nutritive, and not exciting; though nerve stimulants and counter-irritation to the head are often of service.

GENERAL PARALYTIC AND EPILEPTIC STUPOR.-The condition of stupor of the anergic kind is often an incident in those two diseases, most frequently following attacks of convulsions or congestive attacks, but sometimes coming on of itself without any reference to such motor symptoms. Wherever there has been prolonged stupor in general paralysis, we find much brain atrophy after death.

CAUSATION. The causes of stupor are the following:

1. Sexual. The chief of these is the habit of masturbation. I have met with it also as a post-connubial condition, or from excessive sexual intercourse in both sexes in adolescents. In some cases it seemed as if the mental and emotional exaltation had acted as strongly as the physical exhaustion. F. P., and F. S. were examples.

2. Mental and moral shocks and over-work during adolescence.

3. The brain exhaustion caused by acute mental diseases, more especially acute mania.

4. Stupor often occurs as an incident or stage in other mental diseases, notably, as we have seen, in general paralysis and epilepsy.

5. An alcoholic stupor may be caused by excessive drinking, and is thus one form of alcoholic insanity. Such a condition is usually transitory, but not always.

6. Stupor is frequently one of the stages of alternating insanity following the exalted condition. It is more apt to occur in those where the exalted period is acutely maniacal. This stupor is usually the melancholic form. The older the patient the more apt is the stage of reaction after exaltation to be one of stupor. I have now under my care an old gentleman of eighty-four, who, when his periods of exaltation are unusually long, will afterwards become torpid, never speak or take any notice of anything, will not even stand, but must be kept in bed, will scarcely swallow, and this will sometimes continue for four or five weeks. When younger, he never had such attacks. He has labored under irregularly alternating insanity for thirty years.

7. Senility. In the extreme form of senile insanity, the mental faculties disappear so entirely as to constitute them cases of stupor.

Some of these causes may, of course, coexist. The sexual and alcoholic are very apt to do so.

PROGNOSIS IN STUPOR.-In its typical form, in young persons of both sexes, the anergic form (acute dementia) is a very curable form of mental disease. The melancholic form is not so curable, but about fifty per cent. of the cases recover.

TREATMENT OF STUPOR.-All forms need much the same treatment, but in the anergic cases it needs to be supporting and stimulating, and in the melancholic more supporting at first, and stimulating afterwards. Quinine, iron, strychnine pushed to large doses, ergot, warmth, the continued current, exercise, friction, alcoholic stimulants, rousing moral treatment, occupation, distraction of mind are the general indications. In the relation of the clinical histories of the cases described the treatment has been sufficiently spoken of.

LECTURE IX.

STATES OF DEFECTIVE INHIBITION (PSYCHO-KINESIA; HYPERKINESIA; INHIBITORY INSANITY; IMPULSIVE INSANITY; INSANE IMPULSE; VOLITIONAL INSANITY; UNCONTROLLABLE IMPULSE; INSANITY WITHOUT DELUSIONS, EXALTATION, DEPRESSION, OR ENFEEBLEMENT; AFFECTIVE INSANITY).

THE INSANE DIATHESIS.

THE want of the power of self-control is so very common a thing amongst mankind, that to some extent, and in respect to some matters, it may be regarded as the normal condition of our species. A perfect capacity of self-control in all directions and at all times is rather the ideal state at which we aim than the real condition of any of us. The men who have attained this state of inhibitory perfection have been few and far between, and even in regard to them it may be said that they too would have lost their self-control if they had been exposed to sufficient temptation or irritation. But while a perfect mental inhibition may not be attainable, there is a certain amount of this power in all directions, and an absolute power in some directions that is expected of all sane persons. All sane men must control to some extent their animal desires, and they must control absolutely any desires they may have towards homicide. The law assumes, as the basis of all its enactments, that all men have the inherent power to do certain things and avoid other things that would be inconsistent with the well-being of society, or the safety or comfort of their fellow-men. If a man is born of criminal parents, and has been taught to prey on his fellows, and look on them as having no rights that he is bound to respect, if from no fault of his own his brain is weak, and no sense of right and wrong has been implanted in him at all, yet in spite of all this he is held as fully responsible by the law as the strongest, best taught, and most favorably circumstanced man in the country; and this is at present unavoidable, however unscientific it is from the physiological and psychological aspect of brain and mind function. Laws are, after all, largely the reflexes of the laws of nature. If a man has not been taught that an excessive use of alcohol damages or kills, and he drinks it to excess, he suffers just as much as the man who knows its bad effects, and deliberately poisons himself with it. But to this assumed power of mental control in all men the law makes certain exceptions. The first of these is in regard to children, and the second is in regard to persons whose mental power has been affected by disease or want of brain development.

