A TEXT-BOOK OF INSANITY STATE OF CALIFORNIA.

2. DEMENTIA.

Clinically the term ” dementia” is used to characterise
the very large group of cases in which diminution of
intelligence constitutes the most conspicuous feature
in the malady. It is distinguished from idiocy and
imbecility by its history, for whereas in these a
normal grade of intelligence has never been attained,
in dementia the individual is degraded. A normal
grade of intelligence, once attained, has been lost.
The one has never risen above the rank of the pauper ;
the other has once been affluent, but is reduced to
poverty. Apart from the history, there is little to
distinguish them except the age of the patient, and
this is by no means a sure criterion. Idiots, it is true,
rarely attain adult age ; and a person who is mentally
deficient in early life, before the development of
intelligence is complete, is not a dement. But many
imbeciles live to middle life and old age, and are then
indistinguishable mentally from dements ; and many
young adults become demented and might be taken
for imbeciles but for their history. Both imbeciles and
dements are liable to outbreaks of excitement, in which
the form of their insanity becomes that of mania
for the time being. Many patients who, from their
quietude and absence of conspicuously active insanity,
would be classified clinically as dements, are found,
upon examination, to hold delusions of more or less
fixed type, and thus might, with equal propriety, be
placed in another class. By ” dements ” as a variety
of insanity we mean those insane persons in whom
simple impairment of sanity is the most conspicuous
feature, whose intelligence, feeling, and conduct are on
the whole much diminished, but who may entertain

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delusion, who may from time to time exhibit outbreaks of
excitement or of perversion of mind and conduct, who
may now and then become exalted or depressed. When
they exhibit these additional symptoms, the form of
the insanity is no longer pure dementia, but still
they would be clinically classed among dements, the
dementia being still the most conspicuous feature of
their condition.

As a clinical entity, dementia is the natural termina-
tion of life. In the vast majority of cases life is cut
short by accident, or by the quasi-accident of bodily
disease ; but when it goes on until it ceases from pure
exhaustion of the quantum of energy that it received
at conception, it has to pass through dementia on its
way to the end. Some degree of dementia, some
diminution of the vividness of feeling, of the capacity
of thought, of the range and variety of conduct, is
the natural and inevitable accompaniment of the decay
of the bodily power in old age ; and it often happens
that the decay of the highest regions of the brain
outstrips that of the body, so that the dementia sets
in earlier, is more pronounced in degree, and is more
irregular in its manifestations than is usual and normal
in old age, and is out of proportion to the decay of
the bodily capacity. The condition then presented
is the clinical condition of senile dementia.

In senile dementia the most conspicuous aspect is
defect of memory ; the most conspicuous fault is the
outbreak of ill-temper. The defect of memory is
peculiar, and is characterised by the evanescence of
the memory of passing experiences while the memories
of long-past experiences are not only retained, but are
increased in their prominence, in their intensity, and
in the frequence with which they are present in con-

VARIETIES OF INSANITY DEMENTIA. 109

sciousness. The first approaches of senility, which are
perceptible between forty and fifty, are marked, as has
been said, by an inability to recall newly acquired
names, whether of persons or of things, and generally
by a want of nimbleness in the use of substantives-
As age advances, experiences produce impressions
that are less and less enduring, and, in the dementia
of old age, become so transient that events are not
remembered from hour to hour, and often not from
minute to minute. A senile dement will declare that
he has not seen for months a person who spoke to him,
and whom he recognised and answered, five minutes
before he makes the declaration ; and no matter how
important or impressive the event, its memory is
equally evanescent. While he thus forgets with
abnormal celerity and completeness current events,
he retains with punctual fidelity the memories of
experiences that he underwent in youth, and is able
to give accurate descriptions of events that happened
fifty or sixty or more years ago. Nor is this all ; the
memories of long-past experiences are not only faithful,
often surprisingly and unusually faithful and detailed,
but they thrust themselves forward and occupy a much
larger share of consciousness than is usual. People in
middle life, and normal people in old age, are occupied
mainly with the current experiences of their daily life ;
and the reminiscences of childhood are before the mind
but seldom, and for short periods. But in many cases
the senile dement lives his childhood over again. He
is perpetually maundering about things that happened
before his hearers were born, about the events of his
school life and his early love affairs, and not very
infrequently these memories of bygone experiences
take such hold upon him that he actually mistakes

110 TEXT-BOOK OF INSANITY.

the people about him for the companions of his early
life. He addresses his grandchildren by the names of
his schoolfellows, and takes his daughter for his first
sweetheart .

Together with this peculiar defect of memory there
is usually in senile dementia an irritability of temper,
a petulance and impatience, which reproduce the
peculiarities of a spoilt child. If they want a thing,
they must have it on the instant ; they cannot wait
until it is prepared or until it is fetched ; they must
have it now, this moment ; and if it is not forthcoming
they fly into a rage, they stamp, they shout, they
swear, and they often offer such feeble violence as
they are capable of. Like the child, too, they are
easily coaxed into a good humour again ; their ill-
temper is transient, and its occasion soon forgotten.
Another characteristic is the wearisome iteration with
which they will repeat the same thing, their defect
of memory rendering them oblivious to the frequency
of the repetition. Indeed, the repetition of the same
story at short intervals to the same person is as
common an indication of the advent of senility as is
the difficulty of dealing with substantives that has
already been mentioned.

As in idiocy, so in dementia, the failure of sanity
may be due to premature exhaustion of the develop-
mental impetus, or it may be due to the interference
of some extrinsic cause which does not allow the
structure to crumble down, but violently pulls it down.
To enumerate the causes of dementia would be to
enumerate those of insanity, for every other form of
insanity is dementia with superadded symptoms. In
acute insanity, the superadded activity is so over-
whelmingly important and predominant that the

VARIETIES OF INSANITY DEMENTIA. Ill

dementia which underlies it attracts no attention.
When the active symptoms subside, they leave the
dementia outstanding ; and thus it is usually said that
dementia is a result of a previous attack of insanity ;
and while this is a convenient way of describing the
sequence of clinical events, yet, if we are to be
scientifically correct, we ought to say that the sub-
sidence of the active symptoms reveals the dementia
which has throughout co-existed with them. Clinically,
we call a case of insanity one of dementia, not only
when the active symptoms are absent, but when they
are but little prominent, or when they are occasional
only. Dementia is, in fact, the common form of all
insanity, but, when other symptoms are added to the
defect of conduct, intelligence, and feeling which
constitute pure dementia, we give to the form of
insanity some other name, if these symptoms are
conspicuous or enduring. If they are not prominent,
or only occasional, we still call it dementia. Insanity
may come on in middle or early life, may run its
course, and may slowly increase for years, until it
reaches a great depth of dementia, without at any time
exhibiting any of the active symptoms which would
enable us to class it as mania or melancholia, and
without ever being accompanied by delusion, at any
rate by prominent delusion ; and such a case would be
called one of primary dementia.

