The 
Physical Basis of Insanity 
and the Insane Diathesis. 
BY 
WILLIAM A. WHITE, M. D. 
PROM 
American Journal of Insanity, 
APRIL, 1 894. 
UTICA, N. Y. THE PHYSICAL BASIS OF INSANITY AND THE 
INSANE DIATHESIS.* 
BY WILLIAM A. WHITE, M. D., 
Assistant Physician, Binghamton State Hospital, Binghamton, N. Y. 
Gentlemen:—Mental phenomena have been looked upon, in all 
ages and by all peoples, with a very considerable sense of awe and 
reverence and a very deep appreciation of their intrinsic mysteri- 
ousness. When we consider that of all the various forms, exist- 
ing on this earth, man is the most highly evolved and the most 
complex, and that the brain is the most highly evolved and com- 
plex part of man, we are in a position to realize why it is that the 
functions of this wonderful organ have withstood for so many 
hundreds of years the attempts of scientists to classify them under 
the domain of the operation of natural laws. 
It is true that several centuries before Christ a few of those 
master minds of the early Greek and Roman civilizations had be- 
gun to realize the true significance of insanity and had already for- 
mulated many valuable precepts for its treatment. A reference 
to the opinions of Aristotle, Hippocrates, Asclepiades, Cselius 
Aurelianus and many others, are sufficient to make us pause and 
marvel at the magnitude and wonderful insight of those minds 
which could reach conclusions that the results of the scientific 
progress of centuries have hardly altered. 
But the great work which these men had begun was doomed to 
become as naught. With the fall of the civilizations of which they 
were the shining lights they and their works were forgotten; and 
with the plunging of all Europe into the terrible depths of the ignor- 
ance and superstition of the Dark Ages all knowledge of science 
was lost. The human mind, no longer bent upon the elucidation of 
scientific problems and the discovery of scientific truths, reserved 
its energies for the creation and support of a thousand petty dog- 
mas and creeds and strained its forces to sustain a corrupt priest- 
hood, backed by an equally corrupt philosophy. 
During these Dark Ages the lunatic was looked upon either as 
a being possessed of some evil spirit, and consequently worthy 
* Bead before the Binghamton Academy of Medicine, March 15, 1894. PHYSICAL BASIS OF INSANITY. 
only of the greatest condemnation and most severe treatment, or 
as one who had directly received the benefits of God by inspira- 
tion, and was accordingly worshipped and canonized. We can 
hardly imagine more thoroughly unfortunate or unscientific ideas, 
yet for centuries the convictions of the most enlightened people of 
Europe, regarding insanity, were expressed by such phrases as 
“demoniacal possession” and “divine inspiration.” 
Fortunately for us the mind, no matter how serious may be its 
obstacles, is bound to advance. The Dark Ages came to an end 
and the enlightening and vivifying influences of the Reformation 
roused Science from her deep lethargy. Men began once more 
the pursuit of knowledge, and the advance of science proceeded 
directly in proportion to the appearance of the spirit of skeptic- 
ism and the elimination of the element of the supernatural from 
their methods of research. 
The first evidence we have of the redemption of mental science 
appears in the seventeenth century in England, in the works of 
Thomas Willis. He was perhaps the first to indicate the intimate 
relations subsisting between brain and mind. He was followed in 
Germany and Switzerland by Gall and Spurzheim, who, although 
on many points greatly in error, did much to further these views. 
In France, in the latter part of the eighteenth and the beginning 
of the nineteenth centuries, Pinel, followed by Esquirol, discarded 
the older views of the inscrutable nature of insanity and instituted 
great and lasting reforms in the methods of its treatment. 
From those days until the present there has been a constant ad- 
vance in the knowledge of the pathogenesis of insanity; and that 
advance has been contemporary with the discarding not only of 
the element of the supernatural but of all metaphysical speculations 
as to the intrinsic nature of mind as such. The cerebral patholo- 
gist no longer allows his ideas to become warped and distorted by 
an attempt to correlate some fanciful speculations on the operation 
of an imponderable and immaterial soul with his observations of 
tissue changes in the brains of the insane. The modern alienist in 
his studies and investigations never for a moment considers that 
the outward manifestations of mind have any other than a physical 
basis, and the dictum “no psychosis without a neurosis” has be- 
come his guiding axiom. 
