ideas from them. It does this normally when we bring the memory into action in a reasonable and logical manner; it does it abnormally, for instance, in delirium without hallucinations, but in which there is a constant recurrence, in a disorderly manner, of ideas previously formed from former sensorial impressions. The accompanying diagram (Fig. 5) will tend to the elucidation of the views here expressed.

A is an organ of sense, the eye. Through the optic nerve

B an impression received on the retina is transmitted to the sensory ganglion, the optic thalamus C, when it becomes a perception. From the optic thalamus it is transmitted by fibres of the corona radiata D to the cortex E, where it is elaborated into an idea; and from the cortex another form of force may be evolved, and an intelligent action may take place in consequence of the transmission through another set of fibres, F, of a motor impulse to a muscle, G. If there is no organ of sense, there can be no normal sensorial impression; if the optic nerve be divided, the sensation cannot be transmitted to the optic thalamus; if there be a diseased optic thalamus, the sensorial impression will be perverted, and there will be an illusion of centric origin; if the cortex be in a normal condition, this illusion will be corrected and understood as such erroneous perception; if, however, the cortex be diseased, the illusion will be accepted as true, and a false idea, or delusion, will be formed. If the organ of sense receives no impression from without, but if such impression be formed in the optic thalamus, then there is a hallucination; if, again,

the cortex be healthy, this hallucination is appreciated at its full value, and there is a true idea in regard to it; if, on the other hand, the cortex be in an abnormal state, the hallucination is accepted for reality, and a delusion is the result.

Such is, I think, the pathology of perceptional insanity. The lesions of the optic thalamus necessary to the production of a false sensorial impression may be of varied character. Congestion is probably that which most commonly exists, especially in the early stages, and in those cases which are not accompanied by derangements of the other categories of mental faculties. Anæmia is likewise a condition of frequent occurrence. At later periods, as Luys' says, the optic thalami are the seats of degenerations which show that there have been frequent perturbations of the circulation. Sometimes

there is a little hæmorrhagic focus in different stages of regression, and, again, various stages of sclerosis. This sclerosis is accompanied by partial hyperæmia and the production of a large number of amyloid corpuscles. The nerve cells are correspondingly diminished in number, and those which remain have undergone degeneration and atrophy.

Luys' appears to have established the point that in old cases of hallucinations there is a special form of cortical disease affecting the paracental lobe, and which consists of a hypertrophy of this part of the cerebrum on one or both sides. The region in question, therefore, is raised up above the surrounding parts, and presents a gibbous appearance. Incision into the affected portion shows that the convolutions are increased in size, and that a state of hyperæmia exists. Again, there may be atrophy, especially of the frontal convolutions, or a general diminution of the weight of the brain may exist.

But he is very strong in his conviction that there are secondary changes, which are the cause of the transformation of psycho-sensorial hallucinations into those which Baillarger designated psychic, and to which attention has already been called. In my opinion, they are the cause of the hallucination becoming a delusion, and, indeed, between a psychic hallucination and a delusion there is very little difference. The former cannot exist without the involvement of the intellect.

1 "Traité clinique et pratique des maladies mentales," Paris, 1881, p. 305. 2 Op. cit., p. 392.

CHAPTER IV.

II.

INTELLECTUAL INSANITIES.

THE intellectual insanities are characterized by the predominance of intellectual derangement. It is not to be considered for a moment that the perceptions, the emotions, and the will are not also often involved to a marked degree; but, in the forms which I have placed under this head, the intellect is that part of the mind which is pre-eminently disturbed. They are mainly characterized by the existence of delusions, and, if the reader will bear in mind what has been said in regard to delusions, he will at once perceive that they involve the intellect directly and necessarily, without the essential implication of the other categories of mental faculties. Again, there may be conceptions which, though not false, are yet abnormal.

INTELLECTUAL MONOMANIA.

A perversion of the intellect characterized by the existence of delusions limited to a single subject or to a small class of subjects.

Two forms of this affection are met with. In the one there is mental exaltation, in the other there is mental depression.

a-INTELLECTUAL MONOMANIA WITH EXALTATION.