Usually, however, the onset of the insanity is
attended by active symptoms, according to which
the insanity receives its title, and only after it
is laid bare by their subsidence does the dementia
come into clear view. Hence the great majority
of cases of dementia are called secondary, and
are looked upon as consequences of previous attacks

112 TEXT-BOOK OF INSANITY.

of more active insanity. But in every case of
insanity the essential feature is defect. In no case
does disease make a real, a fruitful, addition to function.
The affection of function is always in the direction of
loss, of defect, of diminution. In inflammation, tissue
change is increased in activity, it is true, but it is
carried on upon a lower level. There is increase of
process, but there is diminution of function. In
glycosuria there may be increased production of sugar
by the liver, but there is no real elevation of the
function of this organ, and the general functions of the
body are not increased, but diminished. And so it is in
active insanity. In mania there is great increase of
activity ; in melancholia and in exaltation there is great
increase of feeling; in delusion there is increase in
the ability of mental states to enter into coherent
combinations. But none of these states of increased
activity indicate real operative increase or elevation of
function. On the contrary, they are accompanied by,
and they indicate, diminution of function. For with
all the vivacity of thought that obtains in mania, there
is always an inability to appreciate the circumstances
in which the individual is, and his true relations to
these circumstances. With all the increased activity
of conduct, the conduct is on a lower level ; it is not,
and cannot be, adapted to the circumstances, for the
power of adapting conduct to circumstances, the
highest function of the brain, is defective. With all
the increased intensity of feeling, with the depression
or the exaltation, there is still the mal-adjustment of
this feeling to the circumstances, and there is still the
inability to bring the feeling into correspondence with
the circumstances. And the important, the vital
disorder, is not so much the increase of activity, as the

VARIETIES OF INSANITY DEMENTIA. 113

degradation of activity to a lower level ; is not so much
the excess as the defect ; is not so much the mania, or
the melancholia, or the exaltation, or the delusion,
as the inability to appreciate the mal-adjustment of
conduct and thought and feeling to circumstances, and
to bring about readjustment. So that, in all cases
of insanity, the real and important aberration is not
necessarily the most conspicuous feature the over-
action which may be regarded as adventitious, and to
a certain degree as accidental, but the degradation of
activity to a lower plane ; and it is this degradation
that is indicated by the term ” dementia.”

Allowing that in all forms of insanity this degra-
dation of conduct exists, then the clinical kind of
insanity will depend upon whether the defect is
simple that is to say, upon whether the activity
of mind and conduct are merely degraded and
diminished, and upon the lower plane to which
they are reduced no excess of activity takes
place, in which case it is simple dementia ; or upon
the kind and degree of inferior and debased activity
that goes on at this lower level. When the debased
activity is marked by excess of feeling, we call it
melancholia or exaltation, as the case may be ; when
it is exhibited in excess of low-grade conduct, we call
it mania ; when it occurs in the formation of beliefs,
we call it delusional insanity. In any case of simple
dementia, over-action may occur at the low level to
which the nervous organisation is reduced, and then we
call it a case of dementia with outbreaks of excitement,
or of dementia with delusions, and so forth. Even
when the dementia is deep, when the level to which
the nervous organisation has been degraded is very low,
some over-action upon this lower plane is usual, and

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114 TKXT-BOOK OF INSANITY.

then we witness those forms of dementia in which the
jiatient is excessively voracious, in which he eats all
kinds of filth and rubbish without distinction ; in which
he collects stones and sticks and bits of string and
other rubbish ; in which he tears and destroys his
clothing and anything he can get hold of; in which he
exhibits for many hours every day, and every day for
years together, some simple and inappropriate form of
conduct ; in which he shouts and screams, or pats his
leg, or rubs his clothes together as if in the washtub,
or rocks himself backwards and forwards in his chair, or
repeats the same form of words.

The degrees of dementia are practically infinite.
They range from the trifling decadence of intelligence,
feeling, and conduct that is exhibited by any one after
an enfeebling illness, or at the end of a tiring day,
down to the almost total obliteration of consciousness
and movement in the latest stage of such a disease as
general paralysis, in which the patient lies a mere log,
insensible to all that is passing around him, passing
his motions and urine as he lies, allowing the flies to
walk over his face and into his open mouth without
showing the least sign of disturbance, indifferent to
the sight and smell of food when placed before him,
incompetent even to chew the food placed in his
mouth, and exhibiting only sufficient intelligence to
swallow the pulp with which he is fed.

In this long and uniformly diminishing series we
may mark off separate grades where we please, and
whatever divisions we make will be wholly artificial ;
but there is a practical convenience in distinguishing
between grades of dementia, and the first grade that we
may distinguish is that in which the social activities
alone, or chiefly, are defective. In this respect all the

VARIETIES OF INSANITY-DEMENTIA. 115

insane, without exception, are deficient. As the higher
social qualities are the last to be acquired, so they are
the first to be lost when complete sanity begins to fail.
We never find an insane person who is quite polite.
Ceremonious they often are in an exaggerated degree,
but polite, in the sense of exhibiting those little
benevolences which are as oil in the running of the
social machine, they never are. Even the sanest of the
insane are deficient in courtesy. They may bow you
into their room with an exaggerated affectation of
ceremony, but they fail to offer you a chair; or, if
they go as far as this, they exhibit their want of civility
by engrossing the conversation, and in talking exclu-
sively about themselves ; in their naive boastfulness ;
their engrossment in their own affairs ; their indiffer-
ence to the little ordinary duties of hospitality ; in the
absence of all effort to entertain. In the next grade
of dementia the indifference to social obligations is
greater. The subject of it will receive you in his
shirt-sleeves, he will go about the streets in his
dressing-gown and slippers, he will go to a funeral in
a shooting suit. If a woman, she will be indifferent to
her personal appearance, be untidy, slovenly, and dirty
in her dress, will go about with tangled hair, loose
stockings, and shoes down at heel. If a man, he swears
freely before ladies and strangers, and introduces
objectionable topics of conversation without discerning
any impropriety in so doing ; or he may go further,
and introduce loose women, perhaps his own mistress,
to his wife and daughters, and even bring her to live
in the same house, oblivious to the objectionable
character of his conduct. He loses reticence, and
speaks familiarly of his family affairs, of his income, of
his differences with his wife, of his son’s misconduct,

116 TEXT-BOOK OF INSANITY.

and his daughter’s epilepsy, before strangers, in railway
carriages, in hotel smoking-rooms, in his club. If a
woman, she will talk with similar want of reticence of
her confinements and miscarriages, of her husband’s
unfaithfulness, or her own amours.

The grades of dementia described above may co-exist
with full ability to earn the livelihood and administer
the means, but in the next grade these modes of
conduct also are affected, and the patient becomes
either incapable of appreciating the importance of
continuing his regular employment and of regulating
his expenditure according to his income ; or, while
recognising the importance of doing so, incapable of
appreciating what his income is, and therefore what
his expenditure should be ; or deficient in ability to
follow his employment. In conjunction with these
defects we meet with many forms of excessive action
upon a lower level, which will be alluded to in other
connections.

