gold. Such enormities betoken great weakening of the intellect and judgment.

Primary delusions conduce more to fixity than delusions secondary to hallucinations. The latter, depending as they do upon the stability or instability of the morbid sensory impressions, change with these. When delusions become fixed, they tend to crystallize or become systematized. Systematization consists of combining with the fixed idea complementary delusions in a more or less logical order or of the fantastic elaboration of the original delusion. The degree of organization and perfection of the delusional structure will depend upon fancy, logical faculty, social position, and education of the patient. The most common form of systematization is in the development of secondary grandiose ideas upon a persecutory basis. But almost any of the depressed and exalted delusions previously described may become fixed, systematized, and permanent through the life of the patient.

Delusions may have a retroactive effect in awakening sensory impressions, instead of being aroused by them—that is, may induce illusions and hallucinations. For example, the persecuted patient perceives voices, odors, tastes, pains, etc., often because of his mind being in a state of expectant attention.

Imperative ideas force themselves into consciousness in spite of the efforts of the patient-who recognizes their morbid character-to correct them. They are accompanied, almost without exception, by a depressive affect, a painful sensory tone. They are extremely common in neurasthenia. Senseless phrases or doggerel repeat themselves over and over in the patient's mind. The many varieties of phobia are familiar examples of imperative ideas in neurasthenics (agoraphobia, claustrophobia, mysophobia, etc.). Imperative ideas are also observed in melancholia and in a form of insanity which has been designated as insanity from imperative ideas. In very rare instances they are encountered in early stages of general paresis. They always develop on the basis of a congenital or acquired neuropathic or psychopathic constitution, and are apt to become obstinate features in the mental organization. Almost every imperative idea has its inception in some sort of sensory impression, and the idea may lead to compulsory actions on the part of the patient. But between the imperative idea and the consequent action there is generally a play of judgment, a faltering between the imperative idea and antagonistic or inhibiting concepts. For instance, the patient feels a compulsion to lock a door which he feels sure he has already locked. After an inward debate as to whether he should go back and assure himself that it is locked, which may last many minutes or longer, he goes to lock it, and on leaving the door again the imperative idea arises that it is not locked. The same play of antithetic ideas may occur in reference to anything-the addressing of a letter, the return of a book to a shelf, acts of dressing and undressing, the crossing of a street, etc. In some cases the imperative idea takes the form of compulsion to jump from a height, to laugh in unseemly places; or obscene and sacrilegious words, sentences, and fancies may thrust themselves obstinately into the consciousness.

For

example, a gentleman, and a good Christian, came to me recently overwhelmed with the sacrilegious conceptions which first came to him at a church-service a week or two before-ideas of cohabitation with the Virgin Mary and filthy expressions in relation to Christ. A lady consulted me about a morbid fear that she had of canary birds. She could not enter a house or hotel in which there was a canary bird, because she was afraid that bird-seed might get about and in some way get into her mouth, be swallowed, and grow in her stomach. The contents of these imperative concepts are as varied as those of delusions, though they are almost, without exception, trivial or unpleasant.

Folie du doute is a form of mental disorder in which compulsory ideas assert themselves in the form of questions, religious, metaphysical, or in regard to the most trivial things or events (Shall I do this or that? Why is the table round? Why is the chair by the bed? Why are two and two four ?). One young lady is so incapable of deciding any question that comes up in her mind that she does not know whether she ought to dress or undress, go to bed, eat, sleep, pray, or consult a doctor. Every trivial question of the day requires hours of painful and agonizing debate in her mind.

Imperative ideas frequently impel to compulsory speech and actions. Coprolalia is a not uncommon form of imperative speech in which the patient is impelled to the utterance of obscene words. Quite analogously the patient may be made to make grimaces, or may develop the so-called maladie des tics.

