as Spitzka has said, that in at least 40% of the insane we could find no characteristic lesions of their disease, and in half the remainder only such as might also be due to other morbid conditions. The more recent acquisitions in the anatomy and physiology of the nervous centers have nevertheless opened up a field for rational speculation, at least, if they have not fully demonstrated the basis of all forms of insanity. The changes in the nerve-cell from fatigue, and toxins, demonstrated by Hodge, Barker, and others, are suggestive of the conditions in certain psychoses; and the same is particularly true of the theories of Flechsig, who finds the cerebral cortex chiefly composed of associational or intellectual centers that develop gradually after birth and are only complete at full maturity. Their disorder, or that of their infinitely ramifying and complex connections, can readily be supposed to account for mental derangements, and it is possible to build up elaborate theoretic explanations of the various symptoms on the basis of these findings and their probable extensions. Flechsig's ideas are, however, yet sub judice, and are not accepted as final by all neurologists, and any theory based upon them must be taken simply as theory-not as established fact. This is true, also, of the theory of Dercum, that all types of cerebral derangement may be caused by imperfect or failing contact of the neurons, which are supposed by him to be movable in their dendritic extensions.

It is possible, and perhaps one might say probable, that one or both of these theoretic explanations of mental disorder may be true; but at present they are imagined, not demonstrated, explanations.

When we come to enumerate the actual lesions that have been met with in chronic insanity, we find ourselves in the presence of an infinite variety of morbid conditions, such as might be expected when we con

sider that insanity is itself a disorder of functions, and that it may therefore be the result of whatever can affect the normal action of the intellectual and emotional cerebral centers. The fact, also, that lost or perverted function must have its effects on the organ is also to be borne in mind, and that the lesions found may be as well the results as the causes of the insanity. Some of the appearances are, moreover, only the exaggeration of what is often seen in normal brains, due to the more excessive and ill-regulated excitations of the insane—and such, for example, may be the thickening and opacity of the arachnoid, and the extent and. abundance of the Pacchionian granulations. Others, again, may be a persistence, and exaggeration perhaps, of an infantile condition,* such as the extensive craniodural attachment sometimes met with that is not apparently connected with acute inflammatory processes. These latter also leave traces in adhesions that are especially notable in certain organic insanities, and general paresis in particular. They are also often met with in old cases of secondary dementia, but are less numerous and extensive. Arachnoid cysts and ecchymoses, ossifications of the dura, miliary sclerosis of the cortex, are also conditions claimed to be rather frequent in old cases of insanity, and atrophy of the brain is a common result of long-existing terminal dementia. Edema and anemia are also noted in certain cases. In organic and senile insanities, including under these heads the traumatic forms, we have, of course, every possible lesion that can derange the normal functioning of the brain. The condition of the vascular system is largely the starting-point of these, and arterial disease, either as atheromatous degeneration or sclerosis, or direct in

*This does not refer to inflammatory adhesions, nor in this class of lesions do we include those arrests of development such as we found in idiocy or imbecility, but simply to local anomalies that are not always incompatible with normal cerebral action, but which afford points of weakness under favoring conditions.

flammatory conditions of the vessels are often observed. The lesions also indicate at times a direct toxic or bacterial origin, as in acute delirium, which seems to be sometimes, at least, an infectious and usually rapidly fatal disorder. Alzheimer has called attention to a morbid proliferation of the glia cells and fibers as a common finding in different forms of acute and chronic mental disorder, and holds that this is the more marked the older and more hopeless the case.

In estimating the value of any of the pathologic findings in insanity a number of points have to be considered. The fact that a large proportion of the lesions found are secondary to the disorder, and not its cause, has already been noted. This is particularly true of the microscopic findings, and one has, moreover, to sometimes question the methods, and query whether some of the apparent lesions may not be due to reagents employed. Then the fact must also be kept in mind that has been mentioned in a preceding chapter, that with many of the subjects of mental disorder there has existed a predisposition; they had already unstable brains, ready for disordered function on any provocation. It may be said, indeed, that in acute insanities, as a rule, the more minute and microscopic lesions are practically unknown, or at least that they have not yet been fully and satisfactorily demonstrated, except possibly in intensely toxemic types, such as acute delirium and paresis; and that in the chronic forms they are multiform, and, except in certain special types that can be better described later in the special pathologic portion of this work, they are hardly characteristic. This, of course, excepts those cases where there are pronounced anomalies of the brain, as in idiots, and other defectives, and the gross appearances that have been mentioned as common in a large number of the insane, the evidences of causal organic disease, traumatisms, tumors, etc.

CHAPTER IV.

GENERAL SYMPTOMATOLOGY.

THE symptoms of mental disorder that especially mark it as such are chiefly psychic, and this is so commonly recognized that to the average public they are the only and exclusive ones. There are, it is true, a large number of physical phenomena accompanying insanity, and some of these are so characteristic of and peculiar to the condition of mental derangement that they cannot well be overlooked in discussing their semeiology. There are also many others that are shared in common by various nervous disturbances, and their connection with insanity is, as it were, only incidental; these may in part also receive notice here. When the brain is diseased, the whole body suffers; and this suffering may be through a direct trophic or other influence exerted from the great nerve-center, or it may occur simply as a secondary result of the mental derangement, of the want of the conscious or the subconscious care that the normal individual constantly exercises over his physical welfare. We can hardly agree with Kraepelin when he says that all these do not belong to the phenomena of insanity as such, for it is impossible to completely sever the mental from the bodily symptoms, especially in the disorders of perception which are so closely related to our physical sensations. There are also a large number of bodily symptoms that are almost, if not quite, peculiar to insanity; they only occur in cases of mental disorder. While some of these are more or less restricted to certain forms or types of insanity, others are so generally met with or so eccentric in their occurrence as to well

deserve notice in the general as well as the special symptomatology of these disorders.

Without committing one's self to any special psychologic theories, we can divide the manifestations of mind into four great heads: viz., the sensations, the judgment or intellect, the emotions, and the will. Under the sensations must necessarily be included their conscious appreciation, and the term perception might have been used, though it would be in some respects undesirable for the purpose, as it has a wider application and can be equally associated with the feelings or emotions which for convenience are here separately considered.

Sensations, and to some extent emotions, are the starting-point of all mental activity. An individual born without any sensory organs, were it possible for him to survive, could have no mental development whatever. The essentials of a sensation, with its consequent perception, are an end-organ, a connecting nerve, and a group of perceptive ganglia or cells. In considering mental symptoms we can neglect lower ganglionic or spinal centers, and confine our consideration exclusively to those of the cerebral cortex, where the mind, so to speak, takes cognizance of the message from the periphery. Any of these organs may be deranged, but in insanity it is the alterations of the sense perceptions rather than their suppression that has a symptomatic importance, and then chiefly only when the sensation is not only disordered or perverted, but is so received by the mind as to affect or falsify the judgment. In insanity the judgment must be involved in perceptive or sensory disorders, and practically therefore the mental division is threefold, though for convenience a fourfold division is here adopted.

Growing out of this fourfold division of mind we have, as characteristic derangements of the perceptions