A text-book on mental diseases, for the use of students and practitioners of medicine

Front matter

Gass.

Book.

COPYRIGHT DEPOSIT

Preface

The Science of Mental Diseases advances so rapidly that there is no apology needed for new treatises. All modern English, French, and German books on the subject have proved highly instructive, and have served to educate the profession in a most important branch of medical knowledge. An endeavor is here made to set forth in a condensed but comprehensive manner the present state of the Science of Mental Diseases. The book is made to embrace the wide range of the history, statistics, nosology, etiology, clinical course, symptomatology, pathology, diagnosis, prognosis, and treatment of Mental Disorders.

An attempt has been made to introduce such clear and systematic subdivisions as would best tend to facilitate the comprehension of the whole subject and render the work available for students and practitioners of medicine. The book aims to be a practical guide to the diagnosis and treatment of all the various types of Insanity with which the physician has to deal in public hospitals or private practice, and also to serve as a work of ready reference for psychiatrists, in the emergencies of their specialty. Parts of the treatise may merit the attention of psychologists and of all interested in the study of mental pathology.

VI PREFACE

The whole work is written independently of leading philosophical or medical hypotheses, and is the clinical rendition and general outcome of the writer's experience in psychiatry while in charge of public or private hospitals for the insane, or in practice in New York City. A full table of contents and a complete alphabetical index will render the book of ready service to the busy professional man.

New York City, May, 1897.

Table Of Contents

PART L

GENERAL MENTAL PATHOLOGY.

Chapter I. Page

The Histoey of Insanity, 3

The earliest historical mention of Insanity— Egyptian, Grecian, Roman, and Biblical records of Insanity — Historical sketch of the general condition and treatment of the insane from the earliest to the present time — Summary survey of the evolution of the Science of Psychiatry and of the early literature of the subject.

Chapter II

General principles of statistics as applied to Insanity and errors to be avoided — Correct basis of tabular returns from institutions for the insane — Total numbers of insane ; European, British, and American figures — Reasons for percental increase of insane to general population in civilized countries — General statistics as to sex, age, nativity, civil condition, occupation, form of insanity, heredity, sensorial defect, degree of education, recoveries, relapses, and mortality in Insanity — Rules for correct calculation of statistics.

Chapter III

General nosological principles applicable in Insanity — Former accepted classifications — Nosological divisions of recent standard writers — The author's classification of Insanity.

Chapter IV

Predisposing causes — The predisposing circumstances — The hereditary group of causes— Exciting causes — The bodily causes of mental diseases — The reproductive organs — Gastro-intestinal disorders — Cardiac disease — Pulmonarv affections — Vascular and cir-

Vlll TABLE OF CONTENTS.

PAGE

dilatory disorders. — The physiological crises as etiological factors — Intra-uterine life, birth, dentition, puberty, menopause, and senility — The neuroses in the light of causes : Chorea, epilepsy, hysteria, hypochondria, and neurasthenia, — The toxic origin of Insanity — Vegetable, animal, and mineral poisons most productive of Insanity — Auto-intoxications causing mental disorders — The psychoses from infectious disorders and acute affections of internal organs — The diatheses in their causative relation to the psychoses — Diseases and traumatic lesions of the cerebro-spinal nervous centres followed by Insanity — The reflex and sympathetic origin of mental disease — The psychical causes of Insanity — Fear the basis of a great generic group of emotional causes — Loss of mind as the immediate result of emotional shock — Moral contagion and epidemics of Insanity— Individual infection and communicated Insanity — Mental disorder as the result of simulation.

CHAPTER V. The Evolution, Stadia, Clinecal Progression, and Terminations op

Mental Disorders, 127

Chapter VI

Section I. — Disorders of the Intellect-— P resenlative Faculties — Perception and Consciousness— Pathological states of the muscular, tactile, gustatory, olfactory, auditory, and visual senses — Illusions and hallucinations — Disorders of consciousness — Changes in identity — Double personality — The representative faculties — Memory and imagination — Lesions of memory — Amnesia — Hypermnesia — Paramnesia — Disease of imagination — Phantasmagoria — The rational processes — Thought and reasoning — Disordered thought — Incoherence— Quickened and retarded thought-rate — Reasoning — Definition and description of the origin and nature of delusions.

