole ,

l i fe of its victim and ultimately overthre w her

reason Th is constant di sturbance O f the brain
.

functions by thi s a bnormal press ure produced a

predisposition to insanit y w h ich needed on l v the
,

stress of an acute l ary n gl tl s to call into act i o n the

w hole t rain of s y mptoms O f mania w ith it s w ild
est delusions and most f anci ful hal lucinations
and illusions Gi v en the same cause and a l ike
.
,

result might be expected in any famil y even i f n o

mental or nervous disease could be t raced to any
branch O f the ancestral tree .

A nother cause O f the developing of i n sane

procl ivities is found in the overtaxing o f the
physical po w ers o f the young be f ore the bod y has
been fully developed .

O vertax i ng
The custom o f robb ing childhood of all it s j oys
Phy si ca l by putt i ng ch i ldren scarcely out Of b ab vhood at
, ,

P ow : hard w ork in mines factories shops and stores

, , , ,

f
0 You ng
has produced I n the past an undue pr ed i spO S I tl on
to in sanity among the la b oring class S tar ve the .
 E T I O L OG Y 49

mind and exhaust the gro w ing body and w hat

else could be expected ?
The dire ful resul ts o f
this s y stem have ho w ever n ot failed to produce
, ,

some e ff ect upon the publ ic mind and many salu

tarv la w s have been enacted w hich must greatl y
lessen th is evil in the future .

A nother cause w hich often produces the in sane

Lea r n S el f
diathesi s is the failure in ch ild hood to learn sel f C on trol
cont rol .

Th is is usual l v the faul t O f fond but fool ish

pa rent s A ccustomed f rom the cradle to have
.

ev e r v w h im and desi re grati ed the child comes ,

to expect the same t r eatment from ever y one

un d er all ci rcumstances S oon auv oppos1 tl on I s
.

ercely resented W i th the increase o f y e ars

the sel f w ill gro w s ou t O f all proport ion to all the
other po w ers until any th w art ing may give rise
,

to the most violent and uncont rollable out b ursts

of anger and passion Upon such a foundat ion

.

the superstructure O f h y steria an d the w hole

t rain o f nervous and mental d iseases is easil y and
too O ften erected .
I n dulg en ce
A nother st il l more potent cause is the early ca n ts , S ex
indulgence in intoxicants excessive use o f to
,

bacco especially cigarettes and the deplet ion o f

, ,

the general system by sexual excess \V hatev er .

the moral or social standing of any patient pre

sented f o r exam inat ion care ful inquiry should
,

be made as to the past or present existence o f any

 50 M E N T AL D I SE A SES

o f these habit s as complete abstemio usness i s a

,

necessity o f success ful treatme nt .

Given th is predisposition to insanity and an y ,

uses o f the mental or physical or moral st rains o f l i fe

may act as excit ing causes The l ist is as lon g .

as the incidents of huma n experience Toxic .

agents l ike alcohol narcotics or poisons ci rcu

, , ,

lating in the blood cerebral traumata bodily dis

, ,

ease syph il is in fectious fevers pneumonia di s

, , , ,

orders O f the heart kidneys or genital ia the , , ,

advent of puberty the puerperal state the cl i

, ,

m acte r i c or the onset O f Old age mental shocks

, , ,

loss O f friends disappointment in love business

, ,

failures rel i gious excitement anything w hich

, ,

disturbs the physical mental or moral eq ui l i b , ,

-

r i um ,
may gure as the immediate causat ive
agent .

W hatever the apparent exciting cause the ,

appearance o f insanity is chiey ow ing to the i n

d i v i d ual s vul n erabil ity to the disease w h ich ren

ders him unable to bear the strains o f li fe .

 C H A P T ER I I I .

S Y M P T O M A T O LO G Y .

The great prevalence o f in sanity about to ,

1 I 10 3 00

300 of the total population renders it h ighl y ,

P opul a mn
e ssential that every practitioner of medicine I n sa n e
should have at least a general kno w ledge of its
symptomatology W hile a l arge proportion of
.

the insane either on account of their violence

, ,

excitabil ity or suicidal and homicidal procl ivit ies

, ,

requi re the rest raint and skil l ed care of a hospital

for the insane many in w hom the disease is o f
, ,

a mild and t ransient form can be better cared

,

f or at home and there fore come under the care

,

Of the fam ily physician rather than the special ist .

The prodromal and in itiatory symptoms of every

type of insanity naturally rst fall under the eye
of the general practitioner and h is abil ity to r ec
,

ogn i z e and t rea t them not only has much to d o

w ith the future progress o f the disease but may ,

save the pat ient and family much dist ress and
mani fold annoyances and business compl icat ions
N o Fi xed
.

A s there is n o absolute xed boundary l ine Bounda ry

bet w een sanit y and insanity each individual c a se
,
L i ne

Between
mus t be studied by itsel f W hat mav be sanity S an i a nd
ty
.

in one person may clearly indicate I nsan i ty I n I nsa n i ty

 52 M E N T AL D I SE A SES

a n ot her Bel ie fs and opinions natural to one

.

reared in ignorance and superstit ion may in a

cult ivated and educated person appear as posi tive
proofs o f departure from h is normal mental ity .

W hile most O f the symptoms O f insanity are

psychic a l arge number O f physical phenomena
,

are l iable to accompany the disease .

A mong the most importan t bodily symptoms

are disturbances of sleep .

D I SO R D ER S O F S L EEP .

D i sord ei s

These may assume the form either o f insomnia ,

I n som n i a ,

S om nol en cc
so m nolence or restless sleep
, .

or Restl ess Insomnia i s a characteristic symptom o f a

large proportion of the acute forms O f insa n ity .

I t i s almost invariably encountered in mania and

I n som n i a , mela n chol ia and in the excited stage Of the ci rcu
,

M a ni a ,
lar insani ties From its fre q uen t occurrence in
.

the prodromal periods o f acute insani ty prolonged ,

ci te d S tag e in somnia in on e predisposed to insanity Should

, ,

C i r cul a r
al w ays be regarded as o f serious import O ne .

marked feature especially O f acute maniacal con

,

d i ti on s i s the S l igh t apparent physica l e ff ect pro

,

d uced in these cases by prolonged sleeplessness

, ,
.

weeks may be passed almost devoid o f sleep in ,

man y instances w ith scarcely any evidence o f

,

exhaustion or general physical deterioration

Freque n tly these extended states o f insomnia are
fo l lo w ed by a prolonged period o f coma or som ,
 S Y M P T O M A T O L O GY 53

n ol en ce , as apparent compen sation f or the previ

o usl y experienced lack o f slumber .

SO M N O L EN C E S om n ol e n t e
i n C erta i n
I n certain conditions Of dement ia para l ytica C on di ti on s
and occasionall y in other forms of insa n ity a ,
f
o
D em en ti a
tendency to prolonged and excessive somnol ence P a ra ly ti ca
may prevail .

R ES T L ESS S L EE P R estl ess

m
In some Of the insane the S leep i s disturbed by n a m bul i sm,
sonm am b ul i sm fright ful dreams and by thei r
, ,
a htf ul
D rea m s
susceptibil it y to storms and sudden cl imat ic
changes .

D I SO R D ER S O F N U T RI T I O N D i sord ers

I n acute i n san i tv marked disturbance O f nutri f

o

t ion is generally apparent The excessive ph y s .

ical activity and attendant w aste and the frequent

failure to take su ffi cient food either from a loss ,

o f appetite or on account o f delusions produce ,

a marked decrease in w eight and sooner or l ate r ,

failure of the v ital po w ers and exhaustion of the

patient W ith convalescence the w eight is usu
.
,

al ly regained I f thi s increase o f w eight occurs

.

w ithout a corresponding improvement in the

mental state it is an indication that the case is
,

d ri ft ing into ch ronicity and is an unhope ful S ign .

Disturbances o f digest ion are of common

 54 M E N T AL D I SE A SES

occurrence especial ly constipation The condi

, .

ti on
t ion of the bo w el s S ho uld receive constant at ten
t i on as pronounced and cont inued const ipat ion
,

increases the severit y o f the mental symptoms

and impedes recovery .

C
SE RE I T ONS
The secretions are l iable to be more or less
ti on Lach e ff ected The perspi ration may be diminished or
.

y
r m a ti on ,

S al i vati on
increased and the lach r y mal glands enti rely
inact ive M arked sal ivat i on appears in many
.

forms o f insanity apparent in continuous drool

,

ing the secretion o f sal iva in t w enty four hours

,
-

in some cases being enormous .

Al en stt n a M enst ruation is usual ly disordered an d n ot ,

uncommonly su 1) pressed in acute cases I f the , .

d isease becomes chronic the menstrual disorders ,

may di sappear w ithout mental restoration .

E xa m i n e A thorough exa m inat ion O f the urine S hould

be made i n every case especially for casts albu
, , ,

E very C ase
m i n su gar and the ethereal sulphates as stupor
, , ,

ous and con fused mental states mav ari se from

renal lesions and other psychical phenomena may
,

be o w ing to B righ t s disease or glycosuria T he

.

presence o f indican or skatol in the urine d emon

strates the a b sorption o f the product s o f f erm en
tat i y e changes in the intest ine and demand s ,

cle ansing and asepticising of the canal as a ,

means O f accelerating the cure of the insanity ,

w hich i s o rd i n ar il v of a con fusional t y pe .

 SY M P T O M A T O LO G Y 55

V arious derangement s O f the functions o f the

Speech P a 7
brain and nervo us system may appear evidenced ,
esthesi a s ,

by al terati ons o f di ff erent reexes speech anom , A n es

thesi a s
al ies disturbances in the innervation o f muscles
, ,

and paresthesias and anesthesias o f the sur face

O f the body or Of the internal organs and d i sor ,

ders O f the bladder and bo w el s the result o f ,

diminished nerve tone .

C hanges in the arteries are found in certain ,

A r ter i a l

types o f insanity sho w n by a host of symptoms

,

of arteriosclerosis .

T R O P H I C C H A N G ES zc

C ha ng es
The most important t roph ic disorder in in san

ity is the h aematoma auris or so called insane ,

ear This consist s o f a blood tumor O f the

.

external ear an d is usual l y ascribed to t rauma

,
H am a tom a
'

A ur i s
ti sm The exciting cause is Often a S l igh t t rau
.
, ,

m ati sm but a depraved physical system must be

,

present or its production w oul d be impossible .

I t i s most frequently found in cases o f severe

acute mania ch ronic mania epilepsy and demen
, , ,

tia paralytica The left ear is the on e most com

.

m on l y involved but it has been Observed in both

,

ears I t is regarded as an un favorable sy m p

.

tom although i t is n ot l imited to incurable cases

,

and may occur occasionally in con n ection w ith

, ,

other diseases than insanity especially in idiots , .

The most serious o f the t rophic disorders are

 56 M E N T AL D I SE A SES
B ed S ores bed sores These may occur in connection w ith
.

poorly nouri shed cases of mania or mel anchol ia ,

but are most frequently encountered in paretics .

The cause is found in every case in the depraved

, ,

local nut rition O f the part invo l ved makin g it ,

especial ly susceptible to a breakdo w n from the

sl ightest irritation or pressure .

O ther t roph ic chan ges usually Observed in

E dem a ,

A sphy x i as advanced cases o f dement ia are (e dema and

e asphyxias O f the l imbs indicating ext reme slu g
,
L i n: bs
g i shn e ss o f the circulation .

E xt reme fragil ity of the bones may al so exi st ,

Bones rendering the patien t especial ly l iable to frac

of the
tures from sl igh t fall s or blo w s C ampbell .

found that w hile the normal breaki ng str ain s
,

Of ribs is from 6 2 to 6 5 pounds in paretics it ,

averages only about 44 pounds and in female ,

senile dements it may b e as l ow as 1 1 or 1 2

pounds . This is supposed to arise from a d e
c i en cy o f l ime salts or some O f the other con

st i tuen ts o f the bones .

A nother marked vasomotor symptom is the so

called dermography a condition in w hich a l ine
,

dra w n upon the skin remains visible for some

time either as a red mark or a w hite l ine bor d ere d
,

w ith re d I n ext reme cases sentences may be

.

w ritten upon the skin before the y com pl etel v fad e

a w ay This phenomenon arises from a combina
.

t ion o f local paralysis and spasms .

 S Y M P T O M A T O L O GY 5/

PU L SE
I n melanchol ia in O l d cases of ch ronic de
,

pressive insanity and in stuporous insanity the

, ,

pul se is usual ly S lo w In acute mania the pul se

.
,

although some w hat accelerated is much less 8 0 ,

than w ould be expected from the amount of nu ts

cul a r act ivity The acute del i rium may be at
.

tended by a very rapid pul se In paresis a mark .

ed variation o f the pul se i s apparent in the d i ff er ,

en t stages chie y evidenced in the tension w hich

, ,

is l ow in the rst stage and increased in the sec

ond and may continue to the end o f the th ird
,

stage .

T E M P ER A T U RE
T empera
W h ile in the most Of mental diseases sl i gh t
, ,
tu r e

d i sturbance o f the temperature is apparent in ,

certain forms l ike the ac ute del i rium it mav rise

, ,

several de grees above the n ormal In paresi s .

there is al so a ri se w hich i s more marked in the

,

e v ening and a fter the apoplectic or epileptic seiz

ures that so fre q uently occur In the intense .

exci tement of acute m ania a rise o f a de gree or

tw o may be detected w h ile in for m s of acute,

m el anchol ia the reverse is t rue .

In the severest form s O f depression and in cer

tain stages o f acutely agitated insanity the tem ,

p e r a tu r e may become sub normal A ver y l o-

w .

temperature i s regarded as a bad symptom .

 58 M E N T AL D I SE A SES

N umerous sensory symptoms may accompany

Sy mptom s
insanity in the form of hyperesthesias or hype r
,

algesias or neuralgias
,
A nesthesia or anal
.

gesia to temperature and pain is o fte n en coun

ter ed exposure to intense cold and the in ict ion
,

o f severe burns or inj uries being often attended

w ith slight su ff ering .

D el usi on s,
The characteristic psych ical deviations from
I ll u si on s
,
the normal man i fest in the in sane particularly ,

H al l uci n a

in the subj ect s o f the acute f orm s are delusions , ,

ti on s
,

illusion s ha l lucinations and con fusion A ny o f

, ,
.

these may appear singly o r in combination w ith

the others Delusions may appear unattended
.
,

by il lusions or hallucinations o r hallucinations ,

may b e mani fested v ear s be fore any del usion is

mani fest . M ental con fusion may give rise to
hal luci n ations or hall ucinations may call forth
,

delusions O ccasionally the prost rat ion mav be

.

so pro found that the patient passes into a state

o f complete coma so quickly t hat the t ransient
stage o f con fusion is uno b served In some cases .

the only mental impl icat ion is an excessive gar

r ul ou sn e ss w ith a lack o f logical criticism a t
, ,

tended by continued m otor activity ; l n others ,

simply change in the m oral character appears ,

sho w n by the ma n i festation Of cruel propensities ,

a l ack o f Observance of conventional rules and ,

m ot iveless acts O f violence .

 S Y M PTO M A TO LOG Y 59

DE L U S I O N S
A delusion is si m ply a fal se belief From a .

legal standpoint the presence o f delusion s i n

,

men tal diseases o ther than mania or dementia i s

accepted as conc lu sive proo f of insanity Th is .
,

ho w ever is a fal se co n cept ion as man y of the

, ,

insane never mani fest any delusions and at ,

f
t imes d elusions may be present in persons o
soun d intellects T he characteristic di ff erence
.

bet w een the false conceptions O f the same and th e

insane is that the sane man can correct h is sense

,

errors w hile the in san e man cannot A n in sa n e

,
.

D e n i ti on
delusion is dened by C louston as a bel ie f in D l
qf e u si on
something that w ould be incredible to people o f
the same class educat ion and race as the person
,

w ho expresses it the bel ie f persisting in spite o f

,

proo f to the cont rary th is result ing from di s

,

eased w orking O f the brain convolutions In .

sane delusions are o f endless form and variety .

They may be eeting and transitory or xed and ,

unchangeable They may ll the l i fe w ith j oy

.
D el usi on s
E xpa n si ve
and happiness or plunge the possessor into the a nd

deepest gloom and despai r . D epressi ve

Delusions may be naturally divided in to ex
p an si v e and depressive The expansive
. delu
sions o f the maniac are usually happy and ,

attended by a feeling of superabun d ant energy ,

w h ich mani fest s itsel f in continua l activity In .

 6O M E N T AL D I SE A SES

coherency o f thought and changeabl eness o f

ideas al so may be present Depressive delu
.

sions arising from fal se ideas o f impending ruin

,

and dest itution or o f crimes committed plunge ,

the possessor into the lo w est depths o f d epres

sion and despai r Delusions of persecution di f
.

fer from other depressive delusions in that thev ,

have to d o w ith the enmity o f other persons in

the envi ronment and are not concerned ent irely
w ith the ego o f the patient These delusions are
.

o f especial importance to the general practitioner ,

as they are frequently m et outside O f inst itutions

and render their possessors a menace to society ,

from their act ing as an incentive to assaul ts and

murder The prognostic signi cance O f these
.

delusions varies greatly as the y may be present

,

in curable toxic insanities in melanchol ia w here

,

the prognosis is uncertain and in incurable ,

paranoia .

Delusions are fre q uently elaborated from the

D el usi on s
f r om H al material s suppl ied by hall ucinat ion s In para .

l uci n a ti on s n oia for instance the continual presence of hal

, ,

l uc i n at i on s o f hearing annoying an d terri fying

,

the victim at l ast become crystal l ized into per

,

manent delusions of persecution M an y delu .

sions sprin g from dreams o r are conceived in

hal f sl eep becoming xed and stable b y con ti n u
-
,

o u s brooding upon them : others ari se th rou gh t h e

misconst ruct ion and misappl ication of the patie n t

 S Y M P T O M A T O LO G Y 61

of some paragraph read in some book or paper .

O ther il l organized intel lect s mav build up delu

-

s ions out o f S imple day dreams -

.

The di scovery o f the exi stence of delusions

is o f paramount importance in the diagnosis and
p rognosis o f insanity \V hatev er thei r origin .
,

delusions are symptoms O f a di sordered in tel l ect ,

and in medico legal cases the demonstration o f

-

their p resence i s regarded as positive proo f of

in sanity .

I LLU S I O N S
I l l usi on
"
A n il lusion is a fal se pe rception O f a real Fa l se P er
impression The obj ect perceived i s changed
.
, cepti on f
o a

and p resented to the con sciousness in another R ea l

I mpressi on
form than the real one A n individual w ho .

hears a band o f music in the pattering rain on

a roof or sees a snake in a coil O f rope ex per i
, ,

e n ces an illusion Illusions are of frequent .

occurrence among the sane but appear m uch ,

mor e frequently in the insane By the sane .

mi n d the t rue character o f the illusion is reco g

nized w h ile the in sane mind receives it as an
,

exact percept ion and its intellectual functions

,

are thereby more or less inuenced

, , .

Illusions of any O f the senses may occur the .

I l l usi on s
most common being those of sight O ne of the .

of S ig ht

most frequent of visual il lusions is that of iden

tity Friends are mi staken for st rangers or
.
 62 M E N T AL D I SE A S ES

vice versa L oved and famil iar faces m ay

.

appear distorted and di sgured and un r ecogn i z

able ; surrounding Obj ects may al so seem changed
in form and appearance .

I l l usi on s
Il lusions o f hearing rank next in frequenc y to
of H ea r i ng those O f vi sion T hese consist mostly o f the
.

t rans formation o f sounds heard into w ords or ,

the mi sinterpretation o f overheard conversation .

I l l usi on s I llusions o f organic sensations al so are f re

of O r g a n i c quently noted . Intestinal motions may be
S en sa t i on s,
ascribed to the presence o f an anima l in the
T a ste a n d
,
abdominal cavity .

M uscul a r Illusions Of smel l taste and Of muscul ar sense

, ,
S en se
or mo v ement are of rarer occurrence .

I l l usi on s i n Illusions occur in all forms Of psychoses espe ,

al l A cute
c i al l y in the acute forms .

P sy choses
I llusi ons are O ften d ii cul t to distingu i sh from
hallucinations and on this account some authors
,

regard the tw o as having pract ically the same

ba sis and retain the distinction simply as a mat
ter o f convenience .

H ALL U C I N A T I O N S
A n H al l u A n hal lucination is a fal se perception A n .

hallucination has no material basis Thus w hen .

Per cepti on a person alone in the silence O f the night sees

, ,

some absent friend by h is bedside he has an hal

l uci n ati on of S ight .

Hal lucinations are fal se perceptions th rough

any one O f the se n ses .
 S Y M P T O M A T O L O GY 63

There are halluc inat ions of hearing o f sight , ,

o f smel l O f taste and of feel ing

, ,
.

There are tw o varieties of hall ucinat ions :

1 Those w hich are temporary and indicate
.
T empora ry

some S light disorder of the brain .

P er m a n en t
2 Those w h ich are permanent caused b y
.
,

some serious brain a ff ection .

A lcohol belladonna cocaine stramonium or

, , , ,

q uinine may produce various kinds O f hal lucina

t ions ; but these are temporary and the victim by , ,

argument may b e convinced of thei r fal sity

,
.

The hallucinations O f the insane are perma

nent and xed and exert a p rofound inuence
,

upon their possessors that no amount o f argu

ment can counterac t .

I I A LLU C I N AT I O N S O F H E AR I N G
Hal lucination s o f hearing are the most f r e
quent These may consist o f simple S ounds like
. .
ti on s f
o

the ringing O f bel ls sh rill w h istles the buz z in g , ,

the l ost
of insect s ; i sol ated w ords or compl icated dis Freq uen t
courses The frequency o f ear diseases in the
.

insane a ffl icted w ith audi tory hallucinations is

w orthy O f note \V S ohier B rvan t in an article
. .
,

on The Great P sych ical Importance O f E ar Dis E ar D is

case reports that in 25 3 insane examined by
, , ea se a s a

Koppe Red l i ck and Kau fmann and h imsel f 3 5

, ,
H all uci n a
had normal ears 1 30 ear di sease and 1 7 6 audi, ti on s
tor y hallucinat ions The saluta ry e ff ect of local .
 64 M E N T AL D I SE A SES

t reatme n t in cases reported by B ryant and E mil

,

A mberg in removing these hal lucinations is of

, ,

the h ighest importance as hal lucinations of ,

hea ri n g are considered as un favorable symptoms .

V I SU AL I I A LLU C I N A T I O N S

V i sual N ext in order o f frequency stand hallucina

, ,
H al l uci n a
ti on s N ext t ions o f sigh t These vary greatly as to form
.

to A u ra t i n and di st inctness They may appear as simpl e

.

eeting shado w s or erce ames o f daz zl ing,

bri ghtness or as w ords names or sentences w ri t

, , ,

ten upon the w all s o r i n the sky P ictures beau .

,

t i ful or grotesque may ash be fore the vi sion ,

.

These may be movable or stationar y simple or ,

compl ex pleasing or terri fying

,
.

Vi sua l
H al l uci n a These hal lucinations do not preclude recover y .

ti ons d o n ot Hal lucinations of taste and smell are general l y

Pr ecl u de
combined and occur most r ar el v These a re .

usual ly of a di sagreeable character The pat ient .

perceives the Odor O f chloroform sulphur n ox , ,

T a ste a n d
ious gases or smoke he detects the ta s te o f poi
,

S m el l G en son i n the food or o f urine in h is drinking w ater

,
.

er a l ly C om
These hallucinat ion s are important from thei r
bi n ed a n d
O ccu r M ost being usually associated w ith d angerous f orms
o f insan ity They are usually persisten t and
.

w arrant an un favorable prognosis

a bl e .

Hallucinations O f the genital sen se are al so

encountered espec i al l v in insane females and
, ,

ti on s
'

y
c
form the basi s O f (l el uS I O n s o f being violated or
G en i ta l
Sense sexual ly abused .
 S Y M P T O M A T O L OG Y 65

Hal lucinat ions O f feel ing o f touch of the H a l l uci n a

, ,

thermal sense and the sense of pain are not

, Feel i ng ,

uncommon P at ients complain of ve rmin cra w l

.

T her m al
ing upon them Of being burned w ith red hot
,
-

and P a i n
irons or tort u red by elect ric shocks O thers
, .
S ense U n,

imagine that the body has been changed to w ax f a vora bl e

and the l imbs to glass and the bo w el s to stone .

These hallucinations are o f grave import and

augur il l for their possessors .

A s regards the development o f hallucinat ions ,
m en t o
f
some are doubtless peripheral but the maj ority ,

are cent ra l i n thei r origin Hal lucinat ions ar e . ti on s

never n ew creations but are made up of memory ,

pictures stored up in the cortex ; these may how

, ,

ever make their appearance i n n ew combina

,

tions The congenital ly bl ind never have visual

.

hallucinat ions the congenitally dea f never audi

,

tory hallucination s though they are noted in,

acquired bl indness and dea fness ( P eterso n ) .

A mong the rst indications o f a mental break A bn or m al

do w n may appear an abnormal irritabil ity lack ,

o f sel f cont rol and impul siveness w ith a tend

-
, ,

ency to destroy property or do personal inj ury .

A nother early symptom o f impending mental D i mi nu

ti on of the
disease i s a diminut ion Of the po w er o f conj oined P ower (3/
logical thought The ideas presented are i n co
.

herent and di sconnected and gaps occur in the L og i cal

,
T houg ht
sequence O f th ings remembered .

Disturbance o f the po w er o f attent ion may b e

6
 66 M E N T AL D I SE A SES

mani fested either by undue fatigue from any

,
a nce o
f the
intellectual e ff ort intellectual dullness or com
, ,

p l ete suspen sion O f all voluntary intellectual

activi ty w ith apathy to surroundings and neglect
,

Of the personal appearance A bnormal mobil ity .

o f attention may appear in certain cases every , ,

external impression attracting the patient s at

tention w ithout an abil ity to x it A S a resul t

,
.

o f this disturbance of attention w e have igh t

O f ideas and incoherence w hich are thus di ff e r ,

en ti ated by De Fursac : Fl ight o f ideas almost .

al w ays depe n dent upon an abnormal mobil it y of

attent ion i s con stituted by a rapid successI on of
,

representat ions w h ich appear in the el d o f con

sc i ousn ess w ithout any order at the occasion o f ,

external impressions supercial resemblance s , ,

coexi stences in time or space similarities Of ,

sounds , etc O ne w ord arouses the i d ea Of

.

a nother on e o f a similar sound or having the

same termination (association of assonance ) .

Fl ight O f ideas w as formerly considered ,

Fl ig ht of especially in mania the resul t O f excessive acti v

,

I d eas A sso i ty O f the normal intellectual fu nct ion In .

ci a ted w i th
real ity thi s exa ggerated act ivit y a ff ect s only the
m en t of the automatic intellectual funct ions and is al w a y s ,

H ig her assoc iated w ith an en feeblement O f the higher

Fu n cti on s psych ic funct ions \ Vh i l e in ight o f idea s

.
I

the representatives are still associated by t hei r

rel at ions w hich though supercial are vet real
, , , ,
 S Y M PT O M AT O LOG Y 67

in incoherence they fol lo w each other w ithou t

any apparent connection .

In mania or acute mental con fusion these tw o
s y mptom s m ay appear in succession or together

in the same case .

I M P ERA T I V E I D EA S ,
X ED I D EA S
FI ,
A UTO C H T I I O N

O U S I D EA S

M ental automat ism may be mani fest by the

continued presence O f an all engrossing idea -

that takes complete possession o f the mind .

Th ree varieties o f these ideas have been (li f

f er en t i ated viz
, imperative ideas xed ideas
.
, , ,

and autochthonous ideas and thus de ned by ,

W ernicke .

A n imperative idea imposes itsel f I mpera ti ve

upon the patient s consciousness against h is ow n

'

,
sor sb Pa
w ill ; he recogn izes it s pathological character and ti en t s C on

sci ou sn ess
seeks to rid h imsel f of it I t i s a parasitic idea
.

ag a i n st
recognized b y the patient as such A mother is .

haunted by the idea of kill ing her child w hom ,

as P a tho
she loves dearl y A s she hersel f states she can
.
,
l og i ca l
n o lon ger think o f anything el se ; but She recog

n i z es it as a mor b id pheno m enon and begs to be

rel ieved Of it Th is i s an imperat ive idea

. .

A xed idea on the contrary harmonizes
, ,

w ith the other representat ions There fore it is .

n ot C on si d
never considered by the subj ect as foreign to the er ed b th
y e

S u bj ect as
mind nor as a patholog ical phenomenon .

P a thol og

A mother w ho has lost her child is convinced i cal
 68 M E N T AL D I SE A SES

that i f she had given it a certain kind o f medicine

the child w ould not have died Thi s idea does .

not leave her appears to her per fectly legitimate

,

an d natural ; thi s is a xed idea .

Fixed ideas form the basis Of certain delu
si on al states notably that o f paranoia
,
.

A u toch th0
A utochthonous ideas l ike imperative ideas
, ,
nous I d ea
A ttr i buted are developed alongside of normal associations .

The only di ff erence is in the patient s interpreta

S ome
t ion of them ; w h ile the imperative idea is recog
M a l evol en t n i z ed by hi m as pathological the autochthonous ,

I n uen ce idea i s att ributed to some malevolent inuence ,

most fre q uently to some strange persona l ity I f .

he complains it is to the pol ice o fcer and n ot

,

to the physician A mother bel ieves that her

.

neighbor forces upon her the idea o f kill ing her

child ; th is is an autochthonous idea .

D I S O R D ER S O F TI I E WI LL
The w ill
po w er may be exaggerated dimin
-
,

i shed or abol ished in insanity

,
In many depress .

a
g g er a ted ,
ive states a marked diminutio n o f the w ill po w er -

D i min is apparent Devoid o f energy every exertion

.
, ,

i shed or
,
m ental or physical is an e ff ort and in certai n
, ,

in I n sa n i t
y forms characterized by exhaust ion an a b solute
aboul ia i s evidenced I I I these cases no resist
.

ance is O ff ered to morbid impul ses and their con

duct is governed by their imperat ive concept ions ,

xed or autochthonous ideas or delusions The , .

 S Y M P T O M A T O LO G Y 69

mere suggestion Of an act insures its execut ion .

Deprived Of w ill po w er to resist them these ideas

-
,

in the insane form the basi s f o r thei r frequen t

dangerous explosions and criminal act s ; hence
the k l eptom on i ac steal s the pyromaniac burns
, ,

the homicidal maniac kill s his fello w s and the ,

suicidal mel anchol ic destroys himsel f .

D I S OR D E R S I N TH E E M O T I O N AL S P H E R E
The most commonly encountered emotional
distur bances in insanity are exaltation and
depression .

E xal tation is encountered in maniacal states

i n M au i
and in paresis ranging from mi l d emotional and
,
acal S ta tes

intellectual exhilaration to complete mania w ith a n d P a r esi s

incoordination O f al l the intellectual functions .

E motional depression is on e of the mos t prom i E m oti on a l

nent symptoms in man y forms o f insani ty Thi s .
D epressi on
P rom i n en t
varies from a mild unexplainable sense O f sad
ness and general di scontent to the most intense i n M a ny
For m s of
mental agony .

I n sa n i ty
In certain forms o f insanity intellectual acti v
ity seems comple tely suspended and the pat ients
appear devoid o f any feel ings either good or bad .

In other cases the mental disturbance appear s

limited to the moral or eth ical side o f the charac b / or al a n d
ter W ith these patients every l aw relat ing to
.
E thi cal

decency and propriety is disregarded and eve ry

check O f conscience i s appar en tl v lost W hile .
 / O M E N T AL D I S E A SES

reason ing correctly the patient seems incapable,

o f properly cont roll ing his behaviors .

Loss o
f I n The common inst inct O f sel f preservat ion -

f
sti n ct o
may be lost giving rise to sel f mut ilat ion or sui
,
-

c i d al attempts w ithout the existence Of any per

erv a ti on

version o f the nut rit ional instinct causing ,

paralysis of appetite and utter distaste for food

or a desire f or the most noxious substances .

The sexual inst inct al so m ay su ff er being ,

S ex ual either exalted lost or perverted P erversion o f

, , .

I n sti n ct
E xal ted,
the sexual sense is ho w ever most commonl y , ,

Lost, or found in perver t s on the borderland o f i n san i tv .

P erverted
D I SO R D ER S O F M E MO RY
De fect s of memory are prominent character i st
ics o f certain mental diseases especiall y those o f ,

organic origin .

T w o distinct variet ies o f amnesia a re en coun

A m n esi a ; ter ed : the anterograde w hich appl ies to recent ,

event s and is d ue to a de fault O f xation of a

R etrog ra de
representat ion and the ret rograde w h ich relates
, ,

to occurrences long past and i s caused b y a de fect

of the po w er o f conservatism and reproduction .

A mnesia may be sudden or in sidious in its

Onset
.
stationary
, retrogressive or progressive
,
in ,

it s course I t may be part ial invol ving only one

.
,

class o f impressions l ike names or num be rs o r , ,

general w hen all classes o f imp ressions are i n

,

volve d or it may be l imited to certain periods O f

,
 SY M P T O M A T O LO G Y 71

existence Hallucinations of memor y are al so

.

encountered ; in these cases past events present

themsel ves to the consciousness altered in their ,

detail s an d relation s to the patient and ex agger

ated or diminished in importance The most .

marked di sturbances O f memory are f ound in the

dementias and in the advanced stages the
,

memor y may be completel y obl iterated .

D I S OR D ER S O F JU D G M E N T
A s the result of disorders and de fect s o f
memor y and the presence o f delusion s hal lucina ,
d
j g
u m en t
tions or illusions or imperat ive co n ceptions the
, ,

and
judg ment is faul ty de fective and un rel iabl e
, ,
.

Un rel i a bl e
The de fect in the j udgment m ay vary from a
sl ight loss o f the critical f acul tv to complete d e
ci en cy
. M arked impai rment o f j ud g ment is
dependent upon actual organic brain chan ge and
occurs in terminal dementia senile dementia and
, ,

general paresis .

D I SOR D ER S O F T H E R EAC T I O N S
The various menta l operat ion s n d thei r out D i sorder s
w ar d expression i n the reactions These mav be .
e

either vol untary o r automat ic Bet w een the tw o

.
R eacti on s

there a re all intermediate gradations .

\V e shall consider : ( 1 ) aboulia los s o f w ill ,

po w er (2) automatic reactions

, .
 72 M E N T AL D I sEA S ES

A boul i a ABOU L I A

Loss of Wi l l E nti re loss o f w ill pro d uces e i ther stupor or

P r oduci ng complete automat ism \ V hen less pronounced a
.
,

S tupor or
general languor and d i shear ted n ess is apparent ,

A u tom a an d every act i s labored and pain ful indicat ive .

ti s m O f psychic paralysis .

AU T O M A T I C R EAC T I O N S
A u tom a ti e These may al so be paralyzed and superseded
Rea cti on s ,
by the inertia o f stupor ; or exalted as the result ,
Posi ti ve
N eg a ti ve O f a w eakening of the consc ious w ill .

T w o forms o f auto m atic reactions may be

mani fested the positive and the negat ive
,
.

Posi ti ve Re
P ositive automat ic reactions are revealed
vea l ed by

cl inicall y b v tw o phenomena suggest ibil it y and
impul siveness .

bi l i ty a nd
S uggestibil ity is a condition in w h ich the r eac
726 5 5 tions are cont rol led by external impressions It s .

most marked mani festat ion is catalepsy in w h ich ,

the l im b s adopt and retain any position in w hich

C a ta l epsy they are placed b y the examiner Th is phenom .

enon has been des i g nated w ax y exibil ity ( e x i

hil itas cerea ) .

M any patients appear devoid o f all spontane

ous activit y ,
simply repeat ing the exact w ords
w h ich they may hear or the actions o f those b V
,

w hom they are surrounded but they mav be able ,

to respond promptly to any di rect command

, ,
.
 S Y M P T O M A T O L O GY 73

S ometimes i f set in motion they w ill perform

, ,

correctly any acts to w hich they are accustomed .

Impul sive reactions may be divided into three

group s : (1 ) The passionate impul ses (2) the ,

simple impul ses (3 ) the phenomena O f stereo

,

ty py o

1 P assionate impul ses may be called into

.
P a ssi on ate

action by any i rritation ho w ever sl igh t N u ,

.

P rovoked
me rous patient s exh ibit them especially epilep tics ,
by
I r r i ta ti on
and man iacs A n unpleasant look or the sl igh t
.
,

est touch ou the part o f an associate may pro ,

voke violent personal attacks .

2 The simple impul ses

. purely automatic , ,
S i mpl e
l mpul ses
appear w ithout the sligh test provocation A .

O ccu r w i th
pat ient S itt ing alone in per fect quietude may, , out P r ovo

ca ti on
suddenly spring up and break a w indo w and then
immediatel y return to her previous po sit ion .

A fter w ards although retaining a per f ect remem

,

brance o f her act she is unable to give an v ex

,

planation o f her conduct .

3 S tereotypy is a morbid tendency to assume

S tereotypy
.

cont inuously the same att itudes reiterate the ,

same w ords or sentences or repeat the same ,

mot ions C er tain patients assum e and retain for

.

hours at a time posit ion s exceedingly a w k w ard

,

and uncom fortable O thers repeat interminabl y

.

certain w ords o r ph rases or hum a single l ine O f,

a tune O thers w alk cont inuously back and f or

.

w ard Over one st rip Of ground or hop on one foot ,

 / 4 M E N T AL DI SE A SES

or turn somersaul ts pick at their clothing o r

, ,

grind their teeth .

N eg a ti v i sm N egative automatism forms the basis o f N ega

ti v i sm N egativism according to Kraepel in
.
, ,

consi s ts i n the react ion to stim ul i w hich are the
"
reverse o f the normal reaction P at ient s d o .

j ust the opposite Of that w h ich i s req u ire d o f

them I f asked to prot rude the tongue thev
.

close the teeth rmly ; i f asked to l ie do w n thev ,

get up E very e ff ort in caring for them is st ren

.

uou sl y resi sted bath ing combing the hair o r , ,

attendi n g to any of the cal l s o f nature .

D I ST U RB A N C ES O F E X PR ESS I O N
D i stur b The movement s o f the insane furnish impor
tant cle w s to their part icular type of insanit y .

D em en ti a The su ff erer from dementia pr aecox al though ,

p o ssessed o f accurate comprehension is l istless , ,

l l/ a n i a l acka d aisical uninterested in an y th ing prone to

, ,

P a r a n oi a
d ay dream s senseles s laughter st rained att i
, ,

tudes and sudden impul sive movement s

, .

P aretics are friendl y communicative proud , , ,

egotistic and boast ful o f thei r superior po w e r s

,

and great possession s The depressed mov e .

about slo w l y and laboriously or sit q uietly inter , ,

e sted in noth ing but thei r a gon izin g thou ght s .

The apprehensive are restle ss and un easv bit e .

thei r nail s pul l out thei r hai r and l oud l v bemoa n

, ,

thei r fate In extreme retar d ation the patient s

.
 S Y M P T O M O T O LO G Y 75

remain motionless in bed an s w ering onl y in ,

w hispers .

The maniac rushes about cries laughs sings , , , ,

dances is talkat ive and continua l ly busy Hys

,
.

ter i cal pat ient s by thei r manners and personal

,

appeara n ce st rive to m ake an impression The

,
.

paranoiac w hen at large continually at tempts to

, ,

th w art adversaries ; in con nement he ass umes ,

the digni ed air o f a mart y r and continuall y tries

,

to furnish proo fs Of his pretension s .

The mental state Of the insane is al so revealed

b y thei r speech and w riting The maniac talks .

contin uously in a rambl ing disconnected manner,

.

Pa reti c A r
In paresis there is imper fect art iculation and ti cul ati on
inabil it y to pronounce certain w ords w ith tr em u , I mperf ect
l ousn ess o f the m u scles o f the mouth on attempt
ing to speak The speech of retarded pat ient s i s
.

l ow and d i i cul t
M el a n chol i c
.

M elanchol ics are incl ined to taciturnity or ,

T aci tu r n

their speech is lled w ith their griefs or is a con

ti n uo us succession of groan s an d lamentations .

C a ta ton i c
The catatonic may be mute f or w eeks or sud , M ute

d en l y interrupt h is silence b y shout s and songs

or by a senseless repet ition o f single w ords or
sentences .

The w riting Often mirrors the mental state

and reveal s d elusion s that are concealed in
conversat ion .
 76 M E N T AL D I SE A SES
M a n i ac The maniac w rites voluminously but h is ideas ,
Vol u m i n
ous
are con fused and disconnected and h is characters
O ften illegible .

P a r eti e The w riting of the paretic is lled w ith om is

O m i ssi on s
s i ons blots misp l aced w ords and sentences and
,

, , ,

numerous corrections .

h/ el a nchol i c In melanchol ics and dements the individ u al

an d
characters are imper fect cont racted an d , ,
Dem en t
C ha racte rs cro w ded .

I mperf ect The cataton ic patient ll s h is paper w ith an

C a ta ton i c endless succession O f unintell igible scra w l s .

E n dl ess
S cra wl s
The conduct of the insane reects the morb id
changes in thei r psychic l i fe .

Delusions o f sin fulness incite patient s to pen

ance sel f mutilation or suicide
,
-
, .

Delusions of persecution induce measures o f

de fence complete isolation frequent j ourneyi ngs
, , ,

and assault s upon supposed enemies .

C on duct Hypochondriacal del usions arouse an unsuit

able desire to tr y every advertised cure o f the i r
imagined ill s and exci te an inordinate craving
,

for attention and sympathy .

M aniacal excitement impel s to every for m O f

excess breaches o f decorum immoral act s
, , ,

bra w l s quarrels dest ruction Of property and col

, , ,

l ision s w ith all organized authority .

The paretic w hile prone to every form O f d i s

,

si pat i on o f the maniac and cont inual con i cts

w ith civic au thority th rough hi s expansive ideas ,

 I N F E C T I O N P S YC H O SES 77

is l iable to involve h imsel f and family in nancial

ruin.

The paranoiac in defense o f h is rights be

, ,

s ieges O f cial s and court s w rites love le tters and

,

p roposal s to promi n ent ladies seeks to found

,

rel igious orders or takes the l aw into h is ow n

,

hands an d Shocks the publ ic by some brutal crime .

 C H A P T ER I V

I N FE C T I O N P S YC H O S E S

Fever I n this group are embraced the forms of men

D el i ri u m
n
tal al ienat ion produced primarily by the toxin s
of in fectious disease The y are divided b y .

Post-f eb ri l e Kraepel in into fever del i rium in fect ion deli ria , ,
P sy choses
and post febrile ps y choses
-
.

A . FE E V R D ELI R I UM
The e ff ect o f fever in the product ion o f men
tal disturbances has long been recognized .

M ental aberration varying as to the degree Of

,

severity and length O f durat ion has been r e ,

ported in connection w ith practically all febrile

diseases The fre q uency and severity O f the
.

psych ic mani festations depen d upon the nature

and severity o f the disease the time Of l i fe and , ,

the s usceptibil ity Of the individual a ff ected Four

Four For ms
.

di ff erent forms o f del iri um are encountered ,

varying in severity according to the intensity o f

,

the toxic act ion upon the cortical neurons from ,

sl i ght i rritat ion to paralysi s and complete

dest ruction .

ET I ) LOG Y
The maj orit y of del i rious states occur during
 I N F E C T I O N P S YC H O SES 79

the height o f the disease and vary l ittle in form ,

w hether occurring in connection w ith typhoid

fever pn eumonia inuenza ac ute rheumati sm
, , , ,

meningitis or any of the exanthemata T he

,
.

chie f causative factors are the toxins deve l oped

by the fever the high temperature acceleration C a usa ti ve
, ,
Factor s
of metabol i sm and the disturbed condition of the
,

circulation O ther potent causes are alcohol and

.

an unstable nervo u s system .

P A T H O LO G I CAL A N A T O M Y
The pathological ndings are chi e v found in C ha ng es i n
the cortical cell s w hich sho w changes si m ilar to
, C or ti ca l
those w hich have been produced in animal s b y
the appl ication O f superheated air .

SY M PT O M A T O LO G Y

Four groups o f cases are encountered sub d i ,

Four
v i d ed according to the severity of the symptoms
,
.

The rst group exhibit s i rritabil ity and Sl ight or

pronounced motor restlessness The sleep is .

broken and disturbed by unpleasant dreams .

The patient complains O f pains and unnatural

sensat ions in the head and a general sense of
bodily di scom fort and desires to be le ft undis
,

tu rbed .

In the second g roup the symptoms are inte nsi

hed . Dreaml ike vi sual and au d itor y il l usions
and hallucinat ions begin to appear O bj ect s in .
8O M E N T AL D I SE A SES

the room assume grotes q ue forms The ears are .

lled w ith fright ful sounds or strain s of beauti

ful music are heard Thought is usually con.

fused and dreamy but the patient may momen

,

ta r i l y return to consciousness The emotions .

may be exal ted or depressed and the bodily res t

lessness i s markedly increased .

The th ird group present s a marked increas e

in the num b er and severity of the symptom s .

W ith marked disturbance O f consciousness an d

pronounced con fus ion O f t hought disoriented ,

and obl ivious o f hi s physical ill s the pat ient prat ,

tles continuously The e m otional states are i n

.

ten si ed evidenced by frequent w ild impul sive

, ,

outbreaks soon becoming i rregu lar and un cer

tain , indicating a commencing paralysis T he .

motor restlessness i s in tense an d constant only ,

interr upted by short snatches of S leep .

The fourth group embraces the sev eres t grad e

o f ca ses
. These patients completely disoriente d
,

and obl ivious of all external impressions w he n ,

not comatose talk cont i n uously the conversation ,

being low mumbl ing and incoherent C ephal al

, ,
.

gia and subsul tus tendinum n ow ap pear A state .

of coma vigil w ith lethargy is o f frequen t

, ,

occurrence .

The motor activity varies greatly ; in so m e

cases being extreme in others simply l imited to
,

t w itc hings o f individual muscles o f the l imbs or

 I N F E C T I O N P SYC H O SES 81

face or it may involve the tong ue causing a

, ,

pecul iar enunciation .

C O U R SE
In three fourt hs of the cases the del i rium does
-
Dura ti on
not continue beyond on e w eek and usually d i sap
pears w hen the temperature subsides O cca .
Fourths of
si on al l v the delusional ideas persist for a long the C ases
,

time .

PR O G N O SI S
The prognosis is poo r but varies according to ,

Prog n osi s
the sev erity Of the del i rium being fatal in at least ,

on e th i r d O f those w ho a d vance to the thi rd or

v

fourth grade S ome cases pass from th is di s

.

ease into an exhaust ion psychosis or dement ia .

In others the del i rium is follo w ed l ater by manic

depressive i n sanity dement ia przecox or demen
.

, ,

tia paral vti ca .

T R EA T M E N T
The treatment in general is that deman d ed
, ,

by the init ial di sease M uch benet is d erived

.

from hydrotherapeut ic measures cold packs and .

H y d rother
frequent spon gi ngs or in case of great excite
, ,

ment from the prolonged w arm bath Patients

,
.

should be continual ly w atche d to prevent thei r

doing themselves bodily inj ury or committ ing
suicide The presence o f a competent S killed
.
 82 M E N T AL DI S EA SES

trained nurse at all t imes is imperative as thus ,

mechanical rest raint w hich is highly Obj ectio n al

, ,

can be avoided The remedies shoul d be chosen

.

according to the total it y O f the symptom s The .

remedies most frequently indicated are arsenic ,

baptisia belladonna b r von i a hyosc y amus lach e

, , , .

si s rhus toxicodendron and st ramoni um

,
.

B . I N FEC T I O N D EL I R I A
The in fection del i ria embrace psychoses d evel
oped i n the course o f certain in fect ious diseases ,

including the init ial deli rium O f typhoid and

smallpox and the del iria attending malaria acut e .

ch o r e a inuenza and hydrophobia

, ,
.

The initial del i ria o f typhoid has been mos t

thoroughly studie d and i s best kno w n T he .

o Y
f ip/1M characteristic symptoms o f typhoid del i rium ,

according to Farrar are : 1 ) impai red associa

,

tive act ivity ; (2 ) disorientation ; (3 ) psycho

motor excitement ; (4 ) fallacious sen se percep
tion s w ith developing delusions ; (5 ) anxiou s
"
a ff ective states For a short time preceding the
.

attack the patient is usuall y nervous l e epl e s ,

s s .

and unduly restless especially at night I n pe r

, .

sons w ith a faul t y heredit y the attack mav sud

d en l y develop and i s usual ly fatal .

The initial del i rium o f smallpox u sual l v ,

appearing bet w een the th ird an d fth davs i s .

violent in character and of Short duration T he .

 I N F E CT I O N P S YC I I O SES 83

sym ptoms resemble those o f the initial del irium D el i ri um

Vi ol en t
of typhoid but there i s greater violence w i th
,

pronounced suicidal tendencies and greater men ,

T rem or ,
C on n ul
tal cloud iness Tremor and convul sions m ay
.

si o ns
al so be present A S soon as the eruption appears
.

the mental symptoms usual ly pass a w ay although ,

the y occasionally cont inue into the pustular stage .

Bet w een the eruption and pus fever some ,

patient s exhibit visual and auditory hallucina

tions w h ich S imply disturb them w ithout a ff ect
,

i ng th ei r thought o r conduct R emi ssions m ay .

occur during the dayt ime although the con ,

sc i ou sn ess i s even then some w hat clouded

, ,
.

The del irium rarely persists more than a w eek ,

usually disappearing w ith the onset Of the fever ,

although some cases verge into the characteristic

fever del irium .

The prognosis is bad forty to fty per cent .

Prog nosi s
,
bad
of the cases proving fatal .

The i n fect ion del i rium o f mal aria is mark

ed l v intermittent and accompanies or replaces the

fever It appears most o ften in the tertian o r

.
, ,

q uotidian varieties The del i rium may appear

.
,

f or a f ew days in the commencement O f the dis

,

ease i n l ieu Of the fever I ts characterist ics are

,
. S u dd en D e
vel opm en t
its sudden development anxious excitement deep , ,
,

clouding of consciousness and tendency to great , m en t,

violence The cou rse is usually short follo w ed
.
,
C l oud ed
C onsci ous
by deep Sleep w hen the pat ient upon a w aken
, ,

ing has l ittle or n o remembrance o f hi s illness

,
. Vi ol en ce
 84 . M E N T AL DI SE A SES

The delirium o f acute chorea is characterized

by a mental be fogging attende d by indistinc t ,
C onf usi on ,
B l usi on s, illusions hallucinat ions and d el usI on s
, The ,
.

speech i s disconnected and the patients are dis

ti on s ,
D el usi on s ,
oriented inattent ive and dist ractible The em o
, , .

ti on al attitude varies the patient being depressed , ,

Di stur bed
elated or vio l ent
, .

In addition to the mental symptoms ex agger ,

ated choreic movement s night and day disturb , ,

the su ff erer preventing S leep and inter fering

,

w ith nutri tion .

The duration O f the disease varies from a f ew

da y s to a f ew w eeks f req uen tl v terminati n g ,

fatally .

C l ouded The del irium o f inuenz a is characterized by

clouded co n sciousne ss hallucinations disturbed , ,

l uci n a ti on s, speech and apprehensive e x citement P aralysi s

, .

D istu rbed of speech and deglutition w ith pol y neuritic ,

Speech A p
S y mptoms may al so be present
r ehen si ve
p
.
,

E xci tem en t The mental disorders of hydrop hobia may

usher in the di sease Long be fo r e the charac .

ter i sti c hydrophobia symptoms develop th e

patients su ff er from disturbed sleep become ,

depressed seclusive and subj ect to attacks o f

, ,

E moti on a l an x iety O ccasionally an ir resist ible restles s

.

C ha ng es , ness occurs temporarily rel ieved by violent ex er

,

cise . M arked causeless emotional changes come

C l ea r C on
into prominence and persist through the enti re
sci ousness disease but the consciousness remains clear ex
,
 I N FEC T I O N P S YC H O SES 85

cept dur i ng the spasms In rare instances a con

.

ti n uous changeable del irium is developed Dur .

ing the paroxysm s the anxiety and agitation is

intense and in some cases hallucinations of sight
, ,

and hearing appear The symptoms Of excite

.

ment graduall y diminish and disappear w hen the

paralytic stage is establ ished .

The diag nosis i s based upon the presence o f

psychosensory hy peresthesi ae and the character
i sti c phar y ngeal spasms .

T R EA T M E N T
The t reatme n t o f the di ff erent in fection del i ria
i s based largely upon the t reatment o f the un d er
lying physical disease A bundant liquid n our
.

N on r i sh
i shm en t must al w ays be admini stered In cases .
m en t ,

Prol ong ed
of great motor excitement rel ie f may be Obtained,

th rough the prolonged w a rm bath The bo w el s .

should be kept open by h igh rectal inj ections o f

normal sal t solution i f necessary frequent ush ,

ing of the al imentary canal being demanded to

antagoni ze the underlying tox aemia The reme .

dies shoul d be chosen according to the total it y o f

the mental s y mptoms and those o f the b aS I c
disease .

C . P OST I N FE C T I ON
-
P S YC I I O SES

The post in fection psychoses are characteri zed

-

I n tel l ect
b v a w eakening o f the intellect and emotion s , u ea h
'
 86 M E N T AL DI SE A SES
Del usi on s
, usually accompanied by delusions an d a prevail
Depressi on
ing state of depression M any other psychoses
.
,

the exhaust ion psychoses dementia p rzecox , ,

manic depressive insanity (in fact almost any

-
, ,

form o f mental al ienation ) may date thei r i n cep ,

tion from a fever the rst symptoms o ften

,

appearing be fore the fever symptoms subside .

The post febrile in fection psychoses vary in

-
,

form according to the sever i tv of the attack

, .

In the m ildest form a fter a decl ine o f the

,

fever i n a severe attack O f in fectious disease the ,

patients mani fest a lack o f their accustomed

mental and physical vim E asily fat igued they
.
,

appear d ull an d sluggish remain in bed and d o ,

M en ta l nothing A ll mental e ff ort i s di fcult C om

. .

S y mptom s l t l oriented they are free from hall ucina

p e e y ,

t ions or transient hal lucinations of S ight and

,

hearing appear w hen thev close thei r eves o r ,

unusual physical sensation s are experience d

w h ich they greatly e x aggerate Depressed .
,

w orried or i rritable during the day they may at

, ,

n ight become exceedingly anxious and disturbed .

O ccasionally hypochondriacal ideas w ith suspi ,

cions o f poison may appear or persecutory delu

, ,

sions may arise impell ing the patients to attacks

,

o f violence or to suicidal attempts They appear .

dull and stupid and reserved and are t aciturn re ,

garding thei r mental state The chie f physical .

symptoms are sleeplessness anorexia and loss o f , ,

 I N F E C T I O N P SYC H O SES 87

bodily w eight The diseases most freq uently

.

product ive o f the mild form a re inuenza poly ,

arth ritis and w h ooping cough in child ren I n

,
.

rare instances it fol lo w s tuberculosis and chorea .

The durat ion varies fro m a f ew w eeks to a f ew

month s the improvement be ing apparent w hen
,

the basic physical di sease disappears .

I t may be con founded w ith ch ronic nervous C hro ni c

exhaust ion from w h ich it is di ff erentiated by it s
,

greater severity and obstinacy lack of improve ,

ment from rest and relaxation and the ina ,

b i l i ty o f the patient to recogn ize hi s true m ental

condition .

The second group o f post febrile in fection -

psychoses i s much severer than the rst The .

rst symptoms al w ays arising during the fever

, ,

are delusions hallucinat ions o f an y or all Of the

,
Secon d

senses marked anxious excitement complete di s

, ,
m uch
orientation and mental con fusion W ith a de .
sever er

cl ine o f the temperature and an improvement of ,

tha n rst

the initial d isease the patients become less dis

,

oriented and excited but there is a persistence ,

of the delusions and hall ucinat ions Dej ected .

,

anxious and ugly obstinate and quarrel som e and

, ,

subj ect to passionate outbursts they m ay make ,

attempts at suicide or violently attack those about

,

them The chie f physical symptoms are sleep

.

lessn ess and imper fect nut rition \ V hen the .

appetite and S leep return the menta l symptom s

 88 M E N T A L D I S EA S E S

d i sappea r . T he pat i en t s then r ec o

gn i ze i
t he r

con d t on i i an d gr ad ua l l y ret u rn o rm al
to t he r n i
s t ate b ut f o r som e t i m e a re ea si l v f ati gu ed an d
,

sh ow a l ack o f the i r acc us tom ed m e n ta l an d phys

ic a l po w er A f ew ca se s n ev e r reco ve r De at h
. .

i s rare an d al w ay s res ul t s f rom e x hausti on o r

some co m pl ic at ion T he d i sea se l asts from a
.

f ew months to a v ea r T he d i s ea s e s w i th w hic h
.

th is form i s a s soc i ated a re tvphoi d f e v e r sm all ,

p o x
,
artic u l a r r he um at i sm a n d o c c a,s i on a,
l l y ,

tubercul osis .

M el a n The disease w i th w h ic h it is m ost easil y con

fo un d ed is me l an c hol i a o f i n v olu t ion occurring .

I n vol uti on
in the a d ult as the r es ul t Of som e in fectious d i s
ease The melan chol ic ho w e v er is mo re au x
.
, .

ious and less irrit ab l e ha s few e r ha l l uci n ation s

,

and i s tortured by hi s ow n un w orth iness an d i s

free from persecutor y del u sions I t is dia gnose d .

from dementia praecox b y its greater di sturba n ce

O f apprehension its greater disorientation in th e
, ,

beginning o f the disease and the absence o f neg ,

ati v i sm and stereotyp y .

It i s distin guishe d from manic depressive i n

M an i c
D epressi ve sanity by its greater amount o f psychomoto r
retardati on .

The thi r d is the severest form o f post febril e -

7 hi rd
For m i s the in fection psychosis This is characteri zed by an
.

S ever est intense del i rium soon follo w ed b v stupor \ V i t h

, .

a bet terment Of the physical condit ion the mind

 I N F E CT I ON P S YC I I O SES . 89

remains sluggish the memory poor the j udgment

, ,

faulty and externa l impressions are imperfectly

,

perceived and elaborated Indi ff erent to their .

surroundings incapable O f caring f or themse l ves

, .

the patient s l ie in bed and requi re to be fed and

tended l ike chi l dren S ome are q uiet others peev
.
,

ish and rest l ess P hysically there is failure Of

.

the nut ri tive processes In some cases hemi .

plegia speech de fects and epilepti form sei zures

, ,

occur .

The prognosis is doubt ful as onl y one hal f o f ,

-

the cases recover and that a fter many month s .

P rog n osi s
,

doubtf ul
The other hal f a fter a S lo w improvement remain ,

mentall y impai red forget ful w ith w eak judg

, ,

ment and w ill impoveri shed in thought and

, ,

incapabl e o f any taxing cerebration Thi s form .

is usual l y caused by typhoid fever occasionall y ,

by malar i a .

This form w h ile resembling the stupor of

,
C a ta ton i a
catatonia lacks i ts ne gativism and i s dist in
,

g u i shed f rom manic depressive stupor by the

l ack Of retar d at ion and by it s poor memor y .

T R EA T M E N T
The t reat m ent o f all these types i s largel y that
O f care ful nursing j udicious feeding constant
, ,

w atch fulne ss and the remedies indicated b y each

,

i ndi v idual case .

A nother variet y o f post febrile in fect ion p sy -

 90 M E N T AL D I SE A SES

chosi s follo w ing typhoid i s characteri zed by

,

u rth su d denly developed intense excitement w it h ,

rm
clouding of consciousness ight o f ideas and , .

grandiose delusions The prodrom al symptom s

.

are f ew an d illy de ned I I I the midst o f the

.

f ever follo w ing a stage o f restlessness the

, ,

pat ient s suddenly become disoriented and di s

t r act i b l e. V isual and aud i to rv hallucination s
appear fol lo w ed by expansive fantastic delusion s
,

and marked fabrication The emotions are .

varied and continually change A bsol utel y w ith .

out insight the pat ients exh ibit a ight O f idea s

, ,

productiveness and a ten d en cv to rhyming I m

,
.

p e l l e d by an ove rpo w ering restlessness res t in ,

bed i s impossible S leep is greatly dimin is hed

.
,

food i s discarded and rapid emaciat ion follo w s

, .

In a part o f the cases the course i s rapid and

the term ination favorable In these pat ient s .
,

e ven a fter convalescence is advanced irritabil ity ,

may be present an d a sl ight fatigue mav a w ake n

the w hole t rain o f mental symptoms .

A considerable port io n of these cases develop

dementia Th is form closel y resembles the ex
.

p an s i v e variety o f dement ia paralytica but lack s .

it s ph y sical characteri stics .

The treatment demand ed is rest in bed w a rm ,

baths nourishing food skilled w atch ful nursing

, , ,

and the indicated remedies .

 I N F E C T I O N P SY C H O SES 91

C EREB RO P A T I I I A ,
K O R SA
P S YC I I I C A , T ox E M I A.
,

K O FF S S YN D RO M E P O LY N EU R I T I C P S YC H O

,

S I S K OR S A K O F F S D I SE A SE N EU RO C ERE
,

B R I TE .

This psychosis w hen rst de scribed w as sup

, ,

posed to be caused solely by alcohol but further ,

A l cohol

research has sho w n that it may al so occur as a

post febrile in fection psychosi s A s the sy m p
-
.

toms w hen dependent upon fever are pract ically

the same as w hen caused b y alcohol w e Shall ,

describe them in th is connect ion .

E I T O L O GY
The exact cause o f this disease i s st ill in doubt .

That it i s the resul t o f a tox aemia is admitted but ,

the nature Of the poison has n ot been determined .

While alcohol at rst w as supposed to be in all

, ,

cases an etiological factor it has since been found ,

that the supposition is an error U ndoubtedly the .

condition most frequently develops fro m alcohol ic

poisoning but numerous cases have been recorded
,

w hich have follo w ed typhoid fever tuberculosis , ,

gastro enteriti s diabetes various disturbances of

-
, ,

the kidney an d l iver an d lead and arsenic poison

,

ing or a profuse hemorrhage De Fursac says

. .
, D e Fu r sac

that the polyneuritic psychosi s forms from an ,

etiological standpoint a tran sition bet w een i n f ec ,

tious psychoses toxic psychoses and psycho

, ,

o f exhaustion I I I fact in fection intoxication

.
, , ,
 92 M E N T AL D I SEA sES

and exhaustion each has the po w er to give ri se

to the disease ; it may supervene in the course O f
ch ronic alcohol ism or fol l ow a profuse hem or
,

r hage o r an in fectious diseas e such as inuenza .

It is probable that al l of these factors produce

thei r e ff ect by the same mecha n ism most l ikely
by inducing a disorder O f general nutrition .

result ing in an auto intoxication-
.

me The disease occurs most freque n tly in the

'

prime O f l i fe although child ren and the aged a re

,

n ot exempt .

PA T I I O L O G Y
A great variety o f lesions have been described
b y di ff erent Observers A mong the most impor
.

tant have been d estro y ed nerve cell s and ber s

in the spinal cord numerous smal l hemorrhagic
,

S pot s in the cent ral gray matter di sintegrated ,

peripheral nerves together w ith varied lesion s

,

in nearly al l the interna l organs con rming the ,

vie w derived from cl inical Observation tha t th e

, ,

disease is the result of a general intoxication .

SY M P T O M A T O LO G Y
In alcohol ic cases i n the beginning the sy m p
, ,

emeus
toms may resemble those o f del i rium t remen s .

The onset may be acute or preceded by a pro

d r om al period o f irritabil ity insomnia or dee p
, ,

sleep or stupor A fte r a f ew da v s the agitat io n

.
 I N FECTI O N P SYC I I O SES . 93

an d del iri ous symptoms subside but disorienta ,

n eu r i ti s
tion persists and the cha racterist ic amnesic
symptoms come into prominence together w ith ,

the S igns o f polyneurit is .

L apses o f memory are un recognized by the 1 11 6 721 07]

patie n t and are l ikely to be lled in w ith fabric a

,

tions A lthough con ned in bed the patient may

.
,

describe in detail the incidents Of some excur

, ,

sion made since the physician s last visit clothing

the story w ith every semblance Of t ruth He .

m ay insist that he has vi sited a theat re give the ,

name o f the play describe the principal ac tors

, ,

the parts w h ich they have taken and their cos ,

f umes I n severe cases the patient may be un

.

able to recal l the mos t recent event s W hile r e .

turning from the table he may forget that he has

d ined T he n ame s and faces of w i fe and ch il
.

dren may be forgotten and v et a kno w ledge Of

certain ot her Obj ects and of events may be retain
ed U sually the amnesia is most marked regard
.

ing events w hich have occurred since the onset o f

the disease b u t i t may extend to event s o f early
,

l ife His former employment residence and

.
, ,

fami l y may be enti rely obl iterated from the pa

ti en t s me m ory Di sorientation may be complete

.
,

ex tending to person s time and place S trangers

, ,
.

may be addressed as Old f r iends and w i fe and

children be unrecognized .

C ha n geable and t ran sitory depressive or ex , ,

D el usi on s
 94 M E N T AL D I SE A SES

pa n s i v e ,
terri fying delusions an d hal l uc i n a
or

t ion s may al so be present ; in some cases appear

ing only at night in other cases persi sting ,

th roughou t the day .

O utside o f these disorders the intellect mav

n tal
e
appear l ittle impaired I I I certain matters the .

p an e patients may sho w j udgment ans w er questions , ,

and understand w hat i s said to them cleverl y ,

conceal ing their memor y de fect s Their ow n .

condi tion ho w ever is n ot understood and they

, ,

are u n able to w ork success full y They may .

w rite letters and obey orders but are S hi ftles s ,

and thoughtless In the beginning the emotiona l

.
,

attitude i s on e Of anxiety later changing to i n d i f ,

ference and sl uggishness S ome cases are i rri .

table and suspicious others good natured and ,

e l ated but all are changeable in thei r mood s

, .

A fter the subsidence of the del irium patients are ,

quiet and orderly but from their de cient mem

, ,

or y neglect ful o f their personal duties and give n

,

to repetit ions The ph y sical symptoms are ordi

.

n a r il y those common to m ultiple neurit is Thes e .

are ho w ever somet imes w ant ing W e nd the

, , .

f oot and w rist drop hyperesthesias anesthesias , , ,

and paresthesias aton y and at roph y of certain

,

muscles loss o f tendon re exes c y st ic t roubles

, . ,

some degree of ata x ia disturbances O f speec h ,

and deglut ition paralysis o f the facial nerve an d

,

o f the ey e muscles i rregular an d inactive pupil s

1
, ,
.
 I N FE CTI ON P S YC H O SES

tremors o f the ngers ,

and fre q uent ly epi l epti

form seizures .

C O U R SE A N D PRO G NO S I S
A fter a rapid development the course O f the
p rotra cted
disease i s usually p rotracted last ing fro m a f ew ,

mo n ths to a y ear The disease may terminate in

.

partial or complete restoration death or demen , ,

tia W hen death occurs it usually is the result

.

of tub e rculosis inuenza or pneumonia The

, ,
.

Prog n osi s
prognosis is usual ly bad the majority developing ,
ba d
dementia characterized b y its pecul iar memory
,

defects W hen improvement occurs ho w ever

.
,

per fec t it m ay be an y indulgence in alcohol w i l l

,

precipitate a relapse an d a return o f the ori ginal

S y mptoms .

DI A G N O SI S
The diagnosi s is based u pon the characteristic
memor y de fects the disorientatio n associated
,

w ith apparent lucidit y and the attendant poly

,

neuritic symptoms .

T R EA T M EN T
The t reatment consist s O f rest in bed total ,
T rea tm en t

abstinence from all alcohol ic stimulants and ,

abundant al imentation in a l i q uid form The .

neuritic pain s are best combated by w arm or

cold appl icat io n s according to the in ividua l
,
d
96 M E N T AL DI SE A SES

idiosyncrasies W hen nerve tenderness has sub

.

sided galvanism massage and gymnastic ex e r

, , ,

ci ses w il l help to restore the at rophied muscles .

The remedies most frequently e ff ect ive a r e

aconite anacardium arnica ar sen i cum b ell a
, , , ,

donna bell i s perennis hypericum nux v om ica

, , , ,

plumbum z incum m etal l i cum prescribed acc o rd

, ,

ing to the individual symptoms .

 C H A P T ER V

E X H A UST I O N P S YC H O S ES

The exhaust ion psychoses collapse del irium , ,

amentia and ch ronic nervous exhaustion are

,

psychoses w h ich result from some severe phys

ical strain produced by acute di sease loss o f ,
D e n i ti on
blood or ch ildbi rth w ith w h ich may be asso
, ,

c i ated a tox aemia result ing from an in fectious

organism or the destruct ion Of t issue .

.A C olla pse del irium the acute del irium , ,

deli rium grave phr en om an i a Bell s di sease

, ,

.

ET I O LO G Y

C ollapse del irium is fortunately one o f the

rarest forms O f mental disease C h ri stenson ,

reporting only 33 cases in admi ssions to the

A arhus I nst itut ion and Berkley only th ree in
960 admissions to the Bal t imore A sy l um .

In neurot ic in d ivid ual s thi s disease may arise

from prolonged mental strain severe trauma , .

T ra u m a
surgical Operat ions ps y ch ic shock loss o f blood
,
, , ,

fright exh aust ive di seases such as the ex an E xha u sti on
,

themata typhoi d fever pneumonia er y sipelas

, , , ,

inuenza and especiall y childbi rth

,
.

8
 98 M E N T AL DI SE A SES .

PA TI I O LO G I C A L A NA T O M Y
N umerous changes in the cell s and bres O f
the brain and spinal cord have been ascribed to
Spi n al cor d
the disease by d i ff eren t Observers but as yet n o ,

denite pathology has bee n establ i shed .

SY M P T O M A T O LO G Y
The disease present s tw o marked stages : rst ,

excitement ; second collapse ,

.

There m ay be a prodroma l stage or the inv a

sion may be ext remely sudden cases having bee n ,

recorde d in w hich the patient has become sud

d en l y maniacal on a w akening from sleep .

I f there is a pro d romal stage it i s characte r

i z ed by sleeplessness and a change in the pat ient s

genera l character and appearance : then follo w s

c l ouding o f con sc iousness to mental con fusio n ,

M en tal incapacit y for thou ht pain w ith a feel ing o f

g
, ,

C onf usi on
ful lness of the head and other congest ive ph e
n om en a. SO O I I vivid hal lucinat ions appear th e ,

physical s y m ptoms are intensi ed the nutrition ,

rapidl y sink s an d the intense maniacal del iriu m

,

commences .

In the rst sta ge the malaise extreme cepha ,

l al gi a and i n t ense burst in g sen sa t ion in the head ,

w ith spast ic na rro w ing or more rarel y ine q ual

, , .

i t y O f the pupil s m av stron gly sugge st a be gi n

,
 E X I I A C S T I O N I S YC H O S I S

99

ning meningit is The patien t n o w appears l ike .

on e intox icated ; he staggers about the room ; at

rst perhaps melanchol ic he soon becomes j o y

, , ,

ous dances shout s and indul ges in an expansive

, , ,

hallucinator y imager y The mania soo n i n .

creases to a veritable frenzy The brain con .

,

ti n ual l y stimulated to the h i g hest de gree o f

excitement nigh t and d ay w ithout an y cessation
, , ,

i s engaged w ith a series o f d elusions w h ich so ,

rapi d ly it th rough the mind that any coherenc y

of thought or speech i s impossible In mortal .

terror cause d b y their fear ful delusions the pa

, ,

ti en t s das h themsel ves against the f urniture an d

w all s an d unl ess prevented may d o t hemsel ves

, , ,

seriou s bodil y inj ur y M ore rarely they attack .

their attendants and nurses P er secuting hallu .

c i n ati on s are us u ally present : detectives pursue

them devil s attack them enemies endeavor to

, ,

pois o n them ferocious beast s sprin g upon the m

, .

T hei r skin i s covered w ith vermin or w o rm s

cra w l th rough their esh N ight and d ay un . .

cea si n gl y the y shout sc ream and chatter thei r

, . ,

sen seless j argon .

A t the acme o f the d i sease the m ental co n f u

s i o n increases the del i rium changes : single w or d s
,

or single Sy llables are repeated o ver an d over

again inters persed w ith blo od cur d l in g scream s :
,
-

n or are thei r bo dies le ss active ; arm s han d s , ,

C onf usi on
I n coher e n cy
head and feet are in cont inu ou s mot ion the
. ,
CA E
S O F PU E RP ERA L FO R M O F E H A U ST E
X I V P S YC H O SI S
 Ex H A L S T I O N I S YL H O S ES
'

. 1 01

muscular movements being uncer t ain mas si ve On

O bl i vi on
, .

and aimless Fre q uently and for a con si d e rb al e

.
,

length o f ti m e a sort of ci rcular motion o f the

,

hands about the head is ma d e O ften the teeth .

are ground f or hours at a t ime O ccurrin g a s .

,

this disease usual ly does in persons al rea d y muc h ,

w eakened b y disease its vict ims soon sink from ,

exhaust ion unless great care is exerted E nti rel y .

obl ivious to thei r surroundings or an y th in g tha t

i s tol d them medicine and food have to be ad
,

ministered to them by force .

The general appea rance reveal s at a gl ance

the dangerous condition The e y es are w ild and .

starin g O ften so congested and enlarged that

,

they look a s i f the y w ould burst from the sockets .

The head is intensel y hot tongue heavil y coat ,

ed breath fetid the l ips are d ry teeth covered

, . ,

w ith sordes and the pinche d look O f the face t e

,

veal s the lo w ered vitality The pul se is exceed .

i ngl y rapid small and w eak ranging from 1 00 to

, , I n ten se

1 30 The temperature is al w ays h igh ranging

.
,

from 1 00degrees F to 1 06 degrees F The fever . .

,

ho w ever varies from d ay to d ay in an i rregular

,

fashion S leep is enti rel y w ant i ng unless forced

.

b y d rugs M arke d gast ro intestinal disturb

.
-

a uces commonl y appear L ittle food i s taken .

,

either because O f the persistent nausea an d v omit

ing or as the resul t O f delusions ; and the w eight
,

rapidly dec reases The urine is O f ten scant y o f

.
,
 1 02 M E N T AL D I SE A S ES

h i gh speci c gravit y highl y toxic sho w in g , ,

t races Of albumen an d suga r an increase O f uric ,

acid and indica n and a diminution o f the chlor

,

i d es A poplectic an d epilepti form convul sion s

.

f r eq uen t l v occur .

ou r se The course o f the disease is short ranging ,

rt
f rom a f ew hours to one or tw o w eeks ter m i n at ,

ing usually in death or recover y I f it is the for .

mer the delirium cont inues no S leep comes the

, , ,

pul se increase s in rapidity the temperature con ,

t i n ues to rise and w ith the persistent w eaken ing

, ,

o f the patient the min d becomes less and less cog

,

n i z an t O f its surroundings The tongue no w .

becomes dry and bro w n the forehead i s covered ,

w ith pro fuse s w eating emaciat ion rapidl y ad ,

vances and the su ff erer becomes more and more

,

q uiet but w ith the quiet of exhaustion S leep

,
.

come s n ot but in it s place coma The mo tor

,
.

excitement ceases ataxia and paresis o f the ex

,

tr em i ti es ensue w ith i rregul ar spa smodic

.

mo vement perhaps accompa n ied b y an intens e

,

t remor The del i rium becomes muttering th e

.
,

spastic pupil s rel ax the pulse becomes quicker

.

and w eaker the skin cyanot ic the lungs are hypo

, ,

s tatically engorged and death cl o ses the sce n e

,
.

\ V hen recover y takes place the rst S ign o f .

covery
improvement w il l be a short S lee p from w hic h ,

the pat ient a w akens st ill w ild but evidentl y ,

sl ightl y re freshed : soon Other naps follo w and

 Ex I I A U S T I O N P S Y C H O SES 1 03

u l t imatel y a go o d sleep comes W i th the cessa .

t i o n o f complete sleeplessness the ma n iac al fury .

ab ates the patient beco m es less restless and sud

, ,

d enl y or b y degrees
, regains consciousness , .

the mental storm is passed the pat ient s are

l ikel y to be left in a state Of exh au s tio n from ,

w hich by degrees they are restor ed to m o re or ,

l e s perfect ph y sical health

s
.

PR O G .
I
0S 1 S

The progn osis is al w a y s gra v e as from 50 to .

rog n osi s
/ 5 per cent o f the cases are fatal ; but those w ho
. p
d o not d ie from c ollapse usuall y recover .

T R EA T M E N T
I no form of insanit y is the outcome more
n

depen d ent upon the t reatment The severe .

charac t er o f the ph y sical and mental symptoms

ren d er s the most care ful nursing an d care a
necessit y Because o f thei r w e ak e ne d physical
.

state removal to an in sane hospital i s o f ten i m

,

po ssible W hen a goo d general h o spi tal i s not

.

near at hand the patie n t s m u st remain at home .

O n account O f the intense excitement the con ,

ti n ual attendance o f one or t w o ex per i ence d t rai n

ed nurses is imperative l f possible mechanical . ,

rest raint S hould be avoide d at lea st until appro ,

p r i ate h v d r o th e r apeut i c measures h ave proven

unavail ing T o al la y the hyperexcitement the
.
 1 04 M E N T AL D I SE A SES
Ba ths prolonged w arm bath should be thoroughl y
t ried an d w il l O ften prove e ff ect ive The dura .

tion of the bath according to the necessit ies o f

,

the case may vary from a f ew minutes to several

hours hen the temperature is high and sig ns
,

.
7

Of marked tox aemia are present sal ine in fusion s ,

may prove useful S ymptoms o f collapse m ay

.

i nj ecti on s demand stimulants o r h igh rectal inj ections O f

S ti m ul a n ts normal sal ine sol ution at body temperature .

N u tri ti on
C are f ul attent ion must be given to the nutrition .

by the re gular administ ration every tw o hour s ,

O f small q uantities o f milk or of milk mixed w ith

r aw eggs or b ov i n i n e I f the stomach rej ect s

.

nourishment tw o or th ree nut ritive enemata

,

shoul d be given ever y t w enty four hours .

R E M E D I ES
The remed ies w h ich have cl inicall y proven
most e ff ect ive in the t reatment o f thi s disease
are aconite agaricus m uscar i us belladonn a
, . .

cantharides camphor hyoscyamus stramon iu m

, , ,

and verat rum v iri d e .

ACO N I TE
The pred o minant mental characteristic o f
acon ite i s fear H e n ce as w e Shoul d expec t
.
, ,

A can i te
this drug has prove d w onder full y e ff ective in th i s
Fea r R est
disease The cases that it control s are m o s t
,

l essness .
 EX I I A U ST I O N P S YC I I O S ES 1 05

desperate Its array Of symptoms both mental

.
,

A n
g u i sh
a n d physical are of a h ighly exaggerated type
,
.

O versensit ive to l ight m usic o r noise lled w ith , , ,

delusions O f ghosts and a mul titude Of nameless

horrors terri ed b v darkness or the approach o f
,

any person the pat i ent 1 3 continual l y in a state o f

,

abj ect terror R acked by pain in every bone

.
,

muscle and j oint burn ing up w ith heat tortured

, , ,

b y an unquenchable thi rst the pat ient night and , ,

day roll s from side to side on h is couch o f an

,

guish S uch a group of S y mptoms representing

.
,

a picture o f indescribable agony w oul d seem to ,

demand somet hing more than human means of

rel ie f : y et in j ust such cases aconite has often
, ,

come to the rescue speedily producing result s ,

noth ing short O f marvelous .

A G A R I CU S M U SC A R I U S

Furious fearless menacing f renzy causing

, , , A g a r i cus
t he patient to inj ure himsel f an d others i n co ,

herent talking passing rapidly from one subj ect

, I n coheren t

to another great excitement w ith ceasel ess l o

,

q u ac i t y and exaggerat ion o f the senses to g ether ,

w ith delusions as to his ow n po w er are the S y m p ,

toms demanding aga ricus .

In addit i o n there i s O f ten present a cont inu ous

,

t remor w h i ch w hile not apparent to the observer

, ,

an d only percept ible to the patient produces an ,

indescribable terror .
 1 06 M E N T AL D I SEA SES

\V hi l enot so frequen tly demanded as some o f

the other drugs agaricus w h en indicated is ex ,

ceed i n gl y e f f ective .

B E LLAD O N N A
B ell adonna is one o f our sheet a n chors in th i s
Bel l adon n a d isease bearing some resemblance to aconite
,
.

vi ol en ce
Filled w ith delusions of ev er y conceivable vari
ety intense mental excitement at all time s pre
, , ,

Da ng erous v ail s \V hi l e the d elusions m ay be of a di sagree

.

able characte r the y pro d uce less terror an d fea r

, .

is not so prominent a characteri stic a s in the

aconite patient .

The bell adonna patient i s ho w ever muc h , ,

more violent dangerous and d est ruct i v e : w il l

, ,

bite strike or kick anyone w ho approaches o r

, , ,

dest ro y an y th ing w ithin hi s reach E xceedingl y .

nois y his apartmen ts n ight and d ay resoun d

. , .

w ith songs shout s scream s an d curses

, \V hi l e
, , .

consi d erable fever may be presen t it is not l ikel y ,

to be so general an d m ay not be so inten se as i n

the ac o nite patient .

The general bodil y restless n ess i s al so les s

marked and w hile the ceph alalg ia may be m o r e
,

s e v ere there is not so much gen eral ph y sical pai n

. .

C A M P II O R

V iolent ra ge : scratches spit s bites t ears cloth , . ,

C a mphor
i n g an d foams at the mouth
. De sires to kil l .
 EX I I A U ST I O N P SYC I I O SES 1 07

p eople Talks shouts cries and laughs I I I

.
, , , .

tense fever aggravated by mirror s or an y gli s

,

t ening Obj ect W or se at night w hen alone or in

.
, ,

the darkness .

W hile camphor does not usually play a promi

n ent part in mental therapeutics still it must n o t , ,

be forgotten in thi s disease w hen great fear and

mental exciteme n t are associated w ith ext reme
ph y sical w eaknes s and prostration .

CA N T H AR I D ES
The characteristic indicat ions for cantharides
are great v iolence w ith parox y sms O f rage and
, ,

C a n tha
a desi re to bite an y one w ith in reach tear the ,

clothing w ith the teeth and bark l ike a dog , .

\ V ith these sympto m s o f intense violence may m a 1 vi ol en ce

al so be associated an almost overpo w ering sex ual

excitement .
S ex u a l
exci te m en t
The s y mptoms are aggravated by the sl ightest
touch or any shi n ing Obj ect l ike a mirror or a ,

g l ass Of w ater .

The eves are bright the pupil s w idely d ilated

, ,

b u t the face I s pale yello w and l ikely to be w r i n k

, ,

l ed w ith a constant fro w n an d expression O f

su ff ering. th i s group o f s y mptom s d y suria
is l ikely to be associat e d .

H YO SC YA M U S

Hyoscyamus mav be occasionally demanded

w hen there is great sexual exci t ement w ith a
 1 08 M E N T AL D I SE A SE S
S ex ua l desi re to unco v er the person and a d read O f poi
exci tem en t
son that prevents the patient s taking food or

Fea r of
medicine .

The del i rium o f th is di sease is ho w ever usu , ,

all y O f S O severe a character that h y osc y amus is

of l ittle use .