The lowest grade of dementia is exhibited by those
who have not only wholly lost their ability to ad-
minister their means, but who are deficient also in
that primitive group of activities by which existence
is preserved from day to day and from hour to hour.
If their food is not brought to them, they will make
no effort to provide it for themselves. They have
not sense enough to come in out of the rain. If the
house were on fire they would not know which way to
go to get out of it, even if it occurred to them that
it was desirable to escape. Conduct is reduced to
finding the way from the bedroom to the sitting-
room, from the fireside to the meal-table, and back
again ; or even this modicum of intelligence is lost.
Even in this lowest grade of dementia degrees or

VARIETIES OF INSANITY DEMENTIA. 117

sub-grades are apparent. The most intelligent of
these dements are clean in their personal habits.
The next lower grade is when they pass their urine
under them, but go to the closet to defsecate. Then
this is lost also, and their motions are passed in their
clothes. Then they become incapable of dressing
and then of undressing themselves; and the last
acquirement to be lost is the art of carrying the
food to the mouth when it is placed before them.
Even in this accomplishment there are degrees, for
some can use a knife and fork, some a spoon only,
and last of all, this implement is abandoned, and the
fact that fingers were made before spoons is practically
exemplified, since their use is retained longer.

Several clinical varieties of dementia are commonly
enumerated, but how far it is correct to describe them
as distinct is doubtful. The primary, the secondary,
and the senile are separately dealt with. In addition
to these, there has been described an alcoholic
dementia, which will be dealt with among the in-
sanities due to alcohol, and general paralysis is
sometimes termed by Continental writers dementia
paralytica. The only form of dementia which has
a true clinical distinctness and constitutes a separate
clinical entity is that which is known as stupor.

3. STUPOR.

This is as nearly a distinct and separate form, as
well as variety, of insanity as there is. In pronounced
cases it is quite unmistakable, but it is not always
pronounced, and an element of stupor may often be
distinguished in cases of dementia that would not
be called stuporous, and especially in the young, for

118 TEXT-BOOK OF INSANITY.

stupor occurs usually, though not exclusively, in early
life. It exhibits the signs of exhaustion of nervous
energy, as though the highest regions of the brain
had been emptied of motion and had ceased to act ;
and it is usually preceded by experiences which are
calculated to drain these regions of their energy,
and especially by a combination of several such
drains. If we wished to produce a case of stupor,
we should take a young man between the ages of
eighteen and twenty-five, subject him to severe and
exhausting bodily fatigue, let him at the same time
work hard in preparing for an examination, let him
work too many hours a day, and have insufficient
food, and especially insufficient sleep; and above all,
let him masturbate freely, and at the end of a month
or two he will become insane, and his insanity will
take the form of stupor. If he is so exceptionally
strong that these measures fail to break him down,
the last effort of resistance can be overcome by sub-
jecting him to some severe shock. Let him be
involved in a railway or other accident, or let him
even witness one, or let him come suddenly upon
a dead body, or see his schoolfellow dragged drowned
out of a river, or let him be assaulted and robbed,
or set his house on fire in the night. By such
means may stupor be infallibly produced even in
a strong nature; and a weak nature will not require
such an aggregation of causes. Any one of them will
suffice sometimes, any two of them or three of them
will usually suffice, especially if excessive masturbation
be among them, though this last factor is by no means
essential to the causation of stupor.

Whatever the causation, the insanity may be
stuporose from the outset ; but more usually to the

VARIETIES OF INSANITY STUPOR. 119

exhausting conditions that have been mentioned the
further exhaustion of a few days of acute insanity is
added, and then the stupor comes on. The charac-
teristic of the stuporose patient is his stillness. He
stands with drooping head and hanging arms, with
open mouth and staring lack-lustre eyes, with a face
void of expression, in an attitude void of vigour, and
thus he stands all day. Speak to him, shout at
him, fire a pistol behind him, flick your fingers
within an inch of his eyes, you evoke no response ;
he exhibits no reaction. Saliva hangs in long ropes
from his open mouth, his face is sweaty and greasy,
his pupils large, his tongue flabby, his hands blue,
his pulse feeble. Of food placed before him he takes
no notice, but if it is put into his mouth he will
chew and swallow it. Yet, stupid as he is, and
destitute of most ordinary reactions, except in the
most extreme cases he does not let his urine
dribble, nor does he allow his bowels to act inap-
propriately. He retains both urine and faeces until
he is taken to the closet, and when he is there he
passes them. As he passes his days in a state
closely allied to profound slumber, so he sleeps well
at night.

Such is the appearance and such are the habits of
a well-marked case of stupor. But the condition is
not always as well marked as this, and indeed the
degrees of stupor are very various. In milder cases
the patient moves from place to place of his own
accord, though his movements are seldom and slug-
gish. He may answer when addressed, but the
answer is long in coming, is brief, and is uttered in
a faint monotonous voice. He may keep his mouth
shut, exhibit palpebral reaction, and even look about

120 TEXT-BOOK OF INSANITY.

him from time to time ; in short, he may exhibit n
less degree of the same condition ; or, in rare cases,
the symptoms are not less, but more pronounced.
The patient does not stand, does not move under
any provocation. He lies like a log; he passes his
motions and urine beneath him. He does not even
chew his food. His extremities are not only blue,
but deathly cold, and the circulation in them is so
defective that sometimes sloughs form. His only
spontaneous movements are breathing and swallowing.

While spontaneous movement is absent or mini-
mised, the reaction to ” passive ” or imposed move-
ment presents three well-marked variations. In the
first class, every attempt to move the limbs or the
body is met with obstinate and intense resistance,
which is the same to every variety of movement
and in every part of the body. It is as pronounced
in the jaw as in the arm or leg ; it is as obstinately
opposed to flexion as to extension. It is as difficult
to make such patients change their attitude from
standing to sitting as to make them change from
sitting to standing. The same resistance that is
opposed to everything else is opposed to the adminis-
tration of food ; and of course this is a serious matter,
and influences the prognosis, which is worse than in
the other forms, though not necessarily hopeless.
This obstinate resistance to imposed movement, when
present in stupor, is always associated with melan-
cholic delusion ; it is present in many cases of acute
insanity, and then also is usually associated with
melancholy.

The second and most frequent variation in the
reaction to imposed movement in stupor is the
” cataleptic ” condition, in which there is no resistance

VARIETIES OF INSANITY-STUPOB. 121

to the imposition of movement, and in which any
attitude that we choose to impose upon the patient is
retained by him. When the stuporose condition is not
very pronounced, the attitude is maintained for but a
short time, it may be only a moment or two ; but
when the stupor is deep, the attitude will be main-
tained for long. We raise the patient’s arm over his
head, and there it will remain for several minutes.
Dr. Clouston relates a case in which a stuporose patient
was got out of bed, the chamber pot was put into his
hands, so that he held it under his penis, and then the
attendant went away and forgot him. He remained
in this attitude for several hours. In stuporose cases,
in which this cataleptic condition exists, the prognosis
is usually favourable.

The third variation is that in which there is neither
resistance to, nor retention of, an imposed attitude, but
a flaccid facility. The limbs can be moved with ease,
and fall back after movement into such positions as
require the least exertion to maintain. This is the
condition to which the term ” anergic stupor ” has
been given.

The mental condition in stupor may be in one of
two extreme conditions, or in any intermediate state
between them. In simple stupor, of exaggerated
degree, consciousness is altogether absent ; at least,
we can get no manifestation of consciousness while
the state continues, and when it is past, no memory
whatever remains of the experiences of the stuporose
state. In the minor degrees, consciousness is pro-
portionately diminished. Some sign of consciousness
can be elicited, some slight reaction can be obtained ;
after a question has been many times repeated, some
answer will be given ; after an order has been many

122 TEXT-BOOK OF INSANITY.

times insisted on, some attempt will be made to carry
it out ; and when recovery takes place, some glimmer
of remembrance will be retained of what occurred
during the illness.