The subject of mental inhibitory power should first be studied by us medical men from the point of view of its gradual development in children. Take a child of six months, and there is absolutely no such brain

power existent as mental inhibition; no desire or tendency is stopped or controlled by a mental act. At a year old the rudiments of the great faculty of self-control are clearly apparent in most children. They will resist the desire to seize the gas flame, they will not upset the milk jug, they will obey orders to sit still when they want to run about, all through a higher mental inhibition. But the power of control is just as gradual a development as the motions of the hands. There is no day or year in a child's life after which killing its little brother is murder, and before which it was no crime at all. The law admits and provides in a rough way for this physiological fact as to self-control. We physicians see that this faculty is developed at different ages in different cases. We are bound to give credence to all physiological facts and laws, and it is as much a fact that different brains have different degrees of controlling power after their full development, as it is that they attain their power of control at different ages. As we watch children grow up, we see that some have the sense of right and wrong, the conscience, developed much sooner and much stronger than others, just as some have their eye-teeth much sooner than others; and, looking at adults, we see that some never have much of this sense developed at all. This is notoriously the case in those whose ancestors for several generations have been criminals, insane, or drunkards. Then, again, in other persons the sense of right and wrong is painfully keen from early childhood, and the desire to follow the one and avoid the other earnestly striven after from the first. In some, therefore, conscience is anæsthetic, in others hyperæsthetic, just as sensation may be. Notoriously it is a bad thing to force any sense or mental faculty into too great activity till its brain substratum is sufficiently developed. I have known many children whose anxious parents had made them morally hyperesthetic at early ages through an ethical forcinghouse treatment. I knew one little boy of four, who, by dint of constant effort on the part of his mother, was so sensitive as to right and wrong that he never ate an apple without first considering the ethics of the questions as to whether he should eat it or not; who would suffer acute misery, cry most bitterly, and lose some of his sleep at night if he had shouted too loud at play, or taken more than his share of the cake, he having been taught that these things were "wrong" and "displeasing to God." But the usual anaesthesia that follows too keen feeling succeeded to the precocious moral intensity in this child, for at ten he was the greatest imp I ever saw, and could not be made to see that smashing his mother's watch, or throwing a cat out of the window, or taking what was not his own, were wrong at all. We know that some of the children of many generations of thieves take to stealing as a young wild duck among tame ones takes to hiding in holes, and that the children of savage races cannot be taught at once our ethical feelings. It seems to take many generations to redevelop an atrophied conscience. Professor Benedick, of Vienna, showed, at the International Medical Congress of 1881, in London, a number of brains of habitual criminals which he affirmed had their convolutions arranged in a certain simple form peculiar to the criminal classes, so that on seeing such a brain he could tell the ethical tendencies of the person to whom it belonged, just as you can tell a dog to be a bull-dog by his jaws. There is no doubt that an organic lawless

ness is transmitted hereditarily. Among the many transmitted morbid peculiarities in the children of neurotic and insane parents this is often one. Either a too morbid intensity of desire, or a morbid weakness of control, renders such children prone to early morbid immoralities.