S T RA M O N I U M
N o remed y i s more fre q uentl y demanded than
S tra mon st ramonium .

i um
M ost i n The keynote running th rough al l it s numerous
ten se f or m mental s y mptoms is terror .

f
o m en tal
S t ramon ium is ch ie y dist ingui shed from
aconite belladonna and cantharides b y the i n ten
, ,

sit y rather than the character o f its symptoms .

The excitement O f st ramonium i s o f the most

exaggerated type and appears as a per fec t
f renzy W hen aconite belladonna and can tha r

.
, ,

ides are unavail ing and the excitement seems

continuall y to inc rease in intensit y w e can turn ,

w ith hope to st ramonium w hich seldom d i sap .

points .

y ERA T RU M V I R I DE
V erat rum vi ri d e has f ew mental s y mptom s ,

Ver a tr um
b ut has O ften proven e ff ective in th i s mala d y
w hen the temperature w a s danger o usly h ig h .

H ig h tem
the pul se exceedingl y w eak an d fa st and the res ,
er a tu re ,
p
Rapi d p i r a t i on rapid and i rregul ar It s sphere o f .
 E x H A L S T I O N P S YC I I O S ES
'

1 09

action is l imited to this stage O f the disease and P al :71 31

m l ) 1 m m"
,

as soon as the inten se fever has been cont rolled it

should be di scontinued .

B A cute con fusional in sanit y (amentia )

.
,

hallucinatory insanit y hallucinatory con fusion

, ,

paranoia d i ssoci atI v a (Ziehen ) .

Th is ps y chosis is characterized by the rapid

development of illusion s and hallucinat ions ,

clouded consciousness and motor excitemen t .

ET I O L O GY
This disease most frequently occurs in persons
w ith a bad fam il y h istor y and a marked insane
I m am
diathesis I ts most common vict ims have been
. di a thesi s
w omen in the prime O f l i fe although cases occur ,

ring i n earl y y outh and bet w een the ft ies and

sixt ies have been reporte d The ch ie f cause i s .

exhaustion pro d uced b y some acute disease l ike

, ,

t y phoid fever acute articul ar rheumat ism great

, , E x ha us
l oss o f blood or childbirth
,
Trauma prolonge d .
,

mental st rain mental or physic al shock o r co n

, ,

t in n ed loss o f sleep m ay act as an exciting cause .

A lthough o f rare occurrence abroad (Kraepel in

estimat ing it at on e hal f to one per cent o f the
-
.

admissions to hospital s ) it i s more fre q uentl y

,

encountere d in this countr y

SY M P T O M A T O LO G Y
The incubat ion stage is or d i n aril y S hort and ,
 1 10 M E N T AL DI SE A SES

usually a fter apparent convalescence from some

shor t
febrile or other disease During thi s t ime sign s
.

O f nervous exhaustion appear The pat ient i s .

irritable sleepless or h is sleep i s dist u rbed b y

, ,

t roubled dream s an d he becomes causel essly

frightened su ff ers w ith headache and is S l ightly
, ,

con fused and incapable O f continued thought .

S oon multi form hallucinations of sight hearin g , ,

smell and taste appear w ith increased con fusion

, ,

and inability to reco gni ze h is surroundin gs O ut .

breaks o f excitement w ith marked motor agita

,

tion al ternate w ith the periods o f mental con f u

,

SI O I I
,
but the speech is l imited to single w ords or
meaningless broken sentences .

P ei secuto ry hallucinations appear : he is being

-

fol lo w ed by detectives or poi soned or is a f icte d

, ,
hb n s
D el usi on s .
w ith some dire ful mal ady In other case s the .

h allucinations have a rel igiou s form : C h ri st the ,

V i rgin M ary and angel s are seen I I I still others

, .

the hallucinations are o f an erotic character .

Fill ed w ith continuall y changing del usions one .

moment the patient is possessed o f a d evil the ,

next he communicates w ith the D eit y o r fi lled , ,

w ith terror he frantical ly attempts to escape

,

f rom the horrid S hapes b y w h ich he is su r

rounded A marked characteri st ic is the mental
.

cloudiness O f the patie n t producing complete d i s,

orientation neither h is friends nor su r roundings

,

being recognized .
 Ex I I A L S T I O N P S YC I I O SES
'

111

The mental con fusion is o w ing primarily to t he C onf usi on

great exhaustion o f the brain centers the e ff ects f rom b ra i n

, E x ha us
o f the preceding fever or inammat ion and sec , ,
ti on

on d l y to the overpo w ering hallucination s w hich

, ,

S O absorb the attention as t o make the patient

obl ivious of all that i s occurring about h im .

\ V hen the brain exhaustion has been less

severe the di sease picture i s less st rikin g T h e
,
.

hallucinations though vivid are not so mult i

, ,

form and the menta l obtundity i s sl ight The .

illusions and hallucinations are less complex .

V oi ces sh rieks pi stol shot s and the ringing Of

, , ,

bell s are heard Fear ful shado w s it about the

.

room voices accuse h im of murder and pre d ict

, ,

hi s imprisonment or elect rocut ion The con .

sc i ousn e s s is less obscured and he can give a cor

rect account of himsel f colored ho w ever b y the , , ,

impression ma d e b y the hallucinations The .

patients are quiet apathet ic cont inuall y occupied

, ,

by thei r hallucination s pay l ittle attent ion to ,

thei r surroundings are tractable and give I I I O I I O

, ,

s y llabic an sw ers to q uest ions L ater delu sion s . ,

are developed out o f thei r hallucinations .

L ess frequentl y as a result Of thei r persecu

.

tory delusions motor S y mptoms appea r mani

, ,

f ested in their attempt s to escape supposed i m

pen d ing dangers The y w ill move restlessl y
.

about the room dodging from side to side to

,

avoid the attack s o f imaginar y assassin s or w ill .

 1 12 M E N T AL D I SE A SE S

provide themsel ves w ith w eapons f or de fens e

against thei r supposed enemies The larger .

number remain apathetic .

ar a n oi a
In the S impler form the hallucination s are l im
i ted to a f ew subj ect s cont inually repeated and ,

the condition resembles paranoia ; but the delu

sions are n ot systematized an d the pa t ient s d o
not attempt to de fend them logically A large .

p roportion o f these cases Sho w the delusion s and

con fusion f or w eeks or months w ith varying ,

alternat ives o f l ucidity and exacerbations .

The character of the hal lucinations an d ,

sequen t d elusions may remain unchanged for

,

y ears w ith gradually decreasing mental con f u

,

sion w h ile the sense decept ion s remain x ed but

,

unprogressive .

The ch ie f physical symptoms are disturbed

sleep anorexia constipation loss of w eight a
, , , ,

slo w pul se subnormal temperature and an i n

, ,

crease o f the deep reexes .

u ra ti on The disease usually reaches its height w ith i n

ar t tw o w eeks During the enti re course short
.

remissions and uctuat ions are likely to occur .

The majority of pat ient s recover thei r full reaso n

w ith i n a f ew months Death is in frequent ex
.

cept from suicide A f ew succumb to heart fail

.

ure sepsis and phth i sis

, , .
 E X H AU ST I O N P S YC H O SES 1 13

D I AG N OSI S
A ment ia i s distinguished from the catatonic
form o f dementia pr aecox b y its greater co n f u
sion and impairment of consciousness and mem
ory and its lack of genuine negativism v erb iger
, ,

ation stereotypy mutism and mannerism

, , ,
.

I t may resemble the man ic type of man ic

M ani c
depressive insanit y but can be di ff erentiated by depressi ve
,

its greater inter ference w ith consciousness and I nsa n i ty

greater disturbance Of apprehension Its move .

ment s during excitement are slo w er and pur

. ,

p o se l e s s and ,
in their q uiet interval s the patients
are haz y an d con f used A m entia may al so .

occaS I O I I a l l y re semble dement ia paral y t ica but ,

lacks the characteristic ph y sica l sign s o f tha t

d i sease .

T REA T M E I
'

During the acute stage contin ue d r e st in bed ,

R est
N ou ri sh
S hould be en forced
m en t
.

L iberal q uant i t ies o f easily digested n ouri sh

ment must be a d m ini stered b y force i f necess a r y .

H y drotherapeut ic measures for the all ay ing Of

excitement must be appl ie d C are f ul nursing .

and con stant w atch fulness to prevent sel f inj ury

al so are i m perative O n account Of the t endency

.

to relapses care must be taken that the pat i en t s

,

are n ot subj ected to any emot ional shock during

convalesce n ce o r until health i s full y restored .

9
 1 14 M E N T AL D I SE A SE S

RE M ED I ES
The reme d ies must be selected according to the
S y mptoms of each indivi d ual case .

Those w h ich w e have found most rel iable are

aconite actaea racemosa agaricus alumina am
, , , ,

bra grisea anacardium arnica ar sen i cum bap

, , , ,

t isia bar y ta carb belladonna bryon ia cuprum

,
. . , , ,

digital i s gel semium hyoscyamus lachesi s nux

, , , ,

vomica st ramon ium and veratrum album giv en

, , ,

acc o rding to the follo w ing indication s :

-

A CO N I TE
The aconite patien t is excited restless uneas y , , .

terri ed by m ul titudes of fears and imagination s .

A con i te w ith mind con fu se d w ith w eakness o f memor y ,

Fea r
and i n abil it y for mental l a b or He is hy pe rsen si .

tive cannot bear l i ght noise music He i s i n tol

. . , .

Si i w m e r an t o f pai n cannot hear to be touched i s

, .

changeabl e in moo d one moment gay the ne x t . ,

sad A c onite i s use f ul in the rst stages o f th e

.

disease .

A C T A E A RA C E M O S A
In so mni a hall uci n ations o f sight incessant
. ,

R acem osa
tal k at n en e ch an g m g co n t i n u all v from one sub
H

ss.
I n som n i a
H a ll uci na j cet to an o th e r C ro s s taciturn pul se full an d
.
. ,

o f q uick eve s w il d an d staring t remor scarce l y vi s

, ,

-
a tzW m ss ible but app a rent to touch .
 E X H AU ST I O N P S Y C H O SES 1 15

A G AR I CU S
M arked mental excitement causing at tempt s ,

to inj ure himsel f and others C ontinuous i n co .

E xci tem en t
herent ta l k Disincl inat ion to ans w er question s
.
I n coheren t
,

inabil ity to express himsel f C hangeable .

moods one moment gay the next sad Trem ,
.
a bl en ess
T r em or
ul ousn ess and muscul ar t w itch ing .

ALU M I N A
A pprehensive anxiet y and vague fear fulness .

4l u m i n a
mental con fusion w ith loss o f memory and ina Fea rf ul n ess
b i li ty to express his ideas correctly .
C onf usi on
A ggravation O f the S y mptom s in the morning
on a w akening .

A M B RA G R I SEA

Hallucinations Of sight sees diabol ical faces ,

A m b ra

abou t him S lo w ness Of comprehension w ith

.

marked impai rment o f memor y S leeplessness . .

ha l l uci n a
O bstinate const ipation A ggravated b y the
.
hb n s

presence o f other people .

A N A C AR D I U M
L oss o f memory Dream y condit ion Of mind
.
,
4 n a ca r
dull st upid unable to converse on account O f hi s
, ,

paucity Of ideas and l ack O f mental concent ration .

m em ory
Hal lucinat ions o f hearing C ontinual incl ination
S tupi di ty
.

to sw ear. Desi re to commit suicide by Shoot ing .

 1 16 M E N T AL D I SE A SES

AR N I CA
4 r n i ca S tupid f orget ful taciturn A norexia Thirst
, , . .

S tupi d ,
w i thout fever Dr y ness O f l ips and tongue w ith
.
,
taci tu r n
bro w n st reak th rough tongue an d t rembl ing o f
the lo w er l ip .

AR SEN I CU M

A r scn i cu m Great mental and physical restlessness I I I .

R estl essn css tense mental an guish causing attempt s at suicide ,

E t ha usti on

S ecs
and se l f mutil ation H al lucinati o ns o f sight
-
. .

S ees v ermin cra w ling over him Great physical .

1Vorst ca ses
e x haustion U se ful in the most desperate case s
.
,

w here death i s imminent unless speedy rel ie f i s

obtained .

B A PT I SI A
B apti si a C on fusion o f ideas cannot concentrate th e ,

min d I ndi ff erence stupor fall s asleep w h il e

Body
.
, ,
in
pi eces
being spoken to o r w hile ans w ering Delusion .

that hi s b od y is I n pieces and he cannot get th e

parts toge ther .

B ARY T A C A RR .

Ba ry ta
C arb .
M decient forget s w hat w as j ust sai d
em o r v ,

H mh
or d one or w hat he w as going to do or say I r
, .

m i n ded re sol ute changeable w e akm in d e d chil d ish

, , , .
 EX H A L ST I O N

P S YC H O S ES 1 1/

BE LLA D O N N A
V iolent w ild excitable pugil istic dest ructive
, , , , , Bel l a don n a
l Vi ld ,
m ind lled w it h changeable illusions halluci n a ,
P ug i l i sti c
t ions and delusions or dull stupid and sluggish ,
.
or S tupi d

S leep disturbed or b roken or d ro w siness w ith

, ,

inabil it y to fall asleep .

B RYO N I A
I rritabil ity dread and apprehension for get
, ,
Bry on i a
fulness w ith mental languor con fusion and i n ,

d isposit ion to think .

C onf used

CU PRU M M ET A LL I C U M

\V eak n ess o f mind w ith forget fulness \ V il d .

D el i ri u m
del irium a ssociated w ith feeble une q ual in tre , ,
I l ea h pul se

q uent pul se moi st skin

,
and cold ext remities ,
.

D I G I T AL I S
Dull l e thargic w ith w eakness Of memor y and
, ,

great di f cult y in concentrating the min d Gen .

M en ta l

e ral appearance of w eakness and ex hausti on wea k n ess

Sl ow pu l se
accompanied b y a slo w f eeble pul se , .

G ELS E M I U M

M ind dull con fused incapable o f continued

, ,

thought or of making any p o sitive deci sion .

C el sem i u m
D ro w s y d esi res to rem ain q uiet an d have n o on e
,
C onf used
 1 18 M E N T AL D I SE A SES
O ccipi tal near him M ental exhaustion o ften acco m panied
.

p ai n
b y a dul l occipital pain w h ich m ay extend do w n ,

the shoulders General nervous and muscula r .

prostration .

H Y O S CYA M U S
M ild changeable del i rium I llusions and hal
,
.

m us l uci n a ti on s o f the various senses Fea r O f poi .

C ha ng eabl e
son causing persi stent refusa l O f all food and
,

S ex ual medicine S exual excitement

. M uch muscul ar .

t w itching S tupo r disturbed b y the sl ightest

.

noise .

LA C I I ES I S

Great loquacity A pprehensive j ealous m i s .

, .

L achesi s
t rust ful peevish i rritable w eakness o f memor y
, , , ,

Logn a ci ty mental con fusion an d incoherenc y caused by .

S epti ceem i a ideas rush ing too rapidly through the mind .

U se f ul in cases produced b y septi czem i a .

N UX

\ O M I C A

I rritable cross sullen ugl y tacitur n O b sti

, , , , ,

nate anxious w ith a desire to commit suicide

, ,

Vom i ca but afraid to die M akes mistakes in speakin g .

an d w riting M ental dullness and con fusion i n

.

O bsti n ate
the m o rning and a fter meals .
 E X I I A U ST I O N P S y C I I O S Es 1 19

S T RA M O N I U M
Furious del i rium terri ed by f anci ful delu
,

sions noisy and incoherent C onverses w ith

, .

m on i u m
spirit s and absent persons as i f they w ere pres Fu r i ous
ent but does n ot recognize those about h im .
d el i r i u m
,

C l utches at imaginary obj ect s in the ai r .

C hangeable moods varying from taciturnity to

,

furious raging violence S leeplessness or S leep

.

disturbed b y terri fying dreams .

V ERA T R U M AL B U M Vera tr u m
A l bu m
\ V ild ,
changeable del irium accompanying ex
,

ce s s i v e bodily exhaust ion and th reatened col

G r ea t
lapse .
ex ha u sti on
 C H A P T ER V I

N EU R A S T H E N I A

Kraepel in pl aces acquired ne uras thenia or

ch ronic nervous exhaust ion among the ex haus
tion psychoses separating it from congenital
,

v i si on s
neurasthenia O ther authors hav e d ivided neu
.

r asthen i a into cerebral o r cerebrasthenia spinal ,

or m y elasthenia genital acute h y stero and gas

, , ,

t ric neurasthenia A s the di sease is us ual ly

.

enco unte red the various forms are so mingled

,

an d con fuse d that a di ff erentiation of the di ff er

ent t y pes m ay be impossible nor i s it necessar y ,

for practical purposes \V e shall there fore pre

.

sent here a general descript ion o f neurasthenia .

embracing al l the di ff erent form s simp l y em pha ,

siz ing the fact that exhaustion agencies pla y an

exceedin gly impo rtant part in it s et iology .

( )

y EC RA S I I I EN I A N E E ST I O N
'
O t s A
' '

Rv X I I I

N eura sthenia is one o f the most common o f

t he f u nct ional diseases o f the nervous s y stem .

I t i s especial l y prevalent in the l a rge citie s w here ,

the st rain of m o dern l i fe is greatest \V hi l e .

un d er vari o us names allu si o ns are made to it in

the earl ier medical w riters it i s onl y s ince the
,
 N EU R A ST H E N I A 121

d escription given by Beard in 1 8 7 0 that it has

1 870
held a p rominent place as a disease entity S ince .

that time numerous t reat ises have been w ritten

upon the subj ect by authors in di ff erent countries
u n til today it is on e o f the best kno w n o f the
, ,

functional nervous diseases .

E I T O LO GY
The most important causative factor is here d
ity the maj ority o f the vict im s of neurasthenia
,

reveal ing evidences o f an unstable orga n ization .

A h istory O f migraine o r some nervous i rrita

t ion is usually di scoverable and in man y case s
m arked physical o r psych ical st igmata o f degen
c ration appear . W hile the inherit or o f a so und
n ervous system may w ith stand unscathed the

severest st rains of modern l i fe those less f o r tu ,

n atel v endo w ed fre q uently succumb under com

p a r a t i v e l y easy burden s Bouveret

. declares that
those predestined to nervous disorders m ay go B ou v et er

th rough l i fe w ithout being attacked by a ps y cho

sis or grave organic malad y but they ra rel y ,

escape neurasthenia .I f the cri ses O f pubert y
are w ithstoo d the strain o f the cl i m ax i s or begin
ning sen ile involutio n not i n fre q uentl y deve l ops
a t rain of asthenic s y mptoms .

The neurasthenic age ranges from eighteen to

f t y v e the greatest n umber of cases occurrin g
-
,
tw en ti th e
bet w een the tw ent ieth and ft ieth v ea r s N eu a n d i th
.
e
 1 22 M E N T AL D I SE A SES

r a sthen i c symptoms a re ho w ever occasionall y

, ,

encountere d in ch ildren of t w elve or thi r tee n and

even in the aged The senile variet y is usua l l y
.

associated w ith hypochondriasis an d signs o f

degenerat ion O f the nervous and vascular s y stem .

Both sexes are l iable to the d i sease b ut the ,

pure form is most f requently seen in males .

C ertain races are especiall y l iable to the di s

Raccs l i a bl e ease The H ebre w the A merican the French
.
, ,

man the Ru s sian an d in th is country the I rish

, , , ,

man and E n gl i shman are o ften numbered among

it s victims : the negro an d German are less f re
q uen tly a f icte d w ith neurasthenia .

\V hi l e most preva l ent in d r y temperate cl i

mates i t is not unknow n to the t ropics and i s
often found in the est In d ies and the republ ic s
, ,

o f S outh an d C en tral A merica .

The unnatural excit ing l i fe of the cities w ith ,

its vices and numerous nerve strains is m uch ,

more conducive to the di sease than the quiet l i fe

o f rural communities .

A mong the prominent predisposing caus es

may be m entioned defective educat ion of ch il
i ng ca u ses
d ren failure ear l v to learn sel f cont rol lack o f
,
-
,

moral inst ruction and training of the j udgmen t

a n d w ill an d too stren uous forcing of the ment al
,

po w e r s .

S evere m ala d ie s O f in fa n c y an d childhood ,

E r ha n sti t e
'

d i sea St 5
' various fevers inuenza too frequent pregna n
, ,
 N E U R A S TH E N I A 1 23

cies and prolonged lactation may al so produce

,

n erve exhaustion in the const itut ional ly predis

posed .

Intoxications from alcohol tobacco opium , , ,

cocaine lead or other metall ic poisons by w eak ,

on
:
,

en i n g and depraving the nervous system m ay ,

render it suscept ible to the disease .

A mong the excit ing causes emotional disturb ,

an ec s shocks prolonged mental exertion and

, , ,

ca uses
anxiety and loss o f Sl eep play an important part .

A mong night w orkers telegraphers n i ghtw atch

-
, ,

men and compositors the di sease is fre q uently

,

encountered S exual excess and masturbation

.
,

especially in the young are fre q uent cont ributory ,

factors S yph il itics are O ften neurasthenic

. .

Tra umata cephalic i n j uries and shocks the t e

, ,

sul t o f rail w ay inj uries not i n fre q uently entail ,

neurasthenia .

E ye strain ch ronic mid d le ear di sease nasal

-
,
-
,

stenosis ch ron ic gast ric disorder and disease

, ,

o f the pelvis are other not in fre q uent causes .

W hatever the patent exciting causes n eur as ,

then i as are mainly developed upon an hereditary

basis O n account Of the great variety O f causes

.
ba si s
respon sible for the development o f the disease ,

a care ful st udy o f the etiology O f each case is

imperat ive i f treatment is to be success ful .
 1 24 M E N T AL D I SE A SES

SY M PT O M A T O LOG Y
Wh ile the S y mptoms of neurasthenia are man i
fold they bear so marked a resemblance to one
,

another that a typical case i s as easily r ecogn i z

ea hn ess
able as a case o f other nervous diseases The k ey .

note O f the enti re ensemble is i rritable w eakness .

E xt remel y hypersensit ive any excitement soon,

produces in the patient a sense o f exhaustion ,

fatigue and apath y

,
M ild depression o f a hypo
.

chon d r i acal character prevail s base d upon the

,

physical sensat ions A ll w ork physical or men

.
,

tal produces an inordinate sense o f w earines s

,
.

Tasks formerl y eas y are accompl ished w ith d i f

cult y Devoid o f originat ing po w er a sense O f
.
,

mental incapacity pervades the mind w h ich deep ,

e n s the depression A condit ion O f fear and

.

general apprehension is usually pre sent Thi s .

may be in d e nite as o f some impending disas

,

ter o r assume a de nite shape The patien t

,
.

fears that he is losing h is min d or is ac q ui ring ,

'

some incurable d isease or w il l be paral y zed o r

, ,

a is about to die These fears may so over w helm

.

the min d as to make the person absolutel y miser

able These obsessions are numerous and varie d
.

an d so common that they have been gi ven a di s

t inct nomenclature have a gor aphobia fea r
.
,

of being in open sp ace s : claust rop hobia fear o f ,

c l o se d space s : anthropophobia fear o f m en .

 N E U R A S TH E N I A 1 25

monophobia fear o f sol itude ; pathophobia fear

, ,

of disease ; zoophobia fear o f animal s ; and hun

,

dreds of other fears Impe l le d b y these fears the

.

patient may re fuse to leave his apartment s unless

under guardianship A nother fre q uently disturb
.

ing symptom to rened and cult ivated persons is

the i m pel l an t inc l inat ion to mix blasphemous and
l thy expressions in conversat ion w hich are w ith ,

the greatest d i i cul ty repressed .

The d el i r e d u toucher et d a d oute is al so f re D el i re d a

quently present U nder the former the pat ient toucher et
d u do ute
.
,

has an imperative desi re to touch certain obj ects ,

to investigate the business of others or to read ,

priva te letters w hich tendencies are l iabl e to i n

,

volve him in ser i ous di fcult ies O thers are con.

ti n ual l y disturbed by fears o f contamination from

riding in publ ic conve y ances from shakin g ,

hands or from touching certain substances

,
.

\ V hen d isturbed b y the f ol i o (i n d oute the m ind

is harassed b y reasonings and quest ion s con
cerning e ver y conceivable subj ect N i ght and .

day the victim ph ilosophizes and puzzles himsel f

w ith endless un solvable me n tal equations and
torm ent s ever y one about him b y hi s endless n u
ans w erable queries .

Incapable O f making any posit ive decision ,

fa ul ty in memory devoid O f j udgment and w ill

, ,

C on ti n ua l
timorous and disquieted b y h is numerous fears ,

d oubts and anxieties a constant state o f mental

, ,
 1 26 M E N T AL D I SE A SES

a gitation exist s rendering active mental or phys

,

ical labor an impossibil it y .

bh ar m al N umerous abnormal sensation s in the head are

n sa ti on s
complained o f such as a w eigh t in the sinciput or
,

a band const ricting the vertex or templ es .

S l ight vertigo m ay be present w ith ringing i n the ,

ears musc ae vol itantes and hyperesthesia of the

, ,

scalp A ctual pain is al so frequently ex per i

.

e n c ed especiall y in the occiput and neck and

, ,

extending do w n bet w een the shoulders .

Insom n ia is one of the most troublesome sy m p

I som n i a toms T w o form s are especiall y fre q uent In
. .

the rst the pat ient upon ret i r i ng soon fal l s

asl eep but a f ter tw o or th ree hours suddenl y
, , ,

a w akens and f or the remainder o f the night

tosses restlessl y about arising in the morning ,

total ly unre freshed and enervated O thers for .

,

hours he a w ake t roubled b y their imperative

,

ideas and endless nervous ph y sical sen sat ions ,

thei r onl y re freshi n g sleep coming to w a rd s

morning at the t ime w hen the y should begin
,

t hei r daily duties I I I m an y cases the nocturnal

.
,

res t is disturbed b y unpleasant terri f y ing ,

d reams from w h ich the patients a w aken in terror

,
.

Robbe d o f hi s n atural sleep an d re st b y some one

o f these causes the neurasthenic usuall y arises
,

from h i s be d in t he morni n g t ire d and un re

, .

f reshe d and incapabl e O f per forming hi s daily

d u tie s .
 N E U R A S TH E N I A 1 27

O cul ar t roubles are al so fre q uen t occur of

b
trou l es
re nce Transient di ff use conj unctiva ] conges
.

t i o n s often are apparent in the ear l v morning .

w hich disappea r a fter the morning meal .

V arious pupillary phenomena appear var y ing ,

in di ff erent individual s T he most common anom

.

al y is a moderate dilatat ion o f the pupil s w ith

slo w reaction to l i ght and accommodation L ess .

fre q uently a modern dilatat ion of the pupil s

,

occurs w i th rapid react ion to al terat ions o f l i ght

an d shade the j umping pupil as it has been
,
"

designated The degree O f pupilla ry w iden in g

.

o ften indicates the amoun t o f exhau stion .

M u scae vol itantes are Ofte n present and m ay per

si st for yea rs O phthalmoscopic examinat io ns
.

are usual ly negative .

The ch ie f and most important ocular t ro uble is

the neurasth enic asthenopia the e ves easil y b e then i c
,

A sthen opi a
c omin g fati gued by w rit ing and reading and in , ,

the mo st aggravated cases by simple exposure ,

to light on the st reet s I f the use o f the eves

.

i s persi sted in neuralgias sensations of tension

, ,

in the eyeball s and visual con fusion m ay be ex pe

,

r i en ced. Th is c ondit ion may become so aggr a

y ated as to necessitate secl usion in a diml y
l ighted or even dark room Thi s asthenopia m ay .

be t ran sient or last for month s or d urin g the

,

enti re l i fetime of the pat ient .

L ike perversion s o f innervati o n m ay be appa

 1 28 M E N T AL D I S EA sES

rent in the other special sen ses of taste smell , ,

P er ver si on s
an d hearing The most frequent are the audi
.

ta ste , sm el l
tory hyperesthesia Buz zing w hi z zing th e
,

hea r i ng .
, ,

ringing of be l l s or the sound o f a sea shell in on e -

o r both ears are fre q uent aural S y mpt o m s an d

may cause the greatest annoyance to the su ff ere r ,

not in fre q uently d isturbin g the sleep at night .

Pa i n i n M ost neurasthen ics complain o f pain in the

ba ck back and in many it is the cause o f their m ost
intense su ff ering This i s most common i n
.

w omen and is usually a ggravated b y m enst rua

tion . The intense aggravation from mot io n
causes many to assume a supine posit ion w h ich .

the y are w ith di fcult y induced to change .

These pains o ften in d uce I n the minds o f the pa

t i en ts a bel ie f that they are su ff ering f rom rheu

m ati sm ki d ne y disease tabes or some other o r

, , ,

gani e disease o f the cord .

Ver teb ral

V erte b ral sen sat ions are numerous and va rie d .

sen sa ti on s Those most commonly met are pai n s i n the l o w e r

cervical lumbar an d sacral region s S ensation s .

o f heat b u rning formication of cocc y god y nia o r

, , , .

o f general hyperesthesia o f the enti re spm al co l

um n are al so common Th is sen sitiveness m a y
.

be inten sel y exaggerated over individual vert e

br ae or upon the skin lateral to the column Th i s .

sensit ivene s s in man y cases is so severe that th e

sl ightest touch or even the pressure O f the cl o th

ing may be intoler able I I I other cases this sen

.
 N E U R A S TH E N I A 1 29

S i t i ven essmay not be el icited by pressure but i s ,

apparent a fter prolonged standing or by en forced

movement s of the spinal column These pains .

may be t ransient but are usually sources of dis

,

com fort f or years .

P erhaps the most common and characteristic M usc ul a r

wea hn ess
symptom o f neurasthenia i s neuro muscular -

w eakness A l l neurasthenics complain o f f a

.

t igue A ny mental or physica l e ff ort produces a

.

sensation o f exhaustion enti rely incommensurate

w ith the exertion put forth The patient i s al .

w ays ti red A fter seven or eight hours o f sound

.

sleep the patient either a w akens un re freshed or

a f ew minutes exertion w i l l exhaust all his en

e rgy and f o r the remainder o f the day he i s inca

,

p a c i t ated for any w ork Th is muscular w eak .

ness may n Ot at rst be demon st rable by the

, ,

dynamometer but i f the test s are several times

,

repeated the hand muscles may sho w sl ight loss

o f po w er Thi s motor w eakness is usually gen
.

eral and rarely l imited to on e side o f the body or

the lo w er l imbs is unattended by atrophy and
, ,

never increases to paral y sis .

A rapid vibratory tremor and a b r i l l ar y t re V i b ra tory

mor are al so fre q uently observed ; the orbicu a n d i b ri l
f
laris palpebrarum and oris and the rst i n terO S l a ry tr em or

seous muscle being the muscles most f requently

invo l ved A t remor of the eyel ids al so m ay ap

.

pear i f the patient stands w ith his eyes closed .

10
 1 30 M E N T AL D I SE A S ES

T he deep reexes o f the knees and arms a re

Ofte n exaggerated A S l ight inconstan t f oo t
.

clonus may at times be apparent A l l othe r .

S igns o f muscular rigidity are a b sent .

S tutteri ng S tutte ring at times accompanies n eur a sthe

, ,
D iic ul ty
i n spea hi ng nia but the speech is seldom a ff ected The pa
,
.

tient m ay complain Of d i i cul ty in nding the

right w ord in speaking or a con fusion in w ord s
,

and a tendency to di splace or drop letters i n

speaking or w riting may occasiona l ly occur .

Va som otor
V asomotor disor d ers are not uncommon
di sorders
.

com m on C oldness o f the hands and feet ushes o f th e ,

face al ternating w ith pallor and th robbings i n

,

various part s of the bod v may cause great ,

annoyance .

F un cti on a l Functional heart di sturbances are o f fre q uen t

hea r t d i s
tu r ba n ces
occur rence A t tacks of palpitation tach y card ia
.
, .

or a sensat ion as i f the heart stopped or of inte r

mission o f the beat are frequent causes O f C O I I I
plaint These attacks are l iable to produce grea t
.

mental perturbat ion and form the basis of per

sistent fears Heart murmurs are ra re al
.
,

though a systol ic murmur may appear at the

height o f an excitement V ascul ar murmurs ar e
.

al so present at times .

D ig esti ve Digestive disorders are excee d ingl y com m on .

In the maj orit y O f cases the disturbance i s ga st ro

f re
q uen t

a n d va r i e d intest inal although duodenal indigestion is n ot

,

rare In the milder forms the ph y sical conditio n

.
 N EU R A ST H EN I A 13 1

is slightly a ff ected In the graver forms marked

.

loss in the physical w eight may occur In the .

g ast ric types the symptoms appear shortly a fter

eating ; in the intestinal varieties a fter an i n ,

ter v al o f an hour or longer Immediatel y a fter .

t he ingestion O f food a sense Of rel ie f may be ex

p e r i en ce d w h ich is soon
,
follo w ed by great dis
com fort w ith a sensat ion o f w eight uneasiness ,

great distension and the eructation o f gas A fter

,
.

the food has passed into the bo w el partial rel ie f is

Obtained w h ich may be follo w ed by disturbance

,

in the small intestines Borboryg mi may then .

b egin so severe that the patient m ay be obl ige d

,

to Shun society S evere colicky pains may occur

.
,

w hich are rel ieved by the passage of gas per rec

tum These digest ive disturbances may follo w
.

each meal d epriving the patient O f all enj o y ment

,

o f l i fe I I I the atonic neurasthenic d y spepsias a

.

lack o f hydrochloric acid is found in the gast ric

j uices to w hich the active fermentation m ay b e
,

ascribed O bstinate constipat ion i s a common

.

accompaniment o f nervous dyspepsia the feces ,

w hen expelled being hard scybala or sma l l cy l i n

ders Diarrh oea m ay replace the const ipatio n
.
,

attended by sl igh t emaciation .

In the graver form o f atonic dyspepsia the

symptom s o f the milder are intensi ed E ver y .

N u t i ti on r
meal w hatever its character i s follo w ed b y fer di stur bed
, ,

mentation in the stomach and inte stines I n th is .

 1 32 M E N T AL D I SE A SES

form nut rition is markedly disturbed a decrease ,

in w eight ensues and the emaciation may become

,

ext reme S evere forms Of atonic dyspepsia m ay

.

al so be induced by any emotio n al exci temen t ,

I n testi n a l

di sorders great j oy grief or anger

, , .

ca used by A cute attacks O f intest inal indigestion al so are

ex ci tem en t
com m o n i n neurasthenics These attacks begin .

w ith nausea vomiting and frequent w atery diar

, ,
~

rhoei c di scharges .

E motional disturbances or the excitement o f

any n ew un d ertaking l ike a j ourney or of sing
, ,

ing o r speaking in publ ic may produce a nervous ,

diarrh oea or an attack o f vomit ing .

The most serious bo w el accompaniment o f

neurasthenia is kno w n as mucous enterit is .

Th is occurs but rarely and usually in exhausted

,

w omen bet w een t w enty v e an d forty This i s .

one Of the earl ier symptoms o f nervous w eak

ness It s characteri st ics are a pain ful col ick y
.

d ia rrh oea w ith the passage o f tubul ar casts or

port ions o f casts w hich diarrh oea al ter n ates w ith
,

constipation These cast s are albuminous in

.

character the product o f the decomposition o f

,

the epithel ial cell s of the intest inal w all s .

The appet ite of the neurasthenic i s i rregu l a r

and tf ul W hile some pat ient s are incl ined to
.

Overload the stomach the majority take an i n

,

suffi cient quant ity o f food .

Di f cul t y in s w allo w ing fre q uentl y a eco m

 N E U R A S TH E N IA 1 33

pani cs deglutition at times severe enough to con

,

d eg l u ti ti on
vince the patient that there is some Obstruction
in the (e sophagu s .

A n ot in fre q uent digest ive symptom is the

neurasthenic hunger This consi sts of a feel ing
. N eu rasthe
nic hu ng er
of goneness and emptiness in the stomach w ith
an urgent craving f or food a f ew hours a fter a
,

full meal , w hich i f not immediately sat is ed

, ,

causes a sensat ion o f intense motor w eakness ,

w ith vert igo and often fainting attacks These .

symptoms are all immediately removed by the

ingestion o f food.

The respirations temperature and blood of the

, ,
ra

n eurasthenic are usual ly normal although an ae

,
pera tu r e
mia m ay exist in certain cases .
and bl ood
N o one case exh ibit s all o f the foregoing
n or m al
symptoms Each case is distinct in it sel f The
. .

disease presents great variations O ne n euras .

thenic suff ers ch iey w ith pain in the head i n di vi dua l

,

another w ith pain in the stomach : or insomnia or

morbid fears may be most prominently in evi
dence C are ful q uestioning w ill ho w ever reveal
.
, ,

the t rue nat u re Of the di sease The symptom s

.

may be periodic or i n termittent in their appear

a n ce The majority are more severe in cold than
.

in w arm w eather .

PA T H O G E N ES I S
N eurasthenia i s mainly the resul t Of inherited
 1 34 M E N T AL DI SE A SES
R esul t o f nerve w eakness O n account O f th is inheritance
.

i n her i ted
n er ve
the nervous system is rendered more vulnerabl e
w ea k n ess to depressing agencies w hether they be poison s , ,

in fect ions shocks inj uries or particular nerve

, , ,

st rains .

A utopsies reveal no de n ite material basis for

N o de n i te the disease Wh ile certain discoveries as to
.

m ater i al
basi s changes in cell s and the blood constituents have
been claimed by d i ff erent Observers no de nite ,

pathology has as y et been establ i shed .

D I FFER EN T I AL D I A G N O S I S
The di seases w ith w h ich neurasthen ia i s mos t
l iabl e to be con founded are dementia paralytica
in its early stages cerebral syphi l i s tabes melan
, , ,

chol i a hypochondriasis and hysteria

, ,
.

i a ted f rom
Dem en ti a
D E M EN T I A P A R A LYT I CA
P a ratr ti ca
'

The three characteri stics by w hich n eurasthe

m en ta l
ag e , nia can be dist inguished from dement ia par al y
s m
y p tom s t ica are the condition O f the pupil s the age o f
, ,

the patient and the mental symptoms

, .

In neurasthenia the pupil s are ordinarily mod

e r atel y dilated or i f w idely dilated react readil y
,

Pupi l s to l ight accommodation consensual and sympa

, ,

N eu ra sthe

n i a sl ig ht
thetic stimul i ; the attention reex i s norm al
ly
and the outl ine O f the pupil s S ho w s n o i rregu la r
P a resi s i ty I n dementia paralytica some abnormal it y
a b n or m a l
.

in n i nety
O f reaction is present at an early stage in at , ,
 N E U R A S TH E N I A 1 35

least ninety per cent O f all cases The pupil s p r cen t of

. . e .

ca s s
may be O f normal size but react ions to l ight and .
e

consensual stimuli are sluggish The pupil s may .

be w idely dilated too smal l i rregular in outl ine

. , ,

or unequal an d n on reactive ; or the react ion may

-

be slo w or the reaction at t imes m ay be di ff erent

,

in each eye A t an early stage of the disease

.

there is a diminution or loss o f the attent ion re
exes .

The age O f the pat ient at the time of the at A g , e

N sthe
tack is al so an import ant diagn ostic factor In

en t a
.

neurasthenia the maj orit y o f cases occur be fore

the fort ieth y ear w h ile the mean average of the
,
P a t i c re

av a e er
g
paretic i s fort y on e -

f ty
.

o o e r n

The mental state o f the tw o di seases di ff ers

w idely .Wh ile the neurasthen ic m ay complain
of a failing memory h is l apses are easil y cor ,

r ect ed and are sl ight compared w ith those Of the N u r a s th e e

nic
g oo d
paret ic w ho is ignorant of th is w eakness and P a r l i c
,
e
,

may deny its existence The numerous phobias m a k d ly . r e

i n:pa i ed r
and hypochondriacal anxiet ies O f the n eur asthen
i c do n ot appear in the paret ic w ho al w a y s claim s ,

that he is per fectl y w ell .

The changes I n the character and habit s usu C ha ra cter

a n d ha bi ts
ally marked i n the paretic do not occur in the
cha ng ed i n
neurasthenic The rst suspicion o f the ap
.

proach o f p a resis m ay ari se from the abrupt u n cha ng ed

change in the victim s moral s P re v iousl y hon then i a

est temperate and upright he suddenl y becomes

, , ,
 1 36 M E N T AL D I SE A SES

dishonest intemperate and dissolute NO such

, ,
.

lapses occur in the neurasthenic .

\V hi l e loss O f sexual po w er may occur in the

neurasthenic complete impotence appears in the
,

paret ic fol lo w ing the most intense sexual excite

ment .

I n tel l ig en ce
The intell igence of the neurasthenic i s rarel y
un di stu r bed
disturbed In the paret ic en feeblement o f i n tel l i
.

then i a gence is one of the earl iest symptoms and th e ,

en eef bl ed i n

P a r esi s
j ud gm ent is progressively w eakened as the di s
ease advances .

Voi ce a nd The voice and speech changes SO prominent i n

paresi s al so are lacking in neurasthenia \V hi l e
cha ng es qf
.

P a resi s the voice O f the neurasthenic may be lo w ered an d

the pronunciat ion slo w and uncertain he reveal s
N eu rasthe
,

nia none o f the characteristic j erkiness and thickness ,

w ith el i sions of syll abl es o f the paretic

,
T he .

t remulousness o f the l ips and tongue SO apparen t

in paresis al so is absent in neurasthenia .

D ier en ce The hand w riting al so di ff ers m arkedly T he

i n ha n d
.

wr i ti ng neurasthenic may omit w ords and syllables an d

make mistakes in the use o f w ords but he readil y ,

correct s his errors w h ich the paretic cannot d o

,

even i f h is attention is directed to them and he ,

usual ly denies the existence O f an y mistake .

em
p er a The rise o f temperature common in dement i a
tu re
paralytica does not occur in neurasthenia .

C on vul si on s
E pilepti form and apoplecti form attacks so ,

common in paresis do n ot appear in n eu r a s

,

thenia .
 N E U R A ST H E N I A 1 37

C EREB RAL SY P H I L I S T wo cl a sses

S I phi l i ti c
'

T wo classes o f syph il it ic patients are en coun t N eura sthc

nia
ered in w hich neurasthenic symptoms appear .

In the rst the w eakened nerve po w er is o w in g

Fi r st cl ass
directl y to the virus These pat ients are S leep
.

n er ve
less emotional incapable O f any continued mus
, , wea k ness
ow i ng to
cul a r exertion : the y su ff er w ith pa i ns in l i m bs
vi r u s
and back and w ith a cephalalgia w hich increases
in severity as the d ay advances becoming almost ,

unendurable at night and w hich is on l y rel ieved

,

b y ant is y phil itic reme d ies .

In the second class w e have simply n eur asthe

S econ d cl a ss
nia occurring in persons w ho have previously had
syph il i s In these pat ient s aside from the men
.
nia in per
,
son s w ho
tal impression cause d by the kno w ledge O f the ha ve pre
previous existence o f the disease and the e ff ect v i ou sly ha d

011 the general nut rit ion the s y ph il i s i s not t e

,

sponsible for the asthenic symptoms .

T A B ES D O R SAL I S
The only variety of neurasthenia w h ich could
be con founded w ith tables dorsal is i s the spinal T a bes
,
D orsa l i s
and thi s i s not l ikel y to occur \Vhi l e in spinal
.
usua l ly
neurasthenia pain s in the lo w er l imbs gastro ,

n i z ed by
intestinal crises di ffi culty in locomotio n w eak
. ,

d ieren ce
ness o f the legs loss o f vi ril ity and sper m ato r
,
i n phy si ca l
rhoea and even the R omberg symptom may oc
,

cu r, the absence O f oculo motor symptoms -

,
 1 38 M E N T AL DI SE A SES

at rophy o f the optic nerves diminution O f the ,

deep reexes and anesthetic patches on the sol es

of the feet and Skin Of the legs w ill clearl y reveal ,

the absence o f any cord lesion .

The other mental diseases w ith w h ich n euras

thenia is most frequently con founded are melan
chol i a hypochond ria and hysteria
, ,
.

M E LA N C H O L I A
D i sti n T he lack o f delusions and hallucinat ions an d
g u i she d
r om M el
its characterist ic Obsessions and phobias shoul d
f
readily distinguish it from melancholia .

H Y PO C H O N D R I A

I zy pochon
' I t may at times closely resemble hypochondri a ,

dr i a but the symptoms o f the hypochondriac are much

C ha ng ea bl e
more changeable and more minutely detail e d
heredi ta ry than are those O f the neurasthenic The hyp o .

ta i n t si gn s
,
cho n d r i ac has al so usually a histor y O f here d i
f
o deg en er
, ,

a ti on l ess .
tary taint and sho w s somatic signs O f degenera
pyh si ca l tion The h y pochondriac al so l acks the physica l
.

u ea k n ess

w eakness so characteri st ic o f neurasthenia .

H Y ST ER I A
H y ster i a
I the m inor forms o f hysteria the patient i s
II

m en tal bright an d active o ften gay and c heerful ha s

, ,

sta te ,
n one of the head s y mptoms and characteri st i c
P hy si ca l ly
strong er
paresthesias o f neurasthen ia sleeps and eat s ,
 N E U RA S TH E N I A 1 39

w ell ,
and i s physically v igorous The emot io n al
.
E m oti on a l
cr i ses ,
crises the globus and the clavus pains of hysteria a nd
, ,
q bus
also are absent in neurasthenia .
cl a v us pa i ns

C O U R SE A N D P R O G N O S I S
N eurasthen ia i s essent ially a chronic di sease .

W hile it may develop suddenly as the resul t of di sease

accidents or Shocks or after some acute in fectious
fever i t usual l y comes on gradually and l ast s
,

from on e to seven or eight y ears The course .

varies greatly in ind ividual cases The pat ient .

often improves for w eeks and then a remi ssion

occurs and th is for w ard and back w ard movement
may go on for month s C omplete restoration
.

often takes place but greater care o f the health

,

i s necessitated in the future than previous to the

attack O n account of the great attention
.

w hich neurasthenics are obl ige d to pav to thei r

health the y O ften l ive to Old age .

T R EA T M E N T
The ch ie f aim in the t reatment o f neurasthenia
ai m
m ust be the restorat ion o f the w eakened nerve
r estar a ti on

po w er E ach ca se m u st be st udied b y it sel f and

.

the t reatment adapted to its individual demands .

A ll sources o f reex irritation l ike eve strain

,
-
,

rectal t rouble or sexual irritants such as a tight

, ,

l y hooded cl itoris or constricted prepuce shoul d

-
,

be removed be fore a regular Sy stem o f t reatment

 1 40 M E N T AL D I SE A SES

is begun The habit s o f the pat i ent must be

.

investigation n ot only as regards masturbation ,

excesses in venery smoking stimulan t s an d the

, , ,

taking of narcot ics opium cocaine ether or any

, , , ,

drugs o f the coal tar series but as to t imes o f

-
,

meal s and the character and q uan ti tv o f food

taken .

M oral ,

H y g i en i c
From the nature o f the disease the t reatment

D i eta ry ,
shoul d be divided into moral h y gienic dieta ry , , ,

and medicinal .

M OR AL
N o part o f the treatment is more impor ta nt
M o ra 1 than the moral Ful l o f fears and doubt s o f
.

trea tm en t
f
o lzzjg/zest
ever y description o ften unable to decide the si m
,

zm
'

p or ta m e
p l est question the
,
pat ient needs the guiding co u n
sel of the physician in all the detail s of l i fe .

The physician must be ab l e to inspire absol u te

con dence in h i s ability to cure or all h is e ff o r ts
w ill be fruitless Ho w ever fool ish the fears an d
.

senseless the symptoms the pat ient must n d in ,

the physician a sympathetic l istener and w i se

counselor T o retai n the patient s con de n ce
.

and control her thought s and actions and st il l n ot

feed the disease i s often the physician s most d i f
,

cul t task ; but that task must be accompl ished i f

he expects to ach ieve success The physici an .

that i s lacking in sympathy or devoid o f posi t ive

moral rmness cannot succeed in neurasthenia .
 N E U RA ST H EN IA 14 1

O ften a patient i s more bene ted by positive as

surance that her case i s not hopeless an d tha t
r ecovery i s certain tha n by the drugs admi n

i ster ed .

H YG I EN I C
A ll the surroundings of the patient Shoul d be H y g i en i c
care fully considered The drai n age the ventila
.
,
trea tmen t

t ion o f bedrooms and the drinking w ater Should

,

be investigated Bath s regulated to the i d iosy n

.

c rasi es o f the individual case should be insisted

upon To some neurasthenics a cold sponge or a

.
,

needle o r plunge bath in the early morning i s ex ,

ceedingly bracing ; in others such bath s produc e

exhaust ion and luke w arm or hot bath s are r e
,

quired The w arm bath at night promotes sleep

.

in some cases w hile in others i t causes cardiac

,

throbbings and unpleasant sensat ions in the head ,

and di sturbs sleep A choice may n ot be able to

.

be made until a fter experimentation The e ff ect .

upon the w eight produced b y bathing must be

carefully noted .

The inuence of cl imate al so must be observed .

S n zl a al e
'

For some neurasthenics a h igh al titude fo r others ,

a residence by the sea i s most benecial M any

,
.

city residents derive great bene t from a removal

into the country w here they are freed from the
,

consta n t noise and din o f the st reet s and can

remain most of the time in the open ai r A long .
 1 42 M E N T AL D S I E A SE S

sea voyage has often been a great ai d in restor

ing the lost nerve force The daily rout in e .

shoul d be care full y l aid out so that every hour ,

has something of interest and service to the

patient Th is tends to increase the w eakened
.

w ill po w er and p revent the mind from d w ell ing

-

cont inually upon the b od i l v ailments .

D I ET ARY .

di et The diet o f the patient i s o f the h ighest impor

b
a n a sol u te tance The depleted nerve reserve and the gen
.

eral w eakened physical condit ion demand a sur

plus o f food The majority o f pat ients requir e
.

food in moderate q uant ities at short interval s ,

varying from tw o and a hal f to four hours O n .

account o f the fre q uent occurrence o f dyspeptic

disorders a care ful selection of f ood i s n ecessi
,

tated .

Foods re q ui ring l ittle digestion milk .

koumiss raw eggs or eggn ogs should a t rst
, ,

be admini stered Graduall y to th is diet m ay be

.
,

added moderate amounts o f fresh bee f lamb , .

ch icken turk ev sh bone marro w and fresh veg

, , , ,

etabl es excepting potatoes and graham and ,

w hole w heat bread

-
Fruits o f all kinds except
.
,

bananas and stra w berries m av be a l lo w ed L ib , .

era l q uant it ies o f pure w ater should be taken

bet w een meal s Tea and co ff ee sho ul d be pro
.

hi b i ted but chocol ate cocoa and broma mav be

, , .

a l l o w ed M al t ext ract s in doses o f tw o to fou r

.
,
 N EL RA ST I I E N I A
'

1 43

ounces aid in the digest ion of starch v foods and

,

help n utrition A gl ass o f hot w ater upon rst

.

a w aking in the morning and a hal f hour be fore -

meal s may prove helpful in promot ing secretion .

Hot mal ted milk hot broth o r cocoa taken j ust

, ,

be fore retiring may prove use ful in promoting

sleep but does not agree w ith the pat ient in al l
,

cases P ure olive oil in doses ranging from a tea

.
,

spoon ful to tw o tabl espoon ful s th ree t imes d ai l v ,

also may prove o f great service .

T H ERA P EU T I C M EA S U R ES
Rest i s o f the highest importance in al l cases .

In the severe types it i s o ften absolutely n eces m a ssag e ,

sary to remove the pat ient from home and the

un w ise sym pathv of friends and place her under ,

the care of a nurse w ho should have compl ete ,

control subj ect only to the orders o f the attend

,

ing phv si ci an I n these cases the W eir M itchell

.

t reatment in full o r in a modi ed form i s o f

, ,

the greatest value Thi s t reatm ent consists o f.

rest in bed complete isol ation forced feeding

, , ,

massage and elect ricity \ V hen massage is given

,
.
,

and i t shoul d be in all cases con ned in bed the ,

best t ime for the administ rat ion i s i n the even ing
a fter the patient has retired f o r the ni gh t S uch .

massage o ften proves a great aid in obtaining a

good night s sl eep The masseuse chosen shoul d

.

be on e w ho i s st rong and vigorous an d w h ose

 144 M EN T AL D I SEA SES

touch is agreeabl e to the patient The failure of .

massage t reatment i s often o w ing to the masse u se

and not the system S ome operators i rritate the .

patient and w hen th is occurs others shou l d b e

,

t ried unt i l one is found capable of accompl ish ing

,

the desi red resul t I f such a on e cannot be oh

.

tai n ed the massage should not be employed

, .

E lectricit y either faradism gal van ism or elec

, , ,

t ric bath s is a valuable adj uvant to massage in

,

many cases Its e ff ect s should be carefully

.

w atched and unless i t appears to be bene cial i t

,

should be discontinued .

A s the pat ient s st rength increases short

O ut doo r
,

ex er ci se w alks rides or drives should be advised or out

, ,

door sport s may be encouraged care al w ays being ,

taken that the strength is not overtaxed A fte r .

any outdoor exerci se the patient should l ie do w n

for a short tim e .

In mil d cases w here ent ire w ithdra w al from

P a rti a l st
re
business seem s impossible a rest f or a part of ,

the d av may enable the patient to regain h is for

mer vigor In all cases a short rest i f not more
.
,

than a hal f hour after luncheon is of grea t ,

bene t .

M ED I C A L T R EA T M E N T
Ca re N o class o f patients are more desi rous o f tak
n ece ssa ry to
ing d rugs than neurasthenics Fil led w ith h y po .

r even t
p
dr ug l za bi ts chon d r i acal miseries of every description they ,
 N EU RA ST H EN IA . 14 5

rush from one physician to another clamoring ,

for immediate relie f N ot content w ith the rem

.

edies regularly prescribed by competent medical

men they are prone to supplement these w ith
,

every quack nost rum w h ich they may see ad v er

t i sed . O n account o f th i s tendency great care
should be exerci sed lest they become addicted to
,

some drug habit w hich once establ i shed i t is , ,

almost impossibl e to c ure

'

In selecting the indicated rem ed v care ful ,

analysi s of the mental and physical symptoms i s

necessary \V hi l e any remedy in the materia
.

medica i f called f or by the total it y o f s y mptoms

, ,

should be presc ribed w e shall give the indications

,

f or on l v those most frequent l y demanded .

AC O N I T E
Thi s remedy is frequently use ful in combati n g 4 6 074
[ im
the numerous p hob i as of neurasthenia \ o dru g T
l zf eaa ous
has produced a greater v ar i etv of fears Fear .

o f death darkness noise music people or going

, , , , ,

upon the street s or into cro w ded assembl ies has

,

been experienced by numerous provers A .

f ear f r eq uen tl v dist ressing in neuras thenia o f

, ,

entering a trolley car or a rail road t rain w e have

-
,

m an v times removed by aconite A n i n d esc r i b .

able vague indenite anx iety as to some impend

ing disaster al so has often disappeared under the
in uence of th i s drug .

11
 1 46 M E N T AL I E A S ES
D S

A persistent trial of th is remedy w il l prove i t s

effi cacy w hen the disease presents the charac
te r i sti c symptom s j ust enumerated .

A C T A SA R A C E M O SA
Desire f o r sol itude fea r o f death o r o f b ecom
,
.

R a cem os a ing insane .

Great sensitiveness in the cervical vertebr ae ,

especial ly the low er P ain in the occiput run

'

r a [g i a a mi .
,

U ter i n e ning over the head into the eyes A dapted to .

su ff erers from neuralgia and uterine d istur b

a uces .

A g a ri cu s
A G AR I CU S
S en Si tte e
U se ful in cases excessively troubled b v shoot
ing and burning pains and sensitiveness o f th e
m n seula r spine t w itching of the muscles and paresthes i ae
, ,

t te/zi ng

o f di ff erent portions o f the skin

.

k i
'

sza of
'
n s

A N ACAR D I U M
A nxious and apprehensive o f future m i s f o r
A n a ca r tune desp air o f recovery fear o f paralysis an d
, ,

death ; fearful w hen w alking in the open air and

A nx ie
ty ,
i f anyone approaches ; imagines that he i s su r
f ea r .
f or

g tfe ul n ess rounded l) v enemies ; forget ful ness and general

the r e s ult failure o f memory w ith i n ab i l i tv to concentrate
of e x cess i ve
,

m en ta l the mind .

stra i n Dist ress in stomach rel ieved w hile cat i n o

'

w orse a fter w ard .

 N E U R A ST H E N IA 1 47

Th is remedy is frequently use ful in n eu rasthe

nia produced by excessive mental strain w ith ,

brain fag and compl icated by nervous dyspepsia .

AR G EN T U M NI l
' '

A pprehensive o f some serious illness ; fear o f A rg en tu m

Nit
dying w hen l e ft alone ; a fraid to w alk upon the .

streets lest he may fall do w n in a t or lest the

high buildi n gs mav fa l l do w n upon h im A fraid .
dy spepsi a ,

m uclz g as
o f going upon any high place lest he may th ro w Freq uen tly
himsel f do w n : apprehension w hen going into an y i n di ca ted

public ass embl y

.

O ften indicated in neurasthenia compl icated ,

by nervous d y spepsia characterized b y the for

,

mation o f volumes o f gas w h ich are expelled

,

w ith violence and accompanied b v vertigo .

A RSEN I C U M AL B U M
A rsen zeu m
'

Fear of being alone o f disease o f death o f

, , ,
A loum

committing m urder or suicide .

U se ful w hen there i s great physical exhaustion exh a sti o u n

attending the mental symptoms f req uen tl v com a tt di g

en n

m en ta l
plicated by serious gast ric di sturbance .
sy mptom s

A S A FCE T I D A

A pprehensive of dying i rritable ckl e hys

, , ,
A saf (e ti da
ter i cal
. Great collect ion of atu s that accu A
'
aa ptea to

m ul ates in the abdomen and presses up against

n er v u o s
the lungs p roducing oppression o f breathing
,
.
dy spepti cs
 1 48 M EN T AL D S I E A SE S

A dapted to hysterical neurasthenics subj ect to

severe attacks o f nervous dyspepsia .

B AR YT A CAR B O N I CA
B a ry ta
A nxious and sol icitous about the future ;
E speci al ly
averse to st rangers and company ; a fraid to w al k
wea k upon the st reets ; dread o f men ; startled by the
m i n d ea

least noi se ; i rresolute unable to m ake a deci sion :

ss
ca e
,

memory defective .

B ELLA D O N NA
O ccasional l y indicated w hen sign s o f cerebral
congest ion are prominent attended by hy per sen
,

si ti v en e ss o f the senses and sleeplessness .

B U FO
A version to st rangers anxious ; easi l y frigh t
,

s lti ng
re u ened ; longs for solitude yet fears to be alone
,

fear of disease animal s and death

on
.
, ,
tu r ba ti
or sex ua l
U se ful when the di sease has been caused by
di s as
e e masturbation or disease o f the sexual organs .

CALCAR EA CAR B O N I CA
Calea r ea V ery m el an chol v and depressed : great an x i etv
and palpitat ion : fear ful and apprehensive o f
Usu al ! I '

some impending disaster fear o f faint ing in th e

,

f ro m i ts st reet w h ich prevent s her going out of door s :

con s ti l u
fear o f being a l one o f death insanity o r som e
, ,
hb n a l
sy mpto m s organic disease ; startled b y the least noi se ;
 \I E U R A S T H EN I A 1 49

fright ful dreams a w akening w ith a start w it h

,

great palpitation o f the heart and inability to

free hersel f from the impression o f the dream .

Great fear and anx iety at night . .

M ental symptoms are usual ly associated w ith

the characteristic constitut ional symptoms .

G EL SE M I U M
Gelsemium is one of our mainstays in the treat .

G else m i u m
ment o f neurasthenia The gel semium patient i s
. Du ll stu,

dull stupid sl eepy unable to concent rate the pi d ,

s lee
py ,
, , ,
ver tig o ,

mind i s subj ect to attacks o f vertigo and unabl e

,
pa i n base

to make any decision There i s a continuous dull

.

Fr eq uen tly
ache at the base o f the brain Ent irely l ackin g .

i n d i ea ted
in sel f con d en ce the patient is unable to sing or
-
,
R eli a le b
speak in publ ic although he may have been ac
,

customed to d o so al l h is l i fe A ny sudden em o .

t ion of joy or sorro w w ill bring on a diarrh oea or

an attack of indigestion .

No other remedy is more f req uen tl v indicated

o r more often curat ive .

I G N AT I A
Fear o f some impending mis fortune o f , I gn a ti a
r on i e
thieves of disease o f things coming near
, , ,

startled by the least noise .

Help ful to neurasthenics w ho are by nature

c hronic w orriers or have su ff ered some great

g rief .
 1 50 M E N T AL I
D SE A SES

K AL I CAR B O N I C A
Fear of going into a cro w d of being alone o f , ,

disease o f dying ; intolerance o f human voice

,

easily frightened ; start s w hen touched ; depres s

ed tear ful anxious irritable fret ful
, , , ,
.

K AL I P H O SP H O RI C U M

K al i plzos . A nx iety and causeless nervous dread despond ,

P w' i a m ency regarding bus i ness and pecuniary matter s ;

disincl inat ion to converse or meet people ; look s
m en ta l on the dark side of everyth ing ; dread and ove r
ow n w 'k
sen si tiveness to noise ; undecided an d changeabl e ;
e ff ect s of fright or grie f ; fea r S leeplessnes s ,

restlessness and suspicious fret ful il l tempere d ;

, ,
-

night terrors ; brain fag from over w ork w ith lo s s

o f m em orv ; nervous easi l v startled
,
.

U se ful i n neurasthenia from excessive men tal

labor .

Li li u m LI LI U M T I GRI N U M
ti g r i n u m
N eu
r
as Fear o f some incurable in ternal disease o f b e ,

by
coming insane ; aversion to being alone ; hurrie d
acu te feel ing o f imperative dut i es and m ab rhtv to pe r
"f m m ml
'

form them
o a a
.

v ri n

d so d s
i r er C urat i ve l n neurasthen i a accom pam ed b v
acute uter i ne and ovar i an d i sorders .
 NE U RA ST H EN I A 15 1

LYC O P O D I U M
Dread o f men o f solitude ; fear fu l w hen w alk
,

d i um
ing in open air easily frightened by least noise
, ,
N cu ra s the
indecision . nia wi t h
i n te ti n l
s a
U sually associated w ith characterist ic sy m p
dg s o
i n i e ti n
toms o f d igestive organs .

M O SC H U S
Fear of dea th talks only of dying i rritabl e
, , ,
M osch us
cross scolding ; su ff ocative attacks from closure
,

of the glott is or cramp o f the chest Hysterical .

hy st er i ca l
n e ur a sthe
attacks w ith blueness of the face and foaming at
the mouth C oldness and t remulousness o f the
.

body w ith fainting spel ls and c0pi ous urination

, .

V ertigo P alpitation of the heart

. .

Indicated in neurasthenics subj ect to severe

hysterical attacks and prone to fainting upon the
sl ightest provocation .

P H O SP H O RU S
A nxious restless i rritable startled by the
, , ,
h
P osp ho sru

M uch
sl ightest noise Fear ful o f death o f the future
.
, , o
n er v us

o f being alone aggravated in the evening or dur

,
exh a u s ti on

ing a thunderstorm .

P I CR I C AC I D Pi cr i c a ci d
I n ten se
m en ta l a n d
Great sense o f mental and physical exhaustion .

h s i a l
py c
S exual excitement .
ex ha u sti o n
 M E N T AL D I SE A SES

P U LSA T I LLA
Pulsa ti ll a
N eu r a sthe Fear of ghos ts m en the dark d eath becomin g
, , , ,

f
n i cs o the
in sane going into a cro w d Depressed an d
, .

i n: w e. lach rymos e .

su bj ect to A dapted to neurasthenics of a mild disposition .

u ter i n e
w ith dyspept ic symptoms uterine disea se and , .

su ff erers from l eucorrhea .

R H U S TO X I C O DEN D R O N
R hus tox Great apprehension at night cannot remain i n ,

h
R eum a ti c bed ; fear o f death of i m pending di saster o f
, ,

going into a cro w d : anxiety w orse in the house ,

better in the open ai r ; great restlessness rel ieve d

by motion .

E special ly benecial w here there exists a rheu

mat ic diathesis .

S EPIA
Fear o f being alone o f persons w he n drivin g
, ,

i n the open air ; of starvation ; as to the outcom e

of the disease S ensitive to the least noise
. .

N eurasthenia caused by some ch ronic dehil i

tating uterine disease .

S P I GEL I A
A nxious sol icitous about the future
,
. A frai d
Fu n cti o n a l o f pointed things as pins or needles
, .
 N EU RA ST H EN I A 1 53

U sually associated w ith functional or organic or o gar n ic

disease o f the heart .

di s as e e

S PO N G I A
Fea r o f death o f some impending disaster,
.

S tarts at every noise ; a w akens w ith fear and

terror .

S T RA M O N I U M
Fear o f dark being alone fal l ing w ater
, ,
.

n i um
Th is remedy plays a minor part in n eu rasthe Sel d o m
nia but at times i s use ful i n removing fears
, .
r eq u i r e d
ZI N CU M M ET A LLI C U M

Bene cial i n cases t roubled w ith dull ach ing i n -

Zi n cu m
last dorsal or rst l umbar vertebrae w i t h e x cess
n
ive sensitiveness to touch P ains are aggra .
sen si ti ve

v ated by sit ting rel ieved by w al king

do sa l
.
,

and
Dr E d w ard Fo rn i as o f P h iladelphia P a
.
, ,
.
,
l m ba
u
r

present s in the Hahnemannian M onth l y S ep t , , ver tebr a

1 908 (pages 6 6 6 to an excel lent article

on Traumatic N eurasthenia The remedies
w h ich he recommends and their indications are
as follo w s :

For the indecision w e can study w i th prot
the follo w in g remedies : P ul s Ignat L aches .
,
.
, ,
I n d i si o
ec n

N ux v P etrol A lum A rsenic B ar v ta c

.
,
.
,
.
, , .
,

C alc c N at mur C ham C hina C uprum Fer

. .
, . .
, .
, .
,
 1 54 M E N T AL D I SEA SES

rum H el l eb J
,
od i um Kali c M ag mur M eze r .
, , .
,
. .
, .
,

S ulphur R hus tox Tarax , .

,
.

span d
e For the despondency w e have to look into th e
0
pathogenesi s of A conite A urum P ul sat P al c , ,
.
, . .
,

Ignat ia L ache s S ulphur V era t and V aler ; or

, , ,
.
,

of S il ica S epia Rhus tox P latina A rsenic

, , .
, , ,

A r n ica Gel s N ux v N at mur N at carb

, , .
,
. .
,
. .
,

H y o sc Graph Ly cop Helle h and R uta and

.
, , .
, .
,
.

S taph .

For the apathy and indi ff erence : A rnica ,

H y o sc P hos ac S t ram Ign at B ar y t c

.
, . .
,
.
,
.
,
. .
,

B el l ad C alc c S epia S ilica A rsenic C hina

.
, . .
, , , , ,

H el l eb O pium S taph
.
, ,
.

For phobias (morbi d fears ) A conite A rnica . ,

07 5
A rsenic A ctea Bell C alc c O pium P ul sat
, , .
,
. .
, , .
,

Baryt c L aches C hina P ho sp P latina S epi a

. .
, , , .
, , ,

G el sem S tram S ulphur Fear o f death : A con

.
,
.
,
.

ite A rsenic P latina G el sem A pis B el l ad

, , , .
, ,
.
,

C a n n ind H ell eb L aches

. C o ff ea
.
, .
, , ,

P ho sph H vo sc A ctea r N it aci d Hepar Ipec

.
,
.
, .
,
.
. , .
,

Rhus tox O f publ ic places : A rnica A conit e

.
,
.

O f a cro w d or o f crossing busy st reets : A coni te ,

A rnica A urum P ul sat N at mur A rsen ic

, ,
.
,
. .
,
.

O f being touched or struck by passing person s :

A rnica O f accidents and mi s fortune : A conit e
.
,

A rnica C alc c C y cl a G l on o Graph S ulph

, . .
,
.
, .
, , .
,

Ferrum M ag c O f loss o f reason : C alc c

,
. . . .
,

C ann Ind A conite A lum L il ium P latina an d

. .
, , , ,

Tarantul a hi sp O f closed places : A rse n i c .

'

C arbo v S ulphur H y d roc ac P ul sat

. .
, , . .
,
.
 N E U R A ST H E N I A 155

For xed ideas (obsessions ) A urum Ignat , .
,
O bs ssi o s
e n

B ell ad A nacard Hyos C icuta L ache s C u

.
,
.
,
.
, , ,

prum S tram S il ica P ul sat Thuj a V erat

,
.
, ,
.
, ,
.
,

C ann Ind S ulphur A conite For hy pochon d r i

. .
, , .

ac ideas : C alc c Ign at N ux v L ache s N at . .

,
.
,
.
, ,
.

mur S ulphur P ul sat A conite A rsenic A urum

.
, ,
.
, , ,

B el l ad B ryo n A nacard
.
,
C hamo C h ina , .
,
.
, ,

P hosph C a n st M osch P l atum P hos ac

.
,
.
,
.
,
.
,
. .
,

Rhus tox S epia S taph Tinc .

, ,
.
,
.

Fo r emotional displ ays : Bell H y osc S t ram .
,
.
,
.
,

E m oti o n a l
P ul sat C o ff ea A urum C alc c I gnat L ache s
.
, , ,
. .
,
.
, ,

N ux v B ryo n O pium P latina V aler V erat

.
, , , ,
.
,
.
,

A lb A ugu st C oni M osch P hosph S ulphur

.
, ,
.
,
.
,
.
, ,

A nacard S epia S il ica V iola G el sem S enega .

, , , ,
.
,
.

O f the lach rymose type : P ul s N at m S ulphur .

,
. .
, ,

Ignatia A u rum Ly cop S epia C alc c P lat i n

, ,
.
, ,
. .
,
.

P hosph \ V ith irritabil ity and impat ience :

.

C ham B ryo n Hepar Gels P ul s Kal i c

.
, ,
.
,
.
,
.
,
. .
.

Ly cop S epia N ux v . H y o sc
,
C occs A ctea ,
.
,
.
,
.
,

S enecio C y pr ed S il ica P ho sph S ulph N at

,
.
, ,
.
,
.
, .

mur N it ac W ith variable mood : Ignat

.
,
. .
'

.
,

Pul s C rocus P latina A conite B el l ad A urum

.
, , , ,
.
, ,

S epia M osch V aler S tra m A lumen etc

,
.
,
.
, .
, ,
.

A s stated above the pathological concept o f .

ne u rasthenia is summed in the idea o f pathol og P a thol og 2

'

ical fatigue an d all the psychic phenomena that , f

ca 1 a ti gu e

enter into the cl inical picture o f the disease are

the direct conse q uence o f the sense o f w eariness ,

part ial or general and o f incapacity in con j unc , ,

 1 56 M E N T A L D I SE A S E S

tion w ith the psych ic orientat ion o f each m an ,

and h i s intellectual and e m otive conten t ; or i n ,

other w ords the individual factor This sen se ,

.

o f w eariness seems to have no l imit and yet l et , ,

us repeat i t may be attended by inte rm itten t d i s

,

plays o f emotional activi ty .

Wea r i n ess
For the sense o f w eariness w e m ust consult
such remedies as G el sem C occul P ho s ac .
,
.
, . .
,

A rsenic A rnica P icric acid N ux v C h ina

, , ,
.
, .

C arb veg P hosph R h us tox S taph V erat

. .
,
.
,
.
,
.
,
.
,

S ulph Ipec Ly cop A mm c C austic L ache s

.
, .
,
.
, . .
,
.
, ,

C alc c A fter exertion : A nacard C occul

. . .
,
.
,

S epia A rnica G el sem A fter mental e x ertion :

, ,
.

P i cr i c acid G el sem Ignat C al c c Nux v , .

, .
,
. .
,
.
,

S epia Ly c0p A nacard Laches N at mur S il i

,
.
, .
, ,
. .
,

ca S taph etc
,
.
, .

Fa tig ue
But the fatigue o f neurasthenia i s al so o f
f
o m e nta l
mental origin The mental w eakness is sho w n .

by various kinds o f indecisions but ch iey b v th e ,

impossibil ity to x the attent ion on anyth ing or , ,

better by the inabil ity to attend to anyth ing r e

,

quiring thought ; in fact every mental e x er tio n ,

causes a sense of helplessness sad to contemplat e

and the loss of memory seems to go pari passu
w ith the mental lan guor .

M en ta l
For the mental debil ity w e may su ggest th e
d bi li ty
e
study o f P icric acid G el sem A urum L a che s , .
, , ,

C alc c N ux v Rhus tox H y osc Staph i s

. .
,
.
, .
, .
, .
,

C arbo v C h ina S ulphur N at mur P ul sat S i l

. .
, , , . .
, .
,
 N EU RA ST H EN IA 1 57

ica ,
M S tram V erat A nacard B el lad
er e ,
.
,
.
,
.
,
.
,

Ly cop O pium S epia and P hosph ac C ompl i

.
, , ,
. .

cated w i th injury o f the head : A rnica C icuta , ,

Rhus tox M ercur and Staphi s For the loss

.
, .
,
.

of memory : A nacard A urum A rnica H yper ic .

, , ,
.
,

A lum Bovis .
,
H y osc L ache s N at .
, .
, ,
.

mur Nux m O pium Staphi s S ulph B el l ad

.
,
.
, , .
,
.
,
.
,

B ryon C y cl a Ign at ia H el l eb Ly c0p P et rol

.
,
.
, , .
,
.
, ,

Rhus tox S epia S il ica S t ram V erat V iola

.
, , ,
.
,
.
,
.

The alteration o f nerve function most impor -
I n som n i a
tant in th i s malady is insomnia the resul t almost ,

al w ays of an i rritable and badly nourished bra i n -

,

and sometimes the prod uct o f a xed idea but ,

occasional ly is due to restlessness pain or an , ,

ti cipati on o f evil arising from causes relating to

nances inabil ity to w ork loss of posit ion prog
, , ,

nosis of the case etc ; and more frequently it i s , .

, ,

of purely functional origin occurring par ti cu ,

l arl y in the nervous and impressionable w ho d o ,

not cease to w orry or fret about the accident

w hich brought on his morbid condition or any
establ ished l itigation or la w suit Hamilton .
,

among others bel ieves that i t i s seldom the resul t ,

o f pain for as a rule the headache and other

, , ,

sensory di sturbances are relieved by the supine

position and rest ; that much of the w ake fulness
of the neurasthenics arises from their failure ,

either th rough inability or fatigue to take the ,

necessary exerci se and as a consequence there i s ,

 1 58 M E N T AL D S I E A SE S

m ore or less toxemia due to retained w ast e ,

material w hich is not excreted ; and nally tha t

, , ,

there i s ample reason to bel ieve and many case s ,

support such a concl usion that a gre at deal o f ,

the insomnia o f neurasthenic subj ects originate s

in and i s fostered by an obst inate and cont inue d
, ,

bel ie f that sleep is impossible .

The remedies w hich in connect ion w ith th i s ,

em edi s
e
symptom have sho w n their inuence on th is
,

r malady are the follo w ing : A conite C o ff ea B el , ,

som n i a
lad G el sem N ux v P ul s H y osc I gna t
.
, .
, .
,
.
,
.
,
.
,

C ham R hus C oni O pium M osch S ulph

.
, , .
, ,
.
,
.
,

C hina P hosph C ina J

,
od i um S ecale C austi c .
, , , , ,

A ctea S leep prevented by nervousness call s fo r

.

N ux v C hina C o ff ea S epia M osch Ly cop

.
, , , ,
.
,
.
,

C alc c Graph L ache s Hepar S ulphur a n d

. .
,
.
, , , ,

Teucrium W h en prevented by backache t h i nk

.
,

o f : A mm mur P ul sat Gel s Kal i c etc

. .
,
.
,
.
,
.
,
.

A neurasthenic sensorial disturbance of f r o
quent occurrence i s vert igo w hich may b e found ,

associated w ith tinnitus asthenopia b ut chie y , ,

w ith headache and agoraphobia A sudden .

variation in the blood supply or slo w ness on the

part o f the vascular w all s to adapt themselves to
sudden al teration o f a motor character may ex
plain i ts presence : or perhaps it mav be due to
some inter ference w ith the centr i petal impress
ions from the eye ear muscles or skin w h ich , , , ,

regulate the action o f the equil ibrat ing centr e s

.
 N E U R A ST H E N IA 1 59

In neurasthenia th is svm ptom becomes disagree

able and causes a great deal o f alarm The pa

tient may be un stead v or go do w n and up stai r s

w ith dif culty but not in the w av famil iar in
,

tabes and some other spinal disease I t i s o fte n .

attended by tachyca rdia and rel ieved w hen the

patient l ies do w n .

The remedies to combat th is dist ressing
symptom are : A conite A rnica B el l ad C alc c , , . , . .
,

C hina C oni G el sem Hepar L ache s c op

, .
, .
, , ,
.
,

N ux v B ryon P hosph P ul sat R hus tox S an

.
, .
,
.
, .
, .
,

g ui n S il
, ica S ulph I Ethu sa A mbra
, A mm c .
, , , . .
,

Bar y ta C aust C occul H el l eb Ignat N at m

, .
, .
, .
, .
, . .
,

N i t ac and M erc
. .
, .

I shal l pass over the disorders o f the nerves .

of special senses the circul ator y disturbances the , ,

paresthe sias the visceral disorders w hich are

, ,

secondar y in thi s a ff ection and close th i s sum ,

marv w ith tw o of the most important s y mptoms

of neurasthenia namely headache an d backache , ,
.

The headache is o ften parox v sm al and chi e v H a dache e

pressing as from a helmet (casque n eurasthe

nique de C harcot ) o f variabl e intensity I t may ,
.

be frontal bitemporal occipital and even un i l at

, , ,

eral l ike migraine and the occipital causes more

. ,

su ff ering than the frontal I t mav al so be com .

pressive darting and hammerin g w ith fear o f

, , ,

death I t is w orse b v mental labor and emotion

. ,

and rel ieved b v rest and the supine posit ion .

 160 M E N TAL DI S E A SE S

S omet imes it is attended by congestive con j un c

t iva and tenderness o f the scalp and instead o f ,

headache there is occasionally a feel ing of emp

ti n ess in the head .

T o rel ieve these headaches H oni tnopathv ,

counts man y valuable remedies as fol low s : ,

For helmet like pressure w e can study : L auro -

.
,

M ezer Rhodo S ulph Teucri C y cl am J

.
,
od i um .
,
.
, .
, , ,

N it ac S tann S arsa G l on o Headaches o f a

. .
,
.
, .
, .

pressing character have al so been cured by S il ica ,

C h ina N at mur A nacard Spigel A sarum

,
. .
,
.
,
.
, ,

Ba ryt c C alc c Bovista and L aches For

. .
,
. .
, , .

darting pains con sult : A mbra A rnica A na , ,

card B el l ad C alc c I gnat C hi n a N it ac

.
, .
,
. .
, .
, ,
. .
,

P ul sat S epia S il ica A conit and S ulph

.
,
For , , .
,
.

hammering pains : Ferrum A mbra C alc c , , . .

,

B el l ad I g nat L aches L edum N at mur

.
,
.
, .
, .
,
. .
,

P hosph P ul sat S epia S tram G l on o S ulph

.
,
.
, , .
,
.
, .

M oreover f or frontal headache : A conit A r .
,

a d a ehe
nica A rsenic B ell ad B ryon C hina Ignat
, , .
,
.
, ,
.
,

Ly cop P ho sph S ulph A lumen C alc c C oc

.
, .
, .
, , . .
,

cul Ipecac K r eos N at mur N it ac Nux m

.
, .
,
.
,
. .
,
. .
, .
,

N ux v P etrol P l atina S abad

.
, , , .

For occipital headache : N it ac C alc c . .
, . .
,

a d a che
S epia Ignat C arbo v Kal i c S ulph M osch
,
.
, . .
, . .
,
.
, .
,

M ur ac P et rol M ag m G el sem
. .
, , . .
, .

For unil ateral headache : P ul sat N ux v .
,
.
,

n i l a ter al

a d a che
S anguin C ol oc S epia C hina Ignat A rsenic
.
, .
, , , .
, ,

C alc c C occul Ly cop Ipecac B ryon C hamo

. .
,
.
,
.
, .
,
.
, .
,

C o ff ea A sarum ,
.
 E U RA ST H EN I A 16 1

I f instead of headache there is a feeling of E mpti n ess
emptiness i n the head study : P ul sat C occul ,
.
, .
,
h d
i n the ea

S epia Ignat O pium and O xal ic ac

,
.
, .

The backache of neurasthenia is distressing Lum ba r

and irregular in situat ion but usually is se ated in ,

sacr a l pa i n
the lumbar sacral region The pain is o f a burn-
.

ing character and is felt along the spine ; or is

deep seated w ith or w ithou t super cial hy peres
-
,

thesi a w orse on touch or from pressure

,
I f the .

p ain radiates i t is o ften accompanied w ith numb

ness and t ingl ing i n the extremities and may ,

leave the coccyx tender The pain i s pecul iar .

when the spinal column i s bent for w ard or back

w ard S ometimes i t i s so inten se that it con
.

tin nes w hen the patient is at rest The cutane .

ous hyperesthesia prod uces great discom fort by

contact o f the ordi n ary clothing M uscular .

soreness general and locali zed is often asso

, ,

ci ated w ith the pain .

Dr Farrin gton in his excellent paper on
.
,

r i ng ton s

N eurasthenia publ ished in the H ahnemann i an ,

M onthly of February 1 88 3 gives the follo w ing

, , ,

remedies from w h ich I have al w ays made my

,

selection for cases of spinal trouble : N ux v .

,

P hosph S ele n Helon Graph N at m P ic

.
,
.
,
.
, ,
. .
,

ric ac P ul sat S epia D i osc Zinc S ul ph

.
, .
, ,
.
,
.
,
.
,

I E scul A rg n it A rse n ic A lumi n C occul Gel

,
. .
, , ,
.
,

sem Ch ina C hinin ars I pom eee W hen the

.
, ,
. .
,
.

l umbar spine remain s sensitive he recommends :

12
 16 2 M EN T AL D SE I A SES

P hosph A garic B ryon Ly cop P ul sat S epia

.
,
.
, .
,
.
,
.
, ,

A r senic and A lu m in \ V hen there are trans

, .

verse st itches : S ulphur \ V ith cutting th rough .

the back : N at mur C utt ing do w n the legs : . .

Z inc \ V hen pains go aroun d : P ul sat S epia

. .
, ,

Berbe r \ V hen the pains go do w n to thigh s :

.

S epia \ V hen the pain extend s into the h ips :

.

G el sem B rui sed sensation i s common to n ear l v

.

al l
. Tension i s marked i n Zinc N ux v S ulph .
,
.
,
.
,

N at mur and V alerian

. .
, .

O ther authorities give for backache in gen ,

eral : S epia P uls C alc c P icric ac S ulphur ,

.
,
. .
, .
, .

L aches S il ica N at m K r eos Ly cop Kali c

.
, , . .
,
.
,
.
,
. . .

M ag c Bovis A rnica Zinc P lat ina N ux

. .
, .
, ,
.
, ,

N ux v S ulph ac S t ram M ur ac M erc

.
,
. .
,
.
, . .
,
.
,

A mm c Baryta P hosph V erat and A sarum

. .
, , .
, . .

u I n i ng Fo r burning pains w h ich are almost charac ,

ai n s ter i st i c I have used w ith success S ulphur an d

, , ,

N it ac others recommend C arbo ani and w he n

. . . .
,

located i n the l umbar region N it ac and B ar vta , . . .

