This is a lecture on fixed ideas and obsessions. For the genesis of these two lactors are necessary, first, an excessive condition of feeling; second, a congenital or acquired weakness of mental constitution. The difference between them and paranoia consists in the fact that in the case of obsessions there is no alteration of the personality. The author divides them into (1) obsessional emotions, (2) obsessional ideas, and (3) obsessional impulses. This is not a rigorous psychological distinction, but it is justified by the prevalence of one of the elements constituting each group. The emotional group may be divided into repulsions (or phobias) and imperative desires. The phobia may be general or for one determinate object only. Under the heading of obsessional desires are included dipsomania and certain other drug habits. The obsessional impulses are distinguished by their motor content; as these become more automatic they pass into the group of ties. Obsessional ideas have frequently a hypochondriacal basis. They are rarely accompanied by hallucinations. As regards prognosis there are two classes of cases, first, those in which the original psychical weakness is hereditary or dates from early infancy; second, the cases in which the weakness is acquired. In the first class the outlook is very grave and amelioration only results where development and education are very favourable. Other functions may through time become affected, but it rarely passes into other forms of insanity. Agitated melancholia may, however, develop. Suicide is rare, those affected being generally undecided. The treatment is largely general. Muscular and mental exercises are of benefit, as also outdoor work and electricity. If neurasthenia be present it is an indication for treatment; suggestion may also be tried.

The writers contribute, in this paper, the results of observations made at the Pennsylvania School for Feeble-minded Children at Elwyn, Pa., but state that this is only a partial representation of their work.

In this article, the author studies the cases of 284 young male patients, between fifteen and thirty years of age on admission to the Philadelphia Hospital, having excluded all those who were plainly imbecile, epileptic, or paretic. After alluding to the histories of these cases, alcoholic in forty-four,—although most of these he believes, were moderate drinkers,—he asks “What relations have the doctrines of degeneration with our present subject?” and points out that Esquirol and Morel have observed the tendency of hereditary insanity to appear at puberty and in adolescence, and that the latter author more definitely states that at this period degeneration reveals itself. A degenerate history was obtained in more than three quarters of the author's cases. The anatomical marks of degeneracy also were common, but unfortunately no systematic study of these was made. Obsessions, the psychic stigmata of degeneration according to Magnan, he believes with Régis are rather actual insanities, disorders of the will on a basis of neurasthenia; coming and going with the state of nervous health they are stigmata only as insanity itself is a stigma: to serve as a real test of degeneration, a stigma must be permanent. Only by close anatomical study on a large scale with classification of stigmata, can degeneration obtain a useful clinical significance. He agrees with Morel that the theory of degeneration should be kept single and thought of mainly as related to heredity. It is important not to confuse the two uses of the word “degeneration,” the one being proper to psychiatry, the other to pathological anatomy. With Jaffray he thinks that “to be insane, the patient must be degenerate.”

The notes of an interesting case are given—fully and carefully recorded as Bourneville's cases generally are. A. G—, a girl æt. 14 years was admitted into the Fondation Vallée, March 4th, 1899. Her family history was very bad—father, alcoholic and violent; mother, hysterical, then insane; grandparents, neurotic, as well as several uncles and aunts. The patient was possibly conceived when her father was drunk, her mother being at the time liable to attacks of hysteria. She had once convulsions limited to the face; up to the age of twelve years she had nocturnal incontinence, and after this had attacks of depression, of alternating crying and laughter. When her mother was placed under care, the girl was placed in an orphan school at Les Andelys, where, no doubt, under the influence of the separation from her mother and religious practices she developed mystical delusions—she thought she was Joan of Arc and had blessed visions, etc. A few days later she came under Bourneville's care. The mystical delusions persisted for a few days, and after a short remission (March 9th—23rd) were followed by a period of maniacal excitement—crying, singing, incoherent purposeless movements, extravagance, dirty habits, and insomnia. The attack lasted a week, and was followed by a remission (March 30th—April 21st) after which she was somewhat melancholic for a while, although free from hallucinations and mystical delusions. On May 1st she was practically well. About a year later, menstruation appeared, without any mental disturbance. The treatment consisted in baths and douches, with the administration of chloral and bromides to combat the insomnia and excitement; general exercises, occupation, etc., afterwards.

This is a case with a long chronic evolution, which shows the narrow relations which may exist between dreams and delusions. Whether dreaming during sleep, or apparently at times dreaming when awake, the patient presented persistent delusions which were grafted on or sprang from the dreams, and occasionally led to acts. O. L— was aged 49 when he came under the authors' care, having been in the post office for twenty-four years; he complained of pains in the lower limbs, which exaggerated a natural limp (due to former injuries), and pains in the head, which he referred to visions he had recently experienced. The patient had written a long account of these hallucinations, which revealed two dominant ideas: (1) that the patient was God's elect, and (2) that he was persecuted. To explain them he referred to certain episodes which had occurred far back in his life, and the visions seemed to be of two kinds: (a) representations of his ordinary life; (b) supernatural. As regards these supernatural visions, a few of these were extra-terrestrial (referring to the heavens, to the sun, etc.), but most (a large number altogether) were terrestrial (a rainbow descending about the patient's head, beholding Christ on the Cross appearing on a newspaper he was reading, a star falling and the moon stretching out to catch it, etc.). Hallucinations of hearing occasionally accompanied the last-mentioned hallucination of vision. The ideas of persecution arose in his mind at the time of appearance of these visions; they mostly referred to his thoughts being read. The various hallucinations appear to begin in dreams, during which he is authorised to divulge them, etc.