As we ascend from the lower portions of the spinal cord to the 
cerebral cortex we find that the anatomical structure becomes BY WILLIAM A. WHITE, M, D. 
3 
gradually and progressively more complex, and a study of the 
functions of the various regions will show a correlative increase in 
their complexity. That the cortex, anatomically the most complex 
portion of the nervous system, gives origin to the most complex 
functions thereof, namely, the manifestations of the mind, is an 
undoubted fact. 
No matter what may be our individual ideas regarding the nature 
of mind and its relations to the brain, whether we regard it as an 
entity contemporaneous only with nervous changes, or whether we 
regard it on the one hand as cause, or on the other hand as effect 
of these changes, we must acknowledge that for every psychical 
phenomenon there is a corresponding nervous phenomenon. These 
facts being admitted, it is readily seen that insanity is nothing 
more nor less than a symptom-complex of cortical disease. It is 
here then in the cortex with its almost infinite number of cells and 
complex nexus of intercommunicating fibres that we must look for 
those nervous changes which underlie the psychical manifestations 
of insanity. 
Given a series of cases of insanity in its various forms and stages. 
Do we invariably find, by the means which we have at hand to 
employ, definite or even indefinite nervous changes in this structure 
which would explain in whole or part the symptomatic manifesta- 
tions ? No, we do not. And why not ? 
Here let me call attention to the fact that the complexity of the 
cortex is not alone due to the arrangement of its cells and the in- 
tricateness of its fibres, but in addition to these factors, and more 
important than either or both of them, it depends upon the molec- 
ular structure of its various constituents. 
In those cases then, which show no pathological lesions, the 
changes are such as have occurred in this molecular composition, 
and are as a rule not capable of demonstration. Such cases are 
known as functional diseases, but they are no more functional than 
any others. The pathological changes, although much more mi- 
nute and inappreciable than in structural diseases, are none the less 
real. In view of these considerations, I believe that the future 
progress of psychiatry will be greatly aided by an appeal to the 
laws of chemolytic cleavage and molecular physics. 
Let us look at the structure of the cortex and its relations to in- 
sanity from another point of view. Reasoning by analogy we 
may assume that the growth of the cortex is peripheral, and that PHYSICAL BASIS OF INSANITY. 
the higher and later acquired functions are relegated to its outer 
regions. There is thus what might be called a functional lamin- 
ation, the functions increasing in complexity from within outward. 
In support of the hypothesis that the most general cause of disease 
is the absorption frbm the environment by the tissues of more mo- 
tion than they can retain with the result of producing disintegra- 
tion, molecular and subsequently molar, we find that it is the outer 
regions of the cortex, which are younger and less stably organized, 
that are first affected, and, correlative with these peripheral changes, 
the highest and most complex elements of the mind suffer. 
This course of events is typically illustrated by the progressive 
development of melancholia, mania, and terminal dementia. Mel- 
ancholia would then be the result of disintegration, in part, of the 
highest cortical regions. The functions of these regions being 
carried on with difficulty, there results the painful mental state. 
The office of these higher centres is largely and often essentially 
inhibitory; therefore, further and deeper disease destroying them 
would cause the symptoms of mania, these symptoms not being 
due to an increase in power or capability, but to a removal of in- 
hibitory control. Finally dementia closes the picture, with its 
deep-seated and destructive tissue changes. 
Illusions and hallucinations are in general due to the irregular 
and erratic reaction of a disordered nervous mechanism to the ad- 
vent of peripheral or central excitation. Delusions, on the other 
hand, are secondary changes of a constructive type, but organized 
on the basis of false premises, and through the intermediation of 
disordered sense impressions. 