Section II. — Disorders of the Emotions. — The organic sensations and the' resultant ccensesthesis — The physiological basis of the prevailing emotional mood in Insanity— The rationale of the fundamental emotional tone in states of exaltation and of depression — Cortical disease and the spasmodic liberation of emotions — Generic division of emotions as manifested in Insanity — Egoistic and altruistic feelings— Fear resulting from psychical disintegration the predominant emotion— Other emotions considered in the relative order of their frequency.

Section III.— Disorders of Volition.— Abulia, hyperbulia, parabulia, impellent ideas— Irresistible impulses— Nature of the loss

TABLE OF CONTENTS. IX

PAGE

of inhibition of ideas and actions in special types of Insanity — The appetites and instincts in their basic relation to the will and their perversion in Insanity — Sitophobia, polydypsia, polyphagia, pica, coprophagy, anthropophagy — Sexual perversions — Insomnia — Artificial appetites in mental disorders — The volitional sequelae of mental disorders — The psychic stigmata degenerationis.

Chapter VII

Section I. — The Osseous System. — Microcephalic, macrocephalic, and asymmetrical cranial defects — Facial, dental, and palatine malformations— Other physical stigmata degenerationis — Fragilitas et mollities ossium, ankyloses, arthritis deformans, necroses.

Section II. — The Muscular System. — Changes in general nutrition and in the electro-muscular reactions — Dynamometric and dynamographic variations — Hyperkineses, spasms, tonic and clonic, parakineses, pareses, paralyses, contractures, and atrophies — Muscular inco -ordination, tremors — Ataxic, pseudo-paralytic, cataleptoid, and tetanoid states — Jacksonian ejrilepsies — Changes in

the reflexes — Automatic acts and characteristic attitudes — Disor-

ders of speech in Insanity — Changes in gait and other highly specialized acts — The chirography of the insane — The physiognomy of Insanity with illustrations of the various types.

Section III. — The Vascular System. — Functional and organic cardiac affections — Anomalies of structure and degeneration of vessels — Functional and organic vascular aifections — General and partial anaemias and hyperaemias — Capillary stasis, varicosity, variations of blood-pressure, abnormal pulsation — Angiospastic and angioparetic conditions and general vasomotor disorders — The pulse in Insanity — Descriptions and illustrations of sphygmographic tracings in the various forms of mental disorders.

Section IV. — Changes in the Cutaneous and Other Epithelial Structures. — Pigmentations, desquamations, eruptions, herpes, pemphigus, decubitus, cyanosis, oedema, anidrosis, hyperidrosis, chromodrosis, seborrhoea, hirsuties, canities, anomalies in growth and coloration of hair — The nails and their trophic affections, cutaneous anaesthesias, hyperaesthesias, and paraesthesias, changes in cutaneous reflexes — Superficial temperature changes.

Section V. — Splanchnology col Disorders. — Pulmonary diseases and modifications of respiration — Gastro-intestinal symptoms — The genito-urinary disorders — Biliary, splenic, pancreatic affections.

Section VI. — Nutritive, Secretory, and Trophic Disturbances. — Changes in total weight of body in Insanity— Disorders of second-

X TABLE OF CONTENTS.

PAGE

ary assimilation — Auto-intoxications — The blood in Insanity — The urine in mental disease— The saliva— Trophic tissue clianges — Hematoma auris — Temperature in mental disorders.

Section VII. — Disorders of the Cerebral, Spinal, and Peripheral Nervous System.

Chapter VIII

Section I. — The Pathogenesis of Mental Disorders. — Physiological facts and pathological records — The inherited insane diathesis — The acquired neurotic constitution — Functional brain exhaustions — The earliest nutritive lesions and biochemical cerebral clianges — Insanity from circulatory disorders of the brain — Qualitative changes in cerebral blood-supply — Toxic states — Origin of mental disorder from lesions of cerebral, spinal, or sympathetic nervous system — Reflex or sympathetic Insanity from disease of internal organs— Epochal systemic changes— Cerebral, thermic, chemical, or mechanical traumatism — Emotional traumatism.

