of the depressed portion of the bone, etc. Many of these cases are apocryphal, especially as regards the reported sudden cures after a lapse of several years, but it is altogether possible for the mental faculties to be completely and permanently obtunded by any lesion of sufficient extent and involving the higher centers indispensable to the action of the mind.

The symptoms following brain lesion vary from slight impairment, as already stated, to the condition just described, and not infrequently epilepsy with consequent dementia is a sequel. The cases here considered are, however; those of dementia in its various degrees, and loss of memory, of power of orientation, and of the higher inhibition are the most notable of the special symptoms. The subject may have lost all knowledge of events immediately after the lesion, while he may be able to talk and reason correctly as to matters immediately at hand. The impairment may be such that he may lose himself within a few steps. from his own door, may neglect the ordinary decencies of social life, and in some cases may be unable even to attend to his own slightest wants. These patients are not usually dangerous except to themselves, and in that respect only through their helplessness and their inability to to reason. Nevertheless, there may be suicidal tendencies, and from lack of self-control even homicides may occur; these, however, are so rare that they are not usually considered in describing this special form of insanity. One of the commonest types of organic dementia is that associated with the atheromatous arteries of old age, or, it may be, of premature senility. In some of these cases we have what has been already mentioned, a condition quite closely resembling paresis with its thickened speech, its unsystematized delusive ideas, and general physical weakness. In our opinion the cases of paresis that have been reported in individuals over sixty years of age are generally of

this type, and may or may not have been preceded by earlier specific disease. It is rare to see a typical paretic pass the age of fifty, and we doubt if paresis ever occurs after sixty. The differences are not so very striking to the ordinary observer, but in these aged cases there is a lack of the active delusional type that we see in the majority of those in middle or early life, and the general facies of the disease has a characteristic difference which is hard to describe, but nevertheless exists. If we were asked to be specific in regard to this, we could only say that there is a special senile character, and in the most of these cases we do not find the early antecedents of true paresis. There are also the various physical signs of senile arterial disease, the senile heart, the tortuous vessels, and the general symptoms of pathologic senile decay.

Syphilitic disease may produce an organic dementia with symptoms characteristic of the probable lesions that have occurred within the brain, such as syphilitic growths, syphilitic arteries with hemorrhages, etc.

There is no special characteristic sign which we can name of the dementia from hemorrhage, embolism, thrombosis, tumor, or traumatism, and the diagnosis of these conditions must be made by the history of the case and the special local and other symptoms in the motor and sensory spheres.

The treatment of organic insanity will vary according to the cause, and it is only in a few cases, where the injury is comparatively slight, or in some recent cases, and in cases where specific disease is known or suspected to exist, that the prognosis is hopeful. In the great majority of cases, and especially in those occurring in advanced life, the chances of improvement or recovery are practically nil. There are many patients of this class sent to asylums. They are easily cared for, though sometimes troublesome, and what has to be done for them is to make life as comfortable as possible,

give them such liberties and privileges as are possible, insure their cleanliness and proper nutrition, and protect them from the dangers to which they are liable from their weakness, lack of self-control, and their inability to care for themselves.

Many cases of so-called senile insanity are really of this type, and many cases of organic brain lesions, with mental disorder, have to be classed with other forms of mental disease. A large proportion of the epileptic insanity is truly organic dementia. The same is the case with some forms of delusional insanity which follow injuries, and especially those cases that are due to insolation, which often causes a peculiar type of delusional paranoia without marked dementia. The cases here included are only those in which dementia is the leading feature, and directly traceable to the cerebral lesions, and also often associated with the physical symptoms due to the lesion.

CHAPTER XV.

INSANITIES OF THE NEUROSES.

THE insanities of this group are peculiar in being associated with special forms of nervous disease or with special symptoms, which themselves are not ranked among the mental derangements. It is not in our plan to discuss these disorders or symptoms, but only to describe concisely the psychic derangements sometimes associated with them. Epilepsy, hysteria, etc., so far as they are not directly associated with insanity, their symptoms, treatment, etc., are not considered, and this materially lessens the compass of our subject. Hysteria, it is true, is itself in a certain sense a mental disorder, but in its ordinary manifestations the mental symptoms are not usually considered as insanity, hence these will not be considered here. It is only when the mental changes become so decided that they pass well beyond the borderland region that they are properly called hysteric insanity; so in epilepsy the convulsions and the temporary mental obfuscation and all the manifold other peculiarities may occur and yet the subject not be fairly called insane. For the discussion of these the reader is referred to works especially on nervous disorders; they do not form part of our subject here discussed.

While these neuroses are largely degenerative, and their associated mental disorders are therefore to a great extent based on an originally defective and degenerate constitution, this is not always the case; the neuroses as well as the insanity may be acquired through disease, trauma, or otherwise. It has seemed

best to us therefore to treat of them here rather than in connection with the degenerative insanities.

EPILEPTIC INSANITY.

Epileptic insanity includes all the mental disorders directly associated and connected with the epileptic neurosis. It thus includes a wide range of clinical symptoms, but in all cases they are more or less tinged with the special character stamped upon them by the brain disorder. The proportion of epileptics who are insane is not so great as is sometimes estimated, though some have gone so far as to consider all epileptics as to some degree mentally affected or abnormal. The fact that some of the world's greatest names are those of epileptics would not of itself disprove this, but the other fact, that every physician and, indeed, nearly every one knows, of average individuals who have suffered from the disorder or symptoms of epilepsy, is a stronger proof of its incorrectness. Probably one-half of the epileptics sooner or later suffer some marked mental deterioration if they survive long enough, and in half of these the change may go far enough to make them proper subjects to be called insane. In the other half the mental deterioration is not marked, though the victims are in a large majority of the cases seriously handicapped by their disease. In a very considerable proportion of cases the epilepsy is of rare occurrence, and in some it is merely an episode of a certain period of special stress, and is completely recovered from as far as future attacks are concerned. The great mass of average epileptics are hardly, properly speaking, insane. Many of them are mentally weak in certain directions; many are almost normal; and a few suffer really no evil effects, so far as their mental constitution is concerned, from their rare and episodic attacks.

Epileptic weak-mindedness, which may be called the first degree of epileptic insanity, is characterized by