\V hen the pains are deep seated digging som e -

, ,

have found S epia A conite and D ul cam v er v use , ,

.

ful remedies .
 C H A P T ER V I I

I NT O X I C A T I O N P S YC H O S ES

A L C O H O LI C I N S A N I T I E S

A C U TE A ND C H RO N I C A LC O I I O LI C I N S AN I T I ES

N umerous and varied are the e ff ect s produced

upon the brain and nervous system bv alcohol ic
stimul ants and the ethers w hich the y contain .

We may have alcohol ic del i ria mama melan , ,

chol i a , counter feiting paranoia epileptic and , ,

stuporous states morbid impul siveness and pro

, ,

g re s s i v e dementias W hatever
. the form of the
disease w e n d in all alcohol ic insanities a char
,

acte r i sti c w eakening o f the mind and marked

intel lectual and eth ical deterioration N or are .

the brain and nervous system the sole su ff erers : ti on

A ten ta 1
the arterial sv stem the kidneys l iver Stomach
, , , ,
[ 5thi ca l
and pancreas reveal the destructive in fl uence of
the constant inh ibit ion o f alcohol ic poison N o r .

are the ravages o f this dread d estro ve r l imited

to the alcohol ic himsel f : his ch il d ren a re often
stunted ph y sical ly and mentall y and numbers o f ,

imbeciles epilept ic s and dea f mutes can t race

, ,

their hopeless con d ition to a drunke n parenta ge .

While found at all a ge s ch ronic alcohol i sm i s

'

,
 1 64 M E N T AL I
D SE A SE S

most prevalent bet w een t w enty v e and forty -

ve vear s o f age \V hatev er the age the sy m p

.

toms are practically the sa m e .

G EN ERAL S Y M P T O M S O F ALC O H O L I S M
I n all forms o f acute alcohol ic insan ity illu ,

sions and hallucinations of the special senses are

predominant symptoms They are al so promi .

nent factors in certain o f the ch ronic forms o f

n al alcohol ism The most prevalent hallucinations
.

71 5
are visual the next i n importance being aural
, ,

and not in fre q uentl y a combination of the two

is present These hal lucinations v a rv from
.

sparks ying be fore the eves to complex com

b i n a ti on s o f animal s or groups o f spirits robbers ,

and ghosts al w a y s moving about the compart

ment D el usron s based upon perverted sens e
.

perceptions al so may arise causing the sen sation ,

o f burning cra w ling t ingl ing or numbn ess o f

, , ,

the skin or o f electric shocks in di ff erent parts o f

,

'
nu cuh
m
y the bo d y The perverte d mind o f the alcohol ic
.
,

l usi on s
out o f these abn o rmal sensat ion s c onst ructs v a ,

r i e ti e s o f delusion s of persecut ion by w itchcra ft

an d pl o ts o f enemies to d e st r o v his h a ppiness to ,

take aw av hi s min d hi s m an h o od o r h i s l i fe
, , .

P e rv e rt e d sen sat i o n s in the genital ia stomach , ,

l iver o r lun gs fre q uentl y f o rm the basis O f

,

d elu si on s us u all y pe r secu to r v in f orm

, .

H allucinati o n s o f smel l and ta ste more f re

 I N T o x I C A T I O N P S YC I I O SES 16 5

q u en t l v occur in thi s than i n other forms of i n Ha lluci n a

ti o n s ; s m ell
sanity The pat ients complain tha t chloroform
.

taste
,

is blo w n into the room l th mixed w ith thei r,

food and poison put into thei r drinking w ater

,
.

C ont inually harassed and annoyed by these

p e rsec u to r v delusions the alcohol
, ic frequently
becomes the most dangerous O f pat ients often , Da ng ero u s
frant ically a ttacking those about h im as the au
thors o f al l h is su ff erings and t roubl es .

N umerous sense perversions may occur in Sen se

chronic alcohol ism in the for m o f anesthesia per ver si on s
,

and analgesia O f large areas o f the skin at t imes ,

diminish ing the sensation O f the entire body .

O ne o f the most prevalent symp toms is a mus / uscul a r

cul ar t remor that involves the smal l m u scles o f trem r o
the hands Th i s i s most ap parent in the morn
.

ing o ften di sappearing as the day advances

,
.

M uscular t w itchings spasmodic contract ions

,

and cramps al so are o ften experienced .

The k n eej erk s and other deep reexes are usu

al l v moderately exaggerated in delirium t remen s

and ch ronic alcohol i sm unless the cases are of

,

unusual sever i tv and attended by col lapse w hen ,

the exaggeration m ay be marked L oss o f knee .

j erks i s encountered on l v w hen organic lesion s o f

the posterior root ner v es has taken place .

C L I N I CAL A S P EC T S O F ALC O H O L I S M

( )
1 O r d i n ar v drunkenness .
 1 66 M E N T A L D I SE A SE S

2
( ) A cute alcohol ic i n san i tv (del irium tre
mens ) .

3 ) C h ronic alcohol ic insanity .

A LC O H O L I C P SY C H O SI S
a
( ) M elanchol ia .

(b ) M an ia .

c
( ) A lcohol ic paranoia .

(d ) Kor sakow s psychosis

.

(e ) A lcohol ic pseudo paresis -

.

f
( ) A lcohol ic progressive dementia .

g
( ) A lcohol ic epileptic i n san i tv .

W h ile ordinary drunkenness cannot be ranked

among the in sanities it nevertheless produces
,

certain mental symptoms w hich de m and a brie f

consideration in th is connection .

C ertain nervous symptoms appear in all hard

drinkers either as the result of alcohol ic i n d ul
,

gence or as an inheritance .

A n over w eening egotist regardless of the ,

right s o f others unreasonabl y irritable and prone

,

to violen t outburst s Of bl ind impul si v e passion

rendering h im a terror to w i fe and children en ,

t i r el y regardless o f the feel ings and su ff erings o f

hi s f amily or friends indi ff erent to the opinions

,

4 o mpo i te
c s o f others , the drunkard i s a composite o f the
of th w
e o st r
w orst hum an tra i t s He l ives w ith but one oh
hu ma
.

tr i ts
a
j cet i n v ie w the grati cat ion of hi s in sat iable
,

d esi re for d rink Lo ss of fortune position cast

.
, , ,
 I N TO X I CA T I O N
I

P S YC I I O S ES 16\

a starving family may stare him in the f ace : he

,

cares not S ati sf y his thi rst an d he i s content

. .

A s time passes and the desire becomes more

and more dominant all w ill po w er is lost the . ,

intellectual and ethical facul t ies are w eakened ,

logical thought an d mental concent ration become

impossible the brutal passion s alone remain an d
, ,

he sinks into a state o f hopeless dementia .

O ften posses sed b y an unreasoni n g j ealousy of

his w i fe a xed del u s i on of mari tal i n d el i tv i s
,

d eveloped causing co n t inuous st ri fe in hi s h o me

,

which f r eq uen tl v terminates in the homicide o f

w i fe an d f am i l v .

The ma j or i ty Of d run k ards fortunatel y m eet , ,

an early death th rou gh arteriosclerosi s pneumo ,

nia ci rrhosis o f the l iver or inammation of the

, ,

gast ro intestinal t ract w ith coll iquative diar

-
,

r hte a .

The on l v t reatme nt for the drunkar d is to place

him permanentl y in an i n stitut i o n w here no i n ,

toxicant s can be obtained .

ALC O H O L I C I N S AN I T Y
A C I
'

TE

C L I N I C AL FO R M ( DELI R I I M T R E M E '

I
'

S )
Del i ri um t remens i s by far the mo st common , , . lI ost

form o f alcoh o l ic insanity occur ri n g at some co m m on

,

f o r m
time in the maj orit y o f habitu al drunk a rds The .

appearance of the disease depends more upon the

am ount o f l i q uor taken than up on l o n g c o ntin ue d -
 1 68 M E N T AL DI S E
A S ES

indulgence \V hi l e some person s accustomed to

.
,

daily drinking may for y ears escape others in

, ,

w hom the vice i s o f short durat ion m ay beco m e

vict ims T he greatest d anger l ies in the tak
.

ing o f la rge quantities w ithin a shor t perio d ,

w ithout sui c i en t t ime being allo w ed f or its elim

i n at i o n The same result mav follo w the sudden
.

w ithdra w al o f the accustomed drink M ost o f .

the suff erers from del irium t remens have su f

f er ed previously from gastric cata rrh w ith morn
i n g nausea creat ing a di sincl ination for food and
,

prevent ing assimilation O ften f or davs or .

,
.

w eeks the ph y sical stren gth is almost entirel y

,

sustained by stimulants until collapse occurs and

the t y pical mental symptom s appear .

S uccee d ing the long continued use of alcohol

-
,

or the taking of l a r ge q uant ities w ithi n a short

period certain premonitor y svm ptom s appear
, .

Great i r r i tabi l i tv restlessn ess disturbed sleep

, , ,

apprehension caused by the presence O f sudden

optic or aur al illusions are mani fested \V i thi n
a
,
.

a f ew hours or days the full symptom complex o f

,

the disease i s developed .

The characteristic s y mptoms are the sense

deceptions the m ost common being those o f
,

lluci n a sigh t S parks and ames ash be fore the eves

. ,

horrid animal s inhabit every corner and spr i ng

a) i ng
from e v er y direction Bu w orms
. and o
5

'

" ,

snakes cra w l around R at s and m ice run

.
 I N T O X I CA T I O N P SY C H O SES 169

about Less f req uen tl v are beheld w ild orgies

.

of devils sprites and naked w omen A u

, , .

d i to r v hallucination s al though less frequent than ,

those o f sight are n ot uncommon ,

V oices Shout .

insul ting remarks in the pa tient s ears call h im

names and accuse h im o f crimes Frien d s in

, .

distress appeal to him for help O ne patient o f .

m ine w ho su ff ered from several attacks at each

, ,

attack saw a sca ff old in process of erection be fore

the hospital upon w h ich he decl ared that he w as
,

to be executed O ften the patients behold ene.

m ies point ing guns at them and continuall y ,

dodge to prevent being shot \V om en f r eq uen tl v .

assert that the y are nightly ravi shed .

M an v o f these vi sions are illusion s based upon

some actual percept ion Knot s i n the bed .

clothes are t rans formed into bugs S pots upon .

the w al l change into faces and the creaking o f ,

doors and the ringing o f bel l s are transl ated into

cries for help and w arnings of danger .

Disorientation is n ot uncommon The hos . D i sor i en ta

pital w ard becomes a favorite drinking haunt : - ti on
and the orderl ies f riends an d lon g kno w n ac,
-

q u ai n tan c e s A fter being. con ned to h i s bed

f or days the patient Often regales h i s hearers
,

w ith long account s o f j ou r n ev s he has made dur

ing that t ime and o f sigh ts and pleasures he has
,

enj oyed S till in spite o f such disorientation

.
, .

questions mav be ans w ered sen si b l v and cor

 1 70 M E N T AL D S I E A SE S

r ec tl y , although the ans w ers mav be interrup t

e d by the patient s replying to h is i m agi n a r v
'

voices or attempting to rid himsel f o f the b or r i

ble th ings by w hich his mistaken perception has
surrounded h im .

ha ng ea bl e E ver changeable one moment the pat ien t

,

l aughs and talks the n ext co w ers w ith fear b e

,

fore some fright ful phantasm or possessed b v , ,

sudden violence he m av dest ro y an y th in g w ith i n

,

reach or furiously assault any one w ith w hom he

comes in contact In some cases the imaginar y
.

scenes furnish cont inual e n tertainment T he .

hal lucination s are f r eq uen tl v colored b y the pre

vio n s l i fe and occupation the coachman drive s
his horses the merchant vends his w ares and the
, ,

la w yer t ries his cases .

a lluci n a Hallucinat ions of taste and smell thou gh les s ,

ns o
f common th an those of sight and hearing are n ot ,

ste a n d

t el l
in f re q uently encountered .

Delusion s may arise out o f the hallucinat ions .

but thev are less prominent than in the more

ch ronic stages of alcohol ic i n san i tv \ V h e n .

present they usually relate to the persons by

w hom the patient i s surr o unded Hi s w i fe is de
.

cl a r ed un faith ful his children dea d or he him

, ,

sel f i s to be executed for h is mi sdeeds Del u .

sion s usual ly are o f a depressing character .

E ver restl ess an d un easv the patient is con

,

t i n ual l y in motion and occupies himse l f accord ,

 I N T O X I C A T I O N P S Y C H O SE S 17 1

i ng to the nature of his phantasms it mav be in .

collecting the gol d w ith w hich the oor o f hi s

apartments is stre w n or i n endeavoring to catch
,

the bugs or in sects w ith w h i ch he i s t o rmente d or ,

in attacks upon the horrid beast s b v w h ich he i s

th reatened S el f dest ruction i s rare but sh ould
.
-
,

a l w ays be guarde d against W h ile murderous .

on slaught s are unco m mon still a d el irium t re ,

-

m ens case i s al w a y s dangerous especial ly i f su f , Da ngerou s

f e r i n g from hal l uc m at i o n s that cause him to
regard himsel f in danger since under their i n u ,

ence he mav at tack an v one w ith w hom he comes

in contact S leep is usuall v absent or much dis
.
,

tur b ed in the early stages Of the d isease

, When .

exhausted b v hi s long ph y sical exerti on the pa ,

t ient may sm k i nto a stupor and from that pass

into true sleep .

Beca u se o f the d isturbed con d ition of the d i

g es t i v e organ s little,
food i s usuall y ta k e n and
nut rition is gr eatl v interfere d w ith O ften d elu .

sions o f poison prevail an d on th i s account all

food may be re fused C haracterist ic motor phe
.

n o m en a al w ays appear These consist of a ne

.

muscular t remor especially marked i n the small

,

muscles o f the face and han d s but apparent in all ,

the voluntary muscles Th is t remor under the .

T rem or
,

inuence of stimulation may temporarily cease , ,

so that a cup o f w ater may be carried to the

mouth or a button m ay be fastened provided the ,
 1 72 M E N T AL D S I E A SES

motions are rapid A s soo n ho w ever as the

.
, ,

attention is distracted the t remors are rene w ed .

Th is is not a t rue incoordination but a d e c i en c v

,

ure si s of o f nerve cont rol producing a true paresis o f vol

u n ta r y motion In severe cases t w itch ing an d

ati on .
,

cont ractions of the orbiculari s and occipito fron

tal is muscles occur and a vibratory tremor of the
ton gue appears A n increase o f reex ex c i tabil
.

i ty occurs in all cases that approach collapse

del irium and occasi on al l v an e x citation o f on e
kneej erk causes a contraction o f the correspond
ing muscles of the other leg A n uncertai n .

stumbl ing may be present as the resul t o f m uscu

lar w eakn ess but the patients can usuall y stand
,

rmly w hether the eves are c l osed or open

, .

D isturbance o f the sen sorv nerves appea r i n

the form o f anesthesias paresthesias or anal
, ,

g e si a s.frequently forming the basis o f illu sion s .

The temperature in uncompl icated cases i s

, ,

seldom raised and at t imes i s subnormal Ex .

cepti on s may occur in w h ich case the gravity o f

,

the p rognosis i s increased The respiratio n i s

.

usuall y increased and the pul se is o ften w eak and

rapid and pro fuse diaphoresis m ay occur
, .

C ertain investigators have found marked l eu

si s cocv tosi s during the height of the del i rium th e ,

leucocytes f r eq uen tl v decreasing belo w the n or

mal w ith the subsidence o f the excitement an d
a fter w ard ret urning to the normal number .
 I N T O X I CA T I O N P S Y C H O SES 1 73

R ecent investigations have demon st rated that

albuminuria is usuall y prese n t in the early stages
o f the di sease Lupm an n asserts tha t there is a
.

relation bet w een the presence of albumin and the

del irium the alb umin appearing w hen the del ir
,

ium is inten se and disappearing as the del irium

subsides .

U ncompl icated del i rium us ually results in

prompt recovery the average duration o f an
,

attack being from a w eek to ten days The .

cases that result fatally are usual l v those in

w hich marked gastric disorders and too pr o
longed abstinence have produced such severe
exhaustion that the vital po w ers w ere unable to
battle w ith the di sease .

PA T H O L O GY
N o denite pathology o f acute alcoh ol ic deli r
ium has yet been demonst rated .

T R EA T M EN T
O ne of the w orst problems in th e treatment o f
del i rium tremens i s found in the management o f
the stomach . M a n y cases on account O f thei r
,

chronic gast ric catarrh have f o r so long a t ime

,

depended upon stimul ants to the exc l usion of

food that thei r stomach s have become incapable
, Stom ach
of retaining ordinary food E ven the simplest
.

an d most easi l v digested articles are rej ected and

 1 74 M E N T AL I E A S ES
D S

great d if cul tv i s found in pre ventin g death b v

exhaustion O ften lavage O f the stomach i s
.

n ece s sa r v be fore an y thing w ill be retained .

O n l v the most easily digested foo d in l iquid ,

form and in small q uantit ies w ill at rst be toler ,

ate d and in some cases a l ittle stimulant w ill have

,

to be gi ven to prevent th is being rej ected H ot .

peptonize d milk in small quantities at inte rval s ,

o f n o t more than tw o hours in our experience ,

has been the best diet In m an v cases milk and .

,

vich y in e q ual part s has given good resul t s the ,

vich y supplying su ffi cient st imulus to admit o f the

entire removal o f alcohol H ot milk w hen re .

ta i n ed often facil itates S leep w h ich is the one ,

absolute necessit y f or the restoration o f reason .

The remedies most frequently demanded are

aconite agaricus ar sen i cum belladonna can
, , , ,

tha r i d es cimici fuga h y osc y amus nux vomica

, , , ,

phosphorus stramonium The follo w ing are the

, .

most frequent indicat ions :

AC O N I T E
A con i te T he prevail ing mental attitude of the aconite
aa r hn ess
pat ien t is fear He fears d arkness ghost s
.
, ,

b ei ng s h ot,
being shot at He cringes in terror in the cor
.

ner o f his room or under the bed clothes

ss
.

ne , Sen
Si ti ven ess A ssociated w ith the mental s y mpto m s w e nd
great restle ssness sensit iveness to pain n oi se
, , ,

an d t o uch The ci rculati o n i s accelerated the

. .
 I N TO X I C AT I O N P S YC I I O SES 17 5

pul se full and st rong and there i s general heat

,

ove r the w hole body \V hi l e not as f req uen tl v

.

demanded as some other remedies it has in our ,

hands o ften a ff orded rel ie f .

A G AR I CU S

The agaricus pat ient may be

good n atured l v
excited and talk sing and dance : or be ill
, ,

humored peevish and taciturn ; or a furi o us

, ,

frenzy may prevail .

W ith the mental symptoms there i s a marked

t remulou sness of the tongue and l ips or an inter ext er n a l
and
,

nal sen se o f t remor may exist noticeable b v the , i n ter n al

patient onl y and causing great nerv ous ex
hen nux fail s to
,

c i tem en t and apprehension

7
.

cont rol the characteri stic t remor a garicus mav

succeed .

AR SE N I C U M AL B U M

Great restlessness and uneasiness w ith fear o f Ha lluci n a ,

ti on s of
death ; con stan tl v an n ov ed by the bu gs and ver
sig h t
min that he sees upon the bed and h is person ,

rm i
he unceasingl y t ries to brush them o ff or mav ve n

attempt suicide to escape h is present su ff erin g

and miser y .

\ V ith the mental symptoms the characteri st ic

thirst is fo un d al so great gast ric i rritat ion
, .
 1 76 M E N T AL D S I E A SE S

BE LLA D O N N A
Furious del irium ; the patient bites kicks , ,

i llusi

ons st rikes N umerous illusions hallucinations and
.
, ,

ana
delusions appear illusions and hallucinat i on s o f
,

tio n s of sigh t being the most common The face is

sig h t
.

ushed head hot ; the pupil s are dilate d an d a

,

general cerebral hyper aemia prevail s S leep .

lessness or broken sleep i s usually present .

CA N T H A R I DES

Co n ti n u a l \ V hen the pat ient s strive to bite cont inuall y ,

a ttem ts
p either at those about them or the bed cloth ing ,

Sex ual and are greatl y excited sexually w e h ave given ,

ex it m
c e en t, cantharides w ith marked success These pa .

Fa ce pa le
f ient s are al so hypersensitive to touch or the sight

Dy su r i a o f any dazzl ing obj ect The eye s are brigh t

.
,

p upil s dil ated but the face i s pale y ello w w r i n k

, ,

led and expresses constant suff ering \ V hen

,
.

cant harides is demanded d v su r i a al so is usuall y ,

present .

C I M I C I FU G A

S ees al l sorts o f appearances about him rat s
ti o n s of upon h i s bed w i res to encage h im and some one
s igh t , ,

about to kill h im S uspicious dep ressed . , , an d

suicidal Great sleepl essness

. .

H Y O SC Y A M U S
J ov ou s changeabl e del i rium , w ith much talking
 I N T O X I C A T I O N P S Y C H O SE S 1 77

and laughing M arked sexual excitement w ith

.
, C ha ng e a ble
a desire to expose the person Fear o f poison .
d li
e ri u m

al so i s a prominent symptom of thi s drug and ,

po i son

w hen present can usually be rel ieved by i t .

S

ne ss
S leeplessness and much muscular t w itching al so
are l ikely to occur .

No other remedy has in ou r hands proved more

e ffi cacious especi al l v w hen marked Sleeplessness
,

has occurred .

NU X V O M I CA
N ux vomica i s m ore frequently demanded than
an y other dru g especially w hen the t remor is
,

C fgl i n ess
marked and there a re great ugl iness an d i r r i tab i l ,

i tv and much ga st ric disturbance \ V hen there .

is much trembl ing of tongue l ips and hands

, , ,

nux i f given in the st art w ill greatly improve the

, ,

con d i t i on even i f some other drug has to follo w

,

to complete the cure .

P H O S P I I O RU S

P hosphorus i s indicated w hen the characterist Fa ces

p eer i n g
i c prevail ing symp toms are ill usions o f si ght

sees faces peering from all parts of the room .

There i s al so great sen sit ive n ess to noi se an d ,

I l lus i o n s
often sexual excitement
,
.
o s
f ig h t

S T RA M O N I U M
S t ramonium is especi al l v e ff ectual in the mos t
excited and w ildest cases The prevail ing men .

13
 1 78 M E N T AL D SEI A SE S

tal characteristic is terror w h ich is produced by ,

i ng hal l uci
a o s
n ti n a nd
the various horrible sigh ts and obj ect s w h ic h
o s
i llusi n surround them H all ucinations an d illusions o f
.

ev e r v form are present and are all f right ful and

terror pro d ucing \V hen indicated th i s drug i s

-
.
,

exceedingl y e ff ective .

ALC O H O L I C P S YC I I O S ES

C ontinued inebriety m ay produce mel anchol ia

and mania w h ich di ff er some w hat from the
,

ordinary forms o f those di seases In both the .

melancholias and manias the onset is sudden th e ,

mental re d uction marked the duration brie f and , .

the rest itution sudden and complete .

A LCO R O L I C M ELA N C H O LI A

A side from some headache and more o r l e s s

S leeplessness the alcohol ic melancholic mav pre
,

Hor ri ble sent no prodromata \V i thout w arn i ng hall u . ,

h a lluci na c i n ati on s appear horri b le sights come be fore th e

,
ti ous
eyes friends are murdered prisons are opened
, ,

f or the i r recept ion and the gal lo w s is erec ted f o r

their execution Groans and sh riek s o f agon v
.

ll their ears voices accuse the m of numberles s

,

crimes and heap them w ith abuse M ore rarel y . .

hallucinations of sight o ccur : visions o f animal s ,

devil s w itches come be fore them producing fea r

, ,

and anxiet y A ssociated w ith these hallucin a

.

t ions m av be severe neuralgias o f the peripheral

nerves and suicidal impul ses
,
.
 I N TO X I C AT I O N P S YC I I O S ES 1 79

N ot in frequently albuminuria is present The . A l bu m i

n u ri a
reexes mav be normal lo w ered o r sl ightl y , ,

exalted .

The duration of the disease is ord ina rily from

eight to ten days and upon recovery there i s an
,

indist inct remembrance o f the hal l uci n ator v pe

r i od . Frequently a residue o f the sense d ecep
t ions remains and forms a bas i s of a future del ir
ium o f persecution .

ALC O H O L I C M A N I A
The onset of alcohol ic mania is sudden and is
characterized by a fear O f some impending dan s udden
ger \Vhi l e in this condition the patient is de
.
,

structive and highly dange rou s to auv on e w ith

whom he comes in contact and may commit m o
ti v el ess murders o f w hich he after w ards retains
no remembra n ce .

The premonitory s ym ptom s are increased i rri

tab i l i ty Sleeplessness morbid impul ses increased
, , ,

sex ual excitement a general change in the ap

,

p e a r a n c e and character and an exaggeration

,
of
the desire f or drink .

The excitement is extreme and uncontroll able , I s

n ten e

often impel ling the patient to furious assault s e x it m

c e en t

upon h is f am il v and friends A t the acme of .

excitemen t there I S marked mental con f u sion and

the actions are mot iveless and impul sive T he .

facial and hand muscles exh i b i t marked tremor

 1 80 M E N T AL I
D SE A SES .

and there i s m arked disturbance of the art icul a

tion Facial paral ysis may appear the p upil s
.
,

are unequal or m y otic and the deep and cutane

,

ous reexes are exaggerated Delusions o f .

P a r esi s grandeur similar to those o f paresi s f req uen tl v

appear The patient boast s that he i s a mul ti
.

millionaire C h rist M ahomet or King o f En

, , ,

gland A ny opposit ion el icit s the most extreme

.

outbursts o f violence The delusions are usuall y

.

based upon antecedent hallucinations Heaven .

i s opened or angel s surround h im and the pat ient

converses w ith his angel ic visitants During the .

Rem i ssi on s excitemen t dest ruct ivenes s and a gitation remi s

,

s ions m av occur o n l v to be follo w e d b v rene w ed

,

excitement dest r uct iveness and ag i tat i on unt il

,

the physical po w ers are exhauste d P ain and .

ph y sical d i scom fort seem ent irel y absent the pa ,

t i en t s may bruise thei r bo d ies or break their l i m bs

w ithout au v app a rent discom fort .

D u ra ti on The disease last s from one or tw o days to sev

eral w eeks according to it s gravity T he i m
,
.

provement i s mani fested by the lengthened dura

t i on o f the remi ssions the lessening of the ex
,

c i tem en t and the increased amount and improved

,

characte r o f the sleep \ V ith the decrease in the

.

excitement phv si cal w eakness is mani fested an d

the pat ient graduall y returns to h is normal men
tal state The delusions m av persist f or a con
.

si d e r ab l e period and a certain amount o f mental

deterioration may perm an en tl v remain .

 I N T O X I CA T I O N P S YC I I O S E S 18 1

In a large number o f cases the intense mental

excitement may pass into a muttering del i rium I I I u tter i n
g
w ith sv m ptom s o f collapse and speed i l v termi ,
d a th
e

nate I n death .

T he disease mav run a ch ronic course P ar .

ox y sm s o f violence may occur w ith S hout ing ,

w eeping and dest ruct iveness w hich are succeed ,

e d b v dementia The delusions gradually f ade

.

a w ay the n utrition i s lo w ered the pul se become s

, ,

slo w the arterial tension is lessened and the tem

, ,

p e r a tu r e sinks belo w the normal P aresis ap .

pears there is s w eating the l ips and ex t rem i

, ,

t i es become ataxic and the mind pro gr essi v el v

,

w eakens .

W ithin a f ew month s death occurs from diar

rhoea pneumonia o r a continuous w eakening o f
, ,

the vital po w ers w ith decubitus .

PR O G N O S I S
A guarded prog nosis should be given in all
cases of ch ronic alcohol ic mania N ot more than .

fort y per cent regain thei r normal mental heal th

.
,

man y die from coll apse and a st ill larger number

,

become markedl y demented .

PA T I I O LO G Y
The pathological changes are ch i e v ma n i Cere b r al

f ested in the cerebral c i r cul ato r v sv stem The .

ci ren la to ry
m eninge s and brain substance are marke d l y co n
1 82 M E N T AL D S I E A SE S

geste d w ith varicosity o f the veins general ,

oedema of the bra i n at rophy o f the convolution s

, ,

and dilatation of the vent ricles .

T R EA T M EN T
In the t reatment particular attention shoul d
,

be paid to the nouri shment w h ich shoul d be given ,

in l iq uid form at short i n terva l s The patien t .

should be kept i n bed and the bodily w armt h

should be sustained by hot appl icat ion s and b v a
h igh temperature in the r oom i f necessary .

T he remedies should be selected according to

the svm ptom s I n cases o f collapse in additio n
.
,

to the ordinary heart stimulant s alcohol in some ,

form mav be demanded .

A LC O H O LI C PARA N O I A
Th is form i s usually preceded by a short peri od
o f incubation A fter prolonged alcohol ic i n d ul
.

gence headache appears the sleep is broke n and

, , ,

the ci rcul ation is d isturbed Sud d en l v hallucina .

tions o f hearing or sight appear those o f hearing ,

being the most common Disturbin g voices con .

t i n ual l v ll the pat ient s ears ; thev accuse h im

'

o f being a sexual pervert a seducer or an impo , ,

tent o r ta unt h im w ith being a vict im o f an

,

un faith ful w i fe He hears cont inual ly the mos t

.

disgu sti n g lan guage or i s in formed o f plot s

b ei n g forme d to poison him o r take aw av hi s
v i ril i tv .
 I N TO X I C AT I O N P S YC I I O S ES 1 83

Hallucinat ions O f taste and smell may be pres

ent frequently intermingled w ith delusions
. .

P e secutoi y r
Poisonous gases are b lo w n into his apartments to d lu si on s e

d est ro v h i s health Knives are t h rust into h is

.

be d at nigh t or unseen electric w i res shock him .

T he most common delusions are the sexual and

th ose w hich th reaten hi s health and l i fe The .

enemies are unseen and w ork th rough m v ster i ous

agencies A s a resul t o f hi s persecutor y del u
.

sions the patient is in a constant state o f anxiety

and fear and seeks protect ion from hi s friends
,

or the publ ic authorities Intermingled w ith the .

p e r secu to r v egotist ical

, del usion s may appear .

He i s persecuted because of his eminence or his Delus i on s

of
great w ealth w hich his enemies are attempt ing
a nd u
,
e r
g r
to secure O ccasional ly the delusions o f great
.

pol itical po w er are evidenced The pat ient has .

been appointed j ust ice of the U nited S tates Su

preme C ourt or elected Governor o f the S tate or
, ,

P resident o f the United S tates and i s being kept ,

b v his enem ies out o f his rights .

The termination o f cases of persecutory del i r T er m i n a

ti o n va r i s
i tun varies S ome w hen deprived o f all alcohol ic
.
,
e

stimulant s shortly return to hea l th O thers are

, .

mentally w eakened retaining but vague impres

,

si o ns of thei r delusions In still other cases the

.

hall ucinat ions and delusions hold s w a y for a long

time the mind becoming more an d more w eak
,

ened as t ime passes although in exceptional i n

,
 I 84 M E N T AL I E A SE S
D S

s tances a fter vear s a partial rest itut ion mav

,

occur .

In certain cases of alcoh ol ic persecutory del i r

ium the disease i s the resul t of a gradual ev ol u
tion but the svm ptom s d o not m ateri al l v di ff e r
,

from the form j ust considered The aural h al .

l uc i n at i on s rst appear as noi ses in the ea r .

w h istl ing buzz ing o r roaring

,
Gradually from
, .
,

these distinct voices are developed D v these

, .

voices night and day the patient is mocked

, , .

taunted and anno y ed He is th reatened w ith im

, .

prisonment and death or is told o f h is w i fe s un

faith fulness S exual perversions predominate

. .

U nkno w n persons accuse him o f being an onan

ist a paederast or of being impotent W ith the
, ,
.

advance o f the mental en feeblement hallucina ,

t ions of S ight appear ; visions of ev er v form and

variety are ashed be fore the eves the most com ,

mon being o f a sexual type .

C on ti n ual l v annoyed and i rritated by these hal

l uc i n ati o n s and delusions the patient becomes ,

e xcessively irritable and q uarrel some P ossess .

ed b v delusions as to the i r intent s and purpo ses ,

he may b ecome d an ger ousl v hostile to hi s f am i l v

and friends and attempt to inj ure or kill them .

O n account of thei r d elusions these pat ients a re ,

n
g er ous ranked among the most dangerous o f the insane .

From the constant presence o f these voices and

the bel ie f of h is contin ued persecut ion the patien t ,
 I N T O X I CA T I O N P S YC H O SES 18 5

may develop egot i s tical delusions asserting that ,

he has been raised to some h igh position and is

being d e frauded o f h is legal rights A s a co u se .

q ue n ce he becomes
,
excessively irritab l e and l iable
to furious outbreaks from the sl ightest con trad i c
tion The sleep i s o ften gr eatl v disturbed b y
.

n ightmares or nightly visions .

Facial t remor partial paresi s anesthesias

, , ,

general muscul ar t remor and ser i ous de fect s o f

the memory are usual ly apparent .

From the close resemblance o f this symptom

complex to paranoia it is kno w n as alcohol ic
,

pseudo paranoia .

PR O G N O S I S
The prognosis is bad The mental deteriora . Prog n os i s
baa?
t ion is progressive p recluding auv hope of r e
,

c ov e r v .

T R EA T M E N T
The pat ient should be permanently committed
to an as y lum and d eprived of all alc ohol ic st im u
lant s .

K O RS A K o w S

P S Y C H O S I S O R K O R S A K O FF S '

DI S E A SE
This disease consist s o f certain characteristic
disturbances o f memory associate d w ith svm p di as
se e

toms o f pol y n euriti s the resul t o f prolonged a l co

,

hol ic excesses A s the s y mptoms are practic al l y

.
 1 86 M E N T A L D I SEA SE S

identical w ith those produced b y certain exhaus t

ive diseases and al ready described under post
,

i n f ection psychoses w e shall n ot repea t them ,

here .

A LC O I I O LI C P SEU D O PAR ES I S
I n certain con rmed alcoholics a symptom
complex develops closely resembl ing dement ia
paralyt ica T w o forms are recogni zed
. .

In the rst in a d dition to the ordinary mental

,

w eakness lassitude vest iges o f former hal l uc i n

, ,

at i o n s ,
il lusions or delusions the t remors an d
, ,

other sense perversions w e nd the ataxia o f the ,

a ta x i a paretic di f culties o f speech continuous cepha

, ,

l al gi a and frequent epilept ic and apoplectic sei z

ures T he speech de fect i s ho w ever an ataxia
.
, ,

an d not the stammerin g slurring utterance o f

the t rue paretic N eurit is and amnesia a l s o are
.

fre q uent c h aracteristic compl ications .

The history o f ch ronic alco hol ism usuall y pre

elu d es any di ffi cult y in the diagn osis .

I n the second form the t remor o f the l ips an d

facial muscles an d the epil ept ic seizures do not
De u l si ons appear but delusions o f grandeur are present
, ,

/
0 O f ten connected w ith the sex ual f unctions The .

g r a n deu r patient has unl imited w ealth i s the most honored ,

and inuential o f men or h i s sexual organs ar e ,

the largest in the w orld and h i s po w ers o f p ro

crea tion are unlimited and he i s the husband o f ,

 I N T O X I C A T I O N P S Y C H O SES 187

thousands of the most attractive w omen These .

d elusion s are changeable v a r v i n g from dav to

,

day and may cont inue f o r on l v a f ew d avs or

,

mon th s w hen thev w ill disappear in the pat i ent s

'

a d vancing dement ia The mental feebleness

.

remains permanent but the mental annih ilation

,

is not so complete a s in t r ue d ementia paralytica .

\ eu r i ti s m av not be present in th i s f orm and the

'

pupillary changes are less frequent than i n true P upi tta ry

paresi s al though the l ight reex may be absent
,

and imper fect reac t ion to accommodatio n and

convergence mav be present P upil lary i r regu .

l a r i ti es are n ot un frequentl y discernible \ V hen .

n euritis i s present the deep reexe s are dimin

i shed or absent : in other cases thev are normal

or exaggerated .

ALC O H O L I C D E M E N T I A
A lcoholic dementia is a common resul t o f all
form s of ch ronic alcohol ism but in persons w ith
,

inherited brain w eakness mav assume a progress

ive form I t occurs most f r eq uen tl v during the
.

earl y years of adolescence an d i n the ret rogress

ive perio d o f l i fe .

A progressive m ental en feeblement ending in ,

complete d est r uc t ion o f the rea so n ing faculties ,

frequently occ ur s in youn g persons bet w een the D escen d

ages of eighteen and t w enty ve w ho are the -

dr un ha r d s
descendants o f drunkards al th o ugh the i n d ul
,
 1 88 M E N T AL D S I E A SE S

gence in intoxicants may have been mo d erat e .

In these cases the menta l facul ties are com pl etel v

abol ished and they sink to the level O f brutes .

A n individual w i th a normally heal thy nervou s

organization i s much more l iable to mental dete
r i o r at i o n from the use o f into x icants w hen the

habit is formed late in l i fe than w hen i t is be gu n

in early manhood C h ron ic progressive demen
.

tia is a common occurrence in those cases the ,

em o ry rst symptoms being failure o f memory w hich i s ,

follo w ed by slight motor phenomena and lastl y ,

by progressive mental w eakening terminating i n ,

absolute obl iviousness .

og n osi s The prognosis i s unq ual i ed l y bad W ith .

d r aw al o f the cause may retard the progress b ut ,

the existing mental en feebleme n t is permanen t .

AL C O H O L I C E P I L EP SY
P rolonged alcohol ic indulgence n ot only i mten
s i e s the sev e r i tv o f epi l epsy b ut may be the sol e
,

causative agency E ight to ten per cent o f alco

. .

hol i es ev en tuall v d evelop epileps y the attack s ,

usually appear i ng a fter a prolonged debauch .

The disease may ass ume any o f the regu l a r

forms o f epi l epsv or appear as one o f the epi l ep
tic e q uivalents .

The pro gnosis is un favorable even i f the pro,

d uc i n g cause is removed and repeated seizure s

,

are l iable to produce a fatal i ssue .

 C H A P T ER V I I I

I NT O X I C A T I O N P S YC H O S ES

( C O NT I N UE D )

M O RP H I N I SM

N ext to alcohol among the drugs capable o f

,

producing ch ronic into x ication stands opium and ,

its derivatives From earl iest t imes it s n arcoti z

.

ing and exhilarating e ff ect s have fascinated and

enchanted mankin d From all nations and in
.
,

every cl ime are found its vict ims those in this

, ,

count ry alone numbering more than one hundred

thousan d w ith accessions being d ai l v made to
,

their ranks \V hi l e no class o f s oc i ety i s ex

.
o

empt the me d ical profession furni shes the larg

,
M edi a l
c

est number o f victims The long continued v i g

.
- p r of essi o n

il s and strenuous labo r o f the ph y sician often ,

banish ing sleep w hen i t coul d be obtained render ,

him especi al l v l iable to v i el d to th is alluring drug .

The same danger con front s the professional

nurse as the cont inuall y increasing gro w th o f the
,

evil i n th is class demonstrates \Vhi l e a l arge .

number v i eld to the seduct ions o f the pipe and ,

many con ne them selves to lau d anum the maj or ,

i t v in th is count ry use morphine alone as the ,

 1 90 M E N T AL D SEI A SE S

hypoderm ic syringe a ff ords an easy and e ff ec t ive

mode o f administra t ion .

V arious causes l ead to the cont raction o f th e

habit In the majority o f cases w ith normal
.

nervous organizat ions the agon y o f neural gi a

, ,

tabes or rheumatis m or some other pain ful d i s

di s as s
e e
, ,

ease has caused a resort to the drug at r s t

, ,

th rough the prescript ion o f a physician Fasci .

mated b v its soothing or exh ilarating e ff ects th e ,

patient cont inues i ts use long a fter the su ff erin g

f o r w hich it w as prescribed has passed a w ay n u ,

t il he nds that he is unable to do w ithout i t .

U n sta bl
e In others w ith un stable nervous tempera
o us
n e rv
ments an innate c raving for the drug exist s
tempe a
.
,
r

m en ts Thus the neurasthenic the hypochondriac the , ,

periodical mel anchol ic and the dr unkard tur n

,

inst inctively to opium for amel iorat ion o f the i r

individual miseries .

I n som n i a S till others tortured b v insomnia th rough ,

grie f from loss o f friends or b u siness failure s

or remorse f or thei r m isdeeds seek i m m un i tv i n ,

the obl ivion o f the poppy s j uice

.

A gain others allured b v its temporar y brai n

,

stimulation st rive to e n hance their brain po w e r

,

o w
and augm ent the i r achievements onl y too soo n
p
,
er

to nd t hat thei r abi l i tv for mental w ork has been

thereby dest ro y ed .

The dose taken by the h ab i tu v aries from a

fraction O f a grain to t w enty or even si x tv grain s
 I N T O X I CAT I O N I S YC I I U S ES

19 1

o f morph ine daily O f l au d anum the daily al

.
,

lo w ance mav r each as high as a thousand drops .

O pium is much slo w er than alcohol in pro duc

ing an y degenerative e ff ects upon the system and ,

thev are much less apparent O r d i n ar i l v l i f e is

.
,

not shortened by its use unless so m e other more

danger ous drug l ike coca i ne alcohol o r chlora l
, , , ,

i s taken in conj unct ion w ith it Nor are the ch il .

dren o f the opium end usually a ff ected excep t ,

in those count ries w here the habit has prevailed

for generations .

T w o groups o f s y mptoms appear : ( 1 ) those

di rectl y prod uced b v the drug itsel f and 2) those
w hich are caused b v I ts w ithdra w al .

1 ) T he s y mptoms p roduced by opium var v

greatly according to the individual s nervous o r

g an i z ati o n. M any persons unhampered b v any

inherite d w eakness mav take the drug f or
,

month s and y ears be fore any marked d ete r io r at

ing e ff ects are mani fest In others l ess happily
.
,

or gani zed marked pathological sign s o f nerve

,

change may appea r much more quickly .

The rst sensations produced by the inh ibit ion

of opium are pleasing and exh ilarati n g T he .

brain i s aroused to increased act ivity Thought . I ased

n cr e

i s acce l erate d and the mind w orks w ith a clear

acti vi ty
ness and r api d i tv previously unkno w n the arter ,

ies cont ract the pul se is retarded and the re spira

, .

tion i s deepened S oon a pleasant sense o f lan

.
 192 M E N T AL D I S EA sES

guo r i s experienced fol lo w ed by dro w siness and

,

by sleep broken by pleasing hallucinatory dreams .

These e ff ects endure for ten or t w elve hours and

are succeeded by so cal led abst inence symptoms -
,

malai se dryness o f the mucous membranes dul l

, ,

headache nausea w ith inabil ity for mental or

, ,

p h v s i c al activity A ll o f these .disagreea b l e

symptoms disappear i f the dose is repeated .

\ V ith the morphine habitu the sleep is neve r

D i stu r bd e sound but is disturbed b v con ti n ual l v changing
, ,

sleep dream l ike visions T hese hal l ucm atton s m ay

-
.

be pleasing and enj oyable o r horrid an d te r r i f v

ing O ne o f the ch ie f characteristics o f the V I S
.

ions is an obl iterat ion o f t ime and space : the

w hole drama o f l i fe may pass be fore the e v es in
an instant or an incident read or heard may , ,

see m to be prolonged f or an eternity .

\ V hen the habit i s f ull v establ ished a pro

n oun ced chan g e in the character en sues I rrita .

ble morose sullen t reacherous devoid of moral

, , , ,

I gi bl
n cor r z e
sense incapable o f tell ing the t ruth an y means
, , ,

ho w ever di shonest w ill be adopted by the victi m

,

to obtain the coveted drug His con science seem s .

dead and no m ore unrel iable person can be im ag

i ned . Fortunatel y for the race w ith the estab .

l i shm en t Of the habit the po w er o f propagation

ceases th rough positive i m poten cv .

The physical sympto m s are m ark ed l v charac

ter i st i c The skin becomes d r v di rty an d vel
.
, ,
 I N TO X I C A T I O N P S YC I I O S E S 1 93

low and mav be blotched w ith erupt ions and ,

night and day covered w i th a profuse per spi ra

t ion. The ha i r easi l v w hitens and is lost The .

n ail s become br i tt l e and the teeth loosen and the

secretions dim inish A pecul iar cachexia resul t

.

ing from profound an aemia unerringly marks a A ne m i a

prolonged indulgence i n the habit The pupil s .

contract to a pin poin t and are non reactive to -

l i gh t or occasional l y present ine q ualit ies Trem .

ul ousn e ss especially noticeable in w riting may

, ,

be observed w i th a general lo w ering o f the mus

,

cul ar po w ers The cutaneous and deep reexes

.

m av be lessened or slo w ed and ataxic sign s not ,

in frequently are present A coated ton gue foul .

,

breath constipat ion anorex ia and gastric acidit y

, , ,

reveal the di sordere d condition o f the digest ive Di so rde ed r

organs Inco n tinence or di f c ult y in the passage

.

of urine mav occur al though the secret i on of ,

urine may be au gmented Funct ional disturb .

ance o f the heart i n the form of fal se angina pec

,
Hea t r
toris or attacks of pericardial anxiety may add di st r ba n ce
, n

to the pat i ent s misery O bst inate insomnia a l so

attends the last sta ges o f the disease .

(2) The symptoms o f deprivat ion usual ly

appear w ith in ten to fteen hours after the ordi
n ary dose i s om itted P rominent among these i s
.

a feel ing Of inten se m uscu l ar w eakness attended

by diarrh oea and severe col ic The body is .

bathed in a pro f use perspi ration and a general

14
 1 94 M E N T AL I E A S ES
D S

trem ulousness adds to the patient s mental re st

'

a te '

lessness and t remor The m ost i u ten se nerve .

'

i ns
pains in ev er v part of the bod v may d rive the
, ,

su ff e rer almost to d ist raction Frantic w it h .

agony the patient be g s for Opium and i f hi s re

, ,

quest is grati ed all these s y mptoms i nnn ed i atel v

d isappear .

I f the abst inence i s prolonged for days seriou s ,

el i r i u m mental phenomena an d terri fying hallucinati o n s

rem or
o f sight and hearing simil ar to those accompan y
,
om a
i n g alcohol ic del i rium may appear A general , .

muscular tre m or accompanies the del irium an d

this w i th marked i n ter ference in the ci rculation
,

and respiration w ith th reatened coma mav com

, ,

pel a rene w ed resort to the morphine .

W hen the w ithdra w al is gradua l the sv m p

to m s although distressin g are not so dangerou s
, ,

to li fe General m u scular w eakness w ith atax i c

. ,

ga i t agoniz ing neuralgias paresthesias nausea

, , , .

vomiting pro fuse perspiration abdominal pain

, , .

d isturbance o f the respi ration and the ci rculation .

are attended b v apprehension o f impen d i n g

d eath The mental svm ptom s o f insomnia de
. ,

p ression restlessness defect of memory w ith an

, , ,

in ten se craving f or the dru g accom pan v th e ,

physical symptoms I f the w i thdra w al is n o t

.

di scontinued the general phvsi cal w eakness m a y

,

continue for months culm i nat i ng at last in deat h

,

from a progressive marasmus .

 I N TO X I C A T I O N P S YC I I O S ES 19 5

PR O G N O S I S
The prognosis o f the modern morph ine hab i t P rog n os i s
ba d
is bad M a n y die either a s a resul t o f an over
.

dose or in thei r a tte m pt s to discontinue i ts use

, ,

by the subst i tut i on o f some dangerous heart de

pressant l ike cocaine chloral or on e o f the coal
, , ,

tar products The majority of morph ine hab i t

.

u s ,
after t reatment and being discharged as
recovered soon relapse into the i r old habit Es
,
.

p ec i al l v di ffi cul t of cure are those w ho supera d d

cocaine alcohol o r chloral to the morph ine
, , .

D I A G N OS I S
The dia gnosis is based upon the cont racted
C a chex i a
pupil s the pecul iar cachexia condition o f the
, ,
Shi n
skin mental slu g gishness and the mental charac
, AI i nd
ter i sti cs The presence o f scars from the h y po
.

dermic needl e upon the thighs and arms are al so

highly corroborat ive E xa m inat ion O f the urine.

may a l so reveal the dru g an d con rm the d i agn o

sis W hen morph ine is used in conj unction
.

w ith atropine chl oral and cocaine the d i f cu l tv

, , ,

of the task i s enhanced \ V he n the diagnosis .

cannot other w ise be establ i shed close con n e ,

m ent o f the suspect and development of the absti

n en ce s y mptoms w ill render the deci sion positive .

T R EA T M EN T
T wo methods o f t reat m ent are i n vo g ue : bv
 1 96 M E N T AL D S I E A SE S

on e pat i ent is gradually w eaned by slo w l y

the

diminish ing the ordinary dose by the other the ,

patient is at once ent i re ly deprived o f the drug .

D uring the process the st rength m ust be sus

,

t a i n ed by large quant ities o f the m ost nouris hin g ,

easily digested food and remedies must be ad

-

ministered to co m bat the S leeplessness and sti m u ,

l ate the heart and prevent fatal coll apse .

\V hatev er the method selected the m en d aci tv , ,

s ly ness and cunning Of the patient ren d er suc

,

T r ea tm en t cess f ul treat m ent outside of an institution pra e

m us t be i n
t ically impossible Ho w ever closely the pat ien t
.

sti tu ti on a l
i s w atched w hen at large he i s almost cert ain to
,

obta i n the coveted d rug and frustrate any meas

ures adopted f or cure O f those t reated i n an
.

institutio n b ut a small per cent are permanently .

cured the large maj ority ho w ever long con ned

, , ,

rel apsing w ith in a short period .

C O CA I N I S M
A mong the mos t d angerous O f the enslaving
drugs is coca i ne the alkaloid O f eryth roxylon
,

coca The coca i ne hab i t is one of comparatively

.

recent v ear s the insa n ity w hich i t produce s

,

be i n g rst described by E rlenmeyer in 1 8 8 6 .

m ey er
Fo r the introduction o f the cocaine hab i t th e
1 886
m edical pro fess i on see m s respon sible as it w a s ,

rst employed by physicians to co m bat the d epr i

vat ion s y mptoms o f op i u m the preparation com
,

m o ul y used bei n g the h y drochlorate .

 I N T O X I C A T IO N P S YC H O SES 197

The m aj o r i tv cocaine habit u s have previ

of

ousl y been morphine S laves and use cocaine i n

combinat ion w ith morphine A t the present .

time on account o f the serious resul t s that it

,

produces it has been discarded b v the me d ical

,

profession as an agent i n the t reat m ent of mor

p hi n i sm and,
its vict ims are d i n i m i sh i n g .

T he m aj or i tv o f the slaves o f cocaine are phy

s i c i an s druggists or persons O f unstabl e nervou s
, ,

organizat ion .

SY M P T O MS
T he degree o f tolerance o f th is drug varies
greatl y A d ose o f one or tw o grains i n certain
.

individual s w ill produce dyspn oea irregularity o f ,

the hea rt and symptoms o f collapse w h ile in

, ,

others no perceptible e ff ect w ill be mani fested .

A fata l dose varies from nine to t w ent y grains ,

altho ugh by hab i tu s an even greater amount has

been taken w i th impunit y Because o f the t ran
.

sient e ff ect o f coca i ne frequent repet ition o f the

,

dose is n ecessa rv in order to continue i t s i n u

ence U nl ike opium the poisonous e ff ect s o f
.
,

cocaine may persist for w eeks or even month s

a fter the drug has been d iscontinued and in .

m an v cases the abstinence svm ptom s do n ot ap

pear unt i l the pat ient has been deprived o f the
drug f or several days .

T he admin istration o f a l a rge dose o f coca i ne

 1 98 M E N T AL I E ASES
D S

produces e i ther a state of exaltation or symptom s

of collapse Wh ere the dose i s excessive a mos t
.

alarmi n g condit ion i s developed S i gn s o f .

ex ssi
ce ve paralysi s o f the voluntary muscles w ith w eaken
dos e
ing of the j o i nts faintness i n creasing to com a
, ,

dizz iness t remor vertigo cardiac di sturbance

, , , ,

cyanosis and burning sensations appear follo w ed

, ,

l ater b v del irium hallucinations of hearing sight

, , ,

and smell general impairment o f sensation an d

,

m ot i on and even con v ulsion s The p upil s at r st

,
.
,

w idel y dilated at a l at er period beco m e con

,

tracted and inactive to s t imuli P aralysi s o f th e .

cardiac and respi ratory centers even may occur ,

w ith a fatal issue W hen recovery takes place

.
,

sign s o f nervous irritation and hysterical sym p

toms may be evidenced for days or even w eeks .

O r d i n a r i l v the amount taken is insu f cient to

,

produce such di sast rous result s and the pat i ent i s

restored to his normal condition w ith in a f ew
hours The rst symptoms of a moderate d ose
.

Sy mptom s are usually mental exaltat io n and a ge n eral

f
o m oder a te

sense o f w ell being The intellectual facultie s .

are brightened and stimulated to unusual activity

and the physical pow ers are enhanced The .

stage of exaltation i s of shor t duration and i s

follo w ed by a state of depression w ith a d i m i n u ,

tion o f intel lectual and phv si cal vigor and dis

tu r b a n ce o f t he heart s action A continued use
.

O f the drug pro d uces marked m ental impai rment .

 i N T ox i C A T I O N I SYC H O S ES

1 99

The memory i s w eakened concent rated mental ,

act ivity beco m es i m possible and the victim i s ,

rendered incapable o f carrying on to comp l etion

any physical or m enta l w ork .

When the use of cocaine i s continued espe ,

c i all y i f combined w i th morphine a serious eu ,

sem b le o f ph y sical sv m ptom s appears R apid .

em aciat ion takes place the bod v often being r e

,

I sm a ci ati n o
d uced w ith in a f ew w eeks to on e th ird or one -
o
Yell wshi n
'

f th o f it s normal w eight rem or

The skin becomes .

I r r eg ul a r
of a d i rtv v el l ow i sh hue the face ac q ui res a har
,

asse d appearance and the physical st ren g th is

m a r k ed l v w eakened A general t re m or per
.

vades the w hole bod y especial l y apparent in the

,

ton gue attended b v continuo u s muscular rest

,

lessness The re exes are exa ggerated and

.

muscul ar cramps occur The pup i l s are dilated . ,

S leeplessness prevail s the heart s action i s i rreg

ular and attende d by frequent attacks o f f aint

ing A l thou gh the appet i te m av remain good
.

an d the assi m ilat ion be un i mpa i red an d no sign s

of indige stion appear the emaciation c o ntinues

,

on account o f excess o f w aste over the suppl v .

Sometimes a p o sit ive hall uci n atory insan i t y i s

p r o duced in the cocaine h ab it u closely si m u l a ,
t

ing paranoia U suall v a fter a s hort prodromal

. P ar a n oi a

period o f m o tor restlessness marked suspicion ,

an d di st r u st o f f amil y an d co m pan i ons i s mani

f ested . Hallucination s of hearing sight an d , ,

 200 M E N T AL D I SE A S ES

smell a re s o o n d evelop ed t hose o f heari n g bei n g

.

m os t common O bscene lan gu age is con ti n ual l v

.

p ou red int o the i r ears They are call e d vile

.

names an d accused of unspeakable cr i m es I n .

nu m erab l e ies s w arm be fore thei r e ves and ver

min cover the w all s of their rooms and in fe st
thei r bedding an d cloth ing A mong the m ost .

character i st i c s y mptoms o f th i s d iseased co ndi

tion are the n umerous perversions O f sen si b i l i tv .

O ne o f these kno w n as M a gnan s sign i s almost

'

. ,

sign pathognomonic and consist s o f a se n sa t ion as i f

a foreign bo d y w ere under the skin espec i al l v ,

un d er the ti p o f the n ger or in the palm of the

hand I nnume rable pa resthes i as appear I n
. .

sects an d l ice c ra w l upon the bod v P rickings .

are fel t in the skin and t w itch ings o f in d ividual

muscles occur att ributed to electrical current s
,

th ro w n b y hidden enemies These sensation s . .

Pa r a n o i a f or m ing the b asis o f a paranoia l ike del i rium ,

often render t he victim exceedingl y dange r

ou s, as under thei r inuence de sperate h omi
c i d al at tacks m av be made upon the ind i v id ual s
'

f am i l v o r upon anyone he mav meet L ike the .

su ff erer f r o m a l coho l i c pers ecutor y del irium the ,

cocain i st is lled w ith an overpo w erin g un rea

jea lo u sy f
o sonable j eal o usv tha t i s centere d on his w i fe ,

causing him to misj ud ge the most innocent ac

t ions w hich unles s pre v ente d b v hi s i ncarcera
, ,

tion i n an asv l uni m av culminate i n homici d e

, .
 i NT O X i C A T I O N P S YC I I O SES 201

E xcep t w hen under the co m p l ete inuence o f

the inj ection the con sc i ousness o f the person is
,

sli ghtl y a ff ected The m ost prominent mental

.

symptoms are excitabil ity irritableness to w ar d s

,

f am i l v and fri ends ret i cence and sl ight impai r

, ,

m ent o f m em or v .

The m ost marked deprivation svm ptom s are

faint ing attacks d y spn oea palp i tat i on o f the
, ,

heart w eakened w ill po w er and depression

,
-
.

\ V ith the w ithdra w al o f the drug the hallucina ,

tions and mental cloudiness soon di sappear but ,

the insane j ealous y and ideas of persecution mav

persi st f or w eeks and month s .

C ocaine in sanit y is usual ly o f short durat ion ,

l asting only a f ew w eeks especiall y w hen pro

,

d uced by rapidl y increased dosage .

PR O G N O S I S
The pro gn o sis as to permanent cure i s al w a y s
doubt ful because o f the ten d en cv to re l apses Pr og n o si s
d btf l
,

ou u
ho w ever per fect mav be the recovery fro m an
attack In the m ost favorable cases mental de
.
,

ter i o r ati o n i s apparent evidenced in the w e ak

,

ened w ill po w er and the tendency to resort to

-

cocaine alcoh o l or m orph i ne f or the relie f o f an v

. ,

sl ight mental or ph y sical ail ment .

D I FFER E N T I AL D I A G N O S I S
The paranoia of the cocainist di ff ers from true
p aranoia in the greater n umber o f insane ideas ,
 202 M E N T AL D SE I ASES

in the changeabilit y of the del usion s and the i r

l ess per fect systematization .

The hallucinator y del irium o f cocaine di ff e r s

from the alcohol ic by i ts pecul iar skin hallucina
t i ons the slighter d e g ree o f mental clo udiness
, ,

and the l ack o f albumin in the urine The .

mania o f cocaine i s much m ore severe an d dan

gero n s than the alcohol ic .

T R EA T M E N T
The dangerous tendencies of m ost cases o f
T rea tmen t
ch ronic cocaine insan ity render home t reatmen t
i n sti tu
ti on a l usually i m pract i cab l e U tter l v unt ru st w orthy
.
,

these patient s can w ith the greatest di ffi culty ,

out side o f an in stitut ion be prevented from ob

,

ta i n i n g the drug .

\V hen the daily d osa g e has not been m ore than

ten or fteen grains it m ay be immediately cut
O ff w ith o ut au v dan ger of a fata l resul t but a ,

g radual w ithdra w al i s to be pre ferred During .

thi s process the st rength should be sustained b y

the most nouri sh in g easil y assimilable food gi v ,

en l n l iberal quant it ies at short interva l s .

T he bo w el s and k i d n e v s must be kept active ,

care ful attent ion given to elimina t i o n b v the skin ,

an d su ffi cient sleep be secured .

A care ful w atch should be kep t d ur i n g the

ll a tch f

or
w it hdra w al and any s v m ptom s o f collapse i m
m ed i ate l v combated b v appropriate remedies .
 I N TO X I C A T I O N P S YC I I O SES 203

Th i s vigil ance must be s ustained for several

w eeks as dangerous indic at ions mav arise m an v
,

d a v s a fter the d rug has been en ti r el v discon

t i n ned .

The pat i en t s should be kep t under rest raint '

f or several month s a f ter all sv m ptom s o f the

d i sease h ave disappeared in order to lessen as ,

much as possible the danger of a relapse .

N umerous drugs in addition to those al r ead v

,

mentione d mav exert a poisonous e ff ect on the

,

n ervous sv stem result ing in tem porar v or l ast

,

ing insanit y A m ong the m ost com mon are the

.

bromides quinine io d oform and l ead C hloral

, . .

chloro form e ther bellad o nna sal i cv l i c acid hv

, . , ,

o scv am i n e car b o n dioxi d e an ti y r m e and vari

, p , ,

ou s chemical toxins almost innumerabl e have in

certain susceptible ca se s pro d uce d marked m en

tal d isorders .

The mental disturbances mav be o f su d d en

onset or o f slo w devel o pment .

The m os t comm o n form i s an hal l uci n ato r v

del irium of a maniacal t y pe attended b v more or
l ess mental con fu sion and motor ag i tat i on w ith ,

or w i thout fever the development is

.

slo w chan g e of character

, i rritabil it y ins om n ia
, , ,

and del irious fancies are the characterist ic sy m p

toms \ V hen the at tack i s su d den the brai n i s
. ,

overpo w ered by the to x ine caus i n g various dis ,

tu r b an c es an d al tere d me tabo l i sm .
 204 M E N T AL D SE I A S ES

The duration of these del i ria varies from a

f ew hours to w eeks o r month s or t he y may b e ,

co m e ch ron i c terminating in secondary demen

,

tia O rdinarily after from th ree to fourtee n

.
,

days the mental equil ibrium i s restore d unl es s

,

the individual i s o f a markedly nervous organ i

z ati o n During the ent ire attack interval s o f
.
,

per fect lucidit y m av alternate w ith periods o f

prolonged mental con fusion A continuous de .

l i r i um deepening to so m no l ence and coma fore ,

ff w
r m i m
bodes a fatal termination O rdinarily the sens e .
,

deceptions grad ual l v fade a w ay as recovery pro

g r e sse s and nally ent i rely d isappear A t time s .

recovery is sudden but then relapses are com

,

m on . In ch ronic cases persecutory del usion s

,

are prone to supplant the harassing hallucina

tion s and continue in a modied form until a
w eakening and apathv o f the mental po w ers a re
establ ished .

A correct dia gnosis depends upon a kno w l edge

o f the po i son taken either internally or e x ter
,

nall y W here th i s kno w ledge canno t be obtai n

.

ed the diagnosis mav be exceedingly di ff i cult A

,
.

care ful ph y s i ca l examination shou l d al w ays be

ma d e .N on react ive w idel y dilated pupil s a
- -
,

b l ue l ine on the edge o f the gums the Odor o f the ,

breath or a general cvan oti c condit ion mav sug

,

gest the causative a gent and the nece ssary trea t

m ent .
 I N T O X I C A T I O N P S Y C H O SES

The pat hol ogical anatomy o f these ch ronic

poisonings has not been ful l y establ ished .

T R EA T M EN T
The t reatment m ust vary according to the c aus
ative agent W ith many agents like quinine
.
, ,

iodoform or the sa l ic y lates l itt l e treatment beside

,

the w ithdra w al of the drug w ill be re q uired .

W i th others st renuous e ff orts at el imination o f

,

the poison by the skin kidneys and bo w e l s must

, ,

be made in addit io n to thorough ushing o f the

,

stomach and intestines .

L arge quantities of easily digested foo d m ust

be given at S hort interval s to sustain the st rength .
Sti m ul a n ts
W hen sign s of cardiac w eakness appear st im u ,

l ant s Should be administered every hour i f n eces

sary \ V hen brandy or w hi sky d o not prove su fh
.

cient st rychnine or digital is m av be re q uired n u

,

til all signs o f hea rt f ailure have passe d a w a y .

When maniacal sv m ptom s are p resent the patient

m ust be kept con stan tl v in bed by mechanical r e
JI ust be
,

straint i f necessary A s much sleep as possibl e

.
kept i n bed
shou l d be obtained in order to he l p con serve the
,

pat i ent s st rength unt il the e ff ect s o f the poison

'

have been overcome .

T he forms of poisoning capable of producing

insanity are too numerous to a d mit o f our de
scribing the m all i n detail : w e shall there fore , ,

l i m i t ourselves to a f ew o f the m ost common .

 206 \I N T AL
E I E A S ES
D S

B RO M I S M
The extensive use O f bromides gives to the
al ienist freque n t op portunit ies f or observing the
e ff ects o f excessive d osage A s a rule the mental .
,

M el t /a! symptoms are characterized b v a retardation o f

r eta r da m
the cerebral funct ions Th i s i s mani fested n o t .

onl y in the slo w comprehension o f q uestions b ut

in all the muscular movements The speech i s .

slo w low an d monotonous In addition to thi s

, ,
.

retarded response to an y st imul i marked fail ure ,

o f m em or v con fusion sleepiness or stupor mav

, , ,

b e present assoc i ate d w ith vertigo ataxia epi l ep

, , ,

ti f o r m attacks an d n umerous gastro intest inal

,
-

sym ptoms .

I O DO FO R M
The poisoning from iodo form may resul t from
its external app l ication to w ounds or i t s internal
admini s trat ion .

The psychosis d oes not usually appea r unt il

a fter ten or t w elve davs use o f the drug A fte r
.

a per i o d o f irritabil ity and uneasiness mental ,

co n fusion appears follo w ed soon by hallucina

,

Co nf us i o n t ions The pat i ent s become completely d i so r i

.

H a l l ua n a en ted obl ivious to the lapse of time excitable

'

, , ,

D i sor i en tm
compl aining and d i i cul t to restrain in bed The
, .

o
ti n pul se i s accelerated the te m perature elevated and
, ,

c v an o si s mav appea r The urine reveal s the .

 I N T O X I C AT I ON I S YC I I O SES

20/

presence of iodine and often o f albumin The .

del i rium may persist from four days to a w eek

after entire discont inuance Of the dru g until the ,

urine fail s to give an iod ine reaction .

Q U I N I N E
C ertain persons of ma rked neurotic tempera
ment may become del i rious from d oses o f q ui
n ine per f ectl v harmless to the ordinar y individ
,

ual A young man t w enty v e years of age and

.
,
-

never be fore insane came under my care sev eral

,

years ago A fter a f ew da y s o f t reatment w ith

.

moderate d oses o f q uinine by h is ph y sician he ,

had developed suicidal mania w i th hallucinat ions S n i ci d a l

Of sight and hearing and during one Of h i s paro x
,
n: a n i a

v sm s o f excitement had made an unsuccess ful a t

te m pt at suicide b v j umping from a second stor y -

w indo w hen rst seen by me he w as w ild an d

.
I
,

excitable re q ui ring mechanical restraint i n bed

,

to prevent h is inj uring himsel f and attendants .

C omplete discont inuance of the quinine and the

appl ication o f a f ew indicat ed remedies restore d
h im w ithin a f ew d a y s to his normal mental con
dition in w h ich he has remained for fteen
,

y ears .

L EA D P O I S O N I N G
M ental disturbances f rom lead a re among the I ) e l xa n e
most co m m on and w ere desc ribed b v Dehane a
. s I
77 1
 208 M E N TAL D i sEA sES

early as 1 77 1 Be fore the appearance o f cerebral

.

disturbance the common symptoms O f l ea d po i

,

soning col ic w rist drop pains in the l imbs

, ,
-
, ,

perineal paralysis cramps in the limbs an d s i gn s

, ,

o f innutrition and an aemia are usually observed .

Inso m nia rest l essness vertigo and noises in the

, , ,

head may precede the cerebral sy m pto m s or they

, ,

may be suddenly ushered in by an epilepti form

cti z e
'
convul sion W hen once establ ished the ps y cho
.
,

si s takes the form of active del i rium w ith great

res tlessness hallucinations o f s i ght and hearing
, ,

an d marked tremor C onvul sions or periods o f

.

l ight stupor o r attacks o f co m p l ete coma m av

occur at any time O ther cases simulate d emen
.

t i a par al vt i ca in the i r marked mental en feebl e

ro n i o s ment t remulousness and muscul ar w eakness

, ,
.

g s
The prognosis in these cases i s un favorable .

The pathology is still i n doubt The con sen sus .

of op i n i on favors the vie w that the lead simp l y i s

an incit ing factor i n those espec i a l ly predisposed
to insanity .
 C H A P T ER IX

DE E NT I A P R l EC O X

Under the term dement ia przecox Krae pel in ,

has grouped several co n stitution al ps y c hoses ,

w hich make their appearance abo ut the period

A dol s
e ce n ce
of adolescence C haracteri ze d b y progr e ssive
.

psychic exhaus tion and a ten d en c v to dement ia i t ,

d evelops in i t s course maniacal exc i tement mel

, , ,

an chol i c sv m ptom s an d con f usional state s

, .

It has been divide d i n to th ree forms :

Hebeph renia .

C atatonia .

P aran o id form s .

ET I O LO G Y

P re em i n en tl v a d i sea se of the devel o p m enta l

-

perio d m ore t han sixty per cent of the cases ap

, .

pear be fore the tw en tv f th year There is ho w -

. ,

ever a di ff erence i n the various form s nearly

, ,

three fourth s of the c a ses appearing be f ore the

tw en tv f th vear in hebeph re n ia si x tv eight pe r ,
-

cent in catatonia and f ort y per cent i n the para

.
, .

n o i d form Si x t v four per cent o f the hebe

.
-
.

phre n ic cases are men w hile w omen slightl y pre ,

d ominate i n the catatonic and par anoi d f o rms .

15
 D EM E NTIA I R C O X

. 21 1

Insane parentage is found i n on l v one ha l f of the -

cases but de fective he red i tv appears in about

,

sev e n tv per cent of them : this inuence i s

.
,

ho w eve r more po tent in the paranoid and cata

,

ton i c forms than in the heb eph renic O ne tenth .

-

of the cases are produced b v typhoid and scarlet

fever A smaller percentage o f cases may be
.

trace d to head inj uries A lcohol ism in the father .

may act as a causat ive factor O ther exciting .

causes are severe attacks of children s di seases

rapid gro w th exhausting study over exert ion i n

, ,
-

athletics fright shock emotional excesses and

, . , ,

childbi rth w ith its exhausting sequel ae \V hi l e .

cases may occur in intell igent ch ild ren w ell en ,

do w ed mentally and w ith good physical develop

,
S ti gm a !

m ent in m an y various stigmata of degeneration
era ti on
,

appear such as as y mmet r ies ey e de fects ear or

, , ,

palate mal formatio n s C ertain early mental .

pecul iarities as excess i ve bash fulness precocious

, ,

piety lack o f se l f cont ro l are noticeable in many

,
-
,

patients and a smal l percenta ge have al w av s been

,

m en tal l v de fective .

PA T H O LO G Y

N o de nite pathology has as v et been establ ish

ed but various theories have been advanced as to
,

the nature o f the disease O ne theor v is that .

,

w here the deterioration i s rapi d a lesion o f the

cortical neurons exi st s in some ca ses repa rabl e , ,
 21 2 M E N T AL I E A SES
D S

in o thers permanent and progressive T he exac t .

methods by w hich the chan g es in the nervous sys

t h eory tem are produced are still unkno w n T he most .

prevalent theor y i s that o f Kraepel in th at demen ,

t ia praecox i s a disease o f auto i ntox i cat i on -

.

This hypothesis i s based upon the c l ose relation

sh i p w hich the di sease bears to puberty the f r e ,

quent occurrence of menstrual dera ngeme n t an d ,

the frequency of its rst appea rance during preg

nancy and the puerper i u m A s no positive ana
.

tom i cal basi s for the disease has been establ ished ,

w e must a w ait future investigation for a settl e

ment of it s true nature .

S YM P T O M A T O LO G Y

A s m an v symptoms are common to all forms

I llectual
n te
O f the di sease w e shal l describe these be fore con
,

m en t si d e r i n g those diagn ostic of the individual types .

The b asic s y m pto m o f all the varieties o f th i s

dis ease is intellec tual en feeblement Y et w h il e
.
,

mental w eakness may profoundly a ff ect certain

faculties others remain intact W h ile apparent
,
.

l y oblivious o f h i s surroundings a patient may be

,

completely oriented and give rationa l repl ies as to

h i s location dates and passing daily occurrence s
, , .

The memory al so may be slightl y impai red espe ,

c i al l y for past events know ledge long since ac

,

q uired being detailed w ith scrupulous exactnes s .

Geograph ical facts h istorical epoch s and dates

, ,
 D E M EN T I A t R EC o x

.
=
21 3

and na m es of rulers may be recalled even a fter

evi d ences o f a d vance d deterioration have ap pea r
ed. R ecent event s ho w ever are l iable to be for
, ,

gotten A s the d i sease advances both antero

.
,

grade and ret ro grade amne sia appear the ah ,

terogr ad e rst the ret rograde later

,
and in the , ,

e n d memory mav be almost en t i r el v e ff aced

, At .

tention i s al w ays w eakened and cont i nuous con

cent rat i on i s impossible In the milde st ca ses .

t here is al w ays lack of coherent thou ght w hich in ,

severe cases resul ts in genuine con fusion givin g

, ,

rise to the m ost incoherent forms O f speech The .

follo w ing typical example w e cite from De Fur

i nc oh e
r en t

W hat l iver and bacon is I d on t kno w
'

sac : .

Y ou are a spare : the spare ; that is all It i s A unt .

M ary I s i t A unt M a ry \V oul d you look at the

.
?

thing ? W hat w ould y ou th i nk ?

C old cream .

T hat s al l w ell ; I thou ght a co m ed i ata Don t

.

w o r rv about a com ed i ata You w rite He i s . .

w rit ing S houl dn t w rite T hat i s a l l I ll bet

. . .

you have a lump on vour back That s all I

. .

l ooked ou t the w indo w and I didn t kno w w hat

underground a n nouncements are M v hu sban d .

had to take d a y s for a t o f sickness .

De fect ive j u d ment i s al w a y s from the begin

g
,

ning a prominent symptom Th is may n ot be ac

, .
D 1 f ecti ve

c en tu ated w hen the pat i ent i s i n famil iar sur j d

u gn u n t

roundings but n e w condi tions and circumsta n ces

,

bring i t in to pr o minence Unable to comprehen d .

 21 4 M E N T AL D i sEA SEs

the meaning o f their surroundings the i r act i on s ,

become strange and delusions appear base d upon ,

the i r de fective j udg ment These delusions m av .

be of a persecutory nature grandiose or m ere ly ,

silly A t rst stable then changeable in the late r

.
, ,

stages o f the di sease the y disappear excep t in the

paranoid forms and eve n in these they beco m e i n
,

coherent .

A mong the m ost common and characterist ic

symptom s are those evidenced in the emot ional
o on al
E m ti
eld w h ich may be the rst evidenc es o f m enta l
,

t rouble The patient becomes l istless and i n d i f

.

f e r en t .For m er pl easures cease to amuse stud v ,

an d w ork are ne gl ecte d a ff ection for family and ,

f riends is lost The enti re disposition i s c hange d

. .

E xpressing neither j oy nor sorro w l i st l ess and ,

apathetic i nsens i b l e to hunger or th i rst regard

, ,

less o f the call s of nature obl ivious to everythin g ,

t ran spiring about them the pat i ents m av sit o r ,

s tand ,
f o r hours davs and w eeks S imply staring
, , ,

into vacancy Y et w hil e appear i n g completely

.
,

demented and d e v o i d of all t hought an d activity ,

they are l iable to have sud d en causeless ex pl o

s ions of rage and viol ence In these states fur .

f
o rag e
n i tu r e mav be d e str o v ed w indo w s broken clothes , ,

t o r n personal inj ur y attempte d or violent mo

, ,

t i v el e ss attacks mav be m a d e up o n an v on e in thei r

vicinit y These attacks of violence are u sual l v

.

t r an sitor y but mav en d ure f o r se v eral davs

, .
 D EM ENT I A PR E O C X 21 5

Wh ile the v ol un tar v and normal reaction s are

red uced the automatic reaction s are often ex ag
,

gerated Th is i s especi all y prominent in the

.

catato n ic form H ere each natural impul se .

,

seemingly being met an d overcome b y an oppos

ing impul se gives ri se to actions directl y Opposed
,

to those desired T O th i s condition the na m e o f

.

n egati v is m has been appl ied W hil e in this con .

N eg a ti vi sm
dit ion act i ve resi stance is made b y the patient to
,

ev e r vth i n g w h ich is d one for h im I f asked to .

open the e ve s he closes them ; i f asked to sho w

,

the ton gue he rmly shuts h is teeth : on l v b y

,

fo rce can he b e dressed or undressed : food is re

fu sed : and the urine and feces mav be voluntari l y
retained Th is condit ion may be cont inuous or
. , ,

after being re l i e v e d from i t for several d avs the ,

pat i ent m av a ga i n re l apse into the same state .

S tereot y py o f movements an d att i tu d es v er b i g , S tereotypy

c ration ,grimaces and sil ly l aughter are other
,

ti on
m ani f estat ions o f the repeated recurre nce of the
sa m e impul se For hours pat i ents w ill repeat a
.
,

sin gle w ord or ph rase w alk over the same spot, ,

ta k e d o w n an d put up the hair dress an d undress , ,

o r hum the same l ine of some famil ia r tune .

The capacity f or employment is al w ays w eak

ened \V hi l e capable o f doin g routine w ork n u
.

der d irect ions the y are utte r l v unable to branch

,

ou t i n to n ew elds \V hi l e a f ew patien ts m ay be
.

able to dra w or exhibit some m u sical or techn i ca l

,
M U SC U L A R T E N S IO N I N CAT A T O N I C S T U PO R
 DE M E NTIA P R .E C 0 x 21 7

skill there are al w a y s apparent evidences of

,

mental w eakness .

S O M A T I C D I SO R D ER S
A large v ar i etv o f physical symptoms ha v e
been note d b v various observers but no n e of ,

these can be considered constant o r diagnost ic .

T hev appea r in all three forms of the disease In .

the motor sphere may appear t ransient hemi

l
p g e i a s and monoplegias convul sive h,
y ster i ca l , ,

and epilept i form and apoplect i form attacks The .

tendon reexes may be dimini shed o r abol ished .

but are usually exaggerated Disorders of the .

pupil s are fre q uent but varv : i n eq ual i tv m vd r i a

, .

s i s sluggish reactions O r cont ractions on f orcibl e

,

closure of the ev el id s may occur A nother phe .

n om en o n has been describe d b v P il tz an d by

\Nestphal : I f the patient attempts to sh ut h is
'

eves w h ile his e ff ort is oppose d by the examiner ,

w ho holds the l ids apart f o rc i b l v w ith the ngers ,

a con t ract ion of the pupil takes place w hile the ,

e y ebal l is rolle d up w ar d an d out w ard .

The heart s actio n may be w eak and i rregul ar

'

accelerated or retarded Fre q uent vaso m otor d i s

.

orders appea r oed en i a s c y ano sis o f the ex trem i

, ,

t ies de rmographic and excessive perspirat ion

, .

The temperature mav be subnormal P ol v ur i a .

or ol iguria may be present In some cases there .

is excessive sal ivation In the acute sta ge s lo ss

.
,
 21 8 M E N T AL I E A S ES
D S

of sleep indigest ion const ipation anorexia los s

, , , ,

of w eight and am en or rhma are prominent sy m p

,

tom s : but these may all disappear later i n the di s

ease and a good appet i te develop w ith an increase
,

in esh menstruation beco m e regu lar and th e

,

sk i n assume its normal appearance .

H EB E P H R EN I A
The onset o f th i s for m mav be so gradual and
insi d ious that the most int imate friends m av be
unable to determine its exact be ginn ing Fo r .

v ea r s previous to the de nite establ ishme n t o f the

d i sease the pat ient s mav have m ani fested pe en

,

l i a r i ti e s an d ecen tr i C I ti e s o f manner and cha r

'

ccen tr i c acter l ale th in nervous from ch ild hoo d th e

.

, , ,

c712:
parent s w i l l sav o f such children that they ha v e
i /d h ood
been shy sens i t i ve seclusive j ealous and re l uc t
, , , ,

ant to j oin in the sport s o f other ch il d ren E x .

ce ssi v e l v conscient ious an d rel igious the y ha v e ,

been prone to broo d E mot ionally unb alance d .

,

su dd en outburst s o f passion occur O f uneve n .

cal iber i n school they have sho w n unusual pro

,

c i en c v in certa i n su bj ect s an d great de cienc y i n

o thers . A s the period of pub e r tv i s approached ,

these individual i d i o sv n c rasi e s and eccent ricitie s

ha v e become m ore marked and emphasized un t i l ,

thev ha v e become menta l abnorm al ities or som e ,

acu te d isease or mor al shock mav trans f or m

them int o p o sit ive mental sy mptoms .
 D E M E N T IA P R E C O X 21 9

U sually the rst s y m p to m s el icited are head

,

ache and S leeplessness w hich are follo w ed b y a ,

gradual change of d i spos i t i on The pat ients lose . Sy mptom s

all ambit io n and energy become du l l an d apa ,

thetic sel f absorbed and l istless or careless i rr i

,
-
, ,

tab l e and O bst i nate A l l interest i n w ork or stu d y

.

is l ost an d the y sit about unemployed or remain

in bed for w eeks w ithout evident reason O thers .
,

in place o f thi s mental indolence and apathy ,

evince a marked restlessness w hich preventing ,

,

any cont inued e ff ort drives them ai m l essl v from,

place to p l ace In others an increased sexua l ex

. ,

c i tem en t is aroused and the y plu n ge into pro

,

m i scuo u s sexual excesses A stage o f depression .

Depressi o n

i s ho w ever the most common on set Sad de

, ,
.
,

j e c ted indi
,
ff erent to friends and surroundings ,

borne do w n b v thought s o f death and the i r

mental su ff erings thev m ay make at te m pt s at sui
.

cide Hal l ucinat ions of hearing sight or smell

.
, ,
Ha lluci n a
ti o n s
n o w appea r S t range soun d s th reatening voices
.
,

pouring out oaths curses and i m precat i ons , , .

st rain s of music telephone messages or communi

,

cat ion s fro m another w orld ll thei r ears Grim , .

acing f aces peer at them from the w a l l s or fright ,

ful beast s spring ti p before their e y es or friends ,

long dead appe a r by thei r side L ess fre q uently .

,

the y complain t hat they are being asph y x i ate d b v

nauseous f u m es of chlor o form illuminating gas , ,

and sulphur V ario u s h y peres thes i as m av cause

.
 220 M E N T AL D i sEA S ES

the m to be l i eve that the i r limbs are changed to

glass that the lungs are sol idi e d or the l i ve r
, ,

turned to stone or the bo w el s lled w i th lead

, .

C oinci d ent w ith or preceding the hal luc ination s ,

depressive delusions are l iable to appear T h e .

patient s proclaim themselves criminal s sentenced

to death say that their soul s are l ost and that the v
,

H ypochon are too vile to live P ersecutor y delusions a l so ap

.

dr i a ca l pear causing suspicion o f friends and the i r sur

,
er secu toI y
p
ex a n si z e ,
p
' '
,

roundings fear of poison and bodily harm

, ,
In .

sex ua l the latter course o f the disease and o cc a s i on a l l v

delusi o n s
,

at the onset expansive d elusions appea r and the y

,

proclaim the m se l ves to be the C zar the S aviou r , .

or the possessors of endless w ealth These d e .

l u si o n s m av have a sexual tinge and the posses s ,

ors bel ieve themselves the ch ie f centers o f att ra e

tion to the opposite sex A ll these delusions may
.

be augm ented b v fabrications but del usions and ,

fabrications as the disease advances grad ual l v

, ,

fa d e a w ay until in the last stages on l v i ncoher

, , ,

ent resi d ual s remain w hich seldom co m e to l igh t

,

unless during exciteme n t or as the resu l t of care

ful in q uiry S ome patient s recog niz ing to some
.
,

extent the i r condit io n compl ain of s tran ge fee l

,

ings in the hea d that they attr i bute to c han ges

going on in their brains w hich produce con fusio n
,

and a failure o f m em or v ; but th is Sl i ght kn o w l

edge slo w l y disappears as the d i sease pro gresses .