The case simulates a form of alcoholism. Nightmare, dreaming prolonged into the waking state, general mental confusion superadded—these represent the degrees of infection acting on the brain, and well illustrated in the notes of this observation.

This is a continuation of a paper on dreams (see Revue Scientifique, March 30th, 1901), and deals especially with the dreams of epileptics. Reference is made to Duaste's cases, in which dreams occurred during the epileptic seizure only (Journal de Médecine de Bordeaux, Nos. xlviii and xlvix, 1899); but the possibility of the dream being merely an aura must not be dismissed. Certain characteristics of epileptic dreams are to be noted: the predominance of the colour red; certain parts of the body especially figure: the head, the sexual organs, the chest; the introduction of strong animals, the act of falling, etc.

On January 12th, 1901, H—, æt. 40 years, was admitted to Sainte Anne Asylum, having just escaped imprisonment, owing to Dr. Garnier's certificate of “mental debility, melancholia, confusion of ideas, excitement at intervals, want of appreciation of his condition, etc.” A few days later he came under the care of Dr. Marie at Villejuif. He became troublesome on account of his pilfering habits. On seven or eight occasions he robbed patients of such things as books, ink-stands, pencils, etc. When the objects were found in his pockets, he always maintained that he was driven to steal in spite of himself. In March, he was placed on a diet without salt—or rather with a minimum of salt—(75 grains a day in his bread and milk); in addition, he was given 30 grains of bromide of potassium per diem. On the first day, (March 1st) of this treatment he committed a robbery, but never after. Moreover, his demented appearance improved somewhat, and he became sociable with the other patients; towards the middle of the month he began to occupy himself. At the end of March, he was put on ordinary diet, and the bromide of potassium suppressed, but the kleptomania did not recur. From April 1st to June 19th, he was quiet and well behaved, and presented nothing unusual. Suddenly, on June 15th, he presented slight left hemiplegia on getting up in the morning; he got up, although dazed and complaining of severe headache; at 7 o'clock he was seized with epileptiform convulsions lasting five minutes, followed by coma with high temperature, and ending fatally on the third day. There was marked albuminuria. Venesection was performed. At the autopsy large congested inflamed kidneys were found, and hypertrophic cirrhosis of the liver. The interest of the case is the apparent cure of the kleptomania under the influence of the bromide and cutting off the table salt.

The author describes under this heading a group of cases in which the mental disturbance is always associated with subjective psychical facts. He divides his thirteen cases into three groups. In the first, some illness has directed special attention to the organ afterwards believed to be diseased. In the second, the individuals thought they had heart disease, after having seen cases of it in others. In the third, the psychical trauma was caused by some marked agency as death of friends or parents. The symptoms were mild depression, confusion, and ideas that some organ was diseased. These cases come on in apparently healthy individuals and heredity is generally absent. They differ from hysteria in the absence of any objective phenomena and from phases of pathophobia in being unattended by any signs of degeneracy. The author considers that they arise from the impression absorbing in a morbid way the attention of the subject, and producing the beginning of an association of ideas.

This is a very complete clinical report of a case of some interest. The patient, a man, æt. 68, with nothing special in his family history, had contracted syphilis at the age of 21; twenty years later, after a period of intense brain work, he had a sudden attack of localised frontal headache with paresis of the right side. The paralytic symptoms cleared up rapidly, but the patient remained subject to headache and vertiginous attacks, and also to periodic fits of morbid anger with impulsive violence to things and persons about him. Latterly, these symptoms increased, and the patient's mental power declined.

The author points out, that in relation to crime, it is necessary to consider separately the periodic attacks and the intervallary condition of the epileptic. Of the former he distinguishes three varieties— (1) absences, or petit mal; (2) convulsive attacks; and (3) attacks characterised by phases of altered consciousness—psychic epilepsy. It is regarding the last class of epileptic phenomena—the most important in legal medicine—that Benedikt's remarks are specially interesting. He points out that in these epileptic dream-states the actions performed may be very complex, and may have the appearance of deliberation; that memory may be partially retained for events at any period of the attack; and that the attacks may last for hours, days, or even longer. He considers that such prolonged attacks have affinities with periodic insanity and with dipsomania.

The catatonic condition has as much individual existence as any other form of primary dementia; it is episodic in following other morbid psychical processes. The condition is said to be caused by a particular form of cortico-psychical inhibition, combined with a subcortical inhibition and excitation, particularly of the cortical centres.

The patient was a lad æt. 18. At six years suffered from periodic frontal headaches and hebetude. After two years had vertigo and “absences.” The character changed, and he became strong and irritable. He attempted murder at seventeen, and shortly thereafter had the first attack of “classical” epilepsy. This was followed at intervals by other seizures, and he died in status epilepticus. The autopsy showed numerous cysticercus cysts in the pia, some on the surface free, others embedded in the cortex, which tore as they were removed. These cysts varied in size from a pin's head to a small hazel nut. There were a few subcortical cysts, some in the basal ganglia and lateral ventricles. The pons, cerebellum, and cord were free from cysts, as were also the internal organs. Cysticercosis produces in the brain the same symptoms as other focal lesions. When multiple, and especially when they arise in the period of development, they may produce, instead of an epileptiform phenomenon, a true epilepsy.