Weakness of Judgment.-Innumerable memory-pictures and associated ideas take part in the process of comparison and decision which we know as judgment. Hence any disorder of memory and of its associations, such as loss, defect, or perversions (delusions, hallucinations, or illusions), must naturally influence the character of the judgment. One of the common conditions which impairs judgment is, therefore, intellectual defect, such as congenital or acquired mental weakness. The criteria of idiocy and dementia are poverty of ideas and idea-associations and weakness of judgment. When delusions or imperative ideas exist, the errors of judgment are due to the overriding and eclipsing by single ideas and idea-associations of all others which would in the normal mind give balance, control, and revision to the judgment. Defective judgment varies in degree from a slight loss of the critical faculty to complete deficiency. When the judgment is markedly defective, it depends upon actual organic changes in the brain, such as we observe in idiocy, terminal dementia, senile dementia, and general paresis, and hence as a symptom it is far more ominous than delusions and imperative ideas, which usually rest upon a functional pathological basis. Its significance, then, demands a careful differentiation of this symptom from others with which it might be confused, such as incoherence and thought-inhibition. In incoherence the threads of thought are constantly lost. In thought-inhibition there are a depressive affect and extraordinary slowness of association with correspondingly tardy answers, and, besides, there are variations of depth of inhibition, so that at times complicated answers and judgments are

readily given.

In actual weakness of judgment the judgments rendered are false, and the more incorrect, the more complicated the questions.

DISORDERS OF ACTIONS.

The actions or conduct of a patient depend directly and necessarily upon pathological elements in some part of the psychological processes sensation, memory-pictures, idea-associations, and their emotional affects. They may be classified, following Ziehen, as—

1. Actions induced by sensory disorders.

2. Actions induced by disorders of memory.

3. Actions induced by disorders of the emotions.

4. Actions induced by disorders of the idea-association.

Actions Induced by Sensory Disorders.-Hallucinations and illusions affect the conduct of a patient often markedly, and their influence is always greater than that of normal sensations. Their dominance is the greater in proportion to their number and to the rapidity of their accumulation. Hallucinations gathered slowly in the course of weeks or months, while they may not be corrected, are at least subject to a certain amount of control by the inhibition of normal ideas. In the most chronic forms of hallucination the voices, common sensations, and visions tend to be ignored and to influence to a very slight degree the conduct of the patient. A very important practical feature in regard to hallucinations and their effects upon conduct is their uncertainty. They are never to be reckoned with, and one can never know what sudden violence or destructiveness may result from new hallucinations rising in the patient's brain.

Actions Induced by Defects of Memory.-These are observed in congenital or acquired weak-mindedness, where the conduct is directly ordered by sensory impressions, without that intervention of the play of motives which we observe in normal individuals. They are more like the actions of the lower animals, which may be complete enough in their way, but are not motived by complicated abstract conceptions, because these are wanting.

Actions Induced by Disorders of the Emotions.-As already elsewhere intimated, simple depressed emotions are accompanied by a general motor inhibition, and simple exalted emotions by a general motor agitation. But when the depressed affect attains to the degree of anxious dread, we may have a restlessness, a desire for flight, which in itself amounts to a motor agitation. This anxious state often leads to suicidal attempts, and even to homicidal assaults, arson, and other forms. of crime and violence. The whole nervous system seems to be in such a state of tension that only an explosion can give relief.

In apathetic conditions action is reduced to its minimum.

Where the higher affects, which are at the basis of ethical concepts, are absent or lost, as in congenital or acquired states of mental weakness, crimes against person and property are common.

In conditions of anger and rage there is at first a brief period of

speechlessness and immobility, followed by an explosion of blind and violent motor excitement, in which the most dangerous assaults may be made.

In conditions of changeability or lability of the emotions, we observe analogous motor states-sudden changes from weeping and wailing to boisterous cheerfulness, and vice versa.

A study of emotional expression is of particular diagnostic value in insanity, but the features of such expression and gesticulation are so well known that they need no detailed description here. Each mood, be it simple depression, anxious terror, excitation, anger, apathy, or emotional lability, has its own familiar motor habiliments.

Actions Induced by Disorders of the Idea-association or Stream of Thought. Under this heading are gathered the multiform modes of action caused by increase in the flow of ideas, retardation of the stream of thought, incoherence, delusions, imperative ideas, and weakness of judgment.

In increased rapidity of the flow of ideas we note motor agitation or morbid impulse to movement, varying from simple talkativeness, with active play of expression, to loud garrulity, grimaces, gesticulation, busy walking about, running, dancing, and, in extreme degrees, to undressing, destructiveness of clothing, bedding, furniture, and blind throwing about of the body in every conceivable way. This so-called primary motor agitation should be distinguished from the motor agitation which is secondary to crowding hallucinations (hallucinatory agitation) and to emotions like terror and anger (affective agitation).