The other form of stupor is called melancholia cum
stupore, or melancholia attonita, or melancholy stupor,
since in it there is always misery, and sometimes the
depression is profound. The depression is somewhat
different from that of ordinary melancholia, and is
more of the nature of panic or horror. The sense of
personal unworthiness and incapacity which constitutes
melancholia is, indeed, present, but in addition to this
is an overwhelming horror at something that the
patient deludedly believes to have occurred, or to be
about to occur. Unlike the previous form of stupor,
consciousness is not only present, but seems, as it were,
to be intensified. The patient is keenly alive to
everything that is going on around him, but every-
thing that happens is woven into his dream, and goes
to corroborate and intensify it. If he is compelled, for
instance, to take food, to dress or to undress, to sit
down or to walk, this interference is interpreted by him
to be the actual beginning of that terrible torture to
which he is to be submitted, and the attendants who
so interfere with him are his executioners. Hence
his stubborn resistance.

The treatment of stupor may be summed up in two
words feeding and rest. The state is .one of exhaus-
tion, and the treatment must be directed to restore
the exhausted energy. To this end feeding must be
copious. Such patients must have much more than
the ordinary full diet which would suffice for a healthy
person of the same age, and, in young people at any
rate, it should be highly nitrogenised plenty of eggs

VARIETIES OF INSANITY STUPOR. 123

and plenty of meat, with a moderate quantity of
alcohol. When solid food cannot be administered,
of course slops must be given, but essences and extracts
are useless. Milk is always valuable, and when food
cannot be given in solid form, it should be given, not
as liquid, but as thin porridge, that is to say, with
plenty of finely divided solids suspended in it. Bread
sauce is an excellent food, and may be mixed with
pounded meat.

Kest is the complement of feeding. Since energy
is exhausted, every demand upon energy must be
minimised, and therefore the patient should be kept
warm, and usually he should be kept in bed. He must
be vigilantly watched to prevent masturbation, which
often goes on in a quasi-automatic manner ; and
sleep, the great restorer of exhausted energy, should be
encouraged, and if necessary induced by hypnotics.

The same indications govern our administration of
drugs. Cod-liver oil, Easton’s syrup, and other pre-
parations of iron, quinine, strychnine, and phosphorus
all appear to assist recovery. Baths and friction are
useful, but massage is not advisable.

In simple stupor, the prognosis is usually favour-
able. It occurs commonly in young people, in whom
recuperative power is active, digestion good, and
sleep easily induced; and, moreover, in this form
there is neither refusal of food nor exhaustion from
struggling during its administration. In melancholy
stupor the prospect is much less favourable. It may
occur at any age ; sleep is usually difficult to induce,
and the strenuous resistance to feeding and other
necessary offices keeps a perpetual drain upon the
strength. Hence recovery is in this form less frequent,
it is longer delayed, and a much larger proportion of

124 TEXT-BOOK OF INSANITY.

the cases end either in death or in permanent
insanity.

In other characters, as well as in those mentioned,
melancholic stupor shades off by insensible degrees
into acute insanity, and many cases which would
usually be classed as acute insanity exhibit the panic
and horror that are so prominent in this form of
stupor. When, as not seldom happens, the subject of
melancholic stupor exhibits sudden outbreaks of im-
pulsive violence, directed either against himself or
against others, or similarly impulsive outbreaks of
destructiveness, the case approaches in character to
ordinary acute insanity ; and the affinity of the two
forms of insanity is further exhibited in the occasional
transition of the one into the other. The stuporose
patient loses his apathy, his outbreaks of excitement
become more frequent, and he passes, on his way to
chronic quiet dementia, through a period of ordinary
acute insanity.

4. ACUTE DELIRIOUS MANIA.

This is one of the most definite and clearly dis-
tinguished clinical varieties, as distinguished from
forms, of insanity one of the few varieties of in-
sanity which runs a very definite course. No other
variety of insanity exhibits such extreme and con-
tinuous excitement as acute delirious mania. Even
in acute insanity the patient has his moments of
tranquillity; has snatches, perhaps prolonged periods,
of sleep ; will occasionally answer questions intelli-
gently; will regulate his conduct with some refer-
ence, however distorted, to surrounding circumstances ;

VARIETIES OF INSANITY DELIRIOUS MANIA. 125

will sometimes recognise his friends, and will have
some regard to the decencies of life ; but in acute
delirious mania the alienation is more profound. The
raving is continuous. It goes on incessantly, day
and night, the whole twenty-four hours round. It
is quite incoherent and meaningless, a torrent of
unintelligible utterance. And as is the vocal move-
ment, so are the other bodily movements. The
restless activity is extreme and incessant ; the patient
roams about with ceaseless restlessness, he is never
still, he never lies down, he never sits down, he is
always on his feet, always in movement. He neither
eats nor sleeps ; sometimes he will drink, sometimes
not ; but in any case he never eats voluntarily ;
and is with the greatest difficulty induced to do so.
The length of time that he goes entirely without sleep
is astonishing. Day after day and night after night
he keeps up his incessant movement. You cannot
engage his attention ; he takes no notice when
spoken to. He is indifferent whether he is dressed
or naked ; heat and cold he does not notice ; the calls
of nature he does not answer : his bladder becomes
full, and over full, until his urine dribbles away.
Withal his temperature is raised ; it is seldom much
raised, but it is two or three degrees above normal,
and this feature alone distinguishes this from almost
every other variety of insanity. Such excessive and
continuous waste of tissue and of energy cannot endure
long without producing exhaustion. After a few days of
this extreme restlessness and sleeplessness, the patient
is no longer able to remain on his feet ; he “sinks
to the ground, but still he continues to rave in a
voice hoarse and well-nigh inaudible from incessant
use ; still he continues to toss about MS weary limbs ;

126 TEXT-BOOK OF INSANITY.

and when this stage is reached, the end is not far off.
His mouth becomes dry, sordes accumulate on his lips
and teeth, his heart’s action fails, his pulse flutters,
his breathing becomes a succession of sighs; but still
he mutters in a hoarse whisper his unceasing babble,
until, at the end of seven or eight days, he dies of
exhaustion. Such is the course of a typical case of
acute delirious mania, the ” brain fever ” of older
writers, the most rapid and most terrible variety of
insanity.

It affects both men and women, and usually those
who are in the prime of life from twenty-five to
forty and is usually preceded by some prolonged
and efficient debilitating occurrence, such as an ex-
hausting illness, deficiency of food, rest, and sleep,
anxiety, disappointment, or excessive intellectual
labour.

Acute delirious mania is practically always fatal.
If a case is so mild as to admit of recovery, it would
be one of acute in sanity -rat her than of acute delirious
mania. As to treatment, a padded room is essential.
In no other surroundings can the restlessness of the
patient lead to so little bruising and other injury.
Abundance of food must be given by the stomach
tube, and mingled with it should be given brandy,
strychnia, and large doses of hypnotics paraldehyde,
sulphonal, and trional being the best. For all that
we can do, however, the patient will almost surely
die ; and in the rare cases in which the bodily
health recovers, the patient remains a mental wreck,
a hopeless dement for the rest of his days.