In the slo w l y d e v el oping form s there i s at rst , ,

 DE M ENTIA P R SEC O X 221

little di sturbance O f consc i ousness and the pa

ti en ts are f ai r l v w el l oriented .

When the onset i s acute or subacute marked , ,

clouding of con sciousness and disorie n tat ion are

combined w ith dist inct hallucinations and del u
sions anxiety uneasiness and incoherence O f
, , ,

thought ; friends and companions and famil iar

surro undings appea r st range and the pat i ents are ,

unable to take cognizance of passing event s .

Wh ile at rst there mav be l it tle disturbance O f

, ,

the association of ideas an d the conten t of speech

,

may be coherent and relevant as the disease pro ,

g r e s ses a marked deteriorat ion becomes apparent .

Thought and speech are prof oun d l v incoherent ti on

and di sconnected and at last a re l imited to
, , ,

monosyll ables or to i rrelevant remarks that can

,

be el icited on l v b v questioning .

A progressive w eakening o f the memory ap l l em ory

pears fro m the onset o f the disease Th is i s rst .

apparent i n regard to recent event s \V hi l e .

kno w ledge attained in ear l y l i fe or at school may

be retaine d for a long t ime the events and occur ,

ren ces dating from the onset of the psychosis are

e i ther enti rely forgotte n or i m pe r f ectl v remem

bere d U ninteres ted in thei r surroundings o r
.

i n d{f er ence
w hat occurs about them the pat ients pay littl e
,

attent i on to passing occurrences and thought b e ,

comes more l imite d w ith the prog ress o f the di s

ease P ast experiences from being seldom re
.
,
M U SC U LA R T E NSI O N I N C A TAT O NI C TU P R
S O
 DE M E NTIA P R AE C o x 223

called soon fade out o f the memor y b ut under

, ,

the s t ress of unusual sti m ul ati on ev en ts appa

ren tl v com pl e tel v forgotten m av be remembered .

I m pa i r m ent o f j udgment i s an ear l y s y mptom j udg m en t

an d becomes m ore and m ore m arke d as the d i s

ease progresses Th is is especially emphasi zed i f

.

the patient is removed from the home routine to

w hich he i s accustome d and placed in n ew sur
roud i n
gs .

A mong the most diagnost ic are the changes l i m oti on a l

mani fested i n the emot ional el d dulness and i n ,

d i ff erence bein g the most prominent s y mptoms .

A t rst depressed anxious peev i sh and i rr i ta

, , , ,

ble later the pat ient mav become h y per re l i g i ous

,
-
.

Th is excitement n d s express i on in frequent

prayers and con t i nua l reading o f the B ible : rst ,

i n an at te m pt to atone f o r sins l ater fr o m a b e , ,

l ief that he i s under especial divine guidance or

has received so m e particula r commission fro m
G od . In those w ho have been addicted to m a s
turb at i on the cent ral and impell in g thou ght m av
,

be sexual causing the m ost Shameless mastur b a

,

t i on and indecen t solicitat ions for intercours e .

L ater this excitement disappears

, .

In late stages o f the di sea se al l emotion seems

d ead The visits o f fr i en d s the d eath o f rel a
.
,
em oti o n
t i v e s prod uce no impre ssi o n
, Dev o id o f ca re . .

though tless of the future the patient lea d s an ,

utterly empt y l i fe .
 224 M E N TA L D S I E A SE S

T he conduct and behaviour a re a natural r e ec

Co n d uct
tion of the mental state C areless o f d ress and .

person the patient w i l l sit for hours lo oking at

,

the same page o f a book o r b usied over a singl e ,

l i ne of a l etter He bursts out at times in S i l l v

.
, ,

laughter or makes curio u s gestures or s t range

,

bod ily movement s The silly laughter i s high l y

.

characterist ic and utterl y meaningless and w ith

,

out emot ional signi cance The patient m av sit .

by the day rocking in a chair or staring at v a

c an cy . W hen urged to d o anything he make s ,

violent opposition w hatever the order may be

, ,

w hether to leave hi s chair o r bed pro t ru d e hi s ,

tongue attend to the call s of nature or take food

, ,
.

O ccasionally ts o f viole n ce occur w hen he w il l

, ,

P a ro ry s
.

_
break w indo w s tear h i s clo thing or cause l ess ly
, ,

o
m a l vi len ce
attack those about h im When not under re .

st raint he may run a w ay from ho m e an d w ander

,

aimlessly about the count ry He mav even co m .

mit some criminal act l ike setting re to bu i l d ,

ings . M any cases are given to excessive onan

i sm and others are sexua l pervert s M ost pa
,
.

I l a n n er ti en ts exh ibi t certain manneri sms pecul iarities o f ,

s s
i m speech an d mo vement They frequently contort .

the face w ith grimaces I f an attempt is made .

to shake hands the patient w ill n ot grasp the ex

,

ten d e d han d but w il l simpl y stretch out h is ow n

,

hand sti f y to m eet i t ; th is action is q uite charac

t e r i sti c A ll m ove m ents sho w a certain restraint
.

an d lack of freedom .
 DE M E NTIA P R . EC 0 x
=
225

The speech i s l led w ith m eaningless h igh ,

Letter s
soun d ing ph rases Obsolete wor d s and gram m at i
, ,

cal b l unders and reect s the incoherent thou ght

,

and co n fusion T h e l etters stil l more reveal the

.

mental w eakness These are l led w ith numer

.

o us repetitions prof use underlining d isconnected

, ,

ph rases and are utterl y w ithout sense or mean

,

The physical svm ptom s are numerous and

varied In the beg i nn i ng the appet i te i s poor
.
, ,

l i tt l e or n o food i s taken and there is m arked loss ,

of w eight S leep is disturbed o r l ost T he pupil s

. .

are usuall y dilated the reexes exaggerated , ,

there i s a diminution of sen si b il i tv to pain .

C y anosis local oedema and dermo graph y m av

, ,

reveal the marked vasomotor disturbance The .

menses cease or appear w i th i rregularity S al i .

vation may occur and the bodil y temperature be

lo w ered T he heart s action 1 3 di sturbed and
.

poor ci rculation i s revealed by the cold s w ollen , ,

c yanotic hands and feet A s the d i sease advances

.

the appetite m av return the l ost w eight be r e .

gained and excess i ve corpulence succeed the

,

emaciat ion M enstruation m ay be re establ ishe d

.
-

and the w hole physica l condit ion be improved .

T he course o f the disease is progressive and / en ta l d e

ten d s to mental deterioration Sev en tv v e per .
- o o
ter i ra ti n

cent become pro f oun d l v d emented In seventeen

. .

per cent of the cases a m ilder degree of d eter io r

.
 D EM ENTIA P R E C ox
. 229

ation Obt ains A f ew cases recover sui c i en tl v

.

to return to the i r homes an d en gage in cer tain

routine employments re q ui ring l i t tle bra i n ta x a
t i on but the y are excee d in gl y l iabl e to relapse
, ,

from thei r i n ab i l i tv to properly re gula te thei r

l ives In eight per cen t o f the cases al l mental
. .

"

s y m p to m s disappear Kraepel in ) . .

CA T A T O N I A
The catatonic form i s characterized b v cvcl i c ,

alternat ing per i o d s o f depression mania stupor

, , , ,

and con fus i on .

The rst sta g e of the di sease i s u sual l v tha t o f Depressi o n

depressio n the on set o f w h ich m ay have been
,

gradual For several w ee k s often a f ter a slo w

.
,

an d imperfect convalescence fr om acute d i sease ,

the pat ients have not appeare d q uite natura l .

Friends have not i ce d an unusual q uiet n e ss an d

ser i ousness T hev m ay complain of pains and
.

pecul iar sen sat ions i n the head and d i i cul tv i n ,

concent rating the mind In somnia los s o f appe .

,

tite and excessive nervousness al so m ay be pres

,
Ha lluci n a
ent Gradual l y anx i et y and fear possess the pa
.
, ti o n s a n d

ti en t s an d halluci n ations and del u sions develop .

delu si on s
V oices d i rect the act ions heavenly vi sions appear ,

before the eves faces peer fro m the w al l s an d

, ,

poisonous fumes l l the nost ril s The delusion s .

usually have a rel igious tinge and are changeable ,

and incoherent De ath i s i m mi n ent a s a puni sh

.
 230 M E N T AL D I SE A S ES

ment for innumerable sins C ommanded b v G od .

.

the patient re fuses foo d He is eternall y dam n ed .

,

has ruine d hi s family and has been change d into

a devil The brain has been dissolved the bo d y
.
,

and l imbs have been turne d to stone La ter e x .

,

p a n s i v e delu s ions appear or the y may be presen t,

fro m the onset He i s immortal omnipotent

.
, .

om n i scen t the possessor of mil lions and can heal

, ,

all d i sea ses Earl v in the disease the moveme n t s

.

ra i n t
and actions become con strained The patien t .

m av l ie or stand for hours i n so m e a w k w ard

, ,

position staring xedly at one point C onsciou s

, .

ness is now some w hat clouded there is sl i gh t di s ,

orientat ion an d surroundings are im pe r f ectl v

,

co m prehended W hile he m ay real ize tha t h e

.

i s at home or in an institut ion he m av n o t ,

recognize the persons about h im or everythin g

m ay appear changed causing him to bel ieve that ,

he has been t ran s ferred to heaven or some fo r

e i gn cl ime U nable to reason because of the di s
.
,

connect ion and i n cohe rencv of h is thought s an ,

sw er s to q uestions are cont radictory and i rr el e

vant and continued attent i on i s impossible

,
.

M emory for past event s ho w ever m ay be good , , ,

but i s faul ty regarding occurrences s i nce the on

set of the disease .

A t rst there m ay be marked emotional di s

,

tu rb an ce w ith attacks of violence upon the sl ight

,

est inter ference w h ich is later follo w ed b v in

,
 D E M EN T I A 23 1

di ff erence and placid co n tentment Fol lo w ing .

C a ta ton i e
the d epression the characteristic catat onic
,
stupo r or
stupor or cataton i c exci tement appears : or the
, , ex it m
c e en t

catatonic symptom s m ay usher i n the disease the ,

latter being asserted b y Kraepel in to take place i n

at least one thi rd of the cases The catatonic
-
.

stupor w h ile r esembl ing an ord i n arv stupor

, ,

di ff ers essent ially as the pat ient w hile apparent l y

, ,

obl ivious Of al l h is surroundings m ay be keenly ,

observant o f all that occurs about h im and be

a ble a fter recovery to describe m i n utel v all that
, ,

has t ran spi red during hi s attack .

During the stupor th ree ch aracter i st i c condi C ha r acter

ti ons prevail : negativism stereotv py and pa i sti c
,

thol ogi cal susceptibi l it y .

N egat ivism according to Kraepel in con
, , N egati v i sm
si st s in the reaction to stimul i w h i ch are the r e

verse o f the normal reaction The patients d o .

exactl y the Opposite O f w hat is re q ui red of them .

The rs t mani festation of th i s negat ivi sm is u su

ally mutism w hich mav continue f or w eeks the
, , M u ti sm
pat i ent lying w ith eves closed and in spite o f all , ,

e ff ort s of the questioner re fusing to utter a ,

w ord . The same persistent res i stance i s m ani

f ested a g a i nst any e ff ort to care for h im He .

refuses to dress or undress get up or go to bed , ,

open the e y es put out the tongue bathe attend to

, , ,

the cal l s of nature or eat This condition mav

,
.

last for months requi ring feeding w ith a tube

, ,
 232 M E N T AL D I SE A SE S

catheteri zat ion and enemata Deep pricking o f .

the skin or st i m u l at i on w ith a strong galvanic o r

,

faradic current m av el icit n o evidences o f sen sa

t ion n ot because i t i s n ot felt but because vol u m
, ,

tary reaction is annihilated .

S tereotypy i s mani fested in the pecul iar att i

tudes assumed and the general physiognomy .

T he pat i ent m ay stand sit in a chair or l ie , ,

upon the oor in the most uncom fortable att itude

for hours w ithout movement The arm may be .

raised or the leg extended and ho w ever pa i n fu l , ,

its position there i s no attempt to move it Th e

, .

n g ers mav be so tightly exed that macerat io n

of the pal ms w ill occur unless they are forci bl y
opened The muscular rigidity may be so mark ed
.

that it i s impossible to move a l imb w ithout the

exertion o f great force T he eves mav be tightl y
.

c l ose d the features rigid and the l ips st retched

, ,

out l ike a snout a sign named by K ahl b aum the

,

sn outc r am p .

These phenomena may pers i st for month s or ,

v ear s but almost al w ays in the beginn ing of the

,

d i sease disappear during sleep .

P at hological susceptibility may alternate w i t h

l sus
negativism .

I f an arm or leg i s raised or extended it i s r e ,

ta i n ed i n the position in w hich i t i s placed In .

capab l e of caring for themselves the patient s

q uietly submit to being w ashed d resse d and , ,

combed .
 D EM E NTI A P R ZE C O X 233

Echolal ia and echop raxia are very fre q uent .

\Vord s questions and songs of those about the m

, ,

are mechanical ly repeated and the movement s ,

and act ions o f the ph y sician or of thei r fello w pa -

ti en ts are closely imitated by them From ab so .

lute sil ence the patient mav suddenly break out

into loud prolonged shouting and incessant bab
,

bling or suddenly arousing from hi s stupor may

, , ,

ta l k per f ectl v natur al l y and then in a f ew hours

relapse aga i n i n to the former stuporous condi
tion.

CA T A T O N I C E X C I T EM E N T
E xci tement m av interrupt precede or follo w ,

the stupor The principal characteristics of

.

catatonic excitement are it s freedom from em o,

t i on it s independence of externa l impressions the

, ,

absence o f denite delusions and the universal ,

mani festation O f impul sive actions and stereo

tvped m ove m ents .

In catatonic excitement the extre m e l imit of ,

automatism i s exhibited \V i thout ca u se the .

,

m al i sm
p a r ox v sm s of excitement break out The pa .

tient m ay sud d en l v Spring from h i s cha i r or bed ,

rush w ildly about hi s apart m ent destroy f ur n i ,

t ure break w indo w s f ur i ou sl v attack his attend

, ,

ants or th ro w h imsel f upon the oo r or against

,

the w al ls For hours at a t i m e the body may be

.

sw av ed fro m s i d e to side or the pat i ent may w alk

G RO U P I T H

M A R K E CAT A T N C T E N S ON
D O I I
 D EM EN T I A P R xE C O X

back an d f orth over one path for a dav at a time ,

somet ime s going f o r w ard then back w ar d In ,

.

some patient s f o r w eeks suicidal ten d enc i es are

, ,

mani f ested unattended by any depressing ideas

,

or emotions During the excitement the pat ient s

.
,

are untidy and lthy i n the ext reme often mixin g ,

l th w i th thei r food and soiling their perso n s ,

bed d ing an d apartments

, M arked sexual ex .

c i tem en t al so may prevail S tereotypy and ver

.
S tereoty py ,

b ige rat i on are apparent in the movements atti

on
,

ti
tu d es and conversation A ll the i r act i ons and
, .

m ovement s are purposeless and impul sive and

u sual l v in d ependent o f delusions al though d elu ,

sions mav occasi on al l v be present The speech .

mav consist o f m ere sense l ess syllables or stereo

t y ped exp ression s repeate d often for hours at a
,

time T he same tendenc y is man i fested i n al l

.

the i r l etters in the i r excess i ve un d er l i n i n g sha d

, ,

ing and addit ion o f svm bol s C atatonic stupor

, .

and catatonic excitement succeed each other ,

o ften suddenly during the complete course of the

,

disease The i n ten si tv o f the stupor and excite

.

ment i s subj ect to m a rke d variat ion in individual

cases .

P H Y S I CAL SY M PT O M S

A moderate elevation of temperature varyin g ,

bet w een one hundred and one hun d red an d tw o

d egrees mav occur at the onset o f the attack and
,
 236 M E N T AL D I SEA SES

persist for one or tw o w eeks C ya nosi s dermo .

,

g p
r a h i a and ,
local ized s w eating are common
symptoms C onvul sions occasi on all v occur at
.

the onset o f the di sease Di sturbance of nut r i .

tion is apparent in the l oss of w eight during the

, ,

period of d epress i on an d may pro g ress to ex ,

treme e m ac i at i on in the sta g e o f stupor L ate r .

,

the w eight is regained the pat ie nts often becom ,

ing obese during the stage of deteriorat ion .

During the sta ge of stupor there are coldness o f ,

the skin and slo w ness and feebleness o f th e

,

heart s act i on and sluggi shness o f the bo w el s

, .

C OU R SE
T he usual course in cataton i a is depression ,

excitement deteriorat ion ; but thi s course may

,

varv b v the omission o f the excitement the de ,

mentia immediatel y succee d i n g the stupor I n .

rare cases the excitement may usher i n the di s

ease A p rominent characteristic o f catatonia i s
.

the occurrence of remissions w hich m av last ,

from a fe w hours to vear s .

en ta l

The outco m e accor d i n g to Kraepel in in
, ,

ter i or a
n
eighty si x per cent o f the cases i s ul ti m atel v m en
-
.

tal deterioration w h ich in th i rty nine per cent

,
-
.

becomes extre m e and i n t w enty seven per cent a -

.

mild for m o f dement ia resul ts In abou t thi rtee n .

per cent o f the cases pat ient s see m to recover
.
, .

In the m ost favorable cases ho w ever certai n , ,

 D E M EN T I A P R I C O X
. 237

re m nant s o f the disease re m a i n w h ich w hil e n ot , ,

su fcient to d eba r them from the w or l d di st in ,

gu ish the m from normal i n d i v i d ua l s .

PARA N O I D FO R MS
T he parano i d forms are characterized by the
persistence for v ea r s of d el usions and hall ucina
, ,

tions w ith prog ress i v e d eteriorat ion

, .

T w o principal t y pes are recogn ized : ( I ) the

incoherent type (2) the s y stematized t e The
,
.

rst group o f cases a re possesse d o f numerous

chan g i n g d e l us i on s and hallucinations reveal in g
no coherenc y w hic h are rapidly fol lo w ed by si gn s
,

o f mental en feeblement .

T he development of the disease m a y be slo w ,

inaugurated by numerous symptoms reveal in g a

progressive impairment o f the general health .

The pat ient co m p l a i ns o f pains in the head sleep ,

lessness lack o f energy and inabil it y to w ork

, ,
.

H e becomes irritable m ood v and depressed a n d, ,

shuns soc i et y Soon a multitude o f delusions

.
s on s
D elu i
appears A ll his movement s an d act i ons are
.

c riticised people stare at h i m

, \ V hen he i s on .

the st reet the pol ice are follo w in g him an d hi s

friends are plott ing a gainst h im C on ti n uall v .

changing the delusions soon become fantastic :

,

the heart has been removed the bo w e l s are l le d ,

w i th lead the l imbs par al v z ed Hal lucinatio n s

, .

of hearing s i ght or smel l may be presen t

, ,
 238 M E N T A L D i sEA sEs

V oices accuse him of c r i m es and telephone h im

insul ting messages Fear ful forms ter ri f v hi m
.

D a ng c ro us
at n i ght and poisonous v apors are blo w n i nto h i s
,

apart m ents \Nor r i ed disturbed an d mi st rust

.
, ,

ful o f everyone the patient may be come violen t

,

an d dangerous or seek escape fro m his per secu

tors b v suicide The consciousness usual l v r e
.

mains undistur bed The depressed and anx i ou s

.

mood i s soon superseded b v cheer fulness and ex

d
G ra n i ose
al tat i on The delusions take on a l ike cha racter
d l si s
e u on
.

and gro w more i m probab l e and ridiculous T he .

patient beco m es cheer ful po m pous loq uacious , , ,

and boast ful has been changed into a god i s des

, ,

t i ne d to l i ve forever i s the posse ssor o f mill ions

, ,

and the most talented o f mortal s Filled w ith a .

variet y of delusions he pours them fo rth freely ,

into the ears o f an v w illing l istener ; at r st co

he r en tl v later in an incoherent j umble
,
Q ues .

t i ons ho w ever may be ans w ered correc tl y

, , As .

the d isease progresses speech beco m es un i n tel ,

l igible and con sciousness clouded \V hi l e he .

mav recognize frien d s and h i s locat ion he i s l ia ,

b l e to m i s take hi s assoc i ates for peop l e f o r m e rl v

kno w n A ll i d ea of time i s l ost and mental ap
.

pl ication i s impossible a l though some simple me ,

c han i cal w ork mav be per formed P omp o us .

,

,

egoti st ic and sel f conscious he is seldom de ,

presse d although he m ay at t imes be res tl e ss

, ,

i rr i tab l e an d given to t s of pa ssion A side

, .
 D E M E N T IA P R E C O X 239

f rom the leeplessness and l oss of w eight at the

S ,

onset of the disease f ew ph y sical svm ptom s are

apparent .

The course o f the disease i s con ti n uousl v pro Co u rse

g r e ss i,
v e evidences o f mental deterioration a p p r og r ess i ve

pearing w ithin a f ew month s an d becoming em

h a i z ed b v the end of tw o vea t s
p s .

The second g ro up of cases i s characterized b v Per si sten t

hallucinat ions and delusions more coherent and y s s tem a
ti ed delu z
sv stem ati z ed w h ich mav persist for several
,
si on s ter
v ea r s ; upon thei r d i sappeara n ce the pat i ent is l e ft m i n uti ng
m od er atel v deteriorated Halluci n at ions are
or ati o n
.

common an d a ff ect all the senses The delusions .

are melanchol ic pe r secuto r v or megalomaniacal

, , .

The de l usion s m ay appear sudd en l v a fter a brie f

prodromata or be of slo w development Durin g .

the development of the disease an d o f ten for a ,

long time a fter the patien t s are oriente d thei r

, ,

conscio u sness is c l ear an d thought coherent A t .

rs t sl i ghtl v changed i n character the patient s ,

later pre sent melanchol ic d elusion s more per fectly

sv st em at i z ed t han in ordinar y m elanchol i a suc ,

ceed ed b y per secutory delusion s w h ich are f o l ,

l o w e d b v d elusio n s of gra n deur en d in g i n m ore,

or less pronounced d eme n t ia w ith con f u sion o f

,

thou ght the d elusions bec o min g changeabl e i n

, ,

coherent and n all v fading a w ay A lth ou gh the

, .

sta ges m av varv i n thei r or d er o f appearance the ,

outcome i s a l u a v s deteriorati o n .
 240 M E N T AL D i sEA sEs

D I AG N OS I S
Dem en ti a Dementia pr aecox is di st inguished fro m demen
P ur a ly ti ca
t ia para ly t i ca by the earl ier age o f onset i ts eti ,

ology less rapid deterioration and the absence o f

, ,

the ph y sical signs characterist ic of paresi s .

Pa r a n oi a I t i s distin gu i shed from paranoia b v the less

per fect sv stem ati z ati o n o f the delu sions the de ,

ment ia i t s ear l i er appearance an d i t s m o re rapi d

, ,

course .

PROG NO S I S
The progno sis is un fav o rable R emi ssion s .

f req uen tl v occur and a f e w cases may partiall y

recover remaining for y ears sl i ghtl y demented
, .

The majorit y terminate in m arked menta l dete

r i o r at i o n .

T R EA T M E N T
The majorit y of these cases are better o ff in
inst itut ions as m an v of them are w ith di ffi cult y
,

cared for at home \ V hen kept at home the v .

,

should be put to be d and care f ull v w atched d av

an d n i g h to prevent suicide E spec i al attention
t , .

must be given to bath s an d the care of the person .

E asily digested foo d i n l iberal q uantities mu st

-
. ,

be admin istere d at short i n terva l s b y the nasal ,

tube i f necessar y The bo w el s and bl adder must

.

be given especial attention as the patient i s l i ab l e ,

to ne gl ect the m .
 D EM ENTIA PR . E co x 24 1

From the great v a ri etv of s y mptoms o f the d is

ease a l m ost an v hom oeopathic rem ed v is l iable to
be indicated at some time during the t reatment .

The remedies most l i k el v to be demanded are

acon i te a r sen i cum a l bu m belladonna calcarea
, , , ,

carbonica ch i na hyoscyamus ignat ia nux vom

, , , ,

i ca picric acid phosphoric acid stramonium

.
, , ,

staphy sagr i a sulphur verat rum album

, , .

During the past th ree years Dr H 0 Tyson D ,

. . .
, r .

surgeon to the N ew Y o rk O phthalmic and A ural

Institute N ew Y ork C ity and Dr L P ierce
, , . .

C lark S enior A ttending P hysician to the Hos

,

p i ta l for N ervous D i seases o f New Y ork C ity ,

have made an exhaust ive study of the eve sy m p

toms of dement ia pr aecox The result o f thei r .

labors w as presented to the pub l i c i n an art icle

printed in the Journal o f the A merican M edical
A ssociation M ay 2d 1 908 V ol L pp 1 4 1 5
, , ,
. .
, .

14 1 7 A s these ndings th ro w much l ight upon

the actual character o f the d i sease and w ill be o f
much progn ostic value w e append them as pre ,

sente d in a reprint kindly furnished us bv Dr H . .

O Tyson
. .

Th ree years ago w e undertook an i n d epen d O cula r

ent research on the signicance o f the ocu l ar s ig n s

sign s an d symptoms i n dement ia prze co x \V e .

have analyzed 1 1 5 consecutive cases The w ork .

w as undertaken w ith the vie w that a careful an

alysis of the eye svm ptom s in dement ia praecox
17
 242 M E N T AL D I SEA SE S

might thro w some de nite l ight on the uncertain

an d perplexing pathog enes i s o f the d isor d er I n .

this respect w e be l i eve w e have not been d i sap

,

pointed inasmuch as w e have found deni t e

,

cha n ges and symptoms in all cases w h ich a re

fully distinctive of thi s ps y chos i s .

The fundus changes as seen cl inically may be
divided i nto th ree groups w hich are usual l v in
,

the order of their occurrence as follo w s : ,

Per i n e a r i .1 C ongestion of discs : h y pere m i a and
f
ti s o the
edema ; dilated d ark colored veins ; sl ightly con
O pti c N erve ,

t racted arteries an d bl urring o f the edges of the

discs all varying in degree These changes con
, .

st i tute a l ow grade of perineurit is o f the O ptic

nerve .

Co ngesti o n 2 C ongest ion of the nasal side w i th tem
.
,

f
o the poral pallor o f discs dilated veins contracted
, ,

arteries .

A n em i a 3 P allor of d iscs dil ated veins cont racted
.
, ,

a nd a r ti a l
p arteries These cha n ges constitute anemia and
a trophy of
.

the O pti c partial atroph y of the opt i c nerve .

I Ver ve
O ne hundred and n i ne cases w ere exa m ined
w ith the ophthalmoscope ; 5 5 w ere males and 5 4
females T he ages of the males w ere from 1 2
.

to 47 years an d those of the females w ere fro m

,

1 3 to 39 years .

A l l the di ff erent form s o f dementia przecox
w ere under study W h ile the resu l ts by form
.

t y pes have not been ful l y analyzed w e are p re ,

 DE M E NTIA 243

pare d to sav that the more marked chan ge s in the

eve svn d rom e w ere found i n the m o re rapidl y
d eter i orat i ng ty pes of dementia prze co x .

"
The case s e m brace those w ho have used alco
h ol and tobacco moderately or to exces s as w el l ,

a s abstainers . I t i s poss i b l e that alcohol and

tobacco ha v e cont ributed to w ard the cl inical pic

ture in some cases In di ff erentiatin g the patho

.

logic condition o f the optic n erve in tobacco an d

alcohol users from those in cases of dementia

pr aecox one obser v es cent ral scotoma in the f or

mer The one case sho w ing a cent ral scoto m a
.

for red in dement ia pr aecox ga v e a history of

al coho l and tobacco excesses . The di sc changes
in dementia przecox have so m e rese m b l ance to
those seen i n the toxic amblyopia of tobacco and
alcohol But the fundus chan ges abo ve detailed
.

are seen i n al l cases under stud v There is .

st rong evidence that so m e other potent toxin i s

responsible for the disc changes in dementia pI EE

cox \V e d o not hesitate to sav that w e bel ieve

.

the tox i n i s primaril y a vascular poi so n I ts

.

m ost probable source i s i n the autointoxicat ion

( intestinal put re faction i s almost invariably evi
dent from cl inical symptom s ) from the intestines
or from the l iver I t i s poss i b l e that a faul t y
.

metabol i sm from a perverte d action of some o f

the ductl ess glands (thv roi d e specially ) may be
the pathogenic agent The pr i m ar v departure
.
 244 M E N T AL D I SE A S ES

ei n s fro m the n o rmal in the di sc i s in the veins T hev .

become d ilated tortuous and darker than nor

,

m a l E d ema o f the d i sc appears sho r tl v a fter

.

w ard . The se cha n ge s a re analo gous to tho se

seen i n the passive congestion of the face an d
han d s in dementia pr aec o x cases A l l these ede .

m as pro d uce such lastin g disturbance in the nut ri

tion o f the optic nerve that slo w d e generation
o f the nerve bers nally results Thus of the .
,

1 09 cases examine d b v the Ophthal moscope a l o w ,

grade perineurit is w as fo und 6 2 time s in the righ t

eye and 6 / t i mes in the l e ft Temporal pal lor .
,

w ith nasal side con gested w as found in the r i gh t ,

eye 1 0 t imes in the l e ft e y e 1 1 times P allor o f

, .

di scs w as found i n the right eye 3 7 times an d in

the le ft eve i n 3 1 cases .

Inasmuch as the disc change s in the rst
stages resemble some w hat those seen in ordinary
intestinal toxemia w e have repeate d ly examined
,

the discs in a number o f cases w hile the patient s

w ere un d er active hygienic t reatment o f free
catharsi s intestinal antiseptics bath s and dietet ic
, ,

re gu l at i ons A marked degree o f bette rment

.

w as notice d o f the congestive margins o f th e

discs b ut the cent ra l edema and t rans i t i ona l pal
,

l or have cont i nue d Indeed w hile patient s w er e

.
,

under t h is t reatment a general ph y sical improve

,

ment w as not iced but the mental state seemed

,

l it tle improved .
 DE M ENTI A P RA SC O X 24 5

"
C oinc ident w i th
the stud v of the changes in
t he papi l l ze the pup i l s w ere e xamined in 8 5 cases
, .

The chan ges uni formly found w ere not l e ss S i g

n i c an t .The examination s w ere made in mod
e r atel y l ight room s w i th the e y e s xing a distant

obj ect The size O f the pupil s varied from 3 %

.

mm to 7 mm w i th an average o f 4 7 7 8 5 mm
. .
,
-
.
,

w hile the avera ge of the cont rol pupil s (physi

c i an and attendants ) w as 3 68 8 5 A n average -
.

enlargement of 1 9 8 5 mm for dementia pr aecox

-
.

over the nor m a l w as evident .

The l ight react ion w as act i v e i n 7 1 cases an d
slu ggish i n 1 4 C o n sen sual reaction w as act i ve
.

i n 6 8 cases an d sluggi sh in 1 7 cases .

A ccommodatio n and convergence w ere act i ve

i n 7 1 cases an d sluggish in 1 4 H ippus w as pres .

ent in one case .

The sensor y pupil lary reex w as sl ightl y pos i x
Re e es

t i ve in 6 cases and negat i ve i n / 9 instances The .

p sych ic reex w as sl ightly pos i t i ve in 4 cases and

ne gat ive in 8 5 cases P il tz \V estphal re ex w as
.
-

pos i t i ve in 23 and negative in 8 5 cases .

Great c are w as exerc i se d i n measuring the
pup i l s on account of the ten d en cv o f the eves to
chan ge their v i sual l ines O ne i s apt to compl i
.

cate the accommo d ation and convergence reex

w i th the other test s The ne gative reactions of
.

the pup i l appear to b e due to : 1 ) l oss or part ia l

lo ss of funct i on through de fecti v e nerve i nnerva
 246 M E N T AL D I SEA S ES

p
ui /l a ry tion : (2 ) d e fec t in attent ion : (3 ) dimini s he d
a o s
cti n
apperception .

C orneal sensibil it y w as d i m i n i she d in 6 9 case s
and presen t in 1 7 .

The v i sua l co l or elds w ere exam ine d in 8 1
cases A ll w ere foun d concent rical l y contracted
. .

The largest eld w as 30 d e g rees The small e st .

0 degrees The e l ds w ere pract i ca ll y abol ishe d

. .

The average o f the 8 1 cases w as degree s .

w h ich w a s a marked cont raction from the no r

mal T h i s m av be explained par tiall v b v the i h
.

attent ion o f those patients dimini shed capac i t y,

for external ization an d nal l y and n ot least b v , ,

the edema and congest ion o f the optic nerv e

( perineuriti s ) in the rst stage of d egenerati o n

of the ner v e an d b y the ul timate sh rinkage o f the
n ew connective t i ssue in the partial at roph y o f

the nerve .

The changes i n the di scs pupils v i sua l el d s, ,

and corneal sen s i b i l i t y w h ich w hen taken to

, ,

gether const i tute the n ew s y ndrome a re a l l i n

, ,

accor d w ith each other In our examination o f

.

all other types of insanity imbecil it y or idioc y w e

,

have found n o other condit ion si m il ar to w hat w e

have out l i ne d here for dementia przeco x .

The cl in ical sign i ca n ce of these ndings i s
o f importance :

1 T hev indicate tha t d emen tia pr ze co x i s
.

a ttende d bv such an ea rl v an d c o nstant s vn d rom e

 D EM E N T I A PR ECO X 247

o f altera t io n an d disc visual eld pupil and cor

, ,

nea l sen s i b i l i tv as to materially aid in diagnosti

cating th i s psvchosi s C onsiderat ion Of the syn I m orta n t
.

p
drome w ill part icularly a i d in the di ff erent ial i n

diagn osi s of dementia praecox from the manic di ag n os i s

depressive group acqui red neurasthenia h y ster i a

, ,

and the various forms of i m b eci l i tv and const i

tu ti on al inferiority .

2 The syndrome is a distinct cont ribution to
.

the theor v that dementia pr ae cox i s an autotoxi c A utotox i c

d i sease and that the po i son is primarily vascular
d i s as
,
e e

w hich nally induces neuronic d e g enerat i on It .

po i nts to a toxin o f so m e sort w h ich is either a

,

metabol ic de fect in the tissues (ductless gland

de fect ) or w hat seem s m ore probable that the
, ,

po i son i s generated in the l iver or in the gast ro

i ntest i na l tract it sel f .

3 The svn d r om e is o f pro gn ostic va l ue a s P og n osti c
.
,
r

the severer g ra d es of e v e changes are found i n a lu v e

the more rapidly deter i orat i ng cases .

4 Finally the opt i c nerve l es i on i s q uite in

"
.
,

accord w ith our best kn o w le d ge o f the pathologic P thol og i c a

anatomy of dementia pr aecox in other t racts O f A a to m y n

the brain (than the optic nerve w h ich itsel f mav ,

be counted an analo gue ) The earl v vascul ar .

chan ges in the brain ou ght to receive m ore seri

ou s inve st i gat i on .
 C H A P T ER X

D E M E NT I A P A R A LYT I C A

Y al
The most fear ful of al l the mental scourge s
ypi
,
c

P sy chosi s qf dement ia paralyt ica m ay be regarded as the ty pi

2 0 th
cal psychosis o f the hustl ing bust l i n g w il d , ,

scheming l ife o f the t w ent i eth century Fall in g .

upon i t s victims in the f ti l l maturity o f thei r m en

ta l an d physical po w ers w hen bending beneat h
,

the hea v iest o f l i fe s burdens it represent s the

.

culmination of overstra i n from w ork w orry an d , ,

d i ss i pat i on of ev er v form and shape V aried .

and mult i f orm in i t s rava ges of brain and cord

w hen once i t s hand has been laid upon its subj ec t
hi s d oom i s sealed .

\ V i d e an d extens i ve as i s the kno w ledge o f th i s

disease to d ay its h i stor y as a di stinct psychosis
-
,

ono
1 1I i s comparativel y short In 1 8 1 5 E s q uirol un d er
.
, ,

ma n i a the hea d o f mo n omania note d the fatal nature o f

,

p a r a l v s i s w ith failure o f speech In 1 822 .B o vle ,

w rote regar d ing the muscular an d me n tal sign s

o f these cases an d in 1 8 25 concerning the motor
, ,

an d speech d i sturbance s but re ferred them to

,

arachniti s or ch ronic meningiti s The rst care .

ful d esc ript ion o f the di sease under the title o f

paral y si s ob serve d in the insane w as given b v ,
 D E M E N T I A PARAL YT I CA 249

C al m ei l a pup i l of E squirol in 1 8 26 N ot unt i l

, ,
.

1 8 43 w as i t recognized in th is count ry In that .

year Dr L uther B Bell o f the M c Lean A sylum

. .
, ,

near Boston reporte d severa l cases of the d is

,

ease al l o f w hom d i e d I n 1 8 47 Dr P l i n v E arle

,
.
, . ,

at that time of the Bloomingdale A s y lum and ,

about the same t ime Dr B ingham o f the U tica .

,

S tate Hospital publ ished some cases o f the ,

d i sease .

S ince it s d i scover y much stud v has been given ,

to the d i sease and much has been w r i tten about i t

by a l i en i s t s of th i s coun t r v and E urope O ne o f .

the ful lest and most complete of the older w orks I Vi l l i a m

on the subject i s that of \V i l l i am Jul ius M ickl e
, , j u li us

of L ondon The m ost recent co m p l ete t rea t i se is

.

b y Dr Robert Ho w land C hase of P h il adelphia

. , .

The synonyms of d e m ent i a par al v ti ca are Sy n o y

n m s

paret i c d e m ent i a par al vt i ca d ementia general

, ,

paresis pares i s general paralysi s general par al y

, . ,

sis o f the insane prog ress i v e paralysis of the ,

insane .

O ther ti tles are progressive general paralysis ,

prog ress i ve general paresi s paral y t ic i n san i tv , ,

pro gress i ve par al v si s d i ff use interst it ial per i en ,

cepha l i t i s paral y s i s generale des a l i enes f ol ie

, ,

paral y t ique pe r i en cephal o meningit is di ff usa
ch ron i ca (C al m ei l ) par al v se der irren paral v t , ,

i scher b l O d si n n allgemeine para l y se d er gei stes

,

kranke n psicopatia paral itica M orsell i )

,
.
 D E M E N T I A PA RALY T I CA 25 1

D e n i t i on C hase de nes the disease as fol Ch ase

s
d e n i ti on

Gene ral paresis is a subacute or ch ronic de
generat ive disease o f the brain o ften extendin g ,

to the spinal cord an d the large nerve t runks I t .

i s marked ch iey by progressive en feeblement o f

the min d an d concomitant paresi s of the ent i re
b od v M entally there is moral an d intellectu al
.
,

erversion w ith an abnor m a l sense o f w el l

bein g
p
or actual delusions o f exal tation follo w ed by slo w
dement ia to w h ich i s generally superadded i n
,

sanit y o f the maniacal melanchol ic or con f u , ,

sio ual ty pe P hysical ly there i s gradual devel

.
,

O pm en t of t remor pupillar y changes l oss o f

, ,

coor d i na t i n g po w er especially o f speech and gait :

,

t rophic compl ic at ions : occasionally ep i l ept i for m ,

or apoplecti form seizures : and n al l v paresis .

T O LO G Y
E I

A m i ght be expected a great variety of causes

s ,

have been c ited b v va rious author s as productive

, ,

of th i s d i sease P erhaps no more conden se d

.

summary could be given than the follo w ing o f

"
C hapin i n hi s C ompendium of I n san i tv
, The :

hi sto r v o f the large majority o f cases i s one o f

i nte m perance licentiousness sexual exce ss syph
, , ,

ilis or so m e nervous exhaustion incident to ex

,

cessi v e app l i cat i on to business or the g reat st rai n

attending reverses .
 25 2 M E N TA L D i sEA SES

The numerous agencies m ore or l ess potent , ,

may be ar ranged as predisposing and excit ing

causes .

PR ED I S P O S I N O CAU SES
A mong the predisposing causes are heredit y ,

time Of l i fe sex race occupation social posit ion

, , , , ,

and the unmarried state

A great divergence of opinion ex i st s amon g
author i t i es as to the part pl ayed b v here d ity a s
a pre d i spos i n g factor S ome w r i ters place i t as
.

l ow as ten per cent w h ile others assert that sev

.
,

e n ty per cent of the cases are o w ing to i t s i n u

.

ence The convergence o f opin ion see m s to

.

agree w ith C louston s assert i on that her ed i tarv

,

predispositi o n to insanity is less common in th i s

d i sease than i n the ordinary forms o f insanity .

Kra ft E bing maintain s t hat the predisposition i s
ac q u i re d an d not here d i tar y .

eg i s Regis assert s that the di sease has its source i n

,

an he r ed i tv that is not vesanic but cere b ral ,

arth ritic or con ges ti v e He a l so claim s that co n

,
.

sanguinity con stitutes a pre d i spos i t i on to paresi s .

The percentage o f here d ity is moreover found to , ,

be h i gher a m on g female than male paretics an d

among p auper than private cases P aretics usu .

all y lea v e s m a l l famil ies one th ir d of the mar ,

r i age s being sterile and the families of the r e

maining tw o th irds averagin g o n l v one and one
h al f ch il d .
 D E M E N T I A PARA LY T I CA 25 3

A yn P aresis is a disease of middle l i fe ,

oc Di sease f
o

curring usuall y bet w een the ages o f thi r tv an d

f tv ve w hen the mental and physical po w ers
-
,

are at the i r z en i th and l i f e s bur d ens are the

heavies t an d its strains the greates t I t is rare .

before tw en tv v e and v er v in fre q uent a f te r

-

si x t v . I n w omen the d i sease d evelops from,

th ree to ve vear s ear l i er In fre q uent cases .

have been reported in children as young even as

eleven and t w e l ve years and in men as old as
seven ty ve vet these are the rare except ion s and
-
,

n ot l i k el v to be encountere d .

San P aresis occurs much more frequentl y in

m en than in w omen the relative proport ion varv ,

ing as to country and social standing an d as to

rural and ci tv l i fe I n Germany the avera ge i s
.
,

be tw een eight to one and four to on e In France .

,

the proportion of w omen is dist i nctly h i gher I n .

o u r ow n coun tr v w e nd in the New E ngland

,
-

asvl um s four males to one female ; i n N e w Y ork -

asvl um s (exclusive of N ew York C it y ) about

nine to on e : and in those o f M ichigan th i r teen to ,

one A mong w omen of the h i gher c i rc l es of so

.

c i etv the disease is very rare .

In rural populations the disease i s much less

co m mon and there i s a sl ighter disproportion be
t w een the sexes In the country di st ricts o f
.
Cou n try vs .

France R egis found it on l v on e an d a hal f t i m es

,

more co m m on in m en than in w omen and ,

 25 4 M E N T AL DI S E A SE S

S tearn s i n the S tates of M aine and V ermont

, .

d iscovered one female to th ree male paretics In .

c i t i es the di sease i s n ot only rel ativel y more f re

q uent but there is a much greater di sproportion
,

bet w een the sexes espec i al l v a m ong the higher

,

classes A ccording to R egi s f or ins tance i t i s

.
, ,

thirteen times m ore frequent among the men

than among the w omen of the sa m e class Th e .

d i sease i s found ho w ever to be on the increase

, ,

among w omen e speci all v among those w ho have

,

entere d i nto competition w i th men in occupation s

f o r m e r l v exclusively carried on b v the males .

R ace a n d S oc i al I n uen c es So rare i s pa res i s

Sa xon .

in certain countr i es that for a time i t w a s though t

to be con ned to certa i n races espec i all v to th e ,

A nglo S axon Further experience h as sho w n
.

that it s rare appearance among certa i n peop l e i s

o w ing more to thei r l i fe and surroundings tha n
to the i r nat ionality T o the S cotchman in hi s
.

h ighlands and the I rishman on h i s native bogs the

disease i s unknow n but t ransport the S cotchman
,

to an E ngl ish factory or mine and the I ri shman

Produ t
c
f
o
to an A merican city and each fall s an eas y pre y to
th i s d read monster In s l avery a colored paretic
.

w as unkno w n but n ow free d and t ransplanted to

, ,

cities pares i s claims the same percentage o f

,

negroes as o f w h ites In No r w av an d S w ede n

.

the d isease i s seldom found In France and Ger .

m an v the brain w orkers are its frequent pre y In .

 l ) EM EN T l A PARALY T I CA

En gland an dA meric a the till e r o f the so il i s co m

p a r a t i v e l v free b u t m o ve h i m,to the cit y w ith i t s ,

w h irl hustl e and rush and he imme d iatel y i s eu

, ,

d angere d A s l erkl ev has aptly said : I t is i n

.

the citie s i t here rum an d sv phi l i s d w ell in clo se

,

fello w ship w here the stri fe an d excitement o f

,

modern civil ization i s ever at o o d t i d e that gen .

"
eral pares i s i s ri fe .

S pitzka fr o m a care ful stud v o f

, indigent
i n sane i n N ew York C i tv g i ves the pr o port i on o f ,

genera l pa re t i cs by nat ional itie s a s follo w s :

A n glo S axon ,C elt s Ger m an s , ,

Hebre w s negroe s . The re ,

s ult o f his studies i s f o rmulate d i n to the follo w

ing conclusi o n : The concl usion w ill seem rea

sonable that general pares i s i s more fre q ue n t w ith

races o f a high tha n o f a lo w cerebral or gani za
tion because thei r h igher civil ization in d uces a
,

rest l ess mental ac t i v i tv and i t s a t te n d ant emo

ti on al st rain en er al pares i s
. t here f o re i s n ot
x , ,

a pen al tv of h i gh cerebra l development but the ,

express i on of a d i screpancy bet w een the i n str u

ment and its purpose : of the inade q u ac y o f so m e
brains to support the strain to w h ich the race as ,

"
a w ho l e i s subj ected
,
.

The disease i s foun d m ore fre q uentl y among

the unmarried A mong w omen prost itutes are
. . d
Un m a r r i e
its most co m mon subj ect s The m arr i e d victims .

are f or tun atel v a s a rul e childle ss O cca s i o n

, , .
 256 M E N T AL I E A SES
D S

ally pares i s appears in man and w i fe : sometimes

,

tabes is present in one and general pa ral v si s in

the other .

E X C I T I N G CAU SES
A mong t he m ost importa n t exc iting causes o f
pa res i s mav be mentione d syph il is alcohol ism , .

sexual excess great ne rvous st rains t rauma an d

, , ,

sunst roke .

S y pl i il i s A s to the i m portance of s y ph il is as
.

an exciting cause a great d ivergence of opinion ,

ha s been expressed b v rel iable authors The .

fol lo w ing conclusions o f P eterson a fter a stud v ,

o f sev en tv di ff erent authors mav be regarded as ,

probably correct :

phi ti s 1 A h i stor v of svph i l i s i s found i n s i x tv to
.

sevent y per cent of cases o f general paral y s i s o f

.

the i nsane .

2 The fact must not be lost s i gh t o f that in
.

thirty to f o rtv per cent of these cases n o histor y .

o f s y ph il is congenital or ac q uired is to be found

, ,
.

3 A ntecedent syph i l is is seven to ten t imes
.

m ore fre q uent in general para l y s i s than in other

forms o f insanit y .

4 Svphi l i s i s there fore to be looked upon as
.
, ,

a frequent but n ot constant factor in its pro

, ,

duct ion .

5 But para l y t i c dementia i s not a for m o f
.

spec i c disease not a late svphi l i ti c mani festa

,
 D E M E N T I A PARALY T I CA 25 7

tion nor i s it a form o f degeneration depending N ot a

,

upon the syph il itic poison for i t s or i g i n di s ase .

e
6 The relationship o f syphil i s to general
"
.

paresis l i es in the facts that it is a w idespread dis

order i n all commun ities that i t w eakens the con ,

st i tuti on and vitiates the blood in many w hom it

i n fects and that the s y ste m i s thus prepared in

,

many cases f or the d i rect operat ion of the nal

etiological factors of general paresis vi z alco .
,

hol ism excessive vener y hered i tv and mental

, ,

overst rain and excitement .

A nother important factor in the pro d uct i o n of

paresis is alcohol ism M ick l e at tributes to i n
.

temperance Of the cases of th i s d i sease w h ile ,

some statist ics give as h i gh as th irty per cent .

A s to the pro m i nence of sexual excess as a

causative a genc y t here i s a great divergence o f
opinion In . cases M i ck l e fou n d only ,

per cent o f the cases o w i n g to th is cause D er Dercum

. .

cum asserts that i n the maj ority of the cases sex

,

ual excess i s to be looked upon as an e ff ect of the

disease and n ot as a cause .

The most important o f the exc i t i n g causes are

great nervous st rains produced by over w ork N ervous , ,

overexertion intense and prolonged w orry dis

,
s tra i n
,

appo i nt m ent s serious and apparen tl v hope l ess

,

reverses of fortune : i n fact all causes that tax to ,

the utter m ost the emot ional an d intellectual

facult ies .

18
 25 8 M E N T AL I
D SE A SE S

A mong the o ther i m por tant d i rec t exci t emen t s

T ra um a may be named trauma an d sunstroke In .

o
su n str ke cases M ickle foun d 28 0 att ributa b le to i n iu r v
,

an d 97 to sunst roke .

O ther l ess fre q uent cau ses are lead poi sonin g
and excessive use of tobacco O ccasionall y the .
,

d i sease can be tr aced to the e ff ects o f acu te i l l

nesses such as fevers an d pneumonia In a dd i
, .

K ra epeli n t i on to the causes al read y mentioned Kraepel in ,

A u toi n tox
i ca ti on
assigns much i m portance to autoint o xicati on .

claiming that m an v of the symptoms o f the d i s

ease are produced b v the sudden over w helmin g
of the cortical neurons w ith a toxin b ut adm i t s ,

that the character o f the toxin and the so urce s

from w hich i t ar i ses are q uestions st il l in d oub t .

The ver y e arly indications of pares i s are f re

q uently so sl ight and il l d e n ed as to escape rec
-

ogn i ti on T here are tw o accepted forms of o n

.

set the gradual and the sudden In the latter

, . ,

w i thout w arnin g a su d den attack o f acute mania

,

or an epilepti f orm or apop l ect i form sei zure m av

usher in the d isease I t i s probable eve n
.
,

w hen some violent shock or acci d ent has been

c redited w i th the beginning that some un r ecog ,

n i z ed vague w arnin gs have preceded the real ou

set The d i sease has been v ar iousl v divided b v

.

d i ff erent authors some separat i n g i t i nto tw o

,

d ivision s others i nto four or ve

, I t is there .
,

fore apparent that such divisions a re m ere l v

, ,
 D E M E N T I A PA R AL YT I CA 25 9

arti cial and the demarkations may not be r ead i l v

discerned i n practice A s an aid i n the stud y of
.

its evolution and for purposes o f cl inical d esc r i p

tion w e shall separate it into four typical divi
,

sions :
1 ) A prodroma l stage .

(2 A stage characterized by b r i l l a r t rem

blings slight incoordination o f the muscl es of
,

speech and fac i a l express i on and mental exa l ta

,

tion w ith excitement .

3
( ) A stage of muscular incoordination and
paresi s w ith mental en feeblement .

( )
4 A stage o f advanced paresis w ith l ittle ,

po w er o f p rogression almost inarticulate speech

, ,

and at l ast paralysis w ith mental ext inct ion .

P RO DRO M A L S T AG E
The mental svm ptom s of the p rodromal sta ge
are exceedingl y i nsidious and m ay f o r a lon g
perio d be impercept ibl e except to the c l oses t
friends and associates of the pat ient A gradual . I / n l
ll e ta

w ea hen i ng
w eakening of the mind and a change in the dis
C ha ng e q /
position are the rs t apparent mental svm ptom s .
o o
Di sp s i ti n
T hese changes at rst ver y sl ight soon become
, ,

more and m ore at variance w ith the normal pro

c l i v i ti e s
. S pitzka mentions the case of an i n tel l i
gent merchant i n goo d social standin g w ho ac ,

qui red an a m b i t i on to become a pugil ist f t c ,

q u e n te d l o w places o f amusement and taverns ,

 26 0 M E N TA L D I SEA sES

and became ac q uainted w ith several prize ght -

ers to w hom he paid large sums to be allo w ed to

beat the m T he pat ient forget s nam es and faces
.

and l oses h is natural prec i s io n and m ethod i c i t v .

U nable to x h is attention f or any len gt h o f time ,

M i sta kes i n he m akes mistakes in hi s bu siness transactions

b si ss
u ne
and forget s h i s business engagements M o d er .

ate exercise pro d uces un w onted fatig ue of mind

and body and i f long cont inue d may end in g reat

,

con fusion of i d eas St i ll he may be ab l e to con

.
,

verse rat ionally and follo w out in a fairly correc t

manner the routine of his d ai l v l i fe i f it s d ut i es ,

be not too int ri cate or exact ing He is ho w ever .

, ,

de fective in init iat ive action and n ew project s

cannot be carr i e d out w ith success M any Of the .

m i stakes made during th i s per i o d result from

Forg et/ u forget fulness as i s seen in the case o f a physician
,

71 6 5 5 ho prescribed si x teen g ra i ns of tartar emetic i n

stead O f on e sixteenth of a grain Thi s loss o f
-
.

m e m or y not on l v i s sho w n in the forget fulness of

recent event s and proper names but is apparen t ,

in hi s w rit ing in the mi sspelled w ords omission

, ,

of letters and the leaving o f w or d s out O f sen

,

f ences. I t a l so leads to incon gruity o f con d uct ,

d i sregard O f persona l rights and n eglect o f soc i a l

,

Ha m m o n d duties and courtes i es Hammond relates as an

.
,

ear l y s y mptom the case o f a gentleman w ho stol e

,

the sil ver forks and spoon s f rom the tables a t

w hich he w a s invited to dine and at length w a s
 D E M E N T I A PA RA LY T I CA 26 1

detected w ith a silver sugar bo w l i n hi s pocket -

.

Lew i s
\V e see in short
, says L e w is in h is w hole , ,

m anner of l i fe a w eakening o f mind such as

, ,

mav be noted in the commencement o f senile

dementia but w hich occurring in a ne and vig
, ,

orou s man o f i t mav be thi r tv v e too surel y

, ,
-
,

indicates the ruin even n ow commencing ,
At , .

rst m er el v cross and i rritabl e he soon becomes ,

subj ect to sudden outbursts o f violence from the V i ol en cc

s l i ghtest causes but mav fail to be a ff ecte d b v

,

event s o f v i ta l importance S pit zka mention s a .

patient w ho th re w a kni fe at the servant becaus e

she took h is p l a te a w ay be fore he had as he al ,

l eged nished but w ho heard unmoved a f ew

, , ,

hours l ater of the coll apse Of a l ar ge bus i ness

,

undertaking w h ich involved a l oss to h im of over

,
.

a hundred thousand dollars A complete change .

h
C a nge i n
m en ta li ty
in the man s normal m en tal i tv slo w ly occurs

.

H is hab i t s of l i fe are diametricall y changed .

P r ev i ousl v neat and tidy i n person he becomes ,

car el ess and s l ovenly in appearance .

Formerly honest and truth ful he n ow l i es ,

w ithout obj ect and may steal th i n g s for w hich he

has no poss i b l e use This i s somet imes cal led the
.

medico legal stage because th i s moral pervers i on

-
,

lega l stage
often leads the person into d i i cul ti es w i t h the
legal author i t i es Frequently the nature o f the
.
,

case i s not perce i ve d and the transgressors a re

treated as ordinar y criminal s C hase mentions .
 26 2 M E N T AL I E A SES
D S

the case of a pl u m ber un d er his care w ho w as

arrested for fraudulently tapping a city gas m
,

ain -

w ithout a cert i cate n ear l v a y ear be fore cl ear l v

u n hen
,

ss d i scern ible symptom s appeared .

Temperate and sober al l h is l i fe he n o w sud ,

d en l y becomes addicted to fre q uent an d pro

longed drunken debauches .

x ua l E xceedingly erotic he pl unges i nto sexua l ex

,

ce sses cesses This sexua l excitement may cause the

.

patient to commit act s in such open violat ion o f

pub l i c decency as to bring great disgrace upon
himsel f and famil y O ne case that I exam ined a
.

f ew years a go and pronounced a paretic an d un t

to be al lo w ed at large had sho w n so f ew mental
,

sv m p tom s that h is friends disbel ieved my state

m e n t and re fused to rest rain h i m \V i thi n a f ew .

hours a fter my v i s i t he openly insulted a lady

,

upon a st reet car and w a s arrested and sent to

-

j ail H is release w as granted upon my ce r ti

.

cate o f h is insanity and he w as committed to an

,

a sv l um w here he died in a short time w ith the

,

disease fully deve l oped .

The extent to w h ich sexual excess is carried

in so m e cases see m s almos t incredibl e The
,
.

w i fe o f on e paret ic tol d me that her husband had

ha d co n nection w ith her sixteen times i n one

n ight . M ickle mentions one pat ient w ho in the ,

space of a w eek engaged in about fty act s o f

,

marital co i tus w ith full seminal ej aculat ion on

 DE M E N T I A PAR A LY T I CA 263

each occasion In other cases earl v los s o f sex

.
,

ual desire and po w er occurs .

Y et up to th is stage o f the disease the friends

, ,

m ay be in doubt w hether to ascribe the conduct

of the pat i en t to sin or d i sease .

The earl y physical svm ptom s of th i s stage may

be so inde nite a s to be regarded as purely func
ti on al or m i staken f o r those of neurasthenia or

uncompl icated cerebral asthenia S tearns te ll s .

of a paret i c w ho unable to at ten d to business on

,

account o f restlessness w as t reated b v the famil y

,

physician for mal aria .

O ften the rst physical s y mptom mani fested

,

f
o m us cl es
before any m enta l disorder appears i s a pecul iar ,
cc
i m m ob i l i tv of the muscles of the face Thi s pro .

d uces a stol id mask l ike expression In speaking .
,

there i s an unnatural sti ff ness of the upper l ip ,

w ith a t re m u l ousness of the l i ps and ton gue and

more or less di sturbance o f the speech The .

speech a ff ection may be m erel v a sl i ght hesitancy ,

a stammering or an inabil ity to pron o unce dis

,

ti n ctl v
. T h i s pecul iarity of speech a r i ses from
an ataxia of the speech muscles to gether w ith ,

incoordinate d impul ses from the cort ical motor

speech center T h i s disorder of speech may be
.

but sl ight but suggest s the marked impediments

,

w hich appear in the more advanced sta ges .

This pecul iar sti ff ness of the upper l ip mav

appear very earl v and w hen present I have co m e
,
 26 4 M E N T AL I
D SE A SES

to regard it as almost diagnost ic A f ew v ea r s .

a go I had a patient brought to m e w ith th i s svm p

tom and w ith no pos i t i ve mental symptom o f the
disease excep t a sl ight ten d en cv to enlarge h i s
bus i ness ventures an d th i s q u i te w ith in the
,

bounds o f reason : and f o r w eeks no other sy m p

toms appeared until suddenly a large num b er o f
,

ep i l epto i d co n vul sions occurre d from w hich the ,

patient emerged w ith the disease f ull v d eveloped .

and died w ith in a f ew da y s .

Freq uen tl v these pecul iar muscular change s

,

A ltered may not be present but there i s an alte rat ion i n

,

ed r a m e
pp
u
the patient s o rd i n arv manne r and appearance

.

T he face mav be un u suall v pal e or mav exhibi t ,

an unaccustomed ush or m av become fat an d ,

devoid of i ts natural express i on t si cal l y he .

,

may seem w eak Frequent hea d aches w ith full

.
,

ness pressure and const riction of the head an d

, , ,

attacks of giddiness appear P ain i n the l imbs . .

body and t runk rheumatoid neuralgic or simu

, , , ,

lat ing the l ightning pa i ns o f locomotor atax i a ,

are o ften present The pat i ent co m p l a i ns o f

.

being ti red ; all labor phv si cal or mental i s pe r

, ,

formed w i th d i ffi cul tv .

Insomnia is fre q uent : or i f s l eep i s obta i ne d i t , ,

i s disturbed b y dreams and nightmares or i s un r e

freshing V arious sense disorders m ay prevail
.
,

as l oca l anesthes i as or paresthesias or as aff ec ,

tions of the hear i n g or as al terations of the .

 D E M E N T I A PARALY T I C A 26 5

se n ses o f taste and smell The tendon reexe s .

mav be diminished lost or exaggerated w ith , , ,

l oss o f c remasteric reex and test i cu l ar i n sen si

b i l i tv . Digestive disorders m ay be present such ,

a s gast ric crises capr i c i ous appetite and i r r egu

, ,

l ar action o f the bo w el s .

In women menst rual d isturbances are com

, A l en stru a
m on either d v sm en or r hea o r amenorrhea the
, ,
o
ti n

l atter occurring most f req uen tl v .

P upil la ry anomal ies (cont racted irregula r , .

s l ugg i sh or unequal pupil s ) are mentioned b v

,

Griesinger as antedat ing other s y mptoms for a

l on g time .

C a m pbe ll C lark recor d s a case in w h ich the

o n l v m otor symptoms observed for years w ere

s mal l pupil s tre m or of the tongue and o f the l e ft

, ,

d epressor a l ae nas i .

A mong the g ra v est o f the pro d ro m a l sv m ptom s

are epilepti form or apop l ect i for m seizure s A .

Boston lady w as t reated for four y ea rs w ith bro

m ides f o r epilepsy before the t rue diagnosis o f
,

p aresis w a s made .

B er k/ey s

Berkl e y thus ter sel v summarizes the prodromal

su m m a ry
symptoms :

W hen a man in ear l v middle l i fe , ,

c omes be fore us w ho has sho w n a recent altera

tion in h i s whole cha racter restlessness i r r i tab il , ,

ity together w ith utter indi ff erence to the nee d s

,

o f others and pronounced egoism ; and w hen on

,

e xamination w e can d e m onstrate the presence o f

 266 M E N T AL I E A SE S
D S

pupillary anomalies and abnormal it ies i n the deep

reexes w e are fai r l y sa fe i n concluding tha t w e
,

have to d ea l w i th a paretic .

The duration of the prodromal stage i s fro m

one to th ree y ears or may be much longer The .

cases in w h ich i t is l imited to a f ew w eeks a re

exceedi n gly rare and question able The d i f .

c ulty of denitely xing the length of th i s period

i s enhanced by the tendency to remi ssions .

A fter an inde nite prodromal period the dis ,

ease passes either gradua l ly or abrup t ly into the

, .

rst stage o f the establ ished d i sea se .

In this stage many o f the sv m ptom s presente d

in the initial period are m ore marked than be fore .

en ta l T he mental failure i s emphasi zed b y increased

en feeblement of the m em orv especially for re
ased
cr e
,

cent event s o f the po w er o f attention jud g
, ,

ment and w ill The patient i s n o w unable to

,
.

apprec i ate the actual ci rcumstances in w hich he

is placed or to recogni ze h i s ow n re l at i ons to hi s
business or to the people b y w hom he i s surround
ed The egoti sm and boast fulness of the pro
.

d r om al per i o d are increased and everything i s

greatly exaggerated The pat i ent passes fro m a
.

condition of al teration i nto that of al ienation .

M ost extravagant delu sions n ow m ake thei r

appearance H is w hole bearing an d manner ev i
.

d ence h i s sel f sati s ed state of mind He i s

-
.

very exal ted boast ful and loquacious H e un i

, , .
 DE M E N T IA P A RA LYT I C A 26 7

forml y declares that he i s enj oying the best of

hea l th E verything appears to h im in the most
.

roseate hue He declares that he i s a person of

.
Delus i o n s

the h i ghest rank is po ssessed of endless w ea l th f

o
, ,
g r a n deur
and has no equal i n b eautv and physical st ren gth .

I f the pat i ent i s a w oman she i s endo w ed w ith ,

w ondrous personal beaut y i s the m other o f myri ,

ads of chil dren o r is the fortunate possessor of

,

nu m ber l ess husbands and l overs The charac .

t er i sti c O f these delusion s of grand eur is that ,

they are imper fectly systemat i zed feeb ly he l d , ,

and changeable The pat ient w ho i s the P resi

.

dent O f the U nited States to day may announce -

h imsel f to m orro w as the God o f gods an d

-

the C reator of the universe He may .

reckon h is w eal th to day b y hundreds o f -

thousan d s and to morrow b y m i ll i ons o f -

billion s W hile these expansive delusion s are

.
,

at r st w ithin the ra n ge of possibility the y

, ,

soon pass into the realm of absurd imagina

t ion
. O ne patient asserts tha t he could easil y
run six hu n dred miles in a minute ; that he can
y ; and that b y cutting out h is ent ra i l s he should
m ake h imsel f so l i gh t that he could j u m p a mile
and by constant spr i n g i n g cou l d mount higher

and higher ; that he can speak al l languages .

S ankey ) .A w oman insisted that she w as the
w i fe of the S aviour al so of a certain duke ; that
, ,

she had other husbands m ore than a mill ion ; that,

 26 8 M E N T AL D SE I A SES
God gave her m an y rare j e w el s ; that she had

t w enty Koh i n oor s (S a n-
key-
) A nother .
pa .

t ient d r i ves the l a r gest engine i n the w orld dra w ,

ing a thousand pa l ace cars al l l ined w ith gold and ,

t rimmed w ith pearls w h ich encircles the globe ,

every t w enty four hours stopping only at New

-
,

Y ork S an Francisco C alcutta P ari s and L on

, , , ,

d on . He n ow has formed a ch icken t rust to ex

ten d o v er the w hole earth and w ill reconst ruct the
social s y st e m o f the w orl d so that on l v the C hi ,

nese w ill be employed in hatch ing the e gg s A n .

othe r has a most w on d er f ul herd of catt l e w ith ,

horns forty feet high w ith eyes o f diamond w ith , ,

feet of gold and each cow produces ve hundred

,

pa i l s of milk in tw en tv four hours the pat ient -

,

himsel f milking a thousand a day D e f en .

dor f ) .

cute Thi s stage may be ushered in w i th maniacal

excitement at times reach ing the degree o f acute
,

del i rium from w hich the patient may pass into a

,

comparatively rational state S everal o f these .

attacks follo w ed b y remi ssions may occur l eav ,

ing the mind each time m ore clouded .

M ore r ar el v i n this sta ge mel anchol ia w ith ,

hal luc inat ion s re fusal of foo d and pe r secutor v

, ,

delusions may occur or the stuporous t y pe m av

appear There is al so a hypochondriacal tvpe
.
,

in w h ich the del usions are depressive instead o f

grandiose Thi s condit ion has been called
.
 D E M E N T IA P A RA LYT I C A 26 9

micromania in contradist inct ion to megalomania .

ma ni a
In this condition the delusion s are equally as ab
,

surd extravagant unstable an d un systematized

, , ,

as in the expansive form T he person who w as
.

emperor O f the w orld on e day i s the poorest be g

gar the next ; the creator of the universe yester
day has su n ken into the d eepest pit of perdit ion
to day ; and another w ho ha d the best brain s a
-
,

sto m ach that could accommodate tons of the

rarest d el icacies an d boasted of having a most
,

po w er ful body w akes ti p in the morning to the

,

d i scov e r v that hi s brains are running out and

that hi s stomach is gn a w ed out b y w ild beast s .

( S pit zk a )
The general health of pat i ents in th i s sta ge is
good The food i s enj oy e d an d the sleep at ni ght
.
g ood
is su ffi cient and rest ful O n account of the g reat
.

restlessness duri n g the day the pat i ent may nev

, ,

e r the l e s s
,
lose esh and have a w orn fatigued ,

look The d i a gnost i c physical symptoms are to

.

be Observed in the d e fective speech pupi l l a r v ,

anomal ies and t re m or

, .

The alteration i n the speech m a y at rst be

v er v s l i ght and sca r cel v di scernible The speech .

is at rst s l o w er than norma l the enunciat ion is ,

m ore labored and there i s a l ack o f promptness

, .

This condit ion i s soon follo w ed b v a sl igh t thick

ness 3 blurri n g o f the consonant s and an indis
, ,

ti n ctn ess in pronunciat ion The ideas al so a re

.
 27 0 M E N T AL I E A S ES
D S

so m e w hat incoherent A t rst the hesitancy o f

.

speech and the sl ight impediment i s noticed on l v

w hen the patient i s fatigued but in the l a tt e r , ,

part O f th is stage it becomes more noticeabl e and

,

the speech muscles beco m e more and m ore un con

tr o ll ab l e .

T he ano m al ies of the pupil s var y In so m e .

patients there is a constant ine q ual ity in other s ,

i t only occasionally i s observed In still othe r .

cases they are cont racted w ith more or le s s

, ,

s l ugg i shness to l ight T he shape m av be irre g

,
.

u l ar in one or both either habitua l l y o r occasion

,

al l v
. There is occas i ona ll y di l a t ation O f th e
, ,

pupil s but th i s is l ess common \Yhatev er the

, .

condit ion o f the pup i l s i rrespons i veness i s nearl y

,

al w ays observed .

1 6?
The facia l expressio n n ow undergoes a chan g e .

The natural l i n es of intell igence are smoothed ou t

and partiall y obl iterated p ro d ucing the so called,
-

pet ri ed face \ V hen an atte m pt i s made to
.

speak the ev eb row s are raise d and there i s a

,

s l i ght co n t ractio n and t remor of the occ i p i t o

f rontal is The complexion mav be d ull and
.

l ea d en or have a coa rse an d g reas y look .

ait The ga i t sho w s a sl ight unsteadiness and th e

patient w alks w ith a shambl ing uncertain step a s ,

i f the knees w ere ti red Going up an d d o w n .

stairs i s d i i cul t and the patient o f ten tr i ps on

uneven sur face s .
 DE M E N T IA PARALY T I CA 27 1

Tremor is a prominent s y m pto m in th i s stage ,

T rem or
commencing in the muscles of the face the l i ps . ,

and the tongue and gradually involving the

,

hands and limbs This t remor o f the hands pre

.

vent s the follo w ing o f any occupation re q ui ring

the del i cate a d j ustment and contro l o f the n
gers althou gh the hand w riting may be c o mpara
,

t i v el v s tead v th roughout the stage .

SE C O N D S T A G E (T H I R D P E R I O D )
Thi s s ta ge is cha racteri z ed by a stead i l v i h g
I n cr eas i n
m en ta l eu
creasin g mental en feeblement C onversat i on b e .

ebl em en t
f e
comes m ore and more d iffi cult M any of the pre .

vio n s speech svm ptom s are i ntens i e d T he .

w or d s follo w one another s l o w ly and a re badl y

c onnected . The speech i s d ra w ling hal tin g , ,

s tumb l ing and mav resem b le that of a d runken

,

man The l ab i a l s and l ingual s are pronounced

.

w ith g reat d i ffi cul t v as m ay be seen from the

,

attempted pronunc i at i on o f such w ords as per
"
ambulator art iller y
,
electricity or M eth, ,

odist E pi scopal A change may be not iced i n
.

the q ual i tv o f the vo i ce al so evidenced b y hoarse ,

ness change o f p i tch hollo w ness rou ghness or

, , , ,

w eakness O ften the voice i s monotonous al l

.
, ,

of the w ords being e q ually intoned or thev m av

be uttered w ith an evi d ent propelling force .

T he delusions of grandeur or depression o f the

previous stage beco m e fainter and fainter an d ,
 27 2 M E N T AL I E A SE S
D S

n al l v are com pl etel v lost Ev er v express i on .

and every movement revea l s the increasin g d e

m entia I f the pat ient atte m pt s to w alk h e
.
,

stumbles an d staggers The t runcal m usc l es ar e .

w eak and irregular in action and the body settles

upon i t se l f as seen in advanced age C om
, .

p l e te l v obl ivious of h i s surround ings and the call s

o f n ature the patie n t becomes lth y in the ex
,

t reme The features are fat and abb y w ith th e

.
,

n atural w rinkles and fold s of the skin e ff aced ,

and the vacuous expression o f the face reveal s

emen ti a the deep dement ia w hich n ow ex i s t s O ccasion .

al l v , the features a re distorted bv t remors an d

spasmodic t w itchings bi tt these correspon d to n o,

emotion o f the pat i en t O ccasion al l v there is an .

,

auto m atic grinding o f the teeth The pupil s m av .

be small and contracte d or dilated : as a rule n u , ,

e q uall y The response to l i ght i s imper fect o r

.

w anting The ton gu e can be prot ruded on l y in a

.

j erky manne r w ith great e ff ort and b r i ll ar v ,

moveme n t s on each side o f the mesial l ine mav

, ,

be d i sti n ctl v seen Gro ss and b ruti sh i n h i s m an

.

ner of eat ing care must be taken to prevent the

,

patient s chok i n g
'

Bed sores are l iable to form al so boil s carb un , ,

cles bl ebs herpes zoster or the h aematoma auri s

, ,
.

A popl ecti form an d epilepti form seizures a l so f r e

q uentl y occur during th i s sta ge but are not usu
, ,

al l v follo w ed b y an y permanent l oss of po w er .

 DEM E N T I A PARA LYT 1 C A 27 3

T H I R D ST A G E O F T H E ES T A B L I S H ED D I S EA S E
h i th i s sta g e mental failure i s co m p l e t e
, The .

p o w er o f thought and speech i s abol i she d The .

ex t reme d eg ree o f d ement ia i s reache d an d the

patient as M acpher sen aptl y says actual l v
, ,

falls into the con d ition of a lo w er or d er o f being ,

m o re rese m bli n g a vegetable w ith a d ige st ive tube Veg eta bl

e

than an anima l

wit ha
d
.

s
ig e ti ve
R e d uced to a skeleton the exhau stion an d ema
,
tu b e

c i ati on are ext reme Ev e r v attempte d m o vement

.

i s atte n d e d w ith violent tremor Lo c o m ot i o n i s

.

a tten d e d w ith the greatest d i ff i cult y or i s u tte r l v

i m poss i b l e The patient i s hopel essl v bedridden
. .

The legs are n o w ri gi d l y exed over the a b d o

m en ad d ucted or r m l v crosse d w hile the arm s
, ,

beco m e exe d and dra w n over the chest T he .

p upil s no longer respon d to l i ght an d accomm o da

tion The f ace is d evoid of all expression por
.
,

t rayin g the co m p l ete mental e ff acement Be d .

sores i f not previousl y present n o w appear

, , ,

d ue to t r ophic changes the he al ing o f w hich i s
,

ren d ere d almost impossible from the continual

involuntary passa ge o f feces and uri n e Unabl e .

to fee d himsel f the neces sitate d f o rce d f ee d in g i s

,

rendered d an gerous from the pa t i en t s d i ffi cul tv

'

in s w allo w in g w ithout r i sk of su ff o cat i on .

In th i s hel ple ss state devoi d o f ne a rly e v er y

,

resemblance o f a human bein g the w re tche d su f ,

ferer lies d av after d av until re l ea se d b v dea th .

19
 27 4 M E N T AL D S I E A SES

I n addit ion to the usual form that w e have

j ust d escr i be d special variet ies of paresis are o c
,

ca s i on al l y encountered O ne O f these i s termed

.

the galloping for m .

G a ll pi ngo The galloping f orm a s i ts name su ggest s is so

, ,

F rm o rapid an d violent in i ts action that w ithin a f ew ,

w eeks or month s al l resistance to the disease i s

.

overcome an d d eath resul ts These cases resem .

ble acute del irium Berkley report s one case tha t

.

d el i r i u m
ran it s course i n ve w eeks Zacher h as recorde d .

t w o cases ; one last ing tw o and a hal f m onth s ,

and the other dying in less than four w eeks .

The doubl e form or circula r tvpe o f pares i s

al so is occas i ona ll y m et The cases most f re .

q uently present a h istory o f he r ed i t v The y ex .

hib i t the ch aracter i st i c symptom s O f el ation

w h i ch e i t her w ith or w i thout an interval o f cal m
, .

are follo w ed by the d epress i ve del usion s of m el

an chol i a even w ith suicidal ten d enc i es and some
,

times w i th i d eas o f persecution Follo w ing th e .

depressive stage comes a fresh outbreak of v i o

l ent exc i te m ent o r o f exa l tat i on and expans i v e
del i rium and th i s a ga i n may be succeeded b v
, , , ,

m e l ancho l i a .

The depressed form is claimed b v some authors

If to be exceedingly common Kraepel in assertin g
'

ra e el i n
p ,

that it compri ses one fourth of the cases Th i s

-
.

i s a much higher estimate than could be made o f

the paretics o f th i s coun tr v This form occu r s .
 DEM E N T I A PARALY T I CA 27 5

l a te in l i f e usually a f ter forty y ears o f age and

, ,

i s of short duration r arel v lasting more than two

,

y ears.

T h i s form is characterized by the d epresse d

tone of the emot ional att itude and of the d e l u
sions th roughout the w hole course of the d i seas e .

The h y pochon d r i aca l sel f accusatory and per

-

secuto ry delusions ever present are charact e r H ochon

yp
, ,

i z ed b y their g ross exaggerate d and en ti r el v

, ,

senseless character T he pat i ents complain that

.
delus i o n s

the scalp is rot ti n g a w a y the skull i s ll ing in

,

w ith bone causing the bra i n to shrink the mouth ,

is l led w i th sores the taste is lost the th roat i s

, ,

clogged ti p so that food passes up into the brain ,

the stomach is melted a w ay and the intestines ,

are so paral v z ed that there has been an accumula

tion o f excrement w ith in them f or many m onth s .

and the patient may s i t f or hours w i th the hand

on the throat to prevent the feces coming i nto the
mouth T he pat i ents may accuse themselves of
.

having committed the unpardonable sin and

crimes innumerable and on thi s account sav that
,

they are doomed to cruci xion .

Hal lucinations o f hearing are frequent accom

p a n i m en t s o f these d e l us i ons Soon there i s.

A d ra l h a l
clouding of consciousness Friends are con l uci n a ti on s
.

founded w i th others and they are unable,

to recognize the i r surroundings Ev er y .

thing that occurs about them has refer

 27 6 M E N T AL I E A SE S
D S

e nce to them sel ve s The se pat ie n ts a re au x

.

i o us and restle s s con stantl y pace ti p an d do w n

,

thei r r o o m s m oa n i n g an d groaning pick at the i r ,

nger s pull out thei r hai r an d m a v mutil ate

, ,

them selve s or a ttempt suicide This re stle ssne ss .

i s usuall v of shor t d ura t ion an d in the interval s

, , ,

the patient s are q uiet d epres sed seclusive b u t

, , ,

evince no emot i on S tuporous state s m ay appear

.

d uring w hich the pa t i en t s a r e mute res i st i ve re . ,

f u se nouri shment an d l ie con stan tl v in bed i n one

,

posit ion and obl iviou s o f their surrounding s an d

the call s o f nature a l l o w ing the fece s an d urin e
,

to p a ss unhee d ed O cca sionall y the v are em o

.

t i o n al an d l ach r vm o se Th i s stupo r mav last f o r

.

month s w ith o r w i thou t the acc o mpaniment o f

,

hallucinati o ns and illusion s .

S P I NAL G E N ERAL P A R ES I S

The c a se s a s they rela te to the cord have bee n

evan d i v i d e d b y B eva n L e w i s into the th ree fol lo w ing
en i s
'

varieties : 1 ) In a m aj or i ty o f the c a ses as ,

the on l y evi d e n ce o f spinal impl icatio n w e nd ,

d i m ini she d cu tane ous sen sibi l i ty an d sluggish

k n e e jerk al ter n a ting at a l ater period w ith i n
, . ,

c re a se d knee j erk u su all y a s the d i rect se q uel to

,

a c o n gest ive seizure L a ter in the disease .

,

p ar et i c sympt om s mav preponder ate but the cere ,

br al impl ic ati o n th r o ugh o ut i s al w a y s the more

e m ph a sized (2 The tabetic g r o up w i th m o st
.
 DE M E N T IA P A R A Lv T I C A 27 7

o f the svm ptom s of tabe s dorsal i s Y et w e usu .

ally w itness co m p l e te subsidence o f the special

s pinal s y mpt o m s w hen the f ull development of
the cerebral symptoms is e st abl ished : o r w hat i s .

n o t in fre q ue n t , the anesthe s i a and atax v may

even be replaced b y spast i c paraple gia (3 ) .

The group o f s pastic cases in w hich symm e trical

d escen d i n g sc l erosis o f the lateral c o lumns i s
e a r l v appare n t an d continu o u s : u su al l v a s the ,

se q uel o f co n vul sive seizures and espec i all y f re

q t te n t i n the se subj ect s w ho h a ve been ad d icted to

a l coh o l ic exce s s .

D E M EN T ED FO R M

Th i s fo rm i s charac ter i z e d b v grad ual l v pr o

g r e s s i v e me n tal en feebleme n t w ithout p ro mi
,

n en ce o f hallucinat ion o r d elu sion s o r great

ps y chom o t o r d i sturbance .

I t m ay b e sudd en l v ushere d i n b v c o nvul si o n s

o r gr ad ua l l v develop w itho u t appa rent ca u se .

The mani fe stations Sh o w a c onsi d er abl e d e gree

of varia t i on \ V hen the o n set i s gr a d u al the
.

mav rese m ble neuras then i a The pa .

f i ent s compla i n o f inabil ity to w ork i n er t ia an d , ,

h en i a
t

in d e n i te pain s w ith a feel ing o f pre ssur e in the

h ea d They a r e sl i ghtly f o rget ful a t time s
.
,

d ro w sv an d at othe r s sl ightl y con f u se d b tt t r e

, ,

tain a cl ea r in si h t i n o th ei r co n d i ti on So o n
g

mental deterioration inc re a se s evide n ce d b v th e i r

,
27 8 M E N T A L D I S EA S E S

inabil ity to explain thei r con d uct by errors o f ,

j udgm ent loss o f memory and a b sence o f the

, ,

usual moral feelings W ork becomes i rksome .

an d the y may fall as l eep over it M eal s are for .

gotten mi stakes are made i n gures and impor

, ,

tant m atters are overlooked Good natured and .

-

t ractable the y are easily led ast ray and may drink
,

to excess S ome ca ses are obst i nate and sel f

.

w il led
. Business i s neglecte d and engagement s
are forgotten In conversation thought i s slug
.
,

gish an d lacks individuali ty Disturbance of .

apprehension soon appears the environmen t i s ,

not thoroughly comprehended account o f time i s ,

lost and the patients beco m e con fused as to p l ace

,

and mistake persons The d e l us i ons i f any are .

,

present are w eak childish and easi l y in uenced

, , ,

by suggestion S udden emotional changes are

.
,

at rst apparent but l ater the patient s become

, ,

un i f o rm l v dull and apat hetic A s long as the .

physical nee d s are satised thev are per f ectl v ,

contente d They are friendly to everyone have

. .

a complacent smile w hen addressed and g reet ,

st rangers co rd i al l v A t rst sl ightl y cognizant

.
,

o f the i r condit ion thev may complain o f the i r

,

mental en feeblement but l ater i ncreas i n g dete , , ,

r i o r at i on obscures t his feeb l e capac i tv O ther s .

express a feel ing of w ell being an d per fec t con -

d ence i n their bus i ness capac i tv .