Although the most prominent symptoms of intellectual monomania with exaltation may appear with suddenness, there is almost always a characteristic prodromatic stage, marked by very decided evidences of mental aberration. These usually consist of erroneous conceptions relative to the importance of the affected individual, the attention which others show him, the observation he attracts as he walks the street or enters a room, the unfitness of a man of his parts for the perhaps humble occupation he follows, and the disposition he evinces to talk about his many superior accomplishments or bodily perfections. Gradually these become so pronounced that they attract the attention of those with whom he comes in contact; but, as he continues to transact his business properly, and behaves himself well in other respects,

his condition is rarely, by the superficial observer, regarded as being one of incipient insanity. It is usually supposed at first that what he says of himself is simply an exaggerated style of speaking, and it is remarked of him that he is becoming vain, and otherwise disagreeable. The physician, however, meeting with such a case, will scarcely fail to see that the change of character, or the abnormal development of traits, which previously existed only in light degree, is one of the strongest and most common manifestations of mental derangement.

With these symptoms connected with the mind, there are others of a physical character. There is almost always insomnia, there is sometimes pain or discomfort in the head, there is excessive motility and restlessness, the bowels are constipated, the skin is dry, the eyes are brighter than usual, the speech is hurried, but there is no incoherence of either words or ideas.

Gradually the mental symptoms develop in intensity and definiteness, and one or more delusions become firmly established. They may be based on illusions or hallucinations, or they may arise from purely imaginary premises not connected with the senses. Sometimes they are spontaneous, and at others they appear to come from dreams. In a former chapter I have adduced several examples of delusions obviously the result of strong mental impressions made by dreams.

As instances of the existence of perceptional derangement before the occurrence of delusions of fixed character, and apparently leading logically to the intellectual derangement, I cite the following from my note-books :

The patient, a master plumber, had for several weeks been a little excited in his manner, and disposed to exaggerate his importance as a plumber, contending, with great earnestness, that no one understood the business as well as he did. He had cards printed, announcing himself as having more practical experience than any other plumber in the United States, and that his work could not be excelled, as he had devised new methods of soldering which absolutely did away with all possibility of leaks. He had a large business, and it was known that he had been experimenting with solders, so that, though his statements were regarded as extravagant, they were not looked upon as much more than smart advertising devices.

But one morning he announced to his wife that he had received a communication from a deceased plumber, by which he was informed of a still greater improvement to be made in soldering and in the manufacture of lead pipes. His story was that, while sitting in his shop reflecting on the best method of making lead pipes and solder, he heard a whisper telling him to soak the lead in shark's blood and the solder in shark's urine, and that then neither could ever give way. Steamships, it was told him, could be made of large pipes soldered together. He expressed some surprise that he could not see the individual who spoke to him, and who, he said, called himself the "boss plumber of eternity"; but he did not attempt to account for the invisibility. He was promised by the voice a pre-eminence over all other plumbers, and a degree of wealth such as the most sanguine member of the craft never dreamed it possible to obtain.

All this put him into a state of the greatest good humor. His face wore a continual smile; he talked to every one he met of his great luck, and he joked about the envy of the other plumbers, and of the attempts they would doubtless make to rob him of the honor and profit to accrue to him. As he did no harm to anybody, and as he was perfectly willing to let his son attend to his real business while he worked at his experiments, he was not confined in an asylum. Finally he became less exact in his delusion; he began to be rambling and incoherent, and is now, after over ten years' duration of his insanity, in a condition of chronic mania approaching dementia.

In another case, that of a young lady eighteen years of age, there had been for several weeks a slight degree of mental excitement, which was attributed to suppressed menstruation. But there were no marked signs of insanity till she announced to her mother that angels had been whispering to her all night that the Virgin Mary would soon pay her a visit, and that she must be prepared to receive her august guest with due honor. From that time she became greatly impressed with a sense of her own dignity, and insisted on writing letters to the cardinal and to several bishops, inviting them to be present on the occasion of the visit. The time for this was not fixed; she was informed by the angels that she must be "always ready," for, as "Christ would come as a thief in the night, so would his mother." She therefore always kept her