The above general conclusions serve to harmonize and explain 
the more special results which have recently been arrived at by 
methods of psycho-physical research. Notable among these are 
the conclusions of W. Bevan Lewis, drawn from an elaborate series 
of experiments on the reaction time of optic and acoustic stimuli 
in the various forms of insanity. In harmony with my conclusions 
above, of the destructive nature of the lesions of insanity, he finds 
the reaction time is greater in all forms, not only in melancholia 
and dementia, but also in mania, both acute and chronic. So far 
as I know, the reaction time and accuracy of the other so-called 
special senses, notably the muscular, temperature, and pressure 
senses, together with those of touch, taste and smell, have not as 
yet been carefully studied among the insane. But I feel convinced BY WILLIAM A. WHITE, M. D. 
5 
that when they are, and their results systematically reviewed, that 
they will hut add another argument in support of the general 
propositions laid down in this paper. 
Now that we have arrived at what I believe to be tenable 
hypotheses as to the nature of those physical changes, which under- 
lie the symptomatic manifestations of insanity, let us inquire into 
the nature of that constitutional condition, which predisposes to 
the occurrence of these pathological changes. 
To begin with there are two great varieties of the insane diathe- 
sis, namely, the acquired and the inherited. Every individual is 
born into this world with a certain greater or less amount of 
potentiality to develop. According as to whether these develop- 
mental forces of the brain are early dissipated by faulty modes of 
life, or were originally lacking by virtue of some parental defect, 
we have the acquired or inherited diathesis. As alienists it is the 
latter form which we most often meet and which presents the most 
serious and difficult problems relative to treatment. 
This condition of the inherited insane diathesis is closely related 
to idiocy and imbecility. And here let me call attention to the 
often overlooked distinction between idiocy and imbecility on the 
one hand, and insanity on the other. In the former states we have 
a condition of lack of development only; the individual has pro- 
ceeded to a certain stage and there stopped; whereas in insanity 
there is actual cortical disease, whether or no it be engrafted upon 
an already undeveloped brain. Now the inherited insane diathesis 
is allied to idiocy and imbecility, in just so far as it is the result 
of lack of development. On the other hand, it is distinguished 
from idiocy and imbecility, by the fact that the errors of develop- 
ment are much more irregularly distributed, and more often 
associated with contemporary symptoms of a very high degree of 
organization, which, however, is always strictly limited in its 
manifestations to a very small portion of 'the individual’s mental 
field. 
Such a condition of affairs would render the nervous tissues 
especially prone to disease because here as elsewhere a tissue 
which is not up to the standard of development is predisposed to 
degenerate. The molecular structure of the nerve cells, being in 
unstable equilibrium, is prone to undergo disintegration by the 
process of chemolytic cleavage on the advent of environmental 
forces to the complexity of which it is not adjusted. 6 
PHYSICAL BASIS OP INSANITY. 
The acquired diathesis gives origin to similar conditions not 
apt, however, to he so deep-seated and serious in their results nor 
so intractable to treatment. 
What are the signs and symptoms by which we may recognize 
these conditions? 
First, the mental symptoms are in harmony with our conclusions 
as to the structure and functions of the cortex. They are notably 
those of loss of inhibitory control and marked irregularity and 
lack of coordination in the manifestations of all of the mental 
faculties. These patients are prone to be unreasonable and 
illogical, their emotions are unstable, and react to what would 
normally be insufficient stimuli: they frequently manifest a 
profound egotism with coexisting absence of the altruistic sense. 
Owing to the disordered nervous mechanism, we find the incipient 
stages of delusions will, in time, become fixed and organized, 
if they go in the direction of degeneration. Thus we have agora- 
phobia, claustrophobia, mysophobia, imperative conceptions and 
frequently, in connection with disordered coemesthesis, sexual per- 
versions and beginning derangement of the notion of personality. 
When these changes are especially localized, or noticeably mani- 
fested in particular directions, there occur those conditions known 
as dipsomania, moral imbecility, etc. 
In concurrence with these symptoms of lack of development 
often occur, as before mentioned, symptoms of a very considerable 
development along certain lines; and the recent investigations of 
Cesare Lombroso in Italy have gone far to show the intimate 
relations maintaining between genius and insanity. 