The patients become careless in their dut ie s

 D E M E N T I A PARALY T I C A 27 9

en gagements are forgotten letters go unans w er ,

ed they go to w ork at all hours an d nally stay

, ,

a w ay altogether They are o ften restless w an

.
,

der about and indulge in excesses or commit pet

,

t v cr i m es
The w ill po w er being w eak they are
.
,

easily led ast ray forget w hen to go to meal s an d

, ,

become unt idy in appearance S ome pat i ent s are .

surly repul sive rej ect friendly advances and

, , ,

w ithout reason oppose anyth ing d es i re d of them .

In sp i te o f the i r advanced deteriorat ion they ,

mav greet on e correctly and appear at ease w he n ,

conversing about themselves but at the same , ,

time are disoriented and unab l e to give a coher

,

en t accoun t of thei r l i ves The appet i te is good .

,

the sleep normal and the pat ient s present a p i c

,

ture of hea l th T he mental en feeblement may

.

have been so gradual that friends and relatives

m ay fail to apprec i ate the rea l con d i t i on .

T h i s demented form embraces about fort y per Per cen tag e

cent o f the cases The duration i s short seven
. .
,

teen per cent of the cases dying w ithin six

.

month s and f ew l iving more than th ree y ears

,
.

I U V EN A L G EN ERAL PAR ES I S
Thi s form has al so been ter m e d developmental ,

premature ear ly and precoc i ous paresis

, ,
M ost .

of the cases have been reporte d b y E ngl i sh and

German author i t i es al though it has been recog ,

n i z ed by French and R ussian alieni sts .

 28 0 M E N T AL I E A S ES
D S

I t occurs in cases under tw en t v vea t s o f age .

tw en ty

C louston ha s reporte d tw o cases in g i r l s o f f
y ea r s (
31
ag e teen : N orman one o f a gi rl o f th i rteen ; and R ay
,

mond an d Dunn have each a case of a gi rl o f

nine .

I n almost all cases premonitor y s y mptoms a re

present in d icating change o f disposition los s o f
, ,

G i r ls intere st in the i r surrou n dings m orbid sensitive ,

ness and other mental changes reveal ing mark e d

, ,

diminution and w eakening of nervous energy

Delusion s o f gran d eur se l dom appear and the
maj orit y o f cases are girl s .

RE M l SS I O N S

D i u rna I
O ne of the most interesting f act s connected
rem i ssi on s w i th pares i s i s the occurrence o f remis sio n s .

These u sual l v occur in the rs t or secon d stage o f

the d isease an d may l ast from a f ew w eek s to
,

several month s In the pro d romal peri o d i t o ft e n

.
,

happens t hat signs of the disease m ar k ed l v ap

parent i i i the a f tern o on or e v e n in g m av be e n ,

t i r e l v absent the next morning A t such tim e s .

n o symptom s m a v be reveal e d by an ex aminat io n .

w ith the possible exception o f a sl ight t rem o r o r

i n eq ual i tv o f the pupil s and e v en these mav be in
,

ab e v an ce . \ s eveni n g appears the symptom s

.

mav be aga in pro n o uncedly app a rent S i m ilar in .

charact e r to the se br i e f diur n al remissi on s no

t i ce d in the prodromal peri o d m a v be the pro ,
 DE M E T IA P A R A LYT I C A 28 1
'

lon ge d remi ssion s Observe d i n the a d vanced Prolo ng e d

r em i ssi on s
stages o f the d isease \V h i l e duri n g the remis
.

sion man y o f the symptoms disappear the disease ,

is on l v q uiescent not eradicated and i s cer

, ,

tain to reappear usuall y in a more act i v e f orm

,
.

D urin g the se remi ssions al though the mental ,

s y mpt oms m ay not be apparent there i s usu all y ,

a trem o r o f the l ips and an in eq ual i tv o f the pn

pil s an d the speech is not that o f one in health
. .

Remi ssions have been so complete tha t there ha s

been an en t i re disappearance of all the motor
symptom s an d the min d has seeme d c l ea r a s in
health These cases ha v e at t ime s b een pro
.

n o u n ced cures C oncerning these se eming cure s

. .

Bland for d say s : These cases w oul d be pro

"

n o un ced sane b y any j ury T hev ha v e either lo st .

the i r d e l usion s or are able to concea l them I .

have rece i v e d letters from such w ritten w ith o u t ,

a mistake But these w ho had best reco v ere d

.
, .

are long since d ea d an d I kno w of n o ne w hose

,

d i sease d i d not reappear in a longer or shorter

t ime .

Remissi o n s m a v occur at auv time d u r in g the

progre ss of the d i sease but the d u rati on shorten s ,

as the m al ad v advances I f no other mental .

symptoms ar e apparent there is u sual l v e v i d ence d ,

s o me m oral o b l i q ui tv such as purp o sele ss l v i n g I l l o l

, . ra

abnormal i r r i tab i l i tv or a ten d enc y to e x tr av a

.
o b li q u i ty

gance in b uv i ng or a stol id troubl e d faci al ex

. ,
 28 2 M E N T AL D S I E A SE S

pression The pat i en t usually increases i n stout

.

ness but becomes more feeble in cold w eather

, .

Frequently he feel s w ell converses r ati on al l v

, , ,

evidences a returning interest i n busines s and ,

desi res to resu m e h is former occupation I f per .

m i tted to resu m e h is business continued m enta l ,

e ff ort reveal s his w eakness and i f he attempt s , ,

m anua l w ork the bodily vigor d oes not return :

,

and in e i ther case he soon breaks d o w n Hence . .

i f allo w ed to return ho m e paretics should be kept

,

Supervi si on quiet free from care un d er the supervision o f a

, ,

f
o a physician and prevented from resuming thei r
,
h
p y si ci an
former occupat i ons Un der these co n d itions th e
.

remissions mav be p rolonged but the disease i s ,

s u re to return and often i ts reappea rance i s

m arke d b y an outburst of excitement or viol e n ce
or b v an epilept i for m seizure .

D URA T I O N
The d uration var i es greatly according to the ,

form o f the d i sease the sex o f the pat ient the

, ,

presence or absence of apoplecti form or epi l epti

form seizures and the l i fe and surroundings o f
,

D u r a ti on the pat i ent The average durat ion is in males

.
, ,

fro m tw o to th ree years ; in fe m a l es fro m th ree ,

to four vea r s : w h ile the g reat maj ority O f a l l

cases d ie w i th i n ve vear s C ases have been .

reporte d in w hich the patient has l i ve d ten year s

and Bland ford has recor d e d one case w ho l ived
 D EM ENTIA P A RA LYT I C A 28 3

t w enty seven years ; but these cases can be

-
re

g arded as noted exceptions .

PA T H O L O GY AN D PA T H O L O G I CAL A N A T O M Y
V aried and numerous are the macroscopical
and microscopical ndings recorded by d i ff erent
pathologists w ho have for years assiduously
, , ,

studied the ravages produced b v pares i s upon the

brain an d cord The f ol l ow m g summary by .
,

P eterson embraces nearly al l i f not the ent i re

, , ,

chan ges that have thus far been discovered We

'

t ranscribe the m as presented in C hurch and

P eterson s w ork on N ervous and M ental Di s

eases pp 8 1 9 and 8 20: It i s usual to d escr i b e
,
.

the pathological co n d i t i on underlying paralytic

dementia i n genera l ter m s as a di ff use men ingo
encephal iti s The gross cha n ges observed at
.

autopsy are as follo w s :

1 ) General diminution o f the w eight o f the P te so n s e r

brain.
s u m m a ry

I ncreased uid in the subdural space and

i n the meshes of the arachnoi d (external hyd ro ~

cephalus ) .

3 ) P achymeningitis haem or rhagi ca interna ,

w i th l arge fresh or old h aematomata o f the dura

,

mater (in abo ut hal f o f the cases ) .

4 ) C h ronic leptomeningiti s (O paci tv an d

thicken ing w ith adhesion of the membranes to
,

the cortex ) .
 28 4 M E N T AL D S I E A S ES

N arro w ing o f the cortex w ith gapin g ,

o f the ssures .

Disten sion o f the vent ricles w ith seru m ,

an d granulated an d th ickened ependym a (c h r o n ic

internal h y d rocephal i s
Gr av d e generat ion in the cent r um oval e ,

brain axi s in various col umn s of the spinal cord

, ,

and i n so m e o f the spinal root s and peripheral

n erv e s .

T he mic roscopical ndings m av be summar
i z ed brie y as fo ll o w s :
1 ) C han ges i n the vascular w all s dilati o n ,

of the perivascul ar space s w andering w hite an d ,

red bl o o d corpuscles .

Increase i n the n umber o f the astr o c v te s .

In the ga n gl ion cell s : l o ss o f the nucl eu s

an d n ucl eolus c l o ud v sw ell in g sh rinking o f t he
, ,

pr o top l asmic processe s .

D egenerat i o n and di sappearance o f th e

nerve bers w ith m v el i n e sheath s in the w h it e ,

mat ter an d i n the c o rt e x an d o f the tan gent ia l

,

be rs .

The w h o le c o r tex i s more or less a ff ected but .

o f ten the change s are m o re marked in o n e a r ea

th an in an o ther It i s u su al to nd the fro nt a l

.

l o b e s e pec al l v impl ic ate d

s .

P RO G N O S I S

I ,
7
n rm l
y The pr o gn o si s o f p a re si s i s un i f o rm l v un f a vo r
u n a vora f bl e
able A f ew ca se s o f r eco v e r v have been repor t
.
 DE M E NTI A P A RA LY I I C A
'
28 5

e d In these ca ses it i s probabl e either that

. .

t here w as a mistaken dia gnosi s or that the pa

t i en ts died during a remission A fatal termina .

t ion m av b e re garded as pr act i cal l v i n evitable

'

D I AG N OS I S

ln a t y pical case o f pare sis there i s l i ttle d an ,

g e r o f makin g a w rong diagno si s The case s .

presen ti n g the most di fcul t y are tho se in w h ich

melanchol ia and h y pochondria or maniacal ex
c i tem en t predomi n ate and w here demen t ia exi st s

alone w ithout the ch a racterist ic excitement .

The sv m ptom s mo st rel iable in making a d i agn o

sis o f p aresi s are : a ff ect ion of speech pupi ll a r v ,

p up i l s
anomal ies m uscular t remor an d uncertain ga i t t em or
. ,
r
,

acc ompanied b v intellec tual w eakness and d elu g a i t ,

m en ta l
sions o f grandeur \ V hen th is combinati o n oc
.

awa e ess r n ,

curs there need be no d i i cul t v in recogniz ing the del usi on s

.

disease .

The di sease w ith w h ich in i t s prodromal pe ,

ri n d it is most l iable to be con f ounded is n eu ras N u as

,
e r

M an i a
t he n ia Y et a care ful con sideration o f the tw o
.

diseases w ill reveal s uffi cient marks o f di ff erence

to prevent an v m i s takes being made in the dia g

n osis .

The pupil s of pare si s a re sluggi sh une q ual , ,

pinholes i rregular o r immobile : th o se o f n eur as

,

thenia are act ive and lar ge .

 G od sa v e t he c o m m on w ea l t h o f the S ta te of Ne w Yo rk

O t to H B usc h 3 D i so n S t m e f r o m Ki n g P ar k t h i s
s m o r a i ns . I am
'
I 5 so i n 8
t
b a c k h i s a f t e rn oo n }
. ca

M ay G od sa v e th e co m m o n w eal t h of t he S t a t e of N e w Yo rk .

I S O F H A ND
S A M P LI \V R I T I N G F R O M D I CT A T N O F T H REE C A S ES I O O F
D E M E N T I A P A R A LYT I CA
 di ; v

I m y se l f M r s M a r th a Ly n c h th e w r i te r w o ul d l i k e t o g o t o a N e w Yo r k H o s i ta l
t re t m e n t i s go i n g t o g i v e b i rt h t o M r s Ly n c h , S ta te H os p i t a l M i d l e
.

f or B ab y
gY
a . . .

t ow n, .

Nam e

6 %

A n n ie J B re
. w st e r , New H av en . C on n . T he w or l d is r o un d .

P A R ET I C W R I T I N G
NO I SH O W N

T YP C A L D E F C T A N D N C A T
I G I E S I DI I NG IR
H I D E LU S I ONA L
TR EN D N S A N D 3 C ND T
.

O 2 A O I I O N O F A LM O S T
C M P LE T E A R A P H A
. .

O G I
 M H N T A I D I S EA S ES
.

It
'

n cr

j
-

cr 15

The k n eej e r k s of paresi s dimin i shed e x agge r
. .

a ted or une q ual are in marke d contra st w i th the

, ,

ac ti v e and e q ual tendon reexes o f ne u rasthenia .

Faa '

,
The p ecul iar immobil it y o f the muscle s o f th e
( rom or o f face and the t remor o f the tongue so prominent ,

tong u e
in pa resis a re w an t in g in neurasthe n ia
. .

The p a retic s han d w rit ing su gge st s the ap

'

H an d
f i ng
'

pr o ach o f the disea se w hile the n eurasthenic s

'
a n
'

remain s uncha n ged .

The characteri stic speech de fec t s o f pare si s ar e

never fo und i n n eurasthenia .

The feeling o f cheerfulne ss and carele ss i n d i f

f erence us ually pre sent in the paretic is in mark
. ,

e d c o n t ra st w ith the morbi d fears o f the n eu r a s

thenic . \ V hen depres sion occurs i n the paretic it

i s va gue and inde nite in charac ter w hil e th e ,

n e u ra sthenic i s tormented b v t he bel ie f that som e

particular di sease i s per si sten tl v w o rkin g his d e

s t ruct ion ,and paral v si s i n san i tv an d d eath a re
, ,

his certain doom .

) rg a ) 1 i t T he d i rect signs of begi n ning organic brai n

l esi on s le si o n s evi d e n ced by the lo ss o f memory and gen
eral w eakeni n g o f the intellectual facul t ies a l .

w a v s obser v ed i n the paretic ar e never f o und i n .

n eu ra sthenia .

C on v ul si on s The l i fe o f the neurasthenic moreover i s not

imperille d b v the epilept ic an d apoplect ic seizure s
that are a c o n stant menace to the paretic and f r e
u n t l v bri n g the d i sea se to a cl o se
q e .
 D E M E N T I A PARALY T I CA 28 9

C hronic alcohol ic insanity may resemble pare

s is
, but the per secutory delusions and general
a ttitude o f fear an d dread w hich torture the alco A l eu ta l
'
'

h ol ic are in marked contrast to the mental e x hi l a / tzl u ae

a ration and contented calmness of the paretic .

The speech al so thou gh slurre d and t remulous

,

l ike that o f the paretic is thicker in enunci ation

,

an d lacks the characteri stic v o cal defect s o f

paresis .

The t remor of al cohol i sm i s al so m o re univer

sal in it s di st ribution and not fi rst noticed i n
s pecial groups o f muscles .

The alc o hol ic is al so improved or com pl etel v A on ce

restored by abst inence w h ile the co u rse of the

,

paretic is progressive .

S YI I I I LI T I C

I N SA N I T Y
The di sease most l iable to be con foun d e d w ith
paresis i s s y phil it ic i n san i tv and w hen the s y ph
,

i l i ti c poison a ff ects the cortex a di ff erential dia g

nosis may be imp o ssible except b v observing the
e ff ects o f antisyphil itic remedies .

I n most cases ho w ever the d i ff erence in the

. , I n va si on

ma nner of the invasion and in the character o f

m o/ or
si s ,
the delusion s the form and nature o f the eve
, sy mptom s

p aralysis the l ack o f the motor sympt o m s

, .
tr em or
speed :
the characterist ic t remor of the tongue an d
lips an d the marked di ff erence in the speec h d i s
.

tu r b an ces w ill prevent it s being con founde d w i th

paresis .

20
 29 0 M E N T A L D I S EA SES

From the dementias follo w ing epilepsy lead ,

poisoning tumors and other gross organic brain

, ,

lesions the di ff erentiat ion may usual l v be rea d il y

,

made by bearing in mind the characterist ic

symptoms o f these a ff ections I n cases o f doubt .
,

L um ba r the lumbar puncture may decide the question .

p u n ctu r e
N umerous experiment s by a va riety o f observer s
have establ ished the fact that lymphocytosi s is a ,

con stant and early symptom o f dementia para

D e Fu r sa c
l y t i ca De Fursac quot ing D u pr e says : A n
.
,

increase in the number o f leucocytes in the ceph ,

al o r achi d i an f luid is an almost constant phenom,

enon of general paresis especial ly at the onset , .

Though it never appears in the absence of men

i n geal lesions it s presence el iminates the vesa
,

nias as w ell as the dementias dependent upo n

,

cent ral organic l esions w ithout meningeal i n

"
v ol v em en t such as senile d ementia for instance
,
.

Dr George F B re w ster o f the M iddleto w n S tat e

. .
,

B r ewster
Hospital in an ar t icle in w h ich th is subj ect is d i s
,

cussed sa v s : I n the normal uid (cephal o
,

rach i d ian ) w e usually nd from tw o to th ree cel l s

in the eld I f w e nd more than from th ree to
.

eight w e consider it q uite suspicious I f ove r .

eight in the eld w e regard the resul t as pos i

, .

tive .
 D E M E N T I A PARALY T I CA 29 1

T R EA T M E N T
We are fully convinced that paretics in any ,

stage of the di sease are much bett er off in any

,

reputable hospital for the insane than at home .

H p i t l
While all medical t reatment has thus far proved
os a
. ,
{ r ea l m en t
futile as far as complete restorat ion is concerned ,

st ill the systematic routine of hospital l i fe w ith ,

removal from all the w orries and dut ies o f the

outside w orld w ill greatly amel iorate the condi
,

t ion o f the pat ient and prolong his l i fe .

In the initial stage ho w ever you may be un

, .

able to convince the friends o f the necessity o f

connement in a hospital I f compelled to t reat
.

s uch a case at home you should insi st upon the

,

patient s imme d iate and complete w ithdra w al

'

from bu siness occupations A l l w ork mental .

,

and ph y sical should be ab sol u tel v f orbidden

, .

A ll sources of w orry anxiet y care and excite

, , ,

ment should be avoided an d the rest cure partial -

,

or complete shou l d be at once instituted

. .

The nourishment should be pushed to the full

est extent an d such remedies prescribed as the
prevail ing symptoms may indicate \ V hen the .

disease is full y establi shed the patient i n v ar i a

, ,

bly should be removed to a hospital

, .
 C H A P T ER X I

O RG A N I C D E M ENT I A

A large class of cases of mental impai rmen t

encountered are the d i rect res ult o f some organ ic
brain lesion The type assumed i s usual l y a de
.
, .

mentia w ith a progre ssive w eakening o f the men

tal po w ers attended b v a cer tain amount o f
,

paralysi s .

This or ganic dementia may result from syph

il is or follo w apoplectic embol ic or th rom bot i c
, .

processes or be produced b v a tumor an ab sces s

, , .

or a di ssemina ted or di ff use sclerosis o f the en

cephalon o r be ca used b y pr i m ar v hv d roceph
,

alus men ingit is t rauma capit is or insolat i o n

, . . .

SY P I I I LI T I C D E M EN T I A
S y phil it ic dement ia mav be divided int o tw o
forms progressive d ementia w ith paralysi s an d
. .

dementia w itho ut paralysis .

Both are the resul ts o f the lesions produced b v

p oi son
the syph il itic poi son in the arteries men inge s , ,

and cel ls of the brai n .

Pr og ressi ve S everal t y pes o f s v phi l i ti c i n san i tv ha v e bee n

D em en ti a describe d but progressive dement i a w i th par al y
,
w i th
P d r o b si s
' sis is the most common and prese n ts a st riki n g
cl inical picture .
 OR G A N I C DE M EN I '
m 29 3

The prodromata are the usual severe persist .

mala
ent nocturnal hea d aches a feel ing of phvsi cal
, .

inabil it y for auv w ork then incomplete pto si s or

,

oculo motor paral v si s The para l ysi s advances

-
.

sl ow l v and is never compl ete The ptosi s i s par

.

t ial not su fcient to obscure vision and the

, ,

p a r a l v s i s o f the recti seldom produces a po s itive

s q uint . C ombinations o f par al y si s of the
obl i q ue and st raight m uscles mav occur and n v s
tagm u s is not uncommon L e ss f r eq uen tl v there
.

i s an involvement o f the obl i q ue muscle s \ V ith .

the ocular pa ral v se s a n aesthetic patche s are f r e

q uentl y found upon the skin o f the n o se an d
chec k s and a b ove the eyebro w s L o ss o f v ision .
,

fro m optic neuritis al so i s a fre q uent accom pan i

,

ment .

W ith in a f ew davs o r w eeks me n tal s y mptoms ,

i / em a /
s
y p m tom s
appear . These are cha n geabl e an d vary in se al l a ny ed bl e

verity from dav to d av There is usu ally f o r a

.
.

f ew days or w eeks an exce ssive i r r i tab i l i t v that

.

g r a d u a ll v increases to m aniacal excite m ent thi s .

being succee d ed b y depression 3v th i s time .

marked mental re d uction has been reached evi .

d en ced b y forget fulness and ne glect of the ner

d etail s of l i fe Tra n sie n t fanci ful or e x h au st
.

ive del u si ons may appear w hich change fro m d av

.

to d ay and do not rec u r .

Unless arrested at thi s st a ge the di sease

.
d oe2e

pre ents phenomena of the grave st import

s
. f mr osi s
 29 4 M E N T AL m s E \ sEs -
.

L po n a w akin g in the mor n ing the patient may

'

n d a paresis o f the l eg a rm or face from w h ich

. , ,

he mav slo w l y recover w ith in a f ew davs Th i s .

paresis m ay be accompanied b v a t ransient moto r

aphasia S imilar attack s mav occur w hile the
.

pat ient i s a w ake .

M ixed forms o f convul sions follo w ed b y .

t ransie n t paral y si s of the ext remit ies are more ,

fre q uent than the apoplect ic or epilept i form sei z

ures alone The y are usually preceded by sy m p
.

toms o f in tense cerebral congestion w ith a ful l

C an on/si on s tense pul se C onvul sions n ow commence at r s t
.
,

l imited to one ext remit y then becoming mo re .

w idel y spread and n all v unive rsal i f the attack ,

is prolon ged In a short t ime there is a resto ra

.

tion o f the physical health but w ith each suc , .

ce ss i v e attack the mental impairment is i n c r ea s

,

ed Gra d ually pro n ounced dement ia is devel

.
,

oped w ith somnolence apath y untidiness and

, . , ,

disregard o f the cal ls o f nature .

D ea I }: or
The patient dies a fter a prolonged series o f epi
Dem en ti a l epti c attack s or sinks into the lo w est grade o f
deme n tia in w hich he remain s unt il released b v
,

some acute pul monary or intestinal disease .

The patholog y o f this form of dement ia is l im

Va sen l a : i ted to the vascul a r sv s tem A ll forms of i n am
.

mat ions o f the arteries are found w h ich b v ob l i t , ,

e r a ti n g the vessel s and diminishin g the nut rit i o n

of the cell s produce local a reas o f ce rebral so ft

.
 O R G A N I C D EM EN T I A 29 5

e n i ng S i g ns
. of previous i n am m ati on s of the
pia are almost al w av s discoverable .

D E M EN T I A WI T H O U T PARA LY S I S
The prod romata of th is form o f dement ia are
headache an unusual irritabil ity suspiciousness
. . ,

and loss o f sel f cont rol -

.

The sexual desi re i s occasional ly inc reased but ,

more frequentl y entirely lost Inc reased irrita .

b i l i ty soon appears w ith a tendenc y to viole n ce

,
.

M ental coordination i s lost and a mild dementia

is developed U sually the muscular po w e r is
.
,

dimini shed and an aemic symptoms appear .

P a ral vses are rare but epil epti form and apopl ec
,

ti f orm attacks are common M ildl y demented .

,

the patient may remain unchanged for y ears un ,

til removed by death from some intercurren t

a ff ect ion .

P O ST A P O PL EC T I C A N D E M B O L I C DE M EN T I A
N inety per cent o f cases of organic dement ia
.

resul t either from th rombotic o r embol ic pro

cesses in the cerebral gangl ia and w h ite substance
of the hemispher es or from cerebral hemorrhage .

These dement ias cl osel v simulate senile demen

tia the m aj or i tv of cases occurring in elderly
,

individua l s .

That a very important part in organic psv

choses i s played by her ed i tar v i n stab i l i tv o f the
 29 6 \1 E N T AL m sEA sEs

brai n t is sue is demonst rated bv the fact that ex

tensive cerebral l esion s are o ften found po st ,

mortem w hich have never produced an v svm p

,

t om s o f mental derangement in person s heredi

tar i l v stable .

I n po st apoplectic and em b ol ic dementia th e

most pron o unced symptom i s a perma n ent de f ect
in the memor y These pat ient s are l iable to w a n
.

der from home an d are unable to nd thei r w ay

back ; they forget names f aces and date s an d , ,

have no kno w ledge o f time all o f thei r thou ght s ,

being connected w i th the lo n g past Querulou s .

ness and l achrv m osen ess alternate w ith sil l y gar

r ul i tv and depression M oral obl i q uit y i s n o t
.

uncom m on They steal articles f o r w hich the v

.

have no use an n ov thei r househol d s and are i n

. ,

c l i n ed to seek the society o f the l o w and vici o u s .

O ccasionall y expansive ideas o f w ealth h i gh

, ,

station and po w er are developed

,
.

T I I RO M B O T I C DEM EN T I A
O f all the causes organic dement ia th ro m
of ,

b o si s ranks rst Th rombotic dement ias are the

.

re sult of advanced arteriosclerotic di sease espe .

c i al l y of the gangl ia and medullated ti ssues .

The sv m ptom s are numerous and varied T he .

/ en /o / (te m o st important m ental mani festa t ions are a pr o

te r i or a ti on
g r e s s i v el v fail ing m em orv e spec i all v for recen t
,

occurrence s ,
lack o f j udgm e n t incre asing apa ,
 OR G A N I C DE M EN T I A 297

thy ,
dro w siness or sleepl essness
i r r i tab i l i tv . .

Intense man i acal condit ions mav prevail w ith ,

m o tor agi tation and ext reme l oq uaci tv o f ten te r ,

m i n a ti n g onl y w ith death A marvelous .

st rength is fre q uently man i fested during these

attacks The incessant acti v it y and sleepless
.

ness w h ich one w ould th ink must speed i l v ex

.

haust these patient s may cont inue for w eeks , ,

even w ith the impe rfect feeding that alone i s

possible M el anchol ic cases are more frequent
.

than the maniacal and are of longer durat ion b ut ,

the care o f the patients i s less di fcul t .

the mental sym ptoms are usually a ssoci

ated pronou n ced motor s y mptoms in the form of sy mptom s
tremulous or th icke n ed speech w ith accid pa re ,

sis o f groups o f muscles in one or more ex tr em i

t ies ; but complete paral v si s i s rare S o me .

patient s exhibit a general muscula r t remor inca ,

p a c i tati n g them for act ive m o vement s w hile w ith ,

others a sp astic condition o f the l imbs i s combined

w ith the t rem o r .

E pileptic sei zures not i n f r eq uen tl v fol lo w a fter

the exhibit ion o f motor s y mptoms O ne hal f o f .
-

the cases over sixty eight v ear s of age have sen

-

ile marasmus and the arcus sen il i s The deep .

reexes as a rul e are sl i ghtl v or m arked l v ex

. ,

alte d and occasi on al l v a di ff erence can be de m on

st r ated bet w een the t w o sides Gangren e o f the .

ext remit ies especiall y of the feet i s occa si on al l v

. ,
 29 8 M E N T AL D I S EA S ES

encountered the amputated l imbs revealing

, ,

w ithout exception the presence o f ob l iterating

,

disease o f the arteries .

B I ai n
O rganic dement ia more rarel y result s from
A oscess brain abscess and primar y internal hy d roceph
alus Post men ingiti s dementia i s another i n f re
.

quent form .

Dement ia from disseminated sclerosis pre

P a r esi s sents i n addit ion to the m en tal en feeble m ent the
, ,

scanning speech intent ion tremor an d n y stag

, ,

mus typical o f sclerosi s These cases closel y

, .

resemble the demented form o f paresi s but lack .

the delusions an d marked me n tal disturbance .

S ize and
I n dementia follo w ing brain tumors the men
tom ti on of tal and physical symptoms depend upon the siz e
tu m or
and location o f the tumor and the amount o f
intracranial pressure .

I n certain cases beside the i rritabil ity an d

,

mental o btuseness w e nd l ack o f sel f control
,

and excitement w h ich may in rare case s i n

,

crea se to a frenz y follo w ed in a f ew davs by

. , .

coma and death In the maniacal form hall u

.
,

c i n at i o n s are occasionally found w hich have been ,

evol v ed from the pat ient s former vocation

'

M el ancholia as a result o f brain tumor is very

rare although the stupor mav simulate it
. .

T r aum ati sm may produce all degrees o f inj ury

to the skull and brain resulting s ooner or later i n
.

de m entia .
 O RG A N I C D E M E N T I A 299

In some cases a sl ight inj ur y mav

,
up a
slo w inammat ion that may produce long vear s .

a fter it is f o rgot ten act ive incurable mental

,

d erangement .

D ementia follo w ing insolation h as n o ch a rac

ter i sti c pecul iarities b ut markedl y resemb l es that
,

follo w ing arteriosclerosis .

 CH A PTE R X I I

I N V O LU T I O N A L P S YC H O S ES

M ELA N C H
O L I A S EN I LF D EM . E NTI A
A certain amo unt of mental deterioration is the
normal pro d uct o f advanced age \ V ith ad v an c .

ing y ears the m em o r v m av become less rel iab l e

, ,

the spirit s less b uov an t the ambitions fe w er n ew

, ,

enterprises less att ractive and the capacity f o r ,

w ork lessene d and yet the man mav remain

,

p e r f ec tl v sane.
7 he n ho w ever the natural
,
i n .

heritance is faul ty these normal mental d eter i

,

or at ions are enhanced and pass int opositive men

tal disease The time w hen the signs o f i n san i t v
.

appear d epen d s l argel y upon the condition o f th e

arterial system Wh ile on e person w i t h the i n
.
.

r /er i o l
heritance o f a st rong vascular sv stem may retai n .
'
s/em
hi s mental po w ers unt il he i s fourscore and ten ,

or even longer an other less fortunate in th i s

, ,

regard mav at f orty eight or f tv y ears sho w

.
-

signs o f senile degeneration The stage o f i n v o .

I ut i on may be divided into t w o perio d s the pre .

senile and the senile : the for m er embraci n g th e

time of l i fe bet w een the ftieth and sixtieth v ea r .

the latter that after the sixt ieth year As a .

product of the rst period w e n d mel anchol i a ; .

as a re sult o f the senile perio d se n ile d ementia . .

 I N V O LL T I O N A L
'

P S YC H O S ES 301

M ELA N C I I O LI A

\ I el an chol i ahis been l imited b v Kraepel in to ,

the d epressed condit ions that arise during the

period o f involut ion embracing all the m orb i d l v
,

anxious states not included in other forms of i n

"
sanit y .
(Kraepel i n ) I ts characteri st ic s a n d
'

a o e!i n
p
continuous depression w ith fear sel f accu ato r v .
- s
.

persecutory and hypochon d riacal delu si ons and

, ,

sl i ght cl o udin g of consciousness terminat i n g ,

u sual l v a fter a prot racted course

, i n moder ate ,

mental deterioration .

E I T OL O G Y
E ssentially a disease o f the pre senile p eri o d ,

m elanchol ia usua l l v appears bet w een the ftie th

and sixtieth years rarely be fore f o r t v or a fter
.

s i x tv
. are its most fre q u en t victi m i n s
.

the proport ion according to Kraepel in of si x tv

, .

[ 0 forty : and o f tw o to one accordi n g to P aton .

\Yhi l e only about one hal f o f the cases can be -

t race d to di rect he red i tv a tainted family hi st o ry .

T o i n ted

i s usual l v f ound evidenced b v the occurrence o f

.

apo pl ex v senile dementia or alcohol ism in ot her

, .

members of the famil y M ental shocks or phv s .

ical illnes s are amon g the most fre q uent ex c1 tm g

cau ses .
F E M A LE I NVO LU T I O N A I . M E L AN C H O L I C
 I N V O LU T I O N A L P sy c n 05 158 303

P A T H O L O G I CA L A NA T O M Y
The ch ie f pathological ndings have been
sclerosis of the cerebral arteries beginning atro ,

phy of the brain changes in the nerve cell s in the

,

deeper layers of the cortex and extensive bril .

product ion o f the neurogl ia .

S Y M PTO M A TO LOG Y
The prod romal period i s usuall y long an d i n
d i cati ve o f a progressive change in the enti re
organism The patient m ay f or m onth s com
.

plain of numerous illy d e n ed sv m ptom s C eph

-
.

a l al gi a
,
sleeplessness di sorders of digestion
, ,

w eakness palpitat ion o f the heart noises in the

, ,

ears lack o f mental concent ration and i n ab i l i tv

, ,

for mental or physical w ork A t rst there is .

.

only a sl igh t accentuat ion o f the mental changes

common to old age but a fter some one o f various
, ,

exciting causes has intervened the p at ient m ani ,

fest s a tendency to become more and more ego

cent ric S ad dej ected apprehensive he n d s no
.
, , .

enj oyment in home an d f am i l v Fill ed w ith .

doubt s and fe ars he loses all pleasure and interest

,

in hi s ordinar y occupation s O verpo w ered b v a

.

subj ective feel ing o f insu fciency he dreads to , S ey i n suf

commence any n ew enterprise from a fear o f ,

failure Easi l v con fused an d forget ful all men

.
,

tal w ork becomes a burden an d he nds it d i ffi cul t

 304 M E N T AL D I S EA SES

to d o anything This feel ing o f sel f i n suf c i en c v

.
-
.

one o f the mo st characteri stic symptoms of the

di sease varies in intensity from on e o f mere
,

d ej ect ion to a feel ing o f anguish A s the di sease .

progresses the mental inertness bec o mes more

,

and more pronounced and connected thou gh t and ,

v o l itional movement more and more di fcul t .

During th is period remi ssion s mav occur w hen ,

f o r a f ew hours the apprehensi o n and depression

(hsappea r .

D elusions o f sel f accusation n ow appear -

.

C l i l d /zood
z
S o m e patient s merely accuse themselves o f gen
a ul ts
f eral w rong doing L suall v the accusations a re
-
.
'

re f erre d to s ome t rivial act s in thei r pa st l ives ,

lon g since f o rgotten S ome childhood fol l y or

.

v o u th f ul indiscretion is recalled and co n ti n u al l v

m o urned over as the cause o f thei r present so r

row . Their w hole past l i fe has been a m ist ake
and a failure E ver y thing about them i s a
.

s o urce of anxiety A l l the troubles of those b v

.

w h o m the y are surrounde d have been caused b v

thei r ow n misdeeds Fre q uently the sel f accusa
.
-

ti o ns re fer to their rel igi o us l i fe The y a sse rt .

R el i gi ou s that the y w ere ne v er tr ul v converted that thei r .

pa st rel igious pro fe ssion s w ere a mere sham that .

the v have bee n mere hvpo c r i te s w ho have sinned

a gainst the H ol v Ghost and are possessed o f the

de v il .

A s so ciate d w ith the sel f accusato r v m a v ap -

,
 P s YC I I O S ES 305

pear depressive delusions These pat ient s asser t

.

that thev and thei r famil ies are to be kil led tha t ,

God has condemned them that thev are to be

,

driven from home prosecuted in court and sen

, ,

ten ced to death . T hev m av re fuse to eat claim ,

ing that they are n ot t to l ive and that thev

ought to be starved for thei r crimes They mav .

plead g uil t y of crimes o f w h ich thev are en ti rel v

innocent in the hope o f receiving punishment
,

and thus rel ieving thei r consciences H y pochon .

d r i acal delusions al so are fre q uent These pa .

ti en ts claim that syphil i s cancer or tuberculosi s

. ,

D ef ) essi e r t '

is dest roying their brains stomach and lungs ; d l usi on s

, ,
e
that the y have been poisoned and can n o longer
digest au v food ; that they have in fected their
famil ies w ho al so w ill surel v die Borne do w n
,
.

by these depressive fears these patients mav eat

.

little or n ot at all and decl ine to purchase the

nece ssaries o f l i fe for themsel ves or thei r fam
i l i es clai m ing that it is useless since thev are so
,

soo n to die .

Inde nite tran si tor v hallucinations o f sight

and hearing m ay accompan y th is condit ion .

V oices m ay continual l y urge the patients to sui

cide or torture them b y repeatedly remindin g
,

them of thei r crimes C onsciousness i s usuall y

.

clear ; and there is n o disorientat ion except w it h

reference to thei r delusions w h ich c au se them to D i so i en ta
.
r

mistake st rangers for relat i ves and insist that ti on

21
 30f) M E N T AL D I S EA S ES

t hey are con ned in pri son S till it i s apparen t

. .

that t heir apprehension is sl ightly d i sb r d er ed .

Thought i s coherent an d relevant but centered .

upon their delusions to w hich thei r conver sation

.

i s limited . M any continual ly repeat certain

ph ra ses such as I w ant to go home
, Wh ere ,
" "

are mv children There i s usual l v some recog

n i t i o n o f thei r condition an d they w il l comp l ain

that their minds are not right al though unable to .

r ecognize m an v sv m pto m s of their di sease .

C ertain cases develop fanci ful and sen seless

d epressive and persecutor y delusion s Ev er v .

a n ei /n l th i n g appears changed fr i ends and relat ives are

l u si an s ,

unrecognized N oth ing seems natural ; thev are

.

c o n ned in prison or in a house of ill fame the .

w orld has come to an end t hey are to be executed

.

f or thei r horrible mis d eeds thei r food i s mi x ed

,

w i th the blood o f thei r ch ildren The most ex .

agger ated crimes against mankind are con fessed .

The y have killed thei r parents and thei r child ren

an d blasphemed the H ol v Ghost and are to be ,

pierced w ith hot iron s and boiled in oi l ; but n o

p un i shment is c o mmensurate w ith their gui l t .

27: i i i sti e
O ther case s reveal nih ili stic delu sions These .

I n si on s patients a s sert that they alone exist Thei r .

friends and al l mankind have been dest royed .

There is no longer an v sun moon or earth , ,

.

They themselve s cannot eat o r breathe speak or ,

w alk . Their bo w el s are paral y zed an d thev are

 I N V O L U T I O NAL P S YC I I O S ES 307

ll e d w ith decomposing food : thev cannot l ive

and they canno t die .

Fille d w ith absurd hyp ochon d ri acal ideas the y ,

a ssert that thei r brains ha v e becom e pet ri ed , H y poe/zon

their lungs sol idi ed thei r heart has stopped and
, ,
dr i acal
thev have become changed into animal s O thers .
,

posses sed by sexual delusions assert that st ran ge

.

m en violate them at n igh t and that they are con

ne d in a house of ill fame O ccasional l y ex
.
,

p a n s i v e delusions are present .

H allucinatio n s o f si ht and hearing are com

g

mon H al lucinations of s m el l and taste may ap

.

pear but are less frequent

, .

C louding o f consciousness and d isorientation

f o r time place and perso n s is usuall y appa rent
. ,
.

A ltho ugh thought i s con fused and monotonous ,

these pat ient s m ay an s w er questions and give a

clear description of their s y mptoms S ome have .

an indistinct idea o f their mental state and cl aim

that it has been caused b v poison or hypnoti sm .

T he emotional state is u sually that of depression ,

characterized b v great an x i etv an d apprehensive

ness Th is is much less apparent w hen the pa
.

ti en t s are s u rrounded b v strangers an d in an

un accustomed envi ron m ent than w hen they are

at home w ith friends and rel at ives The face
,
.

reect s the dominant emotio n The forehea d i s .

creased w ith li O r i zon tal w rinkles except bet w een.

the eve s w here there are o ften several sho rt per

. Wr i n k /es
I N VO LL T I O N A L
'

M E LA NC H L A C HA R A CT ER I S T I C F A C I A L
O I
EX PR ESS ON
I
 v o Lt T I O N A L P S YC I I O S ES
'

309

pen d i cul ar furro w s The expression varies w ith

.

the i n ten si tv of the depression .

C onduct varies w ith the sev er i tv o f the d is

ease A lthough w ork is di fcult and distaste ful
.
,

thev may w ork incessantly exhausting thei r ,

s t rength in their endeavors to forget their mi s C on duct

er v. T hev cannot remain quiet S ome m er el v .

w ander abou t aimlessly others in thei r agon y ,

continuall y pace up and do w n moaning groan , ,

ing pra y ing and beseech ing rel ie f bite their n

, , ,

gers p ull out thei r hair tea r thei r clothing and

, , ,

often severely mutilate themselves A m on g .

strangers and in an in st itution they ordinarily

cont rol them selves much more per fect l y than
when at home .C o m mands are promptly obeyed .

Food is taken reluctantl y ei ther from a desire ,

to die or on account of thei r un w orthiness or

from a fear o f poison S ome patients re fuse
.

medicines and bath s others are l thv

, .

A ll these patient s are more or less suicidal and S n i n d al

'
'

require constant w atching S ome are exceed .

i ngl y desperate and w ill adopt any measure to

accompl i sh thei r design Hanging dro w nin g .
, ,

st ran gulation mav be tried or fail ing by these

, ,

means thev m ay j am their head s against the

,

wall s w al l o w glass or auv other substance w hic h

, ,

thev may chance to nd .

 3 10 M E N T AL m sm sas

Y M PTO M S
P H YS I C A L S

O ne o f the earl iest and most prominent o f the

physical symptoms is insomnia The sleep i s .

lessened and w hat is obtained is disturbe d a n d

unrest ful A norexia coated ton gue foul br eath
.
, , .

constipat ion and digestive disorders are u suall y

,

observed The ci rculation is di sturbed the p ul se

.
.

small and i rregular or slo w the l imbs a re c o l d .

and cyanot ic and si g ns o f scl erosi s o f the art e r ie s

.

may be apparent Dermograph y is usually ea s i l v

.

obtained C ardiac lesions are not in freq u en t

.

and complaints o f numerous di st ressing h eart

s y mptoms are common The temperature is n o t .

in fre q uently lo w ere d N umerous senile cha n ges

.

an
g es m ay be noticed tremul ousness o f the tong ue a n d
.

hands paresis o f various muscles sl uggi sh pu

. ,

pil s ph y sical w eakness and a dry and ha rsh s kin

, ,

The w eight is invariably decreased it s inc rea se ,

usuall y being the rst sign o f improvement .

C O U R SE A ND PR O G R ESS
The course o f the di sease i s u sual l v ch ronic .

I r on i c
the duration v ar v i n g from one to tw o y ea r s .

Th roughout the course o f the di sease a variat ion .

el u si on s
in the severit y of the sv m ptom s is common .

D ai l v evening remis sions and morning exacerba

t ions m av appear or exacerbation s may be p ro
d uced b y an n o v an ce s exhaustion o r excitement
. ,
.
 P S YC H O S ES 311

nutrit ion impro v es and the w eight i n

c reases and the sleep beco m es more prolon ged

and rest ful the m ental s y mptoms be gin gr ad ual l v

.

to disappear The delusion s lose their p o w er

.

and the patients b v degrees come to the bel ie f

, ,

that thei r xed ideas and thei r depression are the

result o f phv si cal di sorders The remi ssion s be .

come longer and more marked and the d epressi on

R em i ssi on s
i s supersede d bv irritability and motor restless
ness : the pat ients the n begin to interest them
sel ves i n the d ai l v a f f ai rs o f l i fe S hort relapses .

m ay ho w ever occ ur e v en after convalescence is

. . ,

w ell e stabl ished w hen so me o f the o l d s y mptoms

,

w ill be mani feste d .

D I A G NO S I S
The dia gn osis o f mel anchol ia is not al w a y s
easv .The diseases w ith w h ich it is most l iabl e
to be con founded are the depresse d t y pe of manic
d epressi v e insanit y dementia przeco x and the
. .

d epre s sed form o f dementia paral y t ica .

The slo w er development o f the disease the .

greater degree O f restlessness psychomotor r e ,

tard ati on , uni form despondency long dura ,

tion , gra d ual improvement and the abil it y to .

e xpre ss themsel ves oral ly or in w rit ing w ill usu M an it .

al l v distingui sh the melanchol ic f rom the su erff dep e ssi on r

e r s w ith manic d epressive in sanity .

D m en ti a e
The dementia p rzeco x case i s d istinguishe d b v P a ox r
'
c
 3 12 M EN T AL D I S EA S ES

his emotional indi ff erence negat ivism , ,

ob ses

sions inaccessibil it y impul sive act s and stereo

, , ,

tYPY
Dem en ti a The depressed form of dementia pa ralytic a
P a r a ly ti ea
sho w s much more mental deterioration de fective ,

memory si v an d con t r ad i ct r v d el usion

l l ,
o s a s well ,

as the cha r ac te ri sti c ph y s i cal symp tom s .

PR O G N O S I S
K r a e el i n K raepel i n r ep o rt s th at o n e thi rd c of hi s ases
p
-

fully recov e r e d tw e n tv th r ee pe r c en
.
- t impr o ved .

su i c i en tl v to r e tur n h o m e t w ent y si x per cent

.
- .

became d em ent e d a n d n in e teen per c ent di ed

.
.

S e/I ott w ith in tw o o r th ree y e a r s A ccor d i ng to SC hO tL

. .

thi rty v e an d t w o ten th s o f the ca ses oc

- -

in the f th d eca d e r eco ve r complet e

t w ent y tw o an d tw o t enth s pe r cent
- -
.

occurring i n t he s i x th d ec ade Fr om .

t w ent y per ce n t o f the c ase s su ff e r f t ?

.

rence o f the d i sea se .

T R EA T M EN T
M ost o f th e se c a ses do
t i on al t rea t m e n t bec a
.

seems to r e ta rd th ei r
thei r suici d al te
I f kept a t hom
bed w atch e d con s
,

a t short i n te r val s
 I NV O LL T I O X A L
'

P SYC H O SES 3 13

easily digested food I n the w orst cases force d

.
,

feeding by the nasal tube mav be re q uired A s .

A 7
0 3 0 ] (I ! be
far as possible the tastes o f the patient should be
consulted in the select ion o f the diet due care ,

b eing taken that the food selected is of a highly

nut rit ious character \ V hen the physical po w ers
.

are su fciently imp roved the pat ient should be .

taken out o f bed kept in the open ai r as much as

,

po ssible an d have the mind diverted by w alks

, ,

drives and varied amusement s

,
.

The remedies needed are the same as those pre

v i ou sl v mentioned for depressed states under ,

man i c depressive insanity selected according to ,

the part icular sv m ptom s o f each i n dividual case .

SE N I LE DE M EN T I A

S enile dementia has been de n ed as a pecul iar
state of intellec tual en feebl emen t w ith or w ithout
delusions resulting from cerebral lesions deter
,

mined b v sen i l i tv (De Fursac
.
) .

D e Fa rsa e
A certain amount of w eakeni n g and d i m i n u
tion o f the mental po w ers i s a natural accom pan i
ment o f old age and ca n not be regarded as patho
logical S imple diminution o f the mental po w
.

ers w ith increase d con servat i sm lethargy and

, , ,

habit s o f econom y natural to sen i l i tv d o not con .

sti tu te a t rue i n san i tv .

S enile de m ent ia i s someth ing more and should

be care f ull v d i ff erentiate d fr o m simpl e ol d age .
 3 14 M E N T AL D I S EA SES
D z
'

er en ti
In senile dementia the letha rgy o f old age b e
,
a ti on
f ro m
comes fatuity conservat ism becomes sus picion
, ,

and parsimony evokes delusions of attacks on

r
p p o e r.tv Forget fulness and a diminution o f
mental V i gor are a natural consequence o f O l d
age but the w eaknesses a re recogn ized N ame s
, .

and dates are forgotten but attempts a re made to.

recal l them The dement is en ti rel v obl ivious O f

.

hi s loss of memor y and inc reasin g mental en

f eebl em en t. The dement misappl ies names and
mistakes faces an d seren el v th inks he is ri gh t
,
.

The dement brooks n o correction and allo w s no

inter ference S enile dement ia i s the natural de
.

ca d ence o f ol d age plus the pathological changes

essent ial to the pro d uction o f i n sam ty A mon g .

the rst mani festations of senile dementia is a

loss of memory The occurrences o f the dav
.

mav be enti rely forgotten w hile those o f vear s ,

long past remain bright and clear The event s .

M em or t
'

o f youth are l ived over as i f they had been.

r ecen tl v enacted The same stor y may be un

.

consc i ousl y repeated several times in an hour .

A fter a time the pat ient becomes unabl e to recog

,

nize h is surroundings or the peopl e w ith w hom

he is con ti n ual l v associated He loses h imsel f on .

famil iar st reet s hi s ow n house and apartments

.

appear st ran ge to h im an d he con foun d s the prop

e r tv of others w ith h is o w n Fail ing to reco g .

m z e h is apartment s he become s exceedi n gl y i rr i

.
 P S YC H O S ES 315

tated by the re fusal of hi s fre q uent deman d s to

be taken home . the advance of the disea se ,

even Old memories vani sh and the senile d ement

m ay n o t only forget the faces o f w i fe and ch il
dren but all kno w ledge o f thei r existence m a v be
blotted out .

Un founded prej udices are easi l v formed and P n

'

y nd
'
i ces
w eal th y senile dements are o ften made the sub

j ec t s o f scheming unprincipled person s to the

d et riment o f thei r o w n fam il ies and deare st
friends .

Throughout the evol u tion of a senile dementi a

there is mani fested an increased ego ti sm The .
I a o/ i sm
g
in d ividual s ow n personal it y is al w a y s upper m o st

H is eatin g drinki n g di fculties o f di gestion the

. , .

d ai l v al ternat ions i n h is corporeal perceptions are

al w ays uppermost in h is mind and the perpe tual
brooding over trivialit ies induces mil d me l an
cholic or hypochondriacal states O nly the .

things that concern h imsel f are considered .

\V i f e an d ch ildren m av die but so long as he is

, ,

himsel f ph y sicall y com fortable he cares not : let

,

some of h is creature com forts ho w ever be re fu s

, .

ed O r fo rgotten and he i s immediately excite d

,

an d aroused to angr y rec riminat ion Dictatorial

.
,

egot istical cruel the senile dement is utterl y re

, .

g a r d l e s s o f the feel ings o r righ t s o f his neighb or .

\ V ith the advance o f the disease a pro f ound ,

M or a l d e

m oral deteriorat ion an d degenerac y of the eth teri or a ti on

 3 16 M E N T AL D I S EA S ES

ical feel ings is m ani fested P at ient s f o r m er l v .

,

rened and cult i v ated become coar se and vul gar .

in speech n egl igent in dress lthy and i n tem per

, ,

ate in thei r habit s cruel and in sulti n g in thei r

,

treat m ent o f their children and servant s F re .

q uently the sexual desi re i s increased although .

complete impotency may exist Thi s desire mav .

mani fest itsel f simply in le w d speech and obscene

en i l e letter w rit ing or in absurd and ridiculous pro
-
,

vr i a si s
p o s a l s o f mar riage L ess f r eq ue n t
. l v a senil e
sat v r i a si s may develop causing indecent expos ,

ure o f the genital ia in publ ic places or attempt s at

rape upon l ittle gi rl s or even in f ants \ V ith .

w omen sexual delusion s mav arise o f bein g

,

ni ghtly ravished or carried to houses of prostitu

t io n or thev mav imagine that thev are foll o w ed
.

upon the street s b v men desi rous o f assaul ting

them .

Terri f y ing illusions and hallucinat ion s m av

mani fest themsel ves Deni te hallucinati o ns
.

a r e ho w ever some w hat rare and are u sual l v o f

. ,

an el em en tar v order The frequent ad v an c m g .

dea fness preventing a proper appreciat ion o f the

,

i m pressions received from external agencies m ay ,

give rise to aural hallucination s The ringing o f .

bell s the rustl ing o f the w ind o r the w h istle o f

, .

l o comotives m av be c o n verted into the imper fect

concept ion o f v m ces L e ss f req uen tl v hal l u .
.

c i n a t i on s o f si ght occur .
 t x vo Lt T to x \ L p sv c n o sti s
'

. 3 1/

The un d erlyi n g mood i s o ften melanchol ic and

rarel y th r o u gh the inuence o f depre ssive delu
,

sions or because o f their recognition of t hei r

S n i oi de
mental deterioration senile dement s have com
.

m i tt ed suicide .

The ch ie f and mo st common delusions O f senile

dement s relate to thei r propert y C onvinced o f.

h is absolute penury the milliona i re may depri v e

.

h im sel f o f the simplest neces sities o f l i fe and

star ve in the midst O f his mill ions and though , ,

resi d ing in a palace grovel in l th and s q ual o r

,
.

C ontinually suspicious o f being de frauded or

robbed .the se dements accuse all about
them o f sinister and mal i gn intent ion s .

The agent s and ste w ards in charge o f

thei r property are discharged and oth e r s
employe d w ho soon receive the same t rea t
,

men t until as S pitzka says t he y nd the
, . .

one w ho possesses the undesi rabl e q ual i cations

n ec e ssa r v to the management o f a senile dement :

for experience teaches that int ri gant s and time

ser v ers have had more success in th is direct ion , ,

than straight for w a rd and independent business

men or the honest friends o f the pat ient I tn .

p e l l ed b v their anxiet y for the sec u r i tv o f thei r

possessions they are prone to w ander cont inu
.

ousl v about the house at n ight lookin g f o r ,

th ieve s and are continual ly engaged in devising

.

n e w bol t s and fastenings f o r doors and w indo w s

 M E N T AL D I S E A S ES

an d n ewh iding places for thei r posse ssions

-
.

U nder the inuence of such d elusion s thev mav

i m agine that the y are being poisoned m u rdered , ,

robbed or cut to pieces

, .

R estl essn ess A st riking feat u re o f m an v of these dements i s

a t n zg /zt a great restlessness w h ich comes on e speci al l v at
'

n igh t causing them to w an d er about the house

,
.

t r y to get out o f doors and escape from an i n d e ,

ni te something or somebody .

Foremost among the bodily s y mptom s mav b e

not iced a general senile d ecreptitu d e and a senil e
tremor of the hands Hemiparesis monople gias .
, ,

tr em or and hemiplegias al so appear as the res ul t o f focal ,

brain lesions Complaints ar e o ften made o f

.

se v ere pains all over the body o f vertigo ringing , .

in the ears and sparks b e fore the eyes

,
M arked .

anesthesias al so in v a rious areas or over the

,

w hole body are fre q uently noticed

,
.

D u r a ti on The d urat ion o f senile dement ia i s v er v vari

able I t may go on f o r years but i n rare i n
.
,

stances terminates b v death in a f ew month s, ,

.

I f n o t cut short b v some other intercurrent ill

n ess bed sores and coll iquative diarrh oea are l ia
,

ble to close the hi stor v .

P A T I I O LO G I C A L A N ATO M Y

In ad v a n ced cases o f senile dementia there i s

f o ttn d in the brain atheroma o f the arteries
, , .

th ic k ening o f the membranes a di m inuti on o f the ,

 I N V O LL T I O N A

L P S YC I I O S ES 3 19

w eight the brain thin n ing o f the cortex and a

of ,

decrease in the number of the nerve cell s The .

crani um i s thickened and the dura usual ly ad her

ent to the cal v a r i utn The cerebro Spinal uid i s
.
-

increased The vent ricles are di stended w ith

.

serum Foci o f softe n ing and hemorrhage al so

.

are f r eq uen tl v present .

T R EA T M EN T
\ l ostcases can be treated at home but should ,

be under the care o f a nurse The t reatment .

should be ch ie y hvgi en i c especial attention ,

being given to cleanliness and the admini st rat ion

o f liberal quantit ies of nourishing food and to

giving as much exercise in the open ai r as the

physical condit ion w il l allo w .
 C H A P T ER X I I I

M A N I C D E P R E SS I V E I N S A N I T Y
-

TY PES : M A N I C D E PR ESS ED M I X ED
. .

M anic depressive insanity is mani fested in at

-

tacks that occur th roughout the l i fe of the in d i

vidual w ithout producin g mental dete rioration ,

and is characterized by a ten d en cv to recover and

a tendency to w ard recurrence .

T I O L O GY
E

M anic depressive insanity i s on e of the most

-

common forms o f mental disea se embracing ,

from t w elve to t w ent y per cent o f al l ad m issions

.

to insane hospital s Its ch ie f cause l ies in an i n

.

her i ted predisposition that renders the individ

I II /ter i / a n ee ual incapable o f bearing the st rain s of d ai l v l i fe .

To inheritance from sixt y to eigh ty per cent o f

,
.

all cases may be ascribed In some the disease

. .

is a di rect inheritance from some ancestor In .

many a const itutional tend en cv has been sho w n

,

th rough l i fe evidenced b v undue excitabil ity lack

, ,

o f sel f cont rol and causeless changes o f mood

-
. .

S ome are abnormal ly bright others are shv and.

reserved and occ asion al l v i m beci l i tv is apparent

,

fro m bi rth P h y sical sti gmata are fre q uentl y in

.
 M A N I G D EP R Ess I v E I
-

N SA N I T Y 321

e vidence Handicapped by constitutional w eak

.

ness an v unusual st rain may act as an ex ci t

,

ing cause O verstudy overanxiety shocks loss

.
, , ,

O f sleep trauma insolation any acute disease

, . , .

l ike typhoid fever pneumonia rheumatism or . , .

scarlet fever or an excessive loss o f blood m ay

, ,

i n one previou ly predisposed precipi tate an

s
,

attack .

women are especially susceptible and comprise

about tw o thi rds o f its victims
-
In w omen the .
,
WO W

rst attack may appear coincident w ith the rst

menst ruation In m any the disease mav be gin
.
,

w ith the rst childbi rth and recur w ith each suc
ceed i n g parturition al thou h the cl imacterium
,
g

m a y not cause a cessation o f the attacks .

The t ime of l i fe mo t amenable to its assault s

s

i s bet w een the t w el fth and tw en tv f th y ears -

.

al thou gh attacks have occurred as early as ten

v ea r s and as l ate as seventy years .

Y M P T O M A T O LO G Y
S

I ts symptoms mav b e arranged into th ree

groups
M a n ic .

Depre s ed s
.

M ixed .

M A N I C T Y PE
The manic type m ay b e divided into hv po
mania mania and del irious mania
, ,
.
 MAN I C -
D EP REss n E I N S
'

A N I TY 323

Hypomania is the mildest form o f mania It .

M i l d !

has al so been designated mania mit is o r mit i s "
~

"
sima and fol ie r ai sson n an te
, .

The onset o f the disease i s slo w For a f ew .

davs or perhaps a month sign s o f app roach ing ,

trouble are apparent The appetite fails the .

,

P 51 5 1 !
sy mptom :
tongue is coated the bo w el s are constipated . ,

w eight is lost and the skin looks dirt y

, A dull .

headache w ith sleep l essness and a general mental

inertia un ttin g the pat ient for mental w ork
, .

renders h im depressed or hypochondriacal .

A fter th is stage the bodily ailment s are lessened

,

and a change in the physical appearance bearin g , .

and actions takes place The face becomes .

fl ushed the e ves are bright and the expression of

, ,

gloom and i nert ia is changed to on e o f j oy and

an imat ion P reviously disregard ful of h is per
.

sonal appearance the patient n ow dresses h imsel f

,

in a gaud v and ridiculous manner Fo rm er l v . a n ce

sel f abnegating and reti ring he n ow becomes

-
,

sel f assertive and anxious to att ract attention

-
.

P reviously pessimist ic he i s n ow i m perturb ab l v,

optimi st ic Impervious to care he is n ow j oyous

.
. d
a tti tu e

and happv Former w orries and anxiet ies are

.

forgotten and he is transported to another

realm one o f joy and sunshine Inquiries
,
.

as to h is heal th el icit the universal repl v

that he never fel t so w el l be fore in hi s
"
l i fe
. Filled w ith over w eening egoti sm he ,
 3 24 M E N T AL D I S EA SES

proclaims h is abi l ity to accompl ish grea t

undertakings C onscious o f his ow n great
.

s uperiority he brooks n o inter ference w ith hi s

,

actions or undertakings The sl ightest contra .

diction or attempt at rest raint provokes a violent

outburst o f anger E xceedingly loquacious and .

con dential he may con de his most private a f

,

fai rs to utter strangers A lthou gh the lucidity .

,

orientation and memory may remain intact the

, ,

j udgment and at tention are greatl y impaired and ,

conversat ion and letters are l ikely to sho w

an entire lack in the association o f ideas .

E m oti on a l The mental attitude is that of elat ion .

sta te
the patients are usual l v cheer f ul happy , ,

and exuberant S ome are humorous an d

.

given to facet ious remarks \V hi l e j ovia l .

and friendly they are marke d ly sel sh as

.

far as thei r ow n desi res and w ishes are conce rn

ed O thers are discontented intolerant quarrel
.
, ,

some and rude A l l are impul sive in thei r ac

. .

C on du et tions an d l iable to sudden outburst s o f a n ger upon

the sl ightest provocat ion Devoid o f moral .

sense many l ie cheat and steal w ithout the l east

, , ,

scruple Formerly vi rtuous and abstem iou s

.
,

they may become openly l icentious and drunken .

Incapable of appreciating the character of thei r

conduct the most deplorable acts are regarded
,

w ith complacency Impel led by an increased

.

ps y c homotor acti v i tv the most striking s y mpto m,

 M A N t c D E P REss n E I
-
'

N SA N I T Y 3 25

is their continual restlessness From mornin g .

unt il late at night impervious to fat igue the y are

, ,

doing someth ing Long w alks or j ourne y s are

.

undertaken New business ventures mav be tak

.

en up and fool ish speculat ions entered into often ,

resul ting in the loss Of a l i fetime s accumul ation

.

A l w ays busy w ithout persistent perseverance

,

in any one undertaking thev accompl ish nothin g

, .

P H Y S I CAL S Y M P T OM S
The sleep obtained al though lessened in the
,

number o f hours b v thei r pre ssure of activity is .

profound The appet ite is good the w eight is

. .

retai n ed or inc reased and there i s no loss o f

,

physical st rength .

Improvement i s gradual and subj ect to remis

sions The duration is from a f ew da v s to sev
.

eral month s .

M AN I A
The onset o f man ia is usual l v sudden follo w ,

ing a short period o f de p ression attended b v

dden
,

su
sl ight headache or a general feel ing o f mala i se
and discom fort The characteristic symptoms
.

are rapidly developed The previous dep ression

.

and lassitude change sudd en l v to exal tation and

great psychomotor restlessness and act ivity .

C onsciousness is some w hat disturbed and partial ,

or complete d isorientation is apparent

. .
 3 26 VI EN T A L D I S EA S ES

Friends and acquaintances are un recogn ized

and may be addressed as prominent historical
perso n s or publ ic o ffi cial s L acking in apprehen
.

sion the pat ient s are easily distracted b v any

,

th ing w hich occurs about them Incapable o f .

sustaining a long connected conversation they ,

mav ans w er correctly short questions as to thei r

previous and present condition A l though usu .

al l v exuberant and happy they are easi l v i rri

,

tated an d subj ect to violent outburst s o f temper .

A n y rest raining w ord or cont ra d ictio n w ill call

forth upon the o ff ender torrents of abuse Often ,

E m oti on a l e n ding in a personal assault E xceedingly emo .

t i on a l they shout w ith joy on e moment the nex t

, ,

burst into fl oods o f tears and bit terl y compl ain o f

the abuses to w h ich thev are subj ected .

O v e r ow i n g w ith psych o motor activity they ,

H y per are never quiet They sing dance shout ges

.
, , ,

t i cul ate tear thei r clothing and smear themselve s

,

and their apartment s or adorn themselves w ith

the most incongruous decorat ion s In their eat .

i n g they are especially revolt ing mixing up their ,

food and bol ting it in the most disgu sting

manner .

D estr n eti o e E xceedingly dest ructive nothing is sa fe w ith ,

~

in their reach The y dest ro y furniture clothing

.
, ,

glass bedding anyth ing w ith w hich the y come in

, ,

contact They may be play ful and misch ievous

.

or q uarrel some and violent Impelled b v thei r .

 M A N l c D EP REss n E I
-
'

N SA N I T Y 32/

sexual excitement m an v masturbate sham el essl v

. .
S ex ua l
exci tem en t
expose themselves or make co n stant d eman d s for
.

intercourse The mental exaltat ion an d ex ub er

.

ance o f spirit s m av at rst be but an exaggerat ion

of natural characteri st ics b ut i t i s soon super ,

sed ed b y a mental turmoil Some are d azed and

.

con fused and com pl etel v d i soriented The .

speech m av be incoherent and replete w ith hallu

c i n ati on s an d delusion s The mind may be oc en
.

pied b v a single de l usion or a multitude o f delu

sion s m ay pass th rou gh the brain The d elu .

sion s are usual l v expansive an d changeable .

The hallucinat ions are varied and t r an si to r v .

l i on s

Face s peer at them beaut i ful panorama s are

,

spre ad ou t be fore them or fright ful animal s jump

at the m the s w eetest music ll s thei r ears or an
.

g r y voices th reaten them A ccording to

. the na
ture o f their ment al vision s the patient s are
plea sant cheer ful and t ractable or erce savage
. .

and dangerous The m aj o r i tv of patient s righ t

.
,

in the mid st of the m o st vivid hal l ucination s can .

return m om en tar i l v to reason an d talk coherent

lv. A lthough a deran gement o f the correlation
o f i d ea s and consi d erable ment al obscurat ion i s

apparent amid all the logorrhea vet the j udgment ,

m ay be unperverted A lmost al l are noi s y an d

.

their apartment s night and dav resound w ith

, ,

their shouts of j ov an d peal s o f laughter or w ith ,

C on a u et

groans curses and imprecat ion s Guided en

. .
 328 M EN T AL D I SE A S ES

by thei r delusions these patient s are utterl y

t i r el y ,

unt rust w orth y and need to be constant l y w atched

to prevent their doing damage to thei r surround

ings attendants or themselves They are not

, .

us ual ly suicidal from a desi re to destro y them

,
~

selves but under the inuence o f their delusions

,

may j ump out o f w indo w s o r into the w ater or

re imagining that they are imperviou s to harm
,

or that they are pursued by enemies .

M any o f these are exceedingly dest ructive tear .

O ff all their cloth ing and utte rl v shameless go , .

about en ti rel v nude break w indo w s or furnitur e

.

and i f opposed become exceedingl y violent bit .

ing striking or kicking anyone w ithin reach

, .

Disturbance o f the circulation is evidenced by

the ushed face hot head congested e y es w ith
, ,

dilated pupil s and general heat o f the body T he .

pul se i s strong and full but m av not be greatl y

,
sy mptom s
accelerated and the temperature i s usually not
.

much e l evated The tongue is coated breath of

.
,

fensive but the pat ients u n less prevented b v the

, ,

delusion o f bei n g poisoned mav eat r av en ousl v . .

o ften bolting the food in l arge m asses ; but i n ,

spite o f the enormous quant ities o f foo d taken .

there is a s tead y loss of w eight The bo w el s are .

usually constipated the urine high l y colored and

,

Often scan tv or suppressed A ll o f the se pa .

t i en ts unless prevented by appropriate t reatment

, .

are sleepless and night a fter ni gh t uncea sin gl y

. .
 M A N [C -
D E P R ESS I V E I N S A N I T Y 3 29

engaged by their schemes w il l go w ithout a mo .

ment s or at the most w ith onl y one or tw o

, ,

"
hours sleep E xceedingly n oi sv in man y cases
.
.

thev not only sleep l ittle or none themsel ves but ,

prevent everyone el se from sleeping w ho is w i th

in range o f their voices .

In w omen the menst rual funct ions are l iab l e to

M en str ua
be disturbed and w hen normal thei r occurrence
,
ti on
i s usual ly acco m panied b v marked exacerbation
o f the mental sv m ptom s The menst rual dis .

charge i s in man y o ften exceedingly pro fuse an d

, ,

ext remely O ff en sw e .

A fter a variable length of time the intense ex

c i tem en t decreases and the interval s o f quiet b e

come longer and lon ger S leep returns The . .

hall ucinations and delusion s lessened in intensit y ,

and pal ing be fore returning reason are at l as t ,

recogni z ed as mere deceptions and the individual

p asses on to a more o r less complete recovery .

Ho w ever perfect the recover y the patient i f sub ,

j e ct ed to au v severe mental strain i s l iable to a

recurrence o f the disease The duration varies .

from a f ew davs to tw o or th ree years The .

u sual duration is several month s .

D EL I R I O U S M AN I A
This form i s the most intense o f the maniacal
states It i s character ized by cloud ing of con
.

sc i ou sn e s s i n cohe r en cv o f speech marked p sy

. ,
 3 30 M EN T A L D I S EA SES

chom o to r and numerous hallucinations

acti v i t v

and vague del usions .

O f rare occurrence the disease a fter a short

.

period O f indisposit ion characterize d b v sleep .

lessness and restlessness suddenl y burst s for t h .

hb n s
in ful ly developed form Filled w ith hall uci n a .

tion s o f every form and description reason i s ,

completely dethroned The most charmin g

.

scenes and ent rancing sound s al ternate w ith

sights o f torture and sh rieks of an guish O ne .

moment t ransported to heaven the nex t thev are ,

plunged into the depths o f hell V ague dream .

l ike d epressive or expan sive d elusions soon ap

,

pear O ver w helmed b y th is continuousl y chang

.

C onf u si on
ing host of mental phanto m s a state o f deep con ,

f usion ensues E nti rel y disoriented thei r sur

.
,

roundings appear strange an d frien d s and fa

mil iar f aces are unrecognize d P ro f oun d l v i n .

coherent thev constantly po u r forth an endless

.

t o rrent of senseless w ords or a constant repet i

tion o f single phrases and sentences R unnin g .

the w hole gamut o f the emotions ecstatic j o v , .

di re di stress courage sh rinking timi d ity an d

, ,

apathetic in d i ff erence may be successively di s

p l a v ed in their act ions and b v thei r varied facial
m otor
expressions In the psychomotor eld the acme
.

of maniacal excitement appears The p at ient s .

rush about t heir apartment s gest icula te tear O ff , .

thei r clothin g pou n d upo n the doo r s or w indo w s

, ,
 M A N I c D E P RES S I v E I
-
N SA N I T Y 33 1

s hout sing s w ear pray or smear them selves and

. , .

their apartments I f conned thev continuall y

.
.

l i sten to and ans w er thei r i m agi n ar v voices .

E nt irel y engrossed b v their mental activi t y l it ,

tle foo d i s taken and a s a result the w ei ght d e

c reases O cca sionally muscular t remor is pres
.

ent S leep is greatl v d i sturbed an d at the w orst

.

sta ge of the disease is entirel y absent Disturb .

ance o f the circulat ion i s evidenced in the accel

e r ated pul se ushed face inj ecte d con j un cti vze
, ,

and hot he ad .

The course o f the disease i s u sual l v rapid an ,

abatement o f the symptoms appear i ng I n three or

C ou r se
four w eeks D u rin g the height of the excite
.

ment short interval s of comp o sure la st in g from .

a f ew minutes to a f ew hours may occur but the . .

consciousness i s al w ays clouded Improvement .

may sud d en l v take pl ace but it is u sual l v gradual

. .

A fter the cessation of the exciteme n t vague rem

nants o f hallucinat ion s and d elusions f or a time
m av be apparent but these soo n disap pea r
. .

There is usuall y n o remembrance of the occur

ren ees O f the acute stage A fatal terminat ion .

may en sue as the res ult of exhaustion inj urie s

, , ,

fat embol ism o f the lungs or from some intercur

rent di sease .

Follo w ing the attack signs o f depr ession and

mental and phv si cal exhaust ion may appear un , f i x /t a n s
l i on
tti n g the pat i ent for an v w ork These ho w . .
 3 32 M E N T AL D I S E AS ES

ever usually di sappear w hen the nor m al w eight

,

and st rength i s regained In some of the sever .

est cases a certai n amoun t o f mental en feeble

ment remain s evidenced in impaired j udgm ent ,

insight and abnormal emotional i r r i tab il i tv and

restlessness .

The duration o f maniacal attacks w hatever ,

n r a hb n
the form cannot be predicted w ith certai n tv
,
.

S ome last but a f ew days others continue f o r ,

years Death seldom occurs except as the resul t

.

o f inj ur y or some intercurrent disease .

T R EA T M E N T
The maj ority o f cases o f maniacal excitement
w ill be better cared for in some institution f or the
insane and as soon as the disease is establ i shed
,

should be commi tted I f the patie n t ho w eve r

.
. ,

has ample means he can be cared f o r at ho m e

, .

ho w ever severe the attack I f he is to remain at .

home ample preparat ions must be made for hi s

,

t reatment A large w ell vent ilated room as fa r

.
-
,

as possible from the other members of the famil y ,

should be selected The w indo w s should be f as

.

tened and guarded the doors provided w ith good

,

locks and al l bric a brac and unnecessary f ur n i

- -

ture should be removed O ne and i f necessary. . ,

tw o experienced nurses should be secured and

gi v en enti re charge of the pat ient .

In the treatment o f mania the ph y sician shoul d

 M A NI C -
D EPR ES S I V E I N SA N I T
'

constantly bear in mind that he is d ealing w ith

a very sick pat ient \V hatev er evidence o f bod
.

ily st rengt h mav be di splayed it must be remem ,

Fl t ) si ei a l
'

bered that this strength is spurious and that the

.

, exha u sti on

disease is rapidly exhausting the victim s mental

and physical vita l ity The patient should

. ,

there fore be immediatel y put to bed and kept

,

there b v mechanical restraint i f necessary unt il , ,

convalescence i s fully establ ished A bundant .

l iquid nourishment in the form o f soups bee f tea

, ,

and mil k must be admini stered at regu lar inter

.

val s A sponge bath w ith alcohol and w ater

.
.

ni ght and morning w ill greatly add to the pa

,

t i en t s com fort and help to soothe the nervous

condit ion In cases of great excitement a pro

.

longed hot bath w ill o fte n prove hi ghl v benecial H ot ba tl I s

in producing q uiet and sleep Great care should .

be taken that in hi s violent st ruggles he does n o t

become bruised or inj ured \V here mechanical.

restraint becomes necessar y constant w atch f ul C on sta n t

wa I t ll/ l l
ness must be observed that the circul ation be not
'

disturbed and that no abrasions o f the skin occur .

\Vh i l e constant w atch must be kept night and

d ay it is desi rable that no more persons shoul d
,

be about the patient than are ab sol utel v necessa ry

for h i s care per fect q uiet of bod v and m i nd bein g
as far as possible a ff orded the su ff erer In the .

medication select the remedy w hich from it s ,

m ental an d general s vm pto m s is the c l o se st sim ,

D E PRE SS E D T Y PE O F M AN C D EPR E
I - SS I V E N S AN I T Y H YP OC ON D R I A C A L
I H
 M A N I C D EP RESSI V E I N SA N I TY
-
335

i l arto the case in hand and st ick to it and the

resul t w ill surely re w ard you I f the pat ien t .

d oes not sleep as much as you w ould l ike at rst ,

do not get discouraged as one hour o f natura l ,

sleep is better than many forced by narcotics .

S leeplessness is but on e symptom and as the dis ,

ea se yields to t reatment sleep w ill come naturally ,

and w ith it mental rest and heal ing N umerous .

harmless adj uvant s in the form o f w arm bath s

, ,

hot m ilk or hot mal ted mil k may aid the selecte d ,

remedy w hen persistent sleepl essness prevail s .

G eneral massage in some cases is al so e ff ectual .

The follo w ing l ist o f remedies are those w h ic h

w e have foun d most help ful i n these cases :
A con A garicus A nac A pi s A rs A lb Bell
.
, , .
, ,
. .
,
.
,

C amphor C antharides C ham C al e C arb C im

, ,
.
,
. .
, .
,

Hyos L ach N ux V om Phos P la t S t ram

.
, .
, .
,
.
, ,
.
,

Tarantula H ispania V eratrum A lbum V era , ,

t rum V i ride .

AC O N I TU M
This is frequent l y use ful at the onset of mania
w hen characterized by marked inammatory ac k
a tta c

tion sho w n by full rapid pul se hi gh temperature , ,

g eneral heat of skin great restlessness and,

i n

tense thirst .

The patients evince great fear and anxiety o f Fea rs

mind w ith great nervous ex ci tab i l i tv They are
,
.

tortured by ev er v variety of fear and thei r timid

 3 36 M EN T AL D I S E A SES

ity is stamped upon every l ineament of the coun

ten an ce They are a fraid to go out to cross the
.
,

street or go w here there is any excitement

, .

They have a constant horror of approaching

death darkness and ghost s Though t is con
, .

f u sed the memory w eak and mental labor is an

,

R estl ess n ess

impossibil ity They are restless in body and
.

restless in mind There is n o stabil ity o f

.

thought one moment thev are sad the next gay

, , .

They a re excee d in gly erethist ic oversensitive to .

l ight noise and music intolerant o f pain and can

, .

n ot bear to be touched o r uncovered .

The prevail ing characterist ic o f the maniacal

aconite patient is fear .

W h ile aconite is O ften benecial in the begin

n ing o f the disease it usually has to be follo w ed
,

by some other remedy be fore the c u re is com

pl eted .

A G AR I C U S
Furious fearless menacing frenzy w h ic h
, , ,

causes the patient to assail and inj ure himsel f and

others .

G rea t
Incoherent talking passing rapidly from on e ,

E xci te m en t subj ect to another Great excitement evince d .

,

b v leaping dancing singing w ith great l oq uac i tv

, ,

and exaggeration o f the senses Full o f del u .

sions o f po w er and personal importance H al .

l uc i n at i on s of sight and hearing E xciteme n t .

 M A N t e D EP R ESS I v E I
-
N SA N I T \ '

3 37

follo w ed by sleep w ith great prostration upon

,

a w akening C onstant
. muscular t w itching .

Tremulousness of the w hole body Th i s tremor . T r em or

i s more internal than external and mav greatly
terri fy the patient .

E speciall y use ful in cases compl icated by

chorea and w hen indicated i s exceedin gl y
e ff ectual .

A N ACAR D I C M
Fixed ideas that he i s double that there is no ,

real ity in anyth ing that the body and mind are
,

separated that a stranger i s b v hi s side A ll

,
.

appears l ike a dream Imagines that her hus .

band and child are n ot hers fondles then pushes , .

them a w a y Thinks he i s a demon w hen w alk

.
,

ing feel s that some one is pursuing suspect s ,

ev e r v on e and is con stantl y apprehending t rouble .

C ont i nual l y un d er tw o inuences one incit ing to ,

murder the other urging h im to be good I m

, .

agi n e s that he hears voices of mother and si ster

w ho are far a w ay H as a devil w h ispering

.

bl asphemous w ords in h is ear C o n stant incl ina .

tion to curse and s w ear .

The anacar d ium patient is ch iey character

i z ed b v hi s ugliness and fright ful profan it y
f
o am
'

.
I ty
The ant imonium crude pat ient is peevish the .

chamomilla cross the bell adonna pugili stic the

, ,

nux vomica ugly but the anacardium pat ient is

,

c ussedness it sel f .
 338 M EN T A L D I S EAS E S

\V e ha v e fou n d anacardium more Often cura

M a n i a ca l
t ive in ch ronic maniacal states th an any ot he r
r em ed v .

A P I S M ELL I FI CA
M ental excitement w ith great talkativenes s
, ,

j ealous y an d sexual irritat ion I rritable and .

d gety nothing seem s to sat i s f v

, C on stan tl v .

bus y but does nothing right

. M a m a I n w omen .

from a sexual cause .

This r em ed v w ill p rove help ful w hen the pecu

l iar me n tal state is accompanied b v an i n acti v i t v
o f the ki d ne y s w i th puf n e ss under the ev el i d s
. .

and an a ggrava t ion o f the mental excitement a t

4 P M . .

AR SEN I C U M AL B U M
Bag s S ees ghost s about him an d vermin and bugs
cra w ling upo n his bed Hallucination that there .

is some one by h is side w ho imitates all his ac

t ions Fear that he w il l be obl i ged to kil l some
.

one .

\V h i l e not as fre q uentl y indicated in mania a s

melanchol ia w e have had some exce l lent resul t s
.

w ith th is dr ug w hen the peculiar restlessness .

th i rst ph y sical exhaustion an d midni gh t aggra

.

vation w ere present .

B E LLA DO N NA
The bella d onna pat ient in violent fury bite s . . .

st rikes kicks and tea rs e v erything to piece s

. .
 M A NI c -
D E P R E SS I V E I N S A N I T Y 3 39

H is tal k is excited and incoherent He may be .

exceedingly brave and pugil ist ic o r terri ed b v V i ol en t

p g
u i l i sti c
the horrid creations o f h is disturbed brain .

Ev er v imaginar y hallucination o f sight m a v

pass be fore hi s eyes ghosts h ideous faces dogs
, , , .

bull s animal s men or inst ruments o f torture

, , .

These pat ients are ext remely ckle and thei r

mental states are constantly changing T hev .

may at times dance sing and laugh but the mood

, ,

soon ends in an outburst of rage and violence .

N o other hom oeopathic remedy is more f r e Fr eq uen tly

quently indicated O r as o ften curative in mania as
belladonna The intense cerebral congest ion
.
.

w ild del i rium and ext reme general hy per se n si

ti v en ess o f all the sen ses produced in the provers
is a per fect picture o f th is disease .

A mistake is O ften made in gi v ing it too l ow

We have found it w hen clearl y indicated in thes e
hi ghl v ereth istic cases most e ff ectual in the thi r
ti eth or tw o hundredth potencies .

C A M P I I OR .

The provings o f camphor sho w its po w er o f

producing marked maniacal excitement mani .

f ested in violent overt attacks upo n those about

them even to homici d al attempt s S ome p ro
, .

vers have al so exh ibited suicidal impul ses .

C linically it has proven most e ff ective in mania

w hen attending or follo w ing the stage o f intense
 340 M E N T AL D I S EA sEs

E x ci tm en t excitement great phv si cal exhaustion and pros

w i t/z
t r a ti on are present and the vital po w ers are at
p r ostr a ti on
the lo w est ebb \ V hen the cold cl am m v ski n an d
.

w eak p ul se sho w tha t fatal col lapse 1 5 n m m n en t

ca m phor o ften vies w ith verat rum in ral l y ing the
vital forces and revivi f y ing appa ren tl v hopeles s
cases .

CA N T H AR I DES .

C anthari d es resembl es belladonna in it s viol ent

excitement These patients tear the c l oth in g
.

an d are especiall y incl ined to bite an y one w ho

approaches or they w il l bite sheets an d bed cloth
ing They are restless moan and groan an d
. .

often bark l ike a dog Hallucinations are pres .

ent and thev see and converse w ith people lon g

dead L ike anacardium thev sho w a stron g
.
,

tenden cy to s w ear and are w orse at night .

P u pi l s The eyes are bright pupil s w idel y dilated fac e

, ,

(ti /a ted f v el l ow (unl ike the red face of belladonna ) an d

a ce

w rinkled w ith a constant fro w n and expressio n

,

o f intense su ff ering The sl igh test touch ag

.

g r a v ates the symptom s as al so does any daz zl in g

,

obj ect l ike a mi rror or a glass of w ater

, .

