washes his hands from thirty to forty times daily, and always does so after handling money. The impulses that compel him to calculate are shown almost entirely in business matters, although his habit is now to weigh all coin that he receives or gives out, and this he has done for the past two years. The question of the honesty of others does not seem to figure largely in this procedure, for he weighs the money which he gives to them and counts the bills repeatedly, often following the recipient several times in the day to know whether the amount he has paid is correct. He carries scales with him, not daring to trust himself without them, and while admitting the irksomeness of his bondage, suffers intensely if he forces himself to place them beyond his reach. In his efforts to escape the imperative impulse he often asks his brothers to take charge of his business, and he has finally been obliged to leave everything in their hands.

Some time ago his imperative concepts took another form, which consisted in the belief that paper, pieces of tin, scraps of iron, on the sidewalk, street, or elsewhere, would do injury for which he would be morally, if not legally, responsible if he did not remove them. Paper upon the road that might frighten horses, scrap-tin that might wound them, loose cobblestones, and other objects, he would constantly gather and put out of harm's way. He was so dominated by his morbid fears and the possible consequences of neglect upon his part that he refused to sell nails to his customers without removing the splints, and if the nuts upon the bolts he sold were loose he would screw them up. He would question purchasers as to the possible harm that might have occurred, and upon one occasion, when he went to Long Branch for his vacation, after an hour of anxiety and doubt upon the steamboat, he turned back at Sandy Hook, to remove a banana-skin he had passed without picking up on the sidewalk in New York. His morbid fears were excited by any object which might do harm, matches, combustibles, and sharp tools being included, and he was finally obliged to seek new employment, taking charge of the bill-collecting part of the business. There was not in his case anything that might be regarded as a delusion. His relations with every one except the liquor-dealers were pleasant. He slept well, as a rule, and suffered from insomnia and disturbed digestion only when he underwent a peculiarly distressing period of doubt.

AFFECTIONS OF MEMORY.

An impairment of memory is an exceedingly common symptom of mental disease. It may consist in feeble receptivity-a condition of which implies something more than a failure of attention-which prevents the concept from retaining its place in the brain; or it is due to a convolutional condition where the mental impressions are light or fugacious; or it may arise from an epileptic condition, with temporary abolition of consciousness; or in a graver form it signals a species of involutional degeneration which follows or attains the actual destruction of the cells of the cerebral cortex. It is the all-important symptom in dementia, and most of the disorderly expressions of that condition are directly traceable to mental disorganization. Not only may a stage be reached where the individual stops storing up the freshly received impressions, but ulti

mately all the concepts of previous periods are lost. It is distinct from congenital weakness, which is manifested in amentia, where perceptions are never attended by lasting concepts, the apparatus of reception and appropriation being undeveloped.

Loss of memory usually begins first in the direction of forgetfulness of substantives and proper names. "This," says James (Psychology, vol. i., p. 683), "seems due to the fact that common qualities and names have contracted an infinitely greater number of associations in our minds than the names of most of the persons whom we know. Their memory is better organized. Proper names as well organized as those of our family and friends are recollected as well as those of any other objects. 'Organization' means numerous associations; and the more numerous the associations, the greater the number of paths of recall. For the same reason adjectives, conjunctions, prepositions, and the cardinal verbs, those words, in short, which form the grammatical framework of all our speech, are the very last to decay." As Kussmaul says: "The concreter a conception is, the sooner is its name forgotten. This is because our ideas of persons and things are less strongly bound up with their names than with such abstractions as their business, their circumstances, and their qualities." One of the primary indications of mental impairment is the inability to renew impressions and to recognize their significance, to arrange them and to apply them to events and things; and for this purpose, of course, consciousness is essential. There is a form of cerebral activity which consists in the voluntary birth of ideas that force themselves to the surface without any effort, such a process being often instinctive.