Section II. — The Pathological Anatomy of Insanity. — The Macroscopical Changes. — The cranium — The brain — Lobes, lobules, convolutions, sulci — The nerve-fibre systems : centrum ovale, central ganglia, ventricles — Pons medulla — The membranes : Dura mater, pia mater, arachnoid, ependyma — Cerebral anaemia, hyperemia, atrophy, hypertrophy, oedema, inflammation, sclerosis, abscesses, tumors, hemorrhages — Cerebral vessels — Embolism, thrombosis, arteriosclerosis, aneurisms — The spinal cord— Investing membranes — Descending system-fibre lesions, and cellular degenerations.

ffie Microscopical Changes. — The cortical cells and their various disintegrations — Changes in nuclei, nucleoli, apical and basilar processes of cells — Granular, fatty, moniliform, and pigmentary degenerations — Cellular vacuolation — Colloid bodies — Miliary sclerosis — Phagocytes — Neuroglia fibre-cells — Protoplasmic glia-cells — Changes in the commissural, association, and projection nerve-fibres — The cerebral membranes — The cerebral vessels — Perivascular lymph-spaces — Cellular degenerations of spinal columns, vessels, and membranes. — General principles explanatory of microscopical lesions in the genesis of Insanity.

CHAPTER IX. The Diagnosis of Insanity, 296

Technical difficulties and legal responsibilities— The essential elements of diagnosis — The history of the case antecedent and subsequent to the attack — Medical lines of inquiry and laws of evidence

TABLE OF CONTENTS. XI involved — Complete outline given for the record of histories — The personal examination of the patient — Diagnostic, psychic, and somatic symptoms — Standards of comparison in the determination of Insanity.

The average sane menial standard of mankind, as affected by historic epoch, national crises, degree of civilization, race, caste, occupation, and general environment.

The sane mental standard of the special individual. — Its fluctuations -within physiological limits — The determination of its pathological departures — Conditions of unusual difficulty of diagnosis in childhood, senility, eccentricity, imbecility, deaf- mutism, voluntary mutism, aphasia, habitual drunkenness, and other forms of excessive indulgence of natural or artificial appetites, and supposed recoveries from psychoses.

Feigned Insanity and the detection of various forms of malingering.

The differential diagnosis of mental disorders. — Insanity differentiated from acute brain diseases, from the deliriums of fevers, acute internal inflammations, inanition, sudden losses of blood, commotio cerebri, surgical and other forms of traumatism, acute alcoholism, toxic states, violent emotions, and extreme functional exhaustion of mental powers.

The points to be determined by the diagnosis. — The prime fact of Insanity — The special type — The question of institutional or home treatment — The degree of responsibility in legal cases — The setio-pathology and the general indications for treatment — Complete formula for the mental and physical examination with reference to diagnosis.

CHAPTEE X.

The Peognosis of Insanity, 342

The substance of the prognostic inquiry — The possibility of death — The hope of recovery — The probable duration and mode of termination — The chances of recurrence — The essential elements of prognosis in individual cases — Age, sex, constitution, heredity of the patient, and the form, duration, course, and cause of the attack — Special symptoms of bad prognostic import — Special symptoms of favorable prognostic nature.

Xll TABLE OF CONTENTS.

CHAPTER XL

PAGE

Section I. — The Prophylaxis of Insanity. — The early life and education of children— Advice about marriage and the adult relations of life — State-medicine and regulations for the prevention of mental disease.

Section II. — General Mode of Treatment— Private and public hospitals and their relative advantages — Practical directions for the treatment of cases in private practice.

Section III. — First Attentions to Urgent Symptoms. — Traumatic accidents — Inanition, insomnia, obstipation, retention of urine, gastro-intestinal disorder, exhaustion of vital powers, heart failure — Psychomotor excitement, hallucinatory delirium, acute organic affections, infectious disease.

Section IV. — Certain Specially Troublesome and Responsible Cases. — Destructive patients — Violent and homicidal cases — The actively and passively filthy cases — Feeble, helpless, or bed-ridden patients — Masturbatic and suicidal cases.

Section V. — The Treatment Based on Diagnostic Conclusions and Etiological and Pathological Indications.