The chie f characteristic and the on e w hic h

u su all v call s for the sel ection of cantharides i s

S ex ua l the intense almost overpo w ering sexual excite

,

exci tem en t
ment w h ich accompanies the violence This sex .

ual excitement is the result of intense er ethi s m

 M A N t e D E P RES S I v E I
-
N SA N I T \ '

34 1

and in ammation o f the sexua l organs drivin g ,

the patient to seek sexual grati cat ion H v o s .

c v am us and verat rum album have al so sexual ex

c 1 te m en t but in these drugs there i s a mingl ing

,

o f the psych ical and the physical I n c an tha r .

ides the excitement is solely ph y sical .

The violence o f cantharides i s paroxysmal and E x ci temen t

pa roxy s
terri c w h ile it l asts O n account o f the se x ual m al
.

e xcitement the cantharides patient seeks rel ie f in

cons ta nt masturbation .

This rem ed v is fre q uently in d icated w hen the

c hie f excit ing cause of the disease has been mas

tu rb ati o n. A ssociated w ith th is menta l group

w e u sual l v n d the characterist ic bl adder svm p Bl a dder
toms o f cantharides .

C H A M O M I LLA .

C hamomilla is occasi o n al l v indicated but usu .

all v as an intercurrent remed y w hen its c h arac

ter i st i c s y mptom s are present These pat ient s.

are cross irritable snappish fret ful and cann o t

. . ,
I r r i ta bi l i tv

give a civi l ans w er The y are al w avs out o f

.

humor and cannot bear to be spoken to touche d .

or have an y one near Hallucination s o f hearin g

.

are said to be produced b v this d rttg but w e have ,

fre q uentl y pre scribed it on th is indication an d in

e v e r v case have failed The mental condit ion is
.

w orse d uring me n st ruation .

 3 42 M E N T A L D I S E AS ES

CALCAR EA CAR B O N I CA
isn a l V i sion s o f faces and persons w hen eves are
[l a wna
closed Del i rious talk about re rat s mice and
.
, ,

murder S ees cat s curs and other animal s

.
,

about him and ght s them off Imagines that .

some on e el se is w alking beside her that some ,

th ing hanging over a chair i s a person sitting

there .

C alcarea carbonica i s only bene cial w hen in ,

n sti tu
addit ion to its pecul iar mental symptoms its gen .

n al eral con stitutional sv m ptom s are present .

I I YO SC YA M U S

The hy osc y amus i s n ot as violent an d danger

an
g eo ol e ou s as the bell a d onna and is less w ild and more .

easil y cont rolled than the stramonium patient .

S he sings cries laugh s scolds s w e ars talks ob

, , , , ,

scen el
y and Often accuses hersel f and her hu s

ban d o f in d el ity These patients o ften re fus e

.

food claiming that i t is poisoned The fear o f

, .

p o i son is one o f the common delusion s and no

other drug w ill as o ften remove it w hen present .

The delusions and m oods are exceedin gly

chan geable but the patient is usuall y jol l y and
,

good nature d b ttt n ervous restless and sleep l es s

-
. ,
.

r ua l There is great sexual excitement w ith much ,

lascivious talk and constant desire to expose th e

per son and remain naked H v o scv am us i s espe .

c i al l v su ita b le f o r young hysterica l nervous an d .

ea s i l v excited w omen .
 M A N I C D EPR ESS I V E
-
I N SA N I T v 343

Hyoscyamus is very often demanded in mania .

\ V hen indicated n o remedy is more often cura

t ive
.

LA C H ES I S
L achesis i s usefu l in cases o f insanity w hen
there is great loquacity These patient s talk i n .
Loq uaci ty

cessantly and so rapidly that it is almost i m pos

sible to understand them .

A common delusio n is that the y are dead and

preparations are being made for the funeral .

T hev are proud j ealous suspicious and Often

, ,

have the delusion o f being under superhuman

co n trol .

N LX
'

V OM I C A
N o case is more disagreeable than a nux
maniac O pposed to everyth ing that i s done for
.

h im ever ready to ght w ith those about him he

, ,

may from pure cussedness re f use to eat or drink

an d re q ui re forcible al imentat ion to keep him

alive H e is oversensitive cannot tolerate noi se

. .
,

talking stro n g odors or bright light He is ob

, . Q ua r rel

st i n ate cross q uarrel some and ugly B r y onia is

, , .

b
o sti n a te
al so an ugly remedy but the bryonia patient ,

w ants to keep st ill and be undi sturbed w h il e the ,

nux patient i s restless uneasy and aggressive in,

h i s u gl iness \V hi l e presenting n o marked delu

.

sions from an apparent perversion o f the w hole

,
 3 44 M EN T AL D I S E AS E S

moral nature these patients are often among the

mo st di f fi cult to manage .

\ V it h these marke d mental s y mptoms w e nd

the usual characteristics o f n ttx so that one is not ,

l ikely to make a mistake in the sel ection of the

drug \V hen indicated w e have found th is rem
.

edy on e o f the most sat is factory in it s result s .

although it is often slo w in its action and requi res

to be continued some ti m e .

P H O S P H O RU S
V iol ent del i rium w ith restlessness fear o f
, ,

death and constant d esi re to escape L oud .

screaming w ith attempt s to bite and st rike those

, ,

about h im Hall ucination s o f si ght sees face s

. .

leering at him w herever he may look N ervou s .

excitement starts at the sl i ghtest noise I nten se

. .

sexual desire w ith ent i re shamelessness and con

.

stant attempts to remove all the cloth in g and go

naked Imagines that he i s in several pieces an d
.

cannot properly adjust the fra gments I rritabl e . .

fret ful an d peevish N ervous and f ear ful . ,

w orse to w ard eveni n g sleepless be fore midnight

,
.

P hosphorus is n ot as fre q uently demanded as

some other drugs but ex ceed i n gl v sati sf v i n g
,

w hen in d icated O ne o f its most positive sy m p

.

toms is the presence o f hal lucinatio n s of sight

faces peering from every corner \ V ith th i s .

er y w /zer e
symptom present w e have never fa ile d to rel ieve
.
 M A N I C D E PR ES S I V E I N S A N [ T Y
-

the pat ient b v the exhibit ion of ph o sphorus I t .

is most f req uen tl v demanded in cases w ith se x

E x /za usted
ual excitement and w here the disease has a risen b ra i n a n d
from a depleted state o f the brain and ge n eral n er vou s

sy stem
nervous sv stem .

PLA T I N A
P roud haught y arrogant imagines hersel f
. . .
H a ri g /st I
i mper i ou s
superior to eve ryone about her Imp eri o us and .

di c/ator i u l
dictatorial Thinks she does not be lon g in her
.

o w n f am i l v Treat s in a contemptuous and piti

.

ful manner peopl e usual ly venerate d E v e r v .

thing about her seems small and all p ersons abou t

he r phy si cal l v an d m e n t al l v in ferior to her .

C hangeable mood great joyousness al ternatin g ,

w ith sadness an d depression anxious moros e , . ,

q uarrel some peevish irritable easi l v o ff en d ed

. . , .

N v m pho m an i acal w ith pain f ul sen sI ttv en es s o f

.

the genital s .

The ever present prou d arro ga n t co n tem pt u

-
, .

ous mood w ill precl ude any possibil it y o f mist ake

i n the selection of th is drug I t is mo st f r e .

q ue n tl v indicated in w eak hysterical w omen w ith .

a ten d en cv to n vm phom an i a caused bv irritat i on .

A fy mp/zo
manm
and excitement of the genital ia .

S PO N G I A
H appy jo y ou s w ith a constant de si re to sin g
, .

an d w histle f ol lo w ed b v dist raction o f m i n d an d

.
D E P R E SS I J)
'
TY P E O F MAN I C D PRE
- E SS I V E I NS AN T Y
I
 M A N I C D EPR ESS I V E I N SA N I T Y
-
34 7

disinclinat ion f or all w ork The gaiety of spon .

gia resembles hyoscyamus but is longe r cont in ,

ued and less variable .

E specially valuable in cases w it h a tuberculous T n berou

diathesi s and in patients subj ec t to gl andular en

l argem en ts or w here organic disease of the heart
exist s .

S T RA M O N117 M
Del i rium of fear violent w ith hallucinations
,

o f sight ; sees bugs cats dogs rabbits and horrid

, , ,

beasts on all sides o f h im A ggravation fro m .

the darkness being alone and in the morning

,
.

A mel iorated by light and company .

C onstant movement of the l imbs during ex

c i tem en t Great aversion to uids the sight o f
.
,

w hich at times w il l almost produce convul sion s

, ,
.

Incorrect ideas o f di stance and the sight of sur

rounding obj ect s S creaming catching and F .
,
ea

st riking at fright ful imaginary spect res w h ich del u si on s

,

l l them w ith the utmost terror Furious bites .

,

an d strikes at everyone w ho approaches Fear .

w ith sensation as i f the bed w as being dra w n

from under her and that everyth ing w as fall in g
,

on her The horri fying images appear at the

.

side more o ften than in front S ees black ob .

j e c,t s black people and black clouds Things and .

persons around him appea r changed Imagines .

that he i s alone and aban d on ed in a w ilderness .

 3 48 M EN T AL D I S EAS ES

Talkat ive I magines that he is very la rge and

.

tall but surrounding obj ects a re small Hal lu

. .

c i n at i on s of hearing hears dancing music an d

,

men talking in foreign tongues Hears a voic e .

under the bed at night E xposes genital s . .

The mental state o f the stramonium patient i s

C I za ng ea bl e subj ect to sudden and marked changes O ne .

moment he i s lled w ith horrid fea rs the next ,

he is merry and j oyous sings and dances ; the .

next ful l o f rage he vigorously attacks all about

, ,

him A t times he is proud and hau ghty arro

.
,

gant and intolerant of h is associates or the ,

senses may be dull and a stupid indi ff erence to

everything be mani fested .

\V hi l e representing by its provings a w ide

ran ge of mental sv m ptom s st ramonium has .

Severest
achieved it s greatest curative triumph s in the
severest class of cases .

\ V hen the del i rium is w il d and furious and .

the patient is possessed by the most fear ful del u

sions and hal lucinations then is stramonium ,

most clearl y indicated and seldom fail s to brin g

speed v re l ie f .

VE
'

RA T RU M AL B U M
Del i rium w ith col dness over the w hole bod v
and cold s w eat on the forehead The patient .

p rattles about rel igious subject s and vo w s to be

per fo rmed Imagines he is a prince a n d behave s
.
 M A N I c D E P RES S I v E I
-
N SA N [ T Y 349

in a haughty manner P ersistent raging w ith .

,

great heat o f the bod y N oi s y cursing ho w l .

, ,

ing w ith frequent attempts to escape Runs

,
.

about ho w l ing and screaming w orse in the even .

ing Ill humored irritable vexed from sl ight

.
-
, ,

est cause R ushes about room and tries to ki ss

.

everyone Hal l uci n ations o f sight room ap

.
,

pea rs ful l of people w ith w hom the pat ient con ,

v erses f o r hours S leeplessness w ith con stant

.
,

talking and loud laughter .

The furious del iri um o f veratrum album w ith , F ur i ous d e

v i olence and dest ruct iveness resembles that o f ,
ex l za usti on
belladonna and stramonium In verat rum al .

bum ho w ever w e have much greater physi cal

, ,

exhaustion evidenced b v a w eak pul se coldness

, ,

o f the b od v and c o ld s w eat on the for ehead .

The verat rum pat ient must have speedy rel ie f

or die V eratrum album is especially e ff i cacious
.

in w omen w here the di sease i s dependent upon

,

some di sorder of the sexual organs and is aggr a S ex ua l

org a n s
v a ted at each menstrual period or in w omen ,

w hose menses have been suppressed and w ho i m

agine themselves pregnant .

M any o f these case s are subj ect to amorous

frenzies w h ich are strangely mixed w ith the
,

w ildest rel igious vagaries .

V ERA T R I M '

I R I DE

V erat rum vi ride has f ew mental symptoms r e

corded i n its provi n gs but has been found ex .
 3 50 M E N T AL D I S E AS ES

tr em el v use ful in many mental diseases I t s .

sel ec tton is usual lv determined by its general

physical conditions
hen the temperature i s ver y hi gh the pul se
.

T emper a 7
,

tu re b ig /z
l se a n d
,

exceedingl y rapid and the resp i rat ion i m m od er

p u
res i r a ti on
p atel y hurr i ed it w il l o ften accompl ish w onders
,
.

r api d
I ts sphere of use fulness ho w ever seems l i m
, .

i ted to the resuscitation o f the p hysical po w ers

and w hen this is accompl ished l ittle can be ex
p ec t e d from it as regar d s the restorat ion o f the
patient s reason

.

While any o f the remedies mentioned may be

needed the four mainsprings in the t reatment o f
,

maniacal states are belladonna hvoscy am us . .

st ramonium and veratrum album .

DE PR ESS I V E ST A T ES
The depressive states appear in th ree forms .

simple retardation the delusional form and stu

.

porous depression .

S I M P LE R ET A R D A T I O N
Th is is the mi l dest form o f the disease E x .

cept in a f ew instances w h ich result f r om acut e

,

illness or mental shock the onset is gradual and

,

insidious The prod romata are sl ight and il l

.

dened consisting of a general sense o f ennui

. ,

inso m nia loss of appetite and di scouragemen t

,
.

The w hole as pect o f the pat ient reects the men

 M A NI e -
D E P R E SS I V E I N S A N I T Y 35 1

tal gloom The sad c o untenance an d sluggish

.

movement s evidence the entire lack of interes t

in the a ff ai rs o f li fe The society o f w i fe ch il
.
,

d ren and friends becomes distaste ful I rritable .

.

p eevish gloomy sullen

,
all society i,
s shunned and ,

the pat i ent re m a in s by himsel f w ith bo w ed head

a n d folded arms an d broods over his condition .

Ev e r v thought ev e r v w ord every actio n i s ana

, , M en ta l

l y z ed Intellectual exertion is an i m possi b i l i tv

. .
a na
l
y si s

C on v ersat ion is l imited to simple responses u t

t e red in l o w inexpressive tones A ll actions eat .
,

i n g dressing o r w alking are slo w and c onst rain

,

ed The simplest tasks are burdensome

. V ol i .

a ra l z ed
t ion seems paralyzed and ev e r v deci sion ho w ever p y
'

simple is made w ith d i ffi cul tv and a fter i t i s

, ,

ma d e i s regarded as w rong The emotional .

atti t ude is one of constan t gloom and despond C on sta n t

e nc y The pa st has been a complete failure and

.

the f uture o ff ers no hope Ho w ever spotles s .

thei r past l ives and deep their rel igious convi e

t ions m ay have been they are lled w ith thei r .

o w n un wo rth iness and the utter hopelessness o f

their co n dition S ometimes lled w ith co m pul

.

sive ideas thev are forced to d w ell continuall y

,

upon the horrors w hich a w ait them and their

families .

The condition o f retardat ion may deepen into

a state of stupor P atient s then keep to their . S tupor
beds mute insensible o f thei r surr o und ings and
. .
 352 M E N T AL D I S E A S E S

incapable o f comprehending the si mplest ques

tions or i f they ans w er the repl ies are slo w an d
, ,

hesitating Food placed be fore them i s unno

.

ticed and they have to be fed w ith a sp oon .

W hi l e incapable o f caring f or them selves the v ,

are not lthy .

Thi s stupor soon di sappe ars leaving no re ,

m em b r an ce o f the occ u r re n ces during th i s

period .

Physical symptoms are chi e v l imited to the

circulatory and digestive svstem s The extrem .

ti on , sl ee
p
it ies are cold and cyanot i c the pul se small slo w , ,

and o f l o w tensio n The temperature m a y be

.

subnormal The tongue i s coate d breath foul

.
, ,

the bo w el s constipated appet ite poor an d th e .

digestion imper fect w eight is lost its return sig

. .

nal i n g the end of the attack S leep is insu fcient .

and unrest ful C ephal algia and pains in th e

.

l imbs may be present and the reexes dimini sh

ed or lost .

The durat ion o f the attack varies from a f ew

month s to over a year .

D E LU S I O NAL FO RM
The delusional form is characterize d b v n u
m e r o us depressi v e or hypochondriacal del us i on s
in addition to evidences O f retardation .

S [ou r on set The on set i s usuall v slo w P rece d ing the at .

t ack a general sense o f ill feel i n g m av preva i l or

 M A N I C D E PR ES S I V E
-
I N SA N I T Y

unusual j o y ousness and exh il aration of spi rits .

O ccasionally the immediate precursor i s som e

mental shock or acute illness .

The mental state is that o f intense despond I n tense

ency and sel f depreciation The present a ff ords .
d ep r ess i on

n o j oy the future is hopeless

,
Their past l ives .

have been lled w ith mistakes or crimes a gainst

others and themselves They ha v e ruined thei r
.

families and friends and nothing but perpetual

mi sery a w aits them Poverty stares them in the
.

face or impri sonment or exe cu tion for thei r

num erous crimes .

Hypochondriacal delusions are o f frequent oc H y poc/zon

de
currence In these cases the mind d w ell s contin
.

l usi on s
uall y upon the funct ions o f the body The y .

continually assert that they are su ff ering from

some incurable disease and rush from one doctor
to another seeking rel ie f The victim has syph
.

ilis w h ich is d ecaying hi s hai r skin and l imbs

, ,

and is in fect ing h is family C ancer is destroy .

ing the stomach and bo w el s so that neither food ,

nor drink can be taken The heart is abou t to.

stop from w eakness and he asks you to feel his

pul se to corroborate h is statement He is para .

l y z ed and w ill not move a l imb unti l he forget s

his fancy f or a moment H is brain is l led .

w ith lead so that he canno t think ; the l imbs are

,

made o f glass and must n ot be touched les t they

should be broken O r he m ay assert tha t ther e
.

24
 3 54 M EN T AL D I S E AS E S

is a ball o f re in his s tomach or a l ive animal

.

in his intestines W omen f r eq u en tl v assert tha t

.

they are pregnant and accuse themsel ves o f sex

ual indiscretion s and c rimes O thers lled w ith

.

p e r sec uto r v delusions d eclare that the pol ice are

upon their t rack an d that thev are about to be
executed boiled al ive or burned at the stake
, , .

Borne do w n by the w eight o f their sins thev may .

assert that the y have commit ted the unpardon

able sin f or w hich t hey are eter n al l v damned o r
that the devil ha s al read y taken po sses sion o f
them O ccasi on al l v p o ssessed o f hallucinat ions
.
,

thev mav be dist ressed by the fea rful groan s that

ll their ears or complain o f the poi son ous va pors

w hich the y are con stan tl v inhal ing or the hor ,

ribl e sight s b v w hich thev are surrounded .

The con sciousness mav ho w ever be uncloud

. ,

r i en ted
ed and no signs o f d isor i entation be apparent .

The surroundings m av be full y comp rehended

and q uest ions ans w ered co r rec tl v A n v attempt
.

at letter w riting ho w ever reveals thei r retarda

, ,

t ion o f tho u ght an d th ei r c o n versation c o n t inu

ally tends to rever t to their delusions .

C lear insigh t into their condition m av be

present .

Thei r emot iona l attitude is al w a y s that o f

gloom and despondenc y T hev take little inter
.

est i n thei r surroundings but are con stan tl v eu

.

grossed b y thei r miseries w hich thev may l a

.

ment b v the hour in mon o tono us groans

, .
.
 MANI C -
DE PR ESS I V E I N S A N I TY 35 5

Their actions may be slo w hesitating and , .

A ction s

retarded o r impelled by an unceasing restless

ness thev mav continually pace up and do w n
,

their apartment s pick at thei r cloth ing pull out

, .

their hair and vent thei r indescribable agon v in

groans and moans M ost o f these cases a re sui
.

c i d al and attempts at suicide are ve r v frequent .

S T U P O RO L S
'

D EPR ESS I O N
This form is usual ly preceded b v simple or
delusional depression These patient s exh ibit
.

complete inertia and utter indi ff erence to thei r I n er ti a

surroundings C onsciousness is ent i rely befog

.

C on sci ous
ged O ver w hel med b v a multitude o f variegated
. n ess cl ouded

and incoherent hall uc m atl on s and del usion s .

these patients sit or stand mute mot ionless and .

ab sol u tel v w itho ut w ill po w er enough to rouse

themsel ves out of thei r s t upor Fill ed w ith the .

m ost horribl e phantasms they l ive in one cont in

,

uou s fright ful ni ghtmare w h ich completel y ah

,
Fr ig b t/ ul
sorbs thei r attention E verything about them
.
del u si on s
has been changed and t rans formed The w orl d .

i s being con sumed by re or congea l ed w ith ice .

The rooms in w h ich thev are con ned are grad

u all y closin g in upon t hem Friends are racked
.

an d tortured be fore their eyes T hev them .

sel ves have been trans formed into the most ho r

rible o f animal s Their foo d i s mixed w ith the
.

b lo od o f their dearest friends A ll mental ac

.
 3 56 M E N T AL D I SE AS E S

t ion is paral y zed w ith horror M ental retarda .

d a ti on
r
t ion appears complete ren d ering them incapable
,

O f feeding clothing o r caring f o r themselves in

.

any particul ar They exh ibit no activity and

.

simply l ie in bed stupidly indi ff erent to ever y

,

th ing that t ranspires about them Y et the ex .

pression of anxiety w hich occasionally i ts over

the countenance the resistance to passive move
,

ments and thei r occasional impul sive attempts at

suicide reveal the terror b v w hich they are pos
sessed O ccasionall y a f ew w ords or sentences
.

are slo w ly and i n d i sti n ctl v ut tered .

\ V ith thi s mental state are associated numer

ous sign s o f physical disturbance The eyes are .

lusterless and the facial expression dull and

stupid The patients complain of diz ziness
.
,

ringing in the ears numbness and pain in the

,

head and va gue pains in the l imbs .

ng ue , The tongue is coated breath foul bo w el s con

, ,

el se, tem sti pated and the digest ion impaired U tterly .

r a tu re,

in w ithout desi re for food forced feeding is a ,

necessity to prevent starvat ion and w ith it w eigh t

i s constantly lost S leep is diminished and w h at
.

i s obtained is disturbed and un re freshing The .

pul se is slo w and o f l ow tension evidencing the ,

w eakened heart s action The te m perature i s

.

subnormal The skin is dry and foul or w arm

.

or clamm y ,
except at the ext remities w hich are .

blue and cold C utaneous sen si b i l i tv is d ecreas

.
 M A N I c D E P RESS I v E I
-
N SA N I T Y 357

ed and the tendon reexes mav be diminished or

lost.

The duration o f the depressed t y pe varies

from a f ew days to several months or even year s .

The prognosis is favorable for recovery from

the attack i f not complicated b v severe somati c
lesions .

P hysical imp r ovement i f attended by i n c reas

ed w eight ordinaril y indicates conva l escence .

T R EA T M EN T
The general t reatmen t varies according to the
type o f the di sease In the mildest cases res t
.
, ,

change o f scene w ith cheer ful company and m en

tal recreat ion mav be all that is n ecessar v to e f
f ect a cure .

In the severe forms w hen the disease is estab

,

l i shed a most care ful systematic course of treat

,

ment m ust be pursued either in a sanitarium or ,

at home The pat ient should be put immediately

.

in bed and kept there under the con stant w atch

o f a co m petent nurse A s al l cases are more o r
.

less suicidal the greatest caution must be O h

,

served night and day lest they n d some oppo r

, ,

tun i ty to kill themselves E verything shoul d be .

removed from the roo m w ith w hich they could

possibly inj ure themsel ves C unning cra f tv .
,
C on sta n t
w a tc/zf ul
and desperate unless the greatest care is ob ser v
,
n ess

ed thev w il l succeed in carr v i n g out their suicidal

 3 58 M E N T AL D I S E AS E S

designs A s the majority o f these cases are

.

w eak and an ze m i c mil k eggs in the form o f cus

, ,

t ar d s o r egg nogs
-
strong broth s predigested
, ,

utr i ti on meats and nit rogenous foods should be ad m i n i s

te r ed in l iberal quantit ies A s the taking o f.

food in many cases either from lack o f appetite

,

or on account o f delusions i s str en uousl v ob ,

j ec te d to
, forced feeding i s often necessa ry .

M any patient s w ill take su fcient nouri shment i f

fed w ith a spoon by the nurse in others the nasal ,

tube w ill have to be brought into requisition .

W hen forced feeding is requi red not less than a ,

quart o f milk and egg or st rong broth shoul d be

given t w ice daily .

\ V hen sleepless n ess is persistent it can be com ,

batted b y hot bath s at night lasti n g i f n ecessarv , , ,

from hal f an hour to an hour .

hen the physical pow ers are resuscitated the

7

patients i f st ill depressed should be gotten out o f

bed into the open air and every possible mean s
adopted for diverting the mind and turning i t
back into its normal channel s .

The remedies w hich w e ha v e fou nd most use

ful in treat ing depressed states are A conite ,

A ct aea racemosa A ntimonium crude A lumina

, . ,

A r sen i cum album Baptisia Belladonna C a1

, , ,

carea C arbonica C actus Digital is Gel semium

, , ,

I gnat ia L il ium t igrinum N atrum m ur i ati cum

, , ,

N ux moschata P ul sat illa Phosphoric aci d

, , ,
 MAN I C -
I ) EP RES S I V E I N S A N I TY 3 59

S epia S ulphur V eratrum A lbum w hich shoul d

. . ,

be given a ccording to the follo w ing indications :

AC O N I T E
This remedy i s n ot as frequently indicated in
melanchol ia as in some other o f the mental d i sor
ders In melanchol ia of pregnancy it mav prov e
.
na nc
y

e ff i cacious w hen w e n d vertigo w ith nausea and

great depression on account of fear o f death i n
her approaching parturition causin g ceaseles s ,

w eeping and lamentations There i s al so grea t

.

restlessness and sl eeplessness or sleep disturbe d

by di sagreeable dreams .

A C T ZEA RAC E MO SA
Thinks she i s be coming crazy G reatl v d e .

pressed by fear o f death and a sen sation as i f

something had settled do w n up on the brain ren ,

dering ev erv thi n g dark and obscure S ever e .

pains through the e ves an d w hol e occipital r e

gion as i f they w ere penetrated bv sharp i n stru
,

ments .
R heu m a ti c
E specially suited to rheumat ic and neura l gic
rom
hysterical subj ect s w ho have su ff ered much from f
uter i n e

uterine d isorders . di sord ers

ALU M I N A
S ad depressed dul l stupid lled w ith an in d e
, . , ,

sc ribable fear fulness P eevi sh obst inate not

.
, ,
 M EN T AL D I S EA S ES

incl ined t o do anything Loss o f appet ite w ith.

,

a longi n g for in d igestible substances and ob sti

nate constipation R estless unre freshing sleep
. .

This reme d y is not v er v f req uen tl v demanded .

but when indicated speedy and e ff ectual in i ts

action .

ANT I M O NI I
'

M CR U D E
U ndue an x i et v abou t the present and future .

O bstinate and tac i turn incl ined to suicide b v ,

shooting especially at n ight Dull apathet ic

, .
, .

regardless o f the call s o f nature Ton gue coated .

w h ite A lternate diarrh oea and const ipation

. .

\V ak e f ul at night sleepy in daytime ,

.

A dapted to the most serious fortu s o f the dis

Dem en ti a ease W hen dementia seems imm inent i t shoul d
.

n o t be forgot ten .

A RS E N I C U M AL B U M
I f requested to name the most rel iable and
most frequently indicated remedy for severe
acute cases of me l anchol ia w e should sav w ithou t
hesitation ar sen i cum album .

A typical ar sen i cum case i s one of the most

serious mental di seases encountered A glance .

D espera te w ill cl ear l v reveal the desperate character o f the

ca ses malady The pale face pinched features shr i v
.
, .

cled skin haggard and anxious cou n tenance

. ,

w eak rapid w i r v pul se and r api d l v increasin g

. ,
 M A NI e I N SA N I T v 36 1

e maciation portray the intense virulence o f the

attacking f oe The tongue i s red tremulous
.
, ,

parched and the patient is continual ly tortured b v

the characteristic ar sen i cum th irst C onstantly .

impelled by an overpo w ering restlessness i f al ,

R estl essne ss
S elf m u ti
l o w ed to remain upon their feet the victims un
l a ti on
c easi n gl y pace up and do w n their apartment s S u i ci d al
night and day w ringing their hands and be w ail
,

ing their fate In their agony they p ul l out thei r

.

hai r and bite thei r nails to the quick often caus ,

ing deep ulcers A t last overcome by thei r m en

.

tal anguish and driven to frenzy if n ot prevent ,

e d thev seek an escape from the horrors o f thei r

,

present misery th rough suicide N ot only are .

they suicidal but they may in thei r desperation

,

m utila te themselves pul l out th eir eyelashes o r

, .

tear o ff their ev el i d s and i n ict serious ph y sical

inj uries .

In bed in their restlessness they con stan tl v roll

from side to side and night and day moan groan ,

a n d bitterl y l ament thei r direful fate .

Y et these desperate and apparently hopeless

Freq uen tly
c ases ,
i f prevented from inj uring and kill ing
themsel ves and properly nursed and sustained bv e ec i z e
t '

suf cient nourish ing food by the marvelous i n ,

uen ce of arsen ic are o ften restored to per fect

h ealth of body and mind .

B AP T I SI A
Baptisia is e spec i al l v indicated in the w orst
 36 2 M EN T AL D I S EA sEs

forms of stuporous depression the .

Deep stupor stupor i s deep the temperature high the pul se

, ,

tu re b ig /z .
and respi rat ion rapid the countenance dark and
,

pul se a n d sodden the eye expressionless the breath fetid

, , ,

p i r ati on
r es
the tongue dry and bro w n the stool s involuntar y
rapi d
.

and o ff ensive its e ff ect s are o ften l ittle less th an

,

miraculous .

LLA D O N N A
BE

The belladonna case i s greatly depressed an d

subj ect to violent attacks o f w eeping attende d
by intense fearfulness The head i s hot the fac e
.
,

ushed the pupil s dilated S leeplessness pre

, .

vail s or there is great sleepiness

, the patient ,

a w aking w ith a start the moment she fal l s asleep .

Depressi on \V hen depression occurs in connection w it h

mi t/l
cereb ral marked cerebral congestion no other rem ed v i s
cong esti on as satis factory especially w hen given in the l ow
,

er potencie s .

CALCAR EA CAR B O N I CA
A pprehensive o f mis fortune thinks she w il l ,

die or become c raz y peev i sh obstinate Fac e

.
.
,
.

pale Pyrosis constipation and atul en cy reveal

.
,

th e disordered condition of the digestion T he .

circulat ion i s poor and the sleep unre freshing .

A dapted to poo r l v nouri shed scrofulou s

phthisical w omen .
 M A N I e D E RRES S I V
-
E I N SA N I T Y 36 3

CAC T U S
The cactus patient i s sad from her unalterable
convict ion that she is about to die from the i n
curable disease w ith w hich she i s af i cted or that ,

s ome terrible di saster overhangs her S he i s .

si ve ,

taciturn and incl ined to remain b y hersel f and ta ci tur n

w eep constantl y A ttending the mental sy m p

.

toms w e nd the characteristic heart symptoms H ea r t

an d a sensation as i f so m e heavy w ei ght w ere

pressing do w n upon the brain accompanied by ,

pul sations in the top of the head The patient i s .

also easily frightened and O f ten a w akens at ni ght

in a panic .

D I G I T AL I S
Great anxiety depression and dread of the
,

future w ith sadness and w eeping w orse about

,

six P . M and a ggravated bv music

. M orose .
,

i rritable and gloomy w eaknes s of m em or v dul l

, , ,

stupid and con fused .

The chief indication o f digital i s is a slo w pul se ,

D epressi on
sl ow pul se ,
and w henever this symptom appears attended by cx l za usti on

a general appearance o f exhaustion and d eb i l i tv ,

a prompt and sati sf actor v improvement is sure

to follo w its exh ibition .

CH I NA
C hina m av be called f or w hen the depression
has been prod uced b v some excessive ph y sical
D EPRESS E D T Y PE M A N I C D EPR ESS I E N S A N I T Y
- V I
 M A N I c D E P RES S I \
-
'

E I N SA N I T Y 36 5

drain such as oodi n g leucorrhea or masturba

,
d ra i n s
tion.

The most sati s factory result s from thi s drug

are obtained from the t incture in appreciab l e
doses .

G EL S E M I L M '

Gel semium i s indicated w here there i s fever

attended by marked mental dullness and a desire
to remain quiet and undisturbed in bed L ack .

o f con dence and inabil ity to make any decision

i s also a marked characteristic There al so ex .

i sts a desire to th ro w one s sel f do w n w hen look

'

ing over a heigh t A dull t i red ach ing at the

.

base o f the brain is also frequently present . b ra i n

I G NA T I A
\ V hen the disease has been produce d by shock
or lo n g brooding over real or imaginary t roubles

and w hen the rel ie f o f tears is denied w e nd the

rel ieving remedy in ignat ia .

These patient s are silent and pre fer to remain

by themselves and brood P ro ff ered sympathy
.

is rej ected and yet i f it is not o ff ered they i m

agine themselves neglected b y their friends .

They are obstinate and taciturn often refus ,

i ng to speak w hen addressed A lthough given f i fy steri ca l

.

to brooding they may become hysterical and i n

, w or ri ers
 M EN T AL D I S EA SES

d ul ge in sen seles s laughte r The sleep i s rest

.

less and o ften accompanied by nightmare A l l .

the se patients are incl ined to be h y ste rical .

LI LI I M T I G RI N I
' '

Depression o f spi rits incl in ing the patient to

,

w eep . Timidity apprehensiveness o f some f atal

disease or becoming insane Loss o f m em o r v .

and d i i cul tv in the selection o f proper w ord s

w hen conversin g .P res sure upon the rectum
and i rritabil it y o f the bladder .

A ppl icable to neural gic w omen w ho have su f

f e r ed from fu n ctional or sl i ght or ganic disorders
ona r i c s
'
o f the uterus and ovaries .

N A T RU M M U RI A T I C U M
The nat rum m ur i ati cum pa tient is emaciat ed
Prem a and the face has a prematurel y ol d look The re .

tu r ely ol d
i s lo ss o f m em o r v and disincl ination for all men
tal and ph y sical w ork S he is easily fat ig ued
.

and gr eatl v prost rate d m en tal l v and phy si call v

The se p atient s she d o o d s o f tears and the mor e .

P a rox
y sm s
the v are com forted the m o re v i ol en tl v thev w eep .

T hev are ill hu m ored and easil y provoked b y au v

c o n t radiction The se ca ses seem to re ve l in thei r
.

grie f and derive sati s f act i o n fr o m recal lin g al l

the di s agreeable occurrence s o f the pa st for th e
purp o se o f indul ging in m el an chol v meditati o n .

T he v are taciturn av o id companion ship an d

.
 M A N I C D EPR ESS I V E I N S A N I T Y
-
36 7

think that they are pit ied b v e v eryone because o f

their mis fortunes .

E speciall y indicated w hen the di sease has fol

lo w ed intermittent fever and w hen the attacks o f
w eeping are periodic in their occurrence .

L X M O SC I I A T A
'
\I

N ux moschata is especially adapted to hys

te r i cal melanchol ics The mood is changeabl e
.
,

one moment the patient laugh s the next she cries ,

.

The memory i s poor and there i s marked con f u

sion o f ideas and an inabil ity to continue a t rai n
o f thought for an v length o f t ime A ny attemp t .

at w riting reveal s an incoherenc y in the ideas .

There i s absence o f mind slo w ness o f ideas and ,

d i ffi cul t y in ans w ering q uestions There i s great .

Fa zn tm ss
'

incl inat ion to faint and a tendenc y to sleepiness .

sl ee
pi n ess

PUL S A T I LLA
Fre q uent w eeping sol icitude concernin g
,

health despair o f salvat ion w ith constant prav

, ,

ing and great an gu ish causing her to d esi re to ,

commit suicide .

The grie f o f the pul sat illa patient is change

able and she is subj ect to alternate moods o f cr v
ing and laughing The pul satilla patient is at
.

t imes depressed and tear ful at others cheer ful ,

and happy M ild gentle and a ecti on ate in d i s

.
,

posit i on she is easily persuaded cons o lation is

. ,
 3 08 M E N T AL D I SEA SES

acceptable and she e n joys l ivel y company an d

goo d advice .

A dapted to mild tear ful natures w ith l ittl e ,

vim pul satil la i s frequentl y demanded in the mel

,

1 %zgn a n g/ an cho l i a o f pregnanc y compl icated b v gast ri c

disorders .

P H O S P H O R I C AC I D
Dread of the future w ith anxiet y and doubt ,

about recovery D isincl ination to tal k sadness

.
, ,

g rie f and disposition to w eep M elancholia pro .

d uced by care grie f sorro w or disappoi n ted love

, , ,

excessive menst ruation masturbat ion or ph y sica l ,

ex haustion caused b V overact ivity of the kid

,

nevs .

SE PI A
N ervous sensitive to the least noise S ad
, .

ness w orrying about her health and the future

, ,

w ith frequent attacks o f w eeping w orse in the ,

evening and in the open air Dread of being .

Ah wx b n o alone very i rritable indi ff erence and aversion to

, ,

members of her ow n family Indisposit ion f or .

mental w ork w ith w eak memory and di f cul ty

,

in ex pr essm g her ideas Indol ent mood R est . .

less sleep disturbed by anxious dream s a w aking

, ,

in a fright .

W eak empty gone feel ing in stomach fr eque n t

-
,

desi re to urinate urine th ick sl imy very o ff en , , ,

 M A N I C D EPR ESS I V E
-

I NS A N [T Y 36 9

sive w ith yello w ish sediment P ro fuse yello w

, .

ish or w h ite acrid exceed ingly o ff en sive l eucor

,
O ei zszve
'

I eucor r ea
rhea .

S epia i s chi e y useful w hen the disease occurs

in w ome n w hose const itut ions have been sapped
b y long standing leucorrheas and ch ronic organi c
-
Uter u s and

diseases o f the uterus and ovaries .

ova r i es

S U LP H U R
Disposition to w eep w ishes to die but fears , ,

f or her salvat ion incl ined to d w el l upon rel i gious

,

subj ect s apprehensive of future mis fortune

, ,

variable mood one moment crying the next

, ,

laughing i n disposition to mental or physical

,

labor w ith slo w ness of mind and body grea t

, ,

absence o f mind and forget ful ne ss peevi sh and ,

i rritable .

C onstant heat in top o f head : shooting pain s

i n forehead and temples from w ithin o ut w ard ,

w orse from eating or stoopin g better w hen ,

pressing the head and w hen moving ; pressin g

dull pain in vertex and sinciput rousing from ,

sleep early in mornin g cea sing be fore noon ,

.

Dro w siness during day and w ake fulness at

nigh t unre freshing sleep disturbed b v frigh t ful
, ,

dreams .

S ulphur is excee d in gly use ful as an intercur I n ter m r

rent remedy i n ma n y chronic cases w here the ren t rem e dy

psoric element p redominates I t is al so f r e .

25
 370 M N T A L DI S EAS E S
E

q ue n tly u se f ul a s a d eveloper bringing ou t sy m p ,

toms at rst hi d d en an d unap parent or re v ivin g

the suspen d e d act ion o f an in d icated drug cau s ,

i n g the patient to go on to a rapi d recovery It .

seldom e ff ects a cure unaided b y other dru gs .

V ERA T R I M AL B I ' '

A nxie t y as i f she had comm it ted an evil deed .

sadness despondency an d grie f w ith despai r o f

.
,

her salvation Fear ful and apprehensive of m i s

.

fortune M ind dull and stupid w ith obstinat e

.
,

tac i tu r n i tv .

P a rox y sms of pain in various parts o f th e

head Frontal headache w ith nausea vomit in g
.
, ,

and fever pressive pain in the top o f the head

, .

C ol d spot on vertex Face pale eves xed and .

,

sunken w ith blue or green circles around them

, .

N ose cold and pointed cold s w eat on face and ,

forehead S leepl essness or leep disturb ed b v

.
s

bad dreams .

Great thirst f or cold drinks R avenou s hun .

ger or loss of appetite C onstipation or exhau st .

ive diarrh e a E xcessive w eakness and sud d en

.

sinking o f st rength S kin blue and cold P ul se . .

fre q uent small an d w eak o ften inte rmittent at

, , ,

times almost imperceptible de fect ive ci rculation , .

w ith general appearance of lo w ered v i tal i tv .

S e vere ca 5 6 5
Espec i al l v ei cac i ous in the appa ren tl v most
dep i
r ess on

w i t/z si l t /) 0; hopel es s ca se s o f depre ssion w ith stupor w here ,

 MAN I
C D EP REssn E '

1 N SA N 1 T Y 37 1

the patient sits in a stupid manner w ith the he ad

bent f or w ard taking no apparent not ice o f any
,

thing ans w ering i n monosyllables o r not at al l :

,

o ften eating nothing unless fed skin cold and .

blue pul se w eak and intermitting Wi th the

,
.

foregoing symptoms w e have occasional faint ing

spell s w ith temporary unconsciousne ss and su s
pension o f the heart s action
'

U nder the inuence o f veratrum the depressed

vital po w ers are o ften soon revived and the pa
tient advances to a complete recov er v A fter a .

seeming r ecov erv the patient is l iable to relapse

i f the medicine is too soon discontinued but w hen ,

once the cure is f ul l v accompl ished it usual ly re

mains permanent .

M I X ED T Y PES
To Kraepel in w e are indebted for the d esc r i p
tion o f the pecul iar features o f th is class o f cases .

T hev are cha racteri zed b y the appearance in the

pat ient at the same time o f symptoms o f excite
ment and depression .

These mixed states have been divided b v him

into six chief types .

( )
1 I r as c ib l e m an i a w here
, depression r e

places the ordinar y elation These cases exh ibi t

.

marked maniacal excitement w ith more or less ,

constan t i r r i tab i l i tv N othing pleases them and

.

the v denounce ev er vbod v and e ver y thing about i ng

 37 2 M E N T AL D I S EA S ES .

them . S ome upon the sl ightest provocat io n

burst into paroxysms o f rage or violence O th .

ers are simply disagreea b le and faul t ndin g .

They complain o f thei r attendant s their compa u ,

io n s their food and all their surro undings O n e

,
.

grievance i s no sooner remedied tha n anothe r

takes it s place T hev are persistent inst igat o r s
.

o f t rouble and vex and annoy everyone w ith

w hom they come in contact They are unstabl e

.
,

restless and reveal a moderate ight of ideas .

2
( ) D ep r es s i v e ex c i tem e n t embraces thos e

cases in w hich the restl essness is ent irely d i spr o

p o r t i o n ate to the emotional despondenc y Thes e .

patient s talk continuously but there is no varia

,

t ion to their conversat ion They harp contin.

uall y upon the same st rain and annoy those about

them by reiterating the same delusions usuall y ,

o f a hypochondriacal character W hile a ssert

.

i n g that they have been ma l treated poi soned an d ,

L zttl e sa d that death i s inevitable they evince l ittle sadnes s

'

n ess
or anxie ty and are capable o f applying them
selves w ithout much exhaustion The y m av al so .

on occasion s evince some humor or become i rri

table and aggressive .

3 ) Lt r od uef i z e m an i a is a maniacal stat e

'

D ea rt}; of
i deas accompanied b v a dearth of ideas P erception i s .

slo w and de fect i ve In conversation every ques

.

tion may have to be repeated before it is com

prehended It is w ith d i f cul tv that their atten
.
 M A N I C D EPR ESS I V E I N SA N I T Y
-

tion is xed and repl ies are evasive and i n appro

p r i a te. W hile appearing w eakminded they m a y
Va ri a bl e
possess considerable intellect The mental state .

m en ta l
may be subj ect to w ide variations the patients at ,

one time giving a ready respon se to quest ions at ,

another seeming devoid o f comprehension and

incapable o f responding They are elated hap .
,

py ,
playful and prone to senseless laug h ter .

C onversat ion is incoherent and l imited T hev .

speak slo w ly and are incl ined to reticence espe ,

c i al l y i f le f t to themselves Thou ght seems d i i

.

c ult in the beginning o f conversation but is less ,

mani fest i f the intervie w is prolonged A n um .

natural i rritabil ity is obse rvable By thei r grim .

aces dancing about frequent changing o f their

, ,

c lothing and rearranging o f thei r hair thev r e

Pr essa r e f
o
v eal thei r pressure o f act ivity but lack the con a etzm y
' '

,
g
s tant business o f mania S ome remain q uiet and
.

orderly and on l v a care ful examinat ion can de tect

thei r excitement A n elated frame o f mind is
.
,

ho w ever present evidenced by an unnatural i rri

, ,

tab i l i ty and a tendency to rudeness and senseless

outburst s o f lau ghter S ome are incl ined to sit
.

about inact ive but are easily exc ited to i m m od e r

,

ate laughter or w ithout cause m ay become rude

a n d impudent A ny regular employment is i m
.

possible but they are prone to misch ievousness

,

and dest ru ct ive n e ss an d inc l ined to steal and col

lect useless a rt icl es w ith w h ich thev fi l l thei r
,
 374 M E N T AL D I S E AS E S

pocket s and litter and adorn thei r apartments .

C auseless outbursts o f anger are of frequent oc

currence and t ransient periods of genuine man ia
may occur .

4 ) M an i c s tup or characterizes another group

[a ti on o f cases In these cases elation takes the place
.

o f the ordinary despondency These patient s .

,

although w ell oriented l ie in bed indi ff erent to

, ,

thei r surroundings occasionall y laugh w ithout

, ,

any cause and re fuse to ans w er any question s

, .

In the midst of their stupor suddenly a state o f

ci tem en t excitement may appear during w h ich the pat ient
,

may rush about tear hi s clothing smash f urn i

, ,

ture smear the w all s sing and talk boi sterousl y

, ,

for a f ew hours and then relapse into his previou s

state For short periods some patient s are quiet
.
,

orderly and converse in an intell igent ma n ner .

The facial expression may be bright and cheer

ful and pleasant or xed and staring The pa .

tient may have a per fect re membrance o f hi s

actions but is unable to explain them
,
.

M anic stupor may develop f o r a short period , ,

in a pronounced manic state bet w een a depressiv e

stupor and a manic state .

5
( ) D ep r ess i on a g i h t of i d eas Thes e .

cases though despondent and mute read and um

, ,

d er stan d w hat occurs abo ut them al though thei r ,

general att itude and appearance evidences r e

tar d at i on \ V hen su ffi cie n tly recovered to ex
.
 M A N I C D E PR ESS I V E
-
I NS A N I TY 37 5

pl ain thei r condition these patients state that H dd

oo e

thei r minds w ere so ooded w ith ideas that they w i t/z i deas

co uld n ot give them expression S ome w h ile .

unable to speak can w rite and their productions

are often lled w ith delusional ideas o f fear and

persecution .

6
( ) A nother type i s characterized by d epres

s i on w ith i ght of i d eas and em oti on al el ati on

,
.

These pat ients are usually quiet happy dis , ,

t ractable easi l y irritated given to w itticism s and

, ,

in conversation are easily aroused to a ight o f

ideas and at times even sound associations .

They re m ain quiet in bed occasionally volunteer ,

i n g a remark or burst into boisterous laughter

, ,

but are l iable to become suddenly violent indi ,

cating a condition o f inner tension .

A ttacks o f d oubl e for m may al so be en coun

ter ed These consi st of tw o periods ; on e o f de
.
p er i od s

pression the other o f excitement usually begin

, ,

ning w ith depression The t ransmission from.

depression to excitement may be sudden or grad

ual w ith an i n tery en i n g period o f the mi x ed form
,

o f man ic depressive i n san i tv

-
.

The characteristic symptoms of these periods

do not di ff er from those o f the depressed and ex
cited state s al ready described .

The mixed states occur usually in the transi

T ra n si ti on
tion periods from man ic to depressive states and
,
p a; zod s
'

vice versa and it is only b y the h istor y o f the

, ,
 3 76 M E N T AL D I S E A SES

fully developed disea se tha t w e are a ble to r ecog

,

n i ze them as types o f manic depressive insanity -

.

G EN ERAL C O U R SE
A ttacks o f
manic depressive insanity sho w a
m arked tendency to recur S everal types are
.

recognized designated according to the forms

,

a ssu m ed as
,

A
( ) P eriodic insanities w hich are
, divided
into
( )
a R ecurrent M ania
b
( ) R ecurrent M elanchol ia
B
( ) A lternating insanity
(C ) C i rcular insanity
D
( ) I rregular forms
A
( ) P eriodic insan ities ( )
a, R ecurren t M a
nia Recurrent mani a is characterized by it s
.

m ildness short duration complete mental restor

, ,

ation and subsequent frequent recurrence .

The length o f the attack varies from a f ew

days to several month s .

m m
M ild recurrent mania pre sents th ree char ac
i cs te r i sti c s y mptoms rapid o w o f speech constant
, ,

acti vit y and mental ela tion unattende d b y hallu

c m a tl on s I llusions de l u s ion s o r mental ob scur i tv
, . .

The dise a se utav app ea r w itho ut w a rnin g or a ,

s l i ght feel ing o f disco m fort loss o f appetite w i th

, .

a marked a ged appearance m ay p recede the at

tack S u d d enl y all morbid feel in gs disappea r
.
 M A NI C -
D E PR ESS I V E I N S A N [ T Y 37 7

and a general sense of el ation possesses the pa

tient The eyes become brigh t and sparkl ing
.
,

the face animated the speech rapid uent bright

, , ,

an d w i tty A n unusual excitabi l ity appears

.

w h ich rapidl y increases j oyous and full o f a sel f

,

sat is fact ion and con dence the w hole coun te ,

nance reects the general sense o f happiness .

New enterprises are proj ected far beyond the

l imit s o f common sense love a ff airs come to the,

fore or the patient may plun ge into di ssipation

,

and every form o f excess R estl ess and impell ed .

to constant movement he ies from one projec t

,

to ano ther w ith n o xati on o f purpose ; j ealous

,

o f any opposit ion an y attempted rest raint calls

,

forth a storm of abuse and recriminat ion T he .

D r u n ken
w hole mental frame suggests the earl y sta ge o f
n ess
drunkenness in an excitable person Full o f .

ever cha n ging impul ses he has no time for sl eep

-
, ,

his active brain keeping him in con stant mot i o n .

The same impell ing restlessness prevents h is tak

ing su fcient food and h is bodily w eight de
creases although the appet ite may be good and
,

assimilat ion per fect .

A fter a f ew days or w eeks seldom months , ,

the excitement abates and is succeeded b y a stage

o f exhaustion The patient n ow feel s t i red

.
.

faint m en tal l v and physically w orn out mildly

, ,

depressed and soon passes into his normal state .

 37 8 M E N T AL DI S E AS E S

O ccasionally the attack is more severe ,

w it h
marked motor agitat ion logorrhea and i n coher ,

ence of speech .

P r og n osi s
The prognosis except in the severest cases i s
, ,

favorable and the disea se rarely leaves any si gn s

o f mental deteriorat ion .

R ECU RR E N T M ELA N C H O L I A
A d z a n ced
'
Th is i s a disease o f advanced l i fe \Vhi l e n ot .

e
as common as recurrent mania i t i s n ot i n f r e ,

q uently encountered In w omen it most o fte n .

appears as a post cl imacteric t rouble In men

-
.

failure in the l i fe w ork attended b v m on ev losses

, ,

ill success in business are the usual causes .

\V hi l e in some cases it is traced to direct inherit ~

ance it i s not as o ften base d upon inherited i n

,

stability as i s recurrent mania .

It i s characterized by its mildness and it s lia

b i l i ty to recur at regul ar or irregular interval s .

A lthough devoid of delusions the depres sion ,

passes be y ond the physiological l imits Pos .

sessed by an overpo w ering sense o f lassitude and

gloom the patients recognize its nature and exert
,

all thei r po w ers in vain to overcome it S l o w in .

its inception the d isease i s atte n ded by sleepless

,

ness gast ric and intestinal disorders cephal algia

, , ,

poor ci rculation coated tongu e loss of appetit e

, , ,

decrease of w eigh t inactivity o f the kidneys pree

, ,

cordial anxiety slo w ness o f thought impai red

, ,

memory and a general lack o f interest in l i fe .

 M AN I C -
I JEP RES S I V E I N SA N I T Y 37 9

I II the mildest for m s there is simply an over O erpo er v zr

v

i ng m en ta l
po w ering mental dist ress prevent ing the per di st ss
,
re

f o r m an ce of the ordinary duties o f l i fe These .

symptoms may only appear at certain period s ,

u suall v in the w inter and spring the patient r e ,

turn ing to his normal state in the other seasons .

\ V ith the advent o f the depression the pat ient

suddenly assumes the appearance o f advanced A dva nced
age Filled w ith gloom y thou ght s the society o f
.
a
g
,
e

friends and ac q uaintances I s shunned O rdi .

nary dut ies are neglected and the time is pa ssed

in useless brooding C apable of intelligent con
.

versat ion w hen quest ioned he desc ribes hi s ,

gloomy thoughts doubts his restless nights but

, , ,

reveal s no sign s of delusion s and sho w s no sui

ci d al tendencies He is simply engulphed in
.

menta l darkness and everyth ing is black and

distorted .

In severer forms especial l y i f there have been

,

a ntecedent attacks though t i s retarded al l inter

, ,

est i n family and surroundings is lost and the

pat ient f or days mav devote himsel f onl y to sel f
, ,

exam inat ion and m ay become lled w ith vague

delusions The nights are lled w ith horror N ights of
.

hor ror
from the overpo w erin g presence o f his mor b id
thought s uncont rol led by the correct ing i n u
,

ence o f da y l ight an d f am il v surroundings In .

these cases suicidal impul ses are l iabl e to arise

w ith disast rous result s un l ess care is taken .
 38 0 M E N T AL DI S E AS E S

D I AG N OSI S
The certai n diagnosis o f recurrent mania o r
mel anchol ia can only be made a fter a recurrence
has taken place .

T R EA T M E N T
The t reatment is the same as in other form s
o f mania and mel anchol ia .

AL T ERNA T I N O I N SA N [ T Y
Th is form i s characterized by al ternat in g at
tacks o f mania and melanchol ia separated from ,

each other by sane intervals .

C I RCU LAR I N S A N I T Y
This form o f insanity is cha racteri zed by a n
al ternat ion of states o f melanchol ia and mania .

The duration of each stadium varies in ind i

vidual cases from a f ew days to years In ce r .

tain fully developed cases the periodicity may b e

so w ell establ i shed that the ph y sician can foretell

the number o f days in w hich the patient w ill r e

main in each succeeding stage The maj ority o f .

cases ho w ever are n ot thus perfectly developed

, ,

and w ill onl y present the cardinal factors of the

disease the successive attacks o f melanchol ia and
,

I I I zI I I i zt .

A lar ge number of these cases on account o f ,

the mi l dness o f the attacks never come into the ,

 M A NI c -
D E P R ESS I V E I N SA N I TY 38 1

hands of a physician or i f th ey d o it is usual l y

,

during the stage of depression .

C auses e ff ective in it s production are direct i n

heritance or at least an unstab l e nervous s y stem .

In many cases no competent cause can be traced .

I n persons w ith a marked insane diathesis any

st rain incident to dail y l i fe m av act as an exc iting
ca u se.

The disease is more of ten fou n d in w omen than

in men While it may appear at an v time o f l i fe
.
,

the th ird or fourth decades are most v ulnerable

to its attacks .

It is usuall y di fcul t to state the exact period

at w h ich ci rcular insanity begin s From ch il d .

hood the pat ient may have been subj ect to mild
al tern at ing ts of sadness and gaiety an d the i n
crease i n thei r severity been so gradual that the
exact time w hen the border l and o f sanity w as
crossed mav not have been observed The .

milder forms resemble the simple manias and

melanchol ia in their mental symptoms The so .

matic symptoms are some w hat pecul iar and st rik

ing I n the melanchol ic stage the patient has an
.

aged appearance and seems i n capable o f mental p ea r a n ee

or physical exe rt io n He frequently goes to bed

.

and re fuses to get up and w ith di f cul t y is urged

,

to take food or attend to the demands o f nat ure .

W itho ut delusions he simply seem s deprived o f E ri e rgy l ost

all physical or mental ene rgy S l eep i s di st u rb
.
M AN I C T Y PE M AN I C D E P R ESS H

E I NS AN T Y
I
 M A N I C D E P R E SS I V E
-
I N SA N [ T Y 383

ed the tongue i s coated the appet ite gone the

, .
,

skin di rty the pul se w eak the urine scant y and

, ,

high colored an d bodily w eight d a i l v decreases .

S u d denly a fter a night s s l eep the patient ari se

s

from bed and pronounces h imse l f w ell The ex .

p ression o f the face i s bri ght and j ovous the eyes

S u dden
,

spa rkle and he seems to again have regained his

youth A l l his movements are act ive \ V ork i s
. .

ti v i ty
e agerly recommenced and is rapidly and co r r ectl v

e x ecuted The pul se i s ful l and bounding the

.
,

appetite and sleep return the skin resumes i ts ,

ros y t int and the l ost w eight is rapidl y re gained

and the ki d ne y s become n orm all v active .

N ew plans and proj ect s are entered upon and

pushe d to complet ion B od v and mind are d r i v
.

en to thei r uttermost capacity Th is menta l hv .

p e r ac t i v i tv cont inues f o r a time until w orn out ,

b y this excessive overst rain a reaction sets in and

the melanchol ic sta ge i s begun ane w .

S everer types mav occur w here deep d epr es

sion or even stupor mav alternate w ith maniacal
frenzy necessitating incarceration in an in sti
,

tuti on .

I RR EG U LAR FO R M S
O ther combinations occur such as mel an ,

c ho l i a lucidit y
, mania lucidit y melanchol ia or
, , , ,

periodic ci rcular and at y pical forms mav combine

themsel ves in a complex manner A patient .
 384 M E N T AL D I S E A SE S

prone to circular in sanity may become a periodi c

maniac f or a time or periodical m aniacal at tack s
may change to depressive attacks .

D I AG N OS I S
W hen there has been a previous attack the

d iagnosis is usually easy The chie f dia gnostic .

symptoms are the psychic paralysi s connected

w ith the special s y mptoms of exaltat ion o f the
mental automati sm lack of persistent intellectual
,

en feeblement and frequent recurrence o f the at

tacks w ith complete mental restoration afte r
each .

G en eral It i s di ff erentiated from gen eral p ar es is by i t s

Pa resi s
lack of the persistent intellectual en feeblemen t
and the ph y sical signs pathogn omonic of that
ti on al mel d i sease From i n t ol n f i on al m el an chol i a b v the
.
'

a n e/zol i a
milder character and shorter duration o f it s
moral pain From the d ep r ess i on of d em en ti a
.

p r a

e ox b v its greater amount o f clouding o f con

sci ou sn ess psychomotor retardatio n di ffi culty o f

, ,

thought sparsity of ideas and slo w ness of appl i

,

cat ion o f attent ion .

PR O G N O S I S
The progn osis as to permanent r ecov er v is bad ,

as the individual i s l iable to recurrent attack s

th rou gh l i fe For recover y from individual at
.

tacks good except according to K raepel in in

, , ,
 M A N I C D E P R ES S I V E
-
I N SA N I T Y 38 5

about ve per cen t o f cases w hich from the on
.

set pass directly from on e att ack into another .

M ental deterioration rarely occurs as the re

sult o f the di sease A f ew cases have manic at
.
ti on r a re

tacks w h ich 1ast for years kno w n as chron ic ,

mania but these Sho w l ittl e evidence o f demen

,

tia A certain number of depressive cases m ay

.

su ff er from attacks w hich last f or years w ith

, ,

out marked evidence o f mental deterioration .

Bet w een the attacks pat ie n ts may be able to r e

sume thei r accustomed duties and appear per
f ect l v w ell .

T R EA T M EN T
A s the u n d er l v i n g ca u se o f the d i sease lies in
the individual constitution there is l ittle chance
o f en ti r e l v eradicating it by t reatment The i n .

dividual attacks can be greatly modi ed and

shortened Bet w een the att acks the l i fe shoul d
.

be so moderated that the in d ividual m ay be sub

j ec ted to as l it t l e mental st rain as possible Dur .

ing the attack pat ients are usual l y better kept in

bed and subj ected to forced feeding of as much
nut ritious food as they can digest usual l v in a
liquid form .

The remedies and their indication s have bee n

given under the individual tvpes .

26
 C H A P T ER X I V
P A R A NO I A

The w ord paranoia ( from tapa close to an d

vo us understanding ) indicates a mental disorder
w hich although rare has become o f great imp o r
, .

tance to the medical and le gal pro f ession from

D a ng erous the d angerous character o f the individ ual s
a ff ected .

The paranoiac asi d e f rom h is part icular delu

,

sions m ay not only appear per fectly sane but

, ,

unusually gi fted mental l y he n ce w hen he come s

,

w ithin the pale of the l aw he m ay prove the d eep

j u r i es a n d
est o f puzzles to both j uries and j udges .

P aranoia has been dened as a form of men
tal disease characteri z e d by logical o r s y stema
ti z ed delusions o f persecution and sel f exal tation -

w ithout excitement o f emotion or idea or impai r ,

"
ment of memory Gra s N ervous an d

.
( v M e n

tal Diseases p , .

i ca l
A great number o f varieties have been d escr i b
ed by d i ff erent w riters The t y pical form o f
.

paranoia is term e d chr on i c pr ogr ess i e p ar an oi a '

z
'
.

w hich w e w il l con s i der in d etail Thi s f o rm i s

.

d ivi d e d into four stages p r od r om al p ers ec utor y

, , .

ex p a n s i v e an d p s e ud o d em e n ted
.

we shal l de scribe the sympt o m s of the di ff er

ent stage s in the or d e r o f their d e v elopmen t .
 PA RA N O I A 38 7

The p r od r o m al the hy p ochond r i acal sta ge or

, ,

period o f s ubj ecti ve analysis as it has been vari ,

ou s yl denom inated may have its inception i n I n e

g/l i a i l! n

m
,

d w m oa

early childhood The child is pecul iar m o rb i d ly

.
,

bas h ful shun s the companionsh ip of other chil

,

d ren and is incl ine d to sol itude P ubert y w ith .

,

its n ew bo rn ood o f sensations typical o f this

-
,

period intensi es these morbid proc l ivit ies

, .

The patient begins to notice hi s o w n pecul iarities

and to recogn ize the singularit y o f m an v o f h is
sensat ions w hich are more or less neurasthenic
,

in character paree sthesi as an d pains in various se s ti on s

,
n a

parts o f the bod y ringing in the ea rs sparks be , ,

fore the eyes and the l ike These sensat ions give .

a hypochondriacal coloring to hi s thou ght s .

S oon is ad d ed a co n sci o us n ess o f di f c ul t y in the

concent ration and cont rol o f his thoughts He .

becomes ext remel y int rospective and the more he I trosper n

"w
studies his pecul iar sensations and the phenom
ena o f uncont rol lability o f his thou gh ts the more ,

i n cl ined i s he to seek f o r some cause o f his mor

b id i tv
. A t rst l ike an ordinar y h y pochondriac
,

he studies h im sel f to nd a solution o f the prob ,

lem ; fail ing here he e x te n ds h is investigat ions to

,

h is envi ronment seeki ng there a reason for his

,

s trange f eel ings uneasi n ess an d , morbid

t hought s : S oon ent i rel y sel f concent rated he b e
,
-
,

comes incapable of an y mental or physical em

plo y ment A l l hi s companions appe ar st range
.
PA R A NO A C
I I T H
'
M A R K ED D E LU S ON S
I O F P E RS E C U T I O N
 PARA N O I A 389

an d he gro w s suspicious and dist rust ful o f every S uspi ci o us

thing and everybody He imagines that he i s
.

ridiculed sl ighted and slandered and gro w s more

,

and more gloomy sol itar y and absorbed E very

,
.

thing i n h is past l i fe is studied in the light o f h is

present general d is trust H is physical sy m p .

toms becoming more marked he soon develops ,

illusions and hallucinations o f feel ing smell and ,

taste He is disturbed by unusual noises and

.

sounds w hich rapidl y chan ge into xed hallu

,

ci n a ti on s o f hearing .

Now the second or p er s ec utor y p eri od of p ar a

n oi a is developed the period o f delusional ex
,

planation o f h is t roubles M ul titudes o f xed

.

persec utory delusions l l his mind He l ives i n .

Persecutory
an atmos phere o f suspicion eve rything around ,
del usi on s
h im has a co v ert meaning P eople w atch him on .

the st reet and in publ ic conveyances A ttempts .

are made by unkno w n enemies to poi son him o r

kil l h im by electricity W herever he goes he is
.

pursued by the voices shocks and poisons hence

, ,

he comes to bel ieve that it must be the w ork o f

some great conspi racy The M ason s the Jesu .
,

it s the C athol ics anarchi sts and the pol ice are al l
, ,

in league against h im A s time passes these de

.

l usi on s become more and more xed This sys .

tem of persecutory ideas is buil t up in the most

'

elabo rate w ay and the more educated the individ

ual suff ering from paranoia the more w onder ful
, ,
 390 M E N T AL D I S E AS E S

the organization an d adj ustment o f the variou s

"
part s of the delusional system (P eterso n ) .

C ontinually tormented b v hi s delusions he seeks

, ,

protection from the police o r the Governor of the ,

S tate or the P resident o f the U nited S tates or

,

d i er en t j udicia l authorit ies Fail ing to receive

.

any sati s faction from h is complaint s he often ,

takes the l aw into his ow n hands and w reaks ven

g ea n ce upo n his imaginary enemies These f r e .

quent homicidal attempt s the legitimate outcome,

o f h is delusions render the seclusion o f the para

,

n oi ac an absolute necessity f o r the publ ic sa f etv .

The third stage or ex pans i z e period is a log

,
' '
,

ical outcome o f the tw o previous In h is at .

tempts to explain w hy so many enemies hav e

spr ung up against him the paranoiac co n clude s
D el usi ons
that he must be some great person Sud d en l v he .

9 / di scovers that he is in r eal i tv C h rist or M ahomet ,

g m n den r or some great inventor or has been set aside to

,

establ i sh some social re form o r is the beloved o f ,

some lady of superior station U pon these delu .

sions some w riters have based thei r divi sion s o f

the disease into p ar an oi a r el igi os a p ar an oi a i n ,

p aran oia r ef or m af or i a and p ar an oi a

'

z e n tor za
'
,

e r oti ca . Y et lled and guided as these paran o i

acs are by every variety o f d elusion they may
, ,

possess remarkable j udgment reasoning po w er ,

and memory and may be able to deceive the laity

,

an d many ph y sicians regarding their insanity .

 PARA N O I A 39 1

T hev mav even take the w itness stand to prove I Vi l n ess

s{a 71 d
thei r sanity ans w er questions w ith perfect read i
,
.

ness and logical sequence stand un scathed an ,

analyt ical cross examination stagger J

-
udge and ,

j ury and yet in the next breath say someth ing

that w oul d evidence a rooted delusion These .

pat ient s w rite coherent sensible letters and may

,

d o creditable l iterary w ork ; yet underneath all

this seeming good j udgment and logical ity lurk
thei r delusions x ed and unchangeable coloring
, ,

and shaping al l their thoughts and actions and

rendering them at al l times a menace to soci etv
, ,
.

The loss of eth ical se n se is a marked charac

SJ 7

ter i st i c o f these cases They w ill describe some

.

brutal act w h ich they have performed w ith the

, ,

u tmost equanimity and the most per fect r ecogn i

t ion o f the nature and quality o f the act and it s
conseq uences The follo w ing account given by
.
,

Dr L ander C arter Gra y one o f h is medical ex

.
,

am i n er s o f the notorious paranoiac D oughe r tv

, , ,

i s a good il lust rat ion o f this lack o f ethical sense

and sho w s the mental condition of a typical para
n oi ac I give it in D r Gray s ow n w ord s :
'

. .

Thi s man Dougher ty told me very calmly that

, , , ,
D oug /1 e: {y
05 6

w hen he ha d been committed to the A sv l um t w ice

l

and found that he had no redress he made up his ,

mind that the s y stem o f com m itting peopl e to

A sylums w as de fecti v e : that he sough t f or a ,

long time for the best means of correctin g the

.
392 M E N T AL D I SE AS E S

evil and that he came rel uctantly to the conclu

. ,

sion that a revolut ion as he expressed it w as the

, ,

only e f f ect ive remedy so that he determined to

,

kill the physicians w ho committed h im the Judge ,

w ho had indorsed the commitment the C ommis ,

si on er o f L unacy w ho had approved of it the ,

o ff i cers o f the A sylum to w h ich he had been com

m i tted the second t ime the local C ommissioners
,

of C harity in w hose charge the A sylu m w as and ,

the S tate C ommissioners o f C harity w ho had ,

visitorial po w er over al l the A sylum s o f the S tate .

He a rmed h imsel f w ith tw o re v ol vers and pro ,

ceed ed to the Flatbush L unat ic A sylum w here ,

he shot a young A ssistant physician Dr Llovd , .

,

backed out o f the A sylum keeping everyone at

bay w
,

,
ith h is tw o revolvers and proceeded on the
,

horse cars to the B rooklyn B ridge a distance o f ,

some seven miles to cross over to New Y ork to

. ,

g o on w ith h is murdero u s w ork but

,
fort u natel y

he w as arrested on the bridge at the instance o f

a nother phv si c i an w ho had follo w ed him H e .

s aid that he w as very reluctant to kill Dr L loyd .

,

because he kne w that the latter w as a young man

w hom his parents had educated at co n siderable
sacri ce and because he w as the only son b u t
, ,

he steeled h is heart to the deed by reecting upon

the n ecessi tv o f the revolution wh ich he w as thus
to inaugu rate . He al so said that he had at rst , ,

intended to shoot the cook o f the institution b ut .

 PARA NO I A 39 3

that second though t convinced him that people

might think that there w as an element o f sp ite in
this w hich w ould detract from the moral e ff ect
,

of the deed I remarked at this point t ha t th is

.
, ,

w ould have been rather a smal l a ff air to ki l l the

cook w hereupon he quickly rej oined w ith a
,

chuckle O h i f y ou had eaten the food w hich
, ,

that d d sco undrel cooked you w ould have ,

w anted to kill him and la ughed heartil y

.
,

Thi s is an outl ine o f the ty p i ca l f or m of p ar a

n oi a the chr on i c p r ogr ess i ve and only a short
, ,

descript ion needs to be given of the other forms .

V arious divisions have been made by diff erent

w riters based upon the pecul iar delusions de
v el oped .

Kra ff t E b ing w hose classi cation w e shall fol

-
,

l ow divides the paranoias into tw o groups the

, ,

ear l v and l a te forms p aran oia or igi nar i a an d

p aran oi a tard it a These groups are sub divided
'
.
-

into p ar an oi a s i mp l ex and p ar an oi a hal l uci n ato

r i a w ith minor varieties of p ar a n o i a p ers ec utor i a ,

r el igi os a er oti ca and s nper ba

. The l i tigi ous i n .

sanity or q uer ul en t insanity is included under

paranoia tardiva .

P a r an oi a or igi n ar i a the early form is very , ,

uncommon and resembles the late form It s .

symptoms appear be fore o r during the epoch o f

puberty some cases having been recorded as com

,
[ f ered i l a ry
m en ci n g in earl y childhood M arked heredita ry .
 39 4 M E N T AL D I S E AS ES

t aint and a neuropathic temperament are al w ay s

revea l ed in the hi story These chil d ren are gi v
.

en to day drea m s and are prone to outbreaks o f

-

passions j ealous o f thei r brothe rs and sisters

, ,

w hose t reatment by thei r parent s they conside r

di ff erent from thei r ow n thev n d more pleasure
,

in the compan y o f st rangers than in thei r ow n

C / ul d /I ood
'

home surroundings S eclusive and given to the

.

perusal o f romantic and erotic novel s they de ,

cline to join in the amusements of their brother s

and S isters C onvinced o f the inj ustice of thei r
.

home treatment fal se impressions soon l l thei r

minds Thei r parent s are onl y foster parent s to
.

w hom they have been int rusted R evolvin g .

R 0m a n l i e upon this idea thev soon evolve a romantic fam

,

lt i sl ol y
ily h istory They are really of noble birth and
.

are being deprived o f thei r natural right s .

W h ispered con versation s of thei r parents or ,

teachers or some chance expression are regarded

,

as additional proof S oo n their suspicions ar e

.

accepted as absolute certaint ies and thei r idea s ,

become xed H ome surroundings become un

.

endurable C onvinced of thei r ow n superiorit y

.
,

thev imagine that they are t reated w ith especial

consideration by persons w hom the y meet T he .

papers are fi lled w ith covert al l usI on s to thei r

cases and they occupy their davs and night s in
build ing up elaborate solution s o f the m v stery
pertaining to thei r exal ted bi rth and station A s .
 P A R AN O I A 39 5

pu b e r t appears erotic ideas are m ingled w ith

v l i roti e i d ea s

then m I scon cept i on and hallucinat ions and delu

sions ll their minds Lovers o f high degree .

-

visit them at night In order to be recognized by

.

their lovers w ho are to c arry them a w ay as

,

brides the y clothe themselves in fantastic dresses

,

an d ornaments an d thei r condu ct becomes r i d i c

,
~

ul ous and nonsensical I ndividual s are singled

.

out and sho w ered w ith a ff ect ionate attention to

thei r annoyance and the great m o rti cati on o f

the famil ies and friends o f the patient s E ff ort s .

b y the famil ies and friends o f the pat ient to con

trol th is conduct mav give rise to delusion s of
persecution I m agm m g that all their desires are
.

frustrated and that proper respect is denied them

by thei r famil ies and friends they become more ,

and more intolerant of cont rol and thei r fancied

w rongs become intensi ed and exaggerated .

Thei r future l ives are buil t up o f a texture o f

delusion s st rengthened by recurring hallucina
tions and illusion s .

TH E LA T E PARA NO I A
Wh ile the incubat ion period may date from
adolescence the act ual invasion o f this form may
not occur be fore the thirtieth fortieth or even 1 7: i rti ei ll to
'

, ,

the f tieth vear W ith w omen the pre o r post

.

rea r
cl imacteric epoch s are the most common periods
for its development .
 39 6 M EN T AL DI S EA SES

The simplest and most commo n type o f the di s

ease i s characterized b v systematized persecu tory
delusions w ithout any necessary w eakeni ng o f
,

the intel l igence although the comprehensive fac

,

ul ty sho w s impl ication from their inabil ity to

correct the erroneous impressions received .

TH E P ER S EC U T O RY PARA N O I A
To th is form belong most o f the examples o f
the disease P ossessing by inheritance an ill y
.
, ,

balanced brain these un fortunates exh ibit from

ch ildhood a pecul ia r temper and dis position .

Distrust ful suspicious sel f centered unso cial

, ,
-
, ,

stigm a ta
melanchol ic they pass th rough adolescen c e al
,

w ays alert for slights and insult s from those by ,

w hom thev are surrounded For year s imbue d .

w ith th is mental at m osphere it may need but ,

some sl igh t physical cause l ike an exhau stin g ,

discharge or prol onged sleeplessness to crys tal

,

Del usi on s l ize into delu sions o f persec ution the suspicion s
w hich have long occupied their attent ion A .

ti on
n ew w orld n ow sur ro u nds them Friends and .

acquaintances t reat them unkindly and circul a te

fal se stories about them P eopl e conversing on .
,

the st reet cast un friendly glances at them C ov

, .

ert h int s are made at them in the n e w spap er s .

P reachers allude to them in their sermo n s .

Hemmed in on all sides they ret ire more an d

, ,

more w ith in themsel ves C onversation addres s

.
 PA R A N O I A 39 7

ed to them cau ses i rritation but i f le f t to them ,

selves they feel insulted Y ears may el apse be

.

fore this persecutory system i s completely evolved

and the borderland o f in sanity is passed Grad .

uall y or suddenly as the resul t o f some st rain or

,

exciting cause the t ime comes w hen thei r fal si

,

ed impressions become certaint ies and thev come

under the complete cont rol o f hal l uc I n atI on s ,

il lusions and delusions V oices tell them that

.

thev are in danger from poison that the M asons ,

are conspiring against them S pies are on their .

t rack the pol ice are to arrest them f o r c rimes

,

long S ince committed V oices l l thei r ears w ith

.

vi l e accusations mock at them and cal l them

,

n a m es E lectrical machines are placed in their

.

beds at n ight to sap thei r vital it y and drive them

in sane N eedles and knives are th rust into thei r
.

esh H allucinations of taste and smel l are

. H a l l uci n a
ti on s
mingled w ith those of perverte d c utaneous ori
gin Poi son i s m ixed w ith thei r food and n o x
.

ious gases are blo w n into thei r rooms at night .

C onvinced of the dangers by w hich thev an d thei r

famil ies a re surrounded thev seek protect ion ,

from the authorit ies Getting n o relie f thev y

.

from place to place for sa fet y E ver pursued b v .

thei r persecutors thev at last take the matter i n

,

to thei r ow n han d s and then become a menace to

socie ty O ften in formed b v the voices of the
.

names of thei r tormentors thev may resort to H om i a de

'

homicide .
 398 M E N T AL D I S E AS E S

In the majority o f cases o f p ar an oi a per secu

/ en ta l
tor i a w hen the delusional i n san i tv has reached
p
,
ou er s
r

wea k en its height gradual w eakening o f the mental pow

,

ers ensues altho ugh years may elapse be fore the

,

intell igence evinces an y palpable de fects .

In on e quarter to one th i rd of the cases o f th is

- -
,

m a n to ca l t y pe either suddenly or b v degrees the per secu

, , ,

i dea s to r v are suppl anted b y mega l omaniacal idea s .

The patient n o w asserts that he is a person o f

unusual attainment s and great possessions o r .

has been especi al l v chosen o f Go d as hi s prophe t .

or is the S aviour of the w orl d \V hi l e the .

grandiose i d eas of the paranoiac m ay rival in ab

surdity those of the paretic the v lack the change ,

ableness o f the latter and remain xed and

settled .

( on rse sl ow The course o f p er s ec utor ia p ar a n oi a i s e x ceed

i n gl v slo w althou gh progressive
,
E ven fteen .

or t w ent y y ears may elapse a fter the develop

ment o f the delusions and n o si gns o f terminal
dementia appear .

The most common of the sub groups o f p ers e -

c u tor i a p ar a n o i a is the s ex ual ty p e .

S exu a l
I I I th is form all delusions relate to the sexu a l
org a n s organs often produced b v neurasthenia mastur
, .

b ati o n or actual disease o f these organ s .

j ea l ou sy I I I a paranoic w oman j ealous y i s the cm n m on

basic s y mptom The husband is fal se and l l s
.

the w i fe s r o o m at ni ght w ith unseen w o m en

'
 P A R AN O I A 399

w ith w hom he copulates in her presence The .

most innocen t actions or conversation w ith the

other sex are fal si e d The mal treated w i fe.

condes her w rongs to neighbors and friends and

the peace and happiness o f home is dest ro y e d .

these mi sconceptions a strange min gl ing o f

rel igious ideas mav be blended .

E N N T

I L I A
'

Q R U O S I S I v

O ne o f the forms o f paranoia o f occasional oc

currence has been designated by H it zig q uer ul en t
i n s an i t y .

This psychosis is o f gradual onset an d usuall y

dates it s origin from an actual occurrence some ,
1 (g a l
.

legal inj ustice de feat in court loss o f propert y

, , ,
i i i/ u sti ce

or unj ust a w ard o f damages in w hich the patient

has been the su ff erer

I t u suall y occurs in i n di v i d ual s heredita ril y H e re di ta r
y
tainted w i th marke d st i gmata o f de ge n erat ion .
ta i n t

E thicall y de f ective an exaggerated e gotism

.

arises cau sin g misconcept ion of the right s o f

,

other s and an o ver w eening j ealousy o f their ow n ,

an in fringement o f w h ich i s vi ol entl y re si ste d .

I rritable obstinate sel f w illed the y are prone to

. ,
-
,

f re q uent c o n icts w ith others .

U suall y i n tel l ectual l v belo w the avera ge even .

w hen some acutenes s o f j u d gment is apparent .

La ck of
the m emory goo d an d thought coherent st ill .

m en ta l
there i s a lack o f mental balance mani fe s t an d [ta /a I l a
 400 M E N T AL D I SE AS ES

facts appear in a di storted light E ver d w ell ing .

upon the w rongs they have su ff ered they contin ,

u al l y attempt to secure j ust ice th rough the court s .

Fail ing to w i n thev o f ten accuse their l aw v er s o f

,

t reachery and devote them sel ves to the study o f

the l a w an d hence forth conduct thei r ow n cases .

carrying them from one court to another devot ,

ing thei r w hole t ime and mone y to thi s obj ect .

R efusing to abide by the nal d ec i sion the y w rit e

to j u d ges legisl ators or the P resident o f the
,

United S tates A ns w ers to these letters on l v i n

.

crease the embitterme n t I n s ul ts and th reat s

.

are poured upon the o fcers of the l aw until s teps ,

are taken for thei r c ommitment to some i n st i tu

ti o n w here thev pose as m a rt v r s and dupes o f the
,

l aw .

The se cases a re prone a fter a prol on ged ,

ter i or ati on course to sho w greater mental deterioration than

,

other v ariet ies o f paranoia l n coher en cv an d .

l imitat ion of the co n tent o f speech appears w it h

i n creased peevi shness i rritabil ity an d in some
,

ca ses stupidity .

EX I A N S I V E

PA RA NO I A
Thi s f orm is much less co m mon than the per
secu to ry B ased upon the character o f the delu
.

sions it has been sub d ivi d ed by Kra ff E bing into

,

( )1 or r ef o r m a t i t e p a r a n oi a (
'
2 ) R e ,

l i gi o ns p ar an oi a (3 ) E r oti c p aran oi a
,
.
 PARA N O I A 40]

N V EN T I V E PARA N O I A
I

These pa t ient s are al w av s tainted and usually

imperfectly d eveloped m en tal l v The ch ie f men
.
T a i n ted

tal de fect i s an over w eening sel f importance -

,

w hich for m s a basis for all thei r delusions .

The perio d o f incubation i s long in w h ich the

,

foundat ion o f the disease is laid b v constant I b

n cu a ti on

brooding over future discoveries and I nvent ions

w h ich thev are to bring forth . E ver upo n the
border l ine of paranoia some ext ra physical
,

st rain or sud d en excitement w ill deprive them of

their remain ing reason an d the v announce them

selves as di scoverers o f n ew re l igion s pol it ical ,

re formers and saviours o f mankind C on ned .

in institutio n s inspi red b v thei r hallucinations

,

and delusions thev continue to ela b orate thei r

,

ideas .

A fter v ea r s their delusions become fainter and

a greater or lesser degree of dement ia succeeds .

D emen ti a
R EL I G I O U S PARA N O I A
The subj ect s o f thi s form of paranoia are usu
ally w eakminded or o f on e sided mental develop
-

ment Wea k
I t occurs most frequently in w omen given to m i n ded
wom en
fancies w ho from ch ildhood have been excess
,

i v el y pious and eas i l y inuenced b v rel igious

excitement .

The stage o f incubat ion m av last for months

27
 402 M E N T AL D I S EA SES

or years weakened b y acute disease sexua l

.
,

excess or prolonged penances any exciting cau se , .

l ike disappointment in love mis fortune o r n u ,

usual excitement may has ten it s deve l op m ent

,
.

Frequent precursors are hysteria chlorosis and ,

menstrua l di sorders .

In the acute stage hallucinat ions and delusio n s

.

predominate A t rst hal lucinat ions o f sight

.

si ons
appear the heavens are opened C hrist the V i r
, , ,

gin and A ngel s are seen V oices then announce .

to them that thev are the S on s of God or the

M other o f C h rist A t rst these messages a re
.

passively received L ater a stage o f act ivity .

succeeds in w hich in thei r attempts to carry out

,

thei r missions thev come into con ict w ith the

,

authorities .