In the delirium of fevers and the ravings of the acuter forms of insanity, no form of self-control is expected. The law, from the earliest times, entirely exempted persons suffering from such conditions from responsibility for acts done under their influence. A study of the different varieties of insanity shows us that the power of self-control differs enormously in the various forms, and in different individuals laboring under the same form, while there is no line of demarcation between the state in which a man has "perfect self-control" (to use an expression that cannot be literally true in any case) and that in which he has none at all. Self-control, in short, like all physiological qualities and all mental faculties, exists in every possible degree of strength. Sufficient power of self-control should be the essence and legal test of sanity, if we had any means of estimating it accurately. The accurate clinical study of mind in relation to its ordinary physiological accompaniments, in health and disease, will, I believe, help us in time to make such an estimate in any particular case far more accurately than we are now able to do. The practising physician, from his daily acquaintance with the physiological facts of nature, instinctively makes allowances for lack of selfcontrol in his patients when they are ill, apart from technical insanity. He knows that the thing called "irritability" merely means lack of full vital power, that the "impulses" of the hysterical girl are simply morbidly transformed modes of energy temporarily bursting the bounds of the patient's will, just as fits of weeping are often involuntary and uncontrollable. But the lawyer, and the medical man, who, as a medico-legal witness or adviser, has to consider the social and legal aspect and effect of his opinions, are still chary of admitting mere loss of control or morbid impulse as an excuse for crime. They both like to have other evidence of disorder of the mental function, in the shape of insane delusion or incoherence of speech, before they are willing to put forward the plea of diseased want of self-control in mitigation of legal punishment. Another element than medical facts comes in then, viz., the practical effect of their opinions on society. In a community of perfectly law-abiding people a murder would naturally be attributed to disease, and no objection would be taken by any one to that view of it. But with the world as it exists, it is different.

Before we can give any opinion as to the responsibility or irresponsibility of any case in a court of law, we should see as many cases as we can where want of controlling power or impulsive tendencies constitute the disease or the chief part of it. Such cases exist, though they are not, in a pure form, very numerous. As one stage in cases of insanity they are frequent. Half the suicidal melancholics at the beginning dread the moment when their self-control will be lost. Many of the maniacal cases show at an early stage only loss of self-control, before motor excitement or incoherence comes on. If one has seen many persons in this state about whom there could be no doubt as to their disease, and if one has systematically studied the loss of self-control or morbid impulse as a

mental symptom in the various forms it is found to assume, such experience and study bring much confidence to us in giving private medical advice about this matter, or in giving evidence in the witness-box in regard to one of the most responsible and difficult questions about which a medical man has to come to a decision.

Consider first the variety of simple motor impulses or acts that are physiologically uncontrollable, or partly so, such as coughing, vomiting, etc. Next, look at a more complicated act, that will be recognized by any competent physiologist to be automatic and beyond the control of any ordinary inhibitory power, e. g., irritate and tease a young child of one or two years sufficiently, and it will strike out at you; suddenly strike at a man, and he will either perform an act of defence or offence, or both, quite automatically, and without power of controlling himself. Place a bright tempting toy before a child of a year and it will be instantly appropriated. Place cold water suddenly before a sane man dying of thirst, and he will take and drink it without power of doing otherwise. Exhaustion of nervous energy always lessens the inhibitory power. Who is not conscious of this? 66 Irritability" is one manifestation of this. Many persons have so small a stock of reserve brain power-that most valuable of all brain qualities-that it is soon used up, and you see at once that they lose their power of self-control very soon. They are angels or demons, just as they are fresh or tired. That surplus store of energy or resistive force which provides in persons normally constituted that moderate excesses in all directions shall do no great harm, so long as they are not too often repeated, not being present in those people, over-work, over-drinking, or small debauches, leave them at the mercy of their morbid impulses without power of resistance. Some persons of more mental and nerve force have the fatal power of keeping themselves at work or at dissipation till this surplus reserve stock of resistiveness is altogether exhausted, and they then become unresistive against morbid impulses. Woe to the man who uses up his surplus stock of brain inhibition too near the bitter end, or too often!

In relation to the medico-psychological problems of mental inhibition and impulse, we have to take into account those obscure human tendencies towards killing, towards destructiveness, towards appropriation, towards unrule, some of which exist as inchoate physiological tendencies more or less strong in most human beings, and the gratifying of which gives pleasure. They are best seen in youth, and they often come out in a strong way in disease. Be they transmitted qualities of our far-off progenitors, or physiological weapons to help us in the struggle for existence, or other and normal physiological energies transmuted, there they are, and we must accept them as facts of nature.

The doctrine of nervous inhibition and of inhibitory centres has done very much to definitize our notions in regard to the mental working of the brain. There is, of course, no proof of mental inhibitory centres, but there is mental inhibition, and a function always implies an organ of some sort. When it was demonstrated that the excitation of certain nerves caused not motion, but stoppage of motion; when it was proved that the nutrition of the tissues was largely influenced by the increased or diminished potency of the capillaries or arterioles, and that the latter