vaguely understood. Moreover, it is sufficiently comprehensive to include all the fugues described.

These qualities were not to be found in the other definitions of earlier date (even when they exist, several authors having treated the subject of fugues without defining them) and Joffroy and Dupouy might well exclaim, "How many diverse and contradictory definitions do we not observe, well showing that the problem is not understood in the same manner by all those who have striven to solve it!"

A study of the disturbances of activity included in the above definition quickly shows the extreme frequency of these conditions in the greater number of mental diseases, either as a symptom quite episodic and which might pass unnoticed or, on the contrary, dominate the clinical picture.

Two points, however, should be made immediately. The first concerns the great number of common fugues, due to ordinary and wide-spread phenomena such as maniacal excitement and intellectual enfeeblement. These fugues are in some cases caused by motor, erotic, or intellectual over-activity, reaching, in certain instances, the very borderland of automatism and including all the fugues of simple instability; others being fugues dependent upon dementia, amnesia or confusion, not having their origin in a special disturbance of activity, but exclusively in the diminution or the extinction of one of the higher functions of the brain. They are observed in most chapters upon mental pathology: they elude description.

The second point that should be made is that no fugue whatever can be made the basis of the diagnosis of a precise nosological classification. This is self-evident so far as ordinary fugues are concerned. It might be otherwise concerning those which remain to be described. If these fugues are specific or, if one prefers, symptomatic, they are so not because of a definite disease, but because of a syndrome. We shall find the fugue of melancholia in all the states of depression, and it will occur in identically the same manner and with the sanie pathogeny in simple depression, in involutional melancholia, in the delirium of negation, in toxic depression or that brought about by various organic affections; there is the oneiric fugue, the hallucinatory origin of which is evident, whatever the toxic cause; there is the dromomanic fugue of the impulsive syndrome; there is the secondary fugue, more frequent

in cases of hysterical automatism, but not exclusively attributable thereto; the impulsive fugues and those associated with the dementia of dementia præcox ought not to be included among the common forms of fugue, except as a special evolution of the intellectual enfeeblement whereby they are determined; and the systematized fugues find their essential unity in an underlying paranoia which, according to the case, will systematize a delusion with ideas of grandeur, jealousy, mysticism, or persecution.

It may very well be conceived that, as a consequence of an incidental crisis, an individual subject to systematized delusions might be capable of an oneiric fugue, an hysteric of a fugue of dromomania, a precocious dement of a fugue of melancholia and that any one of these might be capable of ordinary fugues. In one and the same patient the fugues might, under the influence of varying causes, take on diverse forms.

Fugues having a peculiar specific character are: the fugues of melancholia, the oneiric fugues, the epileptic fugues, the impulsive fugues and those due to the dementia of dementia præcox, the fugues of dromomania, the secondary fugues, and the systematized fugues.

The Fugue of Melancholia.-Fugues of melancholia occur as well in conditions of transitory depression as in melancholia with delusions, and even in cases of the syndrome of Cotard, anxiety being the essential pathogenic element. A rapid, accidental onset characterizes it. The fugue is only one of the varieties of raptus melancholicus for the same reason as are a number of serious acts-murders, mutilations, suicides of a particularly horrible character, and may be regarded as a mere equivalent. Frequently the raptus is preceded by abortive attempts.

The state of consciousness of the melancholiac under the influence of raptus is made up of hallucinations coming in a sudden manner, but is especially due to a moral distress, particularly keen, negative in character, causing a feeling of horrible vacuity. During their acts, those subject to the fugues of melancholia are influenced by a profound disturbance of consciousness, the act itself being semi-conscious without being autonomous-detached from the personal consciousness, with which it has merely relations of contact without actual penetration (Séglas).

The impulsion thus produced is sometimes very brief and fol

lowed anew by a motor inhibition which paralyzes the patient's activity. But oftener the impulsion will be of longer duration, either because the anxiety is prolonged, fed by hallucinations, or because delusive ideas arise to fortify and render persistent the original impulsion.

Very curious observations have been published by Lalanne and by Collet, calling attention to patients who, after a brief panic of anxiety, cower in an obscure corner and remain immobile, cast down during long days, without nourishment, thus accomplishing, to quote Collet's very apt expression, a mental escape (" évasion à l'intérieur ") from the asylum.