I f unopposed f ew of these pat ients become

dangerous unless some voice di rects them to put
some sin ful person out of the w orld O pposition .

to thei r vie w s immediatel y provokes violence .

A t l arge they are unbearable and are soon com

m i tted to some institut ion .

M ental w eakness gradual ly ensues the del u .

sions st ill persi sting but marked dementia doe s ,

not occur .

E R O T I C PARA N O I A
Er oti c p ara n oi a is one o f the rarest forms .

In these patients thei r delu sions consist in an

 P LEPT I C
E I I N SA N I T Y 403

imaginary love w hich so m e person o f the oppo I m ag i n a ry

l ove f or
site sex entertains f or them The obj ect i s usu
.

som e pe r son

ally some on e o f a h igher station and en ti rel v of a l u g /ter

unkno w n A s a result they send letters o w ers

.
, , ,

make proposal s o f marriage until their conduct ,

becomes a veritable persecution and they fall into

the hands o f the l aw and are incarcerated in some
inst itution .

PA T H O L O G Y
The pa thology of para n oia is thus far un

kno w n .

PR O G N O S I S
The prognosis as re gards r ecovery is ab so
l utel v un favorable remissions and intermissions
,

are not uncommon and l i fe mav be prolon ged to

a n advanced age .

T R EA T M E N T
The dangerous character of these patient s ren D a ng erou s

ders incarceration in an institution imperative .

The remedies must be chosen according to the

svm ptom s tempo rary alleviation being all t h at
.

can be expected from an v medication .

 C H A P T ER X V

E P I LE P T I C I NS A N I T Y

E pileptic Insanity includes all mental derange

ment s directly connected w ith the E pileptic n eu
rosis I t therefore embraces a gr eat variety o f
.

cl inical symptoms .

\Vhi l e E pilepsy may for years exist w ith ou t

producing any mani fest menta l disturbance ex ,

cepti on al pe rsons even attaining a high degree o f

M en ta lde mental s upremacy yet in a large p roportion o f

,

l ertora ti on cases marked mental deteriorat ion is the res u l t .

Th is mental w eakening may vary fro m a s l ight

dull ing of the mind accompanied by impairm en t
o f memory w ith abnormal i rritabil ity to posit ive
,

i n sanity w ith suicidal or homicidal tend encies or

, ,

demen tia may result The degree o f mental i m

.

pairment depe nds largely upon the frequency o f

the epileptic attacks W hen the epileptic ts oc
.

cur at short interval s for years there is al w av s

,

a tendency to w eaken the intellect even w he re ,

there i s no actual insanity The ner emoti on s .

and sensibil ities are dulled the memory becom es,

faul ty sel f cont rol i s le ssened and the ge n eral

,
-

character i s changed W hile in the interval s

.
, ,

the patient s may be able to engage in ordinary

occupation s they l ack initiative sel f cont rol is ,

-
 -
IZI I LE P T I C

I N SA N I TY 405

l essene d and thei r hori zon i s contracted I f only .

a f ew ts occur during a l i fe time at long inter

, .

val s there mav be no mental impai rment except

, ,

the uncon sciousness at the t ime and the t ransient

con fusion a fter the convul sion \V hen epileptic .

insanity occurs it is usual l y a fter the patient has

su ff ered for v ear s from convul sions The more .

severe and the more fre q uent the ts the greate r ,

is the l iabil ity of insanity I I I exceptional i n .

stances patients mav su ff er severely and f re

q u en tl v from t s , f o r years w ith onl y a sl
,
ight
impairment o f the intellect w h ile others m ay be ,

plunged into furious mania soon a fter thei r rs t

convul sion .

A proper understanding of E pileptic I n san i tv

deman d s a con sideration o f the mental state o f
the patient preceding an attack (2) the .

e ssential characterist ics o f the epileptic sei zures ,

( ) the mental condition subse q uent to the rein

3
statement o f consciousness (4 ) the mental state ,

pre v ail ing in the interval bet w een the convul sions .

\V e shall t here f o re co n sider the subj ect un d er

, ,

the v e he adings o f 1 ) the p r ep ar ox y s m al s tage .

( )2 a p r e m o n i to r
y s t age 3
( ) the. p a r ox y s m a l
s tage , (4 ) a p os t par o r vm zal s tage ( 5 ) the
-
. . .

p
i n ter a r ox y sm al p er i od .

1) T H E PR E PA RO X Y S M AL S T A G E
A n epileptic seizure i s usual l y heralde d b v cer
t ain marke d an d easil v rec o gniz ed sv m pto m s

C A I A TO N IC
'

TENSI O N CA E
S S O F E P LEP T C
I I I NS A NI TY
 P L EP T I C
E I I N SA N I T v 407

These may prevail f or several days or only a f ew

hours be fore the attack These pr em on i to rv
.

sign s w hile v arying in di ff erent individual s are

. ,

so characteri stic that physicians and nurses ac ,

customed to deal w ith epileptics can usually ac ,

cu ratel y foretell the approach of a seizure The .

character undergoes a marked change There i s .

C ha ra cter

increased irritabil ity and unreasonableness P a .

t i en ts ordinarily quiet and peaceable may b ecome

quarrel some and pugil ist ic M arked gloom and

.

despondency may prevail Hypochondriacal no

.

tions come markedly into the foregroun d A n .

uncont rol labl e restlessness an d disconten t may

seize the patient preventing co n centration of the
,

mind upon an v mental or physical w ork S leep .

fail s and meal s are d isregar d ed S ome patients .

are tortured and terrorized by morbid fears ; oth

ers in a state of j oyous elat ion bombastically
, ,

boast of their great mental an d phv si cal po w er s ,

or the ideas may be con fused the po w er o f atten

,

tion diminished and the memory w eakened De .

l u si on s o f suspicion m ay al so appear impell ing ,

the v ictim to act s o f violence or even homicidal

atte m pts .

2) PR E M O N I T O RY S T A G E
Thi s i s not in real ity a stage but the beginning
,

o f a paroxysm . A t th is period appear the so

called w arnings or aur ae A great variety of
.
 408 M E N T AL DI SE AS E S

au rze have been recognized \V e may have aura: .

of the special senses o f the visceral or organi c

,

sensations and intellectual or psych ical auras .

V i sua l a nd V isua l aur ae are numerous and varied thev m av ,

appear as sparks or bright colors be fore the eyes ,

w ere
o r the pat ients may suddenly seem to be th rust

into utter darkness or plunged into a sea o f l igh t ,

o r a complete picture mav be ashed be fore the

eyes The auditor y w arnings though less f re

.
,

quent mav be simple or elaborate in for m

, .

Hi ssing sm gm g w h istl ing explosive noises or

, . . ,

vocal utterance m av be heard or a loss of hear ,

ing a strange unearth ly st il lness m ay p recede the

loss of consciousness Gustatory and ol f actor v
.

aur ae are the least frequent but w hen prese n t ,

consi st o f pecul iar tastes and smell s In vaso .

motor aurze there may be a mottl ing o f the skin .

the hands may become cold and purple the cuta ,

n eou s vein s may look less full than normall y and

a general feel ing o f chil l iness may pervade the

patient attended b y chattering o f the teeth
,
.

V i scer al The v isceral and organic aur ae are the m ost

a n d org a n i c
prevalent These consist o f a choking at the
.

a u re
th roat or a feel ing o f w eight or pain in the epi
g a st r i um or an opening
,
and shutting o f the head .

and cont inue unt il consciousness is lost The .

ps y ch ic aurze are numerous and varied Terror .

,

shuddering depre ssion gaiet y or rage mav sud

. ,

d en l v sei z e the v ictim R eminiscences o f b vgon e

.
 E I I LE P T I C

I NS A N I TY '

d avs may suddenly rush into the mind or po r

tions o f thei r past l ives pass l ike a drama be fore
them \V hatev er the form o f the aurze the pa
.

t i en ts learn to recogni ze them as fore w arnings

o f an attack and are thus o f ten able to prepare

for them .

3) T I I E PAR O X Y S M AL S T A G E
The epilept ic paroxysm may appear in the
form o f the Grand M al or complete attack the .

P etit M al or incomplete attack or as the P sv chi c ,

E q uival ent s of an E pilept ic attack .

The Grand M al present s th ree dist inct periods

1 ) one o f ton i c conv ul s i ons (2) one o f cl on i c ,

con t n l s i on s and (3 ) a p er i od of s tup or

'
.

The attack may be preceded b v an aura or the

patient w ithout w arning m av stagger to a seat
, ,

or suddenl y fall often r ecel v m g severe injurie s

,
.

There m av be the epileptic c r v con sist in g o f ,

sy mptom s
a sudden piercing scream or a succession of
shrieks a plaint ive w ail a long loud groan or a
, ,

mere gurgl ing in the throat The face become s .

d ead l v pale the pup i l s are w idely dil ated an d

,

complete u n con sc i m tsn ess ensues A tonic spasm .

rst appears usually more pronounced on one

,

side o f the body than the other the head and e y e s ,

deviating to the side to w ard w hich the bod y tends

to roll The f ace becomes l ivid and inj ected the
.
.

s w ol len and congested tong ue i s f r eq uen tl v forci

4 10 M EN T AL D I SEA SES

bly prot ruded bet w een the teeth T he chest i s .

xed respiration is arrested the veins o f the

, ,

neck beco m e s w olle n and rigid and marked ey a

nosis appears The t runk is usually rigid an d
.

st r aight Flexion and extension may be com

.

b i n ed in the di ff eren t l imbs or ex i on m ay pre ,

vail th roughout .

A t th is stage a spasm o f the abd ominal muscle s

ex pels the contents of the bladder and at time s
o f the rectum The ton ic stage i s shortly f ol
.

lo w ed by the cl on i c The muscles n ow relax and .

cont ract The face is distorted by horrid gri m

.

aces the eyes j erk i n their sockets there is grind

, ,

ing o f the teeth often causing laceration o f th e

,

cheeks an d to n gue The ai r is f orced n o i si l v i n

.

and out of the chest Froth foams from the .

mouth f r eq uen tl v tinged w ith blood from the

,

lacerated tongue The l imbs and head beat upon

.

the ground The respi ration impeded by the

.

clonic spasm o f the chest i s ine fcient M arked .

asphyxia and cyanosis persists the cardiac ,

movements are precipitate the arterial tensio n ,

intense The cl on i c stage last s from on e to ve

.

minutes terminat ing in full relaxation follow ed

, .

by the period o f stertor The pat ient n ow l ies .

inert w ith ster terous breathing in a state o f pro

, ,

found unconsciousness Th is state varies in .

d uration from a f ew minutes to hours Gradu .

al l v the breathing becomes natural sensibil ity ,

 E P I L EP T I C I N SA N I TY 41 1

and motor po w er are regained and w ith the ex ,

cept i on of a more or less con fused dazed feel ing ,

the patient s previous condition i s completely

r e establ ished .

In the P et it M al w hile a slight contract ion of

,

the face or eyes tongue and neck may be noticed

, ,

M om en ta ry
the distingu ishing characteri st ic is a loss o f con
l oss of con
sci ou sn e ss w h ich i s momentary only Th i s un . sci ousn ess

conscious period may be so short as to escape the

notice o f the careless observe r The conversa .

t ion may sho w only the sl ightest break the pa ,

t ient resuming it w here he broke off and continu

ing as i f noth ing had happened W e have seen .

a patient playing w h ist have an attack bet w ee n

the t ime he had played and h is nex t turn and
make h is pl ay co r rectl v the attack be ing so sl ight
,

that those w ith w hom he w as playing did n ot

not ice anything unusual The patient does not .

fal l and i f w alking may make no change in his

, ,

gait S till brie f and sl ight as are these attacks

.
, ,

thev resul t in the mo st rapid intellectual impair

m ent .

E it her the Grand or P etit M al may occur at

night constituting the cl i n ical v ar i etv kno w n as
,

N oc tur n al Ep il ep s y and for v ear s be un d i scov

. N octu r n a l
ered i f the patient sleeps alone O ften the di s
, .

co ve r v is accidental The su ff erer may even

.

pass throu gh l i f e ign orant o f the sec ret f oe w ho

i s c on stantly sappin g hi s menta l it y \V e had one .
 4 12 M E N T AL D I S E AS E S

pat ient w ho w as a su f f erer from N octurnal Epi

lepsy for more t han t w enty years an d d i ed w ith '

out any suspicio n of its existence O ften these .

attacks cause l ittle discom fort to the patient A .

sl ight headache in the morning a fter the seizure , ,

w ith some con fusion and a sl ight w eakening o f

the memory and a general ti red lame feel ing ,

m a v be all the apparent symptoms I I I som e .

cases the ton gue and l ips w ill be sore and there
m ay be blood upon the pillo w or occasi on all v an
n u r esi s involuntar y evacuat ion o f urine in the bed mav
occur but unless some on e sl eeps near the pa
,

tient and sees and hears him durin g the attack

, ,

neither the patient nor the f am i l v mav discove r

the t rue nature o f the malad y .

Instead o f the or d i n ar v attacks in al ternation ,

w ith them or preceding or immediatel y follo w

,

u i va
ing the major convul sions w e may have the so ,

q
called P s y chic E q uivalents These P s y chic
.

E q ui v a l ents usual ly come on sud d en l v w ithou t

w arning . A l l o f the attacks some w hat resembl e
each other T he patient is not completely un
.

conscious but the consciousness i s dist urbed

. ,

there is a dream l ike altered consciousness in
w hich apparentl y automatic mechanical and con .

scious act s seem to alternate w ith st range pur

o l ss ones In th i s sta ge the patient s m av
p se e .

w alk abo ut run aw av make indecent exposure s

, .

o f tlI eI I I sel v es commence compl icated and appa

.
~
 P L EP T I C
E I I NS A N I TY 4 13

r en tl ypremeditated mov ements and yet after

w ards have n o kno w ledge or remembrance o f
anything w hich they have done Gray mentions .

on e patient of h is a lad of fourteen w ho w ould

, ,

w ander for days about the l o w er quarters o f

New Y ork C ity sometimes earning w ages in
,

some l ight occupat ion w ithout arousing the ,

faintest suspicion in those about him until some ,

n e morning he w ould return to h is normal con

,

dit ion and then quietl y w end h is w ay home O f .

th is character are many of the sudden disappear

an ces of people w hich are daily ch ronicled in the

publ ic press W h ile in thi s state many a crim e

.

has been committed utterly mot iveless and the

, ,

culprit w hen restored to h imsel f has been as un

, ,

conscious of the w hole a ff air as i f he had not

been invol ved therein .

P O ST PAR O X Y S M AL P ER I O D
-

W hatever the form the seizure mental dis

of

turb an ce is l iable to follo w the epileptic attack .

Transient epileptic mania is the most common M ani a

resul t o f the paroxysm al though the mental ex

,

ci tem en t may e x tend over many days w ithout

an y further epileptic seizures intervening The .

epileptic maniac exh ibits certain highl v charact

eristic t raits The e x citement i s intense Driven
. .

by a w ild uncal culating fury in h i s frenzy he ,

may brutally attack w itho ut cause anyone w ith

, ,
 4 14 M E N T AL D I S E AS E S

w hom he comes in contact A ttendants physi .

,

c i an s and friends are all al ike subj ect s o f h is

murderous assaults \V ith v acan tl v starin g

.

e ves pale ghastly face expressionl ess or v i v i d l v

, , ,

bet raying the w ildest passions he is a per fect ,

representation o f a demon inca rnate U tterl y .

obl ivious o f his surroundings deaf to entreat ie s ,

or th reats he o ften makes the most despe rat e

,

attempts at suicide or homicide Impelled b v .

this uncont rollable fury the epil epti c m an i ac ,

_

seems less a h uman bein g than a machine drive n

b y some po w erful disarranged motor renderin g ,

h im the most dangerous of lunatic s .

S ex ua l ex
I n other cases an overpo w erin g sexual exc ite
ci tem en t ment w ith frequent frantic outbursts o f saty r i a
,

si s renders seclusion necessary to prevent ind e

.

cent assaults upon those w ith w hom thev are as

soc i ated .

Not all cases ho w ever are w ild and excited :

, ,

some are simply garrulous incoherent absur d , ,

and fool ish in their actions and appe a rance .

M any are exceedingl y rel igious in their preten

S ions spending much time in reading the B ibl e
,

and in prayer but i f dist u rbed in their devotion s

,

may pour forth a v oll ev o f oaths and f ur iou sl v

assaul t the o ff ender .

In some cases a delusional state precedes the

convul sion and the delusions cont inue a fter the
D el usi on s t prompting to d ee d s of violence Delusion s
,
.
 P LEPT I C
E I I N S A N I TY 415

w hich , be fore the t mav have been held in ab ev

,

ance during the automatic stage succeeding the

, ,

convul sion may entirely control the patient and

,

culminate i n some terrible crime .

The st rangest and most perilous feature o f

E pileptic mental disturbance is the Epileptic A utom a
A utomatism w hich is a marked feature in some
,
ti sm

epileptics after thei r convul sions In th is state .

they may not only per form the most incongruous

acts but mav care fully plan acts o f violence of
,

w hich a fter thei r complete restoration to con

,

sci ou sn ess they have n o remembrance D r

, . .

C louston tel l s o f on e epileptic who in con j un c ,

t ion w ith another pat ient put a stone in the toe ,

o f hi s stocking and tied a strin g about it and then

sl ipped it up his sleeve intending to use it as a , ,

w eapon o f assault upon the Doctor and a head

,

attendant w henever opportunity o ff ered and y et

, ,

w he n recovered from h is epileptic condition he

had n o recol lection of the act This Epileptic .

automatism is of vital importance from a

medico legal standpoint as m an v o f the most
-
,

at roc ious crimes o f epileptics have been commit

ted w hen the y w ere in this condition Dr . .

O range cites a case w here the M other w ho ,

w h ile cutting bread f or her family having her ,

b ab v on her arm became m om en tar i l v un con

,

scious O n ret u rn o f co n sciousness she procee d

.

ed, in an automatic w av to use the kni fe n ot , .

 4 16 M E N TAL DI S EA SES

upon the loa f but upon her child w hose arm she
, ,

amputated . Th is automat ic state may continu e
for hours or even days and during this time the
,

patient may make long j ourneys or perform hi s

regu lar routine w ork w i thout att ract ing the at
tention of persons he meets and w hen he is re ,

stored to hi s normal mental condit ion have n o

remembrance of anyth ing w hich has occurred
subsequent to his convul sion .

H y ster oi d
A ttacl s
e
V iolent H ysteroid A ttacks are al so not i n f re
quent accompaniment s o f an epileptic con v ul si or
in the insane Those most subj ect to these at
.

tacks are voung w omen boys and gi rl s and occa

,

si on al l y young men under th irty v e year s of -

age .

In certain cases the convul sions rapidl y suc

ceed each other the consciousness is n ot restore d
,

bet w een the ts and w e have w hat has been term

Epi lepti c
ed the E pileptic S tatus In thi s state the breath
.

ing and pulse become quickened the temperatur e ,

rises to 1 05 degrees or 1 07 degrees F the com a .

,

and stertor deepen s and death i s liable to resul t .

The con v ul sions n ow become almost continuous ,

but feebler The head and eyes are turne d

.

sl ightl y to on e side there are S l igh t clonic move

,

ments o f the limbs or there mav be merel y sl igh t

convul sive t w itchings of the mouth There i s .

insensit iveness of the conj unctivae the pupil s ,

are w idel y dilated and the face and body are cov
 E P I LEP T I C I N S AN I TY 4 17

ered w ith cold s w eat The temperature may .

vary upon the tw o sides o f the body being h igh ,

est by a degree or more upon the side most con

, ,

v ul sed I f recovery ensues the temperat u re falls

.

most rapidly upon this side unt il the balance is

t e establ ished a fter w hich the decl ine is e q uable
-
,

and continuous on both sides M any epilept ics .

are occasionally subj ect to these outbursts o f con

v ul si on s w hich pass into the S tatus .

W hen death occurs it is due to coll apse menin ,

giti s or exhaustio n w ith hypostatic congestion o f

,

the lungs .

I N T ER P A R O X YS M AL S T A T E
The mental condition of epileptics varies
greatly in the interparo x ysmal state In some .

the mind is p ractical ly normal and they are able

to pursue any e m plo y ment f or w hich they are

tted I n others w hi l e the intel lect is vigorous

.
, ,

the emotions are at fault These patients are .

irritable impul sive easily angered sel f cont rol

, , ,
-

is l acking and upon the sl ightest provoca tion

,

they become involved in broil s and ghts O dd .

ities and eccent ricit ies often appear and the

moral character may appear lacking in develop
ment A large clas s are characterized by mark
.

ed intel lectual perversion P ossessed by del u .

sions impul sive and lacking in sel f cont rol they

,
-
,

are ever prone to acts of violence rendering .

28
 41 8 M E N T AL D I sEA S ES

them ex t rem el v dangerous to any com m un i tv i n

w h ich they may be located L astly w e nd the
.

cases far advanced in de m ent ia N one o f the .

insane sink to a lo w er level than the epilept ic de

men t ment W ith the memory a blank the emotional
.
,

and intellectual faculties dead o ften incapable o f

,

caring for themselves even in the sl igh test d etail .

they lead a purely animal existence Governed .

ent irely by the lo w est animal i n st incts and pas

sions they become the most repul sive and ob n o x
,

ious o f human creatures .

C ertain physical and mental characteristics are

common to the w hole class of epileptics Epi l ep .

t ics as a rule are undersized and constitutional l y

w eak . S ome o f the physical physiological or
mental sign s o f degeneration are al w ays presen t .

gm a ta
A ccording to Fer e the physical stigm ata a r e
,

short stature cranial asymmet ry short parieta l
, ,

o r frontal arc and t rian gular skull ; in w ome n

h igh prominent fore head ; bad teeth badly placed ,

h igh palatal arch ; facial asymmet ry : prominence

of occiput : di ff erences in color size posit ion an d
, ,

shape o f pupil s ; ast i gm at ism ; badly shaped and

badly pl aced ears ; mi splaced cro w n o f scalp ; low
vital capac i tv : smal l genital s atrophic uterus , ,

greater develo pment of the le ft side : long ngers .

S omet imes from a premature ossi cation of su

y si ol og tures w e nd al s o the steepl e shaped skul l or th e
-

m a to ob l i q uel v de formed skull Ph y siological st ig

.
 EP I LEP T I G I N SA N I T v 4 19

m ata a ppear in the form o f lessened mu scular

st rength habit choreas imper fect eves w ith ex
. . ,

c e ssi v e amount o f as t i g mati sm and functional

muscular w eakness The vital capaci tv is dimin.

i shed the di gest ion w eak an d slo w and sexual

,

atrophy or i rritabil ity is l ikel y to be pre sent .

The excretion o f phosphoric acid is bel o w nor

mal as compared w ith urea .

The w hole l i f e and surroundin gs of the E pi

l ep ti c tend to d ev l op the mos t d isagreeabl e men .

t al cha racterist ics S hu t ou t b v h is m al ad v from

.

school s church amusements re fu sed emplo y

, . ,

ment he becomes a soc ial outcast E ver in

,
.

drea d o f an attack of his direful malady his ,

w hole
mind becomes sel f centere d E ver y .

sv m ptom receives the minutest attention and is

thereb y exaggerate d H y pochondriacal melan .

,

cholic irritabl e dist rust ful morose deceit ful

, , , , .
C om posi t
dull apathetic impul sive lacking in sel f cont rol
, , .
-
. p i ctu f
re o

w or st m en
his m in d is a composite picture o f the w orst men ta l cha r a c
tal characteri stics A burden to h is friends an
.
,
ter i sti cs

obj ect of general commiseration the mental ,

t raits o f the E pilept ic are the natural fruitage of

the circumscrib ed l i fe to w h ich he has been con
d enm ed b v h i s dre ad m a l ad v .

M ED I C U L EG AL R ELA T l O N S I I
-
l PS

Noo ther f orm o f M ental Disease is as o fte n

brought to the n o tice o f M e d ico le gal experts an d -
 E P I L EPT I C I N SA N I T Y 4 21

C ourt s o f Justice as E pilep tic I n sanit y O ne .

reaso n for th is is the fre q uency of its occurrence

a m on g criminal s N umbering among it s most
.

freq uent an d potent causes intemperance and

moral and physical de gra d ation the inheritance ,

o f many o f the criminal class it is natural that ,

many c riminal s should be numbered among i t s

victims A nother reason is that the i n san i tv of
.

the E pileptic de gradin g and b r utal i z m g I I I I t s

,

e ff ect upon the victim is l iable to be characteri zed

,

by impul sive acts and in the p ost epileptic autom -

ati sm nd s expres sion in criminal act s of w h ich ,

the perpet rator i s at the t ime enti rel y un con

, ,

scious and a fter w ards retains no remembrance .

In considering the responsibil ity o f the epi l ep

t ic i t i s neces sary to consider in its enti re ty each
, ,

i ndividual case as the m ental dama ge produced

,

by the disease varies so g reatl y in di ff erent

cases E very variety of c r I m e has bee n traced
.

to the E pil eptic and has been excused or puni sh

ed according to the vie w s entertained bv the
,

Judges regarding the disease The con d I t I on o f .

the individual be f ore and a fter the t s and in the .

interval bet w een the convul sions must be con si d

ered The fre q uency o f the ts and the prox
.

i m i ty o f the criminal act to a convul sion is al so

o f the highest importance in determining the

mental it y of the i n dividual w he n the act w as

committed I I I judging the innocence o r crim
.
422 M E N T AL D I SE AS ES

of any act perpetrated a fter an epileptic

i n al i ty
convul sion i t is necessary to decide w hether i t
w as the outcome l st of gen u i n e a uto m a tis m :
, ,

2d , a m otiv el ess un c on tr oll a bl e i m p ul s e : 3d .

the bl i n df r enz y of Ep il ep tic M an ia 4th w as i t ,

i ns tigated a n d p r om p ted b v i ns an e d el us i ons .

M AL I N G ER I N G
The pl ea o f E pileptic i n san i tv has so often been
establ ished as a defense for c r I m e s committed b v
E pilept ics that the disease i s not in frequently
,

feigned b v criminal s in the hope o f thus escap

ing punishment N or is it al w ays an eas y m at
.

ter to detect the impostor From their frequent .

associat ion w ith E pilept ics criminal s o ften be,

come adepts in fei gn ing the di sease \V hi l e the .

characteri stics o f the convul sion m an v o f w hich ,

cannot be assumed usually lead to a speedy de

,

tecti on o f fraud the epilept ic mental conditions

.

are much more successf ull v counter feited The .

fact that epileptics are prone to shamm ing add s

al so to the d i f cul tv of the problem T o estab .

l ish w ith ce r tai n tv the t ruth mav require that the

suspect be kept for some time under skille d
observation .

PR O G N O S I S
The prognosis o f E pil ept ic i n san i tv is bad .

W hatever the form o f the disease its victim s ,

se l dom make a permanent r eco v erv .

 E I I LE P T I C

I N SA N I T Y 423

T R EA T M EN T
The dangerous character of al l in sa n e epi l ep
tics renders thei r t reatment at home inadvisable .

They should at once be com m itte d to some inst i

ti on al trea t
tuti on and kept there for l i f e or u n t il complete m en t
restoration occurs The t reatment in ad d ition .
,

to meeting the peculiar mental svm ptom s o f each

indiv idual case should be that appl icable to the
,

primary di sease C are ful search shoul d be .

made in each case f o r the cause o f the disease .

I f a t umor o r depressed bone appears responsible

this should be imme d iately removed E very re .

Re ex i r ri
ex irritation w hether ari sing from astigm a
, ta ti on s

ti sm de f ect in the eye m u scles a t ight hood of

, ,

the cl itoris a phimosis or some or i ci al t rouble

, , ,

should be removed The diet should be rigidly .

regulated not only as regards the character o f

,

the food but al so as to the time of a d ministra

,

tion and the q uantity taken W hile on account .

o f individual idiosyncrasies it i s impossible to

prescribe an exact diet f or each epileptic in all , ,

D i et

cases animal food should be rest ricte d v ege ,

tables eggs milk and bread bein g the ch ie f de

, ,

p e n d en ce.A ll alcohol ic drinks shoul d be strictly

prohibited .

In the medical treatment in ad d ition to A con , .

,

A nacardium A r sen i cum album B el la d onna

, ,
,

C antharides H y oscyamus Nux v omica S tra

. , ,
424 M E N T AL D I S EA SES

m on i um and V erat rum prescribe d in the M ani

acal or M elanchol ic state s according to thei r
characteristic indications prev io usl v describe d ,

under l\I aI I i c Depressive Insanit y remedies es

'
- -
.

p ec i a ll y a d apted to the epil ept ic symptoms w il l be

required A s the basic d i sease in most cases ha s
.

become ch ronic be fore the d ev eI O pnI en t o f insan

i ty l ittle help aside from the modi cation o f the
,

convul sions can be expected The re m edies mos t .

frequently o f use in this connect ion are A rgent

, ,

nit A rtemisia vul g aris Bu fo C alcarea ca r

.
, . ,

b on i ca C edron C icuta vi r C uprum m etal l i cum

, , .
, ,

L achesis (Enan the crocata O pium P l umbum

, . , ,

S il ica and S ulphur give n according to the fol,

lo w ing in d ications :
A RG E N T U M NIT

Dilatat ion o f pupil s f o r hours or days be fore

, ,

the attack A fter the attack great restlessness

.
,

w ith trembl ing of the head and hands or violent

del i rium .

E specially indicated in ch ronic cases caused b v

frigh t or w here the convul sions occur during
menstruation and at night and w hen the disease .

has produced M elancholia loss o f m em or v and .

general marked mental deterioration .

AR T E M I S l A V UL G AR I S
M oroseness excitabil it y and irritabil it y the
,

d ay be fore the attacks w h ich are follo w ed b v a .

 P LEPT I C
E I I N SAN I T Y 425

d eep sleep and later o ff ensive perspiration smell ,

ing l ike garl ic R epeated attacks a fter a long i n

. R epea ted
te r v al L eft pupil dilated mouth dra w n to le ft
.
,

S ide
,
numb convulsio n s mostly in morning at
,

intervals of two or four months Frequent n oc .

tu rn al paroxysms brought on by su ff ering great ,

grie f ; a fter fri ght after cool ing off w hile over
,

hea ted E pileptic vertigo pet i t mal in the morn

, , ,

ing a fter heaviness in head tongue bitten i n

, , ,

c reased urination S uppressed irregu lar d e

.
, ,

c ient men struation w ith epilept ic convul sions ts ,

e very v e w eeks .

B U FO

E pilepsy caused by onan ism or sexual excess .

O n a n i sm

Fit s occurring during coition a fter fright dur , ,

ing sleep or aggravated by menstruation A ura .

start s from solar plexus o r sexual organs or runs

from uterus to stomach Be fore the attack .

there is marked irritabil ity f o r days incoherent ,

tal king and a tendenc y to hys terical lau gh ing and

crying A ttacks m ay occur in sleep and be f ol
.

l o w ed by severe pain and pressure in top of head

and pro fuse s w eating o f face I f a w ake before .

the attack a sensation of numbness is ex per i

en ced the head is dra w n to the righ t or le ft then
, ,

b ack w ard a t w itching commences in the muscles

,

of the face and then extends to the w hol e bod y ,

t here i s grin d in g o f the teeth foamin g at the ,

 426 M E N T AL D I S E AS E S

mouth the c o nvul sion terminat ing i n a p rofoun d

,

sleep .

It i s appl icab l e to l ow grade epileptic imbec iles

-
.

CA LCAR EA CAR B ON I CA
C alcarea carbonica is o f value m o re fro m it s
ability to correct the pecu l iar d v sc ra si a w h ich ,

underl ies the disease than from any po w er w h ich

,

it has over any pa rticular form of convul sion .

n al
It is curat ive w hen its characteri st ic con sti tu
t i on al sv m ptom s are present .

I t is especially e ffi cacious in man y cases o f pet it

ti t m a l mal w here w e have sudden brie f attacks o f loss
,

of consciousness w ithout conv ul sions Th e .

causes are fright suppression o f some ch ronic

,

eruption and excesses in venery .

S everal variet ies o f A ur ae have been assigned

to i t viz as starting f rom the solar pl exus goin g
,
.
, ,

up w ar d s to the brain or do w n into the uterus a s

, .

i f a mouse w ere running do w n the arm etc but , .

,

w e have been unable to corro b orate them in case s

w hich w e have helped by the d rug .

Th is remedy must o rd i n a r i l v be exhibited for

, ,

a considerable length o f time to obtain i t s ful l

cur at ive e ff ect .

C ED R O N
M enst rual epileps y convul sion s appear w i t h
, .

cl o ck l ike regularit y the dav the me n ses appea r
,
.
 E I I LE P T I C

I N SA N I TY 427

C I CU T A V I R O S A
T his remedy is indicated in a typical attack o f
Grand M a ] The convul sion commences w ith
.

marked rigi d ity o f the body opi sthoton ous or ,

em pr o sthoton ou s the eyes are sensitive to l ight

, ,

x ed and staring the pupils dilated the face

, ,

bluish there i s foam at the mouth the pul se is

, ,

slo w the brea thing oppresse d a series of shocks

, ,

and tremors run f rom the head to the feet the ,

limbs are violentl y di storte d the urine is passed ,

involuntarily there is tympanites complete un

, ,

consciousness and p ro found prostration follo w s

the t .

CU P RU M M ET A LLI C U M

N ausea and vomiting often precede the at

tack The attacks are severe ushered in w ith
.
,

the epileptic cr v the l ips and face are blue the

, ,

ev eb all s rotate there i s frothing at the mouth

, ,

v iolent spasms of the ex o r musc l es and com

p l et e unconsciousness fo l lo w ed by deep sleep .

A fter the attack the patient su ff er s w ith severe

headache extreme exhaustion and sore n ess over
,

the entire body .

N o other remedy in our hands has as often

req u en tl
y
proved curative in Epilepsy M any authors .
cu r a ti ve

limit its sphere to cases w h ich occur at night or

during menst ruation O ur experience has n ot .
 428 M E N T AL D I S E AS E S

veri ed this l im itation I I I several cases appa.

,

r en tl y hopeless w hich had been for years under

,

A llopath ic treatment w e have prom ptl v and per

,

m an en tl v cured the disease w ith th is drug .

L AC H ES I S

A ura begins in the heart S ensat ion as i f .

something ran up the neck and larynx and stop

ped the breath or as i f something ran do w n the
,

spinal cord P atient upon a w aking from sl eep i s

.

suddenly seized by a convul sion .

U se ful in ch ronic cases w hic h complain o f

p
ee great exhaustion in the morning or a fter sleep , ,

and w ho have been addicted to masturbation and

sexual excess .

(E N A N T H E CR O CA T A
Th is remedy has an enviable reputation in th e
t reatment o f epileps y but in our hands has prov
,

ed a di sappointment .

De w e y (P ract ical Hom oeopathic Therapeutics .

p 1 07 ) quotes D r S H Talcott s experienc e

. . . .

w ith this drug as follo w s : 1 The ts decrease .

in num b e r 40 to 50 per cent 2 The con v ul . .

sions are less severe than f orm erl v 3 The r e . .

is l ess maniacal excitement be fore the ts 4 . .

L ess sleeplessness stupor and apathy after the

,

ts and the debil itating e ff ects o f the attacks a re

more quickl y recovered from 5 The patien t s . .
 E P I LE P T I C I N SAN I T Y 429

t reated w ith (En an the

are less i rritable less sus ,

p i c i o u s and less fault n d ing 6 The pat ient

-
s . .

a r e more easi l v cared f o r .

O P I UM

C onvul sions produced by fright N octurnal

. r ight

epilepsy Deep stupor stertorous

.
,
breath ing .

Face red bloated c y anotic distorted

, , , ,
cannot be
aroused from stupor S u ff ocative . paroxysms
d uring convul sive state .

PLU M B U M
V ertigo severe headache either occipital or
, ,

frontal insomnia disordered vision heaviness

, , ,

an d numbness o f the legs be fore the attack .

A fter the attack prolonged snoring sleep w it h ,

slo w ly returning consciousness and paral ysis .

M ind w eak morose an d sad The attacks in

,
.

some cases are coincident w ith menstruation .

C l inically P lumbum has w on its brightest lau O rg a n i c

rels in chron ic cases based upon organic lesions .

SI L I CA
S il ica from it s deep seated action i s most
,
-
,

curative in ch ronic cases It i s especially ef ca .

x ha us
c i ou s w here there i s gr eaf exhaustion o f the ner ti on

vous system characterized by general erethism

,

and hyperaesthesia The patient s are poo rly .

n ourished from thei r i n ab i l i tv to assimilate

,
 430 M E N T AL D I SE A SE S

f ood subj ect to severe neuralgias w hich a re

; ,

aggravated bv noise l ight and mot ion and

, ,

amel iorated by w armth ; con stipat ion ; incl ined to

perspire about the head and feet : take cold eas
ily ; are restless and sleepless at n ight and pre
sent the general constitutional symptoms o f th i s
drug The convul sions generally sprea d fro m
.

the solar plexus to the brain and are preceded b y

coldness o f the left side shaking and t w ist i n g o f
,

the le ft arm occur most frequently at nigh t and

,

are aggravated at the time of the n ew moon .

I t is especially adapted to pati ents w hose d i s

ease has been produced b v mental over w ork and
w orry .

S U LP H U R
A dapted to ch ronic cases w ho have been ad
dicted to se x ual excesses and in w hose system s
Dy scrasi a some dyscrasia l urks or w hen i ts out w ard sy m p
,

toms have been suppressed Be fore the attack .

sensation o f a mouse run n ing do w n back an d

arms or up the leg to ri ght side o f abdomen
,
.

A fter the convul sion deep sleep and intense ex

hausti on .
 C H A P T ER X V I

T ER M I N A L DE M EN T I A

Term inal Dementia is t he inevita b le bourne o f

all insan ities that do n ot end in recovery or death .

The su ff erers from this disease form tw o thi rds -

of all the cases conned in in st itutions for the

insane .

U nder Terminal Dement ia are grouped a great

variety o f men tal w recks the mental en feeble
,
ti / en ta l
c

ment ranging from a slight loss of memor y w ith

an almost imperceptible dimi n ution o f the nor
mal mental acumen to complete animal ism The .

degree o f mental w reckage depends upon the

sev e r i t v o f the mental storm and the original

po w er o f resistance of the brain attacked .

\ V hen M ania M elanchol ia o r C on fusional i n

, ,

sanity has existed for a long time w e nd that a

state of mental en feeblement ensues This con .

dition is much more l iable to result from M ania / a n i a

than M elanchol ia The abnormal brain act ion
.
,

resul ting from the primary disease inter fering ,

w ith nut rition inj uriously a ff ect s the cerebral

,

st ructure the capillaries lymphat ics and even the

, ,

brain coverings the pia mater the l arge vessel s
, ,

the epithel ium the cerebrospinal uid the arach

, ,

n o i d the dura mater and the cal varium

. W hen .
 M E N T A L D I S EA S ES

thi s morbid action has passed over o r exhausted

( IU O II S
'

it sel f w e often nd that the neurons have been

,

so damaged that they become incapable of per

forming thei r normal funct ions Incapaci t ated .

as vehicl es o f normal mental izat ion their nut ri ,

tive receptive const ructive and productive

, ,

po w er being impaired a state o f mental w eaken

,

i n g or dementia result s .

The resulting damage may be simply evidenced

in a slight impairment o f j udgm ent and w ill pow
er Their original force o f character and men
.

tal vigor bei ng lost the patient s become physic

,

ally and mentally indolent The mor al an d .

aest hetic feel ings are blunted the physiogn omy ,

loses its hi ghest expression and the individual

man i fest s a certain childish appearance These .

patient s laugh boisterously over noth ing w ee p ,

about tr i es and become easily enraged w ithou t

cause There is an entire lack o f origination and
.

remnants o f vague hallucination s and delusion s

mav remain shado w s of the primary insanity
,
.

These cases are b i d ab l e and al though incapabl e

,

o f any originality may carry out the pl ans o f

,

others i f not too compl icated A lthough i rrita .

ble and excitable the y are n ot dangerous or i n

,

t ractable and may be fairly use ful members o f

soc i etv Th is is on e end o f the scale o f degen
.

e rat I on but at the other the mental po w ers a r e

,

almo st obl iterated and the accompl ishment s o f

 T E R M I N AL D EM E N T I A 4 33

the past are completely blotted out The present .

arouses n o interest depraved and loath some in , ,

habit s the patient s lead a mere vegetat ive l i fe

, .

Bet w een these tw o ext remes o f sl ight mental .

en feeblement and absolute loss o f mental ity w e ,

nd every shade o f transit ion from st rength to

helplessness .

The change in the intellectual l i fe is vividly

port rayed in the physiognomy of the dement .

n amy
There i s an entire lack o f harm on v in the act io n
of the facial muscles at times on e side show in g ,

activit y w hile the other remains passive This .

lack o f innervation is especial ly observable about

the muscles at the angles o f the eyes and mouth ,

producing a passive leer This loss o f tension .

in the orbicularis al so permits the constant drib

bl ing o f sal iva rendering the patient s ver y d i ffi
,

cul t to keep clean .

The faces o f these patient s d eprived of all ex ,

Faces
pression save some single automatic fatuitous
, ,

smile angry fro w n or furtive look may retain

, , ,

sca rcel v a trace or vest ige o f their former come

l i n ess .

T rophi c disturbances are not uncommon .

E arly sign s o f senil ity may appear in premature

grayness of the hai r diminut ion of the sub cu ,

tan eou s fat w ith w rinkl ing and dr y ness o f the

,

skin O thers take on esh rapidly and become

.

excessively obese .

29
 4 34 M EN T AL D I S E AS E S

There may be a complete loss of the sense of

taste an vth i n g bein g s w al lo w ed w hich the pa
,

tient can get hold o f even the most disgust in g .

substances .

T hev m av del ight in co l lecting st rings stone s .

or pieces o f gl ass an d thei r pocket s and room s

,

are lled w ith all sort s o f rubbish S ome cases .

del ight in f an tasti cal l v deckin g their perso n s w ith

o w ers ribbons or rags bein g utte r l v i n cogn i
, ,

zant o f thei r incongruous appearance .

C l inical ly tw o forms o f dementia are di ff eren

ti ated the A gitated and the P assive
, .

In the A gitated form the patient s are restless .

talkative an d even obtrusive or dest ructive The .

restlessness ho w ever is automatic and the move

, ,

ments are analogous to those sho w n by idiot s .

such as anteroposterior o r l ateral oscillat ion s o f

the b od v O ccasi on al l v these movements take
.

the form o f grimaces or gest iculations of the n

gers arms or han d s S ome patient s w ill w alk
,
.

for a certain distance on a particular st rip o f

ground others run in a ci rcle or w alk back w ards
, ,

or w hen w alking w ill f r eq uen tl v stop and w h i rl

round on the heel .

The speech m ay be verbose but the sen tence s ,

are disconnected and used mechanicall y w ithou t

a clear conception of their meaning and w ithout
association of ideas .

E xpr essi on The expression o f these patients i s si l l v and

 T E R M I NAL D E M E N T I A 43 5

childish T he v are usually calm but the re m av

.
,

be at times exacerbations o f agitation sl ightl v ,

resembl ing maniacal attacks but the violence i s ,

w ithout pu rpose and l acks the emot ional basi s

w hich characterizes the violence o f the maniac .

P assive dementia represents the lo w e st degree P assi ve

of mental apathy .

The countenance i s n ow com pl etel v expression C ou n te

less The l imbs hal f paretic are t w i sted under
.
. ,
n a n ce

their o w ner and in their inactivity the patients

resemble co w ering statues or animal s w hos e ,

cerebral hemispheres have been removed The se .

patients w ill sit f o r hours utterly mot ion l ess

, , ,

w ith the chin sunk upon the breast w hile oods ,

of sal iva continually ow from the mouth .

M ute expressionless regardless o f hunger or

, ,

thi rst or any o f the physical call s they re q ui re to ,

be fed dressed undressed and cared for l ike

, ,

in fants .

A s the deterioration proceeds even the f e w

w ords o f their l imited vocabulary are lost Ut .

ter l v obl ivious o f the past or present w ith com ,

p l e t e mental annihilat ion the pat ient l ives

,
in a

veritable l and o f darkness as d arkness it sel f ,

and of the shado w s of death w here the l ight i s ,

as darkness .

N o greater tragedy o f ex istence can be i m ag

i n ed but f o r tun ate l v nature is merci ful and w ith
,

in a f ew v ear s closes the scene b v death th rough ,

4 36 M E N T AL D I S E AS E S

extension o f cent ral paralysi s or b v an intercur

rent diarrh oea some pulm on ar v disease or so m e
,

other acute a ff ect ion .

T R EA T M EN T
The t reatment o f these cases depends upon
the degree of mental impai rment Wh en the .

mental w eakness is slight these pat ien ts can be

kept at home and under judicious management
, ,

may accompl ish a fai r l i fe s w ork in l ines req ui r

'

ing moderate mental activity The maj ority o f

.

cases are much better o ff in an institution w here ,

they are useful in car r v i n g out its simple daily

routine o f tasks .

The bodily health o f these cases i s usual l v

, ,

good but thei r po w er o f resistance to di sease i s

,

less than that of the normal individual Th e .

worst cases require the constant care and ove r

sight o f a w ell re gulated hospital f or the insane .
 C H A P T ER X V I I
G E N E R A L T RE A T M E N T

The rst
question that arises a fter a ca se of
i n san i tv has been diagnosed is w here shall it be
, ,

t reated at home or in some private or publ ic

,

hospital for the insane ?

t a tm en t
Home Treatment as w e shal l use the term is
. ,
re

n o t l imited to t reatment in the individ u al s ow n

h ome but embraces all t reatment outside of a

,

regular public or private institut ion chartered for

the t reatment o f the insane .

The decision of thi s q uestion mus t depend Fi n a nci al ,

con di ti on
largely upon the nancial condition o f the pa
,

tient h is age the pecul iar t raits of h is f am i l v

, . ,

and the nature o f the illness .

The cases for w hom w e are accustomed to

recommend Home Treatment are the w eal thv
w ho w hatever the form o f the disease can com
, ,

mand the h ighest skill o f experienced physician s

and trained nurses and surround the patien t w ith
e v e r v l ux u r v an d sa feguard thus rendering i n,
You ng

j u r v to h imsel f o r others impossible ; young

people w hose future l ives are thus freed from the Busi n ss e

m n e
stigm a o f incarcerat ion in an instit ut ion : busi
ness men w ho se business prospects are l iable to
be ruined b v a residence in an inst i tut ion harm ,

l ess c hr o nic man iacs melanchol ics w he n the d is

.
 4 38 M E N T AL D i sEA sES

position to suicide no longer exi sts and certain ,

cases o f terminal and senile d ementia w here on l v ,

pat ience tact an d w atch fulness are needed for

,

their care at home The foregoing w e advi se

.

to be given the advantages of Home Treatment .

The follo w ing w e imperatively deman d m ust

have th is form o f t reatment unl ess so poor as t o
,

render it impossible al l cases belonging to the

, ,

I eeti on or In f ection or E xhaust ion P sychoses w hen the ,

x ha a s

sy cho
h igh fever and w eakened bodily condition render
n
p
s removal positively dangerous to the l i fe of the
patient .

A fter an experience o f several vea r s as a phv

si c i an in an insane hospital and a fter man y yea r s

o f experience in the treatment o f every form o f

i n san i t v in private practice w e are convinced
that w here the ci rcumstances and the case w il l
,

permit the Home Treatment o ff ers many ad v an

,

tages over that in an inst itution T o be success .

ful the Home Treatment must be care fully in

augu r ated and st rictly carried out I f these con
.

d i ti on s cannot be ful l l ed all cases are better o ff

i n an institution .

For the inst ruct ion o f those w ho may de sire ,

ti en t

s
or nd it necessar y to treat thei r patient s at
,

me home w e outl ine our ow n method of t reatmen t

,
.

I f the environment is f avorable to recovery the

a ficted one is allo w ed to remain in his family .

In each case the f am i l v is di st inct l y in formed

 G EN ERAL TR E A T M E N T 439

that there is to be n o inter ference on th eir part

w i t h the mode o f t reatment and that the nurses
are to receive n o orders except from the physi
c i an and that nurses and patient are to be ab so
,

l utel y under h is control Treatment in the pa

.

t i en t s home is not ho w ever al w ays practicable

, , ,

as the temperament of other members of the fam

ily may cause an exacerbation of the ailment in
the patient h imsel f or render them l iabl e to a sim
il a r at tack i f con stan tl v subj ected to the patient s

inuence or a change o f scene and associat ion

,

may appear necessary in order to break the pa

t i en t s pain ful train o f though t and give him a

start in the right direct ion Under these cir .

cum stan ce s w e either secure a house and e q uip it

w ith the necessary servant s and nurses and de

vote the establ ishment entirely to the patient or ,

w e obtain suitable accommodations in a private

hotel o r w ith a private family in w hic h are n ot
, ,

w ant ing educat ion ch ristian renement tact

, ,

and plain common sense .

N ext is employed an experienced t rained T r a i n ed

nurse tw o or even th ree i f the case requires it
, n u r se

( n ot members o f the family ) .

The room selected for the su ff erer must be Room

l arge w ell ventilated accessible to the morni n g
, ,

sun and as far removed as possible from the

,

noise of the househol d and the street The w i n .

dow s shoul d be gu arded (i f n ecessar v ) and the

 M EN T AL D I SEA SES

doo rs securely fastened A ll sharp instrument s .

,

such as razors knives sci ssors and small bric a

, , ,
-

brac art icles shoul d o f course be removed C o n

,
.

stant w atch fulness is requi red that the patien t

secures n o cord bandage or article o f cloth in g
,

by w h ich strangu lat ion might be accompl ished ,

and that all dangerous drugs or poisonous sub ,

stances common for househol d p urposes l ike ca r

, ,

b ol i c or oxal ic acid etc be kept under lock an d

, .
,

key .

Kindness faith fulness w atch fulness sympa

, , ,

thy and tact are indispensable in every case B e .

yond these mere general it ies the detail s o f t reat ,

ment must necessarily vary according to the

, ,

nature of the individual case his temperamen t ,

and l iability to inj ure h imsel f or others .

l n A cute C ases in fact in an y case w here the

, ,

physical po w ers are much exhausted the patien t ,

must be kept continually in bed in a recumben t ,

tr ea tm en t position by mechanical means i f n ecessar v

,
.

During thi s t ime a l iberal amount of nourishment

is given in the form of milk eggs raw or cooked , ,

milk w ith egg albumen bee f tea st rong broth s or

, ,

some of the bee f ext racts cereal s vegetabl es an d , ,

frui t In this manner sleep is most easily i n

.

d uced and the w aning strengt h is conserved un t il

the crisis i s passed The high temperature rapid
.
,

pul se restlessness and maniacal fury mav gi ve

,

the pat ient a sembl ance o f st rength The ap .

 G E N E R AL TR E A T M E N T 44 1

pea r an c e ,
ho w ever i s deceptive and unless the
, ,

greatest care is observed this w aste of nervous

force w il l resul t in death by nervous exhaust ion ,

or w hat is far w orse co m plete Dement ia

, , .

During the cont inuance o f the R est Treatment

care must be unceasing that patient and bedding
are kept scrupulousl y clean the pat ient being giv
, C l ea n l i n ess
en a bath of alcohol and w ater night and morning
or at least once a day Frequent vigorous rub
.

bing o f the entire sur face of the body and general

massage w ill al so prove use ful ad j uv an ts in keep
ing up an equable ci rculat ion and exercising the
muscular system Great care must also be taken
.

in the vent ilation and di sinfection o f the room .

During the convalescence o f A cute and in all

ch ronic cases in w h ich the strength w ill permi t
, ,

every suitable outside aid should be adopted to D i ver si on

di rect the su ff erer s mind from it s morbid chan

nel s o f thou ght agreeable companions pleasan t

, ,

surroundings regular exercise in the open air

, ,

carriage drives rides upon horseback and auv

, ,

q uiet amusement o r occupation w h ich w il l divert .

w ithout taxing the mind should be prov ded,

i .

Having thus b r i e v and cursorily described

. .

this form o f t reatment w hich an v ph y sician can

easily car r v out let us consider a f ew o f its ad
,

vantages .

Firs t the t rouble and publ icity of a legal com Leg a l com

m i tm en t o f the patient i s avoided m i tm en t

.
 44 2 M E N T AL D I S E AS ES

R em a i n s a S econd the pat ient remains a citizen No j u r v .

ci ti z en
deprives him of property and accountability
w hen attacked or restores the same to him w hen
,

cured W hen he resumes hi s place in the w orl d

.

he i s simply a man returning to his business a fter

a siege of sickness .

I n di vi dua l U nder Home Treatment furthermore the pa , ,

ca r e
t ient receives individual care and is freed from
any possibility o f abuse \ V ith but one pat ient .

to attend and cont inually exposed to the ove r

,

sight o f the famil y the friends and the phys i ,

c i an ,
the nurse has no oppor tun i tv to give the
patient other than the kindest care the most de .

voted nursing .

Food The food is prepared in accor d ance w ith the i n

d i v i d ual s taste (a n atur al i m po ssibi l i tv in a la rg e

institution ) and being more daintily served i s

,

more tempt ing to the appetite of the patient and

more in accord w ith the needs of a sick person .

I n the severest form s of insanity l ike the I n ,

f ecti on or E xhaustion P sychoses w here the phv s ,

ical po w ers are t ried to the utmost and the feve r

runs at times to al most incredible height s th e
. , ,

chance o f recovery is greatly enhanced by avoi d

ing the necessity of remo v al from home and th e ,

E x ha us exh aust ion o f a rail w ay j ourney No physici an .

ti on of a
w ould advi se a long journey f or a severe case o f
j ou r ney

typhoid in the w orst stage o f the disease yet the

, ,

temperature and p ul se of a patient w ith C ol lap se

 G E N E R AL TR E A T M E N T 44 3

Del irium or S tuporo u s M elanchol ia is o ften

much h igher than that of a Typhoid case I t is .

no w onder that the records o f our I nsane H os

p i ta l s S ho w such enormous death rates in these
cases hen the cases a rrive at the institut ion
.
7

their vital po w ers are completely exhausted and

the y are be y ond the skil l o f an y physician L et .

these cases be properly t reated at home and much

of this danger i s avoided and thei r prospect s of
r eco v e r v are great l y enhanced These are the
.

cases w h ich usual ly die or are en ti rel v restored

to reason hence their proper t reatment is o f the
,

h ighest importance .

A nother advantage i s the lessening o f anxiet y A x ie iy f o

to rel at ives and friends There is n o vantage

. f r i en ds
ground for the imaginat ion The f am i l v kno w s
.

all \ V ith the patient in his ow n home w here

.
,

the friends are cognizant o f ever y mean s em

ployed for h is restoration as w ell as o f al l
,

changes occurring in the course o f the d isease ,

that indescribable burden o f doubt an d suspicion

is l i fted
.

A nother advantage in Home Treatment i s that

the patient is surrounded only by sane com pan S a n e com
a n i on s
ions w hose inuence tends to direct the m ind back p
to its normal channel s .The pain ful scenes un
avoidably connected w ith a disturbed w ard ar e
avoided as w ell as the evil e ff ect s o f association
,

w ith other i n sane pat ients .

 M EN T AL D I SEA SES

A nother advantage i s the lessening o f the

danger o f relapse into M elanchol ia w hen the pa
tient i s i ssuing from a state o f e x citement an d
rst real izes his condition and s u rroundings .

O ften have w e seen maniacal cases w hen su ffi ,

c i en tl y restored to reason to reco nize thei r sur

g
roundings drop into the pro foundest melan
,

chol i a from w hich nothing seemed able to restore

them In a private house restoratio n from i n

.

san ity i s l ike the convalescence from any other

illness In a private family al so e x ists for the
.

patient every form of diversion open to any one .

muse Graduated to h is stage o f co n valescence lectures , ,

n ts
concerts operas theat res can all be ut ilized as
, ,

use ful a ids in the process of cure .

A fter el i m inating all the cases w hich w e have

mentioned a l arge number w ill remain w h ich
should at once be committed to some suitabl e
publ ic or private instit ution f or the insane .

p
osi ta l These include (1 ) all persons o f moderate mean s
es
w here it is impossible to supply the suff erer w it h
the neces sary requi rement s f or thei r proper care
out side the w al l s o f an institution ; (2) S uicidal
C ases W hatever the circumstances o f these
.

patients they are m uch better o ff in an i n sti tu

tion as the facil ities for the accompl i shment o f
,

suicide are too great outside : (3 ) Homicidal

C ases N o physician in our opinion is j ust i e d
. , ,

in imperill i n g the li fe o f friends or nurses b v

 G E N E R AL TR E A T M E N T 44 5

allo w ing such cases to remain out of con nement .

C ommit them at once and take n o chances ; (4 )

P aranoiacs The most dangerous insane are
.

P aranoiacs and n o family or community is sa fe

w h ile on e o f them is at large ; (5 ) Insane Epi l ep
tics . M any o f these patients are exceedingly
dangerous and w hen th is i s the case they sho uld
be immediately placed w here they can d o no
harm ; (6 ) P aretics I n the prodromal stage it .

is often impossible to persuade the relat ives to

send a paretic a w a y A ll cases should give up .

business and be kept as quiet as possible The .

rest treat ment is exceedingly bene cial but it i s ,

al w ays di ffi cul t to carry out A l l o f these cases .

in any stage are much be tter o ff in an inst itution ,

and w hen the disease is fully establ i shed they

should be committed .

In selecting an institut ion it i s al w ays better

to choose on e devoted especially to the treatment
f or the
of the insane Friends frequently desi re to send
.
I n sa n e

the inval id to a general S anitarium but it usually ,

is found to be a mistake i f one compl ies w ith their

w i shes as in the end the patient has to be sent to
,

an insane hospital and much valuable time i s lost

by the experi m ent Friends al so o ften desire to
.

try at rst the e ff ect o f ch ange o f scene and

, ,

t ravel but in the early stages o f any mental dis

, ,

ease th is i s more l iable to aggravate than amel i

,

orate the condition W hen the viol ence o f the .

 446 M E N T AL DI S E AS E S

mental storm has passed and the patient is con

v al e sce n t benet may in some cases be derived
. ,

S ea vo a
y g e f rom t ravel especiall y a sea voyage
, The pa .

t ient shoul d ho w ever be accompanied b v a

, .

ph y sician conversant w it h mental di sease and

ver y l ittle sight seeing be allo w ed Long j our .

neys shoul d be avoide d and these regul ated to the

patient s physical condit ion It is usual l v best to
'

select some quiet spot and t rust to the change o f

scene for the desi red am el ioration and stren gth
en i n g o f the convalescing mind O ur ex per i .

ence has demonstrated that high altitudes a re

best suited to M elanchol ics w hile sea air w ill .

most bene t cases recovering from maniacal

condit ions .

\V he the r t reated at home or in an institut i o n

modern experience has proven that al l form s o f
insanity recover much more rapidly and com
B ed p l e t e l y w hen con ned in bed and t reated as veri
table inval ids Not onl y are the nervous po w e rs
.

conserved but there is l ess daily w aste w hen the

,

pat ients are kept quiet in bed M uch more sleep.

is obtained and the physical forces are much

m ore speed i l v recuperated than w hen the patient s
are allo w ed to exhaust themsel ves by constant
exercise impelled b y thei r mental restlessnes s and
the delusions by w hich thev are governed .

I I I excited and sleepless cases much bene t i s

H ot tu b
ha th often d erived from the prolonged hot tub bath .
 G E N ER AL TR E A T M E N T 44 /

The w ater should be about 9 8 degrees F and the .

pat ient can be kept in it from fteen minutes to

hours i f n ecessar v B y th i s mean s extreme ex
.

c i tem en t i s o ften q uelled and good Sl eep obtaine d

independent o f all drugs .

M any patients are so w eak and exhausted that

thev w illingl y remain in bed others yield to the
,

persuasions o f a t act ful nurse When mechan .

ical rest raint i s required the body bandage or

protection sheet w ill be found the most sati sf ac P rotecti on
sheet
tory and the least i rritating and w hen thus r e
,

st rained the pat ient s soon become resi gned and

q uiet obtain more rest and are less excited than
,

w hen rest raine d by the physical e ff ort s of a

nurse .

\ V hen the physical po w ers are suf ci en tl v re

suscitated b v this en forced rest the complete
restoration w il l be facil itated by the j udicious
employment o f exercise amusement and occupa
,
E xerci se

tion w hich should be care fully init iate d and

,

ad u a l l v inc reased until the n ormal ph y sical and

g r

mental strength is restored .

A l l forms o f insanity require a l iberal amount

o f nourish ing easi l v digested food not only f or
, ,

meeting the d ai l v needs o f the system but f o r the .

repairing o f previous w astes For this purpose

.

the food selected should be that w hich is most D i et

easily assimilated and w hich w ill mo st rapidly
rebuild the depleted an d exhausted phv si cal
448 M E N T AL D I S EA SE S

forces M an v cases either as a re sul t of anor

.
,

ex i a and a general distaste f or all food or on ,

account of their mental excitement w hich cause s ,

them to utterly neglect the demands o f the stom

ach or b v reason o f the delusions by w hich they
,

are governed may either take food in insuffi cient

,

quantit ies or refuse it altogether In an v case .

,

w henever the patient persi stentl y re fuses to tak e

sui c i en t nourishment w hatever the motive it
, ,

should at once be admini stered b v force In .

some cases it may only be necessar y to put the

food in the mouth o f the patient others w ill eat ,

i f thev can obtain the food b v stealth but w ith ,

many the intense excitement or the presence o f

delusion s o f poison mav render feeding by forc e
a necessity In such case s the nasal tube should
.

be resorted to immediately For th is vou can .

use the soft rubber catheter kno w n as P aine s .

feeding tube or any o f the other t ubes o f the

,

same character w h ich are kept by al l dealers in

,

s u rgical instruments The tube a fter being oiled

.

is care fully passed th rough the nose and into the

stomach and to th is is then attached a David
son s sv r i n ge B y th is means any form of l iquid

.

food can be quickly and painlessly inj ected int o

the stomach O rdinarily there is l ittle t rouble in
.

the introduction o f th i s tube The patien t .

should be l aid upon the back and rmly held by

assi stant s to prevent the movement of the head
 G E N ER AL TR E A T M E N T 44 9

and bo d y The onl y danger i s that of passi n g

.

the tube into the lungs To obviate thi s a f ter

.
,

the tube is introduced be fore attaching the ,

syringe put the nger over the end of the tube

, ,

and i f n o ai r comes out w ith the patient s res

p i r a to r v e ff ort s it i s certain that it has entered

the stomach S ome pat ient s may give trouble b y
.

dra w ing the tube out th rough the teeth but i f ,

after the tube has passed the nose it is pushed

rapidly do w n the th roat th is w il l be prevented .

A fter the f ood is inj ected have the nurse hol d

the patient s head do w n upon the pillo w for a f ew
'

moments to prevent vol unta ry ej ect ion o f the

food S ome pat ient s espec i al l v i f laboring un
.
,

der the delusion that thev are being poisoned ,

make st renuous e ff orts to expel the food a fter it

has been inj ected but i f thev are prevented fro m
,

raising the head they cannot succeed Be care .

ful to see that the food to be given is not too

thick other w ise the tube w ill become clogged and
,

it w il l be necessary to remove and clean se i t and

repeat the w hole p rocess I f the tube i s very .

long d o n ot introduce too much of it or it may

become t w i sted on it sel f preventing the inj ection
,

of the foo d and requiring its removal and rein

t rod uct i on .Into the food can be poured the
medicine w hen desi red The amount o f food .

given shoul d be from a pint to a pint and a ha l f

t w ice daily .

30
 4 50 M E N T AL D I S E AS E S

The nasal tube is much better than the stomac h

S tom a eh
pump as w ith the latter the teeth must be prie d
,

open w ith a w edge and are o ften damaged in th e

operation Death s even ha v e been recorded a s
.

occurring d uring the feeding w ith the stomac h

pump w hich i s su ffi cien t ground for its abro ga
,

tion in favor o f the harmless nasal tube .

M uch care shoul d be exercised in the choice o f

foo ds .

The f ood most universally use ful especi al l v ,

during the soj ourn in be d is m il k \V e use i t

,
.

hot or cool n ot cold out o f an ice chest as th i s

, , ,

i s certain to ch il l the stomach and c u rdle int o

indigest ible lumps and ferment an d prod u ce
gases in the stomach and intestines \ V hen tak .

en cool the intro d uction of a l ittle salt or lim e

w ater w ill usually prevent indigest ion \ V he n .

P epton i z ed these metho d s fail it shoul d be peptonized w ith

Fai rch il d s and Foster s peptoniz ing tubes and in
'

,

thi s f o rm can be ad v an tageousl v taken b y th e

most del icate sto m ach s S ome cases do bette r
.

on milk heate d to about blood heat o r a tempera ,

ture higher than the blood and w hen there i s

.

great debil ity and exhaustion this f orm shoul d b e

adopted I f in d oubt as to the purit y o f the m il k
.

supply give onl y steril ize d milk I f it is i m po s

.

sible to purchase steril ized mi l k it i s easi l v pre

,

p a red b v simply raising ordinary milk to a tem

r a tu r e of 1 6 0 degrees F and keeping it the re
p e .
 G E N E R AL TR E A T M E N T 45 1

t w enty o r thi r t v m inutes The amount of milk .

given in t w e nty four hours should range fro m -

th ree pints to th ree q uart s according to the pa ,

t i en t s capacity and po w er o f assimilat ion

H ot .

milk al so serves as a valu able h y pnotic in m an v

cases w hen given at night .

I have had m arked success especia l ly in A lco M i l k n d

'

.
a

hol ic cases w ith milk an d vichy given in e q ual

,

parts For m an v y ears in a large experience on

.
,

an A lcohol ic w ar d of a publ ic hospital w hen

cases have come in a fter a prolonge d debauch ,

w hen the stomach is i rritable I have been in the

habit o f putt in g"them at once upon the vichy and
milk B y using this I have been ab l e to stop all
.

alcohol at once and w ith n o evil result s .

In addit ion to milk strong nourishing soups ,

ch icken la m b clam or oyster broth can be given

, . .

C ream soups av o red w ith cel er v or lettuce o r

.

tomato bean or pea soups m av be added to the

,

dietary A valuable adj uvant is al so found in

.

bo v i n i n e w h ich mav be given t w o o r three times Bovi n i n e

.

d ai l v either alone in w ater or a dessert spoon ful

.

may be put in the milk \V hen the milk is to o .

rich it mav be dilute d b u t i n the ci ty it m o re ,

often req u I res to be enriched by the additio n of

a l ittle cream I I I some cases the milk i s m ore
.

ea s i l v d i e ste d w hen the p arti c le s a r e broken u p

g

b v a thorough shaki n g I I I aged patient s butte r

B u tte m i l k
.

r
'

m ilk i s o f ten b en e cial an d in o ther cases w here

 452 M EN T AL D I S E AS E S

there is an v disturbance o f the kidne y s Kou .

m v ss mav al so help w ith some especi al l v del icat e

st o machs .

g s N ext to milk w e rank e ggs r aw or sl ightl y.

c ooked \ V hen they can be taken r aw the y are

.

e spec i al l v stre n gthening and many ph y sician s

report gI v I ng from th ree to a dozen d ai l v w it h
mar ked benet to their patients P ersonally I .

have not met w ith such marked benecial resul t s

from the excessive engorgement of r aw e ggs I .

have seldom found a patient w ho could long take

more than th ree a dav w ithout some digestive
d i sturbance \ V hen the pat ient obj ect s to taking
.

them alone they can be thoroughl y beaten up

.

w ith milk and i f desired a teaspoon ful or tw o o f

w ine or w hisky or brand y can be added As a .

r ul e I place l ittle rel iance upon st imulants in i n

.

sa n i tv and bel ieve that most pat ient s are bette r

ouston w ithout them C louston ho w ever lavs great

.
, ,

st ress upon the administ rat ion of beer w ines an d ,

spi rit s in certain cases an d reports most gr ati f v

i n g results .

\V hi l e the li q uid diet is being adm ini stered a

sl ice o f t o as ted stal e bre a d o r c ra cker s or z w ie

back mav be al l o w e d tw o or th ree times d ai l v i f

there is a great craving for sol ids .

\V hi l e the patient i s w eak and exhau sted h e

shoul d be fe d once e v er y tw o and a hal f or th re e
hour s from six A M to nine P M. . I f restles s
. .
 G E N E R AL TR E A T M E N T 453

and sleepless at night the f ood shoul d be con

ti n ued nig ht as w ell as day .

the physical po w ers have become n ear l v

restored by the l iquid diet and the w eight has i n

c reased to the normal and convalescence is w el l
begun sol id food may be allo w ed .

T hI s shoul d con sI st at rst ch i e v of ce real s

, , ,

fruits vegetables and fat prod uc m g foods

,
-
.

M eat should be given sparingl y for w h ile it m av ,

benet some cases o f M elanchol ia it is too sti m u ,

~

lating f or M a n iacs P aret ics and E pileptics

,
.

Butter in l iberal quantities ol ive oil cod l iver oil

. ,

and some of the f attv emul sions w ill prove o f

bene t .

During convalescence milk eggs grain foods , , ,

lamb bacon ch icken baked potatoes fres h veg

, , , ,

etables and pl en tv o f fresh fruit w ill hasten re

cov e r y .

A ll food should be o f the best q ual i tv and

cooked and served in the mos t del icate and appe
ti z i n g form Fresh w ater given in l iberal quan
.
,

tities al so exert s a benecial eff ect

,
.

M uch o f the success or failure in the t reatment

o f the insane depends upon the manner and bear

ing o f ph y sicians and nurses w hen in thei r pres

ence A l w ays sho w to an insane person the
.

same courtesv and pol iteness that he w oul d ex P ol i ten ess

pe c t i f he w ere w el l N ever do
. anyth ing in the
presence o f the insane o f w hich v ou w ould n ot
454 M E N T AL D I SEA sES

l ike to be remin d ed a fter t hei r recover y M an v.

o f the insane in thei r w ildest moment s are en

t i r e l y cognizant o f all that occurs about them and

understand all that is said retaining a fter thei r

,

restorat ion a vivid remembrance of all that has

t ranspire d d uring their illness A sunny cheer .

f ul manner ,
kindly sympathy and persistent
hopeful optimist ic assurances o f recov e r v often
d o more than d rugs for the restoration o f the
in sane.

O ccasionally surgical Operations are required

in the t reatment o f the insane .

I I I some cases o f masturbatic i n san i tv in men

circu mcision has been f ollo w ed by cure In .

w omen loosening or exci sion o f the hood of cl i

toris has o ften proved help f ul O r i ci al su rger v
.

claims many victories in the real m o f mental dis

ease and ev er v c ase at the beginning of t reatment
shoul d be care fully examined and i f an y of the se
,

operat ions are re q uired the y should be i m m ed i

,

ately per forme d .

lI YD RO T I I ERA P Y

The extensive use of H vd rotherapy in M e n ta l

Disease is o f com par atI v el y recent date Fi f .

teen years ago a compl ete Hydrotherapeut ic i n

st i tut i on for the care of the Insane w as pr act i

cally unkno w n Toda y in every private an d

.

publ ic H ospital f or the Insane H y drotherapy i s

 G EN E RAL T R EA T M EN T

recogn ized as on e of the most important metho d s

of t reatment \ V ith the recogn ition o f the v a
.

ried uses of w ater an almost complete revolution

,

has been made in the general management o f the

insane .

I n a lar ge measure to H v d rotherapy can be

cre d ited the establ i shment of the n on rest raint -
P estr a i n t

sv stem n o w in vogue in all Hospital s f o r the I I I

sane A kno w l edge o f the varied uses of w ater

.

has relegated to the j unk heap cribs cham i sol e s , ,

mu ff s and lock st raps The demonstration o f

,
.

the soothing and quieting inuence of bath s upon

the brain and general nervous syste m has al so in , ,

all these institutions greatl y diminished the use

of po w erful drugs w ith thei r bane ful t rail o f D r ug s

after e ff ects .

The baths m ost e f cacious in the t reatment o f

M ental Di sease are :
l st . The prolonged hot tub bath .

2d. The hot pack .

3d. The col d pack .

4 th The douche sprav needle bath s

. .

The bath most f req uen tl v use ful especially in ,

P rol ong ed
excite d cases is the p r ol onged hot tub bath The
,
.
hot tub
water should be at a temperature o f 96 degrees
I Va ter 9 6
to 98 degrees F The quant ity of w ater employ
.

to 9 8 I " .

ed shoul d be sui ci en t to a ff ord a considerabl e

degree of b uov an cy so that there mav be as l itt l e
,

pressure as possibl e upon the l imbs and di ff erent

 4 56 M E N T AL D I S E A SES

parts of the bod v The tub i f desi red can be

.
, ,

suppl ied w ith a w ooden cover or a canvas sheet ,

mav be stretched over it great care being oh

,

served that excited or dep ressed cases are allo w

ed n o opportunity o f strangl ing themselves b y
means of the edge o f the sheet I f a portable tub .

is used a long hose carried to the nearest bath

,

room can be util ized for the ingress and egress o f

a r ati on
the w ater supply A s a rule the rst bath
.
,

hath should last from fteen m inutes to an hou r In .

cases of marked excitement the baths may be ,

continued for several hours C ertain ph y sicians

.

gradually increase the len gth of the bath leavin g ,

the pat ient in the bath the rst day f or hal f an

hour the second day one hour ; thi rd day two
,

hours ; fourth day th ree hours and so on up to ,

six or seven hours a day A S a rule excited

.
,

patients become quickly accustomed to the w ate r

and a fter a f ew minutes make no obj ection to the
cont inuance o f the bath W arm baths b y less
.
,

en i n g the arterial tensio n an d the general ner

vous i rritabil ity and relaxing the muscular sys

tem produce sleep and reduce the mental excite
,

me n t For the production of sleep the best time

.
,

f o r its administ ration is j ust be fore ret iring .

The forms o f di sease to w h ich this bath is par

t i cul arl y adapted are the maniaca l types o f
M anic Depressive Insanity the ex ci ted f orm s o f
-
,

P aresis A mentia Febrile Del irium C oll apse D e

, , ,
 G E N E R AL TR E A T M E N T 457

l i r i umKorsako ff s Disease A l coho l ic Hysteric

'

, , ,

al , and E pilept ic Insanity and N eurasthenia , ,

w hen attended by persistent sleeplessness .

The H ot P ack is serviceable w hen on account , H ot Pack

o f a w eak heart cerebral hemorrhage or other
, ,
Wea k
hea r t
reasons the tub bath is cont raindicated The
, .
C ereb r a l
H ot P ack is appl ied in this w ay : A rubber blank hem or

e t is spread upon the patient s bed and upon th i s

a sheet w h ich has been soaked in hot w ater and

,

then w rung out d ry is laid The patient then ,

.

l ies do w n upon this and the enti re body w ith the ,

exception of the head is evenly and closely envel , A / ethod of

oped i n the w et sheet O ne or more w ool l en .
a d m i n i ster

i ng
blankets are then spread over the sheet Thus .

enveloped the patient is allo w ed to remain f or

,

an hour o r longer or i f he fall s asleep u n t il he

,

a w akens Th is bath i s especially advised f or

.

cases o f obstinate sl eeplessness w hether the ,

pat ient is sane or insane and in cases o f insanity , ,

w here the prolonged w arm tub bath does not pro

duce the desired resul ts .

C old bath s on account o f their stimulation o f

, C ol d ba ths
the brain and spinal cord th rough their action ,

upon the sensor y and motor nerves and the

cerebrospinal circulation are coun ter i n d i cated in ,

maniacal cases but often prove use ful i n depress

,

ive an d stuporous states .

The S pinal Douche is administered b v me ans Spi n a l

D ouche
o f variou s nozzles th rou h w hich for a f ew sec
.
g
.
 4 58 M E N T AL D I S E AS E S

on d s onl y f rom a distance of about ten fee t a

, .

strong stream is ej ected up and do w n the pa

ti en t s back For the rst appl icat ion the w ate r
.

should only be moderatel y cold but l ater m ay be ,

re reduced b y degrees to 5 0 d egrees F I f the .

patient s reaction is not good it is w ell for h im

at the beginning to rst take a w a rm bath or

stay for a f ew moment s I n a hot air b ox be fo r e -

it is appl ied The S pinal Douche is ofte n use ful

.

i n N eu rasthenia H vste r i a ap athetic stuporou s

, , . ,

depressed and catalept ic states w here stim ul a

, ,

t ion o f brain spinal cord and general co n d ition

,

i s needed .

A nother method of applying cold w a ter i s the

" "
Dripping S heet B y this method the pat ient
. .

zeet
a fter a cold bath o f 8 5 degrees to 7 5 degrees F . .

stan d ing in w arm w ater or on a dry sur face w it h ,

a cold to w el about the head is w rapped aroun d ,

w ith a l inen sheet w hich has been dipped in w ate r

o f 7 5 degrees to 5 5 degrees F the nurse at the .
. ,

same time applying friction unt il a thorough

,

reaction is apparent Th is bath i s espec i al l v

.

val uable in N euras thenia an d in mental d i sor d er s

w here marked sur face stimulation is d esi red .

A summary o f its varied ben ecial e ff ect s es

tab l i she s H vd r other apy as one of the mo st i m

portant adj unct s in the t re atment o f M enta l

Di sease .
 C H A P T ER X V I I I

M E D I C A L T REA T M E N T

T hi r ty v e vear s ago the application o f drugs

-

to M ental d i sease acc ording to the l aw of sim

.
i

i l a rs w as a n ew and un trodden eld

, S ince that
.

t ime numerous institutions have bee n establ ished

in various S tates o f our U nion and the brilliant
,

result s achieved w ithin and w ithout these i n sti tu

t ions have demonst rated that H om mopathy is as
a thi c
potent in overcoming menta l di sease as an v of p
trea tm en t
the other ills o f h umanity N umerous mental
.

symptoms recorded in our provings have been

. ,

veri ed and numberless bed side experiences have

c l ea r l v sho w n that the Hom oeopath ist needs n o

assistance f rom an y other school of medicine to

success fully combat this most dreaded foe o f
humanity A ny ph y sician w ho care f ul l y studies
.

h is cases and appl ies his m af er i a me d ica accord

ing to the la w s laid do w n b v Hahnemann need
seek n o assistance from opiates hypnotics and
,

anodyne s
I n prescribing a r em ed v for the cure or rel ie f
o f an v form of i n sam tv I t I s n ecessa r v to con

si d er :
l
( ) The patholo gy w h ich f or m s the basis o f P a thol ogy

the disease .
 46 0 M E N T A L D I S E A SE S

zl / en ta l
(2 The mental aberrat ions produced by this
b
a er ra ti on s
physical change .

T ota l i t} ofI
3
( ) The t o t al i t v o f symptoms o f each individ
s m tom s
y p ual case .

E xa m i n a \ V hen ca l led to t reat an y case o f m e n tal di s

ti on
ease a care ful exam ination should be made .

1 A s the patien s ge eral physica l c ndi

'

( ) to t n o

M on .

2
( ) E very physica l disturbance shou l d be con
si d e red and its relat ion to the me n tal disease

accurately determined .

3
( ) E very variation from the patient s nor al
m
mental state shou l d be ascertained .

( )
4 H aving noted al l the subj ective and oh

j ec t i v e symptoms presented by the

, patient to ,

gether w ith those el icited from the ge n eral hi s

tory o f the case these should be made t he basis
,

o f a prescription and the remedy most closely i n

d i cated shoul d be appl ied according to the Law
of Si m i l ar s .

For conve n ience of re ference w e shal l her e

group together the remedies most frequently
curat ive in the di ff erent forms o f insanity and
their characteristic indications .

DE PR ESSED ST A T ES
here group A con A c tzea rac A n timon i
\V e .
,
.
,

um c rude A lumina A rs Bap Bell C alc

, ,
.
,
.
,
.
, .

carb C hina C actus D i g Gel s Ign Li l tig

.
, , . ,
.
,
.
,
. .
,
 M E D I C AL TR E A T M E N T 46 1

N at mur N ux moschata P ul s
. .
, ,
.
, P hos aci d
.
,

S epia S ulphur V erat album

. ,
. .

AC O N I T E
This r em ed v is n ot as f req uen tl v indicated in
Depressed S tates as in some other of the M ental
d isorders In M elanchol ia o f pregnancy it mav
. I hhda n who
l i a o/
r
prove e f cacious w hen there is vertigo w ith nau
sea and great depression on account of fear o f
death w hich the patient con ti n ual l v an nounces
,

imminent in her approaching parturition and ,

dist resses all about her by ceaseless w eeping and

lamentations There is al so great restlessness
.

and sleeplessness or sleep d isturbed b v disagree

able dreams .

AC T 3 !A RAC E M O S A
Thinks she is becoming cr az v G reatl v de .

presse d b v fear of death and a sensat ion as i f

something had settled do w n upon the brain ,

rendering everyth ing dark and obscure S evere .

pains th rough the eyes and w hole occipital region

as i f they w ere penet rated by sharp inst ruments .

N ausea fal se labor pains sleeplessness

, , .

E speciall y suited to rheumat ic and neuralgic

hv ster i cal subj ect s w ho have su ff ered much from
uterine disorders and often indicated i n the M el
u hmnhu a HS
'

a n cho l i a of P regnancy .

ea se
 46 2 M E N T AL D I SE A SE S

A LU M I N A
S ad depressed dull stupid lled w ith an i n
, , , ,

describable fear fulness P eevi sh obstinate no r .

, ,

incl ined to d o anything Loss of appet ite w ith .

,

C ra vi n
g s a longing f or indigest i bl e s ubs tances and ob sti
ti b/
nate const ipation R estless unre fresh ing sleep
. .

g es e

su bsta n ces This remedy is not very fre q uently demande d ,

but w hen indicated speedy and e ff ectual in it s

action .

ANTI MON I U M C RU D U M

U ndue an x i etv about the present and future .

O bstinate and tac1 tur n Incl ined to suicide b v .

shooting especially at night Dul l apat het ic

, .
, ,

regardless o f the cal l s of nature Ton gue coated .

w h ite . A lternate diarrh oea and constipation .

Wake f ul at night sleepy in the d avti m e

,
.

to
A dapted to the most serious forms o f the di s
m en ti a ease W hen dementia seems imminent i t sho ul d
.

n o t be forgotten .

AR S E N I C U M AL B U M
O ne of the most fre q uently indicate d remed ies
in severe acute Depressive S tates .

A tv pical ar sen i cum case i s on e o f the most

serious of mental di seases A glance w ill cl ear l v .

reveal the desperate character of the m al ad v .

The pale face pi n ched features sh riveled ski n

, , ,
 M ED I CAL T R E A T M E N T 46 3

haggard and anxious countenance w eak w i rv ,

pul se and rapidly increasing emaciation port ray

the intense virulence o f the attacking foe The .

tongue is red d ry t remulous an d parched and the depressi on

, .

patient is continually tortured by the char ac ter i s

tic ar en ic um th irst C on stantl y impelled b v an
s .

overpo w ering restlessness i f allo w ed to remain

,

upon their feet the vict ims unceasin gly pace up

,

and do w n thei r apa rtments night and d ay w ring ,

ing the i r hands and be w ail ing thei r fate I n .

thei r agony the y may pull out thei r hair and bite
thei r nai l s to the q uick o ften causing deep ulcers
,
.

A t last overcome by their mental anguish and

.

d riven to frenzy i f not prevented they seek an

, ,

escape from the horrors o f t heir present m i se r v

through suicide N ot on l v are thev suicidal but S u i ci d
.
,
e

the y m av in their desperation mut ilate them

selves pull out the evel ashes or tear o ff thei r eye
,

l ids and in ict serious physical inj urie s In bed .