VARIETIES OF INSANITY. 127

5. ACUTE INSANITY.

The boundary between this and the previous variety
of insanity is not always well defined, but generally,
the whole course and symptoms of acute insanity are
less acute, less rapid, less exaggerated and fulminating,
than those of acute delirious mania; recovery is not
infrequent ; and what differentiates them more sharply
is that in the latter disease the form of insanity is
always that of mania, while acute insanity is of several
types.

The causes and antecedents of acute insanity are
those of insanity in general. It may occur at any
age after sixteen, and in very rare cases before that
age, but is most frequent in the most vigorous period
of life from twenty to forty-five.

Acute insanity is rapid, sometimes sudden, in its
development. The very first thing to attract attention
and to indicate insanity may be a determined attempt
at suicide a leap from a window, a cut throat, or a
dose of poison, or it may be some outrageous or violent
act directed against other people. But usually there
is some warning of what is going to happen. For
days, or even weeks, beforehand, the patient sleeps
little, dreams much and vividly, eats little, finds
himself unable to attend to his business, feels ill,
and perhaps seeks medical advice. Headache is rare,
but often the mind is confused, and the patient dreads
lest he should be going out of his mind ; or he gets
restless, talks too much, pays too many visits, writes
unnecessary letters, sends unnecessary telegrams,
neglects or mismanages his own business, and meddles
with that of every one else.

128 TEXT-BOOK OF INSANITY.

After a few hours, days, or weeks of these initial
symptoms, the disease becomes fully established, and
then exhibits several forms distinguished by the
following characters : In the first form the patient
is excited that is to say, his movements are in
excess ; he talks with rapid fluency and discon-
nectedly ; he utters sometimes a stream of words
in which each suggests the next by sound or mean-
ing, but which are not connected into sentences,
such as ” window, wind, blow, thrashing, smashing,”
or they may be connected into sentences which are
similarly irrelevant to each other, as ” open the
window, give me a glass, drink your brandy, isn’t he
handy ? what a dandy ! fine feathers make fine birds,”
etc. Together with verbal utterance, other move-
ments are in excess, and are similarly disconnected.
The patient roams about the room, he rushes to the
door or the window, he picks up every movable object
and throws it down again, or throws it about the
room, or converts it to some use for which it was
never intended. He upsets the water-jug and the
chamber-pot, he overturns the furniture, he breaks
the windows, he throws the chairs about, he assaults
those who endeavour to control him, he tears his
clothes off, he or she swears, blasphemes, and talks
obscenely ; and all this he does, not with any settled
or intelligent or enduring purpose, but aimlessly,
erratically, and out of the mere exuberance of his
energy.

A second type is the melancholic. In this type the
activity is less, and there is a dominant delusion.
The patient believes that he is ruined, or that he is
damned, or that he has some frightful bodily disease,
or that he is morally a hopeless outcast, and to this

VARIETIES ACUTE INSANITY. 129

belief he gives utterance all day long. He is usually
still over-active, though his over-activity is less. But
he does not sit down, he does not rest ; he shuffles
about the whole day long, giving vent, not with shouts
and outcries, as in the previous type, but in a
muttering, plaintive, miserable voice, to his conviction
of his own ruin, his un worthiness, his incapacity. He
weeps, he moans, he wrings his hands, he tears his
hair, he beats his breast ; he importunes you for a ray
of hope, a glimmer of comfort ; but he refuses to be
comforted. He repeats the same formula over and over
again a thousand times a day : ” Oh ! my poor soul.”
” I am so wicked ! ” “I can’t pay you ! ” ” My poor
wife and children!” “Oh! dear; oh! dear.” “Oh!
my God,” and so forth. He is less inclined to the im-
pulsive outbreaks that are so common in the previous
type, but he is very likely to commit suicide, and he
is more persistent and obstinate in his refusal of food,
while he is less neglectful of personal cleanliness and
less apt to pass his motions and water beneath him.

A third type is the suicidal. Acute insanity of
suicidal type often displays as much restlessness and
over-activity as is seen in the first type that of acute
mania. In every form of acute insanity attempts at
suicide are common events, but in this form the whole
attention and energy are concentrated upon the single
purpose of suicide. The sufferer from acute mania will
try to jump out of the window, or will take up a knife
or a razor and cut himself with it, not, as far as can be
judged, with any deliberate intention of suicide, or of
anything else, but out of pure restlessness and meddle-
someness, combined with inability to appreciate the
nature and quality of his acts. In this, as in every
other type of acute insanity, there is sure to be, at

9

130 TEXT-BOOK OF INSANITY.

some time, refusal of food, but the refusal does not
appear to be the expression of any deliberate intention
of suicide. But in this third variety the whole power
of the mind is absorbed in, and devoted to, the single
object of suicide. The mind is far more alert than in
the other types ; the power of adapting means to ends
is retained to a far greater extent ; and the end which
is sought with inflexible determination, and with the
most flexible adaptation of means, is suicide. To effect
this end they are continually on the watch. In every
object they see a possible means, and they set them-
selves with much ingenious contrivance to reach it,
and possess it. They will promise to eat, if they may
eat by themselves, hoping thereby to be left alone.
They will break glass and crockery to get a cutting
instrument ; they will ravel out the threads of their
clothing to make a cord which they can tie round the
throat ; they will swallow anything that seems un-
wholesome ; will bite a piece out of a tumbler or a cup,
and try to swallow the fragment ; will batter the head
against the wall or floor, and try by the most unusual
as well as by the most obvious means to effect their
purpose. If they find suicide impracticable, or while
they are waiting for a favourable chance to effect it,
they will occupy the time with efforts to reduce their
comfort and give themselves pain, or even mutilate
themselves. They will try to gouge their eyes out
with their fingers, to tear the cheek with the finger in
the mouth, to tear out the testes or to cut off the penis.
Prevented from tying a ligature round the neck, they
will endeavour to tie it round the leg or the penis.
Prevented from knocking their heads against the wall
they will take the skin off their knuckles by the same
means, and so on.

VARIETIES ACUTE INSANITY. 131

A fourth type is the silent, obstinate, resistive.
Patients of this type do not speak. When spoken to
they do not answer. They make for the door, the
window, or the fire, and when restrained will continue
for hours the same silent, dogged, determined effort
to reach the desired destination. They, too, undress
themselves, but they do so, not, as the acute maniac
does, from the mere exuberance of their activity, which
must find some vent, it matters not what, which, when
restrained from taking off the coat, begins to unbutton
the waistcoat or trousers. A patient of this type
undresses himself with the same blind, dogged obstinacy
that he does everything else. He persistently, again
and again for hours together, attacks the same button,
or tries to remove the same garment in the same way.
He, too, refuses food, but he refuses it, not, so far as
can be judged, with suicidal intent, but with the same
resistiveness with which he stubbornly opposes every-
thing that is done for him refuses to be dressed and
to be undressed, to be sat down or stood up, to go to
the closet and to come away from it, to walk about or
to stand still.