The behavior of the movements in regard to retarded flow of thought has already been briefly alluded to. There is a general motor inhibition, varying from simple slowness and difficulty of executing any movement, whether of speech or other muscles, to a complete cessation of voluntary movements, a stuporous or attonitous condition, in which the muscles may be absolutely at rest and flaccid or, on the other hand, in a condition of catatonic tension. In true catatonic tension every attempt at passive movement is resisted, but in another form of this there is a waxy flexibility of the muscles, so that the limbs yield readily to any passive motion, remaining in whatever position the physician desires to place them. Occasionally one encounters in cases of retarded idea-associations, as an expression of motor inhibition, a tendency to the repetition of some restricted voluntary movement in a rhythmical, stereotyped way for days, weeks, months at a time. Such stereotyped motions may be simple anteroposterior oscillations, lateral oscillations, whirling, walking to and fro or in a circle, waving the hands rhythmically-forms of tics exceedingly common in idiocy and imbecility, but common enough in melancholias and terminal dementias. The repetition of stereotyped or automatic phrases is analogous in character to such morbid movements. Motor inhibition is primary or secondary. The primary form is generally a simple resolution or flaccidity, occasionally a slight catatonic tension or flexibilitas cerea. Secondary motor inhibition is due to hallucinations, delusions, and states of mental weak

ness.

Incoherence of ideas leads to a dissociation also in the motor expressions of ideas, parapraxia, paramimia, incoördination, pseudo-ataxia, incoherent agitation, chorea magna, and jactitation. Such motor agitation may be primary or may be the secondary result of innumerable clashing hallucinations and delusions, rapidity of the flight of ideas or of intellectual defects.

Grandiose delusions exert their own peculiar influence on the demeanor and speech of the patient, according to the contents of the exalted ideas. We observe the proud bearing; the self-sufficient, haughty, or secret smile; the withdrawing from others; the tendency to decoration of the person; the attempts to act the parts of the personage he imagines himself to be; the striking peculiarities of handwriting. In some instances delusions of grandeur lead to homicidal, rarely suicidal, attempts (self-crucifixion with the delusion of being Christ). Grandiose erotic ideas sometimes occasion masturbation. Coprophagy and other filthy habits may depend upon grandiose delusions as to extraordinary virtues of the patient's excretions.

In depressed delusions, particularly as regards ideas of sin and poverty, we observe the characteristic melancholy facial expression and attitudes. Attempts at suicide are frequent, and sometimes self-mutilation. Abstention from food is especially common with the delusion of poverty, the patient feeling that he can not pay for anything.

Hypochondriacal ideas influence markedly the patient's actions and conduct. The hypochondriac may neglect every duty in the constant contemplation of his symptoms. He reads medical books, goes from one physician to another, takes to his bed perhaps permanently, and so

on.

The effects of hypochondriasis on motor functions are frequently remarkable, leading sometimes to astasia or abasia, or both; to hypochondriacal ataxia, tremor, or convulsive movements of the extremities. These hypochondriacal motor conditions are always the result of a series of morbid judgments on a hypochondriacal basis, and are to be distinguished from similar hysterical states which have an autochthonous origin without any antecedent conscious reasoning process.

The persecutory delusions lead to systems of self-protection of the most varied kind. Barricades, stopping up of cracks and keyholes, the wearing of peculiar clothing (silk, paper, etc., for instance, as a guard against electrical shocks), avoiding of food and drink which are suspected of containing poison, arming with weapons, frequent change of servants or residence, and complaints to the police or judicial authorities. Homicide is common in these cases.

Imperative ideas lead to imperative movements and actions, and generally in spite of the well-preserved consciousness and judgment of the patient. Such imperative actions are as various in character as the imperative ideas to which they correspond.1

Accompanying Physical Disorders in Insanity.-Among the

1 The foregoing account of the psychopathology of insanity is largely a presentation of the views of Ziehen, to whose excellent work the author must refer readers for greater detail.