Many of the great reforms which have been instituted in the 
course of mankind’s development have owed their origin to men 
of this class. Men, who though suffering from neuroses, in some 
instances even epilepsy, have had brains so highly developed in one 
particular direction that convinced of the value and correctness of 
their views they have been enabled to direct the convictions of 
the people. They might be considered as the products of the social 
states from which they arose, as abnormal developments in one 
direction, arising at a time when society was ripe for reform, and 
only needed their guidance and control to choose and follow the 
right path. 
Unfortunately the manifestations of the insane diathesis do not 
always take this more desirable course, and a considerable number BY WILLIAM A. WHITE, M. I). 
7 
of these mentally alienated persons are relegated to the criminal 
classes. The modern science of criminal anthropology has added 
greatly to our knowledge of this unfortunate and so long misun- 
derstood class of men. The investigations of Lorabroso, Manou- 
vrier, Garofalo, Benedikt, Bertillon, and a host of others have 
thrown new light upon the phenomena of crime. The criminal is 
no longer regarded as always and invariably a responsible person, 
but, on the contrary, as frequently the victim of circumstances, 
and his crime rather a social than an individual phenomenon. 
When the results of the scientific study of the criminal shall have 
been accepted by the world, let us hope that the disgusting spec- 
tacle of a man mounting the gallows to expiate the mistakes of 
his ancestors and his own faulty cerebral organization shall be 
forever rendered impossible. 
There are many other forms which the insane diathesis assumes, 
but those to which I have called your attention are by far the 
most important, and present problems in their consideration which 
are second to none in weight with which the scientific world has 
to cope. 
It would indeed be surprising if all these mental symptoms 
could occur as a result of a lack of developmental forces, and 
there be no signs of this great defect manifest in the other organs 
of the body. As a matter of fact we find on studying this class of 
patients that they do manifest various departures from the normal 
in almost every conceivable direction. These signs are known as 
the signs of degeneration, and have been exhaustively studied by 
Morel, Legrain, Broca, Lombroso, Manouvrier, Ottolenghi, and 
many others. They are especially noticeable as presenting 
symptoms of irregular and disordered development, and the de- 
fective organs present in general atypical and asymmetrical 
characters rather than definite departures from the normal in par- 
ticular directions. To be more explicit these signs are asymmetry 
of the skull, scaphocephalus, plagiocephalus, prognathism, high 
and narrow palate, asymmetrical innervation of the facial muscles, 
strabismus, poorly nourished teeth, deficient vitality, vaso-motor 
disturbances, and a great number of others. Although they 
vary in significance we cannot say that any one of them is pathog- 
nomonic. It is only by their combination that they constitute 
important evidence. 
In reviewing this paper, what are some of the implications 8 
PHYSICAL BASIS OP INSANITY. 
which are of greatest practical importance to the general practi- 
tioner of medicine ? First and foremost is the conclusion that for 
each and every manifestation of mental activity, whether it he the 
fitful flush of an emotional state, or the prolonged and laborious 
process of reasoning, there is a corresponding and correlated nerv- 
ous activity. 
It is easy enough to recognize those dangerous symptoms 
of cerebral exhaustion which afflict the over-worked business 
man, and advise him to leave the worry and work of his office 
and take a trip abroad. But to recognize those subtle depart- 
ures from the normal, manifesting themselves in the child, and 
advise proper methods of education, requires special knowledge 
and skill. With the rapid advances in psychiatry new responsi- 
bilities have been thrust upon the shoulders of the physician, and 
though he may not possess all the requirements necessary to furnish 
such advice, he should be able to appreciate in general the signs 
and symptoms of an abnormal mental state, and refer the parents 
to a skilled alienist. By so doing very frequently an unlimited 
amount of suffering and anguish could be spared and an individual 
who would otherwise end his days in a prison or an asylum be 
rescued ere it were too late and become a useful member of society. 
The physician occupies the same position relative to these ques- 
tions which he does to so many others. He is a quiet, unostenta- 
tious, though constantly working, educator of the people, and I 
believe that largely through his efforts the laity will in time come 
to a correct understanding of the evil effects of faulty unions and 
bad methods of education, and that such knowledge will be em- 
ployed by them in the application of rational methods of pro- 
phylaxis, which after all offers the only satisfactory solution of these 
problems yet reached.