Section VT. — Pharmaceutic Remedies. — Hypnotics, anodynes, depressomotors, vascular sedatives, vascular stimulants, nervous sedatives, nervous stimulants, anaesthetics, laxatives, purgatives, emetics, digestives, tonics, alteratives, eliminators, anti-periodics, emmenagogues, anaphrodisiacs, antiseptics, disinfectants, organic extracts — Their chief uses described in the order above given.

Section VII. — Surgical Procedures. — Trephining — Craniectomy, craniotomy, laminectomy, vertebral puncture, thyroidectomy, hysterectomy, oophorectomy, clitoridectomy, orchidectomy, phlebotomy, transfusion, hypodermoclysis, revulsion, vesication, thermocautery, electrocautery, setons, aquapuncture, acupuncture, hepatic aspiration, enteroclysis, cataphoresis, anaesthetic congelation, gastric lavage — Gynecological local treatment — Electrotherapy and its uses in Insanity.

Section VIII. — Hygienic Measures. The Hygiene of the Residence. — The hygiene of the person — The open-air cure — The rest-cure — Forced recumbence versus forced exercise — Gymnastics — Calisthenics — Swedish movement — Out-door games, horseback and bicycle exercise — Hydrotherapy in Insanity — Ice-cap, spinal bags, sunlight, sun-bath, colored light and its effects — Massage and its application in special cases — Climato -therapy in mental disorders — Mineral springs.

TABLE OF CONTENTS. xiii

Section IX. — The Dietetics of Insanity. — General instructions as to quality and quantity of food — Dietetics of acute mental disorders — The diet of the chronic insane — Figures given for physiological rations required — Formulae for liquid and solid food preparations — Diet in special forms of Insanity — Predigested foods — Eectal alimentation — Artificial feeding — Special directions for the forced feeding of patients and illustrated descriptions of the best apparatus for the purpose.

Section X. — Psychotherapy — General principles of mental therapeutics and the means for enforcing the same — Isolation from family and fiiends — Institutional environment — Trained nurses — Social readjustment — Conduct of physician toward patient — Influence of the opposite sex — Occupation — Diversions — Power of music — Travel and change of scene — Certain intellectual and emotional effects — Appeals to the reason, to the self-respect, and to the emotions of the patient — Discipline, rewards, and punishment — Seclusions—The question of mechanical restraint — Hypnotism — Suggestion—Placebos.

Section XI. — The Convalescent Period. — Removal from institutional care — The cessation of all treatment — The danger of prolonged treatment — Return to business and social rights — Class of cases in which only a partial or tentative restoration to civil rights is advisable — The final advice of the physician to the patient.

Chapter I. Page

Insanity feom General Organic Arrest of Development, . .519

Idiocy, cretinism— Imbecility— The definition, clinical delineation, causes, stadia, symptoms, pathology, differential diagnosis, prognosis, and treatment of the above forms.

XIV TABLE OF CONTENTS.

CHAPTER H.

PAGE

Insanity feom Constitutional Neuropathic States, . . . 540

Insanity of childhood — Primary monomania — Moral insanity — Periodical Insanity — The definition, clinical delineation, causes, stadia, symptoms, pathology, differential diagnosis, prognosis, and treatment of the above forms.

Chapter III

Epileptic, hysterical, hypochondriacal, choreic, and neurasthenic Insanity — The definition, clinical delineation, causes, stadia, symptoms, pathology, differential diagnosis, prognosis, and treatment of the above forms.

CHAPTER IV. Insanity with Physiological Crises, 609

Pubescent, puerperal, climacteric, and senile Insanity — The definition, clinical delineation, causes, stadia, symptoms, pathology, differential diagnosis, prognosis, and treatment of the above forms.

Chapter V

Toxic Insanity — Alcoholism, plumbism, morphinism, hydrargyrism, cocainism, nicotinism.

Diathetic Insanity — Phthisical, podagrous, rheumatic, pellagrous, limopsoitosic, paludal, anaemic, post-febrile, cancerous, and myxedematous Insanity— The definition, clinical delineation, causes, stadia, symptoms, pathology, differential diagnosis, prognosis, and treatment of the above forms.