For the estimation of how far the memory is affected in mental disease we must first test the patient's ability to recall concepts and to fix their importance, to group the ideas and to apply them to himself, and then determine his ability to bring forward details of the past, determine his power of time, localization, and perception, and incidentally his idea of space. With the enfeeblement of memory we find a certain degree of superficial adjustment which the patient uses to adapt himself to his surroundings, and which is the result of his desire not to appear different from others. Of course at a later stage this is lost, and the effort to group and arrange facts leads to incoherence. What might be called the automatism of life is demonstrated in diseases where memory gradually fails; the memory of recalled concepts, lasting when others are forgotten, showing that weak-mindedness of this character, in its insidious advance, is attended by a certain kind of ability upon the part of the patient to recall mental landmarks which he has referred to habitually. Sometimes this apparent integrity is sufficient to impress unthinking

persons.

The minor grades of degeneration are seen in a familiar disease known as aphasia, which is described elsewhere; but it is proper for me to refer to the disturbance of automatism, which is manifested in tricks of speech which sometimes are functional disorders, or, on the other hand, foreshadow mental dissolution, which is not expressed until much later by unmistakable symptoms. These consist in the transposition or substitution of syllables, stuttering, hesitation, and phonetic peculiarities, which may or may not betoken the coming of physical as well as mental breaking down.

DISTURBANCES OF VOLITION AND EMOTION.

The various affections of will incident to mental disease may be considered as those of an exaggerated or active character and those of a depressed or passive character.

The first comprise those which are expressed as the dictate of an hallucination or delusion, or simply as an instinctive or purely impulsive act, or as the result of an imperative concept. To this class belong the peculiar explosions of the epileptic and hysteric and maniac. The violent acts of the former are usually sudden, attended by apparent unconsciousness, and are not remembered afterward. Sometimes the patient while in a precursory attack runs amuck, stabbing or otherwise assaulting those he may by chance meet. The outbreak is paroxysmal and the assault purposeless.

The impulses of the insane find expression in other ways: in destructiveness, self-mutilation, suicide, inordinate consumption of food, the taking of improper things into the stomach, perverted sexual acts, etc.

It is no uncommon thing to find women with hysterical insanity or acute mania tearing their clothing or destroying various objects. Sometimes the insanity of a patient whose condition has not attracted attention is for the first time expressed in an impulse to destroy frail articles. This symptom is most often present in mania and does not seem to be the result of delusion or hallucination, but is clearly an expression of continued and intense excitement. Various lunatics, under the force of dominant concepts, are likely to commit a destructive act of one kind whenever they get an opportunity. What are known as piquers in France are subjects of this class. Some of them cut and slash the dresses of women, or pour vitriol or corrosive fluids thereon, while others surreptitiously clip off the hair of young girls in the streets. This form of imperative concept is likely to go with sexual perversion.

The chronic epileptic is quite likely to commit purposeless acts of destructive mischief-setting fire to buildings or willfully destroying property with apparently no object in view. At other times the impulse is to brutally murder some one. When arson is committed it is apparently motiveless, although the insane love of fire or a desire for notoriety may instigate the act. Often the crime is repeated, and in one case that occurs to me the person, who was subsequently apprehended and tried, was clearly dominated by an imperative concept. Self-mutilation or the mutilation of others is frequent. In the former case it is sometimes suggested by an insane delusion, and the desire to commit a sacrifice may be apparent. Those who suffer from religious delusional insanity not. unrarely cut off their right hand or pluck out their eyes as the result of a too literal interpretation of a scriptural command. Generally as a result of sexual perversion the insane person will horribly mutilate the body of a person he has murdered, or sometimes he will obtain a sexual satisfaction by wounding the genitalia of young women or girls. This is known as sadism, and was first practiced by the Marquis de Sade, whose insane orgies led to his apprehension by the French police. (Vide La Corruption fin de Siècle, Léo Taxtil.)

Fantastic and ingeniously contrived suicides are often committed by the insane, either with delusional suggestion or impulsively. The para

noiac not infrequently infuses into his taking off some element that brings posthumous notoriety, and a crop of imitators repeat his widely advertised death. Kirchhoff has called attention to the fact that the impulsive suicide of the lunatic must be distinguished from that where he jumps from the window or into a river to avoid an imaginary danger suggested by his hallucinations or delusions. The suicidal act is sometimes wholly inexplicable except by inheritance, there being an apparent blind fatality, and no recognizable immediate disturbance of intellect to explain the self-destruction. The writer has had a family of this kind under observation for many years, and no less than six sons and daughters have attempted suicide, or have actually succeeded in destroying themselves, at various times. As a rule the act was committed between the twentieth and thirtieth years, and in no instance was there the least apparent reason or motive.