A fifth type of acute insanity is the sexual. A
sexual proclivity is usually perceptible, as is the
suicidal proclivity, in every case of acute insanity ; but,
in the one matter as in the other, there are cases in
which the proclivity becomes so pronounced, assumes
such dominance, is by so much the most prominent
and conspicuous feature, as to constitute a distinct
type of the malady. The sexual type is exhibited
by women almost exclusively. Few things are more
surprising in insanity than the obscenity and filth that
are uttered by women, and even by young girls, well
bred and carefully brought up, of pure lives, and

132 TEXT-BOOK OF INSANllY.

previously irmocent conversation and behaviour. They
curse and swear like troopers ; they use expressions
of obscenity and blasphemy of which a costermonger
would be ashamed. Nor is it only in their speech that
they display lewdness and indecency. Insane women
of this type make shameless overtures to every man to
whom they have access. Not the gardener nor the
footman ; not the waiter in the hotel in which they
are taken ill ; not the medical man who attends them ;
not even their own brothers or fathers, are exempt
from their libidinous advances. They ogle and leer,
they throw themselves into unseemly and indecent
attitudes, they expose their breasts and legs, and, when
all this is ineffectual, they do not hesitate to ask in
plain terms for what they want to call out of the
window to a passer-by to come to bed with them, or
even, in plain Saxon, to have intercourse with them.
As the melancholic and suicidal varieties of acute
insanity are often called acute melancholia, so the
sexual type is often called nymphomania ; but all are
really varieties of the same malady, in which the
one or the other feature, common to all, becomes
exaggerated and assumes unusual preponderance.

Whatever the type of the acute insanity, there are
certain features common to them all. All, as we have
seen, are potential suicides. In all there is at one time
or another refusal of food, alternating, it may be, with
wolfish voracity. In all there are sexual proclivities,
showing themselves in frequent shameless mastur-
bation, as well as in other ways. In all there is
inattention, not only to ordinary tidiness and clean-
liness, but to the calls of nature. They pass their
urine and motions under them, either occasionally or
habitually, according to the gravity of the case. Their

VARIETIES ACUTE INSANITY. 133

clothes soon become ragged, dirty, stained, and caked
with spilt food. In all cases of acute insanity, sleep-
lessness is a very prominent and very important
symptom. It has usually existed for days or weeks
before the insanity declares itself, and it is aggravated
when this takes place. The length of time for which
they will maintain their excessive activity without
sleep, or with only an hour or two of sleep per night,
is astonishing. They are always constipated, and the
tongue is usually foul, and the breath stinking. They
have usually lost a great deal of weight before the
insanity declares itself. When they are sufficiently
rational to give an account of themselves, they
are found to be suffering from delusions. In the
melancholy type these are the ordinary delusions
of melancholia, sometimes combined with delusions of
persecutory type. In the excited or maniacal type
the delusions are of a very extravagant character. The
patient has visited heaven and made the personal
acquaintance of the Almighty, or he has attended his
own funeral, or he has some other equally extravagant
belief. Hallucinations are rarely prominent, and often
not present in acute insanity, and when present are
usually visual. It is rare for patients with acute
insanity to ” hear voices,” and those who do are usually
of the resistive type.

Acute insanity is very variable in course and duration.
In a few cases it is very evanescent, and clears up
completely and permanently in twenty-four or forty-
eight hours ; and such cases constitute what has been
called mania transitoria. Usually it lasts in full
intensity for from one to four or five weeks, and if the
longer term is reached, it then terminates fatally from
exhaustion. The earlier improvement begins, the more

134 TEXT-BOOK OF INSANITY.

favourable the chance of recovery ; the longer the full
intensity of the malady lasts, the graver the prognosis.
Four or five weeks of really acute mania will kill the
strongest man, and a shorter term, even if not fatal
to life, is very apt to leave irreparable damage to the
brain and mind. Of the five types described, the
resistive is the most unfavourable to life, and the
suicidal is the most apt to leave permanent insanity.
When recovery takes place, it often takes place
suddenly. The patient has a night of long, sound
sleep, and wakes up well, or so nearly well that a few
days completes the recovery ; but this can only happen
when the malady has been of sudden onset and short
duration. In other cases, improvement is gradual, the
excitement subsides, the melancholy clears away, and
the patient passes into a state of slight, or it may
be of grave, dementia, from which he may gradually
emerge, or which may remain permanent for the rest
of a long life. In other cases the subsidence of the
excitement is simultaneous with fixation and systeina-
tisation of the delusions, and the acute insanity merges
without break into paranoia. Even when recovery is
rapid and appears complete, the patient should not
return to the active duties of life for at least a third
or half a year, and he will always be liable, on a
recurrence of the conditions, to a recurrence of the
malady.

The effective treatment of acute insanity, like that of
stupor, which might be made a sixth type of this variety,
may be summed up in two words food and sleep.
In the rare cases in which a patient has been eating
and sleeping fairly well up to the time of the outbreak
of insanity, the prognosis is extremely unfavourable ;
and the more confidently we can attribute the outbreak

VAKIETIES -ACUTE INSANITY. 135

to deficiency of food and sleep, the more confidently
may we expect that the administration of food and
the procurement of sleep will be followed by recovery.
As the sleeplessness depends very largely upon the
inanition, our first care must be to administer abund-
ance of food. The patient must not merely be fed,
he must be over-fed. He must have food in super-
abundance and excess ; he must have twice or three
times as much as would suffice for a healthy man of his
age and weight. What he needs is not extract of meat
and Brand’s essence, and Bovril and Valentine’s meat
juice, and similar concentrates, but bulky, ordinary
food meat and potatoes, bread and butter, rice
pudding, and such like viands in great quantity.
And here we are met at the outset by two serious
difficulties first, that digestion is very frequently
disordered, and, second, that the food is very frequently
refused.

The first difficulty we may often disregard. The
stomach has perhaps been pampered and humoured for
months by discarding first one food and then another
that has been thought to disagree with it, and if it is
taken firmly in hand and compelled to receive all
kinds of bland food, it will do its duty uncom-
plainingly. A more serious matter is that when food
has for months been taken in small quantity only, the
stomach has become contracted, and till it has been
educated to receive larger quantities, it will resent
over-distention by vomiting. In such cases we must
be content to feed very frequently, and gradually to
increase the amount given at each meal.

The other difficulty is far more serious. Pefusal of
food, obstinate resistance to the administration of food,
is a common feature of all the types of acute insanity,

136 TEXT-BOOK OF INSANITY.

and unless it is overcome, the patient will certainly die.
It must therefore be dealt with promptly and vigor-
ously. The patient must be forcibly fed. There are
degrees of persistence of refusal. Some patients will
not feed themselves, but if the food is put to the
mouth, they will take it with docility, chew and
swallow it. Others will take it only if spoon-fed ;
the rest and these are the majority will refuse and
resist every attempt to feed them. Various methods
of forcible feeding are in use for such cases, but I
have no hesitation in condemning all but one. The
nasal tube, a small tube of soft rubber introduced into
the nostril, has been used very largely, but it is so
easy for a suicidal patient, or even a greatly demented
patient, to inhale the food thus administered ; and so
many cases of gangrene of the lung have followed the
use of the method ; that it ought to be abandoned, and
the aesophagial tube used in every case.

