The treatment of these cases is largely moral; as might be supposed, there are few or no tangible physical symptoms to treat. One is limited to the watching for complications and meeting them as they arise. Sometimes, under the influence of delusions of poison, etc., the patients may refuse food, and this may possibly go so far as to endanger their health. Forced feeding for any considerable period, however, is rarely necessary, and should be avoided altogether if possible, as it will be likely to aggravate the delusions and excite dangerous antagonisms.

Confinement in an asylum or hospital for the insane is a very essential part of the treatment, both for the patient and the public, and for the influence of the regulated living and discipline of an asylum, since more than any other insane they can appreciate the reasons and often the reasonableness of their seclusion. Upon many of them it has a very happy effect; in other cases it may be resented, and they become the more dangerous patients. In some of the less aggressive cases during the period of the prevalence of the persecutory delusions, it is felt doubtless as a refuge from their persecutors. If suitable employment is given under judicious control, the delusions often become less prominent, at least objectively, and the patients seem to be actually improving mentally. There is still another class of these patients in whom the delusions are not so imperative in their nature, and in whom there is still such a strong power of self-control that after a stay in the institution they may appear so well as to be allowed to leave, and actually manage to live outside without doing anything to call for their recommittal. They are not cured, but if their delusions are not too strong, and their general dispositions good, they may pass safely beyond the active persecutory stage and act as if they were only eccentric or very moderately abnormal individuals. It cannot be said,

however, that any patient with delusions of persecution and hallucinations of hearing is safe to be at large without oversight.

The original paranoiac may be even more dangerous to society or individuals than the typical one, as is shown by the histories of some noted cases of this kind. The recognition of either form is a matter of serious importance, and it is unfortunate, to say the least, that judges and juries are so backward as to their sequestration and so ready to release them from necessary restraint.

It should be mentioned here that in the management of these patients any argument about their delusions, or even any reference to them, is generally very inadvisable. As in every form of insanity, but especially in this, where the reasoning faculties are often so little generally impaired, it is best to treat the patients as far as possible as rational beings, and gain their cooperation and good-will in the measures to be taken for their benefit. Sometimes they appreciate the motives of those in charge of them, and maintain a friendly feeling toward them, but much depends upon the tact and good judgment of the physician in their management.

CHAPTER XIX.

DEGENERATIVE INSANITIES (Continued).

MORAL INSANITY.

UNDER the head of "moral insanity" we include a class that is clinically distinct enough to be noticed by itself, though it represents perhaps two or more different types in its real relations and nature. Still other conditions might be classed by some under this head; thus, we have spoken already of the moral insanity of a certain type of hypomania. The class of cases here described includes some that may be possibly closely related to hypomania or circular insanity, and some that fall more readily into the category of imbecility. There is a special form of moral insanity sometimes seen in old alcoholic cases; the ethical sense seems altogether abolished in some of them, independently of the alcoholic tendencies; they are absolutely immoral even when compelled by circumstances to be perfectly temperate for long periods and when their intellectual powers seem fully as active and acute as in the normal condition. These are the alcoholic cases that are the terror of asylum authorities, and almost the only class of asylum inmates that is capable of breeding plots and organizing conspiracies among the other patients. Another somewhat similar type is occasionally met with among the epileptics, but it is here much more exceptional. Lombroso, indeed, sees a family relation between epilepsy and moral insanity; and, in fact, an identity, though of somewhat modified type. What is here considered, however, is different from these, at least, in its apparent beginning. It is not asso

ciated with epilepsy or necessarily with any other detectable neurosis or psychosis, though it occurs almost invariably in degenerates with a bad family history in some neurotic or neuropathic particulars, and usually in subjects presenting more or less numerous and prominent physical stigmata, such as cranial facial, aural, genital, or corporeal defects or deformities. It is not necessarily accompanied by any symptoms of mental deficiency or of the ordinary emotional abnormalities of excitement or depression; its essential character is the lack of the power to recognize ethical distinctions and of that dictation or inhibition which in its full normal development we call conscience, including, as it does, the sense of right and of duty. Without this inhibition, which underlies to a degree all the social and altruistic instincts and emotions, and which is even present in the lower animals, the unbridled egoism has full play. Except so far as checked by the intellectual consideration of utility or expediency, there is no limit to the lengths it may go. The condition is, therefore, one of deficiency of an important part of the mental endowment, and we may count it as akin to imbecility or idiocy. It might then be considered as an idiocy by deprivation, accepting the moral faculty as an additional higher sense the organ of which in the cerebrum is functionally inactive or wanting. By the same analogy we might assume as possible in these cases an even higher development. intellectually than ordinarily, just as the other senses appear sometimes to act as substitutes and be even heightened when one is defective or lacking. Be this as it may, it is offered only as a suggestion,—there is in some of these cases no special intellectual deficiency noticeable, at least not until later in life, and for a time at least the subject of moral insanity appears bright and even brilliant in most respects. Ray has given in his "Medical Jurisprudence of Insanity" a

history of such a case, a brilliant lawyer, but an absolutely depraved and conscienceless man, who later in life showed by his insanity of acts that there was with the moral deprivation a serious lack of balance and reaction between his thinking and his acting capacity.

These patients are, as has been said, rare in asylums unless in the progress of the disorder their mental faculties have generally begun to suffer. The symptoms first appear in infancy; the moral development does not take place as in normal children; they lack natural affection; are especially rebellious to authority; brutal and cruel, and unreliable in all respects. The moral development of a child is in all cases largely a matter of education, but these cases lack the basis that is essential to a moral sense. This form of moral insanity, the congenital, may be regarded, when it exists in its fullest extent, as a moral idiocy; there is no material for a moral development. Other cases are less extreme; the moral potentialities are there to a certain extent, and while these children are wayward and hard to bring up in a respectable way, they are not absolutely incapable of learning self-control and appreciating the higher motives of conduct to some extent. Many children are to a certain extent immoral, but these two classes, the moral idiots and the moral imbeciles, differ from the mass in that their original capacity for moral education is lacking. As they pass to adolescence the moral imbeciles may develop a better moral sense and ability for self-control, so that they may, in adult life, become something like normal individuals. They are likely, however, to be always moral weaklings, quick to yield to temptations that would be resisted by a healthy minded man. When these cases are intellectually bright, so that they can fully appreciate utilitarian considerations and control conduct according to them, they may become the sharp unscrupulous swindlers, or business or profes