A morbid propensity not only for the ingestion of large quantities of food, but of foreign substances as well, symptomatizes an impulsive insanity, which may or not be connected with some perversion of the physiological process which regulates the appetite. The tendency of hysterical women to eat chalk or drink acids, the morbid desire for various essential oils and aromatic substances, are minor indications of gustatory and olfactory perversion connected with impulsive acts; but there is an insane longing for foul and repulsive substances, which is present in the victims of evolutional as well as acquired insanity, which leads to the devouring of fæces. Another form of disgusting impulse finds vent in the eating of human flesh. The abstinence from food is usually the result of delusion or hallucination, so that in many asylums the necessity for forced feeding arises, the patient refusing nourishment because he believes he has been gifted with supernatural powers of endurance, or that he is offending God by eating. In other cases where sensorial delusions exist the patient refuses food because he declares his stomach or intestine is tenanted by some living animal. At times refusal of food depends upon the fear of poisoning, such a delusion being one of the most frequent and important of all. Of course real disorders of the gastro-enteric tract will lead to a loss of appetite.

Sexual impulses of an unusual kind betoken the existence of mental degeneration. As a rule such perversion and loss of control belong to the possessor of the "insane diathesis," the victim of evolutional insanity; but the general behavior of the sexual pervert need not be conspicuous. Like the victim of imperative concepts, he is in other ways, as a rule, fairly strong intellectually although he may be the possessor of a congenital weakness which means a complete transposal of his normal appetites and powers. Many individuals entertain sexual longings only for their own sex, and such find a form of gratification which it is not necessary to here particularize (see Dr. Chaddock's article). In many large cities the subjects of the contrary sexual impulse form a class by themselves and are recognized by the police. The men have their balls, where they dress as women even to the details of dainty underwear. (Fig. 12.) They adopt the names of women, and affect a feminine speech and manner, "falling in love" with each other, and writing amatory and obscene letters. In New York City alone there are not less than one hundred of these, who make a profession of male prostitution, soliciting upon the streets and in parks when they get the opportunity. Physically,

many of these men whom I have examined present the stigmata of degenerative insanity, or else physically approach the female type, and hypo- and epispadias are common. The female pervert or Lesbian rarely

differs from others of her sex, except that the active agent is gross, wears mannish attire, and cultivates masculine habits.* Other perverts enjoy sexual pleasure only when themselves subjected to physical pain and degradation; others derive enjoyment solely from torturing the objects of their passion; while others alone gain satisfaction in actual contact with fetiches such as women's shoes and other articles of wear. In mania hysteria and other expansive forms of insanity with exaggerated sexual activity, selfcontrol is in part or totally lost, and we are presented with the conditions of nymphomania and satyriasis, as applied to the female and male, which lead the patients to indulge in reckless excesses, indecent and shameless proposals, and conduct which is a complete departure from the normal state. A refined and high-bred woman will make advances to car-drivers, porters, or servants-black or white; while the victim of satyriasis, who perhaps happens to be a clergyman or dignified banker, will expose his person in public or court the notice of the police. False accusations of improper assault are common with these people, and often lead to unhappy lawsuits or criminal proceedings. The sexual excitement, it must be remembered, may be only a local prompting and have no intellectual participation, and each case should be investigated carefully, with a view to the recognition of the person's ordinary mode of life, previous behavior, etc. As a rule there are concomitant symptoms of insanity.

The conversation of young women who suffer from hysterical insanity is quite apt to direct attention to the mental failure. For a long time before easily recognizable expressions of disease are detected, the patient will constantly talk about subjects naturally avoided by girls. One of my patients, a young person of very pure mind, devoted most of her time during the early development of her insanity to catechising a married sister about copulation and pregnancy, and finally extended her inquiries to the other female and male members of the household. In this

The reader is referred to Krafft-Ebing's Psychopathia Sexualis; Taxtil's La Corruption Fin de Siècle, and various French romances, among them Mademoiselle du Maupin or Mademoiselle Giraud ma Femme.