Of course, in this case, solid food cannot be given
in solid form ; but the same food can be given if it is
first pounded up in a mortar and made into a thin
pulp with milk, and then there is the advantage
that the appetite and palate need not be consulted,
and food, stimulants and drugs can be administered
together. If a really copious and excessive amount of
food is introduced, the difficulty about sleep is already
half overcome ; but there are few cases, though there
are a few, in which food alone is sufficient to procure
sleep. In most cases hypnotic drugs have to be
employed. Our choice of these has greatly extended
of late years. There was a time when opium was the
only soporific ; then chloral and bromide of potassium
were added ; now all these are abandoned in the
treatment of acute insanity, and newly discovered

VARIETIES ACUTE INSANITY. 137

drugs are found to be more efficacious and attended
by fewer disadvantages.

The question often arises, what is to be done upon
the instant to control a patient who has suddenly
become acutely insane in his own house, or in an hotel,
or elsewhere ; who is tearing up his clothes and
smashing the furniture, who has worn out his friends
and the ex-policeman who has been called in to help in
controlling him ? In this state of things we have in
hyoscin an agent of the utmost value. It is made up
for hypodermic use in minute tabloids, and one of these
can be dissolved in a cup of tea or a glass of wine, or,
if needs must, it can be given hypodermically, and its
action is very speedy and very effectual. The usual
doses o-J^ and -fj of a grain are of no use in acute
insanity, and at least -$ should be given under the
skin, or ^ by the mouth. I give -% hypodermically,
and have never seen any ill effects from its use. Ill
effects, and fatal effects, used sometimes to attend its
use when the drug was first introduced, but no case
has been reported of late years, and I cannot help
thinking that when it has been fatal, either the drug
was impure, or it was insufficiently mixed, and larger
doses were given than were intended. At any rate,
if there is any risk attached to its use now, it is a risk
that ought to be run, for the danger of the drug is in
any case not so great as the danger of allowing the
patient to die of exhaustion ; and therefore it should be
given. In this way a breathing-time may be obtained,
during which the friends are freed from the absorbing
task of immediate attendance on the patient, and are
at liberty to take the necessary steps to have him
removed to an institution. For this course is essential
in every case of acute insanity, except, perhaps, when

138 TEXT-BOOK OF INSANITY.

the patient’s friends are very wealthy, and can arrange
for at least three attendants and a medical man to
reside in the house with him, and even then the
conditions for his control and recovery are not so
favourable as they would be in any well-conducted
institution. It is scarcely justifiable to keep up a full
administration of hypnotics merely for the purpose of
facilitating the control of a patient, and unless this is
done, there will be times when two, and even three,
attendants will be insufficient to control an acute
maniac. He should be in a place where practically
unlimited help can be brought to bear to get him
undressed, or dressed, or fed, as the case may be.
There is nothing so likely to produce bodily injuries
as insufficiency of help in these operations.

There is a practical measure of great value, which is
much insisted upon by Dr. Savage in the management
of acute insanity so long as the patient is kept at
home, and this is to remove the patient at once to the
ground floor, bag and baggage, bed and bedding.
Then if he jumps out of the window he can do himself
but little harm.

Useful as hyoscin is as a calmative and controller of
excitement upon emergency, it is not a drug to be used
as an hypnotic, nor is it suitable for prolonged adminis-
tration, for tolerance is soon established, and the dose,
to be effectual, has to be increased. When we desire
an hypnotic effect, the most efficient drug for ordinary
use in acute insanity is sulphonal, a drug that has the
great advantage that it not only induces sleep at night,
but has a calmative influence upon the patient for the
following day. Its disadvantages are various. In the
first place, its action is delayed, and it varies much in
the period after administration at which its effects

VARIETIES-ACUTE INSANITY. 139

begin to be felt. Sometimes it will act in an Lour,
sometimes not for two, three, six, or as much as twelve
hours. It is therefore manifestly inappropriate when
we desire an immediate effect. Trional, upon the
other hand, is a drug whose action is far more speedy,
almost as effectual, and much less lasting. It has none
of the delayed calmative effect that is so characteristic
of, and important in, sulphonal. The best effect of
both drugs is obtained by a combination of the two.
A combination of about J trional with f sulphonal is
most valuable. The trional puts the patient to sleep,
and the sulphonal keeps him asleep ten grains of one
to fifteen grains of the other, or better, fifteen grains of
the one to twenty-five of the other. If this is given
the first night, a less dose will suffice for the second, a
still smaller for the third, and on the fourth night the
patient will usually sleep without drugs. The same
hypnotic should not be given for long together. They
are much more effectual when changes are rung upon
them. In the melancholic form of acute insanity, and
when there is cardiac weakness, paraldehyde is a very
valuable hypnotic.

Mention has already been made of the disorder of
digestion that is so frequent in acute insanity. In any
case in which it is ascertainably present, it must be
treated. There are cases in which the contents of the
stomach undergo putrefactive or fermentative changes
which render them unspeakably foul and offensive, and
when this is the case, or whenever the breath is very
foul, or especially when foul gases are expressed from
the sesophagial tube when the end reaches the stomach,
benefit will be derived from washing out the stomach
at regular intervals.

In all cases of acute insanity, certainly in all which

140 TEXT-BOOK OF INSANITY.

are seven* or prolonged, institution treatment is
essential. In many cases it is far better for the patient
to have the comparative freedom of a padded room
than to be perpetually checked and interfered with by
attendants.

The first favourable symptoms are the establishment
of natural sleep, the voluntary taking of food, sub-
sidence of excitement, and commencing appreciation
by the patient of his circumstances. If all these are
concurrent with a gain of weight, and occur within the
first fortnight, there is reasonable hope of complete
recovery. But if sleep is established, food taken, and
weight gained, while still the mind does not improve,
the prognosis, while improved as to life, is very gloomy
as to recovery of reason ; and if improvement is
delayed beyond the first fortnight, every day’s delay is
of serious consequence.

6. FIXED DELUSION.

This is a very well characterised and very frequent
variety of insanity, but is not often seen outside of
asylums. It is one of the terminations of acute
insanity, and the patient, who had been admitted for
the acute malady, is retained for the rest of his life for
the fixed delusion and the accompanying dementia, in
which it ends.

The character of the delusions is various, but
commonly they are delusions either of exaltation or
of alteration of part of the self. To this variety of
insanity belong practically all the kings, queens,
emperors, and millionaires who are not general para-
lytics, and to this also belong the people who have
weasels, wolves, or crabs in the stomach, glass legs, no

VARIETIES FIXED DELUSION. 141

backs to their heads, whose brains have been taken
out, and who suffer from other changes of the
personality.