The relations existing between fugue and delusional melancholia were much discussed at the Congress of Nantes. There are indeed several authors who attribute to the fugue of melancholia an intellectual pathogenesis and admit that it occurs as the result of a delusion. We have, however, upheld the notion of anxiety as the real cause of the fugue. If there is habitually a delusion capable of furnishing a logical and plausible explanation of the flight, especially in fugues of long duration, the idea of flight, like the delusion in melancholia, is secondary. The idea of flight, like that of suicide or mutilation, may have germinated in the mind of the patient previously to the act; it may arise after its accomplishment to explain it, to analyze it, to justify it; but the essential determining factor of the act, its cause, resides sometimes in an outburst of anxiety, which precedes the inception only by a few moments, sometimes in an exacerbation of a continuous anxious state. There is no deliberation, even delusional, in the accomplishment of the act, in which the will takes little part. The patient has indeed taken account of the possibility of flight, as of any other serious act, suicide in particular. But this is not a case of real premeditation. All melancholiacs have these ideas, these desires in mind. Very few, however, escape or commit suicide. This is because aboulia and inhibition control their acts and, in order that these acts should become decisive and be carried out, some unexpected circumstance is needful, a raptus of alarm, a terrifying panophobia, a sudden impulsion.

The Oneiric Fugue. This form of fugue appears in the course of any sort of oneiric delirium (infection, auto-intoxication, exogenous intoxication), especially in alcoholic and febrile delirium. It is not, however, the only fugue produced by these toxins. We

may easily detect common fugues and fugues of motor instability or of vague uneasiness in the case of the alcoholic. The term cneiric should be reserved for the fugue in correlation with the delirium of the same name and depending immediately upon its principal symptoms; that is to say, brought about, in the confusion more or less deep-seated, by the hallucinatory phantasmagoria. It is thus an integral part of the active dream of the true secondary state of the intoxicated subject.

The provocative hallucinations may be of any sort whatever, of sight, hearing, or psychomotor, but more often multiple and combined.

"

When the hallucinations are well defined, we have, in the case of infectious delirium, what is commonly called an attack of fièvre chaude," and in alcoholism, a condition in which the patient, wholly transported into a world as fantastic as it is frightful, without critical insight into his own perceptions, the terrorizing effects of which are cumulative, is afraid of everything and flees from everything, overcome by a frightful anxiety of hallucinatory origin: this is the overmastering fear, the panophobic raptus.

While his fugue lasts, the victim of oneiric delirium is capable of committing very dangerous acts, among which there are those having the same origin and pathogeny as the fugue.

At times there is added to the sensory cause a special emotional condition, a melancholy feeling of moral distress or even a delusional idea of self-accusation.

The end of the fugue is what might be expected in the case of those distracted; now and then it ceases spontaneously; sometimes exhaustion arrests the patient; in certain cases involuntary suicide interrupts the flight; or it may be an impulsive suicide, delusional but desired and which, by its folly, suggests the suicide of the general paralytic; more often the victim throws himself upon the mercy of the authorities imploring assistance and protection. In its entirety and by reason of its acuteness, the oneiric fugue is of short duration, but liable to recur.

The oneiric fugues due to causes other than alcoholism and infectious delirium are rare; we have mentioned the principal causes. Joffroy and Dupouy include among them certain epileptic fugues. The Epileptic Fugue.-The fugue of epileptics occurs either as a motor or hallucinatory aura; or else, though rarely, in the course.

of an incomplete convulsive attack, in which case it is merely an automatic continuation of the initial movement; or as following attacks, which originate in the course of a paroxysm of excitement; or indeed forming by itself the whole picture. It may be met with apart from any convulsive attack as well as in partial epilepsy.

The deambulation of epileptics takes place in different degrees, ranging from procursory epilepsy, a lower degree of automatism which is not a genuine fugue, to the true fugue, which may have three forms, agitated impulsion accompanied by serious acts, deambulation continuing the movement begun before the comitial vertigo, impulsive vagabondage of rather long duration accompanied by acts more or less co-ordinated or incoherent.

In these various forms there exist general habitual characteristics; the suddenness of the impulsion, unconsciousness-the exception being made that in the case of acts at all complex the unconsciousness is not real or absolute, amnesia which is deepseated, but with the numerous variations to which Maxwell has called attention.

The relations existing between the hysterical and the epileptic fugue have undergone in recent years a serviceable adjustment. Subconscious "ambulatory automatism," of less frequent occurrence, the outward manifestations of which are well co-ordinated, is now ascribed to hysteria. Only the ordinary unconscious ambulatory automatism, in which the patient has a distracted air and presents evident cerebral disturbances, is epileptic. This last form of automatism accompanies or takes the place of vertiginous or convulsive phenomena. The duration varies from a few minutes to several days. The fugue differs from procursive epilepsy only because of longer duration and is also, perhaps, more complex in its manifestations.

In the course of their fugues, epileptics often commit very serious acts against the person--murders, assaults, violations-or against property-theft, incendiarism, or military misdemeanorsnot to mention others. All these acts are closely related to the fugue and due to the same causes.

The Impulsive and Demented Fugue of Dementia Præcox.It is inevitable, in the course of a symptomatological description such as we are here making, that we should feel a certain embarrassment in regard to dementia præcox. There can indeed be