Chapter VI

Insanity with Definite Lesions of the Cerebral, Spinal, Vasomotor or Peripheral Nervous System, .... 654 General paresis— Syphilitic Insanity— Organic dementia- Typhomania— Traumatic and sympathetic Insanity— The definition, clinical delineation, causes, stadia, symptoms, pathology, differential diagnosis, prognosis, and treatment of the above forms.

TABLE OF CONTENTS. XV

Chapter I. The History Of Insanity

It is a universal law that the most highly integrated functions of vital organisms are the most apt to suffer derangement. The human mind, as the highest evolved function of the most wonderfully complex of all organisms, has always been subject to partial or total disintegrations. Historical note of these mental disorders has been made from the earliest to the present time by various writers, and by the careful chronological arrangement and interpretation of the known facts an attempt will here be made to present a brief history of Insanity.

The whole subject is divided, according to chronological order and with reference to the general history of medical science, into four periods.

The first period extends from 1700 B.C. to 400 B.C. — from the first recorded mention of Insanity to the dawn of psychiatric science in the Greek school of medicine.

The second period is from 400 B.C. to 200 a.d. It is the first scientific evolutionary period of psychiatry, ending with the decline of the Greek school of medicine.

The third period, from 200 a.d. to 1500 a.d., is the dormant period of psychiatric science continuing through the Middle Ages to the Renaissance.

The fourth period, from 1500 a.d. to 1800 a.d., is the second evolutionary period of psychiatry from the Eenaissance to the present day.

The actual treatment of the insane as well as the existing knowledge of Insanity during the above periods will he simultaneously considered.

First Period (1700 B.C.—JfOO B.C.).

The modern study of Egyptian antiquities and papyri reveals indications of a knowledge of mental disease even at that prehistoric time. It is not to he understood that it has been possible to decipher from Egyptian hieroglyphic records that at that remote period Insanity was recognized in the sense that it is now known to exist. The conception of Insanity, such as prevails in modern times, would have been a moral impossibility in an Egyptian mind.

All learning was then confined to a caste, to Egyptian priests, whose ideas on all subjects were tinctured largely with a species of mystical religious philosophy.

The obscuration of human intellect did not escape their keen perception, but it was interpreted by them to mean a divine affliction which was to be averted by sacrifices.

The mentally afflicted in those days were therefore taken to the Egyptian temples, and they were there treated by the priests, according to the manner of their peculiar religious practices, by oblations, incantations, purifications, and sacrifices.

Some simple truth of wide application has always formed the basis of philosophic ideas, which have governed the world at all periods of its history. The truth that good and evil exist in the world, when elaborated in the highest Egyptian religious philosophy and applied to the insane, signified that they had become possessed by a good or an evil spirit. This may be said to have been the only principle of classification of Insanity at that time, and it was not without decided indications for treatment.

If the spirit was diagnosed as an evil one it was to be driven out by the most active religious proceedings, and the patient passed through a heroic ordeal. On the other hand, if the spirit was a good one, non-interference was the order of the day, and the patient was treated with deference and even at times regarded as inspired.

Some of the earliest authentic cases of Insanity are related at considerable length in the Bible. The history of King Saul, 1063

THE HISTORY OF INSANITY.

B.C., is probably the first recorded instance of homicidal mania. It is related that he removed his clothes, and that he remained naked by day and by night, and that he attempted to kill David by throwing his javelin at him. David himself, according to biblical account. may be regarded as the first instance of feigned insanity, for when he appeared before King Achish of Gath, according to the words of the Bible, " he scrabbled on the doors of the gates, and he let his spittle fall upon his beard," and the King ordered him from his presence, exclaiming that he had no need that a fool should appear before him.

Another remarkable case of Insanity was that of King Nebuchadnezzar, who became insane 569 B.C. His disease took the form of chronic mania of lycanthropic turn, and for years he wandered in the woods and ate herbs, and his body became covered with an extraordinar}^ growth of hair, and his finger-nails grew to an extreme length. The most astonishing point in the biblical history of this case of Insanity is that Nebuchadnezzar recovered his reason after an attack of seven years' duration, and he was restored to his throne as King of Babylon in the year 563 B.C.