The distinguishing feature of the insanity is that the
delusion has practically no effect upon conduct. The
kings and emperors are content to pass their lives
in the most menial occupations, scrubbing floors and
carrying coal : the queens and duchesses work con-
tentedly in the laundry ; the millionaires see nothing
inconsistent with their wealth in holding a horse for a
copper, or begging for a bit of tobacco. What inca-
pacity they have for more intelligent employment
and the incapacity is often considerable they owe to
their dementia, and not to their delusion. The
delusion is not often prominent. It does not absorb
much of the attention of the patient. He does not
obtrude, it and make himself a nuisance by worrying
about it in season and out of season, as the paranoiac
does. He is often rather reticent about it, and has to
be questioned and cross-examined before he will confess
to it; but once started on the subject, he is usually
difficult to stop. In any case, not only does it not
influence his conduct, but it does not much affect the
rest of his mind. The king and the millionaire do not
appear particularly elated by the knowledge of their
exalted position or their wealth. The man whose legs
are of glass, or whose stomach is tenanted by an
unbidden guest, does not worry about crural fragility
or his parasite. The delusion forms a small and
unimportant part of his mental life, and he pursues
the tenour of his way without regarding it. A large
number of the inmates of lunatic asylums exhibit this
variety of insanity.

The bodily state exhibits nothing characteristic.

14-2 TEXT-BOOK OF INSANITY.

The malady is essentially chronic, unchanging, and
irrecoverable. The patients remain in the same state
of dementia and delusion for the rest of their lives ;
liable, like other dements, to outbreaks of excitement
from time to time ; subject to the common ailments of
humanity, of one of which, in the fulness of time,
they die.

7. PARANOIA.

This is both a form and a variety of insanity : that
is to say, it is not only well characterised as an existing
state, but the state is confined to a single variety of
insanity, which runs a definite course, and it is not
seen in any other variety. By a systematised delusion
is meant a delusion which, to use the language of
modern psychology, constitutes an ” apperceptive
system.” It is an organised body of (false) knowledge,
and it differs from other delusions in the fact that it
colours the whole life of the patient ; it regulates his
daily conduct ; it provides him with an explanation of
all his experiences that are otherwise inexplicable ; it
is his theory of the cosmos.

For instance, his delusion is that he is influenced by
telephones. Whatever he does, and whatever happens
to him, that is in the least out of the ordinary course,
is due to the telephones. He sees a pretty flower, and,
forgetful of the regulations in that case made and
provided, he plucks it ; then he remembers the rule
against picking flowers. It was the telephone that
made him pick it. Intent upon the beauty of some
floral gem, he trips over a grass verge ; it was the
telephone that made him trip. He sits down to write,
but finds his mind confused ; telephones again. He

VARIETIES PAEAN OIA. 143

plays whist, and revokes ; the telephone made him do
so. He plays billiards and loses ; the telephone kept
his balls out of the pockets and put his adversary’s in.
His nose begins to bleed ; the telephones did it. He
gets annoyed and throws his book across the room ; the
telephone prompted him, or possessed him and threw
the book for him. He sees two strangers meet and
chat on the opposite side of the street ; the telephone
is talking to them about him, or they are talking to
him through the telephone, or the telephone is mixed
up with them in some mysterious way.

The precise character of the systematised delusion is
very widely different in different cases, but in all there
are several features in common. Through every
systematised delusion there runs the thread of perse-
cution, which connects them all together in a single
well-characterised group. Every systematised delusion
is a delusion of persecution. The influence, whatever
it be, that acts upon the patient, is always an influence
adverse to him. Secondly, the delusion is a fixed
delusion; it endures without material change, often
without appreciable change, for years and years.
Thirdly, it is associated more closely and more con-
spicuously than any other form of delusion with
confusion of thought. Fourthly, more often than any
other delusions it is associated with hallucination.

The character of the delusion is very various, though,
as has been said, the idea of persecution runs through
them all. The persecutor may be a specific individual,
and in that case may have a real existence or be wholly
imaginary. In a certain case, e.g., the patient was
annoyed by a man whom he had never seen, but whose
presence he felt, whose name was Girardot, and who
haunted the lanes and fields about the patient’s resi-

144 TEXT-BOOK OF INSANITY.

deuce, armed with an apparatus of mirrors and lenses
by which he was enabled to see at all times what the
patient was doing, and to locate him so accurately
that he could pour upon him without fail a stream
of electricity, whicli produced baleful effects. Not
infrequently the persecutor is identified as the
superintendent of the asylum, or the governor of the
gaol, in which the patient has been detained, and who
still, by his emissaries, torments the patient, years
after the latter has been transferred to other care.
They haunt the neighbourhood; they are under the
floor, in the cellars ; they are in rooms above, or on the
roof ; they are in adjoining rooms ; every mishap, every
inconvenience, every disappointment that happens to
the patient is ordered by them. Or the persecutors
are not specifically identified, but pervade the com-
munity. The people in the streets talk to each other
about him ; they look at him in meaning ways ; if
they smile or laugh, it is in contempt or derision of
him ; if he catches scraps of their conversation, this
also has reference to him. He sees two men meet who
are total strangers to him ; they shake hands, they
smile, and ask each other how they do ; the shake of
the hands is a Masonic grip by which each recognises
that the other is in the plot; the smile is an ex-
pression of triumph that they have succeeded in their
nefarious design against him ; the question and answer,
while seemingly innocent, really refer in some way
to him, and means that he is a blasphemer, a
murderer, an adulterer, or what not. In some cases
the delusion is of bodily disfigurement ; for instance,
the nose is too large, is so large as to attract attention,
and the universal topic of conversation, wherever the
patient appears, is the size of his nose.

VARIETIES-PARANOIA. 146

Very often the delusion is of being followed about
and watched, it may be by the police, but more often
by unofficial watchers. Sometimes the vigilant enemy
is a single specific individual, sometimes two or more,
sometimes a number of unspecified individuals.

Perhaps the commonest of all the forms of perse-
cutory delusion is that of being acted upon by some
unseen influence ; and usually the latest conspicuous
discovery in physics is pressed into the service, and
becomes the persecuting agent. In the early part of
the last century, paranoiacs were persecuted by steam
engines ; later, the telegraph was the means of their
persecution ; then, as successive discoveries were made,
electricity, hypnotism, mesmerism, animal magnetism,
telephones, the Rontgen rays, and wireless telegraphy
were made responsible for their sufferings. The
majority still ascribe their persecution to electricity,
and the ” electrics ” constitute the largest class of
paranoiacs. But they are assiduous readers of the
newspapers, for they see in the daily prints references
to themselves in the items of news and in the leading
articles; and whenever a new physical discovery is
announced, it is appropriated by them as a means of
persecution, and the more obscure it is in its nature,
the less they are able to understand of the new process,
the more it commends itself to them as a persecuting
agent. This seems to be the ground upon which
electricity is so often selected. Sometimes, however,
nothing sufficiently mysterious exists among the known
natural agents, and then a new agent is invented to
account for the sufferings. Dr. Conolly Norman gives
an instance of a patient who ascribed his persecution to
a “typhone,” and of another whose thoughts were
” read by a hypophone and translated into logarithms.”

10

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About homelessholocaust

Tijuana Hobo , Hebrew Hobo Railroad Rabbi, The Truth Teller Tell True Truth Truthfully. If the Truth is Repugnant to you, You are a Reagan Cultist. Ronald Reagan was Taught by L. Ron Hubbard, Reagan & Hubbard FOUNDED THE SCIENCE FICTION MIND FUCKING GAME- SCIENTOLOGY- then REAGAN USED NERO LINGUIST PROGRAMMING as PRESIDENT to MURDER THE MINDS of AMERICANS!
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