,

in their restlessness thev con stan tl v rol l from

side to side night and day and moan g roan and ,

bitterl y lament thei r di re ful fate .

Y et these d esperate and apparently hopeless Freq uen i ly

cu ra ti v
cases i f prevented from inj uring or kill ing them
,
e

se l ves an d properl y nursed and sustained b v a

su fcient q uan t i tv o f nourish ing f ood bv the m a r .

velo n s inuence o f A rsenic a re o f ten restored to

,

per f ect he al th o f b od v an d mind .

 4 64 M E N T AL D I S EAS E S

B AP T I S I A .

The e ff ects o f Bapti sia upon the w orst form s

o f S tuporous depression are no less marvelous

than those produced bv A rsenic in desperate

Depressive S tates .

\ V hen v ou encounter a case of S tuporous De

pression w ith an extremely h igh temperature an ,

excessively rapi d pul se an d respi ration w hen the ,

d ark sodden countenance and expressionless eye

clearly indicates the pat ient s utter obl iviousness
'

o f h is surroun d ings and w hen the fetid breath ,

d r y bro w n ton gue sordes covered teeth and

,

Ty phoi d
st ron gly o ff ensive invol untar y stool s reveal the
sta te most d angerous typhoid state look w ith hope to
,

Bapt isia B apt isia w ill check the rapidly ad

.

v an c i n g degeneration Bapt isia w il l antidote the

. .

toxic e ff ect s of the virulent poison circulat ing in

the blood Bapt isia w ill restore the bloated
.

abdomen to it s normal state Bapti sia w ill .

arouse the stupe ed brain from i ts torpidity an d

restore the pat ient to h is normal mental acti v i tv .

I n those c ases w here the symptoms indicate p ro

S epti cee m i a found septic aemia the e ff ect s of B aptisia are
marvelous .

B ELLA D O N NA
The Belladonna case of M elancholia i s gr eatl v
d epre ssed and subj ect to violent attacks o f w eep
 M ED I CAL T R EA T M EN T

ing attended by intense fear ful ness The head .

i s hot the face ushed the pupil s d ilated sleep

, , ,

lessness prevails or there is great sleepiness the ,

pat ient a w aking w ith a s t art the moment she fall s

asleep .

\ V hen depression occurs in connect ion w ith

m a rked passive cerebral congest ion n o other P a ssi t e '

( e r ebra l
remedy is as satis fy ing especiall y w hen given in
,

cong esti on
the lo w er potencies .

CALCAR EA CA R B ON I C A
A pp rehen sive o f mis fortune thinks she w il l .

d ie or become cr az v P eevi sh obstinate the

.
, ,

face is pale pyrosis constipati on an d atul en cv

. .

reveal the d isordered condit ion of the digest ion .

The ci rculation is poor and the sl eep unre fresh

ing .

I d apted to poo rl v nourishe d scrofulous

phthi sical w omen it O lI l l Il

'

CAC T U S
The C actus pa t ient i s sad from her unalterable
convict ion that she is about to die from the i n
curable d i sease w ith w hich she i s a ffl icted or that ,

some terrible di saster overhangs her S he i s .

taciturn and incl ine d to remain b v hersel f and

Depressi on
w eep con stantly A tten d ing the mental sv m p
u i th hea r t
.

'

toms w e n d the characteri st ic heart s y mptoms s m tom s

y p
a n d a sen sat i o n as i f some heav y w eigh t w ere

31
 46 6 M E N T AL D I S E AS E S

pre ssin g d o w n upon the brain accompanied b v ,

pul sat ions in the top o f the head The patien t .

is al so easil y fri gh tene d and o ften a w aken s at

n ight in a panic .

D I G I T AL I S .

Great anxiet y d epression and d read of the

LVor se si x
future w ith sadness and w eeping w orse about
,

P M
. . six P M and aggrava ted b v music
. . M orose . .

i rritable and gloomy w eak n ess o f m em o r v dul l

, , ,

stupid and con fused .

Th robbing hea d ache in forehead or at the bo t .

tom o f the orbits pupil s dilated Red yello w

,
.
, ,

green black and w h ite colors be f ore the eyes

, .

H issing and roaring in the ears face pale S lee p , .

un ea sv and unre fre shing troubl ed b v fre q uent ,

w aking General appeara n ce of w eakness an d

.
,

exhaustion appet ite poor respi ration i rre gu la r

, .

S tol e and di fcult p ul s e sl ow and w eak or sl ow and

, ,

f ul l o f ten intermitt ing w ith sensation at t ime s

, , ,

as i f the heart stopped beat ing accompanied by .

great anxiety faintness sinking at the stomach

, .

and general coldness o f skin and ext remities .

The ch ie f indication of Digital i s i s a slo w

pul se and w henever th is s y mptom appears at .

tended l) y a ge n eral appearance o f exhaust io n

and d eb i l i tv a prompt and sat is factory improv e
,

ment i s sure to follo w i ts exh ibitio n .

 DI E D I C A L T R EA T \ I I N T
I

.

C H I NA
C hina m a v be called f o r w hen the M elanchol ia
has been pr o d uced bv some excessive physical P h i s ca l
y
drai n such as oo d ing p ro fuse leucorrhea o r d a i n
. , r s

masturba t ion To get sat i s f acto r v results from

.

this drug it must be given in the tI n cture in ap

pr ec i ab l e dose s .

G ELS EM I UM
Ge l semium i s indicated in dep re ssion w here
there i s fever attended b y marke d mental dul nes s
and a desire to rema i n q uI et and undisturbed in

bed L ack o f sel f con d en ce and i n ab i l i tv to
.

make an v decision is al so a marked character i s D eci si on

tic There al so exists a d esire to th ro w one s
'

sel f do w n w hen looking over a height A d ul l Ba s o the

f
.

t ired ach ing at the base o f the brain i s al so f r e

q u en tl v present .

I G NA T I A
h the depression has been p roduced by
en

shock or long brooding over real or imaginar y B roodi ng

t rouble s and w hen the rel ie f o f tears i s denied w e
n d the rel ieving remedy in Ignatia These pa .

ti en t s are silent an d pre fer to remain b v them

selves and brood P ro ff ered sy m pathv I s rej ect

.

ed an d vet i f it is not o ff ered thev I m agm e

 468 M E N T A L DI SEA SE S

them selves neglected by thei r friends T hev .

are obstinate and taciturn o fte n re fusing to ,

speak w hen addressed A ltho ugh give n to .

broo d ing thev mav become hysterical and indulge

in senseless laughter The sleep is restl ess and
.

N eg a ti ve often accompanied by nightmare I t i s al so use .

n ess ful in cases in w h ich negat ivism i s a prominent

sv m ptom .

La sci vi ous
n ess w i th
O ne symptom recorded in the provings o f I g

ou t er ecti on s natia as lasciviousness w ithout erections sex
, ,

ual desi re w ith impotence itching around geni ,

"
tal s and on penis w as veri ed b y us in a case o f
,

depression produced by business t roubles Thi s .

m an made constant attempt s to mastur b ate al ,

though seldom able to get an erection The re .

l ie f given b v a high potency o f Ignat ia presc r i b ,

e d en ti rel v upon this s y mptom w as si m pl v ,

magical .

A s some causes o f sexual irritatio n are e x

c eed i n gl v obstinate it w ould be w ell n ot to forge t
,

thi s symptom o f Ignat ia .

LI L I U M TI GR I N U M
D epression of spirits incl ining the patient to
,

w eep . T i m i d i t v apprehen siveness o f some fat a l

,

d ise ase or o f becoming insane Loss o f memo ry .

and d i f cul tv in the select ion o f proper w or d s

w hen conversing . P ressure upon the rec tu m
and i r r i tab i l i tv o f the bladder .
 M E D I C AL TR E A T M E N T 46 9

A ppl icable to neuralgic hysterical w omen w ho H y ster i ca l

,
wom en wi th
have su ff ered from functional o r sl ight organic u ter i n e a n d

d isorders of the uterus and ovaries . ova : i a n d i s

d
or ers

N ATRU M M U RI A T I C U M

The N atrum M ur i ati cum patient is e m acia te d

and the face has a prematurely ol d l ook There .

is loss of memory and disincl ina tion f or al l men

tal and physical w ork S he i s easily fat igu ed
.

and greatl y prost rated mentally and phy si cal l v .

These patients shed ood s of tears and the m ore

they a re com forted the more violently they w eep .

They are ill humored and easily provoked by an y

-

contradiction .

These cases seem to revel in thei r grie f and

d erive satis faction from recall ing all the dis
agreeable occurrences o f the past f or the purpose
of indulging in melancholy meditat io n T hev .

are taciturn avoid companionsh ip and th ink that

,

they are pitied bv ev er von e because o f their mis

fortunes .

Espec i al l v indicated w hen the depression has

follo w ed intermittent fever and w hen the attacks
o f w eeping are periodic in their occurrence .

NUX M O SC I I A T A

N ux M o schata is espec i al l v adapted to hv s ter

ical melanchol ics The mood is changeable one
.
.

moment the patient laugh s the next she crie s

. .
 470 M E N T AL D I S E AS E S

The m em o r v i s poor an d there i s m arked con f u

si o n o f idea s an d an inabil it to continue a t rain
y
o f thought for an v len th of time A attemp t
g n y .

at w riting reveal s an i n cohe ren cv in the i d eas .

There is absence o f mind slo w ness o f i d eas an d

,

d i f fi culty in ans w ering questions There is a .

yster i eul ,
i n t, great incl inat ion to faint and a ten d en c v to sl eepi
n es s .

PU LSA T I LLA
Depression mani fested by fre q uent w eeping ,

sol icitu d e concerning health despair o f salvat io n

,

w ith constant praying and great an g uish cau s ,

i n g her to desire to commit suicide The grie f .

o f the P ulsatilla patient i s c hangeable and she i s

subj ect to alternate moods o f c rying an d la ugh

ing The P ul satilla patient is at t imes d epresse d
.

and tearful at o thers cheer ful an d happy

,
M il d .
,

gentle and a ff ect ionate in di sposition she is ea s ,

i l y persua d ed consolat ion is acceptable and she

,

e n j oys l ively company and goo d a d vice .

-
\ d apted to mil d tear ful natures w ith l ittle v i m .

il d m el P ul satill a is fre q uentl y demanded in the M elan

chol i a o f pr e gn a n c v c o mplicate d b y ga st ric d i s
i h g a str i c
u b/es o rders .

I I I O SI I I O RI C

A C I I)

Dread of the future w i th anxiet y an d d ou b t

,

abo ut recover y Di sincl inat ion to talk S ad

. .
 M sD I C A L TR E A T M E N T 47 l

n es s grie f and dispo sit ion to w eep

.
M elan .
~

cho l i a produced b v care grie f sorro w or d i sa p . ,

. I / a stu r ba
p ointed love exces s ive men st ruation masturba
. , ti on , over
tion or physica l exhaustion caused b v o ver ac t i v a cti ve ki d
n ey s
i t v o f the kidneys .

SE PI A
N ervou s se n sit ive to the least noi se S ad
, .

ness w orrying about her health and the future

, ,

w ith f requent attacks o f w eeping w orse in the ,

evening an d in the open ai r Dread o f being .

alone very irritable Indi ff ere n ce and aversion

,
.

A versi on to
to members o f her famil y I n dispos i t ion for .

mental w ork w ith w eak m em or v and di ffi cul ty in

,

expressing her i deas I ndolent mood R estless . .

sleep disturbed b v anxious dreams a w aking in a

, ,

fright .

\V eak empty gone feeling in stomach f r e

-
,
~

q uent desire to urinate U rine th ick s l im y ver y .

, ,

o ff ensive w ith y ello w ish or reddish se d iment

. .

P ro f use yello w ish o r w h ite acrid ex ceed i n gl y O en si ve

a en s i v e l e uc or r hea . l eucor r hea

S epia is chi e v use fu l in d epression in w omen

w hose con stitutions have been sapped b v a lon g
C h ron i c
standing leucorrhea and ch ronic orgam c di seas e u ter i n e

of the uterus and ovaries .

di sea se

SU LP I I U R

Depres sion w ith disposit ion to w eep : w i shes

,

to d ie but fe a rs for her sa l vat ion : incl ined to

,
 47 2 M E N T AL D I S EAS E S

C ha ng ea bl e d w ell upon rel igious su bj ect s : apprehensive o f

future mis f ortu n e : variable mood one moment ,

crying the next laughing ; indi sposit ion to mental

,

or physical labor : w ith slo w ness o f mind and

bo d y ; great absence of mind and forget fulness
peevis h an d i rritabl e .

C onstant heat in top o f head ; shoot ing pain s

in forehead and temples from w ithin out w ard .

w orse from eating o r stoopin g better w hen ,

pressing the head and w hen moving ; pressing

dul l pain in ver tex and sinciput rousing from ,

sleep earl y in morning ceasing be fore n oon

, .

Dro w siness during day and w ake fulness at

nigh t : un re freshing sleep di sturbed b y fright ful
,

d reams .

Faint w eak sensation in stomach about 1 1

,

A M ; much thi rst w ith l ittle appetite : con stipa

. .

tion w ith hemor rhoids or ten d en c v to earl v

,

m orning diarrh oea : burning in vagina : mense s

too early and pro fuse and lasting too long w ith ,

ushes of heat and w eak faint spell s feet cold or ,

burning in soles o f feet S kin covered w ith pim

.

ples burning and itching easil y ulcerating a fte r

, ,

scratch ing ; sensat ion o f insects cra w l ing on skin

o f face w ith itch ing increased by heat o f bed :
,

sensat ion o f someth ing running from chest t o

t hroat causing a feel ing o f c hokin g in th roat :
,

f re q uent general ashes of heat w ith faintnes s .

 M E D I C AL TR E A T M E N T 47 3

S ulphur is exceedingly use ful as an intercur

rent remedy i n many ch ronic cases w here the
psoric element predominates I t is al so f re .

quently use ful as a developer bringing out sv m p , D evel oper

toms at rst hidden and unapparent or rev 1 v 1 n g ,

the suspended action o f an indicated drug caus ,

ing the patient to go on to a rapid recov er v I t .

seldom e ff ect s a cure unaided by other drugs .

V ER A T R U M A LI ! UM
M elanchol ia w ith anxiety as i f she had com
, ,

m i tted an evil deed ; sadness despondency an d ,

grief w ith involuntary w eeping and despair o f

,

h e r salvat ion Fear ful and apprehensive of mis

.

fortune . M ind d ul l and stupid w ith obst i nate ,

taciturnity .

P aroxysms of pain in v arious part s o f the

hea d Frontal headache w ith nausea vom it ing
.
, ,

and f ever ; p ressive pain in the top o f head ; cold

spot on vertex Face pale eyes xed and sunk
.
,

en w ith blue o r green ci rcles around them

,
.

N ose cold and pointed C old s w eat on face and .

forehead S leeplessness or sleep disturbed b v

.

bad d ream s .

Great thi rst for cold drinks R avenous hun .

ger or loss o f appetite Fre q uent incl inat ion to

,
.

nausea and vomit ing C onst ipation or exhaust .

ive d i a r r htr a E xcessive w eakness and sudden

.
II
'

ea k n ess

sinking of st rength S kin blue and col d P ul se. .

 47 4 M EN T AL D I SE A S ES

fre q uen t small and w eak often intermit te n t at

.
, .

t imes alm o st imperceptible : d e f ective ci rculation ,

w ith general appearance o f lo w ere d vital it y

E specially e ffi cacious in the apparen tl v most
5 6 27 7 6 sl u hopel ess cases o f S tuporous d epression w he re ,

p or ou s de
pra m
the patI en t S I ts I n a stup i d manner w i th the hea d ,

bent for w ard taking n o apparent notice of any

,

th ing ans w ering in monos y llables o r not at al l ;

.

o f ten eating noth i ng unless f ed ; skin cold and ,

blue ; pul se w e ak and intermi tt ing \ V ith the .

foregoing symptoms w e have occasional fainting

spell s w ith tem po r ar v unconsciousness and sus
,

pe n sion o f the heart s action U nder the i n u

'

ence of V erat rum the depresse d v i tal po w ers are

soon revived and the pat ient a d vances to a com
p l e t e recovery The pat ient
. is l iable to a relapse
i f the medicine is too soon discontinued but w hen ,

once the cure is fully accompl i shed it remain s

permanent .

M A N I C S T A TE S
The drugs m o st f r eq uen tl v u se f ul in M an ic
S tates are A con ite A garicus A nacardium A pi s
, , , ,

A r sen i c um alb um B elladonna C amphor C anth

, . ,

arides C hamomill a C alcarea carb C imici fuga

, .
. . ,

H v o scv am us L achesis N ux vomica P hos

, , .

ho r u s P latina S t ramonium Tarantul a hi s

p , . ,

p ania V er at rum album V erat r um vi ride

, ,
.
 \I ED I C A L T REA T M EN T

ACO N I T E
F req uen tl v u se ful at the onse t o f the attack O n set

w hen it is char ac t erized by m arked inammatory

tor y a cti on
action sh o w n b v a f ul l rapi d pul se h igh tempera
, .

ture general heat o f the skin great restlessness

, ,

and intense thirst .

The pat ients evince great fear and anxiety o f

min d w i th grea t nervous excitabil ity They are
, .

torture d by ever y v a r i etv o f f ear and their t imi d Fea r

i t v is stamped upon every l ineame n t of the coun
ten an ce The y a re a fraid to go out to cross the
.
,

street o r go w here there is au v excitement

, .

They have a constant hor ror o f approach in g

death darkne ss and ghosts Thou ght is con fus
, .

ed the memory w eak and mental labor is an i m

,

possibil ity They are restless in bo d y and rest

.

less i n min d There i s n o s tabil ity o f thought

.
,

o n e moment t hev are sad the next gay T he v ,

.

are exceedingly ereth i st ic oversensit ive to l ight , ,

!

r ethi sti c

noise and music intolerant of pain and cannot

.

bear to be touched or uncovere d .

The prevail ing characteristic of the M aniacal

A conite patient i s fear \V hi l e A conite is often
.

exceedingl y bene cial in the beginning o f the dis

ease it usual ly has to be follo w ed by some other
,

r em ed v be f ore the c u re is comp l eted .

A G AR I CU S
Furious , f ear l e ss , menacing f r en z v ,
w h ich
 47 6 M EN T AL DI S EA S ES

causes the pat ient to assai l and inj ure h imsel f

and others I n coherent tal king passing rapidly
.
,

from one subj ect to anothe r Grea t excitement .

evinced by leaping dancing singing w i th great

, ,

l oquacity and e x aggeration o f the senses Full .

o f de l usions o f po w er and personal importance ,

imagines that he is at the gate of Hell o r on the ,

brink of an un fathomable chasm into w h ich he ,

is about to fall Ha l lucinations of sight and

.

hearing E xcitement fol l o w ed by sleep w ith

.
,

great prost ration upon a w aking C onstant mus .

cul a r t w itching Tremulousness o f the w hole

.

body Thi s tremor is more i n te rn al t han exter

.

nal and may greatly terri fy the patient .

E special ly indicated i n cases compl icated bv

C horea and great nervous prost ratio n and w hen ,

indicated is exceedingly e ff ectual .

A NACAR D I U M
Fixed ideas that he is double : that there is no
real ity in anyth ing ; all appears l ike a drea m ; that
the body and mind are separated ; that a strange r
i s by h is side Imagines that her husband and
.

child are n ot hers : fondles then pushes them ,

a w ay Thinks he i s a demon W hen w alking

. .

S uspi ci ou s feel s that so m eo n e is pursui ng s uspects everyone

,

and is con stan tl v apprehending trouble C ontin .

uall y un d er tw o inuences one inciting to mur

.

der the other urging h im to be good I magine s

.
.
 M ED I CAL T R EA T M E N T

that he hears voices o f mother and si ster w ho are A u di tory

far a w ay Has a devil w h ispering blasphemous
.

w ords in h is ear constant incl inat ion to curse an d

,

s w ear .

The A nacardium pat ient is ch iey character

i z ed by his ugl iness and fright ful pr of an i tv .

The A ntimonium C rude patient is peevish the ,

C ham cross the Belladonna p ugil i stic the N ux

.
, ,

V om ugly but the A nacardium pat ient is cussed

.
,

ness it sel f I f y ou have never heard an A na

.

cardium pat ient s w ear y ou have much to learn .

A n A nacardium pat ient can strin g together a

g reater variety o f st rong oath s than any other
being extant The pro fanity and billingsgate o f
.

these pat ient s w ill make an ordinary sh w i fe

appea r reticent and modest .

We have found A nacardium more o ften cura

tive in ch ronic M ania than any other rem ed v . /l / a n ia

A I I S

M ELL I FI CA
M ental excitement w ith great talkativeness ,
Sex ua
j ea l o u sv and sexual irritat ion I rritable and . i r r i ta ti on

d ge ty nothing seems to sati sf v

,
C onst antly .

busy but does nothing right

,
M ama I n w omen.

from a sexual cause Th is remedy w ill prove .

help ful w hen the pecul iar mental state is a ecom

a n i d b v an inactivit y o f the k i d n e v s w ith pu f K i dn ey s
p e

n ess under the eyel ids and an aggravati on of

E x ci tem en t
the mental excitement at 4 P M . . at 4 P .
 47 8 M E N T AL Dl sEA S ES

AR S EN I C U M AL B U M
S ees ghosts about h im and vermi n and bugs ,

ti on s f
o
cra w l ing upon h is bed Hal lucinat ion that there
.

is someone by hi s si d e w ho imitates all hi s ac

tions Fear that he shal l be o b l i ged to kil l s ome
.

on e .

VV hi l enot as fre q uently i n d icate d in mania a s

melanchol ia w e have had some excell ent resul t s
,

w ith th is drug w hen the pecul iar restlessness

, ,

thi rst physical exhaust ion and midn ight aggra

,

vation w ere present .

B EL LA D O N N A
The belladonna patient in violent f urv bites .

st rikes and kicks or tears everyth ing to pieces .

H is talk is exci ted and incoherent He may be .

l ug i l i sti c

exceedingl y brave and pugili stic or terri ed by
the horrid creat ion s o f hi s excited brain Ev e rv .

imaginable hall ucination o f sight may pass b e

fore his eyes ghosts hideous f aces dogs bull s
. , , , ,

animal s men or instruments o f torture These

,
.

patient s are ext remely ckl e and their menta l ,

states are constantl y changing T hev may at .

times dance sing and laugh but the mood soon

. ,

ends in an outburst of rage and violence .

N o other ho m oeopathic r em ed v is more f re

q uen tl v indic ate d o r as often curative in acute
 M ED I CAL T R EA T M EN T

manic states as belladonna The intense cerebral

. A cute
l l/ a n i c
congest ion w ild deli rium and extreme general
,

hypersensit iveness o f all the senses produced in ,

the provers is a per fec t picture of these st ates

, .

A mistake is often made in giving it too l o w

have found it w hen cl earl v indicated in these
hi ghl v ereth istic cases most e ff ectual in the thi r
f l eth or tw o h undredth poten cv .

CA M P H O R
The p rovings of camphor S ho w its po w er of
pro d ucing m arked man iacal excitement m ani
f e sted in violent overt attacks upon those a bou t
them even to homicidal attempts S ome prover s
,
.

have a l so exh ibited suicidal impu l ses .

C l i n i cal l v it has p roven e ff ect ive in ma n i a

w he n attending or follo w ing the stage o f inten s e
excitement great ph y sical exhaustion and pros
, E x ci tem en t
t r at i o n a re present an d the vital po w ers ar e at w i th pr os
,

tr a ti on
the lo w est ebb . \ V hen the col d cl am m v skin and
w eak pu l se sho w that fatal collapse 1 s I mm i nent ,

camphor often vies w ith verat rum in rall y in g

the vital forces and rev i v i f v i n g appa r en tl v h o pe
less cases .

C A N T I I A R I D ES

C antharides re sembles bell ado n n a in i ts violen t

e x citement These patient s tear the clothin g
.
,
I n cl i n a ti on

and are especial l y incl i n ed to bite at an v o n e w ho to bi te

 4 80 M E N T AL D I SE AS E S

approaches o r they w ill bite the sheets and bed

,

clothing They are restless moan and groan

.
, ,

and o ften bark l ike a dog Hal lucination s a re .

present and they see an d converse w ith p eople

,

long dead L ike anac they Sho w a st rong ten

. .

d en cv to s w ear and are w orse at night . The .

Fa ce y ell ow eyes are bright pupil s w idely dil ated face yel lo w
, ,

( unl ike the red face o f and w rinkled w ith

a constant fro w n and expression o f ext reme

su ff ering The sl ightest touch aggravates the

.

symptom s as al so does any dazzlin g obj ect as

, ,

a m i rror or glass o f w ater .

The chie f characteristic ho w ever and the one , ,

w h ich should usual ly call for the selection o f

canthari d es is the intense almost overpo w ering
, ,

S ex ua l
sexual excitement w hich accompanies the v i o
exci tem en t le nce The sexual excitement is the result of
.

i n tense erethism and inammation of the sexual

organ s driving the patient to seek immediate
,

sexual grati cation Hyos an d verat rum have . .

al so sexual excitement but in these drugs the re ,

i s a mingling of the psych ical w ith the ph y sical

in cantharides the excitement i s solel y physical .

The violence of cantharides is parox y smal and

terric w h ile it lasts O n account o f the sex ual.

exc itement the ca n tharides patient seeks constant

r el ie f i n masturbation .

Thi s remedy is fre q uently indicated w hen the

exciting cause o f the d isease has bee n masturba
 M E D I C AL TR E A T M EN T 48 1

tion. A ssociated w ith thi s mental group w e I ll a stu r ba

ti on bl a d
usual ly nd the characteristic bladder symptoms
o f cantharides .
tom 3

C I I A M O M I LLA

C h amomilla is occasi onall y indicated but usu ,

~

al l v as an intercurrent remedy w hen its char,

acte r i st i c s y mptoms are pre sent These pat ients

.

are c ross I rritable snappi sh fret ful and cannot

, , , ,

g ive a civil ans w er They

. are a l w ays out of
hum or and cannot endure to be spoken to touch
, ,

ed or have any one n ear Hal lucination s of hear

.

i n g are said to be produced b v th is d rug b u t w e ,

have fre q uentl y prescribed it on this in d ication ,

an d in ev e r v case have failed M ental condition

.

i s w o rse d u rI n g men st r uation .

CA LC A R EA CAR B ON I C A
V isions of faces an d p ersons w hen eves are V i sua l hal
l uci n a ti on s
clo sed Del iriou s talk abo ut re rats mice an d
.
, ,

m u rder S ees cat s curs and other animal s about

.
,

him an d ght s them o ff Ima gines someone is

, .

w alking beside her that someth in g hanging over

,

the back o f a chai r is a person sitting there .

C alcarea carbonica i s on l v benecial w hen in

a d dit ion to i ts pecul iar mental svm ptom s it s gen ,

eral con st ituti o nal sympt oms are present .

ti on al
32
 48 2 M E N T AL D I SEA SES

H YO S C YA M U S

The hyoscya m us is not as v iolent and d an ger

ous as the bel la d onna and is less w ild an d more
,

easil y cont roll ed than the st ramonium pat ient .

She sings c ries laughs scolds s w ears talks

, , , , .

obscenely and o f ten accuses hersel f and her hus

,

band o f in del ity These pat ient s o ften re f use

.

food claiming that it i s poisoned The fear o f

, .

poison i s one o f the commonest del usions and no ,

other d rug w il l as often r emove it w hen present .

T he del usions and moods are exceedingly cha n ge

able but the pat ient is usual l y j oll y and good
.

nature d but nervous restless and sleepl ess

. , .

S ex ual There i s great sexual excitement w ith much ,

ci tem en t
lasci v ious talk and constant desire to expose the
,

pers o n an d remain naked Hyoscyamus i s espe .

c i al l v suitable f o r young hysterical nervous and , ,

easil y excited w omen .

H y oscy am us is very o ften demanded in m ania .

\ V hen indicated n o remed y i s more o fte n curative .

LAC ES I S
L achesis is use ful in cases o f insanity w hen the
Loq uaa ous
'

p atient is exceedingl y lo q uacious These pat ient s .

t al k i n ce ssantly and so rapidl y that it is almos t

,

imp o ssibl e to understand them A common (l e .

l usi o n i s th at the y are dead an d that prepara .

ti o ns are being made f o r the funeral T hev a re .

 M ED I CAL T R EA T M EN T 483

proud j ealous suspicious and often have the

, , .

del usion o f be ing un d er superhuman cont rol .

O n account o f its marke d action on the ute rus

and its ant iseptic po w ers it i s fre q uentl y demand
ed i n c a ses due to septic aemia .
S epti m m i a

NLK \ O M I C A
' '

N o case is more disagreeable than a nux

maniac O ppose d to everything that is d one f o r
.

him e v er r ead v to ght w ith those about h im

, ,

he mav from pure cussedness re fuse to eat or

, ,

drink an d re q ui re forcibl e al imentation to keep

,

h im al ive H e is oversensitive cannot tol erate

.
,

noi se tal king strong odors or bright l ight He

, , .

is obst inate cross quar rel some and ugl y

, , B ry . .

i s al so u gl y but the bry pat ient w ants to keep

,
.

st ill an d be undi sturbed w hile the nux pat ient ,

is re stle ss une as y an d aggressive in h is u gl ine ss

, .

\V hi l e p resent i n g no marked delu si o ns f r o m an ,

apparent perversion o f the w hole moral nature ,

these patient s are o f ten am o ng the m o st d i f cul t

to mana ge .

\ V ith these marke d mental symptoms w e nd

the usual characteristics of nux so that one is not ,

l i kel v to make a m istake in the select ion o f th e

dru g \ V hen indicated w e have fou n d this rem
.

ed y o n e o f the most sat i s f ac to r v i n i ts resul t s .

al th o ugh it is o f ten slo w in its act i on and r e ,

ui res to be c o n t inue d f o r s o m e ti m e
q .
 48 4 M EN T A L A
D I S E S ES

P I I O S I H O RU S

V iolent del i rium w ith restlessness fear o f

, ,

death and constant desi re to escape L oud .

S eesf a ces sc reaming w ith attempts to bite and strike thos e

a
about him H allucinations of sight sees face s
.
,

l ook leering at him w herever he may look N ervous .

excitement start s at the sli ghtest no i se Intense

,
.

sexual desi re w ith enti re shamelessne ss an d con

stant attempt s to remove all clothing and go
naked I m agines that he is in several pieces and
.
,

cannot properly adj ust the frag ments I rritable .

,

fret f ul and peevish N ervous and fea rful w orse

.
,

to w ard evening sleepless before midni ght

,
.

P hosphorus i s not as frequently demanded as

some other dru gs but exceedingly sati s factory
,

w hen indicated O n e of its most positive sy m p

.

toms is the presence o f hallucinatio n s o f sigh t

faces peering from every corner w ith th i s
sv m ptom present w e have never failed to rel ieve

the patient by the exhibition o f phosphorus It .

S ex ual ex
i s most frequently demanded in cases w ith sex ua l
ci temen t excitement and w here the disease has ari se n
,

from a depleted state o f the brain and ge n e ral

nervous system .

PL A T I N A
P roud haughty arrogant imagines he rsel f
, , ,

superior to ever y one about her I m perious an d .

 M E D I CAL T R EA T M E N T 48 5

d ictatorial Th inks she does not belong to her

.

o w n family Treat s in a contemptuous an d pit i

. A r ro
g a

con tem t
ful manner people usually venerated Ev er v .
p u

thing about her seems small al l persons abou t her ,

are phv si cal l y and men tally in ferior to her .

C han geabl e mood great j oyousness altern at i n g

, ,

w ith sadness and depression A nxious morose .

, ,

q ua rrel some peevish irritab l e easi l v o ff ende d

, , , ,

n ympho maniacal w ith pain ful sen s mv e n e ss o f

the genita l ia .

The ever present proud arrogant con tem ptu , ,

ous m ood w ill preclude any possibil ity o f mistake

i n the se l ect ion of th i s dru g It is mo s t f r e .

quentl y indicated in w eak hysterical w omen w ith , ,

a ten d en cv to n y mphomania caused b y i r r itation m a 1: I d

'

an d excite m ent o f the gen ital ia .

SP O NG I A

Hap py j oyous w ith a con stant irresistible de

, ,

si ng a n d
si re to sing and w h istl e follo w ed b v distractio n
,

o f mind and di sincl ination f o r all w ork The .

g a i et v of spongia resembles h y o sc v am us but i s ,

longer continued and less variable .

E spec i al l v va l uable in cases w ith a tub e rcul a r T u bcr m /a r

diathe sis an d i n p at ient s subj ect to gl andu l ar

,

enl a rgement s o r w h e re or ganic di sea se of the

,

he art exi sts .

 48 6 M E N T AL m sEa sEs

S T RA M O N 1 L M '

Del i rious violent fool ish noi s y j ovo us furi

, , , , ,

ous maniacal Del i rium o f fea r as thou gh a

, .
,

'
dog were attacking him V iolent w ith hallucina .

sual I ta l tions o f sight ; sees b ugs rat s cat s dogs rabbit s , , , ,

i na tzon s
'

and horrid beast s on all sides o f h im A ggrava .

t ion fro m the darkness being alone an d in the ,

morning A mel iorated by l i ght and company

. .

C on stant movement of the l imbs du ring excite

ver si on to
ment Great aversion to uids the sight o f
.
,

w h ic h at times w ill almos t produce convul s i on s .

I n correct ideas o f di stances and th e size o f su r

rounding obj ects S creaming catch ing and
.
,

st riking at ima ginary spectres w hich ll them ,

w ith the utmost terror Furious bites and .

,

ar st rikes at everyone w ho approaches Fea r w ith .

sen sation as i f the bed w as being dra w n from

under her and that everything w as fall ing on
,

her \V hi l e sitt ing on so fa kept holding on to

.

everyth ing to keep from fall ing o ff The hor n .

f y i n g images appear at the side more o ften tha n

in front S ees bl ack obj ect s black peopl e an d
.
,

black clouds Has a constant vision o f an ex

.

ecut i o n e r standing be f ore him : lau ghs and j o ke s

about the hallucination al though it seemed a ,

real ity Things and persons around hi m appea r

.

to be changed Imagine s that he i s alone an d

.

ab an d o ned in a w il d erne ss T al kati ve I ma gin e s . .

 M ED ! CAL T R EA T M E N T

that he is very large and tall but surro unding ,

obj ect s are sm all H all ucinat ions o f hearin g

.
,

he a rs d an c i n m usic and men talking in forei gn

o
'

tongues Hears a voice under the bed at ni ght

. .

Ex poses genital s .

The mental state o f the stramonium patient i s

subj ect to s udden and marked changes O ne . C ang ea l e
moment he is lled w ith horri d fears the next ,

merry and j oyous he sings and dances the next

, ,

f ull o f rage he vi gorously attacks all about him

, .

A t times he is proud haughty an d arrogant an d ,

intolerant o f his associates or the senses may be ,

dul l and a stupid indi ff erence to everyth ing be

mani fested .

\V hi l e representing by its provings a w ide

range of mental symptoms st ramonium has ,

ach ieved its greatest curat ive t riumph s in the

Severest
s everest cl ass o f cases .

\V hen the d el i rium is w il d and furious an d the

p at ient is possessed by the most fear ful delusion s
and hallucinations then is stramonium most ,

clearl y in d icated and seldom fail s to bring speed v

,

rel ie f
,
soon bani shing the horrid ends and
haunt ing images w hich have driven the s uff erer
into a perfect frenz y S t ramonium quiet s h is
.

fears q uell s h is excitement and soothes h im into

,

a re st f ul sleep w h i ch i s the rst step in the return

.

to health an d reason In acute man ic states epi . .

l epti c in sanity and del i rium tremens it i s o ften

i n dic ate d an d frequent l y curative .
 488 M E N T AL D l S EA SES

T A RA N T L
'

LA H [S PA N I A
Delusions w ith hallucinations o f sight sees ,

monsters ghosts faces E xceedingly changeable

, ,
.
,

at one moment laughs and j okes the next taci ,

turn i rritable and u gly A ggravated by music

, . .

C ha ng e Incl ined to n v m phom an i a the patient s he l ped by

a bl e treach
,
,

cr oa s ,u m th i s remedy are characterized b v thei r mental

n i ng chan geableness t reachery and sly cunn in g
,
.

V ERA T RU M AL B U M
Del i rium w i th coldness over the w hole body
,

and c old s w eat on the forehead The patient .

prattles abo ut rel i gious subj ect s a n d vo w s to be

per forme d Imagines he is a prince and behave s
. .

i n a haughty manner P ersistent raging w ith .

great heat o f the bo d y N ois y cursing ho w l i n g .

, , .

w i t h fre q uent attempt s to escape Runs a bo ut .

ho w l ing and sc reamin g w orse in the evenin g , .

Ill humored i rritable v exed from sl i ghtest cause

, , .

R ushes a b out the room and t ries to kiss ever y

b od v Hallucinations o f sight : roo m appears full
.

o f peopl e w ith w hom the patient converses for

.

hours . S leeplessness w ith constant t alki n g and

,

loud lau ghter .

L7 01m ! ex The furious del irium of veratrum album w ith ,

ci tem en t
violence and destruct iveness resem bl es that o f ,
w i t/z g rea t
p r osl r a ti on belladonna an d st ramonium In verat rum album .

ho w ever w e have much greater ph y sical e x hau s

,
 M ED I CAL T R EA T M E N T 489

tion evidenced by a w eak pul se c oldnes s o f the ,

body and cold s w eat on the forehea d The v era .

trum pat ients must have speedy rel ie f or die .

V eratrum album is especially e fcacious in m ania

I Vom m

occurring in w omen w here the disea se is depen d S ex u al ar

ent upon some disorder o f the sexual or gans an d , g a n s

is a ggrava ted at each me n st rual period or i n .

w omen w hose menses have been suppres sed an d

w ho imagine themsel ves pregn ant M an v of .

these cases are subj ect to amoro us frenzies w h ic h .

are stran gel v mixed w ith the w il d est rel i gious

vagaries .

\ ER A T R U M vm w

V erat rum viride has f ew m ental svm pto m s r e

corded in it s provings but has been found ex
,

t r em e l v use f u l in man y mental disea ses l ts .

select i on i s usual l v determined b v i ts general phy

s i c al conditions .

I ts sphere o f u se fulness ho w ever se ems l imit

, ,

ed to the resuscitation o f the physical po w ers an d ,

w hen th is is accompl ished l ittle can be expecte d

from it as re gards the restoration o f the p atient s
'

reason .

A lthou gh any o f the remedies menti o n ed are

liable to be ne e d ed the four main sta y s in the
,

treatme n t o f m an ic states are bel l ad on n a l H O S ,

'

c y a m us s tr a m on i u m and t cr af r um al b u m
,
'
.
490 M N T AL D I SEA S ES
E

The medical treatment o f p ar es is p aran oi a an d

,

d e m en ti a o ff ers l ittle
. Founded upon organi c
lesions of brain and cord all that has thus f ar
,

been accompl ished has been a temporary am el io r

ation o f symptoms w ith sl igh t e ff ect upon the un
d e r l y i n g disease
.
 I N D EX .

Ab li ou a. 72 A mb g Em i l er , . 64
A it
co n e, 1 04, 1 45 , 1 74 .
33 5 , A mb g i ra r sea , 1 15

3 59 . 46 1 . 47 s A m t i 09
en a, 1

A c tze a rac em o sa . 1 1 4, 1 46 . 1 76 , 3 59 , Am i t
n e s a, an e ro gr a e , d t
re rogr ad e .

46 1 7o
A u t d l i i um
c e e r , 97 z\ n aca r d i um . 1 1 5 , 33 7 , .
17 6
Ag i 05
ar c u s , 1 , 1 15, 175, 3 36 47 5 A n es t h i 33
e s a. . 55
Ag ph bi
o ra o a, 1 24 i nd m ti e en a p al vti ca,
ar 264

A go t t m i . \ n o m al i e s of a pp t t e i e. tu 1 n san i ty ,

A l b um i n u n a, 1 79 3 2 . 34
c o ho l i c i n san i ty ,
cr an um i . i n i n san y , it 24

t 67
ac u e, 1 d t l
en a , in i n san i ty , 29

y m
s p t m t l gy o a o o ,
1 67 ear , in i n san i ty 30 ,

p t h l gy 7 3
a o o . 1 ey es, in i n san i ty 9 , 2

t tm t 73
r ea en . 1 genit li i a a, n i ity
n san , 31
A l ohol i
c i i tm
c n san s, 1 63 g it u i
en o- r n ar v fu t i nc on . i n in
hc i p h
r on c . s ee c in . 2 i ty
san ,

t m i re or n, 2 i ti t i
ns nc . n i n sa n i ty , 34
Al h li p y h
co o c s c o se s , 1 66 j w i i m ty 6
a s. n n sa . 2

m l h li
e an c 7 o a, . limb i i ty 3
s, 1n n san , 1

m i 79
an a, 1 lip i i s, i t y 29 n n sa n .

y m p t m t l gy
s o a o o . 1 79 m t fu t i
o or i i nc on . n n san i t v 33
p g ro i 79 n o s s, I n o se , i n i n san i t v , 27

p t h l gy 8
a o o ,
1 1 sen so r v fu t nc i on . i n i n s an m 3 ;
t tm t 8
r ea en , 1 2 s ki n, i n m sa n i ty , 32
A l hol i d m
co c t e en
'
a, 1 87 p
s eec h. in i n s an i ty .
34
p a a oi 8
r n a, 1 2 t o n gue , in i n san i ty . 29

y m p t om t l gy
s a o o . 1 82 A t h p ph bi
n ro 4 o o a, 12

p g ro i 85nos s . 1 A t i m i um d 36 46
n on c ru e, 0, 2

p ud p i
se o- a res s , 18 6 A pp t i t e m li 3
e an o a es . 2

\ l co ho l i s m , A p i m l 338 4 7 7
s e . . .

i i l
c l n ca a s pe c t s
,
A p pl t i f m i
o ec i d or se z u re s . n em en ti a

Al ti g i
t e rn a n n ~a n ity .
376 , p ly t i 7 ar a c a, 2 2

A l mi
u 5na ,
1 1 , 35 9 .
6
4 2 A g t um i t
r en 1 4 n .
,
. 2
49 2 I N DE X
A i r n c a, 1 16 B u t
o v e re . 12 1

A rsen i cum a l b um , 1 16 . 1 75 . B ylo e,

338 360 46 2 47 8 . . . B hy p h l i 6
rac ce a c . 2

A r te m esi a v u l ga r s i . B wt G I
re s e r, eo .
?

At i l
r er a chan ges, 55 B m i m 06
ro s ,
2

A sa f ce ti d a . B y t \V S 63
r an , , .

A th pi
s u th i
en o a . ne ra s en c, 1 27 B y ia 1 1 7
r on ,

A t i gm t i m 3 3
s a s ,
B uf 1 5
o . . 2

A ymm t y f i l 6
s e r ,
ac a , 2 Bu t 13
r on . .

A tt t i p w
en f 66 on o er o
C a tu
, .

A tt t i en x on re e
363 16 5
c s . . .

C al a b
. .

ca r ea c r r

A 108
.
.

urze . . .

6 6 43 1
Au i r s hrem a to m a .
55
2
4 . 4 5 .

C al m ei l
\ u to i n to x i c at i o n
- ,

p
.

C am ho r 06 33 9 47 9
in d em en i a t p x raeco
,
1 , ,

C a th i d
.

d em en ti p lyti a
a ara c
n 07ar 76 es. 1 , 1 . .
17 9
C at al p y 7
.

A ut o m at sm i 2 33
e s
,

C at t i a 09
.

e pi l pt i e c 11 5
a on . 2

C d
.
.

e 126
ro n . .

B ap t i i 6 36s a . 1 1 ,
1 ,
C p h l a hi d i a
e a or c ui d n ,

B at h 333 3 5 8 146
s . . ,
. C b th i
e re o
r as en a . l 2

l d 457
co . C b p t hi p y h i t
ere r o a a s c ca o x zem i a. 91
d i pp i g h t 158
r n s ee ,
. C ham om i ll 18 a, . 1

h t p k 45 ? o ac . C ha g abl n 35 e en e s s .

p o l g d hro t tub on e .
45 5 C hap i 25 n, 1

p i al d u h 1 5 7
s n o c e. . Ch R b t H
ase , 6 o er .
, 2 1

B yt a b 6
ar a c r . 1 1 . d iti f d m ti
e n on o e en a paral x t
Bad e r . 12 1 i ca , 25 1

B d d w m 32
e ar e o en . C hem ocep hal u s . 2 50

B ed so r e s, 56 . 2 7 2, 2 73 Ch i n a. 36 3 , .
16 7
B ll d
e a o n n a. 106 . 1 17 . 1 76 C hr it
s e n so n , 97
3
3 :8 36 2 46 4 4 7 . . C hron i p g i p c ro re s s v e arano a i
38 6 .

B ll d i
e
'

s 97 s ea se . P d m l l yp h
ro ro a i oc ro n d r ic al or .

B ll Lut h B
e . er . . p i d f bj t ier o o su ec ve an a l v si s

B k l y 97 5 5 65
er e . .
2 . 2 ,

B w i g El i
er 14 . se . . pt sy m o ms . 38 7
B i gh m
n a ,
p ut
e rsec o ry s ag e t .
388
Bl k b u
ac rn . 1 y pt
m s om s .
388
Bl d f d 8 8
an or . 2 1. 2 2 e x pa i n s ve s age t 390
Bl i d n 33 n ess . m
y p t s o m s, 39 0

B f agi l i t y f 56
o n e s, r o , C i ut
c a v rosa i . .
1 7
2
 I N D EX 49 3

C i rcu ar l i i t y 3 76 n san , , 380 t tm t 3

rea en ,
1 1

sy m p t m 3 80 o s, C on s tip ti a on ,

et i l gy 38
o o , 1 C o n ul i
v s o n s,

cour se, 38 1 i d m ti p
n l ti
e en a ara y ca . 2 5 8 , 26 5 ,

C la k r pb ll 26 5
,
C am e . 2 7 2, 2 88

C la k r , L P ,. . p hi l i t i d m t i a
sy c e en .

C la i tio
ss 8 ca n, C a i l
r n a om al i
an es,

Ag t i i 5 os n

s, C im i
r l p
na s to i a i ty
ro n e ns n , 37
K a p li 6 r e e n s.
'

C up um m t 1 7 127
r e 1 ,
.

i Z ehen 4
'

s,
D al t o i m 33
C l u t ph bi
n s .
a s ro o a.
D af m ut i m 33
C l u t
e - s
59 80 1 1 5, 15 2
.

o s on , 5 , 2 2, 2 , . .

D ef en d o rf 268
C i i m 96
o ca n s 1
.

iti i ity
.

De of
y m p t m t l gy
n on n san , 2
s 97 o a o o 1

d i ff t i l di g i
eren a a
,

n o s s. 20 1
D e f o n n i ti es of f ace . 26

p g i ro n o s s, 20 1
j aw s , 26

t tm t 0 rea en 2 2
n o se, 27

C ll p
o d l i i m 97
a se e
,

r u ,
p l t
a a e, 27

D e Fu rsac 6 6 ,
co urse . 1 02
. 2 13 . 2 90. 3 13
D ehan e
t i ol gy 9 7
e o
, 207

l i d a t ou h d ut
.

De du
p t h l ogi l
a t omy
o ca an a 98
re c er et o e 1 25

l i i um a ut
,

De
p g o i 03
ro n s s, 1
r , c e, 97

y m p t m at l gy 98
s o o o grav e 97
t
.

rem en s, 1 67
t t m t 03
rea en 1

C o orl ld i d m t i e s
,

n e en a p ze co x ,
r
t tm t 1 73
rea en .

lu i d i t i 59
.

De s on . e n on ,

C b A d w
om e, n re 2
d p i 9 59 27 5
e ress v e. . ,

C om m i tt d w h i e en
,

n san e shou ld b e,
e x p i 59 26 7
an s ve, ,

m ti f om b i b
,

De en a. r ra n a sce ss, 29 8
22

C om m i tm t en re q ui r em en s. t 21
b i t um
ra n 98 o rs, 2

co s t f o 20
d i mi t d l
sse na e sc e ro si s 29 8

f orm s o f ,
,

21
i ol t i o 299
ns a n,

tw o q ual i d p hy i i e s c an s th ree
t um t i m 29 8
ra a s ,

y a i p
e rsti 4 n rac ce, 1
o gr i 92
an c. 2

C on cen r c t i l i m i t t i o f th a n o e i
v sua l causes , 29 2

l d 33 e .
p i l i t i w i t h p al y i
Sy h c ar s s, 29 2

C on d u t 76 c .
p t h l gy
a o o ,

C on fu i l i s on a it y ut n san . ac e, 1 09 p d om at a 29 3
ro r ,

et i l gy 09
o o , 1 y m pt m
s 93
o s. 2

d i ag i n o s s,
3 1 1 Sy p hi l i t i w i t h u t p a l y i
c o ra s s, 29 5

sy m p to m atm ogy . 1 09 p od m at 29 5
r ro a.
49 4 I a ix

sy m pt o m s, 29 5 dp e res se d f o rm . 2 74

i p lyt i
D em en t a ar a ca, sy i n pto m ato l ogy , 2 7 5

d iti
e n 5 on . 2 1 d ubl f
o e o rm . i
c r cu a r l ty p e,

t i l gy 5
e o o . 2 1 2 74

hi t y 48
s or , 2 ga o ll p i ng t o rm ,
y
s n ony m s . 24 0 Juv en al p a i 79 r e s s, 2

p di p i
re s o s n g causes . 25 2 sp i al g n l pa i en e ra re s s . 2 76

age. 2 5 3 y m p t m t l gy
s 76 o a o o . 2

se x . 25 3 du t i ra f d m ti on o e en a pa
co u n ry t vs . c i ty 53 , 2 ral y ti ca . 2 82

r ace an d soc a i l i fl n u en c e s d iti

han w r n g, 28 6 . 28 7 . 2 88

2 54 p t h l gy
a o o an d p t h l gi al
a o o c

i gl l i f 5 5
s n e e, 2 an atom v 2 83

x iti g
e c 5
n 6 causes. 2 p rog no si s. 2

y p
s h i l i 5 6 s. 2 re m i ssi o n s. 2 80

l h l i m 57
a co o s . 2 di i f m h i
agn o s s ro c ro n c al

t i t xi ti
au o n o 58 ca on , 2 coh li i i ty 89
o c n san , 2

n er v ou t i 57 s s ra n . 2 d m ti p
e en a eco x .
rz

u s t k 58
n s ro e, 2 d m t i f ll w i g
e en as o o n epi

x l
se ua 57 ex ce ss . 2 l p y 90 e s . 2

t m t i m 58
r au a s . 2 l ad poi o i g 290
e s n n ,

p d m l t g 59
ro ro a s a e, 2 u a th
ne ia 85 r s en , 2

d ti ur a 60 on , 2 l um b p u t u i ar nc re n.

p hy i l y m p t m 63
s ca s o s . 2 t t m t i 29 1
rea en n .

sy m p t m t l gy o 59 a o o . 2 d m t i a po t popl e t i 29 5
e en . s a c c .

t t g f t bl i h d
rs s a e o es a s e m bo l i
e 29 5 c .

di 66
sea se, 2 y pt m
ms 95 o s. 2

y ms p t m t l gy 6 6o a o o . 2 t h om b t i 29 6
r o c,

d lu i e f g
s on s du 7 o ran e r, 2 6 y ms p t m 2 9 6 o s,

mi m i
c ro 9 an a . 2 6 p i l p t i i u i 29 7
e e c se z res n .

phy i l y m p t m 69 s ca s o s. 2 gang ren e i n , 29 7

s eco n d tg 7 s a e. 2 1 d m en
e t ia p x raec o , 209

b ed sore s. 27 2 et i l ogy 09
o . 2

con v ul s o n s, i 27 2 o ul a
c ig r s ns in .

dm e 7 en ti a . 2 2 245 .

p h 7
s e c
e
,
2 1 p t h l ogy
a o . 211

t hi d t g 73
r s a e, 2 so m ti di d
a c so r er s . 217

y m p t m t l gy
s o a o o . 27 3 sy m p t m at l gy 2 o o o . 1 2

d m t d f m 77
e en e or . 2 h b ph
e ei f m r en c or , 2 18

p t g 79
e rc e n a e. 2 c o u r se, 22 5

s v m p tm n ato l ogy . 27 7 p rogno s s. i 2 25

 1 x 11 1x 49 5

sy m pt o m a o l o gy t . 218 De p re s s o n i i t i ght w h of id eas an d

t t
c a a on i c f o rm , 2 29 e m tio l l ti on a e a on .
37 5
char ac t ri sti c s . 2 29 De p r e ss o n i w i th t p s u o r, 35 5
t
s age of dp e ress o n . i 2 29 De p res s v e e i x it m t c e en , 37 2
t
sy m p om s
,
2 29 D e rc um . 257

t t i t up
ca a o n c s or . 23 1 d e r m ogra p hy , 56
c h t i ti
ar ac e r s c sy m p t om s . D i th i i
a es s f 37 n san e, cau ses o .

23 1 di ip t i d x
ss i x l
a on an e ce s s v e se ua

t t
ca a o ni c x i t m t 33 e c e en . 2 i d lg 14 n u e n ce , .

ch t i ti
a r ac e r s 33 cs , 2 duk r f p t 13
n en n ess o are n s, .

a ut m t i m i
o a33 s n, 2 f ilu t l
a l f t l 14
re o ear n se -
co n ro . .

i id l t d i
su c a 35 en en c es, 2 g i f m t l h k
r e ti g
or en a s oc ac n

t t y py i 35
s e reo n, 2 m th 43 o er ,

v erb i g t i i 35e ra on n. 2 imp f t t iti e r ec

14 nu r on, .

p hy i l y m p t m 3 5
s ca s o s, 2 imp p m t l di t d i g ro er a e rn a e ur n

co u r se , 2 36 p r egn an cy .

p i
rogn o s s. 23 6 t i h bi t f
n a rco c a s o an ce s o r s, t '

4
p ar a n o id f o rm s, 237 t xi g f u d
o ve r a n o n eve o l pd e h
p y
of i n co he ren t typ e . 23 7 i l p w 44
s ca o e rs .

co u r se . 2 39 t um t i m 44
ra a s ,

sy m pt mo s 237 D i t 15
e . . 0

pa r an o id f or m . sv stem ati 7 D ig t i di
es ve so r d er s in n eu ra s th i en a ,

ed typ e, 2 39 1 3o

c o u r se . 2 39 i it li
D g a s 1 1 7 36 3 , , . 466
s
ym pt m o s . 2 39 i
D scs c han ge s i n
. d em en ti a p rzeco x .

d em en ti p a raec o x di. agn o s s i 2 44 ,

f ro m , D o l i choc ephal us ,
26

d em en ti p a ar a lyti ca .
D ou bl f m tt k e or . a ac s of .
375
m an i dp
c e r e ss v e i i n san Do ugh ty 39 er c ase , 1

i ty .
D un n . 2 80

p a ran o a i .
Du p re . 2 90

m m m
t tm t
p g n

r ea en
'

Ear di sea se , cau s e o f ha ll u i t i

c na on s .

63
,

d m t i t m i l 43
e en a er na ,
1
E ar an o m a li 30
gi t t d f m i
e s,
a a e 43 4 or n

y m pst m o s .
.

E ar di sease .
psvcl i i cal im p t o r an c e

f ~
p i f m 13 5
as s v e or , .

y m pt m
s 13 5 o s . .
l
E a r " Daram a 39 3 .

t t m t 13 6
r ea en . .
5 ) m pt0m 5 ~ 39 4
'

D en t l
a m li
an o 9a es 2 EchO l al i a . 2 33

De p i w i t h i ght f i d
re s s o n , o ea s . E cho p ax i r a , 2 33
496 I N D EX
Ego t i m 36s ,
t al x m i t i o
m en e a na n, 12

E l t i i ty
ec r c 44 ,
1 m di o l g l e c -
e a cases, 12

Em t i o l ph
o di
na s e r e. so r d ers o f . 69 p ti t hi t y 0
a en
'

s s or , 1

E t iti mu u
n er s3 co s, 1 2 p l x am i at on
e r son a e n i ,
I I
Epi l pt i
e ut m t i m
c a o a s .
4 15 E x h u t i o p y ho
a s 97 n s c se s,

C W 409 , n e r v o u s. 1 20

m an i a 4 1 3 ,
Exp an s v e i pa ran o a. i
t t
s a us 4 1 6 . Ex p re ss o n i . di s tu b r an ces o f .
74
t i gm t 4 8
s a a, 1 Ey e an om a li es ,
29

Ep i l p t i i
e c i ty 404
n san ,
s y mpt om s in d em e n ti p a e co x
ra

p p re y m
a ro x l t g 406 s a s a e, 2 42 . 2 43 , 24 5 . 246 . 2 47

y m p t om
s 407 s,

p m i t y t g 407
re on or s a e,
Face d f mi ti
. e or es o f , 27

i d m ti p lyti
y m pt m
n e en a a ra ca. 2 7 0, 273
s 408 o s,

p x y m l t g 409
a ro s a s a e,
Fac i l y mm t y
a as e r ,
26

Far ra r 8 2
g d m l 409
ran a
.

y m pt m
s 409 o s,
,

Fa r r i gt n on . 16 1

Fere 4 1 8
p tit m l e a 1 1 1
,

d l i i um
.
,

Fe ve r e 78
y m pt m
r ,
s 4 o s, 1 1
81
tu l pi l p y 4
n oc rn a e e s 1 1
co u r se,

p y h i q ui l t 4
s c c e v a en s ,
,

12
e ti l o ogy , 78

p t p xy m l p i d 4 3
os -
aro s a er o 1
f m 7or s.

ut m t i m 4 5
a o a s 1
,

p at h l gi l o o ca an a om y t . 79
h t id
v s ero tt k 4 6 a
.

ac s. 1
p g i 8 ro n o s s, 1

sy m p to m ato i ogy
m i 43 an a. 1
, 79
t at u 4 6
s s, 1
t tm t 8
rea en ,
1

Fl t h d d
i t p ox y m l t t 4 7
n er ar s a s a e 1
a ea 5 e n e ss , 2

Fl x i b i l i t
.

tig m t 4 8
s a a 1
e 7 as ce rea . 2

Fl x i b i l i t y w x y 7
,

m li g i g i
e a . 2
a n 4 er n n, 22

p g i 4 ro n o s s, 22
Fo rce d f d i g 448 ee n ,

F i Ed w d
t tm t 4 3 rea en 2
o rn a s, 53 ar ,
1

G it i p i 70
,

di t 4 3 e 2
a n ar e s s. 2

G l m i um
,

m di l 1 3 e ca 2
e se 7 49 36 5 4 6 7
. 1 1 , 1 , ,

l p i 49
.
,

G
Epi l pti f m i u i d m ti en e ra a re s s, 2
e or se z r es n e en a

p ly ti ara 7 ca, 2 2
Gen it l a m li
, f 31
an o a es o ,

E q ui l t p y hi 4 1 2
v a en s s c c,
Gen e ra l p l y i f th i a ra 49 s s o e n san e 2

E l m y G y L d
ra Cant 386 39 4 3
er ar er . 1. 1
96
,
r en e er , 1 ,

E ti p
ro c i 10
aran o a, . 2
G i f
r e u ca f d f t i o p i g 4 3
se o e ec n s r n ,

E q ui l
s ro 48
, 2 G i i g
r es n 65 e r, 2

Ex m i
a ti
na f p ti t
on 0 o a en . 1 H ll u i
a t i d iti
c na f 6
on , e n on o . 2

f m i l y hi t o y 0
a s r . 1 ea r di au f 63
sease, c se o ,
 I N DEX 49 7

of f l i g 65 ee n , H y pe restheti c 3 5 ,

of g i talen 64 sen se, H y perm e trophi a 3 3 ,

of h i g 63
ear n
d i td i th f bl m t
,

I w
of p i
eas asso c a e en ee e en
a n 65 sen se,

p m er t 63an en .
of i
h gher p sy c hi fu t i o
c nc n s,

66
f t t
o 64
as e,

t m p y 63
e orar
au ocht t h ou on s. 67

th m ler a 65
,

sen se,
x d 67 e ,

of m ll 64
s e
i ght f 66 o ,

f t u h 65
o o c
,

im p t i er a ve. 67
t i 49
.

I gn a a, 36 5 , 46 7
i u l 64
v s a
1 . 24 1 ,

ll i ut
.

I us on phy scoses i n , 62
H a ll u i t y i
c n a or i ty n san 1 09
ac e

o fu i
c n 09s on . 1
,
d i tio
e n n of , 61

H a mm d 6o
on 2
of hear i n g, 62
la
.

H dw i t i g i p i 286 ,
of m uscu r sen se, 62
an r n n ares s, 28 7
i ti o
.

288
of organ c sen sa n s, 62

d em en ti a p ra co x , 2 26 2 27
of s i ght ,
61
ll
,

of sm e 62
H ead , n arro wf h d o re ea w i th g ea
r t ,
,

w i d t h b hi d 6 e n 2
of t t
as e. 62
p ot
,

Im
o f u u u l bn d th
s a rea 26
en ce. 34
I m pul p a i o at
,

o f u u u l l gt h
n s a en 26
se s ss n e, 73
i m pl 73
,

H ea r t d i tu b s i r an ces, n n euras th en i a.
s e,

1 30
I m p ul i 7
s v en ess. 2

H b ph i 09 8
e e
I f ti
n ec d li i
on e r a. 82
ren a. 2 . 21

H m t m u i
tr eatm ent, 85
e a o 55
a a r s,

i d m t i p al y t i a 7
n e en a ar c 2 2
I n ecf ti on pyh s c o ses, 7
u d l i i um
.

H m e l op i a 33
er a
I n en z a e r o f 84
,

H d i ty 38 1
e re
,

21
I n san i ty ,

l li ut
, ,

a co ho 67
l aw l at i t i a i t y 39
s re ve o ns n
c. ac e, 1

H d i t y ba i
e re ar 3 s s 12
,

al t t i g 376 37 8
e rn a n , .

a t i al ha g i 5 5
.

H u g n er u a thne i 1 33 r s e n c,
r er c n es n,

H y d op h b i a
r o
i ul 376 380
c rc ar , .

H y d ot h ap y 8 1
r er 1 3 4 54 1
cl a i at i
ss 8c on ,

A go t i i 5
, , ,

o l d bat h

s n s,
c 45 7 s,

d i pp i g he t 458
r n s e
K a p lir 6
e e n s

i
.

Z ehen
'

hot pa k 4 5 7 c
s .
4
itm t
,

p l g d h t tub b th 455
ro o n e o a ,
com m en by N . Y . S t t
a e

p i l d u h 45 7
s na o c e, l aw , 13

H y o scy am u s 1 07 , 1 1 8, 1 76 . 24 1 , 342 , d iti

e n on , B ro w er- Ba i tnn s e r,

48 2 2

H y p e res th i e s a, 33 C om b e, A d n r ew , 2

33
498 I N DEX
ear di sea se i n 63 , l p d i d of
s ee so r er s , in , 5 2
Ep i l pti
e c, 404 ti
sec rei 54 on s n.

p xy aro sm a l t ag s e, 409 p h i 75
s eec n.

gran d m l 409 a ,
s t i gm at a of d g e en era t i on
p i od 409er s, in . 24

y m p t om
s 409 s, an o m a li es of a pp t i t e e, 32
n octu l p i l p y 4 1
rn a e e s , 1 car, 30
p t it m l 4
e a ,
1 1 ey e, 29

y mpt m
s 4 o s. 11 gen it l i
a a, 31
p t p ox y m l p i d 4 3
os - ar s a er o ,
1 cran u i m ,
24

ym p t m
s 413 o s, s ki n, 32
m ania 4 3 . 1 t th ee , 29

aut m at i m o 4 5 s , 1 l imb s, 31
hy t i d tt k 4 6
s ero a ac s, 1 t gu on e an d l ip s, 29

i t p ox y m l t t 4 7
n e r ar s a s a e, 1 t f i l 6
asy m m e ry . ac a ,
2

p m o i t o y tag 407
re n r s e, d fo m i t i
e rf p l t es o a a e, 27

y m p t om
s 408 s, phy i l gi l 33 s o o ca ,

p p ox y m l t g 406
re ar s a s a e. p y hi 34s c c,

y m p t om
s 407 s. sy m p t om t l gy 5 1 a o o ,

p y hi q ui al t 4
s c c e v en s, 12 t m p t u i 57
e e ra re n,

t i l gy
e o o t ox i g t cu a en s ca se of .

x mi ti
e a of th i
na on e n
50
san e, 10 t raum at sm i . cau se of ,

fd f d i g i 448
orce ee n n.

l t ub 448
n asa e. t r ea tm t en of , .
136
t oma h pum p 450
s c , m di l
e ca , 459
h d i ty l aw i
e re th y s
'

o . as e o r i ci al su rgery in ,
l t to 39
re a e , 4 54
hy d ot h py i 4 5 4
r era n, t p hi
ro c chan ges in ,
l gal 3 e .
55 .
2 72

ma i d p n c i 30 e r ess ve , 2 ur ne i in , 54
m di l 2 e ca , I n som n i a . 1 26

m t u t i i 54
en s r a on n, I t xi ti o p y h
n o ca 63n s c o ses, 1

ut i t i o
n di o d
r f i n, s r er s o ,
n, I t i p a i 400
n v en ve ar n o a,

53 y m sp t o m 4 0 s, 1

p i od i 376
er c. I od fo m p oi
o r i g f m 206 son n ro ,

q u ul ou 399er s, I gu
r re l a f o m
r 38 3 r s,

pat hol ogy of 9 , I i t bi l i ty b o m l 65

rr a a n r a ,

p ul i 5 7 se n,

re x i 55 e es n. J w a m l fso m d a r e . 26

res t t at m t i re en n, 440 J g
u d m t d i
en d ,
so r er s o f . 71
 I N D EX 499

Jum pi ng pu pi l , 1 27 p at hol gy 208 o ,

Kahl b aum 23 2
p g i 208
ro nos s .

Kal i bo i a 50
,

1
y ms p t m at o l ogy o , 208
ca r
L gal i a i t y 3
n c .

e ns n
K l i p h p h i um 5 o
a os or c , 1
L tte d m ti p
er s e en
,

a e c o x . 2 2 5 , 226
rz
K l hpdh d 5
ee s a e ea . 2
Lew i 6 s 2 1
K j k i d m ti p ly t i
.

L wi B
n ee er s n e en a ar a ca
76
.

e s: e v an . 2
2 7 6 , 288
Li l i m t i gi
u m 5
r nu 1 0 36 6 468
K rae p li e n, 6 . 8 . 1 20, 209 . 2 1 2, 2 29 ,
Li m b m li
s an o 3 a e s.
,

1
, ,

23 1 , 236 2 58 2 74 30 1 312 Li ptocephal us

. . . ,
,
. 25
37 1 .
384 Lum b ar pu tu in d em e n ti
nc re a pa
K ftra . E bi n g, 252 . 39 3 .
400 ral y ti c a , 290
Ko rsak o w
'

s py s cho s s i . 1 85
c o po di u m . 15 1
K o r sa o ff sk

di sease .
91 ,
1 85

cou r se . 95 M ac ph e r so n . 27 3

di g i 95 a n os s . M acroce ph l u a s, 25

t i l gy 9
e o o , 1 M agn an s
'

sig n. 200

p t h l gy 9
a o o ,
2 M l i
a ar a d e n r i um of 83
y m p t m t l gy 9
s o a o o ,
2 M an c i dp i . e ty 3 re ss ve i n san i . 20

t t m t 95
rea en , e ti l gy 3 0
o o 2

L h i
ac es s 8 343 4 8 48
. 1 1 . . 2 . 2 ty p 3 0 es . 2

L h ym ti
ac r 54
a on , m i typ 3
an c e. 21

L t p
a e i 39 5
ar an o a, hy p m i 33
o an a . 2

y m pt m
s 396 o s . sy m pt m 3 3 o s . 2

L w
a f h
s o d i t y 39 e re , p hy i l y m pt m 3 5
s ca s o s, 2

L w f N w Y k St t
a o e t m or a e as o co m i 35 an a . -

m i tm t f i en 3 o n sa n e . 1 c o u r se .
3 29
pp l t l u ti
a ea f S up m
o s ce o re e sy m pt om s .
325
C u t 9
o r . 1 d li i
e r ou s m an i a. 2
3 9
t f pp l 0
co s s o a ea . 2 co u r se 33 1
m t h d f pp l
e o 9 o a ea , 1 d u t i 33 ra on , 2

x m i ti
e a f tw
na q li d on o o ua e ym pt m
s 33 o s . 2

p hy i i 4
s c an s, 1 t t m t 33rea en . 2

j ud g m y d i p e with p
a s en se er d p i t t 3 50
e re ss v e s a es.

l so n a i 5 se rv ce, 1 i m pl t d t i 350
s e re ar a on ,

p l
e rso n a i 5 ser v ce, 1 d u t i 35 ra on , 2

p titi e 5 on . 1 p hy i l y m p t om 35 2 s ca s s,

h i g b f j ud g 6
ea r n e o re e. 1 y m pt ms 3 50 o s .

h i g by f
ea r n 7 r e e r ee , 1 d l u i l f m 35
e s on a or , 2

L w f
a o gu i i t y 39
san n , y m pt ms 353 o s,

L d p i
ea i g 7
o so n n . 20 t up u d p i o 35 5
s o ro s e ress n .
5 00 I N DEX

p t om 35 5
sy m s, M i
an a r ecur ren t , 3 76
p hy i l y m p t om 356
s ca s s, cour se , 37 7
d u at i o 3 5 7
r n, p rogn os s. i 37 8
t at m t 35 7
re en , sy m p t om s. 376
mi x d typ e 37 1 e s, M t
a ern a l d i t d u i g p eg a y 44
e r n r n nc ,

i a i bl m i a 37 1
r sc e an , M e l a hol i a 301
nc ,

dp i e ress v e x i t m t 372 e c e en , c o d u t 309

n c ,

u p od u t i m a i a 37 2 a d p og i 5 10
'

n r c ve n . co u r se n r n o s s,

m i tupo 27 4
an c s r. e t i ol gy 30o ,
1

dep i o w i t h a i ght 01
r e ss n p at hol ogi al a at om y 303 c n ,

id 374
eas, p hy i al y m p t m 3 o
s c s o s, 1

dp i e res s o n w ith i ght f o ui i d a l 309

s c .

i d a a d m ot o al l a
e s, n e
i
n e y m p t m t o l gy 3 03
s o a o ,

t i o 37 5 n, d i agno i 3 1 s s, 1

g l
en e r a o u 3 7 6
c rse . f om m i d p i o 3 1 384
r an c e r ess n, 1,

p i od i i a i t i 3 7 6
er c ns n es, d m tia p
e en x 31 1 re c o ,

recu t m a i a 37 6
r ren n . d m t i pa al y t i a 3 1 2
e en a r c ,

recu t m l a hol i a 376

r ren e nc , p ogn i 3
r o s s, 12

al t at i g i
ern n t 3 7 6 380 n san i y .
, t at m t 3
re en . 12

i ul i a i t y 376 380
c rc ar ns n , , M e l a hol i
nc u t 3 76
a rec r re n .

i gul a f m 376 383

rre r or s. . d i ag o i 380
n s s,

u
rec nt m
r re i an a, s y m p t om 378 s,

co u rse .
37 7 t t m t 380
rea en ,

p r ogn o s s, i 3 78 M e mo y d i r d f 70
so r er s o .

sy m pt o m s, 37 8 M en s r t uat i 54 26 5 329
on , , ,

recu rren t me l an cho l ia M erc e r, i 38

di agn o s s. i 380 M e ry c i sm , 34

p t m 3 78
sy m o s. M i h l t 43
c e e
t at m t 380
re en .
M i kl
c Wm e, .
Jul i us ,
249 . 25 7 . 2 58 ,

c rci ul a i i ty r n san ,
2 62
co u rse, 38 1 M i ph l u 5
c r oc e a s. 2

t i l gy 38
e o o ,
1 M i crom i 69 an a, 2
y m pt m 380
s o s, M ig i 33
ra n e,

m i dp i i
an c i ty e re ss v e n san ,
M i x d ty p
e 37 es, 1
d i g i 384
a n o s s. M ph b i
on o 5 o a, 12
f m p i 384
ro a re s s .
M l
o ra l k sen se. ac of 36
f m i l ut i o l m l
ro n vo na e an \ l o rphi n i sm , 1 89
c ho l i a , 384 d i g i 95
a n o s s, 1
f rom d em en ti p a raeco x , 384 et i l gy 9oo o ,
1
p g i
ro nos s .
384 p g i 95
ro n os s . 1

t tm t
rea en , 38 5 sy m p t m t l gy o a o o ,
19 1
 I N DEX 501

t rea tm t en , 195 Neu ras hen t i c hun ger , 1 33

M or se ll i ,
249 Neurocerev r i te 9 1 ,

M oschu s, 15 1 t
N oc urn a e e sy 4 1 1 l pi l p ,

M o ort sy m pt m i o s n th
rom bot i c Norm an 280 ,

d em en t i a 29 7 .
N u r ont iti sor e r s o f , di d , 5 3, 1 31

M ucou s en e r t i t i 1 32 s, Nux m osc h t 36 7

a a,

M t i m 34 3 1
u s , , 2 Nu x vo m i ca, 1 1 8, 1 7 7 , 24 1 , 343 , 483
M y l t he i
e as 20 n a, 1 Ny stagm us 33
M y p i a 33
o ,

Obl i q u d fo m i ty
e e r of hea d . 25

N ot i
arc h bi t i a
c t o 44
a s n n ce s r s, O ulc ig f d
ar s ns o em en ti a pra cox ,
N ar row h d d 5 ea e n e ss, 2 24 1 , 24 2 , 243 . 244, 24 5 , 246 ,

N l d fo m i t i
asa 7e r es, 2 24 7

N asal t ub 3 3 448 e, 1 . O e d em a. 56
m t hod f f d i g w i t h 448
e o ee n . O en an th e cr oca a. t 420
N t um m u i ti um 366 469
a r r a c . , O pt i c n er v e p i e r n eu r it i s of , in de
N g t i i m 74
e a v s 5 3 , ,
21 , 2 1 m en ti a p rzeco x , 242

N ervo u xh u ti
s e 20 a s on , 1 O p i um , 429
N u l gi
e ra 33 a, O ran ge, Dr .
, 415
N u e t h i 20
ras en a, 1 O rgan c i d em en tia , 29 2

utac 1 20 e, O r i c i al su rge ry . 454

g t i 20
as r c. 1 O ri gm ari a ar an o p i a, 39 3
g i t l 1 20
en a , x p l
O y ce ha us 2 5 .

hy t 1 0
s e ro , 2

t i l gy
e o o 121
P l t
a a e ymm t i l 8
as e r ca . 2

p t h g i 33
a o en e s s
,

1
d m hpd 7 o e s a e ,
2

w i t h G t hi
.

h 7 o c ar c 2
sv m ptom ato l ogy ,
,
1 24

d i ff ti l di g i f m
e ren a a nos s ro de
t fd 7
a -
r oo e , 2

m t i p l y t i 1 34
en a a ra ca.
hi p fd 7 -
roo e , 2

w i th h h h
b l y p hi l i 37
ce re ra s s, 1 7 o r se s o e arc . 2

t b a d l i 37es o r sa s. 1
t u p l ti u 7
or s a a n s. 2

hy p o ho d i c38 n r a. 1
P i 8 99 40 86
a r an o a , 1 2, 1 ,
2 , 2

hy t i 38
s er a, 1
d i t i 386
e n on ,

m l ho l i
e an c 38 a, 1
h ci p g i 386
ro n c ro r e ss v e .

cou rsed p g 1 39an ro r ess

p d m l hy p h d i
ro ro a . oc on r aca l
t t m t 1 39
rea en
p i d f ubj t i
or er o o s ec v e an

l y i 387
,

di t y 14 e ar , 2
a s s,

hy g i i 4 en c , I 1
svm ptom s, 38 7
m l 4o o ra . 1 p t
er sec u o ry s age . t 388
t h p u t i 43 e ra e c. 1 y m pt
s om s, 388
m di l e 44 ca . 1 e xp i an s v e t
s age , 390
5 02 I N D EX
sy mp t om s, 390 P i i
cr c ac id , 1 5 1 , 24 1

o r i gm ari a or ear l y fo rm , 393 P ilt z, 2 1 7

sy m p tom s. 39 3 P l agi ocephal us 25 .

t diar va o r l at fo e rm .
39 5 l ti
P a n a 34 5 484 , ,

sy m p t om s, 39 6 P l um b um 429 ,

p er sec ut o y r , 396 P t al i u n 4
ren a n e ce, 1

cou rse, 398 P u

ress f a t i i t y 373
re o c v .

sy m p t om s, 396 P ot t i on he t 447
r ec s e ,

sex ua L 398 P y hi
s c q ui al t 4
c e v en s, 12

qu er u ous l i n san i ty , 399 P y hi

s c t i gm at a 34
c s .

course. 400 P y h
s c o se s, al ohol i 1 66 c c,

sy m p t om s, 399 i f t i 78
n ec on ,

i n v en t i o f m at i
ve r re o r v e. 40 1 po t f b i l i f t i o 86
s -
e r e n ec n,

s
y m p o m 4t0 s, 1 t at m t 89
re en ,

rel i g i ou 40 1 s, x hau t i on 97
e s ,

ym p t om
s 402 s, i l ut i o al 300
n vo n ,

erot i 40
c, 2 i tox i at i o 63
n c n, 1

p t hol ogy 403

a , p ly u i tic 9o ne r ,
1

p og o i 403
r n s s. P ub t y er t a d at i o f 34
. re r n o ,

t at m t 403
re en , P ul at i ll a 1 5 2 36 7 470
s , , ,

P ara no i a l ohol i 8
a c c, 1 2 P upi l 1 7 1 34
s, 2 ,

di o i ti
ss c a 09
va, 1 j um p i g 27 n ,
1

l i k d l i um 200
e e ri . i d me t i a pa l y t i
n e 26 5 n ra ca. .

P a i d f o m 209
ar no r s, 270

P i 249
ar es s, P ul se , 57
di g o i f m ma i d p
a n s s ro n c e re ss

i vei a i ty 384
ns n ,
Q uerul ous i n san y it . 399

P are s t h i a 5 5 264
es s.
cou r se, 400

P t hol gy 9
a o
,
sy ptm om s , 399
ul t
.

Q uer an en whan si n n
P t hol gi l u
a o ca p t i b i l i t y 23 1
s sce 2 32
, 399

P t h p hob i
a o a. 1 5 2
, ,

Qu i n i n e 207 .

P i d i
er o ic n san i t i 3 76 es , Ray m on d , 280

P er sec ut o y p a r i a 396 ran o . Reac ti on s au om a t ti c, 72

P o
er s n a l i
serv ces, 15 n ega ti 7 v e. 2

P e rsp i t i o 54
ra n. p i t i 72
os v e.

P t
e e r so n , 3 33 4 ,
6 5 256 28 3
. 1, , , , 390 Rec u t m a i a 376
r ren n ,

P titi
e on , 15 Rec u t m l h li
r re n e an c o a .
37 6
P ho p h u 1 5
s or s. 7 7 344 4841, 1 . . Re fe ree, h i g by ear n . 17

P h p h i a i d 4 368 3 70
os or c c , 2 1, . Re x
e 5 5 1 30 2 5
es, . . 2 ,
24 5 , 26 5 ,

P hren om an i a 9 7 . Re f ti
o r ni a p a i ve ar n o a, 400
i l gi l t i g m t ympt m
0

P hy s o o ca s a a, 33 s 40 o s . 1
 I N DE X 503

Reg i s, 2 5 2, 2 5 3 . 2 5 4 Spon g i a. 1 53. 34 5 . 485

li
Re gi ous p a a oi a
r n . 401 S t am m i er n g, 34
sy m p t om s, 402 S taphy sagri a, 24 1

Rhu s tox .
,
1 52 S t 63
earn s, 2

S t pl ee h p d k ull
e-s 5 a e s 2
i i ty l w
,

S an gu of ,
n . a 39 St t y py 7 3 2 1 5
e reo 2 32. . . 2 35
l i t i 54
.
Sa va on ,
S t i l i t y 34
er
k y 6 7 68
.

S an e ,
2 , 2
S t i gm at a f d g at i o 4 o e en e r n, 2
p
Sca hoce hap l u 25 s,
i d m t i p a ox 2 1 1
n e en a r ec
S tio d i o d
ecr e n s,f 54 s r e rs o ,
p hy i al i p i l p sy 4 1 8
s c n e e
,

S lf p t i o l o of 70
,

rese rv a n. ss
S t m h p um p 4 50
-
e ,
o ac
S il d m ti
,

en e 313 e en a,
S t am o i um 1 08 1 1 9 1 5 3 7 7
r n 1 24 1 ,
p t h l ogi al at m y 3 1 8
.
, , , ,

a o c an o
347 , 486
,

y m p t om s 3 4 s, 1
S t utt i g 34 1 30 er n
t at m t 3 9
, ,

re en ,
1
S ugg t i b i l i t y 7 2
es
S il at y i i 3 16 ,

en e s r as s,
S u lp hu 24 1 369 43 0 47
r, 1
m o al d t hi al l o s f 69
, , ,

S en se. r an e c , s o ,
S y m p t om t l ogy 5 1 a o
y m p t om
,

S o y
en s r 58 s s,
S y p hi l i b l d i ff
s ti t cere ra eren a ed
S pie 1 5 2 368 369 47 1
a. . . .
f m u a t h i 37 ro ne 1
r s en a,
S x ual i i t ab i l i t y 34
e rr ,
Sy phi l i ti i i ty 289 c n san
S xu l i t i t x al t d l o t p ,

y p al y i i
e a ns nc e e s er
289
, ,
e e ar s s n.
t d 70 v er e ,
m ot sy m pt m i
or 289 o s n,
S x ual p a a i a 398
e r no
speech
,
in, 289
S h k auoc of d f
, c t i o ff p i g
se e ec n s r n ,
t rem or i n, 289
43
Sil i ca , 4 29 T a esb d l i d i ff
o r sa ti t d f s eren a e rom

Sk i n an om a li es, 3 2 ne u a th ri 1 37
s en a,

S l p di o
ee ,
o f 5 2 53
s r d er s . ,
T aran t ul a hi p a i 488 s n a,

S m ll poa i i t i al d l i i um of 82
- x, n e r ,
'

l
'

ard i v a paran o i a, 395

p og i 83 r n os s . p t m 39 5
sy m o s,

S ou t
n am p 23 cr ,
2 T em p at u 57
er r e,

Sp h 7
eec ,
: T erm i al d m t i a
n e en , 43 1
i al oh l i i a i t y 389
n c o c ns n ,
n euron s . i n , 43 2
t t o i 75ca a n c, ag it t d f
a e o rm 434 ,

d f t i 34 e ec v e, sy m pt m 434 o s,

i m l a h l i a 75
n e nc o ,
p i f m 435
ass ve or ,

f p o t i 7 5 263 269 2 73 288

a re c, , . .
, ympt m
s 43 5 o s,

i y p hi l i t i
n si a i t y 89 c ns n ,
2 p hy i g m y i 433
s o no n .

Sp i g l i 5e a, 1 2 sig f m t l w k
ns o en a ea n ess. 432
S p i al n th i as 0 en a . 12 t t m t 43 6
rea en ,

Sp i t k 4 z 55
a, 69 3 7 1. 2 , 2 , 1 T hom p son , 37