Numerous other instances of mental disease are to be found among biblical records, but those above cited are sufficient to show that at that early historic period Insanity was recognized in types not essentially different from those of a later day. The Jewish idea of the genesis of Insanity was theistic, and the priests were the physicians of the soul, as they alone could intercede in behalf of those inflicted from on high as an indication of divine wrath, or possessed by a demon avenging some sin supposed to have been committed by the sufferer or by his progenitors.

In cases of Insanity complicated with epilepsy demoniacal possession was almost invariably the diagnosis.

Among the early Hebrews the general treatment of the insane, under the direction of the priests, was more humane than at many subsequent periods.

The Oriental Indians, 1100 B.C., possessed considerable traditional medical knowledge. Their learning, however, was confined strictly to a certain order of priests, and it was professedly of an occult and mystical nature, so that it has been difficult to learn what their belief and treatment were as regards mental disease, but it is safe to presume that it did not differ materially from the theories and practices already mentioned as prevalent among the Egyptians.

The history of Insanity among the ancient Greeks takes a wide range, and there is not space to recount here the numerous cases of the disease mentioned by Greek poets, philosophers, and historians. Sophocles and Euripides, Aristotle and Plato, Herodotus and Thucydides, all refer in their writings to cases of Insanity. The poets mention Ajax, Orestes, (Edipus, Hercules, Bellerophon, and Ulysses, who feigned insanity. Then again, there was Cleomenes, King of Sparta, probably the first recorded case of alcoholic Insanity, and King Lycurgus, likely the first lunatic on record as having slain his own son. Herodotus recounts at length the history of three sisters, princesses and the daughters of Pretus, King of Argos, who became .insane simultaneously. They were cases of leprous Insanity, and the mental symptoms took the form of lycanthrop}^, so that they ran wild through the woods, making animal-like noises. Herodotus further relates that they were cured by Melampus by the use of veratrum album, and by bathing in a mountain-stream after they had been chased by youths until they were in a state of profuse perspiration.

The insane among the Greeks were still treated, as among the Egyptians, by priests. The iEsclepiades constituted an hereditary order of priesthood among the Greeks, and they had sole charge of the temple of iEsculapius, to which the insane were conveyed for curative purposes.

Solon (500 B.C.) made laws with reference to the insane, and he denned those lunatics who were to be confined.

With the advance of Greek civilization at this period some of the grosser superstitions with regard to lunatics were dispelled, and it became recognized that they were still human and had certain rights to bo respected.

The Eomans, at a somewhat later period, made wise and complete laws for the control of lunatics, and for the appointment of guardians of their persons and estates, and they defined the insane to be treated in their own houses, and such as were to be confined " pro bono publico." In lunacy, as in other matters, the Eoman law was so perfect a model as to have served as a basis of all subsequent legislation on the subject.

During the long ages embraced in this first period of the history of Insanity there had been a gradual evolution of medical knowledge. Egyptians, Oriental Indians, Turks, Persians, Greeks, and Komans had all contributed something to the common fund of medical lore which, at the close of this first period (400 B.C.), may be said to have attained to the respectable dimensions of a science of medicine. The most crude part of this science, however, was psychiatry, in spite of the fact that in all ages it had been studied by the most learned men, by philosophers, priests, and physicians.

The nomenclature of Insanity was limited to the three terms, phienitis, mania, and melancholia. Phrenitis applied to mental disorder with inflammation of the brain or other internal organs. The etiology of Insanity was based on vague views of changes in the bile, mucus, and other secretions. The treatment was by hygienic means, outdoor games, baths, mineral waters, and a few simple therapeutic remedies, apart from the religious practices on the part of the priests.

Second Period (JfOO B. C.—200 A.D.). The First Scientific Evolutionary Period of Psychiatry, Ending with the Decline of the Greek School of Medicine.

The beginnings of psychiatry having been made by many peoples in various lands, the time was now ripe for some master hand to mould the crude material thus contributed into some definite shape, and the genius for the work arose in no less a person than Hippocrates, the Father of Medicine, himself, who laid the first foundations of the science of psychiatry.

Hippocrates was born 460 B.C., in the island of Cos. His teachings as to Insanity are not given collectively, but they are to be found scattered throughout his wonderful clinical descriptions of diseases in every domain of medical practice.

With but slight knowledge of the anatomy of nervous centres, he still conceived that the brain was the seat of Insanity. He recognized acute and chronic forms of mental disease. He spoke of the latter under the use of the terms mania and melancholia, and to the former he applied the word phrenitis, which he also used to describe Insanity with cerebral or visceral inflammation.

It is evident from his clinical descriptions that he was familiar with puerperal, alcoholic, and epileptic forms of mental disorder. His depictions of insane symptoms bore the stamp of everlasting truth, so that to-day, twenty-three hundred years after they were written, they might be applied to cases of mental disease with truthful fitness.

In his views of the nature of Insanity he was a humoral pathologist. Though descended from the ^sculapian order of priests he completely emancipated himself from their superstitious views. Ht keenly ridiculed their religious ohservanees in the treatment of Insanity, and he boldly declared that epilepsy was not a sacred disease (mal sacer), or an infliction "by the gods, as was then believed. His genius did not enable him, however, to rise above philosophic heights, for, though he ignored the priests, he agreed with the philosophers in locating Insanity sometimes as a disease of the soul which resides in the head, and at other times as a disorder of the soul which, it was taught, had its habitat in other parts of the body. It is to be borne in mind that philosophy at that time embraced and controlled all branches of human knowledge.

Hippocrates employed in the treatment of Insanity bleeding, purging, emetics, counter-irritants, mineral waters and baths, gymnastics and outdoor games, together with music, travel, and change of climate.

In general, it may be said that Hippocrates had humane and, for his time, remarkably advanced ideas of the treatment of the insane.

Following Hippocrates, the physicians for the next two centuries would seem to have simply pursued imperfectly the maxims of the Father of Medicine in psychiatry.

During the Alexandrian period of medicine, judging from subsequent citations by Galen of the writings of Herophilus and Erasistratus (300 B.C.), no special additions would seem to have been made to the knowledge of mental disease. It would appear, however, that Erasistratus was gifted with perspicacity in defending the doctrine that the superficial parts of the brain were especially concerned in intellection, and might be taken as a measure of the degree of individual intelligence.

Asclepiades of Bithynia (circa 100 B.C.) was a bold and original writer, and he did not even hesitate to differ from the views of Hippocrates in certain respects. He had just conceptions of the derivation of disease from bad water, food, and air, and he attached much importance to hygienic conditions in treatment. He made a clear distinction between mental disease with and without fever. He observed the transformation of one form of Insanity into another, and he made a special study of the deranged perceptions of the insane. In his treatment he discarded dark rooms and bleeding; and he used poppy, henbane, sun baths, inunctions, and water-cure — espeeially cold baths. His enthusiasm in the doctrine of the transformation of one type of mental disease into another led him into some inconsistency in the use of intoxication to convert incurable into curable forms of Insanity. He seems to have made a somewhat free use of mechanical restraint, and he added nothing to the terminology of the subject, but employed the terms phrenitis, mania, and melancholia, then in common use.

Titus Aufidius of Sicily (44 B.C.) was a student of Asclepiades, though he does not appear, to say the least, to have improved upon his master's teachings. He seems to have believed that the insane retained, to a considerable degree, their free will and responsibility, and that their efforts at self-control might be materially aided by severe measures. He accordingly favored deprivation of food and drink as punishment, and he even prescribed flagellation in extreme cases. In order to make a pleasurable change in the organic emotions he occasionally recommended sexual indulgence in melancholia.

Celsus (25 B.C. — 45 a.d.) considered Insanity to be due to perversion of the secretions. The doctrine of heredity had not yet come into vogue. He distinguished between Insanity with and without fever, and divided it into acute and chronic forms, which were partial or general in type. He was acquainted with the hallucinations of the insane and described them. He attached great importance to individual differences in patients and the treatment to be given them, and he gave complete instructions for the hygienic and moral measures to be employed. Exercise in the open air, bathing, music, reading, the removal of fear by kindness or by deceit, if necessary, were some of his resources. Other measures which he deemed remedial were decidedly harsh, and consisted in restraints and even severe punishments of various kinds, to subdue violent cases of mental disease.